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Banc-Husu AM, Shiau H, Dike P, Shneider BL. Beyond Varices: Complications of Cirrhotic Portal Hypertension in Pediatrics. Semin Liver Dis 2023; 43:100-116. [PMID: 36572031 DOI: 10.1055/s-0042-1759613] [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: 12/28/2022]
Abstract
Complications of cirrhotic portal hypertension (PHTN) in children are broad and include clinical manifestations ranging from variceal hemorrhage, hepatic encephalopathy (HE), ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS) to less common conditions such as hepatopulmonary syndrome, portopulmonary hypertension, and cirrhotic cardiomyopathy. The approaches to the diagnosis and management of these complications have become standard of practice in adults with cirrhosis with many guidance statements available. However, there is limited literature on the diagnosis and management of these complications of PHTN in children with much of the current guidance available focused on variceal hemorrhage. The aim of this review is to summarize the current literature in adults who experience these complications of cirrhotic PHTN beyond variceal hemorrhage and present the available literature in children, with a focus on diagnosis, management, and liver transplant decision making in children with cirrhosis who develop ascites, SBP, HRS, HE, and cardiopulmonary complications.
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Affiliation(s)
- Anna M Banc-Husu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Henry Shiau
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Peace Dike
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Valencia E, Vakili K, Thiagarajan RR, Mullen MP, Fynn-Thompson F, Weldon CB, Duvall MG. Case 2-2022: An Adolescent Male in Cardiac Arrest 3 Days After Liver Transplantation for End-Stage Liver Disease. Pediatr Crit Care Med 2022; 23:e440-e450. [PMID: 35969659 PMCID: PMC9426743 DOI: 10.1097/pcc.0000000000002994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Eleonore Valencia
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | | | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | - Christopher B Weldon
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Melody G Duvall
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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Outcome of paediatric portopulmonary hypertension in the modern management era: A case report of 6 patients. J Hepatol 2021; 74:742-747. [PMID: 33276028 DOI: 10.1016/j.jhep.2020.11.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/25/2020] [Accepted: 11/16/2020] [Indexed: 12/30/2022]
Abstract
Portopulmonary hypertension is a rare but serious complication of portal hypertension or portosystemic shunting. Portopulmonary hypertension is an indication for liver transplantation or shunt closure. However, liver transplantation is contraindicated in patients with severe pulmonary arterial hypertension. Reported mortality rates are high in children with portopulmonary hypertension and there are scarce recommendations on its management. Our aim was to report on our real-world experience of managing portopulmonary hypertension in a specialised centre. We describe a series of 6 children with portopulmonary hypertension. Their median age at diagnosis was 13 years (range 10-15). The underlying liver conditions were cirrhosis of unknown origin (1), congenital portocaval shunts (3), biliary atresia (1), and portal vein cavernoma with surgical mesenterico-caval shunt (1). Median mean pulmonary arterial pressure was 47 mmHg (range 32-70), and median pulmonary vascular resistance was 6.6 Wood units (range 4.3-15.4). All patients except one were treated with a combination of pulmonary arterial hypertension-specific therapy (phosphodiesterase type 5 inhibitors and/or endothelin receptor antagonists and/or prostacyclin analogues). Three patients then benefited from shunt closure and the others underwent liver transplantation. Five patients showed improvement or stabilisation of pulmonary arterial hypertension with no deaths after a mean follow-up of 39 months. Based on our limited experience, early and aggressive treatment with a combination of pulmonary arterial hypertension-specific therapy significantly improves patients' haemodynamic profile and enables the performance of liver transplantation and shunt closure with satisfactory outcomes.
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Le Fevre ER, McGrath KH, Fitzgerald DA. Pulmonary Manifestations of Gastrointestinal, Pancreatic, and Liver Diseases in Children. Pediatr Clin North Am 2021; 68:41-60. [PMID: 33228942 DOI: 10.1016/j.pcl.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary manifestations of gastrointestinal (GI) diseases are often subtle, and underlying disease may precede overt symptoms. A high index of suspicion and a low threshold for consultation with a pediatric pulmonologist is warranted in common GI conditions. This article outlines the pulmonary manifestations of different GI, pancreatic, and liver diseases in children, including gastroesophageal reflux disease, inflammatory bowel disease, pancreatitis, alpha1-antitrypsin deficiency, nonalcoholic fatty liver disease, and complications of chronic liver disease (hepatopulmonary syndrome and portopulmonary hypertension).
