Portal hypertension from chronic liver disease leads to the formation of collateral blood vessels called spontaneous portosystemic shunts (SPSS). These shunts may form from existing vessels or through neo-angiogenesis. Their location affects clinical outcomes due to varying risks and complications. This review summarizes current knowledge on SPSS, covering their clinical impact and management strategies. Recent data suggest that SPSS increases the risk of variceal bleeding, regardless of shunt size. The size of the shunt is crucial in the rising incidence of hepatic encephalopathy (HE) linked to SPSS. It also increases the risk of portopulmonary hypertension and portal vein thrombosis. Detecting and assessing SPSS rely on computed tomography (CT) and magnetic resonance imaging. CT enables precise measurements and the prediction of cirrhosis progression. Management focuses on liver disease progression and SPSS-related complications, like HE, variceal bleeding, and portopulmonary hypertension. Interventional radiology techniques such as balloon-occluded, plug-assisted, and coil-assisted retrograde transvenous obliteration play a pivotal role. Surgical options are rare but are considered when other methods fail. Liver transplantation (LT) often resolves SPSS. Intraoperative SPSS ligation is still recommended in patients at high risk for developing HE or graft hypoperfusion.

UNASSIGNED: Portal vein thrombosis is a common problem of end-stage liver disease in patients with portal hypertension and Yerdel grade IV thrombosis may be a contraindication for liver transplantation. Advances in surgical technique have indicated the feasibility of liver transplantation with PVT such as Reno-portal anastomosis, cavo-portal hemitransposition, but low graft portal blood perfusion and regional portal hypertension were the limitations.
UNASSIGNED: We introduce a new approach for portal system reconstruction in a patient underwent liver transplantation: A 28-year-old male was diagnosed with Budd-Chari syndrome and portal hypertension with grade IV portal vein thrombosis.
UNASSIGNED: The \"Pull-out\" technique was applicated for thrombectomy, which can aid in exposing the superior mesenteric vein and portal vein branches and reducing technical difficulties associated with the identification and dissociation of surrounding anatomical structures. To collect sufficient portal vein blood perfusion and avoid regional portal hypertension, the portal vein system was reconstructed through double-approach procedure: reno-portal anastomosis combined with portal-portal anastomosis.
UNASSIGNED: Based on a precision preoperative evaluation, application of the Pull-out technique and double-approach procedure may be an effective method of thrombectomy especially in cases of grade IV portal vein thrombosis.

Nodular regenerative hyperplasia (NRH) is a primary disease of the liver that may cause noncirrhotic portal hypertension. Common causes include autoimmune, hematologic, immune deficiency, and myeloproliferative disorders. Given the limited data regarding the development of NRH in contemporary immunosuppressive protocols and the occurrence of NRH post-liver transplantation, we systematically reviewed NRH as it pertains to liver transplantation. We performed a comprehensive search for NRH and transplantation. Nineteen studies were identified with relevant data for NRH as an indication for a liver transplant. Thirteen studies were identified with relevant data pertaining to NRH development after liver transplant. Pooled analysis revealed 0.9% of liver transplant recipients had NRH. A total of 113 patients identified with NRH underwent liver transplantation. Most series report transplants done after the failure of endoscopic banding and TIPS management of portal hypertension. Reported 5-year graft and patient survival ranged from 73%-78% and 73%-90%. The pooled incidence of NRH after liver transplant for all indications was 2.9% and caused complications of portal hypertension. Complications related to portal hypertension secondary to NRH are a rare indication for a liver transplant. NRH can develop at any time after liver transplantation often without an identifiable cause, which may lead to portal hypertension requiring treatment or even re-transplantation.

OBJECTIVE: Impact of type 2 diabetes mellitus (T2DM) in patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT) remains poorly defined. The objective of the present study is to evaluate the relationship between T2DM and clinical outcomes among patients with LT waitlist registrants. We hypothesize that the presence of T2DM will be associated with worse clinical outcomes.
METHODS: 593 patients adult (age 18 years or older) who were registered for LT between 1/2010 and 1/2017 were included in this retrospective analysis. The impact of T2DM on liver-associated clinical events (LACE), survival, hospitalizations, need for renal replacement therapy, and likelihood of receiving LT were evaluated over a 12-month period. LACE was defined as variceal hemorrhage, hepatic encephalopathy, and ascites. Kaplan-Meier and Cox regression analysis were used to determine the association between T2DM and clinical outcomes.
RESULTS: The baseline prevalence of T2DM was 32% (n = 191) and patients with T2DM were more likely to have esophageal varices (61% vs. 47%, p = 0.002) and history of variceal hemorrhage (23% vs. 16%, p = 0.03). The presence of T2DM was associated with increased risk of incident ascites (HR 1.91, 95% CI 1.11, 3.28, p = 0.019). Patients with T2DM were more likely to require hospitalizations (56% vs. 49%, p = 0.06), hospitalized with portal hypertension-related complications (22% vs. 14%; p = 0.026), and require renal replacement therapy during their hospitalization. Patients with T2DM were less likely to receive a LT (37% vs. 45%; p = 0.03). Regarding MELD labs, patients with T2DM had significantly lower bilirubin at each follow-up; however, no differences in INR and creatinine were noted.
CONCLUSIONS: Patients with T2DM are at increased risk of clinical outcomes. This risk is not captured in MELD score, which may potentially negatively affect their likelihood of receiving LT.

In 2023, Chinese Society of Hepatology of Chinese Medical Association convened a panel of experts to update the Chinese guidelines on the management of ascites and associated complications in cirrhosis which was launched in 2017 and renamed this guidelines as \"Guidelines on the Management of Ascites in Cirrhosis.\" This comprehensive resource offers essential recommendations for the diagnosis and treatment of cirrhotic ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome.

