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Sarma MS, Seetharaman J. Pediatric non-cirrhotic portal hypertension: Endoscopic outcome and perspectives from developing nations. World J Hepatol 2021; 13:1269-1288. [PMID: 34786165 PMCID: PMC8568571 DOI: 10.4254/wjh.v13.i10.1269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/27/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
Non-cirrhotic portal hypertension (NCPH) forms an important subset of portal hypertension in children. Variceal bleed and splenomegaly are their predominant presentation. Laboratory features show cytopenias (hypersplenism) and preserved hepatic synthetic functions. Repeated sessions of endoscopic variceal ligation or endoscopic sclerotherapy eradicate esophageal varices in almost all cases. After variceal eradication, there is an increased risk of other complications like secondary gastric varices, cholangiopathy, colopathy, growth failure, especially in extra-hepatic portal vein obstruction (EHPVO). Massive splenomegaly-related pain and early satiety cause poor quality of life (QoL). Meso-Rex bypass is the definitive therapy when the procedure is anatomically feasible in EHPVO. Other portosystemic shunt surgeries with splenectomy are indicated when patients present late and spleen-related issues predominate. Shunt surgeries prevent rebleed, improve growth and QoL. Non-cirrhotic portal fibrosis (NCPF) is a less common cause of portal hypertension in children in developing nations. Presentation in the second decade, massive splenomegaly and patent portal vein are discriminating features of NCPF. Shunt surgery is required in severe cases when endotherapy is insufficient for the varices. Congenital hepatic fibrosis (CHF) presents with firm palpable liver and splenomegaly. Ductal plate malformation forms the histological hallmark of CHF. CHF is commonly associated with Caroli’s disease, renal cysts, and syndromes associated with neurological defects. Isolated CHF has a favourable prognosis requiring endotherapy. Liver transplantation is required when there is decompensation or recurrent cholangitis, especially in Caroli’s syndrome. Combined liver-kidney transplantation is indicated when both liver and renal issues are present.
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Affiliation(s)
- Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Jayendra Seetharaman
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Rajesh S, Mukund A, Sureka B, Bansal K, Ronot M, Arora A. Non-cirrhotic portal hypertension: an imaging review. Abdom Radiol (NY) 2018; 43:1991-2010. [PMID: 29564495 DOI: 10.1007/s00261-018-1570-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Non-cirrhotic portal hypertension (NCPH) comprises a group of diseases that are characterized by increased portal pressure in the absence of cirrhosis of the liver. It may arise as a result of either primary hepatic disease or the effects of systemic disorders on liver. The natural course of NCPH is largely indolent and benign with an overall better outcome than cirrhosis, as long as the complications of portal hypertension are properly managed and regular surveillance is carried out. However, due to the numerous and variable etiological factors and lack of standardized diagnostic criteria, this entity is under-recognized clinically as well as pathologically and often gets mislabeled as cryptogenic cirrhosis. Therefore, it is imperative for radiologists to be aware of the imaging features of various entities that constitute NCPH to facilitate early recognition of this disorder. The present review shall comprehensively discuss the role of imaging in the diagnosis of obliterative portal venopathy, which is a common and one of the most poorly understood disorders leading to NCPH. The other radiologically relevant entities will also be briefly appraised.
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Affiliation(s)
- S Rajesh
- The Liver Unit, Cochin Gastroenterology Group, Department of Diagnostic and Interventional Radiology, Ernakulam Medical Centre, Kochi, India
| | - Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, Off Abdul Gaffar Khan Marg, New Delhi, 110070, India
| | - Binit Sureka
- Department of Diagnostic Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, Off Abdul Gaffar Khan Marg, New Delhi, 110070, India
| | - Kalpana Bansal
- Department of Diagnostic Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, Off Abdul Gaffar Khan Marg, New Delhi, 110070, India
| | - Maxime Ronot
- Service de Radiologie, AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, Beaujon, 100 boulevard General Leclerc, 92118, Clichy, France
| | - Ankur Arora
- Department of Radiology, Worthing Hospital, Western Sussex NHS Foundation Trust, Worthing, BN11 2DH, UK.
