Transection of the oesophagus for bleeding oesophageal varices

Does primary sclerosing cholangitis occurring in association with inflammatory bowel disease differ from that occurring in the absence of inflammatory bowel disease? A study of sixty-six subjects

Primary sclerosing cholangitis often occurs in association with inflammatory bowel disease, particularly ulcerative colitis but also Crohn's disease of the colon either with or without terminal ileal disease. Little data exist as to the effect of inflammatory bowel disease on the presenting symptoms, radiological features, response to liver transplantation, and potential risk of bile duct carcinoma in individuals with primary sclerosing cholangitis. In an effort to answer these questions, 66 patients with primary sclerosing cholangitis were studied. The definitive diagnosis of primary sclerosing cholangitis in each was accomplished using cholangiography, which in each case demonstrated characteristic beading, ectasia and stricturing of the intrahepatic and extrahepatic bile ducts. Inflammatory bowel disease was present in 47 (71.2%) patients. Thirty nine (59.1%) had ulcerative colitis; their mean age was 42.5 +/- 11.6 yr (mean +/- SD), and the male/female ratio was 2.9:1. In addition, eight patients (12.1%) had Crohn's colitis; their mean age was 40.5 +/- 6.5 yr, and the male/female ratio of this group was 1:1. Nineteen patients (28.8%) had primary sclerosing cholangitis without any inflammatory bowel disease; their mean age was 42.0 +/- 12.1 yr, and the male/female ratio in this group was 0.72:1. Seventy-two percent of the patients without inflammatory bowel disease had either jaundice, pruritus or fatigue at presentation compared with 41% of the patients with inflammatory bowel disease (p less than 0.05). In contrast, abnormal liver function tests were more common as the first manifestation of liver disease in the latter group (38% vs. 11%; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Hormonal and metabolic changes during exercise in cirrhotic patients

The metabolic response to exercise was compared in 10 cirrhotic patients (P) in a stable clinical condition and in 6 sedentary, age-matched, normal subjects (C) performing 32 minutes of treadmill exercise with the same constant workload corresponding to three to four times their resting oxygen uptake. Taking indirect calorimetry as reference, respiratory exchanges indicated that cirrhotic patients consumed carbohydrates almost exclusively, unlike the normal controls, who consumed lipids and glucids in about the same proportions (RQ: 0.98 +/- 0.04 v 0.87 +/- 0.04, P less than .0001). In the patients, this carbohydrate path of exercise metabolism lowered glycemia from the resting value of 5.23 +/- 0.16 mmol/L to 4.03 +/- 0.37 mmol/L (P less than .0001) and raised the plasma lactate concentration from 2.08 +/- 0.24 mmol/L at rest to 3.48 +/- 0.32 mmol/L at the eighth minute of exercise (P less than .001), thus suggesting defective liver glyconeogenesis. Fatty free acids and glycerol remained almost constant during exercise, whereas catecholamines increased. Insulin levels were high in patients at rest (67.1 +/- 14.5 U/mL v 15.1 +/- 3.5 U/mL); they declined sharply at the onset of exercise but nevertheless remained high compared to those observed in the controls (P less than .0001). Glucagon increased in exercising patients from 88.3 +/- 21.3 pg/mL to 127.4 +/- 30.6 pg/mL (NS). Esterified plasma carnitine declined in the patients from 13.0 +/- 2.2 mumol/L to 8.6 +/- 1.5 mumol/L (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Taking the tension out of the portal system. An approach to the management of portal hypertension in the 1990s

The past decade saw the emergence of sclerotherapy and vasoactive pharmacologic agents as alternatives to surgery in the prevention and treatment of variceal haemorrhage. Despite encouraging results from clinical trials with regard to the prevention of rebleeding, these modalities of therapy have made no major impact on survival. This failure to alter radically the clinical outcome results from the fact that in many patients with cirrhosis death is primarily related to the degree of hepatic decompensation rather than the prevention or control of variceal bleeding. Advances in our knowledge of vasoactive mediators, receptor function, and altered vascular reactivity have provided increased insight into the circulatory disturbances that characterise cirrhosis and portal hypertension. Earlier and more aggressive pharmacologic intervention with single or combination drug therapy may inhibit fibrogenesis, reduce portal vascular resistance, and improve liver function and therefore provide effective prophylaxis against variceal haemorrhage. The emergence of reliable prognostic indices for variceal bleeding should help identify patients at risk who would benefit from prophylaxis with either drugs or sclerotherapy. Transplantation will be increasingly considered in the patient at high risk of recurrent bleeding before the stage of severe hepatic decompensation (the risks of the transplant then become very much greater), as the definitive means for reducing mortality in cirrhosis and portal hypertension.

Serum-ascites albumin gradients in nonalcoholic liver disease

Several studies performed in alcoholics with advanced liver disease have demonstrated a positive correlation between the serum-ascites albumin gradient (SAAG) and measured portal venous pressure. A single study performed in 15 patients with exudative malignant ascites and 29 patients with alcoholic liver disease demonstrated that a SAAG of less than 1.1 was essentially diagnostic of a malignant origin of the ascites. In an effort to confirm and extend these observations to individuals with nonalcoholic liver disease, 24 patients with nonalcoholic liver disease and 11 with alcoholic liver disease undergoing orthotopic liver transplantation (OTLx) were studied. At the time of liver transplantation, each had their serum and ascitic fluid albumin levels determined, the gradient calculated, and their portal venous pressure (PVP) as well as the corrected portal venous pressure (PPc) measured directly. A significant correlation (r = 0.624) between the PPc and the SAAG was found in the 11 alcoholics (P less than 0.05). No such correlation existed for those with nonalcoholic liver disease (r = 0.398). Moreover, a SAAG less than 1.1 was found in three of nonalcoholics with cirrhosis in the absence of an abdominal malignancy. We conclude that (1) the SAAG and PPc are statistically related to each other in individuals with alcoholic liver disease but not in those with a nonalcoholic cause for cirrhosis, and (2) SAAG less than 1.1 is not diagnostic of abdominal malignancy but can occur in those with advanced nonmalignant hepatic disease.

Tianeptine binding to human plasma proteins and plasma from patients with hepatic cirrhosis or renal failure

1. The binding of tianeptine to human plasma, isolated plasma proteins, red blood cells and to plasma from patients with cirrhosis or renal failure was studied in vitro by equilibrium dialysis. 2. Tianeptine is highly bound to plasma (95%) at therapeutic concentrations (0.3-1 microM). No saturation of the binding sites was seen. 3. Human serum albumin (HSA) was shown to be mainly responsible for this binding (94%) with a saturable process characterized by one binding site with a moderate affinity (Ka = 4.2 x 10(4) M-1) and a non-saturable process with a low total affinity (nKa = 1.2 x 10(4) M-1). 4. Like many basic and amphoteric drugs, tianeptine showed a saturable binding to alpha 1-acid glycoprotein (AAG) with one site and a moderate affinity (Ka = 3.7 x 10(4) M-1). Its binding to lipoproteins and red blood cells (RBC) was weak and non-saturable. Over the range of therapeutic drug concentrations (0.3-1 microM), the unbound fraction in blood remains constant (4.5%). 5. Interactions were studied using non-esterified fatty acids (NEFA) at pathological concentrations; they altered tianeptine binding to plasma and to isolated HSA. Tianeptine seems to bind to a HSA site different from sites I (warfarin) and II (diazepam), but close to site II. It also shares the only basic-site on AAG. However, at therapeutic drug concentrations (0.3-1 microM), not all of these interactions occur. 6. The binding of tianeptine varied according to HSA, AAG and NEFA concentrations both in patients and healthy subjects. In patients with chronic renal failure having high NEFA concentrations the unbound fraction of tianeptine (fu) increased from 0.045 to 0.153 compared with normal (P less than 0.001). In cirrhotic patients, with relatively low HSA concentrations, the fu of tianeptine increased from 0.045 to 0.088 compared with normal (P less than 0.01). 7. Multiple regression analysis of all of the data indicated that the fu of tianeptine was related significantly to HSA, NEFA and AAG concentrations, with a particularly strong correlation with NEFA concentrations. Therefore, variation of HSA and NEFA concentrations in patients on maintenance therapy may cause an increase of tianeptine fu.

