MedPix Medical Image Database COW - Case of the Week Case Contributor: Laura N Modzelewski Affiliation: National Naval Medical Center Bethesda

MedPix No: History Pt Demographics: Age = 51 y.o. Gender = man 51 year old male with a history of ESLD (HCV, ETOH) with intractable ascites requires weekly to biweekly large volume paracentesis. He presents to the hospital after his long-standing umbilical hernia burst in the shower releasing an estimated 1 gallon of ascitic fluid. Downloaded by (-1)

MedPix No: EXAM & LABS Vitals: Afebrile. BP 97/55, HR 77, RR 18. Appearance: In NAD.Mentation: A&O x 3. Eyes: No scleral icterus.Lungs: Fine bibasilar crackles.Heart: RRRAbdomen: Mildly distended abdomen with subtle caput. The umbilical hernia sac appears hyperpigmented with a focal area of necrosis. Abdomen is nontender. Mild splenomegaly.Neuro: Unremarkable.Extremities: 3+ pitting edema of the bilateral lower extremities.LABS:ALT 36AST 46T BILI 2.2Alk Phos 103Alb 1.6WBC 7.4Hb 9.8Hct 28Plt 106Creatnine 1.6 (inc from 1.1) - likely prerenal PT/PTT/INR /33.7/1.3

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Recannalized paraumbilical vein is a hypoechoic serpiginous tubular structure in the region of the ligamentum teres between the left medial and left lateral segments of the liver. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Recannalized paraumbilical vein with hepatofugal flow consistent with portal hypertension. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Main portal vein is patent. The Doppler waveform is venous but flow directionality is equivocal (hepatopetal versus hepatofugal). Likely the focal pulsatile appearance mid waveform is artifactual versus a manifestation of right heart dysfunction. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) LONG - liver is 11 cm. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) LONG - spleen is 16.1 cm. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Axial contrast-enhanced CT image through the upper abdomen demonstrates a small liver with a nodular contour. The paraumbilical vein is recannalized and large caliber. There is perihepatic ascites and a moderate-sized right pleural effusion. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Axial contrast-enhanced CT image through the upper abdomen demonstrates, again, a small nodular liver. The spleen appears enlarged. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Hepatic venogram. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Portagram. The right portal vein opacifies with contrast after a successful puncture via the right hepatic vein. Downloaded by (-1)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Portosystemic shunt. The parenchymal Wallstent is deployed and dilated to 12 mm. Its course is a smooth curve. The portosystemic shunt gradient is < 12 mmHg. Downloaded by (-1)

FINDINGS 1) CT CHESTa) Axial contrast-enhanced CT image through the upper abdomen demonstrates a small liver with a nodular contour. The umbilical vein is recannalized and large caliber. There is perihepatic layering ascites and a moderate sized right pleural effusion. b) Axial contrast-enhanced CT image through the upper abdomen demonstrates, again, a small nodular liver. The spleen appears slightly enlarged.2)ULTRASOUND - PRE TIPSa) Long liver 11.0 cm.b) Long spleen 16.1 cm.c) Recannalized paraumbilical vein is a hypoechoic serpiginous tubular structure in the region of the ligamentum teres between the medial left and lateral left segments of the liver. d) Recannalized paraumbilical vein with hepatofugal flow consistent with portal hypertension.e) Main portal vein is patent. The Doppler waveform is venous but flow directionality is equivocal (hepatopetal versus hepatofugal). Likely the focal pulsatile appearance mid waveform is artifactual versus a manifestation of right heart dysfunction (patient with no known history). 3) TIPS:a) Hepatic venogram.b) On portal venous puncture, the right portal vein opacifies with contrast administration. The portal system is successfully accessed for portosystemic shunt placement.c) The parenchymal Wallstent is deployed and dilated to 12 mm. Its course is a smooth curve. The portosystemic shunt gradient is < 12 mmHg.

DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? PORTAL HYPERTENSION DIFFERENTIAL: - A) INTRAHEPATIC - - Presinusoidal - 1) Hepatic fibrosis - 2) Schistosomiasis - 3) Lymphoma - 4) Sarcoidosis - - Postsinusoidal - 1) Cirrhosis - 2) Venoocclusive disease - - B) EXTRAHEPATIC - - Prehepatic - 1) Portal vein thrombosis - 2) Portal vein compression - - Posthepatic - 1) Hepatic vein thrombosis - 2) IVC obstruction - 3) Constrictive pericarditis - - C) HYPERDYNAMIC (Arterio-portal fistula) - -

Diagnosis: TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) Dx Confirmed by:

DISCUSSION See Factoid.