A method of measuring quantitative hepatic function and hemodynamics in cirrhosis: the changes following distal splenorenal shunt

Quantitative measurement is required to define the severity of chronic liver disease and the effects of therapy on its complications. This paper presents a method of such assessment based on measurement of hepatocyte function, liver volume, functional liver blood flow, portal perfusion and cardiac output. Data are presented on 54 patients evaluated prior to, and one year after DSRS for variceal bleeding. Preoperative testing showed that alcoholics (n = 24) had significantly (p less than 0.05) larger liver and smaller spleen volumes than nonalcoholic cirrhotics (n = 22) and patients with portal vein thrombosis (n = 8), but that the other parameters were not significantly different by etiologies. At one year after DSRS: all groups showed a significant (p less than 0.01) reduction of 41 per cent in spleen size: liver volume was significantly (p less than 0.05) reduced in cirrhotics: there was a significantly (p less than 0.01) greater loss of portal perfusion in alcoholic cirrhosis: liver blood flow showed a significant (p less than 0.05) rise in alcoholics when compared to nonalcoholics and portal vein thrombosis patients: cardiac output rose in alcoholic cirrhosis: hepatocyte function was not significantly different in any group. This study shows that in patients all doing well clinically one year after DSRS, there are markedly different hemodynamic responses. Further studies on cirrhosis aimed at improving therapy for its complications should include some objective, quantitative assessment, first to define the study population, and second to measure the effect of the therapy.

The fasting B6 vitamer profile and response to a pyridoxine load in normal and cirrhotic subjects

This study established the fasting plasma and urine profiles of vitamin B6 in cirrhotics and assessed the response to an oral dose of pyridoxine. High-performance liquid chromatography was used to measure all vitameric coenzymatic and degradatory forms. In 31 patients with cirrhosis and 15 healthy controls, fasting plasma and 24-hr urine collection showed: plasma pyridoxal-5'-phosphate, the biologically active form, was significantly (p less than 0.001) reduced in cirrhotics (mean +/- S.D.: 5.7 +/- 3.2 ng per ml) compared to normals (14.2 +/- 7.5 ng per ml); plasma pyridoxal was detected in more cirrhotics (48%) than normals (28%); pyridoxic acid, the end catabolite, was significantly (p less than 0.05) lower in plasma of cirrhotics compared to normals, but 24-hr urine excretion was not different. Administration of 25 mg of pyridoxine to 7 cirrhotics and 5 normals showed the following plasma changes: pyridoxine rapidly peaked at 30 min and was totally cleared from plasma by 3 hr; plasma pyridoxal and pyridoxic acid increased in parallel up to 40-fold over baseline by 1 to 2 hr and rapidly fell toward baseline by 8 hr, and plasma pyridoxal-5'-phosphate, in contrast, increased significantly (p less than 0.05) from baseline by 60 min and was maintained above normal for 24 hr. The area under the plasma concentration vs. time curve (AUC) for pyridoxal-5'-phosphate was significantly (p less than 0.05) less for the cirrhotics than normals and showed a significant negative correlation to hepatocyte function and blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Denervated splenopancreatic flap for chronic pancreatitis

Various surgical procedures have addressed the disabling pain of chronic pancreatitis. Pain control must be weighed against the surgical morbidity and metabolic consequences of operation. Although ductal drainage works well for patients with dilated ducts, a new procedure was devised to avoid the diabetic morbidity of near-total pancreatectomy or pancreaticoduodenectomy in patients with small duct pancreatitis. Five patients have undergone the splenopancreatic flap procedure. The head of the pancreas is resected in a manner similar to near-total pancreatectomy, while the body and tail are denervated by dissection from their bed, with retrograde perfusion from the splenic hilus. All patients are alive a mean of 9 months after operation, and none is diabetic. Only one patient requires narcotic analgesics. Although none is asymptomatic, all have shown significant weight gain, and four of five are vocationally rehabilitated. Flap viability and the absence of transgastric varices have been documented by angiography and CT scanning. Although the durability of pain relief and islet cell function is unknown, these results suggest that this procedure may offer an alternative to major resection in chronic pancreatitis.

LeVeen vs Denver peritoneovenous shunts for intractable ascites of cirrhosis. A randomized, prospective trial

Peritoneovenous shunts (PVSs) have provided salutary effects on medically recalcitrant ascites, functional renal impairment, nutritional derangements, ventilatory embarrassment, and locomotion potential in patients with cirrhosis. While the LeVeen (LPVS) and Denver (DPVS) PVSs are most frequently implanted in such patients, postoperative complications of bleeding gastroesophageal varices, sepsis, and shunt occlusion occur with notable frequency. Addressing primarily the complication of PVS occlusion, a randomized prospective trial of LPVSs and DPVSs was conducted in cirrhotic patients with refractory ascites. From July 1, 1982 to July 1, 1984, 26 initial PVSs were implanted for hepatic-related intractable ascites. Twenty-two patients were eligible for randomization (cirrhosis, sterile ascites, initial PVS, total bilirubin level less than or equal to 6.0 mg/dL, prothrombin time less than or equal to 5-s prolongation, serum creatinine level less than or equal to 2.0 mg/dL [creatinine clearance rate greater than or equal to 20 mL/min], absence of recent [less than 30 days] bleeding gastroesophageal varices, or absent spontaneous encephalopathy). Twelve LPVSs and ten DPVSs were implanted; however, one patient with a DPVS was found to have hepatic polycystic disease and was excluded from analysis. All patients were followed up until death or Jan 1, 1985. The PVS patency determinations included contrast shuntography, technetium Tc 99m albumin scintigraphy, sequential manual compression (DPVS), and operative or autopsy observation. Using the Kaplan-Meier actuarial analysis, the LPVS patency proved to be highly superior to that of the DPVS, while survival was not significantly different. As LPVS and DPVS complications other than patency are comparable, the LPVS is preferred for its superior patency in cirrhotic patients with intractable ascites.

