Splenorenal Shunt Research Articles

Lessons Learned from Inappropriate Ligation of the Left Renal Vein for a Large Splenorenal Shunt in Living Donor Liver Transplantation

During living donor liver transplantation, a large spontaneous splenorenal shunt (SRS) should be addressed to obtain adequate portal inflow. Various procedures such as direct ligation of the SRS, splenectomy, left renal vein ligation (LRVL), and renoportal anastomosis can be applied to treat a large SRS according to the hemodynamics of the portal flow and anatomic conditions. Of these surgical procedures, LRVL is a simple and effective solution for treatment of a large SRS. However, to perform a LRVL, rigorous evaluation of the recipient`s anatomic and hemodynamic variations is mandatory. In the present case, we ligated the left renal vein to treat a large SRS, which resulted in an unexpected thrombosis of the left renal vein and remaining portal vein stenosis in the SRS. Therefore, we revised our decisions regarding whether the LRVL was properly applied.

Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver transplantation.

Patients with large spontaneous splenorenal shunts (SRSs) prove challenging during liver transplantation (LT), regardless of organizing portal vein (PV) thrombosis. Here, we detail the clinical outcomes of 26 patients who underwent direct ligation of large SRSs during LT. Direct ligation of large SRS was applied in poor portal flow during LT. We performed temporary test clamping of the SRS before direct ligation and applied PV pressure monitoring in patients who showed signs of portal hypertension, such as bowel edema. We retrospectively reviewed and evaluated their clinical outcomes. Among 843 patients who underwent LT between 2010 and 2015, 26 (3.1%) underwent direct ligation of SRS without any intraoperative event. Mean preoperative Model for End-Stage Liver Disease score was 16.7 ± 9.0. The main PV diameter on preoperative computed tomography was 8.3 ± 3.4 mm (range, 3.0-14.0 mm). SRS was easily identified at just below the distal pancreas and beside the inferior mesenteric vein in all patients. Accompanying PV thrombectomy was done in 42.3% of patients. Among 26 patients, massive and prolonged ascites was evident in 15.4% (n = 4) postoperatively. They were all living donor LT recipients with a small PV diameter (4.0-6.7 mm). Except for 1 patient who underwent splenic artery embolization, ascites was tolerable and well controlled by conservative management. There was a 7.7% rate of major complications related to direct ligation, including reoperation due to combined ligation of SRS along with a left renal vein at the confluence. Except for 1 hospital mortality due to sepsis, 25 patients (96.2%) are alive with no evidence of further PV complications. In conclusion, direct ligation of large SRS during LT is a safe and feasible method to overcome the effects of a large SRS. Liver Transplantation 23 899-906 2017 AASLD.

Proximal spleno-renal shunt with retro-aortic left renal vein in a patient with extra-hepatic portal vein obstruction: first case report

BackgroundPresence of retro-aortic left renal vein poses special challenge in creating spleno-renal shunt potentially increasing the chance of shunt failure. The technical feasibility and successful outcome of splenectomy with proximal spleno-renal shunt (PSRS) with retro-aortic left renal vein is presented for the first time. The patient was treated for portal hypertension and hypersplenism due to idiopathic extra-hepatic portal vein obstruction.Case presentationA twenty year old male suffering from idiopathic extra-hepatic portal vein obstruction presented with bleeding esophageal varices, portal hypertensive gastropathy, asymptomatic portal biliopathy and symptomatic hypersplenism. As variceal bleeding did not respond to endoscopic and medical treatment, surgical portal decompression was planned. On preoperative contrast enhanced computed tomography retro-aortic left renal vein was detected. Splenectomy with proximal splenorenal shunt with retro-aortic left renal vein was successfully performed by using specific technical steps including adequate mobilisation of retro-aortic left renal vein and per-operative pressure studies. Perioperative course was uneventful and patient is doing well after 3 years of follow up.ConclusionsPSRS is feasible, safe and effective procedure when done with retro-aortic left renal vein for the treatment of portal hypertension related to extra-hepatic portal vein obstruction provided that attention is given to key technical considerations including pressure studies necessary to ensure effective shunt. Present case provides the first evidence that retro-aortic left renal vein can withstand the extra volume of blood flow through the proximal shunt with effective portal decompression so as to treat all the components of extra-hepatic portal vein obstruction without causing renal venous hypertension.

