Is portal vein cavernous transformation a component of congenital hepatic fibrosis?

Natural History and Outcomes of Cavernous Transformation of the Portal Vein in Cirrhosis

BACKGROUND AND AIMS

Cavernous transformation of the portal vein can occur after portal vein thrombosis (PVT). In this study, we investigated clinical complications associated with cavernous transformation in the context of cirrhosis and PVT.

METHODS

In this retrospective cohort analysis, 204 patients with cirrhosis and PVT with or without cavernous transformation were identified using MUSC's Clinical Data Warehouse between January 1, 2013, through December 31, 2019. Complete demographic data, clinical history, and laboratory tests were abstracted from the electronic medical record.

RESULTS

Of 204 patients, 41 (20%) had cavernous transformation. MELD, Child-Pugh, and Charlson Comorbidity Index scores were similar among groups. There were no significant differences in the prevalence of esophageal varices (with or without bleeding), splenomegaly, or hepatic encephalopathy in patients with and without cavernous transformation, although ascites tended to be lower in patients with cavernous transformation (31/41 (76%) vs 142/163 (87%), p = 0.06). Patients with cavernous transformation were significantly less likely to have hepatocellular carcinoma (HCC) (13/41 (32%) vs 81/163 (50%), p < 0.05) and had significantly lower APRI (1.4 vs 2.0, p < 0.05) and Fib-4 (4.7 vs 6.5, p < 0.05). Patients with cavernous transformation had lower 5-year mortality (12/41 (29%) vs 81/163 (49%) died, p = 0.06). The 10-year mortality of patients with cavernous transformation without HCC was significantly lower than in those without cavernous transformation (8/28 (29%) vs 46/82 (56%), respectively, p < 0.05).

CONCLUSIONS

Patients with cavernous transformation appeared to have better outcomes than those without cavernous transformation.

Imaging of fibropolycystic liver disease

Fibropolycystic liver diseases (FLDs) make up a rare spectrum of heritable hepatobiliary diseases resulting from congenital ductal plate malformations (DPMs) due to the dysfunction of proteins expressed on the primary cilia of cholangiocytes. The embryonic development of the ductal plate is key to understanding this spectrum of diseases. In particular, DPMs can result in various degrees of intrahepatic duct involvement and a wide spectrum of cholangiopathies, including congenital hepatic fibrosis, Caroli disease, polycystic liver disease, and Von Meyenberg complexes. The most common clinical manifestations of FLDs are portal hypertension, cholestasis, cholangitis, and (in rare cases) cholangiocarcinoma. This article reviews recent updates in the pathophysiology, imaging, and clinical management of FLDs.

Clinical application of liver stiffness measurement in patients with cavernous transformation of portal vein

The clinical outcomes differ between patients with cavernous transformation of the portal vein (CTPV) with and without cirrhosis. Therefore, invasive liver biopsy may be needed for the differential diagnosis of patients with CTPV with or without cirrhosis. The present study aimed to investigate the diagnostic efficacy of liver stiffness measurements (LSM) for the prediction of cirrhosis in patients with CTPV. A total of 20 patients with CTPV, 34 with chronic hepatitis B (CHB)-related cirrhosis and 20 healthy volunteers, were retrospectively recruited in the study. CTPV was diagnosed with contrast-enhanced computed tomography (CT) and ultrasound for the abdomen. LSM values were detected for each patient, while liver biopsy was performed in each patient in the CTPV and cirrhosis groups. The results demonstrated that LSM values were significantly lower in the CTPV group (12.5 kPa; range, 6.8-21.5 kPa) compared with the CHB-related cirrhosis group (21.0 kPa; range, 15.5-27.2 kPa; P=0.017). However, this was still higher compared with healthy volunteers (4.9 kPa; range 4.0-5.8 kPa; P<0.001). In addition, CTPV patients with cirrhosis (17.7 kPa; range, 13.9-30.8 kPa) exhibited significantly increased LSM values compared with those without cirrhosis (6.4 kPa; range, 5.7-7.8 kPa; P<0.001). Furthermore, LSM values in CTPV patients without cirrhosis were slightly higher compared with those of healthy volunteers (P=0.003), while no statistically significant difference was observed in LSM between CTPV patients with cirrhosis and CHB-related cirrhosis group. These findings indicated that LSM values could be used for the differential diagnosis of CTPV patients with or without cirrhosis. However, further validation studies are needed.

CONGENITAL HEPATIC FIBROSIS AND OBLITERATIVE PORTAL VENOPATHY WITHOUT PORTAL HYPERTENSION - A REVIEW OF LITERATURE BASED ON AN ASYMPTOMATIC CASE

The disease and the case reported here are relevant especially because of their varied clinical presentation, possibility of being associated with other disorders affecting several organs and possible differential diagnoses. Congenital Hepatic Fibrosis is an autosomal recessive disease due to mutation in the PKHD1 gene, which encodes the fibrocystin/polyductine protein. It is a cholangiopathy, characterized by varying degrees of periportal fibrosis and irregular proliferation of bile ducts. Affected patients are typically diagnosed in childhood, but in some cases the disease may remain asymptomatic for many years. The exact prevalence and incidence of the disease are not known, but it is consider a rare disease, with a few hundred cases described worldwide. It can affect all ethnic groups and occur associated with various hereditary and non-hereditary disorders. The clinical presentation is quite variable, with melena and hematemesis being initial symptoms in 30%-70% of the cases. More rarely, they may present episodes of cholangitis. The disease has been classified into four types: portal hypertension, cholestasis / cholangitis, mixed and latent. Diagnosis begins with imaging tests, but the definition is made by the histopathological sample. So far, there is no specific therapy that can stop or reverse the pathological process. Currently, the therapeutic strategy is to treat the complications of the disease.