Propranolol in the prevention of recurrent variceal hemorrhage in cirrhotic patients. A controlled trial

A double-blind controlled study of long-acting propranolol in the secondary prevention of variceal hemorrhage was conducted in 81 cirrhotic patients. After the index hemorrhage, all patients were treated with injection sclerotherapy on one occasion to secure hemostasis and then randomized within 72 h to propranolol or placebo therapy which was continued for 2 yr. Study endpoints were severe recurrence of variceal hemorrhage or death. Forty-two patients did not fulfill the entry criteria for the study. Thirty-eight patients received propranolol of whom 18 (47%) had further hemorrhage, 14 died, eight had side-effects (2 withdrawals), and 3 did not complete follow-up. Forty-three patients received placebo of whom 33 (77%) had further hemorrhage, 19 died, 5 had side-effects (2 withdrawals), and 5 failed to complete follow-up. The median time from onset of hemorrhage to starting drug therapy was 6 days for both groups. Life table analysis showed an equivalent incidence of further hemorrhage in both groups over the first 60 days, following which the propranolol group did consistently better than the placebo group. There was a significantly lower incidence of rebleeding in modified Child's C patients receiving propranolol (39%) than those on placebo (90%). No statistically significant effect on mortality was seen. In this study, propranolol reduced the incidence of late recurrence of variceal hemorrhage in patients with cirrhosis.

Alterations of glucose metabolism in chronic liver disease

The prevalence of glucose intolerance has been studied by oral glucose tolerance test in 670 patients affected by chronic liver disease. The glycometabolic status was evaluated by criteria given by WHO in 1980. Sixty-nine subjects appeared to be affected by chronic persistent hepatitis and 140 by chronic active hepatitis. In these patients the prevalence of diabetic responses (DR) did not differ much from that of the general population in our geographic area. In contrast, a markedly higher frequency of DR appeared in a cirrhotic group of 401 patients compared to non-cirrhotic subjects. The cirrhotics, divided according to different disease stages, showed a higher DR frequency in decompensated patients than in well compensated patients, the prevalence reaching 63% in the former subgroup. The coincident presence of hepatocarcinoma - documented in 60 other cirrhotic patients - does not modify the prevalence of diabetes. Other risk factors for diabetes such as age, sex, and family history have been considered. Our results suggest that: (1) all these factors seem not to play a major role in the pathogenesis of alterations of glucose metabolism in patients suffering from chronic liver disease, and therefore (2) liver cirrhosis by itself might be a risk factor in the disturbance of glucose tolerance.

Can hepatic failure after surgery for hepatocellular carcinoma in cirrhotic patients be prevented?

To study the causes of postoperative hepatic failure in cirrhotic patients undergoing resection for hepatocellular carcinoma, we evaluated data on 126 cirrhotic patients surgically treated from 1977 to 1987. The records of 102 patients with a good postoperative course (survival group) and 24 patients who developed hepatic failure and died (hepatic failure group) were reviewed. No difference in preoperative liver function was apparent between the 2 groups. Histologically, moderate to severe inflammatory activity in the liver was present in 20 (83%) of 24 patients in the hepatic failure group. Major hepatic resections (lobectomy and extended lobectomy) were more frequent in the hepatic failure group. Mean perioperative blood loss was 1,945 g and 4,322 g in the survival and hepatic failure groups, respectively, with a significant difference (p less than 0.01). Major postoperative complications occurred in 22 (22%) of 102 patients in the survival group and major complications followed by hepatic failure occurred in 21 (88%) of 24 patients in the hepatic failure group, with a significant difference (p less than 0.001). In light of these data, we propose that: (a) histological examination should be done before the resection, (b) perioperative blood loss should be less than 2,000 g, and (c) intensive care is needed postoperatively to prevent complications which might lead to hepatic failure.

Association of transdermal nitroglycerin to vasopressin infusion in the treatment of variceal hemorrhage: a placebo-controlled clinical trial

The aim of this study was to evaluate, using a double-blind technique, the efficacy of the association of transdermal nitroglycerin to vasopressin infusion for the treatment of variceal bleeding. Sixty-nine cirrhotic patients with active variceal bleeding were randomly allocated to receive vasopressin (0.4 to 0.8 unit per min until variceal bleeding has been controlled for 12 hr) associated with nitroglycerin administered transdermically in a slow-release preparation (10 mg in 24 hr) or placebo. An initial control of variceal hemorrhage was achieved in 83% of the patients receiving vasopressin-nitroglycerin and in 74% in the vasopressin-placebo group. Owing to a lower frequency of recurrent bleeding during therapy (18 vs. 42%, p = 0.11), vasopressin-nitroglycerin achieved a definitive control of bleeding in a higher proportion of patients than vasopressin-placebo (73 vs. 54%, p = 0.13). The group treated with the drug combination showed favorable results in relation to transfusion requirements (2.9 +/- 0.4 vs. 4.2 +/- 0.5 units, p = 0.05), total dose of vasopressin required (453 +/- 47 vs. 587 +/- 50 units, p less than 0.05), need of balloon tamponade (6 vs. 15, p less than 0.05) and requirement for emergency surgery (0 vs. 4, p = 0.07). There were no significant differences in the undesirable effects associated with treatment, observed in 37 and 49% of cases, respectively. Hospital mortality was similar (33 vs. 25%). This study demonstrates that transdermal nitroglycerin improves the effectiveness of vasopressin for controlling variceal hemorrhage.

Combined upper and lower gastrointestinal endoscopy: a prospective study in alcoholic and nonalcoholic cirrhosis

Upper gastrointestinal hemorrhage is one of the more important complications of cirrhosis. Most of the available data regarding the prevalence of upper and lower gastrointestinal sites of bleeding in cirrhotic patients have been obtained in individuals with alcoholic cirrhosis evaluated in the course of an acute gastrointestinal bleeding episode. Few data exist, however, as to the prevalence of either potential bleeding sites or of normal endoscopic findings in hemodynamically stable individuals with cirrhosis of any etiology. Five hundred ten cirrhotic subjects, who were evaluated for possible liver transplantation (OLTx) between January 1985 and June 1987, were included in this study. Seventy-five had alcoholic cirrhosis and 435 had nonalcoholic cirrhosis of various etiologies. Of these 510 patients, 412 underwent combined upper and lower gastrointestinal endoscopy and 98 underwent upper gastrointestinal endoscopy alone. Gastritis, gastric and duodenal ulcer disease were found significantly (each at least p less than 0.025) more often in patients with alcoholic liver disease than in those with nonalcoholic liver disease. The prevalence of the various lower gastrointestinal lesions in both groups was similar. Of particular interest is the fact that in alcoholic cirrhotics, the prevalence of gastritis, gastric ulcer and duodenal ulcer disease was unrelated to the degree of portal hypertension, whereas in the nonalcoholic cirrhotics the prevalence of gastritis and duodenal ulcer disease but not gastric ulcer disease was associated significantly with the degree of portal hypertension as assessed by the presence or absence of large esophageal varices, ascites, and hepatic encephalopathy.

