1
|
Ghuman SS, Gupta S, Buxi TBS, Rawat KS, Yadav A, Mehta N, Sud S. The Abernethy malformation-myriad imaging manifestations of a single entity. Indian J Radiol Imaging 2021; 26:364-372. [PMID: 27857464 PMCID: PMC5036336 DOI: 10.4103/0971-3026.190420] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Abernethy malformation, also known as congenital extrahepatic portosystemic shunts (CEPS) is a rare clinical entity and manifests with different clinical symptoms. CEPS are abnormalities of vascular development where there is shunting of portal blood into the systemic venous system. Multidetector computed tomography (MDCT) is a fast and effective modality for evaluation of CEPS. CT displays all the information desired by the surgeon as well as the clinician including the anatomy of the splenic and superior mesenteric veins, size and site of the shunt, presence or absence of the portal vein radicles, and helps to plan the therapy and even the follow-up of these patients. Contrast-enhanced magnetic resonance imaging (MRI) has also emerged as a promising tool for the evaluation of liver lesions associated with the malformation. The Radiologist should be aware of the various imaging appearances of this entity including its complications. In this article, we describe the imaging appearances of CEPS, their complications, and their imaging appearances on CT and MRI. We have also described various associated anomalies.
Collapse
Affiliation(s)
- Samarjit S Ghuman
- Department of Radiodiagnosis, Sir Gangaram Hospital, New Delhi, India
| | - Saumya Gupta
- Department of Radiodiagnosis, Sir Gangaram Hospital, New Delhi, India
| | - T B S Buxi
- Department of Radiodiagnosis, Sir Gangaram Hospital, New Delhi, India
| | - Kishan S Rawat
- Department of Radiodiagnosis, Sir Gangaram Hospital, New Delhi, India
| | - Anurag Yadav
- Department of Radiodiagnosis, Sir Gangaram Hospital, New Delhi, India
| | - Naimish Mehta
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Seema Sud
- Department of Radiodiagnosis, Sir Gangaram Hospital, New Delhi, India
| |
Collapse
|
2
|
Transjugular intrahepatic portosystemic shunt creation may be associated with hyperplastic hepatic nodular lesions in the long term: an analysis of 18 pediatric and young adult patients. Pediatr Radiol 2021; 51:1348-1357. [PMID: 33783576 DOI: 10.1007/s00247-021-05010-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Retrospective studies have demonstrated the efficacy and safety of pediatric and adolescent transjugular intrahepatic portosystemic shunt (TIPS), but long-term outcomes warrant further investigation. OBJECTIVE To report on the development of hyperplastic hepatic nodular lesion development in children and young adults (<21 years) with TIPS patency >3 years. MATERIALS AND METHODS Eighteen children and young adults, including 10 (55.6%) females and 8 (44.4%) males, underwent TIPS creation with >3 years' patency and follow-up evaluation at a tertiary children's hospital. The mean age at the time of TIPS creation was 12.5±5.1 years (range: 1.5-20.0 years). The mean model for end-stage liver disease (MELD) at the time of TIPS creation was 8.1±1.6 (range: 6-11). Indications for TIPS creation included acute variceal bleeding (8/18, 44.4%), primary (1/18, 5.6%) or secondary (7/18, 38.9%) prevention of varices, portal vein thrombosis (1/18, 5.6%), and splenic sequestration (1/18, 5.6%). Technical successes, intra-procedural parameters, hemodynamic and clinical successes, TIPS patencies, adverse events, imaging evaluations, and follow-ups were recorded. RESULTS All (100%) TIPS placements were successful; however, a direct intrahepatic portosystemic shunt was created in one (5.6%) patient. Mean reduction of the portosystemic shunt gradient was 9.1±3.3 mmHg (range: 4-16 mmHg). Seventeen (94.4%) patients demonstrated clinical success with resolution of their initial clinical indication for TIPS placement. The 3-year TIPS primary, primary-assisted, and secondary patencies were 83.3% (15/18), 94.4% (17/18), and 100% (18/18), respectively. Two (11.1%) patients developed mild, medically controlled hepatic encephalopathy. One (5.6%) patient developed hepatopulmonary syndrome. Nine (50%) patients developed single or multiple hepatic nodules at a mean imaging surveillance time after TIPS of 4.4±3.0 years (range: 1.5-10.2 years). Six (33.3%) patients developed nodules >1 cm with imaging features most consistent with focal nodular hyperplasia or focal nodular hyperplasia-like nodules. The mean follow-up duration was 5.7±2.9 years (range: 3.0-13.1 years). CONCLUSION Long-term (>3 years) portosystemic shunting via TIPS is associated with the development of hepatic nodular lesions in children. Consequently, children with TIPS may need gray-scale assessment of hepatic parenchyma as part of routine ultrasound exams and extended imaging surveillance until more is understood regarding the natural history of induced nodularity.
Collapse
|
3
|
Uchida H, Sakamoto S, Kasahara M, Kudo H, Okajima H, Nio M, Umeshita K, Ohdan H, Egawa H, Uemoto S. Longterm Outcome of Liver Transplantation for Congenital Extrahepatic Portosystemic Shunt. Liver Transpl 2021; 27:236-247. [PMID: 37160013 DOI: 10.1002/lt.25805] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/01/2020] [Accepted: 05/01/2020] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is often viewed as the last resort for the treatment of congenital extrahepatic portosystemic shunt (CEPS) due to advancement of imaging and interventional radiology techniques. However, some patients still require LT, and criteria for LT are yet to be determined. We conducted a national survey of patients undergoing LT for CEPS between June 1998 and August 2018 and evaluated the clinical data and outcomes with a review of previously reported patients from the English-language medical literature. A total of 26 patients underwent LT in Japan at a median age of 5.2 years old. The most common indications for LT were persistent hyperammonemia (54%) and liver mass (50%), followed by pulmonary complications (38%). Pulmonary complications in all patients, including intrapulmonary shunt and pulmonary hypertension (PH), were improved after LT. Regarding the 29 previously reported patients in the English-language literature, a liver nodule (49%), including hepatoblastoma and hepatocellular carcinoma, was the most common indication for LT, followed by pulmonary complications (34%). A total of 25 (96%) patients in our survey and 26 (90%) patients in the literature review were alive with a median follow-up period of 9.5 and 1.6 years, respectively. Although LT has a limited role in management of CEPS, our study indicated that LT was safe as an alternative treatment for select patients with malignant tumor or pulmonary complications and those with complications related to new portosystemic collateral vessels after shunt closure, such as PH or hepatopulmonary syndrome.
