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Satai M, Vaidya A, Rathod K, Singh A, Harindranath S, Patra BR, Shukla A. Partial Splenic Artery Embolization for the Management of Symptomatic Hypersplenism in Portal Hypertension: Clinical Insights from a Case Series. J Clin Exp Hepatol 2024; 14:101435. [PMID: 38827583 PMCID: PMC11140206 DOI: 10.1016/j.jceh.2024.101435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 04/20/2024] [Indexed: 06/04/2024] Open
Abstract
Background and aims Partial splenic artery embolization (PSAE) is an alternative treatment modality for managing hypersplenism secondary to portal hypertension. We are presenting a case series of patients with portal hypertension who underwent PSAE for symptomatic hypersplenism. Methods We included patients with portal hypertension who underwent PSAE from January 2022 to December 2022. Patients' characteristics and procedure related complications were noted. Data were analyzed for improvement in the hematological parameters. Results A total of 11 (7 women, median age 34 [18-56] years) patients were included. Three patients were cirrhotic (hepatitis B-2, metabolic dysfunction-associated steatotic liver disease -1) and 8 were non-cirrhotic (extra-hepatic portal vein obstruction-5, Non cirrhotic portal fibrosis-3). Splenic artery aneurysm was concomitantly present in 5 cases. Technical success was achieved in all cases. Post embolization, hemoglobin, white blood cells and platelet counts improved at 4 weeks, 12 weeks and 24 weeks along with symptomatic improvement. All patients had post-embolization syndrome. One patient developed transient ascites and secondary bacterial peritonitis which was managed conservatively. One patient died due to splenic abscess and septicemia. Conclusion Although, hematological parameters and symptoms improve post procedure, PSAE is associated with major complications and should be performed judiciously in selected cases only. Graphical abstract is presented in Figure 1.
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Affiliation(s)
- Mayur Satai
- Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Arun Vaidya
- Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | - Ankita Singh
- Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | | | - Akash Shukla
- Seth GS Medical College and KEM Hospital, Mumbai, India
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2
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Premkumar M, Anand AC. Porto-sinusoidal Vascular Disease: Classification and Clinical Relevance. J Clin Exp Hepatol 2024; 14:101396. [PMID: 38601747 PMCID: PMC11001647 DOI: 10.1016/j.jceh.2024.101396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/05/2024] [Indexed: 04/12/2024] Open
Abstract
Non-cirrhotic portal hypertension (NCPH) is a well-recognized clinico-pathological entity, which is associated with clinical signs and symptoms, imaging, and endoscopic features of portal hypertension (PHT), in absence of cirrhosis. In patients with NCPH without known risk factors of PHT or extrahepatic portal vein thrombosis, the condition is called idiopathic non-cirrhotic portal hypertension (INCPH). There are multiple infectious, immune related causes, systemic diseases, drug and toxin exposures, haematological disorders, and metabolic risk factors that have been associated with this INCPH. However, the causal pathogenesis is still unclear. The Vascular liver disorders interest group group recently proposed porto-sinusoidal vascular disease (PSVD) as a syndromic entity, which provides definite histopathological criteria for diagnosis of NCPH (table 1). The three classical histo-morphological lesions specific for PSVD include obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal fibrosis. The PSVD definition includes patients with portal vein thrombosis, PVT, and even those without PHT, thus broadening the scope of diagnosis to include patients who may have presented early, prior to haemodynamic changes consistent with PHT. However, this new diagnosis has pros and cons. The cons include mandating invasive liver biopsy to assess the PSVD histological triad in all patients with NCPH, an erstwhile clinical diagnosis in Asian patients. In addition, the natural history of the subclinical forms of PSVD without PHT and linear progression to develop PHT is unknown yet. In this review, we discuss the diagnosis and treatment of INCPH/PSVD, fallacies and strengths of the old and new schema, pathobiology of this disease, and clinical correlates in an Asian context. Although formulation of standardised diagnostic criteria is useful for comparison of clinical cohorts with INCPH/PSVD, prospective clinical validation in global cohorts is necessary to avoid misclassification of vascular disorders of the liver.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anil C. Anand
- Department of Hepatology, Kalinga Institute of Medical Sciences, Bhubaneshwar, Odisha, India
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3
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Noble S, Linz M, Correia E, Shalaby A, Bittencourt LK, Sclair SN. Porto-sinusoidal Vascular Disease and Portal Hypertension. Clin Liver Dis 2024; 28:455-466. [PMID: 38945637 DOI: 10.1016/j.cld.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Porto-sinusoidal vascular disease (PSVD) is the medical diagnosis for a patient who has portal hypertension in the absence of cirrhosis on liver biopsy. There are several specific histologic findings for PSVD, including obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal fibrosis. Epidemiologic reports vary widely among regions; PSVD comprises less than 10% of causes of portal hypertension in Western countries but incidence has been found to be as high as 48% in India. There is an expansive list of etiologies that have been reported to cause PSVD.
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Affiliation(s)
- Sarah Noble
- Digestive Health Institute, University Hospitals, Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Marguerite Linz
- Department of Internal Medicine, University Hospitals, Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Eduardo Correia
- Department of Radiology, University Hospitals, Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Akram Shalaby
- Department of Pathology, University Hospitals, Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Leonardo Kayat Bittencourt
- Department of Radiology, University Hospitals, Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Seth N Sclair
- Digestive Health Institute, University Hospitals, Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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4
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Malik A, Malik S, Farooq A, Malik MI, Javaid S. Histopathological features of idiopathic portal hypertension: A systematic review and meta-analysis. Sci Prog 2024; 107:368504241264996. [PMID: 39053026 PMCID: PMC11282518 DOI: 10.1177/00368504241264996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
BACKGROUND Portal hypertension (PH) is a clinically significant entity that could present with life-threatening gastrointestinal bleeding. Cirrhosis is the most common cause of PH, with well-documented histopathology and etiology. However, in idiopathic portal hypertension (IPH), no single histopathologic finding is associated with PH. Our systematic review aims to identify and summarize the prevalence of the common histological findings of IPH. METHODS We systematically searched PubMed, Cochrane CENTRAL, Web of Science, and Scopus till 1ST March 2022 for studies describing the histopathological features of IPH. Data were extracted from eligible studies and pooled as events rate and 95% confidence interval (CI) using binary random-effects model by open meta-analyst software. RESULTS We included 23 retrospective studies with a total sample size of 813 patients. The overall incidence of nodular regenerative hyperplasia was 38.6%, 59.8% for portal fibrosis, 51.3% for periportal fibrosis, 39.3% for perisinusoidal fibrosis, 89.8% for portal vein sclerosis, 42.2% for portal inflammation, 53.3% for mega-sinusoids, 39.5% for thickening of portal vein branches, 93.8% for narrowing of portal veins, 53.3% for hepatic veins/venous outflow obstruction, 51.4% for aberrant portal/periportal vessels, 42.4% for shunt vessel, 50.9% for ductular proliferation, and 16.3% for steatosis. CONCLUSION Due to the relatively non-pathognomonic and non-specific nature of IPH, a combination of different histological features such as the portal and periportal fibrosis, portal vein sclerosis, mega-sinusoids, narrowing of portal veins, hepatic venous outflow obstruction, aberrant portal or periportal vessels, and ductular proliferation may be of value in diagnosing IPH as the incidence rate of these features was at approximately 50%.
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Affiliation(s)
- Adnan Malik
- Mountain Vista Medical Center, Midwestern University Program, Mesa AZ, USA
| | - Sohira Malik
- Penn State College of Medicine, Hershey, PA, USA
| | - Ahsan Farooq
- Penn State College of Medicine, Hershey, PA, USA
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5
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Giri S, Anand AC. Non-cirrhotic intrahepatic portal hypertension: Is the gun loaded? Indian J Gastroenterol 2024; 43:285-287. [PMID: 37940774 DOI: 10.1007/s12664-023-01466-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, 751 024, India
| | - Anil Chandra Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, 751 024, India.
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Jafari P, Evaristo G, Du XA, Sharma AE, Marcus V, Liu X, Zhao L, Westerhoff M, Hart J. Portosinusoidal Vascular Disorder: A Heretofore Unrecognized Manifestation of Sickle Cell Disease? Mod Pathol 2024; 37:100351. [PMID: 37820763 DOI: 10.1016/j.modpat.2023.100351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/10/2023] [Accepted: 10/04/2023] [Indexed: 10/13/2023]
Abstract
Portosinusoidal vascular disorder (PSVD) is a recently proposed histopathologic entity that encompasses a spectrum of often subtle hepatic microvascular lesions and related microarchitectural abnormalities. Clinical manifestations may arise years after histologic diagnosis and include extrahepatic portal vein thrombosis and portal hypertension. While the histopathologic features of PSVD have been associated with numerous clinical conditions, most notably prothrombotic/vasculopathic disorders, PSVD has not yet been described in sickle cell disease. This gap is striking given the central role of microvascular dysfunction in sickle cell disease and well-described patterns of hepatic injury and dysfunction in this population. This case series is the first to explore the prevalence and pathogenesis of PSVD in sickle cell disease. Forty-one diagnostically adequate liver biopsies from patients with sickle cell disease were identified across the archives of 5 tertiary medical centers. All biopsies exhibited at least 1 histopathologic feature associated with PSVD (mean 3.8 features/case). Overall, 90.2% of patients met the criteria for a diagnosis of PSVD based on the presence of specific histopathologic and/or clinical findings. Immunohistochemical stains for von Willebrand factor, CD34, and glutamine synthetase were performed on 36 cases (87.8%). Aberrant (centrilobular sinusoidal) CD34 and von Willebrand factor staining was present in 97.2% and 86.1% of cases, respectively. Glutamine synthetase reactivity was at least mildly decreased in zone 3 hepatocytes in 52.8% of cases. We posit that chronic erythrocyte sickling results in dysfunction and remodeling of the portal microvasculature, culminating in regression of zone 3 hepatocytes. The presence of PSVD may explain, at least in part, the hepatic dysfunction observed in this patient population. These patients may also benefit from extended clinical surveillance for portal hypertension and other complications. While subtle and prone to overdiagnosis, the features of PSVD should be carefully considered when interpreting liver biopsies from patients with sickle cell disease.
