Association of Budd-Chiari syndrome and celiac disease

Gastrointestinal System: COVID-19 and Potential Mechanisms Associated with Coagulopathy

SARS-CoV-2 is a novel coronavirus that expanded worldwide, generating a pandemic of acute respiratory syndrome called "coronavirus disease 2019" (COVID-19), which resulted in a global health crisis. The spectrum of COVID-19 manifestations ranges from none or mild symptoms to severe respiratory failure associated with systemic manifestations, mostly gastrointestinal symptoms. Hypercoagulability is an important feature of COVID-19 disease, which can potentially influence patients' prognosis. Therefore, gastroenterologists should focus on subjects with concomitant hypercoagulable gastrointestinal disorders as they may display a higher risk of thrombotic complications during SARS-CoV-2 infection. The aim of this review is to summarize the available evidence regarding the interplay of the prothrombotic pathogenetic mechanisms of both COVID-19 and hypercoagulable digestive diseases and the possible clinical implications. We summarized the potential interplay of prothrombotic mechanisms of both COVID-19 and hypercoagulable digestive diseases in the graphical abstract.

Celiac Disease and Thrombotic Events: Systematic Review of Published Cases

Extraintestinal manifestations of celiac disease (CD) should be considered, even in patients without typical intestinal symptoms. The aim of our study is to examine the literature regarding the occurrence of thrombotic events in CD, and to synthesize the data from case reports and case series. A systematic review of the literature was conducted by searching the Pub-Med/MEDLINE database, from the date of database inception to January 2022, to identify published cases and case series on this topic, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 55 cases were included in the study. The majority of patients were previously healthy individuals, with no comorbidities. In less than one-third of the cases (30.91%), the diagnosis of CD was established before the onset of thrombosis, while in the remaining cases (34.54%), thrombosis preceded the diagnosis or was diagnosed concomitantly with CD. The most common sites for thrombosis occurrence were hepatic veins (30.91%), while thrombosis of cerebral blood vessels, deep venous thrombosis of lower extremities, and pulmonary thromboembolism were less frequent. Thrombosis was most commonly isolated to one site only (78.18%). In 69.09% of cases (n = 38), some form of anticoagulation, along with a gluten-free diet, was initiated.

Celiac Disease and Portal Hypertension: A Causal Association or Just a Coincidence?

INTRODUCTION

Celiac disease (CD) has been linked to portal hypertension (PHT) of varied etiology, but the causality association has never been proved. We aim to study the prevalence of CD in patients of PHT of different etiology.

METHODS

A prospective observational study was conducted from June 2017 to December 2018 involving all the cases of PHT of varied etiology. Consecutive patients of PHT with chronic liver disease (CLD) of defined etiology like ethanol, viral hepatitis (B or C), Budd-Chiari syndrome (BCS), autoimmune-related cirrhosis, and cryptogenic CLD (cCLD) (group A) and those with noncirrhotic PHT (NCPHT), which included noncirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO) (group B), were screened for CD by IgA anti-tTG antibody followed by duodenal biopsy in serology-positive patients.

RESULTS

Out of a total of 464 patients, group A constituted 382 patients, CLD related to ethanol (155), cCLD (147), hepatitis B (42), hepatitis C (21), autoimmune (10), and BCS (7), whereas 82 patients were in group B with NCPF (64) and EHPVO (18). Total 29 patients were diagnosed with CD in both groups, 17 in group A (4.5%) and 12 in group B (14.6%). In group A, 13 patients with cCLD, two with HBV-related CLD, one with BCS, and one with autoimmune-related CLD were concomitantly diagnosed as CD. In group B, CD was diagnosed in 12 patients of NCPF (11) and EHPVO (1). Liver histology showed chronic hepatitis in two patients and was normal in three patients.

CONCLUSION

CD is common in PHT of different etiology, especially in cCLD, NCPH and autoimmune hepatitis; however, the etiological basis for this association is still to be defined. The likelihood of CD is higher in liver disease than the general population, and these patients should be screened for CD.

