Hypersplenism in Patients With Liver Cirrhosis and Portal Hypertension
Hypersplenism in Patients With Liver Cirrhosis and Portal Hypertension
The spleen could be considered a neglected organ. To date, it has been deemed an ancillary
 organ in portal hypertension or an organ localization in lymphoproliferative diseases.
 Hypersplenism is a common disorder characterized by an enlarged spleen which causes rapid and
 premature destruction of blood cells. It can result from any splenomegaly. It is most common
 with splenomegaly secondary to portal hypertension and hematological disorders. Portal
 Hypertension is an important cause of splenomegaly in most tropical countries This work will
 involve a series of studies aiming to:

 1. Assess the prevalence and pattern of hypersplenism, and grade the severity of cytopenias
 in patients with cirrhosis and portal hypertension.

 2. Elucidate the relationship between hypersplenism, in these patients, and:

 1. The severity of liver cirrhosis as assessed by Child's and the Model of End-stage
 Liver Disease (MELD) scores.

 2. The presence and grade of gastroesophageal varices as assessed by upper endoscopy.

 3. The presence of hepatocellular carcinoma

 4. Portal hemodynamics and portal vein thrombosis as assessed by Doppler Ultrasound.

 3. Test the hypothesis that leucopenia in cirrhotic patients may be caused, at least in
 part, by apoptosis of polymorphnuclear leucocytes.
Hypersplenism is a clinical syndrome characterized by: (1) Splenomegaly (2) Pancytopenia or a
 reduction in the number of one or more types of blood cells (3) Normal production or
 hyperplasia of the precursor cells in the marrow or a so called maturation arrest (4)
 Decreased red blood cells survival (5) Decreased platelet survival. In hypersplenism, its
 normal function accelerates, and begins automatically to remove cells that may still be
 normal in function. It can be classified into three categories: I) Primary hypersplenism; II)
 Secondary hypersplenism; III) Occult hypersplenism. A number of mechanisms causing
 hypersplenism have been identified, and mainly involve retention in the spleen, phagocytosis,
 and autoimmunity.

 PMN have a short life-span and spontaneously undergo apoptosis in the living body. Although
 neutropenia in cirrhotic patients is associated with the presence of splenomegaly and
 increased clearance of granulocytes in the spleen, the complete sequence of events leading to
 neutropenia in cirrhosis is at present unknown. Although neutrophils are programmed to
 undergo apoptosis at the time of differentiation, the rate of apoptosis is under the
 regulation of external factors. Therefore, changes in the rate of PMN apoptosis are likely to
 occur in the setting of cirrhosis. The rate of apoptosis and its contribution in in cirrhotic
 patients with or without neutropenia and hypersplenism need further evaluation.

 Hypersplenism is a common complication in patients with chronic liver diseases, leading to
 decreases in platelet and hemoglobin levels, and correlates with the severity of cirrhosis.
 Splenomegaly is often used radiologically as an indicator of cirrhosis. Moreover, one study
 has shown that hypersplenism is more frequent and more severe in younger cirrhotic patients,
 and another one has addressed that platelet count to spleen diameter ratio non-invasively
 identifies severe fibrosis and cirrhosis in patients with chronic hepatitis and cirrhosis.
 Many studies also investigated the relationship between size of gastroesophageal varices and
 platelet count/spleen diameter ratio in cirrhotic patients which was found that it could be
 used as also a non-invasive indicator of esophageal varices. Indeed, there is little
 published on the actual frequency of hypersplenism.

 Hypersplenism is correlated with increased risk of hepatocellular carcinoma in post-hepatitis
 cirrhosis. One study addressed that several factors including hypersplenism in post hepatitis
 cirrhosis may contribute to hepatocellular carcinoma development. It also addressed the
 efficiency of splenectomy in reducing hepatocellular carcinoma risk. Another study concluded
 that microwave ablation of the spleen combined with partial hepatectomy is a safe and
 effective technique for treatment of hepatocellular carcinoma and hypersplenism.

 It has been shown that portal venous pressure positively correlates with spleen size.
 Duplex-Doppler has been employed in pathophysiological investigations of portal hemodynamics
 and is accepted as the first-line imaging technique in patients with suspected portal
 circulation disorders, particularly in portal hypertension. The measurement of the hepatic
 venous pressure gradient has served as the gold standard for assessing the degree of portal
 hypertension, however, due to its invasive nature and the requirements for skilled expertise
 and special equipment, some Ultrasound indices, such as Hepatic Vein and Portal Vein indices,
 exhibited an increased accuracy for diagnosing portal hypertension. These indices may be
 useful in clinical practice for the detection of significant portal hypertension.

 To date, no studies have fully assessed these correlations of hypersplenism in the same
 cirrhotic patients, which can be useful in diagnostic aspects, assessment, grading of
 severity, therapeutic interventions or even leading to the development of a new scoring
 system for hypersplenism.
Inclusion Criteria:

 -  All patients with documented evidence of liver cirrhosis (of any etiology other than
 alcoholic cirrhosis) and portal hypertension, based on clinical examination, abdominal
 ultrasound examination, upper gastrointestinal endoscopy.

 -  Male and female patients aged between 18-60 years.

 Exclusion Criteria:

 -  Patients with splenomegaly of any cause other than liver cirrhosis.

 -  Patients with any lymphoproliferative disorders.

 -  Patients with extrahepatic malignancy.

 -  Patients younger than 18 years old.

 -  Any associated cardiovascular disease.

 -  Failure to obtain consent.