Spontaneous porto-systemic shunts(SPSS)are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates,probably as a consequence of worsening portal hypertension,but without achieving an ...Spontaneous porto-systemic shunts(SPSS)are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates,probably as a consequence of worsening portal hypertension,but without achieving an effective protection against cirrhosis'complications.Several types of SPSS have been described in the literature,each one associated with different clinical manifestations.In particular,recurrent or persistent hepatic encephalopathy is more frequent in patients with splenorenal shunt,while the presence of gastric varices and consequently the incidence of variceal bleeding is more common in gastrorenal shunt.In the advanced stage,the presence of large SPSS can lead to the so called“portosystemic shunt syndrome”,characterized by a progressive deterioration of hepatic function,hepatic encephalopathy and,sometimes,portal vein thrombosis.The detection of SPSS in patients with liver cirrhosis is recommended in order to prevent or treat recurrent hepatic encephalopathy or variceal bleeding.展开更多
AIM:To present a dedicated series of transjugular intrahepatic porto-systemic shunts(TIPS) in the elderly since data is sparse on this population group.METHODS:A retrospective review was performed of patients at least...AIM:To present a dedicated series of transjugular intrahepatic porto-systemic shunts(TIPS) in the elderly since data is sparse on this population group.METHODS:A retrospective review was performed of patients at least 65 years of age who underwent TIPS at our institutions between 1997 and 2010.Twentyfive patients were referred for TIPS.We deemed that 2 patients were not considered appropriate candidates due to their markedly advanced liver disease.Of the 23 patients suitable for TIPS,the indications for TIPS placement was portal hypertension complicated by refractory ascites alone(n = 9),hepatic hydrothorax alone(n = 2),refractory ascites and hydrothorax(n = 1),gastrointestinal bleeding alone(n = 8),gastrointestinal bleeding and ascites(n = 3).RESULTS:Of these 23 attempted TIPS procedure patients,21 patients had technically successful TIPS procedures.A total of 29 out of 32 TIPS procedures including revisions were successful in 21 patients with a mean age of 72.1 years(range 65-82 years).Three of the procedures were unsuccessful attempts at TIPS and 8 procedures were successful revisions of our existing TIPS.Sixteen of 21 patients who underwent successful TIPS(excluding 5 patients lost to follow-up) were followed for a mean of 14.7 mo.Ascites and/or hydrothorax was controlled following technically successful procedures in 12 of 13 patients.Bleeding was controlled following technically successful procedures in 10 out of 11 patients.CONCLUSION:We have demonstrated that TIPS is an effective procedure to control refractory complications of portal hypertension in elderly patients.展开更多
AIMTo determine the impact of transjugular intrahepatic porto-systemic shunt (TIPS) on post liver transplantation (LT) outcomes. METHODSUtilizing the United Network for Organ Sharing (UNOS) database, we compared patie...AIMTo determine the impact of transjugular intrahepatic porto-systemic shunt (TIPS) on post liver transplantation (LT) outcomes. METHODSUtilizing the United Network for Organ Sharing (UNOS) database, we compared patients who underwent LT from 2002 to 2013 who had underwent TIPS to those without TIPS for the management of ascites while on the LT waitlist. The impact of TIPS on 30-d mortality, length of stay (LOS), and need for re-LT were studied. For evaluation of mean differences between baseline characteristics for patients with and without TIPS, we used unpaired t-tests for continuous measures and χ<sup>2</sup> tests for categorical measures. We estimated the impact of TIPS on each of the outcome measures. Multivariate analyses were conducted on the study population to explore the effect of TIPS on 30-d mortality post-LT, need for re-LT and LOS. All covariates were included in logistic regression analysis. RESULTSWe included adult patients (age ≥ 18 years) who underwent LT from May 2002 to September 