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Bevilacqua M, De Marco L, Stupia R, Cattazzo F, Zoncapé M, Paon V, Ieluzzi D, Dalbeni A, Sacerdoti D. Hepatofugal portal flow is highly predictive of acute-on-chronic liver failure: A new hemodynamic patho-physiological hypothesis. Dig Liver Dis 2024; 56:1522-1528. [PMID: 38281869 DOI: 10.1016/j.dld.2024.01.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND AND AIMS Acute-on-chronic liver failure (ACLF) is a severe complication of advanced liver disease. A significant number of ACLF patients have not clear precipitating factors. The aim of the study was to investigate the role of alterations in porto-hepatic hemodynamics, especially non-forward portal flow (NFPF), in ACLF and liver-related mortality. METHODS 233 cirrhotic patients were included in the study with a median follow-up of 24 months. Color-Doppler ultrasound was used to assess portal vein patency, flow direction and significant porto-systemic collaterals (>8 mm). Patients with active cancer, both at baseline and during follow-up and severe non liver-related comorbidities were excluded. ACLF and liver-related mortality were recorded during follow-up. RESULTS Fifty-six patients (24%) developed ACLF; 24 (10,3%) had baseline NFPF. In survival analysis, NFPF, but not portal vein thrombosis, was independently associated with ACLF development (HR 2.85 95% C.I. [1.49-5.42], p = 0.001) and liver-related mortality (HR 2.24 95% C.I. [1.16-4.28], p = 0.015), even after adjustment for liver disease severity scores, age and etiology of liver disease. CONCLUSION NFPF is independently associated with ACLF development and liver-related mortality, regardless of etiology, severity disease scores and portal vein thrombosis. Although there is no specific measure to reverse NFPF, patients with NFPF should receive prompt intensive management and urgent prioritization for liver transplantation. CLINICAL TRIAL NUMBER 2730 CESC.
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Affiliation(s)
- Michele Bevilacqua
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Leonardo De Marco
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Roberta Stupia
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Filippo Cattazzo
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Mirko Zoncapé
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Veronica Paon
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Donatella Ieluzzi
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Andrea Dalbeni
- General Medicine C, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - David Sacerdoti
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.
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Friis KH, Thomsen KL, Laleman W, Montagnese S, Vilstrup H, Lauridsen MM. Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis. J Clin Med 2023; 13:14. [PMID: 38202028 PMCID: PMC10779844 DOI: 10.3390/jcm13010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.
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Affiliation(s)
- Karina Holm Friis
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, 3000 Leuven, Belgium
| | - Sara Montagnese
- Department of Medicine, University of Padova, 35122 Padova, Italy
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
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Shiratori S, Okada K, Sugita J, Nishida M, Iwai T, Ota S, Hashimoto D, Teshima T. HokUS-10 scoring system predicts the treatment outcome for sinusoidal obstruction syndrome after allogeneic hematopoietic stem cell transplantation. Sci Rep 2023; 13:17374. [PMID: 37833418 PMCID: PMC10575893 DOI: 10.1038/s41598-023-43806-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
Hepatic sinusoidal obstruction syndrome (SOS) is a severe and life-threatening complication after allogeneic hematopoietic stem cell transplantation (HSCT). We conducted a multi-center retrospective study to evaluate the utility of our ultrasonographic scoring system for the diagnosis of SOS (HokUS-10) in predicting SOS-related mortality (SOS-RM). We analyzed a total of 42 patients who developed SOS after HSCT. The cumulative incidences of SOS-RM, non-relapse mortality (NRM), and overall survival at day 180 after the diagnosis of SOS were 26.4%, 28.8% and 54.5%, respectively. The area under the receiver operating characteristic curve analysis showed that the optimal cut-off value of HokUS-10 total score to predict SOS-RM was 8 points after the treatment of SOS. In the individual HokUS-10 score, ascites and portal vein flow-related scores (PV mean velocity and PV flow direction) after the treatment of SOS were shown as significant risk factors for SOS-RM. Our study suggested that US findings after the treatment can predict the treatment outcomes for SOS.
