1
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Agha HM, Mashoor S, Ghobashy M, AbdelMassih A, Gaber H, El-Karaksy H. Off-label use of muscular VSD device for closure of a rare congenital portosystemic shunt. Egypt Heart J 2024; 76:34. [PMID: 38521846 PMCID: PMC10960785 DOI: 10.1186/s43044-024-00467-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/13/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Congenital portosystemic shunt (CPSS) is a vascular malformation in which portal blood drains toward the systemic circulation, leading to pulmonary hypertension. CASE PRESENTATION A 10-year-old patient was brought for evaluation because of dyspnea on exertion. Echocardiography revealed a pulmonary hypertension of 75 mmHg, and multi-slice CT angiography revealed the presence of a CPSS. Closure was finally implemented using a muscular ventricular septal defect device. Follow-up of the patient revealed a gradual decline in pulmonary hypertension. CONCLUSIONS CPSS is an overlooked cause of reversible pulmonary hypertension (PH). Closure of such lesions and reversal pulmonary hypertension are possible via catheterization. The preferred device type depends largely on the intervening team. Plugs are the first choice for interventional radiologists, while ventricular and atrial septal occluder devices and duct occluders are preferred by pediatric cardiologists.
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Affiliation(s)
- Hala Mounir Agha
- Pediatric Cardiology Unit, Pediatrics' Department, Faculty of Medicine, Cairo University, P.O BOX: 12411, Cairo, Egypt
| | - Shady Mashoor
- Interventional Radiology Unit, Radiology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Ghobashy
- Interventional Radiology Unit, Radiology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Antoine AbdelMassih
- Pediatric Cardiology Unit, Pediatrics' Department, Faculty of Medicine, Cairo University, P.O BOX: 12411, Cairo, Egypt.
| | - Hanya Gaber
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hanaa El-Karaksy
- Pediatric Hepatology Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
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2
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Banc-Husu AM, Shiau H, Dike P, Shneider BL. Beyond Varices: Complications of Cirrhotic Portal Hypertension in Pediatrics. Semin Liver Dis 2023; 43:100-116. [PMID: 36572031 DOI: 10.1055/s-0042-1759613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Complications of cirrhotic portal hypertension (PHTN) in children are broad and include clinical manifestations ranging from variceal hemorrhage, hepatic encephalopathy (HE), ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS) to less common conditions such as hepatopulmonary syndrome, portopulmonary hypertension, and cirrhotic cardiomyopathy. The approaches to the diagnosis and management of these complications have become standard of practice in adults with cirrhosis with many guidance statements available. However, there is limited literature on the diagnosis and management of these complications of PHTN in children with much of the current guidance available focused on variceal hemorrhage. The aim of this review is to summarize the current literature in adults who experience these complications of cirrhotic PHTN beyond variceal hemorrhage and present the available literature in children, with a focus on diagnosis, management, and liver transplant decision making in children with cirrhosis who develop ascites, SBP, HRS, HE, and cardiopulmonary complications.
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Affiliation(s)
- Anna M Banc-Husu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Henry Shiau
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Peace Dike
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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3
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Flores-Calderón J, Cisneros-Garza LE, Chávez-Barrera JA, Vázquez-Frias R, Reynoso-Zarzosa FA, Martínez-Bejarano DL, Consuelo-Sánchez A, Reyes-Apodaca M, Zárate-Mondragón FE, Sánchez-Soto MP, Alcántara-García RI, González-Ortiz B, Ledesma-Ramírez S, Espinosa-Saavedra D, Cura-Esquivel IA, Macías-Flores J, Hinojosa-Lezama JM, Hernández-Chávez E, Zárate-Guerrero JR, Gómez-Navarro G, Bilbao-Chávez LP, Sosa-Arce M, Flores-Fong LE, Lona-Reyes JC, Estrada-Arce EV, Aguila-Cano R. Consensus on the management of complications of cirrhosis of the liver in pediatrics. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:462-485. [PMID: 35810090 DOI: 10.1016/j.rgmxen.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/08/2022] [Indexed: 12/07/2022]
Abstract
The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.
