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Novak I, Bass LM. Gastrointestinal Bleeding in Children: Current Management, Controversies, and Advances. Gastrointest Endosc Clin N Am 2023; 33:401-421. [PMID: 36948753 DOI: 10.1016/j.giec.2022.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) in children has many causes, with its prevalence varying by age. Often presenting as hematemesis or melena, the initial treatment is stabilization of the patient, including protection of the airway, fluid resuscitation, and a transfusion hemoglobin threshold of 7 g/L. Endoscopy should be performed with the goal of using combinations of therapies to treat a bleeding lesion, generally involving epinephrine injection along with either cautery, hemoclips, or hemospray. This review discusses the diagnosis and treatment of variceal and non-variceal gastrointestinal bleeding in children with a focus on current advances in the treatment of severe UGIB.
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Affiliation(s)
- Inna Novak
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA.
| | - Lee M Bass
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Avenue, Chicago, IL 60611, USA
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Sonavane AD, Bagde A, Raut V, Marar S, Sawant A, Shah K, Raj A, Thorat A, Chaksota H, Biradar V, Vasanth S, Nagral A, Mirza D. Therapeutic coil embolization of dominant shunt in hepatopulmonary syndrome enhances post-liver transplant respiratory recovery. Pediatr Transplant 2020; 24:e13729. [PMID: 32436643 DOI: 10.1111/petr.13729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/15/2020] [Accepted: 04/15/2020] [Indexed: 12/23/2022]
Abstract
Coil embolization of the atypical enlarged pulmonary artery/arteriole with visible shunting may improve hypoxemia in patients with hepatopulmonary syndrome (HPS). When used selectively in cases with large shunts, either pre- or post-liver transplantation (LT), it can aid an early recovery and reduce morbidity. We present a case where a large intrapulmonary shunt was embolized preoperatively to improve hypoxemia associated with HPS and enhance post-operative recovery.
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Affiliation(s)
- Amey D Sonavane
- Department of Adult and Pediatric Hepatology, Apollo Hospitals, Navi Mumbai, India
| | - Abhijit Bagde
- Department of Adult and Pediatric Hepatology, Apollo Hospitals, Navi Mumbai, India
| | - Vikram Raut
- Department of Liver Transplantation and HPB Surgery, Apollo Hospitals, Navi Mumbai, India
| | - Shaji Marar
- Department of Interventional Radiology, Apollo Hospitals, Navi Mumbai, India
| | - Ambreen Sawant
- Department of Anaesthesiology, Apollo Hospitals, Navi Mumbai, India
| | - Ketul Shah
- Department of Liver Transplantation and HPB Surgery, Apollo Hospitals, Navi Mumbai, India
| | - Amruth Raj
- Department of Liver Transplantation and HPB Surgery, Apollo Hospitals, Navi Mumbai, India
| | - Ashok Thorat
- Department of Liver Transplantation and HPB Surgery, Apollo Hospitals, Navi Mumbai, India
| | - Harshit Chaksota
- Department of Anaesthesiology, Apollo Hospitals, Navi Mumbai, India
| | - Vishnu Biradar
- Department of Adult and Pediatric Hepatology, Apollo Hospitals, Navi Mumbai, India
| | - Suresh Vasanth
- Department of Anaesthesiology, Apollo Hospitals, Navi Mumbai, India
| | - Aabha Nagral
- Department of Adult and Pediatric Hepatology, Apollo Hospitals, Navi Mumbai, India
| | - Darius Mirza
- Department of Liver Transplantation and HPB Surgery, Apollo Hospitals, Navi Mumbai, India
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Soulaidopoulos S, Goulis I, Cholongitas E. Pulmonary manifestations of chronic liver disease: a comprehensive review. Ann Gastroenterol 2020; 33:237-249. [PMID: 32382226 PMCID: PMC7196609 DOI: 10.20524/aog.2020.0474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH.
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Affiliation(s)
- Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration General Hospital, National and Kapodistrian University of Athens (Stergios Soulaidopoulos)
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Hippokration General Hospital, Medical School of Aristotle University of Thessaloniki (Ioannis Goulis)
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens (Evangelos Cholongitas), Greece
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Slowik V, Monroe EJ, Friedman SD, Hsu EK, Horslen S. Pressure gradients, laboratory changes, and outcomes with transjugular intrahepatic portosystemic shunts in pediatric portal hypertension. Pediatr Transplant 2019; 23:e13387. [PMID: 30932316 DOI: 10.1111/petr.13387] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Indications for TIPS are well described in adults and involve complications of PHTN. Complications from PHTN are associated with PSG of > 12 mm Hg in adults. It is unclear if these parameters apply to children with PHTN. OBJECTIVE To assess whether adult criteria for TIPS placement can be utilized in children, describe laboratory changes over time, and report outcomes. METHODS We performed a retrospective review of 34 pediatric patients who underwent TIPS, examining indications, radiology, PSG reductions, laboratory changes, and outcomes. RESULTS Most patients had PHTN due to parenchymal liver disease including congenital hepatic fibrosis (n = 5), biliary atresia (n = 5), cystic fibrosis-related liver disease (n = 3) and cavernous transformation of the portal vein (n = 6). Indications for TIPS included variceal bleeding, recurrent ascites, and maintenance of portal vein flow following thrombolysis. Variceal bleeding was observed in six children with PSG < 12 mm Hg. Minor complications occurred in eight subjects. Continued bleeding occurred in one patient. Six patients were successfully bridged to transplantation, and three patients died secondary to end-stage disease. Standard laboratory tests stabilized after TIPS placement and hematocrit increased. CONCLUSION TIPS placement in pediatric patients was performed for complications of PHTN. Unlike adult series, a substantial proportion of our cases treated extrahepatic PHTN from cavernous transformation of the portal vein. Children presented with sequelae of PHTN with PSG below 12 mm Hg, below the adult standard. We found TIPS in pediatrics to be safe and effective with laboratory stabilization and improvement in hematocrit.
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Affiliation(s)
- Voytek Slowik
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
| | - Eric J Monroe
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Seth D Friedman
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Evelyn K Hsu
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
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Abstract
Cirrhosis is a complex process in which the architecture of the liver is replaced by structurally abnormal nodules due to cirrhosis. Cirrhosis frequently leads to the development of portal hypertension. In children, portal hypertension may be caused by a wide range of etiologies, including extrahepatic portal vein obstruction, biliary atresia, alpha 1 antitrypsin deficiency, and autoimmune hepatitis. Gastroesophageal varices and ascites are two of the complications of portal hypertension likely to cause morbidity and mortality. This review also discusses extrahepatic manifestations of portal hypertension and treatment options.
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Affiliation(s)
- Catherine A Chapin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box #65, Chicago, IL 60611, USA
| | - Lee M Bass
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box #65, Chicago, IL 60611, USA.
