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Roccarina D, Deganello A, Buscemi P, Cidoni D, Meloni MF. Diagnostic insights into splenic pathologies: the role of multiparametric ultrasound. Abdom Radiol (NY) 2024:10.1007/s00261-024-04628-7. [PMID: 39417855 DOI: 10.1007/s00261-024-04628-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 09/24/2024] [Accepted: 10/02/2024] [Indexed: 10/19/2024]
Abstract
Ultrasound (US) evaluation of the spleen is mandatory in the assessment of patients with chronic liver disease, and splenomegaly can be a sign of systemic diseases. However, due to the lack of distinctive ultrasound findings in specific splenic pathologies, clinical diagnosis can be very challenging. Splenomegaly, defined by increased splenic dimensions, can indicate underlying systemic conditions and is a common manifestation of portal hypertension (PH). Ultrasound and Doppler techniques help assessing splenic involvement in PH. Splenic stiffness measurement, using elastography, offers additional diagnostic accuracy, especially when liver stiffness measurements are inconclusive. CEUS enhances the diagnostic capability for focal splenic lesions, differentiating between benign and malignant lesions by their distinct enhancement patterns, and plays also a critical role in the context of splenic traumatic pathology. Overall, CEUS significantly improves the characterization of splenic pathology, reducing the need for invasive procedures and ensuring appropriate patient management. This review article describes the normal US findings of the spleen and examines the role of multiparametric US in the evaluation of the most common splenic pathologies encountered in the daily clinical practice.
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Affiliation(s)
- Davide Roccarina
- Department of Internal Medicine and Hepatology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
- UCL Division of Medicine - Institute for Liver and Digestive Health, UCL, London, UK.
| | - Annamaria Deganello
- Department of Radiology, Faculty of Life Sciences and Medicine, King's College Hospital, London, UK
| | - Paolo Buscemi
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University Hospital of Palermo, Palermo, Italy
| | - Debora Cidoni
- Department of Radiology, School of Medicine, Papa Giovanni XXIII Hospital, University Milano Bicocca, Bergamo, Italy
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de Silva AP, Niriella MA, Nishad N, Jayasundara H, Jayasena H, Samarawickrama VT, Ranawaka C, Basnayake K, de Silva ST, de Silva HJ. Splenic Stiffness Measurement Combined With Liver Stiffness Measurement Compared With Baveno VII Criteria in Predicting the Presence of Oesophageal and Gastric Varices in Patients With Compensated Advanced Liver Cell Disease (cALCD). Cureus 2024; 16:e65954. [PMID: 39221371 PMCID: PMC11365573 DOI: 10.7759/cureus.65954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) is being increasingly used as a screening tool to predict varices. Our aim was to test the utility of Baveno VII criteria and other combinations of LSM, platelet count (PC), and splenic stiffness measurement (SSM) to predict the presence of varices in a cohort of Sri Lankan patients with compensated advanced liver cell disease (cALCD). METHODS Consecutive patients with newly diagnosed Child-Pugh class A cALCD (non-viral, BMI<30) were recruited prospectively. They underwent gastroscopy. LSM and SSM were taken using vibration-controlled transient elastography (VCTE) (Echosens FibroScan 502 Touch; Echosens SA, Paris, France) by a single operator who was unaware of endoscopy findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of different Baveno VII criteria to predict the varices and different combinations of LSM, SSM, and PC were also explored. RESULTS One hundred and seventy-four individuals were recruited. The mean age was 61.4 ((95% CI: 59.7-62.8) years. A total of 110 individuals were males, and 106 had varices. Our results indicated that the three Baveno VII criteria had sensitivities of 61%, 63%, and 42%, and specificities of 79%, 77%, and 87% to predict varices. SSM>30kPa alone and in combination with LSM>15kPa had sensitivities of 81 and 75%, specificities of 72 and 83%, PPVs of 82 and 87%, NPVs of 71% and 67%, and accuracies of 78 and 78%, respectively, to predict varices. CONCLUSION Baveno VII criteria had a low sensitivity but high specificity in predicting the presence of varices. However, SSM>30kPa alone or in combination with LSM>15kPa had better sensitivity, specificity, PPV, NPV, and accuracy in predicting varices.
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Affiliation(s)
- Arjuna P de Silva
- Department of Medicine, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Madunil A Niriella
- Department of Medicine, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Nilanga Nishad
- Gastroenterology and Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, GBR
| | - Hishali Jayasundara
- Department of Gastroenterology, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Hiruni Jayasena
- Department of Medicine, Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, LKA
| | - Vajira T Samarawickrama
- Department of Gastroenterology and Hepatology, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Chamila Ranawaka
- Department of Gastroenterology and Hepatology, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Kumarini Basnayake
- Gastroenterology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, GBR
| | - Shamila T de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, LKA
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Atsukawa M, Tsubota A, Kondo C, Toyoda H, Takaguchi K, Nakamuta M, Watanabe T, Morishita A, Tani J, Okubo H, Hiraoka A, Nozaki A, Chuma M, Kawata K, Uojima H, Ogawa C, Asano T, Mikami S, Kato K, Matsuura K, Ikegami T, Ishikawa T, Tsuji K, Tada T, Tsutsui A, Senoh T, Kitamura M, Okubo T, Arai T, Kohjima M, Morita K, Akahane T, Nishikawa H, Iwasa M, Tanaka Y, Iwakiri K. ALBI score predicts morphological changes in esophageal varices following direct-acting antiviral-induced sustained virological response in patients with liver cirrhosis. J Gastroenterol 2024; 59:709-718. [PMID: 38727822 DOI: 10.1007/s00535-024-02109-8] [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: 11/07/2023] [Accepted: 04/21/2024] [Indexed: 07/29/2024]
Abstract
BACKGROUND This study aimed to clarify the morphological changes in esophageal varices after achieving sustained virological response (SVR) with direct-acting antivirals (DAAs) in patients with cirrhosis. METHODS A total of 243 patients underwent esophagogastroduodenoscopy before DAA treatment and after achieving SVR. Morphological changes in esophageal varices were investigated using esophagogastroduodenoscopy. RESULTS This study comprised 125 males and 118 females with a median age of 68 years. Esophageal varices at baseline were classified into no varix in 155 (63.8%), F1 in 59 (24.3%), F2 in 25 (10.3%) and F3 in 4 (1.6%) patients. The improvement, unchanged, and aggravation rates of esophageal varices after SVR were 11.9%, 73.3%, and 14.8%, respectively. High ALBI score at SVR12 was an independent factor associated with post-SVR esophageal varices aggravation (p = 0.045). Time-dependent receiver operating characteristic (ROC) curve analysis revealed a cut-off value of - 2.33 for ALBI score at SVR12 in predicting post-SVR esophageal varices aggravation. Of the 155 patients without esophageal varices at baseline, 17 developed de novo post-SVR esophageal varices. High ALBI score at SVR12 was a significant independent factor associated with de novo post-SVR esophageal varices (p = 0.046). ROC curve analysis revealed a cut-off value of - 2.65 for ALBI score at SVR12 in predicting de novo post-SVR esophageal varices. CONCLUSIONS Patients with cirrhosis can experience esophageal varices aggravation or de novo esophageal varices, despite achieving SVR. In particular, patients with high ALBI score at SVR12 have a high likelihood of developing post-SVR esophageal varices aggravation or de novo post-SVR esophageal varices.
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Affiliation(s)
- Masanori Atsukawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, Japan.
| | - Akihito Tsubota
- Project Research Units (PRU) Research Center for Medical Science, The Jikei University School of Medicine, Tokyo, Japan
| | - Chisa Kondo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan
| | - Koichi Takaguchi
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Makoto Nakamuta
- National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Tsunamasa Watanabe
- Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Asahiro Morishita
- Department of Gastroenterology, Kagawa University Graduate School of Medicine, Kagawa, Japan
| | - Joji Tani
- Department of Gastroenterology, Kagawa University Graduate School of Medicine, Kagawa, Japan
| | - Hironao Okubo
- Department of Gastroenterology, Juntendo Nerima University Hospital, Tokyo, Japan
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Akito Nozaki
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Makoto Chuma
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kazuhito Kawata
- Hepatology Division, Department of Internal Medicine II, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Chikara Ogawa
- Department of Gastroenterology and Hepatology, Takamatsu Red Cross Hospital, Takamatsu, Japan
| | - Toru Asano
- Department of Internal Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Shigeru Mikami
- Department of Internal Medicine, Division of Gastroenterology, Kikkoman General Hospital, Noda, Japan
| | - Keizo Kato
- Division of Gastroenterology and Hepatology, Shinmatusdo Central General Hospital, Matsudo, Japan
| | - Kentaro Matsuura
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Tadashi Ikegami
- Division of Hepatology and Gastroenterology, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Toru Ishikawa
- Department of Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Kunihiko Tsuji
- Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Toshifumi Tada
- Department of Internal Medicine, Japanese Red Cross Himeji Hospital, Hygo, Japan
| | - Akemi Tsutsui
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Tomonori Senoh
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Michika Kitamura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Tomomi Okubo
- Department of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Taeang Arai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, Japan
| | - Motoyuki Kohjima
- National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kiyoshi Morita
- Department of Gastroenterology, Toyota Kosei Hospital, Toyota, Japan
| | - Takehiro Akahane
- Department of Gastroenterology, Japanese Red Cross Ishinomaki Hospital, Miyagi, Japan
| | - Hiroki Nishikawa
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology, Mie University School of Medicine, Mie, Japan
| | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Katsuhiko Iwakiri
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, Japan
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Yang TC, Chen WC, Hou MC, Chen PH, Lee PC, Chang CY, Lu HS, Chen YJ, Hsu SJ, Huang HC, Luo JC, Huang YH, Lee FY. Endoscopic variceal ligation versus propranolol for the primary prevention of oesophageal variceal bleeding in patients with hepatocellular carcinoma: an open-label, two-centre, randomised controlled trial. Gut 2024; 73:682-690. [PMID: 38123994 DOI: 10.1136/gutjnl-2023-330419] [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: 06/04/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE This randomised trial aimed to address whether endoscopic variceal ligation (EVL) or propranolol (PPL) is more effective at preventing initial oesophageal variceal bleeding (EVB) in patients with hepatocellular carcinoma (HCC). DESIGN Patients with HCC and medium-to-large oesophageal varices (EVs) but without previous EVB were randomised to receive EVL (every 3-4 weeks until variceal eradication) or PPL (up to 320 mg daily) at a 1:1 ratio. Long-term follow-up data on EVB, other upper gastrointestinal bleeding (UGIB), non-bleeding liver decompensation, overall survival (OS) and adverse events (AEs) were analysed using competing risk regression. RESULTS Between June 2011 and April 2021, 144 patients were randomised to receive EVL (n=72) or PPL (n=72). In the EVL group, 7 patients experienced EVB, and 30 died; in the PPL group, 19 patients had EVB, and 40 died. The EVL group had a lower cumulative incidence of EVB (Gray's test, p=0.009) than its counterpart, with no mortality difference (Gray's test, p=0.085). For patients with Barcelona Clinic Liver Cancer (BCLC) stage A/B, EVL was better than PPL in reducing EVB (p<0.001) and mortality (p=0.003). For patients beyond BCLC stage B, between-group outcomes were similar. Other UGIB, non-bleeding liver decompensation and AEs did not differ between groups. A competing risk regression model confirmed the prognostic value of EVL. CONCLUSION EVL is superior to PPL in preventing initial EVB in patients with HCC. The benefits of EVL on EVB and OS may be limited to patients with BCLC stage A/B and not to those with BCLC stage C/D. TRIAL REGISTRATION NUMBER NCT01970748.
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Affiliation(s)
- Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Chi Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Post-Baccalaureate Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ping-Hsien Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, West Garden Hospital, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Yu Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiao-Sheng Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shao-Jung Hsu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Chun Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiing-Chyuan Luo
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Yauh Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
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Ali K, Slah-Ud-Din S, Afzal M, Tariq MR, Waheed T, Yousuf H. Non-invasive Fibrosis Markers for Predicting Esophageal Varices: A Potential Alternative to Endoscopic Screening. Cureus 2024; 16:e56433. [PMID: 38638761 PMCID: PMC11024663 DOI: 10.7759/cureus.56433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Chronic liver infections and diseases lead to chronic liver injury, which results in fibrosis. Due to this continuous scarring and regeneration, cirrhosis occurs, which is also responsible for several adverse sequelae, including but not limited to esophageal varices. Cirrhosis has resulted in patients' increased morbidity and mortality, especially in low socioeconomic settings such as Pakistan. Endoscopy is the gold standard for measuring the presence or absence of esophageal varices, along with their grade. Currently, some non-invasive markers (aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), fibrosis 4 (FIB-4), AAR to platelet ratio index (AARPRI), aspartate aminotransferase-to-platelet ratio index (APRI), S-index, King's score) are being established that make use of laboratory tests, such as a complete blood profile, liver function profile, and coagulation profile, to estimate the extent of hepatic fibrosis. OBJECTIVES The objective of this study is to establish a correlation between non-invasive markers of fibrosis and the presence of esophageal varices and to assess their potential as a substitute for gastrointestinal endoscopy screening. Additionally, the study aims to compare these six scores, thereby generating data on their individual and relative accuracy. METHODOLOGY This was a cross-sectional study conducted at the Shalamar Institute of Health Sciences, Lahore, Pakistan. Outpatient (OPD) data were obtained from the Shalamar online portal system from June 2022 to December 2022. Laboratory tests, abdominal ultrasounds, and endoscopy results were accessed and recorded in the questionnaire. The patient's medical records and contact numbers were also noted in case further questions arose. Data were then compiled into a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA) and analyzed after computing the non-invasive procedure formulas. It was analyzed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY). P-values were calculated, and conclusions were drawn. RESULTS Of the sample size of 100 patients with liver damage and injury, 60% were male and 40% were female. Among males, 15% had a milder (grade 1) degree of esophageal varices, and 45% had a moderate to advanced degree (grades 2-3) of esophageal varices. Among females, 19% had mild (grade 1) varices, while 21% had severe (grade 3) varices. The most common cause of varices in patients who had developed fibrosis and/or cirrhosis was hepatitis C, with a wide margin of other causes. The p-values obtained showed that from the selected list of non-invasive markers of fibrosis, only FIB-4 and AARPRI were statistically significant with p-values of 0.036 and 0.022, respectively. PRACTICAL IMPLICATIONS Though endoscopy is currently the gold-standard procedure for detecting the presence or absence and grade of esophageal varices, it is invasive, which makes the patients extremely uncomfortable and apprehensive. It can also lead to post-procedure infection, internal hemorrhages, and trauma due to instrument use. Due to its invasive nature, some patients also tend to refuse this procedure. Non-invasive fibrosis markers can help make a diagnosis without undergoing an endoscopy, which in turn will improve patient compliance and satisfaction. CONCLUSION It was observed that FIB-4 and AARPRI can be used together as reliable markers to assess the presence or absence of esophageal varices.
