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Ma AS, Thuluvath PJ. The Role of Endoscopy for Primary and Secondary Prophylaxis of Variceal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:231-248. [PMID: 38395481 DOI: 10.1016/j.giec.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Cirrhosis is associated with a high morbidity and mortality. One of the most serious and unpredictable complication of cirrhosis, with a high mortality rate, is bleeding from esophagogastric varices. Endoscopic screening of varices followed by primary prophylactic treatment with beta blockers or band ligation in the presence of large esophageal varices will reduce the variceal bleeding rates and thereby reduce mortality risks in those with advanced cirrhosis. There is a paucity of data on primary prophylaxis of gastric varices but secondary prophylaxis includes glue injection, balloon-occluded retrograde transvenous obliteration, or transjugular intrahepatic portosystemic shunting with coil embolization.
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Affiliation(s)
- Andrew S Ma
- Institute for Digestive Health and Liver Disease Mercy Medical Center, Professional Office Building, 7th Floor 345 St. Paul Place, Baltimore, MD 21202, USA
| | - Paul J Thuluvath
- Institute for Digestive Health and Liver Disease Mercy Medical Center, Professional Office Building, 7th Floor 345 St. Paul Place, Baltimore, MD 21202, USA.
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2
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Ravindranath A, Yachha SK. An Approach to Investigations of Chronic Liver Disease. Indian J Pediatr 2024; 91:262-269. [PMID: 37702974 DOI: 10.1007/s12098-023-04751-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 06/23/2023] [Indexed: 09/14/2023]
Abstract
Chronic liver disease (CLD) in children is more diverse compared to adults with respect to the etiology, progression and response to therapy. After history and clinical examination, the first step is to confirm the presence of CLD with basic blood investigations and ultrasonography. Markers of portal hypertension are splenomegaly, increased portal vein diameter, thrombocytopenia and presence of varices on endoscopy. The next step is to evaluate the etiology of CLD which will depend on the age of the child and needs targeted investigations as metabolic and inherited causes predominate in early childhood. CLD progression ought to be monitored regularly and several non-invasive markers are available but they have to be evaluated further in children. Since CLD progresses, complications have to be detected early not only to initiate appropriate treatment but also to prognosticate.
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Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Institute of Gastrointestinal Sciences, Apollo BGS Hospitals, Kuvempunagar, Mysore, Karnataka, 570023, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Sakra World Hospital, Bengaluru, Karnataka, 560103, India.
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3
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Ali H, Pamarthy R, Bolick NL, Ali E, Paleti S, Kapuria D. Downhill esophageal varices: a systematic review of the case reports. EXPLORATION OF MEDICINE 2022. [DOI: 10.37349/emed.2022.00096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aim: The etiologies, presentation, and management of downhill varices in the era of modern medicine are relatively under-explored and mostly limited to case reports or case series.
Methods: Published case reports/series of patients ≥ 18 years old with proven/probable downhill esophageal varices were searched on Ovid MEDLINE and Ovid EMBASE for all published cases up to January 2021.
Results: The mean age was 50.9 (standard deviation ± 17.6) years old for all downhill variceal cases. End-stage renal disease was the most common comorbidity (43.9%), followed by thyroid disease (12.2%), Behçet’s disease (9.8%), and pulmonary hypertension (7.3%). Dialysis catheters, central venous grafts, or additional catheters were additional risk factors (51.2%). Variceal bleeding presenting as hematemesis, melena, or both was the most common presenting symptom (80.5%).
Conclusions: Dialysis catheter-associated superior vena cava obstruction resulted in an increased risk of downhill varices. Other causes include thyroid malignancies, pulmonary hypertension, and Behçet’s disease.
