Portosystemic Collaterals Research Articles

Difference between type 2 gastroesophageal varices and isolated fundic varices in clinical profiles and portosystemic collaterals.

BACKGROUNDThere is significant heterogeneity between gastroesophageal varices (GOV2) and isolated gastric varices (IGV1). The data on the difference between GOV2 and IGV1 are limited.AIMTo determine the etiology, clinical profiles, endoscopic findings, imaging signs, portosystemic collaterals in patients with GOV2 and IGV1. METHODS Medical records of 252 patients with gastric fundal varices were retrospectively collected, and computed tomography images were analyzed.RESULTSSignificant differences in routine blood examination, Child–Pugh classification and MELD scores were found between GOV2 and IGV1. The incidence of peptic ulcers in patients with IGV1 (26.55%) was higher than that of GOV2 (11.01%), while portal hypertensive gastropathy was more commonly found in patients with GOV2 (22.02%) than in those with IGV1 (3.54%). Typical radiological signs of cirrhotic liver were more commonly observed in patients with GOV2 than in those with IGV1. In patients with GOV2, the main afferent vessels were via the left gastric vein (LGV) (97.94%) and short gastric vein (SGV) (39.18%). In patients with IGV1, the main afferent vessels were via the LGV (75.61%), SGV (63.41%) and posterior gastric vein (PGV) (43.90%). In IGV1 patients with pancreatic diseases, spleno-gastromental-superior mesenteric shunt (48.15%) was a major collateral vessel. In patients with fundic varices, the sizes of gastric/esophageal varices were positively correlated with afferent vessels (LGVs and PGVs) and efferent vessels (gastrorenal shunts). The size of the esophageal varices was negatively correlated with gastrorenal shunts in GOV2 patients. CONCLUSIONSignificant heterogeneity in the etiology and vascular changes between GOV2 and IGV1 is useful in making therapeutic decisions.

Microbiota transplantation in portal hypertension: promises and pitfalls.

In this commentary, we discuss new findings indicating that microbiota transplantation has favorable impact on portal hypertension (PH) in the experimental model of cirrhosis induced by bile duct ligation (BDL) (Huang et al.; Clin Sci (Lond) (2021) 135(24): 2709-2728, doi: 10.1042/CS20210602). Sinusoidal PH is an ominous outcome of advanced chronic liver disease, characterized by increased intrahepatic vascular resistance (IHVR), splanchnic hyperemia, and the development of portosystemic collaterals. In the work of Huang et al., microbiota transplantation not only alleviated splanchnic hyperdynamic circulation by improving vascular responsiveness and decreasing mesenteric angiogenesis, but also reduced blood flow in portosystemic collaterals. Surprisingly, however, microbiota transplantation had no effect on intrahepatic vasoconstriction in this experimental model. We discuss these observations in the context of recent literature showing that manipulation of the gut microbiota (either by transplantation or through the use of probiotics) may improve IHVR, which is one of the earliest abnormalities in the pathogenesis of sinusoidal PH. Further research is needed to explore the specific molecular and cellular targets associated with the correction of dysbiosis in liver disease.

ROLE OF COLOR DOPPLER ULTRASONOGRAPHY IN THE EVALUATION OF PORTAL VENOUS HYPERTENSION

Chronic alcoholism, obesity and viral hepatitis (B & C virus) are main causes for chronic liver disease. In cirrhotic patients, portal hypertension and its complications lead to signicant morbidity and mortality. Ultrasound technique, such as duplex ultrasonography ,spectral and color Doppler imaging are the modalities of choice. Study was undertaken to evaluate spectrum of color Doppler sonographic ndings in portal hypertension, to study ow metric changes in portal hypertension and to look for presence of various Porto-systemic collaterals. Result of study shows alcoholic liver disease as the main cause for liver cirrhosis. Maximum number of patients with splenorenal collaterals. Color Doppler sonography is a valuable non-invasive alternative which provides precise information in localizing and characterizing portal vein in patients with portal hypertension and identify the presence of various Porto-systemic collaterals. The hepatic vein damping index (DI) correlates well with the severity of liver dysfunction in terms of Child Pugh score.

