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Complications of Liver Cirrhosis
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Nutrition 2001 Sep;17(9):761-5
Nutritional assessment in various stages of liver cirrhosis.
Roongpisuthipong C, Sobhonslidsuk A, Nantiruj K, Songchitsomboon S
Department of Medicine, Ramathibodi Hospital, Mahidol University,
Bangkok, Thailand
OBJECTIVES: The aims of this study
were to determine the prevalence of protein-calorie malnutrition,
characteristics, and clinical importance of nutrition disorders in
patients with liver cirrhosis according to severity of disease. METHODS:
Nutrition assessments such as subjective global assessment,
anthropometric and biochemical measurements, immunocompentency, thiamin
and riboflavin status in 60 patients with cirrhosis (33 male and 27
female) were recorded between June 1999 and December 1999 at an
outpatient clinic at Ramathibodi Hospital, Bangkok, Thailand. The origin
of liver disease was alcohol related in 50% of patients. Child-Pugh
criteria were used to establish the severity of liver disease. RESULTS:
In terms of energy malnutrition, 13.3% of patients had ideal body
weights below 90% and 11.7% had body mass indexes below 18.5 kg/m(2).
Protein malnutrition (low albumin) and immunoincompetence (abnormal
response to skin tests) were found much more frequently (45% and 22%)
than energy malnutrition. Patients with alcoholic cirrhosis had ascites
(P < 0.05) and hepatic encephalopathy (P < 0.001) more frequently and
less triceps skinfold thickness than those with non-alcoholic cirrhosis.
Subjective global assessment and serum proteins correlated with the
degree of liver-function impairment, but immunologic tests correlated
inversely in cirrhosis patients. Mean values for creatinine-height
index, hemoglobin, cholesterol, and complement C4 showed significant
decreases in severe liver failure (Child-Pugh class C) only in patients
with alcoholic cirrhosis (P < 0.05). Malnutrition was correlated with
the clinical severity of liver disease.CONCLUSIONS: The study showed
that protein-energy malnutrition is a common complication of liver
cirrhosis. Nutritional disorders appeared to be related to the degree of
liver injury and the etiology of nutritional disorders. Nutritional
disorders were more severe with alcoholic cirrhosis than with
non-alcoholic cirrhosis.
---
Semin Oncol 2001 Oct;28(5):450-9
Surveillance for hepatocellular carcinoma.
Sherman M
University of Toronto and University Health Network, Toronto, Ontario,
Canada.
Surveillance for hepatocellular
carcinoma (HCC) in patients with recognized risk factors remains
controversial. The populations for whom surveillance may be appropriate
include all patients with established cirrhosis, and hepatitis B (HBV)
carriers, even in the absence of cirrhosis. However, even these risk
groups can be stratified into patients with higher or lower risk. The
most appropriate surveillance test is periodic ultrasound examination,
although the optimum screening interval has not been defined.
Alphafetoprotein (AFP) is a poor surveillance test, lacking in
sensitivity and specificity. There are no randomized controlled trials
confirming that surveillance for HCC reduces disease-specific mortality.
Modeling studies, however, have suggested that screening is
cost-effective and reduces group mortality by a small amount. The
criteria by which cancer surveillance programs in general can be judged
have been described. Surveillance for HCC meets some of these criteria,
but not all. In particular, more effective treatments have to be
developed to improve the outcome of surveillance. Although there is no
firm evidence to support the practice of surveillance for HCC, this has
become common practice, forever preventing the definitive study from
being performed. Nonetheless, surveillance is recommended in order to
identify patients with small HCCs, who can be entered into trials of
therapy of these tumors. Semin Oncol 28:450-459.
---
Eur J Gastroenterol Hepatol 2001
Apr;13(4):349-58
Primary prophylaxis of variceal bleeding in cirrhosis.
Brett BT, Hayes PC, Jalan R
Department of Gastroenterology and Hepatology, University College London
Hospitals, UK.
Variceal bleeding is the result of
portal hypertension, which is a major complication of liver cirrhosis
and carries a high mortality rate. Because of the mortality associated
with variceal bleeding, strategies for prevention of the first bleed is
important. Risk stratification is important in determining those at risk
of bleeding from varices and current data suggest that patients with
large varices with red signs, severe underlying liver disease and those
who have a hepatic venous pressure gradient of greater than 12 mmHg are
at high risk of bleeding. Surveillance for varices in patients with
cirrhosis is therefore important. The current review evaluates the role
of various treatments in the primary prophylaxis of variceal bleeding.
The current first choice treatment is non-selective beta-blockers; which
is cheap, easy to administer, and reduces the risk of first variceal
haemorrhage significantly. Combination of beta-blockers and nitrates
looks promising but needs further evaluation. Endoscopic variceal band
ligation compares favourably with non-selective beta-blockers in
preventing the first bleeding episode in cirrhotic patients and may be
an alternative for patients who cannot tolerate, or have
contraindications to beta-blockers. The role of monitoring the hepatic
venous pressure gradient in those being treated with pharmacological
agents, the role of newer drugs such as non-selective beta-blockers with
intrinsic alpha-adrenergic activity and angiotensin receptor blockers
require further evaluation.
---
N Engl J Med 2001 Aug
30;345(9):647-55
Endoscopic ligation compared with combined treatment with nadolol and
isosorbide mononitrate to prevent recurrent variceal bleeding.
Villanueva C, Minana J, Ortiz J, Gallego A, Soriano G, Torras X, Sainz
S, Boadas J, Cusso X, Guarner C, Balanzo J
Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau,
Barcelona, Spain. cvillaneuva@hsp.santpau.es
BACKGROUND: After an episode of
acute bleeding from esophageal varices, patients are at high risk for
recurrent bleeding and death. We compared two treatments to prevent
recurrent bleeding--endoscopic ligation and combined medical therapy
with nadolol and isosorbide mononitrate. METHODS: We randomly assigned
144 patients with cirrhosis who were hospitalized with esophageal
variceal bleeding to receive treatment with endoscopic ligation (72
patients) or the combined medical therapy (72 patients). Sessions of
ligation were repeated every two to three weeks until the varices were
eradicated. The initial dose of nadolol was 80 mg orally once daily,
with adjustment according to the resting heart rate; isosorbide
mononitrate was given in increasing doses, beginning at 20 mg once a day
at bed time and rising over the course of one week to 40 mg orally twice
a day, unless side effects occurred. The primary end points were
recurrent bleeding, complications, and death. RESULTS: The median
follow-up period was 21 months. A total of 35 patients in the ligation
group and 24 in the medication group had recurrent bleeding. The
probability of recurrence was lower in the medication group, both for
all episodes related to portal hypertension (P=0.04) and for recurrent
variceal bleeding (P=0.04). There were major complications in nine
patients treated with ligation (seven had bleeding esophageal ulcers and
two had aspiration pneumonia) and two treated with medication (both had
bradycardia and dyspnea) (P=0.05). Thirty patients in the ligation group
died, as did 23 patients in the medication group (P=0.52). The
probability of recurrent bleeding was lower for patients with a
hemodynamic response to therapy, defined as a decrease in the hepatic
venous pressure gradient of more than 20 percent from the base-line
value or to less than 12 mm Hg (18 percent, vs. 54 percent in patients
with no hemodynamic response at one year; P<0.001), and the probability
of survival was higher (94 percent vs. 78 percent at one year, P=0.02).
CONCLUSIONS: Combined therapy with nadolol and isosorbide mononitrate is
more effective than endoscopic ligation for the prevention of recurrent
bleeding and is associated with a lower rate of major complications. A
hemodynamic response to treatment is associated with a better long-term
prognosis.
---
Endoscopy 2001 Sep;33(9):737-46
Meta-analysis: efficacy of therapeutic regimens in ongoing variceal
bleeding.
Gross M, Schiemann U, Muhlhofer A, Zoller WG
Klinikum der Universitat Munchen, Medizinische Poliklinik-Innenstadt,
Germany. mgross@pk-i.uni-muenchen.de
BACKGROUND AND STUDY AIMS: Variceal
bleeding is a major cause of mortality in liver cirrhosis. Therapeutic
options include medical (vasoconstrictive/vasoactive drugs) and
endoscopic (sclerotherapy/ligation) treatments. Most studies evaluating
acute esophageal bleeding have included patients with both ongoing and
recent bleeding. Therefore therapeutic efficacy in ongoing bleeding may
not have been adequately determined in these studies. A meta-analysis
was performed for two reasons: first to compare directly the various
treatments in the case of ongoing bleeding, as this would not be
accomplished by a single trial, and secondly, to determine the success
rates of each treatment option based on a larger number of patients.
METHODS: An extensive Medline search identified 13 randomized controlled
trials with precise statements of the number of patients with ongoing
bleeding and their clinical outcomes. All studies followed a similar
design and a Q test excluded heterogeneity of the studies. Data were
pooled and cumulative success rates were calculated. RESULTS: Ligation
appeared to be the most effective treatment (91.0 %, 95 % CI 82.4-96.3
%); it was significantly more successful than vasoconstrictive treatment
(vasopressin/terlipressin 68.7 %, 61.7-75.2 %; P < 0.002,
chi-squared-test) or vasoactive treatment (somatostatin/octreotide, 75.9
%, 68.1-82.6 %; P < 0.02) treatment, but was not statistically better
than sclerotherapy (81.1 %, 71.7-88.4 %). The latter therapy was not
statistically superior to medical treatment options. Calculations of
estimated true effects, which take into account the weight of each
study, rendered similar results. CONCLUSION: Ligation is the most
effective treatment option. No significant difference was found between
the efficacy of sclerotherapy and treatment with somatostatin or
octreotide.
---
Zhonghua Yi Xue Za Zhi (Taipei) 2001
May;64(5):299-304
Esophageal cancer after endoscopic injection sclerotherapy for
esophageal varices.
Ng KW, Tan SW, Chen YH, Chen HC, Wu CS, Liang CT, Jiang CF
Division of Gastroenterology, Department of Internal Medicine, Far
Eastern Memorial Hospital, 21, Sec. 2, Nan-Ya South Road, Panchiao,
Taipei 220, Taiwan.
