S2392 Diagnosis and Management of Spontaneous Splenorenal Shunts

Abstract

INTRODUCTION: Splenorenal shunts are a rare complication of liver diseases including liver cirrhosis. Diseases of the liver can cause portal hypertension leading to a backflow of blood in the portal circulation and potential formation of a shunt between the splenic and left renal vein. This shunt can cause blood to bypass the liver, leading to less liver perfusion and worsening liver disease. This can cause hepatic encephalopathy due to a buildup of liver toxins adversely affecting the brain. We describe the outcomes of two different patients who developed splenorenal shunts. CASE DESCRIPTION/METHODS: Patient 1 was a 71 year old female who initially presented with periodic bouts of abrupt hepatic encephalopathy. She had been previously diagnosed with cryptogenic cirrhosis and portal hypertension. Head CT showed no brain abnormalities, but abdominal CT revealed a splenorenal shunt. She underwent shunt embolization which resulted in improved cognition and mentation. One year later she again presented to the ER with altered mental status. A CT scan showed a new splenorenal shunt. During embolization, she aspirated with subsequent pneumonia, renal failure, encephalopathy, and hypotension. The patient was moved into hospice care, and she expired three days later. Patient 2 was a 54 year old male with a history of living donor liver transplant for cryptogenic cirrhosis with incidental liver cancer seen on explant. His course was complicated by multiple bouts of acute cellular rejection and encephalopathy. He presented two years after transplant with altered mental state. Head CT and MRI showed no abnormalities, but abdominal CT showed the presence of a splenorenal shunt. He underwent embolization of the shunt without complications. At his follow up visits he has shown marked cognitive improvement and is without confusion since the procedure. He has not had any recurrence of confusion or the splenorenal shunt. DISCUSSION: Splenorenal shunts present added complications for individuals suffering from liver disease. In these cases, the patients developed hepatic encephalopathy as a result of their shunts, and in both cases the doctors initially believed the problem to be with their brains before detailed abdominal imaging. Embolization of the shunts lead to recovery from the hepatic encephalopathy. While the procedure to repair the shunts is effective it is not without risks. Close attention to abdominal imaging in liver patients presenting with encephalopathy is key to proper diagnosis and subsequent management.