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Affiliation(s)
- J Flores-Calderón
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico.
| | | | - J A Chávez-Barrera
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | | | | | | | | | | | | | - M P Sánchez-Soto
- Hospital de Especialidades del Niño y la mujer de Querétaro Dr. Felipe Núñez Lara, Querétaro, Mexico
| | | | - B González-Ortiz
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - S Ledesma-Ramírez
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - D Espinosa-Saavedra
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | | | - J Macías-Flores
- Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Mexico
| | | | - E Hernández-Chávez
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - J R Zárate-Guerrero
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - G Gómez-Navarro
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - L P Bilbao-Chávez
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - M Sosa-Arce
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - L E Flores-Fong
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - J C Lona-Reyes
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - E V Estrada-Arce
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - R Aguila-Cano
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
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4
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Xu H, Cheng B, Wang R, Ding M, Gao Y. Portopulmonary hypertension: Current developments and future perspectives. LIVER RESEARCH 2022. [DOI: 10.1016/j.livres.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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5
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Aneja A, Scott E, Kohli R. Advances in management of end stage liver disease in children. Med J Armed Forces India 2021; 77:129-137. [PMID: 33867627 DOI: 10.1016/j.mjafi.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023] Open
Abstract
End stage liver disease (ESLD) is an irreversible condition that is a management challenge to the paediatrician. The aetiology and natural history of ESLD in children is not only distinct from adults but also variable depending upon the age of presentation. Children are especially vulnerable to developmental delay, frailty and malnutrition. Nutritional support is the cornerstone of management of these children as it has a significant impact on the clinical course and survival, both before and after transplantation. Further, the complications of ESLD in children including but not limited to, ascites, portal hypertension, spontaneous bacterial peritonitis and encephalopathy raise unique management challenges. In this review we provide a concise review of and highlight recent advances in the management of paediatric ESLD.
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Affiliation(s)
- Aradhana Aneja
- Classified Specialist (Pediatrics) & Pediatric Gastroenterologist, Army Hospital (R&R), New Delhi, India
| | - Elizabeth Scott
- Transplant Dietitian, Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, USA
| | - Rohit Kohli
- Head of Division, Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, USA
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6
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Outcome of paediatric portopulmonary hypertension in the modern management era: A case report of 6 patients. J Hepatol 2021; 74:742-747. [PMID: 33276028 DOI: 10.1016/j.jhep.2020.11.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/25/2020] [Accepted: 11/16/2020] [Indexed: 12/30/2022]
Abstract
Portopulmonary hypertension is a rare but serious complication of portal hypertension or portosystemic shunting. Portopulmonary hypertension is an indication for liver transplantation or shunt closure. However, liver transplantation is contraindicated in patients with severe pulmonary arterial hypertension. Reported mortality rates are high in children with portopulmonary hypertension and there are scarce recommendations on its management. Our aim was to report on our real-world experience of managing portopulmonary hypertension in a specialised centre. We describe a series of 6 children with portopulmonary hypertension. Their median age at diagnosis was 13 years (range 10-15). The underlying liver conditions were cirrhosis of unknown origin (1), congenital portocaval shunts (3), biliary atresia (1), and portal vein cavernoma with surgical mesenterico-caval shunt (1). Median mean pulmonary arterial pressure was 47 mmHg (range 32-70), and median pulmonary vascular resistance was 6.6 Wood units (range 4.3-15.4). All patients except one were treated with a combination of pulmonary arterial hypertension-specific therapy (phosphodiesterase type 5 inhibitors and/or endothelin receptor antagonists and/or prostacyclin analogues). Three patients then benefited from shunt closure and the others underwent liver transplantation. Five patients showed improvement or stabilisation of pulmonary arterial hypertension with no deaths after a mean follow-up of 39 months. Based on our limited experience, early and aggressive treatment with a combination of pulmonary arterial hypertension-specific therapy significantly improves patients' haemodynamic profile and enables the performance of liver transplantation and shunt closure with satisfactory outcomes.
