Endoscopic sclerotherapy versus portacaval shunt in patient with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up

In a continuation of a trial for which preliminary results were reported in the Journal two years ago, a total of 64 patients with Child Class C cirrhosis and variceal hemorrhage requiring six or more units of blood were randomly assigned to receive either a portacaval shunt (32 patients) or endoscopic sclerotherapy (32 patients). The duration of initial hospitalization and the total amount of blood transfused during hospitalization were significantly less in the patients receiving sclerotherapy (P less than 0.001). There was no difference in short-term survival (50 percent of the sclerotherapy group were discharged alive, as compared with 44 percent of the shunt-surgery group). Both groups were followed for a mean of 530 days after randomization. Rebleeding from varices, the duration of rehospitalization for hemorrhage, and transfusions received after discharge were all significantly greater in the sclerotherapy group (P less than 0.001). Forty percent of the sclerotherapy-treated patients discharged alive (7 of 16 patients) ultimately required surgical treatment for bleeding varices, despite a mean of 6.1 treatment sessions. Health care costs and long-term survival did not differ significantly between the groups (P greater than 0.05). We conclude that although endoscopic sclerotherapy is as good as surgical shunting for the acute management of variceal hemorrhage in poor-risk patients with massive bleeding, sclerotherapy-treated patients in whom varices are not obliterated and bleeding continues should be considered for elective shunt surgery.     

Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites

BACKGROUND. There is no satisfactory treatment for refractory ascites in patients with cirrhosis. Both peritoneovenous shunts and paracentesis have been used, but there is uncertainty about their relative merits. METHODS. We studied 89 patients with cirrhosis and refractory ascites who were randomly assigned to receive either repeated large-volume paracentesis plus intravenous albumin or a LeVeen peritoneovenous shunt. Patients in the paracentesis group in whom recurrent tense ascites developed during follow-up were treated with paracentesis, and those in the peritoneovenous-shunt group with diuretic agents or by the insertion of a new shunt if there was shunt obstruction. RESULTS. During the first hospitalization, ascites was removed in all 41 patients in the paracentesis group and in 44 of the 48 patients in the peritoneovenous-shunt group. The mean (+/- SD) duration of hospitalization in the two groups was 11 +/- 5 and 19 +/- 9 days, respectively (P less than 0.01). There were no significant differences in the number of patients who had complications or died. During follow-up, 37 patients in each group were hospitalized again. In the paracentesis group, the number of rehospitalizations for any reason (174 vs. 97 in the peritoneovenous-shunt group) or for ascites (125 vs. 38) was significantly higher, and the median time to a first readmission for any reason (1 +/- 1 vs. 2 +/- 2 months) or for ascites (2 +/- 2 vs. 8 +/- 17 months) was significantly shorter than in the peritoneovenous-shunt group. The total times in the hospital during follow-up, however, were similar in the two groups (48 +/- 49 and 44 +/- 39 days, respectively). Three patients had obstructions of their peritoneovenous shunts during their first hospitalizations, and 15 patients had a total of 20 obstructions during follow-up. Survival was similar in both groups. CONCLUSIONS. The LeVeen shunt and paracentesis are equally effective in relieving refractory ascites. The former may provide better long-term control of ascites, but shunt occlusion is common and survival is not improved.     

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices.

BACKGROUND. Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. METHODS. In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. RESULTS. Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections. CONCLUSIONS. Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.     

Prophylaxis of first variceal hemorrhage in patients with liver cirrhosis

Summary Prophylaxis of bleeding from esophageal varices is a very tempting concept at first glance, especially under the assumption of a high mortality associated with first variceal hemorrhage. Up to now four different measures have been tried for prophylaxis: portacaval shunt operation, devascularization procedures, sclerotherapy, and drugs. With the exception of portacaval shunts, ongoing controlled trials show a weak trend toward reduction of variceal bleeding and prolongation of survival in selected patients with compensated cirrhosis and large varices. However, prophylaxis of first variceal bleeding must still be regarded as experimental and should be restricted to controlled clinical studies.Abbreviations ICG Indocyanine-green - WHVP/FHVP-gradient Wedged hepatic venous pressure minus free hepatic venous pressure gradient     

