Embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy.

PURPOSE: To evaluate the efficacy of embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy (CRHE). METHODS: Seven cirrhotic patients with CRHE refractory to medical treatment (3 men and 4 women, mean age 66 years) were studied. Five patients had splenorenal shunts, 1 had a gastrorenal shunt, and 1 had an intrahepatic portal vein-hepatic vein shunt. Shunt embolization was performed using stainless steel coils, with a percutaneous transhepatic portal vein approach in 4 patients and a transrenal vein approach in 3 patients. RESULTS: After embolization, the shunt disappeared in 4 patients on either ultrasound pulsed Doppler monitoring or portography. Complications observed in the 7 patients were fever, transient pleural effusion, ascites, and mild esophageal varices. For 3-6 months after embolization, the 4 patients whose shunts disappeared showed minimal or no reappearance of a shunt, and had no recurrence of encephalopathy. The serum ammonia levels decreased and electroencephalograms also improved. One of the 4 patients, who developed mild esophageal varices, required no treatment. Treatment was effective in 3 of the 4 patients (75%) who underwent embolization via a transhepatic portal vein. CONCLUSION: Transvascular embolization of shunts improved the outcome in 4 of 7 patients. The most effective embolization was achieved via the percutaneous transhepatic portal vein approach.

Noninvasive endoscopical measurement of gastric mucosal blood flow in the anesthetized rat.

Endoscopical measurement of gastric mucosal blood flow seems to provide substantial advantages for noninvasive and repetitive scrutiny, especially in small animals. We employed a quartz probe 0.5 mm in diameter which was inserted into the gastric lumen through the forceps channel (0.8 mm in diameter) of the endoscope. Gastric mucosal blood flow determined with this probe in combination with laser Doppler velocimetry were sufficiently consistent and reproducible in the corpus as long as the tissue-to-probe distance was positioned in gentle contact with the gastric mucosa perpendicularly. Topical application of endothelin-1 produced a significant long-lasting decline in gastric mucosal blood flow, although laparotomy per se resulted in a slight decrease of the blood flow. Endoscopic measurement of gastric mucosal blood flow seems simple and reproducible with high potential for chronic studies.

Reduced thyroidal uptake of inorganic iodine in liver cirrhosis.

Thyroid function was investigated in patients with liver cirrhosis. 123I uptake after four hours was significantly reduced in the liver cirrhosis group (n = 19) compared with the control group (n = 16) (2.6 +/- 0.3% vs. 5.0 +/- 0.6%, mean +/- SE, p < 0.01). There was no significant difference in the blood inorganic iodine level between the two groups, and the blood 123I count after ingestion of 123I capsules was not significantly different between the two groups. The area of the thyroid was slightly smaller in the cirrhosis group. A thyroid stimulating hormone (TSH) loading test showed no significant difference in the TSH value at any time point. The serum albumin level and prothrombin time were significantly associated with the 4-hour thyroidal 123I uptake (p < 0.01, p < 0.05, respectively). We show that the thyroidal inorganic iodine uptake was reduced in patients with liver cirrhosis and this reduction correlates with the severity of liver cirrhosis. Possible mechanisms include abnormal thyroid iodine transport capacity or reduced turnover of thyroid hormones resulting in a reduction in iodine uptake in liver cirrhosis.

[Detection of Helicobacter pylori by culture and the 13C-urea breath test using an automated breath 13C analyzer].

Up to now, the diagnosis of H. pylori infection has been made by the breath test using 13C-urea. In this study, 13C-urea breath samples were tested in 34 patients (peptic ulcer scar 17, chronic gastritis 17 cases) with an automated breath 13C analyzer (ABCA. Europa Scientific, Crewe, UK) and compared with the results of endoscopical diagnosis for H. pylori infection. Endoscopic and 13C-urea breath test (13C-UBT) were performed before eradicative medication. We described a modified protocol for the growth grade of H. pylori colonies in microbiology (H. pylori score), and for the delta 13C area under curve (AUC; permil*hr) obtained from each sample of expired breath. There was a significant correlation between delta 13C-AUC and the delta 13C level of each sample, but the correlation coefficient obtained at 10min (R2 = 0.582) was lower than that obtained at the other four time points (20min; 0.891, 30min; 0.949, 40min; 0.946, 50min; 0.946, 60min; 0.820). The delta 13C-AUC well correlated with H. pylori score (p < 0.01), none of 26 H. pylori positive patients detected by culture was 13C-UBT negative (delta 13C-AUC < 8.2 permil*hr in mean + 2SD of H. pylori negative group). In conclusion, 13C-UBT using ABCA has high sensitivity and specificity, and it provides a non-invasive method for the detection of H. pylori urease activity.

[Usefulness of every-other day administration of proton pump inhibitors from the standpoint of continuous 48-hour pH measurements-- Comparison of cimetidine, omeprazole, and lansoprazole].

