Hisashi Hidaka

Kaoru Fujii

Keiji Matsunaga

Wasaburo Koizumi

Yasuaki Furue

Journal of Medical Case Reports

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JOURNAL OF MEDICAL
CASE REPORTS
Furue et al. Journal of Medical Case Reports  (2015) 9:62 
DOI 10.1186/s13256-015-0546-3CASE REPORT Open AccessIntraperitoneal bleeding after balloon-occluded
retrograde transvenous obliteration: a case report
Yasuaki Furue1, Hisashi Hidaka1*, Kaoru Fujii2, Keiji Matsunaga2 and Wasaburo Koizumi1Abstract
Introduction: Hepatic encephalopathy is an important underlying cause of consciousness disorders. Possible causes
of hepatic encephalopathy include hepatic failure and shunt encephalopathy resulting from a portosystemic
venous shunt. Balloon-occluded retrograde transvenous obliteration is generally an effective treatment for hepatic
encephalopathy.
Case presentation: A 73-year-old Japanese woman was referred to our department because of disturbance of
consciousness. Hepatic venous angiography disclosed a shunt between her left hepatic vein and her portal
vein. The shunt was closed with the use of coils and N-butyl 2-cyanoacrylate. One hour after the procedure,
she lost consciousness. The bleeding was ascribed to catheter-induced vascular injury. Emergency angiography
was performed, and hemostasis was achieved with coils.
Conclusion: Although bleeding is relatively rare after balloon-occluded retrograde transvenous obliteration,
postoperative intraperitoneal bleeding is a serious complication.
Keywords: Hepatic encephalopathy, Hepatic vein, Portal vein, ShuntIntroduction
Hepatic encephalopathy is an important underlying cause
of consciousness disorders and should be included in the
differential diagnosis [1]. Possible causes of hepatic en-
cephalopathy include hepatic failure and shunt ence-
phalopathy resulting from a portosystemic venous shunt
[1,2]. Balloon-occluded retrograde transvenous obliter-
ation (BRTO) is generally an effective and safe treatment
for hepatic encephalopathy [3-6]. Here we report a case
of intraperitoneal bleeding that occurred after BRTO.Case presentation
A 73-year-old Japanese woman presented disturbance of
consciousness and wooziness. Her history included an
atrial septal defect (ASD), tricuspid valve insufficiency,
and atrial fibrillation. Closure of the ASD and tricuspid
annuloplasty had been performed in October 1998. In
February 2011, abdominal ultrasonography revealed a
portosystemic venous shunt. She had been experiencing* Correspondence: hisashi7@kitasato-u.ac.jp
1Department of Gastroenterology, Internal Medicine, Kitasato University
School of Medicine, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku,
Sagamihara, Kanagawa 252-0374, Japan
Full list of author information is available at the end of the article
© 2015 Furue et al.; licensee BioMed Central. T
Commons Attribution License (http://creativec
reproduction in any medium, provided the or
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unless otherwise stated.progressive bouts of wooziness since September 2012
and consulted a local physician. Hepatic encephalopathy
was suspected, and she was referred to our hospital. Her
blood ammonia level was 187μg/dL (normal range: 12 to
66μg/dL), suggesting that the wooziness was caused by
hyperammonemia. Contrast-enhanced computed tomog-
raphy (CT) showed a shunt involving the lateral superior
branch of the portal vein (P2), the lateral inferior branch
of the portal vein (P3), and the hepatic vein. She was
admitted to undergo shunt closure by BRTO.
She had no history of cigarette smoking or drinking.
Her Japan Coma Scale was 1, her blood pressure was
132/81mmHg, and her pulse rate was 93 beats/minute.
A physical examination revealed no distinct abnormal-
ities. Her platelet count was decreased, but there were
no liver-function abnormalities potentially related to the
hyperammonemia (Table 1). The results of tests for hepa-
titis B surface antigen and hepatitis C virus antibodies
were negative. Viral hepatitis was, therefore, ruled out.
Contrast-enhanced CT showed a shunt involving her
left hepatic vein, P2, and P3 (Figure 1). Upper gastrointes-
tinal endoscopy showed no evidence of esophagogastric
varices. After admission, she was restricted to high-
protein meals and received an amino-acid preparation.his is an Open Access article distributed under the terms of the Creative
ommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
iginal work is properly credited. The Creative Commons Public Domain
g/publicdomain/zero/1.0/) applies to the data made available in this article,
Table 1 Laboratory data before the balloon-occluded
retrograde transvenous obliteration procedure
WBC 3000 /μL CK 86 IU/L
RBC 32,900 /μL T.Cho 134 mg/dL
Hb 11.7 g/dL TG 28 mg/dL
Ht 35.8 % Glu 75 mg/dL
Plt 97,000 /μL BUN 12.9 mg/dL
PT-% 55.2 % Cr 0.56 mg/dL
aPTT 32.4 Seconds NH3 109 μg/dL
TP 6.5 g/dL Na 141 mEq/L
