JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Post-traumatic Hepatic Arterioportal Fistula
Peeyush Bhargava, MD, Guillermo Sangster, MD, Chaitanya Ahuja, MD, Quyen Chu, MD
Hepatic arterioportal fistula is an abnormal communication between a hepatic artery branch and a portal vein branch. It is a rare complication of trauma or an interventional procedure. We present the case of a 26-year- old male who was shot in the epigastrium. After resuscitation in the emergency room, and initial surgical exploration, the computed tomography (CT) showed transection of the right branch of hepatic artery and suspected communication with the right branch of the portal vein. Selective digital subtraction angiography of the hepatic artery confirmed an arterioportal fistula. The patient was treated surgically with ligation of the transected right hepatic artery and trisegmentectomy of the right lobe of the liver. Early treatment of hepatic arterioportal fistulas is indicated as they can lead to portal hypertension and its sequelae. Digital subtraction angiography is the gold standard in the diagnosis and treatment, but surgery may be needed for large fistulas.
INTRODUCTION
Hepatic abnormal communications between a hepatic arterial branch and a portal venous branch. The most common causes of hepatic APFs are trauma, interventional procedures, and vascular malformations.1 They can result in portal hypertension and other hemodynamic imbalances.1 Portal hypertension occurs due to creation of an inflow block resulting from the interruption of portal venous flow by the inflow of arterial blood with subsequent increased pressure in portal vein radicals. Hepatic APFs are usually small and self-limiting, however, in rare cases, fistulae can enlarge with time and become clinically symptomatic (e.g. esophageal varices and ascites)1. Cross-sectional imaging using CT and magnetic resonance imaging (MRI) has a role in characterizing these fistulas and their imaging appearances have been described in detail.2-4 Digital subtraction angiography (DSA) is the gold standard in the diagnosis and treatment of APFs.8 In this report, we present a patient with APF secondary to a gunshot injury to the epigastrium which led to transection of the right branch of the hepatic artery, injury to the right portal vein, and creation of a fistula between them. This was confirmed on DSA and treated surgically. arterioportal fistulae (APF) are
blood pressure in the low 90s. An entry wound was visible in the epigastrium, without a definite exit wound. Intravenous access was obtained in bilateral antecubital veins and the right femoral vein. Two units of packed RBCs and 1000 ml of intravenous fluids (0.9% saline) were administered. The patient was then sedated and intubated in the ER. The initial hematocrit was 30% and later increased to 35% and 41%, after resuscitation. Initial laboratory tests revealed: BUN 10.0 mg/dl, Creatinine 0.73 mg/dl, total protein 5.4 mg/dl, total bilirubin 1.7 mg/dl, AST (Aspartate Aminotransferase) of 1524 U/L, ALT (Alanine Aminotransferase) of 1258 U/L, alkaline phosphatase of U/L, findings consistent with liver injury. Patient was then intubated and transferred to the operating room for an emergent exploratory laparotomy (indicated for suspected bowel perforation from the gunshot injury) which showed the hepatic segment 4 entry of the bullet and exit from the caudate lobe. Injury to the superior pole of the right kidney was also seen. A cholecystectomy was performed (to visualize the bullet tract but no injury was noted to the gall bladder), a drain was placed at the site of the right superior renal pole injury, and the patient was then transferred to the intensive care unit (ICU). Thereafter, a CT scan was performed (about eight hours after the laparotomy to look for additional injuries) using the trauma protocol. CT of the chest, abdomen, and pelvis was acquired 60 seconds after the administration of 145 ml of IV contrast (Visipaque 320 mg/ml) and delayed images acquired at five minutes. CT showed a grade 4 injury (AAST liver injury scale) with hepatic laceration extending from segment 4 to the caudate lobe (Figure 1).
CASE REPORT
A 26-year-old male was brought to the emergency room (ER) with history of gunshot injury to the upper abdomen about one hour before presentation. Patient had a GCS (Glasgow Coma Scale) of 13 when he was brought to the ER (hospital day one), the airway was maintained, he had tachycardia with a heart rate of 130 beats/minute, and he was hypotensive with systolic
88 La State Med Soc VOL 170 MAY/JUNE 2018
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