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Luo J, Li M, Wu J, Wang H, Pan T, Wu C, Chen J, Huang M, Jiang Z. Transjugular intrahepatic portosystemic shunt for portal hypertension with chronic portal vein occlusion. Eur J Radiol 2024; 171:111316. [PMID: 38237521 DOI: 10.1016/j.ejrad.2024.111316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 11/07/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE This study aims to evaluate the long-term patency of transjugular intrahepatic portosystemic shunt (TIPS) and determine the predictors of shunt dysfunction in patients with chronic portal vein occlusion (CPVO). METHOD This retrospective study was conducted from December 2010 to December 2020 in patients with portal hypertension and CPVO. Patients were followed up from initial TIPS insertion to December 2022 or death. Details of TIPS procedure, adverse events and clinical outcomes were recorded. The cumulative rate of shunt patency was calculated by the Kaplan-Meier method and compared by using the log-rank test. Independent predictors of shunt dysfunction were calculated with the Cox regression model. A nomogram comprising independent variables was developed to enhance the predictive accuracy of shunt patency. RESULTS One hundred six patients (mean age, 45.3 years ± 13.6; 71 males and 35 females) were enrolled in the study. TIPS procedure was technically successful in 100 of 106 patients (94.3 %). The primary shunt patency rates for all 100 patients were 78.9 %, 74.7 %, 67.2 %, and 62.4 % at 6, 12, 24, and 36 months, respectively, and the overall shunt patency rates were 88.9 %, 86.8 %, 83.6 %, and 81.2 % at 6, 12, 24, and 36 months, respectively. Independent predictor of shunt dysfunction were inadequate inflow from superior mesenteric vein or splenic vein (the maximum diameter < 8 mm) and platelet count ≥ 300 × 109/L. The developed nomogram is a simple tool for accurately predicting shunt patency. CONCLUSIONS In patients with CPVO, inadequate inflow and high platelet count are important factors for TIPS dysfunction.
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Affiliation(s)
- Junyang Luo
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China
| | - Mingan Li
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China
| | - Jialin Wu
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China
| | - Haofan Wang
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China
| | - Tao Pan
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China
| | - Chun Wu
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China
| | - Junwei Chen
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China
| | - Mingsheng Huang
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China.
| | - Zaibo Jiang
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, PR China.
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Vidal-González J, Martínez J, Mulay A, López M, Baiges A, Elmahdy A, Lampichler K, Maleux G, Chang J, Poncela M, Low G, Ghigliazza G, Zipprich A, Picón C, Shah R, Llop E, Darnell A, Maurer MH, Bonne L, Ramón E, Quiroga S, Abraldes JG, Krag A, Trebicka J, Ripoll C, La Mura V, Tandon P, García-Martínez R, Praktiknjo M, Laleman W, Reiberger T, Berzigotti A, Hernández-Gea V, Calleja JL, Tsochatzis EA, Albillos A, Simón-Talero M, Genescà J. Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis. JHEP Rep 2024; 6:100977. [PMID: 38283756 PMCID: PMC10820312 DOI: 10.1016/j.jhepr.2023.100977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 01/30/2024] Open
Abstract
Background & Aims Spontaneous portosystemic shunts (SPSS) develop frequently in cirrhosis. Changes over time and the effect of aetiological interventions on SPSS are unknown, so we aimed to explore the effect of these variables on SPSS evolution. Methods Patients with cirrhosis from the Baveno VI-SPSS cohort were selected provided a follow-up abdominal CT or MRI scan was available. Clinical and laboratory data were collected at baseline and follow-up. Imaging tests were reviewed to evaluate changes in the presence and size of SPSS (large (L)-SPSS was ≥8 mm) over time. Regarding alcohol- or HCV-related cirrhosis, two populations were defined: cured patients (abstinent from alcohol or successful HCV therapy), and non-cured patients. Results A total of 617 patients were included. At baseline SPSS distribution was 22% L-SPSS, 30% small (S)-SPSS, and 48% without (W)-SPSS. During follow-up (median follow-up of 63 months), SPSS distribution worsened: L-SPSS 26%, S-SPSS 32%, and W-SPSS 42% (p <0.001). Patients with worse liver function during follow-up showed a simultaneous aggravation in SPSS distribution. Non-cured patients (n = 191) experienced a significant worsening in liver function, more episodes of liver decompensation and lower transplant-free survival compared to cured patients (n = 191). However, no differences were observed regarding SPSS distribution at inclusion and at follow-up, with both groups showing a trend to worsening. Total shunt diameter increased more in non-cured (52%) than in cured patients (28%). However, total shunt area (TSA) significantly increased only in non-cured patients (74 to 122 mm2, p <0.001). Conclusions The presence of SPSS in cirrhosis increases over time and parallels liver function deterioration. Aetiological intervention in these patients reduces liver-related complications, but SPSS persist although progression is decreased. Impact and implications There is no information regarding the evolution of spontaneous portosystemic shunts (SPSS) during the course of cirrhosis, and especially after disease regression with aetiological interventions, such as HCV treatment with direct-acting antivirals or alcohol abstinence. These results are relevant for clinicians dealing with patients with cirrhosis and portal hypertension because they have important implications for the management of cirrhosis with SPSS after disease regression. From a practical point of view, physicians should be aware that in advanced cirrhosis with portal hypertension, after aetiological intervention, SPSS mostly persist despite liver function improvement, and complications related to SPSS may still develop.
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Affiliation(s)
- Judit Vidal-González
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Akhilesh Mulay
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Marta López
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Anna Baiges
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Ahmed Elmahdy
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katharina Lampichler
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Johannes Chang
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Marta Poncela
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Gavin Low
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Gabriele Ghigliazza
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
| | - Carmen Picón
- Department of Radiology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Spain
| | - Rushabh Shah
- Royal Free Hospital Radiology Department, Royal Free Hospital and University College London, London, UK
| | - Elba Llop
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Anna Darnell
- Department of Radiology, Hospital Clínic, Universitat de Barcelona, Barcelona Spain
| | - Martin H. Maurer
- Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Lawrence Bonne
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Enrique Ramón
- Digestive Radiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Sergi Quiroga
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan G. Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Aleksander Krag
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
| | - Vincenzo La Mura
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Puneeta Tandon
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Rita García-Martínez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Michael Praktiknjo
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Virginia Hernández-Gea
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - José Luis Calleja
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Emmanuel A. Tsochatzis
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Macarena Simón-Talero
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Joan Genescà
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - for the Baveno VI-SPSS group from the Baveno Cooperation
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
- Department of Radiology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Spain
- Royal Free Hospital Radiology Department, Royal Free Hospital and University College London, London, UK
- Department of Radiology, Hospital Clínic, Universitat de Barcelona, Barcelona Spain
- Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
- Digestive Radiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Internal Medicine B, University of Münster, Münster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Division of Gastroenterology and Hepatology, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
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Nakano M, Yamamoto A, Oka H, Yamazaki O, Jogo A, Kageyama K, Takahashi T, Nishida N, Miki Y. Repeated rough coiling technique of portosystemic shunt: A novel treatment for hepatic encephalopathy. Radiol Case Rep 2024; 19:349-356. [PMID: 38028288 PMCID: PMC10663638 DOI: 10.1016/j.radcr.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Hepatic encephalopathy (HE) usually occurs in the end stages of cirrhosis. During these stages, portosystemic shunt (PSS) is one cause of severe HE. Previous reports have demonstrated that shunt embolization is effective in cases involving a large PSS. However, embolization is risky in some patients because severe ascites and esophageal varices may result from aggravation of portal hypertension. Herein, we report a case in which intentional flow reduction was repeatedly performed for spleno-renal shunt using 2 flow reduction methods, debranching and the rough coiling technique, for a patient with severe HE for whom embolization of the whole PSS pathway was risky. Complete embolization was finally achieved by repeated flow reduction over 5 sessions. The patient tolerated treatment well with no ascites for 4 years after total embolization. If embolization of the whole PSS puts the patient at risk for refractory HE, repeatable flow reduction might provide a good alternative path to single-step embolization.
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Affiliation(s)
- Mariko Nakano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
- Department of Radiology, Housenka Hospital, Osaka, Japan
| | - Hiroko Oka
- Department of Gastroenterology, Housenka Hospital, Osaka, Japan
| | | | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | | | - Norifumi Nishida
- Department of Radiology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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Kothari R, Khanna D, Kar P. To evaluate the prevalence of spontaneous portosystemic shunts in decompensated cirrhosis patients and its prognostic significance. Indian J Gastroenterol 2023; 42:677-685. [PMID: 37642937 DOI: 10.1007/s12664-023-01393-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 05/10/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Spontaneous portosystemic shunts (SPSS) are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates, probably as a consequence of worsening portal hypertension, but without achieving an effective protection against cirrhosis complications. This study was conducted to detect the prevalence of portosystemic shunts in liver cirrhosis patients and analyze its prognostic role. METHOD We conducted a prospective observational study, where 92 patients with decompensated cirrhosis were evaluated based on history, physical examination, biochemical tests and abdominal computed tomography (CT) angiography findings. A follow-up was done after six months for the development of cirrhosis-related complications. RESULTS Of the 92 cirrhotic patients, 57.6% had SPSS (large SPSS + small SPSS) detected by multi-detector computed tomographic angiography. Overall, we found large SPSS in 24 (26.1%) patients, small SPSS in 29 (31.5%) patients and no shunt in 39 (42.4%) patients. Among the shunts, the splenorenal shunt is the most frequent type (25, 27.2%) followed by the paraumbilical shunt (20.7%). Previous decompensating events, including hepatic encephalopathy, ascites, spontaneous bacterial peritonitis and gastrointestinal bleed, were experienced more frequently by the large SPSS group followed by the small SPSS and without SPSS groups. Regarding follow-up, decompensating episodes of hepatic encephalopathy developed more frequently in patients with large SPSS (41.7%) than in patients with small SPSS (24.1%) followed by patients without SPSS (12.8%). CONCLUSION In summary, all cirrhotic patients should be studied with radiological imaging to detect the presence of portosystemic shunts. In several cases, patients with large SPSS had a more impaired liver function and more frequent complications of portal hypertension. So, these patients would probably benefit from a closer surveillance and more intensive therapy.
