Unilateral asterixis due to a lesion of the ventrolateral thalamus

A case of unilateral asterixis in a man with a focal ischaemic lesion of the contralateral ventral thalamus is presented. Atypically, the movements were present at rest and had a pattern of activation that resulted in an initial misdiagnosis of epilepsia partialis continua. This case emphasises the importance of electromyographic analysis in establishing the correct diagnosis of involuntary movements before starting specific treatment.

[Dyskinesia in metabolic encephalopathy]

We have described several kinds of involuntary movements occurring in metabolic encephalopathies. They are often associated with slowing of electroencephalographic basic activities and with loss of consciousness. Laboratory studies disclose the cause of the encephalopathies. Asterixis, first reported in hepatic encephalopathy, is produced by EMG silence during voluntary contraction. Myoclonus is associated with a short excessive EMG discharges. Tremor is caused by grouping EMG discharges. Some other kinds of involuntary movements are seen in metabolic encephalopathies. Clinical features of hepatic, uremic, hypoxic, and hypoglycemic encephalopathies are briefly described.

Control of cerebral oedema by total hepatectomy and extracorporeal liver support in fulminant hepatic failure

Keeping a patient with fulminant hepatic failure (FHF) alive until a donor liver is available for transplantation can be a problem. We describe an 18-year-old woman with paracetamol-induced FHF, who was treated by total hepatectomy, hypothermia, plasma exchange, and extracorporeal liver support. The patient was anhepatic for 14 h. The liver-support system consisted of plasma separation and perfusion through a charcoal filter and a hollow-fibre module seeded with matrix-attached porcine hepatocytes. With artificial liver treatment there was reversal of severe neurological dysfunction, normalisation of intracranial pressure, and decreased serum ammonia. The patient underwent emergency transplantation with an ABO-incompatible liver, followed by transplantation with a compatible organ eight days later. The patient has fully recovered and is neurologically intact.

Liver transplantation during pregnancy

We present a case of successful liver transplantation during the midtrimester of pregnancy, showing that pregnancy itself is not a contraindication to liver transplantation with life-threatening illness. Improvements in anaesthetic and surgical technique will enhance the possibility of foetal survival.

Fulminant hepatic failure

FHF is an uncommon but devastating condition affecting otherwise healthy persons which causes significant morbidity and mortality. The etiologic factor is most commonly viral infection, with drugs and metabolic disorders being relatively less common causes. Hopefully, newer diagnostic techniques such as PCR will increase our understanding of the causes and pathogenesis of this disorder. Medical management at the present time must focus on anticipating, preventing, and rapidly identifying and treating complications that may affect every major organ system. Encouraging research continues on the clinical application of hepatotrophic drugs and artificial liver support systems, both as potentially definitive therapies and as maintenance for patients awaiting transplantation. Consultation with physicians at a transplant center should be sought early in the course of the patient's hospitalization when OLT is being considered. Liver transplantation has dramatically changed the outlook for patients with FHF, with current survival rates in the 55% to 75% range. The continuing challenge for the transplant team is to allocate available donor organs to those patients who would not otherwise survive, but also to provide OLT in a timely fashion to ensure the best chance of post-transplantation recovery. Newer techniques such as heterotopic liver transplantation, reduced-size organ transplantation, and the utilization of living related donors may further improve the survival of these patients.

Fulminant hepatic failure after Lepiota mushroom poisoning

We present ten patients who suffered from a cyclopeptide syndrome from two different foci, one caused by Lepiota helveola (seven cases) and the other by Lepiota brunneoincarnata (three cases). Of the ten victims, five recovered completely after the intestinal stage and the other five developed a phase of visceral involvement with alterations of liver function. In two patients, hepatic function became normal after the 7th day after ingestion. Three patients developed fulminant hepatitis and two of these died of adult respiratory distress syndrome. The fulminant hepatitis patient who later improved developed active chronic hepatitis 1 year later. Finally, five patients developed mixed polyneuropathy. In this paper the indications for orthotopic liver transplant (OLTx) are discussed and the development of late complications such as active chronic hepatitis and mixed polyneuropathy are considered.

