Cholangiopathy in extrahepatic portal venous obstruction. Radiological appearances

Portal cavernoma cholangiopathy: Update and recommendations on diagnosis and management

Portal cavernoma cholangiopathy is defined as an obstruction of the biliary system due to distended veins surrounding bile ducts that mainly occur in patients with extrahepatic portal venous obstruction. The periductal venous plexuses encircling the ducts can cause morphological changes which may or may not become symptomatic. Currently, non-invasive techniques such as ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and dynamic contrast enhanced magnetic resonance images are being used to diagnose this disorder. Only a few patients who have symptoms of biliary obstruction require drainage which might be accomplished using endoscopic stenting, decompression of the portal venous system usually via a lienorenal shunt, a difficult direct hepaticojejunostomy, and rarely a liver transplant.

Portal Cavernoma Cholangiopathy in Children: An Evaluation Using Magnetic Resonance Cholangiography and Endoscopic Ultrasound

BACKGROUND

Portal cavernoma cholangiopathy (PCC) refers to abnormalities of the extra- and intrahepatic bile ducts in patients with portal cavernoma. The literature on PCC in children is very scarce. This study aimed at characterizing PCC in children with extrahepatic portal venous obstruction (EHPVO) using endoscopic ultrasound (EUS) and magnetic resonance cholangiography/portovenography (MRC/MRPV).

METHODS

A total of 53 consecutive children diagnosed with EHPVO were prospectively evaluated for PCC using MRC/MRPV and EUS. Chandra classification was used for type of involvement and Llop classification for grading of severity.

RESULTS

All 53 children (100%) had PCC changes on MRC/EUS, but none were symptomatic. Extrahepatic ducts (EHDs) and intrahepatic ducts were involved in majority (85%), and 58.5% had severe changes. Periductal thickening/irregularity (71%) was the commonest change in intrahepatic ducts, whereas irregular contour of the duct with scalloping (68%); common bile duct (CBD) angulation (62.3%) were the frequent changes in the EHDs. Increased CBD angulation predisposed to CBD strictures (P = 0.004). Both left and right branches of portal vein were replaced by collaterals in all children. Among the EUS biliary changes, para-pericholedochal, intrapancreatic, and intramural gall bladder collaterals had significant association with severity, with higher frequency of occurrence in children with the most severe Llop Grade.

CONCLUSIONS

PCC develops early in the disease course of EHPVO, in children, but is asymptomatic despite severe changes. EUS biliary changes are more likely to be observed with increasing severity of PCC.

Pediatric non-cirrhotic portal hypertension: Endoscopic outcome and perspectives from developing nations

Non-cirrhotic portal hypertension (NCPH) forms an important subset of portal hypertension in children. Variceal bleed and splenomegaly are their predominant presentation. Laboratory features show cytopenias (hypersplenism) and preserved hepatic synthetic functions. Repeated sessions of endoscopic variceal ligation or endoscopic sclerotherapy eradicate esophageal varices in almost all cases. After variceal eradication, there is an increased risk of other complications like secondary gastric varices, cholangiopathy, colopathy, growth failure, especially in extra-hepatic portal vein obstruction (EHPVO). Massive splenomegaly-related pain and early satiety cause poor quality of life (QoL). Meso-Rex bypass is the definitive therapy when the procedure is anatomically feasible in EHPVO. Other portosystemic shunt surgeries with splenectomy are indicated when patients present late and spleen-related issues predominate. Shunt surgeries prevent rebleed, improve growth and QoL. Non-cirrhotic portal fibrosis (NCPF) is a less common cause of portal hypertension in children in developing nations. Presentation in the second decade, massive splenomegaly and patent portal vein are discriminating features of NCPF. Shunt surgery is required in severe cases when endotherapy is insufficient for the varices. Congenital hepatic fibrosis (CHF) presents with firm palpable liver and splenomegaly. Ductal plate malformation forms the histological hallmark of CHF. CHF is commonly associated with Caroli’s disease, renal cysts, and syndromes associated with neurological defects. Isolated CHF has a favourable prognosis requiring endotherapy. Liver transplantation is required when there is decompensation or recurrent cholangitis, especially in Caroli’s syndrome. Combined liver-kidney transplantation is indicated when both liver and renal issues are present.

Extrahepatic Portal Vein Obstruction in Children: Role of Preoperative Imaging

Aim:

Extrahepatic portal vein obstruction (EHPVO) is characterized by features of recent thrombosis or portal hypertension with portal cavernoma as a sequel of portal vein obstruction. Imaging of spleno-portal axis is the mainstay for the diagnosis of EHPVO. The aim of this study is to analyze the role of imaging in the preoperative assessment of the portal venous system in children with EHPVO.

