World Journal of Surgery

, Volume 18, Issue 2, pp 171–175 | Cite as

Relation between liver pathology and prognosis in patients with portal hypertension

  • P. Aiden McCormick
  • Andrew K. Burroughs
Article

Abstract

The most common causes of variceal bleeding are cirrhosis, schistosomiasis, and extrahepatic portal venous obstruction. The prognosis for an individual patient depends on the severity of the bleeding episode and the underlying liver function. Liver function is determined to a large extent by the underlying liver pathology. Patients with noncirrhotic portal hypertension or cirrhosis with good liver function have good short- and long-term prognoses. In patients with established cirrhosis, the presence of alcoholic hepatitis, hepatocellular carcinoma, or portal venous thrombosis may adversely affect prognosis. In addition to affecting prognosis, the underlying pathology may also influence choice of treatment. This point is particularly true for treatments such as shunt surgery, liver transplantation, or transjugular intrahepatic shunts.

Résumé

Les causes les plus fréquentes de varices oesophagiennes sont la cirrhose, la bilharziose (schistosomiase) et l'occlusion de la veine porte extrahépatique. Le pronostic pour un individu donné dépend de la sévérité de l'hémorragie et de la fonction hépatique. La fonction hépatique est elle-même déterminée par la pathologie sous-jacente. Les patients ayant une hypertension portale d'origine non cirrhotique ou une cirrhose avec une fonction hépatique conservée ont un meilleur pronostic à court et à long terme. Chez le patient ayant une cirrhose établie, la présence d'une hépatite alcoolique, d'un carcinome hépatocellulaire et/ou d'une thrombose de la veine porte sont des facteurs de mauvais pronostic. La pathologie sous-jacente peut influencer non seulement le pronostic, mais aussi le choix du traitement. Ceci est particulièrement vrai pour le traitement par anastomose portocave, la transplantation ou le shunt intrahépatique transjugulaire.

Resumen

Las causas más comunes de hemorragia varicosa son la cirrosis, la esquistosomiasis y la obstrucción portal extrahepática. El pronóstico en cada individuo depende de la severidad del' episodio de sangrado y del estado de la función hepática, estado que depende en gran parte de la patología hepática subyacente. Los pacienes con hipertensión portal de origen no cirrótico o con cirrosis y buena función hepática tienen un buen pronóstico, tanto a corto como a largo plazo. En los pacientes con cirrosis establecida, la presencia de hepatitis alcohólica, de carcinoma hepatocellular y/o de trombosis de la vena porta puede afectar el pronóstico en forma adversa. Además de afectar el pronóstico, la patología subyacente puede también influenciar la modalidad de tratamiento. Esto es particularmente cierto en modalidades terapéuticas tales como cirugía derivativa (“shunts”), trasplante hepático o “shunts” transyugulares intrahepáticos (TIPS).

