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Malik A, Malik S, Farooq A, Malik MI, Javaid S. Histopathological features of idiopathic portal hypertension: A systematic review and meta-analysis. Sci Prog 2024; 107:368504241264996. [PMID: 39053026 PMCID: PMC11282518 DOI: 10.1177/00368504241264996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
BACKGROUND Portal hypertension (PH) is a clinically significant entity that could present with life-threatening gastrointestinal bleeding. Cirrhosis is the most common cause of PH, with well-documented histopathology and etiology. However, in idiopathic portal hypertension (IPH), no single histopathologic finding is associated with PH. Our systematic review aims to identify and summarize the prevalence of the common histological findings of IPH. METHODS We systematically searched PubMed, Cochrane CENTRAL, Web of Science, and Scopus till 1ST March 2022 for studies describing the histopathological features of IPH. Data were extracted from eligible studies and pooled as events rate and 95% confidence interval (CI) using binary random-effects model by open meta-analyst software. RESULTS We included 23 retrospective studies with a total sample size of 813 patients. The overall incidence of nodular regenerative hyperplasia was 38.6%, 59.8% for portal fibrosis, 51.3% for periportal fibrosis, 39.3% for perisinusoidal fibrosis, 89.8% for portal vein sclerosis, 42.2% for portal inflammation, 53.3% for mega-sinusoids, 39.5% for thickening of portal vein branches, 93.8% for narrowing of portal veins, 53.3% for hepatic veins/venous outflow obstruction, 51.4% for aberrant portal/periportal vessels, 42.4% for shunt vessel, 50.9% for ductular proliferation, and 16.3% for steatosis. CONCLUSION Due to the relatively non-pathognomonic and non-specific nature of IPH, a combination of different histological features such as the portal and periportal fibrosis, portal vein sclerosis, mega-sinusoids, narrowing of portal veins, hepatic venous outflow obstruction, aberrant portal or periportal vessels, and ductular proliferation may be of value in diagnosing IPH as the incidence rate of these features was at approximately 50%.
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Affiliation(s)
- Adnan Malik
- Mountain Vista Medical Center, Midwestern University Program, Mesa AZ, USA
| | - Sohira Malik
- Penn State College of Medicine, Hershey, PA, USA
| | - Ahsan Farooq
- Penn State College of Medicine, Hershey, PA, USA
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2
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Kaur B, Vipani A, Trivedi H, Kuo A, Guindi M, Yang JD, Ayoub WS. Traditional Chinese Medicine, Cordyceps, Related to Hepatoportal Sclerosis. ACG Case Rep J 2023; 10:e01206. [PMID: 38033616 PMCID: PMC10686585 DOI: 10.14309/crj.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023] Open
Abstract
We describe a case of hepatoportal sclerosis (HPS) identified in an 81-year-old woman taking a traditional Chinese herbal supplementation, Cordyceps. The patient presented with splenomegaly and weight loss. After an extensive evaluation, liver biopsy confirmed loss of the small portal veins with characteristics of obstruction at the level of the small and large portal veins, suggestive of HPS. After a comprehensive history and exclusion of other etiological factors, patient's HPS was attributed to Cordyceps use. Ultimately, the patient's features of HPS improved with the cessation of Cordyceps.
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Affiliation(s)
- Bhupinder Kaur
- Division of Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Aarshi Vipani
- Division of Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Hirsh Trivedi
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Alexander Kuo
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Maha Guindi
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Walid S. Ayoub
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
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3
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Mathuram Thiyagarajan U, Lee S, Shapiro A. First Successful Liver-Alone Transplantation for TERT (Telomerase Reverse Transcriptase)-Telomeropathy-Related Hepatoportal Sclerosis Cirrhosis. Cureus 2023; 15:e41296. [PMID: 37539400 PMCID: PMC10394478 DOI: 10.7759/cureus.41296] [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: 06/27/2023] [Indexed: 08/05/2023] Open
Abstract
Hepatoportal sclerosis is a rare but well-described condition leading to end-stage liver disease. Telomeropathy is a rare genetic disorder which manifests as premature senescence of cells leading to multisystem disease involving bone marrow, lungs and skin. To the best of our knowledge, there is no report of telomeropathy precipitating end-stage liver disease. Our case presented hepatopulmonary syndrome. Herein, we report a successful liver transplantation in a patient who suffered hepatoportal cirrhosis from telomerase reverse transcriptase (TERT)-telomeropathy.
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Affiliation(s)
| | - Samuel Lee
- Gastroenterology, Faculty of Medicine, University of Calgary, Calgary, CAN
| | - Amj Shapiro
- Surgery, Medicine and Surgical Oncology, University of Alberta Hospital, Edmonton, CAN
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4
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Di Giorgio A, Matarazzo L, Sonzogni A, Nicastro E, Pietrobattista A, Cananzi M, Gaio P, Sciveres M, Di Leo G, Iorio R, Marseglia A, Carioli G, Maggiore G, Guido M, D'Antiga L. Paediatric porto-sinusoidal vascular disease: Two different clinical phenotypes with subtle histological differences. Liver Int 2023. [PMID: 37157951 DOI: 10.1111/liv.15603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/13/2023] [Accepted: 04/23/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS In paediatrics, porto-sinusoidal vascular disease (PSVD) is relatively unknown and probably underdiagnosed. We aimed to describe clinical phenotypes, histology and outcome of children diagnosed with PSVD. METHODS Retrospective multicentre study of children diagnosed with PSVD. Diagnosis of PSVD was based on histopathology reports; liver specimens were re-evaluated by two expert liver pathologists. RESULTS Sixty two children diagnosed with PSVD (M/F = 36/26, median age 6.6 years, range 3.3-10.6), from 7 centres, were included. Thirty-six presented with non-cirrhotic portal hypertension, PH, (PH-PSVD Group = 58%) while 26 had a liver biopsy because of chronic elevation of transaminases without PH (noPH-PSVD Group = 42%). On histology review, the two groups differed for the prevalence of obliterative portal venopathy (more prevalent in PH-PSVD, p = 0.005), and hypervascularised portal tracts (more common in noPH-PSVD, p = 0.039), the other histological changes were equally distributed. At multivariate analysis, platelet count ≤185 000/mm3 was the only independent determinant of PH (p < 0.001). After a median follow-up of 7 years (range 3.0-11.2), in PH-PSVD group 3/36 (8%) required TIPS placement, 5/36 (14%) developed pulmonary vascular complications of PH, and 7/36 (19%) required liver transplantation. In noPH-PSVD none progressed to PH nor had complications. CONCLUSIONS Paediatric patients with PSVD present with two different clinical phenotypes, one characterised by PH and one by chronic elevation of transaminases without PH. PSVD should be included among the conditions causing isolated hypertransaminasaemia. On histology, the differences between the two groups are subtle. Medium-term outcome is favourable in patients without PH; progression of the disease is observed in those with PH.
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Affiliation(s)
- Angelo Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenza Matarazzo
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Emanuele Nicastro
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Andrea Pietrobattista
- Hepatology, Gastroenterology, Digestive Endoscopy, Nutrition, and Liver Transplantation Unit, IRCCS Bambino Gesù, Pediatric Hospital, Rome, Italy
| | - Mara Cananzi
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Paola Gaio
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Marco Sciveres
- Paediatric Department and Transplantation, ISMETT, Palermo, Italy
| | | | - Raffaele Iorio
- Department of Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Antonio Marseglia
- Fondazione IRCCS Casa Sollievo della Sofferenza, Division of Pediatrics, San Giovanni Rotondo, Italy
| | - Greta Carioli
- FROM Research Foundation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology, Digestive Endoscopy, Nutrition, and Liver Transplantation Unit, IRCCS Bambino Gesù, Pediatric Hospital, Rome, Italy
| | - Maria Guido
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
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5
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Zhang X, Durham KM, Garza AA, Murali AR. Portal vein thrombosis, hepatic decompensation, and survival in patients with porto-sinusoidal vascular disease and portal hypertension. J Gastroenterol 2023; 58:268-276. [PMID: 36692825 DOI: 10.1007/s00535-023-01957-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/07/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Porto-sinusoidal vascular disease (PSVD) is a novel nomenclature to describe non-cirrhotic portal hypertension and characteristic histology without portal vein thrombosis (PVT). It is a more inclusive definition than the previously well-recognized entity idiopathic non-cirrhotic portal hypertension. There is a paucity of data on PSVD patients. METHODS A total of 33 patients diagnosed with PSVD and portal hypertension (PH) between 2005 and 2021 were included. Data were retrieved from electronic medical record system and analyzed. RESULTS Of the 33 patients, 6 (18%) occurred in post-transplant allograft liver. After a median follow-up of 96 months (interquartile range, IQR [52, 139]), 14 deaths occurred (42%), 4 directly related to decompensated liver disease. The Kaplan-Meier survival estimates at 1, 5, and 10 years were 94%, 87% and 58%. PVT occurred in 10 patients (30%). The Nelson-Aalen cumulative risk estimate for PVT at 1, 5 and 10 years were 16%, 25% and 48%. The median model for end-stage liver disease and Child-Pugh score at initial presentation were 8 (IQR [7-12]) and 5 [5-6], and increased to 13 [8, 18] and 7 [5, 8], respectively, at the end of follow-up. Of the 11 patients who presented with splenomegaly and no specific sign of PH, 7 (64%) developed varices and 3 (27%) ascites at a median follow-up of 100 months. CONCLUSIONS PSVD with PH is not a benign entity. Mortality, PVT and hepatic decompensation are common. Patients with PSVD must be closely monitored, including those who only have non-specific clinical signs (e.g., splenomegaly) of PH.