We reported two cases of squamous
cell carcinoma of the esophagus following endoscopic injection
sclerotherapy (EIS) for esophageal varices. Both patients were cigarette
smokers and had a long history of alcohol abuse. HBsAg and Anti-HCV were
negative, and Anti-HBs was positive in one of the patients. They were
diagnosed as alcoholic cirrhosis with esophageal varices and received
EIS treatment. Sotradecol was utilized as the sclerosant with a mean
total volume of around 30 ml. Patients developed dysphagia at 5 and 48
months following EIS, respectively. Endoscopic examination showed
stenosis and ulcerative mass at the lower portion of the esophagus.
Biopsy revealed well- to moderately differentiated squamous cell
carcinoma of the esophagus. We conclude that endoscopic follow-up is
essential and carcinoma of the esophagus should be included in the
differential diagnosis for esophageal ulceration and dysphagia following
EIS, particularly in those patients with risk factors for developing
esophageal carcinoma.
---
Am J Gastroenterol 2001
Jul;96(7):2206-10
Risk factors for the development of renal dysfunction in hospitalized
patients with cirrhosis.
Hampel H, Bynum GD, Zamora E, El-Serag HB
Section of Internal Medicine, The Houston Department of Veterans Affairs
Medical Center, Baylor College of Medicine, Texas 77030, USA.
OBJECTIVE: Hospitalized patients
with liver cirrhosis are predisposed to acute renal failure. We sought
to identify the role of liver disease severity, infectious
complications, and in-hospital treatment with aminoglycosides as risk
factors for acute renal failure among patients with cirrhosis. METHODS:
In a retrospective, case-control study at the Albuquerque VA Medical
Center, electronic and manual chart review was employed to identify all
hospitalized patients with a diagnosis of cirrhosis and normal renal
function (serum creatinine < or = 1.3 mg/dl) at the time of
hospitalization. Cases were defined as patients who developed renal
dysfunction (increase in creatinine of > or = 1.0 mg/dl) within 15 days
of hospitalization, and the remaining patients were controls. RESULTS:
Of 93 patients, there were 23 cases and 70 controls. There were no
significant differences in age, etiology of cirrhosis, serum levels of
albumin, or bilirubin, prothrombin time, encephalopathy, bacteremia,
urinary tract infection, or occurrence of esophageal variceal bleeding.
Patients who developed renal dysfunction were more likely to have
ascites (87% vs 41%, p < 0.01), spontaneous bacterial peritonitis (44%
vs 1%, p < 0.01), and treatment with i.v. aminoglycosides (48% vs 19%, p
< 0.01). In a multivariate logistic regression analysis, aminoglycosides
treatment was a strong risk factor for renal dysfunction (adjusted odds
ratio = 4.0, 95% CI = 1.4-11), independent of the severity of liver
disease or peritonitis. CONCLUSION: Avoidance of aminoglycoside
antibiotics may reduce the occurrence of renal dysfunction in
hospitalized patients with cirrhosis. In addition, close monitoring of
renal function should be employed among patients with ascites and/or
spontaneous bacterial peritonitis.
---
Gastroenterology 2001
Oct;121(4):908-14
Isosorbide Mononitrate in the Prevention of First Variceal Bleed in
Patients Who Cannot Receive beta-blockers.
Garcia-Pagan JC, Villanueva C, Vila MC, Albillos A, Genesca J, Ruiz-Del-Arbol
L, Planas R, Rodriguez M, Calleja JL, Gonzalez A, Sola R, Balanzo J,
Bosch J, Group MO
Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic,
IDIBAPS, University of Barcelona, Barcelona, Spain.
Background & Aims: Nonselective
beta-blockers (beta-blockers) are very effective in preventing first
variceal bleeding (FVB) in patients with cirrhosis. However, 15%-25% of
patients have contraindications or develop severe side effects
precluding its use. The present study evaluates whether
isosorbide-5-mononitrate (Is-MN) effectively prevents variceal bleeding
in patients with contraindications or who could not tolerate
beta-blockers. Methods: One hundred thirty-three consecutive cirrhotic
patients with gastro-esophageal varices and contraindications or
intolerance to beta-blockers were included in a multicenter,
prospective, double-blind randomized controlled trial. Sixty-seven were
randomized to receive Is-MN, and 66 to receive placebo. Results: There
were no significant differences in the 1- and 2-year actuarial
probability of experiencing a FVB between the 2 treatment groups.
Presence of variceal red signs at endoscopy was the only variable
independently associated with an increased risk of variceal bleeding on
follow-up (relative risk 3.4; P < 0.01). Survival and adverse events
were similar in the 2 groups. There were no significant differences in
the incidence of ascites or changes in renal function. Conclusions:
Is-MN does not reduce the incidence of FVB in patients with cirrhosis
and esophageal varices who cannot be treated with beta-blockers because
contraindications or intolerance to these drugs, suggesting that Is-MN
has no place in the primary prophylaxis of variceal bleeding.
---
Gut 2001 Mar;48(3):390-6
Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic
variceal ligation in the prevention of variceal rebleeding in patients
with cirrhosis: a randomised trial.
Pomier-Layrargues G, Villeneuve JP, Deschenes M, Bui B, Perreault P,
Fenyves D, Willems B, Marleau D, Bilodeau M, Lafortune M, Dufresne MP
Liver Unit, Hopital Saint-Luc, CHUM and Universite de Montreal, 164,
East Rene-Levesque Boulevard, Montreal, Quebec, Canada H2X 1P1.
hepato.saint-lux@sympatico.ca
BACKGROUND AND AIMS: The
transjugular intrahepatic portosystemic shunt (TIPS) is a new
therapeutic modality for variceal bleeding. In this study we compared
the two year survival and rebleeding rates in cirrhotic patients treated
by either variceal band ligation or TIPS for variceal bleeding. METHODS:
Eighty cirrhotic patients (Pugh score 7-12) with variceal bleeding were
randomly allocated to TIPS (n=41) or ligation (n=39), 24 hours after
control of bleeding. RESULTS: Mean follow up was 581 days in the
ligation group and 678 days in the TIPS group. The two year survival
rate was 57% in the TIPS group and 56% in the ligation group (NS); the
incidence of variceal rebleeding after two years was 18% in the TIPS
group and 66% in the ligation group (p<0.001). Uncontrolled rebleeding
occurred in 11 patients in the ligation group (eight were rescued by
emergency TIPS) but in none of the TIPS group. The incidence of
encephalopathy at two years was 47% in the TIPS group and 44% in the
ligation group (NS). CONCLUSIONS: TIPS did not increase the two year
survival rate compared with variceal band ligation after variceal
bleeding in cirrhotic patients with moderate or severe liver failure. It
significantly reduced the incidence of variceal rebleeding without
increasing the rate of encephalopathy.
---
J Hepatol 2000;32(1 Suppl):157-70
Complications of cirrhosis. II. Renal and circulatory dysfunction.
Lights and shadows in an important clinical problem.
Arroyo V, Jimenez W
Institute of Digestive Diseases and Hormonal Laboratory, Hospital Clinic
Universitari, University of Barcelona, Spain. arroyo@medicina.ub.es
The pathophysiology of circulatory
and renal dysfunction in cirrhosis and the treatment of ascites and
related conditions (hepatorenal syndrome and spontaneous bacterial
peritonitis) have been research topics of major interest during the last
two decades. However, many aspects of these problem remain unclear and
will constitute major areas of investigation in the next millennium. The
pathogenesis of sodium retention, the most prevalent renal function
abnormality of cirrhosis, is only partially known. In approximately one
third of patients with ascites, sodium retention occurs despite normal
activity of the renin-aldosterone and sympathetic nervous systems and
increased circulating plasma levels of natriuretic peptides and activity
of the so-called natriuretic hormone. These patients present an
impairment in circulatory function which, although less intense, is
similar to that of patients with increased activity of the
renin-aldosterone and sympathetic nervous systems, suggesting that
antinatriuretic factors more sensitive to changes in circulatory
function that these systems may be important in the pathogenesis of
sodium retention in cirrhosis. The development of drugs that inhibit the
tubular effect of antidiuretic hormone and increase renal water
excretion without affecting urine solute excretion has opened a field of
great interest for the management of water retention and dilutional
hyponatremia in cirrhosis. Two families of drugs, the V2 vasopressin
receptor antagonists and the kappa-opioid agonists, have been shown to
improve free water clearance and correct dilutional hyponatremia in
human and experimental cirrhosis with ascites. The first type of drugs
blocks the tubular effect of antidiuretic hormone and the second
inhibits antidiuretic hormone secretion by the neurohypophysis. On the
other hand, two new treatments have also been proved to reverse
hepatorenal syndrome in cirrhosis. The most interesting one is that
based on the simultaneous administration of plasma volume expansion and
vasoconstrictors. The second is transjugular intrahepatic porto-systemic
shunt. The long-term administration (1-3 weeks) of analogs of
vasopressin (ornipressin or terlipressin) or other vasoconstrictors
together with plasma volume expansion with albumin is associated with a
dramatic improvement in circulatory function and normalization of serum
creatinine concentration in patients with severe hepatorenal syndrome.
Of interest is the observation that in many of these patients,
hepatorenal syndrome does not recur following discontinuation of the
treatment, thus raising important questions about the mechanism by which
hepatorenal syndrome follows a progressive course in most untreated
cases. The pathogenesis of circulatory dysfunction in cirrhosis and the
role of local mechanisms in the development of the splanchnic arteriolar
vasodilation associated with portal hypertension will continue as
important topics in clinical and basic research in Hepatology. Of
special interest is the study of the mechanism by which circulatory
function further deteriorates following complications such as severe
bacterial infection or therapeutic interventions such as therapeutic
paracentesis, and the adverse consequences of the impairment in
circulatory function on renal and hepatic hemodynamics. Finally,
although major advances have been made concerning the treatment and
secondary prophylaxis of spontaneous bacterial peritonitis in cirrhosis,
many aspects of the pathogenesis of this infection remain unclear. The
mechanism of bacterial translocation and of the colonization of bacteria
in the ascitic fluid are particularly important to design adequate
measures for primary prophylaxis of this severe bacterial infection.