Heme oxygenase 1 gene single nucleotide polymorphism (rs2071746) as a predictor of esophageal varices development in cirrhotic patients

BackgroundPortal hypertension is the pathophysiological process associated with the occurrence of portosystemic collaterals and usually ends with the development of Esophageal varices (EVs). Early detection helps to avoid or delay variceal bleeding. This disease is related to increased oxidative stress in the liver. One of the antioxidant enzymes that guard cells against damage from this stress is Heme oxygenase-1 (Hmox1). This study aimed to assess the reliability of single nucleotide polymorphism (SNP) in (Hmox1) (rs2071746) as a noninvasive approach for predicting the development of EVs and its importance for proper interpretation in clinical practice. Methods50 cirrhotic patients with esophageal varices and 50 cirrhotic patients without varices were enrolled in this study. Laboratory assesment, ultrasound, and endoscopy were done. They were genotyped for Hmox1 (rs2071746) by TaqMan allele discrimination real-time PCR on a Rotor-Gene System. ResultsPatients with esophageal varices had statistically significant lower platelet count and platelets count / splenic diameter ratio, and higher portal vein diameter than those without EVs. T allele frequency was higher in Patients with varices than those without (P-value= 0.03). Carrying TT genotype of Hmox1promotor had 13.5fold increased risk for esophageal varices development than carrying AA genotype. ConclusionT allele in Hmox1 SNP (rs2071746) gene could be a useful predictor of EVs presence in cirrhotic patients. Hmox1 is a promising genetic factor that influence the development and the grade of EVs in cirrhotic patients. It can also be used in prediction and risk stratification of such patients.

Progressive Perianal Necrotising Soft Tissue Infection in Decompensated Chronic Liver Disease: A Case Report

Necrotising soft tissue infection in diabetics is known to carry a significant risk of mortality, while if it is associated with chronic liver disease (CLD) Child C, the mortality further increases. CLD alone has a predicted 5-year survival of 50%. This case report selectively highlights the occurrence of perianal spreading cellulitis in the presence of liver disease and diabetes with stress on special considerations. A 50-year-old male, presented with decompensated Child’s C CLD in metabolic acidosis with reduced urine output, deranged renal function, ascites and elevated bilirubin levels along with perianal pathology that began as a seemingly innocuous painful swelling. He was found to have extensive necrotising infection extending beyond the perianal region to involve the gluteal skin, perineum and scrotum and had poor anal sphincter tone. MRI revealed an extensive collection of pus involving both ischiorectal fossae extending extra-peritoneally into the left side of the pelvis. Special preoperative considerations involved optimising hydration (while avoiding overload), correcting acidosis arranging adequate blood products in view of coagulopathy and anaemia. The necessity of debridement for source control carried with it the attendant risk of further decompensation of CLD besides major haemorrhage from porto-systemic collaterals. Diversion, though imperative, carried the risk continuous peri-stomal seepage of ascites We describe a case of diversion after physiological stabilisation and highlight graded damage control measures for optimal outcomes and preventing stoma related complications in such immunocompromised patients.

Clinical Applications of 4D Flow MRI in the Portal Venous System.

