Transection of the oesophagus for bleeding oesophageal varices

Prospective randomized trial comparing two injection techniques for sclerosing oesophageal varices: over-tube and free-hand

The safety, efficacy and complications of two techniques of endoscopic injection sclerotherapy were examined in 102 consecutive patients, using either a totally transparent over-tube or the free-hand technique. The choice of treatment was at random. There was a significantly higher control of variceal bleeding when the over-tube technique was used (100 per cent versus 77 per cent, P less than 0.05). The frequency of re-bleeding before the eradication of oesophageal varices was significantly less in the over-tube group than in the free-hand group (P less than 0.01), although all re-bleedings were well controlled with additional injections of 5 per cent ethanolamine oleate. There was no significant difference between the two techniques with regard to the frequency of endoscopic injection sclerotherapy for eradication of oesophageal varices. The over-tube technique is safer than the free-hand technique and takes less time to accomplish; at the initial session of treatment, time and bleeding during these techniques were 11.5 +/- 2.3 min (mean +/- s.d.) and 7.3 +/- 5.9 ml in the over-tube technique, and 20.4 +/- 4.1 min and 45.1 +/- 30.0 ml in the free-hand technique (P less than 0.001, in both time and bleeding).

Variceal bleeding: does variable delay in trial entry invalidate comparison between trials?

Variation in time of patient admission to studies of prognosis after variceal haemorrhage has been proposed as a major factor in the wide range of reported results. A study of 144 unselected subjects with a low initial mortality (3% at two days) suggests that the effect has been overemphasised and studies in which time of entry is later than the date of bleeding may be usefully compared. Reanalysis of previous work suggests that even in populations with a high initial mortality limited comparisons between studies can still be usefully made. It is stressed that survival analysis must be started from the date of study entry and not from the date of the index bleed which involves incorporating a retrospective period of survivorship.

Pharmacokinetics of erythromycin in patients with severe cirrhosis. Respective influence of decreased serum binding and impaired liver metabolic capacity

Pharmacokinetic parameters were studied after i.v. infusion of erythromycin (500 mg) in five patients with alcoholic cirrhosis and six normal subjects. Serum AAG levels were 4.7 +/- 2.4 mumol l-1 in cirrhotics and 10.3 +/- 2.1 +/- mumol l-1 in normals. The unbound fraction (fu) of erythromycin was significantly higher in cirrhotic patients (58.3 +/- 17.7%) than in normal subjects (30.5 +/- 2.8%, P less than 0.01), and a negative correlation was found between fu values and serum AAG (r = -0.867, P less than 0.01). Due to increase in fu, volume of distribution (Vss) was significantly augmented in cirrhotics (85.5 +/- 23.8 l vs 57.6 +/- 14.8 l, P less than 0.05). Serum clearance of unbound erythromycin (CLu) was significantly reduced in cirrhotic patients (42.2 +/- 10.1 l h-1 vs 113.2 +/- 44.2 l h-1 in normal subjects, P less than 0.01). This led to marked elevation of serum concentrations of unbound drug and was entirely explained by the decrease of non renal (i.e. hepatic intrinsic) clearance (31.6 +/- 7.5 l h-1 in cirrhotics, 98.6 +/- 41.5 l h-1 in normals, P less than 0.02); renal clearance remained unchanged. It is concluded that in cirrhotic patients, low serum AAG levels and reduced liver metabolic capacity may lead to marked changes in pharmacokinetics of erythromycin, and that similar results might be expected for drugs which exhibit the same serum binding and pharmacokinetic behaviour as erythromycin.

[Sex hormones and the hypophyseo-gonadal axis in females with liver cirrhosis in postmenopause]

The hormonal status of men with cirrhosis of the liver has been investigated in numerous studies. Little, however, is known about changes of sexual hormones in women afflicted by this disorder. In a study of 31 postmenopausal women (mean age 63 +/- 8 years) suffering from cirrhosis of various etiology (alcoholic, n = 8; posthepatitic B, n = 1; PBC, n = 5; cryptogenetic, n = 17) the blood levels of estradiol (E2), estrone (E1), androstenedione (A), testosterone (T) and basal and stimulated values of gonadotropins are reported and compared with the data obtained in an age-matched control group (n = 9). In cirrhosis a significant increase of the median E2 (28 vs 12 pg/ml, P less than 0.01) was found, whereas the changes of the blood levels of E1 (88 vs 76 pg/ml), A (63 vs 111 ng/dl), and T (0.30 vs 0.15 ng/ml) did not attain statistical significance in comparison to controls. Within the study group, however, a significant positive correlation with the degree of decompensation of cirrhosis (Childscore A-C) was observed for the steroid hormones measured. Thus, in subgroup C the hormone levels are higher than physiologically expected for postmenopausal women. On the other hand the median FSH (32 vs 48 mU/ml, P less than 0.05) is significantly lower in cirrhosis compared to controls with a trend to decreased values of LH. Very low levels of LH and FSH are found in decompensated cirrhosis. The decrease of LH and FSH can partly be explained by the rise of peripheral hormones (i.e. E2, E1, and in some cases T and A).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery in the patient with liver disease

This article deals with the effects of anesthesia and surgery on the healthy and diseased liver and the preoperative assessment of patients with liver disease. Emphasis is placed on estimating surgical risk. Guidelines for optimal preoperative preparation are discussed.

Propranolol for prevention of recurrent gastrointestinal bleeding in patients with cirrhosis: a prospective study of factors associated with rebleeding

In a previous randomized trial, we demonstrated that propranolol prevented recurrent gastrointestinal bleeding in patients with cirrhosis. We have undertaken the present study in a new group of patients to ascertain the factors associated with rebleeding. Among 232 patients with cirrhosis admitted for gastrointestinal bleeding, 127 were included. They received propranolol orally at a dose reducing the heart rate by 25%. The median follow-up period was 682 days. The following factors were studied: cause of cirrhosis; severity of cirrhosis; hepatocellular carcinoma recognized after inclusion; compliance; persistent decrease in heart rate; dose of propranolol; alcohol abstinence; previous history of hemorrhage; time interval from hemorrhage to onset of propranolol administration, and source of bleeding. The percentage of patients free of rebleeding was 71% at 1 year and 57% at 2 years. Only five factors were significantly and independently associated with rebleeding: occurrence of hepatocellular carcinoma; lack of compliance; lack of persistent decrease in heart rate; lack of abstinence, and previous history of bleeding. In conclusion, this study confirms the results of our previous trial and suggests that certain factors play a role in the mechanism of rebleeding in patients receiving propranolol.

