Hepatic Vascular Disease Research Articles

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache in Patients Undergoing Lower Abdominal Surgeries

Abstract Background Postdural puncture headache (PDPH) is a complication of spinal anesthesia or lumbar puncture and is an unpleasant experience for the patient as well as the anesthetist. It is thought to result from meningeal traction related to low cerebrospinal fluid (CSF) pressure or cerebral vasodilation as an indirect effect of decreased CSF pressure. Neostigmine is a reversible inhibitor of the enzyme cholinesterase, which results in an increased concentration of the neurotransmitter acetylcholine. It produces cholinergic-mediated analgesia and has been used as an adjunct analgesic postoperatively. Neostigmine can pass through the choroid plexus but not the blood–brain barrier, the central effect of both neostigmine and atropine influence both CSF secretion and cerebral vascular tone which are the primary pathophysiological changes in PDPH. Objective Assess the effectiveness of postdural anesthesia with addition of Neostigmine and Atropine versus conventional postdural anesthesia. Patients and Methods A 90 patients were included in our prospective randomized controlled double-blind study that was conducted at Ain Shams University Hospitals for 4 months on patients who fulfilled the inclusion criteria: patients with ASA Grade I & II, aged from (18 to 40) years old and scheduled for cesarean section. All patients aged >18 or <40, body weight >50, ASA III, IV, patients with uncontrolled chronic diseases such as hypertension, cardiac, renal, hepatic, cerebral diseases and peripheral vascular diseases, patients with history of PDPH, chronic headache, cluster headache, migraine, convulsions, cerebrovascular accident, signs of meningismus, preeclampsia, eclampsia coagulopathy, and previous neurological diseases and patients with history of bronchial asthma were excluded. Patients were divided into 2 groups: Group I (experimental group): neostigmine and atropine and Group II (placebo group): Saline placebo. Results The results of this study showed that incidence of postoperative headache was significantly lower among the intervention group, furthermore, VAS was significantly lower in the experimental arm versus placebo one. However, there was no significant difference regarding demographic, vital signs, and need for post-operative analgesia. The presented study showed that there is statistically non-significant difference between the studied groups regarding age, weight, and height and body mass index. There is statistically non-significant difference between the studied groups regarding duration of surgery. Conclusion After demonstrating many management options for post dural puncture headache (PDPH), in this study, we tried to prove the value of the use of neostigmine as a new management option that looks promising to alleviate the symptoms of such distressing condition. The current study results proved that the drug reduced the number of cases that experienced (PDPH) after spinal anesthesia for lower segment caesarean section, and how it prevent &control headache. A combination of neostigmine and atropine are effective in managing PDPH by reducing the associated VAS score and preventing persistence of headache.

Metformin ameliorates liver fibrosis induced by congestive hepatopathy via the mTOR/HIF-1α signaling pathway

Introduction and ObjectivesCongestive hepatopathy (CH) is a hepatic vascular disease that results in chronic liver congestion, which can lead to liver fibrosis. New uses of metformin have been discovered over the years. However, the function of metformin in congestive liver fibrosis is not yet fully understood. This study aimed to investigate the effect of metformin on liver fibrosis in a mouse model of CH. Materials and MethodsPartial ligation of the inferior vena cava (pIVCL) was used to establish a mouse model of liver congestion. Metformin (0.1%) was added to the daily drinking water of the animals, and the effect of metformin on liver tissue was studied after 6 weeks. Hepatic stellate cells (HSCs) were also stimulated with CoCl2 to investigate the inhibitory impact of metformin on the mammalian target of rapamycin (mTOR)/hypoxia-inducible factor-1α (HIF-1α) pathway. ResultsMetformin attenuated liver congestion; decreased the expression of collagen, fibronectin, α-smooth muscle actin (α-SMA), and HIF-1α; and ameliorated liver fibrosis in pIVCL mice. The proliferation and migration of HSCs were inhibited by metformin in vitro, which prevented α-SMA expression and restrained HSC activation. The expression levels of phosphorylated-mTOR, HIF-1α, and vascular endothelial growth factor were also decreased. ConclusionsMetformin inhibits CH-induced liver fibrosis. Functionally, this beneficial effect may be the result of inhibition of HSC activation and of the mTOR/HIF-1α signaling pathway.