Prevalence and Clinical Characteristics of Spontaneous Splenorenal Shunt in Liver Cirrhosis: A Retrospective Observational Study Based on Contrast-Enhanced Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) Scans.

BackgroundThis is a retrospective observational study evaluating the prevalence and clinical characteristics of spontaneous splenorenal shunt in liver cirrhosis.Material/MethodsWe included a total of 105 cirrhotic patients who were admitted to our hospital between June 2012 and December 2013 and underwent contrast-enhanced CT and/or MRI scans at admissions. Spontaneous splenorenal shunt was identified. Clinical and laboratory data were compared between cirrhotic patients with and without spontaneous splenorenal shunt.ResultsThe prevalence of spontaneous splenorenal shunt was 10.5% (11/105). The prevalence of hepatic encephalopathy was higher in patients with spontaneous splenorenal shunt than in those without spontaneous splenorenal shunt (18.2% vs. 4.3%, p=0.062), but the difference between them was not statistically significant. The prevalence of acute upper-gastrointestinal bleeding was lower in patients with spontaneous splenorenal shunt than in those without spontaneous splenorenal shunt (0% vs. 18.1%, p=0.205), but the difference between them was not statistically significant. Patients with spontaneous splenorenal shunt had significantly higher Child-Pugh scores (9.50±1.65 vs. 7.43±2.02, p=0.002) and MELD scores (11.26±7.29 vs. 5.67±6.83, p=0.017) than those without spontaneous splenorenal shunt. In-hospital mortality was similar between them (0% vs. 4.3%, p=1.000).ConclusionsSpontaneous splenorenal shunt might be associated with worse liver function in liver cirrhosis, but not with in-hospital mortality.

Complex portal venous inflow reconstruction in liver transplantation: the option of left renal portal vein transposition

Objective: Portal vein thrombosis (PVT) is a technically challenging complication of portal hypertension arising in 25% of liver transplant candidates. Management largely depends on anatomy and extent of the thrombosis. There is a growing need for innovative options for portal inflow reconstruction. In complicated cases where reconstruction options are limited, strategies to avoid the morbidity associated with portocaval transposition should be considered. In these circumstances, a renal-portal transposition may be a unique option for establishing portal inflow. We report a case of a patient who underwent successful transplant by performing a left renal-portal transposition. Methods: Pre-operative CT imaging demonstrated splenorenal varices and a large spontaneous splenorenal shunt. Attempts at intraoperative primary thrombectomy were unsuccessful. The donor portal vein was anastomosed end-to-end to the left renal vein. Portal inflow was measured to be 1.8 liters/minute Results: Successful portal inflow was established by utilizing an enlarged left renal vein for a renal-portal transposition. The patient had an uncomplicated post transplant course. At one year, the patient is doing well with good graft function and patent portal inflow (Figure 1). Conclusion: Patients with portal vein thrombosis manifest various patterns of venous collaterals. Large varices communicating with spontaneous splenorenal shunts can be a viable source of splanchnic venous inflow for portal vein reconstruction. In highly selected patients, a renal-portal transposition is a unique reconstructive option that should be considered as an alternative to performing a portocaval transposition.

Su1483 - Spontaneous Splenorenal Shunts Do not Predict Outcomes in Decompensated Cirrhosis

Su1483 - Spontaneous Splenorenal Shunts Do not Predict Outcomes in Decompensated Cirrhosis

Vascular Diseases of the Spleen: A Review.

Vascular diseases of the spleen are relatively uncommon in the clinical practice. However, the reported incidence has been progressively increasing, probably due to advances in the imaging modalities used to detect them. This disease condition often presents with non-specific clinical manifestations, but can be associated with significant morbidity and mortality. This review article aims to provide updated clinical information on the different vascular diseases of the splenic vasculature—splenic vein thrombosis, splenic vein aneurysm, splenic artery aneurysm, splenic arteriovenous fistula, and spontaneous splenorenal shunt—in order to aid clinicians in early diagnosis and management.

