Effects of combined splenorenal shunt devascularization and devascularization only on hemodynamics of the portal venous system in patients with portal hypertension

Shunt and devascularization have totally different effects on hemodynamics of the portal venous system , and the actual results of combined shunt and devascularization should be determined by more clinical observations. This study aimed to evaluate effects on hemodynamics of the portal venous system after conventional spleno-renal shunt combined with pericardial devascularization and pericardial devascularization only. METHODS: In 20 patients who had received conventional splenorenal shunt combined with pericardial devascularization(CP) and 18 who had received pericardial devascularization and splenectomy (PCDV), hemodynamic parameters of the portal venous system were studied by magnetic resonance angiography 1 week before and 2 weeks after operation. Free portal pressure was detected continuously by a transducer during the operation. RESULTS: Compared to the preoperative data, a decreased flow of the portal vein (PVF) (563.12±206.42 ml/min vs 1080.63±352.85 ml/min, P<0.05), a decreased diameter of the portal vein (PVD) (1.20±0.11 cm vs 1.30±0.16 cm, P<0.01 ), a decreased free portal preasure ( FPP ) (21.50±2.67 mmHg vs 29.88±2.30 mmHg, P<0.01) and an increased flow of the superior mesenteric vein (SMVF) (1105.45±309.03 ml/min vs 569.13±178.46 ml/min, P < 0.05) were found in the CP group after operation; a decreased PVD (1.27±0.16 cm vs 1.40±0.23 cm, P<0.05), a decreased PVF (684.60±165.73 ml/min vs 1175.64±415.09 ml/min, P<0.05), a decreased FPP (24.40±3.78 mmHg vs 28.80±3.56 mmHg, P<0.05) and an increased SMVF (697.91+121.83 ml/min vs 521.30±115.82 ml/min, P<0.05) were found in the PCDV group. After operation, the PVF of CP group (563.12±206.42 ml/min vs 684.60±165.73 ml/min, P>0.05) was not decreased significantly while FPP (21.50±2.67 mmHg vs 24.40±3.78 mmHg, P< 0.01) was decreased significantly as compared with that of the PCDV group. PVF and FPP could be decreased by both surgical procedures, but the effect of decreasing FPP is much better in the combined procedures than in PCDV. Since there is no significant difference in PVF between the two groups, the combined procedures could integrate advantages of shunt with those of the devascularization, maintaining the normal anatomy structure of the hepatic portal vein, and should be one of the best choices for patients with PHT when surgical interventions are considered.

Novel therapy for non-cirrhotic hyperammonemia due to a spontaneous splenorenal shunt

Spontaneous splenorenal shunts in the absence of cirrhosis have rarely been reported as a cause hyperammonemia with encephalopathy. Several closure techniques of such lesions have been described. Here we report a case of a patient with no history of liver disease who developed significant confusion. After an extensive workup, he was found to have hyperammonemia and encephalopathy due to formation of a spontaneous splenorenal shunt. There was no evidence of cirrhosis on biopsy or imaging and no portal hypertension when directly measured. The shunt was 18 mm and too large for embolization so the segment of the splenic vein between the portal vein and the shunt was occluded using an Amplatzer plug. Thus, the superior mesenteric flow was directed entirely to the liver. After interventional radiology closure of the shunt using this technique there was complete resolution of symptoms.The case represents the first report of a successful closure of splenorenal shunt via percutaneous embolization of the splenic vein with an amplatzer plug using a common femoral vein approach.

