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S L H, Pottakkat B, Gnanasekaran S, Raja K. Unconventional shunt surgery for non-cirrhotic portal hypertension in patients not suitable for proximal splenorenal shunt. Ann Hepatobiliary Pancreat Surg 2023; 27:264-270. [PMID: 37357160 PMCID: PMC10472123 DOI: 10.14701/ahbps.23-002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUNDS/AIMS Proximal splenorenal shunt (PSRS) is a commonly performed procedure to decompress portal hypertension, in patients with refractory variceal bleed, especially in non-cirrhotic portal hypertension (NCPH). If conventional methods are hindered by any technical or pathological factors, alternative surgical techniques may be required. This study analyzes the effectiveness of various unconventional shunt surgeries performed for NCPH. METHODS A retrospective analysis of NCPH patients who underwent unconventional shunt surgeries during the period July 2011 to June 2022 was conducted. All patients were followed up for a minimum of 12 months with doppler study of the shunt to assess shunt patency, and upper gastrointestinal endoscopy to evaluate the regression of varices. RESULTS During the study period, 130 patients underwent shunt surgery; among these, 31 underwent unconventional shunts (splenoadrenal shunt [SAS], 12; interposition mesocaval shunt [iMCS], 8; interposition PSRS [iPSRS], 6; jejunal vein-cava shunt [JCS], 3; left gastroepiploic-renal shunt [LGERS], 2). The main indications for unconventional shunts were left renal vein aberration (SAS, 8/12), splenic vein narrowing (iMCS, 5/8), portalhypertensive vascular changes (iPSRS, 6/6), and portomesenteric thrombosis (JCS, 3/3). The median fall in portal pressure was more in SAS (12.1 mm Hg), and operative time more in JCS, 8.4 hours (range, 5-9 hours). During a median follow-up of 36 months (6-54 months), shunt thrombosis had been reported in all cases of LGERS, and less in SAS (3/12). Variceal regression rate was high in SAS, and least in LGERS. Hypersplenism had reversed in all patients, and 6/31 patients had a recurrent bleed. CONCLUSIONS Unconventional shunt surgery is effective in patients unsuited for other shunts, especially PSRS, and it achieves the desired effects in a significant proportion of patients.
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Affiliation(s)
- Harilal S L
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kalayarasan Raja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Sarma MS, Seetharaman J. Pediatric non-cirrhotic portal hypertension: Endoscopic outcome and perspectives from developing nations. World J Hepatol 2021; 13:1269-1288. [PMID: 34786165 PMCID: PMC8568571 DOI: 10.4254/wjh.v13.i10.1269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/27/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
Non-cirrhotic portal hypertension (NCPH) forms an important subset of portal hypertension in children. Variceal bleed and splenomegaly are their predominant presentation. Laboratory features show cytopenias (hypersplenism) and preserved hepatic synthetic functions. Repeated sessions of endoscopic variceal ligation or endoscopic sclerotherapy eradicate esophageal varices in almost all cases. After variceal eradication, there is an increased risk of other complications like secondary gastric varices, cholangiopathy, colopathy, growth failure, especially in extra-hepatic portal vein obstruction (EHPVO). Massive splenomegaly-related pain and early satiety cause poor quality of life (QoL). Meso-Rex bypass is the definitive therapy when the procedure is anatomically feasible in EHPVO. Other portosystemic shunt surgeries with splenectomy are indicated when patients present late and spleen-related issues predominate. Shunt surgeries prevent rebleed, improve growth and QoL. Non-cirrhotic portal fibrosis (NCPF) is a less common cause of portal hypertension in children in developing nations. Presentation in the second decade, massive splenomegaly and patent portal vein are discriminating features of NCPF. Shunt surgery is required in severe cases when endotherapy is insufficient for the varices. Congenital hepatic fibrosis (CHF) presents with firm palpable liver and splenomegaly. Ductal plate malformation forms the histological hallmark of CHF. CHF is commonly associated with Caroli’s disease, renal cysts, and syndromes associated with neurological defects. Isolated CHF has a favourable prognosis requiring endotherapy. Liver transplantation is required when there is decompensation or recurrent cholangitis, especially in Caroli’s syndrome. Combined liver-kidney transplantation is indicated when both liver and renal issues are present.
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Affiliation(s)
- Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Jayendra Seetharaman
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Liu D, Deng J, Zhang Z, Zhang ZY, Sun YG, Yang T, Yao H. Orbitofrontal control of visual cortex gain promotes visual associative learning. Nat Commun 2020; 11:2784. [PMID: 32493971 PMCID: PMC7270099 DOI: 10.1038/s41467-020-16609-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/14/2020] [Indexed: 01/09/2023] Open
Abstract
The orbitofrontal cortex (OFC) encodes expected outcomes and plays a critical role in flexible, outcome-guided behavior. The OFC projects to primary visual cortex (V1), yet the function of this top-down projection is unclear. We find that optogenetic activation of OFC projection to V1 reduces the amplitude of V1 visual responses via the recruitment of local somatostatin-expressing (SST) interneurons. Using mice performing a Go/No-Go visual task, we show that the OFC projection to V1 mediates the outcome-expectancy modulation of V1 responses to the reward-irrelevant No-Go stimulus. Furthermore, V1-projecting OFC neurons reduce firing during expectation of reward. In addition, chronic optogenetic inactivation of OFC projection to V1 impairs, whereas chronic activation of SST interneurons in V1 improves the learning of Go/No-Go visual task, without affecting the immediate performance. Thus, OFC top-down projection to V1 is crucial to drive visual associative learning by modulating the response gain of V1 neurons to non-relevant stimulus. The orbitofrontal cortex (OFC) encodes expected outcomes and plays a key role in outcome-guided behavior. The authors show here that the top-down projection from the OFC to the visual cortex drives visual associative learning by modulating the response gain of V1 neurons to non-relevant stimuli.
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Affiliation(s)
- Dechen Liu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Juan Deng
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China
| | - Zhewei Zhang
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.,University of Chinese Academy of Sciences, Beijing, 100049, China.,Institute of Neuroscience, Key Laboratory of Primate Neurobiology, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China
| | - Zhi-Yu Zhang
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Yan-Gang Sun
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.,Shanghai Center for Brain Science and Brain-Inspired Intelligence Technology, Shanghai, 201210, China
| | - Tianming Yang
- Institute of Neuroscience, Key Laboratory of Primate Neurobiology, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.,Shanghai Center for Brain Science and Brain-Inspired Intelligence Technology, Shanghai, 201210, China
| | - Haishan Yao
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China. .,Shanghai Center for Brain Science and Brain-Inspired Intelligence Technology, Shanghai, 201210, China.
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Prasad D, Sen Sarma M, Yachha SK, Srivastava A, Poddar U. Pediatric non-cirrhotic portal fibrosis: role of endoscopic management in determining long-term outcome. Hepatol Int 2019; 14:281-287. [PMID: 31468295 DOI: 10.1007/s12072-019-09979-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/09/2019] [Indexed: 12/11/2022]
Abstract
AIMS Non-cirrhotic portal fibrosis (NCPF) is a rare cause of pediatric portal hypertension. There is abundant literature in adults but paucity of data in children. We aimed to evaluate and compare the endoscopic and long-term outcomes of children with NCPF. METHODS Consecutive children (≤ 18 years) diagnosed with NCPF evaluated for clinical and endoscopic profile and outcome. The cohort underwent 3 weekly endoscopic sessions until esophageal variceal eradication followed by 6-12 monthly endoscopic surveillance. Non-bleeders and bleeders were compared for endoscopic outcome. RESULTS Forty-five NCPF children with median age of 14.5 (6-18) years and symptom duration 12 (1-120) months presented with spleen-related issues (78%), esophageal varices (96%), primary gastric varices (56%), and portal hypertensive gastropathy (89%). Thirty-three patients undergoing endotherapy (secondary prophylaxis n = 22, primary prophylaxis n = 11) showed primary eradication of varices after 5 (2-12) sessions. 36% showed recurrence of esophageal varices in 11 (6-42) months and secondary gastric varices developed in 12%. Overall 87% patients required endoscopic intervention at onset or follow-up. Poor outcome was observed in ten patients (n = 9 bleeders). Three children died of variceal bleeding before endoscopic eradication of esophageal varices. Three developed decompensation after a median follow-up of 48 (3-120) months and referred for liver transplantation. Four patients required surgery for portal hypertension. CONCLUSIONS Overall, endoscopic outcome of NCPF is favorable. One-third patients have recurrence of esophageal varices. Small proportion of bleeders have poor outcome.
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Affiliation(s)
- Durga Prasad
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India.
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
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Mishra PK, Patil NS, Saluja S, Narang P, Solanki N, Varshney V. High patency of proximal splenorenal shunt: A myth or reality ? - A prospective cohort study. Int J Surg 2016; 27:82-87. [PMID: 26804351 DOI: 10.1016/j.ijsu.2015.12.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 11/29/2015] [Accepted: 12/08/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Proximal splenorenal shunt (PSRS) is a well-accepted surgical procedure for non-cirrhotic portal hypertension (NCPH). Though a patent shunt is important for good long term outcome, there are very few studies on patency of these shunts. We analysed shunt patency using dynamic computed tomographic (CT) portography and compared it with other modalities. METHODS From 2004 to 2014, 50 patients with PSRS were evaluated prospectively for shunt patency using dynamic CT portography, clinical parameters and ultrasound Doppler. RESULTS The causes of NCPH were extrahepatic portal vein obstruction (EHPVO) in 38 patients and non-cirrhotic portal fibrosis (NCPF) in 12 patients. The shunt patency rate using clinical parameters, ultrasound Doppler and dynamic CT portography were 70%, 40% and 60% respectively. Clinical parameters overestimated while ultrasound Doppler underestimated the shunt patency rate. Dynamic portography had 100% correlation with conventional angiography in the five patients when this was done. The site of shunt could be demonstrated convincingly by dynamic CT portography. The shunt patency rate decreased over time. It was 64%, 60% and 43% in <1 year, 1-5 years and >5 years respectively. Our NCPF patients had a greater shunt patency rate compared to EHPVO patients (9/12 vs. 21/38) though the difference was not significant. Only size of the splenic vein had a significant impact on the shunt patency rate on statistical analysis. CONCLUSIONS Dynamic CT portography is useful for evaluation of shunt patency. Proximal splenorenal shunts have a high blockage rate which has hitherto not been reported.
