Ettinger Portosystemic Shunt Liver

Front 1

In normal circulation, how is blood returned from the liver to the systemic circulation?

Back 1

portal vein

Front 2

The pancrease, spleen, stomach, and intestines blood then gose to the ____ and exits into the ____

Back 2

liver/hepatic veins
caudal vena cava

Front 3

What structure in the fetal circulation that bypasses the hepatic circulation. If dosen't close, then it becomes PSS.

Back 3

ductus venosus

Front 4

The pancrease, spleen, stomach, and intestines blood then gose to the ____ and exits into the ____

Back 4

liver/hepatic veins
caudal vena cava

Front 5

These shunts are found in large breed dogs. These dogs also tend to show more severe clinical signs.

Back 5

IHPSS

Front 6

These types of shunts are found in small toy breed dogs

Back 6

EHPSS

Front 7

Acquired shunts are MC occur due to this

Back 7

chronic protal hypertension which leads to opening of fetal vessels

Front 8

MC clinical sign of PSS?
How much of the liver must be destroyed for that to happen?

Back 8

hepatic encephalopathy
70%

Front 9

What type of shunt is most common in cats?

Back 9

EHPSS

Front 10

What are C/S and signalment for PSS?

Back 10

<2 years of age
"fail to thrive"
CNS, GI and urinary issues
Ptylasm in cats
GI ulcers

Front 11

What other problems should be looked for in dogs/cats with PSS?

Back 11

other congential defects such as cryptorchidism adn heart murmurs

Front 12

What ocular abnormality should be looked for

Back 12

Front 13

What clin path changes should suspect of PSS (7)

Back 13

nonregenerative normocytic/normochromic anemia
target cells
thrombocytopenia
K9: decreased BUN, Alb, Cholest, glucose
Fe: Decreased BUN/Creat
2-3X ALP/ALT
Decreased USG and ammonium biurate cyrstals.

Front 14

What is the name of the urinary crystals found with PSS?

Back 14

ammonium biurate

Front 15

Back 15

ammonium biurate

Front 16

What is a recommended test for PSS?

Back 16

bile acid (12 hour fast)
2 hours after eating a meal

Front 17

What is the route/pathogenesis of bile?

Back 17

liver produces bile acids
stored in gallbladder
secreted into duodenum
aid in lipid metabolism and fat digestion
resorbed in the illeum
enter portal circulation
enter the liver

Front 18

Besides bile acids, what other test can be done to DX PSS?

Back 18

Ammonium tollerance test; however, it must be run within 20 min of collection. Cannot be done if have HE.

Front 19

What immaging modalities can be used to DX PSS?

Back 19

US
Scintigraphy
CT angiography - gold standard
MRI angiography
portovenography - jejunal vein catheterization

Front 20

Medical TX for PSS:

Back 20

Enemas
lactulose
AB: metronidazole, ampicillin, neomycin
TX for coagulopathy if present
TX for GI ulceration - H2 blockers, sucralfate etc.
TX for seizure control
TX for cerebral edema
Hepatoprotective TX: SAMe, Ursodeoxycholic acid, Vit E, Milk thistle (Silymarin) and L-carnitine.

Front 21

MST of dogs with only medical managment for PSS?

Back 21

MST 9.9 months

Front 22

What is the TX of choice for PSS?

Back 22

SX

Front 23

What is the goal of PSS SX

Back 23

To occulde the vessel completely and redirect blood flow to the liver. Partial shunt occulsion has a worse prognosis.
However, small % of patients can have complete shunt ligation without portal hypertension

Front 24

What happens if ligation occurs too acutely:

Back 24

ascities
intesting congesion
diarrhea
hypoxia
bowel death
multiple acquired PSS

Front 25

What are some of the gradual shunt occulsion devices

Back 25

ameroid constrictor
cellophane bands
hydraulic occluder

Front 26

Why are IHPSS more difficult that EHPSS

Back 26

larger shunts
located within the parenchyma
not easy to find

Front 27

Why is it more difficult/even possible to completely occlusion?

