Paediatric hepatocellular adenomas: Lessons from a systematic review of relevant literature

Hepatocellular adenomas (HCAs) are rare benign liver tumours. Predisposing factors and complication rates appear to differ among children and adults. In the present study, we aimed to systematically characterise paediatric HCAs and determine their course, complications, and management. Medical history, clinical symptoms, imaging, histopathology, and genetics of children with HCAs were collected through a systematic and comprehensive review of the published literature. A total of 316 children with HCAs were included in the present study. HCAs were diagnosed primarily in girls (59.3%) and at a mean age of 11.5 (range 0-17.7) years. The majority (83.6%) of HCAs occurred in children with predisposing diseases, of which glycogen storage disease was the most common, followed by portosystemic shunts and MODY3 (maturity-onset diabetes of the young type 3). Each of these diseases leads to a well-defined HCA molecular pattern. A significant number of HCAs either bled (24.7%) or transformed (14.8%) over time. HCA transformation was significantly more frequent in children with portosystemic shunts and in β-catenin-mutated HCAs, while haemorrhages were more frequent in children exposed to hormones and those with larger lesions. Management was primarily guided by any predisposing conditions and the number of lesions. Therefore, vascular shunts were closed when possible, while complicated lesions were resected. Liver transplantation has made it possible to treat adenomatosis, as well as any underlying diseases. Progress in understanding genetic and/or malformative contributions, which appear to be significant in paediatric HCAs, have provided insights into tumour pathogenesis and will further guide patient surveillance and management.

Anatomical classification of feline congenital extrahepatic portosystemic shunts based on CT angiography: A SVSTS and VIRIES multi-institutional study in 231 cats

The prevalence of anatomical-based subtypes of feline congenital extrahepatic portosystemic shunts (EHPSS) has not been completely elucidated. The goal of this study was to use CT angiography to create an anatomical-based nomenclature system for feline congenital EHPSS. Additionally, subjective portal perfusion scores were generated to determine if intrinsic portal vein development was associated with different shunt conformations or patient age at the time of CT. The SVSTS and VIRIES list services were used to recruit cases. Data collected included patient DOB, gender, breed, weight, CT date, and reported diagnosis. Shunts were classified based upon (1) the shunt portal vessel(s) of origin, (2) the shunt systemic vessel(s) of insertion, and (3) any substantial portal vessels contributing to the shunt. Additionally, hepatic portal perfusion was subjectively scored between 1 (poor/none) and 5 (good/normal) based on the caliber of the intrahepatic PVs. A total of 264 CT scans were submitted from 29 institutions. Due to exclusion criteria, 33 (13%) were removed, leaving 231 CT scans to be included. Twenty-five different EHPSS anatomies were identified with five classifications accounting for 78% of all shunts (LGP [53%], LGC-post [11%], LCG [7%], LGC-pre [4%], and PC [4%]). Shunt origin involved the left gastric vein in 75% of the described classifications. Significant differences were identified among the five most common shunt types with respect to age at the time of CT scan (P = .002), breed (P < .001), and subjective portal perfusion score (P < .001). This refined anatomical classification system for feline EHPSS may enable improved understanding, treatment comparisons, and outcome prediction for cats with these anomalies.

Portosystemic shunt surgery for severe portal hypertension due to portal thrombosis after bariatric surgery

Portal vein thrombosis is a rare complication after laparoscopic sleeve gastrectomy, a widely performed bariatric surgery procedure. Occasionally, the development of portal vein thrombosis can progress to more severe conditions, including portal hypertension and cavernomatosis, thereby presenting a complex and challenging clinical scenario. The management of such complications often requires careful consideration; however, surgical intervention in the form of a splenorenal shunt is an exceptional indication. We present the case of a 33-year-old female patient who had previously undergone laparoscopic sleeve gastrectomy in 2014 and subsequently developed portal thrombosis, followed by cavernomatosis and associated complications of portal hypertension. A proximal splenorenal shunt procedure and splenectomy were successfully performed to manage portal hypertension. The presentation of this clinical case aims to contribute to the available evidence and knowledge surrounding this rare and challenging pathology.

Significance of portal venous blood flow as a factor to determine liver function in patients with decompensated cirrhosis due to hepatitis C virus infection following achievement of sustained viral response by sofosbuvir plus velpatasvir

AIM

To determine the outcomes concerning portal venous blood flow and portosystemic shunts in patients with decompensated cirrhosis due to hepatitis C virus (HCV) infection who achieved sustained viral response (SVR) following antiviral therapy.

METHODS

Portal hypertension-related events and liver function were evaluated in 24 patients achieving SVR following sofosbuvir plus velpatasvir therapy.

RESULTS

Serum albumin level (median; g/dL) increased from 2.9 at baseline to 3.5 at 12 weeks after the end of treatment (EOT) (p = 0.005), while liver volumes (cm3 ) decreased from 1260 to 1150 (p = 0.0002). Portal hypertension-related events developed in 10 patients (41.7%), and the cumulative occurrence rates after the EOT were 29.2%, 33.3%, and 46.1% at 24, 48, and 96 weeks, respectively. Multivariate logistic regression analysis revealed that the maximal diameter of the shunts (p = 0.0235) was associated with the development of the events, with a cut-off value of 8.3 mm (p = 0.0105). Meanwhile, multiple linear regression analysis revealed that portal venous blood flow, liver volume, serum albumin, and bilirubin levels at baseline were associated with serum albumin levels at 12 weeks after EOT (p = 0.0019, p = 0.0154, p = 0.0010, and p = 0.0350, respectively).

CONCLUSION

In patients with decompensated cirrhosis due to HCV infection, the baseline portal venous blood flow and liver volume and function were predictive of liver function following SVR, while the maximal diameter of portosystemic shunts predicted the occurrence of portal hypertension-related events.

Flumazenil Treatment for Diazepam-Associated Neurological Signs in a Cat With a Portosystemic Shunt

A 7-month-old female spayed domestic short hair cat was presented for evaluation of inadequate clinical response to medical management for hepatic encephalopathy (HE). An abdominal computed tomography (CT) was to be performed but the cat developed 2 grand mal seizures shortly after presentation. Minimal handling and no drugs had been administered before the seizures. A single dose of diazepam (0.3 mg/kg, IV) was administered after each seizure. Another seizure occurred 24 hours after hospitalization and diazepam (0.5 mg/kg, IV) was once again administered. Seizures ceased but neurological signs worsened and included head pressing, loss of menace response, and a stuporous mentation. Due to unresponsiveness to treatment that included administration of intravenous fluids, levetiracetam, ampicillin/sulbactam, and retention enemas (water with lactulose), a dose of flumazenil (0.01 mg/kg) was administered IV and resulted in immediate but transient improvement of clinical signs. The stuporous state returned after 60 min post-treatment and an additional dose of IV flumazenil (0.01 mg/kg) was administered with the same outcome. Based on this positive clinical response, IV infusion of flumazenil was initiated at 0.01 mg/kg/h following a loading dose of 0.005 mg/kg. Due to minimal improvement in neurological signs, flumazenil IV infusion was increased gradually until reaching the effective dose of 0.1 mg/kg/h. Flumazenil IV infusion was continued for 24 hours with improvements in neurological signs, which did not return upon gradual decrease of the flumazenil dose. This is the first report describing the use of a flumazenil IV infusion to improve neurological signs in a cat with a PSS and HE treated with diazepam.

