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Zhang Y, Liu H, Xiong Q, Zhong Y, Liu D, Chen W, Yang Y. Application of liver biopsy in etiological diagnosis of unexplained portal hypertension: Porto-sinusoidal vascular disease should not be ignored. Medicine (Baltimore) 2024; 103:e39819. [PMID: 39331914 PMCID: PMC11441879 DOI: 10.1097/md.0000000000039819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2024] Open
Abstract
The diagnostic value of liver biopsy has been confirmed in patients with abnormal liver test results; however, little data are available on its application in patients with portal hypertension. This study aimed to investigate the utility of liver biopsy for the etiological diagnosis of unexplained portal hypertension, and explore the clinical and pathological characteristics of each etiology. A retrospective observational analysis was conducted on 1367 patients who underwent liver biopsy at the Second Hospital of Nanjing from 2017 to 2019. Of these, 188 patients with unexplained portal hypertension were enrolled. The clinical and pathological characteristics were collected and reassessed in a multidisciplinary team meeting. Among these patients, 174 (92.6%, 174/188) had a definite etiological diagnosis through liver biopsy. The main etiologies were autoimmune hepatitis in 47 patients (25%, 47/188), autoimmune hepatitis-primary biliary cirrhosis overlap syndrome in 41 patients (21.8%, 41/188), and porto-sinusoidal vascular disease (PSVD) in 40 patients (21.3%, 40/188). Compared to liver cirrhosis, PSVD patients were younger and the liver function damage of which was subtler. The widths of portal vein diameter were widest in PSVD but the liver stiffness measurement were almost normal. Splenomegaly was common in PSVD, but ascites were less frequent than in autoimmune hepatitis (25.0% vs 51.1%, P = .013). Based on the histological patterns, we found that cholestatic liver diseases such as primary biliary cirrhosis, autoimmune hepatitis-primary biliary cirrhosis overlap syndrome, and progressive familial intrahepatic cholestasis could lead to non-cirrhotic portal hypertension, while vascular liver diseases such as PSVD and Budd-Chiari syndrome could also show fibrous proliferation as the disease progresses. Liver biopsy is safe and valuable for etiological diagnosis of unexplained portal hypertension. Cirrhosis is the leading cause of portal hypertension, and porto-sinusoidal vascular diseases should also be considered. Clinical features may be helpful in suggesting the cause; however, pathological examination is still indispensable for disease diagnosis and progression assessment.
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Affiliation(s)
- Yu Zhang
- Department of Medicine, Southeast University, Nanjing, China
- Department of Infectious and Liver Diseases, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Hongli Liu
- Department of Medicine, Southeast University, Nanjing, China
| | - Qingfang Xiong
- Department of Infectious and Liver Diseases, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yandan Zhong
- Department of Infectious and Liver Diseases, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Duxian Liu
- Department of Pathology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wei Chen
- Clinical Research Center, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yongfeng Yang
- Department of Infectious and Liver Diseases, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
- The Clinical Infectious Disease Center of Nanjing, Nanjing, China
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2
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Ucdal M, Simsek C, Durak B, Balaban HY. Letter: Prospective evaluation of patients with non-cirrhotic portal hypertension: A single-centre study. Aliment Pharmacol Ther 2024. [PMID: 39329463 DOI: 10.1111/apt.18255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
LINKED CONTENTThis article is linked to Mironova et al papers. To view these articles, visit https://doi.org/10.1111/apt.17987 and https://doi.org/10.1111/apt.18292
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Affiliation(s)
- Mete Ucdal
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Cem Simsek
- Division of Department of Gastroenterology, Hepatology Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Bahaddin Durak
- Division of Department of Gastroenterology, Hepatology Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Hatice Yasemin Balaban
- Division of Department of Gastroenterology, Hepatology Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Da Rocha Ribas PA, Da Rocha Ribas JÁ, Mialski Fontana R. Thrombotic Events in a Patient With Acute Toxoplasmosis. Cureus 2024; 16:e69797. [PMID: 39308842 PMCID: PMC11414767 DOI: 10.7759/cureus.69797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2024] [Indexed: 09/25/2024] Open
Abstract
The etiology of venous thromboembolism is multifactorial, with causes being classified as either provoked or unprovoked, making it difficult to attribute a single factor as the cause of the thromboembolic event in most cases. The relationship between inflammation and thrombotic phenomena is well established. Here, we describe the uncommon occurrence of thromboses in a previously healthy patient with acute toxoplasmosis. The patient initially presented with fatigue, abdominal pain, fever and dyspnea. The diagnosis was confirmed through toxoplasmosis serology in a set of admission laboratory tests, and further imaging studies revealed the presence of pulmonary embolism and portal vein thrombosis. The patient was treated with anticoagulants and sulfamethoxazole-trimethoprim, showing improvement in the following days. This case highlights the importance of considering infectious diseases, such as toxoplasmosis, in the differential diagnosis of thrombosis, even in previously healthy individuals. To our knowledge, this is the second reported case of this association in Brazil.
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Affiliation(s)
| | | | - Rafael Mialski Fontana
- Infectious Disease Service, Clinical Hospital Complex of the Federal University of Paraná, Curitiba, BRA
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Pugliese N, Ponziani FR, Cerini F, di Tommaso L, Turati F, Maggioni M, Manini MA, Santopaolo F, Bianco C, Masetti C, Giustiniani MC, La Vecchia C, Valenti L, Terracciano L, Viganò M, Aghemo A. Link between persistent, unexplained gamma-glutamyltransferase elevation and porto-sinusoidal vascular disorder. JHEP Rep 2024; 6:101150. [PMID: 39263328 PMCID: PMC11387327 DOI: 10.1016/j.jhepr.2024.101150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 06/14/2024] [Accepted: 06/19/2024] [Indexed: 09/13/2024] Open
Abstract
Background & Aims Porto-sinusoidal vascular disorder (PSVD) is a group of vascular disorders characterized by lesions involving portal venules and sinusoids, irrespective of the presence of portal hypertension. Liver biopsy is essential for diagnosis. In a single-center study, we demonstrated high rates of PSVD in patients with persistently elevated gamma-glutamyltransferase (GGT). This multicenter study aims to establish PSVD prevalence in a larger dataset of individuals with persistent and unexplained GGT elevation, and to identify associated risk factors. Methods The study included all patients who underwent liver biopsy for persistent and unexplained GGT elevation in five Italian hepatology units between March 2015 and December 2021. Results A total of 144 patients met the inclusion criteria. The majority were males (76/144, 52.8%) and mean age was 51.9 years (range 19-74). Only 12 (8.3%) had liver stiffness measurements (LSM) >10 kPa, while 7 (4.8%) had ultrasound evidence of portal hypertension. Histological findings were consistent with PSVD in 96 patients (67%). Alternative diagnoses were steatohepatitis in 13 (9%), sarcoidosis in 3 (2%) and congenital hepatic fibrosis in 3 (2%) patients. Histological findings were non-specific in 29 (20%) patients. PSVD was associated with male sex (odds ratio [OR] 2.60, 95% CI 1.13-5.99), LSM <10 kPa (OR 11.05, 95% CI 2.16-56.66) and GGT <200 U/L (OR 2.69, 95% CI 1.22-5.98). Conclusions PSVD was the main cause of persistent and unexplained elevation of GGT3. Male sex, LSM <10 kPa and GGT <200 U/L were associated with PSVD. These findings highlight the role of liver biopsy in elucidating the underlying pathology and aiding in the diagnosis of patients with persistent and unexplained GGT elevation. Impact and implications In outpatient settings, it is common to encounter individuals with persistent and unexplained gamma-glutamyltransferase elevations. This study reveals, for the first time, a non-negligible prevalence of porto-sinusoidal vascular disorder among these individuals when they undergo liver biopsy. Male sex, liver stiffness measurement <10 kPa, and gamma-glutamyltransferase <200 IU/L predict this histological finding. These results may raise awareness of clinically relevant conditions that may be present in patients with persistent liver enzyme changes, even in the absence of signs of advanced chronic liver disease or portal hypertension. Additionally, the data may encourage further studies in the field of porto-sinusoidal vascular disorder, particularly to define its clinical evolution in patients without signs of portal hypertension at diagnosis.
