Ascites is the most common cause of decompensation in cirrhosis, and 5% to 10% of patients with compensated cirrhosis develop ascites each year. The main factor of ascites formation is renal sodium retention due to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system by the reduced effective volume secondary to splanchnic arterial vasodilation. Diagnostic paracentesis is indicated in all patients with a new onset of grade 2 or 3 ascites and in those admitted to hospital for any complication of cirrhosis. A serum-ascites albumin gradient of ≥1.1 g/dL indicates portal hypertension with an accuracy of approximately 97%. Sodium restriction, diuretics, and large volume paracentesis are the mainstay of treatment in grade 1 to 3 ascites. The refractoriness of ascites is associated with a poor prognosis with a median survival of approximately six months. Repeated large volume paracentesis plus albumin is the first line treatment, and liver transplantation is recommended in patients with refractory ascites. A careful selection of patients is also important to obtain the beneficial effects of transjugular intrahepatic portosystemic shunts in refractory ascites. This review details the recent diagnosis and treatment of cirrhotic ascites.
Ascites* ; Diagnosis ; Diuretics ; Fibrosis ; Humans ; Hypertension, Portal ; Liver Cirrhosis ; Liver Transplantation ; Paracentesis ; Portasystemic Shunt, Surgical ; Prognosis ; Renin-Angiotensin System ; Sodium ; Sympathetic Nervous System ; Vasodilation

PURPOSE: Recent studies investigating new strategies to modulate the immune system have utilized animal models of liver transplantation (LT). However, the anhepatic phase (AHP) remains a crucial problem in LT. The aim of the present study is to introduce a technique for successful orthotopic LT in cynomolgus monkeys using an early-reperfusion strategy. METHODS: Orthotopicallo-LT was performed with seven donor/recipient pairs of cynomolgus monkeys. RESULTS: In 2 recipients, liver allografts were perfused after suprahepatic inferior vena cava (SHIVC), portal vein (PV), and infrahepatic inferior vena cava (IHIVC) anastomosis. To reduce the time of AHP in five recipients, liver allografts ware perfused after SHIVC and PV anastomosis while the IHIVC was not anastomosed. In the latter strategy, the AHP was reduced from 46 minutes to 31 minutes and a 24-hour survival rate of 80% was achieved. CONCLUSION: Our results indicate that an early-reperfusion strategy can be successfully used to establish a LT model in cynomolgus monkeys with a consistently high rate of animal survival.
Allografts ; Animals ; Immune System ; Liver Transplantation ; Liver ; Macaca fascicularis ; Models, Animal ; Portal Vein ; Primates ; Reperfusion ; Survival Rate ; Vena Cava, Inferior

The renin-angiotensin system (RAS) is an important regulator of cirrhosis and portal hypertension. As hepatic fibrosis progresses, levels of the RAS components angiotensin (Ang) II, Ang-(1–7), angiotensin-converting enzyme (ACE), and Ang II type 1 receptor (AT1R) are increased. The primary effector Ang II regulates vasoconstriction, sodium homoeostasis, fibrosis, cell proliferation, and inflammation in various diseases, including liver cirrhosis, through the ACE/Ang II/AT1R axis in the classical RAS. The ACE2/Ang-(1–7)/Mas receptor and ACE2/Ang-(1–9)/AT2R axes make up the alternative RAS and promote vasodilation, antigrowth, proapoptotic, and anti-inflammatory effects; thus, countering the effects of the classical RAS axis to reduce hepatic fibrogenesis and portal hypertension. Patients with portal hypertension have been treated with RAS antagonists such as ACE inhibitors, Ang receptor blockers, and aldosterone antagonists, with very promising hemodynamic results. In this review, we examine the RAS, its roles in hepatic fibrosis and portal hypertension, and current therapeutic approaches based on the use of RAS antagonists in patients with portal hypertension.
Angiotensin-Converting Enzyme Inhibitors ; Angiotensins ; Cell Proliferation ; Fibrosis* ; Hemodynamics ; Humans ; Hypertension, Portal* ; Inflammation ; Liver Cirrhosis ; Mineralocorticoid Receptor Antagonists ; Receptors, Angiotensin ; Renin-Angiotensin System* ; Sodium ; Vasoconstriction ; Vasodilation

