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.

Hepatic extravasation complicated by umbilical venous catheterization in neonates: A 5-year, single-center experience

BACKGROUND

Care of newborns in the neonatal intensive care unit generally involves umbilical venous catheterization (UVC) for central vein access to enable medical needs. The study aimed to evaluate the sonographic appearance, risk factors, and outcomes of UVC-related hepatic extravasation (HE) in neonates.

METHODS

A 5-year retrospective study where 33 neonates were enrolled with a diagnosis age ranging from 2 to 25 days. 78.8% of the subjects had UVC malpositioning shown on initial radiography. All neonates sonographically diagnosed with HE, and follow-up ultrasound (US) was performed.

RESULTS

The main findings of HE on US were hyperechoic or heterogeneous lesions of a lobulated (51.7%) or wedge shape (48.3%), located mainly in the left lobe (72.7%). The mean time to resolution of HE was 2.25 months. Seven (21.2%) patients showed hepatic vascular thrombosis at follow-up. Two (6%) patients had abnormal liver function, which subsequently normalized.

CONCLUSION

Malposition of the UV catheter was the predisposing factor for UVC-related HE in neonates. US facilitates detection of UVC malpositioning and diagnosis of HE, as well as delayed complications. A shorter duration of UVC placement is associated with favorable outcomes of UVC-related HE in neonates.

Venobiliary fistula related to umbilical venous catheter in a newborn

We present a case of venobiliary fistula due to umbilical venous catheter (UVC). UVC was inserted the day before surgery in a newborn who was scheduled for type IIIB jejunal atresia surgery. The UVC was superimposed on the liver. It was noted that the gastric drainage became chylous and increased to 790 and then 1977 mL daily. I.v. contrast tomography with 650 mL contrast showed that the opaque substance was dispersed around the catheter and a venobiliary fistula formed, with the administered fluid accumulating in the duodenum. Rapid improvement was seen in the clinical picture after the UVC was removed. Venobiliary fistula may develop in patients with UVC that is not placed appropriately, and can direct the fluid administered from the UVC to the gastrointestinal system through the choledochal duct. The importance of contrast computed tomography in the diagnosis of venobiliary fistula in the newborn is also emphasized.

Point-of-care ultrasound for monitoring catheter tip location during umbilical vein catheterization in neonates: a prospective study

Background

Point-of-care ultrasound (POCUS) can guide umbilical vein catheter placement in real time and monitor catheter tip position, allowing avoidance of severe complications due to catheter malposition. This study aims to explore the effectiveness of POCUS in guiding venous catheter insertion and monitoring complications.

Methods

Sixty-eight neonates with ultrasound-guided venous catheter insertion at the Neonatal Department of Dongguan Children's Hospital between December 2020 and February 2022 were included. POCUS was applied to monitor catheter tip location daily until catheter removal. A displacement range exceeding the intersection of the inferior vena cava and right atrium by ±0.5 cm was considered misalignment.

Results

Sixty-four neonates had a displaced catheter tip (94.1%, 64/68), with a median displacement distance of 0.4 cm (minimum -0.2 cm, maximum 1.2 cm). Ten neonates had a misalignment (14.7%, 10/68) caused by displacement. Displacement usually occurs within 2-4 days after placement, with displacement rates of 94.1% (64/68), 90.6% (58/64), and 98.3% (59/60) on days 2, 3, and 4, respectively, and could still occur on day 9 post-placement. In addition, misalignment mainly occurs on the second day after placement. During the monitoring process, 58 neonates had catheter tip displacement ≥2 times, resulting in 252 displacement and 22 misalignment incidents. Among them, the catheter tip migrated outward from the inferior vena cava seven times, all of which were removed in time. Ultrasound was used for positioning 486 times, and x-ray was indirectly avoided 486 times.

Conclusion

The catheter tip is prone to displacement and misalignment after umbilical vein catheterization, which most commonly occurs on days 2-4. POCUS is recommended for daily monitoring of the tip location during umbilical vein catheterization until catheter removal.

Identification of Neonatal Factors Predicting Pre-Discharge Mortality in Extremely Preterm or Extremely Low Birth Weight Infants: A Historical Cohort Study

BACKGROUND/OBJECTIVES

This study identified early neonatal factors predicting pre-discharge mortality among extremely preterm infants (EPIs) or extremely low birth weight infants (ELBWIs) in China, where data are scarce.

METHODS

We conducted a retrospective analysis of 211 (92 deaths) neonates born <28 weeks of gestation or with a birth weight <1000 g, admitted to University Affiliated Hospitals from 2013 to 2024 in Guangzhou, China. Data on 26 neonatal factors before the first 24 h of life and pre-discharge mortality were collected. LASSO-Cox regression was employed to screen predictive factors, followed by stepwise Cox regression to develop the final mortality prediction model. The model's performance was evaluated using the area under the curve (AUC) of the receiver operating characteristic, calibration curves, and decision curve analysis.

RESULTS

The LASSO-Cox model identified 13 predictors that showed strong predictive accuracy (AUC: 0.806/0.864 in the training/validation sets), with sensitivity and specificity rates above 70%. Among them, six predictors remained significant in the final stepwise Cox model and generated similar predictive accuracy (AUC: 0.830; 95% CI: 0.775-0.885). Besides the well-established predictors (e.g., gestational age, 5 min Apgar scores, and multiplicity), this study highlights the predictive value of the maximum FiO2. It emphasizes the significance of the early use of additional doses of surfactant and umbilical vein catheterization (UVC) in reducing mortality.

CONCLUSIONS

We identified six significant predictors for pre-discharge mortality. The findings highlighted the modifiable factors (FiO2, surfactant, and UVC) as crucial neonatal factors for predicting mortality risk in EPIs or ELBWIs, and offer valuable guidance for early clinical management.