2013. Only those undergoing TIPS after listing and before liver transplant were included in the TIPS group. We excluded patients with variceal bleeding within two weeks of listing for LT and those listed for acute liver failure or hepatocellular carcinoma. Of 114770 LT in the UNOS database, 32783 (28.5%) met inclusion criteria. Of these 1366 (4.2%) had TIPS between the time of listing and LT. We found that TIPS increased the days on waitlist (408 ± 553 d) as compared to those without TIPS (183 ± 330 d), P P P = 0.001) by TIPS to LOS. CONCLUSIONTIPS did increase time on waitlist for LT. More importantly, TIPS was not associated with 30-d mortality and re-LT, but it did lengthen hospital LOS after transplantation.展开更多
Budd-Chiari syndrome(BCS)is an uncommon disease of the liver,characterised by obstruction of the hepatic venous outflow tract.The etiological spectrum of BCS as well as venous obstruction pattern show wide geographica...Budd-Chiari syndrome(BCS)is an uncommon disease of the liver,characterised by obstruction of the hepatic venous outflow tract.The etiological spectrum of BCS as well as venous obstruction pattern show wide geographical and demographic variations across the globe.Compared to adults with BCS,children have primary BCS as the predominant etiology,earlier clinical presentation,and hence better treatment outcome.Underlying prothrombotic conditions play a key role in the etiopathogenesis of BCS,though work-up for the same is often unyielding in children.Use of next-generation sequencing in addition to conventional tests for thrombophilia leads to better diagnostic yield.In recent years,advances in radiological endovascular intervention techniques have revolutionized the treatment and outcome of BCS.Various non-invasive markers of fibrosis like liver and splenic stiffness measurement are being increasingly used to assess treatment response.Elastography techniques provide a novel non-invasive tool for measuring liver and splenic stiffness.This article reviews the diagnostic and therapeutic advances and challenges in children with BCS.展开更多
A severe spinal cord involvement may rarely occur in patients with cirrhosis and other chronic liver diseases;this complication is usually associated with overt liver failure and surgical or spontaneous porto-systemic...A severe spinal cord involvement may rarely occur in patients with cirrhosis and other chronic liver diseases;this complication is usually associated with overt liver failure and surgical or spontaneous porto-systemic shunt.Hepatic myelopathy(HM)is characterized by progressive weakness and spasticity of the lower extremities,while sensory and sphincter disturbances have rarely been described and are usually less important.The diagnosis is assigned in the appropriate clinical setting on clinical grounds after the exclusion of other clinical entities leading to spastic paraparesis.Magnetic resonance imaging is often unremarkable;however,also intracerebral corticospinal tract abnor-malities have been reported recently.The study of motor evoked potentials may disclose central conduction abnormalities even before HM is clinically manifest.HM responds poorly to blood ammonia-lowering and other conservative medical therapy.Liver transplantation represents a potentially definitive treatment for HM in patients with decompensated cirrhosis of Child-Pugh B and C grades.Other surgical treatment options in HM include surgical ligation,shunt reduction,or occlusion by interventional procedures.展开更多
Portal biliopathy(PB) is defined as the presence of biliary abnormalities in patients with non-cirrhotic/nonneoplastic extrahepatic portal vein obstruction(EHPVO) and portal cavernoma(PC). The pathogenesis of PB is du...Portal biliopathy(PB) is defined as the presence of biliary abnormalities in patients with non-cirrhotic/nonneoplastic extrahepatic portal vein obstruction(EHPVO) and portal cavernoma(PC). The pathogenesis of PB is due to ab extrinseco compression of bile ducts by PC and/or to ischemic damage secondary to an altered biliary vascularization in EHPVO and PC. Although asymptomatic biliary abnormalities can be frequently seen by magnetic resonance cholangiopancreatography in patients with