Budd-Chiari Syndrome-A Single Center Experience From the United Kingdom.

Pediatric Budd-Chiari syndrome (BCS) is a rare cause of portal hypertension and liver disease in Europe and North America. In order to understand the long-term effect of radiological intervention on BCS we performed a single center retrospective review. Fourteen cases were identified; 6 of 14 (43%) had a congenital thrombophilia with many having multiple prothrombotic mutations. Two were managed with medical anticoagulation alone and two required super-urgent transplant for acute liver failure. The remaining 10 of 14 (71%) underwent radiological intervention: 1 of 14 thrombolysis, 5 of 14 angioplasty, and 4 of 14 transjugular intrahepatic portosystemic shunt (TIPS). Six of 14 (43%) patients required repeat radiological intervention (1 angioplasty, 5 TIPS) but none required surgical shunts or liver transplantation for chronic liver disease. The time between diagnosis and treatment did not predict the need for repeat radiological intervention. These data show that radiological intervention can be highly effective, and reduces the need for surgery, though it requires specialist multidisciplinary teams for monitoring.

Utility and cost evaluation of multiparametric magnetic resonance imaging for the assessment of non-alcoholic fatty liver disease.

BACKGROUND: Validated diagnostic tools that are accurate, cost effective and acceptable to patients are required for disease stratification and monitoring in NAFLD. AIMS: To investigate the performance and cost of multiparametric MRI alongside existing biomarkers in the assessment of NAFLD. METHODS: Adult patients undergoing standard of care liver biopsy for NAFLD were prospectively recruited at two UK liver centres and underwent multiparametric MRI, blood sampling and transient elastography withing 2 weeks of liver biopsy. Non-invasive markers were compared to histology as the gold standard. RESULTS: Data were obtained in 50 patients and 6 healthy volunteers. Corrected T1 (cT1) correlated with NAFLD activity score (ρ = 0.514, P < .001). cT1, enhanced liver fibrosis (ELF) test and liver stiffness differentiated patients with simple steatosis and NASH with AUROC (95% CI) of 0.69 (0.50-0.88), 0.87 (0.77-0.79) and 0.82 (0.70-0.94) respectively and healthy volunteers from patients with AUROC (95% CI) of 0.93 (0.86-1.00), 0.81 (0.69-0.92) and 0.89 (0.77-1.00) respectively. For the risk stratification of NAFLD, multiparametric MRI could save £150,218 per 1000 patients compared to biopsy. Multiparametric MRI did not discriminate between individual histological fibrosis stages in this population (P = .068). CONCLUSIONS: Multiparametric MRI accurately identified patients with steatosis, stratifies those with NASH or simple steatosis and reliably excludes clinically significant liver disease with superior negative predictive value (83.3%) to liver stiffness (42.9%) and ELF (57.1%). For the risk stratification of NAFLD, multiparametric MRI was cost effective and, combined with transient elastography, had the lowest cost per correct diagnosis.

Emergency treatment of haemorrhaging coeliac or mesenteric artery aneurysms and pseudoaneurysms in the era of endovascular management.

OBJECTIVES: Patients requiring emergency treatment of visceral artery aneurysms (VAAs) can be treated by endovascular or surgical techniques. Outcomes after failed attempts at endovascular control are unclear as is the present role of surgery. This study reviewed treatment and outcomes of a contemporary cohort of patients with symptomatic VAAs at a tertiary referral centre. METHODS: Patients undergoing emergency treatment of a VAA of the coeliac, mesenteric arteries, or their branches were identified over a 5-year period. Patient variables, treatments, and outcomes were assessed. RESULTS: Forty-eight patients underwent 65 radiological and two surgical procedures. Pseuodaneuryms were present in 45 (94%) of patients. Interventional radiology procedures were the initial treatment in every patient. The initial success was 40 out of 48 (83%). Patients requiring more than one procedure were all successfully treated. Regarding initial failures, if the VAA sac could not be accessed at angiography an alternative procedure to control the VAA was required in every case. If initial endovascular treatment failed, repeating the same procedure was successful in half of the patients. Ultrasound-guided percutaneous VAA embolisation was used in four patients. The 30-day mortality was eight out of 48 (17%). There were four recorded complications including one death directly attributable to VAA treatment. CONCLUSIONS: Patients needing emergency treatment of a VAA could be well served by non-surgical management. When the initial attempt at control of bleeding is unsuccessful it is important to consider non-conventional means of accessing these arteries. The need for surgery, in selected centres, may exist for a small group of patients after initial failed radiological treatment only.