Materials and Methods:

A hospital-based cross-sectional study was conducted on twenty children with EHPVO aged between 1 and 18 years over a period of 1 year. The children were evaluated clinically, followed by upper gastrointestinal endoscopy. Radiological assessment included imaging of the main portal vein, its right and left branches, splenic vein, and superior mesenteric vein using color Doppler ultrasonography (CDUSG) and magnetic resonance portovenogram (MRP). Evidence of portal biliopathy, status of collaterals, and possible sites for portosystemic shunt surgery were also examined.

Results:

All the patients presented in chronic stage with portal cavernoma and only one patient (5%) had bland thrombus associated with cavernoma. The CDUSG and MRPs had a sensitivity of 66.6-90% and 96.7% and specificity of 91.5% and 98.3% respectively with regard to the assessment of the extent of thrombus formation and flow in the portal venous system. Both the modalities were found to be complementary to each other in preoperative assessment of EHPVO. However, the sensitivity of MRP was slightly superior to CDUSG in detecting occlusion and identifying portosystemic collaterals and dilated intrahepatic biliary radicals.

Conclusion:

Results of the present study indicate that MRP is well suited and superior to CDUSG in the preoperative imaging of patients with EHPVO.

Spectrum of biliary abnormalities in portal cavernoma cholangiopathy (PCC) secondary to idiopathic extrahepatic portal vein obstruction (EHPVO)-a prospective magnetic resonance cholangiopancreaticography (MRCP) based study

OBJECTIVE

To characterize biliary abnormalities seen in portal cavernoma cholangiopathy (PCC) on MR cholangiopancreaticography (MRCP) and elucidate certain salient features of the disease by collaborating our findings with those of previous studies.

METHODS

We prospectively enrolled 52 patients with portal cavernoma secondary to idiopathic extrahepatic portal vein obstruction, who underwent a standard MRCP protocol. Images were analyzed for abnormalities involving the entire biliary tree. Terms used were those proposed by the Indian National Association for Study of the Liver. Angulation of the common bile duct (CBD) was measured in all patients with cholangiopathy.

RESULTS

Cholangiopathy was seen in 80.7% of patients on MRCP. Extrahepatic ducts were involved in 95% of patients either alone (26%) or in combination with the intrahepatic ducts (69%). Isolated involvement of the intrahepatic ducts was seen in 4.8% of patients. Abnormalities of the extrahepatic ducts included angulation (90%), scalloping (76.2%), extrinsic impression/indentation (45.2%), stricture (14.3%) and smooth dilatation (4.8%). The mean CBD angle was 113.2 ± 19.8°. Abnormalities of the intrahepatic ducts included smooth dilatation (40%), irregularity (28%) and narrowing (9%). Cholelithiasis, choledocholithiasis and hepatolithiasis were seen in 28.6% (12) patients, 14.3% (6) patients and 11.9% (5) patients, respectively. There was a significant association between choledocholithiasis and CBD stricture, with no significant association between choledocholithiasis and cholelithiasis. A significant association was also seen between hepatolithiasis and choledocholithiasis.

CONCLUSION

The spectrum of biliary abnormalities in PCC has been explored and some salient features of the disease have been elucidated, which allow a confident diagnosis of this entity. Advances in knowledge: PCC preferentially involves the extrahepatic biliary tree. Changes in the intrahepatic ducts generally occur as sequelae of involvement of the extrahepatic ducts, although isolated involvement of the intrahepatic ducts does occur. Increased angulation of the CBD and scalloping are most commonly seen. Angulation may predispose to choledocholithiasis and thus development of symptomatic cholangiopathy. Choledocholithiasis and hepatolithiasis occur as sequelae of PCC.

Safety of supramesocolic surgery in patients with portal cavernoma without portal vein decompression. Large single centre experience

BACKGROUND

Supra-mesocolic surgery (SMS) is complicated in patients with portal vein cavernoma (PC) and portal decompression is recommended. The aim of this study was to report a large single centre of SMS in patients with PC without portal decompression.

METHODS

Between 2006 and 2013, all patients who met inclusion criteria were analyzed retrospectively. The primary endpoint was the feasibility rate, surgical and postoperative outcome. The secondary endpoints were the long-term outcome of patients who underwent biliary bypass for cholangitis. Risk factors for complications were studied.

RESULTS

Thirty patients underwent 51 procedures. Pancreatitis was the main etiology of PC (19/30) and biliary obstruction was mainly related to the underlying disease and not to portal cholangiopathy (12/14). All planned procedures were successfully completed. Fourteen patients underwent biliary bypass. Median blood loss (250 ml), transfusion (n = 7), mortality (n = 0), overall morbidity (n = 12) and the median hospital stay (10 days). Good long-term control of cholangitis was achieved in the 9 patients alive with available follow-up. Significant risk factors for complications were a previous abdominal wall scar, previous intra-abdominal surgical field and liver fibrosis.