Evaluation of the hemodynamics in the portal venous system plays an essential role in many hepatic pathologies. Changes in portal flow and vessel morphology are often indicative of disease.Routinely used imaging modalities, such as CT, ultrasound, invasive angiography, and MRI, often focus on either hemodynamics or anatomical imaging. In contrast, 4D flow MRI facilitiates a more comprehensive understanding of pathophysiological mechanisms by simultaneously and noninvasively acquiring time-resolved flow and anatomical information in a 3D imaging volume.Though promising, 4D flow MRI in the portal venous system is especially challenging due to small vessel calibers, slow flow velocities, and breathing motion. In this review article, we will discuss how to account for these challenges when planning and conducting 4D flow MRI acquisitions in the upper abdomen. We will address patient preparation, sequence acquisition, postprocessing, quality control, and analysis of 4D flow data.In the second part of this article, we will review potential clinical applications of 4D flow MRI in the portal venous system. The most promising area for clinical utilization is the diagnosis and grading of liver cirrhosis and its complications. Relevant parameters acquired by 4D flow MRI include the detection of reduced or reversed flow in the portal venous system, characterization of portosystemic collaterals, and impaired response to a meal challenge. In patients with cirrhosis, 4D flow MRI has the potential to address the major unmet need of noninvasive detection of gastroesophageal varices at high risk for bleeding. This could replace many unnecessary, purely diagnostic, and invasive esophagogastroduodenoscopy procedures, thereby improving patient compliance with follow-up. Moreover, 4D flow MRI offers unique insights and added value for surgical planning and follow-up of multiple hepatic interventions, including transjugular intrahepatic portosystemic shunts, liver transplantation, and hepatic disease in children. Lastly, we will discuss the path to clinical implementation and remaining challenges.

Application of Proximal Splenic Vein Embolization to Interrupt Complicated Large Splenorenal Shunts in Adult Living Donor Liver Transplantation

Introduction: In adult living donor liver transplantation (ALDLT) for a patient who has large splenorenal shunts (SRS), their interruption is utmost important to maintain adequate portal flow by avoidance of portal steal through the preexisting SRS. We effectively managed most of the recipients with surgical ligation and/or additional radiologic embolization using by intraoperative cine-portogram (IOP). However, when complete interruption is not achieved in a few recipients having complicated large SRS, it may leave a chance of lethal portal flow steal afterwards. The aim of study is to evaluate efficacy and safety of proximal splenic vein embolization (PSVE) for recipients having complicated large SRS. Method: PSVE was performed in 13 patients between April 2014 and November 2017. We performed a retrospective analysis of preoperative images, postoperative graft and recipient outcomes, and presence of isolated portal hypertension. Results: Ten patients underwent PSVE as an additional secondary method because of for portal steal syndrome through the remaining SRS after surgical interruption and/or embolization, and 3 patients underwent PSVE only as a primary method of SRS interruption. In all 13 patients, portal steal on the final IOP completely disappeared after PSVE. All patients recovered with satisfactory regeneration of the partial liver graft without the reappearance of portosystemic collaterals, and there were no procedure-related complications. Conclusion: PSVE is an effective and safe procedure to secure adequate portal flow without portal steal for patients with complicated large SRS arising from multiple sites of the splenic vein or escaping to multiple terminal ends.

Isolated Giant Mesenteric Vein and Anomalous Inferior Mesenteric Vein Insertion in the Presence of Cirrhosis – A Cadaveric Case Report

The inferior mesenteric vein is one of the tributaries of the portal vein which receives blood from the large intestine, sigmoid colon and the rectum. It usually connects with the splenic vein before draining into the portal vein. It may however show variations such as joining the superior mesenteric vein directly or to the confluence of the superior mesenteric vein and splenic vein. Varices of the inferior mesenteric vein can be seen in the presence of portal hypertension due to various reasons and this can be isolated or in association with other portosystemic collaterals. We report a case of a giant isolated inferior mesenteric vein with an anomalous insertion. The inferior mesenteric vein was seen to be connected to the superior mesenteric vein before draining into the portal vein. Further, on the distal end it was seen to be connected to the left renal vein, which in turn had dilated and enlarged. The left testicular vein was observed draining in to the inferior mesenteric vein but was not enlarged. The superior mesenteric vein, splenic vein and portal vein were not enlarged or varicosed even though the liver showed features of cirrhosis with no obvious signs of splenic enlargement. This report contributes to enhance the knowledge on a rare anatomical connection between portal system and the systemic circulation and will be important to surgeons operating in this area.