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Affiliation(s)
- Kunza Ali
- Medicine and Surgery, Shalamar Medical & Dental College, Lahore, PAK
| | - Saad Slah-Ud-Din
- Internal Medicine, Shalamar Medical & Dental College, Lahore, PAK
| | | | - Mah R Tariq
- Graduate Medical Education, Combined Military Hospital (CMH) Lahore Medical College and Institute of Dentistry, Lahore, PAK
| | - Tallha Waheed
- Internal Medicine, Combined Military Hospital (CMH) Lahore Medical College and Institute of Dentistry, Lahore, PAK
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Gu W, Zeleke Y, Hortlik H, Schaaf L, Uschner FE, Schulz M, Tischendorf M, Peiffer KH, Brol MJ, Kimmann M, Vogl T, Köhler M, Meyer C, Gerbes A, Rössle M, Laleman W, Zipprich A, Steib C, Praktiknjo M, Trebicka J. Use and outcome of TIPS in hospitalized patients in Germany: A Nationwide study (2007-2018). Hepatol Commun 2023; 7:e0237. [PMID: 37708430 PMCID: PMC10503680 DOI: 10.1097/hc9.0000000000000237] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/14/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The number of complications in patients admitted for cirrhosis has increased over time. Portal hypertension is the driver of many complications of cirrhosis. TIPS placement is the most effective treatment of portal hypertension. The aim of this study was to analyze the use and impact of TIPS placement in the last decade in a nationwide study in Germany. METHODS We analyzed 14,598 admissions of patients for TIPS insertions in Germany from 2007 to 2018 using the DRG system, 12,877 out of 2,000,765 total admissions of patients with cirrhosis. All diagnoses and procedures were coded according to ICD-10-CM and OPS codes. The data were analyzed, focusing on the number of admissions and in-hospital mortality. RESULTS The number of TIPS placements increased over the last decade. In-hospital mortality of cirrhotic patients with TIPS decreased when it was placed for severe bleeding (15.2% [TIPS] vs. 19.5% [endoscopy treatment]), ascites (8.7% [TIPS] vs. 14.4% [paracentesis]), and hepatorenal syndrome (HRS) (17.1% [TIPS] vs. 43.3% [no-TIPS]). In the case of bleeding, TIPS significantly decreased in-hospital mortality and also in ascites and HRS. During hospitalization, 22.6% admissions of patients with TIPS insertion showed HE. However, in-hospital mortality in patients admitted with HE grades 1 or 2 and TIPS was lower than in patients without TIPS. In the logistic regression, a higher HE grade(3 and 4), infection, and circulatory disease were found to be independently associated with in-hospital mortality in patients with TIPS insertion. CONCLUSION Our nationwide study demonstrates that TIPS insertion is increasingly used in Germany. TIPS improves outcomes, especially in patients with ascites and HRS, regardless of lower HE grades, while higher HE grades, infection, and circulatory diseases seem to be associated with risk of in-hospital mortality.
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Affiliation(s)
- Wenyi Gu
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Yasmin Zeleke
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Hannah Hortlik
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Louisa Schaaf
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Frank E. Uschner
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Martin Schulz
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Kai-Henrik Peiffer
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Thomas Vogl
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Köhler
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Carsten Meyer
- Clinic for Radiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Martin Rössle
- Department of Internal Medicine II, Faculty of Medicine, Medical Centre University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wim Laleman
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexander Zipprich
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christian Steib
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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Header DA, Ellakany WI, Ellakany AI. Fecal calprotectin level as a marker of esophageal varices in Egyptian HCV cirrhotic patients. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:333-340. [PMID: 35810088 DOI: 10.1016/j.rgmxen.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION AND AIM Esophageal varices are one of the complications of portal hypertension in cirrhotic patients that lead to high morbidity and mortality. Our aim was to assess the fecal calprotectin (FC) level in Egyptian cirrhotic patients as a non-invasive marker for the presence of esophageal varices. MATERIALS AND METHODS The current study included 250 participants in the period from June 2019 to November 2020, divided into three groups: group 1: 100 HCV cirrhotic patients with esophageal varices that would then be subdivided, according to the Paquet classification; group 2: 100 HCV cirrhotic patients without esophageal varices; group 3: 50 normal age and sex-matched healthy subjects as the control group. Patients with other causes of abnormal calprotectin results were excluded. RESULTS The comparison of FC in the three study groups revealed a statistically significant difference, with FC levels higher in groups 1 and 2 (mean 66.4±10.41 and 48.4±10.92, respectively). There was a significant difference in FC levels between the subgroups, subdivided according to the Paquet classification (P=.001). FC levels were higher in the grade III and IV subgroups. FC in the diagnosis of HCV cirrhotic patients with esophageal varices showed the best performance when the cut-off value was >55; AUC was 0.918, with 92% sensitivity, 95% specificity, and 93% accuracy. CONCLUSION FC levels serve as a screening tool for esophageal varices. FC was higher in cirrhotic patients with esophageal varices, especially in the grade III and IV subgroups, according to the Paquet classification.
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Affiliation(s)
- D A Header
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Alejandría, Alejandría, Egypt.
| | - W I Ellakany
- Departamento de Medicina Tropical, Facultad de Medicina, Universidad de Alejandría, Alejandría, Egypt
| | - A I Ellakany
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Alejandría, Alejandría, Egypt
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Baldisseri F, Wrona A, Menegatti D, Pietrabissa A, Battilotti S, Califano C, Cristofaro A, Di Giamberardino P, Facchinei F, Palagi L, Giuseppi A, Delli Priscoli F. Deep Neural Network Regression to Assist Non-Invasive Diagnosis of Portal Hypertension. Healthcare (Basel) 2023; 11:2603. [PMID: 37761800 PMCID: PMC10530845 DOI: 10.3390/healthcare11182603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
Portal hypertension is a complex medical condition characterized by elevated blood pressure in the portal venous system. The conventional diagnosis of such disease often involves invasive procedures such as liver biopsy, endoscopy, or imaging techniques with contrast agents, which can be uncomfortable for patients and carry inherent risks. This study presents a deep neural network method in support of the non-invasive diagnosis of portal hypertension in patients with chronic liver diseases. The proposed method utilizes readily available clinical data, thus eliminating the need for invasive procedures. A dataset composed of standard laboratory parameters is used to train and validate the deep neural network regressor. The experimental results exhibit reasonable performance in distinguishing patients with portal hypertension from healthy individuals. Such performances may be improved by using larger datasets of high quality. These findings suggest that deep neural networks can serve as useful auxiliary diagnostic tools, aiding healthcare professionals in making timely and accurate decisions for patients suspected of having portal hypertension.
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Affiliation(s)
- Federico Baldisseri
- Department of Computer, Control and Management Engineering (DIAG), University of Rome “La Sapienza”, Via Ariosto 25, 00185 Rome, Italy; (A.W.); (D.M.); (A.P.); (S.B.); (C.C.); (A.C.); (P.D.G.); (F.F.); (L.P.); (A.G.); (F.D.P.)
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9
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Dantas Machado AC, Ramos SF, Gauglitz JM, Fassler AM, Petras D, Aksenov AA, Kim UB, Lazarowicz M, Barnard Giustini A, Aryafar H, Vodkin I, Warren C, Dorrestein PC, Zarrinpar A, Zarrinpar A. Portosystemic shunt placement reveals blood signatures for the development of hepatic encephalopathy through mass spectrometry. Nat Commun 2023; 14:5303. [PMID: 37652904 PMCID: PMC10471626 DOI: 10.1038/s41467-023-40741-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/09/2023] [Indexed: 09/02/2023] Open
Abstract
Elective transjugular intrahepatic portosystemic shunt (TIPS) placement can worsen cognitive dysfunction in hepatic encephalopathy (HE) patients due to toxins, including possible microbial metabolites, entering the systemic circulation. We conducted untargeted metabolomics on a prospective cohort of 22 patients with cirrhosis undergoing elective TIPS placement and followed them up to one year post TIPS for HE development. Here we suggest that pre-existing intrahepatic shunting predicts HE severity post-TIPS. Bile acid levels decrease in the peripheral vein post-TIPS, and the abundances of three specific conjugated di- and tri-hydroxylated bile acids are inversely correlated with HE grade. Bilirubins and glycerophosphocholines undergo chemical modifications pre- to post-TIPS and based on HE grade. Our results suggest that TIPS-induced metabolome changes can impact HE development, and that pre-existing intrahepatic shunting could be used to predict HE severity post-TIPS.
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Affiliation(s)
| | - Stephany Flores Ramos
- Division of Gastroenterology and Hepatology, University of California, San Diego, La Jolla, CA, USA
- Biomedical Sciences Graduate Program, University of California, San Diego, La Jolla, CA, USA
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA
| | - Julia M Gauglitz
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Anne-Marie Fassler
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Daniel Petras
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
- CMFI Cluster of Excellence, Interfaculty Institute of Microbiology and Infection Medicine, University of Tübingen, Tübingen, Germany
| | - Alexander A Aksenov
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
- Department of Chemistry, University of Connecticut, Storrs, CT, USA
| | - Un Bi Kim
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael Lazarowicz
- Department of Radiology, Division of Interventional Radiology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Abbey Barnard Giustini
- Division of Gastroenterology and Hepatology, University of California, San Diego, La Jolla, CA, USA
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sounds Health Care System, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Hamed Aryafar
- San Diego Imaging, San Diego, CA, USA
- Departments of Radiology, University of California San Diego Medical Center, La Jolla, CA, USA
| | - Irine Vodkin
- Division of Gastroenterology and Hepatology, University of California, San Diego, La Jolla, CA, USA
| | - Curtis Warren
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Pieter C Dorrestein
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
- Center for Microbiome Innovation, University of California, San Diego, La Jolla, CA, USA
- Department of Computer Science and Engineering, University of California, San Diego, La Jolla, CA, USA
- Center for Computational Mass Spectrometry, University of California, San Diego, La Jolla, CA, USA
| | - Ali Zarrinpar
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA.
- Department of Biochemistry and Molecular Biology, College of Medicine, University of Florida, Gainesville, FL, USA.
- J. Crayton Pruitt Family Department of Biomedical Engineering, Herbert Wertheim College of Engineering, University of Florida, Gainesville, FL, USA.
| | - Amir Zarrinpar
- Division of Gastroenterology and Hepatology, University of California, San Diego, La Jolla, CA, USA.
- Center for Microbiome Innovation, University of California, San Diego, La Jolla, CA, USA.
- Jennifer Moreno Department of Veterans Affairs Medical Center, La Jolla, CA, USA.
- Institute of Diabetes and Metabolic Health, University of California, San Diego, La Jolla, CA, USA.
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10
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Miller A, Bernshteyn M, Achakzai B, Macfie R. Closure of a distal splenorenal shunt as a therapy for refractory hyperammonaemia in setting of neuropsychiatric symptoms. BMJ Case Rep 2023; 16:e255610. [PMID: 37591624 PMCID: PMC10441096 DOI: 10.1136/bcr-2023-255610] [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: 08/19/2023] Open
Abstract
Before the widespread use of the transjugular intrahepatic portosystemic shunt, portal hypertension was addressed by the creation of an operative distal splenorenal shunt (DSRS). DSRS was largely regarded as a safe and effective therapy, though it did have a risk of precipitating hyperammonaemia and hepatic encephalopathy.A woman suffered a gunshot wound to the abdomen. This trauma led to portal vein thrombosis, cavernous transformation of the vein and eventually bleeding oesophageal varices from portal hypertension. A DSRS was created to decrease portal hypertension. Years later, she had profound depression with psychomotor slowing in the setting of hyperammonaemia. To reduce hepatic encephalopathy as a contributor to her neuropsychiatric condition, her shunt was closed. The hyperammonaemia resolved and neuropsychiatric symptoms improved.This case highlights several interesting clinical features, including portal hypertension due to chronic portal vein occlusion, cavernous transformation, a surgical DSRS causing hyperammonaemia and hepatic encephalopathy manifesting as neuropsychiatric symptoms.