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Affiliation(s)
- Xiaocen Zhang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, USA
| | - Katelin Marie Durham
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, USA
| | - Alexander Austin Garza
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, USA
| | - Arvind R Murali
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, USA.
- Liver Center, Orlando Health Digestive Health Institute, 89 W. Copeland Dr., Orlando, FL, USA.
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Valainathan SR, Sartoris R, Elkrief L, Magaz M, Betancourt F, Pellegrino S, Nivolli A, Dioguardi Burgio M, Flattet Y, Terraz S, Drilhon N, Lazareth M, Herrou J, Bruno O, Payance A, Plessier A, Durand F, Ronot M, Valla D, Paradis V, Garcia‐Pagan JC, Vilgrain V, Rautou P. Contrast-enhanced CT and liver surface nodularity for the diagnosis of porto-sinusoidal vascular disorder: A case-control study. Hepatology 2022; 76:418-428. [PMID: 35092315 PMCID: PMC9544289 DOI: 10.1002/hep.32367] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/10/2022] [Accepted: 01/21/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Porto-sinusoidal vascular disorder (PSVD) is a rare and commonly overlooked cause of portal hypertension. The interest of CT analysis, including quantification of liver surface nodularity (LSN) for PSVD diagnosis has not been established. This study aimed at assessing the performance of LSN and CT features for a PSVD diagnosis in patients with signs of portal hypertension. APPROACH AND RESULTS This retrospective case-control study included a learning cohort consisting of 50 patients with histologically proven PSVD, according to VALDIG criteria, and 100 control patients with histologically proven cirrhosis, matched on ascites. All patients and controls had at least one sign of portal hypertension and CT available within 1 year of liver biopsy. Principal component analysis of CT features separated patients with PSVD from patients with cirrhosis. Patients with PSVD had lower median LSN than those with cirrhosis (2.4 vs. 3.1, p < 0.001). Multivariate analysis identified LSN < 2.5 and normal-sized or enlarged segment IV as independently associated with PSVD. Combination of these two features had a specificity of 90% for PSVD and a diagnostic accuracy of 84%. Even better results were obtained in an independent multicenter validation cohort including 53 patients with PSVD and 106 control patients with cirrhosis (specificity 94%, diagnostic accuracy 87%). CONCLUSIONS This study that included a total of 103 patients with PSVD and 206 patients with cirrhosis demonstrates that LSN < 2.5 combined with normal-sized or enlarged segment IV strongly suggests PSVD in patients with signs of portal hypertension.
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Affiliation(s)
- Shantha Ram Valainathan
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Riccardo Sartoris
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Laure Elkrief
- Service d’Hépato‐gastroentérologieHôpitaux Universitaires de GenèveGenevaSwitzerland,Service d’Hépato‐GastroentérologieHôpital TrousseauCHRU de ToursToursFrance
| | - Marta Magaz
- Barcelona Hepatic Hemodynamic LaboratoryLiver UnitHospital Clínic de BarcelonaIDIBAPSCIBERehdEuropean Reference Network for Rare Vascular Liver DiseasesUniversitat de BarcelonaBarcelonaSpain
| | - Fabian Betancourt
- Barcelona Hepatic Hemodynamic LaboratoryLiver UnitHospital Clínic de BarcelonaIDIBAPSCIBERehdEuropean Reference Network for Rare Vascular Liver DiseasesUniversitat de BarcelonaBarcelonaSpain
| | - Silvia Pellegrino
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Arianna Nivolli
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Marco Dioguardi Burgio
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Yves Flattet
- Service d’Hépato‐gastroentérologieHôpitaux Universitaires de GenèveGenevaSwitzerland
| | - Sylvain Terraz
- Department of RadiologyUniversity Hospitals of GenevaGenevaSwitzerland
| | - Nicolas Drilhon
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Marie Lazareth
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Julia Herrou
- Department of RhumatologyHôpital CochinAssistance Publique‐Hôpitaux de ParisParisFrance
| | - Onorina Bruno
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Audrey Payance
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Aurélie Plessier
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - François Durand
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Maxime Ronot
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Dominique‐Charles Valla
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
| | - Valérie Paradis
- Department of PathologyUniversité de ParisAP‐HP, Hôpital BeaujonBeaujon HospitalAssistance Publique‐Hôpitaux de ParisClichyFrance
| | - Juan Carlos Garcia‐Pagan
- Barcelona Hepatic Hemodynamic LaboratoryLiver UnitHospital Clínic de BarcelonaIDIBAPSCIBERehdEuropean Reference Network for Rare Vascular Liver DiseasesUniversitat de BarcelonaBarcelonaSpain
| | - Valérie Vilgrain
- Centre de Recherche sur l’inflammationInsermUMR 1149Université de ParisParisFrance,Department of RadiologyAP‐HP NordHôpital BeaujonClichyFrance
| | - Pierre‐Emmanuel Rautou
- Service d'HépatologieDMU DIGESTCentre de Référence des Maladies Vasculaires du FoieFILFOIEERN RARE‐LIVERCentre de Recherche sur l’inflammationInsermUMR 1149Université de ParisAP‐HPHôpital BeaujonParisFrance
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Kmeid M, Liu X, Ballentine S, Lee H. Idiopathic Non-Cirrhotic Portal Hypertension and Porto-Sinusoidal Vascular Disease: Review of Current Data. Gastroenterology Res 2021; 14:49-65. [PMID: 34007347 PMCID: PMC8110235 DOI: 10.14740/gr1376] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/30/2021] [Indexed: 12/29/2022] Open
Abstract
Idiopathic non-cirrhotic portal hypertension (INCPH) is a clinicopathologic disease entity characterized by the presence of clinical signs and symptoms of portal hypertension (PH) in the absence of liver cirrhosis or known risk factors accountable for PH. Multiple hematologic, immune-related, infectious, hereditary and metabolic risk factors have been associated with this disorder. Still, the exact etiopathogenesis is largely unknown. The recently proposed porto-sinusoidal vascular disease (PSVD) scheme broadens the spectrum of the disease by also including patients without clinical PH who are found to have similar histopathologic findings on core liver biopsies. Three histomorphologic lesions have been identified as specific for PSVD to include obliterative portal venopathy, nodular regenerative hyperplasia and incomplete septal cirrhosis/fibrosis. However, these findings are often subtle, under-recognized and subjective with low interobserver agreement among pathologists. Additionally, the natural history of the subclinical forms of the disease remains unexplored. The clinical course is more favorable compared to cirrhosis patients, especially in the absence of clinical PH or liver dysfunction. There are no universally accepted guidelines in regard to diagnosis and treatment of INCPH/PSVD. Hence, this review emphasizes the need to raise awareness of this entity by highlighting its complex pathophysiology and clinicopathologic associations. Lastly, formulation of standardized diagnostic criteria with clinical validation is necessary to avoid misclassifying vascular diseases of the liver and to develop and implement targeted therapeutic strategies.
