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Portal vein thrombosis （PVT） refers to thromboembolism that occurs in the extrahepatic main portal vein and/or intrahepatic portal vein branches. PVT is the result of the combined effect of multiple factors， but its pathogenesis remains unclear. Animal models are an important method for exploring the pathophysiological mechanism of PVT. Based on the different species of animals， this article reviews the existing animal models of PVT in terms of modeling methods， principles， advantages and disadvantages， and application.
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Non-cirrhotic splanchnic vein thrombosis （NC-SVT） mainly includes portal vein thrombosis， superior mesenteric vein thrombosis， splenic vein thrombosis， and hepatic vein thrombosis （Budd-Chiari syndrome）， and its prevalence rate is increasing with the increase in the incidence rates of related underlying diseases. Due to the harm of NC-SVT， there have been significant improvements in the awareness and ability for diagnosis among clinicians. However， anticoagulation and intervention therapies for thrombosis are often taken seriously in treatment， while the screening for risk factors or underlying diseases leading to SVT is ignored， which may affect the treatment outcome of thrombus in some patients and delay the diagnosis and treatment of the underlying disease. This article mainly introduces the acquired， hereditary， systemic， and local underlying diseases associated with the development of NC-SVT.
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Objective To investigate the long-term efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of primary biliary cholangitis (PBC) with portal hypertension. Methods A retrospective analysis was performed for 102 patients who received TIPS in Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2015 to August 2021, and these patients were divided into PBC group with 41 patients and viral hepatitis cirrhosis group with 81 patients. Related indicators were collected, including routine blood test results, liver and renal function, coagulation function, portal vein thrombosis, hepatic encephalopathy, and etiology of TIPS treatment shortly after admission, preoperative portal venous pressure, and stents used in surgery, and Child-Pugh score was calculated. Follow-up data were collected and analyzed, including postoperative upper gastrointestinal rebleeding, stent dysfunction, hepatic encephalopathy, and the data on survival and prognosis. The independent samples t -test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of continuous data with skewed distribution between two groups; the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier method was used for survival analysis, and the log-rank test was used for survival difference analysis. Results In the PBC group and the viral hepatitis cirrhosis group, the median percentage of reduction in portal venous pressure after surgery was 33.00% and 35.00%, respectively, and there was no significant difference between the two groups ( P > 0.05). At the end of follow-up, there were no significant differences between the PBC group and the viral hepatitis cirrhosis group in stent dysfunction rate (14.63% vs 24.69%, χ 2 =1.642, P > 0.05), upper gastrointestinal rebleeding rate (17.07% vs 24.69%, χ 2 =0.917, P > 0.05), the incidence rate of overt hepatic encephalopathy (12.20% vs 7.41%, χ 2 =0.289, P > 0.05), and disease-specific death rate (14.63% vs 9.88%, χ 2 =0.229, P > 0.05). Conclusion For PBC patients with portal hypertension, TIPS can achieve the same efficacy as the treatment of portal hypertension caused by viral hepatitis cirrhosis and can also effectively reduce portal hypertension without increasing the incidence rate of complications and disease-specific death rate. Therefore, it is a safe and effective treatment method.