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Affiliation(s)
- Alexander Miller
- Department of Gastroenterology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Michelle Bernshteyn
- Department of Gastroenterology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Basit Achakzai
- Department of Interventional Radiology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Rebekah Macfie
- Department of Surgical Oncology, Guthrie Robert Packer Hospital, Sayre, PA, USA
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11
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Isaak A, Chang J, Mesropyan N, Kravchenko D, Endler C, Bischoff L, Böhling N, Pieper CC, Kuetting D, Strassburg CP, Attenberger U, Jansen C, Praktiknjo M, Luetkens JA. Cardiac involvement in non-cirrhotic portal hypertension: MRI detects myocardial fibrosis and oedema similar to compensated cirrhosis. Eur Heart J Cardiovasc Imaging 2023; 24:949-960. [PMID: 36423215 DOI: 10.1093/ehjci/jeac235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/04/2022] [Indexed: 08/03/2023] Open
Abstract
AIMS The exact role of portal hypertension in cirrhotic cardiomyopathy remains unclear, and it is uncertain whether cardiac abnormalities also occur in non-cirrhotic portal hypertension (NCPH). This magnetic resonance imaging (MRI) study aimed to evaluate the presence of subclinical myocardial dysfunction, oedema, and fibrosis in NCPH. METHODS AND RESULTS In this prospective study (2018-2022), participants underwent multiparametric abdominal and cardiac MRI including assessment of cardiac function, myocardial oedema, late gadolinium enhancement (LGE), and abdominal and cardiac mapping [T1 and T2 relaxation times, extracellular volume fraction (ECV)]. A total of 111 participants were included [44 participants with NCPH (48 ± 15 years; 23 women), 47 cirrhotic controls, and 20 healthy controls]. The cirrhotic group was dichotomized (Child A vs. Child B/C). NCPH participants demonstrated a more hyperdynamic circulation compared with healthy controls (cardiac index: 3.7 ± 0.6 vs. 3.2 ± 0.8 L/min/m², P = 0.004; global longitudinal strain: -27.3 ± 4.6 vs. -24.6 ± 3.5%, P = 0.022). The extent of abnormalities indicating myocardial fibrosis and oedema in NCPH was comparable with Child A cirrhosis (e.g. LGE presence: 32 vs. 33 vs. 69%, P = 0.004; combined T1 and T2 elevations: 46 vs. 27 vs. 69%, P = 0.017; NCPH vs. Child A vs. Child B/C). Correlations between splenic T1 and myocardial T1 values were found (r = 0.41; P = 0.007). Splenic T1 values were associated with the presence of LGE (odds ratio, 1.010; 95% CI: 1.002, 1.019; P = 0.013). CONCLUSION MRI parameters of myocardial fibrosis and oedema were altered in participants with NCPH to a similar extent as in compensated cirrhosis and were associated with splenic markers of portal hypertension, indicating specific portal hypertensive cardiomyopathy.
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Affiliation(s)
- Alexander Isaak
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Narine Mesropyan
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Dmitrij Kravchenko
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Christoph Endler
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Leon Bischoff
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Nina Böhling
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Claus C Pieper
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Daniel Kuetting
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Ulrike Attenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Julian A Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
- Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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12
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Zhu W, Wang X, Lv Y, Chen H, Chen X, Li X, Zhu S, Lin Z, Wang G. Comparison of long-term outcomes of splenectomy with periesophagogastric devascularization and transjugular intrahepatic portosystemic shunt in treating cirrhotic portal hypertension patients with recurrent variceal bleeding. Langenbecks Arch Surg 2023; 408:215. [PMID: 37247018 PMCID: PMC10227160 DOI: 10.1007/s00423-023-02933-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/07/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) and splenectomy with periesophagogastric devascularization (SPD) are widely used to treat cirrhotic portal hypertension (PH) and prevent variceal rebleeding. However, direct comparisons between these two approaches are rare. This study was designed to compare the long-term outcomes of TIPS and SPD in patients with cirrhotic PH and variceal rebleeding. METHODS The study included cirrhotic PH patients with a history of gastroesophageal variceal bleeding between 18 and 80 years of age who were admitted to the Third Affiliated Hospital of Sun Yat-sen University from January 2012 to January 2022. Patients were enrolled into two groups according to TIPS or SPD was performed. Baseline characteristics were matched using propensity score matching (PSM). RESULTS A total of 230 patients underwent TIPS, while 184 underwent SPD. PSM was carried out to balance available covariates, resulting in a total of 83 patients in the TIPS group and 83 patients in the SPD group. Patients in SPD group had better liver function during 60 months follow-up. Five-year overall survival rates in SPD group and TIPS group were 72 and 27%, respectively, at 2 years were 88 and 86%, respectively. The 2- and 5-year freedom from variceal rebleeding rates were 95 and 80% in SPD group and 80 and 54% in TIPS group. CONCLUSIONS SPD is clearly superior to TIPS in terms of OS and freedom from variceal rebleeding in patients with cirrhotic PH. In addition, SPD improved liver function in patients with cirrhotic PH.
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Affiliation(s)
- Wenfeng Zhu
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xiaowen Wang
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Yun Lv
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
| | - Haoqi Chen
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xiaolong Chen
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xuejiao Li
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Shuguang Zhu
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Zexin Lin
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
| | - Genshu Wang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510630, China.
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China.
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Díaz LA, Pages J, Mainardi V, Mendizabal M. Inpatient Hepatology Consultation. Med Clin North Am 2023; 107:555-565. [PMID: 37001953 DOI: 10.1016/j.mcna.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Cirrhosis is the end-stage of chronic liver disease and constitutes a leading cause of potential years of working life lost, especially in the Americas and Europe. Its natural history is characterized by an asymptomatic phase called compensated cirrhosis, followed by a rapidly progressive phase characterized by liver-related complications termed decompensated cirrhosis. Complications could be related to portal hypertension and/or liver dysfunction, including ascites, portal hypertensive gastrointestinal bleeding, encephalopathy, and jaundice. This review will discuss some of the most important precipitants of hepatic decompensation, including acute variceal bleeding, spontaneous bacterial peritonitis, and hepatic encephalopathy.
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14
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Dantas Machado AC, Ramos SF, Gauglitz JM, Carpenter AM, Petras D, Aksenov AA, Kim UB, Lazarowicz M, Giustini AB, Aryafar H, Vodkin I, Warren C, Dorrestein PC, Zarrinpar A, Zarrinpar A. Pre- and Post-Portosystemic Shunt Placement Metabolomics Reveal Molecular Signatures for the Development of Hepatic Encephalopathy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.02.22281374. [PMID: 36711444 PMCID: PMC9882439 DOI: 10.1101/2023.01.02.22281374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hepatic encephalopathy (HE) is a common complication of advanced liver disease causing brain dysfunction. This is likely due to the accumulation of unfiltered toxins within the bloodstream. A known risk factor for developing or worsening HE is the placement of a transjugular intrahepatic portosystemic shunt (TIPS), which connects the pre-hepatic and post-hepatic circulation allowing some blood to bypass the dysfunctional liver and decreases portal hypertension. To better understand the pathophysiology of post-TIPS HE, we conducted a multi-center prospective cohort study employing metabolomic analyses on hepatic vein and peripheral vein blood samples from participants with cirrhosis undergoing elective TIPS placement, measuring chemical modifications and changes in concentrations of metabolites resulting from TIPS placement. In doing so, we identified numerous alterations in metabolites, including bile acids, glycerophosphocholines, and bilirubins possibly implicated in the development and severity of HE.
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15
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Insight into microvascular adaptive alterations in the Glisson system of biliary atresia after Kasai portoenterostomy using X-ray phase-contrast CT. Eur Radiol 2022; 33:4082-4093. [PMID: 36576546 DOI: 10.1007/s00330-022-09364-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/20/2022] [Accepted: 12/05/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To investigate microvascular alterations in the Glisson system of biliary atresia (BA) patients after Kasai portoenterostomy (KP) using three-dimensional (3D) virtual histopathology based on X-ray phase-contrast CT (PCCT). METHODS Liver explants from BA patients were imaged using PCCT, and 32 subjects were included and divided into two groups: KP (n = 16) and non-KP (n = 16). Combined with histological analysis and 3D visualization technology, 3D virtual histopathological assessment of the biliary, arterial, and portal venous systems was performed. According to loop volume ratio, 3D spatial density, relative surface area, tortuosity, and other parameters, pathological changes of microvasculature in the Glisson system were investigated. RESULTS In the non-KP group, bile ducts mostly manifested as radial multifurcated hyperplasia and twisted into loops. In the KP group, the bile duct hyperplasia was less, and the loop volume ratio of bile ducts decreased by 13.89%. Simultaneously, the arterial and portal venous systems presented adaptive alterations in response to degrees of bile duct hyperplasia. Compared with the non-KP group, the 3D spatial density of arteries in the KP group decreased by 3.53%, and the relative surface area decreased from 0.088 ± 0.035 to 0.039 ± 0.015 (p < .01). Deformed portal branches gradually recovered after KP, with a 2.93% increase in 3D spatial density and a decrease in tortuosity from 1.17 ± 0.06 to 1.14 ± 0.04 (p < .01) compared to the non-KP group. CONCLUSION 3D virtual histopathology via PCCT clearly reveals the microvascular structures in the Glisson system of BA patients and provides key insights into the morphological mechanism of microvascular adaptation induced by biliary tract dredging after KP in BA disease. KEY POINTS • 3D virtual histopathology via X-ray phase-contrast computed tomography clearly presented the morphological structures and pathological changes of microvasculature in the Glisson system of biliary atresia patients. • The morphological alterations of microvasculature in the Glisson system followed the competitive occupancy mechanism in the process of biliary atresia.
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Maruyama H, Tobari M, Nagamatsu H, Shiina S, Yamaguchi T. Contrast-enhanced ultrasonography for the management of portal hypertension in cirrhosis. Front Med (Lausanne) 2022; 9:1057045. [PMID: 36590972 PMCID: PMC9794740 DOI: 10.3389/fmed.2022.1057045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
Portal hypertension is a major pathophysiological condition in patients with cirrhosis. This accounts for the occurrence and severity of the various manifestations. The degree is determined by the portal pressure or hepatic venous pressure gradients, both of which are obtained by invasive interventional radiological procedures. Ultrasound (US) is a simple and minimally invasive imaging modality for the diagnosis of liver diseases. Owing to the availability of microbubble-based contrast agents and the development of imaging modes corresponding to contrast effects, contrast-enhanced US (CEUS) has become popular worldwide for the detailed evaluation of hepatic hemodynamics, diffuse liver disease, and focal hepatic lesions. Recent advancements in digital technology have enabled contrast-based demonstrations with improved resolution, leading to a wider range of applications. This review article describes the current role, benefits, and limitations of CEUS in the management of portal hypertension.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, Tokyo, Japan,*Correspondence: Hitoshi Maruyama
| | - Maki Tobari
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | | | - Suichiro Shiina
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Tadashi Yamaguchi
- Center for Frontier Medical Engineering, Chiba University, Chiba, Japan
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17
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Sakiani S, Heller T, Koh C. Current and investigational drugs in early clinical development for portal hypertension. Front Med (Lausanne) 2022; 9:974182. [PMID: 36300180 PMCID: PMC9589453 DOI: 10.3389/fmed.2022.974182] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The development of portal hypertension leads to a majority of complications associated with chronic liver disease. Therefore, adequate treatment of portal hypertension is crucial in the management of such patients. Current treatment options are limited and consist mainly of medications that decrease the hyperdynamic circulation, such as non-selective beta blockers, and treatment of hypervolemia with diuretics. Despite these options, mortality rates have not improved over the last two decades. Newer, more effective treatment options are necessary to help improve survival and quality of life in these patients. Areas covered Multiple preclinical models and clinical studies have demonstrated potential efficacy of a variety of new treatment modalities. We introduce treatment options including the use of vasodilation promotors, vasoconstriction inhibitors, anticoagulants, antiangiogenics, and anti-inflammatory drugs. We examine the most recent studies for treatment options within these drug classes and offer insights as to which show the most promise in this field. Methodology Published studies that identified novel medical treatment options of portal hypertension were searched using PubMed (https://pubmed.ncbi.nlm.nih.gov/). Clinical trials listed in Clinicaltrials.gov were also searched with a focus on more recent and ongoing studies, including those with completed recruitment. Searching with key terms including "portal hypertension" as well as individually searching specific treatment medications that were listed in other publications was carried out. Finally, current societal guidelines and recent review articles relevant to the management of portal hypertension were evaluated, and listed references of interest were included. Conclusion Many ongoing early phase studies demonstrate promising results and may shape the field of portal hypertension management in future. As concrete results become available, larger RCTs will be required before making definitive conclusions regarding safety and efficacy and whether or not they can be incorporated into routine clinical practice. Statins, anticoagulants, and PDE inhibitors have been among the most studied and appear to be most promising.
