Congenital extrahepatic portosystemic deviation of gastric vein with azygos in a bitch

Background: Portosystemic shunt (PSS), an alteration commonly found in toy dogs, is caused by an anastomosis between the systemic and portal circulation, interfering with the metabolism of several toxins. It can be of congenital or acquired origin and is classified as intra- or extrahepatic. Clinical signs include the gastrointestinal tract, nervous system, and urinary system according to the fraction of the shunt. It is diagnosed by several imaging tests and exploratory laparotomy. Therapy involves drug therapy and/or surgical correction of the anomalous vessels. Thus, the aim is to present an unusual case of extrahepatic cPSS originating from the left gastric vein and insertion into the azygos vein. Case: A 2-year-old female toy poodle, spayed, weighing 2.7 kg was treated with a history of recurrent cystitis and neurological signs such as focal seizures, ataxia, tremors, blindness, lethargy, head pressing, and compulsive gait. Complementary tests revealed normochromic microcytic anemia, neutrophilia-induced leukocytosis, monocytosis, and lymphopenia. Biochemical analysis revealed hypoproteinemia due to hypoglobulinemia, an increase in alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transferase, and a decrease in urea. In the urinalysis, ammonium biurate crystals were detected, and Doppler ultrasound revealed microhepathy and the presence of an anomalous gastrosplenic vein inserted into the azygos vein, a finding compatible with the congenital extrahepatic PSS. Abdominal tomography confirmed vascular deviation with a sinuous path originating from the left gastric and splenic veins, inserting into the azygos vein, measuring approximately 5.95 cm in length. Cranial tomography revealed changes consistent with hepatic encephalopathy. Drug therapy was performed with hydration, liver chow, lactulose, probiotics, metronidazole, S-adenosyl-L-methionine, and ursodeoxycholic acid, and after 15 days, surgery was performed to place a 3.5 mm ameroid constrictor ring for gradual occlusion of the anomalous vessel. The animal recovered well, and a control abdominal ultrasound was repeated 30 days after the procedure, noting that the constrictor had not yet fully occluded the deviation. Doppler imaging revealed a favorable evolution with an increase in the diameter of the portal vein in the hepatopetal direction. The patient was followed-up for a year and had a normal and healthy life. Discussion: Extrahepatic PSS is frequently diagnosed in purebred and toy dogs, commonly occurring between the portal vein and one of its tributaries, with a lower frequency of anomalous vessels between the azygos veins, as in the present report. The patient's age and clinical signs were compatible with the disease, in addition to ammonia biurate crystals and hematological and biochemical alterations. The neurological clinical signs observed were compatible with hepatic encephalopathy secondary to congenital PSS. The imaging examinations facilitated the identification of the extrahepatic vascular anomaly, with the tomography being more accurate and helping in proper surgical planning. Clinical treatment should be performed for presurgical stabilization, and occlusion can be performed by placing cellophane bands or an ameroid constrictor, which is the technique of choice for congenital PSS, as it allows for slow constriction to avoid acute portal hypertension, as in this case, emphasizing that anesthesia in animals with portosystemic shunts must be performed with care.

Anestesia para correção de shunt portossistêmico com anel de ameróide em cão / Anesthesia for the correction of portosystemic shunt with an ameroid ring in a dog