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Affiliation(s)
- Rishabh Kothari
- Department of Gastroenterology, Max Super Speciality Hospital, Vaishali, Ghaziabad, 201 012, India
| | - Deepanshu Khanna
- Department of Gastroenterology, Max Super Speciality Hospital, Vaishali, Ghaziabad, 201 012, India
| | - Premashis Kar
- Department of Gastroenterology, Max Super Speciality Hospital, Vaishali, Ghaziabad, 201 012, India.
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Abstract
Hepatic encephalopathy (HE) is brain dysfunction secondary to liver insufficiency or portosystemic shunting. HE is a major burden on patients and caregivers, impairs quality of life and is associated with higher mortality. Overt HE is a clinical diagnosis while Covert HE, needs specialized diagnostic strategies. Mainstay of treatment of HE is nonabsorbable disaccharides such as lactulose as well as rifaximin; however, investigational therapies are discussed in this review. Better tools are needed to prognosticate which patients will go on to develop HE but microbiome and metabolomic-driven strategies are promising. Here we review methods to prevent the HE development and admissions.
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Chooklin SM, Chuklin SS. Esophageal and stomach varices: physiological and anatomical features of formation. KLINICHESKAIA KHIRURGIIA 2022. [DOI: 10.26779/2522-1396.2022.7-8.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Esophageal and stomach varices: physiological and anatomical features of formation
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Laleman W, Praktiknjo M, Lauridsen MM, Bonne L, Vanderschueren E, Verslype C, Krag A, Trebicka J, Maleux G. Closing spontaneous portosystemic shunts in cirrhosis: Does it make sense? Does it work? What does it take? Metab Brain Dis 2022; 38:1717-1728. [PMID: 36401681 DOI: 10.1007/s11011-022-01121-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/28/2022] [Indexed: 11/21/2022]
Abstract
Spontaneous portosystemic shunts (SPSS) are an often neglected cause of hepatic encephalopathy associated with cirrhosis. Nowadays, SPSS are considered as radiological biomarkers of clinically significant portal hypertension rather than the previous dogmatic perceived decompressive vessels. SPSS are not rare as they can be diagnosed in over 60% of the patients with cirrhosis by mere contrast-enhanced CT. Moreover, they are clinically relevant since they impact on all portal hypertensive related complications, in particular medically refractory HE, and represent an independent predictor of decompensation and mortality in cirrhosis, irrespective of the type of SPSS. Taken together, these elements warrant strategies to target these shunts directly which is currently is achieved via interventional radiology embolization. In this review, we discuss why it makes sense to tackle SPSS, how to do it and what it takes to do it right based on aggregated literature.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
| | - Michael Praktiknjo
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital of South Denmark, Esbjerg, Denmark
| | - Lawrence Bonne
- Department of Radiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Chris Verslype
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, University Hospital of South Denmark, Esbjerg, Denmark
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
- European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Watanabe Y, Osaki A, Yamazaki S, Yamazaki H, Kimura K, Takaku K, Sato M, Waguri N, Terai S. Two cases of portal-systemic encephalopathy caused by multiple portosystemic shunts successfully treated with percutaneous transhepatic obliteration. Clin J Gastroenterol 2022; 15:968-974. [DOI: 10.1007/s12328-022-01671-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
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9
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Ke Q, Wang Z, Huang X, Li L, Wu W, Qiu L, Jiao Y, Xie Y, Peng X, Liu J, Guo W. Splenic vein embolization as a feasible treatment for patients with hepatic encephalopathy related to large spontaneous splenorenal shunts. Ann Hepatol 2022; 27:100725. [PMID: 35623551 DOI: 10.1016/j.aohep.2022.100725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/04/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Although splenic vein embolization (SVE) has been performed for the management of patients with hepatic encephalopathy (HE) related to large spontaneous splenorenal shunts (SSRS) in recent years, its role remains poorly defined. In this study, we aimed to explore the safety and efficacy of SVE for HE patients with large SSRS. MATERIALS AND METHODS Data from cirrhotic patients who were confirmed to have recurrent or persistent HE related to large SSRS and underwent SVE from January 2017 to April 2021 were retrospectively collected and analyzed at our center. The primary endpoints were the change of HE severity at 1 week after embolization and the recurrence of HE during the follow-up period. The secondary endpoints were procedure-related complications and changes in laboratory indicators and hepatic function (Child-Pugh score/grade and model for end-stage liver disease score). RESULTS Of the eight cirrhotic patients included in the study, six were diagnosed with recurrent HE, and the others were diagnosed with persistent HE. Embolization success was achieved for all patients (100%), and no immediate procedure-related complications, de novo occurrence, or aggravation of symptoms related to portal hypertension were observed during the long-term follow-up. HE status was assessed at 1 week after embolization. The results demonstrated that the symptoms were mitigated in three patients and resolved completely in five patients. During the follow-up period, all patients were free of HE within 1 month after embolization, but one patient experienced the recurrence of HE within 6 months and another one experienced the recurrence of HE within 1 year. Compared with the preoperative parameters, the Child-Pugh score and grade were significantly improved at 1 week and 1 month after embolization (all P<0.05), and the serum ammonia level was significantly lower at 1 month after embolization (P<0.05). CONCLUSIONS SVE could be considered as a feasible treatment for patients with HE related to large SSRS, but further validation is required.
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Affiliation(s)
- Qiao Ke
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China; College of Clinical Medicine for Oncology, Fujian Medical University, Fuzhou, Fujian, China
| | - Zhiyong Wang
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Xinhui Huang
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Ling Li
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Weimin Wu
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Linbin Qiu
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yubin Jiao
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yixing Xie
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Xiaosong Peng
- Department of Geriatric Medicine, The Third Hospital of Xiamen, Xiamen, Fujian, China.
| | - Jingfeng Liu
- College of Clinical Medicine for Oncology, Fujian Medical University, Fuzhou, Fujian, China; The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China.
| | - Wuhua Guo
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China.
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10
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Yonezawa H, Jogo A, Yamamoto A, Nota T, Murai K, Ogawa S, Nakano M, Kageyama K, Hamamoto S, Sohgawa E, Hamuro M, Kaminou T, Miki Y. A case of venous aneurysm of a splenorenal shunt. BJR Case Rep 2021; 7:20210011. [PMID: 35136621 PMCID: PMC8803243 DOI: 10.1259/bjrcr.20210011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/29/2021] [Accepted: 05/24/2021] [Indexed: 12/29/2022] Open
Abstract
A 66-year-old man presented with liver cirrhosis due to non-alcoholic steatohepatitis and hyperammonemia. Contrast-enhanced CT showed a dilated and tortuous splenorenal shunt and a large venous aneurysm in the shunt. The venous aneurysm showed gradual enlargement over 10 years and worsening hyperammonemia, so balloon-occluded retrograde transvenous obliteration was performed. Under balloon occlusion, 5% ethanolamine oleate was injected from a microcatheter into the venous aneurysm, which was subsequently embolized with microcoils. Contrast-enhanced CT after the procedure showed complete thrombosis of the venous aneurysm. 10 months later, the venous aneurysm reduced in size, and hyperammonemia had improved.
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Affiliation(s)
- Hiroki Yonezawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Takehito Nota
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Mariko Nakano
- Department of Radiology, National Hospital Organization Osaka Minami Medical Center, Kawachinagano-shi, Osaka, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Shinichi Hamamoto
- Department of Radiology, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Masao Hamuro
- Department of Radiology, Izumiotsu Municipal Hospital, Izumiotsu-shi, Osaka, Japan
| | - Toshio Kaminou
- Advanced Imaging & Minimally Invasive Therapy Center, Tsukazaki Hospital, Himeji-shi, Hyogo, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
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11
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Bosch J. Small diameter shunts should lead to safe expansion of the use of TIPS. J Hepatol 2021; 74:230-234. [PMID: 32987029 DOI: 10.1016/j.jhep.2020.09.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/02/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is increasingly used worldwide to treat the complications of portal hypertension in patients with advanced cirrhosis. However, its use is hampered by the risk of causing hepatic encephalopathy and of worsening liver function. The reported haemodynamic targets used to guide TIPS are too narrow to be achieved in most cases and are perhaps not entirely adequate nowadays as they were obtained in the pre-covered stent era. We propose that small diameter TIPS - alone or combined to pharmacological therapy or ancillary interventional radiology procedures - may overcome these limitations while maintaining the beneficial effects of the procedure.
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Affiliation(s)
- Jaume Bosch
- Department of Biomedical Research, Bern University; Hepatology, University Clinic for Visceral Medicine and Surgery, Inselspital, Bern (CH); University of Barcelona, IDIBAPS and CIBERehd, Barcelona (Spain).
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12
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Vidal-González J, Quiroga S, Simón-Talero M, Genescà J. Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem. Therap Adv Gastroenterol 2020; 13:1756284820961287. [PMID: 33062057 PMCID: PMC7533929 DOI: 10.1177/1756284820961287] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/02/2020] [Indexed: 02/04/2023] Open
Abstract
Portal hypertension is the main consequence of liver cirrhosis, leading to severe complications such as variceal hemorrhage, ascites or hepatic encephalopathy. As an attempt to decompress the portal venous system, portal flow is derived into the systemic venous system through spontaneous portosystemic shunts (SPSSs), bypassing the liver. In this review, we aim to provide an overview of the published reports in relation to the prevalence and physiopathology behind the appearance of SPSS in liver cirrhosis, as well as the complications derived from its formation and its management. The role of SPSS embolization is specifically discussed, as SPSSs have been assessed as a therapeutic target, mainly for patients with recurrent/persistent hepatic encephalopathy and preserved liver function. Furthermore, different aspects of the role of SPSS in liver transplantation, as well as in candidates for transjugular intrahepatic portosystemic shunt are reviewed. In these settings, SPSS occlusion has been proposed to minimize possible deleterious effects, but results are so far inconclusive.