Neurofibromas can occur anywhere in the body, but they usually involve the head, neck, pelvis, and extremities. Abdominal visceral involvement is rare, and intrahepatic involvement is even less common. We describe a patient who suffered from plexiform neurofibromatosis with liver involvement. A 49-year-old man, who had previously been diagnosed with neurofibromatosis, underwent esophagogastroduodenoscopy and abdominal ultrasonography for screening purposes. Esophagogastroduodenoscopy showed grade 2 esophageal varices and abdominal ultrasonography showed conglomerated nodules with echogenic appearances in the perihepatic space. Magnetic resonance imaging showed presumed plexiform neurofibroma involving the lesser sac and hepatic hilum and encasing the common hepatic artery celiac trunk and superior mesenteric artery left portal triad. We report an unusual case of portal hypertension attributed to the compressive narrowing of the portal vein by presumed as plexiform neurofibroma at the lesser sac and hepatic hilum.
Abdomen/diagnostic imaging ; Endoscopy, Digestive System ; Esophageal and Gastric Varices/pathology ; Hepatic Artery/diagnostic imaging ; Humans ; Hypertension, Portal/*diagnosis ; Liver/diagnostic imaging ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Neurofibroma, Plexiform/*diagnosis/diagnostic imaging ; Tomography, X-Ray Computed ; Ultrasonography

Portal hypertension can arise from any condition interfering with normal blood flow at any level within the portal system. Herein, we presented two uncommon cases of the portal hypertension and its treatment with brief literature review. A 71-year-old man who underwent right hemihepatectomy revealed a tumor recurrence adjacent to the inferior vena cava (IVC). After radiofrequency ablation (RFA) with lymph node dissection, he was referred for abdominal distension. The abdomen computed tomography scan showed severe ascites with a narrowing middle hepatic vein (MHV) and IVC around the RFA site. After insertion of two stents at the IVC and MHV, the ascites disappeared. Another 73-year-old man underwent right trisectionectomy of liver and segmental resection of the portal vein (PV). After operation, he underwent conservative management due to continuous abdominal ascites. The abdomen computed tomography scan showed severe ascites with obliteration of the left PV. After insertion of stent, the ascites disappeared. A decrease of the pressure gradient between the PV and IVC is one of the important treatment strategies for portal hypertension. Vascular stent is useful in the reduction of pressure gradient and thus, can be a treatment option for portal hypertension.
Abdomen ; Aged ; Ascites ; Catheter Ablation ; Constriction, Pathologic ; Hepatic Veins ; Humans ; Hypertension, Portal* ; Liver ; Lymph Node Excision ; Portal System ; Portal Vein ; Recurrence ; Stents ; Vena Cava, Inferior

OBJECTIVE: To evaluate the feasibility, safety, and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) to treat gastric variceal hemorrhage in patients with portal hypertension. MATERIALS AND METHODS: From May 2012 to June 2014, 19 patients (11 men and 8 women, median age; 61, with history of gastric variceal hemorrhage; 17, active bleeding; 2) who underwent PARTO using a vascular plug and a gelfoam pledget were retrospectively analyzed. Clinical and laboratory data were examined to evaluate primary (technical and clinical success, complications) and secondary (worsening of esophageal varix [EV], change in liver function) end points. Median follow-up duration was 11 months, from 6.5 to 18 months. The Wilcoxon signed-rank test was used to compare laboratory data before and after the procedure. RESULTS: Technical success (complete occlusion of the efferent shunt and complete filling of gastric varix [GV] with a gelfoam slurry) was achieved in 18 of 19 (94.7%) patients. The embolic materials could not reach the GV in 1 patient who had endoscopic glue injection before our procedure. The clinical success rate (no recurrence of gastric variceal bleeding) was the same because the technically failed patient showed recurrent bleeding later. Acute complications included fever (n = 2), fever and hypotension (n = 2; one diagnosed adrenal insufficiency), and transient microscopic hematuria (n = 3). Ten patients underwent follow-up endoscopy; all exhibited GV improvement, except 2 without endoscopic change. Five patients exhibited aggravated EV, and 2 of them had a bleeding event. Laboratory findings were significantly improved after PARTO. CONCLUSION: PARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension.
Aged ; Balloon Occlusion ; Embolization, Therapeutic ; Endoscopy, Digestive System ; Esophageal and Gastric Varices/complications/radiography/*therapy ; Female ; Gastrointestinal Hemorrhage/therapy ; Gelatin Sponge, Absorbable/chemistry ; Humans ; Hypertension, Portal/complications ; Male ; Middle Aged ; Retrospective Studies ; Tomography, X-Ray Computed

