Volume 88 - 2025 - Fasc.3 - Case reports
Simultaneous portosystemic shunt and proximal splenic artery embolization for patients with therapy-refractory hepatic encephalopathy at risk of portal hypertensive complications
Background: Hepatic encephalopathy (HE) is a well-known
complication of cirrhosis. When HE recurs despite optimal
treatment or without a clear precipitant, a portosystemic shunt
may be the culprit. We present a case of therapy-refractory HE
caused by a spontaneous portosystemic shunt (SPSS).
Clinical case: A 69-year-old male with MASLD-related
cirrhosis, with a medical history of biliopancreatic diversion
and variceal bleeding, presented with his fifth episode of HE
despite maximal pharmacological treatment. Initial lab tests and
infectious screen were negative. Abdominal CT scan showed a
paraesophageal shunt, supplied by the coronary vein. To address
HE, SPSS closure was planned. Since SPSS closure could aggravate
PHT and subsequently increase paracentesis frequency or induce
variceal bleeding, this was combined with a proximal splenic
artery embolization (pSAE). pSAE after SPSS closure resulted
in a reduction of hepatic venous pressure gradient (HVPG) from
21mmHg to 15 mmHg. HE symptoms resolved, pharmacological
treatment was stopped, and paracentesis became less frequent.
Weeks later, the patient was readmitted with abdominal pain, and
CT confirmed splenic infarction. Recurrent spontaneous bacterial
peritonitis necessitated splenectomy, which was complicated by
hemorrhage, septic shock, and death.
Conclusion: This case highlights the potential of combining
SPSS closure and pSAE, two procedures that have not been
combined before to our knowledge, to effectively reduce HE
and HVPG, enabling cessation of anti-encephalopathic therapy
and lowering paracentesis frequency. However, altered vascular
anatomy can lead to complications such as splenic infarction.
Although splenic infarction occurred as a complication, we believe
this novel combined procedure warrants further investigation.
When blood mimics bile: A case of haemorrhagic cholecystitis masquerading as biliary pancreatitis
Background: Cholecystitis and pancreatitis are frequent
indications for hospitalization in gastroenterology and
hepatology, predominantly due to cholelithiasis. Standard
management strategies with imaging and cholecystectomy are
common practice. This case report highlights the importance of
considering atypical causes in patients presenting with symptoms
suggestive of cholecystitis and pancreatitis.
Case Report: A female patient presented repeatedly to the
emergency department with atypical ultrasound findings
suggestive of cholecystitis with secondary pancreatitis. Following
an episode of severe upper gastrointestinal bleeding, a diagnosis
of haemobilia with secondary pancreatitis was established.
Discussion: This case illustrates that haemobilia can present
with symptoms resembling calculous cholecystitis and biliary
pancreatitis. Diagnosis can be challenging, especially in the
absence of recent procedures or known malignancy. Quincke’s
triad—pain, jaundice, and bleeding—is observed in only a third
of cases.
Conclusion: Haemobilia, though rare, is an important
differential diagnosis in cases of upper gastrointestinal bleeding
and biliary obstruction. A multidisciplinary approach is
essential for prompt diagnosis and appropriate treatment.
Small Intestine Venous Ischemia, an Uncommon Carcinoid Tumour Complication
Neuroendocrine tumours (NETs) are slow-growing
neoplasms, with small intestine NETs being the most
common in the gastrointestinal tract, often presenting
with nonspecific symptoms, leading to diagnostic
delays. Case Report: An 82-year-old man presented
with abdominal pain and symptoms suggesting bowel
obstruction. CT-scan revealed a partially calcified
mesenteric mass causing venous engorgement and
ischemia of the adjacent small bowel. Surgery confirmed
a NET metastasis. Discussion: Fibrous, retractile,
mesenteric NET metastases can be responsible for
compression of veins, causing upstream engorgement
and necrosis. Treatment mainly involves resection.
Conclusion: NET mesenteric metastases can cause
vascular complications and subsequent organ ischemia.
Hepatitis E infection complicated by bilateral neuralgic amyotrophy and phrenic nerve palsy: a case report
Hepatitis E is an increasingly recognized cause of acute
hepatitis in the Western world and is often complicated by
extrahepatic manifestations, particularly neurological ones such
as neuralgic amyotrophy (NA). NA is a disease of the brachial
plexus, characterized by sudden onset of severe pain and muscle
weakness, typically affecting the shoulders and upper limbs and
can even extend to the diaphragm. Recent data suggest that its
presence is linked to a HEV infection in 10% of the cases. Due to
its rarity, there are currently no established treatment guidelines.
Here we present a case of a 44-year-old man who developed
bilateral NA and phrenic nerve palsy as a consequence of an acute
hepatitis E infection.