Portal Flow Velocity Research Articles

Efficacy of transjugular intrahepatic portosystemic shunts in treating cirrhotic esophageal-gastric variceal bleeding.

Esophageal-gastric variceal bleeding (EGVB) represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes. Interventional therapy, a rapidly developing treatment modality over the past few years, has found widespread application in clinical practice due to its minimally invasive characteristics. However, whether transjugular intrahepatic portosystemic shunt (TIPS) treatment has an impact on patient prognosis remains controversial. To probing the efficacy of TIPS for treating cirrhotic EGVB and its influence on the prognosis of patients afflicted by this disease. A retrospective study was conducted on ninety-two patients presenting with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022. Based on the different modes of treatment, the patients were assigned to the study group (TIPS received, n = 50) or the control group (percutaneous transhepatic varices embolization received, n = 42). Comparative analyses were performed between the two groups preoperatively and one month postoperatively for the following parameters: Varicosity status; hemodynamic parameters [portal vein flow velocity (PVV) and portal vein diameter (PVD); platelet count (PLT); red blood cell count; white blood cell count (WBC); and hepatic function [albumin (ALB), total bilirubin (TBIL), and aspartate transaminase (AST)]. The Generic Quality of Life Inventory-74 was utilized to assess quality of life in the two groups, and the 1-year postoperative rebleeding and survival rates were compared. Following surgical intervention, there was an improvement in the incidence of varicosity compared to the preoperative status in both cohorts. Notably, the study group exhibited more pronounced enhancements than did the control group (P < 0.05). PVV increased, and PVD decreased compared to the preoperative values, with the study cohort achieving better outcomes (P < 0.05). PLT and WBC counts were elevated postoperatively in the two groups, with the study cohort displaying higher PLT and WBC counts (P < 0.05). No differences were detected between the two groups in terms of serum ALB, TBIL, or AST levels either preoperatively or postoperatively (P < 0.05). Postoperative scores across all dimensions of life quality surpassed preoperative scores, with the study cohort achieving higher scores (P < 0.05). At 22.00%, the one-year postoperative rebleeding rate in the study cohort was significantly lower than that in the control group (42.86%; P < 0.05); conversely, no marked difference was observed in the 1-year postoperative survival rate between the two cohorts (P > 0.05). TIPS, which has demonstrated robust efficacy in managing cirrhotic EGVB, remarkably alleviates varicosity and improves hemodynamics in patients. This intervention not only results in a safer profile but also contributes significantly to a more favorable prognosis.

Association between endotoxemia and blood no in the portal circulation of cirrhotic patients: results of a pilot study.

Pathophysiology of portal vein thrombosis (PVT) in cirrhosis is still not entirely understood. Elevated levels of lipopolysaccharides (LPS) in portal circulation are significantly associated with hypercoagulation, increased platelet activation and endothelial dysfunction. The aim of the study was to investigate if LPS was associated with reduced portal venous flow, the third component of Virchow's triad, and the underlying mechanism. Serum nitrite/nitrate, as a marker of nitric oxide (NO) generation, and LPS were measured in the portal and systemic circulation of 20 patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) procedure; portal venous flow velocity (PVV) was also measured in each patient and correlated with NO and LPS levels. Serum nitrite/nitrate and LPS were significantly higher in the portal compared to systemic circulation; a significant correlation was found between LPS and serum nitrite/nitrate (R = 0.421; p < 0.01). Median PVV before and after TIPS was 15 cm/s (6-40) and 31 cm/s (14-79), respectively. Correlation analysis of PVV with NO and LPS showed a statistically significant negative correlation of PVV with portal venous NO concentration (R = - 0.576; p = 0.020), but not with LPS. In vitro study with endothelial cells showed that LPS enhanced endothelial NO biosynthesis, which was inhibited by L-NAME, an inhibitor of NO synthase, or TAK-242, an inhibitor of TLR4, the LPS receptor; this effect was accomplished by up-regulation of eNOS and iNOS. The study shows that in cirrhosis, endotoxemia may be responsible for reduced portal venous flow via overgeneration of NO and, therefore, contribute to the development of PVT.