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7
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Le Fevre ER, McGrath KH, Fitzgerald DA. Pulmonary Manifestations of Gastrointestinal, Pancreatic, and Liver Diseases in Children. Pediatr Clin North Am 2021; 68:41-60. [PMID: 33228942 DOI: 10.1016/j.pcl.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary manifestations of gastrointestinal (GI) diseases are often subtle, and underlying disease may precede overt symptoms. A high index of suspicion and a low threshold for consultation with a pediatric pulmonologist is warranted in common GI conditions. This article outlines the pulmonary manifestations of different GI, pancreatic, and liver diseases in children, including gastroesophageal reflux disease, inflammatory bowel disease, pancreatitis, alpha1-antitrypsin deficiency, nonalcoholic fatty liver disease, and complications of chronic liver disease (hepatopulmonary syndrome and portopulmonary hypertension).
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Affiliation(s)
- Emily R Le Fevre
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales 2145, Australia
| | - Kathleen H McGrath
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales 2145, Australia; Faculty Health Sciences, University of Sydney, Sydney, New South Wales, Australia.
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8
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Wacker J, Aggoun Y, Terraz S, Golay E, Maggio AB, Vallée JP, Hachulla AL, Lador F, Barazzone C, McLin V, Beghetti M. A 13-Year-Old Male With Diagnosed Idiopathic Pulmonary Hypertension. Chest 2020; 158:e295-e298. [DOI: 10.1016/j.chest.2020.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/12/2020] [Indexed: 10/22/2022] Open
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9
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Stepffer C, Marques A, Barbosa JD, Ferrario S, Haag D. Pulmonary Arterial Hypertension in a Patient with a Portosystemic Shunt: Diagnostic Challenge. CASE (PHILADELPHIA, PA.) 2020; 4:93-96. [PMID: 32337399 PMCID: PMC7175750 DOI: 10.1016/j.case.2019.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pediatric pulmonary arterial hypertension (PAH) is a rare condition. The diagnostic algorithm in PAH is key to address rare pathology and make a diagnosis. Portosystemic shunt is a rare anomaly of the mesenteric vasculature. PAH is diagnosed by echocardiography and portocaval shunt is diagnosed using image. Infrequent case of reversible PAH after surgical repair of Abernethy malformation.
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Affiliation(s)
| | - Adelia Marques
- Hospital de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | | | - Sofía Ferrario
- Hospital de Niños Juan P. Garrahan, Buenos Aires, Argentina
| | - Dora Haag
- Hospital de Niños Juan P. Garrahan, Buenos Aires, Argentina
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10
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Abstract
Biliary atresia is a progressive inflammatory sclerosing disease of the bile ducts in the neonatal liver. Without surgical intervention these patients are destined to succumb to the disease. The development of the hepatoportoenterostomy in 1959 and liver transplantation in 1963 ushered a new era of success treating these patients. While many surgical modifications and adjuncts to treatment have been attempted over the last 50 years, the mainstay of treatment to give the child the best chance at prolonged survival with the native liver is a properly performed operation, in a timely fashion, with minimal post-operative complications. This review presents the authors current practice guideline to achieve these goals.
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Affiliation(s)
- Frederick M Karrer
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora CO, USA.
| | - Jonathan P Roach
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora CO, USA
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11
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Lee WS, Wong SY, Ivy DD, Sokol RJ. Hepatopulmonary Syndrome and Portopulmonary Hypertension in Children: Recent Advances in Diagnosis and Management. J Pediatr 2018. [PMID: 29514741 DOI: 10.1016/j.jpeds.2017.12.068] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Way Seah Lee
- Department of Pediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia; University Malaya Pediatrics and Child Health Research Group, University Malaya, Kuala Lumpur, Malaysia.
| | - Shin Yee Wong
- Department of Pediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - D Dunbar Ivy
- Section of Pediatric Cardiology, Department of Pediatrics, and the Heart Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Ronald J Sokol
- Pediatric Liver Center, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, and the Digestive Health Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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12
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Lee WS, Ong SY, Foo HW, Wong SY, Kong CX, Seah RB, Ng RT. Chronic liver disease is universal in children with biliary atresia living with native liver. World J Gastroenterol 2017; 23:7776-7784. [PMID: 29209118 PMCID: PMC5703937 DOI: 10.3748/wjg.v23.i43.7776] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/03/2017] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the medical status of children with biliary atresia (BA) surviving with native livers.