Comments and illustrations of the WFUMB CEUS liver guidelines: Rare vascular pathology, part II.

In this second part of the topic the hepatic pseudoaneurysm, hepatic infarction, and pylephlebitis are discussed as acute and potentially life-threatening hepatic vascular diseases. The focus is on their appearance on B-mode ultrasonography, duplex ultrasonography, and contrast-enhanced ultrasonography. Zahn's pseudo infarction is an important differential diagnosis to wedge-shaped hepatic infarction in this context. Knowledge of the data should help raise awareness of these rare findings, to come up with relevant differential diagnoses in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

Significance of histological assessment in drug-induced liver injury

Liver histological assessment is of great clinical significance for the diagnosis, classification, and prognosis prediction of drug-induced liver injury (DILI). Liver histological evaluation can effectively supplement RUCAM. The clinical phenotypes of DILI are complex and diverse, including acute, chronic and severe hepatic injury. DILI has multiple insult-targets, including hepatocytes, cholangiocytes, and vascular endothelial cells and others. The pathological damage patterns are similar to many types of non-DILI liver diseases, therefore making differential diagnosis difficult. New anti-tumor drugs such as immune checkpoints inhibitors and targeted therapy are widely used in clinical antineoplastic practice, thus the growing incidence of related liver injury occurs. Liver histological examination can effectively assess the pathological phenotypes and severity of DILI, so as to guide treatment. In uncommon conditions such as special types of DILI (such as hepatic vascular disease), DILI with other competitive etiology overlapping, chronic DILI, and DILI induced liver failure, liver histological assessment can provide strong support for identifying the cause, rational treatment, and prognosis. Currently, the histological evaluation system for drug-induced liver injury seems to be a lack of consensus, and the diagnosis of DILI is short of highly specific and sensitive serological markers. All in all, liver histological assessment plays a crucial role in the diagnosis and differential diagnosis of DILI.

Clinical anatomy of hepatic vessels by computed tomography angiography: A minireview.

The liver has a complex vascular anatomy with a unique dual blood supply. Clinical conditions of the liver vary widely and include disorders originating in the vascular and biliary systems as well as the parenchyma. In most vascular disorders, the effects on the liver are generally subclinical because of its abundant blood supply. However, early diagnosis of such vascular diseases can significantly reduce patient morbidity and mortality. Because imaging findings of vascular disease are not always readily apparent, diagnosis can be difficult. Computed tomography angiography is an excellent imaging modality for visualizing the vascular anatomy of patients for treatment planning. In this review article, we focus on the vascular anatomy of the liver and the imaging findings in some acute hepatic vascular diseases.

Research progress of hepatic sinusoidal obstruction syndrome

Hepatic sinusoidal obstruction syndrome (HSOS) is a hepatic vascular disease that begins with injury to hepatic sinusoidal endothelial cells, and has a fatality rate of over 80% in its severe form. Therefore, early diagnosis and treatment are crucial to delay HSOS progression and reduce mortality. However, clinicians' understanding of the disease is still insufficient, and the clinical manifestations of the disease are similar to liver diseases caused by other etiologies, resulting in a high rate of misdiagnosis. This article mainly introduces the HSOS recent developments in the etiology and pathogenesis, clinical manifestations and auxiliary examinations, diagnostic criteria, treatment, and prevention.

Emphasis on the prevention and treatment of hepatic vascular diseases

Portal hypertension, as a common and complex hepatic vascular disease, is a key pathophysiological link in many events of acute cirrhosis decompensation and the progression of multiple organ failure. The most effective measure to reduce portal hypertension is a transjugular intrahepatic portosystemic shunt (TIPS). Maintaining liver function, reducing complications, and improving patients' quality of life and survival time are positively impacted by early TIPS insertion. Patients with cirrhosis have a risk of portal vein thrombosis (PVT) that is 1 000 times higher than that of the normal population. Hepatic sinusoidal obstruction syndrome has a severe clinical course and a high mortality risk. The primary treatment approaches for PVT and HSOS are anticoagulation and TIPS. The innovative magnetic anastomosis vascular technique significantly shortens the anhepatic time and restores normal liver function in patients following liver transplantation.