Assessment of hepatic fibrosis, portal hemodynamic changes, and disease severity in patients with HCV-related liver cirrhosis after sustained virologic response to direct-acting antiviral drugs (DAAs)

BackgroundRegression of fibrosis and improvement of portal hemodynamics after achievement of sustained viral response (SVR) in patients with chronic hepatitis C (HCV) is a subject of debate in different studies. Some studies reported improvement in the degree of fibrosis, while others did not find significant changes.ObjectiveWe aimed to evaluate changes in liver fibrosis, portal hemodynamics and clinical outcomes in patients with chronic HCV-related liver cirrhosis after the achievement of SVR with direct-acting antiviral drugs (DAAs).Patients and methodsIn our prospective longitudinal study, a total of 100 patients with chronic HCV infection-related liver cirrhosis were recruited, received DAAs, and completed the follow-up period. Clinical evaluation for assessment of liver disease severity using MELD and Child–Pugh class and scores were done. A noninvasive assessment of liver fibrosis using serum biomarkers (APRI index & FIB4 score) and share wave elastography (SWE) was done. Portal hemodynamic evaluation using Doppler ultrasound was done. All were done at baseline and 3 and 12 months after the end of therapy.ResultsA significant reduction in the degree of fibrosis was observed. Share wave elastography (SWE) readings showed 19.79% and 30.45% reduction 3 and 12 months after the end of therapy respectively (P < 0.001). Regarding the FIB4 score, the percentage of score reduction was 19.8% and 26.46% 3 and 12 months after the end of therapy, respectively (P < 0.01). APRI scores showed 22.6% and 41.09% reduction 3 and 12 months after the end of therapy respectively (P < 0.001). Significant improvement in Child–Pugh scores 3 and 12 months after the end of treatment was observed. Doppler ultrasound showed a significant increase in portal vein flow velocity, a significant decrease in time average mean velocity, and cross-section area 12 months after the end of treatment.ConclusionThere was a considerable degree of reduction of liver fibrosis, improvement of portal hemodynamics, and Child–Pugh score in cirrhotic HCV patients who achieved SVR after DAAs.Trial registrationClinicalTrials.gov, ID: NCT03241823. Registered on 08 May 2017.

Prognostic value of virtual portal pressure gradient response in compensated cirrhotic patients treated with carvedilol.

This study aimed to assess the prognostic significance of virtual portal pressure gradient (vPPG) response to carvedilol in patients with compensated cirrhosis (CC). Compensated cirrhosis patients with high-risk varices were prospectively enrolled to receive carvedilol for prevention of first variceal hemorrhage (VH) and followed up for 1year. The vPPG response was defined as a reduction of vPPG >10% from baseline after 1-month therapy. Logistic and Cox regression analyses were performed to identify independent predictors for vPPG response and first decompensation, respectively. Competitive risk models were constructed to predict disease progression, and validated using the C-index, Kaplan-Meier analysis, competitive risk analysis, and calibration curves. A total of 129 patients completed this study, of whom 56 (43.4%) achieved vPPG response and were referred as vPPG responders. Baseline vPPG, red color sign, Model for End-stage Liver Disease score, serum monocyte chemoattractant protein-1 (MCP-1), and laminin levels significantly correlated with vPPG response, which itself was further documented as an independent predictor of VH, ascites, and overall decompensation events in CC. Moreover, the red color sign or Child-Turcotte-Pugh score effectively predicted VH, while ascites correlated well with portal flow velocity or MCP-1. The predictive models for VH and ascites showed a good discrimination with C-index values of 0.747 and 0.689 respectively, and the high consistency on calibration curves. The vPPG response could be used as a noninvasive tool for prediction of disease progression in patients with CC.

Effectiveness of Duplex Doppler Sonography of Portal Vein as a Supplementary Tool in Diagnosis of Pediatric Appendicitis

Background Acute appendicitis is the most common surgical emergency in pediatric patients. Ultrasound is the preferred initial imaging modality to evaluate children with clinically- suspected appendicitis. whether by directly visualizing the inflamed appendix or by using secondary signs. However. rate of falsely negative or equivocal exams is still high, leading to a risk of complications from negative appendectomies as well as delayed diagnosis. Objective To evaluate the diagnostic accuracy of portal vein flow velocity and diameter in diagnosis of pediatric acute appendicitis Patients and Methods A cross-sectional study over the course of 6 months from June until November 2021. Portal vein diameter and peak systolic flow velocity were measured for 75 pediatric patients with clinically suspected appendicitis referred to radiodiagnosis department at Ain Shams University Hospitals for a pelvi-abdominal ultrasound examination. The largest appendix diameter secondary sonographic signs, and total leucocytic count were recorded if available. Results The mean age of the population was 112 ± 4.12 years (range. 3-18 years). Mean portal vein flow velocity was 38.94 ± 9.59 cm/s in the appendicitis group and 27.96 ± 6.98 cites in the non-appendicitis group. Median portal vein flow velocity was significantly higher in the appendicitis group (p &amp;lt; 0.001 with an overall diagnostic accuracy 82.1% at cut-off value of &amp;gt; 33.3 cm/sec. Mean portal vein diameter was 9.37±2.01 mm in the appendicitis group and 8.84 ± 2.19 mm in the non-appendicitis group, showing no statistically significant difference (P = 0.27). The presence of right iliac fossa echogenic fat was highly significant (P &amp;lt; 0.001) in predicting acute appendicitis. Conclusion The use of portal vein velocity as a supplementary tool improved the diagnostic performance and increased the sensitivity of ultrasound in diagnosing acute appendicitis. thus, decreasing the incidence of delayed appendectomies that have an increased risk of complications as well as decreasing the incidence of unnecessary appendectomies. Further studies are required to establish a comprehensive guideline to use it as a tool in ultrasound examinations of these patients.

