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Matsubara Y, Tsuboi A, Hirata I, Sumioka A, Takasago T, Tanaka H, Yamashita K, Hiyama Y, Takigawa H, Murakami E, Tsuge M, Urabe Y, Oka S. Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes. BMC Gastroenterol 2024; 24:287. [PMID: 39187770 PMCID: PMC11346274 DOI: 10.1186/s12876-024-03377-7] [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: 03/06/2024] [Accepted: 08/14/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes. METHODS This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23-87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups. RESULTS Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037). CONCLUSIONS Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.
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Affiliation(s)
- Yuka Matsubara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
- Department of Gastroenterology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Issei Hirata
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Takasago
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuichi Hiyama
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Eisuke Murakami
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masataka Tsuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Brzdęk M, Zarębska-Michaluk D, Kukla M, Janocha-Litwin J, Dybowska D, Janczewska E, Lorenc B, Berak H, Mazur W, Tudrujek-Zdunek M, Klapaczyński J, Piekarska A, Sitko M, Laurans Ł, Parfieniuk-Kowerda A, Flisiak R. Real-world experience with direct-acting antiviral therapy in HCV-infected patients with cirrhosis and esophageal varices. Pharmacol Rep 2024:10.1007/s43440-024-00639-9. [PMID: 39162985 DOI: 10.1007/s43440-024-00639-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 08/11/2024] [Accepted: 08/12/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection affects 50 million people worldwide with around 242,000 deaths annually, mainly due to complications such as cirrhosis and hepatocellular carcinoma (HCC). Portal hypertension (PH) caused by cirrhosis leads to severe consequences, including esophageal varices (EV). This study aimed to evaluate the effectiveness and safety of direct-acting antiviral (DAA) treatment in patients with and without EV. METHODS This retrospective analysis involved consecutive HCV-infected adults undergoing DAA therapy at 22 Polish hepatology centers from July 1, 2015, to December 31, 2022. Patients with cirrhosis were categorized based on the presence of EV diagnosed by gastroscopy. Treatment effectiveness was measured by sustained virologic response (SVR), with safety outcomes monitored for 12 weeks post-treatment. RESULTS A population of 3393 HCV-infected patients with cirrhosis was divided into groups with (A, n = 976) and without (B, n = 2417) EV. Group A showed a significantly higher prevalence of comorbidities and concomitant medications. Genotype (GT)1b infections predominated in both groups, and GT3 infections were more common in the EV group. Group A exhibited more severe liver disease, and higher rates of decompensation, HCC, and HBV co-infection. SVR was significantly higher in group B (91.5% vs. 96.3%, p < 0.0001). Male gender, GT3, EV presence, and Child-Pugh grade B were identified as independent negative SVR predictors. Group A had a worse safety profile, with notably higher adverse event incidence and mortality. CONCLUSIONS DAA therapies are highly effective and well tolerated in patients with cirrhosis, but EV presence predicts poorer virologic responses.
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Affiliation(s)
- Michał Brzdęk
- Collegium Medicum, Jan Kochanowski University, aleja IX Wieków Kielc 19A, Kielce, 25-317, Poland.