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Zhao H, Liu F, Yue Z, Wang L, Fan Z, He F. Clinical efficacy of transjugular intrahepatic portosystemic shunt in the treatment of hepatopulmonary syndrome. Medicine (Baltimore) 2017; 96:e9080. [PMID: 29245324 PMCID: PMC5728939 DOI: 10.1097/md.0000000000009080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) reduces the portal venous pressure of patients with hepatopulmonary syndrome (HPS).To describe the patients who underwent TIPS for the treatment of HPS.A retrospective study was performed on 81 patients with HPS and gastrointestinal hemorrhage treated with TIPS. Thirty patients underwent TIPS through the main portal vein (group A), 24 through the left branch of the portal vein (group B), and 27 through the right branch of the portal vein (group C). The partial pressure of arterial oxygen (PaO2), alveolar-to-arterial oxygen partial pressure gradient (A-aPO2), oxygen saturation (SO2), and complications were recorded and compared. The survival rate for each group was calculated.The technical success rate was 100% in the 3 groups. Preoperative portal vein pressure showed no significant differences between the 3 groups, which was decreased post-TIPS operation. In group A, PaO2 and SO2 were higher in 15 days and 3 months postoperative than preoperative (P < .05), whereas A-aPO2 was lower (P < .05). No difference occurred between 12 months post- and preoperative group. In group C, PaO2 and SO2 did not alter significantly at each time point after operation (P > .05), whereas A-aPO2 decreased at 3 months (P = .041) than preoperative. In group B, all indicators at each follow-up time point after TIPS were improved significantly as compared with the preoperative group (P < .05), which showed an excellent effect on hypoxemia treatment. Although the 1-year survival rate of 3 groups of patients was 92.85%, 90.90%, and 91.67%, respectively, the rate of hepatic encephalopathy and hepatic myelopathy was 33.33% (10/30), 16.67% (4/24), and 33.33% (9/27) after TIPS.TIPS reduced the pressure of the portal vein effectively and alleviated hypoxemia in most HPS patients successfully. Thus, the left branch of the portal vein is optimal for TIPS owing to fewer complications and efficacy in improving PaO2 as compared with the main portal vein and right branch.
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Iqbal S, Smith KA, Khungar V. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Implications for Liver Transplantation. Clin Chest Med 2017; 38:785-795. [PMID: 29128026 DOI: 10.1016/j.ccm.2017.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) represent serious pulmonary complications of advanced liver diseases. Orthotopic liver transplantation (OLT) is capable of completely resolving the underlying abnormalities associated with HPS. On the other hand, post-OLT response in patients with PoPH is less predictable, although heavily influenced by pre-OLT mean pulmonary arterial pressure. It remains the case that the opportunity to reverse 2 potentially fatal organ dysfunctions in the liver and the lung make HPS and PoPH more than worthy for further clinical investigations.
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Affiliation(s)
- Shaz Iqbal
- Department of Medicine, General Internal Medicine Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Kerri Akaya Smith
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 834 West Gates Building, Philadelphia, PA 19104, USA
| | - Vandana Khungar
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street 2 Dulles, Philadelphia, PA 19104, USA.
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10
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International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation 2017; 100:1440-52. [PMID: 27326810 DOI: 10.1097/tp.0000000000001229] [Citation(s) in RCA: 246] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Two distinct pulmonary vascular disorders, hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) may occur as a consequence of hepatic parenchymal or vascular abnormalities. HPS and POPH have major clinical implications for liver transplantation. A European Respiratory Society Task Force on Pulmonary-Hepatic Disorders convened in 2002 to standardize the diagnosis and guide management of these disorders. These International Liver Transplant Society diagnostic and management guidelines are based on that task force consensus and should continue to evolve as clinical experience dictates. Based on a review of over 1000 published HPS and POPH articles identified via a MEDLINE search (1985-2015), clinical guidelines were based on, selected single care reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Guidelines are presented in 5 parts; I. Definitions/Diagnostic criteria; II. Hepatopulmonary syndrome; III. Portopulmonary hypertension; IV. Implications for liver transplantation; and V. Suggestions for future clinical research.
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Tsauo J, Weng N, Ma H, Jiang M, Zhao H, Li X. Role of Transjugular Intrahepatic Portosystemic Shunts in the Management of Hepatopulmonary Syndrome: A Systemic Literature Review. J Vasc Interv Radiol 2016; 26:1266-71. [PMID: 26074026 DOI: 10.1016/j.jvir.2015.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/20/2015] [Accepted: 04/21/2015] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To evaluate the role of transjugular intrahepatic portosystemic shunt (TIPS) creation in the management of hepatopulmonary syndrome (HPS). MATERIALS AND METHODS A MEDLINE (PubMed) search from January 1990 to April 2015 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was restricted to the English language and human subjects. Inclusion criteria were patients with HPS who underwent TIPS creation for any indication. Exclusion criteria was age < 18 years. RESULTS Ten studies consisting of 12 patients with HPS were included. Eight patients had very severe HPS, 2 had severe HPS, and 2 had moderate HPS. Transjugular intrahepatic portosystemic shunt creation was technically successful in all patients, without complications. Mean portosystemic pressure gradients before and after the procedure were 18.2 mm Hg (range, 10-30 mm Hg) and 6.5 mm Hg (range, 3-15 mm Hg), respectively. The mean duration of follow-up was 9.3 months (range, 0.75-36 mo). Improvement in oxygenation occurred in 9 patients but was not sustained after 4 months in 2 patients. In the remaining 3 patients, oxygenation remained unchanged; it worsened after 4 months in 1 patient. Four patients underwent liver transplantation. Two patients died of multiple organ dysfunction syndrome and 1 died of sepsis. The remaining patients were alive and well at the time of last follow-up. CONCLUSIONS Transjugular intrahepatic portosystemic shunt creation shows promise in the management of HPS. Future prospective studies are warranted.
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Affiliation(s)
- Jiaywei Tsauo
- Institute of Interventional Radiology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China.; Department of Radiology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China
| | - Ningna Weng
- Institute of Interventional Radiology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China.; Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China
| | - Huaiyuan Ma
- Institute of Interventional Radiology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China.; Department of Radiology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China
| | - Mingshan Jiang
- Institute of Interventional Radiology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China.; Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China
| | - He Zhao
- Institute of Interventional Radiology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China.; Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China
| | - Xiao Li
- Institute of Interventional Radiology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, Sichuan, China..
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Cosarderelioglu C, Cosar AM, Gurakar M, Dagher NN, Gurakar A. Hepatopulmonary Syndrome and Liver Transplantation: A Recent Review of the Literature. J Clin Transl Hepatol 2016; 4:47-53. [PMID: 27047772 PMCID: PMC4807143 DOI: 10.14218/jcth.2015.00044] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 12/14/2022] Open
Abstract
A severe and common pulmonary vascular complication of liver disease is hepatopulmonary syndrome (HPS). It is a triad of liver dysfunction and/or portal hypertension, intrapulmonary vascular dilatations, and increased alveolar-arterial oxygen gradient. Prevalence varies according to various study groups from 4%-47%. While the most common presenting symptom of HPS is dyspnea, it is usually asymptomatic, and thus all liver transplant candidates should be screened for its presence. Pulse oximetry is a useful screening method, but arterial blood gas examination is the gold standard. If there is an abnormal P (A-a)O2 gradient, microbubble transthoracic echocardiography should be done for diagnosis. Outcome is unpredictable, and there is currently no effective medical therapy. The only effective therapy is considered to be liver transplantation. Complete resolution of HPS after liver transplantation is seen within a year in most HPS patients.
