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Wang DX, Wu XJ, Yu JZ, Zhan JY, Xing FF, Liu W, Chen JM, Liu P, Liu CH, Mu YP. Visualizing global progress and challenges in esophagogastric variceal bleeding. World J Gastrointest Surg 2025; 17:102020. [DOI: 10.4240/wjgs.v17.i4.102020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2024] [Revised: 01/20/2025] [Accepted: 02/13/2025] [Indexed: 03/29/2025] Open
Abstract
BACKGROUND Esophageal and gastric variceal bleeding is a catastrophic complication of portal hypertension, most commonly caused by cirrhosis of various etiologies. Although a considerable body of research has been conducted in this area, the complexity of the disease and the lack of standardized treatment strategies have led to fragmented findings, insufficient information, and a lack of systematic investigation. Bibliometric analysis can help clarify research trends, identify core topics, and reveal potential future directions. Therefore, this study aims to use bibliometric methods to conduct an in-depth exploration of research progress in this field, with the expectation of providing new insights for both clinical practice and scientific research.
AIM To evaluate research trends and advancements in esophagogastric variceal bleeding (EGVB) over the past twenty years.
METHODS Relevant publications on EGVB were retrieved from the Web of Science Core Collection. VOSviewer, Pajek, CiteSpace, and the bibliometrix package were then employed to perform bibliometric visualizations of publication volume, countries, institutions, journals, authors, keywords, and citation counts.
RESULTS The analysis focused on original research articles and review papers. From 2004 to 2023, a total of 2097 records on EGVB were retrieved. The number of relevant publications has increased significantly over the past two decades, especially in China and the United States. The leading contributors in this field, in terms of countries, institutions, authors, and journals, were China, Assistance Publique-Hôpitaux de Paris, Bosch Jaime, and World Journal of Gastroenterology, respectively. Core keywords in this field include portal hypertension, management, liver cirrhosis, risk, prevention, and diagnosis. Future research directions may focus on optimizing diagnostic methods, personalized treatment, and multidisciplinary collaboration.
CONCLUSION Using bibliometric methods, this study reveals the developmental trajectory and trends in research on EGVB, underscoring risk assessment and diagnostic optimization as the core areas of current focus. The study provides an innovative and systematic perspective for this field, indicating that future research could center on multidisciplinary collaboration, personalized treatment approaches, and the development of new diagnostic tools. Moreover, this work offers practical research directions for both the academic community and clinical practice, driving continued advancement in this domain.
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Affiliation(s)
- De-Xin Wang
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai 201203, China
| | - Xue-Jie Wu
- Heilongjiang University of Chinese Medicine, Harbin 150040, Heilongjiang Province, China
| | - Jin-Zhong Yu
- Department of Gastroenterology Endoscopy, Shuguang Hospital Affiliated to Shanghai University of Chinese Medicine, Shanghai 201203, China
| | - Jun-Yi Zhan
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai 201203, China
| | - Fei-Fei Xing
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai 201203, China
| | - Wei Liu
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai 201203, China
| | - Jia-Mei Chen
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai 201203, China
| | - Ping Liu
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai 201203, China
| | - Cheng-Hai Liu
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai 201203, China
| | - Yong-Ping Mu
- Cell Biology Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Institute of Liver Diseases, Shanghai Academy of Chinese Medicine, Shanghai 201203, China
- Clinical Key Laboratory of Traditional Chinese Medicine of Shanghai, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Liver and Kidney Disease of the Ministry of Education, Shanghai 201203, China
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Villanueva C, Tripathi D, Bosch J. Preventing the progression of cirrhosis to decompensation and death. Nat Rev Gastroenterol Hepatol 2025; 22:265-280. [PMID: 39870944 DOI: 10.1038/s41575-024-01031-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2024] [Indexed: 01/29/2025]
Abstract
Two main stages are differentiated in patients with advanced chronic liver disease (ACLD), one compensated (cACLD) with an excellent prognosis, and the other decompensated (dACLD), defined by the appearance of complications (ascites, variceal bleeding and hepatic encephalopathy) and associated with high mortality. Preventing the progression to dACLD might dramatically improve prognosis and reduce the burden of care associated with ACLD. Portal hypertension is a major driver of the transition from cACLD to dACLD, and a portal pressure of ≥10 mmHg defines clinically significant portal hypertension (CSPH) as the threshold from which decompensating events may occur. In recent years, innovative studies have provided evidence supporting new strategies to prevent decompensation in cACLD. These studies have yielded major advances, including the development of noninvasive tests (NITs) to identify patients with CSPH with reasonable confidence, the demonstration that aetiological therapies can prevent disease progression and even achieve regression of cirrhosis, and the finding that non-selective β-blockers can effectively prevent decompensation in patients with cACLD and CSPH, mainly by reducing the risk of ascites, the most frequent decompensating event. Here, we review the evidence supporting new strategies to manage cACLD to prevent decompensation and the caveats for their implementation, from patient selection using NITs to ancillary therapies.
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Affiliation(s)
- Càndid Villanueva
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Ministerio de Sanidad, Madrid, Spain.
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham Health Partners, Birmingham, UK
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jaume Bosch
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Ministerio de Sanidad, Madrid, Spain
- Department of Visceral Surgery and Medicine (Hepatology), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Berzigotti A. Optimizing non-invasive monitoring of the therapeutic response to NSBBs in portal hypertension: is machine learning the answer? Hepatol Int 2025:10.1007/s12072-025-10804-8. [PMID: 40056326 DOI: 10.1007/s12072-025-10804-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2025] [Accepted: 02/18/2025] [Indexed: 03/10/2025]
Affiliation(s)
- Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Dhar J, Yadav A, Mitra S, Nabi Z, Aggarwal M, Gupta P, Facciorusso A, Crinò SF, Trikudanathan G, Samanta J. Endoscopic ultrasound guided liver biopsy and portal pressure gradient: when, why and how? Can it become the standard of care in endo-hepatology? Expert Rev Gastroenterol Hepatol 2025:1-18. [PMID: 39980174 DOI: 10.1080/17474124.2025.2469838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Revised: 02/14/2025] [Accepted: 02/17/2025] [Indexed: 02/22/2025]
Abstract
INTRODUCTION The armamentarium of 'Endo-hepatology' is proliferating with the advancements in techniques and availability of new devices in the field of endoscopic ultrasound (EUS). This has resulted in the merger of multitude of diagnostic and therapeutic interventions, such as EUS-liver biopsy (LB), EUS-angioembolization of gastric varices, EUS-portal pressure gradient (PPG) measurement, and others into a 'one-stop-shop' for efficient patient management. Lack of standardization of these techniques forms a major hinderance in their widespread adoption. AREAS COVERED A comprehensive literature search was undertaken across various databases on EUS-LB and EUS-PPG till November 2024 for reviews, observational studies, and randomized trials on EUS-LB and EUS-PPG, describing its indications, technique, and data of safety and efficacy, detailing its role in day-to-day clinical practice. EXPERT OPINION EUS-LB and EUS-PPG have shown promise in the ever-growing field of endo-hepatology. EUS-LB has exhibited excellent safety profile and comparable tissue yield compared to its percutaneous counterpart. On the other hand, EUS-PPG seems to be a viable alternative although it needs to be standardized further. From a patient and hospital perspective, they might prove to be convenient and cost-effective. Nevertheless, more evidence is warranted before they can be labeled as the new standard of care.
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Affiliation(s)
- Jahnvi Dhar
- Department of Gastroenterology and Hepatology, Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India
| | - Amit Yadav
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Suvradeep Mitra
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manik Aggarwal
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Antonio Facciorusso
- Department of Experimental Medicine, Section of Gastroenterology, University of Salento, Lecce, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Rajpurohit S, Musunuri B, Basthi Mohan P, Bhat G, Shetty S. Is carvedilol superior to propranolol in patients with cirrhosis with portal hypertension: a systematic and meta-analysis. Drugs Context 2025; 14:2024-11-3. [PMID: 40017728 PMCID: PMC11867166 DOI: 10.7573/dic.2024-11-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 01/10/2025] [Indexed: 03/01/2025] Open
Abstract
Background Carvedilol has shown greater potency than propranolol as a β-blocker in managing cardiac conditions. However, its efficacy in reducing portal hypertension (PHTN) in patients with cirrhosis remains unclear. This study evaluates the efficacy and safety of carvedilol compared with propranolol in managing PHTN. Methods A systematic review and meta-analysis were conducted using PubMed, Scopus and Embase databases. Randomized controlled trials comparing carvedilol and propranolol were included. Primary outcomes were changes in hepatic venous pressure gradient, wedge hepatic venous pressure and free hepatic venous pressure. Secondary outcomes included heart rate, cardiac output and mean arterial pressure. Tertiary outcomes assessed adverse event incidences. Results Six randomized controlled trials involving 336 patients (171 carvedilol, 165 propranolol) were analysed. Carvedilol significantly reduced hepatic venous pressure gradient (mean difference (MD): 2.22 (95% CI 1.82-2.62); p<0.00001) and wedge hepatic venous pressure (MD: 2.38 (95% CI 1.92-2.84); p<0.00001). Propranolol significantly reduced cardiac output (MD: -0.60 (95% CI -0.74 to -0.45); p<0.00001). Mean arterial pressure was significantly lower in the carvedilol group (MD: 1.79 (95% CI 0.38-3.20); p=0.01). Adverse events, such as orthostatic hypotension and increased diuretic use, were more frequent in the carvedilol group but were manageable. Conclusion Carvedilol demonstrates superior efficacy in reducing PHTN compared with propranolol, with a slightly higher but tolerable adverse event profile. It may be considered the first-line treatment for PHTN. Further research is needed to validate long-term benefits and safety.
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Affiliation(s)
- Siddheesh Rajpurohit
- Department of Gastroenterology & Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Balaji Musunuri
- Department of Gastroenterology & Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pooja Basthi Mohan
- Department of Gastroenterology & Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ganesh Bhat
- Department of Gastroenterology & Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shiran Shetty
- Department of Gastroenterology & Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Crăciun R, Grapă C, Mocan T, Tefas C, Nenu I, Buliarcă A, Ștefănescu H, Nemes A, Procopeț B, Spârchez Z. The Bleeding Edge: Managing Coagulation and Bleeding Risk in Patients with Cirrhosis Undergoing Interventional Procedures. Diagnostics (Basel) 2024; 14:2602. [PMID: 39594268 PMCID: PMC11593119 DOI: 10.3390/diagnostics14222602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 11/17/2024] [Accepted: 11/18/2024] [Indexed: 11/28/2024] Open
Abstract
This review addresses the peri-procedural bleeding risks in patients with cirrhosis, emphasizing the need for careful coagulation assessment and targeted correction strategies. Liver disease presents a unique hemostatic challenge, where traditional coagulation tests may not accurately predict bleeding risk, complicating the management of procedures like paracentesis, endoscopic therapy, and various interventional procedures. As such, this paper aims to provide a comprehensive analysis of current data, guidelines, and practices for managing coagulation in cirrhotic patients, with a focus on minimizing bleeding risk while avoiding unnecessary correction with blood products. The objectives of this review are threefold: first, to outline the existing evidence on bleeding risks associated with common invasive procedures in cirrhotic patients; second, to evaluate the efficacy and limitations of standard and advanced coagulation tests in predicting procedural bleeding; and third, to examine the role of blood product transfusions and other hemostatic interventions, considering potential risks and benefits in this delicate population. In doing so, this review highlights patient-specific and procedure-specific factors that influence bleeding risk and informs best practices to optimize patient outcomes. This review progresses through key procedures often performed in cirrhotic patients. The discussion begins with paracentesis, a low-risk procedure, followed by endoscopic therapy for varices, and concludes with high-risk interventions requiring advanced hemostatic considerations. Each chapter addresses procedural techniques, bleeding risk assessment, and evidence-based correction approaches. This comprehensive structure aims to guide clinicians in making informed, evidence-backed decisions in managing coagulation in cirrhosis, ultimately reducing procedural complications and improving care quality for this high-risk population.
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Affiliation(s)
- Rareș Crăciun
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Cristiana Grapă
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Tudor Mocan
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
- UBBmed Department, Babeș-Bolyai University, 400084 Cluj-Napoca, Romania
| | - Cristian Tefas
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Iuliana Nenu
- Department of Physiology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Alina Buliarcă
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
| | - Horia Ștefănescu
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Andrada Nemes
- 2nd Department of Anesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Intensive Care Unit, Cluj-Napoca Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Bogdan Procopeț
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Zeno Spârchez
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.C.); (C.G.); (A.B.); (B.P.); (Z.S.)