Prospective Study Comparing Outcome following Complete Polypropylene Suture Ligation versus Partial Thin Film Band Attenuation of Congenital Portosystemic Shunts in Dogs

The main objective was to conduct a prospective study reporting the outcome for dogs with an extrahepatic congenital portosystemic shunt (CPSS) treated with a 'complete ligation where possible' philosophy. The second aim was to compare the outcomes following complete (C) polypropylene suture ligation versus partial thin film band (TFB) attenuation of a CPSS in dogs. Dogs that could not tolerate acute complete shunt ligation at surgery received partial shunt attenuation with TFB. Peri-operative complications, mortality, follow-up imaging findings, pre- and post-operative bile acid stimulation test results and details of any revision surgery performed were recorded. A follow-up health-related quality of life questionnaire enabled the calculation of a postoperative clinical shunt score, a quality of life score, and determined if any dogs were still on a hepatic diet and/or other medical management at a minimum of 6 months after surgery. Of the 110 dogs enrolled, 57 received complete ligation and 53 received partial TFB attenuation. Peri-operative mortality, the occurrence of post-attenuation neurological complications, the occurrence of multiple acquired shunts, the postoperative clinical shunt score and quality of life score were not significantly different between the two groups. Dogs in the C group were older, heavier and demonstrated a greater number of shunt classifications where the entry into the systemic circulation was the phrenic vein or azygous vein. Dogs in the TFB group had a greater number of unchanged bile acid concentrations after surgery, were more likely to remain on the hepatic diet and/or medical management after surgery and underwent a greater number of revision surgeries. There was variability in the precision of both ultrasound and computed tomographic angiography follow-up imaging compared to intra-operative mesenteric portovenography findings at revision surgery. Overall, dogs with an extrahepatic portosystemic shunt receiving either complete acute shunt ligation or partial TFB shunt attenuation are expected to have an excellent long-term clinical outcome and there is no reason to suggest that a dog able to tolerate complete acute shunt closure should be denied the benefit of this.

Three-Dimensional Models of Liver Vessels for Navigation during Laparotomic Attenuation of Intrahepatic Portosystemic Shunt in Dogs

Laparotomic attenuation of an intrahepatic portosystemic shunt (IHPSS) is more difficult than an extrahepatic one, and results in a higher risk of complications because the identification of the aberrant vessel in the liver remains often a challenge. Excessive preparation and traction of the parenchyma results in trauma, bleeding, and prolonged surgery, which is what worsens the prognosis. Therefore, based on computed tomographic angiography, we printed 3-dimensional (3D) individual patient liver models, scaled 1:1, and used them for surgery planning and as a guide during intraoperative identification of the shunt in four dogs with IHPSS. The advantages of the 3D technology are simple and precise planning of the surgery, fast intraoperative identification of the shunt, and low invasive dissection of the liver parenchyma. We conclude that 3D technology can potentially raise the recovery rate. To the best of our knowledge, this was the first application of 3D models in the surgery of canine IHPSS.

Outcomes in dogs with congenital extrahepatic portosystemic shunts treated with surgical ligation or medical management

OBJECTIVE

The objective of this study was to evaluate differences in outcomes in dogs treated for extrahepatic portosystemic shunts (EHPSS) by either complete suture ligation, partial suture ligation or medical management.

STUDY DESIGN

This wasa retrospective, single institutional study.

SAMPLE POPULATION

Dogs (n = 152) with EHPSS treated with suture ligation (n = 62), surgery with no ligation (n = 2), or medical management (n = 88).

METHODS

Medical records were reviewed for data on signalment, treatment variables, complications, and outcome. Kaplan-Meier plots were generated to assess survival across groups. Cox's proportional hazard models were used to assess the relationship between survival times and multiple predictor variables. For outcomes of interest, backwards, stepwise regression was performed (p < 0.05).

RESULTS

Complete suture ligation was possible in 46/64 (71.9%) of dogs where surgical attenuation was attempted. One dog was euthanized following partial suture ligation due to suspected portal hypertension. Dogs with complete suture ligation of the EHPSS had a significantly longer median survival time (MST) compared to the medical management group (MST not reached vs. 1730 days [p < 0.001]). Complete resolution of clinical signs (without the need for further medical treatment or dietary changes) was achieved in 16/20 (80.0%) dogs with complete suture ligation and 4/10 (40.0%) dogs with partial suture ligation of their EHPSS.

CONCLUSION

Suture ligation (complete or partial) for the treatment of EHPSS, where clinically possible, yielded the best clinical outcome and increased longevity compared to medical management in this study.

CLINICAL SIGNIFICANCE

While medical management for the treatment of EHPSS in dogs is a valid treatment option, better clinical outcomes are achieved with surgical intervention.

Congenital Portosystemic Shunts in Dogs and Cats: Treatment, Complications and Prognosis

Congenital portosystemic shunts (CPSS) are a common vascular anomaly of the liver in dogs and cats. Clinical signs of CPSS are non-specific and may wax and wane, while laboratory findings can raise the clinical suspicion for CPSS, but they are also not specific. Definitive diagnosis will be established by evaluation of liver function tests and diagnostic imaging. The aim of this article is to review the management, both medical and surgical, complications, and prognosis of CPSS in dogs and cats. Attenuation of the CPSS is the treatment of choice and may be performed by open surgical intervention using ameroid ring constrictors, thin film banding, and partial or complete suture ligation or by percutaneous transvenous coil embolization. There is no strong evidence to recommend one surgical technique over another. Medical treatment strategies include administration of non-absorbable disaccharides (i.e., lactulose), antibiotics, and dietary changes, and are indicated for pre-surgical stabilization or when surgical intervention is not feasible. After CPSS attenuation, short- and long-term post-surgical complications may be seen, such as post-operative seizures and recurrence of clinical signs, respectively. Prognosis after surgical attenuation of CPSS is generally favorable for dogs and fair for cats.

A case report

Congenital portosystemic shunt is a venous vascular abnormality that connects portal and systemic circulation, resulting in diversion of the blood flow, bypassing the hepatic passage. It is a rare malformation; its incidence varies from 1:30 000 to 1:50 000 newborns. It may be asymptomatic or present with complications in the pediatric age or, less frequently, in the neonatal age. Upon diagnosis, the need for a surgical or an intravascular intervention for closure should be defined. This decision depends on the malformation anatomical characteristics, clinical manifestations, and complications. We present the case of a 1-month-old patient referred to our center for the study of neonatal cholestatic hepatitis, with a diagnosis of extrahepatic portosystemic shunt. Intravascular closure of the defect was performed with significant subsequent improvement.

Congenital Portosystemic Shunts in Dogs and Cats: Classification, Pathophysiology, Clinical Presentation and Diagnosis

Congenital portosystemic shunts (CPSS) are abnormal vascular communications between the portal and the systemic circulation, bypassing the hepatic parenchyma and resulting in liver hypoplasia and hepatic insufficiency. Such connections develop in utero and persist postnatally. CPSS are among the two most common congenital vascular anomalies of the liver in small animals, along with primary hypoplasia of the portal vein without portal hypertension (PHPV without PH). CPSS can be extrahepatic (ECPSS), most commonly diagnosed in small and toy breed dogs and cats, or intrahepatic (ICPSS), most commonly seen in large breed dogs. Single ECPSS is the most common type encountered in both dogs and cats. Clinical signs of CPSS are non-specific and may wax and wane, while laboratory findings can raise clinical suspicion for CPSS, but they are also not specific. Definitive diagnosis will be established by evaluation of liver function tests, such as determination of fasting plasma ammonia (FA) levels, and pre- and postprandial serum bile acids concentrations, and diagnostic imaging. The purpose of this article is to review the definition, classification, pathogenesis, clinical presentation, and diagnosis of CPSS in dogs and cats, highlighted by the authors' clinical experience.