Collapse
Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hironori Kudo
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Masaki Nio
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
| | - Koji Umeshita
- Department of Surgery, Osaka University, Osaka, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroto Egawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shinji Uemoto
- Department of Surgery, Kyoto University, Kyoto, Japan
| | | |
Collapse
|
4
|
Yam MKH, Cheung KO, Sim SW, Lee PSF. An adolescent girl in Hong Kong with type Ib Abernethy malformation complicated by multiple focal nodular hyperplasia. Radiol Case Rep 2020; 15:2477-2481. [PMID: 33014233 PMCID: PMC7522042 DOI: 10.1016/j.radcr.2020.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 10/26/2022] Open
Abstract
Congenital portosystemic venous shunts are developmental anomalies. They represent portal communication with the systemic circulation. The pathogenesis is linked to the complexity of the embryological development of the inferior vena cava and portal vein. We reported a case of an asymptomatic 14-year-old Chinese adolescent girl in Hong Kong with a confirmed congenital portosystemic shunt type 1b. The condition can be diagnosed using contrast-enhanced CT scans and MRIs. Early recognition of the condition is important due to elevated risks of developing hepatocellular tumours. Liver transplantation may be considered curative.
Collapse
Affiliation(s)
- Max Kai Ho Yam
- Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, NT., Hong Kong.,North District Hospital, 9 Po Kin Road, Sheung shui, New Territories, Hong Kong
| | - Kin On Cheung
- Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, NT., Hong Kong.,North District Hospital, 9 Po Kin Road, Sheung shui, New Territories, Hong Kong
| | - Shiu Wah Sim
- Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, NT., Hong Kong.,North District Hospital, 9 Po Kin Road, Sheung shui, New Territories, Hong Kong
| | - Paul Sing Fun Lee
- Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, NT., Hong Kong.,North District Hospital, 9 Po Kin Road, Sheung shui, New Territories, Hong Kong
| |
Collapse
|
5
|
D'Souza AM, Towbin AJ, Gupta A, Alonso M, Nathan JD, Bondoc A, Tiao G, Geller JI. Clinical heterogeneity of pediatric hepatocellular carcinoma. Pediatr Blood Cancer 2020; 67:e28307. [PMID: 32307899 DOI: 10.1002/pbc.28307] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/11/2020] [Accepted: 03/16/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is often a chemoresistant neoplasm with a poor prognosis. Pediatric HCC may reflect unique biological and clinical heterogeneity. PROCEDURE An IRB-approved retrospective institutional review of patients with HCC treated between 2004 and 2015 was undertaken. Clinical, radiographic, and histologic data were collected from all patients. RESULTS Thirty-two patients with HCC, median age 11.5 years (range 1-20) were identified. Seventeen patients had a genetic or anatomic predisposition. Histology was conventional HCC (25) and fibrolamellar HCC (7). Evans staging was 1 (12); 2 (1); 3 (10); 4 (9). Sixteen patients underwent resection at diagnosis and five patients after neoadjuvant chemotherapy. Surgical procedures included liver transplantation (LT, 11), hemihepatectomy (9), and segmentectomy (1). Eighteen patients had medical therapy (13 neoadjuvant, 5 adjuvant). Most common initial medical therapy included sorafenib alone (7) and cisplatin/doxorubicin-based therapy (8). Overall, 14 (43.8%) patients survived with a median follow-up of 58.8 months (range 26.5-157.6). Cause of death was most often linked to lack of primary tumor surgery (11). Of the survivors, Evans stage was 1 (11), 2 (1), and 3 (2, both treated with LT). Four of 18 patients (22%) who received medical therapy, 8 of 17 patients with a predisposition (47%), and 14 of 21 patients (66%) who underwent surgery remain alive. CONCLUSIONS Genetic and anatomic predisposing conditions were seen in over half of this cohort. Evans stage 1 or 2 disease was linked to improved survival. LT trended toward improved survival. Use of known chemotherapy agents may benefit a smaller group of pediatric HCC and warrants formal prospective study through cooperative group trials.