Good clinical outcomes following transjugular intrahepatic portosystemic stent-shunts in Budd-Chiari syndrome.

BACKGROUND: There have been encouraging reports on transjugular intrahepatic portosystemic stent-shunt (TIPSS) for Budd-Chiari syndrome (BCS). Long-term data are lacking. AIM: To assess long-term outcomes and validate prognostic scores following TIPSS for BCS. METHODS: A single centre retrospective study. Patients underwent TIPSS using bare or polytertrafluoroethane (PTFE)-covered stents. RESULTS: Sixty-seven patients received successful TIPSS between 1996 and 2012 using covered (n = 40) or bare (n = 27) stents. Patients included had a Male: Female ratio of 21:46, and were characterised (mean ± s.d.) by age 39.9 ± 14.3 years, Model of end stage liver disease (MELD) 16.1 ± 7.0 and Child's score 8.8 ± 2.0. Seventy-eight percent had haematological risk factors. Presenting symptoms were ascites (n = 61) and variceal bleeding (n = 6). Nine patients underwent hepatic vein dilatation or stenting prior to TIPSS. Mean follow-up was 82 months (range 0.5-184 months). Fifteen percent had post-TIPSS encephalopathy. Two have been transplanted. Primary patency rates (76% vs. 27%, P < 0.001) and shunt re-interventions (22% vs. 100%, P < 0.001) significantly favoured covered stents. Secondary patency was 99%. Six-, 12-, 24-, 60- and 120-month survival was 97%, 92%, 87%, 80% and 72% respectively. Six patients had liver related deaths. Two patients developed hepatocellular carcinoma. The BCS TIPS PI independently predicted mortality in the whole cohort, but no prognostic score was a significant predictor of mortality after subgroup validation. CONCLUSIONS: Long-term outcomes following TIPSS for Budd-Chiari syndrome are very good. PTFE-covered stents have significantly better primary patency. The value of prognostic scores is controversial. TIPSS should be considered as first line therapy in symptomatic patients in whom hepatic vein patency cannot be restored.

Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study.

OBJECTIVE: To evaluate mildly abnormal liver function test (LFT) results in general practice among patients who do not have known liver disease. DESIGN: Prospective cohort study of people with abnormal LFT results identified in primary care. Participants were intensively investigated using a common protocol and followed up for 2 years. Substudies investigated the psychological sequelae of abnormal test results, clinicians' reasons for testing, decision options when LFT results were abnormal and early detection of liver fibrosis. SETTING: Eleven primary-care practices: eight in Birmingham and three in Lambeth. PARTICIPANTS: Adults with abnormal LFT results who did not have pre-existing or obvious liver disease. Eight analytes were included in the panel of LFTs. MAIN OUTCOME MEASURES: Statistical tests were used to identify the interactions between clinical features, the initial pattern of abnormal LFT results and (1) specific viral, genetic and autoimmune diseases, such as viral hepatitis, haemochromatosis and primary biliary cirrhosis; (2) a range of other serious diseases, such as metastatic cancer and hypothyroidism; (3) 'fatty liver' not associated with the above; and (4) the absence of detectable disease. RESULTS: Fewer than 5% of people with abnormal LFT results had a specific disease of the liver, and many of these were unlikely to need treatment. The diagnostic potential of the LFT panel is largely subsumed into just two analytes: alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Gamma-glutamyltransferase (GGT) offers a small increase in sensitivity at the margin at the cost of a large loss of specificity. Eighty-four per cent of abnormal LFT results remain abnormal on retesting 1 month later. In many cases, carrying out a definitive or specific test will be more efficient than repeating LFTs, with a view to specific testing only if the test remains abnormal. An ultrasound diagnosis of 'fatty liver' was present in nearly 40% of patients with abnormal LFTs and a small amount of weight loss over 2 years was associated with a reduced incidence of liver fat. There was a J-shaped relationship between alcohol intake and fatty liver in men. An abnormal LFT result causes temporary anxiety, which does not appear to promote sustained behaviour change. CONCLUSIONS: Liver disease is rare among people with abnormal LFT results in primary care. Only two analytes (ALT and ALP) are helpful in identifying the majority of liver disease. GGT adds little information in return for a high false-positive rate but it is sensitive to alcohol intake. LFT results seldom revert from abnormal to normal over a 1-month period, and modelling shows that repeating an abnormal LFT panel, as recommended in the current guidelines, is inefficient. LFTs are often undertaken to meet perceived patient need for a blood test, but as they are neither specific nor indicative of any particular disease they are among the least suitable tests for this purpose. Obesity and raised ALT provide strong evidence for a presumptive diagnosis of 'fatty' liver. Abnormal LFTs and 'fatty' liver provoke only short-term anxiety and neither is associated with sustained weight loss. Even a small amount of weight loss reduces liver fat. FUTURE WORK RECOMMENDATIONS: (1) the cases of 'fatty liver' and controls should be followed up in the long term to identify features that predict development of hepatosteatosis and then cirrhosis; (2) the acceptability of replacing the traditional six- to eight-analyte LFT panel with a drop down menu including the ALT/ALP combination should be evaluated. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Cholangiocarcinoma complicating primary sclerosing cholangitis: a 24-year experience.

