Fatal hepatic necrosis after shock

A clinicopathological study was undertaken in 15 cases of massive hepatic necrosis after shock. The GOT and GPT level exceeded 1000 units in 10 cases. The 15 cases consisted of 3 diagnosed as fulminant hepatitis clinically and 12 diagnosed as disseminated intravascular coagulation (DIC) or multiple systemic organ failure (MOF) from the unremarkableness of liver dysfunction. It was noteworthy that sepsis and surgery were closely associated with these lesions. The weight of the liver at autopsy ranged from 800 to 2,700 g. Liver necrosis was macroscopically characterized by clear demarcation of the necrotic areas sharply separated from the surrounding liver parenchyma, showing the appearance of so-called "map-like necrosis". Microscopically, the lesions in these subjects showed mainly the pattern of centrilobular necrosis. As observed in the burn shock case (case 12), the shock which provoked in different phases of time seemed to have repeated its attack. These liver necroses were considered to result from severe systemic circulatory disturbance or intrahepatic circulatory disturbance. The possibility is indicated that the generalized or univisceral Shwartzman reaction, and repeated and combined severe shock participated in the pathogenesis. Fibrin thrombi aggrevate tissue perfusion and accelerate anoxia. Heparin therapy seemed effective in these cases if administered at an appropriate time.

Controlled hyperventilation in the prevention of cerebral oedema in fulminant hepatic failure

Raised intracranial pressure due to cerebral oedema is a major cause of death in fulminant hepatic failure and in the present study we have carried out a controlled clinical trial of continuous hyperventilation in the prevention of this complication. Twenty patients were electively hyperventilated to maintain PaCO2 between 3.5 and 5 kPa. In the other 35 patients mechanical ventilation was instituted only if severe hypoxia or hypercapnia occurred. Cerebral oedema, diagnosed clinically or by a rise in intracranial pressure to greater than 30 mm Hg, occurred in 85% of hyperventilated patients and in 86% of those not so treated. Although there was no significant reduction in the number of episodes of cerebral oedema in the hyperventilated patients (4.8 episodes/24 h) as compared with the controls (5.3 episodes/24 h), hyperventilation did appear to delay the onset of coning but on the basis of these results could not be recommended to be used routinely as a prophylactic measure in the prevention of cerebral oedema in this condition.

Substitution of antithrombin III in shock and DIC: a randomized study

In 51 shock patients with DIC Antithrombin III (AT III) substitution, heparin or a combination of both substances respectively was administered. In the two groups which had been given AT III substitution the concentration of AT III rose considerably higher than the activity. There was a drop of the platelet count in both groups which had received heparin. C1 esterase inhibitor was diminished in the beginning but spontaneously increased in all groups. This increase was slowest in the group without substitution of AT III. The blood loss in cases of traumatic shock was considerably higher in the group which had received both substances. The consumption of AT III concentrates was slightly higher in the combined therapy group than in the AT III group. The duration of symptoms of DIC was considerably shorter in the two substituted groups than in the heparin group. It is concluded that additional administration of heparin does not improve the effect of AT III substitution in patients with DIC and that side effects such as thrombocytopenia and an increased blood loss are likely to develop when both substances are given simultaneously.

Successful administration of metoclopramide for the treatment of nausea in patients with advanced liver disease. A double-blind controlled trial

A double-blind comparison of metoclopramide versus placebo was performed on 8 cirrhotic patients with nausea (8 cases) and heartburn (3 of the 8 cases) plus mild portal-systemic encephalopathy. As metoclopramide is a dopamine antagonist and dopamine-inadequate neurotransmission has been implicated in the pathogenesis of hepatic coma, this study was also designed to evaluate the effects of metoclopramide on mental state. The study included basal, placebo, metoclopramide, and final periods; each period lasted for 2 wk. Throughout the study patients received 3 g/day of neomycin and an 1800-cal diet containing 40 g/day of mixed protein. During the placebo and metoclopramide phases patients received either two 10-mg metoclopramide capsules t.i.d. or identical placebo capsules. During the study, biweekly liver function tests and portal-systemic encephalopathy parameters were evaluated. A self-evaluation for the presence of nausea and heartburn was also obtained. To monitor the dopamine-blockade effect of metoclopramide, serum prolactin levels were measured. Metoclopramide significantly suppressed the subjective signs of nausea (7 of 8 cases) and heartburn (all cases). Serum prolactin levels were 22 +/- 21 ng/ml, 30 +/- 31 ng/ml, 110 +/- 57 ng/ml (p less than 0.01), and 18.6 +/- 2 ng/ml during basal, placebo, metoclopramide, and final periods, respectively. In spite of these signs of dopamine blockade, no deterioration in mental state, asterixis, electroencephalograms, blood ammonia levels, or psychometric testings were observed. In addition, no extrapyramidal signs were noticeable during any period of the study. One patient presented transient somnolence at the end of the metoclopramide period. We conclude that dopamine blockade is not associated with the appearance of portal-systemic encephalopathy. Metoclopramide is a safe and effective treatment for nausea and heartburn in patients with advanced liver disease.

