Left gastric arteriovenous fistula after selective distal splenorenal shunt

We present the case of a 64-year-old alcoholic who had suffered two episodes of hemorrhage from esophageal varices. For control of variceal hemorrhage, he underwent a distal splenorenal shunt. His immediate postoperative course was complicated by the development of marked ascites and intermittent episodes of encephalopathy. Routine postoperative angiography was performed after 4 months and demonstrated a fistula between the left gastric artery and vein. Patency of the shunt was demonstrated by direct percutaneous splenoportography. Two months after this admission, the patient was readmitted with the complaints of anorexia and nausea. Marked encephalopathy was noted. Eight hours following admission, he developed acute abdominal distention and hypotension. An abdominal tap revealed bloody fluid, and the patient was immediately prepared for transport to the operating room. He suffered cardiac arrest during transport, and all efforts at resuscitation were unsuccessful. Although a postmortem examination was not performed, it is suspected the arteriovenous fistula resulted in severe portal venous hypertension leading to intraperitoneal rupture of one of the affected veins, producing a massive hemoperitoneum.