Intrahepatic portosystemic venous shunts: spectrum of CT findings in external and internal subtypes

Aberrant Collaterals in Cirrhosis and Challenges in its Management

Portosystemic collateral formation in cirrhotic patients plays an essential role in the natural history of patients. A thorough understanding of collateral anatomy and hemodynamics in cirrhosis, it is important to envisage diagnosis and outcomes of portal hypertension. The understanding of the patterns of aberrant portosystemic collateral channels has important implications both for the clinician and the interventionist. In this case report, our patient presented to us with the formation of aberrant collaterals at the site of subcostal hernia for which he underwent a mesh repair eight years back. The technical challenges in the management of shunt closure of these aberrant collaterals were discussed.

Esophageal and stomach varices: physiological and anatomical features of formation

Esophageal and stomach varices: physiological and anatomical features of formation

Intrahepatic Portosystemic Shunt via the Right Adrenal Vein in an Asymptomatic Cirrhotic Patient

PURPOSE

Intrahepatic portosystemic shunts (PSSs) draining to the inferior vena cava (IVC) via the right adrenal vein have been reported very rare and all the reported patients presented with hepatic encephalopathy. Here, we present a patient with intrahepatic PSS via the right adrenal vein diagnosed incidentally in the absence of encephalopathy.

CASE PRESENTATION

suspecting nodule on the ultrasound was examined by computed tomography (CT) and magnetic resonance imaging (MRI). A 4 cm in diameter hepatocellular carcinoma (HCC) was detected. In addition to HCC, an abnormal shunt between the right posterior portal vein and the IVC via the right adrenal vein was also detected.

RESULTS

To the best of our knowledge, this is the first case with intrahepatic PSS via the right adrenal vein diagnosed incidentally in the absence of encephalopathy and the fourth case with this abnormal shunt in English literature.

CONCLUSIONS

Intrahepatic PSS via the right adrenal vein is seen very rare. It may be asymptomatic at the time of diagnosis but has the potential to cause various problems later on, especially hepatic encephalopathy. The radiologist must be aware about this abnormal shunt.

[A case of neuronal intranuclear inclusion disease with serial MRI changes observed from before onset of forgetfulness]

A 70-year-old woman presented with a 6-year history of cognitive dysfunction, neurogenic bladder, constipation and recurrent vomiting, and gradual worsening of symptoms. At the first admission to our department, she was also found to have hepatic encephalopathy due to intrahepatic portosystemic shunt. Head MRI revealed abnormal signal intensity at the corticomedullary junction, the splenium of the corpus callosum, and bilateral middle cerebellar peduncles on DWI. She was diagnosed with intranuclear inclusion disease (NIID) based on skin biopsy and genetic testing of NOTCH2NLC. In a retrospective review of serial head MRI findings for ten years, abnormal signal intensity at the corticomedullary junction and the splenium of the corpus callosum on MRI existed prior to the onset of cognitive dysfunction, and expanded gradually. For early diagnosis of NIID, it is important to focus not only on the characteristic high signal intensity at the corticomedullary junction, but also on the signal at the splenium of the corpus callosum from the early stage.

Intrahepatic Portosystemic Shunt in a Young Female: Views from a Developing Country

A young female presented to us with abdominal distension along with pedal edema. She had no prior medical or surgical history apart from a caesarean section done a few years prior. Initial workup showed low hemoglobin, low serum albumin and slight raised ESR. Her LFTs were slightly deranged. Ultrasound abdomen had evidence of portal hypertension along with splenomegaly. While ultrasound hepatic Doppler revealed a portosystemic shunt between the portal vein and the left hepatic vein, with a shunt ratio of 7.1%. CT scan abdomen confirmed these findings and a diagnosis of Type III intrahepatic portosystemic shunt and spleno-renal shunt was made. Since the patient was currently asymptomatic, she was advised regular follow-ups and was managed conservatively.

