1
|
Bhandari K, Mishra S, Sen K, Basnet P, Shah PK, Yadav M. A rare case of esophageal variceal bleeding as a result of portal hypertension due to extra-hepatic portal vein obstruction and its management in a 7-year-old. Int J Surg Case Rep 2024; 116:109362. [PMID: 38340628 PMCID: PMC10943650 DOI: 10.1016/j.ijscr.2024.109362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Extrahepatic Portal Vein Obstruction is the most common cause of portal hypertension in children. However, it has a very low prevalence. Esophageal varices due to portal hypertension in children can lead to recurrent episodes of upper gastrointestinal bleeding, which can have a sinister outcome if timely diagnosis and treatment are not initiated. CASE PRESENTATION A 7-year-old male child presents with recurrent episodes of upper gastrointestinal bleeding for 3 years. Clinical examination reveals pallor and splenomegaly. Laboratory investigations revealed signs of hypersplenism with anemia, leucopenia and thrombocytopenia, and Doppler ultrasonography and CT abdomen and pelvis revealed splenic vein thrombosis with splenomegaly and cavernous transformation of the portal vein. The patient was managed operatively with splenectomy with splenorenal shunting and devascularization of esophagogastric varices. DISCUSSION Extrahepatic Portal Vein obstruction is the most common cause of noncirrhotic portal hypertension in children. Its occurrence in the pediatric population is very rare. Portal hypertension can lead to variceal bleeding and splenomegaly, which can have a significant impact on a child's long-term health. Because of its insidious nature, a meticulous workup is required for its diagnosis, and treatment in the pediatric population is difficult, and appropriate guidelines for its management specifically targeting the pediatric population are lacking. CONCLUSION Extrahepatic Portal Vein obstruction is rare in children with a difficult diagnosis and management. Despite these hindrances, timely intervention can lift a significant burden of its detrimental outcome off the young children and drastically uplift the quality of life of these patients.
Collapse
Affiliation(s)
- Kritick Bhandari
- KIST Medical College and Teaching Hospital, Gwarko, Imadol, Lalitpur 44600, Nepal.
| | - Sarmendra Mishra
- Department of General Surgery, KIST Medical College and Teaching Hospital, Imadol, Lalitpur, Nepal
| | - Kamana Sen
- KIST Medical College and Teaching Hospital, Gwarko, Imadol, Lalitpur 44600, Nepal
| | - Prasnna Basnet
- KIST Medical College and Teaching Hospital, Gwarko, Imadol, Lalitpur 44600, Nepal
| | - Pawan Kumar Shah
- KIST Medical College and Teaching Hospital, Gwarko, Imadol, Lalitpur 44600, Nepal
| | - Manish Yadav
- Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Nepal
| |
Collapse
|
2
|
Goel P, Bhatnagar V, Chennur VS. Makeshift Shunts in Extrahepatic Portal Vein Obstruction in Pediatric Population. J Indian Assoc Pediatr Surg 2024; 29:152-158. [PMID: 38616824 PMCID: PMC11014182 DOI: 10.4103/jiaps.jiaps_21_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/23/2021] [Accepted: 10/25/2021] [Indexed: 04/16/2024] Open
Abstract
Background and Objectives More than 20% of patients with extrahepatic portal vein obstruction (EHPVO) may be deemed as nonshuntable due to lack of a suitable vein. The role of "makeshift shunts" or "lesser shunts" assumes importance in such cases. In this report, the authors have shared their experience with the makeshift shunts in the management of portal hypertension in children with emphasis upon anatomic considerations, resolution of symptoms, outcomes after surgery, and shunt patency. Materials and Methods During the period 1983-2018, 138 children with portal hypertension were managed under the care of a single surgeon (VB). Of them, 134 were EHPVO. Children with EHPVO were treated with splenectomy and proximal lienorenal shunt (n = 107), splenectomy and devascularization (n = 21), and makeshift shunts (n = 6). Makeshift shunts comprised (i) side-to-side right gastroepiploic vein (Rt-GEV) to left renal vein (LRV) shunt (n = 1), (ii) superior mesenteric vein (SMV) to inferior vena cava (IVC) shunt using a spiral saphenous venous graft (n = 1), (iii) side-to-side inferior mesenteric vein (IMV) to LRV shunt (n = 2), (iv) side-to-side IMV to IVC shunt (n = 1), (v) end-to-side IMV to IVC shunt (n = 1), and (vi) side-to-side IMV to LRV shunt (n = 1) in a case of crossed fused renal ectopia. Results Following the creation of portosystemic shunt, a decline in portal pressure was demonstrated in all six patients. There was resolution of symptoms including hematemesis, melena, and anorectal variceal bleed. None of the patients demonstrated the features of hepatic encephalopathy. The associated portal cavernoma cholangiopathy (n = 1) also resolved following Rt-GEV to LRV shunt. Shunt patency was documented for the entire duration of follow-up (1.5-4 years) in five of six patients; the sixth patient demonstrated shunt block at 6-month follow-up but without recurrence of symptoms. Conclusions Makeshift shunts offer a viable alternative to standard portosystemic shunting in pediatric patients with a nonshuntable vein. The selection of such shunts is, however, subject to surgeon's preferences and has to be individualized to local anatomy.
Collapse
Affiliation(s)
- Prabudh Goel
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Veereshwar Bhatnagar
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | | |
Collapse
|
3
|
Giri S, Singh A, Angadi S, Kolhe K, Roy A. Prevalence of hepatic encephalopathy in patients with non-cirrhotic portal hypertension: A systematic review and meta-analysis. Indian J Gastroenterol 2023; 42:642-650. [PMID: 37589913 DOI: 10.1007/s12664-023-01412-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/02/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Hepatic encephalopathy, (HE) although commonly associated with cirrhosis, has also been reported in non-cirrhotic portal hypertension (NCPH). The importance of identifying and treating HE in NCPH lies in the fact that many patients may be wrongly diagnosed as having psychiatric or neurologic disorders. Hence, we aimed to systematically review the prevalence of HE in NCPH. METHODS A comprehensive search of three databases (Medline, Embase and Scopus) was conducted from inception to November 2022 for studies reporting on the prevalence of minimal HE (MHE) and overt HE (OHE) in patients with NCPH. Results were presented as pooled proportions with their 95% confidence intervals (CI). RESULTS Total 25 studies (n = 1487) were included after screening 551 records. The pooled prevalence of MHE in NPCH was 32.9% (95% CI: 26.7-39.0) without any difference between adult (32.9%, 95% CI: 23.5-42.3) and pediatric patients (32.6%, 95% CI: 26.1-39.1) (p = 0.941). There was no significant difference in the prevalence between patients with NCPH and compensated cirrhosis with odds ratio of 1.06 (95% CI: 0.77-1.44). The pooled event rate for prior history of OHE in NCPH was 1.2% (95% CI: 0.3-2.1). CONCLUSION Around one-third of the patients with NCPH have MHE, irrespective of age group. OHE is extremely rare in NCPH and is usually associated with a precipitating factor.