Portal-systemic encephalopathy and hypothalamic hypothyroidism: effect of thyroid hormone on ammonia metabolism

We describe a 53-year-old woman with portal-systemic encephalopathy and altered thyroid function. Endocrinological studies revealed low levels of free thyroid hormone with an inappropriately low level of thyroid-stimulating hormone that responded to bolus injection of thyrotropin-releasing hormone with a normal but somewhat delayed pattern. On the diagnosis of hypothalamic hypothyroidism, she was treated with levothyroxine sodium. Thyroid hormone replacement improved not only the symptoms of hypothyroidism but the hyperammonemia and consciousness disturbance, which suggested a hitherto undescribed possibility that hypothyroidism may be an exacerbation factor of hyperammonemia and portal-systemic encephalopathy.

Paroxystic neuropsychological symptoms as the early expression of hepatic encephalopathy. A case report

A 52-year-old patient presented with paroxystic episodes of generalized apraxia, anomia, agraphia and acalculia. The transient character of these attacks was supported by several neuropsychological examinations. Initially a tentative diagnosis of multiple TIA's was made. Treatment consisted of antiplatelet aggregation therapy. Three years later, however, paroxystic neuropsychological symptomatology occurred more frequently with an increase of severity. The patient was again seen and the differential diagnosis included epilepsy or a metabolic disturbance, in casu hepatic encephalopathy. A therapeutic trial with carbamazepine was started but the patient deteriorated further. He developed a flapping tremor and became stuporous. The blood ammonia was high and there were triphasic waves on the EEG. A probable diagnosis of hepatic encephalopathy was made and carbamazepine therapy was withdrawn. There was a good response on low protein diet and lactulose.

Hepatic hemodynamic features in patients with esophageal or gastric varices

One hundred and fifty cirrhotic patients with or without esophageal varices and/or gastric varices were investigated by endoscopy and hepatic venous catheterization to evaluate differences in the degree of portal hypertension, main portal venous diameter and frequency of portal systemic encephalopathy. Hemodynamic values were correlated with varices size as assessed by endoscopy. Patients with large gastric varices had wedged hepatic venous pressures and hepatic venous pressure gradients which were lower than patients with esophageal varices only, but similar to patients without varices. In addition, in patients with large gastric varices, a decrease in the diameter of the main portal vein and an increase in the incidence of chronic portal systemic encephalopathy were noted. Our results implied that patients with large gastric varices presented different hemodynamic features including the degree of portal hypertension and the incidence of portal systemic encephalopathy from patients with esophageal varices only.

Fulminant hepatic failure

Fulminant hepatic failure (FHF) is defined as acute liver failure with hepatic encephalopathy in patients with no history or stigmata of chronic liver disease. Historically, its prognosis was extremely poor. However, the emergence of orthotopic liver transplantation as a viable form of therapy for liver failure and advances in intensive care medicine have improved patient survival dramatically. Treatment of this condition revolves around supportive medical care and timely referral for orthotopic liver transplantation as necessary. Treatment needs to be individualized for each patient, because prognosis varies, depending on the etiology of the condition. The clinical manifestations of FHF and the management of this condition are discussed. Future prospects for the management of FHF are also reviewed.