| | - Dorota Zarębska-Michaluk
- Department of Infectious Diseases and Allergology, Jan Kochanowski University, Kielce, 25- 317, Poland
| | - Michał Kukla
- Department of Internal Medicine and Geriatrics, Faculty of Medicine, Jagiellonian University Medical College, Kraków, 31-688, Poland
- Department of Endoscopy, University Hospital, Kraków, 30-688, Poland
| | - Justyna Janocha-Litwin
- Department of Infectious Diseases and Hepatology, Wrocław Medical University, Wrocław, 50- 367, Poland
| | - Dorota Dybowska
- Department of Infectious Diseases and Hepatology, Faculty of Medicine, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University, Toruń, 87-100, Poland
- Voivodeship Infectious Observation Hospital in Bydgoszcz, Bydgoszcz, 85-030, Poland
| | - Ewa Janczewska
- Department of Basic Medical Sciences, School of Public Health in Bytom, Medical University of Silesia, Katowice, 40-055, Poland
| | - Beata Lorenc
- Pomeranian Center of Infectious Diseases, Medical University, Gdańsk, 80-214, Poland
| | - Hanna Berak
- Outpatient Clinic, Hospital for Infectious Diseases in Warsaw, Warsaw, 01-201, Poland
| | - Włodzimierz Mazur
- Clinical Department of Infectious Diseases in Chorzów, Medical University of Silesia, Katowice, 40-055, Poland
| | | | - Jakub Klapaczyński
- Department of Internal Medicine and Hepatology, The National Institute of Medicine of the Ministry of Interior and Administration, Warszawa, 02-507, Poland
| | - Anna Piekarska
- Department of Infectious Diseases and Hepatology, Medical University of Łódź, Łódź, 90- 419, Poland
| | - Marek Sitko
- Department of Infectious and Tropical Diseases, Jagiellonian University, Kraków, 31- 088, Poland
| | - Łukasz Laurans
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, Szczecin, 70-204, Poland
- Multidisciplinary Regional Hospital in Gorzów Wielkopolski, Gorzów Wielkopolski, 66-400, Poland
| | - Anna Parfieniuk-Kowerda
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, 15-089, Poland
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, 15-089, Poland
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Seo B, Lee JH, Jang EJ, Park SW, Park JS, Park SJ, Kim SJ, Yeon JW, Lee AY, Seo JY. Small Bowel Variceal Bleeding in Patients with Liver Cirrhosis Treated with Transarterial Embolization: Case Series. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:304-309. [PMID: 38130001 DOI: 10.4166/kjg.2023.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/26/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023]
Abstract
Small bowel variceal bleeding is a rare cause of gastrointestinal hemorrhage, with clinical manifestations ranging from asymptomatic incidental findings to life-threatening conditions. The diagnosis and management of small bowel bleeding are challenging because of the localization of the lesion and the difficulty of the procedure. Trans-arterial embolization (TAE) is a secure and straightforward method for treating ectopic varices. On the other hand, there have been limited local studies on the outcomes of TAE for patients with small bowel variceal hemorrhage. This paper reports patients diagnosed with small bowel variceal bleeding and treated with TAE.
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Affiliation(s)
- Boram Seo
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Ju Ho Lee
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Eun Jeong Jang
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Sang Woon Park
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Ju Sang Park
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Sang Jong Park
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Sang-Jung Kim
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Jae Woo Yeon
- Department of Radiology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Ah Young Lee
- Department of Gastroenterology, CHA Gangnam Medical Center, CHA University of School of Medicine, Seoul, Korea
| | - Jun-Young Seo
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
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Cicero G, Aricò FM, Viola A, Ascenti V, Mazziotti S. Portal hypertensive enteropathy: multimodality assessment through computed tomography and magnetic resonance enterography. Radiol Case Rep 2022; 17:4804-4808. [PMID: 36212766 PMCID: PMC9535273 DOI: 10.1016/j.radcr.2022.09.046] [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: 08/26/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 11/29/2022] Open
Abstract
Portal hypertension consists in an increased portal vein pressure due to prehepatic, hepatic, or posthepatic conditions, with cirrhosis representing the most common cause. The gastrointestinal tract can be secondarily affected not only with varices formation, whose rupture is one of the most dangerous complications, but also with small and large bowel involvement which can predispose to chronic intestinal bleeding. These conditions respectively take the name of portal hypertensive enteropathy and portal colonopathy and their assessment are of almost exclusive pertinence of endoscopic techniques. Up to now, only few reports have described this condition from the radiological point of view. Nevertheless, imaging modalities are not burdened by the invasiveness of endoscopic procedures and are also capable in providing useful information about the intestinal tract as well as the surrounding tissues. This is the first case reporting a diffuse involvement of the small bowel and the right colon in a patient suffering of portal hypertension due to cirrhosis evaluated through the performance of computed tomography and magnetic resonance enterography.