Radiological anatomy of spontaneous splenorenal shunts in patients with chronic liver disease

We evaluated anatomical variations of spontaneous splenorenal shunt (SSRS) and the prevalence of portosystemic shunts in patients with chronic liver disease by CT. A total of 451 patients with chronic liver disease underwent contrast-enhanced computed tomography between October 2010 and April 2011. The prevalence of portosystemic shunts including SSRS and gastrorenal shunt, and the frequency of hepatic encephalopathy were examined. The course of the shunt and the point of confluence with the renal vein of the SSRS were analyzed. SSRSs or gastrorenal shunts were found in 11.1 and 5.0% of the patients, respectively. Anatomical variations were classified into three types according to the point of confluence as follows: type 1=the SSRS joined the inferior phrenic vein (n=33), type 2=the SSRS joined the gonadal vein (n=7), and type 3=the SSRS joined the left renal vein (n=14). The course of the SSRS from the splenic hilum was classified as medial (n=46), posterior (n=2), or anterolateral (n=2). SSRSs were classified into three types depending on the confluence point with the renal vein, and into three types of course. These findings are useful for preoperative information.

Splenectomy during whole liver transplantation: a morbid procedure which does not adversely impact long-term survival

BackgroundIndications for splenectomy (SP) during whole liver transplantation (LT) remain controversial and SP is often avoided because of common complications. We aimed to evaluate specific complications of these combined procedures. MethodsData were retrospectively analysed. Splenectomy was performed in patients with splenorenal shunt and/or splenic artery aneurysms or hypersplenism. Patients undergoing simultaneous transplantation and splenectomy (LTSP group) were matched to a non-splenectomy group (LT group). ResultsBetween 1994 and 2013, we included 47 and 94 patients in LTSP and LT groups, respectively. The LTSP patients had a higher rate of pre-LT portal vein thrombosis (PVT). The LTSP group had a longer operative time and greater blood loss. Mean follow-up was 101 months and 5-year survivals were identical (LTSP 85% vs LT 88%, p = 0.831). Hospital morbidity and rejection incidence were comparable, whereas de novo PVT (34% vs 2%, p < 0.0001) and infection (47% vs 25%, p = 0.014) rates were higher after SP. ConclusionSplenectomy during LT is technically demanding and exposes recipients to a higher thrombosis rate, therefore portal vein patency must be specifically assessed postoperatively. In selected recipients, SP can be performed without increased mortality but at the price of worsening outcome as evidenced by greater risk of infection and PVT.

脾静脈切離を伴う膵頭十二指腸切除術時の遠位脾腎静脈吻合による脾静脈再建

脾静脈切離を伴う膵頭十二指腸切除術時の遠位脾腎静脈吻合による脾静脈再建

頻回の胃静脈瘤破裂に対し splenorenal shunt with splenectomy を選択した肝前性門脈圧亢進症の 1 例

頻回の胃静脈瘤破裂に対し splenorenal shunt with splenectomy を選択した肝前性門脈圧亢進症の 1 例

Interrelationship between insulin resistance and portal haemodynamic abnormality in cirrhosis.

Background: There are only limited data regarding the effect of impaired portal circulation on the glucose metabolism. The study prospectively examined the interrelationship between insulin resistance (IR) and portal haemodynamic abnormality in cirrhosis.Methods: There were 53 cirrhosis patients (61.6 ± 13.0 years) all presenting gastroesophageal varices. Portal haemodynamics by both hepatic venous catheterisation and Doppler ultrasound were examined with respect to the homeostasis model assessment (HOMA)-IR and HOMA2-IR. The IR was defined by HOMA-IR > 3.0 or HOMA2-IR > 2.0.Results: Forty-two patients (79.2%) had collateral vessels, 38 with left gastric vein, 12 with short/posterior gastric vein, 9 with splenorenal shunt, and 3 with inferior mesenteric vein. Multivariate analysis provided significant factors; wedged hepatic venous pressure (HR1.183, 95% CI 1.012-1.383, p=0.035) for HOMA-IR > 3.0, body mass index for HOMA2-IR > 2.0 (HR1.490, 95% CI 1.176-1.888, p=0.001), and collateral flow volume for both HOMA-IR > 3.0 (HR1.007, 95% CI 1.001-1.014, p=0.015) and HOMA2-IR > 2.0 (HR 1.007, 95% CI 1.002-1.013, p=0.009). The best cut-off value of collateral flow volume was 165 ml/min for detecting the HOMA-IR > 3.0 showing area under the receiver operating characteristic curve (AUROC) 0.688 (Odds ratio, 5.33) with sensitivity 70% and specificity 69.6%, and was 165 ml/min for detecting median value of HOMA2-IR > 2.0 showing AUROC 0.698 (odds ratio, 5.7) with sensitivity 75% and specificity 65.5%.Conclusion: There is a close linkage between the IR and impaired portal haemodynamics presented by the collateral development, suggesting the underlying pathogenesis of portal hypertension in cirrhosis patients.