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Burroughs, A.K., D'Heygere, F., McIntyre, N.: Pitfalls in studies of prophylactic therapy for variceal bleeding in cirrhotics. Hepatology 6:1407, 1986Google Scholar
  2. 2.
    Graham, D.Y., Smith, J.L.: The course of patients after variceal hemorrhage. Gastroenterology 80:800, 1981Google Scholar
  3. 3.
    Burroughs, A.K., Mezzanotte, G., Phillips, A., McCormick, P.A., McIntyre, N.: Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates. Hepatology 9:801, 1989Google Scholar
  4. 4.
    Kleber, G., Sauerbruch, T., Ansari, H., Paumgartner, G.: Prediction of variceal hemorrhage in cirrhosis: a prospective follow-up study. Gastroenterology 100:1332, 1991Google Scholar
  5. 5.
    Pascal, J.P., Cales, P., Multicenter Study Group: Propranolol in the prevention of first upper gastrointestinal tract hemorrhage in patients with cirrhosis of the liver and esophageal varices. N. Engl. J. Med. 317:856, 1987Google Scholar
  6. 6.
    Italian Multicenter Project for Propranolol in Prevention of Bleeding: Propranolol for prophylaxis of bleeding in cirrhotic patients with large varices: a multicenter, randomized clinical trial. Hepatology 8:1, 1988Google Scholar
  7. 7.
    Ideo, G., Gellati, G., Fesce, E., Grimoldi, D.: Nadolol can prevent the first gastrointestinal bleeding in cirrhotics: a prospective, randomized study. Hepatology 8:6, 1988Google Scholar
  8. 8.
    Lebrec, D., Poynard, T., Capron, J.P., et al.: Nadolol for prophylaxis of gastrointestinal bleeding in patients with cirrhosis: a randomized trial. J. Hepatol. 7:118, 1988Google Scholar
  9. 9.
    Vererans Affairs Cooperative Variceal Sclerotherapy Group: Prophylactic sclerotherapy for esophageal varices in men with alcoholic liver disease: a randomized, single-blind, multicenter clinical trial. N. Engl. J. Med. 324:1779, 1991Google Scholar
  10. 10.
    Sauerbruch, T., Wotzka, R., Kopcke, W., et al.: Prophylactic sclerotherapy before the first episode of variceal hemorrhage in patients with cirrhosis. N. Engl. J. Med. 319:8, 1988Google Scholar
  11. 11.
    Piai, G., Cipolletta, L., Claar, M., et al.: Prophylactic sclerotherapy of high risk esophageal varices: results of a multicentric prospective controlled trial. Hepatology 8:1495, 1988Google Scholar
  12. 12.
    Colombo, M., De Franchis, R., Tommasini, M., Sangiovanni, A., Dioguardi, N.: β-Blockade prevents recurrent gastrointestinal bleeding in well-compensated patients with alcoholic cirrhosis: a multicenter randomized controlled trial. Hepatology 9:433, 1989Google Scholar
  13. 13.
    Garden, O.J., Mills, P.R., Birnie, G.G., Murray, G.D., Carter, D.C.: Propranolol in the prevention of recurrent variceal hemorrhage in cirrhotic patients: a controlled trial. Gastroenterology 98:185, 1990Google Scholar
  14. 14.
    Lebrec, D., Poynard, T., Bernuau, J., et al.: A randomized controlled study of propranolol for prevention of recurrent gastrointestinal bleeding in patients with cirrhosis: a final report. Hepatology 4:355, 1984Google Scholar
  15. 15.
    Villeneuve, J.P., Pomier-Layrargues, G., Infante-Rivard, C., et al.: Propranolol for the prevention of recurrent variceal hemorrhage: a controlled trial. Hepatology 6:1239, 1986Google Scholar
  16. 16.
    Orrego, H., Blake, J.E., Blendis, L.M., Medline, A.: Prognosis of alcoholic cirrhosis in the presence and absence of alcoholic hepatitis. Gastroenterology 92:208, 1987Google Scholar
  17. 17.
    Okuda, K., Okuda, H.: Primary liver cell carcinoma. In Oxford Textbook of Clinical Hepatology, N. McIntyre, J.P. Benhamou, J. Bircher, M. Rizzetto, J. Rodes, editors. Oxford, Oxford University Press, 1991, pp. 1019–1053Google Scholar
  18. 18.
    Okuda, K., Ohnishi, K., Kimura, K., et al.: Incidence of portal vein thrombosis in liver cirrhosis: an angiographic study in 708 patients. Gastroenterology 89:279, 1985Google Scholar
  19. 19.
    Sarfeh, I.J.: Portal vein thrombosis associated with cirrhosis. Arch. Surg. 114:902, 1979Google Scholar
  20. 20.
    Lebrec, D., Sicot, C., Degott, C., Benhamou, J.P.: Portal hypertension and primary biliary cirrhosis. Digestion 14:220, 1976Google Scholar
  21. 21.
    Thornton, J.R., Triger, D.R., Losowsky, M.S.: Variceal bleeding is associated with reduced risk of severe cholestasis in primary biliary cirrhosis. Q. J. Med. 71:467, 1989Google Scholar
  22. 22.
    Warren, K.S., Reboucas, G.: Blood ammonia during bleeding from esophageal varices in patients with hepatosplenic schistosomiasis. N. Engl. J. Med. 271:921, 1964Google Scholar
  23. 23.
    Rodriguez, H.F., Garcia-Palmieri, M.R., Rivera, J.V., Rodriguez-Molina, R.: A comparative study of portal and bilharzial cirrhosis. Gastroenterology 29:235, 1955Google Scholar
  24. 24.
    Watt, G., Padre, L.P., Tuazon, M., Wotherspoon, A., Adapon, B.: Hepatic parenchymal dysfunction in Schistosoma japonicum infection. J. Infect. Dis. 164:1186, 1991Google Scholar