Hemostasis in children undergoing liver transplantation

We reviewed the records of 200 children who underwent 238 orthotopic liver transplantations in order to determine which preoperative factors could predict intraoperative blood loss. A coagulation abnormality score (CAS) was calculated by allowing one point for each abnormality in six preoperative coagulation tests. The mean CAS values were significantly greater in children suffering from fulminant hepatic failure (Fulm) or post-necrotic cirrhosis (PNC) and those having retransplantation (ReTx) than in those with disease of other etiologies. No correlation was found between the CAS and the mean blood requirements in the different etiology groups. According to the amount of blood transfused, children could be divided in two groups. Group 1 were those with biliary atresia and ReTx, who received more than 200 ml/kg. Group 2 included those with PNC, Fulm, metabolic diseases, and Alagille syndrome and Byler disease, who received less than 140 ml/kg. The mean CAS was significantly lower and the PT significantly better in Group 1. We conclude that preoperative coagulation tests were weak predictors of intraoperative bleeding. The etiology of the underlying liver disease and previous abdominal surgery play an important role in the occurrence of severe bleeding. Intraoperatively, children presented the same hemostatic changes as adults.

Prior esophageal variceal bleeding does not adversely affect survival after orthotopic liver transplantation

Prior variceal bleeding may adversely affect the prognosis of orthotopic liver transplantation. We studied this question by evaluating all 175 adult patients undergoing orthotopic liver transplantation at our institution to determine risk factors associated with mortality after transplantation. Seventy patients demonstrated prior variceal bleeding, and of those, 32 had a course of sclerotherapy. Thirteen also had portal systemic shunts. Compared with the 105 transplant patients who had no prior bleeding, patients who bled were more likely to have parenchymal liver disease (74% vs. 50%), equally likely to have cholestatic liver disease (19%), and less likely to have malignancy (6% vs. 19%) or fulminant liver failure (1% vs. 12%). Bleeding patients also were more likely to be Child-Pugh class C (46% vs. 35%). By the common closing date of December 31, 1990, 26 patients (37%) with prior bleeding and 48 patients (46%) without bleeding died after transplantation. From survival curves, patients with prior bleeding had improved survival rates at 1 yr (65% vs. 54%), at 3 yr (60% vs. 47%) and at 5 yr (55% vs. 43%), although the differences were not statistically significant. With a proportional hazards model to adjust for confounding effects, the relative risk of mortality among patients with prior bleeding was 0.60 (95% confidence interval, 0.27 to 1.30). Sclerotherapy or portal systemic shunts did not alter survival. Important adverse risk factors for mortality included older age at transplantation, black race, malignant disease and more advanced Child-Pugh class. This study suggests that prior esophageal variceal bleeding did not adversely affect the mortality of patients undergoing orthotopic liver transplantation.

Liver transplantation for fulminant hepatic failure

In conclusion, the availability of liver transplantation has dramatically advanced the management of fulminant hepatic failure. A major responsibility of the gastroenterologist/hepatologist involved in the care of patients with liver failure is early decision making regarding likelihood of spontaneous recovery and consideration toward referral to a transplantation center. In particular, patients with exposure to drugs or toxins (other than acetaminophen); patients with presumed non-A, non-B hepatitis; children or older patients; patients with prolonged jaundice; profoundly jaundiced patients; or patients with severe coagulopathy should be given the highest consideration for urgent transplantation. Supportive care should take into account the potential complications of bleeding, sepsis, cerebral edema, renal failure, and respiratory failure. Such complications are the major limiting factors that prevent patients with fulminant hepatic failure from undergoing liver transplantation and contribute to the majority of postoperative deaths among patients who undergo transplantation. If these issues are heeded, and in light of emerging therapeutic modalities and surgical innovations, it is anticipated that ongoing improvement of the overall outcome of patients with fulminant hepatic failure will continue to be seen.