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Affiliation(s)
- Hassam Ali
- 1Department of Internal Medicine, East Carolina University, Greenville, NC 27834, USA
| | - Rahul Pamarthy
- 1Department of Internal Medicine, East Carolina University, Greenville, NC 27834, USA
| | - Nicole Leigh Bolick
- 2Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Eslam Ali
- 3Department of Gastroenterology, East Carolina University, Greenville, NC 27834, USA
| | - Swathi Paleti
- 4Department of Gastroenterology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Devika Kapuria
- 5Department of Gastroenterology, Washington University in St. Louis, St. Louis, MO 63130, USA
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CT hepatic arterial perfusion index does not allow stratification of the degree of esophageal varices and bleeding risk in cirrhotic patients in Child-Pugh classes A and B. Abdom Radiol (NY) 2021; 46:5586-5597. [PMID: 34453180 PMCID: PMC8590679 DOI: 10.1007/s00261-021-03259-6] [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: 07/09/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/17/2022]
Abstract
Purpose To evaluate if the hepatic arterial perfusion index (HPI) in liver parenchyma of cirrhotic patients can serve as a surrogate parameter for stratifying the degree of esophageal varices and related bleeding risks. Methods CT image data of sixty-six patients (59 men; mean age 68 years ± 10 years) with liver cirrhosis (Child–Pugh class A (35/66, 53%), B (25/66, 38%), and C (6/66, 9%) who underwent perfusion CT (PCT) for hepatocellular carcinoma (HCC) screening between April 2010 and January 2019 were retrospectively identified. HPI, a parameter calculated by a commercially available CT liver perfusion analysis software that is based on the double maximum slope model, using time attenuation curve to determine perfusion, was correlated with the degree of esophageal varices diagnosed at endoscopy and the number of bleeding events. Results Eta correlation coefficient for HPI/presence of esophageal varices was very weak (0.083). Spearman-Rho for HPI/grading of esophageal varices was very weak (0.037 (p = 0.804)). Kendall-Tau-b for HPI/grading of esophageal varices was very weak (0.027 (p = 0.807)). ANOVA and Bonferroni post-hoc-tests showed no significant difference of HPI between different grades of esophageal varices (F (3, 62) = 1.676, p = 0.186). Eta correlation coefficient for HPI/bleeding event was very weak (0.126). Conclusion The stratification of the degree of esophageal varices and the related bleeding risk by correlation with the HPI as a surrogate parameter for portal venous hypertension was not possible for patients with liver cirrhosis in Child–Pugh class A and B. Graphic abstract ![]()
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Khan A, Bailey CW. Unique Method of Transjugular Intrahepatic Portosystemic Shunt Reduction for Refractory Hepatic Encephalopathy. Cureus 2021; 13:e18838. [PMID: 34804693 PMCID: PMC8592787 DOI: 10.7759/cureus.18838] [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] [Accepted: 10/16/2021] [Indexed: 12/03/2022] Open
Abstract
We report the case of a 27-year-old female patient with a history of cryptogenic cirrhosis who was admitted to the hospital due to multiple episodes of hematemesis secondary to bleeding esophageal varices. The varices were persistent and refractory to endoscopic intervention, so an emergent transjugular intrahepatic portosystemic shunt (TIPS) was performed by interventional radiology (IR). Months later, the patient returned to the hospital unresponsive with acute intermittent hepatic encephalopathy which required a TIPS reduction by IR. Once the TIPS reduction was performed, the patient’s hepatic encephalopathy declined, and her symptoms improved. Here, we present a unique method of TIPS reduction utilizing a single Viabahn VBX balloon-expandable stent (W. L. Gore & Associates, Inc; Flagstaff, AZ) to constrain the existing TIPS stent.
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Affiliation(s)
- Ayub Khan
- Medicine, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Christopher W Bailey
- Interventional Radiology, Virginia Commonwealth University School of Medicine, Richmond, USA
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Kaczmarek DJ, Kupczyk P, Schultheiß M, Chang J, Jansen C, Trebicka J, Weismüller T, Vilz TO, Luu AM, Attenberger U, Strassburg CP, Meyer C, Praktiknjo M. TIPS for the management of stomal variceal bleeding due to cirrhotic and non-cirrhotic portal hypertension. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 60:753-760. [PMID: 34741298 DOI: 10.1055/a-1508-6446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Portal hypertension (PH) is associated with the development of esophageal or gastric varices, which can cause bleedings with high mortality. Varices can also manifest at sites of stomata. These parastomal varices can cause recurrent variceal bleedings (VB) despite local therapies. We present a case series of parastomal VB due to PH that were managed with implantation of transjugular intrahepatic portosystemic shunt (TIPS). METHODS We retrospectively included all patients (pt) from 2 tertiary medical centers with parastomal VB between January 2014 and February 2020 who underwent the TIPS procedure. RESULTS Nine pt were included. Seven pt had liver cirrhosis, mostly alcohol-related. Two pt had non-cirrhotic PH due to porto-sinusoidal vascular disease (PSD). Four pt had a colostomy, 1 an ileostomy, and 4 an ileal conduit. Malignancy was the leading cause of stoma surgery. All 9 pt suffered from recurrent parastomal VB despite non-selective beta-blocker and/or local therapy (e.g., compression, coagulation, suture ligation, or surgical stoma revision). All pt received TIPS implantation. In 7 pt, TIPS implantation led to sustainable hemostasis. Two pt suffered a bleeding relapse that was attributable to TIPS dysfunction. TIPS revision with coil embolization of the varices terminated the VB sustainably in both pt. CONCLUSIONS In pt presenting with recurrent stomal bleedings, parastomal varices as a rare complication of PH must be taken into consideration as an underlying cause. In our case series, we managed to sustainably cease parastomal VB by TIPS implantation with or without coil embolization of the ectopic varices.
