Portal Vein Pressure Research Articles

A110 FEASIBILITY OF EUS-GUIDED PORTAL PRESSURE GRADIENT MEASUREMENT WITHOUT DEEP SEDATION: A PATH TO ACCURATE PORTAL PRESSURE DETERMINATION

AimsHepatic venous pressure gradient (HVPG) is the gold standard for the diagnosis and staging of portal hypertension. Previous studies have shown that it underestimates pre-sinusoidal portal hypertension. Endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) can safely measure direct portal vein pressure (PVP) and bridge this diagnostic gap. However, EUS-PPG has so far been performed with patients under deep sedation which can alter HVPG measurement and lead to misclassification of portal hypertension. Ketamine, a conscious sedation agent, has minimal effect on portal hemodynamics. We present our center’s experience with EUS-PPG under ketamine and low dose midazolam.MethodsWe retrospectively reviewed consecutive patients undergoing EUS-PPG with conscious sedation using ketamine and low-dose midazolam (<0.02 mg/kg) at the McGill University Health Centre from February to May 2021. Patients were placed in the left lateral position. Hepatic vein and portal vein were located through EUS via a trans-gastric/hepatic approach. A through the scope 25-gauge needle attached to a manometer was advanced through the liver to measure hepatic vein pressure (HVP) and portal vein pressure (PVP). Three measurements were sampled per vessel and mean pressure differences calculated to obtain PPG. PPG was considered reliable if the differences between the values was no more than 1mmHg.ResultsThree patients underwent EUS-PPG for evaluation of pre-sinusoidal portal hypertension. Cirrhosis was excluded in all patients based on recent liver biopsy or transient elastography. The first patient is a 69-year-old man with splenomegaly and recanalization of the paraumbilical vein on imaging. He received 80 mg of ketamine and no midazolam. HVPG measured was 1 mmHg. EUS-PPG was successful with PPG of 6 mmHg (HVP= 7 mmHg, and PVP= 13 mmHg). The second patient is a 42-year-old woman with previous sleeve gastrectomy and known with portal cavernoma. She received 120 mg of ketamine and 1 mg of midazolam. EUS-PPG was technically difficult due to respiratory movements. The measurement was not considered reliable as differences in PPG were as high as 2mmHg. In this case, PPG was 0mmHg (HVP= 15mmHg, and PVP= 15mmHg). The third patient, a 74-year-old man with hepatic steatosis and splenomegaly received 70 mg of ketamine and 1 mg of midazolam. EUS-PPG was successful (HVP= 3mmHg, PVP= 3mmHg) yielding a PPG 0mmHg. All patients tolerated the procedure well with no procedural or sedation-related complicationsConclusionsOur early experience suggests that EUS-PPG can be successfully and safely performed in patients under conscious sedation with ketamine and low-dose midazolam. This combination may avoid deep sedation with high dose midazolam or propofol which are known to alter accuracy of HVPG. Measurement of HVP (left) and PVP (right)Funding AgenciesNone

Effects of plasma lipopolysaccharide changes on platelet release of vascular endothelial growth factor and thromobospondin-1 in patients with cirrhotic portal hypertension after TIPS procedure