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Affiliation(s)
- Judit Vidal-González
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sergi Quiroga
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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13
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Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis. J Hepatol 2020; 72:1140-1150. [PMID: 31954206 DOI: 10.1016/j.jhep.2019.12.021] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/12/2019] [Accepted: 12/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that the presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, the presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcomes in patients with liver cirrhosis. METHODS In this retrospective international multicentric study, CT scans of 908 cirrhotic patients with SPSS were evaluated for TSA. Clinical and laboratory data were recorded. Each detected SPSS radius was measured and TSA calculated. One-year survival was the primary endpoint and acute decompensation (oHE, variceal bleeding, ascites) was the secondary endpoint. RESULTS A total of 301 patients (169 male) were included in the training cohort. Thirty percent of all patients presented with >1 SPSS. A TSA cut-off of 83 mm2 was used to classify patients with small or large TSA (S-/L-TSA). Patients with L-TSA presented with higher model for end-stage liver disease score (11 vs. 14) and more commonly had a history of oHE (12% vs. 21%, p <0.05). During follow-up, patients with L-TSA experienced more oHE episodes (33% vs. 47%, p <0.05) and had lower 1-year survival than those with S-TSA (84% vs. 69%, p <0.001). Multivariate analysis identified L-TSA (hazard ratio 1.66; 95% CI 1.02-2.70, p <0.05) as an independent predictor of mortality. An independent multicentric validation cohort of 607 patients confirmed that patients with L-TSA had lower 1-year survival (77% vs. 64%, p <0.001) and more oHE development (35% vs. 49%, p <0.001) than those with S-TSA. CONCLUSION This study suggests that TSA >83 mm2 increases the risk for oHE and mortality in patients with cirrhosis. Our results support the clinical use of TSA/SPSS for risk stratification and decision-making in the management of patients with cirrhosis. LAY SUMMARY The prevalence of spontaneous portosystemic shunts (SPSS) is higher in patients with more advanced chronic liver disease. The presence of more than 1 SPSS is common in advanced chronic liver disease and is associated with the development of hepatic encephalopathy. This study shows that total cross-sectional SPSS area (rather than diameter of the single largest SPSS) predicts survival in patients with advanced chronic liver disease. Our results support the clinical use of total cross-sectional SPSS area for risk stratification and decision-making in the management of SPSS.
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14
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Rodriguez EA, Perez R, Zhang N, Lim ES, Miller C, Schwartz MA, McGirr AJ, Srinivasan A, Hewitt W, Silva AC, Rakela J, Vargas HE. Clinical Outcomes of Portosystemic Shunts on the Outcome of Liver Transplantation. Liver Transpl 2020; 26:693-701. [PMID: 31872966 DOI: 10.1002/lt.25710] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/07/2019] [Indexed: 12/24/2022]
Abstract
Spontaneous portosystemic shunts (SPSSs) have been associated with worse clinical outcomes in the pre-liver transplantation (LT) setting, but little is known about their post-LT impacts. Our aim was to compare LT candidates with and without SPSSs and assess the impact of SPSSs on patient mortality and graft survival in the post-LT setting. Patients 18 years or older with abdominal imaging done prior to LT were included. Exclusion criteria were the presence of pre-LT surgical shunts, LT indications other than cirrhosis, and combined solid organ transplantations. SPSSs were classified as absent, small, or large according to their maximum diameter (8 mm). Multiple variables that could influence the post-LT course were extracted for analysis. Patient and graft survival were estimated using the Kaplan-Meier method and were compared between groups using a log-rank test. The project received institutional review board approval. We extracted data from 326 patients. After comparing patients without SPSS or with small or large SPSSs, no statistical difference was found for overall patient survival: no SPSS (n = 8/63), reference; small SPSS (n = 18/150), hazard ratio (HR), 1.05 (95% confidence interval [CI], 0.45-2.46); and large SPSS (n = 6/113), HR, 0.60 (95% CI, 0.20-1.78); P = 0.20. Also, no difference was found for graft survival: no SPSS (n = 11/63), reference; small SPSS (n = 21/150), HR, 0.80 (95% CI, 0.38-1.70); large SPSS (n = 11/113), HR, 0.59 (95% CI, 0.25-1.40); P = 0.48. Similarly, no statistical significance was found for these variables when comparing if the graft used was procured from a donation after circulatory death donor versus a donation after brain death donor. In conclusion, the previously described association between SPSSs and worse clinical outcomes in pre-LT patients seems not to persist once patients undergo LT. This study suggests that no steps to correct SPSS intraoperatively are necessary.
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Affiliation(s)
- Eduardo A Rodriguez
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ.,Division of Transplantation Center, Mayo Clinic Arizona, Phoenix, AZ
| | - Rachel Perez
- Mayo Clinic Alix School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Nan Zhang
- Department of Health Science Research, Section of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ
| | - Elisabeth S Lim
- Department of Health Science Research, Section of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ
| | | | | | - Aidan J McGirr
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Ananth Srinivasan
- Division of Transplantation Center, Mayo Clinic Arizona, Phoenix, AZ.,Division of Transplantation Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Winston Hewitt
- Division of Transplantation Center, Mayo Clinic Arizona, Phoenix, AZ.,Division of Transplantation Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Alvin C Silva
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Jorge Rakela
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ.,Division of Transplantation Center, Mayo Clinic Arizona, Phoenix, AZ
| | - Hugo E Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ.,Division of Transplantation Center, Mayo Clinic Arizona, Phoenix, AZ
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15
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Nardelli S, Riggio O, Gioia S, Puzzono M, Pelle G, Ridola L. Spontaneous porto-systemic shunts in liver cirrhosis: Clinical and therapeutical aspects. World J Gastroenterol 2020; 26:1726-1732. [PMID: 32351289 PMCID: PMC7183860 DOI: 10.3748/wjg.v26.i15.1726] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
Spontaneous porto-systemic shunts (SPSS) are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates, probably as a consequence of worsening portal hypertension, but without achieving an effective protection against cirrhosis' complications. Several types of SPSS have been described in the literature, each one associated with different clinical manifestations. In particular, recurrent or persistent hepatic encephalopathy is more frequent in patients with splenorenal shunt, while the presence of gastric varices and consequently the incidence of variceal bleeding is more common in gastrorenal shunt. In the advanced stage, the presence of large SPSS can lead to the so called “portosystemic shunt syndrome”, characterized by a progressive deterioration of hepatic function, hepatic encephalopathy and, sometimes, portal vein thrombosis. The detection of SPSS in patients with liver cirrhosis is recommended in order to prevent or treat recurrent hepatic encephalopathy or variceal bleeding.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
| | - Marta Puzzono
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
| | - Giuseppe Pelle
- Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina 04100, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
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16
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Mukund A, Chalamarla LK, Singla N, Shasthry SM, Sarin SK. Intractable hepatic encephalopathy in cirrhotic patients: mid-term efficacy of balloon-occluded retrograde portosystemic shunt obliteration. Eur Radiol 2020; 30:3462-3472. [PMID: 32048037 DOI: 10.1007/s00330-019-06644-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the efficacy and intermediate-term outcome of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hepatic encephalopathy (HE) secondary to portosystemic shunt (PSS) in cirrhotic patients. MATERIALS AND METHODS Institutional review board (IRB) approval was obtained for this study and hospital records of patients who underwent BRTO, from August 2011 to August 2015, were analyzed. Based on the inclusion and exclusion criteria, 39 patients (age, 54.07 ± 9.1 years (37-67 years); 33 males and 6 females) with cirrhosis and spontaneous PSS were included. Clinical and laboratory parameters and HE grade were evaluated in all patients before and after the procedure. RESULTS Forty sessions of BRTO were attempted in 39 patients. Follow-up imaging revealed complete obliteration of the treated PSS in all patients with clinical success in 37 patients (94.9%). The 1-, 2-, 3-, 4-, 5-, 6-, and 7-year HE-free survival rates among responders were 91.7%, 91.7%, 88.8%, 85.5%, 80.8%, 80.8%, and 80.8% respectively and overall survival rates were 89.7%, 82.1%, 76.9%, 74.4%, 74.4%, 64.8%, and 64.8% respectively. Logistic regression highlighted Child-Turcotte-Pugh (CTP) score at 6 months as a positive predictive factor of HE recurrence with a cutoff of ≥ 9. Five patients (12.8%) had fever and leukocytosis and 1 (2.6%) patient developed spontaneous bacterial peritonitis after the procedure. CONCLUSION BRTO is an effective treatment for refractory HE in cirrhotics secondary to large PSS with a few possible complications. KEY POINTS • BRTO is an effective and safe treatment for refractory HE, arising from PSS in cirrhotic patients. • Patients with preserved liver function show better outcome and CTP score is the most important predictor of relapse during follow-up.
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Affiliation(s)
- Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India.
| | - Lakshmi Kumar Chalamarla
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | - Nishant Singla
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | | | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
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17
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Philips CA, Rajesh S, Augustine P, Padsalgi G, Ahamed R. Portosystemic shunts and refractory hepatic encephalopathy: patient selection and current options. Hepat Med 2019; 11:23-34. [PMID: 30774483 PMCID: PMC6355170 DOI: 10.2147/hmer.s169024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Portosystemic shunt (PS) syndrome encompasses a spectrum of disease manifestations ranging from asymptomatic portal hypertension to recurrent and refractory hepatic encephalopathy, ultimately culminating in progressive hepatic failure in patients of cirrhosis and associated large PSs. PSs commonly seen in cirrhosis include splenorenal, gastrorenal, and dilated paraumbilical veins, all of which can present with recurrent or refractory hepatic encephalopathy. In this exhaustive review, we describe the anatomy of PSs, elucidate new theories on their pathophysiology, discuss the clinical implications of PSs in cirrhosis, provide details on different techniques (classical and novel) of shunt embolization, and explore all the pertinent current literature on shunt embolization for refractory and recurrent hepatic encephalopathy, all of which are enumerated with extensive images and illustrations.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
| | - Sasidharan Rajesh
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
| | - Philip Augustine
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
| | - Guruprasad Padsalgi
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
| | - Rizwan Ahamed
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
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18
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Nardelli S, Gioia S, Ridola L, Riggio O. Radiological Intervention for Shunt Related Encephalopathy. J Clin Exp Hepatol 2018; 8:452-459. [PMID: 30564003 PMCID: PMC6286445 DOI: 10.1016/j.jceh.2018.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 04/25/2018] [Indexed: 12/12/2022] Open
Abstract
Hepatic Encephalopathy (HE) is a neuropsychiatric syndrome that occurs in up to 30% of patients with cirrhosis. HE may be a consequence of pure liver failure, as in patients with fulminant hepatitis, or of the combination of liver failure and portal-systemic shunting, as in patients with liver cirrhosis. Several clinical and pathophysiologic observations suggest the importance of portal-systemic shunts in the development of HE. Episodes of HE are usually related to precipitating events, such as infections or gastrointestinal bleeding; a minority of cirrhotic patients experienced a chronic HE, refractory to standard medical treatment. This latter type of HE should be related to spontaneous or radiological (such as Transjugular Intrahepatic Portosystemic Shunt (TIPS)) portal systemic shunts, that could be restricted or occluded in patients with chronic HE. Both TIPS reduction and shunt occlusion are radiological procedures, safe and effective to ameliorate neurological symptoms in patients with refractory HE.