Prediction of outcome following acute variceal haemorrhage

In order to identify factors predicting survival following acute variceal haemorrhage, data were collected prospectively from 100 admissions in 70 patients managed by a standard policy employing oesophageal tamponade, injection sclerotherapy and, if necessary, oesophageal transection. Of the ten predictive factors identified by univariate analysis, only prothrombin ratio, serum creatinine and the presence of encephalopathy on admission were shown by stepwise logistic regression to have independent significance. The derived regression equation allowed clearer identification than conventional scoring systems of high and low risk groups and successfully predicted outcome in 90 per cent of admissions.

Organic delusions: phenomenology, anatomical correlations, and review

Organic delusions are common, but have received little systematic study. Review of the literature reveals that they occur most commonly in toxic-metabolic processes and in disorders affecting the limbic system and basal ganglia. A prospective study of 20 consecutive patients with organic delusions revealed four general types of false beliefs: simple persecutory delusions, complex persecutory delusions, grandiose delusions, and those associated with specific neurological defects (anosognosia, reduplicative paramnesia). Simple delusions responded best to treatment, and complex delusions were more resistent. Acting on delusional beliefs was not unusual, and treatment of the delusions was an important aspect of management of the patient.

[Hepatic encephalopathy: study of 50 cases]

The authors present a retrospective study of 50 patients with hepatic encephalopathy treated at the University Hospital, Faculty of Medicine of Ribeirão Preto since 1959 and discuss clinical, laboratory and anatomo-pathologic aspects. The diagnoses of the different types of liver disease as well as the factors that triggered the episodes of hepatic coma and pre-coma are reported and the role of the measurement of arterial blood gases in establishing the diagnosis is emphasized.

[Case of hepatic coma with lateral conjugate deviation of gaze]

The forced horizontal deviation of gaze, persisting more then 48 hours, has been observed during a rapidly developing hepatic coma in a patient whose post mortem examination did not reveal any structural lesion involving the central nervous system.

Peritoneovenous shunts: predictive factors of early treatment failure

Death or uncorrectable shunt malfunction occurred within 4 months in a majority (23) of 39 consecutive alcoholics who had peritoneovenous shunts. Clinical, biochemical, and operative variables in these patients were reviewed to detect factors that might predict early failure. Hepatorenal disease, expressed as the sum of total bilirubin and creatinine greater than 4 mg/dl, characterized 15 of 18 early deaths and was a reliable preoperative criterion of clinical outcome (p less than 0.001). Except for prothrombin elevation, abnormal coagulation indices did not predict early failure. Encephalopathy was more prevalent in patients who died (p less than 0.05). Among operative variables, failure to drain ascites was associated with more hospital deaths (p less than 0.05) and documentation of venous catheter placement in a central location reduced likelihood of early shunt malfunction (p less than 0.001). Preference for the LeVeen or Denver shunt did not affect the rate of early shunt malfunction. The overriding predictive factor was hepatorenal disease, both obvious and occult, by which judicious patient selection may avoid early death in surgical palliation for intractable alcoholic ascites.

Fulminant hepatic failure due to allopurinol

A 58-year-old Chinese woman was admitted to hospital with a presumed hypersensitivity reaction to allopurinol. Her illness was characterised by high fever, eosinophilia, exfoliative dermatitis and jaundice. She developed fulminant hepatic failure and septicemia with a fatal outcome. Clinical details are presented and the possible relationship of allopurinol hypersensitivity to renal impairment is discussed.