---
J Hepatol 2000;32(1 Suppl):141-56
Complications of cirrhosis. I. Portal hypertension.
Bosch J, Garcia-Pagan JC
Hepatic Hemodynamic Laboratory, IMD, Hospital Clinic, IDIBAPS,
University of Barcelona, Spain.
Increased resistance to portal blood
flow is the primary factor in the pathophysiology of portal
hypertension, and is mainly determined by the morphological changes
occurring in chronic liver diseases. This is aggravated by a dynamic
component, due to the active-reversible- contraction of different
elements of the porto-hepatic bed. A decreased synthesis of NO in the
intrahepatic circulation is the main determinant of this dynamic
component. This provides a rationale for the use of vasodilators to
reduce intrahepatic resistance and portal pressure. Another factor
contributing to aggravate the portal hypertension is a significant
increase in portal blood flow, caused by arteriolar splanchnic
vasodilation and hyperkinetic circulation. Splanchnic arteriolar
vasodilation is a multifactorial phenomenon, which may involve local
(endothelial) mechanisms as well as neurogenic and humoral pathways.
Most pharmacological treatments have been aimed at correcting the
increased portal blood inflow by the use of splanchnic vasoconstrictors,
such as beta-blockers, vasopressin derivatives and somatostatin. Several
studies have demonstrated that changes in the hepatic venous pressure
gradient (HVPG) during maintenance therapy are useful to identify those
patients who are going to have a variceal bleeding or rebleeding. The
wide individual variation in the HVPG response to pharmacological
treatment makes it desirable to schedule follow-up measurements of HVPG
during pharmacological therapy. A priority for research in the
forthcoming years is to develop accurate non-invasive methods to assess
prognosis, which can be used to substitute or as surrogate indicators of
the HVPG response. In the clinical management of portal hypertension,
beta-blockers are at present the only accepted treatment for the
prevention of variceal bleeding. Whether the association of
isosorbide-5-mononitrate will improve the high efficacy of beta-blockers
is questionable. The efficacy of more aggressive techniques, such as
endoscopic band ligation, should be further tested against beta-blockers
in patients with a high risk of bleeding. In the treatment of acute
variceal bleeding, administration of somatostatin or terlipressin is an
established therapy. It may be used alone or, preferably, as an initial
treatment before sclerotherapy or endoscopic band ligation. No more than
two sessions of endoscopic treatment should be used to control the
bleeding. If the bleeding is not easily controlled, other alternatives
such as transjugular intrahepatic portosystemic shunts (TIPS) or
derivative surgery should be considered, the former being the best in
patients with poor liver function. Recent studies suggest that early
measurement of HVPG during variceal bleeding may be used as a guide for
therapeutic decisions in the treatment of patients with acute variceal
bleeding. Those patients with a high HVPG have a high risk of poor
evolution, and may be candidates for more intensive and aggressive
therapy, such as surgery or TIPS. Those with lower HVPG have a very high
probability of an uneventful evolution, and may thus be managed more
conservatively using medical and endoscopic treatments. Pharmacological
agents (propranolol or nadolol), endoscopic treatment (preferably
banding ligation) or surgery can be used to prevent rebleeding. A
pending task for the new millennium is to assess whether the early
treatment of asymptomatic, compensated cirrhotic patients with portal
pressure reducing agents can prevent the development of esophageal
varices and of other complications of portal hypertension.
---
Am J Gastroenterol 2000
Feb;95(2):540-2
An endoscopic injection with N-butyl-2-cyanoacrylate used for colonic
variceal bleeding: a case report and review of the literature.
Chen WC, Hou MC, Lin HC, Chang FY, Lee SD
Department of Medicine, Veterans General Hospital-Taipei, Taiwan.
We report a 64-yr-old patient with
liver cirrhosis and bleeding esophageal varices that were obliterated by
repeated endoscopic sclerotherapy. Eleven years later, he developed a
massive, life-threatening rectosigmoid variceal hemorrhage. An
endoscopic injection with N-butyl-2-cyanoacrylate (Histoacryl),
performed over the rectosigmoid varices, achieved temporary hemostasis.
The etiology, prevalence, relationship with portal hypertension,
diagnosis, and treatment of colorectal varices are discussed.
---
Am J Gastroenterol 2000
Feb;95(2):503-8
Natural history of cirrhotic patients with small esophageal varices: a
prospective study.
Zoli M, Merkel C, Magalotti D, Gueli C, Grimaldi M, Gatta A, Bernardi M
Dipartimento di Medicina Interna, Cardioangiologia, Epatologia,
Universita di Bologna, Italy.
OBJECTIVE: Contrasting data are
available on the natural history and bleeding risk of small esophageal
varices. The aim of this prospective study was to evaluate a large
series of consecutive cirrhotics with a first endoscopic diagnosis of
small varices. METHODS: Between 1987 and 1992, 258 patients with small
varices and no previous bleeding were enrolled. Patients were clinically
examined every 6 months and were followed until a first episode of
bleeding and/or death, or until June 1998. None received any treatment
to prevent bleeding. Endoscopies were planned at 18-month intervals.
RESULTS: The cumulative risk of bleeding was low (3% at 2 yr and 8% at 4
yr) and remained low in patients in whom varices remained small at 2nd
endoscopy, whereas it increased significantly when varices enlarged. The
increase of varices appeared to be rather linear in time: at the 2nd
endoscopy varices remained small in 79% of patients and increased in
21%; at the 3rd endoscopy varices remained small in 55%, whereas at the
4th 33% of patients still had small varices. Clinical and biochemical
data at the 1st and 2nd endoscopy were included in a multiple logistic
regression analysis. Only the increase in Child-Pugh score appeared to
be a significant predictor of enlarged varices; the risk of aggravation
increased by 37.5% for every unit of impairment of the score.
CONCLUSIONS: The present study shows that patients with small varices
have a low bleeding risk. An increase in Child-Pugh score during
follow-up suggests enlargement of varices, thus an increase in bleeding
risk. In these patients closer endoscopic surveillance is recommended.
---
Am J Gastroenterol 2000
Mar;95(3):768-71
Comparison of endoscopic variceal sclerotherapy alone and in combination
with octreotide in controlling acute variceal hemorrhage and early
rebleeding in patients with low-risk cirrhosis.
Zuberi BF, Baloch Q
Chandka Medical College, Larkana, Pakistan.
OBJECTIVE: Efficacy of endoscopic
variceal sclerotherapy (EVS) alone and in combination with octreotide in
controlling acute variceal bleeding and preventing early rebleeding was
compared in a double-blind study. METHODS: Consecutive patients
presenting with variceal bleeding with low-risk liver cirrhosis were
randomized into two groups. Group A received EVS with 3-5 ml of
ethanolamine oleate per varix and placebo injection at 50 microg/h;
group B received the combined therapy of EVS and octreotide 50 microg/h
continuously for 5 days. A total of 70 patients (mean age, 38.4 +/- 8.6
yr) were selected for the study, which included 56 men (mean age, 37.9
+/- 8.5 yr) and 14 women (mean age, 40.6 +/- 9.0 yr). Thirty-five
patients were allocated in each group. RESULTS: In group A bleeding was
controlled in 30 patients (85.7%) and in group B in 33 (94.3%) (p =
0.24). The number of patients who rebled during the first 5 days after
sclerotherapy was eight (22.9%) and two (5.7%) in groups A and B,
respectively (p = 0.04). The mean packs of blood transfused to the
patients of groups A and B were 2.1 +/- 1.2 packs and 1.5 +/- 0.7 packs,
respectively (p = 0.03). The mean hospital stay of group A was 6.6 +/-
1.3 days, whereas that in group B was 5.9 +/- 1.2 days (p = 0.04). One
patient from each group died during the course of the study.
CONCLUSIONS: No significant difference was observed in arrest of
bleeding in the two groups, but episodes of early rebleeding, blood
transfusions, and hospital stay was significantly less in group B.
---
Gut 1999 Feb;44(2):270-3
Anti-inflammatory drugs and variceal bleeding: a case-control study.
De Ledinghen V, Heresbach D, Fourdan O, Bernard P, Liebaert-Bories MP,
Nousbaum JB, Gourlaouen A, Becker MC, Ribard D, Ingrand P, Silvain C,
Beauchant M
CHU, Poitiers, France.
BACKGROUND: Non-steroidal
anti-inflammatory drugs (NSAIDs) can have severe gastrointestinal
effects and cause peptic ulcers to bleed. Acute bleeding from
oesophageal varices is a major complication of cirrhosis of the liver.
AIMS: To investigate the role, using a case-control study, of NSAIDs in
first bleeding episodes associated with oesophageal or cardial varices
in cirrhotic patients. Patients/METHODS: A structured interview was
conducted of 125 cirrhotic patients with bleeding mainly related to
oesophageal varices and 75 cirrhotic controls with oesophageal varices
who had never bled. RESULTS: Cirrhotic patients who were admitted for
bleeding related to portal hypertension were more likely to have used
NSAIDs during the week before the index day (31 of 125 (25%)) than the
cirrhotic controls (eight of 75 (11%); odds ratio = 2.8, p = 0.016). Use
of aspirin alone or combined with other NSAIDs was also more prevalent
in the cases (21 of 125 (17%)) than in the controls (three of 75 (4%);
odds ratio = 4.9, p = 0.007). Logistic regression analysis showed that
NSAID use (p = 0.022, odds ratio = 2. 9, 95% confidence interval = 1.8
to 4.7) and variceal size (p<0.001, odds ratio = 4.0, 95% confidence
interval = 1.4 to 11.5) were the only variables independently associated
with the risk of bleeding. CONCLUSIONS: Aspirin, used alone or combined
with other NSAIDs, was associated with a first variceal bleeding episode
in patients with cirrhosis. Given the life threatening nature of this
complication, the possible benefit of this treatment should be weighed
against the risk shown here. No firm conclusions could be drawn on
non-aspirin NSAIDs used alone.