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Affiliation(s)
- Silvia Nardelli
- Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, “Sapienza” University of Rome, Rome, Italy,Address for correspondence: Silvia Nardelli, Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, “Sapienza” University of Rome, Rome, Italy.
| | - Stefania Gioia
- Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, “Sapienza” University of Rome, Rome, Italy
| | - Lorenzo Ridola
- Department of Gastroenterology, “Santa Maria Goretti” Hospital, “Sapienza” Polo Pontino, Latina, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, “Sapienza” University of Rome, Rome, Italy
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19
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Loggini A, Martinez RC, Kramer CL. Cerebral Herniation from Hyperammonemic Cerebral Edema: A Potentially Reversible Neurological Emergency. Neurocrit Care 2018; 30:681-685. [DOI: 10.1007/s12028-018-0578-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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20
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Simón-Talero M, Roccarina D, Martínez J, Lampichler K, Baiges A, Low G, Llop E, Praktiknjo M, Maurer MH, Zipprich A, Triolo M, Vangrinsven G, Garcia-Martinez R, Dam A, Majumdar A, Picón C, Toth D, Darnell A, Abraldes JG, Lopez M, Kukuk G, Krag A, Bañares R, Laleman W, La Mura V, Ripoll C, Berzigotti A, Trebicka J, Calleja JL, Tandon P, Hernandez-Gea V, Reiberger T, Albillos A, Tsochatzis EA, Augustin S, Genescà J, Yu D, Téllez L, Mandorfer M, Garcia-Pagan JC, Berbel C, Ferrusquia J, Ble M, Garcia-Criado MA, Belmonte E, Ney M, Margini C, Casu S, Murgia G, Ludwig C, Rönsch M, Stoevesandt D, Carrion L, Botella ER. Association Between Portosystemic Shunts and Increased Complications and Mortality in Patients With Cirrhosis. Gastroenterology 2018; 154:1694-1705.e4. [PMID: 29360462 DOI: 10.1053/j.gastro.2018.01.028] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 12/28/2017] [Accepted: 01/15/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Spontaneous portosystemic shunts (SPSS) have been associated with hepatic encephalopathy (HE). Little is known about their prevalence among patients with cirrhosis or clinical effects. We investigated the prevalence and characteristics of SPSS in patients with cirrhosis and their outcomes. METHODS We performed a retrospective study of 1729 patients with cirrhosis who underwent abdominal computed tomography or magnetic resonance imaging analysis from 2010 through 2015 at 14 centers in Canada and Europe. We collected data on demographic features, etiology of liver disease, comorbidities, complications, treatments, laboratory and clinical parameters, Model for End-Stage Liver Disease (MELD) score, and endoscopy findings. Abdominal images were reviewed by a radiologist (or a hepatologist trained by a radiologist) and searched for the presence of SPSS, defined as spontaneous communications between the portal venous system or splanchnic veins and the systemic venous system, excluding gastroesophageal varices. Patients were assigned to groups with large SPSS (L-SPSS, ≥8 mm), small SPSS (S-SPSS, <8 mm), or without SPSS (W-SPSS). The main outcomes were the incidence of complications of cirrhosis and mortality according to the presence of SPSS. Secondary measurements were the prevalence of SPSS in patients with cirrhosis and their radiologic features. RESULTS L-SPSS were identified in 488 (28%) patients, S-SPSS in 548 (32%) patients, and no shunt (W-SPSS) in 693 (40%) patients. The most common L-SPSS was splenorenal (46% of L-SPSS). The presence and size of SPSS increased with liver dysfunction: among patients with MELD scores of 6-9, 14% had L-SPSS and 28% had S-SPSS; among patients with MELD scores of 10-13, 30% had L-SPSS and 34% had S-SPSS; among patients with MELD scores of 14 or higher, 40% had L-SPSS and 32% had S-SPSS (P < .001 for multiple comparison among MELD groups). HE was reported in 48% of patients with L-SPSS, 34% of patients with S-SPSS, and 20% of patients W-SPSS (P < .001 for multiple comparison among SPSS groups). Recurrent or persistent HE was reported in 52% of patients with L-SPSS, 44% of patients with S-SPSS, and 37% of patients W-SPSS (P = .007 for multiple comparison among SPSS groups). Patients with SPSS also had a larger number of portal hypertension-related complications (bleeding or ascites) than those W-SPSS. Quality of life and transplantation-free survival were lower in patients with SPSS vs without. SPSS were an independent factor associated with death or liver transplantation (hazard ratio, 1.26; 95% confidence interval, 1.06-1.49) (P = .008) in multivariate analysis. When patients were stratified by MELD score, SPSS were associated with HE independently of liver function: among patients with MELD scores of 6-9, HE was reported in 23% with L-SPSS, 12% with S-SPSS, and 5% with W-SPSS (P < .001 for multiple comparison among SPSS groups); among those with MELD scores of 10-13, HE was reported in 48% with L-SPSS, 33% with S-SPSS, and 23% with W-SPSS (P < .001 for multiple comparison among SPSS groups); among patients with MELD scores of 14 or more, HE was reported in 59% with L-SPSS, 57% with S-SPSS, and 48% with W-SPSS (P = .043 for multiple comparison among SPSS groups). Patients with SPSS and MELD scores of 6-9 were at higher risk for ascites (40.5% vs 23%; P < .001) and bleeding (15% vs 9%; P = .038) than patients W-SPSS and had lower odds of transplant-free survival (hazard ratio 1.71; 95% confidence interval, 1.16-2.51) (P = .006). CONCLUSIONS In a retrospective analysis of almost 2000 patients, we found 60% to have SPSS; prevalence increases with deterioration of liver function. SPSS increase risk for HE and with a chronic course. In patients with preserved liver function, SPSS increase risk for complications and death. ClinicalTrials.gov ID NCT02692430.
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Affiliation(s)
- Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Davide Roccarina
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Katharina Lampichler
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Anna Baiges
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Gavin Low
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Elba Llop
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Martin H Maurer
- Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Michela Triolo
- Internal Medicine, IRCCS San Donato, Department of Biomedical Sciences for Health, University of Milan, San Donato Milanese, Milan, Italy
| | - Guillaume Vangrinsven
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Rita Garcia-Martinez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain; Instituto de Investigacion Sanitaria Gregorio Marañon, Madrid, Spain
| | - Annette Dam
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Avik Majumdar
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Carmen Picón
- Department of Radiology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Spain
| | - Daniel Toth
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Anna Darnell
- Department of Radiology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Juan G Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Marta Lopez
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Guido Kukuk
- Department of Radiology, University of Bonn, Bonn, Germany
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Vincenzo La Mura
- Internal Medicine, IRCCS San Donato, Department of Biomedical Sciences for Health, University of Milan, San Donato Milanese, Milan, Italy; Centro di Ricerca Coordinata "A. M. e A. Migliavacca per lo Studio e la Cura delle Malattie del Fegato," Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | | | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
| | - Jose Luis Calleja
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Puneeta Tandon
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Virginia Hernandez-Gea
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Emmanuel A Tsochatzis
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Salvador Augustin
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
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Nakazawa M, Imai Y, Uchiya H, Ando S, Sugawara K, Nakayama N, Tomiya T, Mochida S. Balloon-occluded retrograde transvenous obliteration as a procedure to improve liver function in patients with decompensated cirrhosis. JGH OPEN 2017; 1:127-133. [PMID: 30483549 PMCID: PMC6207025 DOI: 10.1002/jgh3.12020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/27/2017] [Accepted: 10/03/2017] [Indexed: 01/29/2023]
Abstract
Aim Portosystemic shunts aggravate liver function by decreasing portal blood flow. The usefulness of balloon-occluded retrograde transvenous obliteration (B-RTO), a standardized therapeutic procedure for gastric fundal varices (GFV), for the improvement of liver function was evaluated in cirrhotic patients with or without varices. Methods The subjects were 161 patients with portosystemic shunts. A balloon catheter was inserted into the shunts, followed by the injection of 5% ethanolamine oleate through the catheter under balloon inflation. The balloon was kept inflated for 6 to 48 h. Results B-RTO was performed as a therapy for GFV in 112 patients and for the improvement of liver function in 49 patients. The targets were splenorenal shunts in 104 patients (93.6%) in the former group and 33 patients (67.3%) in the latter group, and the procedures were successfully completed in 109 (97.3%) and 39 (79.6%) patients, respectively. In both groups, the serum albumin levels were increased and the serum ammonia levels were decreased at more than 1 month after the procedures, compared with the baseline levels, whereas significant improvements in the Child-Pugh scores and prothrombin times were only seen in the latter group. In these patients, the portal blood flows evaluated using Doppler ultrasound were increased at 1 week after the procedures, compared with the baseline levels. Conclusions B-RTO is a useful therapeutic procedure for improving liver function even in patients without GFV by increasing the portal venous flow with successfully targeted, uncommon portosystemic shunts.
