Influence of shunt occlusion on liver volume and functions in hyperammonemic cirrhosis patients having large porto-systemic shunts: a randomized control trial.

BACKGROUND AND AIMS: Spontaneous-portosystemic-shunts (SPSS) in cirrhosis deprive the liver of nutrient-rich portal blood and contribute to recurrent hepatic encephalopathy (HE). We evaluated the effects of shunt occlusion and redirecting portal blood to liver on its volume and functions. METHODS: Cirrhosis patients presenting with recurrent HE and having SPSS were randomized to receive standard medical treatment (SMT) or shunt occlusion (SO). The later was performed by plug-assisted or balloon-occluded retrograde transvenous obliteration. The primary endpoint was change in liver volume after a minimum follow-up of 3 months. Secondary objectives included clinical course, liver disease severity indices, arterial ammonia levels and bone density. RESULTS: Of 40 enrolled patients, 4 in SMT and 2 in SO group were lost to follow-up. The SO was complete in 17 and partial in one, achieving non-recurrence of HE in 17 (94.4%). In these patients, the mean liver volume increased (baseline 1040 ± 335 ml to 1132 ± 322 ml, 8.8% increase, p < 0.001) and was observed in 16/18 (88.89%) patients. In the SMT group, the liver volume decreased (baseline 988 ± 270 ml to 904 ± 226 ml, 8.6% reduction, p = 0.009) during the same period. Serum albumin increased in SO group (2.92 ± 0.40 g/dl to 3.30 ± 0.49 g/dl, p = 0.006) but reduced in SMT group (2.89 ± 0.43 g/dl to 2.59 ± 0.65 g/dl, p = 0.047). After SO, the patients showed a reduction in serum-ammonia levels (181.06 ± 86.21 to 107.28 ± 44.53 µ/dl, p = 0.001) and an improvement in MELD-Na and bone density compared to SMT group. There were no major adverse events following shunt occlusion. CONCLUSION: Occlusion of large SPSS results in improving the volume and synthetic functions of the liver by restoring hepato-petal portal flow besides reducing serum-ammonia level and recurrence of HE. CLINICALTRIALS: gov number, NCT03293459.

Unusual cause of seizure in a child: Intracranial calcified metastasis of osteosarcoma.

Intracranial parenchymal calcification has both benign and malignant etiologies. Calcifications by malignant etiologies are comparatively rare. Malignant calcification has numerous causes. Calcified brain metastasis from osteosarcoma is one such cause. We present histopathologically confirmed intracranial calcified metastasis in a 10 year old girl. This girl had received treatment for primary osteosarcoma of the left femur with pulmonary metastases. Radiological imaging with Positron emission tomography-computed tomography revealed an intracranial calcified lesion in the frontal lobe and she was successfully operated for the same. The malignant causes of intracranial calcifications are reviewed and radiological differential diagnoses of malignant intracranial calcifications are discussed in this case report. Prior history, strong clinical suspicion, and radiological imaging are needed to arrive at the diagnosis of intracranial calcified metastasis from primary osteosarcoma of the appendicular skeleton.