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Affiliation(s)
- Souichi Shiratori
- Department of Hematology, Hokkaido University Hospital, N15 W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Kohei Okada
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Junichi Sugita
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Mutsumi Nishida
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Takahito Iwai
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Shuichi Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Daigo Hashimoto
- Department of Hematology, Hokkaido University Hospital, N15 W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Hospital, N15 W7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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4
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Kageyama K, Yamamoto A, Jogo A, Sohgawa E, Izuta S, Himoto D, Kakimi A, Kita R, Miki Y. Identification of reversed portal flow on 4DCT and of factors contributing to reversed portal flow in patients with liver cirrhosis and portosystemic shunt before interventional radiology procedures. Hepatol Res 2023; 53:228-237. [PMID: 36356950 DOI: 10.1111/hepr.13855] [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] [Received: 08/06/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/12/2022]
Abstract
AIM Patients with liver cirrhosis and portosystemic shunt occasionally develop reversed portal flow in the portal venous system. The factors contributing to reversed portal flow in these patients remain unclear. The aim of this study was to identify factors contributing to reversed portal flow in patients with portosystemic shunts based on four-dimensional computed tomography (4DCT), which visualized flow dynamics in the portal venous system. METHODS Data from 34 consecutive patients with portosystemic shunts who had undergone 4DCT before interventional radiology procedures were retrospectively investigated in this study. Uni- and multivariate analyses were performed to identify factors contributing to reversed portal flow. RESULTS Flow dynamics could be visualized on 4DCT in 32 of the 34 patients. Fifteen patients had forward portal flow; 17 had reversed portal flow. The main portal, splenic, and superior mesenteric veins displayed reversed portal flow in five, 12, and five vessels, respectively. Portosystemic shunt originating from splenic and superior mesenteric veins, worse albumin-bilirubin score, and small main portal vein diameter were significant factors contributing to reversed portal flow in both univariate (p = 0.049, p = 0.027, and p = 0.002) and multivariate (odds ratio [OR] 6.345, p = 0.012; OR 4.279, p = 0.039; and OR 5.516, p = 0.019) analyses. CONCLUSIONS The reversed portal flow was visualized on 4DCT. Portosystemic shunt originating distant to the liver, worse albumin-bilirubin score, and small diameter of the main portal vein were factors contributing to reversed flow in the portal venous system.
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Affiliation(s)
- Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shinichiro Izuta
- Department of Central Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Daisuke Himoto
- Department of Central Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Akihiko Kakimi
- Department of Central Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Ryuichi Kita
- Department of Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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Zhang SR, Ma Y, Zhou B, Li GY, Chen P, Chen G. Case report and literature review: Isolated HCC- recurrence in gallbladder after curative resection. Front Surg 2023; 10:1115181. [PMID: 37181591 PMCID: PMC10174458 DOI: 10.3389/fsurg.2023.1115181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 04/04/2023] [Indexed: 05/16/2023] Open
Abstract
Background Liver resection (LR) is considered the mainstay treatment for eligible patients with hepatocellular carcinoma (HCC) and provides a 5-year overall survival (OS) of 60%-80%. However, the recurrence rate within five years after LR remains high, ranging from 40% to 70%. Recurrence in gallbladder after liver resection is extremely rare. Here, we present a case of isolated recurrence in gallbladder after curative resection of HCC and review the relevant literature. No similar cases have been reported before. Case presentation A 55-year-old male patient was diagnosed with HCC in 2009 and subsequently underwent a right posterior sectionectomy of the liver. In 2015, the patient underwent liver tumor radiofrequency ablation and three transarterial chemoembolization (TACE) procedures in succession for HCC recurrence. In 2019, a gallbladder lesion was detected by computed tomography (CT) without perceivable intrahepatic focus. We performed an en bloc resection of the gallbladder and hepatic segment IVb. The pathological biopsy suggested that the gallbladder tumor was moderately differentiated HCC. The patient survived more than 3 years in good condition, and there were no signs of tumor recurrence. Conclusions In patients with isolated gallbladder metastasis, if the lesion can be resected en bloc without remnants, surgery should be the preferred option. Both postoperative molecularly targeted drugs and immunotherapy are expected to improve the long-term prognosis.