METHODS In this cross-sectional review, data collected included complications of chronic liver disease (CLD) (cholangitis in the preceding 12 mo, portal hypertension, variceal bleeding, fractures, hepatopulmonary syndrome, portopulmonary hypertension) and laboratory indices (white cell and platelet counts, total bilirubin, albumin, international normalized ratio, alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transpeptidase). Ideal medical outcome was defined as absence of clinical evidence of CLD or abnormal laboratory indices.
RESULTS Fifty-two children [females = 32, 62%; median age 7.4 years, n = 35 (67%) older than 5 years] with BA (median age at surgery 60 d, range of 30 to 148 d) survived with native liver. Common complications of CLD noted were portal hypertension (40%, n = 21; 2 younger than 5 years), cholangitis (36%) and bleeding varices (25%, n = 13; 1 younger than 5 years). Fifteen (29%) had no clinical complications of CLD and three (6%) had normal laboratory indices. Ideal medical outcome was only seen in 1 patient (2%).
CONCLUSION Clinical or laboratory evidence of CLD are present in 98% of children with BA living with native livers after hepatoportoenterostomy. Portal hypertension and variceal bleeding may be seen in children younger than 5 years of age, underscoring the importance of medical surveillance for complications of BA starting at a young age.
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Affiliation(s)
- Way Seah Lee
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur 59100, Malaysia
- Paediatrics and Child Health Research Group, University Malaya, Kuala Lumpur 50603, Malaysia
| | - Sik Yong Ong
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur 59100, Malaysia
| | - Hee Wei Foo
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur 59100, Malaysia
| | - Shin Yee Wong
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur 59100, Malaysia
| | - Chen Xi Kong
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur 59100, Malaysia
| | - Ru Bin Seah
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur 59100, Malaysia
| | - Ruey Terng Ng
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur 59100, Malaysia
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13
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Tingo J, Rosenzweig EB, Lobritto S, Krishnan US. Portopulmonary hypertension in children: a rare but potentially lethal and under-recognized disease. Pulm Circ 2017; 7:712-718. [PMID: 28704131 PMCID: PMC5841896 DOI: 10.1177/2045893217723594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Portopulmonary hypertension (PoPH) is defined by the combination of portal hypertension and precapillary pulmonary arterial hypertension (PAH). Very little is known about this process in pediatric patients but prognosis is generally poor. We review our institutional experience and report on five patients with pediatric PoPH. The median age of PoPH diagnosis was six years and PAH was 14 years. PAH diagnosis was made by echocardiogram in all patients, four of whom also had cardiac catheterization. The median mean pulmonary artery pressure (mPAP) was 48.5 mmHg (interquartile range [IQR] = 46–60) with a median pulmonary vascular resistance index (PVRi) of 9 WU*M2 (IQR = 8–22). All were acute pulmonary vasodilator testing non-responsive. All patients received targeted therapies. Three of five patients (60%) died despite an evidence-based approach to care. Of those who died, timing from the PoPH diagnosis to death ranged from three days to three years. Based upon our limited experience, PoPH is a disorder with significant mortality in childhood and challenges in treatment. Future research, focused on screening and early targeted treatment strategies, may alter the current dismal prognosis for these children.
