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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


Complications of Liver Cirrhosis

https://ssl.adgrafix.com/users/lifestag/cirrhosis/complications.html

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.