Portal cavernoma-associated cholangiopathy: a clinical and MR cholangiography coupled with MR portography imaging study

Spectrum of biliary abnormalities in portal cavernoma cholangiopathy (PCC) secondary to idiopathic extrahepatic portal vein obstruction (EHPVO)-a prospective magnetic resonance cholangiopancreaticography (MRCP) based study

OBJECTIVE

To characterize biliary abnormalities seen in portal cavernoma cholangiopathy (PCC) on MR cholangiopancreaticography (MRCP) and elucidate certain salient features of the disease by collaborating our findings with those of previous studies.

METHODS

We prospectively enrolled 52 patients with portal cavernoma secondary to idiopathic extrahepatic portal vein obstruction, who underwent a standard MRCP protocol. Images were analyzed for abnormalities involving the entire biliary tree. Terms used were those proposed by the Indian National Association for Study of the Liver. Angulation of the common bile duct (CBD) was measured in all patients with cholangiopathy.

RESULTS

Cholangiopathy was seen in 80.7% of patients on MRCP. Extrahepatic ducts were involved in 95% of patients either alone (26%) or in combination with the intrahepatic ducts (69%). Isolated involvement of the intrahepatic ducts was seen in 4.8% of patients. Abnormalities of the extrahepatic ducts included angulation (90%), scalloping (76.2%), extrinsic impression/indentation (45.2%), stricture (14.3%) and smooth dilatation (4.8%). The mean CBD angle was 113.2 ± 19.8°. Abnormalities of the intrahepatic ducts included smooth dilatation (40%), irregularity (28%) and narrowing (9%). Cholelithiasis, choledocholithiasis and hepatolithiasis were seen in 28.6% (12) patients, 14.3% (6) patients and 11.9% (5) patients, respectively. There was a significant association between choledocholithiasis and CBD stricture, with no significant association between choledocholithiasis and cholelithiasis. A significant association was also seen between hepatolithiasis and choledocholithiasis.

CONCLUSION

The spectrum of biliary abnormalities in PCC has been explored and some salient features of the disease have been elucidated, which allow a confident diagnosis of this entity. Advances in knowledge: PCC preferentially involves the extrahepatic biliary tree. Changes in the intrahepatic ducts generally occur as sequelae of involvement of the extrahepatic ducts, although isolated involvement of the intrahepatic ducts does occur. Increased angulation of the CBD and scalloping are most commonly seen. Angulation may predispose to choledocholithiasis and thus development of symptomatic cholangiopathy. Choledocholithiasis and hepatolithiasis occur as sequelae of PCC.

Portal biliopathy

Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).

Safety of supramesocolic surgery in patients with portal cavernoma without portal vein decompression. Large single centre experience

BACKGROUND

Supra-mesocolic surgery (SMS) is complicated in patients with portal vein cavernoma (PC) and portal decompression is recommended. The aim of this study was to report a large single centre of SMS in patients with PC without portal decompression.

METHODS

Between 2006 and 2013, all patients who met inclusion criteria were analyzed retrospectively. The primary endpoint was the feasibility rate, surgical and postoperative outcome. The secondary endpoints were the long-term outcome of patients who underwent biliary bypass for cholangitis. Risk factors for complications were studied.

RESULTS

Thirty patients underwent 51 procedures. Pancreatitis was the main etiology of PC (19/30) and biliary obstruction was mainly related to the underlying disease and not to portal cholangiopathy (12/14). All planned procedures were successfully completed. Fourteen patients underwent biliary bypass. Median blood loss (250 ml), transfusion (n = 7), mortality (n = 0), overall morbidity (n = 12) and the median hospital stay (10 days). Good long-term control of cholangitis was achieved in the 9 patients alive with available follow-up. Significant risk factors for complications were a previous abdominal wall scar, previous intra-abdominal surgical field and liver fibrosis.

CONCLUSION

SMS can be safely performed in patients with PC. In patients with risk factors for complications, portal decompression should be discussed.

Imaging and radiological interventions in extra-hepatic portal vein obstruction

Extrahepatic portal vein obstruction (EHPVO) is a primary vascular condition characterized by chronic long standing blockage and cavernous transformation of portal vein with or without additional involvement of intrahepatic branches, splenic or superior mesenteric vein. Patients generally present in childhood with multiple episodes of variceal bleed and EHPVO is the predominant cause of paediatric portal hypertension (PHT) in developing countries. It is a pre-hepatic type of PHT in which liver functions and morphology are preserved till late. Characteristic imaging findings include multiple parabiliary venous collaterals which form to bypass the obstructed portal vein with resultant changes in biliary tree termed portal biliopathy or portal cavernoma cholangiopathy. Ultrasound with Doppler, computed tomography, magnetic resonance cholangiography and magnetic resonance portovenography are non-invasive techniques which can provide a comprehensive analysis of degree and extent of EHPVO, collaterals and bile duct abnormalities. These can also be used to assess in surgical planning as well screening for shunt patency in post-operative patients. The multitude of changes and complications seen in EHPVO can be addressed by various radiological interventional procedures. The myriad of symptoms arising secondary to vascular, biliary, visceral and neurocognitive changes in EHPVO can be managed by various radiological interventions like transjugular intra-hepatic portosystemic shunt, percutaneous transhepatic biliary drainage, partial splenic embolization, balloon occluded retrograde obliteration of portosystemic shunt (PSS) and revision of PSS.

Portal biliopathy treated with endoscopic biliary stenting

Portal biliopathy is defined as abnormalities in the extra- and intrahepatic ducts and gallbladder of patients with portal hypertension. This condition is associated with extrahepatic venous obstruction and dilatation of the venous plexus of the common bile duct, resulting in mural irregularities and compression of the biliary tree. Most patients with portal biliopathy remain asymptomatic, but approximately 10% of them advance to symptomatic abdominal pain, jaundice, and fever. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography are currently used as diagnostic tools because they are noninvasive and can be used to assess the regularity, length, and degree of bile duct narrowing. Management of portal biliopathy is aimed at biliary decompression and reducing the portal pressure. Portal biliopathy has rarely been reported in Korea. We present a symptomatic case of portal biliopathy that was complicated by cholangitis and successfully treated with biliary endoscopic procedures.