Shunts for portal hypertension: MR and angiography for determination of patency

Twenty-eight patients with selective and nonselective shunts for portal hypertension were evaluated using magnetic resonance (MR) imaging. Angiographic correlation was obtained in 25 patients. MR imaging enabled the detection of a patent shunt by visualizing the "flow void" phenomenon in 21 patients. Two patients had thrombosed shunts. In these 23 patients, there was no discrepancy between the findings from MR imaging and those from angiography. In the remaining five patients, there was an area of artifact in which no signal was noted, and the shunt could not be evaluated. In all five patients who had this artifact, steel coils were noted in the area of the phenomenon. Thus, MR imaging seems to be an accurate method for detecting shunt patency in all patients with shunts except those who have had prior embolization with steel coils.

In vivo measurement of leucine metabolism with stable isotopes in normal subjects and in those with cirrhosis fed conventional and branched-chain amino acid-enriched diets

Low plasma levels of branched-chain amino acids, leucine, isoleucine, and valine are postulated to play an etiologic role in hepatic encephalopathy. Supplementation is advocated to reverse encephalopathy and improve nutritional status and survival. We measured in vivo leucine metabolism in normal individuals (n = 5) and in two groups of patients with cirrhosis (n = 8) with a primed continuous infusion of L-[15N, 1-13C] leucine to quantitate the following parameters of leucine metabolism: nitrogen and carbon fluxes, oxidation, contribution to protein synthesis, breakdown of endogenous protein to leucine, deamination and reamination to/from ketoisocaproate. Studies were performed in the fasting and fed states with a conventional enteral diet (Propac) and a branched chain-enriched diet (one third Propac plus two thirds Hepatic-Aid). In vivo leucine metabolism was similar in the fasting and fed states in normal individuals in patients with cirrhosis and with both diets when studied at a protein intake of 0.6 gm/kg ideal body weight/day. When fed these diets, oxidation increased (p less than 0.05) and breakdown decreased (p less than 0.05). The Hepatic-Aid diet increased (p less than 0.05) nitrogen and carbon fluxes significantly more than did the standard diet. Four additional patients with cirrhosis on a diet with more protein were studied (0.75 gm/kg ideal body weight/day). Carbon and nitrogen fluxes, oxidation, synthesis, and deamination were increased (p less than 0.05) when patients with cirrhosis were fed the Propac diet compared with those who fasted. The Hepatic-Aid diet further increased (p less than 0.05) all parameters except synthesis and did not decrease protein breakdown. These data show that patients with cirrhosis metabolize leucine in vivo in a manner identical to that of normal subjects and that leucine-enriched formulas increase oxidation to CO2 without improving protein synthesis.

The Emory prospective randomized trial: selective versus nonselective shunt to control variceal bleeding. Ten year follow-up

From 1971 to 1975, 55 patients with variceal bleeding secondary to cirrhosis were entered into a prospective randomized trial comparing distal splenorenal (selective) and H-graft interposition (nonselective) shunt. This 10-year follow-up documents that selective shunt is better (p less than 0.05) in four of the five variables monitored. Control of bleeding: selective shunt prevented variceal bleeding better than interposition shunt due to the higher (0.05 less than p less than 0.1) occlusion rate (30%) of interposition shunt. Selective shunt maintained postoperative portal perfusion better (p less than 0.01) than patent interposition shunt. Seventy-five per cent of selective shunt survivors have portal perfusion at 10 years: no patient with a patent nonselective shunt perfuses the liver. Quantitative liver function was better preserved (p less than 0.01) 10 years after selective shunt than nonselective shunt. Postoperative encephalopathy occurred in fewer (p less than 0.01) selective (27%) than nonselective (75%) shunt patients over the 10 years. Survival: in the randomized population, the improved survival in the selective shunt subgroup did not reach statistical significance. However, improved survival was confirmed in nonalcoholics. Five of eight nonalcoholics operated with selective shunt are alive at 10 years with patent shunts. No nonalcoholic, of seven total, operated with nonselective shunt survived 10 years with a patent shunt. These data show that selective shunt was superior to nonselective shunt. There was less rebleeding and encephalopathy after distal splenorenal shunt; postoperative portal perfusion and hepatic function were maintained.