Improve the understanding of hepatic disease related pulmonary vascular disease

Hepatic disease-related pulmonary vascular disease refers to the changes in the structure or function of pulmonary circulation caused by liver parenchymal or hepatic vascular diseases, mainly including hepatopulmonary syndrome characterized by hypoxemia, portopulmonary hypertension characterized by pulmonary hypertension, and hepatic vascular shunt characterized by increased cardiac output and pulmonary hypertension. Early diagnosis and treatment of liver disease and early evaluation of liver transplantation may significantly improve the prognosis for patients with hepatic disease-related pulmonary vascular disease. Moreover, it is necessary to improve clinicians' understanding of this disease and strengthen multidisciplinary cooperation, improve the level of diagnosis and treatment.

Chinese multidisciplinary collaborative expert consensus for the diagnosis and treatment of Budd-Chiari syndrome (2021 version)

Budd-Chiari syndrome (B-CS) is a complicated hepatic vascular disease caused by hepatic venous outflow obstruction.There are significant differences in the pathogenesis and treatment of B-CS between China and Western countries.Given the characteristics of B-CS in our country,Budd-Chiari Syndrome and Hepatic Vascular Diseases Professional Committee of Chinese Research Hospital Association organizes domestic experts in this field to formulate the "Chinese multidisciplinary collaborative expert consensus for the diagnosis and treatment of Budd-Chiari syndrome（2021 version）".This consensus elaborates the research status of epidemiology,pathogenesis,disease classification,clinical manifestations,diagnosis and treatment of B-CS in China.Conducting basic research on pathogenesis and clinical research with high level evidence are important work direction in the future.This consensus is expected to provide guidance for clinicians to make optimal therapeutic schedules,so as to further standardize and improve the comprehensive diagnosis and treatment and basic research level of B-CS in China.

Liver magnetic resonance imaging: how we do it.

Magnetic resonance imaging is used for evaluating focal liver lesions, hepatic vascular diseases, biliary diseases and diffuse liver diseases in children. MRI examinations take a long time, often requiring sedation or anesthesia in smaller children. This makes it essential to understand the concepts and technique necessary to obtain an optimal examination for answering the clinical question while minimizing the need for sedation/anesthesia. We discuss key concepts including appropriate sequence selection, choice of contrast media, dynamic imaging, phases of contrast enhancement and protocol organization.

Clinical features and prognosis of primary myelofibrosis with hepatic vascular disease and/or portal hypertension

Objective To investigate the clinical features, liver histopathological features, treatment, and prognosis of primary myelofibrosis (PMF)-associated hepatic vascular disease and portal hypertension. Methods A retrospective analysis was performed for the clinical and pathological features of 68 patients who were diagnosed with PMF in 960 Hospital of the PLA Joint Logistics Support Force and Xijing Hospital of Digestive Diseases, Air Force Medical University, from July 2010 to December 2020, among whom 22 patients had hepatic vascular disease/portal hypertension as the main manifestation. The patients were divided into two groups according to the presence or absence of thrombosis, and treatment and prognosis were summarized. The Kaplan-Meier method was used to plot survival curves, and the log-rank test was used to compare long-term survival rate between the two groups. Results Among the 68 patients with PMF, 22 had hepatic vascular disease and/or portal hypertension, resulting in a prevalence rate of 32.35%, and among these 22 patients, 13 (59.1%) had extrahepatic portal vein occlusion, 1 (4.5%) had Budd-Chiari syndrome, and 8 (36.4%) had portal hypertension. Biopsy was performed for 7 patients, and pathological results showed extramedullary hematopoiesis in the liver and varying degrees of infiltration of lymphocytes, plasma cells, and eosinophils at the lobular and portal areas, but the lobular structure was normal. A total of 7 patients died during follow-up, among whom 5 died of complications associated with thrombosis or portal hypertension. The overall median survival time was 57.99 months for all patients; the median survival time was 45.33 months in patients with thrombosis and 64.00 months in patients without thrombosis, and although there was no significant difference between the two groups (χ2=3.035, P=0.081), the non-thrombosis group tended to have better survival and prognosis than the thrombosis group. Conclusion The possibility of PMF as the primary disease should be considered for patients with hepatic vascular disease and portal hypertension. Patients with PMF should be screened for hepatic vascular disease, and early intervention should be given. The patients without thrombosis tend to have better survival and prognosis than those with thrombosis.