PC(77%-100%), only a part of these(5%-38%) are symptomatic. Clinical presentation includes jaundice, cholangitis, cholecystitis, abdominal pain, and cholelithiasis. In this subset of patients is required a specific treatment. Different therapeutic approaches aimed to diminish portal hypertension and treat biliary strictures are available. In order to decompress PC, surgical porto-systemic shunt or transjugular intrahepatic porto-systemic shunt can be performed, and treatment on the biliary stenosis includes endoscopic(Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy, balloon dilation, stone extraction, stent placement) and surgical(bilioenteric anastomosis, cholecystectomy) approaches. Definitive treatment of PB often requires multiple and combined interventions both on vascular and biliary system. Liver transplantation can be considered in patients with secondary biliary cirrhosis, recurrent cholangitis or unsuccessful control of portal hypertension.展开更多
AIM:To investigate the effect of transjugular intra-hepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.METHODS: Twenty-one patients with liver cirrhosis and clinical indicati...AIM:To investigate the effect of transjugular intra-hepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.METHODS: Twenty-one patients with liver cirrhosis and clinical indications for TIPS insertion were investigated before and 1, 4, 12, 52 wk after TIPS. For each patient we assayed body composition parameters [dry lean mass, fat mass, total body water (TBW)], routine liver and kidney function tests, and free fatty acids (FFA). Glucose and insulin were measured for the calculation of the homeostasis model assessment insulin resistance (HOMA-IR); liver function was measured by the galactose elimination capacity (GEC); the severity of liver disease was graded by model for end-stage liver disease (MELD).RESULTS: Porto-systemic gradient decreased after TIPS (6.0±2.1 mmHg vs 15.8±4.8 mmHg, P<0.001). Patients were divided in two groups according to initial body mass index. After TIPS, normal weight patients had an increase in dry lean mass (from 10.9±5.9 kg to 12.7±5.6 kg, P=0.031) and TBW (from 34.5±7.6 L to 40.2±10.8 L,P=0.007), as well as insulin (from 88.9±49.2 pmol/L to 164.7±107.0 pmol/L,P=0.009) and HOMA-IR (from 3.36%±2.18% to 6.18%±4.82%,P=0.023). In overweight patients only FFA increased significantly (from 0.59±0.24 mmol/L to 0.93±0.34 mmol/L, P=0.023).CONCLUSION: TIPS procedure is effective in lowering portal pressure in patients with portal hypertension and improves body composition without significant changes in metabolic parameters.展开更多
BACKGROUND Duodenal varices are a lesser-known complication with non-cirrhotic portal hypertension. We report a circuitous route from missed diagnosis of duodenal varices to correction. An extremely rare case of duode...BACKGROUND Duodenal varices are a lesser-known complication with non-cirrhotic portal hypertension. We report a circuitous route from missed diagnosis of duodenal varices to correction. An extremely rare case of duodenal variceal bleeding secondary to idiopathic portal hypertension(IPH) is expounded in this study, which was controlled by transjugular intra-hepatic porto-systemic shunt(TIPS) plus embolization. CASE SUMMARY A 46-year-old woman with anemia for two years was frequently admitted to the local hospital. Upon examination, anemia was attributed to gastrointestinal tract bleeding, which resulted from duodenal variceal bleeding detected by repeated esophagogastroduodenoscopy. At the end of a complete workup, IPH leadingto duodenal varices was diagnosed. Portal venography revealed that the remarked duodenal varices originated from the proximal superior mesenteric vein. TIPS plus embolization with coils and Histoacryl was performed to obliterate the rupture of duodenal varices. The anemia resolved, and the duodenal varices completely vanished by 2 mo after the initial operation. CONCLUSION TIPS plus embolization may be more appropriate to treat the bleeding of large duodenal varices.展开更多
