Development of large spleno-adreno-renal shunt after endoscopic sclerotherapy

Endoscopic sclerotherapy is now a well-established form of treatment for bleeding esophageal varices. However, it is not known what effect obliteration of varices has on the development of natural portosystemic shunts. We have studied 15 patients bleeding from esophageal varices due to extrahepatic portal venous obstruction with splenoportovenography, before and after endoscopic obliteration of varices. A splenorenal (natural) shunt was defined when the contrast, injected into the spleen, immediately revealed the inferior vena cava. Such shunts were seen in 6 (40%) of 15 patients after the obliteration of esophageal varices and with a mean interval between the two sessions of splenoportovenography of 23.5 mo. In contrast, none of the 13 patients with bleeding due to extrahepatic portal venous obstruction developed splenorenal shunts (p < 0.05) in the absence of treatment over a mean period of 40.8 mo. After obliteration, reappearance of esophageal varices requiring sclerotherapy was observed only in patients who did not develop shunts (p < 0.05). In conclusion, natural splenorenal shunts were seen frequently in a group of patients with extrahepatic portal venous obstruction observed for 23.5 mo who also underwent sclerotherapy. It appears that splenorenal shunts result from sclerotherapy, and protect patients from rebleeding and recurrence of varices.