TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT-SHUNT AFTER ORTHOTOPIC LIVER-TRANSPLANTATION IN A PATIENT WITH EARLY RECURRENCE OF PORTAL-HYPERTENSION OF UNKNOWN ORIGIN

A 65-year-old italian patient developed complicated portal hypertensio n immediately after orthotopic liver transplantation (OLT) necessitati ng shunt creation. One to five weeks after OLT, massive ascitic fluid losses of up to 121/day developed. Vascular and major hepatic-parenchy mal abnormalities were excluded by duplexsonography, angiography and i nitial histology, respectively. A peritoneovenous shunt (Denver-shunt) on day 31 after OLT reduced (by about 50%) but did not stop ascitic f luid losses. Furthermore, three variceal bleedings occurred after impl antation of the Denver-shunt. Direct portgraphy on day 45 after OLT re vealed portal hypertension (pressure gradient of 26 mmHg) requiring th e implantation of a transjugular intrahepatic portosystemic stent-shun t (TIPS) leading to a reduction of the pressure gradient to 13 mmHg. S ubsequently, ascites resolved within ten days and esophageal varices i mproved. Liver function parameters normalized inspite of recurrence of HCV infection with detection of HCV RNA in serum already in the fifth week after OLT. During follow up, histological findings deteriorated from mild changes to extended fibrosis at day 61 after OLT, which migh t have contributed to the maintenance of portal hypertension. The dete rioration of liver histology was accompanied by an improvement/normali zation of liver graft function. There was no evidence for additional v iral liver infections, e. g. hepatitis B or cytomegalovirus infection. This case illustrates an etiologically unclear syndrome developing di rectly after OLT and reaffirms the effectiveness of TIPS in the treatm ent of complicated portal hypertension even after liver transplantatio n.