Hyperammonemic Encephalopathy in a Patient with Pancreatic Neuroendocrine Tumor and Portosystemic Shunt

Hyperammonemia can lead to encephalopathy and may be accompanied by a diagnostic dilemma. Imaging as well as biochemical analyses are the cornerstone for identifying possible underlying causes such as severe liver disease or urea cycle defect. We report a case of a patient that presented with neurological deficits based on hyperammonemia in the presence of a large pancreatic neuroendocrine tumor (PNET) and portosystemic shunts in the liver. Prior cases are rather scarce, and the exact mechanism is not fully understood. The case illustrates the added value of a multimodality imaging approach in patients presenting with hyperammonemia-induced encephalopathy.

Congenital Portosystemic Shunts: Variable Clinical Presentations Requiring a Tailored Endovascular or Surgical Approach

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.

Radiologic Evaluation of Portosystemic Shunts in Humans and Small Animals: Review of the Literature with Clinical Case Reports

The portal venous system is a network of vessels that carry blood from the capillary beds of the major abdominal organs to the liver. During embryology, the portal venous system can develop aberrantly, leading to vascular connections between the portal and systemic venous circulation known as portosystemic shunts. The purpose of this comparative review with a few short representative case reports was to present the similarities and differences in portosystemic shunts in humans and small animals and their radiologic evaluation. Aberrant vascular connections between the portal and systemic venous circulation enable portal blood to bypass metabolism and detoxification in the liver, leading to significant clinical implications. Portosystemic shunts are very rare in humans, but these connections are much more common in small animals, affecting up to 0.6% of small animals. Portosystemic shunts can be congenital or acquired and are divided into intrahepatic and extrahepatic types. Because of its ability to accurately assess abdominal structures, large vessels, and their flow dynamics without anesthesia, ultrasonography has become the first imaging modality employed for the diagnostic evaluation of portosystemic shunts in both humans and small animals. This is usually followed by contrast-enhanced computed tomographic angiography in order to better define the exact shunt anatomy and to plan treatment. It is important to understand the embryology, anatomy, pathology, and pathophysiology of portosystemic shunts in order to understand the findings of radiologic imaging and to initiate appropriate treatment.

Abernethy Malformation Masquerading as Congenital Heart Disease: A Boy With Cyanosis, Clubbing, and Hypoxia

Abernethy malformation is an extrahepatic congenital portosystemic shunt characterized by the diversion of the portal blood away from the liver through a shunt that drains directly into the inferior vena cava. We present a case of a male child with Abernethy malformation, which was initially diagnosed as cyanotic heart disease due to pulmonary arteriovenous malformation. However, after proper clinical evaluation and investigations, the diagnosis of Abernethy malformation was established. Thereafter, the patient was successfully treated with endovascular embolization. At one year follow-up, marked relief in exertional dyspnea and improvement in physical growth was achieved with no observable complications.

Transjugular Intrahepatic Portosystemic Shunt in Chronic Portal Vein Thrombosis-From Routine Recommendations to Demanding Scenarios

Portal vein thrombosis (PVT), particularly the presence of portal cavernoma, was traditionally considered a relative contraindication for transjugular intrahepatic portosystemic shunting (TIPS) due to the technical difficulties in accessing and maneuvering the portal vein and avoiding the high risk for bleeding periportal collaterals. However, the last decade has seen a surge in the number of studies-mostly case reports and small series of patients-demonstrating that TIPS is not only technically feasible in the vast majority of these patients but also provides effective and long-term control of symptoms associated with portal hypertension in cases refractory to the standard line of therapy. The present article aims to provide a concise but exhaustive overview of the role and the standard and technically difficult TIPS placement scenarios in patients with chronic non-malignant PVT and with and without underlying liver disease. The review is strategically punctuated by exemplary instances from the authors' experience.

Comparison of Veterinary Student Understanding of Extrahepatic Portosystemic Shunts when Given a Pre-Lecture Activity of a Text-Only Narrative versus an Interactive Electronic Book

Complex vascular anomalies are often difficult concepts for veterinary medical students to comprehend, as knowledge of normal anatomy, visualization of the abnormal anatomy, and understanding of the physiologic implications of that abnormality are all required to appreciate the clinical impacts of the anomaly. Access to interactive three-dimensional models of both the normal and abnormal vasculatures may improve student comprehension. In this study, third-year veterinary medical students in a core small animal digestive diseases course completed a pre-lecture assignment consisting of a text-only narrative (n = 100) or an interactive electronic book (e-book; n = 102) focused on extrahepatic portosystemic shunts, followed by two generative learning activities in which they described portal anatomy and extrahepatic portosystemic shunts. An optional, anonymous post-lecture learning assessment was given to both groups. Although no difference in post-lecture assessment scores was identified between the groups, students using the interactive e-book spent significantly longer on the pre-lecture assignment and activities than students in the text-only narrative group. Students in the text-only narrative group were more likely to use spatial visualization strategies during the generative learning activities than students in the e-book group. There was no correlation between time spent on the pre-lecture tasks and learning assessment score. Interactive e-books and generative learning activities may be useful adjunct pre-lecture learning tools for teaching of complex vascular anomalies to veterinary medical students.

Infra-cardiac TAPVC with an intrahepatic portosystemic shunt: A rare association

Total anomalous pulmonary venous connection (TAPVC) is an uncommonly encountered cyanotic congenital heart disease characterized by anomalous drainage of the pulmonary veins. Concomitant venous anomalies are rarely found in these patients. We present a case of an infra-cardiac TAPVC with an intrahepatic portosystemic shunt, where a vascular channel was seen between the middle hepatic vein and the left branch of the portal vein with fusiform dilatation of the latter, diagnosed on computed tomography angiography.

Comparison of diet, lactulose, and metronidazole combinations in the control of pre-surgical clinical signs in dogs with congenital extrahepatic portosystemic shunts

BACKGROUND

Hepatic supportive diet (HSD), lactulose, and antimicrobials are medical treatments for dogs with congenital extrahepatic portosystemic shunts (cEHPSS). The relative contribution of these treatment components is currently unknown.

OBJECTIVES

To determine which treatment combinations are most efficacious in pre-surgical control of clinical signs of cEHPSS in dogs.

ANIMALS

Thirty-six dogs with untreated cEHPSS.

METHODS

Three-arm randomized clinical trial. At inclusion (T0), dogs were divided into 3 groups: HSD (n = 12), HSD + lactulose (n = 12), or HSD + metronidazole (n = 12) and received the randomized treatment for 4 weeks (T1) followed by combined treatment of HSD + lactulose + metronidazole for 2 weeks or until cEHPSS attenuation (T2). Clinical score as well as fasting ammonia (FA) and C-reactive protein (CRP) concentrations were compared among groups and time points.

RESULTS

Thirty-four dogs were evaluated. Thirty-four dogs reached T1 and 29 dogs T2. At T1, clinical scores decreased in the HSD + lactulose (n = 11; P = .001), but not in the HSD (n = 8; P = .96) and HSD + metronidazole (n = 10; P = .06) groups. Adding metronidazole to HSD + lactulose (n = 11) did not result in further clinical score improvement (T2; P = 1.000). Moderate and weak correlation between clinical score and FA and clinical score and CRP was present (ρ = .35, P < .001; ρ = .27, P = .01, respectively) with FA decreasing over time on medical treatment (P = .001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Combined HSD + lactulose seems sufficient for pre-surgical cEHPSS stabilization unlike sole HSD or HSD + metronidazole. Medical treatment of cEHPSS clinical signs decreases FA.

Congenital portosystemic shunt with multiple splenic artery aneurysms: Reversing pulmonary hypertension and preventing aneurysm rupture

We report an unusual occurrence of multiple splenic artery aneurysms and splenomegaly in a young woman with severe pulmonary hypertension, secondary to a congenital portosystemic shunt (CPS). The splenic artery was occluded using an Amplatzer Duct Occluder-II device, and closure of the large intrahepatic CPS was achieved using a muscular ventricular septal defect occluder. There was resolution of splenomegaly with normal pulmonary artery pressures, a few months after the procedure.