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Pawar S, Zanwar V, Mohite A, Surude R, Rathi P, Balasubramani M. A Family of Congenital Hepatic Fibrosis and Atypical Retinitis Pigmentosa. Clin Pract 2015; 5:792. [PMID: 26918098 PMCID: PMC4745592 DOI: 10.4081/cp.2015.792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/28/2015] [Indexed: 12/24/2022] Open
Abstract
Congenital hepatic fibrosis is a rare cause of portal hypertension and esophageal varices in children. We report cases of siblings with biopsy proven congenital hepatic fibrosis and with atypical retinitis pigmentosa. They presented with repeated episodes of jaundice along with progressive decrease of vision in night. They had hepatosplenomegaly and portal hypertension with esophageal varices. One of the siblings had a large regenerating nodule replacing the entire right lobe of the liver and other one developed repeated hematemesis. This constellation of diagnosis belongs to the ciliopathy group of disorders. The spectrum of ciliopathy disorders has been evolving, and it varies from mild to severe manifestations.
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Affiliation(s)
| | | | | | | | | | - Meenakshi Balasubramani
- Department of Pathology, Topiwala National Medical College and Bai Yamunabai Laxman Nair Hospital , Mumbai, Maharashtra, India
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Poddar U, Shava U, Yachha SK, Agarwal J, Kumar S, Baijal SS, Srivastava A. β-Blocker therapy ameliorates hypersplenism due to portal hypertension in children. Hepatol Int 2014; 9:447-53. [PMID: 25788181 DOI: 10.1007/s12072-014-9575-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 08/21/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND/PURPOSE Thrombocytopenia due to hypersplenism precludes percutaneous liver biopsy in many cases of chronic liver disease (CLD). The aim of this study was to assess the efficacy of propranolol in correcting platelet counts (>100,000/mm(3)) to ensure percutaneous liver biopsy in children with CLD. METHODS From January 2005 to December 2012, 51 consecutive children (mean age 11.5 ± 3.0 years, 34 boys) with CLD who needed liver biopsy but could not be done due to hypersplenism-related thrombocytopenia (platelets <100,000/mm(3) and/or total leukocyte counts <4,000/mm(3) with splenomegaly) were recruited and given a 4-week trial of long-acting propranolol (1.5-2 mg/kg/day). Hemodynamic parameters and splenic artery hemodynamics by Doppler ultrasound were recorded before and after the propranolol trial. Response to therapy was defined as improvement of platelet counts to ≥10(5)/mm(3). RESULTS Thirty-two (62.7%) children responded to propranolol therapy and their mean platelet counts increased from 57.5 ± 13.0 × 10(3) to 140.7 ± 43.3 × 10(3)/mm(3), p = 0.0001. Liver biopsy could be done in 29. While comparing responders with non-responders, baseline spleen size (7.4 ± 3.3 vs. 12.7 ± 4.5 cm, p = 0.0001) and platelet counts (57.5 ± 13.0 × 10(3) vs. 39.5 ± 14.5 × 10(3), p = 0.0001) were found to be significant. ROC curve suggested a cut-off value of ≤8.5 cm of spleen and ≥53,000 platelets as predictors of response. With propranolol, mean arterial pressure and spleen size reduced (p < 0.05) and splenic artery resistance increased significantly (p = 0.005) in responders. CONCLUSIONS Propranolol corrects thrombocytopenia and makes liver biopsy possible in almost two-thirds of cases by reducing splenic sequestration through splenic artery vasoconstriction. The baseline spleen size and platelet counts determine the effectiveness of therapy. A trial of β-blocker is worth carrying out in cases where liver biopsy is contraindicated due to hypersplenism-related thrombocytopenia.