Alb 3.4 g/dL K 4.2 mEq/L
T.Bil 1.3 mg/dL Cl 108 mEq/L
D.Bil 0.6 mg/dL Ca 9.1 mg/dL
AST 24 IU/L CRP <0.1 mg/dL
ALT 20 IU/L AFP 3.7 ng/mL
LDH 264 IU/L DCP 18 mAU/mL
ALP 178 IU/L HBsAg (−)
γ-GTP 36 IU/L HCV-Ab (−)
AMY 70 IU/L
AFP: alpha-fetoprotein; Alb: albumin; ALP: alkaline phosphatase; ALT: alanine
aminotransferase; AMY: amylase; aPTT: activated partial thromboplastin time;
AST: aspartate aminotransferase; BUN: blood urea nitrogen; Ca: calcium; CK: creatine
kinase; Cl: chloride; Cr: creatinine; CRP: C-reactive protein; D.Bil: direct bilirubin; DCP:
des-gamma-carboxy prothrombin; γ-GTP: γ-glutamyl transpeptidase; Glu: glucose;
Hb: hemoglobin; HBsAg: hepatitis B surface antigen; HCV-Ab: hepatitis C virus anti-
bodies; Ht: hematocrit; K: potassium; LDH: lactate dehydrogenase; Na: sodium; NH3:
ammonia; Plt: platelet; PT-%: prothrombin time percent; RBC: red blood cell; T.Bil:
total bilirubin; T.Cho: total cholesterol; TG: triglycerides; TP: total protein; WBC: white
blood cell.
Figure 1 Abdominal contrast-enhanced computed tomography. Abdo
lateral superior branch (P2) and the lateral inferior branch of the portal vein
anastomosed to P2 and P3 via shunts (white arrowheads).
Furue et al. Journal of Medical Case Reports  (2015) 9:62 Page 2 of 4Her wooziness improved 2 days later, and her blood
ammonia returned to a normal level (62μg/dL) within 1
week. Hyperammonemia due to a portosystemic venous
shunt was diagnosed. Because she was elderly and had
decreased cardiac function after closure of the ASD and
tricuspid annuloplasty, surgical treatment was considered
too dangerous. After explaining the situation to her and
her family and receiving informed consent, BRTO was
performed. An approach was made from her right in-
ternal jugular vein. Her left hepatic vein had anastomosed
to the left inferior phrenic vein (Figure 2A). The contrast
medium showed that her left hepatic vein had anasto-
mosed to P3 via a shunt (size: 10mm), thus forming a
loop-like route (Figure 2B). Embolization was performed
using coils on the portal vein side of this route (Figure 2C).
Subsequent angiography of P2 confirmed the presence of
a shunt (size: 6mm) and the blood flow to her hepatic
vein. Embolization was performed using coils on the por-
tal vein side of the shunt (Figure 2D). Coils were again
emplaced to P3, and fine branches were embolized using
a mixture of N-butyl-2-cyanoacrylate (NBCA) and iodized
oil (ratio, 1:3). In addition, coils were emplaced in the por-
tal vein side of the shunt involving P3 and her left hepatic
vein. Angiography via the route last approached revealed
the blood flow from P3 to her left hepatic vein. Therefore,
coils were placed at the hepatic vein side of the shunt
involving P3 and her left hepatic vein. Embolization was
performed with the use of NBCA. After embolization, the
lack of movement of contrast medium in her hepatic vein
was confirmed completing the procedure.minal contrast-enhanced computed tomography shows shunts of the
(P3) with the left hepatic vein (black arrow). The left hepatic vein had
Figure 2 Balloon-occluded retrograde transvenous obliteration of the intrahepatic portosystemic shunt was performed using N-butyl-
2-cyanoacrylate and embolization coils. (A) The left inferior phrenic vein (white arrow) merged into the left hepatic vein (black arrow). (B) The
left hepatic vein (black arrow) via a shunt (size: 10mm; white arrowhead) merged with the lateral inferior branch of the portal vein (P3). The left
hepatic vein was occulted transiently with a balloon. (C) After the shunt was embolized with coils, the lateral superior branch of the portal vein
(P2) also merged with the left hepatic vein via other shunts (size: 6mm; white arrowheads). (D) The shunt was embolized using coils.
Furue et al. Journal of Medical Case Reports  (2015) 9:62 Page 3 of 4After returning to the ward, she presented with pale-
ness, hypotension (systolic blood pressure, 48mmHg),
and an increased pulse rate of 120 beats/minute. Intraper-
itoneal bleeding was suspected, so contrast-enhanced CT
was performed. Slight leakage of contrast medium from
her left inferior phrenic vein was seen (Figure 3A). Angi-
ography revealed leakage of contrast medium from her
left inferior phrenic vein (Figure 3B). Embolization was,
therefore, performed using NBCA and embolization coils.
The procedure was performed while she received a blood
transfusion. On the day after the vascular embolization,
her hemoglobin level returned to her normal level.
Because her state of shock did not improve, she was intu-
bated and admitted to our intensive care unit. She
responded to the blood transfusion, supplementation ofFigure 3 Contrast-enhanced computed tomography and angiography
Remarkable leakage of contrast medium from the left inferior phrenic vein
liver. There were coil embolizations of shunts (black arrows). (B) Angiograp