应用PTFE门腔H型吻合治疗门脉高压症

目的:本研究的目的是了解血管移植物PTFE在分流道的通畅率,分流口径对向肝血流的影响以及减压效果和并发症。方法:用内径10mm普通PTFE和带支撑环的PTFE先后为12例及8例肝硬化门脉高压症患者进行了门腔静脉间的H型分流术,其中肝功能在Child A级13例,B级5例,C级2例。平均年龄43.4岁。结果:无手术死亡。术后平均随访17.2月,脑病Ⅰ～Ⅱ级2例,无曲张静脉破裂再出血。术后门脉系统彩色多谱勒超声及血管造影检查,向肝血流量无明显影响,分流道通畅率90％,普通PTFE者血栓形成2例。结论:该技术在减低门脉压力,保证向肝血流,预防再出血等方面均取得了良好结果。其中带支撑者优于普通型。     

Prophylactic sclerotherapy before the first episode of variceal hemorrhage in patients with cirrhosis

The value of sclerotherapy as prophylaxis against the first episode of variceal hemorrhage has not been established. Therefore, we randomly assigned 133 patients with cirrhosis of the liver (of alcoholic origin in 66 percent), esophageal varices, and no previous intestinal bleeding to either prophylactic sclerotherapy (n = 68) or no prophylaxis (n = 65). The groups were comparable in hepatic function, endoscopic findings, and the pathogenesis of cirrhosis. All patients who subsequently had a first episode of variceal hemorrhage received sclerotherapy whenever possible. During a median follow-up of 22 months, variceal hemorrhage occurred in 28 percent of the patients receiving sclerotherapy and 37 percent of the controls (P = 0.3). Thirty-five percent of the sclerotherapy group and 46 percent of the control group died. The survival curves (Kaplan-Meier) of both groups were similar (P = 0.2). However, among patients with alcoholic and moderately decompensated cirrhosis (Child-Pugh group B), survival was significantly higher in those receiving sclerotherapy, although the risk of bleeding was only marginally reduced by this procedure. We conclude that prophylactic sclerotherapy does not significantly reduce the risk of bleeding from esophageal varices, but that a subgroup of patients with esophageal varices and moderately decompensated alcoholic cirrhosis may benefit from prophylactic sclerotherapy because of factors not solely attributable to prevention of an initial episode of variceal bleeding.     

Surgery for variceal bleeding in cirrhosis: a review of our experience and present concepts.

The major cause of portal hypertension in Western countries is nutritional cirrhosis (parenchymal block) related to alcoholism. A third of those patients die of variceal bleeding when increased pressure within the varices precipitates bleeding. Construction of portal systemic shunts is aimed at reducing the pressure within the varices and thereby decreasing the risk of bleeding. However, it increases the incidence of hepatic encephalopathy and hence should be used only in patients who have bled. The remaining function appears to be the main factor that determines survival and the incidence of encephalopathy in obese individuals. Portacaval shunts almost completely eliminate the risk of bleeding. There is a greater incidence of hepatic encephalopathy with this procedure than with other shunts. The splenorenal shunt and the distal splenorenal shunt appear to work well in selected patients. Technically, it is a more difficult procedure. The interposition mesocaval shunt is technically easier and is also helpful in patients with ascites. Its post-shunt encephalopathy rate, however, is higher than the splenorenal shunt or the distal splenorenal shunt, though less than the portacaval shunts. Experience with the newer arterialized portacaval and coronary caval shunts is limited. A non-shunt procedure, such as the one described by Sugiura, with impressive results and follow-up may become more acceptable as experience grows.     

A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites

BACKGROUND: In patients with cirrhosis and ascites, creation of a transjugular intrahepatic portosystemic shunt may reduce the ascites and improve renal function. However, the benefit of this procedure as compared with that of large-volume paracentesis is uncertain. METHODS: We randomly assigned 60 patients with cirrhosis and refractory or recurrent ascites (Child-Pugh class B in 42 patients and class C in 18 patients) to treatment with a transjugular shunt (29 patients) or large-volume paracentesis (31 patients). The mean (+/-SD) duration of follow-up was 45+/-16 months among those assigned to shunting and 44+/-18 months among those assigned to paracentesis. The primary outcome was survival without liver transplantation. RESULTS: Among the patients in the shunt group, 15 died and 1 underwent liver transplantation during the study period, as compared with 23 patients and 2 patients, respectively, in the paracentesis group. The probability of survival without liver transplantation was 69 percent at one year and 58 percent at two years in the shunt group, as compared with 52 percent and 32 percent in the paracentesis group (P=0.11 for the overall comparison, by the log-rank test). In a multivariate analysis, treatment with transjugular shunting was independently associated with survival without the need for transplantation (P=0.02). At three months, 61 percent of the patients in the shunt group and 18 percent of those in the paracentesis group had no ascites (P=0.006). The frequency of hepatic encephalopathy was similar in the two groups. Of the patients assigned to paracentesis in whom this procedure was unsuccessful, 10 received a transjugular shunt a mean of 5.5+/-4 months after randomization; 4 had a response to this rescue treatment. CONCLUSIONS: In comparison with large-volume paracentesis, the creation of a transjugular intrahepatic portosystemic shunt can improve the chance of survival without liver transplantation in patients with refractory or recurrent ascites.     