BACKGROUND: Partial porto-systemic shunts have been popularized because of reported low rate of mortality and morbidity (especially encephalopathy, liver failure and oc- clusion). To further investigate these assumpti...BACKGROUND: Partial porto-systemic shunts have been popularized because of reported low rate of mortality and morbidity (especially encephalopathy, liver failure and oc- clusion). To further investigate these assumptions, we ret- rospectively reviewed the results of partial porta-caval shunts performed at different stages of liver disease. METHODS: Twenty-nine cirrhotic patients underwent a partial porta-caval shunt with a ringed polytetrafluoroethy- lene interposition prosthesis of 8-mm ( 20 patients) or 10- mm (9 patients) in diameter. Pre- and post-shunt porta- caval pressure was measured in all patients. Twelve patients (41.4%) belonged to Child A, 11 Child B (37.9%), and 6 Child C (20.7%). Eleven patients (37.9%) suffered from hepatic encephalopathy preoperatively. Twelve patients (41%) were operated on in emergency/urgency. RESULTS: Porta-caval pressure gradient, reduced signifi- cantly using either 8- or 10-mm prosthesis. The overall ear- ly mortality and morbidity were 13. 8% and 48% respec- tively. The early mortality and morbidity were different be- tween patients of Child A and B when compared to those of Child C (0 vs 66.6% and 34.8% vs 66.6% respectively). No patient re-bled early from varices. The overall late mor- tality and morbidity were 40% and 64% respectively. Shunt thrombosis and stenosis took place in 16% and 8% of the two groups of patients respectively; variceal re-bleeding oc- curred in 4 patients (16%). Encephalopathy occurred post- operatively in 5 patients (20%), acute in 3 patients (12%), and chronic in 2 (8%). The actuarial survival rate at 3 and 5 years was 92% and 75% for patients of Child A, 70% and 60% for patients of Child B, and 0% for patients of Child C. CONCLUSIONS: Our results indicate that partial porta-ca- val shunt with a small diameter interposition H-graft is an effective procedure for the treatment of variceal bleeding, as well as for the prevention of re-bleeding in patients of Child A and those of Child B, as an elective or emergency/ urgency procedure, with a low rate of complications and encephalopathy. This technique could be used safely in pa- tients with good liver function but they should be moni- tored closely because of the risk of shunt occlusion.展开更多
AIM: To examine the correlation between the porto-systemic hypertension evaluated by portal shunt index (PSI) and life-threatening complications, including hepatocellular carcinoma (HCC), liver failure (Child-Pugh sta...AIM: To examine the correlation between the porto-systemic hypertension evaluated by portal shunt index (PSI) and life-threatening complications, including hepatocellular carcinoma (HCC), liver failure (Child-Pugh stage progression), and esophagogastric varices. METHODS: Two hundred and twelve consecutive subjects with HCV-related cirrhosis (LC-C) underwent per-rectal portal scintigraphy. They were allocated into three groups according to their PSI: group Ⅰ, PSI≤10%; group Ⅱ, 10%<PSI<30%; and group Ⅲ, 30%≤PSI. Of these, selected 122 Child-Pugh stage A (Child A) subjects were included in analysis (a mean follow-up period of 5.9±5.4 years, range 6 mo-21 years). RESULTS: No significant correlation between PSI and cumulative probability of HCC incidence was observed. Cumulative probability of Child A to B progression was tended to be higher in group Ⅲ than in group Ⅰ, and significantly higher in group Ⅲ than in group Ⅱ (62% vs 34%, 62% vs 37%; P = 0.060, <0.01; respectively). Cumulative probability of varices tended to be higher in group Ⅲ than in group Ⅰ (31% vs 12%, P = 0.090). On multivariate analyses, significant correlation between PSI and Child A to B progression was observed, and no significant correlation between PSI and HCC incidence or varices progression was observed. CONCLUSION: Patients with LC-C of Child A will progress to Child B rapidly after their PSI reaches 30% or higher. PSI can be used to predict occult progressive porto-systemic shunting and liver failure non-invasively. It indicates that PSI may play an important role in follow-up of the porto-systemic hypertension gradient for outpatients with LC unlike hepatic venous catheterization.展开更多
