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Okello M, Srikant S, Darshit D, Ocama P. Outcomes of Proximal Spleno-Renal Shunt Operations for Idiopathic Portal Hypertension in Tertiary Hospital in the Sub-Sahara. Int Med Case Rep J 2024; 17:381-386. [PMID: 38681996 PMCID: PMC11055520 DOI: 10.2147/imcrj.s453341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/13/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose Idiopathic portal hypertension (IPH) also known as non-cirrhotic portal hypertension is an entity of hepatic conditions including disorders of blood vessels that leads to portal hypertension (PHT). Current management of PHT includes medical or endoscopic therapy. A proximal spleno-renal shunt (PSRS) operation has been shown to improve the outcomes of patients with IPH with upper gastrointestinal bleeding refractory to medical and endoscopic therapy in high income countries but the same has not been well described in our resource limited setting. Patients and methods This study consecutively included patients who were diagnosed with IPH on pre-operative imaging and underwent PSRS surgery. Data on four patients across the time period of 3 years was obtained with a male to female ratio of 1:1 and age range of 7 to 34 years. Results All patients in this study had features of upper gastrointestinal bleeding and, after an endoscopy they were all diagnosed with grade IV esophageal varices. Symptom duration prior to admission varied between 3 months to 8 years. All these patients had multiple episodes of rebleeding varices with recurrent admissions and were managed conservatively by multiple blood transfusions and propranolol tablets, pre-operatively. Only one patient had previous variceal band ligation done though he developed rebleeding. All four patients underwent both PSRS surgery and splenectomy and were intra-operatively verified to have a normal smooth liver and thus IPH was the cause of the esophageal varices. After an average follow-up period of 26.5 months, we found that all patients were alive with early symptomatic relief, no recurrent bleeding and no long-term complications. Conclusion Good outcomes were achieved in terms of symptom resolution, endoscopic variceal resolution at follow-up endoscopy, length of stay ranging from 8 to 15 days and all four patients were alive at the time of follow-up, that ranged from 14 to 46 months.
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Affiliation(s)
- Michael Okello
- Society of Uganda Gastrointestinal and Endoscopic Surgeons (SUGES), Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Dave Darshit
- Department of Surgery, Lubaga Hospital, Kampala, Uganda
| | - Ponsiano Ocama
- Makerere University College of Health Sciences, Kampala, Uganda
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Swaroop S, Vaishnav M, Arora U, Biswas S, Aggarwal A, Sarkar S, Khanna P, Elhence A, Kumar R, Goel A, Shalimar. Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis. J Clin Exp Hepatol 2024; 14:101291. [PMID: 38544766 PMCID: PMC10964076 DOI: 10.1016/j.jceh.2023.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/01/2023] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India. METHODS We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population. RESULTS We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%). CONCLUSIONS Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.
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Affiliation(s)
- Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya Sarkar
- Department of Anaesthesia, All India Institute of Medical Sciences, Kalyani, West Bengal, India
| | - Puneet Khanna
- Department of Anaesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Amit Goel
- Department of Hepatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
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Sunar Yayla EN, Sarı S, Gürcan Kaya N, Eğrİtaş Gürkan Ö, Sözen H, Özen İO, Dalgıç A, Dalgıç B. Portal Hypertension in Children: A Tertiary Center Experience in Turkey. Pediatr Gastroenterol Hepatol Nutr 2023; 26:301-311. [PMID: 38025487 PMCID: PMC10651363 DOI: 10.5223/pghn.2023.26.6.301] [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: 05/19/2023] [Revised: 08/09/2023] [Accepted: 09/16/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Portal hypertension (PH) and its complications have a significant impact on morbidity and mortality. This study aimed to evaluate the etiology; clinical, laboratory, and endoscopic findings; treatment approaches; long-term outcomes; and prognosis of pediatric PH. Methods This retrospective study included 222 pediatric patients diagnosed with PH between 1998 and 2016, and data encompassing clinical, laboratory, and radiological features; treatments; and complications were analyzed. Results The most common causes of PH were portal vein thrombosis (20.3%), progressive familial intrahepatic cholestasis (18.9%), and biliary atresia (12.2%). Among the enrolled patients, 131 (59.0%) were included in the cirrhotic group and 91 (41.0%) in the non-cirrhotic group. Hepatomegaly and increased transaminase levels were more frequent in the cirrhotic group than in the non-cirrhotic group. Additionally, portal gastropathy, esophageal varices, and variceal bleeding were more frequent in the non-cirrhotic group, whereas ascites, hepatopulmonary syndrome and hepatic encephalopathy were more common in the cirrhotic group. The incidence of hepatomegaly was higher in the presinusoidal group than in the prehepatic group (p<0.001). Hyperbilirubinemia was more frequent in the prehepatic group (p=0.046). The frequency of esophageal varices was similar between the prehepatic and presinusoidal groups; however, variceal bleeding was more frequent in the prehepatic group (p=0.002). Conclusion Extrahepatic portal vein obstruction, genetic-metabolic diseases, and biliary atresia were the most prevalent causes of PH in our country. In patients with PH, hepatomegaly, increased transaminase levels, and synthesis dysfunction were suggestive of cirrhotic PH. Notably, PH in patients without cirrhosis might be more severe than that in those with cirrhosis.
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Affiliation(s)
| | - Sinan Sarı
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Neslihan Gürcan Kaya
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ödül Eğrİtaş Gürkan
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Hakan Sözen
- Division of Transplantation Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - İbrahim Onur Özen
- Department of Pediatric Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Aydın Dalgıç
- Division of General Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Buket Dalgıç
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
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S L H, Pottakkat B, Gnanasekaran S, Raja K. Unconventional shunt surgery for non-cirrhotic portal hypertension in patients not suitable for proximal splenorenal shunt. Ann Hepatobiliary Pancreat Surg 2023; 27:264-270. [PMID: 37357160 PMCID: PMC10472123 DOI: 10.14701/ahbps.23-002] [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] [Received: 01/09/2023] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 06/27/2023] Open
Abstract
Backgrounds/Aims Proximal splenorenal shunt (PSRS) is a commonly performed procedure to decompress portal hypertension, in patients with refractory variceal bleed, especially in non-cirrhotic portal hypertension (NCPH). If conventional methods are hindered by any technical or pathological factors, alternative surgical techniques may be required. This study analyzes the effectiveness of various unconventional shunt surgeries performed for NCPH. Methods A retrospective analysis of NCPH patients who underwent unconventional shunt surgeries during the period July 2011 to June 2022 was conducted. All patients were followed up for a minimum of 12 months with doppler study of the shunt to assess shunt patency, and upper gastrointestinal endoscopy to evaluate the regression of varices. Results During the study period, 130 patients underwent shunt surgery; among these, 31 underwent unconventional shunts (splenoadrenal shunt [SAS], 12; interposition mesocaval shunt [iMCS], 8; interposition PSRS [iPSRS], 6; jejunal vein-cava shunt [JCS], 3; left gastroepiploic-renal shunt [LGERS], 2). The main indications for unconventional shunts were left renal vein aberration (SAS, 8/12), splenic vein narrowing (iMCS, 5/8), portalhypertensive vascular changes (iPSRS, 6/6), and portomesenteric thrombosis (JCS, 3/3). The median fall in portal pressure was more in SAS (12.1 mm Hg), and operative time more in JCS, 8.4 hours (range, 5-9 hours). During a median follow-up of 36 months (6-54 months), shunt thrombosis had been reported in all cases of LGERS, and less in SAS (3/12). Variceal regression rate was high in SAS, and least in LGERS. Hypersplenism had reversed in all patients, and 6/31 patients had a recurrent bleed. Conclusions Unconventional shunt surgery is effective in patients unsuited for other shunts, especially PSRS, and it achieves the desired effects in a significant proportion of patients.
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Affiliation(s)
- Harilal S L
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kalayarasan Raja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Panda A, Narayanan D, Netaji A, Varshney VK, Agarwal L, Garg PK. Spontaneous hepatic arterioportal fistula in extrahepatic portal vein obstruction: Combined endovascular and surgical management. Ann Hepatobiliary Pancreat Surg 2023; 27:307-312. [PMID: 36944615 PMCID: PMC10472122 DOI: 10.14701/ahbps.22-126] [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: 12/02/2022] [Revised: 01/07/2023] [Accepted: 01/16/2023] [Indexed: 03/23/2023] Open
Abstract
Hepatic arterioportal fistulae are abnormal communications between the hepatic artery and portal vein. They are reported to be congenital or acquired secondary to trauma, iatrogenic procedures, hepatic cirrhosis, and hepatocellular carcinoma, but less likely to occur spontaneously. Extrahepatic portal venous obstruction (EHPVO) can lead to pre-hepatic portal hypertension. A spontaneous superimposed hepatic arterioportal fistula can lead to pre-sinusoidal portal hypertension, further exacerbating its physiology. This report describes a young woman with long-standing EHPVO presenting with repeated upper gastrointestinal variceal bleeding and symptomatic hypersplenism. Computed tomography scan demonstrated a cavernous transformation of the portal vein and a macroscopic hepatic arterioportal fistula between the left hepatic artery and portal vein collateral in the central liver. The hepatic arterioportal fistula was associated with a flow-related left hepatic artery aneurysm and a portal venous collateral aneurysm proximal and distal to the fistula, respectively. Endovascular coiling was performed for the hepatic arterioportal fistula, followed by proximal splenorenal shunt procedure. This case illustrates an uncommon association of a spontaneous hepatic arterioportal fistula with EHPVO and the utility of a combined endovascular and surgical approach for managing multifactorial non-cirrhotic portal hypertension in such patients.