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Affiliation(s)
- Pramod Kumar Mishra
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India.
| | - Nilesh Sadashiv Patil
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Sundeep Saluja
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Poonam Narang
- Department of Radio Diagnosis, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Nisha Solanki
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Vaibhav Varshney
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
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Surgical and endovascular treatment of severe complications secondary to noncirrhotic portal hypertension: experience of 56 cases. Ann Vasc Surg 2013; 27:441-6. [PMID: 23465435 DOI: 10.1016/j.avsg.2012.05.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 05/21/2012] [Accepted: 05/23/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Major complications of noncirrhotic portal hypertension (NCPH) include bleeding esophagogastric varices, hypersplenism, ascites, and bowel ischemia under acute circumstances. The aim of this article is to determine the outcomes of surgical and endovascular treatments for severe complications from NCPH. METHODS From January 2000 to June 2011, 56 patients with symptomatic NCPH underwent open surgery or endovascular thrombolysis. The medical records were retrospectively reviewed. Of the 56 patients, there were 39 males and 17 females. The mean age was 21 years, ranging from 2 to 54 years. Forty-one of them were diagnosed to have prehepatic portal vein obstruction (PHPVO), 9 had Budd-Chiari syndrome (BCS), and 6 had noncirrhotic portal fibrosis (NCPF). All patients were symptomatic from 5 days to 14 years (mean 25 months). Portosystemic shunt (PSS) was primarily performed in 49 patients. Shunts were as follows: 35 mesocaval; 7 splenorenal; 4 portocaval; 2 paraumbilical-jugular; and 1 portal to right atrial. Esophagogastric devascularization was performed in 3 patients, but was converted to mesocaval shunt later in 2. The remaining 4 patients with acute superior mesenteric vein (SMV) and portal vein thrombosis were treated with endovascular catheter-directed thrombolysis. Warfarin was prescribed to all the patients for at least 6 months. Mean follow-up was 57 months, ranging from 2 to 125 months. The outcomes, focusing on 30-day mortality, recurrent bleeding, and hypersplenism, were recorded. RESULTS In the 49 patients undergoing primary PSS, the shunts remained patent and there was no recurrent variceal bleeding during the follow-up. All 3 patients with esophagogastric devascularization had recurrent variceal bleeding at 8, 13, and 24 months postoperatively. Two of them were converted to mesocaval shunt, and 1 died before redo operation. Thrombolysis in all 4 patients with acute SMV and portal thrombosis was technically successful. Three of the 4 survived without complications and 1 died from small bowel infarction due to recurrent thrombosis 40 days later. In the 47 patients with hypersplenism, mean platelet counts increased from 43×10(9)/L to 239×10(9)/L 2 weeks after surgery. Ascites in 30 of the 31 patients disappeared within 2 months after PSS. There was no postoperative encephalopathy, and perioperative 30-day mortality was 0%. CONCLUSIONS PSS can be employed to treat bleeding esophagogastric varices and severe hypersplenism secondary to NCPH. Post-PSS encephalopathy is less of a concern in NCPH patients with normal liver function. Endovascular catheter-directed thrombolysis via superior mesenteric artery is a useful alternative treatment for acute portal and/or mesenteric venous thrombosis.
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Kassem MI, El-Haddad HM, El-Bahrawi HA. Laparoendoscopic transgastric histoacryl injection of gastric varices: a new surgical approach. J Laparoendosc Adv Surg Tech A 2012. [PMID: 23198953 DOI: 10.1089/lap.2012.0241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Gastric varices (GVs) are a common finding in Egyptian patients with portal hypertension due to cirrhosis or schistosomal hepatic fibrosis. These patients present with an acute attack or history of hematemesis. Endoscopic histoacryl injection is the standard treatment in Egypt; however, because of technical difficulties it is possible to inject only a little amount of this material, as it may endanger the channels of the flexible endoscope. We thought of a new surgical laparoendoscopic technique to obviate the need for repeated endoscopies and complete obliteration of GVs. PATIENTS AND METHODS This study was conducted on 20 patients with portal hypertension and GVs. After the patient was placed under general anesthesia, a small gastrostomy was done in the anterior gastric wall through which a 10-mm trocar was inserted for the laparoscopic camera. Injection of GVs was done via a spinal needle or a central venous line needle inserted directly. Injection of an adequate amount of histoacryl was done under direct vision. RESULTS This study was conducted from July 2009 to August 2011 on 20 patients with GVs. The age range was from 22 to 56 years, with a mean age of 39.8±7.85 years. There were 14 men (70%) and 6 women (30%). Fourteen patients (70%) showed complete obliteration of GVs after one session of treatment, whereas 6 patients (30%) had unsatisfactory results and were subjected to another session. GVs were completely obliterated after the second session in 4 patients. Two cases of recurrence of GVs were operated on. CONCLUSIONS This new technique enabled us to inject GVs with a suitable amount of glue material under direct vision without harming the endoscope. Use of this procedure is recommended in patients fit for surgery and those who had failed endoscopic injection sclerotherapy.
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Affiliation(s)
- Mohamed I Kassem
- Gastrointestinal Surgical Unit, General Surgery Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.
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Endoscopic color Doppler ultrasonography for esophagogastric varices. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2012; 2012:859213. [PMID: 23213271 PMCID: PMC3507078 DOI: 10.1155/2012/859213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 10/05/2012] [Accepted: 10/20/2012] [Indexed: 02/06/2023]
Abstract
Esophagogastric varices are considered to be the most common complication in patients with portal hypertension. Endoscopic ultrasonography not only visualizes the surface of the varices but also provides detailed information about their internal structure. The direction of blood flow can be determined and its velocity measured only via endoscopic color Doppler ultrasonography (ECDUS). This can show graphically esophageal varices, paraesophageal veins, and passageways in esophageal variceal patients and gastric varices, perigastric collateral veins in gastric variceal patients. It is important to evaluate the hemodynamics of the portal venous system when treating the esophago-gastric varices. ECDUS is a useful modality for the evaluation of the detailed hemodynamics and the therapeutic effects of esophago-gastric varices.
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Krishnan A, Srinivasan V, Venkataraman J. Variceal recurrence, rebleeding rates and alterations in clinical and laboratory parameters following post-variceal obliteration using endoscopic sclerotherapy. J Dig Dis 2012; 13:596-600. [PMID: 23107447 DOI: 10.1111/j.1751-2980.2012.00633.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To study the rates of variceal recurrence and rebleeding following sclerotherapy and its effect on clinical and laboratory parameters in patients with portal hypertension. METHODS A total of 237 patients with portal hypertension together with esophageal variceal bleeding were included in the study. There were 138 patients with cirrhosis (group I), 42 with non-cirrhotic portal fibrosis (group II), and 57 with extrahepatic portal vein obstruction (group III). Baseline data and post-obliteration follow-up for rebleeding rates and changes in clinical and laboratory parameters were recorded. RESULTS In all, 106 patients in group I, 31 in group II and 43 in group III experienced obliteration of varices. The recurrence of grade II varices occurred in 17 patients (9.4%) during a mean period of 9 months. Rebleeding from varices was observed in 4 patients (3.8%) in group I and 1 (3.2%) in group II, while none in group III experienced rebleeding. There was a significant improvement in ascites, jaundice, liver status, international normalized ratio and platelet count in group I patients after variceal eradication (P < 0.05). The main cause of death in the cirrhotic patients was active liver disease but not rebleeding. CONCLUSIONS Following obliterative endoscopic sclerotherapy, rates of recurrence and rebleeding were significantly low when patients are kept under close observation. Disappearance of varices or reduction of variceal size improves the liver status in surviving cirrhotic patients.
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Affiliation(s)
- Arunkumar Krishnan
- Department of Gastroenterology and Hepatology, Stanley Medical College Hospital, Chennai, India
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Yilmaz G, Sari S, Egritas O, Dalgic B, Akyol G. Hepatoportal sclerosis in childhood: some presenting with cholestatic features (a re-evaluation of 12 children). Pediatr Dev Pathol 2012; 15:107-113. [PMID: 22150463 DOI: 10.2350/11-04-1017-oa.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hepatoportal sclerosis (HPS) is a syndrome of obscure etiology, and is one of the causes of noncirrhotic portal hypertension (PH). We aimed to investigate this heterogeneous group of patients whose presentation showed cholestatic features, histopathologically. Between 1999 and 2009, 12 children diagnosed with HPS were retrospectively evaluated. HPS was diagnosed with evidence of PH, noncirrhotic liver biopsy with typical histopathologic findings, and exclusion of other possible causes of PH. The data was obtained from pathology reports and microscopic slides. In histopathological re-evaluation fibrosis state, aberrant portal vessels, portal tract dilation and inflammation, ductular reaction, regenerative nodular hyperplasia, acinar transformation, presence of bile pigment, and cholangitis were noted. Serum alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl, alkaline phosphatase, bilirubin, and albumin levels, presentation patterns, and radiologic findings were assessed. Familial relationship degrees were also investigated. Twelve patients (9 boys, 3 girls; 3-180 months) were re-evaluated. Two pairs of the patients were siblings. Parents of 7 patients were consanguine. The most common presenting symptom was abdominal distension. Histopathologically, all patients had hepatoportal sclerosis/intimal fibrous thickening of portal vein and periportal fibrosis, acinar transformation, and regenerative nodules not surrounded by fibrous septae. Eight patients had vascular aberrations, 7 had ductular reaction, 1 showed mild cholangitis, and 1 had canalicular bile pigment. We conclude that genetic predisposition might be a possible factor for HPS development in Turkish patients and it should be kept in mind that cholestatic features noticed in histopathological evaluation may represent a variant group in the spectrum of HPS.