Extrahepatic portosystemic shunts(EPS)are abnormal con-nections between the portal and systemic circulations.Ac-quired EPS occur most commonly in adults and are usually associated with portal hypertension due to cirrh...Extrahepatic portosystemic shunts(EPS)are abnormal con-nections between the portal and systemic circulations.Ac-quired EPS occur most commonly in adults and are usually associated with portal hypertension due to cirrhosis.Acquired EPS cases can be further subdivided into two types:variceal(pre-existing)EPS and non-variceal EPS(NVEPS).Variceal EPS arise from originally small vessels with pre-existing dual portal and systemic drainage.Due to elevated portal pres-sure,these vessels dilate and undergo a reversal of flow,sending blood back to the systemic circulation.A much less common and,therefore,underappreciated subset of acquired EPS is NVEPS,which consists of aberrant connections that did not previously exist between the portal vein and large systemic vessels,usually in the presence of portal hyperten-sion.Neoangiogenesis results in the development of abnor-mal anastomoses between the portal vein and other large veins,resulting in splenorenal,gastrorenal,portocaval,and mesocaval shunts.While not uncommon,they are frequently overlooked in the diagnosis and treatment of portal hyperten-sion and can pose significant diagnostic and therapeutic chal-lenges.Because the treatment of variceal EPS and NVEPS can differ markedly,it is important to correctly diagnose NVEPS and institute appropriate management.The aim of this arti-cle was to review acquired EPS,with particular attention to NVEPS,updating the pathogenesis,diagnosis,and treatment.展开更多
文摘Spontaneous porto-systemic shunts(SPSS)are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates,probably as a consequence of worsening portal hypertension,but without achieving an effective protection against cirrhosis'complications.Several types of SPSS have been described in the literature,each one associated with different clinical manifestations.In particular,recurrent or persistent hepatic encephalopathy is more frequent in patients with splenorenal shunt,while the presence of gastric varices and consequently the incidence of variceal bleeding is more common in gastrorenal shunt.In the advanced stage,the presence of large SPSS can lead to the so called“portosystemic shunt syndrome”,characterized by a progressive deterioration of hepatic function,hepatic encephalopathy and,sometimes,portal vein thrombosis.The detection of SPSS in patients with liver cirrhosis is recommended in order to prevent or treat recurrent hepatic encephalopathy or variceal bleeding.
文摘AIM:To present a dedicated series of transjugular intrahepatic porto-systemic shunts(TIPS) in the elderly since data is sparse on this population group.METHODS:A retrospective review was performed of patients at least 65 years of age who underwent TIPS at our institutions between 1997 and 2010.Twentyfive patients were referred for TIPS.We deemed that 2 patients were not considered appropriate candidates due to their markedly advanced liver disease.Of the 23 patients suitable for TIPS,the indications for TIPS placement was portal hypertension complicated by refractory ascites alone(n = 9),hepatic hydrothorax alone(n = 2),refractory ascites and hydrothorax(n = 1),gastrointestinal bleeding alone(n = 8),gastrointestinal bleeding and ascites(n = 3).RESULTS:Of these 23 attempted TIPS procedure patients,21 patients had technically successful TIPS procedures.A total of 29 out of 32 TIPS procedures including revisions were successful in 21 patients with a mean age of 72.1 years(range 65-82 years).Three of the procedures were unsuccessful attempts at TIPS and 8 procedures were successful revisions of our existing TIPS.Sixteen of 21 patients who underwent successful TIPS(excluding 5 patients lost to follow-up) were followed for a mean of 14.7 mo.Ascites and/or hydrothorax was controlled following technically successful procedures in 12 of 13 patients.Bleeding was controlled following technically successful procedures in 10 out of 11 patients.CONCLUSION:We have demonstrated that TIPS is an effective procedure to control refractory complications of portal hypertension in elderly patients.