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Affiliation(s)
| | - Patrick Kupczyk
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | | | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Jonel Trebicka
- Medizinische Klinik 1, University of Frankfurt, Frankfurt am Main, Germany
| | - Tobias Weismüller
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Tim Oliver Vilz
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - Andreas Minh Luu
- St. Josef Hospital, Department of Surgery, Ruhr University Bochum, Bochum, Germany
| | | | | | - Carsten Meyer
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
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Abstract
Cirrhosis is the fifth leading cause of death in adults. Advanced cirrhosis can cause significant portal hypertension (PH), which is responsible for many of the complications observed in patients with cirrhosis, such as varices. If portal pressure exceeds a certain threshold, the patient is at risk of developing life-threatening bleeding from varices. Variceal bleeding has a high incidence among patients with liver cirrhosis and carries a high risk of mortality and morbidity. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiologic interventions. In terms of management, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires swift intervention to stop the bleeding and achieve durable hemostasis. We describe the pathophysiology of cirrhosis and PH to contextualize the formation of gastric and esophageal varices. We also discuss the currently available treatments and compare how they fare in each stage of clinical management, with a special focus on drugs that can prevent bleeding or assist in achieving hemostasis.
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Abstract
INTRODUCTION There is a growing need for identification of non-endoscopic, non-invasive methods that can accurately predict esophageal varices (EV). Previous studies found an inconclusive correlation between blood ammonia level and the presence and size of EV. AIM We aimed at assessing the value of serum ammonia as a non-invasive method for early prediction of EV. PATIENT AND METHODS The study included 204 patients with HCV-related cirrhosis. The selected patients were categorized into two groups: patients with EV and those without, also patients with no or small EV and with large EV group. All patients underwent a complete biochemical workup, ultrasound and upper GI endoscopy. Child-Pugh class, Model of End-Stage Liver Disease (MELD) score and platelet count/splenic diameter ratio, and serum ammonia level. RESULTS There was a statistical difference between the two groups of patients regarding the following parameters: serum ammonia, international normalized ratio, portal vein diameter, spleen diameter, Child-Pugh class, MELD score, platelet count/splenic diameter ratio, aspartate aminotransferase-to-platelet ratio index, alanine aminotransferase-to-aspartate aminotransferase ratio, Forns index, FIB-4 and King's score. Serum ammonia could predict the presence of EV using a cutoff value of 82 (µmol/L) with a sensitivity of 92.3%, specificity 92%. In addition, a cutoff of 95.5 (µmol/L) could predict large EV with a sensitivity of 92.7% and a specificity of 92.3%. Serum Ammonia in cirrhosis with large EV was 143 ± 39 µmol/L and in cirrhosis with small/without EV was 80.7 ± 9.7 µmol/L (P < 0.0001). Platelet/spleen ratio was 555.9 ± 187.3 in cirrhosis with EV and 694.4 ± 74.2 in cirrhosis without EV (P < 0.0001). Platelet/spleen ratio was 407.7 ± 107.1 in cirrhosis with large EV and 690.4 ± 103.7 in cirrhosis with small/without EV (P < 0.0001). CONCLUSION Serum ammonia can accurately predict the presence and the size of EV in patients with liver cirrhosis with high sensitivity and specificity.
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Bangaru S, Benhammou JN, Tabibian JH. Noninvasive scores for the prediction of esophageal varices and risk stratification in patients with cirrhosis. World J Hepatol 2020; 12:908-918. [PMID: 33312418 PMCID: PMC7701959 DOI: 10.4254/wjh.v12.i11.908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/13/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023] Open
Abstract
The primary purpose of variceal screening in patients with cirrhosis is to detect gastroesophageal varices at high risk of hemorrhage and implement preventative intervention(s). It was previously recommended that all patients with cirrhosis undergo initial and periodic longitudinal variceal screening via upper endoscopy. However, there has been growing interest and methods to identify patients with cirrhosis who may not have clinically significant portal hypertension and therefore be unlikely to have varices requiring intervention or benefit from upper endoscopy. Because the population of patients with compensated advanced chronic liver disease continues to grow, it is neither beneficial nor cost-effective to perform endoscopic variceal screening in all patients. Therefore, there is ongoing research into the development of methods to non-invasively risk stratify patients with cirrhosis for the presence of high-risk esophageal varices and effectively limit the population that undergoes endoscopic variceal screening. This is particularly important and timely in light of increasing healthcare reform and barriers to healthcare. In this review, we discuss and compare, with respect to test characteristics and clinical applicability, the available methods used to non-invasively predict the presence of esophageal varices.