Splenectomy is contraindicated for thrombocytopenia secondary to portal hypertension

We believe that splenectomy is contraindicated in patients with portal hypertension and secondary hypersplenism. The greatest threat to life in this group of patients is variceal bleeding, and the primary consideration in the management of these patients should be to control this bleeding. Concomitant improvement in the hematologic indices of hypersplenism is achieved by DSRS.

Toward quantification of athetotic movements by frequency spectrum analysis

The frequency spectrum of the elbow movements of one normal subject and six handicapped subjects were obtained in order to investigate the possibility of using this technique in quantifying athetosis. The frequency spectrum technique appears to be useful but data from more subjects must be obtained and specific details regarding scaling need to be investigated.

Determination of the parameters for an athetotic arm model

A model is developed to represent elbow motions of a cerebral palsied arm with athetotic movements. The parameters of the model are defined and determined. The resulting computer model can then be used to either generate athetotic motions or to regenerate prerecorded experimental data.

Approach to the spectrum of Budd-Chiari syndrome: which patients require portal decompression?

Budd-Chiari syndrome (occlusion of the hepatic veins) represents a spectrum disorder. From 1974 to 1984, 20 patients with the syndrome were managed. Eleven required shunt surgery (Group 1) and 5 were managed with nonshunt therapy (Groups 2 and 3). Results have been good. Retrospective review of the liver biopsy specimens showed that Group 1 patients had a greater degree of zone 3 necrosis than Group 2 and 3 patients. We submit that presence of zone 3 necrosis on an initial liver biopsy specimen may define the failing liver of Budd-Chiari syndrome that requires conversion of the portal vein to an outflow tract by shunting.

Emergency distal splenorenal shunts for variceal hemorrhage refractory to nonoperative control

Two points are emphasized by this report. First, every attempt should be made to control acute variceal hemorrhage nonoperatively. Such control can be gained in about 80 percent of patients, allowing for a period of stabilization of liver disease, correction of coagulation defects, and nutritional repletion. Operative mortality then becomes equivalent to that in other elective candidates. Second, when necessary, because of ongoing hemorrhage in the face of maximal nonoperative therapy, selective shunting can be accomplished on an emergency basis. In our study, it resulted in a 70 percent survival rate and excellent protection against recurrent variceal hemorrhage with long-term maintenance of portal perfusion in 89 percent of the patients.

A denervated pancreatic flap for control of chronic pain in pancreatitis

These preliminary results of a new approach for the control of pain in chronic pancreatitis are presented with the hope that others experienced in this field will test this concept.

Peritoneovenous shunts. Lessons learned from an eight-year experience with 70 patients

The peritoneovenous shunt (PVS) is preferred over other treatment modalities in the treatment of the cirrhotic patient who has intractable ascites. The favorable effects on nutrition, pulmonary, and renal function, in addition to prompt control of ascites, frequently overshadow potentially life-threatening complications. We summarized our experience with the PVS in 70 patients with portal hypertension at Emory University, Atlanta, and identified the perioperative complications and operative mortalities. Late complications of sepsis and variceal hemorrhage were frequent and often were fatal. Of the multiple preoperative clinical and laboratory determinants, only the serum bilirubin level (greater than or equal to 3 mg/dL) was predictive of the operative mortality and longevity of survivors. The PVS should be reserved for patients with disabling, truly refractory ascites.

Selective variceal decompression in portal vein thrombosis

Thirty-two patients with congenital portal vein thrombosis have been managed for bleeding gastro-oesophageal varices. Fifteen had splenectomy and/or other therapy before referral: nine were managed by endoscopic sclerosis, four by devascularization and two by total shunt; six rebled. Seventeen had their spleen 'in situ' at referral and were evaluated for selective shunt: thirteen had distal splenorenal shunts (DSRS)--one transiently rebled despite a patent shunt and one had shunt thrombosis; four had no veins suitable for shunt, and were managed by splenectomy and devascularization, with two rebleeds. Detailed study of seven patients before, and 1 year after DSRS, showed a rise in platelet count, maintenance of hepatocyte function, portal perfusion, liver blood flow and liver size. The spleen showed a significant (P less than 0.025) reduction in size with trans-splenic decompression. We conclude that DSRS provides an excellent method for long-term control of bleeding in such patients, without alteration of liver function or haemodynamics. Patients managed by splenectomy and direct ablative procedures have a significantly (P less than 0.05) greater risk of rebleeding than patients receiving DSRS.