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Objective:To investigate the relationship between hepatic venous pressure gradient (HVPG) and parameters of Doppler ultrasound in patients with pyrroidine alkaloid-related hepatic sinusoidal obstruction syndrome (PA-HSOS).Methods:From February 17, 2017 to April 22, 2020, the clinical data of 68 patients with PA-HSOS who underwent HVPG manometry and Doppler ultrasound examination at Drum Tower Hospital, the Affiliated Medical College of Nanjing University were retrospectively analyzed, which included HVPG, Drum Tower severity scoring (DTSS), time from PA-HSOS related symptoms appeared to diagnosis after taking pyrroidine alkaloid (hereinafter referred to as diagnosis time), and parameters of Doppler ultrasound induding portal vein trunk diameter (PD), peak portal vein velocity (PPV), splenic vein trunk diameter (SD) and peak splenic vein velocity (PSV). Receiver operating characteristic curve (ROC) was used to determine the optimal cut-off value of HVPG for predicting non-response to anticoagulation therapy. Binary logistic regression was used to analyze the independent risk factors for non-response to anticoagulation therapy, and Kaplan-Meier survival curve was used to analyze the prognostic survival rate of patients with different HVPG levels. Unitary linear regression was applied to analyze the correlation of HVPG with PD, PPV, SD and PSV in patients with different HVPG levels, patients with mild, moderate and severe DTSS, and patients with diagnosis time >1 month or ≤ 1 month. Chi-square test was used for statistical analysis.Results:The results of ROC analysis showed that the optimal cut-off value of HVPG for predicting non-response to anticoagulant therapy was 20.165 mmHg(1 mmHg=0.133 kPa). The result of multivariate analysis indicated that high HVPG (HVPG>20.165 mmHg) was an independent risk factor for predicting non-response to anticoagulant therapy ( OR (95% confidence interval)=6.039(1.466 to 24.869), P=0.013). Kaplan-Meier survival curve demonstrated that prognostic survival rate of patients with high HVPG was lower than that of patients with low HVPG (HVPG≤20.165 mmHg) (78.4% vs.96.8%), and the difference was statistically significant( χ2=4.74, P=0.030). The results of unitary linear regression analysis showed that there was a negative correlation between HVPG and PPV in 68 patients with PA-HSOS( r=-0.330, P=0.006); HVPG was positively correlated with PD and SD in patients with high HVPG ( r=0.540 and 0.341, P=0.001 and 0.039); there was a negative correlation between HVPG and PSV in patients with mild DTSS ( r=-0.519, P=0.019), HVPG was negatively correlated with PPV in patients with moderate DTSS ( r=-0.400, P=0.014). In patients with diagnosis time ≤1 month, there was a negative correlation between HVPG and PPV ( r=-0.391, P=0.010). Conclusions:HVPG can assist in judging the response to anticoagulation therapy and the prognosis of patients with PA-HSOS. Parameters of Doppler ultrasound can help to assess the degree of HVPG elevation in patients with PA-HSOS under certain conditions.
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Hepatic sinusoidal obstruction syndrome (HSOS) is a vascular liver disease characterized by varying degrees of liver injury and portal hypertension. HSOS in China is mostly associated with the intake of pyrrolizidine alkaloids. The step-up approach with anticoagulant therapy and transjugular intrahepatic portosystemic shunt (TIPS) as the core treatment methods is the therapy currently recommended for this disease. Subcutaneous injection of low-molecular-weight heparin is the first choice for anticoagulant therapy, and oral warfarin can be used in combination or sequentially to enhance anticoagulation. Patients with no response to anticoagulant therapy can switch to TIPS. The Drum Tower Severity Score (DTSS) system can be used during treatment to evaluate the severity of the disease, in order to identify high-risk patients earlier and switch to TIPS in time, thereby improving the prognosis of patients.
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Objective:To explore the role of serum pyrrole-protein-adduct (PPA) in evaluating the severity and predicting the anticoagulant efficacy in patients with pyrrolidine alkaloid-related hepatic sinusoidal obstruction syndrome (PA-HSOS).Methods:From April 2018 to December 2019, the data of 48 patients with PA-HSOS admitted and treated at Drum Tower Hospital, Affiliated Medical College of Nangjing University were collected, which included PPA level, portal vein velocity (PVV), ascites grading, PA-HSOS severity grading (according to the new severity grading criteria for suspected hepatic sinusoidal obstruction syndrome in adults by the European Society of Blood and Bone Marrow Transplantation and adjusted) and the outcome of anticoagulation. Patients with acute onset (onset of symptoms within 1 month after consuming pyrrolizidine alkaloid-containing plants) were taken as