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Khan HH, Kaufman SS, Yazigi NA, Khan KM. Outcomes of Portosystemic Shunts in Children with and without Liver Transplantation. Pediatr Gastroenterol Hepatol Nutr 2024; 27:37-42. [PMID: 38249644 PMCID: PMC10796260 DOI: 10.5223/pghn.2024.27.1.37] [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: 01/08/2023] [Revised: 05/19/2023] [Accepted: 09/12/2023] [Indexed: 01/23/2024] Open
Abstract
Purpose Limited data exist regarding outcome and morbidity associated with portosystemic shunts in the pediatric transplant population. Our study assesses the outcomes of pediatric patients who underwent a portosystemic shunt procedure, both with and without liver transplantation (LT). Methods This study retrospectively reviewed the medical records of pediatric patients aged 0-19 years who underwent shunt placement between 2003 and 2017 at a tertiary care center. The analysis included cases of shunt placement with or without LT. Results A total of 13 pediatric patients were included in the study with median age of 8.8 years. Among the cases, 11 out of 13 (84.6%) underwent splenorenal shunt, 1 (7.7%) underwent a mesocaval shunt, and another 1 (7.7%) underwent a Modified Rex (mesoportal) shunt. Additionally, 5 out of 13 (38.5%) patients had LT, with 4 out of 5 (80.0%) receiving the transplant before shunt placement, and 1 out of 5 (20.0%) receiving it after shunt placement. Gastrointestinal bleeding resulting from portal hypertension was the indication in all cases. A total of 10 complications were reported in 5 patients; the most common complication was anemia in 3 (23.1%) patients. At the most recent follow-up visit, the shunts were functional without encephalopathy, and no deaths were reported. Conclusion Shunt placement plays a crucial role in the management of patients with portal hypertension. Our study demonstrates favorable long-term outcomes in pediatric patients who underwent shunt placement. Long term shunt outcomes were similar and unremarkable in patients with LT and without LT.
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Affiliation(s)
- Hamza Hassan Khan
- Department of Pediatrics, Shawn Jenkins Children’s Hospital, Medical University of South Carolina, Charleston, SC, USA
| | - Stuart S. Kaufman
- Department of Pediatrics, Transplant Institute, Medstar Georgetown University Hospital, Washington, D.C., USA
| | - Nada A. Yazigi
- Department of Pediatrics, Transplant Institute, Medstar Georgetown University Hospital, Washington, D.C., USA
| | - Khalid M. Khan
- Department of Pediatrics, Transplant Institute, Medstar Georgetown University Hospital, Washington, D.C., USA
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Saarela KM, Hsu EK. Improving the quality of care in pediatric patients with cirrhosis. Clin Liver Dis (Hoboken) 2024; 23:e0208. [PMID: 38872785 PMCID: PMC11168843 DOI: 10.1097/cld.0000000000000208] [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: 03/15/2024] [Accepted: 04/15/2024] [Indexed: 06/15/2024] Open
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Sunar Yayla EN, Sarı S, Gürcan Kaya N, Eğrİtaş Gürkan Ö, Sözen H, Özen İO, Dalgıç A, Dalgıç B. Portal Hypertension in Children: A Tertiary Center Experience in Turkey. Pediatr Gastroenterol Hepatol Nutr 2023; 26:301-311. [PMID: 38025487 PMCID: PMC10651363 DOI: 10.5223/pghn.2023.26.6.301] [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: 05/19/2023] [Revised: 08/09/2023] [Accepted: 09/16/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Portal hypertension (PH) and its complications have a significant impact on morbidity and mortality. This study aimed to evaluate the etiology; clinical, laboratory, and endoscopic findings; treatment approaches; long-term outcomes; and prognosis of pediatric PH. Methods This retrospective study included 222 pediatric patients diagnosed with PH between 1998 and 2016, and data encompassing clinical, laboratory, and radiological features; treatments; and complications were analyzed. Results The most common causes of PH were portal vein thrombosis (20.3%), progressive familial intrahepatic cholestasis (18.9%), and biliary atresia (12.2%). Among the enrolled patients, 131 (59.0%) were included in the cirrhotic group and 91 (41.0%) in the non-cirrhotic group. Hepatomegaly and increased transaminase levels were more frequent in the cirrhotic group than in the non-cirrhotic group. Additionally, portal gastropathy, esophageal varices, and variceal bleeding were more frequent in the non-cirrhotic group, whereas ascites, hepatopulmonary syndrome and hepatic encephalopathy were more common in the cirrhotic group. The incidence of hepatomegaly was higher in the presinusoidal group than in the prehepatic group (p<0.001). Hyperbilirubinemia was more frequent in the prehepatic group (p=0.046). The frequency of esophageal varices was similar between the prehepatic and presinusoidal groups; however, variceal bleeding was more frequent in the prehepatic group (p=0.002). Conclusion Extrahepatic portal vein obstruction, genetic-metabolic diseases, and biliary atresia were the most prevalent causes of PH in our country. In patients with PH, hepatomegaly, increased transaminase levels, and synthesis dysfunction were suggestive of cirrhotic PH. Notably, PH in patients without cirrhosis might be more severe than that in those with cirrhosis.