Endoscopic findings in alcoholic liver disease: does gender make a difference?

Alcohol abuse and alcoholic liver disease are major health problems in many parts of the world. The prevalence of alcoholic liver disease is directly related to both rate and duration of alcohol intake. It is a widely held belief that women are more susceptible to the hepatotoxic effects of ethanol, and develop alcohol-related liver disease more readily than do men. A lower volume of distribution for alcohol, greater immune reactivity and higher activity of alcohol metabolizing enzymes in women are considered, at least in part, to be responsible for the greater susceptibility of women to alcoholic liver disease. Little data exist as to the extent of gastrointestinal involvement in advanced alcoholic liver disease, and even less, as to the relationship of these potential gastrointestinal lesions with gender, and whether or not female patients develop gastrointestinal complications at an earlier time in their liver disease natural history and whether when it occurs it is more severe than that seen in males. To answer these questions, 75 subjects (49 men and 26 women) with alcoholic liver disease underwent elective upper and lower gastrointestinal endoscopy while they were clinically stable. The prevalence of the various gastrointestinal lesions did not differ significantly between male and female alcoholics except for gastric ulcer (GU) and nonspecific inflammatory changes of the colon which were more common in females than in males (23.1% vs. 6.1% and 11.1% vs. 0%, respectively; both p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Neuropsychological deficits and morphological MRI brain scan abnormalities in apparently healthy non-encephalopathic patients with cirrhosis. A controlled study

By means of psychometric testing, we have determined the frequency of latent hepatic encephalopathy in a group of 19 cirrhotics with no clinical evidence of encephalopathy. Magnetic resonance imaging (MRI) of the brain was performed in order to determine whether morphological cerebral abnormalities were associated with latent encephalopathy. Nineteen age and educationally matched patients with normal liver function acted as controls. Significant differences (P less than 0.05) between cirrhotics and controls were found in tests of short-term visual memory and speed of reaction to light (cirrhotics 316 +/- 132 ms vs. controls 225 +/- 36 ms), sound (cirrhotics 361 +/- 152 ms vs. controls 236 +/- 52 ms) and choice (cirrhotics 651 +/- 190 ms vs. controls 406 +/- 101 ms) stimuli (all values mean +/- S.D.). Reitan trail test performance, however, was similar in both groups. (Trail A: cirrhotics 43 +/- 19 s vs. controls 35 +/- 13 s; Trail B: cirrhotics 105 +/- 66 s vs. controls 93 +/- 36 s.) In patients with cirrhosis, MRI revealed statistically significant increases in the maximum fissure width of right frontal sulci, right and left parietal sulci, inter-hemispheric fissure width and in bicaudate index. These changes, indicating cerebral atrophy, were largely confined to alcoholics. There was poor correlation between measurements of cerebral morphology and neuropsychological performance, only 10% of associations achieving statistical significance.

Plasma leucine enkephalin is increased in liver disease

Plasma methionine enkephalin is increased in liver disease and may contribute to some of the clinical manifestations of hepatic failure. To determine if another 'small' opioid peptide is increased in the plasma of patients with liver disease, leucine enkephalin was measured by radioimmunoassay. Its plasma concentration was raised approximately five-fold in patients with acute liver disease (median 1490 pmol/l, range 830-2420) and three-fold in patients with cirrhosis with ascites (960 pmol/l, 470-2900), compared with disease controls (325 pmol/l, 180-740) and healthy controls (305 pmol/l, 180-560). The increase in plasma leucine enkephalin was proportional to the degree of liver damage, as judged in the patients with acute liver disease by its correlation with the prothrombin time (r = 0.691, p less than 0.01) and alanine aminotransferase (r = 0.502, p less than 0.05), and in the patients with cirrhosis by its negative correlation with the plasma albumin (r = -0.743, p less than 0.001). It is unclear whether the raised plasma leucine enkephalin in liver disease is a consequence of diminished hepatic inactivation, increased secretion from sympathetic nerves and adrenal glands, or both.

Prognosis after the first episode of gastrointestinal bleeding or coma in cirrhosis. Survival and prognostic factors

Hepatic encephalopathy and gastrointestinal (GI) bleeding are the most serious complications in cirrhosis. The purpose of this study was to examine survival after the first episode of GI bleeding or coma, or both, and to identify variables associated with the subsequent survival in 284 consecutive patients with cirrhosis admitted to one division of hepatology over a period of 81 months. Patients who only bled had markedly longer survival than those who only had coma, whereas those who had both bleeding and coma had by far the poorest survival, only 15% being alive 1 year later. Several other variables showed a significant association with survival. In a Cox multiple regression analysis the following four variables showed significant association with a short survival: coma and bleeding at the episode, ascites, low prothrombin index, and high serum creatinine. The prognostic index derived from the Cox model, which was validated by a split-sample testing technique, may be used to refine prognostic estimation in this subgroup of severely ill cirrhotic patients.

Long-term prognosis of esophageal variceal cases treated with injection sclerotherapy

One hundred fifty-two patients with esophageal varices underwent a total of 485 injection sclerotherapy procedures (mean, 3.2 times per each case). During 5 years of observation, 20 cases (13.2%) died following injection sclerotherapy. The 3-year survival rates, based on the Kaplan-Meier method, were 42% for emergency cases, 75% for elective cases and 90% for prophylactic cases. Significant differences (P less than 0.05) by the generalized Wilcoxon test were observed in the survival rates between emergency cases and prophylactic cases, and also between elective cases and prophylactic cases. Two cases (8.6%) of failure to control acute hemostasis were experienced. Twenty cases of bleeding after sclerotherapy were experienced, and 8 died of bleeding. The three-year bleeding rate according to the Kaplan-Meier method was 59% for emergency cases, 25% for elective cases and 7% for prophylactic cases. A significant difference (P less than 0.05) by the generalized Wilcoxon test was observed in the bleeding rate between elective cases and prophylactic cases. Non-bleeding rate (100%-bleeding rate) after sclerotherapy showed almost the same values as the survival rate. These results indicate that upper digestive tract hemorrhage influences the prognosis of patients after sclerotherapy.

Successful endoscopic obturation of gastric varices with butyl cyanoacrylate

In 27 patients who had bled from esophagogastric varices, large-sized and/or actively bleeding gastric varices were endoscopically obturated with the tissue adhesive butyl cyanoacrylate. Active bleeding was stopped in six patients. Rebleeding occurred in 10 patients; in four patients, rebleeding was due to ruptured gastric varices, occurred early and was successfully treated by reinjection of gastric varices; in one patient, rebleeding was attributed to ulceration on an injected gastric varix. Eight patients died: two of rebleeding (from esophageal varices or undetermined source), four of sepsis and/or liver failure and two at home of undetermined cause. No specific complication due to injection of gastric varices was observed. The results obtained in this series of patients with gastric varices obturated by injection of butyl cyanoacrylate are much more satisfactory than those obtained in previously published series of patients with gastric varices treated by injection of sclerosants.