- Gastoenterology Clinic, “Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
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Qiu Q, Ai Y, Pan Y, Luo W, Xu Z, Chen S, Lin J. Assessment of high-risk gastroesophageal varices in cirrhotic patients using quantitative parameters from dual-source dual-energy CT. Abdom Radiol (NY) 2024:10.1007/s00261-024-04666-1. [PMID: 39542947 DOI: 10.1007/s00261-024-04666-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 10/27/2024] [Accepted: 10/28/2024] [Indexed: 11/17/2024]
Abstract
PURPOSE To investigate the clinical value of dual-source dual-energy CT (dsDECT) quantitative parameters in evaluating hemodynamics and predicting high-risk gastroesophageal varices in cirrhotic patients. METHODS 98 consecutive patients were collected in this prospectively study and all patients underwent an abdominal triple-phase contrasted-enhanced examination with dsDECT. Iodine concentration (IC) and normalized iodine concentration (NIC) of the liver parenchyma, spleen parenchyma and aorta at different phases were recorded, and arterial iodine fraction (AIF), iodine washout rate (IWR), and extracellular volume (ECV) were calculated. Using upper gastrointestinal endoscopy as the reference standard, patients who met the inclusion and exclusion criteria were divided into groups with varices need treatment (VNT) and non-VNT. The clinical characteristics, traditional CT features and quantitative dsDECT parameters were compared between the VNT group and the non-VNT group using univariate analysis. The binary logistics analysis was used to build a model for diagnosing VNT. The receiver operating characteristic (ROC) curve was used for analysis and the DeLong test was used to compare different ROC curves. RESULTS Finally, 57 patients were included in this study. Univariate analysis showed statistically significant differences in NIC of the liver at the portal venous phase (NIC-LPVP), IWR of the liver (IWR-L) and spleen volume between the VNT group and the non-VNT group (p < 0.05). The mixed-CT model was built by binary logistics analysis. The ROC curves of NIC-LPVP, IWR-L, spleen volume and the mixed-CT model were statistically significant (p < 0.05) for predicting VNT in cirrhotic patients, among which the area under the ROC curve of the mixed-CT model was the highest. CONCLUSION Dual-source dual-energy CT has added clinical value in evaluating hepatic hemodynamics and diagnosing VNT in patients with liver cirrhosis.
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Affiliation(s)
- Qixuan Qiu
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yingjie Ai
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yijun Pan
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, China
| | - Wei Luo
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, China
| | - Zhihan Xu
- CHN DI CT Collaboration, Siemens Healthineers Ltd, Shanghai, China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiang Lin
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, China.
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Mao Y, Fang Z, He Y, Jin J, Ding X, Kong D. Correlation between the diameter of esophageal varices measured using a virtual ruler under endoscopy and portal pressure gradient. Front Med (Lausanne) 2024; 11:1443581. [PMID: 39606628 PMCID: PMC11598435 DOI: 10.3389/fmed.2024.1443581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 10/15/2024] [Indexed: 11/29/2024] Open
Abstract
Background Esophageal variceal diameter (EVD) is a crucial factor in determining the risk of esophageal variceal bleeding, which is associated with an increased portal pressure gradient (PPG). However, research into the relationship between EVD and PPG has been limited, primarily because the assessment of EVD depends on visual estimation during endoscopy. Recently, we developed an artificial intelligence (AI)-based method to accurately detect EVD. In this study, we aim to investigate the correlation between EVD and PPG, with the goal of evaluating EVD as a potential non-invasive indicator of PPG. Methods This study included both retrospective and prospective data from 128 patients diagnosed with portal hypertension and gastroesophageal varices, gathered from two medical institutions. Clinical data including PPG, biochemical markers, and routine blood tests were collected. In the retrospective phase, EVD was evaluated using an AI-based virtual ruler. In the prospective phase, PPG was measured using radiological intervention methods, and EVD was measured during endoscopy with the aid of AI. Results A positive correlation between PPG and EVD was identified (r = 0.521, P < 0.001), which was further supported by multivariate linear regression analysis (b = 6.521, t = 6.872, P < 0.001). When patients were stratified into two groups based on PPG levels (27 patients with PPG < 20 mmHg and 101 patients with PPG ≥ 20 mmHg), a significant difference in EVD was observed between the groups (OR = 29.275, 95% CI 5.590-153.304, P < 0.001), with larger EVD in the higher PPG group. These findings suggest that EVD may serve as a predictor of adverse events associated with elevated PPG levels. In addition, receiver operating characteristic (ROC) curve analysis showed that EVD had an accuracy of 0.814 in diagnosing PPG function (standard error 0.048, 95% CI 0.720-0.908; P < 0.001), indicating that PPG levels are likely to exceed 20 mmHg when the variceal diameter is greater than 1.1 cm. Conclusion EVD demonstrated a positive correlation with PPG and could potentially be used as a predictive marker for assessing PPG levels. These findings provide novel insights for the non-invasive evaluation of PPG in clinical practice.
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Affiliation(s)
- Yudi Mao
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Province Key Laboratory of Digestive Diseases, Hefei, China
- Department of Geriatrics and Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Zhongliang Fang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Province Key Laboratory of Digestive Diseases, Hefei, China
- Department of Geriatrics and Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Yingying He
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Province Key Laboratory of Digestive Diseases, Hefei, China
| | - Jing Jin
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Province Key Laboratory of Digestive Diseases, Hefei, China
| | - Xiping Ding
- Department of Geriatrics and Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Derun Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Province Key Laboratory of Digestive Diseases, Hefei, China
- Continuous Education College, Anhui Medical University, Hefei, China
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Alvarado-Tapias E, Brujats A, Puente A, Ardevol A, Rodriguez-Arias A, Fajardo J, Pavel O, Garcia-Guix M, Aracil C, Poca M, Cuyàs B, Cantó E, Montañés R, Garcia-Osuna A, Escorsell À, Torras X, Villanueva C. Hemodynamic effects of carvedilol plus simvastatin in cirrhosis with severe portal hypertension and suboptimal response to β-blockers: A double-blind, placebo-controlled, randomized trial. Hepatology 2024:01515467-990000000-01072. [PMID: 39509369 DOI: 10.1097/hep.0000000000001148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 10/08/2024] [Indexed: 11/15/2024]
Abstract
BACKGROUND AND AIMS Carvedilol is a nonselective β-blocker (NSBB) with anti-α1-adrenergic activity, more effective than traditional NSBBs in reducing portal pressure hepatic venous pressure gradient (HVPG). However, 35%-45% of patients still have insufficient HVPG decrease. Statins ameliorate endothelial dysfunction, reduce hepatic vascular resistance, and have pleiotropic effects. We investigated whether the addition of simvastatin improves the efficacy of carvedilol on HVPG in cirrhosis with severe portal hypertension and suboptimal response to traditional NSBBs. METHODS Patients with cirrhosis and high-risk varices referred for primary prophylaxis were consecutively included. HVPG was measured at baseline and again after i.v. propranolol. Suboptimal responders (HVPG decrease <20%) were treated with carvedilol and were randomized to double-blind administration of placebo or simvastatin. Chronic HVPG response was assessed after 4-6 weeks, repeating HVPG measurements after a standard liquid meal to estimate endothelial dysfunction. Plasma samples were obtained before each study to investigate inflammatory parameters. RESULTS Of 184 eligible patients, 82 were randomized to carvedilol + simvastatin (N = 41) or carvedilol + placebo (N = 41). Baseline characteristics were similar. HVPG significantly decreased with both, carvedilol + simvastatin (18.6 ± 4 to 15.7 ± 4 mm Hg, p < 0.001) and carvedilol + placebo (18.9 ± 3 to 16.9 ± 3 mm Hg, p < 0.001). The decrease was greater with carvedilol + simvastatin (2.97 ± 2.5 vs. 2.05 ± 1.6 mm Hg, p = 0.031). An HVPG decrease ≥20% occurred in 37% versus 15% of patients, respectively (OR: 3.37, 95% CI = 1.15-9.85; p = 0.021). With test meal, HVPG increased in both groups ( p < 0.01), although carvedilol + simvastatin attenuated such increment (12 ± 8% vs. 23 ± 16%, p < 0.001). Cytokine levels (Interleukine-6, monocyte-chemoattractant protein-1, and malondialdehyde) decreased significantly more with carvedilol + simvastatin ( p < 0.01). The incidence of adverse events was similar. CONCLUSIONS In patients with severe portal hypertension (all with high-risk varices) and suboptimal hemodynamic response to traditional NSBBs, combined therapy with carvedilol plus simvastatin significantly enhances the portal pressure reduction achieved with carvedilol monotherapy, improves endothelial dysfunction, and reduces proinflammatory cytokines.
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Affiliation(s)
- Edilmar Alvarado-Tapias
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Anna Brujats
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Angela Puente
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Alba Ardevol
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Javier Fajardo
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Oana Pavel
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Marta Garcia-Guix
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Carles Aracil
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Elisabet Cantó
- Inflammatory Diseases Department, Institut Recerca Hospital Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Rosa Montañés
- Inflammatory Diseases Department, Institut Recerca Hospital Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Alvaro Garcia-Osuna
- Department of Biochemistry, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Àngels Escorsell
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Xavier Torras
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Càndid Villanueva
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
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10
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Tevethia HV, Pande A, Vijayaraghavan R, Kumar G, Sarin SK. Combination of carvedilol with variceal band ligation in prevention of first variceal bleed in Child-Turcotte-Pugh B and C cirrhosis with high-risk oesophageal varices: the 'CAVARLY TRIAL'. Gut 2024; 73:1844-1853. [PMID: 39067870 DOI: 10.1136/gutjnl-2023-331181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 07/01/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES Beta-blockers and endoscopic variceal band ligation (VBL) have been preferred therapies for primary prophylaxis of variceal bleeding. However, the choice of therapy in patients with advanced liver disease with high-risk varices is not clear. A comparison of these therapies alone or in combination to prevent the first variceal bleed in advanced cirrhosis patients was carried out. DESIGN 330 Child-Turcotte-Pugh (CTP) B and C cirrhosis patients, with 'high-risk' varices were prospectively enrolled (n=110 per group) to receive carvedilol (group A), VBL (group B) or combination (group C). Primary endpoint was reduction in the incidence of first variceal bleed at 12 months. The secondary endpoints included overall mortality, bleed-related mortality, new-onset decompensation, change in hepatic vein pressure gradient (HVPG) and treatment-related adverse events. RESULTS The patients were predominantly males (85.2%), aged 51.4±10.5 years with CTP score of 8.87±1.24, MELD score 15.17±3.35 and HVPG-16.96±3.57 mm Hg. The overall incidence of variceal bleed was 23.8% (n=78) at 1 year. Intention-to-treat analysis showed that the combination arm (group C) significantly reduced the incidence of first variceal bleed by 62.9% as compared with group B (HR 0.37, 95% CI 0.192 to 0.716, p<0.003) and by 69.3% as compared with group A (HR 0.31, 95% CI 0.163 to 0.578, <0.001). The overall mortality was 13.6% (45/330). The 1-year mortality in group C was lowest among the three groups (A, B, C=20%, 14.5%, 6.3%, p=0.012). Reduction in HVPG (20.8% vs 25.1%, p=0.54) and the rate of non-response to carvedilol (53.4% vs 41.25%, p=0.154) were not different between group A and C patients. The incidence of new-onset ascites, spontaneous bacterial peritonitis, shock, and acute kidney injury and postbleed organ failure was also comparable between the groups. CONCLUSION In CTP B and C cirrhosis patients with high-risk varices, combination of carvedilol and VBL is more effective than either therapy alone, for primary prevention of variceal bleeding. TRIAL REGISTRATION NUMBER NCT03069339.
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Affiliation(s)
| | - Apurva Pande
- Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Guresh Kumar
- Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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11
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Brzdęk M, Zarębska-Michaluk D, Kukla M, Janocha-Litwin J, Dybowska D, Janczewska E, Lorenc B, Berak H, Mazur W, Tudrujek-Zdunek M, Klapaczyński J, Piekarska A, Sitko M, Laurans Ł, Parfieniuk-Kowerda A, Flisiak R. Real-world experience with direct-acting antiviral therapy in HCV-infected patients with cirrhosis and esophageal varices. Pharmacol Rep 2024; 76:1114-1129. [PMID: 39162985 PMCID: PMC11387439 DOI: 10.1007/s43440-024-00639-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 08/11/2024] [Accepted: 08/12/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection affects 50 million people worldwide with around 242,000 deaths annually, mainly due to complications such as cirrhosis and hepatocellular carcinoma (HCC). Portal hypertension (PH) caused by cirrhosis leads to severe consequences, including esophageal varices (EV). This study aimed to evaluate the effectiveness and safety of direct-acting antiviral (DAA) treatment in patients with and without EV. METHODS This retrospective analysis involved consecutive HCV-infected adults undergoing DAA therapy at 22 Polish hepatology centers from July 1, 2015, to December 31, 2022. Patients with cirrhosis were categorized based on the presence of EV diagnosed by gastroscopy. Treatment effectiveness was measured by sustained virologic response (SVR), with safety outcomes monitored for 12 weeks post-treatment. RESULTS A population of 3393 HCV-infected patients with cirrhosis was divided into groups with (A, n = 976) and without (B, n = 2417) EV. Group A showed a significantly higher prevalence of comorbidities and concomitant medications. Genotype (GT)1b infections predominated in both groups, and GT3 infections were more common in the EV group. Group A exhibited more severe liver disease, and higher rates of decompensation, HCC, and HBV co-infection. SVR was significantly higher in group B (91.5% vs. 96.3%, p < 0.0001). Male gender, GT3, EV presence, and Child-Pugh grade B were identified as independent negative SVR predictors. Group A had a worse safety profile, with notably higher adverse event incidence and mortality. CONCLUSIONS DAA therapies are highly effective and well tolerated in patients with cirrhosis, but EV presence predicts poorer virologic responses.
