Congenital portohepatic vein fistula that resolved spontaneously in a neonate

A case of a newborn with an intrahepatic congenital portosystemic venous shunt with concurrent congenital duodenal web

Intrahepatic congenital portosystemic venous shunts are rare vascular anomalies. We report a unique case of a neonate with an intrahepatic congenital portosystemic venous shunt with concurrent congenital duodenal web. Such association has not been previously reported to our knowledge. Interestingly, the shunt became apparent on the seventh day, after a delayed start of oral feeding due to the neonate’s recovery from the duodenal web surgery. The shunt was small and the clinical symptomatology mild. No direct treatment was required. The laboratory and the ultrasound follow-up of the child noted a spontaneous resolution of the shunt by the age of six months.

Predisposing Factors for Spontaneous Closure of Congenital Portosystemic Shunts

In a review of 382 cases of congenital portosystemic shunt, we found that presentation with neonatal cholestasis strongly predicts spontaneous closure of intrahepatic shunts (OR 8.3, 95% CI 3.4-20.2). Spontaneous closure before the 24th month of age is more likely for distal or multiple shunts, but rare for patent ductus venosus.

Congenital portosystemic shunts: prenatal manifestations with postnatal confirmation and follow-up

OBJECTIVES

The purpose of this study was to evaluate prenatal sonographic findings that could be helpful for diagnosis of congenital intrahepatic portosystemic venous shunts and the follow-up results.

METHODS

Six neonates with congenital shunts between the portal vein and hepatic vein were enrolled in this study. Prenatal sonography was performed in 5 cases. We categorized the cases according to a previously published classification of intrahepatic portosystemic venous shunts and retrospectively reviewed the prenatal and postnatal sonographic examinations to identify findings that might be helpful for diagnosing shunts prenatally. Follow-up sonographic examinations were done until closure of the shunts. Clinical features were also determined.

RESULTS

According to the original reports, intrahepatic portosystemic venous shunts were diagnosed by prenatal sonography in 2 of 5 cases. In the remaining 3 cases, there were suggestive abnormal findings on retrospective review, including an abnormal intrahepatic tubular structure, a prominent hepatic vein, and congestive heart failure. Postnatal sonography showed type 2 shunts in all 6 cases. In 1 case, there were 2 type 2 lesions between two branches of the left portal vein and the middle and left hepatic veins. On follow-up sonography, 5 of the 6 congenital shunts had spontaneously closed by 11 months of age. One case was treated with coil embolization during the neonatal period. Intrauterine growth restriction was the most commonly clinical feature prenatally.

CONCLUSIONS

Findings such as an abnormal tubular structure, a prominent hepatic vein, and congestive heart failure can be important clues for identifying congenital intrahepatic portosystemic venous shunts on prenatal sonography. The use of prenatal and postnatal sonography is feasible for detection and evaluation of these shunts.

Congenital portosystemic shunts and AMPLATZER vascular plug occlusion in newborns

Congenital portosystemic shunts (CPSs) may cause myriad manifestations. They can be detected prenatally, in infancy, or later. They may involute, cause acute symptoms, or remain unrecognized and cause chronic disease. As CPSs can require treatment, early diagnosis allows close monitoring. In symptomatic patients, interventional catheterization embolization of CPSs can be undertaken at any age.

[Abdominal vascular malformations and Down syndrome]

Malformations of the abdominal venous system are rare vascular disorders. These entities are associated with other malformations and with chromosomal anomalies such as trisomy 21. Abdominal venous malformations are probably the most frequent congenital vascular malformations in Down syndrome. Prenatal diagnosis allows the early follow-up and treatment of complications. We present a case of Down syndrome associated with an abdominal venous malformation diagnosed at the first trimester of pregnancy.

