Dopamine infusion in patients with hepatic encephalopathy: plasma levels and haemodynamic changes

During a constant infusion of dopamine (DA 4.5 micrograms/kg/min), the plasma levels of DA reached at 30 min of infusion were 81 +/- 6.9 ng/ml and 71.6 +/- 14.8 ng/ml in patients with hepatic encephalopathy (HE) and control patients, respectively. In both groups of patients, the plasma levels of DA did not change between 30 and 60 min of continuous DA infusion. The DA infusion was associated with an increase of arterial blood pressure, heart rate and cardiac index. In the patients with HE, the increase in cardiac index was directly correlated with the plasma level of DA (r = 0.843, p less than 0.01). The present results clearly demonstrate that in HE circulating DA does not accumulate during continuous infusion of DA. They further provide evidence that the increase in circulating catecholamines in HE reflects increased release from the sympatho-adrenal system.

Thrombin-antithrombin III complex in fulminant hepatic failure: evidence for disseminated intravascular coagulation and relationship to outcome

Indirect evidence has suggested that intravascular coagulation may occur in patients with fulminant hepatic failure (FHF), the most severe form of acute liver disease. Thrombin is inhibited in circulation by antithrombin III, and measurement of the thrombin-antithrombin III complex (TAT) is a direct measure of thrombin formation. Using a new rapid enzyme-linked immunosorbent assay we have measured TAT in 54 patients on admission, with fulminant hepatic failure. TAT was significantly increased in patients with FHF compared with control subjects (25.8 +/- 2.7 micrograms l-1) compared with 2.6 +/- 0.2 micrograms l-1; n = 10: P less than 0.001). Patients who survived had significantly lower TAT levels than those who did not (17.2 +/- 2.7 micrograms l-1; n = 27 compared with 34.0 +/- 4.2 micrograms l-1; n = 27: P less than 0.005) and patients with FHF caused by viral hepatitis had significantly lower TAT levels than those with FHF due to paracetamol overdose (14.6 +/- 4.7 micrograms l-1; n = 9 compared with 28.0 +/- 3.1 micrograms l-1; n = 45: P less than 0.05). Levels of TAT correlated significantly with prothrombin time (r = 0.36, P less than 0.01) and inversely with fibrinogen (r = -0.51, P less than 0.001). There was no significant correlation with antithrombin III concentration. Thus, using a simple and rapid technique, we have been able to demonstrate increased levels of TAT complex in patients with FHF. This provides more direct evidence of intravascular coagulation and thrombin generation in these patients. These results confirm that the coagulation system is activated in FHF.

Resolution of the adult respiratory distress syndrome following colectomy and liver transplantation

A 32-year-old woman with liver failure from end-stage cirrhosis and ulcerative colitis developed septicemia and severe ARDS. Subtotal colectomy and a successful liver transplantation resulted in complete resolution of the ARDS.

Prothrombinex-induced thrombosis and its management with regional plasminogen activator in hepatic failure

Fulminant hepatic failure causes a bleeding diathesis as a result of impaired synthesis of hepatic clotting factors, thrombocytopenia, fibrinolysis and disseminated intravascular coagulation. Administration of clotting factor concentrates can cause thrombosis in patients with acute hepatic failure. Regional infusion of recombinant tissue-type plasminogen activator may be used to induce local thrombolysis. A case report of a five-year-old child is presented and the literature is reviewed.

Flumazenil does not improve hepatic encephalopathy associated with acute ischemic liver failure in the rabbit

The effect of flumazenil, a benzodiazepine antagonist, on hepatic encephalopathy was studied in rabbits with acute hepatic failure induced by a two-stage liver devascularization procedure. The rabbits were randomized for treatment with 5 mg/kg of flumazenil or the placebo. The drug was administered at two easily recognizable time points in the course of the encephalopathy: first, when the righting reflex was disturbed, and second, when the animal could no longer achieve to the sitting position. The response after flumazenil did not differ from that after the placebo, as measured by clinical evaluation and automated EEG analysis. Furthermore, the progression of the encephalopathy, as measured by the survival time after the first injection, was not affected by flumazenil.

