The duodenum in liver cirrhosis: endoscopic, morphological and clinical findings

Utility of histology for the diagnosis of portal hypertensive gastroenteropathy. Concordance between the endoscopic image and gastrointestinal biopsies. Role of the CD34 marker

INTRODUCTION

Upper gastroscopy in patients with cirrhosis often reveals non-specific lesions, which are usually oriented as portal hypertensive gastropathy (PHG). However, the diagnosis of PHG can be difficult, both from an endoscopic and histological point of view. The study of CD34 expression, which enhances the endothelial cells of the microvasculature, could help the differential diagnosis. The objectives of this study were to evaluate the correlation between endoscopy and histology in the diagnosis of PHG and to assess the utility of CD34 in the diagnosis of PHG.

MATERIAL AND METHODS

The results of immunostaining with CD34 gastric fundus biopsies from 100 cirrhotic patients and 20 controls were compared with the endoscopic images.

RESULTS

The correlation between the histology and the endoscopic diagnosis of PHG was very low (kappa=0.15). In addition, the measurement of the diameter of the gastric vessels enhanced by the use of immunohistochemical staining (CD34) did not show good correlation with the endoscopic diagnosis (p=.26) and did not provide relevant information for the histological diagnosis of PHG either.

DISCUSSION

The correlation between histology and endoscopy is low for the diagnosis of PHG. The use of immunostaining for CD34 does not seem to improve the diagnostic yield of the histological study.

Utility of histology for the diagnosis of portal hypertensive gastroenteropathy. Concordance between the endoscopic image and gastrointestinal biopsies. Role of the CD34 marker

INTRODUCTION

Upper gastroscopy in patients with cirrhosis often reveals non-specific lesions, which are usually oriented as portal hypertensive gastropathy (PHG). However, the diagnosis of PHG can be difficult, both from an endoscopic and histological point of view. The study of CD34 expression, which enhances the endothelial cells of the microvasculature, could help the differential diagnosis. The objectives of this study were to evaluate the correlation between endoscopy and histology in the diagnosis of PHG and to assess the utility of CD34 in the diagnosis of PHG.

MATERIAL AND METHODS

The results of immunostaining with CD34 gastric fundus biopsies from 100 cirrhotic patients and 20 controls were compared with the endoscopic images.

RESULTS

The correlation between the histology and the endoscopic diagnosis of PHG was very low (kappa=0.15). In addition, the measurement of the diameter of the gastric vessels enhanced by the use of immunohistochemical staining (CD34) did not show good correlation with the endoscopic diagnosis (p=.26) and did not provide relevant information for the histological diagnosis of PHG either.

DISCUSSION

The correlation between histology and endoscopy is low for the diagnosis of PHG. The use of immunostaining for CD34 does not seem to improve the diagnostic yield of the histological study.

Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study

BACKGROUND/AIMS

The clinical course and exacerbation of portal hypertensive enteropathy (PHE) are yet to be fully clarified. This study aimed to identify factors related to PHE exacerbation in patients with liver cirrhosis (LC).

METHODS

Fifty patients with LC (33 male; mean age, 67 years), who underwent capsule endoscopy (CE) at the Hiroshima University Hospital between February 2009 and September 2015, were followed up for >6 months. Exacerbation is defined as the appearance of new lesions or worsening of existing lesions. The association between PHE exacerbation and the clinical factors was evaluated.

RESULTS

PHE exacerbation was identified in 24 out of 50 (48%) of cases: erythema (14 cases); angioectasia (11 cases); erosions (9 cases); villous edema (8 cases); and esophageal varices (EVs; 6 cases). The following factors were significantly associated with PHE exacerbation: portosystemic shunts, EVs and portal hypertensive gastropathy (PHG) exacerbation. After therapy, CE findings among the 24 cases were as follows: villous edema (19 cases); erythema (17 cases); angioectasia (16 cases); erosions (12 cases); and EVs (9 cases), and no observable abnormalities in 2 cases. On multivariate analysis, exacerbation of EVs and PHG were independent predictors of PHE exacerbation.

CONCLUSION

EVs and PHG exacerbation may predict PHE exacerbation in patients with LC.

Duodenal polyposis secondary to portal hypertensive duodenopathy

Portal hypertensive duodenopathy (PHD) is a recognized, but uncommon finding of portal hypertension in cirrhotic patients. Lesions associated with PHD include erythema, erosions, ulcers, telangiectasia, exaggerated villous pattern and duodenal varices. However, duodenal polyposis as a manifestation of PHD is rare. We report a case of a 52-year-old man who underwent esophagogastroduodenoscopy and was found with multiple small duodenal polyps ranging in size from 1-8 mm. Biopsy of the representative polyps revealed polypoid fragments of duodenal mucosa with villiform hyperplasia lined by reactive duodenal/gastric foveolar epithelium and underlying lamina propria showed proliferating ectatic and congested capillaries. The features were diagnostic of polyps arising in the setting of PHD.