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Affiliation(s)
- Michał Brzdęk
- Collegium Medicum, Jan Kochanowski University, aleja IX Wieków Kielc 19A, Kielce, 25-317, Poland.
| | - Dorota Zarębska-Michaluk
- Department of Infectious Diseases and Allergology, Jan Kochanowski University, Kielce, 25- 317, Poland
| | - Michał Kukla
- Department of Internal Medicine and Geriatrics, Faculty of Medicine, Jagiellonian University Medical College, Kraków, 31-688, Poland
- Department of Endoscopy, University Hospital, Kraków, 30-688, Poland
| | - Justyna Janocha-Litwin
- Department of Infectious Diseases and Hepatology, Wrocław Medical University, Wrocław, 50- 367, Poland
| | - Dorota Dybowska
- Department of Infectious Diseases and Hepatology, Faculty of Medicine, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University, Toruń, 87-100, Poland
- Voivodeship Infectious Observation Hospital in Bydgoszcz, Bydgoszcz, 85-030, Poland
| | - Ewa Janczewska
- Department of Basic Medical Sciences, School of Public Health in Bytom, Medical University of Silesia, Katowice, 40-055, Poland
| | - Beata Lorenc
- Pomeranian Center of Infectious Diseases, Medical University, Gdańsk, 80-214, Poland
| | - Hanna Berak
- Outpatient Clinic, Hospital for Infectious Diseases in Warsaw, Warsaw, 01-201, Poland
| | - Włodzimierz Mazur
- Clinical Department of Infectious Diseases in Chorzów, Medical University of Silesia, Katowice, 40-055, Poland
| | | | - Jakub Klapaczyński
- Department of Internal Medicine and Hepatology, The National Institute of Medicine of the Ministry of Interior and Administration, Warszawa, 02-507, Poland
| | - Anna Piekarska
- Department of Infectious Diseases and Hepatology, Medical University of Łódź, Łódź, 90- 419, Poland
| | - Marek Sitko
- Department of Infectious and Tropical Diseases, Jagiellonian University, Kraków, 31- 088, Poland
| | - Łukasz Laurans
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, Szczecin, 70-204, Poland
- Multidisciplinary Regional Hospital in Gorzów Wielkopolski, Gorzów Wielkopolski, 66-400, Poland
| | - Anna Parfieniuk-Kowerda
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, 15-089, Poland
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, 15-089, Poland
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12
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Kwape L, Gabriel S, Abdelsalem A, Rose P, Bathobakae L, Peterson D, Moodley D, Parker M, Moolla S, Parker A, Siamisang K, Van Rensburg C, Fredericks E. Evaluation of Noninvasive Tools for Predicting Esophageal Varices in Patients With Cirrhosis at Tygerberg Hospital, Cape Town. Int J Hepatol 2024; 2024:9952610. [PMID: 39296589 PMCID: PMC11410406 DOI: 10.1155/2024/9952610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 07/23/2024] [Accepted: 08/06/2024] [Indexed: 09/21/2024] Open
Abstract
Background: In patients with cirrhosis, esophageal variceal hemorrhage (EVH) is a devastating consequence of portal hypertension (PH). Upper endoscopy is considered the gold standard for the detection and diagnosis of esophageal varices (EVs), despite being invasive and costly. This study was aimed at identifying and evaluating the diagnostic accuracy of noninvasive tools in predicting EVs in patients with compensated cirrhosis. Methods: This cross-sectional study included 50 patients with compensated cirrhosis at the Tygerberg Hospital Gastroenterology Clinic in Cape Town between November 2022 and May 2023. We collected clinical, anthropometric, and laboratory data from patients' physical and electronic charts. All patients underwent an abdominal ultrasound, vibration-controlled transient elastography (VCTE) to assess liver and splenic stiffness, and upper endoscopy. In this comparative study, we evaluated the diagnostic accuracy of different noninvasive tools in detecting EVs in patients with compensated cirrhosis. Results: Of the 50 patients included in the study, 30 (60%) were female and 20 (40%) were male. The patients' age ranged from 18 to 83, with a mean age of 46.6 years. Cirrhosis was mainly due to alcohol use (n = 11, 22%), hepatitis B virus (HBV) infection (n = 11, 22%), and autoimmune hepatitis (n = 10, 20%). The patients included in the study were divided into two subgroups: with (n = 34, 68%) or without (n = 16, 32%) EVs. Statistically significant differences were detected between groups in platelet count (PC), liver stiffness measurement (LSM), spleen stiffness measurement (SSM), portal vein diameter (PVD), bipolar spleen diameter (SBD), aspartate aminotransferase-to-platelet ratio index (APRI), fibrosis-4 index (FIB-4), platelet/bipolar spleen diameter ratio (PSR), liver stiffness-spleen size-platelet ratio (LSPS), liver stiffness-spleen stiffness-platelet ratio score (LS3PS), and spleen stiffness-spleen size-platelet ratio score (SSPS) (p < 0.001). The highest diagnostic precision was observed with SSM (96%), SSPS (96%), LS3PS (94%), LSPS (94%), PSR (94%), and PC (92%). SBD (88%), LSM (86%), APRI (82%), and FIB-4 (82%) had the lowest diagnostic accuracy. Conclusion: SSM and SSPS have the highest diagnostic accuracy for predicting the presence of EVs in patients with compensated cirrhosis. LSPS, LS3PS, and PSR come second at 94%. We recommend SSM and SSPS in institutions with transient elastography equipped with the software necessary to measure splenic stiffness. We introduce and propose LS3PS as a novel composite score for predicting the presence of EVs in patients with compensated cirrhosis. Large-sample-size studies are needed to validate these prediction scores and to allow direct comparison with Baveno VII. These prediction tools can help clinicians avoid unnecessary endoscopic procedures in patients with compensated cirrhosis, especially in developing countries with limited resources such as South Africa.
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Affiliation(s)
- Lawrence Kwape
- Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Shiraaz Gabriel
- Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Ahmad Abdelsalem
- Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Penelope Rose
- Department of Paediatrics and Child Health Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Lefika Bathobakae
- Internal Medicine St. Joseph's University Medical Center, Paterson, New Jersey, USA
| | - Dale Peterson
- Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Desiree Moodley
- Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Mohammed Parker
- Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Saadiq Moolla
- Division of Pulmonology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Arifa Parker
- Unit for Infection Prevention and Control Department of Medicine Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- Division of Infectious Diseases Department of Medicine Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Keatlaretse Siamisang
- Department of Family Medicine and Public Health University of Botswana, Gaborone, Botswana
| | - Christoffel Van Rensburg
- Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Ernst Fredericks
- Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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13
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Jarasvaraparn C, Thoe J, Rodenbarger A, Masuoka H, Payne RM, Markham LW, Molleston JP. Biomarkers of fibrosis and portal hypertension in Fontan-associated liver disease in children and adults. Dig Liver Dis 2024; 56:1335-1342. [PMID: 38220486 DOI: 10.1016/j.dld.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/19/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Fontan-associated liver disease (FALD) refers to structural and functional changes of the liver caused by the physiology of the Fontan palliation. Currently, liver biopsy is the gold standard to assess liver fibrosis of FALD. AIM Investigate biomarkers correlating with severity of liver biopsy fibrosis in FALD. METHODS A retrospective study of post-Fontan patients ≥ 10 years of age who underwent liver biopsy was conducted. Advanced liver disease (ALD) was defined as bridging fibrosis and/or cirrhosis on liver biopsy. AST-to-platelet ratio index (APRI), Fibrosis-4 (FIB-4) and Liver Stiffness Measurement (LSM) from FibroScan were used as non-invasive fibrosis scores. RESULTS Sixty-six patients (26/47; 55.3% adults and 13/19 children; 68.4%) had ALD on biopsy. ALD was associated with lower platelet count (151 vs. 198 K/uL, p = 0.003), higher APRI (0.64 vs. 0.32, p = 0.01), higher FIB-4 (0.64 vs. 0.32, p = 0.02). Liver fibrosis score correlated with APRI (0.34, p = 0.02) and FIB-4 (0.47, p = 0.001) in adults. LSM had a high sensitivity at 81.3% with 45.5% specificity at a cut-off 18.5 kPa. CONCLUSIONS APRI and FIB-4 had modest discrimination to identify adults with advanced liver disease, but not children, indicating that these values may be followed as a marker of FALD progression in older patients.
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Affiliation(s)
- Chaowapong Jarasvaraparn
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University, 705 Riley Hospital Drive, ROC 4210, Indianapolis, Indiana 46202, United States.
| | | | | | - Howard Masuoka
- Division of Gastroenterology, Hepatology and Nutrition Riley Hospital for Children at IU Health, Indiana University School of Medicine, United States
| | | | | | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University, 705 Riley Hospital Drive, ROC 4210, Indianapolis, Indiana 46202, United States
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14
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Garcia-Guix M, Ardevol A, Sapena V, Alvarado-Tápias E, Huertas A, Brujats A, Fajardo J, Cuyas B, Poca M, Guarner C, Torras X, Escorsell À, Villanueva C. Influence of further decompensation on survival across clinical stages of decompensated cirrhosis: The role of portal hypertension and HVPG changes. Liver Int 2024; 44:1971-1989. [PMID: 38634685 DOI: 10.1111/liv.15937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND AIMS Decompensated-cirrhosis encompasses several stages with different prognosis, such as bleeding, ascites and bleeding-plus-ascites. Development of further-decompensation worsens survival, while non-selective β-blockers (NSBBs) can modify the risk. However, how this applies to each stage is uncertain. We aimed to investigate, in each stage of decompensated-cirrhosis, the influence of further-decompensation on mortality and whether changes in portal-pressure (HVPG) under NSBBs influence these outcomes. METHODS Patients with variceal bleeding were consecutively included differentiating those with bleeding-alone from those who also had ascites. Patients with ascites and high-risk varices referred for primary-prophylaxis were also investigated. A baseline haemodynamic study was performed and was repeated after 1-3-months under NSBBs. Outcomes were investigated by competing-risk. RESULTS Totally 103 patients had bleeding-alone, 186 bleeding-plus-ascites and 187 ascites-alone. Mean follow-up was 32-months (IQR, 12-60). Patients with bleeding-plus-ascites had higher HVPG and were more hyperdynamic than patients with ascites-alone and these than those with bleeding-alone. At each stage, the mortality risk was more than twice in patients developing further-decompensation vs. those without (p < .001). In each stage, HVPG-decrease under NSBBs showed better discrimination to predict further-decompensation than the baseline MELD, Child-Pugh or HVPG, by time-dependent ROC-curves (c-statistic >70%). At each stage, patients without HVPG-decreases, either ≥10% or ≥20% from the baseline, had higher risk of further-decompensation (sHR from 2.43 to 6.73, p < .01) and worse survival. CONCLUSIONS In each stage of decompensated cirrhosis, mortality risk significantly and very markedly increase with further-decompensation. HVPG-non-response to NSBBs may adequately stratify the risk of further decompensation and death, in each stage. This suggests potential benefit with pre-emptive therapies in HVPG-non-responders at each-stage.
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Affiliation(s)
- Marta Garcia-Guix
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alba Ardevol
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Sapena
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
- Medical Statistics Core Faculty, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Edilmar Alvarado-Tápias
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Anna Huertas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Brujats
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier Fajardo
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Berta Cuyas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - María Poca
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Carlos Guarner
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Xavier Torras
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Àngels Escorsell
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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15
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Duarte-Rojo A, Patel K, Rockey DC. Noninvasive assessment of liver fibrosis and portal hypertension. Curr Opin Gastroenterol 2024; 40:148-155. [PMID: 38547334 DOI: 10.1097/mog.0000000000001019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW The result of ongoing liver injury - and disease, regardless of cause - is fibrosis, and fibrosis appears to be a critically important result of ongoing injury. Further, in a number of different liver diseases, the presence of fibrosis has prognostic value. Therefore, the assessment of fibrosis is of critical clinical importance. Given the importance of fibrosis, there has been a rapid evolution in the use of noninvasive liver tests. This review highlights a number of the core principles surrounding. RECENT FINDINGS The use of noninvasive test has progressed rapidly over the last decade and data are rapidly accumulating. New terminology has been adapted by the American Association for the Study of Liver Disease (AASLD) for noninvasive assessment of liver disease and termed 'NILDA' (Non-Invasive Liver Disease Assessment). Blood based such as APRI and or FIB-4 and imaging tests such as liver stiffness measurement (LSM) have moderate to high degrees of accuracy for detection of advanced liver fibrosis (≥ F2) and even higher accuracy for detection of severe fibrosis (F4 or cirrhosis). NILDA are particularly effective at the ends of the liver disease spectrum. For example, a very low LSM (less than 7 kPa) essentially excludes significant fibrosis or portal hypertension, and a very high LSM (> 25 kPa) makes significant fibrosis with portal hypertension (cirrhosis) highly likely. SUMMARY NILDA are currently front and center in terms of assessment of the severity of liver disease. In all patients with known or suspected liver disease, noninvasive blood tests, including APRI and or FIB-4, should be the initial choice to assess the severity of liver fibrosis and/or portal hypertension. In most patients, these tests should be followed with imaging evaluation. The most commonly available imaging is LSM, which appears to be more accurate in predicting fibrosis severity, and is superior to blood tests in the assessment of portal hypertension. In situations in which there is diagnostic uncertainly, liver biopsy with or without HVPG remains an important consideration.