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Affiliation(s)
- Guldal Yilmaz
- Gazi University, Faculty of Medicine, Department of Pathology, Ankara, Turkey.
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Bayan K, Tüzün Y, Yılmaz Ş, Canoruc N, Dursun M. Analysis of inherited thrombophilic mutations and natural anticoagulant deficiency in patients with idiopathic portal hypertension. J Thromb Thrombolysis 2008; 28:57-62. [PMID: 18685811 DOI: 10.1007/s11239-008-0244-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2008] [Accepted: 06/23/2008] [Indexed: 01/04/2023]
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Abstract
Portal hypertension, a major hallmark of cirrhosis, is defined as a portal pressure gradient exceeding 5 mm Hg. In portal hypertension, porto-systemic collaterals decompress the portal circulation and give rise to varices. Successful management of portal hypertension and its complications requires knowledge of the underlying pathophysiology, the pertinent anatomy, and the natural history of the collateral circulation, particularly the gastroesophageal varices.
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Affiliation(s)
- Nagib Toubia
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, MCV, Box 980341, Richmond, VA 23298-0341, USA
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Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Akaike J. Observation of gastric variceal flow characteristics by endoscopic ultrasonography using color Doppler. Am J Gastroenterol 2008; 103:575-80. [PMID: 18028507 DOI: 10.1111/j.1572-0241.2007.01644.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the endoscopic color Doppler ultrasonography (ECDUS) findings of gastric varices and to determine the role of ECDUS in the diagnosis of gastric varices. METHODS Using ECDUS, we evaluated 114 patients with gastric varices found consecutively by routine upper endoscopy. We monitored the color flow images of gastric varices and perigastric collateral veins. We measured the blood flow velocity of gastric varices and the thickness of the gastric wall to submucosal gastric varices with this technique, and investigated the usefulness of ECDUS in evaluating the hemodynamics of gastric varices. Endoscopic findings of gastric varices were evaluated according to the grading system of the Japanese Research Committee on Portal Hypertension. RESULTS Color flow images of gastric varices and perigastric veins were delineated in all 114 patients with ECDUS. Evaluation of blood flow velocity in the 114 gastric varices revealed velocities of 7.7-35.7 cm/s (mean 18.2 +/- 5.9 cm/s). The velocities (23.7 +/- 6.4 cm/s, N = 21) of large, coil-shaped (F3)-type gastric varices were significantly higher than those (16.7 +/- 4.9 cm/s, N = 93) of enlarged tortuous (F2)-type varices (P < 0.0001). The 114 gastric varices were at 1.0-2.2 mm (1.6 +/- 0.3 mm) of gastric wall thickness. The thickness (1.2 +/- 0.1 mm, N = 22) for red color sign (RC)- or erosion-positive varices was significantly less than that (1.7 +/- 0.2 mm, N = 92) for the negative cases (P < 0.0001). The mean velocity was 28.0 +/- 6.1 cm/s in bleeding cases (N = 4) and 17.6 +/- 5.5 cm/s in nonbleeding cases (N = 110), and the velocities of the bleeding cases were significantly higher than those of the nonbleeding cases (P < 0.001). The mean thickness of the gastric wall was 1.2 +/- 0.2 mm for bleeding cases and 1.6 +/- 0.3 mm for nonbleeding cases, and the mean wall thickness in the bleeding cases was significantly less than in the nonbleeding cases (P < 0.001). CONCLUSIONS ECDUS is a useful modality for diagnosis of the hemodynamics of gastric varices and may allow the prediction of a high risk for hemorrhage.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan, USA
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SATO T, YAMAZAKI K, TOYOTA J, KARINO Y, OMURA T, SUGA T. Use of the Ultrasonic Microprobe to Evaluate Gastric Varices –Comparison with Endoscopic Color Doppler Ultrasonography–. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1997.tb00485.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Takahiro SATO
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Katsu YAMAZAKI
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Jouji TOYOTA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Yoshiyasu KARINO
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Takumi OMURA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Toshihiro SUGA
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
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15
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Köksal AS, Köklü S, Ibiş M, Balci M, Ciçek B, Saşmaz N, Sahin B. Clinical features, serum interleukin-6, and interferon-gamma levels of 34 turkish patients with hepatoportal sclerosis. Dig Dis Sci 2007; 52:3493-8. [PMID: 17404864 DOI: 10.1007/s10620-006-9596-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 09/04/2006] [Indexed: 12/27/2022]
Abstract
Hepatoportal sclerosis (HPS) is a clinical disorder of obscure pathogenesis with a variable clinical profile. The aim of the study was to summarize the clinical features of Turkish patients with HPS and to measure the serum levels of interleukin (IL)-6 and interferon (IFN)-gamma to determine the T helper cell profile in the pathogenesis. The study was conducted on 34 HPS patients (17 men, 17 women; mean age at diagnosis, 27+/-10 years) and 15 healthy controls. The clinical features of HPS patients including demographics, clinical history, laboratory, and ultrasonography findings were summarized. Serum IL-6 and IFN-gamma levels were measured by using commercially available enzyme-linked immunosorbent assay kits. Gastrointestinal bleeding was the most common dominant presenting symptom. Majority of the patients had preserved liver function tests. Serum triglyceride levels were decreased in 30%. Abdominal ultrasonography revealed well-demarcated bands of increased echogenicity surrounding the portal vein wall and sudden narrowing of the intrahepatic second-degree portal vein branches in all cases. Spontaneous shunts and/or collaterals were seen in 13 cases (37%). Extrahepatic portal vein thrombosis were seen in 7 (20%) patients after at least 5 years of disease duration. Serum levels of both IL-6 (median, 3.2 pg/mL) and IFN-gamma (median, 7.8 pg/mL) were significantly higher in HPS patients compared with the control group (median, 1 pg/mL). HPS has variable clinical profile in different geographic areas of the world. Both Th1 and 2 cells may have a role in the regulation of immune response and pathogenesis of the disease.
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Affiliation(s)
- Aydin Seref Köksal
- Department of Gastroenterology, Ankara Oncology Hospital, Ankara, Turkey
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16
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Abstract
Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is associated not only with a high mortality, but also with a high recurrence rate in those who survive. Therefore, management should focus on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control hemorrhage during the acute bleeding episode (emergency treatment), and to prevent rebleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This article reviews management of acute variceal bleeding.
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Affiliation(s)
- Adil Habib
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University Medical Center, MCV Box 980341, Richmond, VA 23298-0341, USA
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17
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Abstract
Many advances have occurred in the management of varices over the years. Guidelines based on sound evidence have been developed to manage the esophageal variceal hemorrhage. Less is known about how best to manage some of the more difficult cases of bleeding related to portal hypertension. This article reviews evidence in the hypertensive gastropathy, ectopic varices, and management of patients who are intolerant of or have not responded to beta-blocker therapy. The goal of this article is to review the sparse available evidence and to suggest reasonable management options.
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Affiliation(s)
- Atif Zaman
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mailcode PV310, Portland, OR 97210, USA.
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18
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Zargar SA, Javid G, Khan BA, Shah OJ, Yattoo GN, Shah AH, Gulzar GM, Singh J, Shah NA, Shafi HM. Endoscopic ligation vs. sclerotherapy in adults with extrahepatic portal venous obstruction: a prospective randomized study. Gastrointest Endosc 2005; 61:58-66. [PMID: 15672057 DOI: 10.1016/s0016-5107(04)02455-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic sclerotherapy is a well-established treatment for bleeding esophageal varices, although it has a substantial complication rate. A prospective randomized trial was conducted to determine whether endoscopic variceal ligation is safer and more effective than sclerotherapy in adults with bleeding esophageal varices because of extrahepatic portal venous obstruction. METHODS Thirty-six patients underwent sclerotherapy and 37 had band ligation. RESULTS Ligation and sclerotherapy were equally effective for achieving variceal eradication (94.6% vs. 91.7%, respectively; p=0.67). However, ligation achieved eradication with fewer endoscopic sessions (3.7 [1.2] vs. 7.7 [3.3]; p <0.0001) and within a shorter time interval (50.1 [17.7] days vs. 99 [54.8] days; p <0.0001). In the ligation group, recurrent bleeding was less frequent (2.7% vs. 19.4%; p=0.028; however, Bonferroni correction for multiple testing removes this significance) and the rate of major complications was lower (2.7% vs. 22.2%; p=0.014). Total cost per patient was significantly higher in the sclerotherapy vs. the ligation group ($216.6 [71.8] vs. $182.6 [63.4]; p=0.035). During the follow-up period after variceal eradication, no significant differences were found between the sclerotherapy and the ligation groups with respect to recurrent bleeding (3% vs. 2.9%; p=1.0), esophageal variceal recurrence (9.1% vs. 11.4%; p=1.0), and formation of new gastric varices (9.1% vs. 14.3%; p=0.51). CONCLUSIONS Variceal band ligation is superior to sclerotherapy, because it is less costly and achieves variceal eradication more quickly, with lower relative frequencies of recurrent variceal bleeding and complications.