Metabolism of vitamin B-6 by human liver

The enzymes that metabolize vitamin B-6 were analyzed in liver biopsy samples from five patients without hepatic disease by using methods optimized for small samples. Pyridoxal kinase (EC 2.7.1.35) activities were 11.2 +/- 3.6 nmol/minute per gram of tissue and 0.16 +/- 0.05 nmol/minute per milligram of soluble protein (mean +/- SD); a clear dependence of the activity on zinc as the divalent cation was observed. Pyridoxine (pyridoxamine) 5'-phosphate oxidase (EC 1.4.3.5) activities, when using N-(5'-phosphopyridoxyl)-[3H]tryptamine as the substrate, were 0.64 +/- 0.22 pmol/minute per milligram of protein and 47 +/- 19 pmol/minute per gram of tissue. The activities were 63 +/- 18% lower when riboflavin 5'-phosphate was omitted from the assay; hence, it appears the oxidase is only partially saturated with its cofactor. The pyridoxal 5'-phosphate hydrolase(s) activities at alkaline pH were 282 +/- 183 nmol/minute per gram of tissue and 4.0 +/- 3.2 nmol/minute per milligram of particulate protein. Pyridoxal was rapidly oxidized to pyridoxic acid (28.1 +/- 19.8 nmol/minute per gram of tissue and 0.37 +/- 0.24 nmol/minute per milligram of soluble protein) by soluble enzyme(s), and the rate was unaffected by pyridine nucleotides. These experiments constitute the first quantitative analyses of the enzymes responsible for metabolizing vitamin B-6 in human liver, and provide data for interpreting the pharmacokinetics of B-6 utilization by humans, as well as methods for investigating diseases with aberrant metabolism of this nutrient.

Two stage surgical management of the Budd-Chiari syndrome associated with obstruction of the inferior vena cava

A new, staged surgical approach to the treatment of Budd-Chiari syndrome complicated by inferior vena caval obstruction has been described. The first stage consists of a mesoatrial shunt. After an interval to allow hepatic decongestion, re-establishment of caval flow and overall improvement in the status of the patient, a portacaval shunt is established and the mesoatrial shunt removed. Such a staged procedure produced an excellent result in the patient reported upon in this study and represents a treatment option in similar patients with Budd-Chiari syndrome complicated by obstruction of the inferior vena cava.

Preservation of distal splenorenal shunt in a patient requiring left nephrectomy

We report a case in which a prior distal splenorenal shunt for bleeding esophageal varices was preserved during subsequent left nephrectomy for adenocarcinoma. At nephrectomy portal hypertension with numerous collateral varices to the splenic vein was not a major technical problem. Shunt integrity was documented by postoperative angiography.

Restoration of portal venous perfusion and reversal of encephalopathy by balloon occlusion of portal systemic shunt

Operative ligation of total portasystemic shunts is effective in reversing hepatic encephalopathy but is associated with significant mortality. In the case reported, invasive radiographic techniques were used to occlude a mesorenal shunt and reverse recurrent, disabling encephalopathy in a 72-yr-old woman. Occlusion of the shunt, coupled with coronary vein embolization, improved angiographic portal perfusion from grade IV to grade I, increased nutrient liver blood flow from 577 ml/min to 848 ml/min, and increased the hepatic fraction of cardiac output from 8.8% to 24.9%. Improved hepatocyte function was measured by an increase in galactose elimination capacity from 123 mg/min to 166 mg/min and a decrease in fasting ammonia from 107 micrograms/dl to 33 micrograms/dl. A 10-mo follow-up showed that there has been no recurrence of encephalopathy or variceal hemorrhage. Based on this experience, we conclude that (a) in selected cases total portasystemic shunts can be occluded by invasive radiographic techniques, and (b) restoration of portal perfusion can reverse hepatic encephalopathy and improve liver function.

Selective variceal decompression after splenectomy or splenic vein thrombosis. With a note on splenopancreatic disconnection

Eight patients have had selective variceal decompression after a splenectomy or splenic vein thrombosis with successful control of bleeding. The principle veins utilized in these patients, either alone or in combination, were: (a) the splenic remnant, (b) the coronary, (c) the gastroepiploic, and (d) an inferior mesenteric that joined the splenic. High quality preoperative angiography is essential but operative exploration is often required to assess fully the possible shunt options. Simple splenectomy for thrombocytopenia in portal hypertension is rarely justifiable and creates far more problems than it solves. Complete splenopancreatic disconnection extends the selective shunt concept.

Variceal hemorrhage in the veteran population. To shunt or not to shunt?

Portasystemic decompression remains the most definitive procedure in the control of portal hypertension (PHT) and bleeding gastroesophageal varices (BGEV). However, controversy prevails regarding shunt timing, type, and even propriety, especially in alcoholics. Analysis of a recent portal hypertension questionnaire submitted to 75 university-affiliated Veterans Administration Medical Centers (VAMC) reflected optimism regarding portasystemic shunts for the management of bleeding varices; disappointingly, however, on the average, only 20 to 25 per cent of variceal bleeders underwent definitive surgical management of any type. Ending in January 1980, a 14-year experience at the Atlanta VAMC with 72 portasystemic shunts was reviewed and demonstrates that shunt procedures may be extended to the veteran, predominantly alcoholic, population. Criteria for successful patient selection and operation are presented. While elective variceal decompression, preferably by the distal splenorenal shunt operation, may be performed with minimal morbidity and mortality, more efficient control of alcoholism is essential to prevent late deaths from hepatic failure.

Distal splenorenal shunt in treatment of bleeding esophageal varices in renal transplant recipients

We conclude from this study that bleeding esophageal varices may occur as a late complication of liver disease associated with chronic renal failure and renal transplantation. In two of the three patients reported upon, the liver disease was probably determined on the basis of cirrhosis, secondary to chronic, active hepatitis from non-A, non-B hepatitis, while the third patient had hepatic fibrosis. Such bleeding is best controlled by selective variceal decompression with a DSRS. Finally, it is technically feasible to perform a DSRS upon some patients following a left nephrectomy, and the renal vein is of adequate caliber even in the presence of nonfunctioning kidneys.