文摘AIMTo determine the impact of transjugular intrahepatic porto-systemic shunt (TIPS) on post liver transplantation (LT) outcomes. METHODSUtilizing the United Network for Organ Sharing (UNOS) database, we compared patients who underwent LT from 2002 to 2013 who had underwent TIPS to those without TIPS for the management of ascites while on the LT waitlist. The impact of TIPS on 30-d mortality, length of stay (LOS), and need for re-LT were studied. For evaluation of mean differences between baseline characteristics for patients with and without TIPS, we used unpaired t-tests for continuous measures and χ<sup>2</sup> tests for categorical measures. We estimated the impact of TIPS on each of the outcome measures. Multivariate analyses were conducted on the study population to explore the effect of TIPS on 30-d mortality post-LT, need for re-LT and LOS. All covariates were included in logistic regression analysis. RESULTSWe included adult patients (age ≥ 18 years) who underwent LT from May 2002 to September 2013. Only those undergoing TIPS after listing and before liver transplant were included in the TIPS group. We excluded patients with variceal bleeding within two weeks of listing for LT and those listed for acute liver failure or hepatocellular carcinoma. Of 114770 LT in the UNOS database, 32783 (28.5%) met inclusion criteria. Of these 1366 (4.2%) had TIPS between the time of listing and LT. We found that TIPS increased the days on waitlist (408 ± 553 d) as compared to those without TIPS (183 ± 330 d), P P P = 0.001) by TIPS to LOS. CONCLUSIONTIPS did increase time on waitlist for LT. More importantly, TIPS was not associated with 30-d mortality and re-LT, but it did lengthen hospital LOS after transplantation.
文摘Budd-Chiari syndrome(BCS)is an uncommon disease of the liver,characterised by obstruction of the hepatic venous outflow tract.The etiological spectrum of BCS as well as venous obstruction pattern show wide geographical and demographic variations across the globe.Compared to adults with BCS,children have primary BCS as the predominant etiology,earlier clinical presentation,and hence better treatment outcome.Underlying prothrombotic conditions play a key role in the etiopathogenesis of BCS,though work-up for the same is often unyielding in children.Use of next-generation sequencing in addition to conventional tests for thrombophilia leads to better diagnostic yield.In recent years,advances in radiological endovascular intervention techniques have revolutionized the treatment and outcome of BCS.Various non-invasive markers of fibrosis like liver and splenic stiffness measurement are being increasingly used to assess treatment response.Elastography techniques provide a novel non-invasive tool for measuring liver and splenic stiffness.This article reviews the diagnostic and therapeutic advances and challenges in children with BCS.
文摘A severe spinal cord involvement may rarely occur in patients with cirrhosis and other chronic liver diseases;this complication is usually associated with overt liver failure and surgical or spontaneous porto-systemic shunt.Hepatic myelopathy(HM)is characterized by progressive weakness and spasticity of the lower extremities,while sensory and sphincter disturbances have rarely been described and are usually less important.The diagnosis is assigned in the appropriate clinical setting on clinical grounds after the exclusion of other clinical entities leading to spastic paraparesis.Magnetic resonance imaging is often unremarkable;however,also intracerebral corticospinal tract abnor-malities have been reported recently.The study of motor evoked potentials may disclose central conduction abnormalities even before HM is clinically manifest.HM responds poorly to blood ammonia-lowering and other conservative medical therapy.Liver transplantation represents a potentially definitive treatment for HM in patients with decompensated cirrhosis of Child-Pugh B and C grades.Other surgical treatment options in HM include surgical ligation,shunt reduction,or occlusion by interventional procedures.
文摘Portal biliopathy(PB) is defined as the presence of biliary abnormalities in patients with non-cirrhotic/nonneoplastic extrahepatic portal vein obstruction(EHPVO) and portal cavernoma(PC). The pathogenesis of PB is due to ab extrinseco compression of bile ducts by PC and/or to ischemic damage secondary to an altered biliary vascularization in EHPVO and PC. Although asymptomatic biliary abnormalities can be frequently seen by magnetic resonance cholangiopancreatography in patients with PC(77%-100%), only a part of these(5%-38%) are symptomatic. Clinical presentation includes jaundice, cholangitis, cholecystitis, abdominal pain, and cholelithiasis. In this subset of patients is required a specific treatment. Different therapeutic approaches aimed to diminish portal hypertension and treat biliary strictures are available. In order to decompress PC, surgical porto-systemic shunt or transjugular intrahepatic porto-systemic shunt can be performed, and treatment on the biliary stenosis includes endoscopic(Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy, balloon dilation, stone extraction, stent placement) and surgical(bilioenteric anastomosis, cholecystectomy) approaches. Definitive treatment of PB often requires multiple and combined interventions both on vascular and biliary system. Liver transplantation can be considered in patients with secondary biliary cirrhosis, recurrent cholangitis or unsuccessful control of portal hypertension.