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Affiliation(s)
- Pari Jafari
- Department of Pathology, University of Chicago Medicine, The University of Chicago, Chicago, Illinois.
| | - Gertruda Evaristo
- Department of Pathology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Xiaotang Alison Du
- Department of Pathology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Aarti E Sharma
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victoria Marcus
- Department of Pathology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Lei Zhao
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maria Westerhoff
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - John Hart
- Department of Pathology, University of Chicago Medicine, The University of Chicago, Chicago, Illinois
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Buyruk AM, Erdoğan Ç, Tekin F, Turan İ, Özütemiz Ö, Ersöz G. The use of fully covered self-expandable metal stents in the endoscopic treatment of portal cavernoma cholangiopathy. BMC Gastroenterol 2023; 23:414. [PMID: 38017393 PMCID: PMC10683077 DOI: 10.1186/s12876-023-03042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND AND AIMS There are different therapeutic approaches for biliary strictures and reducing portal hypertension in patients with symptomatic portal cavernoma cholangiopathy (PCC). Endoscopic treatment includes endoscopic biliary sphincterotomy (EST), dilation of stricture with a biliary balloon, placement of plastic stent(s) and stone extraction. Fully covered self-expandable metal stent (FCSEMS) is placed as a rescuer in case of haemobilia seen after EST, dilation of stricture and removal of plastic stent rather than the stricture treatment itself. In this retrospective observational study, we sought to assess the clinical outcomes of FCSEMS as the initial treatment for PCC-related biliary strictures. MATERIALS AND METHODS Twelve symptomatic patients with PCC both clinically and radiologically between July 2009 and February 2019 were examined. Magnetic resonance cholangiopancreatography (MRCP) and cholangiography were employed as the diagnostic imaging methods. Chandra-Sarin classification was used to distinguish between biliary abnormalities in terms of localization. Llop classification was used to group biliary abnormalities associated with PCC. Endoscopic partial sphincterotomy was performed in all the patients. If patients with dominant strictures 6-8-mm balloon dilation was first performed. This was followed by removal of the stones if exist. Finally, FCSEMS placed. The stents were removed 6-12 weeks later. RESULTS The mean age of the patients was 40.9 ± 10.3 years, and 91.6% of the patients were male. Majority of the patients (n = 9) were noncirrhotic. Endoscopic retrograde cholangiopancreatography (ERCP) findings showed that 11 of the 12 patients were Chandra Type I and one was Chandra Type IIIa. All the 12 patients were Llop Grade 3. All patients had biliary involvement in the form of strictures. Stent placement was successful in all patients. FCSEMSs were retained for a median period of 45 days (30-60). Seven (58.3%) patients developed acute cholecystitis. There was no occurrence of bleeding or other complications associated with FCSEMS replacement or removal. All patients were asymptomatic during median 3 years (1-10) follow up period. CONCLUSIONS FCSEMS placement is an effective method in biliary strictures in case of PCC. Acute cholecystitis is encountered frequently after FCSEMS, but majority of patients respond to the medical treatment. Patients should be followed in terms of the relapse of biliary strictures.
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Affiliation(s)
| | - Çağdaş Erdoğan
- Department of Gastroenterology, University of Health Sciences, Ankara Etlik City Hospital, Ankara, Turkey.
| | - Fatih Tekin
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - İlker Turan
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Ömer Özütemiz
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Galip Ersöz
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
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8
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Fiordaliso M, Marincola G, Pala B, Muraro R, Mazzone M, Di Marcantonio MC, Mincione G. A Narrative Review on Non-Cirrohotic Portal Hypertension: Not All Portal Hypertensions Mean Cirrhosis. Diagnostics (Basel) 2023; 13:3263. [PMID: 37892084 PMCID: PMC10606323 DOI: 10.3390/diagnostics13203263] [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: 08/30/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Non-cirrhotic portal hypertension (NCPH), also known as idiopathic non-cirrhotic portal hypertension (INCPH) and porto-sinusoidal vascular disorder (PSVD), is a rare disease characterized by intrahepatic portal hypertension (IPH) in the absence of cirrhosis. The precise etiopathogenesis of IPH is an area of ongoing research. NCPH diagnosis is challenging, as there are no specific tests available to confirm the disease, and a high-quality liver biopsy, detailed clinical information, and an expert pathologist are necessary for diagnosis. Currently, the treatment of NCPH relies on the prevention of complications related to portal hypertension, following current guidelines of cirrhotic portal hypertension. No treatment has been studied that aimed to modify the natural history of the disease; however, transjugular intrahepatic porto-systemic shunt (TIPS) placement, shunt and liver transplantation are considerable symptomatic options. In this review, we discuss the heterogeneity of NCPH as well as its etiopathogenesis, clinical presentation and management issues. Starting from the assumption that portal hypertension does not always mean cirrhosis, cooperative studies are probably needed to clarify the issues of etiology and the possible genetic background of this rare disease. This knowledge might lead to better treatment and perhaps better prevention.
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Affiliation(s)
- Michele Fiordaliso
- Department of Medicine and Ageing Sciences, University “G. D’Annunzio” of Chieti–Pescara, Via dei Vestini 29, 66100 Chieti, Italy;
| | - Giuseppe Marincola
- Bariatric and Metabolic Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy;
| | - Barbara Pala
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa, 1035/1039, 00189 Rome, Italy;
| | - Raffaella Muraro
- Department of Innovative Technologies in Medicine & Dentistry, University “G. D’Annunzio” of Chieti–Pescara, Via dei Vestini 29, 66100 Chieti, Italy; (R.M.); (M.M.); (M.C.D.M.)
| | - Mariangela Mazzone
- Department of Innovative Technologies in Medicine & Dentistry, University “G. D’Annunzio” of Chieti–Pescara, Via dei Vestini 29, 66100 Chieti, Italy; (R.M.); (M.M.); (M.C.D.M.)
| | - Maria Carmela Di Marcantonio
- Department of Innovative Technologies in Medicine & Dentistry, University “G. D’Annunzio” of Chieti–Pescara, Via dei Vestini 29, 66100 Chieti, Italy; (R.M.); (M.M.); (M.C.D.M.)
| | - Gabriella Mincione
- Department of Innovative Technologies in Medicine & Dentistry, University “G. D’Annunzio” of Chieti–Pescara, Via dei Vestini 29, 66100 Chieti, Italy; (R.M.); (M.M.); (M.C.D.M.)
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9
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Giri S, Singh A, Angadi S, Kolhe K, Roy A. Prevalence of hepatic encephalopathy in patients with non-cirrhotic portal hypertension: A systematic review and meta-analysis. Indian J Gastroenterol 2023; 42:642-650. [PMID: 37589913 DOI: 10.1007/s12664-023-01412-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/02/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Hepatic encephalopathy, (HE) although commonly associated with cirrhosis, has also been reported in non-cirrhotic portal hypertension (NCPH). The importance of identifying and treating HE in NCPH lies in the fact that many patients may be wrongly diagnosed as having psychiatric or neurologic disorders. Hence, we aimed to systematically review the prevalence of HE in NCPH. METHODS A comprehensive search of three databases (Medline, Embase and Scopus) was conducted from inception to November 2022 for studies reporting on the prevalence of minimal HE (MHE) and overt HE (OHE) in patients with NCPH. Results were presented as pooled proportions with their 95% confidence intervals (CI). RESULTS Total 25 studies (n = 1487) were included after screening 551 records. The pooled prevalence of MHE in NPCH was 32.9% (95% CI: 26.7-39.0) without any difference between adult (32.9%, 95% CI: 23.5-42.3) and pediatric patients (32.6%, 95% CI: 26.1-39.1) (p = 0.941). There was no significant difference in the prevalence between patients with NCPH and compensated cirrhosis with odds ratio of 1.06 (95% CI: 0.77-1.44). The pooled event rate for prior history of OHE in NCPH was 1.2% (95% CI: 0.3-2.1). CONCLUSION Around one-third of the patients with NCPH have MHE, irrespective of age group. OHE is extremely rare in NCPH and is usually associated with a precipitating factor.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Ankita Singh
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, 400 012, India
| | - Sumaswi Angadi
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Kailash Kolhe
- Department of Gastroenterology, Narayana Hospital, Nanded, 431 602, India
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispecialty Hospital, Kolkata, 700 054, India.
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10
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Zhang X, Durham KM, Garza AA, Murali AR. Portal vein thrombosis, hepatic decompensation, and survival in patients with porto-sinusoidal vascular disease and portal hypertension. J Gastroenterol 2023; 58:268-276. [PMID: 36692825 DOI: 10.1007/s00535-023-01957-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/07/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Porto-sinusoidal vascular disease (PSVD) is a novel nomenclature to describe non-cirrhotic portal hypertension and characteristic histology without portal vein thrombosis (PVT). It is a more inclusive definition than the previously well-recognized entity idiopathic non-cirrhotic portal hypertension. There is a paucity of data on PSVD patients. METHODS A total of 33 patients diagnosed with PSVD and portal hypertension (PH) between 2005 and 2021 were included. Data were retrieved from electronic medical record system and analyzed. RESULTS Of the 33 patients, 6 (18%) occurred in post-transplant allograft liver. After a median follow-up of 96 months (interquartile range, IQR [52, 139]), 14 deaths occurred (42%), 4 directly related to decompensated liver disease. The Kaplan-Meier survival estimates at 1, 5, and 10 years were 94%, 87% and 58%. PVT occurred in 10 patients (30%). The Nelson-Aalen cumulative risk estimate for PVT at 1, 5 and 10 years were 16%, 25% and 48%. The median model for end-stage liver disease and Child-Pugh score at initial presentation were 8 (IQR [7-12]) and 5 [5-6], and increased to 13 [8, 18] and 7 [5, 8], respectively, at the end of follow-up. Of the 11 patients who presented with splenomegaly and no specific sign of PH, 7 (64%) developed varices and 3 (27%) ascites at a median follow-up of 100 months. CONCLUSIONS PSVD with PH is not a benign entity. Mortality, PVT and hepatic decompensation are common. Patients with PSVD must be closely monitored, including those who only have non-specific clinical signs (e.g., splenomegaly) of PH.
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Affiliation(s)
- Xiaocen Zhang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, USA
| | - Katelin Marie Durham
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, USA
| | - Alexander Austin Garza
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, USA
| | - Arvind R Murali
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, USA.
- Liver Center, Orlando Health Digestive Health Institute, 89 W. Copeland Dr., Orlando, FL, USA.
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11
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Veiga ZST, Fernandes FF, Guimarães L, Piedade J, Pereira GHS. Natural History of Hepatosplenic Schistosomiasis (HSS) Non–Cirrhotic Portal Hypertension (NCPH): Influence of Gastrointestinal Bleeding and Decompensation in Prognosis. Trop Med Infect Dis 2023; 8:tropicalmed8030145. [PMID: 36977145 PMCID: PMC10054624 DOI: 10.3390/tropicalmed8030145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/02/2023] Open
Abstract
Background: Hepatosplenic schistosomiasis (HSS) is a peculiar form of non-cirrhotic portal hypertension (NCPH). Although HSS patients present normal hepatic function, some evolve signs of hepatocellular failure and features of decompensated cirrhosis. The natural history of HSS-NCPH is unknown. Methods: A retrospective study was conducted that evaluated patients who fulfilled clinical-laboratorial criteria for HSS. Results: A total of 105 patients were included. Eleven patients already presented with decompensated disease and had lower transplant-free survival at 5 years than those without (61% vs. 95%, p = 0.015). Among 94 patients without prior decompensation, the median follow-up was 62 months and 44% of them had varicose bleeding (two or more episodes in 27%). Twenty-one patients presented at least one episode of decompensation (10-year probability 38%). Upon multivariate analysis, varicose bleeding and higher bilirubin levels were associated with decompensation. The 10-year probability of survival was 87%. Development of decompensation and age were predictive of mortality. Conclusion: HSS is characterized by multiple episodes of GI bleeding, a high probability of decompensation and reduced survival at the end of the first decade. Decompensation is more common in patients with varicose esophageal bleeding and is associated with lower survival.