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Affiliation(s)
- Ananya Panda
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Durgadevi Narayanan
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Arjunlokesh Netaji
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vaibhav Kumar Varshney
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Lokesh Agarwal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Gama MCFDLR, Fagundes EDT, Queiroz TCN, Rodrigues AT, Vieira LC, Ferreira AR. PREDICTIVE FACTORS OF MORBIDITY ASSOCIATED WITH ESOPHAGEAL VARICEAL BLEEDING IN CHILDREN WITH PORTAL HYPERTENSION. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:247-256. [PMID: 37556751 DOI: 10.1590/s0004-2803.202302023-37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/20/2023] [Indexed: 08/11/2023]
Abstract
•Most data on the natural history of portal hypertension come from studies in adults. •The morbidity rate of upper gastrointestinal bleeding in children with portal hypertension tend to be underestimated. •This study showed the relevance of morbidity rates after variceal hemorrhage in pediatric patients, especially those with cirrhosis. •Patients with hemodynamic instability requiring blood transfusion or expansion on admission are at increased risk of complications secondary to upper gastrointestinal bleeding and should be closely monitored. Background - Most data on the natural history of portal hypertension come from studies in adults. The morbidity rate of upper gastrointestinal bleeding (UGIB) in children with portal hypertension has not been systematically characterized. Objective - To describe the morbidity and mortality of UGIB in pediatric patients with portal hypertension and identify predictive factors for the occurrence of its main complications. Methods - This retrospective study included pediatric patients with cirrhotic portal hypertension or with extrahepatic portal vein obstruction (EHPVO). Mortality and UGIB complications within a period of up to 6 weeks of the bleeding were investigated. To determine the predictive factors of morbidity, a multivariate analysis was performed using logistic regression; all results were considered significant at P<0.05. Results - A total of 86 patients (51.2% with EHPVO and 48.8% with cirrhosis) had 174 bleeding events. Ascites was the most common complication (43.1% of all cases), being more prevalent in patients with cirrhosis (P<0.001). Cirrhosis was a predictor of the occurrence of any morbidity (OR 20.3). The need for blood transfusion was predictor of at least one complication (OR 5.8), ascites (OR 7.2) and infections (OR 3.8) in the general group and at least one complication (OR 11.3) and ascites (OR 5.8) in cirrhotic patients. The need for expansion was a predictor of any morbidity (OR 4.6) and infections (OR 3.9) in the general group, in addition to being predictor of infection in cirrhotic patients (OR 5.4). There were no deaths from UGIB in the six weeks post-bleeding. Conclusion - The study showed the relevance of morbidity after UGIB in pediatric patients with portal hypertension, especially in those with cirrhosis. The patients with hemodynamic instability requiring blood transfusion or expansion on admission are at increased risk of complications related to upper gastrointestinal bleeding and should be closely monitored.
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Affiliation(s)
| | - Eleonora Druve Tavares Fagundes
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Thaís Costa Nascentes Queiroz
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
| | - Adriana Teixeira Rodrigues
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Luiza Caroline Vieira
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Alexandre Rodrigues Ferreira
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brasil
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Sooraj K, Shivani FNU, Hassan Khan M, Kumar RR, Bai S, Hussaini H, Rakesh FNU, Jamil A, Arshad H, Naz S. Frequency of Causes of Portal Hypertension in Children. Cureus 2022; 14:e25934. [PMID: 35844324 PMCID: PMC9282599 DOI: 10.7759/cureus.25934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction The most common etiology of portal hypertension (PH) in children is obstruction at the presinusoidal or sinusoidal level. In addition, portal vein thrombosis (PVT) and biliary atresia are the most prevalent extrahepatic causes. This study aims to evaluate all the possible etiologies leading to PH in the pediatric population and provide the most common cause associated with this condition along with the age group most frequently affected by it. Material and Methods From January 2018 to December 2020, a cross-sectional study was carried out in tertiary care hospitals in Pakistan. A total of 100 children, both male and female, aged one month to 15 years and diagnosed with PH, were enrolled for the evaluation for the causes of PH. The Statistical Package for the Social Sciences (SPSS), version 20, was used to analyze the data. Results The mean age of enrolled participants was 9.01 ± 2.81 years. It was found that PVT (63%) was the most common cause of PH, followed by liver cirrhosis (19%) and biliary atresia (18%). Age of more than eight years was significantly associated with PVT (p-value: 0.007). Conclusion In children, PH may be caused by a wide range of etiologies. It is imperative to understand the underlying etiologies contributing to PH for proper guidance and management, prevention, and overall outcomes.
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Jagadisan B, Dhawan A. Emergencies in paediatric hepatology. J Hepatol 2022; 76:1199-1214. [PMID: 34990749 DOI: 10.1016/j.jhep.2021.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022]
Abstract
The aetiology of several liver diseases in children is age specific and many of these conditions have significant and potentially long-term clinical repercussions if not diagnosed early and managed in a timely fashion. We address 5 clinical scenarios that cover most of the diagnostic and therapeutic emergencies in children: infants with liver disease; acute liver failure; management of bleeding varices; liver-based metabolic disorders; and liver tumours and trauma. A wide spectrum of conditions that cause liver disease in infants may present as conjugated jaundice, which could be the only symptom of time-sensitive disorders - such as biliary atresia, metabolic disorders, infections, and haematological/alloimmune disorders - wherein algorithmic multistage testing is required for accurate diagnosis. In infantile cholestasis, algorithmic multistage tests are necessary for an accurate early diagnosis, while vitamin K, specific milk formulae and disease-specific medications are essential to avoid mortality and long-term morbidity. Management of paediatric acute liver failure requires co-ordination with a liver transplant centre, safe transport and detailed age-specific aetiological work-up - clinical stabilisation with appropriate supportive care is central to survival if transplantation is indicated. Gastrointestinal bleeding may present as the initial manifestation or during follow-up in patients with portal vein thrombosis or chronic liver disease and can be managed pharmacologically, or with endoscopic/radiological interventions. Liver-based inborn errors of metabolism may present as encephalopathy that needs to be recognised and treated early to avoid further neurological sequelae and death. Liver tumours and liver trauma are both rare occurrences in children and are best managed by a multidisciplinary team in a specialist centre.
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Affiliation(s)
- Barath Jagadisan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK.
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Sarma MS, Seetharaman J. Pediatric non-cirrhotic portal hypertension: Endoscopic outcome and perspectives from developing nations. World J Hepatol 2021; 13:1269-1288. [PMID: 34786165 PMCID: PMC8568571 DOI: 10.4254/wjh.v13.i10.1269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/27/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
Non-cirrhotic portal hypertension (NCPH) forms an important subset of portal hypertension in children. Variceal bleed and splenomegaly are their predominant presentation. Laboratory features show cytopenias (hypersplenism) and preserved hepatic synthetic functions. Repeated sessions of endoscopic variceal ligation or endoscopic sclerotherapy eradicate esophageal varices in almost all cases. After variceal eradication, there is an increased risk of other complications like secondary gastric varices, cholangiopathy, colopathy, growth failure, especially in extra-hepatic portal vein obstruction (EHPVO). Massive splenomegaly-related pain and early satiety cause poor quality of life (QoL). Meso-Rex bypass is the definitive therapy when the procedure is anatomically feasible in EHPVO. Other portosystemic shunt surgeries with splenectomy are indicated when patients present late and spleen-related issues predominate. Shunt surgeries prevent rebleed, improve growth and QoL. Non-cirrhotic portal fibrosis (NCPF) is a less common cause of portal hypertension in children in developing nations. Presentation in the second decade, massive splenomegaly and patent portal vein are discriminating features of NCPF. Shunt surgery is required in severe cases when endotherapy is insufficient for the varices. Congenital hepatic fibrosis (CHF) presents with firm palpable liver and splenomegaly. Ductal plate malformation forms the histological hallmark of CHF. CHF is commonly associated with Caroli’s disease, renal cysts, and syndromes associated with neurological defects. Isolated CHF has a favourable prognosis requiring endotherapy. Liver transplantation is required when there is decompensation or recurrent cholangitis, especially in Caroli’s syndrome. Combined liver-kidney transplantation is indicated when both liver and renal issues are present.
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Affiliation(s)
- Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Jayendra Seetharaman
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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10
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Understanding EHPVO. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02833-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Shanmugam N, Sathyasekaran M, Rela M. Pediatric Liver Disease in India. Clin Liver Dis (Hoboken) 2021; 18:155-157. [PMID: 34691403 PMCID: PMC8518350 DOI: 10.1002/cld.1138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/17/2021] [Accepted: 05/05/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Naresh Shanmugam
- The Institute of Liver Disease & TransplantationDr. Rela Institute & Medical CentreBharath Institute of Higher Education & ResearchChennaiIndia
| | - Malathy Sathyasekaran
- Kanchi Kamakoti CHILDS Trust HospitalCHILDS Trust Medical Research FoundationChennaiIndia
| | - Mohamed Rela
- The Institute of Liver Disease & TransplantationDr. Rela Institute & Medical CentreBharath Institute of Higher Education & ResearchChennaiIndia
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Shukla A, Shreshtha A, Mukund A, Bihari C, Eapen CE, Han G, Deshmukh H, Cua IHY, Lesmana CRA, Al Meshtab M, Kage M, Chaiteeraki R, Treeprasertsuk S, Giri S, Punamiya S, Paradis V, Qi X, Sugawara Y, Abbas Z, Sarin SK. Budd-Chiari syndrome: consensus guidance of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 2021; 15:531-567. [PMID: 34240318 DOI: 10.1007/s12072-021-10189-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/11/2021] [Indexed: 02/07/2023]
Abstract
Budd Chiari syndrome (BCS) is a diverse disease with regard to the site of obstruction, the predisposing thrombophilic disorders and clinical presentation across the Asia-Pacific region. The hepatic vein ostial stenosis and short segment thrombosis are common in some parts of Asia-Pacific region, while membranous obstruction of the vena cava is common in some and complete thrombosis of hepatic veins in others. Prevalence of myeloproliferative neoplasms and other thrombophilic disorders in BCS varies from region to region and with different sites of obstruction. This heterogeneity also raises several issues and dilemmas in evaluation and approach to management of a patient with BCS. The opportunity to recanalize hepatic vein in patients with hepatic vein ostial stenosis or inferior vena cava stenting or pasty among those membranous obstruction of the vena cava is a unique opportunity in the Asia-Pacific region to restore hepatic outflow closely mimicking physiology. In order to address these issues arising out of the diversity as well as the unique features in the region, the Asia Pacific Association for Study of Liver has formulated these guidelines for clinicians.
