Pattern of Serum Amino Acids in Patients with Liver Cirrhosis

The serum amino acid pattern was studied in 30 patients with alcoholic liver cirrhosis, in 15 patients with non-alcoholic cirrhosis, and in nine healthy controls. Patients with alcoholic liver cirrhosis had significantly increased serum levels of aspartic acid, proline, methionine, tyrosine, phenylalanine, and tryptophan compared with controls. Valine was significantly decreased. Patients with non-alcoholic liver cirrhosis differed from patients with alcoholic liver cirrhosis only in having significantly greater serum levels of glycine. The serum amino acid pattern of nine cirrhotic patients who underwent mesocaval interposition shunt surgery because of bleeding esophageal varices was prospectively compared with that of nine matched patients treated with transesophageal sclerotherapy. A further significant increase in methionine and tyrosine serum levels was noted after shunt surgery. It is concluded that sclerotherapy influences serum amino acids less, which might be an advantage in relation to the development of hepatic encephalopathy.     

Endoscopic characterization of the small bowel in patients with portal hypertension evaluated by double balloon endoscopy

BACKGROUND: The endoscopic abnormalities present in the small bowel (SB) of patients with portal hypertension (PH) are not well understood. This study sought to evaluate endoscopic findings of the SB in patients with PH by double balloon endoscopy (DBE). METHODS: We evaluated the endoscopic findings of SB in 15 patients with PH and 49 controls without liver disease or PH. A total of 24 and 90 procedures were performed for PH patients and control patients, respectively, through oral and/or anal approaches. RESULTS: Fourteen of the 15 patients exhibited villous abnormalities, including edema (73%), atrophy (40%), and reddening (47%) of villi. Vascular lesions, such as angiodysplasia-like abnormalities (67%), dilated/proliferated vessels (93%), and varices (7%), were observed in all patients with PH. Although they were associated with ascites, these abnormalities did not correlate with any laboratory findings. None of these abnormalities was observed in controls. Definitive or suspected bleeding sources were identified in 9 of 13 patients with both PH and obscure gastrointestinal bleeding (OGIB), which was similar to the incidence in controls with OGIB. Although the frequency of postprocedure fever (>37.5 degrees C) was higher in patients with PH in comparison to controls (29% vs. 2%, P < 0.01), endoscopic treatment under DBE was performed on 3 PH patients without serious complications. CONCLUSIONS: Endoscopic abnormalities of the SB may be prevalent in patients with PH. Although postprocedure fever of DBE may occur more commonly in patients with PH, DBE is useful as both a diagnostic and therapeutic tool to evaluate the SB.     

Evaluation of Gallbladder Motility in Patients with Liver Cirrhosis

To investigate the postprandial gallbladder motility, including emptying and refilling, in cirrhotic patients and to evaluate the relationship to the presence of gallstones and various humoral mediators, 82 patients with liver cirrhosis and 40 age- and sex-matched healthy subjects were enrolled into this study. Postprandial gallbladder volumes were measured with ultrasonography every 15 min for 2 hr. Plasma levels of estradiol, testosterone, substance P, and nitrate/nitrite were also measured. Cirrhotic patients showed a higher prevalence of gallstones than healthy subjects (41% vs 15%, P = 0.003), and the prevalence increased with the progression of liver cirrhosis (Child-Pugh class A: 26%, B: 44%, and C: 65%, P = 0.02). Plasma levels of estradiol, testosterone, and substance P, and nitrate/nitrite and estradiol/testosterone ratios were not different between cirrhotic patients with and without gallstones. However, postprandial refilling of the gallbladders was significantly impaired in patients with cirrhosis, especially in those combined with gallstones. There was no significant difference in the postprandial gallbladder motility between cirrhotic patients with and without elevated plasma levels of estradiol, testosterone, and substance P and nitrate/nitrite, and estradiol/testosterone ratios. Gallstones were common in patients with liver cirrhosis and the prevalence increased with the progression of liver diseases. Sex hormones, substance P, and nitrate/nitrite did not play major roles in the formation of gallstones in cirrhotic patients. Refilling of the gallbladder was significantly impaired in patients with liver cirrhosis, especially in those with gallstones, and may play an important role in the pathogenesis of gallstones.     

