Fístula arterio-venosa intrahepática como causa de hipertensión portal no cirrótica, en paciente portador de hepatitis autoinmune: diagnóstico y tratamiento: caso clínico

Portal hypertension (PH) is defined as pathological increase of hydrostatic pressure in the portal venous system, usually related to liver cirrhosis. Among the uncommon causes of PH is the arteriovenous intra or extrahepatic fistula (AVF) of traumatic, iatrogenic or congenital origin. Clinical history and ultrasound findings of AVF are very important for the diagnosis. From a therapeutic point of view, there are three alternatives: clinical/imaging follow-up, surgical repair and transcutaneous catheter embolization. A report of a clinical case and a review of the literature are presented. Patient with portal hypertension as a result of intra hepatic AVF, successfully treated by transcutaneous catheter embolization. A 54 year-old female patient, and cholecystectomized and with history of breast cancer, presented altered liver function tests several months after gallbladder surgery. Once biliary disease was ruled out, liver biopsy was performed, which was compatible with autoimmune hepatitis. During follow-up, intrahepatic AVF was observed by means of ultrasound. Underlying disease was successfully managed with Prednisone and Azathioprine. Nine years later, she experienced an episode of confusion and disorientation compatible with hepatic encephalopathy (HE) and esophageal varices diagnosed by upper endoscopy. Laboratory tests and imaging did not show progression baseline liver disease. Angiographic procedures confirmed an intra hepatic AVF and selective embolization was carried out. There was clinical remission of HE and esophageal varices. We concluded, that transcutaneous catheter embolization is a valid alternative for the treatment of intra hepatic AVF, which accounted for the successful result for this particular patient. La hipertension portal (HP) se define como el aumento patologico de la presion hidrostatica en el sistema venoso portal, habitualmente relacionada con cirrosis hepatica. Entre las causas infrecuentes de HP esta la fistula arterio-venosa (FAV) intra o extrahepatica de origen traumaticas, iatrogenicas o congenitas entre otras. En el diagnostico son importantes los antecedentes clinicos y hallazgos ecograficos que demuestran FAV. Desde el punto de vista terapeutico, existen tres alternativas: seguimiento clinico y de imagenes, reparacion quirurgica y embolizacion con cateter transcutaneo. Se presenta caso clinico de paciente con (HP) a consecuencia de una FAV intrahepatica, tratada satisfactoriamente mediante embolizacion con cateter transcutaneo y revision de la literatura pertinente. Se trata de una paciente de 54 anos con antecedentes de cancer mamario y colecistectomia en quien se constatan alteraciones de pruebas hepaticas varios meses con posterioridad a cirugia vesicular. Una vez descartada patologia biliar, se realizo biopsia hepatica la que fue compatible con hepatitis autoinmune. Durante el seguimiento se pesquiso FAV intrahepatica como hallazgo ecografi co. Su enfermedad de base se trato satisfactoriamente con Prednisona y Azatioprina. Nueve anos mas tarde, consulta por episodio de confusion y desorientacion compatible con encefalopatia hepatica (EH) y presencia de varices esofagicas a la endoscopia. Tanto el laboratorio como imagenes no mostraron progresion de enfermedad hepatica de base. Es sometida a procedimiento angiografico, que confirmo FAV intrahepatica, procediendo a embolizacion selectiva. Hubo remision del cuadro clinico de EH y regresion de las varices esofagicas. Se concluye que la embolizacion con cateter transcutaneo, es una alternativa valida en el tratamiento de FAV intrahepaticas, terapia que constituyo la solucion definitiva del cuadro clinico reportado.