Left-Sided Portal Hypertension Revisited

Original Article

Original Article Archives of Clinical Arch Clin Exp Surg 2016;5:211-215 Experimental Surgery doi:10.5455/aces.20151012124201

Increased of Langerhans Cells in Smokeless Tobacco-Associated Oral Mucosal Lesions Lef-sided portal hypertension revisited Antonio Manenti1, Erica Pavesi1, Alberto Farinetti1, Dario Colasanto2 Érica Dorigati de Ávila1, Rafael Scaf de Molon2, Melaine de Almeida Lawall1, Renata Bianco Consolaro1, Alberto Consolaro1 ABSTRACT Background: Splenic vein obstruction can lead to left-sided portal hypertension, which is a rare segmental portal hypertension condition, often caused by infammatory or neoplastic disease of the pancreas. Today, adequate study by cross- sectional imaging, e.g., ultrasound and computed tomography, allows the identifcation of particular features of the venous collateral pathways that favor the development of gastroesophageal varices. 1Bauru Dental School Methods: A retrospective study of 15 cases of left-sided portal hypertension secondary to complete thrombosis of the University of São Paulo splenicAbstract vein was performed, with special attention to the morphodynamic conditions predicting the development of gastroesophageal varices. Bauru–SP, Brazil Results:Objective: In patients To withevaluate left-sided the portal changes hypertension, in the number gastroesophageal of Langerhans varices were Cells greatly (LC) favored observed by two in conditions: the epithelium of 2 collateralsmokeless pathways tobacco directed (SLT-induced) to the gastric fundus lesions. and hypertension in the left gastric vein. This last condition typically oc- Araraquara Dental School curs when the left gastric vein infows into an already obstructed splenic trunk, or in the case of concomitant portal hyper- São Paulo State University tension.Methods: On the Microscopiccontrary, patients sections with left-sided from portalbiopsies hypertension carried andout collaterals in the buccal connected mucosa with theof twentyleft renal patients,or adrenal who were Araraquara-SP, Brazil veinschronic have minorusers risk of smokelessof gastroesophageal tobacco varices. (SLT), were utilized. For the control group, twenty non-SLT users of SLT Conclusions:with normal In mucosaevery case were of left-sided selected. portal Te hypertension,sections were upper studied digestive with endoscopy routine coloringand close and follow-up were are immunostained rec- Received: February 05, 2012 ommended. Besides, computed tomography can demonstrate particular conditions directly favoring gastroesophageal Accepted: February 29, 2012 varices,for S-100, and aid CD1a, in selection Ki-67 of andthe appropriate p63. Tese therapeutic data were decisions. statistically analyzed by the Student’s t-test to investigate the Arch Clin Exp Surg 2012;X: X-X Keydif words:erences Left-sided in the expressionportal hypertension, of immune splenic markersvein thrombosis, in normal portal mucosahypertension and in SLT-induced leukoplakia lesions. DOI: 10.5455/aces.20120229052919 Results: Tere was a signifcant diference in the immunolabeling of all markers between normal mucosa Corresponding author Introductionand SLT-induced lesions (p<0.001). Te leukoplakiafeatures lesions of LSPH.in chronic SLT users demonstrated a signifcant Érica Dorigati de Avila Leincreasef-sided in portal the number hypertension of Langerhans (LSPH) cells is a and par- in the absenceToday, the of renewedepithelial interest dysplasia. in LSPH has been pro- Departamento de Estomatologia ticularConclusion: hemodynamic T conditione increase involving in the number the region of these of cellsmoted represents by modern the cross-sectional initial stage of imagingleukoplakia. tools, e.g., da Faculdade de Odontologia de the splenic vein. Tis rare syndrome can be considered color Doppler ultrasound (US) and contrast-enhanced Bauru Key words: Smokeless tobacco, leukoplakic lesions, cancer, langerhans cells, chewing tobacco. Universidade de São Paulo (USP) a typical example of segmental portal hypertension and thin section (2.5 mm) angio computed tomography Avenida Alameda Octávio it is ofen secondary to neoplastic or infammatory pa- (CT), which allow precise study of the entire portal ve- Pinheiro Brizola, 9-75, 17012-901 thologyIntroduction of the pancreas. nous systemcontact [1-4]. with Te aim the of oral our retrospective mucosa and study creates a Bauru–SP, Brasil Trombosis of the splenic vein and subsequent de- was to moreanalyze alkalinethe diferent environment, morphodynamic its and products clini- may [email protected] velopmentAmong of collateral tobacco systems users, are the there two distinctiveis a false becal- aspects of this disease. even be more aggressive to tissue [5]. Te Author afliations : 1Department of Surgery, 2Department of Radiology, University of Modena, Modena ,Italy Correspondencelief that SLT : Antonio is safe Manenti, because MD, Department it ofis Surgery, not Universityburned, of Modena, Modena, Italy. e-mail: [email protected] Received / Accepted : August 25, 2015 / October 07, 2015 percentage of SLT users is lower compared which leads many people to quit cigaretes and start using SLT [1]. However, SLT con- to cigarete users; however, usage is increasing tains higher concentrations of nicotine than among young individuals and it is therefore a cigaretes and, in addition, nearly 30 carci- signifcant and disturbing danger [6,7]. nogenic substances, such as tobacco-specifc Initial studies on the efects of SLT on the N-nitrosamines (TSNA), which is formed oral mucosa demonstrated the formation of during the aging process of the tobacco, [2-4] white lesions induced by chronic exposure to and which presents high carcinogenic poten- tobacco, characterized by epithelial thicken- tial. Moreover, because the tobacco has direct ing, increased vascularization, collagen altera- Left-sided portal hypertension 212

