Difference between revisions of "Portosystemic Shunt"

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Also known as: '''''Portocaval Shunt — Patent Ductus Venosus — Portosystemic Vascular Anomalies
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==Introduction==
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'''Portosystemic shunts (PSS)''' are anomalous vascular connections between the portal and systemic venous systems.  These vessels shunt blood from the '''hepatic portal vein''' (deriving from the stomach, intestines, [[Pancreas - Anatomy & Physiology|pancreas]] and [[Spleen - Anatomy & Physiology|spleen]]) directly into '''systemic venous system''', bypassing the [[Liver - Anatomy & Physiology|liver]].
  
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==Signalment==
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Portosystemic shunts may be '''congenital''' or they may be '''acquired''' with diseases that cause portal hypertension.  In the developing embryo, the cardinal veins form the systemic abdominal veins (the caudal vena cava, azygos, renal and gonadal veins) whereas the vitelline veins form the hepatic sinusoids, the portal vein and its tributaries, of which the largest are the left gastric, splenic, cranial and caudal mesenteric and gastroduodenal veins.  The [[Foetal Circulation - Anatomy & Physiology|ductus venosus]], a component of the foetal circulation that directs blood from the umbilical vein to the vena cava, is also part of the vitelline system.  If a functional blood vessel (ductus venosus or otherwise) connects the vitelline and cardinal systems after birth, a PSS develops.  However, in the normal animal, there are numerous non-functional connections between the two systems that may open if the pressure in the portal vein rises, leading to the formation of multiple extrahepatic acquired shunts in disease that cause portal hypertension.  Although most congenital shunts run from the portal vein to the vena cava, their embryological origin explains why shunts may also run from the splenic or gastroduodenal veins to the vena cava or azygos vein.
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*Relatively common in dog, especially small breed dogs
 
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*Purebred dogs are more at risk
 
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*Occasionally seen in cats, horses, cows and pigs
 
  
 +
Congenital shunts represent approximately 70% of the total number diagnosed in dogs and constitute the majority of those diagnosed in cats.  Congenital shunts usually involve a single (or occasionally double) anomalous vessel which may be located outside of the hepatic parenchyma (extrahepatic) or within it (intrahepatic).  Extrahepatic shunts accounts for 63% of single shunts in the dog and they are most commonly found in miniature and toy breeds.  Intrahepatic shunts are often located within the left lobes of the liver and occur due to persistence of the foetal [[Foetal Circulation - Anatomy & Physiology|ductus venosus]]<ref>White RN, Burton CA. '''Anatomy of the patent ductus venosus in the dog.''' ''Vet Rec. 2000 Apr 8;146(15):425-9.''</ref>.  This form of shunt is most common in large breed dogs and patent ductus venosus is an inherited condition in Irish wolfhounds.  Intrahepatic shunts running through the central or right liver lobes are recognised and these may have a different embryological origin.
  
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==Description==
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Acquired shunts represent approximately 20% of those diagnosed in dogs and they often consist of multiple small vessels.  They arise due to portal hypertension, following an increased resistance to portal blood flow.  The increased pressure in the portal vein and its tributaries causes numerous non-functional microvascular communications with the systemic venous system to open.  The causes of portal hypertension are numerous and they may be divided into pre-hepatic, hepatic and post-hepatic:
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'''Portosystemic shunts (PSS)''' are anomalous vascular connections between the portal and systemic venous systems.  This allows for some portal blood draining from the [[Alimentary - Anatomy & Physiology #Stomach|stomach]], [[Alimentary - Anatomy & Physiology #Small Intestine|intestines]], [[Pancreas - Anatomy & Physiology|pancreas]] and [[Spleen - Anatomy & Physiology|spleen]] to bypass the [[Liver - Anatomy & Physiology|liver]] and drains directly into the systemic circulation.  PSS may be congenital or acquired secondary to portal hypertension.
+
*Pre-hepatic
 +
**'''Right-sided congestive heart failure''', including '''cardiac tamponade'''.
 +
*Hepatic
 +
**'''Acute fulminant hepatitis''', '''chronic hepatic failure with fibrosis''' or '''[[Hepatic Neoplasia|neoplasia]]'''
 +
*Post-hepatic
 +
**'''[[Thrombosis|Thrombosis of the portal vein]]''', '''hepatic arteriovenous fistulae''' and '''congenital hypoplasia of the portal vein.'''
  
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Congenital PSS occurs in approximately 70% of PSS in dogs and majority of PSS in cats.  It commonly present as a single, or at most double, extrahepatic or intrahepatic anomalous vessel.  Extrahepatic PSS accounts for 63% of single shunts in dog and is more commonly found in miniature and toy-breed dogs. Intrahepatic shunts are usually left-sided, resulting from persistent foetal [[Foetal Circulation - Anatomy & Physiology|ductus venosus]], and more common in large breed dogs. Right-sided or central intrahepatic shunts are recognised and these may have a different embryological origin.
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The pathophysiology of PSS relates to the shunting of portal blood directly into the systemic circulation, resulting in hyperammonaemia and [[Hepatic Encephalopathy|hepatic encephalopathy]].  Animals with PSS also have reduced function of the hepatic component of the monocyte phagocyte system (chiefly the Kupffer cells) and they often develop bacteraemia.  Gram negative bacteria deriving from the GI tract are involved most commonly.  This phenomenon may be of greater importance with acquired PSS <ref>Tobias KM, Besser TE. '''Evaluation of leukocytosis, bacteremia, and portal vein partial oxygen tension in clinically normal dogs and dogs with portosystemic shunts.''' ''J Am Vet Med Assoc. 1997 Sep 15;211(6):715-8.''</ref><ref>Howe LM, Boothe DM, Boothe HW. '''Detection of portal and systemic bacteremia in dogs with severe induced hepatic disease and multiple portosystemic shunts.''' ''Am J Vet Res. 1999 Feb;60(2):181-5.''</ref>.
  