A comparison of sclerotherapy with staple transection of the esophagus for the emergency control of bleeding from esophageal varices

We compared two procedures for the emergency treatment of bleeding esophageal varices in patients who did not respond to blood transfusion and vasoactive drugs. We randomly assigned 101 patients with cirrhosis of the liver and bleeding esophageal varices to undergo either emergency sclerotherapy (n = 50) or staple transection of the esophagus (n = 51). Four patients assigned to sclerotherapy and 12 assigned to staple transection did not actually undergo those procedures, but all analyses were made on an intention-to-treat basis. Total mortality did not differ significantly between the two groups; the relative risk of death for staple transection as compared with sclerotherapy was 0.88 (95 percent confidence interval, 0.51 to 1.54). Mortality at six weeks was 44 percent among those assigned to sclerotherapy and 35 percent among those assigned to staple transection. Complication rates were similar for the two groups. An interval of five days without bleeding was achieved in 88 percent of those assigned to staple transection and in 62 percent of those assigned to sclerotherapy after a single injection (P less than 0.01) and 82 percent after three injections. In only 2 of the 11 patients who received a third sclerotherapy injection was bleeding controlled for more than five days, and 9 died. We conclude that staple transection of the esophagus is as safe as sclerotherapy for the emergency treatment of bleeding esophageal varices and that it is more effective than a single sclerotherapy procedure. We currently recommend surgery after two injection treatments have failed.

Platelet aggregability after endoscopic intravariceal injection of 5 per cent ethanolamine oleate into oesophageal varices

Platelet aggregability and the coagulative and fibrinolytic systems were examined in 45 patients who underwent endoscopic injection sclerotherapy for oesophageal varices. Five per cent ethanolamine oleate, the sclerosant used, was injected into the oesophageal varices. There were significant increases in the concentrations of fibrinopeptide A, fibrinopeptide B-beta-15-42 and fibrin degradation products-E after the sclero-therapy. At 1 h after the sclerotherapy the mean(s.e.m.) platelet aggregation was significantly suppressed to 71.9(4.2) per cent of that before the treatment (P less than 0.01). There was a gradual recovery within 1 week to the same level seen before the sclerotherapy. Thromboxane B2 and 6-keto-prostaglandin F1 alpha, both stable products of thromboxane A2 and prostacyclin respectively, showed significant temporary increases after the sclerotherapy (P less than 0.01). The peak increase in the level of thromboxane B2 was noted within 1 h after the sclerotherapy and earlier than that for 6-keto-prostaglandin F1 alpha. This increased ratio of prostacyclin and thromboxane A2 may be related to the marked limitation in platelet aggregation.

Reduction of portal pressure by acute administration of furosemide in patients with alcoholic cirrhosis

In patients with cirrhosis, it has been demonstrated that blood volume and degree of portal hypertension are correlated. Hence, a reduction of blood volume by furosemide could decrease portal pressure and could thereby be useful in the treatment of portal hypertension. Splanchnic and systemic haemodynamics were evaluated before and 1 h after intravenous administration of furosemide (0.75 mg/kg) in 10 patients with cirrhosis. Furosemide significantly increased haemoglobin from 12.4 to 13.0 g/dl and patients passed more than 1 l of urine within the 3 h following furosemide administration. These findings confirm that blood volume decreased after diuretic administration. Cardiac output significantly decreased from 6.6 +/- 2.3 to 5.5 +/- 2.2 l/min, while arterial pressure and heart rate did not change significantly. Furosemide significantly decreased wedged hepatic venous pressure from 31.1 +/- 6.2 to 27.7 +/- 5.2 mmHg, but not free hepatic venous pressure. Accordingly, the hepatic venous pressure gradient significantly decreased from 22.1 +/- 5.4 to 19.5 +/- 4.0 mmHg. Azygos blood flow and hepatic blood flow also significantly decreased from 0.40 +/- 0.17 to 0.31 +/- 0.13 l/min and from 1.49 +/- 0.50 to 0.82 +/- 0.30 l/min, respectively. These results show that diuretic therapy markedly influences splanchnic haemodynamics.

Prevention of stricture formation after endoscopic sclerotherapy of esophageal varices

In order to evaluate the effectiveness of an intensive acid protection regimen in preventing sclerotherapy-associated esophageal strictures, 62 patients undergoing sclerotherapy were randomized to receive either acid protection (antacids, cimetidine, and sucralfate) or no acid protection. Of 31 patients (38.7%) in the no acid protection group, 12 developed a symptomatic stricture during the course of sclerotherapy compared with 3 patients (9.7%) in the group assigned to acid protection (p less than 0.01). Our study demonstrates that a vigorous acid protection regimen will help prevent symptomatic esophageal strictures associated with variceal sclerotherapy.

Lack of effects of isosorbide-5-mononitrate on hepatic hemodynamics in HBsAg-positive cirrhosis

We conducted a randomized controlled hemodynamic study to evaluate the effect of placebo and 20 mg isosorbide-5-mononitrate, a long-acting organic nitrate, in 19 patients with HBsAg-positive cirrhosis by the simultaneous measurement of portal venous pressure and wedged hepatic venous pressure. Baseline values for the two groups were similar. One hour after oral administration of 20 mg isosorbide-5-mononitrate in 10 patients, mean arterial pressure, mean pulmonary arterial pressure and pulmonary capillary wedge pressure significantly decreased from 92 +/- 13 (mean +/- S.D.) to 82 +/- 14 mmHg, from 12.9 +/- 4.5 to 9.3 +/- 2.4 mmHg and from 6.9 +/- 3.4 to 4.3 +/- 1.8 mmHg, respectively. However, both portal venous pressure gradient (from 18.1 +/- 3.6 to 17.5 +/- 3.0 mmHg) and hepatic venous pressure gradient (from 17.8 +/- 5.2 to 16.6 +/- 5.3 mmHg) remained unchanged during the study. In six patients who received 20 mg isosorbide-5-mononitrate twice daily for 7 days, hepatic venous pressure gradient remained unaltered as compared to basal and 1-hr values. There was no significant change in cardiac index, heart rate or systemic vascular resistance in either immediate (1-hr) or delayed (7-day) studies. Three patients (30%) developed mild headache or dizziness and two patients (20%) demonstrated systolic hypotension (less than mmHg) during the immediate study. This study shows that isosorbide-5-mononitrate appears to have no effect in treating portal hypertension in patients with HBsAg-positive cirrhosis. In addition, the isosorbide-5-mononitrate may affect the systemic circulation more than the portal circulation.

Effect of D-tryptophan-6-luteinizing hormone-releasing hormone on the tumoral growth and plasma sex steroid levels in cirrhotic patients with hepatocellular carcinoma

Certain evidence suggests androgen dependence of hepatocellular carcinoma in cirrhotic patients. Consequently, it was postulated that antiandrogen therapy might be effective in the treatment of hepatocellular carcinoma. D-Tryptophan-6-luteinizing hormone-releasing hormone is a potent agonist analog of luteinizing hormone-releasing hormone which, when chronically administered, inhibits the pituitary gonadal axis and testicular androgen secretion in man. We studied the effects of D-tryptophan-6-luteinizing hormone-releasing hormone on tumoral growth in 17 male cirrhotic patients with hepatocellular carcinoma. After 3 to 6 months of therapy, no tumoral response was observed. Furthermore, measurements of plasma levels of testosterone, dihydrotestosterone, androstenedione, estradiol, estrone and sex hormone-binding globulin were performed before and 3 months after initiation of the antiandrogenic treatment. Before treatment, hypoandrogenism and hyperestrogenism were present; D-tryptophan-6-luteinizing hormone-releasing hormone induced a fall in plasma testosterone and dihydrotestosterone levels. Only a moderate decrease in estradiol and no modification of plasma estrone and sex hormone-binding globulin were found, indicating that the hyperestrogenemia of cirrhotic patients could be attributed to an increase in peripheral aromatization of androgens of adrenal origin. The inability of D-tryptophan-6-luteinizing hormone-releasing hormone to reduce the growth of hepatocellular carcinoma is not totally in disagreement with the concept of androgen dependence of hepatocellular carcinoma since D-tryptophan-6-luteinizing hormone-releasing hormone does not inhibit the production of androgens of adrenal origin.