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Affiliation(s)
- Emily R Le Fevre
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales 2145, Australia
| | - Kathleen H McGrath
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales 2145, Australia; Faculty Health Sciences, University of Sydney, Sydney, New South Wales, Australia.
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Children and Adolescents with Pulmonary Arterial Hypertension: Baseline and Follow-Up Data from the Polish Registry of Pulmonary Hypertension (BNP-PL). J Clin Med 2020; 9:jcm9061717. [PMID: 32503164 PMCID: PMC7356296 DOI: 10.3390/jcm9061717] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/21/2022] Open
Abstract
We present the results from the pediatric arm of the Polish Registry of Pulmonary Hypertension. We prospectively enrolled all pulmonary arterial hypertension (PAH) patients, between the ages of 3 months and 18 years, who had been under the care of each PAH center in Poland between 1 March 2018 and 30 September 2018. The mean prevalence of PAH was 11.6 per million, and the estimated incidence rate was 2.4 per million/year, but it was geographically heterogeneous. Among 80 enrolled children (females, n = 40; 50%), 54 (67.5%) had PAH associated with congenital heart disease (CHD-PAH), 25 (31.25%) had idiopathic PAH (IPAH), and 1 (1.25%) had portopulmonary PAH. At the time of enrolment, 31% of the patients had significant impairment of physical capacity (WHO-FC III). The most frequent comorbidities included shortage of growth (n = 20; 25%), mental retardation (n = 32; 40%), hypothyroidism (n = 19; 23.8%) and Down syndrome (n = 24; 30%). The majority of children were treated with PAH-specific medications, but only half of them with double combination therapy, which improved after changing the reimbursement policy. The underrepresentation of PAH classes other than IPAH and CHD-PAH, and the geographically heterogeneous distribution of PAH prevalence, indicate the need for building awareness of PAH among pediatricians, while a frequent coexistence of PAH with other comorbidities calls for a multidisciplinary approach to the management of PAH children.
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Rosenzweig EB, Abman SH, Adatia I, Beghetti M, Bonnet D, Haworth S, Ivy DD, Berger RMF. Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management. Eur Respir J 2019; 53:1801916. [PMID: 30545978 PMCID: PMC6351335 DOI: 10.1183/13993003.01916-2018] [Citation(s) in RCA: 323] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features of adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for the care of children with PAH, as presented by the Paediatric Task Force of the 6th World Symposium on Pulmonary Hypertension. We provide updates of the current definition, epidemiology, classification, diagnostics and treatment of paediatric PAH, and identify critical knowledge gaps. Several features of paediatric PAH including the prominence of neonatal PAH, especially in pre-term infants with developmental lung diseases, and novel genetic causes of paediatric PAH are highlighted. The use of cardiac catheterisation as a diagnostic modality and haemodynamic definitions of PAH, including acute vasoreactivity, are addressed. Updates are provided on issues related to utility of the previous classification system to reflect paediatric-specific aetiologies and approaches to medical and interventional management of PAH, including the Potts shunt. Although a lack of clinical trial data for the use of PAH-targeted therapy persists, emerging data are improving the identification of appropriate targets for goal-oriented therapy in children. Such data will likely improve future clinical trial design to enhance outcomes in paediatric PAH.
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Affiliation(s)
- Erika B Rosenzweig
- Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Steven H Abman
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Ian Adatia
- Glenwood Children's Heart Clinic, Edmonton, AB, Canada
| | - Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque Pédiatrique, University Hospitals of Geneva and Lausanne, Lausanne, Switzerland
| | - Damien Bonnet
- Hôpital Necker Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | | | - D Dunbar Ivy
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Lee WS, Wong SY, Ivy DD, Sokol RJ. Hepatopulmonary Syndrome and Portopulmonary Hypertension in Children: Recent Advances in Diagnosis and Management. J Pediatr 2018. [PMID: 29514741 DOI: 10.1016/j.jpeds.2017.12.068] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Way Seah Lee
- Department of Pediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia; University Malaya Pediatrics and Child Health Research Group, University Malaya, Kuala Lumpur, Malaysia.
| | - Shin Yee Wong
- Department of Pediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - D Dunbar Ivy
- Section of Pediatric Cardiology, Department of Pediatrics, and the Heart Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Ronald J Sokol
- Pediatric Liver Center, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, and the Digestive Health Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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