Collapse
Affiliation(s)
- Amber M D'Souza
- Division of Pediatric Hematology/Oncology, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anita Gupta
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maria Alonso
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alex Bondoc
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Greg Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James I Geller
- Division of Pediatric Hematology/Oncology, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| |
Collapse
|
6
|
DiPaola F, Trout AT, Walther AE, Gupta A, Sheridan R, Campbell KM, Tiao G, Bezerra JA, Bove KE, Patel M, Nathan JD. Congenital Portosystemic Shunts in Children: Associations, Complications, and Outcomes. Dig Dis Sci 2020; 65:1239-1251. [PMID: 31549332 PMCID: PMC8180198 DOI: 10.1007/s10620-019-05834-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Congenital portosystemic shunt (CPSS) is a rare malformation in which splanchnic venous flow bypasses the liver. CPSS is associated with other congenital anomalies and syndromes and can be associated with life-threatening complications. CPSS and their management remain underreported in the literature. Here, we review the clinical characteristics, management, and outcomes of a cohort of children and young adults with CPSS from two pediatric centers. METHODS Cases of CPSS from Cincinnati Children's Hospital Medical Center and C.S. Mott Children's Hospital were reviewed to define CPSS anatomy, associated anomalies, complications, interventions, and outcomes. The imaging features and histopathology of liver lesions were characterized in detail. RESULTS A total of 11 cases were identified. Median age was 10 years (range 0-26); 8 (73%) cases were female. Associated anomalies included six patients with heterotaxy (55%), five patients with congenital heart disease (45%), three patients with Turner syndrome (27%), and two patients with omphalocele, exstrophy, imperforate anus, spinal defects (OEIS) complex (18%). Eight (73%) cases had hyperammonemia ± encephalopathy. A 4-month-old presented with hepatopulmonary syndrome, and 12-year-old presented with pulmonary hypertension. Eight patients (73%) had liver lesions including five with premalignant adenomas and three with well-differentiated hepatocellular carcinoma (HCC). Four children underwent successful CPSS occlusion/ligation. Three children underwent liver transplant (2) or resection (1) for HCC without recurrence at extended follow-up. CONCLUSIONS CPSS is associated with multiple anomalies (heterotaxy, congenital heart disease) and syndromes (Turner syndrome). CPSS liver lesions should be very carefully evaluated due to risk of premalignant adenomas and HCC. Serious complications of CPSS can occur at a young age but can be managed endovascularly or with open surgery.
Collapse
Affiliation(s)
- Frank DiPaola
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, C.S. Mott Children’s Hospital, MPB D5200, 1500 East Medical Center Drive, SPC 5718, Ann Arbor, MI 48109-5718, USA
| | - Andrew T. Trout
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, MLC 5031, 3333 Burnet Avenue, Cincinnati, OH 45229, USA,Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Ashley E. Walther
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS #100, Los Angeles, CA 90027, USA
| | - Anita Gupta
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, MLC 1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Rachel Sheridan
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, MLC 1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Kathleen M. Campbell
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Greg Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, MLC 2023, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Jorge A. Bezerra
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Kevin E. Bove
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, MLC 1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Manish Patel
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, MLC 5031, 3333 Burnet Avenue, Cincinnati, OH 45229, USA,Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Jaimie D. Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, MLC 2023, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| |
Collapse
|
7
|
Kemp SR. Sonography Aids in Diagnosis of Congenital Absence of Portal Vein in Patient With Marfan Syndrome: A Case Study. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2019. [DOI: 10.1177/8756479319848747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Skylar R. Kemp
- Department of Radiology Ultrasound, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| |
Collapse
|
8
|
Xie L, Li Y, Jiang X, Zhao J, Xiao T. A 10-year-old boy with dyspnea and hypoxia: abernathy malformation masquerading as pulmonary arteriovenous fistula. BMC Pediatr 2019; 19:55. [PMID: 30744582 PMCID: PMC6371454 DOI: 10.1186/s12887-019-1422-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 01/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background Abernethy malformation is an extremely rare congenital malformation characterised by an extrahepatic portosystemic shunt. Children with Abernathy malformation can develop hepatopulmonary syndrome (HPS) with pulmonary arteriovenous fistulas (PAVF) or pulmonary hypertension. PAVF manifests as central cyanosis with effort intolerance. We report a case of PAVF in a Ten-year-old Boy. Persistent symptoms identified Abernathy malformation as the cause of progressive symptoms and current understanding of this rare malformation is reviewed. Case presentation A case of 10-year-old boy with Abernethy malformation complicated with HPS initially managed as PAVF was presented. Selective lung angiography showed a typical diffuse reticular pattern on right lower lung, which suggested PAVF. However, cyanosis was not improved post transcatheter coil embolization. Then, liver disease was considered although the patient had normal aspartate aminotransferase and alanine aminotransferase. The significantly elevated serum ammonia was attracted our attention. Abdominal computed tomography also exhibited enlarged main portal vein (MPV), cirsoid spleen vein, and superior mesenteric vein (SMV). Angiography with direct opacification of the SMV with a catheter coming from the inferior vena cava (IVC) and going to the SMV via the shunt vessel (SHUNT) between the MPV and IVC. Occlusion the IVC with an inflated balloon, injection of contrast medium via a catheter placed in the SMV, MPV was showed and absence of intrahepatic branches. Abernethy malformation IB type is finally confirmed. Conclusions Abernethy malformation is an unusual cause for development of PAVF and cyanosis in children. Clinicians must be suspicious of Abernethy malformation complicated with HPS. If patients have abnormal serum ammonia and enlarged MPV in abdominal CT, cathether angiography should be done to rule out Abernethy malformation.
Collapse
Affiliation(s)
- Lijian Xie
- Department of Cardiology, Shanghai Children's Hospital, Shanghai Jiaotong University, No. 355 Luding Road, Shanghai, 200062, China
| | - Yun Li
- Department of Cardiology, Shanghai Children's Hospital, Shanghai Jiaotong University, No. 355 Luding Road, Shanghai, 200062, China
| | - Xunwei Jiang
- Department of Cardiology, Shanghai Children's Hospital, Shanghai Jiaotong University, No. 355 Luding Road, Shanghai, 200062, China
| | - Jian Zhao
- Department of Cardiology, Shanghai Children's Hospital, Shanghai Jiaotong University, No. 355 Luding Road, Shanghai, 200062, China
| | - Tingting Xiao
- Department of Cardiology, Shanghai Children's Hospital, Shanghai Jiaotong University, No. 355 Luding Road, Shanghai, 200062, China.