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Affiliation(s)
- Saroja Bangaru
- Internal Medicine, Gastroenterology, University of California at Los Angeles, Los Angeles, CA 90025, United States
| | - Jihane N Benhammou
- The Vatche and Tamar Manoukian Division of Digestive Diseases, University of California at Los Angeles, Los Angeles, CA 90095, United States
| | - James H Tabibian
- Department of Medicine, Olive View-University of California at Los Angeles Medical Center, Sylmar, CA 91342, United States
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
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10
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Lesmana CRA, Raharjo M, Gani RA. Managing liver cirrhotic complications: Overview of esophageal and gastric varices. Clin Mol Hepatol 2020; 26:444-460. [PMID: 33053928 PMCID: PMC7641566 DOI: 10.3350/cmh.2020.0022] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/23/2020] [Indexed: 02/07/2023] Open
Abstract
Managing liver cirrhosis in clinical practice is still a challenging problem as its progression is associated with serious complications, such as variceal bleeding that may increase mortality. Portal hypertension (PH) is the main key for the development of liver cirrhosis complications. Portal pressure above 10 mmHg, termed as clinically significant portal hypertension, is associated with formation of varices; meanwhile, portal pressure above 12 mmHg is associated with variceal bleeding. Hepatic vein pressure gradient measurement and esophagogastroduodenoscopy remain the gold standard for assessing portal pressure and detecting varices. Recently, non-invasive methods have been studied for evaluation of portal pressure and varices detection in liver cirrhotic patients. Various guidelines have been published for clinicians’ guidance in the management of esophagogastric varices which aims to prevent development of varices, acute variceal bleeding, and variceal rebleeding. This writing provides a comprehensive review on development of PH and varices in liver cirrhosis patients and its management based on current international guidelines and real experience in Indonesia.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Division of Hepatobiliary, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia.,Digestive Disease & GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia
| | - Monica Raharjo
- Division of Hepatobiliary, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
| | - Rino A Gani
- Division of Hepatobiliary, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
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Annicchiarico BE, Santonocito C, Siciliano M, Scapaticci M, Guarino D, Di Stasi C, Riccioni ME, Di Stasio E, Capoluongo E, Gasbarrini A. ACE I allele is associated with more severe portal hypertension in patients with liver cirrhosis: A pilot study. Dig Liver Dis 2019; 51:293-296. [PMID: 30236768 DOI: 10.1016/j.dld.2018.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 08/03/2018] [Accepted: 08/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND In liver cirrhosis, the renin-angiotensin-aldosterone system is involved in the pathogenesis of portal hypertension. Its effector, angiotensin II, is generated by angiotensin-converting enzyme (ACE). Serum ACE levels are affected by I/D polymorphism of its gene, with alleles I and D being associated, respectively, with lesser and greater activity of the enzyme. In cirrhotic patients carrying the ACE I allele, an increased risk for gastro-oesophageal varices was observed. AIM The aim of our study was to evaluate whether ACE I/D polymorphism influenced portal pressure. METHODS Fifty-one consecutive cirrhotic patients were divided based on ACE genotype (DD, ID, and II). Kidney and liver function tests, upper endoscopy, and hepatic venous pressure gradient measurement (HVPG) were performed in all patients. RESULTS The presence of the ACE I allele was associated with a higher HVPG value (18.7±6.4 vs 10.3±6.3mmHg; P<.001), higher frequency of large gastrooesophageal varices (59.3% vs 25.0%; P<.05), and higher frequency of variceal bleeding (63.0% vs 29.2%; P<.05). No significant differences were found between patients with and those without the ACE I allele regarding Child-Pugh score, MELD score, ascites, and hepatic encephalopathy. CONCLUSION ACE I/D polymorphism seems to influence the severity of portal hypertension and the risk of variceal bleeding in liver cirrhosis, regardless of the severity of liver disease.