Objective: To investigate the effects of plasma lipopolysaccharide (LPS) concentration changes on platelet release of vascular endothelial growth factor (VEGF) and thrombospondin (TSP)-1 in patients with decompensated cirrhotic portal hypertension after transjugular intrahepatic portosystemic shunt (TIPS) procedure. Methods: 169 cases with cirrhotic portal hypertension were enrolled, of which 81 cases received TIPS treatment. LPS, VEGF, and TSP-1 concentrations with different Child-Pugh class in peripheral blood plasma of patients were measured. After pre-incubation of normal human platelets with different concentrations of LPS and stimulated by collagen in vitro, platelet PAC-1 expression rate, VEGF, and TSP-1 concentrations were detected. PAC-1 expression rate and the concentrations of LPS, VEGF and TSP-1 in peripheral blood plasma of patients before and after TIPS procedure were detected. The relationship between plasma LPS, VEGF and TSP-1 concentrations and Child-Pugh score changes in patients after TIPS procedure was analyzed. Statistical analysis was performed by t-test, one-way ANOVA or Pearson's rho according to different data. Results: Plasma LPS and TSP-1 concentrations were significantly higher in Child-Pugh class C patients than class A and B, but the concentration of plasma VEGF was significantly lower than class A and B (P < 0.01). In vitro experiments showed that concentration of LPS, TSP-1, and platelet PAC-1 expression rate was higher in the supernatant, but the difference in the concentration of VEGF in the supernatant was not statistically significant. Portal vein pressure and platelet activation were significantly decreased (P < 0.01) in patients after TIPS procedure. Portal venous pressure, platelet activation, plasma LPS, and TSP-1 levels were significantly decreased continuously, while VEGF levels were significantly increased continuously after TIPS procedure. Plasma LPS concentration was positively correlated with TSP-1 concentration (r = 0.506, P < 0.001), and negatively correlated with VEGF concentration (r = -0.167, P = 0.010). Child-Pugh score change range was negatively correlated with change range of plasma VEGF concentration (r = -0.297, P = 0.016), and positively correlated with change range of plasma TSP-1 concentration (r = 0.145, P = 0.031) after TIPS. Conclusion: Portal venous pressure gradient, plasma LPS concentration and corresponding platelet activation was decreased in cirrhotic portal hypertension after TIPS procedure, and with TSP-1 reduction and VEGF elevation it is possible to reduce the liver function injury caused by portal venous shunt.

What is the Risk Factor of Graft Mortality in Patients who Underwent Simultaneous Splenectomy during Living Donor Liver Transplantation?

Introduction: Splenectomy is performed in living donor liver transplantation (LDLT) for portal flow modulation. The aim of this study was to identify the risk factor of 6-month graft mortality in patients who underwent splenectomy in LDLT. Methods: Data from 441 adult patients who underwent simultaneous splenectomy during primary LDLT were collected retrospectively. Risk factors of 6-month graft mortality were investigated. Results: Mean recipient age was 55 years. Mean donor age was 38.7 years. Two hundred and five patients (46.5%) received left lobe graft. Mean graft weight (GW)-standard liver weight ratio was 41.5% and GW-recipient weight ratio was 0.79%. Six-month graft survival rate after LDLT in 441 patients was 93.8%, which was significantly better compared to patients without simultaneous splenectomy or splenic artery ligation (83.9%, p<0.0001). Univariate analysis revealed the following risk factors for 6-month graft mortality in patients with splenectomy: neutrophil-lymphocyte ratio > 4, acute liver failure, hospitalized before LDLT, donor > 60 years of age, MELD score > 22, pre-LDLT platelet < 40, 000/mm3, portal vein pressure when LDLT finished (PVP) > 20 mmHg. Multivariate analysis identified that donor > 60 years of age (Hazard ratio=4.50, p=0.049), pre-LDLT platelet < 40, 000/mm3 (Hazard ratio=2.58, p=0.03), and PVP > 20 mmHg (Hazard ratio=7.46, p<0.001) were the independent risk factors of 6-month graft mortality after LDLT. Conclusion: Splenectomy improves graft survival rate after LDLT. Careful attention is needed for patients with platelet < 40, 000/mm3, PVP > 20 mmHg, and received graft from donor > 60 years of age.

Angiographic diagnosis for accurate assessment of congenital porto-systemic shunt and extrahepatic portal vein obstruction in children.