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Affiliation(s)
| | - Sinan Sarı
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Neslihan Gürcan Kaya
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ödül Eğrİtaş Gürkan
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Hakan Sözen
- Division of Transplantation Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - İbrahim Onur Özen
- Department of Pediatric Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Aydın Dalgıç
- Division of General Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Buket Dalgıç
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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5
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Deniz S, Schinner R, Monroe EJ, Horslen S, Srinivasa RN, Lv Y, Fan D, Han G, Sarma MS, Srivastava A, Poddar U, Yadav R, Hoang TPT, Lange CM, Öcal O, Ricke J, Seidensticker M, Lurz E, Di Giorgio A, D'Antiga L, Wildgruber M. Outcome of Children with Transjugular Intrahepatic Portosystemic Shunt: A Meta-Analysis of Individual Patient Data. Cardiovasc Intervent Radiol 2023; 46:1203-1213. [PMID: 37532945 PMCID: PMC10471675 DOI: 10.1007/s00270-023-03520-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023]
Abstract
PURPOSE The purpose of the study was to investigate outcome after pediatric transjugular intrahepatic portosystemic shunt (TIPS) with respect to survival MATERIAL AND METHODS: After searching for studies on TIPS in children in Ovid, Medline, Embase, Scopus and Cochrane published between 2000 and 2022, individual patient data were retrieved from five retrospective cohorts. Overall survival (OS) and transplant-free survival (TFS) were calculated using Kaplan-Meier analysis and log-rank test and compared to the indication (ascites vs. variceal bleeding) as well as to the level of obstruction (pre-hepatic vs. hepatic vs. post-hepatic). Additionally, TIPS patency was analyzed. RESULTS n = 135 pediatric patients were included in the final analysis. Indication for pediatric TIPS creation was heterogeneous among the included studies. TIPS patency decreased from 6 to 24 months, subsequent pediatric liver transplantation was performed in 22/135 (16.3%) of cases. The presence of ascites was related with poorer TFS (HR 2.3, p = 0.023), while variceal bleeding was not associated with impaired survival. Analysis of the level of obstruction (pre-hepatic, hepatic and post-hepatic) failed to prove significantly reduced OS for post-hepatic obstruction (HR 3.2, p = 0.092) and TFS (HR 1.3, p = 0.057). There was no difference in OS and TFS according to age at time of TIPS placement. CONCLUSIONS The presence of ascites associates with impaired survival after TIPS in children, with no differences in survival according to the age of the child. Interventional shunt procedures can be considered feasible for all ages. LEVEL OF EVIDENCE Level 2a.
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Affiliation(s)
- Sinan Deniz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Regina Schinner
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Eric J Monroe
- Department of Radiology, University of Wisconsin, Madison, WA, USA
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Ravi N Srinivasa
- Division of Vascular and Interventional Radiology, Department of Radiology, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Yong Lv
- Military Medical Innovation Center, State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Moinak Sen Sarma
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Anshu Srivastava
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Ujjal Poddar
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Rajanikant Yadav
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Thi Phuong Thao Hoang
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian M Lange
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Osman Öcal
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Eberhard Lurz
- Division for Pediatric Gastroenterology, Hepatology and Transplantation, Department for Pediatrics, Dr. Von Haunersches Kinderspital, University Hospital, LMU Munich, Munich, Germany
| | - Angelo Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Flores-Calderón J, Cisneros-Garza LE, Chávez-Barrera JA, Vázquez-Frias R, Reynoso-Zarzosa FA, Martínez-Bejarano DL, Consuelo-Sánchez A, Reyes-Apodaca M, Zárate-Mondragón FE, Sánchez-Soto MP, Alcántara-García RI, González-Ortiz B, Ledesma-Ramírez S, Espinosa-Saavedra D, Cura-Esquivel IA, Macías-Flores J, Hinojosa-Lezama JM, Hernández-Chávez E, Zárate-Guerrero JR, Gómez-Navarro G, Bilbao-Chávez LP, Sosa-Arce M, Flores-Fong LE, Lona-Reyes JC, Estrada-Arce EV, Aguila-Cano R. Consensus on the management of complications of cirrhosis of the liver in pediatrics. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:462-485. [PMID: 35810090 DOI: 10.1016/j.rgmxen.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/08/2022] [Indexed: 12/07/2022]
Abstract
The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.
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Affiliation(s)
- J Flores-Calderón
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico.
| | | | - J A Chávez-Barrera
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | | | | | | | | | | | | | - M P Sánchez-Soto
- Hospital de Especialidades del Niño y la mujer de Querétaro Dr. Felipe Núñez Lara, Querétaro, Mexico
| | | | - B González-Ortiz
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - S Ledesma-Ramírez
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - D Espinosa-Saavedra
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | | | - J Macías-Flores
- Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Mexico
| | | | - E Hernández-Chávez
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - J R Zárate-Guerrero
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - G Gómez-Navarro
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - L P Bilbao-Chávez
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - M Sosa-Arce
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - L E Flores-Fong
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - J C Lona-Reyes
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - E V Estrada-Arce
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - R Aguila-Cano
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
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7
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Sooraj K, Shivani FNU, Hassan Khan M, Kumar RR, Bai S, Hussaini H, Rakesh FNU, Jamil A, Arshad H, Naz S. Frequency of Causes of Portal Hypertension in Children. Cureus 2022; 14:e25934. [PMID: 35844324 PMCID: PMC9282599 DOI: 10.7759/cureus.25934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction The most common etiology of portal hypertension (PH) in children is obstruction at the presinusoidal or sinusoidal level. In addition, portal vein thrombosis (PVT) and biliary atresia are the most prevalent extrahepatic causes. This study aims to evaluate all the possible etiologies leading to PH in the pediatric population and provide the most common cause associated with this condition along with the age group most frequently affected by it. Material and Methods From January 2018 to December 2020, a cross-sectional study was carried out in tertiary care hospitals in Pakistan. A total of 100 children, both male and female, aged one month to 15 years and diagnosed with PH, were enrolled for the evaluation for the causes of PH. The Statistical Package for the Social Sciences (SPSS), version 20, was used to analyze the data. Results The mean age of enrolled participants was 9.01 ± 2.81 years. It was found that PVT (63%) was the most common cause of PH, followed by liver cirrhosis (19%) and biliary atresia (18%). Age of more than eight years was significantly associated with PVT (p-value: 0.007). Conclusion In children, PH may be caused by a wide range of etiologies. It is imperative to understand the underlying etiologies contributing to PH for proper guidance and management, prevention, and overall outcomes.
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Bello FPS, Preto-Zamperlini M, Schvartsman C, Farhat SCL. Reply to "Does timing of endoscopy matter for acute upper gastrointestinal bleeding in pediatric portal hypertension?". Dig Liver Dis 2022; 54:146-147. [PMID: 34852979 DOI: 10.1016/j.dld.2021.11.005] [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: 10/29/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 12/11/2022]
Affiliation(s)
| | - Marcela Preto-Zamperlini
- Emergency Department, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil
| | - Cláudio Schvartsman
- Emergency Department, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Sylvia Costa Lima Farhat
- Emergency Department, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil.