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Acquired PSS occurs in approximately 20% of PSS and often consists of multiple shunts.  They arise due to portal hypertension, following an increased resistance to portal blood flow.  This leads to opening of some of the numerous normal, non-functional microvascular communications.  Underlying causes of portal hypertension included acute fulminant hepatitis, [[Hepatic Lipidosis - WikiClinical|hepatic fibrosis]], [[Hepatic Neoplasia - WikiClinical|hepatic neoplasia]], portal vein [[Thrombosis - Pathology|thrombosis]], hepatic arteriovenous fistulae and congenital hypoplasia of the portal vein.
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==Signalment==
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Congenital portosystemic shunts are diagnosed regularly in dogs under one year of age, although they may be ten years old or more at presentation.  Extrahepatic shunts occur most commonly in dogs of the small or toy breeds, including Shih tzus, West Higland white terriers, Maltese terriers and Yorkshire terriers.  Intrahepatic shunts are much less common and occur in larger breeds such as Irish wolfhounds (in which patent ductus venosus is thought to be inherited<ref>van Steenbeek FG, Leegwater PA, van Sluijs FJ, Heuven HC, Rothuizen J. '''Evidence of inheritance of intrahepatic portosystemic shunts in Irish Wolfhounds.''' ''J Vet Intern Med. 2009 Jul-Aug;23(4):950-2. Epub 2009 May 30.''</ref>), golden retrievers and Australian cattle dogs<ref>Hunt GB. '''Effect of breed on anatomy of portosystemic shunts resulting from congenital diseases in dogs and cats: a review of 242 cases.''' ''Aust Vet J. 2004 Dec;82(12):746-9.''</ref>. The condition occurs occasionally in cats, horses, cows and pigs.
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The pathophysiology of PSS relates to the shunting of blood directly from the systemic circulation, resulting in hyperammonaemia and [[Hepatic Encephalopathy]].
 
  
 +
Acquired shunts occur in animals with portal hypertension, of which the most common causes are [[Hepatitis, Chronic|chronic hepatitis]] in dogs and cholangitis in cats.
  
 
==Diagnosis==
 
==Diagnosis==
 
===Clinical Signs===
 
===Clinical Signs===
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*Young animals, usually under 1 years of ages, but can sometimes be up to 10 years or older
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All portosystemic shunts are likely to cause [[Hepatic Encephalopathy|hepatic encephalopathy]](HE) and PSS is the major cause of this disease. HE mainly causes waxing and waning neurological signs, including central blindness, seizures, depression and bizarre behaviour.  Cats often show hypersalivation/ptyalism.
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*Failure to thrive, small body stature or weight loss
 
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*Waxing and waning neurological signs due to [[Hepatic Encephalopathy|hepatic encephalopathy]]. These are usually most severe an hour or two post prandial but this may not be obvious in all cases
 
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**Bizarre behaviour
 
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**[[Forebrain Disease - Pathology #Circling, Head Pressing, Compulsive Walking|Head pressing]]
 
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**[[Forebrain Disease - Pathology #Seizures|Seizures]]
 
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**Intermittent blindness. 
 
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*Ptyalism in cats
 
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*Dysuria, stranguria, haematuria, pollakiuria and urethral obstruction
 
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**An increase in ammonium concentration in the blood decreases the ability of enzymes to convert [[Urate Metabolism - Pathology|uric acid]] to allantoin, thereby resulting in urate urolithiasis.
 
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*Intermittent [[Stomach and Abomasum Consequences of Gastric Disease - Pathology|vomiting]] or [[Diarrhoea|diarrhoea]]
 
  
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In additon, animals with congenital PSS may show the following signs:
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*'''Failure to thrive''', small body size or weight loss.  It may be useful to compare the animal to its littermates to assess whether it is stunted.
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*'''Urinary tract signs''', including dysuria, stranguria, haematuria and pollakiuria.  These signs occur because an increased blood ammonia concentration decreases the ability of enzymes to convert [[Urate Metabolism - Pathology|uric acid]] to allantoin, resulting in urate urolithiasis and urethral obstruction.  Ammonium biurate are the most common uroliths to be formed.
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*'''Polyuria and polydipsia''' occur for reasons that are not fully understood.  Urea synthesis is reduced in animals with PSS (because ammonia is not taken up by the liver in the normal way) and a reduction in the urea concentration of the renal medulla reduces the ability of the kidney to concentrate urine.  The hypofunctional liver probably also degrades cortisol at a reduced rate, increasing the circulating concentration of this diuretic hormone. 
 +
*Intermittent '''gastro-intestinal signs''' such as [[Vomiting|vomiting]] and [[Diarrhoea|diarrhoea]].
 +
*'''Ascites''' may occur due to [[Hypoalbuminaemia|hypoalbuminaemia]].
 +
*'''Bleeding tendencies''' due to coagulopathy, but this condition is often subclinical.
 +
*Cats may develop '''copper-coloured irises''' because they do not produce the normal yellow/green pigments in their livers.
 +
*Animals may have other '''congenital abnormalities''', including [[Hernia|hernias]] and cryptorchidism.
 +
 +
Animals suffering from primary liver disease with acquired PSS may show signs associated with the underlying disease, including [[Icterus|icterus]], hepatomegaly, pain on abdominal palpation, inappetance and polyuria and polydipsia.  Such animals may also show ascites due to portal hypertension and this may be a possible source of confusion as the same sign is seen with congenital PSS.
  
 
===Laboratory Tests===
 
===Laboratory Tests===
 
====Haematology====
 
====Haematology====
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*Microcytosis
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Animals with congenital PSS often have '''microcytic normochromic red blood cells''' due to sequestration of iron <ref>Simpson KW, Meyer DJ, Boswood A, White RN, Maskell IE. '''Iron status and erythrocyte volume in dogs with congenital portosystemic vascular anomalies.''' ''J Vet Intern Med. 1997 Jan-Feb;11(1):14-9.''</ref>.  '''Leucocytosis''' may occur as a response to bacteraemia due to a reduction in hepatic phagocytic activity.
 +
 
 +
Animals with inflammatory liver disease may have '''leucocytosis''' of various types and may have '''acanthocytic''' red blood cells.
  
 
====Biochemistry====
 
====Biochemistry====
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*Decreased blood urea nitrogen (BUN)
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The following features might be expected on a biochemical profile of an animal with a congenital PSS:
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*Hypoalbuminaemia
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*'''Decreased serum urea concentration''', due to reduced hepatic synthesis
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*Hypocholesterolaemia
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*'''[[Hypoalbuminaemia]]''' due to reduced synthesis.
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*Hypoglycaemia
+
*'''Hypocholesterolaemia''' due to disruption of the entero-hepatic circulation so that cholesterol must be used constantly to synthesise new bile acids because those returning from the GI tract cannot be extracted by the liver in sufficient quantities.
 +
*'''Hypoglycaemia''', which often occurs with acute HE.
  
