Intrahepatic arterioportal shunt
Intrahepatic arterioportal shunts represent abnormal flow between the portal venous system and a hepatic arterial system within the liver. They can be a reversible cause of portal hypertension.
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Clinical presentation
Clinical features will depend on the size and other underlying pathology. Small shunts can be asymptomatic.
Pathology
Intrahepatic vascular shunts can be divided according to the cause into:
-
tumorous shunt
- occurs with hepatocellular carcinoma and to a lesser extent hepatic hemangioma
- trans-tumoral shunt is due to abnormal communication between the feeding artery and draining vein of the tumor which results in increased vascularity around the tumor manifested as peritumoral transient hepatic attenuation differences (THAD)
- portal vein may show early enhancement in the dynamic arterial scan without enhancement of its main tributaries the splenic and superior mesenteric veins
-
non tumorous shunt
- mainly due to liver biopsy and other hepatic intervention
- may be due to liver cirrhosis itself owing to deformation of hepatic sinusoids which increases arterial pressure or portal vein extrinsic compression that also leads to increased arterial pressure
- congenital intrahepatic arterioportal fistula (rare) 3
Differential diagnosis
Sometimes arterioportal shunt appears in dynamic CT as enhancing nodule, which can mimic hepatocellular carcinoma. The best way to differentiate is by using MRI with SPIO (superparamagnetic iron oxide) which is deposited in hepatocellular carcinoma and washed out in vascular shunt.
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Hepatobiliary pathology
- depositional disorders
- infection and inflammation
- liver abscess
- hepatic hydatid infection
- cirrhosis
- hepatitis
- cholecystitis
- cholangitis
- malignancy
- liver and intrahepatic bile duct tumors
- benign epithelial tumors
- hepatocellular hyperplasia
- hepatocellular adenoma
- hepatic/biliary cysts
- benign nonepithelial tumors
- primary malignant epithelial tumors
- hepatocellular carcinoma
- hepatocellular carcinoma variants
-
cholangiocarcinoma
- intra-hepatic
- mass-forming type
- periductal infiltrating type - Klatskin tumors
- intraductal growing type
- extra-hepatic/large duct type
- intra-hepatic
- biliary cystadenocarcinoma
- combined hepatocellular and cholangiocarcinoma
- hepatoblastoma
- undifferentiated carcinoma
- primary malignant nonepithelial tumors
- hematopoietic and lymphoid tumors
- primary hepatic lymphoma
- hepatic myeloid sarcoma (hepatic chloroma)
- secondary tumors
- miscellaneous
- adrenal rest tumors
- hepatic carcinosarcoma
- hepatic fibroma
- hepatic Kaposi sarcoma
- hepatic lipoma
- hepatic mesenchymal hamartoma
- hepatic myxoma
- hepatic rhabdoid tumor
- hepatic solitary fibrous tumor
- hepatic teratoma
- hepatic yolk sac tumor
- inflammatory myofibroblastic tumor (inflammatory pseudotumor)
- nodular regenerative hyperplasia
- pancreatic rest tumors
- primary hepatic carcinoid
- benign epithelial tumors
- liver and intrahepatic bile duct tumors
- metabolic
- trauma
-
vascular and perfusion disorders
- portal vein related
- hepatic artery related
- hepatic veins related
- inferior vena cava related
- other
- third inflow
- liver thrombotic angiitis
- infra diaphragmatic total anomalous pulmonary venous return (TAPVR)
- hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)