48-Hour Hemodynamic Effects of Octreotide on Postprandial Splanchnic Hyperemia in Patients with Liver Cirrhosis and Portal Hypertension

Octreotide is effective during 48 h in the treatment of acute variceal bleeding, probably by reducing variceal blood flow and pressure. Its basal and postprandial effects on splanchnic and systemic hemodynamics, and hormonal changes over this time interval have not yet been studied. Twenty-four patients with cirrhosis and portal hypertension were randomized to receive a liquid meal and either octreotide (Oct, 100 g bolus intravenous, followed after 2 h by a continuous infusion of 25 g/hr for 20 hr) or placebo (Plac) given at three consecutive days. Splanchnic (Doppler ultrasound) and systemic hemodynamics (noninvasive cardiac monitoring) were assessed on four consecutive days (one control day and three treatment days) during 2 hr. The postprandial increase in mean blood velocity of the superior mesenteric artery (SMA-V _mean, +44%), portal blood velocity (PV-V _mean, +44%) and total hepatic blood flow (HBF, +40%) observed in the placebo group during the control day was abolished during the first day of treatment (SMA-V_mean, +3%, P < 0.01; PV-V_mean, +6%, P < 0.05; HBF, –25%, P < 0.01) and still reduced after 48 hr in the octreotide group (SMA-V_mean, +28%, P < 0.05; PV-V_mean, +22%, P > 0.05; HBF, –8%, P < 0.05). The postprandial increase in cardiac index (CI, +10%) and decrease in systemic vascular resistance index (SVRI, –6%) were blunted after the initial injection of octreotide only (CI, –8%, P < 0.05; SVRI, +18%, P < 0.01). Endothelin-1-levels, which were increased at baseline (Plac 25 ± 17, Oct 16 ± 13 ng/liter, P > 0.05) decreased significantly after 48 hr of treatment with octreotide (Plac 27 ± 20, Oct 8 ± 4 ng/liter, P < 0.05). Octreotide is effective during 48 hr in the prevention of postprandial hyperemia in cirrhotics, even if its efficacy is decreasing over time. Moreover it may have positive effects on systemic vasodilation in cirrhotics. These findings suggest a potential role of this drug in the chronic treatment of portal hypertension.     

Dehydrogenase Activity in Liver Biopsies from Patients with Cirrhosis

The activity of succinic (SDH), NADH- and NADPH-dehydrogenase was determined by the Nitro-BT method. In biopsies from patients with moderate and severe cirrhosis a lower activity of SDH was observed than in biopsies from those without or with slight alterations. The findings may indicate that liver failure is caused by a decrease in SDH-activity in addition to a reduction in liver-cell mass by the fibrosis.     

Gastroduodenal Vascular Ectasia in Patients with Liver Cirrhosis

The purpose of this study was to determine the incidence of hemorrhage due to vascular ectasia of the upper gastrointestinal tract in patients with liver cirrhosis and to assess the prevalence in cirrhotic patients without clinically overt gastrointestinal bleeding. Out of 96 cirrhotic patients with upper gastrointestinal bleeding, vascular ectasia was diagnosed in 6 patients (6.3%) as the cause of bleeding. These 6 patients had numerous spotty or confluent erythemas consisting of ectatic and tortuous capillaries throughout the antrutn and 4 patients required blood transfusion before diagnostic en-doscopy. Several sessions of endoscopic electrocoagulation resulted in eradication of almost all the abnormal vascular lesions and marked improvement of their anemia without further transfusion. The procedure was well tolerated and no resultant complications were encountered. Among 206 cirrhotic patients without clinically overt gastrointestinal bleeding 25 patients (12.1%) were diagnosed with vascular ectasia. The hemoglobin level was significantly lower in patients with vascular ectasia than those without vascular ectasia but the other features did not differ between the two groups. Vascular ectasia is an important cause of upper gastrointestinal bleeding and anemia in patients with liver cirrhosis. Endoscopic electrocoagulation may be a safe and effective treatment for controlling blood loss from gastroduodenal vascular ectasia in this subset of patients. (Dig Endosc 1999; 11: 241–245)     

