Case Report: Clinical Features of Congenital Portosystemic Shunts in the Neonatal Period

Long-term follow-up and transcatheter embolization of extrahepatic congenital portosystemic shunt with shifting hemodynamics

Congenital portosystemic shunt (CPSS) is a rare vascular anomaly in which portal vein blood flows into the systemic circulation without passing through the liver. They occur in approximately 1 in 30,000-50,000 live births. We present an 11-year-old patient with an extrahepatic CPSS managed with long-term follow-up. The initial clinical presentation showed no significant abnormalities. Subsequent assessments revealed slightly elevated ammonia (NH3) and total bile acids (TBAs). Two times angiography at the ages of 2 and 11 years confirmed a shunt between the portal vein and left renal vein, with a gradual shift in blood flow dominance from the celiac artery-splenic vein system to the superior mesenteric artery-superior mesenteric vein system as the patient aged. Due to the risk of complications, transcatheter shunt embolization was performed, utilizing 12 coils to achieve complete shunt embolization. Post-embolization, NH3, and TBA levels normalized, and the patient remained asymptomatic. This case highlights the importance of timing in CPSS intervention, particularly with shifting hemodynamics and underscores the need for further studies on optimal intervention timing in pediatric CPSS.

Congenital portosystemic shunts: experience of a tertiary Tunisian referral center

Congenital portosystemic shunt is a rare condition in which communications between the systemic venous circulation and the portal veins drain blood directly into the systemic circulation. Diagnosis may occur from the prenatal period to adulthood. Nevertheless, diagnosing and treating a congenital portosystemic shunt, particularly in the perinatal stage, remain challenging, as multiple complications can occur. This study aimed to describe the clinical characteristics of 3 cases of congenital portosystemic shunts diagnosed during pregnancy or the neonatal period, the diagnostic procedures, and their outcomes. This study reported 3 cases of full-term newborns with a congenital portosystemic shunt diagnosed at neonatal age. Case 1 was antenatally diagnosed with a congenital portosystemic shunt, which was confirmed postnatally via computed tomography and was associated with malformed ductus venosus and hypoplasia of the right portal vein. Cases 2 and 3 were siblings: a boy who had diffuse hemangiomatosis and a congenital portosystemic shunt complicated with severe persistent pulmonary hypertension and a girl who presented with a congenital portosystemic shunt and Kell alloimmunization. Congenital portosystemic shunts can be detected on prenatal ultrasounds during the etiologic workup of one of its complications or may be incidentally identified later in life. Children with congenital portosystemic shunts may develop various biological abnormalities, such as pulmonary hypertension, hypoxemia, encephalopathy, and liver tumors. A multidisciplinary approach and standardized protocols are required to optimize the management of congenital portosystemic shunts and minimize the short- and long-term consequences of congenital portosystemic shunts.

Case Report: Management of a congenital intrahepatic portosystemic shunt with portal vein aneurysm in a child using 3D computer-assisted partial right hepatectomy

Congenital portosystemic shunts (CPSS) are rare pediatric vascular malformations characterized by abnormal development of the portal vein, which is attributed to incomplete embryonic remodeling of the hepatic and surrounding vasculature. CPSS manifests in two main forms: intrahepatic and extrahepatic. This study details the management of a pediatric patient diagnosed with Congenital Intrahepatic Portosystemic Shunt (CIPS) who was referred to our institution. By using a computer-assisted surgical system, the right hepatectomy was successfully performed, guided by precise intraoperative navigation based on three-dimensional reconstructions of enhanced CT imagery. The patient exhibited a favorable postoperative recovery trajectory, with the absence of complications or recurrence throughout the monitoring period.