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6
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Yoshida H, Shimizu T, Yoshioka M, Matsushita A, Kawano Y, Ueda J, Kawashima M, Taniai N, Mamada Y. The Role of the Spleen in Portal Hypertension. J NIPPON MED SCH 2023; 90:20-25. [PMID: 36908126 DOI: 10.1272/jnms.jnms.2023_90-104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023]
Abstract
As liver disease progresses, intrahepatic vascular resistance increases (backward flow theory of portal hypertension) and collateral veins develop. Adequate portal hypertension is required to maintain portal flow into the liver through an increase in blood flow into the portal venous system (forward flow theory of portal hypertension). The splenic artery resistance index is significantly and selectively elevated in cirrhotic patients. In portal hypertension, a local hyperdynamic state occurs around the spleen. Splenomegaly is associated with a poor prognosis in cirrhosis and is caused by spleen congestion and by enlargement and hyperactivation of splenic lymphoid tissue. Hypersplenism can lead to thrombocytopenia caused by increased sequestering and breakdown of platelets in the spleen. The close relationship between the spleen and liver is reflected in the concept of the hepatosplenic axis. The spleen is a regulatory organ that maintains portal flow into the liver and is the key organ in the forward flow theory of portal hypertension. This review summarizes the literature on the role of the spleen in portal hypertension.
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Affiliation(s)
| | | | | | | | | | - Junji Ueda
- Department of GI and HBP Surgery, Nippon Medical School
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7
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Han SK, Kim MY, Kang SH, Baik SK. Application of ultrasound for the diagnosis of cirrhosis/portal hypertension. J Med Ultrason (2001) 2022; 49:321-331. [PMID: 35179669 DOI: 10.1007/s10396-022-01191-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022]
Abstract
With advances in technologic approaches in patients with cirrhosis, including the improvement of management, a simple, one-step approach for advanced fibrotic state of the liver is clinically useful. Although refining the diagnosis of cirrhosis to reflect disease heterogeneity is essential, current diagnostic tests have not kept pace with the progression of this new paradigm. There are unmet needs in primary care centers with respect to patients with cirrhosis. Liver biopsy and measurement of hepatic venous pressure gradient in patients with cirrhosis are the gold standards for the estimation of hepatic fibrosis, and they have diagnostic and prognostic value. However, both approaches are invasive and cannot be used repeatedly in clinical practice. Ultrasonography (US) is safe, easy to perform, inexpensive, and yields numerical and accurate results. Conventionally, the size of the liver and spleen, bluntness of the liver edge, nodularity of the liver surface, and coarseness of the liver parenchyma have been known as useful parameters for hepatic fibrosis or portal hypertension (PHT) in chronic liver disease. Additionally, some functional US indices including Doppler and CEUS-based examination have been suggested as promising markers for diagnosing cirrhosis and PHT. Identification of the reproducibility and long-term prognostic value through further investigations can demonstrate the clinical usefulness of functional US indices, which are characterized as quantitative parameters for hepatic fibrosis and PHT.
