Radiological interventions in portal hypertension.

Hepatoportal sclerosis in childhood: A mimic of extrahepatic portal vein obstruction

Therapies for bleeding gastric varices: is the fog starting to clear?

BACKGROUNDBleeding ectopic varices located in the small bowel (BEV-SB) caused by portal hypertension (PH) are rare and life-threatening clinical scenarios. The current management of BEV-SB is unsatisfactory. This retrospective study analyzed four cases of BEV-SB caused by PH and detailed the management of these cases using enteroscopic injection sclerotherapy (EIS) and subsequent interventional radiology (IR).AIMTo analyze the management of BEV-SB caused by PH and develop a treatment algorithm.METHODSThis was a single tertiary care center before-after study, including four patients diagnosed with BEV-SB secondary to PH between January 2019 and December 2023 in the Air Force Medical Center. A retrospective review of the medical records was conducted. The management of these four patients involved the utilization of EIS followed by IR. The management duration of BEV-SB in each patient can be retrospectively divided into three phases based on these two approaches: Phase 1, from the initial occurrence of BEV-SB to the initial EIS; phase 2, from the initial EIS to the initial IR treatment; and phase 3, from the initial IR to December 2023. Descriptive statistics were performed to clarify the blood transfusions in each phase.RESULTSFour out of 519 patients diagnosed with PH were identified as having BEV-SB. The management duration of each phase was 20 person-months, 42 person-months, and 77 person-months, respectively. The four patients received a total of eight and five person-times of EIS and IR treatment, respectively. All patients exhibited recurrent gastrointestinal bleeding following the first EIS, while no further instances of gastrointestinal bleeding were observed after IR treatment. The transfusions administered during each phase were 34, 31, and 3.5 units of red blood cells, and 13 units, 14 units, and 1 unit of plasma, respectively.CONCLUSIONEIS may be effective in achieving hemostasis for BEV-SB, but rebleeding is common, and IR aiming to reduce portal pressure gradient may lower the rebleeding rate.

Management of Portal Hypertension

Octreotide is an effective portal hypotensive drug in the control of variceal bleeding. Tetrandrine is a type of calcium channel blocker recently reported to reduce portal hypertension. The present study was undertaken to investigate the haemodynamic effects of octreotide and tetrandrine, alone and in combination, in portal hypertensive rats. Portal hypertension was induced by partial portal vein ligation. Portal hypertensive rats were allocated into one of the four groups: vehicle group (saline, 0.5 mL/day), octreotide group (100 microg/kg per 12 h), tetrandrine group (20 mg/kg per 12 h), and octreotide (100 microg/kg per 12 h) plus tetrandrine (20mg/kg per 12 h) group. Tetrandrine or saline was administered by gavage, and octreotide by subcutaneous injection. The drug was given for 8 consecutive days, starting 1 day before ligation and continuing onwards. Haemodynamic parameters were measured thereafter, using the radioactive microsphere method. The portal venous pressure and portal tributary blood flow were significantly reduced, while portal territory and renal vascular resistances were significantly enhanced, by octreotide, tetrandrine, or octreotide plus tetrandrine in portal hypertensive rats, compared with the vehicle group. Our results showed that long-term administration of octreotide, tetrandrine, or octreotide plus tetrandrine led to portal hypotensive effects in portal hypertensive rats, but octreotide alone exerted better anti-hyperdynamic effects compared with tetrandrine alone. A combination of octreotide and tetrandrine offered no major beneficial anti-hyperdynamic effects compared with octreotide alone.

Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children

Esophageal varices are life-threatening complications in which the enlargement of the esophageal veins causes bleeding and reduces blood flow to the esophagus. They are complications caused by portal hypertension, renal failure, hepatic dysfunction, and infection. The leading cause of esophageal varices is cirrhosis, as patients with this disease are more susceptible to forming esophageal varices. Bleeding episodes occur due to the rupture of the blood vessels. We present the case of a 45-year-old male patient in the hospital with a history of chronic alcohol use and clinical symptoms of hematemesis, a distended abdomen, and melena. The patient experienced mild symptoms of giddiness and dizziness after undergoing various radiological investigations, laboratory tests, ultrasonography (USG), and CT scans. USG diagnosed portal hypertension, gross ascites, pleural effusion, and hepatosplenomegaly. A CT scan diagnosed the patient with esophageal varices and testicular carcinoma. Laboratory tests diagnosed anemia. The treatment plan included oral and intravenous iron supplements, blood transfusions, vitamin B12, folate supplements, and nonselective beta-blockers to manage portal hypertension and reduce variceal bleeding risk. During acute bleeding episodes, vasoconstrictors and endoscopic band ligation were employed. Regular endoscopies and hepatic venous catheterization were conducted to monitor and manage the condition. Follow-up included regular assessments of hemoglobin levels, iron status, liver function tests, and periodic endoscopies. The patient's adherence to beta-blockers was closely monitored. Esophageal varices, often resulting from portal hypertension because of cirrhosis, require early diagnosis and a combination of pharmacological and endoscopic treatments to prevent complications. Advances in treatment have reduced mortality rates, but effective management of portal hypertension and liver dysfunction remains crucial.

Combination of splanchnic vasoconstrictors and endoscopic band ligation is an effective treatment strategy for acute variceal hemorrhage; but how do we get those drugs approved by the FDA?

Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.