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Affiliation(s)
- Caglar Cosarderelioglu
- Johns Hopkins University School of Medicine, Department of Gastroenterology/Hepatology, Baltimore, MD, USA
| | - Arif M. Cosar
- Johns Hopkins University School of Medicine, Department of Gastroenterology/Hepatology, Baltimore, MD, USA
| | - Merve Gurakar
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Nabil N. Dagher
- Johns Hopkins University School of Medicine, Department of Surgery/Liver Transplant, Baltimore, MD, USA
| | - Ahmet Gurakar
- Johns Hopkins University School of Medicine, Department of Gastroenterology/Hepatology, Baltimore, MD, USA
- Correspondence to: Ahmet Gurakar, 720 Rutland Avenue, Ross Research Building, Suite #918, Baltimore, Maryland, 21205, USA, Tel: 410-614-3369, Fax: 410-367-2328, E-mail:
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Abstract
Hepatopulmonary syndrome (HPS) is a pulmonary complication observed in patients with chronic liver disease and/or portal hypertension, attributable to an intrapulmonary vascular dilatation that may induce severe hypoxemia. Microvascular dilation and angiogenesis in the lung have been identified as pathologic features that drive gas exchange abnormalities in experimental HPS. Pulse oximetry is a useful screening test for HPS, which can guide subsequent use of arterial blood gases. Contrast-enhanced echocardiography, perfusion lung scanning, and pulmonary arteriography are three currently used diagnostic imaging modalities that identify the presence of intrapulmonary vascular abnormalities. The presence of HPS increases mortality and impairs quality of life, but is reversible with liver transplantation. No medical therapy is established as effective for HPS. At the present time, liver transplantation is the only available treatment for HPS.
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Affiliation(s)
- Yong Lv
- Department of Liver Disease, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China,
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14
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Nacif LS, Andraus W, Pinheiro RS, Ducatti L, Haddad LBP, D'Albuquerque LC. The hepatopulmonary syndrome. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2015; 27:145-7. [PMID: 25004294 PMCID: PMC4678680 DOI: 10.1590/s0102-67202014000200012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 02/25/2014] [Indexed: 12/17/2022]
Abstract
Introduction The hepatopulmonary syndrome has been acknowledged as an important vascular
complication in lungs developing systemic hypoxemia in patients with cirrhosis and
portal hypertension. Is formed by arterial oxygenation abnormalities induced from
intrapulmonary vascular dilatations with liver disease. It is present in 4-32% of
patients with cirrhosis. It increases mortality in the setting of cirrhosis and
may influence the frequency and severity. Initially the hypoxemia responds to
low-flow supplemental oxygen, but over time, the need for oxygen supplementation
is necessary. The liver transplantation is the only effective therapeutic option
for its resolution. Aim To update clinical manifestation, diagnosis and treatment of this entity. Method A literature review was performed on management of hepatopulmonary syndrome. The
electronic search was held of the Medline-PubMed, in English crossing the headings
"hepatopulmonary syndrome", "liver transplantation" and "surgery". The search was
completed in September 2013. Results Hepatopulmonary syndrome is classically defined by a widened alveolar-arterial
oxygen gradient (AaPO2) on room air (>15 mmHg, or >20 mmHg in patients
>64 years of age) with or without hypoxemia resulting from intrapulmonary
vasodilatation in the presence of hepatic dysfunction or portal hypertension.
Clinical manifestation, diagnosis, classification, treatments and outcomes are
varied. Conclusion The severity of hepatopulmonary syndrome is an important survival predictor and
determine the improvement, the time and risks for liver transplantation. The liver
transplantation still remains the only effective therapeutic.
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Affiliation(s)
- Lucas Souto Nacif
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of São Paulo, São Paulo, SP, Brazil
| | - Wellington Andraus
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of São Paulo, São Paulo, SP, Brazil
| | - Rafael Soares Pinheiro
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of São Paulo, São Paulo, SP, Brazil
| | - Liliana Ducatti
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of São Paulo, São Paulo, SP, Brazil
| | - Luciana B P Haddad
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of São Paulo, São Paulo, SP, Brazil
| | - Luiz Carneiro D'Albuquerque
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of São Paulo, São Paulo, SP, Brazil
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Nacif LS, Andraus W, Sartori K, Benites CM, Santos VR, Rocha-Filho JA, D'Albuquerque LC. Hypoxia among patients on the liver-transplant waiting list. ACTA ACUST UNITED AC 2014; 27:56-8. [PMID: 24676301 PMCID: PMC4675473 DOI: 10.1590/s0102-67202014000100014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 12/17/2013] [Indexed: 12/24/2022]
Abstract
Background Hepatopulmonary syndrome is formed by a triad of liver disease, intrapulmonary
vascular dilatation and changes in blood gases. This condition is present in 4-32%
of patients with cirrhosis. Aim To analyze the blood gas changes data of patients in liver-transplant waiting
list. Method Clinical data of 279 patients in liver transplantation waiting list in May 2013
were studied. Overall patient was analyzed by the demographic aspects,
laboratorial and image findings on exams that determine lung disease (hypoxemia)
in these cirrhotic patients. The mean values and standard deviations were used to
examine normally distributed variables. Results There was a high prevalence of male patients (68%); the mean age was
51(±5,89) years, and the predominant reason for listing was hepatitis C
cirrhosis. The MELD score mean was 16±5,89, without prioritization or
special situation. The most common blood type was O in 129 cases (46%) and the
mean of body max index was 25,94±4,58. Regarding arterial blood gas tests
was observed 214 patients with PaO2 <90 mmHg, 80 with PaO2 <80 mmHg and 39
with PaO2 <50 mmHg. In relation to O2 saturation, 50 patients had
<90%, 33 <80% and 10 <50%. Conclusion Was observed a high rate of hypoxemia in patients on waiting list liver
transplant. Due to the high severity and morbidity, is suggested better monitoring
and therapeutic support to hypoxemic patients on liver transplant waiting
list.
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Affiliation(s)
- Lucas Souto Nacif
- Department of Gastroenterology, School of Medicine, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Wellington Andraus
- Department of Gastroenterology, School of Medicine, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Kathryn Sartori
- Department of Gastroenterology, School of Medicine, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Carlos Marlon Benites
- Department of Gastroenterology, School of Medicine, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Vinicius Rocha Santos
- Department of Gastroenterology, School of Medicine, University of Sao Paulo, Sao Paulo, SP, Brazil
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Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.