Unsatisfactory outcomes of prolonged ischemic priapism without early surgical^shunts： our clinical experience and a review of the literature

Ischemic priapism is a rare occurrence which can cause severe erectile dysfunction （ED） without timely treatment. This retrospective study reports our experience in treating prolonged ischemic priapism and proposes our further considerations. In this paper, a total of nine patients with prolonged ischemic priapism underwent one to three types of surgical shunts, including nine Winter shunts, two AI-Ghorab shunts and one Grayhack shunt. During the follow-up visit （after a mean of 21.11 months）, all patients＇ postoperative characters were recorded, except one patient lost for death. Six postoperative patients accepted a 25-mg oral administration of sildenafil citrate. The erectile function of the patients was evaluated by their postoperative 5-item version of International Index of Erectile Function Questionnaire （IIEF-5）, which were later compared with their premorbid scores. All patients had complete resolutions, and none relapsed. The resolution rate was 100%. Seven patients were resolved with Winter shunts, one with an AI-Ghorab shunt and one with a Grayhack shunt. The mean hospital stay was 8.22 days. There was only one urethral fistula, and the incidence of postoperative ED was 66.67%. Four patients with more than a 72-h duration of priapism had no response to the long-term phosphodiesterase type 5 （PDE-5） inhibitor treatment. These results suggest that surgical shunts are an efficient approach to make the penis flaccid after prolonged priapism. However, the severe ED caused by prolonged duration is irreversible, and long-term PDE-5 inhibitor treatments are ineffective. Thus, we recommend early penile prosthesis surgeries for these patients.

Renoportal anastomosis in living donor liver transplantation with prior proximal splenorenal shunt

For transplant surgeons, end-stage liver disease with portal venous thrombosis and a previous splenorenal shunt(SRS) is a significant challenge during liver transplantation. Thrombosis of the portal vein can be corrected by surgical interventions, such as portal venous thrombectomy or surgical removal of the thrombosed portal vein. Even also placement of a graft between the mesenteric vein and the graft portal vein can be performed. If these maneuvers fail, a renoportal anastomosis(RPA) can be performed to achieve adequate graft inflow. A 51-year-old male patient who had a history of proximal SRS and splenectomy underwent living donor liver transplantation(LDLT) due to cryptogenic cirrhosis. LDLT was performed with RPA using a cadaveric iliac vein graft. The early postoperative course of the patient was completely uneventful and he was discharged 20 d after transplantation. To the best of our knowledge, this was the first patient to receive LDLT with RPA after surgical proximal SRS and splenectomy.

Fathal pulmonary hypertension after distal splenorenal shunt in schistosomal portal hypertension

Mansonic schistosomiasis is the main cause of portal hypertension in Brazil. Hepatosplenic (HS) form is manifested by hepatomegaly mainly on the left hepatic lobe associated with large splenomegaly and bleeding due to esophageal varices with high mortality rates.

Ductus Arteriosus Stent Compared with Surgical Shunt for Infants with Ductal-Dependent Pulmonary Blood Flow: A Systematic Review and Meta-Analysis

The aim of this study was to perform a systematic review and meta-analysis to evaluate the safety and efficacy of ductus arteriosus stent(DAS)compared with surgical systemic-pulmonary artery shunt(SPS)in patients with ductal-dependent pulmonary blood flow.A literature search was conducted in PubMed,Embase,and the Cochrane Library databases from their inception to December 2020.Two reviewers independently screened the articles,evaluated the quality of the articles,and collected the data.Meta-analyses were conducted using fixed and random effects models.We used the I-square(I2)test to examine heterogeneity and the funnel plot Egger’s test was used to test for publication bias.We analyzed nine studies including 842 patients were included in the present study(DAS:n=295;SPS:n=547).There was a benefit in favor of DAS group for medium-term mortality(RR,0.63;95%CI,[0.40,0.99];P=0.91,I^(2)=0%).DAS group demonstrated a reduced risk for complications compared with SPS(RR,0.46;95%CI,[0.29,0.72];P=0.78,I^(2)=0%).There was an increased risk for unplanned reintervention for DAS(RR,1.77;95%CI,[1.42,2.20];P=0.61,I2=0%).DAS demonstrated shorter mean intensive care unit length of stay(MD,–5.12;95%CI,[–7.33,–2.91];P=0.005,I^(2)=76%).There was also demonstrated higher postprocedure oxygen saturation for SPS over DAS(MD,1.78;95% CI,[0.92,2.64];P=0.46,I2=0%).There was no difference between the two groups in terms of mortality within 30 days,Nakata Index,and hospital length of stay.Conclusions:In terms of initial palliative surgical in the ductal-dependent pulmonary blood flow,DAS demonstrated a lower risk of medium-term mortality,lower risk of complications,higher risk of unplanned reintervention,shorter ICU length of stay,and higher postprocedure oxygen saturation compared with SPS.