Prevention of recurrent bleeding in cirrhotics with recent variceal hemorrhage: prospective, randomized comparison of propranolol and sclerotherapy

To compare the efficacy of endoscopic paravariceal sclerotherapy and oral propranolol in the prevention of recurrent upper gastrointestinal bleeding, 78 cirrhotic patients were randomly assigned to either treatment after an endoscopically proven bleed from esophageal varices. After randomization, but before treatment had been started, a total of eight patients had to be withdrawn from the study due to early rebleeding (requiring emergency sclerotherapy) or violations of the protocol. Among the 70 patients analyzed (36 sclerotherapy, 34 propranolol), both treatment groups were comparable with respect to demographic, clinical and laboratory data. The groups also did not differ with respect to continued alcohol intake. Sclerotherapy was performed twice weekly using 1% polidocanol as the sclerosing agent until the varices were eradicated or well-covered by fibrous tissue. Propranolol was given twice daily at a dose reducing the resting heart rate by 25% (60 to 320 mg per day; mean +/- SD = 161 +/- 80 mg per day). Patients were followed for up to 2 years with visits at 3 monthly intervals (mean follow-up = sclerotherapy, 14 months; propranolol, 9.2 months). Life table analysis of patients without rebleeding from nonvariceal sites revealed a tendency in favor of propranolol; however, the difference did not reach statistical significance. No significant difference was observed between sclerotherapy and propranolol in the proportion of patients rebleeding from esophageal varices or from all sources of upper gastrointestinal bleeding. Furthermore, survival was similar in both treatment groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Sonographic evaluation of the portal venous system after elective endoscopic sclerotherapy of esophageal varices

In order to evaluate possible changes in the portal venous system after endoscopic sclerosis of esophageal varices, 25 cirrhotic patients underwent abdominal ultrasonography before the first session of sclerotherapy and after eradication of esophageal varices had been achieved. The caliber of the portal, splenic, and superior mesenteric veins was measured sonographically in each case. Sonographic results were compared statistically before and after sclerotherapy. Neither evidence of significant variations in the caliber of the portal veins nor thrombotic obliteration was seen. These results support the view that sclerotherapy has no significant negative side effects on the portal venous system.

Hemodynamic effects of a clonidine-induced decrease in sympathetic tone in patients with cirrhosis

A decrease in plasma noradrenaline--a reflection of sympathetic nervous system activity--by clonidine, a centrally acting alpha 2-agonist, could reduce the hyperdynamic circulation observed in cirrhosis and may thereby decrease portal hypertension. Plasma noradrenaline concentration and plasma renin activity as well as systemic and splanchnic hemodynamics were measured in 12 patients with cirrhosis and ascites before and after administration of either 150 micrograms of clonidine or placebo. Plasma noradrenaline concentration significantly decreased in all patients after clonidine administration, whereas plasma renin activity did not change significantly. There were statistically significant reductions of cardiac output (-17.4%), mean arterial pressure (-12.2%), hepatic venous pressure gradient (-19.7%) and azygos blood flow (-26.6%) after administration of clonidine. No significant correlation was found between the reduction of plasma noradrenaline concentration and changes in systemic or splanchnic hemodynamics. Hepatic blood flow was not changed by clonidine. Placebo administration had no effect on any laboratory or hemodynamic measurement. We conclude that the reduction in sympathetic nervous system activity by clonidine and the subsequent decrease in the hyperdynamic circulation suggests that sympathetic overactivity contributes to the circulatory derangements in patients with cirrhosis.

Denver peritoneovenous shunting for malignant or cirrhotic ascites. A prospective consecutive series

A Denver peritoneovenous (PV) shunt was inserted in 54 consecutive patients for relief of malignant (24 patients) or cirrhotic (30) refractory ascites. The median age of both groups was 58 years, and the most frequent diagnoses were gastrointestinal (15) or ovarian (7) cancers and alcoholic cirrhosis (25). Median survival time was 1.7 and 3.5 months (range, 0.1-15.5 and 0.1-50.5), and the 1-month mortality 42% and 27%, respectively. Postoperative 24-h urinary output increased by 2-31, and the 1-week weight reduction was 8 and 11 kg, respectively, compared with before shunting. Complete shunt failure was encountered early in two patients, due to catheter malposition and clotting. Four more patients experienced transient failure, for an early dysfunction rate of 11%. A shunt-related operative mortality of 6% was caused by pulmonary oedema (two patients) and sepsis (one patient). Shunt malfunction intervened in almost half (6 of 14) of the cancer patients surviving 1 month but was relieved in all but 1. In 3 of 22 cirrhotic 1-month survivors, the Denver shunt had to be removed owing to clotting or sepsis (2 patients) or revised because of blockage. Seven patients with cirrhosis are alive a median of 18 months (range, 2-51) after PV shunt surgery. Side effects were detected in 22 patients (41%): thromboembolism (9 patients), sepsis (7), initially bleeding oesophageal varices (3), DIC syndrome (2), postoperative hepatic coma (2), ascitic leakage (2), and pulmonary oedema (2). Patients with gastrointestinal cancers or severe cardiac disease did not benefit from the procedure. A history of hepatic encephalopathy or a serum bilirubin level above about 100 mumol/l was a bad prognostic sign. We could confirm the reported considerable morbidity and mortality after PV shunting, but also its efficiency in certain cases. Careful patient selection and follow-up study, timing of operation, and adherence to technical details are mandatory to improve the results.

Sedation for gastroscopy: a comparative study of midazolam and Diazemuls in patients with and without cirrhosis

A double-blind controlled study comparing the effects of intravenous Diazemuls (0.15 mg kg-1) with midazolam (0.07 mg kg-1) in patients with normal liver function and with cirrhosis and portal hypertension is described. The clinical effect of the two drugs was assessed by serial tests of psychomotor function before and at varying intervals after administration. Using this dosage regime, midazolam caused significantly greater impairment in psychomotor function in both cirrhotic and non cirrhotic subjects, and the time taken for recovery of normal function was also significantly prolonged. Patients with cirrhosis showed a significantly prolonged recovery time following administration of either benzodiazepine compared with the controls. Administration of midazolam in a lower dose might reduce the degree of sedation and shorten the recovery time, but this could also lead to a loss of some of the amnesic effect. Caution is recommended in the administration of benzodiazepines to patients with cirrhosis.

