Gadolinium enhanced three-dimensional magnetic resonance portography with subtraction

Patterns of portosystemic collaterals and diameters of portal venous system in cirrhotic patients with hepatitis B on magnetic resonance imaging: Association with Child-Pugh classifications

BACKGROUND AND OBJECTIVE

To determine associations of patterns of portosystemic collaterals and diameters of portal venous system in cirrhotic patients with hepatitis B on magnetic resonance (MR) imaging with Child-Pugh classification.

MATERIALS AND METHODS

Eighty-eight consecutive patients with cirrhosis resulting from chronic hepatitis B graded by Child-Pugh classifications were recruited and undergone MR portography. Patterns of the collaterals (presented as no collateral, isolated esophageal varices, and esophageal varices combined with other shunts), and diameters of portal venous system including portal vein (PV), left portal vein (LPV), right portal vein (RPV), splenic vein (SV) and superior mesenteric vein (SMV) were assessed statistically to determine associations of patterns of collaterals and diameters of the portal veins with Child-Pugh classification.

RESULTS

From no collateral, to isolated esophageal varices, and to the varices combined with other shunts, the Child-Pugh classifications tended to increase (r=0.516, P<0.001). Diameters of PV, LPV, RPV, SV and SMV tended to increase from Child-Pugh A to B but decrease from B to C. Differences in diameter of LPV and SV were significant between Child-Pugh A-B and C (all P<0.05) while no differences in diameters of other portal veins were found (all P>0.05). For discriminating Child-Pugh A-B from C, either a cut-off LPV diameter of 8.98mm or SV diameter of 9.10mm achieved a sensitivity of 67%-70%, specificity of 51%-53%.

CONCLUSION

Patterns of portosystemic collaterals and diameters of LPV and SV tend to be associated with Child-Pugh classifications of cirrhosis.

Identification of Perforators in Patients with Duodenal Varices by Endoscopic Ultrasound-A Case Series [with video]

BACKGROUND/AIMS

Duodenal varices (DV) are ectopic varices which can cause massive gastrointestinal bleeding. The diagnosis of DV may be difficult; sometimes they can be hidden behind duodenal folds. The aim of the study was to evaluate DV by endoscopic ultrasound.

METHODS

Endoscopic ultrasound was done in patients detected or suspected to be having DV. The para duodenal varices were identified and subsequently hemodynamic evaluation of DV was done.

RESULTS

Endoscopic ultrasound identified perforators in seven cases of DV.

CONCLUSION

The endoscopic ultrasound can help in detection of DV underlying thickened folds. It can also help in hemodynamic evaluation of DV.

Current status of ectopic varices in Japan: Results of a survey by the Japan Society for Portal Hypertension

AIM

The Clinical Research Committee of the Japan Society for Portal Hypertension has conducted a nationwide questionnaire survey to clarify the current status of ectopic varices in Japan.

METHODS

A total of 173 cases of ectopic varices were collected.

RESULTS

Duodenal varices were found in 57 cases, and most of them were located in the descending to transverse parts. There were 11 cases of small intestinal varices and 6 cases of colonic varices, whereas 77 patients had rectal varices, accounting for the greatest proportion (44.5%). Other sites of varices were the biliary tract, anastomotic sites, the stoma, and the diaphragm. Liver cirrhosis was the most frequent diseases (80.3%) underlying ectopic varices. It was noted that patients with rectal varices frequently had a history of esophageal varices (94.8%) and received endoscopic treatment (87.0%). The treatments for ectopic varices were as an emergency in 46.5%, elective in 35.4% and prophylactic in 18.2%. In emergency cases, endoscopic therapy was most frequent (67.4%), followed by interventional radiology (IVR; 15.2%), and endoscopy-IVR combination (6.5%). Elective treatment was performed by endoscopy in 34.3%, IVR in 28.6%, combined endoscopy-IVR in 5.7%, and surgical operation in 25.7%. The prophylactic treatment was endoscopic in 50.0%, IVR in 33.3%, combined treatments in 11.1%, and prophylactic surgery in none. The change of ectopic varices after treatment was disappearance in 54.9%, remnant in 35.4% and recurrence in 9.7%. The rate of disappearance was significantly lower in rectal varices (40.8%) than in duodenal varices (73.4%). The patient outcome did not differ among the various sites of the lesion. Conslusions: Current status of ectopic varices in Japan has been clarified by a nationwide questionnaire survey. The authors expect that the pathophysiology of ectopic varices will be further elucidated, and that improved diagnostic modalities and treatment methods are established in the future.