Priapism secondary to chronic myeloid leukemia treated by a surgical cavernosa-corpus spongiosum shunt: Case report

Priapism secondary to chronic myeloid leukemia(CML)is rarely observed in the clinic.Here,we present an 18-year-old patient with priapism for over 72 h due to hyperleukocytosis.Emergent interventions such as therapeutic aspiration and intracorporal injection of phenylephrine failed before a surgical corpora cavernosa-corpus spongiosum shunt was inserted to relieve symptoms.During hospitalization,bone marrow aspiration confirmed the diagnosis of CML.

Progress and Prospects of Surgical Treatment of Portal Hypertension

Portal hypertension is a group of syndrome characterized by splenic hyperfunction, esophageal and gastric varices and ascites caused by abnormal portal vein hemodynamics. Among them, upper gastrointestinal bleeding caused by esophageal and gastric varices is the most dangerous complication, which often threatens the lives of patients. After half a century of development, the treatment of portal hypertension is divided into two categories: medical drug therapy, endoscopic therapy and surgical treatment. With the understanding of portal hypertension and the continuous development of medical technology, the surgical operation of portal hypertension has also been greatly improved, reducing postoperative complications and improving the quality of life of patients after operation. However, at present, there is no surgical method that can completely cure portal hypertension. This article reviews the progress of surgical treatment of portal hypertension in recent years, in order to provide reference for the surgical treatment of portal hypertension.

Evaluation of surgical procedure selection based on intraoperative free portal pressure measurement in patients with portal hypertension

BACKGROUND: Various surgical procedures can be used to treat liver cirrhosis and portal hypertension. How to select the most appropriate procedure for patients with portal hypertension has become a difficult problem. This study aimed to analyze the relationship between the value of intraoperative free portal pressure (FPP) and postoperative complications, and to explore the significance of intraoperative FPP measurement with respect to surgical procedure selection. METHODS: The clinical data of 187 patients with portal hypertension who received pericardial devascularization and proximal splenorenal shunt combined with devascularization (combined operation) at the Department of General Surgery in our hospital from January 2001 to September 2008 were retrospectively analyzed. Among the patients who received pericardial devascularization, those with a postoperative FPP >= 22 mmHg were included in a high-pressure group (n=68), and those with FPP <22 mmHg were in a low-pressure group (n=49). Seventy patients who received the combined operation comprised a combined group. The intraoperative FPP measurement changes at different times, and the incidence of postoperative complications in the three groups of patients were compared. RESULTS. The postoperative FPP value in the high-pressure group was 27.5 +/- 2.3 mmHg, which was significantly higher than that of the low-pressure (20.9 +/- 1.8 mmHg) or combined groups (21.7 +/- 2.5 mmHg). The rebleeding rate in the high-pressure group was significantly higher than that in the low-pressure and combined groups. The incidence rates of postoperative hepatic encephalopathy and liver failure were not statistically different among the three groups. The mortality due to rebleeding in the low-pressure and combined groups (0.84%) was significantly lower than that of the high-pressure group. CONCLUSIONS: The study demonstrates that FPP is a critical measurement for surgical procedure selection in patients with portal hypertension. A FPP value >= 22 mmHg after splenectomy and devascularization alone is an important indicator that an additional proximal splenorenal shunt needs to be performed. (Hepatobiliary Pancreat Dis Int 2010; 9: 269-274)

Management of hypersplenism in non-cirrhotic portal hypertension:a surgical series