Effect of gastrorenal shunt and splenorenal shunt on endoscopic treatment of gastric varices

Effect of gastrorenal shunt and splenorenal shunt on endoscopic treatment of gastric varices

早期から脾腎短絡路の発達を認めたAMA・M2抗体陰性の無症候性非硬変性原発性胆汁性胆管炎の一例

早期から脾腎短絡路の発達を認めたAMA・M2抗体陰性の無症候性非硬変性原発性胆汁性胆管炎の一例

Homocysteine deteriorates intrahepatic derangement and portal-systemic collaterals in cirrhotic rats.

In liver cirrhosis, the altered levels of vasoactive substances, especially endothelin-1 (ET-1) and nitric oxide (NO) lead to elevated intrahepatic resistance, increased portal-systemic collaterals and abnormal intra- and extra-hepatic vascular responsiveness. These derangements aggravate portal hypertension-related complications such as gastro-oesophageal variceal bleeding. Homocysteine, a substance implicated in cardiovascular diseases, has been found with influences on vasoresponsiveness and angiogenesis. However, their relevant effects in liver cirrhosis have not been investigated. In the present study, liver cirrhosis was induced by common bile duct ligation (BDL) in Sprague-Dawley rats. In acute study, the results showed that homocysteine enhanced hepatic vasoconstriction to ET-1 but decreased portal-systemic collateral vasocontractility to arginine vasopressin (AVP). Homocysteine down-regulated hepatic phosphorylated endothelial NO synthase (p-eNOS) and p-Akt protein expressions. Inducible NOS (iNOS) and cyclooxygenase (COX)-2 expressions were up-regulated by homocysteine in splenorenal shunt (SRS), the most prominent intra-abdominal collateral vessel. In chronic study, BDL or thioacetamide (TAA) rats received homocysteine or vehicle for 14days. The results revealed that homocysteine increased hepatic collagen fibre deposition and fibrotic factors expressions in both BDL- and TAA-induced liver fibrotic rats. Portal-systemic shunting and expressions of mesenteric angiogenetic factors [vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), PDGF receptor β (PDGFRβ) and p-eNOS] were also increased in BDL rats. In conclusion, homocysteine is harmful to vascular derangements and liver fibrosis in cirrhosis.

Graft inflow modulation in adult-to-adult living donor liver transplantation: A systematic review.

Small-for-size syndrome (SFSS) has an incidence between 0 and 43% in small-for-size graft (SFSG) adult living donor liver transplantation (LDLT). Portal hypertension following reperfusion and the hyperdynamic splanchnic state are reported as the major triggering factors of SFSS. Intra- and postoperative strategies to prevent or to reduce its onset are still under debate. We analyzed graft inflow modulation (GIM) during adult LDLT considering the indications, efficacy of the available techniques, changes in hemodynamics and outcomes. A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central. Treatment outcomes including in-hospital mortality and morbidity, re-transplantation rate, 1-, 3-, and 5-year patient overall survival and 1-, 3-, and 5-year graft survival rates, hepatic artery and portal vein flows and pressures before and after inflow modulation were analyzed. From 563 articles, 12 studies dated between 2003 and 2014 fulfilled the selection criteria and were therefore included in the study. These comprised a total of 449 adult patients who underwent inflow modulation during adult-to-adult LDLT. Types of GIM described were splenic artery ligation, splenectomy, meso-caval shunt, spleno-renal shunt, portocaval shunt, and splenic artery embolization. Mortality and morbidity ranged between 0 and 33% and 17% and 70%, respectively. Re-transplantation rates ranged between 0% and 25%. GIM was associated with good survival for both graft and recipients, reaching an 84% actuarial rate at 5 years. Through the use of GIM, irrespective of the technique, a statistically significant reduction of PVF and PVP was obtained. GIM is a safe and efficient technique to avoid or limit portal hyperperfusion, especially in cases of SFSG, decreasing overall morbidity and improving outcomes.