Fetal-TAPSE for Surveillance of Cardiac Function in Growth-Restricted Fetuses With a Portosystemic Shunt

OBJECTIVES

Congenital portosystemic shunt (CPSS) in a growth-restricted fetus may lead to cardiac overload and ultimately hemodynamic imbalance. The aim of the study was to describe the application of tricuspid annular plane systolic excursion (TAPSE) for surveillance of cardiac function in growth-restricted fetuses diagnosed with CPSS.

METHODS

The study group consisted of 7 fetuses with growth restriction diagnosed with CPSS between 2018 and 2020. Patients were followed longitudinally every 2 weeks. Sonographic fetal-TAPSE (f-TAPSE) was performed every 2 weeks. At each visit, the following parameters were recorded: estimated fetal weight, biophysical profile, nonstress test, Doppler flow indices, and fetal cardiothoracic index. Postnatal laboratory and imaging tests were retrieved from the medical files.

RESULTS

Mean gestational age at diagnosis of CPSS was 32 + 1 weeks. Cardiomegaly was observed in all cases. All portosystemic shunts were classified as intrahepatic. Values of f-TAPSE were above the 95th percentile in 6/7 fetuses at presentation and throughout follow-up. Gestational age at delivery ranged between 36 + 5 and 38 + 5 weeks. Postnatally, spontaneous closure of the shunt was noted in 2 infants. Transient hyperammonemia was diagnosed in 2 neonates, with no signs of the characteristic complication.

CONCLUSIONS

In growth-restricted fetuses diagnosed concomitantly with CPSS, f-TAPSE offers a practical sonographic tool for assessment of cardiac function and may serve as an additional clinical marker for follow-up. The appearance of cardiomegaly in growth-restricted fetuses should prompt a dedicated sonographic evaluation of the fetal portal system.

Improved survival in children with HPS: Experience from two high volume liver transplant centers across continents

BACKGROUND

Severe HPS increases morbidity and mortality after LT in children. We reviewed the combined experience of LT for HPS in children from two LT centers in Europe and Asia.

METHODS

All children with "proven" HPS as per ERS Task Force criteria (detailed in manuscript) who underwent LT were categorized into M (PaO₂ ≥80 mmHg), Mo (PaO₂  = 60-79 mmHg), S (50-59 mmHg), and VS (PaO₂ <50 mmHg) HPS, based on room air PaO₂ .

RESULTS

Twenty-four children with HPS underwent 25 LT (one re-transplantation) at a median age of 8 years (IQR, 5-12), after a median duration of 8 (4-12) months following HPS diagnosis. Mechanical ventilation was required for a median of 3 (1.5-27) days after LT. Ten children had "S" post-operative hypoxemia, requiring iNO for a median of 5 (6-27) days. "VS" category patients had significantly prolonged invasive ventilation (median 35 vs. 3 and 1.5 days; p = .008), ICU stay (median 39 vs. 8 and 8 days; p = .007), and hospital stay (64 vs. 26.5 and 23 days; p < .001) when compared to "S" and "M/Mo" groups, respectively. The need for pre-transplant home oxygen therapy was the only factor predicting need for re-intubation. Patient and graft survival at 32 (17-98) months were 100% and 95.8%. All children ultimately had complete resolution of HPS.

CONCLUSIONS

VS HPS is associated with longer duration of mechanical ventilation and hospital stay, which emphasizes the need for early LT in these children.

Novel transcatheter treatment for staged closure of Abernethy malformation with portal hypoplasia

Portosystemic shunts are rare congenital malformations that come to attention due to various hepatic and extrahepatic manifestations. Management of this malformation is dictated by the presence and adequacy of intrahepatic portal radicals. Staged occlusion of the shunt is recommended in patients with severely hypoplastic portal radicals. We describe a novel transcatheter technique that we improvised for staged occlusion of Abernethy malformation in a 2-year-old girl.

Minimal portosystemic encephalopathy: A new nosological entity in patients with hereditary haemorrhagic telangiectasia

BACKGROUND

Portosystemic shunts in Hereditary Haemorrhagic Telangiectasia (HHT) are often overlooked by conventional imaging although they could reduce hepatic clearance of gut-derived toxins.

AIMS

To evaluate, the presence of subclinical neurological alterations (SNAs), that we named "minimal portosystemic encephalopathy" (mPSE) in HHT patients without advanced liver disease (ALD).

METHODS

In this cross sectional study, consecutive HHT outpatients were firstly screened by critical flicker frequency (CFF) test (abnormal ≤39Hz), and the simplified animal naming test (S-ANT₁) (abnormal <15) was used to confirm the diagnosis of mPSE. Furthermore, we evaluated the effect of lactulose administration on mPSE. Multi-slice CT, cerebral dynamic magnetic resonance, laboratory analyses and transient elastography were also used.

RESULTS

None of the 37 enrolled patients showed portosystemic shunts at imaging techniques. However, 33 patients had normal CFF values (CFF-) and 4 displayed CFF alterations (37.0±0.7Hz, CFF+). The S-ANT₁ confirmed an impaired neurological performance (10.2±2.8) in CFF+ patients thus confirming the presence of mPSE. Noteworthy, lactulose administration determined a CFF increase (39.1±0.4Hz) and S-ANT₁ normalization in these patients. Neither mPSE- nor mPSE+ patients had ALD and showed similar demographic, clinical and laboratory parameters. Finally, no mPSE+ patient showed radiologically-detectable brain vascular malformations or other brain abnormalities at imaging.

CONCLUSIONS

HHT patients represent a human model of mPSE secondary to portosystemic shunts escaping radiological detection. mPSE evaluation should be incorporated in HHT surveillance protocols since it can affect both health-related/social aspects and pharmacokinetics of orally administered drugs with a narrow therapeutic index and high hepatic first-pass uptake.

Nomogram for hepatic venous pressure gradient in patients with cirrhosis

OBJECTIVE

The hepatic venous pressure gradient (HVPG) plays an important role in the treatment and prognosis of patients with cirrhosis. Our study aimed to develop and validate a nomogram for an HVPG >12 mmHg.

METHODS

A retrospective study was performed to create a nomogram for an HVPG >12 mmHg in a training cohort that was validated in another cohort. The discriminatory ability and calibration of the nomogram were tested using the C-statistic, area under the receiver operating characteristic curve (AUROC) and calibration plots.

RESULTS

The nomogram was based on portosystemic shunts identified on computed tomography images, the etiology of cirrhosis and the Child-Pugh grade. These parameters were significantly associated with an HVPG >12 mmHg (P < 0.05 for both the training and validation cohorts). In the training cohort, the model showed good discrimination (C-statistic, AUROC, and R² of 0.71, 0.71 and 0.13, respectively) and good calibration. The total cutoff value was 112 and the sensitivity and specificity were 57.1% and 77.6%, respectively. The application of the nomogram in the validation cohort still yielded good discrimination (C-statistic 0.75 [95% confidence interval 0.61-0.89], AUROC 0.75, and R² 0.16) and good calibration.

CONCLUSIONS

This nomogram is a convenient tool for predicting an HVPG >12 mmHg in patients with cirrhosis and can help clinicians quickly identify patients with decompensated cirrhosis.

Outcomes of transjugular intrahepatic portosystemic shunt procedures: a 10-year experience

INTRODUCTION

Transjugular intrahepatic portosystemic shunt (TIPSS) is an effective modality in reducing portal pressure, and its current main indications are for the management of recurrent ascites and variceal bleeding. The demand and indications for TIPSS are growing. However, it is a complicated and technically demanding procedure with poorer outcomes associated with low volume centres. The aim of this study was, therefore, to review the outcomes of TIPSS at a 'low volume' single centre. Outcomes assessed included indications, safety, efficacy and survival.