Maintenance of nutritional competence after gastric partitioning for morbid obesity

Can normal nutritional status, as indicated by albumin, transferrin and lean body mass values, be maintained during a 100 lb weight loss after gastric partitioning? Fifteen morbidly obese patients with normal nutritional status were fed three diets before (diet A) and after (diets B and C) gastric partitioning, and changes in albumin, transferrin, and lean body mass were monitored. Diets A and C were compositionally equal and contained 40 to 60 g of protein and 600 to 900 calories administered in six to eight equally divided portions per day. Diet B contained 20 to 40 g of protein and 600 to 800 calories per day and was given through a gastrostomy tube for three months after surgery while oral input was limited to noncaloric liquids. Results showed that weight loss was more rapid before surgery with diet A, than after surgery with diet B or C (diet A versus diet B, p less than 0.05; diet A versus diet C, p less than 0.05). Lean body mass was maintained with each diet, but transferrin (p less than 0.01) and albumin (p less than 0.05) decreased while patients were fed diet B. When gastrostomy tube feedings were discontinued, diet C restored albumin and transferrin to preoperative values (diet C versus diet B, p less than 0.05, diet C versus diet A, p greater than 0.1). Total postoperative weight loss averaged 106 +/- 20 lb after 2 years. These data show that in carefully selected patients with morbid obesity who demonstrate compliance to diet A before surgery, a 100 lb weight loss may be achieved while nutritional competence is maintained.

Cimetidine does not reduce liver blood flow in cirrhosis

Cimetidine has been shown to reduce liver blood flow, as measured by indocyanine green clearance, in normal subjects. Concern over the potential deleterious effects of such reduction in cirrhosis led to the measurement of blood flow in 14 cirrhotics receiving oral or intravenous cimetidine. Liver blood flow was measured by the clearance of galactose at steady state during infusion of 40 mg per min. In six patients receiving 300 mg cimetidine by mouth each 6 hr for 4 days, basal flow (1,019 +/- 186 ml per min) was not significantly altered by cimetidine (1,087 +/- 156 ml per min). Intravenous infusion of cimetidine (300 mg) did not significantly alter flow in five patients between the basal (1,096 +/- 334 ml per min) and treatment periods (1,051 +/- 383 ml per min). Hepatic extraction of galactose in three patients (82 +/- 19%) was not significantly altered by cimetidine infusion (81 +/- 13%). The failure to reduce liver blood flow with cimetidine in this population may be due to their diminished proportion of portal venous flow, or alternatively suggests that histamine is not an important modulator of flow via H2 receptors. At a clinical level, the use of cimetidine in this population can continue without fear of further reduction in liver blood flow.

Hemodynamic differences between alcoholic and nonalcoholic cirrhotics following distal splenorenal shunt--effect on survival?

The distal splenorenal shunt significantly improves 5-year survival from variceal bleeding in nonalcoholic (70%) compared to alcoholic (45%) cirrhosis patients. This study quantitates hemodynamic differences occurring in the first year after DSRS in 16 alcoholic compared to eight nonalcoholic patients. Portal venous perfusion was retained significantly better (p less than .01) by the nonalcoholic (seven of eight) than by the alcoholic (four of sixteen) patients. Mean liver blood flow (p less than 0.07), flow/unit liver volume (p less than .05), and flow required to perform a specific hepatocyte function (p less than 0.05) all increased significantly in the alcoholic compared to nonalcoholic group. Cardiac output increased significantly in the alcoholic patients (p less than 0.05), but was unchanged in the nonalcoholic patients. The alcoholic patients divided into two subsets, 11 who showed increase in flow (1082 +/- 260 to 1496 +/- 388 ml/min) and five who did not (1246 +/- 269 to 994 +/- 159 ml/min). The former had significantly (p less than 0.05) poorer hepatocyte function and had a significant (p less than 0.05) increase in flow/unit volume and flow/unit function at 1 year, which may have helped to maintain hepatocyte integrity. The latter, in parallel with the nonalcoholic patients, showed no significant change in these parameters and maintained a good functional hepatocyte mass. These data lead us to hypothesize that: 1) alcoholic liver injury has an increased risk of leading to loss of portal perfusion after DSRS, 2) as hepatocyte function falls, there is initial increase in hepatic arterial flow in alcoholic patients, triggered by increase in cardiac output, and 3) progressive injury and/or failure of the compensatory hemodynamic mechanism leads to earlier mortality in alcoholic patients. In contrast, the nonalcoholic cirrhosis patients preserve portal perfusion and maintain liver blood flow, both quantitatively and qualitatively, with retained hepatocyte function and improved survival.

