title: Puzzles in practice: splenic vein thrombosis.
abstract: This report details a 58-year-old gentleman who presented to his outpatient primary care physician's clinic several times over four weeks for ongoing epigastric pain radiating into his left flank, dry heaving, and constipation. He was presumed to have gastritis at each visit and prescribed escalating doses of proton pump inhibitors. Due to the unrelenting pain, he eventually was admitted to the hospital and diagnosed with splenic vein thrombosis after computed tomography imaging of the abdomen. Our literature search revealed that pancreatic pathology is overwhelmingly the contributing factor to splenic vein thrombosis. Our patient had prominent collateral vasculature, suggesting that his splenic vein thrombosis was chronic in nature and likely the cause of his ongoing abdominal pain. Splenic vein thrombosis is an uncommon cause of abdominal pain, but one that should be included in the treating physician's differential diagnoses when abdominal pain is ongoing despite medical therapy. Although he had no evidence of initial findings on radiography, our patient was eventually diagnosed with biopsy-proven pancreatic cancer. Our case report demonstrates how patients presenting with persistent or worsening abdominal pain despite the use of proton pump inhibitors or other acid reducing agents and potential 'red flag' findings such as decreased appetite and weight loss should be worked up for other potential sources of abdominal pathology.
authors.affiliation: a Family Medicine Residency , Moses Cone Health System Ringgold standard institution , Greensboro , NC , USA.
authors.forename: Brittany
authors.initials: B
authors.lastname: McIntyre
authors.affiliation: a Family Medicine Residency , Moses Cone Health System Ringgold standard institution , Greensboro , NC , USA.
authors.forename: Melanie
authors.initials: M
authors.lastname: Marsh
authors.affiliation: a Family Medicine Residency , Moses Cone Health System Ringgold standard institution , Greensboro , NC , USA.|b Department of Family Medicine , University of North Carolina at Chapel Hill School of Medicine Ringgold standard institution , Chapel Hill , NC , USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Walden
mesh_terms: D015746:Abdominal Pain / Q000209:etiology*; D000230:Adenocarcinoma / Q000150:complications* / Q000175:diagnosis; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000150:complications* / Q000175:diagnosis; D013162:Splenic Vein; D014057:Tomography, X-Ray Computed; D020246:Venous Thrombosis / Q000000981:diagnostic imaging / Q000209:etiology*; D015431:Weight Loss
keywords: Primary care; abdominal imaging; abdominal pain; medical education