Do corticosteroids reduce mortality from alcoholic hepatitis? A meta-analysis of the randomized trials

PURPOSE

To determine whether corticosteroids affect short-term mortality from alcoholic hepatitis.

DATA IDENTIFICATION

Studies published from 1966 to 1989 were identified through a MEDLINE computer search and an extensive manual search of the bibliographies of identified articles.

STUDY SELECTION

We found 11 randomized studies (10 of which were placebo controlled) that assessed mortality in hospitalized patients diagnosed with acute alcoholic hepatitis and treated with corticosteroids.

DATA EXTRACTION

Two critical appraisers independently evaluated trial quality and abstracted quantitative data on clinical characteristics of the populations, interventions, and all-cause mortality.

RESULTS OF DATA SYNTHESIS

Overall, the protective efficacy (or percent reduction in mortality) of corticosteroids was 37% (95% CI, 20% to 50%). Protective efficacy was higher among trials with higher quality scores and trials that excluded subjects with active gastrointestinal bleeding. In subjects with hepatic encephalopathy, protective efficacy was 34% overall (CI, 15% to 48%). It was also higher among trials with higher quality scores and trials excluding subjects with acute gastrointestinal bleeding, but was not present among trials with lower quality scores or trials that did not exclude subjects with acute gastrointestinal bleeding. In subjects without hepatic encephalopathy, corticosteroids had no protective effect, and this lack of efficacy was consistent across all trial subgroups.

CONCLUSIONS

These results suggest that corticosteroids reduce short-term mortality in patients with acute alcoholic hepatitis who have hepatic encephalopathy, that the protective effect depends on the exclusion criterion of acute gastrointestinal bleeding and is influenced by trial quality, and that corticosteroids are of no benefit in patients without hepatic encephalopathy.

Selective shunt versus nonshunt surgery for management of both schistosomal and nonschistosomal variceal bleeders

This clinical study included 219 (Child A/B) consecutive variceal bleeders. Electively 123 had distal splenorenal shunt (DSRS) and 96 had splenectomy with gastroesophageal devascularization (S&GD). Liver pathology was documented in 73% of patients, with schistosomal fibrosis in 41% and nonalcoholic cirrhosis or mixed pattern (fibrosis and cirrhosis) in 59%. The surgical groups were similar before operation, with a mean follow-up of 82 +/- 13 and 78 +/- 18 months, respectively (range, 60 to 120 months). The two pathologic populations were also similar before each and both procedures. The operative mortality rates were low, with incidences of 3.3% (DSRS) and 3.1% (S&GD). Rebleeding occurred significantly (p less than 0.05) more frequently after S&GD (27%) compared to DSRS (5.7%). Sclerotherapy salvaged 65% of S&GD rebleeders. Encephalopathy developed significantly (p less than 0.05) more after DSRS (18.7%) compared to S&GD (7.3%), with no significant difference among the current survivors. The difference in overall rebleeding and encephalopathy rates between both procedures was statistically related to patients with cirrhosis and mixed lesions (p less than 0.05). Distal splenorenal shunt significantly reduced the endoscopic variceal size more than S&GD (p less than 0.05). Prograde portal perfusion was documented in 94% of patients in each group, with a variable distinct pattern of portaprival collaterals in 91% (DSRS) and 65% (S&GD). The total population cumulative survival was similar with 80% for DSRS and 79% for S&GD (plus sclerosis in 23%), with hepatic cell failure the cause of death in 46% and 50%, respectively. However, in the schistosomal patients, survival was better improved after DSRS (90%) compared to S&GD (75%), with no difference among the cirrhotic and mixed group (DSRS 73%, S&GD 72%). In conclusion (1) both DSRS and S&GD have low operative mortality rates, (2) DSRS is superior to S&GD in the schistosomal patients, and (3) S&GD backed by endosclerosis for rebleeding is a good surgical alternative to selective shunt in the nonalcoholic cirrhotic and mixed population.