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Affiliation(s)
- Manabu Nakazawa
- Department of Gastroenterology and Hepatology, Faculty of Medicine Saitama Medical University Saitama Japan
| | - Yukinori Imai
- Department of Gastroenterology and Hepatology, Faculty of Medicine Saitama Medical University Saitama Japan
| | - Hiroshi Uchiya
- Department of Gastroenterology and Hepatology, Faculty of Medicine Saitama Medical University Saitama Japan
| | - Satsuki Ando
- Department of Gastroenterology and Hepatology, Faculty of Medicine Saitama Medical University Saitama Japan
| | - Kayoko Sugawara
- Department of Gastroenterology and Hepatology, Faculty of Medicine Saitama Medical University Saitama Japan
| | - Nobuaki Nakayama
- Department of Gastroenterology and Hepatology, Faculty of Medicine Saitama Medical University Saitama Japan
| | - Tomoaki Tomiya
- Department of Gastroenterology and Hepatology, Faculty of Medicine Saitama Medical University Saitama Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Faculty of Medicine Saitama Medical University Saitama Japan
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Shunt occlusion for portosystemic shunt syndrome related refractory hepatic encephalopathy-A single-center experience in 21 patients from Kerala. Indian J Gastroenterol 2017; 36:411-419. [PMID: 29124669 DOI: 10.1007/s12664-017-0787-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 09/08/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Large spontaneous portosystemic shunts (SPSS) are seen in a subset of patients with liver disease and medically refractory recurrent/persistent hepatic encephalopathy (MRHE). Shunt occlusion has been shown to improve clinical outcomes. METHODS We retrospectively analyzed patient characteristics, SPSS attributes, procedural features, baseline clinical and investigational parameters, neurological outcomes, adverse effects (procedure and portal hypertension related), and risk factors predicting outcomes in liver disease patients undergoing shunt occlusion procedure for MRHE. RESULTS Between October 2016 and July 2017, 21 patients (Child-Pugh score, CTP 6 to 13) with mean model of end-stage liver disease (MELD) and MELD-sodium scores 15.7 and 19.3 respectively with MRHE [3-cirrhotic Parkinsonism (CP)] were diagnosed to have single or multiple large SPSSs. A total of 29 shunts were occluded (1 surgical, 20 non-surgical). Recurrent and persistent HE and CP markedly improved in the short (n=20, 1 to 3 months), intermediate (n=12, 3 to 6 months), and long (n=7, 6 to 9 months) follow up. None had spontaneous or persistent HE at a median follow up 105 (30 to 329) days (p<0.05). Motor, speech, sleep abnormalities, daily activities of living, and liver disease severity scores improved significantly on follow up. Baseline arterial ammonia showed a statistically significant reduction in all time periods of follow up after shunt occlusion (p<0.05). CTP >11 predicted mortality post shunt occlusion (p=0.04). Embolization of large SPSS in liver disease patients with MRHE and modestly preserved liver function is safe and efficacious and associated with improved quality of life and can function as a bridge to liver transplantation in accurately selected patients.
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Ochi H, Aono M, Takechi S, Mashiba T, Yokota T, Joko K. Successful splenorenal shunt occlusion with balloon-occluded retrograde transvenous obliteration yielded improvement of residual liver function, enabled administration of direct-acting antivirals, and achieved sustained virological response to hepatitis C virus: A case report. J Dig Dis 2017; 18:125-129. [PMID: 28102583 DOI: 10.1111/1751-2980.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 01/05/2017] [Accepted: 01/09/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Hironori Ochi
- Department of Center for Liver and Biliary Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Michiko Aono
- Department of Center for Liver and Biliary Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shunji Takechi
- Department of Center for Liver and Biliary Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Toshie Mashiba
- Department of Center for Liver and Biliary Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Tomoyuki Yokota
- Department of Center for Liver and Biliary Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Kouji Joko
- Department of Center for Liver and Biliary Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
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24
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Lynn AM, Leise MD. Reply. Liver Transpl 2016; 22:1736-1737. [PMID: 27731936 DOI: 10.1002/lt.24647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/16/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Amanda M Lynn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Lynn AM, Singh S, Congly SE, Khemani D, Johnson DH, Wiesner RH, Kamath PS, Andrews JC, Leise MD. Embolization of portosystemic shunts for treatment of medically refractory hepatic encephalopathy. Liver Transpl 2016; 22:723-31. [PMID: 26970243 PMCID: PMC4917293 DOI: 10.1002/lt.24440] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/28/2016] [Accepted: 02/06/2016] [Indexed: 01/13/2023]
Abstract
Treatment options for refractory hepatic encephalopathy (HE) are limited. Patients who fail medical management may harbor large portosystemic shunts (PSSs) which are possible therapeutic targets. This study aims to describe patient selection, effectiveness, and safety of percutaneous PSS embolization in those with medically refractory HE. A retrospective evaluation of consecutive adult patients with medically refractory HE referred for PSS embolization at a tertiary center was performed (2003-2015). Patient data collected included the type of HE, medications, Model for End-Stage Liver Disease (MELD) score, shunt type, embolization approach, and materials used. Outcomes of interest were immediate (7 days), intermediate (1-4 months), and longer-term (6-12 months) effectiveness and periprocedural safety. Effectiveness was determined based on changes in hospitalization frequency, HE medications, and symptoms. Twenty-five patients with large PSS were evaluated for shunt embolization. Five were excluded due to high MELD scores (n = 1), comorbid conditions (n = 1), or technical considerations (n = 3). Of 20 patients who underwent embolization, 13 had persistent and 7 had recurrent HE; 100% (20/20) achieved immediate improvement. Durable benefit was achieved in 100% (18/18) and 92% (11/12) at 1-4 and 6-12 months, respectively. The majority (67%; 8/12) were free from HE-related hospitalizations over 1 year; 10% developed procedural complications, and all resolved. Six developed new or worsening ascites. In conclusion, PSS embolization is a safe and effective treatment strategy that should be considered for select patients with medically refractory HE. Liver Transplantation 22 723-731 2016 AASLD.
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Affiliation(s)
- Amanda M. Lynn
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, CA
| | - Stephen E. Congly
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Disha Khemani
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - David H. Johnson
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Russell H. Wiesner
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Patrick S. Kamath
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - James C. Andrews
- Department of Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN
| | - Michael D. Leise
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
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Study of pulmonary dysfunctions in liver cirrhosis. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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An J, Kim KW, Han S, Lee J, Lim YS. Improvement in survival associated with embolisation of spontaneous portosystemic shunt in patients with recurrent hepatic encephalopathy. Aliment Pharmacol Ther 2014; 39:1418-26. [PMID: 24754260 DOI: 10.1111/apt.12771] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 12/16/2013] [Accepted: 04/07/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Spontaneous portosystemic shunt (SPSS) is a frequent cause of recurrent hepatic encephalopathy (HE) in patients with cirrhosis. AIM To assess the effectiveness and optimal candidate selection for embolisation of SPSS, for the treatment of recurrent HE in patients with cirrhosis. METHODS This retrospective cohort study compared 17 patients with recurrent HE who achieved complete occlusion of SPSS by angiographic embolisation and 17 control patients. RESULTS Most baseline characteristics were similar in the two groups. The 2-year HE recurrence rate was significantly lower in the embolisation than in the control group (39.9% vs. 79.9%, P = 0.02), whereas their 2-year overall survival rates were similar (64.7% vs. 53.4%, P = 0.98). Model for end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) score were significant predictors of 2-year patient mortality in the embolisation group. Analysis of patients with MELD <15 in the absence of hepatocellular carcinoma (HCC) showed that 2-year overall survival rate was significantly higher in the embolisation group than in the control group (100% vs. 60%, P = 0.03). The median changes in MELD (-1.6 vs. 2.5, P < 0.01), CTP score (-3 vs. 0, P < 0.01), and liver volume (61 mL vs. -117 mL; P = 0.046) at 1 year significantly favoured the embolisation group. Serious clinical complications after embolisation occurred only in patients who had MELD ≥15 and/or HCC at baseline, with all six dying within 1 year. CONCLUSIONS Embolisation of a large spontaneous portosystemic shunt may be associated with improved survival and liver function, as well as prevention of hepatic encephalopathy in cirrhotic patients with recurrent hepatic encephalopathy and modestly preserved liver function.
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Affiliation(s)
- J An
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Nardone R, Höller Y, Storti M, Lochner P, Tezzon F, Golaszewski S, Brigo F, Trinka E. Spinal cord involvement in patients with cirrhosis. World J Gastroenterol 2014; 20:2578-85. [PMID: 24627593 PMCID: PMC3949266 DOI: 10.3748/wjg.v20.i10.2578] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 01/03/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
A severe spinal cord involvement may rarely occur in patients with cirrhosis and other chronic liver diseases; this complication is usually associated with overt liver failure and surgical or spontaneous porto-systemic shunt. Hepatic myelopathy (HM) is characterized by progressive weakness and spasticity of the lower extremities, while sensory and sphincter disturbances have rarely been described and are usually less important. The diagnosis is assigned in the appropriate clinical setting on clinical grounds after the exclusion of other clinical entities leading to spastic paraparesis. Magnetic resonance imaging is often unremarkable; however, also intracerebral corticospinal tract abnormalities have been reported recently. The study of motor evoked potentials may disclose central conduction abnormalities even before HM is clinically manifest. HM responds poorly to blood ammonia-lowering and other conservative medical therapy. Liver transplantation represents a potentially definitive treatment for HM in patients with decompensated cirrhosis of Child-Pugh B and C grades. Other surgical treatment options in HM include surgical ligation, shunt reduction, or occlusion by interventional procedures.
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Splenic Vein Embolization Using Coil Anchors and Prophylactic Occlusion of a Hepatofugal Collateral for Hepatic Encephalopathy due to Splenorenal Shunt: Technical Note and Literature Review. Case Rep Radiol 2013; 2013:160653. [PMID: 23607030 PMCID: PMC3623118 DOI: 10.1155/2013/160653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/28/2013] [Indexed: 02/04/2023] Open
Abstract
Purpose. Interventional treatment strategies for patients with encephalopathy due to splenorenal shunt remain controversial. Portosplenic blood flow separation by occluding the splenic vein could avoid the complication of severe portal hypertension, but it would require repeated reintervention due to recurrence of symptoms. This paper describes occlusion of the splenic vein using coil anchors and prophylactic embolization of a collateral hepatofugal vessel with no recurrence of hyperammonemia. Materials and Methods. A 51-year-old woman with severe cirrhosis had hepatic encephalopathy due to a large splenorenal shunt. The serum ammonia level was 132 μ g/dL. Via a transileocolic approach, the splenic vein was completely embolized with 0.035-inch metallic coils using coil anchors while preserving the splenorenal shunt. In addition, one of the collateral vessels of the portal vein, the retrogastric vein, was also embolized prophylactically. Results. After this procedure, the serum ammonia level decreased immediately to 24 μ g/dL. The portal venous pressure increased by only 1.5 mmHg. Hepatic encephalopathy had not been observed for 25 months after the procedure, and neither retention of ascites nor worsening of esophageal varices and liver function was observed. Conclusion. This procedure appears to be safe and effective for hepatic encephalopathy caused by a splenorenal shunt.