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Affiliation(s)
- Showkat Ali Zargar
- Department of Gastroenterology and General Sugery, Sher-i-Kashmir Institute of Medical Sciences, Sringar, Kashmir, India
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19
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Rangari M, Gupta R, Jain M, Malhotra V, Sarin SK. Hepatic dysfunction in patients with extrahepatic portal venous obstruction. Liver Int 2003; 23:434-9. [PMID: 14986818 DOI: 10.1111/j.1478-3231.2003.00879.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Extrahepatic portal venous obstruction (EHPVO) developing due to thrombotic occlusion of the portal vein in children is generally considered a benign disease. Whether hepatic dysfunction develops in these patients in the absence of a gastrointestinal bleed has not been well studied. MATERIALS AND METHODS Forty-three patients with EHPVO who had not bled in the last 3 months were studied. Patients were divided into those with (group I) or without ascites (group II). Matched cirrhotic patients with ascites (group III) served as controls. Clinical, biochemical, ultrasonographic, and histopathological evaluation was carried out. Portal biliopathy was assessed in five patients in group I and in 12 patients in group II by cholangiography. RESULTS Of 43 EHPVO patients, ascites was seen in nine (21%) patients (group I). Thirty-four patients had no ascites (group II). Serum ALT (54 +/- 24 vs. 34 +/- 10 IU/l, P < 0.01), albumin (3.2 +/- 0.3 vs. 3.7 +/- 0.4 g/dl, P < 0.01), and prothrombin time difference (9.0 +/- 4.5 vs. 2.4 +/- 1.9 s, P < 0.05) were deranged in patients in group I compared with group II. Patients in group I were 4 years older, and the duration of portal hypertension was longer than in group II (11.5 vs. 5.6 year, P < 0.05). Portal biliopathy changes were significantly more severe in group I than in group II patients. Ascites was high gradient in all the patients in group I and the serum-ascitic albumin gradient was comparable between groups I and III. None of the EHPVO patients, but four cirrhotic patients, developed spontaneous bacterial peritonitis during a follow-up of 11 +/- 4 months. CONCLUSIONS Hepatic dysfunction in the form of ascites and deranged liver functions is not uncommon in patients with EHPVO, more so in patients with prolonged portal hypertension. Based on our data it would be worthwhile to study whether prolonged portal vein thrombosis in EHPVO patients could lead to progressive liver disease.
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Affiliation(s)
- M Rangari
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi 110002, India
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20
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Abstract
Portal hypertension bleeding is a common and serious complication of cirrhosis. All patients with cirrhosis should undergo endoscopy and be evaluated for possible causes of current or future portal hypertensive bleeding. Possible causes of bleeding include esophageal varices, gastric varices, and PHG. Patients with esophageal varices at high risk of bleeding should be treated with nonselective beta-blockers for primary prevention of variceal hemorrhage. HVPG measurements represent the optimal way to monitor the success of pharmacologic therapy. EVL may be used in those with high-risk varices who do not tolerate beta-blockers. When active bleeding develops, simultaneous and coordinated attention must be given to hemodynamic resuscitation, prevention and treatment of complications, and active control of bleeding. In cases of acute esophageal variceal (Fig. 5) and PHG bleeding, terlipressin, somatostatin, or octreotide should be started. Endoscopic treatment is provided for those with bleeding esophageal varices. If first-line therapy fails, TIPS or surgery may need to be performed. Unlike esophageal variceal or PHG bleeding, there is no established optimal treatment for gastric variceal bleeding. Individual and specific treatment modalities for acute gastric variceal bleeding must be calculated carefully after considering side effects.
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Affiliation(s)
- Kevin M Comar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, MCV Box 980711, Sanger Hall 12011, Richmond, VA 23298-0711, USA
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Sökücü S, Süoglu OD, Elkabes B, Saner G. Long-term outcome after sclerotherapy with or without a beta-blocker for variceal bleeding in children. Pediatr Int 2003; 45:388-94. [PMID: 12911472 DOI: 10.1046/j.1442-200x.2003.01743.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Esophageal variceal bleeding is a life-threatening complication of portal hypertension. Optimal treatment for the prophylaxis of variceal rebleeding in children has not yet been determined. In the present study, we aimed to compare the long-term efficacy of endoscopic sclerotherapy with or without oral beta-blocker therapy in the secondary prophylaxis of variceal bleeding. METHODS Thirty-eight children who had undergone endoscopic sclerotherapy (EST) sessions for variceal bleeding in the Department of Pediatric Gastroenterology, Istanbul University Istanbul School of Medicine, were entered into this retrospective cohort study. Twenty patients (mean +/- SD age 7.0 +/- 2.7 years) had undergone only sclerotherapy sessions (SG), whereas 18 patients (mean age 6.8 +/- 3.4 years) had received oral propranolol (1-2 mg/kg per day) additionally for 2 years (SPG). The number of patients with successful obliteration, the time required for obliteration and variceal recurrence rate were analyzed as primary indicators of the effectiveness of therapy. RESULTS Variceal obliteration was achieved in 16 of 20 patients (80%) in the SG group and in 16 of 18 patients (88%) in the SPG group. Time required for variceal obliteration was significantly shorter in the SPG group compared with the SG group (4.1 +/- 1.4 vs 3.2 +/- 0.9 months; P < 0.05). The variceal recurrence rate was 65 and 38.8% in the SG and SPG groups, respectively. Compared with the SG group, less variceal rebleeding was observed during EST in the SPG group (25 vs 16.6%, respectively).However, these differences were not statistically significant. CONCLUSIONS Endoscopic sclerotherapy combined with oral propranolol treatment shortens the time required for variceal obliteration. However, the other indicators of treatment effectiveness are not influenced statistically by the addition of propranolol to the treatment regimen. Randomized prospective clinical studies in larger pediatric series are needed before offering a combination of EST with oral propranolol as the most rational approach in the secondary treatment of esophageal variceal bleeding in children.
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Affiliation(s)
- Semra Sökücü
- Departmentof Pediatric Gastroenterology and Hepatology, Istanbul School of Medicine and Instituteof Child Health, Istanbul University, Istanbul, Turkey
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22
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Zargar SA, Javid G, Khan BA, Yattoo GN, Shah AH, Gulzar GM, Singh J, Rehman BU, Din Z. Endoscopic ligation compared with sclerotherapy for bleeding esophageal varices in children with extrahepatic portal venous obstruction. Hepatology 2002; 36:666-672. [PMID: 12198659 DOI: 10.1053/jhep.2002.35278] [Citation(s) in RCA: 153] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endoscopic sclerotherapy is an effective treatment for bleeding esophageal varices, but it is associated with significant complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, has been shown to be superior to sclerotherapy in adult patients with cirrhosis. To determine the efficacy and safety of endoscopic sclerotherapy and ligation, the 2 methods were compared in a randomized control trial in 49 children with extrahepatic portal venous obstruction who had proven bleeding from esophageal varices. Twenty-four patients were treated with sclerotherapy and 25 with band ligation. No significant differences were found between the sclerotherapy and ligation groups in arresting active index bleeding (100% each) and achieving variceal eradication (91.7% vs. 96%, P =.61). Band ligation eradicated varices in fewer endoscopic sessions than did sclerotherapy (3.9 +/- 1.1 vs. 6.1 +/- 1.7, respectively, P <.0001). The rebleeding rate was significantly higher in the sclerotherapy group (25% vs. 4%, P =.049), as was the rate of major complications (25% vs. 4%, P =.049). After eradication, esophageal variceal recurrence was not significantly different in patients treated by ligation than by sclerotherapy (17.4% vs. 10%, P =.67). In conclusion, variceal band ligation in children is a safe and effective technique that achieves variceal eradication more quickly, with a lower rebleeding rate and fewer complications compared with sclerotherapy.
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Affiliation(s)
- Showkat Ali Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.
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23
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Yoshida H, Onda M, Tajiri T, Toba M, Umehara M, Mamada Y, Taniai N, Yamashita K. Endoscopic Injection Sclerotherapy for the Treatment of Recurrent Esophageal Varices after Esophageal Transection. Dig Endosc 2002. [DOI: 10.1046/j.1443-1661.2002.00185.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Dhiman RK, Chawla Y, Vasishta RK, Kakkar N, Dilawari JB, Trehan MS, Puri P, Mitra SK, Suri S. Non-cirrhotic portal fibrosis (idiopathic portal hypertension): experience with 151 patients and a review of the literature. J Gastroenterol Hepatol 2002; 17:6-16. [PMID: 11895549 DOI: 10.1046/j.1440-1746.2002.02596.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-cirrhotic portal fibrosis (NCPF), the equivalent of idiopathic portal hypertension in Japan and hepatoportal sclerosis in the United States of America, is a common cause of portal hypertension in India. The clinical features, portographic and histological findings, and management of 151 patients with non-cirrhotic portal fibrosis are presented. METHODS The disease is diagnosed by the presence of unequivocal evidence of portal hypertension in the definite absence of liver cirrhosis and extrahepatic portal vein obstruction (EHPVO). Retrospective analysis of records of 151 patients with NCPF was analyzed for the clinical presentation, physical findings, laboratory tests, radiological and histological findings, and for the outcome of treatment. RESULTS The disease is characterized by massive splenomegaly with anemia, preserved liver function and benign prognosis in a majority of patients. Splenoportovenography (SPV) showed massive dilatation of the portal and splenic veins, and the presence of collaterals. Twenty-four (15.9%) patients showed evidence of natural/spontaneous shunts (splenorenal 15, umbilical nine) on SPV; these patients had a lower incidence of variceal bleeding. Liver histology demonstrated maintained lobular architecture, portal fibrosis of variable degree, sclerosis and obliteration of small-sized portal vein radicles, and subcapsular scarring with the collapse of the underlying parenchyma. Piecemeal or hepatocytic necrosis was absent in all histology specimens. Three patients showed nodular transformation along with abnormal liver functions, and may represent late manifestation of NCPF where features are similar to those seen in patients with incomplete septal cirrhosis. In the initial part of the study, surgery (side-to-side lieno-renal shunt) was the preferred modality of treatment, however, endoscopic sclerotherapy or variceal ligation has now become the preferred first line of management of variceal bleeding. CONCLUSIONS The epidemiological and clinical features of NCPF have more similarity to IPH than has previously been documented. The development of spontaneous shunts tends to protect these patients from variceal bleeding.