O shunt ou desvio portossistêmico (DPS) é uma conexão anormal entre a circulação portal e sistêmica, que desvia o fluxo sanguíneo do fígado em variados graus. Nesse contexto, uma anestesia de qualidade e segura faz toda diferença na recuperação do paciente. Com isso, o presente trabalho teve o objetivo de relatar a técnica anestésica utilizada para o tratamento cirúrgico de um caso de shunt portossistêmico congênito em um cão da raça Yorkshire Terrier, fêmea, de quatro anos, pesando aproximadamente quatro quilos, que apresentava sintomas neurológicos decorrentes de encefalopatia hepática, devido à DPS. Para a medicação pré-anestésica (MPA), foi utilizado o cloridrato de remifentanila (2mg), na taxa de 10µg/Kg/h. Propofol (1%) foi utilizado para indução anestésica, na dose de 1mg/Kg/min, e para anestesia periglótica foi usado cloridrato de lidocaína (2%), no volume de 0,1mL/Kg. Quanto à manutenção anestésica, foi utilizado isoflurano (100%), em um vaporizador universal, citrato de maropitant (1%) em infusão contínua, na taxa de 30µg/Kg/h, cloridrato de remifentanila (2%), na mesma taxa utilizada na MPA, cetamina (10%), na taxa de 0,6mg/Kg/h, e brometo de rocurônio (10mg/mL), na dose de 0,15mg/Kg. Antes do início da cirurgia, foi realizado um bloqueio intraperitoneal com cloridrato de ropivacaína (0,4mg/Kg) diluída em 0,4mL/Kg, na dose de 0,1mL/Kg. Durante todo o procedimento cirúrgico, não houveram intercorrências nem alterações nos parâmetros fisiológicos. Dessa forma, pôde-se observar a eficácia da técnica anestésica utilizada para correção de shunt portossistêmico em um cão apresentando sintomatologia neurológica.

Shunt or portosystemic deviation (DPS) is an abnormal connection between portal and systemic circulation that diverts blood flow from the liver to varying degrees. In this context, quality and safe anesthesia makes all the difference in the patient's recovery. Thus, the present study aims to report the anesthetic technique used for the surgical treatment of a case of congenital portosystemic shunt in a four-year-old Yorkshire Terrier dog, weighing approximately four kilograms, which presented neurological symptoms resulting from of hepatic encephalopathy due to DPS. For pre-anesthetic medication (MPA), remifentanil hydrochloride (2mg) was used at a rate of 10µg/Kg/h. Propofol (1%) was used for anesthetic induction at a dose of 1mg/kg/min and for periglotic anesthesia lidocaine hydrochloride (2%) in a volume of 0.1mL/kg was used. As for anesthetic maintenance, isoflurane (100%) in a universal vaporizer, maropitant citrate (1%) in continuous infusion, at the rate of 30µg/Kg/h, remifentanil hydrochloride (2%), at the same rate used in MPA, ketamine (10%) at a rate of 0.6mg/kg/h and rocuronium bromide (10mg/mL), at a dose of 0.15mg/kg. Before the start of surgery, an intraperitoneal block was performed with ropivacaine hydrochloride (0.4mg/kg) diluted in 0.4mL/kg, in the dose of 0.1mL/kg. Throughout the surgical procedure, there were no complications or changes in physiological parameters. Thus, it was possible to observe the effectiveness of the anesthetic technique used to correct portosystemic shunt in a dog presenting neurological symptoms.

Anestesia para correção de shunt portossistêmico com anel de ameróide em cão / Anesthesia for the correction of portosystemic shunt with an ameroid ring in a dog

O shunt ou desvio portossistêmico (DPS) é uma conexão anormal entre a circulação portal e sistêmica, que desvia o fluxo sanguíneo do fígado em variados graus. Nesse contexto, uma anestesia de qualidade e segura faz toda diferença na recuperação do paciente. Com isso, o presente trabalho teve o objetivo de relatar a técnica anestésica utilizada para o tratamento cirúrgico de um caso de shunt portossistêmico congênito em um cão da raça Yorkshire Terrier, fêmea, de quatro anos, pesando aproximadamente quatro quilos, que apresentava sintomas neurológicos decorrentes de encefalopatia hepática, devido à DPS. Para a medicação pré-anestésica (MPA), foi utilizado o cloridrato de remifentanila (2mg), na taxa de 10µg/Kg/h. Propofol (1%) foi utilizado para indução anestésica, na dose de 1mg/Kg/min, e para anestesia periglótica foi usado cloridrato de lidocaína (2%), no volume de 0,1mL/Kg. Quanto à manutenção anestésica, foi utilizado isoflurano (100%), em um vaporizador universal, citrato de maropitant (1%) em infusão contínua, na taxa de 30µg/Kg/h, cloridrato de remifentanila (2%), na mesma taxa utilizada na MPA, cetamina (10%), na taxa de 0,6mg/Kg/h, e brometo de rocurônio (10mg/mL), na dose de 0,15mg/Kg. Antes do início da cirurgia, foi realizado um bloqueio intraperitoneal com cloridrato de ropivacaína (0,4mg/Kg) diluída em 0,4mL/Kg, na dose de 0,1mL/Kg. Durante todo o procedimento cirúrgico, não houveram intercorrências nem alterações nos parâmetros fisiológicos. Dessa forma, pôde-se observar a eficácia da técnica anestésica utilizada para correção de shunt portossistêmico em um cão apresentando sintomatologia neurológica.(AU)