Collapse
Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Ankita Singh
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, 400 012, India
| | - Sumaswi Angadi
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Kailash Kolhe
- Department of Gastroenterology, Narayana Hospital, Nanded, 431 602, India
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispecialty Hospital, Kolkata, 700 054, India.
| |
Collapse
|
4
|
Tanaka H, Muromachi K, Tamai T, Hashiguchi M, Enokizono R, Nakajyo Y, Iryo Y, Hori T, Tsubouchi H, Ido A. Extrahepatic portal vein aneurysm in which the acute thrombogenic process triggered by trauma confirmed by abdominal ultrasonography: a case report. Clin J Gastroenterol 2023; 16:702-708. [PMID: 37248440 PMCID: PMC10226713 DOI: 10.1007/s12328-023-01815-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 05/11/2023] [Indexed: 05/31/2023]
Abstract
Extrahepatic portal vein aneurysm (PVA) is a rare condition in which the extrahepatic portal vein is partially dilated into a sac-like or spindle-like shape. Usually, patients are followed, but surgery is considered in cases of rupture, thrombus, or enlargement. We report a case of thrombus formation in an extrahepatic portal vein aneurysm following trauma that resulted in regression of the aneurysm and extrahepatic portal vein occlusion. Immediately after the trauma, ultrasonography showed moderately hyperechoic structures and comet signs along the vessel wall of the aneurysm and turbulent blood flow in the aneurysm, like in a whirlpool. There were floating point-like echogenic features, which were presumed to be microthrombi. In other words, the trauma might have triggered Virchow's triad: changes in the vessel wall, changes in blood properties, and blood stagnation. This is a valuable case in which ultrasonography imaging revealed interesting changes during the thrombus formation process inside an extrahepatic portal vein aneurysm. The aneurysm's size was reduced by thrombus-induced organization, but the main trunk of the portal vein became deficient in blood flow, resulting in extrahepatic portal vein occlusion. This case is suggestive of the mechanism of extrahepatic portal vein occlusion.
Collapse
Affiliation(s)
- Hozuka Tanaka
- Department of Clinical Laboratory Technology, Kagoshima City Hospital, Kagoshima City, Japan
| | - Kaori Muromachi
- Department of Laboratory Medicine, Kagoshima City Hospital, Kagoshima City, Japan
| | - Tsutomu Tamai
- Department of Gastroenterology, Kagoshima City Hospital, 37-1 Uearatacho, Kagoshima City, Kagoshima, Japan.
| | - Masafumi Hashiguchi
- Department of Gastroenterology, Maehara General Medical Hospital, Kagoshima City, Japan
| | - Ryuhei Enokizono
- Department of Clinical Laboratory Technology, Kagoshima City Hospital, Kagoshima City, Japan
| | - Yuuki Nakajyo
- Department of Clinical Laboratory Technology, Kagoshima City Hospital, Kagoshima City, Japan
| | - Yumi Iryo
- Department of Clinical Laboratory Technology, Kagoshima City Hospital, Kagoshima City, Japan
| | - Takeshi Hori
- Department of Laboratory Medicine, Kagoshima City Hospital, Kagoshima City, Japan
- Department of Gastroenterology, Kagoshima City Hospital, 37-1 Uearatacho, Kagoshima City, Kagoshima, Japan
| | - Hirohito Tsubouchi
- Department of Laboratory Medicine, Kagoshima City Hospital, Kagoshima City, Japan
| | - Akio Ido
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| |
Collapse
|
5
|
Yuldashev RZ, Aliev MM, Maksudov MF, Khaydarov UO, Shokhaydarov S. Angiographic patterns of portal venous system in children with extrahepatic portal hypertension and its etiological and clinical relevance. Pediatr Surg Int 2023; 39:97. [PMID: 36723662 DOI: 10.1007/s00383-023-05384-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE To study the relationship between the angiographic pattern of extrahepatic portal vein obstruction (EHPVO) and its etiology and clinical manifestations. METHODS Clinical, etiological, and angiographic findings in 155 children with EHPVO were reviewed. Anatomy of extrahepatic portal venous system (EPVS) was categorized into five imaging patterns. Assessment of the severity of esophageal and gastric varices (EV and GV) was performed by upper gastrointestinal endoscopy. RESULTS Based on multislice CT angiography, most commonly observed pattern of EHPVO was type I (48.4%) and type II (29%). According to anamnesis, 68 (43.8%) children had pathological conditions in neonatal period. Of these, 35 (22.6%) had an umbilical vein catheterization, 11 (7.1%) had a history of omphalitis, and 9 (5.8%) had prolonged jaundice. Thirteen (8.4%) patients had various septic conditions in neonatal period and it was more common associated with widespread thrombosis throughout the EPVS (type 5)-28% of observations. Significantly lower risk of bleeding from EV (p = 0.01) was noted in children with type IV pattern, whereas children with type III and V patterns had higher grades of EV. CONCLUSION Angiographic pattern of portomesenteric occlusion may provide a clue to its etiology, and clinical manifestation, especially in children with widespread thrombosis throughout the EPVS.
Collapse
|
6
|
Zhou Y, Zhuang Z, Yu T, Zhang W, Ma J, Yu J, Yan Z, Luo J. Long-term efficacy and safety of anticoagulant for cavernous transformation of the portal vein cirrhotic patient with extrahepatic portal vein obstruction. Thromb J 2023; 21:6. [PMID: 36631860 PMCID: PMC9832773 DOI: 10.1186/s12959-023-00449-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND/AIMS Cavernous transformation of the portal vein (CTPV) in cirrhotic patients with extrahepatic portal vein obstruction (EHPVO) was a relatively rare disease and had no consensus on the treatment. Our study aimed to explore the value of anticoagulation with warfarin treatment for CTPV cirrhotic patients with EHPVO. METHODS From January 2015 to December 2019, the clinical characteristics of cirrhotic patients who were diagnosed as CTPV with EHPVO were retrospectively analyzed. Eligible patients were distributed into the anticoagulation group (n = 46) and control group (n = 38). The change of portal vein thrombosis, hepatic decompensation, survival and adverse events were evaluated between the two groups. RESULTS The median follow-up of our patients was 51 months in the anticoagulation group and 44 months in the control group. The progress rate of the portal vein was higher in patients from the control groups (n = 12) than in patients from the anticoagulation group (n = 4, p = 0.008). There was no significant difference between the partial recanalization rate and stable rate between the two groups. Patients in anticoagulation group developed less hepatic decompensation than those in control group (13.0% vs 34.2%, p = 0.021). The Kaplan-Meier curve showed that patients in the anticoagulation group had a better prognosis than patients in the control group (P < 0.022). There were no serious complications due to warfarin treatment. CONCLUSION For CTPV cirrhotic patients with EHPVO, anticoagulation with warfarin treatment was effective and safe. Anticoagulants could prevent portal vein thrombosis progression, hepatic decompensation and death. In addition, our results showed little benefit of anticoagulants on thrombosis recanalization.