[Treatment of non-cirrhotic, non-tumoural portal vein thrombosis]

Thrombosis of the splenoportal axis not associated with liver cirrhosis or neoplasms is a rare disease whose prevalence ranges from 0.7 to 3.7 per 100,000 inhabitants. However, this entity is the second most common cause of portal hypertension. Prothrombotic factors are present as an underlying cause in up to 70% of patients and local factors in 10-50%. The coexistence of several etiological factors is frequent. Clinical presentation may be acute or chronic (portal cavernomatosis). The acute phase can present as abdominal pain, nausea, vomiting, fever, rectorrhagia, intestinal congestion, and ischemia. In this phase, early initiation of anticoagulation is essential to achieve portal vein recanalization and thus improve patient prognosis. In the chronic phase, symptoms are due to portal hypertension syndrome. In this phase, the aim of treatment is to treat or prevent the complications of portal hypertension. Anticoagulation is reserved to patients with a proven underlying thrombophilic factor.

Comparative evaluation of magnetic resonance cholangiopancreatography/magnetic resonance splenoportovenography and endoscopic ultrasound in the diagnosis of portal cavernoma cholangiopathy

BACKGROUND

Magnetic resonance cholangiopancreatography/magnetic resonance splenoportovenography (MRCP/MRSPV) is now the investigation of choice for the diagnosis of portal cavernoma cholangiopathy (PCC). Endoscopic ultrasound (EUS) is an emerging diagnostic modality for the diagnosis of PCC and may be better than MRCP/MRSPV to see the layer-wise localization of varices and to differentiate between varices, stone, and malignancy.

METHODS

Retrospective data of 50 patients of extrahepatic portal vein obstruction (EHPVO) were collected, and comparison between MRCP/MRSPV and EUS was done for the diagnosis of PCC.

RESULTS

Out of 50 patients, 56 % (28) were males, 44 % (22) females, and 24 % (12) symptomatic. Biliary changes were seen in 40 patients (80 %). Epicholedochal collateral (EPEC) was detected in 48 % and 20 % in MRCP/MRSPV and EUS, respectively. Perforators (PER) and intracholedochal collateral (ICC) were better seen with EUS (72 % and 48 %) as compared to MRCP/MRSPV (0 % and 8 %), and p-values were significant (<0.05). EUS has a sensitivity of 33.33 % and a specificity of 92.31 % for EPEC. Portal cavernoma (PC) and collateral at porta (CP), paracholedochal collateral (PAC), perisplenic (PS) and peripancreatic collateral (PPC), pericholedochal collateral (PEC), intrahepatic biliary radical dilatation (IHBRD), perigallbladder collateral (PG), common bile duct dilatation (CBDD) and common hepatic duct dilatation (CHDD), common bile duct stricture (CBDS), and retropancreatic collateral (RPC) were comparable between the two modalities.

CONCLUSIONS

EUS detected PER and ICC better than MRCP/MRSPV, while MRCP/MRSPV was more sensitive for detecting EPEC.

Portal Vein Stenting for Portal Biliopathy with Jaundice

Portal biliopathy refers to obstruction of the bile duct by dilated peri- or para-ductal collateral channels following the main portal vein occlusion from various causes. Surgical shunt operation or endoscopic treatment has been reported. Herein, we report a case of portal biliopathy that was successfully treated by interventional portal vein recanalization.

Imaging Diagnosis of Splanchnic Venous Thrombosis

Splanchnic vein thrombosis (SVT) is a broad term that includes Budd-Chiari syndrome and occlusion of veins that constitute the portal venous system. Due to the common risk factors involved in the pathogenesis of these clinically distinct disorders, concurrent involvement of two different regions is quite common. In acute and subacute SVT, the symptoms may overlap with a variety of other abdominal emergencies while in chronic SVT, the extent of portal hypertension and its attendant complications determine the clinical course. As a result, clinical diagnosis is often difficult and is frequently reliant on imaging. Tremendous improvements in vascular imaging in recent years have ensured that this once rare entity is being increasingly detected. Treatment of acute SVT requires immediate anticoagulation. Transcatheter thrombolysis or transjugular intrahepatic portosystemic shunt is used in the event of clinical deterioration. In cases with peritonitis, immediate laparotomy and bowel resection may be required for irreversible bowel ischemia. In chronic SVT, the underlying cause should be identified and treated. The imaging manifestations of the clinical syndromes resulting from SVT are comprehensively discussed here along with a brief review of the relevant clinical features and therapeutic approach.

[Natural history of portal cavernoma without liver disease. A single centre retrospective study of 32 cases]

PURPOSE

Portal cavernoma follows a chronic occlusion of the portal vein. The long-term consequences of portal cavernoma are not well known. The objective of this study was to report the aetiology of the portal cavernoma and its natural course after excluding liver diseases causes.

METHODOLOGY

A single centre retrospective study based on the data collected from the radiology department of the Clermont-Ferrand hospital was conducted from 2000 to 2011. All the patients for whom an imagery found a portal cavernoma have been looked for excluding the patients having a liver disease whatever the aetiology and the Budd-Chiari syndrome.

