Recanalized Paraumbilical Vein Leading to Hepatic Myelopathy Causing Spastic Paraparesis in a Patient with Chronic Liver Disease

A 34-year-old male visited our hospital with complaints of recurrent episodes of altered behavior since past 6 months along with difficulty in walking since past 3 months. He was diagnosed of chronic liver disease in the past. Examination revealed spasticity and brisk deep tendon reflexes in both the lower limbs. His blood investi-gations and spinal cord imaging was normal. Based on his clinical features, a possibility of portosystemic shunt-ing leading to portosystemic encephalopathy (PSE) and shunt myelopathy was suspected. A computed tomography portography showed a recanalized paraumblical vein draining portal blood into external iliac veins. Patient underwent shunt occlusion (Figure-2). One month after the procedure, while there was no recurrence of symptoms of PSE, those of myelopathy remained unchanged. Shunt myelopathy is a rare complication of spon-taneous or iatrogenic portosystemic shunts. Unlike PSE, the management of shunt myelopathy is uncertain due to limited evidence. Limited evidence suggests reversal of myelopathy after early shunt occlusion, highlighting the irreversible changes that may set in spinal cord due to delayed diagnosis. Our case highlights an important but a rare complication of portosystemic shunting in chronic liver disease which should be kept in mind if these patients develop symptoms attributable to spinal cord disease. ( J CLIN EXP HEPATOL 2023;13:372-376)