Shunt or portosystemic deviation (DPS) is an abnormal connection between portal and systemic circulation that diverts blood flow from the liver to varying degrees. In this context, quality and safe anesthesia makes all the difference in the patient's recovery. Thus, the present study aims to report the anesthetic technique used for the surgical treatment of a case of congenital portosystemic shunt in a four-year-old Yorkshire Terrier dog, weighing approximately four kilograms, which presented neurological symptoms resulting from of hepatic encephalopathy due to DPS. For pre-anesthetic medication (MPA), remifentanil hydrochloride (2mg) was used at a rate of 10µg/Kg/h. Propofol (1%) was used for anesthetic induction at a dose of 1mg/kg/min and for periglotic anesthesia lidocaine hydrochloride (2%) in a volume of 0.1mL/kg was used. As for anesthetic maintenance, isoflurane (100%) in a universal vaporizer, maropitant citrate (1%) in continuous infusion, at the rate of 30µg/Kg/h, remifentanil hydrochloride (2%), at the same rate used in MPA, ketamine (10%) at a rate of 0.6mg/kg/h and rocuronium bromide (10mg/mL), at a dose of 0.15mg/kg. Before the start of surgery, an intraperitoneal block was performed with ropivacaine hydrochloride (0.4mg/kg) diluted in 0.4mL/kg, in the dose of 0.1mL/kg. Throughout the surgical procedure, there were no complications or changes in physiological parameters. Thus, it was possible to observe the effectiveness of the anesthetic technique used to correct portosystemic shunt in a dog presenting neurological symptoms.(AU)

Abordagem transcirúrgica e acompanhamento pós-operatório de um canino com um shunt esplênico-azigos / Transurgical approach and postoperative follow-up of a canine with a splenic-azygos shunt

Background: The most frequent hepatic circulatory abnormality in dogs is the portosystemic shunt, characterized by an atypical deviation of the hepatic blood flow, that causes the blood that should be drained by the liver through the portal vein to be diverted to another systemic vein, as a result of the presence of the anomalous vessel. This diversion leads to reduced hepatic blood flow and, consequently, organ dysfunction, along with the accumulation of many toxins in the circulation, for instance, ammonia and short-chain fatty acids. The main objective of this paper is to Report the clinical case of a canine female diagnosed with an extrahepatic portosystemic shunt and submitted to surgical treatment using an ameroid constrictor ring in the obstruction of the anomalous vessel. Case: A canine Shih-Tzu, at the age of 1 year and 8 months, was brought to the Veterinary Hospital presenting a history of emesis and smaller body structure than other animals from the same litter. The animal had been diagnosed with portosystemic shunt at age 1 month, by means of complementary biochemistry, ultrasonography and computed tomography examinations. The latter identified the anomalous vessel, which originated from the left gastric vein and was inserted into the azygos vein in the portohepatic region. During the surgical intervention, after median pre-retro-umbilical celiotomy, a calibrous vessel was identified, coming out of the junction of two splenic veins and a gastric vein that penetrated the diaphragm and connected to the azygos vein in the thorax before flowing into the vena cava

Abordagem transcirúrgica e acompanhamento pós-operatório de um canino com um shunt esplênico-azigos / Transurgical approach and postoperative follow-up of a canine with a splenic-azygos shunt