 
====Other Tests====
 
====Other Tests====
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*Increased postprandial ± preprandial [[Liver - Anatomy & Physiology #Bile Acids|bile acids]]
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*'''Increased postprandial ± preprandial [[Liver - Anatomy & Physiology #Bile Acids|bile acid]]''' concentrations.  Bile acids are normally removed from the portal blood by the liver but, in an animal with PSS, they enter the systemic venous system directly.  If the preprandial level is elevated beyond ~100 umol/l, a bile acid stimulation test will not achieve any higher sensitivity for the detection of PSS.  A bile acid stimulation test is performed by measuring preprandial bile acids, feeding the animal and measureing post prandial bile acids two hours later.  The preprandial sample may occasionally be higher than the postprandial if a gall bladder contraction occurred just before the first sample was taken.  Measurement of serum bile acid concentration has a sensitivity of >90% for the detection of congenital portosystemic shunts but its specificity is much lower than that of an ammonia tolerance test because it may be elevated in many other types of liver disease <ref name="one">Gerritzen-Bruning MJ, van den Ingh TS, Rothuizen J. '''Diagnostic value of fasting plasma ammonia and bile acid concentrations in the identification of portosystemic shunting in dogs.''' ''J Vet Intern Med. 2006 Jan-Feb;20(1):13-9.''</ref>.
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*Increased ammonia levels
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*'''Increased blood ammonia concentration''' is diagnostic of PSS for the same reasons as are elevated bile acids.  An ammonia tolerance test can be performed by administering ammonium chloride (or a small meal) to a fasted animal and measuring the change in blood ammonia level.  Samples must be frozen immediately after collection as continued red blood cell metabolism will artificially raise ammonia levels in stored samples.  Elevated fasting ammonia concentration is reported to have a sensitivity of 100% for the detection of congenital portosystemic shunts <ref name="one">nothing</ref>.
 +
*'''Reduced serum iron concentration''' due to sequestration.
 +
*'''Clotting times''' can be measured in animals where a coagulopathy is suspected.
 +
*'''Analysis of urine''' will show that it has a low specific gravity and cytological examination may reveal the presence of urate crystals which resemble 'thorn apples' or 'mites'.  If the animal is suffering from cystitis or urethral obstruction due to urolithiasis, haematuria, pyuria or proteinuria may also be detected.
  
 +
===Diagnostic Imaging===
 +
====Radiography====
 +
A definitive diagnosis relies on visualisation of the shunting blood vessel but radiography may reveal changes that are supportive of a diagnosis of PSS:
 +
*'''Renomegaly''' is thought to occur as the kidneys attempt to remove and metabolise ammonia.
 +
*'''Microhepatica''' probably occurs because the liver is deprived of growth factors from the pancreas and other abdominal organs which are usually carried to it in the portal blood, for example the somatomedins (insulin-like growth factors, IGFs).
 +
*'''Urate uroliths''' are '''radiolucent''' and will not be detected by radiographs.
 +
 +
====Ultrasonography====
 +
The shunting vessel may be identified by ultrasound scan<ref>d'Anjou MA, Penninck D, Cornejo L, Pibarot P. '''Ultrasonographic diagnosis of portosystemic shunting in dogs and cats.''' ''Vet Radiol Ultrasound. 2004 Sep-Oct;45(5):424-37.''</ref>, especially if a '''colour flow Doppler''' facility is available.  Congenital shunts are usually thin-walled, tortuous vessels with '''turbulent flow''' and it should be noted that they may run between the tributaries of the portal vein and the azygos vein, rather than the portal vein itself.  Acquired shunting vessels can often be located around the cranial pole of the left kidney.  It may require some skill to find a shunting vessel. 
 +
 +
Scans of the urinary bladder and urethra may reveal the presence of '''urate uroliths''' and '''thickening of the bladder wall''' due to cystitis.
  
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===Diagnostic Imaging===
+
====Positive Contrast Portography====
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A definitive diagnosis relies on visualisation of the shunting blood vessel.  This may be done with either ultrasonography or contrast portography or at surgery.
+
The gold standard technique for diagnosis of PSS is mesenteric portovenography, which involves catheterisation of a mesenteric vein and injection of a water soluble iodine-containing contrast medium into the portal circulation.  Radiographs are then made to follow the course of the medium through the portal system and liver.  The medium can be injected percutaneously into the spleen (under ultrasound guidance) in a less invasive variant of this technique but the spleen may overly the location of the shunt in the subsequent radiographs.
  
 +
====Nuclear Scintigraphy====
 +
A further technique available in some veterinary hospitals is nuclear scintigraphy.  A radioactive substance (pertechnetate Tc 99m) bound to a marker substance is administered by high colonic infusion and a gamma camera is used to image the liver and heart.  In animals with a shunt, the material will reach the heart at a faster rate (within 2 seconds) than in normal animals.
  
 
==Treatment==
 
==Treatment==
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*Surgical ligation of the anomalous vessels
+
In animals with acquired PSS, the underlying cause should be treated and [[Hepatic Encephalopathy|hepatic encephalopathy should be managed]]. '''Acquired shunts should never be ligated''' as they occur as a compensatory response to portal hypertension and ligation would increase portal pressure.
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**Portal hypertension is possible post ligation.  For this reason, a partial ligation is performed initally, followed by a complete ligation a few months later.
 
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*Medical treatment of [[Hepatic Encephalopathy #Medical Management|Hepatic Encephalopathy]]
 