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Affiliation(s)
- Kavish R Patidar
- Department of Internal Medicine, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA
| | - Malcolm Sydnor
- Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980615, Richmond, VA 23298-0615, USA; Surgery, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA; Vascular Interventional Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA.
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17
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DellaVolpe JD, Garavaglia JM, Huang DT. Management of Complications of End-Stage Liver Disease in the Intensive Care Unit. J Intensive Care Med 2014; 31:94-103. [PMID: 25223828 DOI: 10.1177/0885066614551144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 07/14/2014] [Indexed: 12/19/2022]
Abstract
The management of critically ill patients with end-stage liver disease can be challenging due to the vulnerability of this population and the wide-ranging complications of the disease. This review proposes an approach based on the major organ systems affected, to provide a framework for managing the most common complications. Although considerable practice variation exists, a focus on the evidence behind the most common practices will ensure the development of the optimal skillset to appropriately manage this disease.
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Affiliation(s)
- Jeffrey D DellaVolpe
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey M Garavaglia
- Department of Pharmacy & Therapeutics, Transplant Intensive Care Unit, UPMC Presbyterian Shadyside, Pittsburgh, PA, USA
| | - David T Huang
- Department of Critical Care Medicine, Director Multidisciplinary Acute Care Research Organization, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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18
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Alhosh R, Genyk Y, Alexopoulos S, Thomas D, Zhou S, Yanni G, Kerkar N. Hepatopulmonary syndrome associated with nodular regenerative hyperplasia after liver transplantation in a child. Pediatr Transplant 2014; 18:E157-60. [PMID: 24820314 DOI: 10.1111/petr.12281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2014] [Indexed: 12/12/2022]
Abstract
HPS is a significant complication of portal hypertension in children with chronic liver disease and is an established indication for LT. It is characterized clinically by the triad of pulmonary vascular dilatation causing hypoxemia in the setting of advanced liver disease. NRH, a cause of non-cirrhotic portal hypertension, is characterized by diffuse benign transformation of the hepatic parenchyma into small regenerative nodules with minimal or no fibrosis. Development of NRH and HPS in pediatric LT recipients has not been reported, although occasional cases have been reported in adult LT recipients. In this report, we discuss a case of a three-yr-old male who developed HPS, two yr after LT. Pulmonary and cardiac causes for hypoxemia were ruled out by appropriate investigations including a chest X ray, echocardiogram, cardiac catheterization, and a CT angiographic study. The diagnosis of HPS was confirmed via bubble echocardiogram that demonstrated intrapulmonary shunting. Open liver biopsy revealed marked NRH. The patient underwent liver retransplantation that resulted in complete reversal of his pulmonary symptoms and normal oxygen saturations within three months after LT.
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Affiliation(s)
- Rabea Alhosh
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital Los Angeles/Keck School of Medicine of USC, Los Angeles, CA, USA
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19
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Parker R. Role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Clin Liver Dis 2014; 18:319-34. [PMID: 24679497 DOI: 10.1016/j.cld.2013.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A transjugular intrahepatic portosystemic shunt (TIPS) is an expandable metal stent inserted via the jugular vein that creates a shunt from the portal vein to the systemic circulation via an artificial communication through the liver. It is used to treat complications of portal hypertension. In addition to rescue treatment in variceal bleeding, TIPS can play an important role in prevention of rebleeding. TIPS can improve symptoms if medical treatment of ascites or hepatic hydrothrorax has failed, but may not improve survival. Selected cases of Budd-Chiari syndrome improve with TIPS. This article discusses the indications, evidence, and complications of TIPS.
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Affiliation(s)
- Richard Parker
- NIHR Centre for Liver Research, University of Birmingham, Birmingham B15 2TT, UK.
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20
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Abstract
The hepatopulmonary syndrome (HPS) is a pulmonary complication of cirrhosis and/or portal hypertension whereby patients develop hypoxemia as a result of alterations in pulmonary microvascular tone and architecture. HPS occurs in up to 30% of patients with cirrhosis. Although the degree of hypoxemia does not reliably correlate with the severity of liver disease, patients with HPS have a higher mortality than do patients with cirrhosis without the disorder. There has been progress into defining the mechanisms that lead to hypoxemia in HPS, but to date there are no therapeutic options for HPS aside from liver transplantation.
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21
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Abstract
PURPOSE OF REVIEW To discuss the advances in the understanding of the pathophysiology of experimental and human hepatopulmonary syndrome (HPS) and in the management of HPS, particularly regarding liver transplantation. RECENT FINDINGS Advances have been made in defining the pathophysiology of HPS in experimental models as well as in human disease, including the role of endothelin-1, pulmonary monocytes, and angiogenesis. Additionally, the implications of the presence of HPS as it relates to prioritizing patients for liver transplantation and posttransplant outcomes will also be reviewed. SUMMARY Mechanisms of disease continue to be defined in HPS, providing potential targets for pharmacologic intervention. Outcomes after liver transplantation are also becoming clearer, including the management of HPS with severe hypoxemia.
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22
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Tumgor G. Cirrhosis and hepatopulmonary syndrome. World J Gastroenterol 2014; 20:2586-2594. [PMID: 24627594 PMCID: PMC3949267 DOI: 10.3748/wjg.v20.i10.2586] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 01/05/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterized as a triad: liver disease, intrapulmonary vascular dilatation and arterial hypoxemia. HPS is reported to be present in 4% to 32% of adult patients with end-stage liver disease and in 9%-20% of children. The pathogenesis of HPS has not been clearly identified. Portal hypertension causes impairment in the perfusion of the bowel and increases the enteral translocation of Gram (-) bacteria and endotoxins. This stimulates the release of vasoactive mediators, such as tumor necrosis factor-alpha, heme oxygenase-derived carbon monoxide and nitric oxide. Genetic alterations have not been associated with this syndrome yet; however, cytokines and chemokines have been suggested to play a role. Recently, it was reported that cumulated monocytes lead to the activation of vascular endothelial growth factor-dependent signaling pathways and pulmonary angiogenesis, which plays an important role in HPS pathogenesis. At present, the most effective and only radical treatment is a liver transplant (LT). Cirrhotic patients who are on the waiting list for an LT have a shorter survival period if they develop HPS. Therefore, it is suggested that all cirrhotic cases should be followed closely for HPS and they should have priority in the waiting list.
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23
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Abstract
Hepatopulmonary syndrome (HPS) is a serious vascular complication of liver disease that occurs in 5-32% of patients with cirrhosis. The presence of HPS markedly increases mortality. No effective medical therapies are currently available and liver transplantation is the only established treatment option for HPS. The definition and diagnosis of HPS are established by the presence of a triad of liver disease with intrapulmonary vascular dilation that causes abnormal arterial gas exchange. Experimental biliary cirrhosis induced by common bile duct ligation in the rat reproduces the pulmonary vascular and gas exchange abnormalities of human HPS and serves as a pertinent animal model. Pulmonary microvascular dilation and angiogenesis are two central pathogenic features that drive abnormal pulmonary gas exchange in experimental HPS, and thus might underlie HPS in humans. Defining the mechanisms involved in the microvascular alterations of HPS has the potential to lead to effective medical therapies. This Review focuses on the current understanding of the pathogenesis, clinical features and management of HPS.