Sucralfate for the prevention of early rebleeding following injection sclerotherapy for esophageal varices

One hundred eighty patients with variceal bleeding and treated by long-term sclerotherapy were randomized into a prospective randomized controlled clinical trial to assess the efficacy of sucralfate in reducing the frequency of rebleeding from esophageal ulceration prior to variceal obliteration. Overall, 29 (32%) of the 92 patients treated with the addition of sucralfate rebled, compared to 37 (42%) of 88 patients managed by sclerotherapy alone (p less than 0.10), but when patients with well-compensated liver disease were considered, the respective figures were 14 (24%) and 25 (42%)--a statistically significant difference (p less than 0.05). The frequency (approximately 70%), number (per patient) and extent of sclerotherapy-induced esophageal mucosal ulceration were not different for the two groups, although proven rebleeding from the ulceration occurred less frequently in those receiving sucralfate (10 and 20 occasions, respectively, p less than 0.05). Mortality was not different for the two groups. Thus, use of sucralfate will reduce the frequency of rebleeding during long-term treatment by sclerotherapy, although benefit appears to be restricted to well-compensated patients and without an endoscopic overt effect upon esophageal mucosal ulceration.

Blunted natriuretic response and low blood pressure after atrial natriuretic factor in early cirrhosis

We compared the natriuretic response to a standard dose of atrial natriuretic factor in nine patients with early cirrhosis (no ascites or edema) with the response in normal subjects displaying a range of baseline sodium excretions due to different sodium intakes (20 mmoles per day, n = 9; 100 mmoles per day, n = 9, and 200 mmoles per day, n = 9). In these normal subjects, sodium output rose, in the same order, from 49 +/- 12 to 177 +/- 26, from 116 +/- 21 to 365 +/- 106 and from 228 +/- 29 to 901 +/- 85 mumoles per min in the first 20 min after 100 micrograms atrial natriuretic factor (human atrial natriuretic factor 99-126). Thus, irrespective of basal excretion, natriuresis rose by at least 2-fold. In the cirrhotic patients, natriuresis rose from 173 +/- 42 to 305 +/- 77 mumoles per min, that is by hardly 1-fold, significantly less than in the normal subjects (p less than 0.01). Renal function studies indicated that atrial natriuretic factor caused less rise in glomerular filtration rate and in fractional sodium excretion. Atrial natriuretic factor induced a fall in blood pressure only in the cirrhotic group, from 130 +/- 4/81 +/- 2 to 108 +/- 4/68 +/- 3 mmHg (p less than 0.001). Plasma atrial natriuretic factor was not low in the cirrhotic patients. Although these data are compatible with a primary disturbance of sodium excretion in early cirrhosis without ascites, such an explanation is complicated by the concomitant drop in blood pressure after atrial natriuretic factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Improved results with selective distal splenorenal shunt in a highly selected patient population. A prospective study

In a 5-year period 299 patients were admitted to the Heinz-Kalk Hospital with bleeding esophageal varices. Patients with acute bleeding were treated with endoscopic sclerotherapy. Sessions were performed as many times as needed for each individual case. One hundred seventy-eight patients in Child-Pugh class C were excluded from surgical treatment; the remaining 121 patients (Child AB) were selected using the following criteria: liver volume (ultrasound) between 1000 to 2500 ml, portal perfusion (sequential scintigraphy) more than 30%, no activity or progression of liver disease proved by biopsy, no stenosis of the hepatic arteries, and suitable anatomy to perform the Warren shunt. Only 32 patients fulfilled these criteria. In seven of these cases the shunt was technically impossible to perform. Operative mortality rate was 8% and the late mortality rate was 12%. No history of rebleeding, encephalopathy, and/or shunt thrombosis was recorded. Five-year survival rate, according to the method of Kaplan-Meier was 75%. We conclude that the Warren shunt is the treatment of choice for elective management of bleeding esophageal varices. The postoperative results can be improved with strict selection using the above criteria. The preoperative use of sclerotherapy has a positive influence. Prophylactic management to prevent encephalopathy is also recommended.

Midazolam versus diazepam for combined esophogastroduodenoscopy and colonoscopy

This study compares the effects of two different benzodiazepines used for conscious sedation during combined upper gastrointestinal endoscopy (EGD) and colonoscopy. Subjects were assessed for their degree of analgesia and amnesia for the procedure, prior experience with endoscopy, and willingness to undergo another similar procedure should such be necessary. The patients were randomized single blind to receive either midazolam or diazepam for their preprocedure sedation. The amount of preprocedure sedation utilized was determined by titration of the dose to achieve slurring of speech. Prior to receiving either agent, the subjects were shown a standard card containing pictures of 10 common objects, were asked to name and remember them, and were told they would be "quizzed" (at 30 min and 24 hr) after being sedated for their recollection as to the objects pictured on the card. Each subject filled out a questionnaire addressing their perceived discomfort during the endoscopic procedure and their memory of the procedure 24 hr after the procedure. Sixty-three percent of the midazolam-sedated subjects reported total amnesia for their colonoscopy vs 20% of diazepam-sedated patients (P less than 0.001). Fifty-three percent of midazolam-sedated patients reported total amnesia of their upper gastrointestinal endoscopy vs only 23% of diazepam-sedated subjects (P less than 0.05). The midazolam-sedated subjects reported experiencing less pain with both upper gastrointestinal endoscopy (P less than 0.05) and colonoscopy (P less than 0.001) than did the diazepam-sedated group. Most importantly, the midazolam group was more willing to undergo another similar endoscopic procedure should they be asked to do so by their physician (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Indocyanine green intrinsic hepatic clearance as a prognostic index of survival in patients with cirrhosis

The prognostic value of quantitative liver function tests in patients with cirrhosis is not clearly established. Indocyanine green intrinsic hepatic clearance (ICG-IHC) is a quantitative liver function parameter independent of liver blood flow, which was shown to correlate strictly with the Child-Turcotte-Pugh (CTP) classification of severity of liver disease. Few data are available on its prognostic value. One hundred and five patients with cirrhosis were studied. ICG-IHC was measured according to the 'sinusoidal perfusion' model. Median ICG-IHC in the whole series was 374 ml/min (interquartile range: 214-496 ml/min). During follow-up (mean 31 months; max. 48 months) 38 patients died. The probability of survival was lower in patients with ICG-IHC lower than 300 ml/min (35% at 48 months) than in patients with ICG-IHC between 300 and 1000 ml/min (70%), or with ICG-IHC over 1000 ml/min (80%) (P = 0.02). Also s-albumin (P less than 0.01), ascites (P = 0.001) and CTP class (P less than 0.001) were significant predictors of survival. On incorporation of age, sex, etiology of cirrhosis, ICG-IHC, s-albumin, s-bilirubin, prothrombin index, ascites and encephalopathy, into a multiple regression analysis according to the Cox's model, the results showed only ascites and s-albumin to be independent significant predictors of survival, while ICG-IHC was not among the covariates independently predictive of survival. When CTP class was added to the investigated covariates, the results showed it as the only independent predictor of survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Frequent endoscopic variceal sclerotherapy increases risk of complications. Prospective randomized controlled study of two treatment schedules

In an effort to determine the optimal dose and frequency of chronic endoscopic variceal sclerotherapy, a prospective randomized controlled study comparing two treatment schedules of sclerotherapy was carried out over a 21-month period. Patients with variceal hemorrhage were randomly assigned to receive sclerotherapy at weekly intervals using injection volumes of greater than 15 cc at each treatment or at mean intervals of three days using volumes of less than 10 cc per treatment. Esophageal perforation occurred in three patients (15%) in the small-dose, frequent-injection group as compared to none in the large-dose weekly treatment group (P = 0.07), leading to premature termination of the study. The mean time to rebleeding was significantly shorter in the small-dose, frequent-treatment group (P = 0.05). Variceal obliteration was achieved in a mean of 66% of patients in both groups with no difference in the time to obliteration or the frequency of other complications. Sclerotherapy offered at less than weekly intervals is less effective and is associated with an increased frequency of serious and life threatening complications.

