[Effects of neomycin on intestinal digestion, absorption and fermentation of carbohydrates in patients with liver cirrhosis: evidence for an alternative therapeutic mechanism in hepatic encephalopathy]. / Efectos de neomicina sobre la digestion, absorción y fermentación intestinal de carbohidratos en pacientes con cirrosis hepatica: evidencia para un mecanismo terapeutico alternativo en la encefalopatia hepática.

BACKGROUND: Despite non absorbable antibiotics and neomycin may have antagonistic effects on intestinal bacterial environment, both have synergistic effects in the treatment of hepatic encephalopathy. This could be due to their action on different enteric flora or a neomycin induced carbohydrate malabsorption. AIM: To investigate the effects of neomycin on intestinal digestion, absorption and fermentation of carbohydrates in patients with liver cirrhosis. PATIENTS AND METHODS: Thirty eight Child B or C cirrhotic patients separated in three groups; subjects within each group were randomized to receive neomycin (2/g/day for 10 days, n = 8) or placebo (n = 4). Absorption of lactose and d-xylose and fermentation of d-xylose, lactose and lactulose (measured using hydrogen breath tests) were studied before and after the treatment period. RESULTS: Neomycin did not change lactose fermentation but reduced plasma glucose rise after lactose ingestion (38.8 +/- mg/dl to 22 +/- 6 mg/dl p < 0.05). Plasma d-xylose levels at 30 min and its 5 h urinary excretion were reduced by neomycin from 19 +/- 3 to 9 +/- 2 mg/dl and from 4.9 +/- 0, 8 to 2.6 +/- 0.3 g/5h respectively (p < 0.05). Fermentation of d-xylose, lactose and lactulose was not reduced by neomycin. No significant changes were observed after placebo treatment. CONCLUSIONS: Neomycin therapy is associated with a reduction of intestinal digestion and absorption of carbohydrates, preserving bacterial fermentation capacity, probably increasing the non absorbable carbohydrate load reaching the colon.

[Hepatotoxicity induced by valproic acid in adults. Report of 3 cases]. / Hepatotoxicidad inducida por ácido valproico en adultos. Presentación de tres casos.

Valproic acid is a useful antiepileptic drug, with occasional gastrointestinal side effects. Hepatotoxicity is the most serious adverse reaction and, although rare, it can be fatal. Risk factors for hepatotoxicity are an age of less than two years, polytherapy and mental retardation; it has been rarely reported in adults. We report three mentally retarded adult patients receiving polytherapy, who developed valproic acid induced hepatotoxicity. Two patients had a symptomatic hepatitis with a concomitant paradoxical increase in seizure frequency and one an asymptomatic alteration of hepatic function tests. After discontinuing the drug, the hepatitis subsided. We conclude that hepatotoxicity must be considered as a possible side effect of valproic acid and we suggest some recommendations for its early detection.

[Correlation between serum globulin levels and hepatitis C virus antibody]. / Correlación entre niveles de globulinas séricas y anticuerpo anti-virus C de la hepatitis.

BACKGROUND: some studies have suggested that the elevation of serum globulins in patients with chronic autoimmune hepatitis, paraproteinemias and rheumatoid arthritis could affect the determination of false positive hepatitis C virus antibodies (anti-HCV). AIM: to study the relationship between positive anti-HCV and serum levels of globulins in patients with liver disease. PATIENTS AND METHODS: one hundred thirty one patients with liver disease, 49 alcoholic, 38 cryptogenetic, 17 autoimmune and 27 with other causes, were studies prospectively measuring simultaneously anti-HCV and serum levels of total, gamma and immuno-globulins (IgA, IgG and IgM). These levels were compared between anti-HCV positive and negative groups and correlated with the ratio between serum optical density/cutoff optical density of the anti HCV assay. RESULTS: Twenty eight patients (21.3%) were anti-HCV positive, no differences in serum globulins between these patients and anti-HCV negative patients and no correlations between serum globulins and anti-HCV optical densities were observed. CONCLUSIONS: the hypergamma-globulinemia observed in these patients with liver diseases would not be responsible for positive hepatitis C virus antibodies.