Systematic review: endoscopic and imaging-based techniques in the assessment of portal haemodynamics and the risk of variceal bleeding

BACKGROUND

Invasive measurement of the hepatic venous pressure gradient (HVPG) is regarded as the gold standard for risk stratification and the evaluation of pharmaceutical agents in patients with portal hypertension.

AIM

To review the techniques for endoscopic and imaging-based assessment of portal haemodynamics, with particular emphasis on trials where the results were compared with HVPG or direct portal pressure measurement.

METHODS

Systematic search of the MEDLINE electronic database with keywords: portal hypertension, variceal bleeding, variceal pressure, endoscopic ultrasound, Doppler ultrasonography, magnetic resonance angiography, CT angiography, hepatic venous pressure gradient.

RESULTS

Computed tomography angiography and endoscopic ultrasound (EUS) have been both employed for the diagnosis of complications of portal hypertension and for the evaluation of the efficacy of endoscopic therapy. Colour Doppler ultrasonography and magnetic resonance angiography has given discrepant results. Endoscopic variceal pressure measurements either alone or combined with simultaneous EUS, correlate well with HVPG and risk of variceal bleeding and have a low interobserver variability.

CONCLUSIONS

Endoscopic and imaging-based measurements of portal haemodynamics provide an alternate means for the assessment of complications of portal hypertension. Further studies are required to validate their use in risk stratification and the evaluation of drug therapies in patients with portal hypertension.

Splenic autotransplantation and oesophageal transection anastomosis in patients with portal hypertension (26 years clinical observation)

The surgical treatment methods for cirrhosis patients complicated with portal hypertension are complicated. In this study, we evaluated the effectiveness of a new treatment strategy: splenic auto-transplantation and oesophageal transection anastomosis on 274 patients from three aspects: clinical observation, splenic immunology and portal dynamics. From 1979 to 2005, 274 cirrhosis patients with portal hypertension who underwent the new treatment strategy were followed up to observe different clinical indexes, which were then compared with those of the traditional surgery treatment. From 1999 to 2002, a randomized control trial (RCT) was performed on 40 patients to compare their immune function after operation. From 1994 to 2004, another RCT was carried out on 28 patients to compare the portal dynamics through three-dimensional dynamic contrast enhanced MR angiography (3D DEC MRA) investigation after operation. Among 274 patients (mean age 41.8 years), the emergency operative mortality (4.4%), selective operative mortality (2.2%), complication rate (17.9%), morbidity of hepatic encephalopathy (<1%), bleeding rate of portal hypertension gastritis (PHG) (9.1%), and morbidity of hepatic carcinoma (8%) were similar to those under traditional operation; the spleen immunology function (Tuftsin, IgM) decreased among the groups 2 months after operation. Through 3D DCE MRA, the cross section area, the velocity and volume of blood flow of main portal vein decrease significantly after operation in both groups, the auto transplantation group was significantly lower in velocity and volume of blood flow than in the control group. Splenic auto transplantation and esophageal transection anastomosis are a safe, effective, and reasonable treatment strategy for portal hypertension with varicial bleeding. It can not only correct hypersplenism but also completely stanch blood, and auto transplanted spleen in the retroperitoneal space can preserve immune function and establish abroad collateral circulation.

Gadolinium-Enhanced Phase-Contrast Magnetic Resonance Portography

PURPOSE

The purpose of this study was to investigate the effect and usefulness of gadolinium-chelated contrast medium in phase-contrast magnetic resonance (MR) portography.

METHODS

Twenty-six patients (21 men, 5 women; aged 34 to 79 years, mean 62 years) underwent respiratory-triggered 3-dimensional phase-contrast portography before and after administration of gadolinium in a 1.5T MR unit. Coronal maximum intensity projection (MIP) images of the portal vein were reconstructed and compared to conventional arterial portograms regarding visualization. Signal-to-noise ratio (SNR) and portal vein-to-liver contrast-to-noise ratios (CNR) of main, right, right anterior, right posterior, left portal veins, and umbilical portion were measured on both non-enhanced and gadolinium-enhanced images and compared.

RESULTS

Portal veins and branches were more clearly visualized on the gadolinium-enhanced than on the non-enhanced images. Compared to arterial portography, gadolinium-enhanced portography showed similar performances in visualization, except in the right posterior branch and left portal vein. No severe image degradation from respiration was experienced. SNR was significantly higher on the gadolinium-enhanced than on non-enhanced images except in the right anterior branch. CNR was significantly higher on the gadolinium-enhanced than on the non-enhanced images at all measured locations.

CONCLUSIONS

Administration of gadolinium improves the SNR and CNR of phase-contrast portography and visualization of the portal vein. The phase-contrast technique with gadolinium enhancement can be used to evaluate the portal vein as a supplemental technique.