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Kelly C, Buscarini E, Manfredi G, Gregory S, Heneghan MA. Hepatic manifestations of hereditary haemorrhagic telangiectasia. Liver Int 2024; 44:2220-2234. [PMID: 38847503 DOI: 10.1111/liv.16008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/01/2024] [Accepted: 05/25/2024] [Indexed: 08/30/2024]
Abstract
Hereditary haemorrhagic telangiectasia is a genetic condition of abnormal blood vessel formation resulting from an imbalance of pro- and anti-angiogenic products of the transforming growth factor β/bone morphogenetic protein signalling pathway which contributes to vascular remodelling and maintenance. Hepatic vascular malformations are common although less frequently symptomatic, but may result in high-output cardiac failure, portal hypertension and biliary ischaemia. Whilst the understanding of the genetic and cell signalling pathways that are the hallmark of hereditary haemorrhagic telangiectasia have been clarified, there remain challenges in therapy for these patients. Only patients with symptomatic hepatic vascular malformations require treatment, with most (63%) responding to first-line medical therapy. For non-responders, bevacizumab is effective in reducing cardiac output in those with heart failure secondary to hepatic vascular malformations as well as other manifestations of the disease. Although liver transplantation is the only curative option, optimal timing is critical. Novel anti-angiogenetic drugs and those that target aberrant cell signalling pathway are being explored.
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Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, Kings College Hospital, London, UK
| | | | - Guido Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
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Morales-Tovar D, Martínez-Sánchez FD, Gabutti-Thomas A, Rivera-Martínez R, Córdova-Gallardo J. A Rare Association: Hereditary Hemorrhagic Telangiectasia with Liver Cirrhosis Causing Portal Hypertension. Case Rep Gastrointest Med 2024; 2024:3574725. [PMID: 38273971 PMCID: PMC10807975 DOI: 10.1155/2024/3574725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/10/2023] [Accepted: 12/28/2023] [Indexed: 01/27/2024] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is a vascular disorder of autosomal dominant etiology. The hallmark clinical feature is the presence of recurrent episodes of epistaxis in patients with vascular malformations and a tendency to bleed. We present the case of a 71-year-old woman who presented to the emergency department with upper gastrointestinal bleeding caused by esophageal varices, in conjunction with gastric angiodysplasias. The presence of oronasopharyngeal telangiectasias and hepatomegaly raised suspicion of HHT. The diagnostic workup confirmed the presence of angiodysplasia in the gastric region, portal arteriovenous malformation, and a pulmonary shunt.
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Affiliation(s)
- Denisse Morales-Tovar
- Facultad de Medicina, Universidad Nacional Autónoma de México, Escolar 411A, Copilco Universidad, Coyoacán, Ciudad de México 04360, Mexico
- Department of Internal Medicine, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
| | - Froylan D. Martínez-Sánchez
- Facultad de Medicina, Universidad Nacional Autónoma de México, Escolar 411A, Copilco Universidad, Coyoacán, Ciudad de México 04360, Mexico
- Department of Internal Medicine, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
| | - Alejandro Gabutti-Thomas
- Department of Interventional Radiology, Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Ciudad de México 14080, Mexico
| | - Rodolfo Rivera-Martínez
- Department of Imageology, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
| | - Jacqueline Córdova-Gallardo
- Facultad de Medicina, Universidad Nacional Autónoma de México, Escolar 411A, Copilco Universidad, Coyoacán, Ciudad de México 04360, Mexico
- Department of Hepatology, Hospital General Dr. Manuel Gea Gonzalez, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Ciudad de Mexico 14080, Mexico
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Guilhem A, Dupuis-Girod S, Espitia O, Rivière S, Seguier J, Kerjouan M, Lavigne C, Maillard H, Magro P, Alric L, Lipsker D, Parrot A, Leguy V, Vanlemmens C, Guibaud L, Vikkula M, Eyries M, Valette PJ, Giraud S. Seven cases of hereditary haemorrhagic telangiectasia-like hepatic vascular abnormalities associated with EPHB4 pathogenic variants. J Med Genet 2023; 60:905-909. [PMID: 36813543 DOI: 10.1136/jmg-2022-109107] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND EPHB4 loss of function is associated with type 2 capillary malformation-arteriovenous malformation syndrome, an autosomal dominant vascular disorder. The phenotype partially overlaps with hereditary haemorrhagic telangiectasia (HHT) due to epistaxis, telangiectases and cerebral arteriovenous malformations, but a similar liver involvement has never been described. METHODS Members of the French HHT network reported their cases of EPHB4 mutation identified after an initial suspicion of HHT. Clinical, radiological and genetic characteristics were analysed. RESULTS Among 21 patients with EPHB4, 15 had a liver imaging, including 7 with HHT-like abnormalities (2 female patients and 5 male patients, ages 43-69 years). Atypical epistaxis and telangiectases were noted in two cases each. They were significantly older than the eight patients with normal imaging (median: 51 vs 20 years, p<0.0006).The main hepatic artery was dilated in all the cases (diameter: 8-11 mm). Six patients had hepatic telangiectases. All kind of shunts were described (arteriosystemic: five patients, arterioportal: two patients, portosystemic: three patients). The overall liver appearance was considered as typical of HHT in six cases.Six EPHB4 variants were classified as pathogenic and one as likely pathogenic, with no specific hot spot. CONCLUSION EPHB4 loss-of-function variants can be associated with HHT-like hepatic abnormalities and should be tested for atypical HHT presentations.