Abnormalities in proximal small bowel motility in patients with cirrhosis.

Because altered intestinal motility could be involved in the pathogenesis of small intestine bacterial overgrowth observed in some patients with cirrhosis, we investigated fasting proximal small bowel motility in 16 cirrhotic patients and 8 healthy controls. In addition, the effects of oral tetracycline administration on duodenal motility were investigated in seven cirrhotic patients with evidence of bacterial overgrowth. The mean duration and characteristics of the migrating motor complex were analyzed. Cyclic activity was observed in all healthy controls. It was absent in two cirrhotic patients showing a prolonged phase 2-like pattern. The duration of cycles was significantly longer in the remaining 14 patients with cirrhosis (166 +/- 19 min) compared with controls (81 +/- 14 min; p < 0.02). This difference was caused by a prolonged phase 2 (138 +/- 19 min in patients with cirrhosis vs. 52 +/- 11 min in controls; p < 0.02). Marked changes in the contraction pattern during phase 2 were noted in cirrhotic patients. They were characterized by multiple clusters (frequency, 12 +/- 1/hr; duration, 38 +/- 3 sec) of contractions (frequency, 11 +/- 1 cpm) separated by quiescent periods (duration, 2.4 +/- 0.2 min). This motility profile filled up 58% +/- 8% of the total duration of phase 2, and it was observed in patients with and without bacterial overgrowth. Treatment with tetracycline was followed by only mild modifications, such as a reduction of the fraction of phase 2 occupied by multiple-clustered contractions. In conclusion, an altered proximal small bowel motility has been observed in patients with cirrhosis. These disturbances appear not to be dependent on the presence of bacterial overgrowth.

[Lactulose fermentation and lactose absorption in Chilean patients with liver cirrhosis: importance for hepatic encephalopathy therapy]. / Fermentación de lactulosa y absorción de lactosa en pacientes chilenos con cirrosis hepática: importancia para la terapia de la encefalopatía hepática.

BACKGROUND: Non-absorbable carbohydrates are widely used in the therapy of hepatic encephalopathy. It has been argued that their effects depend on intestinal fermentation. In some geographic areas other than Chile up to 27% of healthy inhabitants are not able to increase breath hydrogen after a lactulose load, a parameter of intestinal fermentation of carbohydrate. Lactose has been proposed as an alternative to non-absorbable disaccharides in patients with lactase deficiency. AIM: To investigate intestinal fermentation of lactulose and lactose malabsorption in Chilean patients with liver cirrhosis. PATIENTS AND METHODS: 22 healthy controls and 52 patients with liver cirrhosis (16 with hepatic encephalopathy) were prospectively studied by means of lactulose or lactose hydrogen breath tests and lactose tolerance test. MAIN RESULTS: In the control group, 19% were non-hydrogen excretors after lactulose, meanwhile a significant rise in breath hydrogen concentration was observed in all cirrhotic patients (p < 0.01). Lactose tolerance test was indicative of lactase persistance in 37% of cirrhotics and in 43% of controls (NS). Finally, 41% of cirrhotics and 50% of controls had a normal lactose hydrogen breath test (NS). These results were not significantly modified by the presence of hepatic encephalopathy. CONCLUSION: Our data suggest that a lack in bacterial fermentation is not a cause of lactulose therapy failure in Chilean patients with hepatic encephalopathy. Lactose might be an inappropriate substitute to lactulose treating a significant proportion of patients with this condition in our country.

[Bacteriuria in patients with primary biliary cirrhosis]. / Bacteriuria en pacientes con cirrosis biliar primaria.

