Case of Ectopic Variceal Bleed Managed With Percutaneous Transhepatic Portal Vein Recanalization

A variety of complications and associated clinical presentations may be seen in patients with cirrhotic and non-cirrhotic portal hypertension. We present one such case of Upper GI hemorrhage from ectopic duodenal varices in a case of pre-hepatic portal hypertension due to Extrahepatic Portal Venous Obstruction (EHPVO). The case was managed successfully with endovascular Portal Vein Recanalization (PVR) and metallic stent deployment. With adequate technical success, improved symptoms, and laboratory parameters, the patient was discharged on long-term anticoagulation and interval follow-up.

Management of a complex transjugular intrahepatic portosystemic shunt dysfunction with endotipsitis through rotational thrombectomy

Transjugular intrahepatic portosystemic shunting (TIPS) is an established strategy for the management of complications of portal hypertension. Endoprosthetic infection ("endotipsitis") is a rare but serious and difficult-to-treat complication of TIPS placement. Here we report the occurrence of an infected thrombus complicating TIPS placement in a patient with extra-hepatic portal vein obstruction, recurrent variceal bleeding and portal biliopathy accompanied by recurrent cholangitis. Infected thrombotic material within TIPS could be removed only by employing rotational thrombectomy. This procedure revealed the presence of a biliary fistula which carried pathogens in the systemic circulation. The multiple episodes of sepsis did no longer recur following exclusion of the biliary fistula. This case highlights the possibility to use rotational thrombectomy for the management of complex cases of TIPS dysfunction.

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.

Unconventional Shunts in Extrahepatic Portal Venous Obstruction-A Retrospective Review

Background

Proximal splenorenal shunt (PSRS) is one of the most commonly performed portosystemic shunt (PSS) in extrahepatic portal venous obstruction (EHPVO) for portal decompression. Sometimes various anatomical and surgical factors related to the splenic vein and/or left renal vein may make the construction of a PSRS difficult or impossible. Unconventional shunts are required to tide over such conditions.

Methods

From January 2008 to December 2018, 189 patients with EHPVO underwent PSS, of which, the 10 patients who underwent unconventional shunts form the study group of this paper.

Results

The ten unconventional shunts included 8 proximal splenoadrenal shunts, one collateral-renal shunt, and one inferior mesenteric vein to inferior vena cava (IMV-Caval) shunt. The mean percentage drop in omental pressure was 34.2% post-shunt with a mean anastomotic diameter of 13.7 ± 3.1 mm. Three patients experienced some form of postoperative complication. With a mean follow-up period of 32.3 months (maximum of 111 months) all patients had patent shunts on follow-up Doppler. None of the patients had variceal bleed, or features of biliopathy and hepatic encephalopathy in follow-up.

Conclusion

Unconventional shunts can be used safely and effectively with good postoperative outcomes in EHPVO.

Maternal and neonatal outcomes in extra hepatic portal vein obstruction: Our experience

Background:

Women with Extra hepatic portal vein obstruction (EHPVO) are mostly young and belong to Asian countries. In the Indian subcontinent, 20–30% variceal bleeds are caused by EHPVO. Hence pregnancy is a concern in such patients. The objective of this study is to observe the maternal and neonatal outcomes in women with EHPVO.

Materials and Method:

Extra hepatic portal vein obstruction was studied retrospectively in 28 pregnancies in 20 women from Jan 2011 to July 2018 at a tertiary hospital in South India and the pregnancy outcomes were observed during this period. Institutional Review Board approval obtained.

Results:

The mean age of the women was 24.3 years and the mean age of diagnosis was 18.5 years. Splenomegaly, thrombocytopenia and anaemia were seen in 22 (78.5%), 17 (60.7%) and 8 (28.5%) of pregnancies, respectively. Rate of abortions and preterm deliveries were 2 (7.1%, n =28) and 10 (35.7%, n =28). There was one stillbirth (3.6%) in the study group. EHPVO was diagnosed in 25 (89.3%) women prenatally in our series. During pregnancy only one woman had variceal bleed, which was managed conservatively. Blood and blood product transfusion was required in 7(25%) of women and there was no maternal mortality.

Conclusion:

Pregnancies in EHPVO have good maternal and neonatal outcomes, provided they are taken care of by a multidisciplinary approach in a tertiary care centre.

Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report

Introduction and importance

Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions.

Case presentation

A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis.

Clinical discussion

The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases.

Conclusion

The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.