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Tannuri ACA, Chavez LS, Guimarães JX, Gonçalves JDO, Serafini S, Souza GCD, Malheiros DMAC, Paes VR, Tannuri U. Cardiac and renal effects of liver cirrhosis in a growing animal model. Acta Cir Bras 2021; 36:e360806. [PMID: 34644774 PMCID: PMC8516424 DOI: 10.1590/acb360806] [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: 04/06/2021] [Accepted: 07/02/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To assess the biochemical, histological, histomorphometric and molecular effects of biliary duct ligation (BDL) induced liver cirrhosis in the heart and kidneys. METHODS Thirty-two weaning rats (21 days old, 50-70 g) underwent BDL and were divided in four groups (euthanasia after two, four, six, and eight weeks, respectively) and compared to control groups. RESULTS The animals' hearts of group 3 were bigger than those of the control group (p=0.042), including thinner right ventricle wall, decreased internal diameter of ventricles, and increased perivascular collagen deposition in left ventricle, as well as increased interstitial collagen in right ventricle after six weeks. In the kidneys of groups 3 and 4, bilirubin impregnation in the tubules, hydropic degeneration, loss of nuclei and lack of plasmatic membrane limits were noted. Nitric oxide synthase (NOS) gene expressions were higher in group 1 (p=0.008), and endothelial nitric oxide synthase (eNOS) gene expressions were elevated in all experimental groups (p=0.008, p=0.001, p=0.022, and p=0.013, respectively). In the heart, a decreased expression of eNOS in group 1 (p=0.04) was observed. CONCLUSIONS Liver cirrhosis leads to histological and histomorphometric alterations in the heart and kidneys, with changes in the NOS and eNOS gene expressions, that may suggest a role in the associated myocardial and renal manifestations.
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Wu JF. Prevention of gastroesophageal variceal bleeding in children: The role and efficacy of primary prophylaxis. Pediatr Neonatol 2021; 62:235-236. [PMID: 33941345 DOI: 10.1016/j.pedneo.2021.04.005] [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] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan South Rd., Taipei, Taiwan.
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11
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Lee WS, Song ZL, Em JM, Chew KS, Ng RT. Role of primary prophylaxis in preventing variceal bleeding in children with gastroesophageal varices. Pediatr Neonatol 2021; 62:249-257. [PMID: 33546933 DOI: 10.1016/j.pedneo.2021.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/18/2020] [Accepted: 01/11/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Primary endoscopic prophylaxis in pediatric gastroesophageal varices is not universally practiced. We aimed to determine the role of primary endoscopic prophylaxis in preventing variceal bleeding in gastroesophageal varices in children. METHODS We reviewed all children with gastroesophageal varices seen in our unit from 2000 to 2019. Primary prophylaxis was defined as endoscopic procedure without a preceding spontaneous bleeding and secondary prophylaxis as preceded by spontaneous bleeding. High-risk varices were defined as presence of grade III esophageal varices, cardia gastric varices or cherry red spots on the varices. Outcome measures (spontaneous rebleeding within 3 months after endoscopic procedure, number of additional procedures to eradicate varices, liver transplant [LT], death) were ascertained. RESULTS Sixteen of 62 (26%) patients (median [± S.D.] age at diagnosis = 5.0 ± 4.3 years) with varices had primary prophylaxis, 38 (61%) had secondary prophylaxis while 8 (13%) had no prophylaxis. No difference in the proportion of patients with high-risk varices was observed between primary (88%) and secondary (92%; P = 0.62) prophylaxis. As compared to secondary prophylaxis, children who had primary prophylaxis were significantly less likely to have spontaneous rebleeding (6% vs. 38%; P = 0.022) and needed significantly fewer repeated endoscopic procedures (0.9 ± 1.0 vs. 3.1 ± 2.5; P = 0.021). After 8.9 ± 5.5 years of follow-up, overall survival was 85%; survival with native liver was 73%. No statistical difference was observed in the eventual outcome (alive with native liver) between primary and secondary (71% vs. 78%, P = 0.78). CONCLUSION Children with PHT who had primary prophylaxis had less subsequent spontaneous rebleeding and needed fewer additional endoscopic procedures as compared to secondary prophylaxis but did not have an improved eventual outcome. Screening endoscopy in all children who have signs of PHT and primary prophylaxis in high-risk esophageal varices should be considered before eventual LT.
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Affiliation(s)
- Way Seah Lee
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia; Paediatrics and Child Health Research Group, University Malaya, Kuala Lumpur, Malaysia.
| | - Zhi Liang Song
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Jun Min Em
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Kee Seang Chew
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Ruey Terng Ng
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
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12
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Razek AAKA, Hafez MM, Mahmoud W, Ismail AR, Ali KM, Barakat TE. Diffusion tensor imaging of the spleen in prediction and grading of esophageal varices in cirrhotic children with portal hypertension. Jpn J Radiol 2021; 39:907-913. [PMID: 33914254 DOI: 10.1007/s11604-021-01123-7] [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: 01/30/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To assess diffusion tensor imaging (DTI) of spleen in prediction and grading of esophageal varices (OV) in cirrhotic children. METHODS This prospective study was conducted upon 30 children with cirrhotic children with OV and 10 age-gender matched controls that underwent DTI of abdomen. Mean diffusivity (MD) and fractional anisotropy (FA) of spleen were calculated and matched with the grading of OV at endoscopy and laboratory biomarkers of portal hypertension. RESULTS Mean ADC of spleen in patient was significantly different (p = 0.001) from that of controls by both reviewers respectively. The cutoff ADC measurement of the spleen used for prediction of OV was ≥ 0.75 and ≥ 0.76 × 10-3mm2/s with AUC was 0.993 and 0.997 for both reviewers respectively. The FA of the spleen in patient was different (p = 0.01) from of controls of both reviewers respectively. Cutoff FA of spleen used for prediction of OV was ≤ 0.35 and ≤ 0.36 for both observers respectively. ADC and FA of spleen was correlated with platelets count (r = - 0.713, 0.392; p = 0.001, 0.012) and prothrombin time (r = 0.518, - 0.380; p = 0.001, 0.016). CONCLUSION DTI metrics of spleen can predict and grade OV and correlated with laboratory biomarkers of portal hypertension.