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Affiliation(s)
- Junlan Zhang
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030-1501, USA
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24
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Wallace MC, James AL, Marshall M, Kontorinis N. Resolution of severe hepato-pulmonary syndrome following transjugular portosystemic shunt procedure. BMJ Case Rep 2012; 2012:bcr.02.2012.5811. [PMID: 22669921 DOI: 10.1136/bcr.02.2012.5811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The hepato-pulmonary syndrome (HPS) is a relatively common complication of hepatic disease that leads to hypoxaemia and dyspnoea secondary to pulmonary shunting. A number of pharmacological therapies have been trialled, yet liver transplantation remains the only definitive treatment. The use of a transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal hypertension and improve oxygenation remains controversial in HPS due to the lack of large clinical series or randomised controlled trials. We present a case of HPS successfully treated with TIPS and review the relevant literature.
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Affiliation(s)
- Michael C Wallace
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia.
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25
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The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status. Int J Hepatol 2012; 2012:167868. [PMID: 22888442 PMCID: PMC3408669 DOI: 10.1155/2012/167868] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/18/2012] [Indexed: 02/06/2023] Open
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.
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26
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El-Shabrawi MHF, Kamal NM. Medical management of chronic liver diseases (CLD) in children (part II): focus on the complications of CLD, and CLD that require special considerations. Paediatr Drugs 2011; 13:371-83. [PMID: 21999650 DOI: 10.2165/11591620-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Treatment of the causes of many chronic liver diseases (CLDs) may not be possible. In this case, complications must be anticipated, prevented or at least controlled by the best available therapeutic modalities. There are three main goals for the management of portal hypertension: (i) prevention of the first episode of variceal bleeding largely by non-selective β-adrenoceptor antagonists, which is not generally recommended in children; (ii) control of bleeding by using a stepwise approach from the least to most invasive strategies; (iii) and prevention of re-bleeding using bypass operations, with particular enthusiasm for the use of meso-Rex bypass in the pediatric population. Hepatic encephalopathy management also consists of three main aspects: (i) ruling out other causes of encephalopathy; (ii) identifying and treating precipitating factors; and (iii) starting empiric treatment with drugs such as lactulose, rifaximin, sodium benzoate, and flumazenil. Treatment of mild ascites and peripheral edema should begin with the restriction of sodium and water, followed by careful diuresis, then large-volume paracentesis associated with colloid volume expansion in severe cases. Empiric broad spectrum antimicrobial therapy should be used for the treatment of spontaneous bacterial peritonitis, bacterial and fungal sepsis, and cholangitis, after taking appropriate cultures, with appropriate changes in therapy after sensitivity testing. Empirical therapies continue to be the standard practice for pruritus; these consist of bile acid binding agents, phenobarbital (phenobarbitone), ursodeoxycholic acid, antihistamines, rifampin (rifampicin), and carbamazepine. Partial external biliary diversion can be used in refractory cases. Once hepatorenal syndrome is suspected, treatment should be initiated early in order to prevent the progression of renal failure; approaches consist of general supportive measures, management of concomitant complications, screening for sepsis, treatment with antibiotics, use of vasopressin analogs (terlipressin), and renal replacement therapy if needed. Hepatopulmonary syndrome and portopulmonary hypertension are best managed by liver transplantation. Provision of an adequate caloric supply, nutrition, and vitamin/mineral supplements for the management of growth failure, required vaccinations, and special care for ensuring psychologic well-being should be ensured. Anticoagulation might be attempted in acute portal vein thrombosis. Some CLDs, such as extrahepatic biliary atresia (EHBA), Crigler-Najjar syndrome, and Indian childhood cirrhosis, require special considerations. For EHBA, Kasai hepatoportoenterostomy is the current standard surgical approach in combination with nutritional therapy and supplemental fat and water soluble vitamins, minerals, and trace elements. In type 1 Crigler-Najjar syndrome, extensive phototherapy is the mainstay of treatment, in association with adjuvant therapy to bind photobilirubin such as calcium phosphate, cholestyramine, or agar, until liver transplantation can be carried out. Treating Indian childhood cirrhosis with penicillamine early in the course of the disease and at doses similar to those used to treat Wilson disease decreases the mortality rate by half. New hopes for the future include extracorporeal liver support devices (the molecular adsorbent recirculating system [MARS®] and Prometheus®), hepatocyte transplantation, liver-directed gene therapy, genetically engineered enzymes, and therapeutic modalities targeting fibrogenesis. Hepapoietin, a naturally occurring cytokine that promotes hepatocyte growth, is under extensive research.
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27
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Willis AD, Miloh TA, Arnon R, Iyer KR, Suchy FJ, Kerkar N. Hepatopulmonary syndrome in children - is conventional liver transplantation always needed? Clin Transplant 2010; 25:849-55. [DOI: 10.1111/j.1399-0012.2010.01378.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Herzer K, Post F, Canbay A, Gerken G. [Pulmonary affection in advanced liver disease - hepatepulonary syndrome and portopulmonary hypertension]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 2010; 105:916-923. [PMID: 21240591 DOI: 10.1007/s00063-010-1157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Accepted: 10/25/2010] [Indexed: 05/30/2023]
Abstract
Patients suffering from severe chronic liver disease, in particular cirrhosis, are at risk for pulmonary complications. The leading clinical symptom is shortness of breath, which can accompany the actual disease as indirect effect because of anemia, faint muscles or ascites. On the other hand, dyspnea can have multiple additive causes in case of accompanying cardial or pulmonary disease. The hepatopulmonary syndrome (HPS) and the portopulmonary hypertension (PoPH) belong to the most relevant pulmonary complications in liver cirrhosis. HPS appears to be more common than PoPH and the presence of either entity increases morbidity and mortality in patients with liver disease. The two diseases have to be strictly distinguished, as they have opposed histological and pathophysiological origin. While the HPS is a dilatative pulmonary- vascular disease, the PoPH is a constrictive or obliterative pulmonary-vascular disease in the context of a liver disease or a portal hypertension. Therefore, these diseases are separate entities also when it comes to diagnostics and therapy.
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Affiliation(s)
- Kerstin Herzer
- Zentrum für Innere Medizin, Gastroenterologie und Hepatologie, Essen, Germany.