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Affiliation(s)
- Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, 226014, India,
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Sun LP, Tong QX, Jie SH, Diseases DOI, Hospital U, Technology HUOSA, 430022 W, Province H, China. Progress in research of molecular markers for hepatic oval cells Li-Ping Sun, Qiao-Xia Tong, Sheng-Hua Jie. Shijie Huaren Xiaohua Zazhi 2011; 19:3616-3622. [DOI: 10.11569/wcjd.v19.i35.3616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension is defined as an increase in blood pressure in the veins of the portal system and extensive formation of portal-systemic communicating branches, which results from a blockage in the portal blood flow or abnormal blood increment. Generally, cirrhotic portal hypertension is common more than non-cirrhotic portal hypertension, but the latter is caused by a group of diseases, such as idiopathic portal hypertension(IPH), pancreatic sinistral portal hypertension (PSPH), cavernous transformation of the portal vein (CTPV), congenital hepatic fibrosis (CHF), Budd-Chiari syndrome (BCS), hepatic sinusoidal obstruction syndrome (SOS), portal vein thrombosis (PVT), myeloproliferative disease (MLD), hepatic amyloidosis, and hemochromatosis (HC). This paper reviews the rare causes of portal hypertension and their diagnosis.
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Sidhu GS, Thapa BR, Rawal P, Prasad KK, Nain CK, Nagi B, Singh K. Brush border enzymes and absorptive capacity in extrahepatic portal venous obstruction in children. Hepatol Int 2010; 4:762-6. [PMID: 21286348 DOI: 10.1007/s12072-010-9211-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 08/04/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Portal hypertension may affect intestinal functions, brush border enzymes and absorption parameters. Information about these in extrahepatic portal venous obstruction (EHPVO) in children is limited and poorly reported. We therefore studied the brush border enzymes and absorptive capacity in EHPVO in children. METHODS The study was conducted on 52 children of EHPVO. The diagnosis of EHPVO was made on the basis of clinical presentation and ultrasound examination. All patients underwent upper gastrointestinal endoscopy. Endoscopic tissue biopsies from duodenum were taken on aluminum foils and kept immediately at -20°C for estimation of brush border enzymes. Tissue biopsies were homogenized in sodium maleate buffer, 0.1 M pH 6.0, by a homogenizer and processed for the enzymes: lactase, maltase, and sucrase. Enzyme levels were compared to normal healthy controls (n = 20). d-Xylose test, stool acid steatocrit for fat excretion in stools and stool alpha-1 antitrypsin were done to know about the absorptive parameters. RESULTS Enzyme levels of lactase (6.21 ± 5.67 IU/mg) and sucrase (37.07 ± 21.06 IU/mg) in EHPVO group were significantly lower as compared to lactase (23.32 ± 10.48 IU/mg) and sucrase (95.96 ± 46.55 IU/mg) in normal healthy controls. Maltase levels were lower, but difference was not statistically significant in EHPVO group (56.90 ± 28.65 IU/mg) as compared to normal controls (63.28 ± 22.88 IU/mg). There was no significant difference of urinary d-xylose and stool fat in patients with normal or short stature EHPVO patients. CONCLUSION EHPVO leads to decrease in levels of brush border enzymes in small bowel but their absorption capacity remains normal.
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Affiliation(s)
- Gurbakhshish Singh Sidhu
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012 India
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Abstract
Congenital hepatic fibrosis (CHF) is an autosomal recessive disorder that belongs to the family of fibropolycystic liver diseases. This family includes a spectrum of disorders which are usually found in combination with each other and are usually inherited. Clinically fibropolycystic diseases have three effects being present in different proportions, those of a space occupying lesion, of portal hypertension and of cholangitis. In most patients, the first manifestations of CHF are signs and symptoms related to portal hypertension such as splenomegaly and varices. Portal hypertension in these patients has been attributed to the hypoplasia or compression of the portal vein radicles in the fibrous bands. Cavernous transformation of the portal vein (CTPV) is a relatively rare condition resulting from extrahepatic portal vein obstruction with recanalization or collateral vein formation to bypass the obstruction. It has been found that patients with CHF having an accompanying CTPV have relatively large splenomegaly and suffers more frequent episodes of bleeding from esophageal varices.We believe that CTPV is a congenital component of CHF and also one of the important causative factors of portal hypertension in these patients.