Effect of branched chain amino acid infusions on body protein metabolism in cirrhosis of liver

Thirty seven patients with established cirrhosis of the liver were subjected to measurement of body protein metabolism using L-(1-14C) labelled leucine as a tracer. The effects of disease severity and those of solutions containing 0%, 16%, 35%, 53%, and 100% branched chain amino acids were evaluated. Significant increases in protein synthesis were noted with solutions containing 35%, 53%, and 100% branched chain amino acids, but in patients receiving 100% branched chain amino acids without additional essential amino acid supplement the increase in synthesis was matched by a significant increase in protein breakdown. Protein balance was thus improved only in patients receiving 35% and 53% branched chain amino acids. It was concluded that the high increase in protein breakdown in patients receiving 100% branched chain amino acids was undesirable, and such a solution should not be recommended for clinical use.

Propranolol for the prevention of recurrent variceal hemorrhage: a controlled trial

We conducted a prospective, randomized single-blind trial of propranolol for the prevention of recurrent variceal bleeding. Seventy-nine patients shown to have variceal hemorrhage at endoscopy were included in the study within 72 hr following diagnosis. Fifty-seven patients had alcoholic cirrhosis, 10 cryptogenic cirrhosis, 6 posthepatitic cirrhosis, 4 biliary cirrhosis, 1 portal vein thrombosis without cirrhosis and 1 idiopathic portal hypertension. The severity of liver disease at inclusion was assessed according to the Pugh modification of the Child-Turcotte classification: 9 (11%) had Class A; 41 (52%) Class B, and 29 (37%) Class C disease. Patients were randomly assigned by sealed envelope to the propranolol group (42 patients) or the placebo group (37 patients). Propranolol dosage was titrated in order to produce plasma concentrations of propranolol of 50 to 150 ng per ml. beta-blockade was also confirmed by isoproterenol testing. The cumulative percentages of patients free of rebleeding 1 and 2 years after inclusion were 31 and 21% in the propranolol group, and 25 and 17% in the placebo group; both differences were not significant. Cumulative 1 and 2 years survival were also comparable: 64 and 54% in the propranolol group vs. 70 and 63% in the placebo group. There was no evidence for a therapeutic effect of propranolol after adjusting for potential confounding variables by multiple logistic regression. We conclude that propranolol is not effective for the prevention of variceal rebleeding, when administered early following the initial bleed, in cirrhotics unselected with respect to the severity of the liver disease.

Sympathetic tone modulates portal venous pressure in alcoholic cirrhosis

Sixteen alcoholic cirrhotic patients with portal hypertension were studied before and after 2.5 micrograms/kg intravenous clonidine. In six patients portal venous pressure was assessed simultaneously by wedged hepatic vein and transhepatic portal vein cannulation. Wedged hepatic vein pressure accurately reflected portal venous pressure both before and after clonidine (r = 0.912 and 0.940; p less than 0.01). In all the other ten patients, sympathetic tone, measured by total plasma noradrenaline spillover, was high (755 +/- 123 ng/min; normal 296 +/- 29 ng/min). It fell significantly after clonidine (378 +/- 95 ng/min; p less than 0.01). This fall was associated with a decrease in corrected wedged hepatic vein pressure (18.6 +/- 1.1 to 13.4 +/- 0.5 mm Hg; p less than 0.01) but no change in estimated hepatic blood flow (934 +/- 94 to 976 +/- 102 ml/min), indicating a fall in postsinusoidal hepatic vascular outflow resistance. Clonidine-induced changes in mean arterial pressure and cardiac output were independent of the change in portal venous pressure. The results suggest that in alcoholic cirrhosis there is a labile component of hepatic vascular resistance which is partly under sympathetic nervous control and is thus potentially sensitive to pharmacological control.

Results of a randomized trial of end-to-side portacaval shunt and distal splenorenal shunt in alcoholic liver disease and variceal bleeding

Since 1976, we have compared the end-to-side portacaval shunt (PCS) with the distal splenorenal shunt (DSRS) in patients with alcoholic liver disease and recurrent variceal bleeding. Fifty-four patients were randomly assigned to receive either shunt procedure. There were 27 patients in each group and both groups were highly comparable in clinical and laboratory characteristics. Median follow-up was 31 mo in each group. Postoperative complications and operative mortality (7% after PCS, 12% after DSRS) were comparable. Spontaneous portasystemic encephalopathy developed in 32% of the patients at risk after PCS and in 39% after DSRS. Rebleeding from varices occurred in 4% of the patients after PCS and in 27% after DSRS. Cumulative survival was not significantly different between groups (5-yr survival: 31% after PCS, 43% after DSRS). We have failed to demonstrate superiority of DSRS in our patients with alcoholic liver disease with respect to postoperative encephalopathy or survival, and have experienced an unusually high rate of variceal rebleeding after DSRS.

Influence of the degree of liver failure on systemic and splanchnic haemodynamics and on response to propranolol in patients with cirrhosis

Systemic and splanchnic haemodynamics were studied in patients with cirrhosis who had been classified in three groups (A, B, and C) according to the degree of liver failure (modified Pugh's classification). In patients of group A, cardiac index was significantly lower than that of group C and systemic vascular resistance was higher, but not significantly so, than that of patients with liver failure. Wedged hepatic venous pressure was significantly lower in the former group than in the latter. In patients in group B, corresponding values fell between those of groups A and C. Azygos blood flow averaged 0.477 +/- 0.242 l/min (mean +/- SD) in group A and it was significantly lower than in groups B and C (0.642 +/- 0.224 and 1.061 +/- 0.476 l/min, respectively). In the three groups, acute administration of propranolol induced statistically significant changes in systemic and splanchnic haemodynamics. In patients of group C but not of group B, the mean value of azygos blood flow after propranolol remained significantly higher than in group A. Moreover, the fraction of azygos blood flow to cardiac output decreased in groups A and B while slightly increased in group C. This study shows that in patients with cirrhosis, the degree of liver failure may be a determinant for the haemodynamic responses to drugs acting on portal hypertension.