Anastomoses portosystémiques intrahépatiques idiopathiques : à propos de 4 observations

Intrahepatic portosystemic anastomoses are macroscopic communications between the venous portal system and the systemic circulation and located partly in the liver. We report 4 new cases of type II shunts, which illustrate the circumstances of the diagnosis of these exceptional anomalies. For 2 children, the diagnosis was done antenataly by US and spontaneous involution in a few months was observed. In the third case the malformation was evidenced fortuitously at 3 weeks of life, and this 6-year-old child remains completely asymptomatic so far. Then, in the fourth case, a cerebral venous thrombosis was fortuitously and antenatally evidenced in an otherwise uneventful pregnancy and portosystemic shunt was demonstrated postnataly in the extensive work up of the neonate.

Congenital intrahepatic arterioportal and portosystemic venous fistulae with jejunal arteriovenous malformation depicted on multislice spiral CT

We report a symptomatic infant with very rare congenital arterioportal and portosystemic venous fistulae in the liver. Multislice CT after partial transcatheter embolisation revealed not only the complicated vascular architecture of the lesion, but also an incidental jejunal arteriovenous malformation which explained the patient's melena. The patient underwent ligation of the hepatic artery and resection of the jejunal arteriovenous malformation. Postoperative multislice CT clearly demonstrated the success of the treatment.

Intrahepatic portosystemic venous shunt: diagnosis by colour/power Doppler imaging and three-dimensional ultrasound

Intrahepatic portosystemic venous shunt, considered to be a rare disease, can lead to hepatic encephalopathy. With recent advances in diagnostic imaging techniques, the number of reports of intrahepatic portosystemic venous shunts identified incidentally in patients without symptoms are increasing. We report an intrahepatic portosystemic venous shunt that was diagnosed incidentally by real-time ultrasound and colour Doppler imaging, including the use of three-dimensional ultrasound using minimum intensity projections and power Doppler.

The human fetal venous system: normal embryologic, anatomic, and physiologic characteristics and developmental abnormalities

OBJECTIVE

The introduction of high-resolution ultrasonography combined with color-coded Doppler imaging offered a breakthrough in the evaluation of the human fetal venous system, considerably enhancing our understanding of fetal venous circulation in normal physiologic conditions, as well as providing us the ability to study circulatory changes in abnormal circumstances. The purpose of this study was to describe the normal anatomic development and complex of anomalies of the human fetal venous system and to review recently published series of these anomalies.

METHODS

Normal embryologic and anatomic development is described. An English language literature search of recent MEDLINE listings was performed to glean data from recently published series reporting prenatal diagnosis of the various anomalies and their associated malformations.

RESULTS

Anomalies of the human fetal venous system occur sporadically, often associated with cardiac or other malformations. The pathophysiologic mechanisms leading to abnormal in utero development of the human venous system remain largely undetermined. On the basis of the type of vein involved, embryologic precursor, and etiologic correlation (primary or secondary), classification into 4 major groups is described.

CONCLUSIONS

Prenatal evaluation of fetuses found to have anomalies of the venous system should include a careful search for cardiac anomalies, including pulmonary venous drainage, and a detailed anatomic survey of the umbilical, portal, hepatic, and ductal systems to determine aberrant communication and, if possible, to discover clues to systemic diseases or thromboembolic phenomena.

Abnormalities of the fetal central veins and umbilico-portal system: prenatal ultrasonographic diagnosis and proposed classification

OBJECTIVES

Anomalies of the fetal venous system are poorly documented and their pathogenesis is not well understood. The present study was undertaken to review the spectrum of fetal central veins and umbilico-portal system anomalies, and to propose a classification system.

METHODS

A 7-year restrospective survey was conducted.