Diagnostic Accuracy of Portal Vein Flow Velocity for Esophageal Varices in Cirrhotic Patients.

Background Variceal bleeding is a life-threatening complication of cirrhosis. Traditionally, endoscopy has been utilized as a preferred modality for the detection and grading of esophageal varices. However, endoscopy is an invasive procedure and may not be readily available in resource-limited settings. To overcome this limitation, various non-invasive tests, including Doppler ultrasonography (DUS) with portal vein (PV) velocity measurement, have been investigated to predict the presence of esophageal varices (EV). This study aimed to evaluate the potential utility of portal vein flow velocity (PVFV) as a non-invasive alternative to endoscopic screening for predicting the presence of esophageal varices among cirrhotic patients. Methodology This validation cross-sectional study was carried out at the Department of Gastroenterology and Hepatology, Pakistan Kidney and Liver Institute & Research Centre (PKLI&RC), Lahore, Pakistan from June 8, 2022, to March 8, 2023. Cirrhotic patients were enrolled based on clinical, laboratory, and radiological assessments. Doppler ultrasonography was performed to measure portal vein flow velocity along other relevant indices. Subsequently, all patients underwent endoscopic evaluation to screen and grade the esophageal varices. Univariate and multivariate logistic regression analyses were performed to identify significant clinical predictors of EV based on the results of the independent sample t-tests or Mann-Whitney U tests. Receiver operating characteristic (ROC) curves were employed to determine the optimal cut-off value for portal vein flow velocity (PVFV). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated based on the identified cut-off value. A p-value ≤ 0.05 was considered statistically significant. Results A cohort of 137 cirrhotic patients was enrolled. The study population consisted of 92 males (67.2%) and 45 females (32.8%). Endoscopic screening confirmed the presence of esophageal varices in 81 patients (59.91%). A multivariate analysis revealed that aspartate aminotransferase to platelet ratio index (APRI) (p=0.008) and portal vein flow velocity (p=0.001) were significant factors associated with esophageal varices and were used for receiver operating characteristic (ROC) analysis. The area under the curve (AUC) for PVFV was 0.981, and for APRI, it was 0.711. At a cut-off value of 18 cm/sec for PVFV, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for esophageal varices were found to be 93.83%, 92.86%, 95%, 91.23%, and 93.43%, respectively. Conclusion Measurement of portal vein flow velocity using Doppler ultrasonography (DUS) is a reliable screening method for predicting the presence of esophageal varices (EV) in patients with liver cirrhosis. DUS offers several advantages, including its non-invasive nature, cost-effectiveness, and widespread availability, making it a recommended approach due to its high diagnostic accuracy.

Assessment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome using different scanning approaches for the ultrasonographic evaluation of portal vein blood flow and hepatic artery resistive index in hematopoietic stem cell transplant recipients.

Sinusoidal obstruction syndrome (SOS) is a fatal complication of hematopoietic stem cell transplantation (HSCT). Previously, we established a scoring system (Hokkaido ultrasound-based scoring system-10; HokUS-10) comprising 10 ultrasound parameters for SOS diagnosis. In HokUS-10, the portal vein time-averaged flow velocity (PV TAV) and hepatic artery resistive index (HA RI) are measured using subcostal scanning. However, measurement errors and delineation difficulties occur. Therefore, we aimed to prospectively evaluate PV TAV and HA RI measurements obtained via intercostal scanning as an alternative method to subcostal scanning and determine their cutoff values. HokUS-10 was administered before and after HSCT. PV TAV and HA RI were measured on subcostal and right intercostal scans. We performed 366 scans on 74 patients. The median value (range) of PV TAV in the main and right portal veins was 15.0cm/s (2.2-49.6cm/s) and 10.5cm/s (1.6-22.0cm/s), respectively. A low correlation was observed between the two values (r = 0.39, p < 0.01). The highest diagnostic value of the right portal vein was less than 8.0cm/s. The median value (range) of HA RI in the proper and right hepatic arteries was 0.72 (0.52-1.00) and 0.70 (0.51-1.00), respectively. A strong correlation was observed between the two values (r = 0.65, p < 0.01). The highest diagnostic value of the right HA RI was 0.72 or higher. Quantitative measurement of PV TAV and HA RI using intercostal scanning can be appropriately performed as an alternative method to using subcostal scanning.