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Affiliation(s)
| | - Mona Mohamed Hafez
- Cardiology Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Walaa Mahmoud
- Department of Diagnostic Radiology, Mansoura Faculty of Medicine, Mansoura University, Mansoura, 13551, Egypt
| | - Ahmed Ramadan Ismail
- Gastroenterology and Hepatology Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Khadiga M Ali
- Department of Pathology, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Tarek Elsayed Barakat
- Gastroenterology and Hepatology Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Jain AK, Anand R, Lerret S, Yanni G, Chen JY, Mohammad S, Doyle M, Telega G, Horslen S. Outcomes following liver transplantation in young infants: Data from the SPLIT registry. Am J Transplant 2021; 21:1113-1127. [PMID: 32767649 PMCID: PMC7867666 DOI: 10.1111/ajt.16236] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) in young patients is being performed with greater frequency. We hypothesized that objective analysis of pre-, intra-, and postoperative events would help understand contributors to successful outcomes and guide transplant decision processes. We queried SPLIT registry for pediatric transplants between 2011 and 2018. Outcomes were compared for age groups: 0-<3, 3-<6, 6-<12 months, and 1-<3 years (Groups A, B, C, D respectively) and by weight categories: <5, 5-10, >10 kg; 1033 patients were available for analysis. Cholestatic disease and fulminant failure were highest in group A and those <5 kg; and biliary atresia in group C (72.8%). Group A had significantly higher life support dependence (34.6%; P < .001), listing as United Network for Organ Sharing status 1a/1b (70.4%; P < .001), and shortest wait times (P < .001). The median (interquartile range) for international normalized ratio and bilirubin were highest in group A (3.0 [2.1-3.9] and 16.7 [6.8-29.7] mg/dL) and those <5 kg (2.6 [1.8-3.4] and 13.5 [3.0-28.4] mg/dL). A pediatric end -stage liver disease score ≥40, postoperative hospital stays, rejection, and nonanastomotic biliary strictures were highest in group A with lowest survival at 93.1%. Infants 0 to <3 months and those <5 kg need more intensive care with lower survival and higher complications. Importantly, potential LT before reaching status 1a/1b and aggressive postoperative management may positively influence their outcomes.
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Affiliation(s)
- Ajay K. Jain
- Saint Louis University, Saint Louis, Missouri, USA
| | | | - Stacee Lerret
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - George Yanni
- Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | | | - Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Majella Doyle
- Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Greg Telega
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Simon Horslen
- Liver and Small Bowel Transplantation, Seattle Children’s Hospital, Seattle, Washington, USA
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Cifuentes LI, Gattini D, Torres-Robles R, Gana JC. Band ligation versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2021; 1:CD011561. [PMID: 33522602 PMCID: PMC8094619 DOI: 10.1002/14651858.cd011561.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including bleeding (haemorrhage) from oesophageal and gastrointestinal varices. Variceal bleeding commonly occurs in children and adolescents with chronic liver disease or portal vein thrombosis. Prevention is, therefore, important. Randomised clinical trials have shown that non-selective beta-blockers and endoscopic variceal band ligation decrease the incidence of variceal bleeding in adults. In children and adolescents, band ligation, beta-blockers, and sclerotherapy have been proposed as primary prophylaxis alternatives for oesophageal variceal bleeding. However, it is unknown whether these interventions are of benefit or harm when used for primary prophylaxis in children and adolescents. OBJECTIVES To assess the benefits and harms of band ligation compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase, and two other databases (April 2020). We scrutinised the reference lists of the retrieved publications, and we also handsearched abstract books of the two main paediatric gastroenterology and hepatology conferences from January 2008 to December 2019. We also searched clinicaltrials.gov, the United States Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the World Health Organization (WHO) for ongoing clinical trials. We imposed no language or document type restrictions on our search. SELECTION CRITERIA We aimed to include randomised clinical trials irrespective of blinding, language, or publication status, to assess the benefits and harms of band ligation versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. If the search for randomised clinical trials retrieved quasi-randomised and other observational studies, then we read them through to extract information on harm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to perform this systematic review. We used GRADE to assess the certainty of evidence for each outcome. Our primary outcomes were all-cause mortality, serious adverse events and liver-related morbidity, and quality of life. Our secondary outcomes were oesophageal variceal bleeding and adverse events not considered serious. We used the intention-to-treat principle. We analysed data using Review Manager 5. MAIN RESULTS One conference abstract, describing a feasibility multi-centre randomised clinical trial, fulfilled our review inclusion criteria. We judged the trial at overall high risk of bias. This trial was conducted in three hospital centres in the United Kingdom. The aim of the trial was to determine the feasibility and safety of further larger randomised clinical trials of prophylactic band ligation versus no active treatment in children with portal hypertension and large oesophageal varices. Twelve children received prophylactic band ligation and 10 children received no active treatment. There was no information on the age of the children included, or about the diagnosis of any child included. All children were followed up for at least six months. Mortality was 8% (1/12) in the band ligation group versus 0% (0/10) in the no active intervention group (risk ratio (RR) 2.54, 95% confidence interval (CI) 0.11 to 56.25; very low certainty of evidence). The abstract did not report when the death occurred, but we assume it happened between the six-month follow-up and one year. No child (0%) in the band ligation group developed adverse events (RR 0.28, 95% CI 0.01 to 6.25; very low certainty of evidence) but one child out of 10 (10%) in the no active intervention group developed idiopathic thrombocytopaenic purpura. One child out of 12 (8%) in the band ligation group underwent liver transplantation versus none in the no active intervention group (0%) (RR 2.54, 95% CI 0.11 to 56.25; very low certainty of evidence). The trial reported no other serious adverse events or liver-related morbidity. Quality of life was not reported. Oesophageal variceal bleeding occurred in 8% (1/12) of the children in the band ligation group versus 30% (3/10) of the children in the no active intervention group (RR 0.28, 95% CI 0.03 to 2.27; very low certainty of evidence). No adverse events considered non-serious were reported. Two children were lost to follow-up by one-year. Ten children in total completed the trial at two-year follow-up. There was no information on funding. We found two observational studies on endoscopic variceal ligation when searching for randomised trials. One found no harm, and the other reported E nterobacter cloacae septicaemia in one child and mild, transient, upper oesophageal sphincter stenosis in another. We did not assess these studies for risk of bias. We did not find any ongoing randomised clinical trials of interest to our review. AUTHORS' CONCLUSIONS The evidence, obtained from only one feasibility randomised clinical trial at high risk of bias, is very scanty. It is very uncertain about whether prophylactic band ligation versus sham or no (active) intervention may affect mortality, serious adverse events and liver-related morbidity, or oesophageal variceal bleeding in children and adolescents with portal hypertension and large oesophageal varices. We have no data on quality of life. No adverse events considered non-serious were reported. The results presented in the trial need to be interpreted with caution. In addition, the highly limited data cover only part of our research question; namely, children with portal hypertension and large oesophageal varices. Data on children with portal vein thrombosis are lacking. Larger randomised clinical trials assessing the benefits and harms of band ligation compared with sham treatment for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis are needed. The trials should include important clinical outcomes such as death, quality of life, failure to control bleeding, and adverse events.