RESULTS

Thirty-two cases (18 women and 14 men) were selected. The mean age at diagnosis was 54.2 years and the mean follow-up period was 5.4 years. The discovery of a portal cavernoma was incidental for 8 cases. An aetiology was found for 24 cases: it was an haematological aetiology in 15 cases (10 myeloproliferative syndromes, 2 antiphospholid syndromes, 1 thalassemia major, 1 hyperhomocysteinemia, 1 prothrombin gene mutation), a general aetiology in 2 cases (1 coeliac disease, 1 pancreatic neoplasia), and a local inflammation in 7 cases. A dysmorphic aspect of the liver was noticed on medical imaging for 11 out of the 32 cases. A liver biopsy was performed in 4 patients and was normal for all of them. Sixteen patients developed oesophageal varices, 4 patients developed ascites, 3 developed asymptomatic biliary compression by the portal cavernoma, and the patient who had been followed for the longest time (15 years) developed an encephalopathy.

CONCLUSION

In addition to its underlying etiology, the prognosis of portal is mainly related to the occurrence of oesophageal varices that may develop during the follow-up of the patients.

Multimodality imaging of primary extrahepatic portal vein obstruction (EHPVO): what every radiologist should know

Portal vein thrombosis (PVT) is a frequent complication of liver cirrhosis, but it can also occur as a primary vascular disorder amid absent liver disease. Extrahepatic portal vein obstruction (EHPVO) refers to the obstruction of the extrahepatic portal vein with or without involvement of the intrahepatic portal vein branches, splenic and/or superior mesenteric vein. It is a distinct disorder that excludes PVT occurring in concurrence with liver cirrhosis or hepatocellular carcinoma. The term "EHPVO" implies chronicity and is principally reserved for a long-standing condition characterized by cavernous transformation of the portal vein. The most characteristic imaging manifestation is the formation of portoportal collaterals (via the venous plexi of Petren and Saint) that allow hepatopetal flow. However, this collateral circulation is insufficient resulting in clinically significant pre-hepatic portal hypertension, wherein the liver function and structure remain preserved until late. Although the long-term (more than 10 years) survival with controlled variceal bleeding is up to 100%, affected individuals have an impaired quality of life owing to portal cavernoma cholangiopathy, hypersplenism, neurocognitive dysfunction and growth retardation. Imaging diagnosis is not always straightforward as the collaterals can also present as a tumour-like solid mass that can be inadvertently biopsied. Moreover, EHPVO has its implications for the biliary tree, arterial circulation, liver/splenic volumes and stiffness, which merit proper understanding but have not been so well described in literature. In this review, we present the complete spectrum of the vascular, biliary and visceral changes with a particular emphasis on what our medical/surgical hepatology colleagues need to know from us in the pre-operative and post-operative settings.

Portal biliopathy as a complication of extrahepatic portal hypertension: etiology, presentation and management

Portal biliopathy (PB) refers to the biliary abnormalities of the biliary ducts observed in patients with extrahepatic portal hypertension. Although majority of patients are asymptomatic, approximately 20% of these patients present with biliary symptoms (pain, pruritus, jaundice, cholangitis). The pathogenesis of PB is uncertain but compression by dilated veins into or around common bile duct may play the main role. CT-scan, MR cholangiopancreatography with MR portography should be the initial investigations in the evaluation of PB. Treatment is limited to symptomatic cases and is dictated by clinical manifestations and complications of the disease. Treatment of PB could be done by endoscopy (sphincterotomy, stone extraction or biliary stenting of the common bile duct) or surgery (definitive decompression by porto-systemic shunt followed by bilioenteric anastomosis, if necessary). This review describes pathogenesis, clinical features, investigation and management of portal biliopathy.

Intraductal ultrasonographic anatomy of biliary varices in patients with portal hypertension

BACKGROUND AND OBJECTIVES

The term, portal biliopathy, denotes various biliary abnormalities, such as stenosis and/or dilatation of the bile duct, in patients with portal hypertension. These vascular abnormalities sometimes bring on an obstructive jaundice, but they are not clear which vessels participated in obstructive jaundice. The aim of present study was clear the bile ductal changes in patients with portal hypertension in hopes of establishing a therapeutic strategy for obstructive jaundice caused by biliary varices.

MATERIALS AND METHODS

Three hundred and thirty-seven patients who underwent intraductal ultrasound (IDUS) during endoscopic retrograde cholangiography for biliary abnormalities were enrolled. Portal biliopathy was analyzed using IDUS.

RESULTS

Biliary varices were identified in 11 (2.7%) patients. IDUS revealed biliary varices as multiple, hypoechoic features surrounding the bile duct wall. These varices could be categorized into one of two groups according to their location in the sectional image of bile duct: epicholedochal and paracholedochal. Epicholedochal varices were identified in all patients, but paracholedochal varices were observed only in patients with extrahepatic portal obstruction.

CONCLUSION

IDUS was useful to characterize the anatomy of portal biliopathy in detail.

Portal Hypertensive Biliopathy: An Infrequent Cause of Biliary Obstruction

Introduction

Biliary obstruction is usually caused by choledocholithiasis. However, in some circumstances, alternative or concurring unusual ethiologies such as portal hypertensive biliopathy (PHB) must be considered.

Clinical case

We present the case of a 36-year-old female complaining of jaundice and pruritus. Liver function tests were compatible with biliary obstruction and the ultrasound scan of the abdomen showed dilatation of the intrahepatic biliary ducts, a dilated common bile duct (CBD) and biliary calculi. The computed tomography of the abdomen revealed a portal cavernoma encasing the CBD.

Discussion

Portal cavernoma, the hallmark of extrahepatic portal venous obstruction, can cause PHB. When symptomatic, chronic cholestasis is present if a dominant stricture exists whereas biliary pain and acute cholangitis occur when choledocholithiasis prevails. Management must be individualized and usually includes endoscopic therapy to address choledocholithiasis and shunt surgery for definitive treatment.