Hepatic Encephalopathy and Challenges in Elderly –An Updated Review

Hepatic encephalopathy, a type of brain disorder induced by hepatic dysfunction and portal system blood starvation. HE is the serious consequence of chronic liver disease that causes changes in individual behaviour, awareness, perception, activity performed. Depending on the severity, this split in two types: covert hepatic encephalopathy and overt hepatic encephalopathy. Most often utilised criteria for rating HE are the West Haven criteria (WHC). Septicaemia, GI hemorrhage, diuretic overdose, and dehydration, these risk factors are for the hepatic encephalopathy. The diagnosis is primarily clinical, but there are other possible causes for the altered state of mind. These patients have the poorer results, drop standard of living, and elevated hospital care utilization, inflicting financial and emotional load on caregivers. Other possible causes for the change in behavior consciousness should be ruled out, therefore the diagnosis is mainly clinical. Other possible causes for the altered mental state have been ruled out therefore the diagnosis is mainly clinical. The three major HE types are as follows: Acute liver failure leads to type A HE. Portosystemic bypass/shunting causes Type B HE. Cirrhosis-related HE of type C. Ammonia cannot be removed effectively due to liver dysfunction portosystemic collaterals. As a result, increased the level of NH3 in blood plasma & breaches the BBB, resulting in brain damage edema. The patient's mental state, musculoskeletal system, and mood/behavior are all affected by the symptoms of HE. These symptoms might range in severity, but they can start highly light.

Microbiota transplants from feces or gut content attenuated portal hypertension and portosystemic collaterals in cirrhotic rats.

Liver cirrhosis and portal hypertension is the end of chronic liver injury with hepatic, splanchnic and portosystemic collateral systems dysregulation. Liver injury is accompanied by gut dysbiosis whereas dysbiosis induces liver fibrosis, splanchnic angiogenesis and dysregulated vascular tones vice versa, making portal hypertension aggravated. It has been proved that intestinal microbiota transplantation alleviates dysbiosis. Nevertheless, the influences of microbiota transplantation on cirrhosis-related portal hypertension are not so clear. Liver cirrhosis with portal hypertension was induced by bile duct ligation (BDL) in rats. Sham rats were surgical controls. Rats randomly received vehicle, fecal or gut (terminal ileum) material transplantation. The results showed that microbiota transplantation from feces or gut material significantly reduced portal pressure in cirrhotic rats (P=0.010, 0.044). Hepatic resistance, vascular contractility, fibrosis and relevant protein expressions were not significantly different among cirrhotic rats. However, microbiota transplantation ameliorated splanchnic hyperdynamic flow and vasodilatation. Mesenteric angiogenesis, defined by whole mesenteric window vascular density, decreased in both transplantation groups and phosphorylated endothelial nitric-oxide synthase (eNOS) was down-regulated. Portosystemic shunts determined by splenorenal shunt (SRS) flow decreased in both transplantation groups (P=0.037, 0.032). Shunting severity assessed by microsphere distribution method showed consistent results. Compared with sham rats, cirrhotic rats lacked Lachnospiraceae. Both microbiota transplants increased Bifidobacterium. In conclusion, microbiota transplantation in cirrhotic rats reduced portal pressure, alleviated splanchnic hyperdynamic circulation and portosystemic shunts. The main beneficial effects may be focused on portosystemic collaterals-related events, such as hepatic encephalopathy and gastroesophageal variceal hemorrhage. Further clinical investigations are mandatory.

Distinct prognostic value of different portal hypertension-associated features in patients with primary biliary cholangitis