Prognostic value of the aminopyrine breath test in cirrhotic patients

The aminopyrine breath test has been proposed as a quantitative test of hepatic function, but its long-term prognostic value in patients with cirrhosis has not been determined. The aim of this study was to examine the usefulness of the aminopyrine breath test in assessing prognosis and to compare it with traditional methods of evaluating liver function. One-hundred eighty-seven patients with histologically confirmed cirrhosis were studied prospectively. An aminopyrine breath test was obtained at the time of inclusion in the study and results were expressed as per cent of the dose excreted in 2 hr. At inclusion, the severity of liver disease was also assessed according to the Pugh modification of the Child-Turcotte classification based on ascites, neurological status, serum albumin, serum bilirubin and prothrombin time. Mean follow-up was 844 days. During that period, 59 of 187 patients died of their liver disease. Two-year survival decreased with increasing Child-Turcotte classification score: survival was 98% in Child Class A patients (n = 62), 66% in Child Class B (n = 76) and 36% in Child Class C (n = 49) (chi 2 = 65.6, p less than 0.001). Two-year survival also decreased significantly with increasing degree of aminopyrine breath test abnormalities: survival was 90% in patients with aminopyrine breath test greater than 4% (n = 56); 78% in patients with aminopyrine breath test = 2 to 4% (n = 66), and 43% in patients with aminopyrine breath test less than 2% (n = 65) (chi 2 = 36.9, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic sclerotherapy for esophageal varices

Sclerotherapy for esophageal varices is now well established as a method of treatment for varices which have bled initially and then have been controlled by medical means. The long term outcome of such treatment is now under study. The value of sclerotherapy for acutely bleeding varices or as a prophylactic measure in patients with varices that have not bled is more controversial and its role awaits the outcome of additional controlled trials.

The management of acutely bleeding varices by injection sclerotherapy

Acutely bleeding varices present a therapeutic dilemma because of the limited efficacy and high complication rates of conventional treatments. Over a period of 26 months, 56 episodes of acutely bleeding varices were treated with injection sclerotherapy as the initial management. Immediate control of haemorrhage was achieved in 91% of patients and control of bleeding during the hospital admission in 84%. Balloon tamponade and surgery were reserved for those patients in whom bleeding was not controlled by sclerotherapy; in 66% of patients the bleeding was controlled by sclerotherapy alone. Of the 56 episodes, 75% survived their admission to hospital. Acute injection sclerotherapy is as least as effective as conventional therapies in the control of bleeding with a low incidence of complications. The technique can be used in all patients irrespective of the severity of their liver disease and, when bleeding is controlled, allows the physician the choice of all the available prophylactic therapies.

Distal splenorenal (Warren) shunt in the management of actively bleeding oesophageal varices

Distal splenorenal shunts have been performed on 53 patients during or soon after variceal haemorrhage. In 38 patients active haemorrhage was occurring at the time of operation or was controlled by tamponade and 12 of these patients died. There was no mortality in the semi-elective group. A higher mortality was found in patients with poor liver reserve and in whom prolonged conservative management had been attempted. Rebleeding occurred in 20 per cent of patients in the early postoperative period and this was a significant factor in the death of three patients. Of 39 patients with longer term follow-up, 8 suffered minor encephalopathy. Subsequent mortality could be related to the progression of liver disease and was no worse than that seen in a population of cirrhotic patients.

Use of propranolol to reduce the rebleeding rate during injection sclerotherapy prior to variceal obliteration

In a prospective, randomized controlled trial, 53 patients with variceal hemorrhage from portal hypertension, including 44 with cirrhosis, were allocated, after initial control of the bleeding, to treatment by sclerotherapy alone, or by this together with oral propranolol in a dose sufficient to reduce resting pulse rate by 25% during the period up to the time when varices were obliterated. Eight of the 27 patients undergoing sclerotherapy alone rebled during this period as compared to 7 of the 26 patients in the additional propranolol group (p greater than 0.80), two patients from each group dying from uncontrollable variceal hemorrhage. Propranolol precipitated encephalopathy in one patient and complicated resuscitation following bleeding in a second, and as there was no evidence in this study that use of the drug reduced the frequency or severity of the variceal bleeding, its administration cannot be recommended during the period prior to obliteration of varices by sclerotherapy.

Evidence for down-regulation of beta-2-adrenoceptors in cirrhotic patients with severe ascites

The density and affinity of beta-2-adrenoceptors on mononuclear cells from peripheral blood were studied in fifteen patients with cirrhosis of different severity and in thirteen controls. There was no significant difference between cirrhotic patients and controls in density or affinity of beta-2 binding sites. Within the cirrhotic group, however, the number of binding sites per cell was significantly lower in patients with severe ascites than in patients with mild to moderate or no ascites. This down-regulation of beta-adrenoceptors could influence the haemodynamic response to beta-blockers.

A randomized trial of vasopressin and vasopressin plus nitroglycerin in the control of acute variceal hemorrhage

A randomized trial was undertaken to determine efficacy of nitroglycerin when added to a vasopressin infusion in both reducing the complication rate and giving improved control of acute variceal hemorrhage. Seventy-two bleeding episodes in 57 patients were included, with vasopressin being used on 34 occasions and vasopressin plus nitroglycerin on 38 occasions, for an infusion period of 12 hr. At the end of the 12-hr period, hemorrhage had been controlled significantly more frequently in those receiving combined therapy (26 of 38; 68%) than in those given vasopressin alone (15 of 34; 44%, p less than 0.05), although this difference was not statistically significant if those patients in whom therapy was discontinued due to drug complications were excluded from the analysis [hemorrhage controlled in the combined group (68%) and vasopressin alone (48%); chi 2 = 2.4, p greater than 0.05]. Major complications requiring cessation of therapy were significantly less common in those given nitroglycerin--one occasion compared to seven in those given vasopressin alone (p less than 0.02). Thus, the addition of nitroglycerin to a vasopressin infusion results in a lower rate of complications and is more effective in controlling variceal hemorrhage.

Effects of repeated injection sclerotherapy on acid gastroesophageal reflux

Acid gastroesophageal reflux was determined by long-term pH monitoring in 19 consecutive variceal bleeders after 5 to 20 (mean, 10.3 +/- 1 SEM) sclerotherapy sessions with the flexible endoscope using polidocanol 1% as sclerosant. Fifteen cirrhotics with untreated varices served as controls. Percentage time of esophageal pH less than 4 (3.3 +/- 0.7 SEM vs. 5.2 +/- 2.2 in the controls) and mean duration of reflux episodes (2.9 +/- 0.4 vs. 3.0 +/- 0.7 min) showed no significant differences between both groups. The findings indicate that repeated injection sclerotherapy with the flexible endoscope does not lead to an enhancement of acid gastroesophageal reflux.