Management of Patients with Paroxysmal Nocturnal Hemoglobinuria (PNH) - Data from the Spanish PNH Registry

Introduction: Patients with PNH often need surgery due to disease-related complications. However, surgery, anesthesia, and possible surgical complications, including inflammation and acidosis, can trigger complement activation, making surgery an important risk factor for hemolysis (Ando K, et al. Ann Hematol 2012;91:1987-8; van Bijnen ST, et al. Eur J Haematol 2011;87:376-8). Here we report data on the clinical management and treatment results of patients with PNH undergoing surgery.Patients and Methods: We collected data on 14 surgical interventions of 11 patients (8 males; age, 25-76 years). All patients had a high prevalence of PNH clone cells (55-99% in PMN) and were receiving eculizumab (ECU). Types of surgery were: 6 laparoscopic cholecystectomies, a transjugular intrahepatic portosystemic shunt, a distal splenorenal shunt, a laparoscopic Achilles allograft ligamentoplasty, a gastrectomy, an emergency appendectomy, and 3 urologic interventions. Ten patients received ECU 900 mg, while one (patient E, surgery 6) received 1200 mg since he had developed hemolysis at a previous surgical intervention (surgery 5). In two cases (patient G, surgery 8; patient H surgery 11), an additional dose of ECU was administered before surgery. Patient H (surgery 11) had developed hemolysis at previous surgical interventions (surgeries 9 and 10). In most cases, either the date of the ECU dose was taken into account when scheduling surgery or the ECU dose was moved forward to coincide with the date of surgery. The time between the last ECU dose and surgery was normally one day (range, 1-8).Results: In nine cases, transfusions were required due to hemorrhagic complications. Patient I (surgery 12) had a thrombotic event leading to acute myocardial infarction one week after surgery. Increased hemolysis was observed (increased LDH and/or presence of hemoglobinuria) in five cases (patients E, H, I and K; surgeries 5, 9, 10, 12 and 14) during the week following surgery. Two of these patients (patients E and H) later underwent additional surgery (surgery 6, and surgeries 10 and 11, respectively). The pre-surgical ECU dose was increased in surgery 6 (patient E) and an extra dose was administrated in surgery 11 (patient H) and no hemolysis was observed. (See Table.)Discussion: Our findings lead us to recommend that the date of surgery and/or the date of the ECU dose should be adapted to allow as short a time as possible between the last dose of ECU and surgery. Preferably, ECU should be administered just before surgery in order to avoid complications. The normal ECU dose could be increased or an extra dose be administered in order to minimize the risk of hemolysis in high-risk patients or in those with a previous history of surgery-related hemolysis. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Challenges in Achieving Hemostasis in Gastroesophageal Variceal Bleeding

A 67-year-old man with cirrhosis secondary to non-alcoholic steatohepatitis (MELD score 16) presented to an outside facility with hematemesis and presyncope. At endoscopy, esophageal varices (EV) without bleeding stigmata and fundal varices with overlying clot were noted. CT showed a large splenorenal shunt (SRS). An attempt at transjugular intrahepatic portosystemic shunt (TIPS) was aborted due to a small portal vein. Upon transfer to our institution, gastroesophageal varices type II (GOV2) per Sarin classification with fibrin plug involving a fundal varix was noted on repeat endoscopy. Due to the high risk of glue embolization via the SRS, a combined interventional radiologic-endoscopic approach consisting of balloon-retrograde transvenous occlusion (BRTOcc) of the SRS with endoscopic cyanoacrylate-Lipiodol (4:1 ratio) injection was performed successfully with obturation of the fundal varices. Further bleeding episodes from EV and from recurrent gastric varices (GV) at 24 weeks prompted coil embolization of GV and TIPS placement. Patient is currently awaiting liver transplantation. This case illustrates several important points. First, the off-label use of cyanoacrylate injection is successful in treating bleeding GV at least in the short-term, but GV do recur. Second, the risk of systemic glue embolization via large SRS can be minimized via the BRTOcc technique. Third, TIPS remains a primary or salvage technique for bleeding gastroesophageal varices when technically feasible.