BACKGROUND:Hypersplenism is commonly seen in patients with non-cirrhotic portal hypertension(NCPH).While a splenectomy alone can effectively relieve the hypersplenism,it does not address the underlying portal hypertension.The present study was undertaken to analyze the impact of shunt and non-shunt operations on the resolution of hypersplenism in patients with NCPH.The relationship of symptomatic hypersplenism,severe hypersplenism and number of peripheral cell line defects to the severity of portal hypertension and outcome was also assessed.METHODS:A retrospective analysis of NCPH patients with hypersplenism managed surgically between 1999 and 2009 at our center was done.Of 252 patients with NCPH,64(45 with extrahepatic portal vein obstruction and 19 with non-cirrhotic portal fibrosis) had hypersplenism and constituted the study group.Statistical analysis was done using GraphPad InStat.Categorical and continuous variables were compared using the chi-square test,ANOVA,and Student’s t test.The MannWhitney U test and Kruskal-Wallis test were used to compare non-parametric variables.RESULTS:The mean age of patients in the study group was 21.81±6.1 years.Hypersplenism was symptomatic in 70.3% with an incidence of spontaneous bleeding at 26.5%,recurrent anemia at 34.4%,and recurrent infection at 29.7%.The mean duration of surgery was 4.16±1.9 hours,intraoperative blood loss was 457±126(50-2000) mL,and postoperative hospital stay 5.5±1.9 days.Following surgery,normalization of hypersplenism occurred in all patients.On long-term followup,none of the patients developed hepatic encephalopathy and 4 had a variceal re-bleeding(2 after a splenectomy alone,1 each after an esophago-gastric devascularization and proximal splenorenal shunt).Patients with severe hypersplenism and those with defects in all three peripheral blood cell lineages were older,had a longer duration of symptoms,and a higher incidence of variceal bleeding and postoperative morbidity.In addition,patients with triple cell line defects had elevated portal pressure(P=0.001),portal biliopathy(P=0.02),portal gastropathy(P=0.005) and intraoperative blood loss(P=0.001).CONCLUSIONS:Hypersplenism is effectively relieved by both shunt and non-shunt operations.A proximal splenorenal shunt not only relieves hypersplenism but also effectively addresses the potential complications of underlying portal hypertension and can be safely performed with good long-term outcome.Patients with hypersplenism who have defects in all three blood cell lineages have significantly elevated portal pressures and are at increased risk of complications of variceal bleeding,portal biliopathy and gastropathy.

Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension

AIM:To determine the clinical value of a splenorenal shunt plus pericardial devascularization(PCVD)in portal hypertension(PHT)patients with variceal bleeding.METHODS:From January 2008 to November 2012,290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding:207 patients received a routine PCVD procedure(PCVD group),and83 patients received a PCVD plus a splenorenal shunt procedure(combined group).Changes in hemodynamic parameters,rebleeding,encephalopathy,portal vein thrombosis,and mortality were analyzed.RESULTS:The free portal pressure decreased to 21.43±4.35 mmHg in the combined group compared with24.61±5.42 mmHg in the PCVD group(P<0.05).The changes in hemodynamic parameters were more significant in the combined group(P<0.05).The long-term rebleeding rate was 7.22%in the combined group,which was lower than that in the PCVD group(14.93%),(P<0.05).CONCLUSION:Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT.It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.