METHODS

A retrospective study was undertaken of all patients who underwent a TIPSS procedure over 10 years at tertiary referral centre for complex liver disease and transplantation. Kaplan-Meier method was used to calculate actuarial survival and log-rank analysis was used to determine significant differences in survival.

RESULTS

Thirty-eight patients underwent the TIPSS procedure between January 2008 and December 2018. Technical, haemodynamic and clinical success were 95%, 92% and 92% respectively. Cumulative survival at one month, one year and five years were 86.8%, 72% and 44.7% respectively. Results achieved standards published in practice parameters to evaluate TIPSS safety and efficacy.

CONCLUSION

At a low volume centre, TIPSS usage was associated with high rates of technical, haemodynamic (HPVG reduction) and clinical success. Low volume should not be a contraindication to providing a TIPSS service; however, auditing outcomes and understanding specific institutional factors that influence quality are important requirements for low volume centres.

Real-world efficacy and safety of 12-week sofosbuvir/velpatasvir treatment for patients with decompensated liver cirrhosis caused by hepatitis C virus infection

AIM

This study aimed to evaluate the real-world efficacy and safety of 12-week sofosbuvir/velpatasvir (SOF/VEL) treatment for patients with decompensated liver cirrhosis caused by hepatitis C virus (HCV) infection.

METHODS

A total 72 of patients with Child-Pugh (CP) class B or C were enrolled. We evaluated the sustained virologic response at 12 weeks after the end of treatment (SVR12), adverse events (AEs), and changes in the liver function.

RESULTS

All participants had genotype 1 or 2 HCV infection. At baseline, the numbers of patients with CP class B and C were 59 and 13, respectively. The overall SVR12 rate was 95.8% (69/72); 94.9% (56/59) in CP class B and 100% (13/13) in CP class C. The serum albumin level, prothrombin time and ascites were significantly improved (P < 0.01); however, the serum bilirubin level and encephalopathy did not improve. Among patients who achieved SVR12, 75.0% showed an improvement in their CP score, while 5.9% showed a worsening. The presence of large portosystemic shunt (diameter ≥6 mm) and hyperbilirubinemia (≥2.0 mg/dL) were independent factors that interfered with the improvement in the CP score (P < 0.05). The most common AEs were encephalopathy (15.3%) and skin symptoms (7.9%). Two patients discontinued SOF/VEL due to AEs.

CONCLUSIONS

Treatment with SOF/VEL for 12 weeks was relatively safe and effective for patients with decompensated cirrhosis. An SVR provided an improvement of the liver function in the majority of patients. However, large portosystemic shunt and hyperbilirubinemia were independent factors that interfered with the improvement in the CP score.

Neurological Symptoms of Congenital Portosystemic Shunt Reversed by Venous Endovascular Intervention: A Six Years Follow-Up Study

Congenital portosystemic shunt (CPSS) is a rare disorder characterized by a diversion of Porto-mesenteric blood into systemic veins. Type I is an end to side fistula between the portal vein and the inferior vena cava. Type II is a side to side fistula between the main portal vein or its branches and mesenteric, splenic, gastric, and systemic veins. Clinical presentation of these patients varies. Treatment and management are guided by the type of malformation and clinical presentation. Herein, we present a case of CPSS Type IIb with neurological symptoms, treated with endovascular occlusion with 6-year follow-up without remission.

Feline abdominal ultrasonography: what's normal? what's abnormal? Hepatic vascular anomalies

PRACTICAL RELEVANCE

Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. Although hepatic vascular anomalies are less common than disorders of the hepatic parenchyma and biliary tree, our understanding and recognition of these is gradually increasing with advancements in ultrasound technology and image quality.

CLINICAL CHALLENGES

Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even differentiating between normal variation and pathological changes can be challenging for all but the most experienced. In addition, some views may be obscured by overlying structures; for example, the termination of a shunt entering the left phrenic or azygous veins is often difficut to see due to the high probability of lung passing between the shunt and the transducer as the cat breathes.

EQUIPMENT

Ultrasound facilities are readily available to most practitioners, although use of ultrasonography as a diagnostic tool is highly dependent on operator experience.

AIM

This review, part of an occasional series on feline abdominal ultrasonography, discusses the appearance of various hepatic vascular anomalies. It is aimed at general practitioners who wish to improve their knowledge and confidence in feline abdominal ultrasound and is accompanied by high-resolution images. Ultrasound of the liver and biliary tree were discussed in articles published in January and May 2019, respectively.

EVIDENCE BASE

Information provided in this article is drawn from the published literature and the author's own clinical experience.

Involvement of portosystemic shunts in impaired improvement of liver function after direct-acting antiviral therapies in cirrhotic patients with hepatitis C virus

AIM

Factors responsible for impaired improvement of liver function despite sustained viral response after direct-acting antiviral agents therapies in cirrhotic patients with hepatitis C virus need to be elucidated.

METHODS

Liver function and the extent of portosystemic shunting were evaluated for 79 patients with compensated cirrhosis, in whom sustained viral response had been achieved after direct-acting antiviral agents therapies for hepatitis C virus at least 3 years earlier.

RESULTS

Portosystemic shunts were observed in 63 patients (80%). Improvement and worsening, as compared with the baseline, of esophageal/gastric varices after direct-acting antiviral agents therapies was seen in three patients (4%) and 10 patients (13%), respectively. Portal hypertension-related events, such as varices and ascites requiring treatment, were observed in six patients (8%), in whom three patients showing worsening of Child-Pugh scores were included. Multivariate analysis showed that maximal diameter of the shunts (P = 0.012) and serum Mac-2 binding protein glycosylation isomer levels at the end of treatment (P = 0.005) were associated with the development of portal hypertension-related events, with cut-off values of 5.25 mm (P = 0.001) and 6.84 cut-off index (P < 0.001), respectively. The increase of serum albumin levels at 3 years, as compared with the baseline, was smaller in 22 patients having shunts with maximal diameters of ≥5 mm than in the remaining 57 patients (P = 0.034), whereas no such difference was seen between the patients with and without elevation of serum Mac-2 binding protein glycosylation isomer level of ≥6.8 cut-off index.

CONCLUSIONS

A large size of portosystemic shunts was found to be a crucial determinant of impaired improvement of liver function, as well as of the development of portal hypertension-related events, even after sustained viral response in patients with compensated cirrhosis.

Successful management of clinical signs associated with hepatic encephalopathy with manual therapeutic plasma exchange in a dog

OBJECTIVE

To describe the use of manual therapeutic plasma exchange (TPE) to manage hepatic encephalopathy (HE) in a dog.

CASE SUMMARY

A 9-year-old neutered female Dachshund presented for HE secondary to a previously diagnosed portosystemic shunt. The hyperammonemia and severe clinical signs of HE persisted despite extensive medical management. Therapeutic plasma exchange was performed for stabilization prior to surgical shunt ligation. A total of 1 plasma volume was processed during a single manual TPE session. The ammonia immediately prior to TPE was 235 μmol/L (reference interval, 10-30 μmol/L) and decreased to 117 μmol/L by the end of the session. The dog showed significant improvement in clinical signs shortly after the session and remained stable thereafter. Shunt ligation was performed 5 days later with no complications observed with TPE or postoperatively. The dog was discharged 3 days after surgery with no neurological signs and was doing well 100 days after surgery.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first published report of manual TPE to manage HE in veterinary medicine. Therapeutic plasma exchange should be further investigated as a possible strategy to manage clinical signs of HE in patients that are refractory to medical management. Achieving this with manual TPE may be considered in patients that are too small for conventional TPE due to extracorporeal volume or in situations where conventional TPE is not available.