CONCLUSION

SMS can be safely performed in patients with PC. In patients with risk factors for complications, portal decompression should be discussed.

Imaging and radiological interventions in extra-hepatic portal vein obstruction

Extrahepatic portal vein obstruction (EHPVO) is a primary vascular condition characterized by chronic long standing blockage and cavernous transformation of portal vein with or without additional involvement of intrahepatic branches, splenic or superior mesenteric vein. Patients generally present in childhood with multiple episodes of variceal bleed and EHPVO is the predominant cause of paediatric portal hypertension (PHT) in developing countries. It is a pre-hepatic type of PHT in which liver functions and morphology are preserved till late. Characteristic imaging findings include multiple parabiliary venous collaterals which form to bypass the obstructed portal vein with resultant changes in biliary tree termed portal biliopathy or portal cavernoma cholangiopathy. Ultrasound with Doppler, computed tomography, magnetic resonance cholangiography and magnetic resonance portovenography are non-invasive techniques which can provide a comprehensive analysis of degree and extent of EHPVO, collaterals and bile duct abnormalities. These can also be used to assess in surgical planning as well screening for shunt patency in post-operative patients. The multitude of changes and complications seen in EHPVO can be addressed by various radiological interventional procedures. The myriad of symptoms arising secondary to vascular, biliary, visceral and neurocognitive changes in EHPVO can be managed by various radiological interventions like transjugular intra-hepatic portosystemic shunt, percutaneous transhepatic biliary drainage, partial splenic embolization, balloon occluded retrograde obliteration of portosystemic shunt (PSS) and revision of PSS.

Comparative evaluation of magnetic resonance cholangiopancreatography/magnetic resonance splenoportovenography and endoscopic ultrasound in the diagnosis of portal cavernoma cholangiopathy

BACKGROUND

Magnetic resonance cholangiopancreatography/magnetic resonance splenoportovenography (MRCP/MRSPV) is now the investigation of choice for the diagnosis of portal cavernoma cholangiopathy (PCC). Endoscopic ultrasound (EUS) is an emerging diagnostic modality for the diagnosis of PCC and may be better than MRCP/MRSPV to see the layer-wise localization of varices and to differentiate between varices, stone, and malignancy.

METHODS

Retrospective data of 50 patients of extrahepatic portal vein obstruction (EHPVO) were collected, and comparison between MRCP/MRSPV and EUS was done for the diagnosis of PCC.

RESULTS

Out of 50 patients, 56 % (28) were males, 44 % (22) females, and 24 % (12) symptomatic. Biliary changes were seen in 40 patients (80 %). Epicholedochal collateral (EPEC) was detected in 48 % and 20 % in MRCP/MRSPV and EUS, respectively. Perforators (PER) and intracholedochal collateral (ICC) were better seen with EUS (72 % and 48 %) as compared to MRCP/MRSPV (0 % and 8 %), and p-values were significant (<0.05). EUS has a sensitivity of 33.33 % and a specificity of 92.31 % for EPEC. Portal cavernoma (PC) and collateral at porta (CP), paracholedochal collateral (PAC), perisplenic (PS) and peripancreatic collateral (PPC), pericholedochal collateral (PEC), intrahepatic biliary radical dilatation (IHBRD), perigallbladder collateral (PG), common bile duct dilatation (CBDD) and common hepatic duct dilatation (CHDD), common bile duct stricture (CBDS), and retropancreatic collateral (RPC) were comparable between the two modalities.

CONCLUSIONS

EUS detected PER and ICC better than MRCP/MRSPV, while MRCP/MRSPV was more sensitive for detecting EPEC.

Imaging Diagnosis of Splanchnic Venous Thrombosis

Splanchnic vein thrombosis (SVT) is a broad term that includes Budd-Chiari syndrome and occlusion of veins that constitute the portal venous system. Due to the common risk factors involved in the pathogenesis of these clinically distinct disorders, concurrent involvement of two different regions is quite common. In acute and subacute SVT, the symptoms may overlap with a variety of other abdominal emergencies while in chronic SVT, the extent of portal hypertension and its attendant complications determine the clinical course. As a result, clinical diagnosis is often difficult and is frequently reliant on imaging. Tremendous improvements in vascular imaging in recent years have ensured that this once rare entity is being increasingly detected. Treatment of acute SVT requires immediate anticoagulation. Transcatheter thrombolysis or transjugular intrahepatic portosystemic shunt is used in the event of clinical deterioration. In cases with peritonitis, immediate laparotomy and bowel resection may be required for irreversible bowel ischemia. In chronic SVT, the underlying cause should be identified and treated. The imaging manifestations of the clinical syndromes resulting from SVT are comprehensively discussed here along with a brief review of the relevant clinical features and therapeutic approach.

