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


METHODS
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.
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Letícia de Campos
Lde C
Franzoni
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Fábio Cardoso
FC
de Carvalho
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Rafael Gomes de Almeida
RG
Garzon
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Fábio da Silva
Fda S
Yamashiro
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Laís
L
Augusti
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Lívia Alves Amaral
LA
Santos
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Mariana de Souza
Mde S
Dorna
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Júlio Pinheiro
JP
Baima
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Talles Bazeia
TB
Lima
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Carlos Antonio
CA
Caramori
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Giovanni Faria
GF
Silva
Letícia de Campos Franzoni, Fábio da Silva Yamashiro, Laís Augusti, Lívia Alves Amaral Santos, Mariana de Souza Dorna, Júlio Pinheiro Baima, Talles Bazeia Lima, Carlos Antonio Caramori, Giovanni Faria Silva, Fernando Gomes Romeiro, Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, UNESP, 18 618 970 Botucatu, Sao Paulo, Brazil.
Fernando Gomes
FG
Romeiro
D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006501:Hepatic Encephalopathy / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008102:Liver Circulation; D008103:Liver Cirrhosis / Q000150:complications* / Q000175:diagnosis; D008875:Middle Aged; D010690:Phlebography; D017082:Portal Pressure; D011169:Portal Vein / Q000000981:diagnostic imaging / Q000503:physiopathology*; D012008:Recurrence; D013162:Splenic Vein / Q000000981:diagnostic imaging / Q000503:physiopathology*; D016896:Treatment Outcome; D020246:Venous Thrombosis / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology
Liver cirrhosis; Port systemic shunt; Portal vein thrombosis; Recurrent hepatic encephalopathy; Shunt embolization