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Affiliation(s)
- Giuseppe Cicero
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico “G. Martino” Via Consolare Valeria 1, 98100, Messina, ITALY
| | - Francesco Marcello Aricò
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico “G. Martino” Via Consolare Valeria 1, 98100, Messina, ITALY,Corresponding author.
| | - Anna Viola
- Inflammatory bowel disease Unit, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Velio Ascenti
- Diagnostic and Interventional Radiology Unit, University of Milan, Milano, Italy
| | - Silvio Mazziotti
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico “G. Martino” Via Consolare Valeria 1, 98100, Messina, ITALY
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Nasr S, Dahmani W, Jaziri H, Becheikh Y, Ameur W, Elleuch N, Jmaa A. Massive hematochezia due to jejunal varices successfully treated with coil embolization. Clin Case Rep 2022; 10:e6339. [PMID: 36188043 PMCID: PMC9487444 DOI: 10.1002/ccr3.6339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/27/2022] [Accepted: 08/30/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Sahar Nasr
- Department of Gastroenterology University of Sousse Sousse Tunisia
| | - Wafa Dahmani
- Department of Gastroenterology University of Sousse Sousse Tunisia
| | - Hanene Jaziri
- Department of Gastroenterology University of Sousse Sousse Tunisia
| | | | - Wafa Ben Ameur
- Department of Gastroenterology University of Sousse Sousse Tunisia
| | - Nour Elleuch
- Department of Gastroenterology University of Sousse Sousse Tunisia
| | - Ali Jmaa
- Department of Gastroenterology University of Sousse Sousse Tunisia
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Coelho M, Dantas E, Freire R, Oliveira A. Severe portal hypertensive enteropathy: Is that really it? A case report of clinical and endoscopic exuberance. Dig Liver Dis 2022; 54:834-835. [PMID: 33500238 DOI: 10.1016/j.dld.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Mariana Coelho
- Gastroenterology Department, Hospital de São Bernardo, Centro Hospitalar de Setúbal, Portugal.
| | - Eduardo Dantas
- Gastroenterology Department, Hospital de São Bernardo, Centro Hospitalar de Setúbal, Portugal
| | - Ricardo Freire
- Gastroenterology Department, Hospital de São Bernardo, Centro Hospitalar de Setúbal, Portugal
| | - Ana Oliveira
- Gastroenterology Department, Hospital de São Bernardo, Centro Hospitalar de Setúbal, Portugal
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7
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Saad ZM, El-Dahrouty AH, El-Sayed AM, Keryakos HKH, Fanous NN, Mostafa I. Small-bowel mucosal changes in Egyptian cirrhotic patients with portal hypertension using capsule endoscopy versus single-balloon enteroscopy. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-00025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Small-bowel mucosal abnormalities that may occur secondary to portal hypertension in patients with liver cirrhosis have an impact on health and quality of life. In spite of the importance of these changes, little is known about the frequency and features of small-bowel changes in cirrhotic patients with portal hypertension. Eighty cirrhotic patients with or without esophageal or gastric varices were recruited in this study as well as 60 age- and sex-matched controls. All study participants underwent capsule endoscopy. In addition, half of the patients and controls were randomized to receive single-balloon enteroscopy.
Results
The prevalence of small-bowel mucosal changes was statistically significantly higher in cirrhotic patients than in controls; 57% versus 6.7%, respectively (p < 0.05). Cirrhotic patients with portal hypertensive gastropathy showed a significant increase in the small-bowel changes (p < 0.001). Small-bowel changes were significantly higher in patients with higher MELD and Child-Pugh scores (p < 0.001). Moreover, capsule endoscopy was more effective in the detection of small-bowel changes than single-balloon enteroscopy.
Conclusions
Mucosal changes associated with portal hypertensive enteropathy are more prevalent in cirrhotic patients, regardless of the presence or absence of gastric varices. Small-bowel mucosal changes in patients with portal hypertensive enteropathy were more common in patients who suffered from portal hypertensive gastropathy and were positively correlated with advanced chronic liver disease.