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29
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Al-Hussaini A, Taylor RM, Samyn M, Bansal S, Heaton N, Rela M, Mieli-Vergani G, Dhawan A. Long-term outcome and management of hepatopulmonary syndrome in children. Pediatr Transplant 2010; 14:276-82. [PMID: 19686444 DOI: 10.1111/j.1399-3046.2009.01218.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
UNLABELLED We aim to report a single center experience of the management and long term outcome of HPS in pediatric liver transplant recipients. A retrospective review of children with HPS from 1990 to 2004. INCLUSION CRITERIA liver disease or portal hypertension, hypoxemia (PaO(2) < 70 mmHg or SaO(2) < 95%) and intrapulmonary shunting documented by macroaggregated albumin scan ratio of >4% (classified mild group [<20%], moderate group [20-40%] and severe group [>40%]). Resolution of HPS post-liver transplant was defined as PaO(2) > 70 mmHg or SaO(2) > 95%. Eighteen children (six male [34%], median age at diagnosis of HPS 8.6 [1-15.5] yr) had HPS: biliary atresia (n = 8), idiopathic biliary cirrhosis (n = 4), progressive intrahepatic cholestasis (n = 2), miscellaneous (n = 4). The majority had mild shunting (n = 8). Fourteen underwent transplantation with resolution of HPS in 13. Six developed complications: hepatic artery thrombosis (n = 4), biliary (n = 2). Four children died (28%), two pretransplant. There was a tendency towards shunt fraction worsening to a slower degree over time. One-yr survival rate post-transplant was 93%. Median PaO(2) was significantly lower in non-survivors compared to survivors (43 vs. 55.2 mmHg, p = 0.03). There was correlation between oxygen parameters pretransplant and time to HPS resolution post-transplant. HPS is reversible after transplant, but is associated with increasing mortality and morbidity.
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Affiliation(s)
- Abdulrahman Al-Hussaini
- Paediatric Liver Centre, King's College London School of Medicine at King's College Hospital NHS Foundation Trust, London, UK
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30
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Thevenot T, Pastor CM, Cervoni JP, Jacquelinet C, Nguyen-Khac E, Richou C, Heyd B, Vanlemmens C, Mantion G, Di Martino V, Cadranel J. Le syndrome hépatopulmonaire. ACTA ACUST UNITED AC 2009; 33:565-79. [DOI: 10.1016/j.gcb.2009.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 08/12/2008] [Accepted: 03/12/2009] [Indexed: 12/17/2022]
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31
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Tumgor G, Arikan C, Yuksekkaya HA, Cakir M, Levent E, Yagci RV, Kilic M, Aydogdu S. Childhood cirrhosis, hepatopulmonary syndrome and liver transplantation. Pediatr Transplant 2008; 12:353-7. [PMID: 18435611 DOI: 10.1111/j.1399-3046.2007.00807.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The hepatopulmonary syndrome (HPS) is characterized as a triad: liver disease, intrapulmonary vascular dilatation, and arterial hypoxemia. The aim of this study is to analyze outcome of children with HPS in liver transplant era. METHODS Between September 1996 and November 2006, 172 cirrhotic patients (median age 5 years; range 0.2-22 years, M/F; 97/75) were followed at Ege University Pediatric Gastroenterology, Hepatology and Nutrition Unit. All patients were evaluated by chest radiography, arterial blood gas analysis, and alveolar-arterial oxygen tension difference, contrast echocardiography (CEE) after and before the liver transplantation. RESULTS HPS was diagnosed in 33 patients (19%) by CEE. None of them had pulmonary hypertension. HPS was not found related to etiology of the liver disease. Portal hypertension was found related to the development of HPS (75.7% in patients with HPS and 54.6% in others, p = 0.02). 17 of 33 patients with HPS underwent liver transplantation. Preoperative and postoperative period of these patients was uneventful. Patients were extubated in the operating room except for two. Median follow up of transplanted children was 1.9 year (range; 0.75-10 years). Arterial blood gas analysis and CEE positivity regressed in all of them by postoperative 6th month. CONCLUSIONS HPS is a serious and important complication of cirrhotic children that leads to tissue hypoxia and central cyanosis. HPS seems reversible after liver transplantation in all patients.
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Affiliation(s)
- Gokhan Tumgor
- Department of Pediatric, Division of Gastroenterology, Hepatology and Nutrition, Ege University School of Medicine Organ Transplantation and Research Center, Izmir, Turkey.
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32
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Noli K, Solomon M, Golding F, Charron M, Ling SC. Prevalence of hepatopulmonary syndrome in children. Pediatrics 2008; 121:e522-7. [PMID: 18310172 DOI: 10.1542/peds.2007-1075] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The hepatopulmonary syndrome is defined as a triad of liver disease, hypoxemia, and intrapulmonary vascular dilation. The reported prevalence of hepatopulmonary syndrome in adults with cirrhosis ranges from 4% to 29%; however, the prevalence of hepatopulmonary syndrome and its outcome in children is unknown. The objective of this study was to describe prospectively the prevalence of intrapulmonary vascular dilation and hepatopulmonary syndrome in children with liver disease. METHODS Pulse oximetry was undertaken in children with liver disease, and those with oxygen saturation < or = 97%, those with cirrhosis, and those with clinically severe portal hypertension from other causes underwent contrast-enhanced echocardiography for detection of intrapulmonary vascular dilations. Patients with intrapulmonary vascular dilation underwent arterial blood gas analysis and technetium-99m-labeled macroaggregated albumin scan. RESULTS Oxygen saturation was measured in 301 children and was < or = 97% in 8. These 8 and an additional 18 patients with cirrhosis or portal hypertension underwent contrast-enhanced echocardiography. Seven (27%) patients had intrapulmonary vascular dilation detected by contrast-enhanced echocardiography; 2 of these patients had abnormal arterial blood gas analysis and thus met diagnostic criteria for hepatopulmonary syndrome (representing 8% of patients with cirrhosis or severe portal hypertension). Both patients with hepatopulmonary syndrome had abnormal pulse oximetry. Technetium-99m-labeled macroaggregated albumin scans for 6 patients showed a median 6.5% (range: 4%-12%) tracer uptake outside the lungs. CONCLUSIONS Hepatopulmonary syndrome occurs in an important minority of children with cirrhosis or severe portal hypertension. Additional studies should be undertaken to determine the importance of intrapulmonary vascular dilation without hepatopulmonary syndrome and the impact of hepatopulmonary syndrome on the outcomes of affected children.
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Affiliation(s)
- Khalid Noli
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8, Canada
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Saad NE, Lee DE, Waldman DL, Saad WE. Pulmonary Arterial Coil Embolization for the Management of Persistent Type I Hepatopulmonary Syndrome after Liver Transplantation. J Vasc Interv Radiol 2007; 18:1576-80. [DOI: 10.1016/j.jvir.2007.08.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abstract
Hepatopulmonary syndrome is characterized by advanced liver disease, hypoxemia, and intrapulmonary shunting. The only reported curative option is orthotopic liver transplantation. We describe here a beneficial effect of inhaled prostacyclin including a decrease in respiratory symptoms and improved oxygenation in this clinical situation, with no approved pharmacological long-term therapy. The prostanoid iloprost, approved for pulmonary and portopulmonary hypertension, caused an increase in oxygenation, relief of dyspnea, and increased exercise tolerance in a patient suffering from liver-cirrhosis-associated hepatopulmonary syndrome. After liver transplantation, restitution of hepatopulmonary syndrome did not occur immediately. Inhaling iloprost resulted in improved physical condition and better clinical rehabilitation potential until hypoxemia finally resolved 3 months after transplantation. Therefore, iloprost could improve quality of life in patients with hepatopulmonary syndrome waiting for liver transplantation and post surgery until the resolution of the hypoxemia.