Review on diagnostic criteria of hepatic sinusoidal obstruction syndrome

Hepatic sinusoidal obstruction syndrome (HSOS) is a kind of hepatic vascular disease which is characterized by damage to hepatic sinusoidal endothelial cells, centrilobular hepatic vein and/or interlobular vein, resulting in stenosis or lumen occlusion, hepatic injury and acute sinusoidal portal hypertension. Generally, most patients with HSOS have mild manifestations, but in severely ill patients, the disease can lead to multiple organ dysfunction/failure, and the mortality rate can be as high as 70%-80%. Therefore, it is important to identify and treat HSOS as soon as possible. This paper introduces the current clinical diagnostic criteria of HSOS, including the Modified Seattle and Baltimore Criteria along with "Nanjing Criteria", and reviews their characteristics, scope of application and limitations.

Hypertrophied Right Inferior Phrenic Artery in Cirrhotic Patients without Hepatocellular Carcinoma: An Interesting Observation on 256 Slice Multidetector Computed Tomography

Abstract Aim To evaluate whether right inferior phrenic artery (RIPA) is a source of extrahepatic arterial supply to the liver in cirrhotic patients without hepatocellular carcinoma (HCC) using 256 slice computed tomography (CT). Materials and Methods Institutional review board approval was obtained for this retrospective study. A total of 262 consecutive cirrhotic patients (male:female–172:90; mean age 56.45 ± 12.96 years) without HCC and hepatic vascular invasion, and who underwent technically successful multiphase CT, were included in the study. Additionally, 280 noncirrhotic patients (male:female–169:111; mean age 54.56 ± 14.21 years) who underwent abdominal multiphase CT scans for indications other than liver disease and did not have focal liver lesions or hepatic vascular disease were included as a control group. The RIPA and left inferior phrenic artery (LIPA) diameters were measured at the level of the ascending segment of IPA located anterior to the diaphragmatic crus. The relationship between RIPA diameters and Child–Pugh score was assessed. Results The cirrhotic patient group and control group were matched for age (p = 0.11) and gender (p = 0.20). The mean diameter of RIPA in the cirrhotic group (1.93 ± 0.4 mm) was significantly higher than in the control group (1.50 ± 0.5 mm), p < 0.001. The mean diameter of LIPA in the cirrhotic group (1.34 ± 0.5 mm) was not significantly higher than in the control group (1.30 ± 0.5 mm), p = 0.32. We found a statistically linear and moderate degree relationship between RIPA diameter values and Child–Pugh scores (p = 0.002, r = 0.593). Conclusion RIPA is hypertrophied in patients with cirrhosis without HCC. It may be an important contributor to the blood flow to the liver in cirrhotic patients even without HCC, especially with portal hypertension.

Progress in the clinical diagnosis and treatment of hepatic vascular diseases

The liver has a very special dual blood supply, including the portal vein (65%~75%) and hepatic artery (25%~35%). The hepatic veins returns blood to the systemic circulation via the portal vein, and hepatic artery after hepatic sinusoidal confluence. The lesions on the hepatic vein and its branches can cause ischemia and hypoxia or obstruction of the drainage system, portal hypertension, upper gastrointestinal variceal bleeding, hepatic encephalopathy, and so on. Clinically, hepatic vascular diseases are relatively rare, so the diagnosis and treatment are relatively difficult. Herein, we review the diseases related to the hepatic vascular system.

Expert consensus on the clinical management of pyrrolizidine alkaloid-induced hepatic sinusoidal obstruction syndrome.