Portal hemodynamic effects of different TKIs in patients with advanced hepatocellular carcinoma: A prospective cohort study.

e15126 Background: Tyrosine kinase inhibitors (TKIs) are considered to have effects on portal collateral circulation with portal hypertension. According to previous small sample clinical reports, short-term administration of sorafenib might have an effect of decreasing portal venous pressure, while lenvatinib aggravated portal hypertension. Long-term effects of TKIs on portal pressure are still unclear. Therefore, We conducted a prospective cohort study to explore the efficacy of different TKIs for portal circulation in patients with advanced hepatocellular carcinoma. Methods: 27 Child-Pugh class A or B patients with advanced HCC were enrolled in this study, 13 patients received lenvatinib, 7 patients sorafenib, and 7 patients regorafenib. Changes of portal hemodynamic parameters were measured by duplex Doppler ultrasonography, including portal venous area (PVA), portal venous flow velocity (PVV) and congestion index (CI) before and after administration of TKIs for an average 40-50 days. Results: In both regorafenib and sorafenib cohorts, PVA decreased after treatment, although the difference was not significant. PVF significantly reduced in sorafenib cohort (24.96±5.60 vs. 15.46±4.50, P= 0.014) and regorafenib cohort (21.43±2.09 vs. 16.01±1.28, P= 0.024), therefore CI significantly increased in sorafenib cohort (0.060±0.042 vs. 0.088±0.040, P= 0.046) and regorafenib cohort (0.068±0.032 vs. 0.090±0.030, P= 0.043). In lenvatinib, both PVA and PVF have no significant change, while CI increased significantly (0.057±0.027 vs. 0.074±0.040, P= 0.030). Conclusions: In this study, TKIs showed different effects on portal hemodynamic change in advanced HCC. Large sample and long time follow-up research will be necessary to verify their clinical and mechanism effects. [Table: see text]

Balloon angioplasty versus stent placement for the treatment of portal vein stenosis in children: a single center experience.

To evaluate the safety and efficacy of percutaneous interventional treatment of portal vein stenosis in children. A retrospective analysis of all interventional treatments for portal vein stenosis in pediatric patients at a single institution from 2010 to 2021 was conducted. Platelet count, spleen size and portal vein flow velocity were assessed during the follow-up period. Primary and primary assisted patency time were determined. A total of ten children (median age 28.5months, interquartile range (IQR): 2.75-52.5months) with portal vein stenosis after Mesorex-Shunt (n = 4), liver transplantation (n = 3) and other etiologies (n = 3) underwent 15 interventional procedures. There were five reinterventions and one discontinued intervention. The technical success rate was 93.3% (14/15) and clinical success of treated patients was 100% (14/14). Median follow-up was 18months (IQR: 13.5-81months). The median primary patency time for stent placement was 70months (IQR: 13.5-127.25months). For balloon angioplasty, the median primary patency time was 9months (IQR 7.25-11.5months), while the median assisted primary patency time was 14months (IQR: 12 to 15months). Platelet count, spleen size and portal vein flow velocity reliably corresponded to recurrence of portal vein stenosis in asymptomatic patients during follow-up. Interventional treatment is a safe and efficient method to treat portal vein stenosis with long patency times, regardless of etiology. Primary stent placement shows a higher primary patency time than balloon angioplasty. Implementation of stent placement as the primary interventional method may improve patency times and reduce the need for repeat reinterventions in pediatric patients.

Evaluation of Portal, Splenic, and Hepatic Vein Flows in Children Undergoing Congenital Heart Surgery

Little is known about changes in portal, splenic, and hepatic vein flow patterns in children undergoing congenital heart surgery. This study aimed to determine the characteristics of portal, splenic, and hepatic vein flow patterns using ultrasonography in children undergoing cardiac surgery. Single-center, prospective observational study. Tertiary children's hospital, operating room. Children undergoing cardiac surgery. The authors obtained ultrasound data from the heart, inferior vena cava, portal, splenic, and hepatic veins before and after surgeries. In the biventricular group, which included children with atrial and ventricular septal defects and pulmonary stenosis (n=246), the portal pulsatility index decreased from 38.7% to 25.6% (p < 0.001) after surgery. The preoperative portal pulsatility index was significantly higher in patients with pulmonary hypertension (43.3% v 27.4%; p < 0.001). In the single-ventricle group (n=77), maximum portal vein flow velocities of Fontan patients were significantly lower (13.5 cm/s) compared with that of patients with modified Blalock-Taussig shunt (19.7 cm/s; p=0.035) or bidirectional cavopulmonary shunt (23.1 cm/s; p < 0.001). The cardiac index was inversely correlated with the portal pulsatility index in the bidirectional cavopulmonary shunt and Fontan circulation. (β=-5.693, r2=0.473; p=0.001) The portal pulsatility index was correlated with splenic venous pulsatility and hepatic venous atrial reverse flow velocity in biventricular and single-ventricle groups. The characteristics of venous Doppler patterns in the portal, splenic, and hepatic veins differed according to congenital heart disease. Further studies are required to determine the association between splanchnic venous Doppler findings and clinical outcomes in this population.

