Improvement in Irretractable Pruritus With Intrahepatic Portosystemic Shunt Embolization: From MAID to a New Lease on Life.

Pruritus is a common, often debilitating symptom of liver disease. While most commonly seen in the setting of cholestasis and biliary obstruction, intrahepatic portosystemic shunts (PSSs) may also present with pruritus. The pathophysiology of intractable pruritus is not well understood and often requires multimodal management. We present a rare case of an 81-year-old woman with severe medically refractory pruritus with elevated serum bile acids in the absence of chronic liver disease. Antipruritics and plasmapheresis produced minimal relief, leading her to contemplate medical assistance in dying (MAID). Imaging during workup revealed two intrahepatic shunts, anomalously connecting the right portal and hepatic veins. Endovascular shunt embolization led to normalization of her serum bile acids and produced remarkable symptomatic relief. This highlights a rare but treatable cause of pruritus in an adult without chronic liver disease or biliary obstruction, while showcasing embolization as a safe and effective treatment strategy with significant improvement of the patient's quality of life.