Upper gastrointestinal bleeding secondary to gastric varices due to segmental portal hypertension after Warshaw-type distal pancreatectomy.

Abstract

The Warshaw-type distal pancreatectomy is a surgical technique that preserves the spleen by ligating the splenic vessels while maintaining perfusion through the short gastric vessels and the left gastroepiploic artery. Although generally safe, it may lead to the development of left-sided (sinistral) portal hypertension, with the formation of perigastric collateral circulation and the appearance of gastric varices. While these varices are often asymptomatic, a minority of patients may develop complications such as upper gastrointestinal bleeding.

We present the case of a 38-year-old woman previously treated with a Warshaw-type distal pancreatectomy for mesenteric fibromatosis, who presented with hematemesis and syncope. Endoscopic evaluation revealed gastric varices, and imaging studies confirmed this diagnosis, demonstrating perisplenic collaterals associated with interruption of the splenic venous axis, consistent with postsurgical left-sided portal hypertension.

The patient received initial treatment with cyanoacrylate injection, somatostatin infusion, and blood transfusion, followed by initiation of beta-blocker therapy as secondary prophylaxis. She remained hemodynamically stable without further bleeding. Due to her postoperative vascular anatomy, radiological embolization and other shunt procedures were not feasible. Given the presence of significant thrombocytopenia, elective splenectomy was indicated as definitive treatment, resulting in complete resolution of the condition.

This case highlights a rare but potentially serious complication of the Warshaw technique and underscores the importance of considering sinistral portal hypertension as a cause of gastrointestinal bleeding, even many years after surgery. Individualized management and a multidisciplinary approach are essential for optimal outcomes.

Keywords: upper gastrointestinal bleeding, Gastric varices, Warshaw.