Portal hypertensive duodenopathy manifesting as "kissing" duodenal ulcers in a nigerian with alcoholic cirrhosis: a case report and brief review of the literature

Multiple duodenal ulcers are an uncommon finding in portal hypertensive duodenopathy (PHD). They represent a potential source of clinically significant bleeding from the upper gastrointestinal system in patients with cirrhosis. As this particular ulcer entity in relation to PHD has no distinguishing symptoms aside from those relating to the consequent bleeding, most of them are found either on routine endoscopic screening for cirrhotics or on endoscopic examination for cause(s) of bleeding in this patient population. The case documented below highlights many of the aspects of pathogenesis, associations, and consequences of this unique endoscopic finding in cirrhotic patients.

Portal hypertensive duodenopathy: clinical, endoscopic, and histopathologic profiles

OBJECTIVE

Description of the clinical, endoscopic, and histopathologic detailed profiles of duodenal affection in portal hypertensive patients.

METHODS

A total of 105 patients with chronic liver disease and portal hypertension (PH) were included, upper endoscopy was performed, and two duodenal biopsies were obtained from the bulb and distal to the ampulla, for histopathologic examination. Twenty dyspeptic patients with normal upper endoscopy were included as controls.

RESULTS

Of the portal hypertensive patients, 54 (51.4%) had endoscopic duodenopathy (ED) lesions including erythema, erosions, ulcers, telangiectasia, exaggerated villous pattern, duodenal varices, and mixed lesions. ED was significantly higher in patients having severe than mild gastropathy (56.8% vs 23.5%, P<0.05) with no relation to size of esophageal varices or variceal bleeding. ED was a source of overt bleeding in 6.7% and occult bleeding in 2.9% of patients. Histopathologically, vascular changes included either capillary congestion (in more than half of biopsies) or capillary angiogenesis (in more than one-quarter of biopsies). Nonvascular changes included increased apoptosis (in about 16% of biopsies), fibrous proliferation (in about 4% of biopsies), and villous changes (in 11.4% of distal biopsies). All changes were not statistically different between patients with and without ED. In dyspeptic patients, only minimal histopathologic changes were noted.

CONCLUSIONS

ED is significantly higher in patients with severe gastropathy and causes gastrointestinal bleeding in 9.5% of patients. Capillary angiogenesis is an important vascular mechanism for adaptation to PH. The overall existence of histopathologic duodenopathy is much higher than that of ED and occurs with a similar prevalence in patients with and without ED.

Portal hypertensive duodenal polyp: A case report

Abnormalities of gastric mucosa in patients with portal hypertension are well documented. Manifestations of portal hypertension in small bowel and colon are less common. Colonic polypoid lesions microscopically consisting of a normal mucosa, with dilatation of submucosal vessels, have been described. We here report the first case of portal hypertensive duodenal polyp, responsible for gastro-intestinal bleeding. Endoscopic treatment turned out to be successful.

Diagnosing and treating bleeding portal hypertensive duodenopathy

Portal hypertensive duodenopathy is a rare condition related to liver cirrhosis; there is little in the literature about its clinical significance and management. It seems to be endoscopically and histologically similar to portal hypertensive gastropathy, which is well defined. We report the case of a patient, initially treated for acute bleeding resulting from the rupture of esophageal varices, who developed an atypical endoscopic picture of portal hypertensive duodenopathy over a 6-month period. After microscopic definition of the disease we found chronic bleeding which required blood transfusions. Medical treatment did not solve the problem. We describe an approach using the argon plasma coagulator.

Prevalence of portal hypertensive duodenopathy in cirrhosis: clinical and haemodynamic features

OBJECTIVES

To estimate the prevalence of portal hypertensive duodenopathy (PHD) in patients with cirrhosis and portal hypertension, and to evaluate its relationship with clinical and haemodynamic parameters.

PATIENTS AND METHODS

Endoscopy reports and clinical history of 549 consecutive patients with cirrhosis and portal hypertension were evaluated retrospectively. A diagnosis of PHD was obtained in those patients with a congestive vascular pattern of the duodenum.