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Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India.
| | | | - Amar Mukund
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - C E Eapen
- Christian Medical College, Vellore, India
| | - Guohong Han
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Hemant Deshmukh
- Dean and Head of Radiology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Ian Homer Y Cua
- Institute of Digestive and Liver Diseases, St Lukes Medical Center, Global City, Philippines
| | - Cosmas Rinaldi Adithya Lesmana
- Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
| | - Mamun Al Meshtab
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
- Center for Innovative Cancer Therapy, Kurume University Research, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Masayoshi Kage
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Roongruedee Chaiteeraki
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sombat Treeprasertsuk
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suprabhat Giri
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Sundeep Punamiya
- Vascular and Interventional Radiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valerie Paradis
- Dpt dAnatomie Pathologique, Hôpital Beaujon, 100 bd du Gal Leclerc, Clichy, 92110, France
| | - Xingshun Qi
- General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, China
| | - Yasuhiko Sugawara
- Department of Transplantation and Pediatric Surgery, Kumamoto University, Kumamoto, Japan
| | - Zaigham Abbas
- Department of Hepatogastroenterology, Dr. Ziauddin University Hospital Clifton, Karachi, Pakistan
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13
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Shrestha BM, Shrestha S, Kharel S, K C A, Shrestha S, Pradhan S, Bhandari RS. Jejunal varices with extra hepatic portal vein obstruction: A case report. Int J Surg Case Rep 2021; 83:105964. [PMID: 34004566 PMCID: PMC8141758 DOI: 10.1016/j.ijscr.2021.105964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction and importance Extrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare. Presentation of case We report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices. Discussion Portal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices. Conclusion Jejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy. Intestinal varices are rarely developed as new collaterals accompanying portal hypertension with EHPVO (Extrahepatic portal vein obstruction). Jejunal varices must be considered in patients with a negative source of bleed on upper and lower GI endoscopy.
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Affiliation(s)
| | - Suraj Shrestha
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Sanjeev Kharel
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal.
| | - Ajay K C
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Sujan Shrestha
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Sumita Pradhan
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Ramesh Singh Bhandari
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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14
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Oliveira APPD, Ferreira AR, Fagundes EDT, Queiroz TCN, Carvalho SD, Neto JAF, Bittencourt PFS. Endoscopic prophylaxis and factors associated with bleeding in children with extrahepatic portal vein obstruction. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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15
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Oliveira APPD, Ferreira AR, Fagundes EDT, Queiroz TCN, Carvalho SD, Neto JAF, Bittencourt PFS. Endoscopic prophylaxis and factors associated with bleeding in children with extrahepatic portal vein obstruction. J Pediatr (Rio J) 2020; 96:755-762. [PMID: 31666182 PMCID: PMC9432056 DOI: 10.1016/j.jped.2019.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate factors associated with upper digestive hemorrhage and primary and secondary endoscopic prophylaxis outcomes in children with extrahepatic portal vein obstruction. METHODS This observational and prospective study included 72 children with extrahepatic portal vein obstruction who were followed from 2005 to 2017. Risk factors associated with upper digestive hemorrhage and the results of primary and secondary prophylaxis of these patients were evaluated. RESULTS Fifty patients (69.4%) had one or more episodes of bleeding during follow-up, with a median age at first hemorrhage of 4.81 years. The multivariate analysis showed that medium- to large-caliber esophageal varices were associated with an 18-fold risk of upper digestive hemorrhage (95% CI: 4.33-74.76; p < 0.0001). Primary prophylaxis was administered to 14 patients, with eradication in 85.7%; however, 14.3% of these patients had hemorrhages during the follow-up period and 41.7% had a relapse of varices. Secondary prophylaxis was administered to 41 patients. Esophageal varices were eradicated in 90.2% of patients. There were relapse and re-bleeding of esophageal varices in 45.9% and 34.1% of the children, respectively. CONCLUSION Primary and secondary endoscopic prophylaxes showed high rates of esophageal varix eradication, but with significant relapses. Eradication of esophageal varices cannot definitively prevent recurrent upper digestive hemorrhage, since bleeding from alternate sites can occur. Medium- and large-caliber esophageal varices were associated with upper digestive hemorrhage in patients with extrahepatic portal vein obstruction. To the best of the authors' knowledge, this study is the first to evaluate bleeding risk factors in children with extrahepatic portal vein obstruction.
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Affiliation(s)
- Ana Paula Pereira de Oliveira
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Departamento de Pediatria, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brazil.
| | - Alexandre Rodrigues Ferreira
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Departamento de Pediatria, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brazil
| | - Eleonora Druve Tavares Fagundes
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Departamento de Pediatria, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brazil
| | - Thaís Costa Nascentes Queiroz
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Departamento de Pediatria, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brazil
| | - Simone Diniz Carvalho
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Departamento de Pediatria, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brazil
| | - José Andrade Franco Neto
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Departamento de Pediatria, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brazil
| | - Paulo Fernando Souto Bittencourt
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Departamento de Pediatria, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brazil
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16
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Pediatric living donor liver transplantation with non-anatomical portal vein reconstruction in idiopathic extrahepatic portal vein thrombosis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Wu L, Zhang G, Guo C. Thromboelastography Detects Possible Coagulation Disturbance in Pediatric Patients with Portal Cavernoma. Transfus Med Hemother 2020; 47:135-143. [PMID: 32355473 DOI: 10.1159/000501229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/29/2019] [Indexed: 02/02/2023] Open
Abstract
Background Thromboelastography (TEG) allows a dynamic assessment of clot formation and dissolution that might be useful for assessing the relative contribution of the coagulation components to overall clot formation and dissolution, but it has not been fully defined in patients with portal cavernoma (PC). Methods We retrospectively recruited consecutive patients with PC between July 2006 and June 2016 who had no abdominal malignancy or liver cirrhosis. Blood samples were drawn on admission and were subjected to coagulation parameter assessment, including conventional coagulation tests, measurement of the circulating levels of procoagulant and anticoagulant factors, and TEG assessment. Results Compared with controls, patients with PC showed significant reductions in the serum levels of procoagulant factors and anticoagulants factors, whereas factor VIII was slightly elevated. TEG showed clot formation (α-angle), and the maximal clot strength (MA) was higher in patients with PC than in controls, indicating a hypercoagulable state. Thrombocytopenia decreased both clot formation (α-angle) and the maximal clot strength (MA) but was still significantly higher than the control. Furthermore, patients with PC had a higher level of D-dimer and LY30 than did controls, indicating the in vivo activation of coagulation and fibrinolysis. Conclusion TEG analysis showed that patients with PC were in a hypercoagulable state that could be partially masked by thrombocytopenia secondary to splenomegaly and hypersplenism in these patients, which indicates that our current prophylaxis and therapy regimen could be improved.
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Affiliation(s)
- Linfeng Wu
- Chongqing Medical University, Chongqing, China.,Department of Nephrology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Gaofu Zhang
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China.,Department of Nephrology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Chunbao Guo
- Chongqing Medical University, Chongqing, China.,Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, China
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18
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Long-term Outcomes and Health Perceptions in Pediatric-onset Portal Hypertension Complicated by Varices. J Pediatr Gastroenterol Nutr 2020; 70:628-634. [PMID: 31990868 DOI: 10.1097/mpg.0000000000002643] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Outcomes of pediatric-onset portal hypertension are poorly defined. We aimed to assess population-based long-term outcomes of pediatric-onset portal hypertension complicated by varices. METHODS All children with esophageal varices (n = 126) were identified from 14,144 single nationwide referral center endoscopy reports during 1987 to 2013, and followed up through national health care and death registers. A questionnaire was sent to survivors (n = 94) of whom 65 (69%) responded. RESULTS Nineteen underlying disorders included biliary atresia (35%), extrahepatic portal vein obstruction (35%), autosomal recessive polycystic kidney disease (7%), and other disorders (23%). During median follow-up of 15.2 (range 0.5-43.1) years patients underwent median 9 (1-74) upper gastrointestinal endoscopies. Esophageal varices were first observed at a median age of 4.0 (0.3-18.2) years, 112 (89%) patients underwent median 6 (1-56) sclerotherapy/banding sessions, and 61 (48%) experienced median 2 (range 1-20) variceal bleeding episodes. Forty-eight surgical shunt procedures were performed to 41 (36%) patients and 38% underwent liver transplantation. Portal hypertensive biliopathy was diagnosed in 4 patients. Hepatopulmonary syndrome necessitated liver transplantation in 2 patients, hepatic encephalopathy in 2, and hepatorenal syndrome in 1. No patient died of variceal bleeding. Patient-reported perception of health on a scale of 1 to 10 was 9 (range 4-10), and 86% reported no current symptoms attributable to esophageal varices. CONCLUSIONS Pediatric-onset portal hypertension is a heterogeneous disease with significant long-term morbidity, requiring multimodal approach with considerable resources and continuation of follow-up in adulthood. Although mortality to variceal bleeding was avoided, bleeding episodes recurred also in adulthood, while patient-reported health of long-term survivors was encouraging.
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19
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Kumar N, Srivastava A, Kumari N, Mittal S, Yachha SK, Nayez Z, Poddar U. Prevalence, nature, and predictors of colonic changes in children with extrahepatic portal vein obstruction. Gastrointest Endosc 2020; 91:849-858. [PMID: 31816313 DOI: 10.1016/j.gie.2019.11.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The medical literature on colonic changes in children with extrahepatic portal venous obstruction (EHPVO) is limited. We evaluated EHPVO children for prevalence, nature, and relation of colonic changes with disease duration, extent of splenoportal axis (SPA) thrombosis, portal hypertensive gastropathy (PHG), and esophageal varices (EVs). The correlation between histologic and endoscopic changes was studied. METHODS Subjects were evaluated by colonoscopy with ileoscopy and biopsy sampling, clinico-laboratory profiles, and SPA imaging. Colonic changes were classified as varices (rectal/colonic) and portal hypertensive colopathy (PHC; colitis-like or vascular lesions). Morphometric analysis of colonic biopsy specimens was performed. RESULTS Fifty-four children (median age, 12 years [range, 8-15]; hematochezia in 9 [16.6%]) were evaluated. Rectal and colonic varices were seen in 51 (94%) and 2 (3.7%) cases, respectively. Seventy-five percent of patients had PHC, and colitis-like lesions were more common than vascular lesions (36/40 vs 23/40; P = .001). Colopathy changes were pancolonic in 52.5%, left-sided in 42.5%, and right-sided in 5% of cases. Sixteen percent of patients (8/49) had ileal changes. Children with PHC had PHG more often (90% vs 57%; P = .01), more endotherapy sessions (mean 6 [range, 4-8] vs 2 [range, 1-4]; P = .03), and large EVs less often (12.5% vs 43%; P = .02) than those without colopathy. The extent of SPA thrombosis was similar in patients with and without PHC. The number of capillaries per crypt was higher in EHPVO than in control subjects. Morphometric changes had no correlation with endoscopy. CONCLUSIONS Most EHPVO children had colonic changes, and 16% had ileopathy. "Colitis-like" changes and left-side involvement were more common. Patients with PHG and eradicated EVs had a higher risk of PHC.