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Affiliation(s)
- Lorena I Cifuentes
- Division of Paediatrics, Evidence-based Health Care Programme, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniela Gattini
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Romina Torres-Robles
- Sistema de Bibliotecas UC, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Cifuentes LI, Gattini D, Torres-Robles R, Gana JC. Beta-blockers versus placebo or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2021; 1:CD011973. [PMID: 33498095 PMCID: PMC8078150 DOI: 10.1002/14651858.cd011973.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including haemorrhage from oesophageal and gastrointestinal varices. Variceal haemorrhage commonly occurs in children with chronic liver disease or portal vein thrombosis. Therefore, prevention is important. Band ligation, beta-blockers, and sclerotherapy have been proposed as alternatives for primary prophylaxis of oesophageal variceal bleeding in children. However, primary prophylaxis is not the current standard of care in paediatric patients because it is unknown whether those treatments are of benefit or harm when used for primary prophylaxis in children and adolescents. OBJECTIVES To determine the benefits and harms of beta-blockers compared with placebo or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase, LILACS, and Science Citation Index Expanded (April 2020). We screened the reference lists of the retrieved publications and manually searched the main paediatric gastroenterology and hepatology conference (NASPGHAN and ESPGHAN) abstract books from 2008 to December 2019. We searched clinicaltrials.gov, the United States Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the World Health Organization (WHO) for ongoing clinical trials. We imposed no language or document type restrictions on our search. SELECTION CRITERIA We planned to include randomised clinical trials, irrespective of blinding, language, or publication status to assess benefits and harms. We included observational studies, retrieved with the searches for randomised clinical trials, for a narrative report of harm. DATA COLLECTION AND ANALYSIS We planned to summarise data from randomised clinical trials by standard Cochrane methodologies. We planned to asses risk of bias and use GRADE to assess the certainty of evidence. Our primary outcomes were all-cause mortality, serious adverse events and liver-related morbidity, and health-related quality of life. Our secondary outcomes were oesophageal variceal bleeding and adverse events not considered serious. We planned to use intention-to-treat principle. We planned to analyse data with RevMan Analysis. MAIN RESULTS We found no randomised clinical trials that assessed beta-blockers compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. We found four observational studies that reported on harms. As a systematic search for observational studies was not planned, we only listed the reported harms in a table. AUTHORS' CONCLUSIONS Randomised clinical trials assessing the benefits or harms of beta-blockers versus placebo or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are lacking. Therefore, trials with adequate power and proper design, assessing the benefits and harms of beta-blockers versus placebo on patient-relevant clinical outcomes, such as mortality, quality of life, failure to control variceal bleeding, and adverse events are needed. Unless such trials are conducted and the results become published, we cannot make any conclusions regarding the benefits or harms of the two interventions.
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Affiliation(s)
- Lorena I Cifuentes
- Division of Paediatrics, Evidence-based Health Care Programme, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniela Gattini
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Romina Torres-Robles
- Sistema de Bibliotecas UC, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Gana JC, Cifuentes LI, Gattini D, Torres-Robles R. Band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2020; 11:CD011803. [PMID: 33164205 PMCID: PMC8078550 DOI: 10.1002/14651858.cd011803.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including haemorrhage from oesophageal and gastrointestinal varices. Variceal haemorrhage commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. In adults, numerous randomised clinical trials have demonstrated benefits of non-selective beta-blockers and endoscopic variceal ligation as primary prevention in decreasing the risk of variceal haemorrhage. In children, band ligation, beta-blockers, and sclerotherapy have been proposed as alternatives for primary prophylaxis of oesophageal variceal bleeding. However, primary prophylaxis is not the current standard of care in children because it is unknown whether those treatments are of benefit or cause harm when used for primary prophylaxis of oesophageal variceal bleeding in children and adolescents. OBJECTIVES To determine the benefits and harms of band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase, LILACS, and Science Citation Index Expanded (27 April 2020). We scrutinised the reference lists of retrieved publications, and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from 2008 to 2019. We searched ClinicalTrials.gov, FDA, EMA, and WHO for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA We planned to include randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. If the search for randomised clinical trials retrieved quasi-randomised and observational studies, then we read them through to extract information on harms. DATA COLLECTION AND ANALYSIS We planned to summarise data from randomised clinical trials by standard Cochrane methodologies. We planned to assess risk of bias and use GRADE to assess the certainty of evidence per outcome. Our primary outcomes were all-cause mortality, serious adverse events and liver-related morbidity, and quality of life. Our secondary outcomes were oesophageal variceal bleeding and adverse events not considered serious. We planned to analyse data with intention-to-treat. We planned to use Review Manager 5 to analyse the data. MAIN RESULTS We found no randomised clinical trials assessing band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. AUTHORS' CONCLUSIONS Randomised clinical trials assessing the benefits or harms of band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are lacking. Therefore, trials with adequate power and proper design, assessing the benefits and harms of band ligation versus sclerotherapy on patient-relevant clinical outcomes such as mortality, quality of life, failure to control variceal bleeding, and adverse events are needed. Unless such trials are conducted and the results become published, we cannot make any conclusions regarding the benefits or harms of these two interventions.