Congenital hepatic fibrosis in a child with Prader-Willi syndrome: a novel association

Prader-Willi syndrome (PWS) is a rare genetic disorder caused by deletion or unexpression of the chromosome 15 (q 11-13). Symptomatologies include hypotonia, hyperphagia, cognitive impairment, and characteristic dysmorphic profile. Here, we report a 4-year-old boy with PWS who presented with complications of congenital hepatic fibrosis. The uniparental heterodisomy makes it unlikely that the hepatic fibrosis was caused by unmasking of a recessive mutation on the maternal chromosome 15 although we cannot exclude the possibility of a recessively inherited mutation elsewhere given the parental consanguinity. This is the first report of congenital hepatic fibrosis in PWS.

Cavernous vessels around a patent portal trunk in the liver hilum

OBJECTIVES

Cavernous transformation of the portal vein (CTPV) is considered a sequel to extrahepatic portal vein obstruction. However, we have observed an unusual finding of cavernous vessels around a patent portal trunk in the liver hilum. The aim of our study is to describe the imaging features, clinical profiles, management, and outcome of these patients.

MATERIAL AND METHODS

We re-evaluated the images of all consecutive non-malignant and non-cirrhotic patients with a diagnosis of CTPV admitted to our department between July 2002 and June 2010. The patients with a patent portal trunk were enrolled in this study.

RESULTS

A total of five patients had cavernous vessels around a patent portal trunk. Of them, all presented with abdominal distension, and one with recurrent variceal bleeding. Hepatomegaly and splenomegaly were found in one and four patients, respectively. All but one with previous splenectomy had a decreased platelet count. Three patients had a high level of alkaline phosphatase and/or γ-glutamyl transferase. Serum bilirubin, albumin, and creatinine were in normal range. Endoscopy demonstrated varices in three patients. Mild ascites was detected in one patient by ultrasound. Conservative therapy was given to two patients with mild abdominal discomfort. Splenectomy or partial spleen embolization was given to two patients with hypersplenism. A transjugular intrahepatic portosystemic shunt insertion was performed in one patient for the prevention of recurrent variceal bleeding. All patients were alive during follow-up.

CONCLUSIONS

These unusual findings led us to believe that cavernous vessels could develop around a patent portal trunk. Further studies are necessary to explore its pathogenesis.

Portal ductopathy: Clinical importance and nomenclature

Non-cirrhotic portal hypertension (PHT) accounts for about 20% of all PHT cases, portal vein thrombosis (PVT) resulting in cavernous transformation being the most common cause. All known complications of PHT may be encountered in patients with chronic PVT. However, the effect of this entity on the biliary tree and pancreatic duct has not yet been fully established. Additionally, a dispute remains regarding the nomenclature of common bile duct abnormalities which occur as a result of chronic PVT. Although many clinical reports have focused on biliary abnormalities, only a few have evaluated both the biliary and pancreatic ductal systems. In this review the relevant literature evaluating the effect of PVT on both ductal systems is discussed, and findings are considered with reference to results of a prominent center in Turkey, from which the term “portal ductopathy” has been put forth to replace “portal biliopathy”.

Experience of a single center with congenital hepatic fibrosis: A review of the literature

Congenital hepatic fibrosis (CHF) is an autosomal recessive inherited malformation defined pathologically by a variable degree of periportal fibrosis and irregularly shaped proliferating bile ducts. It is one of the fibropolycystic diseases, which also include Caroli disease, autosomal dominant polycystic kidney disease, and autosomal recessive polycystic kidney disease. Clinically it is characterized by hepatic fibrosis, portal hypertension, and renal cystic disease. CHF is known to occur in association with a range of both inherited and non-inherited disorders, with multiorgan involvement, as a result of ductal plate malformation. Because of the similarities in the clinical picture, it is necessary to differentiate CHF from idiopathic portal hypertension and early liver cirrhosis, for which a liver biopsy is essential. Radiological tests are important for recognizing involvement of other organ systems. With regards to our experience at Hacettepe University, a total of 26 patients have been diagnosed and followed-up between 1974 and 2009 with a diagnosis of CHF. Presentation with Caroli syndrome was the most common diagnosis, with all such patients presenting with symptoms of recurrent cholangitis and symptoms related to portal hypertension. Although portal fibrosis is known to contribute to the ensuing portal hypertension, it is our belief that portal vein cavernous transformation also plays an important role in its pathogenesis. In all patients with CHF portal vein morphology should be evaluated by all means since portal vein involvement results in more severe and complicated portal hypertension. Other associations include the Joubert and Bardet-Biedl syndromes.

The immunopathology of human biliary cell epithelium

Bile ducts lined with biliary epithelial cells, or cholangiocytes, are the main components of the biliary system in liver. Cholangiocytes participate in the production and transport of bile substances, as well as participate in immune responses. Cholangiocytes protect against pathogens by expressing toll-like receptors and anti-microbial peptides; act as antigen-presenting cells by expressing human leukocyte antigen molecules and costimulatory molecules; recruit leukocytes to the target site by expressing adhesion molecules, cytokines, and chemokines; and induce apoptosis of leukocytes to limit the immune responses. Several cholangiopathies result from dysfunctions of the biliary system. They can broadly be divided into autoimmune, genetic, infectious, drug, and ischemic-injury-induced categories. The pathogenesis of many of these cholangiopathies is unclear and treatment is limited. Further understanding of the complexity of the biliary system is critical for medical advancements in this field.