The gallbladder wall thickness in correlation with portal hemodynamic changes in cirrhotic patients

Background The gallbladder wall thickness (GBWT) is affected by portal hypertension, so GBWT can predict portal hemodynamic changes. Aim To determine whether noninflammatory GBWT correlates with portal hemodynamic changes and esophageal varices (EV) in cirrhotic patients. Patients and methods A total of 80 patients were enrolled in this cross-sectional study. Patients consisted of 30 cirrhotic patients with EV, 30 cirrhotic patients without EV, and 20 noncirrhotic individuals as a control group. Complete blood count, liver function tests, hepatitis C virus antibody, and HBsAg were assessed. Child–Pugh score was calculated in cirrhotic patients. Moreover, abdominal ultrasonography was performed for measuring wall thickness of the gallbladder, spleen length, and portal vein diameter. Moreover, portal vein Doppler was done for portal blood mean flow velocity measurement. Upper gastrointestinal tract endoscopy was done. Results GBWT was significantly increased in cirrhotic patients with EV compared with cirrhotic patients with without EV and noncirrhotic individuals (P&lt;0.001). Moreover, GBWT was significantly correlated with spleen length, portal vein diameter, and portal velocity in cirrhotic patients with EV (P&lt;0.001). Conclusion The GBWT could be one of the simple noninvasive predictors of portal hypertension and EV as it was positively correlated with portal hemodynamic changes that accompany cirrhotic portal hypertension.

Variation in hepatic segmental portal venous pulsed wave Doppler flow distribution in patients with NAFLD: A pilot study.

To evaluate the segmental variations in portal venous pulsed wave colour Doppler flow velocity in patients with moderate to severe non-alcoholic fatty liver disease in comparison with healthy controls. In this prospective, observational, case-control study, the maximum velocity of all the segmental branches of portal vein were evaluated on colour Doppler in patients with moderate to severe non-alcoholic fatty liver disease, and the values were compared between three groups (1) Healthy controls (n = 30), (2) non-alcoholic fatty liver disease group, that is moderate to severe fatty liver without features of portal hypertension (n = 32) and (3) non-alcoholic steatohepatitis-portal hypertension group, that is those non-alcoholic fatty liver disease patients with features of portal hypertension (n = 13). Compared to controls, non-alcoholic fatty liver disease group showed a lower velocity in all the eight segments of liver. The ratio of segment 2 to segment 7 peak portal vein maximum velocity was significantly higher in non-alcoholic fatty liver disease (1.03 ± 0.21) compared to controls (0.90 ± 0.17) and even higher in non-alcoholic steatohepatitis-Portal hypertension group (1.83 ± 0.40) with p value of 0.003. Our study demonstrates the occurrence of flow redistribution occurring in cases of non-alcoholic fatty liver disease patients with the left lobe receiving higher portal venous flow. This flow redistribution was even more pronounced in a subset of non-alcoholic fatty liver disease patients who developed features of portal hypertension.

Doppler Ultrasound Assessment of Portal Venous Flow Changes During Pregnancy

Background &amp; Objectives: We aimed to evaluate portal venous flow changes during pregnancy by evaluating flow velocities and patterns in relation to gestational age. Methods: A total of 130 pregnant comprised (age, 18–45 years [mean, 29.3± 5.31 years]) were recruited. The subjects were divided into: Group 1: thirty four subjects in the 1sttrimester; Group 2: fifty five subjects in the 2nd trimester; and Group 3: forty one subjects in the 3rd trimesters. Portal vein diameter and maximum and minimum velocities were measured from the main portal vein. Spectral analysis was performed by calculating the portal vein pulsatility: minimum portal vein velocity divided by its maximum velocity. Results: The (mean±SD) maximum flow velocities (cm/sec) were higher in group 2 (31.58± 10.33) than those in groups 1 (29.44± 8.97) and 3: (26.8± 6.78), with a significant difference between groups 2 and 3. The mean minimum flow velocities were again higher in group 2: (20.89 ± 5.99) than those in groups 1 (17.71± 5.67) and 3 (18.2± 4.9) with a significant difference between groups 1 and 2. There were no statistically significant differences in mean portal vein diameter among the groups. The portal vein pulsatility value progressively increased with increasing gestational age from 0.60 in the first trimester to 0.68 in the third trimester, with statistical significant differences between groups 1 and 2 and groups 1 and 3. Conclusion: There is a significant increase in maximum portal vein flow velocity during the second trimester, with decreased waveform pulsatility with advancing gestational age.