research subjects. The combination of PPA with PVV or with ascites classification of PA-HSOS severity assessment model was fitted by logistic regression, and the logit values of 2 combination models were calculated, the formula was logit 1=0.034×PPA(nmol/L)+ 0.055×PVV(cm/s)-3.287, logit 2=0.039×PPA(nmol/L)-2.712×ascites grade 2 (Yes=1, No=0)-0.388×ascites grade 3 (Yes=1, No=0)-0.899. The patients received initial anticoagulation therapy at Drum Tower Hospital, Affiliated Medical College of Nanjing University were selected as research subjects. The anticoagulant efficacy prediction model of combination of PPA with serum creatinine (SCR) and with hepatic venous pressure gradient (HVPG) was fitted by logistic regression, and the logit value was calculated, the formula was logit 3=0.013×PPA(nmol/L)+ 0.064×SCR (mol/L)+ 0.542×HVPG (mmHg, 1 mmHg=0.133 kPa)-16.005. The predictive value of PPA in evaluating the severity of PA-HSOS and anticoagulant efficacy was evaluated. Receiver operating characteristic curve analysis was performed for statistical analysis. Results:The serum PPA level of 48 patients was 10.81 nmol/L (3.91 nmol/L, 32.04 nmol/L). Among them, 33 cases (68.8%) were mild PA-HSOS, 3 cases (6.2%) were moderate PA-HSOS, no severe PA-HSOS case and 12 cases (25.0%) were very severe PA-HSOS. Among 23 patients received initial anticoagulant therapy at Drum Tower Hospital, Affiliated Medical College of Nanjing University and with complete data, 8 patients responded and survived, and 15 patients did not respond (5 patients died, 1 patient relieved after continue anticoagulant therapy, and 9 patients survived after switching to anticoagulant therapy and transjugular intrahepatic portosystemic shunt (TIPS) treatment). One patient without initial anticoagulant therapy, survived after TIPS treatment because of the progress of the disease. Area under the curve (AUC) of PPA to assess the severity of acute onset PA-HSOS was 0.75, 95% confidence interval ( CI) was 0.52 to 0.98 ( P=0.047). When PPA≥45.519 nmol/L, the specificity and sensitivity in evaluating severe and very severe PA-HSOS was 100.0% and 57.1%, respectively. AUC of combination of PPA and PVV to assess the severity of PA-HSOS was 0.77, 95% CI was 0.55 to 1.00 ( P=0.032). When the logit of combination model≥0.180, the specificity and sensitivity in evaluating severe and very severe PA-HSOS was 71.4% and 81.8%, respectively. AUC of combination of PPA and ascites grade (grade 1, 2 or 3) to assess the severity of PA-HSOS was 0.85, 95% CI was 0.63 to 1.00 ( P=0.005). When the logit of combination model≥0.347, the specificity and sensitivity in evaluating severe and very severe PA-HSOS was 85.7% and 92.0%, respectively. AUC of combination of PPA, SCR and HVPG to predict anticoagulation efficacy was 0.85, 95% CI was 0.69 to 1.00 ( P=0.009). When the logit≥0.393, the specificity and sensitivity in predicting anticoagulation efficacy was 62.5% and 91.7%, respectively. Conclusions:PPA can be used to assess the severity of acute onset PA-HSOS patients, and combined with ascites grading can significantly improve its efficiency. PPA combined with SCR and HVPG can better predict anticoagulant efficacy.
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Objective:To evaluate the regular endoscopic therapy for esophageal and gastric variceal bleeding (EGVB) in patients with liver cirrhosis.Methods:A total of 305 patients of EGVB with liver cirrhosis who received endoscopic hemostasis in Nanjing Drum Tower Hospital between January 2015 and January 2018 were included in the retrospective cohort study. Patients were divided into the regular endoscopic treatment group ( n=145) and the irregular endoscopic treatment group ( n=160). The primary outcome measure was rebleeding rate, and the secondary outcome measures were follow-up time, rebleeding interval and rebleeding mortality. Results:There were no significant differences between the two groups in terms of gender composition, average age, etiology composition, the cause of disease under or out of control, liver reserve function, or administration of non-selective β-blockers ( P>0.05), and the baseline data were comparable. The rebleeding rate was 11.7% (17/145) in the regular endoscopic treatment group and 41.9% (67/160) in the irregular endoscopic treatment group ( χ2=38.74, P<0.001). The follow-up time, rebleeding intervals and mortalies of rebleeding in the regular endoscopic treatment group and the irregular endoscopic treatment group were 28.14±11.11 months and 21.10±12.37 months ( t=5.21, P<0.001), 12.0 (6.0, 23.0) months and 1.0 (1.0, 6.0) months ( U=164.00, P<0.001), and 1.4% (2/145) and 10.6% (17/160) ( χ2=11.13, P=0.001), respectively. Conclusion:Compared with irregular endoscopic treatment, regular endoscopic treatment of EGVB in patients with liver cirrhosis has more clinical significance, which can significantly reduce the rebleeding rate, prolong the rebleeding interval, and reduce the mortality of rebleeding.