Elevated systemic total bile acids escalate susceptibility to alcohol-associated liver disease

Excessive alcohol consumption is a major global health problem. Individuals with alcoholic liver disease often exhibit elevated serum total bile acids (TBAs). Nevertheless, the extent to which high TBA contributes to alcohol-associated liver disease (AALD) remains elusive. To investigate this, wild-type mice were categorized into normal (nTBA) and high (hTBA) TBA groups. Both groups underwent chronic-binge ethanol feeding for 4 weeks, followed by additional weekly ethanol doses. Ethanol feeding worsened AALD in both male and female mice with elevated serum TBA, characterized by liver dysfunction and steatosis. Decreased hepatic expression of genes involved in mitochondrial β-oxidation and lipid transport in ethanol-fed hTBA mice suggests that altered fatty acid metabolism contributed to AALD. Our findings, which represent the first to link high serum TBA to increased AALD susceptibility, underscore the importance of proactive serum TBA screening as a valuable tool for identifying individuals at high risk of developing AALD.

Physiological and behavioural implications of the portosystemic shunt in C57Bl/6J mice

A significant fraction of the popular inbred C57Bl/6J mice show structural and biochemical features of the congenital portosystemic shunt (PSS). How this hepatic abnormality affects physiological and behavioural parameters has not been explored in detail. Here, we confirmed the frequent occurrence of the PSS in C57Bl/6J mice by three different methods. We screened a cohort of 119 C57Bl/6J mice for total bile acids (TBA) in plasma, identified 11 animals (9.2%) with high TBA (>11 µm; 171.1 ± 76.8 µm), and confirmed PSS presence in that subset by magnetic resonance angiography and 1H-magnetic resonance spectroscopy of brain metabolites in the hippocampal area. In addition to the high glutamine and low myo-inositol levels, we detected lower levels of several neurotransmitters and metabolites in the hippocampus, higher brain weight and volume, as well as enhanced brain glucose utilisation in the PSS mice. We also observed differences in peripheral organ weights, haematological cell counts and clinical chemistry parameters in C57Bl/6J mice with and without PSS. Animals with PSS were slightly hyperlocomotive, had better balance on the rotarod, showed altered gait properties, and displayed attenuated fear memory in the fear conditioning test. Furthermore, we revealed a significant alteration of the pharmacokinetic profile of diazepam in C57Bl/6J mice with PSS. Our data support previous reports of hepatic disturbances and demonstrate an altered neurobiological phenotype in C57Bl/6J mice with PSS. Such congenital differences between inbred C57Bl/6J littermates may significantly distort experimental outcomes of pharmacological, behavioural and genetic studies. KEY POINTS: A significant proportion of C57Bl/6J mice, an inbred strain popular in preclinical research, have congenital portosystemic shunts (PSS) that allow venous blood to enter systemic circulation bypassing the liver. In this study, we extended existing knowledge of PSS consequences, particularly with respect to the effects on brain structure and function. We demonstrated that C57Bl/6J mice with PSS differ from their normal counterparts in brain size and contents of several neuroactive substances, as well as in peripheral organ weights, rate of glucose utilisation, blood cell counts and blood clinical chemistry parameters. C57Bl/6J mice with PSS showed altered locomotor behaviour, performed worse in a memory test and had abnormal blood pharmacokinetics of a benzodiazepine drug after a single administration. PSS presence may significantly complicate the interpretation of experiments in C57Bl/6J mice; therefore, we propose that before their use in biomedical studies, these mice should be screened with a simple blood test.

Off-label use of muscular VSD device for closure of a rare congenital portosystemic shunt

BACKGROUND

Congenital portosystemic shunt (CPSS) is a vascular malformation in which portal blood drains toward the systemic circulation, leading to pulmonary hypertension.

CASE PRESENTATION

A 10-year-old patient was brought for evaluation because of dyspnea on exertion. Echocardiography revealed a pulmonary hypertension of 75 mmHg, and multi-slice CT angiography revealed the presence of a CPSS. Closure was finally implemented using a muscular ventricular septal defect device. Follow-up of the patient revealed a gradual decline in pulmonary hypertension.

CONCLUSIONS

CPSS is an overlooked cause of reversible pulmonary hypertension (PH). Closure of such lesions and reversal pulmonary hypertension are possible via catheterization. The preferred device type depends largely on the intervening team. Plugs are the first choice for interventional radiologists, while ventricular and atrial septal occluder devices and duct occluders are preferred by pediatric cardiologists.

