In Reply to: Case 0498_09 --Hepatic vein occlusion posted by Editor on March 31, 1998 at 14:49:30:
WE HAD AN IDENTICAL CASE WALK IN RECENTLY. SHE WAS THREE MONTHS POSTPARTUM AND SUBSEQUENTLY DIAGNOSED WITH ANTICARDIOLIPIN ANTIBODIES. SHE PRESENTED SIMILARLY, ONLY WE WERE FORTUNATE ENOUGH TO DILATE A LEFT HEPATIC VEIN STENOSIS WITH GOOD CLINICAL AND VENOGRAPHIC RESULT. WE ALSO TREATED HER CONVENIENTLY REPLACED RIGHT HEPATIC ARTERY WITH A UK INFUSION, WHICH DID NOT HAVE ANY DISCERNABLE ARTERIOGRAPHI/VENOGRAPHIC OR CLINICAL IMPACT. (HER IMPROVEMENT WAS LARGELY RELATED TO LEFT HV PTA, WE SUSPECT).
ALTHOUGH THERE IS SOME EVIDENCE OF HEPATOCYTE DYSFUNCTION, IT SOUNDS LIKE HER BX IS COMPATIBLE WITH A CHRONIC PROCESS. ALSO, THERE IS NO MENTION OF NECROSIS, WHICH AT OUR INSTITUTION, MAKES THE HEPATOLOGISTS VERY NERVOUS, WHICH IN TURN, MAKES US MUCH MORE AGGRESSIVE RE: TIPS. I SUSPECT THAT OUR HEPATOLOGISTS WOULD WATCH HER VERY CLOSELY ON ANTICOAGULATION. AT THE FIRST SIGN OF PROGRESSIVE LOVER DYSFUNCTION, SHE WOULD BE OFF TO THE ANGIO SUITE FOR A TIPS.
I DON'T THINK ANYONE HAS DEFINITELY ANSWERED THE QUESTION RE: TIPS VS. SURGICAL SHUNT VS. TRANSPLANTATION. OBVIOUSLY, RARITY OF THE DISEASE MAKES THE NUMBERS ARE SMALL. THE JOHNS HOPKINS SURGERY FOLKS MAKE A COMPELLING ARGUMENT FOR SURGICAL SHUNTING. I WOULD RAISE THE POINT, HOWEVER, THAT IF TRANSPLANTATION DOES BECOME NECESSARY, WOULDN'T PRIOR SHUNT SURGERY MAKE A TRANSPLANT THAT MUCH MORE TECHNICALLY DEMANDING?