Effective treatment of hypertension without medication: is it possible?

Transjugular intrahepatic portasystemic shunts (TIPS) provide a low-resistance pathway between the hepatic veins and the intrahepatic portion of the portal vein for blood to return to the heart in patients with portal hypertension thereby bypassing and decompressing the hepatic sinusoids. The ability to achieve portal venous decompression like a surgical portacaval shunt by TIPS without the attendant risks of general anesthesia and major surgery have led to a resurgence in interest in mechanical portal decompression for the treatment of portal hypertension. While several large controlled studies have examined the role of TIPS in the management of sinusoidal portal hypertension (1, 2, 3), its use for postsinusoidal and especially presinusoidal portal hypertension remain to be fully evaluated. In this issue, Ganger et al.(4) extend the body of anecdotes and small series existing in literature (5, 6, 7, 8, 9) by documenting the efficacy and safety of TIPS for postsinusoidal (Budd-Chiari syndrome) or presinusoidal (portal vein thrombosis) portal hypertension.

Blood pressure as a potential biomarker of the efficacy angiogenesis inhibitor

The management of CSPH in patients undergoing systemic treatment for HCC has emerged as a critical concern due to the absence of reliable diagnostic criteria and uncertainties surrounding therapeutic approaches. This review aims to underscore the primary pathophysiological aspects linking HCC and PH, while also addressing the current and emerging clinical strategies for the management of portal hypertension. A review of studies from January 2003 to June 2023 was conducted using the PubMed database and employing MeSH terms, such as "hepatocellular carcinoma", "immune checkpoint inhibitors", "systemic therapy", "portal hypertension", "variceal bleeding" and "tyrosine kinase inhibitors". Despite promising results of tyrosine kinase inhibitors in animal models for PH and fibrosis, only Sorafenib has demonstrated similar effects in human studies, whereas Lenvatinib appears to promote PH development. The impact of Atezolizumab/Bevacizumab on PH remains uncertain, with an increasing risk of bleeding related to Bevacizumab in patients with prior variceal hemorrhage. Given the absence of specific guidelines, endoscopic surveillance during treatment is advisable, and primary and secondary prophylaxis of variceal bleeding should adhere to the Baveno VII recommendations. Furthermore, in patients with advanced HCC, refinement of diagnostic criteria for CSPH and guidelines for its surveillance are warranted.

Liver disease is the second cause of death in cystic fibrosis. The most deleterious complication of liver disease is portal hypertension, which has an estimated prevalence of up to 8%. Portal hypertension may manifest itself by splenomegaly, hypersplenism, gastro-oesophageal bleeding and ascites. The aim of our study was to determine the prevalence, risk factors and invasive management of portal hypertension at our centre. One hundred and fifty patients with cystic fibrosis were followed up between 1975 and 2000 in the national cystic fibrosis centre in Israel. Forty patients (27%) had liver disease. All underwent clinical evaluation and laboratory and imaging studies. Portal hypertension was diagnosed in 10 patients (7%), of whom eight were male. The mean age at diagnosis was 11 years (range, 4-17 years). All had severe mutations of the cystic fibrosis transmembrane conductance regulator gene (the CFTR gene), pancreatic insufficiency, meconium ileus or distal intestinal obstruction syndrome and variceal bleeding. Seven patients underwent sclerotherapy to control acute bleeding. Four underwent portosystemic shunting (functioning up to 37 years). Two patients with severe lung and liver disease underwent transjugular intrahepatic portosystemic shunting, which provided bleeding control, but both died while waiting for lung/liver transplantation. One patient underwent liver transplantation due to liver failure and still had good liver and lung function 10 years later. Portal hypertension is more common among Israeli patients with cystic fibrosis. The unique genetic composition of our population may explain this phenomenon. Risk factors include male gender, pancreatic insufficiency, severe CFTR mutations, meconium ileus and meconium ileus equivalent. Sclerotherapy is the main option to control oesophageal variceal bleeding, while portosystemic shunts offer a prolonged alternative treatment for refractory bleeding. A transjugular intrahepatic portosystemic shunt and liver transplantation may also be effective, but further research is required in order to establish their role.

Refractory esophageal varices that are difficult to control or unresponsive to endoscopic treatment remain a major clinical challenge in the management of portal hypertension. This review provides a comprehensive overview of treatment strategies for these cases, along with a comparative analysis of the American Association for the Study of Liver Diseases, Baveno VII, and Japanese clinical practice guidelines. Treatment approaches are classified into four domains: endoscopic therapy, interventional radiology (IVR), surgical procedures, and internal medicine-based strategies. In recent years, clinical practice has shifted from traditional surgical interventions and transjugular intrahepatic portosystemic shunt (TIPS) to minimally invasive IVR techniques, such as partial splenic embolization, percutaneous transhepatic obliteration, and transileocolic vein obliteration, often combined with endoscopic methods. In Japan, where TIPS is not routinely performed due to limited availability and lack of insurance coverage, these alternative IVR procedures are more commonly utilized. Differences among regional guidelines highlight the need for adaptable treatment strategies based on local resources and institutional expertise. Effective management of refractory cases requires multidisciplinary collaboration among gastroenterologists, interventional radiologists, and surgeons. This review emphasizes the importance of integrating international evidence with local clinical practice to develop a tailored, team-based approach that improves outcomes in patients with complex variceal disease.