Human thrombin plus 5 per cent ethanolamine oleate injected to sclerose oesophageal varices: a prospective randomized trial

Fifty cirrhotic Japanese patients with oesophageal varices underwent sclerotherapy in a prospective randomized trial carried out to examine the effects of human thrombin given concomitantly with the sclerosant 5 per cent ethanolamine oleate. The two groups (25 patients each) were comparable with regard to size of the oesophageal varices, and the aetiology and severity of the liver disease. Twenty-five patients, 13 and 12 in the thrombin + and - groups, respectively, had at least one episode of variceal bleeding. The remaining 25 were given prophylactic injections. There was a significantly lower rate of occurrence of bleeding from injection sites when the injection needle was removed at the initial session of sclerotherapy in the thrombin + group, where human thrombin was injected (0.2-0.3 ml, 100-150 units per injection) just before removal of the injection needle. Endoscopy at 1 week after the initial session showed a significantly (P less than 0.05) higher rate of disappearance of red colour signs on varices in the thrombin + group (96 per cent) than in the thrombin - group (72 per cent). Fibrin degradation product E-fraction (FDP-E) values increased 1 h, 1 day and 6 days after the initial session of sclerotherapy in the two groups. The rate of increase in FDP-E values 1 h after sclerotherapy was significantly larger (P less than 0.001) in the thrombin + than in the thrombin - group. There was no clinical sign of disseminated intravascular coagulation. Administration of human thrombin plus a sclerosant seems to be useful and efficacious, especially for patients with huge oesophageal varices.

Portal hypertension

Portal hypertension is a frequent syndrome characterized by a chronic increase in portal venous pressure and by the formation of portal-systemic collaterals. Its main consequence is massive bleeding from ruptured esophageal and gastric varices. Bleeding is promoted by increased portal and variceal pressure, and is favored by dilatation of the varices. The evaluation of the portal hypertensive patient should include the assessment of portal vein patency by ultrasonography, endoscopic evaluation of the presence, size, and extent of esophageal varices, and hemodynamic studies with measurements of portal pressure and of portal-collateral blood flow. The preferred techniques are hepatic vein catheterization and measurement of azygos blood flow. Endoscopic measurements of variceal pressure and estimations of portal blood velocity by the Doppler technique have recently been introduced, but are still research procedures. Acute variceal hemorrhage should be treated under intensive care. Specific therapy to arrest variceal bleeding includes balloon tamponade, vasopressin, somatostatin, sclerotherapy, and emergency surgery. Treatment of portal hypertension is aimed at preventing variceal hemorrhage and bleeding-related deaths. Pharmacologic prophylaxis is based on the use of drugs that cause a sustained reduction in portal pressure; most studies have used propranolol. Surgery and endoscopic sclerotherapy can also be used to prevent rebleeding.

Low dose of nitroglycerin failed to improve splanchnic hemodynamics in patients with cirrhosis: evidence for an impaired cardiopulmonary baroreflex function

High doses of nitroglycerin may decrease portal pressure in patients with cirrhosis with untoward effects such as arterial hypotension and a decrease in systemic O2 uptake. In the present study, low doses of nitroglycerin (7 to 15 micrograms per min, i.v.) were administered in 11 patients with cirrhosis in order to unload cardiopulmonary baroreceptor--one of the possible mechanisms by which nitroglycerin may improve splanchnic hemodynamics--and moreover to avoid deleterious systemic effects. Nitroglycerin significantly decreased right atrial pressure (-35%) and pulmonary wedged pressure (-27%) with significant increase in plasma norepinephrine concentration (+23%), which indicated that cardiopulmonary baroreceptor unloading was achieved. Changes in systemic hemodynamics were slight, although significant, with a decrease in arterial pressure (-8%) and an increase in heart rate (+8%); this indicates a minimal effect on high-pressure baroreflexes. In contrast, no significant change was observed in hepatic venous pressure gradient, hepatic blood flow and azygos blood flow. However, the fraction of cardiac output reaching the azygos system significantly increased by 18%. Plasma renin activity did not change significantly. Moreover, O2 transport and uptake were significantly decreased. These findings show that low doses of nitroglycerin failed to improve splanchnic hemodynamics in patients with cirrhosis. These results suggest an impaired cardiopulmonary baroreflex function which is probably located on the efferent arch.

Spontaneous ruptured hepatocellular carcinoma. An appraisal of surgical treatment

Spontaneous rupture with bleeding is not an infrequent complication of hepatocellular carcinoma (HCC). From May, 1972 to January, 1987, 56 symptomatic patients with ruptured HCC were managed by plication of the lesion (2 patients), ligation of either the common hepatic artery, CHAL, (39 patients), or selectively, the arterial branch supplying the tumor-bearing lobe of liver, SHAL, (8 patients), and hepatic resection, HR, (7 patients). Effective hemostasis was achieved in 68.1% of patients with the use of hepatic artery ligation (HAL). SHAL provides a comparable control of bleeding but no demonstrable reduction of postoperative organ failure when compared with CHAL. The operative treatment employed had no influence on either the postoperative rates of morbidity, mortality, or survival. However, the rate of hospital mortality was high among the four patients who had emergency anatomical lobectomy, despite the absence of severe cirrhosis. Hepatic artery ligation, either CHAL or SHAL, is a satisfactory definitive hemostatic measure for unresectable HCC when it ruptured. SHAL is probably preferred to routine emergency HR for patients with potentially resectable lesions. Nonetheless, for selected patients with easily accessible lesions, segmentectomy or subsegmentectomy could still be contemplated in the absence of severe cirrhosis.

Population pharmacokinetic analysis of bisoprolol

The technique of population pharmacokinetic analysis was employed to study the variability in the dose concentration relationship of bisoprolol during its clinical development. The influence of demographic factors on the variability of clearance was investigated in 3 different populations: group I, patients (including an elderly group) with essential hypertension receiving multiple oral doses of bisoprolol 10 or 20mg for 3 months; group II, patients with different degrees of renal impairment and healthy controls; and group III, patients with different types of hepatic impairment and healthy controls. Patients and controls in groups II and III received only a single oral dose of bisoprolol 10mg. The 3 data sets were analysed separately, using a non-linear mixed effects model (the NONMEM program). A 2-compartment pharmacokinetic model with first-order absorption described the data adequately. The typical values of volume of central compartment, volume of distribution at steady-state and the absorption rate constant for the 3 populations were: for group I, 68L, 235L, and 0.7h-1; for group II, 28L, 179L, and 0.3h-1; and for group III, 55L, 256L, and 0.4h-1, respectively. Plasma clearance was related to age in group I, to serum creatinine in group II and to aspartate transaminase activity in group III. The 68% confidence limits for clearance and elimination half-life were 8.2 to 21.5 L/h and 7.6 to 19.7h, respectively, for 50-year-old patients in group I. The analysis predicted that progressive increases in serum creatinine or aspartate transaminase activity will result in only a 50% reduction of clearance.

Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates

The importance of variable time of entry for analysis of survival following variceal bleeding has recently been disputed. In a study of 194 cirrhotic patients with bleeding esophageal varices in whom 2-day mortality was 3%, statistically significant differences in both survival and rebleeding rates were obtained by shifting the starting point for analysis of survival by 2 weeks following admission to hospital or by 5 days for the analysis of rebleeding. In addition, the curve of hazard function for death or for failure to control bleeding following admission clearly showed that any change in entry time in a study of variceal bleeding would introduce bias and alter survival or rebleeding rates. Thus, the starting point for analysis following variceal hemorrhage is an important confounding variable when calculating both survival and rebleeding. It should always be taken into account, particularly in clinical trials, which are often performed in centers where patients are referred from other hospitals at different times following bleeding.

Prophylactic endoscopic sclerotherapy of oesophageal varices in liver cirrhosis. A multicentre prospective controlled randomised trial in Vienna

The effect of prophylactic treatment of oesophageal varices by endoscopic injection sclerotherapy before the first episode of variceal haemorrhage was studied in patients with cirrhosis in a prospective, randomised and controlled multicentre trial. From February 1984 to March 1987 patients with liver cirrhosis and large varices (stage III-IV according to Paquet) were treated and followed up. The sample comprised 87 patients: 45 in the prophylactic treatment and 42 in the control group. After excluding drop outs, 41 patients were treated in each group. Twenty nine per cent of patients in the sclerotherapy group and 34% in the control group had a variceal haemorrhage during the period of observation. There was no significant difference in the distributions of the bleeding free intervals between the sclerotherapy and the control groups. During the follow up period 24% of patients in the sclerotherapy group and 46% in the control group died. The distribution of survival times indicates a tendency towards longer survival of patients with prophylactic sclerotherapy, particularly in those with alcoholic cirrhosis.

Pharmacodynamic and pharmacokinetic study of propranolol in patients with cirrhosis and portal hypertension

1. The aim of this study was to investigate the pharmacokinetics and the beta-adrenoceptor blocking activity according to time of conventional (C) and long acting (LA) propranolol in cirrhotic patients. Twenty-four patients with alcoholic cirrhosis and oesophageal varices were randomly assigned to receive either 160 mg C propranolol, 160 mg LA propranolol or placebo acutely and then following repeated administration (acute and chronic phases). Thereafter propranolol concentrations and beta-adrenoceptor blockade (resting and exercise heart rates) were measured at different intervals. 2. The Cmax was significantly higher with C propranolol in both phases. The time of Cmax was significantly later with LA propranolol in both phases. The AUCs were significantly higher after chronic administration with both formulations of propranolol. 3. The exercise peaks of beta-adrenoceptor blockade were similar between the two formulations and between the two phases of administration of propranolol. The duration of effective beta-adrenoceptor blockade was significantly longer in the chronic phase and seemed to be longer with LA than with C propranolol although this was not significant (72 +/- 31 vs 48 +/- 18 h, respectively). 4. There was a significant correlation between the log propranolol concentration and exercise heart rate but not with resting heart rate. No correlation could be demonstrated between pharmacological data and the Child Pugh score. 5. We conclude that in cirrhotic patients exercise testing was a reliable method in the assessment of beta-adrenoceptor blockade. Pharmacology of propranolol was found to be different according to the formulation or to the phase of administration.

Esophageal tamponade in the management of acute variceal hemorrhage

Over a seven-year period, 138 patients with portal hypertension presented on 223 occasions with endoscopically proven acute variceal hemorrhage. Hemorrhage ceased spontaneously on 92 occasions (41%). On 126 occasions (57%) passage of the four-lumen modification of the Sengstaken-Blakemore tube was required, and hemorrhage was successfully controlled in 98%. Intubation was refused on five occasions (2%). Hemorrhage recurred during these 223 admissions on 47 occasions (21%); on 11 occasions a second rebleed occurred and on two occasions, a third. Tamponade was required during all of these rebleeds and arrest of hemorrhage was achieved in 87%. Hemorrhage in patients with poorer modified Child's grade was less likely to cease with intubation. The overall rate of control in the 186 episodes of hemorrhage requiring tamponade was 94%. There were 28 complications attributed to the use of tamponade in 186 episodes of hemorrhage (15%). On 12 occasions these complications proved fatal (6.4%). In four further patients failure of tamponade to control hemorrhage was fatal.

Renal function and effective beta-blockade in cirrhosis with ascites. Relationship with baseline sympathoadrenergic tone

Renal function, plasma norepinephrine, renin activity (PRA) and aldosterone were determined in 17 cirrhotics with ascites, before and after effective beta-blockade (resting heart rate reduction greater than or equal to 20%) induced by oral propranolol. The drug lowered PRA (from 2.86 +/- 0.96 (S.E.) to 1.86 +/- 0.7 ng/ml/h; P less than 0.005) and plasma aldosterone (from 309.0 +/- 59.2 to 202.6 +/- 26.7 pg/ml; P less than 0.005). As expected, plasma norepinephrine (PNC) increased from 90.7 +/- 12.2 to 176.8 +/- 43 ng/l (P less than 0.01) in the 10 patients with normal basal values ('normal-PNC' group), but it decreased in 6 of the 7 patients with basal sympathoadrenergic hypertone ('high-PNC' group; mean value from 352.6 +/- 37.8 to 273 +/- 39.3 ng/ml (P = 0.06). Glomerular filtration rate and filtered sodium load did not change in the group as a whole and in 'normal-PNC' cirrhotics (from 83.2 +/- 7.1 to 81.4 +/- 7.8 ml/min, and from 11.63 +/- 0.96 to 11.45 +/- 1.14 mmol/min), but rose in 'high-PNC' patients (from 60.7 +/- 9.1 to 109.3 +/- 27.2 ml/min, and from 8.39 +/- 1.31 to 15.47 +/- 3.95 mmol/min; P less than 0.05). Renal sodium excretion increased from 2.45 +/- 0.75 to 3.16 +/- 1.01 mmol/h (P less than 0.01) in the group as a whole. Such an increase, however, was confined to 'high-PNC' cirrhotics. In this group, the tubular rejection fraction did not change and post-beta-blockade sodium excretion was correlated with the filtered sodium load (Rs = 0.83; P less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of platelet aggregation by abnormal high density lipoprotein particles in plasma from patients with hepatic cirrhosis

ADP-induced aggregation of normal washed platelets was measured by nephelometry in the presence of plasma high density lipoprotein (HDL) from normal subjects and from 30 patients with hepatic cirrhosis. HDL, at one-eighth of its plasma concentration, inhibited platelet aggregation; the effect of cirrhotic HDL (40% [SD 29%] inhibition) was significantly greater than that of normal HDL (16% [11%]). The mean apolipoprotein E content of cirrhotic HDL was significantly higher than that of normal HDL, and strongly inhibitory HDL contained twice as many apolipoprotein-E-rich particles as weakly inhibitory HDL. Inhibition of platelet aggregation was correlated with the apolipoprotein E content of HDL from patients with cirrhosis.