[Fulminant hepatic failure in children]

We report the clinical characteristics and course of 38 children with fulminant liver failure. A viral etiology was demonstrated in 19 patients out of 25 with serologic screening (virus A in 17 patients, B in 2 patients). One patient had toxic liver damage from ingestion of a caustic substance. Mean age was 4 years and 6 months. Jaundice was present in all but 2 patients at admission. Encephalopathy developed at a mean of 13 days and 17 children were admitted with stage 3 or 4 coma. Evidence of severe liver failure was present in every patient. A lower prothrombin time and higher bilirrubin concentration were shown by non survivors. Hypoglycemia developed in 37% of patients, seizures in 37%, gastrointestinal bleeding in 45%, respiratory failure in 32% and severe infection in 32%. Overall mortality rate was 42% raising to 83% in patients with stage 3 coma at admission. Thus, although the etiology of fulminant liver failure differs in children as compared to adults, mortality rate and complications are similar.

[Fulminant and subfulminant viral hepatitis]

The adjectives fulminant and subfulminant apply to those forms of acute hepatitis where the prothrombin level falls below 50 p. 100 of its normal value and which is complicated by clinical hepatic encephalopathy. The most frequent cause is an acute viral hepatitis, notably that due to the B virus. Beside jaundice and encephalopathy, the most striking manifestations consist of low factor V level, cardiocirculatory hyperkinesia, acute renal failure due to hypovolaemia, respiratory alkalosis and sometimes hypoglycaemia or hypophosphataemia. The mortality rate, which is 75 p. 100 overall, varies with the causative virus. The prognosis is based on the degree of factor V decrease rather than on the severity of the encephalopathy. Coagulant fractions and nervous sedatives may obscure the prognosis and should not be administered. With emergency liver transplantation, 60 p. 100 of the patients who would have died survive. Early hospitalization of patients with severe acute hepatitis (prothrombin level below 50 p. 100 of its normal value, but no hepatic encephalopathy) is associated with much lower mortality rates and could be used to prevent transformation into fulminant or subfulminant hepatitis.

Increased densities of peripheral-type benzodiazepine receptors in brain autopsy samples from cirrhotic patients with hepatic encephalopathy

Peripheral-type benzodiazepine receptors were evaluated using the specific ligand [3H]-PK 11195 in brain homogenates from nine cirrhotic patients who died in hepatic coma and from an equal number of age-matched control subjects. Histopathological studies showed evidence of severe Alzheimer type II astrocytosis in the brains of all cirrhotic patients. Saturation-binding assays revealed a single saturable binding site for [3H]-PK 11195 in brain, with affinities in the 2- to 3-nmol/L range. Diazepam was found to be a relatively potent inhibitor of 3H-PK 11195 binding (IC50 = 253 nmol/L), whereas the central benzodiazepine antagonist Ro 15-1788 displaced 3H-PK 11195 binding with low affinity (IC50 greater than 40 mumols/L). Densities of [3H]-PK 11195 binding sites were found to be increased by 48% (p less than 0.01) and 25% (p less than 0.05) in frontal cortex and caudate nuclei, respectively, from cirrhotic patients. Densities of [3H]-PK 11195 binding sites in frontal cortex from two nonencephalopathic cirrhotic patients were not significantly different from control values. No concomitant changes of affinities of these binding sites were observed. Because it has been suggested that peripheral-type benzodiazepine receptors may be localized on mitochondrial membranes and may therefore be involved in cerebral oxidative metabolism, the alterations observed in this study could be of pathophysiological significance in hepatic encephalopathy.