Urologic imaging and correlation with serum laboratory determinations in staging gynecologic malignancies

The records of 526 patients with gynecologic malignancies were reviewed to determine the correlation of urologic imaging modalities with serum renal function studies in detecting ureteral obstruction at the time of initial staging. Three hundred and forty-three of these patients had excretory urograms and 305 patients had concurrent serum urea nitrogen and creatinine determinations and 261 patients had concurrent radionuclide bone scans. Twenty-six patients had concurrent sonograms. Hydronephrosis (either unilateral or bilateral) was demonstrated at urography in 11% of patients with carcinoma of the cervix and ovary, but in only two percent of patients with carcinoma of the endometrium (the latter probably due to anatomic differences and an earlier stage of disease at the time of presentation). Serum urea nitrogen and creatinine determinations were abnormal in only 30% of the patients with urinary obstruction. Although only a small proportion of patients with hydronephrosis had bone scans and sonography, these appeared to be sensitive methods of detecting obstructions, but were more expensive than urography.

Management of stenosis of distal splenorenal shunt by balloon dilation

Stenosis of a distal splenorenal shunt may lead to inadequate variceal decompression with the risk of rebleeding. We report this complication in three patients at five, 16 and 17 months after DSRS, with successful management by balloon dilation. One patient had rebled from varices and the other two showed roentgenologic evidence of inadequate variceal decompression. All of the shunts were patent but showed a mean pressure gradient of 15 millimeters of mercury which was reduced to a mean of 7 millimeters of mercury by dilation. Angiography at 15 months showed no restenosis and sustained reduction of the pressure gradient in one patient. The other two patients await long term follow-up observation. Rebleeding or reappearance of varices are indications for repeat angiography after DSRS to determine the cause. The risk of dilating a venous anastomosis must be weighed against the risk of rebleeding; the results of this report demonstrate that this can be done with a satisfactory outcome.

Effective liver blood flow: determination by galactose clearance

Effective liver blood flow is the portion of total flow that perfuses functional sinusoids and is available for metabolic exchange. Clearance of galactose from blood at concentrations below 10 mg/dl (0.555 mmol/l) measures this index and is calculated during continuous infusion of 5% D-galactose at a rate of 50 mg/min. The low galactose concentrations are measured accurately by a new fluorometric assay, which gives a precision +/- 0.2 mg/dl (0.011 mmol/l). In healthy people, plasma galactose clearance was 1366 +/- 172 ml/min, and hepatic extraction was 95%. Clearance in cirrhotics depends on the stage of their disease: in a stable group of patients with advanced cirrhosis, clearance was 835 +/- 87 ml/min with hepatic extraction ranging from 60% to 95%. The day-to-day coefficient of variation was 4.5%. Direct comparison with flow-probe liver blood flow measured in 11 normal dogs showed that galactose clearance was not significantly different. These findings support the hypothesis that galactose clearance correlates with effective liver blood flow.

Total parenteral nutrition with F080 in cirrhotics with subclinical encephalopathy

It has been proposed that hepatic encephalopathy and malnutrition in cirrhosis can be reversed by infusion of a protein formula (F080) enriched with branched-chain amino acids (valine, leucine, isoleucine) and containing decreased amounts of aromatic amino acids (phenylalanine, tyrosine, tryptophan). This hypothesis was tested by measuring changes in encephalopathy status, plasma ammonia, amino acid profile, and liver function during seven metabolic balance studies in three patients with cirrhosis and subclinical encephalopathy given increasing amounts (20-100 g/d) of F080. The results showed the following: 1) positive nitrogen balance was achieved only with 80 and 100 g F080/day; 2) plasma ammonia fell during negative, but increased during positive nitrogen balance; 3) plasma tyrosine and cystine fell significantly (p less than 0.05) with all intakes of F080; 4) the abnormal branched-chain to aromatic amino acid ratio was reversed; 5) extracellular volume was expanded in all patients; 6) albumin, bilirubin, prothrombin time became abnormal; and 7) encephalopathy did not significantly change from baseline. It is concluded that, in this population, F080 is an inadequate nutritional formula when given as the sole protein source because it produces hypotyrosinemia and hypocystinemia. The marked changes in the ratio of branched-chain to aromatic amino acids are not accompanied by improvement in encephalopathy.

Comparison of the effects of Hepatic-Aid and a Casein modular diet on encephalopathy, plasma amino acids, and nitrogen balance in cirrhotic patients

Hepatic-Aid is purported to ameliorate encephalopathy and promote positive nitrogen balance in protein-intolerant, cirrhotic patients by correcting their imbalanced amino acid profile. This study evaluated Hepatic-Acid by comparing a 50-g Casein diet with an identical diet with 20-g Casein/30-g Hepatic-Aid per day in a cross-over study. Four patients with biopsy-proven stable cirrhosis, encephalopathy, and under-nutrition were studied. Each study period included three days of equilibration and eight days of metabolic balance, with the following measured at baseline and on balance days 5 and 8: routine biochemistry, fasting ammonia, psychometric tests, EEG, and plasma amino acid profiles. There was no significant change in clinical status, routine biochemistry, fasting ammonia, psychometrics or EEG between the two study periods. Mean (+/-SD) nitrogen balance on the Casein diet at 1.5 +/- 1.5 g/day was not significantly different from that on the Hepatic-Aid diet at 1.5 +/- 1.2 g/day. Plasma amino acid profiles showed a significant fall (p less than 0.05) in fasting and intraprandial tyrosine (tyr) and phenylalanine (phe) on Hepatic-Aid, but only intraprandial leucine (leu), isoleucine (ile), and valine (val) were significantly increased (p less than 0.05) on Hepatic-Aid. The ratio leu + ile + val to tyr + phe was significantly increased (p less than 0.05) on Hepatic-Aid. It is concluded that Hepatic-Aid, as given in this study, maintains N balance similar to Casein, alters the amino acid profile towards normal, but does not ameliorate encephalopathy.