---
Eur J Gastroenterol Hepatol 1998
Dec;10(12):1041-4
Longer treatment with vasoactive drugs to prevent early variceal
rebleeding in cirrhosis.
de Franchis R
Department of Internal Medicine, IRCCS Ospedale Maggiore Policlinico,
Milan, Italy.
Bleeding oesophageal varices (BOV),
resulting from portal hypertension, can prove fatal. Not only is it
important to stop the initial bleeding, which may lead to hypovolaemic
shock, but also to treat this condition in the longer term, and,
consequently, the prevention of rebleeding needs to be addressed. This
review highlights the current findings on the haemostatic drug,
terlipressin, focusing particular attention on the potential for
longer-term treatment strategies in the prevention of rebleeding. The
efficacy of terlipressin in treating acute BOV, its low incidence of
severe side-effects (comparable to those of somatostatin) and its
favourable comparison with sclerotherapy in the prevention of early
rebleeds, all indicate the potential for terlipressin administration to
be extended to 5 days in the longer-term treatment of BOV. In addition,
terlipressin administration, in conjunction with sclerotherapy, can
significantly reduce the likelihood of rebleeding compared with
sclerotherapy alone and further supports its potential use in the
longer-term treatment of BOV.
---
Hunan I Ko Ta Hsueh Hsueh Pao
1997;22(3):212-4
[Analysis of the curative effect on ascites in liver cirrhosis by
integrated traditional Chinese and Western medicine].
[Article in Chinese]
Xia H, Xia Y, Lo J
Department of Medicine, Second Affiliated Hospital, Hunan Medical
University, Changsha.
Eighty eight patients with cirrhosis
ascites were treated with regular medicine and peritoneal cavity
administration or with traditional Chinese medicine and western
medicine. The results were as follows: The urine volume per day was
markedly increased in the group treated with traditional Chinese
medicine and western medicine, the abdominal circuit decreased, and the
time of ascites disappearonce significantly shortened. There was a
significant difference betwee the regular group and the peritoneal
cavity administration group (P < 0.01); the serum albumin/globulin ratio
was remarkably increased (P < 0.05). The curative effect on ascites
disappearonce in the traditional Chinese medicine and western medicine
group prevailed over the other two groups (P < 0.01).
---
J Gastroenterol Hepatol 1999
Mar;14(3):220-4
Endoscopic variceal ligation for primary prophylaxis of oesophageal
variceal bleed: preliminary report of a randomized controlled trial.
De BK, Ghoshal UC, Das T, Santra A, Biswas PK
Department of Medicine, Institute of Postgraduate Medical Education and
Research, Calcutta, West Bengal, India. dngm@apex.mail.com
BACKGROUND: Prevention of variceal
bleeding, a major cause of morbidity and mortality, is an important goal
in the management of patients with portal hypertension (PHT). Although
propranolol has been found useful in preventing the first episode of
variceal bleeding (primary prophylaxis) in cirrhotic PHT, it has
limitations which include side effects, contraindications,
non-compliance and failure in some patients. Endoscopic variceal
ligation (EVL) has not been used for primary prophylaxis. METHODS:
Thirty cirrhotic patients with PHT, grade III to IV oesophageal varices,
hepatic venous pressure gradient > or = 12 mmHg and no prior history of
upper gastrointestinal bleeding were randomized to receive propranolol
(to reduce their pulse rate by 25% from baseline, n = 15) and EVL
(weekly to fortnightly until variceal eradication, n = 15). The two
groups were comparable. All the patients in EVL group had variceal
eradication during 3.8 +/- 2.2 sessions. RESULTS: There was no major
complication or interval bleeding. During a follow-up period of 17.6 +/-
4.7 months, varices recurred in three, two of which bled (successfully
treated by EVL). In contrast, during this period of follow up one
patient in the propranolol group had variceal bleeding (P=NS). Side
effects of propranolol included symptomatic bradycardia requiring
reduction of dose in one of 15 patients. CONCLUSIONS: Although sample
size in this study is small, it seems that EVL may be a good option for
primary prophylaxis for variceal bleeding in patients with cirrhotic PHT;
further studies on a larger number of patients and longer follow up are
required.
---
J Gastroenterol Hepatol 1999
Mar;14(3):236-40
Endoscopic variceal ligation is a sufficient procedure for the treatment
of oesophageal varices in patients with hepatitis C liver cirrhosis:
comparison with injection sclerotherapy.
Hata Y, Hamada E, Takahashi M, Ota S, Ogura K, Shiina S, Okamoto M,
Okudaira T, Teratani T, Maeda S, Koike Y, Sato S, Obi S, Tanaka T,
Kawabe T, Shiratori Y, Kawase T, Nomura M, Omata M
The Second Department of Internal Medicine, University of Tokyo, Japan.
AIMS: Endoscopic variceal ligation (EVL)
is a recently developed alternative to endoscopic injection
sclerotherapy (EIS) for the treatment of oesophageal varices. Endoscopic
variceal ligation and EIS were compared in an attempt to clarify the
efficacy and safety of EVL for patients with cirrhosis due to hepatitis
C. METHODS: Endoscopic variceal ligation was performed in 60 patients
and EIS in 30. Varices were eradicated in all patients by EVL and 87%
(26 out of 30) by EIS. RESULTS: There was no significant difference
between EVL and EIS in relation to the incidence of bleeding and the 5
year survival rate after treatment. There were no severe complications
except mild substernal pain after EVL, while pulmonary embolism occurred
in one patient receiving EIS. CONCLUSIONS: Endoscopic variceal ligation
is a safe and effective technique for eradicating oesophageal varices in
patients with hepatitis C cirrhosis.
---
J Gastroenterol Hepatol 1999
Mar;14(3):241-4
Evaluation of endoscopic variceal ligation in prophylactic therapy for
bleeding of oesophageal varices: a prospective, controlled trial
compared with endoscopic injection sclerotherapy.
Gotoh Y, Iwakiri R, Sakata Y, Koyama T, Noda T, Matsunaga C, Ogata SI,
Ishibashi S, Sakata H, Tsunada S, Fujimoto K
Department of Internal Medicine, Saga Medical School, Japan.
BACKGROUND: To evaluate the efficacy
of endoscopic variceal ligation (EVL) in prophylactic therapy for
oesophageal varices, we performed a randomized prospective trial to
compare the recurrence of oesophageal varices treated by EVL with those
treated by endoscopic injection sclerotherapy. METHODS: Fifty patients
with liver cirrhosis were divided into two groups at random, after
informed consents were obtained, to receive prophylactic therapy for
bleeding of oesophageal varices. Group 1 patients underwent sessions of
sclerotherapy with 5% ethanolamine oleate used as the sclerosant. Group
2 patients underwent EVL followed by one or two sessions of
sclerotherapy. RESULTS: During the 18 month follow-up period, both the
recurrence rate in group 2 (56%) and the incidence of bleeding (20%)
were significantly higher compared with group 1 (recurrence rate 16%,
bleeding 0%). CONCLUSIONS: This result indicates that EVL is not
effective for prophylactic therapy for oesophageal varices in liver
cirrhosis.
---
Br J Surg 1999 Apr;86(4):437-46
Endoscopic band ligation of oesophageal varices.
Tait IS, Krige JE, Terblanche J
Department of Surgery and MRC Liver Research Centre, University of Cape
Town and Groote Schuur Hospital, Cape Town, South Africa.
BACKGROUND: For 25 years the optimal
management of bleeding oesophageal varices has included endoscopic
injection sclerotherapy (EIS) both to arrest bleeding and to prevent
rebleeding. However, the recent innovation of endoscopic variceal
ligation (EVL) may be a more effective treatment; this paper reviews its
efficacy. METHODS: All Medline (National Library of Medicine, Washington
DC, USA) articles containing the text words 'oesophageal varices', 'sclerotherapy'
or 'band ligation' were reviewed. Prospective randomized studies
comparing sclerotherapy with band ligation, or combinations thereof,
were included. RESULTS: After an acute variceal bleed EVL is as
effective as EIS for control and eradication of oesophageal varices.
Initial control of bleeding is similar, but eradication is achieved in
fewer sessions with EVL. EVL is associated with lower rebleeding rates
and fewer procedure-related complications; it is also more effective for
control of active bleeding at initial endoscopy. Combination therapy (EIS
plus EVL) confers no advantage over EVL alone. CONCLUSION: EVL is
similar to EIS for control of bleeding varices, but the former has less
associated morbidity, lower rebleeding rates and achieves more rapid
variceal eradication. EVL should be considered the endoscopic treatment
of choice in the management of variceal haemorrhage.
---
J Gastroenterol Hepatol 1999
Mar;14(3):225-30
Long-term follow up of a randomized, controlled trial on prophylactic
sclerotherapy of small oesophageal varices in liver cirrhosis.
Strauss E, Ribeiro MF, Albano A, Honain NZ, Maffei RA Jr, Caly WR Clinic
of Gastroenterology, Hospital Heliopolis, Sao Paulo, Brazil. estrauss@spider.usp.br
BACKGROUND: In order to evaluate the
prophylactic impact of sclerotherapy of small varices in patients with
cirrhosis and no endoscopic signs suggesting risk of haemorrhage, a
randomized clinical trial was performed. METHODS: Seventy-one
hospitalized patients met the inclusion criteria of diagnosis of
cirrhosis with no previous bleeding and small varices. Due to exclusion
criteria of: gastroduodenal ulcers (n = 5), diverticulosis (n = 1),
hepatic insufficiency (n = 10), hepatocellular carcinoma (n = 4), death
before randomization (n = 6), age over 70 (n = 1) and denial of consent
to participate in the study (n = 1), 43 patients could be randomized, 21
for sclerotherapy and 22 for the control group. Two patients (one in
each group) were lost to follow up, and another patient, although not
lost, refused sclerotherapy after randomization. Ethanolamine oleate was
used as the sclerosing agent. All patients were followed up for a mean
time of 60 months, initially every 2 months for the first 2 years and
clinical and endoscopic controls were performed each 6-12 months
thereafter. RESULTS AND CONCLUSIONS: During the first 2 years clinical
assessment showed that there were five bleedings in the sclerotherapy
group and none in the control group, but mortality was similar in both
groups. Long-term follow up continued to show a higher prevalence of
bleeding in the sclerotherapy group but that mortality was not different
from the control group.