Background: The most frequent hepatic circulatory abnormality in dogs is the portosystemic shunt, characterized by an atypical deviation of the hepatic blood flow, that causes the blood that should be drained by the liver through the portal vein to be diverted to another systemic vein, as a result of the presence of the anomalous vessel. This diversion leads to reduced hepatic blood flow and, consequently, organ dysfunction, along with the accumulation of many toxins in the circulation, for instance, ammonia and short-chain fatty acids. The main objective of this paper is to Report the clinical case of a canine female diagnosed with an extrahepatic portosystemic shunt and submitted to surgical treatment using an ameroid constrictor ring in the obstruction of the anomalous vessel. Case: A canine Shih-Tzu, at the age of 1 year and 8 months, was brought to the Veterinary Hospital presenting a history of emesis and smaller body structure than other animals from the same litter. The animal had been diagnosed with portosystemic shunt at age 1 month, by means of complementary biochemistry, ultrasonography and computed tomography examinations. The latter identified the anomalous vessel, which originated from the left gastric vein and was inserted into the azygos vein in the portohepatic region. During the surgical intervention, after median pre-retro-umbilical celiotomy, a calibrous vessel was identified, coming out of the junction of two splenic veins and a gastric vein that penetrated the diaphragm and connected to the azygos vein in the thorax before flowing into the vena cava…(AU)

Congenital extrahepatic portosystemic deviation in a mixed-breed dog

Background: Portosystemic deviation (PSD) is a congenital or acquired vascular anomaly that allows an abnormal bloodflow from the portal vein directly to the systemic circulation. This liver by-pass avoids hepatic metabolism of severaltoxins. Congenital PSDs are usually solitary and extra-hepatic, with a high incidence in pure-breed dogs. Acquired PSDsare usually multiple and occur as a consequence of portal hypertension. Surgery is the definitive treatment. Cliniciansand surgeons may present difficulties in the propaedeutic of animals with PSD. This paper aims at reporting a successfulsurgical treatment of a solitary extra-hepatic congenital PSD in a mixed-breed dog.Case: A 7-month-old mixed-breed dog, female, spayed, weighing 8 kg, was presented with a history of sudden syncopeafter feeding. Complementary exams revealed normocytic hypochromic anaemia, hypoalbuminemia and increased alanineaminotransferase and alkaline phosphatase. Abdominal ultrasound revealed an anomalous vessel inserted in the caudalcava vein, compatible with a congenital extra-hepatic PSD. Computed tomography revealed the anomalous vessel, with1,1 cm of diameter, originated from the cranial mesenteric vein and it inserted in the cranial margin of the caudal cavavein. A medical support was started with hydration, metronidazole, lactulose, probiotic and Hepatic diet. After 15 days thedog was submitted to surgery and a 5 mm ameroid constrictor ring was placed to gradually close the anomalous vessel.The dog recovered well and an abdominal ultrasound was repeated after 30 days, showing the ameroid constrictor ringring in the left cranial abdominal region, occluding the PSD close to its insertion in the caudal cava vein...

Congenital extrahepatic portosystemic deviation in a mixed-breed dog

Background: Portosystemic deviation (PSD) is a congenital or acquired vascular anomaly that allows an abnormal bloodflow from the portal vein directly to the systemic circulation. This liver by-pass avoids hepatic metabolism of severaltoxins. Congenital PSDs are usually solitary and extra-hepatic, with a high incidence in pure-breed dogs. Acquired PSDsare usually multiple and occur as a consequence of portal hypertension. Surgery is the definitive treatment. Cliniciansand surgeons may present difficulties in the propaedeutic of animals with PSD. This paper aims at reporting a successfulsurgical treatment of a solitary extra-hepatic congenital PSD in a mixed-breed dog.Case: A 7-month-old mixed-breed dog, female, spayed, weighing 8 kg, was presented with a history of sudden syncopeafter feeding. Complementary exams revealed normocytic hypochromic anaemia, hypoalbuminemia and increased alanineaminotransferase and alkaline phosphatase. Abdominal ultrasound revealed an anomalous vessel inserted in the caudalcava vein, compatible with a congenital extra-hepatic PSD. Computed tomography revealed the anomalous vessel, with1,1 cm of diameter, originated from the cranial mesenteric vein and it inserted in the cranial margin of the caudal cavavein. A medical support was started with hydration, metronidazole, lactulose, probiotic and Hepatic diet. After 15 days thedog was submitted to surgery and a 5 mm ameroid constrictor ring was placed to gradually close the anomalous vessel.The dog recovered well and an abdominal ultrasound was repeated after 30 days, showing the ameroid constrictor ringring in the left cranial abdominal region, occluding the PSD close to its insertion in the caudal cava vein...(AU)