Injection sclerotherapy of oesophageal varices with the free-hand technique: experience in Hong Kong

A prospective study of the efficacy of injection sclerotherapy with the free-hand technique for acute bleeding oesophageal varices was conducted, to evaluate its use in the control of acute variceal bleeding and to assess long-term sclerotherapy as the definitive treatment. Between July 1981 and January 1985, a total of 108 patients (96 men, 12 women with mean age of 54.4 years) had intravariceal injection of 5 per cent ethanolamine oleate. The majority had non-alcoholic cirrhosis and alcoholism accounted for only 18.5 per cent. There were 22 Child's A, 42 Child's B and 44 Child's C patients. During the 411 sessions of injection, major complications occurred in 12 patients (11.1 per cent) with 3 deaths. Of the 145 episodes of acute variceal bleeding 91.7 per cent were successfully controlled. In episodes which required more than one injection to control the bleeding, there was a high mortality of 75 per cent. Over the three and a half year period, 33 out of the 93 patients on long-term sclerotherapy had re-bled (35.5 per cent). Varices were obliterated in 27 patients with a mean of 5.4 injections. From our experience, the procedure is safe and effective. However, its status as a definitive treatment when compared with conventional surgical treatment requires further controlled evaluation.

Alterations in isoprenaline sensitivity in patients with cirrhosis: evidence of abnormality of the sympathetic nervous activity

Isoprenaline sensitivity and plasma catecholamine concentrations were studied to assess the sympathetic nervous activity in 13 patients with alcoholic cirrhosis and were compared with five controls. In patients with cirrhosis, the dose of isoprenaline required to increase the resting heart rate by 25 beats min-1 (chronotropic dose 25 or CD25) ranged from 2.50 to 34.73 micrograms (median: 4.47 micrograms) and was significantly higher than in controls (range: 0.66 to 2.76 micrograms, median: 1.34 micrograms). In cirrhotic patients, CD25 values were significantly correlated with plasma albumin concentration, resting heart rate and wedged hepatic venous pressure. In patients with cirrhosis, plasma noradrenaline concentrations ranged from 192 to 978 pg ml-1 (median: 444 pg ml-1) and adrenaline concentrations ranged from 5 to 183 pg ml-1 (median: 47 pg ml-1). No correlation was found between noradrenaline or adrenaline concentrations and CD25 values in cirrhotic patients. In conclusion, in patients with cirrhosis, beta-adrenoceptor responsiveness assessed by isoprenaline sensitivity is altered.

Prognostic significance of serum bile acids in cirrhosis

The value of serum bile acid concentrations for predicting prognosis in cirrhotics was compared with the prognostic significance of clinical and laboratory findings in a prospective 1-year study of 76 patients with cirrhosis. A commercial radioimmunoassay for total serum-conjugated primary bile acids was used. Of 76 patients, 16 died within the follow-up period. The concentration of bile acids in serum more closely correlated with mortality in cirrhosis than the commonly used clinical and laboratory parameters such as the Number Connection Test, ascites, albumin, pseudocholinesterase, bilirubin, prothrombin time and nutritional state. Serum bile acids alone yielded a prediction of mortality comparable to the Child classification. When logistic regression analysis was performed, optimal prediction of prognosis was achieved with the combination of serum bile acids and the Number Connection Test. Serum bile acid levels alone or in combination with the Number Connection Test may be a clinically useful prognostic index in cirrhosis.

Preponderance of serum and intra-hepatic 5 alpha-dihydrotestosterone in males with hepatocellular carcinoma despite low circulating androgen levels

To investigate possible influences of the sex-steroid milieu on hepatocellular carcinoma (HCC) and vice versa, circulating and intra-hepatic sex-steroid levels were investigated and compared with the levels in cirrhosis alone. In cirrhotic men with HCC, serum 17 beta-oestradiol levels were normal, unlike the elevated levels in men with cirrhosis alone. Total and free levels of testosterone and 5 alpha-dihydrotestosterone (DHT) were lower in patients with HCC than in cirrhotic or normal men; the greater decrease in testosterone levels caused an elevated DHT: testosterone ratio. Hypothalamic-pituitary axis dysfunction demonstrated for HCC and cirrhotic groups could not explain the differences in sex-steroids between them. Compared with normal tissue, HCC cytosol had lower testosterone and similar DHT levels; both androgens were higher than in cirrhotic tissue, and the intracellular DHT: testosterone ratio in the tumour was much higher than in control tissue. Results suggest alterations in sex-steroid metabolism in HCC favouring hepatic accumulation of 5 alpha-reduced metabolites aided by the elevated intracellular sex-hormone binding globulin levels shown in HCC tissue.

Hemostasis and fibrinolysis in severe liver failure and their relation to hemorrhage

In a study of severe, decompensated liver failure, we tried to find a correlation between hemorrhage and parameters of hemostasis and fibrinolysis. Three groups of patients were studied: alcoholic cirrhosis; nonalcoholic cirrhosis, and acute liver failure without known prior liver disease. The two cirrhotic groups did not differ significantly from each other in coagulation or in fibrinolytic parameters, although liver function was more impaired in nonalcoholic cirrhosis. The levels of clotting factors, antithrombin III, prekallikrein, plasminogen and alpha 2-antiplasmin were significantly lower in the third group. Mean values of fibrinolytic activity (fibrin plate method) were slightly reduced as compared to normal in all three groups. Tissue plasminogen activator-related antigen tended to be elevated especially in alcoholic cirrhosis. The free fast-acting plasminogen activator inhibitor showed extremely high and extremely low levels in some patients among all three groups. Nonvariceal, capillary-type bleeding, including mucosal bleeding, hematomas and bleeding from puncture sites correlated with low thrombotest and normotest levels (p less than 0.01), low fibrinogen concentration (p less than 0.05) and with a high quotient of fibrinolytic activity (square root of lysis area) and normotest (p less than 0.001). The ratio between fibrin formation and dissolution appears to be an important parameter of hemorrhagic tendency in liver disease. Variceal bleeding appeared not to be related to impairment of hemostasis or fibrinolysis.

Effect of somatostatin on oesophageal variceal pressure assessed by direct measurement

The effect of a single bolus of somatostatin on oesophageal variceal pressure has been studied in 7 patients with cirrhosis and 5 patients with non-cirrhotic portal hypertension using a non-invasive variceal pressure gauge. Both groups of patients demonstrated similar reductions in variceal pressure with all subjects demonstrating a fall. The timing, duration and magnitude of this reduction in variceal pressure in response to somatostatin showed considerable individual variation which may explain the previous reports of a variable response to treatment of variceal haemorrhage with somatostatin. This individual variation should be borne in mind in the planning of future studies in the treatment of oesophageal variceal haemorrhage. The pneumatic pressure gauge allows the non-invasive study of the effects of drugs on variceal and portal pressure.