Hypofibrinolysis in Pediatric Patients with Veno-Occlusive Disease in Hematopoietic Stem Cell Transplantation

Background Veno-occlusive disease (VOD) is a serious complication of hematopoietic stem cell transplantation (HSCT) with a high incidence in pediatric patients (11-27%). In clinical practice, VOD is diagnosed with criteria including weight gain, ascites, hepatomegaly, hyperbilirubinemia, and refractory thrombocytopenia. To date, there are no established markers for an earlier diagnosis of VOD. The aspect of assessing hypofibrinolysis, which plays a role in VOD pathogenesis, has not been elucidated. This study aimed to detect signs of hypofibrinolysis in HSCT and VOD patients using thrombelastography parameters and to discover correlations between alterations of these parameters and established symptoms of VOD. Patients and Methods Patients admitted for HSCT to the pediatric HSCT ward at the University Children's Hospital Tübingen, Germany, between May 2020 and November 2021 were prospectively enrolled (study group). Patients who underwent minor surgical procedures or follow-up blood tests years after recovering from oncological diseases and who were otherwise healthy, were recruited as a control group. Blood samples for thrombelastography (EX and TPA test, including the coagulation time (CT), clot formation time (CFT), clot amplitude after 5 minutes (A05), maximum clot firmness (MCF), maximum lysis (ML), α-angle, and lysis time (LT)) were taken once to twice weekly in addition to daily routine blood tests in patients undergoing HSCT. Routine testing included blood counts, coagulation parameters, d-dimers, and bilirubin. VOD symptoms were monitored daily and body weight was measured twice a day. Ultrasound screenings for ascites, progredient hepatomegaly, and portal venous flow velocity were performed in case of suspected VOD. All patients received intravenous anticoagulation with 100 IU/kg and day of unfractionated heparin. Of the control group patients, 6 ml blood was collected once per patient for routine coagulation testing and thrombelastography. Results A total of 51 patients with a median age of 7.8 years were recruited in the study group. Of these patients, five (9.8%) developed VOD and received defibrotide treatment. The VOD was graded moderate (n=2; 4%), severe (n=1; 2%) or very severe (n=2; 4%). Defibrotide treatment was initiated for 4 weeks or until the resolution of symptoms in standard dosing (25 milligrams per kilogram per day (mg/kg/d)) in four doses over 2 hours). The control group consisted of 55 patients with a median age of 6.7 years. A significant difference in thrombelastographic measurements was observed when comparing the VOD to the HSCT group. The lysis time after activation of fibrinolysis in the TPA test was prolonged in the VOD group at 3 weeks after HSCT (d+14 to +21: VOD: 330±67 seconds, HSCT: 246±53 seconds, p=0.0106). Additionally, a significant difference between the VOD and control groups was observed in days +14 to +21 (control: LT 234±50 seconds, p=0.0299). For the time points of day 0 to +6 and day +7 and +13 after HSCT lysis time was also prolonged in VOD patients, but without statistical significance (LT: d0 to +6: VOD: 304±57 seconds; HSCT: 251±67 seconds, p=0.06; d+7 to +13: VOD: 278±34 seconds; HSCT: 255±70 seconds, p=0.12). It was observed that LT correlated positively with weight gain (>5%), progredient hepatomegaly, right upper quadrant pain and reduced portal venous flow velocity (d0 to d+6: weight gain: r=0.31, p=0.0351; pain: r=0.44, p=0.0018; hepatomegaly: r=0.37, p=0.0108; d+7 to +13: pain: r=0.35, p=0.0143; hepatomegaly: r=0.39, p=0.0058; d+14 to d+21: weight gain: r=0.42, p=0.0035; pain: r=0.37, p=0.0103; hepatomegaly: r=0.44, p=0.0020; reduced portal venous flow velocity: r=0.35, p= 0.0167). Conclusions The results suggest that HSCT patients and patients diagnosed with VOD show signs of hypofibrinolysis. Fibrinolysis can be assessed in a rapid and accessible way via thrombelastography. Therefore, thrombelastography might be a useful tool to facilitate early diagnosis of VOD and to identify high-risk patients. Larger studies are needed to determine specific cut-off-values. Stefanie Hammer and Michaela Döring contributed equally to this work.