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Affiliation(s)
- Michel Kmeid
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - Xiuli Liu
- Department of Pathology and Laboratory Medicine, University of Florida at Gainesville, FL, USA
| | - Samuel Ballentine
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hwajeong Lee
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
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8
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Liang J, Shi C, Dupont WD, Salaria SN, Huh WJ, Correa H, Roland JT, Perri RE, Washington MK. Key histopathologic features in idiopathic noncirrhotic portal hypertension: an interobserver agreement study and proposal for diagnostic criteria. Mod Pathol 2021; 34:592-602. [PMID: 32958831 DOI: 10.1038/s41379-020-00676-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 12/16/2022]
Abstract
Histologic features of idiopathic noncirrhotic portal hypertension (INCPH), loosely termed as obliterative portal venopathy (OPV), are heterogenous, often subtle, and overlap with other entities. To this date, no consensus histopathologic diagnostic criteria have been established for INCPH. For these reasons, rendering a reproducible consensus histologic diagnosis of OPV on a liver biopsy may often be challenging even for experienced hepatopathologists. We report herein a two-phase interobserver agreement study on the diagnosis of OPV and assessed the relative value of histologic features in 104 liver biopsies in distinguishing between INCPH and non-INCPH with the goal to obtain a consensus on specific practical diagnostic criteria. Six hepatopathologists blinded to clinical information and original pathologic diagnosis reviewed internet-based case study sets with high-resolution whole-slide images. The initial interobserver agreement on OPV was expectedly low, but significantly improved (moderate agreement in most categories) upon adopting a consensus view recognizing portal vein sclerosis as the only strong independent histologic predictor for INCPH, and that contrary to the conventional view, aberrant portal/periportal vessels does not significantly contribute to the positive assignment of OPV status. We propose a three-tiered classification with diagnostic criteria to facilitate the histologic assignment of OPV status for the evaluation of INCPH. Furthermore, we have validated the performance of the proposed criteria either based on histology alone or coupled with clinicopathologic correlation. This classification may aid in practical histologic assessment of liver biopsies with or without portal hypertension and help to improve diagnostic consistency and accuracy.
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Affiliation(s)
- Jiancong Liang
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Chanjuan Shi
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Safia N Salaria
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Won Jae Huh
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernan Correa
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph T Roland
- Epithelial Biology Center and Department of Surgery, Vanderbilt University School of Medicine and the Nashville VA Medical Center, Nashville, TN, USA
| | - Roman E Perri
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mary Kay Washington
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
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9
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Zhang X, Thomas C, Schiano TD, Thung SN, Ward SC, Fiel MI. Aberrant von Willebrand factor expression of sinusoidal endothelial cells and quiescence of hepatic stellate cells in nodular regenerative hyperplasia and obliterative portal venopathy. Histopathology 2020; 76:959-967. [PMID: 31994248 DOI: 10.1111/his.14083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/20/2020] [Accepted: 01/25/2020] [Indexed: 02/06/2023]
Abstract
AIMS Nodular regenerative hyperplasia (NRH) and obliterative portal venopathy (OPV), entities that comprise idiopathic non-cirrhotic portal hypertension (INCPH), are under-recognised diseases of uncertain aetiology and the diagnosis can be easily missed on liver biopsy. The expression of CD34 and von Willebrand factor (vWF) in liver sinusoidal endothelial cells (LSEC) and alpha-smooth muscle actin (ASMA) in hepatic stellate cells (HSCs) is unknown in NRH and OPV. We sought to investigate the pathogenesis and potential immunomarkers that might aid in making the diagnosis of NRH and OPV. METHODS AND RESULTS Immunohistochemical (IHC) staining for CD34, vWF and ASMA was performed in clinically and histologically well-characterised NRH (n = 15) and OPV (n = 47) liver specimens. Among the 47 OPV cases, 37 (78.7%) had concurrent features of NRH. CD34 positive staining was mainly confined to small vessels in the portal tracts and LSECs in periportal areas, a finding similar to that in non-NRH/OPV livers. However, expression of vWF in LSECs was positive in the compressed sinusoids of NRH and in a patchy or geographic pattern, particularly prominent in the perivenular areas and dilated sinusoids of OPV cases. HSCs were negative for ASMA in all NRH and OPV cases. CONCLUSION Our findings indicate that NRH may be a subtle but common concurrent morphological feature in OPV. The aberrant expression of vWF in LSECs suggests that endothelial injury may play a role in the pathogenesis, which may thus aid in the recognition and diagnosis of NRH and OPV, particularly when confronted with otherwise apparent normal liver histology on needle biopsy.
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Affiliation(s)
- Xuchen Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Courtney Thomas
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas D Schiano
- Department of Medicine - Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Swan N Thung
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephen C Ward
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M Isabel Fiel
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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11
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Can we differentiate HIV-associated obliterative portopathy from liver cirrhosis using MRI? Eur Radiol 2019; 30:213-223. [PMID: 31410601 DOI: 10.1007/s00330-019-06391-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/18/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023]
Abstract
AIM To describe the magnetic resonance imaging (MRI) features of HIV-associated obliterative portopathy (HIV-OP) and determine the most indicative appearance of this condition on MRI by using a retrospective case-control study. METHODS MRI examinations of 24 patients with HIV-OP (16 men, 8 women; mean age = 48 ± 6.6 [SD] years; age range, 35-71 years) were analyzed by two blinded observers and compared with those obtained in 18 HIV-infected patients with hepatic cirrhosis (14 men, 4 women; mean age = 51 ± 3.4 [SD] years; age range, 35-60 years). Images were qualitatively and quantitatively analyzed with respect to imaging presentation. Comparisons were performed using uni- and multivariate analyses. RESULTS Regular liver contours had the highest accuracy for the diagnosis of HIV-OP (83%, 35 of 42; 95% confidence interval [CI], 69-93%) and was the most discriminating independent variable for the diagnosis of HIV-OP (odds ratio, 51; 95%CI, 4.96-1272%) (p < 0.0001). At multivariate analysis, the width of segment 4 in millimeters (OR = 1.23 [95%CI, 1.05-1.44%]; p = 0.011) and the presence of regular liver contours (OR = 7.69 [95%CI, 1.48-39.92%]; p = 0.015) were the variables independently associated with the diagnosis of HIV-OP. CONCLUSIONS Regular liver contours are the most discriminating independent variable for the diagnosis of HIV-OP but have limited accuracy. Familiarity with this finding may help differentiate HIV-OP from cirrhosis in HIV-infected patients. KEY POINTS • Regular liver contour is the most discriminating independent variable for the diagnosis of HIV-OP (odds ratio = 51) with 83% accuracy. • At multivariate analysis, the width of segment 4 in millimeters and the presence of regular liver contours are the variables independently associated with the diagnosis of HIV-OP. • MRI helps diagnose HIV-OP in the presence of several categorical findings, which are more frequently observed in HIV-OP patients than in HIV patients with cirrhosis.
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12
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Hernández-Gea V, Baiges A, Turon F, Garcia-Pagán JC. Idiopathic Portal Hypertension. Hepatology 2018; 68:2413-2423. [PMID: 30066417 DOI: 10.1002/hep.30132] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/16/2018] [Indexed: 12/12/2022]
Abstract
Idiopathic portal hypertension (IPH) is a rare disorder characterized by clinical portal hypertension in the absence of a recognizable cause such as cirrhosis. Laboratory tests often reveal a preserved liver function with anemia, leukopenia, and thrombocytopenia due to splenomegaly. Imaging studies reveal signs of portal hypertension, whereas liver stiffness and portal pressure values are usually normal or slightly elevated. Liver biopsy is considered mandatory in order to rule out other causes of portal hypertension, mainly cirrhosis. Liver histology may only show subtle or mild changes, and the definite diagnosis of IPH often requires an expert pathologist and a high-quality specimen. The most frequent clinical presentation is variceal bleeding. Ascites is rarely observed initially, although it may occasionally appear during follow-up. Typical histological findings associated with IPH have been described in patients without portal hypertension, probably representing early stages of the disease. Although the pathophysiology of this entity remains largely unknown, it is frequently associated with underlying immunological disorders, bacterial infections, trace metal poisoning, medications, liver circulatory disturbances, and thrombotic events. The long-term prognosis of patients with IPH, where ascites and the underlying condition are important prognostic factors, is better than in patients with cirrhosis. Treatments that modify the natural history of the disease remain an unmet need, and management of IPH is frequently restricted to control of portal hypertension-related complications.