Collapse
Affiliation(s)
- Yongjie Zhou
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiquan Zhuang
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Xiamen Branch, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianzhu Yu
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China
| | - Wen Zhang
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingqin Ma
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaze Yu
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiping Yan
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China ,grid.8547.e0000 0001 0125 2443Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Jianjun Luo
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China ,grid.8547.e0000 0001 0125 2443Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
7
|
Brichard M, Iesari S, Lerut J, Reding R, Goffette P, Coubeau L. Meso-Rex bypass for the management of extrahepatic portal vein obstruction in adults (with video). Hepatobiliary Pancreat Dis Int 2022; 21:25-32. [PMID: 34426078 DOI: 10.1016/j.hbpd.2021.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Extrahepatic portal vein obstruction (EHPVO) results in severe portal hypertension (PHT) leading to severely compromised quality of life. Often, pharmacological and endoscopic management is unable to solve this problem. Restoring hepatic portal flow using meso-Rex bypass (MRB) may solve it. This procedure, uncommon in adult patients, is considered the treatment of choice for EHPVO in children. METHODS From 1997 to 2018, 8 male and 6 female adults, with a median age of 51 years (range 22-66) underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels, Belgium. Symptoms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings, sepsis due to portal biliopathy, and/or severe abdominal discomfort. The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein. RESULTS Median operative time was 500 min (range 300-730). Median follow-up duration was 22 months (range 2-169). One patient died due to hemorrhagic shock following percutaneous transluminal intervention for early graft thrombosis. Major morbidity, defined as Clavien-Dindo score ≥ III, was 35.7% (5/14). Shunt patency at last follow-up was 64.3% (9/14): 85.7% (6/7) of pure venous grafts and only 42.9% (3/7) of prosthetic graft. Symptom relief was achieved in 85.7% (12/14) who became asymptomatic after MRB. CONCLUSIONS Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications. In such patients, MRB represents the only and last resort to restore physiological portal vein flow. Although successful in a majority of patients, this procedure is associated with major morbidity and mortality and should be done in tertiary centers experienced with vascular liver surgery to get the best results.
Collapse
|
8
|
Yamoto M, Chusilp S, Alganabi M, Sayed BA, Pierro A. Meso-Rex bypass versus portosystemic shunt for the management of extrahepatic portal vein obstruction in children: systematic review and meta-analysis. Pediatr Surg Int 2021; 37:1699-1710. [PMID: 34714410 DOI: 10.1007/s00383-021-04986-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Extrahepatic portal vein obstruction (EHPVO) is a major cause of non-cirrhotic portal hypertension in children. Surgical procedures for EHPVO include portosystemic shunts (PSS) and meso-Rex bypass (MRB). We conducted a systematic review and meta-analysis to compare the effectiveness of MRB versus PSS in EHPVO patients. METHODS A systematic literature search was performed using four databases. Articles reporting EHPVO and comparing patients who received MRB and PSS were included in the analysis. RESULTS We retrieved 851 papers, of which five observational studies met the inclusion criteria. There was no difference in shunt complications, mortality, or gastrointestinal bleeding after surgery between MRB and PSS in the meta-analysis. MRB had increased shunt complications compared with PSS in the non-comparative studies. MRB had a potential advantage over PSS in long-term prognosis in one comparative study. Overall, the quality of the evidence was low. CONCLUSIONS Based on available data, our meta-analysis indicates that MRB does not increase shunt complications, mortality, or gastrointestinal bleeding after surgery. The present study did not reveal superiority for either MRB or PSS. The paucity of well conducted trials in this area justifies future multicenter studies and studies that examine long-term outcomes.
Collapse
Affiliation(s)
- Masaya Yamoto
- Division of General and Thoracic Surgery, Translational Medicine, The Hospital for Sick Children, 1526-555 University Ave., Toronto, ON, M5G 1X8, Canada.,Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Sinobol Chusilp
- Division of General and Thoracic Surgery, Translational Medicine, The Hospital for Sick Children, 1526-555 University Ave., Toronto, ON, M5G 1X8, Canada.,Division of Pediatric Surgery, Department of Surgery, Khon Kaen University, Khon Kaen, Thailand
| | - Mashriq Alganabi
- Division of General and Thoracic Surgery, Translational Medicine, The Hospital for Sick Children, 1526-555 University Ave., Toronto, ON, M5G 1X8, Canada
| | - Blayne Amir Sayed
- Division of General and Thoracic Surgery, Translational Medicine, The Hospital for Sick Children, 1526-555 University Ave., Toronto, ON, M5G 1X8, Canada.,Division of General Surgery, Department of Surgery, Toronto General Hospital-University Health Network, Toronto, ON, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, Translational Medicine, The Hospital for Sick Children, 1526-555 University Ave., Toronto, ON, M5G 1X8, Canada.
| |
Collapse
|
9
|
Sarma MS, Seetharaman J. Pediatric non-cirrhotic portal hypertension: Endoscopic outcome and perspectives from developing nations. World J Hepatol 2021; 13:1269-1288. [PMID: 34786165 PMCID: PMC8568571 DOI: 10.4254/wjh.v13.i10.1269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/27/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
Non-cirrhotic portal hypertension (NCPH) forms an important subset of portal hypertension in children. Variceal bleed and splenomegaly are their predominant presentation. Laboratory features show cytopenias (hypersplenism) and preserved hepatic synthetic functions. Repeated sessions of endoscopic variceal ligation or endoscopic sclerotherapy eradicate esophageal varices in almost all cases. After variceal eradication, there is an increased risk of other complications like secondary gastric varices, cholangiopathy, colopathy, growth failure, especially in extra-hepatic portal vein obstruction (EHPVO). Massive splenomegaly-related pain and early satiety cause poor quality of life (QoL). Meso-Rex bypass is the definitive therapy when the procedure is anatomically feasible in EHPVO. Other portosystemic shunt surgeries with splenectomy are indicated when patients present late and spleen-related issues predominate. Shunt surgeries prevent rebleed, improve growth and QoL. Non-cirrhotic portal fibrosis (NCPF) is a less common cause of portal hypertension in children in developing nations. Presentation in the second decade, massive splenomegaly and patent portal vein are discriminating features of NCPF. Shunt surgery is required in severe cases when endotherapy is insufficient for the varices. Congenital hepatic fibrosis (CHF) presents with firm palpable liver and splenomegaly. Ductal plate malformation forms the histological hallmark of CHF. CHF is commonly associated with Caroli’s disease, renal cysts, and syndromes associated with neurological defects. Isolated CHF has a favourable prognosis requiring endotherapy. Liver transplantation is required when there is decompensation or recurrent cholangitis, especially in Caroli’s syndrome. Combined liver-kidney transplantation is indicated when both liver and renal issues are present.
