Spontaneous aneurysmal portohepatic fistula

A 77-year-old asymptomatic male was referred by his family doctor with this liver test: total bilirubin (TB) 1.84 mg/dl, WBC 3,700/μL, platelets 109,000/μL, and GGT 71 U/L. Past medical history: no allergies to medication. Hypertension treated with captopril 25 mg/day. No abdominal surgery or trauma or liver biopsies. Drinker of 40 g alcohol daily. No known liver disease. No family history of interest. Physical examination showed no stigmata for chronic liver disease, and the abdomen was soft. CBC: leukocytes 2,990/μL, neutrophils 860/μL, lymphocytes 1,570/μL, platelets 112,000/μL, hemoglobin 138 g/L, hematocrit 0.396 L/L, MCV 90.4 fl, prothrombin activity 75.6%, cephalin time 33.6 seg, TB 1.73 mg/dl, GGT 72 U/L, with glucose, urea, creatinine, AST, ALT, ALP, Ca, serum ferritin, amylase, Na, K, TSH, AFP, and autoantibodies (ANA, AMA, SMA) within normal values. Hepatitis B and C were negative. Doppler ultrasounds and computed tomography (CT) + abdominal reconstruction with volume-rendering phase (Figs. 1 and 2) showed a dilated right suprahepatic vein, in its distal end an expansion in the two converging aneurysmatic segmental right portal branches. At this stage no portal flow is seen in the other branches. The main portal branch and the left branch had a normal caliber. The spleen was normal in size. The gallbladder and pancreas had no changes. No free fluid. An inferior vena cava to the left, with retroaortic iliac bifurcation and iliac veins being prominent. There is some increased density in the mesenteric fat due to diffuse, likely venous engorgement.