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Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
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13
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Guido M, Alves VAF, Balabaud C, Bathal PS, Bioulac-Sage P, Colombari R, Crawford JM, Dhillon AP, Ferrell LD, Gill RM, Hytiroglou P, Nakanuma Y, Paradis V, Quaglia A, Rautou PE, Theise ND, Thung S, Tsui WMS, Sempoux C, Snover D, van Leeuwen DJ. Histology of portal vascular changes associated with idiopathic non-cirrhotic portal hypertension: nomenclature and definition. Histopathology 2018; 74:219-226. [DOI: 10.1111/his.13738] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/07/2018] [Accepted: 08/18/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Maria Guido
- Department of Medicine-DIMED; Pathology Unit; University of Padova; Padova Italy
| | - Venancio A F Alves
- Department of Pathology; University of Sao Paulo School of Medicine; Sao Paulo Brazil
| | | | - Prithi S Bathal
- Department of Pathology; University of Melbourne; Melbourne Vic. Australia
| | - Paulette Bioulac-Sage
- Department of Pathology; CHU Bordeaux, and Inserm U1053; Bordeaux University; Bordeaux France
| | | | - James M Crawford
- Department of Pathology and Laboratory Medicine; Donald and Barbara School of Medicine at Hofstra/Northwell; New York NY USA
| | - Amar P Dhillon
- Department of Cellular Pathology; UCL Medical School; London UK
| | - Linda D Ferrell
- Department of Pathology; University of California; San Francisco CA USA
| | - Ryan M Gill
- Department of Pathology; University of California; San Francisco CA USA
| | - Prodromos Hytiroglou
- Department of Pathology; Aristotle University Medical School; Thessaloniki Greece
| | - Yasuni Nakanuma
- Department of Diagnostic Pathology; Shizuoka Cancer Centre; Shizuoka Japan
| | | | - Alberto Quaglia
- Institute of Liver Studies; King's College Hospital and King's College; London UK
| | - Pierre E Rautou
- Department of Hepatology; Hopital Beaujon; University of Paris; Paris France
| | - Neil D Theise
- Department of Pathology; New York University School of Medicine; New York NY USA
| | - Swan Thung
- Department of Pathology; Icahn School of Medicine at Mount Sinai; New York NY USA
| | | | - Christine Sempoux
- Service of Clinical Pathology; Lausanne University Hospital; Institute of Pathology; Lausanne Switzerland
| | - Dale Snover
- Department of Pathology; Fairview Southdale Hospital; Edina MN USA
| | - Dirk J van Leeuwen
- Section of Gastroenterology and Hepatology; Geisel School of Medicine at Dartmouth College; Hanover NH USA
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14
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Jha RC, Khera SS, Kalaria AD. Portal Vein Thrombosis: Imaging the Spectrum of Disease With an Emphasis on MRI Features. AJR Am J Roentgenol 2018; 211:14-24. [DOI: 10.2214/ajr.18.19548] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Reena C. Jha
- Department of Radiology, MedStar Georgetown University Hospital, 3800 Reservoir Rd, NW, Lombardi, G-184, Washington, DC 20007
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15
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Pathology of idiopathic non-cirrhotic portal hypertension. Virchows Arch 2018; 473:23-31. [DOI: 10.1007/s00428-018-2355-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/29/2018] [Accepted: 04/02/2018] [Indexed: 12/15/2022]
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16
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Seijo S, Lozano JJ, Alonso C, Miquel R, Berzigotti A, Reverter E, Turon F, Martínez-Chantar ML, Castro A, Mato JM, Hernández-Gea V, Bosch J, García-Pagán JC. Metabolomics as a diagnostic tool for idiopathic non-cirrhotic portal hypertension. Liver Int 2016; 36:1051-8. [PMID: 26394550 DOI: 10.1111/liv.12972] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/31/2015] [Indexed: 02/13/2023]
Abstract
BACKGROUND Idiopathic non-cirrhotic portal hypertension (INCPH) is a rare life-threatening liver disease that lacks a specific diagnostic test being frequently misdiagnosed as cryptogenic cirrhosis. Preliminary data from our group identified a plasma metabolomic profile able to differentiate INCPH from patients with cirrhosis (CH) and healthy volunteers (HV). However, the untargeted methodology applied was unable to identify all the specific metabolites, hampering the possibility of building-up diagnostic models. This study applies a wide-coverage of previously identified metabolites through a high-throughput metabolomics technology, evaluating if there is a metabolomic profile that allows a non-invasive diagnosis of INCPH. METHODS We included 34 patients with INCPH, 34 with CH and 34 HV. We performed a targeted metabolomic analysis of serum samples using UPLC-MS. The best combination of a set of specific metabolites was obtained using stepwise logistic regression (LR) and recursive partitioning analysis (RPA). RESULTS After internal cross-validation, LR analysis identified a subset of 5-metabolites that clearly differentiate INCPH patients from CH and HV (average corrected optimism AUROC = 0.8871 [0.838-0.924]). Using high and low cut-off values the model has an excellent capacity to respectively diagnose or exclude INCPH. The RPA analysis strategy used the 3-metabolites signature differentiating INCPH from CH and the 2-metabolites signature differentiating INCPH from HV. A decision tree applying sequentially these metabolic profiles diagnosed 88% of INCPH patients. CONCLUSIONS Different metabolomic profiles allow the diagnosis of INCPH with high specificity and sensibility and may represent excellent clinical tools for its diagnosis avoiding multiple and invasive tests.
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Affiliation(s)
- Susana Seijo
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Juan Jose Lozano
- Bioinformatic Platform, CIBERehd, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | | | - Rosa Miquel
- Pathology Deparment, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Annalisa Berzigotti
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Enric Reverter
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mari Luz Martínez-Chantar
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,CIC bioGUNE, Bizkaia, Spain
| | | | - Jose M Mato
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,CIC bioGUNE, Bizkaia, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Jaume Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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17
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18
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Lee H, Rehman AU, Fiel MI. Idiopathic Noncirrhotic Portal Hypertension: An Appraisal. J Pathol Transl Med 2015; 50:17-25. [PMID: 26563701 PMCID: PMC4734966 DOI: 10.4132/jptm.2015.09.23] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 09/23/2015] [Indexed: 02/07/2023] Open
Abstract
Idiopathic noncirrhotic portal hypertension is a poorly defined clinical condition of unknown etiology. Patients present with signs and symptoms of portal hypertension without evidence of cirrhosis. The disease course appears to be indolent and benign with an overall better outcome than cirrhosis, as long as the complications of portal hypertension are properly managed. This condition has been recognized in different parts of the world in diverse ethnic groups with variable risk factors, resulting in numerous terminologies and lack of standardized diagnostic criteria. Therefore, although the diagnosis of idiopathic noncirrhotic portal hypertension requires clinical exclusion of other conditions that can cause portal hypertension and histopathologic confirmation, this entity is under-recognized clinically as well as pathologically. Recent studies have demonstrated that variable histopathologic entities with different terms likely represent a histologic spectrum of a single entity of which obliterative portal venopathy might be an underlying pathogenesis. This perception calls for standardization of the nomenclature and formulation of widely accepted diagnostic criteria, which will facilitate easier recognition of this disorder and will highlight awareness of this entity.
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Affiliation(s)
- Hwajeong Lee
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - Aseeb Ur Rehman
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - M Isabel Fiel
- Department of Pathology, The Mount Sinai Medical Center, New York, NY, USA
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19
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Lee H, Ainechi S, Singh M, Ells PF, Sheehan CE, Lin J. Histological Spectrum of Idiopathic Noncirrhotic Portal Hypertension in Liver Biopsies From Dialysis Patients. Int J Surg Pathol 2015; 23:439-46. [DOI: 10.1177/1066896915582264] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objectives. Liver biopsy is performed for various indications in dialysis patients. Being a less-common subset, the hepatic pathology in renal dialysis is not well documented. Idiopathic noncirrhotic portal hypertension (INCPH) is a clinical entity associated with unexplained portal hypertension and/or a spectrum of histopathological vascular changes in the liver. After encountering INCPH and vascular changes of INCPH in 2 renal dialysis patients, we sought to further investigate this noteworthy association. Materials and methods. A random search for patients on hemodialysis or peritoneal dialysis with liver biopsy was performed. Hematoxylin and eosin, reticulin, trichrome, and CK7 stains were performed on formalin-fixed, paraffin-embedded tissue sections. Histopathological features were reviewed, and the results were correlated with clinical findings. Results. In all, 13 liver biopsies were retrieved. The mean cumulative duration of dialysis was 50 months (range = 17 months to 11 years). All patients had multiple comorbidities. Indications for biopsy were a combination of abnormal liver function tests (6), portal hypertension (4), ascites (3), and possible cirrhosis (3). Two patients with portal hypertension underwent multiple liver biopsies for diagnostic purposes. All (100%) biopsies showed some histological features of INCPH, including narrowed portal venous lumen (9), increased portal vascular channels (8), shunt vessels (3), dilated sinusoids (9), regenerative nodule (5), and features of venous outflow obstruction (3). No cirrhosis was identified. Conclusion. Liver biopsies from patients on dialysis demonstrate histopathological vascular changes of INCPH. Some (31%) patients present with portal hypertension without cirrhosis. The histological changes may be reflective of underlying risk factors for INCPH in this group.