Collapse
Affiliation(s)
- Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Jayendra Seetharaman
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| |
Collapse
|
10
|
Sasturkar SV, Agrawal N, Arora A, Kumar MPS, Kilambi R, Thapar S, Chattopadhyay TK. Laparoscopic cholecystectomy in patients with portal cavernoma without portal vein decompression. J Minim Access Surg 2021; 17:351-355. [PMID: 32964890 PMCID: PMC8270052 DOI: 10.4103/jmas.jmas_106_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC. Patients and Methods Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips. Results Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130-250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four. Conclusion LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.
Collapse
Affiliation(s)
| | - Nikhil Agrawal
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Asit Arora
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - M P Senthil Kumar
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ragini Kilambi
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shalini Thapar
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Tushar Kanti Chattopadhyay
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| |
Collapse
|
11
|
Vadlapudi SS, Jagadisan B, Ananthkrishnan R, Narayanaswamy S. Splenic stiffness and platelet count to predict varices needing treatment in pediatric extrahepatic portal vein obstruction. Indian J Gastroenterol 2020; 39:576-83. [PMID: 33231766 DOI: 10.1007/s12664-020-01099-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/16/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surveillance endoscopy to detect varices needing treatment (VNT) is important to prevent bleeding and morbidity in portal hypertension. In adult and pediatric cirrhosis, platelet count and liver stiffness measurement (LSM) are useful in selecting patients for endoscopy. Such recommendations do not exist for extrahepatic portal vein obstruction (EHPVO). Splenic stiffness measurement (SSM) has been studied in adult and pediatric EHPVO with conflicting results and methodological errors. This study evaluates the role of platelet counts and SSM to predict VNT and bleeding in pediatric EHPVO while comparing LSM and SSM between pediatric EHPVO and controls. METHODS One hundred and seven children (55 with EHPVO and 52 controls) were recruited. Clinical, biochemical, hematological, and radiographic parameters of all children were noted. All children with EHPVO underwent endoscopy. RESULTS Of the 55 children with EHPVO, 48 (87.3%) had VNT. There was no difference in the platelet counts (85,000/mm3 vs. 120,000/mm3, p = 0.58) and SSM (3.62 vs. 3.19, p = 0.05) between EHPVO children with VNT and those without. They had poor sensitivity and specificity to predict VNT. EHPVO children with bleeding had higher SSM that those without. LSM was higher among EHPVO than among controls (1.19 vs. 1.10, p = 0.003). Those with LSM higher than controls had normal liver histology. CONCLUSION SSM is higher in EHPVO bleeders but SSM and platelet counts are unreliable to predict VNT in pediatric EHPVO. Surveillance endoscopies may be needed in all pediatric EHPVO until better screening strategies are available. TRIAL REGISTRATION Not applicable.
Collapse
|
12
|
Abdelkder HM, Abdel-Latif M, Abdelsattar M, Allam AE, Youssef AA. Splenectomy with proximal spleno-left portal shunt for extrahepatic portal vein obstruction in children. J Pediatr Surg 2020; 55:2238-2242. [PMID: 32680585 DOI: 10.1016/j.jpedsurg.2020.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 05/24/2020] [Accepted: 06/14/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE To report our initial experience with splenectomy and proximal spleno-left portal shunt as an alternative to the standard Rex shunt, when not applicable, in children with Extrahepatic Portal Vein Obstruction (EHPVO). METHODS Patients from March 2015 till September 2018, with EHPVO not suitable for Rex shunt or whose caregivers refused to consent for Internal Jugular Vein (IJV) dissection were assessed and prepared for splenectomy with proximal spleno-left portal shunt. The operative technique includes splenectomy, freeing of the splenic vein from the pancreatic bed till its junction with the inferior mesenteric vein, and then anastomosis with the intrahepatic left portal vein at the Rex recess. A distal lieno-renal shunt was performed in one patient and was excluded from the study. RESULTS A total of 14 patients (mean age: 4.6 years) underwent splenectomy with proximal spleno-left portal shunt during the study period. The mean operative time was 246 min, while the mean postoperative hospital stay was 4.1 days. The patients' follow up period ranged from 6 to 42 months (median: 19.6 months). Only two patients had a single attack of variceal bleeding, 2 and 2.5 months postoperative respectively, and required endoscopic management with no further bleeding episodes. While the rest of patients showed an improvement of their variceal grades after the surgery. CONCLUSION Splenectomy with proximal spleno-left portal shunt seems to be a valuable alternative to the standard Rex shunt in treatment of children with EHPVO unsuitable for or following unsuccessful Rex shunt. LEVEL OF EVIDENCE IV.
Collapse
|
13
|
Nicoară-Farcău O, Rusu I, Stefănescu H, Tanțău M, Badea RI, Procopeț B. Diagnostic challenges in non-cirrhotic portal hypertension - porto sinusoidal vascular disease. World J Gastroenterol 2020; 26:3000-3011. [PMID: 32587444 PMCID: PMC7304099 DOI: 10.3748/wjg.v26.i22.3000] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/31/2020] [Accepted: 05/27/2020] [Indexed: 02/06/2023] Open
Abstract
Non-cirrhotic portal hypertension consists of a group of diseases characterized by signs and complications of portal hypertension, which differ from cirrhosis through histological alterations, hemodynamic characterization and, clinical outcome. Because of the similarities in clinical presentation and imaging signs, frequently these patients, and particularly those with porto-sinusoidal vascular disease (PSVD), are misdiagnosed as having liver cirrhosis and thus raising difficulties in their diagnosis. The most challenging differentiation to be considered is between PSVD and cirrhosis and, although not pathognomonic, liver biopsy is still the standard of diagnosis. Although they still require extended validation before being broadly used, new non-invasive methods for the diagnosis of porto-sinusoidal vascular disease, like transient elastography, contrast-enhanced ultrasound or metabolomic profiling, have shown promising results. Another issue is the differentiation between PSVD and chronic extrahepatic portal vein obstruction, especially now when it is known that 40% of patients suffering from PSVD develop portal vein thrombosis. In this particular case, once the portal vein thrombosis occurred, the diagnosis of PSVD is impossible according to the current guidelines. Moreover, so far, the differentiation between PSVD and sinusoidal obstruction syndrome has not been clear so far in particular circumstances. In this review we highlighted the diagnostic challenges regarding the PSVD, as well as the current techniques used in the evaluation of these patients.
