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Gandotra A, Taneja S, Premkumar M, Verma N, De A, Rathi S, Duseja A. Bloody Lips - Gluing Bleeding Lower Lip Spider Angioma in Decompensated Cirrhosis. J Clin Exp Hepatol 2024; 14:101308. [PMID: 38261889 PMCID: PMC10797178 DOI: 10.1016/j.jceh.2023.101308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/25/2023] [Indexed: 01/25/2024] Open
Abstract
Spider angiomas are dilated vascular channels in the skin. They have a central arteriole with surrounding vascular channels resembling legs of a spider, hence the name. They are frequently associated with liver cirrhosis, thyrotoxicosis, and pregnancy. We present the case of a 49-year-old gentleman who was referred to our liver clinic with complaints of jaundice and ascites of one-month duration. The patient was a chronic alcohol consumer, consuming country-made liquor, 80-100 grams/day for past 8-10 years. He was diagnosed with Acute on chronic liver failure with a model for end-stage liver disease score of 38. During his hospital stay, he developed active spurting from a spider angioma on his lower lip (video 1), which was initially tackled with hand compressions, which stopped bleeding for a few minutes, restarting again after the compressions were lifted. It was then decided to inject 0.1 mL cyanoacrylate glue injection using a 21-gauge needle, immediately stopping active spurt (video 2), (Figure 1). A small ulcer formed at the injection site, which healed in few days, and the patient was discharged to home. Spider angiomas are characteristic cutaneous manifestation of liver cirrhosis with a specificity of 95%.1 The prevalence of spider angiomas in cirrhosis is reported to be around 30-40%. Li Hongyu et al. in their study on 198 individuals reported the prevalence to be 47%.2 They can be graded from grade 1+ (readily recognizable containing a body, legs, and surrounding erythema) to grade 4+ (visible pulsations with a hand lens and raised central punctum with many obvious "spider legs" radiating from it).3 Underlying pathogenesis in cirrhosis is multifactorial including decrease levels of testosterone and high levels of estradiol,4 hyperdynamic circulation, high levels of substance-P, and vascular endothelial growth factor leading to angiogenesis and vasodilation.5,6 Spider angiomas can be single or multiple and are usually seen in the territory of superior vena cava-the face (nose, lips, forehead), upper chest, and arms.2 These lesions have been associated with bleeding esophageal varices and hepatopulmonary syndrome. Bleeding from spider angiomas is unusual. Rarely, fine-needle electrocautery, potassium-titanyl-phosphate (KTP) laser, or electro desiccation has been used to clear spider angiomas for cosmetic concerns. Treatment includes hand or ice compressions and treating the underlying cause. Use of cyanoacrylate glue for bleeding spider angioma has not been reported in the literature. We think this can be a handy bedside tool to combat an active spurt of bleeding when conventional methods have failed, as in our case; however, further studies are warranted.
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Affiliation(s)
- Akash Gandotra
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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2
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Ke Q, He J, Huang X, Li L, Liu J, Guo W. Spontaneous portosystemic shunts outside the esophago-gastric region: Prevalence, clinical characteristics, and impact on mortality in cirrhotic patients: A systematic review and meta-analysis. Eur J Intern Med 2023; 112:77-85. [PMID: 36990875 DOI: 10.1016/j.ejim.2023.03.024] [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: 12/21/2022] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Spontaneous portosystemic shunt (SPSS) other than esophago-gastric varices is one of the consequences of cirrhosis-induced portal hypertension (PHT), but its role is not fully understood. Therefore, we conducted a systematic review and meta-analysis to determine the prevalence and clinical characteristics of SPSS (excluding esophago-gastric varices) and its impact on mortality in patients with cirrhosis. METHODS Eligible studies were identified from MedLine, PubMed, Embase, Web of Science, and Cochrane Library between Jan 1, 1980 and Sep 30, 2022. Outcome indicators were SPSS prevalence, liver function, decompensated events, and overall survival (OS). RESULTS Totally, 2015 studies were reviewed, of which 19 studies recruiting 6884 patients were included. On pooled analysis, the prevalence of SPSS was 34.2% (26.6%∼42.1%). SPSS patients had significantly higher Child-Pugh scores and grades and Model for End-stage Liver Disease scores (all P<0.05). Moreover, SPSS patients experienced a higher incidence of decompensated events, including hepatic encephalopathy, portal vein thrombosis, and hepatorenal syndrome (all P<0.05). Additionally, SPSS patients had significantly shorter OS than the non-SPSS group (P<0.05). CONCLUSIONS In patients with cirrhosis, SPSS outside the esophago-gastric region is common, characterized by severe impairment of liver function, high rates of decompensated events, including HE, PVT, and hepatorenal syndrome, as well as a high mortality rate.