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Affiliation(s)
| | | | | | | | | | - Jingmei Lin
- Indiana University School of Medicine, Indianapolis, IN, USA
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20
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Aggarwal S, Fiel MI, Schiano TD. Obliterative portal venopathy: a clinical and histopathological review. Dig Dis Sci 2013; 58:2767-76. [PMID: 23812828 DOI: 10.1007/s10620-013-2736-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 05/29/2013] [Indexed: 12/12/2022]
Abstract
Non-cirrhotic portal hypertension (NCPH) is characterized by the elevation of the portal pressure in the absence of cirrhosis. Obliterative portal venopathy (OPV) as a cause of NCPH is being increasingly diagnosed, especially after recent reports of its occurrence in patients with HIV using didanosine. Patients usually present with episodes of variceal hemorrhage and other features of portal hypertension including jaundice, ascites, encephalopathy and hepatopulmonary syndrome. Hepatic synthetic function is typically well preserved and the laboratory evaluation in OPV patients typically reveals only mild nonspecific hematological abnormalities chiefly related to hypersplenism. Its diagnosis remains a challenge and patients are often mistakenly diagnosed as having cirrhosis. Despite the increasing recognition of OPV, its etiology and pathogenesis are still unclear. A number of etiologies have been proposed including genetic predisposition, recurrent bacterial infections, HIV infection and highly active antiretroviral therapy, an altered immune response, hypercoagulability, and exposure to chemicals and certain medications. Histopathological evaluation remains critical in excluding cirrhosis and other causes of portal hypertension, and is the only way of definitively establishing the diagnosis of OPV. Clinicians should have a high index of suspicion for OPV in patients who present with variceal bleeding and splenomegaly and who do not have other features of cirrhosis. The purpose of this review is to summarize the known etiologies for OPV and its associated clinical aspects and correlations, and to also provide ample histophotomicrographs of OPV to aid in the diagnosis. It will also help raise awareness of this entity amongst pathologists and clinicians alike.
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Affiliation(s)
- Sourabh Aggarwal
- School of Medicine, Western Michigan University, Kalamazoo, MI, USA
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21
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Cantez MS, Gerenli N, Ertekin V, Güllüoğlu M, Durmaz Ö. Hepatoportal sclerosis in childhood: descriptive analysis of 12 patients. J Korean Med Sci 2013; 28:1507-11. [PMID: 24133357 PMCID: PMC3792606 DOI: 10.3346/jkms.2013.28.10.1507] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 07/29/2013] [Indexed: 11/20/2022] Open
Abstract
Hepatoportal sclerosis (HPS) is defined as sclerosis of portal areas in the absence of cirrhosis. There is little information about HPS in children in the literature. The aim of this study was to describe the clinical presentation, associated disorders, laboratory characteristics and outcome of children who were diagnosed as HPS. This study included 12 children diagnosed as HPS by the Pathology Department between 2005 and 2011. Data were collected from the gastroenterology clinic charts retrospectively, including demographics, presentation characteristics, laboratory data and recent status of patients. Twelve patients were enrolled (6 girls, 6 boys). The median age of patients was 13.5 yr. Median age at the time of biopsy was 11 yr. Four patients had splenomegaly, 3 had esophageal varices, one had hepatopulmonary syndrome and had been transplanted. Smooth muscle antibody was found positive in 4 patients, without autoimmune hepatitis findings in liver biopsy. One patient had celiac disease and another patient had positive celiac disease serology but pathology findings. Another patient had Turner's syndrome. Mean follow-up time was 39 months (3.3 yr) after biopsy. Hepatoportal sclerosis does not necessarily present with portal hypertension in children.
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Affiliation(s)
- Mustafa Serdar Cantez
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Istanbul, Turkey
| | - Nelgin Gerenli
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Istanbul, Turkey
| | - Vildan Ertekin
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Istanbul, Turkey
| | - Mine Güllüoğlu
- Istanbul University, Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey
| | - Özlem Durmaz
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Istanbul, Turkey
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22
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Tuyama AC, Krakauer M, Alzaabi M, Fiel MI, Legnani P, Schiano TD. Mercaptopurine-induced hepatoportal sclerosis in a patient with Crohn's disease. J Crohns Colitis 2013; 7:590-3. [PMID: 22841133 DOI: 10.1016/j.crohns.2012.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 07/06/2012] [Accepted: 07/06/2012] [Indexed: 02/08/2023]
Abstract
Thiopurines play a pivotal role in the management of inflammatory bowel disease. Azathioprine and mercaptopurine have been associated with a number of liver abnormalities, including hepatitis, veno-occlusive disease, nodular regenerative hyperplasia, and peliosis hepatitis. Patients treated with azathioprine and mercaptopurine have their liver chemistry tests routinely checked due to this potential for hepatotoxicity. Hepatoportal sclerosis is a cause of non-cirrhotic portal hypertension that is increasingly being recognized; its etiopathogenesis is not well defined. We present the first case report of mercaptopurine-induced hepatoportal sclerosis leading to non-cirrhotic portal hypertension in a patient with Crohn's disease. He had been treated with mercaptopurine for five years, and his liver chemistry tests were always within normal limits. This case underscores the potential serious liver adverse events that may arise silently and go undetected during treatment with mercaptopurine, and should alert clinicians as to the potential need to discontinue mercaptopurine in this setting.
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Affiliation(s)
- Ana C Tuyama
- Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, United States
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23
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Ataide EC, Dos Santos IN, Martins DL, Pereira TS, de Souza Almeida JR, Stucchi RSB, Escanhoela CAF, Boin IDFSF. Liver failure and the need for transplantation in 6 patients with hepatoportal sclerosis. Transplant Proc 2013; 45:1907-9. [PMID: 23769069 DOI: 10.1016/j.transproceed.2013.01.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/24/2013] [Indexed: 10/26/2022]
Abstract
Hepatoportal sclerosis (HPS), first reported by Mikkelsen et al in 1965, is a pathologic condition that does not cause cirrhotic portal hypertension. The primary hepatic lesion in HPS is found in portal vein branches with preserved synthetic function. Rarely do patients with HPS need liver transplantation. The aim of this study was to describe the clinical and pathologic features of 6 HPS cases who underwent liver transplantation (OLT). From 2000 to 2008, 6 OLT candidates were diagnosed with HPS: 3 displayed bleeding varices and 4 ascites. Child-Pugh evaluation was class B (n = 4) or C (n = 2). The Model for End-stage Liver Disease scores were 18 (n = 2), 20 (n = 3), and 22 (n = 1). Cirrhosis resulted from presumed diagnoses of alcohol n = (1), autoimmune n = (2) or cryptogenic cirrhosis n = (3). On histologic examination, there was marked phlebosclerosis in all cases, including nonocclusive portal vein thrombosis (n = 3), intense portal fibrosis (n = 1), moderate portal fibrosis (n = 5), and uniform moderate sinusoidal dilatation without megasinusoid formation, but with ductal biliary proliferation and ductal biliary fibrosis in all cases. Cholestasis was observed in 1 and incomplete septal cirrhosis in 4 cases. None of the subjects showed histological features of the presumed underlying liver disease. The overall survival of this group was no different from that of other OLT patients. HPS causing hepatic failure may require liver transplantation. Fhlebosclerosis andportal fibrosis may contribute to the loss of hepatic synthesis leading to the need for hepatic transplant. Significant portal fibrosis and phlebosclerosis can contribute to hepatic parenchymal and posterior synthetic loss.
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Affiliation(s)
- E C Ataide
- Unit of Liver Transplantation, Campinas, Brazil.