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8
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Karpova RV, Russkova KS, Lavrentieva YN. Increases in Autoantibody Level Associated with Degenerative Changes in the Intestinal Mucosa in Liver Cirrhosis. Clin Exp Gastroenterol 2020; 13:315-320. [PMID: 32904688 PMCID: PMC7457723 DOI: 10.2147/ceg.s263176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/12/2020] [Indexed: 12/25/2022] Open
Abstract
Background Portal hypertensive colonopathy is a consequence of portal hypertension that develops in hepatic cirrhosis. Pathological processes occurring in intestinal epithelium cells can be revealed by changes in the autoantibody titers to intestinal antigens. It is important both in diagnosis and in the evaluation of the treatment effectiveness. Purpose To investigate the effect of portal hypertension in patients with liver cirrhosis on degenerative processes in the walls of the small and large intestines after stimulation of liver regeneration with cryoprecipitate. Methods Thirty-six patients with liver cirrhosis underwent a procedure for percutaneous introduction of cryoprecipitate into the liver tissue. Before and 1 year after it, all the patients were measured for portal blood flow parameters, performed colonoscopy with biopsy, and determined autoantibodies to intestinal antigens (ItM, SCM) in the blood. Comparative analyses of changes in the large intestine mucosa before and after reducing portal hypertension by stimulating liver regeneration with cryoprecipitate were conducted. Results Here, we show that the degenerative process in the mucosa of the intestines increases, despite the positive dynamics of portal blood flow parameters after the liver regeneration. Autoantibodies values for the intestine antigens were higher than normal in 22 of the 36 patients after 1 year of introduction of cryoprecipitate into the liver. Morphological analysis of the intestinal wall showed the presence of edema/mucosal atrophy and neutrophilic/lymphocytic-histiocytic infiltration in 28 of the 36 patients. Conclusion Changes in autoantibodies to intestinal antigens are an informative method for diagnosing colonopathy and enteropathy at early stages, providing the possibility to administer proper timely treatment. Patients with hepatic cirrhosis are recommended to have their intestinal microflora tested and be administered drugs that improve their composition.
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Affiliation(s)
- Radmila V Karpova
- Department of Faculty Surgery No.1, University Clinical Hospital No.1, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ksenia S Russkova
- Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Yuliya N Lavrentieva
- Department of Faculty Surgery No.1, University Clinical Hospital No.1, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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9
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Hamet B, Durot C, Djelouah M, Adlani I, Marchal A, Arrivé L, Hoeffel C. Involvement of small bowel in systemic disease: CT and MR imaging finding. Clin Imaging 2020; 67:74-85. [PMID: 32526662 DOI: 10.1016/j.clinimag.2020.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 12/19/2022]
Abstract
Computerized tomography (CT) and magnetic resonance imaging (MRI), particularly MR Enterography, are the standard cross-sectional imaging modalities used to study small bowel involvement in a context of multiorgan disease. Clinical symptoms are generally nonspecific in such cases. Moreover, imaging findings of the different conditions often overlap. However, analysis of the location, distribution of the lesions on the small bowel wall, as well as of the rest of the bowel and of distant organs, may help narrow the spectrum of diagnoses of multiorgan conditions involving both the small bowel and other organs. The purpose of this presentation is to review and illustrate the CT and MRI features of small bowel involvement in systemic disease. Based on the underlying mechanism, we will categorize them as follows: congenital/hereditary, immunologic, infiltrative, vascular, infectious and miscellaneous.
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Affiliation(s)
- Blandine Hamet
- Department of Radiology, Centre Hospitalo-Universitaire de Reims, Reims 51092, France.
| | - Carole Durot
- Department of Radiology, Centre Hospitalo-Universitaire de Reims, Reims 51092, France.
| | - Manel Djelouah
- Department of Radiology, Centre Hospitalo-Universitaire de Reims, Reims 51092, France.
| | - Ibrahim Adlani
- Department of Radiology, Centre Hospitalo-Universitaire de Reims, Reims 51092, France.
| | - Aude Marchal
- Department of Pathology, Centre Hospitalo-Universitaire de Reims, Reims 51092, France.
| | - Lionel Arrivé
- Department of Radiology, Saint Antoine Hospital, Assistance Publique-Hopitaux de Paris, Sorbonne University, France.
| | - Christine Hoeffel
- Department of Radiology, Centre Hospitalo-Universitaire de Reims, Reims 51092, France; Université de Reims Champagne Ardenne, CReSTIC EA 3804, 51097 Reims, France.
