title: Hepatic arterioportal fistula presenting as gastric variceal hemorrhage.
abstract: Hepatic arterioportal fistulae (APF) are abnormal communications between the hepatic artery and the portal vein. In this report, we present the second case in the literature of a symptomatic APF presenting as a gastric variceal bleeding. A 55-year-old female presented to our facility with hematemesis. Upper endoscopy revealed a bleeding gastric varix. A computed tomography scan identified a large left hepatic lobe APF between the left hepatic artery and the left portal vein. Through angiography coil embolization was performed and with resultant loss of arterial flow, the APF was decompressed. On hospital day 3, the patient developed new melena. Portovenogram was performed and a TIPS stent was deployed. The patient subsequently did well. Hepatic arterioportal fistulae can result in portal hypertension secondary to arterial blood flowing directly into the portal vein bypassing the hepatic sinusoids. Iatrogenic causes (e.g. percutaneous liver biopsy) represent more than 50% of published cases of APFs. Most APFs resolve spontaneously as they are small and peripherally located. In rare instances, when APFs are centrally located, clinical symptoms develop. There have been 30 reported cases of symptomatic intrahepatic APFs following percutaneous liver biopsy. Of those, only one case presented as a gastric variceal bleed. Digital subtraction angiography is the gold standard in the diagnosis and treatment of APFs. In addition to initial embolization, we elected to treat the patient with TIPS due to the magnitude of her bleed. Although rare, intrahepatic APF should be kept on the differential of a patient presenting with isolated gastric varices.
authors.affiliation: Division of Gastroenterology and Hepatology, Phoenix Veterans Affairs Medical Center, Arizona, USA.
authors.forename: Bobby R
authors.initials: BR
authors.lastname: Kakati
authors.affiliation: Department of Internal Medicine, Phoenix Veterans Affairs Medical Center, Arizona, USA.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Pedersen
authors.affiliation: Division of Interventional Radiology and Endovascular Specialists, Banner Good Samaritan Medical Center, Arizona, USA.
authors.forename: Steve Y
authors.initials: SY
authors.lastname: Chen
authors.affiliation: Division of Interventional Radiology and Endovascular Specialists, Banner Good Samaritan Medical Center, Arizona, USA.
authors.forename: Kevin S
authors.initials: KS
authors.lastname: Hirsch
authors.affiliation: Division of Gastroenterology, Arizona Digestive Health, Arizona, USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Berggreen
authors.affiliation: University of Arizona College of Medicine, Phoenix Banner Transplant and Advanced Liver Disease Center, Banner Good Samaritan Medical Center Phoenix, Arizona, USA.
authors.forename: Anil B
authors.initials: AB
authors.lastname: Seetharam
mesh_terms: D001164:Arteriovenous Fistula / Q000150:complications* / Q000000981:diagnostic imaging / Q000628:therapy; D001706:Biopsy / Q000009:adverse effects; D003937:Diagnosis, Differential; D004621:Embolization, Therapeutic / Q000379:methods; D004932:Esophageal and Gastric Varices / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D006499:Hepatic Artery / Q000000981:diagnostic imaging* / Q000293:injuries; D006801:Humans; D008099:Liver / Q000473:pathology; D008875:Middle Aged; D011169:Portal Vein / Q000000981:diagnostic imaging* / Q000293:injuries; D014057:Tomography, X-Ray Computed