Hepatic sinusoidal obstruction syndrome (HSOS) is a hepatic vascular disease presenting with abdominal distension, pain in the hepatic region, ascites, jaundice, and hepatomegaly. In China, this disease is often associated with the oral intake of plants that contain pyrrolidine alkaloids. The existing guidelines are limited to HSOS associated with hematopoietic stem cell transplantation in Western countries. The Hepatobiliary Diseases Committee of the Chinese Society of Gastroenterology convened an expert consensus conference on the diagnosis and treatment of PA-HSOS to evaluate current research in China and abroad. The "Nanjing criteria" developed by the committee to diagnose PA-HSOS include a confirmed history of PA-containing plant use and (i) abdominal distention and/or pain in the hepatic region, hepatomegaly, and ascites; (ii) elevation of serum total bilirubin or abnormal laboratory liver tests; (iii) evidence on enhanced computed tomography or magnetic resonance imaging; or (iv) pathological evidence that rules out other known causes of liver injury. Supportive symptomatic treatment, anticoagulant therapy, and placement of a transjugular intrahepatic portosystemic shunt for patients who do not respond to medical treatment are effective for the treatment of PA-HSOS. The benefits of glucocorticoids and prostaglandin E1 in PA-HSOS are not clear.

Big steps in advances of doppler ultrasound

Doppler Ultrasound is clinically important for evaluation of various hepatic vascular disease as well as hepatic vessel evaluation after liver transplantation. However, there are some limitations in conventional Doppler methods as follows: 1) time consuming and labor intensive and 2) limited slow flow sensitivity. There are two recently advanced Doppler signal-processing methods (i.e., UltraFast and superb microvascular imaging), which overcome those limitations. UltraFast Doppler ultrasound, which emerged with the advent of massive parallel computing (or processing) capabilities, transmits several tilted plane waves into the medium and coherently sums the backscattered echoes to reconstruct US images, leading to a marked increase in the frame rate, while conventional ultrasound imaging involves sequential medium insonification via focused beams and successive image reconstruction. A stored UltraFast Doppler clip contains information on both spectral analysis and color-coded flow imaging and could be retrospectively evaluated quantitative analysis, because UltraFast ultrasound has high spatio-temporal resolution. Superb microvascular imaging (SMI, Cannon Medical Systems Corporation, Tochigi, Japan) uses a different kind of adaptive wall filter, which could minimize the flash artifact and increased sensitivity to slow flow and improve the signal detection of flow from small vessels. Therefore, in clinical practice, UltraFast Doppler can be performed by anyone. If the exam protocol such as acquisition of clip by less experienced sonographer and evaluation by retrospective wave reconstruction by specialist can be established, efficient work force management can be possible. Superb Microvascular imaging can distinguish very slow portal flow by portal hyper tension and so forth from thrombus. Thrombus can be evaluated with almost the same resolution as CT. The weak flow of a small hepatic artery hiding by vigorous flow of portal vein after liver transplantation can be also distinguished. In conclusion, smart application of recent advanced Doppler technique will help comprehensive assessment of hepatic vascular abnormalities.

A Comprehensive Approach to Hepatic Vascular Disease.

The liver has a complex vascular supply, which involves the inflow of oxygenated blood through the hepatic artery (systemic circulation) and deoxygenated blood through the portal vein (portal circulation), as well as the outflow of deoxygenated blood through the hepatic veins to the inferior vena cava. A spectrum of vascular variants can involve the liver. Some of these variants may result in areas of enhancement that can mimic more serious pathologic conditions. In this article, the authors discuss a spectrum of variants and pathologic conditions that may involve the liver vasculature. These include variants, anomalies, and diseases involving the portal vein, such as rudimentary portal vein, thrombosis, cavernous transformation, thrombotic angiitis, thrombophlebitis, transient hepatic attenuation difference or transient hepatic intensity difference, portal venous aneurysm, and portal vein gas. The hepatic artery can be involved by various diseases, including thrombosis, stenosis, and aneurysm or pseudoaneurysm. Unusual "third inflow" sources of venous inflow are also discussed, including aberrant right gastric vein, aberrant left gastric vein, epigastric-paraumbilical veins, and cholecystic vein. A spectrum of variants and diseases involving the inferior vena cava and hepatic veins, including thrombosis, Budd-Chiari syndrome, veno-occlusive disease, stenosis, torsion, congestive hepatopathy, and peliosis hepatis, are discussed. Vascular shunts are illustrated, including portosystemic shunts (intra- and extrahepatic), arterioportal shunt, shunts of hereditary hemorrhagic telangiectasia, and acquired arteriovenous fistula. Familiarity with the pathogenesis and imaging features of these vascular entities can aid radiologic diagnoses and guide appropriate patient management. ©RSNA, 2017.