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24
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Seijo S, Lozano JJ, Alonso C, Reverter E, Miquel R, Abraldes JG, Martinez-Chantar ML, Garcia-Criado A, Berzigotti A, Castro A, Mato JM, Bosch J, Garcia-Pagan JC. Metabolomics discloses potential biomarkers for the noninvasive diagnosis of idiopathic portal hypertension. Am J Gastroenterol 2013; 108:926-32. [PMID: 23419380 DOI: 10.1038/ajg.2013.11] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Idiopathic portal hypertension (IPH) is a rare cause of portal hypertension that lacks a specific diagnostic test. Requiring ruling-out other causes of portal hypertension it is frequently misdiagnosed. This study evaluates whether using high-throughput techniques there is a metabolomic profile allowing a noninvasive diagnosis of IPH. METHODS Thirty-three IPH patients were included. Matched patients with cirrhosis (CH) and healthy volunteers (HV) were included as controls. Metabolomic analysis of plasma samples was performed using UPLC-time-of-flight-mass spectrometry. We computed Student's P-values, corrected by multiple comparison and VIP score (Variable Importance in the Projection). The metabolites were selected with an adjusted Benjamini Hochberg P value <0.05. We use markers with a greater VIP score, to build partial least squares projection to latent structures regression with discriminant analysis (PLS-DA) representative models to discriminate IPH from CH and from HV. The performance of the PLS-DA model was evaluated using R(2) and Q(2) parameter. An additional internal cross-validation was done. RESULTS PLS-DA analysis showed a clear separation of IPH from CH with a model involving 28 metabolites (Q(2)=0.67, area under the curve (AUC)=0.99) and a clear separation of IPH from healthy subjects with a model including 31 metabolites (Q(2)=0.75, AUC=0.98). After cross-validation, both models showed high rates of sensitivity (94.8 and 97.5), specificity (89.1 and 89.7), and AUC (0.98 and 0.98), reinforcing the strength of our findings. CONCLUSIONS A metabolomic profile clearly differentiating patients with IPH from CH and healthy subjects has been identified using subsets of 28 and 31 metabolites, respectively. Therefore, metabolomic analysis appears to be a valuable tool for the noninvasive diagnosis of IPH.
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Affiliation(s)
- Susana Seijo
- Liver Unit, Hepatic Hemodynamic Laboratory, Institut de Malalties Digestives i Metaboliques, Hospital Clínic-Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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25
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Etiologic types of end-stage chronic liver disease in adults: analysis of prevalence and their temporal changes from a study on native liver explants. Eur J Gastroenterol Hepatol 2012; 24:1199-208. [PMID: 22751227 DOI: 10.1097/meg.0b013e32835643f1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Whole native livers from orthotopic liver transplant (LT) recipients provide an ideal resource material for the proper identification and etiologic evaluation of end-stage liver diseases in these patients. This study determined the etiologic types of chronic liver disease (CLD) in adults of our geographic region receiving living donor LT and projected approximate estimates of their current prevalence and temporal changes in these in the general population. MATERIALS AND METHODS The final etiologic categorization of CLD in 372 adult LT recipients was made only after correlating the morphologic findings on explanted whole native livers with all pre-LT data and diagnosis. RESULTS The final etiologic categorizations of end-stage CLD in the majority (88.4%) of explanted livers in our series were as follows: hepatitis virus related--48.6% [hepatitis C virus (HCV)--31.1%, hepatitis B virus (HBV)--15.9%, HCV and HBV--1.6%]; alcohol related--23.1%; and NALD related--16.7%. Of 84 cases clinically considered as cryptogenic cirrhosis, 57 and nine were finally categorized as nonalcoholic fatty liver disease (NAFLD) cirrhosis and noncirrhotic portal fibrosis, respectively. Hepatocellular carcinoma (HCC) was found in 20.7% of all livers, 81.8% of these tumors developing in HBV-related and/or HCV-related CLD and 9.1% each in alcohol-related and NAFLD-related CLD. CONCLUSION The etiology of end-stage CLD in adults of our region has changed over time. HCV, more than HBV, is now the major cause of both CLD and HCC; alcohol-related CLD has increased significantly and several cases of cirrhosis clinically considered as cryptogenic, some of them with HCC, evolve from NAFLD. A proportion of cryptogenic cirrhosis cases that require LT are constituted by the noncirrhotic disease noncirrhotic portal fibrosis.
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Hepatoportal sclerosis: CT and MRI appearance with histopathologic correlation. AJR Am J Roentgenol 2012; 198:370-6. [PMID: 22268180 DOI: 10.2214/ajr.11.6855] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purposes of this study were to describe the spectrum of cross-sectional imaging findings of pathologically proven hepatoportal sclerosis and to compare the features of advanced and nonadvanced hepatoportal sclerosis. MATERIALS AND METHODS Eighteen patients with a histopathologic diagnosis of hepatoportal sclerosis who had concurrent MRI or CT images participated in the study. The following imaging features were assessed: presence of liver nodularity and liver lesions, portal vein patency, presence and degree of portal hypertension, liver volume, and caudate-to-right lobe ratio. These features were compared between patients who underwent transplant and those who did not. RESULTS The 18 patients (11 men and one boy, six women; mean age, 46.5 years) had hepatoportal sclerosis confirmed with liver biopsy (14 patients) or explant (four patients). Fourteen patients underwent contrast-enhanced MRI, and five underwent CT. The imaging findings were as follows: liver surface nodularity, five patients (all four transplant, one nontransplant) (p = 0.0016); evidence of portal hypertension, 17 patients; increased caudate-to-right lobe ratio, 16 patients; high periportal signal intensity on T2-weighted images, six patients; portal vein occlusion with cavernous transformation, five patients. The transplant patients had smaller pretransplant liver volume than did nontransplant patients (p < 0.04). CONCLUSION Hepatoportal sclerosis is characterized by caudate lobe hypertrophy and right hepatic lobe atrophy, preserved liver volume, and lack of the liver nodularity associated with portal hypertension. In advanced cases, liver nodularity and atrophy produce an imaging appearance indistinguishable from that of cirrhosis.
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Glatard AS, Hillaire S, d'Assignies G, Cazals-Hatem D, Plessier A, Valla DC, Vilgrain V. Obliterative portal venopathy: findings at CT imaging. Radiology 2012; 263:741-50. [PMID: 22474672 DOI: 10.1148/radiol.12111785] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To retrospectively analyze the computed tomographic (CT) findings in a single-center series of adult patients with biopsy-proved obliterative portal venopathy (OPV) and to compare them with those observed in patients with cirrhosis. MATERIALS AND METHODS The requirement for informed consent was waived. This institutional review board-approved study included 42 consecutive patients with a histologically proved diagnosis of OPV who underwent CT at diagnosis. The clinical characteristics at diagnosis were recorded, and CT examination results were reviewed. Two radiologists evaluated portal vein patency and intrahepatic portal branches, the morphologic changes in the liver, the presence of hepatic nodules, and signs of portal hypertension in consensus. The control group consisted of 42 patients who had histologically proved cirrhosis. CT findings were compared between the OPV patient group and the cirrhotic group and also among the conditions associated with patients with OPV. The Fisher exact test was used. P values of .05 or less were considered to indicate significant differences. RESULTS The following CT findings were observed significantly more frequently in OPV than in cirrhosis: extrahepatic portal vein thrombosis (18 [43%] of 42 vs five [12%] of 42); intrahepatic portal abnormalities (18 [58%] of 31 vs one [2%] of 42) such as reduced caliber, occlusive thrombosis, and lack of visibility; focal nodular hyperplasia-like nodules (six [14%] of 42 vs 0 [0%] of 42); and perfusion disorders (15 [36%] of 42 vs six [14%] of 42). Conversely, the combination of hypertrophy of the caudate lobe and atrophy of segment IV (27 [64%] of 42 vs 10 [24%] of 42) and nodular surface (37 [88%] of 42 vs seven [17%] of 42) were seen significantly more often in cirrhosis. CONCLUSION Characteristic CT findings in patients with OPV that differ from those in patients with cirrhosis were shown, the most common being the presence of intra- or extrahepatic portal abnormalities.