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Affiliation(s)
- Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lorena I Cifuentes
- Division of Paediatrics, Evidence-based Health Care Programme, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniela Gattini
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Romina Torres-Robles
- Sistema de Bibliotecas UC, Pontificia Universidad Católica de Chile, Santiago, Chile
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Henkel S, Vetterly C, Squires R, McKiernan P, Squires J. Pharmacological management of portal hypertension and its complications in children: lessons from adults and opportunities for the future. Expert Opin Pharmacother 2020; 22:291-304. [PMID: 33074032 DOI: 10.1080/14656566.2020.1825685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Portal hypertension (PHT) and its complications in children are thought to be distinct from adult PHT in several areas, including the underlying bio-physiology of a child in which PHT develops, but also because of the pediatric-specific etiologies that drive disease progression. And yet pharmacologic approaches to PHT in children are mainly based on adult data, modified for pediatric practice. This reality has been driven by a lack of data specific to children. AREAS COVERED The authors discuss current therapeutic approaches to PHT in children, including management of acute gastrointestinal variceal bleed, pharmacotherapy in prophylaxis, and established and emerging therapies to combat systemic co-morbidities that result from PHT. The few areas where pediatric-specific data exist are highlighted and the many gaps in knowledge that remain unresolved are underscored. EXPERT OPINION Despite decades of experience, optimal management of pediatric PHT remains undefined. In large part, this can be directly linked to a lack of basic understanding related to the unique pathophysiology and natural history that defines PHT in children. As a result, meaningful research into the utility and effectiveness of pharmacotherapy in children with PHT remains in its infancy. Large, multi-center, prospective studies will be needed to begin to establish an infrastructure on which a pediatric-specific research agenda can be built.
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Affiliation(s)
- Sarah Henkel
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - Carol Vetterly
- Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Pharmacy , Pittsburgh, PA
| | - Robert Squires
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - Patrick McKiernan
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - James Squires
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
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Cost-effectiveness Analysis of Feeding Guidelines for Infants Following Intestinal Surgery. J Pediatr Gastroenterol Nutr 2020; 70:657-663. [PMID: 31977952 DOI: 10.1097/mpg.0000000000002642] [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: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to determine the cost-effectiveness of postoperative feeding guidelines to reduce complications in infants with intestinal surgery compared to standard feeding practices. METHODS Using outcomes from a cohort study, Markov models from health care and societal perspectives simulated costs per hospitalization among infants fed via guidelines versus standard practice. Short-term outcomes included intestinal failure-associated liver disease, necrotizing enterocolitis after feeding, sepsis, and mortality. Effectiveness was measured as length of stay. The incremental cost-effectiveness ratios (ICER) compared cost over length of stay. Univariate and multivariate probabilistic sensitivity analyses with 10,000 Monte Carlo Simulations were performed. A second decision tree model captured the cost per quality-adjusted life years (QALYs) using utilities associated with long-term outcomes (liver cirrhosis and transplantation). RESULTS In the hospital perspective, standard feeding had a cost of $31,258,902 and 8296 hospital days, and the feeding guidelines had a cost of $29,295,553 and 8096 hospital days. The ICER was $-9832 per hospital stay with guideline use. More than 90% of the ICERs were in the dominant quadrant. Results were similar for the societal perspective. Long-term costs and utilities in the guideline group were $2830 and 0.91, respectively, versus $4030 and 0.90, resulting in an ICER of $-91,756/QALY. CONCLUSION In our models, feeding guideline use resulted in cost savings and reduction in hospital stay in the short-term and cost savings and an increase in QALYs in the long-term. Using a systematic approach to feed surgical infants appears to reduce costly complications, but further data from a larger cohort are needed.
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Gattini D, Cifuentes LI, Torres-Robles R, Gana JC. Sclerotherapy versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2020; 3:CD011573. [PMID: 32133620 PMCID: PMC7059883 DOI: 10.1002/14651858.cd011573.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including bleeding (haemorrhage) from oesophageal and gastrointestinal varices. Variceal bleeding commonly occurs in children with chronic liver disease or portal vein obstruction. Therefore, prevention is important. Primary prophylaxis of variceal bleeding in adults is the established standard of care because of the results of numerous randomised clinical trials demonstrating the efficacy of non-selective beta-blockers or endoscopic variceal ligation in decreasing the incidence of variceal bleeding. In children, band ligation, beta-blockers, and sclerotherapy have been proposed as alternatives for primary prophylaxis of oesophageal variceal bleeding. However, it is unknown whether those treatments are of benefit or harm when used for primary prophylaxis in children. OBJECTIVES To assess the benefits and harms of sclerotherapy compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase Elsevier, and two other registers in February 2019. We scrutinised the reference lists of the retrieved publications, and performed a manual search of the main paediatric gastroenterology and hepatology conference (NASPGHAN and ESPGHAN) abstracts from January 2008 to December 2018. We searched four registries for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA We included randomised clinical trials irrespective of blinding, language, or publication status assessing sclerotherapy versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to perform this systematic review. We used the intention-to-treat principle to analyse outcome data, and GRADE to assess the certainty of evidence per outcome. MAIN RESULTS We found only one randomised clinical trial that fulfilled our inclusion criteria. The trial was at high risk of bias. The trial included 108 Brazilian children with median age of 4.3 years (range 11 months to 13 years). Fifty-six children were randomised to prophylactic sclerotherapy (ethanolamine oleate 2%) and 52 children to no intervention (control). Children were followed up for a median of 4.5 years. Eight children (six from the sclerotherapy group versus two from the control group) dropped out before the end of the trial. The follow-up was from 18 months to eight years. Mortality was 16% (9/56 children) in the sclerotherapy group versus 15% (8/52 children) in the control group (risk ration (RR) 1.04, 95% confidence interval (CI) 0.44 to 2.50; very