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Affiliation(s)
- Nagendra Kumar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
| | - Niraj Kumari
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
| | - Somit Mittal
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
| | - Surender K Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
| | - Zafar Nayez
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
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Goel A, Ramakrishna B, Zachariah U, Sajith KG, Burad DK, Kodiatte TA, Keshava SN, Balasubramanian KA, Elias E, Eapen CE. What makes non-cirrhotic portal hypertension a common disease in India? Analysis for environmental factors. Indian J Med Res 2020; 149:468-478. [PMID: 31411170 PMCID: PMC6676844 DOI: 10.4103/ijmr.ijmr_1405_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.
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Affiliation(s)
- Ashish Goel
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Banumathi Ramakrishna
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Uday Zachariah
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - K G Sajith
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Deepak K Burad
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Thomas A Kodiatte
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Shyamkumar N Keshava
- Department of Radio-diagnosis, Division of GI Sciences, Christian Medical College, Vellore, India
| | - K A Balasubramanian
- Department of Wellcome Research Laboratory, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Elwyn Elias
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India; Liver Unit, University Hospitals, Birmingham, UK
| | - C E Eapen
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
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21
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Ravindranath A, Sen Sarma M, Yachha SK, Lal R, Singh S, Srivastava A, Poddar U, Neyaz Z, Behari A. Outcome of portosystemic shunt surgery on pre-existing cholangiopathy in children with extrahepatic portal vein obstruction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 27:141-148. [PMID: 31654467 DOI: 10.1002/jhbp.692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study was performed to assess the effect of portosystemic shunt surgery (PSS) on portal cavernoma cholangiopathy (PCC) in children with extrahepatic portal vein obstruction (EHPVO). METHODS Children with EHPVO and PCC (unfit for Meso-Rex shunt) underwent magnetic resonance cholangiogram (MRC) and magnetic resonance portovenogram (MRPV) before non-selective PSS. PCC was graded by modified Llop classification. Those with patent shunt were re-evaluated at least 6 months after surgery with MRC, MRPV and compared with pre-shunt images. RESULTS Twenty-five children underwent PSS (central end to side splenorenal shunt with splenectomy [n = 24], mesocaval shunt [n = 1]). Pre-surgery MRC showed PCC grade I in 11, grade II in 1 and grade III in 13. MRPV showed superior mesenteric vein (SMV) block in 20. Re-assessment for PCC 18 (6 to 54) months after surgery showed grade I in 6 and grade III in 19. Thus, PCC was progressive in 6 and static in 19. Density of peribiliary collaterals decreased in 5 (SMV patent, static PCC), increased in 3 and remained unchanged in 17. Splenomegaly-related problems, gastroesophageal varices and other intra-abdominal (esophageal, perisplenic and perigastric) collaterals ameliorated in all. CONCLUSION Non-selective PSS decompresses esophago-gastro-splenic venous circuit effectively but fails to ameliorate cholangiopathy and peribiliary collaterals. Persistence of cholangiopathy is attributable to SMV block.
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Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Richa Lal
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Somesh Singh
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Zafar Neyaz
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anu Behari
- Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Monroe EJ, Shivaram GM. Pediatric Hepatobiliary Interventions in the Setting of Intrahepatic Vascular Malformations, Portal Hypertension, and Liver Transplant. Semin Roentgenol 2019; 54:311-323. [PMID: 31706365 DOI: 10.1053/j.ro.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Within the broad spectrum of pediatric hepatobiliary disorders, hepatic vascular malformations, portal hypertension, and hepatic transplant interventions pose numerous challenges. The role of interventional radiology within each of these conditions is discussed herein, beginning with endovascular management of high flow hepatic vascular malformations. Next, while becoming less common in adult populations, surgical portoportal and portosystemic shunts remain prevalent in many pediatric centers. Shunt anatomy is reviewed along with endovascular management techniques for shunt dysfunction. Next, the growing experience with pediatric transjugular intrahepatic portosystemic shunt placement is reviewed along with tips for success in pediatric patients. Finally, pediatric hepatic transplant interventions are discussed with technical notes pertinent to split liver anatomy.
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Affiliation(s)
- Eric J Monroe
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington, Seattle, WA.
| | - Giridhar M Shivaram
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington, Seattle, WA
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Ede CJ, Ede R, Brand M. Selective versus non‐selective shunts for the prevention of variceal rebleeding. Cochrane Database Syst Rev 2019; 2019:CD013471. [PMCID: PMC6837277 DOI: 10.1002/14651858.cd013471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2024]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of any type of selective shunt versus any type of non‐selective shunt for the prevention of oesophagogastric variceal rebleeding in people with portal hypertension.
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Affiliation(s)
- Chikwendu J Ede
- University of the WitwatersrandDepartment of Surgery7 York RoadJohannesburgSouth Africa2193
| | - Roseline Ede
- University of the WitwatersrandDepartment of Dermatology7 York Road, ParktownJohannesburgSouth AfricaGauteng
| | - Martin Brand
- University of PretoriaDepartment of SurgeryPretoriaSouth Africa0001
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24
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Abstract
Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are prototype noncirrhotic causes of portal hypertension (PHT), characterized by normal hepatic venous pressure gradient, variceal bleeds, and moderate to massive splenomegaly with preserved liver synthetic functions. Infections, toxins, and immunologic, prothrombotic and genetic disorders are possible causes in IPH, whereas prothrombotic and local factors around the portal vein lead to EHPVO. Growth failure, portal biliopathy, and minimal hepatic encephalopathy are long-term concerns in EHPVO. Surgical shunts and transjugular intrahepatic portosystemic shunt resolve the complications secondary to PHT. Meso-Rex shunt is now the standard-of-care surgery in children with EHPVO.
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Affiliation(s)
- Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi 110 070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi 110 070, India.
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25
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Butt N, Akbar A, Fahad A. An Unusual Case of Congenital Hepatic Fibrosis with Retinitis Pigmentosa. Cureus 2019; 11:e5788. [PMID: 31728235 PMCID: PMC6827873 DOI: 10.7759/cureus.5788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/27/2019] [Indexed: 11/15/2022] Open
Abstract
Congenital hepatic fibrosis (CHF) is a rare hereditary autosomal recessive disorder due to periportal fibrosis and ductal plate malformation. It is just one of many different malformations collectively named oculo-encephalo-hepato-renal syndrome. The major presenting feature is upper gastrointestinal bleeding due to portal hypertension secondary to the development of esophageal varices. Herein we report a case of CHF with retinitis pigmentosa but lacking the distinctive multisystem malformations associated with other well-known syndromes associated with CHF. In cases of CHF, search for other organ involvement is important at the time of presentation as well as during follow-up.
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Affiliation(s)
- Nazish Butt
- Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Ali Akbar
- Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
| | - Anoshia Fahad
- Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi, PAK
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26
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Di Giorgio A, De Angelis P, Cheli M, Vajro P, Iorio R, Cananzi M, Riva S, Maggiore G, Indolfi G, Calvo PL, Nicastro E, D'Antiga L. Etiology, presenting features and outcome of children with non-cirrhotic portal vein thrombosis: A multicentre national study. Dig Liver Dis 2019; 51:1179-1184. [PMID: 30928422 DOI: 10.1016/j.dld.2019.02.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/20/2018] [Accepted: 02/24/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Non-cirrhotic portal vein thrombosis (PVT) is a main cause of portal hypertension in children. We describe the characteristics at presentation and outcome of a cohort of patients with PVT to determine clinical features and predictors of outcome. METHODS We recorded: (1) Associated factors: prematurity, congenital malformations, neonatal illnesses, umbilical vein catheterization (UVC), deep infections, surgery; (2) congenital and acquired prothrombotic disorders; (3) features at last follow up including survival rate and need for surgery. RESULTS 187 patients, mean age at diagnosis 4 ± 3.7 years, had a history of prematurity (61%); UVC (65%); neonatal illnesses (79%). The diagnosis followed the detection of splenomegaly (40%), gastrointestinal bleeding (36%), hypersplenism (6%), or was incidental (18%). Of 71 patients who had endoscopy at presentation 62 (87%) had oesophageal varices. After 11.3 years' follow up 63 (34%) required surgery or TIPS. Ten-year survival rate was 98%, with 90% shunt patency. Spleen size, variceal bleeding and hypersplenism at presentation were predictors of surgery or TIPS (p < 0.05). CONCLUSION PVT is associated with congenital and acquired co-morbidities. History of prematurity, neonatal illnesses and UVC should lead to rule out PVT. Large spleen, variceal bleeding and hypersplenism at presentation predict the need for eventual surgery in a third of cases.
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Affiliation(s)
- Angelo Di Giorgio
- Paediatric Liver, GI and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Paola De Angelis
- Paediatric Surgery and Endoscopy, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Maurizio Cheli
- Paediatric Surgery, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Pietro Vajro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" Section of Pediatrics, University of Salerno, Baronissi (Salerno), Italy
| | - Raffaele Iorio
- Paediatric Liver Unit, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - Mara Cananzi
- Unit of Pediatric Gastroenterology and Hepatology, Dpt. of Women's and Children's Health, University Hospital of Padova, Italy
| | - Silvia Riva
- Paediatric department and transplantation, Ismett, Palermo, Italy
| | - Giuseppe Maggiore
- Paediatric Section of the Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Pier Luigi Calvo
- Paediatric Gastroenterology, Department of Pediatrics, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Emanuele Nicastro
- Paediatric Liver, GI and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Liver, GI and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy.
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Al-Qurashi FO, Aladsani AA, Al Qanea FK, Faisal SY. Portal Hypertension of a Delayed Onset Following Liver Abscesses in a 12-Month-Old Infant: A Case Report and Review of the Literature. Pediatr Gastroenterol Hepatol Nutr 2019; 22:400-406. [PMID: 31338316 PMCID: PMC6629598 DOI: 10.5223/pghn.2019.22.4.400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 04/28/2018] [Accepted: 05/27/2018] [Indexed: 11/17/2022] Open
Abstract
We report a 12-month-old female infant who had a history of neonatal sepsis with liver micro-abscesses that resolved with intravenous antibiotics during neonatal period. During her neonatal admission period, no umbilical vein catheter was inserted. Also, she did not undergo any abdominal surgeries or had a postnatal history of necrotizing enterocolitis. However, the child developed upper gastrointestinal bleeding in form of hematemesis and melena secondary to esophageal varices at the age of 12 months with an extra-hepatic portal vein obstruction with cavernous transformation and portal hypertension subsequently. The child underwent a successful endoscopic injection sclerotherapy. She is now 20-month-old and has portal hypertension but otherwise asymptomatic. We are proposing the possibility of a delayed-onset portal hypertension as a complication of liver abscess and neonatal sepsis.