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Tashiro H, Ide K, Amano H, Kobayashi T, Onoe T, Ishiyama K, Kuroda S, Tazawa H, Kono H, Aikata H, Takahashi S, Chayama K, Ohdan H. Surgical treatment for portosystemic encephalopathy in patients with liver cirrhosis: Occlusion of portosystemic shunt in combination with splenectomy. Hepatol Res 2013; 43:249-54. [PMID: 22734925 DOI: 10.1111/j.1872-034x.2012.01059.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM Operative ligation of the portosystemic shunt may control hepatic encephalopathy effectively, but the subsequent increase in portal vein pressure (PVP) leads to high mortality. Splenectomy can decrease inflow into the portal system, resulting in decreased portal pressure. METHODS We retrospectively examined the effect of splenectomy in combination with shunt closure on portosystemic encephalopathy. RESULTS Clinical symptoms of encephalopathy disappeared in all six patients who underwent splenectomy in combination with portosystemic shunt ligation, with the exception of one patient who had relapsing encephalopathy after 6 months. Follow-up computed tomography showed complete obliteration of the portosystemic shunts, except in the one patient with relapsing encephalopathy who underwent balloon-occluded retrograde transvenous obliteration for the remaining splenorenal shunt 8 months after surgery. PVP significantly decreased after splenectomy. PVP did not increase to the baseline PVP value after ligation of the shunts, except in two patients who had elevated PVP after surgery: PVP increased from 18 to 19 mmHg after ligation in one patient and from 18 to 23 mmHg in one patient. CONCLUSION Splenectomy followed by surgical ligation of the portosystemic shunt may be feasible and safe for cirrhotic patients with portosystemic shunts.
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Affiliation(s)
- Hirotaka Tashiro
- Departments of Gastroenterological Surgery Gastroenterology and Hepatology, Hiroshima University Hospital, Hiroshima, Department of Gastroenterology, Kure Medical Center, Kure, Japan
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Wang MQ, Liu FY, Duan F. Management of surgical splenorenal shunt-related hepatic myelopathy with endovascular interventional techniques. World J Gastroenterol 2012; 18:7104-8. [PMID: 23323015 PMCID: PMC3531701 DOI: 10.3748/wjg.v18.i47.7104] [Citation(s) in RCA: 9] [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: 03/05/2012] [Revised: 08/25/2012] [Accepted: 09/19/2012] [Indexed: 02/06/2023] Open
Abstract
We present a case with hepatic myelopathy (HM) due to a surgical splenorenal shunt that was successfully treated by endovascular interventional techniques. A 39-year-old man presented with progressive spastic paraparesis of his lower limbs 14 mo after a splenorenal shunt. A portal venogram identified a widened patent splenorenal shunt. We used an occlusion balloon catheter initially to occlude the shunt. Further monitoring of the patient revealed a decrease in his serum ammonia level and an improvement in leg strength. We then used an Amplatzer vascular plug (AVP) to enable closure of the shunt. During the follow up period of 7 mo, the patient experienced significant clinical improvement and normalization of blood ammonia, without any complications. Occlusion of a surgically created splenorenal shunt with AVP represents an alternative therapy to surgery or coil embolization that can help to relieve shunt-induced HM symptoms.
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Al-Osaimi AMS, Sabri SS, Caldwell SH. Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Preprocedural Evaluation and Imaging. Semin Intervent Radiol 2012; 28:288-95. [PMID: 22942546 DOI: 10.1055/s-0031-1284455] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Patients undergoing balloon retrograde transvenous obliteration (BRTO) are mostly decompensated cirrhotic with either bleeding gastric varices (GV) or hepatic encephalopathy. It is crucial that clinicians are up-to-date with the assessments needed prior to BRTO to anticipate and prevent complications, and to deliver critical quality care. These patients will require preprocedural assessments and management, including endoscopic, clinical, laboratory, and imaging evaluation. Endoscopic evaluation is mandatory prior to BRTO, and it is highly recommended that it be performed at the same institution where BRTO will be performed. It is essential that clinicians are aware of the potential benefits and complications that may result from BRTO. These complications should be anticipated and prevented when possible. For GV bleeders, there should be consideration of a transvenous intrahepatic portosystemic shunt (TIPS) during or before BRTO in patients with refractory ascites or pleural effusion, as well as endoscopic banding or a TIPS in patients with high-risk esophageal varices. Patients undergoing BRTO are usually complicated and require a team approach. In this article, the authors address these assessment and preparatory management and planning procedures prior to the BRTO procedure as well as expected outcomes and potential complications.
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Sauer BG, Sabri SS, Shami VM, Al-Osaimi AMS. Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Follow-Up and Postprocedural Imaging. Semin Intervent Radiol 2012; 28:325-32. [PMID: 22942550 DOI: 10.1055/s-0031-1284459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The majority of patients undergoing balloon retrograde transvenous obliteration (BRTO) are decompensated cirrhotic for either bleeding gastric varices (GV) or hepatic encephalopathy. These patients will require close follow-up and assessments pre- and post-BRTO including clinical, laboratory, endoscopic, and imaging evaluations. It is essential that clinicians are aware of the potential benefits and complications that may result from BRTO. These complications may include fever, chest or epigastric pain, hemoglobinuria, transient hypertension, nausea or vomiting, and many more. These complications usually resolve within the first 10 days. Laboratory abnormalities are transient and uncommon. Radiologic and endoscopic follow-up are required including computed tomography (CT), magnetic resonance imaging (MRI), routine upper endoscopy and endoscopic ultrasound (EUS), which are detailed in this review. Patients undergoing BRTO are usually complicated and will require a team approach. This team should include the hepatologist, endoscopist, and interventional radiologist. Understanding and open dialogue are essential in the management of post-BRTO patients. The authors review the possible benefits, potential complications, and the evaluation tools needed to improve outcomes.
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Al-Osaimi AMS, Caldwell SH. Medical and endoscopic management of gastric varices. Semin Intervent Radiol 2012; 28:273-82. [PMID: 22942544 DOI: 10.1055/s-0031-1284453] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the past 20 years, our understanding of the pathophysiology and management options among patients with gastric varices (GV) has changed significantly. GV are the most common cause of upper gastrointestinal bleeding in patients with portal hypertension after esophageal varices (EV) and generally have more severe bleeding than EV. In the United States, the majority of GV patients have underlying portal hypertension rather than splenic vein thrombosis. The widely used classifications are the Sarin Endoscopic Classification and the Japanese Vascular Classifications. The former is based on the endoscopic appearance and location of the varices, while the Japanese classification is based on the underlying vascular anatomy. In this article, the authors address the current concepts of classification, epidemiology, pathophysiology, and emerging management options of gastric varices. They describe the stepwise approach to patients with gastric varices, including the different available modalities, and the pearls, pitfalls, and stop-gap measures useful in managing patients with gastric variceal bleed.
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Affiliation(s)
- Abdullah M S Al-Osaimi
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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35
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Waguri N, Hayashi M, Yokoo T, Sato R, Arao Y, Setsu T, Sato M, Kohisa J, Hama I, Ohsugi K, Aiba T, Yoneyama O, Furukawa K, Sugimura K, Igarashi K, Suda T. Simultaneous combined balloon-occluded retrograde transvenous obliteration and partial splenic embolization for portosystemic shunts. J Vasc Interv Radiol 2012; 23:650-7. [PMID: 22459878 DOI: 10.1016/j.jvir.2012.01.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 01/13/2012] [Accepted: 01/16/2012] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the efficacy and safety of simultaneous combined balloon-occluded retrograde transvenous obliteration (B-RTO) and partial splenic embolization (PSE) for gastric varices and/or hepatic encephalopathy. MATERIALS AND METHODS B-RTO was performed in 19 consecutive patients with gastric varices and/or hepatic encephalopathy, of whom 10 received simultaneous combined B-RTO and PSE (group 1) and nine received B-RTO monotherapy (group 2). To evaluate the safety of these techniques, we analyzed 20 patients who received PSE monotherapy during the same period as a control group (group 3). Outcomes were retrospectively assessed. RESULTS No significant differences were observed in baseline characteristics among the three groups except for significantly lower platelet counts and larger spleen volumes in group 3. In all cases in groups 1 and 2, gastric varices disappeared and hepatic encephalopathy improved after treatment. Procedure times were not significantly different between groups 1 and 2 (P = .7435). In group 1, the volume of sclerosing agent required for B-RTO was significantly lower (P = .0355) and exacerbation of esophageal varices was significantly less frequent (P = .0146) than in group 2. Few serious complications occurred in patients who received combined therapy. CONCLUSIONS This study indicates that concomitant PSE may help diminish the increase in portal venous pressure after B-RTO for portosystemic shunts, and may allow a reduction in the volume of hazardous sclerosing agent used. It is worth evaluating the efficacy of simultaneous B-RTO and PSE in a prospective study.
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Affiliation(s)
- Nobuo Waguri
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, 467-3 Shumoku, Chuo-ku, Niigata 950-1197, Japan.