BACKGROUND: Controversies exist about the association between significant bacteriuria and primary biliary cirrhosis. There is evidence suggesting that infections by Gram negative bacteria may be implicated in the pathogenesis of this liver disease. AIM: To compare the incidence of bacteriuria in patients with primary biliary cirrhosis and those with autoimmune chronic hepatitis. PATIENTS AND METHODS: Twenty women with primary biliary cirrhosis and twenty three female patients with autoimmune chronic hepatitis were prospectively studied by routine bacteriological cultures of midstream urine specimens. Samples were obtained at three months intervals or when patients complained of symptoms suggesting urinary tract infection. Significant bacteriuria was defined as the growth of > 10(5) organisms/ml in pure culture. RESULTS: During 8 +/- 1 months of follow up. 60 urine samples from patients with primary biliary cirrhosis and 73 from autoimmune hepatitis cases were tested. Twenty one samples of patients with primary biliary cirrhosis (35%) were positive for significant bacteriuria compared with 7 from women with autoimmune hepatitis (9%); p < 0.01. In the follow up, ten patients with primary biliary cirrhosis (50%) and six with autoimmune hepatitis (26%) developed at least one episode of significant bacteriuria. CONCLUSION: These results suggest that female patients with primary biliary cirrhosis are in higher risk of significant bacteriuria than women with autoimmune hepatitis. Prospective studies evaluating the effects of long-term antibiotic therapy on cholestasis parameters in primary biliary cirrhosis are deserved.

[Hepatitis B virus vaccine: early and late response in Chileans with high risk of infection]. / Vacuna contra el virus de la hepatitis B: respuesta precoz y tardía en Chilenos con alto riesgo de infección.

BACKGROUND: Hepatitis B vaccine has demonstrated to be very effective and safe preventing hepatitis B virus infection. Long term protection induced by hepatitis B vaccination depends on the initial immune response and the declining rate of anti-HBs titers. AIM. To investigate early and late response to hepatitis B vaccine in a sample of high risk Chilean population. MATERIAL AND METHODS: Thirty one subjects (20 relatives of hepatitis B chronic carriers, 10 health service workers and one HIV seropositive) were vaccinated with a plasma derivated hepatitis B vaccine. Early and late response were estimated by anti-HBs titers. RESULTS: Twenty eight subjects (90%) produced protective titers of anti-HBs after 2 months from the third dose of vaccine (early response), and they remained at these levels in 75% of vaccinated individuals after three years (late response). All the subjects without protective titers after the three year follow up had produced anti-HBs levels lower than 300 UI at the early response. Hepatitis B vaccination was not associated with significant side effects. CONCLUSIONS: This experience confirms that hepatitis B vaccine is safe and effective inducing immunity in high risk subjects. Our data suggest that the early response to hepatitis B vaccine is able to identify those subjects requiring closer surveillance for boosters.

[Post sinusoidal obstruction of the hepatic venous flow associated with antiphospholipid syndrome in 3 cases]. / Obstrucción postsinusoidal del flujo venoso hepático asociado a síndrome antifosfolípido en 3 casos.

Three cases of post-sinusoidal hepatic blood flow obstruction as the main feature of antiphospholipid syndrome are reported. Clinically, these patients developed jaundice, malaise, ascites and hepatomegaly. Ultrasonography-Doppler and hepatic venography showed small hepatic vein disease in two and partial occlusion in the suprahepatic segment of inferior vena cava in the remaining patient. In all, anticardiolipin antibodies were positive and activated partial thromboplastin time was prolonged. This experience emphasizes that in patients with post sinusoidal portal hypertension, a systematic search for antiphospholipid syndrome must be carried out.

[Morphology of the myenteric plexus of the small intestine in patients with liver cirrhosis]. / Morfologia de los plexos mientericos del intestino delgado en pacientes con cirrosis hepática.

BACKGROUND: Patients with liver cirrhosis develop small bowel dysmotility of unknown etiology. Morphological features in the enteric nervous system and the intestinal smooth muscle may shed light on pathophysiology of the gut motility disturbances in this disease. AIM: To investigate the morphology of the myenteric plexuses and smooth muscle layers of the small intestine in patients with liver cirrhosis. PATIENTS AND METHODS: Full thickness biopsies of duodenum, jejunum and ileum from seven cirrhotic patients and seven controls were stained with several techniques, including silver impregnation. Neuronal counting and light microscopy studies were stained performed. RESULTS: The neuronal count was not significantly different in patients with cirrhosis compared to controls in duodenal samples (1.6 +/- 0.4 cel/mm vs 1.6 +/- 0.2 cel/mm), jejunal tissue (1.2 +/- 0.3 cel/mm vs 1.4 +/- 0.2 cel/mm), and in ileal specimens (0.8 +/- 0.3 cel/mm vs 0.9 +/- 0.2 cel/mm). In both groups, evidence of fibrosis or inflammation in myenteric plexuses and in smooth muscle was not found. Also, intestinal neuronal dysplasia was absent in cirrhotic patients as in controls. CONCLUSION: These results suggest that small bowel dysmotility in patients with liver cirrhosis is not related to structural changes in myenteric plexuses or in intestinal smooth muscle noted by light microscopy.