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Affiliation(s)
- Faisal Othman Al-Qurashi
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ahmed Abdullah Aladsani
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Fatema Khalil Al Qanea
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sarah Yousef Faisal
- Department of Radiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Banerjee A, Bishnu S, Dhali GK. Acute upper gastrointestinal bleed: An audit of the causes and outcomes from a tertiary care center in eastern India. Indian J Gastroenterol 2019; 38:190-202. [PMID: 31140049 DOI: 10.1007/s12664-018-00930-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/30/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND/PURPOSE OF THE STUDY Acute upper gastrointestinal (UGI) bleed is a life-threatening emergency carrying risks of rebleed and mortality despite standard pharmacological and endoscopic management. We aimed to determine etiologies of acute UGI bleed in hospitalized patients and outcomes (rebleed rates, 5-day mortality, in-hospital mortality, 6-week mortality, need for surgery) and to determine predictors of rebleed and mortality. METHODS Clinical and endoscopic findings were recorded in patients aged > 12 years who presented within 72 h of onset of UGI bleed. Outcomes were recorded during the hospital stay and 6 weeks after discharge. RESULTS A total of 305 patients were included in this study, mean age being 44 ± 17 years. Most common etiology of UGI bleed was portal hypertension (62.3%) followed by peptic ulcer disease (PUD) (16.7%). Rebleed rate within 6 weeks was 37.4% (portal hypertension 47.9%, PUD 21.6%, malignancy 71.4%). Five-day mortality was 2.3% (malignancy 14.3%, portal hypertension 3.2%); the in-hospital mortality rate was 3.0% (malignancy 14.3%, portal hypertension 3.2%, PUD 0.0%) and 4.9% at 6 weeks (malignancy 28.6%, portal hypertension 5.8%, PUD 0.0%). Surgery was required in 4.59% patients. On multivariate analysis, post-endoscopy Rockall score was significantly predictive of rebleed in both portal hypertension- and PUD-related rebleed. No factors were found predictive of mortality in multivariate analysis. CONCLUSION Portal hypertension remains the commonest cause of UGI bleed in India and carries a higher risk of rebleed and mortality as compared to PUD-related bleed. Post-endoscopy Rockall score is a useful tool for clinicians to assess risk of rebleed.
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Affiliation(s)
- Arka Banerjee
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research and SSKM Hospital, Kolkata, 700 020, India
| | - Saptarshi Bishnu
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research and SSKM Hospital, Kolkata, 700 020, India.
| | - Gopal Krishna Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research and SSKM Hospital, Kolkata, 700 020, India
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Bertino F, Hawkins CM, Shivaram G, Gill AE, Lungren MP, Reposar A, Sze DY, Hwang GL, Koo K, Monroe E. Technical Feasibility and Clinical Effectiveness of Transjugular Intrahepatic Portosystemic Shunt Creation in Pediatric and Adolescent Patients. J Vasc Interv Radiol 2019; 30:178-186.e5. [PMID: 30717948 DOI: 10.1016/j.jvir.2018.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/28/2018] [Accepted: 10/06/2018] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To examine the technical feasibility and clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation in children and adolescents. MATERIALS AND METHODS Retrospective review was performed of 59 patients (mean age 12.6 y [range, 1.5-20 y], mean weight 47.5 kg [range, 11.4-112.2 kg], mean Model for End-stage Liver Disease/Pediatric End-stage Liver Disease score 12.5 [range, 6-33]) who underwent 61 TIPS attempts at 3 tertiary children's hospitals from 2001 to 2017 for acute esophageal or gastroesophageal variceal bleeding, primary and secondary prevention of variceal bleeding, and refractory ascites. Pediatric liver disease etiologies included biliary atresia, cystic fibrosis, and ductal plate anomalies. Technical, hemodynamic, and clinical success and patency rates were reported at 1, 6, 12, and 24 months. Statistical analysis evaluated reasons for clinical failure. Kaplan-Meier analysis measured clinical success, patency, and transplant-free survival. RESULTS Technical success was 93.4% (57/61) in 59 consecutive patients. Most common TIPS indications were treating and preventing esophageal and gastroesophageal variceal bleeding (57/59; 96.6%). Hemodynamic success was 94% (47/50). Clinical success was 80.7% (45/56). Two-year clinical success for acute variceal bleeding and ascites was 94.1% and 100%, respectively. Overall patency at 1, 6, 12, and 24 months was 98.0%, 97.8%, 94.3%, and 91.3%. Two-year transplant-free survival was 88.8%. Overall and major complication rates were 21.2% (13/61) and 8.2% (5/61), with 3 mortalities. Gradient reduction < 12 mm Hg correlated with clinical success (P < .01). CONCLUSIONS TIPS creation in pediatric patients is technically feasible and clinically efficacious for treatment and prevention of esophageal and gastroesophageal variceal hemorrhage. High 2-year clinical success, patency, and survival rates should encourage providers to consider portosystemic shunts as a bridge to liver transplantation.
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Affiliation(s)
- Frederic Bertino
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - C Matthew Hawkins
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Giri Shivaram
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Anne E Gill
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Matthew P Lungren
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Aaron Reposar
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Daniel Y Sze
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Gloria L Hwang
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Kevin Koo
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Eric Monroe
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
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Abstract
BACKGROUND There is a lack of clarity about the approach to and management of upper gastrointestinal (UGI) bleeding in children. AIM To examine the recent literature on UGI bleeding in children in order to outline the diagnostic approach and management. METHODS The English language literature was searched for articles on UGI bleeding in children. Special attention was paid to its prevalence, risk factors, clinical approach and management. RESULTS Although UGI bleeding is a common complication (10%) in paediatric intensive care units (PICU), clinically significant UGI bleeding (haemodynamic instability, fall in haemoglobin by 2 g/dL and/or a requirement for blood transfusion) is less common (1.6%). In low- and middle-income countries, clinically significant UGI bleeding is commonly owing to variceal bleeding whereas non-variceal aetiologies (e.g. peptic ulcer disease) are common in high-income countries. The fundamental clinical principles of managing UGI bleeding are immediate assessment of severity, detecting possible causes and stabilising the haemodynamic status. In suspected cases of variceal bleeding, intravenous octreotide and, in non-variceal bleeding, administration of a proton pump inhibitor (PPI) should be commenced immediately. UGI endoscopy plays a vital role in diagnosis and management. Over-transfusion should be avoided (target haemoglobin 7-9 g/dL). Stress ulcer prophylaxis is recommended in a select group of patients in PICUs (e.g. respiratory failure, coagulopathy and paediatric risk of mortality score ≥10). CONCLUSIONS In clinically significant UGI bleeding, the primary goal is to restore the haemodynamic status, followed by early endoscopy. Intravenous octreotide in suspected variceal and PPI in non-variceal bleeding should be administered early. Stress ulcer prophylaxis should be restricted to high-risk children only.
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Affiliation(s)
- Ujjal Poddar
- a Department of Pediatric Gastroenterology , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
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Zhang Z, Chen X, Li C, Feng H, Yu H, Zhu R, Wang T. Safety and Efficacy of a Novel Shunt Surgery Combined with Foam Sclerotherapy of Varices for Prehepatic Portal Hypertension: A Pilot Study. Clinics (Sao Paulo) 2019; 74:e704. [PMID: 31433045 PMCID: PMC6691837 DOI: 10.6061/clinics/2019/e704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 05/13/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This pilot study investigated the safety and efficacy of a novel shunt surgery combined with foam sclerotherapy of varices in patients with prehepatic portal hypertension. METHODS Twenty-seven patients who were diagnosed with prehepatic portal hypertension and underwent shunt surgeries were divided into three groups by surgery type: shunt surgery alone (Group A), shunt surgery and devascularization (Group B), and shunt surgery combined with foam sclerotherapy (Group C). Between-group differences in operation time, intraoperative blood loss, portal pressure decrease, postoperative complications, rebleeding rates, encephalopathy, mortality rates and remission of gastroesophageal varices were compared. RESULTS Groups A, B and C had similar operation times, intraoperative bleeding, and portal pressure decrease. The remission rates of varices differed significantly (p<0.001): one patient in Group A and 6 patients in Group B had partial response, and all 9 patients in Group C had remission (2 complete, 7 partial). Two Group A patients and one Group B patient developed recurrent gastrointestinal bleeding postoperatively within 12 months. No postoperative recurrence or bleeding was observed in Group C, and no sclerotherapy-related complications were observed. CONCLUSIONS Shunt surgery combined with foam sclerotherapy obliterates varices more effectively than shunt surgery alone does, decreasing the risk of postoperative rebleeding from residual gastroesophageal varices. This novel surgery is safe and effective with good short-term outcomes.
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Affiliation(s)
- Zhe Zhang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Xueming Chen
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Chenyu Li
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Hai Feng
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Hongzhi Yu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Renming Zhu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Tianyou Wang
- Department of Thoracic Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
- Corresponding author. E-mail:
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Kamani L, Ahmad BS, Arshad M, Ashraf P. Safety of endoscopic N-Butyl-2 Cyanoacrylate injection for the treatment of bleeding gastric varices in children. Pak J Med Sci 2018; 34:1363-1368. [PMID: 30559786 PMCID: PMC6290215 DOI: 10.12669/pjms.346.16044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective: To determine the safety and efficacy of N-butyl 2-cyanoacrylate in bleeding gastric varices in children. Methods: This retrospective observational study was conducted in the Department of Gastroenterology and Pediatric Surgery in Liaquat National Hospital Karachi between January 2010 and January 2017. Gastric fundal varices were obliterated in pediatric population with single shot of N-butyl-2 Cyanoacrylate 0.50ml diluted with 0.50ml of Lipoidal with use of forward-viewing video endoscope with 22-gauge needle. The primary outcome was primary hemostasis, Secondary outcome was complications, re-bleeding and mortality. Results: Thirty patients was included in the study, 18(60%) were male with mean age of 7.12± 2.9 years. Non cirrhotic portal hypertension was the most common etiology in 15 (50%) patients, followed by liver cirrhosis secondary to hepatitis B and D co-infection in 6(20%) patients. Primary hemostasis was achieved in 29 (96.7%), while 3(10%) patients developed re-bleeding after 48 hours, and hemostasis was achieved after second session of endoscopic obliteration. Abdominal pain and fever developed in 3(10%) patients which was managed conservatively. Mortality was observed in 1(3%) of cases due to sepsis after shunt surgery. Conclusion: Endoscopic fundal varix obliteration with N Butyl-2 cyanoacrylate was safe and effective in treatment of gastric variceal hemorrhage in children.
