title: Rectal arterio-portal fistula: an unusual cause of persistent bleeding per rectum following a proximal spleno-renal shunt.
abstract: 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 localization and super-selective embolization of the rectal arterio-portal 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 highlight awareness of this unusual condition, discuss the diagnostic workup and our management approach.
authors.affiliation: Department of General Surgery, Singapore General Hospital, Singapore 169608, Singapore.
authors.forename: Hao Yun
authors.initials: HY
authors.lastname: Yap
authors.forename: Ser Yee
authors.initials: SY
authors.lastname: Lee
authors.forename: Yaw Fui Alexander
authors.initials: YF
authors.lastname: Chung
authors.forename: Kiang Hiong
authors.initials: KH
authors.lastname: Tay
authors.forename: Albert Su-Chong
authors.initials: AS
authors.lastname: Low
authors.forename: Choon Hua
authors.initials: CH
authors.lastname: Thng
authors.forename: Krishnakumar
authors.initials: K
authors.lastname: Madhavan
mesh_terms: D000328:Adult; D000792:Angiography; D019468:Disease Management; D004621:Embolization, Therapeutic; D005260:Female; D006470:Hemorrhage / Q000209:etiology*; D006801:Humans; D006975:Hypertension, Portal / Q000601:surgery*; D012003:Rectal Fistula / Q000150:complications* / Q000175:diagnosis* / Q000628:therapy; D013164:Splenorenal Shunt, Surgical; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: Arteriovenous malformations; Esophageal varices; Portal hypertension; Portal vein thrombosis; Splenorenal shunt