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.

Pregnancy with portal hypertension

Even though pregnancy is rare with cirrhosis and advanced liver disease, but it may co-exist in the setting of non-cirrhotic portal hypertension as liver function is preserved but whenever encountered together is a complex clinical dilemma. Pregnancy in a patient with portal hypertension presents a special challenge to the obstetrician as so-called physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Risks of variceal bleed and hepatic decompensation increase many fold during pregnancy. Optimal management revolves round managing the portal hypertension and its complications. Thus management of such cases requires multi-speciality approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. With advancement in medical field, pregnancy is not contra-indicated in these women, as was previously believed. This article focuses on the different aspects of pregnancy with portal hypertension with special emphasis on specific cause wise treatment options to decrease the variceal bleed and hepatic decompensation. Based on extensive review of literature, management from pre-conceptional period to postpartum is outlined in order to have optimal maternal and perinatal outcomes.

Portal biliopathy in patients with non-cirrhotic portal hypertension: does the type of surgery affect outcome?

OBJECTIVES

After portosystemic anastomoses for biliopathy, some patients continue to suffer biliary obstruction. The effects of splenectomy and devascularization of the abdominal oesophagus and upper stomach are unclear. The aim of the current study was to determine the features of portal biliopathy (PB) in patients with non-cirrhotic portal hypertension, and to investigate outcomes in these patients after surgical procedures.

METHODS

A retrospective study of 56 patients who underwent surgery for PB during 1996-2010 was conducted. Data on presenting features, treatment received and outcomes were analysed.

RESULTS

In total, 41 of these patients had extrahepatic portal venous obstruction and 15 had non-cirrhotic portal fibrosis. Forty patients underwent shunt surgery and 16 underwent splenectomy and devascularization. Median bilirubin levels fell from 1.8 mg/dl (range: 0.4-5.9 mg/dl) to 1.0 mg/dl (range: 0.3-5.4 mg/dl) after shunt surgery and from 1.9 mg/dl (range: 0.6-4.0 mg/dl) to 1.2 mg/dl (range: 0.6-5.2 mg/dl) after splenectomy-devascularization. On follow-up, five of 33 patients had persistent jaundice after successful shunt surgery. These patients had a history of multiple endoscopic stentings and three patients had demonstrated a dominant common bile duct stricture preoperatively.

CONCLUSIONS

Portal biliopathy was reversed in 38 of 43 patients by either portosystemic shunting or splenectomy-devascularization. In five patients, direct biliary decompressive procedures were required because of shunt blockage or a non-reversible biliary stricture.

What makes non-cirrhotic portal hypertension a common disease in India? Analysis for environmental factors

In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.

The current clinical aspects of idiopathic portal hypertension

IDIOPATHIC PORTAL HYPERTENSION (IPH) COMPRISES DISORDERS DEVELOPING INCREASED PORTAL PRESSURE IN THE ABSENCE OF CIRRHOSIS: the clear mechanisms to explain this disease are still not well recognized. IPH usually suggests a benign prognosis, but sometimes is complicated with severe hemorrhage due to ruptured esophageal varices, or massive splenomegaly. Conventional treatments for those complications for patients with cirrhosis usually works when diverted to patients with IPH, although some of those patients might require liver transplantation if the treatment fails. However, there are few consistent treatment strategies for IPH itself, its complications or the indications for liver transplantation. In this mini review, we summarize the clinical manifestations and several potential theories to explain the etiology, as well as the current treatment options for IPH.

IgA nephropathy, non-cirrhotic portal fibrosis, and POEMS syndrome: A rare combination in the long-term follow-up of Sjögren's syndrome

Sjögren's syndrome is a heterogeneous autoimmune disorder that may be associated with systemic manifestations involving multiple organs. We herein reported a rare combination of immunoglobulin A nephropathy; non-cirrhotic portal fibrosis; and polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome in a 15-year follow-up of a female patient initially diagnosed with Sjögren's syndrome. The patient had excessive lymphoproliferation featured by lymphadenopathy and hyperglobulinemia. The diagnoses of immunoglobulin A nephropathy and non-cirrhotic portal fibrosis were confirmed by renal and liver biopsies. She received prolonged corticosteroids and immunosuppressive drugs, which improved immunoglobulin A nephropathy but did not hinder the progression of portal fibrosis, leading to intractable variceal bleeding. The patient died of repeated hematemesis despite endoscopic variceal ligation. Valuable pathological information of multi-organ involvement as well as detailed clinical course were presented to facilitate further understanding of this rare entity. Excessive lymphoproliferation might play an important role in the progression of systemic complications in Sjögren's syndrome, which requires prolonged immunosuppression and organ-specific treatment.

Comparison of surgical outcomes between shunt surgery and devascularization in non-cirrhotic portal hypertension

Objectives

Non-cirrhotic portal hypertension (NCPH) is the most common cause of portal hypertension and upper gastro-intestinal bleeding in children and adolescents in developing nations. It is characterized by features of portal hypertension with preserved liver function. Proximal splenorenal shunt (PSRS) and esophagogastric devascularization are the two most commonly performed surgeries for its management. The present study is aimed at comparison of surgical outcomes between these two procedures.

Material and Methods

Between April 2018 and March 2022, prospectively maintained data of consecutive NCPH cases who underwent surgical intervention was reviewed retrospectively. Cases were categorized into two groups- shunt surgery and devascularization. The pre-operative characteristics, peri-operative morbidity and long-term outcomes were compared between the groups.

Results

Of 112 cases who were treated during the study period, 54 cases which underwent surgery were included in the study. Of these, 20 cases underwent PSRS, and splenectomy and devascularization was performed in 34 cases. There was no difference in pre-operative variables between the two groups. Patients undergoing PSRS experienced longer duration of surgery (260 vs. 200 minutes, p <0.001), and those in the devascularization group had significantly greater operative blood loss (350 vs. 455 ml, p <0.001). Post-operative morbidity was comparable between the two groups. Hypersplenism was corrected in all cases and no cases reported rebleeding after median follow-up of 30 months. Three cases in each group developed features of portal biliopathy in follow up period.

Conclusion

Both PSRS and devascularization procedures have comparable efficacy and safety in the management of NCPH.

A Narrative Review on Non-Cirrohotic Portal Hypertension: Not All Portal Hypertensions Mean Cirrhosis

Non-cirrhotic portal hypertension (NCPH), also known as idiopathic non-cirrhotic portal hypertension (INCPH) and porto-sinusoidal vascular disorder (PSVD), is a rare disease characterized by intrahepatic portal hypertension (IPH) in the absence of cirrhosis. The precise etiopathogenesis of IPH is an area of ongoing research. NCPH diagnosis is challenging, as there are no specific tests available to confirm the disease, and a high-quality liver biopsy, detailed clinical information, and an expert pathologist are necessary for diagnosis. Currently, the treatment of NCPH relies on the prevention of complications related to portal hypertension, following current guidelines of cirrhotic portal hypertension. No treatment has been studied that aimed to modify the natural history of the disease; however, transjugular intrahepatic porto-systemic shunt (TIPS) placement, shunt and liver transplantation are considerable symptomatic options. In this review, we discuss the heterogeneity of NCPH as well as its etiopathogenesis, clinical presentation and management issues. Starting from the assumption that portal hypertension does not always mean cirrhosis, cooperative studies are probably needed to clarify the issues of etiology and the possible genetic background of this rare disease. This knowledge might lead to better treatment and perhaps better prevention.