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Affiliation(s)
- Qiao Ke
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, No. 420, Fuma Road, Fuzhou, Fujian 350014, China; Department of Hepatopancreatobiliary Surgery, Clinical Oncology School of Fujian Medical University, No. 312, Xihong Road, Fuzhou, Fujian 350025, China
| | - Jian He
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, No. 420, Fuma Road, Fuzhou, Fujian 350014, China
| | - Xinhui Huang
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, No. 420, Fuma Road, Fuzhou, Fujian 350014, China
| | - Ling Li
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, No. 420, Fuma Road, Fuzhou, Fujian 350014, China
| | - Jingfeng Liu
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, No. 420, Fuma Road, Fuzhou, Fujian 350014, China; Department of Hepatopancreatobiliary Surgery, Clinical Oncology School of Fujian Medical University, No. 312, Xihong Road, Fuzhou, Fujian 350025, China.
| | - Wuhua Guo
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, No. 420, Fuma Road, Fuzhou, Fujian 350014, China.
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Muacevic A, Adler JR. Spider Angioma Number and Location as Potential Prognostic Indicators in Chronic Liver Disease: A Case Report. Cureus 2023; 15:e34193. [PMID: 36843700 PMCID: PMC9951817 DOI: 10.7759/cureus.34193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 01/25/2023] [Indexed: 01/26/2023] Open
Abstract
Spider angiomas (SAs) are a well-known physical exam feature found in patients with chronic liver disease. While SAs are thought to correspond with a higher risk of mortality in chronic liver disease (CLD) patients, only few studies have been done to assess the number and location of SAs as prognostic indicators. We present a case of a 64-year-old patient with decompensated CLD who was found to have three SAs on physical exam. The patient presented to the inpatient service at a community hospital in Miami, Florida. He had experienced previous esophageal varices banding, had a Model for End-Stage Liver Disease (MELD) score of 31, and needed large-volume paracentesis due to significant ascites. It was determined that he had a very poor prognosis and was in need of a liver transplant. We suggest that more research is necessary to determine if there is a prognostic importance to the number and location of SAs in patients with CLD, as earlier interventions could potentially lead to improvements in outcomes through this physical exam finding.
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Affiliation(s)
- Alexander Muacevic
- Internal Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - John R Adler
- Internal Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
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Thabut D, Weil D, Bouzbib C, Rudler M, Cassinotto C, Castéra L, Serste T, Oberti F, Ganne-Carrié N, de Lédinghen V, Bourlière M, Bureau C. Non-invasive diagnosis and follow-up of portal hypertension. Clin Res Hepatol Gastroenterol 2022; 46:101767. [PMID: 34332128 DOI: 10.1016/j.clinre.2021.101767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
Compensated advanced chronic liver disease (cACLD) describes the spectrum of advanced fibrosis/cirrhosis in asymptomatic patients at risk of developing clinically significant portal hypertension (CSPH, defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg). Patients with cACLD are at high risk of liver-related morbidity and mortality. In patients at risk of chronic liver disease, cACLD is strongly suggested by a liver stiffness (LSM) value >15 kPa or clinical/biological/radiological signs of portal hypertension, and ruled out by LSM <10 kPa, or Fibrotest® ≤0.58, or Fibrometer® ≤0.786. Patients with chronic liver disease (excluding vascular diseases) with a LSM <10 kPa are at low risk of developing portal hypertension complications. The presence of CSPH can be strongly suspected when LSM is ≥20 kPa. In a patient without clinical, endoscopic or radiological features of portal hypertension, measurement of the HVPG is recommended before major liver or intra-abdominal surgery, before extra-hepatic transplantation and in patients with unexplained ascites. Endoscopic screening for oesophageal varices can be avoided in patients with LSM <20 kPa and a platelet count >150 G/L (favourable Baveno VI criteria) at the time of diagnosis. There is no non-invasive method alternative for oeso-gastroduodenal endoscopy in patients with unfavourable Baveno criteria (liver stiffness ≥20 kPa or platelet count ≤50 G/l). Platelet count and liver stiffness measurements must be performed once a year in patients with cACLD with favourable Baveno VI criteria at the time of diagnosis. A screening oeso-gastroduodenal endoscopy is recommended if Baveno VI criteria become unfavourable.