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Affiliation(s)
- Brigida E Annicchiarico
- Department of Internal Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy
| | - Concetta Santonocito
- Laboratory of Clinical Molecular Biology, Department of Biochemistry & Clinical Biochemistry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy.
| | - Massimo Siciliano
- Department of Internal Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy
| | - Margherita Scapaticci
- Laboratory of Clinical Molecular Biology, Department of Biochemistry & Clinical Biochemistry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy; Laboratory Medicine Department, San Camillo Hospital, Treviso, Italy
| | - Donatella Guarino
- Laboratory of Clinical Molecular Biology, Department of Biochemistry & Clinical Biochemistry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy
| | - Carmine Di Stasi
- Department of Bioimaging and Radiological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy
| | - Maria E Riccioni
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy
| | - Enrico Di Stasio
- Laboratory of Clinical Molecular Biology, Department of Biochemistry & Clinical Biochemistry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy
| | - Ettore Capoluongo
- Laboratory of Clinical Molecular Biology, Department of Biochemistry & Clinical Biochemistry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy
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Nazeer SS, Saraswathy A, Shenoy SJ, Jayasree RS. Fluorescence spectroscopy as an efficient tool for staging the degree of liver fibrosis: an in vivo comparison with MRI. Sci Rep 2018; 8:10967. [PMID: 30030510 PMCID: PMC6054616 DOI: 10.1038/s41598-018-29370-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 07/06/2018] [Indexed: 12/20/2022] Open
Abstract
The study utilizes autofluorescence spectroscopy (AFS) along with multivariate spectral analysis for differentiating various stages of hepatic fibrosis. AFS has recently emerged as an efficient tool for evaluating the variations in different endogenous flurophores. In this study, the potential of AFS for differentiating the stages of liver fibrosis is assessed and compared with the results of enzyme evaluation, histopathology and the most advanced diagnostic tool, MRI. Using a fiber optic probe, the emission profile of the flurophores such as flavin adenine dinucleotide (FAD), lipofuscin-like lipopigments (lipopigments), porphyrins and the variation in the total hemoglobin concentration are evaluated in vivo on liver fibrosis induced animal models adopting a minimally invasive technique. Significant difference (p < 0.05) in the level of these biomarkers was observed between different stages of liver fibrosis. Normal hepatic tissue could be distinguished from mild and moderate hepatic fibrosis with a sensitivity of 95 to 100% and specificity of 90 to 100% using multivariate spectral analysis. The results are favourable to consider this technique as a potential tool for diagnosing liver fibrosis at an early stage, which is monumental as it otherwise can lead to cirrhosis and liver failure.
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Affiliation(s)
- Shaiju S Nazeer
- Division of Biophotonics and Imaging, Biomedical Technology Wing Sree Chitra Tirunal Institute for Medical Sciences & Technology, Poojappura, Thiruvananthapuram, 695 012, Kerala, India.,Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ariya Saraswathy
- Division of Biophotonics and Imaging, Biomedical Technology Wing Sree Chitra Tirunal Institute for Medical Sciences & Technology, Poojappura, Thiruvananthapuram, 695 012, Kerala, India.,Department of Physics, NSS College, Pandalam, Kerala, India
| | - Sachin J Shenoy
- Division of In Vivo Models and Testing, Biomedical Technology Wing Sree Chitra Tirunal Institute for Medical Sciences & Technology, Poojappura, Thiruvananthapuram, 695 012, Kerala, India
| | - Ramapurath S Jayasree
- Division of Biophotonics and Imaging, Biomedical Technology Wing Sree Chitra Tirunal Institute for Medical Sciences & Technology, Poojappura, Thiruvananthapuram, 695 012, Kerala, India.
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13
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Maruyama H, Yokosuka O. Ultrasonography for Noninvasive Assessment of Portal Hypertension. Gut Liver 2018; 11:464-473. [PMID: 28267700 PMCID: PMC5491080 DOI: 10.5009/gnl16078] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/07/2016] [Accepted: 06/18/2016] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension is a major pathophysiology in patients with cirrhosis. Portal pressure is the gold standard to evaluate the severity of portal hypertension, and radiological intervention is the only procedure for pressure measurement. Ultrasound (US) is a simple and noninvasive imaging modality available worldwide. B-mode imaging allows broad applications for patients to detect and characterize chronic liver diseases and focal hepatic lesions. The Doppler technique offers real-time observation of blood flow with qualitative and quantitative assessments, and the application of microbubble-based contrast agents has improved the detectability of peripheral blood flow. In addition, elastography for the liver and spleen covers a wider field beyond the original purpose of fibrosis assessment. These developments enhance the practical use of US in the evaluation of portal hemodynamic abnormalities. This article reviews the recent progress of US in the assessment of portal hypertension.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
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14
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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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Abstract
Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.