肝硬化门脉高压患者胰岛细胞早期分泌相的变化

选择肝硬化门脉高压患者（Ｃｈｉｌｄ－Ｐｕｇｈ 分级Ｂ级）２０ 例及健康对照者２０ 例，快速静脉注射左旋精氨酸（Ｌ－Ａｒｇ）２０ｍ ｌ，于注射前及注射后２、４、６ 分钟分别测血清胰岛素（Ｉｎｓ）、Ｃ肽（Ｃ－ｐ）和胰升糖素（Ｇｃ）水平。对照组另行葡萄糖（Ｇｌｕ）兴奋试验，方法同上。结果显示，对照组经葡萄糖和Ｌ－Ａｒｇ 刺激后２ 分钟Ｉｎｓ、Ｃ－ｐ 分泌达峰值，前者峰值虽高于后者，但无明显差异（Ｐ＞ ０．０５）。肝硬化门脉高压组空腹时Ｉｎｓ和Ｇｃ高于对照组（Ｐ均＜ ０．０５），Ｌ－Ａｒｇ 兴奋后２ 分钟两组Ｉｎｓ、Ｃ－ｐ 和Ｇｃ达峰值，门脉高压组Ｉｎｓ和Ｇｃ峰值虽高于对照组，但峰值较空腹值升高倍数却低于对照组（Ｐ均＜ ０．０５）。提示肝硬化门脉高压患者存在胰岛素抵抗、胰升糖素血症及胰岛早期储备能力下降     

肝硬化患者胃黏膜前列腺素E2的研究

目的研究肝硬化患者胃黏膜前列腺素E2(PGE2)及意义。方法选取肝硬化患者60例及慢性胃炎、非溃疡性消化不良(NUD)患者各80例,行上消化道内镜检查,取胃窦及胃体各1块黏膜组织,用RIA法检测PGE2含量。结果(1)肝硬化组胃黏膜PGE2含量明显低于慢性胃炎及NUD组。(2)在肝硬化患者中,胃黏膜PGE2含量门脉高压胃病(PHG)组明显低于非PHG组,肝源性溃疡(HU)组亦明显低于非HU组,而与肝功能分级无关。结论(1)肝硬化胃黏膜防御机制减弱。(2)肝硬化胃黏膜PGE2的异常参与PHG及HU的形成。     

Relationship between Peripheral Portal Blood Flow and Liver Function in Patients with Liver Cirrhosis: Pulsed Doppler Ultrasonographic Study

Nishihara K, Sakata K, Yagyu T, Nakashima K, Suzuki T. Relationship between peripheral portal blood flow and liver function in patients with liver cirrhosis. Pulsed Doppler ultrasonographic study. Scand J Gastroenterol 1994;29:859-864.

Background: The relationship between portal hemodynamics and liver function in patients with liver cirrhosis remains unclear. Methods: Using pulsed Doppler ultrasonography, we investigated portal hemodynamics in the trunk and the intrahepatic peripheral vessels and its relation to liver function in cirrhotic patients. Results: The portal blood flow in the right anterior branch (RAB) in cirrhotic patients (n equals; 40) was significantly lower (p < 0.01) than that in normal subjects (n equals; 40). In the cirrhotic patients the portal blood flow in the RAB was significantly correlated with the values of serum albumin, total bilirubin, cholesterol, cholinesterase, prothrombin time, and ICG R-15, and that in group C (Child's grading) was significantly decreased (p < 0.01) compared with that in group A. No such difference was found in the main portal vein, the right posterior branch, or the umbilical portion of the left portal vein. Conclusions: The decrease in blood flow in the RAB is closely related to the impairment of liver function in cirrhotic patients.     