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Emre S, Arnon R, Cohen E, Morotti RA, Vaysman D, Shneider BL. Resolution of hepatopulmonary syndrome after auxiliary partial orthotopic liver transplantation in Abernethy malformation. A case report. Liver Transpl 2007; 13:1662-8. [PMID: 18044784 DOI: 10.1002/lt.21349] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Congenital absence of portal vein and extrahepatic portocaval shunt, also referred to as an Abernethy type 1, is a rare malformation of the mesenteric vasculature. A 9-year-old girl presented with dyspnea on exertion and orthodeoxia. A diagnosis of an Abernethy malformation type 1b and hepatopulmonary syndrome (HPS) was made, and she underwent auxiliary partial orthotopic liver transplantation (APOLT). Symptoms and signs of HPS resolved 2 months after the operation. HPS in Abernethy syndrome is a manifestation of normal portal blood flow bypassing the liver and can be ameliorated by redirecting blood flow to a segment of liver with normal portal anatomy. APOLT is a feasible and successful surgical procedure for patients with Abernethy malformation and HPS.
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Affiliation(s)
- Sukru Emre
- Department of Pediatrics, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, NY, USA.
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Gupta NA, Abramowsky C, Pillen T, Redd D, Fasola C, Heffron T, Romero R. Pediatric hepatopulmonary syndrome is seen with polysplenia/interrupted inferior vena cava and without cirrhosis. Liver Transpl 2007; 13:680-6. [PMID: 17457897 DOI: 10.1002/lt.21113] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a triad of liver dysfunction, hypoxemia, and intrapulmonary vascular dilatation. We describe the prevalence and clinical features of HPS at a pediatric liver transplant center. Patients referred to Children's Healthcare of Atlanta/Emory University transplant program from February 1999 to May 2005 were reviewed. Oxygen saturation in room air was screened by percutaneous pulse oximetry. HPS cases were compared with similar age non-HPS recipients (n = 38) to determine differences in clinical characteristics, Pediatric End-Stage Liver Disease (PELD) scores, and posttransplantation survival. Of 211 patients referred and 114 patients transplanted, 7 met criteria for HPS (3.3% and 6.1%, respectively). Patients with HPS had lower PELD score (-0.4 +/- 5.9 vs. 11 +/- 11; P = 0.01) and total bilirubin (1.7 +/- 1.1 vs. 11.2 +/- 10.1; P = 0.02) at the time of transplantation. Four of 7 patients with HPS had polysplenia/interrupted inferior vena cava (PS/IVC) compared with 0 of 38 age-matched controls (P = 0.0002). Three patients with HPS did not have cirrhosis; 2 of these 3 had PS/IVC. All HPS cases normalized room air oxygen saturation by 6 months, and survival after transplantation in HPS cases was 100%. Marked hepatic synthetic or biochemical dysfunction may not be present, and cirrhosis is not a requirement for the development of HPS in children. HPS in children is frequently associated with PS/IVC. Histologic evidence of abnormal intrahepatic portal vein flow and the demonstration of portosystemic communications at any level should be sought in children presenting with unexplained intrapulmonary vascular dilatation. Liver transplantation for HPS in childhood may be appropriate even in the absence of cirrhosis.
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Abstract
Cirrhosis is the twelfth commonest cause of death in the United States, with more than 27,000 deaths and more than 421,000 hospitalizations annually. Currently, there are more than 17,000 patients awaiting liver transplantation in the United States across the 11 United Network for Organ Sharing regions. Approximately 10% of such patients will die awaiting transplantation.
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Affiliation(s)
- Priya Grewal
- The Division of Liver Diseases, Recanati-Miller Transplantation Institute, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10029, USA.
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38
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Abstract
This review will discuss the use of transjugular intrahepatic portosystemic stent-shunt in a number of relatively uncommon clinical situations. In particular, we will focus our paper on the use of transjugular intrahepatic portosystemic stent-shunt for hepatic hydrothorax, hepatopulmonary syndrome, veno-occlusive disease, portal hypertensive gastropathy and gastric antral vascular ectasia, before surgery and after liver transplantation.
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Affiliation(s)
- George Therapondos
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada.
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Affiliation(s)
- David T Palma
- University of Alabama at Birmingham Liver Center, MCLM 290, 1918, University Boulevard, Birmingham, AL 35294, USA
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Tumgor G, Ozkan T, Ulger Z, Kilic M, Aydogdu S. Liver transplantation of a child with child a cirrhosis and severe hepatopulmonary syndrome. Transplant Proc 2006; 38:1432-4. [PMID: 16797324 DOI: 10.1016/j.transproceed.2006.02.106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2005] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a clinical state defined by a chronic hepatic disorder, intrapulmonary vascular dilatation, and altered gas exchange resulting in hypoxemia. Cirrhosis of the liver is the most common condition associated with HPS. A 3-year-old boy who presented with end-stage liver disease and severe hepatopulmonary syndrome underwent orthotopic liver transplantation (OLT). The findings of HPS resolved immediately after OLT. His status is within normal limits at 6 months after liver transplantation.
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Affiliation(s)
- G Tumgor
- Department of Pediatric Gastroenterology/Hepatology/Nutrition and Organ Transplantation and Research Center, Ege University School of Medicine, Izmir, Turkey.
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41
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Abstract
The hepatopulmonary syndrome (HPS) is an important and often under-recognized vascular complication of cirrhosis and portal hypertension characterized by pulmonary vascular dilatation, which results in hypoxemia. This syndrome is identified in as many as 20% of patients who are evaluated for orthotopic liver transplantation (OLT), and it has recently been found to increase mortality in affected patients, particularly when hypoxemia is severe. Currently, OLT is the only therapy established to reverse intrapulmonary vasodilatation, although postoperative mortality is increased in patients with severe hypoxemia. No randomized controlled trials of pharmacologic therapies have been undertaken, but supplemental oxygen improves oxygenation. Data derived from case reports, small studies, and experimental models suggest that pharmacologic therapies may be effective. In cirrhotic patients with HPS, particularly those with moderate hypoxemia (PaO2 < 60 mmHg), OLT should be considered prior to the development of severe deoxygenation. Supplemental oxygen should be given to patients with a PaO2 < 60 mmHg or those with exercise oxygen desaturation. For those patients with mild hypoxemia or those who are not OLT candidates, a trial of pharmacologic treatment may be considered.