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Kumamoto M, Toyonaga A, Inoue H, Miyakoda K, Morita Y, Emori K, Sakamoto Y, Oho K, Sata M. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol 2010; 25:1129-35. [PMID: 20594229 DOI: 10.1111/j.1440-1746.2010.06262.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS It is well known that a large portosystemic shunt develops during portal hypertension. In this study, we studied the long-term effects of a large splenorenal shunt (SRS) on liver function and survival. METHODS The subjects were divided into three groups: an SRS (-) group consisting of cirrhotic patients without SRS; an SRS (+) group consisting of patients with gastric fundal varices and SRS; and a balloon-occluded retrograde transvenous obliteration (B-RTO) group with a completely obliterated SRS by B-RTO. We compared the following among these groups: the total bilirubin levels, serum albumin levels, prothrombin times, changes in Child-Pugh scores, and survival rates. RESULTS After a 3-year follow-up period the Child-Pugh scores showed significant differences among the SRS (+), SRS (-), and B-RTO groups. The score worsened for the SRS (+) group. The cumulative survival rates were significantly different between the SRS (+) and SRS (-) groups and between the SRS (+) and B-RTO groups. The vital prognosis worsened for the SRS (+) group. CONCLUSIONS The presence of a large splenorenal shunt (portosystemic shunt) was indicated to lower liver function and vital prognosis. B-RTO, which completely obliterates large splenorenal shunts, inhibited the lowering of hepatic functional reserve and the worsening of vital prognosis, indicating a protective role. Liver pathology and the presence of a large portosystemic shunt each separately result in progressive liver dysfunction and worsen the survival rate. We found that such a pathological condition had occurred due to a large portosystemic shunt, and it should be called 'portosystemic shunt syndrome.'
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Affiliation(s)
- Masafumi Kumamoto
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan.
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Riggio O, Ridola L, Pasquale C. Hepatic encephalopathy therapy: An overview. World J Gastrointest Pharmacol Ther 2010; 1:54-63. [PMID: 21577297 PMCID: PMC3091148 DOI: 10.4292/wjgpt.v1.i2.54] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 01/24/2010] [Accepted: 01/31/2010] [Indexed: 02/06/2023] Open
Abstract
Type-C hepatic encephalopathy (HE) is a severe complication of cirrhosis, which seriously affects quality of life and is strongly related to patient survival. Treatment based on a classical pharmacological approach that is aimed at reducing the production of gut-derived toxins, such as ammonia, is still under debate. Currently, results obtained from clinical trials do not support any specific treatment for HE and our competence in testing old and new treatment modalities by randomized controlled trials with appropriate clinically relevant end-points urgently needs to be improved. On the other hand, patients who are at risk for HE are now identifiable, based on studies on the natural history of the disease. Today, very few studies that are specifically aimed at establishing whether HE may be prevented are available or in progress. Recent studies have looked at non absorbable disaccharides or antibiotics and other treatment modalities, such as the modulation of intestinal flora. In the treatment of severe stage HE, artificial liver supports have been tested with initial positive results but more studies are needed.
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Affiliation(s)
- Oliviero Riggio
- Oliviero Riggio, Lorenzo Ridola, Chiara Pasquale, Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome 00185, Italy
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Abstract
BACKGROUND Hepatic encephalopathy (HE) is a severe complication of cirrhosis, seriously affecting the patients' quality of life. The classical approach aimed at reducing the production of gut-derived toxins, such as ammonia, is under debate as, at the moment, the information obtained from the clinical trials does not support any specific treatment for HE. OBJECTIVES i) To discuss present therapeutic strategies and possible future developments; ii) to identify areas of medical needs and iii) to suggest the ideal design and methodology for randomized controlled trials (RCTs) in HE. METHODS Current approaches were obtained from already available RCTs or from experimental animal studies. Those approaches developed from studies on HE pathophysiology were considered as working hypotheses for future therapies. RESULTS/CONCLUSION Our competence in testing old and new treatment modalities by RCTs with appropriate clinically relevant end points should urgently be improved. The patients at risk of HE are identifiable, and studies specifically aimed at establishing whether HE may be prevented or not are needed. As far as new treatment modalities are concerned, RCTs on the modulators of the intestinal bacterial flora and on the molecular adsorbent recirculating system are already available, but further studies are needed to confirm these promising approaches.
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Affiliation(s)
- Oliviero Riggio
- Sapienza Università di Roma, Dipartimento di Medicina Clinica, II Gastroenterologia, Viale dell' Università 37, 00185 Roma, Italy.
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Successful embolization of a spontaneous mesocaval shunt using the Amplatzer Vascular Plug II. Cardiovasc Intervent Radiol 2009; 33:1044-8. [PMID: 19908090 DOI: 10.1007/s00270-009-9739-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 10/08/2009] [Indexed: 12/27/2022]
Abstract
A 48-year-old man with alcoholic liver cirrhosis and hepatic encephalopathy was found to have a large, spontaneous mesocaval shunt. The shunt was successfully occluded with the use of an Amplatzer Vascular Plug. To our knowledge, this is the first report of the use of this device to embolize a mesocaval shunt involving the superior mesenteric vein.
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40
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Successful portal-systemic shunt occlusion of a direct shunt between the inferior mesenteric vein and inferior vena cava with balloon-occluded retrograde transvenous obliteration following recanalization after placing a covered stent in the portal and superior mesenteric veins. Jpn J Radiol 2009; 27:180-4. [DOI: 10.1007/s11604-009-0320-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Accepted: 02/24/2009] [Indexed: 10/20/2022]
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Murakami M, Nishino K, Satou T, Takaoka Y, Murakami S, Murakami B, Chikamori F, Kokubu S. Percutaneous transretroperitoneal direct approach to occlude a major shunt in a patient with extrahepatic portal-systemic encephalopathy. Hepatol Res 2009; 39:313-7. [PMID: 19261003 DOI: 10.1111/j.1872-034x.2008.00444.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A 73-year-old woman had sudden dystrophy and amnesia in our hospital. Her serum ammonia level was high. Marked collateral vessels from the splenic vein to the left renal vein around the spleen were seen on a computed tomography (CT) scan with contrast enhancement. An abdominal angiogram showed that the direction of the splenic vein was hepatofugal on superior mesenteric arterial portography, with a marked splenorenal shunt on splenic arterial portography. Hepatic encephalopathy due to a marked extrahepatic portal-systemic shunt was diagnosed. Transjugular retrograde obliteration (TJO) was attempted, but the catheter and guide wire could not selectively approach the splenorenal shunt because of many outflow routes. We punctured the vessels from the left side of the back under ultrasonographic guidance. We injected microcoils and ethanolamine oleate to completely obliterate the shunt. Marked collateral vessels showed no venous flow on a CT scan after treatment. The serum ammonia level was in the normal range. There has been no recanalization of the shunt vessels for 4 years after treatment. Hepatic encephalopathy has not recurred, and no other collateral vessels have developed. To our knowledge, this is the first report to document the use of a percutaneous transretroperitoneal direct approach to occlude a major shunt in a patient with extrahepatic portal-systemic encephalopathy.
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Affiliation(s)
- Masato Murakami
- Department of Internal Medicine, Murakami Memorial Hospital, Saijo City, Ehime, Japan
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Transjugular intrahepatic portosystemic shunts in hemodialysis-dependent patients and patients with advanced renal insufficiency: safety, caution, and encephalopathy. J Vasc Interv Radiol 2008; 19:516-20. [PMID: 18375295 DOI: 10.1016/j.jvir.2007.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 11/11/2007] [Accepted: 11/15/2007] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To retrospectively determine the acute safety and chronic outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with hemodialysis-dependent end-stage renal disease for control of bleeding and refractory ascites. MATERIALS AND METHODS Four dialysis-dependent patients and one renal transplant recipient (glomerular filtration rate, 27 mL/min) underwent TIPS creation for treatment of refractory ascites (n = 3) and recurrent portal hypertensive bleeding (n = 1). A sixth patient developed unrelated renal failure 3 years after initial TIPS formation and presented with encephalopathy at that time. All had nearly normal liver function test results and no previous baseline encephalopathy. Three dialysis recipients underwent dialysis immediately after the TIPS procedure in an intensive care unit; one did not. RESULTS There were no complications of fluid overload or pulmonary edema after TIPS creation in the patients who immediately underwent dialysis. The one patient in whom dialysis was delayed developed respiratory failure and shock liver (ie, ischemic hepatitis). Ascites resolved in all three patients, and no recurrent variceal bleeding occurred during a mean follow-up of 17 months. Severe, grade 2-4 hepatic encephalopathy developed in all patients; in one patient, its onset was delayed until the onset of renal failure 3 years after the original TIPS procedure. Shunt reduction was required in four cases and competitive variceal embolization was required in one to reduce portosystemic diversion. No less than grade 1 episodic baseline encephalopathy was present in all patients despite continued use of the maximum prescribed medical therapy thereafter. CONCLUSIONS TIPS creation is effective in controlling ascites and bleeding in functionally anephric patients, but at the cost of marked and disproportionate hepatic encephalopathy. Prompt, acute postprocedural dialysis and fluid management is critical for safe creation of a TIPS in dialysis-dependent patients.
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Seman M, Scatton O, Zalinski S, Chrissostalis A, Legmann P, Soubrane O. Laparoscopic division of a portosystemic shunt to treat chronic hepatic encephalopathy. HPB (Oxford) 2008; 10:211-3. [PMID: 18773056 PMCID: PMC2504377 DOI: 10.1080/13651820802007456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Indexed: 12/12/2022]
Abstract
In the event of liver cirrhosis with severe portal hypertension, voluminous portosystemic shunt may lead to refractory encephalopathy. Obliteration of the shunt has been described as a satisfactory therapeutic solution, and reported procedures are mainly endovascular embolization and surgical shunt ligation through laparotomy. The former procedure is less invasive and seems to be as efficient. Laparoscopy, which is widely recognized to minimize mortality and morbidity in cirrhotic patients undergoing surgery, has never been used for such a procedure. Shunt division can therefore be considered using this modern approach to good effect and reduced morbidity. In support of this view, we report a case of severe chronic encephalopathy cured by laparoscopic surgical division of a large shunt after failure of the percutaneous technique.