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Affiliation(s)
- Nicola Pugliese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Francesca Romana Ponziani
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Federica Cerini
- Hepatology Unit, San Giuseppe Hospital, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca di Tommaso
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Pathology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Federica Turati
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Maggioni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathology, Milan, Italy
| | | | - Francesco Santopaolo
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Cristiana Bianco
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Precision Medicine, Biological Resource Center and Department of Transfusion Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Masetti
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | | | - Carlo La Vecchia
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Precision Medicine, Biological Resource Center and Department of Transfusion Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luigi Terracciano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Pathology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Mauro Viganò
- Gastroenterology, Hepatology and Transplantation Unit, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
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Frank C, Amily N, Kelly E, Kimpton M, Villeneuve P, O'Meara P. Polyglobulie essentielle et hypertension portale non cirrhotique diagnostiquées en cours de grossesse. CMAJ 2024; 196:E951-E955. [PMID: 39134310 PMCID: PMC11318984 DOI: 10.1503/cmaj.231170-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024] Open
Affiliation(s)
- Cairina Frank
- Départements de médecine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) et d'obstétrique et gynécologie (Amily), Université d'Ottawa, Ottawa, Ont.
| | - Noor Amily
- Départements de médecine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) et d'obstétrique et gynécologie (Amily), Université d'Ottawa, Ottawa, Ont
| | - Erin Kelly
- Départements de médecine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) et d'obstétrique et gynécologie (Amily), Université d'Ottawa, Ottawa, Ont
| | - Miriam Kimpton
- Départements de médecine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) et d'obstétrique et gynécologie (Amily), Université d'Ottawa, Ottawa, Ont
| | - Pierre Villeneuve
- Départements de médecine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) et d'obstétrique et gynécologie (Amily), Université d'Ottawa, Ottawa, Ont
| | - Paloma O'Meara
- Départements de médecine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) et d'obstétrique et gynécologie (Amily), Université d'Ottawa, Ottawa, Ont
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Adhariensya A, Yarman IP. Distal splenorenal shunt in an 8-year-old girl with rupture esophageal varices due to non-cirrhotic portal hypertension: A case report. Int J Surg Case Rep 2024; 121:109941. [PMID: 38943932 PMCID: PMC11261400 DOI: 10.1016/j.ijscr.2024.109941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/15/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024] Open
Abstract
INTRODUCTION Esophageal varices are dilated distal submucosal esophageal veins that connect the portal and systemic circulations. They are formed due to portal hypertension, which commonly resulted from cirrhosis. We presented an 8-year-old girl with esophageal varices without signs of cirrhosis. This case report aims to describe non-cirrhotic portal hypertension causing esophageal varices in a school-age girl. PRESENTATION OF CASE An 8-year-old girl presented with one month of progressive hematemesis. The patient had been diagnosed with esophageal varices since she was 6 years old. Liver function test was within normal limits, complete blood count revealed bicytopenia. DISCUSSION Due to well-preserved liver function, the patient underwent distal splenorenal shunt (DSRS). After the surgical procedure, the patient's clinical condition generally improved. CONCLUSION NCPH (non-cirrhotic portal hypertension) is treated similarly with cirrhotic portal hypertension. DSRS could be the treatment of choice for refractory esophageal varices.
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Affiliation(s)
- Agung Adhariensya
- General Surgery Department, Faculty of Medicine Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Indonesia.
| | - Indra Prasetya Yarman
- Vascular and Endovascular Division, General Surgery Department, Faculty of Medicine Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Indonesia
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Tonutti A, Pugliese N, Ceribelli A, Isailovic N, De Santis M, Colapietro F, De Nicola S, Polverini D, Selmi C, Aghemo A. The autoimmune landscape of Porto-sinusoidal vascular disorder: What the rheumatologist needs to know. Semin Arthritis Rheum 2024; 67:152467. [PMID: 38805899 DOI: 10.1016/j.semarthrit.2024.152467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
Porto-sinusoidal vascular disorder (PSVD) encompasses a group of vascular disorders characterized by lesions of the portal venules and sinusoids with clinical manifestations ranging from non-specific abnormalities in serum liver enzymes to clinically overt portal hypertension and related complications. Several reports have documented cases of PSVD in patients with systemic autoimmune conditions, such as systemic lupus erythematosus, systemic sclerosis, and rheumatoid arthritis. It is of note that these diseases share specific pathophysiological features with PSVD, including endothelial dysfunction, vascular inflammation, and molecular signatures. This narrative review aims to summarize the current knowledge on the association between PSVD and systemic autoimmune diseases, emphasizing the importance of promptly recognizing this condition in the rheumatological practice, and highlighting the key aspects where further research is necessary from both pathogenic and clinical perspectives.
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Affiliation(s)
- Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Nicola Pugliese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Angela Ceribelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Natasa Isailovic
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesca Colapietro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Stella De Nicola
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Davide Polverini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy.
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
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Coukos A, Saglietti C, Sempoux C, Haubitz M, Greuter T, Mittaz-Crettol L, Maurer F, Mdawar-Bailly E, Moradpour D, Alberio L, Good JM, Baerlocher GM, Fraga M. High prevalence of short telomeres in idiopathic porto-sinusoidal vascular disorder. Hepatol Commun 2024; 8:e0500. [PMID: 39037376 PMCID: PMC11265777 DOI: 10.1097/hc9.0000000000000500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/01/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Telomeres prevent damage to coding DNA as end-nucleotides are lost during mitosis. Mutations in telomere maintenance genes cause excessive telomere shortening, a condition known as short telomere syndrome (STS). One hepatic manifestation documented in STS is porto-sinusoidal vascular disorder (PSVD). METHODS As the etiology of many cases of PSVD remains unknown, this study explored the extent to which short telomeres are present in patients with idiopathic PSVD. RESULTS This monocentric cross-sectional study included patients with histologically defined idiopathic PSVD. Telomere length in 6 peripheral blood leukocyte subpopulations was assessed using fluorescent in situ hybridization and flow cytometry. Variants of telomere-related genes were identified using high-throughput exome sequencing. In total, 22 patients were included, of whom 16 (73%) had short (9/22) or very short (7/22) telomeres according to age-adjusted reference ranges. Fourteen patients (64%) had clinically significant portal hypertension. Shorter telomeres were more frequent in males (p = 0.005) and patients with concomitant interstitial lung disease (p < 0.001), chronic kidney disease (p < 0.001), and erythrocyte macrocytosis (p = 0.007). Portal hypertension (p = 0.021), low serum albumin level (p < 0.001), low platelet count (p = 0.007), and hyperbilirubinemia (p = 0.053) were also associated with shorter telomeres. Variants in known STS-related genes were identified in 4 patients with VSTel and 1 with STel. CONCLUSIONS Short and very short telomeres were highly prevalent in patients with idiopathic PSVD, with 31% presenting with variants in telomere-related genes. Telomere biology may play an important role in vascular liver disease development. Clinicians should consider measuring telomeres in any patient presenting with PSVD.
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Affiliation(s)
- Alexander Coukos
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Chiara Saglietti
- Institute of Pathology, Department of Laboratory Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christine Sempoux
- Institute of Pathology, Department of Laboratory Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Haubitz
- Department of Biomedical Research, Laboratory for Hematopoiesis and Molecular Genetics, University of Bern, Bern, Switzerland
| | - Thomas Greuter
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Division of Gastroenterology and Hepatology, Department of Medicine, GZO-Zurich Regional Health Center, Wetzikon, Switzerland
| | - Laureane Mittaz-Crettol
- Genetic Medicine, Department of Laboratory Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabienne Maurer
- Genetic Medicine, Department of Laboratory Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Elise Mdawar-Bailly
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Darius Moradpour
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Department of Oncology, Hematology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Marc Good
- Genetic Medicine, Department of Laboratory Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Gabriela M. Baerlocher
- Department of Biomedical Research, Laboratory for Hematopoiesis and Molecular Genetics, University of Bern, Bern, Switzerland
| | - Montserrat Fraga
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Khavandi MM, Habibollahi P. Trans-splenic Sharp Recanalization, Extra-Anatomic Portal Vein Reconstruction, and Intrahepatic Portosystemic Shunt creation for the Treatment of Portal Hypertension in a Patient with Polycythemia Vera and JAK2 Mutation. Cardiovasc Intervent Radiol 2024; 47:1148-1151. [PMID: 38937292 DOI: 10.1007/s00270-024-03766-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/12/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Mohammad Mahdi Khavandi
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Peiman Habibollahi
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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10
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Cazacu SM, Alexandru DO, Dumitrescu D, Vieru AM, Urhuț MC, Săndulescu LD. Prevalence and Risk Factors for Portal Cavernoma in Adult Patients with Portal Vein Thrombosis. Diagnostics (Basel) 2024; 14:1445. [PMID: 39001335 PMCID: PMC11241764 DOI: 10.3390/diagnostics14131445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/25/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024] Open
Abstract
Portal vein thrombosis (PVT) represents a restriction or occlusion of the portal vein by a blood clot, which can appear in liver cirrhosis, inherited or acquired thrombophilia, malignancies, abdominal infection, abdominal inflammation, and injury to the portal vein; it can evolve to local venous extension, recanalization, or portal cavernoma (PC). This research represents an observational study of patients admitted with a diagnosis of PVT between January 2018 and December 2022. We assessed the rate of and risk factors for PC. In total, 189 patients with PVT were included; the rate of PC was 14.8%. In univariate and multivariate analysis, the main risk factors for the presence of PC were etiology (thrombophilia, myeloproliferative disorders, local inflammatory diseases, and idiopathic causes), prior PVT, and complete versus incomplete or single-branch portal obstruction. In patients with superior mesenteric vein (SMV) thrombosis, distal obstruction was more prone to PC than proximal obstruction. The main predictive factors were etiology, prior PVT, complete PVT obstruction, and no prior non-selective beta-blocker (NSBB) use; in patients with SMV thrombosis, the distal extension was more significantly associated with the risk of PC. We propose a composite score for the prediction of PC which includes etiology, prior diagnosis of PVT, prior NSBB use, complete versus incomplete PVT, and distal versus proximal SMV thrombosis, with good accuracy (AUC 0.822) and an estimated sensitivity of 76.92% and specificity of 82.39% at a cut-off value of 4.