  
 +
Animals affected by congenital PSS may be managed either medically or surgically but a recent study has shown that those undergoing surgical ligation of the shunting vessel have a longer median survival time<ref>Greenhalgh SN, Dunning MD, McKinley TJ, Goodfellow MR, Kelman KR, Freitag T, O'Neill EJ, Hall EJ, Watson PJ, Jeffery ND '''Comparison of survival after surgical or medical treatment in dogs with a congenital portosystemic shunt.''' ''J Am Vet Med Assoc. 2010 Jun 1;236(11):1215-20.''</ref>.  Medical management is often employed in those animals that show few clinical signs on presentations, are older or which have a shunt that is not amenable to ligation. 
 +
 +
===Medical Management===
 +
A suitable regime would incorporate the following features:
 +
*A '''diet''' with '''protein of high quality''' and with both soluble and insoluble fibre.  Severe protein restriction is only necessary in animals showing signs of HE and it is otherwise detrimental because animals with PSS are often hypoalbuminaemic.  A protein of high quality is selected so that excess amino acids are not available to colonic bacteria and suitable sources include cottage cheese in dogs or white fish in cats.  Soluble fibre acts in a similar manner to lactulose (below) whereas insoluble fibre decreases intestinal transit time and helps to prevent constipation.
 +
*'''[[Lactulose]]''', a synthetic disaccharide that causes acidification of the colonic environment when it is fermented by bacteria. This environment promotes the conversion of ammonia to ammonium and the latter ions are not easily absorbed due to their electrical charge.  The trapped ammonia is therefore excreted in faeces. Lactulose is also a cathartic laxative that reduces the amount of time available for colonic bacteria to act on surplus amino acids.
 +
*Administration of '''oral antibiotics''' to reduce the numbers of colonic bacteria.  Neomycin, ampicillin or metronidazole are commonly used for this purpose.
 +
 +
===Surgical Ligation===
 +
This is the treatment of choice for congenital PSS but it may cause adverse effects in the post-operative period.  Consideration must also be given to the choice of anaesthetic drugs as animals with PSS have a reduced ability to metabolise drugs in the liver and often undergo prolonged recoveries from sedation or anaesthesia.  Highly protein bound drugs should also be avoided as their effective concentration will be increased in hypoalbuminaemia.
 +
 +
====Anaesthesia====
 +
Benzodiazepines should be avoided as they are highly protein-bound and they may also worsen any pre-existing HE.  Phenothiazine tranquilisers (acepromazine) and barbiturates should be avoided because they are metabolised in the liver. 
 +
 +
During anaesthesia, blood glucose concentration should be measured regularly in animals with congenital PSS as they quickly become hypoglycaemic.  Consideration should also be given to warming strategies (such as heat pads, warmed intra-venous fluids and insulation) as they also rapidly become hypothermic.
 +
 +
====Surgical Procedure====
 +
It is highly advisable to refer animals with PSS to a specialist centre for surgical management and post-operative intensive care.  The abdomen should be explored thoroughly in case of multiple shunts and the bladder should also be examined as it may contain urate uroliths that could be removed during the same procedure.
 +
 +
=====Extrahepatic Shunts=====
 +
A ventral midline coeliotomy is performed and the shunting vessel is identified.  If pre-operative imaging revealed the location of the shunt, it should be found easily but intra-operative mesenteric portovenography can be performed by catheterising a jejunal vein and instilling contrast medium.  As a guide, the vena cava accepts blood from the renal veins and the small phrenico-abdominal veins before it reaches the hepatic hilus.  Any vessel that joins the vena cava between the phrenico-abdominal and hepatic veins is abnormal.
 +
 +
Direct ligation of the shunt will cause a large rise in portal pressure, reducing the venous drainage and perfusion of the organs draining into the portal vein.  For this reason, a tributary to the portal vein (such as a jejunal vein) should be catheterised to allow the portal pressure to be measured directly during the procedure.  When the shunt is ligated, the portal pressure should not rise by more than 10 cm of water from its baseline value and it should not rise above an absolute value of '''20-23 cm of water'''.  If the portal pressure rises above this level, the surgeon is likely to notice that the '''intestines are blanched''' (due to reduced perfusion), that the '''pulses in the mesenteric arteries are hyperkinetic''', that the '''intestines show vigorous contractility''' and that the '''pancreas appears oedematous'''.  If any of these signs are observed, the shunt should be attenuated rather than completely ligated.
 +
 +
For complete ligation, silk is often used as a suture material in dogs because its presence promotes a fibrous reactions which reinforces the ligature.  Although silk is often categorised as a non-absorbable suture material, its strength is lost after 6 months and it is often fully absorbed after approximately 2 years.  Better knot security can be achieved if the silk is wet when the ligatures are tied.  Since silk does not stimulate a strong inflammatory response in cats, it is preferable to use the synthetic non-absorbable monofilament polypropylene in this species.
 +
 +
If the shunt cannot be ligated, attenuation may be achieved by three major techniques:
 +
*An '''ameroid constrictor''' consists of a ring of stainless steel with an inner collar of casein.  When the ring is applied around a vessel, the casein sheath swells gradually to occlude blood flow and it may also stimulate some fibrosis.  Placement of an ameroid constrictor also results in a much shorter surgical time than complete ligation <ref>Hurn SD, Edwards GA. '''Perioperative outcomes after three different single extrahepatic portosystemic shunt attenuation techniques in dogs: partial ligation, complete ligation and ameroid constrictor placement.''' ''Aust Vet J. 2003 Nov;81(11):666-70.''</ref>.   
 +
*'''Cellophane banding''' involves the application of cellophane around the shunt. Real cellophane is made from regenerated cellulose. <ref>Smith et al [http://www.ncbi.nlm.nih.gov/pubmed/23550728] </ref>evaluated commonly used sources of cellophane and determined that only one was cellulose based and not a plastic. This may be why historical outcomes of cellophane banding for attenuation of portosystemic shunts has been variable, especially in cats. Cellophane has reportedly variable outcomes in cats, and some surgeons will prefer it not be used in this species, however recent literature suggests that good outcomes can still be achieved<ref>[http://www.ncbi.nlm.nih.gov/pubmed/21194327]</ref>.Cellophane made from cellulose is a foreign material and is passed around the shunting vessel and secured in place to stimulate fibrosis, resulting in gradual occlusion. There is now a commercial supplier of cellophane for veterinary use<ref>[https://www.cellovet.com]</ref>. 
 +
*'''Partial ligation''' is achieved by applying a loose ligature to the shunt so that some blood flow still occurs.  In a proportion of animals, a complete ligation will then have to be performed at a later date.
 +
 +
=====Intrahepatic Shunts=====
 +
Intrahepatic shunts are much more difficult to locate and ligate than are extrahepatic shunts and owners should be warned of this fact before a procedure is undertaken.  The shunt may be located by palpation of a soft area over a hepatic lobe or, if the vessel runs within a left lobe, it may be located where it joins the hepatic vein.  Intra-operative ultrasound can also be employed to find a shunt.  Extensive dissection may be required to expose a shunt running through the hepatic parenchyma before it can be ligated and an ultrasonic aspirator can be used for this purpose.   
 +
 +
Another option involves temporarily occluding the hepatic blood flow and incising into the caudal vena cava (an '''intravascular approach''').  The shunt is identified where it enters the vena cava (cranial to the liver) and pledget-buttressed sutures are used to close the mouth of the vessel.
 +
 +
====Post-operative Care====
 +
The following syndromes may be encountered after ligation of a shunt:
 +
*'''Intra-abdominal haemorrhage''', which may require a further surgical procedure if severe or may be managed with a belly bandage.
 +
*'''Portal hypertension''', causing ascites, haemorrhagic diarrhoea, septic shock and a painful abdomen.  The abdominal girth is often measured regularly after the surgical procedure to assess the degree of abdominal distension.  Some ascites is to be expected but severe clinical signs warrant a further surgical procedure to loosen the ligature around the shunt.  Ascites should resolve over time but it can be managed with the diuretic spironolactone (because it occurs in part due to inappropriate activation of the renin-angiotensin-aldosterone system).
 +
*'''Portal vein thrombosis''' because portal blood flow may be drastically reduced.
 +
*'''Seizures''' or '''status epilepticus''', particularly in small breeds of dog.  Seizures occur most commonly 1-3 days after ligation and probably result from rebalancing of neurotransmitter levels in the CNS.  Long-term anticonvulsant therapy may be required and some animals may acquire permanent defects, such as blindness.
  