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Affiliation(s)
- Marie Seman
- Department of Hepatobiliary Surgery and Liver Transplantation, Université Paris DescartesParisFrance
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Université Paris DescartesParisFrance
| | - Stephane Zalinski
- Department of Hepatobiliary Surgery and Liver Transplantation, Université Paris DescartesParisFrance
| | - Ariane Chrissostalis
- Department of Hepatobiliary Surgery and Liver Transplantation, Université Paris DescartesParisFrance
| | - Paul Legmann
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris DescartesParisFrance
| | - Olivier Soubrane
- Department of Hepatobiliary Surgery and Liver Transplantation, Université Paris DescartesParisFrance
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Zidi SH, Zanditenas D, Gelu-Siméon M, Rangheard AS, Valla DC, Vilgrain V, Pelletier GM. Treatment of chronic portosystemic encephalopathy in cirrhotic patients by embolization of portosystemic shunts. Liver Int 2007; 27:1389-93. [PMID: 18036102 DOI: 10.1111/j.1478-3231.2007.01602.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
UNLABELLED AIMS/BACKGROUNDS: Large spontaneous portal-systemic shunts can occasionally be the cause of chronic and disabling encephalopathy in cirrhotic patients. Shunt embolization has been proposed, however the clinical relevance of this technique remains uncertain. METHODS/RESULTS We report our results in seven patients treated by shunt embolization. Although the procedure was achieved and technically successful in all patients, the clinical results were poor as long-term improvement was obtained in only one patient. Three patients died within 3 months after the procedure from cirrhoses' end stage complications. CONCLUSION We believe that optimal management of these patients with chronic spontaneous encephalopathy is liver transplantation.
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Affiliation(s)
- Sémia H Zidi
- Hopital Bicetre, Hepatology and Gastroenterology, Le Kremlin-Bicêtre, France
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45
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Concomitant Hepatic Encephalopathy and Refractory Ascites: Successful Treatment with Staged Embolization of Two Large Portosystemic Shunts and Transjugular Intrahepatic Portosystemic Shunt Placement. J Vasc Interv Radiol 2007; 18:1441-6. [DOI: 10.1016/j.jvir.2007.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Charalabopoulos K, Peschos D, Zoganas L, Bablekos G, Golias C, Charalabopoulos A, Stagikas D, Karakosta A, Papathanasopoulos A, Karachalios G, Batistatou A. Alterations in arterial blood parameters in patients with liver cirrhosis and ascites. Int J Med Sci 2007; 4:94-7. [PMID: 17396160 PMCID: PMC1838824 DOI: 10.7150/ijms.4.94] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2006] [Accepted: 03/01/2007] [Indexed: 01/10/2023] Open
Abstract
In cirrhotic patients, in addition to hepatocytes and Kuppfer cells dysfunction circulatory anatomic shunt and ventilation/perfusion (V(A)/ Q) ratio abnormalities can induce decrease in partial pressure of oxygen in arterial blood (PaO(2)), in oxygen saturation of hemoglobin (SaO(2)) as well as various acid-base disturbances. We studied 49 cases of liver cirrhosis (LC) with ascites compared to 50 normal controls. Causes were: posthepatic 37 (75.51%), alcoholic 7 (14.24%), cardiac 2 (4.08%), and cryptogenic 3 (6.12%). Complications were: upper gastrointestinal bleeding 24 (48.97), hepatic encephalopathy 20 (40.81%), gastritis 28 (57.14%), hepatoma 5 (10.2%), renal hepatic syndrome 2 (4.01%), HbsAg (+) 24 (48.97%), and hepatic pleural effusions 7 (14.28%). Average PaO(2) and SaO(2) were 75.2 mmHg and 94.5 mmHg, respectively, compared to 94.2 mmHg and 97.1 mmHg of the control group, respectively (p value in both PaO(2) and SaO(2 )was p<0.01). Respiratory alkalosis, metabolic alkalosis, metabolic acidosis, respiratory acidosis and metabolic acidosis with respiratory alkalosis were acid-base disturbances observed. In conclusion, portopulmonary shunt, intrapulmonary arteriovenous shunt and V(A)/Q inequality can induce a decrease in PaO(2) and SaO(2) as well as various acid-base disturbances. As a result, pulmonary resistance is impaired and patients more likely succumb to infections and adult respiratory distress syndrome.
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Riggio O, Efrati C, Catalano C, Pediconi F, Mecarelli O, Accornero N, Nicolao F, Angeloni S, Masini A, Ridola L, Attili AF, Merli M. High prevalence of spontaneous portal-systemic shunts in persistent hepatic encephalopathy: a case-control study. Hepatology 2005; 42:1158-65. [PMID: 16250033 DOI: 10.1002/hep.20905] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Large spontaneous portal-systemic shunts have been occasionally described in patients with cirrhosis. This study was undertaken to assess the prevalence of portal-systemic shunts in patients with cirrhosis with recurrent or persistent hepatic encephalopathy (HE) as compared with patients with cirrhosis without HE. Fourteen patients with cirrhosis with recurrent or persistent HE (cases) and 14 patients with cirrhosis without previous or present signs of overt HE matching for age and degree of liver failure (controls) were studied. Each patient underwent neurological assessment and cerebral magnetic resonance (MR) imaging to exclude organic neurological pathological conditions. HE evaluation included psychometric performance (Trail-Making Test A), electroencephalogram (EEG), mental status examination and grading, arterial, venous, and partial pressure of ammonia determination. The presence of portal-systemic shunts was assessed by portal venous phase multidetector-row spiral computed tomography (CT). Large spontaneous portal-systemic shunts were detected in 10 patients with HE and in only 2 patients without HE (71% vs. 14%; chi square = 9.16; df = 1.0; P = .002). The patients with HE presented ascites (P = .002) and medium/large esophageal varices (P = .02) less frequently than the control group. In conclusion, our study suggests that large spontaneous shunts may often sustain the chronicity of HE; the presence of large shunts should be sought in patients with cirrhosis with recurrent or persistent HE.
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Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Division of Gastroenterology; University of Rome La Sapienza, Rome, Italy.
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Dell'era A, Bosch J. Review article: the relevance of portal pressure and other risk factors in acute gastro-oesophageal variceal bleeding. Aliment Pharmacol Ther 2004; 20 Suppl 3:8-15; discussion 16-7. [PMID: 15335392 DOI: 10.1111/j.1365-2036.2004.02109.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastro-oesophageal variceal bleeding is the last step in a chain of events that starts with an increased portal pressure, and is followed by the formation and progressive dilatation of gastro-oesophageal varices. When the tension of the thin wall of the varices exceeds its elastic limit, the varices rupture and bleed. Wall tension is directly proportional to variceal pressure (which is a function of portal pressure) and variceal radius, and inversely related to the thickness of the variceal wall. The above facts explain why a high portal pressure (usually determined by the hepatic venous pressure gradient, or HVPG) and the presence at endoscopy of large varices with red wheals, red spots or diffuse redness on the varices (signalling a reduced wall thickness) correlate with the risk of bleeding.
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Affiliation(s)
- A Dell'era
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Spain
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Takayama Y, Moriura S, Nagata J, Akutagawa A, Hirano A, Ishiguro S, Matsumoto T, Sato T. Embolization of the left portal vein to inferior vena cava shunts for chronic recurrent hepatic encephalopathy via the mesenteric vein. J Gastroenterol Hepatol 2001; 16:1425-8. [PMID: 11851846 DOI: 10.1046/j.1440-1746.2001.02508.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Diagnostic imaging and embolization therapy for very rare intrahepatic portal-systemic shunts with liver cirrhosis are reported. An 82-year-old woman was admitted to the hospital (Yachiyo Hospital) because of hepatic encephalopathy. Computed tomography with contrast enhancement demonstrated anomalous vessels between the portal vein and the inferior vena cava. Those shunts were suspected as the cause of her encephalopathy with hyperammonemia. Portography through McBurney's laparotomy demonstrated two portal-caval shunts; one was from the bifurcation of the portal vein and the other was from the left portal vein. They seemed to originate from the vascular system of the caudate lobe, and were obstructed with stainless coils. The patient is well with a normal serum ammonia level 40 months following the intervention.
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Affiliation(s)
- Y Takayama
- Department of Surgery, Yachiyo Hospital, Aichi, Japan.
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Abstract
1. Acute Encephalopathy in Cirrhosis A. GENERAL MEASURES. Tracheal intubation in patients with deep encephalopathy should be considered. A nasogastric tube is placed for patients in deep encephalopathy. Avoid sedatives whenever possible. Correction of the precipitating factor is the most important measure. B. SPECIFIC MEASURES i. Nutrition. In case of deep encephalopathy, oral intake is withheld for 24-48 h and i.v. glucose is provided until improvement. Enteral nutrition can be started if the patient appears unable to eat after this period. Protein intake begins at a dose of 0.5 g/kg/day, with progressive increase to 1-1.5 g/kg/day. ii. Lactulose is administered via enema or nasogastric tube in deep encephalopathy. The oral route is optimized by dosing every hour until stool evacuation appears. Lactulose can be replaced by oral neomycin. iii. Flumazenil may be used in selected cases of suspected benzodiazepine use. 2. Chronic Encephalopathy in Cirrhosis i. Avoidance and prevention of precipitating factors, including the institution of prophylactic measures. ii. Nutrition. Improve protein intake by feeding dairy products and vegetable-based diets. Oral branched-chain amino acids can be considered for individuals intolerant of all protein. iii. Lactulose. Dosing aims at two to three soft bowel movements per day. Antibiotics are reserved for patients who respond poorly to disaccharides or who do not exhibit diarrhea or acidification of the stool. Chronic antibiotic use (neomycin, metronidazole) requires careful renal, neurological, and/or otological monitoring. iv. Refer for liver transplantation in appropriate candidates. For problematic encephalopathy (nonresponsive to therapy), consider imaging of splanchnic vessels to identify large spontaneous portal-systemic shunts potentially amenable to radiological occlusion. In addition, consider the combination of lactulose and neomycin, addition of oral zinc, and invasive approaches, such as occlusion of TIPS or surgical shunts, if present. Minimal or Subclinical Encephalopathy Treatment can be instituted in selected cases. The most characteristic neuropsychological deficits in patients with cirrhosis are in motor and attentional skills (60). Although these may impact the ability to perform daily activities, many subjects can compensate for these defects. Recent studies suggest a small but significant impact of these abnormalities on patients' quality of life (61), including difficulties with sleep (62). In patients with significant deficits or complaints, a therapeutic program based on dietary manipulations and/or nonabsorbable disaccharides may be tried. Benzodiazepines should not be used for patients with sleep difficulties.
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Affiliation(s)
- A T Blei
- Department of Medicine, Lakeside VA Medical Center and Northwestern University, Chicago, Illinois 60611, USA
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