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Affiliation(s)
- Alexandre Guilhem
- Service de Génétique, Centre de Référence pour la maladie de Rendu-Osler, CHU Lyon, Lyon, France
| | - Sophie Dupuis-Girod
- Service de Génétique, Centre de Référence pour la maladie de Rendu-Osler, CHU Lyon, Lyon, France
- Laboratory Biology of Cancer and Infection, CEA de Grenoble, Grenoble, France
| | - Olivier Espitia
- Department of Internal and Vascular Medicine, CHU Nantes, Nantes, France
| | - Sophie Rivière
- Médecine Interne et Maladies Multi-Organiques, CHU Montpellier, Montpellier, France
| | - Julie Seguier
- Département de Médecine Interne, Hôpital de la Timone, Marseille, France
| | | | | | - Hélène Maillard
- Service de Médecine Interne et Immunologie Clinique, CHU Lille, Lille, France
| | - Pascal Magro
- Service de Pneumologie, Hôpital Bretonneau, Tours, France
| | - Laurent Alric
- Médecine Interne, Département des Maladies Digestives, CHU Toulouse, Toulouse, France
| | - Dan Lipsker
- Clinique Dermatologique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Vanessa Leguy
- Service de Médecine Interne et Immunologie Clinique, CHU Dijon, Dijon, France
| | - Claire Vanlemmens
- Service Hépatologie et soins intensifs digestifs, CHU Besancon, Besancon, France
| | - Laurent Guibaud
- Service d'Imagerie Médicale Pédiatrique et Foetale, CHU Lyon, Lyon, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, Bruxelles, Belgium
| | - Melanie Eyries
- Genetics, Groupe Hospitalier Pitié-Salpétrière, AP-HP, Paris, France
| | | | - Sophie Giraud
- Service de Génétique, Centre de Référence pour la maladie de Rendu-Osler, CHU Lyon, Lyon, France
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Cheong I. Heart Failure Due to Liver Involvement of Hereditary Hemorrhagic Telangiectasia, Diagnosed by Point-of-Care Ultrasonography. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2022. [DOI: 10.1177/87564793221123075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Osler-Weber-Rendu syndrome, also known as hereditary hemorrhagic telangiectasia (HHT), is a rare inherited disorder characterized by the presence of systemic arteriovenous malformations, which most commonly affects the liver. One of the most serious complications of liver compromise is high output heart failure (HOHF). In this case study, point-of-care ultrasonography is utilized as a means to describe the diagnostic findings of an intensive care unit patient diagnosed with liver involvement of HHT and the development of HOHF.
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Affiliation(s)
- Issac Cheong
- Department of Critical Care Medicine, Sanatorio De los Arcos, Buenos Aires, Argentina
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina
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Xiang J, Xie W, Zhang C, Wang H. Right hemihepatectomy combined with ligation of the common hepatic artery and gastroduodenal artery for the treatment of intrahepatic HHT: A case report. Front Surg 2022; 9:900297. [PMID: 36017509 PMCID: PMC9395736 DOI: 10.3389/fsurg.2022.900297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a rare disease that lacks effective treatment. Here, the authors report the case of a 30-year-old woman presenting with abdominal pain accompanied by severe malnutrition. After a definite diagnosis of HHT involvement in the liver, liver transplantation was the first-choice treatment according to the guidelines of HHT. However, the patient firmly refused liver transplantation. Finally, a new type of surgery, right hemihepatectomy combined with ligation of the common hepatic artery and gastroduodenal artery, was performed based on careful study of the case and with the maximum benefit of the patient in mind. Although the patient developed transient liver dysfunction after surgery, she eventually recovered well and continued to be followed up. As far as we know, this is the first report of this kind of surgery for the treatment of intrahepatic HHT.
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Affiliation(s)
- Jifeng Xiang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Wei Xie
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Cuncheng Zhang
- Department of Ultrasonography, Chongqing General Hospital, Chongqing, China
| | - Huaizhi Wang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
- Correspondence: Huaizhi Wang
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LeGout JD, Bolan CW, Bowman AW, Caserta MP, Chen FK, Cox KL, Sanyal R, Toskich BB, Lewis JT, Alexander LF. Focal Nodular Hyperplasia and Focal Nodular Hyperplasia-like Lesions. Radiographics 2022; 42:1043-1061. [PMID: 35687520 DOI: 10.1148/rg.210156] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Focal nodular hyperplasia (FNH) is a benign lesion occurring in a background of normal liver. FNH is seen most commonly in young women and can often be accurately diagnosed at imaging, including CT, MRI, or contrast-enhanced US. In the normal liver, FNH frequently must be differentiated from hepatocellular adenoma, which although benign, is managed differently because of the risks of hemorrhage and malignant transformation. When lesions that are histologically identical to FNH occur in a background of abnormal liver, they are termed FNH-like lesions. These lesions can be a source of diagnostic confusion and must be differentiated from malignancies. Radiologists' familiarity with the imaging appearance of FNH-like lesions and knowledge of the conditions that predispose a patient to their formation are critical to minimizing the risks of unnecessary intervention for these lesions, which are rarely symptomatic and carry no risk for malignant transformation. FNH is thought to form secondary to an underlying vascular disturbance, a theory supported by the predilection for formation of FNH-like lesions in patients with a variety of hepatic vascular abnormalities. These include abnormalities of hepatic outflow such as Budd-Chiari syndrome, abnormalities of hepatic inflow such as congenital absence of the portal vein, and hepatic microvascular disturbances, such as those that occur after exposure to certain chemotherapeutic agents. Familiarity with the imaging appearances of these varied conditions and knowledge of their association with formation of FNH-like lesions allow radiologists to identify with confidence these benign lesions that require no intervention. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Jordan D LeGout
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Candice W Bolan
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Andrew W Bowman
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Melanie P Caserta
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Frank K Chen
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Kelly L Cox
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Rupan Sanyal
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Beau B Toskich
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Jason T Lewis
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Lauren F Alexander
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
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