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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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Ielasi L, Tonnini M, Piscaglia F, Serio I. Current guidelines for diagnosis and management of hepatic involvement in hereditary hemorrhagic teleangiectasia. World J Hepatol 2023; 15:675-687. [PMID: 37305373 PMCID: PMC10251273 DOI: 10.4254/wjh.v15.i5.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
Hereditary hemorrhagic teleangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is the most common cause of hepatic vascular malformations in adults. Different vascular shunts (arteriovenous, arterioportal or portovenous) lead to different clinical manifestations. Even though no hepatic-related symptoms are reported in the majority of cases, the severity of liver disease could lead to refractory medical conditions, in some cases requiring liver transplantation. The aim of this manuscript is to provide an updated overview of the current evidence regarding the diagnosis and treatment of HHT liver involvement and liver-related complications.
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Affiliation(s)
- Luca Ielasi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Department of Internal Medicine, Ospedale per gli Infermi di Faenza, Faenza 48018, Italy
| | - Matteo Tonnini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Ilaria Serio
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
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Robinson EB, Jordan G, Katz D, Sundaram SS, Boster J, Brigham D, Ladd P, Chan CM, Shay RL, Ochmanek E, Annam A. Congenital Portosystemic Shunts: Variable Clinical Presentations Requiring a Tailored Endovascular or Surgical Approach. JPGN REPORTS 2023; 4:e279. [PMID: 37181921 PMCID: PMC10174742 DOI: 10.1097/pg9.0000000000000279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/21/2022] [Indexed: 05/16/2023]
Abstract
Congenital portosystemic shunts (CPSS) are rare developmental anomalies resulting in diversion of portal flow to the systemic circulation. These shunts allow intestinal blood to reach the systemic circulation directly, and if persistent or large, may lead to long-term complications. CPSS can have a variety of clinical presentations that depend on the substrate that is bypassing hepatic metabolism or the degree of hypoperfusion of the liver. Many intrahepatic shunts spontaneously close by 1 year of age, but extrahepatic and persistent intrahepatic shunts require intervention by a single session or staged closure with a multidisciplinary approach. Early detection and appropriate management are important for a good prognosis. The aim of this case series is to describe the varied clinical presentations, treatment approaches, and outcomes of 5 children with CPSS at our institution. Management of these patients should involve a multidisciplinary team, including interventional radiology, surgery, hepatology, and other medical services as the patient's clinical presentation warrants. Regardless of clinical presentation, if a CPSS persists past 1-2 years of age, closure is recommended.
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Affiliation(s)
- Eduardo Bent Robinson
- From the Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gregory Jordan
- From the Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Danielle Katz
- Division of Pediatric Radiology, Department of Radiology, University of Colorado, Aurora, CO, USA
| | - Shikha S. Sundaram
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Julia Boster
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Dania Brigham
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Patricia Ladd
- Division of Pediatric Radiology, Department of Radiology, University of Colorado, Aurora, CO, USA
| | - Christine M. Chan
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Rebecca L. Shay
- Division of Neonatology, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Emily Ochmanek
- Division of Interventional Radiology, Department of Radiology, University of New Mexico, Albuquerque, NM, USA
| | - Aparna Annam
- Division of Pediatric Radiology, Department of Radiology, University of Colorado, Aurora, CO, USA
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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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Kobayashi S. Hepatic pseudolesions caused by alterations in intrahepatic hemodynamics. World J Gastroenterol 2021; 27:7894-7908. [PMID: 35046619 PMCID: PMC8678815 DOI: 10.3748/wjg.v27.i46.7894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/23/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatic pseudolesion may occur in contrast-enhanced computed tomography and magnetic resonance imaging due to the unique haemodynamic characteristics of the liver. The concept of hepatic arterial buffer response (HABR) has become mainstream for the understanding of the mechanism of the reciprocal effect between hepatic arterial and portal venous flow. And HABR is thought to be significantly related to the occurrence of the abnormal imaging findings on arterial phase of contrast enhanced images, such as hepatic arterial-portal vein shunt and transient hepatic attenuation difference, which mimic hypervascular tumor and may cause clinical problems. Third inflow to the liver also cause hepatic pseudolesion, and some of the cases may show histopathologic change such as focal hyperplasia, focal fatty liver, and focal sparing of fatty liver, and called pseudotumor. To understand these phenomena might be valuable for interpreting the liver imaging findings.
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Affiliation(s)
- Satoshi Kobayashi
- Department of Quantum Medical Technology, Kanazawa University Graduate School of Medical Sciences, Kanazawa 9200942, Ishikawa, Japan
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