Congenital porto-systemic shunt (CPSS) is a rare disease and can cause fatal complications. Accurate angiographic assessment is mandatory for proper treatment. Although technically difficult, we developed assessment techniques and assessed their accuracy. One technique came from evaluating patients with extrahepatic portal vein obstruction (EHPVO). We conducted a single center retrospective study to evaluate the efficacy of angiographic diagnostic procedure for the assessment of CPSS and EHPVO, and its impact on patients' subsequent interventions and clinical course. Eight patients with CPSS and two patients with EHPVO who underwent diagnostic angiography were included. Assessment of the intrahepatic portal vein was performed in all patients. The route of the shunt, and portal vein pressure under shunt occlusion, were also evaluated for patients with CPSS. Evaluation was first attempted with a balloon angiographic catheter (standard method). Three additional techniques were performed as needed: (i) direct wedge-catheter injection without balloon inflation, (ii) use of occlusion balloon in two patients, and (iii) hybrid angiography with sheath placement directly into the superior mesenteric vein. The standard method was sufficient in four patients. On the other hand, all three techniques were required in two patients each. One lost contact during follow up, but all other patients underwent optimal intervention. There were no complications related to the angiographic procedure. Use of direct wedge-catheter injection without balloon inflation, occlusion balloon, and hybrid catheterization improved the diagnostic yield in patients with CPSS or EHPVO.

Endoscopic Ultrasound-guided Portal Pressure Gradient Measurement Is Technically Successful and Safe Without Deep Sedation: A Proof-of-Concept Case Series

The hepatic venous pressure gradient (HVPG), which is the difference between the wedged (WHVP) and free hepatic vein pressures (FHVP), is the gold standard to evaluate portal hypertension in patients with cirrhosis 1 Bosch J Abraldes JG Berzigotti A et al. The clinical use of HVPG measurements in chronic liver disease. Nat Rev Gastroenterol Hepatol. 2009; 6: 573-582 Crossref PubMed Scopus (436) Google Scholar . Unfortunately, there currently exists a gap in the evaluation of patients with pre-sinusoidal portal hypertension, where HVPG is known to underestimate portal pressure. Endoscopic ultrasound-guided portal pressure gradient measurement (EUS-PPG) has recently brought back the possibility of safely obtaining direct portal vein pressure (PVP) and represents a long-awaited less-invasive diagnostic tool for patients with suspected pre-sinusoidal portal hypertension.

Two Cases of Splenectomy Combined with Hepatectomy for Patients with Insufficient Future Liver Remnant Volume

The usefulness of splenectomy combined with hepatectomy for patients without liver cirrhosis (LC) have been equivocal, even though splenectomy for hepatocellular carcinoma (HCC) patients with portal hypertension could improve the surgical safety. We performed splenectomy with hepatectomy in one case of HCC patient with LC and one case of intrahepatic cholangiocarcinoma (ICC) patient without LC. Therefore, we will report the cases. Case 1: A 77-year-old woman with LC underwent hepatectomy for HCC in liver segment 5 with portal vein (PV) tumor thrombosis. Her blood test showed platelets count of 148,000 /μl, ICG 15-minute value of 18.3%, ICG-K value of 0.110. Right lobectomy was planned, and the future liver remnant volume (FLRV) was 336 ml (36.1%) / remnant liver ICG-K value was 0.039. Intraoperative PV pressure slightly increased from 10 to 11 mmHg after hepatectomy, and decreased to 9 mmHg after splenectomy. She was discharged 18 days after the operation without any major complications. Case 2: A 46-year-old man without LC underwent hepatectomy for ICC. His blood test showed platelets count of 248,000 /μl, ICG 15-minute value of 12.9%, ICG-K value of 0.152. Extended right lobectomy was planned and the FLRV was 736 ml (39.3%) / remnant liver ICG-K value was 0.059. Intraoperative PV pressure increased from 20 to 25 mmHg after hepatectomy, and decreased to 20 mmHg after splenectomy. He was discharged 31 days after the operation without any major complications, but intractable ascites. Conclusion: Splenectomy combined with hepatectomy for patients without LC may improve the surgical safety.

