Man with tarry stools.

CASE PRESENTATION

A 56‐year‐old man presented to the emergency department because of tarry stools during the previous 2 days. Physical examination revealed mild splenomegaly. Laboratory tests confirmed microcytic anemia with a hemoglobin level of 6 g/dL. Blood transfusion was performed. Point‐of‐care ultrasound showed an absence of fluid in the Morrison pouch, but showed clusters of dilated anechoic cystic structures along an enlarged spleen (Figure 1, left; Video E1). Color doppler showed vascular flow signals between the spleen and left kidney (Figure 1, right; Video E2). Computed tomography confirmed typical lienorenal varices (Figure 2). Terlipressin was administered, and emergent esophagogastroduodenoscopy was performed with ligation of spurting esophageal varices. The patient was successfully discharged to the hepatology clinic with follow‐up.

FIGURE 1

Ultrasonography performed in a coronal view at left flank near the splenorenal level showed clusters of dilated anechoic cystic structures along an enlarged spleen (left panel). Color doppler showed vascular flow signals within the anechoic structures between the spleen and left kidney (right panel, arrows). SP, spleen

FIGURE 2

Computed tomography of the abdomen at the arterial phase showed typical lienorenal varices located in the lienorenal ligament between the spleen and left kidney (arrows)

DIAGNOSIS

Lienorenal varices caused by portal hypertension

In patients with portal hypertension (PH), spontaneous portosystemic collateral plays a decompressive role to prevent the formation of esophageal varices. Portosystemic collaterals can manifest as dilated gastrorenal, paraumbilical, or paraduodenal veins or even manifest at distal sites. Ultrasound visibility of these collateral venous dilatations depends on the habitus and bowel gas of the patient. Lienorenal varices are the dilatation of vessels in the lienorenal ligament; they serve as a diagnostic hallmark of PH. Located between the spleen and kidney, lienorenal varices are more easily recognized than other collateral veins. Because splenomegaly is a sensitive but nonspecific sign of PH, identifying other signs of PH may avoid the pitfall of treating varices as an ulcer bleeding.

Supporting Information

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Supporting Information

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