Portal Hypertensive Biliopathy: An Infrequent Cause of Biliary Obstruction

Introduction

Biliary obstruction is usually caused by choledocholithiasis. However, in some circumstances, alternative or concurring unusual ethiologies such as portal hypertensive biliopathy (PHB) must be considered.

Clinical case

We present the case of a 36-year-old female complaining of jaundice and pruritus. Liver function tests were compatible with biliary obstruction and the ultrasound scan of the abdomen showed dilatation of the intrahepatic biliary ducts, a dilated common bile duct (CBD) and biliary calculi. The computed tomography of the abdomen revealed a portal cavernoma encasing the CBD.

Discussion

Portal cavernoma, the hallmark of extrahepatic portal venous obstruction, can cause PHB. When symptomatic, chronic cholestasis is present if a dominant stricture exists whereas biliary pain and acute cholangitis occur when choledocholithiasis prevails. Management must be individualized and usually includes endoscopic therapy to address choledocholithiasis and shunt surgery for definitive treatment.

MRI of cholangiocarcinoma

Cholangiocarcinomas are the second most common primary hepatobiliary tumors after hepatocellular carcinomas. They can be categorized either based on their location (intrahepatic/perihilar/extrahepatic distal) or their growth characteristics (mass-forming/periductal-infiltrating/intraductal) because they exhibit varied presentations and outcomes based on their location and or pattern of growth. The increased risk of cholangiocarcinoma in PSC necessitates close surveillance of these patients by means of imaging and laboratory measures; and because currently surgical resection is the only effective treatment for cholangiocarcinoma, the need for accurate pre-operative staging and assessment of resectability has emphasized the role of high quality imaging in management. Today magnetic resonance imaging (MRI) is the modality of choice for detection, pre-operative staging and surveillance of cholangiocarcinoma.

Analysis of bile in various hepatobiliary disease states: A pilot study

AIM

Our study aims to find various enzymatic and biochemical components of bile and their clinical or prognostic correlation with regard to progression and severity of hepatobiliary diseases.

MATERIALS AND METHODS

It was a cross-sectional study where all the patients suffering from choledochal cyst (CDC), extrahepatic portal venous obstruction (EHPVO), and infantile obstructive cholangiopathy undergoing diagnostic preoperative cholangiogram; and patients with history of total parenteral nutrition (TPN) undergoing surgery for some other condition were included in the study. Intraoperatively, bile was collected from the gallbladder and sent for estimation of amylase, lipase, sodium, potassium, calcium, chloride, bicarbonate, total bilirubin, pH, cholesterol, triglycerides, and total bile acid.

RESULTS

A total of 80 patients were included in the study (20 in each of the four disease-based groups). Amylase, lipase, and pH were significantly different among the patients of CDC when compared with the presence or absence of dilated intrahepatic biliary radicals. Similarly, amylase, lipase, and pH were also significantly different among the patients of EHPVO when compared with presence or absence of biliopathy. Levels of cholesterol and bile acid were significantly higher in patients who were evaluated after 1 year following TPN than those who were evaluated before 1 year. The patients of infantile cholangiopathy, who had history of fever, had significantly higher level of calcium.

CONCLUSION

The components of bile show close correlation with various clinical and prognostic markers, there is a very close correlation between these parameters and the clinical severity, disease progression, and final outcome.

Imaging of portal cavernoma cholangiopathy

Portal cavernoma cholangiopathy (PCC) refers to the biliary changes which occur in the setting of extrahepatic portal vein obstruction and secondary portal cavernoma formation. The main radiological findings include the vascular changes in the form of portosystemic collaterals and biliary changes in the form of extrinsic impressions and strictures. Till date, conventional cholangiography has been the gold standard for the diagnosis of PCC. However, it is an invasive procedure and is associated with complications. At present there is a transition towards non-invasive modalities like ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI). The recent advances in these modalities provide an excellent delineation of both the vascular and the biliary changes non-invasively in a short time. The findings of PCC using these newer modalities are not so well described in literature. The findings of PCC also overlap with malignant conditions of biliary tract such as cholangiocarcinoma and compression of biliary tract by malignant adenopathies. In this article we describe the vascular and biliary changes associated with PCC on US, CT and MRI. We also describe the imaging findings using each modality along with their advantages and disadvantages.