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Affiliation(s)
- Radha Krishan Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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25
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Abstract
Gastric varices and portal hypertensive gastropathy (PHG) are an important complication of both generalized and segmental portal hypertension. The natural history and risk factors for bleed from GV are not extensively studied as that for esophageal varices. Recently, effective therapy for gastric variceal bleed in form of tissue adhesives, balloon-occluded retrograde transvenous obliteration of gastric varices (BRTO) has been developed. Further advances are still needed regarding natural history, risk factors, bleeding, and mechanism of GV rupture.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G. B. Pant Hospital, New Delhi, India.
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26
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Abstract
Noncirrhotic portal hypertension represents a heterogeneous group of conditions that have distinct clinical and hemodynamic features that often help distinguish them from cirrhosis. [figure: see text] The sites of portal flow resistance may not be precisely localized to one area of the hepatic lobule and may extend beyond the site where the pathogenetic process began. Even in patients with portal hypertension caused by an increased flow, there may be subsequent development of increased resistance. The prognosis is variable; outcomes are better in patients with presinusoidal portal hypertension. A good understanding of the presentation of the various noncirrhotic conditions that cause portal hypertension will help determine the cause, the site of resistance, and the therapeutic plan. Ascites is not a feature of presinusoidal portal hypertension, whereas it may be the predominant feature in postsinusoidal portal hypertension.
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Affiliation(s)
- E Molina
- Center for Liver Diseases, University of Miami School of Medicine, Miami, Florida, USA
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27
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Gotoh Y, Iwakiri R, Sakata Y, Koyama T, Noda T, Matsunaga C, Ogata SI, Ishibashi S, Sakata H, Tsunada S, Fujimoto K. Evaluation of endoscopic variceal ligation in prophylactic therapy for bleeding of oesophageal varices: a prospective, controlled trial compared with endoscopic injection sclerotherapy. J Gastroenterol Hepatol 1999; 14:241-4. [PMID: 10197493 DOI: 10.1046/j.1440-1746.1999.01841.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND To evaluate the efficacy of endoscopic variceal ligation (EVL) in prophylactic therapy for oesophageal varices, we performed a randomized prospective trial to compare the recurrence of oesophageal varices treated by EVL with those treated by endoscopic injection sclerotherapy. METHODS Fifty patients with liver cirrhosis were divided into two groups at random, after informed consents were obtained, to receive prophylactic therapy for bleeding of oesophageal varices. Group 1 patients underwent sessions of sclerotherapy with 5% ethanolamine oleate used as the sclerosant. Group 2 patients underwent EVL followed by one or two sessions of sclerotherapy. RESULTS During the 18 month follow-up period, both the recurrence rate in group 2 (56%) and the incidence of bleeding (20%) were significantly higher compared with group 1 (recurrence rate 16%, bleeding 0%). CONCLUSIONS This result indicates that EVL is not effective for prophylactic therapy for oesophageal varices in liver cirrhosis.
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Affiliation(s)
- Y Gotoh
- Department of Internal Medicine, Saga Medical School, Japan
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Dash SC, Bhuyan UN, Dinda AK, Saxena S, Agarwal SK, Tiwari SC, Nundy S. Increased incidence of glomerulonephritis following spleno-renal shunt surgery in non-cirrhotic portal fibrosis. Kidney Int 1997; 52:482-5. [PMID: 9264006 DOI: 10.1038/ki.1997.357] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In a prospective study of 200 non-cirrhotic portal fibrosis (NCPF) patients, 7% had mild proteinuria and their renal biopsies showed mild mesangial proliferative glomerulonephritis (mes-PGN). The remaining 93% biopsies were normal. However, following the insertion of a spleno-renal shunt (SRS) for portal hypertension 32% of these patients developed nephrotic syndrome in five years. Renal histology revealed mesangiocapillary glomerulonephritis (MCGN) (18.5%), mes-PGN (9%), minimal change nephropathy (3%), and chronic sclerosing GN (1.5%). Immunofluorescence showed granular deposition of IgA and C3. IgA2 was the predominant form of Ig in the glomerular deposits, indicating that IgA in the immune complexes was derived from the gastrointestinal tract. Electron microscopy revealed electron dense deposits in the mesangium. In contrast to the NCPF patients who underwent a SRS for portal hypertension, the 200 patients in our study who underwent spleno-renal shunting because of extra hepatic portal obstruction did not have renal disease, nor did they develop renal disease during the five-year post-operative follow-up. Fifty percent of the glomerulonephritis (GN) in the NCPF group progressed to renal failure in five years; 46.6% continued to have proteinuria. Low serum complement, C3 (40%) and circulating immune complexes (14.8%) were detected in the glomerulonephritis group. Our study shows that: (i) there is a high rate of the occurrence of GN following SRS in NCPF patients, but not in those with normal livers; (ii) the type of GN is primarily IgA nephropathy; and (iii) the GN could be the result of defective hepatic reticuloendothelial function in the NCPF group that is worsened by the shunting procedure.
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Affiliation(s)
- S C Dash
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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29
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Abstract
BACKGROUND Bleeding from gastric varices is often a serious medical emergency. The role of endoscopy in the management of gastric variceal bleeding is still controversial. The types of gastric varices and their respective management strategies have not been identified. METHODS Gastric varices were observed in 209 patients with portal hypertension. Seventy-one patients (with cirrhosis 33, noncirrhotic 38) underwent gastric variceal sclerotherapy, 53 of these (75%) for gastric variceal bleeding. By use of a previously described classification, gastric varices were divided into gastroesophageal varices, type 1 (GOV1) and type 2 (GOV2), and isolated gastric varices, type 1 (IGV 1). Gastric variceal sclerotherapy was done every week using a combination technique of paravariceal and intravariceal injections with absolute alcohol. RESULTS Emergency gastric variceal sclerotherapy arrested acute bleeding in 12 (66.7%) of 18 patients. Variceal obliteration was achieved in 43 of the 60 (71.6%) patients who underwent repeated elective sclerotherapy. Variceal obliteration was higher in patients with GOV1 (94.4%) than in those with GOV2 (70.4%) and IGV1 (41%). Rebleeding after elective gastric variceal sclerotherapy was seen in 5.5%, 19%, and 53%, respectively, in the three types of gastric varices. Gastric variceal recurrence was not seen during a mean follow-up of 24.2 +/- 22.9 months. Seventeen (24%) patients died, nearly equally from rebleeding and liver failure. CONCLUSIONS (1) Sclerotherapy can effectively arrest acute gastric variceal bleeding and achieve gastric variceal obliteration, (2) it is more effective in patients with gastroesophageal varices, and (3) alternative therapies need to be evaluated for patients with IGV1.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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30
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Abstract
This article reviews the different conditions leading to noncirrhotic intrahepatic portal hypertension, describes the related vascular lesions, and provides a review of the clinical characteristics, diagnosis, and treatment options available. Diseases associated with noncirrhotic portal hypertension are also specifically discussed.
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Affiliation(s)
- S Hillaire
- Laboratoire d'Hemodynamique Splanchnique et de Biologie Vasculaire, Unité de Recherches de Physiopathologie Hépatique (INSERM U-24), Service d'Hépatologie, Hôpital Beaujon, Clichy, France
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Waked I, Korula J. Analysis of long-term endoscopic surveillance during follow-up after variceal sclerotherapy from a 13-year experience. Am J Med 1997; 102:192-9. [PMID: 9217570 DOI: 10.1016/s0002-9343(96)00401-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the course of patients with bleeding esophageal varices treated with endoscopic sclerotherapy after obliterating varices and to determine the cost benefits of long-term endoscopic surveillance from a retrospective analysis of a 13-year experience. LOCATION University-affiliated teaching hospital and county facility. METHODS Patients whose varices were obliterated by endoscopic sclerotherapy were considered for the study if they had a minimum of 12 months of follow-up. Sclerotherapy was initially performed weekly, increasing intervals to eventual yearly treatments. Varices were reobliterated if they reformed. Variables assessed were rebleeding, mortality, employment status, and cost based on allowable and reimbursed Medicare rates. RESULTS Of 324 patients who achieved variceal obliteration, analysis included 104 eligible patients who were followed up for > 12 months (41 +/- 28). Varices reformed in 73 patients (71%), mostly in the first year after obliteration or reobliteration. Abstinent alcoholic patients were least likely to reform varices. Nineteen patients (18%) had 23 rebleeding episodes, and in 10 patients (10%) portalsystemic shunt was placed. Survival was 84% and bleeding-related mortality was 6%. Significantly more patients were employed while on the program compared with entry. The yearly cost of treating variceal reformers ($2,117) was significantly higher than variceal nonreformers ($1,735), but the overall cost of maintaining a patient on a chronic sclerotherapy program was relatively small. CONCLUSIONS The low rebleeding, low mortality, and relatively low cost in patients managed long term by chronic sclerotherapy underscores the benefits of this treatment program.