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Ectopic varices are an unusual cause of lower GI bleeding caused by porto-systemic collaterals.

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Ectopic varices most commonly occur at jejuno-ileum, but duodenal varices are more prone to bleed.

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The optimal management varies with each case due to paucity of treatment guidelines.

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Decompressive shunt with splenectomy and segmental resection of intestine effectively prevents rebleeding.

Comparison of unenhanced and contrast-enhanced 3 T magnetic resonance portovenography in children with extra hepatic portal venous obstruction

PURPOSE

To evaluate role of 3-T magnetic resonance portovenography (MRPV) in children with extra hepatic portal venous obstruction (EHPVO) and compare unenhanced and contrast-enhanced sequences.

METHODS

20 Children with EHPVO underwent MRPV using unenhanced [T2, T1 pre-contrast, Balanced turbo field echo (BTFE)] and contrast-enhanced (CE) modified DIXON (mDIXON) sequences. The images were evaluated for the patency of abdominal veins, hepatic and splenic parenchyma by two radiologists for interobserver agreement.

RESULTS

BTFE and post-contrast mDIXON sequences performed best for evaluation of abdominal veins. Concordance between the BTFE and CE sequences was good to very good for both the radiologists for splenic vein (SV) evaluation. The concordance between the two sequences for evaluation of superior mesenteric vein and its confluence with the SV was less remarkable and varied from fair to good, while the interobserver agreement was very good to perfect. The interobserver agreement between the BTFE and CE sequence for the evaluation of left renal vein was very good, while that for IVC was perfect. The agreement between BTFE and CE sequence was perfect for the evaluation of right and middle hepatic veins, while the interobserver agreement was good to perfect. The interobserver agreement was poor for evaluation of hepatic parenchyma on BTFE sequence as compared to CE sequence, and moderate for splenic parenchyma.

CONCLUSION

BTFE sequence is the single best unenhanced MR pulse sequence to detect all the vascular structures in children with EHPVO. CE-MRI is not superior to BTFE sequence and should be used at the discretion of the radiologist.

Management of a rare case of extra hepatic portal vein obstruction with temporomandibular joint ankylosis and review of literature

Extrahepatic portal venous obstruction (EHPVO) and temporomandibular joint (TMJ) ankylosisis are significant problems in Asian countries. Both EHPVO and bilateral TMJ ankylosis may have rare association due to protein C and S deficiency which may cause hypercoagulability as well as reduced fibrinolytic activity. Ankylosis arising in early childhood is associated with facial asymmetry, feeding difficulty and speech development alterations. It is also associated with great challenges of endoscopic management in extra hepatic portal vein obstruction (EHPVO) with variceal bleed as well as air way management during surgical management and post-operative recovery. Recently a case series had shown association of TMJ ankylosis with EHPVO due to protein C deficiency which might be an etiological factor for both EHPVO as well as TMJ ankylosis. This case report documents a case of 14 year young girl who had TMJ ankylosis due to ear infection and EHPVO with esophageal varices had multiple episodes of upper GI bleed with mild deficiency of protein C and S, successfully managed with proximal splenorenal shunt to prevent further episodes of upper GI bleed, as endoscopic management is not feasible due to TMJ ankylosis.

Correlation of endoscopic findings with Doppler ultrasound in portal hypertension in children

Aim of the study

To determine the correlation of the endoscopic findings with portal Doppler and ultrasound (USG) in children with suspected portal hypertension (PHT).

Material and methods

Eighty children with extrahepatic portal vein obstruction (EHPVO) and chronic liver disease (CLD) were included in this retrospective study conducted over a period of 1 year. All patients underwent upper gastrointestinal (GI) endoscopy and Doppler.

Results

The etiology was EHPVO in 30 (37.5%) patients, biliary atresia in 12 (15%), Budd-Chiari syndrome in 11 (13.7%), Wilson’s disease in 10 (12.5%), idiopathic CLD in 8 (10%), autoimmune hepatitis in 4 (5%), glycogen storage disease (GSD) in 3 (3.8%), non-alcoholic liver disease (NAFLD) in 1 (1.3%) and systemic lupus erythematosus (SLE) in 1 (1.3%) patient. Fifty-three (66.25%) patients had esophageal varices on endoscopy, of whom 3 (3.8%) had associated gastric varices. Portal hypertensive gastropathy (PHG) was present in 30 (37.5%) patients, of whom 10 (12.5%) had severe PHG. Forty-one (51.3%) patients had PHT on Doppler (κ correlation 0.43). Kappa correlation was 0.43 in patients with biliary atresia, 0.31 in Budd-Chiari syndrome, 0.23 in idiopathic CLD, 0.21 in CLD, and 0.05 in Wilson’s disease. All (100%) EHPVO patients and 39 (78%) CLD patients had PHT on USG. Endoscopic findings of PHT were seen in 24 (80%) EHPVO patients and 29 (58%) CLD patients. All patients with EHPVO had cavernous transformation of the portal vein on Doppler. For patients with CLD, the common Doppler findings were collaterals seen in 35 patients and reversal of flow in 12 patients.