---
N Engl J Med 1999 Apr
1;340(13):988-93
Comparison of endoscopic ligation and propranolol for the primary
prevention of variceal bleeding.
Sarin SK, Lamba GS, Kumar M, Misra A, Murthy NS
Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India.
sksarin@nda.vsnl.net.in
BACKGROUND AND METHODS: We compared
propranolol therapy and endoscopic ligation for the primary prevention
of bleeding from esophageal varices. This prospective, controlled trial
included consecutive eligible patients who had large varices (>5 mm in
diameter) that were at high risk for bleeding. The patients were
assigned to either propranolol therapy, at a dose sufficient to decrease
the base-line heart rate by 25 percent, or variceal ligation, to be
performed weekly until the varices were obliterated or so reduced in
size that it was not possible to continue treatment. RESULTS: Of the 89
patients, 82 of whom had cirrhosis of the liver, 44 received propranolol
and 45 underwent variceal ligation. The mean (+/-SD) duration of
follow-up in each group was 14+/-9 and 13+/-10 months, respectively. The
mean time required to achieve an adequate reduction in the heart rate
was 2.5+/-1.7 days; the mean number of sessions needed to complete
variceal ligation was 3.2+/-1.1. After 18 months, the actuarial
probability of bleeding was 43 percent in the propranolol group and 15
percent in the ligation group (P=0.04). Twelve patients in the
propranolol group and four in the ligation group had bleeding. Three of
the four in the ligation group had bleeding before their varices had
been obliterated. Nine patients in the ligation group had recurrent
varices, a mean of 3.7 months after the initial treatment. Five patients
in each group died; bleeding from the varices was the cause of death of
four patients in the propranolol group and of three in the ligation
group. There were no serious complications of variceal ligation; in the
propranolol group, treatment was stopped in two patients because of side
effects. CONCLUSIONS: In patients with high-risk esophageal varices,
endoscopic ligation of the varices is safe and more effective than
propranolol for the primary prevention of variceal bleeding.
---
Hepatology 1999 Apr;29(4):1074-7
Cost analysis for the prevention of variceal rebleeding: a comparison
between transjugular intrahepatic portosystemic shunt and endoscopic
sclerotherapy in a selected group of Italian cirrhotic patients.
Meddi P, Merli M, Lionetti R, De Santis A, Valeriano V, Masini A, Rossi
P, Salvatori F, Salerno F, de Franchis R, Capocaccia L, Riggio O
Department of Clinical Medicine, University of Rome "La Sapienzao,"
Rome, Italy.
The aim of the present study was to
compare the cumulative cost of the first 18-month period in a selected
group of Italian cirrhotic patients treated with transjugular
intrahepatic portosystemic shunt (TIPS) versus endoscopic sclerotherapy
(ES) to prevent variceal rebleeding. Thirty-eight patients enrolled in a
controlled trial were considered (18 TIPS and 20 sclerotherapy). The
number of days spent in the hospital for the initial treatment and
during the follow-up period were defined as the costs of
hospitalization. ES sessions, TIPS procedures, angioplasty or addition
of a second stent to maintain the shunt patency, were defined as the
costs of therapeutic procedures. The two groups were comparable for age,
sex, and Child-Pugh score. During the observation period 4 patients died
in the TIPS group, and 2 died and 1 was transplanted in the
sclerotherapy group. The rebleeding rate was significantly higher in the
sclerotherapy group. Despite this, the number of days spent in the
hospital was similar in the two groups. This was because of a higher
number of hospital admissions for the treatment of hepatic
encephalopathy and shunt insufficiency in the TIPS group. The
therapeutic procedures were more expensive for TIPS. Consequently, the
cumulative cost was higher for patients treated with TIPS than for those
treated with sclerotherapy. The extra cost was because of the initial
higher cost of the procedure and the difference was still maintained at
the end of the 18-month follow-up. When the cumulative costs were
expressed per month free of rebleeding, the disadvantage of TIPS
disappeared. In conclusion, a program of prevention of variceal
rebleeding with TIPS, despite the longer interval free of rebleeding, is
not a cost-saving strategy in comparison with sclerotherapy.
---
J Gastroenterol 1999
Apr;34(2):159-62
Evaluation of endoscopic injection sclerotherapy with and without
simultaneous ligation for the treatment of esophageal varices.
Nishikawa Y, Hosokawa Y, Doi T, Endo H, Tanimizu M, Hyodo I, Jinno K,
Sakata T, Tomoda J
Department of Internal Medicine and Clinical Research, National Shikoku
Cancer Center Hospital, Matsuyama, Japan.
For more effective and simple
endoscopic injection sclerotherapy (EIS) for esophageal varices, we
developed an EIS procedure with ligation (EISL) that is non-invasive, in
which EIS and endoscopic variceal ligation (EVL) are performed
simultaneously. In this study, we compared EISL and EIS in a randomlized
sample of patients (n = 14 for each procedure). For EISL, EVL was
performed, including the injection site, after the injection of 5%
ethanolamine oleate with iopamidol (EOI) into a varix. The mean number
of treatment sessions required for eradication of esophageal varices was
2.3+/-0.5 for EISL and 3.9+/-0.8 for EIS (P < 0.001); the mean number of
treatment sites was 6.2+/-2.2 for EISL and 14.0+/-5.0 for EIS (P <
0.001); the mean total amount of EOI used was 13.8+/-5.2ml for EISL and
26.3+/-9.8ml for EIS (P < 0.001). There were no significant differences
in rates of recurrence of varices or in bleeding between the two groups.
For EISL, fewer treatment sessions and less sclerosant were sufficient,
probably because the sclerosants were more effective due to the blockage
of variceal blood flow by the ligation. This method should provide a
novel modification of EIS.
---
J Hepatol 1997 May;26(5):1034-41
Endoscopic sclerotherapy versus variceal ligation in the long-term
management of patients with cirrhosis after variceal bleeding. A
prospective randomized study.
Avgerinos A, Armonis A, Manolakopoulos S, Poulianos G, Rekoumis G,
Sgourou A, Gouma P, Raptis S
2nd Department of Gastroenterology, Evangelismas Hospital, Athens,
Greece.
BACKGROUND/AIMS: Long-term
endoscopic injection sclerotherapy of oesophageal varices prevents
rebleeding in patients with cirrhosis surviving an acute variceal
bleeding episode. However, this treatment is associated with a
substantial complication rate. Endoscopic band ligation is a newly
developed technique in an attempt to provide a safer alternative. The
aim of this study was to compare the efficacy and safety of injection
sclerotherapy versus variceal ligation in the management of patients
with cirrhosis after variceal haemorrhage. METHODS: Seventy-seven
patients with cirrhosis who proved to have oesophageal variceal bleeding
were studied. After initial control of haemorrhage by sclerotherapy, 40
of the patients were randomly assigned to sclerotherapy and 37 to
ligation. Both procedures were performed under midazolam sedation at
intervals of 7-14 days until all varices in the distal oesophagus were
eradicated or were too small to receive further treatment. RESULTS: The
eradication of varices required a lower mean number of sessions with
ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002).
The mean duration of follow-up was similar in both groups (15.6 months
+/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients
remaining free from recurrent bleeding against time was significantly
higher in the ligation group as compared to the sclerotherapy group (chi
2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in
the ligation group as compared to 24 (60%, p = 0.05) in the
sclerotherapy group. The mortality rate was similar in both groups (20%
and 21%, respectively). CONCLUSIONS: Variceal ligation is better than
sclerotherapy in the long-term management of patients with cirrhosis
after variceal haemorrhage which was initially controlled with
sclerotherapy.
---
Hepatogastroenterology 1997
Mar-Apr;44(14):467-71
Repeated injection sclerotherapy is preferable to combined therapy with
variceal ligation to avoid recurrence of esophageal varices:--a
prospective randomized trial.
Iso Y, Kawanaka H, Tomikawa M, Matsumata T, Kitano S, Sugimachi K
Department of Surgery, Saiseikai Yahata General Hospital, Kitakyushu,
Japan.
BACKGROUND/AIMS: The aim of this
prospective randomized study is to investigate the safety, efficacy,
complications and recurrence of varices after repeated endoscopic
injection sclerotherapy (EIS), and combined therapy of endoscopic
variceal ligation (EVL) and repeated EIS, for the treatment of
esophageal varices. MATERIAL AND METHODS: Sixty-one consecutively
treated cirrhotic patients were examined. Thirty patients were placed
randomly in the EIS group and the other 31 in the EVL+EIS group. For the
EIS group, EIS was repeated at weekly intervals using 5% ethanol- amine
oleate (EO) until all the varices had been eradicated. In the EVL+EIS
group, EVL was done at the initial session, then EIS was repeated at
weekly intervals from one week after EVL. RESULTS: There was no
significant difference between the EIS and EVL+EIS groups with regard to
the rate of eradication (80.0% vs 74.2%), the total number of treatment
(4.1 +/- 0.8 sessions of EIS vs EVL and 3.0 +/- 0.5 sessions of EIS) and
hospitalization time (4.9 +/- 1.6 vs 4.4 +/- 1.0 weeks). The total
volume of EO used for the EVL+EIS group was significantly less than that
for the EIS group (26.3 +/- 8.3 vs 47.1 +/- 11.6 ml, p < 0.01) and the
incidence of minor complications at the initial treatment in the EVL+EIS
group was significantly (p < 0.01) lower than that in the EIS group.
Follow-up endoscopy showed that the rate of attaining circumferential
ulceration and the following fibrotic scarring in the EVL+EIS group was
significantly lower than that in the EIS group (21.7% vs 91.7%, p <
0.01) and that the incidence of variceal recurrence was significantly
higher in the EVL+EIS group than in the EIS group (39.1% vs 8.3%, p <
0.05) over a median follow-up of 12.3 months. CONCLUSION: The combined
therapy of EVL and repeated EIS seems favorable from the viewpoint of
fewer complications, but repeated EIS is preferable to combined therapy
to avoid recurrence of the esophageal varices.
