Splenorenal Shunt

Clinical History

A 52-year-old female presented with complaints of epigastric and left lower quadrant abdominal pain. Lipase was normal. Reports regular alcohol use.

Imaging Findings

CECT of the abdomen and pelvis demonstrated mild hepatomegaly, measuring 19 cm craniocaudally, without nodularity. Splenic and esophageal varices were noted. No ascites, splenomegaly, or pleural effusion was present. The portal vein was normal in size, measuring approximately 12 mm in diameter. Splenorenal shunting was identified.
Figure 1 a-d: Axial CECT images demonstrate a tortuous splenic varix (asterisk) that exits at the region of the splenic hilum, traverses superiorly and posteriorly to the spleen before entering the retroperitoneum and joining the left renal vein. Note the absence of ascites and the normal sized spleen.
Figure 2: Coronal reconstruction demonstrating the splenic varix (red arrow) joining the renal vein.

Discussion

There are multiple main portosystemic collateral pathways which can undergo variceal dilation in the setting of portal hypertension and cirrhosis. Well known collaterals include the left gastric vein, paraumbilical veins and rectal veins [1]. However, nearly any vein in the abdomen can contribute to a portosystemic collateral pathway, and the presence of these collaterals may be the only sign of significant hepatic dysfunction [1, 2].

Spontaneous splenorenal portosystemic shunts are relatively common findings in patients with cirrhosis [3]. One study reviewed sonographic evaluations in 109 cirrhotic patients and discovered spontaneous portosystemic shunts in 38%. Splenorenal shunts were most commonly identified at 21% compared to other collaterals [4]. CT plays an important role with identification, as sometimes these deep shunts are not well seen on ultrasound. Typical CT findings are a grouping of tortuous veins in the splenic hilum which traverse a retroperitoneal channel into a dilated left renal vein [5, 6].

In this particular patient, a spontaneous splenorenal shunt was identified as a tortuous splenic varix that takes a tortuous retroperitoneal course before draining into the left renal vein. The patient’s labs were notable for INR 2.2 (on no anticoagulation), Total Bilirubin 12.4 mg/dl (Direct 7.5mg/dl), Albumin 2.4 g/dl. Her MELD score at the time of imaging was 25. Despite the severity of her liver disease, the classic findings of portal hypertension such as portal vein dilatation, splenomegaly and ascites were not present likely because of this splenorenal shunt. Other signs of portal hypertension such as the presence of varicies and cavernous transformation of the portal vein. Although these sequela of portal hypertension are kept in check, the increased risk of hepatic encephalopathy is a feared complication due to the shunting, similarly to post-TIPS [7].

Differential Diagnosis List

Final Diagnosis

Spontaneous splenorenal shunt

URL:	https://www.eurorad.org/case/14061
DOI:	10.1594/EURORAD/CASE.14061
ISSN:	1563-4086