[Are disturbances of small intestinal motility associated with hyperglucagonemia in patients with liver cirrhosis?]. / Estan los trastornos motores del intestino delgado relacionados con la hiperglucagonemia en pacientes con cirrosis hepatica?

Patients with liver cirrhosis develop marked abnormalities in small bowel motility and high plasma glucagon levels. Disturbances in small intestinal motor activity could be related to hyperglucagonemia. To investigate the relationship between fasting plasma glucagon levels and changes in small bowel motility in patients with liver cirrhosis, eighteen cirrhotic patients and ten controls were studied. Plasma glucagon was measured by RIA. Mouth to cecum transit time was estimated by lactulose hydrogen breath test. Fasting small bowel motility was investigated by means of intraluminal manometry. Plasma glucagon levels were significantly higher in patients with cirrhosis (61 +/- 5 pmol/l) than in controls (32 +/- 3 pmol/l); p < 0.01. In patients with liver disease, plasma glucagon levels were not significantly correlated to mouth to cecum transit time (r: -0.32), duration of migrating motor complex (r: -0.24), nor to the frequency of multiple clustered contractions (r: -0.26). The degree of small bowel dysmotility is not related to plasma glucagon levels in patients with hepatic cirrhosis. These results do not support the hypothesis that hyperglucagonemia plays an important pathogenic role in the abnormalities of gut motility in cirrhosis.

[Microscopic colitis and collagenous colitis. An entity not yet reported in Chile]. / Colitis microscopica y colitis colagena. Una entidad clinica no descrita en Chile.

Collagenous and microscopic colitis have been described as causes for abundant watery diarrhea with a normal radiologic and endoscopic aspect of the colonic mucosa. Microscopic colitis is characterized by diffuse intraepithelial lymphocytic infiltration and collagenous colitis by thickening of subepithelial collagen layer greater than 15 microns with or without inflammatory changes of the mucosa. Here are reported 5 patients with microscopic colitis and 4 with collagenous colitis. The mean age was 52 years (range 40 to 68) with an equal sex distribution. Diarrhea was of longstanding duration without weight loss, anemia or hypoalbuminemia. Occasionally the volume of diarrhea was over 1 L a day. One patient had steatorrhea that proved resistant to a gluten free diet. Endoscopic and radiologic findings were normal in every patient and the diagnosis was based on typical histology. Azulfidine therapy was successful in 7 patients and prednisone in another. Colonic biopsy should be performed in every patient with chronic diarrhea.

[Peptic ulcer and endoscopic signs of portal hypertension in patients with primary biliary cirrhosis]. / Ulcera péptica y signos endoscópicos de hipertensión portal en pacientes con cirrosis biliar primaria.

BACKGROUND: Controversies exist on the prevalence of peptic ulcer and on the relationship between the presence of portal hypertension associated lesions in the upper gastrointestinal tract and the histological and functional stages of primary biliary cirrhosis AIM: To evaluate the prevalence of peptic ulcer and endoscopic signs of portal hypertension in subjects with primary biliary cirrhosis. PATIENTS AND METHODS: A retrospective study based on upper gastrointestinal endoscopies in 36 patients with primary biliary cirrhosis and 45 subjects with chronic active hepatitis. SETTING: Gastroenterology Center, Hospital Clínico, University of Chile, Santiago. MAIN RESULTS: No differences were demonstrated between the two groups for the prevalence of peptic ulcer (11% in primary biliary cirrhosis vs 13% in chronic active hepatitis). Esophageal varices were found in 5 of 16 patients (31%) in prefibrotic stages of primary biliary cirrhosis compared with 10 of 20 (50%) in whom fibrosis or cirrhosis were noted; NS. Endoscopic signs suggesting hypertensive gastropathy were present in 2 patients with early primary biliary cirrhosis (13%) and in 5 (25%) in advanced stages. CONCLUSIONS: Peptic ulcer is not more prevalent in patients with primary biliary cirrhosis than in those suffering from chronic active hepatitis. Esophageal varices and endoscopic stigmata of portal hypertension induced changes in gastric mucosa can be observed in early stages of primary biliary cirrhosis.