Clinical course of cirrhosis in young adults and therapeutic potential of liver transplantation

The lack of information on survival in young adults with cirrhosis and the increasing use of liver transplantation in this age group have led us to carry out a retrospective analysis of the clinical course and survival in 83 young adults aged between 15 and 30 years presenting to the Liver Unit between 1970 and 1983. Fifty four (65%) patients had cirrhosis at initial presentation and in the remaining 29 (35%) this developed within the study period. The overall five year survival of the group, excluding 14 cases treated by transplantation, was 70%. When considered according to aetiological groups this was 83% in those with chronic active hepatitis, 60% in those with cryptogenic cirrhosis and 37% in Wilson's disease. When considered in relation to Child's grading, only three deaths occurred in the 45 patients with well-compensated liver disease (Child's grade A and B). Of the 38 patients with Child's grade C, 20 (83%) of the 24 patients not undergoing transplantation have died, whereas eight (57%) of the 14 receiving liver grafts are alive and well.

Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy?

This paper reports the incidence and natural history of macroscopic gastritis in a series of 127 consecutive patients with portal hypertension of various aetiologies. Gastritis was observed endoscopically in 65 patients (51%) and was of two main types. Twenty eight patients had severe or persistent gastritis which caused clinically significant bleeding on 80 occasions and accounted for 25% of the bleeds from all sources. The remainder had mild gastritis. The presence of gastritis seemed to be independent of the severity of liver disease or the degree of rise of wedged hepatic venous pressure and there was no difference in age, sex, or drugs prescribed in patients with or without gastritis. The mean follow up period and the mean number of sclerotherapy treatments was significantly greater (p less than 0.005) in patients with gastritis. Full thickness gastric biopsies in seven surgical patients and 11 autopsy specimens showed dilated and tortuous submucosal veins. Endoscopic biopsies in 14 patients showed vascular ectasia in the mucosal layer which was in excess of the degree of inflammatory infiltrate. Gastritis occurred in patients with portal hypertension of all common aetiologies and the clinical and pathological evidence supports the contention that it reflects a congested gastric mucosa and should be renamed congestive gastropathy. As injection sclerotherapy improves survival from variceal bleeding congestive gastropathy may become more common. The response to conventional ('anti-erosive') therapy is poor and measures aimed at reducing the gastric portal pressure may be the only effective means of treating this condition.

Morbidity and mortality after peritoneovenous shunt surgery for refractory ascites

A prospective analysis of the morbidity and mortality after peritoneovenous shunting was carried out in 25 patients who had a total of 27 shunts for refractory ascites. Major complications were limited to the patients in whom ascites was secondary to hepatic rather than peritoneal disease. Immediate postoperative complications followed 17 out of the 23 shunts carried out in patients with liver disease and included septicaemia (two), profound hypotension (two), pulmonary oedema (one), and clinically evident disseminated intravascular coagulation (14). Long term morbidity was again limited to the patients with liver disease and included chronic shunt infection (two) and major venous thrombosis (two). Shunt associated mortality was only seen in the patients with liver disease. Despite late shunt blockage in five long term survivors with alcoholic liver disease fluid retention was easily controlled by simple medical means probably because of improved liver function associated with abstinence from alcohol. It is concluded that: (1) patients with hepatic and malignant ascites respond differently to the insertion of a peritoneovenous shunt; (2) Shunt patency should be monitored regularly in patients with liver disease and, because of the potential for septic and thrombotic complications, if blocked the shunt should be removed and; (3) because of the morbidity and mortality of peritoneovenous shunt surgery in patients with liver disease and refractory ascites, an alternative mode of therapy, such as repeated ultrafiltration and reinfusion of ascitic fluid, may be a more effective initial therapeutic approach especially in patients in whom there is a reversible element to their underlying liver disease.

Treatment of acute hepatic encephalopathy in cirrhotics with a branched-chain amino acids enriched versus a conventional amino acids mixture. A controlled study of 70 patients

Acute hepatic encephalopathy in 70 cirrhotic patients was monitored during parenteral administration of amino acids between January 1979 and January 1984. The diagnosis of cirrhosis was confirmed by needle biopsy, and HE by conventional clinical and EEG parameters. The infusion of AA solutions was initiated 48 h after admission and during a 5-day period: 34 patients received a control aminoacid solution, a commercially available AA mixture (Azonutril), and 36 patients a modified solution enriched in BAA prepared from crystallized AA dissolved in distilled water. The calorie intake for both groups was 1600 calories per day from glucose and lipid emulsion. No significant difference was noted based on clinical evolution, even though the plasma AAA/BAA ratio was corrected using the modified AA solution. Of the 34 patients in Group 1: 10 improved, 14 were unchanged, 10 deteriorated and 7 died. Of the 36 patients in Group 2: 12 improved, 14 were unchanged, 10 deteriorated and 7 died. EEG tracing evolved in parallel fashion. The authors conclude that modified AA solutions are ineffective in the treatment of acute hepatic encephalopathy in cirrhotic patients.

Improved survival following injection sclerotherapy for esophageal varices: final analysis of a controlled trial

Long-term follow-up (median: 37 months; range: 19 to 68) of the 116 patients (56 sclerotherapy, 60 control group) entered into a controlled trial of endoscopic variceal sclerotherapy has shown a total of 18 deaths in the sclerotherapy group, including five from variceal bleeding compared with 32 deaths in the control group (p less than 0.01), of which 25 were from variceal hemorrhage (p less than 0.001). Survival as assessed by cumulative life analysis was significantly better in those treated by sclerotherapy (p less than 0.001). Both the cumulative proportion of patients rebleeding and the total number of episodes of variceal hemorrhage were also significantly less in the sclerotherapy group (p less than 0.01). Recurrence of varices was observed in 27 of 45 patients in whom variceal obliteration was initially observed at a median of 11 months (range: 2 to 27) later, although in only 12 of these did bleeding recur and was the cause of death in one.