Serum melatonin in dogs with congenital portosystemic shunting, with and without hepatic encephalopathy

BACKGROUND

Melatonin is a hormone produced and secreted primarily by the pineal gland and mainly metabolised in the liver. Increased melatonin concentrations have been reported in human cirrhosis and hepatic encephalopathy (HE), a syndrome of neurological dysfunction. The pathogenesis of canine HE is incompletely understood. Melatonin has been hypothesised as a contributor to the development of HE. The aim of this study was to investigate whether serum melatonin concentrations are increased in canine congenital portosystemic shunting (cPSS), with and without HE.

METHODS

Medical records were retrospectively reviewed, for which archived (-80°C) serum samples were available. A canine competitive ELISA was used to measure melatonin in two cohorts: dogs with a final diagnosis of cPSS (n=23) with and without clinical signs of HE, and healthy dogs (n=15).

RESULTS

Melatonin concentrations were not significantly different (P=0.81) between healthy controls (median 27.2 pg/mL, range 19.8-161.5 pg/mL) and dogs with cPSS (median 25.7 pg/mL, range 18.5-244.9 pg/mL). Serum melatonin did not differ between cPSS patients with and without clinical signs of HE (P>0.99). No correlation was found between serum melatonin and blood ammonia (Spearman rank correlation coefficient, r_s =-0.41, P=0.08).

CONCLUSION

Serum melatonin is not increased in canine cPSS with and without HE. We found no evidence that altered melatonin metabolism plays a role in the pathogenesis of cPSS-associated HE.

Diagnostic value of blood variables following attenuation of congenital extrahepatic portosystemic shunt in dogs

BACKGROUND

The aims of this study were to determine if extrahepatic portosystemic shunt (EHPSS) postoperative closure could be predicted based on preoperative blood analyses and to determine the accuracy of blood variables to evaluate persistence of portosystemic shunting postoperatively (multiple acquired portosystemic shunts (MAPSS) or persistent EHPSS).

METHODS

Retrospectively, 62 dogs treated surgically for congenital EHPSS that underwent postoperative trans-splenic portal scintigraphy or CT angiography three to six months postoperatively were included.

RESULTS

None of the studied preoperative blood variables could unambiguously predict surgical outcome. Elevated postoperative fasting venous ammonia (FA) concentration always indicated surgical failure (persistent shunting or MAPSS), but normal FA did not provide any information on the postoperative shunting status. Paired serum bile acids (SBA) were not reliable enough to confirm or exclude postoperative shunting. In the presence of low normal postoperative FA levels, elevated preprandial SBA was more likely in dogs with persistent shunting (sensitivity of 0.79, specificity of 0.83), whereas postprandial SBA below reference limit was more often observed in case of surgical success (sensitivity of 0.93, specificity of 0.67).

CONCLUSION

Blood variables, and more specifically the combination of FA and SBA, are not a valuable alternative to advanced medical imaging to reliably assess the surgical outcome after EHPSS surgery.

Treatment of congenital extrahepatic portosystemic shunts in dogs: A systematic review and meta-analysis

Background

Several options have been proposed for the treatment of congenital extrahepatic portosystemic shunts (cEHPSS) in dogs, but formal comparisons among different treatment options are currently unavailable. A previous evidence‐based review (2012) found low quality of evidence for papers assessing the treatment of cEHPSS in dogs.

Objectives

To assess the quality of evidence available in the treatment of cEHPSS, summarize the current state of knowledge with respect to outcome after cEHPSS management, and compare different treatment techniques.

Animals

Not used.

Methods

A bibliographic search was performed without date or language restrictions. Studies were assessed for quality of evidence (study design, study group sizes, subject enrollment quality, and overall risk of bias) and outcome measures reported (perioperative outcome, clinical outcome, and surgical or interventional outcome), all reported with 95% confidence intervals. A network meta‐analysis was performed.

Results

Forty‐eight studies were included. Six retrospective studies (grade 4b) compared 2 techniques and 7 were abstracts (grade 5). The quality of evidence was low and risk of bias high. Regarding surgical outcome, statistically significant superiority of ameroid constrictor over thin film band was observed (P = .003). No other comparisons were statistically significant.

Conclusions and Clinical Importance

The evidence base of choice of treatment of cEHPSS in dogs remains weak despite recent publications on the subject. Ameroid is superior to thin film band in causing EHPSS closure. Blinded randomized studies comparing different treatment modalities, which routinely include postoperative imaging to assess cEHPSS closure and acquired portosystemic shunt development are essential.

Intrahepatic arterial localizer guided transjugular intrahepatic portosystemic shunt placement: Feasibility, efficacy, and technical success assessed by a case series-a STROBE- compliant article

Transjugular intra-hepatic portosystemic shunts (TIPS) had been considered a standard procedure in patients suffering from portal hypertension. The most challenging step in TIPS placement is blind puncture of the portal vein. We had established a localization method by introducing an Intra-Hepatic Arterial based puncture directing Localizer (IHAL) with the assistance of the enhanced computed tomography (CT) reconstruction. This study aimed to evaluate the feasibility, efficacy, and technical success of this method.From June 2018 to August 2018, 10 consecutive patients suffering from refractory ascites or esophageal gastric bleeding by liver cirrhosis were included in this retrospective study to evaluate feasibility, efficacy, and technical success of enhanced CT assisted IHAL-guided puncture of the portal vein. As a control, 10 patients receiving TIPS placement before Jun 2018 with cone beam CT (CBCT)-guided puncture were included to compare the reduction of portal-systemic pressure gradient (PSPG), portal entry time (PET), the number of puncture, dose area product (DAP) and contrast medium consumption.Technical success was 100% in the study group (IHAL-guided group) and in 90.0% of the control group (CBCT-guided group). Appropriate IHAL point could be achieved in all patients under the enhanced CT reconstruction assistance. The median number of punctures and DAP in IHAL group were significantly less than those in CBCT group. The reduction of PSPG, PET, and contrast medium consumption in IHAL group showed no significant differences than those in CBCT group.Enhanced CT reconstruction assisted IHAL-guided portal vein puncture is technically feasible and a reliable tool for TIPS placement resulting in a significant reduction of the number of punctures and DAP.

A case report on an incidental discovery of congenital portosystemic shunt

RATIONALE

Congenital portosystemic shunt (Abernethy malformation) is a rare entity causing the portal blood to drain directly into the systemic circulation, eluding the liver. These shunts arise through disturbances in the embryonic development.

PATIENT CONCERNS

A 9-year-old male patient was referred to our department for further evaluation of a vascular malformation which was diagnosed in another facility when the patient was 2 years old, following a routine abdominal ultrasound. The patient had no complaints and the physical examination was normal at all times.

DIAGNOSIS

Laboratory tests and esogastroduodenoscopy were normal. The abdominal ultrasound showed a side-to-side shunt between a short portal trunk and the inferior vena cava. A hepatic mass suggestive for focal noduar hyperplasia was seen in the left liver lobe. Abdominal angio-computed tomography (angio-CT) was performed and the ultrasonographic anomalies were confirmed. Multiple other vascular malformations were diagnosed-hepatic artery emerging from the superior mesenteric artery, with early division; hepatic veins forming a short common trunk before draining into the inferior vena cava; supranumerary right renal artery emerging from the aorta, tributary for the upper renal pole. Ecocardiography showed left superior vena cava persistence. The final diagnosis was Abernathy malformation type IB. In the meantime the patient was diagnosed with allergic asthma.

INTERVENTIONS

No surgical cure was pursued because the malformation was an incidental discovery.

OUTCOMES

The patient was followed-up closely from the final diagnosis (when he was 9 years old) to present (he is currently 10 years old) with no change in his status-he remained asymptomatic.