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Affiliation(s)
- I Waked
- Department of Medicine, University of Southern California School of Medicine, Los Angeles, California, USA
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32
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Kollias J, Jeans PL, Padbury RT, Toouli J. Gastric devascularization and splenectomy for bleeding gastric varices. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1995; 65:804-7. [PMID: 7487731 DOI: 10.1111/j.1445-2197.1995.tb00565.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Gastric varices may be associated with oesophageal varices in patients with portal hypertension. Control of haemorrhage from gastric varices is often difficult. Between June 1988 and February 1990, six patients underwent gastric devascularization in an effort to control life-threatening haemorrhage from bleeding gastric varices after non-operative measures failed. In all six patients the bleeding was controlled. There was one peri-operative death due to hepatic failure. Four patients experienced postoperative respiratory or urinary tract infections that responded to appropriate antibiotic and respiratory support measures. After a mean follow-up period of 44 months, eradication of gastric varices was achieved in all five survivors. Gastric devascularization is an effective surgical measure for good palliation and control of life-threatening haemorrhage from bleeding gastric varices.
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Affiliation(s)
- J Kollias
- Department of Surgery, Flinders Medical Centre, Flinders University of South Australia, Bedford Park, Adelaide, Australia
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33
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Hou MC, Lin HC, Kuo BI, Chen CH, Lee FY, Lee SD. Comparison of endoscopic variceal injection sclerotherapy and ligation for the treatment of esophageal variceal hemorrhage: a prospective randomized trial. Hepatology 1995. [PMID: 7768494 DOI: 10.1002/hep.1840210607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To determine the efficacy of endoscopic variceal sclerotherapy (EVS) and ligation (EVL) in the management of esophageal variceal bleeding, 134 cirrhotic patients were randomized to receive either treatment. The clinical and endoscopic characteristics were similar in both groups. Active bleeding was controlled with ligation (20 of 20) as efficiently as with sclerotherapy (14 of 16). Elective sclerotherapy consumed less time than ligation (7.9 +/- 1.8 minutes vs. 11.5 +/- 2.7 minutes, P < .001), but there was no difference between emergent sclerotherapy (14.5 +/- 5.8 minutes) and ligation (14.9 +/- 4.1 minutes). Ligation reduced one grade of variceal size more quickly than sclerotherapy (1.1 +/- 0.4 vs. 2.0 +/- 1.7 session, P < .001). The rebleeding rate was lower with ligation (13 of 67 vs. 28 of 67, P < .01). Esophageal ulcer was the most common source of rebleeding. Recurrence of varices appears more probable with ligation (P = .079). The complication rate was higher with sclerotherapy (15 of 67 vs. 3 of 67, P < .01), with esophageal stricture being the most common cause. Survival rate was the same in both groups even after stratifying patients into good and poor hepatic reserve groups. Hepatic failure was the major cause of death, followed by exsanguination. In summary, EVL was superior to EVS regarding rebleeding and complications but not in other aspects such as time consumption in elective treatment and recurrence of varices. Substantial results for long-term follow-up are required before conclusion of the treatment of choice.
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Affiliation(s)
- M C Hou
- Department of Medicine, Veterans General Hospital-Taipei, Taiwan, Republic of China
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34
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Karrer FM, Holland RM, Allshouse MJ, Lilly JR. Portal vein thrombosis: treatment of variceal hemorrhage by endoscopic variceal ligation. J Pediatr Surg 1994; 29:1149-51. [PMID: 7965524 DOI: 10.1016/0022-3468(94)90298-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Thirty-one endoscopic variceal ligation (EVL) procedures have been done in seven consecutively treated children who had esophageal varices resulting from portal vein thrombosis. Using an elastic band ligature device attached to a standard flexible endoscope, the varices in the distal 5 cm of the esophagus were mechanically strangulated. Typically, one to three varices were banded at each session. The children were between 8 months and 19 years of age at the onset of variceal bleeding. Treatment initially required frequent procedures (every 2 to 4 weeks), but the interval was gradually extended to biannual or annual. Treatment was assessed by survival, complications, incidence of rebleeding, and obliteration of varices. Each patient had from 3 to 9 EVL sessions. There were no deaths related to EVL. There were no complications. Only one patient had rebleeding in the interval between sessions. The follow-up period is 3 to 12 years. In three of the six surviving patients, the varices have been completely eradicated. The remaining three are completing treatment. Endoscopic variceal ligation is safe efficacious treatment for control of variceal bleeding caused by portal vein thrombosis. In our experience, the technique has eliminated the need for portosystemic shunting in this patient population.
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Affiliation(s)
- F M Karrer
- Department of Surgery, University of Colorado School of Medicine, Children's Hospital, Denver
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35
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Lin CY, Lin PW, Tsai HM, Lin XZ, Chang TT, Shin JS. Influence of paraesophageal venous collaterals on efficacy of endoscopic sclerotherapy for esophageal varices. Hepatology 1994; 19:602-8. [PMID: 8119684 DOI: 10.1002/hep.1840190310] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To determine the diagnostic accuracy of computer tomography in the detection of venous collaterals surrounding the esophagus in patients with portal hypertension, preoperative computer tomography interpretations of these veins in 15 patients who were candidates for the Sugiura procedure for treatment of esophageal varices were correlated with those of the intraoperative assessment. Laparotomy revealed severe paraesophageal varices in five patients; four of them were found to have paraesophageal varices in computer tomography films. The sensitivity and specificity of computer tomography in diagnosing severe paraesophageal varices were 80% and 100%, respectively. A second assessment was performed in 59 additional patients with esophageal variceal hemorrhage to investigate the influence of paraesophageal varices on the efficacy of endoscopic sclerotherapy in the treatment of varices. The patients were divided into two groups: Group A included 17 patients with and group B 42 patients without paraesophageal varices on presclerotherapy computer tomography. All patients underwent elective sclerotherapy after being deemed hemodynamically stable. Patients in group A required more treatment sessions, more sclerosant and longer periods to obliterate varices completely than did group B patients. Eight patients in group A and six in group B (57% vs. 16%, p < 0.05) had variceal recurrence after obliteration during mean follow-ups of 20.8 and 19.9 mo, respectively. The mean time elapsed before variceal reappearance was shorter for group A than for group B (4.1 +/- 3.3 vs. 11.8 +/- 2.7 mo, p < 0.05). Among patients who developed new varices, five patients in group A and one in group B experienced repeat bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C Y Lin
- Department of Internal Medicine, Medical College, National Cheng-Kung University, Tainan, Taiwan
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36
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Avgerinos A, Rekoumis G, Klonis C, Papadimitriou N, Gouma P, Pournaras S, Raptis S. Propranolol in the prevention of recurrent upper gastrointestinal bleeding in patients with cirrhosis undergoing endoscopic sclerotherapy. A randomized controlled trial. J Hepatol 1993; 19:301-11. [PMID: 8301065 DOI: 10.1016/s0168-8278(05)80586-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The purpose of this study was to investigate the possible value of continuous administration of propranolol in the prevention of recurrent upper gastrointestinal bleeding in patients with cirrhosis undergoing chronic endoscopic sclerotherapy. Among 239 patients admitted for acute variceal bleeding, 85 with cirrhosis were randomized to receive sclerotherapy either alone (40) or in combination with propranolol (45). Sclerotherapy was carried out with an intravariceal injection of 5% ethanolamine oleate through a fiberoptic endoscope. The procedure was performed every week, until the esophageal varices at the gastroesophageal junction were too small for any further injections. Varices were reinjected if they recurred. Propranolol was given orally twice a day until heart rate was reduced by 25% in the resting position. The mean follow-up period was 23.2 and 24.2 months for sclerotherapy and the sclerotherapy plus propranolol groups, respectively. During this period a significant (P = 0.001) reduction in the recurrence of esophageal varices was observed in patients treated with the combination of sclerotherapy plus propranolol compared with those treated with sclerotherapy alone. However, the time of rebleeding from any source or from esophageal varices did not differ significantly between the two groups. In the sclerotherapy group 21 patients rebled (35 bleeding episodes) compared with 14 (22 episodes) in the combination therapy group. Patients in the sclerotherapy group were more prone to bleed from gastric varices and congestive gastropathy than patients treated with the combination of sclerotherapy plus propranolol (P = 0.012). Twenty-five patients in the endoscopic sclerotherapy group developed complications attributed to sclerotherapy compared with 23 patients in the sclerotherapy plus propranolol group. Complications directly attributable to propranolol were observed in 11 patients. Three of these patients stopped taking the drug due to heart failure (1) and flapping tremor (2). Eight patients (17.8%) died in the latter group while the corresponding figure in the sclerotherapy group was nine (22.5%). It is concluded that the continuous administration of propranolol may reduce incidences of recurrent upper gastrointestinal hemorrhage from gastric sources in patients with cirrhosis undergoing chronic sclerotherapy.