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Affiliation(s)
- Sasan Sakiani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Baltimore, MD, United States
| | - Theo Heller
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Christopher Koh
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
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Rajakannu M, Coilly A, Cherqui D, Cunha AS, Castaing D, Adam R, Samuel D, Vibert E. Liver stiffness-based model predicts hepatic venous pressure gradient in patients with liver disease. HPB (Oxford) 2022; 24:1796-1803. [PMID: 35504833 DOI: 10.1016/j.hpb.2021.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/31/2021] [Accepted: 11/07/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim was to develop a model to predict clinically significant portal hypertension, hepatic venous pressure gradient (HVPG) ≥10 mmHg using pre-operative noninvasive makers. METHODS Patients who have been programmed for liver resection/transplantation were enrolled prospectively. Preoperative liver stiffness measurement (LSM), liver function test (LFT), and intraoperative HVPG were assessed. A probability score model to predict HVPG≥10 mmHg called HVPG10 score was developed and validated. RESULTS A total of 161 patients [66% men, median age of 63 years] were recruited for the study. Median LSM, and HVPG were 9.5 kPa, and 5 mmHg respectively. HVPG10 score was developed using independent predictors of HVPG≥10 mmHg in the training set were LSM, total bilirubin, alkaline phosphatase, and international normalized ratio. Area under receiver operating curve of HVPG10 score in the training and validation sets were 0.91 and 0.93 respectively with a cutoff of 15. In the overall cohort, HVPG10 score≥15 had 83% accuracy, 90% sensitivity, 81% specificity and 96% negative predictive value in predicting HVPG≥10 mmHg. CONCLUSION HVPG10 score is an easy-to-use noninvasive continuous scale tool to rule out clinically significant portal hypertension in >95% patients with chronic liver disease.
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Affiliation(s)
- Muthukumarassamy Rajakannu
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Audrey Coilly
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Denis Castaing
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - René Adam
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Inserm, Unité UMR-S 776, Villejuif, France
| | - Didier Samuel
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Eric Vibert
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France.
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19
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Morrow MK, Gonzalez RS. Gastric Histopathologic Findings Are Similar in Portal Hypertension Patients With and Without Endoscopic Portal Hypertensive Gastropathy. Am J Clin Pathol 2022; 158:632-638. [PMID: 36124648 DOI: 10.1093/ajcp/aqac098] [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: 04/25/2022] [Accepted: 07/12/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Portal hypertensive gastropathy (PHG) is a diagnosis made based on endoscopic findings in the appropriate clinical setting. Biopsy may be taken during endoscopy for correlation, but the pathologist may encounter a myriad of nonspecific histologic findings. We undertook this study to evaluate contexts where a histologic diagnosis of PHG might be rendered on biopsy. METHODS Two cohorts were established: stomach biopsy specimens from patients with cirrhosis or undergoing varices screening (n = 188) and stomach biopsy specimens with findings interpreted as PHG in the pathology report (n = 29). RESULTS In the first cohort, cases with endoscopic varices more frequently displayed foveolar hyperplasia and acute inflammation, with no other histologic differences between cases with and without endoscopic PHG, clinical varices, and clinical cirrhosis. Cases from the second cohort showed no histologic differences when stratified for endoscopic PHG, endoscopic varices, and clinical cirrhosis. Our second cohort displayed the majority of charted histologic findings more frequently than the first. Our results indicate that neither an endoscopic appearance of PHG nor particular clinical diagnoses associated with PHG translate into specific histologic findings. CONCLUSIONS Although the histologic findings charted displayed increased frequency in pathology reports with an interpretation of PHG, histology should not be used reliably in the diagnosis of PHG.
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Affiliation(s)
- Matthew K Morrow
- From the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Raul S Gonzalez
- From the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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20
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Machado P, Gupta I, Fenkel JM, Gummadi S, Stanczak M, Wessner CE, Shaw CM, Schultz S, Soulen MC, Wallace K, Eisenbrey JR, Forsberg F. Ultrasound Pressure Estimation for Diagnosing Portal Hypertension in Patients Undergoing Dialysis for Chronic Kidney Disease. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2181-2189. [PMID: 34850412 PMCID: PMC9156659 DOI: 10.1002/jum.15897] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/08/2021] [Accepted: 10/27/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Hepatic venous pressure gradient (HVPG) is considered the standard in quantifying portal hypertension, but can be unreliable in dialysis patients. A noninvasive ultrasound technique, subharmonic-aided pressure estimation (SHAPE), may be a valuable surrogate of these pressure estimates. This study compared SHAPE and HVPG with pathology findings for fibrosis in dialysis patients. METHODS This was a subgroup study from an IRB-approved trial that included 20 patients on dialysis undergoing SHAPE examinations of portal and hepatic veins using a modified Logiq 9 scanner (GE, Waukesha, WI), during infusion of Sonazoid (GE Healthcare, Oslo, Norway). SHAPE was compared to HVPG and pathology findings using the Ludwig-Batts scoring system for fibrosis. Logistic regression, ROC analysis, and t-tests were used to compare HVPG and SHAPE with pathological findings of fibrosis. RESULTS Of 20 cases, 5 had HVPG values corresponding to subclinical and clinical portal hypertension (≥6 and ≥10 mmHg, respectively) while 15 had normal HVPG values (≤5 mmHg). SHAPE and HVPG correlated moderately (r = 0.45; P = .047). SHAPE showed a trend toward correlating with fibrosis (r = 0.42; P = .068), while HVPG did not (r = 0.18; P = .45). SHAPE could differentiate between mild (stage 0-1) and moderate to severe (stage 2-4) fibrosis (-10.4 ± 4.9 dB versus -5.4 ± 3.2 dB; P = .035), HVPG could not (3.0 ± 0.6 mmHg versus 4.8 ± 0.7 mmHg; P = .30). ROC curves showed a diagnostic accuracy for SHAPE of 80%, while HVPG reached 76%. CONCLUSION Liver fibrosis staging in dialysis patients evaluated for portal hypertension appears to be more accurately predicted by SHAPE than by HVPG; albeit in a small sample size.
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Affiliation(s)
- Priscilla Machado
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ipshita Gupta
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jonathan M Fenkel
- Division of Gastroenterology and Hepatology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Maria Stanczak
- Department of Medical Imaging and Radiation Sciences, Thomas Jefferson University, Philadelphia, PA, USA
| | - Corinne E Wessner
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Colette M Shaw
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Susan Schultz
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael C Soulen
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - John R Eisenbrey
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
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21
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Effect of Direct-Acting Antiviral Agents on Gastroesophageal Varices in Patients with Hepatitis C Virus-Related Cirrhosis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081077. [PMID: 36013545 PMCID: PMC9415929 DOI: 10.3390/medicina58081077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/06/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022]
Abstract
Aim: In patients with hepatitis C virus-related liver cirrhosis (LC) who achieve sustained virological responses (SVRs) through treatment with direct-acting antiviral agents (DAAs), it remains unclear whether there are improvements in gastroesophageal varices (GEVs) and portal hypertension. We investigated changes in liver function and GEVs that occurred after DAA therapy. Materials and Methods: We evaluated the medical records of 195 patients with hepatitis C virus-related LC who received DAAs. A total of 171 patients achieved SVRs, among whom 36 had GEVs before or after receiving DAA therapy. The liver function, fibrosis, and GEVs were re-evaluated every 6 months after receiving DAA therapy. The risk factors for progressive GEVs were investigated. Results: DAA therapy resulted in improvements in liver function (indicated by aspartate transaminase, alanine transaminase, and serum albumin levels) and fibrosis (indicated by type IV collagen levels and the Fibrosis-4 index). After receiving DAA therapy, 27 patients had stable GEVs and 9 had progressive GEVs. With respect to GEV grades before DAA therapy, there was a significant difference between patients with stable and progressive GEVs (p = 0.027). Presence of grade-2 GEVs before starting DAA therapy was a risk factor for GEV progression (odds ratio: 5.83; p = 0.04). Patients with grade-2 GEVs had significantly shorter progression-free periods than those with grade < 2 GEVs (p = 0.025). Conclusions: DAA therapy does not ameliorate GEVs. Furthermore, grade-2 GEVs can worsen after DAA therapy. Therefore, patients with GEVs of grades ≥ 2 should undergo endoscopic surveillance after receiving DAAs.
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22
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Choi SJ, Lee SS, Jung KH, Lee JB, Kang HJ, Park HJ, Choi SH, Kim DW, Jang JK. Noncirrhotic Portal Hypertension after Trastuzumab Emtansine in HER2-positive Breast Cancer as Determined by Deep Learning-measured Spleen Volume at CT. Radiology 2022; 305:606-613. [PMID: 35943338 DOI: 10.1148/radiol.220536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Trastuzumab emtansine (T-DM1) is an antibody-drug conjugate approved for use in human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Case reports have suggested an association between T-DM1 and portal hypertension. Purpose To evaluate the association of T-DM1 therapy with spleen volume changes and portal hypertension on CT scans and clinical findings compared with lapatinib and capecitabine therapy. Materials and Methods Patients with HER2-positive breast cancer who were administered at least two cycles of T-DM1 or lapatinib and capecitabine (controls) in a tertiary institution from 2001 to 2020 and who underwent CT before initial treatment and at least once during treatment were retrospectively enrolled. Spleen volume changes and the signs of portal hypertension (gastroesophageal varix [GEV], spontaneous portosystemic shunt [SPSS], and ascites) were evaluated at contrast-enhanced CT. Patients were followed until treatment ended or for 2 years after the start of treatment. Spleen volume changes were measured with a deep learning algorithm and evaluated by using a linear mixed model. The incidences of splenomegaly and portal hypertension were compared between the T-DM1 and control groups by using a χ2 test or Fisher exact test. Results The T-DM1 group included 111 patients (mean age, 54 years ± 11 [SD]; 111 women) and the control group included 122 patients (mean age, 50 years ± 9; 121 women). Spleen volume progressively increased with T-DM1 therapy but was constant in the control group (104% ± 5 vs -1% ± 6 at the 33rd treatment cycle, respectively; P < .001). Incidences of splenomegaly (46% [51 of 111] vs 3% [four of 122] of patients; P < .001), GEV (11% [12 of 111] vs 1% [one of 122] of patients; P < .001), and SPSS (27% [30 of 111] vs 1% [one of 122] of patients; P < .001) were higher in the T-DM1 group than in the control group. Conclusion Trastuzumab emtansine therapy was associated with noncirrhotic portal hypertension at CT, with higher incidences of splenomegaly, gastroesophageal varix, and spontaneous portosystemic shunt than those with lapatinib and capecitabine therapy. © RSNA, 2022 Online supplemental material is available for this article.
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Affiliation(s)
- Se Jin Choi
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Seung Soo Lee
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Kyung Hae Jung
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Jung Bok Lee
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Hyo Jeong Kang
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Hyo Jung Park
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Sang Hyun Choi
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Dong Wook Kim
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Jong Keon Jang
- From the Departments of Radiology and Research Institute of Radiology (S.J.C., S.S.L., H.J.P., S.H.C., D.W.K., J.K.J.), Oncology (K.H.J.), Clinical Epidemiology and Biostatistics (J.B.L.), and Pathology (H.J.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
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Kumar A, Maruyama H, Arora A, Sharma P, Anikhindi SA, Bansal N, Kumar M, Ranjan P, Sachdeva M, Khare S. Diagnostic accuracy of transient elastography in diagnosing clinically significant portal hypertension in patients with chronic liver disease: a systematic review and meta-analysis. J Med Ultrason (2001) 2022; 49:333-346. [DOI: 10.1007/s10396-022-01239-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/31/2022] [Indexed: 10/16/2022]
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24
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Tadelle A. QT Interval Prolongation in Cirrhotic Cardiomyopathy. RESEARCH REPORTS IN CLINICAL CARDIOLOGY 2022. [DOI: 10.2147/rrcc.s371615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Jeong J, Tanaka M, Iwakiri Y. Hepatic lymphatic vascular system in health and disease. J Hepatol 2022; 77:206-218. [PMID: 35157960 PMCID: PMC9870070 DOI: 10.1016/j.jhep.2022.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/13/2022] [Accepted: 01/31/2022] [Indexed: 02/07/2023]
Abstract
In recent years, significant advances have been made in the study of lymphatic vessels with the identification of their specific markers and the development of research tools that have accelerated our understanding of their role in tissue homeostasis and disease pathogenesis in many organs. Compared to other organs, the lymphatic system in the liver is understudied despite its obvious importance for hepatic physiology and pathophysiology. In this review, we describe fundamental aspects of the hepatic lymphatic system and its role in a range of liver-related pathological conditions such as portal hypertension, ascites formation, malignant tumours, liver transplantation, congenital liver diseases, non-alcoholic fatty liver disease, and hepatic encephalopathy. The article concludes with a discussion regarding the modulation of lymphangiogenesis as a potential therapeutic strategy for liver diseases.
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Affiliation(s)
- Jain Jeong
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Masatake Tanaka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuko Iwakiri
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.