AIM: To report the prevalence and outcome of cholangiocarcinoma arising in primary sclerosing cholangitis for a British tertiary referral centre. METHODS: All patients diagnosed with primary sclerosing cholangitis and concurrent cholangiocarcinoma were identified from a prospectively maintained departmental database, and the mode of presentation, management and outcome were determined. RESULTS: Of 370 patients with primary sclerosing cholangitis, 48 patients (13%) were diagnosed with a cholangiocarcinoma within a median time of 0.51 months (range: 0-73.12) from presentation to the unit. Mode of presentation included: inoperable tumours (n = 14); incidental findings in transplant hepatectomy specimens (n = 13); primary sclerosing cholangitis follow-up (n = 9); transplant work-up (n = 5); transplant waiting list (n = 5); suspected tumour confirmed at transplant (n = 1), and incidental finding at cholecystectomy (n = 1). The diagnosis was confirmed by: radiology-guided biopsy (n = 27); MRI (n = 3); CT (n = 2); laparoscopy or laparotomy (n = 2), and frozen section at transplant (n = 1). Management consisted of: transplantation (n = 14, including 1 abandoned); hepatic resection (n = 8), and palliation through stenting (n = 26). The overall median survival of the cohort was 4.9 months (range: 0.09-104.5). Median survival ranged from 2.6 months (range: 0.09-35.3) for palliation to 7.6 months (range: 0.6-99.6) for transplantation and 52.8 months (range: 3.7-104.5) for resection. There was no difference in survival between the transplant and resection groups (p = 0.14). CONCLUSIONS: Cholangiocarcinoma is a common finding in primary sclerosing cholangitis and regular screening of this cohort of patients at referring centres is advocated to detect early tumours, as surgical treatment at an early stage offers significantly better outcomes for this cohort of patients.

Post-transplant lymphoproliferative disease in liver transplantation.

Post-transplant lymphoproliferative disease (PTLD) is a well recognized complication of solid organ transplantation and therapeutic immunosuppression, first reported in 1968. PTLD incorporates a spectrum of abnormalities ranging from a benign infectious mononucleosis-like illness to non-Hodgkin's lymphoma with nodal and extranodal site involvement. The first liver transplant was performed at our institution in January 1982. This retrospective study examined the incidence of PTLD, reason for the original transplants, presenting symptoms, radiological findings, immunosuppression regimens and outcomes of these patients. From a total of 2005 adult liver transplants, 23 patients (1.1%) were identified with PTLD. The average age of these patients at the time of transplant was 46.5 years, with a ratio of female-to-male of 14:9. Indication for transplant ranged from primary biliary cirrhosis (eight patients) to epitheloid haemangioendothelioma (one patient). The average time interval between transplant and diagnosis of PTLD was 50 months. Imaging abnormalities identified included generalized lymphadenopathy, liver and portal masses, splenic enlargement, bowel, eye, cerebral and neck involvement; and in two patients, no radiological abnormality. The most common histological findings ranged from B-cell non-Hodgkin's lymphoma (five patients) to early PTLD in one patient. Our rate of PTLD is lower compared with published literature and demonstrates a much longer time interval from transplant to occurrence of PTLD than previously appreciated. This could be secondary to a low immunosuppression therapy followed at our institution. From a few months to several years after liver transplantation, the radiologist needs to be alert to the possibility of PTLD and thorough imaging is required to detect the wide variety of potential presentations.