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Affiliation(s)
- Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Keyur Patel
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Don C Rockey
- Medical University of South Carolina Digestive Disease Research Center and the Medical University of South Carolina, Charleston, South Carolina, USA
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Cromer M, Wilcox CM, Shoreibah M. Beta-blockers and cirrhosis: Striking the right balance. Am J Med Sci 2024; 367:228-234. [PMID: 38262558 DOI: 10.1016/j.amjms.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 01/16/2024] [Indexed: 01/25/2024]
Abstract
Decompensated cirrhosis is associated with a significantly increased risk of mortality. Variceal hemorrhage (VH) further increases the risk of mortality, and of future variceal bleed events. Non-selective beta-blockers (NSBBs) are effective therapy for primary and secondary prophylaxis of VH and have become the cornerstone of pharmacologic therapy in cirrhosis. Beta-blockers are associated with reduced overall mortality and GI-bleeding related mortality in patients with decompensated cirrhosis; they may also confer hemodynamically independent beneficial effects. Long-term treatment with beta-blockers may improve decompensation-free survival in compensated cirrhosis with clinically significant portal hypertension (CSPH). Carvedilol more effectively lowers the hepatic vein portal gradient than traditional NSBBs and has been shown to improve survival in compensated cirrhosis. Treatment goals in compensated cirrhosis with CSPH should focus on early utilization of beta-blockers to prevent decompensation and reduce mortality.
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Affiliation(s)
- Mark Cromer
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - C Mel Wilcox
- Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Mohamed Shoreibah
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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17
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Jirapinyo P, Thompson CC, Garcia-Tsao G, Zucker SD, Ryou M. The effect of endoscopic gastric plication on portosystemic pressure gradient in patients with nonalcoholic fatty liver disease and compensated advanced chronic liver disease. Endoscopy 2024; 56:56-62. [PMID: 37532114 DOI: 10.1055/a-2146-8857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
BACKGROUND The goals of therapy for patients with nonalcoholic fatty liver disease and compensated advanced chronic liver disease include weight loss and reduction of the portosystemic pressure gradient (PPG) to decrease the risk of hepatic decompensation. Endoscopic gastric plication (EGP) is an effective endoscopic weight loss procedure. This study aimed to assess the effect of EGP on PPG. METHODS In this prospective pilot study, patients with nonalcoholic fatty liver disease and compensated advanced chronic liver disease underwent endoscopic ultrasound-guided PPG measurement prior to and at 6 months following EGP. Primary outcomes were the change in PPG and proportion of patients experiencing ≥ 20 % reduction in PPG at 6 months. Secondary outcomes included percent total weight loss (TWL) and changes in noninvasive tests of fibrosis. RESULTS 20 patients were included. Baseline median body mass index and liver stiffness measurement were 40.2 kg/m2 (range 30.1-56.7) and 14.7 kPa (range 8.2-36), respectively. At 6 months, median PPG decreased from 5.4 mmHg (range 0.7-19.6) to 1.8 mmHg (range 0.4-17.6) (P = 0.002), with 79 % (11/14) experiencing ≥ 20 % reduction. Patients experienced 12.5 % (6.5 %-26.1 %) TWL (P < 0.001) at 6 months, with 89 % (17/19) achieving ≥ 7 % and 68 % (13/19) achieving ≥ 10 % TWL. There were significant improvements in noninvasive tests of fibrosis. CONCLUSION EGP appeared to be effective at reducing PPG in patients with nonalcoholic fatty liver disease and compensated advanced chronic liver disease.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, United States
- Section of Digestive Diseases, VA-CT Healthcare System, West Haven, Connecticut, United States
| | - Stephen D Zucker
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
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18
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Mingpun W, Sobhonslidsuk A, Chumnumwat S. Optimal resting heart rate and ascites-related death in patients with cirrhosis and ascites using nonselective beta-blockers (ORCA). Clin Transl Sci 2024; 17:e13681. [PMID: 37950532 PMCID: PMC10766015 DOI: 10.1111/cts.13681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/09/2023] [Accepted: 11/05/2023] [Indexed: 11/12/2023] Open
Abstract
Nonselective beta-blockers (NSBBs) may exacerbate ascites by impairing cardiac function. This study evaluated the impact of achieving a heart rate target of 55-60 beats per minute (bpm) on ascites-related death and complications from worsening ascites in patients with cirrhosis and diuretic-responsive ascites using NSBBs. A retrospective study was conducted at the Faculty of Medicine Ramathibodi Hospital, Mahidol University (2012-2022) and analyzed patients with cirrhosis and diuretic-responsive ascites using NSBBs (propranolol/carvedilol) for variceal bleeding prophylaxis. The outcomes were incidence of ascites-related death and complications from worsening ascites, comparing the achievable target group (heart rate 55-60 bpm) and the unachievable target group (heart rate >60 bpm). A total of 206 patients were included in the study, with a median follow-up time of 20 months. The patients were divided into an achievable target group (n = 75, median heart rate = 58.0 bpm) and an unachievable target group (n = 131, median heart rate = 73.6 bpm). Propranolol was the most used NSBB (95.1%). The adjusted hazard ratio (HR) for ascites-related death from spontaneous bacterial peritonitis (SBP) or refractory ascites (RA) or hepatorenal syndrome (HRS) or hepatic encephalopathy (HE) showed no difference between the groups (adjusted HR 0.59 [0.23-1.54]; p = 0.28). Additionally, no significant difference was found in the incidence of complications between groups, including SBP, RA, HRS, and HE. Achieving a heart rate target of 55-60 bpm with NSBBs for variceal bleeding prophylaxis is safe in patients with diuretic-responsive ascites and cirrhosis.
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Affiliation(s)
- Warunee Mingpun
- Department of Pharmacy, Faculty of PharmacyMahidol UniversityBangkokThailand
- Department of Pharmaceutical Care, Faculty of PharmacyChiang Mai UniversityChiang MaiThailand
| | - Abhasnee Sobhonslidsuk
- Division of Gastroenterology and Hepatology, Faculty of Medicine, Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Supatat Chumnumwat
- Department of Pharmacy, Faculty of PharmacyMahidol UniversityBangkokThailand
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Martino A, Amitrano L, Guardascione M, Di Serafino M, Bennato R, Martino R, de Leone A, Orsini L, Romano L, Lombardi G. The role of computed tomography for the prediction of esophageal variceal bleeding: Current status and future perspectives. World J Gastrointest Endosc 2023; 15:681-689. [PMID: 38187916 PMCID: PMC10768040 DOI: 10.4253/wjge.v15.i12.681] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/13/2023] [Accepted: 11/27/2023] [Indexed: 12/15/2023] Open
Abstract
Esophageal variceal bleeding (EVB) is one of the most common and severe complications related to portal hypertension (PH). Despite marked advances in its management during the last three decades, EVB is still associated with significant morbidity and mortality. The risk of first EVB is related to the severity of both PH and liver disease, and to the size and endoscopic appearance of esophageal varices. Indeed, hepatic venous pressure gradient (HVPG) and esophagogastroduodenoscopy (EGD) are currently recognized as the “gold standard” and the diagnostic reference standard for the prediction of EVB, respectively. However, HVPG is an invasive, expensive, and technically complex procedure, not widely available in clinical practice, whereas EGD is mainly limited by its invasive nature. In this scenario, computed tomography (CT) has been recently proposed as a promising modality for the non-invasive prediction of EVB. Although CT is only a diagnostic modality, thus being not capable of supplanting EGD or HVPG in providing therapeutic and physiological data, it could potentially assist liver disease scores, HVPG, and EGD in a more effective prediction of EVB. However, to date, evidence concerning the role of CT in this setting is still lacking. Our review aimed to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Lucio Amitrano
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marianna Guardascione
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Raffaele Bennato
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Rossana Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Annalisa de Leone
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
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Hassan M, Merza N, Nawras Y, Bahbah EI, Al-Hillan A, Ahmed Z, ElSheref SEDM, Dahiya DS, Dar S, Al Azzawi M, Kobeissy A. Continuous vs. intermittent terlipressin infusion for portal hypertension: a systematic review and meta-analysis. Ann Med Surg (Lond) 2023; 85:5001-5010. [PMID: 37811089 PMCID: PMC10553058 DOI: 10.1097/ms9.0000000000001261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 08/23/2023] [Indexed: 10/10/2023] Open
Abstract
Background Portal hypertension, a major complication of chronic liver disease, often leads to life-threatening variceal bleeding, managed effectively with vasoactive drugs like terlipressin. However, the most optimal method of terlipressin administration, continuous versus intermittent infusion, remains a subject of debate, necessitating this systematic review and meta-analysis for evidence-based decision-making in managing this critical condition. Methods This systematic review and meta-analysis adhered to the PRISMA standards and explored multiple databases until 6 April 2023, such as MEDLINE through PubMed, Scopus, Web of Science, and CENTRAL. Independent reviewers selected randomized controlled trials (RCTs) that met specific inclusion criteria. After assessing study quality and extracting necessary data, statistical analysis was performed using Review Manager (RevMan), with results presented as risk ratios (RR) or mean differences. Results Five RCTs (n=395 patients) were included. The continuous terlipressin group had a significantly lower risk of rebleeding (RR=0.43, P=0.0004) and treatment failure (RR=0.22, P=0.02) and fewer total adverse effects (RR=0.52, P<0.00001) compared to the intermittent group. However, there were no significant differences between the two groups in mean arterial pressure (P=0.26), length of hospital stays (P=0.78), and mortality rates (P=0.65). Conclusion This study provides robust evidence suggesting that continuous terlipressin infusion may be superior to intermittent infusions in reducing the risk of rebleeding, treatment failure, and adverse effects in patients with portal hypertension. However, further large-scale, high-quality RCTs are required to confirm these findings and to investigate the potential benefits of continuous terlipressin infusion on mortality and hospital stays.
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Affiliation(s)
| | | | - Yusuf Nawras
- The University of Toledo, College of Medicine and Life Sciences, Toledo, Ohio
| | - Eshak I. Bahbah
- Department of Internal Medicine, Al Azhar University, New Damietta, Egypt
| | - Alsadiq Al-Hillan
- Gastroenterology Department, Corewell health/Willam Beaumont University Hospital, Michigan
| | | | | | - Dushyant S. Dahiya
- Division of Gastroenterology, University of Kansas School of Medicine, Kansas City
| | - Sophia Dar
- Gastroenterology Department, Southern Illinois University, Springfield, Illinois, USA
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Vukotic R, Di Donato R, Roncarati G, Simoni P, Renzulli M, Gitto S, Schepis F, Villa E, Berzigotti A, Bosch J, Andreone P. 5-MTHF enhances the portal pressure reduction achieved with propranolol in patients with cirrhosis: A randomized placebo-controlled trial. J Hepatol 2023; 79:977-988. [PMID: 37482222 DOI: 10.1016/j.jhep.2023.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 05/12/2023] [Accepted: 06/02/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND & AIMS β-blockers reduce hepatic venous pressure gradient (HVPG) by decreasing portal inflow, with no reduction in intrahepatic vascular resistance. 5-Methyltetrahydrofolate (5-MTHF) can prevent oxidative loss of tetrahydrobiopterin (BH4), a cofactor for endothelial nitric oxide synthase coupling. It also converts homocysteine (tHcy) into methionine and enables the degradation of asymmetric dimethylarginine (ADMA), an inhibitor of endothelial nitric oxide synthase. The aim of this study was to evaluate the effects of 5-MTHF in combination with propranolol on HVPG and nitric oxide bioavailability markers in patients with cirrhosis and portal hypertension. METHOD Sixty patients with cirrhosis and HVPG ≥12 mmHg were randomized 1:1 to receive treatment with 5-MTHF+propranolol or placebo+propranolol for 90 days under double-blind conditions. HVPG and markers of nitric oxide bioavailability (BH4, ADMA and tHcy) were measured again at the end of treatment. RESULTS Groups were similar in terms of baseline clinical and hemodynamic data and nitric oxide bioavailability markers. HVPG decreased in both groups, but the magnitude of the change was significantly greater in the group treated with 5-MTHF+propranolol compared to placebo+propranolol (percentage decrease, 20 [29-9] vs. 12.5 [22-0], p = 0.028), without differences in hepatic blood flow. At the end of treatment, 5-MTHF+propranolol (vs. placebo+propranolol) was associated with higher BH4 (1,101.4 ± 1,413.3 vs. 517.1 ± 242.8 pg/ml, p <0.001), lower ADMA (109.3 ± 52.7 vs. 139.9 ± 46.7 μmol/L, p = 0.027) and lower tHcy (μmol/L, 11.0 ± 4.6 vs. 15.4 ± 7.2 μmol/L, p = 0.010) plasma levels. CONCLUSION In patients with cirrhosis and portal hypertension, 5-MTHF administration significantly enhanced the HVPG reduction achieved with propranolol. This effect appears to be mediated by improved nitric oxide bioavailability in the hepatic microcirculation. CLINICAL TRIAL EUDRACT NUMBER 2014-002018-21. IMPACT AND IMPLICATIONS Currently, the pharmacological prevention of cirrhosis complications due to portal hypertension, such as esophageal varices rupture, is based on the use of β-blockers, but some patients still present with acute variceal bleeding, mainly due to an insufficient reduction of portal pressure. In this study, we sought to demonstrate that the addition of folic acid to β-blockers is more effective in reducing portal pressure than β-blockers alone. This finding could represent the basis for validation studies in larger cohorts, which could impact the future prophylactic management of variceal bleeding in cirrhosis. Enhancing the benefit of β-blockers with a safe, accessible, cost-effective drug could improve clinical outcomes in cirrhosis, which in turn could translate into a reduction in the rates and costs of hospitalization, and ultimately into improved survival.
