An Inferior Mesenteric-Caval Shunt via the Internal Iliac Vein with Portosystemic Encephalopathy.

Abstract

Wereport here a case of an unusual extrahepatic portosystemic venous shunt in a 37-year-old woman without liver cirrhosis or portal hypertension, whodeveloped portal systemic encephalopathy. Angiography demonstrated an inferior mesenteric-caval shunt characterized by the presence of direct communicationof the inferior mesenteric vein with the left internal iliac vein. After the treatment with percutaneous transcatheter embolization of the shunt via a femoral vein approach using coils, she had no episode of portal systemic encephalopathy. (Internal Medicine 40: 887-890, 2001)

Successful portal-systemic shunt occlusion of a direct shunt between the inferior mesenteric vein and inferior vena cava with balloon-occluded retrograde transvenous obliteration following recanalization after placing a covered stent in the portal and superior mesenteric veins

“…7,8 There have been many reports about obstructing the portal-systemic shunt wherein the hyperammonemia and clinical symptoms were alleviated in patients with hepatic encephalopathy. [7][8][9]13,15,16 In our patient, liver function was preserved before the procedure. However, we were apprehensive about the possible development of ascites and worsening of esophageal varices by a sudden increase in portal pressure after complete obliteration of the dilated IMV shunt because the IMV shunt vessel was large and received most of the SMV and splenic fl ow.…”

“…Nowadays, less invasive endovascular procedures have been advocated as alternatives to surgical ligation. [5][6][7][8][9][12][13][14][15][16] In Japan, BRTO is widely accepted for obliterating gastric varices with the transvenous approach. 4,17 This method is also used for obliterating portal-systemic shunts.…”

Portosystemic Encephalopathy without Liver Cirrhosis Masquerading as Depression

“…According to our literature review, 24 cases of portosystemic encephalopathy without liver cirrhosis have been reported, including 20 from East Asia (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15) and four from the USA (16)(17)(18)(19), since Raskin et al reported the first case in 1964 (16). Previous studies involved mostly women (83%), with a mean age of 67.5 years (range: 37-86 years).…”

Insight into congenital absence of the portal vein: Is it rare?

“…Healthy brain may tolerate to high ammonia levels, while aging brain may not cope with high ammonia and other metabolites and develop symptoms [96][97][98] . Such mechanisms may contribute to the delayed presentation with hyperammonemia-related encephalopathy [99] . Moreover, another plausible one is that the thin anastomoses at birth slowly become large as the patient ages.…”

“…The occlusion techniques include surgical ligation [56,96,123] and interventional embolization [124][125][126] . Otake et al [99] used coils as embolic materials, because they can progressively occlude the shunt, avoiding acute overload of the portal venous system, and confirmed that there is no evidence that the shunt vessels were recanalized after a two-year follow-up period. The treatment for venous shunts in type Ⅰ patients without severe symptoms other than liver tumors and LDs is inactive, indicating that close clinical, biochemical, and imaging follow-up should be performed.…”