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Affiliation(s)
- Seul Ki Han
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsanro, Wonju, 220-701, Republic of Korea
| | - Moon Young Kim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsanro, Wonju, 220-701, Republic of Korea.,Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.,Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Seong Hee Kang
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsanro, Wonju, 220-701, Republic of Korea.,Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsanro, Wonju, 220-701, Republic of Korea. .,Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea. .,Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
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8
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Yokoyama S, Ishizu Y, Honda T, Imai N, Ito T, Yamamoto K, Tsuzuki T, Ishigami M. Absence of large portal collateral vessels is associated with spontaneous improvement of cirrhotic portal vein thrombosis. Hepatol Res 2022; 52:199-209. [PMID: 34687492 DOI: 10.1111/hepr.13725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/03/2021] [Accepted: 10/20/2021] [Indexed: 01/03/2023]
Abstract
AIM Portal vein thrombosis (PVT) is a major complication in patients with liver cirrhosis (LC). In some cases, PVT decreases spontaneously, but the factors that predict this are still not fully understood. METHODS This was a retrospective, multicenter study that included 77 consecutive patients with cirrhotic PVT. Forty-eight patients did not undergo anticoagulation and 29 patients did between the time of the first diagnosis of PVT and the follow-up radiological imaging undertaken 1-6 months later. A complete disappearance and 25% shrinkage of PVT was defined as complete remission (CR) and partial remission (PR), respectively. Portosystemic collateral vessels larger than 9 mm in diameter were defined as large collateral vessels. RESULTS Complete remission + PR was found in 37.5% of the anticoagulation-naïve patients. On univariate analysis, the absence of large collateral vessels, absence of PVT in the main trunk of the portal vein, a high platelet count, and a low FIB-4 index were significant factors associated with CR + PR. On multivariate analysis, the absence of large collateral vessels was the unique factor associated with CR + PR of PVT (odds ratio 5.9; 95% confidence interval, 1.73-20.1). The CR + PR rate for anticoagulated patients was 44.8%. However, no predictors for a good treatment effect of anticoagulation for PVT were identified. CONCLUSIONS Spontaneous improvement of PVT in patients with LC can be expected when large collateral vessels are absent. For these patients, the option of observing them without anticoagulation can be considered in expectation of spontaneous reduction of PVT.
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Affiliation(s)
- Shinya Yokoyama
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Yoji Ishizu
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Norihiro Imai
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Takanori Ito
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Kenta Yamamoto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Tomoyuki Tsuzuki
- Department of Internal Medicine, Toyota Kosei Hospital, Toyota, Aichi, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
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Salman A, Salman MA, Ismaeel Saadawy AM, Tourky M, Shawkat M. Portal venous hemodynamics as predictors for the development and grades of esophageal varices in
Post‐HCV
cirrhotic patients: An Egyptian center study. ADVANCES IN DIGESTIVE MEDICINE 2021. [DOI: 10.1002/aid2.13209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Ahmed Salman
- Internal Medicine Department, Faculty of Medicine Cairo University Cairo Egypt
| | - Mohamed A. Salman
- General Surgery Department, Faculty of Medicine Cairo University Cairo Egypt
| | | | - Mohamed Tourky
- General Surgery Department Omm Elmisrien General Hospital Cairo Egypt
| | - Mohamed Shawkat
- Internal Medicine Department, Faculty of Medicine Minia University Minia Egypt
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10
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Yi F, Guo X, Wang L, Xu X, An Y, Tang Y, Zhang W, Tacke F, Arora A, Qi X. Impact of spontaneous splenorenal shunt on liver volume and long-term survival of liver cirrhosis. J Gastroenterol Hepatol 2021; 36:1694-1702. [PMID: 33393106 DOI: 10.1111/jgh.15386] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/03/2020] [Accepted: 12/19/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Spontaneous splenorenal shunt (SSRS) is one of the manifestations of portal hypertension in liver cirrhosis. However, the impact of SSRS on long-term survival of cirrhotic patients remains unclear. We hypothesize that SSRS may worsen liver dysfunction and deteriorate prognosis in liver cirrhosis by decreasing hepatic perfusion. METHODS Patients with liver cirrhosis who were admitted to our department between December 2014 and August 2019 and underwent contrast-enhanced computed tomography or magnetic resonance imaging scans were prospectively collected. The maximum diameters of SSRS and portal vein system vessels were retrospectively measured. Liver-to-abdominal area ratio, Child-Pugh, and model for end-stage liver disease scores were calculated. RESULTS Overall, 122 cirrhotic patients were included. The prevalence of SSRS was 30.3% (37/122). Median diameter of SSRS was 13.5 mm. Patients with SSRS had significantly thinner diameters of right portal vein (9 mm vs 11.2 mm, P = 0.001) and main portal vein (15.3 mm vs 16.8 mm, P = 0.017) than those without SSRS. Patients with SSRS had significantly lower liver-to-abdominal area ratio score (25.39 vs 31.58, P < 0.001) and higher Child-Pugh (7 vs 6, P = 0.046) and model for end-stage liver disease (12.17 vs 9.79, P < 0.006) scores than those without SSRS. Patients with SSRS had a significantly lower cumulative survival rate than those without SSRS (P = 0.014). Cox regression analysis also showed that SSRS was a risk factor of death of cirrhotic patients (hazard ratio = 4.161, 95% confidence interval = 1.215-14.255, P = 0.023). CONCLUSIONS Spontaneous splenorenal shunt may narrow portal vein diameter and shrink liver volume, thereby worsening liver function and increasing mortality in liver cirrhosis.