[Transvenous hepatic biopsy in patients with blood coagulation disorders]. / Biopsia hepatica transvenosa en pacientes con defectos de la coagulacion sanguinea.

Severe clotting defects represent the main contraindication to percutaneous liver biopsy. A transvenous liver puncture technique has been developed for patients suffering from blood coagulation disorders. This approach was attempted in 17 of 148 consecutive patients (12%) in whom a needle liver biopsy was indicated. Hepatic tissue samplings were successfully obtained in 16 subjects. The mean size of the specimens was 7 mm. The clinical diagnosis or therapy were modified in 7 patients when the histopathology report was available. No complications related to the procedure occurred. Our early experience suggests that transvenous liver biopsy is indicated in one/ninth of cases in whom hepatic tissue sample is required for diagnosis. This technique is safe, and it has a high success rate to provide liver tissue samples.

[Patients with liver cirrhosis: mouth-cecum transit time and gastric emptying of solid foods]. / Pacientes con cirrosis hepatica: tiempo de transito boca-ciego y vaciamiento gastrico de solidos.

As altered gastrointestinal motility could be involved in the pathogenesis of small intestinal bacterial overgrowth observed in liver cirrhosis, we investigated mouth to caecum transit time (MCTT) and solid meal gastric emptying (SMGE) in patients with cirrhosis. MCTT was estimated in 20 cirrhotics and 12 healthy controls using lactulose hydrogen breath test. SMGE was measured in 12 patients with cirrhosis and 27 controls by means of 99-m Tc-sulphur colloid labelling egg albumin and gamma scintigraphy. T1/2 and percentage of marker remaining in stomach (MRS) at 60, 90, and 120 min were calculated. MCTT was prolonged in patients with cirrhosis (111 +/- 7 min) compared to controls (83 +/- 6 min; p < 0.02). No significant differences were demonstrated in SMGE t1/2 between controls (84 +/- 5 min) and cirrhotics (91 +/- 6 min). Also, MRS was similar in patients with cirrhosis and healthy controls at 60, 90 and 120 min. We conclude that MCTT is prolonged in patients with cirrhosis. In addition, our data suggest that pyloruscaecum component plays the main role in delaying orocaecal transit time in cirrhosis.

[Effect of hyperosmotic solutions on duodenal motility: a mechanism of resistance or of propulsion to the luminal flow?]. / Efecto de soluciones hiperosmóticas en la motilidad duodenal: un mecanismo de resistencia o de propulsión al flujo luminal?

Infusion of hyperosmotic solutions into the duodenum lead to increased motility. To investigate the mechanism of this effect, 9 healthy volunteers received small infusions of hypertonic (1250 mOsm/kg) NaCl or glucose. Intestinal motility was registered using manometric system with multiple lumens 3 cm apart. Nineteen glucose infusions did not modify intestinal motility. Of 43 NaCl infusions, motility was increased in 24, 7 of them with a typical migratory complex, phase III. In 17 cases, non propagated contractions increasing in a cephalo-caudal direction were noted. The latter may be related to delayed gastric emptying associated to hyperosmotic loads.

[Bacterial overgrowth in small intestine in patients with liver cirrhosis]. / Sobrecrecimiento bacteriano del intestino delgado en pacientes con cirrosis hepática.