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Affiliation(s)
- Lubna Kamani
- Dr. Lubna Kamani, FCPS, MRCP(UK), FRCP, Department of Gastroenterology and Hepatology, Liaquat National Hospital &Medical College, Karachi, Pakistan
| | - Baseer Sultan Ahmad
- Dr. Baseer Sultan Ahmad, FCPS, Department of Gastroenterology and Hepatology, Liaquat National Hospital &Medical College, Karachi, Pakistan
| | - Muhammad Arshad
- Dr. Muhammad Arshad, FRCS, Department of Pediatric Surgery, Liaquat National Hospital &Medical College, Karachi, Pakistan
| | - Pervez Ashraf
- Dr. Pervez Ashraf, MRCP, FRCP, Department of Gastroenterology and Hepatology, Liaquat National Hospital &Medical College, Karachi, Pakistan
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Abstract
BACKGROUND AND AIMS The need for primary prophylaxis of variceal bleeding in children is unclear due to insufficient evidence of the efficacy of prophylactic therapy and the mortality and morbidity associated with the first bleeding event. Previous studies have provided estimates of mortality. We aimed to investigate the morbidity associated with acute variceal bleeding (AVB) in children and to identify contributing factors. METHODS We retrospectively reviewed children with chronic liver disease or portal vein thrombosis admitted with acute upper gastrointestinal bleeding between 2000 and 2015. RESULTS Seventy AVB episodes in 57 children (median age 6 years, 52% girls) were included, 58% with cirrhosis and 30% portal vein thrombosis. Approximately 67% were the patient's first bleed. Post-AVB morbidity was present in 57% of all episodes and in 64% of first bleeds and included: ascites (34%), infection (30%), respiratory complications (24%), intensive care unit admission (20%), rebleed (11%), encephalopathy (7%), acute kidney injury (6%), and failure to control bleed (4%). Two patients died (4% of first bleeds, 8% of cirrhotics' first bleeds) within 6 weeks of bleeding. Median length of stay was 7 days. Overall morbidity was associated with total bilirubin (P = 0.001). Ascites after AVB was associated with pediatric end-stage liver disease (P = 0.0007), total bilirubin (P = 0.001), and cirrhosis (P = 0.006). Median length of stay was longer in patients with morbidities (18 vs 4 days, P < 0.0001). CONCLUSION Children with AVB suffer significant morbidity but have a low risk of death. Morbidity should therefore be considered in future studies measuring the risks and benefits of primary prophylaxis of first AVB in children.
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Non-invasive Markers of Portal Hypertension: Appraisal of Adult Experience and Potential Utilisation in Children. J Pediatr Gastroenterol Nutr 2018; 66:559-569. [PMID: 29287004 DOI: 10.1097/mpg.0000000000001882] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Portal hypertension (PHT) is a significant cause of morbidity and mortality in children with chronic liver disease and portal vein obstruction. Increased portal pressure results in variceal formation along the gastrointestinal (GI) tract resulting in major bleeding. Identifying children with significant PHT who are more likely to suffer GI bleeding has been challenging and the role of surveillance upper GI endoscopy has been debated. This review analyses research done on serum biomarkers and imaging techniques as possible predictors of significant PHT. We evaluated the research performed on adult population, as well as the limited work done on children, to identify promising areas for future research. A literature search was conducted on "PubMed." Several search terms were used including "portal hypertension," "paediatric portal hypertension," "non-invasive markers of portal hypertension," "spleen stiffness," "liver stiffness," "elastography," and "endothelial damage." The articles included were selected based on their relevance to the purpose of our review. The research suggests a combination of several biomarkers, in addition to an imaging technique such as transient elastography or magnetic resonance elastography, would allow for the best prediction of significant varices. The most promising indicators would be those that are applicable in both intra- and extra-hepatic causes of PHT. Further research on these predictors in children with PHT is required to determine their potential role as selection criteria for PHT and stratification of surveillance GI endoscopies.
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Elwadhi A, Mukherjee SB. Extra Hepatic Portal Vein Obstruction – Unobstructed. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1325-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Khanna R, Sarin SK. Idiopathic portal hypertension and extrahepatic portal venous obstruction. Hepatol Int 2018; 12:148-167. [PMID: 29464506 DOI: 10.1007/s12072-018-9844-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are non-cirrhotic vascular causes of portal hypertension (PHT). Variceal bleed and splenomegaly are the commonest presentations. AIM The present review is intended to provide the existing literature on etiopathogenesis, clinical profile, diagnosis, natural history and management of IPH and EHPVO. RESULTS IPH and EHPVO are both characterized by normal hepatic venous pressure gradient, moderate to massive splenomegaly with preserved liver synthetic functions. While the level of block in IPH is presinusoidal, in EHPVO it is at prehepatic level. Infections, autoimmunity, drugs, immunodeficiency and prothrombotic states are possible etiological agents in IPH. Contrastingly in EHPVO, prothrombotic disorders and local factors around the portal vein are the incriminating factors. Diagnosis is often clinical, supported by simple radiological tools. Natural history is defined by episodes of variceal bleed and symptoms related to enlarged spleen. Growth failure, portal biliopathy and minimal hepatic encephalopathy are additional concerns in EHPVO. Long-term survival is reasonably good with endoscopic surveillance; however, parenchymal extinction leading to decompensation is seen in a minority of patients in both the disorders. Surgical shunts revert the complications secondary to PHT. Meso-Rex shunt has become the standard surgery in children with EHPVO. CONCLUSION This review gives a detailed summary of these two vascular conditions of liver-IPH and EHPVO. Further research is needed to understand the pathogenesis and natural history of these disorders.
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Affiliation(s)
- Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
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Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan. Hepatol Res 2017; 47:373-386. [PMID: 28058764 DOI: 10.1111/hepr.12862] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/29/2016] [Accepted: 01/04/2017] [Indexed: 12/18/2022]
Abstract
Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.
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Beattie W, Magnusson M, Hardikar W, Monagle P, Ignjatovic V. Characterization of the coagulation profile in children with liver disease and extrahepatic portal vein obstruction or shunt. Pediatr Hematol Oncol 2017; 34:107-119. [PMID: 28570120 DOI: 10.1080/08880018.2017.1313919] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Chronic liver disease causes a disruption of procoagulant and anticoagulant factors, resulting in a fragile state, prone to increased rates of both bleeding and thrombosis. Currently, there is limited literature describing the changes observed in pediatric liver disease and extrahepatic portal vein obstruction or shunt. This study aimed to describe the changes that occur in children with chronic liver disease and extrahepatic portal vein obstruction or shunt. MATERIALS AND METHODS We measured the concentration and activity of key procoagulant and anticoagulant factors in children with liver disease, children with extrahepatic portal vein obstruction or shunt, and healthy children. RESULTS Children with severe liver disease had coagulopathic changes, including either decreased concentration or activity of factor II, factor V, and factor VII. Nineteen percent (8/42) of the cohort had significant bleeding. Thrombophilic changes were also observed, including decreased concentration or activity of protein C, protein S, and antithrombin and increased concentration and activity of factor VIII and Von Willebrand factor. Similar coagulation factor changes were observed in children with extrahepatic portal vein obstruction or shunt. There was a trend toward greater changes in coagulation factor activity compared to concentration. CONCLUSION This study provides a detailed description of the changes in both the concentration and activity of coagulation factors in pediatric liver disease and extrahepatic portal vein obstruction or shunt. Interestingly, procoagulant and anticoagulant factors were deranged in portal vein obstruction or shunt to a similar degree as in liver disease. An improved understanding of the coagulation profile in the pediatric setting will contribute to the improved management of liver disease and extrahepatic portal obstruction or shunt. ABBREVIATIONS PELD: pediatric end-stage liver disease score; MELD: model for end-stage liver disease score; ELISA: enzyme-linked immunosorbent assay; MCRI: Murdoch Childrens Research Institute; FII: factor II; FV: factor V; FVII: factor VII; FVIII: factor VIII; AT: antithrombin III; A2M: alpha-2-macroglobulin; vWF: Von Willebrand factor; PC: protein C; PS: protein S; ISTH-BAT: International Society on Thrombosis and Haemostasis Bleeding Assessment Tool.