 
==Prognosis==
 
==Prognosis==
−
Excellent prognosis in dog for resolution of clinical signs after total surgical ligation.  However, the response of cat to surgical intervention in cats is less promising than in dogs.
+
The prognosis for outcome depends on the age of presentation and the urea concentration at presentation, with older dogs with higher levels of urea having better outcomes.  Dogs usually respond very well to total surgical ligation if they do not experience severe adverse effects in the week following the procedure but the response in cats is less favourable.
  
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{{Learning
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|flashcards = [[Small Animal Soft Tissue Surgery Q&A 20]]
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|literature search = [http://www.cabdirect.org/search.html?q=%28%28title%3A%28Portosystemic%29+OR+title%3A%28Portocaval%29%29+AND+title%3A%28shunt%29%29+OR+title%3A%28%22Patent+Ductus+Venosus%22%29+OR+title%3A%28%22Portosystemic+Vascular+Anomal*%22%29 Portosystemic Shunt publications]
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|pages = [[PDF Document - Portosystemic Shunts]]
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|Vetstream = [https://www.vetstream.com/felis/Content/Disease/dis00664.asp Congenital Portosystemic Shunt]
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}}
  
 
==References==
 
==References==
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<references/>
 
*Ettinger, S.J. and Feldman, E. C. (2000) '''Textbook of Veterinary Internal Medicine Diseases of the Dog and Cat Volume 2''' (Fifth Edition) ''W.B. Saunders Company''.
 
*Ettinger, S.J. and Feldman, E. C. (2000) '''Textbook of Veterinary Internal Medicine Diseases of the Dog and Cat Volume 2''' (Fifth Edition) ''W.B. Saunders Company''.
 
*Fossum, T. W. et. al. (2007) '''Small Animal Surgery (Third Edition)''' ''Mosby Elsevier''.
 
*Fossum, T. W. et. al. (2007) '''Small Animal Surgery (Third Edition)''' ''Mosby Elsevier''.
 
*Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''.
 
*Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''.
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*Watson, P. (1997) '''Decision making in the management of portosystemic shunts''' ''In Practice'' 19;106 - 120 [http://inpractice.bvapublications.com/cgi/reprint/19/3/106?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=portosystemic+shunt&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT]
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* [http://inpractice.bvapublications.com/cgi/reprint/19/3/106?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=portosystemic+shunt&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT Watson, P. (1997) '''Decision making in the management of portosystemic shunts''' ''In Practice'' 19;106 - 120]
  
  
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==From Pathology==
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{{review}}
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{{OpenPages}}
  
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*seen in dogs and cats
 
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*Inherited in Irish wolfhounds
 
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**Not known what mode of inheritance in this breed
 
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*these are vessles that allow the blood in the portal vein to bypass the [[Liver - Anatomy & Physiology|liver]] tissue (parenchyma)
 
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*congenital
 
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**shunting from the portal vein directly into the vena cava, azygos or renal vein
 
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**this is the common type seen in small dogs and cats - usually a single communication between the vessels, occasionally multiple
 
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**larger breeds tend to have the shunting to the vena cava take place within the [[Liver - Anatomy & Physiology|liver]] itself (persistent ductus venosus)
 
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*acquired
 
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**due to hepatic fibrosis whcih results in increased resistance of flow of blood into the [[Liver - Anatomy & Physiology|liver]] from the portal vein
 
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**produces hypertension in the portal vein and fluid accumulates in the peritoneal cavity - '''ascites'''
 
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**several thin-walled tortuous vessels may be seen connecting the mesenteric veins to the vena cava, and the [[Liver - Anatomy & Physiology|liver]] looks atrophic and fibrosed
 
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*Bacteraemia is a common finding in severe hepatic disease and PSS in humans
 
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**portal or systemic
 
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**usually Gram-negatives
 
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**also seen in dogs with PSS
 
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**presumably due to reduced effectiveness of phagocytic activity in these [[Liver - Anatomy & Physiology|livers]]
 
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**or due to shunting of blood around the liver
 
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NB: portosystemic shunt is a major cause of hepatic encephalopathy (need link), therefore the affected animals are stunted and seem dull or stupid because of the toxic substances in their systemic circulation
 
 
[[Category:Liver_-_Developmental_Pathology]]
 
[[Category:Liver_-_Developmental_Pathology]]
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[[Category:Liver_-_Circulatory_Disturbances]]
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[[Category:Liver Diseases - Dog]][[Category:Liver Diseases - Cat]][[Category:Liver Diseases - Cattle]][[Category:Liver Diseases - Sheep]][[Category:Alimentary Diseases - Pig]][[Category:Liver Diseases - Horse]]
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[[Category:Vascular Diseases - Dog]][[Category:Vascular Diseases - Cat]][[Category:Cardiovascular Diseases - Cattle]][[Category:Cardiovascular Diseases - Sheep]][[Category:Cardiovascular Diseases - Pig]][[Category:Vascular Diseases - Horse]]
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[[Category:Expert_Review - Small Animal]]
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[[Category:Cardiology Section]]

Latest revision as of 09:27, 21 June 2016


Also known as: Portocaval Shunt — Patent Ductus Venosus — Portosystemic Vascular Anomalies

Introduction

Portosystemic shunts (PSS) are anomalous vascular connections between the portal and systemic venous systems. These vessels shunt blood from the hepatic portal vein (deriving from the stomach, intestines, pancreas and spleen) directly into systemic venous system, bypassing the liver.