Abnormal glucose homeostasis and fasting intolerance in patients with congenital porto-systemic shunts

In physiological glucose homeostasis, the liver plays a crucial role in the extraction of glucose from the portal circulation and storage as glycogen to enable release through glycogenolysis upon fasting. In addition, insulin secreted by the pancreas is partly eliminated from the systemic circulation by hepatic first-pass. Therefore, patients with a congenital porto-systemic shunt present a unique combination of (a) postabsorptive hyperinsulinemic hypoglycaemia (HH) because of decreased insulin elimination and (b) fasting (ketotic) hypoglycaemia because of decreased glycogenolysis. Patients with porto-systemic shunts therefore provide important insight into the role of the portal circulation and hepatic function in different phases of glucose homeostasis.

Reactive hypoglycemia owing to an intrahepatic congenital portosystemic shunt in an older patient

An 85-year-old woman was admitted to our hospital because of hypoglycemia and impairment of consciousness several hours after breakfast. Because the hypoglycemia predominantly occurred 2-4 h after meals, we diagnosed reactive hypoglycemia. An oral glucose tolerance test showed prolonged hyperinsulinemia following the postprandial hyperglycemia, with a subsequent rapid decrease in blood glucose concentration. The post-stimulus plasma C-peptide concentration was relatively low compared to the plasma insulin concentration. Abdominal computed tomography revealed an intrahepatic congenital portosystemic shunt (CPSS). On the basis of these findings, we concluded that the reactive hypoglycemia was induced by the CPSS, via a reduction in hepatic insulin extraction. Treatment with an alpha-glucosidase inhibitor resolved the reactive hypoglycemia. CPSS comprises anomalous vascular connections between the portal vein and the systemic venous circulation, and reactive hypoglycemia is a rare complication of this malformation, which has most frequently been reported in children, with only a few cases reported in adults. However, this case indicates that even in adult patients, imaging studies should be conducted to rule out CPSS as the cause of the reactive hyperglycemia.

Congenital intrahepatic portosystemic shunt with spontaneous resolution in a newborn with severe fetal growth restriction

Owing to the advances in ultrasound, there are increasing reports of intrahepatic portosystemic shunt (IPSS) diagnosis in utero. However, few neonatal cases of IPSS diagnosed by abdominal ultrasonography screening at birth have been reported. This case demonstrated abdominal ultrasonography at birth was useful for the early detection of congenital IPSS.

Prenatal ultrasonographic features and follow-up outcomes of 19 cases of congenital intrahepatic portosystemic venous shunts diagnosed during the foetal period

Background

To investigate the prenatal ultrasonographic features and case characteristics of the congenital intrahepatic portosystemic venous shunt (IHPSS) diagnosed during the foetal period and analyse its prognosis.

Methods

We conducted a retrospective cohort study of patients diagnosed with IHPSS between 2016 and 2021. IHPSS was defined as an abnormal connection between the foetal intrahepatic portal and the hepatic veins.

Results

In this study, 19 foetuses were identified, including 12 cases of single shunt and 7 cases of multiple shunts, with a gestational age of 33.8 ± 4.5 (range 25–40) weeks at diagnosis. In the single-shunt group, the origin position of the shunts was all from the left branch of the portal vein (LPV), whereas in the multiple-shunt group, the origin position of the shunts was from the LPV in six cases. Common concomitant intrauterine abnormalities of IHPSS include foetal growth restriction (47.4%) and foetal cardiac enlargement (21.1%). The postnatal manifestations of IHPSS include biochemical abnormalities (increased gamma-glutamyl transferase and bilirubin levels), neonatal hypoglycaemia, neonatal hyperammonaemia, pulmonary hypertension, multiple intrahepatic hyperechoic nodules, and cutaneous haemangiomas. Spontaneous closure of shunts occurred in ten cases, and the mean time to shunt closure was 8.1 months (1–28 months).

Conclusions

Most IHPSS found during the foetal period is located in the left branch of the portal vein, and the gestational age at diagnosis is usually in the late second or third trimester. Spontaneous closure of shunts can occur in most live births, and the prognosis is good.