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Affiliation(s)
- Sergiu Marian Cazacu
- Research Center of Gastroenterology and Hepatology, Gastroenterology Department, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349, Craiova, Romania; (S.M.C.); (L.D.S.)
| | - Dragoș Ovidiu Alexandru
- Biostatistics Department, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349 Craiova, Romania;
| | - Daniela Dumitrescu
- Imaging Department, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349 Craiova, Romania;
| | - Alexandru Marian Vieru
- Doctoral School, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349 Craiova, Romania;
| | - Marinela Cristiana Urhuț
- Doctoral School, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349 Craiova, Romania;
| | - Larisa Daniela Săndulescu
- Research Center of Gastroenterology and Hepatology, Gastroenterology Department, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349, Craiova, Romania; (S.M.C.); (L.D.S.)
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11
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Guixé-Muntet S, Quesada-Vázquez S, Gracia-Sancho J. Pathophysiology and therapeutic options for cirrhotic portal hypertension. Lancet Gastroenterol Hepatol 2024; 9:646-663. [PMID: 38642564 DOI: 10.1016/s2468-1253(23)00438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 04/22/2024]
Abstract
Portal hypertension represents the primary non-neoplastic complication of liver cirrhosis and has life-threatening consequences, such as oesophageal variceal bleeding, ascites, and hepatic encephalopathy. Portal hypertension occurs due to increased resistance of the cirrhotic liver vasculature to portal blood flow and is further aggravated by the hyperdynamic circulatory syndrome. Existing knowledge indicates that the profibrogenic phenotype acquired by sinusoidal cells is the initial factor leading to increased hepatic vascular tone and fibrosis, which cause increased vascular resistance and portal hypertension. Data also suggest that the phenotype of hepatic cells could be further impaired due to the altered mechanical properties of the cirrhotic liver itself, creating a deleterious cycle that worsens portal hypertension in the advanced stages of liver disease. In this Review, we discuss recent discoveries in the pathophysiology and treatment of cirrhotic portal hypertension, a condition with few pharmacological treatment options.
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Affiliation(s)
- Sergi Guixé-Muntet
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sergio Quesada-Vázquez
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jordi Gracia-Sancho
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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12
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Frank C, Amily N, Kelly E, Kimpton M, Villeneuve P, O'Meara P. Polycythemia vera and noncirrhotic portal hypertension diagnosed during pregnancy. CMAJ 2024; 196:E657-E660. [PMID: 38772602 PMCID: PMC11104577 DOI: 10.1503/cmaj.231170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024] Open
Affiliation(s)
- Cairina Frank
- Departments of Medicine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) and Obstetrics and Gynecology (Amily), University of Ottawa, Ottawa, Ont.
| | - Noor Amily
- Departments of Medicine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) and Obstetrics and Gynecology (Amily), University of Ottawa, Ottawa, Ont
| | - Erin Kelly
- Departments of Medicine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) and Obstetrics and Gynecology (Amily), University of Ottawa, Ottawa, Ont
| | - Miriam Kimpton
- Departments of Medicine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) and Obstetrics and Gynecology (Amily), University of Ottawa, Ottawa, Ont
| | - Pierre Villeneuve
- Departments of Medicine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) and Obstetrics and Gynecology (Amily), University of Ottawa, Ottawa, Ont
| | - Paloma O'Meara
- Departments of Medicine (Frank, Kelly, Kimpton, Villeneuve, O'Meara) and Obstetrics and Gynecology (Amily), University of Ottawa, Ottawa, Ont
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13
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Gruszecka J, Filip R. Epidemiological Study of Pathogens in Spontaneous Bacterial Peritonitis in 2017-2024-A Preliminary Report of the University Hospital in South-Eastern Poland. Microorganisms 2024; 12:1008. [PMID: 38792837 PMCID: PMC11123777 DOI: 10.3390/microorganisms12051008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Spontaneous Bacterial Peritonitis (SBP) is a serious complication and a common cause of death in patients with liver cirrhosis. Between January 2017 and March 2024, a retrospective study was conducted involving 302 patients (>18 years old) with ascites treated at a tertiary referral center in south-eastern Poland. Microbiological analysis of the ascitic fluids was performed in all patients. The presence of microorganisms was found in samples from 17 patients, and 21 pathogens were isolated, including 15 Gram-positive bacteria and 6 Gram-negative bacteria. Staphylococcus epidermidis, MRCNS (methicillin-resistant coagulase-negative staphylococci, resistant to all beta-lactam antibiotics: penicillins, penicillins with beta-lactamase inhibitor, cephalosporins and carbapenems) was the main pathogen detected (19.05%, 4/21), followed by Enterococcus faecalis (9.52%, 2/21), Enterococcus faecium (9.52%, 2/21), Staphylococcus haemolyticus, MRCNS (4.76%, 1/21), Streptococcus mitis (9.52%, 2/21), Streptococcus parasanguinis (9.52%, 2/21), Micrococcus luteus (4.76%, 1/21) and Bacillus spp. (4.76%, 1/21). The following Gram-negative bacteria were also found in the specimens examined: Escherichia coli, ESBL (extended-spectrum β-lactamase producing E. coli) (4.76%, 1/21), Escherichia coli (4.76%, 1/21), Pseudomonas aeruginosa (4.76%, 1/21), Klebsiella oxytoca (9.52%, 2/21) and Sphingomonas paucimobilis (4.76%, 1/21). Gram-positive bacteria caused nosocomial infections in nine patients with SBP, Gram-negative bacteria caused nosocomial infections in two patients. In six patients with SBP, community-acquired infections caused by Gram-negative bacteria were found in three cases, Gram-positive bacteria in two cases, and in one case, community-acquired infection was caused by mixed Gram-positive and Gram-negative. Bacteria isolated from patients with hospital-acquired SBP showed higher drug resistance than those found in patients with non-hospital SBP. Bacterial infections in cirrhotic patients with complications may be responsible for their deteriorating health. Prompt intervention is critical to reducing mortality.
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Affiliation(s)
- Jolanta Gruszecka
- Institute of Health Sciences, Medical College of Rzeszow University, 35-310 Rzeszow, Poland;
- Department of Clinical Microbiology, Clinical Hospital No. 2, 35-301 Rzeszow, Poland
| | - Rafał Filip
- Faculty of Medicine, Medical College of Rzeszow University, 35-959 Rzeszow, Poland
- IBD Unit, Department of Gastroenterology, Clinical Hospital No. 2, 35-301 Rzeszow, Poland
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14
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Ebrahim MA, Zaher EA, Patel P, Ahmed MK, Ahmed K. Non-cirrhotic Ascites: A Case of Severe Alcoholic Hepatitis. Cureus 2024; 16:e58187. [PMID: 38741864 PMCID: PMC11089831 DOI: 10.7759/cureus.58187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
This case report presents a unique instance of ascites in acute alcoholic hepatitis (AH) occurring in a non-cirrhotic patient. Comprehensive diagnostic evaluation excluded alternative etiologies, pinpointing sinusoidal non-cirrhotic portal hypertension. Present therapeutic modalities for AH, including steroids and pentoxifylline, offer limited efficacy, necessitating ongoing investigation. Liver transplantation may be contemplated in refractory cases. This case underscores the intricate nature of AH presentations and the challenges in their management, emphasizing the imperative need for continued research to delineate optimal therapeutic strategies. Early intervention remains pivotal in addressing AH complications, underscoring the need for heightened clinical vigilance and proactive treatment approaches in such cases.