Anatomo-functional features Several pathophysiological and clinical aspects of LSPH are correlated with the anatomy of the splenic venous system. Te splenic vein is the main channel of venous drainage of the spleen and the upper gastric greater curvature. Important collaterals stem from its proximal portion, close to the splenic hilum: the short gastric veins, linked to the venous apparatus of the stomach and the lef gastroepiploic vein, connect with the portal vein. Other spleen venous collaterals are represented by the splenorenal and splenoadrenal veins, which join with the inferior vena cava system. Figure 1. The short gastric veins direct the splenic outfow toward the Te middle portion of the splenic vein receives gastric fundus; the left gastric vein supplies adequate drainage into the portal trunk. other tributaries: the pancreatic collaterals, and sometimes, in an anatomical variant, the lef gastric vein. Te inferior mesenteric vein usually infows to the most dis- tal part of the splenic vein and it is rarely involved in the collateral pathways. Patients and Methods We reviewed radiological images and clinical re- ports of 15 cases of LSPH observed between 2009 and 2013. Te inclusion criteria were: age between 25 and 65 years; normal liver biochemical tests, including transaminases, and cholestasis and hepatic synthetic function indices; and careful morphological study of the abdomen by US and CT proving complete obstruction of the splenic vein, but normal morphology of the Figure 2. The splenic venous outfow is mainly directed to the left adrenal and renal veins. liver and the portomesenteric venous trunk. Te exclusion criteria were: only partial obstruction of the splenic vein; pre-existing diseases of the liver, spleen, portomesenteric trunk, upper digestive tract other than the pancreas, retroperitoneum and retrop- eritoneal organs; and any previous abdominal surgery. We selected a group of 15 cases comprising 8 men and 7 women aged 47–65 years. In these patients, splenic vein thrombosis was secondary to chronic pancreatitis (4 cases), pancreatic pseudocyst (3 cases), pancreatic body cancer (4 cases) and primary prothrombotic state (4 cases). Results Diferent morphodynamic conditions could be Figure 3. The left gastric vein, fowing into an obstructed splenic vein, identifed. is congested, and it favors the development of gastroesophageal In 9 cases (60%), the splenic venous outfow was varices. www.acesjournal.org Archives of Clinical and Experimental Surgery 213 Manenti A et al.