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Affiliation(s)
- Ranka Vukotic
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Roberto Di Donato
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Greta Roncarati
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Patrizia Simoni
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Gitto
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Filippo Schepis
- Department of Internal Medicine, Gastroenterology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Villa
- Department of Internal Medicine, Gastroenterology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jaume Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Kumar R, Kumar S, Prakash SS. Compensated liver cirrhosis: Natural course and disease-modifying strategies. World J Methodol 2023; 13:179-193. [PMID: 37771878 PMCID: PMC10523240 DOI: 10.5662/wjm.v13.i4.179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 09/20/2023] Open
Abstract
Compensated liver cirrhosis (CLC) is defined as cirrhosis with one or more decompensating events, such as ascites, variceal haemorrhage, or hepatic encephalopathy. Patients with CLC are largely asymptomatic with preserved hepatic function. The transition from CLC to decompensated cirrhosis occurs as a result of a complex interaction between multiple predisposing and precipitating factors. The first decompensation event in CLC patients is considered a significant turning point in the progression of cirrhosis, as it signals a drastic decline in median survival rates from 10-12 years to only 1-2 years. Furthermore, early cirrhosis has the potential to regress as liver fibrosis is a dynamic condition. With the advent of effective non-invasive tools for detecting hepatic fibrosis, more and more patients with CLC are currently being recognised. This offers clinicians a unique opportunity to properly manage such patients in order to achieve cirrhosis regression or, at the very least, prevent its progression. There are numerous emerging approaches for preventing or delaying decompensation in CLC patients. A growing body of evidence indicates that treating the underlying cause can lead to cirrhosis regression, and the use of non-selective beta-blockers can prevent decompensation by lowering portal hypertension. Additionally, addressing various cofactors (such as obesity, diabetes, dyslipidaemia, and alcoholism) and precipitating factors (such as infection, viral hepatitis, and hepatotoxic drugs) that have a detrimental impact on the natural course of cirrhosis may benefit patients with CLC. However, high-quality data must be generated through well-designed and adequately powered randomised clinical trials to validate these disease-modifying techniques for CLC patients. This article discussed the natural history of CLC, risk factors for its progression, and therapeutic approaches that could alter the trajectory of CLC evolution and improve outcomes.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Sudhir Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Sabbu Surya Prakash
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
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Mazumder NR, Jezek F, Tapper EB, Beard DA. Portal Venous Remodeling Determines the Pattern of Cirrhosis Decompensation: A Systems Analysis. Clin Transl Gastroenterol 2023; 14:e00590. [PMID: 37092902 PMCID: PMC10522110 DOI: 10.14309/ctg.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 04/25/2023] Open
Abstract
INTRODUCTION As liver disease progresses, scarring results in worsening hemodynamics ultimately culminating in portal hypertension. This process has classically been quantified through the portosystemic pressure gradient (PSG), which is clinically estimated by hepatic venous pressure gradient (HVPG); however, PSG alone does not predict a given patient's clinical trajectory regarding the Baveno stage of cirrhosis. We hypothesize that a patient's PSG sensitivity to venous remodeling could explain disparate disease trajectories. METHODS We created a computational model of the portal system in the context of worsening liver disease informed by physiologic measurements from the field of portal hypertension. We simulated progression of clinical complications, HVPG, and transjugular intrahepatic portosystemic shunt placement while only varying a patient's likelihood of portal venous remodeling. RESULTS Our results unify hemodynamics, venous remodeling, and the clinical progression of liver disease into a mathematically consistent model of portal hypertension. We find that by varying how sensitive patients are to create venous collaterals with rising PSG we can explain variation in patterns of decompensation for patients with liver disease. Specifically, we find that patients who have higher proportions of portosystemic shunting earlier in disease have an attenuated rise in HVPG, delayed onset of ascites, and less hemodynamic shifting after transjugular intrahepatic portosystemic shunt placement. DISCUSSION This article builds a computational model of portal hypertension which supports that patient-level differences in venous remodeling may explain disparate clinical trajectories of disease.
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Affiliation(s)
- Nikhilesh R. Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Filip Jezek
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
- Institute of Pathological Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Daniel A. Beard
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
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Bosch J. Carvedilol as Best β-Blocker for Secondary Prophylaxis of Variceal Bleeding: Are We There, or Not Yet? Clin Gastroenterol Hepatol 2023; 21:2195-2196. [PMID: 36064098 DOI: 10.1016/j.cgh.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Jaume Bosch
- University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland, Hospital Clinic-IDIBAPS and Ciberehd, University of Barcelona, Barcelona, Spain.
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Elghezewi A, Hammad M, El-Dallal M, Mohamed M, Sherif A, Frandah W. Trends in Hospitalizations of Esophageal Varices From 2011 to 2018: A United States Nationwide Study. Gastroenterology Res 2023; 16:171-183. [PMID: 37351074 PMCID: PMC10284649 DOI: 10.14740/gr1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/17/2023] [Indexed: 06/24/2023] Open
Abstract
Background Prevalence of gastroesophageal varices is around 50% of patients with cirrhosis. In compensated cirrhosis they are present in 30-40%. Progression from small to large varices occurs at rate of 10-12% annually. That percentage increases significantly in decompensated liver cirrhosis with gastroesophageal varices found in 85% of patients. Variceal hemorrhage occurs at a rate around 10-15% per year. The outcome of variceal hemorrhage depends on the severity of liver disease, size of varices, and presence of stigmata of recent bleeding (red whale sign). Six-week mortality of variceal hemorrhage ranges between 15% and 25%. Without treatment, variceal hemorrhage tends to recur in 60% of patients within 1 - 2 years. The aim of the study was to assess demographics of esophageal varices with and without bleeding, geographic distribution, comorbidities, outcomes, main payers, and cost of hospitalizations. Methods The National Inpatient Sample (NIS) database from year 2011 to 2018 was used. Patients who had a primary diagnosis of esophageal varices with or without bleeding were identified using the International Classification of Diseases, Ninth Revision (ICD-9) codes (456.0 for esophageal varices with bleeding, and 456.1 for esophageal varices without bleeding), and International Classification of Diseases, 10th Revision (ICD-10) codes (I85.01 for esophageal varices with bleeding, and I85.00 for esophageal varices without bleeding) in the first two discharge diagnoses. The propensity score to calculate the inverse probability treatment weighting (IPTW) to adjust between the differences of the compared groups was implemented. Two groups were compared in terms of their hospitalization outcomes, including LOS, hospital charges, hospital mortality, and disposition. Results A total of 322,761 patients were admitted with esophageal varices between 2011 and 2018, with 236,802 (73.6%) had bleeding esophageal varices and 85,959 (26.4%) had nonbleeding esophageal varices. The majority of the patients from both groups were white (66%), covered with Medicare (38% in the esophageal varices with bleeding vs. 41% in the nonbleeding group). There was a steady increase of patients admitted with nonbleeding esophageal varices. Most common comorbidities were liver diseases, alcohol abuse, uncomplicated hypertension and depression in both groups. There were no significant changes in OLS over the years in both groups, but there was a significant increase in hospital charges, especially in the patients with bleeding esophageal varices starting in 2015, and no change in mortality throughout the years. Regarding hospital disposition, there was a notable decline in rehab discharge in the bleeding esophageal varices group. Conclusions Esophageal varices with and without bleeding have been steadily increasing since the beginning of this century. This may result in a substantial impact on increasing health care costs and utilization due to acute variceal hemorrhage. Odds of death, transfer to urban hospital, and transfer to visiting nursing assistance remained unchanged.
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Affiliation(s)
- Abdelwahap Elghezewi
- Department of Internal Medicine. Marshall University Hospital, Huntington, WV 25701, USA
| | - Mohamad Hammad
- Department of Internal Medicine. Marshall University Hospital, Huntington, WV 25701, USA
| | - Mohammed El-Dallal
- Department of Gastroenterology and Hepatology, Marshall University Hospital, Huntington, WV 25701, USA
| | - Mujtaba Mohamed
- Department of Gastroenterology and Hepatology, Marshall University Hospital, Huntington, WV 25701, USA
| | - Ahmed Sherif
- Department of Gastroenterology and Hepatology, Marshall University Hospital, Huntington, WV 25701, USA
| | - Wesam Frandah
- Department of Gastroenterology and Hepatology, Marshall University Hospital, Huntington, WV 25701, USA
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Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023; 15:216-239. [PMID: 37138933 PMCID: PMC10150286 DOI: 10.4253/wjge.v15.i4.216] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Gastroenterology, Sohana Multispeciality Hospital, Mohali 140308, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Kotani K, Enomoto M, Uchida-Kobayashi S, Tamori A, Yukawa-Muto Y, Odagiri N, Motoyama H, Kozuka R, Kawamura E, Hagihara A, Fujii H, Kageyama K, Yamamoto A, Yoshida A, Higashiyama S, Kawabe J, Kawada N. Short-term hepatocyte function and portal hypertension outcomes of sofosbuvir/velpatasvir for decompensated hepatitis C-related cirrhosis. J Gastroenterol 2023; 58:394-404. [PMID: 36729172 PMCID: PMC10049944 DOI: 10.1007/s00535-023-01963-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/26/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND It is unclear whether hepatocyte function and/or portal hypertension improves if a sustained virologic response (SVR) is achieved with direct-acting antivirals in patients with decompensated hepatitis C-related cirrhosis. METHODS We examined the safety and efficacy of a 12-week course of sofosbuvir/velpatasvir (SOF/VEL) in 20 patients with decompensated hepatitis C-related cirrhosis. We also investigated changes in the hepatocyte receptor index (LHL15) and blood clearance index (HH15) by Tc-99 m-galactosyl human serum albumin scintigraphy, liver stiffness measurement (LSM) by transient elastography, and hepatic venous pressure gradient (HVPG) in patients who achieved an SVR at 24 weeks after treatment (SVR24). RESULTS One patient discontinued treatment because of rectal variceal hemorrhage, and 19 patients completed treatment. SVR24 was achieved in 17 patients (89%). Median LHL15 increased from 0.72 pre-treatment to 0.82 after SVR24 (p = 0.012), and median HH15 decreased from 0.82 pre-treatment to 0.76 after SVR24 (p = 0.010). The percentage of patients with LSM ≥ 20 kPa was 90% before treatment and remained at 90% after SVR24. However, the percentage with severe portal hypertension (defined as HVPG ≥ 12 mmHg) decreased from 92% pre-treatment to 58% after SVR24 (p = 0.046). Patients with a decreased HVPG from pre-treatment to after SVR24 had a smaller pre-treatment spleen volume than those with an increased HVPG (median, 252 vs. 537 mL, p = 0.028). CONCLUSION Achieving SVR24 with SOF/VEL treatment in patients with decompensated hepatitis C-related cirrhosis can be expected to improve hepatocyte function and portal hypertension on short-term follow-up.
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Affiliation(s)
- Kohei Kotani
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Masaru Enomoto
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Sawako Uchida-Kobayashi
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Akihiro Tamori
- Department of Hepatology, Kashiwara Municipal Hospital, 1-7-9 Houzenji, Kashiwara, Osaka, 582-0005, Japan
| | - Yoshimi Yukawa-Muto
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Naoshi Odagiri
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Hiroyuki Motoyama
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ritsuzo Kozuka
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Etsushi Kawamura
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Atsushi Hagihara
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Hideki Fujii
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Atsushi Yoshida
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shigeaki Higashiyama
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Joji Kawabe
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
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Gupta AN, Sze DY, Rigas DA. Smaller Diameter and Adjustable Diameter Transjugular Intrahepatic Portosystemic Shunts. Semin Intervent Radiol 2023; 40:21-26. [PMID: 37152799 PMCID: PMC10159728 DOI: 10.1055/s-0043-1764285] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Complications of overshunting, including hepatic encephalopathy and hepatic insufficiency, remain prevalent following transjugular intrahepatic portosystemic shunt (TIPS) creation. Smaller diameter TIPS may reduce the risk of overshunting, but the use of smaller stents must be weighed against the risk of undershunting and persistent or recurrent hemorrhage, ascites, and other complications of portal hypertension. This article explores the question of optimal shunt diameter by examining outcomes for smaller diameter TIPS stent-grafts (<10 mm), underdilated stent-grafts, and variable diameter stent-grafts.
