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Affiliation(s)
- Lauren A Beste
- From the General Medicine Service (L.A.B.), Health Services Research and Development (L.A.B.), and Hospital and Specialty Medicine Service (L.A.B., P.B.C.) of the Veterans Affairs (VA) Puget Sound Health Care System, and Department of Medicine, University of Washington School of Medicine (L.A.B., P.B.C.) - both in Seattle; and the Medicine Service, VA Ann Arbor Healthcare System (R.H.M., S.S.), and Department of Internal Medicine, University of Michigan Health System (R.H.M., S.S.) - both in Ann Arbor
| | - Richard H Moseley
- From the General Medicine Service (L.A.B.), Health Services Research and Development (L.A.B.), and Hospital and Specialty Medicine Service (L.A.B., P.B.C.) of the Veterans Affairs (VA) Puget Sound Health Care System, and Department of Medicine, University of Washington School of Medicine (L.A.B., P.B.C.) - both in Seattle; and the Medicine Service, VA Ann Arbor Healthcare System (R.H.M., S.S.), and Department of Internal Medicine, University of Michigan Health System (R.H.M., S.S.) - both in Ann Arbor
| | - Sanjay Saint
- From the General Medicine Service (L.A.B.), Health Services Research and Development (L.A.B.), and Hospital and Specialty Medicine Service (L.A.B., P.B.C.) of the Veterans Affairs (VA) Puget Sound Health Care System, and Department of Medicine, University of Washington School of Medicine (L.A.B., P.B.C.) - both in Seattle; and the Medicine Service, VA Ann Arbor Healthcare System (R.H.M., S.S.), and Department of Internal Medicine, University of Michigan Health System (R.H.M., S.S.) - both in Ann Arbor
| | - Paul B Cornia
- From the General Medicine Service (L.A.B.), Health Services Research and Development (L.A.B.), and Hospital and Specialty Medicine Service (L.A.B., P.B.C.) of the Veterans Affairs (VA) Puget Sound Health Care System, and Department of Medicine, University of Washington School of Medicine (L.A.B., P.B.C.) - both in Seattle; and the Medicine Service, VA Ann Arbor Healthcare System (R.H.M., S.S.), and Department of Internal Medicine, University of Michigan Health System (R.H.M., S.S.) - both in Ann Arbor
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Maruyama H, Kondo T, Sekimoto T, Yokosuka O. Differential Clinical Impact of Ascites in Cirrhosis and Idiopathic Portal Hypertension. Medicine (Baltimore) 2015; 94:e1056. [PMID: 26131820 PMCID: PMC4504543 DOI: 10.1097/md.0000000000001056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 05/28/2015] [Accepted: 06/02/2015] [Indexed: 12/20/2022] Open
Abstract
Cirrhosis and idiopathic portal hypertension (IPH) are 2 major diseases showing portal hypertension. However, characteristics and outcomes of IPH with ascites have not yet been determined. The aim of the study was to examine the influence of ascites on the long-term clinical course of IPH.This observational study compared the long-term clinical findings including portal hemodynamics demonstrated by Doppler ultrasonography between 166 cirrhosis (87 males and 79 females; mean age ± standard deviation, 62.5 ± 11.8 years; age range, 20-89 years) and 14 IPH patients (3 males and 11 females; mean age ± standard deviation, 64.2 ± 6.6 years; age range, 51-78 years). Both groups comprised of consecutive patients from November 2007 through February 2013 and were studied retrospectively. The median observation period was 33.4 months for ascites and 34.5 months for survival.Ascites was detected in 60/166 (36.1%) and 116/166 (69.9%) cirrhosis patients and in 7/14 (50%) and 9/14 (64.3%) IPH patients, at baseline and at the end of the observation period, respectively. The cumulative incidence of ascites was 12.3% at 1 year, 35.9% at 3 years, and 59.9% at 5 years in cirrhosis, and 25% at 3 years, and 50% at 5 years in IPH (P = 0.36). Deterioration of ascites in patients showing mild ascites at baseline was found in 32.4% of cirrhosis patients and 42.9% of IPH patients (P = 0.41). Serum creatinine (mg/dl) at baseline was significantly higher in IPH patients who developed ascites (n = 2, 0.74 ± 0.14) than in those who did not (n = 5, 0.526 ± 0.06, P = 0.029). The overall survival rate appeared to favor IPH (100% at 1 year, 92.9% at 3 and 5 years; P = 0.2) more than cirrhosis (87.7% at 1 year, 75.2% at 3 years, and 63.6% at 5 years), but did not reach statistical significance. However, in patients with ascites at baseline, the survival rate was significantly better in IPH (100% at 1, 3, and 5 years, P = 0.04) than in cirrhosis (69.1% at 1 year, 43% at 3 years, 34.4% at 5 years).The presence of ascites at baseline correlated with worse survival rates in patients with cirrhosis as compared to those with IPH as the underlying etiology.