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Affiliation(s)
- Anne-Sophie Glatard
- Department of Radiology, Assistance-Publique Hôpitaux de Paris, APHP, Hôpital Beaujon, 100 bd du Général Leclerc, 92110 Clichy, France
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Yilmaz G, Sari S, Egritas O, Dalgic B, Akyol G. Hepatoportal sclerosis in childhood: some presenting with cholestatic features (a re-evaluation of 12 children). Pediatr Dev Pathol 2012; 15:107-13. [PMID: 22150463 DOI: 10.2350/11-04-1017-oa.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hepatoportal sclerosis (HPS) is a syndrome of obscure etiology, and is one of the causes of noncirrhotic portal hypertension (PH). We aimed to investigate this heterogeneous group of patients whose presentation showed cholestatic features, histopathologically. Between 1999 and 2009, 12 children diagnosed with HPS were retrospectively evaluated. HPS was diagnosed with evidence of PH, noncirrhotic liver biopsy with typical histopathologic findings, and exclusion of other possible causes of PH. The data was obtained from pathology reports and microscopic slides. In histopathological re-evaluation fibrosis state, aberrant portal vessels, portal tract dilation and inflammation, ductular reaction, regenerative nodular hyperplasia, acinar transformation, presence of bile pigment, and cholangitis were noted. Serum alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl, alkaline phosphatase, bilirubin, and albumin levels, presentation patterns, and radiologic findings were assessed. Familial relationship degrees were also investigated. Twelve patients (9 boys, 3 girls; 3-180 months) were re-evaluated. Two pairs of the patients were siblings. Parents of 7 patients were consanguine. The most common presenting symptom was abdominal distension. Histopathologically, all patients had hepatoportal sclerosis/intimal fibrous thickening of portal vein and periportal fibrosis, acinar transformation, and regenerative nodules not surrounded by fibrous septae. Eight patients had vascular aberrations, 7 had ductular reaction, 1 showed mild cholangitis, and 1 had canalicular bile pigment. We conclude that genetic predisposition might be a possible factor for HPS development in Turkish patients and it should be kept in mind that cholestatic features noticed in histopathological evaluation may represent a variant group in the spectrum of HPS.
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Affiliation(s)
- Guldal Yilmaz
- Gazi University, Faculty of Medicine, Department of Pathology, Ankara, Turkey.
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Hübscher SG. Pathology of non-cirrhotic portal hypertension and incomplete septal cirrhosis. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.mpdhp.2011.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Schouten JNL, Garcia-Pagan JC, Valla DC, Janssen HLA. Idiopathic noncirrhotic portal hypertension. Hepatology 2011; 54:1071-81. [PMID: 21574171 DOI: 10.1002/hep.24422] [Citation(s) in RCA: 209] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 04/28/2011] [Indexed: 02/06/2023]
Abstract
Idiopathic noncirrhotic portal hypertension (INCPH) is characterized by an increased portal venous pressure gradient in the absence of a known cause of liver disease and portal vein thrombosis. In contrast to the high prevalence of this disorder in India, INCPH is a rare disease in the Western world. The etiology of INCPH can be divided in five categories: chronic infections, exposure to medication or toxins, thrombophilia, immunological disorders, and genetic disorders. Multifactorial etiology can also be encountered. Chronic abdominal infection is incriminated as the most important etiological factor in Eastern patients and thrombophilia in Western patients. The majority of patients with INCPH initially present with signs or complications of portal hypertension (mainly variceal bleeding and splenomegaly). These patients usually have preserved liver function. Liver function impairment occurs mainly in the context of intercurrent conditions. Patients with INCPH are often clinically and radiologically misdiagnosed as liver cirrhosis, so that a liver biopsy is indispensable to discriminate cirrhosis from INCPH. Histopathological characteristics of INCPH are heterogeneous, demonstrating overlap between several pathological entities (e.g., hepatoportal sclerosis, nodular regenerative hyperplasia, and incomplete septal cirrhosis). Even though hemodynamical changes in INCPH patients are not comparable to those in cirrhotics, prophylaxis and treatment of variceal bleeding are recommended to be similar. Anticoagulation therapy must be considered only in patients who develop portal vein thrombosis. INCPH has been considered a disorder with a relatively benign disease course. However, liver failure, hepatic encephalopathy, and hepatopulmonary syndrome can occur and are considered indications for liver transplantation.
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Affiliation(s)
- Jeoffrey N L Schouten
- Department of Gastroenterology Hepatology, University Hospital Rotterdam, Rotterdam, The Netherlands
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Beyazit Y, Ibis M, Purnak T, Turhan T, Kekilli M, Kurt M, Sayilir A, Onal IK, Turhan N, Tas A, Köklü S, Haznedaroglu IC. Elevated levels of circulating angiotensin converting enzyme in patients with hepatoportal sclerosis. Dig Dis Sci 2011; 56:2160-5. [PMID: 21290180 DOI: 10.1007/s10620-011-1580-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 01/11/2011] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS Hepatoportal sclerosis (HPS) is a clinicopathologic condition that is clinically characterized by portal hypertension (varices and portosystemic collateral vessels), splenomegaly and pancytopenia, in the absence of cirrhosis. Although the etiology is obscure, a number of theories such as immunologic and vascular endothelial cellular abnormalities have been put forward to explain the underlying pathophysiology. Angiotensin-converting enzyme (ACE), an important molecule of the renin-angiotensin system (RAS), is also known as a regulatory molecule in systemic and portal circulation in distinct disorders. The aim of the present study was to investigate the possible role of the ACE in the context of RAS in HPS pathogenesis. MATERIALS AND METHODS The study was conducted on 30 HPS patients (16 men, 14 women; median age 36 years, range 18-63) and 20 healthy controls. The clinical features of HPS patients including demographics, laboratory, and ultrasonography findings were summarized. Serum ACE levels were measured by using commercially available kits. RESULTS Serum median ACE levels were 36 (8-174) U/l and 16 (8-43) U/l for the HPS patients and controls, respectively. Serum ACE levels were significantly higher in patients with HPS compared to the control group (P < 0.05). CONCLUSION ACE in the context of RAS may be associated with pathological endothelial occlusive events in the microenvironment of the portal circulation in HPS. Revealing the interactions between circulating and local RAS within the hepatic microenvironment would enlighten the biologic basis and clinical management of liver diseases.
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Affiliation(s)
- Yavuz Beyazit
- Department of Gastroenterology, Turkiye Yuksek İhtisas Education and Research Hospital, Sihhiye, 06100, Ankara, Turkey.
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Obliterative portal venopathy: portal hypertension is not always present at diagnosis. J Hepatol 2011; 54:455-61. [PMID: 21087805 DOI: 10.1016/j.jhep.2010.07.038] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 07/02/2010] [Accepted: 07/05/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Previous studies on obliterative portal venopathy (OPV) have been biased due to the selection of patients with non-cirrhotic portal hypertension. The aim of this study was to clarify the characteristics of OVP diagnosed by liver biopsy. METHODS Fifty-nine consecutive patients with OPV were retrospectively selected on strict histological criteria. Clinical, laboratory, portal vein patency, and associated disorders potentially involving vascular alterations were analyzed. The occurrence of complications was recorded during follow-up. RESULTS Mean age at diagnosis was 38.5±15 years old. Initial presentation was portal hypertension (64% of patients) and/or extrahepatic portal vein thrombosis (EHPVT) (22%) or isolated abnormal laboratory tests (20%). Associated diseases found at diagnosis were: prothrombotic disorders (30% of patients) and immune-mediated disorders (17%); 53% of patients had no causal factor (idiopathic OPV). During follow-up (median 8.6 years, range 1-23 years), features of portal hypertension worsened in 46% of patients; EHPVT and portal hypertension were finally found in 44% and 88% of patients. Anti-coagulation and beta-blockers were administered in 47% and 59% of patients, respectively. Severe complications (liver transplantation and/or death) occurred in 11 (19%) patients, 8 had idiopathic OPV. Patients with prothrombotic disorders received earlier anticoagulation therapy; all survived without transplantation. CONCLUSIONS A confident diagnosis of OPV can be done by biopsy and is conceivable in patients under 40 years without clinically significant portal hypertension. Poor outcome was noted in 19% of patients, most of them affected with idiopathic OPV. Patients with prothrombotic disorders received early anticoagulation and appeared to have a better outcome despite a high proportion of EHPVT.
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Saigal S, Nayak NC, Jain D, Kumaran V, Mohanka R, Saraf N, Rastogi A, Mehta N, Nundy S, Soin A. Non-cirrhotic portal fibrosis related end stage liver disease in adults: evaluation from a study on living donor liver transplant recipients. Hepatol Int 2011; 5:882-9. [PMID: 21484137 DOI: 10.1007/s12072-010-9246-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Accepted: 12/20/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND That non-cirrhotic portal fibrosis (NCPF) can lead to end stage chronic liver disease (CLD) has been convincingly demonstrated only recently after the study of explant livers from clinically cirrhosis cases. AIMS This study attempted to determine the frequency of NCPF among adults transplanted for end stage CLD and to identify parameters for a pre-transplant diagnosis of NCPF. METHODS Several parameters were analyzed in three categories of cases: pure NCPF (n = 10), overlap NCPF (n = 10), and NAFLD cirrhosis controls (n = 44). Morphologic features of NCPF were looked for in explant livers of all these. RESULTS Explant livers in the pure NCPF group were non-cirrhotic and showed histologic features of NCPF. These features were also present in all cases of overlap NCPF in the background of established cirrhosis of other etiologies but absent in the NAFLD cirrhosis controls. Values of seven objective and two subjective parameters showed significant differences between pure NCPF and NAFLD control groups. Compared to NAFLD controls, the model for end stage liver disease (MELD) score, body mass index (BMI), bilirubin, albumin, aspartate amino transferase (AST), and international normalized ratio (INR) were significantly less, whereas variceal grade was higher in the pure NCPF group. CONCLUSIONS The study concludes that in our population, NCPF constitutes about 5% of the subset of end stage CLD considered eligible for liver transplantation (LT), presenting mostly as cryptogenic cirrhosis (CC). A diagnosis of NCPF should be considered when patients presumed to have cryptogenic or other cirrhosis become eligible for LT even in the presence of relatively well-preserved liver function and low MELD scores. End stage CLD manifests at earlier age, when cirrhosis of another etiology supervenes on pre-existent NCPF.
