A 37-year-old woman with chronic portal vein thrombosis and cavernous transformation presented due to a recurrent episode of hematemesis. She had previously undergone multiple esophageal band ligations for esophageal varices seen on esophagogastroduodenoscopy (EGD). Ultrasonography showed elevated portal pressures and magnetic resonance cholangiopancreatography (MRCP) showed portal vein thrombosis. In addition, there were dilated periportal varices (cavernous transformation) exerting mass effect on the extrahepatic common bile duct and severe intrahepatic biliary ductal dilation involving all hepatic segments. Liver enzymes were persistently elevated in a cholestatic pattern: aspartate aminotransferase (AST) 64 U/L, alanine aminotransferase (ALT) 48 U/L, alkaline phosphatase (ALK) 303 U/L, total bilirubin (Tbili) 8.4 mg/dl, albumin 3.8 g/dl, and prothrombin time 11.9 seconds.
The liver was noncirrhotic on biopsy. Computed tomography (CT) of the abdomen showed large varices in the porta hepatis and portal vein thrombosis that appeared chronic in nature with cavernous transformation. Operative management with a mesocaval shunt was planned with the hopes of reducing portal pressure and preventing recurrent GI bleeding, portal biliopathy, and secondary cirrhosis. A selective shunt, such as a splenorenal shunt, selects nonintestinal flow to be shunted to the systemic venous drainage and has the advantage of reducing the incidence of encephalopathy. This type of shunt, however, would not have adequately reduced variceal pressures and therefore the decision was made to proceed with a mesocaval shunt.
The patient underwent an ERCP to better assess the biliary anatomy, as part of the preoperative evaluation for a shunt. During the procedure, she developed active hemobilia (Figure 1) from a newly discovered periampullary varix (Figure 2). A biliary covered metal stent was immediately placed, but without hemostasis. Due to ongoing bleeding that required activation of a massive transfusion protocol, an exploratory laparotomy was performed with emergent mesocaval shunt placement (Figures 3 and 4). An 8 mm ringed polytetrafluoroethylene (PTFE) graft was used to create a mesocaval shunt between the proximal superior mesenteric vein (SMV) and the infrarenal inferior vena cava (IVC). Portal pressures decreased by 8 mmHg after shunting and the bleeding stopped. She remained hemodynamically stable and was discharged ten days postoperatively. Follow-up mesocaval shuntogram showed a patent shunt with an outflow pressure of 13 mm Hg at the IVC and a portosystemic pressure gradient of 12 mm Hg. Two months postoperatively, she had an AST of 56 U/L, ALT 51 U/L, ALK 416 U/L, and Tbili 0.9 mg/dl. To date, she has had no episodes of hepatic encephalopathy.