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Affiliation(s)
- Hitoshi Maruyama
- From Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan (HM, TK, TS, OY)
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Abstract
In current medical practice, the clinical diagnosis of cirrhosis is rendered when a patient has suggestive imaging findings or features of portal hypertension (pHTN). Liver biopsy may be considered to assess potential underlying cause(s). Cirrhosis, however, is not the only etiology of pHTN; in fact, schistosomiasis remains a significant factor worldwide. pHTN results from obstruction of hepatic blood flow; it is classified clinically based on either the anatomic location of obstruction or hepatic venous pressure gradient measurements. The clinical categories carry clinicopathologic significances. Histopathologically, pHTN is manifest with either cirrhotic or noncirrhotic features. Noncirrhotic pHTN results from a heterogeneous group of disease processes, all of which result in vascular remodeling with variable parenchymal nodularity and fibrosis. This review summarizes liver biopsy findings of cirrhosis and possible etiologies and provides a stepwise approach for the histologic differential diagnosis of a liver biopsy done for "cirrhosis."
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Yilmaz G, Sari S, Egritas O, Dalgic B, Akyol G. Hepatoportal sclerosis in childhood: some presenting with cholestatic features (a re-evaluation of 12 children). Pediatr Dev Pathol 2012; 15:107-13. [PMID: 22150463 DOI: 10.2350/11-04-1017-oa.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hepatoportal sclerosis (HPS) is a syndrome of obscure etiology, and is one of the causes of noncirrhotic portal hypertension (PH). We aimed to investigate this heterogeneous group of patients whose presentation showed cholestatic features, histopathologically. Between 1999 and 2009, 12 children diagnosed with HPS were retrospectively evaluated. HPS was diagnosed with evidence of PH, noncirrhotic liver biopsy with typical histopathologic findings, and exclusion of other possible causes of PH. The data was obtained from pathology reports and microscopic slides. In histopathological re-evaluation fibrosis state, aberrant portal vessels, portal tract dilation and inflammation, ductular reaction, regenerative nodular hyperplasia, acinar transformation, presence of bile pigment, and cholangitis were noted. Serum alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl, alkaline phosphatase, bilirubin, and albumin levels, presentation patterns, and radiologic findings were assessed. Familial relationship degrees were also investigated. Twelve patients (9 boys, 3 girls; 3-180 months) were re-evaluated. Two pairs of the patients were siblings. Parents of 7 patients were consanguine. The most common presenting symptom was abdominal distension. Histopathologically, all patients had hepatoportal sclerosis/intimal fibrous thickening of portal vein and periportal fibrosis, acinar transformation, and regenerative nodules not surrounded by fibrous septae. Eight patients had vascular aberrations, 7 had ductular reaction, 1 showed mild cholangitis, and 1 had canalicular bile pigment. We conclude that genetic predisposition might be a possible factor for HPS development in Turkish patients and it should be kept in mind that cholestatic features noticed in histopathological evaluation may represent a variant group in the spectrum of HPS.
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Affiliation(s)
- Guldal Yilmaz
- Gazi University, Faculty of Medicine, Department of Pathology, Ankara, Turkey.
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Hirashita T, Ohta M, Kai S, Masuda T, Eguchi H, Iwashita Y, Ogawa T, Kitano S. Implications of portal vein thrombosis after splenectomy for patients with idiopathic portal hypertension. Surg Today 2011; 41:1475-80. [PMID: 21969148 DOI: 10.1007/s00595-010-4523-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 09/16/2010] [Indexed: 12/16/2022]
Abstract
PURPOSE Idiopathic portal hypertension (IPH) is considered to be closely related to portal vein thrombosis (PVT). The aim of this study was to clarify the incidence, clinical characteristics, and outcomes of PVT in patients with IPH after splenectomy. METHODS We investigated the rates, clinical characteristics, and outcomes of PVT in 18 patients who underwent splenectomy for IPH, during a mean follow-up period of 152 ± 83 months. RESULTS Seven of the 18 patients (39%) experienced gastrointestinal bleeding, which was from the varices in 4. Eight patients (44%) had PVT, and the mean interval until its detection after splenectomy was 22 ± 41 months. The cumulative gastrointestinal bleeding rates 5, 10, and 15 years after surgery were 24%, 31%, and 41%, respectively. The cumulative survival rates 5, 10, and 15 years after surgery were 94%, 74%, and 65%, respectively. There were no significant differences in the cumulative gastrointestinal bleeding and survival rates between patients with and those without PVT. CONCLUSION Despite the high incidence of PVT in IPH patients postsplenectomy, it may not be related to their gastrointestinal bleeding or prognosis.
