Portal gastropathy and duodenopathy in children with extrahepatic and intrahepatic portal hypertension: endoscopic diagnosis and histologic scoring

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

AIM

To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review.

METHODS

Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG.

RESULTS

PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension.

CONCLUSION

PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Cirrhosis in children and adolescents: An overview

Several conditions, especially chronic liver diseases, can lead to cirrhosis in children and adolescents. Most cases in clinical practice are caused by similar etiologies. In infants, cirrhosis is most often caused by biliary atresia and genetic-metabolic diseases, while in older children, it tends to result from autoimmune hepatitis, Wilson's disease, alpha-1-antitrypsin deficiency and primary sclerosing cholangitis. The symptoms of cirrhosis in children and adolescents are similar to those of adults. However, in pediatric patients, the first sign of cirrhosis is often poor weight gain. The complications of pediatric cirrhosis are similar to those observed in adult patients, and include gastrointestinal bleeding caused by gastroesophageal varices, ascites and spontaneous bacterial peritonitis. In pediatric patients, special attention should be paid to the nutritional alterations caused by cirrhosis, since children and adolescents have higher nutritional requirements for growth and development. Children and adolescents with chronic cholestasis are at risk for several nutritional deficiencies. Malnutrition can have severe consequences for both pre- and post-liver transplant patients. The treatment of cirrhosis-induced portal hypertension in children and adolescents is mostly based on methods developed for adults. The present article will review the diagnostic and differential diagnostic aspects of end-stage liver disease in children, as well as the major treatment options for this condition.

Duodenal morphometry and small bowel permeability in children with portal hypertension

OBJECTIVE

We prospectively studied children with portal hypertension (PHT) for portal hypertensive duodenopathy (PHTD) and small bowel intestinal permeability (SIP) with the objectives of defining histopathological parameters for PHTD and to find out whether any association existed among structural changes, SIP, and nutritional status.

METHOD

SIP was assessed by using lactulose and mannitol sugar probes in 31 children with PHT (cirrhosis n = 15 and extrahepatic portal venous obstruction n = 16) and 15 healthy children as controls. Morphometric assessment from duodenal biopsies was done in children with PHT. SIP and morphometric parameters were correlated with nutritional status and dietary intake.

RESULTS

Among children with PHT, 48% had PHTD defined as presence of villous atrophy (villous to crypt ratio < 2.5:1), dilated capillaries (capillary diameter > 16.8 μm, capillary area > 151 μm, capillary perimeter > 56 μm), and thickened muscularis mucosae (>22.2 μm). Lactulose excretion alone was increased in children with PHT as compared with healthy children (median %: 0.03, 0.02, and 0.01 for cirrhosis, extrahepatic portal venous obstruction, and controls, respectively [P < 0.01]) signifying increased paracellular permeability in PHT. Children with PHT had significantly lower z scores for height, weight, and triceps skin-fold thickness (<-2SD), whereas no differences were found in dietary intake between patients and controls. Increased SIP, nutritional compromise, and PHTD in our patients had no correlation.

CONCLUSIONS

PHT is often associated with duodenopathy. SIP does occur as a result of increased paracellular permeability. Factors of increased SIP, undernutrition, and PHTD do not have correlation in childhood PHT.

Investigation into celiac disease in Indian patients with portal hypertension

BACKGROUND

There is limited data on celiac disease in patients with cryptogenic cirrhosis or idiopathic noncirrhotic intrahepatic portal hypertension (NCIPH). Our objective was to evaluate for celiac disease in patients with portal hypertension in India.

METHODS

Consecutive patients with portal hypertension having cryptogenic chronic liver disease (cases) and hepatitis B- or C-related cirrhosis (controls) were prospectively enrolled. We studied tissue transglutaminase (tTG) antibody and duodenal histology in study patients.

RESULT

Sixty-one cases (including 14 NCIPH patients) and 59 controls were enrolled. Celiac disease was noted in six cases (including two NCIPH patients) as compared to none in controls. In a significant proportion of the remaining study subjects, duodenal biopsy showed villous atrophy, crypt hyperplasia, and lamina propria inflammation, not accompanied by raised intraepithelial lymphocytes (IELs); this was seen more commonly in cases as compared to controls. An unexpectedly high rate of tTG antibody positivity was seen in study subjects (66 %) of cases as compared to 29 % in controls (p-value < 0.001), which could indicate false-positive test result.

CONCLUSION

In this study, 10 % of patients with unexplained portal hypertension (cryptogenic chronic liver disease) had associated celiac disease. In addition, an unexplained enteropathy was seen in a significant proportion of study patients, more so in patients with cryptogenic chronic liver disease. This finding warrants further investigation.

Surgical and endovascular treatment of severe complications secondary to noncirrhotic portal hypertension: experience of 56 cases

BACKGROUND

Major complications of noncirrhotic portal hypertension (NCPH) include bleeding esophagogastric varices, hypersplenism, ascites, and bowel ischemia under acute circumstances. The aim of this article is to determine the outcomes of surgical and endovascular treatments for severe complications from NCPH.

METHODS

From January 2000 to June 2011, 56 patients with symptomatic NCPH underwent open surgery or endovascular thrombolysis. The medical records were retrospectively reviewed. Of the 56 patients, there were 39 males and 17 females. The mean age was 21 years, ranging from 2 to 54 years. Forty-one of them were diagnosed to have prehepatic portal vein obstruction (PHPVO), 9 had Budd-Chiari syndrome (BCS), and 6 had noncirrhotic portal fibrosis (NCPF). All patients were symptomatic from 5 days to 14 years (mean 25 months). Portosystemic shunt (PSS) was primarily performed in 49 patients. Shunts were as follows: 35 mesocaval; 7 splenorenal; 4 portocaval; 2 paraumbilical-jugular; and 1 portal to right atrial. Esophagogastric devascularization was performed in 3 patients, but was converted to mesocaval shunt later in 2. The remaining 4 patients with acute superior mesenteric vein (SMV) and portal vein thrombosis were treated with endovascular catheter-directed thrombolysis. Warfarin was prescribed to all the patients for at least 6 months. Mean follow-up was 57 months, ranging from 2 to 125 months. The outcomes, focusing on 30-day mortality, recurrent bleeding, and hypersplenism, were recorded.

RESULTS

In the 49 patients undergoing primary PSS, the shunts remained patent and there was no recurrent variceal bleeding during the follow-up. All 3 patients with esophagogastric devascularization had recurrent variceal bleeding at 8, 13, and 24 months postoperatively. Two of them were converted to mesocaval shunt, and 1 died before redo operation. Thrombolysis in all 4 patients with acute SMV and portal thrombosis was technically successful. Three of the 4 survived without complications and 1 died from small bowel infarction due to recurrent thrombosis 40 days later. In the 47 patients with hypersplenism, mean platelet counts increased from 43×10(9)/L to 239×10(9)/L 2 weeks after surgery. Ascites in 30 of the 31 patients disappeared within 2 months after PSS. There was no postoperative encephalopathy, and perioperative 30-day mortality was 0%.

CONCLUSIONS

PSS can be employed to treat bleeding esophagogastric varices and severe hypersplenism secondary to NCPH. Post-PSS encephalopathy is less of a concern in NCPH patients with normal liver function. Endovascular catheter-directed thrombolysis via superior mesenteric artery is a useful alternative treatment for acute portal and/or mesenteric venous thrombosis.