Non-cirrhotic intrahepatic portal hypertension (NCIPH), also called idiopathic or
benign, may lead to life-threatening complications. It is a rare indication for orthotopic
liver transplantation (OLTx), although it may remain underdiagnosed. Overt symptoms
of portal hypertension, predominantly variceal bleedings, misleadingly suggest that
these patients are cirrhotic. Non-cirrhotic intrahepatic portal hypertension can be
related to obliteration of portal venous microcirculation as a consequence of ADAMTS13
deficiency, a metalloproteinase which cleaves the ultra-large molecular weight forms
of von Willebrand factor (VWF). The physiological role of VWF, secreted from endothelium,
is to facilitate platelet adhesion at sites of endothelial damage. Decreased ADAMTS13
activity and persistence of ultra-large VWF at the endothelial surface predisposes
to platelet clumping, causing microvascular occlusion. We describe the first OLTx
for ADAMTS13 deficiency-related NCIPH in Poland.
A 20-year-old, previously healthy male student presented with upper gastrointestinal
bleeding. Gastroduodenoscopy revealed active bleeding from oesophageal varices, which
was successfully treated with endoscopic banding ligation. Physical examination showed
splenomegaly, but was otherwise normal with no signs suggesting chronic liver disease.
Laboratory investigations were all normal except thrombocytopenia of 40,000/ml. Viral,
metabolic, and autoimmunological markers of liver disease as well as bone marrow examination
were normal. Transjugular liver biopsy was performed and was essentially normal. However,
the tissue sample size was rather slight and we were not able to measure hepatic venous
pressure gradient (HVPG). Percutaneous liver biopsy performed later confirmed these
findings. Contrast enhanced magnetic resonance imaging scan excluded portal vein thrombosis
and Budd-Chiari syndrome. Laboratory investigations showed undetectable levels of
ADAMTS13. The patient has been followed up over a period of 5 years, showing constant
progression of his portal hypertension with continuous enlargement of his spleen (Figures
1 and 2) and frequent oesophageal/gastric variceal treatments. Follow-up liver biopsy
showed progression to F2 fibrosis. He underwent OLTx with rapid recovery and remains
extremely well 6 months after surgery. The histological changes in the explanted liver
are shown in Figures 3 A–C.
Figure 1
Magnetic resonance imaging of portal hypertension
Figure 2
Computed tomography images of the liver hypotrophy and spleen enlargement
Figure 3
Histopathology of the explanted liver: A – Liver fibrosis with inflammatory infiltrates.
Neocholangioles, small venules, and lack of correct arterioles. Haematoxylin and eosin
stain (H + E). Objective magnification 10×. B – Thick irregular vessels with narrowed
lumen in liver hilus. Haematoxylin and eosin stain (H + E). Objective magnification
4×. C – Venulitis, haemorrhages. Haematoxylin and eosin stain (H + E). Objective magnification
20×
Non-cirrhotic intrahepatic portal hypertension secondary to ADAMTS13 deficiency is
a progressive condition and in case of uncontrolled symptoms of portal hypertension
may require liver transplantation. Non-cirrhotic intrahepatic portal hypertension
is also called idiopathic or benign portal hypertension. The latter term is misleading
as it was shown that more than half of these patients develop liver failure when observed
over a median period of 88 months [1]. Thus NCIPH is considered a rare but clinically
important cause of portal hypertension. The underlying problem is related to the obliteration
of portal venous microcirculation, secondary to the deficiency of ADAMTS13, a metalloproteinase
that cleaves the ultra-large molecular weight forms of VWF to smaller ones [2]. The
physiological role of VWF, secreted from endothelium, is to facilitate platelet adhesion
at sites of endothelial damage. Mutations of ADAMTS13 are seen in congenital TTP,
while antibodies to ADAMTS13 are found in the majority of adult acquired cases. Decreased
ADAMTS13 activity and persistence of ultra-large VWF at the endothelial surface is
thought to predispose to platelet clumping, causing microvascular occlusion. The imbalance
in VWF and ADAMTS13 levels in portal microcirculation, where hepatic arterial blood
pressures are superimposed, with upstream relation to hepatic stellate cells, would
provide a mechanism for obliteration of terminal portal venules, which is characteristic
of NCIPH. In our patient plasma activity of ADAMTS13 was below 1%, and its inhibitor
was within the normal ranges. He has been treated with β-blockers and remains clinically
stable with appropriate endoscopic surveillance. However, in sequential MRI and computed
tomography imagines, atrophy of the right lobe of the liver has been observed, with
enlargement of the left lobe, periportal fibrosis, varices, and dilatation of the
portal tract veins. Chronic NCIPH leads to hepatic atrophy, although the progression
of the disease is usually slow. The disorder can be associated with celiac disease
and ulcerative colitis, and sustained deficiency of ADAMTS13 appears characteristic
of NCIPH despite preserved liver function [1]. Older age at first presentation, hepatic
encephalopathy, and portal vein thrombosis were found to be significant predictors
of reduced transplant-free survival with, as already mentioned, progression to decompensated
liver disease and the need for liver transplantation in a significant proportion of
patients [1].