Surgical management of portal cavernoma cholangiopathy

The majority of patients with portal cavernoma cholangiopathy (PCC) are asymptomatic, however some (5-38%) present with obstructive jaundice, cholangitis, or even biliary pain due to bile duct stones which form as a result of stasis. Most patients with extrahepatic portal venous obstruction (EHPVO) present with variceal bleeding and hypersplenism and these are the usual indications for surgery. Those who present with PCC may also need decompression of their portosystemic system to reverse the biliary obstruction. It is important to realize that though endoscopic drainage has been proposed as a non-surgical approach to the management of PCC it is successful in only certain specific situations like those with bile duct calculi, cholangitis, etc. A small proportion of such patients will continue to have biliary obstruction and these patients are thought to have a mechanical ischemic stricture. These patients will require a second stage procedure in the form of a bilioenteric bypass to reverse the symptoms related to PCC. In the absence of a shuntable vein splenectomy and devascularization may resolve the PCC in a subset of patients by decreasing the portal pressure.

Endoscopic retrograde cholangiography in portal cavernoma cholangiopathy - results from different studies and proposal for uniform terminology

Portal cavernoma cholangiopathy (PCC) refers to a constellation of secondary changes in the biliary tree in patients with chronic portal vein (PV) thrombosis and portal cavernoma formation. These findings of PCC are seen in the extra-hepatic bile duct(s), with or without involvement of the 1st or 2nd degree intra-hepatic bile ducts. Of all patients with chronic PV thrombosis, cholangiographic features of PCC are found in 80%-100%. The biliary changes are symptomatic in a smaller proportion of 5%-38% patients. Choledocholithiasis and hepatolithiasis occur in 5%-20%, independent of the occurrence of cholelithiasis. We review the published literature on cholangiographic description of PCC. We also propose standardized nomenclature for the cholangiographic findings, namely: extrinsic impressions/indentations, shallow impressions, irregular ductal contour, stricture (s), upstream dilatation, filling defects, bile duct angulation, and ectasia.

Non-cirrhotic portal hypertension - diagnosis and management

NCPH is a heterogeneous group of liver disorders of vascular origin, leading to PHT with near normal HVPG. NCPF/IPH is a disorder of young adults or middle aged women, whereas EHPVO is a disorder of childhood. Early age acute or recurrent infections in an individual with thrombotic predisposition constitute the likely pathogenesis. Both disorders present with clinically significant PHT with preserved liver functions. Diagnosis is easy and can often be made clinically with support from imaging modalities. Management centers on control and prophylaxis of variceal bleeding. In EHPVO, there are additional concerns of growth faltering, portal biliopathy, MHE and parenchymal dysfunction. Surgical shunts are indicated in patients with failure of endotherapy, bleeding from sites not amenable to endotherapy, symptomatic hypersplenism or symptomatic biliopathy. Persistent growth failure, symptomatic and recurrent hepatic encephalopathy, impaired quality of life or massive splenomegaly that interferes with daily activities are other surgical indications. Rex-shunt or MLPVB is the recommended shunt for EHPVO, but needs proper pre-operative radiological assessment and surgical expertise. Both disorders have otherwise a fairly good prognosis, but need regular and careful surveillance. Hepatic schistosomiasis, CHF and NRH have similar presentation and comparable prognosis.

Portal cavernoma cholangiopathy-clinical characteristics

Because of the presence of portal cavernoma, paracholedochal and pericholedochal varices, portal cavernoma cholangiopathy (PCC) has become an entity unique to patients with extrahepatic portal venous obstruction (EHPVO). Majority of patients with these abnormalities are asymptomatic and are incidentally detected to have the presence of biliary abnormalities on cholangiography. Minority of patients present with symptoms of chronic cholestasis with or without biliary pain or acute cholangitis related most often to the presence of biliary strictures or stones. Other than the age of the patient and duration of EHPVO, presence of gall stones and common bile duct stones are other risk factors for the causation of symptoms in patients with PCC. This review summarizes the clinical characteristics of asymptomatic and symptomatic patients with PCC giving details of the prevalence of symptoms, their risk factors and overall burden of symptomatic PCC.

Natural history of portal cavernoma cholangiopathy

The natural history of portal cavernoma cholangiopathy (PCC) is poorly defined and poorly understood. It develops early after acute portal vein thrombosis (PVT) if there is failure of recanalization. In PCC, the likelihood of progression of biliary abnormalities after 1 year is extremely low. The natural history of PCC is conveniently divided into asymptomatic and symptomatic stages. The majority of patients with PCC are asymptomatic and are detected incidentally on imaging. Limited data suggest that asymptomatic PCC is static or only slowly progressive in the initial stages. However, most workers agree that, overall, PCC is a slowly progressive disease. Symptomatic PCC represents a late stage in its natural history. Finding strictures with dilatation at cholangiography is associated with a higher risk of developing symptoms of PCC. Onset of symptoms is often precipitated by the development of biliary sludge or calculi and treating calculi usually relieves symptoms for prolonged periods of time. Clinical presentations include biliary pain, obstructive jaundice, acute cholangitis, acute cholecystitis, or other presentations of gallstone disease. Progressive liver dysfunction and secondary biliary cirrhosis can develop in a minority of patients.