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Affiliation(s)
- William Beattie
- a Murdoch Childrens Research Institute , Parkville , Victoria , Australia.,b Department of Paediatrics , The University of Melbourne , Parkville , Victoria , Australia
| | - Maria Magnusson
- a Murdoch Childrens Research Institute , Parkville , Victoria , Australia.,c MMK, Division of Clinical Chemistry and Coagulation & CLINTEC, Division of Paediatrics , Karolinska Institutet, Astrid Lindgren Children's Hospital, Karolinska University Hospital , Stockholm , Sweden
| | - Winita Hardikar
- d Department of Gastroenterology , Royal Children's Hospital , Parkville , Victoria , Australia
| | - Paul Monagle
- a Murdoch Childrens Research Institute , Parkville , Victoria , Australia.,b Department of Paediatrics , The University of Melbourne , Parkville , Victoria , Australia.,e Department of Clinical Haematology , Royal Children's Hospital , Parkville , Victoria , Australia
| | - Vera Ignjatovic
- a Murdoch Childrens Research Institute , Parkville , Victoria , Australia.,b Department of Paediatrics , The University of Melbourne , Parkville , Victoria , Australia
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Poddar U, Borkar V, Yachha SK, Srivastava A. Endoscopic management of bleeding gastric varices with N-butyl, 2-cyanoacrylate glue injection in children with non-cirrhotic portal hypertension. Endosc Int Open 2016; 4:E1063-E1067. [PMID: 27757413 PMCID: PMC5066454 DOI: 10.1055/s-0042-114981] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/29/2016] [Indexed: 12/15/2022] Open
Abstract
Background and study aims: In view of the paucity of literature, we carried out this audit to evaluate the safety and efficacy of N- butyl, 2-cynoacrylate glue injection therapy in secondary prophylaxis of gastric varices in children. Patients and methods: Consecutive children (≤ 18 years) with non-cirrhotic portal hypertension who presented with bleeding from gastric varices and who had undergone cyanoacrylate glue injection therapy were included. They were evaluated for safety, efficacy and complications. Their long-term outcomes and follow-up were recorded. Results: Over 11 years, 28 children with median age 13 (range, 8 to 18) years (68 % boys), underwent cyanoacrylate glue injection for bleeding gastric varices. In 25 (89 %) cases, extrahepatic portal venous obstruction was the etiology and isolated gastric varices were the source of the bleeding. Primary and secondary gastric variceal bleeding was seen in 11 (39 %) and 17 (61 %) children, respectively. A total 36 sessions with median volume of 2 (range, 1 - 5) mL of glue injections were required (2 sessions in 8 children). Hemostasis was achieved in all and 57 % had gastric variceal obliteration. Two children had early (< 1 month) rebleeding and 2 children had late rebleeding. One child had gastric ulcer. Over a median follow-up of 24 (8 - 98) months, 14 children underwent surgery (12 porto-systemic shunt), 2 were lost to follow-up, 1 died and there was no recurrence of bleeding in the remaining 11. Conclusions: Cyanoacrylate glue injection is highly effective mode of secondary prophylaxis of bleeding gastric varices in children with non-cirrhotic portal hypertension. Rebleeding occurred in 14 % but treatment-related complications were uncommon. However, a large controlled clinical trial is required to confirm our findings.
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Affiliation(s)
- Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute
of Medical Sciences, Lucknow, India,Corresponding author Ujjal Poddar, MD, DNB, DM, Professor Department of Pediatric Gastroenterology, SGPGIMS, Lucknow226014, Uttar PradeshIndia+915222668017
| | - Vibhor Borkar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute
of Medical Sciences, Lucknow, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute
of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute
of Medical Sciences, Lucknow, India
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Hepatic arterial buffer response: pathologic evidence in non-cirrhotic human liver with extrahepatic portal vein thrombosis. Mod Pathol 2016; 29:489-99. [PMID: 26916069 DOI: 10.1038/modpathol.2016.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/13/2016] [Accepted: 01/22/2016] [Indexed: 02/07/2023]
Abstract
Increase in hepatic arterial flow in response to reduced portal flow (hepatic arterial buffer response) has been demonstrated experimentally and surgically. We provide pathologic evidence for hepatic arterial buffer response in non-cirrhotic patients with extrahepatic portal vein thrombosis and elucidate the histopathologic spectrum of non-cirrhotic portal vein thrombosis. Liver biopsies and resections from non-cirrhotic patients with extra-hepatic portal vein thrombosis were retrieved. Morphologic features, extent of CD34 staining, outer diameters, luminal diameters and wall thickness of hepatic arteries cut in cross-section and outer diameters of cross-sectioned paired bile ducts were compared with age- and gender-matched controls. There were 12 male and 9 female patients. Measurements of 280 and 193 arteries from patients and controls, respectively, demonstrated statistically significant (P<0.05) arterial dilatation (increase in percentage of arterial lumen to outer diameter) and arterial wall thinning in resection specimens of non-cirrhotic patients with extra-hepatic portal vein thrombosis. Subtle and/or focal dilatation of central veins, portal veins and sinusoids; focal trabecular thinning/thickening and mild ductular reaction were common findings in both the patient and control groups. Diffuse and obvious changes, and portal vein absence or attenuation were seen only in the patient group. Capillarization of sinusoids was not seen on CD34 stain. Two patients showed significant ductular reaction, one of who developed biliary strictures on follow-up. Hepatic arterial dilatation and wall thinning in non-cirrhotic patients with portal vein thrombosis provide pathologic evidence of hepatic arterial buffer response in the human liver. Obvious and diffuse sinusoidal dilatation and absence or attenuation of portal veins are highly suggestive of extrahepatic portal vein thrombosis in non-cirrhotic patients with portal hypertension. Periportal shunt vessels, hypervascular portal tracts, muscularized portal veins, large thick-walled or dilated arteries aid diagnosis but are rare findings. Normal or near-normal biopsies do not rule out portal vein thrombosis.
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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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Sumiyoshi T, Shima Y, Okabayashi T, Negoro Y, Kozuki A, Iwata J, Saisaka Y, Tokumaru T, Nakamura T, Morita S. Epiploic gonadal vein as a new bypass route for extrahepatic portal venous obstruction: report of a case. Surg Case Rep 2016; 1:109. [PMID: 26943433 PMCID: PMC4615993 DOI: 10.1186/s40792-015-0112-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/16/2015] [Indexed: 11/27/2022] Open
Abstract
A 61-year-old man was referred to our hospital to treat extrahepatic portal venous obstruction. Endoscopic injection sclerotherapy (EIS) was performed for the esophageal varices; however, the patient returned with massive hematemesis from gastric varices 6 months after treatment. Although the varices were treated with EIS, gastric devascularization and splenectomy concomitant with shunt surgery were required to treat uncontrollable, frequent diarrhea and abdominal distension. Because the splenic vein, left gastric vein, left portal vein, and inferior vena cava were inadequate for anastomosis, an epiploic gonadal vein bypass was performed. The bypass graft remains patent 7 months after surgery, and the patient is in good health without any clinical symptoms. We describe a new bypass route for extrahepatic portal venous obstruction.
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Affiliation(s)
- Tatsuaki Sumiyoshi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan.
| | - Yasuo Shima
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Takehiro Okabayashi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Yuji Negoro
- Department of Gastroenterology, Kochi Health Sciences Center, Kochi, Japan
| | - Akihito Kozuki
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Jun Iwata
- Department of Diagnostic Pathology, Kochi Health Sciences Center, Kochi, Japan
| | - Yuichi Saisaka
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Teppei Tokumaru
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Toshio Nakamura
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Sojiro Morita
- Department of Radiology, Kochi Health Sciences Center, Kochi, Japan
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Mishra PK, Patil NS, Saluja S, Narang P, Solanki N, Varshney V. High patency of proximal splenorenal shunt: A myth or reality ? - A prospective cohort study. Int J Surg 2016; 27:82-87. [PMID: 26804351 DOI: 10.1016/j.ijsu.2015.12.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 11/29/2015] [Accepted: 12/08/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Proximal splenorenal shunt (PSRS) is a well-accepted surgical procedure for non-cirrhotic portal hypertension (NCPH). Though a patent shunt is important for good long term outcome, there are very few studies on patency of these shunts. We analysed shunt patency using dynamic computed tomographic (CT) portography and compared it with other modalities. METHODS From 2004 to 2014, 50 patients with PSRS were evaluated prospectively for shunt patency using dynamic CT portography, clinical parameters and ultrasound Doppler. RESULTS The causes of NCPH were extrahepatic portal vein obstruction (EHPVO) in 38 patients and non-cirrhotic portal fibrosis (NCPF) in 12 patients. The shunt patency rate using clinical parameters, ultrasound Doppler and dynamic CT portography were 70%, 40% and 60% respectively. Clinical parameters overestimated while ultrasound Doppler underestimated the shunt patency rate. Dynamic portography had 100% correlation with conventional angiography in the five patients when this was done. The site of shunt could be demonstrated convincingly by dynamic CT portography. The shunt patency rate decreased over time. It was 64%, 60% and 43% in <1 year, 1-5 years and >5 years respectively. Our NCPF patients had a greater shunt patency rate compared to EHPVO patients (9/12 vs. 21/38) though the difference was not significant. Only size of the splenic vein had a significant impact on the shunt patency rate on statistical analysis. CONCLUSIONS Dynamic CT portography is useful for evaluation of shunt patency. Proximal splenorenal shunts have a high blockage rate which has hitherto not been reported.
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Affiliation(s)
- Pramod Kumar Mishra
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India.
| | - Nilesh Sadashiv Patil
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Sundeep Saluja
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Poonam Narang
- Department of Radio Diagnosis, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Nisha Solanki
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Vaibhav Varshney
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
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Pawar S, Zanwar V, Mohite A, Surude R, Rathi P, Balasubramani M. A Family of Congenital Hepatic Fibrosis and Atypical Retinitis Pigmentosa. Clin Pract 2015; 5:792. [PMID: 26918098 PMCID: PMC4745592 DOI: 10.4081/cp.2015.792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/28/2015] [Indexed: 12/24/2022] Open
Abstract
Congenital hepatic fibrosis is a rare cause of portal hypertension and esophageal varices in children. We report cases of siblings with biopsy proven congenital hepatic fibrosis and with atypical retinitis pigmentosa. They presented with repeated episodes of jaundice along with progressive decrease of vision in night. They had hepatosplenomegaly and portal hypertension with esophageal varices. One of the siblings had a large regenerating nodule replacing the entire right lobe of the liver and other one developed repeated hematemesis. This constellation of diagnosis belongs to the ciliopathy group of disorders. The spectrum of ciliopathy disorders has been evolving, and it varies from mild to severe manifestations.
