Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy

Abstract

Hepatic encephalopathy (HE) is a cognitive disturbance characterized by neuropsychiatric alterations. It occurs in acute and chronic hepatic disease and also in patients with portosystemic shunts. The presence of these portosystemic shunts allows the passage of nitrogenous substances from the intestines through systemic veins without liver depuration. Therefore, the embolization of these shunts has been performed to control HE manifestations, but the presence of portal vein thrombosis is considered a contraindication. In this presentation we show a cirrhotic patient with severe HE and portal vein thrombosis who was submitted to embolization of a large portosystemic shunt. Case report: a 57 years-old cirrhotic patient who had been hospitalized many times for persistent HE and hepatic coma, even without precipitant factors. She had a wide portosystemic shunt and also portal vein thrombosis. The abdominal angiography confirmed the splenorenal shunt and showed other shunts. The larger shunt was embolized through placement of microcoils, and the patient had no recurrence of overt HE. There was a little increase of esophageal and gastric varices, but no endoscopic treatment was needed. Since portosystemic shunts are frequent causes of recurrent HE in cirrhotic patients, portal vein thrombosis should be considered a relative contraindication to perform a shunt embolization. However, in particular cases with many shunts and severe HE, we found that one of these shunts can be safely embolized and this procedure can be sufficient to obtain a good HE recovery. In conclusion, we reported a case of persistent HE due to a wide portosystemic shunt associated with portal vein thrombosis. As the patient had other shunts, she was successfully treated by embolization of the larger shunt.

Keywords: Recurrent hepatic encephalopathy, Liver cirrhosis, Port systemic shunt, Shunt embolization, Portal vein thrombosis

Core tip: Portosystemic shunts are a cause of hepatic encephalopathy and decreased survival of cirrhotic patients. The embolization of these shunts has been performed to control hepatic encephalopathy manifestations, but the presence of portal vein thrombosis is considered a contraindication. We presented a cirrhotic patient with persistent hepatic encephalopathy and hepatic coma. She had a wide splenorenal shunt and also portal vein thrombosis. As she had other shunts, we performed the embolization of the largest shunt and she achieved a good recovery. In conclusion, for patients with many shunts and severe hepatic encephalopathy, one of these shunts can be successfully embolized.