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Affiliation(s)
- Ozlem Yonem
- Hacettepe University Faculty of Medicine, Department of Gastroenterology, Sihhiye 06100, Ankara, Turkey
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Akhan O, Karaosmanoğlu AD, Ergen B. Imaging findings in congenital hepatic fibrosis. Eur J Radiol 2007; 61:18-24. [PMID: 17164079 DOI: 10.1016/j.ejrad.2006.11.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 11/02/2006] [Indexed: 10/23/2022]
Abstract
Congenital hepatic fibrosis (CHF) is a rare congenital multisystemic disorder, mostly inherited in autosomal recessive fashion, primarily affecting renal and hepatobiliary systems. Main underlying process of the disease is the malformation of the ductal plate, the embryological precursor of the biliary system, and secondary biliary strictures and periportal fibrosis ultimately leading to portal hypertension. The natural course of the disease is highly variable ranging from minimally symptomatic disease to true cirrhosis of the liver. However, in most patients the most common manifestations of the diseases that are related to portal hypertension, particularly splenomegaly and bleeding varices. Many other disease processes may co-exist with the disease including Caroli's disease, choledochal cysts and autosomal recessive polycystic kidney disease (ARPKD) reflecting the mulstisystemic nature of the disease. The associating biliary ductal disease led the authors to think that all these entities are a continuum and different reflections of the same underlying pathophysiological process. Although, conventional method of diagnosis of CHF is the liver biopsy the advent of imaging technologies and modalities, today, may permit the correct diagnosis in a non-invasive manner. Characteristic imaging features are generally present and recognition of these findings may obviate liver biopsy while preserving the diagnostic accuracy. In this article, it is aimed to increase the awareness of the practising radiologists to the imaging findings of this uncommon clinical disorder and trail the blaze for future articles relating to this issue.
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Affiliation(s)
- Okan Akhan
- Department of Radiology, Hacettepe University, School of Medicine, 06100 Ankara, Turkey.
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Affiliation(s)
- Surender Kumar Yachha
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Abstract
Portal hypertension (PHT) is common in children and a majority of cases in India are constituted by extrahepatic portal venous obstruction or cirrhosis of liver. Morbidity and mortality in this condition is related to variceal bleeding, most commonly from esophageal varices. Acute variceal bleeding is best controlled by endoscopic therapy. Somatostatin and octreotide are useful in acute variceal bleeding as a supplementary therapy. Acute variceal bleeding uncontrolled by medical therapy merits preferably a shunt surgery or devascularization depending upon etiology of PHT and expertise of the surgeon. Acute variceal bleeding originating from gastric varices can be effectively controlled by endoscopic injection of tissue adhesive agent (n-butyl 2 cyanoacrylate). Eradication of esophageal varices by endoscopic measures (sclerotherapy or band ligation) is successful in prevention of recurrence of bleeding. Surgical portosystemic shunts especially in non-cirrhotic PHT are successful in achieving portal decompression and significant reduction in recurrence of variceal bleeding. Role of beta-blockers in primary prophylaxis of variceal bleeding in children still remains to be substantiated.
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Affiliation(s)
- S K Yachha
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Barakat M. Doppler sonographic findings in children with idiopathic portal vein cavernous deformity and variceal hemorrhage. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2002; 21:825-830. [PMID: 12164564 DOI: 10.7863/jum.2002.21.8.825] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To describe the flow patterns in the portal vascular territory in children with portal vein cavernous deformity. METHODS The study included 12 children (age 4-10 years) with hematemesis, melena, or both in whom B-mode gray scale sonography revealed small anechoic spaces replacing the site of the portal vein. The portal vein cavernous deformity was present either alone (in 8 patients) or with congenital hepatic fibrosis (in 4). Doppler sonography (color and spectral) was performed to assess the flow in the portal vascular territory, splenic vein, intrasplenic veins, and abdominal collaterals. RESULTS Doppler sonography confirmed the venous flow waveform in the cavernous portal vein in all children with normal flow direction in the few intrahepatic portal vein branches and also in the intrahepatic veins. Splenomegaly was present in all. The intrasplenic veins were dilated in all but had normal flow direction except in 2 with spontaneous trans-splenic shunts. Gallbladder varices were shown in 4 patients, and perisplenic collaterals were shown in 3. CONCLUSIONS Doppler sonography is a valuable noninvasive imaging technique for assessment of the portal hemodynamic profile in patients with portal vein cavernous deformity, which can affect subsequent treatment decision making. Trans-splenic shunts are uncommon, but this Doppler sonographic report documents such shunts in children with portal hypertension.
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Affiliation(s)
- Maha Barakat
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Egypt
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