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Affiliation(s)
- A Avgerinos
- 2nd Department of Gastroenterology, Evangelismos Hospital, Athens, Greece
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37
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Lo GH, Lai KH, Lee SD, Tsai YT, Lo KJ. Does propranolol maintain post-sclerotherapy variceal obliteration? A prospective randomized study. J Gastroenterol Hepatol 1993; 8:358-62. [PMID: 8374092 DOI: 10.1111/j.1440-1746.1993.tb01528.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Variceal recurrence and rebleeding are common after initial obliteration by injection sclerotherapy. To investigate whether propranolol can maintain variceal obliteration by sclerotherapy, 59 patients with oesophageal variceal bleeding after sclerotherapy were enrolled. Patients were allocated to propranolol treatment (30 patients) or served as controls (29 patients). After a mean follow up of 2 years and 4 months, 53 patients completed the study. Fifty-eight per cent of the propranolol group versus 77% of the control group experienced recurrent varices (P = 0.20). Fifteen per cent of the propranolol group versus 11% of the control group developed cardiac varices. Recurrent variceal bleeding was encountered in 27% of the propranolol group and 19% of the control group. Three patients in the propranolol group, compared with two patients in the control group, died of massive variceal bleeding. Eighty per cent of them bled from cardiac varices. Both groups had similar survival rates. We therefore concluded that the use of propranolol after variceal obliteration by sclerotherapy can neither prevent oesophagogastric variceal recurrence nor prevent further rebleeding.
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Affiliation(s)
- G H Lo
- Department of Medicine, Veterans General Hospital-Kaohsiung, Taiwan, Republic of China
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38
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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39
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Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16:1343-9. [PMID: 1446890 DOI: 10.1002/hep.1840160607] [Citation(s) in RCA: 837] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
To determine the prevalence and natural history of gastric varices, we prospectively studied 568 patients (393 bleeders and 175 nonbleeders) with portal hypertension (cirrhosis in 301 patients, noncirrhotic portal fibrosis in 115 patients, extrahepatic portal vein obstruction in 117 patients and hepatic venous outflow obstruction in 35 patients). Primary (present at initial examination) gastric varices were seen in 114 (20%) patients; more were present in bleeders than in non-bleeders (27% vs. 4%, respectively; p < 0.001). Secondary (occurring after obliteration of esophageal varices) gastric varices developed in 33 (9%) patients during follow-up of 24.6 +/- 5.3 mo. Gastric varices (compared with esophageal varices) bled in significantly fewer patients (25% vs. 64%, respectively). Gastric varices had a lower bleeding risk factor than did esophageal varices (2.0 +/- 0.5 vs. 4.3 +/- 0.4, respectively) but bled more severely (4.8 +/- 0.6 vs. 2.9 +/- 0.3 transfusion units per patient, respectively). Once a varix bled, mortality was more likely (45%) in gastric varix patients. Gastric varices were classified as gastroesophageal or isolated gastric varices. Type 1 gastroesophageal varices (lesser curve varices) were the most common (75%). After obliteration of esophageal varices, type 1 gastroesophageal varices disappeared in 59% of patients and persisted in the remainder; bleeding from persistent gastroesophageal varices was more common than it was from gastroesophageal varices that were obliterated (28% vs. 2%, respectively; p < 0.001). Type 2 gastroesophageal varices, which extend to greater curvature, bled often (55%) and were associated with high mortality. Type 1 isolated gastric varices patients had only fundal varices, with a high (78%) incidence of bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology and Radiology, G.B. Pant Hospital, New Delhi, India
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40
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Mathur SK, Naik SR, Supe AN, Plumber ST, Pipalia ST, Bhalerao RA. Endoscopic esophageal variceal sclerotherapy using 3% aqueous phenol. Gastrointest Endosc 1992; 38:152-7. [PMID: 1568612 DOI: 10.1016/s0016-5107(92)70381-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic esophageal variceal sclerotherapy was performed in 301 patients with portal hypertension (emergency, 72 and elective, 229) using 3% aqueous phenol as sclerosant. The cause of portal hypertension was cirrhosis of the liver in 189 patients (Child's class A-48, B-66, and C-75), extrahepatic portal venous obstruction (EHPVO) in 90, and non-cirrhotic portal fibrosis in 22 patients. In the emergency group, active bleeding was controlled in 87% of cases. Re-bleeding occurred in 101 of 290 (35%) surviving patients. Obliteration of varices was achieved in 228 (84%) patients, with a mean of 5.14 +/- 2.27 sclerotherapy sessions. Of 301 patients, 29 (9.6%) had an early in-hospital mortality (30.5% in emergency and 3% in elective group), with 16 deaths due to variceal bleeding. Of the remaining 272 patients, 40 (15%) died during follow-up, of which only 11 died of variceal bleeding. Complications, such as superficial ulcers, dysphagia, and strictures, were observed in 14%, 7% of emergency, and 3% of elective patients. None of the patients developed systemic toxicity. In conclusion, 3% aqueous phenol is an effective, safe, and economical sclerosant for esophageal variceal sclerotherapy.
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Affiliation(s)
- S K Mathur
- Department of Surgery and Gastroenterology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Bombay, India
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41
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Sarin SK, Sreenivas DV, Lahoti D, Saraya A. Factors influencing development of portal hypertensive gastropathy in patients with portal hypertension. Gastroenterology 1992; 102:994-9. [PMID: 1537536 DOI: 10.1016/0016-5085(92)90188-5] [Citation(s) in RCA: 121] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Portal hypertensive gastropathy (PGP) is an important cause of bleeding in portal hypertension patients. Although hyperdynamic congestion seems to be the underlying mechanism, the factors that influence the development of PGP are not understood. To investigate these, 107 patients [cirrhosis, 35; noncirrhotic portal fibrosis (NCPF), 24; extrahepatic portal vein obstruction (EHPVO), 46; Budd-Chiari syndrome, 2] were prospectively studied. Eighty-three patients had Child's A, 17 had Child's B, and 7 had Child's C liver disease. Before sclerotherapy, although intravariceal pressure was similar, 4 cirrhosis patients (3.7%) but no NCPF or EHPVO patients had PGP. After sclerotherapy, 21 additional patients (20.3%) developed PGP during a follow-up of 23.2 +/- 3.4 months (range, 1-52). The incidence of PGP was higher in cirrhotic patients (37.1%) than in NCPF (16.7%; P less than 0.05) or EHPVO (8.7%; P less than 0.01) patients. The probability of developing PGP among all patients at the end of 52 months of follow-up was 30%, more in cirrhosis than in EHPVO (55% vs. 15%; P less than 0.005). Only 2 patients bled from PGP during follow-up. Development of PGP correlated with severity of liver disease, being more common in Child's C than Child's A patients (87% vs. 13%; P less than 0.001). PGP was seen more often in patients with gastroesophageal varices than in patients with esophageal varices alone (42% vs. 11%; P less than 0.01). In conclusion, the results show that development of PGP is significantly influenced by sclerotherapy, severity of liver disease, etiology of portal hypertension, coexisting gastric varices and is not directly correlated with intravariceal pressure.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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42
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Abstract
The portal vein is the main source of blood and hepatotrophic factors to the liver. Partial portal-vein ligation in rats results in reduced growth compared with that in control rats. To investigate whether extrahepatic portal vein obstruction occurring in early childhood influences growth in humans, anthropometric and nutritional assessments were prospectively carried out in 61 patients with extrahepatic portal vein obstruction. Comparisons were made with 183 matched healthy controls using National Center of Health Statistics reference. Fifty-one percent of children with extrahepatic portal vein obstruction had stunted growth (height for age less than 90% of normal), compared with 16% of controls (p less than 0.01). Growth retardation was severe in patients with longer (greater than 5 yr) than with shorter (less than 2.5 yr) duration of clinical portal hypertension (height for age, 88.0 +/- 3.2 vs. 95.1 +/- 3.0; p less than 0.01). Little difference was seen in the energy intake (1,302 +/- 463 kcal/day vs. 1,335 +/- 449 kcal/day; p = not significant) and weight for height index (83.6 +/- 9.3 vs. 88.0 +/- 7.9; p = not significant) between extrahepatic portal vein obstruction patients and controls. This suggested that despite comparable nutrition, marked growth retardation occurred in extrahepatic portal vein obstruction patients. Incremental growth velocity was studied in 31 patients; in 24 (73%) the baseline Z score (-2.1 +/- 0.2) had decreased further (-2.4 +/- 0.2) at the end of follow-up (15.5 +/- 1.6 mo). Although the incremental height velocity was only 56% of the expected height, incremental weight gain was 98% of the expected weight for the attained height.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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43
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Vakili C, Farahvash MJ, Bynum TE. "Endemic" idiopathic portal hypertension: report on 32 patients with non-cirrhotic portal fibrosis. World J Surg 1992; 16:118-24; discussion 124-5. [PMID: 1290252 DOI: 10.1007/bf02067126] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The clinical features, surgical management, and long term follow up of 32 patients from Iran with idiopathic portal hypertension are reported. Many features of the disease are similar to those reported from India and Japan. The unsuspected finding was a 46% history of marked pica of clay (geophagia) in a subset of 26 patients. In addition, 81% of our patients had a prolonged prothrombin time, despite otherwise normal to minimally abnormal liver function tests. Liver biopsies revealed intrahepatic periportal fibrosis with subintimal thickening of terminal branches, and in many specimens a striking peri-ductular fibrosis was seen in the adjacent bile ducts. The spleen was very large with a dilated artery (external diameter: 11 mm to 15 mm). Portal venous pressure (PVP) was measured intra-operatively before and after clamping the splenic artery (SA). Clamping the SA consistently caused a decreased in PVP which ranged from 2.0 to 18.2 cm water with the mean +/- SEM of 9.7 +/- 1.5 cm water (p < 0.001, paired t-test). It was equivalent to 32.3 +/- 3.6% decrease in PVP. Fifteen selected patients (Group I) were managed with splenectomy with excellent short and long term results. The selection criteria for splenectomy included a decrease in PVP to < 24 cm of water after clamping the SA. Three patients from this group were re-examined 10 to 12 years following splenectomy. Cirrhosis had not developed, but the minimal abnormalities in the liver function tests had persisted.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C Vakili
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
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44
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Abstract
Effective control of variceal rebleeding (secondary prophylaxis) or prevention of the initial bleeding (primary prophylaxis) are the main objectives of the treatment of portal hypertension. Endoscopic sclerotherapy is the treatment of choice for secondary prophylaxis, since it significantly decreases rebleeding and, to some extent, mortality. A combination of propranolol and sclerotherapy may be of benefit by decreasing postsclerotherapy rebleeding. Endoscopic variceal band ligation and transjugular intrahepatic shunt are emerging as useful alternative techniques. Devascularisation and preferably selective shunts should be reserved for use as salvage of sclerotherapy failures. Liver transplantation, if feasible, could become the ultimate therapy by controlling variceal bleeding and improving hepatic function. Pharmacotherapy, while not very successful for secondary prophylaxis, has shown promise for primary prophylaxis of variceal bleeding. Nonselective beta-blockers significantly decrease the rebleeding rates but are associated with only marginal survival benefits. beta-Blockers alone cannot decrease the hepatic venous pressure gradient adequately (to less than 12mm Hg). Combination with nitrates and other drugs may prove beneficial and requires clinical evaluation. Endoscopic sclerotherapy and surgery have little role in primary prevention of variceal bleeding in patients with cirrhosis but need evaluation in noncirrhotic patients.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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45
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Chaudhary A, Aranya RC. Devascularization following endoscopic sclerotherapy of oesophageal varices: dangers and difficulties. Br J Surg 1991; 78:1249-51. [PMID: 1958997 DOI: 10.1002/bjs.1800781032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Twenty-three patients underwent devascularization operations for acute variceal bleeding. All had received endoscopic sclerotherapy, either long-term or just before surgery. The oesophagus and peri-oesophageal tissues showed either oedematous or fibrotic reaction depending on the number and duration of sessions of sclerotherapy. These changes in the oesophagus and surrounding tissues were responsible for intraoperative oesophageal perforation and postoperative anastomotic leaks. To obviate these problems, stapling of the anterior and posterior walls of the stomach was tried and found to be safer than stapled transection of the oesophagus. During follow-up, varices reappeared in over 75 per cent of patients and were managed by further sclerotherapy. Patients who did not receive sclerotherapy had a higher incidence of rebleeding.
