Intrahepatic arterioportal fistula with portal hypertension

Case contributed by Albina Polianskaia
Diagnosis certain

Presentation

Hypogastric pain and abdominal distension

Patient Data

Age: 65 years
Gender: Male

Dilation and tortuosity of the common hepatic artery, portal vein, and its branches due to an arterio-portal shunt in segment VI.

Liver with surface nodularity as well as caudate and left hepatic lobe hypertrophy, findings suggestive of chronic liver disease. A hypodense area in segment IV with homogeneous enhancement in the equilibrium phase is indicative of a focal steatosis/perfusion disorder.

Esophageal varices and a small sliding hiatal hernia are observed. Cicatricial changes in segment VI with vascular-like calcifications. Cholelithiasis. Moderate ascites, indicating decompensated portal hypertension.

DSA reveals hypertrophy of the common and right hepatic arteries, along with hypertrophy of the portal vein and the presence of an arterioportal fistula in segment VI.

Intrahepatic arterioportal fistula postembolization.

Case Discussion

An intrahepatic arterioportal shunt or arterioportal fistula is a vascular anomaly with communication between a hepatic arterial branch and the portal venous system leading to redistribution of arterial flow into a focal region of portal venous flow. Although most intrahepatic arterioportal shunts are small and asymptomatic, it is crucial to identify them because they can induce portal hypertension.

Our patient presented with hypogastric pain and progressive abdominal distension, initially interpreted as diverticulitis. After a computed tomography, a gastroscopy was performed, leading to upper gastrointestinal bleeding due to acute portal hypertension. The bleeding was successfully stopped through endoscopic band ligation. The intrahepatic arterioportal fistula was embolized using coils and glue on three separate days, resulting in a favorable final outcome.

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