Sonographic findings in noncirrhotic portal fibrosis

[Role of splenectomy in the treatment of non-cirrhotic portal hypertension: about 3 cases]

L’hypertension portale non cirrhotique est une affection décrite pour la première fois par Guido BANTI en 1898 comme une affection associant une hypertension portale avec splénomégalie et anémie sur foie sain. Le diagnostic repose sur l’échographie abdominale, la splénoportographie et la biopsie hépatique. Le but de notre travail est d’évaluer la place de la splénectomie dans l’hypertension portale non cirrhotique à travers une étude rétrospective portant sur 3 malades dont 2 femmes et un homme pris en charge dans notre formation entre Janvier 2010 et Septembre 2016. Le diagnostic de l’hypertension portale idiopathique a été basé sur les critères suivants : une hypertension portale, la présence des varices oesophagiènnes avec une splénomégalie, l’absence de cirrhose ou d’autres affections hépatiques responsables de l’hypertension portale. La splénectomie a été réalisée chez les 3 malades. L’évolution après la splénectomie était marquée par la normalisation des signes cliniques, radiologiques et biologiques de cette affection, avec absence de récidive des varices œsophagiennes. La splénectomie associée à la ligature des varices œsophagiennes pourraient être suffisantes pour traiter ce syndrome et surtout ses conséquences sans avoir recours à une dérivation spléno-rénale.

Hepatoportal sclerosis: CT and MRI appearance with histopathologic correlation

OBJECTIVE

The purposes of this study were to describe the spectrum of cross-sectional imaging findings of pathologically proven hepatoportal sclerosis and to compare the features of advanced and nonadvanced hepatoportal sclerosis.

MATERIALS AND METHODS

Eighteen patients with a histopathologic diagnosis of hepatoportal sclerosis who had concurrent MRI or CT images participated in the study. The following imaging features were assessed: presence of liver nodularity and liver lesions, portal vein patency, presence and degree of portal hypertension, liver volume, and caudate-to-right lobe ratio. These features were compared between patients who underwent transplant and those who did not.

RESULTS

The 18 patients (11 men and one boy, six women; mean age, 46.5 years) had hepatoportal sclerosis confirmed with liver biopsy (14 patients) or explant (four patients). Fourteen patients underwent contrast-enhanced MRI, and five underwent CT. The imaging findings were as follows: liver surface nodularity, five patients (all four transplant, one nontransplant) (p = 0.0016); evidence of portal hypertension, 17 patients; increased caudate-to-right lobe ratio, 16 patients; high periportal signal intensity on T2-weighted images, six patients; portal vein occlusion with cavernous transformation, five patients. The transplant patients had smaller pretransplant liver volume than did nontransplant patients (p < 0.04).

CONCLUSION

Hepatoportal sclerosis is characterized by caudate lobe hypertrophy and right hepatic lobe atrophy, preserved liver volume, and lack of the liver nodularity associated with portal hypertension. In advanced cases, liver nodularity and atrophy produce an imaging appearance indistinguishable from that of cirrhosis.

Noncirrhotic portal hypertension

Portal hypertension is characterized by an increase in portal pressure (> 10 mmHg) and could be a result of cirrhosis of the liver or of noncirrhotic diseases. When portal hypertension occurs in the absence of liver cirrhosis, noncirrhotic portal hypertension (NCPH) must be considered. The prognosis of this disease is much better than that of cirrhosis. Noncirrhotic diseases are the common cause of portal hypertension in developing countries, especially in Asia. NCPH is a heterogeneous group of diseases that is due to intrahepatic or extrahepatic etiologies. In general, the lesions in NCPH are vascular in nature and can be classified based on the site of resistance to blood flow. In most cases, these disorders can be explained by endothelial cell lesions, intimal thickening, thrombotic obliterations, or scarring of the intrahepatic portal or hepatic venous circulation. Many different conditions can determine NCPH through the association of these various lesions in various degrees. Many clinical manifestations of NCPH result from the secondary effects of portal hypertension. Patients with NCPH present with upper gastrointestinal bleeding, splenomegaly, ascites after gastrointestinal bleeding, features of hypersplenism, growth retardation, and jaundice due to portal hypertensive biliopathy. Other sequelae include hyperdynamic circulation, pulmonary complications, and other effects of portosystemic collateral circulation like portosystemic encephalopathy. At present, pharmacologic and endoscopic treatments are the treatments of choice for portal hypertension. The therapy of all disorders causing NCPH involves the reduction of portal pressure by pharmacotherapy or portosystemic shunting, apart from prevention and treatment of complications of portal hypertension.

