Henry Ford Health System Jackson, MI, United States
Parth Patel, MD1, Danielle Ross, 2, Akhil Rahman, MD1, Merritt Bern, MD1 1Henry Ford Health System, Jackson, MI; 2Michigan State University College of Osteopathic Medicine, Jackson, MI
Introduction: Superior mesenteric arteriovenous fistulous connections are a rare yet reversible cause of portal hypertension. While some cases are spontaneous, most are iatrogenic and result after bowel surgery. We report a case of superior mesenteric arteriovenous fistula (SMAVF), causing severe portal hypertension, which was initially thought to be secondary to alcoholic cirrhosis. This patient had a remote history of bowel resection secondary to injury during hysterectomy.
Case Description/Methods: A 61year-old female presented to the emergency department because of abdominal distension and pain progressing over one week. At this time, she provided an alcohol use history for 4-5 beers per day. She was found to have liver enzymes and synthetic functions within normal limits. A CT abdomen was done, which showed a large amount of ascites. Several hours later, she reported hematochezia which led to an upper GI endoscopy with incomplete banding of esophageal varices. The patient had an atypical presentation of severe portal hypertension, without evidence of decreased liver synthetic function with a normal INR (1.08) and normal albumin (3.2 g/dL) thus prompting a secondary review of CT scans yielding the diagnosis of SMAVF. MRI confirmed these findings, and she subsequently underwent SMAVF embolization and detachable coil packing via left brachial access. She was started on Heparin due to concern of SVM propagation and had repeated upper GI endoscopy for complete banding of varices. At a follow-up visit, six weeks after embolization, her abdominal distension and pain resolved after embolization.
Discussion: Our patient presented with a case of SMAVF fistula with complicating ascites and esophageal varices in the setting of a remote (17 years) bowel resection. This rare diagnosis should be considered in portal hypertension without corresponding deficits in synthetic functions of the liver.
Figure: Severely dilated mesenteric vein with contrast opacification, fistula between the left lower quadrant SMA branch and the adjacent mesenteric vein. Increasing ascites and diffuse small bowel wall thickening noted.
Parth Patel indicated no relevant financial relationships.
Danielle Ross indicated no relevant financial relationships.
Akhil Rahman indicated no relevant financial relationships.
Merritt Bern indicated no relevant financial relationships.
Parth Patel, MD1, Danielle Ross, 2, Akhil Rahman, MD1, Merritt Bern, MD1. P3066 - Superior Mesenteric Arteriovenous Fistula Treated with Embolization, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.