Maze patrolling,open-field behavior and runway activity following experimental portacaval anastomosis in rats

Surgical construction of a portacaval shunt in patients with debilitating liver cirrhosis is frequently followed by the development of hepatic encephalopathy, characterized by severe cognitive and neuromuscular abnormalities. The rat with a portacaval anastomosis provides a heuristic animal model for the biochemical consequences of the portosystemic diversion of the circulation; the behavioral effects of such shunting were studied in the present investigation. The spontaneous behavior of male Sprague-Dawley rats with a chronic experimental portacaval anastomosis (end-to-side) was evaluated in a complex enclosed maze, an illuminated open field and an enclosed hexagonal runway. There was little evidence that portacaval shunted rats differed from sham operated rats in total activity, explored area, maze-center entry, or in either of two indexes of the efficiency of patrolling within a complex Dashiell-type maze over 13 successive days with three different maze configurations. Similarly, experimental and control rats did not differ in any of several responses assessed in an illuminated open field. However, rats with a portacaval shunt were hypoactive in a runway test given two months postsurgery. All experimental subjects were verified to have an open portacaval shunt and to have sustained significant liver atrophy. These results emphasize the subtle nature of the behavioral effects resulting from the surgical construction of a portacaval anastomosis in rats.     

Constant mean airway pressure with different patterns of positive pressure breathing during the adult respiratory distress syndrome

Twenty-one ARDS patients were divided into two groups of severity according to FIO2 and PEEP required to maintain an adequate gas exchange. The 10 most severe patients (group A) underwent continuous positive pressure ventilation (CPPV) (I/E 3:1) with the mean airway pressure maintained at 21 +/- 6.2 cmH2O. The PEEP values were 12.6 +/- 4.3 cmH2O during CPPV and 6.5 +/- 3.7 cmH2O during IRV (p less than 0.01). Eleven less severe ARDS patients (group B) underwent CPPV and positive pressure spontaneous breathing (CPAP) at constant mean airway pressure of 14.3 +/- 3.8 cmH2O. The PEEP was 7 +/- 2.5 cmH2O during CPPV and 14.9 +/- 4.3 cmH2O during CPAP (p less than 0.001). In five patients of each group, the SF6 shunt was measured as representative of true shunt. The results showed that gas exchange, including true shunt, and haemodynamics did not change between CPPV and IRV and between CPPV and CPAP tests. Taken with previous work on mean airway pressure, our results further support the concept that the main determinant of oxygenation and haemodynamics is the mean airway pressure, irrespective of the PEEP level and of the mode of ventilation.     

Effects of portacaval shunt and transposition on fatty acid and cholesterol biosynthesis in rat liver

Male rats underwent either portacaval shunt or portacaval transposition; in both cases, sham-operated pair-fed rats served as controls. Three weeks after a portacaval shunt, fasting serum values of glucose (-35%) and cholesterol (-24%) were lower, and fasting plasma glucagon was higher (+65%). The wet weight of the liver and its total content in DNA, RNA, and protein decreased by 43, 40, 43, and 48%, respectively. The supernatant of liver obtained after centrifugation at 700 g incorporated less [1-14C]acetate (-56%) into fatty acids and less [1-14C]acetate (-94%) and [2-14C]mevalonate (-37%) into cholesterol. The activity of acetyl CoA carboxylase was reduced by 56%. The in vivo incorporation of [3H]H2O into liver fatty acids was 83% lower and that into liver cholesterol was 39% lower than in pair-fed controls. Several of the preceding parameters, including in vitro and in vivo labeling of hepatic fatty acids and cholesterol, were found to be mostly normal in rats with portacaval transposition. These data suggest that the reduction of fatty acid and cholesterol biosynthesis in the liver of rats with portacaval shunt was due to the reduction of total hepatic blood flow rather than to the diversion of portal blood constituents.     

Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites

The optimal management of severe ascites in patients with alcoholic cirrhosis has not been defined. in a 5 1/2-year study, we randomly assigned 299 men with alcoholic cirrhosis, who had persistent or recurrent severe ascites despite a standard medical regimen, to receive either intensive medical treatment or peritoneovenous (LeVeen) shunting. We identified three risk groups: Group 1 had normal or mildly abnormal results on liver-function tests, Group 2 had more severe liver dysfunction or previous complications, and Group 3 had severe prerenal azotemia without kidney disease. For the patients who received the medical treatment and those who received the surgical treatment combined, the median survival times were 1093 days in Group 1, 222 days in Group 2, and 37 days in Group 3 (P less than or equal to 0.01) for all comparisons). For all the groups combined, the median time to the resolution of ascites was 5.4 weeks for medical patients and 3.0 weeks for surgical patients (P less than 0.01). Within each risk group, mortality during the initial hospitalization and median long-term survival were similar among patients receiving either treatment. However, the median time to the recurrence of ascites in Group 1 was 4 months in medical patients, as compared with 18 months in surgical patients (P = 0.01); in Group 2 it was 3 months in medical patients as compared with 12 months in surgical patients (P = 0.04). The median duration of hospitalization was longer in medical patients than in surgical patients (6.1 vs. 2.4 weeks in Group 1 [P less than 0.001] and 5.0 vs. 3.1 weeks in Group 2 [P less than 0.01]). Group 3 was too small to permit a meaningful comparison. During the initial hospitalization, the incidence of infections, gastrointestinal bleeding, and encephalopathy was similar among the medical and surgical patients. We conclude that peritoneovenous shunting alleviated disabling ascites more rapidly than medical management. However, survival was closely related to the severity of the illness at the time of randomization and was not altered by shunting.     

Beta-adrenergic-antagonist drugs in the prevention of gastrointestinal bleeding in patients with cirrhosis and esophageal varices. An analysis of data and prognostic factors in 589 patients from four randomized clinical trials. Franco-Italian Multicenter Study Group.

BACKGROUND. The value of beta-adrenergic-antagonist drug therapy for the prevention of initial episodes of gastrointestinal bleeding in patients with cirrhosis and esophageal varices is uncertain, both positive and negative study results having been reported. METHODS. In this study, we analyzed data on individual patients from four randomized, controlled trials to assess the efficacy of this treatment. Of the 589 patients studied, 286 received a beta-adrenergic-antagonist drug (propranolol in 203 and nadolol in 83) and 303 received placebo. RESULTS. After two years, the mean (+/- SE) percentage of patients who had had no upper gastrointestinal bleeding was 78 +/- 3 percent in the beta-adrenergic-antagonist treatment group and 65 +/- 3 percent in the control group (P = 0.002). The percentage of patients without fatal bleeding was 90 +/- 2 percent in the treatment group and 82 +/- 3 percent in the control group (P = 0.01). The percentage of patients surviving after two years was 71 +/- 3 percent in the treatment group and 68 +/- 3 percent in the control group (P = 0.34). After age and severity of cirrhosis were taken into account, the survival rate was better in the treatment group (P = 0.09). The percentage of surviving patients who had had no bleeding after two years was 62 +/- 3 percent in the treatment group and 53 +/- 3 percent in the control group (P = 0.04). Both propranolol and nadolol prevented a first episode of bleeding. Severe cirrhosis and especially the presence of ascites were associated with bleeding (P less than 0.001) and death (P less than 0.001) in both groups. The efficacy of beta-adrenergic-antagonist therapy in the prevention of bleeding (P less than 0.001) and of fatal bleeding (P = 0.004) and in the prevention of bleeding or death (P = 0.005) was the same after adjustment for cause and severity of cirrhosis, ascites, and size of varices. CONCLUSIONS. Propranolol and nadolol are effective in preventing first bleeding and reducing the mortality rate associated with gastrointestinal bleeding in patients with cirrhosis, regardless of severity.     