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Affiliation(s)
- Fangfang Yi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Yang An
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Yufu Tang
- Department of Hepatic Surgery, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Wenwen Zhang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Department of Nuclear Medicine, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Berlin, Germany
| | - Ankur Arora
- Department of Radiology, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
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11
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Kageyama K, Yamamoto A, Jogo A, Izuta S, Himoto D, Kakimi A, Sohgawa E, Miki Y. Visualization of flow dynamics in the portal circulation using 320-detector-row computed tomography: a feasibility study. Eur Radiol Exp 2021; 5:1. [PMID: 33432529 PMCID: PMC7801554 DOI: 10.1186/s41747-020-00197-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/26/2020] [Indexed: 11/21/2022] Open
Abstract
Multidetector row computed tomography (CT) scanners perform dynamic scanning and have a wide scan range. Time-resolved three-dimensional CT (i.e., 4D CT) has recently enabled visualization of flow in neurovascular vessels. We hypothesized that 4D CT technology would be a useful and non-invasive method for visualizing the flow dynamics of the portal circulation. The aim of this study was to evaluate the technical feasibility of 4D CT for visualizing flow dynamics in the portal circulation using 320-detector-row CT. 4D CT images of 18 consecutive patients with portal circulation including gastrorenal shunt were retrospectively evaluated for their ability to generate flow dynamics of the portal circulation. Flow dynamics could be visualized by 4D CT in 68 of the 72 vessels in the portal vein, splenic vein, superior mesenteric vein, and gastrorenal shunt. Flow direction could not be identified in four vessels, all of them being superior mesenteric veins. Flow direction was recognized on 4D CT in the 68 vessels of the portal circulation. A preliminary validation study revealed that flow direction of all 19 vessels in the portal circulation had concordance between 4D CT and color Doppler ultrasound. 4D CT could visualize flow dynamics of the portal circulation.
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Affiliation(s)
- Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shinichiro Izuta
- Department of Central Radiology, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan
| | - Daisuke Himoto
- Department of Central Radiology, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan
| | - Akihiko Kakimi
- Department of Central Radiology, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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12
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Krabbe J, Ruske N, Kanzler S, Reiss LK, Ludwig A, Uhlig S, Martin C. Retrograde perfusion in isolated perfused mouse lungs-Feasibility and effects on cytokine levels and pulmonary oedema formation. Basic Clin Pharmacol Toxicol 2019; 125:279-288. [PMID: 30925204 DOI: 10.1111/bcpt.13236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/22/2019] [Indexed: 01/20/2023]
Abstract
Retrograde lung vascular perfusion can appear in high-risk surgeries. The present report is the first to study long-term retrograde perfusion of isolated perfused mouse lungs (IPLs) and to use the tyrosine kinase ephB4 and its ligand ephrinB2 as potential markers for acute lung injury. Mouse lungs were subjected to anterograde or retrograde perfusion with normal-pressure ventilation (NV) or high-pressure ventilation (=overventilation, OV) for 4 hours. Outcome parameters were cytokine, ephrinB2 and ephB4 levels in perfusate samples and bronchoalveolar lavage (BAL), and the wet-to-dry ratio. Anterograde perfusion was feasible for 4 hours, while lungs receiving retrograde perfusion presented considerable collapse rates. Retrograde perfusion resulted in an increased wet-to-dry ratio when combined with high-pressure ventilation; other physiological parameters were not affected. Cytokine levels in BAL and perfusate, as well as levels of soluble ephB4 in BAL were increased in OV, while soluble ephrinB2 BAL levels were increased in retrograde perfusion. BAL levels of ephrinB2 and ephB4 were also determined in vivo, including mice ventilated for 7 hours with normal-volume ventilation (NVV) or high-volume ventilation (HVV) with increased levels of ephB4 in HVV BAL compared to NVV. Retrograde perfusion in IPL is limited as a routine method to investigate effects due to collapse for yet unclear reasons. If successful, retrograde perfusion has an influence on pulmonary oedema formation. In BAL, ephrinB2 seems to be up-regulated by flow reversal, while ephB4 is a marker for acute lung injury.