ADAMTS-13/von Willebrand factor ratio: A prognostic biomarker for portal vein thrombosis in compensated cirrhosis. A prospective observational study

Background and aimsIn cirrhosis, decreased portal flow velocity, thrombophilia factors, and portal hypertension are considered risk factors for portal vein thrombosis (PVT). In cirrhosis, the transformation of the stellate cells causes a progressive decrease of ADAMTS-13, while VWF multimers secretion by endothelial cells is strongly enhanced. This imbalance leads to an accumulation of ultra-large VWF multimers that in sinusoidal circulation could favor PVT both in intra- and extra-hepatic branches, mostly in decompensated cirrhosis. This prospective study was aimed at identifying possible clinical, biochemical, and hemostatic factors predictive for non-tumoral PVT in a cohort of patients with compensated cirrhosis. MethodsSeventynine compensated cirrhosis patients were prospectively followed for 48 months, receiving a periodic Doppler-ultrasound liver examination associated with an extensive evaluation of clinical, biochemical, and hemostatic profile. ResultsFive patients developed PVT (cumulative prevalence = 6.3%), occurring 4–36 months after enrollment. In logistic regression analysis, the ADAMTS-13/VWF:GpIbR ratio < 0.4 was the only independent variable significantly associated with PVT (OR 14.6, 95% C.I.:1.36–157.2, p = 0.027). A Cox-regression-analysis confirmed this finding (HR = 7.7, p = 0.027). ConclusionsThe ADAMTS-13/VWF ratio < 0.4 measured in compensated cirrhosis could be a reliable predictive biomarker for PVT development, paving the way to novel therapeutic strategies to prevent and treat PVT in this clinical setting.

Early prevention and risk factors analysis of portal vein system thrombosis after laparoscopic splenectomy and pericardial devascularization

BackgroundPortal vein system thrombosis (PVST) is a common postoperative complication brought by laparoscopic splenectomy and pericardial disconnection (LSD) among patients who suffered from portal hypertension and hypersplenism. This research lies mainly in probing into the risk factors of PVST and evaluating the effects of warfarin on PVST prevention.Materials and methodsWe took 131 individuals who have carried out LSD from January 2015 to January 2021. Patients were divided into warfarin group (n = 68) and aspirin group (n = 63). Meanwhile, thrombosis factors were analyzed in PVST arm (n = 48) and non-PVST arm (n = 83).ResultsWe analyzed the early postoperative anticoagulation effect, 20 patients (29.4%) in the warfarin group developed PVST, and 28 patients (44.4%) in the aspirin group. The chance to PVST during the first year after operation was lower in the warfarin group than in the aspirin group (F = 13.43, P = 0.006). Risk factors for PVST were analyzed, and diabetes, the diameter of the portal vein and splenic vein, and the velocity of portal blood flow were statistically significant between the PVST arm and non-PVST arm (P < < 0.05). Multiple logistic regression analyses have shown that diabetes, portal vein diameter, splenic vein diameter, and the velocity of portal blood flow were the risk factors of PVST.ConclusionsThe portal vein diameter, splenic vein diameter, portal vein flow velocity, and diabetes are risk factors for the PVST after LSD. The prophylactic use of warfarin anticoagulation markedly decreases the probability of occurrence of the PVST in patients with portal hypertension after LSD compared to aspirin.Graphical abstract

The Value of Color Doppler Ultrasound and CT Combined with Serum AFP Examination in the Diagnosis of Hepatocellular Carcinoma.

Objective To evaluate the value of the combination of color Doppler ultrasound, computed tomography (CT), and serum tumor marker alpha-fetoprotein (AFP) examination in the diagnosis of hepatocellular carcinoma (HCC). Methods 98 patients with HCC (malignant tumor group) and 50 liver lesion patients (benign control group), were selected for the study, and retrospective statistical methods were used to evaluate the diagnostic values of the three examinations on hepatocellular carcinoma. Results (1) When comparing color Doppler ultrasound blood flow parameters, the hepatic artery diameter, peak flow velocity, minimum flow velocity, and resistance index (RI) of hepatocellular carcinoma were significantly higher than those of the benign control group (P < 0.05), while the portal vein flow velocity was significantly lower than that of the control group (P < 0.05). (2) Enhanced CT imaging of hepatocellular carcinoma lesions showed mostly outflow-type enhancement changes, with high- or slightly high-density shadowing and uneven enhancement in the arterial phase, relatively low density and withdrawal of enhancement in the portal vein phase and delayed phase. (3) The serum AFP level of hepatocellular carcinoma patients was significantly higher than that of the benign control group (P < 0.01). (4) The sensitivity of color Doppler ultrasound, CT, and serum AFP alone for the diagnosis of HCC was 79.59%, 85.71%, and 66.33%, and the accuracy was 83.78%, 87.16%, and 74.32%, respectively, while the combination of the three tests could significantly increase the sensitivity to 96.94% and the accuracy to 93.92%, compared with each individual test (P < 0.01). Conclusion Color Doppler ultrasound and CT combined with serum AFP examination could significantly improve the sensitivity and accuracy of hepatocellular carcinoma diagnosis, reduce misdiagnosis, and facilitate early diagnosis and clinical early intervention.