Primary hepatocellular cancer in the explanted liver: outcome of transplantation and risk factors for HCC recurrence.

AIM: To evaluate the risk of recurrence of hepatocellular cancer (HCC) after liver transplantation (LT). METHODS: The clinical records of 104 patients with HCC in the explanted liver were examined. RESULTS: HCC recurrence occurred in 12 patients. Recurrence was observed in all patients with a single nodule greater than 5 cm. Among the 5 patients with more than 3 tumours with a maximum diameter of 4.5 cm, no recurrence occurred. The survival rates were 81% and 64% at 1 and 5 years, respectively; the recurrence-free survival at 1 and 5 years was, respectively, 93% and 82%. Pre-LT alpha-fetoprotein (AFP) increased at a greater magnitude in patients who experienced recurrence, compared to those who did not. Tumour diameter, differentiation, satellitosis, AFP and the magnitude of AFP increase were predictive of recurrence. The 1- and 5-year recurrence-free survival for the 68 patients who had a single nodule up to 5 cm, or up to 3 nodules all less than 4.5 cm and with a maximum cumulative diameter of 8 cm, or more than 3 nodules all less than 2.5 cm, were 95% and 92%, respectively. For the 13 patients not meeting these criteria, the 1- and 5-year recurrence-free survival was, respectively, 75% and 54% (log Rank test p=0.019). CONCLUSIONS: Patients with more than 3 small HCC nodules before LT could still have a good outcome without recurrence. A rapid increase in AFP could be useful in identifying patients with a greater risk of post-LT HCC recurrence.

Favourable medium term outcome following hepatic vein recanalisation and/or transjugular intrahepatic portosystemic shunt for Budd Chiari syndrome.

BACKGROUND: We report our experience with management of patients with Budd Chiari syndrome over the past two decades. In 1996 we described a novel approach involving recanalisation of hepatic veins by combined percutaneous and transvenous approaches. This was incorporated into an algorithm published in 1999 in which our preferred treatment for all cases of Budd Chiari syndrome with short segment occlusion or stenosis of the hepatic veins involves recanalisation of the hepatic veins by transvenous or combined percutaneous-transvenous approaches. In symptomatic Budd Chiari syndrome where recanalisation is not possible, we perform transjugular intrahepatic portosystemic shunts (TIPS) because TIPS decompresses the portal circulation directly in an adjustable way. In this series of patients with Budd Chiari syndrome treated with radiological interventions alone, we assess their medium term outcome using two independent objective prognostic indices. METHODS: We retrospectively studied 61 patients with non-malignant Budd Chiari syndrome treated by radiological intervention alone in our centre. RESULTS: Actuarial survival for the entire cohort at one year and five years was 94% and 87%, respectively. Survival of our patients with mild disease (according to the Murad classification) was 100% at one year and at five years, with intermediate disease severity 94% at one year and 86% at five years, and with severe disease 85% at one year and 77% at five years. CONCLUSION: Management of Budd Chiari syndrome by interventional radiology resulted in excellent medium term survival for patients in all categories of disease severity.

Role of surgical portosystemic shunts in the era of interventional radiology and liver transplantation.