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Affiliation(s)
| | - Eli A Zaher
- Internal Medicine, Ascension Saint Joseph - Chicago, Chicago, USA
| | - Parth Patel
- Internal Medicine, Ascension Saint Joseph - Chicago, Chicago, USA
| | - Marwan K Ahmed
- Internal Medicine, Ascension Saint Joseph - Chicago, Chicago, USA
| | - Kanwal Ahmed
- Internal Medicine, Ascension Saint Joseph - Chicago, Chicago, USA
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15
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Shah AA, Priyatha V, Ali Y, Wahab A, Salarzai MA, Ahmad J, Salih N. A Rare Case of Portal Hypertension and Ascites Following Intrauterine Fetal Death: A Case Report. Cureus 2024; 16:e55364. [PMID: 38562337 PMCID: PMC10982831 DOI: 10.7759/cureus.55364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
We present a rare case of a 25-year-old woman who developed idiopathic portal hypertension and ascites four days after delivering a stillborn child at term. She had no previous liver illness or risk factors for portal vein thrombosis. Investigations revealed a dilated portal vein, esophageal varices, and high serum-albumin gradient ascites, all of which point to a presinusoidal etiology of portal hypertension. There was no indication of cirrhosis, hepatic or portal vein thrombosis, metabolic or autoimmune liver diseases, or persistent infections. She was treated with antibiotics, diuretics, and beta-blockers, and she underwent a therapeutic paracentesis. The etiology of her portal hypertension remains undetermined. Idiopathic portal hypertension is a rare condition of unknown etiology, characterized by portal hypertension without cirrhosis or thrombosis. It is linked to several risk factors and histological abnormalities, and it can be accompanied by portal hypertension consequences, such as variceal hemorrhage and ascites. The diagnosis is made using clinical criteria and the elimination of alternative causes of portal hypertension. Management is mostly symptomatic, intending to avoid and treat portal hypertension consequences. The prognosis varies according to the underlying etiology and presence of complications.
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Affiliation(s)
- Aizaz A Shah
- Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Vemparala Priyatha
- Internal Medicine, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
| | - Yamna Ali
- Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Abdul Wahab
- Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | | | - Junaid Ahmad
- Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Noman Salih
- Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
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16
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Gioia S, Baiocchini A, d'Amati G, Tavano D, Ridola L, Nardelli S, de Felice I, Lapenna L, Merli M, Pellicelli A, Giannelli V, Riggio O. Porto-sinusoidal vascular disorder (PSVD): Application of new diagnostic criteria in a multicenter cohort of patients. Dig Liver Dis 2024; 56:291-296. [PMID: 37550100 DOI: 10.1016/j.dld.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND AND AIM The term porto-sinusoidal vascular disorder (PSVD) was recently proposed to replace that of idiopathic non-cirrhotic portal hypertension (INCPH) to describe patients with typical histological lesions in absence of cirrhosis, irrespective of the presence/absence of portal hypertension (PH), and new diagnostic criteria were defined. The study aimed to compare the applicability between the diagnostic criteria of PSVD and those of INCPH. MATERIALS AND METHODS 53 patients affected by PSVD were enrolled. Biochemical, clinical, ultrasound and histological data, the presence and type of associated diseases were recorded in a database. According to the new criteria, histological data and signs of PH were divided into specific and non-specific. Percutaneous and transjugular biopsies were compared to establish the usability of the two methods for diagnostic purposes. RESULTS In 85% of the patients the diagnosis of PSVD was obtained by applying the first criterion (25 had specific histological signs with specific signs of PH); one patient presented with specific histological signs but no PH. In 8 patients the diagnosis was obtained by applying the second criterion. 19% of patients had portal vein thrombosis. Finally, the prevalence of the various histological lesions was similar between the patients submitted to percutaneous and transjugular liver biopsy. CONCLUSIONS The study confirms that the diagnostic criteria of PSVD lead to the inclusion of a greater number of patients than INCPH.
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Affiliation(s)
- Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
| | - Andrea Baiocchini
- Department of Pathology, San Camillo Forlanini Hospital, Rome, Italy
| | - Giulia d'Amati
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniele Tavano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ilaria de Felice
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Adriano Pellicelli
- Liver Unit, Department of Liver Transplant, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Valerio Giannelli
- Liver Unit, Department of Liver Transplant, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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17
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Shah M, Gill R, Hotwani P, Moparty H, Kumar N, Gala D, Kumar V. A Case of Non-cirrhotic Portal Hypertension With Antiphospholipid Syndrome. Cureus 2024; 16:e53843. [PMID: 38465021 PMCID: PMC10924662 DOI: 10.7759/cureus.53843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/12/2024] Open
Abstract
Nodular regenerative hyperplasia (NRH) and obliterative portal venopathy (OPV) are two causes of non-cirrhotic portal hypertension (NCPH), which is a vascular liver disease wherein clinical signs of portal hypertension (PHT), such as esophageal varices, ascites, and splenomegaly develop in the absence of cirrhosis and portal vein thrombosis. The etiology often remains unidentified, but herein we present the case of a 56-year-old male with NCPH and refractory ascites who underwent liver biopsy confirming NRH and OPV. Etiological workup revealed beta-2 glycoprotein-1 and anticardiolipin antibodies, concerning antiphospholipid syndrome (APS) despite no prior history of thrombosis. The patient underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure for his refractory ascites and was started on prophylactic anticoagulation owing to a concern for APS with clinical improvement in his ascites and shortness of breath. Pursuing TIPS earlier in the setting of refractory ascites, as well as offering anticoagulation therapy for patients with possible APS to prevent the development of potential thromboses, could be appropriate recommendations to prevent complications in the disease course. This case report highlights the need for further investigations on the etiologies, diagnosis pathways, and treatment options for NCPH.
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Affiliation(s)
- Mili Shah
- Internal Medicine, American University of the Caribbean School of Medicine, Sint Maarten, SXM
| | - Razia Gill
- Internal Medicine, American University of the Caribbean School of Medicine, Sint Maarten, SXM
| | - Priya Hotwani
- Internal Medicine, Parkview Medical Center, Fort Wayne, USA
| | - Hamsika Moparty
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, USA
| | - Naresh Kumar
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, USA
| | - Dhir Gala
- Internal Medicine, American University of the Caribbean School of Medicine, Sint Maarten, SXM
| | - Vikash Kumar
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, USA
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18
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Philips CA, Sarin SK. Noncirrhotic portal hypertension-Historical perspectives bring clarity to the entity and its management. Clin Liver Dis (Hoboken) 2024; 23:e0232. [PMID: 38881719 PMCID: PMC11177835 DOI: 10.1097/cld.0000000000000232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 03/29/2024] [Indexed: 06/18/2024] Open
Affiliation(s)
- Cyriac Abby Philips
- Department of Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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19
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da Cunha Agostini L, Almeida TC, da Silva GN. ANRIL, H19 and TUG1: a review about critical long non-coding RNAs in cardiovascular diseases. Mol Biol Rep 2023; 51:31. [PMID: 38155319 DOI: 10.1007/s11033-023-09007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/30/2023] [Indexed: 12/30/2023]
Abstract
Cardiovascular diseases are the leading cause of death worldwide. They are non-transmissible diseases that affect the cardiovascular system and have different etiologies such as smoking, lipid disorders, diabetes, stress, sedentary lifestyle and genetic factors. To date, lncRNAs have been associated with increased susceptibility to the development of cardiovascular diseases such as hypertension, acute myocardial infarction, stroke, angina and heart failure. In this way, lncRNAs are becoming a very promising point for the prevention and diagnosis of cardiovascular diseases. Therefore, this review highlights the most important and recent discoveries about the mechanisms of action of the lncRNAs ANRIL, H19 and TUG1 and their clinical relevance in these pathologies. This may contribute to early detection of cardiovascular diseases in order to prevent the pathological phenotype from becoming established.