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26
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van Hoeve W, de Vargas Serrano M, Te Winkel L, Forsberg F, Dave JK, Sarkar K, Wessner CE, Eisenbrey JR. Improved Sensitivity of Ultrasound-Based Subharmonic Aided Pressure Estimation Using Monodisperse Microbubbles. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1781-1789. [PMID: 34724241 DOI: 10.1002/jum.15861] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/29/2021] [Accepted: 10/01/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Subharmonic aided pressure estimation (SHAPE) has been shown effective for noninvasively measuring hydrostatic fluid pressures in a variety of clinical applications. The objective of this study was to explore potential improvements in SHAPE sensitivity using monodisperse microbubbles. METHODS Populations of monodisperse microbubbles were created using a commercially available microfluidics device (Solstice Pharmaceuticals). Size distributions were assessed using a Coulter Counter and stability of the distribution following fabrication was evaluated over 24 hours. Attenuation of the microbubble populations from 1 to 10 MHz was then quantified using single element transducers to identify each formulation's resonance frequency. Frequency spectra over increasing driving amplitudes were investigated to determine the nonlinear phases of subharmonic signal generation. SHAPE sensitivity was evaluated in a hydrostatic pressure-controlled water bath using a Logiq E10 scanner (GE Healthcare). RESULTS Monodisperse lipid microbubble suspensions ranging from 2.4 to 5.3 μm in diameter were successfully created and they showed no discernable change in size distribution over 24 hours following activation. Calculated resonance frequencies ranged from 2.1 to 6.3 MHz and showed excellent correlation with microbubble diameter (R2 > 0.99). When investigating microbubble frequency response, subharmonic signal occurrence was shown to begin at 150 kPa peak negative pressure, grow up to 225 kPa, and saturate at approximately 250 kPa. Using the Logiq E10, monodisperse bubbles demonstrated a SHAPE sensitivity of -0.17 dB/mmHg, which was nearly twice the sensitivity of the commercial polydisperse microbubble currently being used in clinical trials. CONCLUSIONS Monodisperse microbubbles have the potential to greatly improve the sensitivity of SHAPE for the noninvasive measurement of hydrostatic pressures.
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Affiliation(s)
| | | | | | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jaydev K Dave
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kausik Sarkar
- Department of Mechanical and Aerospace Engineering, The George Washington University, Washington, DC, USA
| | - Corinne E Wessner
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - John R Eisenbrey
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
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Cannella R, Tselikas L, Douane F, Cauchy F, Rautou PE, Duran R, Ronot M. Imaging-guided interventions modulating portal venous flow: evidence and controversies. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100484. [PMID: 35677591 PMCID: PMC9168703 DOI: 10.1016/j.jhepr.2022.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/07/2022]
Abstract
Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.
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28
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Wieland A, Etzion O, Ali RO, Levy E, Kleiner DE, Helmke SM, Heller T, Everson GT. HepQuant SHUNT Detects Portal Hypertension in Early Stages of Clinically Compensated Chronic Liver Disease. Clin Gastroenterol Hepatol 2022; 20:e890-e894. [PMID: 33895359 PMCID: PMC8531144 DOI: 10.1016/j.cgh.2021.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/20/2021] [Indexed: 02/07/2023]
Abstract
Physicians use portal pressure measurements in clinical practice and research but the methods are invasive, can cause complications, and are resource intensive.1-3 Herein we describe preliminary findings of the minimally invasive HepQuant-SHUNT test in the diagnosis of portal hypertension in precirrhotic and compensated cirrhotic patients.
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Affiliation(s)
- Amanda Wieland
- Section of Hepatology, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | | | | | - Steve M. Helmke
- Section of Hepatology, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO,HepQuant LLC, Greenwood Village, CO, 80111
| | | | - Gregory T. Everson
- Section of Hepatology, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO,HepQuant LLC, Greenwood Village, CO, 80111
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Urinary BA Indices as Prognostic Biomarkers for Complications Associated with Liver Diseases. Int J Hepatol 2022; 2022:5473752. [PMID: 35402050 PMCID: PMC8986411 DOI: 10.1155/2022/5473752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Hepatobiliary diseases and their complications cause the accumulation of toxic bile acids (BA) in the liver, blood, and other tissues, which may exacerbate the underlying condition and lead to unfavorable prognosis. To develop and validate prognostic biomarkers for the prediction of complications of cholestatic liver disease based on urinary BA indices, liquid chromatography-tandem mass spectrometry was used to analyze urine samples from 257 patients with cholestatic liver diseases during a 7-year follow-up period. The urinary BA profile and non-BA parameters were monitored, and logistic regression models were used to predict the prognosis of hepatobiliary disease-related complications. Urinary BA indices were applied to quantify the composition, metabolism, hydrophilicity, and toxicity of the BA profile. We have developed and validated the bile-acid liver disease complication (BALDC) model based on BA indices using logistic regression model, to predict the prognosis of cholestatic liver disease complications including ascites. The mixed BA and non-BA model was the most accurate and provided higher area under the receiver operating characteristic (ROC) and smaller akaike information criterion (AIC) values compared to both non-BA and MELD (models for end stage liver disease) models. Therefore, the mixed BA and non-BA model could be used to predict the development of ascites in patients diagnosed with liver disease at early stages of intervention. This will help physicians to make a better decision when treating hepatobiliary disease-related ascites.
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Gawande A, Mukewar S, Daswani R, Bhaware B, Mukewar S. Recent Endoscopic Ultrasound-Related Publications With Potential to Influence Clinical Practice. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1741107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
AbstractThe field of endoscopic ultrasound (EUS) has evolved significantly over the last two decades from being a tool of only diagnostic purpose to tissue acquisition and now therapeutic potential. There have been several important publications in the field of EUS in the last few years, which had a major impact in the clinical management of various gastrointestinal disorders. In this review, we discuss four such articles that in our opinion will significantly impact the role of EUS in treating various conditions. The first article is a randomized controlled trial comparing EUS-guided gall bladder drainage with percutaneous gall bladder drainage for high-risk acute cholecystitis. The second article is a randomized controlled trial comparing EUS versus minimally invasive surgery for necrotizing pancreatitis. The third article is a novel human study of EUS-guided portal pressure measurement in patients with portal hypertension. The last article is also a randomized controlled trial evaluating the role of rapid on-site evaluation for EUS-guided fine needle biopsy in solid pancreatic lesions.
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Affiliation(s)
- Atul Gawande
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Shrikant Mukewar
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Ravi Daswani
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Bhushan Bhaware
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Saurabh Mukewar
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
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Li Q, Guo X, Feng J, Xu X, Chawla S, Li H, Qi X. Risk Factors for Esophageal Collateral Veins in Cirrhosis with and without Previous Endoscopic Esophageal Variceal Therapy. Can J Gastroenterol Hepatol 2022; 2022:6666791. [PMID: 35028303 PMCID: PMC8752234 DOI: 10.1155/2022/6666791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Portosystemic collateral vessels are a sign of portal hypertension in liver cirrhosis. Esophageal collateral veins (ECVs) are one major type of portosystemic collateral vessels, which increase the recurrence of esophageal varices and bleeding after variceal eradication. However, the risk factors for ECVs were still unclear. METHODS We retrospectively screened cirrhotic patients who had contrast-enhanced computed tomography (CT) images to evaluate ECVs and upper gastrointestinal endoscopic reports to evaluate gastroesophageal varices at our department. Univariate and multivariate logistic regression analyses were performed to explore the independent risk factors for ECVs. Odds ratios (ORs) were calculated. Subgroup analyses were performed in patients with and without previous endoscopic variceal therapy which primarily included endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). RESULTS Overall, 243 patients were included, in whom the prevalence of ECVs was 53.9%. The independent risk factors for ECVs were hepatitis C virus infection (OR = 0.250, p = 0.026), previous EVL (OR = 1.929, p = 0.044), platelet (OR = 0.993, p = 0.008), and esophageal varices needing treatment (EVNTs) (OR = 2.422, p = 0.006). The prevalence of ECVs was 60.8% (73/120) in patients undergoing EVL, 50% (10/20) in those undergoing EIS, and 47.5% (48/101) in those without previous endoscopic variceal therapy. The independent risk factors for ECVs were the use of nonselective beta-blockers (OR = 0.294, p = 0.042) and EVNTs (OR = 3.714, p = 0.006) in subgroup analyses of patients with and without previous endoscopic variceal therapy, respectively. CONCLUSIONS The presence of ECVs should be closely associated with the severity of portal hypertension in liver cirrhosis. Risk of ECVs might be increased by previous EVL.
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Affiliation(s)
- Qianqian Li
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- 2Postgraduate College, Dalian Medical University, Dalian 116044, China
| | - Xiaozhong Guo
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Ji Feng
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Xiangbo Xu
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- 3Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110840, China
| | - Saurabh Chawla
- 4Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Hongyu Li
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Xingshun Qi
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- 2Postgraduate College, Dalian Medical University, Dalian 116044, China
- 3Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110840, China
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Portal venous pressure in non-cirrhotic bilharzial patients undergoing elective splenectomy, can it affect mortality? A prospective study. Acta Gastroenterol Belg 2021; 84:557-561. [PMID: 34965035 DOI: 10.51821/84.4.004] [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] [Indexed: 11/21/2022]
Abstract
Background and study aims To evaluate the impact of intraoperatively measured portal vein pressure (PVP) on mortality in non-cirrhotic bilharzial patients undergoing splenectomy. Methods The present study is a prospective study that was conducted in Egypt from April 2014 to April 2018. Adult patients with non-cirrhotic bilharziasis who were scheduled to undergo splenectomy were included. Studied cases were divided into a survival cohort and a non-survival cohort. The main objective was the correlation between the incidence of mortality and intraoperative PVP. Results The present work comprised 130 cases with a mean age of 51.8 ± 6.4 years old. The in-hospital mortality rate was 22.3%, with sepsis as a major cause of death (37.9%). In term of the association between preoperative variables and mortality, survivors had statistically significant lower portal vein diameter (13.6 ± 1.8 versus 15.2 ± 1.8mm; p<0.001) and higher portal vein velocity (14.2 ± 1.8 versus 10.4 ± 2.3 cm/sec; p<0.001) than nonsurvivors. The survived patients had significantly lower PVP (13.9 ± 1.1 versus 17.7 ± 2.7; p<0.001). A cut-off value of ≥14.5 mmHg, the PVP yielded a sensitivity of 86.2% and a specificity of 69% for the prediction of mortality. The association analysis showed a statistically significant association between mortality and postoperative liver function parameters. Conclusions High intraoperative PVP is linked to early postoperative death in non-cirrhotic cases undergoing splenectomy. Our study showed that PVP > 14.5mmHg was an independent predictor of death and showed good diagnostic performance for the detection of early postoperative mortality.
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Hepatic Vein Contrast-Enhanced Ultrasound Subharmonic Imaging Signal as a Screening Test for Portal Hypertension. Dig Dis Sci 2021; 66:4354-4360. [PMID: 33392869 PMCID: PMC9026769 DOI: 10.1007/s10620-020-06790-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Portal hypertension is the underlying cause of most complications associated with cirrhosis, with the hepatic venous pressure gradient (HVPG) used for diagnosis and disease progression. Subharmonic imaging (SHI) is a contrast-specific imaging technique receiving at half the transmit frequency resulting in better tissue suppression. AIMS To determine whether the presence of optimized SHI signals inside the hepatic vein can be used as a screening test for portal hypertension. METHODS This prospective trial had 131 patients undergoing SHI examination of portal and hepatic veins using a modified Logiq 9 scanner (GE, Waukesha, WI). Images acquired after infusion of the ultrasound contrast agent Sonazoid (GE Healthcare, Oslo, Norway) were assessed for the presence of optimized SHI signals in the hepatic vein and compared to the HVPG values obtained as standard of care. RESULTS Of 131 cases, 64 had increased HVPG values corresponding to subclinical (n = 31) and clinical (n = 33) portal hypertension (> 5 and > 10 mmHg, respectively), and 67 had normal HVPG values (< 5 mmHg). Two readers performed independent, binary qualitative assessments of the acquired digital clips. Reader one (experienced radiologist) achieved for the subclinical subgroup sensitivity of 98%, specificity of 88%, and ROC area of 0.93 and for the clinical subgroup sensitivity of 100% and specificity of 61%, with an ROC area of 0.74. Reader two (less experienced radiologist) achieved for the subclinical subgroup sensitivity of 77%, specificity of 76%, and ROC area of 0.76 and for the clinical subgroup sensitivity of 88% and specificity of 63%, with an ROC area of 0.70. Readers agreement was of 83% with kappa value of 0.66. CONCLUSION The presence of optimized SHI signals inside the hepatic vein can be a qualitative screening test for portal hypertension, which could reduce the need for invasive diagnostic procedures.
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Kawaguchi T, Honda A, Sugiyama Y, Nakano D, Tsutsumi T, Tahara N, Torimura T, Fukumoto Y. Association between the albumin-bilirubin (ALBI) score and severity of portopulmonary hypertension (PoPH): A data-mining analysis. Hepatol Res 2021; 51:1207-1218. [PMID: 34534392 DOI: 10.1111/hepr.13714] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Portopulmonary hypertension (PoPH) is a severe complication of chronic liver disease. We aimed to investigate the etiology of chronic liver disease and the factors associated with the severity of PoPH. SUBJECTS AND METHODS Echocardiography was undergone in 833 patients with chronic liver disease during 2005-2019 and 13 patients (1.6%) were diagnosed with PoPH in this observational study. At the diagnosis of PoPH, liver function was evaluated by albumin-bilirubin (ALBI) score. Severe PoPH was defined as (1) mean pulmonary arterial pressure (mPAP) ≥50 mmHg or (2) mPAP: 35-49 mmHg and pulmonary vascular resistance ≥400 dyne/s/cm5 . Factors associated with severe PoPH were evaluated by decision-tree analysis. RESULTS In patients with PoPH, the leading etiology of chronic liver disease was hepatitis C virus (HCV) (46.2% [sustained virological response (SVR): 23.1% and non-SVR: 15.4%]). Severe PoPH was observed in 53.8% of patients and the 5-year survival rate was 48.1%. There was a significant correlation of mPAP with ALBI score (r = 0.6456, p = 0.0171). In the decision-tree and random forest analyses, the most impacted classifier for severe PoPH was the ALBI score. In patients with ALBI score ≥-1.45, all patients showed severe PoPH, while the prevalence of severe PoPH was 25.0% in patients with ALBI score <-1.45. CONCLUSIONS We found that HCV including SVR was the major etiology of chronic liver disease in patients with PoPH. Moreover, we revealed that the ALBI score was the most impacted factor associated with severe PoPH. Thus, ALBI score may be useful for the estimation of pulmonary vascular resistance.