We compared the usefulness of proton pump inhibitors (PPIs) every other day, with H2-blocker, in terms of inhibitory effect on gastric acid secretion. The dosages were as follows; cimetidine (CIM), 800mg and 400mg every day; omeprazole (OPZ) 20mg, and lansoprazole (LPZ), 30mg every other day. We continuously measured intragastric pH and calculated the time that pH was maintained at pH4 or more (pH4 holding time). The pH4 holding time as a part of total measurement time was significantly longer in the PPI every other day groups than in the H2-blocker groups, but there were no significant differences between the groups during the night. In PPI every other day groups, pH4 holding time of daytime period was suggested to be longer than on H2-blocker groups. In conclusion, their efficacy was greater than in the CIM group, and they appear to have a broad range of applications to the treatment of peptic ulcer.

A study of endotoxaemia in patients with primary biliary cirrhosis.

Hepatic reticuloendothelial function may be diminished in patients with primary biliary cirrhosis. Endotoxin concentrations in peripheral blood and in the superior mesenteric vein were measured, by the beta-glucan sensitive, factor-free, endotoxin-specific limulus assay, in patients with primary biliary cirrhosis and liver cirrhosis (non-PBC cirrhosis). Endotoxaemia was detected in the peripheral blood of seven out of nine patients (78%) with asymptomatic primary biliary cirrhosis, but in only two out of thirteen patients (15%) with non-PBC cirrhosis. The endotoxin level was significantly higher in the earlier stages of primary biliary cirrhosis than in the later stages (P < 0.05). The endotoxin level in superior mesenteric vein blood was significantly lower in patients with primary biliary cirrhosis than in patients with non-PBC cirrhosis. Peripheral endotoxaemia in patients with primary biliary cirrhosis may be due to the diminished capacity of the hepatic reticuloendothelial system, for phagocytosis of endotoxin.

Hepatic arterial and portal venous oxygen content and extraction in liver cirrhosis.

We examined the oxygen content in the hepatic arterial, hepatic venous and portal venous blood to evaluate the oxygen supply to the liver and hepatic oxygen extraction in cirrhosis. The arterial-portal venous difference of the oxygen content was within the normal range in cirrhosis patients, although the oxygen content of the hepatic artery and portal vein was lower than in the control patients. The hepatic venous oxygen content was normal in the cirrhosis patients. The oxygen tension and saturation were always higher in the splenic vein than in the other branches of the portal system. Oxygen was supplied chiefly by the hepatic artery, and arterial oxygen extraction was normal in cirrhosis. In addition, there was no change in arterial extraction during oxygen inhalation by cirrhosis patients. Portal venous oxygen extraction was decreased in cirrhosis and was increased by oxygen inhalation. These findings indicate the autoregulation of hepatic oxygen through a mutual relationship between the hepatic arterial and the portovenous oxygen supply.

Effect of hepatic collateral hemodynamics on gastric mucosal blood flow in patients with liver cirrhosis.

The dependence of the gastric mucosal change in liver cirrhosis on the extrahepatic collaterals is still unknown. Therefore we studied the influence of these collateral hemodynamics on gastric mucosal blood flow and gastric mucosal lesions. The subjects were 23 cirrhotic patients and were divided into two groups by the findings of percutaneous transhepatic portography. The first group consisted of 14 cases whose extrahepatic collaterals were via esophageal varices (group I). The second group included 9 cases having collaterals other than esophageal varices (group II). Multiple red spots were observed in 13 of 14 cases in group I, and two of nine cases in group II. Gastric mucosal blood flow was 2.0 +/- 0.9 volts (mean +/- SD) in group I, 4.0 +/- 1.2 in group II. A statistically significant difference was observed between groups I and II. Gastric mucosal blood flow was not significantly correlated with portal venous pressure in group I. It is concluded that, in liver cirrhosis, gastric mucosal blood flow is changeable according to the types of the extrahepatic collaterals.

[The study of endotoxin levels in portal venous system in liver cirrhosis].

In the patients with liver cirrhosis, endotoxin levels were measured in portal venous system by the toxicolor method and the mechanism of endotoxemia in the peripheral vein was studied. On endotoxin levels in portal venous system, the superior mesenteric vein had the highest level. Endotoxemia was observed most frequently in the superior mesenteric vein (78%), and 50% in the truncal portal vein and 55% in the peripheral vein. The hepatic "endotoxin extraction ratio" which is considered to reflect the Kupffer cell function of clearing endotoxin and the severity of cirrhosis were not related each other. On the other hand, in view of the extrahepatic portal shunt, systemic endotoxemia appeared more frequently in the patients with the other collaterals than the esophageal varices. Therefore, it was concluded that systemic endotoxemia in liver cirrhosis was related with the type of extrahepatic portal collaterals.