  25. 25.
    Mohamed, A.E., alKarawi, M.A., alOtaibi, R., Hanid, M.A.: Results of sclerotherapy in 100 patients: comparison of the outcome between schistosomiasis and hepatitis B. Hepatogastroenterology 36:333, 1989Google Scholar
  26. 26.
    Garcia-Palmieri, M.R., Marcial-Rojas, R.A.: Portal hypertension due to schistosomiasis mansoni. Am. J. Med. 27:811, 1959Google Scholar
  27. 27.
    Kiire, C.F.: Controlled trial of propranolol to prevent recurrent variceal bleeding in patients with non-cirrhotic portal fibrosis. B. M. J. 298:1363, 1989Google Scholar
  28. 28.
    Da Silva, L.C., Carrilho, F.J.: Hepatosplenic schistosomiasis: pathophysiology and treatment. Gastroenterol. Clin. North Am. 21:163, 1992Google Scholar
  29. 29.
    Wanless, I.R.: Micronodular transformation (nodular regenerative hyperplasia) of the liver: a report of 64 cases among 2,500 autopsies and a new classification of benign hepatocellular nodules. Hepatology 11:787, 1990Google Scholar
  30. 30.
    Colina, F., Alberti, N., Solis, J.A., Martinez-Tello, F.J.: Diffuse nodular regenerative hyperplasia of the liver (DNRH): a clinicopathologic study of 24 cases. Liver 9:253, 1989Google Scholar
  31. 31.
    Wanless, I.R., Peterson, P., Das, A., Boitnott, J.K., Moore, G.W., Bernier, V.: Hepatic vascular disease and portal hypertension in polycythemia vera and agnogenic myeloid metaplasia: a clinicopathological study of 145 patients examined at autopsy. Hepatology 12:1166, 1990Google Scholar
  32. 32.
    Snover, D.C., Weisdorf, S., Bloomer, J., McGlave, P., Weisdorf, D.: Nodular regenerative hyperplasia of the liver following bone marrow transplantation. Hepatology 9:443, 1989Google Scholar
  33. 33.
    Sahni, P., Pande, G.K., Nundy, S.: Extrahepatic portal vein obstruction. Br. J. Surg. 27:1201, 1990Google Scholar
  34. 34.
    Webb, L.J., Sherlock, S.: The aetiology, presentation and natural history of extrahepatic portal venous obstruction. Q. J. Med. 48:627, 1979Google Scholar
  35. 35.
    Cohen, J., Edelman, R.R., Chopra, S.: Portal vein thrombosis: a review. Am. J. Med. 92:173, 1992Google Scholar
  36. 36.
    Merkel, C., Bolognesi, M., Bellon, S., et al.: Long-term follow-up of adult patients with non-cirrhotic obstruction of the portal system: comparison with cirrhotic patients. J. Hepatol. 15:299, 1992Google Scholar
  37. 37.
    Valla, D., Casadevall, N., Huisse, M.G., et al.: Etiology of portal vein thrombosis in adults: a prospective evaluation of primary myeloproliferative disorders. Gastroenterology 94:1063, 1988Google Scholar
  38. 38.
    Cardin, F., Graffeo, M., McCormick, P.A., Sherlock, S., McIntyre, N., Burroughs, A.K.: Adult “idiopathic” extra hepatic venous thrombosis: importance of putative “latent” myeloproliferative disorders and comparison with cases with a known aetiology. Dig. Dis. Sci. 37:335, 1992Google Scholar
  39. 39.
    Evans, G.R.D., Yellin, A.E., Weaver, R.A., Stain, S.C.: Sinistral (left-sided) portal hypertension. Am. Surg. 56:758, 1990Google Scholar
  40. 40.
    Okuda, K., Kono, K., Ohnishi, K., et al.: Clinical study of eighty-six cases of idiopathic portal hypertension and comparison with cirrhosis with splenomegaly. Gastroenterology 86:600, 1984Google Scholar
  41. 41.
    Dilawari, J.B., Ganguly, S., Chawla, Y.: Non-cirrhotic portal fibrosis. Ind. J. Gastroenterol. 11:31, 1992Google Scholar
  42. 42.
    Eguchi, A., Hashizume, M., Kitano, S., Tanoue, K., Wada, H., Sugimachi, K.: High rate of portal thrombosis after splenectomy in patients with esophageal varices and idiopathic portal hypertension. Arch. Surg. 126:752, 1991Google Scholar
  43. 43.
    Tzakis, A., Todo, S., Stieber, A., et al.: Venous jump grafts for liver transplantation in patients with portal vein thrombosis. Transplantation 48:530, 1989Google Scholar
  44. 44.
    Pande, G.K., Reddy, V.M., Kar, P., et al.: Operations for portal hypertension due to extrahepatic obstruction: results and 10 year follow up. B. M. J. 295:1115, 1987Google Scholar
  45. 45.
    Roessle, M., Noeldge, G., Ochs, A., Haag, K., Sellinger, M., Gerok, W.: Feasibility of transjugular intrahepatic portosystemic stent shunt (TIPS) in the treatment of fulminant Budd-Chiari syndrome (BCS) [abstract]. Gastroenterology 102:A875, 1992Google Scholar
  46. 46.
    Radosevich, P.M., Ring, R.J., La Berge, J.M., et al.: Transjugular intrahepatic porto-systemic shunts in patients with portal vein occlusion. Radiology 186:523, 1993Google Scholar
  47. 47.
    Conn, H.O.: Transjugular intrahepatic portal-systemic shunts: the state of the art. Hepatology 17:148, 1993Google Scholar

Copyright information

© Société Internationale de Chirurgie 1994

Authors and Affiliations

  • P. Aiden McCormick
    • 1
  • Andrew K. Burroughs
    • 1
  1. 1.University Department of Medicine, Hepatobiliary and Liver Transplant UnitRoyal Free Hospital School of MedicineLondonUnited Kingdom

Personalised recommendations