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Gastrointestinal Bleeding Secondary to Portal Hypertensive Duodenopathy in a Patient with Decompensated Liver Cirrhosis. Case Rep Gastrointest Med 2018; 2018:9430701. [PMID: 30498606 PMCID: PMC6220751 DOI: 10.1155/2018/9430701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/28/2018] [Accepted: 08/12/2018] [Indexed: 12/17/2022] Open
Abstract
With alcoholic cirrhosis and nonalcoholic fatty liver disease continuously on the rise in the United States, there is also a corresponding rise in portal hypertension. Portal hypertensive duodenopathy (PHD) is a complication of portal hypertension not commonly seen in cirrhotic patients. We present a case of a 46-year-old man who presented with decompensated liver cirrhosis secondary to gastrointestinal bleed. The patient underwent esophagogastroduodenoscopy (EGD) with findings indicative of PHD. Patient subsequently underwent transjugular intrahepatic portosystemic shunt (TIPS) with resolution of gastrointestinal bleed. We highlight TIPS as a management strategy in patients with PHD for whom less invasive measures are not effective.
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11
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Portal hypertension: The desperate search for the placenta. Curr Res Transl Med 2018; 67:56-61. [PMID: 30503816 DOI: 10.1016/j.retram.2018.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 09/17/2018] [Accepted: 09/30/2018] [Indexed: 12/10/2022]
Abstract
We propose that the circulatory impairments produced, in both portal hypertension and liver cirrhosis, to a certain degree resemble those characterizing prenatal life in the fetus. In fact, the left-right circulatory syndrome is common in cirrhotic patients and in the fetus. Thus, in patients with portal hypertension and chronic liver failure, the re-expression of a blood circulation comparable to fetal circulation is associated with the development of similar amniotic functions, i.e., ascites production and placenta functions, and portal vascular enteropathy. Therefore, these re-expressed embryonic functions are extra-embryonic and responsible for prenatal trophism and development.
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12
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Nam SJ, Kim JH, Park SC. The Usefulness of New-Generation Capsule Endoscopy in Patients with Portal Hypertensive Enteropathy. Clin Endosc 2018; 51:505-507. [PMID: 30449077 PMCID: PMC6283760 DOI: 10.5946/ce.2018.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/31/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Seung-Joo Nam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Ji Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sung Chul Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
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Video Capsule Endoscopy in the Assessment of Portal Hypertensive Enteropathy. Int J Hepatol 2018; 2018:5109689. [PMID: 30515332 PMCID: PMC6236554 DOI: 10.1155/2018/5109689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/02/2018] [Accepted: 09/17/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The features of the portal hypertension enteropathy (PHE) vary from mild mucosal changes to varices with or without bleeding. The prevalence and the development are not fully understood. AIM Our aim is to examine the prevalence and the different manifestations of PHE using video capsule endoscopy (VCE). METHODS It is a single center retrospective study of patients with cirrhosis, who had VCE. Based on the published literature, we divided the PHE lesions into vascular lesions and mucosal lesions. RESULTS Of the 100 patients with cirrhosis that had a VCE study, the mean age was 62.82 years. Male gender was predominant (64%), while Caucasians represented 82% of the cohort. The most common etiology of cirrhosis was chronic alcohol abuse followed by chronic hepatitis C virus and nonalcoholic steatohepatitis. VCE detected small bowel lesions in 71% of the patients while the features of PHE were found in 65% from the total cohort. AVMs and inflammatory changes were the most common findings, followed by bleeding. More than 50% of the lesions were vascular in nature. The risk of finding PHE in decompensated cirrhosis is twice that in compensated cirrhosis. Forty-five patients had negative EGD exam for any active bleeding, esophageal varices, portal hypertensive gastropathy, or gastric varices. Of these, 69% had features of PHE in their VCE. CONCLUSIONS VCE detected small bowel lesions in 71% of our cohort. There is a high prevalence of PHE in decompensated cirrhosis. Vascular lesions are the most common finding in the small bowel of this population.
