The role of ultrasound examination in early detection and follow-up of arterio-portal shunts

Aim: To underline the importance of ultrasound examination in the diagnosis and follow-up of arterio-portal shunts of different causes, by comparatively presenting the case of 2 patients followed in the Center of Internal Medicine of Fundeni Clinical Institute, who developed this type of shunt.

Case 1: Female patient, 54 years old, with a history of cholecistectomy (1997), in our observation since 2001 and diagnosed with primitive biliary cirrhosis in 2002, when liver biopsy was performed. In November 2006 during a routine medical check-up in our center, standard 2D US and Doppler US showed an arterio-portal shunt between the right portal vein and the right hepatic artery, without clinical significance and without clinical or US signs of portal hypertension. In April 2007 endoscopy and US examination showed significant signs of portal hypertension (esophageal varices III-IV, severe portal-hypertensive gastropathy, ascites). CT, MRI and arteriography confirmed the high-flow arterio-portal shunt as cause of portal hypertension. In June 2007 partial occlusion of the shunt was performed in Niguarda Ca'Granda Hospital Milan using microspirals and spirals (3–8mm) and the normal, hepatopet flow in the portal system was re-established. Ultrasonographic follow-up of the patient showed significant reduction of portal hypertension (no ascites, no gastropathy and esophageal varices grade I in September 2007), and in February 2008 no ultrasonographic signs of portal hypertension were present.

Case 2: Male patient, 52 years old, diagnosed with chronic lymphatic leukemia in 1989 after splenectomy for tumoral spleen, was admitted in our center in June 2007 with the diagnosis of portal hypertension of unknown cause. US examination showed thrombosis of the portal trunk and the presence of an arterio-portal shunt. CT and MRI confirmed the above-mentioned abnormalities and also described thrombosis of the superior mesenteric vein. Banding ligation was performed for III-rd degree esophageal varices. Due to the fact that arteriography performed in Niguarda Ca'Granda Hospital in Milan showed a hepatopet flow in the shunt, with no clinical consequences and that the esophageal varices were supplied from the mesenteric venous system, it was decided not to close the shunt.

Conclusions: Our presentation underlines the role of ultrasound examination in the early detection of arterio-portal shunts of different causes, even in the absence of other signs of portal hypertension.