Clinical analysis of surgical treatment of portal hypertension

AIM: To review the experience in surgery for 508 patients with portal hypertension and to explore the selection of reasonable operation under different conditions.METHODS: The data of 508 patients with portal hypertension treated surgically in 1991-2001 in our centers were analyzed. Of the 508 patients, 256 were treated with portaazygous devascularization (PAD),167 with portasystemic shunt (PSS), 62 with selective shunt (SS), 11 with combined portasystemic shunt and portaazygous devascularization (PSS+PAD), 9 with liver transplantation (LT), 3 with union operation for hepatic carcinoma and portal hypertension (HCC+PH).RESULTS: In the 167 patients treated with PSS, free portal pressure (FPP) was significantly higher in the patients with a longer diameter of the anastomotic stoma than in those with a shorter diameter before the operation (P＜0.01). After the operation, FPP in the former patients markedly decreased compared to the latter ones (P＜0.01).The incidence rate of hemorrhage in patients treated with PAD, PSS, SS, PSS+PAD, and HCC+PH was 21.09% (54/256), 13.77 (23/167), 11.29 (7/62), 36.36% (4/11),and 100% (3/3), respectively. The incidence rate of hepatic encephalopathy was 3.91% (10/256), 9.58% (16/167),4.84% (3/62), 9.09% (1/11), and 100% (3/3), respectively while the operative mortality was 5.49% (15/256), 4.22% (7/167), 4.84% (3/62), 9.09% (1/11), and 66.67% (2/3) respectively. The operative mortality of liver transplantation was 22.22% (2/9).CONCLUSION: Five kinds of operation in surgical treatment of portal hypertension have their advantages and disadvantages. Therefore, the selection of operation should be based on the actual needs of the patients.

Transcatheter Closure of Postoperative Residual Atrial or Ventricular Septal Shunts in Patients with Congenital Heart Disease

Background:Transcatheter closure(TCC)has emerged as the preferred treatment for selected congenital heart disease(CHD).While TCC offers benefits for patients with postoperative residual shunts,understanding its mid-and long-term efficacy and safety remains crucial.Objective:This study aims to assess the mid-and long-term safety and efficacy of TCC for patients with residual atrial or ventricular septal shunts following CHD correction.Methods:In this consecutive retrospective study,we enrolled 35 patients with residual shunt who underwent TCC or surgical repair of CHD between June 2011 to October 2022.TCC candidacy was determined based on established criteria.Echocardiography and electrocardiogram were conducted during the perioperative period and continued as part of long-term follow-up.Results:Among the patients,5(14.3%)exhibited interatrial shunt-ing,while 30(85.7%)had interventricular shunting.TCC was successfully implemented in 33 of 35 patients,with exceptions in two cases of post-ventricular septal defect repair due to anatomical challenges involving the shape and aortic angulation.This resulted in a TCC success rate of 94.3%.Trace residual shunt was detected in two interventricular shunting cases and a mild residual shunt in one interventricular shunting case;all resolved by the three-month follow-up after TCC.Minor complications included one hematoma at the puncture site and one transient junctional rhythm during the perioperative period.During a median follow-up of 73 months,there were no instances of residual shunt,device embolization,occluder displacement,valve insufficiency,malignant arrhythmia,infective endocarditis,death,or other serious complications.Conclusion:TCC is an effective and safe therapy for patients with residual atrial or ventricular septal shunts following CHD correction.Thesefindings support the consideration of TCC as the preferred treatment option for appropriate patient populations.

Transjugular Intrahepatic Portosystemic Shunt Versus Surgical Shunting in the Management of Portal Hypertension

Background:The purpose of this article was to clarify the optimal management concerning transjugular intrahepatic portosystemic shunts (TIPSs) and surgical shunting in treating portal hypertension.Methods:All databases,including CBM,CNKI,WFPD,Medline,EMBASE,PubMed and Cochrane up to February 2014,were searched for randomized controlled trials (RCTs) comparing TIPS with surgical shunting.Four RCTs,which were extracted by two independent investigators and were evaluated in postoperative complications,mortality,2-and 5-year survival,hospital stay,operating time and hospitalization charges.Results:The morbidity in variceal rehemorrhage was significantly higher in TIPS than in surgical shunts (odds ratio [OR] =7.45,95％confidence interval [CI]:(3.93-14.15),P ＜ 0.00001),the same outcomes were seen in shunt stenosis (OR =20.01,95％ CI:(6.67-59.99),P ＜ 0.000001) and in hepatic encephalopathy (OR =2.50,95％ CI:(1.63-3.84),P ＜ 0.0001).Significantly better 2-year survival (OR =0.66;95％ CI:(0.44-0.98),P =0.04) and 5-year survival (OR =0.44; 95％ CI:(0.30-0.66),P ＜ 0.00001) were seen in patients undergoing surgical shunting compared with TIPS.Conclusions:Compared with TIPS,postoperative complications and survival after surgical shunting were superior for patients with portal hypertension.Application of surgical shunting was recommended for patients rather than TIPS.