LESSONS

Angio-CT should be the performed whenever a vascular malformation is suspected in order to establish a correct diagnosis, because portosystemic shunts carry a high risk of severe complications. Knowing that patients with portosystemic shunts may have pulmonary hypertension, respiratory complaints should be carefully evaluated-in this particular case, even though the most probable cause for the respiratory symptoms was pulmonary hypertension, it was ruled out by cardiac ultrasonography and further investigations confirmed the diagnosis of allergic asthma.

Feasibility of complete surgical ligation on 72 dogs with singular extrahepatic congenital portosystemic shunt based on portal pressure and comparison of intraoperative mesenteric portovenography

The relation between complete or partial ligation of extrahepatic portosystemic shunting and intraoperative mesenteric portovenography (IMP) was evaluated in 72 canines. Of the 72 dogs, 55 had complete ligation and 17 underwent partial ligation of abnormal vessels. IMP allowed evaluation of the number of intrahepatic portal branches and ratio of the diameter of cranial (CrPV) and caudal main portal vein (CaPV) at the shunt location. Nearly all cases in the complete ligation group and nearly half of the cases in the partial ligation group had three or more portal vein branches. CrPV/CaPV was 0.75 ± 0.24 in the complete ligation group and 0.29 ± 0.15 in the partial ligation group. CrPV/CaPV can be an effective new method for assessing IMP.

Survey of surgical specialists' content preferences in radiology reports for extrahepatic portosystemic shunts

The aim of this prospective, survey study was to assess the opinions of specialist surgeons as to the preferred content, nomenclature, and classification of extrahepatic portosystemic shunts for inclusion in radiology reports. A link to an online survey was sent by email to members of the European College of Veterinary Surgeons and the Association of Veterinary Soft Tissue Surgeons, and was made available on the American College of Veterinary Surgeons web forum and Facebook page. There were 93 respondents (survey sent to over 2500 email addresses and made available in two online locations). Most respondents agreed that they both review the images themselves (87/92, 95%) and read the radiology report (82/92, 89%) prior to surgery. Most respondents believed that the radiology report should contain a detailed anatomic description of the insertion (83/92, 90%), origin (54/91, 59%), and course (70/92, 76%) of the shunt, as well as a measure of the diameter of the shunting vessel at its insertion (54/92, 59%). Most respondents (70/90, 78%) disagreed that a brief description of shunt type, such as portocaval or portophrenic, was sufficient. Respondents were undecided regarding the use of an alphanumeric classification system (36/92, 39% agree; 32/92, 35% disagree). There was agreement that details of the presence or absence of urolithiasis (91/93, 98%), renomegaly (54/93, 58%), and peritoneal fluid (72/92, 78%) should be included in the report. The results of this study will help to guide reporting radiologists in providing descriptions of extrahepatic portosystemic shunts that include information most preferred by the recipient surgeons.

Lipogranulomas and pigment granulomas in livers of dogs with portosystemic shunt

Lipogranulomas are lesions found in histopathological liver examination in humans and in various animal species, including dogs, especially those with portosystemic shunts. They consist of macrophages and other inflammatory cells, and sometimes they contain iron salts (pigment granuloma). This study aimed at determining the number of granulomas and cellular composition of lipogranulomas in dogs with the congenital extrahepatic portosystemic shunt, and to identify factors associated with their development. 44 archival liver samples from dogs with portosystemic shunt were stained using HE, Perl's method and - in randomly-selected cases - immunohistochemically against CD56, CD20 and CD3 (DAKO). A reduction in the size of the liver was observed in all dogs during laparotomy, and the diameter of the vessel circumventing the liver was also measured (in 24 dogs). Lipogranulomas were found in 52.3% of samples; iron salts were present in 47.8% of them; 72% of cells in lipogranulomas were macrophages. In lipogranulomas both types of lymphocytes - T and B - were seen. The presence of lipogranulomas in liver samples in dogs was connected with fatty degeneration of hepatocytes and was correlated with the age of animals and with the diameter of the abnormal vessel circumventing the liver. Their formation appears to be triggered by severe ischemia and shortage of nutrient supply.

Anomalies of the Portal Venous System in Dogs and Cats as Seen on Multidetector-Row Computed Tomography: An Overview and Systematization Proposal

This article offers an overview of congenital and acquired vascular anomalies involving the portal venous system in dogs and cats, as determined by multidetector-row computed tomography angiography. Congenital absence of the portal vein, portal vein hypoplasia, portal vein thrombosis and portal collaterals are described. Portal collaterals are further discussed as high- and low-flow connections and categorized in hepatic arterioportal malformation, arteriovenous fistula, end-to-side and side-to-side congenital portosystemic shunts, acquired portosystemic shunts, cavoportal and porto-portal collaterals. Knowledge of different portal system anomalies helps understand the underlying physiopathological mechanism and is essential for surgical and interventional approaches.

Laparoscopic Partial Closure for Congenital Portosystemic Shunt-Indications, Postoperative Management, and Subsequent Complete Closure

Extrahepatic congenital portosystemic shunts (CPSSs) can be occluded by surgical or endovascular approaches. However, when the estimated portal vein (PV) pressure after the closure is high enough to induce symptoms associated with portal hypertension, partial closure is recommended to avoid life-threatening events. In this study, we attempted laparoscopic partial closure of a CPSS in two patients. Along with intraoperative real-time measuring of the PV pressure and angiography, laparoscopic partial closure was performed to achieve a PV pressure of ≤25 mmHg. Subsequently, the intrahepatic portal system grew in both patients. The partially ligated CPSS closed spontaneously in the first patient. In the second patient, laparoscopic complete closure was performed for the residual CPSS 6 months after the first operation. To our knowledge, this is the first report of laparoscopic partial closure for CPSS. Minimally invasive laparoscopic partial ligation of CPSS is technically feasible and useful when the estimated PV pressure is too high to tolerate one-step complete closure.

Regional gray matter abnormality in hepatic myelopathy patients after transjugular intrahepatic portosystemic shunt: a voxel-based morphometry study

Hepatic myelopathy is a complication seen in patients with chronic liver failure with physiologic or iatrogenic portosystemic shunting. The main symptom is progressive lower limb dyskinesia. The role of the brain motor control center in hepatic myelopathy is unknown. This study aimed to investigate the gray matter changes in patients with hepatic myelopathy secondary to transjugular intrahepatic portosystemic shunt and to examine their clinical relevance. This was a cross-sectional study. Twenty-three liver failure patients with hepatic myelopathy (hepatic myelopathy group), 23 liver failure patients without hepatic myelopathy (non-hepatic myelopathy group) after transjugular intrahepatic portosystemic shunt, and 23 demographically matched healthy volunteers were enrolled from March 2014 to November 2016 at Xijing Hospital, Air Force Military Medical University (Fourth Military Medical University), China. High-resolution magnetization-prepared rapid gradient-echo brain imaging was acquired. Group differences in regional gray matter were assessed using voxel-based morphometry analysis. The relationship between aberrant gray matter and motor characteristics was investigated. Results demonstrated that compared with the non-hepatic myelopathy group, gray matter volume abnormalities were asymmetric, with decreased volume in the left insula (P = 0.003), left thalamus (P = 0.029), left superior frontal gyrus (P = 0.006), and right middle cingulate cortex (P = 0.021), and increased volume in the right caudate nucleus (P = 0.017), corrected with open-source software. The volume of the right caudate nucleus in the hepatic myelopathy group negatively correlated with the lower limb clinical rating of the Fugl-Meyer Assessment (r = -0.53, P = 0.01). Compared with healthy controls, patients with and without hepatic myelopathy exhibited overall increased gray matter volume in both thalami, and decreased gray matter volume in both putamen, as well as in the globus pallidus, cerebellum, and vermis. The gray matter abnormalities we found predominantly involved motor-related regions, and may be associated with motor dysfunction. An enlarged right caudate nucleus might help to predict weak lower limb motor performance in patients with preclinical hepatic myelopathy after transjugular intrahepatic portosystemic shunt. This study was approved by the Ethics Committee of Xijing Hospital, Air Force Military Medical University (Fourth Military Medical University), China (approval No. 20140227-6) on February 27, 2014.

