Effect of portal hypertension on in vivo bile acid-mediated small intestinal mucosal injury in the rat

Video Capsule Endoscopy in the Assessment of Portal Hypertensive Enteropathy

BACKGROUND

The features of the portal hypertension enteropathy (PHE) vary from mild mucosal changes to varices with or without bleeding. The prevalence and the development are not fully understood.

AIM

Our aim is to examine the prevalence and the different manifestations of PHE using video capsule endoscopy (VCE).

METHODS

It is a single center retrospective study of patients with cirrhosis, who had VCE. Based on the published literature, we divided the PHE lesions into vascular lesions and mucosal lesions.

RESULTS

Of the 100 patients with cirrhosis that had a VCE study, the mean age was 62.82 years. Male gender was predominant (64%), while Caucasians represented 82% of the cohort. The most common etiology of cirrhosis was chronic alcohol abuse followed by chronic hepatitis C virus and nonalcoholic steatohepatitis. VCE detected small bowel lesions in 71% of the patients while the features of PHE were found in 65% from the total cohort. AVMs and inflammatory changes were the most common findings, followed by bleeding. More than 50% of the lesions were vascular in nature. The risk of finding PHE in decompensated cirrhosis is twice that in compensated cirrhosis. Forty-five patients had negative EGD exam for any active bleeding, esophageal varices, portal hypertensive gastropathy, or gastric varices. Of these, 69% had features of PHE in their VCE.

CONCLUSIONS

VCE detected small bowel lesions in 71% of our cohort. There is a high prevalence of PHE in decompensated cirrhosis. Vascular lesions are the most common finding in the small bowel of this population.

Clinical significance of small-bowel villous edema in patients with liver cirrhosis: A capsule endoscopy study

BACKGROUND AND AIM

The relationship between the presence of villous edema (VE) in portal hypertensive enteropathy and clinical factors remains unclear. The aim of this study was to reveal the clinical factors related to VE in patients with liver cirrhosis (LC), and investigate the clinical significance of VE.

METHODS

Between February 2009 and September 2016, 363 consecutive patients with LC underwent capsule endoscopy for diagnosing portal hypertensive enteropathy at Hiroshima University Hospital. We evaluated the relationship between the presence of VE and patients' clinical characteristics, findings of esophagogastroduodenoscopy and computed tomography, and survival time.

RESULTS

Villous edema was observed in 131 patients (36%), and severe lesions were found in 71 (20%). The presence of VE was significantly greater in patients with Child-Pugh classification B or C, esophageal varices, portal hypertensive gastropathy (PHG), ascites, portal vein thrombosis (PVT), and splenomegaly. In multivariate analysis, Child-Pugh class B or C, esophageal varices, PVT, and splenomegaly were significant predictive factors for the presence of VE. Severe VE was significantly greater in patients with Child-Pugh class B or C, serum albumin level ≤ 3.2 mg/dL, PHG, and PVT. In multivariate analysis, PHG, Child-Pugh class B or C, PVT, were significant predictive factors for severe VE.

CONCLUSIONS

Clinical factors related to portal hypertension were significantly correlated with VE. In particular PVT was correlated with the appearance and exacerbation of VE. Periodic capsule endoscopy in LC patients may lead to early detection of portal hypertension and PVT.

Effect of endoscopic variceal obliteration by band ligation on portal hypertensive gastro-duodenopathy: endoscopic and pathological study

INTRODUCTION AND AIM

A few studies have shown that the degree of portal hypertensive gastropathy (PHG) and duodenopathy (PHD) has been worsening after the introduction of therapeutic endoscopic interventions. This study aimed to determine the impact of esophageal variceal eradication by endoscopic variceal ligation (EVL) on PHG and PHD using endoscopic and histopathologic assessment.

METHODS

Fifty patients with esophageal varices for which EVL was indicated were included. EVL was carried out until complete variceal eradication was achieved. The degree of severity of PHG and PHD were recorded before and 4 weeks after variceal eradication. Biopsies were taken from various parts of the stomach and duodenum before and 4 weeks after variceal eradication.