Collapse
Affiliation(s)
- Oana Nicoară-Farcău
- University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca 400000, Romania
- Gastroenterology Department, Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Cluj-Napoca 400000, Romania
| | - Ioana Rusu
- University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca 400000, Romania
- Pathology Department, Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Cluj-Napoca 400000, Romania
| | - Horia Stefănescu
- Gastroenterology Department, Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Cluj-Napoca 400000, Romania
| | - Marcel Tanțău
- University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca 400000, Romania
- Gastroenterology Department, Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Cluj-Napoca 400000, Romania
| | - Radu Ion Badea
- University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca 400000, Romania
- Imagistic Department, Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Cluj-Napoca 400000, Romania
| | - Bogdan Procopeț
- University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca 400000, Romania
- Gastroenterology Department, Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Cluj-Napoca 400000, Romania
| |
Collapse
|
14
|
Yuldashev RZ, Aliev MM, Shokhaydarov SI, Tursunova DB. Spleen stiffness measurement as a non-invasive test to evaluate and monitor portal hypertension in children with extrahepatic portal vein obstruction. Pediatr Surg Int 2020; 36:637-641. [PMID: 32206893 DOI: 10.1007/s00383-020-04648-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of the study was to test the feasibility of spleen stiffness measurement (SSM) by two-dimensional shear wave elastography (2D-SWE) and compare data on its diagnostic use with upper gastrointestinal endoscopy in children with extrahepatic portal hypertension (EHPH) before and after surgery. METHODS A total of 44 children were included in this study [34 children with EHPH (main group)] and 10 controls (7.57 ± 1.22 years), who underwent ultrasonography including SSM by 2D-SWE. Patients in the main group also underwent upper gastrointestinal endoscopy (UGE) and CT angiography. The main group was divided into three subgroups: Group A: patients with EHPH without large spontaneous portosystemic shunts (n = 15); Group B: patients with EHPH with large spontaneous portosystemic shunts (n = 9); Group C: patients with EHPVO and after surgical portosystemic shunts (n = 10). RESULTS According to UGE, children in group A had significantly higher grades of esophageal varices (EV) (2.3 ± 0.14; p < 0.001) compared to those in groups B and C. After surgical shunting procedures (in group C), the grade of EV declined to 0.37 ± 0.14. There was significant difference (p < 0.001) in the mean SS of children in group A (70 ± 4.64 kPa) compared to those in group B (37.04 ± 4.62 kPa) and group C (26.3 ± 2.9 kPa). After surgery, SS decreased but remained elevated compared with controls (26.3 ± 2.9 vs 17.85 ± 1.3 kPa; p = 0.016). The SS showed a small but significant correlation with grades of EV (r = 0.56, p = 0.002). CONCLUSIONS The SS measured by 2D-SWE is feasible in children with EHPH and the results reflect the presence or degree of EV, thus elastography of spleen is useful in monitoring portal hypertension before and after shunt surgeries.
Collapse
Affiliation(s)
- R Z Yuldashev
- Department of Pediatric Surgery, Republican Specialized Scientific Practical Medical Center of Pediatrics, Tashkent, Uzbekistan. .,Department of Pediatric Surgery, Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan.
| | - M M Aliev
- Department of Pediatric Surgery, Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
| | - Sh I Shokhaydarov
- Department of Pediatric Surgery, Republican Specialized Scientific Practical Medical Center of Pediatrics, Tashkent, Uzbekistan
| | - D B Tursunova
- Department of Radiology, Republican Specialized Scientific Practical Medical Center of Pediatrics, Tashkent, Uzbekistan
| |
Collapse
|
15
|
Liao TY, Liaw CC, Hsu HC, Hsieh CH, Chang JWC, Juan YH. Extrahepatic Portal Venous Obstruction With Hepatic Enzyme Elevation Resembling Hepatitis in Patients With Cancer. In Vivo 2020; 33:1697-1702. [PMID: 31471426 DOI: 10.21873/invivo.11658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/08/2019] [Accepted: 07/15/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIM Chemotherapy is often halted due to abnormal liver function resembling hepatitis. But the cause can be extrahepatic portal venous obstruction (EHPVO) with hepatic enzyme elevation rather than being an adverse effect of chemotherapy. We investigated EHPVO with hepatic enzyme elevation in patients with cancer. PATIENTS AND METHODS Data of these hospitalized patients with solid tumors between January 2013 and September 2017 were collected. The criteria for study inclusion were: (i) Extrahepatic malignancy; (ii) computed tomographic scans showing a tumor with external compression of the extrahepatic portal vein; and (iii) serum aminotransferase (AST) or alanine transaminase (ALT) level three times above the normal value. RESULTS Thirteen out of 377 (3%) patients developed EHPVO with hepatic enzyme elevation, as demonstrated from computed tomographic scan. Four cases (31%) also had vascular thrombosis (three portal vein and one inferior vena cava). Serum AST increased from 34±11 to 169±94 U/l. ALT increased from 9±38 to 177±104 U/l. There was no relationship of EHPVO with viral markers and cirrhosis. Six cases received chemotherapy with liver function improvement. CONCLUSION EHPVO occurred in patients with metastatic cancer, leading to hepatic enzyme elevation resembling hepatitis without hepatitis risk factors and cirrhosis. Before withholding chemotherapy due to hepatic enzyme elevation, the possibility of EHPVO should firstly be excluded.
Collapse
Affiliation(s)
- Tzu-Yao Liao
- Division of Hemato-Oncology, Department of Internal Medicine, Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C
| | - Chuang-Chi Liaw
- Division of Hemato-Oncology, Department of Internal Medicine, Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C.
