Grand Rounds

Extrahepatic portal hypertension

Medical Sciences Department, Pediatric Oncall, Mumbai

Address for Correspondence: Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.

Clinical Problem :
Case Report:- A 12 year old body born of non consanguineous marriage presented with hematemesis. Oesophageogastroscopy {OGDscopy} showed portal hypertension. Liver functions were normal. Colour Doppler of abdomen showed multiple collaterals. Child was diagnosed as a case of extrahepatic portal hypertension and underwent splenic artery embolization as he had recurrent hematemesis inspite of Sclerotherapy. He continued to have hematemesis with signs of hypersplenism and thus was operated for splenectomy with mesocaval shunt. After the surgery, child again had 2 episodes of hematemesis and varices on OGDscopy.

Why did the child have hematemesis inspite of shunt surgery_?

Discussion :
Hematemesis is portal hypertension occurs due to bleeding from varices. Varices are porto-systemic anastomosis that occur to relieve the portal pressure. If the portal pressure is very high, then bleeding can occur as the varices burst. Sclerotherapy is a palliative therapy in which varices that look impending for bursting are sclerosed to prevent bleeding. Splenectomy with shunt surgery help to decrease portal pressures as well as create an artificial shunt between systemic and portal circulation to relieve the portal pressures. Thus, in a child with shunt surgery and normal liver, the prognosis is good. However in a child with liver disease, there is always a risk of precipitating hepatic encephalopathy as the toxic metabolites tend to bypass the liver and do not get degraded and can affect the brain. A repeat bleeding post shunt surgery denotes that the portal pressures have again increased. This suggests occlusion of the shunt and the child should be investigated for the same. In this child, colour doppler was done and it was found that mesocaval shunt was not visualized suggesting that shunt was blocked. The child is again on regular Sclerotherapy.

E-published: October 2009, Vol 6 Issue 10 Art No. 55

Correct Answers :  yes 100%
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