RESULTS

The whole Baveno score (4 vs. 2.5) increased significantly after variceal eradication when compared to those before eradication (p < 0.05). After obliteration, only 19 (38 %) patients had mild PHG versus 37 (74 %) before EVL, while severe PHG was found in 31 (62 %) patients versus 11 (22 %) before EVL and the difference was highly statistically significant. No significant changes were found regarding endoscopic PHD lesions before and after variceal eradication. Pathological changes as average blood vessel count, angiogenesis, ectasia and blood extravasation in stomach and duodenum significantly increased after EVL. Large esophageal varices (III-IV) and Baveno score (>1) at baseline endoscopy were independent risk factors for development of severe PHG after variceal obliteration (p < 0.05).

CONCLUSION

PHG increased significantly, endoscopically and pathologically, after variceal obliteration by EVL. Although PHD did not significantly change as documented by endoscopy, pathological examination documented statistically significant changes in the duodenum after EVL.

Small bowel abnormalities in patients with compensated liver cirrhosis

BACKGROUND

Although capsule endoscopy is available as a minimally invasive imaging technique that contributes significantly to the detection of small bowel lesions, there are only a very few published descriptions of small bowel abnormalities in patients with portal hypertension.

AIMS

The aim of this study was to characterize the occurrence of small bowel lesions by means of capsule endoscopy in patients with portal hypertension, particularly those with compensated liver cirrhosis and associated anemia.

METHODS

Sixty consecutive patients who met our criteria underwent capsule endoscopy. The frequency, type, and distribution of small bowel lesions were determined, and clinical factors associated with the lesions were examined.

RESULTS

Small bowel abnormalities were found in 40 patients (67 %), including erythema (n = 32, 53 %), erosion (n = 10, 17 %), angioectasia (n = 9, 15 %), varices (n = 4, 7 %), and villous edema (n = 4, 7 %). Most lesions were located in the proximal or middle small bowel. Factors associated with the lesions were Child-Pugh class B (vs. class A, P = 0.0023), ascites (vs. no ascites, P = 0.0085), and portal hypertensive gastropathy (vs. no portal hypertensive gastropathy, P = 0.0434).

CONCLUSIONS

We found capsule endoscopy to be a useful diagnostic modality for detecting clinically significant small bowel lesions in patients with compensated liver cirrhosis. Based on our results, we suggest that this procedure should be especially considered for patients with Child-Pugh class B disease, ascites, and/or portal hypertensive gastropathy if they show evidence of gastrointestinal blood loss and/or iron-deficiency anemia.

Brush border enzymes and absorptive capacity in extrahepatic portal venous obstruction in children

BACKGROUND AND OBJECTIVE

Portal hypertension may affect intestinal functions, brush border enzymes and absorption parameters. Information about these in extrahepatic portal venous obstruction (EHPVO) in children is limited and poorly reported. We therefore studied the brush border enzymes and absorptive capacity in EHPVO in children.

METHODS

The study was conducted on 52 children of EHPVO. The diagnosis of EHPVO was made on the basis of clinical presentation and ultrasound examination. All patients underwent upper gastrointestinal endoscopy. Endoscopic tissue biopsies from duodenum were taken on aluminum foils and kept immediately at -20°C for estimation of brush border enzymes. Tissue biopsies were homogenized in sodium maleate buffer, 0.1 M pH 6.0, by a homogenizer and processed for the enzymes: lactase, maltase, and sucrase. Enzyme levels were compared to normal healthy controls (n = 20). d-Xylose test, stool acid steatocrit for fat excretion in stools and stool alpha-1 antitrypsin were done to know about the absorptive parameters.

RESULTS

Enzyme levels of lactase (6.21 ± 5.67 IU/mg) and sucrase (37.07 ± 21.06 IU/mg) in EHPVO group were significantly lower as compared to lactase (23.32 ± 10.48 IU/mg) and sucrase (95.96 ± 46.55 IU/mg) in normal healthy controls. Maltase levels were lower, but difference was not statistically significant in EHPVO group (56.90 ± 28.65 IU/mg) as compared to normal controls (63.28 ± 22.88 IU/mg). There was no significant difference of urinary d-xylose and stool fat in patients with normal or short stature EHPVO patients.