Ductular Reaction and the K7-19 Progenitor Cell Sequence in Vascular Liver Disease: A New Perspective to Pathogenetic Mechanisms of Injury and Repair

Background:Ductular reaction (DR), a process intricately connected with hepatocyte progenitor cells (HPCs) at the canal of Hering evokes considerable scientific interest. The present study was undertaken to (a) identify DR patterns in different subsets of hepatic vascular disease, (b) localize intermediate hepatobiliary progenitors activated in response to stresses to vascular flow while studying their K7/19 immunoexpression profiles, and (c) possibly provide new insights to pathogenesis. Methods: Forty-six cases of hepatic vasculopathy including Budd-Chiari syndrome [BCS] (11), acute hemorrhagic necrosis [AHN] (6), veno-occlusive disease [VOD] (7), non-cirrhotic portal fibrosis [NCPF] (10), extrahepatic portal vein obstruction [EHPVO] (10) and chronic venous congestion [CVC] (2) were randomly selected. Mean DR was scored as 1: 2–5, 2: 6–8, 3 > 8 after counting ductules per portal tract (D/ PT) separately on K7 and 19 immunostains. Extraportal ‘‘progenitors’’ were semiquantitatively graded as 0: None, 1: Occasional, 2: Significant number. This was done separately for hepatocytic and ductular cells on K7 & 19. Zonation effect, if any was noted. Results: DR, intermediate hepatocytic progenitors and extraportal ductules were seen in 69.5/45.6%, 84.7/30.4% and 65.2/50% cases respectively on K7/ 19 stain. DR was seenmost frequently in the subset of AHN (100%) and least in EHPVO (40%). All cases of BCS, AHN and CVC showed intermediate K7+ hepatocytic cells. Extraportal ductular cells (K7+/K19 ) were most common in AHN (100%) and showed a distinct centrilobular pattern. Conclusions: Derangements in vascular flow trigger prominent ductular reaction in all subsets of hepatic vasculopathy barring EHPVO. Severe parenchymal loss as seen in AHN activates both biliary and hepatocytic intermediate cells possibly as a response to extensive parenchymal cell loss. Vascular liver diseases show heterogeneity in K7/19 expression profiles of extraportal progenitors across all subsets, emphasizing that as a group vasculopathies may be trickier to reverse. Timely diagnosis hence is paramount tominimize damage. Corresponding author Tel: +91 9718599073: Puja Sakhuja. E-mail: pujasak@gmail.com

Diagnosis and treatment of peliosis hepatis

Peliosis hepatis is a rare benign hepatic vascular disease. There is the lack of specific clinical features and preoperative diagnosis. A patient with intermittent liver area pain was admitted to the Third Central Hospital of Tianjin in April 2014. The patient with space-occupying lessions of the right lobe of liver was preliminarily diagnosed as with hepatocellular tumor or vasogenic tumor by computed tomography and B ultrasound examinations and then received liver resection combined with cholecystectomy. The result of postoperative pathological examination confirmed peliosis hepatis with adenomatous hyperplasia of liver cells. The patient was followed up till October 20, 2014 without recurrence. Key words: Peliosis hepatis; Hepatectomy

Lebertransplantation als Therapie von seltenen Erkrankungen beim Erwachsenen

In addition to the main indications pertaining to 95 % of all patients receiving liver transplantation in Germany, there are numerous other diseases that may become clinically evident in the adult age and may lead to the decision for liver transplantation. These may be metabolic diseases with their main defect located in the liver, malformations of liver cells, hepatic vascular diseases and rare tumours of the liver. Standard exceptions for the listing are in place only for a limited number of diseases. Exact diagnostics and the point in time for transplantation are crucial for the prognosis.