BACKGROUND: In the present era of liver transplantation and transjugular intrahepatic portosystemic shunts, the role and choice of shunt surgery for portal hypertension was reviewed. METHODS: This retrospective study analysed the management of patients with portal hypertension in a tertiary liver transplant unit between June 1993 and May 2002. During this 9-year interval, 394 patients underwent endoscopic control of varices, 235 transjugular intrahepatic portosystemic shunts were inserted, 1142 liver transplants were performed, while only 29 patients needed a surgical portosystemic shunt. RESULTS: Twenty-nine shunt operations were performed in nine patients with cirrhosis, one patient with congenital hepatic fibrosis and 19 without parenchymal liver disease. There were 12 side-to-side lienorenal, nine mesocaval, three proximal lienorenal, two distal lienorenal, two portacaval and one mesoportal shunts. Encephalopathy was seen in five of 11 patients with a non-selective shunt, but did not occur after side-to-side or selective lienorenal shunt procedures. At a median follow-up of 42.5 months, one mesocaval shunt had thrombosed and one portacaval shunt had stenosed; both were successfully managed by percutaneous intervention. To date, six patients have died; two succumbed to postoperative complications, one of which was related to the shunt. CONCLUSION: Patients with Budd-Chiari syndrome and cirrhosis can nearly always be managed by a combination of endoscopy, interventional radiology and liver transplantation. In the rare instances when these therapies fail in patients with cirrhosis, a side-to-side lienorenal shunt is a good option.

Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome.

BACKGROUND: Portal vein thrombosis (PVT) has been seen as an obstacle to liver transplantation (LTx). Recent data suggest that favorable results may be achieved in this group of patients but only limited information from small size series is available. The present study was conducted in an effort to review the surgical options in patients with PVT and to assess the impact of PVT on LTx outcome. Risk factors for PVT and the value of screening tools are also analyzed. METHODS: Adult LTx performed from 1987 through 1996 were reviewed. PVT was retrospectively graded according to the operative findings: grade 1: <50% PVT +/- minimal obstruction of the superior mesenteric vein (SMV); grade 2: grade 1 but >50% PVT; grade 3: complete PV and proximal SMV thrombosis; grade 4: complete PV and entire SMV thrombosis. RESULTS: Of 779 LTx, 63 had operatively confirmed PVT (8.1%): 24 had grade 1, 23 grade 2, 6 grade 3, and 10 grade 4 PVT. Being male, treatment for portal hypertension, Child-Pugh class C, and alcoholic liver disease were associated with PVT. Sensitivity of ultrasound (US) in detecting PVT increased with PVT grade and was 100% in grades 3-4. In patients with US-diagnosed PVT, an angiogram was performed and ruled out a false positive US diagnosis in 13%. In contrast with US, angiograms differentiated grade 1 from grade 2, and grade 3 from grade 4 PVT. Grade 1 and 2 PVT were managed by low dissection and/or a thrombectomy; in grade 3 the distal SMV was directly used as an inflow vessel, usually through an interposition donor iliac vein; in grade 4 a splanchnic tributary was used or a thrombectomy was attempted. Transfusion requirements in PVT patients (10 U) were higher than in non-PVT patients (5 U) (P<0.01). In-hospital mortality for PVT patients was 30% versus 12.4% in controls (P<0.01). Patients with PVT had more postoperative complications, renal failure, primary nonfunction, and PV rethrombosis. The overall actuarial 5-year patient survival rate in PVT patients (65.6%) was lower than in controls (76.3%; P=0.04). Patients with grade 1 PVT, however, had a 5-year survival rate (86%) identical to that of controls, whereas patients with grades 2, 3, and 4 PVT had reduced survival rates. The 5-year patient survival rate improved from the 1st to the 2nd era in non-PVT patients (from 72% to 83%; P<0.01), in grade 1 PVT (from 53% to 100%; P<0.01), and in grades 2 to 4 PVT (from 38% to 62%; P=0.11). CONCLUSIONS: The value of US diagnosis in patients with PVT depends on the PVT grade, and false negative diagnoses occur only in incomplete forms of PVT (grades 1-2). The degree of PVT dictates the surgical strategy to be used, thrombectomy/low dissection in grade 1-2, mesoportal jump graft in grade 3, and a splanchnic tributary in grade 4. Taken altogether, PVT patients undergo more difficult surgery, have more postoperative complications, have higher in-hospital mortality rates, and have reduced 5-year survival rates. Analysis by PVT grade, however, reveals that grade 1 PVT patients do as well as controls; only grades 2 to 4 PVT patients have poorer outcomes. With increased experience, results of LTx in PVT patients have improved and, even in severe forms of PVT, a 5-year survival rate >60% can now be achieved.