Portal cavernoma cholangiopathy - history, definition and nomenclature

Biliary changes secondary to portal hypertension, especially in portal cavernoma secondary to extrahepatic portal vein obstruction have long been described in literature under different names by various authors. Most of the times these changes are asymptomatic and discovered on imaging, but can occasionally cause obstructive jaundice. There is no consensus on the appropriate nomenclature and definition of this entity. This article reviews the history of portal hypertensive biliopathy and the Indian Association for the Study of Liver Working Party consensus definition and nomenclature for it.

Liver transplantation for portal cavernoma cholangiopathy

Portal cavernoma cholangiopathy (PCC) is a difficult clinical problem, where the portal cavernoma is both the cause of biliary obstruction and the obstacle to its safe surgical treatment. The available endoscopic and surgical treatment is successful in majority and further intervention is seldom required since the native liver is normal. PCC is not an accepted indication for liver transplantation as only a small proportion of patients will fail both endoscopic and surgical treatment and progressive liver failure is rarely seen. Secondary biliary cirrhosis as a result of long standing biliary obstruction is an accepted indication however establishing a portal inflow in these patients is often difficult and challenging. The deceased donor liver transplantation would always be preferable over living donor liver transplantation as PCC is usually a non-emergency transplant and the graft can have portal blood inflow through a conduit to even a small segment of patent portal venous system or even to a cavernoma vessel.

Portal cavernoma cholangiopathy: consensus statement of a working party of the Indian national association for study of the liver

Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.

[Cavernous transformation of the portal vein in children: about 11 cases]

Le cavernome portal est la conséquence d'une occlusion chronique, du système porte extra-hépatique formé d'un réseau de veines dont le calibre est augmenté et au sein desquelles chemine un sang portal hépatopéte. Chez l'enfant, est une cause majeure d'hypertension portale dite «pré ou infra-hépatique» ou encore «extra-hépatique». Onze cas de cavernome porte parmi 78 cas d'hypertension portale ont été colligés au service sur une période allant du Janvier 2003 au Septembre 2012. L’âge de nos patients variait entre 2 et 15 ans et le sexe ratio est de 1,75. Tous nos patients étaient admis au stade d'hypertension portale avec la splénomégalie SMG (100% des cas); hémorragies digestives (63%); ascite (36%); la circulation veineuse collatérale CVC et l'hépatomégalie HMG (27%). L'exploration endoscopique a objectivé la présence de varices ‘sophagiennes dans tous les cas avec une gastropathie hypertensive dans 27% et des varices ectopiques chez 36%. Les perturbations biologiques étaient dominées par la pancytopénie. Le bilan de thrombophilie était demandé pour tous les malades mais réalisé mais n'est réalisé que chez trois revenus normaux chez deux et a objectivé une baisse de protéine S chez le troisième. L’échographie abdominale était le moyen de diagnostic positif et l’écho-doppler a confirmé l'HTP chez tous nos patients. Aucun de nos malades n'a pu être opéré pour le moment. La ligature a été réalisée chez 54,5%. Dix patients ont nécessité une transfusion sanguine. L’évolution globale de nos patients est favorable. La durée moyenne d’évolution du cavernome porte chez nos patients est de quatre ans.

Portal biliopathy diagnosed using color Doppler and contrast-enhanced ultrasound

Portal biliopathy is a morphological abnormality of the biliary ductal and gallbladder wall associated with portal hypertension. A patient with essential thrombocythemia was initially diagnosed with extrahepatic portal vein obstruction (EHPVO). The contrast-enhanced computed tomography (CT) findings were similar to those of cholangiocarcinoma or sclerosing cholangitis. However, color Doppler and contrast-enhanced ultrasound (US) were more specific. The paracholedocheal veins around the bile ducts appeared as beads soon after the injection of contrast medium, followed by linear enhancement of the epicholedochal veins and the gradual enhancement of the whole bile ducts. These findings led to a diagnosis of portal biliopathy, which prevented the patient from having to endure hazardous procedures such as bile duct biopsies. Color Doppler and contrast-enhanced US findings are useful for diagnosing or ruling out portal biliopathy in patients who present with EHPVO.