BackgroundPrimary biliary cholangitis (PBC) may progress to cirrhosis and clinically significant portal hypertension (CSPH). This study assesses different features of CSPH and their distinct prognostic impact regarding decompensation and survival in patients with PBC.MethodsPatients with PBC were identified during a database query of our digital patient reporting system.ResultsA total of 333 PBC patients (mean age 54.3 years, 86.8% females, median follow-up 5.8 years) were retrospectively assessed and 127 (38.1%) showed features of CSPH: 63 (18.9%) developed varices, 98 (29.4%) splenomegaly, 62 (18.6%) ascites and 20 (15.7%) experienced acute variceal bleeding. Splenomegaly, portosystemic collaterals and esophageal varices were associated with an increased 5-year (5Y) risk of decompensation (15.0%, 17.8% and 20.9%, respectively). Patients without advanced chronic liver disease (ACLD) had a similar 5Y-transplant free survival (TFS) (96.6%) compared to patients with compensated ACLD (cACLD) but without CSPH (96.9%). On the contrary, PBC patients with cACLD and CSPH (57.4%) or decompensated ACLD (dACLD) (36.4%) had significantly decreased 5Y survival rates. The combination of LSM < 15 kPa and platelets ≥ 150G/L indicated a negligible risk for decompensation (5Y 0.0%) and for mortality (5Y 0.0%). Overall, 44 (13.2%) patients died, with 18 (40.9%) deaths attributed to CSPH-related complications.ConclusionIn PBC, features of CSPH may occur early and indicate an increased risk for subsequent decompensation and mortality. Hence, regular screening and on-time treatment for CSPH is crucial. Combining LSM and platelets serves as a valuable preliminary assessment, as LSM < 15 kPa and platelets ≥ 150G/L indicate an excellent long-term outcome.

Longitudinal Analysis of the Effect of Repeated Transarterial Chemoembolization for Liver Cancer on Portal Venous Pressure.

ObjectivesInvestigate long-term effects of repeated transarterial chemoembolization (TACE) on portal venous pressure (PVP) using non-invasive surrogate markers of portal hypertension.MethodsRetrospective, Institutional Review Board-approved study. 99 patients [hepatocellular carcinoma (HCC) group (n=57); liver metastasis group (n=42)] who underwent 279TACEs and had longitudinal pre-/post-therapy contrast-enhanced-MRI (n=388) and complete blood work were included. Outcomes of interest were platelet count (PC), spleen volume, ascites and portosystemic collaterals. Variables included TACE type/number, tumor type, microcatheter location, Child-Pugh, baseline tumor burden (tumor number/total/largest size), vessel invasion, alpha-fetoprotein, Eastern Cooperative Oncology Group (ECOG) performance status, and Model for End-Stage Liver Disease (MELD) score. Generalized Estimating Equations assessed the associations between TACE and outcomes. Power analysis determined the sample size was sufficient.ResultsNo significant change in PC over time was observed in either groups, regardless of liver function (P>0.05). Baseline spleen volume was 226 cm3 for metastatic group, and was larger by 204 cm3 for HCC group (P<0.001). Spleen volume increased by 20 cm3 (95%CI: 8-32; P=0.001) for both groups after 1stTACE and by 16cm3/TACE (P=0.099) over the full follow-up (up to 9TACEs). Spleen volume also tended to increase by 23cm3 (95%CI: -1–48; P=0.064) with higher tumor burden. Odds of developing moderate/severe ascites for metastatic patients was decreased by 0.5 (95%CI: 0.3–0.9; P=0.014), regardless of the Child-Pugh, and increased by 1.5 (95%CI: 1.2–1.9; P<0.001) among HCC patients with unstable Child-Pugh, whereas no change was noted with stable Child-Pugh. HCC patients with unstable Child-Pugh demonstrated a significant increase in portosystemic collaterals number over time (P=0.008). PVP-related complications such as variceal bleeding post-TACE were low (0.4%).ConclusionRepeated TACEs did seem to have an impact on PVP. However, the increase in PVP had marginal effects with low portal hypertension-related complications.

Validation of a standardized CT protocol for the evaluation of varices and porto-systemic shunts in cirrhotic patients