Branched chain enriched amino acid versus glucose treatment of hepatic encephalopathy. A double-blind study of 65 patients with cirrhosis

We studied the effects of infusion of a branched chain enriched amino acid mixture versus glucose on acute hepatic encephalopathy in patients with cirrhosis. Sixty-five patients were randomly treated with 1 g/kg per day of an amino acid mixture with 40% branched chain contents (32 patients), or isocaloric glucose (33 patients) for a maximum of 16 days. The regimens further included glucose infusion to a total of 26.5 kcal/kg per day and lactulose. The patients took part in the study for 5-6 days. In each group 17 patients woke up. In the amino acid group eleven died and four developed renal failure. In the glucose group ten died, three developed renal and two respiratory failure, and one remained encephalopathic. The coma score worsened in three of the patients who died in the amino acid group, but in all patients who died in the glucose group. The negative nitrogen balance on entry reversed in the amino acid group, but not in the glucose group. Thus, the branched chain enriched amino acid supplement did not change the prognosis for wake-up, but had other effects on the cerebral state and on nitrogen homeostasis.

Prospective study of bacterial infection in acute liver failure: an analysis of fifty patients

Fifty consecutive patients admitted with acute liver failure, minimal grade II encephalopathy, were studied prospectively to determine the incidence, timing and cause of bacterial infection, the relationship to clinical criteria for infection; and the influence of early microbiological diagnosis on clinical outcome. There were 53 proven bacterial infections in 40 patients, whereas in 5 of the remaining 10 patients infection was suspected on clinical grounds in the absence of significant cultures. Seven patients (14%) had more than one bacterial infection, and four patients had simultaneous infections caused by different organisms at each site. Fourteen infections (26.4%) were associated with bacteremia, and in six of these no source was found. Twenty-five infections (47.1%) arose from the respiratory tract, 12 (22.6%) from the urinary tract and 2 (3.7%) from central venous cannulas. Thirty-seven (69.8%) of the 53 infections were due to gram-positive bacteria; Staphylococcus aureus accounted for 19 (35.8%) of all the infections. Thirty patients died (60%), 28 of whom had bacterial infection at some time; in 24 of these the infection was diagnosed less than 24 hr before death. All nine deaths that occurred more than 7 days after admission were directly attributable to microbial infection. Clinical features such as elevated temperature and elevated peripheral white blood cell count were poor indicators of bacterial infection because these were absent in 30.2% of cases. These data show that there is a high incidence of bacterial infection early in the course of acute liver failure and suggest that prophylactic antimicrobial therapy, although unproven, might be justified.

Early changes in intracranial pressure during haemofiltration treatment in patients with grade 4 hepatic encephalopathy and acute oliguric renal failure

We measured the intracranial pressure (ICP), using a subdural catheter in nine patients admitted with grade 4 hepatic encephalopathy due to fulminant hepatic failure complicated by oliguric renal failure. Six patients received daily machine haemofiltration and four patients were treated with continuous arteriovenous haemofiltration (CAVHF). The mean ICP increased during the first hour of machine haemofiltration from 9 +/- 1.4 mmHg to 13 +/- 1.8 mmHg (P less than 0.05), and there was a reduction in the mean arterial pressure from 92.4 +/- 2.7 mmHg to 81 +/- 3.2 mmHg (P less than 0.05) resulting in a reduction in cerebral perfusion pressure of up to 30%. The group treated by CAVHF, although having a greater mean ICP prior to treatment (19 +/- 4.8 mmHg) and a lower mean arterial pressure (66 +/- 3.6 mmHg) and consequently a lower cerebral perfusion pressure, did not show any increase in ICP or reduction in mean arterial or cerebral perfusion pressure. There was a significant reduction in serum osmolality during the first hour of treatment in the machine haemofiltration group (314 +/- 4 mOsm/kg to 309 +/- 4 mOsm/kg, P less than 0.05), whereas there was no corresponding change in the CAVHF group. This suggests that CAVHF is to be preferred for the treatment of acute renal failure in such patients who are at considerable risk of developing cerebral oedema.