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Kunihara S, Oka S, Tanaka S, Otani I, Igawa A, Nagaoki Y, Aikata H, Chayama K. Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study. Digestion 2018; 98:33-40. [PMID: 29672296 DOI: 10.1159/000486666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/08/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS The clinical course and exacerbation of portal hypertensive enteropathy (PHE) are yet to be fully clarified. This study aimed to identify factors related to PHE exacerbation in patients with liver cirrhosis (LC). METHODS Fifty patients with LC (33 male; mean age, 67 years), who underwent capsule endoscopy (CE) at the Hiroshima University Hospital between February 2009 and September 2015, were followed up for >6 months. Exacerbation is defined as the appearance of new lesions or worsening of existing lesions. The association between PHE exacerbation and the clinical factors was evaluated. RESULTS PHE exacerbation was identified in 24 out of 50 (48%) of cases: erythema (14 cases); angioectasia (11 cases); erosions (9 cases); villous edema (8 cases); and esophageal varices (EVs; 6 cases). The following factors were significantly associated with PHE exacerbation: portosystemic shunts, EVs and portal hypertensive gastropathy (PHG) exacerbation. After therapy, CE findings among the 24 cases were as follows: villous edema (19 cases); erythema (17 cases); angioectasia (16 cases); erosions (12 cases); and EVs (9 cases), and no observable abnormalities in 2 cases. On multivariate analysis, exacerbation of EVs and PHG were independent predictors of PHE exacerbation. CONCLUSION EVs and PHG exacerbation may predict PHE exacerbation in patients with LC.
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Affiliation(s)
- Sayoko Kunihara
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Ichiro Otani
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Atsushi Igawa
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuko Nagaoki
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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15
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Goenka MK, Shah BB, Rai VK, Jajodia S, Goenka U. Mucosal Changes in the Small Intestines in Portal Hypertension: First Study Using the Pillcam SB3 Capsule Endoscopy System. Clin Endosc 2018; 51:563-569. [PMID: 30300988 PMCID: PMC6283757 DOI: 10.5946/ce.2018.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS To evaluate patients with portal hypertension (PH) of varied etiologies for portal hypertensive enteropathy (PHE) using the PillCam SB3 capsule endoscopy (CE) system. METHODS Consecutive patients with PH presenting with unexplained anemia and/or occult gastrointestinal bleeding were evaluated using the PillCam SB3 CE system. Abnormal findings were categorized as vascular or non-vascular. The patients with ongoing bleeding caused by PHE were treated. The correlation of the CE scores of PHE with the clinical, laboratory, and endoscopic features was determined. RESULTS Of the 43 patients included in the study, 41 (95.3%) showed PHE findings. These included varices (67.4%), red spots (60.5%), erythema (44.2%), villous edema (46.5%), telangiectasia (16.3%), and polyps (16.3%). The CE scores varied from 0 to 8 (mean±standard deviation, 4.09±1.8). Five patients (11.6%) showed evidence of ongoing or recent bleeding due to PHE. Three of these five patients underwent endotherapy, and one patient underwent radiological coil placement. CONCLUSION The PillCam SB3 CE system revealed a high prevalence of PHE in the patients with PH. Using this system, evidence of bleeding due to PHE was found in a small but definite proportion of the patients.
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Affiliation(s)
| | - Bhavik Bharat Shah
- Institute of Gastro-Sciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Vijay Kumar Rai
- Institute of Gastro-Sciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Surabhi Jajodia
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
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16
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Iwata Y, Nishikawa H, Enomoto H, Yoh K, Ishii A, Yuri Y, Ishii N, Miyamoto Y, Hasegawa K, Nakano C, Takata R, Nishimura T, Aizawa N, Sakai Y, Ikeda N, Takashima T, Iijima H, Nishiguchi S. Efficacy of capsule endoscopy in patients with cirrhosis for the diagnosis of upper gastrointestinal lesions and small bowel abnormalities: a study protocol for prospective interventional study. BMJ Open Gastroenterol 2017; 4:e000168. [PMID: 29177064 PMCID: PMC5689481 DOI: 10.1136/bmjgast-2017-000168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND AIMS The role of capsule endoscopy (CE) in patients with liver cirrhosis (LC) has yet to be established; however, it is likely that it will remain a valuable diagnostic modality in several groups of patients with LC. The primary aims of the current prospective interventional study are to examine the prevalence for small bowel lesions and transit time of CE in the gastrointestinal tract in patients with LC with oesophageal varices (EVs) requiring endoscopic therapies. METHODS AND ANALYSIS The current study will be a single-centre prospective interventional study. Our study participants are LC subjects with portal hypertension who were determined to be necessary for prophylactic endoscopic therapies for EVs. From the view point of safety, patients with gastrointestinal obstruction or fistula or those being suspected of having gastrointestinal obstruction or fistula will be excluded from our study. Patients with implanted medical devices will be also excluded. CE will be performed prior to prophylactic endoscopic therapies in the same hospitalisation and relevant images will be analysed after 8 hours by expert endoscopists. This study will continue to recruit until 50 participants. ETHICS AND DISSEMINATION This study has received approval from the Institutional Review Board at Hyogo College of Medicine (approval no. 2680). The study protocol, informed assent form and other submitted files were reviewed and acknowledged. Final data will be publicly scattered regardless of the study results. A report releasing study results will be submitted for publication in a suitable journal after being finished in data collection. TRIAL REGISTRATION NUMBER UMIN000028433 (https://upload.umin.ac.jp/).
