Brigham & Women's Hospital Boston, MA, United States
Pichamol Jirapinyo, MD, MPH, Christopher C. Thompson, MD, MSc, FACG, Marvin Ryou, MD Brigham & Women's Hospital, Boston, MA
Introduction: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide with the prevalence approaching 90% in patients with obesity. Nonalcoholic steatohepatitis (NASH) is an aggressive form of NAFLD with an increased risk of cirrhosis. The treatment for NASH is limited to lifestyle modification.
Case Description/Methods: Our patient was a 68-year-old woman with obesity and compensated NASH cirrhosis. She underwent an attempted Roux-en-Y gastric bypass, which was aborted due to cirrhosis. Transient elastography suggested cirrhosis with liver stiffness of 17 kPa.
This case represents the convergence of endobariatrics and endohepatology. Specifically, we demonstrate the use of endoscopic gastric plication (EGP) to treat obesity and NASH in a patient with cirrhosis, as well as the application of endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement to monitor its changes following EGP.
Prior to EGP, she underwent EUS-guided PPG measurement. Specifically, a transgastric transhepatic puncture with a 25-gauge fine needle aspiration needle into the hepatic vein was achieved. The manometer and needle were flushed with heparinized saline solution. The manometer reading rose and plateaued. The process was repeated at least two more times and the average manometer number represented hepatic venous pressure (HVP). The needle was slowly withdrawn under Doppler. Subsequently, the portal vein was punctured, and the same steps repeated to measure the portal vein pressure (PVP). In this case, the average HVP and PVP were 17 mmHg and 28.5 mmHg. Therefore, her PPG prior to EGP was 11.5 mmHg.
The patient then underwent an EGP procedure. The first set of plications was placed in the distal gastric body perpendicular to the length of the stomach to reduce its width. The second and third sets of plications were placed longitudinally to shorten the gastric length. The last set of plications was then placed at the proximal gastric body to further reduce its width.
At 9 months, her weight decreased from 279 to 255 pounds, representing an 8.6% weight loss. Her liver stiffness decreased from 17 to 7.6 kPa, suggesting regression from stage 4 to stage 2 fibrosis. A follow-up PPG showed a PPG of 8 mmHg, representing a 30% reduction.
Discussion: This case demonstrates the safety and efficacy profile of EGP for the treatment of compensated NASH cirrhosis with improvement in liver fibrosis and PPG.
Marvin Ryou: Boston Scientific – Consultant. Cook Medical – Consultant, Grant/Research Support. Enterasense Ltd – Consultant. Fujifilm – Consultant. GI Windows – Consultant. Medtronic – Consultant. Olympus – Consultant, Grant/Research Support. Pentax – Consultant.
Pichamol Jirapinyo, MD, MPH, Christopher C. Thompson, MD, MSc, FACG, Marvin Ryou, MD. P1756 - Effects of Endoscopic Gastric Plication on Portal Pressure Gradient in a Patient With Non-Alcoholic Steatohepatitis Cirrhosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.