| |
Collapse
|
9
|
De Vito C, Tyraskis A, Davenport M, Thompson R, Heaton N, Quaglia A. Histopathology of livers in patients with congenital portosystemic shunts (Abernethy malformation): a case series of 22 patients. Virchows Arch 2019; 474:47-57. [PMID: 30357455 PMCID: PMC6323085 DOI: 10.1007/s00428-018-2464-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/24/2018] [Accepted: 09/27/2018] [Indexed: 12/12/2022]
Abstract
Congenital portosystemic shunt (CPSS) is a congenital anomaly resulting in partial or complete diversion of the portal blood into the systemic circulation. The literature on the histological changes in livers of patients with CPSS is limited. Liver histology of 22 consecutive patients managed in our institution between 2001 and 2016 was reviewed. Twenty-one patients were children at the time of diagnosis. Thirty-two specimens were available and consisted of three explant livers and 29 biopsy samples from 19 patients. Sixteen samples were from wedge biopsies taken at the time of shunt closure. Thirteen were from core needle biopsies taken during clinical work-up. A variable proportion of portal tracts contained prominent thin-walled channels (PTWCs) and arterio-biliary dyads. The proportion of portal tracts containing triads, arterio-biliary dyads and biliary monads varied considerably in the different samples. Dilated inlet venules, increase in the number of portal arteries or the presence of portal arteries of increased size, deposition of copper-associated protein, sinusoidal dilatation, capillarization and intralobular individual arteries were present. Physiological nuclear vacuolation of periportal hepatocytes was absent in most samples from our paediatric patients. Presence of PTWCs, arterial-biliary dyads, increased arterial profiles in portal tracts and lobule and lack of the physiological periportal vacuolated hepatocytes in children are the most characteristic histological changes of CPSS in the liver periphery.
Collapse
Affiliation(s)
- Claudio De Vito
- King's College Hospital, Institute of Liver Studies, London, UK
- Division of Clinical Pathology, Geneva University Hospital, Geneva, Switzerland
| | | | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Richard Thompson
- King's College Hospital, Institute of Liver Studies, London, UK
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital London, London, UK
| | - Nigel Heaton
- King's College Hospital, Institute of Liver Studies, London, UK
| | - Alberto Quaglia
- King's College Hospital, Institute of Liver Studies, London, UK.
- Department of Cellular Pathology Royal Free Hospital, University College, London, UK.
| |
Collapse
|
10
|
Sanada Y, Mizuta K. Congenital absence of the portal vein: translated version. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:359-369. [PMID: 30160060 DOI: 10.1002/jhbp.572] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congenital portosystemic shunt (CPS) is classified into type I (congenital absence of the portal vein) and type II, depending on the presence or absence of the intrahepatic portal vein. Reports still exist on cases in which psychiatric diseases or mental retardation was diagnosed or cases in which diagnosis and treatment are not performed until severe pulmonary complications occur, indicating the need to recognize CPS. Herein, we reviewed epidemiology, etiology, classification, symptom, diagnosis, and treatment based on clinical view points of CPS. For clinical view points, classification according to (1) the presence or absence of the intrahepatic portal venous system (IPVS) and (2) the extrahepatic or intrahepatic of shunt sites, facilitates the understanding of pathophysiological conditions and is useful in selecting a treatment for symptomatic CPS. Radiological and pathological examinations are important in IPVS evaluations, and IPVS evaluations are currently essential to make diagnoses by portography with balloon occlusion and liver biopsy. Symptomatic CPS (hepatic nodular lesions, portosystemic encephalopathy, and pulmonary complications, etc.) is an indication of treatment by shunt closure, but an indication of treatment for asymptomatic CPS is the challenge going forward.
Collapse
Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi 329-0498, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi 329-0498, Japan
| |
Collapse
|
11
|
Kroencke T, Murnauer M, Jordan FA, Blodow V, Ruhnke H, Schaller T, Märkl B. Radioembolization for Hepatocellular Carcinoma Arising in the Setting of a Congenital Extrahepatic Portosystemic Shunt (Abernethy Malformation). Cardiovasc Intervent Radiol 2018; 41:1285-1290. [PMID: 29675774 DOI: 10.1007/s00270-018-1965-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 04/12/2018] [Indexed: 11/24/2022]
Abstract
In a 50-year-old male with an incidentally discovered hepatocellular carcinoma, a congenital extrahepatic portosystemic shunt with the absence of the portal vein (Abernethy syndrome) was diagnosed by imaging. This study aims to discuss the variant anatomy relevant to this splanchnic vascular malformation, review its association with the development of liver neoplasms, and report the safety and efficacy of TARE followed by resection for a HCC arising in this rare condition.
Collapse
Affiliation(s)
- Thomas Kroencke
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - Marcus Murnauer
- Department of General, Visceral and Transplant Surgery, Klinikum Augsburg, Augsburg, Germany
| | | | - Vera Blodow
- Department of Nuclear Medicine, Klinikum Augsburg, Augsburg, Germany
| | - Hannes Ruhnke
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Tina Schaller
- Institute of Pathology, Klinikum Augsburg, Augsburg, Germany
| | - Bruno Märkl
- Institute of Pathology, Klinikum Augsburg, Augsburg, Germany
| |
Collapse
|
12
|
Christou N, Dib N, Chuffart E, Taibi A, Durand-Fontanier S, Valleix D, Mathonnet M. Stepwise management of hepatocellular carcinoma associated with Abernethy syndrome. Clin Case Rep 2018; 6:930-934. [PMID: 29744090 PMCID: PMC5930207 DOI: 10.1002/ccr3.1384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/05/2017] [Accepted: 10/18/2017] [Indexed: 12/22/2022] Open
Abstract
Patients with congenital agenesis of the portal vein may develop hepatocellular tumors due to enhanced arterial blood flow. These tumors may be benign (FNH, adenomas) or malignant (hepatoblastoma, HCC). Liver resection can be proposed, and preoperative arterial embolization may decrease blood loss during surgery. Liver transplantation with PV reconstruction is also an option.