Extrahepatic portosystemic shunt in a 8 month-old female maltese dog / Shunt portossistêmico extra-hepático em cadela maltês de 8 meses

The shunt portosystemic or portosystemic deviation (PSD) are unique or multiples vascular communications between the systemic circulaton and the portal circulation, that permit blood flow reaches the circulatory system without first passing trhought the hepatic metabolization. May be acquired or congenital and can also be classified as intrahepatic located within the liver or extrahepatic located outside the liver parenquima. The acquired form is usually associated with intra-hepatic disorders. They usually suggest tortuous vessels that communicate with the caudal vena cava in the region of the left kidney. The congenital form is associated with genetic lineage and one of the most affected  is Maltese breed. This case report describes the diagnostis and treatment of a eight year-old female Maltese dog presenting extrahepatic Portosystemic Shunt. The patient showed signs of hepatic encephalopathy, such as restlessnees, weakness, deambulation, head tremor and impaired visual. Complementary exam demonstrated: postprandial glicemia near the lower limit of reference, alkaline phosphatase (ALP) and alanine aminotransferase (ALT) increased and hipoalbuminemia. Ultrasonography revealed the presence of vesical calculus and bilateral kidney, liver decreases and increased echogenicity, gallbladder with anechoic content and high cellularity may suggest liver/ colangiohepatopatia and extra

 O shunt portossistêmico ou desvio portossistêmico (DPS) são comunicações vasculares únicas ou múltiplas entre a circulação sistêmica e a circulação portal, que permite que o sangue portal chegue ao sistema circulatório sem antes passar pela metabolização hepática. Podem ser adquiridos ou congênitos e também podem ser classificados como intra-hepático, localizado dentro do fígado, ou extra-hepático, localizado fora do parênquima hepático. A forma adquirida normalmente está associada com distúrbios intra-hepáticos. Eles normalmente sugerem vasos tortuosos que se comunicam com a veia cava caudal na região do rim esquerdo. A forma congênita está associada a genética e uma das linhagens mais acometidas é a raça maltês. O presente relato de caso descreve o diagnóstico e tratamento de uma cadela maltês de oito meses de idade com Shunt portossistêmico extra-hepático. A paciente apresentava sinais de encefalopatia hepática, como: inquietação, locomoção apoiando-se nas paredes, compressão da cabeça contra a parede, tremores de cabeça e deficiência visual. Exames complementares constataram: glicemia pós-prandial próximo do valor inferior de referência, fosfatase alcalina (FA) e alanina aminotransferase (ALT) aumentadas e hipoalbuminemia. A ultra-sonografia revelou a presença de cálculo vesical e cálculo renal bilateral, fígado diminuÃ

Extrahepatic portosystemic shunt in a 8 month-old female maltese dog / Shunt portossistêmico extra-hepático em cadela maltês de 8 meses

The shunt portosystemic or portosystemic deviation (PSD) are unique or multiples vascular communications between the systemic circulaton and the portal circulation, that permit blood flow reaches the circulatory system without first passing trhought the hepatic metabolization. May be acquired or congenital and can also be classified as intrahepatic located within the liver or extrahepatic located outside the liver parenquima. The acquired form is usually associated with intra-hepatic disorders. They usually suggest tortuous vessels that communicate with the caudal vena cava in the region of the left kidney. The congenital form is associated with genetic lineage and one of the most affected  is Maltese breed. This case report describes the diagnostis and treatment of a eight year-old female Maltese dog presenting extrahepatic Portosystemic Shunt. The patient showed signs of hepatic encephalopathy, such as restlessnees, weakness, deambulation, head tremor and impaired visual. Complementary exam demonstrated: postprandial glicemia near the lower limit of reference, alkaline phosphatase (ALP) and alanine aminotransferase (ALT) increased and hipoalbuminemia. Ultrasonography revealed the presence of vesical calculus and bilateral kidney, liver decreases and increased echogenicity, gallbladder with anechoic content and high cellularity may suggest liver/ colangiohepatopatia and extrah