Gastrointestinal Manifestations of Adult Cystinosis in Iran: A Descriptive Study.

Background: Cystinosis is a multisystemic disease caused by the accumulation of cystine crystals in the kidney and many other organs. This disease most often involves children. Recent developments in the treatment procedures have improved the chance of patients surviving as long as puberty. This study discusses the importance of immediate diagnosis and early treatment of the disease with cystagon, which reduces gastrointestinal complications in such patients. Methods: This descriptive study was performed on 19 adult patients (over 18 years old) with cystinosis who were observed by nephrologists from medical universities throughout Iran. Gastrointestinal complications were studied in the patients. Data were analyzed using SPSS Version 22. Results: The mean age of patients at the time of enrollment was 23.89 ± 5.06 years. Seventeen (89.4%) patients of this group had received renal replacement therapy (3 dialysis, 14 renal transplantation) due to end-stage renal disease and 2 (10.5%) of them were in stages 2 and 3 of chronic kidney disease. Three patients (15.7%) had hepatomegaly and splenomegaly; liver enzymes were normal in all patients. One patient (5.2%) had increased portal vein flow velocities, 2 of the patients (10.5%) underwent percutaneous endoscopic gastrostomy implantation due to severe dysphagia and eventually died. Most gastrointestinal symptoms in patients were nausea and abdominal pain. Conclusion: Early diagnosis and treatment with the proper dose of cystagon can increase life expectancy, reduce complications, and improve the patient's quality of life.

Role of portal color Doppler ultrasonography as noninvasive predictive tool for esophageal varices in cirrhotic patients

BackgroundEsophageal varices (EV) is the most common apprehensive complication of portal hypertension in patients with cirrhotic liver. Guidelines recommend Upper gastro-intestinal endoscopic screening for EV in patients with newly diagnosed chronic cirrhosis (Imperiale et al. in Hepatology 45(4):870–878, 2007). Yet, it is invasive, time consuming and costly. To avoid unnecessary endoscopy, some studies have suggested Doppler ultrasound examination as simple, and noninvasive tool in prediction and assessment of severity of EV (Agha et al. in Dig Dis Sci 54(3):654–660, 2009). Our study was to assess the role of different Doppler indices of portal vein, hepatic and splenic arteries as a noninvasive tool for prediction of esophageal varices in cirrhotic patients.ResultsThis prospective case control study was conducted on 100 cirrhotic liver patients and 100 of healthy volunteers as control group. Patients were subjected to clinical examination, upper gastrointestinal tract endoscopy, abdominal ultrasonography with duplex Doppler evaluation of different portal Doppler hemodynamic indices were done for each patient. The results revealed that portal vein diameter, hepatic artery pulsatility index, portal hypertensive index, portal vein flow velocity, portal congestion index have high sensitivity for prediction of EV. However, Splenic artery resistance index, hepatic artery resistance index HARI, liver vascular index and platelet count/spleen diameter have less sensitivity for prediction of EV.ConclusionMeasuring the portal hemodynamic indices can help physicians as noninvasive predictors of EV in cirrhotic patients to restrict the need for unnecessary endoscopic screening especially when endoscopic facilities are limited.

Triplex Sonographic Evaluation of Portal Vein Indices Among Adults in Port Harcourt, Nigeria.

Chronic liver disease is characterized by progressive hepatic fibrosis and changes in hepatic vascular hemodynamics. Sonography is a readily available tool in the assessment of the hepatic hemodynamic alterations that occur in chronic liver diseases. This study was aimed at sonographically determining the portal vein indices in apparently healthy adults by estimating the portal vein diameter, cross-sectional area, and portal vein velocity. This was a prospective, cross-sectional study carried out among 62 apparently healthy individuals. The participants underwent gray scale and Doppler ultrasonographic examinations of the portal vein. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) IBM Corp. version 23.0 (Armonk, NY: USA). The comparison of means of two groups was with the unpaired t-test, and level of significance was set at 5% (P < 0.05). Forty-six (74.2%) of the 62 participants recruited were male and 16 (25.8%) were female. Participants were aged 18-65 years with a mean age of 39.90 ± 10.34 years. The means of portal vein diameter, cross-sectional area, and portal vein velocity are 1.15 ± 0.12 cm, 0.88 ± 0.18 cm2, and 18.37 ± 2.04 cm/s, respectively. There was no statistically significant difference of all portal vein ultrasound parameters between males and females, except portal vein flow velocity which was higher in males, t-test = 2.273 and P = 0.027 (>0.05). There was no significant correlation between age and ultrasound parameters P > 0.05. The normal values of portal vein diameter, cross-sectional area, and portal vein velocity were established.