First-order clearance of plasma galactose: the effect of liver disease

Galactose clearance kinetics at plasma concentrations of 0.01-0.1 mg/ml were studied during continuous infusion of 25-100 mg D-galactose per minute. In 10 subjects, plasma galactose vs. time curves during 140-min infusion, and 60 min thereafter, showed the data to fit a single-compartment model and attain 95% of plasma steady state by 80 min. Doubling the infusion rate in 14 subjects resulted in an 8% reduction in clearance at the higher rate. Hepatic extraction in normal subjects was 94%, while in cirrhotics it was 79%. Day-to-day reproducibility in 11 subjects gave a coefficient of variation of 4.5%. Extrahepatic clearance showed 2% of the total to occur in the urine, and 2.3% to occur by erythrocyte metabolism. The overall mean (+/-SD) clearance in the normal subjects of 1378 +/- 218 ml/min was significantly (p less than 0.05) greater than for the stable cirrhotics at 918 +/- 279 ml/min, but not significantly different from patients with acute hepatocellular damage at 1186 +/- 300 ml/min. This index gives flow-dependent hepatic clearance, and provides a noninvasive measure of effective liver blood flow.

The incidence and natural history of thrombus in the portal vein following distal splenorenal shunt

The incidence of thrombus formation in the portal vein following distal splenorenal shunt was 4% occlusive and 14% nonocclusive from 1974 to 1977, and 6% occlusive and 22% nonocclusive in 1980. The increased incidence was probably due to more aggressive ligation of collaterals on the portal vein. Ten patients with this complication were evaluated prospectively with clinical and biochemical parameters, angiography, and nutrient hepatic perfusion. In this group, one thrombus was occlusive immediately after operation, and nine were nonocclusive: eight of the latter resolved by six months, but one progressed to total thrombosis. There were no demonstrable adverse clinical or biochemical sequelae. Angiography showed continuing portal perfusion in the face of nonocclusive thrombus, but at six months there was increased collateral formation and significant (p less than 0.05) reduction in portal vein diameter, from 20 +/- 4 mm to 14 +/- 5 mm. Nutrient hepatic perfusion at six months, 896 +/- 257 ml/min, was not significantly different from that seen prior to operation, 848 +/- 92 ml/min. It is concluded that the natural history of nonocclusive portal vein thrombus after distal splenorenal shunt is resolution, and management should be expectant.

Ten years portal hypertensive surgery at Emory. Results and new perspectives

Five hundred four Shunt procedures have been done at Emory University Hospitals between 1971 and 1981 to decompress bleeding esophageal varices. This paper reviews how far the experiences of a prospective randomized study (55 patients) of distal splenorenal shunts against total shunts is supported by the nonrandomized experience (449 patients), and outlines our current methods of management dictated by this experience. The overall operative mortality for 348 selective shunts is 4.1% and for 156 nonselective shunts, 14.1%. The five-year survival following Selective shunt is 59%, and following nonselective shunt is 49%: more than half the selective shunt patients are alive, in contrast to the median survival of 44.5 months for patients having nonselective shunts. Following Selective shunt, the survival in nonalcoholic patients is significantly better than the median survival of alcoholic patients of 57 months. Encephalopathy, reported at three years after surgery in the randomized patients was significantly (p < 0.001) lower after selective shunt (12%) compared to nonselective shunt (52%): in the same population at seven years, all patients with patent nonselective shunts have clinical or subclinical encephalopathy, but only 30% of the selective shunt patients have subclinical encephalopathy. Shunt patency, immediately after surgery, is 93% following selective shunt, with only two documented late thromboses: nine of nine patients, at a mean of seven years, retain patency in the randomized study. Shunt occlusion increases with time after interposition nonselective shunts: seven of 13 are occluded at a mean follow-up of seven years in the randomized study. Portal venous perfusion is retained in 93% of patients seven to ten days after selective shunt, but in no patient with a patent nonselective shunt. Late portal perfusion is maintained in nine of the eleven patients in the randomized group studied at a mean of seven years after selective shunt. Restoration of portal perfusion has led to clearing of encephalopathy and improvement in hepatic function in six patients. The following conclusions are made: (1) selective shunts can be done with low operative mortality, and long-term patency with excellent control of bleeding; (2) hepatic portal venous perfusion has been maintained after selective shunt for ten years, and this is vital for preventing encephalopathy and maintaining hepatic function; (3) long-term survival after selective shunt is better than any reported series for nonselective shunt; and (4) selective shunts are the operative procedure of choice for variceal decompression and nonselective shunts should rarely be performed for elective decompression.