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Affiliation(s)
- Miguel R Arguedas
- Department of Medicine, Division of Gastroenterology/Hepatology, University of Alabama at Birmingham, MCLM 290, 1530 3rd Avenue South, Birmingham, AL 35294, USA
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Martinez-Palli G, Drake BB, Garcia-Pagan JC, Barbera JA, Arguedas MR, Rodriguez-Roisin R, Bosch J, Fallon MB. Effect of transjugular intrahepatic portosystemic shunt on pulmonary gas exchange in patients with portal hypertension and hepatopulmonary syndrome. World J Gastroenterol 2005; 11:6858-62. [PMID: 16425397 PMCID: PMC4725048 DOI: 10.3748/wjg.v11.i43.6858] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the impact of transjugular intrahepatic portosystemic shunt (TIPS) on pulmonary gas exchange and to evaluate the use of TIPS for the treatment of hepatopulmonary syndrome ( HPS ).
METHODS: Seven patients, three of them with advanced HPS, in whom detailed pulmonary function tests were performed before and after TIPS placement at the University of Alabama Hospital and at the Hospital Clinic, Barcelona, were considered.
RESULTS: TIPS patency was confirmed by hemodynamic evaluation. No changes in arterial blood gases were observed in the overall subset of patients. Transient arterial oxygenation improvement was observed in only one HPS patient, early after TIPS, but this was not sustained 4 mo later.
CONCLUSION: TIPS neither improved nor worsened pulmonary gas exchange in patients with portal hypertension. This data does not support the use of TIPS as a specific treatment for HPS. However, it does reinforce the view that TIPS can be safely performed for the treatment of other complications of portal hypertension in patients with HPS.
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Affiliation(s)
- Graciela Martinez-Palli
- Servei d'Anestesiologia i Reanimacio Hospital Clinic, Institut d'Investigacions Biomediques august Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
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44
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Abstract
The hepatopulmonary syndrome is an increasingly important vascular complication of cirrhosis where microvascular dilatation impairs arterial oxygenation in the setting of liver disease. This syndrome is identified in as many as 20% of patients evaluated for liver transplantation and results in increased mortality. No clearly effective medical therapies are available, and liver transplantation is the only established treatment. Pathophysiologic insights obtained from experimental models may lead to the development of novel and effective medical treatments.
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Affiliation(s)
- Miguel R Arguedas
- Department of Medicine, Division of Gastroenterology/Hepatology, University of Alabama at Birmingham, 1530 3rd Avenue South, Birmingham, AL 35294, USA
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45
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Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol 2005; 16:615-29. [PMID: 15872315 DOI: 10.1097/01.rvi.0000157297.91510.21] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Thomas D Boyer
- Liver Research Institute, University of Arizona School of Medicine, AHSC 245136, Tucson, 85750, USA.
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46
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Liu M, Tian D, Wang T, Tang W, Liang K. Correlation between pulmonary endothelin receptors and alveolar-arterial oxygen gradient in rats with hepatopulmonary syndrome. ACTA ACUST UNITED AC 2005; 25:494-6. [PMID: 16463654 DOI: 10.1007/bf02895997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The correlation between pulmonary endothelin receptors and alveolar-arterial oxygen gradient (A-aDO2) in rats with hepatopulmonary syndrome was investigated. Animals were divided into 2 groups: Sham-operated (Sham) group and common bile duct ligation (CBDL) group. Arterial blood gas was evaluated by a blood gas analyzer. The concentrations of ET-1 in blood and lung tissue sample were evaluated by radioimmunoassay. The distribution and expression of two kinds of subtype receptor of ET-1, ETRA and ETRB were examined by in situ hybridization. The results showed that the level of A-aDO2 was higher in CBDL group than that in Sham group (P < 0.05). The levels of plasma and pulmonary ET-1 in CBDL group were both higher than in Sham group (P < 0.05). There was no significant difference in average A of ETRA between two groups by imaging analysis (0.21 +/- 0.06 vs 0.22 +/- 0.08, P > 0.05), while that of ETRB was higher in CBDL group than in Sham group (0.58 +/- 0.16 vs 0.28 +/- 0.07, P < 0.05). The expression of ETRB in lung was positively correlated with A-aDO2 (P < 0.05). It was concluded that the widened A-aDO2 may be related with enhancement of the expression of ETRB in lung.
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Affiliation(s)
- Mei Liu
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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47
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The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005; 41:386-400. [PMID: 15660434 DOI: 10.1002/hep.20559] [Citation(s) in RCA: 286] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Chevallier P, Novelli L, Motamedi JP, Hastier P, Brunner P, Bruneton JN. Hepatopulmonary syndrome successfully treated with transjugular intrahepatic portosystemic shunt: a three-year follow-up. J Vasc Interv Radiol 2004; 15:647-8. [PMID: 15178729 DOI: 10.1097/01.rvi.0000127885.68272.e9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Hamada M, Tokumoto Y, Furukawa S, Minami H, Hiasa Y, Michitaka K, Horiike N, Onji M. Hepatopulmonary syndrome in a patient with primary biliary cirrhosis. Intern Med 2004; 43:458-60. [PMID: 15283179 DOI: 10.2169/internalmedicine.43.458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 54-year-old Japanese woman with primary biliary cirrhosis (PBC) was admitted to our hospital due to hepatic coma and refractory pleural effusion. The physical examination revealed clubbed fingers and collateral veins. The patient had an increased alveolar-arterial oxygen gas tension difference. The levels of anti-mitochondrial antibody (AMA) and AMA M2 was 80 times normal. A technetium 99m-labeled macro-aggregated human albumin scintigram showed uptake in the spleen and the kidneys. A diagnosis of hepatopulmonary syndrome (HPS) was made. HPS may be overlooked because of the lack of symptoms. We conclude that closer attention should be paid to the occurrence of HPS.
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Affiliation(s)
- Maho Hamada
- Third Department of Internal Medicine, Ehime University School of Medicine, Ehime
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50
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Abstract
The clinically and pathophysiologically distinct entities of portopulmonary hypertension and hepatopulmonary syndrome occur in a substantial proportion of patients who have advanced liver disease of different causes. These disorders are notoriously underdiagnosed, but they have a substantial impact on survival and require focused treatment. Abnormal intrapulmonary vascular dilatation, the hallmark of hepatopulmonary syndrome, can cause profound hypoxaemia that can be very difficult to treat. By contrast, portopulmonary hypertension results from excessive pulmonary vasoconstriction and vascular remodelling that eventually leads to right-heart failure. Insights into the pathogeneses of these syndromes have led to novel therapeutic approaches. However, in severely affected patients, effective treatment remains a difficult task. In selected patients, liver transplantation represents the only treatment option, but the decision to do isolated liver transplantation is particularly challenging in patients who have severe pulmonary disease involvement. Data from several centres have contributed to provide criteria that allow improved prediction of which patients may, or may not, benefit from liver transplantation alone.
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, 30623 Hannover, Germany.
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