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Affiliation(s)
- Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Akihiro Honda
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yoichi Sugiyama
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Dan Nakano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Tsubasa Tsutsumi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Nobuhiro Tahara
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Takuji Torimura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
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Frangakis C, Sohn JH, Bas A, Chapiro J, Schernthaner RE, Lin M, Hamilton JP, Pawlik TM, Hong K, Duran R. Longitudinal Analysis of the Effect of Repeated Transarterial Chemoembolization for Liver Cancer on Portal Venous Pressure. Front Oncol 2021; 11:639235. [PMID: 34804911 PMCID: PMC8602787 DOI: 10.3389/fonc.2021.639235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 10/22/2021] [Indexed: 12/05/2022] Open
Abstract
Objectives Investigate long-term effects of repeated transarterial chemoembolization (TACE) on portal venous pressure (PVP) using non-invasive surrogate markers of portal hypertension. Methods Retrospective, Institutional Review Board-approved study. 99 patients [hepatocellular carcinoma (HCC) group (n=57); liver metastasis group (n=42)] who underwent 279TACEs and had longitudinal pre-/post-therapy contrast-enhanced-MRI (n=388) and complete blood work were included. Outcomes of interest were platelet count (PC), spleen volume, ascites and portosystemic collaterals. Variables included TACE type/number, tumor type, microcatheter location, Child-Pugh, baseline tumor burden (tumor number/total/largest size), vessel invasion, alpha-fetoprotein, Eastern Cooperative Oncology Group (ECOG) performance status, and Model for End-Stage Liver Disease (MELD) score. Generalized Estimating Equations assessed the associations between TACE and outcomes. Power analysis determined the sample size was sufficient. Results No significant change in PC over time was observed in either groups, regardless of liver function (P>0.05). Baseline spleen volume was 226 cm3 for metastatic group, and was larger by 204 cm3 for HCC group (P<0.001). Spleen volume increased by 20 cm3 (95%CI: 8-32; P=0.001) for both groups after 1stTACE and by 16cm3/TACE (P=0.099) over the full follow-up (up to 9TACEs). Spleen volume also tended to increase by 23cm3 (95%CI: -1–48; P=0.064) with higher tumor burden. Odds of developing moderate/severe ascites for metastatic patients was decreased by 0.5 (95%CI: 0.3–0.9; P=0.014), regardless of the Child-Pugh, and increased by 1.5 (95%CI: 1.2–1.9; P<0.001) among HCC patients with unstable Child-Pugh, whereas no change was noted with stable Child-Pugh. HCC patients with unstable Child-Pugh demonstrated a significant increase in portosystemic collaterals number over time (P=0.008). PVP-related complications such as variceal bleeding post-TACE were low (0.4%). Conclusion Repeated TACEs did seem to have an impact on PVP. However, the increase in PVP had marginal effects with low portal hypertension-related complications.
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Affiliation(s)
- Constantine Frangakis
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jae Ho Sohn
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Ahmet Bas
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States.,Department of Radiology, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Julius Chapiro
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, United States
| | - Ruediger E Schernthaner
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States
| | - MingDe Lin
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, United States
| | - James P Hamilton
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, United States
| | - Kelvin Hong
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Rafael Duran
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States.,Department of Radiology and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Khan A, Bailey CW. Unique Method of Transjugular Intrahepatic Portosystemic Shunt Reduction for Refractory Hepatic Encephalopathy. Cureus 2021; 13:e18838. [PMID: 34804693 PMCID: PMC8592787 DOI: 10.7759/cureus.18838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2021] [Indexed: 12/03/2022] Open
Abstract
We report the case of a 27-year-old female patient with a history of cryptogenic cirrhosis who was admitted to the hospital due to multiple episodes of hematemesis secondary to bleeding esophageal varices. The varices were persistent and refractory to endoscopic intervention, so an emergent transjugular intrahepatic portosystemic shunt (TIPS) was performed by interventional radiology (IR). Months later, the patient returned to the hospital unresponsive with acute intermittent hepatic encephalopathy which required a TIPS reduction by IR. Once the TIPS reduction was performed, the patient’s hepatic encephalopathy declined, and her symptoms improved. Here, we present a unique method of TIPS reduction utilizing a single Viabahn VBX balloon-expandable stent (W. L. Gore & Associates, Inc; Flagstaff, AZ) to constrain the existing TIPS stent.
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Affiliation(s)
- Ayub Khan
- Medicine, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Christopher W Bailey
- Interventional Radiology, Virginia Commonwealth University School of Medicine, Richmond, USA
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Lesmana CRA, Paramitha MS, Gani RA, Lesmana LA. The role of endoscopic ultrasound for portal hypertension in liver cirrhosis. J Med Ultrason (2001) 2021; 49:359-370. [PMID: 34797476 DOI: 10.1007/s10396-021-01165-4] [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: 06/01/2021] [Accepted: 08/14/2021] [Indexed: 10/19/2022]
Abstract
Chronic liver disease is still a major problem because disease progression will ultimately lead to liver cirrhosis. Portal hypertension is the hallmark in advanced liver disease management. By establishing portal vein access, endoscopic ultrasound (EUS) has been utilized in various clinical applications. In comparison to standard upper gastrointestinal endoscopy, EUS-Doppler has been shown to be a better modality for detecting esophageal and gastric varices along with peri-esophageal collateral veins, para-esophageal collateral veins, and perforating veins, and may be used to objectively predict the recurrence of bleeding. EUS-guided portal vein catheterization has also been proposed to overcome the limitations of trans-jugular approaches. The combination of EUS-elastography and azygos vein evaluation can also enhance the diagnostic accuracy of each modality. Another well-known implementation of EUS-guided procedures is in the management of ascites; particularly in paracentesis and ascitic fluid analysis. In addition, the most common clinical application of EUS in the treatment of portal hypertension is through vascular therapy or creation of intrahepatic portosystemic shunts. Major drawbacks of EUS mainly revolve around technical difficulties, the high cost of the procedure, as well as the requirement of more studies in humans to evaluate EUS-guided advanced therapeutic modalities in portal hypertension.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia. .,Digestive Disease and GI Oncology Center, Medistra Hospital, Jakarta, Indonesia.
| | - Maria Satya Paramitha
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
| | - Rino A Gani
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
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Gupta I, Fenkel JM, Eisenbrey JR, Machado P, Stanczak M, Wessner CE, Shaw CM, Miller C, Soulen MC, Wallace K, Forsberg F. A Noninvasive Ultrasound Based Technique to Identify Treatment Responders in Patients with Portal Hypertension. Acad Radiol 2021; 28 Suppl 1:S128-S137. [PMID: 33341374 DOI: 10.1016/j.acra.2020.11.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/18/2020] [Accepted: 11/28/2020] [Indexed: 02/07/2023]
Abstract
RATIONALE AND OBJECTIVE Subharmonic aided pressure estimation (SHAPE) is based on the inverse relationship between the subharmonic amplitude of ultrasound contrast microbubbles and ambient pressure. The aim of this study was to verify if SHAPE can accurately monitor disease progression in patients identified with portal hypertension. MATERIALS & METHODS A modified Logiq 9 scanner with a 4C curvi-linear probe (GE, Waukesha, WI) was used to acquire SHAPE data (transmitting and receiving at 2.5 and 1.25 MHz, respectively) using Sonazoid (GE Healthcare, Oslo, Norway; FDA IND 124,465). Twenty-one (median age 59 years; 12 Males) of the 178 patients enrolled in this institutional review board approved study (14F.113) were identified as having clinically significant portal hypertension based on their hepatic venous pressure gradient results ≥ 10 mmHg. Repeat SHAPE examinations were done every 6.2 months. Liver function tests and clinical indicators were used to establish treatment response. RESULTS Of the 21 portal hypertensive subjects, 11 had successful follow up scans with an average follow up time of 6.2 months. There was a significantly larger SHAPE signal reduction in the group who were classified as treatment responders (n = 10; -4.01±3.61 dB) compared to the single nonresponder (2.33 dB; p < 0.001). Results for responders matched the corresponding clinical outcomes of improved model for end stage liver disease (MELD) scores, improvement in underlying cause of portal hypertension, improved liver function tests and reduced ascites. CONCLUSION SHAPE can potentially monitor disease progression in portal hypertensive patients and hence, may help clinicians in patient management. A larger study would further validate this claim.
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Galizzi HO, Couto CA, Taranto DOL, Araújo SIO, Vilela EG. Accuracy of non-invasive methods/models for predicting esophageal varices in patients with compensated advanced chronic liver disease secondary to nonalcoholic fatty liver disease. Ann Hepatol 2021; 20:100229. [PMID: 32745630 DOI: 10.1016/j.aohep.2020.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Nonalcoholic fatty liver disease (NAFLD) patients can progress to cirrhosis. In these, there is a compensated stage in which esophageal varices can exist. However, no more than 20% of these patients have varices needing treatment (VNT). OBJECTIVE Evaluate the accuracy of non-invasive models to predict esophageal varices, as well as their performance to avoid esophagogastroduodenoscopy (EGD) with a risk of missing VNT of less than 5%, in Brazilian patients with compensated advanced chronic liver disease (cACLD) secondary to NAFLD. METHODS Twenty-one patients with biopsy-proven cACLD secondary to NAFLD were submitted to liver stiffness measurement (LSM) by transient elastography (TE), and data were collected to measure platelet count/spleen diameter ratio (PSR), LSM-spleen diameter to platelet ratio score (LSPS), varices risk score (VRS), Baveno VI, Expanded Baveno VI and NAFLD cirrhosis criteria. RESULTS The mean age was 61 (±6.6) years, and 81% were female; 14% presented VNT. For detection of VNT, LSPS and VRS performed excellently, with an area under receiver operating characteristic (AUROC) of 0.961 for both. LSM presented an AUROC of 0.889 and a cutoff point of 21.8 kPa. LSPS and VRS enabled sparing 75-80% of EGDs for VNT, with no risk of missing varices. Expanded Baveno VI enabled sparing 71% of EGDs, with 4.8% risk of missing VNT. CONCLUSION LSPS and VRS performed excellently in both predicting VNT and sparing EGD, and Expanded Baveno VI showed good performance in sparing EGDs, with acceptable risk of missing VNT. An LSM cutoff point was established and had good performance.
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Affiliation(s)
- Humberto O Galizzi
- Postgraduate Program in Sciences Applied to Adult Health, Federal University of Minas Gerais Medical School (Programa de Pós-Graduação em Ciências Aplicadas à Saúde do Adulto, Faculdade de Medicina da Universidade Federal de Minas Gerais), Brazil.
| | - Claudia A Couto
- Postgraduate Program in Sciences Applied to Adult Health, Federal University of Minas Gerais Medical School (Programa de Pós-Graduação em Ciências Aplicadas à Saúde do Adulto, Faculdade de Medicina da Universidade Federal de Minas Gerais), Brazil; Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Brazil
| | - Daniela O L Taranto
- Diagnostic Imaging Unit of the Clinical Hospital of the Federal University of Minas Gerais, Brazil
| | | | - Eduardo G Vilela
- Postgraduate Program in Sciences Applied to Adult Health, Federal University of Minas Gerais Medical School (Programa de Pós-Graduação em Ciências Aplicadas à Saúde do Adulto, Faculdade de Medicina da Universidade Federal de Minas Gerais), Brazil; Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Brazil
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Dos Santos Pinheiro C, de Oliveira Gomes CG, Ribeiro Lima Machado C, Guedes LR, Rocha HC, Guimarães RG, Carvalho FAC, Saturnino SF, do Nascimento VC, de Andrade MVM, Vilela EG. Performance of High Mobility Protein Group 1 and Interleukin-6 as Predictors of Outcomes Resulting from Variceal Bleeding in Patients with Advanced Chronic Liver Disease. Inflammation 2021; 45:544-553. [PMID: 34618276 DOI: 10.1007/s10753-021-01565-1] [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: 06/14/2021] [Revised: 08/08/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
Variceal bleeding is a serious complication in cirrhotic patients and is related to increased expression of inflammatory mediators that accentuate circulatory dysfunction. The study aims to evaluate the performance of high mobility protein group 1 (HMG1) and interleukin-6 (IL-6) as predictors of acute kidney injury (AKI), infection and death in these patients. Fifty patients who were diagnosed with advanced chronic liver disease with variceal bleeding were included. The mean age was 52.8 ± 10.8 years, and 33 (66%) were male. Twenty-one (42%) patients were classified as Child-Pugh C, 21 (42%) Child-Pugh B and 8 (16%) Child-Pugh A. The mean HMG1 serum level was 2872.36 pg/mL ± 2491.94, and the median IL-6 serum level was 47.26 pg/mL (0-1102.4). In AKI, the serum level of HMG1 that performed best on the ROC curve was 3317.9 pg/mL. The IL-6 serum level was not associated with AKI. HMG1 and IL-6 cut-off values that better predicted infection were 3317.9 pg/mL and 72.9 pg/mL, and for mortality, the values were 2668 pg/mL and 84.5 pg/mL, respectively. In multivariate analysis, the variables that were associated with AKI and infection outcomes were model for end-stage liver disease and HMG1. Infections were related to the risk of death. Clinical and laboratory variables related to the outcomes were identified. Serum levels of HMG1 were associated with AKI and infection and had good performance in the ROC curve. IL-6 levels were not maintained in logistic regression outcomes but had good performance in infection and death outcomes. Such data will be useful for comparisons and possible future validations.
