Dragoteanu M, Balea IA, Dina LA, Piglesan CD, Grigorescu I, Tamas S, Cotul SO. Staging of portal hypertension and portosystemic shunts using dynamic nuclear medicine investigations. World J Gastroenterol 2008; 14(24): 3841-3848 [PMID: 18609707 DOI: 10.3748/wjg.14.3841]
Corresponding Author of This Article
Dr. Mircea Dragoteanu, PhD, Department of Nuclear Medicine, Clinical Emergency Hospital "Prof dr Octavian Fodor", str. Croitorilor 19-21 Cluj-Napoca, 400162, Romania. dragoteanu@yahoo.co.uk
Article-Type of This Article
Clinical Research
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World J Gastroenterol. Jun 28, 2008; 14(24): 3841-3848 Published online Jun 28, 2008. doi: 10.3748/wjg.14.3841
Staging of portal hypertension and portosystemic shunts using dynamic nuclear medicine investigations
Mircea Dragoteanu, Ioan A Balea, Liliana A Dina, Cecilia D Piglesan, Ioana Grigorescu, Stefan Tamas, Sabin O Cotul
Mircea Dragoteanu, Cecilia D Piglesan, Stefan Tamas, Sabin O Cotul, Department of Nuclear Medicine, “Professor, Dr. Octavian Fodor” Clinical Emergency Hospital, 19-21 Croitorilor Street, Cluj-Napoca 400162, Romania
Ioan A Balea, Resident doctor in nuclear medicine, “Professor, Dr. Octavian Fodor” Clinical Emergency Hospital, 19-21 Croitorilor Street, Cluj-Napoca 400162, Romania
Liliana A Dina, Ioana Grigorescu, Department of Internal Medicine, “Professor, Dr. Octavian Fodor” Clinical Emergency Hospital, 19-21 Croitorilor Street, Cluj-Napoca 400162, Romania
Author contributions: Dragoteanu M headed the investigation team, designed and coordinated the study, made the interpretation of the results, introduced the new parameters and classification, worked on the preparation and revision of the manuscript and on the statistical analysis of data; Balea IA assisted with the manuscript preparation and revision and the statistical analysis of data; Dina LA participated in the selection and follow up of the patients, the statistical analysis of the data and the evaluation of the per-rectal portal scintigraphy classical method based on the per-rectal portal shunt index; Piglesan CD, Tamas S as physicists were members of the investigation team; Grigorescu I participated in the selection and follow up of the patients and assisted with the statistical analysis of the data; Cotul SO is a retired honorary professor. As chief of laboratory before 2002 he introduced the classic per-rectal portal scintigraphy and liver angioscintigraphy into practice in this hospital and was a member of the investigation team.
Correspondence to: Dr. Mircea Dragoteanu, PhD, Department of Nuclear Medicine, Clinical Emergency Hospital "Prof dr Octavian Fodor", str. Croitorilor 19-21 Cluj-Napoca, 400162, Romania. dragoteanu@yahoo.co.uk
Telephone: +40-722-381851
Fax: +40-264-455995
Received: December 26, 2007 Revised: April 29, 2008 Accepted: May 6, 2008 Published online: June 28, 2008
Abstract
AIM: To explore portal hypertension and portosystemic shunts and to stage chronic liver disease (CLD) based on the pathophysiology of portal hemodynamics.
METHODS: Per-rectal portal scintigraphy (PRPS) was performed on 312 patients with CLD and liver angioscintigraphy (LAS) on 231 of them. The control group included 25 healthy subjects. We developed a new model of PRPS interpretation by introducing two new parameters, the liver transit time (LTT) and the circulation time between right heart and liver (RHLT). LTT for each lobe was used to evaluate the early portal hypertension. RHLT is useful in cirrhosis to detect liver areas missing portal inflow. We calculated the classical per-rectal portal shunt index (PRSI) at PRPS and the hepatic perfusion index (HPI) at LAS.
RESULTS: The normal LTT value was 24 ± 1 s. Abnormal LTT had PPV = 100% for CLD. Twenty-seven non-cirrhotic patients had LTT increased up to 35 s (median 27 s). RHLT (42 ± 1 s) was not related to liver disease. Cirrhosis could be excluded in all patients with PRSI < 5% (P < 0.01). PRSI > 30% had PPV = 100% for cirrhosis. Based on PRPS and LAS we propose the classification of CLD in 5 hemodynamic stages. Stage 0 is normal (LTT = 24 s, PRSI < 5%). In stage 1, LTT is increased, while PRSI remains normal. In stage 2, LTT is decreased between 16 s and 23 s, whereas PRSI is increased between 5% and 10%. In stage 3, PRSI is increased to 10%-30%, and LTT becomes undetectable by PRPS due to the portosystemic shunts. Stage 4 includes the patients with PRSI > 30%. RHLT and HPI were used to subtype stage 4. In our study stage 0 had NPV = 100% for CLD, stage 1 had PPV = 100% for non-cirrhotic CLD, stages 2 and 3 represented the transition from chronic hepatitis to cirrhosis, stage 4 had PPV = 100% for cirrhosis.
CONCLUSION: LTT allows the detection of early portal hypertension and of opening of transhepatic shunts. PRSI is useful in CLD with extrahepatic portosystemic shunts. Our hemodynamic model stages the evolution of portal hypertension and portosystemic shunts. It may be of use in the selection of patients for interferon therapy.