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Affiliation(s)
- Dominique Thabut
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France.
| | - Delphine Weil
- Service d'hépatologie, CHRU Besançon, Besançon, France
| | - Charlotte Bouzbib
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Marika Rudler
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Christophe Cassinotto
- Radiologie diagnostique et interventionnelle Saint Eloi, CHU Montpellier, Montpellier, France
| | - Laurent Castéra
- Service d'Hépatologie, Hôpital Beaujon, Université de Paris, APHP, Paris, France
| | - Thomas Serste
- Service d'hépato-gastroentérologie, CHU Saint-Pierre, Bruxelles, France
| | - Frédéric Oberti
- Service d'hépato-gastroentérologie et oncologie digestive, CHU Angers, Angers, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, Hôpital Avicenne, APHP, Université Sorbonne Paris Nord, Bobigny & INSERM UMR 1138, Centre de Recherche des Cordeliers, Université de Paris, France
| | - Victor de Lédinghen
- Service d'hépato-gastroentérologie et d'oncologie digestive, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac & INSERM U1053, Université de Bordeaux, Bordeaux, France
| | - Marc Bourlière
- Service d'hépato-gastroentérologie, Hôpital Saint Joseph & INSERM UMR 1252 IRD SESSTIM Aix Marseille Université, Marseille, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU Toulouse, Toulouse, France
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Connor SG, Parizel PM, Wycoco V, Prentice DA. The relationship between spider naevi & de novo arteriovenous malformations in chronic liver disease. BJR Case Rep 2022; 8:20220081. [PMID: 36211609 PMCID: PMC9518740 DOI: 10.1259/bjrcr.20220081] [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: 05/31/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 11/24/2022] Open
Abstract
We report a patient with decompensated alcoholic liver cirrhosis (Child-Turcotte-Pugh class C) who developed a de novo left frontal cerebral AVM and a subcutaneous left temporal scalp spider naevus. Arteriovenous malformations (AVMs) are vascular abnormalities previously thought to be congenital in nature, although new research has revealed the potential for de novo AVM formation through a two-hit hypothesis. We propose that the oestrogen-rich environment seen in chronic liver disease could act as the second hit to allow for an angiogenic state favouring de novo AVM development. We also postulate that spider naevi are formed through a similar mechanism and may represent early-stage AVMs.
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Affiliation(s)
- Sophia G Connor
- Department of Neurology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Paul M Parizel
- David Hartley Chair of Radiology, Royal Perth Hospital & University of Western Australia, Perth, Australia
- Western Australia National Imaging Facility (WA NIF) Node, Perth, Western Australia
| | - Victor Wycoco
- The Neurological Intervention & Imaging Service of Western Australia (NIISWA), Hospital Ave, Nedlands, Western Australia, Australia
| | - David A Prentice
- The Perron Institute for Translational and Neurological Science, QE II Medical Centre Ralph & Patricia Sarich Neuroscience Building, 8 Verdun St, Nedlands, Western Australia, Australia
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Computed Tomography Images of Spontaneous Portosystemic Shunt in Liver Cirrhosis. Can J Gastroenterol Hepatol 2022; 2022:3231144. [PMID: 35719322 PMCID: PMC9200601 DOI: 10.1155/2022/3231144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 04/23/2022] [Accepted: 05/11/2022] [Indexed: 12/05/2022] Open
Abstract
Spontaneous portosystemic shunt (SPSS) refers to collateral vessels that communicate between the portal vein system and systemic circulation. SPSS mainly includes esophageal varices, gastric varices, left gastric vein, recanalized paraumbilical vein, abdominal wall varices, and spontaneous splenorenal shunt. SPSS contributes to the development of hepatic encephalopathy caused by portal vein inflow bypassing and carries a higher risk of death in liver cirrhosis. Abdominal contrast-enhanced computed tomography is a major imaging approach to establish a diagnosis of SPSS and evaluate its location and feature. This review primarily describes the main contrast-enhanced CT features of SPSS in liver cirrhosis.
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Dong RJ, Yang HS, Li J, Wang RR, Wang L, Li YY. Giant Spider Angioma Following Cirrhosis in HIV-Infected Individuals. Am J Med Sci 2022; 364:347-352. [DOI: 10.1016/j.amjms.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/10/2021] [Accepted: 12/20/2021] [Indexed: 11/01/2022]
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8
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Jadaun SS, Saigal S, Hasnain A, Kumar M, Agrawal D, Singh S, das D, Agarwal S, Gupta S. An Unusual Case of Hepato-Pulmonary-Cutaneous Syndrome With Giant Spider Angioma and Intracranial Bleed. J Clin Exp Hepatol 2022; 12:1252-1254. [PMID: 35814518 PMCID: PMC9257850 DOI: 10.1016/j.jceh.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/24/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Shekhar Singh Jadaun
- Department of Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India,Address for correspondence: Sanjiv Saigal, Department of Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India.