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Affiliation(s)
- Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX.
| | - Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sheharyar K Merwat
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX
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Balogh J, Gordon-Burroughs S, Schwarz P, Galati J, McFadden R, Cusick M, Snyder M, Bailey H, Weiner M, Wong A, Ochoa R, Saharia A, Gaber A, Ghobrial R. Treatment of Refractory Gastrointestinal Bleeding in Patients With Portal Hypertension: A Case Series and Treatment Algorithm. Transplant Proc 2017; 49:1864-1869. [DOI: 10.1016/j.transproceed.2017.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 06/16/2017] [Indexed: 12/29/2022]
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Abstract
PURPOSE The purpose of this study is to evaluate the relationship between right inferior phrenic artery diameter and portal hypertension in cirrhotic patients. METHODS CT examinations of 38 patients with chronic liver disease (patient group) and 40 patients without any liver disease (control group) were evaluated. The right inferior phrenic artery diameter of the patient and control group were measured. CT findings of portal hypertension, which were accepted as ascites, collaterals, splenomegaly and portal vein diameter greater than 13 mm, were determined and scored in the patient group. Patients obtained scores between one and four with respect to portal hypertension findings, and the scores were compared with phrenic artery diameters. Child-Pugh and MELD scores of the patients were also calculated. RESULTS The mean diameter of the right inferior phrenic artery in the patient group was larger than that in the control group (p < 0.001). The mean phrenic artery diameter of the patients with score 1 was significantly different from those with score 2 (p = 0.028), score 3 (p = 0.001) and score 4 (p = 0.005). We found a linear and moderate relationship between phrenic artery diameter values and Child-Pugh scores (p = 0.012, r = 0.405). CONCLUSION Dilatation of the right inferior phrenic artery in cirrhotic patients may be a nonspecific sign of developing portal hypertension.
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Hepatic Failure. PRINCIPLES OF ADULT SURGICAL CRITICAL CARE 2016. [PMCID: PMC7123541 DOI: 10.1007/978-3-319-33341-0_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The progression of liver disease can cause several physiologic derangements that may precipitate hepatic failure and require admission to an intensive care unit. The underlying pathology may be acute, acute-on chronic, or chronic in nature. Liver failure may manifest with a variety of clinical signs and symptoms that need prompt attention. The compromised synthetic and metabolic activity of the failing liver affects all organ systems, from neurologic to integumentary. Supportive care and specific therapies should be instituted in order to improve outcome and minimize time of recovery. In this chapter we will discuss the definition, clinical manifestations, workup, and management of acute and chronic liver failure and the general principles of treatment of these patients. Management of liver failure secondary to certain common etiologies will also be presented. Finally, liver transplantation and alternative therapies will also be discussed.
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Deng Q, Cai T, Zhang S, Hu A, Zhang X, Wang Y, Huang J. Autologous Peripheral Blood Stem Cell Transplantation Improves Portal Hemodynamics in Patients with Hepatitis B Virus-related Decompensated Cirrhosis. HEPATITIS MONTHLY 2015; 15:e32498. [PMID: 26977164 PMCID: PMC4774339 DOI: 10.5812/hepatmon.32498] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/08/2015] [Accepted: 11/08/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic hepatitis B virus (HBV) infection may eventually lead to decompensated liver cirrhosis, which is a terminal illness. OBJECTIVES The aim of this study was to investigate the therapeutic efficacy of autologous peripheral blood stem cell (APBSC) transplantation to improve portal vein hemodynamics in patients with HBV-related decompensated cirrhosis. PATIENTS AND METHODS This prospective study included 68 hospitalized patients who were diagnosed with HBV-related decompensated cirrhosis. These patients were divided into two groups: the transplantation group included 33 patients, while the control group included 35. Both groups received conventional medical treatment simultaneously, and APBSC transplantation was performed on the patients in the transplantation group. We evaluated the effects of APBSC transplantation on postoperative liver function using the following indices: total bilirubin, serum prothrombin and albumin, spleen size, and portal vein hemodynamics. Postoperatively, all of the patients were followed up at 24, 36, and 48 weeks. RESULTS The transplantation group had no serious reactions. Compared with the control group, albumin and prothrombin activity in the transplantation group was significantly improved at 24, 36, and 48 weeks after the procedure, and spleen length and portal vein diameter were substantially reduced at 48 weeks. The velocity of peak portal vein blood flow and mean maximum portal vein blood flow were greatly increased in the APBSC transplantation group at 36 and 48 weeks, respectively; however, there was also decreased portal vein diameter, which reduced portal vein pressure in patients with HBV-related decompensated cirrhosis. CONCLUSIONS APBSC transplantation greatly benefits HBV-linked decompensated cirrhosis patients and should be recommended in clinical practice.