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Affiliation(s)
- Jennifer Tingo
- Department of Pediatric Cardiology, Columbia University Medical Center and Morgan Stanley Children’s Hospital of New York Presbyterian Hospital, New York, NY, USA
- Current affiliation: Department of Pediatric Cardiology, St Christopher’s Hospital for Children and Drexel University College of Medicine, Philadelphia, PA, USA
| | - Erika B. Rosenzweig
- Department of Pediatric Cardiology, Columbia University Medical Center and Morgan Stanley Children’s Hospital of New York Presbyterian Hospital, New York, NY, USA
| | - Steven Lobritto
- Department of Pediatric Hepatology, Columbia University Medical Center and Morgan Stanley Children’s Hospital of New York Presbyterian Hospital, New York, NY, USA
| | - Usha S. Krishnan
- Department of Pediatric Cardiology, Columbia University Medical Center and Morgan Stanley Children’s Hospital of New York Presbyterian Hospital, New York, NY, USA
- Usha Krishnan, Department of Pediatrics (Pediatric Cardiology), Columbia University Medical Center, Morgan Stanley Children’s Hospital of New York Presbyterian Hospital, CHN 2N # 255, 3959 Broadway, New York, NY 10032, USA.
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14
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International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation 2017; 100:1440-52. [PMID: 27326810 DOI: 10.1097/tp.0000000000001229] [Citation(s) in RCA: 251] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Two distinct pulmonary vascular disorders, hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) may occur as a consequence of hepatic parenchymal or vascular abnormalities. HPS and POPH have major clinical implications for liver transplantation. A European Respiratory Society Task Force on Pulmonary-Hepatic Disorders convened in 2002 to standardize the diagnosis and guide management of these disorders. These International Liver Transplant Society diagnostic and management guidelines are based on that task force consensus and should continue to evolve as clinical experience dictates. Based on a review of over 1000 published HPS and POPH articles identified via a MEDLINE search (1985-2015), clinical guidelines were based on, selected single care reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Guidelines are presented in 5 parts; I. Definitions/Diagnostic criteria; II. Hepatopulmonary syndrome; III. Portopulmonary hypertension; IV. Implications for liver transplantation; and V. Suggestions for future clinical research.
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15
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Duché M, Ducot B, Ackermann O, Guérin F, Jacquemin E, Bernard O. Portal hypertension in children: High-risk varices, primary prophylaxis and consequences of bleeding. J Hepatol 2017; 66:320-327. [PMID: 27663417 DOI: 10.1016/j.jhep.2016.09.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/09/2016] [Accepted: 09/12/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Primary prophylaxis of bleeding is debated for children with portal hypertension because of the limited number of studies on its safety and efficacy, the lack of a known endoscopic pattern carrying a high-risk of bleeding for all causes, and the assumption that the mortality of a first bleed is low. We report our experience with these issues. METHODS From 1989 to 2014, we managed 1300 children with portal hypertension. Endoscopic features were recorded; high-risk varices were defined as: grade 3 esophageal varices, grade 2 varices with red wale markings, or gastric varices. Two hundred forty-six children bled spontaneously and 182 underwent primary prophylaxis. The results of primary prophylaxis were reviewed as well as bleed-free survival, overall survival and life-threatening complications of bleeding. RESULTS High-risk varices were found in 96% of children who bled spontaneously and in 11% of children who did not bleed without primary prophylaxis (p<0.001), regardless of the cause of portal hypertension. Life-threatening complications of bleeding were recorded in 19% of children with cirrhosis and high-risk varices who bled spontaneously. Ten-year probabilities of bleed-free survival after primary prophylaxis in children with high-risk varices were 96% and 72% for non-cirrhotic causes and cirrhosis respectively. Ten-year probabilities of overall survival after primary prophylaxis were 100% and 93% in children with non-cirrhotic causes and cirrhosis respectively. CONCLUSION In children with portal hypertension, bleeding is linked to the high-risk endoscopic pattern reported here. Primary prophylaxis of bleeding based on this pattern is fairly effective and safe. LAY SUMMARY In children with liver disease, the risk of bleeding from varices in the esophagus is linked to their large size, the presence of congestion on their surface and their expansion into the stomach but not to the child's age nor to the cause of portal hypertension. Prevention of the first bleed in children with high-risk varices can be achieved by surgery or endoscopic treatment, and decreases mortality and morbidity.