RESULTS

Nineteen fetuses showed abnormal connection between central veins and the fetal heart. Three fetuses showed abnormal connections of the cardinal veins, two of which had interruption of the inferior vena cava, and one had isolated persistent left superior vena cava. Anomalies of pulmonary veins were seen in four fetuses: in two with asplenia syndrome, a vertical confluent pulmonary artery was observed. In a further two cases total anomalous pulmonary venous connections were found. Abnormalities of the umbilical vein (UV) were seen in 10 cases; seven had persistent right UV, and three had a spectrum of anomalies: One had abnormal connections of the UV to the left iliac vein associated with agenesis of the ductus venosus (DV) and hydrops fetalis. One case showed in utero occlusion of the DV by echogenic foci that resulted in a persistent left proximal UV and porto-systemic shunt. One case had obliteration of the DV secondary to in utero fetal hepatic fibrosis. Abnormalities of the vitelline veins or portal system were demonstrated in two cases. One had a left porto-systemic shunt which resolved spontaneously at 3 months of age, and one had secondary partial occlusion of the left portal system with liver echogenicities and direct communication of the UV with the right atrium. None of the 19 cases had an abnormal karyotype or evidence of in utero infection.

CONCLUSIONS

Detection of various fetal vein anomalies in utero is feasible. The anomalies vary according to embryologic precursors or etiology. Two major mechanisms seem to be involved in the genesis of fetal vein anomalies: in most cases primary maldevelopment of the venous system occurs, while in the minority secondary anomalies from possible thromboembolic events or systemic disease may play a role.

Congenital extrahepatic portocaval shunts--the Abernethy malformation

The first account of an absent portal vein and a congenital mesenterico-caval shunt was given by John Abernethy in 1793. Five new cases of congenital extrahepatic portocaval shunts are described in this report. One end-to-side shunt with congenital absence of the portal vein (type 1 shunt) is the 13th case in the literature. Four are side-to-side (type 2) shunts of which there have been only two previous reports. Type 1 shunts are associated with other congenital abnormalities and have only been recognized in girls. Five of these cases developed liver tumours. Type 2 shunts are rarer, and four of five have been boys. They are not usually associated with other anomalies. Encephalopathy may be associated with these shunts in adults, and surgical closure of the side-to-side shunts is therefore recommended. End-to-side shunts are not correctable but the abnormal anatomy may create a problem for hepatic transplantation, should this be necessary for associated disorders such as biliary atresia. "The Abernethy Malformation" would seem to be a suitable eponym for congenital extrahepatic portocaval shunts.

Intrahepatic portal-hepatic venous shunts demonstrated by US, CT, and MR imaging

PURPOSE

Radiological findings were investigated in 6 cases of intrahepatic portal-hepatic venous shunt (IPHVS) without chronic liver disease.

MATERIAL AND METHODS

Six patients with IPHVS were examined using US, CT and MR imaging. US was performed in all patients and color Doppler imaging in 5 patients. CT was performed after i.v. bolus injection of contrast medium in 4 patients. MR imaging and MR angiography were performed in one patient.

RESULTS

The shunt was present in the right lobe in 4 patients and in the left lobe in 2 patients. The shunts consisted of focally dilated or tubular vessels (1 aneurysmal) in 4 patients, and multiple small vessels in 2 patients. US revealed anechoic structures with various configurations at the shunt. Color Doppler imaging could detect blood flow in various directions in the shunt vessels in 5 patients. CT and MR images showed these abnormal vascular structures in the liver. MR angiography was also useful for evaluating the relationship between the portal and the hepatic veins.

CONCLUSION

Color Doppler imaging was the best modality for evaluation of IPHVS.

Congenital absence of the portal vein: two cases and a proposed classification system for portasystemic vascular anomalies

Congenital absence of the portal vein (CAPV) is an unusual condition that often is associated with other anomalies. This is the first report of reduced-size liver transplant in a patient with CAPV. Because the presence of this rare congenital portasystemic shunt, there was no portal-systemic pressure differential, and thus an absence of collateral vessels in the pretransplant state. As a result, surgery was complicated by severe mesenteric edema caused by an increase in portal pressure when the allograft was implanted. The morbidity associated with CAPV usually results from associated conditions, but if transplantation is necessary, careful management of mesenteric congestion is crucial to success. The authors' experience and a review of the literature indicate that the CAPV can be classified into one of two groups of portasystemic anomalies.