The challenging diagnosis of sinistral portal hypertension in a patient with liver cirrhosis: a case report and literature review.

Background: Left-sided portal hypertension (LSPH) is commonly associated with pancreatic disease and typically manifests with gastrointestinal bleeding, but not with ascites or hypoalbuminemia. The coexistence of LSPH with liver cirrhosis complicates diagnosis and management, as standard imaging often fails to identify the underlying cause of portal hypertension-related complications. Case presentation: We report a case of a 59-year-old man with decompensated alcohol-related cirrhosis and prior pancreatic surgery, who presented with recurrent gastrointestinal bleeding, severe hypoalbuminemia, and treatment-refractory ascites, all of which persisted despite placement of a transjugular intrahepatic portosystemic shunt (TIPS). Diagnostic work-up included repeated imaging and hemodynamic measurements. Importantly, invasive splenoportography was the only approach that allowed the detection of a hemodynamically significant splenic vein stenosis, and subsequent percutaneous transluminal angioplasty (PTA) led to rapid clinical improvement. Key finding: Standard imaging failed to detect a splenic vein stenosis, which was identified only by invasive phlebography performed via the already placed TIPS. Following PTA, ascites resolved, serum albumin normalized, and no further gastrointestinal bleeding occurred. To our knowledge, this is the first case report describing the full reversal of such a constellation of symptoms after treatment of splenic vein stenosis. Conclusion: This case demonstrates that splenic vein stenosis can cause both hemorrhagic and non-hemorrhagic complications in patients with cirrhosis. Recognition and interventional treatment of LSPH may reverse refractory ascites and hypoalbuminemia, highlighting the importance of high clinical suspicion and invasive evaluation in complex portal hypertension cases.