| | - Hui-Ching Hsu
- Division of Chinese Acupuncture and Traumatology, Department of Traditional Chinese Medicine, Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C
| | - Chia-Hsun Hsieh
- Division of Hemato-Oncology, Department of Internal Medicine, Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C
| | - John Wen-Cheng Chang
- Division of Hemato-Oncology, Department of Internal Medicine, Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C
| | - Yu-Hsiang Juan
- Department of Medical Imaging and Intervention, Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C
| |
Collapse
|
16
|
Ravindranath A, Sen Sarma M, Yachha SK, Lal R, Singh S, Srivastava A, Poddar U, Neyaz Z, Behari A. Outcome of portosystemic shunt surgery on pre-existing cholangiopathy in children with extrahepatic portal vein obstruction. J Hepatobiliary Pancreat Sci 2019; 27:141-148. [PMID: 31654467 DOI: 10.1002/jhbp.692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study was performed to assess the effect of portosystemic shunt surgery (PSS) on portal cavernoma cholangiopathy (PCC) in children with extrahepatic portal vein obstruction (EHPVO). METHODS Children with EHPVO and PCC (unfit for Meso-Rex shunt) underwent magnetic resonance cholangiogram (MRC) and magnetic resonance portovenogram (MRPV) before non-selective PSS. PCC was graded by modified Llop classification. Those with patent shunt were re-evaluated at least 6 months after surgery with MRC, MRPV and compared with pre-shunt images. RESULTS Twenty-five children underwent PSS (central end to side splenorenal shunt with splenectomy [n = 24], mesocaval shunt [n = 1]). Pre-surgery MRC showed PCC grade I in 11, grade II in 1 and grade III in 13. MRPV showed superior mesenteric vein (SMV) block in 20. Re-assessment for PCC 18 (6 to 54) months after surgery showed grade I in 6 and grade III in 19. Thus, PCC was progressive in 6 and static in 19. Density of peribiliary collaterals decreased in 5 (SMV patent, static PCC), increased in 3 and remained unchanged in 17. Splenomegaly-related problems, gastroesophageal varices and other intra-abdominal (esophageal, perisplenic and perigastric) collaterals ameliorated in all. CONCLUSION Non-selective PSS decompresses esophago-gastro-splenic venous circuit effectively but fails to ameliorate cholangiopathy and peribiliary collaterals. Persistence of cholangiopathy is attributable to SMV block.
Collapse
Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Richa Lal
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Somesh Singh
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Zafar Neyaz
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anu Behari
- Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
17
|
Long L, Jinshan Z, Zhen C, Qi L, Ning D, Mei D, Wei C. Portal-to-right portal vein bypass for extrahepatic portal vein obstruction. J Pediatr Surg 2018; 53:1403-1407. [PMID: 29198895 DOI: 10.1016/j.jpedsurg.2017.10.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 08/25/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Rex shunt (mesenteric-to-left portal vein bypass) is considered a more physiologically rational treatment for EHPVO than other portosystemic systemic shunts in children. However, about 13.6% of children with EHPVO do not have usable left portal veins and up to 28.1%. Rex operations in children are not successful. Hence, a Rex shunt in these children was impossible. This study reports a novel approach by portal-to-right portal vein bypass for treatment of children with failed Rex shunts. MATERIAL AND METHODS Eight children (age 6.1years, range 3.5-8.9years) who underwent Rex shunts developed recurrent gastrointestinal bleeding and hypersplenism 13months (11-30months) postoperatively. After ultrasound confirmation of blocked shunt, they underwent exploration. Three patients were found to have right portal vein agenesis. Five patients (62.5%) were found to have the patent right portal vein, with the diameter of 3-6mm. Four patients underwent bypass between the main portal vein in the hepatoduodenal ligament and the right portal vein by interposing an inferior mesenteric vein autograft, whereas the remaining patient underwent a bypass using ileal mesenteric vein autograft. RESULTS The operations took 2.3h (1.9-3.5h). The estimated blood loss was 50ml (30-80ml), with no complication. The portal venous pressure dropped from 34.6cmH2O (28-45 cmH2O) before the bypass to 19.6cmH2O (14-24cmH2O) after the bypass. The 5 patients were followed up for 10.2months (4-17months) and the post-operative ultrasound and CT angiography confirmed the patency of all the grafts and disappearance of the portal venous cavernova in all five patients. CONCLUSION The portal-to-right portal vein bypass technique is feasible and safe for treatment of children with EHPVO who have had failed Rex shunts. Our preliminary result indicates that this technique extends the success of Rex shunt from left portal vein to right portal vein and open a new indication of physiological shunt for some of the children who not only have had failed Rex shunts or but also are not suitable for the Rex shunts. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Li Long
- Department of Pediatric Surgery, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, 100021, People's Republic of China; Medical Department, Peking University, Beijing, 100000, People's Republic of China.
| | - Zhang Jinshan
- Department of Pediatric Surgery, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, 100021, People's Republic of China; Medical Department, Peking University, Beijing, 100000, People's Republic of China
| | - Chen Zhen
- Department of Pediatric Surgery, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, 100021, People's Republic of China
| | - Li Qi
- Department of Pediatric Surgery, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, 100021, People's Republic of China
| | - Dong Ning
- Department of Pediatric Surgery, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, 100021, People's Republic of China
| | - Diao Mei
- Department of Pediatric Surgery, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, 100021, People's Republic of China
| | - Cheng Wei
- Department of Pediatric Surgery, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, 100021, People's Republic of China
| |
Collapse
|
18
|
Abstract
The two cornerstones of management for Extrahepatic portal vein obstruction (EHPVO) are endotherapy and surgery [Porto-systemic shunts (PSS)/Mesorex bypass (MRB)]. Endotherapy is the mainstay of treatment for acute variceal bleed control and has also been used extensively for secondary prophylaxis till variceal eradication is achieved. However, long-term follow-up beyond endoscopic eradication of esophageal varices (EEEV) indicates that there are numerous delayed bleed and non bleed sequelae of EHPVO, which merit surgery as a definitive procedure to decompress the hypertensive portal venous system. While endotherapy obliterates natural porto-systemic collaterals in the gastroesophageal region, persistently raised portal pressures manifest as an increase in secondary isolated gastric varices, ectopic varices, portal hypertensive vasculopathy, issues related to massive splenomegaly, portal biliopathy, growth retardation and hence impaired quality of life (QOL). An ideal management strategy should address both bleed and non-bleed consequences of EHPVO and translate into a near normal QOL. Further, MRB has opened up new dimensions to the management philosophy of EHPVO. This review article critically evaluates the role of surgery and endotherapy based on available literature and authors' own experience.Surgery and endotherapy are complementary. However, with increasing duration of follow-up post EEEV, it is evident that there is resurgence in the role of surgery (PSS/MRB) as a single one time definitive procedure for alleviating all bleed and delayed non bleed sequelae of EHPVO.Surgery for EHPVO (PSS/MRB) should not be allowed to become a dying art and future generations of surgeons should continue to receive training in this specialized area of surgery.
