S2344 An Extraordinary Cause of Non-Cirrhotic Portal Hypertension and Gastric Varices—Splenic Arteriovenous Fistula
Bibliographic record
Abstract
Introduction: Splenic arteriovenous (AV) fistulas are exceedingly rare. To our knowledge, this is the first occurrence of splenic AV fistulas leading to development of non-cirrhotic portal hypertension and gastric varices. Case Description/Methods: A 33-year-old male with no past medical history presented with a few months’ history of fatigue and upper abdominal discomfort, with no history of overt gastrointestinal bleeding. Laboratory tests revealed a low hemoglobin level of 74 g/L and ferritin of 3.4 ug/L with normal liver function tests. An esophagogastroduodenoscopy (EGD) revealed a cluster of isolated gastric fundal varices with stigmata of adherent clots, which was confirmed on endoscopic ultrasound. A FibroScan measured liver stiffness at 4.2 kilopascals indicating no fibrosis and chronic liver disease workup for viral hepatitis, Wilson’s, autoimmune hepatitis, and alpha-1-antitrypsin deficiency were negative. The patient denied any history of significant alcohol use. Computerized tomography (CT) of his abdomen and pelvis revealed a dilated portal and splenic vein suggestive of portal hypertension, with no thrombosis. There was hypoattenuation of the spleen posteriorly, concerning for infarct. There was a fistula between the splenic artery and vein, and a large saccular splenic artery aneurysm (SAA) measuring approximately 2.3 x 3.2 x 3.2 cm. There was no thrombus within the portal system vasculature. The patient underwent laparoscopic splenectomy and resection of the SAA. A repeat EGD 8 months following the surgery showed complete resolution of the gastric varices. Discussion: Splenic AV fistulas are exceedingly rare. The majority occur after rupture of an SAA. Splenic AV fistulas can also be traumatic, congenital, or infectious in origin. In our case, increased blood flow through the splenic AV fistula likely led to the development of the SAA as well as the patient’s non-cirrhotic portal hypertension and gastric varices. While the development of SAA due to splenic AV fistula has been observed in two previous case reports, our case report is the first documented occurrence of gastric varices secondary to splenic AV fistula. Given the rarity of splenic AV fistulas and SAA, there are no published guidelines on the management of these clinical entities. Different approaches include surgical/laparoscopic resection, ligation, as well as endovascular techniques. The optimal approach will depend on various factors including patient comorbidities, size of the SAA, and location of the AV fistulas.Figure 1.: A) Computerized tomography revealing a splenic arteriovenous fistula (yellow arrow) with early enhancement of the splenic vein from the shunt (blue arrow) and a large saccular splenic artery aneurysm (red arrow). B) Computerized tomography revealing a splenic arteriovenous fistula C) Reconstructed image showing a diffusely enlarged splenic artery with perihilar aneurysm along with diffusely aneurysmal splenic vein outflow beyond fistulas.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.003 | 0.002 |
| Insufficient payload (model declined to judge) | 0.009 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".