RESULTS

PHD was found in 46 patients (8.4%). Previous endoscopic band ligation and coexistence of severe gastropathy were significantly more frequent in PHD group. Systemic and hepatic haemodynamic evaluations were performed in 20 patients with PHD and 160 without PHD: the mean hepatic venous pressure gradient was higher in those cases with PHD (22.5 (5.4) vs. 19.8 (5.5) mmHg, P=0.045). Hypertensive colopathy was found in seven out of the 10 patients with PHD and a colonoscopic evaluation. In five of six patients PHD disappeared after liver transplant.

CONCLUSIONS

PHD is an uncommon finding of portal hypertension in cirrhotic patients. It is associated with previous endoscopic band ligation, to manifestations of portal hypertension in other sites of the gastrointestinal tract and to greater values of hepatic venous pressure gradient. The clinical relevance of this syndrome remains to be determined.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Duodenal erosions, a common and distinctive feature of portal hypertensive duodenopathy

OBJECTIVE

The aim of the present study was to assess the presence of duodenal erosion and its clinical characteristics on endoscopy in patients with portal hypertension who had undergone endoscopic injection sclerotherapy and/or endoscopic variceal ligation for esophagogastric varices.

METHODS

The subjects were 440 patients with portal hypertension, 450 with chronic hepatitis as a related control group, and 450 who underwent upper endoscopic examination as part of their routine physical examination as the controls. The underlying hepatic disease, hepatic function, and endoscopic findings of duodenal erosion among the patients with portal hypertension were studied.

RESULTS

Duodenal erosion was found in 68 patients with portal hypertension (68 of 440, 15.5%), four patients with chronic hepatitis (four of 450, 0.9%), and two controls (two of 450, 0.4%). The incidence of duodenal erosion among the patients with portal hypertension was significantly higher than that in the other two groups (p < 0.01, p < 0.01, respectively). The lesions commonly observed in duodenitis are speckle erosions mainly located in the duodenal bulb. However, the most frequently seen form of duodenal erosion among the patients with portal hypertension extended from the superior portion to the descending portion, and tended to show a circular alignment along the Kerckring's folds. The patients with portal hypertension with reduced hepatic reserve capacity had more severe duodenal erosion. Endoscopic ultrasonography revealed thickening of the duodenal wall and proliferation of vascular structures within and around the wall. The histological findings of the duodenal erosion included edema and vascular dilation in the mucosal and submucosal layers.

CONCLUSIONS

The location of duodenal erosion in patients with portal hypertension differs from that in patients with ordinary duodenitis. Duodenal erosion in patients with portal hypertension is considered to be one of the lesions of portal hypertensive duodenopathy.

Frequency and factors influencing portal hypertensive gastropathy and duodenopathy in cirrhotic portal hypertension

Portal hypertensive gastropathy and duodenopathy are distinct clinical and endoscopic entities. Data on factors influencing the development of these lesions are still emerging. Data on portal hypertensive duodenopathy are scarce. We prospectively studied 230 patients with liver cirrhosis and oesophageal varices attending the liver clinic of the Sanjay Gandhi Post Graduate Institute of Medical Sciences. One hundred and forty-two patients had no history of upper gastrointestinal bleeding, while the remainder had bled in the past. Endoscopic appearances were recorded before starting patients on a sclerotherapy programme. Forty-four patients were re-evaluated after variceal eradication. The frequency of portal hypertensive gastropathy (PHG) and duodenopathy (PHD) was 61 and 14%, respectively. Mild PHG was present in 85% and was severe in the rest. Portal hypertensive duodenopathy was mild in 50%, while in the other half it was severe. There was no relationship of PHG and PHD to: (i) a history of upper gastrointestinal bleed; (ii) size of oesophageal varices; (iii) aetiology of liver cirrhosis; or (iv) liver function status as assessed by Child Pugh's scores (P = NS for all). The prevalence of PHG was higher in those patients with oesophagogastric varices (74 of 107; 69%) compared with patients with oesophageal varices alone (68 of 123; 55%; P < 0.05). However, no such increase in frequency of PHD was noted in patients with oesophagogastric varices. Sclerotherapy increased the frequency of PHG. Twenty-four patients had PHG before starting sclerotherapy, while it was noted in 33 patients 1-3 months after variceal eradication (P < 0.05). In contrast, there was no increase in the prevalence of portal hypertensive duodenopathy after sclerotherapy (P = NS). There was no correlation between endoscopic and histological changes of PHG and PHD. In conclusion, PHG is quite frequent in patients with cirrhosis and its frequency increases with the presence of oesophagogastric varices and after sclerotherapy. However, the frequency of PHD is low and is not affected by the factors studied.