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Affiliation(s)
- Camilla Dos Santos Pinheiro
- Faculdade de Medicina da, Postgraduate Program in Sciences Applied To Adult Health, Federal University of Minas Gerais Medical (Programa de Pós-Graduação Em Ciências Aplicadas À Saúde Do Adulto, Universidade Federal de Minas Gerais), Belo Horizonte, Brazil.
| | - Célio Geraldo de Oliveira Gomes
- Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Camilla Ribeiro Lima Machado
- Faculdade de Medicina da, Postgraduate Program in Sciences Applied To Adult Health, Federal University of Minas Gerais Medical (Programa de Pós-Graduação Em Ciências Aplicadas À Saúde Do Adulto, Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Ludmila Resende Guedes
- Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Henrique Carvalho Rocha
- Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Roberto Gardone Guimarães
- Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Fernando Antônio Castro Carvalho
- Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Saulo Fernandes Saturnino
- Intensive Care Unit of Clinical Hospital of the Federal University of Minas Gerais (Hospital das Clínicas da Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Vanuza Chagas do Nascimento
- Faculdade de Medicina da, Postgraduate Program in Sciences Applied To Adult Health, Federal University of Minas Gerais Medical (Programa de Pós-Graduação Em Ciências Aplicadas À Saúde Do Adulto, Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Marcus Vinicius Melo de Andrade
- Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
| | - Eduardo Garcia Vilela
- Faculdade de Medicina da, Postgraduate Program in Sciences Applied To Adult Health, Federal University of Minas Gerais Medical (Programa de Pós-Graduação Em Ciências Aplicadas À Saúde Do Adulto, Universidade Federal de Minas Gerais), Belo Horizonte, Brazil.,Alfa Institute of Gastroenterology of the Clinical Hospital of the Federal University of Minas Gerais (Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais), Belo Horizonte, Brazil
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Yang C, Liu J, Shi Q, Huang S, Zhou C, Wang Y, Li T, Chen Y, Xiong B. Effect of splenectomy on the outcomes in patients with cirrhosis receiving transjugular intrahepatic portosystemic shunt. J Gastroenterol Hepatol 2021; 36:2893-2902. [PMID: 33973270 PMCID: PMC8518516 DOI: 10.1111/jgh.15543] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/28/2021] [Accepted: 05/08/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Patients indicated to transjugular intrahepatic portosystemic shunt (TIPS) placement may have splenectomy history due to thrombocytopenia. This study aimed to evaluate the effect of prior splenectomy on TIPS procedure and post-TIPS outcomes. METHODS We conducted a longitudinal analysis based on a cohort of 284 patients with cirrhosis submitted to TIPS; 74 patients had splenectomy history (splenectomy group) and 210 did not (non-splenectomy group). Cox proportional hazards models were used to evaluate the association between splenectomy and outcomes after TIPS. The primary outcome was shunt dysfunction. Secondary outcomes included all-cause mortality, clinical recurrence of bleeding or ascites, and overt hepatic encephalopathy (OHE). RESULTS During a median follow-up of 16.2 months, the splenectomy group had significantly lower rates of postoperative shunt patency (85.5% vs 95.6% at 1 year and 75.2% vs 86.5% at 2 years; adjusted hazard ratio [HR] 2.53; 95% confidence interval [CI] 1.21-5.12; P = 0.01) and higher risk of OHE (adjusted HR 1.82; 95% CI 1.03-3.54; P = 0.04). But the risk of mortality (adjusted HR 0.87; 95% CI 0.41-1.87; P = 0.73) and recurrent bleeding or ascites (adjusted HR 1.17; 95% CI 0.53-2.35; P = 0.77) showed no statistical difference. Multivariate analysis confirmed splenectomy history and endoscopic therapy as independent predictors of shunt dysfunction. Besides, pre-TIPS splenectomy increased the difficulty of TIPS procedure by complicating portal vein puncture. CONCLUSIONS For patients with cirrhosis submitted to TIPS, prior splenectomy complicated TIPS procedure and increased the risk of shunt dysfunction and OHE after TIPS, but was not significantly associated with the occurrence of mortality and recurrent bleeding or ascites.
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Affiliation(s)
- Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
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Turaga RC, Satyanarayana G, Sharma M, Yang JJ, Wang S, Liu C, Li S, Yang H, Grossniklaus H, Farris AB, Gracia-Sancho J, Liu ZR. Targeting integrin αvβ3 by a rationally designed protein for chronic liver disease treatment. Commun Biol 2021; 4:1087. [PMID: 34531529 PMCID: PMC8445973 DOI: 10.1038/s42003-021-02611-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/26/2021] [Indexed: 12/22/2022] Open
Abstract
Chronic Liver Diseases (CLD) are characterized by abnormal accumulation of collagen fibrils, neo-angiogenesis, and sinusoidal remodeling. Collagen deposition along with intrahepatic angiogenesis and sinusoidal remodeling alters sinusoid structure resulting in portal hypertension, liver failure, and other complications. Efforts were made to develop treatments for CLDs. However, the success of such treatments is limited and unpredictable. We report a strategy for CLD treatment by induction of integrin αvβ3 mediated cell apoptosis using a rationally designed protein (ProAgio). ProAgio is designed to target integrin αvβ3 at a novel site. Integrin αvβ3 is highly expressed in activated Hepatic Stellate Cells (HSC), angiogenic endothelium, and capillarized Liver Sinusoidal Endothelial Cells (LSEC). ProAgio induces apoptosis of these disease causative cells. Tests with liver fibrosis mouse models demonstrate that ProAgio reverses liver fibrosis and relieves blood flow resistance by depleting activated HSC and capillarized LSEC. Our studies demonstrate an effective approach for CLD treatment.
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Affiliation(s)
- Ravi Chakra Turaga
- Department of Biology, Georgia State University, Atlanta, GA, 30324, USA
| | | | - Malvika Sharma
- Department of Biology, Georgia State University, Atlanta, GA, 30324, USA
| | - Jenny J Yang
- Department of Chemistry, Georgia State University, Atlanta, USA
| | | | | | - Sun Li
- Department of Chemistry, Georgia State University, Atlanta, USA
| | - Hua Yang
- Department Ophthalmology, Emory University, Atlanta, GA, 30322, USA
| | | | | | | | - Zhi-Ren Liu
- Department of Biology, Georgia State University, Atlanta, GA, 30324, USA.
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Queck A, Uschner FE, Ferstl PG, Schulz M, Brol MJ, Praktiknjo M, Schierwagen R, Klein S, Strassburg CP, Meyer C, Jansen C, Berres ML, Trebicka J. Role of circulating angiogenin levels in portal hypertension and TIPS. PLoS One 2021; 16:e0256473. [PMID: 34432848 PMCID: PMC8386873 DOI: 10.1371/journal.pone.0256473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
Background Pathogenesis of portal hypertension is multifactorial and includes pathologic intrahepatic angiogenesis, whereby TIPS insertion is an effective therapy of portal hypertension associated complications. While angiogenin is a potent contributor to angiogenesis in general, little is known about its impact on TIPS function over time. Methods In a total of 118 samples from 47 patients, angiogenin concentrations were measured in portal and inferior caval vein plasma at TIPS insertion (each blood compartment n = 23) or angiographic intervention after TIPS (each blood compartment n = 36) and its relationship with patient outcome was investigated. Results Angiogenin levels in the inferior caval vein were significantly higher compared to the portal vein (P = 0.048). Ten to 14 days after TIPS, inferior caval vein angiogenin level correlated inversely with the portal systemic pressure gradient (P<0.001), measured invasively during control angiography. Moreover, patients with TIPS revision during this angiography, showed significantly lower angiogenin level in the inferior caval vein compared to patients without TIPS dysfunction (P = 0.01). Conclusion In cirrhosis patients with complications of severe portal hypertension, circulating levels of angiogenin are derived from the injured liver. Moreover, angiogenin levels in the inferior caval vein after TIPS may predict TIPS dysfunction.
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Affiliation(s)
- Alexander Queck
- Department of Internal Medicine 1, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Frank E. Uschner
- Department of Internal Medicine 1, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Philip G. Ferstl
- Department of Internal Medicine 1, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Martin Schulz
- Department of Internal Medicine 1, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Maximilian J. Brol
- Department of Internal Medicine 1, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Robert Schierwagen
- Department of Internal Medicine 1, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Sabine Klein
- Department of Internal Medicine 1, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Christian P. Strassburg
- Department of Internal Medicine I, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Carsten Meyer
- Department of Radiology, University Hospital, University Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, University of Bonn, Bonn, Germany
| | | | - Jonel Trebicka
- Department of Internal Medicine 1, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
- * E-mail:
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Engelman D, Moreau M, Lepida A, Zaouak Y, Paesmans M, Awada A. Metastatic breast cancer and pseudocirrhosis: an unknown clinical entity. ESMO Open 2021; 5:e000695. [PMID: 32487541 PMCID: PMC7265039 DOI: 10.1136/esmoopen-2020-000695] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/25/2020] [Accepted: 04/14/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Pseudocirrhosis is a radiological term used to describe rapid changes in the contour of liver invaded by metastases and treated with chemotherapy. Our primary objectives were to analyse the clinical and biological characteristics of those patients with breast cancer and to assess the prevalence of complications generally associated with decompensated cirrhosis. We have also assessed associated treatments and response. METHODS This retrospective study included all women with metastatic breast cancer to the liver who had imaging protocols describing diffuse liver contour abnormalities during systemic treatment between 2003 and 2018 in our centre. The following were identified: neoplastic characteristics, complications presented, treatments administered and response. RESULTS 48 patients were included. There was a trend towards an increased proportion of luminal cancers (88.2%, n=30, p=0052) when compared with our hospital cancer registry. Most patients (97.9%, n=47) had a widespread liver invasion, 58.3% (n=28) had ascites on physical examination; 90% (n=18) of ascites were classified as transudate. Nearly 23% (n=11) of patients had oesophageal varices and 6.5% (n=3) had an episode of variceal rupture. At the time of the appearance of liver contour abnormalities, the most frequently used molecules were: 5-fluorouracil (22.9%; n=11) and cisplatin (18.8%; n=9). A partial response was observed in 52.1% (n=25) of patients. CONCLUSION This is the largest reported series of patients with pseudocirrhosis. Many patients developed complications related to portal hypertension and liver failure, similar to those observed in decompensated cirrhosis. Luminal subtypes could be over-represented. In our series, pseudocirrhosis appears to develop at the expense of extensive liver disease burden and most often under 5-fluorouracil, or its derivatives, with or without cisplatin, possibly following a response to treatment.
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Affiliation(s)
- Dan Engelman
- Oncology Medicine Department, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium.
| | - Michel Moreau
- Data Centre, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Antonia Lepida
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Yasmine Zaouak
- Radiology Department, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianne Paesmans
- Data Centre, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Ahmad Awada
- Oncology Medicine Department, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
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Matsui T, Nagai H, Watanabe G, Yoshimine N, Amanuma M, Kobayashi K, Ogino Y, Mukozu T, Matsukiyo Y, Daido Y, Wakui N, Nakano S, Shinohara M, Momiyama K, Kudo T, Maruyama K, Igarashi Y. Usefulness of virtual touch tissue quantification for predicting the presence of esophageal varices in patients with liver cirrhosis. JGH Open 2021; 5:695-704. [PMID: 34124388 PMCID: PMC8171162 DOI: 10.1002/jgh3.12558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/20/2021] [Accepted: 04/29/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Measuring the hepatic venous pressure gradient (HVPG) is an established technique to detect increased portal pressure and predict the presence of esophageal varices (EVs); however, the risk of the test is greater than the information it provides. This study aimed to clarify the usefulness of virtual touch tissue quantification (VTQ), which assesses liver stiffness, in predicting the presence of EVs in patients with liver cirrhosis by comparing it with HVPG. METHODS Two hundred seventeen patients with liver cirrhosis underwent VTQ, HVPG measurement, and upper endoscopy. Patients were divided into three groups: group V, hepatitis C virus liver cirrhosis (n = 40); group A, alcoholic liver cirrhosis (n = 116); and group N, other liver cirrhosis (n = 61). In each group, we performed linear regression analysis of VTQ and HVPG data. The accuracy of VTQ and HVPG measurement in predicting the presence of EVs and high-risk EVs (EV category F2 and F3) was assessed by area under the receiver operating characteristic curve (AUROC). RESULTS VTQ was significantly correlated with the HVPG in the whole patients and in each group, and both VTQ and HVPG values were significantly higher in patients with EVs and high-risk EVs than in those without. The AUROC for the presence of EVs for VTQ was 0.76 in the whole sample, 0.76 in group V, 0.79 in group A, and 0.67 in group N; and for HVPG, 0.92, 0.94, 0.93, and 0.88, respectively. For VTQ, the AUROC for the presence of high-risk EVs was 0.78 in the whole sample, 0.78 in group V, 0.73 in group A, and 0.73 in group N; and for HVPG, it was 0.85, 0.82, 0.85, and 0.82, respectively. CONCLUSION VTQ was reliable at predicting the presence of EVs and high-risk EVs. Therefore, we propose that VTQ is a useful, noninvasive tool for predicting the presence of EVs in daily medical care.
