ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Unusual Cause of Ascites Takamune Yamaguchi, Kiyoshi Hasegawa, and Norihiro Kokudo Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan

Question: A 78-year-old man was admitted to our department with a history of excessive weight gain (8 kg/mo), anorexia, and edema of the lower extremities. The patient had been regularly followed since undergoing liver resection for colorectal liver metastasis 7 years previously, and had had no evidence of recurrence. He had a past medical history of diabetes mellitus, hyperuricemia, chronic renal failure, and hypertension. Physical examination revealed a normal body temperature and distended abdomen, but no abdominal tenderness. Significant laboratory results at admission included the following: hemoglobin, 10.2 g/dL (normal range, 13.8-16.6); serum albumin, 2.5 g/dL (normal range, 3.9-4.9); blood urea nitrogen, 35.8 mg/dL (normal range, 9.0-21.0); and serum creatinine, 1.4 mg/dL (normal range, 0.6-1.2). Abdominal ultrasonography revealed massive ascites, which was treated initially by administration of diuretics. Contrastenhanced CT in the arterial phase is shown in Figure A. Ascitic fluid cytology was negative for malignant cells. What was the diagnosis? How should the patient be managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.10.050

Gastroenterology 2015;148:e3–e4

ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 2: Portal Hypertension Owing to Arterioportal Shunt

The thick and thin lines visualized as high densities on arterial phase contrast-enhanced CT were regarded as the left portal vein (Figure B, arrow) and hepatic artery (Figure B, arrowhead), respectively, suggesting presence of an arterioportal shunt. Angiography of the left hepatic artery revealed the left portal vein (Figure C, arrowhead) through the shunt (Figure C, arrow). Because there was no other cause for the massive ascites, we suspected that this arterioportal shunt increased the portal pressure, causing massive ascites. We occluded the shunt by an interventional radiologic technique, and the symptoms of portal hypertension (the ascites, edema, and body weight increase) improved markedly. The patient lost 8.3 kg over the 3 weeks after the embolization. CT imaging performed 3 months after embolization revealed significant decrease in the ascites. Arterioportal shunt, of which the second most common symptom is ascites,1 is a rare vascular disorder caused by trauma, iatrogenic procedures, congenital vascular malformations, tumors, or aneurysms.2 Causative iatrogenic procedures include operative maneuvers (such as manual exploration, mobilization, and temporary vessel occlusion), which occasionally cause tissue damage and circulatory disturbances.3 The arterioportal shunt in this case might have been related to past surgical maneuvers. Arterioportal shunt should be always kept in mind as a possible cause of ascites.

References 1. 2. 3.

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Vathey JN, Tomczak RJ, Helmberger T, et al. The arterioportal fistula syndrome: clinicopathologic features, diagnosis and therapy. Gastroenterology 1997;113:1390–1401. Nojiri K, Sugimoto K, Shiraki K. Ascites caused by arterioportal fistula 15 years after liver biopsy. Clin Gastroenterol Hepatol 2011;9:e31–e32. Goshima S, Kanematsu M, Matsuo M, et al. Early-enhancing nonneoplastic lesions on gadolinium-enhanced magnetic resonance imaging of the liver following partial hepatectomy. J Magn Reson Imaging 2004;20:66–74.

An unusual cause of ascites.

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