Portal vein thrombosis

Portal vein thrombosis is an important cause of portal hypertension. PVT occurs in association with cirrhosis or as a result of malignant invasion by hepatocellular carcinoma or even in the absence of associated liver disease. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Endothelial activation and stagnant portal blood flow also contribute to formation of the thrombus. Acute non-cirrhotic PVT, chronic PVT (EHPVO), and portal vein thrombosis in cirrhosis are the three main variants of portal vein thrombosis with varying etiological factors and variability in presentation and management. Procoagulant state should be actively investigated. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) on the other hand requires the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state, however data is awaited in those with no underlying prothrombotic states. TIPS and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Thrombolysis and thrombectomy have some role. TARE is a new modality for management of HCC with portal vein invasion.

Portal vein thrombosis

Portal vein thrombosis (PVT) is the blockage or narrowing of the portal vein by a thrombus. It is relatively rare and has been linked with the presence of an underlying liver disease or prothrombotic disorders. We present a case of a young male who presented with vague abdominal symptoms for approximately one week. Imaging revealed the presence of multiple nonocclusive thrombi involving the right portal vein, the splenic vein, and the left renal vein, as well as complete occlusion of the left portal vein and the superior mesenteric vein. We discuss pathogenesis, clinical presentation, and management of both acute and chronic thrombosis. The presence of PVT should be considered as a clue for prothrombotic disorders, liver disease, and other local and general factors that must be carefully investigated. It is hoped that this case report will help increase awareness of the complexity associated with portal vein thrombosis among the medical community.

Portal vein thrombosis

Portal vein thrombosis (PVT) is a rare event in the general medical setting that commonly complicates cirrhosis with portal hypertension, and can also occur with liver tumors. The diagnosis is often incidental when a thrombus is found in the portal vein on imaging tests. However, PVT may also present with clinical symptoms and can progress to life-threatening complications of ischemic hepatitis, liver failure, and/or small intestinal infarction. This article reviews the pathophysiology of this disorder, with a major focus on PVT in patients with cirrhosis, and presents detailed guidelines on optimal diagnostic and therapeutic strategies.

Review article: portal vein obstruction--epidemiology, pathogenesis, natural history, prognosis and treatment

BACKGROUND

Portal vein obstruction may be due to portal vein thrombosis (PVT) or its sequale, the portal cavernoma. PVT is a common complication in liver cirrhosis, however, it may also occur as a primary vascular disorder, in absence of any liver disease.

AIM

To review the current knowledge on nomenclature, etiology, pathophysiology, clinical presentation, diagnostic workup and management of adult patients with obstruction in the portal vein, either as a primary vascular disease in adults, or as a complication of liver cirrhosis.

METHODS

A structured search in PubMed was performed using defined keywords (portal vein obstruction, extra-hepatic portal vein obstruction, PVT and portal cavernoma), including full text articles and abstracts in English language.

RESULTS

Several causes, operating both at local and systemic level, might play an important role in the pathogenesis of PVT. Frequently, more than one risk factor could be identified; however, occasionally no single factor is discernible. Diagnosis of portal vein obstruction depends on clinical presentation, imaging and laboratory investigations. Prompt treatment greatly affects the patient's outcome.

CONCLUSIONS

Portal vein obstruction occurring either due to thrombosis in the portal vein or due to the portal cavernoma, can contribute to significant morbidity and mortality in patients with or without cirrhosis. In recent years our understanding of etio-pathogenesis of portal vein obstruction has evolved tremendously, which has led to significant improvement in treatment outcomes. There are still areas where more studies are needed to better clarify the management issues of portal vein obstruction.

MRI of cholangiocarcinoma

Cholangiocarcinomas are the second most common primary hepatobiliary tumors after hepatocellular carcinomas. They can be categorized either based on their location (intrahepatic/perihilar/extrahepatic distal) or their growth characteristics (mass-forming/periductal-infiltrating/intraductal) because they exhibit varied presentations and outcomes based on their location and or pattern of growth. The increased risk of cholangiocarcinoma in PSC necessitates close surveillance of these patients by means of imaging and laboratory measures; and because currently surgical resection is the only effective treatment for cholangiocarcinoma, the need for accurate pre-operative staging and assessment of resectability has emphasized the role of high quality imaging in management. Today magnetic resonance imaging (MRI) is the modality of choice for detection, pre-operative staging and surveillance of cholangiocarcinoma.

Etiology and Complications of Portal Vein Thrombosis

BACKGROUND

Portal venous occlusion represents a disorder with considerable clinical relevance. The underlying causes of portal vein thrombosis (PVT) are frequently multifactorial and include malignancies, progressive chronic liver diseases, processes localized to the epigastrium and hepatobiliary system, and acquired as well as inherited thrombophilia. The three main categorical groups are malignant thrombosis, cirrhotic PVT, and non-malignant, non-cirrhotic PVT.

METHODS

Review of the literature.

RESULTS

The site, the extent, its chronicity, and the course of thromboses characterize a relatively heterogeneous clinical presentation and the ensuing complications in affected patients. While the occlusion of the extrahepatic portal and splenic vein likely provokes mainly complications related to portal hypertension, mesenteric venous obstruction shows a high rate of complications and mortality due to intestinal infarction. Especially in patients with liver cirrhosis, special care is warranted with regard to PVTs due to their pathogenetic role and influence on patient survival.

CONCLUSION

This article aims to summarize the current opinion on etiologies, risk factors, and complications of this heterogeneous condition in adults.

Non-cirrhotic portal hypertension

Non-cirrhotic portal hypertension (NCPH) encompasses a wide range of disorders, primarily vascular in origin, presenting with portal hypertension (PHT), but with preserved liver synthetic functions and near normal hepatic venous pressure gradient (HVPG). Non-cirrhotic portal fibrosis/Idiopathic PHT (NCPF/IPH) and extrahepatic portal venous obstruction (EHPVO) are two prototype disorders in the category. Etiopathogenesis in both of them centers on infections and prothrombotic states. Presentation and management strategies focus on repeated well tolerated episodes of variceal bleed and moderate to massive splenomegaly and other features of PHT. While the long-term prognosis is generally good in NCPF, portal biliopathy and parenchymal extinction after prolonged PHT makes outcome somewhat less favorable in EHPVO. While hepatic schistosomiasis, congenital hepatic fibrosis and nodular regenerative hyperplasia have their distinctive features, they often present with NCPH.