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Affiliation(s)
- Mathieu Duché
- Hépatologie Pédiatrique and Centre de Référence National de l'Atrésie des Voies Biliaires, Hôpital Bicêtre, AP-HP and Université Paris-Sud 11, Le Kremlin-Bicêtre 94275, France; Radiologie Pédiatrique, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre 94275, France.
| | - Béatrice Ducot
- Santé Publique et Èpidémiologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre 94275, France; Inserm, CESP Centre for Research in Epidemiology and Population Health, U1018, Epidemiology of Reproduction and Children Development Team, 94276 Le Kremlin-Bicêtre, France; Université Paris-Sud 11, UMRS 1018, 94276 Le Kremlin-Bicêtre, France
| | - Oanez Ackermann
- Hépatologie Pédiatrique and Centre de Référence National de l'Atrésie des Voies Biliaires, Hôpital Bicêtre, AP-HP and Université Paris-Sud 11, Le Kremlin-Bicêtre 94275, France
| | - Florent Guérin
- Chirurgie Pédiatrique Hôpital Bicêtre, AP-HP and Université Paris-Sud 11, Le Kremlin-Bicêtre 94275, France
| | - Emmanuel Jacquemin
- Hépatologie Pédiatrique and Centre de Référence National de l'Atrésie des Voies Biliaires, Hôpital Bicêtre, AP-HP and Université Paris-Sud 11, Le Kremlin-Bicêtre 94275, France; Inserm U 1174, Hepatinov, Université Paris-Sud 11, Orsay 91405, France
| | - Olivier Bernard
- Hépatologie Pédiatrique and Centre de Référence National de l'Atrésie des Voies Biliaires, Hôpital Bicêtre, AP-HP and Université Paris-Sud 11, Le Kremlin-Bicêtre 94275, France
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16
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Abstract
Portopulmonary hypertension (POPH) is a form of pulmonary arterial hypertension occurring in the setting of portal hypertension with or without hepatic cirrhosis. The presence of both portal and pulmonary vascular disease contributes to complicated hemodynamics and therapeutic challenges, though the severities do not appear to correlate directly. Diagnosis of POPH, and distinction from the commonly observed hyperdynamic state of end-stage liver disease, is typically accomplished with an initial screening transthoracic echocardiogram, followed by right heart catheterization for confirmation of hemodynamic parameters. Though few studies have directly evaluated use in POPH, pulmonary artery-directed therapy is the cornerstone of management, along with consideration of liver transplantation. Perioperative and long-term outcomes are variable, but uniformly worse in the setting of uncontrolled pulmonary pressures. Risk stratification and optimal patient selection for these interventions are areas of ongoing investigation.
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Sundaram SS, Mack CL, Feldman AG, Sokol RJ. Biliary atresia: Indications and timing of liver transplantation and optimization of pretransplant care. Liver Transpl 2017; 23:96-109. [PMID: 27650268 PMCID: PMC5177506 DOI: 10.1002/lt.24640] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 09/10/2016] [Indexed: 12/12/2022]
Abstract
Biliary atresia (BA) is a progressive, fibro-obliterative disorder of the intrahepatic and extrahepatic bile ducts in infancy. The majority of affected children will eventually develop end-stage liver disease and require liver transplantation (LT). Indications for LT in BA include failed Kasai portoenterostomy, significant and recalcitrant malnutrition, recurrent cholangitis, and the progressive manifestations of portal hypertension. Extrahepatic complications of this disease, such as hepatopulmonary syndrome and portopulmonary hypertension, are also indications for LT. Optimal pretransplant management of these potentially life-threatening complications and maximizing nutrition and growth require the expertise of a multidisciplinary team with experience caring for BA. The timing of transplant for BA requires careful consideration of the potential risk of transplant versus the survival benefit at any given stage of disease. Children with BA often experience long wait times for transplant unless exception points are granted to reflect severity of disease. Family preparedness for this arduous process is therefore critical. Liver Transplantation 23:96-109 2017 AASLD.