| | - Ana Hasnain
- Department of Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Mukesh Kumar
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Dhiraj Agrawal
- Department of Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shweta Singh
- Anesthesia & Critical Care, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Dibyajyoti das
- Anesthesia & Critical Care, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shaleen Agarwal
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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Gao S, Gang J, Yu M, Xin G, Tan H. Computational analysis for identification of early diagnostic biomarkers and prognostic biomarkers of liver cancer based on GEO and TCGA databases and studies on pathways and biological functions affecting the survival time of liver cancer. BMC Cancer 2021; 21:791. [PMID: 34238253 PMCID: PMC8268589 DOI: 10.1186/s12885-021-08520-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 06/17/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Liver cancer is the sixth most commonly diagnosed cancer and the fourth most common cause of cancer death. The purpose of this work is to find new diagnostic biomarkers or prognostic biomarkers and explore the biological functions related to the prognosis of liver cancer. METHODS GSE25097 datasets were firstly obtained and compared with TCGA LICA datasets and an analysis of the overlapping differentially expressed genes (DEGs) was conducted. Cytoscape was used to screen out the Hub Genes among the DEGs. ROC curve analysis was used to screen the Hub Genes to determine the genes that could be used as diagnostic biomarkers. Kaplan-Meier analysis and Cox proportional hazards model screened genes associated with prognosis biomarkers, and further Gene Set Enrichment Analysis was performed on the prognosis genes to explore the mechanism affecting the survival and prognosis of liver cancer patients. RESULTS 790 DEGs and 2162 DEGs were obtained respectively from the GSE25097 and TCGA LIHC data sets, and 102 Common DEGs were identified by overlapping the two DEGs. Further screening identified 22 Hub Genes from 102 Common DEGs. ROC and survival curves were used to analyze these 22 Hub Genes and it was found that there were 16 genes with a value of AUC > 90%. Among these, the expression levels of ESR1,SPP1 and FOSB genes were closely related to the survival time of liver cancer patients. Three common pathways of ESR1, FOBS and SPP1 genes were identified along with seven common pathways of ESR1 and SPP1 genes and four common pathways of ESR1 and FOSB genes. CONCLUSIONS SPP1, AURKA, NUSAP1, TOP2A, UBE2C, AFP, GMNN, PTTG1, RRM2, SPARCL1, CXCL12, FOS, DCN, SOCS3, FOSB and PCK1 can be used as diagnostic biomarkers for liver cancer, among which FOBS and SPP1 genes can also be used as prognostic biomarkers. Activation of the cell cycle-related pathway, pancreas beta cells pathway, and the estrogen signaling pathway, while on the other hand inhibition of the hallmark heme metabolism pathway, hallmark coagulation pathway, and the fat metabolism pathway may promote prognosis in liver cancer patients.
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Affiliation(s)
- Shiyong Gao
- Drug Engineering and Technology Research Center, Harbin University of Commerce, Harbin, 150076, Heilongjiang, China.
- Heilongjiang Provincial Key Laboratory of Tumor Prevention and Antitumor Drugs, Harbin, 150076, Heilongjiang, China.
| | - Jian Gang
- Drug Engineering and Technology Research Center, Harbin University of Commerce, Harbin, 150076, Heilongjiang, China
- Heilongjiang Provincial Key Laboratory of Tumor Prevention and Antitumor Drugs, Harbin, 150076, Heilongjiang, China
| | - Miao Yu
- Drug Engineering and Technology Research Center, Harbin University of Commerce, Harbin, 150076, Heilongjiang, China
- Heilongjiang Provincial Key Laboratory of Tumor Prevention and Antitumor Drugs, Harbin, 150076, Heilongjiang, China
| | - Guosong Xin
- Drug Engineering and Technology Research Center, Harbin University of Commerce, Harbin, 150076, Heilongjiang, China
- Heilongjiang Provincial Key Laboratory of Tumor Prevention and Antitumor Drugs, Harbin, 150076, Heilongjiang, China
| | - Huixin Tan
- Department of pharmacy, The Fourth Affiliated Hospital of Harbin Medicine University, Harbin, 150001, Heilongjiang, China.
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Atefeh M. A microneedling device for the treatment of spider vein: A case report. J Cosmet Dermatol 2020; 20:2571-2573. [PMID: 33270981 DOI: 10.1111/jocd.13858] [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: 06/21/2020] [Revised: 09/27/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022]
Abstract
Spider vein is mostly seen in patients with liver disease, although the underlying problem is sometimes unknown. If spider vein appears on the face, it can affect the self-esteem and self-image of patients. Particularly, females are more vulnerable to these complications. Spider nevi are mostly left untreated since they are considered a cosmetic matter; in case of treatment, the procedure is costly with limited satisfaction. Therefore, this study reports the successful treatment of a spider vein case using a microneedling procedure.
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