Hepatobiliary and Pancreatic: Inferior mesenteric vein‐left gonadal vein shunt aggravating hepatic encephalopathy

Abstract

In cirrhosis, the development of hepatic encephalopathy is largely determined by the function of residual hepatocytes and by the extent of vascular collaterals that divert portal blood to the systemic circulation. These portosystemic shunts can be categorized into intrahepatic and extrahepatic types. Common extrahepatic shunts involve gastroesophageal, gastrorenal, splenorenal and paraumbilical vessels. Under most circumstances, the presence of hepatic encephalopathy is a relative contraindication to the insertion of a transjugular intrahepatic portosystemic shunt (TIPS). However, in the patient described below, TIPS permitted closure of an unusual shunt that was followed by improvement in encephalopathy. In 2011, a woman, aged 47, was admitted to our hospital with episodes of drowsiness attributed to hepatic encephalopathy. She was known to have hepatitis B with advanced cirrhosis (ChildPugh class C). In 2006, she was treated medically for a major gastrointestinal bleed attributed to esophageal varices but there were no subsequent episodes of bleeding. Medical treatment for hepatic encephalopathy had included dietary protein restriction, lactulose, branched-chain amino acids and a course of rifaximin. On examination, she had several spider nevi and peripheral edema. An abdominal ultrasound study and a contrast-enhanced computed tomography scan showed that the portal vein was relatively narrow. However, the splenic vein, inferior mesenteric vein, left renal vein and left gonadal vein were markedly dilated. Subsequently, a catheter was passed into the left renal vein through the inferior vena cava. The injection of contrast revealed dilatation of the left renal vein and left gonadal vein and a varicose shunt between the left gonadal vein and the left inferior mesenteric vein. A transjugular intrahepatic portosystemic shunt was then placed within the liver to reduce the portal pressure. Direct portography at the time of insertion of the stent (Figure 1) shows the stent (black arrowhead), the splenic vein (white arrowhead), the inferior mesenteric vein (solid arrow) and the varicosity (dotted arrow) linking the inferior mesenteric vein to the left gonadal vein. The shunt was successfully embolized using coils (Figure 2). The patient has now been followed for 4 months without a recurrence of encephalopathy and without dietary or drug therapy. Patency of the portosystemic shunt was confirmed by an ultrasound study.