Treatment of Splenic Varices

Diagnostic Approach

Cross-sectional imaging (CT or MRI) is essential to determine the underlying cause of splenic varices, particularly to identify splenic vein occlusion or thrombosis 1, 3
Contrast-enhanced imaging helps distinguish between varices caused by portal hypertension versus those caused by splenic vein occlusion 2
Hepatic wedge pressure measurements can help determine if significant portal hypertension is present 1

The American College of Radiology recommends splenic vein recanalization as the first-line treatment for splenic varices due to splenic vein occlusion, with excellent long-term outcomes and no recurrence of bleeding 1, 2, 4
Partial splenic embolization is a highly effective alternative when recanalization isn't possible, decreasing flow through varices by reducing splenic volume 1, 2, 4, 5
Splenectomy is a definitive treatment that removes the source of blood flow and pressure to varices, with a 100% success rate in controlling bleeding and no recurrence 1, 3, 4
TIPS (Transjugular Intrahepatic Portosystemic Shunt) is effective for both gastric and esophageal varices in portal hypertension, diverting portal flow away from varices 1, 6
BRTO (Balloon-occluded Retrograde Transvenous Obliteration) requires a gastrorenal shunt for technical feasibility, but may increase risk of esophageal variceal hemorrhage 1, 2, 6

Obtain cross-sectional imaging to determine if splenic varices are due to splenic vein occlusion/thrombosis, portal hypertension, or combined etiology 1, 3
For splenic vein occlusion, attempt splenic vein recanalization if technically feasible, or consider partial splenic embolization or splenectomy 1, 3, 4
For portal hypertension-related varices, consider TIPS for refractory bleeding, and combine endoscopic therapy with pharmacological management 1, 3

Failure to obtain cross-sectional imaging may lead to misdiagnosis of the underlying cause 3
Endoscopic management alone is inadequate for long-term control of bleeding due to splenic vein occlusion 3
Occlusion of the splenic vein segment between the main portal vein and inferior mesenteric vein may result in portal vein thrombosis 4
TIPS creation alone should not be performed in the presence of portal vein occlusion 5
In patients with peristomal varices, TIPS appears more effective than sclerotherapy, but local therapy may serve as a bridge to definitive treatment 7