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Affiliation(s)
- Shikha S. Sundaram
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cara L. Mack
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Amy G. Feldman
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Ronald J. Sokol
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Biliary atresia: Clinical advances and perspectives. Clin Res Hepatol Gastroenterol 2016; 40:281-287. [PMID: 26775892 DOI: 10.1016/j.clinre.2015.11.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 11/03/2015] [Accepted: 11/16/2015] [Indexed: 02/04/2023]
Abstract
Biliary atresia (BA) is a rare and severe inflammatory and obliterative cholangiopathy that affects both extra- and intrahepatic bile ducts. BA symptoms occur shortly after birth with jaundice, pale stools and dark urines. The prognosis of BA has dramatically changed in the last decades: before the Kasai operation most BA patients died, while nowadays with the sequential treatment with Kasai operation±liver transplantation BA patient survival is close to 90%. Early diagnosis is very important since the chances of success of the Kasai procedure decrease with time. The causes of BA remain actually unknown but several mechanisms including genetic and immune dysregulation may probably lead to the obliterative cholangiopathy. Current research focuses on the identification of blood or liver factors linked to the pathogenesis of BA that could become therapeutic targets and avoid the need for liver transplantation. No similar disease leading to total obstruction of the biliary tree exists in older children or adults. But understanding the physiopathology of BA may highlight the mechanisms of other destructive cholangiopathies, such as sclerosing cholangitis.
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Shneider BL, de Ville de Goyet J, Leung DH, Srivastava A, Ling SC, Duché M, McKiernan P, Superina R, Squires RH, Bosch J, Groszmann R, Sarin SK, de Franchis R, Mazariegos GV. Primary prophylaxis of variceal bleeding in children and the role of MesoRex Bypass: Summary of the Baveno VI Pediatric Satellite Symposium. Hepatology 2016; 63:1368-80. [PMID: 26358549 DOI: 10.1002/hep.28153] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/01/2015] [Accepted: 09/05/2015] [Indexed: 12/17/2022]
Abstract
UNLABELLED Approaches to the management of portal hypertension and variceal hemorrhage in pediatrics remain controversial, in large part because they are not well informed by rigorous clinical studies. Fundamental biological and clinical differences preclude automatic application of approaches used for adults to children. On April 11-12, 2015, experts in the field convened at the first Baveno Pediatric Satellite Meeting to discuss and explore current available evidence regarding indications for MesoRex bypass (MRB) in extrahepatic portal vein obstruction and the role of primary prophylaxis of variceal hemorrhage in children. Consensus was reached regarding MRB. The vast majority of children with extrahepatic portal vein obstruction will experience complications that can be prevented by successful MRB surgery. Therefore, children with extrahepatic portal vein obstruction should be offered MRB for primary and secondary prophylaxis of variceal bleeding and other complications, if appropriate surgical expertise is available, if preoperative and intraoperative evaluation demonstrates favorable anatomy, and if appropriate multidisciplinary care is available for postoperative evaluation and management of shunt thrombosis or stenosis. In contrast, consensus was not achieved regarding primary prophylaxis of varices. Although variceal hemorrhage is a concerning complication of portal hypertension in children, the first bleed appears to be only rarely fatal and the associated morbidity has not been well characterized. CONCLUSION There are few pediatric data to indicate the efficacy and safety of pharmacologic or endoscopic therapies as primary prophylaxis or that prevention of a sentinel variceal bleed will ultimately improve survival; therefore, no recommendation for primary prophylaxis with endoscopic variceal ligation, sclerotherapy, or nonspecific beta-blockade in children was proposed.
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Affiliation(s)
- Benjamin L Shneider
- Texas Children's Hospital and the Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Daniel H Leung
- Texas Children's Hospital and the Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Anshu Srivastava
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Simon C Ling
- Hospital for Sick Children and the Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Mathieu Duché
- Hépatologie Pédiatrique and Centre de Référence National de l'Atrésie des Voies Biliaires, Radiologie Pédiatrique, Université Paris-Sud 11, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | | | | | | | - Jaime Bosch
- Hospital Clinic-IDIBAPS and CIBEREHD, Barcelona, Spain
| | | | - Shiv K Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
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