OBJECTIVE: To evaluate the efficacy and safety of balloon-occluded retrograde transvenous obliteration (BRTO) with sodium tetradecyl sulfate (STS) liquid sclerotherapy of gastric varices. MATERIALS AND METHODS: Between February 2012 and August 2014, STS liquid sclerotherapy was performed in 17 consecutive patients (male:female = 8:9; mean age 58.6 years, range 44-86 years) with gastric varices. Retrograde venography was performed after occlusion of the gastrorenal shunt using a balloon catheter and embolization of collateral draining veins using coils or gelfoam pledgets, to evaluate the anatomy of the gastric varices. We prepared 2% liquid STS by mixing 3% STS and contrast media in a ratio of 2:1. A 2% STS solution was injected into the gastric varices until minimal filling of the afferent portal vein branch was observed (mean 19.9 mL, range 6-33 mL). Patients were followed up using computed tomography (CT) or endoscopy. RESULTS: Technical success was achieved in 16 of 17 patients (94.1%). The procedure failed in one patient because the shunt could not be occluded due to the large diameter of gastrorenal shunt. Complete obliteration of gastric varices was observed in 15 of 16 patients (93.8%) with follow-up CT or endoscopy. There was no rebleeding after the procedure. There was no procedure-related mortality. CONCLUSION: BRTO using STS liquid can be a safe and useful treatment option in patients with gastric varices.
Adult ; Aged ; Aged, 80 and over ; Balloon Occlusion ; Contrast Media/*chemistry ; Demography ; Embolization, Therapeutic ; Endoscopy, Digestive System ; Esophageal and Gastric Varices/*therapy ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Portal Vein/radiography ; Sclerotherapy ; Sodium Tetradecyl Sulfate/*chemistry ; Tomography, X-Ray Computed

To investigate the correlations among total liver CT perfusion parameters, unpaired arteries (UAs) and microvessel area (MVA) in a rabbit liver VX2 tumor model, and to learn the tumoral angiogenesis condition and the mechanisms for perfusion imaging.
 Methods: Rabbits with or without the inoculated VX2 tumor in the liver underwent total liver CT perfusion imaging 2 weeks after the operation. Perfusion parameters included blood flow (BF), blood volume (BV), arterial liver perfusion (ALP), portal liver perfusion (PVP), hepatic perfusion index (HPI) for the tumor rim and the surrounding liver tissue. After the examination, the UAs and MVA of tumor tissues were obtained by immunohistochemical staining. The differences of perfusion parameters between the vital tumor rim and the surrounding liver tissue were compared. The correlations among perfusion parameters, UAs and MVA were analyzed.
 Results: There was significant difference between the CT perfusion parameters at the tumor rim and the surrounding liver tissue or liver tissue of the control group (P<0.05), but there was no significant difference between the perfusion parameters at the surrounding liver tissues of the experimental group and the control (P>0.05). There was positive correlation between UAs and MVA. UAs and MVA were positively correlated with BF, ALP and BV at the tumor rim. UAs and MVA were negatively correlated with PVP. HPI positively correlated with UAs, but it was not correlated with MVA.
 Conclusion: Total liver CT perfusion can provide quantitative information to evaluate the artery and portal vein perfusion of liver VX2 tumor, and to assess the degree of tumor angiogenesis.
Animals ; Arteries ; diagnostic imaging ; Blood Volume ; Carcinoma ; Immunohistochemistry ; Liver Circulation ; Liver Neoplasms ; blood supply ; diagnostic imaging ; Microvessels ; diagnostic imaging ; Neoplasm Transplantation ; Neoplasms, Squamous Cell ; Neovascularization, Pathologic ; diagnostic imaging ; Perfusion Imaging ; statistics & numerical data ; Portal System ; diagnostic imaging ; Rabbits ; Tomography, X-Ray Computed ; methods ; statistics & numerical data

Portal vein embolization (PVE) is known as an effective and safe preoperative procedure that increases the future liver remnant (FLR) in patients with insufficient FLR. However, some possible major complications can lead to non-resectability or delayed elective surgery that results in increased morbidity and mortality. Although the majority of these complications are rare, knowledge of the radiologic findings of post-procedural complications facilitate an accurate diagnosis and ensure prompt management. We accordingly reviewed the CT findings of the complications of PVE.
Aged ; Cholangiocarcinoma/radiography/therapy ; Embolization, Therapeutic/*adverse effects ; Female ; Humans ; Hypertension, Portal/etiology ; Liver Neoplasms/radiography/*therapy ; Male ; Middle Aged ; Portal Vein/*radiography ; Tomography, X-Ray Computed ; Vascular System Injuries/etiology ; Venous Thrombosis/etiology

Owing to the high prevalence of various chronic liver diseases, cirrhosis is one of the leading causes of morbidity and mortality worldwide. In recent years, the development of non-invasive tests of fibrosis allows accurate diagnosis of cirrhosis and reduces the need for liver biopsy. In this review, we discuss the application of these non-invasive tests beyond the diagnosis of cirrhosis. In particular, their role in the selection of patients for hepatocellular carcinoma surveillance and varices screening is highlighted.
Biomarkers/blood ; Carcinoma, Hepatocellular/diagnosis ; *Elasticity Imaging Techniques ; Endoscopy, Digestive System ; Humans ; Hypertension, Portal/complications ; Liver Cirrhosis/complications/*diagnosis ; Liver Neoplasms/diagnosis ; Risk Factors