Ascites in Adult Patients With Cyanotic Congenital Heart Disease

Hematologic, neurologic, renal, and rheumatic complications in patients with cyanotic congenital heart disease are well known. However, the effects of this condition on the liver are poorly described. Between April 2005 and April 2010, 25 adults with cyanotic congenital heart disease were studied to determine clinical history, liver ultrasonographic data, and liver histological presentation. Twenty-five patients, with a median age of 28.7 ± 8.3 years and a basal tissue hemoglobin oxygen saturation of 83.3% ± 6.8%, were studied. Liver ultrasonographic examination showed abnormalities in 10 of 20 patients (50%): 6 patients (30%) had hepatomegaly, 2 patients (10%) heterogeneous parenchyma echo pattern, and 2 patients (10%) increased portal echogenicity. Ascites was found in 7 patients (28%): 4 patients had refractory ascites and 3 patients anasarca. Patients with anasarca responded well to oral and intravenous furosemide, but those with isolated ascites did not. No data to indicate severe ventricular dysfunction or severe valve regurgitation were seen. In patients with refractory ascites who had therapeutic paracentesis, serum–ascites albumin gradient in ascites was greater than 1.1 g/dL. No significant association was found between patients with or without ascites when laboratory data and New York Heart Association functional class were compared. Liver biopsy was performed in 6 patients (24%). The most remarkable liver histological finding, in those with refractory ascites, was the existence of periportal fibrosis associated with sinusoidal dilatation. Periportal liver fibrosis associated with congestive heart failure, sepsis, or a long-term Fontan procedure can trigger refractory ascites formation.

Paediatric chronic liver diseases: how to investigate and follow up? Role of imaging in the diagnosis of fibrosis

Chronic liver diseases are rare in children, but encompass a wide spectrum of disorders that may all be complicated by liver fibrosis and therefore by portal hypertension. They may be classified according to the level of portal flow obstruction: prehepatic, intrahepatic or suprahepatic. Most of them, except presinusoidal diseases, may progress to cirrhosis that carries additional risks of impaired liver function and development of hepatocellular carcinoma. Imaging plays an important role in guiding the diagnosis and biopsy and for follow-up during treatment. US, with high-frequency transducers and Doppler, is the first modality of choice, directs the rest of the investigations and guides interventional radiology. MDCT has made great progress and has replaced angiography for diagnostic purposes. MRI is indicated for parenchyma and nodule characterization and for biliary tract evaluation. To avoid liver biopsy, several elasticity imaging techniques have been developed and have to be evaluated for accuracy and convenience in children. The role of each modality with main imaging findings is described in extrahepatic portal vein obstruction, hepatoportal sclerosis, congenital hepatic fibrosis, cirrhosis and Budd-Chiari syndrome.

Adams-Oliver syndrome and hepatoportal sclerosis: occasional association or common mechanism?

Adams-Oliver syndrome (AOS) is characterized by the association of scalp and skull defects and abnormalities of terminal limbs. Congenital heart malformations have also been reported. Hepatoportal sclerosis (HPS) is a rare cause of portal hypertension in children characterized by abnormalities of intra-hepatic portal veins, portal fibrosis, and nodular regeneration. Etiopathogenesis of these rare disorders remains unclear, but the hypothesis of vascular thrombotic mechanism has been suggested. Association of both syndromes has been reported in only one child. We now report on two unrelated children with AOS and HPS, one child harboring a factor V Leiden mutation. We hypothesize that the association of both disorders may not be fortuitous and reinforces the idea that AOS and HPS may share a vascular thrombotic mechanism.

Periportal fibrosis and other liver ultrasonography findings in vinyl chloride workers

AIMS

To investigate the presence of liver lesions and their relation with vinyl chloride monomer (VCM) exposure or other personal risk factors, in workers involved in the production of VCM and polyvinyl chloride (PVC).

METHODS

A liver ultrasonography examination was conducted in 757 workers, some of whom had long standing service in the production of VCM and PVC. The study involved: assessment of individual past and present VCM exposure of each worker; collection of past personal health history, lifestyle and personal data; routine liver function tests; and liver ultrasonography.

RESULTS

No cases of liver malignancies were detected. Angiomas and liver cysts were found with a frequency of occurrence within the expected range of the general population. The main findings consisted of hepatomegaly (34.7%), steatosis (31.8%), and periportal fibrosis (16.0%). A logistic regression analysis indicated that hepatomegaly and steatosis were associated with obesity and lipid metabolism disturbances and not with VCM exposure. Periportal fibrosis, in addition to constitutional or dietary factors, was shown to be associated with VCM exposure, but only when maximum exposure in the subject's history had been at least 200 ppm as a yearly average; no effects were observed at 50 ppm or below.

CONCLUSIONS

Workers exposed to 200 ppm VCM for at least one year have a fourfold increased risk of developing periportal liver fibrosis. Liver ultrasonography is a suitable and important diagnostic test for the medical surveillance of vinyl chloride workers.