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Affiliation(s)
- Zulane S. T. Veiga
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, Ministry of Health, Rio de Janeiro 22640-100, Brazil
| | - Flávia F. Fernandes
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, Ministry of Health, Rio de Janeiro 22640-100, Brazil
| | - Lívia Guimarães
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, Ministry of Health, Rio de Janeiro 22640-100, Brazil
| | - Juliana Piedade
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, Ministry of Health, Rio de Janeiro 22640-100, Brazil
| | - Gustavo Henrique S. Pereira
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, Ministry of Health, Rio de Janeiro 22640-100, Brazil
- School of Medicine, Estácio de Sá University, Rio de Janeiro 25550-100, Brazil
- Correspondence: ; Tel.: +55-21-39779893; Fax: +55-21-39779265
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12
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Khatoon N, Keaveny AP, Carames GP, Krishna M, Lewis J, Nakhleh RE. Hepatoportal Sclerosis-A Clinicopathologic Review of 28 Cases. GASTRO HEP ADVANCES 2023; 2:303-306. [PMID: 39132644 PMCID: PMC11308675 DOI: 10.1016/j.gastha.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/05/2023] [Indexed: 08/13/2024]
Abstract
Background and Aims The aim of this study was to review a large series of cases with hepatoportal sclerosis (HPS) as a pathologically recognizable entity in liver tissue specimens and describe the associated clinical and radiographic manifestations, along with the outcomes of this entity. Methods Data were collected through a retrospective chart review. Results Twenty-eight patients were identified that had pathologically defined HPS. All patients had a significant past medical history and signs and symptoms of portal hypertension. The most consistent laboratory finding was an elevated alkaline phosphatase. Radiographically, 9 patients were mistakenly identified as having advanced fibrosis/cirrhosis. The initial histologic diagnosis was made on biopsy in 20 patients and after transplant in 8 patients. The severity of symptoms was variable and required transplantation in 11 patients, 3 were treated with transjugular intrahepatic portosystemic shunt, and the remaining patients were treated symptomatically. Conclusion HPS is associated with past medical history that may be causal in nature. Signs and symptoms may be severe enough to require liver transplantation. A significant proportion of patients are radiographically misdiagnosed as cirrhosis. In this small series, overall outcomes for transplanted patients are acceptable.
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Affiliation(s)
- Nazia Khatoon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | - Andrew P. Keaveny
- Division of Gastroenterology and Hepatology, Department of Transplant Medicine, Mayo Clinic, Jacksonville, Florida
| | - Gian P. Carames
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | - Murli Krishna
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | - Jason Lewis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | - Raouf E. Nakhleh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
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13
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Jin SJ, Choi WM. Porto-Sinusoidal Vascular Disease: A Concise Updated Summary of Epidemiology, Pathophysiology, Imaging, Clinical Features, and Treatments. Korean J Radiol 2023; 24:31-38. [PMID: 36606618 PMCID: PMC9830138 DOI: 10.3348/kjr.2022.0668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 01/03/2023] Open
Affiliation(s)
- Su Jin Jin
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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14
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Hirano N, Iseki M, Morikawa T, Umino Y, Aoki S, Inoue K, Nakayama S, Miura T, Masuda K, Ishida M, Ohtsuka H, Mizuma M, Nakagawa K, Kume K, Masamune A, Kamei T, Unno M. Pancreaticoduodenectomy for pancreatic head cancer with cavernous transformation of the portal vein: a case report. Surg Case Rep 2022; 8:127. [PMID: 35771287 PMCID: PMC9247133 DOI: 10.1186/s40792-022-01463-0] [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: 04/18/2022] [Accepted: 05/27/2022] [Indexed: 12/01/2022] Open
Abstract
Background Cavernous transformation of the portal vein (CTPV) due to extrahepatic portal vein obstruction is a rare vascular anomaly. Since its symptoms usually appear in childhood, most of the adult cases are detected unexpectedly with other diseases. Only a few reports have described surgical difficulties in patients with CTPV. We report a case of pancreatic head cancer with CTPV in a patient who underwent pancreaticoduodenectomy. Case presentation A 77-year-old man with epigastric and back pain was referred to our hospital. Computed tomography revealed a tumor in the pancreatic head and a CTPV near the hepatic hilum. CTPV consisted of two main collateral vessels connected by multiple surrounding small vessels. Also, portal vein obstruction was observed near the hepatic hilum, which was far from the pancreatic head tumor. After confirming that there was no distant metastasis by a thorough whole-body search, we performed a pancreaticoduodenectomy following neoadjuvant chemotherapy. During the operation, we carefully manipulated the area of the CTPV and omitted lymph node dissection in the hepatoduodenal ligament to prevent massive venous bleeding and intestinal congestion. Pancreaticoduodenectomy was performed without any intraoperative complications and the postoperative course was uneventful. Complete tumor resection was histologically confirmed. Conclusion Although pancreaticoduodenectomy for patients with CTPV involves many surgical difficulties, we successfully performed it by determining specific treatment strategies tailored to the patient and following careful and delicate surgical procedures.
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15
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Bhavsar R, Yadav A, Nundy S. Portal cavernoma cholangiopathy: Update and recommendations on diagnosis and management. Ann Hepatobiliary Pancreat Surg 2022; 26:298-307. [PMID: 36168271 PMCID: PMC9721250 DOI: 10.14701/ahbps.22-029] [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: 05/17/2022] [Accepted: 06/07/2022] [Indexed: 12/15/2022] Open
Abstract
Portal cavernoma cholangiopathy is defined as an obstruction of the biliary system due to distended veins surrounding bile ducts that mainly occur in patients with extrahepatic portal venous obstruction. The periductal venous plexuses encircling the ducts can cause morphological changes which may or may not become symptomatic. Currently, non-invasive techniques such as ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and dynamic contrast enhanced magnetic resonance images are being used to diagnose this disorder. Only a few patients who have symptoms of biliary obstruction require drainage which might be accomplished using endoscopic stenting, decompression of the portal venous system usually via a lienorenal shunt, a difficult direct hepaticojejunostomy, and rarely a liver transplant.
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Affiliation(s)
- Ruchir Bhavsar
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India,Corresponding author: Ruchir Bhavsar, MS, Fellowship in Surgical Gastroenterology and Liver Transplantation Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India Tel: +91-9898269932, E-mail: ORCID: https://orcid.org/0000-0002-7026-5245
| | - Amitabh Yadav
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
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16
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Valainathan SR, Sartoris R, Elkrief L, Magaz M, Betancourt F, Pellegrino S, Nivolli A, Dioguardi Burgio M, Flattet Y, Terraz S, Drilhon N, Lazareth M, Herrou J, Bruno O, Payance A, Plessier A, Durand F, Ronot M, Valla D, Paradis V, Garcia‐Pagan JC, Vilgrain V, Rautou P. Contrast-enhanced CT and liver surface nodularity for the diagnosis of porto-sinusoidal vascular disorder: A case-control study. Hepatology 2022; 76:418-428. [PMID: 35092315 PMCID: PMC9544289 DOI: 10.1002/hep.32367] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/10/2022] [Accepted: 01/21/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Porto-sinusoidal vascular disorder (PSVD) is a rare and commonly overlooked cause of portal hypertension. The interest of CT analysis, including quantification of liver surface nodularity (LSN) for PSVD diagnosis has not been established. This study aimed at assessing the performance of LSN and CT features for a PSVD diagnosis in patients with signs of portal hypertension. APPROACH AND RESULTS This retrospective case-control study included a learning cohort consisting of 50 patients with histologically proven PSVD, according to VALDIG criteria, and 100 control patients with histologically proven cirrhosis, matched on ascites. All patients and controls had at least one sign of portal hypertension and CT available within 1 year of liver biopsy. Principal component analysis of CT features separated patients with PSVD from patients with cirrhosis. Patients with PSVD had lower median LSN than those with cirrhosis (2.4 vs. 3.1, p < 0.001). Multivariate analysis identified LSN < 2.5 and normal-sized or enlarged segment IV as independently associated with PSVD. Combination of these two features had a specificity of 90% for PSVD and a diagnostic accuracy of 84%. Even better results were obtained in an independent multicenter validation cohort including 53 patients with PSVD and 106 control patients with cirrhosis (specificity 94%, diagnostic accuracy 87%). CONCLUSIONS This study that included a total of 103 patients with PSVD and 206 patients with cirrhosis demonstrates that LSN < 2.5 combined with normal-sized or enlarged segment IV strongly suggests PSVD in patients with signs of portal hypertension.
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Affiliation(s)
- Shantha Ram Valainathan
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Riccardo Sartoris
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Laure Elkrief
- Service d’Hépato‐gastroentérologieHôpitaux Universitaires de GenèveGenevaSwitzerland,Service d’Hépato‐GastroentérologieHôpital TrousseauCHRU de ToursToursFrance
| | - Marta Magaz
- Barcelona Hepatic Hemodynamic LaboratoryLiver UnitHospital Clínic de BarcelonaIDIBAPSCIBERehdEuropean Reference Network for Rare Vascular Liver DiseasesUniversitat de BarcelonaBarcelonaSpain
| | - Fabian Betancourt
- Barcelona Hepatic Hemodynamic LaboratoryLiver UnitHospital Clínic de BarcelonaIDIBAPSCIBERehdEuropean Reference Network for Rare Vascular Liver DiseasesUniversitat de BarcelonaBarcelonaSpain
| | - Silvia Pellegrino
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Arianna Nivolli
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Marco Dioguardi Burgio
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Yves Flattet
- Service d’Hépato‐gastroentérologieHôpitaux Universitaires de GenèveGenevaSwitzerland
| | - Sylvain Terraz
- Department of RadiologyUniversity Hospitals of GenevaGenevaSwitzerland
| | - Nicolas Drilhon
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Marie Lazareth
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Julia Herrou
- Department of RhumatologyHôpital CochinAssistance Publique‐Hôpitaux de ParisParisFrance
| | - Onorina Bruno
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Audrey Payance
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Aurélie Plessier
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - François Durand
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Maxime Ronot
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Dominique‐Charles Valla
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Valérie Paradis
- Department of PathologyUniversité de ParisAP‐HP, Hôpital BeaujonBeaujon HospitalAssistance Publique‐Hôpitaux de ParisClichyFrance
| | - Juan Carlos Garcia‐Pagan
- Barcelona Hepatic Hemodynamic LaboratoryLiver UnitHospital Clínic de BarcelonaIDIBAPSCIBERehdEuropean Reference Network for Rare Vascular Liver DiseasesUniversitat de BarcelonaBarcelonaSpain
| | - Valérie Vilgrain
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Pierre‐Emmanuel Rautou
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
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17
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Porto-Sinusoidal Vascular Disease in a Patient With Diffuse Aortitis and Massive Ascites. ACG Case Rep J 2022; 9:e00812. [PMID: 35811580 PMCID: PMC9263492 DOI: 10.14309/crj.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
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18
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Porto-Sinusoidal Vascular Disease: A Pediatric Study of 30 Patients. J Pediatr Gastroenterol Nutr 2022; 74:e132-e137. [PMID: 35258501 DOI: 10.1097/mpg.0000000000003445] [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
OBJECTIVES Porto-sinusoidal vascular disease (PSVD) refers to a broad spectrum of histological lesions and phenotypic expressions. There are only a few reported pediatric cases in the literature. The primary outcomes of this study were to describe the phenotype of children with PSVD, to specify their mode of presentation and their clinical, biological, histological, and radiological characteristics as well as to identify their underlying etiologies. METHODS This is a descriptive, retrospective, and monocentric study of children followed at our reference center for rare vascular liver diseases. RESULTS Our study included 30 children ages 2months to 17.4years at the time of diagnosis. in most cases, the diagnosis was made incidentally without manifestation of any clinical symptom but rather on the finding of splenomegaly on physical examination (n = 9) or biological abnormalities (n = 13). In the other cases, the main presenting symptom was an upper gastrointestinal bleeding (n = 6). At the first visit, liver laboratory values were either normal (37%) or slightly disturbed. Anemia and/or thrombocytopenia associated with hypersplenism were found in 60% of patients. Liver biopsy was necessary for diagnosis. A total of 80% of cases had no identified etiology. After a median follow-up of 4.5 years, 33% had not developed portal hypertension (PHT) and we reported the first pediatric case of hepatocellular carcinoma in PSVD children. CONCLUSIONS PSVD is responsible for nonspecific symptomatology with variable evolution sometimes marked by serious complications requiring invasive treatments or even liver transplantation. Regular monitoring is essential to prevent, detect, and treat complications.