PurposeThe aim of the present study was to propose and validate a standardized CT protocol for evaluating all the types of portosystemic collaterals (P-SC), including gastroesophageal varices and spontaneous portosystemic shunts (SPSS), and to evaluate the prognostic role of portal hypertension CT features for the prediction of the hepatic decompensation risk in cirrhotic patients. MethodsA retrospective cohort study of 184 advanced chronic liver disease who underwent CT scan between January 2014 and December 2017. Patients with an interval > 6 months between the imaging, elastometric, endoscopic and biochemical evaluation were excluded, as well as patients with previous transjugular intrahepatic portosystemic shunt (TIPS), liver transplantation (LT) or terminal medical conditions. Data on liver disease history, co-morbidities, endoscopic and radiologic findings were collected. The incidence of hepatic decompensation and other events, such as portal vein thrombosis, HCC, TIPS placement, LT, death, and its cause, were also recorded.The procedure was performed at baseline and after the administration of contrast agent using a multiphasic technique and bolus tracking. Two senior radiologists working in different centres and a non-expert radiologist reviewed all CT examinations, to evaluate both intra-observer and inter-observer variability of the CT protocol and to obtain an external validation. The radiological variables were evaluated using both univariate and adjusted multivariate competing risk regression models. ResultsBoth intra-observer and inter-observer agreement were excellent in detection and measurement of almost all types of P-SC. The presence of SPSS, a spleen diameter > 16 cm, a portal vein diameter > 17 mm and the presence of ascites resulted independent predictors of decompensation-free survival for cirrhotic patients and were incorporated in an easy-to-use score (AUROC = 0.799, p-value = 0.732) which can the risk of decompensation at 5 years, ranking it as low (11.3%), moderate (35.6%) or high (70.8%). ConclusionsThe CT protocol commonly performed during the HCC surveillance program for cirrhotic patients is valid for detecting all types of P-SC. The radiological score identified to predict the decompensation-free survival for cirrhotic patients could be an easy-to-use clinical tool.

Matrix metalloproteinase-9 inhibition or deletion attenuates portal hypertension in rodents.

Liver cirrhosis and portal hypertension are accompanied by hyperdynamic circulation, angiogenesis and portosystemic collaterals. Matrix metalloproteinases (MMPs) participate in fibrogenesis and angiogenesis, however, whether they can be targeted in cirrhosis treatment is unclear. Therefore, we performed three series of experiments to investigate this issue. Liver cirrhosis was induced by common bile duct ligation (BDL) in Sprague‐Dawley rats. Sham‐operated rats served as controls. Rats were randomly allocated to receive vehicle, minocycline (a nonselective MMP inhibitor) or SB‐3CT (MMP‐2 and −9 inhibitor) for 28 days in the first and second series, respectively. MMP‐9 knockout mice were used in the third series. The results showed that minocycline ameliorated portal hypertension, hemodynamic abnormalities, reduced collateral shunting, mesenteric vascular density, plasma VEGF level and alleviated liver fibrosis. SB‐3CT attenuated portal hypertension, hemodynamic derangements, reduced shunting, mesenteric vascular density, mesenteric VEGF protein expression, and liver fibrosis. Knockout BDL mice had significantly alleviated portal hypertension, liver fibrosis, liver α‐SMA and mesenteric eNOS protein expressions compared to wild‐type BDL mice. Liver SMAD2 phosphorylation was down‐regulated in all series with MMP inhibition or knock‐out. In conclusion, MMP‐9 inhibition or deletion ameliorated the severity of cirrhosis, portal hypertension, and associated derangements. MMP‐9 may be targeted in the treatment of liver cirrhosis.

Noninvasive assessment of clinically significant portal hypertension using ΔT1 of the liver and spleen and ECV of the spleen on routine Gd-EOB-DTPA liver MRI

PurposeTo analyze the predictive value of ΔT1 of the liver and spleen as well as the extracellular volume fraction (ECV) of the spleen as noninvasive biomarkers for the determination of clinically significant portal hypertension (CSPH) on routine Gd-EOB-DTPA liver MRI. Method195 consecutive patients with known or suspected chronic liver disease from 9/2018 to 7/2019 with Gd-EOB-DTPA liver MRI and abdominal T1 mapping were retrospectively included. Based on the presence of splenomegaly with thrombocytopenia, ascites and portosystemic collaterals, the patients were divided into noCSPH (n = 113), compensated CSPH (cCSPH, ≥1 finding without ascites; n = 55) and decompensated CSPH (dCSPH, ascites ± other findings; n = 27). T1 times were measured in the liver, spleen and abdominal aorta in the unenhanced and contrast-enhanced T1 maps. Native T1 times and ΔT1 of the liver and spleen as well as ECV of the spleen were compared between groups using the Kruskal-Wallis test with Dunn’s post hoc test. Furthermore, cutoff values for group differentiation were calculated using ROC analysis with Youden’s index. ResultsΔT1 of the liver was significantly lower in patients with cCSPH and dCSPH (p < 0.001) compared to patients with noCSPH. In the ROC analyses for differentiation between noCSPH and CSPH (cCSPH + dCSPH), a cutoff of < 0.67 for ΔT1 of the liver (AUC = 0.79) performed better than ΔT1 (AUC = 0.69) and ECV (AUC = 0.63) of the spleen with cutoffs of > 0.29 and > 41.9, respectively. ConclusionΔT1 of the liver and spleen in addition to ECV of the spleen allow for determination of CSPH on routine Gd-EOB-DTPA liver MRI.

Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction – A case report

Introduction and importanceAmong the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions.Case presentationA 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis.Clinical discussionThe diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases.ConclusionThe main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.

Hemodynamic effect through a novel endoscopic intervention in management of varices and hypersplenism (with video)

We previously reported a new and combined EUS-guided intervention in a patient with portal hypertension, consisting of obliteration of varices and partial splenic embolization (PSE). Performing PSE is known to diminish the increase in portal venous pressure after endoscopic intervention for varices. The aim of this study was to use multidetector CT portal venography to evaluate the anatomy of esophagogastric varices (EGV) and the impact on hemodynamics of portosystemic collaterals shortly after the concomitant procedures. From October 2019 to December 2020, 5 patients with cirrhosis and with clinically significant portal hypertension who had variceal bleeding history and hypersplenism were treated with combined endoscopic obliteration for varices and EUS-guided PSE. Multidetector CT portal venography was applied to assess the anatomic drainage patterns of the EGV, diameters of feeders and drainage vessels, and splenic embolization rate. Within 5 days after concomitant endoscopic interventions, we observed decreased mean diameters of the left gastric vein, short gastric vein, and azygos vein as .3mm, 1.0mm, and 5.2mm compared with 3.11mm, 7.1mm, and 5.4mm before the procedures, respectively. Patients showed increased white blood cells (mean count of 2.7× 109/L before vs 5.8× 109/L after) and platelets (mean count of 52.8× 109/L before vs 95.8× 109/L after). The mean splenic embolization rate was 64.5% (range, 28.8%-84.6%). Our experience may illustrate an alternative technique of combining EUS-guided PSE with endoscopic therapy of varices to treat patients with portal hypertension.

Liver Stiffness by Transient Elastography to Detect Porto‐Sinusoidal Vascular Liver Disease With Portal Hypertension

Porto-sinusoidal vascular liver disease (PSVD) is a rare cause of portal hypertension. PSVD is still often misdiagnosed as cirrhosis, emphasizing the need to improve PSVD diagnosis strategies. Data on liver stiffness measurement using transient elastography (TE-LSM) in PSVD are limited. The aim of this study was to evaluate the accuracy of TE-LSM to discriminate PSVD from cirrhosis in patients with signs of portal hypertension. Retrospective multicenter study comparing TE-LSM in patients with PSVD, according to Vascular Liver Disease Interest Group criteria, with patients with compensated biopsy-proven cirrhosis associated with alcohol (n=117), HCV infection (n=110), or NAFLD (n=46). All patients had at least one sign of portal hypertension among gastroesophageal varices, splenomegaly, portosystemic collaterals, history of ascites, or platelet count < 150 × 109 /L. The 77 patients with PSVD included in the test cohort had lower median TE-LSM (7.9 kPa) than the patients with alcohol-associated, HCV-related, and NAFLD-related cirrhosis (33.8, 18.2, and 33.6kPa, respectively; P<0.001). When compared with cirrhosis, a cutoff value of 10kPa had a specificity of 97% for the diagnosis of PSVD with a 85% positive predictive value. A cutoff value of 20kPa had a sensitivity of 94% for ruling out PSVD with a 97% negative predictive value. Of the patients, 94% were well-classified. Even better results were obtained in a validation cohort including 78 patients with PSVD. This study including a total of 155 patients with PSVD and 273 patients with cirrhosis demonstrates that TE-LSM<10kPa strongly suggests PSVD in patients with signs of portal hypertension. Conversely, when TE-LSM is >20kPa, PSVD is highly unlikely.

