الفهرس 
Introduction and aims of the work
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Abstract
Portosystemic collateral vessels (PSCVs) are a consequence of the portal hypertension that occurs in patients with chronic liver diseases, and are responsible for numerous disease complications, including bleeding esophageal and gastric varices and hepatic encephalopathy.The portosystemic collateral circulation can be classified into uncommon collateral circulation (UCC) and common collateral circulation (CCC). The CCC has been studied for a long time, and includes both the esophageal and gastric varices, abdominal and umbilical vein dilation, and hemorrhoidal vein dilation. However, to our knowledge, the UCC, including splenorenal, gastric-renal, retroperitoneal, and cardiac angle venous shunts, were not well described in literature so far.So, our aims were to study the significance of PSCVs in relation to the presence, site, and grade of varices, function of the liver (Child-Pugh-Turcotte score and MELD score), portal pressure as measured by HVPG and also to describe and classify the sites and shapes of PSCVs and classify the splenic collaterals “The Assiut Classification of Splenic Collaterals; ACSC”.In this descriptive and analytical study, a total of one hundred from the outpatient clinic and the inpatient wards of the Department of Tropical Medicine and Gastroenterology at Assiut University and Al-Rajhi University Liver Hospitals were enrolled according to the inclusion criteria. Fifty cases were cirrhotics with collaterals and the other fifty cases were cirrhotics without collaterals. We included patients with liver cirrhosis, portal hypertension and splenomegaly and excluded those with any previous attack of upper GIT bleeding, previous band ligation or sclerotherapy, patients on current or past treatment with beta-blockers, patients with impaired renal function, and those who refused to participate.
All patients were subjected to detailed medical history, complete clinical examination, and and abdominal ultrasound examination (for screening for the presence of collaterals). Blood samples were tested for complete blood count, liver function tests, renal profile, international normalization ratio (INR) The patients’ liver disease severity were classified according to their Child-Pugh grading and MELD score.Abdominal helical CT scans were carried out on using a General Electric16-slice CT. Scanning protocol consisted of an initial non-contrast study to identify the liver location and subsequently, 120 mL of nonionic water soluble contrast material (Ultravest) was injected through a pressure injector at the rate of 3 mL/second. Arterial phase images initiated 30 second after initiation of contrast material injection. Portovenous phase images were acquired 70 seconds after initiation of contrast injection and finally an equilibrium phase was acquired 180 seconds after initiation of contrast injection. Source images were transferred to the vendor workstation for reconstruction of 3-D images using maximum intensity projection and volume-rendering algorithmsUpper endoscopy and colonoscopy were carried out by a single endoscopist at the same endoscopy unit on a Pentax type gastroscope and colonoscope, and if esophageal varices were present, their size was graded as I-IV, using the Paquet Grading System. HVPG measurement was done for ten patients after an overnight fast, under conscious sedation, and monitoring for vital signs. Briefly, under local anesthesia and aseptic conditions, a venous introducer was placed in the femoral vein using then Seldinger technique. With the introducer in place, a 7-French balloon tipped catheter (Swan-Ganz, CORODYNTM P1F7, B.Braun Melsungen, Poland) was advanced through it under fluoroscopic guidance and hooked into a hepatic vein. The FHVP was measured by keeping the tip of the catheter ‘free’ in the hepatic vein, and the WHVP was measured after inflating the catheter balloon. This study showed that there were statistically significant difference between the mean Child and MELD score as p value were .000 and 0.50 respectively. The mean number of recurrent hepatic encephalopathy episodes or attacks over the last six months in the studied patients was 3.87±2.28, with a highly statistically significant difference between patients with and those without collaterals (P<0.001). There was also a highly statistically significant difference (p<0.001) in both upper endoscopy and colonoscopy as no varices in 42% of cirrhotic patients with collaterals. Advanced esophageal varices (OVIII-IV) was detected in 36% of patient without collaterals, and in only 10% of those with collaterals. In addition, combined esophageal and gastric varices were found in 20% of cirrhotic patients without collaterals, and in only 6% of patients with collaterals. Indeed, 80% of patients with collaterals had no piles while only 55% of the cirrhotic patients without collaterals had no piles. There was a highly statistically significant difference in mean portal vein (PV) diameter between patient with and without collaterals (p<0.001). The PV was dilated in 74% and 48% of the cirrhotic patients with collaterals and those without collaterals respectively. Only 8% of the patients with PSCVs showed a thrombosed PV, but none of those without collateral had a thrombosed PV. HCC was associated with development of collateral in 88.2% and only 11.8% of HCC patients had no collaterals.This study demonstrated that 94% of the cirrhotic patients with collaterals had splenic collateral (84% isolated splenic and 12% splenic with other collaterals such as ovarian varices, periportal, retropubic, and recanalised paraumblical vein, and/or urinary bladder varices). Isolated lienogastric and periportal were present in about 6% of patients.
The splenic collaterals were classified (ACSC) as hilar in 29.8%, in the lower pole of spleen in 25.5%, and it was combined hilar, upper, and lower pole in only 6.4%. Also, the splenic collaterals were grape-like in 44.7%, serpiginous in 40.4%, and worm-like in 14.9% of cases.
The mean splenic size longest diameter in the studied patients was 14.74±2.06 cm with no statistically significant difference between patients with and without collaterals as (p=0.788).We conclude from this study that:
Presence of PSCVs is a good indicator of the presence and severity of gastroesophageal varices, piles, and the recurrence of hepatic encephalopathy in patients with cirrhosis and portal hypertension.
Splenorenal collaterals are the most common type of PSCVs.
Splenic collaterals have variable locations and shapes, and the significance of that requires further investigation.
Patients with PSCVs has less HVPG and more gastroesophageal varices and more HCC. MDCT is a useful method that provides an accurate delineation of both the distribution and the extent of PSCVs. It can play an essential role not only in the diagnosis of PHT, but also in the evaluation of therapeutic options as well. Radiologists must be capable of identifying PSCVs for further understanding of their pathophysiology.