Does Arterialization of Portal Vein Have Any Effects in Large-for-Size Liver Transplantation? Hemodynamic, Histological, and Biomolecular Experimental Studies

Background: In pediatric liver transplantation, the optimal size of the transplanted liver ranges between 0.8% and 4.0% of the recipient’s weight. Sometimes, the graft weight exceeds this upper limit, characterizing the large-for-size condition potentially associated with reduced blood flow and worsening of ischemia-reperfusion injury. Therefore, it would be beneficial to increase the portal flow through arterialization of the portal vein. Materials and methods: Fifteen pigs underwent large-for-size liver transplants. They were divided into two groups: control (CTRL 6 animals – conventional technique) and arterialization – a shunt was established between the portal vein and the splenic artery (ART 9 animals). Hemodynamic, biochemical, histological, and molecular variables were compared. Results: Arterialization resulted in a significant increase in portal vein pressure but no changes in other hemodynamic variables, as shown in the analysis of variance. It was observed lower ALT values (p = 0.007), with no differences regarding the values of blood pH and lactate (p = 0.54 and p = 0.699 respectively) or histological variables (edema, steatosis, inflammation, necrosis, and IRI – p = 1.0, p = 0.943, p = 0.174, p = 0.832, p = 0.662, respectively). The molecular studies showed significantly increased expression of IL6 after 3 hours of reperfusion (p = 0.048) and decreased expression of ICAM immediately after reperfusion (p = 0.03). The regression analysis suggested a positive influence of portal flow and pressure on biochemical parameters. Conclusion: Arterialization of the portal vein showed no histological, biochemical, or molecular benefits in large-for-size transplantation.

Subharmonic Scattering of SonoVue Microbubbles Within 10-40-mmHg Overpressures In Vitro.

Ultrasound contrast agent microbubbles are considered promising sensors to measure portal vein pressure noninvasively. In this study, we investigated the subharmonic scattering power and optimal incident acoustic pressure of SonoVue microbubbles (concentration: [Formula: see text]/mL 0.9% NaCl solution) in the ambient pressure range of 10-40 mmHg with 10-mmHg increments at a temperature of 25 °C. The results demonstrated that the subharmonic response of the SonoVue microbubbles existed in three stages: the first growth stage (40-300 kPa), saturation (300-400 kPa), and the second growth stage (400-540 kPa). In the first growth stage, the subharmonic amplitude increased with ambient pressure. However, while the ambient pressure increased, the subharmonic amplitude decreased in the second growth stage. The best correlation of the subharmonic amplitudes with the ambient pressures was obtained at a high incident acoustic pressure of 520 kPa (sensitivity: 0.15 dB/mmHg, r2 = 0.99 , and root-mean-square error = 0.49 mmHg), which indicated that the subharmonic signals in the second growth stage might be suitable for estimating low ambient pressures. The results presented in our study may pave the way for portal vein pressure estimation using SonoVue microbubbles as sensors in clinical applications.

The use of ex-vivo liver perfusion circuit in sheep model: Preliminary report.

Objectives:To describe a novel animal model for ex-vivo liver perfusion.Methods:This study was carried out at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, between September 2016 and January 2019. We assembled a perfusion circuit operated by a continuous pressure-driven arterial pump with continuous portal and arterial pressure and volume measurements. We used normothermic oxygenated perfusate. The livers used were retrieved from the sheep.Results:Ex-vivo continuous perfusion of the liver was achieved for up to 9 hours with stable pressure and volume in both hepatic artery and portal vein. In 4 experiments the arterial pressure was kept in a range of 48-52 mmHg with a mean of 51.75±4.31 resulting in arterial volume at steady state of 223.5±48.25 ml/minute (95% confidence level). At steady state the mean portal pressure was 16.25±1.45 mmHg with a mean volume of 854±313.75 ml/minute (95% confidence level). Bile production was observed during the perfusion period. Hemodynamic parameters were similar to the physiological parameters observed in normothermic perfusion model of the porcine liver.Conclusion:A normothermic oxygenated ex-vivo perfusion circuit was successfully constructed using the sheep liver. A sustainable functional circuit with physiological hemodynamic parameters was achieved. Further study on sheep model seems to be feasible.