Collapse
Affiliation(s)
- Niki Christou
- Department of Digestive and Endocrine Surgery University Hospital of Limoges 2 avenue Martin Luther King 87042 Limoges Cedex France
| | - Nabil Dib
- Department of Digestive and Endocrine Surgery University Hospital of Limoges 2 avenue Martin Luther King 87042 Limoges Cedex France
| | - Etienne Chuffart
- Department of Digestive and Endocrine Surgery University Hospital of Limoges 2 avenue Martin Luther King 87042 Limoges Cedex France
| | - Abdelkader Taibi
- Department of Digestive and Endocrine Surgery University Hospital of Limoges 2 avenue Martin Luther King 87042 Limoges Cedex France
| | - Sylvaine Durand-Fontanier
- Department of Digestive and Endocrine Surgery University Hospital of Limoges 2 avenue Martin Luther King 87042 Limoges Cedex France
| | - Denis Valleix
- Department of Digestive and Endocrine Surgery University Hospital of Limoges 2 avenue Martin Luther King 87042 Limoges Cedex France
| | - Muriel Mathonnet
- Department of Digestive and Endocrine Surgery University Hospital of Limoges 2 avenue Martin Luther King 87042 Limoges Cedex France
| |
Collapse
|
13
|
de la Torre AN, Contractor S, Castaneda I, Cathcart CS, Razdan D, Klyde D, Kisza P, Gonzales SF, Salazar AM. A Phase I trial using local regional treatment, nonlethal irradiation, intratumoral and systemic polyinosinic-polycytidylic acid polylysine carboxymethylcellulose to treat liver cancer: in search of the abscopal effect. J Hepatocell Carcinoma 2017; 4:111-121. [PMID: 28848723 PMCID: PMC5557908 DOI: 10.2147/jhc.s136652] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose To determine the safety of an approach to immunologically enhance local treatment of hepatocellular cancer (HCC) by combining nonlethal radiation, local regional therapy with intratumoral injection, and systemic administration of a potent Toll-like receptor (TLR) immune adjuvant. Methods Patients with HCC not eligible for liver transplant or surgery were subject to: 1) 3 fractions of 2-Gy focal nonlethal radiation to increase tumor antigen expression, 2) intra-/peri-tumoral (IT) injection of the TLR3 agonist, polyinosinic-polycytidylic acid polylysine carboxymethylcellulose (poly-ICLC), to induce an immunologic “danger” response in the tumor microenvironment with local regional therapy, and 3) systemic boosting of immunity with intramuscular poly-ICLC. Primary end points were safety and tolerability; secondary end points were progression-free survival (PFS) and overall survival (OS) at 6 months, 1 year, and 2 years. Results Eighteen patients with HCC not eligible for surgery or liver transplant were treated. Aside from 1 embolization-related severe adverse event, all events were ≤grade II. PFS was 66% at 6 months, 39% at 12 months, and 28% at 24 months. Overall 1-year survival was 69%, and 2-year survival 38%. In patients <60 years old, 2-year survival was 62.5% vs. 11.1% in patients aged >60 years (P<0.05). Several patients had prolonged PFS and OS. Conclusion Intra-tumoral injection of the TLR3 agonist poly-ICLC in patients with HCC is safe and tolerable when combined with local nonlethal radiation and local regional treatment. Further work is in progress to evaluate if this approach improves survival compared to local regional treatment alone and characterize changes in anticancer immunity.
Collapse
Affiliation(s)
- Andrew N de la Torre
- Department of Surgery, St Joseph's Regional Medical Center, Paterson.,Department of Surgery, Rutgers New Jersey Medical School-University Hospital
| | - Sohail Contractor
- Department of Interventional Radiology, Rutgers New Jersey Medical School-University Hospital
| | - Ismael Castaneda
- Department of Surgery, St Joseph's Regional Medical Center, Paterson
| | | | - Dolly Razdan
- Department of Radiation Oncology, Clara Maas Hospital, Belleville, NJ
| | - David Klyde
- Department of Interventional Radiology, Rutgers New Jersey Medical School-University Hospital
| | - Piotr Kisza
- Department of Interventional Radiology, Rutgers New Jersey Medical School-University Hospital
| | - Sharon F Gonzales
- Department of Interventional Radiology, Rutgers New Jersey Medical School-University Hospital
| | | |
Collapse
|
14
|
Benedict M, Rodriguez-Davalos M, Emre S, Walther Z, Morotti R. Congenital Extrahepatic Portosystemic Shunt (Abernethy Malformation Type Ib) With Associated Hepatocellular Carcinoma: Case Report and Literature Review. Pediatr Dev Pathol 2017; 20:354-362. [PMID: 28727971 DOI: 10.1177/1093526616686458] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abernethy malformation, also termed congenital portosystemic shunt and congenital absence of portal vein is the result of malformation of the splanchnic venous system. Congenital portosystemic shunts are divided into extra- and intrahepatic shunts. Two shunts have been defined: Type I is characterized by the complete diversion of portal blood into the vena cava with an associated congenital absence of the portal vein. Type II is defined by an intact but diverted portal vein through a side-to-side, extrahepatic connection to the vena cava. The clinical manifestations of Abernethy malformation are diverse with a typical presentation consisting of hypoxia and hepto-pulmonary syndrome. Histologically, focal nodular hyperplasia, nodular regenerative hyperplasia, liver adenoma, hepatoblastoma, and hepatocellular carcinoma have all been reported. Herein, we report a case of Abernethy malformation, type Ib, in a 12-month-old male who was found to have a small hepatocellular carcinoma at the time of explant. The immunohistochemical characteristics in relation to the genetic aspects are discussed. To our knowledge, this is the first reported case of hepatocellular carcinoma developing in a patient who is under the age of 5 years with Abernethy malformation.