---
Chung Hua I Hsueh Tsa Chih (Taipei)
1994 Nov;54(5):321-8
Sclerotherapy on liver cirrhosis with esophageal variceal bleeding:
eight years of experience.
Cheng CY, Chen GH, Chang CS, Tseng CC, Chen TY, Lin CK, Pan HK, Huang
CK, Hsieh PF, Huang PT
Department of Internal Medicine, Chung Shan Medical and Dental College
Hospital, Taichung, Taiwan, R.O.C.
BACKGROUND. Patients with liver
cirrhosis usually die of hepatic failure and variceal bleeding.
Successful treatment of the latter can reduce mortality. Sclerotherapy
is one method often used. This study compared (a) the successful rate of
acute bleeding control; (b) short- and long-term survival rate between
those with and without treatment with sclerotherapy to evaluate the
clinical benefit of sclerotherapy for liver cirrhosis patients with
esophageal variceal bleeding. METHODS. Between August 1983 and December
1991, 183 cirrhotic patients with esophageal variceal bleeding receiving
endoscopic injection sclerotherapy (EIS) was compared with 123 patients
without sclerotherapy treatment retrospectively. The severity of
underlying liver disease was classified using a modified Child's
classification. Sclerotherapy was done within 48 hours after active
bleeding in the sclerotherapy-treated group, while the medical treatment
group received Sengstaken-Blakemore (SB) tube or pitressin infusion
only. RESULTS. Successful rate of acute bleeding control was 81.63%
(120/147) in the EIS group and 59.35% (73/123) in the medical treatment
group. The worse the hepatic function of the patients, the lower the
success of acute bleeding control in both groups. Fifty subjects
(74.63%) had varices eradicated in 67 sclerotherapy treatment patients
with regular follow-up. Patients receiving EIS had a better long-term
survival than those without treatment. Benefit of EIS on long-term
survival was more significant in Child B patients and less in Child C
and Child A patients. Death from variceal bleeding was lower in the EIS
group than in the medical treatment group (32% vs 62.6%). Complications
of EIS were rare. Eight patients died of aspiration pneumonia,
spontaneous bacterial peritonitis or acute renal failure after
sclerotherapy, and most were Child B and C patients. Sixteen patients
had esophageal stricture. Four needed dilatation treatment. CONCLUSIONS.
The sclerotherapy-treated group had a higher control rate of acute
bleeding and lower mortality rate from esophageal variceal bleeding
compared with the medical-treated group. The procedure prolonged
long-term survival in Child B patients but did so less frequently in
Child A and Child C patients. The incidence of complications was low. As
a whole, EIS is a safe and efficient method for control of esophageal
variceal bleeding.
---
Am J Gastroenterol 1999
May;94(5):1361-5
Predictors of clinical response to transjugular intrahepatic
portosystemic shunt (TIPS) in cirrhotic patients with refractory ascites.
Deschenes M, Dufresne MP, Bui B, Fenyves D, Spahr L, Roy L, Lafortune M,
Pomier-Layrargues G
Gastroenterology Division, Royal-Victoria Hospital and McGill
University, Montreal, Quebec, Canada.
OBJECTIVE: Transjugular intrahepatic
portosystemic shunt (TIPS) is used increasingly as a treatment for
refractory ascites. The aim of the present study was to determine the
prognostic value of different parameters in predicting a favorable
evolution following TIPS in a cohort of 53 cirrhotic patients without
organic renal disease and with refractory ascites. METHODS: Patients
were classified as good responders if they survived more than 6 months,
without severe chronic hepatic encephalopathy and with good control of
ascites. The prognostic value for a good outcome was evaluated using
age, creatinine clearance, plasma renin activity, plasma aldosterone,
and Pugh score. RESULTS: Good control of ascites was obtained in 90%.
The cumulative survival rate was 54% at 6 months, 48% at 1 yr, and 39%
at 2 yr. The vast majority of patients died of complications of hepatic
insufficiency. Severe chronic hepatic encephalopathy developed in 26%.
Overall, a good clinical response was observed in 47%. Creatinine
clearance was identified as the only pre-TIPS factor to be significantly
and independently associated with a good clinical response to TIPS for
refractory ascites. A good clinical response was observed in 57% of
patients with a creatinine clearance >36 ml/min compared to 9% of those
with a clearance <36 ml/min (p < 0.01). This cutoff point in creatinine
clearance had a sensitivity of 96% and a specificity of 36%; positive
predictive and negative predictive values were 57% and 90%,
respectively. CONCLUSIONS: TIPS might be useful for the treatment of
refractory ascites in cirrhotic patients without severe renal function
impairment. However, the TIPS usefulness still has to be demonstrated
compared to large volume paracentesis or Leveen shunt. In patients with
poor renal function or with liver failure after TIPS, liver
transplantation should be considered.
---
Acta Biomed Ateneo Parmense
1996;67(3-4):143-9
TIPS (transjugular intrahepatic portosystemic shunt): state of art and
personal experience.
Ugolotti U, Larini P, Marcato C, Saccani A, Pedretti G
Istituto di Scienze Radiologiche, Universita degli Studi di Parma,
Italy.
After a brief historical view, we
describe the basic technique currently used to create percutaneous
portosystemic shunt. Between September 1992 and March 1995, TIPS was
achieved in 50 out of 52 patients; main indications included bleeding
from esophageal or gastric varices and refractory ascites. The mean
portal pressure reduction was 14.9 mmHg and the mean residual
portosystemic gradient was 10.5 mmHg. The average follow-up time was
11.8 months; in this period the overall mortality rate was 28%, while
rebleeding occurred in 8 patients and new onsets of encephalopathy
occurred in 4 cases. The major problems were due to shunt related
complications observed in 46% of the patients; close follow-up and
reintervention are required to keep the shunt previous. TIPS, developed
ad an alternative to surgery and endoscopic sclerotherapy, is an
effective and relatively safe procedure for the treatment of symptomatic
portal hypertensive patient.
---
Dig Dis Sci 1998 Nov;43(11):2459-62
Does transjugular intrahepatic portosystemic shunt (TIPS) resolve
thrombocytopenia associated with cirrhosis?
Jabbour N, Zajko A, Orons P, Irish W, Fung JJ, Selby RR
Pittsburgh Transplant Institute, University of Pittsburgh, School of
Medicine, Pennsylvania, USA.
Thrombocytopenia is frequently
present in patients with cirrhosis. The effect of portal decompression
on thrombocytopenia using a variety of shunt procedures has been
contradictory. Transjugular intrahepatic portosystemic shunt (TIPS) has
been proposed as a less invasive procedure for portal decompression,
mainly for control of variceal bleeding or intractable ascites. Its
effect on thrombocytopenia has not been defined yet. The aim of this
review is to define the effect of TIPS on patients with cirrhosis and
thrombocytopenia. Sixty-two patients who underwent TIPS at the
University of Pittsburgh and survived without transplant for more than
two months were included. Platelet count was determined prior to TIPS as
well as at one-week, one-month, and three-month intervals after TIPS.
The prevalence of thrombocytopenia prior to TIPS was 49%. TIPS had no
effect on thrombocytopenia even when the portosystemic gradient was
reduced to less than 12 mm Hg. In conclusion, portal decompression after
TIPS did not affect the degree of thrombocytopenia.
---
Przegl Lek 1998;55(9):469-74
[Intrahepatic portocaval shunt as a new method for treating and
prevention of bleeding from esophageal varices in portal hypertension].
[Article in Polish]
Wroblewski T, Rowinski O, Pawlak J, Polanski S, Jaworski M, Michalowicz
B, Malkowski P, Karwowski A, Pruszynski B
Katedry I Kliniki Chirurgii Ogolnej i Chorob Watroby Akademii Medycznej
w Warszawie.
The aim of this study was the
presentation of percutaneous transjugular intrahepatic porto-systemic
shunt (TIPS) and its place among the other methods of the treatment of
esophageal variceal bleedings. In the period from June 1992 to December
1997, 31 cirrhotic patients with portal hypertension and recurrent
variceal bleedings were submitted for TIPS. This group consisted of 14
female and 17 male patients, their age ranging from 17 to 68 years
(average 52). According to Child-Pugh classification 4 patients
represented group A, 11--group B and 16--group C. Each of these patient
was admitted to our Department after recurrent bleeding, resistant to
typical treatment: terlipressein infusion, balloon tamponade and
endoscopic sclerotherapy. In 24 patients (78%) TIPS was performed
successfully. In 7 cases TIPS was performed in candidates for orthotopic
liver transplantation. CONCLUSIONS: TIPS is quite new, nearly 10 years
old method for portal decompression. It is an effective and less
invasive method than surgical procedures in the treatment of portal
hypertension, especially in Child-Pugh group B and C patients if the
sclerotherapy is not effective. It protects cirrhotic patients waiting
for liver transplantation against the esophageal bleedings.
---
Hepatology 1999 Mar;29(3):632-9
Transjugular intrahepatic portosystemic shunt: short-term and long-term
effects on hepatic and systemic hemodynamics in patients with cirrhosis.
Lotterer E, Wengert A, Fleig WE First
Department of Medicine, University of Halle-Wittenberg, Halle (Salle),
Germany.