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Objective:To explore the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of esophago-gastric variceal bleeding (EGVB) complicated with cavernous transformation of portal vein (CTPV).Methods:From January 1, 2015 to December 31, 2018, the clinical data of liver cirrhosis patients with EGVB and complicated with (CTPV group) or without (non-CTPV group) CTPV receiving TIPS at Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School were retrospectively analyzed. The success rate of operation, stent patency rate, recurrent bleeding rate, incidence and survival rate of hepatic encephalopathy of CTPV group and non-CTPV group were analyzed. Independent samples t test, Mann-Whitney U test and chi-square test were used for statistical analysis. Kaplan-Meier method was used for survival analysis. Results:A total of 37 liver cirrhosis patients with EGVB and CTPV receiving TIPS treatment were screened out, among which 10 patients (27.0%) failed the portal vein puncture during the TIPS and switched to endoscopic treatment, the success rate was 73.0%. A total of 460 liver cirrhosis patients with EGVB and non-CTPV received TIPS treatment, among which TIPS in 18 patients (3.9%) was failed, and the success rate was 96.1%. With 1∶2 ratio propensity matching, 54 patients were enrolled in non-CTPV group. In the CTPV group, after TIPS treatment, the average portal vein pressure decreased from (28.9±5.1) mmHg (1 mmHg=0.133 kPa) to (18.8±4.5) mmHg, and the difference was statistically significant ( t=7.122, P<0.01). The median follow-up time was 33 months(1 to 66 months). There were no significant differences between the CTPV group and the non-CTPV group in one-year of cumulative stent patency rate (75.0% vs. 86.8%), recurrent upper gastrointestinal bleeding rate of hepatic encephalopathy (21.0% vs. 10.0%), the incidence of hepatic encephalopathy (34.8% vs. 22.2%) and the survival rate (80.7% vs. 88.9%)(all P >0.05). Conclusion:TIPS is safe and effective in the treatment of liver cirrhosis patients with EGVB and CTPV, and does not increase the incidence of postoperative complications and long-term mortality.
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Malnutrition is common in patients with liver cirrhosis, especially with a high incidence rate in the decompensated stage, which mainly manifests as protein-energy malnutrition and has a negative impact on the prognosis of patients. The main causes of malnutrition in liver cirrhosis are insufficient intake and increased consumption. Body composition assessment is an important method to evaluate the type of malnutrition in liver cirrhosis. European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines suggest that Nutritional Risk Screening 2002 (NRS2002) should be used for nutritional risk screening, and cirrhotic patients with an NRS2002 score of ≥3 are considered at the risk of malnutrition. ESPEN guidelines recommend a daily energy intake of 30-35 kcal/kg and a daily protein intake of 1.2-1.5 g/kg for patients with liver cirrhosis. Transjugular intrahepatic portosystemic shunt can effectively reduce portal hypertension in patients with liver cirrhosis and help to improve their nutritional status.