Hepatic encephalopathy, bacterial infections and endotoxemia in cirrhotic patients have been related to colonic flora. However, an abnormal small bowel bacterial content could also be implied. We investigated small bowel bacterial overgrowth (SIBO) by jejunal cultures in 14 cirrhotic patients and 5 control subjects, and indirectly by the lactulose H2 breath test in 22 patients with cirrhosis and 12 controls. SIBO was demonstrated by cultures in 64% of cirrhotic patients and 1 of 5 controls. The breath test was positive for SIBO in 45% of patients with cirrhosis and 8% of controls. No differences were noted between patients with alcoholic and non-alcoholic liver disease. According to fasting H2 breath levels, SIBO was significantly correlated with the Child-Pugh score for hepatic function (r = 0.45; p < 0.05). Also, patients with positive criteria for SIBO in jejunal cultures had worse hepatic function in comparison to cirrhotics with normal jejunal bacterial counts (p < 0.05). Thus SIBO is frequent in patients with hepatic cirrhosis and is associated with impairment in hepatic function.

Serum copper in intrahepatic cholestasis of pregnancy

La Colestasis intrahepática del embarazo está caracterizada por fluctuaciones clínicas y bioquímicas y por ello nuevos métodos de diagnóstico son necesarios. El objetivo de este estudio fue investigar niveles séricos de cobre y actividad cobre oxidasa en el curso de la colestasis intra hepática del embarazo (CIE). 28 pacientes con CIE y 25 embarazadas sanas fueron incluídas en el estudio. Estudios funcionales hepáticos de rutina, ácidos biliares en el suero en ayunas, niveles séricos de cobre y actividad cobre oxidada, fueron los estudios fundamentales efectuados. En la CIE los niveles séricos del cobre fueron significativamente más altos que en los controles (274 ñ 49 Ag/dl vs 176 ñ 34Ag/dl, p < ou = 0.001). La actividad cobre oxidasa llegó a un nivel de 78 ñ 15 Ag/dl) en la CIE diferente a lo observado en las embarazadas sanas (64 ñ 8 mg/dl, p < 0.02). Contrariamente a las marcadas oscilaciones en los niveles séricos de ácidos biliares libres, los niveles séricos del cobre permanecieron elevados durante el seguimiento con pequeñas fluctuaciones y no se pudo demostrar correlación entre niveles séricos de ácidos biliares libres y de cobre (r; 0.17, NS). En el trabajo de parto se observó un aumento significativo de los niveles séricos del cobre tanto en las pacientes con CIE (de 251 ñ 50Ag/dl a 297 ñ 55 Ag/dl, p < 0,01) como en embarazadas normales (de 169 ñ 34 a 192 ñ 42 Ag/dl, p < 0,01). Este incremento de los niveles séricos del cobre estuvo asociado con una elevación en pico de la actividad cobre oxidasa. Los niveles de cobre en suero y de actividad cobre oxidasa están elevados en la colestasis intrahepática del embarazo y pueden se considerados como importantes medios de diagnóstico. Los disturbios en el metabolismo del cobre observados en este estudio están de acuerdo con la hipótesis de que el embarazo normal está asociado con una discreta colestasis mientras que la CIE representa una forma de respuesta inapropiada (AU)