CONCLUSION

EHPVO leads to decrease in levels of brush border enzymes in small bowel but their absorption capacity remains normal.

Prehepatic portal hypertension produces increased mast cell density in the small bowel and in mesenteric lymph nodes in the rat

BACKGROUND

Because most of the characteristics of the portal hypertensive enteropathy can be explained on the basis of increased levels of mast cell mediators, the purpose of the present paper was to study mast cell splanchnic infiltration.

METHODS

Duodenum, jejunum, ileum and mesenteric lymph node complex infiltration by mast cells was assayed by a stereological technique in control rats (group I; n = 5) and in an experimental model of portal hypertension (the portal vein-stenosed rat, group II; n = 5) at 6 weeks after operation.

RESULTS

Intestinal and mesenteric lymph node complex infiltration by mast cells increased in the animals with partial portal vein ligation. The mast cell density progressively increased distally along the small bowel. The mast cell increase in the mesenteric lymph node complex in portal vein-stenosed rats was greater than in the duodenum (P = 0.001), jejunum (P = 0.006) and ileum.

CONCLUSION

The rise of mast cells density in the small bowel and mesenteric lymph node complex in rats with partial portal vein ligation suggests that these cells are involved in the etiopathogenesis of experimental portal prehepatic hypertensive enteropathy.

Portal hypertension: return to fetal life to re-attempt differentiation?

We speculate on the final meaning of the alterations that characterize portal hypertensive enteropathy. The similarity of these alterations with certain morphofunctional characteristics of prenatal splanchnic development makes it possible to hypothesize that the dedifferentiation with return to early stages of development could constitute a portal hypertension induced pathogenic mechanism.

Differential in vivo and in vitro intestinal permeability to lactulose and mannitol in animals and humans: a hypothesis

BACKGROUND/AIMS

Clinical interpretation of urinary recovery ratios of lactulose and mannitol is hampered by incomplete understanding of the mechanisms of transmucosal passage. The aim of this study was to compare in vivo and in vitro probe permeability.

METHODS

Stripped sheets of small intestine from rodents and human biopsy specimens were mounted in Ussing chambers, and mucosa-to-serosa fluxes of lactulose and mannitol were determined. Urinary recovery of orally applied probes was measured in rodents, cats, and humans.

RESULTS

In vitro lactulose/mannitol flux ratios were close to 0.8 in all species. Urinary recovery ratios differed between rodents and cats or humans; low ratios in cats and humans were due to high mannitol recovery.

CONCLUSIONS

Interspecies variation in urinary recovery of mannitol is caused by differences specific for the intact small intestines in vivo. Because hyperosmolality of villus tips in vivo varies, being highest in humans and cats as a result of vascular countercurrent multiplication, it is hypothesized that the high urinary recovery of mannitol in these species is caused by solvent drag through pores that allow the passage of mannitol but not of lactulose. Therefore, the lactulose/mannitol ratio is primarily a standard for the normal functioning of villus epithelial cells in metabolite absorption and for normal villus blood flow.

The effect of portal hypertension on indomethacin-induced small intestinal ulceration in the rat

The purpose of this study was to determine whether portal hypertension potentiates intestinal ulceration induced by indomethacin. Portal hypertension was produced in male Sprague-Dawley rats by two-staged ligation of the portal vein. Sham-operated rats were used as controls. The rats were given 20 mg/kg of indomethacin intragastrically, 7 and 14 days, respectively, after complete portal vein ligation. Forty-eight and 72 h after indomethacin, portal pressures were measured and the whole small intestine removed for quantitative measurement of the percent of the mucosa ulcerated by computerized image analysis. There were no differences in the area of ulceration between the portal hypertensive and sham-operated rats at either 7 or 14 days, despite the presence of significant portal hypertension. Portal hypertension does not appear to potentiate small intestinal ulceration induced by indomethacin in rats.