Multidetector-Row Computed Tomography and Colour Doppler Imaging in the Evaluation of Patients with Extrahepatic Portal Hypertension: A Prospective Study

Background and aims: Evaluating patients of extrahepatic portal hypertension with Colour Doppler and MDCT to study the morphology of splenoportal axis, determining the site of obstruction, the anatomy of portosystemic collaterals, any associated vascular aneurysms, and features of portal biliopathy. Materials and methods: We studied 45 patients (aged 6-55 years) with clinical features of portal hypertension with no identifiable hepatic cause or extrahepatic portal venous occlusion on sonography. All cases underwent Doppler ultrasound and MDCT. The data was compiled and analyzed. A comparative evaluation of Doppler imaging and MDCT was performed with the help of Cohen's kappa test to assess the agreement between the two modalities. Results: MDCT provides better details about the morphology of the splenoportal axis, the site, and cause of block, as well as the extent and distribution of collateral groups. Colour Doppler has an advantage over MDCT in determining the direction and pattern of blood flow within the splenoportal axis, various collaterals, and spontaneous shunts, along with a better depiction of features of portal biliopathy. Colour Doppler is inadequate in the visualization of gastroesophageal and retroperitoneal varices. Identification of spontaneous spleno-adreno-renal and gastrorenal shunts is achieved with the high agreement between Colour Doppler and MDCT. Conclusion: MDCT should be preferred for preoperative evaluation of patients being contemplated for shunt surgery. Colour Doppler imaging of portal biliopathy is sufficiently characteristic to avoid other invasive modalities. The two modalities provide complementary information in the evaluation of patients with extrahepatic portal hypertension.

Abstract No. 131 Embolization of parastomal and small bowel ectopic varices utilizing a transhepatic antegrade approach: a case series

Ectopic varices (EVs) are abnormally dilated splanchnic veins or portosystemic collaterals that occur anywhere along the gastrointestinal tract. Although EVs comprise a small subset of variceal hemorrhages, EVs are associated with mortality rates reported as high as 40%. The ideal management approach to treating parastomal and small bowel EVs is yet to be established. The purpose of this project is to evaluate the outcomes following percutaneous antegrade transhepatic venous obliteration (PATVO) in patients presenting with active bleeding from parastomal or small bowel EVs. A retrospective review of nine patients who underwent ten PATVO interventions for EVs at our tertiary care institution was performed. Inclusion criteria was age > = 18 years and acute or chronic bleeding from parastomal or small bowel EVs. Technical success was defined as resolution of varices on angiography immediately after embolization. Early clinical success was defined as resolution of bleed for at least 30 days after procedure. Technical success rate was 100% (n = 9), and early clinical success rate was 88.9% (n = 8). Intra- and post-operative complication rate was 0%. Re-bleed rate of 22.2% (n = 2) at a mean of 274.5 days was established after initial PATVO procedure due to unresolved underlying portal hypertension. These patients were successfully treated with TIPS. Within our study population, 22.2% (n = 2) of patients underwent prior surgical interventions for variceal bleeding that resulted in clinical failure and subsequent re-bleeding prior to being referred to interventional radiology. These patients were successively treated with PATVO, resulting in complete technical and early clinical success. PATVO is an effective option for embolization of bleeding from parastomal and small bowel EVs. Given the high technical success rate and satisfactory early clinical success, PATVO should be considered as the primary treatment option prior to attempting TIPS, especially considering these patients have multiple comorbidities often precluding surgical options. Additionally, PATVO is less invasive than TIPS, and demonstrates a lower incidence of complications and faster recovery period. In patients who present with recurrent bleeding despite PATVO due to unresolved portal hypertension, TIPS remains a valid option.