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Affiliation(s)
- Aakash N. Gupta
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Daniel Y. Sze
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Diamanto Amanda Rigas
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
- Division of Interventional Radiology, Department of Radiology, Veteran Administration Palo Alto Health Care System, Palo Alto, California
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29
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Roldán-Alzate A, Reeder SB. Image-based Vascular Modeling for Portal Hypertension Diagnosis. Radiology 2023; 307:e223163. [PMID: 36719296 DOI: 10.1148/radiol.223163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Alejandro Roldán-Alzate
- From the Departments of Mechanical Engineering (A.R.A.), Radiology (A.R.A., S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI 53705
| | - Scott B Reeder
- From the Departments of Mechanical Engineering (A.R.A.), Radiology (A.R.A., S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI 53705
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The Risk of Endoscopy-Related Bleeding in Patients with Liver Cirrhosis: A Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010170. [PMID: 36676794 PMCID: PMC9863762 DOI: 10.3390/medicina59010170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
Background and Objectives: The risk of bleeding after endoscopic procedures in patients with liver cirrhosis remains unclear because of secondary blood coagulation disorders. In this study, we used various indices to evaluate the risk of bleeding in patients with cirrhosis. Materials and Methods: Patients with liver cirrhosis aged ≥18 years who underwent endoscopic interventions at Kyung Hee University Hospital at Gangdong between February 2007 and September 2021 were included. Clinical information, including demographic data, laboratory results, the presence of cirrhosis complications, and the degree of fibrosis, was checked and evaluated based on medical records. Results: A total of 101 patients with cirrhosis were analyzed. A total of 16 of the 101 patients (15.8%) experienced bleeding after the endoscopic procedure. One patient (0.99%) presented with spurting, while the others presented with mild oozing. All patients underwent hemostatic procedures using hemoclips. The presence of a varix significantly increased post-endoscopic bleeding (p = 0.03). Patients with FIB > 3.25 showed a statistically significant bleeding tendency (p = 0.00). Conclusions: There was no significant difference in bleeding risk according to the platelet count, prothrombin time, Child−Pugh score, and model for end-stage liver disease (MELD). Considering the degree of liver fibrosis and the invasiveness of the planned procedure, most endoscopic procedures can be performed safely but should be further evaluated in a cohort with a larger sample size.
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31
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Sauerbruch T, Hennenberg M, Trebicka J, Schierwagen R. Beta-blockers in patients with liver cirrhosis: Pragmatism or perfection? Front Med (Lausanne) 2023; 9:1100966. [PMID: 36743678 PMCID: PMC9891090 DOI: 10.3389/fmed.2022.1100966] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
With increasing decompensation, hyperdynamic circulatory disturbance occurs in liver cirrhosis despite activation of vasoconstrictors. Here, the concept of a therapy with non-selective beta-blockers was established decades ago. They lower elevated portal pressure, protect against variceal hemorrhage, and may also have pleiotropic immunomodulatory effects. Recently, the beneficial effect of carvedilol, which blocks alpha and beta receptors, has been highlighted. Carvedilol leads to "biased-signaling" via recruitment of beta-arrestin. This effect and its consequences have not been sufficiently investigated in patients with liver cirrhosis. Also, a number of questions remain open regarding the expression of beta-receptors and its intracellular signaling and the respective consequences in the intra- and extrahepatic tissue compartments. Despite the undisputed role of non-selective beta-blockers in the treatment of liver cirrhosis, we still can improve the knowledge as to when and how beta-blockers should be used in which patients.
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Affiliation(s)
- Tilman Sauerbruch
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Martin Hennenberg
- Department of Urology, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Münster, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Robert Schierwagen
- Department of Internal Medicine B, University of Münster, Münster, Germany
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32
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Lv Y, Fan D, Han G. Transjugular intrahepatic portosystemic shunt for portal hypertension: 30 years experience from China. Liver Int 2023; 43:18-33. [PMID: 35593016 DOI: 10.1111/liv.15313] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/05/2022] [Accepted: 05/15/2022] [Indexed: 01/04/2023]
Abstract
Liver diseases are a major cause of illness and death worldwide. In China, liver diseases, primarily viral hepatitis, affect approximately 300 million people, thus having a major impact on the global burden of liver diseases. Portal hypertension is the most severe complication of chronic liver diseases, including ascites, hepatic encephalopathy and bleeding from gastroesophageal varices. Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of these complications. Since its introduction 30 years ago in China, the use of TIPS has evolved and has played an increasingly important role in the management of the complications of portal hypertension. This review will focus on the history, current application and management of complications of TIPS in China.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, China.,Military Medical Innovation Center, Fourth Military Medical University, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, China
| | - Guohong Han
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, China
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Shirane Y, Murakami E, Imamura M, Kosaka M, Johira Y, Miura R, Murakami S, Yano S, Amioka K, Naruto K, Ando Y, Uchikawa S, Teraoka Y, Uchida T, Fujino H, Ono A, Nakahara T, Kawaoka T, Miki D, Yamauchi M, Okamoto W, Tsuge M, Chosa K, Awai K, Aikata H, Oka S. Hepatic venous pressure gradient after balloon-occluded retrograde transvenous obliteration and liver stiffness measurement predict the prognosis of patients with gastric varices. BMC Gastroenterol 2022; 22:535. [PMID: 36550416 PMCID: PMC9773455 DOI: 10.1186/s12876-022-02616-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Balloon-occluded retrograde transvenous obliteration (BRTO) is a treatment option for patients with gastric varices (GVs). This study aimed to clarify the clinical significance of portal hypertension estimated by the hepatic venous pressure gradient (HVPG), subsequent exacerbation of esophageal varices (EVs), and prognosis of patients who underwent BRTO for GVs. METHODS Thirty-six patients with GVs treated with BRTO were enrolled in this study, and their HVPG was measured before (pre-HVPG) and on the day after BRTO (post-HVPG). After BRTO, patients were followed-up for a median interval of 24.5 (3-140) months. Clinical factors related to EVs exacerbation and prognosis after BRTO were retrospectively analyzed. RESULTS Post-HVPG increased compared to pre-HVPG in 21 out of 36 patients (58%), and post-HVPG was overall significantly higher compared to pre-HVPG (P = 0.009). During the observation period, 19 patients (53%) developed EVs exacerbation, and the cumulative EVs exacerbation rates at 1, 3 and 5 years after BRTO were 27%, 67%, and 73%, respectively. Pre-HVPG was not related to EVs exacerbation, although elevation of post-HVPG to ≥ 13 mmHg (P < 0.01) and high level of serum aspartate aminotransferase (P < 0.05) were significant independent risk factors for EVs exacerbation after BRTO. Fourteen patients (38.9%) died during the observation period. An elevated value of liver stiffness measurement (LSM) of ≥ 21 kPa was a significant independent risk factor for poor prognosis after BRTO (P < 0.05). CONCLUSIONS HVPG increases after BRTO. HVPG after BRTO has greater predictive ability for subsequent EVs exacerbation than HVPG before BRTO. LSM is a potential prognostic parameter in patients who undergo BRTO.
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Affiliation(s)
- Yuki Shirane
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Eisuke Murakami
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Michio Imamura
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Masanari Kosaka
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Yusuke Johira
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Ryoichi Miura
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Serami Murakami
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Shigeki Yano
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Kei Amioka
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Kensuke Naruto
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Yuwa Ando
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Shinsuke Uchikawa
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Yuji Teraoka
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Takuro Uchida
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Hatsue Fujino
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Atsushi Ono
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Takashi Nakahara
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Tomokazu Kawaoka
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Daiki Miki
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Masami Yamauchi
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan ,grid.470097.d0000 0004 0618 7953Cancer Treatment Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Wataru Okamoto
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan ,grid.470097.d0000 0004 0618 7953Cancer Treatment Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Masataka Tsuge
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan ,grid.257022.00000 0000 8711 3200Natural Science Center for Basic Research and Development, Hiroshima University, Hiroshima, Japan
| | - Keigo Chosa
- grid.257022.00000 0000 8711 3200Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuo Awai
- grid.257022.00000 0000 8711 3200Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Aikata
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
| | - Shiro Oka
- grid.257022.00000 0000 8711 3200Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
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Zimmermann HW, Trautwein C, Bruns T. [Current diagnostics and treatment of portal hypertension]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2022; 63:1257-1267. [PMID: 36374293 DOI: 10.1007/s00108-022-01427-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
In industrial nations portal hypertension is mostly a consequence of liver cirrhosis and is a prerequisite for complications, such as esophageal varices and ascites. The pathophysiology of portal hypertension is complex. It is defined as an increase in the hepatovenous pressure gradient to > 5 mm Hg, with complications to be expected at ≥ 10 mm Hg. Measurement of the pressure of the hepatic vein occlusion is the gold standard for estimating portal pressure but this is not very practical. Liver elastography, in particular, has proven to be an effective noninvasive tool to identify patients with clinically significant portal hypertension (CSPH). Current treatment concepts address the CSPH even before the onset of complications to reduce the likelihood of decompensation. In addition to beta blockers, a transjugular intrahepatic portosystemic shunt is the most important procedure to lower portal vein pressure and enables an improvement in the prognosis of selected patients.
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Affiliation(s)
- Henning W Zimmermann
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - Christian Trautwein
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
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Wang L, Zhang Y, Wu YF, Yue ZD, Fan ZH, Zhang CY, Liu FQ, Dong J. Computed tomography perfusion in liver and spleen for hepatitis B virus-related portal hypertension: A correlation study with hepatic venous pressure gradient. World J Gastroenterol 2022; 28:6068-6077. [PMID: 36405387 PMCID: PMC9669822 DOI: 10.3748/wjg.v28.i42.6068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/14/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatic venous pressure gradient (HVPG) is the gold standard for diagnosis of portal hypertension (PH). However, its use can be limited because it is an invasive procedure. Therefore, it is necessary to explore a non-invasive method to assess PH.
AIM To investigate the correlation of computed tomography (CT) perfusion of the liver with HVPG and Child-Pugh score in hepatitis B virus (HBV)-related PH.
METHODS Twenty-eight patients (4 female, 24 male) with gastroesophageal variceal bleeding induced by HBV-related PH were recruited in our study. All patients received CT perfusion of the liver before transjugular intrahepatic portosystemic stent-shunt (TIPS) therapy. Quantitative parameters of CT perfusion of the liver, including liver blood flow (LBF), liver blood volume (LBV), hepatic artery fraction, splenic blood flow and splenic blood volume were measured. HVPG was recorded during TIPS therapy. Correlation of liver perfusion with Child-Pugh score and HVPG were analyzed, and the receiver operating characteristic curve was analyzed. Based on HVPG (> 12 mmHg vs ≤ 12 mmHg), patients were divided into moderate and severe groups, and all parameters were compared.
RESULTS Based on HVPG, 18 patients were classified into the moderate group and 10 patients were classified into the severe group. The Child-Pugh score, HVPG, LBF and LBV were significantly higher in the moderate group compared to the severe group (all P < 0.05). LBF and LBV were negatively associated with HVPG (r = -0.473, P < 0.05 and r = -0.503, P < 0.01, respectively), whereas splenic blood flow was positively associated with hepatic artery fraction (r = 0.434, P < 0.05). LBV was negatively correlated with Child-Pugh score. Child-Pugh score was not related to HVPG. Using a cutoff value of 17.85 mL/min/100 g for LBV, the sensitivity and specificity of HVPG ≥ 12 mmHg for diagnosis were 80% and 89%, respectively.
CONCLUSION LBV and LBF were negatively correlated with HVPG and Child-Pugh scores. CT perfusion imaging is a potential non-invasive quantitative predictor for PH in HBV-related liver cirrhosis.
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Affiliation(s)
- Lei Wang
- Department of Intervention Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Zhang
- Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yi-Fan Wu
- Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Zhen-Dong Yue
- Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Zhen-Hua Fan
- Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Chun-Yan Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Fu-Quan Liu
- Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Jian Dong
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Selvakumar SC, Auxzilia Preethi K, Veeraiyan DN, Sekar D. The role of microRNAs on the pathogenesis, diagnosis and management of portal hypertension in patients with chronic liver disease. Expert Rev Gastroenterol Hepatol 2022; 16:941-951. [PMID: 36315408 DOI: 10.1080/17474124.2022.2142562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Portal hypertension (PH) is the elevated pressure in the portal vein, which results in poor functioning of the liver and is influenced by various factors like liver cirrhosis, nonalcoholic fatty liver disease, schistosomiasis, thrombosis, and angiogenesis. Though the diagnosis and treatment have been advanced, early diagnosis of the disease remains a challenge, and the diagnosis methods are often invasive. Hence, the clear understanding of the molecular mechanisms of PH can give rise to the development of novel biomarkers which can pave way for early diagnosis in noninvasive methods, and also the identification of target genes can elucidate an efficient therapeutic target. AREAS COVERED PubMed and Embase database was used to search articles with search terms 'Portal Hypertension' or 'pathophysiology' and 'diagnosis' and 'treatment' or "role of miRNAs in portal hypertension. EXPERT OPINION Interestingly, biomarkers like microRNAs (miRNAs) have been studied for their potential role in various diseases including hypertension. In recent years, miRNAs have been proved to be an efficient biomarker and therapeutic target and few studies have assessed the roles of miRNAs in PH. The present paper highlights the potential roles of miRNAs in PH.