Transjugular Portosystemic Stent Shunt: Impact of Right Atrial Pressure on Portal Venous Hemodynamics Within the First Week

PurposePorto-systemic pressure gradient is used to prognosticate rebleeding and resolution of ascites after TIPS. This study investigates the reliability of portal pressure characteristics as quantified immediately after TIPS placement and at short-term control.Patients and MethodsPortal venous pressure (PVP) and right atrial pressure (RAP) were prospectively obtained before and after TIPS as well as ≥ 48 h after TIPS procedure. Porto-systemic pressure gradients (PSG) and pressure changes were calculated. A multivariate regression analysis was performed to predict portal hemodynamics at short-term control.ResultsThe study included 124 consecutive patients. Indications for TIPS were refractory ascites, variceal bleeding or combinations of both. Pre- and post-interventional PSG yielded 16.4 ± 5.3 mmHg and 5.9 ± 2.7 mmHg, respectively. At that time, 105/124 patients (84.7%) met the target (PSG ≤ 8 mmHg). After 4 days (median), PSG was 8.5 ± 3.5 mmHg and only 66 patients (53%) met that target. In patients exceeding the target PSG at follow-up, PVP was significantly higher and RAP was lower resulting in the increased PSG. The highly variable changes of RAP were the main contributor to different pressure gradients. In the multivariate regression analysis, PVP and RAP immediately after TIPS were predictors for PSG at short-term control with moderately predictive capacity (AUC = 0.75).ConclusionBesides the reduction of portal vein pressure, the highly variable right atrial pressure was the main contributor to different pressure gradients. Thus, immediate post-TIPS measurements do not reliably predict portal hemodynamics during follow-up. These findings need to be further investigated with respect to the corresponding clinical course of the patients.

Portal venous pressure in non-cirrhotic bilharzial patients undergoing elective splenectomy, can it affect mortality? A prospective study.

To evaluate the impact of intraoperatively measured portal vein pressure (PVP) on mortality in non-cirrhotic bilharzial patients undergoing splenectomy. The present study is a prospective study that was conducted in Egypt from April 2014 to April 2018. Adult patients with non-cirrhotic bilharziasis who were scheduled to undergo splenectomy were included. Studied cases were divided into a survival cohort and a non-survival cohort. The main objective was the correlation between the incidence of mortality and intraoperative PVP. The present work comprised 130 cases with a mean age of 51.8 ± 6.4 years old. The in-hospital mortality rate was 22.3%, with sepsis as a major cause of death (37.9%). In term of the association between preoperative variables and mortality, survivors had statistically significant lower portal vein diameter (13.6 ± 1.8 versus 15.2 ± 1.8mm; p<0.001) and higher portal vein velocity (14.2 ± 1.8 versus 10.4 ± 2.3 cm/sec; p<0.001) than nonsurvivors. The survived patients had significantly lower PVP (13.9 ± 1.1 versus 17.7 ± 2.7; p<0.001). A cut-off value of ≥14.5 mmHg, the PVP yielded a sensitivity of 86.2% and a specificity of 69% for the prediction of mortality. The association analysis showed a statistically significant association between mortality and postoperative liver function parameters. High intraoperative PVP is linked to early postoperative death in non-cirrhotic cases undergoing splenectomy. Our study showed that PVP > 14.5mmHg was an independent predictor of death and showed good diagnostic performance for the detection of early postoperative mortality.