Effect of renal replacement therapy on patients with combined acute renal and fulminant hepatic failure

The mortality of patients with combined acute hepatic and renal failure remains high. Previous studies have reported both patient morbidity and mortality directly attributable to the use of extracorporeal circuits used to treat renal failure. We investigated the effect of various modes of renal replacement therapy in 30 consecutive patients referred with both fulminant hepatic and acute renal failure. Cardiac output decreased during the first hour of 30 intermittent machine haemofiltration treatments, by 15 +/- 3%, as did tissue oxygen delivery, 16 +/- 3% and tissue oxygen uptake, 13 +/- 4%, whereas there was no significant change during 30 continuous hemofiltration and/or dialysis treatments. Intracranial pressure remained stable during the continuous modes but increased from 9 +/- 2 mm Hg to 17 +/- 2 mm Hg, P < 0.01, during intermittent machine hemofiltration, with the greatest increase of 55 +/- 9% within the first hour. Mean arterial blood pressure was stable during treatment with the continuous modes, but decreased by 20 +/- 3% during the first hour of intermittent machine hemofiltration, resulting in a maximum reduction in cerebral perfusion pressure of 35 +/- 8%. In this group of critically ill patients continuous modes of renal replacement therapy resulted in superior cardiac and intracranial stability compared to standard intermittent modes of treatment.

Controlled trial of antithrombin III supplementation in fulminant hepatic failure

Patients with fulminant hepatic failure have severe circulatory disturbances which may be due to fibrin and cellular plugs in micro-vessels which are a consequence of intravascular coagulation and which can lead to multiorgan failure. Since antithrombin III supplementation has been shown to be beneficial in animal models of septic shock with disseminated intravascular coagulation, a controlled study was performed to investigate the effect of antithrombin III supplementation in fulminant hepatic failure. Twenty-five patients in grade III or IV coma were selected on the basis of evidence of sepsis, intravascular coagulation and a high risk of developing multiorgan failure. Thirteen patients received 3000 units of antithrombin III (Kybernin P; Behringwerke), followed by a further 1000 units every 6 h. Antithrombin III activity increased from 0.26 +/- 0.04 SE U/ml to 0.82 +/- 0.07 U/ml at 3 h post infusion (normal range 0.80-1.20 U/ml) and remained greater than 0.80 U/ml throughout the study without any apparent increase in the frequency of bleeding. However, survival was not improved and markers of intravascular coagulation remained similar between the two groups. Thus, although the antithrombin III deficiency in fulminant hepatic failure can be corrected by supplementation with antithrombin III concentrate, its use in the prevention of intravascular coagulation and to avoid microvessel plugging needs to be studied at an earlier stage in the disease.

[Spontaneous rupture of an umbilical hernia in decompensated liver cirrhosis]

The case of a spontaneous rupture of an umbilical hernia of a 52 year old patient, secondary to cirrhosis of the liver, is described as a rare complication of portal hypertension with massive ascites. Additionally a survey of the literature is given.

Cerebral function analyzing monitor and visual evoked potentials as a noninvasive method of detecting cerebral dysfunction in patients with acute hepatic and renal failure treated with intermittent machine hemofiltration

We monitored the effect of 7 intermittent machine hemofiltration treatments in 4 patients with fulminant hepatic failure who had progressed to grade IV coma and developed acute oliguric renal failure. Prior to treatment the processed EEG showed excess slow wave activity, and the latency of the later visual evoked potentials (N2 and P2) was delayed. Following treatment there was a further increase in both EEG slow wave activity and latency of the N1, N2, and P2 potentials. Intracranial pressure increased from a median of 8 mm Hg (2-12, range) to 14 (8-28) following treatment, p < 0.05. There was a correlation between intracranial pressure and all of the later visual evoked potentials, for N3 r = 0.71, for P1 r = 0.39, and P2 r = 0.74, all p < 0.05. Although there appeared to be a good correlation between intracranial pressure and the noninvasive electrophysiological recordings, there were major changes in intracranial pressure, cerebral perfusion pressure, and cerebrospinal fluid pH during the first hour of treatment, during which time there were no discernable changes in EEG or evoked potentials. In this study, non-invasive neurophysiological methods were not found to be reliable as invasive methods in assessing acute, minute-by-minute changes in cerebral metabolism but these methods may have a role in the longer term in assessing patient prognosis.