Liver function tests may be abnormal and the fistula can usually be demonstrated by ultrasonography with Doppler, computed tomography or magnetic resonance imaging. However, most patients proceed to angiography as the definitive diagnostic procedure. The patient illustrated below was

a 55-year-old man who presented with abdominal pain after meals and persistent diarrhea. His symptoms began after a suicidal stab wound into the abdomen 8 months previously. Screening blood tests including liver function tests were within the reference range. However, abdominal ultrasonography with Doppler showed marked dilatation of the left portal vein with an arterial RXDX-106 cost waveform in the lateral segment (Figure 1). An abdominal computed tomography scan showed engorgement of the right and left portal veins, a superior mesenteric vein of small caliber and edematous thickening of the entire colonic wall. A celiac angiogram detected an abnormal shunt

in which the GDC-0449 left hepatic artery drained into the portal vein (Figure 2). A superior mesenteric angiogram also showed flow into the left hepatic artery via duodenal collaterals. The initial treatment was an attempt to close the fistula using embolization of the left hepatic artery with N-butyl-cyanoacrylate and microcoils. However, this was unsuccessful and was followed by surgical ligation of the left hepatic artery. Surgery was followed by a rapid reduction in abdominal pain and with resolution of diarrhea. In the above case, we attribute abdominal pain and diarrhea to a decrease in blood flow in mesenteric

arteries causing intestinal ischemia. The majority of patients with intrahepatic arterioportal fistulae can be treated by embolization of the hepatic artery but, in a minority, this may fail because of large fistulae with rapid flow rates. Extrahepatic arterioportal fistulae are usually treated by surgery. Contributed by “
“A 53-year-old man was investigated because of chronic diarrhea over 2 months. He had a history of human immunodeficiency virus (HIV) infection and a prior hospitalization for acquired immunodeficiency syndrome (AIDS)-related neutropenic fever treated with broad spectrum antibiotics followed by initiation of highly-active antiretroviral MCE公司 therapy. He complained of a 30-pound weight loss and 6 episodes of watery diarrhea per day. Clinical examination revealed an afebrile, lethargic man with hypovolemia (blood pressure, 80/50 and heart rate, 130 beats/min). There was mild abdominal tenderness in the left lower quadrant without distension or peritoneal signs and pitting edema to mid-shin. Laboratory studies revealed white blood cell count 9,300 cells/µl, sodium 126 mmol/L, and absolute CD4 count 41 cells/µl. The HIV viral load was undetectable (HIV RNA <400 copies/mL). The albumin was 1.4 g/dL, decreased from 3.1 g/dL one month previously. Stool cultures and enzyme immunosorbent assay (EIA) for Clostridium difficile toxins A&B were negative.