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Affiliation(s)
- Lívia da Cunha Agostini
- Programa de Pós-Graduação em Ciências Farmacêuticas (CiPharma), Escola de Farmácia, Universidade Federal de Ouro Preto, Morro do Cruzeiro, s/nº, Ouro Prêto, Minas Gerais, CEP 35402-163, Brazil
| | - Tamires Cunha Almeida
- Escola Superior Instituto Butantan (ESIB), Laboratório de Dor e Sinalização, Instituto Butantan, São Paulo, São Paulo, Brazil
| | - Glenda Nicioli da Silva
- Programa de Pós-Graduação em Ciências Farmacêuticas (CiPharma), Escola de Farmácia, Universidade Federal de Ouro Preto, Morro do Cruzeiro, s/nº, Ouro Prêto, Minas Gerais, CEP 35402-163, Brazil.
- Departamento de Análises Clínicas (DEACL), Escola de Farmácia, Universidade Federal de Ouro Preto, Ouro Prêto, Brazil.
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20
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Gioia S, Carnevale R, Tavano D, Overi D, Ridola L, Nardelli S, Merli M, d'Amati G, Pellicelli A, Cardinale V, Giannelli V, Baiocchini A, Riggio O, Gaudio E, Carpino G. Association between gut-derived endotoxins and porto-sinusoidal vascular disorder with portal hypertension. Aliment Pharmacol Ther 2023; 58:1205-1216. [PMID: 37728001 DOI: 10.1111/apt.17727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/15/2023] [Accepted: 09/10/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Porto-sinusoidal vascular disorder (PSVD) is characterised by lesions involving portal veins and sinusoids in absence of cirrhosis with an unclear pathophysiology. However, its association with immunodeficiency, bowel disorders and abdominal bacterial infections supports the role of altered intestinal permeability and gut-derived endotoxins. The study aimed at assessing the association between serological markers of increased intestinal permeability, pro-aggregating/procoagulant state and liver injury in PSVD and portal hypertension. METHODS Thirty-three patients with biopsy-proven PSVD and portal hypertension and 33 healthy subjects were submitted to a venous blood sampling for the measurement of zonulin and lipopolysaccharides (LPS) as markers of intestinal permeability, of s-Glycoprotein VI, sP-selectin, ADAMTS13 and von Willebrand factor (vWF), as markers of platelet aggregation and microvascular inflammation, factor VIII and F1 + 2 as markers of hypercoagulability. In 17 PSVD patients, histomorphological and immunohistochemical study on liver biopsies was performed. RESULTS Compared with controls, PSVD patients had higher levels of LPS, zonulin, vWF, factor VIII and sP-selectin, F1 + 2. ADAMTS13 was reduced. Serum LPS correlated with zonulin, sP-selectin, FVIII and vWF. At histological analysis, PSVD specimens had increased LPS localisation, toll-like receptor-4(TLR4)-positive macrophages and platelet number compared with samples from healthy liver donors. TLR4+ macrophage number correlated with portal inflammation and fibrosis. Sinusoid dilation and capillarisation were observed. PSVD biopsies showed signs of biliary damage and reduced ductular reaction without alteration in Sox9+ cell population. CONCLUSIONS PSVD patients display an altered intestinal permeability and endotoxemia correlated to a pro-aggregating/procoagulant state; histologically, PSVD was associated with increased TLR4+ cell involvement and platelet clumps within sinusoids. Our study suggests that LPS-TLR4 pathway could contribute to the pathophysiological basis of PSVD with portal hypertension.
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Affiliation(s)
- Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- IRCCS Neuromed, Località Camerelle, Pozzilli (IS), Italy
| | - Daniele Tavano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Diletta Overi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia d'Amati
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Adriano Pellicelli
- Liver Unit, Department of Liver Transplant, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Valerio Giannelli
- Liver Unit, Department of Liver Transplant, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Andrea Baiocchini
- Department of Pathology, San Camillo Forlanini Hospital, Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Guido Carpino
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
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21
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Gioia S, Riggio O, Nardelli S, Ridola L, Marzano C. Clinical outcomes and prognostic factors in non-cirrhotic non-neoplastic patients with portal vein thrombosis: A single-centre experience. Dig Liver Dis 2023; 55:1487-1495. [PMID: 37230857 DOI: 10.1016/j.dld.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/03/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION The knowledge of natural history and prognostic factors of portal vein thrombosis (PVT) is still based on a limited number of studies. AIM To describe our single-center experience with 79 consecutive non-neoplastic non-cirrhotic patients with PVT (15 recent/64 chronic PVT). RESULTS Among patients with recent PVT, 7 received anticoagulation alone, 4 systemic thrombolysis, 3 direct thrombolysis through a TIPS and 1 TIPS alone. Portal recanalization was achieved in 11 patients. In patients with chronic PVT, the rate of variceal progression was high (20% at one year and 50% at two years). The thrombotic involvement of splenic and superior mesenteric veins was the only risk factor for variceal enlargement. The cumulative bleeding rates were 10% at one year and 20% at two years. A multisegmental thrombosis and large varices at entry and a previous variceal bleeding were the independent predictors for variceal bleeding. The cumulative rate of new thrombotic events was 14% at one year and 18% at two years. Eight patients died, 2 because of thrombotic events. There were no bleeding-related deaths. Two-year cumulative survival rate was 90%. CONCLUSIONS Our study supports the importance of anticoagulation especially when a more extended thrombosis is present. Moreover, in patients with chronic PVT, the timing of follow-up endoscopy should be based on the extension of thrombosis and not, as in cirrhosis, on the size of varices at first endoscopy.
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Affiliation(s)
- Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Marzano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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22
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Baumert LS, Shih A, Chung RT. Management of liver disease and portal hypertension in common variable immunodeficiency (CVID). JHEP Rep 2023; 5:100882. [PMID: 37869072 PMCID: PMC10585302 DOI: 10.1016/j.jhepr.2023.100882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/30/2023] [Accepted: 07/22/2023] [Indexed: 10/24/2023] Open
Abstract
Patients with common variable immunodeficiency (CVID) frequently develop liver disease and associated complications, which represent an increasingly prevalent unmet medical need. The main hepatic manifestation of CVID is nodular regenerative hyperplasia (NRH), resulting in non-cirrhotic portal hypertension (NCPH). Liver disease is often underdiagnosed, leading to poor outcomes and decreased survival. The increasing numbers of patients with CVID who are diagnosed late with progressive liver disease underscores the importance of appropriate clinical management and treatment of liver complications. At the same time, specific guidelines for the clinical management of CVID-related liver disease are still lacking. Here, we review the epidemiology of CVID-related liver disease, reveal new insights into NRH and NCPH biology and highlight recently uncovered opportunities for NCPH diagnostics in CVID. Finally, we focus on current management of liver disease, portal hypertension and its complications - the key challenge in patients with CVID. Specifically, we review recent data regarding the role of transjugular intrahepatic portosystemic shunt and liver transplantation in clinical management. The role for anticoagulants and immunosuppressants targeting the pathogenesis of NRH will also be discussed. We propose an updated algorithm for the diagnostic work-up and treatment of NCPH in CVID. Finally, we consider future needs and therapeutic opportunities for CVID-related liver disease.
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Affiliation(s)
- Lukas S. Baumert
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Faculty of Medicine, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Angela Shih
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T. Chung
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Giri S, Singh A, Angadi S, Kolhe K, Roy A. Prevalence of hepatic encephalopathy in patients with non-cirrhotic portal hypertension: A systematic review and meta-analysis. Indian J Gastroenterol 2023; 42:642-650. [PMID: 37589913 DOI: 10.1007/s12664-023-01412-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/02/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Hepatic encephalopathy, (HE) although commonly associated with cirrhosis, has also been reported in non-cirrhotic portal hypertension (NCPH). The importance of identifying and treating HE in NCPH lies in the fact that many patients may be wrongly diagnosed as having psychiatric or neurologic disorders. Hence, we aimed to systematically review the prevalence of HE in NCPH. METHODS A comprehensive search of three databases (Medline, Embase and Scopus) was conducted from inception to November 2022 for studies reporting on the prevalence of minimal HE (MHE) and overt HE (OHE) in patients with NCPH. Results were presented as pooled proportions with their 95% confidence intervals (CI). RESULTS Total 25 studies (n = 1487) were included after screening 551 records. The pooled prevalence of MHE in NPCH was 32.9% (95% CI: 26.7-39.0) without any difference between adult (32.9%, 95% CI: 23.5-42.3) and pediatric patients (32.6%, 95% CI: 26.1-39.1) (p = 0.941). There was no significant difference in the prevalence between patients with NCPH and compensated cirrhosis with odds ratio of 1.06 (95% CI: 0.77-1.44). The pooled event rate for prior history of OHE in NCPH was 1.2% (95% CI: 0.3-2.1). CONCLUSION Around one-third of the patients with NCPH have MHE, irrespective of age group. OHE is extremely rare in NCPH and is usually associated with a precipitating factor.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Ankita Singh
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, 400 012, India
| | - Sumaswi Angadi
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Kailash Kolhe
- Department of Gastroenterology, Narayana Hospital, Nanded, 431 602, India
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispecialty Hospital, Kolkata, 700 054, India.