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ObjectiveTo investigate the clinical features and causes of death after transjugular intrahepatic portosystemic shunt (TIPS) in patients with hepatic sinus obstruction syndrome (HSOS), as well as the prevention and treatment measures to further improve the survival rate of such patients. MethodsA retrospective analysis was performed for 293 patients with HSOS who were admitted to Nanjing Drum Tower Hospital from January 2013 to December 2019, among whom 20 patients died after TIPS. General information, laboratory examination, and clinical treatment regimen were analyzed, and clinical indices and complications were compared at different stages of the disease. The paired t-test was used for comparison of normally distributed continuous data between groups, and the Wilcoxon rank-sum test was used for comparison of non-normally distributed continuous data between groups. ResultsThe mean survival time was 15.15±4.21 weeks for the 20 patients who died, among whom there were 15 male patients and 5 female patients, with a mean age of 67.60±7.01 years; there were 17 patients (85%) aged ≥60 years, and more than 90% of the patients had abdominal distention and oliguria. Among the 20 patients who died, 9 (45%) had chronic underlying diseases, and 5 (25%) had more than two underlying diseases. Portal venous pressure decreased from 21.67±5.15 mm Hg before surgery to 8.17±4.98 mm Hg after surgery (t=10.318,P＜0.05). The levels of total bilirubin, direct bilirubin, and D-dimer were significantly higher than the normal values before surgery, and there were significant increases in these levels on day 5 after surgery (Z=3.823,3.823,2.756, all P＜0.05); the hemoglobin level, platelet count, and creatinine level tended to decrease on day 5 after surgery (t=4.979,t=2.147,Z=-3.125, all P＜005). Three patients had hepatic encephalopathy before surgery, while 10 patients (50%) had hepatic encephalopathy after surgery. Causes of death included acute liver failure, infectious shock, and multiple organ failure syndrome (MODS). ConclusionThe possible risk factors for death after TIPS in HSOS patients include underlying diseases, high bilirubin, and complications such as hepatic encephalopathy and renal dysfunction. Causes of death mainly include acute liver failure and MODS. Ultrasound and laboratory markers should be reexamined during anticoagulation therapy to identify the patients with progression to severe diseases as early as possible, and in case of progressive deterioration of indices, TIPS should be selected as early as possible to improve the survival rate and prognosis of such patients. In addition, hemobilia should be observed during and after surgery, and intervention measures should be adopted in time to further reduce mortality rate.
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Objective To evaluate the feasibility and safety of endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) measurement in the normal porcine model.Methods Four pigs,2 male and 2 female,aged 8-12 months,weighing 20-30 kg were selected in the experiment.Under general anesthesia and EUS guidance,a 22 G fine needle connected to electrocardiograph monitor with a central vein pressure manometer was used to puncture and measure pressures in the portal vein (PV) and hepatic vein (HV) or inferior vena cava (IVC).Pressures were measured three times for each vessel and the mean pressure was recorded.The PPG was recorded as the difference between the PV pressure and HV or IVC pressure.Vital signs during and after the procedure and operation-related complications were monitored.Results EUS-PPG measurement was successful in all targeted vessels.The PV pressure,HV or IVC pressure,and PPG was 11.0±1.0 mmHg(1 mmHg=0.133 kPa),7.3±1.1 mmHg and 3.8±0.9 mmHg,respectively.No adverse event occurred.Conclusion EUS-PPG measurement has a high successful rate and reliable accuracy and safety reflecting the portal vein pressure.
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Objective To study the clinical characteristics of gynura segetum induced hepatic sinusoidal obstruction syndrome (HSOS).Methods From July 2008 to October 2016,a total of 115 cases of gynura segetum caused HSOS were retrospectively analyzed.The history of taking gynura segetum before disease onset was recorded and epidemiologic data of main clinical symptoms,clinical manifestations,laboratory examinations,imaging and pathological features were observed.Results Among the 115 cases of HSOS,there were 113 patients with abdominal pain,106 with anorexia and 42 with jaundice sclera.A total of 108 patients displayed increased serum total bilirubin,41 of them only with mildly increased total bilirubin.There were 29 patients with albumin lower than 30 g/L,64 patients with prolonged prothrombin time (PT) and PT of 11 patients was prolonged for more than three seconds.Meanwhile,31 patients were with prolonged activated partial prothrombin time (APTT).A total of 60 patients had low platelet count.And 92 patients underwent ultrasound examination,among them,71 patients had enlarged liver size,79 patients with uneven internal echo of liver,70 patients with ascites,14 patients with patchy low echo tissue around hepatic venous.A total of 60 patient accepted computed tomography (CT) examination,and all of them had ascites,14 patients with mildly enlarged spleen and eight patients with gastro-esophageal varices.The results of CT plain scan indicated hepatomegaly,decreased liver density,map-like changes of patchy low density in delayed phase,heterogeneous enhancement of liver parenchyma in arterial phase,compression and deformation of liver segment of inferior vena cava and halo sign around venous portal vein.The results of pathological examination demonstrated the widening of hepatic sinusoid with hemorrhage and congestion,destruction of liver plate in zone Ⅲ area.There were seven patients who received hepatic venous pressure gradient (HVPG) measurement which were all significantly increased.Conclusions The characteristics of patients with gynura segetum caused HSOS are abdominal pain,anorexia and jaundice;mildly increased serum total bilirubin and albumim liver enlargement,slow blood velocity of portal vein and splenic veim increased HVPG,hepatic sinus congestion and cell coagulation necrosis in zone Ⅲ area.