Back 27

larger size of vessel
and difficult to place gradual occulding devices.

Front 28

Complication rates are higher with which type of PSS?

Back 28

30-75% for IHPSS
9-50% for EHPSS

Front 29

What is a novel intravascular approach for IHPSS?

Back 29

PTCE
percutaneous transvenous coil embolization
Few complications ~15%

Front 30

Gerneral complications following PSS attenuation:

Back 30

neurologic abnormalitites(seizures)
acute portal hypertension (ascities, abd pain, hypotension)
persistent shunting - recurrent C/S

Front 31

What additional risk do IHPSS have?

Back 31

GI ulceration and bleeding which is the most common long-term morbidity and mortality
Life long antacid therapy needed.

Front 32

Perioperative managment of cats with PSS is similar to dogs except for the high frequency of

Back 32

neurological signs both peroperatively and postoperatively despite medical therapy

Front 33

Post-operative rate of EHPSS in cats is

Back 33

Low - just like in dogs

Front 34

What are hepatic arteriovenous malformations?

Back 34

rare vascular anomalies involving mulitple arterial comminunications to the portal vein.

Front 35

TX for HAVM?

Back 35

liver lobectomy, ligation of the nutrient artery or fluoroscopically guided glue amolization of the abnomral vessles.

Front 36

Long term outcome for hepatic arteriovenous malformations?

Back 36

fair to good 40-60%
75% of dogs need dietary of medical TX too

Front 37

When are biochemical panels evaluated post-sx?

Back 37

1 month, then wean medical management over the next 2-4 weeks.

Front 38

Prognosis for medical managment along for PSS is

Back 38

guarded to poor due to progressive liver atrophy and C/S.

Front 39

Is there any correlation between bile acid levels, serum protein levels, ALB, liver anzymes and survival times?

Back 39

No

Front 40

Prognosis for medical managment along for PSS is

Back 40

guarded to poor due to progressive liver atrophy and C/S.

Front 41

EHPSS mortality rates
with ligation vs. guradal constriction devices

Back 41

up to 30%
approx <10%

Front 42

Is there any correlation between bile acid levels, serum protein levels, ALB, liver anzymes and survival times?

Back 42

No

Front 43

What is the most common cause of death after EHPSS SX?

Back 43

consistent neurological signs.

Front 44

EHPSS mortality rates
with ligation vs. guradal constriction devices

Back 44

up to 30%
approx <10%

Front 45

Prognosis for medical managment along for PSS is

Back 45

guarded to poor due to progressive liver atrophy and C/S.

Front 46

What is the most common cause of death after EHPSS SX?

Back 46

consistent neurological signs.

Front 47

IHSS MST?

Back 47

1-3 yr

Front 48

Is there any correlation between bile acid levels, serum protein levels, ALB, liver anzymes and survival times?

Back 48

No

Front 49

EHPSS mortality rates
with ligation vs. guradal constriction devices

Back 49

up to 30%
approx <10%

Front 50

What is the most common cause of death after EHPSS SX?

Back 50

consistent neurological signs.

Front 51

IHSS MST?

Back 51

1-3 yr

Front 52

BW, TP, ALB< and BUN have been identified as prognostic factors in which type of shunt?

Back 52

IHPSS

Front 53

80% post-operative complication rate has occured with this type of shunt?

Back 53

IHPSS

Front 54

What procedure has a periprocudeal survival for HAVM of 100%

Back 54

glue embolization

Front 55

Cats have up to ___% have postoperative complications poast SX for PSS.

Back 55

75%

Front 56

What are the two main complications postoperatively for cats with PSS?

Back 56

generalized seizures
and central blindness (generally resoves with time)

Front 57

Despite the increased complications in cats, overall ____ rate is low

Back 57

mortality

Front 58

Dogs with acquired PSS often present with these C/S

Back 58

ascities
HE

Front 59

What is the TX for acquired PSS?

Back 59

ligation of individual shunts dosen't work
caval banding
survival times for SX vs. medical are similar