Treatment of multiple huge liver cysts in a hybrid operating room: a case report

BackgroundLiver cysts are common, with most cases being asymptomatic. In symptomatic cases, the disease is amenable to treatment. However, huge or multiple liver cysts with vascular narrowing and associated systemic symptoms are extremely rare. Furthermore, the performance of a reliable and effective surgery in such cases remains a major problem. Here, we report a case of multiple giant liver cysts with impaired blood flow surgically treated in a hybrid operating room.Case presentationA 73-year-old male presented to a previous doctor with leg edema and dyspnea on exertion; computed tomography revealed that the cause complaint was right lung and heart compression and inferior vena cava (IVC) stenosis due to huge liver cysts in the caudal lobe. The patient was referred to our hospital because of disease recurrence despite percutaneous aspiration of the cyst. Multiple liver cysts were observed in addition to the drained cysts, two of which were located on both sides of the IVC and caused IVC stenosis. We performed open surgery for the liver cysts and used the hybrid operating room for intraoperative IVC angiography and measuring the hepatic vein and portal vein (PV) pressure. We performed unroofing of the hepatic cyst and cauterization of the cyst wall on the hepatic side. Angiography was performed before and after unroofing of the liver cysts, and IVC stenosis release was confirmed. IVC pressure measured at the peripheral side of the stenosis and PV pressures were continuously measured during surgery and were confirmed to have decreased during the opening of the liver cysts. The patient had a good postoperative course and was discharged on the 10th postoperative day. No recurrence was observed 6 months postoperatively.ConclusionsCyst unroofing surgery using angiography in a hybrid operating room is a useful treatment for deep hepatic lesions in that vascular stenosis improvement can be intraoperatively confirmed. Moreover, in cases wherein the cyst compresses the vasculature, intraoperative monitoring of IVC and PV pressures can be used to prove that the liver cyst is hemodynamically involved.

Decompensation in Advanced Nonalcoholic Fatty Liver Disease May Occur at Lower Hepatic Venous Pressure Gradient Levels Than in Patients With Viral Disease

Portal hypertension is the strongest predictor of hepatic decompensation and death in patients with cirrhosis. However, its discriminatory accuracy in patients with nonalcoholic fatty liver disease (NAFLD) has been challenged because hepatic vein catheterization may not reflect the real portal vein pressure as accurately as in patients with other etiologies. We aimed to evaluate the relationship between hepatic venous pressure gradient (HVPG) and presence of portal hypertension-related decompensation in patients with advanced NAFLD (aNAFLD). Multicenter cross-sectional study included 548 patients with aNAFLD and 444 with advanced RNA-positive hepatitis C (aHCV) who had detailed portal hypertension evaluation (HVPG measurement, gastroscopy, and abdominal imaging). We examined the relationship between etiology, HVPG, and decompensation by logistic regression models. We also compared the proportions of compensated/decompensated patients at different HVPG levels. Both cohorts, aNAFLD and aHVC, had similar baseline age, gender, Child-Pugh score, and Model for End-Stage Liver Disease score. Median HVPG was lower in the aNAFLD cohort (13 vs 15 mmHg) despite similar liver function and higher rates of decompensation in aNAFLD group (32% vs 25%; P= .019) than in the aHCV group. For any of the HVPG cutoff analyzed (&lt;10, 10-12, or 12 mmHg) the prevalence of decompensation was higher in the aNAFLD group than in the aHCV group. Patients with aNAFLD have higher prevalence of portal hypertension-related decompensation at any value of HVPG as compared with aHCV patients. Longitudinal studies aiming to identify HVPG thresholds able to predict decompensation and long-term outcomes in aNAFLD population are strongly needed.

Decompensated Acute Heart Failure Accompanied with Cardiac Cirrhosis and Chronic Disease Anemia in Child

Continuous heart failure can lead to complications to other systems, one of which is the hepatic system. Heart failure results in venous congestion in the portal vein so that the portal vein pressure increases, which is called portal hypertension. Portal hypertension causes fluid to pass through the walls of blood vessels and into the tissues. Management of decompensatory heart failure accompanied by comorbi d disease in cardiac cirrhosis includes drugs management that does not aggravate the liver, namely angiotensin converting enzyme inhibitors and loop diuretic agents. Also, non-pharmacological management such as resting position and a diet sufficient in protein and low salt help improve the patient's general condition. This case report aims to present a de compensated heart failure accompanied by cardiac cirrhosis and anaemia of chronic disease in a child.