Celiac disease with Budd-Chiari syndrome: A rare association

Budd-Chiari syndrome is characterized by hepatic venous outflow tract obstruction. We describe an 18-year-old female of known celiac disease presented with progressive abdomen distention and shortness of breath for the last 1 month. Computed tomography of abdomen revealed hepatic vein obstruction. The patient was diagnosed with Budd-Chiari syndrome. Coagulation profile showed an increased homocysteine level. Serum folate level was also decreased. The patient was put on oral anticoagulant with a gluten-free diet. After 4 weeks, the patient showed significant improvement with decreased ascites. The association of Budd-Chiari syndrome with Celiac disease has not yet been fully understood. There have been few reports that described this rare association. Budd-Chiari syndrome should be considered as an important differential in a patient with unexplained ascites and celiac disease.

Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan

Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.

Budd-Chiari syndrome associated with coeliac disease: case report and literature review

We report a case of Budd-Chiari syndrome occurring in a patient with coeliac disease, who presented with symptoms of increased abdominal girth, right upper quadrant pain and shortness of breath for three weeks prior to admission. Initial assessment revealed the presence of moderate ascites, hepatosplenomegaly and right-sided pleural effusion. Further diagnostic work-up established a diagnosis of chronic Budd-Chiari syndrome. Interestingly, complete screening for pro-thrombotic factors was negative. A review of the literature on this association disclosed only 28 similar cases, with the majority of them describing individuals of North African origin. Interestingly, in the majority of cases no specific thrombotic factor could be identified, suggesting that coeliac disease may play a role in this thrombotic disorder.

[Splanchnic venous thrombosis: A monocentric study of 31 cases]

INTRODUCTION

Splanchnic vein thrombosis (SVT) denotes thrombosis of the hepatic venous system and of the extrahepatic portal system. They are often the manifestation of one or more underlying prothrombotic states and can sometimes present problems of therapeutic care.

METHODS

We report a monocentric study of 31 cases of SVT observed in an internal medicine department between January 2006 and June 2012. Epidemiological, clinical, laboratory, therapeutic and outcome data were analyzed.

RESULTS

There was a slight female predominance (sex-ratio: 1.2). Median patient age at diagnosis was 37 years. Most cases of SVT were chronic (61.2%). Abdominal pain was the predominant symptom in acute cases while the predominant signs in chronic forms were signs of portal hypertension. Extrasplanchnic thrombosis was noted in seven patients (22.5%). Behçet's disease was the most common etiology (32%). The treatment was based on anticoagulants and corticosteroids and immunosuppressants when an inflammatory etiology was found. The average follow-up was 17 months. There were five deaths (16%).

CONCLUSION

SVT often reflects the existence of a disease and/or an underlying prothrombotic state that should be identified to adapt the treatment and to avoid fatal complications.

[An atypical presentation of celiac disease: central retinal vein occlusion]

Parmi les complications thrombotiques de la maladie cœliaque l'occlusion de la veine centrale de la rétine a été exceptionnellement décrite. Nous rapportons l'observation d'une patiente âgée de 27 ans chez qui le diagnostic de maladie cœliaque a été porté dans le cadre du bilan étiologique d'une occlusion de la veine centrale de la rétine. L'interrogatoire ne révélait pas de diarrhée chronique ou de douleurs abdominales. La présence d'un amaigrissement, d'une anémie ferriprive et d'une hypocholestérolémie ont permis l'orientation vers la maladie cœliaque. La positivité des anticorps anti endomysium et la biopsie duodénale montrant l'atrophie villositaire confirmaient ce diagnostic. Le régime sans gluten associé à un traitement par aspirine avait partiellement amélioré l'acuité visuelle chez notre patiente. Cette présentation atypique de la maladie cœliaque souligne la diversité des manifestations extra-digestives au cours de cette maladie et l'intérêt de penser à la maladie cœliaque même lorsque ces manifestations sont inaugurales.