Mechanistic insight, diagnosis, and treatment of ammonia-induced hepatic encephalopathy

Hepatic encephalopathy is a neuropsychological syndrome due to biochemical disturbance of brain function in advanced liver disease patients. Diagnosis and treatment of the condition is very demanding and has negative toll on finances with increased healthcare utilization. The pathophysiology is not completely understood; however, there is evidence that ammonia plays an important role in the etiology. Conventional methods of solely relying on blood ammonia level to diagnose hepatic encephalopathy did not help much; likewise, the use of lactulose alone in treating hepatic encephalopathy has also been discouraged. This paper analyzed the current knowledge regarding the mechanism of how ammonia disrupts the normal brain function as well as the use of latest diagnosing tools including those under development to evaluate the neuropsychiatric state of patients and their quality of life. The efficacies of lactulose and rifaximin combination for short-term and long-term treatment in addition to nutritional interventions and other drugs undergoing clinical trials were also reviewed.

Caroli's-type ductal plate malformation and a portosystemic shunt in a 4-month-old kitten

Case summary

A 4-month-old neutered male Russian Blue kitten had a 4 week history of hypersalivation and failure to thrive. In addition, there was a 2 week history of soft tissue swelling on the ventral abdomen, which had failed to improve with antimicrobial therapy. There were no significant physical examination or neurological deficits on examination; however, the cat had a quiet demeanour for its age. Postprandial bile acids were increased (32 µmol/l; reference interval <25 µmol/l). An abdominal CT scan revealed changes consistent with an extrahepatic portosystemic shunt and inflammation of fat of the ventral abdominal body wall. Surgical biopsy and culture of the subcutaneous swelling identified non-infectious steatitis. Ten weeks following initial presentation, surgical exploration, liver biopsy and ligation of the portosystemic shunt were performed. Liver biopsy was submitted to the Anatomical Pathology Laboratory of Cornell University Animal Health Diagnostic Center, New York, USA. Histopathology revealed a ductal plate malformation (Caroli’s type), as well as changes consistent with a portosystemic shunt.

Relevance and novel information

Ductal plate malformations are rarely described in the veterinary literature. To our knowledge this is the first reported case of Caroli’s-type malformation in a cat. There are no biochemical changes that allow for differentiation of ductal plate malformations from other hepatopathies. Liver biopsy is required for a definitive diagnosis.

Comparison of patients with hepatic encephalopathy and those with gastric varices before and after balloon-occluded retrograde transvenous obliteration

AIM

To compare the clinical characteristics of patients with hepatic encephalopathy (HE) and those with gastric varices (GV) before and after balloon-occluded retrograde transvenous obliteration (BRTO).

METHODS

Eighty cirrhotic patients who underwent BRTO, including 42 men and 38 women, and whose mean age was 68 years, comprised the HE (n = 18) and GV (n = 62) groups. The patients' data before and 1 month after BRTO were analyzed.

RESULTS

Before BRTO, the groups did not differ in their portal flow volume (PFV) or hepatic venous pressure gradient (HVPG). The portal vein (PV) was narrower and the splenic vein (SpV) was wider in the HE group than in the GV group. The SpV flow was hepatofugal in 75.0% of HE patients and hepatopetal in 92.6% of GV patients. The Child-Pugh (CP) score of the HE group was significantly higher than that of the GV group pre-BRTO. After BRTO, the PFV and HVPG increases in the HE group equaled those in the GV group, and the PV dilation was similar in both groups. Conversely, the SpV was significantly contracted for HE patients, but significantly dilated for GV patients. Postoperatively, the SpV flow was hepatopetal in all patients. Compared to that in the GV group, the CP score decreased markedly in the HE group, and no significant increases in complications occurred post-BRTO for HE patients.

CONCLUSIONS

The HE patients showed distinct portal-splenic hemodynamics before and after BRTO. Balloon-occluded retrograde transvenous obliteration markedly improved hepatic function in the HE group compared with the GV group.

The Abernethy malformation with inferior caval vein hypoplasia: a tailored technique for transcatheter closure and an insight into embryological perspective

Abernethy malformations manifest as hepatopulmonary syndrome, pulmonary vasculopathy, or encephalopathy. A novel intervention in a child with portosystemic shunt and inferior caval vein hypoplasia led to complete normalisation of hypoxia and relief of obstruction in the inferior caval vein. Embryological explanations of venous anomalies may indicate that inferior caval vein anomalies are frequent but under-recognised in patients with Abernethy malformation.

Precision Onion Skinning Technique for Transjugular Intrahepatic Portosystemic Shunt Revision

A transjugular intrahepatic portosystemic shunt is the standard of care for complications of portal hypertension, such as variceal bleeding, refractory ascites, and hepatic hydrothorax. Hepatic encephalopathy, hepatic insufficiency, and right heart failure are the major complications after shunt creation. If medical management is unsuccessful, the interventionalist is consulted to close/revise the shunt. Closure of the shunt results in a dangerously abrupt increase in portal pressure, increasing risk for life-threatening variceal bleeding. Methods for revising these shunts are reported, which result in coarse adjustments in shunt diameter, causing rapid changes in portosystemic gradients. Our method for shunt revision utilizes carefully sized covered stents deployed in a controlled “onion skin” fashion to produce a narrowing within the hepatic venous limb of the shunt to precisely calibrate the desired portosystemic gradient.

Portal-systemic Encephalopathy due to Complicated Spleno-renal Shunt Successfully Treated with Balloon-occluded Retrograde Transvenous Obliteration Using a Double Coaxial Balloon Catheter System and Shape-memory Coils

A 70-year-old woman with hepatitis C cirrhosis underwent balloon-occluded retrograde transvenous obliteration for hepatic encephalopathy due to spleno-renal shunt. Because the shunt was thick, long, and winding, we used a coaxial and double interruption system, which enables the effective occlusion of the drainage route, and shape-memory coils, which are more physically stable than conventional metallic coils because they form three-dimensional loops. The patient was successfully treated with the combined usage of these devices, resulting in a normal serum ammonia level. Thereafter, the patient was treated with direct-acting antivirals, and a sustained virological response was achieved.

Balloon-occluded retrograde transvenous obliteration as a procedure to improve liver function in patients with decompensated cirrhosis

Aim

Portosystemic shunts aggravate liver function by decreasing portal blood flow. The usefulness of balloon-occluded retrograde transvenous obliteration (B-RTO), a standardized therapeutic procedure for gastric fundal varices (GFV), for the improvement of liver function was evaluated in cirrhotic patients with or without varices.

Methods

The subjects were 161 patients with portosystemic shunts. A balloon catheter was inserted into the shunts, followed by the injection of 5% ethanolamine oleate through the catheter under balloon inflation. The balloon was kept inflated for 6 to 48 h.

Results

B-RTO was performed as a therapy for GFV in 112 patients and for the improvement of liver function in 49 patients. The targets were splenorenal shunts in 104 patients (93.6%) in the former group and 33 patients (67.3%) in the latter group, and the procedures were successfully completed in 109 (97.3%) and 39 (79.6%) patients, respectively. In both groups, the serum albumin levels were increased and the serum ammonia levels were decreased at more than 1 month after the procedures, compared with the baseline levels, whereas significant improvements in the Child-Pugh scores and prothrombin times were only seen in the latter group. In these patients, the portal blood flows evaluated using Doppler ultrasound were increased at 1 week after the procedures, compared with the baseline levels.

Conclusions

B-RTO is a useful therapeutic procedure for improving liver function even in patients without GFV by increasing the portal venous flow with successfully targeted, uncommon portosystemic shunts.