Fig. 1. The portal vein (arrows) has been attenuated and displaced by the hypertrophied caudate lobe. A large amount of ascites is present.

This 48 year old male has a long history of ethanol abuse. He was advised to stop drinking on multiple occasions and finally was able to stop in December, 2000. Much to his surprise and disappointment, his alcoholic cirrhosis progressed and his ascites increased. He was admitted to the medical service in June for increasing abdominal girth, increasing lower extremity edema and pain, and mental confusion. Bedside paracenteses have done little to ease his discomfort. He is Childs Stage C+.

The CT scan (Figure 1) showed that the portal vein (arrows) has been attenuated and displaced by the hypertrophied caudate lobe. More inferiorly (Figure 2), the caudate lobe (CL) is hypertrophied; the portal vein (arrow) is of small caliber, laterally rotated and irregular. The remainder of the liver is small; significant ascites is present. Another lower image (Figure 3) shows lateral rotation of the liver with the gallbladder (black arrow) immersed in an ascitic sea outside of a true GB fossa; the portal vein (white arrow) is diminutive.

The CVIR Division was consulted; a TIPSS was deemed inappropriate due to the marked distortion of the portal vein anatomy.

1. Having failed medical therapy, would you "TIP" him and if so how?

2. Is there anything else to offer except a peritoneal shunt?

Case 1197_01 -- Transfemoral Catheterization of the Portal Vein