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Affiliation(s)
| | | | | | | | | | - Meenakshi Balasubramani
- Department of Pathology, Topiwala National Medical College and Bai Yamunabai Laxman Nair Hospital , Mumbai, Maharashtra, India
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Borkar VV, Poddar U, Kapoor A, Ns S, Srivastava A, Yachha SK. Hepatopulmonary Syndrome in children: a comparative study of non-cirrhotic vs. cirrhotic portal hypertension. Liver Int 2015; 35:1665-72. [PMID: 25351435 DOI: 10.1111/liv.12708] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 10/17/2014] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Hepatopulmonary syndrome in children has not been extensively studied particularly in different subsets of portal hypertension. We prospectively studied hepatopulmonary syndrome in children with cirrhosis and extrahepatic portal venous obstruction. Their comparison might shed light on the pathogenesis of hepatopulmonary syndrome. METHODS Between 1 to 18 years of age, 135 children with portal hypertension (cirrhosis 35, extrahepatic portal venous obstruction 100) were studied. Hepatopulmonary syndrome was diagnosed by the presence intrapulmonary shunt using transthoracic contrast echocardiography and hypoxia/orthodeoxia (in arterial blood gas examination). Comparative analyses were done for both the groups, and also intra- and intergroups with and without hepatopulmonary syndrome. RESULT Of 135 children, hepatopulmonary syndrome occurred more frequently in cirrhosis (40%) than extrahepatic portal venous obstruction (13%) (P = 0.01). Cirrhotics with hepatopulmonary syndrome were symptomatic (85% vs. 14%, P < 0.001) and had longer disease duration [16(1-120) months vs. 28 (1-168) months, P = 0.01] as compared to cirrhotics without hepatopulmonary syndrome. Prevalence of hepatopulmonary syndrome among cirrhotics did not correlate with the severity of liver disease as assessed by both paediatric end-stage liver disease score and Child-Turcotte-Pugh score. Patients with extrahepatic portal venous obstruction and hepatopulmonary syndrome remain asymptomatic manifesting with clubbing alone (38%). CONCLUSIONS Hepatopulmonary syndrome occurs more frequently in cirrhosis, a majority being symptomatic with more severity in comparison to extrahepatic portal venous obstruction having no symptoms and less severity. There seems to be a role of liver dysfunction besides portal hypertension as an added factor in the pathogenesis of hepatopulmonary syndrome.
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Affiliation(s)
- Vibhor V Borkar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Aditya Kapoor
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Srivatsa Ns
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Surender K Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Abstract
Portal vein thrombosis is an important cause of portal hypertension. PVT occurs in association with cirrhosis or as a result of malignant invasion by hepatocellular carcinoma or even in the absence of associated liver disease. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Endothelial activation and stagnant portal blood flow also contribute to formation of the thrombus. Acute non-cirrhotic PVT, chronic PVT (EHPVO), and portal vein thrombosis in cirrhosis are the three main variants of portal vein thrombosis with varying etiological factors and variability in presentation and management. Procoagulant state should be actively investigated. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) on the other hand requires the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state, however data is awaited in those with no underlying prothrombotic states. TIPS and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Thrombolysis and thrombectomy have some role. TARE is a new modality for management of HCC with portal vein invasion.
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Key Words
- ACLA, anti-cardiolipin antibody
- AFP, alpha feto protein
- BCS, Budd-Chiari syndrome
- CDUS, color doppler ultrasonography
- CT, computed tomography
- CTP, Child Turcotte Pugh
- EHPVO, extra hepatic portal venous obstruction
- EST, endoscopic sclerotherapy
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- IGF-1, insulin like growth factor-1
- IGFBP-3, insulin like growth factor binding protein-3
- INR, international normalized ratio
- JAK-2, Janus kinase 2
- LA, lupus anticoagulant
- LMWH, low molecular weight heparin
- MELD, model for end stage liver disease
- MPD, myeloproliferative disorder
- MRI, magnetic resonance imaging
- MTHFR, methylenetetrahydrofolate reductase
- MVT, mesenteric vein thrombosis
- OCPs, oral contraceptive pills
- PAI-1 4G-4G, plasminogen activator inhibitor type 1- 4G/4G genotype
- PNH, paroxysmal nocturnal hemoglobinuria
- PV, portal vein
- PVT
- PVT, portal vein thrombosis
- PWUS, Pulsed Wave ultrasonography
- RFA, radio frequency ablation
- SMA, superior mesenteric artery
- SMV, superior mesenteric vein
- TAFI, thrombin activatable fibrinolysis inhibitor
- TARE, Trans arterial radioembolization
- TB, tuberculosis
- TIPS, transjugular intrahepatic portosystemic shunt
- UFH, unfractionated heparin
- acute and chronic
- anticoagulation
- imaging
- prothrombotic
- rtPA, recombinant tissue plasminogen activator
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Affiliation(s)
- Yogesh K. Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Zárate Mondragón F, Romero Trujillo JO, Cervantes Bustamante R, Mora Tiscareño MA, Montijo Barrios E, Cadena León JF, Cázares Méndez M, Toro Monjaraz EM, Ramírez Mayans J. Clinical, radiologic, and endoscopic characteristics upon diagnosis of patients with prehepatic portal hypertension at the Instituto Nacional de Pediatría from 2001 to 2011. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2014; 79:244-9. [PMID: 25453721 DOI: 10.1016/j.rgmx.2014.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 07/22/2014] [Accepted: 09/25/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehepatic portal hypertension in children can be asymptomatic for many years. Once diagnosed, the therapeutic measures (pharmacologic, endoscopic, and surgical) are conditioned by the specific characteristics of each patient. In Mexico, there are no recorded data on the incidence of the disease and patient characteristics. AIMS To determine the main clinical, radiologic, and endoscopic characteristics upon diagnosis of these patients at the Instituto Nacional de Pediatría within the time frame of January 2001 and December 2011. METHODS A cross-sectional, retrolective, descriptive, and observational study was conducted in which all the medical records of the patients with portal hypertension diagnosis were reviewed. RESULTS There was a greater prevalence of prehepatic etiology (32/52) (61.5%) in the portal hypertension cases reviewed. Males (62.5%) predominated and 11 of the 32 patients were under 4 years of age. The primary reason for medical consultation was upper digestive tract bleeding with anemia (71.9%) and the main pathology was cavernomatous degeneration of the portal vein (65.6%). Splenoportography was carried out on 17 of the 32 patients. A total of 65.5% of the patients received the combination therapy of propranolol and a proton pump inhibitor. Initial endoscopy revealed esophageal varices in 96.9% of the patients, 12 of whom presented with gastroesophageal varices. Congestive gastropathy was found in 75% of the patients. The varices were ligated in 8 cases, sclerotherapy for esophageal varices was carried out in 5 cases (15.6%), and sclerotherapy for gastric varices was performed in 2 patients. Seventeen patients (53.1%) underwent portosystemic diversion: 10 of the procedures employed a mesocaval shunt and 7 a splenorenal shunt. Nine patients (28.1%) underwent total splenectomy. CONCLUSIONS The primary cause of the disease was cavernomatous degeneration of the portal vein; it was predominant in males and the first symptom was variceal bleeding.
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Affiliation(s)
- F Zárate Mondragón
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México.
| | - J O Romero Trujillo
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - R Cervantes Bustamante
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - M A Mora Tiscareño
- Departamento de Radiología, Instituto Nacional de Pediatría, México D.F., México
| | - E Montijo Barrios
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - J F Cadena León
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - M Cázares Méndez
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - E M Toro Monjaraz
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - J Ramírez Mayans
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
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Zárate Mondragón F, Romero Trujillo J, Cervantes Bustamante R, Mora Tiscareño M, Montijo Barrios E, Cadena León J, Cázares Méndez M, Toro Monjaraz E, Ramírez Mayans J. Clinical, radiologic, and endoscopic characteristics upon diagnosis of patients with prehepatic portal hypertension at the Instituto Nacional de Pediatría from 2001 to 2011. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2014. [DOI: 10.1016/j.rgmxen.2014.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Poddar U, Shava U, Yachha SK, Agarwal J, Kumar S, Baijal SS, Srivastava A. β-Blocker therapy ameliorates hypersplenism due to portal hypertension in children. Hepatol Int 2014; 9:447-53. [PMID: 25788181 DOI: 10.1007/s12072-014-9575-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 08/21/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND/PURPOSE Thrombocytopenia due to hypersplenism precludes percutaneous liver biopsy in many cases of chronic liver disease (CLD). The aim of this study was to assess the efficacy of propranolol in correcting platelet counts (>100,000/mm(3)) to ensure percutaneous liver biopsy in children with CLD. METHODS From January 2005 to December 2012, 51 consecutive children (mean age 11.5 ± 3.0 years, 34 boys) with CLD who needed liver biopsy but could not be done due to hypersplenism-related thrombocytopenia (platelets <100,000/mm(3) and/or total leukocyte counts <4,000/mm(3) with splenomegaly) were recruited and given a 4-week trial of long-acting propranolol (1.5-2 mg/kg/day). Hemodynamic parameters and splenic artery hemodynamics by Doppler ultrasound were recorded before and after the propranolol trial. Response to therapy was defined as improvement of platelet counts to ≥10(5)/mm(3). RESULTS Thirty-two (62.7%) children responded to propranolol therapy and their mean platelet counts increased from 57.5 ± 13.0 × 10(3) to 140.7 ± 43.3 × 10(3)/mm(3), p = 0.0001. Liver biopsy could be done in 29. While comparing responders with non-responders, baseline spleen size (7.4 ± 3.3 vs. 12.7 ± 4.5 cm, p = 0.0001) and platelet counts (57.5 ± 13.0 × 10(3) vs. 39.5 ± 14.5 × 10(3), p = 0.0001) were found to be significant. ROC curve suggested a cut-off value of ≤8.5 cm of spleen and ≥53,000 platelets as predictors of response. With propranolol, mean arterial pressure and spleen size reduced (p < 0.05) and splenic artery resistance increased significantly (p = 0.005) in responders. CONCLUSIONS Propranolol corrects thrombocytopenia and makes liver biopsy possible in almost two-thirds of cases by reducing splenic sequestration through splenic artery vasoconstriction. The baseline spleen size and platelet counts determine the effectiveness of therapy. A trial of β-blocker is worth carrying out in cases where liver biopsy is contraindicated due to hypersplenism-related thrombocytopenia.
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Affiliation(s)
- Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, 226014, India,
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Abstract
Non-cirrhotic portal hypertension (NCPH) encompasses a wide range of disorders, primarily vascular in origin, presenting with portal hypertension (PHT), but with preserved liver synthetic functions and near normal hepatic venous pressure gradient (HVPG). Non-cirrhotic portal fibrosis/Idiopathic PHT (NCPF/IPH) and extrahepatic portal venous obstruction (EHPVO) are two prototype disorders in the category. Etiopathogenesis in both of them centers on infections and prothrombotic states. Presentation and management strategies focus on repeated well tolerated episodes of variceal bleed and moderate to massive splenomegaly and other features of PHT. While the long-term prognosis is generally good in NCPF, portal biliopathy and parenchymal extinction after prolonged PHT makes outcome somewhat less favorable in EHPVO. While hepatic schistosomiasis, congenital hepatic fibrosis and nodular regenerative hyperplasia have their distinctive features, they often present with NCPH.
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Affiliation(s)
- Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi 110070, India.
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi 110070, India
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