Neonatal Cholestasis as Initial Presentation of Portosystemic Shunt: A Case Report

Congenital intrahepatic portosystemic shunts are rare in children. Portosystemic venous malformations are characterized by extreme clinical variability. We report a full-term 33-day-old male infant presenting with neonatal jaundice. On physical examination, he had generalized icterus and the liver was palpable 3.5 cm below the right costal margin. He had no other symptoms. Laboratory tests showed AST 632 U/L, ALT 198 U/L, total bilirubin 12.1 mg/dL, conjugated bilirubin 10.2 mg/dL, alkaline phosphatase 753 U/L, GGT 47 U/L and glucose 67 U/L. Colour Doppler ultrasonography showed the left portal vein was more dilated than the right portal branch and communication with dilated left hepatic vein. There was no evidence of portal hypertension, heart failure, hepatopulmonary syndrome and encephalopathy during his hospital stay, so he was discharged from the pediatric department and his parents advised to attend monthly follow-up. Congenital portosystemic shunts are rarely observed in the childhood period.¹ Depending on anatomic characteristics they may be intrahepatic or extrahepatic.² Intrahepatic portosystemic shunts (PSS) are observed between the portal vein and hepatic vein or vena cava inferior.3, 4 Small shunts may close themselves before the age of 2 years.⁵ With the increase in use of imaging methods, diagnosing PSS has become easier, with an increase in the number of cases reported.⁶ Neonatal cholestatis is a frequent complication of PSS.¹ We present a case presenting with neonatal cholestasis diagnosed with congenital intrahepatic PSS.

Understanding the Pathophysiology of Portosystemic Shunt by Simulation Using an Electric Circuit

Portosystemic shunt (PSS) without a definable cause is a rare condition, and most of the studies on this topic are small series or based on case reports. Moreover, no firm agreement has been reached on the definition and classification of various forms of PSS, which makes it difficult to compare and analyze the management. The blood flow can be seen very similar to an electric current, governed by Ohm's law. The simulation of PSS using an electric circuit, combined with the interpretation of reported management results, can provide intuitive insights into the underlying mechanism of PSS development. In this article, we have built a model of PSS using electric circuit symbols and explained clinical manifestations as well as the possible mechanisms underlying a PSS formation.

Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review

The purpose of this article is to describe the various portosystemic collateral pathways pertinent to portal hypertension on multi-detector row computed tomography (MDCT) and their clinical relevance, with special emphasis on the uncommon ones. The knowledge and understanding of the various patterns of portosystemic collateral channels has important implications both for the clinician and the interventionist. MDCT with its advanced post processing capabilities can exquisitely demonstrate these vascular pathways to help in therapeutic decision making.

Teaching points

• Portosystemic collaterals are an important cause of bleeding and hepatic encephalopathy.

• Radiologists should be familiar with the imaging findings to effectively identify them.

• Pre-operative knowledge of portosystemic collaterals is essential to avoid inadvertent vascular injury.

Rare, spontaneous trans-splenic shunt and intra-splenic collaterals with attendant splenic artery aneurysms in an adult patient with compensated cirrhosis and portal hypertension

We present a rare case of spontaneous trans-splenic shunt and intra-splenic collaterals in a patient with liver cirrhosis and portal hypertension. The shunt and presence of cirrhosis and portal hypertension was incidentally detected by abdominal computed tomographic imaging during evaluation for abdominal pain. There has been a single report on the presence of trans-splenic shunt in two children with extra-hepatic portal venous obstruction but no cases that report intra-splenic collaterals: to the best of our knowledge, this is the first reported case of spontaneous trans-splenic shunt in the presence of intra-splenic collaterals and incidental multiple splenic artery aneurysms that developed in an adult with compensated cirrhosis and portal hypertension.

Multidetector CT findings of right intrahepatic portosystemic venous shunt

PURPOSE

To evaluate multidetector CT features of right intrahepatic portosystemic venous shunt (IPSVS).

MATERIALS AND METHODS

Pathways of right IPSVS were evaluated from 20 patients. Diameters of right portal veins were measured in IPSVS patients, 30 cirrhotic and 30 healthy patients.

RESULT

Among 22 IPSVSs, shunt between posterior branch and inferior phrenic vein was most common. Diameters of the posterior branch were larger in IPSVS patients than in other groups.

CONCLUSION

Most right IPSVSs drain to inferior phrenic vein through dilated posterior branch.

Imaging findings in incidental intrahepatic portal venous shunts

OBJECTIVE

The purpose of our study was to describe the imaging findings in incidentally discovered intrahepatic portal venous shunts.

CONCLUSION

Intrahepatic portal venous shunts are uncommon hepatic vascular anomalies that are often not associated with manifestations of liver disease or symptoms. They are most often solitary and in the left hepatic lobe. Identification of 25 intrahepatic portal venous shunts at a single institution over 6 years suggests that they may be more common than previously known and that with an increasing use of imaging, they may be identified more often in the future.