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Affiliation(s)
- Julia Krabbe
- Medical Faculty, Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany.,Medical Faculty, Institute of Occupational, Social and Environmental Medicine, RWTH Aachen University, Aachen, Germany
| | - Nadine Ruske
- Medical Faculty, Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Stephanie Kanzler
- Medical Faculty, Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Lucy Kathleen Reiss
- Medical Faculty, Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Andreas Ludwig
- Medical Faculty, Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Stefan Uhlig
- Medical Faculty, Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Christian Martin
- Medical Faculty, Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
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13
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Maruyama H, Kato N. Advances in ultrasound diagnosis in chronic liver diseases. Clin Mol Hepatol 2019; 25:160-167. [PMID: 30773001 PMCID: PMC6589854 DOI: 10.3350/cmh.2018.1013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/25/2018] [Indexed: 02/07/2023] Open
Abstract
Chronic liver disease is a major disorder worldwide. A better understanding of anatomy, blood flow, and pathophysiology may be a key issue for their proper management. Ultrasound (US) is a simple and non-invasive diagnostic tool in the abdominal field. Doppler mode offers real-time hemodynamic evaluation, and the contrast-enhanced US is one of the most frequently used modalities for the detailed assessment. Further development in digital technology enables threedimensional (3D) visualization of target images with high resolution. This article reviews the wide ranges of application in the abdominal US and describes the recent progress in the diagnosis of chronic liver diseases.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Chiba University Graduate School of Medicine, Chiba, Japan
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Maruyama H, Yokosuka O. Ultrasonography for Noninvasive Assessment of Portal Hypertension. Gut Liver 2018; 11:464-473. [PMID: 28267700 PMCID: PMC5491080 DOI: 10.5009/gnl16078] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/07/2016] [Accepted: 06/18/2016] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension is a major pathophysiology in patients with cirrhosis. Portal pressure is the gold standard to evaluate the severity of portal hypertension, and radiological intervention is the only procedure for pressure measurement. Ultrasound (US) is a simple and noninvasive imaging modality available worldwide. B-mode imaging allows broad applications for patients to detect and characterize chronic liver diseases and focal hepatic lesions. The Doppler technique offers real-time observation of blood flow with qualitative and quantitative assessments, and the application of microbubble-based contrast agents has improved the detectability of peripheral blood flow. In addition, elastography for the liver and spleen covers a wider field beyond the original purpose of fibrosis assessment. These developments enhance the practical use of US in the evaluation of portal hemodynamic abnormalities. This article reviews the recent progress of US in the assessment of portal hypertension.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
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Non-invasive Markers of Portal Hypertension: Appraisal of Adult Experience and Potential Utilisation in Children. J Pediatr Gastroenterol Nutr 2018; 66:559-569. [PMID: 29287004 DOI: 10.1097/mpg.0000000000001882] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Portal hypertension (PHT) is a significant cause of morbidity and mortality in children with chronic liver disease and portal vein obstruction. Increased portal pressure results in variceal formation along the gastrointestinal (GI) tract resulting in major bleeding. Identifying children with significant PHT who are more likely to suffer GI bleeding has been challenging and the role of surveillance upper GI endoscopy has been debated. This review analyses research done on serum biomarkers and imaging techniques as possible predictors of significant PHT. We evaluated the research performed on adult population, as well as the limited work done on children, to identify promising areas for future research. A literature search was conducted on "PubMed." Several search terms were used including "portal hypertension," "paediatric portal hypertension," "non-invasive markers of portal hypertension," "spleen stiffness," "liver stiffness," "elastography," and "endothelial damage." The articles included were selected based on their relevance to the purpose of our review. The research suggests a combination of several biomarkers, in addition to an imaging technique such as transient elastography or magnetic resonance elastography, would allow for the best prediction of significant varices. The most promising indicators would be those that are applicable in both intra- and extra-hepatic causes of PHT. Further research on these predictors in children with PHT is required to determine their potential role as selection criteria for PHT and stratification of surveillance GI endoscopies.
