What makes non-cirrhotic portal hypertension a common disease in India? Analysis for environmental factors

Abstract

In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.

Arsenic exposure and non-carcinogenic health effects

“…[31][32][33][34][35][36][37] A main consequence of chronic high-level arsenic exposure is NCIPH that is a result of chronic microangiopathy of portal vein branches, leading to intrahepatic portal vein occlusion. 38 In agreement with this, populations with elevated ingest of arsenic in drinking water have a high prevalence of NCIPH in presence of skin arsenicosis. 32,33,35,39 In fact, a study performed in Chandigarh, India, showed that arsenic levels in liver biopsy of patients of NCIPH were significantly higher (0.887 ± 0.404 ppm) compared with cirrhosis patients (0.178 ± 0.171 ppm) and control individuals (0.071 ± 0.058 ppm); interestingly, some of the NCIPH patients consumed drinking water with high arsenic content (0.360 and 0.549 ppm).…”

Traditional Chinese Medicine, Cordyceps, Related to Hepatoportal Sclerosis

“…5 There are various disorders associated with noncirrhotic portal hypertension including chronic or recurrent infections, genetic disorders, thrombophilia, immunological disorders, and exposure to drugs or toxins. 1,2,9 These factors are believed to contribute to portal vascular endothelium aggregation; however, the precise pathophysiology is likely multifactorial and remains unknown. 2 Our patient had no recent or history of infections, bleeding issues, or genetic/immunological disorders.…”

“…Hepatoportal sclerosis (HPS) as a cause of noncirrhotic intrahepatic portal hypertension is a rare clinicopathologic condition of uncertain etiology. 1 The exact precipitants of HPS remain unclear. To date, there are only limited studies that evaluate the role of Chinese herbal supplementation in the development of HPS.…”

Obliterative Portal Venopathy Caused by Oral Contraceptive Pills: A Case Report

“…OPV is poorly understood since it lacks pathognomonic clinical features. It is a subtype of noncirrhotic portal hypertension (NCPH) which itself is rare in the USA but is relatively common in India [ 4 ]. The etiopathogenesis of OPV is unknown and several hypotheses are proposed including antiretroviral therapy, hypercoagulability, genetic predisposition, recurrent bacterial infections, and chemical/toxin exposure [ 5 ].…”