Collapse
Affiliation(s)
- Richa Lal
- Department of Pediatric Surgical Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Manish K Gupta
- Department of Pediatric Surgical Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| |
Collapse
|
19
|
Madhusudhan KS, Sharma R, Kilambi R, Shylendran S, Shalimar, Sahni P, Gupta AK. 2D Shear Wave Elastography of Liver in Patients with Primary Extrahepatic Portal Vein Obstruction. J Clin Exp Hepatol 2017; 7:23-27. [PMID: 28348467 PMCID: PMC5357710 DOI: 10.1016/j.jceh.2016.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 12/22/2016] [Indexed: 12/12/2022] Open
Abstract
AIMS To evaluate liver stiffness (LS) in patients of primary extrahepatic portal vein obstruction (EHPVO) using 2D shear wave elastography (SWE) and compare it with healthy volunteers. METHODS Fifty patients (mean age: 22.4 years) of EHPVO and 25 healthy volunteers were included in the study. Liver function tests and viral markers were done in both groups and endoscopy in EHPVO group, followed by ultrasonography and SWE of liver. Liver elastography was done with patients/volunteers in supine position through right intercostal space. The LS for right lobe of liver was recorded in kilopascals. Three such measurements were taken and the mean of both groups were compared. The variables were also correlated with mean LS using Pearson's correlation coefficient in EHPVO group. RESULTS There was no significant difference in the mean LS in patients of EHPVO (5.96 kPa) and healthy volunteers (5.47 kPa) (P = 0.093). There was no significant correlation between LS with duration of symptoms, hematemesis, esophageal varices, total bilirubin, serum alkaline phosphatase and aspartate aminotranferase levels in EHPVO group. CONCLUSION SWE of liver may be used as a simple additional tool in the diagnosis of patients of EHPVO who show LS values similar to normal liver.
Collapse
Affiliation(s)
- Kumble S. Madhusudhan
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India,Address for correspondence: Raju Sharma, Professor, Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sudhin Shylendran
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Arun K. Gupta
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| |
Collapse
|
20
|
Domínguez Amillo E, De la Torre Ramos C, Andrés Moreno A, Encinas Hernández JL, Hernández Oliveros F, López Santamaría M. [Results of the mesoportal bypass (Rex shunt) in the treatment of idiopathic extrahepatic portal vein obstruction in children]. Cir Pediatr 2017; 30:22-27. [PMID: 28585786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Extrahepatic portal vein obstruction (EPVO) is the principal cause of portal hypertension in children. The objective of this study was to analyze the capacity of the surgical technique that creates a mesoportal shunt to treat changes caused by EPVO. METHODS Retrospective review of patients with idiopathic EPVO who underwent a mesoportal shunt and analysis of the changes in the number of leucocytes, platelets, prothrombin time and spleen size one year after the surgery. RESULTS Twelve patients underwent surgery, out of which 10 had prior leukopenia, 11 thrombopenia, 9 longer prothrombin times and all had hypersplenism. One patient suffered a postoperative shunt thrombosis, was reoperated and underwent a change in the operative technique. The remaining patients (92%) have functioning shunts 4.3 ± 2.5 years after surgery, and none have suffered any episode of gastrointestinal bleeding. One year after surgery, there were significant changes in the number of platelets, prothrombin time and spleen size, with no significant changes in the number of leukocytes. However, the number of patients who went from a leukopenic to a normal state was significant, as happened with changes in prothrombin time. CONCLUSIONS Mesoportal Rex shunt improves some of the disorders caused by portal hypertension in children suffering EPVO, with a high rate of surgical success. This technique should be of first choice in these patients.
Collapse
Affiliation(s)
- E Domínguez Amillo
- Departamento de Cirugía Pediátrica. Hospital Universitario La Paz. Madrid
| | | | - A Andrés Moreno
- Departamento de Cirugía Pediátrica. Hospital Universitario La Paz. Madrid
| | | | | | - M López Santamaría
- Departamento de Cirugía Pediátrica. Hospital Universitario La Paz. Madrid
| |
Collapse
|
21
|
Abstract
The term portal cavernoma cholangiopathy refers to the biliary tract abnormalities that accompany extrahepatic portal vein obstruction (EHPVO) and subsequent cavernous transformation of the portal vein. EHPVO is a primary vascular disorder of the portal vein in children and adults manifested by longstanding thrombosis of the main portal vein. Nearly all patients with EHPVO have manifestations of portal cavernoma cholangiopathy, such as extrinsic indentation on the bile duct and mild bile duct narrowing, but the majority are asymptomatic. However, progressive portal cavernoma cholangiopathy may lead to severe complications, including secondary biliary cirrhosis. A spectrum of changes is seen radiologically in the setting of portal cavernoma cholangiopathy, including extrinsic indentation of the bile ducts, bile duct stricturing, bile duct wall thickening, angulation and displacement of the extrahepatic bile duct, cholelithiasis, choledocholithiasis, and hepatolithiasis. Radiologists must be aware of this disorder in order to provide appropriate imaging evaluation and interpretation, to facilitate appropriate treatment and to distinguish this entity from its potential radiologic mimics.
Collapse
Affiliation(s)
- Lauren N Moomjian
- Department of Radiology, Virginia Commonwealth University Medical Center, 1250 East Marshall Street, PO Box Number 980615, Richmond, VA, 23298, USA.
| | - Sarah G Winks
- Department of Radiology, Virginia Commonwealth University Medical Center, 1250 East Marshall Street, PO Box Number 980615, Richmond, VA, 23298, USA
| |
Collapse
|
22
|
Mir TA, Misgar RA, Laway BA, Shah OJ, Shah ZA, Zargar SA. Prevalence and pattern of growth abnormalities in children with extrahepatic portal vein obstruction: Response to shunt surgery. Indian J Endocrinol Metab 2016; 20:763-766. [PMID: 27867876 PMCID: PMC5105557 DOI: 10.4103/2230-8210.192912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Growth retardation is common in children with extrahepatic portal vein obstruction (EHPVO) and growth hormone (GH) resistance may play a dominant role. The aim of this study was to ascertain growth parameters and growth-related hormones in children with EHPVO, comparing with controls and to study the response of shunt surgery on growth parameters. MATERIALS AND METHODS The auxological and growth-related hormone profile (GH; insulin-like growth factor binding protein-3 [IGFBP-3] and IGF-1) of thirty children with EHPVO were compared with controls. The effect of shunt surgery on growth parameters in 12 children was also studied. RESULTS The mean height standard deviation score (HSDS) of cases (-1.797 ± 1.146) was significantly lower than that of controls (-0.036 ± 0.796); the mean weight SDS of cases (-1.258 ± 0.743) was also lower than that of controls (-0.004 ± 0.533). The mean GH level of cases (5.00 ± 6.46 ng/ml) was significantly higher than that of controls (1.78 ± 2.04 ng/ml). The mean IGF-1 level of cases (100.25 ± 35.93 ng/ml) was significantly lower as compared to controls (233.53 ± 115.06 ng/ml) as was the mean IGFBP-3 level (2976.53 ± 1212.82 ng/ml in cases and 5183.28 ± 1531.28 ng/ml in controls). In 12 patients who underwent shunt surgery, growth parameters significantly improved. CONCLUSIONS Marked decrease in weight and height SDSs associated with GH resistance is seen in children with EHPVO, which improves with shunt surgery.