Serum copper in intrahepatic cholestasis of pregnancy

La Colestasis intrahepática del embarazo está caracterizada por fluctuaciones clínicas y bioquímicas y por ello nuevos métodos de diagnóstico son necesarios. El objetivo de este estudio fue investigar niveles séricos de cobre y actividad cobre oxidasa en el curso de la colestasis intra hepática del embarazo (CIE). 28 pacientes con CIE y 25 embarazadas sanas fueron incluídas en el estudio. Estudios funcionales hepáticos de rutina, ácidos biliares en el suero en ayunas, niveles séricos de cobre y actividad cobre oxidada, fueron los estudios fundamentales efectuados. En la CIE los niveles séricos del cobre fueron significativamente más altos que en los controles (274 ñ 49 µg/dl vs 176 ñ 34µg/dl, p < ou = 0.001). La actividad cobre oxidasa llegó a un nivel de 78 ñ 15 µg/dl) en la CIE diferente a lo observado en las embarazadas sanas (64 ñ 8 mg/dl, p < 0.02). Contrariamente a las marcadas oscilaciones en los niveles séricos de ácidos biliares libres, los niveles séricos del cobre permanecieron elevados durante el seguimiento con pequeñas fluctuaciones y no se pudo demostrar correlación entre niveles séricos de ácidos biliares libres y de cobre (r; 0.17, NS). En el trabajo de parto se observó un aumento significativo de los niveles séricos del cobre tanto en las pacientes con CIE (de 251 ñ 50µg/dl a 297 ñ 55 µg/dl, p < 0,01) como en embarazadas normales (de 169 ñ 34 a 192 ñ 42 µg/dl, p < 0,01). Este incremento de los niveles séricos del cobre estuvo asociado con una elevación en pico de la actividad cobre oxidasa. Los niveles de cobre en suero y de actividad cobre oxidasa están elevados en la colestasis intrahepática del embarazo y pueden se considerados como importantes medios de diagnóstico. Los disturbios en el metabolismo del cobre observados en este estudio están de acuerdo con la hipótesis de que el embarazo normal está asociado con una discreta colestasis mientras que la CIE representa una forma de respuesta inapropiada

[Liver cirrhosis and portal hypertension: non-invasive measurement of blood flow in the portal vein with Doppler-duplex]. / Cirrosis hepática e hipertensión portal: medición no invasiva del flujo sanguíneo de la vena porta con Doppler-duplex.

Doppler-duplex has been widely used to quantify blood flow. Nevertheless, its usefulness in assessing portal vein flow (PVF) has been questioned due to technical problems: vessel cross sectional area measurements, interobserver variability, and PVF changes related to physiological events. This study was aimed to measure PVF in patients with cirrhosis and portal hypertension, to estimate changes in PVF during the respiratory cycle, and to evaluate intraobserver variability of Doppler-duplex technique. Twenty-two patients with liver cirrhosis and portal hypertension and 22 healthy subjects were included. One operator made 6 measurements of portal vein diameter (D) and mean flow velocity in inspiration and aspiration. Area of the vessel (A) and PVF were calculated by a microprocessor. Interobserver variability was estimated for each subject and a mean was determined for each group. In the control group, PVF was 901 +/- 39 ml/min in inspiration and 633 +/- 38 ml/min in aspiration; p < 0.001. In patients with cirrhosis PVF was 1303 +/- 121 ml/min in inspiration and 1003 +/- 96 ml/min in aspiration; p < 0.001. Intraobserver variability was 6.0 +/- 0.6% for D, 12.0 +/- 3% for MV and 18.3 +/- 1.6% for PVF in healthy subjects and 5.3 +/- 0.7% for D, 9.2 +/- 0.9% for MV and 15.2 +/- 1.5% for PVF in patients with cirrhosis and portal hypertension. In conclusion, PVF is significantly increased in cirrhotics. PVF was higher in inspiration than espiration in both groups. The Doppler-duplex method evaluation of PVF has an important intraobserver variability (18.3 +/- 1.6%). Then, changes in PVF less than 20% are not accurately measured by this technique.

Usefulness of ascites/serum lactic dehydrogenase activity ratio in the initial approach to ascites.

To investigate the usefulness of ascitic fluid protein and lactic dehydrogenase activity separating uncomplicated portal hypertension related ascites (PHRA) from non PHRA and complicated PHRA, 58 patients with full diagnosis of the cause of ascites were prospectively studied. Ascitic fluid protein led to misclassify 30% of non PHRA and complicated PHRA, and 13% uncomplicated PHRA. Ascites/serum protein ratio did not improve the diagnostic efficacy of ascites protein concentration alone. Lactic dehydrogenase activity classified properly all uncomplicated PHRA but only 64% of non PHRA and complicated PHRA. All PHRA without complications and 92% of non PHRA and PHRA with complications were correctly allocated by ascites/serum dehydrogenase activity ratio. This criteria had higher sensitivity and efficiency than total protein concentration (p < 0.05). Our data suggest that ascites/serum lactic dehydrogenase ratio may offer advantages over ascites total protein concentration discriminating uncomplicated PHRA from non PHRA and PHRA with complications in the initial approach to a peritoneal effusion.