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Objective To investigate the correlation between liver and spleen stiffness measured by acoustic radiation force impulse (ARFI) and hepatic venous pressure gradient (HVPG),and to evaluate its efficiency in the diagnosis of portal hypertension.Methods From April 2014 to March 2016,20 cases underwent HVPG measurement because of liver cirrhosis were enrolled.Before HVPG measurement,liver and spleen stiffness were assessed with ARFI.The correlation between HVPG and age,alanine aminotransferase (ALT),aspartate aminotransferase (AST),total hilirubin,serum albumin,platelet count,prothrombin time,aspartate aminotransferase to platelet ratio index (APRI) score,Child-Pugh score,model for end-stage liver disease (MELD) score,liver stiffness and spleen stiffness were analyzed.Pearson correlation and Spearman rank correlation were performed for statistical analysis.Results HVPG,liver and spleen stiffness were successfully measured in all 20 patients.The mean liver stiffness was (1.78±0.29) m/s,the mean spleen stiffness was (3.37±0.44) m/s and HVPG was (16.10±5.14) mmHg (1 mmHg=0.133 kPa).Age,ALT,AST,total bilirubin,serum albumin,platelet count,prothrombin time,APRI score,Child-Pugh score and MELD score were all not correlated with HVPG (all P＞0.05).But HVPG was positively correlated with liver and spleen stiffness (r=0.449,P=0.047;r=0.487,P=0.030).In the diagnosis of HVPG≥12 mmHg,the area under curve (AUC) of liver stiffness was 0.875,the optimal cut-off value was 1.77 m/s,the sensitivity was 68.6 ％ and the specificity was 100.0％.In the diagnosis of HPVG≥20 mmHg,the AUC of liver stiffness was 0.798,the optimal cut off value was 1.85 m/s,the sensitivity was 100.0％ and the specificity was 68.8％.The AUC of spleen stiffness was 0.820,the optimal cut-off value was 3.23 m/s,the sensitivity was 100.0 ％ and the specificity was 56.3％.Conclusion In patients with liver cirrhosis,liver stiffness and spleen stiffness assessed by ARFI are positively correlated with HVPG and therefore ARFI has certain application value in the noninvasive diagnosis of portal hypertension.
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Objective To investigate the type,clinical and imaging features of iatrogenic bile duct injury and the efficacy and safety of endoscopic and interventional radiology therapy.Methods A total of 48 patients with iatrogenic bile duct injury who have undergone endoscopic and/or interventional therapy from January 1st 2013 to June 30th 2016 were enrolled.Patients' general information,causes of injury,clinical manifestations,treatment methods,efficacy and complications were retrospectively analyzed.Results The causes of iatrogenic bile duct injury were cholecystectomy(45.8％,22/48),liver transplantation (35.4％,17/48),transjugular intrahepatic portosystemic shunt (8.3％,4/48),Roux-en-Y anastomosis (6.3％,3/48) and endoscopic retrograde cholangiopancreatography (4.2％,2/48).The most common type of iatrogenic bile duct injury was stenosis of intra/extra bile ducts (66.7％,32/48).Other types included biliary fistula(18.8％,9/48),hemobilia (10.4％,5/48) and stenosis of anastomotic stoma (4.2％,2/48).The most common clinical manifestations were jaundice (37.5％,18/48) and abdominal pain (29.2％,14/48).Other clinical manifestations were fever (14.6％,7/48),hematemesis or melena (8.3％,4/48) and abnormal drainage fluid (8.3％,4/48).Diagnosis was confirmed by angiography,cholangiography or endoscopy.The overall effective rate of minimally invasive therapy was 91.7％ (44/48) and the most common complications were fever (16.7％,8/48) and pancreatitis (10.4％,5/48).Other complications were hemobilia (2.1％,1/48),cardia dilaceration (2.1％,1/48) and biliary fistula caused by catheter shedding(2.1％,1/48).Conclusion Iatrogenic bile duct injury could occur after upper abdominal surgeries,endoscopic or interventional procedures.Early diagnosis and treatment with endoscopic or vascular interventional methods can achieve satisfying efficacy and safety.