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Affiliation(s)
- Yoshinori Iwata
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Nishikawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Center for Clinical Research and Education, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirayuki Enomoto
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazunori Yoh
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Akio Ishii
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yukihisa Yuri
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Noriko Ishii
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuho Miyamoto
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kunihiro Hasegawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Chikage Nakano
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ryo Takata
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takashi Nishimura
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Nobuhiro Aizawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshiyuki Sakai
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naoto Ikeda
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tomoyuki Takashima
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shuhei Nishiguchi
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Center for Clinical Research and Education, Hyogo College of Medicine, Nishinomiya, Japan
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Egea Valenzuela J, Fernández Llamas T, García Marín AV, Alberca de Las Parras F, Carballo Álvarez F. Diagnostic and therapeutic features of small bowel involvement in portal hypertension. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:856-862. [PMID: 28747052 DOI: 10.17235/reed.2017.4596/2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Enteropathy is a lesser known complication of portal hypertension and consists of different changes in the mucosal layer of the small bowel which lead to the appearance of vascular and inflammatory lesions. It can be an important co-factor in the development of anemia in the cirrhotic population, and nowadays an easy and non-invasive diagnosis can be made thanks to capsule endoscopy. However, it is rarely considered in the management of patients with portal hypertension. Some aspects such as pathogenesis or incidence remain unclear and no specific recommendations are included in the guidelines regarding diagnosis or treatment. A review of the available literature was performed with regards to the most relevant aspects of this entity.
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Affiliation(s)
- Juan Egea Valenzuela
- Unidad de Gestión Clínica de Digestivo, Hospital Clínico Universitario Virgen de la Arrixa, España
| | | | | | - Fernando Alberca de Las Parras
- Servicio de Medicina de Aparato Digestivo., Hospital Clínico Universitario Virgen de la Arrixaca. IMIB-Arrixaca., España
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18
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Aller MA, Arias N, Peral I, García-Higarza S, Arias JL, Arias J. Embrionary way to create a fatty liver in portal hypertension. World J Gastrointest Pathophysiol 2017; 8:39-50. [PMID: 28573066 PMCID: PMC5437501 DOI: 10.4291/wjgp.v8.i2.39] [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: 12/05/2016] [Revised: 01/18/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension in the rat by triple partial portal vein ligation produces an array of splanchnic and systemic disorders, including hepatic steatosis. In the current review these alterations are considered components of a systemic inflammatory response that would develop through three overlapping phenotypes: The neurogenic, the immune and the endocrine. These three inflammatory phenotypes could resemble the functions expressed during embryonic development of mammals. In turn, the inflammatory phenotypes would be represented in the embryo by two functional axes, that is, a coelomic-amniotic axis and a trophoblastic yolk-sac or vitelline axis. In this sense, the inflammatory response developed after triple partial portal vein ligation in the rat would integrate both functional embryonic axes on the liver interstitial space of Disse. If so, this fact would favor the successive development of steatosis, steatohepatitis and fibrosis. Firstly, these recapitulated embryonic functions would produce the evolution of liver steatosis. In this way, this fat liver could represent a yolk-sac-like in portal hypertensive rats. After that, the systemic recapitulation of these embryonic functions in experimental prehepatic portal hypertension would consequently induce a gastrulation-like response in which a hepatic wound healing reaction or fibrosis occur. In conclusion, studying the mechanisms involved in embryonic development could provide key results for a better understanding of the nonalcoholic fatty liver disease etiopathogeny.
