Fundal variceal bleeding after correction of portal hypertension in patients with cirrhosis

Background: Management of fundal variceal bleeding is challenging. Generally, a portal pressure of greater than 12 mm Hg is required for bleeding to occur, but fundal variceal bleeding persists in some patients despite adequate portal decompression. Methods and observations: Five patients with cirrhosis evaluated for upper GI hemorrhage from fundal varices underwent upper endoscopy followed by angiography, which documented a spontaneous splenogastrorenal shunt. Observations: All patients bled at portal pressures of less than 12 mm Hg. Despite correction to values of 0 to 7 mm Hg, bleeding recurred in 4 of 5 patients, 3 of whom required repeated embolization sessions because of reformation of the splenogastrorenal collateral. Conclusions: Hemodynamically significant bleeding can occur from gastric fundal varices supplied by a splenogastrorenal collateral despite low portal venous pressure. Furthermore, portal decompression alone does not prevent recurrent bleeding via this collateral. Selective catheterization of the splenic vein is often needed to document its presence. To tailor effective therapy, accurate recognition of this collateral and its hemodynamic features are essential.