产前超声诊断胎儿VACTERL联合征合并肝内门-腔静脉分流1例

孕妇25岁,孕3产1;孕25^(+5)周产前超声提示胎儿发育异常,无家族遗传病史及不良孕产史。产科查体及实验室检查无特殊。产前超声:胎儿生长发育与孕周相符,胎心率148次/分;C3为半椎体(图1A),左侧第10、11肋间隙变窄(图1B),T_(6-7)椎间隙变窄;室间隔上部回声连续性中断约0.30cm,心室水平见过隔血流信号(图1C);食管上段盲袋样扩张,宽约0.80cm;胃泡充盈差。

肝硬化自发性脾肾分流治疗后再出血及5年生存率的影响因素分析

目的探讨肝硬化自发性脾肾分流(SSRS)患者治疗后再出血及5年生存率的影响因素,以期为临床评估肝硬化患者预后提供依据。方法选取2014年6月—2018年6月复旦大学附属中山医院及厦门分院收治的肝硬化合并SSRS患者95例,所有患者均获得5年及以上随访结果。根据随访过程中是否再次发生消化道出血分为再出血组(n=27)和未再出血组(n=68)。计量资料两组间比较采用成组t检验或Mann-Whitney U检验。计数资料组间比较采用χ^(2)检验或Fisher精确概率法。采用单因素和多因素Cox回归分析筛选SSRS患者的预后影响因素,Kaplan-Meier法描述生存结局。相关性采用Pearson或Spearman相关性分析。结果再出血组脾肾分流直径[4.60(3.20~5.90)mm vs 3.45(2.10~5.45)mm,Z=1.973,P=0.048]和门静脉压力梯度[(18.57±6.60)mmHg vs(15.06±5.82)mmHg,t=2.280,P=0.026]均显著高于未再出血组,门静脉直径[(14.04±2.90)mm vs(15.45±2.90)mm,t=2.138,P=0.035]显著低于未再出血组。相关性分析结果显示,脾肾分流直径与门静脉直径呈负相关(r_(s)=-0.211,P=0.040)。治疗后5年内的不良事件包括消化道再出血(27.4%)、门静脉血栓(11.6%)、感染(4.2%)、脑出血(1.1%)和脑梗死(1.1%)。脾肾分流直径(RR=1.173,95%CI:1.001~1.374,P=0.048)和肠系膜上静脉直径(RR=0.844,95%CI:0.746~0.956,P=0.007)是治疗后5年消化道再出血的独立影响因素。胆红素(RR=1.028,95%CI:1.010~1.046,P=0.002)和尿素氮(RR=1.347,95%CI:1.116~1.625,P=0.002)是治疗后5年生存率的独立危险因素。结论脾肾分流直径与肝硬化患者预后密切相关,对于肝硬化合并SSRS患者,应加强对脾肾分流直径的影像学随访。

Peritoneovenous shunt for intractable ascites due to hepatic lymphorrhea after hepatectomy

A peritoneovenous shunt has become one of the most effi cient procedures for intractable ascites due to liver cirrhosis.A case of intractable ascites due to hepatic lymphorrhea after hepatectomy for hepatocellular carcinoma that was successfully treated by the placement of a peritoneovenous shunt is presented.A 72-year-old Japanese man underwent partial resection of the liver for hepatocellular carcinoma associated with hepatitis C viral infection.After hepatectomy,a considerable amount of ascites ranging from 800-4600 mL per day persisted despite conservative therapy,including numerous infusions of albumin and plasma protein fraction and administration of diuretics.Since the patient's general condition deteriorated,based on the diagnosis of intractable hepatic lymphorrhea,a subcutaneous peritoneovenous shunt was inserted.The patient's postoperative course was uneventful and the ascites decreased rapidly,with serum total protein and albumin levels and hepatic function improving accordingly.For intractable ascites due to hepatic lymphorrhea after hepatectomy,we recommend the placement of a peritoneovenous shunt as a procedure that can provide immediate effectiveness without increased surgical risk.