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ObjectiveTo investigate the short-term effect and safety of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of decompensated primary biliary cirrhosis (PBC). MethodsThe clinical data of 26 patients with decompensated PBC who received TIPS in Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2009 to May 2015 were analyzed retrospectively. The indicators including portal venous pressure, liver function, and survival before and after TIPS during 1 year of follow up were compared. The Friedman test was applied as the rank sum test for multiple related samples, the Wilcoxon test was applied as the paired rank sum test, and the Kaplan-Meier curve was applied for survival analysis. ResultsAll patients had significantly reduced mean portal pressure after TIPS(1911 (16.35-22.05) mmHg vs 27.93 (25.26-30.87) mmHg; Z=-4.199, P＜0.001). Within 3 months after TIPS, the patients showed significant increases in total bilirubin, Model for End-Stage Liver Disease score, and bile acid (χ2=26.000, 18.429, and 16.353, all P＜0001). The most common postoperative complication was pyrexia, which had an incidence rate of 80.77% (21/26), followed by hepatic encephalopathy, with an incidence rate of 19.23% (7/26). The survival rates at 6 and 12 months after surgery were both 92.3% (24/26). ConclusionsTIPS has good short- to medium-term effect and safety in the treatment of decompensated PBC, and its long-term effect still needs to be proved.
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In recent years, with the development in basic research and clinical application, the success rate of transjugular intrahepatic portosystemic shunt (TIPS) has been increased significantly, and stent restenosis rate and the incidence of postoperative hepatic encephalopathy have been controlled. With reference to the authors′ clinical practice and hot topics of conferences at home and abroad, this article introduces the advances in TIPS-related techniques and their application in liver cirrhosis, including TIPS puncture technique, TIPS stent, TIPS-related hepatic encephalopathy and its prevention and treatment, TIPS indications and contraindications, the issues solved by TIPS in liver cirrhosis, and the advantages and disadvantages of TIPS in the treatment of esophagogastric variceal bleeding compared with other therapeutic methods, in order to make contributions to the development of TIPS and bring more benefits to patients with liver cirrhosis.
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Liver fibrosis is the intermediate process in the progression of various chronic liver diseases to liver cirrhosis, and its serious complications affect the prognosis of patients with chronic liver diseases. However, so far, there remain no effective drugs for the treatment of liver fibrosis. This article investigates the development and progression of liver fibrosis from the aspects of signaling pathways and molecular mechanisms and briefly introduces the latest research advances in the roles of signaling pathways, including transforming growth factor-β/Smad pathway, platelet-derived growth factor pathway, leptin signaling pathway, and connective tissue growth factor pathway, chemokines, neuroendocrine factors, and angiogenesis in the development of liver fibrosis, so as to enhance the knowledge of the development of liver fibrosis and provide a theoretical basis for the research on molecular-targeted drugs based on the pathogenesis of liver fibrosis.