Enteral hyperalimentation in undernourished patients with cirrhosis and ascites

Available enteral hyperalimentation solutions used to treat undernourished cirrhotic, ascitic patients with protein intolerance are excessive in water, sodium, and in some cases protein. This study investigated the use of enteral formulae tailored to the water, sodium, and protein tolerance of 10 undernourished subjects with ascites due to alcoholic liver disease (n = 8) and postnecrotic cirrhosis (n = 2). During a 10- to 60-day (mean +/- 80 = 37 +/- 19) hyperalimentation period, three subjects were treated with a low Na (1g Na/2000 kcal), high caloric density formula (2 kcal/ml); previous encephalopathy in seven remaining subjects required infusion of a low Na, low protein (40 g/day) modular high caloric density formula. The high caloric density formula protein content in 6/7 subjects was increased to 80 to 143 g without adverse effect. Nine subjects tolerated the program well and showed improvement in the following indices: serum albumin, creatinine/height, and midarm muscle and fat areas. In selected cases, enteral hyperalimentation solutions with appropriate composition can be safely and effectively administered to cachectic cirrhotic subjects with ascites.

Measurement of liver and spleen volume by computed tomography. Assessment of reproducibility and changes found following a selective distal splenorenal shunt

Liver and spleen size were measured in 11 normal subjects and 12 patients with cirrhosis. Volume was calculated by adding together the area measurements obtained from successive transverse abdominal scans. The normal mean volume of the liver (+/- S.D.) was 1,493 +/- 230 cm3 and that of the spleen was 219 +/- 76 cm3; interobserver variability was 4-8% and the day-to-day coefficient of variation was 6-10%. In cirrhotic patients studied prior to and 7-10 days after a distal splenorenal shunt, the mean liver volume fell from 1,642 to 1,529 cm3 (p less than 0.06) and the mean spleen volume from 660 to 507 cm3 (p less than 0.006), supporting the use of such a shunt in selective decompression of varices and maintenance of portal hypertension. This is a clinically useful method of measuring organ volume with the required sensitivity.

Radionuclide angiography of the liver and spleen. Noninvasive method for assessing the ratio of portal venous to total hepatic blood flow and portasystemic shunt patency

Radioactivity verus time curves were generated for the first pass of technetium-99m pertechnetate through the left ventricle, kidneys, spleen and liver, after a 20 mCi peripheral intravenous bolus injection. The rate of change of radioactivity in these organs before recirculation is proportional to blood flow through the organ. The hepatic perfusion index, defined as the ratio of portal flow to total hepatic blood flow, was correlated with the angiographic grade of portal perfusion. The hepatic perfusion index in seven normal subjects was 66.0 +/- 3.4 percent (mean +/- standard error of the mean), and in 22 cirrhotic patients with decreasing angiographic perfusion of grades 1 to 4 the index was 54 +/- 4.6, 37 +/- 2.6, 17 +/- 4.7 and 3 +/- 1.1 percent, respectively. The correlation between the calculated perfusion index and the angiographic grade of portal flow was highly significant (p less than 0.001). The passage of radionuclide through the spleen differed before and after shunt surgery in patients with portal hypertension. The slope to height ratio, based on the downslope of the splenic curve, was significantly greater (p less than 0.01) in the shunted patients and provided a simple index for assessing shunt patency.

A noninvasive method for measuring portal venous/total hepatic blood flow by hepatosplenic radionuclide angiography

Radionuclide angiography was used to generate first-pass radioactivity vs. time curves for the left heart, right hepatic lobe, right lung, spleen, and both kidneys following rapid intravenous injection of 20 mCi (740 MBq) of 99mTc-pertechnetate. Seven normal subjects were examined as well as 57 cirrhotic patients, who also underwent angiographic grading of portal venous perfusion. For analysis, two time points were identified: (a) t0, when 99mTc first entered the liver (the initial rise of either curve); and (b)tc, when 99mTc was maximal in abdominal organs (the renal peak). Analysis was based on the slopes of the two phases of the hepatic curves t0 + 7 seconds and Tc + 7 seconds; this time selection permitted analysis of all curves. The hepatic perfusion index (HPI) = slope (tc + 7 secs)/slope (t0 + 7 secs) + slope (tc + 7 secs). The mean HPI for the normal subjects was 66% +/- 7; for the cirrhotic patients with angiographic Grades I, II, III, and IV, the HPI was 52% +/- 9, 37% +/- 6, 15% +/- 7, and 3% +/- 4, respectively. Correlation between HPI and angiography was significant (p less than 0.001). This method offers a readily available, rapid, relatively inexpensive, and quantitative method of grading the ratio of portal venous to total hepatic blood flow.

Reticuloendothelial function in rheumatoid arthritis: correlation with disease activity and circulating immune complexes

Fourteen patients with active rheumatoid arthritis had their reticuloendothelial function tested with clearance of heat damaged radiolabeled autologous erythrocytes. Only 3 of these 14 patients had prolonged red blood cell (RBC) clearance. No correlation was found between RBC clearance and level of circulating immune complexes, disease activity or disease duration.