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Affiliation(s)
- Sushmaa Chandralekha Selvakumar
- Centre for Cellular and Molecular Research, Saveetha Dental College & Hospitals, Saveetha Institute of Medical & Technical Sciences (SIMATS), Saveetha University, Chennai, India
| | - K Auxzilia Preethi
- Centre for Cellular and Molecular Research, Saveetha Dental College & Hospitals, Saveetha Institute of Medical & Technical Sciences (SIMATS), Saveetha University, Chennai, India
| | - Deepak Nallaswamy Veeraiyan
- Department of Prosthodontics, Saveetha Dental College & Hospitals, Saveetha Institute of Medical & Technical Sciences (SIMATS), Saveetha University, Chennai, India
| | - Durairaj Sekar
- Centre for Cellular and Molecular Research, Saveetha Dental College & Hospitals, Saveetha Institute of Medical & Technical Sciences (SIMATS), Saveetha University, Chennai, India
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Thabut D, Weil D, Bouzbib C, Rudler M, Cassinotto C, Castéra L, Serste T, Oberti F, Ganne-Carrié N, de Lédinghen V, Bourlière M, Bureau C. Non-invasive diagnosis and follow-up of portal hypertension. Clin Res Hepatol Gastroenterol 2022; 46:101767. [PMID: 34332128 DOI: 10.1016/j.clinre.2021.101767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
Compensated advanced chronic liver disease (cACLD) describes the spectrum of advanced fibrosis/cirrhosis in asymptomatic patients at risk of developing clinically significant portal hypertension (CSPH, defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg). Patients with cACLD are at high risk of liver-related morbidity and mortality. In patients at risk of chronic liver disease, cACLD is strongly suggested by a liver stiffness (LSM) value >15 kPa or clinical/biological/radiological signs of portal hypertension, and ruled out by LSM <10 kPa, or Fibrotest® ≤0.58, or Fibrometer® ≤0.786. Patients with chronic liver disease (excluding vascular diseases) with a LSM <10 kPa are at low risk of developing portal hypertension complications. The presence of CSPH can be strongly suspected when LSM is ≥20 kPa. In a patient without clinical, endoscopic or radiological features of portal hypertension, measurement of the HVPG is recommended before major liver or intra-abdominal surgery, before extra-hepatic transplantation and in patients with unexplained ascites. Endoscopic screening for oesophageal varices can be avoided in patients with LSM <20 kPa and a platelet count >150 G/L (favourable Baveno VI criteria) at the time of diagnosis. There is no non-invasive method alternative for oeso-gastroduodenal endoscopy in patients with unfavourable Baveno criteria (liver stiffness ≥20 kPa or platelet count ≤50 G/l). Platelet count and liver stiffness measurements must be performed once a year in patients with cACLD with favourable Baveno VI criteria at the time of diagnosis. A screening oeso-gastroduodenal endoscopy is recommended if Baveno VI criteria become unfavourable.
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Affiliation(s)
- Dominique Thabut
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France.
| | - Delphine Weil
- Service d'hépatologie, CHRU Besançon, Besançon, France
| | - Charlotte Bouzbib
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Marika Rudler
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Christophe Cassinotto
- Radiologie diagnostique et interventionnelle Saint Eloi, CHU Montpellier, Montpellier, France
| | - Laurent Castéra
- Service d'Hépatologie, Hôpital Beaujon, Université de Paris, APHP, Paris, France
| | - Thomas Serste
- Service d'hépato-gastroentérologie, CHU Saint-Pierre, Bruxelles, France
| | - Frédéric Oberti
- Service d'hépato-gastroentérologie et oncologie digestive, CHU Angers, Angers, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, Hôpital Avicenne, APHP, Université Sorbonne Paris Nord, Bobigny & INSERM UMR 1138, Centre de Recherche des Cordeliers, Université de Paris, France
| | - Victor de Lédinghen
- Service d'hépato-gastroentérologie et d'oncologie digestive, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac & INSERM U1053, Université de Bordeaux, Bordeaux, France
| | - Marc Bourlière
- Service d'hépato-gastroentérologie, Hôpital Saint Joseph & INSERM UMR 1252 IRD SESSTIM Aix Marseille Université, Marseille, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU Toulouse, Toulouse, France
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Kristensen H, Kimer N, Møller S. Indications and methods for measuring portal hypertension in cirrhosis. Scand J Gastroenterol 2022; 57:1149-1157. [PMID: 35514215 DOI: 10.1080/00365521.2022.2065889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background and objectives: Over the last decade our understanding of the pathophysiology of portal hypertension has increased. Novel diagnostic technologies have facilitated and improved the diagnosis and treatment of hepatic fibrosis and cirrhosis. With this review we aim to provide an overview of contemporary diagnostic principles of portal hypertension and indications for measuring portal pressure in cirrhosis.Methods: By review of current literature, we assessed new and old principles of measuring portal hypertension and the diagnostic values of the methods.Results: Invasive measurement of the portal pressure is still the gold standard to quantitate portal hypertension and to assess response to vasoactive treatment. The size of the portal pressure is important to assess since it contains information on the course of the disease and risk of developing hepatic decompensation, hepatocellular carcinoma, and mortality. Reliable non-invasive Elastography techniques are emerging that adequately assess portal pressure, but the available methods are not yet sufficiently accurate.Conclusion: Although elastography techniques provide valuable information and are good monitoring tools, liver vein catheterization remains valuable in diagnosing and monitoring portal hypertension, especially in combination with a trans-jugular liver biopsy.
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Affiliation(s)
- Helle Kristensen
- Gastro Unit, Medical Division, University Hospital Hvidovre, Hvidovre, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center of Functional Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Hyodo R, Takehara Y, Naganawa S. 4D Flow MRI in the portal venous system: imaging and analysis methods, and clinical applications. Radiol Med 2022; 127:1181-1198. [PMID: 36123520 PMCID: PMC9587937 DOI: 10.1007/s11547-022-01553-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/29/2022] [Indexed: 02/07/2023]
Abstract
Thus far, ultrasound, CT, and 2D cine phase-contrast MRI has been adopted to evaluate blood flow and vascular morphology in the portal venous system; however, all these techniques have some shortcomings, such as limited field of view and difficulty in accurately evaluating blood flow. A new imaging technique, namely 3D cine phase-contrast (4D Flow) MRI, can acquire blood flow data of the entire abdomen at once and in a time-resolved manner, allowing visual, quantitative, and comprehensive assessment of blood flow in the portal venous system. In addition, a retrospective blood flow analysis, i.e., "retrospective flowmetry," is possible. Although the development of 4D Flow MRI for the portal system has been delayed compared to that for the arterial system owing to the lower flow velocity of the portal venous system and the presence of respiratory artifacts, several useful reports have recently been published as the technology has advanced. In the first part of this narrative review article, technical considerations of image acquisition and analysis methods of 4D Flow MRI for the portal venous system and the validations of their results are described. In the second part, the current clinical application of 4D Flow MRI for the portal venous system is reviewed.
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Affiliation(s)
- Ryota Hyodo
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Yasuo Takehara
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
- Department of Fundamental Development for Advanced Low Invasive Diagnostic Imaging, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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40
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Vranić L, Nadarevic T, Štimac D, Fraquelli M, Manzotti C, Casazza G, Colli A. Liver and spleen stiffness as assessed by vibration controlled transient elastography for diagnosing clinically significant portal hypertension in comparison with other elastography-based techniques in adults with chronic liver disease. Hippokratia 2022. [DOI: 10.1002/14651858.cd015415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Luka Vranić
- Department of Gastroenterology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Tin Nadarevic
- Department of Radiology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Davor Štimac
- Department of Gastroenterology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit; Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milano; Milan Italy
| | - Cristina Manzotti
- Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
| | - Giovanni Casazza
- Department of Clinical Sciences and Community Health - Laboratory of Medical Statistics, Biometry and Epidemiology "G.A. Maccacaro"; Università degli Studi di Milano; Milan Italy
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
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41
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Hofer BS, Simbrunner B, Bauer DJM, Paternostro R, Schwabl P, Scheiner B, Semmler G, Hartl L, Jachs M, Datterl B, Staettermayer AF, Trauner M, Mandorfer M, Reiberger T. Acute hemodynamic response to propranolol predicts bleeding and nonbleeding decompensation in patients with cirrhosis. Hepatol Commun 2022; 6:2569-2580. [PMID: 35808889 PMCID: PMC9426394 DOI: 10.1002/hep4.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/17/2022] [Accepted: 05/29/2022] [Indexed: 11/29/2022] Open
Abstract
Nonselective beta‐blockers are used as prophylaxis for variceal bleeding in patients with advanced chronic liver disease (ACLD). The acute hemodynamic response to intravenous propranolol (i.e., ≥10% reduction in hepatic venous pressure gradient [HVPG]) is linked to a decreased risk of variceal bleeding. In this study, we aimed to investigate the overall prognostic value of an acute response in compensated and decompensated ACLD. We analyzed the long‐term outcome of prospectively recruited patients with ACLD following a baseline HVPG measurement with an intraprocedural assessment of the acute hemodynamic response to propranolol. Overall, we included 98 patients with ACLD (mean ± SD age, 56.4 ± 11.5 years; 72.4% decompensated; 88.8% varices; mean ± SD HVPG, 19.9 ± 4.4 mm Hg) who were followed for a median of 9.6 (interquartile range, 6.5–18.2) months. Fifty‐seven patients (58.2%) demonstrated an acute hemodynamic response to propranolol that was associated with a decreased risk of variceal bleeding (at 12 months, 3.6% vs. 15% in nonresponder; log‐rank, p = 0.038) and hepatic decompensation (at 12 months, 23% vs. 33% in nonresponder; log‐rank, p = 0.096). On multivariate analysis, the acute response was an independent predictor of first/further hepatic decompensation (adjusted hazards ratio, 0.31; 95% confidence interval [CI], 0.13–0.70; p = 0.005). Importantly, there was a tendency toward a prolonged transplant‐free survival in acute responders compared to nonresponders (34.2; 95% CI, 29.2–39.2 vs. 25.2; 95% CI, 19.8–30.6 months; log‐rank, p = 0.191). Conclusions: Patients with ACLD who achieve an acute hemodynamic response to intravenous propranolol experience a lower risk of variceal bleeding and nonbleeding hepatic decompensation events compared to nonresponders. An assessment of the acute hemodynamic response to intravenous propranolol provides important prognostic information in ACLD.
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Affiliation(s)
- Benedikt S Hofer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - David J M Bauer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Barbara Datterl
- Pharmacy Department, Vienna General Hospital, Vienna, Austria
| | - Albert F Staettermayer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
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Turco L, García‐Tsao G. Portal pressure reductions induced by nonselective beta-blockers improve outcomes and decrease mortality in patients with cirrhosis with and without ascites. Clin Liver Dis (Hoboken) 2022; 20:1-4. [PMID: 35899241 PMCID: PMC9306434 DOI: 10.1002/cld.1210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 01/03/2022] [Accepted: 01/12/2022] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Laura Turco
- 1Internal Medicine Unit for the Treatment of Severe Organ FailureIRCCS Azienda Ospedaliero‐Universitaria di BolognaItaly
| | - Guadalupe García‐Tsao
- Section of Digestive DiseasesYale School of MedicineNew HavenConnecticutUSA
- Section of Digestive DiseasesVA Connecticut Healthcare SystemWest HavenConnecticutUSA
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Evaluation of hepatic hemodynamics (hepatic venous pressure gradient) during right heart catheterization: a comprehensive review. Curr Probl Cardiol 2022; 47:101278. [DOI: 10.1016/j.cpcardiol.2022.101278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 01/01/2023]
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Roldán-Alzate A, Campo CA, Mao L, Said A, Wieben O, Reeder SB. Characterization of mesenteric and portal hemodynamics using 4D flow MRI: the effects of meals and diurnal variation. Abdom Radiol (NY) 2022; 47:2106-2114. [PMID: 35419747 PMCID: PMC10599799 DOI: 10.1007/s00261-022-03513-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the variability of blood flow measurements using 4D flow MRI in the portal and mesenteric circulations and to characterize the effects of meal ingestion, time of day, and between-day (diurnal) variations on portal and mesenteric hemodynamics. METHODS In this IRB-approved and HIPAA-compliant study, 7 healthy and 7 portal hypertension patients imaged. MRI exams were conducted at 3 T using a 32-channel body coil with large volumetric coverage and 1.25-mm isotropic true spatial resolution. Blood flow was quantified (L/min) in the hepatic and splanchnic vasculature. The first MR scan was performed after at least 8 h of fasting. Subsequently, subjects ingested 574 mL EnSure Plus® orally. A second acquisition was started 20 min after the meal ingestion. A third scan was performed before lunch and a fourth acquisition took place 20 min after lunch. A fifth scan was performed around 4 pm. Finally, subjects returned one week later for a repeat morning visit, with identical conditions as the first visit. RESULTS In healthy controls significant increase in blood flow was seen in the PV, SMV, SMA, HA, and SCAo in response to breakfast but only the SCAo, SMA, SMV, and PV had a significant response to lunch. In general, patients with cirrhosis showed reduced response to meals compared to that in healthy controls. Additionally, PV flow in patients had the highest value in the afternoon. CONCLUSION Effects of meal ingestion, time of day, and between-day variations were characterized using Radial 4D flow MRI in patients with cirrhosis and healthy controls.