Portosystemic shunts may be congenital or they may be acquired with diseases that cause portal hypertension. In the developing embryo, the cardinal veins form the systemic abdominal veins (the caudal vena cava, azygos, renal and gonadal veins) whereas the vitelline veins form the hepatic sinusoids, the portal vein and its tributaries, of which the largest are the left gastric, splenic, cranial and caudal mesenteric and gastroduodenal veins. The ductus venosus, a component of the foetal circulation that directs blood from the umbilical vein to the vena cava, is also part of the vitelline system. If a functional blood vessel (ductus venosus or otherwise) connects the vitelline and cardinal systems after birth, a PSS develops. However, in the normal animal, there are numerous non-functional connections between the two systems that may open if the pressure in the portal vein rises, leading to the formation of multiple extrahepatic acquired shunts in disease that cause portal hypertension. Although most congenital shunts run from the portal vein to the vena cava, their embryological origin explains why shunts may also run from the splenic or gastroduodenal veins to the vena cava or azygos vein.

Congenital shunts represent approximately 70% of the total number diagnosed in dogs and constitute the majority of those diagnosed in cats. Congenital shunts usually involve a single (or occasionally double) anomalous vessel which may be located outside of the hepatic parenchyma (extrahepatic) or within it (intrahepatic). Extrahepatic shunts accounts for 63% of single shunts in the dog and they are most commonly found in miniature and toy breeds. Intrahepatic shunts are often located within the left lobes of the liver and occur due to persistence of the foetal ductus venosus[1]. This form of shunt is most common in large breed dogs and patent ductus venosus is an inherited condition in Irish wolfhounds. Intrahepatic shunts running through the central or right liver lobes are recognised and these may have a different embryological origin.

Acquired shunts represent approximately 20% of those diagnosed in dogs and they often consist of multiple small vessels. They arise due to portal hypertension, following an increased resistance to portal blood flow. The increased pressure in the portal vein and its tributaries causes numerous non-functional microvascular communications with the systemic venous system to open. The causes of portal hypertension are numerous and they may be divided into pre-hepatic, hepatic and post-hepatic:

  • Pre-hepatic
    • Right-sided congestive heart failure, including cardiac tamponade.
  • Hepatic
    • Acute fulminant hepatitis, chronic hepatic failure with fibrosis or neoplasia
  • Post-hepatic

The pathophysiology of PSS relates to the shunting of portal blood directly into the systemic circulation, resulting in hyperammonaemia and hepatic encephalopathy. Animals with PSS also have reduced function of the hepatic component of the monocyte phagocyte system (chiefly the Kupffer cells) and they often develop bacteraemia. Gram negative bacteria deriving from the GI tract are involved most commonly. This phenomenon may be of greater importance with acquired PSS [2][3].

Signalment

Congenital portosystemic shunts are diagnosed regularly in dogs under one year of age, although they may be ten years old or more at presentation. Extrahepatic shunts occur most commonly in dogs of the small or toy breeds, including Shih tzus, West Higland white terriers, Maltese terriers and Yorkshire terriers. Intrahepatic shunts are much less common and occur in larger breeds such as Irish wolfhounds (in which patent ductus venosus is thought to be inherited[4]), golden retrievers and Australian cattle dogs[5]. The condition occurs occasionally in cats, horses, cows and pigs.

Acquired shunts occur in animals with portal hypertension, of which the most common causes are chronic hepatitis in dogs and cholangitis in cats.

Diagnosis

Clinical Signs

All portosystemic shunts are likely to cause hepatic encephalopathy(HE) and PSS is the major cause of this disease. HE mainly causes waxing and waning neurological signs, including central blindness, seizures, depression and bizarre behaviour. Cats often show hypersalivation/ptyalism.

In additon, animals with congenital PSS may show the following signs:

  • Failure to thrive, small body size or weight loss. It may be useful to compare the animal to its littermates to assess whether it is stunted.
  • Urinary tract signs, including dysuria, stranguria, haematuria and pollakiuria. These signs occur because an increased blood ammonia concentration decreases the ability of enzymes to convert uric acid to allantoin, resulting in urate urolithiasis and urethral obstruction. Ammonium biurate are the most common uroliths to be formed.
  • Polyuria and polydipsia occur for reasons that are not fully understood. Urea synthesis is reduced in animals with PSS (because ammonia is not taken up by the liver in the normal way) and a reduction in the urea concentration of the renal medulla reduces the ability of the kidney to concentrate urine. The hypofunctional liver probably also degrades cortisol at a reduced rate, increasing the circulating concentration of this diuretic hormone.
  • Intermittent gastro-intestinal signs such as vomiting and diarrhoea.
  • Ascites may occur due to hypoalbuminaemia.
  • Bleeding tendencies due to coagulopathy, but this condition is often subclinical.
  • Cats may develop copper-coloured irises because they do not produce the normal yellow/green pigments in their livers.
  • Animals may have other congenital abnormalities, including hernias and cryptorchidism.

Animals suffering from primary liver disease with acquired PSS may show signs associated with the underlying disease, including icterus, hepatomegaly, pain on abdominal palpation, inappetance and polyuria and polydipsia. Such animals may also show ascites due to portal hypertension and this may be a possible source of confusion as the same sign is seen with congenital PSS.

Laboratory Tests

Haematology

Animals with congenital PSS often have microcytic normochromic red blood cells due to sequestration of iron [6]. Leucocytosis may occur as a response to bacteraemia due to a reduction in hepatic phagocytic activity.

Animals with inflammatory liver disease may have leucocytosis of various types and may have acanthocytic red blood cells.

Biochemistry

The following features might be expected on a biochemical profile of an animal with a congenital PSS:

  • Decreased serum urea concentration, due to reduced hepatic synthesis
  • Hypoalbuminaemia due to reduced synthesis.
  • Hypocholesterolaemia due to disruption of the entero-hepatic circulation so that cholesterol must be used constantly to synthesise new bile acids because those returning from the GI tract cannot be extracted by the liver in sufficient quantities.
  • Hypoglycaemia, which often occurs with acute HE.