Effects of portacaval diversion on lipid metabolism in rat adipose tissue

Male rats were submitted for 3 wk either to portacaval shunt or to portacaval transposition. In both cases, sham-operated pair-fed rats served as controls. After an overnight fast, insulinemia was similar in all groups, but glucagonemia was significantly higher (by 65%) and serum glucose significantly lower (by 35%) in rats with a portacaval shunt. The lipid metabolism of epididymal adipose tissue was studied in vitro, as well as in vivo. In rats with a portacaval shunt, in vitro lipogenesis from [U-14C]glucose, [1-14C]acetate, or 3H2o was 60-80% lower than in sham-operated pair-fed controls. Twice as much in vitro basal lipolysis could be determined. In addition, in vivo lipogenesis from 3H2O was markedly decreased (6 times). By contrast, in rats with portacaval transposition, in vitro lipogenesis was higher (by 80-140%) and basal lipolysis lower (by 63%) than in pair-fed controls. Thus, even when the nutritional state was taken into consideration, the type of portal diversion was the determining factor in influencing lipid metabolism in epididymal adipose tissue.     

Early administration of vapreotide for variceal bleeding in patients with cirrhosis

BACKGROUND: In patients with cirrhosis, pharmacologic or endoscopic treatment may control variceal bleeding. However, the effects of early administration of a somatostatin analogue followed by endoscopic treatment are unknown. METHODS: We studied the effects of treatment with vapreotide, a somatostatin analogue, begun before endoscopic treatment in 227 patients with cirrhosis who were hospitalized for acute upper gastrointestinal bleeding. The patients were randomly assigned to receive vapreotide (a 50-microg intravenous bolus followed by an infusion at a rate of 50 microg per hour for five days) or placebo within a mean (+/-SD) of 2.3+/-1.5 hours after admission. All the patients received endoscopic treatment a mean of 2.6+/-3.3 hours after the infusion was begun. After the exclusion of 31 patients whose bleeding was not caused by portal hypertension, there were 98 patients in each group. RESULTS: At the time of endoscopy, active bleeding was evident in 28 of 91 patients in the vapreotide group (31 percent), as compared with 43 of 93 patients in the placebo group (46 percent) (P=0.03). During the five-day infusion, the primary objective--survival and control of bleeding--was achieved in 65 of 98 patients in the vapreotide group (66 percent) as compared with 49 of 98 patients in the placebo group (50 percent) (P=0.02). The patients in the vapreotide group received significantly fewer blood transfusions (2.0+/-2.2 vs. 2.8+/-2.8 units, P=0.04). Overall mortality rates at 42 days were not significantly different in the two groups. CONCLUSIONS: In patients with cirrhosis and variceal bleeding, the combination of vapreotide and endoscopic treatment is more effective than endoscopic treatment alone as a method of controlling acute bleeding. However, the use of combination therapy does not affect mortality rates at 42 days.     

Short-term biological effects of synthetic salmon calcitonin in Paget's disease. Influence of posology]

In ten patients with Paget's disease of bone (Group I) intramuscular injection of 50 MRC units of synthetic Salmon calcitonin (SCT) induced a marked decrease of serum calcium (-1,444 mg%), serum phosphorus (-1,06 mg%), urinary total hydroxyproline (-71%), and a marked increase of urinary cyclic AMP (+ 114%). These changes occur at maximum 6 hours after the injection with a return to the initial values after 24 hours. In six other patients with Paget's disease (Group II) the acute biological effects were of the same nature and magnitude after the injection of 100 MRC units of SCT. In this group a significant but temporary increase of the plasma parathyroid hormone level was demonstrated. The magnitude of the hypocalcemia seems proportional to the initial serum alkaline phosphatase and urinary hydroxyproline levels. After one month of treatment, the alkaline phosphatase and urinary hydroxyproline have more marked and more regular decrease in group II who received 100 MRC units of SCT daily than in group I who received 50 MRC units three times a week. The cellular mechanisms of these biological changes are discussed. A posology of two daily injections of 50 MRC units of SCT is suggested when a quick and maximum stoppage of pagetic remodeling is required.     

Hyperlipidemia and insulin resistance are induced by protease inhibitors independent of changes in body composition in patients with HIV infection