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Wöran K, Semmler G, Jachs M, Simbrunner B, Bauer DJM, Binter T, Pomej K, Stättermayer AF, Schwabl P, Bucsics T, Paternostro R, Lampichler K, Pinter M, Trauner M, Mandorfer M, Stift J, Reiberger T, Scheiner B. Clinical Course of Porto-Sinusoidal Vascular Disease Is Distinct From Idiopathic Noncirrhotic Portal Hypertension. Clin Gastroenterol Hepatol 2022; 20:e251-e266. [PMID: 33279774 DOI: 10.1016/j.cgh.2020.11.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/08/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Porto-sinusoidal vascular disease (PSVD) was recently proposed as novel clinical entity characterized by typical histological changes with or without portal hypertension (PH) in the absence of cirrhosis. Thus, we aimed to describe clinical characteristics and the outcome of PSVD patients and to compare these to patients meeting traditional idiopathic non-cirrhotic portal hypertension (INCPH) criteria. METHODS Patients undergoing liver biopsy (baseline) ±hepatic venous pressure gradient (HVPG) measurement at the Vienna General Hospital between 2000-2019 were screened for PSVD and INCPH criteria. RESULTS 91 patients were diagnosed with PSVD of which 28 (30.8%) also fulfilled INCPH criteria (INCPH+/PSVD+). Specific histological and specific clinical PH signs were found in 72 (79.1%) and 54 (59.3%) patients, respectively. INCPH+/PSVD+ showed higher Child-Pugh-scores (7±2 vs 6±1 points; P = .002) and a higher prevalence of decompensation (57.1% vs 28.6%; P = .009) than INCPH-/PSVD+ patients. Importantly, hepatic decompensation after three years (3Y) occurred in 11.2% of PSVD patients with specific clinical signs of PH, while no decompensation occurred in patients with only specific histological or with unspecific clinical/histological signs (P = .002). When categorizing by INCPH definition, 3Y decompensation was 13.4% in INCPH+/PSVD+ and 3.8% in INCPH-/PSVD+ (P = .120). While overall mortality was similar in INCPH+/PSVD+ (n = 6; 21.4%) and INCPH-/PSVD+ (n = 10; 15.9%) patients (P = .558), liver-related mortality tended to be higher in INCPH+/PSVD+ (6.9%) than in INCPH-/PSVD+ (0%; P = .078). CONCLUSION Novel PSVD criteria facilitate diagnosis. Compared to INCPH, clinical course of PSVD patients is more favorable. Importantly, specific signs of PH including varices and collaterals are associated with hepatic decompensation and mortality.
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Affiliation(s)
- Katharina Wöran
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria; CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - David Josef Maria Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Teresa Binter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Katharina Pomej
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Katharina Lampichler
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Judith Stift
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria; CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Rare Liver Disease Center of the European Reference Network RARE-LIVER, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
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20
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Araújo C, Nunes VS, Santos G, Freitas LARD, Schinoni MI, Paraná R. HISTOPATHOLOGICAL, CLINICAL AND EPIDEMIOLOGICAL FEATURES OF HEPATOPORTAL SCLEROSIS IN A REFERRAL CENTER FOR LIVER DISEASE IN NORTHEASTERN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:276-280. [PMID: 34705959 DOI: 10.1590/s0004-2803.202100000-48] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hepatoportal sclerosis HPS or obliterative portal venopathy (OPV), one of the differential diagnoses for non-cirrohtic portal hypertension, is characterized by the disappearance of the portal branches, portal and septal fibrosis, perisinusoidal fibrosis and regenerative nodular hyperplasia (RNH). It is a spectral disease that may progress to severe portal hypertension. Its etiopathogenesis is still little understood, especially in Brazil, it has been probably misdiagnosed due to its histopatological similarities with the hepatosplenic form of schistosomiasis. OBJECTIVE To analyze the profile of patients with HPS in Northeastern Brazil and to demonstrate the pathological characteristics of HPS. METHODS We retrospectively analyzed cases of OPV in liver biopsies and explants from a referral center for liver in Bahia - Brazil. The qualitative and quantitative analysis of the portal tracts and liver parenchyma was made so that comparisons could be done among the HPS findings of our population and the findings described by other authors. RESULTS From the 62 patients identified with HPS, 42% were male, while 58% were female. The average age at diagnosis was 48.3 years. From this group, we analyzed the liver biopsy of 10 patients whose diagnosis of schistosomiasis could be ruled out. From these 100% (10/10) presented dense portal fibrosis and portal venous obliteration. Liver parenchymal atrophy was present in 60% (6/10) of the patients, sinusoidal dilation was present in 30% (3/10), the presence of portal septa occurred in 50% (5/10) and dense portal fibrosis in all patients analyzed. Nodular regenerative hyperplasia was found in 30% (3/10) of the patients. CONCLUSION HPS seems to be neglected and misdiagnosed in Brazil, due to its similarities with schistossomiasis. In our study dense portal fibrosis, obliteration of the portal vein branches, parenchymal atrophy, sinusoidal dilatation and parenchymal nodular hyperplasia were the main histopathological findings and were similar to that described in other countries.
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Affiliation(s)
- Caio Araújo
- Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil
| | - Vinícius Santos Nunes
- Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, BA, Brasil
| | - Genario Santos
- Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, BA, Brasil
| | - Luiz Antônio Rodrigues de Freitas
- Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil.,Instituto Gonçalo Moniz - Fundação Oswaldo Cruz, Departamento de Patologia, Salvador, BA, Brasil
| | | | - Raymundo Paraná
- Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil
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21
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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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22
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Singh SP, Wadhawan M, Acharya SK, Bopanna S, Madan K, Sahoo MK, Bhat N, Misra SP, Duseja A, Mukund A, Anand AC, Goel A, Satyaprakash BS, Varghese J, Panigrahi MK, Tandan M, Mohapatra MK, Puri P, Rathi PM, Wadhwa RP, Taneja S, Thomas V, Bhatia V. Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding. Indian J Gastroenterol 2021; 40:519-540. [PMID: 34890020 DOI: 10.1007/s12664-021-01169-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 02/04/2023]
Abstract
Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.
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Affiliation(s)
- Shivaram P Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, 753 001, India.
| | - Manav Wadhawan
- Department of Hepatology and Liver Transplant, Institute of Liver and Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
| | - Subrat K Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, 751 024, India
| | - Sawan Bopanna
- Department of Gastroenterology and Hepatology, Fortis Flt. Lt. Rajan Dhall Hospital, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi, 110 070, India
| | - Kaushal Madan
- Department of Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, 110 017, India
| | - Manoj K Sahoo
- Department of Medical Gastroenterology, IMS and SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, 751 003, India
| | - Naresh Bhat
- Department of Gastroenterology and Hepatology, Aster CMI Hospital, Bangalore, 560 092, India
| | - Sri P Misra
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, 211 001, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Anil C Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, 751 024, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | | | - Joy Varghese
- Department of Hepatology and Transplant Hepatology, Institute of Liver Disease and Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Chennai, 600 100, India
| | - Manas K Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751 019, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, 500 082, India
| | - Mihir K Mohapatra
- Department of Surgical Gastroenterology, Srirama Chandra Bhanja Medical College, Cuttack, 753 007, India
| | - Pankaj Puri
- Department of Gastroenterology and Hepatology, Fortis Escorts Liver and Digestive Diseases Institute, Okhla Road, New Delhi, 110 025, India
| | - Pravin M Rathi
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, 400 008, India
| | - Rajkumar P Wadhwa
- Department of Gastroenterology, Apollo BGS Hospital, Adichuchanagiri Road, Kuvempunagar, Mysore, 570 023, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Varghese Thomas
- Department of Gastroenterology, Malabar Medical College Hospital, Modakkallur, Calicut, 673 321, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
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Umemura A, Nitta H, Takahara T, Hasegawa Y, Katagiri H, Kanno S, Kobayashi M, Ando T, Sato A, Uesugi N, Sugai T, Sasaki A. Laparoscopic Left Hepatectomy with Middle Hepatic Vein Resection for Hepatocellular Carcinoma with Extrahepatic Portal Vein Obstruction. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e928801. [PMID: 33642565 PMCID: PMC7930512 DOI: 10.12659/ajcr.928801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Patient: Female, 70-year-old Final Diagnosis: Hepatocellular carcinoma with extrahepatic portal vein obstruction Symptoms: — Medication:— Clinical Procedure: Preoperative simulation and intraoperative navigation technique Specialty: Surgery
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Affiliation(s)
- Akira Umemura
- Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | | | - Shoji Kanno
- Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Megumi Kobayashi
- Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Taro Ando
- Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Ayaka Sato
- Department of Molecular Diagnostic Pathology, Iwate Medical University, Morioka, Iwate, Japan
| | - Noriyuki Uesugi
- Department of Molecular Diagnostic Pathology, Iwate Medical University, Morioka, Iwate, Japan
| | - Tamotsu Sugai
- Department of Molecular Diagnostic Pathology, Iwate Medical University, Morioka, Iwate, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
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24
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Koga A, Murakami M, Kurihra Y, Ishida T, Hosokawa M, Tamura N, Imamura M, Kawai K. Portal hypertension in prolonged anorexia nervosa with laxative abuse: a case report with liver and kidney biopsy data. Eat Weight Disord 2021; 26:733-738. [PMID: 32342271 DOI: 10.1007/s40519-020-00902-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/09/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE We previously reported three cases of portal hypertension in patients with prolonged anorexia nervosa (AN) with laxative abuse and self-induced vomiting; we now report a fourth, similar case. METHODS A 34-year-old woman with anorexia nervosa, binge-eating/purging type (AN-BP), presented to the Kohnodai Hospital National Center for Global Health and Medicine Psychosomatic Medicine Department for treatment of low body weight. We conducted hepatic and renal biopsies and cardiac magnetic resonance imaging (CMR) to evaluate her complicated liver disease, renal failure, and cardiac insufficiency, respectively. RESULTS Enhanced computed tomography revealed ascites, splenomegaly, and gastroesophageal varices, indicating portal hypertension. The liver and kidney biopsies demonstrated chronic hepatitis without evidence of hepatic cirrhosis and tubulointerstitial nephritis, respectively. CMR demonstrated decreased myocardial mass. CONCLUSION We found tubulointerstitial nephritis and decreased myocardial mass in a patient with non-cirrhotic portal hypertension and prolonged AN with laxative abuse and habitual self-induced vomiting. We propose that reciprocal interactions between multiple factors related to AN, including laxative toxicity, dehydration, renal disorder, and cardiac insufficiency, result in portal hypertension. Level of Evidence Level V.