文摘AIM:To investigate the effect of transjugular intra-hepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.METHODS: Twenty-one patients with liver cirrhosis and clinical indications for TIPS insertion were investigated before and 1, 4, 12, 52 wk after TIPS. For each patient we assayed body composition parameters [dry lean mass, fat mass, total body water (TBW)], routine liver and kidney function tests, and free fatty acids (FFA). Glucose and insulin were measured for the calculation of the homeostasis model assessment insulin resistance (HOMA-IR); liver function was measured by the galactose elimination capacity (GEC); the severity of liver disease was graded by model for end-stage liver disease (MELD).RESULTS: Porto-systemic gradient decreased after TIPS (6.0±2.1 mmHg vs 15.8±4.8 mmHg, P<0.001). Patients were divided in two groups according to initial body mass index. After TIPS, normal weight patients had an increase in dry lean mass (from 10.9±5.9 kg to 12.7±5.6 kg, P=0.031) and TBW (from 34.5±7.6 L to 40.2±10.8 L,P=0.007), as well as insulin (from 88.9±49.2 pmol/L to 164.7±107.0 pmol/L,P=0.009) and HOMA-IR (from 3.36%±2.18% to 6.18%±4.82%,P=0.023). In overweight patients only FFA increased significantly (from 0.59±0.24 mmol/L to 0.93±0.34 mmol/L, P=0.023).CONCLUSION: TIPS procedure is effective in lowering portal pressure in patients with portal hypertension and improves body composition without significant changes in metabolic parameters.
基金Supported by National Natural Science Foundation of China under Grant No.81503437
文摘BACKGROUND Duodenal varices are a lesser-known complication with non-cirrhotic portal hypertension. We report a circuitous route from missed diagnosis of duodenal varices to correction. An extremely rare case of duodenal variceal bleeding secondary to idiopathic portal hypertension(IPH) is expounded in this study, which was controlled by transjugular intra-hepatic porto-systemic shunt(TIPS) plus embolization. CASE SUMMARY A 46-year-old woman with anemia for two years was frequently admitted to the local hospital. Upon examination, anemia was attributed to gastrointestinal tract bleeding, which resulted from duodenal variceal bleeding detected by repeated esophagogastroduodenoscopy. At the end of a complete workup, IPH leadingto duodenal varices was diagnosed. Portal venography revealed that the remarked duodenal varices originated from the proximal superior mesenteric vein. TIPS plus embolization with coils and Histoacryl was performed to obliterate the rupture of duodenal varices. The anemia resolved, and the duodenal varices completely vanished by 2 mo after the initial operation. CONCLUSION TIPS plus embolization may be more appropriate to treat the bleeding of large duodenal varices.
文摘BACKGROUND: Partial porto-systemic shunts have been popularized because of reported low rate of mortality and morbidity (especially encephalopathy, liver failure and oc- clusion). To further investigate these assumptions, we ret- rospectively reviewed the results of partial porta-caval shunts performed at different stages of liver disease. METHODS: Twenty-nine cirrhotic patients underwent a partial porta-caval shunt with a ringed polytetrafluoroethy- lene interposition prosthesis of 8-mm ( 20 patients) or 10- mm (9 patients) in diameter. Pre- and post-shunt porta- caval pressure was measured in all patients. Twelve patients (41.4%) belonged to Child A, 11 Child B (37.9%), and 6 Child C (20.7%). Eleven patients (37.9%) suffered from hepatic encephalopathy preoperatively. Twelve patients (41%) were operated on in emergency/urgency. RESULTS: Porta-caval pressure gradient, reduced signifi- cantly using either 8- or 10-mm prosthesis. The overall ear- ly mortality and morbidity were 13. 8% and 48% respec- tively. The early mortality and morbidity were different be- tween patients of Child A and B when compared to those of Child C (0 vs 66.6% and 34.8% vs 66.6% respectively). No patient re-bled early from varices. The overall late mor- tality and morbidity were 40% and 64% respectively. Shunt thrombosis and stenosis took place in 16% and 8% of the two groups of patients respectively; variceal re-bleeding oc- curred in 4 patients (16%). Encephalopathy occurred post- operatively in 5 patients (20%), acute in 3 patients (12%), and chronic in 2 (8%). The actuarial survival rate at 3 and 5 years was 92% and 75% for patients of Child A, 70% and 60% for patients of Child B, and 0% for patients of Child C. CONCLUSIONS: Our results indicate that partial porta-ca- val shunt with a small diameter interposition H-graft is an effective procedure for the treatment of variceal bleeding, as well as for the prevention of re-bleeding in patients of Child A and those of Child B, as an elective or emergency/ urgency procedure, with a low rate of complications and encephalopathy. This technique could be used safely in pa- tients with good liver function but they should be moni- tored closely because of the risk of shunt occlusion.