Although protease inhibitor (PI) therapy has improved the clinical status of patients with HIV infection, concerns have arisen that such treatment may have deleterious effects on glucose control, lipid metabolism, and body fat distribution. To determine whether initiation of PI therapy uniquely affects glucose and lipid metabolism, we analyzed paired data in HIV-infected patients before and after beginning antiretroviral therapy that included a PI (PI; N = 20) or lamivudine (3TC) but no PI (3TC; N = 9); and a control group on stable regimens that included neither of these agents (CONT: N = 12). Measurements included fasting glucose; insulin; triglycerides; total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol; HIV RNA; CD4+ lymphocytes; weight; and total and regional body composition. Neither weight nor total or regional fat content changed significantly in any group during the period of observation. Nonetheless, in patients beginning PI therapy, there were significant increases in glucose (+9+/-3 mg/dl; p = .0136), insulin (+12.2+/-4.9 U/ml; p = .023), triglycerides (+53+/-17 mg/dl; p = .0069), and total and LDL cholesterol (+32+/-11 and +18+/-5 mg/dl; p = .0082 and .0026, respectively). None of these parameters changed significantly in the 3TC or CONT groups. The PI and 3TC groups experienced comparable increases in CD4+ lymphocytes, suggesting that the observed metabolic effects may be associated with PIs uniquely, rather than improvement in clinical status. However, it is also possible that the metabolic effects of PIs are associated with more effective viral suppression, because a greater proportion of patients in the PI group achieved undetectable levels of virus. We conclude that changes in glucose and lipid metabolism are induced by PI therapy in the absence of significant changes in weight or fat distribution. Longer periods of follow-up will be required to determine the clinical significance of these changes. However, at the moment, the risks associated with these metabolic effects do not appear to outweigh improvements in survival seen with PI therapy.     

Prophylactic sclerotherapy of large esophageal varices

We randomly assigned 95 patients with large esophageal varices (Grade 3 or 4) who had not previously had upper gastrointestinal tract bleeding to two groups: 49 received intravariceal sclerotherapy, and 46 were followed as controls. Over a mean follow-up of 13 months there was no difference between the sclerotherapy group and the control group in mortality (24.4 percent) or any significant difference in average hospital stay per month (3.0 vs. 2.6 days). Sclerotherapy was associated with significantly more episodes of upper gastrointestinal bleeding (26 vs. 10 episodes, P less than 0.05); 75 percent of deaths in the sclerotherapy group were related to bleeding, as compared with 18 percent in the control group. An additional 54 patients with cirrhosis who did not qualify for the study were also followed--20 with small varices and 34 with none. Mortality was 20 and 15 percent, respectively; no deaths were due to bleeding. We conclude that prophylactic sclerotherapy does not provide clinical benefit to patients with large esophageal varices.     

Astrocytes of the cerebral cortex in hepatosplenic schistosomiasis mansoni and in liver cirrhosis

Summary A morphological, quantitative and karyometric study of astrocytes of the cerebral cortex in patients with liver cirrhosis, hepatosplenic schistosomiasis mansoni and controls is reported. Cell proliferation was commonly seen but there was no significant increase in number of astrocytes in either cirrhosis and schistosomiasis groups. A highly significant increase in astrocyte nuclear volume in cirrhosis and schistosomiasis in relation to controls was observed. The astrocyte average nuclear volume in the cirrhotics was also significantly increased in relation to the schistosomiasis group. From the present data and those reported by other investigators it may be concluded that under normal conditions the astrocyte population is continually reforming and it proliferates in liver cirrhosis and hepatosplenic schistosomiasis. It seems that the morphological, quantitative and karyometric astrocyte changes in schistosomiasis may be the result of the same factors as those previously described for liver cirrhosis and experimental portacaval shunt.Supported by Grant n^o 11112036/76 from CNPq     

Alpha 1-antitrypsin deficiency and liver cirrhosis in adults. An analysis of 35 Swedish autopsied cases

alpha 1-Antitrypsin (AAT) deficiency in adults predisposes to lung and liver disease, but its natural history is incompletely known. To better characterize the liver disease, all known deceased adult Swedish patients known to us with homozygous (PiZZ) AAT-deficiency, who had undergone autopsy during the 20-year period 1963-82 were reviewed. Of 94 such patients, 35 had cirrhosis (27 males and eight females) with a mean age at death of 65.5 +/- 10.5 (SD) years compared to 53.6 +/- 12.8 years (p less than 0.01) for the 59 non-cirrhotic patients. The longer survival suggests less severe lung disease in the cirrhotic group. Clinically these patients most frequently presented with ascites or other signs of portal hypertension. Evidence of alcohol overconsumption, chronic viral hepatitis, or autoimmune disease was rare. Aside from low plasma AAT levels, laboratory and other clinical features were indistinguishable from those of decompensated cirrhosis of any etiology. The prognosis was generally grave with a mean survival of two years after diagnosis. Fourteen of the 35 cirrhotics (10 males and four females) had primary liver cancer (PLC) at autopsy. We conclude that cirrhosis and PLC are more frequent complications in elderly patients with AAT-deficiency than was previously known. These complications had a marked male predominance.