Hyperprolactinemia in hepatic encephalopathy may result from impaired central dopaminergic neurotransmission

Ten patients with liver disease and hepatic encephalopathy (HE) and eight normal controls were studied. Five of the 10 HE patients had hyperprolactinemia. The administration of L-dopa produced a decrease of serum prolactin in all. Prior administration of Carbidopa, a peripheral decarboxylase inhibitor, did not change the prolactin suppression by L-dopa in the normal controls or in the patients with normal baseline prolactin levels. In the hyperprolactinemic group, Carbidopa significantly inhibited the response to L-dopa. Impaired central neurotransmission, at least involving the hypothalamic-pituitary dopaminergic system, may underlie the hyperprolactinemia in HE.

Ammonia-induced swelling of rat cerebral cortical slices: implications for the pathogenesis of brain edema in acute hepatic failure

The pathogenesis of brain edema in fulminant hepatic failure is incompletely understood. Our previous studies in models of this disease suggest the presence of a cytotoxic mechanism; as cortical astrocytes appeared predominantly swollen, we hypothesized that ammonia, metabolized to glutamine solely within this cell, could play a role in brain water accumulation. We determined ammonia levels in different brain regions of rats after hepatic devascularization, a model previously shown to exhibit brain edema. Concentrations of 2.5 mM were observed in the edematous cerebral cortex. We then added several concentrations of ammonium chloride to the first cortical brain slice, a preparation used to study cytotoxic brain edema. At a final bath concentration of ammonia of 5 and 10 mM, swelling could be detected: a decrease in the space of distribution of inulin was seen at the 10 mM concentration, suggesting intracellular water accumulation. Neuropathologically, astrocytes appeared involved even at subswelling doses of ammonia. Octanoic acid, at a 10 mM concentration, also resulted in demonstrable swelling. Ammonia, at concentrations in the incubation bath that approach the levels seen in an in vivo model of brain edema, results in water accumulation of cortical brain slices. Toxins implicated in the pathogenesis of hepatic encephalopathy, such as ammonia and octanoic acid, may, result in brain water accumulation.

Neurologic manifestations of hepatic disease

Neurologic complications of hepatic disease are not uncommon and involve the CNS more often than the peripheral nervous system or muscles. Progress in the therapy of neurologic disorders associated with hepatic failure has occurred in recent years. Notably, exciting developments in the treatment of hepatic encephalopathy with benzodiazepine antagonists will lead to a better understanding of the pathophysiology of this encephalopathy. The future use of these agents may eventually help reduce the morbidity and mortality of hepatic encephalopathy. The role of this class of drug in other metabolic encephalopathies remains to be established. Furthermore, new therapeutic and surgical alternatives to the treatment of Wilson disease also enhance our therapeutic options. The fate of patients with Wilson disease with fulminant hepatic disease and those patients unable to tolerate or unresponsive to penicillamine therapy has been greatly improved.

Anesthesia for liver transplantation

A successful liver transplant program needs cooperation and communication from the surgical, blood banking, pathology, primary care, and anesthesia services. Rapid availability of laboratory data, efficient blood banking services, ability to infuse blood products rapidly, coagulation management capability, and plentiful manpower are essential.

Hepatic encephalopathy

Hepatic encephalopathy (HE) is a complex reversible syndrome that can progress to coma. Recently, behavioral and electrophysiologic ameliorations of HE have been reported to occur in animal models of fulminant hepatic failure (FHF) and, in uncontrolled studies, in a majority of patients with FHF or cirrhosis following the intravenous administration of the benzodiazepine (BZ) receptor antagonist, flumazenil. These observations, while not excluding a role for other mechanisms in the mediation of HE, raise the possibility that an endogenous BZ receptor ligand with agonist properties may contribute to the manifestations of HE by allosterically potentiating GABA-mediated neurotransmission.