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Affiliation(s)
- Teijiro Hirashita
- Department of Surgery I, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
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Maruyama H, Shimada T, Ishibashi H, Takahashi M, Kamesaki H, Yokosuka O. Delayed periportal enhancement: a characteristic finding on contrast ultrasound in idiopathic portal hypertension. Hepatol Int 2011; 6:511-9. [DOI: 10.1007/s12072-011-9285-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 06/02/2011] [Indexed: 12/13/2022]
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Maruyama H, Okugawa H, Kobayashi S, Yoshizumi H, Takahashi M, Ishibashi H, Yokosuka O. Non-invasive portography: a microbubble-induced three-dimensional sonogram for discriminating idiopathic portal hypertension from cirrhosis. Br J Radiol 2011; 85:587-95. [PMID: 21343319 DOI: 10.1259/bjr/25522379] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The aim of this prospective study was to elucidate the efficacy of contrast-enhanced three-dimensional (3D) ultrasound with Sonazoid(®) (GF Healthcare, Oslo, Norway) as a non-invasive tool to discriminate idiopathic portal hypertension (IPH) from cirrhosis by demonstration of portal vein structure. METHODS There were 16 patients: 11 with biopsy-proven cirrhosis and 5 with biopsy-proven IPH. Intrahepatic right portal vein images were taken by 3D ultrasound from 1 min after the injection of Sonazoid (0.0075 ml kg(-1)). Portal vein appearances were compared between 3D ultrasound and percutaneous transhepatic portography (PTP) by four independent reviewers. Sensitivity, specificity and area under the receiver operating characteristic curve (Az) of the images were used for the diagnosis of cirrhosis/IPH, and interimaging, inter-reviewer and interoperator agreement were examined. RESULTS Sensitivity, specificity and Az of PTP for the diagnosis of cirrhosis/IPH were 63.6%/100%, 100% and 0.9 (0.71-1.0) by Reviewer I and 90.9%/100%, 100% and 1.0 by Reviewer III, respectively. Similarly, sensitivity, specificity and Az of 3D ultrasound for diagnosis of cirrhosis/IPH were 54.5%/80%, 100% and 0.96 (0.84-1.0) by Reviewer II and 72.7%/80%, 100% and 0.97 (0.9-1.0) by Reviewer IV, respectively. Diagnostic agreement between PTP and 3D ultrasound was good between Reviewers I and II (κ=0.793) and good between Reviewers III and IV (κ=0.732). Inter-reviewer agreement was good between Reviewers I and III for PTP diagnosis (κ=0.735), and good between Reviewers II and IV for 3D ultrasound diagnosis (κ=0.792). Interoperator agreement of diagnostic results was good (κ=0.740). CONCLUSION Non-invasive visualisation of intrahepatic portal vein structure by contrast-enhanced 3D ultrasound with Sonazoid may have the potential to discriminate IPH from cirrhosis.
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Affiliation(s)
- H Maruyama
- Department of Medicine and Clinical Oncology, Chiba University Graduate School of Medicine, Chuou-ku, Japan.