Imaging in clinical decision-making for portal vein thrombosis

Thrombosis of the portal venous system is a frequent and potentially life-threatening condition that can take place in a number of different clinical settings including liver cirrhosis, hepatocellular carcinoma, other solid tumours, abdominal septic foci, acute pancreatitis, haematological malignancies and congenital or acquired prothrombotic disorders. Clinical decision-making in patients with thrombosis of the portal venous system is a particularly complex process owing to the heterogeneity of the population affected by this condition and the lack of high-quality evidence from randomized controlled trials for the use of anticoagulation therapy in these patients. This Review discusses the available data regarding how imaging can provide assistance to physicians involved in this decision-making process in different clinical settings. A flowchart illustrating how to use imaging in this setting, based on current evidence and on the experience of the Vascular Liver Diseases Group of the Hospital Clinic in Barcelona, is also presented.

Portal vein thrombosis and liver transplantation: implications for waiting list period, surgical approach, early and late follow-up

Portal vein thrombosis (PVT) is a well-known and relatively common complication of liver cirrhosis. In the past, PVT was considered as a contraindication for liver transplantation (LT). To characterize prevalence, risk factors, perioperative management and outcome of PVT in the setting of LT, the English literature published between 1991 and 2011 was reviewed. Of 6807 articles, 280 were selected, and 39 experiences were analyzed in detail (methodology, type and duration of treatments, peri-operative management, strategy to avoid recurrence, strengths and weaknesses, Oxford evidence level, citations). 3/39 studies were prospective; 9/39 were based on prospectively recorded databases; no studies of 1, 2a, 3a level of evidence were present; 5/39 were recognized as level 2b, 23/39 as level 3b, and 8/39 as level 4. High complication rate has been reported with consequent effect on graft and patient survival. Overall, PVT presents today good results similar to those obtained in patients without PVT undergoing LT even if they require a higher transfusion number and a longer ICU/hospital stay. Reported cases were retrospectively stratified according to Yerdel classification. Grade 1-2 patients (76%) do well with eversion thromboendovenectomy, resection of damaged vein and porto-portal anastomosis. Results of patients with grade 3-4 (24%) are inferior, however data on outcome in this subsets are fragmented and do not allow a reliable analysis. Moreover, results obtained in grade 3-4 cases are better in transplant centers with large specific experience. The small number of reports suggests caution. The role of anticoagulant treatment is still debated. Although in cirrhotics with PVT LT remains a demanding procedure, PVT should not be considered a contraindication anymore.

Portal vein thrombosis in liver cirrhosis

Portal vein thrombosis (PVT) is considered to be a frequent complication of liver cirrhosis. However, unlike PVT in patients without cirrhosis, very few data are available on the natural history and management of PVT in cirrhosis, despite its association with potentially life-threatening conditions, such as gastroesophageal bleeding and acute intestinal ischemia. Moreover, no consensus regarding PVT in cirrhosis exists. Suggested causes of PVT in cirrhosis include reduced portal blood flow velocity, multiple congenital or acquired thrombophilic factors, inherited or acquired conditions, and derangement of liver architecture. However, the understanding of PVT in cirrhosis is incomplete. In addition, information on the management of PVT in cirrhosis is inadequate. The aims of this review are to: (1) assemble data on the physiopathological mechanism, clinical findings, diagnosis and management of PVT in cirrhosis; (2) describe the principal factors most frequently involved in PVT development; and (3) summarize the recent knowledge concerning diagnostic and therapeutic procedures.

Imaging of portal cavernoma cholangiopathy

Portal cavernoma cholangiopathy (PCC) refers to the biliary changes which occur in the setting of extrahepatic portal vein obstruction and secondary portal cavernoma formation. The main radiological findings include the vascular changes in the form of portosystemic collaterals and biliary changes in the form of extrinsic impressions and strictures. Till date, conventional cholangiography has been the gold standard for the diagnosis of PCC. However, it is an invasive procedure and is associated with complications. At present there is a transition towards non-invasive modalities like ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI). The recent advances in these modalities provide an excellent delineation of both the vascular and the biliary changes non-invasively in a short time. The findings of PCC using these newer modalities are not so well described in literature. The findings of PCC also overlap with malignant conditions of biliary tract such as cholangiocarcinoma and compression of biliary tract by malignant adenopathies. In this article we describe the vascular and biliary changes associated with PCC on US, CT and MRI. We also describe the imaging findings using each modality along with their advantages and disadvantages.

Surgical management of portal cavernoma cholangiopathy

The majority of patients with portal cavernoma cholangiopathy (PCC) are asymptomatic, however some (5-38%) present with obstructive jaundice, cholangitis, or even biliary pain due to bile duct stones which form as a result of stasis. Most patients with extrahepatic portal venous obstruction (EHPVO) present with variceal bleeding and hypersplenism and these are the usual indications for surgery. Those who present with PCC may also need decompression of their portosystemic system to reverse the biliary obstruction. It is important to realize that though endoscopic drainage has been proposed as a non-surgical approach to the management of PCC it is successful in only certain specific situations like those with bile duct calculi, cholangitis, etc. A small proportion of such patients will continue to have biliary obstruction and these patients are thought to have a mechanical ischemic stricture. These patients will require a second stage procedure in the form of a bilioenteric bypass to reverse the symptoms related to PCC. In the absence of a shuntable vein splenectomy and devascularization may resolve the PCC in a subset of patients by decreasing the portal pressure.

