A 74-year-old woman with HCV cirrhosis associated with Child stage B8 haemochromatosis with multiple admissions with the diagnosis of recurrent severe hepatic encephalopathy (17 admissions in 20 months). Conventional abdominal ultrasound showed a heterogeneous liver parenchyma with no space-occupying lesions compatible with chronic liver disease, a 13 mm patent portal vein and a homogeneous, slightly enlarged spleen (13 cm). On the other hand, the doppler study showed reversal of flow in the portal and splenic veins, without a clear portal-systemic shunt. AngioCT was then performed, revealing a marked collateral circulation and an associated spleno-renal shunt. The patient maintained persistently elevated ammonium levels. Partial embolisation of the shunt with microcoils was performed using interventional radiology, resulting in a marked slowing of blood flow through the shunt. Post-embolisation abdominal ultrasound showed hepatopetal portal flow with persistent hepatopoietic flow in the splenic vein and decreased perisplenic collateral circulation.
After embolisation the patient experienced immediate clinical improvement and ammonium levels normalised. In the 18 months following shunt embolisation, she required hospital admission on three occasions, in relation to mild hydropic decompensation, hepatorenal syndrome and grade I hepatic encephalopathy. Post-embolisation oral endoscopy was performed and no oesophago-gastric varices were observed.