Other Tests

  • Increased postprandial ± preprandial bile acid concentrations. Bile acids are normally removed from the portal blood by the liver but, in an animal with PSS, they enter the systemic venous system directly. If the preprandial level is elevated beyond ~100 umol/l, a bile acid stimulation test will not achieve any higher sensitivity for the detection of PSS. A bile acid stimulation test is performed by measuring preprandial bile acids, feeding the animal and measureing post prandial bile acids two hours later. The preprandial sample may occasionally be higher than the postprandial if a gall bladder contraction occurred just before the first sample was taken. Measurement of serum bile acid concentration has a sensitivity of >90% for the detection of congenital portosystemic shunts but its specificity is much lower than that of an ammonia tolerance test because it may be elevated in many other types of liver disease [7].
  • Increased blood ammonia concentration is diagnostic of PSS for the same reasons as are elevated bile acids. An ammonia tolerance test can be performed by administering ammonium chloride (or a small meal) to a fasted animal and measuring the change in blood ammonia level. Samples must be frozen immediately after collection as continued red blood cell metabolism will artificially raise ammonia levels in stored samples. Elevated fasting ammonia concentration is reported to have a sensitivity of 100% for the detection of congenital portosystemic shunts [7].
  • Reduced serum iron concentration due to sequestration.
  • Clotting times can be measured in animals where a coagulopathy is suspected.
  • Analysis of urine will show that it has a low specific gravity and cytological examination may reveal the presence of urate crystals which resemble 'thorn apples' or 'mites'. If the animal is suffering from cystitis or urethral obstruction due to urolithiasis, haematuria, pyuria or proteinuria may also be detected.

Diagnostic Imaging

Radiography

A definitive diagnosis relies on visualisation of the shunting blood vessel but radiography may reveal changes that are supportive of a diagnosis of PSS:

  • Renomegaly is thought to occur as the kidneys attempt to remove and metabolise ammonia.
  • Microhepatica probably occurs because the liver is deprived of growth factors from the pancreas and other abdominal organs which are usually carried to it in the portal blood, for example the somatomedins (insulin-like growth factors, IGFs).
  • Urate uroliths are radiolucent and will not be detected by radiographs.

Ultrasonography

The shunting vessel may be identified by ultrasound scan[8], especially if a colour flow Doppler facility is available. Congenital shunts are usually thin-walled, tortuous vessels with turbulent flow and it should be noted that they may run between the tributaries of the portal vein and the azygos vein, rather than the portal vein itself. Acquired shunting vessels can often be located around the cranial pole of the left kidney. It may require some skill to find a shunting vessel.

Scans of the urinary bladder and urethra may reveal the presence of urate uroliths and thickening of the bladder wall due to cystitis.

Positive Contrast Portography

The gold standard technique for diagnosis of PSS is mesenteric portovenography, which involves catheterisation of a mesenteric vein and injection of a water soluble iodine-containing contrast medium into the portal circulation. Radiographs are then made to follow the course of the medium through the portal system and liver. The medium can be injected percutaneously into the spleen (under ultrasound guidance) in a less invasive variant of this technique but the spleen may overly the location of the shunt in the subsequent radiographs.

Nuclear Scintigraphy

A further technique available in some veterinary hospitals is nuclear scintigraphy. A radioactive substance (pertechnetate Tc 99m) bound to a marker substance is administered by high colonic infusion and a gamma camera is used to image the liver and heart. In animals with a shunt, the material will reach the heart at a faster rate (within 2 seconds) than in normal animals.

Treatment

In animals with acquired PSS, the underlying cause should be treated and hepatic encephalopathy should be managed. Acquired shunts should never be ligated as they occur as a compensatory response to portal hypertension and ligation would increase portal pressure.

Animals affected by congenital PSS may be managed either medically or surgically but a recent study has shown that those undergoing surgical ligation of the shunting vessel have a longer median survival time[9]. Medical management is often employed in those animals that show few clinical signs on presentations, are older or which have a shunt that is not amenable to ligation.

Medical Management

A suitable regime would incorporate the following features:

  • A diet with protein of high quality and with both soluble and insoluble fibre. Severe protein restriction is only necessary in animals showing signs of HE and it is otherwise detrimental because animals with PSS are often hypoalbuminaemic. A protein of high quality is selected so that excess amino acids are not available to colonic bacteria and suitable sources include cottage cheese in dogs or white fish in cats. Soluble fibre acts in a similar manner to lactulose (below) whereas insoluble fibre decreases intestinal transit time and helps to prevent constipation.
  • Lactulose, a synthetic disaccharide that causes acidification of the colonic environment when it is fermented by bacteria. This environment promotes the conversion of ammonia to ammonium and the latter ions are not easily absorbed due to their electrical charge. The trapped ammonia is therefore excreted in faeces. Lactulose is also a cathartic laxative that reduces the amount of time available for colonic bacteria to act on surplus amino acids.
  • Administration of oral antibiotics to reduce the numbers of colonic bacteria. Neomycin, ampicillin or metronidazole are commonly used for this purpose.

Surgical Ligation

This is the treatment of choice for congenital PSS but it may cause adverse effects in the post-operative period. Consideration must also be given to the choice of anaesthetic drugs as animals with PSS have a reduced ability to metabolise drugs in the liver and often undergo prolonged recoveries from sedation or anaesthesia. Highly protein bound drugs should also be avoided as their effective concentration will be increased in hypoalbuminaemia.

Anaesthesia

Benzodiazepines should be avoided as they are highly protein-bound and they may also worsen any pre-existing HE. Phenothiazine tranquilisers (acepromazine) and barbiturates should be avoided because they are metabolised in the liver.

During anaesthesia, blood glucose concentration should be measured regularly in animals with congenital PSS as they quickly become hypoglycaemic. Consideration should also be given to warming strategies (such as heat pads, warmed intra-venous fluids and insulation) as they also rapidly become hypothermic.

Surgical Procedure

It is highly advisable to refer animals with PSS to a specialist centre for surgical management and post-operative intensive care. The abdomen should be explored thoroughly in case of multiple shunts and the bladder should also be examined as it may contain urate uroliths that could be removed during the same procedure.

Extrahepatic Shunts

A ventral midline coeliotomy is performed and the shunting vessel is identified. If pre-operative imaging revealed the location of the shunt, it should be found easily but intra-operative mesenteric portovenography can be performed by catheterising a jejunal vein and instilling contrast medium. As a guide, the vena cava accepts blood from the renal veins and the small phrenico-abdominal veins before it reaches the hepatic hilus. Any vessel that joins the vena cava between the phrenico-abdominal and hepatic veins is abnormal.

Direct ligation of the shunt will cause a large rise in portal pressure, reducing the venous drainage and perfusion of the organs draining into the portal vein. For this reason, a tributary to the portal vein (such as a jejunal vein) should be catheterised to allow the portal pressure to be measured directly during the procedure. When the shunt is ligated, the portal pressure should not rise by more than 10 cm of water from its baseline value and it should not rise above an absolute value of 20-23 cm of water. If the portal pressure rises above this level, the surgeon is likely to notice that the intestines are blanched (due to reduced perfusion), that the pulses in the mesenteric arteries are hyperkinetic, that the intestines show vigorous contractility and that the pancreas appears oedematous. If any of these signs are observed, the shunt should be attenuated rather than completely ligated.