基金Supported by the Study Group of Portal Malcirculation supported by Ministry of Health, Labour and Welfare
文摘AIM: To examine the correlation between the porto-systemic hypertension evaluated by portal shunt index (PSI) and life-threatening complications, including hepatocellular carcinoma (HCC), liver failure (Child-Pugh stage progression), and esophagogastric varices. METHODS: Two hundred and twelve consecutive subjects with HCV-related cirrhosis (LC-C) underwent per-rectal portal scintigraphy. They were allocated into three groups according to their PSI: group Ⅰ, PSI≤10%; group Ⅱ, 10%<PSI<30%; and group Ⅲ, 30%≤PSI. Of these, selected 122 Child-Pugh stage A (Child A) subjects were included in analysis (a mean follow-up period of 5.9±5.4 years, range 6 mo-21 years). RESULTS: No significant correlation between PSI and cumulative probability of HCC incidence was observed. Cumulative probability of Child A to B progression was tended to be higher in group Ⅲ than in group Ⅰ, and significantly higher in group Ⅲ than in group Ⅱ (62% vs 34%, 62% vs 37%; P = 0.060, <0.01; respectively). Cumulative probability of varices tended to be higher in group Ⅲ than in group Ⅰ (31% vs 12%, P = 0.090). On multivariate analyses, significant correlation between PSI and Child A to B progression was observed, and no significant correlation between PSI and HCC incidence or varices progression was observed. CONCLUSION: Patients with LC-C of Child A will progress to Child B rapidly after their PSI reaches 30% or higher. PSI can be used to predict occult progressive porto-systemic shunting and liver failure non-invasively. It indicates that PSI may play an important role in follow-up of the porto-systemic hypertension gradient for outpatients with LC unlike hepatic venous catheterization.
文摘Extrahepatic portosystemic shunts(EPS)are abnormal con-nections between the portal and systemic circulations.Ac-quired EPS occur most commonly in adults and are usually associated with portal hypertension due to cirrhosis.Acquired EPS cases can be further subdivided into two types:variceal(pre-existing)EPS and non-variceal EPS(NVEPS).Variceal EPS arise from originally small vessels with pre-existing dual portal and systemic drainage.Due to elevated portal pres-sure,these vessels dilate and undergo a reversal of flow,sending blood back to the systemic circulation.A much less common and,therefore,underappreciated subset of acquired EPS is NVEPS,which consists of aberrant connections that did not previously exist between the portal vein and large systemic vessels,usually in the presence of portal hyperten-sion.Neoangiogenesis results in the development of abnor-mal anastomoses between the portal vein and other large veins,resulting in splenorenal,gastrorenal,portocaval,and mesocaval shunts.While not uncommon,they are frequently overlooked in the diagnosis and treatment of portal hyperten-sion and can pose significant diagnostic and therapeutic chal-lenges.Because the treatment of variceal EPS and NVEPS can differ markedly,it is important to correctly diagnose NVEPS and institute appropriate management.The aim of this arti-cle was to review acquired EPS,with particular attention to NVEPS,updating the pathogenesis,diagnosis,and treatment.