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Lapenna L, Di Cola S, Gazda J, De Felice I, Gioia S, Merli M. New Indications for TIPSs: What Do We Know So Far? J Clin Exp Hepatol 2023; 13:794-803. [PMID: 37693277 PMCID: PMC10483008 DOI: 10.1016/j.jceh.2023.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/29/2023] [Indexed: 09/12/2023] Open
Abstract
Since 1988, transjugular intrahepatic portosystemic shunt (TIPS) has been an effective therapy for portal hypertension in many settings. Thanks to continuous technical improvements and a wiser selection of patients, excellent results have been achieved with this therapeutic strategy. The historical indications for TIPS placement, in the context of liver cirrhosis, such as refractory ascites and variceal bleeding are now well established and known. However, in recent years, new indications are emerging. These have been investigated and approved in some studies but are not yet included in guidelines and clinical practice. This review aims to highlight what is new for the role of TIPS in portal vein thrombosis (especially in patients awaiting liver transplantation), in recurrent ascites and not only refractory ascites, as a neoadjuvant therapy before abdominal surgery and, finally, in the setting of noncirrhotic portal hypertension. All these new aspects are addressed in this review with a critical approach based on the literature revision and clinical practice. Future research is needed to explore and validate the new role of TIPS in these scenarios.
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Affiliation(s)
- Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Jakub Gazda
- 2nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital in Kosice, Slovakia
| | - Ilaria De Felice
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
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Giri S, Singh A, Roy A, Patel RK, Tripathy T, Angadi S. Noninvasive differentiation of porto-sinusoidal vascular disorder from cirrhosis: a systematic review. Abdom Radiol (NY) 2023; 48:2340-2348. [PMID: 37119294 DOI: 10.1007/s00261-023-03927-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Porto-sinusoidal vascular disorder (PSVD) is one of the common causes of portal hypertension and has overlapping features with early cirrhosis. The differentiation of PSVD from cirrhosis requires a liver biopsy, which is invasive and has potential complications. This systematic review aimed at summarizing the current evidence on the performance of noninvasive modalities for differentiating PSVD from cirrhosis. METHODS A comprehensive search of electronic databases of MEDLINE, Embase, and Scopus was conducted from 2000 to October 2022 for the studies comparing the elastographic and radiological features of PSVD and cirrhosis, using liver biopsy as the gold standard. RESULTS A total of 12 studies were included in the systematic review. Transient elastography (TE) as a modality was studied in five studies, MR elastography (MRE) in two, contrast CT in two, Contrast CT and MRI in two, and ARFI in only one. Both TE and MRE showed a significantly lower liver stiffness measurement and a higher splenic stiffness measurement with a higher SSM/LSM ratio with PSVD, compared to cirrhosis. Among the radiological features, focal nodular hyperplasia-like lesions, portal vein abnormalities (intrahepatic and extrahepatic), and a larger spleen size favored a diagnosis of PSVD. In contrast, surface nodularity and atrophy of segment IV with a segment I hypertrophy favored a diagnosis of cirrhosis. CONCLUSION Elastography and cross-sectional imaging can help differentiate PSVD from early cirrhosis with good accuracy. Further studies are required to assess the diagnostic role of a combination of both modalities.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, 4th Floor, Specialty Block, Panjagutta, Hyderabad, Telangana, 500082, India
| | - Ankita Singh
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Akash Roy
- Institute of Liver and Gastrosciences, Apollo Multispecialty Hospital, Kolkata, India
| | - Ranjan Kumar Patel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Taraprasad Tripathy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Sumaswi Angadi
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, 4th Floor, Specialty Block, Panjagutta, Hyderabad, Telangana, 500082, India.
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Song XJ, Liu JL, Jia SY, Zhang K. Portal vein computed tomography imaging characteristics and their relationship with bleeding risk in patients with liver cirrhosis undergoing interventional therapy. World J Clin Cases 2023; 11:4277-4286. [PMID: 37449217 PMCID: PMC10336985 DOI: 10.12998/wjcc.v11.i18.4277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND This study aimed to analyze the predictive value of multi-slice spiral computed tomography (CT) perfusion imaging for upper gastrointestinal bleeding in patients with cirrhotic portal hypertension. A total of 62 patients with cirrhotic portal hypertension and 28 healthy individuals were included. The results showed that multi-slice spiral CT perfusion imaging had a significant predictive value for upper gastrointestinal bleeding in patients with cirrhotic portal hypertension. The vascular area, number of vascular cross-sections, and gastric coronary vein diameter (GCVD) showed high predictive values, with the vascular area having the best predictive value.
AIM To investigate the predictive accuracy of multi-slice spiral CT perfusion imaging for upper gastrointestinal bleeding in patients with cirrhosis and portal hypertension.
METHODS This study included 62 patients with cirrhotic portal hypertension (disease group) and 28 healthy individuals (control group). The disease group was further divided into two subgroups: Group A (n = 27, bleeding) and group B (n = 35, no bleeding). All patients underwent multi-slice spiral CT perfusion imaging at our hospital, and we compared various parameters such as liver blood flow, vein size, number of blood vessels, and blood vessel area between the two groups. We employed statistical analysis to identify factors associated with upper gastrointestinal bleeding and created a graph comparing the predictive value of different factors for bleeding.
RESULTS We found no difference in hepatic artery (HAP) levels among the three groups (all P > 0.05). The portal vein levels in groups A and B were much lower than in the control group; group A was much lower than group B (all P < 0.05). The HAP perfusion index levels in groups A and B were much higher than in the control group; group A was much higher than group B (all P < 0.05). The portal vein diameter, splenic vein diameter, and GCVD levels in groups A and B were much higher than in the control group; those in group A were much higher than those in group B (all P < 0.05). The number of blood vessels and blood vessel area in groups A and B were much higher than in the control group; those in group A were much higher than those in group B (all P < 0.05). The statistical method showed a strong link between GCVD, number of blood vessels, blood vessel area, and upper gastrointestinal bleeding (odds ratio = 1.275, 1.346, 1.397, P < 0.05). The graph showed that GCVD, number of blood vessels, and blood vessel area could predict bleeding well, with blood vessel area having the best prediction power.
CONCLUSION That multi-slice spiral CT perfusion imaging can predict upper gastrointestinal bleeding well in patients with cirrhosis and high blood pressure in the portal vein. GCVD, number of blood vessels, and blood vessel area had high prediction power. The blood vessel area had the best prediction power, with an area under the curve of 0.831.
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Affiliation(s)
- Xue-Jing Song
- Department of Medical Oncology, Shijiazhuang People’s Hospital, Shijiazhuang 050000, Hebei Province, China
| | - Jing-Lei Liu
- Department of Interventional Treatment, 980 (Bethune International Peace) Hospital of PLA Joint Logistics Support Forces, Shijiazhuang 050051, Hebei Province, China
| | - Shu-Ya Jia
- Department of Rehabilitation, Shijiazhuang People’s Hospital, Shijiazhuang 050000, Hebei Province, China
| | - Kai Zhang
- Department of Medical Oncology, Shijiazhuang People’s Hospital, Shijiazhuang 050000, Hebei Province, China
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Kiran HS, Karkra R, Laghima VN, Venkatesh CR. Chronic Extrahepatic Portal Vein Occlusion in a Young Patient. Cureus 2023; 15:e40806. [PMID: 37485108 PMCID: PMC10362884 DOI: 10.7759/cureus.40806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Extrahepatic portal vein obstruction (EHPVO) is a rare condition characterized by the occlusion or narrowing of the portal vein outside the liver. We present a case report of a patient with EHPVO secondary to combined protein C and S deficiency and pancytopenia secondary to hypersplenism, highlighting the clinical presentation, diagnostic challenges, and management strategies. Early recognition of this condition and prompt initiation of appropriate treatment can prevent life-threatening complications such as variceal bleeding and portal hypertension. This case underscores the need for a high index of suspicion for inherited thrombophilias in patients presenting with portal vein thrombosis, particularly in the absence of traditional risk factors.