S2005 Effects of Endoscopic Gastric Plication on Portal Pressure Gradient in a Patient With Non-Alcoholic Steatohepatitis Cirrhosis

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide with the prevalence approaching 90% in patients with obesity. Nonalcoholic steatohepatitis (NASH) is an aggressive form of NAFLD with an increased risk of cirrhosis. The treatment for NASH is limited to lifestyle modification. Case Description/Methods: Our patient was a 68-year-old woman with obesity and compensated NASH cirrhosis. She underwent an attempted Roux-en-Y gastric bypass, which was aborted due to cirrhosis. Transient elastography suggested cirrhosis with liver stiffness of 17 kPa. This case represents the convergence of endobariatrics and endohepatology. Specifically, we demonstrate the use of endoscopic gastric plication (EGP) to treat obesity and NASH in a patient with cirrhosis, as well as the application of endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement to monitor its changes following EGP. Prior to EGP, she underwent EUS-guided PPG measurement. Specifically, a transgastric transhepatic puncture with a 25-gauge fine needle aspiration needle into the hepatic vein was achieved. The manometer and needle were flushed with heparinized saline solution. The manometer reading rose and plateaued. The process was repeated at least two more times and the average manometer number represented hepatic venous pressure (HVP). The needle was slowly withdrawn under Doppler. Subsequently, the portal vein was punctured, and the same steps repeated to measure the portal vein pressure (PVP). In this case, the average HVP and PVP were 17 mmHg and 28.5 mmHg. Therefore, her PPG prior to EGP was 11.5 mmHg. The patient then underwent an EGP procedure. The first set of plications was placed in the distal gastric body perpendicular to the length of the stomach to reduce its width. The second and third sets of plications were placed longitudinally to shorten the gastric length. The last set of plications was then placed at the proximal gastric body to further reduce its width. At 9 months, her weight decreased from 279 to 255 pounds, representing an 8.6% weight loss. Her liver stiffness decreased from 17 to 7.6 kPa, suggesting regression from stage 4 to stage 2 fibrosis. A follow-up PPG showed a PPG of 8 mmHg, representing a 30% reduction. Discussion: This case demonstrates the safety and efficacy profile of EGP for the treatment of compensated NASH cirrhosis with improvement in liver fibrosis and PPG. Watch video at https://bit.ly/3i0axL1.

Pregnancy Outcome in Patients with Budd Chiari Syndrome: A Single Centre Experience

Abstract Background Budd-Chiari syndrome (BCS) is a rare disease caused by hepatic venous outflow obstruction and results in hepatic failure due to sinusoidal congestion, decrease in the blood supply to the to the liver and increase the pressure in portal vein . Objectives The aim beyond this study is assessment of the maternal and foetal events in a group of women who became pregnant while having BCS. Patients and methods It is a prospective and retrospective study which was conducted on 32 patients with Budd- Chiari syndrome admitted to Ain Shams University Hospitals, Tropical Medicine department or attended the outpatient clinics during the period from May 2006 to March 2019 who became pregnant after diagnosis by BCS . Results Number of cases that underwent tips revision 3 cases and one case underwent liver transplantation after delivery and 2 cases had died during follow up.Using . of enoxaparin in 1st trimester in our cases as a significant protective factor against abortion. Conclusion BCS isn’t a contraindication to pregnancy in patients with a well-controlled disease. Fetal outcome remains relatively poor, which is at least partly due to the underlying prothrombotic disorders. so patients should be accurately informed about the risk of this pregnancies .

Causes of portal hypertension in children.

Objective: To determine different causes of portal hypertension in children. Study Design: Cross Sectional study. Setting: Department of Pediatric Medicine, Department of Pediatric Gastroenterology and Department of Medical Emergency, The Children’s Hospital and Institute of Child Health, Multan. Period: 3rd April 2019 to 2nd October 2019. Material &amp; Methods: A total of 71 children presenting with portal hypertension aged 1 month to 15 years of either gender were included. Newborns or children with congenital heart diseases were excluded. Patient samples were collected for complete blood counts and liver function tests, Ultrasound Abdomen and color Doppler ultrasonography were done for portal vein pressure to determine various causes of portal hypertension. Results: Overall, mean age was 9.00 ± 3.64 years. Out of the 71 patients, 51 (71.83%) were male and 20 (28.17%) were females. Different causes of portal hypertension were portal vein thrombosis in 48 (67.61%), liver cirrhosis in 14 (19.72%) and biliary atresia in 9 (12.68%) children. Conclusion: Among children having portal hypertension, portal vein thrombosis was noted to be the commonest cause followed by liver cirrhosis and biliary atresia.

Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound.

The diagnosis and management of cirrhosis and portal hypertension (PH) with its complications including variceal hemorrhage, ascites, and hepatic encephalopathy continues to evolve. Although there are established “standards of care” in liver biopsy and measurement of PH, gastric varices remain an area without a universally accepted therapeutic approach. The concept of “Endo Hepatology” has been used to describe of the applications of endoscopic ultrasound (EUS) to these challenges. EUS-liver biopsy (EUS-LB) offers an alternative to percutaneous and transjuglar liver biopsy without compromising safety or efficacy, and with added advantages including the potential to reduce sampling error by allowing biopsies in both hepatic lobes. Furthermore, EUS-LB can be performed during the same procedure as EUS-guided portal pressure gradient (PPG) measurements, allowing for the collection of valuable diagnostic and prognostic data. EUS-guided PPG measurements provide an appealing alternative to the transjugular approach, with proposed advantages including the ability to directly measure portal vein pressure. In addition, EUS-guided treatment of gastric varices (GV) offers several possible advantages to current therapies. EUS-guided treatment of GV allows detailed assessment of the vascular anatomy, similar efficacy and safety to current therapies, and allows the evaluation of treatment effect through doppler ultrasound visualization. The appropriate selection of patients for these procedures is paramount to ensuring generation of useful clinical data and patient safety.

Two Birds with One Stone

Despite improved serological and imaging diagnostic methods, liver biopsy remains an essential tool in diagnosing, evaluating and managing liver diseases. Endoscopic ultrasound-guided liver biopsy (EUS-LB) has been demonstrated to be a safe, feasible and effective technique with at least comparable or even better samples than transjugular or percutaneous liver biopsies.1-3 EUS-LB has various advantages: better patient comfort, if needed portal vein pressure measurements can be conducted simultaneously and different regions in the liver can be easily sampled. Moreover, as demonstrated in this case, EUS-LB can be performed concomitantly with an upper, lower endoscopy or EUS.

Trans-jugular intrahepatic portosystemic shunt in patients with hepatic cellular carcinoma: A preliminary study.

To analyze the effects of trans-jugular intrahepatic portosystemic shunt (TIPS) on portal hypertension and liver function in patients with hepatocellular carcinoma (HCC). Thirteen patients with hemorrhage caused by portal hypertension and HCC who received TIPS and antitumor treatment were retrospectively analyzed. Trans-arterial chemoembolization, microwave ablation, target therapy, and immunetherapy or combined therapy were performed to treat HCC. Child-Pugh score was applied to estimate liver functions before and after TIPS. Shunting patency, overall survival (OS), and progression-free survival were analyzed. The median age was 58 (interquartile range: 52.5-62.5) years. The ratio with ascites before and after TIPS was 84.6% (11/13) and 7.7% (1/13), with P < 0.001. The ratio with Child-Pugh A before and after TIPS were 61.5% (8/13) and 84.6% (11/13) respectively, with P = 0.179. Mean portal vein pressure before and after TIPS was 27.85 ± 7.02 mmHg and 16.23 ± 6.61 mmHg, respectively, with P = 0.001. Two-year shunting patency rate was 61.5%. Median OS was 29.8 ± 11.5 months (95% confidence interval [CI] 22.8-36.7), and median progression-free survival was 20.2 ± 13.2 months (95% CI 12.2-28.1). TIPS could reduce ascites, down-regulate the Child-Pugh score, and give a chance for further anti-tumor therapy.