Cirrhotic cardiomyopathy represents a syndrome of cardiac dysfunction associated with advanced liver disease. It is the result of complex pathophysiological processes that complicate the course of the disease, and is generally associated with a poor prognosis. Pathophysiologically, portal hypertension is the key factor leading to hyperdynamic circulation, via over-activation of the neurohumoral axis. Intestinal obstruction, subclinical inflammation and hepatocellular insufficiency, with defective synthesis or metabolism of several vasoactive mediators, are essential components of this process. Since it is usually unapparent at rest and only unmasked by an inadequate cardiac response to hemodynamic stress, the diagnosis of cirrhotic cardiomyopathy is challenging and demands a multimodal approach. There is currently no specific therapy, but there are prognostically effective drugs available to treat heart failure. Therefore, it is crucial to identify patients with chronic liver disease and heart failure in order to ameliorate their outcome. This article attempts to highlight the most important aspects of cirrhotic cardiomyopathy and draws attention to this condition.

OBJECTIVE: To compare the efficacy of endoscopic injection sclerotherapy with N-butyl cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (either transjugular intrahepatic portosystemic shunt (TIPSS) or balloon-occluded retrograde transvenous obliteration (BRTO)) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding (AVB) from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year.
METHODS: Consecutive cirrhosis patients with AVB from cardiofundal varices were randomized into two arms (45 in each) after primary hemostasis by EIS-CYA. In the \'endoscopic intervention\' (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6 and 12 months), while in the \'radiological intervention\' (RI) arm, patients underwent TIPSS or BRTO followed by endoscopic surveillance.
RESULTS: GV rebleed rates at 1 year were higher in the EI arm compared to the RI arm: 11 (24·4%; 95% CI: 12·9%-39·5%) versus 1 (2·2%; 95% CI: 0·1%-11·8%); (p=0·004) [ARD: 22.2% (95% CI: 8.4%-36.6%)]. GV rebleed related mortality in the EI arm [8 (17·8%; 95% CI: 8·0%-32·1%)] was significantly higher than in the RI arm [1 (2·2%; 0·1%-11·8%)] (p=0.030) [ARD: 15.6 (95% CI: 2.9%-29.2%)], however, there was no difference in all-cause mortality between the two groups (12 [26·7%; 95% CI: 14·6 to 41·9] versus 7 [15·6%; 95% CI: 6·5 to 29·5]). Numbers needed to treat (NNT) to prevent one GV-related rebleed at 1 year was 4.5.
CONCLUSIONS: Radiological intervention for secondary prophylaxis reduces rebleeding from gastric varices and GV rebleeding related mortality in patients with gastric variceal hemorrhage. (CTRI/2021/02/031396).

BACKGROUND: Portal hypertension affects hepatic, splanchnic and portosystemic collateral systems. Although alcohol is a well-known risk factor for liver cirrhosis, it also affects vascular contractility. However, the relevant effects on portal hypertension have not been evaluated in non-alcoholic cirrhosis. This study aimed to investigate the impacts of low-dose alcohol on portal hypertension-related derangements in non-alcoholic cirrhotic rats.  Methods: Sprague-Dawley rats received bile duct ligation to induce cirrhosis or sham operation as controls. The chronic or acute effects of low-dose alcohol (2.4 g/kg/day, oral gavage, approximately 1.3 drinks/day in humans) were evaluated.

 Results: The chronic administration of low-dose alcohol did not precipitate liver fibrosis in the sham or cirrhotic rats, however it significantly increased splanchnic blood inflow (P=0.034) and portosystemic collaterals (P=0.001). Mesenteric angiogenesis and pro-angiogenic proteins were upregulated in the alcohol-treated cirrhotic rats, and poorer collateral vasoresponsiveness to vasoconstrictors (P<0.001) was noted. Consistently, acute alcohol administration reduced splenorenal shunt resistance. Collateral vasoresponsiveness to vasoconstrictors also significantly decreased (P=0.003).

 Conclusions: In non-alcoholic cirrhosis rats, a single dose of alcohol adversely affected portosystemic collateral vessels due to vasodilatation. Long-term alcohol use precipitated splanchnic hyperdynamic circulation, in which mesenteric angiogenesis played a role. Further studies are warranted to evaluate the benefits of avoiding low-dose alcohol consumption in patients with non-alcoholic cirrhosis.

To avoid recurrent variceal bleeding, transjugular intrahepatic portosystemic shunt (TIPS) in conjunction with variceal embolization is considered to be an effective strategy. However, due to changes in conditions and variations in the patient\'s state, individuals undergoing TIPS may face challenges and limitations during procedures. The transjugular technique and combined transsplenic portal venous recanalization (PVR) with TIPS were not effective in this case due to a blocked portal vein and a previous splenectomy. With an abdominal incision, we successfully punctured the mesenteric venous system and navigated the occluded segment of the portal vein through the mesenteric approach. TIPS was then performed under balloon guidance. This study aims to explore the management of risks and complications during surgical operations and propose multiple preoperative surgical techniques to improve the success rate of the procedure.

The transjugular intrahepatic portosystemic shunt is a rising interventional procedure with multiple indications and high technical success but with risks of biliary injuries, an underreported scenario. We present an 11-year-old patient with biliary injury with a leak, biloma formation, and biliary obstruction caused by the percutaneous procedure. Interventional radiology drainages addressed these complications by resolving the leak and biloma. These biliary complications in percutaneous procedures and their management are rarely reported in the medical literature, making their management not standard. We highlight drainage management and the importance of sharing it to add experience to this clinical scenario and encourage sharing cases with similar diagnoses.