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Affiliation(s)
- Qinzhi Deng
- Department of Liver Disease, Ningbo No. 2 Hospital, Ningbo, China
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ting Cai
- Department of Liver Disease, Ningbo No. 2 Hospital, Ningbo, China
| | - Shun Zhang
- Department of Liver Disease, Ningbo No. 2 Hospital, Ningbo, China
| | - Airong Hu
- Department of Liver Disease, Ningbo No. 2 Hospital, Ningbo, China
| | - Xingfen Zhang
- Department of Liver Disease, Ningbo No. 2 Hospital, Ningbo, China
| | - Yinyin Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianrong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Corresponding Author: Jianrong Huang, State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China. Tel: +86-57187236743, Fax: +86-57187236743, E-mail:
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Chu H, Han W, Wang L, Xu Y, Jian F, Zhang W, Wang T, Zhao J. Long-term efficacy of subtotal splenectomy due to portal hypertension in cirrhotic patients. BMC Surg 2015. [PMID: 26205377 PMCID: PMC4511991 DOI: 10.1186/s12893-015-0077-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Portal hypertension (PHT) requires invasive measures to prevent rupture and bleeding of esophagogastric varices; however, the long-term results of subtotal splenectomy plus fixation of the retrosternal omentum majus (SSFROM) have not been reported. Specifically, the advantages and disadvantages of surgery that preserves the spleen and the long-term hematologic effects have not been described. Study design Our studies relating to SSFROM commenced in February 1999. As of April 2014 we have performed 256 subtotal splenectomies The records of 65 patients with PHT who underwent SSFROM were reviewed retrospectively. Results Four patients died within 4 years of surgery, with a 4-year survival rate of 94 %; the 11-year survival rate was 60 %. Eleven patients (17 %) had re-bleeding from esophagogastric varices. The white blood cell and platelet counts were higher 6 and 11 years post-operatively compared with pre-operative values (P < 0.01). Portal venous diameter, portal venous flow volume, splenic artery flow volume, as well as splenic length, thickness, and average cross-sectional areas were shown to be significantly constricted or decreased (P < 0.01). The proportion of serum CD3+ T cells, CD4+ T cells, and CD8+ T cells was increased (P < 0.01), while the serum levels of macrophage colony-stimulating factor and granulocyte-macrophage colony-stimulating factor were significantly decreased (P < 0.01). There was no significant change in the serum levels of IgA, IgM, IgG, and Tuftsin (P > 0.05). DSA demonstrated that 15 cases formed collateral circulations between the portal vein and superior vena cava. Conclusion SSFROM provide long-term hemostasis for esophagogastric variceal bleeding in PHT and corrected hypersplenism. SSFROM is an effective treatment for patients with PHT in whom long-term survival is expected.
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Affiliation(s)
- Haibo Chu
- Center of General Surgery, The 89th Hospital of People's Liberation Army, West Beigong Road 256, Weifang, 261021, China
| | - Wei Han
- Center of General Surgery, The 89th Hospital of People's Liberation Army, West Beigong Road 256, Weifang, 261021, China
| | - Lei Wang
- Department of Postgraduate, Weifang Medical University, Weifang, 261042, China
| | - Yongbo Xu
- Center of General Surgery, The 89th Hospital of People's Liberation Army, West Beigong Road 256, Weifang, 261021, China
| | - Fengguo Jian
- Department of General Surgery, Changyi People's Hospital, Changyi, 261300, China
| | - Weihua Zhang
- Department of General Surgery, Weifang Traditional Chinese Medicine Hospital, Weifang, 261041, China
| | - Tao Wang
- Department of Pathology, The 89th Hospital of People's Liberation Army, Weifang, 261021, China
| | - Jianhua Zhao
- Center of General Surgery, The 89th Hospital of People's Liberation Army, West Beigong Road 256, Weifang, 261021, China.