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Affiliation(s)
- Aiko Koga
- Department of Psychosomatic Medicine, Kohnodai Hospital, National Center for Global Health Medicine, 1-7-1, Kohnodai, Ichikawa City, Chiba, 272-8516, Japan
| | - Masafumi Murakami
- Department of Psychosomatic Medicine, Kohnodai Hospital, National Center for Global Health Medicine, 1-7-1, Kohnodai, Ichikawa City, Chiba, 272-8516, Japan
| | - Yu Kurihra
- Department of Psychosomatic Medicine, Kohnodai Hospital, National Center for Global Health Medicine, 1-7-1, Kohnodai, Ichikawa City, Chiba, 272-8516, Japan
| | - Tsuyoshi Ishida
- Department of Clinical Examination Laboratory, Kohnodai Hospital, National Center for Global Health Medicine, 1-7-1, Kohnodai, Ichikawa City, Chiba, 272-8516, Japan
| | - Mariko Hosokawa
- Department of Psychosomatic Medicine, Kohnodai Hospital, National Center for Global Health Medicine, 1-7-1, Kohnodai, Ichikawa City, Chiba, 272-8516, Japan
| | - Naho Tamura
- Department of Psychosomatic Medicine, Kohnodai Hospital, National Center for Global Health Medicine, 1-7-1, Kohnodai, Ichikawa City, Chiba, 272-8516, Japan
| | - Masatoshi Imamura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health Medicine, 1-7-1, Kohnodai, Ichikawa City, Chiba, 272-8516, Japan
| | - Keisuke Kawai
- Department of Psychosomatic Medicine, Kohnodai Hospital, National Center for Global Health Medicine, 1-7-1, Kohnodai, Ichikawa City, Chiba, 272-8516, Japan.
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25
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Vallonthaiel AG, Baloda V, Singh L, Yadav R, Kilambi R, Battu S, Sreenivas V, Pal S, Acharya SK, DattaGupta S, Shalimar, Das P. Histological analyses of trucut liver biopsies from patients with noncirrhotic portal fibrosis and extra-hepatic portal vein obstruction. INDIAN J PATHOL MICR 2021; 64:S127-S135. [PMID: 34135154 DOI: 10.4103/ijpm.ijpm_387_20] [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: 11/04/2022] Open
Abstract
Background Both noncirrhotic portal fibrosis (NCPF) and extrahepatic portal venous obstruction (EHPVO) are important causes of noncirrhotic portal hypertension (PH) in the Asian region. In this study, we analyzed the histopathological changes of liver needle-core biopsies from patients with NCPF and EHPVO. Patients and Methods The patients were diagnosed as per the Asia Pacific Association for the Study of Liver (APASL) criteria. Minimum adequacy criteria for liver core biopsies were defined, and finally, 69 liver biopsies from patients with NCPF and 100 liver biopsies from patients with EHPVO were analyzed. All histological parameters were predefined, and three experienced pathologists analyzed the biopsies after reaching consensus. Institute ethics committee clearance was taken. Results Although some histological features were overlapping, phlebosclerosis of intra-hepatic branches of the portal vein (PV), periportal aberrant vascular channels, remnant portal tracts, and hepatic fibrosis beyond the portal tracts without the formation of complete hepatic nodules (P < 0.001 for all) were common histological characteristics of NCPF on core-needle liver biopsies; while maintained lobular architecture, nonspecific dilatation of PV branches, absence of intra-hepatic PV phlebosclerosis, aberrant vascular channels, and significant fibrosis were characteristics of EHPVO. Conclusions Despite the considerable histological overlap between NCPF and EHPVO, careful histological evaluation, supplemented by clinical features, radiological and biochemical findings can help in making a conclusive diagnosis. Patients with NCPF and EHPVO with clinical jaundice show transaminitis, high serum alkaline phosphatase level, more variceal bleed, and histological evidences of nodular regenerative hyperplasia.
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Affiliation(s)
| | - Vandana Baloda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Lavleen Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajni Yadav
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sudha Battu
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sujoy Pal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Subrat K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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26
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Abstract
COVID causing Banti's syndrome has not been reported in literature yet. Banti’s syndrome is a rare disorder characterized by splenomegaly, ascites, and portal hypertension without coexisting cirrhosis of the liver. Here we report a case of a 32-year-old man who presented with hematemesis, and further workup revealed that the patient had bleeding varices, ascites, and splenomegaly, thus completing the picture of Banti’s syndrome. Although this is a rare disorder, Banti's syndrome must be taken into account in a patient presenting with hematemesis and splenomegaly. The patient had flu-like symptoms for three weeks but did not seek any medical help and eventually presented with Banti's syndrome. His serology was positive for COVID-19. The coronavirus (COVID-19), discovered in 2019, has been creating havoc since it first emerged in China and is now spreading worldwide. Its presentation is somewhat similar to influenza.
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Affiliation(s)
- Zohra R Malik
- Internal Medicine, St. John's Episcopal Hospital, Far Rockaway, USA
| | - Zareen Razaq
- Internal Medicine, Ghurki Trust Teaching Hospital, Lahore, PAK
| | - Melody Siff
- Internal Medicine, St. John's Episcopal Hospital, Far Rockaway, USA
| | - Saher Sheikh
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
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27
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De Gottardi A, Rautou PE, Schouten J, Rubbia-Brandt L, Leebeek F, Trebicka J, Murad SD, Vilgrain V, Hernandez-Gea V, Nery F, Plessier A, Berzigotti A, Bioulac-Sage P, Primignani M, Semela D, Elkrief L, Bedossa P, Valla D, Garcia-Pagan JC. Porto-sinusoidal vascular disease: proposal and description of a novel entity. Lancet Gastroenterol Hepatol 2020; 4:399-411. [PMID: 30957754 DOI: 10.1016/s2468-1253(19)30047-0] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 12/14/2022]
Abstract
Portal hypertension in the absence of portal vein thrombosis and without cirrhosis, but with mild or moderate alterations of liver histology (eg, obliterative venopathy, nodular regenerative hyperplasia, or incomplete septal cirrhosis) is being increasingly recognised. Owing to the heterogeneity of causes and histological findings, a substantial number of terms have been used to describe such idiopathic non-cirrhotic portal hypertension. Patients with the same clinical and histological features exist, but without portal hypertension at the time of diagnosis. Therefore, improved criteria are needed to define this form of liver disease. Here, we propose the term porto-sinusoidal vascular disease, since all lesions found involve the portal venules or sinusoids. The definition of this entity is based on the characteristic absence of cirrhosis with or without signs of portal hypertension or histological lesions. The presence of known causes of liver disease does not rule out porto-sinusoidal vascular disease, but specific causes of vascular liver disease are excluded from its definition. The diagnosis of porto-sinusoidal vascular disease is based on liver biopsy and might include signs specific for portal hypertension with normal or mildly elevated liver stiffness values and no complete portal vein thrombosis. We provide simple diagnostic criteria, because agreement on a uniform nomenclature is an essential requirement for future collaborative studies.
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Affiliation(s)
- Andrea De Gottardi
- University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Hôpital Beaujon, Clichy, France; Centre de Recherche de l'Inflammation, Inserm and Université Paris Diderot, Paris, France
| | | | - Laura Rubbia-Brandt
- Service de Pathologie Clinique, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Frank Leebeek
- Department of Haematology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain; CIBER Hepatic and Digestive Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - Filipe Nery
- Centro Hospitalar Universitário and EpiUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Aurélie Plessier
- Service d'Hépatologie, Hôpital Beaujon, Clichy, France; Centre de Recherche de l'Inflammation, Inserm and Université Paris Diderot, Paris, France
| | - Annalisa Berzigotti
- University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | | | - Massimo Primignani
- Gastroenterologia ed Epatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - David Semela
- Gastroenterology and Hepatology, Kantonsspital, St Gallen, Switzerland
| | - Laure Elkrief
- Hepatology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Dominique Valla
- Service d'Hépatologie, Hôpital Beaujon, Clichy, France; Centre de Recherche de l'Inflammation, Inserm and Université Paris Diderot, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain; CIBER Hepatic and Digestive Diseases, Instituto de Salud Carlos III, Madrid, Spain.
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Saluja SS, Kumar A, Govind H, Varshney VK, Khullar R, Mishra PK. Splenectomy with endotherapy in non-cirrhotic portal fibrosis related portal hypertension: Can it be an alternative to proximal spleno-renal shunt? Ann Hepatobiliary Pancreat Surg 2020; 24:168-173. [PMID: 32457262 PMCID: PMC7271099 DOI: 10.14701/ahbps.2020.24.2.168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/01/2020] [Accepted: 03/04/2020] [Indexed: 01/08/2023] Open
Abstract
Backgrounds/Aims Proximal splenorenal shunt (PSRS) is usually done in symptomatic non-cirrhotic portal fibrosis (NCPF). The outcomes of splenectomy with endotherapy in non-bleeder NCPF patients has not been well studied. We here by aimed to study the post-surgical outcomes on short and long-term basis between PSRS and splenectomy among non-bleeder NCPF patients. Methods The consecutive non-bleeder NCPF patients whom underwent either splenectomy or PSRS from 2008 to 2016 were enrolled. The patients were followed up post-surgery clinically and biochemical investigations, Doppler ultrasound and upper gastrointestinal endoscopy were done as required. The peri-operative parameters compared were operative time, blood loss, hospital stay and morbidity. The long-term outcome measures compared were incidence of portal hypertension (PHTN) related bleed, change in grade of varices, shunt patency, shunt complications and thrombosis of spleno-portal axis. Results Among 40 patients with non-bleeder status, 24 underwent splenectomy and 16 underwent PSRS. The baseline characteristics including indication of surgery, biochemical investigations and grade of varices were comparable between PSRS and splenectomy. The peri-operative morbidity was not significantly different between two groups. The median follow up duration was 42 months (12-72 months), the decrement in grade of varices was significantly higher in PSRS group (p=0.03), symptomatic PHTN related UGIB was non-significant between PSRS and splenectomy (p=0.5). In PSRS group, 3 (18.3%) patients had shunt thrombosis (n=1) & encephalopathy (n=2) while in splenectomy group two patients developed thrombosis of splenoportal axis. Conclusions Splenectomy with endotherapy is alternative to PSRS in non-bleeder NCPF patients with indications for surgery.