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Seiji K, Akinobu T, Iwamuro M, Tetsuya Y, Yoshiyasu K, Kou M, Toshihiro I, Yoshiro K, Yuzo U, Takahito Y, Hiroyuki O. Safety and Efficacy of Small Bowel Examination by Capsule Endoscopy for Patients before Liver Transplantation. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8193821. [PMID: 28168199 PMCID: PMC5266832 DOI: 10.1155/2017/8193821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/14/2016] [Indexed: 12/27/2022]
Abstract
Background and Aims. Gastrointestinal surveillance is a requirement prior to liver transplantation (LT), but small intestine examination is not generally undertaken. The aim of the present study was to evaluate the safety and efficacy of capsule endoscopy (CE) for patients with end-stage liver disease. Methods. 31 patients who needed LT were enrolled, and 139 patients who underwent CE over the same period of time acted as controls. Results. Frequency of successful achievement of evaluation of the full length of the small bowel, the mean gastric transit time, and the mean small bowel transit time were not significantly different between the two groups. Abnormalities in the small bowel were found in 26 patients. Comparative analysis revealed that history of EV rupture, history of EV treatment, red color sign of EV, and presence of PHG or HCC were significantly associated with patients with >2 two such findings (high score group). Conclusions. Small bowel examination by CE in patients before liver transplantation could be performed safely and is justified by the high rate of abnormal lesions detected particularly in patients with history of EV therapy or bleeding, red color sign, and presence of PHG or HCC. This study was registered in the UMIN Clinical Trial Registry (UMIN 000008672).
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20
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Imai J, Suzuki T, Yoshikawa M, Dekiden M, Nakae H, Nakahara F, Tsuda S, Mizukami H, Koike J, Igarashi M, Yabe H, Mine T. Fatal Hemorrhagic Gastrointestinal Angioectasia after Bone Marrow Transplantation for Dyskeratosis Congenita. Intern Med 2016; 55:3441-3444. [PMID: 27904106 PMCID: PMC5216140 DOI: 10.2169/internalmedicine.55.7462] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Dyskeratosis congenita (DC) is a rare inherited disease in which the telomere complex cannot be maintained. Shortened telomeres can cause a number of clinical conditions. We herein report a case of unrelated bone marrow transplantation due to aplastic anemia associated with DC. The patient died of uncontrollable refractory intestinal bleeding. Three cases of DC with life-threatening hemorrhaging after transplantation have been reported; however, the bleeding origin could not be determined. Our case is the only patient in which a gastrointestinal bleeding point, jejunal multiple angioectasia, was determined.
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Affiliation(s)
- Jin Imai
- Department of Gastroenterology, Tokai University School of Medicine, Japan
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21
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Capsule Endoscopy for Portal Hypertensive Enteropathy. Gastroenterol Res Pract 2015; 2016:8501394. [PMID: 26819613 PMCID: PMC4706926 DOI: 10.1155/2016/8501394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 07/15/2015] [Indexed: 02/08/2023] Open
Abstract
Portal hypertensive enteropathy (PHE) is a mucosal abnormality of the small bowel that is observed in patients with portal hypertension (PH) and can lead to gastrointestinal bleeding and anemia. The pathogenesis is still not completely understood. The introduction of new endoscopic methods, including capsule endoscopy (CE) or balloon-assisted enteroscopy, has increased the detection of these abnormalities. CE can also serve as a road map for deciding subsequent interventions and evaluating the treatment effect. The prevalence of PHE is reportedly 40-70% in patients with PH. Endoscopic findings can be roughly divided into vascular and nonvascular lesions such as inflammatory-like lesions. Traditionally, PHE-associated factors include large esophageal varices, portal hypertensive gastropathy or colopathy, Child-Turcotte-Pugh class B or C, a history of variceal treatment, and acute gastrointestinal bleeding. More recently, on using scoring systems, a high computed tomography or transient elastography score was reportedly PHE-related factors. However, the prevalence of PHE and its related associated factors remain controversial. The management of PHE has not yet been standardized. It should be individualized according to each patient's situation, the availability of therapy, and each institutional expertise.
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