放射核素定量检查评价肝硬化患者的肝脏贮备功能

目的：本文对３６例肝硬化患者采用９９ｍＴＣＥＨＩＤＡ（二乙基丁酰苯胺基亚氨二醋酸）进行肝脏动态显像检查，并作定量分析，以便对肝硬化患者的贮备功能作出正确估价。方法：每位患者在检查前禁食４小时以上，检查时仰卧于ｒ相同探头下，静注８８ｍＴＣＥＨＩＤＡＦ４０ＭＢｇ，前位连续功态采集每一帧／６０秒，连续采集３０分钟，６０分钟再作静态采集一帧，经计算机处理手作定量分析。结果：结果表明肝硬化者血液中清除指数（Ｈ５／Ｈ２ｍｉｎ）、心肝比值（Ｈ５／Ｌ５ｍｉｎ）均较对照组明显增大，而３０分钟排泄率则较对照组为低（ＥＸ３０ｍｉｎ）、两组核素显像定量值相比均有显著差异（Ｐ＜０．０１），且与肝硬心病情程度相关，按ｃｈｉｌｄＰｎｇｈ分期，Ａ、Ｂ、Ｃ级之间Ｈ５／Ｈ２ｍｉｎ、Ｈ５／Ｌ５ｍｉｎ、Ｅ×３０ｍｉｎ核素定量结果互相对比均有显著差异（Ｐ＜０．０５～０．０１）。上述三项参数与肝功能实验检测指标间有一定相关性。结论：本组资料提示该方法较敏感反映肝硬化不同时期的贮备功能，对肝硬化的早期诊断等有一定的临床价值。     

Development of Gastroesophageal Varices and Risk of Variceal Bleeding in Patients With Cirrhosis

Abstract: We studied the relationships between portal pressure measured using the portal venous pressure gradient, the development of gastroesophageal varices, and the risk of variceal bleeding in 56 patients with cirrhosis. Portal pressure was higher in patients with varices than in those without (P>0.01), and 11 mmHg was the lowest portal pressure measured in the patients with varices. The size of the varices was not associated with the portal pressure. There was no difference in the value of portal pressure measurements for the patients with variceal bleeding and those without and there was no linear-relationship between the degree of portal hypertension and the rate of variceal bleeding. 12 mmHg was the lowest portal pressure measured in the patients with variceal bleeding. The size of the varices was related to the rate of variceal bleeding (P>0.05). We conclude that (a) a portal pressure of 11 mmHg is necessary for the formation of varices, (b) 12 mmHg of portal pressure is necessary for variceal bleeding to occur but the degree of portal hypertension has no predictive value for the risk of variceal bleeding, and (c) the size of the varices does not depend on the degree of portal hypertension but is associated with the risk of variceal bleeding.     

Hepatic-Associated Immunoglobulin-A Nephropathy in a Child with Liver Cirrhosis and Portal Hypertension

Hepatic-associated immunoglobulin A (IgA) nephropathy is a relatively common condition that occurs in adults with liver cirrhosis and portal hypertension. However, it is rare in children. This condition is characterized by the deposition of IgA in the renal glomeruli. The present report describes a 14-year-old boy with cryptogenic liver cirrhosis and portal hypertension who presented with hematuria and proteinuria associated with histological changes of IgA nephropathy.     

肝硬化患者胃粘膜幽门螺杆菌检出的初步观察

本文对72例肝硬化患者进行了胃镜下胃粘膜活检检测幽门螺杆菌（HP）。组织学检查HP阳性42例，阳性率58．33％，HP感染和患者的肝功能Child分级无明显相关，亦和胃镜下食管静脉曲张的有无及曲张的严重程度无显著相关，而和胃粘膜活动性炎症及二十指肠溃疡的发生有明显相关。认为在肝硬化患者中，所存在的慢性活动性胃炎的主要病因仍是HP感染，HP可能在肝源性十二指肠溃疡的发病机制中起重要作用。     