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Affiliation(s)
- Sundeep Singh Saluja
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Ajay Kumar
- Department of Gastromedicine, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Hari Govind
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Vaibhav Kumar Varshney
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Rahul Khullar
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Pramod Kumar Mishra
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
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Eusébio CP, Correia S, Silva F, Almeida M, Pedroso S, Martins LS, Diais L, Queirós J, Pessegueiro H, Vizcaíno R, Henriques AC. Refractory ascites and graft dysfunction in early renal transplantation. ACTA ACUST UNITED AC 2020; 41:570-574. [PMID: 30897191 PMCID: PMC6979575 DOI: 10.1590/2175-8239-jbn-2018-0175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 01/31/2019] [Indexed: 12/31/2022]
Abstract
The occurrence of ascites after Renal Transplant (RT) is infrequent, and may be a consequence of surgical or medical complications. Case report: 61 year-old, male, history of arterial hypertension, tongue carcinoma and alcoholic habits 12-20g/day. He had chronic kidney disease secondary to autosomal dominant polycystic kidney disease, without hepatic polycystic disease. He underwent cadaver donor RT in September 2017. He had delayed graft function by surgically corrected renal artery stenosis. He was admitted in January 2018 for ascites de novo, with no response to diuretics. HE had visible abdominal collateral circulation. Graft dysfunction, adequate tacrolinemia, Innocent urinary sediment, mild anemia, without thrombocytopenia. Serum albumin 4.0g / dL. Normal hepatic biochemistry. Peritoneal fluid with transudate characteristics and serum albumin gradient > 1.1. Ultrasound showed hepatomegaly, permeable vascular axes, without splenomegaly. Mycophenolate mofetil was suspended, with reduced remaining immunosuppression. He maintained refractory ascites: excluded infectious, metabolic, autoimmune and neoplastic etiologies. No nephrotic proteinuria and no heart failure. MRI: micronodules compatible with bile cysts. Upper Digestive Tract Endoscopy did not show gastroesophageal varicose veins. Normal abdominal lymphoscintigraphy. He underwent exploratory laparoscopy with liver biopsy: incomplete septal cirrhosis of probable vascular etiology some dilated bile ducts. He maintained progressive RT dysfunction and restarted hemodialysis. The proposed direct measurement of portal pressure was delayed by ascites resolution. There was further recovery of the graft function. Discussion: Incomplete septal cirrhosis is an uncommon cause of non-cirrhotic portal hypertension. Its definition is not well known, morphological and pathophysiological. We have not found published cases of post-RT ascites secondary to this pathology, described as possibly associated with drugs, immune alterations, infections, hypercoagulability and genetic predisposition.
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Affiliation(s)
| | - Sofia Correia
- Serviço de Nefrologia e Transplantação Renal do Centro Hospitalar do Porto, Porto, Portugal
| | - Filipa Silva
- Serviço de Nefrologia e Transplantação Renal do Centro Hospitalar do Porto, Porto, Portugal
| | - Manuela Almeida
- Serviço de Nefrologia e Transplantação Renal do Centro Hospitalar do Porto, Porto, Portugal
| | - Sofia Pedroso
- Serviço de Nefrologia e Transplantação Renal do Centro Hospitalar do Porto, Porto, Portugal
| | - La Salete Martins
- Serviço de Nefrologia e Transplantação Renal do Centro Hospitalar do Porto, Porto, Portugal
| | - Leonídio Diais
- Serviço de Nefrologia e Transplantação Renal do Centro Hospitalar do Porto, Porto, Portugal
| | - José Queirós
- Serviço de Nefrologia e Transplantação Renal do Centro Hospitalar do Porto, Porto, Portugal
| | - Helena Pessegueiro
- Serviço de Gastroenterologia do Centro Hospitalar do Porto, Porto, Portugal
| | - Ramon Vizcaíno
- Serviço de Anatomia Patológica do Centro Hospitalar do Porto, Porto, Portugal
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Kotani K, Kawada N. Long-term outcome of pediatric non-cirrhotic portal fibrosis from the viewpoint of endoscopic profile. Hepatol Int 2020; 14:164-166. [PMID: 32170597 DOI: 10.1007/s12072-020-10028-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 02/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Kohei Kotani
- Department of Hepatology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
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Goel A, Ramakrishna B, Zachariah U, Sajith KG, Burad DK, Kodiatte TA, Keshava SN, Balasubramanian KA, Elias E, Eapen CE. What makes non-cirrhotic portal hypertension a common disease in India? Analysis for environmental factors. Indian J Med Res 2020; 149:468-478. [PMID: 31411170 PMCID: PMC6676844 DOI: 10.4103/ijmr.ijmr_1405_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.
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Affiliation(s)
- Ashish Goel
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Banumathi Ramakrishna
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Uday Zachariah
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - K G Sajith
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Deepak K Burad
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Thomas A Kodiatte
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Shyamkumar N Keshava
- Department of Radio-diagnosis, Division of GI Sciences, Christian Medical College, Vellore, India
| | - K A Balasubramanian
- Department of Wellcome Research Laboratory, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Elwyn Elias
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India; Liver Unit, University Hospitals, Birmingham, UK
| | - C E Eapen
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
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Ghonge NP, Sahu A. 'Hepato-diaphragmatic fat interposition' and 'increased right hemi-diaphragmatic thickness': new imaging signs for early diagnosis of hepatic cirrhosis on routine CT abdomen. Abdom Radiol (NY) 2020; 45:153-160. [PMID: 31542819 DOI: 10.1007/s00261-019-02230-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cirrhosis of liver is often a silent disease and need early diagnosis for effective treatment strategy. OBJECTIVES The present article aims to describe new imaging signs for early diagnosis of cirrhosis on routine CT. These are 'hepato-diaphragmatic fat interposition' (HDFI) and 'increased right hemi-diaphragmatic thickness' (increased r-DT sign). MATERIALS AND METHODS This was a retrospective study based on the presence or absence of cirrhosis of liver (n = 100). 'HDFI sign' was labeled as positive if F is more than 50% of D; where F is the medio-lateral extent of the intra-abdominal fat along the postero-medial margin of liver and D is the distance from the lateral vertebral margin to the medial margin of the outer-most rib in the same axial image. Increased 'r-DT sign' is labeled when the dimension on right side exceeds left side by at least 0.2 cm. Pearson χ2 was performed to calculate the p value. A p value of < 0.05 was considered to indicate a significant difference. RESULTS There was a significant difference between cirrhotic and normal group, The sensitivity, specificity, positive predictive value and the negative predictive value of HDFI sign was found to be 94%, 62%, 71.21% and 91.17%, while that of increased r-DT sign was found to be 96%,52%, 66.66% and 92.85%. The area under the ROC curve for the HDFI sign was found to be 0.78 as compared to 0.74 for the increased r-DT sign. CONCLUSION Both these new signs should be used as additional imaging signs for early diagnosis of cirrhosis.
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Affiliation(s)
| | - Amit Sahu
- Max Superspeciality Hospital, Saket, New Delhi, India
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Abstract
Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are prototype noncirrhotic causes of portal hypertension (PHT), characterized by normal hepatic venous pressure gradient, variceal bleeds, and moderate to massive splenomegaly with preserved liver synthetic functions. Infections, toxins, and immunologic, prothrombotic and genetic disorders are possible causes in IPH, whereas prothrombotic and local factors around the portal vein lead to EHPVO. Growth failure, portal biliopathy, and minimal hepatic encephalopathy are long-term concerns in EHPVO. Surgical shunts and transjugular intrahepatic portosystemic shunt resolve the complications secondary to PHT. Meso-Rex shunt is now the standard-of-care surgery in children with EHPVO.
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Affiliation(s)
- Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi 110 070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi 110 070, India.
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Prasad D, Sen Sarma M, Yachha SK, Srivastava A, Poddar U. Pediatric non-cirrhotic portal fibrosis: role of endoscopic management in determining long-term outcome. Hepatol Int 2019; 14:281-287. [PMID: 31468295 DOI: 10.1007/s12072-019-09979-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/09/2019] [Indexed: 12/11/2022]
Abstract
AIMS Non-cirrhotic portal fibrosis (NCPF) is a rare cause of pediatric portal hypertension. There is abundant literature in adults but paucity of data in children. We aimed to evaluate and compare the endoscopic and long-term outcomes of children with NCPF. METHODS Consecutive children (≤ 18 years) diagnosed with NCPF evaluated for clinical and endoscopic profile and outcome. The cohort underwent 3 weekly endoscopic sessions until esophageal variceal eradication followed by 6-12 monthly endoscopic surveillance. Non-bleeders and bleeders were compared for endoscopic outcome. RESULTS Forty-five NCPF children with median age of 14.5 (6-18) years and symptom duration 12 (1-120) months presented with spleen-related issues (78%), esophageal varices (96%), primary gastric varices (56%), and portal hypertensive gastropathy (89%). Thirty-three patients undergoing endotherapy (secondary prophylaxis n = 22, primary prophylaxis n = 11) showed primary eradication of varices after 5 (2-12) sessions. 36% showed recurrence of esophageal varices in 11 (6-42) months and secondary gastric varices developed in 12%. Overall 87% patients required endoscopic intervention at onset or follow-up. Poor outcome was observed in ten patients (n = 9 bleeders). Three children died of variceal bleeding before endoscopic eradication of esophageal varices. Three developed decompensation after a median follow-up of 48 (3-120) months and referred for liver transplantation. Four patients required surgery for portal hypertension. CONCLUSIONS Overall, endoscopic outcome of NCPF is favorable. One-third patients have recurrence of esophageal varices. Small proportion of bleeders have poor outcome.
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Affiliation(s)
- Durga Prasad
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India.
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
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Sun Y, Lan X, Shao C, Wang T, Yang Z. Clinical features of idiopathic portal hypertension in China: A retrospective study of 338 patients and literature review. J Gastroenterol Hepatol 2019; 34:1417-1423. [PMID: 30462857 DOI: 10.1111/jgh.14552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/03/2018] [Accepted: 11/09/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Idiopathic portal hypertension (IPH) refers to a relatively rare condition characterized by intrahepatic portal hypertension in the absence of underlying disease such as liver cirrhosis. METHODS We retrospectively reviewed 338 patients with IPH that were diagnosed at the pathological consultation center of our hospital. RESULTS The ratio of male to female patients was 1:1. Mean age at onset was 35.1 ± 16.5 years; male patients on average were 12 years younger than female patients at onset. The median duration from onset to IPH diagnosis was 12 months. In 50 patients, medication use may have been an etiological factor. The most common clinical manifestations were splenomegaly (91.3%) and hypersplenism (68.9%); 57.0% patients presented varicosis, while 25.1% patients had a history of variceal bleeding. Nodular regenerative hyperplasia was found in 22.2% liver biopsies. Among patients for whom laboratory data were available, 65.0%, 50.3%, and 71.4% patients presented leukopenia, anemia, and thrombocytopenia due to hypersplenism. Liver function was mostly in the compensated stage. Female patients showed worse leukopenia and anemia, while male patients were more likely to have abnormal serum transaminase and bilirubin levels. Sixty-seven patients received surgical or interventional treatment. CONCLUSIONS High-quality liver biopsy, detailed clinical information, and expert pathologist are necessary for diagnosis of IPH. IPH can occur concurrently with other liver disease such as hepatitis and drug-induced liver injury. Medication appears to be an important etiological factor for IPH in China. Management approach was largely focused on treatment of portal hypertension and its complications.