Percutaneous portal vein thrombolysis and endovascular stent for management of posttransplant portal venous conduit thrombosis.

BACKGROUND: Thrombosis of a portal vein conduit after liver transplant is an uncommon clinical situation. Percutaneous thrombolytic therapy for this condition has not been widely described. METHODS: We describe a case of thrombosis of a portal vein (PV) conduit subsequent to orthotopic liver transplantation that was successfully treated by percutaneous portal vein thrombolysis by using tissue plasminogen activator, angioplasty, and endovascular stent placement. RESULTS: A satisfactory outcome was achieved with a patent portal vein, on ultrasound, at 8-month follow-up. CONCLUSION: A percutaneous transhepatic approach to treatment of thrombosis of a portal vein conduit appears to be a promising technique to use to avoid surgery, with good medium-term results.

Managing Budd-Chiari syndrome: a retrospective review of percutaneous hepatic vein angioplasty and surgical shunting.

BACKGROUND: The role of percutaneous hepatic vein angioplasty in the management of Budd-Chiari syndrome has not been well defined. Over a 10 year period at our unit, we have often used this technique in cases of short length hepatic vein stenosis or occlusion, reserving surgical mesocaval shunting for cases of diffuse hepatic vein occlusion or failed angioplasty. AIMS: To review the outcome of angioplasty and surgical shunting to define their respective roles. PATIENTS: All patients treated by angioplasty or surgical shunting for non-malignant hepatic vein obstruction over a ten year period from 1987 to 1996. METHODS: A case note review of pretreatment features and clinical outcome. RESULTS: Angioplasty was attempted in 21 patients with patent hepatic vein branches and was successful in 18; in three patients treatment was unsuccessful and these patients had surgical shunts. Fifteen patients were treated by surgical shunting only. Mortality according to definitive treatment was 3/18 following angioplasty and 8/18 following surgery; in most cases this reflected high risk status prior to treatment. Venous or shunt reocclusion rates were similar for both groups and were associated with subtherapeutic warfarin in half of these cases. Most surviving patients in both groups are asymptomatic although one surgical patient has chronic hepatic encephalopathy. CONCLUSION: With appropriate case selection, many patients with Budd-Chiari syndrome caused by short length hepatic vein stenosis or occlusion may be managed successfully by angioplasty alone. Medium term outcome is good following this procedure provided that anticoagulation is maintained. Further follow up is required to assess for definitive benefits but we suggest that this should be included as a valid initial approach in the algorithm for management of Budd-Chiari syndrome.

A novel dosage approach for evaluation of SMANCS [poly-(styrene-co-maleyl-half-n-butylate) - neocarzinostatin] in the treatment of primary hepatocellular carcinoma.

We report a Phase I/II clinical trial of poly-(styrene-co-maleyl-half-n-butylate)-neocarzinostatin (SMANCS) for intra-arterial treatment of hepatoma. Early patients received 4 or 8 mg SMANCS dissolved in Lipiodol; later patients were treated according to tumour size and degree of filling achieved. SMANCS/Lipiodol drained rapidly from normal liver but was retained within tumour interstitium. Tumour nodules filled with SMANCS/Lipiodol usually stabilised and often regressed. No UICC criteria-defined responses were achieved, partly due to difficulties of filling several lesions simultaneously. Signs of therapeutic activity suggest a more extensive clinical study is warranted.

The presence and significance of lymphadenopathy detected by CT in primary sclerosing cholangitis.