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Abstract
Chronic injury to the liver from a variety of different sources can result in irreversible scarring of the liver, known as cirrhosis. Cirrhosis is a major cause of morbidity and mortality in the USA, and according to the Centers for Disease Control and Prevention was responsible for 31,903 deaths in 2010 alone. It is thus of the utmost importance to appropriately manage these patients in the inpatient and outpatient setting to improve morbidity and mortality. In this review, we address four major areas of cirrhosis management: outpatient management of portal hypertension with decompensation, hepatic encephalopathy, hepatorenal syndrome, and bleeding/coagulation issues. Outpatient management covers recommendations for health care maintenance and screening. Hepatic encephalopathy encompasses a brief review of pathophysiology, treatment in the acute setting, and long-term prevention. Hepatorenal syndrome is discussed in regards to pathophysiology and treatment in the hospital setting. Finally, a discussion of the assessment of coagulation profiles in cirrhosis and recommendations for bleeding and thrombosis complications is included. These topics are not all encompassing with regard to this complicated population, but rather an overview of a few medical problems that are commonly encountered in their care.
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Affiliation(s)
- Neeral L Shah
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | | | | | - Scott L Cornella
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Parvinian A, Gaba RC. Outcomes of TIPS for Treatment of Gastroesophageal Variceal Hemorrhage. Semin Intervent Radiol 2014; 31:252-7. [PMID: 25177086 DOI: 10.1055/s-0034-1382793] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.
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Affiliation(s)
- Ahmad Parvinian
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Bolognesi M, Verardo A, Pascoli MD. Peculiar characteristics of portal-hepatic hemodynamics of alcoholic cirrhosis. World J Gastroenterol 2014; 20:8005-8010. [PMID: 25009370 PMCID: PMC4081669 DOI: 10.3748/wjg.v20.i25.8005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 12/31/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
Alcohol-related cirrhosis is a consequence of heavy and prolonged drinking. Similarly to patients with cirrhosis of other etiologies, patients with alcoholic cirrhosis develop portal hypertension and the hepatic, splanchnic and systemic hemodynamic alterations that follow. However, in alcoholic cirrhosis, some specific features can be observed. Compared to viral cirrhosis, in alcohol-related cirrhosis sinusoidal pressure is generally higher, hepatic venous pressure gradient reflects portal pressure better, the portal flow perfusing the liver is reduced despite an increase in liver weight, the prevalence of reversal portal blood flow is higher, a patent paraumbilical vein is a more common finding and signs of hyperdynamic circulations, such as an increased cardiac output and decreased systemic vascular resistance, are more pronounced. Moreover, alcohol consumption can acutely increase portal pressure and portal-collateral blood flow. Alcoholic cardiomyopathy, another pathological consequence of prolonged alcohol misuse, may contribute to the hemodynamic changes occurring in alcohol-related cirrhosis. The aim of this review was to assess the portal-hepatic changes that occur in alcohol-related cirrhosis, focusing on the differences observed in comparison with patients with viral cirrhosis. The knowledge of the specific characteristics of this pathological condition can be helpful in the management of portal hypertension and its complications in patients with alcohol-related cirrhosis.
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"Downhill" Esophageal Varices due to Dialysis Catheter-Induced Superior Vena Caval Occlusion: A Rare Cause of Upper Gastrointestinal Bleeding. Case Rep Gastrointest Med 2013; 2013:830796. [PMID: 23509642 PMCID: PMC3590564 DOI: 10.1155/2013/830796] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 01/20/2013] [Indexed: 12/13/2022] Open
Abstract
"Downhill" varices are a rare cause of acute upper gastrointestinal bleeding. Rarely these varices are reported in patients receiving hemodialysis as a complication of chronic dialysis vascular access. We present a case of acute upper gastrointestinal bleeding in an individual with end-stage renal disease receiving hemodialysis. Esophagogastroduodenoscopy revealed "downhill" varices in the upper third of the esophagus without any active bleeding at the time of the procedure. An angiogram was performed disclosing superior vena caval occlusion, which was treated with balloon angioplasty. Gastroenterologists should have a high index of suspicion for these rare "downhill" varices when dealing with acute upper gastrointestinal bleeding in patients receiving hemodialysis and manage it appropriately using endoscopic, radiological, and surgical interventions.
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25
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Silva G. New serum markers for predicting esophageal varices: is it a reality? J Gastroenterol Hepatol 2013; 28:4-5. [PMID: 23278151 DOI: 10.1111/jgh.12025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2012] [Indexed: 12/31/2022]
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