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Affiliation(s)
- Yongliang Sun
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xu Lan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Chen Shao
- Department of Pathology, Beijing You'an Hospital affiliated with Capital Medical University, Beijing, China
| | - Tailing Wang
- Department of Pathology, China-Japan Friendship Hospital, Beijing, China
| | - Zhiying Yang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
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Ohfuji S, Furuichi Y, Akahoshi T, Kage M, Obara K, Hashizume M, Matsuura T, Fukushima W, Nakamura Y. Japanese periodical nationwide epidemiologic survey of aberrant portal hemodynamics. Hepatol Res 2019; 49:890-901. [PMID: 30945395 PMCID: PMC6850208 DOI: 10.1111/hepr.13343] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 12/15/2022]
Abstract
AIM Idiopathic portal hypertension (IPH), extrahepatic portal obstruction (EHO), and Budd-Chiari syndrome (BCS) are characterized by aberrant portal hemodynamics of unknown etiology. The aim of this study was to explore trends in the descriptive epidemiology of these diseases through periodical nationwide surveys. METHODS Nationwide epidemiologic surveys were undertaken in 1999, 2005, and 2015 using the same protocol. The survey targets were selected from all departments of gastrointestinal medicine, surgery, pediatrics, and pediatric surgery in Japan by stratified random sampling according to the number of beds. We asked each department to complete a mail-back questionnaire on the annual numbers of patients with IPH, EHO, and BCS during the preceding year. RESULTS The estimated number of BCS patients increased from 280 (95% confidence interval, 200-360) in 1999 survey to 410 (300-530) in 2015 survey, whereas the number of IPH and EHO patients has remained largely unchanged during the 15 years (IPH was approximately 1000; EHO was approximately 770 in 2015 survey). The mean age at symptom onset was approximately 45 years for IPH, 30 years for EHO, and 40 years for BCS over the past 15 years. Those who described disease aggravation from the time of diagnosis accounted for approximately 10% of IPH, 15% of EHO, and 20% of BCS patients in each of the three surveys. CONCLUSIONS In Japan, the prevalence of BCS is increasing, while those of IPH and EHO appear to be stable. Clinical characteristics, including prognoses, have remained largely unchanged in the past 15 years.
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Affiliation(s)
- Satoko Ohfuji
- Department of Public HealthOsaka City University Graduate School of MedicineOsakaJapan
| | - Yoshihiro Furuichi
- The 4th Department of Internal MedicineTokyo Medical UniversityTokyoJapan
| | - Tomohiko Akahoshi
- Department of Disaster and Emergency MedicineKyushu University Graduate School of Medical SciencesFukuokaJapan
| | - Masayoshi Kage
- Research Center for Innovative Cancer TherapyKurume UniversityKurumeJapan
| | - Katsutoshi Obara
- Department of Advanced Gastrointestinal EndoscopyFukushima Medical UniversityFukushimaJapan
| | - Makoto Hashizume
- Department of Disaster and Emergency MedicineKyushu University Graduate School of Medical SciencesFukuokaJapan
| | - Tomoka Matsuura
- Department of Public HealthOsaka City University Graduate School of MedicineOsakaJapan
| | - Wakaba Fukushima
- Department of Public HealthOsaka City University Graduate School of MedicineOsakaJapan
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Koga A, Toda K, Tatsushima K, Matsuubayashi S, Tamura N, Imamura M, Kawai K. Portal hypertension in prolonged anorexia nervosa with laxative abuse: A case report of three patients. Int J Eat Disord 2019; 52:211-215. [PMID: 30636007 PMCID: PMC6590132 DOI: 10.1002/eat.23007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 11/07/2018] [Accepted: 12/08/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE There has been no report on portal hypertension related to anorexia nervosa (AN). METHOD We describe three cases of portal hypertension manifesting with collateral circulation represented by gastroesophageal varices in prolonged AN with laxative abuse and self-vomiting. These women, in their 20s to 50s, were diagnosed as having AN binging and purging type (AN-BP) that included self-induced vomiting and abuse of irritating laxatives (more than 100 tablets daily). RESULTS Case 1 showed prominent ascites and a gastro-renal shunt on computed tomography scanning. Case 2 showed gastroesophageal varices on endoscopic examination. Case 3 showed gastroesophageal varices on computed tomography scanning and endoscopic examination. We performed liver biopsies in all patients and found only slight pericellular fibrosis. Our patients showed typical symptoms of portal hypertension, although liver cirrhosis was not present. DISCUSSION We speculated that abnormal eating and purging behaviors were involved in the development of portal hypertension. We hypothesized that long-term laxative abuse, dehydration, and abnormal eating behavior are involved in the development of portal hypertension, considering these were common features in our patients. Portal hypertension and gastroesophageal varices should be considered as one of the potentially existing complications in prolonged AN-BP with self-induced vomiting and abuse of irritating laxatives.
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Affiliation(s)
- Aiko Koga
- Department of Psychosomatic MedicineKohnodai Hospital, National Center for Global Health MedicineIchikawa CityChibaJapan
| | - Kenta Toda
- Department of Psychosomatic MedicineKohnodai Hospital, National Center for Global Health MedicineIchikawa CityChibaJapan
| | - Keita Tatsushima
- Department of Psychosomatic MedicineKohnodai Hospital, National Center for Global Health MedicineIchikawa CityChibaJapan
| | - Sunao Matsuubayashi
- Department of Psychosomatic MedicineFukuoka Tokusyuukai HospitalKasuga CityFukuokaJapan
| | - Naho Tamura
- Department of Psychosomatic MedicineKohnodai Hospital, National Center for Global Health MedicineIchikawa CityChibaJapan
| | - Masatoshi Imamura
- Department of Gastroenterology and HepatologyKohnodai Hospital, National Center for Global Health MedicineIchikawa CityChibaJapan
| | - Keisuke Kawai
- Department of Psychosomatic MedicineKohnodai Hospital, National Center for Global Health MedicineIchikawa CityChibaJapan
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Guido M, Alves VAF, Balabaud C, Bathal PS, Bioulac-Sage P, Colombari R, Crawford JM, Dhillon AP, Ferrell LD, Gill RM, Hytiroglou P, Nakanuma Y, Paradis V, Quaglia A, Rautou PE, Theise ND, Thung S, Tsui WMS, Sempoux C, Snover D, van Leeuwen DJ. Histology of portal vascular changes associated with idiopathic non-cirrhotic portal hypertension: nomenclature and definition. Histopathology 2018; 74:219-226. [DOI: 10.1111/his.13738] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/07/2018] [Accepted: 08/18/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Maria Guido
- Department of Medicine-DIMED; Pathology Unit; University of Padova; Padova Italy
| | - Venancio A F Alves
- Department of Pathology; University of Sao Paulo School of Medicine; Sao Paulo Brazil
| | | | - Prithi S Bathal
- Department of Pathology; University of Melbourne; Melbourne Vic. Australia
| | - Paulette Bioulac-Sage
- Department of Pathology; CHU Bordeaux, and Inserm U1053; Bordeaux University; Bordeaux France
| | | | - James M Crawford
- Department of Pathology and Laboratory Medicine; Donald and Barbara School of Medicine at Hofstra/Northwell; New York NY USA
| | - Amar P Dhillon
- Department of Cellular Pathology; UCL Medical School; London UK
| | - Linda D Ferrell
- Department of Pathology; University of California; San Francisco CA USA
| | - Ryan M Gill
- Department of Pathology; University of California; San Francisco CA USA
| | - Prodromos Hytiroglou
- Department of Pathology; Aristotle University Medical School; Thessaloniki Greece
| | - Yasuni Nakanuma
- Department of Diagnostic Pathology; Shizuoka Cancer Centre; Shizuoka Japan
| | | | - Alberto Quaglia
- Institute of Liver Studies; King's College Hospital and King's College; London UK
| | - Pierre E Rautou
- Department of Hepatology; Hopital Beaujon; University of Paris; Paris France
| | - Neil D Theise
- Department of Pathology; New York University School of Medicine; New York NY USA
| | - Swan Thung
- Department of Pathology; Icahn School of Medicine at Mount Sinai; New York NY USA
| | | | - Christine Sempoux
- Service of Clinical Pathology; Lausanne University Hospital; Institute of Pathology; Lausanne Switzerland
| | - Dale Snover
- Department of Pathology; Fairview Southdale Hospital; Edina MN USA
| | - Dirk J van Leeuwen
- Section of Gastroenterology and Hepatology; Geisel School of Medicine at Dartmouth College; Hanover NH USA
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Etzion O, Takyar V, Novack V, Gharib AM, Canales R, Adebogun A, Matsumoto E, Eccleston JL, Kleiner DE, Rosenzweig SD, Gunay‐Aygun M, Uzel G, Fuss I, Childs R, Holland SM, Levy EB, Liang TJ, Heller T, Koh C. Spleen and Liver Volumetrics as Surrogate Markers of Hepatic Venous Pressure Gradient in Patients With Noncirrhotic Portal Hypertension. Hepatol Commun 2018; 2:919-928. [PMID: 30094403 PMCID: PMC6078215 DOI: 10.1002/hep4.1198] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/12/2018] [Accepted: 04/18/2018] [Indexed: 12/13/2022] Open
Abstract
Noncirrhotic portal hypertension (NCPH) is a rare disease that may lead to serious clinical consequences. Currently, noninvasive tools for the assessment of NCPH are absent. We investigated the utility of spleen and liver volumetrics as a marker of the presence and severity of portal hypertension in this population. A cohort of NCPH patients evaluated between 2003 and 2015 was retrospectively studied. The association of spleen and liver volumes with the hepatic venous pressure gradient (HVPG) level was evaluated using locally weighted scatterplot smoothing curves. A cohort of patients with viral hepatitis-related liver disease was used as controls. Of the 86 patients with NCPH evaluated during the study period, 75 (mean age, 35 ± 17; 73% males) were included in the final analysis. Patients with portal hypertension had significantly higher spleen and liver to body mass index (BMI) ratios compared to patients with HVPG <5 mm Hg (39.5 ± 27.9 versus 22.8 ± 10.6 cm3/kg/m2, P = 0.003; 91.1 ± 40.1 versus 71.4 ± 16.7 cm3/kg/m2, P = 0.014, for spleen/BMI and liver/BMI, respectively). In contrast to the patients with viral hepatitis, a positive linear correlation was observed in the NCPH cohort between spleen/BMI and liver/BMI (above a cutoff of 25 and 80 cm3/kg/m2, respectively) and HVPG level. Additionally, only in the NCPH cohort was an increase in spleen/BMI range quartile predictive of a higher prevalence of portal hypertension and clinically significant portal hypertension (trend, P = 0.014 and 0.031, respectively). Conclusion: Spleen and liver volumetrics may have utility in the assessment of NCPH as a noninvasive biomarker that can be performed using routine radiologic examinations. Further studies are needed to validate these findings. (Hepatology Communications 2018; 00:000-000).
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Affiliation(s)
- Ohad Etzion
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Varun Takyar
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Victor Novack
- Clinical Research CenterSoroka University Medical CenterBeer‐ShivaIsrael
| | - Ahmed M. Gharib
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Raissa Canales
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Akeem Adebogun
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Eric Matsumoto
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Jason L. Eccleston
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer InstituteNational Institutes of HealthBethesdaMD
| | - Sergio D. Rosenzweig
- Department of Laboratory MedicineNational Institutes of Health Clinical CenterBethesdaMD
| | - Meral Gunay‐Aygun
- Medical Genetics BranchNational Human Genome Research InstituteBethesdaMD
| | - Gulbu Uzel
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMD
| | - Ivan Fuss
- Mucosal Immunity Section, National Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMD
| | - Richard Childs
- National Heart, Lung, and Blood Institute, Hematology BranchNational Institutes of HealthBethesdaMD
| | - Steven M. Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMD
| | - Elliot B. Levy
- Center for Interventional OncologyNational Institutes of HealthBethesdaMD
| | - T. Jake Liang
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
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Hepatic Histology and Morphometric Measurements in Idiopathic Extrahepatic Portal Vein Thrombosis in Children, Correlated to Clinical Outcome of Meso-Rex Bypass. Ann Surg 2018; 267:1179-1184. [DOI: 10.1097/sla.0000000000002128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
PURPOSE OF REVIEW Noncirrhotic portal hypertension represents a heterogeneous group of liver disorders that is characterized by portal hypertension in the absence of cirrhosis. The purpose of this review is to serve as a guide on how to approach a patient with noncirrhotic portal hypertension with a focus on recent developments. RECENT FINDINGS Recent studies pertaining to noncirrhotic portal hypertension have investigated aetiological causes, mechanisms of disease, noninvasive diagnostic modalities, clinical characteristics in the paediatric population and novel treatment targets. SUMMARY Noncirrhotic portal hypertension is an underappreciated clinical entity that can be difficult to diagnosis without a healthy suspicion. Diagnosis then relies on a comprehensive understanding of the causes and clinical manifestations of this disease, as well as a careful interpretation of the liver biopsy. Noninvasive approaches to diagnosis may play a significant role moving forward in this disease. Treatment in NCPH remains largely targeted at the individual sequalae of portal hypertension.