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Affiliation(s)
- Alejandro Roldán-Alzate
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792-3252, USA.
- Department of Mechanical Engineering, University of Wisconsin, Madison, USA.
- Department of Biomedical Engineering, University of Wisconsin, Madison, USA.
| | - Camilo A Campo
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792-3252, USA
| | - Lu Mao
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, USA
| | - Adnan Said
- Department of Medicine, University of Wisconsin, Madison, USA
| | - Oliver Wieben
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792-3252, USA
- Department of Medical Physics, University of Wisconsin, Madison, USA
- Department of Biomedical Engineering, University of Wisconsin, Madison, USA
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792-3252, USA
- Department of Medical Physics, University of Wisconsin, Madison, USA
- Department of Biomedical Engineering, University of Wisconsin, Madison, USA
- Department of Emergency Medicine, University of Wisconsin, Madison, USA
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Guo H, Zhang M, Zhang N, Yin X, Cheng Y, Gu L, Wang X, Xiao J, Wang Y, Zou X, Zhuge Y, Zhang F. Number of endoscopic sessions to eradicate varices identifies high risk of rebleeding in cirrhotic patients. BMC Gastroenterol 2022; 22:213. [PMID: 35505293 PMCID: PMC9063156 DOI: 10.1186/s12876-022-02283-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background and aims Risk stratification to identify patients with high risk of variceal rebleeding is particularly important in patients with decompensated cirrhosis. In clinical practice, eliminating gastroesphageal varices thoroughly after sequential endoscopic treatment reduces the rebleeding rate, however, no simple method has been build to predict high risk of variceal rebleeding. We conducted this study to explore the value of the number of endoscopic sessions required to eradicate gastroesphageal varices in identifying high risk of rebleeding. Patients and methods Consecutive cirrhotic patients received sequential endoscopic therapy between January 2015 and March 2020 were enrolled. Endoscopic treatment was performed every 1–4 weeks until the eradication of varices. The primary endpoint was variceal rebleeding. Results A total of 146 patients were included of which 60 patients received standard therapy and 86 patients underwent sequential endoscopic treatment alone. The cut-off value of the number of sequential endoscopic sessions is 3.5 times. Variceal rebleeding was significant higher in patients with endoscopic sessions > 3 times versus ≤ 3 times (61.5% vs. 17.5%, p < 0.001). Variceal rebleeding of patients with endoscopic sessions ≤ 3 times was significant lower than patients with > 3 times in group of standard therapy (19.6% vs. 88.9%, p < 0.001) and endoscopic therapy (15.9% vs. 47.1%, p = 0.028) respectively. Conclusion The number of sequential endoscopic sessions required to eradicate the varices is related to the risk of variceal rebleeding in patients with cirrhosis. If three times of endoscopic treatment can not eradicate the varices, a more aggressive treatment such as TIPS should be seriously considered. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02283-0.
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Affiliation(s)
- Huiwen Guo
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Ming Zhang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Na Zhang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Xiaochun Yin
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Yang Cheng
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Lihong Gu
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Xixuan Wang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Jiangqiang Xiao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Yi Wang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Xiaoping Zou
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China.
| | - Feng Zhang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China.
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Abstract
PURPOSE OF REVIEW This article discusses the most recent studies regarding the emerging field of endohepatology - the use of diagnostic and therapeutic endoscopic tools for the management of patients with liver disease and portal hypertension. RECENT FINDINGS New research has shown that liver biopsy specimens obtained by each Endoscopic ultrasound (EUS)-guidance, the percutaneous approach, and the transjugular approach contained sufficient portal triads to adequately analyzed by experienced pathologists - suggesting that any of these routes of liver biopsy is clinically acceptable; further, all had similar rates of adverse events. An initial prospective study showed that EUS guided portal pressure measurement was safe, effective, and accurate. A recent metanalysis showed that EUS-guided cyanoacrylate injection and coil embolization was statistically more efficacious and with less complications than EUS guided cyanoacrylate injection and EUS guided coil injection alone, suggesting that combination therapy appears to be the preferred approach for gastric varices (GV) bleeding. A prospective study evaluating focal liver lesions showed that the use of artificial intelligence had up to 100% sensitivity and 81% specificity for identifying malignant focal liver lesions. SUMMARY EUS guided liver biopsy is safe and enables accurate diagnosis of underlying liver disease. EUS guided portal pressure measurement is also safe and is accurate. Combination therapy of EUS guided cyanoacrylate injection and coil embolization is more efficacious and has less complications than injection or coil therapy alone when used for GV bleeding. Artificial intelligence is highly sensitive and specific when used in conjunction with EUS in the diagnosis of malignant focal liver lesions. Endohepatology is a rapidly expanding field with great potential.
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Affiliation(s)
- Jerome C Edelson
- Department of Gastroenterology and Hepatology
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Natalie E Mitchell
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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Hilscher MB, Wells ML, Venkatesh SK, Cetta F, Kamath PS. Fontan-associated liver disease. Hepatology 2022; 75:1300-1321. [PMID: 35179797 DOI: 10.1002/hep.32406] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Moira B Hilscher
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Michael L Wells
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Sudhakar K Venkatesh
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Frank Cetta
- Division of Pediatric CardiologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMinnesotaUSA
| | - Patrick S Kamath
- Division of Gastroenterology and HepatologyDepartment of MedicineMayo ClinicRochesterMinnesotaUSA
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Hajifathalian K, Westerveld D, Kaplan A, Dawod E, Herr A, Ianelli M, Saggese A, Kumar S, Fortune BE, Sharaiha RZ. Simultaneous EUS-guided portosystemic pressure measurement and liver biopsy sampling correlate with clinically meaningful outcomes. Gastrointest Endosc 2022; 95:703-710. [PMID: 34890694 DOI: 10.1016/j.gie.2021.11.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/13/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The measurement of the portosystemic pressure gradient (PSG) in patients with advanced liver disease is helpful to assess the severity of portal hypertension (PH) and predict adverse clinical outcomes. EUS-guided PSG (EUS-PSG) measurement is a novel tool to assess PSG in all patients with advanced liver disease. We sought to assess the safety, feasibility, and technical success of simultaneous EUS-PSG measurement and EUS-guided liver biopsy sampling using a single-center experience. METHODS Patients with suspected liver disease or cirrhosis were enrolled prospectively from 2020 to 2021. EUS-PSG was measured by calculating the difference between the mean portal pressure and the mean hepatic vein pressure. PH was defined as PSG >5 mm Hg and clinically significant PH as PSG ≥10 mm Hg. The primary outcomes were procedural technical success rate and correlation of EUS-PSG with fibrosis stage obtained from concurrent EUS-guided liver biopsy sampling and the correlation of EUS-PSG with patients' imaging, clinical, and laboratory findings. The secondary outcome was occurrence of procedural adverse events (AEs). RESULTS Twenty-four patients were included in the study. PSG measurement and EUS-guided liver biopsy sampling were successful in 23 patients (technical success rate of 96%) and 24 patients (100% success), respectively. Analysis revealed a significant association between both PSG and liver stiffness measured on transient elastography (P = .011) and fibrosis-4 score (P = .026). No significant correlation was found between the fibrosis stage on histology and measured PSG (P = .559). One mild AE of abdominal pain was noted. Additionally, EUS-PSG was predictive of clinically evident PH. CONCLUSIONS Simultaneous EUS-PSG measurement and EUS-guided liver biopsy sampling were both feasible and safe and correlated with clinically evident PH and noninvasive markers of fibrosis.
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Affiliation(s)
- Kaveh Hajifathalian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Donevan Westerveld
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Alyson Kaplan
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Enad Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Andrea Herr
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Mallory Ianelli
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Allysa Saggese
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Sonal Kumar
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Brett E Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
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Yu Q, Huang Y, Li X, Pavlides M, Liu D, Luo H, Ding H, An W, Liu F, Zuo C, Lu C, Tang T, Wang Y, Huang S, Liu C, Zheng T, Kang N, Liu C, Wang J, Akçalar S, Çelebioğlu E, Üstüner E, Bilgiç S, Fang Q, Fu CC, Zhang R, Wang C, Wei J, Tian J, Örmeci N, Ellik Z, Asiller ÖÖ, Ju S, Qi X. An imaging-based artificial intelligence model for non-invasive grading of hepatic venous pressure gradient in cirrhotic portal hypertension. Cell Rep Med 2022; 3:100563. [PMID: 35492878 PMCID: PMC9040173 DOI: 10.1016/j.xcrm.2022.100563] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 12/19/2021] [Accepted: 02/17/2022] [Indexed: 12/15/2022]
Abstract
The hepatic venous pressure gradient (HVPG) is the gold standard for cirrhotic portal hypertension (PHT), but it is invasive and specialized. Alternative non-invasive techniques are needed to assess the hepatic venous pressure gradient (HVPG). Here, we develop an auto-machine-learning CT radiomics HVPG quantitative model (aHVPG), and then we validate the model in internal and external test datasets by the area under the receiver operating characteristic curves (AUCs) for HVPG stages (≥10, ≥12, ≥16, and ≥20 mm Hg) and compare the model with imaging- and serum-based tools. The final aHVPG model achieves AUCs over 0.80 and outperforms other non-invasive tools for assessing HVPG. The model shows performance improvement in identifying the severity of PHT, which may help non-invasive HVPG primary prophylaxis when transjugular HVPG measurements are not available.
aHVPG is an automated HVPG quantitative estimation model based on CT aHVPG has the potential to assess HVPG and outperforms other non-invasive tools Non-invasive tools may help PHT monitoring when invasive HVPG is not available
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Affiliation(s)
- Qian Yu
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yifei Huang
- CHESS Center, Institute of Portal Hypertension, First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaoguo Li
- CHESS Center, Institute of Portal Hypertension, First Hospital of Lanzhou University, Lanzhou, China
| | - Michael Pavlides
- Radcliffe Department of Medicine, Oxford Centre for Magnetic Resonance Research, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Dengxiang Liu
- CHESS Working Party, Xingtai People's Hospital, Xingtai, China
| | - Hongwu Luo
- Department of General Surgery, Third Xiangya Hospital of Central South University, Changsha, China
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Weimin An
- Department of Radiology, Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Fuquan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Changzeng Zuo
- CHESS Working Party, Xingtai People's Hospital, Xingtai, China
| | - Chunqiang Lu
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Tianyu Tang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yuancheng Wang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Shan Huang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chuan Liu
- CHESS Center, Institute of Portal Hypertension, First Hospital of Lanzhou University, Lanzhou, China
| | - Tianlei Zheng
- CHESS Center, Institute of Portal Hypertension, First Hospital of Lanzhou University, Lanzhou, China
| | - Ning Kang
- CHESS Center, Institute of Portal Hypertension, First Hospital of Lanzhou University, Lanzhou, China
| | - Changchun Liu
- Department of Radiology, Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Jitao Wang
- CHESS Working Party, Xingtai People's Hospital, Xingtai, China
| | - Seray Akçalar
- Department of Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Emrecan Çelebioğlu
- Department of Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Evren Üstüner
- Department of Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Sadık Bilgiç
- Department of Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Qu Fang
- Shanghai Aitrox Technology Corporation, Shanghai, China
| | - Chi-Cheng Fu
- Shanghai Aitrox Technology Corporation, Shanghai, China
| | - Ruiping Zhang
- Department of Radiology, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi, China
| | - Chengyan Wang
- Human Phenome Institute, Fudan University, Shanghai, China
| | - Jingwei Wei
- Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, China.,Beijing Key Laboratory of Molecular Imaging, Beijing, China
| | - Jie Tian
- Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, China.,Beijing Key Laboratory of Molecular Imaging, Beijing, China
| | - Necati Örmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Zeynep Ellik
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Özgün Ömer Asiller
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Shenghong Ju
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, First Hospital of Lanzhou University, Lanzhou, China
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50
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Invasive Hemodynamic Evaluation of the Fontan Circulation: Current Day Practice and Limitations. Curr Cardiol Rep 2022; 24:587-596. [PMID: 35230616 DOI: 10.1007/s11886-022-01679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Establishing the Fontan circulation has led to improved survival in patients born with complex congenital heart diseases. Despite early success, the long-term course of Fontan patients is complicated by multi-organ dysfunction, mainly due to a combination of low resting and blunted exercise-augmented cardiac output as well as elevated central venous (Fontan) pressure. Similarly, despite absolute hemodynamic differences compared to the normal population with biventricular circulation, the "normal" ranges of hemodynamic parameters specific to age-appropriate Fontan circulation have not been well defined. With the ever-increasing population of patients requiring Fontan correction, it is of utmost importance that an acceptable range of hemodynamics in this highly complex patient cohort is better defined. RECENT FINDINGS Multiple publications have described hemodynamic limitations and potential management options in patients with Fontan circulation; however, an acceptable range of hemodynamic parameters in this patient population has not been well defined. Identification of "normal" hemodynamic parameters among patients with Fontan circulation will allow physicians to more objectively define indications for intervention, which is a necessary first step to eliminate institutional and regional heterogeneity in Fontan management and potentially improve long-term clinical outcomes.
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