Portal biliopathy

Biliary ductal changes are a common radiological finding in patients with portal hypertension, however only a small percentage of patients (5%-30%) develop symptomatic bile duct obstruction. The exact pathogenesis is not clear, but an involvement of factors such as bile duct compression by venous collaterals, ischemia, and infection is accepted by most authors. Although endoscopic retrograde cholangiopancreatography was used to define and diagnose this condition, magnetic resonance cholangiopancreatography is currently the investigation of choice for diagnosing this condition. Treatment is indicated only for symptomatic cases. Portosystemic shunts are the treatment of choice for symptomatic portal biliopathy. In the majority of patients, the changes caused by biliopathy resolve after shunt surgery, however, 15%-20% patients require a subsequent bilio-enteric bypass or endoscopic management for persistent biliopathy. There is a role for endoscopic therapy in patients with bile duct stones, cholangitis or when portosystemic shunt surgery is not feasible.

Portal ductopathy: Clinical importance and nomenclature

Non-cirrhotic portal hypertension (PHT) accounts for about 20% of all PHT cases, portal vein thrombosis (PVT) resulting in cavernous transformation being the most common cause. All known complications of PHT may be encountered in patients with chronic PVT. However, the effect of this entity on the biliary tree and pancreatic duct has not yet been fully established. Additionally, a dispute remains regarding the nomenclature of common bile duct abnormalities which occur as a result of chronic PVT. Although many clinical reports have focused on biliary abnormalities, only a few have evaluated both the biliary and pancreatic ductal systems. In this review the relevant literature evaluating the effect of PVT on both ductal systems is discussed, and findings are considered with reference to results of a prominent center in Turkey, from which the term “portal ductopathy” has been put forth to replace “portal biliopathy”.

Portal biliopathy: a study of 39 surgically treated patients

BACKGROUND

Portal biliopathy (PBP) denotes intra- and extrahepatic biliary duct abnormalities that occur as a result of portal hypertension and is commonly seen in extrahepatic portal vein obstruction (EHPVO). The management of symptomatic PBP is still controversial.

METHODS

Prospectively collected data for surgically managed PBP patients from 1996 to 2007 were retrospectively analysed for presentation, clinical features, imaging and the results of surgery. All patients were assessed with a view to performing decompressive shunt surgery as a first-stage procedure and biliary drainage as a second stage-procedure if required, based on evaluation at 6 weeks after shunt surgery.

RESULTS

A total of 39 patients (27 males, mean age 29.56 years) with symptomatic PBP were managed surgically. Jaundice was the most common symptom. Two patients in whom shunt surgery was unsuitable underwent a biliary drainage procedure. A total of 37 patients required a proximal splenorenal shunt as first-stage surgery. Of these, only 13 patients required second-stage surgery. Biliary drainage procedures (hepaticojejunostomy [n= 11], choledochoduodenostomy [n= 1]) were performed in 12 patients with dominant strictures and choledocholithiasis. One patient had successful endoscopic clearance of common bile duct (CBD) stones after first-stage surgery and required only cholecystectomy as a second-stage procedure. The average perioperative blood product transfusion requirement in second-stage surgery was 0.9 units and postoperative complications were minimal with no mortality. Over a mean follow-up of 32.2 months, all patients were asymptomatic. Decompressive shunt surgery alone relieved biliary obstruction in 24 of 37 patients (64.9%) and facilitated a safe second-stage biliary decompressive procedure in the remaining 13 patients (35.1%).

CONCLUSIONS

Decompressive shunt surgery alone relieves biliary obstruction in the majority of patients with symptomatic PBP and facilitates endoscopic or surgical management in patients who require second-stage management of biliary obstruction.

Obstructive jaundice caused by a portal cavernoma

A 69-year-old Japanese man was admitted to our hospital because of acute cholangitis with biliary obstruction. The cause of obstruction was either compression by a portal cavernoma or cavernous transformation. Multidetector row computed tomography (MDCT) and abdominal ultrasonography (US) revealed a portal cavernoma around the common bile duct. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiography (ERC) demonstrated characteristic short, smooth narrowing of the bile duct. Endoscopic US and intraductal US demonstrated collateral vessels around the bile duct and were helpful for ruling out a neoplastic lesion. Thus, a combination of imaging modalities was useful for diagnosing this hepatobiliary complication, portal biliopathy.

Portal hypertensive biliopathy: a rare cause of childhood cholestasis

Portal hypertensive biliopathy (PHB) is defined as abnormal biliary changes that take place most likely secondary to extrahepatic portal vein obstruction (EHPVO) with portal hypertension. This condition may be asymptomatic or could lead to a cholestatic state, which is not well-described in children. We report a child who developed a cholestatic nature with portal hypertension some time after having neonatal surgery for duodenal atresia. We discuss the differential diagnosis and management of this rare condition. Symptomatic PHB has been only rarely reported in children. It should be suspected in patients with portal hypertension and having features of biliary obstruction. Hepaticojejunostomy may have a therapeutic role in selected patients in whom endoscopic or percutaneous manipulation of the biliary tree is unsuccessful and who have not responded to a surgical portal-systemic shunt procedure.