[Thyroid hormones in women with liver cirrhosis]

Basal thyroid hormone levels were measured in 68 women with liver cirrhosis (LC) of different etiology (alcoholic n = 34, posthepatitic B n = 9, PBC n = 5, cryptogenetic n = 18, M. Wilson n = 2). In addition the rise of TSH after 400 micrograms TRH was measured in 23 women with LC and compared with the data obtained from 17 women of a control group. There was no difference of the median T4-concentrations (LC 8.0 micrograms/dl versus 7.2 micrograms/dl) but a significant correlation of T4 to the grade of decompensation of LC. In contrast of T4 there was a marked decrease of T3 in LC-patients (109 ng/dl versus 143 ng/dl) and a rise of reverse T3 (0.21 ng/ml versus 0.13 ng/ml). The decrease of T3 and rise of reverse T3 equally correlated to the severeness of LC. TBG concentrations fell according to the grade of decompensation of LC and T4/TBG-quotient exhibited no difference to the control data (0.51 both). Though basal thyroid hormones and TSH show euthyroidism the significant augmented TSH release after TRH (delta-TSH 7.0 versus 3.2 microU/ml) indicate a status of latent hypothyroidism. In alcoholic cirrhosis the degree of TSH release was much higher than in non alcoholic cirrhosis. Estradiol and estrone levels correlated significantly negatively to T4, T3, estrone negatively to TBG and positively to reverse T3 but not to TSH and TSH release. Otherwise TSH release correlated positively to estradiol. The thyroid status in women with liver cirrhosis does not differ from the thyroid hormone profile found in men with cirrhosis.

Long term follow-up of patients following successful selective and non-selective portasystemic shunt surgery

The long term morbidity and mortality of two consecutive groups of patients undergoing successful shunt surgery for bleeding oesophageal varices has been studied. Twenty-seven patients with a non-selective shunt in the form of a mesocaval Dacron 'H' graft and 21 patients with selective variceal decompression via a distal lienorenal shunt, all of whom had a patent shunt on discharge from hospital, were included in the study. Shunt associated encephalopathy was documented in 77% of the patients following mesocaval shunts and only 19% of patients following distal lienorenal surgery. Other postoperative morbidity was largely related to problems with the synthetic Dacron graft. Late shunt blockage, often resulting in recurrent variceal bleeding, was documented in 25% of these patients and shunt infection was responsible for complicating fatal disseminated sepsis in 18.5%. Long term survival, as assessed by life table analysis, following distal lienorenal shunt surgery was consistently better than that following mesocaval shunts. This was largely due to specific problems which could be directly related to the synthetic nature of the Dacron graft. It is concluded that the mesocaval Dacron interposition graft carries the potentially lethal long term complications of shunt blockage and infection rendering it unsuitable as a portasystemic shunt. Provided that successful surgery can be performed the distal lienorenal shunt may be a more appropriate alternative due to its reduced shunt related morbidity and, possibly, mortality.

A prospective, randomized controlled trial of chronic esophageal variceal sclerotherapy

The results of a prospective, randomized controlled trial of chronic esophageal variceal sclerotherapy conducted over a 38-month period are presented. One-hundred twenty patients were randomized following variceal bleeding, 63 to esophageal variceal sclerotherapy and 57 to control. Mean follow-up was similar in both groups (esophageal variceal sclerotherapy, 12.5 +/- 8.8 months; control, 14.9 +/- 6.6 months). Twenty-one percent of the patients in each group were lost to follow-up. Esophageal variceal sclerotherapy decreased rebleeding as evidenced by a decrease in the mean bleeding risk factor, transfusion requirement and by an increase in bleeding free interval; differences between the treated and control groups in these parameters were especially significant after variceal obliteration. A high incidence of asymptomatic ulceration and low frequency of strictures were notable effects of esophageal variceal sclerotherapy. Cumulative life table analysis revealed no differences in survival between esophageal variceal sclerotherapy and control groups. However, when patients who received portal-systemic shunt surgery (esophageal variceal sclerotherapy, 6%; control, 28%) were removed from the analysis at the time the shunt surgery was performed (defining the shunt as an endpoint, a significant difference in survival (p less than 0.05, F ratios) in favor of esophageal variceal sclerotherapy was observed.

The prevention of recurrent variceal haemorrhage by chronic injection sclerotherapy

Forty eight patients who have survived admission with acute variceal haemorrhage have been readmitted and entered into a programme of chronic injection sclerotherapy to prevent recurrent variceal haemorrhage. Two hundred and nineteen elective courses of injections were performed at fibreoptic endoscopy with minor complications occurring in six patients. Twenty three patients rebled on 33 occasions but in only five instances did haemorrhage occur following variceal obliteration. With 67 per cent of patients surviving one year, this treatment option offers a satisfactory means of preventing recurrent haemorrhage when variceal obliteration is achieved.

Management of complications of portal hypertension

The management of portal hypertension focuses on control of its complications, the most important of which is bleeding esophageal varices. Other complications, such as ascites, bleeding intestinal stomas, and hypersplenism, rarely require surgical intervention. Other than medical management, the three basic procedures now available for the treatment of bleeding esophageal varices include decompression of varices with a portosystemic shunt, nonshunting operations that attack directly the esophageal variceal-bearing area, and liver transplantation as the procedure of choice in selected patients. Patients who present with episodes of acute bleeding are usually treated initially with medical therapy including acute sclerotherapy or balloon tamponade techniques when necessary. If the patient fails to respond or if episodes of bleeding recur, further therapy is required. Although selection of therapy remains controversial, it is based on multiple factors. These include the basic pathogenic mechanism of portal hypertension in the individual patient, status of the patient as defined by Child's classification, elective or urgent nature of the operation, hemodynamic stability of the patient at the time of the procedure, site of the block in the portal system, and caliber and anatomic relationship of the vessels available for anastomosis in the portal system. Additional factors include the presence and severity of ascites or encephalopathy, age of the patient, site of bleeding (esophageal or gastric), severity of associated hypersplenism, and techniques and expertise available at a given institution. Shunting procedures achieve the best long-term control of bleeding, but they can precipitate the development of encephalopathy. Nonshunting procedures do not induce encephalopathy, but they are usually associated with a high rate of rebleeding. Also, with the possible exception of sclerotherapy, they are still associated with a high operative mortality rate in alcoholic patients classified as Child's C. Although sclerotherapy controls acute variceal bleeding more successfully than conventional methods, it is not readily applicable in patients with bleeding gastric varices. Also, it has not yet clearly been proved to be an effective method of permanent control of gastroesophageal bleeding and has not been demonstrated to increase survival. The new methods of extensive esophagogastric devascularization (for example, porta-azygos disconnection using the Sugiura procedure) are attractive because of the low late recurrence rate for bleeding without the induction of encephalopathy.(ABSTRACT TRUNCATED AT 400 WORDS)

B1 selective adrenoreceptor blockade for the long term management of variceal bleeding. A prospective randomised trial to compare oral metoprolol with injection sclerotherapy in cirrhosis

Oral metoprolol, in a dose sufficient to reduce resting pulse rate by 25%, was compared with repeated injection sclerotherapy for the long term management of variceal bleeding. The prospective, randomised study was undertaken in 32 patients with biopsy proven cirrhosis and variceal bleeding who were Grade A or B on a modified Child's classification. In the 15 patients receiving metoprolol, portal pressure showed a mean fall of 3.7 mmHg (17.3 +/- 1.2 to 13.6 +/- 1.2 mmHg, p less than 0.01) after four weeks of continuous therapy, as compared with pretreatment levels. Nine of the 15 patients taking metoprolol had further bleeding (total of 21 episodes) compared with six of 17 in the sclerotherapy group (nine episodes). The risk of bleeding per patient/month of follow up was three times higher in the metoprolol group compared with those treated by sclerotherapy (0.14 and 0.04 respectively, p less than 0.025). Rebleeding in the metoprolol group occurred in six of the patients who had a fall in portal pressure of 10% or more.