Portal cavernoma cholangiopathy-clinical characteristics

Because of the presence of portal cavernoma, paracholedochal and pericholedochal varices, portal cavernoma cholangiopathy (PCC) has become an entity unique to patients with extrahepatic portal venous obstruction (EHPVO). Majority of patients with these abnormalities are asymptomatic and are incidentally detected to have the presence of biliary abnormalities on cholangiography. Minority of patients present with symptoms of chronic cholestasis with or without biliary pain or acute cholangitis related most often to the presence of biliary strictures or stones. Other than the age of the patient and duration of EHPVO, presence of gall stones and common bile duct stones are other risk factors for the causation of symptoms in patients with PCC. This review summarizes the clinical characteristics of asymptomatic and symptomatic patients with PCC giving details of the prevalence of symptoms, their risk factors and overall burden of symptomatic PCC.

Natural history of portal cavernoma cholangiopathy

The natural history of portal cavernoma cholangiopathy (PCC) is poorly defined and poorly understood. It develops early after acute portal vein thrombosis (PVT) if there is failure of recanalization. In PCC, the likelihood of progression of biliary abnormalities after 1 year is extremely low. The natural history of PCC is conveniently divided into asymptomatic and symptomatic stages. The majority of patients with PCC are asymptomatic and are detected incidentally on imaging. Limited data suggest that asymptomatic PCC is static or only slowly progressive in the initial stages. However, most workers agree that, overall, PCC is a slowly progressive disease. Symptomatic PCC represents a late stage in its natural history. Finding strictures with dilatation at cholangiography is associated with a higher risk of developing symptoms of PCC. Onset of symptoms is often precipitated by the development of biliary sludge or calculi and treating calculi usually relieves symptoms for prolonged periods of time. Clinical presentations include biliary pain, obstructive jaundice, acute cholangitis, acute cholecystitis, or other presentations of gallstone disease. Progressive liver dysfunction and secondary biliary cirrhosis can develop in a minority of patients.

Portal cavernoma cholangiopathy - history, definition and nomenclature

Biliary changes secondary to portal hypertension, especially in portal cavernoma secondary to extrahepatic portal vein obstruction have long been described in literature under different names by various authors. Most of the times these changes are asymptomatic and discovered on imaging, but can occasionally cause obstructive jaundice. There is no consensus on the appropriate nomenclature and definition of this entity. This article reviews the history of portal hypertensive biliopathy and the Indian Association for the Study of Liver Working Party consensus definition and nomenclature for it.

Endoscopic management of portal cavernoma cholangiopathy: practice, principles and strategy

Portal cavernoma cholangiopathy (PCC) is the presence of typical cholangiographic changes in patients with a portal cavernoma due to chronic portal vein thrombosis, in the absence of other biliary tract diseases. Probably due to biliary stasis related to the cavernoma, there is a high incidence of biliary sludge and calculi in PCC, which trigger symptoms that resolve with appropriate interventions. Persistent and troublesome symptoms are usually due to biliary stenoses or strictures, which may occur with or without biliary calculi and may be short or long, solitary or multifocal, extrahepatic or intrahepatic. Experience with endoscopic interventions in PCC over the last twenty years has shown that it is the procedure of choice for bile duct calculi. Plastic stenting with repeated, timely, stent exchanges is the first line intervention for jaundice or cholangitis due to biliary strictures. If biliary obstruction does not resolve, portosystemic shunt surgery (PSS) or transjugular intrahepatic portosystemic stent shunt (TIPS) is performed to decompress the portal cavernoma. However, for patients with non-shuntable veins or blocked shunts, repeated plastic stent exchanges are the only option though there are reports of the use of biliary self-expandable metal stents in this situation. If symptomatic biliary obstruction persists after successful PSS or TIPS, second stage biliary surgery may be necessary. Recent experience suggests that treating biliary strictures in PCC on the lines of postoperative benign biliary strictures with balloon dilatation and repeated exchanges of plastic stent bundles may be effective therapy. Endoscopic management appears to be associated with an increased frequency of hemobilia, which usually responds to standard management. Recurrent cholangitis with formation of sludge and concretions may be a problem with repeated stent exchanges, especially if patient compliance is poor. In conclusion, the current understanding is that symptomatic PCC is best managed jointly by the endoscopist and surgeon with sequential interventions designed initially to establish and maintain biliary drainage, then to decompress the portal cavernoma and, finally, if required, second stage biliary surgery or endotherapy for biliary strictures. Endoscopic therapy occupies a central role in management before, during and after surgical therapy. Paradigms of endoscopic therapy continue to evolve as knowledge of pathogenesis and natural history improves and newer approaches and techniques are applied.

Liver transplantation for portal cavernoma cholangiopathy

Portal cavernoma cholangiopathy (PCC) is a difficult clinical problem, where the portal cavernoma is both the cause of biliary obstruction and the obstacle to its safe surgical treatment. The available endoscopic and surgical treatment is successful in majority and further intervention is seldom required since the native liver is normal. PCC is not an accepted indication for liver transplantation as only a small proportion of patients will fail both endoscopic and surgical treatment and progressive liver failure is rarely seen. Secondary biliary cirrhosis as a result of long standing biliary obstruction is an accepted indication however establishing a portal inflow in these patients is often difficult and challenging. The deceased donor liver transplantation would always be preferable over living donor liver transplantation as PCC is usually a non-emergency transplant and the graft can have portal blood inflow through a conduit to even a small segment of patent portal venous system or even to a cavernoma vessel.

Pathogenesis of Portal Cavernoma Cholangiopathy: Is it Compression by Collaterals or Ischemic Injury to Bile Ducts During Portal Vein Thrombosis?