Collapse
Affiliation(s)
- Mark Benedict
- 1 Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Sukru Emre
- 2 Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zenta Walther
- 1 Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Raffaella Morotti
- 1 Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
15
|
Sharma R, Suddle A, Quaglia A, Peddu P, Karani J, Satyadas T, Heaton N. Congenital extrahepatic portosystemic shunt complicated by the development of hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int 2015; 14:552-7. [PMID: 26459734 DOI: 10.1016/s1499-3872(15)60418-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Congenital extrahepatic portosystemic shunt, also known as Abernethy malformation, is a rare congenital malformation. It causes shunting of blood through a communication between the portal and systemic veins such as a patent ductus venous. We report 3 cases of Abernethy malformation complicated by the development of hepatocellular carcinoma. Additionally, we comprehensively reviewed all previously reported cases and highlighted common features that may help in early diagnosis and appropriate management. Patients with Abernethy malformation may have an increased propensity to develop hepatocellular carcinoma. All 5 previously reported cases, plus the three of our patients, have a type 1 (complete) shunt suggesting a role for absent portal blood flow in the pathogenesis of hepatocellular carcinoma. Congenital extrahepatic portosystemic shunt should be sought for in cases with raised serum ammonia, hepatic encephalopathy or hepatocellular carcinoma in the absence of cirrhosis.
Collapse
Affiliation(s)
- Ruchi Sharma
- Department of Hepatopancreaticobiliary Surgery, Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
| | | | | | | | | | | | | |
Collapse
|
16
|
Brasoveanu V, Ionescu MI, Grigorie R, Mihaila M, Bacalbasa N, Dumitru R, Herlea V, Iorgescu A, Tomescu D, Popescu I. Living Donor Liver Transplantation for Unresectable Liver Adenomatosis Associated with Congenital Absence of Portal Vein: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:637-44. [PMID: 26386552 PMCID: PMC4581685 DOI: 10.12659/ajcr.895235] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Abernethy malformation (AM), or congenital absence of portal vein (CAPV), is a very rare disease which tends to be associated with the development of benign or malignant tumors, usually in children or young adults. CASE REPORT We report the case of a 21-year-old woman diagnosed with type Ib AM (portal vein draining directly into the inferior vena cava) and unresectable liver adenomatosis. The patient presented mild liver dysfunction and was largely asymptomatic. Living donor liver transplantation was performed using a left hemiliver graft from her mother. Postoperatively, the patient attained optimal liver function and at 9-month follow-up has returned to normal life. CONCLUSIONS We consider that living donor liver transplantation is the best therapeutic solution for AM associated with unresectable liver adenomatosis, especially because compared to receiving a whole liver graft, the waiting time on the liver transplantation list is much shorter.
Collapse
Affiliation(s)
- Vladislav Brasoveanu
- "Dan Setlacec" Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Mihnea Ioan Ionescu
- "Dan Setlacec" Center for General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Razvan Grigorie
- "Dan Setlacec" Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Mariana Mihaila
- Department of Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania
| | - Nicolae Bacalbasa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Radu Dumitru
- Department of Radiology and Imagistics, Fundeni Clinical Institute, Bucharest, Romania
| | - Vlad Herlea
- Department of Morphopathology, Fundeni Clinical Institute, Bucharest, Romania
| | - Andreea Iorgescu
- Department of Morphopathology, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Department of Anesthesiology, Fundeni Clinical Institute, Bucharest, Romania
| | - Irinel Popescu
- "Dan Setlacec" Center for General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| |
Collapse
|
17
|
Sanada Y, Mizuta K, Niki T, Tashiro M, Hirata Y, Okada N, Yamada N, Ihara Y, Urahashi T, Soejima Y, Fukusato T, Kondo F. Hepatocellular nodules resulting from congenital extrahepatic portosystemic shunts can differentiate into potentially malignant hepatocellular adenomas. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:746-56. [DOI: 10.1002/jhbp.277] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 06/18/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke City Japan
| | - Koichi Mizuta
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke City Japan
| | - Toshiro Niki
- Department of Pathology; Jichi Medical University; Shimotsuke City Japan
| | - Masahisa Tashiro
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke City Japan
| | - Yuta Hirata
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke City Japan
| | - Noriki Okada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke City Japan
| | - Naoya Yamada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke City Japan
| | - Yoshiyuki Ihara
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke City Japan
| | - Taizen Urahashi
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke City Japan
| | - Yurie Soejima
- Department of Pathology; Teikyo University School of Medicine; Itabashi City Japan
| | - Toshio Fukusato
- Department of Pathology; Teikyo University School of Medicine; Itabashi City Japan
| | - Fukuo Kondo
- Department of Pathology; Teikyo University School of Medicine; Itabashi City Japan
| |
Collapse
|
18
|
Mistinova J, Valacsai F, Varga I. Congenital absence of the portal vein--Case report and a review of literature. Clin Anat 2015; 23:750-8. [PMID: 20533511 DOI: 10.1002/ca.21007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 04/13/2010] [Accepted: 04/20/2010] [Indexed: 01/30/2023]
Abstract
Congenital absence of the portal vein (CAPV) is a rare anomaly in which the intestinal and the splenic venous drainage bypass the liver and drain into systemic veins through various venous shunts. To our knowledge, we have reviewed all 83 cases of CAPV, since first described in 1793. This equates to a rate of almost 2.5 cases per year over the last 30 years. Morgan and Superina (1994, J. Pediatr. Surg. 29:1239-1241) proposed the following classification of portosystemic anomalies; either the liver is not perfused with portal blood because of a complete shunt (Type I) or the liver is perfused with portal blood due to the presence of a partial shunt (Type II). In our case, abdominal venous blood drained into the suprarenal inferior vena cava via the left renal vein and dilated left gastric veins. After analyzing all reported cases, we recognize that more than 65% of patients are females and more than 30% of all published cases had been diagnosed by the age of 5 years. Additional anomalies are common in CAPV. In the reported cases, more then 22% of patients had congenital heart disease. Other commonly found anomalies include abnormalities of the spleen, urinary and male genital tract, brain as well as skeletal anomalies. Hepatic changes such as focal nodular hyperplasia, hepatocellular carcinoma, and hepatoblastoma are diagnosed in more then 40% of patients. This article also illustrates the radiological findings of CAPV. Radiological evaluation by ultrasound, CT, and MRI is helpful to detect coexisting abnormalities.