Prediction of outcome following acute variceal haemorrhage

In order to identify factors predicting survival following acute variceal haemorrhage, data were collected prospectively from 100 admissions in 70 patients managed by a standard policy employing oesophageal tamponade, injection sclerotherapy and, if necessary, oesophageal transection. Of the ten predictive factors identified by univariate analysis, only prothrombin ratio, serum creatinine and the presence of encephalopathy on admission were shown by stepwise logistic regression to have independent significance. The derived regression equation allowed clearer identification than conventional scoring systems of high and low risk groups and successfully predicted outcome in 90 per cent of admissions.

Endoscopic Nd:YAG laser therapy for active esophageal variceal bleeding. A randomized controlled study

A randomized controlled double-blind study was undertaken to assess the efficacy and safety of endoscopic neodymium:yttrium aluminum garnet (Nd:YAG) laser therapy for active esophageal variceal bleeding. Ten patients were randomized to the laser treatment group and 10 to a control group that received sham endoscopy and standard medical therapy. Initial hemostasis was achieved in seven laser-treated patients but in 0 of 10 controls receiving sham treatment (p less than 0.002). However, four of the seven who were initially controlled with laser therapy had rebleeding 12 to 48 hours later; thus, three of 10 laser patients had lasting hemostasis. The mean blood transfusion requirements were similar in both groups (laser = 7.3 units; control = 7.8 units). Six of the 10 laser-treated patients were discharged from the hospital and four died. There were seven hospital deaths in the control group and three patients were discharged (p = 0.22). In two patients in the treatment group, laser therapy increased bleeding. There were no perforations.

Long-term sclerotherapy of bleeding esophageal varices in patients with liver cirrhosis. An evaluation of mortality and rebleeding risk factors

Ninety-six liver cirrhosis patients with bleeding esophageal varices receiving long-term sclerotherapy with the flexible endoscope were studied prospectively to analyze mortality and rebleeding risk factors. The difference in the 1-year survival rates of Child's groups A (100%) and B (82%) versus Child's C patients (38%) was highly significant (p less than 0.001). Multivariate analysis revealed that, as single factors, serum bilirubin, grade of ascites, and prothrombin time and, as a combination, the four variables bilirubin, ascites, aspartate aminotransferase, and age distinguished best between survivors and non-survivors during the first 6 months after inclusion in the study. For the separation of rebleeders and non-rebleeders during the first 2 months, prothrombin time and grade of ascites gave the best distinction. Thus, cirrhotics with variceal hemorrhage, ascites, jaundice, and a prolonged prothrombin time remain a high-risk group also with long-term sclerotherapy.

Total and renal sympathetic nervous system activity in alcoholic cirrhosis

Basal sympathetic nervous system activity was assessed in 8 unmedicated patients with alcoholic cirrhosis using a previously developed radiotracer method for measuring total and renal noradrenaline release to, and clearance from, plasma. Compared to the control group total noradrenaline clearance was significantly increased in the patients with advanced alcoholic cirrhosis (Pugh grade C) [1.89 +/- 0.13 vs 1.51 +/- 0.11 l/min, P less than 0.05) indicating that endogenous plasma noradrenaline levels underestimate total sympathetic nervous system activity in these patients. Renal noradrenaline clearance was similar to controls independent of the severity of the liver disease. Both total and renal noradrenaline release were significantly increased in the patients with cirrhosis. The ratio of renal to total noradrenaline release was similar in cirrhotic (26 +/- 7%) and control (23 +/- 5%) groups. Increased arterial plasma adrenaline levels, indicative of adrenal medullary stimulation, were also evident in the patients with cirrhosis and correlated significantly with total noradrenaline spillover (r = 0.732, P less than 0.05). These results strongly suggest that in patients with cirrhosis, rather than a preferential increase in renal sympathetic tone, the increase is part of a pattern of generalized sympathoadrenomedullary activation. Although renal renin secretion was significantly increased in the cirrhotic group no correlation with renal noradrenaline release was seen (r = 0.199), raising the possibility that in cirrhosis renal sympathetic tone is not a major determinant of renal renin secretion. Finally, renal noradrenaline release did not correlate with renal blood or plasma flow but an influence of the sympathetic nervous system on renal function was suggested by the correlation observed between total noradrenaline spillover and impaired salt (r = -0.683, P less than 0.05) and water excretion (r = -0.702, P less than 0.05) demonstrated in the cirrhotic patients.

Sclerotherapy of esophageal varices: an endoscopic and portographic study

A prospective series of 26 patients with portal hypertension and recent bleeding from esophageal varices was investigated with percutaneous transhepatic selective portography (PTP). PTP was performed immediately prior to and, in 23 patients, just after the initial endoscopic injection sclerotherapy (ST) session to study the acute effects of ST on the mediastinal portal-systemic collaterals. Late follow-up PTP was performed after a median of 8 months in 21 of 26 patients considered endoscopically to be free from esophageal varices after a median of 6 ST sessions. Five patients rebled from esophageal or gastric varices during the follow-up period of 15 months, but there were no fatalities due to variceal hemorrhage. In all patients, the initial PTP showed portal-systemic mediastinal collaterals. Immediately after ST, it was not possible to opacify esophageal varices at all (10 patients) or only partially (7 patients). Five patients died prior to late follow-up PTP. Endoscopic judgment of complete eradication of esophageal varices after repeated ST was in agreement with the late PTP results in 18 of 21 patients. In one patient, PTP showed residual esophageal varices subsequently confirmed by endoscopy. The results were uncertain in two patients for technical reasons. This study supports the opinion that submucosal esophageal varicose veins, as visualized by PTP, can be efficiently eradicated by serial ST, leaving the other mediastinal collaterals unaffected.