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Affiliation(s)
- Teppei Matsui
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Hidenari Nagai
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Gou Watanabe
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Naoyuki Yoshimine
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Makoto Amanuma
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Kojiro Kobayashi
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Yuu Ogino
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Takanori Mukozu
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Yasushi Matsukiyo
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Yasuko Daido
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Noritaka Wakui
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Shigeru Nakano
- Division of GastroenterologySaiseikai Yokohamashi Tobu HospitalYokohamaJapan
| | - Mie Shinohara
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Koichi Momiyama
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
| | - Takehide Kudo
- Division of Biomedical LaboratoryToho University Omori Medical CenterTokyoJapan
| | - Kenichi Maruyama
- Division of Biomedical LaboratoryToho University Omori Medical CenterTokyoJapan
| | - Yoshinori Igarashi
- Division of Gastroenterology and HepatologyToho University Omori Medical CenterTokyoJapan
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Xiao N, Li XL, Zhu XD, Huang C, Shen YH, Zhou J, Fan J, Sun HC. Increase of Portal Vein Pressure Gradient After Hepatectomy Predicts Post-operative Liver Dysfunction. Surg Innov 2021; 29:145-153. [PMID: 33993786 DOI: 10.1177/15533506211018620] [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: 11/15/2022]
Abstract
Background. Post-hepatectomy liver failure (PHLF) is an important cause of mortality and morbidity. Whether Child-Pugh A patients with varying degrees of cirrhosis are good candidates for hepatectomy is disputed. The purpose of this study was to analyze the impact of portal venous pressure gradient (PVPG) variation during surgery on PHLF. Methods. PVPG, the pressure gradient between the portal vein and central vein, was measured in consecutive patients before and after liver resection. The optimal cutoff of PVPG to predict PHLF was determined by receiver operating characteristic curve analysis. Risk factors for PHLF were subjected to univariate and multivariable analysis. Results. Sixty Child-Pugh A patients were recruited. The mean PVPG was increased from 5.17 ± 4.78 mm of mercury (mmHg) to 6.37 ± 4.44 mmHg after liver resection. The optimal cutoff value of PVPG increments to predict PHLF was 1.5 mmHg. Multivariable analysis showed prothrombin time (PT), post-hepatectomy PVPG increments of 1.5 mmHg or greater, and resected liver segments of 3 or more to be independent predictors of PHLF. Conclusions. Acute PVPG increase after hepatectomy is associated with a higher risk of PHLF in Child-Pugh A patients.
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Affiliation(s)
- Nan Xiao
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Zhongshan Hospital, 92323Fudan University, Shanghai, China
| | - Xiao-Long Li
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Zhongshan Hospital, 92323Fudan University, Shanghai, China
| | - Xiao-Dong Zhu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Zhongshan Hospital, 92323Fudan University, Shanghai, China
| | - Cheng Huang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Zhongshan Hospital, 92323Fudan University, Shanghai, China
| | - Ying-Hao Shen
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Zhongshan Hospital, 92323Fudan University, Shanghai, China
| | - Jian Zhou
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Zhongshan Hospital, 92323Fudan University, Shanghai, China
| | - Jia Fan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Zhongshan Hospital, 92323Fudan University, Shanghai, China
| | - Hui-Chuan Sun
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Zhongshan Hospital, 92323Fudan University, Shanghai, China
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Rastogi A, Patil N, Maiwall R, Bihari C, Soshee A, Sarin SK. Second-harmonic generation (SHG) microscopy and hepatic venous pressure gradient-based validation of a novel histological staging system for alcoholic hepatitis. Virchows Arch 2021; 479:493-506. [PMID: 33797570 DOI: 10.1007/s00428-021-03089-3] [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: 11/08/2020] [Revised: 03/06/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
Alcoholic hepatitis (AH) lacks specific histological staging. A novel fibrosis staging that encompasses perisinusoidal fibrosis and cirrhosis sub-stages, substantiated by Hepatic venous pressure gradient (HVPG) and automated fibrosis quantification, is imperative. To correlate novel histological staging system of AH with second-harmonic generation microscopy (SHG)-based q-fibrosis, HVPG, and activated hepatic stellate cells (HSCs). Liver biopsies of AH (n = 175) were staged semi-quantitatively as F0, F1, F2, F3A and F3B and Laennec substages of cirrhosis 4A, 4B and 4C. Stages were correlated with SHG q-fibrosis parameters, HVPG and HSCs. Mean age 41.2 ± 9.4 years, 96.6% males, bilirubin 20.58 ± 8.0 mg/dl and Maddrey's discriminant function 78.9 ± 36.7 displayed advanced fibrosis in 98.6%. With increasing histological stages, an increase in q-fibrosis indices and mean HVPG (p < 0.0001) were recorded; stage 4C showed the most significant difference from other stages (p < 0.000). Stages 3A and 3B were comparable with the stages 4A and 4B, respectively, for q-fibrosis (p = 1) and HVPG (p = 1). HSCs (> 30%) were significantly higher in stage 3 (75%) compared with 4 (49%) and 2 (59%), p = 0.018. Overall agreement for histological staging was excellent for all stages (0.82). SHG quantified fibrosis and HVPG corroborates the novel histological staging of AH. Expansive PCF matches with collagen content and clinical severity to early sub-stages of cirrhosis. This highlights the need for an accurate quantification and inclusion of PCF as a separate stage. SHG-based quantification can be a useful adjunct to histological fibrosis staging systems.
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Affiliation(s)
- Archana Rastogi
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India.
| | - Nayana Patil
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
| | - Rakhi Maiwall
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
| | - Chhagan Bihari
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
| | - Ananda Soshee
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
| | - Shiv K Sarin
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
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Misra V, Agrawal R, Misra SP. Portal hypertensive vasculopathy - An entity worth remembering with non-neoplastic gastrointestinal lesions. INDIAN J PATHOL MICR 2021; 64:S32-S42. [PMID: 34135136 DOI: 10.4103/ijpm.ijpm_201_21] [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
Portal hypertensive vasculopathy (PHV) represents an increase in the pressure in the portal circulation. This increased pressure leads to changes in the mucosa that can be appreciated endoscopically as well as histopathologically. Lesions can be observed in the entire gastrointestinal tract (GIT) including stomach, duodenum, jejunum and colon. The histological changes are appreciated mainly in the mucosal and submucosal blood vessels. A knowledge of these lesions as well as the changes helps in separating them from other close differentials with specific treatment to be instituted. The pathogenesis of the hemodynamic changes is not well-understood. The underlying factor is increased portal pressure. Studies indicate, that besides increased portal pressure other factors in combination led to the observed changes. Portal hypertensive gastropathy (PHG) is seen in the gastric body and fundus, while varices are noted in the cardia and fundus. Changes may be seen in the small intestine and throughout the colon with anorectal varices. Histopathological changes include dilated, congested and ectatic capillaries and edema in the lamina propria besides a large spectrum of other histopathological changes. Mucosal capillaries with thick irregular wall show absence of red blood cells in the lumen. Thickening of the vessel wall serves as a better marker than the vascular diameter when portal hypertension (PHT) is considered. Long standing cases may show fibrosis in lamina propria. At times, these changes may lead to occult gastrointestinal bleeding. Important differentials need to be ruled out in all the cases as the treatment and the outcome of all differs. Endoscopically or histopathologically if the mucosal changes are observed they should not be overlooked and a detailed work-up must be carried out.
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Affiliation(s)
- Vatsala Misra
- Department of Pathology and Gastroenterology, MLN Medical College, Prayagraj, Uttar Pradesh, India
| | - Ranjan Agrawal
- Department of Pathology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
| | - Sri Praksh Misra
- Department of Pathology and Gastroenterology, MLN Medical College, Prayagraj, Uttar Pradesh, India
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Li QQ, Li HY, Bai ZH, Philips CA, Guo XZ, Qi XS. Esophageal collateral veins in predicting esophageal variceal recurrence and rebleeding after endoscopic treatment: a systematic review and meta-analysis. Gastroenterol Rep (Oxf) 2020; 8:355-361. [PMID: 33163190 PMCID: PMC7603868 DOI: 10.1093/gastro/goaa004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/20/2019] [Accepted: 08/13/2019] [Indexed: 12/15/2022] Open
Abstract
Background Endoscopic treatment is recommended for the management of esophageal varices. However, variceal recurrence or rebleeding is common after endoscopic variceal eradication. Our study aimed to systematically evaluate the prevalence of esophageal collateral veins (ECVs) and the association of ECVs with recurrence of esophageal varices or rebleeding from esophageal varices after endoscopic treatment. Methods We searched the relevant literature through the PubMed, EMBASE, and Cochrane Library databases. Prevalence of paraesophageal veins (para-EVs), periesophageal veins (peri-EVs), and perforating veins (PVs) were pooled. Risk ratio (RR) and odds ratio (OR) with 95% confidence intervals (CIs) were calculated for cohort studies and case-control studies, respectively. A random-effects model was employed. Heterogeneity among studies was calculated. Results Among the 532 retrieved papers, 28 were included. The pooled prevalence of para-EVs, peri-EVs, and PVs in patients with esophageal varices was 73%, 88%, and 54%, respectively. The pooled prevalence of para-EVs and PVs in patients with recurrence of esophageal varices was 87% and 62%, respectively. The risk for recurrence of esophageal varices was significantly increased in patients with PVs (OR = 9.79, 95% CI: 1.95-49.22, P = 0.006 for eight case-control studies), but not in those with para-EVs (OR = 4.26, 95% CI: 0.38-38.35, P = 0.24 for four case-control studies; RR = 1.81, 95% CI: 0.83-3.97, P = 0.14 for three cohort studies). Patients with para-EVs had a significantly higher incidence of rebleeding from esophageal varices (RR = 13.00, 95% CI: 2.43-69.56, P = 0.003 for two cohort studies). Statistically significant heterogeneity was notable across the meta-analyses. Conclusions ECVs are common in patients with esophageal varices. Identification of ECVs could be helpful for predicting the recurrence of esophageal varices or rebleeding from esophageal varices after endoscopic treatment.
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Affiliation(s)
- Qian-Qian Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
| | - Hong-Yu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
| | - Zhao-Hui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, India
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
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Gunarathne LS, Rajapaksha H, Shackel N, Angus PW, Herath CB. Cirrhotic portal hypertension: From pathophysiology to novel therapeutics. World J Gastroenterol 2020; 26:6111-6140. [PMID: 33177789 PMCID: PMC7596642 DOI: 10.3748/wjg.v26.i40.6111] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/28/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension and bleeding from gastroesophageal varices is the major cause of morbidity and mortality in patients with cirrhosis. Portal hypertension is initiated by increased intrahepatic vascular resistance and a hyperdynamic circulatory state. The latter is characterized by a high cardiac output, increased total blood volume and splanchnic vasodilatation, resulting in increased mesenteric blood flow. Pharmacological manipulation of cirrhotic portal hypertension targets both the splanchnic and hepatic vascular beds. Drugs such as angiotensin converting enzyme inhibitors and angiotensin II type receptor 1 blockers, which target the components of the classical renin angiotensin system (RAS), are expected to reduce intrahepatic vascular tone by reducing extracellular matrix deposition and vasoactivity of contractile cells and thereby improve portal hypertension. However, these drugs have been shown to produce significant off-target effects such as systemic hypotension and renal failure. Therefore, the current pharmacological mainstay in clinical practice to prevent variceal bleeding and improving patient survival by reducing portal pressure is non-selective -blockers (NSBBs). These NSBBs work by reducing cardiac output and splanchnic vasodilatation but most patients do not achieve an optimal therapeutic response and a significant proportion of patients are unable to tolerate these drugs. Although statins, used alone or in combination with NSBBs, have been shown to improve portal pressure and overall mortality in cirrhotic patients, further randomized clinical trials are warranted involving larger patient populations with clear clinical end points. On the other hand, recent findings from studies that have investigated the potential use of the blockers of the components of the alternate RAS provided compelling evidence that could lead to the development of drugs targeting the splanchnic vascular bed to inhibit splanchnic vasodilatation in portal hypertension. This review outlines the mechanisms related to the pathogenesis of portal hypertension and attempts to provide an update on currently available therapeutic approaches in the management of portal hypertension with special emphasis on how the alternate RAS could be manipulated in our search for development of safe, specific and effective novel therapies to treat portal hypertension in cirrhosis.
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Affiliation(s)
- Lakmie S Gunarathne
- Department of Medicine, Melbourne Medical School, The University of Melbourne, Heidelberg, VIC 3084, Australia
| | - Harinda Rajapaksha
- School of Molecular Science, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC 3086, Australia
| | | | - Peter W Angus
- Department of Gastroenterology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Chandana B Herath
- Department of Medicine, Melbourne Medical School, The University of Melbourne, Heidelberg, VIC 3084, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170, Australia
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