Collapse
Affiliation(s)
- Jana Mistinova
- Department of Radiology, Faculty of Medicine and University Hospital, Comenius University Bratislava, Slovak Republic
| | | | | |
Collapse
|
19
|
Sokollik C, Bandsma RHJ, Gana JC, van den Heuvel M, Ling SC. Congenital portosystemic shunt: characterization of a multisystem disease. J Pediatr Gastroenterol Nutr 2013; 56:675-81. [PMID: 23412540 DOI: 10.1097/mpg.0b013e31828b3750] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Congenital portosystemic shunts (CPSSs) are rare but increasingly recognized as a cause of important multisystem morbidity. We present new cases and a systematic literature review and propose an algorithm for the identification and care of affected patients. METHODS We reviewed the charts of consecutive patients seen in our pediatric liver clinic between 2003 and 2010 and systematically reviewed the literature of cases with CPSS. RESULTS We identified 316 published cases and 12 patients in our own clinic. Of the published cases (177 male), 185 had an extrahepatic and 131 an intrahepatic portosystemic shunt. Diagnosis was made at any age, from prenatal to late adulthood. Cardiac anomalies were found in 22% of patients. The main complications were hyperammonemia/neurological abnormalities (35%), liver tumors (26%), and pulmonary hypertension or hepatopulmonary syndrome (18%). The spectrum of neurological involvement ranged from changes in brain imaging, subtle abnormalities on neuropsychological testing, through learning disabilities to overt encephalopathy. Spontaneous shunt closure occurred mainly in infants with intrahepatic shunts. Therapeutic interventions included shunt closure by surgery or interventional radiology techniques (35%) and liver transplantation (10%) leading to an improvement of symptoms in the majority. These findings mirror the observations in our own patients. CONCLUSIONS In this largest review of the reported clinical experience, we identify that children with CPSS may present with otherwise unexplained developmental delay, encephalopathy, pulmonary hypertension, hypoxemia, or liver tumors. When CPSS is diagnosed, children should be screened for all of these complications. Spontaneous closure of intrahepatic shunts may occur in infancy. Closure of the shunt is indicated in symptomatic patients and is associated with a favorable outcome.
Collapse
Affiliation(s)
- Christiane Sokollik
- Department of Paediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Toronto, The Hospital for Sick Children, Ontario, Canada
| | | | | | | | | |
Collapse
|
20
|
Schaeffer DF, Laiq S, Jang HJ, John R, Adeyi OA. Abernethy malformation type II with nephrotic syndrome and other multisystemic presentation: an illustrative case for understanding pathogenesis of extrahepatic complication of congenital portosystemic shunt. Hum Pathol 2013; 44:432-7. [DOI: 10.1016/j.humpath.2012.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Revised: 08/21/2012] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
|
21
|
Guérin F, Blanc T, Gauthier F, Abella SF, Branchereau S. Congenital portosystemic vascular malformations. Semin Pediatr Surg 2012; 21:233-44. [PMID: 22800976 DOI: 10.1053/j.sempedsurg.2012.05.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Congenital portosystemic shunts are developmental abnormalities of the portal venous system resulting in the diversion of portal blood away from the liver to the systemic venous system. Such malformations are believed to come from an insult occurring between the fourth and eighth week of gestation during the development of hepatic and systemic venous systems, and could explain their frequent association with cardiac and other vascular anomalies. They are currently categorized into end-to-side shunts (type I) or side-to-side shunts (type II). This article aims to review the common symptoms and complications encountered in congenital portosystemic shunts, the surgical and endovascular treatment, and the role of liver transplantation in this disease. We will also focus on the current controversies and the areas where there is potential for future studies.
Collapse
Affiliation(s)
- Florent Guérin
- Department of Pediatric Surgery, Bicêtre Hospital, Paris, France.
| | | | | | | | | |
Collapse
|
22
|
Osorio MJ, Bonow A, Bond GJ, Rivera MR, Vaughan KG, Shah A, Shneider BL. Abernethy malformation complicated by hepatopulmonary syndrome and a liver mass successfully treated by liver transplantation. Pediatr Transplant 2011; 15:E149-51. [PMID: 20565695 DOI: 10.1111/j.1399-3046.2010.01337.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A seven-yr-old boy presented with persistent oxygen requirement following a respiratory infection. Physical exam was remarkable for orthodeoxia and digital clubbing. Laboratory evaluation showed elevated A-a oxygen gradient of 48 mmHg and mildly elevated transaminases. Sonography showed a 13 cm multilobulated liver mass and a biopsy revealed histological findings consistent with focal nodular hyperplasia. MAA scan revealed 23% right to left shunting. Abdominal CTA and MRV demonstrated the absence of the intrahepatic portal vein with an extrahepatic portocaval shunt. Abernethy malformation is a rare anomalous intra- or extrahepatic communication between portal blood flow and systemic venous return. In rare cases, Abernethy malformation results in HPS. Ours is the sixth case report to describe the co-existence of these two entities. Surgical correction of anomalous hepatic vasculature or liver transplant is imperative to restoration of lung function and also to prevent progression of possible malignant liver tumors. We describe the second patient with Abernethy and HPS who underwent liver transplant with complete resolution of HPS.