Conclusions

Doppler ultrasound followed by endoscopy should be used to diagnose PHT in children. In children with biliary atresia, Doppler ultrasound may miss changes of PHT.

Predictors of insufficient recanalization and portal hypertensive complications after treatment of non-cirrhotic, non-malignant portal vein thrombosis - a population-based study

OBJECTIVES

In acute portal vein thrombosis (PVT), a six-month anticoagulation treatment achieves complete recanalization in only 35%-45% of patients, but the predictors of poor treatment responses are unclear. We examined treatment outcomes in PVT and aimed to identify predictors of incomplete recanalization and portal hypertensive complications.

MATERIALS AND METHODS

This retrospective study comprised patients diagnosed with PVT between 2006 and 2015. Key exclusion criteria were liver cirrhosis, malignancy, and age <18.

RESULTS

The final cohort comprised 145 patients, of whom 132 (92%) were primarily treated with anticoagulation. The 5-year cumulative incidence of complete recanalization was 42% and of portal hypertensive complications, 31%. Independent predictors of insufficient recanalization were sub-acute or chronic thrombosis (hazard ratio (HR) 3.1, 95% CI 1.6-5.8), while acute pancreatitis was a protective factor (HR 0.3, 95% CI 0.2 - 0.7). Independent predictors of incident portal hypertensive complications were as cites at baseline (HR 3.3, 95% CI 1.7-6.7), sub-acute or chronic thrombosis (HR 2.9, 95% CI 1.6-5.3), extension of thrombosis to the splenic or mesenteric vein (HR 2.6, 95% CI 1.2-5.7), myeloproliferative disease (HR 3.0, 95% CI 1.4-6.5), and anemia (HR 2.1, 95% 1.1-3.9), while acute pancreatitis was a protective factor (HR 0.1, 95% CI 0.03-0.5).

CONCLUSIONS

Etiology and age of thrombosis are associated with treatment responses in PVT. The presence of ascites at baseline, etiology, and extent of thrombosis, a non-acute thrombosis and anemia, are associated with the risk of portal hypertensive complications. Etiology and extent of thrombosis should be taken into account when determining the treatment (method) for PVT.

Bile duct wall calcification: A rare entity in portal cavernoma cholangiopathy

Cavernomatous transformation of the portal vein, seen in extrahepatic portal venous obstruction (EHPVO), can cause impingement or ischemic insult on bile ducts manifesting as “portal cavernoma cholangiopathy” (PCC). Bile duct wall calcification in portal biliopathy is a rare occurrence and has not been reported in the literature to the best of our knowledge. We report a 59-year-old male, a known case of EHPVO, who had undergone laparoscopic cholecystectomy, splenectomy, and splenorenal shunt in the past. The patient had now presented to us in view of recurrent episodes of cholangitis for which a bilioenteric bypass was planned. Intraoperatively, dilated and densely thickened bile ducts with multiple pericholedochal collaterals were noted. Incision of common hepatic duct and left hepatic duct showed completely calcified ductal wall with no visible healthy mucosa. Calcifications were removed partially from the bile duct walls near choledochotomy site. With the anticipation of futile benefit from bilioenteric bypass, Roux-en-Y HJ was abandoned. Hepaticoduodenostomy was done to prevent bile leak from choledochotomy site.

Gastric Varices in Cirrhosis vs. Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-butyl-2-cyanoacrylate Injection

BACKGROUND

Gastric varices (GV) are found in patients with portal hypertension. Incidence of bleeding from GV is relatively low, but is severe, and associated with higher mortality.

AIMS AND OBJECTIVES

To compare the types of GV in cirrhosis vs. extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N-butyl-2-cyanoacrylate (NBC, glue) injection.