The pathogenesis of portal cavernoma cholangiopathy (PCC) is important as it can impact the choice of treatment modalities. PCC consists of a reversible component, which resolves by decompression of collaterals as well as a fixed component, which persists despite the decompression of collaterals. The reversible component is due to compression by large collaterals located adjacent to the bile duct as well as possibly intracholedochal varices. The fixed component is likely to be due to ischemia at the time of portal vein thrombosis, local ischemia by compression as well as encasement by a solid tumor-like cavernoma comprising of fibrous hilar mass containing multiple tiny collateral veins rather than markedly enlarged portal collaterals. Although cholangiographic abnormalities in portal hypertension are common, the prevalence of symptomatic PCC is low. This is likely to be related to the cause of portal hypertension, the duration of portal hypertension and possibly the pattern of occlusion of the splenoportal axis. There may possibly be higher prevalence of symptomatic PCC in extension of the thrombosis to the splenomesentric veins.

Portal cavernoma cholangiopathy: consensus statement of a working party of the Indian national association for study of the liver

Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.

Portal hypertensive biliopathy: A single center experience and literature review

Portal hypertensive biliopathy (PHB) is characterized by anatomical and functional abnormalities of the intrahepatic, extrahepatic and pancreatic ducts, in patients with portal hypertension associated to extrahepatic portal vein obstruction and less frequently to cirrhosis. These morphological changes, consisting in dilatation and stenosis of the biliary tree, are due to extensive venous collaterals occurring in an attempt to decompress the portal venous blockage. It is usually asymptomatic until it progresses to more advanced stages with cholestasis, jaundice, biliary sludge, gallstones, cholangitis and finally biliary cirrhosis. Imaging modalities of the biliary tree such as Doppler ultrasound, computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography are essential to establish the diagnosis and the need of therapeutical interventions. Once the diagnosis is established, treatment with ursodesoxycholic acid seems to be beneficial. Decompression of the biliary tree to dilate, remove stones or implant biliary prosthesis by endoscopic or surgical procedures (hepato-yeyunostomy) usually resolves the cholestatic picture and prevents septic complications. The ideal treatment is the decompression of the portal system, with transjugular intrahepatic porto-systemic shunt or a surgical porto-systemic shunt. Unfortunately, few patients will be candidates for these procedures due to the extension of the thrombotic process. The purpose of this paper is to report the first 3 cases of PHB seen in a Colombian center and to review the literature.

Prevalence of paroxysmal nocturnal hemoglobinuria in Chinese patients with Budd-Chiari syndrome or portal vein thrombosis

BACKGROUND AND AIM

Routine screening for paroxysmal nocturnal hemoglobinuria (PNH) in patients with Budd-Chiari syndrome (BCS) or portal vein thrombosis (PVT) has been recommended in Western countries. However, little is known about whether the routine screening test should be necessary in Chinese patients with BCS or PVT. We conducted a prospective observational study to examine the prevalence of PNH in these patients.

METHODS

Patients with primary BCS or non-malignant PVT who were consecutively admitted to our department or regularly followed up between September 2009 and December 2011 were eligible for the study and detected the expression of CD55 and CD59 on erythrocytes and granulocytes. The CD55 or CD59 deficiency was considered as the proportion of erythrocytes or granulocytes with normal expression of CD55 or CD59 was less than 90%. PNH was diagnosed by both CD55 and CD59 deficient clone at flow cytometry of peripheral blood cells.

RESULTS

CD55 and/or CD59 deficiencies were found in 1.6% (2/127) of patients with primary BCS, 1.0% (1/100) of non-malignant and non-cirrhotic patients with PVT, and 4.7% (4/85) of cirrhotic patients with PVT. Only one patient had both CD55 and CD59 deficiencies on granulocytes. But he had been diagnosed with PNH before BCS.

CONCLUSIONS

Paroxysmal nocturnal hemoglobinuria was very rare in Chinese patients with BCS or PVT, suggesting that routine screening for PNH should not be indiscriminately performed in such patients.

CT features of non-malignant portal vein thrombosis: a pictorial review

Portal vein thrombosis (PVT) is a rare clinical entity in general population, but a relatively frequent entity in liver cirrhosis. Severe PVT-related complications are potentially lethal, such as ischemic intestinal infarction and complications of portal hypertension. Additionally, occlusive PVT can not only increase the incidence of variceal rebleeding, but also significantly decrease the cirrhotic patients' survival. Based on the clinical significance of PVT, early diagnosis is very critical to allow for rapid establishment of appropriate treatment and improvement of prognosis. Dynamic CT scan is an important diagnostic modality of PVT. The objective of this pictorial review is to illustrate various CT features of non-malignant portal vein thrombosis and its associated abnormalities. Evolution of portal vein thrombosis, such as stage, degree, and extension of thrombus, can be evaluated according to CT demonstrations, which is helpful to timely adopt appropriate treatment modality. Other associated CT findings include the dilation of collateral veins around the obstructed portion of portal vein and the hepatic perfusion and morphology abnormalities.

Portal biliopathy

Biliary ductal changes are a common radiological finding in patients with portal hypertension, however only a small percentage of patients (5%-30%) develop symptomatic bile duct obstruction. The exact pathogenesis is not clear, but an involvement of factors such as bile duct compression by venous collaterals, ischemia, and infection is accepted by most authors. Although endoscopic retrograde cholangiopancreatography was used to define and diagnose this condition, magnetic resonance cholangiopancreatography is currently the investigation of choice for diagnosing this condition. Treatment is indicated only for symptomatic cases. Portosystemic shunts are the treatment of choice for symptomatic portal biliopathy. In the majority of patients, the changes caused by biliopathy resolve after shunt surgery, however, 15%-20% patients require a subsequent bilio-enteric bypass or endoscopic management for persistent biliopathy. There is a role for endoscopic therapy in patients with bile duct stones, cholangitis or when portosystemic shunt surgery is not feasible.