Superiority of the Child-Pugh classification to quantitative liver function tests for assessing prognosis of liver cirrhosis

To evaluate the prognostic value of quantitative liver function tests in comparison with established prognostic variables, the data of 47 patients with liver cirrhosis were analysed. A total of 16 variables, comprising the galactose elimination capacity and the indocyanine green clearance, the Child-Pugh classification, and several clinical and biochemical variables were subjected to Kaplan-Meier life-table analysis and Cox proportional hazards regression analysis. As independent variables, poor prognosis was associated significantly with increasing Child-Pugh score (p less than 0.00001), whereas the galactose elimination capacity (p = 0.03) and the indocyanine green clearance (p less than 0.001) were less sensitive indicators. The regression analysis showed prognostic value in decreasing sequence for Child-Pugh classification, age, sex, history of upper GI haemorrhage, and alkaline phosphatase activity. The quantitative liver function tests evaluated in the present work have less prognostic value than routinely accessible variables.

Propranolol in prevention of rebleeding from oesophageal varices during the course of endoscopic sclerotherapy

Thirty-one patients admitted with the first bleeding episode from oesophageal varices were randomized in a double-blind manner to receive oral propranolol, 160 mg daily, for 6 months (n = 15) or matching placebo (n = 16) for the same period. Endoscopy was performed each month during the 6 months and additionally after a further 3 months. The oesophageal varices were injected paravariceally with 2% aethoxysclerol until obliteration. If rebleeding occurred, additional sclerotherapy was performed. In the group treated with sclerotherapy and propranolol 3 patients rebled (20%; 95% confidence limits, 4%-48%), whereas 12 patients treated with sclerotherapy and placebo rebled (75%; 95% confidence limits, 48%-93%; p less than 0.05). There were no side effects to treatment in either of the groups, and it is concluded that administration of propranolol reduces the frequency of variceal rebleeding before variceal obliteration during a course of endoscopic sclerotherapy.

Antipyrine clearance per unit liver volume in cirrhotics with and without hepatocellular carcinoma indicating a correlation with histological change of the liver

The antipyrine metabolizing capacity was studied in 12 patients with cirrhosis of the liver and 12 with cirrhosis and hepatocellular carcinoma (HCC). Antipyrine clearance (Cl) and liver volume (LV) were measured and the antipyrine clearance per unit liver volume (Cl/LV) was calculated. The patients with HCC showed a significantly lower Cl value than those without HCC but there was no significant difference in Cl/LV between the two groups. This suggested that the lower Cl values in the HCC patients resulted from a decrease in residual liver mass. Cl/LV showed positive correlation with % parenchymal cell mass as an indicator of residual parenchymal cell mass per unit volume of liver. This result showed a correlation of Cl/LV with histological change of the liver in cirrhotics.

Propranolol does not alter cerebral blood flow and functions in cirrhotic patients without previous hepatic encephalopathy

Since it has been suggested that propranolol could lead to hepatic encephalopathy, we undertook a study to assess the effects of propranolol on cerebral blood flow and cerebral functions. Sixteen patients with alcoholic cirrhosis and large esophageal varices and without major hepatic dysfunction (Child-Pugh score less than 14) or previous hepatic encephalopathy were randomized to receive either propranolol or placebo. The following measurements were performed before and 15 min after single intravenous administration of 15 mg propranolol or placebo and again 1 week after chronic oral administration of propranolol 160 mg per day or placebo: cerebral blood flow by the xenon-133 inhalation technique, quantitative electroencephalogram, psychometric test (number connection test), arterial ammonia, pH and pCO2, resting and exercise heart rates (after single administration, electroencephalogram, number connection test and biochemical measurements were not performed). Cerebral blood flow was not significantly modified by treatment (propranolol group: 80 +/- 23 vs. 76 +/- 11 and 83 +/- 9; placebo group: 73 +/- 10 vs. 75 +/- 11 and 81 +/- 18 ml per 100 gm per min, respectively, before and after single and repeated administration). Likewise, neither of the two treatments significantly altered number connection test, quantitative electroencephalogram index, arterial ammonia, pH and pCO2. We conclude that, in this population of cirrhotic patients, propranolol did not alter cerebral blood flow or neuropsychological functions. As a consequence, hemodynamic alterations cannot be considered as causes of possible cerebral side effects of propranolol in cirrhotic patients without severe hepatic dysfunction and previous hepatic encephalopathy.

Polymorphonuclear cell count response and duration of antibiotic therapy in spontaneous bacterial peritonitis

The purposes of this study were (a) to measure serially ascitic fluid polymorphonuclear cell response in treated spontaneous bacterial peritonitis and (b) to determine whether an ascitic fluid polymorphonuclear cell count of less than 250 per mm3 on serial paracenteses was a satisfactory endpoint for antibiotic therapy. Thirty of 33 patients showed an exponential fall in ascitic fluid polymorphonuclear cell count after 48 hr of antibiotic therapy; the magnitude of decrease correlated with survival (p less than 0.01). Among the patients whose antibiotic therapy was discontinued when the ascitic fluid polymorphonuclear cell count reached 250 per mm3 or less, the duration of therapy was considerably shorter than for the patients who received "conventional" therapy (p less than 0.01). Recurrence of spontaneous bacterial peritonitis was similar in the two groups. Mortality correlated with the severity of underlying liver disease but not with duration of antibiotic therapy.

Atrial natriuretic factor and renin-aldosterone in volume regulation of patients with cirrhosis

The role of the atrial natriuretic factor and of the main counteracting sodium-retaining principle, the renin-aldosterone system, in acute volume regulation of cirrhosis of the liver has been investigated. Central volume stimulation was achieved in 21 patients with cirrhosis, 11 without and 10 with ascites, and 25 healthy controls by 1-hr head-out water immersion. Immersion prompted a highly significant (p less than 0.001) increase of atrial natriuretic factor plasma concentrations in cirrhotic patients without ascites from 8.5 +/- 1.3 fmoles per ml to 16.5 +/- 2.6 fmoles per ml, comparable to the stimulation in control subjects (6.0 +/- 0.6 fmoles per ml to 13.6 +/- 2.6 fmoles per ml). In cirrhotic patients with ascites, atrial natriuretic factor increase (from 7.7 +/- 1.3 fmoles per ml to 11.4 +/- 2.3 fmoles per ml) was blunted (p less than 0.05). Plasma renin activity and plasma aldosterone concentration were elevated in cirrhotic patients, especially in the presence of ascites. Following immersion, plasma renin activity and plasma aldosterone concentration were reduced similarly in all groups. Water immersion induced a more pronounced natriuresis and diuresis in control subjects than in cirrhotic patients. Neither atrial natriuretic factor nor plasma renin activity nor plasma aldosterone concentration alone correlated to sodium excretion. However, atrial natriuretic factor to plasma aldosterone concentration ratios were closely correlated to basal and stimulated natriuresis in cirrhotic patients, particularly in those with ascites. These data suggest that atrial natriuretic factor and the renin-aldosterone system influence volume regulation in patients with cirrhosis.

Randomized controlled study of propranolol for prevention of recurrent esophageal varices bleeding in patients with cirrhosis

A randomized controlled trial of propranolol was conducted in 36 adult cirrhotic patients after active esophageal variceal hemorrhage had been controlled. Seventy-eight percent of the 18 patients on propranolol and 72% of the patients on a placebo were of Pugh's class A. Of the patients treated with propranolol, 94%, 87%, 68% and 57% were free from rebleeding 6, 12, 18 and 24 months after entry, respectively. The corresponding figures in control patients were 81%, 59%, 30% and 15%, respectively. The percentages of patients free from rebleeding were significantly higher in the propranolol group than in the control group (P less than 0.05). No significant adverse effect was observed during the study, except for a patient who developed hepatic decompensation 14 months after propranolol therapy. It was concluded that propranolol was a safe and effective drug for the prevention of variceal rebleeding in patients with good liver functional reserve.