Figure 4. CT scans demonstrating diferent gastric venous collateral pathways. A: Congestion of the gastroepiploic veins; B: Retrogastric venous collaterals; C: A dilated left gastric vein (arrow). directed toward the gastric fundus by the short gastric Discussion veins, and then to the portal system through the lef We merely included gastric and esophageal varices gastric vein (Figure 1). Tere was no association with as a unique complication of LSPH, although recogniz- splenomegaly or gastroesophageal varices, confrming ing that isolated gastric varices are typical of this dis- hemodynamic equilibrium. Te primary disease was ease [2]. chronic pancreatitis in 3 cases, pancreatic pseudocysts CT allows detailed study of the entire portal venous in 2 cases, tumor of the pancreatic body in 2 cases and system, including the splenic vein and its collaterals, prothrombotic state with thrombosis of the femoroili- with the only limitation being the thinner branches. ac venous trunks in 2 cases. Terefore, if an obstructed splenic vein is discovered, In 3 patients (20%), 1 with chronic pancreatitis, adequate study of its collaterals by cross-sectional imag- 1 with pancreatic pseudocysts, and 1 with prothrom- ing is essential (Figure 4) [5,6]. US does not have an botic state, the collateral venous system involved the equivalent value to CT, as results are sometimes infu- splenorenal or splenoadrenal collaterals, but not the enced by transient hemodynamic conditions and inter- gastroesophageal compartment. Tere was no associa- observer variations. tion with gastroesophageal varices (Figure 2). Te splenic vein receives its main blood supply In the remaining 3 cases (20%), 2 with pancreatic from the spleen and collaterals located in its proximal body cancer and 1 with pro-thrombotic state, the col- portion. Terefore, thrombosis, although initial but in- lateral pathways developed toward the gastric fundus terrupting the blood fow, easily spreads along the vein through the short gastric veins. Te lef gastric vein, by the mechanism of upstream congestion and down- infowing in an anatomical variant into a completely stream stasis. thrombosed splenic trunk, appeared congested and A direct equivalence relation between complete surrounded by many collaterals, blocking adequate ve- obstruction of the splenic vein and secondary gastroe- nous drainage from the stomach. In this last group, we sophageal varices cannot always be verifed because of found LSPH was associated with mild splenomegaly, the diferent features of the collateral pathway. We de- a mean volume increase of 20% and gastroesophageal termined two main anatomo-functional conditions that varices, as demonstrated by CT and by upper digestive prevent the development of gastroesophageal varices. endoscopy (Figure 3). First, the splenic venous outfow is directed through In all cases, the diagnosis of LSPH was incidental the short gastric veins toward the gastric fundus, then during study of the underlying disease, considering arrives at the portal system through the lef gastric vein mild splenomegaly can remain asymptomatic. (Figure 1). We observed no dilatation of the inferior mesen- Second, the main collateral pathway of the splenic teric vein or ectopic abdominal varices. vein develops toward the renal and adrenal veins, linked Archives of Clinical and Experimental Surgery Year 2016 | Volume 5 | Issue 4 | 211-215 Left-sided portal hypertension 214 with the inferior vena cava system (Figure 2). Tis last portal hypertension. Dig Dis Sci 2007;52:1142-9. condition is favored by adhesions between the spleen 3. Sakorafas H, Sarr MG, Farley DR, Farnell MB. Te and the retroperitoneum and by splenomegaly. signifcance of sinistral portal hypertension com- On the contrary, the onset of gastroesophageal plicating chronic pancreatitis. Am J Surg 2000; varices is facilitated by a collateral splenic pathway di- 179:129-33. rected towards the gastric fundus and by its subsequent 4. Wang L, Liu G-J, Chen Y-X, Dong H-P, Wang L-X. congestion. Tis typically happens when the lef gastric Sinistral portal hypertension: clinical features and vein infows, in an anatomical variant, into an obstructed surgical treatment of chronic vein occlusion. Med splenic vein, or when there is association with a portal hy- Princ Pract 2012;21:20-3. pertension condition (Figure 3) [7-11]. Tis last hemo- 5. Agarwal A, Jain M. Multidetector CT portal venog- dynamic situation can be more correctly recognized as a raphy in evaluation of portosystemic collateral ves- complication of generalized portal hypertension. sels. J Med Imag Rad Oncol 2008;52:4-9. We must remember that the spleen collaterals can 6. Sharma M, Rameshbabu CS. Collateral pathways also involve mainly the gastroepiploic and transverse in portal hypertension. J Clin Exp Hepatol 2012;2: colonic veins [12,13]. Tis condition, not observed 338-52. in our series, is more common afer pancreaticoduo- 7. Marn CS, Edgar K, Franvi IR. CT diagnosis of denectomy and spleen-preserving pancreatectomy splenic vein occlusion: imaging feature, etiology, and when performed with splenic vein ligation. It can also clinical manifestation. Abdom Imaging 1995;20:78- cause early postoperative bleeding [14-20]. 81. Te abovementioned anatomo-functional algo- 8. Sabri SS, Saad WEA. Anatomy and classifcation of rithms do not exempt patients, in the case of demon- gastrorenal and gastrocaval shunt. Semin Intervent strated LSPH, from upper digestive endoscopy and Radiol 2011;28:296-302. close follow-up [8-14]. 9. Saad WE. Vascular anatomy and the morphologic Moreover, in patients with bleeding gastroesopha- and hemodynamic classifcation of gastric varices geal varices, especially without signs of liver disease, and spontaneous portosystemic shunts relevant to LSPH has to be considered in the diferential diagnosis, BRTO procedure. Tech Vasc Interv Radiol 2013; and a CT study is mandatory [21]. 16:60-100. Conclusions 10. Zhao LQ, He W, Ji H, Liu P, Li P. 64-row multide- LSPH is a clinical syndrome with diferent aspects tector computed tomography portal venography of and possible complications, especially gastroesophage- gastric variceal collateral circulation. World J Gas- al varices. Currently, in absence of specifc clinical signs, troenterol 2010;16:1003-7. it can also be easily diagnosed by radiological imaging, 11. Rebibo L, Chivot C, Fuks D, Sabbagh C, Yzet T, and it can complicate any abdominal surgery [22-24]. Regimbeau JM. Tree-dimensional computed to- In the case of LSPH, diferent therapeutic strate- mography analysis of the lef gastric vein in pan- gies are possible today: splenic artery embolization, createctomy. HPB (Oxford) 2012;14:414-21. splenectomy and splenectomy plus gastroesophageal 12. Kiyosue H, Ibukuro K, Maruno M, Tamone S, devascularization. Detailed study of the hemodynamic Hongo N, Mori H. Multidetector CT anatomy of conditions associated with this syndrome is necessary drainage routes of gastric varices: a pictorial review. for appropriate treatment. Radiographics 2013;33:87-100. Confict of interest statement 13. Ibukuro K, Ishii R, Fukuda H, Abe S, Tsukiyama Te authors have no conficts of interest to declare. T. Collateral venous pathways in the transverse References mesocolon and greater omentum in patients with 1. Madsen MS, Petersen TH, Sommer H. Segmental pancreatic disease. AJR Am J Roentgenol 2004; portal hypertension. Ann Surg 1986;204:72-7. 182:1125-87. 2. 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Archives of Clinical and Experimental Surgery Year 2016 | Volume 5 | Issue 4 | 211-215