low-certainty evidence). Upper gastrointestinal bleeding occurred in 21% (12/56) of the children in the sclerotherapy group versus 46% (24/52) in the control group (RR 0.46, 95% CI 0.26 to 0.83; very low-certainty evidence). There were more children with congestive hypertensive gastropathy in the sclerotherapy group than in the control group (14% (8/56) versus 6% (3/52); RR 2.48, 95% CI 0.69 to 8.84; very low-certainty evidence). The incidence of gastric varices was similar between the sclerotherapy group and the control group (11% (6/56) versus 10% (5/52); RR 1.11, 95% CI 0.36 to 3.43; very low-certainty evidence). The incidence of bleeding from gastric varices was higher in the sclerotherapy group than in the control group (4% (3/56) versus 0% (0/52); RR 6.51, 95% CI 0.34 to 123.06; very low-certainty evidence). The study did not assess health-related quality of life. Oesophageal variceal bleeding occurred in 5% (3/56) of the children in the sclerotherapy group versus 40% (21/52) of the children in the control group (RR 0.13, 95% CI 0.04 to 0.42; very low-certainty evidence). The most prevalent complications (defined as non-serious) were pain and fever after the procedure, which promptly resolved with analgesics. However, numerical data on the frequency of these adverse events and their occurrences in the two groups were lacking. No funding information was provided. We found no ongoing trials. AUTHORS' CONCLUSIONS The evidence, obtained from one randomised clinical trial at high risk of bias, is very uncertain on whether sclerotherapy has an influence on mortality and if it may decrease first upper gastrointestinal or oesophageal variceal bleeding in children. The evidence is very uncertain on whether sclerotherapy has an influence on congestive hypertensive gastropathy, incidence on gastric varices, and incidence of bleeding from gastric varices. Health-related quality of life was not measured. There were no serious events caused by sclerotherapy, and analysis of non-serious adverse events could not be performed due to lack of numerical data. The GRADE assessment of each outcome showed a very low-certainty evidence. The results of the trial need to be interpreted with caution. Larger randomised clinical trials, following the SPIRIT and CONSORT statements, assessing the benefits and harms of sclerotherapy compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are needed. The trials should include important clinical outcomes such as death, failure to control bleeding, and adverse events.
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Affiliation(s)
- Daniela Gattini
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Gastroenterology and Nutrition Department, Division of Paediatrics, Santiago, Chile
| | - Lorena I Cifuentes
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Division of Paediatrics, Evidence-based Health Care Programme, Lira 85, 5º piso, Santiago, Metroplitana, Chile, 833-0074
| | - Romina Torres-Robles
- Pontificia Universidad Católica de Chile, Sistema de Bibliotecas UC, Santiago, Región Metropolitana, Chile, 8330074
| | - Juan Cristóbal Gana
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Gastroenterology and Nutrition Department, Diagonal Paraguay 362, 8th Floor, Santiago, Region Metropolitana, Chile, 8330074
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Gattini D, Cifuentes LI, Torres-Robles R, Gana JC. Sclerotherapy versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2020; 1:CD011659. [PMID: 31922266 PMCID: PMC6956467 DOI: 10.1002/14651858.cd011659.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including bleeding (haemorrhage) from oesophageal and gastrointestinal varices. Variceal bleeding commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. Primary prophylaxis of variceal bleeding in adults is the established standard of care because of the results of numerous randomised clinical trials demonstrating the efficacy of non-selective beta-blockers or endoscopic variceal ligation in decreasing the incidence of variceal bleeding. However, sclerotherapy is the only endoscopic prophylactic option currently available in infants weighing less than 10 kg of bodyweight due to the size of the endoscopic ligator. OBJECTIVES To assess the benefits and harms of sclerotherapy versus any type of beta-blocker for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase Elsevier, LILACS (Bireme), and Science Citation Index Expanded (Web of Science) in February 2019. We scrutinised the reference lists of the retrieved publications and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from January 2008 to December 2018. We searched ClinicalTrials.gov, FDA, EMA, and WHO, for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA We planned to include randomised clinical trials irrespective of blinding, language, or publication status, assessing sclerotherapy versus any type of beta-blocker for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. We planned to include quasi-randomised and other observational studies retrieved with the searches for randomised clinical trials for report of harm. DATA COLLECTION AND ANALYSIS We planned to collect and summarise data from randomised clinical trials as described in our protocol, using standard Cochrane methodologies. MAIN RESULTS We found no randomised clinical trials assessing sclerotherapy versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. AUTHORS' CONCLUSIONS Randomised clinical trials assessing the benefits or harms of sclerotherapy versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis are lacking. Therefore, trials with adequate power and proper design, assessing the benefits and harms of sclerotherapy versus beta-blockers on patient-relevant clinical outcomes such as mortality, failure to control bleeding, and adverse events are needed. Unless such trials are conducted and the results become published, we cannot make any conclusions regarding the benefits or harms of the two interventions.
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Affiliation(s)
- Daniela Gattini
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Gastroenterology and Nutrition Department, Division of Paediatrics, Santiago, Chile
| | - Lorena I Cifuentes
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Division of Paediatrics, Evidence-based Health Care Programme, Lira 85, 5º piso, Santiago, Metroplitana, Chile, 833-0074
| | - Romina Torres-Robles
- Pontificia Universidad Católica de Chile, Sistema de Bibliotecas UC, Santiago, Región Metropolitana, Chile, 8330074
| | - Juan Cristóbal Gana
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Gastroenterology and Nutrition Department, Diagonal Paraguay 362, 8th Floor, Santiago, Region Metropolitana, Chile, 8330074
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Blachman-Braun R, Lopez-Verdugo F, Alonso D, Book L, Feola GP, Rodriguez-Davalos MI. Revision of meso-Rex bypass utilizing a collateral vein in a patient with portal steal phenomenon after liver transplant: A case report. Int J Surg Case Rep 2019; 60:230-233. [PMID: 31252380 PMCID: PMC6600796 DOI: 10.1016/j.ijscr.2019.05.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/07/2019] [Accepted: 05/27/2019] [Indexed: 12/13/2022] Open
Abstract
Re-do of a meso-Rex Bypass is a feasible option with good outcomes. A large collateral vein is an alternative for an autologous venous conduit in a MRB. Large collaterals ligation during MRB should be performed to avoid portal steal.
