P2891 - A Case of Non-Cirrhotic Portal Hypertension Due to Intrahepatic Arterioportal Fistula With Remote History of Abdominal Gunshot Wound Sparing the Liver

Yasir Rajwana, MD¹, Joseph R. Depasquale, MD, FACG², Lloyd Brown, MD³, Abhishek Kumar, MD³, Pratik Shukla, MD^3
1Jersey City Medical Center, Newark, NJ; ²Jersey City Medical Center, Jersey City, NJ; ³Rutgers New Jersey Medical School, Newark, NJ

Introduction: Arterioportal fistula is a communication between the splanchnic and portal circulation which can result in clinical symptoms and complications of portal hypertension. It can be congenital or acquired, from penetrating or blunt abdominal trauma.We present a case of a 73 year old man with no prior history of liver disease who presented with new onset ascites,found to have high SAAG ratio and APF on imaging. The only identified etiology for the fistula was a gunshot wound in 1973 in which liver was reported as spared. The case highlights the importance of considering APF as a possible yet overlooked cause of non-cirrhotic portal hypertension.

Case Description/Methods: A 73 year old man presented with recent abdominal pain and distension.Medical history was significant for Atrial fibrillation for which he was on Metoprolol and Apixaban. He reported a history of laparotomy following a gunshot wound in 1973 with reported sparing of the liver. He had marked abdominal distension with fluid thrill. There were no appreciable spider nevi, palmar erythema or Dupuytrens contracture.Labs revealed Hb of 11.2 g/dl, Plt 279, PT 16 sec, INR 1.47 , ALT 31 U/L ,AST 42 U/L,Bilirubin 0.8 mg/dl ,Alp 161, Albumin 7.0 g/dl.Viral hepatitis serology and titers for ANA, ASMA, and AMA were normal.
CT of abdomen showed moderate ascites and a right portal vein “varix”. Paracentesis with fluid analysis revealed a High SAAG ratio. An APF was identified in the right lobe of the liver on triple phase CT scan.FibroScan performed showed no fibrosis. Patient was started on diuretics and Interventional radiology was consulted for embolization of the fistula. Ascites and symptoms completely resolved following embolization on subsequent follow up.

Discussion: Literature reports many cases of direct or blunt trauma to the liver later resulting in APF causing portal hypertension. This case is unique in that no direct trauma to the liver was identified and the fistula developed more than 45 years after the gunshot wound. The resolution of ascites and symptoms after embolization and absence of fibrosis supports assumption that the fistula was not a chronic problem and developed more than 45 years after the initial injury. The importance of triple phase imaging in any patient with suspected vascular cause of portal hypertension is clear from the case. We postulate that the patient’s APF and resultant portal hypertension were secondary to the remote gunshot wound with a slowly evolving course over a 45 year span culminating in an acute APF.


Figure: Arterioportal Fistula pre and post Embolization


Disclosures:
Yasir Rajwana indicated no relevant financial relationships.
Joseph Depasquale indicated no relevant financial relationships.
Lloyd Brown indicated no relevant financial relationships.
Abhishek Kumar indicated no relevant financial relationships.
Pratik Shukla indicated no relevant financial relationships.


Yasir Rajwana, MD¹, Joseph R. Depasquale, MD, FACG², Lloyd Brown, MD³, Abhishek Kumar, MD³, Pratik Shukla, MD³. P2891 - A Case of Non-Cirrhotic Portal Hypertension Due to Intrahepatic Arterioportal Fistula With Remote History of Abdominal Gunshot Wound Sparing the Liver, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.