Collapse
Affiliation(s)
- Maria Joana Osorio
- Pediatrics and Child Neurology Resident PGY3, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA.
| | | | | | | | | | | | | |
Collapse
|
23
|
Sanada Y, Urahashi T, Ihara Y, Wakiya T, Okada N, Yamada N, Egami S, Hishikawa S, Kawano Y, Ushijima K, Otomo S, Sakamoto K, Nakata M, Yasuda Y, Mizuta K. The role of operative intervention in management of congenital extrahepatic portosystemic shunt. Surgery 2011; 151:404-11. [PMID: 21962400 DOI: 10.1016/j.surg.2011.07.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 07/08/2011] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS Congenital extrahepatic portosystemic shunt (CEPS) is a rare venous malformation in which mesenteric venous blood drains directly into the systemic circulation. It is still a matter of debate whether conservative or operative strategies should be used to treat symptomatic CEPS. The aim of this study was to evaluate the role of operative intervention in the management of CEPS. METHODS Between June 2004 and August 2010, 6 consecutive patients with symptomatic CEPS were treated in our department. There were 3 male and 3 female patients, with a median age of 3.5 years (range, 1-8). Their demographic, clinical, and laboratory data were analyzed. All patients were scheduled to undergo shunt ligation or liver transplantation (LT). RESULTS Living donor LT was carried out in 4 patients, and shunt ligation in 2. After a median follow-up of 25 months, all the patients are alive currently with marked relief of symptoms. CONCLUSION Shunt ligation or LT for symptomatic CEPS is potentially curative.
Collapse
Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, Tochigi, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Alonso-Gamarra E, Parrón M, Pérez A, Prieto C, Hierro L, López-Santamaría M. Clinical and radiologic manifestations of congenital extrahepatic portosystemic shunts: a comprehensive review. Radiographics 2011; 31:707-22. [PMID: 21571652 DOI: 10.1148/rg.313105070] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congenital extrahepatic portosystemic shunt (CEPS) is a rare condition in which the portomesenteric blood drains into a systemic vein, bypassing the liver through a complete or partial shunt. Most often, the diagnosis is made primarily with Doppler ultrasonography. Computed tomographic angiography and magnetic resonance angiography are used for further classification of the shunt and assessment of accompanying anomalies. Conventional angiography is necessary when results of the other tests disagree or are inconclusive. CEPS is classified into two types according to the pattern of anastomoses between the portal vein and systemic vein. In type 1, intrahepatic portal venous supply is absent; in type 2, intrahepatic portal venous supply is preserved. Type 1 usually occurs in girls with associated malformations, such as situs ambiguous with polysplenia and congenital heart defects. Associated anomalies are less frequent in type 2, and symptoms usually develop later without a gender preference. Hepatic encephalopathy and liver dysfunction are possible complications of both types and usually develop during adulthood. Both types are also associated with regenerative hepatic nodules. The clinical setting and imaging appearance of these nodules can help one avoid misdiagnosis. Definitive treatment of CEPS is determined by the type of shunt. Liver transplantation is the only effective treatment for symptomatic type 1 CEPS; surgical closure or embolization of the shunt is the therapeutic approach for type 2.
Collapse
Affiliation(s)
- Eduardo Alonso-Gamarra
- Department of Pediatric Radiology, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain.
| | | | | | | | | | | |
Collapse
|
25
|
Congenital absence of the portal vein in a middle-aged man. Surg Radiol Anat 2010; 33:369-72. [DOI: 10.1007/s00276-010-0711-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 08/03/2010] [Indexed: 10/18/2022]
|
26
|
Sanada Y, Mizuta K, Kawano Y, Egami S, Hayashida M, Wakiya T, Mori M, Hishikawa S, Morishima K, Fujiwara T, Sakuma Y, Hyodo M, Yasuda Y, Kobayashi E, Kawarasaki H. Living Donor Liver Transplantation for Congenital Absence of the Portal Vein. Transplant Proc 2009; 41:4214-9. [DOI: 10.1016/j.transproceed.2009.08.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 02/19/2009] [Accepted: 08/17/2009] [Indexed: 01/08/2023]
|
27
|
Shen GHHLG, Zhu JYJHMYF, Yang J, Mei JH, Zhu YF. Insight into congenital absence of the portal vein: Is it rare? World J Gastroenterol 2008; 14:5969-79. [PMID: 18932274 PMCID: PMC2760189 DOI: 10.3748/wjg.14.5969] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Congenital absence of portal vein (CAPV) was a rare event in the past. However, the number of detected CAPV cases has increased in recent years because of advances in imaging techniques. Patients with CAPV present with portal hypertension (PH) or porto-systemic encephalopathy (PSE), but these conditions rarely occur until the patients grow up or become old. The patients usually visit doctors for the complications of venous shunts, hepatic or cardiac abnormalities detected by ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). The etiology of this disease is not clear, but most investigators consider that it is associated with abnormal embryologic development of the portal vein. Usually, surgical intervention can relieve the symptoms and prevent occurrence of complications in CAPV patients. Moreover, its management should be stressed on a case-by-case basis, depending on the type or anatomy of the disease, as well as the symptoms and clinical conditions of the patient.
Collapse
|
28
|
Pey F, Bureau C, Otal P, Vinel JP, Rousseau H. Anomalies congénitales et acquises du système porte. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1155-1976(07)41406-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
29
|
Fukushima N, Kuromatsu R, Uchiyama D, Itano S, Takata A, Ando E, Sumie S, Torimura T, Uchida M, Nakashima O, Kojiro M, Sata M. Hyperplastic nodular hepatic lesions following end-to-side portacaval shunting in childhood. Intern Med 2007; 46:1203-8. [PMID: 17675770 DOI: 10.2169/internalmedicine.46.6419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a 48-year-old man with nodular intrahepatic lesions accompanied by communication between the inferior vena cava and portal systems as well as absence of intrahepatic portal veins. After infection with malaria in childhood, end-to-side portacaval shunting had been performed to treat upper gastrointestinal bleeding at the age of 15 years. A biopsy specimen obtained under ultrasonographic guidance showed hyperplastic nodules suggestive of focal nodular hyperplasia. The estradiol concentration in the blood was elevated (55 pg/ml). This case suggests that portacaval shunting may be associated with hyperplastic liver nodules through hyperestrogenemia and abnormal hepatic hemodynamics.
Collapse
Affiliation(s)
- Nobuyoshi Fukushima
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|