2. Clinical History
• 60 year-old female – 7 children
• 2months ago:
Alimentary & biliary vomiting
Diarrhea 5 – 6 / day with tenesmus
Abdominal pain especially epigastric
Relieved by defecation
3. Clinical examination
• BP 105/70 mmHg
• Pulse 90/min
• Temperature 37.5 C
• Generalized abdominal tenderness
• Hepatomegaly (3 fingers width)
• Ascites
• Continuous murmur in the left fifth inter-costal space
4. Laboratory studies
• Hemoglobin: 10.7
• Total bilirubin 1.5 (direct 0.7)
• Alkaline Phosphatase x 4 ULN
• ALAT 43 (N 40)
• ASAT 25 (N 38)
• PT 60 %
• Albumin 3.1
• HBs Ag +
• HBe Ag –
• Anti HCV –
5. Ascitic fluid examination
• Total protein 1.3
• Albumin 0.5
• WBC 1 130 Lymphocytes 90%
Neutrophils 7 %
• RBC 760
• Abnormal cells Negative
• KB Negative
10. Doppler Sonogram
• Venous circulation in vessel of splenic hilum
• Dilated splenic artery 14 mm
• Low RI in SA in hilum 0.42
• RI in intra-splenic arteries 0.61
• Arterialisation of flow in splenic vein
• Mean velocity in portal vein 12 cm/sec
• Normal hepatic veins
Diagnosis: Splenic arterio-venous fistula
21. Surgical intervention
• Great amount of ascites
• Thrill in the splenic hilum
• Severe dilatation of splenic vein in hilum
• Ligation of splenic vein proximal to dilatation
• Splenectomy
• Liver biopsy
• Drainage & closure
23. Post-operative course
• Abdominal pain & low grade fever (38.5)
• WBC 12 800 (N 77 %)
• Abdominal US 1 week post-op:
Thrombosis of SV & PV
• IV heparin by pomp (1 000 U/h)
• Warfarin per os
24. Arterio-Portal Fistula Syndrome
APFS
• Fistula involving one or several arteries & the portal
vein or one of its tributaries
• Hepatic artery: 65% of cases
Splenic artery: 11% of cases
SMA or IMA: 24% of cases
• Up to 1996, 75 cases of splenic arterio-venous fistula
reported in the medical litterature
Z Gastroenterol 1996 ; 34 : 234 – 249.
26. APFS – Treatment
• Recommended even in asymptomatic patient
• Depends on Cause – size of vessels – facilities
• Embolization Procedure of choice now
Small – intrahepatic – iatrogenic
Different materials (Gelfoam-Ballons)
• Surgery Large – other traumatic injuries
Resection – legation
27. Conclusions
• When PV > 2 cm we should suspect APFS
• Doppler sonogram is a good modality for diagnosis
• Splenectomy is an alternative to embolisation in large
fistula located in the splenic hilum
• Portal hypertention caused by APFS is a curable
disorder unlike many of the other causes of PH