Encephalopathy Secondary to a Surgical Splenorenal Shunt

Case: A 56 year old female with history of portal hypertension(PH) secondary to scleroderma (CREST variant) complicated by recurrent esophageal variceal treated by a surgical splenorenal shunt and splenectomy six months prior to presentation was admitted for confusion. Vital signs were within normal limits. Physical exam was notable for mild encephalopathy and asterixis. Labs on admission showed alkaline phosphatase of 154 and ammonia of 288; CBC, BMP, and other liver enzymes were normal. A work up for infection including chest X-ray, urinalysis and blood cultures was negative. CT head was negative for any acute process. CT angiography demonstrated widely patent splenorenal shunt with a decrease in size of the portal vein and preferential drainage into the splenic vein; thus causing minimal hepatic clearance. Patient was started on lactulose and rifaximin with immediate improvement of symptoms. Few weeks later, patient underwent an endovascular splenorenal shunt closure by interventional radiology. Post procedural imaging showed patent portal vein flow. Discussion: Hepatic encephalopathy(HE) is a spectrum of reversible neuropsychiatry abnormalities in patients with liver dysfunction. The exact mechanism of HE is not well understood but thought to be due to an increase in the ammonia level. Typically, hyperarammonemia is seen in cirrhotic patients with PH. However, there several etiologies for non-cirrhotic portal hypertension (NCPH) exist. Pathophysiology behind NCPH is vascular in nature and attributed to endothelial cell lesions, intimal thickening, thrombotic obliterations, or scarring of the intrahepatic portal or hepatic venous circulation. One rare cause of NCPH is scleroderma, an autoimmune connective tissue disease with features including vascular injury and fibrosis of skin and various internal organs including the liver. The main treatment of NCPH is aiming to decrease PH; this can be done surgically by creating portosystemic shunts. In our case, a preferential flow into the shunt and away from the portal vein caused decrease hepatic clearance leading to HE. Although surgical shunts are a rare cause of hyperammonemic encephalopathy, this case highlights the importance of a thorough work up in patients presenting with new encephalopathy.

Complicated Portal Cavernoma Cholangiopathy (PCC) in a Patient with Pre-existing TIPS Managed Successfully by Endoscopic Biliary Stenting

PCC is the presence of typical cholangiographic changes in patients with a portal cavernoma due to chronic portal vein thrombosis (PVT), in the absence of other biliary tract diseases. Symptomatic PCC is rare; estimates range between 5-38% of patients with PVT. A 41 year old black woman with a PMH of Hodgkin's lymphoma s/p chemotherapy, isolated factor VII deficiency, complicated cirrhosis s/p TIPS and PVT presented to GI clinic with RUQ pain, dark urine, and acholic stool. Physical examination revealed scleral icterus and RUQ tenderness. The total bilirubin was 3.3 MG/DL, AST 111 U/L, ALT 29 U/L, ALP 603, and INR 1.4. After hospitalization, MRCP and MRI pancreas revealed cavernous portal vein transformation and chronic intrahepatic biliary dilation compatible with PCC. There was narrowing of the biliary system at the confluence secondary to extrinsic compression from cavernous transformation. No CBD dilation or filling defects, pancreatic mass, or PD dilation was noted. ERCP with an occlusion cholangiogram revealed a normal CBD. Unexpected vigorous hemobilia was encountered. Cholangioscopy was limited by fresh blood and clots up to the confluence - a bleeding source could not be identified. Interventional Radiology was consulted. CT angiogram revealed no active bleeding. TIPS was patent. Overnight the patient developed fever, leukocytosis, increasing RUQ abdominal pain, and worsening bilirubin consistent with ascending cholangitis. Antibiotics were initiated. Emergent ERCP was performed. Balloon sweeps of the CBD extracted clots and re-precipitated hemobilia. Cholangiogram revealed turbulence and dilution of contrast at the confluence, suggesting a bleeding source in the vicinity. A fully covered metallic stent was deployed at the confluence. Cholangioscopy was performed through the stent. No active bleeding was noted. The patient did well post procedure with resolution of bleeding, pain, and fever. Treatment of complicated PCC is multi faceted. It involves endoscopic biliary decompression followed by portal decompression (proximal splenorenal shunt or TIPS). Patients who remain symptomatic may undergo biliary drainage surgeries (hepaticojejunostomy or choledochojejunostomy). Hemobilia has been reported rarely after balloon sweeps, attributed to suspected intracholedochal varices and managed successfully by covered metal stents.Figure 1Figure 2Figure 3