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Maruyama H, Ishibashi H, Takahashi M, Imazeki F, Yokosuka O. Effect of signal intensity from the accumulated microbubbles in the liver for differentiation of idiopathic portal hypertension from liver cirrhosis. Radiology 2009; 252:587-94. [PMID: 19508988 DOI: 10.1148/radiol.2522081899] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To examine the possibility of using contrast material-enhanced ultrasonography (US) to differentiate idiopathic portal hypertension (IPH) from cirrhosis. MATERIALS AND METHODS This was an institutional review board-approved prospective study with written informed consent. The study consisted of 23 patients (mean age, 60 years +/- 11; range, 37-85 years) with biopsy-proved cirrhosis, 10 patients (mean age, 65 years +/- 8; range, 51-78 years) with IPH, and 27 control subjects (mean age, 46 years +/- 17; range, 26-82 years) without any focal hepatic lesions or portal vein thrombosis. The patients underwent contrast-enhanced US for the observation of the right liver lobe. The time of the onset of contrast enhancement in the right hepatic artery and right portal vein was examined at vascular phase under continuous low-power emission, and signal intensity differences (in decibels) by using instantaneous high-power emission in the liver parenchyma were analyzed at late phase (15 minutes). Interobserver variability was quantified as coefficients of variation. RESULTS Onset time of contrast enhancement in the right portal vein was significantly longer for both IPH (22 sec +/- 3.9, P = .0035) and cirrhosis (19.3 sec +/- 4.7, P = .04) patients than for control subjects (17 sec +/- 3.3), with no significant difference in the onset time in the right hepatic artery. Images obtained in both IPH patients (21.2 dB +/- 1.4) and control subjects (22.1 dB +/- 2.2) had significantly higher signal intensity differences than those obtained in cirrhosis patients (13.8 dB +/- 2.8, P < .0001), with no significant difference between images of IPH patients and control subjects. Signal intensity differences of more than 18 dB had 100% sensitivity and specificity for the diagnosis in IPH patients and control subjects. Interobserver variability for signal intensity differences was 8.7%. CONCLUSION Contrast-enhanced US may offer the possibility for a simple, easy, and noninvasive diagnosis of IPH.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Medicine and Clinical Oncology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuou-ku, Chiba 260-8670, Japan.
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Rapkiewicz AV, Patel SY, Holland SM, Kleiner DE. Hepatoportal venopathy due to disseminated Mycobacterium avium complex infection in a child with IFN-gamma receptor 2 deficiency. Virchows Arch 2007; 451:95-100. [PMID: 17554558 DOI: 10.1007/s00428-007-0427-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 02/14/2007] [Accepted: 04/25/2007] [Indexed: 11/29/2022]
Abstract
The control of intracellular microorganisms such as mycobacteria is largely dependent on the adaptive immune response, specifically the interaction of T helper cells and antigen presenting cells such as macrophages. The interferon gamma (IFN-gamma) pathway activation is crucial for containment and killing of mycobacteria, as evidenced by the fact that defects in this pathway often result in profound infections with both tuberculous and non-tuberculous mycobacteria. We herein report a case of a child with autosomal recessive IFN-gamma receptor 2 (IFN-gammaR2) deficiency who developed hepatic venopathy secondary to disseminated Mycobacterium avium complex (MAC) infection.
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Affiliation(s)
- Amy V Rapkiewicz
- Laboratory of Pathology, National Cancer Institute, National Institute of Health, Bethesda, MD, USA.
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Avendano CE, Flume PA, Baliga P, Lewin DN, Strange C, Reuben A. Hepatopulmonary syndrome occurring after orthotopic liver transplantation. Liver Transpl 2001; 7:1081-4. [PMID: 11753911 DOI: 10.1053/jlts.2001.29416] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) is an infrequent complication of liver cirrhosis. Orthotopic liver transplantation (OLT) has gained increasing acceptance as a treatment modality for HPS, although there have been reports of HPS developing after OLT with documented recurrence of cirrhosis. We describe the case of a 9-year-old boy who underwent OLT at 7 months of age because of biliary atresia. He subsequently developed HPS in the setting of chronic rejection without cirrhosis or evidence of portal hypertension. Re-OLT resulted in resolution of HPS and a good clinical outcome.
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Affiliation(s)
- C E Avendano
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
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Abstract
Noncirrhotic portal hypertension represents a heterogeneous group of conditions that have distinct clinical and hemodynamic features that often help distinguish them from cirrhosis. [figure: see text] The sites of portal flow resistance may not be precisely localized to one area of the hepatic lobule and may extend beyond the site where the pathogenetic process began. Even in patients with portal hypertension caused by an increased flow, there may be subsequent development of increased resistance. The prognosis is variable; outcomes are better in patients with presinusoidal portal hypertension. A good understanding of the presentation of the various noncirrhotic conditions that cause portal hypertension will help determine the cause, the site of resistance, and the therapeutic plan. Ascites is not a feature of presinusoidal portal hypertension, whereas it may be the predominant feature in postsinusoidal portal hypertension.
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Affiliation(s)
- E Molina
- Center for Liver Diseases, University of Miami School of Medicine, Miami, Florida, USA
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