A large inferior mesenteric-caval shunt via the internal iliac vein

Abstract

A large portosystemic shunt between the inferior mesenteric vein and the right internal iliac vein in a 28-yr-old non-cirrhotic man is presented. This collateral was discovered by ultrasound done as a screening examination for gastrointestinal bleeding. The direct communication of the inferior mesenteric vein with the internal iliac vein was demonstrated by computed tomography and percutaneous transhepatic portography. Surgical ligation of the collateral, performed to prevent future portosystemic encephalopathy, resulted in reduction of serum ammonia level and cessation of long-standing hemorrhoidal bleeding.

Congenital portosystemic shunts with and without gastrointestinal bleeding – case series

“…Liver transplantation [17], surgical ligation of the shunt [16] and embolization of the shunt using the Amplatzer vascular plug [18] have been reported to be successful for the treatment of congenital portosystemic shunt with gastrointestinal bleeding. Blanc et al [23] and Franchi-abella et al [22] reported a large series of successful treatments of congenital portosystemic shunt patients using shun closure; however, they did not mention whether any of the patients presented with gastrointestinal bleeding.…”

“…We reviewed the literature and found nine cases of congenital portosystemic shunt presenting with gastrointestinal bleeding [3,[12][13][14][15][16][17][18][19]. Of the eight patients with extrahepatic congenital portosystemic shunts, seven had a type I shunt and one had a type II shunt [3,[12][13][14][15][16][17]19].…”

“…Of the eight patients with extrahepatic congenital portosystemic shunts, seven had a type I shunt and one had a type II shunt [3,[12][13][14][15][16][17]19]. In these eight patients, the shunt drained the portal blood into the unilateral and/or bilateral internal iliac veins via the inferior mesenteric vein, two into the bilateral internal iliac veins, two into the left internal iliac vein and two into the right internal iliac vein; for the other two cases, the specific vein(s) that received the shunted portal blood were not mentioned in the literature [3,[12][13][14][15][16][17]19]. It was speculated that the abundant developing collaterals, such as the superior hemorrhoidal plexus, connected the inferior mesenteric and iliac veins [15].…”

Extrahepatic Portal-Systemic Encephalopathy without Portal Hypertension.

“…Although in this case, ligation of the artificial shunt was performed because of severe post-shunt hepatic encephalopathy, esophageal varices which reappeared postoperatively did not rupture and hepatic encephalopathy improved. There are also other reported cases whose courses after shunt closure were uneventful in spite of mild PH (Horiguchi et al 1988;Nagino et al 1992). These suggest that even patients with PH can be successfully treated with shunt closure if PH is mild and the patient's general condition is good.…”

“…Factually Alagille et al (1986) found that hepatic encephalopathy did not develop in any of 42 young patients (age range, 23 months to 14 years and 2 months) with portal vein obstruction who underwent portal-systemic surgical shunt for symptoms of PH. Moreover, it was reported that two young patients with a PSS did not develop hepatic encephalopathy, even though their shunt volume was large (Horiguchi et al 1988;Nagino et al 1992). Our patient 3, aged 67, also did not show any accompanying disturbance of consciousness due to hepatic encephalopathy, in spite of the severe hyperammoniemia, high retention percentage of indocyanine green in serum at 15 min, and precirrhotic state.…”