Patients with primary sclerosing cholangitis (PSC) are at increased risk of developing cholangiocarcinoma, which adversely affects their survival especially after orthotopic liver transplantation. All CT scans of patients with PSC referred to the Liver Unit at the Queen Elizabeth Hospital since 1992 were reviewed. The location of any lymph node with a short axis diameter greater than normal was documented. The incidence of lymphadenopathy and cholangiocarcinoma was also documented. 36 scans are reviewed, including eight with cholangiocarcinoma as well as PSC. Abdominal lymphadenopathy was present in 26 cases (66%) and 45 separate lymph node groups were involved in these patients. There were eight cases of cholangiocarcinoma; five were detectable on CT, but only four had significant lymphadenopathy. The remaining three cases of cholangiocarcinoma were not detectable on CT and only one of these had lymphadenopathy. Follow-up of the remaining patients has not demonstrated the development of cholangiocarcinoma. Lymphadenopathy is commonly demonstrated by CT in PSC patients, but does not imply malignancy and should not exclude a patient from undergoing liver transplantation. Conversely cholangiocarcinoma may develop without significant lymphadenopathy.

Obstructive sleep apnoea syndrome (OSAS) as a complication of carcinoid syndrome treated successfully by hepatic artery embolization.

Obstructive sleep apnoea syndrome (OSAS) appears to be an extremely rare complication of carcinoid syndrome and has not yet been reported in the literature. We describe a 75-year-old patient with a history of bronchial carcinoid who besides typical carcinoid syndrome symptoms developed sleep disturbance and day lethargy caused by massive facial and nasal tissue oedema. Sleep apnoea was confirmed by sleep study. Abdominal ultrasound and computed tomography (CT) scan showed the presence of multiple liver metastases. Because the patient did not respond to octreotide therapy, embolization of the hepatic artery was performed. After this procedure we observed dramatic improvement of the patient's life quality, and rapid disappearance of facial swelling and sleep apnoea symptoms. We conclude that hepatic artery embolization appeared to be an effective method of abolishing obstructive sleep apnoea associated with carcinoid syndrome.

Radiological intervention in Budd-Chiari syndrome: techniques and outcome in 18 patients.

We reviewed our experience of the therapeutic role of radiology in Budd-Chiari syndrome. Patients with stenosis and/or occlusion of the main hepatic veins and/or inferior vena cava (IVC) are suitable for radiological intervention (35% in our series). Eighteen patients (mean age 37.4 years) have undergone radiological intervention over the past 8 years. The site of obstruction was the hepatic veins in 12/18 patients while 6/18 patients had both hepatic vein and IVC obstruction, which in two was due to tumour thrombus. One patient had repeated dilatations of a mesocaval shunt; 49 angiographic venous dilatations were performed (18 during initial intervention, 31 on review) including 10 recanalizations of occlusions. A combined transhepatic-transjugular approach was used for 10/49 procedures. Thrombolysis was performed in 5/18 and stent insertion in 6/18 patients. Three serious complications occurred (IVC stent migration, hepatic artery pseudoaneurysm, myocardial puncture). Follow-up, after initial intervention, has continued for a mean of 24.2 months (range 4 days-92 months). Symptoms related to hepatic venous outflow obstruction were fully relieved in 10/18 (56%) patients and partially relieved in 4/18 (22%) patients. Close monitoring (and re-intervention) during the early post-intervention period is needed because 28% of initial venous dilatations failed to provide adequate venous return in the first instance. Once the patient is stabilized regular review is mandatory as HV restenosis is common after 10 months or more follow-up. The efficacy and safety of radiological intervention make it the preferred first line of treatment in selected patients with Budd-Chiari syndrome.

Case report: paravesical suture granuloma resembling bladder carcinoma on CT scanning.

Paravesical granuloma formation is a rare complication of inguinal herniorrhaphy. Infected non-absorbable suture material is the usual cause. We present a case of paravesical granuloma that was initially thought to be bladder carcinoma both clinically and on CT scanning. The patient presented with urinary symptoms. Repeated biopsies revealed only reactive changes with no evidence of malignancy. CT showed a mass which appeared to arise from the anterior aspect of the bladder with a central area of low attenuation. The diagnosis was established at cystoscopy with deep resection of the mass, when two retained silk stitches with surrounding pus and granulation tissue was found. The diagnosis of paravesical suture granuloma (PSG) should be considered in patients with suprapubic symptoms, no haematuria, an atypical mass and a history of herniorrhaphy, which may have been many years prior to the time of presentation.