Evaluation of Cingulate Gyrus Blood Flow in Patients With Liver Cirrhosis

Although neuropsychological tests are commonly applied to detect minimal hepatic encephalopathy (HE) in patients with liver cirrhosis (LC), they provide no information about the cerebral regions involved. Recently, it has been reported that some populations of alcoholic cirrhotics, with mild HE, have reduced cerebral metabolic rate for glucose in bifrontal cortices and in the anterior cingulate gyrus. We evaluated the degree of reduction in blood flow at the anterior cingulate gyrus and the frontal lobes in cirrhotic patients who underwent single photon emission computed tomography (SPECT). Data were obtained from 47 cirrhotic patients and 47 subjects without LC. Three radiologists unaware of the results of laboratory tests visually evaluated the transaxial, coronal, and sagittal views of SPECT. The area and the degree of blood flow reduction in the anterior cingulate gyrus and frontal lobes were scored. Reduced blood flow in the anterior cingulate gyrus was observed in most LC patients. In patients without overt HE, poor performance in neuropsychological tests was correlated with reduced cerebral blood flow in the anterior cingulate gyrus. Blood flow in the anterior cingulate gyrus as measured by SPECT may be a simple and good indicator of cerebral functional changes in patients with LC.     

Domperidone-Induced Increase in Lower Oesophageal Sphincter Pressure Does Not Affect Azygos Blood Flow in Patients with Cirrhosis

An increase in lower oesophageal sphincter pressure induced by domperidone has previously been reported to decrease superior portosystemic collateral flow in patients with portal hypertension owing to cirrhosis. Although a 10-mg intravenous dose of domperidone was effective in increasing lower oesophageal sphincter tone in a group of six patients with cirrhosis, the same dose failed to affect azygos blood flow in a matched group of six patients. The results do not support the hypothesis that an increase in lower oesophageal sphincter tone can decrease flow through oesophageal varices in patients with cirrhosis.     

肝硬变患者肝脏体积改变与肝功能的关系

本文应用放免法检测３４例肝炎后肝硬变血清ＨＡ、ＣＧ等肝功能指标结合测量ＣＴ片上肝脾体积改变以探讨两者的关系。结果显示随着肝硬变患者Ｃｈｉｌｄ分级增加，肝功能损害加重，表现为ＨＡ和ＣＧ浓度逐渐上升，ＰＴ时间延长和白蛋白浓度降低。肝脏体积缩小，与ＨＡ、ＣＧ及ＰＴ时间呈负相关（分别为ｒ＝－０．８０４、－０．８９３、－０．８７４、Ｐ＜０．０１）及与白蛋白呈正相关（ｒ＝０．７２２、Ｐ＜０．００１），而脾脏体积改变与上述指标相反，即与ＨＡ、ＣＧ呈正相关，与白蛋白呈负相关，且ＣｈｉｌｄＡ、Ｂ、Ｃ三级之间差异显著（Ｐ＜０．００１）。结果表明，在检测肝功能的同时测量肝脏及脾脏体积可能有助于对肝硬变患者判断预后及指导治疗。     

Effect of Metoclopramide on Portal Blood Flow in Patients with Liver Cirrhosis,Measured by the Pulsed Doppler System

The effect of metoclopramide on portal blood flow, the maximal diameter of the portal vein, and some cardiovascular haemortynamic variables was studied in 10 patients with cirrhosis of the liver and portal hypertension. Portal vein haemo-dynamics were studied by the pulsed Doppler system. Within 15 min of intravenous administration of 20 mg metoclopramide, portal blood velocity and portal blood flow decreased significantly, from 11.2 ± 1.1 to 10.8 ± 1.2 cm/sec and from 769.0 ± 87.7 to 707.9 ± 84.2 ml/min, respectively (p < 0.001). Within about 30 min portal blood velocity and portal blood flow returned to basal values (p >0.05). The maximal diameter of the portal vein, systolic and diastolic blood pressure, and heart rate remained unchanged. These results support the hypothesis that metoclopramide, which raises lower oesophageal sphincter pressure and reduces intravariceal blood flow, significantly decreases the portal blood flow in cirrhotic patients with portal hypertension.     

Gastrointestinal endoscopy in the cirrhotic patient

As advances in liver disease continue, including the increasing use of liver transplantation, the endoscopist needs to be familiar with the standards of care and potential complications in the management of the cirrhotic population. This includes both elective endoscopic procedures, such as screening colonoscopies and variceal banding, as well as the acutely bleeding cirrhotic patient. Peri-procedural management and standards of care for acute gastrointestinal hemorrhaging of cirrhotic patients will be emphasized. This article will focus on the plethora of data available to highlight the benefits of endoscopic intervention in the care of patients with liver disease and outline the areas of future emphasis.