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Pathology of idiopathic non-cirrhotic portal hypertension. Virchows Arch 2018; 473:23-31. [DOI: 10.1007/s00428-018-2355-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/29/2018] [Accepted: 04/02/2018] [Indexed: 12/15/2022]
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43
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Spectrum of histopathological changes in patients with non-cirrhotic portal fibrosis. Hepatol Int 2018; 12:158-166. [DOI: 10.1007/s12072-018-9857-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/15/2018] [Indexed: 12/13/2022]
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Khanna R, Sarin SK. Idiopathic portal hypertension and extrahepatic portal venous obstruction. Hepatol Int 2018; 12:148-167. [PMID: 29464506 DOI: 10.1007/s12072-018-9844-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are non-cirrhotic vascular causes of portal hypertension (PHT). Variceal bleed and splenomegaly are the commonest presentations. AIM The present review is intended to provide the existing literature on etiopathogenesis, clinical profile, diagnosis, natural history and management of IPH and EHPVO. RESULTS IPH and EHPVO are both characterized by normal hepatic venous pressure gradient, moderate to massive splenomegaly with preserved liver synthetic functions. While the level of block in IPH is presinusoidal, in EHPVO it is at prehepatic level. Infections, autoimmunity, drugs, immunodeficiency and prothrombotic states are possible etiological agents in IPH. Contrastingly in EHPVO, prothrombotic disorders and local factors around the portal vein are the incriminating factors. Diagnosis is often clinical, supported by simple radiological tools. Natural history is defined by episodes of variceal bleed and symptoms related to enlarged spleen. Growth failure, portal biliopathy and minimal hepatic encephalopathy are additional concerns in EHPVO. Long-term survival is reasonably good with endoscopic surveillance; however, parenchymal extinction leading to decompensation is seen in a minority of patients in both the disorders. Surgical shunts revert the complications secondary to PHT. Meso-Rex shunt has become the standard surgery in children with EHPVO. CONCLUSION This review gives a detailed summary of these two vascular conditions of liver-IPH and EHPVO. Further research is needed to understand the pathogenesis and natural history of these disorders.
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Affiliation(s)
- Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
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Martín-Llahí M, Albillos A, Bañares R, Berzigotti A, García-Criado MÁ, Genescà J, Hernández-Gea V, Llop-Herrera E, Masnou-Ridaura H, Mateo J, Navascués CA, Puente Á, Romero-Gutiérrez M, Simón-Talero M, Téllez L, Turon F, Villanueva C, Zarrabeitia R, García-Pagán JC. Enfermedades vasculares del hígado. Guías Clínicas de la Sociedad Catalana de Digestología y de la Asociación Española para el Estudio del Hígado. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:538-580. [DOI: 10.1016/j.gastrohep.2017.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
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Sharma P, Agarwal R, Dhawan S, Bansal N, Singla V, Kumar A, Arora A. Transient Elastography (Fibroscan) in Patients with Non-cirrhotic Portal Fibrosis. J Clin Exp Hepatol 2017; 7:230-234. [PMID: 28970710 PMCID: PMC5620350 DOI: 10.1016/j.jceh.2017.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 03/01/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Non-cirrhotic portal hypertension (NCPH) is a common cause of variceal bleed in developing countries. Transient elastography (TE) using Fibroscan is a useful technique for evaluation of fibrosis in patients with liver disease. There is a paucity of studies evaluating TE in patients with Non-cirrhotic portal fibrosis (NCPF) and none in Asian population. Aim of this study was to evaluate role of TE in NCPF. METHODS Retrospective data of consecutive patients of NCPF as per Asian pacific association for the study of liver (APASL) guidelines were noted. All patients had liver biopsy, TE, computed tomography of abdomen and hepatic venous pressure gradient (HVPG). Twenty age and gender matched healthy subjects and forty age matched patients with cirrhosis with Child's A were taken as controls. RESULTS A total of 20 patients with age [median 29.5 (13-50) years], Male:Female = 11:9 with a diagnosis of NCPF were enrolled from January 2011 to December 2015. Of 20 patients 18 patients had variceal bleed and required endoscopic band ligation. There was no difference in haemoglobin and platelet count between patients with cirrhosis and NCPF, but total leucocyte count was significantly lower in patients with NCPF compared to patients with cirrhosis (3.2 vs 6.7 × 103/cumm, P = 0.01). TE (Fibroscan) was high in patients with NCPF compared to healthy controls (6.8 vs 4.7 kPa, P = 0.001) but it was significantly low compared to cirrhotic patients (6.8 vs 52.3 kPa, P = 0.001). HVPG is significant low in patients with NCPF compared to patients with cirrhosis (5.0 vs 16.0 mmHg, P = 0.001). CONCLUSION Transient elastography (Fibroscan) is significantly low in patients with NCPF compared to patients with cirrhosis. It is a very useful non-invasive technique to differentiate between Child's A cirrhosis and non-cirrhotic portal fibrosis.
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Key Words
- APASL, Asian pacific association for the study of liver
- EVL, endoscopic variceal ligation
- FHVP, free hepatic venous pressure
- HVPG, hepatic venous pressure gradient
- IPH, idiopathic portal hypertension
- IQR, interquartile range
- LS, liver stiffness
- NCPF
- NCPF, non-cirrhotic portal fibrosis
- PHT, portal hypertension
- SR, success rate
- TE, transient elastography
- TM, time motion
- WHVP, wedged (occluded) hepatic venous pressure
- fibroscan
- transient elastography
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Affiliation(s)
- Praveen Sharma
- Sir Ganga Ram Hospital, New Delhi, India,Address for correspondence: Sir Ganga Ram Hospital, New Delhi, India
| | | | - Shashi Dhawan
- Department of Gastroenterology and Pathology, Sir Ganga Ram Hospital, New Delhi, India
| | | | | | | | - Anil Arora
- Sir Ganga Ram Hospital, New Delhi, India
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Abstract
OBJECTIVES Noncirrhotic portal fibrosis (NCPF) has been classically described as a disease of young to middle age with limited literature regarding its occurrence, onset, or clinical presentation in children. We hereby present a series of 19 patients diagnosed and managed as NCPF in pediatric age group. METHODS A retrospective review of all the patients presenting to the pediatric hepatology department (age <18 years) and diagnosed as NCPF was done and data were evaluated. RESULTS A total of 19 patients were diagnosed as NCPF with median age at onset of symptoms and diagnosis as 10 years and 13.8 years respectively. Majority presented with left upper quadrant discomfort or mass. Laboratory parameters showed hypersplenism in majority with preserved liver synthetic functions. Median values for hepatic venous pressure gradient and liver stiffness measurement were 13.5 mmHg and 10.6 kPa, respectively. Classical hepatic histopathological features seen were maintained lobular architecture, atretic portal tracts, approximation of portal-portal and portal-central areas, and aberrant peripheral portal channels. During follow-up, majority of the patients did not show disease progression. CONCLUSIONS NCPF is not an uncommon entity in pediatric population with age of onset in early second decade. Hepatic histopathology must be used to exclude cirrhosis and to confirm the diagnosis. Hepatic venous pressure gradient and liver stiffness measurement values, in some cases, may overlap with those in patients with cirrhosis and may not be diagnostic in isolation. Any patient presenting with evidence of portal hypertension with preserved hepatic functions, irrespective of the age, should be evaluated for possible NCPF.
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Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan. Hepatol Res 2017; 47:373-386. [PMID: 28058764 DOI: 10.1111/hepr.12862] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/29/2016] [Accepted: 01/04/2017] [Indexed: 12/18/2022]
Abstract
Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.
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Hepatic encephalopathy in patients with non-cirrhotic portal hypertension: Description, prevalence and risk factors. Dig Liver Dis 2016; 48:1072-7. [PMID: 27448844 DOI: 10.1016/j.dld.2016.06.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/06/2016] [Accepted: 06/14/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a common complication of cirrhosis but it is less studied in patients with non-cirrhotic portal hypertension (NCPH). AIMS To describe the prevalence of cognitive impairment (overt and covert HE) in NCPH patients and to identify the risk factors for its development. METHODS 51 patients with NCPH, 35 with chronic portal vein thrombosis (PVT) and 16 with idiopathic non-cirrhotic portal hypertension (INCPH), were evaluated for the presence of previous or present overt HE (OHE). The psychometric hepatic encephalopathy score and the SCAN battery were used to detect the presence of covert HE (CHE). 34 compensated cirrhotic patients were used as control. In NCPH patients, abdominal scans were performed to detect the presence of shunts. RESULTS None of the patients experienced OHE at evaluation while 5.7% of PVT and 12.5% of INCPH patients referred at least one documented episode of previous OHE, similarly to patients with cirrhosis (14.7%). Even if lower than in patients with cirrhosis (64.7%), a considerable proportion of patients with chronic PVT (34.3%) and INCPH (25%) had CHE (p=0.008). The presence of a large portal-systemic shunt was the only factor significantly correlated to cognitive impairment in NCPH patients. CONCLUSION HE is a tangible complication of NCPH and is mainly related to the presence of portal-systemic shunts.
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Riggio O, Gioia S, Pentassuglio I, Nicoletti V, Valente M, d’Amati G. Idiopathic noncirrhotic portal hypertension: current perspectives. Hepat Med 2016; 8:81-8. [PMID: 27555800 PMCID: PMC4968980 DOI: 10.2147/hmer.s85544] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The term idiopathic noncirrhotic portal hypertension (INCPH) has been recently proposed to replace terms, such as hepatoportal sclerosis, idiopathic portal hypertension, incomplete septal cirrhosis, and nodular regenerative hyperplasia, used to describe patients with a hepatic presinusoidal cause of portal hypertension of unknown etiology, characterized by features of portal hypertension (esophageal varices, nonmalignant ascites, porto-venous collaterals), splenomegaly, patent portal, and hepatic veins and no clinical and histological signs of cirrhosis. Physicians should learn to look for this condition in a number of clinical settings, including cryptogenic cirrhosis, a disease known to be associated with INCPH, drug administration, and even chronic alterations in liver function tests. Once INCPH is clinically suspected, liver histology becomes mandatory for the correct diagnosis. However, pathologists should be familiar with the histological features of INCPH, especially in cases in which histology is not only requested to exclude liver cirrhosis.
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Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Stefania Gioia
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Ilaria Pentassuglio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Valeria Nicoletti
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Michele Valente
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giulia d’Amati
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
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