For complete ligation, silk is often used as a suture material in dogs because its presence promotes a fibrous reactions which reinforces the ligature. Although silk is often categorised as a non-absorbable suture material, its strength is lost after 6 months and it is often fully absorbed after approximately 2 years. Better knot security can be achieved if the silk is wet when the ligatures are tied. Since silk does not stimulate a strong inflammatory response in cats, it is preferable to use the synthetic non-absorbable monofilament polypropylene in this species.

If the shunt cannot be ligated, attenuation may be achieved by three major techniques:

  • An ameroid constrictor consists of a ring of stainless steel with an inner collar of casein. When the ring is applied around a vessel, the casein sheath swells gradually to occlude blood flow and it may also stimulate some fibrosis. Placement of an ameroid constrictor also results in a much shorter surgical time than complete ligation [10].
  • Cellophane banding involves the application of cellophane around the shunt. Real cellophane is made from regenerated cellulose. [11]evaluated commonly used sources of cellophane and determined that only one was cellulose based and not a plastic. This may be why historical outcomes of cellophane banding for attenuation of portosystemic shunts has been variable, especially in cats. Cellophane has reportedly variable outcomes in cats, and some surgeons will prefer it not be used in this species, however recent literature suggests that good outcomes can still be achieved[12].Cellophane made from cellulose is a foreign material and is passed around the shunting vessel and secured in place to stimulate fibrosis, resulting in gradual occlusion. There is now a commercial supplier of cellophane for veterinary use[13].
  • Partial ligation is achieved by applying a loose ligature to the shunt so that some blood flow still occurs. In a proportion of animals, a complete ligation will then have to be performed at a later date.
Intrahepatic Shunts

Intrahepatic shunts are much more difficult to locate and ligate than are extrahepatic shunts and owners should be warned of this fact before a procedure is undertaken. The shunt may be located by palpation of a soft area over a hepatic lobe or, if the vessel runs within a left lobe, it may be located where it joins the hepatic vein. Intra-operative ultrasound can also be employed to find a shunt. Extensive dissection may be required to expose a shunt running through the hepatic parenchyma before it can be ligated and an ultrasonic aspirator can be used for this purpose.

Another option involves temporarily occluding the hepatic blood flow and incising into the caudal vena cava (an intravascular approach). The shunt is identified where it enters the vena cava (cranial to the liver) and pledget-buttressed sutures are used to close the mouth of the vessel.

Post-operative Care

The following syndromes may be encountered after ligation of a shunt:

  • Intra-abdominal haemorrhage, which may require a further surgical procedure if severe or may be managed with a belly bandage.
  • Portal hypertension, causing ascites, haemorrhagic diarrhoea, septic shock and a painful abdomen. The abdominal girth is often measured regularly after the surgical procedure to assess the degree of abdominal distension. Some ascites is to be expected but severe clinical signs warrant a further surgical procedure to loosen the ligature around the shunt. Ascites should resolve over time but it can be managed with the diuretic spironolactone (because it occurs in part due to inappropriate activation of the renin-angiotensin-aldosterone system).
  • Portal vein thrombosis because portal blood flow may be drastically reduced.
  • Seizures or status epilepticus, particularly in small breeds of dog. Seizures occur most commonly 1-3 days after ligation and probably result from rebalancing of neurotransmitter levels in the CNS. Long-term anticonvulsant therapy may be required and some animals may acquire permanent defects, such as blindness.

Prognosis

The prognosis for outcome depends on the age of presentation and the urea concentration at presentation, with older dogs with higher levels of urea having better outcomes. Dogs usually respond very well to total surgical ligation if they do not experience severe adverse effects in the week following the procedure but the response in cats is less favourable.


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References

  1. ↑ White RN, Burton CA. Anatomy of the patent ductus venosus in the dog. Vet Rec. 2000 Apr 8;146(15):425-9.
  2. ↑ Tobias KM, Besser TE. Evaluation of leukocytosis, bacteremia, and portal vein partial oxygen tension in clinically normal dogs and dogs with portosystemic shunts. J Am Vet Med Assoc. 1997 Sep 15;211(6):715-8.
  3. ↑ Howe LM, Boothe DM, Boothe HW. Detection of portal and systemic bacteremia in dogs with severe induced hepatic disease and multiple portosystemic shunts. Am J Vet Res. 1999 Feb;60(2):181-5.
  4. ↑ van Steenbeek FG, Leegwater PA, van Sluijs FJ, Heuven HC, Rothuizen J. Evidence of inheritance of intrahepatic portosystemic shunts in Irish Wolfhounds. J Vet Intern Med. 2009 Jul-Aug;23(4):950-2. Epub 2009 May 30.
  5. ↑ Hunt GB. Effect of breed on anatomy of portosystemic shunts resulting from congenital diseases in dogs and cats: a review of 242 cases. Aust Vet J. 2004 Dec;82(12):746-9.
  6. ↑ Simpson KW, Meyer DJ, Boswood A, White RN, Maskell IE. Iron status and erythrocyte volume in dogs with congenital portosystemic vascular anomalies. J Vet Intern Med. 1997 Jan-Feb;11(1):14-9.
  7. ↑ 7.0 7.1 Gerritzen-Bruning MJ, van den Ingh TS, Rothuizen J. Diagnostic value of fasting plasma ammonia and bile acid concentrations in the identification of portosystemic shunting in dogs. J Vet Intern Med. 2006 Jan-Feb;20(1):13-9. Cite error: Invalid <ref> tag; name "one" defined multiple times with different content
  8. ↑ d'Anjou MA, Penninck D, Cornejo L, Pibarot P. Ultrasonographic diagnosis of portosystemic shunting in dogs and cats. Vet Radiol Ultrasound. 2004 Sep-Oct;45(5):424-37.
  9. ↑ Greenhalgh SN, Dunning MD, McKinley TJ, Goodfellow MR, Kelman KR, Freitag T, O'Neill EJ, Hall EJ, Watson PJ, Jeffery ND Comparison of survival after surgical or medical treatment in dogs with a congenital portosystemic shunt. J Am Vet Med Assoc. 2010 Jun 1;236(11):1215-20.
  10. ↑ Hurn SD, Edwards GA. Perioperative outcomes after three different single extrahepatic portosystemic shunt attenuation techniques in dogs: partial ligation, complete ligation and ameroid constrictor placement. Aust Vet J. 2003 Nov;81(11):666-70.
  11. ↑ Smith et al [1]
  12. ↑ [2]
  13. ↑ [3]


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