Comparison of a new stent and Wallstent for transjugular intrahepatic portosystemic shunt in a porcine model

AIM To evaluate a new balloon-expandablestainless steel stent (Cordis stent ) in atransjugular intrahepatic portosystemic shunt(TIPS) porcine model and compared withWallstent.METHODS TIPS was performed in 26 normaldomestic pigs weighing 20 kg-30 kg using aCordis stent or Wallstent (13 pigs in each stent).All pigs were sacrificed at the 14th day afterTIPS. The stent deployment delivery system,stent patency, and stent recoil after placementwere evaluated. Proliferative response inrepresentative histological sections from thecenter, hepatic and portal regions of the twostent designs were quantified.RESULTS The shunt was widely patent in 4pigs in the Cordis stent group (4/12, prematuredead in 1 pig), and in 5 pigs in the Wallstentgroup (5/13). All remaining stents of bothdesigns were occluded or stenotic. The meanquantified proliferation including thickness ofthe proliferation and the ratio of proliferation:total area in three assayed regions in Cordisstent and Wallstent was 2.18 mm:2.00 mm, and59.18 mm2: 51.66 mm2, respectively (P ＞0.05).The delivery system and mechanical propertiesof the Cordis stent fuctioned well.CONCLUSION The new Cordis stent isappropriate for TIPS procedure.

Rectal arterio-portal fistula: An unusual cause of persistent bleeding per rectum following a proximal spleno-renal shunt

Gastrointestinal arterio-venous malformations are a known cause of gastrointestinal bleeding. We present a rare case of persistent rectal bleeding due to a rectal arterio-portal venous fistula in the setting of portal hypertension secondary to portal vein thrombosis. The portal hypertension was initially surgically treated with splenectomy and a proximal splenorenal shunt. However, rectal bleeding persisted even after surgery, presenting us with a diagnostic dilemma. The patient was re-evaluated with a computed tomography mesenteric angiogram which revealed a rectal arterio-portal fistula. Arterio-portal fistulas are a known but rare cause of portal hypertension, and possibly the underlying cause of continued rectal bleeding in this case. This was successfully treated using angiographic localizationand super-selective embolization of the rectal arterioportal venous fistula via the right internal iliac artery. The patient subsequently went on to have a full term pregnancy. Through this case report, we hope to high-light awareness of this unusual condition, discuss the diagnostic workup and our management approach.

Side effects of budesonide in liver cirrhosis due to chronic autoimmune hepatitis: Influence of hepatic metabolism versus portosystemic shunts on a patient complicated with HCC

AIM: To investigate the systemic availability of budesonide in a patient with Child A drrhosis due to autoimmune hepatitis (AIH) and primary hepatocellular carcinoma, who developed serious side effects.METHODS: Serum levels of budesonide, 6β-OH-budesonide and 16α-OH-prednisolon were measured by HPLC/MS/MS;portosysternic shunt-index (SI) was determined by 99mTc nuclear imaging. All values were compared with a matched control patient without side effects.RESULTS: Serum levels of budesonide were 13-fold increased in the index patient. The ratio between serum levels of the metabolites 6β-OH-budesonide and 16α-OH-prednisolone, respectively, and serum levels of budesonide was diminished (1.0 vs. 4.0 for 6β-OH-budesonide, 4.2 vs.10.7 for 16α-OH-prednisolone). Both patients had portosystemic SI (5.7% and 3.1%) within the range of healthy subjects.CONCLUSION: Serum levels of budesonide vary up to 13-fold in AIH patients with Child A cirrhosis in the absence of relevant portosysternic shunting. Reduced hepatic metabolism, as indicated by reduced metabolite-to-drug ratio, rather than portosystemic shunting may explain systemic side effects of this drug in cirrhosis.