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Affiliation(s)
- A Chaudhary
- Department of Gastrointestinal Surgery, G.B. Pant Hospital, New Delhi, India
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46
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Kochhar R, Goenka MK, Mehta SK. Outcome of injection sclerotherapy using absolute alcohol in patients with cirrhosis, non-cirrhotic portal fibrosis, and extrahepatic portal venous obstruction. Gastrointest Endosc 1991; 37:460-464. [PMID: 1916169 DOI: 10.1016/s0016-5107(91)70780-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In order to assess the comparative efficacy and safety of endoscopic injection sclerotherapy in patients with portal hypertension of different etiology, i.e., cirrhosis, non-cirrhotic portal fibrosis, and extrahepatic portal venous obstruction, 87 patients with variceal bleeding were initiated on sclerotherapy using absolute alcohol. There was no significant difference in the success rate of sclerotherapy as well as in the number of sessions and volume of alcohol required for variceal obliteration between the three groups. Major complications included esophageal ulcers (30.0%), symptomatic strictures (18.6%), and interval re-bleed (17.1%) with similar complication rates for the three groups (p greater than 0.05). There was no difference between patients with Child's class A cirrhosis compared with classes B and C together with respect to efficacy and complications of sclerotherapy. Fifty patients (25 cirrhosis, 11 non-cirrhotic portal fibrosis, and 14 extrahepatic portal venous obstruction) with complete variceal obliteration were followed up for a mean period of 16.5 months. Sixteen patients (32%) had variceal recurrence, but bleeding due to recurrent varices occurred in only one case. There was no difference among the three groups for overall variceal recurrence, although recurrence tended to be somewhat later in extrahepatic portal venous obstruction (9.4 +/- 4.0 months) compared with that in cirrhosis (5.1 +/- 3.6 months) and non-cirrhotic portal fibrosis (4.8 +/- 2.6 months).
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Affiliation(s)
- R Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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47
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Sauerbruch T, Fischer G, Ansari H. Variceal injection sclerotherapy. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1991; 5:131-53. [PMID: 1854983 DOI: 10.1016/0950-3528(91)90009-p] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
With the development and widespread use of flexible endoscopes, injection sclerotherapy of oesophageal varices has advanced beyond the early stages. Although slightly different techniques and different sclerosants are used, the results are not strikingly different. The cumulative rate of adverse effects is in the range of 20 to 40%, with a procedure-related mortality of around 1 to 2%. Sclerotherapy is the best available treatment for haemostasis of acute oesophageal variceal bleeding. However, as a long-term therapy it is less effective in the prevention of recurrent gastrointestinal bleeding events, since obliteration of all varices often takes several months. Furthermore, extra-oesophageal bleeding is not amenable to sclerotherapy. Thus, if repeated injections fail to prevent recurrent bleeding, other options such as shunt surgery, transection, chronic medical portal decompression with beta-blockers or even liver transplantation should be considered according to the needs of the individual patient. Prophylaxis of first variceal haemorrhage was beneficial in selected patients with a high bleeding risk. It cannot, however, be generally recommended at present.
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48
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Misra SP, Dwivedi M, Misra V, Agarwal SK, Gupta R, Gupta SC, Mital VP. Endoscopic and histologic appearance of the gastric mucosa in patients with portal hypertension. Gastrointest Endosc 1990; 36:575-9. [PMID: 2279646 DOI: 10.1016/s0016-5107(90)71167-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
To assess reliability of the endoscopic and histologic appearance of the gastric mucosa for diagnosing portal hypertension, 50 patients with portal hypertension and 1323 controls were studied. Endoscopic evidence of mild gastritis was seen more frequently in patients with portal hypertension than in the control group (42% vs. 13.1%, p less than 0.001). The mosaic sign was also seen more frequently in patients with portal hypertension compared with controls (14% vs. 0.9%, p less than 0.001). However, the mosaic sign was found to be nonspecific, and the sensitivity for diagnosis of portal hypertension was only 14%. Biopsy specimens from the stomach of all patients with portal hypertension and 100 controls with a normal endoscopic appearance revealed mucosal vascular congestion in 72% of patients with portal hypertension compared with 59% of controls (NS). There was no correlation between endoscopic and histologic evidence of congestive gastropathy. Similarly, there was no correlation between the severity of mucosal vascular congestion and the degree of inflammatory changes observed in the biopsy specimens; both in the control (r = 0.1) and in patients with portal hypertension (r = 0.14). It is concluded that endoscopic and histologic features of the gastric mucosa in patients with portal hypertension are of low sensitivity and nonspecific and cannot be used to diagnose portal hypertension.
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Affiliation(s)
- S P Misra
- Department of Gastroenterology and Pathology, Medical College, Allahabad, India
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Heseltine D, Bramble M, Cole A, Clarke D, Castle W. Weber-Christian disease producing splenic vein occlusion and bleeding gastric varices: successful treatment with sclerotherapy. Postgrad Med J 1990; 66:321-5. [PMID: 2385562 PMCID: PMC2429406 DOI: 10.1136/pgmj.66.774.321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A 48 year old woman with intra-abdominal Weber-Christian disease presented with bleeding gastric varices and evidence of splenic vein occlusion. We describe the problems encountered in making this diagnosis and subsequent treatment.
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Affiliation(s)
- D Heseltine
- Middlesbrough General Hospital, Cleveland, UK
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Abstract
Various sclerotherapy techniques have proved successful in the management of acute variceal bleeding and in long-term control of patients after a variceal bleed. We prefer either an intravariceal or a combined intravariceal and paravariceal technique using ethanolamine oleate, but we advocate that individual units utilize the technique with which they have the most experience. The use of an unmodified flexible endoscope has been almost universally accepted. Once active variceal bleeding is diagnosed on emergency endoscopy, immediate emergency sclerotherapy should be performed. When this is not possible, bleeding should be controlled by balloon-tube tamponade with subsequent delayed emergency sclerotherapy after resuscitation. Patients with variceal bleeding that has stopped at the time of the diagnostic endoscopy can either be treated by immediate sclerotherapy or be observed initially and subsequently treated using the long-term management policy of the unit concerned. Over 90% of actively bleeding patients should be controlled using emergency sclerotherapy. Failures are defined as patients who have more than two acute variceal bleeds during a single hospital admission. Such patients should be identified early and treated either by simple staple-gun transection or by an emergency portosystemic shunt. Repeated injection sclerotherapy using a flexible endoscope and the technique with which the group concerned has the most experience is recommended as the primary form of treatment for the majority of patients after a proven esophageal variceal bleed. Repeat injection treatments should probably be performed at weekly intervals until the esophageal varices are eradicated, with follow-up at 6-month or yearly intervals thereafter. Recurrent varices should be treated similarly. Failures of sclerotherapy are defined as patients who have either recurrent bleeds or in whom varices are difficult to eradicate. They require either a portosystemic shunt or a devascularization and transection operation. All patients presenting with cirrhosis and variceal bleeding should be evaluated for liver transplantation; unfortunately, however, few variceal bleeders are candidates for transplantation. Prophylactic sclerotherapy in patients with esophageal varices that have not bled remains unjustified outside of controlled trials. Available trials have produced conflicting data.
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Affiliation(s)
- J Terblanche
- Department of Surgery, University of Cape Town, South Africa
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