FRI-436-Congenital porto-systemic shunts in children: Preliminary results from the IRCPSS

Congenital portosystemic shunts: experience of a tertiary Tunisian referral center

Congenital portosystemic shunt is a rare condition in which communications between the systemic venous circulation and the portal veins drain blood directly into the systemic circulation. Diagnosis may occur from the prenatal period to adulthood. Nevertheless, diagnosing and treating a congenital portosystemic shunt, particularly in the perinatal stage, remain challenging, as multiple complications can occur. This study aimed to describe the clinical characteristics of 3 cases of congenital portosystemic shunts diagnosed during pregnancy or the neonatal period, the diagnostic procedures, and their outcomes. This study reported 3 cases of full-term newborns with a congenital portosystemic shunt diagnosed at neonatal age. Case 1 was antenatally diagnosed with a congenital portosystemic shunt, which was confirmed postnatally via computed tomography and was associated with malformed ductus venosus and hypoplasia of the right portal vein. Cases 2 and 3 were siblings: a boy who had diffuse hemangiomatosis and a congenital portosystemic shunt complicated with severe persistent pulmonary hypertension and a girl who presented with a congenital portosystemic shunt and Kell alloimmunization. Congenital portosystemic shunts can be detected on prenatal ultrasounds during the etiologic workup of one of its complications or may be incidentally identified later in life. Children with congenital portosystemic shunts may develop various biological abnormalities, such as pulmonary hypertension, hypoxemia, encephalopathy, and liver tumors. A multidisciplinary approach and standardized protocols are required to optimize the management of congenital portosystemic shunts and minimize the short- and long-term consequences of congenital portosystemic shunts.

Expert management of congenital portosystemic shunts and their complications

Congenital portosystemic shunts are often associated with systemic complications, the most challenging of which are liver nodules, pulmonary hypertension, endocrine abnormalities, and neurocognitive dysfunction. In the present paper, we offer expert clinical guidance on the management of liver nodules, pulmonary hypertension, and endocrine abnormalities, and we make recommendations regarding shunt closure and follow-up.

Presentation of Congenital Portosystemic Shunts in Children

Background: Congenital portosystemic shunts (CPSS) are rare vascular anomalies resulting in communications between the portal venous system and the systemic venous circulation, affecting an estimated 30,000 to 50,000 live births. CPSS can present at any age as a multi-system disease of variable severity mimicking both common and rare pediatric conditions. Case presentations: Case A: A vascular malformation was identified in the liver of a 10-year-old girl with tall stature, advanced somatic maturation, insulin resistance with hyperinsulinemia, hyperandrogenemia and transient hematuria. Work-up also suggested elevated pulmonary pressures. Case B: A young girl with trisomy 8 mosaicism with a history of neonatal hypoglycemia, transient neonatal cholestasis and tall stature presented newly increased aminotransferase levels at 6 years of age. Case C: A 3-year-old boy with speech delay, tall stature and abdominal pain underwent abdominal ultrasound (US) showing multiple liver nodules, diagnosed as liver hemangiomas by hepatic magnetic resonance imaging (MRI). Management and outcome: After identification of a venous malformation on liver Doppler US, all three patients were referred to a specialized liver center for further work-up within 12 to 18 months from diagnosis. Angio-computed tomography (CT) scan confirmed the presence of either an intrahepatic or extrahepatic CPSS with multiples liver nodules. All three had a hyperintense signal in the globus pallidus on T1 weighted cerebral MRI. Right heart catheterization confirmed pulmonary hypertension in cases A and C. Shunts were closed either using an endovascular or surgical approach. Liver nodules were either surgically removed if there was a risk of malignant degeneration or closely monitored by serial imaging when benign. Conclusion: These cases illustrate most of the common chief complaints and manifestations of CPSS. Liver Doppler US is the key to diagnosis. Considering portosystemic shunts in the diagnostic work-up of a patient with unexplained endocrine, liver, gastro-intestinal, cardiovascular, hematological, renal or neurocognitive disorder is important as prompt referral to a specialized center may significantly impact patient outcome.