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Piecha F, Peccerella T, Bruckner T, Seitz HK, Rausch V, Mueller S. Arterial pressure suffices to increase liver stiffness. Am J Physiol Gastrointest Liver Physiol 2016; 311:G945-G953. [PMID: 27288426 DOI: 10.1152/ajpgi.00399.2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 06/01/2016] [Indexed: 01/31/2023]
Abstract
Noninvasive measurement of liver stiffness (LS) has been established to screen for liver fibrosis. Since LS is also elevated in response to pressure-related conditions such as liver congestion, this study was undertaken to learn more about the role of arterial pressure on LS. LS was measured by transient elastography (μFibroscan platform, Echosens, Paris, France) during single intravenous injections of catecholamines in anesthetized rats with and without thioacetamide (TAA)-induced fibrosis. The effect of vasodilating glycerol trinitrate (GTN) on LS was also studied. Pressures in the abdominal aorta and caval and portal veins were measured in real time with the PowerLab device (AD Instruments, Dunedin, New Zealand). Baseline LS values in all rats (3.8 ± 0.5 kPa, n = 25) did not significantly differ from those in humans. Epinephrine and norepinephrine drastically increased mean arterial pressure (MAP) from 82 to 173 and 156 mmHg. Concomitantly, LS almost doubled from 4 to 8 kPa, while central venous pressure remained unchanged. Likewise, portal pressure only showed a slight and delayed increase. In the TAA-induced fibrosis model, LS increased from 9.5 ± 1.0 to 25.6 ± 14.7 kPa upon epinephrine injection and could efficiently be decreased by GTN. We finally show a direct association in humans in a physiological setting of elevated cardiac output and MAP. During continuous spinning at 200 W, MAP increased from 84 ± 8 to 99 ± 11 mmHg while LS significantly increased from 4.4 ± 1.8 to 6.7 ± 2.1 kPa. In conclusion, our data show that arterial pressure suffices to increase LS. Moreover, lowering MAP efficiently decreases LS in fibrotic livers that are predominantly supplied by arterial blood.
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Affiliation(s)
- Felix Piecha
- Department of Medicine, Salem Medical Center and Center for Alcohol Research and Liver Disease, University of Heidelberg, Heidelberg, Germany; and
| | - Teresa Peccerella
- Department of Medicine, Salem Medical Center and Center for Alcohol Research and Liver Disease, University of Heidelberg, Heidelberg, Germany; and
| | - Tom Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Helmut-Karl Seitz
- Department of Medicine, Salem Medical Center and Center for Alcohol Research and Liver Disease, University of Heidelberg, Heidelberg, Germany; and
| | - Vanessa Rausch
- Department of Medicine, Salem Medical Center and Center for Alcohol Research and Liver Disease, University of Heidelberg, Heidelberg, Germany; and
| | - Sebastian Mueller
- Department of Medicine, Salem Medical Center and Center for Alcohol Research and Liver Disease, University of Heidelberg, Heidelberg, Germany; and
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