Hypercoagulability in celiac disease--an update

Celiac disease is a life-long autoimmune disease affecting multiple organs of genetically susceptible individuals. One of the extra intestinal manifestations of the disease is thromboembolic events like strokes, veins' thrombosis, and pregnancy losses. Hypercoagulable autoimmune diseases like lupus erythematosus and antiphospholipid syndrome, associated with celiac disease just add risk to the patients. Pathogenic predisposing avenues increasing the hypercoagulability in celiac disease are multiple: nutritional deficiencies (B12, folate, and vitamin K), genetic predisposition (MTHFR mutations), thrombophilic autoantibodies, hyperhomocysinemia, endothelial dysfunction and platelet abnormalities. Primary pharmacologic thromboprophylaxis or treating the predisposing factors should be considered on a personal basis.

Clinical and prothrombotic profile of hepatic vein outflow tract obstruction

OBJECTIVE

To study the clinical as well as prothrombotic profile and outcome of hepatic venous outflow tract obstruction in children.

METHODS

This is a prospective study of a cohort of hepatic venous outflow tract obstruction (HVOTO) pediatric cases. All children and adolescents presenting with acute or chronic liver disease were screened for HVOTO with ultrasound and Doppler imaging and confirmed by multidetector computerised tomography (MDCT) with contrast enhancement.

RESULTS

Of the 162 cases of chronic liver disease, 13 (7.4 %) were diagnosed to have HVOTO. Ascites and edema over the feet were the most prominent features. Anabolic steroids and herbal drugs were being taken by one case each. Six cases were diagnosed on Doppler and for rest 7 cases conclusive diagnosis was made on multidetector computerised tomography. Five out of 13 cases were heterogenous (CT) for mutation of the gene encoding methylene tetrahydrofolate reductase (MTHFR) and one case of these was also heterogenous for Factor Leiden V. One case was known celiac and developed HVOTO and was also found to be having hepatocellular carcinoma. Other causes were drug induced, pressure on inferior vena cava (IVC) and inferior vena cava (IVC) web. Thus the authors could find a prothrombotic cause for 10 out of 13 (76.9 %) cases. Three cases did not need any intervention. In one patient with infective thrombus of the IVC intervention was not planned. Six underwent angioplasty and 3 underwent transjugular intrahepatic portosystemic shunt. All were asymptomatic with improving growth parameters at follow up.

CONCLUSIONS

Ascites, pedal edema, prominent abdominal veins and hepatomegaly should raise the suspicion of HVOTO in childhood liver disease. Majority of the cases would be harbouring a prothrombotic cause. MTHFR mutation was the commonest cause of HVOTO in the present study. Angioplasty and/or transjugular intrahepatic portosystemic shunt (TIPSS) can successfully treat HVOTO.

[Intracardiac thrombosis during celiac disease]

Thrombotic events occurring in the course of celiac disease are frequently reported in the literature. The localization is often unusual, mainly affecting the hepatic veins. To our knowledge, this is the first report of intracardiac thrombosis occurring in a patient with celiac disease. A 32-year-old patient with celiac disease adhered poorly to his gluten-free diet. He suffered an ischemic stroke revealing an intracardiac thrombus, which, on radiological imaging, simulated a multiple myxoma. Histological examination of the resected tumor enabled the correct diagnosis. Biological findings revealed severe protein C and S deficiency. The patient improved with anticoagulant therapy and gluten-free diet.

Celiac disease and chronic liver disease: is there a relationship?

Celiac disease is a multisystem disease, and the liver is affected in a subset of patients. We herein present a case series of 25 patients with celiac disease who had evidence of cirrhosis of the liver. We retrospectively reviewed the case records of patients with celiac disease having concomitant cirrhosis. The diagnosis of celiac disease was made on the basis of the modified European Society of Pediatric Gastroenterology, Hepatology, and Nutrition criteria. Of 25 patients (nine males; mean age 28.8 ± 16.6 years) with celiac disease and cirrhosis, 17 patients presented predominantly with cirrhosis, while 8 presented primarily with celiac disease. Five patients had known cause of cirrhosis (autoimmune hepatitis, three; PBC, one; hepatic venous outflow tract obstruction, one); the remaining 20 were cryptogenic. Gluten-free diet led to improvement in diarrhea and anemia and to a better control of ascites and other features of liver failure. Some patients with cryptogenic cirrhosis have coexistent celiac disease, and they show response to gluten-free diet. Patients with cryptogenic cirrhosis should be screened for celiac disease.