Collapse
Affiliation(s)
- Toufeeq Ahmad Mir
- Department of Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Raiz Ahmad Misgar
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Bashir Ahmad Laway
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Omar Javed Shah
- Department of Surgical Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Zafar Amin Shah
- Department of Immunology and Molecular Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Showkat Ali Zargar
- Department of Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| |
Collapse
|
23
|
Shinkai M, Mochizuki K, Kitagawa N, Take H, Usui H, Yamoto KN, Fujita S, Ohhama Y. Usefulness of a recanalized umbilical vein for vascular reconstruction in pediatric hepatic surgery. Pediatr Surg Int 2016; 32:553-8. [PMID: 27083897 DOI: 10.1007/s00383-016-3893-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Pediatric surgeons currently engage in various abdominal vascular surgeries, which sometimes require vascular conduits or grafts. Herein, we report our experience with patients undergoing vascular reconstruction using a recanalized umbilical vein (rUV) and their long-term outcome. METHOD Five patients with extrahepatic portal vein obstruction (EHPVO) underwent mesenterico-/porto-left portal vein (PV) bypass surgery using a short rUV conduit with an interposition vein graft. A sixth neonate with a huge hepatic tumor underwent PV reconstruction with anastomosis of rUV to the proximal PV stump following right hepatectomy with partial PV resection. A seventh patient underwent living donor liver transplantation for recurrent hepatoblastoma. The hepatic inferior vena cava (IVC) was resected because of tumor involvement and reconstructed by transposition of the infrahepatic IVC and interposition of rUV obtained from the donor liver graft. RESULTS Sufficient flow through rUV was achieved and maintained in all patients without any complications during follow-up (0.7-6.9 years). Esophageal varices, splenomegaly, and other laboratory test abnormalities because of portal hypertension disappeared after surgery in patients with EHPVO. CONCLUSION Our experience confirmed the usefulness and long-term patency of rUV as an entry to the intrahepatic PV and as a free vascular graft to reconstruct PV or IVC.
Collapse
Affiliation(s)
- Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan.
| | - Kyoko Mochizuki
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Norihiko Kitagawa
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Hiroshi Take
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Hidehito Usui
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Kaori Nakamura Yamoto
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Shogo Fujita
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Youkatsu Ohhama
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| |
Collapse
|
24
|
Abstract
Portal biliopathy (PB) refers to the biliary abnormalities of the biliary ducts observed in patients with extrahepatic portal hypertension. Although majority of patients are asymptomatic, approximately 20% of these patients present with biliary symptoms (pain, pruritus, jaundice, cholangitis). The pathogenesis of PB is uncertain but compression by dilated veins into or around common bile duct may play the main role. CT-scan, MR cholangiopancreatography with MR portography should be the initial investigations in the evaluation of PB. Treatment is limited to symptomatic cases and is dictated by clinical manifestations and complications of the disease. Treatment of PB could be done by endoscopy (sphincterotomy, stone extraction or biliary stenting of the common bile duct) or surgery (definitive decompression by porto-systemic shunt followed by bilioenteric anastomosis, if necessary). This review describes pathogenesis, clinical features, investigation and management of portal biliopathy.
Collapse
Affiliation(s)
- B Le Roy
- Service de chirurgie et oncologie digestive, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand, France; Service de chirurgie hépatobiliaire, centre hépato-bilaire Paul-Brousse, 94800 Villejuif, France
| | - M Gelli
- Service de chirurgie hépatobiliaire, centre hépato-bilaire Paul-Brousse, 94800 Villejuif, France
| | - B Serji
- Service de chirurgie hépatobiliaire, centre hépato-bilaire Paul-Brousse, 94800 Villejuif, France; Faculté de médecine, université Mohammed Premier Oujda, Morocco
| | - R Memeo
- Service de chirurgie hépatobiliaire, centre hépato-bilaire Paul-Brousse, 94800 Villejuif, France
| | - E Vibert
- Service de chirurgie hépatobiliaire, centre hépato-bilaire Paul-Brousse, 94800 Villejuif, France.
| |
Collapse
|
25
|
Qi XS, Bai M, He CY, Yin ZX, Guo WG, Niu J, Wu FF, Han GH. Prognostic factors in non-malignant and non-cirrhotic patients with portal cavernoma: An 8-year retrospective single-center study. World J Gastroenterol 2013; 19:7447-7454. [PMID: 24259977 PMCID: PMC3831228 DOI: 10.3748/wjg.v19.i42.7447] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 08/01/2013] [Accepted: 08/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the outcome of non-malignant and non-cirrhotic patients with portal cavernoma and to determine the predictors for survival.
METHODS: Between July 2002 and June 2010, we retrospectively enrolled all consecutive patients admitted to our department with a diagnosis of portal cavernoma without abdominal malignancy or liver cirrhosis. The primary endpoint of this observational study was death and cause of death. Independent predictors of survival were identified using the Cox regression model.
RESULTS: A total of 64 patients were enrolled in the study. During a mean follow-up period of 18 ± 2.41 mo, 7 patients died. Causes of death were pulmonary embolism (n = 1), acute leukemia (n = 1), massive esophageal variceal hemorrhage (n = 1), progressive liver failure (n = 2), severe systemic infection secondary to multiple liver abscesses (n = 1) and accident (n = 1). The cumulative 6-, 12- and 36-mo survival rates were 94.9%, 86% and 86%, respectively. Multivariate Cox regression analysis demonstrated that the presence of ascites (HR = 10.729, 95%CI: 1.209-95.183, P = 0.033) and elevated white blood cell count (HR = 1.072, 95%CI: 1.014-1.133, P = 0.015) were independent prognostic factors of non-malignant and non-cirrhotic patients with portal cavernoma. The cumulative 6-, 12- and 36-mo survival rates were significantly different between patients with and without ascites (90%, 61.5% and 61.5% vs 97.3%, 97.3% and 97.3%, respectively, P = 0.0008).
CONCLUSION: The presence of ascites and elevated white blood cell count were significantly associated with poor prognosis in non-malignant and non-cirrhotic patients with portal cavernoma.
Collapse
|
26
|
Ng CH, Lai L, Lok KH, Li KK, Szeto ML. Choledochal varices bleeding: A case report. World J Gastrointest Endosc 2010; 2:190-2. [PMID: 21160747 PMCID: PMC2999127 DOI: 10.4253/wjge.v2.i5.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 03/23/2010] [Accepted: 03/30/2010] [Indexed: 02/05/2023] Open
Abstract
Choledochal varices are a rare cause of hemobilia associated with chronic portal vein thrombosis. We present a case of chronic portal vein thrombosis complicated with bleeding from choledochal varices. The presentation, clinical manifestations and management are described.
Collapse
Affiliation(s)
- Chi Ho Ng
- Chi Ho Ng, Lawrence Lai, Ka Ho Lok, Kin Kong Li, Ming Leung Szeto, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong, China
| | | | | | | | | |
Collapse
|