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  1. P SCHWAB,
  1. Division of Internal Medicine
  2. University of Texas Health Science Center at Houston
  3. Correspondence to: Dr Shehzad Basaria, Division of Endocrinlogy and Metabolism
  4. Johns Hopkins University School of Medicine
  5. 1830 E Monument Street, Suite 332
  6. Baltimore, MD 21287, USA

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    A 54 year old man with Child's C liver cirrhosis resulting from alcohol abuse presented with pleuritic right upper quadrant abdominal pain. He did not have ascites or any history of gastrointestinal bleeding. On examination, his liver was palpable 4 cm below the costal margin and was lobular and non-tender. Abdominal ultrasound revealed a mass in the right lobe of the liver (later proved by biopsy to be a hepatoma) as well as a shunt on Doppler study. Magnetic resonance angiography of the liver (fig 1) revealed a shunt (S) between the portal vein (PV) and the hepatic vein (HV) which is seen joining the right atrium (RA) leading to the inferior vena cava (IVC). On further questioning, the patient admitted being stabbed in the right upper quadrant 20 years ago.  The majority of the patients with Child's C cirrhosis have complications like ascites or gastrointestinal bleeding caused by portal hypertension. The trauma experienced by our patient resulted in formation of a transcutaneous intrahepatic portocaval shunt or “auto-TIPS” (transjugular intrahepatic portosystemic shunt) which prevented the development of portal hypertension.

    Figure 1

    Magnetic resonance angiogram of the liver.