Celiac disease and autoimmune-associated conditions

Celiac disease (CD) is frequently accompanied by a variety of extradigestive manifestations, thus making it a systemic disease rather than a disease limited to the gastrointestinal tract. This is primarily explained by the fact that CD belongs to the group of autoimmune diseases. The only one with a known etiology is related to a permanent intolerance to gluten. Remarkable breakthroughs have been achieved in the last decades, due to a greater interest in the diagnosis of atypical and asymptomatic patients, which are more frequent in adults. The known presence of several associated diseases provides guidance in the search of oligosymptomatic cases as well as studies performed in relatives of patients with CD. The causes for the onset and manifestation of associated diseases are diverse; some share a similar genetic base, like type 1 diabetes mellitus (T1D); others share pathogenic mechanisms, and yet, others are of unknown nature. General practitioners and other specialists must remember that CD may debut with extraintestinal manifestations, and associated illnesses may appear both at the time of diagnosis and throughout the evolution of the disease. The implementation of a gluten-free diet (GFD) improves the overall clinical course and influences the evolution of the associated diseases. In some cases, such as iron deficiency anemia, the GFD contributes to its disappearance. In other disorders, like T1D, this allows a better control of the disease. In several other complications and/or associated diseases, an adequate adherence to a GFD may slow down their evolution, especially if implemented during an early stage.

The thrombophilic network of autoantibodies in celiac disease

BACKGROUND

Celiac disease is a life-long autoimmune condition, affecting genetically susceptible individuals that may present with thromboembolic phenomena. This thrombophilia represents a puzzle with multiple constituents: hyperhomocysteinemia, B12 and\or folate deficiency, methylenetetrahydrofolate reductase mutations, and protein C and S deficiency due to vitamin K deficiency. However, the well known thrombogenic factors, antiphosphatidylserine/prothrombin and antiprothrombin have never been explored in celiac disease.

METHODS

The serum autoantibody levels were determined in 248 individuals, classified into three groups. Group 1 comprised 70 children with definitive celiac disease (age: 7.04 ±4.3 years, male to female ratio 1.06) and group 2 comprised 88 normal children (age: 6.7 ±4.17 years, male to female ratio 0.87), representing controls. The pediatric populations were compared to group 3, which included 90 adults who were family members (parents) of group 1 (age: 34.6 ±11.35 years, male to female ratio 1.2). Antibodies were checked by enzyme-linked immunosorbent assay.

RESULTS

Mean optical density levels of serum antiphosphatidylserine/prothrombin immunoglobulin G antibodies were 32.4 ±19.4, 3.6 ±2.5 and 16.1 ±15.8 absorbance units in groups 1, 2 and 3 respectively (P <0.0001), with 45.7%, 0% and 7.8% of groups 1, 2 and 3 respectively positive for the antibody (P <0.01). Mean optical density levels of serum antiphosphatidylserine/prothrombin immunoglobulin M antibodies were 14.2 ±8.7, 6.7 ±6.4 and 12.4 ±15.5 absorbance units in groups 1, 2 and 3 respectively (P <0.0001), with 7.1%, 3.4% and 9.9% of groups 1, 2 and 3 positive for the antibody. Mean optical density levels of serum antiprothrombin and antiphospholipid immunoglobulin G antibodies were higher in groups 1 and 3 compared with 2 (P <0.005) and in groups 1 and 2 compared with 3 (P <0.01), respectively. Groups 1, 2 and 3 were positive for antiphospholipid immunoglobulin G antibodies (groups 1 and 2 compared with 3) . Celiac disease sera harbor a higher antiprothrombin immunoglobulin G level compared with controls.

CONCLUSIONS

It is suggested that the intestinal injury, endothelial dysfunction, platelet abnormality and enhanced apoptosis recently described in celiac disease are at the origin of the increased exposure of phospholipids or new epitopes representing autoantigens. Those autoantibodies might play a pathogenic role in the thrombophilia associated with celiac disease and represent markers for potential anticoagulant preventive therapy.