inferior phrenic vein. (C) Contrast-enhanced computed tomography 2 mon
hemostasis (white arrowhead).coagulation factors, and artificial ventilation management;
the acute phase resolved. The intraperitoneal hematoma
also improved (Figure 3C). Subsequently, pleural effusion
developed in association with elevated portal vein pres-
sure and chronic heart failure but improved after treat-
ment with an oral diuretic (furosemide 20mg/day) and
beta-blocker (carvedilol: 10mg/day). She had general
muscle atrophy, particularly of her skeletal muscles due
to the extensive hospitalization. Therefore, she had phys-
ical therapy rehabilitation for 1 month. She received treat-
ment in our hospital for 3 months and was then
discharged. She subsequently visited our hospital every 2
months after the treatment for 2 years. She has never
since presented with any symptoms of hepatic encephal-
opathy (Figure 4).. (A) Contrast-enhanced computed tomography to diagnose bleeding.
was seen (black arrowhead). There was excessive blood around the
hy revealed leakage of contrast medium (white arrows) from the left
ths later. There were no ascites around the liver. There were coils for
Figure 4 Course of the blood ammonia level. BRTO: balloon-
occluded retrograde transvenous obliteration.
Furue et al. Journal of Medical Case Reports  (2015) 9:62 Page 4 of 4Discussion
To the best of our knowledge, this is the first report in
which intraperitoneal bleeding occurred after BRTO,
which is generally an effective treatment for hepatic
encephalopathy and gastric varices [3-6]. In a Japanese
national survey the incidence of complications after
BRTO (in patients with a prolonged hospital stay) was
only 1.4% [3]. The most common complication was
aggravation of liver dysfunction in 0.66% of patients,
followed by pulmonary failure in 0.17%, gastrointestinal
bleeding in 0.1%, heart failure in 0.06%, and aggravation
of renal dysfunction in 0.06% [3]. Therefore, BRTO is
considered to be a safe procedure.
In the present case, intraperitoneal bleeding might
have been caused by vascular injury due to manipulation
of the catheter, which might have strayed into the left
inferior phrenic vein during BRTO. The left inferior
phrenic vein was not used for shunt embolization in the
present patient. Blood flow from the left inferior phrenic
vein might have been blocked by the inflated balloon,
thereby precluding detection of the vein intraoperatively.
After returning to the ward, the patient had hypotension
and an increased heart rate, and intraperitoneal bleeding
was diagnosed with CT. Transcatheter embolization was
performed under angiographic guidance for hemostasis.
Although the present case was extremely rare, such
complications present a very serious threat. Imaging ex-
aminations such as CT should, therefore, be performed
after BRTO. To provide safer therapy, indications for
treatment (evaluation of hepatic function), and treat-
ment response should be carefully evaluated. On the
basis of our experience with the present patient, our
hospital now requires that CT be performed after BRTO
on the day of the procedure.
Conclusions
BRTO is currently recognized as a relatively safe and
minimally invasive treatment. Intraperitoneal bleedingafter BRTO is relatively rare but serious; therefore, cau-
tion is required, for example our hospital now requires a
CT examination after BRTO on the day of the procedure.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Abbreviations
ASD: Atrial septal defect; BRTO: Balloon-occluded retrograde transvenous
obliteration; CT: Computed tomography; NBCA: N-butyl-2-cyanoacrylate;
P2: Lateral superior branch of the portal vein; P3: Lateral inferior branch of
the portal vein.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
YF was the attending resident, gathered patient information, and
contributed to writing the manuscript. HH was the attending physician,
gathered patient information, and designed and wrote the manuscript. KF,
KM, and WK contributed to the writing of the manuscript. All the authors
read and approved the final version of the manuscript.
Acknowledgements
We thank Robert E. Brandt, Founder, CEO, and CME of MedEd Japan, for
editing the manuscript.
Author details
1Department of Gastroenterology, Internal Medicine, Kitasato University
School of Medicine, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku,
Sagamihara, Kanagawa 252-0374, Japan. 2Department of Diagnostic
Radiology, Kitasato University School of Medicine, Sagamihara, Japan.
Received: 1 October 2014 Accepted: 18 February 2015
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Intraperitoneal bleeding after balloon-occluded retrograde transvenous obliteration: a case report

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Intraperitoneal bleeding after balloon-occluded retrograde transvenous obliteration: a case report

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