The aim of this prospective,
nonrandomized study was to assess the short- and long-term effects of
transjugular intrahepatic portosystemic shunt (TIPS) on hepatic and
systemic hemodynamics and on gastroesophageal collateral flow in
patients with cirrhosis and failure of chronic sclerotherapy. Cardiac
output (CO), free and wedged pulmonary artery pressure (FPAP and WPAP),
systemic vascular resistance (SVR), azygos venous blood flow (AzVBF),
and the relative (portal minus vena cava) pressure in the portal vein (rel.PP)
were determined immediately before, 30 minutes, 1 week, 3 months, and 1
year after TIPS implantation in 21 patients with alcoholic and biliary
cirrhosis with repeated bleeding from esophageal varices despite chronic
sclerotherapy. TIPS was inserted when patients were in a stable
hemodynamic condition. Palmaz stents were dilated to a 10-mm to 14-mm
diameter until gastroesophageal collaterals were no longer visible on
direct splenoportography. Relative portal pressure decreased from 21 +/-
5 mm Hg to 11 +/- 5 mm Hg 30 minutes after the procedure (P <.001). CO
increased from 7.1 +/- 1.5 L/min at baseline to 8.9 +/- 2.0 L/min (P
<.005) at 30 minutes, 8.2 +/- 2.0 L/min (P <. 01) at 1 week, and 8.0 +/-
2.0 L/min (P <.01) at 3 months after TIPS, and returned to 7.2 +/- 1.3
L/min (ns) after 1 year. Before TIPS, SVR was 990 +/- 285 dyne. sec.
cm-5 and decreased to 856 +/- 252 dyne. sec. cm-5 (P <.05) and 866 +/-
267 dyne. sec. cm-5 (P <.05) at 30 minutes and 1 week after the
procedure, and increased again to 903 +/- 208 dyne. sec. cm-5 (ns) and
1,016 +/- 260 dyne. sec. cm-5 (ns) at 3 months and 1 year, respectively.
AzVBF continuously decreased from 474 +/- 138 mL/min before TIPS to 335
+/- 116 mL/min, 289 +/- 147 mL/min, 318 +/- 157 mL/min, and 250 +/- 104
mL/min (all P <.005) at 30 minutes, 1 week, 3 months, and 1 year after
TIPS. Portal decompression after TIPS is associated with a significant
increase of CO for at least 3 months, which is only partly explained by
a transient decrease of SVR. After 1 year, CO had returned to baseline
levels. Despite an immediate decrease in portal pressure, the reduction
of blood flow through gastroesophageal collaterals is delayed and not
complete before 1 year after TIPS. In contrast to previous short-term
observations, TIPS does not seem to cause long-term aggravation of the
hyperkinetic circulation in patients with cirrhosis.
---
Semin Liver Dis 1997;17(3):249-60
Treatment of patients with cirrhosis and ascites.
Runyon BA
Transplantation Institute, Loma Linda University Medical Center, CA
92354, USA.
The treatment of patients with
cirrhosis and fluid overload has undergone substantial change in recent
years, because of new information regarding old treatments, as well as
new treatments. The goals of treatment are to maximize life expectancy
and quality of life. Development of ascites is a landmark in the natural
history of cirrhosis signaling poor life expectancy, in general.
Patients who are appropriate candidates for liver transplantation should
undergo evaluation for this procedure after development of ascites.
Patients awaiting transplantation as well as non-candidates for this
procedure should be managed by restriction of dietary sodium and
prescription of diuretics. This approach is effective in controlling
fluid overload in > 90% of patients. Only the 10% who fail this simple
medical treatment should be considered for second-line therapy.
---
Ann Chir 1999;53(10):966-72
[Role of surgery in the treatment of refractory ascites in cirrhotic
patients].
[Article in French]
Borie DC, Vaillant JC, Breton S, Hannoun L
Service de Chirurgie Digestive, Hepato-Biliaire et de Transplantation
Hepatique, Groupe Hospitalier Pitie-Salpetriere, Paris.
dominique.borie@psl.ap-hop-paris.fr
Ascites, generally directly
reflecting portal hypertension, is the commonest cause of
hospitalisation in patients with cirrhosis. In almost 10% of patients
with ascites, optimal medical treatment combining bed rest, salt and
water restriction, and diuretic treatment, is unable to induce sodium
excretion and decrease the volume of the ascites, corresponding to the
definition of refractory ascites. In other cases, it is the treatment of
ascites itself (salt and water restriction and diuretics) which induce
complications: water and electrolyte disturbances, functional renal
failure, encephalopathy, the development of which also corresponds to
refractory ascites. The therapeutic armamentarium for the management of
refractory ascites remains varied, with the use of aspiration of ascites
with compensation, peritoneovenous shunts, transhepatic or surgical
porto-systemic anastomoses, and finally, liver transplantation. At the
present time, each therapeutic measure must be taken while keeping in
mind the possibility of subsequent liver transplantation and the
potential risk of compromising liver transplantation by inappropriate
treatments. In this context, the authors review and analyse the
respective places of the various therapeutic modalities in the
management of refractory ascites in cirrhotic patients.
---
J Gastrointest Surg 1998
Nov-Dec;2(6):585-91
Small-diameter prosthetic H-graft portacaval shunt: definitive therapy
for variceal bleeding.
Rosemurgy AS, Serafini FM, Zervos EE, Goode SE
Division of Surgical Digestive Disorders, Tampa General Hospital,
Department of Surgery, University of South Florida College of Medicine
33601, USA.
Partial portal decompression has
become a popular option in the treatment of complicated portal
hypertension. This study was undertaken to report long-term follow-up
after partial portal decompression obtained utilizing 8 mm prosthetic
H-graft portacaval shunts. A total of 110 consecutive patients underwent
H-graft portacaval shunting through a protocol that detailed care and
studies from 1988 to 1996. Prospective follow-up recorded efficacy of
partial portal decompression, shunt patency, morbidity of shunting, and
survival. Seventy males and 40 females, whose average age was 54 +/-12.7
years (standard deviation), underwent shunting. Cirrhosis was due to
alcohol abuse in 64%. Fourteen percent were in Child's class A, 55% in
Child's class B, and 31% in Child's class C. Shunts were undertaken as
emergencies in 20%, urgently in 13%, and electively in 67%. Shunting
decreased portal pressure in all patients (30 +/-5.3 Hg to 19.9 -/+5.5
mm Hg; P <0.001). Early and late thrombosis was 6.4% and 3.6%,
respectively. Late rebleeding occurred in 5.4%. Perioperative (30-day)
mortality was 11.8%, and was highest for patients in Child's class C.
Three-year survival was 53%. Five-year survival was 41%. Partial portal
decompression is achieved with H-graft portacaval shunting. Rebleeding,
shunt occlusion, and encephalopathy are uncommon. In this series of
unselected older patients with alcoholic cirrhosis, 5-year survival
after H-graft portacaval shunting was greater than 40% with minimal
intervention.
---
Vestn Khir Im I I Grek 1991
May;146(5):26-8
[Endovascular surgery and the validation of immunocorrection in patients
with liver cirrhosis complicated by portal hypertension].
[Article in Russian]
Karimov ShI, Kim VF, Iunusov IR
An analysis of results of complex
clinico-immunological studies in 110 patients with liver cirrhosis
complicated by portal hypertension has been made. A scheme of
immunocorrective therapy with T-activin in patients with liver cirrhosis
complicated by portal hypertension is substantiated and developed for
performing roentgen endovascular interventions.
---
Br J Clin Pharmacol 1996
May;41(5):409-13
Haemodynamic effects of molsidomine and propranolol in patients with
cirrhosis.
Combis JM, Vinel JP, Badia P, Barange K, Payen JL, Combis F, Desmorat H,
Pascal JP
Service d'hepato-gastroenterologie, CHU Purpan, Toulouse, France.
Propranolol and molsidomine have
both been shown to decrease the hepatic venous pressure gradient in
patients with cirrhosis. The present study aimed at assessing the
effects of the combination of these two drugs on splanchnic and systemic
haemodynamics of cirrhotic patients. Fifteen patients with biopsy proven
alcoholic cirrhosis had haemodynamic measurements under basal
conditions, 60 min after oral administration of 4 mg molsidomine then 15
min after intravenous administration of 15 mg propranolol. As compared
with baseline values, molsidomine was found to decrease mean arterial
pressure (-7.9%, (P < 0.01), cardiac output (-7.3%, P < 0.01), pulmonary
wedged pressure (-45.8%, (P < 0.05) and hepatic venous pressure gradient
(-11.7%, P < 0.01). Propranolol decreased heart rate (-21%, P < 0.01),
further decreased cardiac output (-20.6%, (P < 0.01) and hepatic venous
pressure gradient (-10.5%, P < 0.01). As a whole, molsidomine plus
propranolol decreased mean arterial pressure (-8%, P < 0.01), heart rate
(-19%, P < 0.01), cardiac output (-26.5%, P < 0.01) and hepatic venous
pressure gradient (-21%, P < 0.01). Pulmonary wedged pressure, liver
blood flow and hepatic intrinsic clearance of indocyanine green were not
significantly changed by the association of molsidomine and propranolol.
We conclude that in patients with cirrhosis, molsidomine and propranolol
potentiate their effects on hepatic venous pressure gradient. Such a
combination could therefore prove useful in the treatment of portal
hypertension.
---
Ann Fr Anesth Reanim
1996;15(4):514-24
[Indications and role of albumin, plasma volume expansion excluded, in
the preoperative or postoperative management of portal hypertension].
[Article in French]
Moreau R, Valla D
Service d'hepatologie, Inserm U24, hopital Beaujon, Clichy, France.
Low serum albumin levels are common
in patients with cirrhosis and liver failure. Decreased synthesis is the
main but not the only mechanism leading to decreased serum levels. The
consequences of low albumin concentrations are a decreased plasma
colloid osmotic pressure and a decreased binding of liposoluble
xenobiotics and endogenous substances. Besides the fluid accumulation in
pleura and peritoneum, the complications directly related to low serum
albumin levels have been only poorly assessed. An increase in serum
albumin levels (by a few g.L-1) for a few days can be achieved by the
infusion of large amounts of human albumin (approximately 120 g over 3
days). The efficacy of this treatment has been only tested in
association with large paracentesis: albumin infusion, which induces
volume expansion, reduced the incidence of hyponatremia and functional
renal failure. No significant effect on ascites production rate or
survival has been observed. Similar results were achieved through
polygelin or dextran-70 infusions. No well-conducted controlled study on
the value of albumin infusion in other circumstances apart from
cirrhotic patients is available. In conclusion, albumin infusion should
be reserved to the treatment of hyponatraemia or functional renal
failure complicating cirrhosis with severe liver failure and marked
hypoalbuminaemia, when the infusion of colloids failed to correct these
anomalies.
---
Surgery 1999 Oct;126(4):708-11;
discussion 711-3
Surgical portosystemic shunts for treatment of portal hypertensive
bleeding: outcome and effect on liver function.