 O shunt portossistêmico ou desvio portossistêmico (DPS) são comunicações vasculares únicas ou múltiplas entre a circulação sistêmica e a circulação portal, que permite que o sangue portal chegue ao sistema circulatório sem antes passar pela metabolização hepática. Podem ser adquiridos ou congênitos e também podem ser classificados como intra-hepático, localizado dentro do fígado, ou extra-hepático, localizado fora do parênquima hepático. A forma adquirida normalmente está associada com distúrbios intra-hepáticos. Eles normalmente sugerem vasos tortuosos que se comunicam com a veia cava caudal na região do rim esquerdo. A forma congênita está associada a genética e uma das linhagens mais acometidas é a raça maltês. O presente relato de caso descreve o diagnóstico e tratamento de uma cadela maltês de oito meses de idade com Shunt portossistêmico extra-hepático. A paciente apresentava sinais de encefalopatia hepática, como: inquietação, locomoção apoiando-se nas paredes, compressão da cabeça contra a parede, tremores de cabeça e deficiência visual. Exames complementares constataram: glicemia pós-prandial próximo do valor inferior de referência, fosfatase alcalina (FA) e alanina aminotransferase (ALT) aumentadas e hipoalbuminemia. A ultra-sonografia revelou a presença de cálculo vesical e cálculo renal bilateral, fígado diminuído e aumento da ecogenicidade, vesícula biliar com con

Extrahepatic portosystemic shunt in a 8 month-old female maltese dog / Shunt portossistêmico extra-hepático em cadela maltês de 8 meses

The shunt portosystemic or portosystemic deviation (PSD) are unique or multiples vascular communications between the systemic circulaton and the portal circulation, that permit blood flow reaches the circulatory system without first passing trhought the hepatic metabolization. May be acquired or congenital and can also be classified as intrahepatic located within the liver or extrahepatic located outside the liver parenquima. The acquired form is usually associated with intra-hepatic disorders. They usually suggest tortuous vessels that communicate with the caudal vena cava in the region of the left kidney. The congenital form is associated with genetic lineage and one of the most affected  is Maltese breed. This case report describes the diagnostis and treatment of a eight year-old female Maltese dog presenting extrahepatic Portosystemic Shunt. The patient showed signs of hepatic encephalopathy, such as restlessnees, weakness, deambulation, head tremor and impaired visual. Complementary exam demonstrated: postprandial glicemia near the lower limit of reference, alkaline phosphatase (ALP) and alanine aminotransferase (ALT) increased and hipoalbuminemia. Ultrasonography revealed the presence of vesical calculus and bilateral kidney, liver decreases and increased echogenicity, gallbladder with anechoic content and high cellularity may suggest liver/ colangiohepatopatia and extrah

O shunt portossistêmico ou desvio portossistêmico (DPS) são comunicações vasculares únicas ou múltiplas entre a circulação sistêmica e a circulação portal, que permite que o sangue portal chegue ao sistema circulatório sem antes passar pela metabolização hepática. Podem ser adquiridos ou congênitos e também podem ser classificados como intra-hepático, localizado dentro do fígado, ou extra-hepático, localizado fora do parênquima hepático. A forma adquirida normalmente está associada com distúrbios intra-hepáticos. Eles normalmente sugerem vasos tortuosos que se comunicam com a veia cava caudal na região do rim esquerdo. A forma congênita está associada a genética e uma das linhagens mais acometidas é a raça maltês. O presente relato de caso descreve o diagnóstico e tratamento de uma cadela maltês de oito meses de idade com Shunt portossistêmico extra-hepático. A paciente apresentava sinais de encefalopatia hepática, como: inquietação, locomoção apoiando-se nas paredes, compressão da cabeça contra a parede, tremores de cabeça e deficiência visual. Exames complementares constataram: glicemia pós-prandial próximo do valor inferior de referência, fosfatase alcalina (FA) e alanina aminotransferase (ALT) aumentadas e hipoalbuminemia. A ultra-sonografia revelou a presença de cálculo vesical e cálculo renal bilateral, fígado diminuído e aumento da ecogenicidade, vesícula biliar com con