METHODS

Four hundred and fifty-four patients undergone glue injection of GV for primary prophylaxis or control of bleeding for first episode of bleeding from GV between August 2010 and August 2015 were analyzed.

RESULTS

Of 454 patients, 64% (n = 292) were cirrhotics and 36% (n = 162) had EHPVO. Types of GV were GOV1 in 16.4% (n = 48) of cirrhotics vs. 7.4% (n = 12) of EHPVO, GOV2 in 76.7% (n = 224) of cirrhotics vs. 53.1% (n = 86) of EHPVO, Isolated gastric Varices (IGV1) in 39.5% (n = 64) of patients with EHPVO vs. 6.8% (n = 20) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 2.89 ± 1.59 ml over a median of 1 session (range: 1-7). The total volume of glue required was lower in cirrhotics (2.44 ± 1.17 ml vs. 3.69 ± 1.91 ml, P < 0.05) than in EHPVO patients. One hundred and seventeen (40.1%) of cirrhotics required >1 sessions of glue injection as compared to 102 (63%) of EHPVO patients. Over mean follow up of 14.7 ± 6.46 months, rebleeding (10% vs. 13%) was similar in patients with cirrhosis and EHPVO and mortality (15.4% vs. 2.5%) was higher in cirrhotics than EHPVO.

CONCLUSION

In patients with bleeding from GV, GOV2 are more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for GV obturation.

Non-cirrhotic portal hypertension - diagnosis and management

NCPH is a heterogeneous group of liver disorders of vascular origin, leading to PHT with near normal HVPG. NCPF/IPH is a disorder of young adults or middle aged women, whereas EHPVO is a disorder of childhood. Early age acute or recurrent infections in an individual with thrombotic predisposition constitute the likely pathogenesis. Both disorders present with clinically significant PHT with preserved liver functions. Diagnosis is easy and can often be made clinically with support from imaging modalities. Management centers on control and prophylaxis of variceal bleeding. In EHPVO, there are additional concerns of growth faltering, portal biliopathy, MHE and parenchymal dysfunction. Surgical shunts are indicated in patients with failure of endotherapy, bleeding from sites not amenable to endotherapy, symptomatic hypersplenism or symptomatic biliopathy. Persistent growth failure, symptomatic and recurrent hepatic encephalopathy, impaired quality of life or massive splenomegaly that interferes with daily activities are other surgical indications. Rex-shunt or MLPVB is the recommended shunt for EHPVO, but needs proper pre-operative radiological assessment and surgical expertise. Both disorders have otherwise a fairly good prognosis, but need regular and careful surveillance. Hepatic schistosomiasis, CHF and NRH have similar presentation and comparable prognosis.

Brush border enzymes and absorptive capacity in extrahepatic portal venous obstruction in children

BACKGROUND AND OBJECTIVE

Portal hypertension may affect intestinal functions, brush border enzymes and absorption parameters. Information about these in extrahepatic portal venous obstruction (EHPVO) in children is limited and poorly reported. We therefore studied the brush border enzymes and absorptive capacity in EHPVO in children.

METHODS

The study was conducted on 52 children of EHPVO. The diagnosis of EHPVO was made on the basis of clinical presentation and ultrasound examination. All patients underwent upper gastrointestinal endoscopy. Endoscopic tissue biopsies from duodenum were taken on aluminum foils and kept immediately at -20°C for estimation of brush border enzymes. Tissue biopsies were homogenized in sodium maleate buffer, 0.1 M pH 6.0, by a homogenizer and processed for the enzymes: lactase, maltase, and sucrase. Enzyme levels were compared to normal healthy controls (n = 20). d-Xylose test, stool acid steatocrit for fat excretion in stools and stool alpha-1 antitrypsin were done to know about the absorptive parameters.

RESULTS

Enzyme levels of lactase (6.21 ± 5.67 IU/mg) and sucrase (37.07 ± 21.06 IU/mg) in EHPVO group were significantly lower as compared to lactase (23.32 ± 10.48 IU/mg) and sucrase (95.96 ± 46.55 IU/mg) in normal healthy controls. Maltase levels were lower, but difference was not statistically significant in EHPVO group (56.90 ± 28.65 IU/mg) as compared to normal controls (63.28 ± 22.88 IU/mg). There was no significant difference of urinary d-xylose and stool fat in patients with normal or short stature EHPVO patients.

CONCLUSION

EHPVO leads to decrease in levels of brush border enzymes in small bowel but their absorption capacity remains normal.