Raised plasma concentrations of 3-methoxy-4-hydroxyphenylethyleneglycol in cirrhotic patients with or without hepatic encephalopathy

We measured the plasma concentration of a centrally derived noradrenaline (NA) metabolite, 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG), in 20 cirrhotic patients (eight with (group A) and 12 without (group B) hepatic encephalopathy (HE] and in 14 age matched healthy subjects to study if the central NA metabolism would be altered in liver cirrhosis patients, particularly in those with HE. The mean (SEM) plasma MHPG concentrations in the patient groups, group A (74.9 (8.6) pmol/l) and B (54.8 (7.2) pmol/l), were significantly (p less than 0.01) greater than in the control group (22.3 (2.0) pmol/l), and that in group A was significantly (p less than 0.05) greater than in group B. The plasma concentration of MHPG observed in these study subjects (n = 34) correlated (rs = 0.77, p less than 0.01) more strongly with the ratio of plasma catecholamine precursor amino acids (tyrosine and phenylalanine) to other neutral amino acids (tryptophan, leucine, isoleucine, and valine) known to compete with catecholamine precursor amino acids for uptake into the brain than with plasma concentration of tyrosine plus phenylalanine alone (rs = 0.63, p less than 0.01). In addition, the mean plasma MHPG concentrations measured in another group of eight cirrhotic patients (group C) during HE (79.3 (10.6) pmol/l) was significantly (p less than 0.01) greater than that measured after the recovery from HE (47.2 (5.2) pmol/l). The results suggest that the central NA metabolism may be altered in patients with liver cirrhosis, particularly in those with HE, and that the derangement in the central NA metabolism may be associated not only with an increase in plasma catecholamine precursor amino acids but also with a decrease in branched chain amino acids.

[Acute pregnancy fatty liver with survival of the mother and child]

A case of acute fatty liver as a rare cause of pregnancy-induced jaundice is reported. Near term the 25-year-old patient became rapidly jaundiced. On admission laboratory tests showed signs of incipient coagulopathy and impaired renal function. When fetal vital signs deteriorated cesarean section was performed. After surgery the fullblown picture of disseminated intravascular coagulation developed, with profuse bleeding only controllable by rigorous substitution of plasma factors. Acute hepatic insufficiency with ascites followed. Despite the marked bilirubin elevation the hepatic enzymes were only slightly raised. In addition, acute renal insufficiency, pancreatitis and hyperuricemia developed. Under intensive care the patient recovered slowly and was discharged after 4 weeks with a healthy baby.

[An autopsied case of type II citrullinemia--transient effectiveness with either citrate or benzoate to the consciousness disturbance]

A 44-year-old man suffered from repeated impairment of consciousness associated with flapping tremor, myoclonus and generalized convulsions, and died in coma 6 months after admission. He had had a psychosomatically underdeveloped childhood, with a propensity for legumes without a family history of the same or a record of consanguinity. On admission, he had disturbed consciousness and emaciation without other physical abnormalities. The EEG revealed diffuse slow waves with occasional appearance of triphasic waves. A high level of serum citrulline (534.7 nmol/ml) was recognized and the assay of urea cycle enzymes in the liver demonstrated decreased argininosuccinate synthetase (ASS) activity (0.062 U/g liver, 7.4% of that in normal liver), although no kinetic abnormality was found. Accordingly he was diagnosed as having type II citrullinemia. In addition, this case could be classified as cluster type of localization of the ASS in the liver by immunohistochemical study. There were characteristic findings concerning his clinical picture and laboratory data, such as a significant correlation between the grade of disturbed consciousness and arterial blood gas pH (r = 0.61, p less than 0.01). However, the blood ammonia level did not always correlate with the severity of disturbed consciousness. Oral treatment with sodium citrate and sodium benzoate was very effective, though transiently, for disturbed consciousness in this case. Pathological findings of the autopsied liver were fatty change and fibrosis. Neuropathologically, characteristic findings were brain edema with cerebellar tonsilar herniation, laminar necrosis with spongy formation in cerebral cortex, and Alzheimer type II glia. The relationship between citrullinemia and other hepatic encephalopathy was also discussed.