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Affiliation(s)
- H S Kiran
- Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education & Research (JSSAHER), Mysuru, IND
| | - Rohan Karkra
- Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education & Research (JSSAHER), Mysuru, IND
| | - V N Laghima
- Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education & Research (JSSAHER), Mysuru, IND
| | - C R Venkatesh
- Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education & Research (JSSAHER), Mysuru, IND
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Suárez-Díaz S, García-Calonge M, Mendoza-Pacas G, Mozo-Avellaneda L, Caminal-Montero L. Non-Cirrhotic Portal Hypertension in Systemic Lupus Erythematosus. Cureus 2023; 15:e35494. [PMID: 36999104 PMCID: PMC10049850 DOI: 10.7759/cureus.35494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2023] [Indexed: 03/01/2023] Open
Abstract
We report the case of idiopathic non-cirrhotic portal hypertension associated with systemic lupus erythematosus in a 43-year-old woman who suffered from breast cancer. We review this rare condition, as well as its diagnostic and therapeutic approaches.
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Maternal and perinatal outcome in pregnancies complicated with portal hypertension: a systematic review and meta-analysis. Hepatol Int 2023; 17:170-179. [PMID: 35802227 DOI: 10.1007/s12072-022-10385-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portal hypertension is secondary to either cirrhotic or non-cirrhotic causes, and complicating pregnancy poses a challenge to the treating team. A systematic review was performed to determine maternal and perinatal outcomes in women with portal hypertension. Outcomes were compared among those with cirrhotic (CPH) with non-cirrhotic portal hypertension (NCPH) as well as non-cirrhotic portal fibrosis (NCPF) with extra-hepatic portal vein obstruction (EHPVO). METHODS Medline and EMBASE databases were searched for studies reporting outcomes among pregnant women with portal hypertension. Reference lists from relevant papers and reviews were hand-searched for appropriate citations. Data were extracted to describe maternal complications, obstetric and neonatal outcomes. A random-effects model was used to derive pooled estimates of various outcomes, and final estimates were reported as percentages with a 95% confidence interval (CI). Cumulative, sequential and sensitivity analysis was studied to assess the temporal trends of outcomes over the period. RESULTS Information on 895 pregnancies among 581 patients with portal hypertension was included from 26 studies. Portal hypertension was diagnosed during pregnancy in 10% (95% CI 4-24%). There were 22 maternal deaths (0%, 95% CI 0-1%), mostly following complications from variceal bleeding or hepatic decompensation. Variceal bleeding complicated in 14% (95% CI 9-20%), and endoscopic interventions were performed in 12% (95% CI 8-17%) during pregnancy. Decompensation of liver function occurred in 7% (95% CI 3-12%). Thrombocytopenia was the most common complication (41%, 95% CI 23-60%). Miscarriages occurred in 14% (95% CI 8-20%), preterm birth in 27% (95% CI 19-37%), and low birth weights in 22% (95% CI 15-30%). Risk of postpartum hemorrhage was higher (RR 5.09, 95% CI 1.84-14.12), and variceal bleeding was lower (RR 0.51, 95% CI 0.30-0.86) among those with CPH compared to NCPH. Risk of various outcomes was comparable between NCPF and EHPVO. CONCLUSION One in ten pregnancies complicated with portal hypertension is diagnosed during pregnancy, and thrombocytopenia is the most common complication. Hepatic decompensation and variceal bleeding remain the most common cause of maternal deaths, with reduced rates of bleeding and its complications reported following the introduction of endoscopic procedures during pregnancy. CPH increases the risk of postpartum hemorrhage, whereas variceal bleeding is higher among NCPH.
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Rare hepatocellular carcinoma presentation: Hepatoportal sclerosis. HEPATOLOGY FORUM 2023; 4:35-36. [PMID: 36843893 PMCID: PMC9951896 DOI: 10.14744/hf.2022.2022.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/07/2022] [Accepted: 08/09/2022] [Indexed: 01/19/2023]
Abstract
Hepatoportal sclerosis (HPS) is an idiopathic non-cirrhotic portal hypertension (INCPH) characterized by hypersplenism, portal hypertension, and splenomegaly. Hepatocellular carcinoma (HCC) is the most common form of liver cancer. Non-cirrhotic portal hypertension is an extremely rare cause of HCC. A 36-year-old woman was referred to our hospital with esophageal varices. All serologic tests for etiology were negative. Serum ceruloplasmin and serum Ig A-M-G were normal. In the follow-up, two liver lesions were identified on a triple-phase computer. The lesions had arterial enhancement but no washout in the venous phase. In the magnetic resonance imaging examination, differentiation in favor of HCC was considered at one of the lessions. Radiofrequency ablation therapy was first applied to a patient who had no signs of metastasis. Within 2 months, the patient underwent a living donor liver transplant. In explant pathology, well-differentiated HCC and HPS were considered the cause of non-cirrhotic portal hypertension. The patient has been followed without relapse for 3 years. The development of HCC in INCPH patients is still debatable. Despite the presence of liver cell atypia and pleomorphism in nodular regenerative hyperplasia liver specimens, a causal link between HCC and INCPH is yet to be established.
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Interventional Management of Portal Hypertension in Cancer Patients. Curr Oncol Rep 2022; 24:1461-1475. [PMID: 35953600 DOI: 10.1007/s11912-022-01319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches. RECENT FINDINGS In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.
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Giri S, Sahoo S. Pregnancy in Patients with Non-cirrhotic Portal Hypertension: A Literature Review. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:609-613. [PMID: 35760363 PMCID: PMC9948258 DOI: 10.1055/s-0042-1748973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Pregnancy in non-cirrhotic portal hypertension (NCPH) is an uncommon condition. Its management is challenging both to the obstetricians as well as to the gastroenterologists due to the lack of more extensive studies and standard clinical practice guidelines. These patients are at increased risk of portal hypertension (PTH) complications, especially variceal bleeding, and with an increased incidence of adverse maternal and fetal outcomes. Hence, a multidisciplinary approach is required for management of pregnancy in NCPH. This short review describes the different aspects of pregnancy with NCPH, emphasizing specific strategies for preventing and managing PTH from the preconceptional period to postpartum.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shradhanjali Sahoo
- Department of Maternal and Fetal Medicine, Fernandez Hospital, Hyderabad, Telangana, India
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Gairing SJ, Galle PR, Schattenberg JM, Kostev K, Labenz C. Portal vein thrombosis is associated with an increased risk of bone fractures. PLoS One 2022; 17:e0267535. [PMID: 35452487 PMCID: PMC9032344 DOI: 10.1371/journal.pone.0267535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/10/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Portal vein thrombosis (PVT) is a rare but severe disease that often leads to portal hypertension-related complications. It is well-known that patients with portal hypertension associated with liver cirrhosis are at increased risk for bone fractures, however data on the impact of PVT on fracture risk are lacking.
Aims
This study aimed to explore the impact of PVT on the incidence of bone fractures in a large German primary care cohort.
Methods
Patients with PVT were extensively matched to non-PVT individuals in a 1:5 ratio. The primary outcome of the study was the incidence of any bone fracture.
Results
This study included 596 patients with PVT and 2,980 non-PVT individuals. During five years of follow-up, the cumulative incidence of bone fractures was significantly higher in PVT patients (n = 87, 13.6%) than in those without PVT (n = 186, 6.7%) (p<0.001). In Cox-regression analyses, PVT was positively associated with bone fractures (HR: 2.16; 95% CI: 1.59–2.93). This association was stronger in women (HR: 2.55; 95% CI: 1.65–3.95) than in men (HR: 1.87; 95% CI: 1.22–2.87). The strongest association was observed in the age group 51–60 years (HR: 2.50, 95% CI: 1.40–4.47). The association between PVT and bone fractures was maintained in subgroup analyses of patients with (HR: 2.03, 95% CI: 1.13–3.63) and without liver cirrhosis (HR: 1.82, 95% CI: 1.28–2.58).