Introduction In children with extrahepatic portal vein obstruction or those who develop portal vein thrombosis after liver transplant, the use of Meso-Rex Bypass (MRB) creates a more physiological state by redirecting mesenteric blood flow back into the intrahepatic portal system via a venous conduit. Presentation of case A 3-year-old female with biliary atresia associated with polysplenia syndrome and a surgical history of Kasai portoenterostomy procedure, and an ABO incompatible whole liver transplant. Within a year after transplant she presented with prehepatic portal hypertension, that was treated with MRB using a deceased donor ABO compatible iliac vein as conduit. Six months later, she was taken to the operating room for bypass revision, during the procedure the MRB showed no flow and no thrombus, and a large splenorenal collateral vein that was causing a portal perfusion steal phenomenon was observed. After dissecting the collateral vein, an 8 cm x8 mm segment of this vessel was used as an autologous conduit to re-do the Rex. Discussion Failed of MRB can be attributed to portal steal phenomenon, hypercoagulable disorders, bypass contraction or kinking. In this case we believe the culprit to be the former. When there is a history of longstanding portal hypertension, large collaterals develop; thus, intraoperative portal vein flow measurement is critical and ligation of large collaterals during liver transplantation and MRB should be performed to avoid portal steal phenomenon postprocedure. Conclusion Using a collateral vein as an alternative autologous venous conduit is a feasible option that can have durable success.
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Affiliation(s)
- Ruben Blachman-Braun
- Pediatric Liver Transplantation, Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - Fidel Lopez-Verdugo
- Pediatric Liver Transplantation, Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - Diane Alonso
- Pediatric Liver Transplantation, Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - Linda Book
- Pediatric Liver Disease and Transplant Program, Intermountain Primary Children's Hospital, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - G Peter Feola
- Department of Radiology, Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
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Clinically Evident Portal Hypertension: An Operational Research Definition for Future Investigations in the Pediatric Population. J Pediatr Gastroenterol Nutr 2019; 68:763-767. [PMID: 30908382 PMCID: PMC6534459 DOI: 10.1097/mpg.0000000000002333] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Portal hypertension (PHT) is a major cause of morbidity and mortality in pediatric liver diseases. Thus, research into causes and disease modifiers in PHT in these conditions is vitally important. PHT is rarely directly or indirectly measured in the assessment of children with chronic liver disease. A straightforward, reproducible definition of PHT could be invaluable for consistently identifying patients with PHT and for grouping these patients according to their risk of complications from their disease. We propose the term Clinically Evident Portal Hypertension (CEPH) to denote clinical findings that demonstrate evidence of elevated portal pressure. When CEPH criteria are met, PHT is highly likely to be present, although it is likely that PHT exists for variable periods of time before meeting CEPH criteria. Use of this research definition of CEPH will allow for consistent identification of these patients by clinicians in nearly any clinical setting and serve as a clinical milepost that may dictate future prognosis in pediatric patients with cirrhosis.
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Zhong HJ, Sun HH, Xue LF, McGowan EM, Chen Y. Differential hepatic features presenting in Wilson disease-associated cirrhosis and hepatitis B-associated cirrhosis. World J Gastroenterol 2019; 25:378-387. [PMID: 30686905 PMCID: PMC6343092 DOI: 10.3748/wjg.v25.i3.378] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/03/2019] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cirrhosis is a chronic late stage liver disease associated with hepatitis viruses, alcoholism, and metabolic disorders, such as Wilson disease (WD). There are no clear markers or clinical features that define cirrhosis originating from these disparate origins. We hypothesized that cirrhosis is not one disease and cirrhosis of different etiology may have differential clinical hepatic features. AIM To delineate the liver features between WD-associated cirrhosis and hepatitis B-associated cirrhosis in the Chinese population. METHODS In this observational study, we reviewed the medical data of consecutive inpatients who had WD-associated cirrhosis or hepatitis B-associated cirrhosis from January 2010 to August 2018, and excluded patients who had carcinoma, severe heart or pulmonary diseases, or other liver diseases. According to the etiology of cirrhosis, patients were divided into two groups: WD-associated cirrhosis group (60 patients) and hepatitis B-associated cirrhosis group (56 patients). The liver fibrosis degree, liver function indices, and portal hypertension features of these patients were compared between the two groups. RESULTS No inter-group differences were observed in the diagnostic liver fibrosis markers, however, clinical features clearly defined the origin of cirrhosis. WD-associated cirrhosis patients (16-29 years) had lower levels of alanine transaminase, aspartate transaminase, and bilirubin, lower prothrombin time, lower incidence of hepatic encephalopathy, and lower portal vein diameter (P < 0.05), compared to cirrhosis resulting from hepatitis B in older patients (45-62 years). Importantly, they had decreased risks of progression from Child-Pugh grade A to B (odds ratio = 0.046, 95% confidence interval: 0.006-0.387, P = 0.005) and of ascites (odds ratio = 0.08, 95% confidence interval: 0.01-0.48, P = 0.005). Conversely, WD-associated cirrhosis patients had a higher risk of splenomegaly (odds ratio = 4.15, 95% confidence interval: 1.38-12.45, P = 0.011). CONCLUSION WD-associated cirrhosis presents a higher risk of splenomegaly associated with leukopenia and thrombocytopenia, although revealing milder liver dysfunction and portal hypertension symptoms, which recommends WD patients to be monitored for associated complications.
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Affiliation(s)
- Hao-Jie Zhong
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510000, Guangdong Province, China
- Department of Gastroenterology, Guangdong Medical University, Zhanjiang 524000, Guangdong Province, China
| | - Huan-Huan Sun
- Department of Gastroenterology, The First Affiliated Hospital of Xi’an Jiao Tong University, Xi’an 710000, Shaanxi Province, China
| | - Lan-Feng Xue
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510000, Guangdong Province, China
| | - Eileen M McGowan
- Faculty of Science, University of Technology Sydney, Sydney NSW 2007, Australia
| | - Yu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510000, Guangdong Province, China
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