Knechtle SJ, D'Alessandro AM, Armbrust MJ, Musat A, Kalayoglu M
Department of Surgery, University of Wisconsin Medical School, Madison,
USA.
BACKGROUND: Since the advent of
liver transplantation and transjugular intrahepatic portosystemic shunts
(TIPS), the role of surgical portosystemic shunts in the treatment of
portal hypertension has changed. However, we have continued to use
portosystemic shunts in patients with noncirrhotic portal hypertension
and in patients with Child's A cirrhosis. METHODS: We performed 48
surgical portosystemic shunt procedures between 1988 and 1998. The
outcomes of these patients were evaluated to assess the efficacy of this
treatment. Data from 39 of 48 patients were available for analysis. The
average follow-up was 42 months. RESULTS: Liver function generally
remained stable for the patients; only 2 patients had progressive liver
failure and required transplant procedures. Gastrointestinal bleeding (3
patients), encephalopathy (3 patients), and shunt thrombosis (3
patients) were rare. Patient survival was 81% at 4 years, similar to
survival with liver transplantation (P = .22). CONCLUSIONS: Surgical
shunts remain the treatment of choice for prevention of recurrent
variceal bleeding in patients with good liver function and portal
hypertension.
---
Am J Gastroenterol 1995
May;90(5):788-93
Oral administration of nipradilol and the acute and chronic splanchnic
hemodynamic effects of a new beta-blocker with nitrovasodilating
properties in patients with liver cirrhosis.
Sugano S, Kawafune T, Suzuki T, Kubota M, Okajima T, Sumino Y, Akita H
Division of Gastroenterology and Hepatology, Saiseikai Wakakusa
Hospital, Yokohama, Japan.
OBJECTIVES: We studied the effects
of nipradilol, which has both a nonselective beta-blocker action and a
vasodilating action similar to nitroglycerin, on portal hypertension.
METHODS: We measured hepatic venous pressure gradient and splanchnic and
systemic hemodynamics before beginning therapy, 2 h after an oral dose
of 6 mg, and after either 6 months of nipradilol 6 mg twice a day (n =
14) or of a placebo (n = 6) in 20 cirrhotic patients. RESULTS: No
significant changes were observed after the administration of the
placebo. Oral nipradilol induced a significant reduction in the hepatic
venous pressure gradient (base line: 14.8 +/- 3.2 mm Hg vs 2 h: 12.3 +/-
3.4 mm Hg, p < 0.01; 6 mo: 12.5 +/- 3.2 mm Hg, p < 0.05) without a
significant change in the free hepatic venous pressure. The hepatic
vascular resistance decreased significantly (base line: 1811 +/- 778
dyn.sec.cm-5 vs 2 h: 1540 +/- 701 dyn.sec.cm-5, p < 0.05; 6 mo: 1564 +/-
693 dyn.sec.cm-5, p < 0.05) without a significant change in hepatic
blood flow. A decrease in the hepatic venous pressure gradient greater
than 10% was observed in nine patients (64%), defined as "responders,"
at 2 h and in 10 patients (71%) at 6 months. The reduction of mean heart
rate and hepatic venous pressure gradient in these responders was 16.2%
and 28.3% at 2 h and 15.1% and 27.1% at 6 months, respectively.
CONCLUSIONS: We found that in some cirrhotic patients, at the doses used
in this study, long term oral nipradilol administration produces a
reduction in the hepatic venous pressure gradient with both a
beta-blocking and a nitrovasodilating action.
---
Hepatology 1994 Sep;20(3):611-7
Hemodynamic effects of alpha-adrenergic blockade with prazosin in
cirrhotic patients with portal hypertension.
Albillos A, Lledo JL, Banares R, Rossi I, Iborra J, Calleja JL, Garrido
A, Escartin P, Bosch J
Department of Gastroenterology, Clinica Puerta de Hierro, Madrid, Spain.
This study was aimed at
investigating whether the blockade of alpha 1-adrenergic receptors could
reduce portal pressure in cirrhosis. Splanchnic and systemic
hemodynamics were measured in 12 cirrhotic patients with esophageal
varices at baseline and 1 hr after oral administration of 2 mg of
prazosin (acute study). Measurements were repeated in 10 of these 12
patients after a 3-mo course of 5 mg/12 hr of prazosin (long-term
study). Short-term prazosin significantly lowered the hepatic venous
pressure gradient from 20.1 +/- 1.3 to 14.4 +/- 0.9 mm Hg (-25.7%) (p <
0.01), and chronic prazosin reduced it to 16.5 +/- 1.3 mm Hg (-19.1%) (p
< 0.01). Hepatic blood flow was increased, thus changes in the hepatic
venous pressure gradient resulted from a reduction in the estimated
hepatic vascular resistance. Reductions in hepatic venous pressure
gradient achieved after short-term and long-term prazosin were not
significantly different. Reductions in mean arterial pressure and
systemic vascular resistance were significantly greater after short-term
than after long-term prazosin. Long-term prazosin was associated with
significant increases in hepatic and intrinsic hepatic clearances of
indocyanine green. This therapy also led to an increase in pulmonary
capillary pressure (+ 28.6%, p < 0.05) and body weight (+ 3.06%, p <
0.01) and a decrease in hematocrit (-6.1%, p < 0.05) and urinary sodium
excretion (-22.6%, p < 0.05). In contrast, there were no hemodynamic
changes in a group of six cirrhotic patients receiving placebo. In
cirrhotic patients, short-term prazosin lowers portal pressure by
decreasing hepatic vascular resistance.
---
J Hepatol 1994 Apr;20(4):542-7
The acute and chronic effects of isosorbide-5-mononitrate on portal
haemodynamics in cirrhosis.
Grose RD, Plevris JN, Redhead DN, Bouchier IA, Hayes PC
Department of Medicine, Royal Infirmary Edinburgh, Scotland, United
Kingdom.
The effects of acute and chronic
administration of isosorbide-5-mononitrate on portal and systemic
circulation was studied in patients with cirrhosis and portal
hypertension. Acute administration reduced the mean arterial pressure
and hepatic venous pressure gradient (18.4 +/- 0.9 to 16.5 +/- 0.9
mmHg), whilst having a variable effect on azygos blood flow. The hepatic
venous pressure gradient fell consistently only in patients in whom the
azygos blood flow increased acutely. With chronic administration no
reduction in mean arterial and hepatic venous pressure gradient was
identified before rechallenge, despite a marked and consistent reduction
in azygos flow (540 +/- 89 to 306 +/- 60 ml/min). Rechallenge with
isosorbide-5-mononitrate in patients on chronic nitrate therapy
reproduced the haemodynamic effects identified with acute
administration, lowering mean arterial and hepatic venous pressure
gradient (19 +/- 1.5 to 16.0 +/- 1.8 mmHg) with a variable effect on
azygos flow. The wedged hepatic venous pressure was significantly lower
than pretreatment values (19.9 +/- 1.6 compared with 23.4 +/- 2.1 mmHg).
We conclude that acute nitrate administration lowers the hepatic venous
pressure gradient, either by reducing portal venous inflow or by
reducing portal-collateral resistance. Chronic administration reduces
portal-collateral flow without consistently lowering the hepatic venous
pressure gradient. No evidence of nitrate tolerance or tachyphylaxis was
observed.
---
Arq Gastroenterol 1996
Oct-Dec;33(4):201-6
[Transjugular intrahepatic portosystemic shunts (TIPS) as a bridge for
liver transplantation].
[Article in Portugese]
de Oliveira e Silva A, Cardoso ES, de Melo CR, dos Santos TE, Mourao GS,
Meniconi MT, Santos Junior ED, Copstein JL, D'Albuquerque LA
Departamento de Gastroenterologia da Faculdade de Medicina da
Universidade de Sao Paulo.
Transjugular intrahepatic
portosystemic shunts (TIPS) represents a new surgical technique
minimally invasive utilized in the treatment of portal hypertension.
Such technique avoid the risks of general anesthesia, and major surgery
like portocava anastomosis, reducing the hepatic-portal gradient, and
help bleeding esophagogastric varices, hemorrhagic congestive
gastropathy and refractary ascites. Certainly diminishes the intensity
of intraperitoneal colorectal circulation and the necessity of blood
transfusion during surgery for liver transplantation. In this report we
reported the first case in Brazil of the implant of TIPS like
preparation for liver transplantation in cirrhotic alcoholic patient. We
made consideration about techniques aspects and surgery evolution. This
new interesting technique applied for this type of patients is indicated
as a bridge for candidates for liver transplantation.
---
J Intern Med 1993 May;233(5):385-92
Vegetable versus animal protein diet in cirrhotic patients with chronic
encephalopathy. A randomized cross-over comparison.
Bianchi GP, Marchesini G, Fabbri A, Rondelli A, Bugianesi E, Zoli M,
Pisi E
Institute of General Clinical Medicine, University of Bologna, Italy.
In a randomized cross-over
comparison, the effects of a mainly vegetable protein diet were compared
with an animal protein diet in eight patients with cirrhosis and chronic
permanent encephalopathy, under optimum lactulose therapy. After a
run-in period, patients were fed two equi-caloric, equi-nitrogenous
diets for 7 days (71 g total proteins), containing either 50 g protein
of animal origin or 50 g vegetable proteins. In the last 3 days of each
period, nitrogen balance was significantly better during the vegetable
protein diet (+0.2 (SD 1.4) g vs. -1.7 (2.4); P < 0.01), the difference
being entirely due to a reduced urinary nitrogen excretion. Average
daytime integrated blood glucose was slightly higher during vegetable
proteins, whereas insulin, plasma amino acids and ammonia were lower.
The clinical grading of encephalopathy improved slightly on vegetable
proteins, and psychometric tests improved significantly, but remained
grossly abnormal. Compliance to dietary manipulation was good. The data
prove that a mainly vegetable protein diet is worthwhile in cirrhotic
patients with chronic encephalopathy under optimum lactulose therapy.
Improved nitrogen balance may be related to more effective nitrogen use
for protein synthesis, probably due to blunted hormonal response, and
largely outweighs the effects on encephalopathy.
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