Therapeutic strategies in symptomatic portal biliopathy

SUMMARY BACKGROUND DATA

Chronic portal obstruction can lead to formation of portal cavernoma (PC). Half of all patients with PC will develop cholestasis, termed portal biliopathy, and some will progress to symptomatic biliary obstruction. Because of the high hemorrhage risk associated with biliary surgery in patients with PC, the optimal therapeutic strategy is controversial.

METHODS

Retrospective review of a single hepatobiliary center experience, including 64 patients with PC identified 19 patients with concurrent symptomatic biliary obstruction. Ten patients underwent initial treatment with a retroperitoneal splenorenal anastomosis. For the remaining 9 patients, portal biliopathy was managed without portosystemic shunting (PSS). Outcomes, including symptom relief, the number of biliary interventions, and survivals, were studied in these 2 groups.

RESULTS

Within 3 months of PSS, 7 of 10 patients (70%) experienced a reduction in biliary obstructive symptoms. Five of these 10 patients subsequently underwent uncomplicated biliary bypass, and none has recurred with biliary symptoms or required biliary intervention with a mean follow-up of 8.2 years. For patients without PSS, repeated percutaneous and endobiliary procedures were required to relieve biliary symptoms. Four of the 9 patients with persistent PC required surgical intrahepatic biliary bypass, which was technically more challenging. With a mean follow-up of 8 years, 1 of these 9 patients died of severe cholangitis, 1 remained jaundiced, and 7 were asymptomatic.

CONCLUSIONS

This study, which represents the largest published experience with the surgical treatment of patients with symptomatic portal biliopathy, indicates that retroperitoneal splenorenal anastomosis improves outcomes and should be the initial treatment of choice.

Biliary abnormalities associated with portal biliopathy: evaluation on MR cholangiography

OBJECTIVE

The purpose of our study was to evaluate the MRI features of portal biliopathy.

CONCLUSION

MR cholangiography coupled with dynamic 3D gradient-echo imaging could not only detect portal vein occlusion, cavernous transformation, and gallbladder varices but is also suitable for delineating associated bile duct abnormalities.

Recent concepts regarding extra-hepatic portal hypertension

Extra-hepatic portal hypertension (EHPH) defined as non cirrhotic, presinusoidal and prehepatic portal hypertension, with obstruction and cavernomatous transformation of the main portal vein, entails a high, early and prolonged risk of gastro-intestinal bleeding (GIB) mainly from esophageal and/or gastric varices, and less often a risk of cholangiopathy or protein-losing enteropathy. Diagnosis of EHPH may be done with non invasive imaging techniques. Assessment of bleeding risk is based on results of endoscopic examination. Occurence of a bleeding episode or onset during follow-up of endoscopic signs of high risk of GIB require radical eradication of varices. Radical cure of EHPH is achieved at best by bypass surgery restoring a physiological portal flow, and as a second choice by shunt surgery. Endoscopic therapy has a place as first line treatment of GIB episodes, and also in a few cases with poor extrahepatic portal network contra-indicating efficient vascular surgery.

Portal cavernoma-associated cholangiopathy: a clinical and MR cholangiography coupled with MR portography imaging study

Although biliary symptoms appear to be uncommon in patients with portal cavernoma, almost all of them have endoscopic retrograde cholangiographic abnormalities. The mechanisms underlying the biliary changes are explained poorly. This study in patients with portal cavernoma had 3 aims: (1) to assess the manifestations related to biliary involvement; (2) to evaluate with magnetic resonance (MR) imaging the aspect and frequency of cholangiographic changes; and (3) to clarify the mechanisms underlying biliary involvement. From December 1999 to July 2001, 25 consecutive adults with portal cavernoma without cancer or cirrhosis were studied with MR cholangiography coupled with MR portography. Seven patients presented with clinical manifestations of biliary disease. MR cholangiography findings were stenosis in 21 patients, with upstream dilatation in 16 and displacement in 13. MR cholangiography coupled with MR portography showed in all cases that the biliary abnormalities were secondary to a mass effect directly related to pressure by the cavernoma. In conclusion, in patients with portal cavernoma, clinical manifestations of biliary disease are most frequent; the cholangiographic abnormalities are very common and usually are caused by a mass effect by pressure from the veins composing the cavernoma. MR cholangiography coupled with MR portography is an effective noninvasive examination for simultaneous visualization of bile ducts and their relationship to the cavernoma.