Conclusions
PVT is independently associated with a higher incidence of bone fractures. Patients with PVT should be critically evaluated for fracture risk and preventive measures should be considered.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter Robert Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jörn Markus Schattenberg
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | | | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- * E-mail:
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Zhu K, Zhang W, Shao W, Ding J, Ma C. Report of a case of cirrhotic portal hypertension with ectopic varices in the bilateral pulmonary hilar. DEN OPEN 2022; 2:e99. [PMID: 35873504 PMCID: PMC9302055 DOI: 10.1002/deo2.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/13/2022] [Accepted: 01/22/2022] [Indexed: 11/08/2022]
Abstract
Here, we report the case of patient cirrhosis with esophageal and gastric fundal varices who developed rare ectopic varices in the bilateral pulmonary hilar after repeated endoscopic treatments (tissue adhesive for gastric fundal varices + esophageal variceal ligation + esophageal variceal sclerotherapy) accompanied by serious shortness of breath. After transjugular intrahepatic portosystemic shunt + gastric coronary vein embolization, the shortness of breath was relieved, and the portography review indicated that the ectopic varices in the pulmonary hilar were significantly improved.
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Affiliation(s)
- Ke Zhu
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
| | - Wei Zhang
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
| | - Wei Shao
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
| | - Jing Ding
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
| | - Chao Ma
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
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Levigard RB, Salas H, Serrão H, Diniz F, Nogueira CAV, de Oliveira AA, Leite NC, Ladeira M, Chindamo MC, Pereira G. Liver Growth and Portal Hypertension Improvement After Percutaneous Recanalization of Chronic Portal Vein Thrombosis in Non-Cirrhotic Participants. Cardiovasc Intervent Radiol 2022; 45:582-589. [PMID: 35166884 DOI: 10.1007/s00270-022-03065-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/24/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate liver function improvement and volume gain after percutaneous recanalization of chronic portal vein thrombosis (PVT) in non-cirrhotic patients. MATERIALS AND METHODS In this retrospective study, five non-cirrhotic participants between 21 and 67 years old with secondary chronic PVT (4-21 years from diagnose) were submitted to percutaneous portal vein recanalization, followed by varices and shunts embolization. RESULTS After a mean of 12.6 months, all portal veins remained patent and there was complete resolution of portal hypertension (PH) symptoms in all participants. There was a significant increase in liver volume of 39.8 ± 19.0% (p = 0.042), platelets count of 53120 ± 20188/μl (p = 0.042), and a significant decrease in total bilirubin levels from 1.04 ± 0.23 mg/dL to 0.51 ± 0.09 mg/dL (p = 0.043). We also found a non-significant increase in albumin levels from 3.88 ± 0.39 g/dL to 4.38 ± 0.27 g/dL (p = 0.078) and decrease in spleen diameter from 16.88 ± 4.03 cm to 14.15 ± 2.72 cm (p = 0.068). DISCUSSION In this retrospective study, even with a small number of participants, we were capable of showing a median of 39.8% increase in liver volume, laboratorial liver function improvement, platelets count and resolution of PH symptoms, including gastroesophageal varices disappearance after portal vein recanalization followed by shunt embolization. CONCLUSION In this small series of cases, recanalization of chronic PVT in non-cirrhotic participants was feasible, successful and safe despite the prolonged time of occlusion. This is a new and promising approaching to an old and still challenging disease.
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Affiliation(s)
- Raphael Braz Levigard
- Interventional Radiology Department, Rede D' Or/São Luiz, Rua Real Grandeza 108, sala 113, Botafogo, Rio de Janeiro, RJ, 22281-034, Brazil.
| | - Henrique Salas
- Interventional Radiology Department, Rede D' Or/São Luiz, Rua Real Grandeza 108, sala 113, Botafogo, Rio de Janeiro, RJ, 22281-034, Brazil
| | - Henrique Serrão
- Interventional Radiology Department, Rede D' Or/São Luiz, Rua Real Grandeza 108, sala 113, Botafogo, Rio de Janeiro, RJ, 22281-034, Brazil
| | - Felipe Diniz
- Interventional Radiology Department, Rede D' Or/São Luiz, Rua Real Grandeza 108, sala 113, Botafogo, Rio de Janeiro, RJ, 22281-034, Brazil
| | | | | | - Nathalie Carvalho Leite
- Department of Internal Medicine/Hepatology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcia Ladeira
- Emergency Department, Rede D' Or/São Luiz, Rio de Janeiro, Brazil
| | - Maria Chiara Chindamo
- Department of Internal Medicine/Hepatology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gustavo Pereira
- Department of Internal Medicine / Hepatology, Federal Hospital of Bonsucesso, Rio de Janeiro, Brazil
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Cognitive Impairement in Non-Cirrhotic Portal Hypertension: Highlights on Physiopathology, Diagnosis and Management. J Clin Med 2021; 11:jcm11010101. [PMID: 35011842 PMCID: PMC8745274 DOI: 10.3390/jcm11010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022] Open
Abstract
Hepatic encephalopathy (HE) is one of the most frequent complications of cirrhosis. Several studies and case reports have shown that cognitive impairment may also be a tangible complication of portal hypertension secondary to chronic portal vein thrombosis and to porto-sinusoidal vascular disease (PSVD). In these conditions, representing the main causes of non-cirrhotic portal hypertension (NCPH) in the Western world, both overt and minimal/covert HE occurs in a non-neglectable proportion of patients, even lower than in cirrhosis, and it is mainly sustained by the presence of large porto-systemic shunt. In these patients, the liver function is usually preserved or only mildly altered, and the development of porto-systemic shunt is either spontaneous or iatrogenically frequent; HE is an example of type-B HE. To date, in the absence of strong evidence and large cooperative studies, for the diagnosis and the management of HE in NCPH, the same approach used for HE occurring in cirrhosis is applied. The aim of this paper is to provide an overview of type B hepatic encephalopathy, focusing on its pathophysiology, diagnostic tools and management in patients affected by porto-sinusoidal vascular disease and chronic portal vein thrombosis.
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Bonjour TJ. The ambiguous abdomen in a basic military trainee. JAAPA 2021; 34:54-56. [PMID: 34582388 DOI: 10.1097/01.jaa.0000791496.19639.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Timothy J Bonjour
- Timothy J. Bonjour is associate dean of graduate allied health education at the San Antonio Uniformed Services Health Education Consortium and practices emergency medicine at Brooke Army Medical Center, Fort Sam Houston and Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, in San Antonio, Tex. The author has disclosed no potential conflicts of interest, financial or otherwise
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Kmeid M, Liu X, Ballentine S, Lee H. Idiopathic Non-Cirrhotic Portal Hypertension and Porto-Sinusoidal Vascular Disease: Review of Current Data. Gastroenterology Res 2021; 14:49-65. [PMID: 34007347 PMCID: PMC8110235 DOI: 10.14740/gr1376] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/30/2021] [Indexed: 12/29/2022] Open
Abstract
Idiopathic non-cirrhotic portal hypertension (INCPH) is a clinicopathologic disease entity characterized by the presence of clinical signs and symptoms of portal hypertension (PH) in the absence of liver cirrhosis or known risk factors accountable for PH. Multiple hematologic, immune-related, infectious, hereditary and metabolic risk factors have been associated with this disorder. Still, the exact etiopathogenesis is largely unknown. The recently proposed porto-sinusoidal vascular disease (PSVD) scheme broadens the spectrum of the disease by also including patients without clinical PH who are found to have similar histopathologic findings on core liver biopsies. Three histomorphologic lesions have been identified as specific for PSVD to include obliterative portal venopathy, nodular regenerative hyperplasia and incomplete septal cirrhosis/fibrosis. However, these findings are often subtle, under-recognized and subjective with low interobserver agreement among pathologists. Additionally, the natural history of the subclinical forms of the disease remains unexplored. The clinical course is more favorable compared to cirrhosis patients, especially in the absence of clinical PH or liver dysfunction. There are no universally accepted guidelines in regard to diagnosis and treatment of INCPH/PSVD. Hence, this review emphasizes the need to raise awareness of this entity by highlighting its complex pathophysiology and clinicopathologic associations. Lastly, formulation of standardized diagnostic criteria with clinical validation is necessary to avoid misclassifying vascular diseases of the liver and to develop and implement targeted therapeutic strategies.
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Affiliation(s)
- Michel Kmeid
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - Xiuli Liu
- Department of Pathology and Laboratory Medicine, University of Florida at Gainesville, FL, USA
| | - Samuel Ballentine
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hwajeong Lee
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
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Reddy R. Extrahepatic portal vein obstruction with portal cavernoma transformation in a child. APOLLO MEDICINE 2021. [DOI: 10.4103/am.am_52_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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