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Affiliation(s)
- Sanjiv Saigal
- Department of Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
| | - Nabeen C Nayak
- Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India
| | - Deepali Jain
- Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India.
| | - Vinay Kumaran
- Department of Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
| | - Ravi Mohanka
- Department of Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Saraf
- Department of Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
| | - Amit Rastogi
- Department of Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
| | - Naimesh Mehta
- Department of Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
| | - Arvinder Soin
- Department of Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
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Schiano TD, Uriel A, Dieterich DT, Fiel MI. The development of hepatoportal sclerosis and portal hypertension due to didanosine use in HIV. Virchows Arch 2010; 458:231-5. [PMID: 21057809 DOI: 10.1007/s00428-010-1004-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 10/16/2010] [Accepted: 10/19/2010] [Indexed: 01/09/2023]
Abstract
Hepatoportal sclerosis (HPS) is one of several entities known to cause noncirrhotic portal hypertension. To date, its etiology is unknown. There have been increasing reports of HPS occurring in patients with human immunodeficiency virus (HIV), and the US Food and Drug Administration (FDA) recently issued an advisory regarding the development of noncirrhotic portal hypertension in association with didanosine (ddI) use. We report on a patient with HIV who had taken ddI for 4 years and who developed portal hypertension. Histopathological review of paired liver biopsies showed an initial drug hepatotoxicity, microvascular liver injury, and the presence of HPS. Despite cessation of ddI, the latter biopsy showed resolution of the drug-induced injury, but it also showed progression of the HPS. The patient's portal hypertension also progressed suggestive of an unremitting vascular injury. This case demonstrates the development of HPS resulting from a drug-induced microvascular injury. The paired biopsies demonstrate that the initial vascular injury may disappear but that the portal hypertension and HPS progress.
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Affiliation(s)
- Thomas D Schiano
- Division of Liver Diseases, Department of Medicine, The Mount Sinai Medical Center, New York, NY, USA
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Emre S, Dugan C, Frankenberg T, Hudgins LC, Gagliardi R, Artis AT, Rodriguez-Laiz G, Gondolesi G, Shneider BL, Kerkar N. Surgical portosystemic shunts and the Rex bypass in children: a single-centre experience. HPB (Oxford) 2009; 11:252-7. [PMID: 19590656 PMCID: PMC2697896 DOI: 10.1111/j.1477-2574.2009.00047.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Accepted: 02/15/2009] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study aimed to illustrate the indications for, and types and outcomes of surgical portosystemic shunt (PSS) and/or Rex bypass in a single centre. METHODS Data were collected from children with a PSS and/or Rex bypass between 1992 and 2006 at Mount Sinai Medical Center, New York. RESULTS Median age at surgery was 10.7 years (range 0.3-22.0 years). Indications included: (i) refractory gastrointestinal bleeding in portal hypertension associated with (a) compensated cirrhosis (n= 12), (b) portal vein thrombosis (n= 10), (c) hepatoportal sclerosis (n= 3); (ii) refractory ascites secondary to Budd-Chiari syndrome (n= 3), and (iii) familial hypercholesterolaemia (n= 4). There were 20 distal splenorenal, four portacaval, three Rex bypass, two mesocaval, two mesoatrial and one proximal splenorenal shunts. At the last follow-up (median 2.9 years, range 0.1-14.1 years), one shunt (Rex bypass) was thrombosed. Two patients had died and two had required a liver transplant. These had a patent shunt at last imaging prior to death or transplant. CONCLUSIONS Portosystemic shunts and Rex bypass have been used to manage portal hypertension with excellent outcomes. In selected children with compensated liver disease, PSS may act as a bridge to liver transplantation or represent an attractive alternative.
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Affiliation(s)
- Sukru Emre
- Recanati Miller Transplant Institute, Mount Sinai School of MedicineNew York, NY, USA,Department of Surgery, Yale University School of MedicineNew Haven, CT, USA
| | - Christina Dugan
- Recanati Miller Transplant Institute, Mount Sinai School of MedicineNew York, NY, USA
| | - Tamara Frankenberg
- Recanati Miller Transplant Institute, Mount Sinai School of MedicineNew York, NY, USA
| | | | - Rosemarie Gagliardi
- Recanati Miller Transplant Institute, Mount Sinai School of MedicineNew York, NY, USA
| | - A Tarik Artis
- Recanati Miller Transplant Institute, Mount Sinai School of MedicineNew York, NY, USA
| | | | - Gabriel Gondolesi
- Recanati Miller Transplant Institute, Mount Sinai School of MedicineNew York, NY, USA,Fundación Favaloro, Buenos AiresArgentina
| | - Benjamin L Shneider
- Recanati Miller Transplant Institute, Mount Sinai School of MedicineNew York, NY, USA,Department of Paediatrics, Mount Sinai School of MedicineNew York, NY, USA,Department of Paediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical CenterPittsburgh, PA, USA
| | - Nanda Kerkar
- Recanati Miller Transplant Institute, Mount Sinai School of MedicineNew York, NY, USA,Department of Paediatrics, Mount Sinai School of MedicineNew York, NY, USA
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Geramizadeh B, Malek-Hosseini S, Salahi H, Bahador A, Nikeghbalian S. Liver Failure and the Need for Transplantation in Three Patients With Hepatoportal Sclerosis. Transplant Proc 2008; 40:3526-8. [DOI: 10.1016/j.transproceed.2008.06.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 05/07/2008] [Accepted: 06/23/2008] [Indexed: 01/14/2023]
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Affiliation(s)
- Dominique Charles Valla
- Service d'Hépatologie, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Denis Diderot-Paris 7, and INSERM U773-CRB3, Clichy, France.
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Cuadrado Lavín A, Aresti Zárate S, Delgado Tapia A, Figols Ladrón De Guevara FJ, Salcines Caviedes JR. Hepatoportal sclerosis: a cause of portal hypertension to bear in mind. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:104. [PMID: 18279649 DOI: 10.1157/13116079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Schiano TD, Kotler DP, Ferran E, Fiel MI. Hepatoportal sclerosis as a cause of noncirrhotic portal hypertension in patients with HIV. Am J Gastroenterol 2007; 102:2536-40. [PMID: 17640321 DOI: 10.1111/j.1572-0241.2007.01428.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatoportal sclerosis (HPS) is a cause of noncirrhotic portal hypertension, with patients typically presenting with variceal bleeding. It is idiopathic in nature but is felt to be due to an abnormality of the intrahepatic vasculature. HPS is characterized by varying degrees of portal fibrosis, sclerosis of portal vein branches and dilatation of sinusoidal spaces. Nodular regenerative hyperplasia (NRH), another cause of noncirrhotic portal hypertension, has also been recently described in HIV patients initially diagnosed as having cryptogenic liver disease. METHODS/RESULTS We describe four cases of HIV+ patients presenting with noncirrhotic portal hypertension; liver biopsies were reviewed by an experienced liver pathologist and found to be consistent with HPS. No other etiologies for their liver disease were found. CONCLUSIONS HPS has been recently identified as a cause of noncirrhotic portal hypertension in patients with HIV. It should be considered in the differential diagnosis of HIV patients presenting with variceal bleeding. We postulate that it may be due to intrahepatic microthrombosis or an altered hepatic fibrogenesis related to highly active antiretroviral therapy or due to HIV itself.
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Affiliation(s)
- Thomas D Schiano
- The Recanati/Miller Transplantation Institute, and the Division of Liver Diseases, Department of Medicine, The Mount Sinai Medical Center, New York, New York 10029, USA
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