How can portal vein cavernous transformation cause chronic incomplete biliary obstruction?

Biliary disease in the setting of non-cirrhotic portal vein thrombosis (and similarly in portal vein cavernous transformation) can become a serious problem during the evolution of disease. This is mostly due to portal biliary ductopathy. There are several mechanisms that play a role in the development of portal biliary ductopathy, such as induction of fibrosis in the biliary tract (due to direct action of dilated peribiliary collaterals and/or recurrent cholangitis), loss of biliary motility, chronic cholestasis (due to fibrosis or choledocholithiasis) and increased formation of cholelithiasis (due to various factors). The management of cholelithiasis in cases with portal vein cavernous transformation merits special attention. Because of a heterogeneous clinical presentation and concomitant pathophysiological changes that take place in biliary anatomy, diagnosis and therapy can become very complicated. Due to increased incidence and complications of cholelithiasis, standard treatment modalities like sphincterotomy or balloon sweeping of bile ducts can cause serious problems. Cholangitis, biliary strictures and hemobilia are the most common complications that occur during management of these patients. In this review, we specifically discuss important issues about bile stones related to bile duct obstruction in non-cirrhotic portal vein thrombosis and present evidence in the current literature.

Portal biliopathy: imaging manifestations on multidetector computed tomography and magnetic resonance imaging

Portal biliopathy refers to biliary abnormalities secondary to extrahepatic portal vein obstruction and cavernous transformation and is caused by vascular compression from peribiliary collateral vessels, producing segmental stenoses of the common bile duct and abnormal liver function test (LFT) results. A review of imaging studies yielded 18 patients with abnormal LFT results, biliary tract dilatation, and extrahepatic portal vein obstruction with cavernous transformation. Multidetector computed tomography and magnetic resonance imaging showed biliary stenotic segments in 11 patients secondary to extrinsic compression from enlarged peribiliary collaterals. Clinical and imaging follow-up demonstrated improvement in LFT results with minimal decrease in bile duct dilatation, eliminating percutaneous or endoscopic biliary intervention.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Klatskin-like lesions

Hilar cholangiocarcinoma, also known as Klatskin tumour, is the commonest type of cholangiocarcinoma. It poses unique problems in the diagnosis and management because of its anatomical location. Curative surgery in the form of major hepatic resection entails significant morbidity. About 5-15% of specimens resected for presumed Klatskin tumour prove not to be cholangiocarcinomas. There are a number of inflammatory, infective, vascular, and other pathologies, which have overlapping clinical and radiological features with a Klatskin tumour, leading to misinterpretation. This paper aims to summarise the features of such Klatskin-like lesions that have been reported in surgical literature.

Management of hepatic vascular diseases

Primary damage to hepatic vessels is rare. (i) Hepatic arterial disorders, related mostly to iatrogenic injury and occasionally to systemic diseases, lead to ischemic cholangiopathy. (ii) Hepatic vein or inferior vena cava thrombosis, causing primary Budd-Chiari syndrome, is related typically to a combination of underlying prothrombotic conditions, particularly myeloproliferative neoplasms, factor V Leiden, and oral contraceptive use. The outcome of Budd-Chiari syndrome has markedly improved with anticoagulation therapy and, when needed, angioplasty, stenting, TIPS, or liver transplantation. (iii) Extrahepatic portal vein thrombosis is related to local causes (advanced cirrhosis, surgery, malignant or inflammatory conditions), or general prothrombotic conditions (mostly myeloproliferative neoplasms or factor II gene mutation), often in combination. Anticoagulation at the early stage prevents thrombus extension and, in 40% of the cases, allows for recanalization. At the late stage, gastrointestinal bleeding related to portal hypertension can be prevented in the same way as in cirrhosis. (iv) Sinusoidal obstruction syndrome (or venoocclusive disease), caused by agents toxic to bone marrow progenitors and to sinusoidal endothelial cells, induces portal hypertension and liver dysfunction. Decreasing the intensity of myeloablative regimens reduces the incidence of sinusoidal toxicity. (v) Obstruction of intrahepatic portal veins (obliterative portal venopathy) can be associated with autoimmune diseases, prothrombotic conditions, or HIV infection. The disease can eventually be complicated with end-stage liver disease. Extrahepatic portal vein obstruction is common. Anticoagulation should be considered. (vi) Nodular regenerative hyperplasia is induced by the uneven perfusion due to obstructed sinusoids, or portal or hepatic venules. It causes pure portal hypertension.

[Cholangiopathy associated with portal hypertension]

Portal cholangiopathy encompasses a group of abnormalities of the biliary system and gallbladder that occur secondary to chronic portal vein thrombosis and collateral venous circulation. Chronic obstruction of the portal vein is a frequent cause of gastrointestinal variceal bleeding, but data on biliary tract abnormalities are limited. We report the case of a male patient with obstructive jaundice secondary to portal cholangiopathy. We describe the pathogenesis of this entity, and the various diagnostic and therapeutic options available.

Portal ductopathy: Clinical importance and nomenclature

Non-cirrhotic portal hypertension (PHT) accounts for about 20% of all PHT cases, portal vein thrombosis (PVT) resulting in cavernous transformation being the most common cause. All known complications of PHT may be encountered in patients with chronic PVT. However, the effect of this entity on the biliary tree and pancreatic duct has not yet been fully established. Additionally, a dispute remains regarding the nomenclature of common bile duct abnormalities which occur as a result of chronic PVT. Although many clinical reports have focused on biliary abnormalities, only a few have evaluated both the biliary and pancreatic ductal systems. In this review the relevant literature evaluating the effect of PVT on both ductal systems is discussed, and findings are considered with reference to results of a prominent center in Turkey, from which the term “portal ductopathy” has been put forth to replace “portal biliopathy”.