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Objective To explore the effects of different treatments on prognosis of patients with Gynura segetum caused hepatic vein occlusion disease (HVOD).Methods From July 2008 to January 2016,85 patients with Gynura segetum caused HVOD were enrolled and received treatment of liver function protection and microcirculation improvement.According to different treatment options,patients were divided into non-anticoagulation group,nowanticoagulation transfered to transjugular intrahepatic portosystem stent-shunt (TIPS) group,anticoagulation group,anticoagulation transfered to TIPS group and anticoagulation-TIPS step-by-step treatment group.The efficacy of each group was observed.Chi square test was performed for statistical analysis.Results Among 22 patients who received nonanticoagulation treatment,six (27.3％) patients were cured and 14 (63.6％) patients died during the treatment period;besides two (9.1 ％) patients received TIPS because of ineffective treatment and achieved longterm survival.Among 63 patients treated with combination of low-molecular-weight heparin and warfarin,six (9.5％) patients died and 36(57.1％) patients were cured.The cure rate was higher than that of nonanticoagulation group (x2 =5.820,P=0.016).Other 21 patients received TIPS treatment,achieved longterm survival except one patient died from surgical complications.The cure rate of anticoagulation-TIPS step treatment group was 88.9 ％ (56/63) which was higher than that of non-anticoagulation group,and the difference was statistically significant (x2 =31.350,P＜0.01).Conclusions Compared to conventional liver function protection treatment and symptomatic treatment,anticoagulation therapy significantly increases the cure rate of patients with Gynura segetum caused HVOD.Anticoagulation-TIPS step-by-step treatment further improves the cure rate.
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Background:Cholangiocarcinoma(CCA)is a fatal digestive system tumor arising from biliary epithelium. Claudin-4,a key constituent of intercellular tight junction,is aberrantly and widely expressed in various epithelial tumors,and is correlated with tumorigenesis and tumor progression. Aims:To investigate the expression of claudin-4 in CCA and its correlation with clinicopathological characteristics of the tumor and patient’s prognosis. Methods:Immunohistochemistry was used to determine the expression rate and intensity of claudin-4 in CCA tissue and matched paracancerous tissue of 77 CCA patients. Correlation of claudin-4 expression in CCA with its clinicopathological characteristics was analyzed,and survival analysis was conducted by using Kaplan-Meier method. Results:Claudin-4 was strongly expressed in CCA tissue and mildly or weakly expressed in matched paracancerous tissue;the immunohistochemical score was significantly higher in cancerous tissue than in paracancerous tissue(9. 22 ± 3. 62 vs. 7. 12 ± 4. 26,P 0. 05). Conclusions:Claudin-4 is highly expressed in CCA and negatively correlated with tumor differentiation. It might be a novel diagnostic biomarker and therapeutic target for CCA.
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Objective To explore the correlation between wedged hepatic vein pressure (WHVP) and directly measured portal vein pressure (PVP) and further analyze the correlation between hepatic venous pressure gradient (HVPG) and portal pressure gradient (PPG).Methods From December 2012 to April 2014,the related data including WHVP,free hepatic venous pressure (FHVP),inferior vena cava pressure (IVCP) and PVP of patients who received transjugular interahepatic portosystem stentshunt (TIPS) treatment were collected,and HVPG and PPG were calculated.The correlations between WHVP and PVP,between FHVP and IVCP,between HVPG and PPG were analyzed.Pearson's correlation analysis were performed for correlation analysis.Results Twenty two patients matched the criteria were enrolled during the December 2012 to April 2014.The mean pressures of PVP and WHVP were (28.07±4.43) mmHg (1 mmHg=0.133 kPa) and (26.22±5.91) mmHg,respectively.PVPand WHVP were positively correlated,the correlation coefficient of them was 0.431 (P=0.045) and slope was0.323.The mean pressures of FHVP and IVCP were (7.31±3.37) mmHg and (6.82±4.01) mmHg,respectively.FHVP and IVCP were positively correlated,the correlation coefficient of them was 0.845 (P＜0.01) and slope was 0.711.The mean pressures of PPG and HVPG was (21.02±3.76) mmHg and (18.90±4.86) mmHg,respectively.There was no correlation between PPG and HVPG,the correlation coefficient of them was 0.014 (P=0.951).Conclusions There is a good correlation between PVP and WHVP,and so is the correlation between FHVP and IVCP.However,there is no good correlation between HVPG and PPG in this study because of the effects of many factors.