Randomized, double-blind, placebo-controlled trial of somatostatin for variceal bleeding. Emergency control and prevention of early variceal rebleeding

A randomized, double-blind, placebo-controlled trial of somatostatin was conducted among 120 patients admitted for bleeding esophageal varices (59 placebo, 61 somatostatin). An initial 250-micrograms bolus of somatostatin followed by a 5-day continuous infusion of 250 micrograms/h and an identical administration of placebo were evaluated for both the control of bleeding and prevention of early rebleeding from varices. Failure to control bleeding occurred in 22 (36%) somatostatin patients vs. 35 (59%) placebo patients, with time to failure occurring earlier with placebo (P = 0.036). blood and plasma transfused per hour during drug infusion of trial drug was reduced in the somatostatin group: median 0.033 vs. 0.105 unit/h (P = 0.025). Use of balloon tamponade was halved in somatostatin-treated patients. The average effect of somatostatin was a 41% reduction in the hazard of failure (95% confidence interval, -1% to 65%, P = 0.0545) after adjustment for the severity of liver disease, which was the only other variable having a significant influence on time to failure. There was no difference in 30-day mortality per admission (7 placebo, 9 somatostatin) or complications. It is concluded that somatostatin is safe and more effective than placebo for the control of variceal bleeding.

The effect of non-protein liquid meals on the hepatic venous pressure gradient in patients with cirrhosis

It has been suggested that protein feeding increases portal pressure in cirrhotic patients, but that carbohydrate and fat have little effect. We examined the relationship between feeding and portal pressure, using different liquid test meals (250 or 500 ml non-protein, 250 ml protein-containing, 500 ml water), in 29 alcoholic patients with cirrhosis and portal hypertension. The mean hepatic venous pressure gradient (HVPG) increased significantly 30 min after the protein meal (10% increase; p = 0.009) and returned to basal levels at 60 min. The mean HVPG also increased significantly after the non-protein meal: after 500 ml the increase was 23% at 30 min (p = 0.046) and 17% at 60 min (p = 0.12); and after 250 ml it was 15% at 30 min (p = 0.012) and 7% at 60 min (p = 0.05). Ingestion of 500 ml water caused a small, non-significant, increase in mean HVPG. Plasma glucagon levels increased significantly at 30 and 60 min after the protein meal, but did not change significantly after the non-protein meal or water. Both protein-containing and non-protein meals significantly elevate HVPG in alcoholic patients with cirrhosis and portal hypertension.

Bleeding time in patients with hepatic cirrhosis

OBJECTIVE

To determine the frequency of an abnormal bleeding time in patients with cirrhosis and to relate this to known factors that affect primary haemostasis and to the severity of liver disease.

DESIGN

Prospective clinical and laboratory study in patients admitted for complications or investigations of liver disease.

SETTING

Royal Free Hospital hepatobiliary and liver transplantation unit.

SUBJECTS

100 Consecutive inpatients aged 17-74 with various forms of cirrhosis, including alcoholic, biliary, autoimmune, viral, and cryptogenic. At least 10 days had elapsed since any episodes of bleeding, resolution of sepsis, or alcohol intake. No patient was taking any drug known to affect primary haemostasis.

MAIN OUTCOME MEASURES

Bleeding time as measured with the Simplate double blade template device. A bleeding time longer than 10 minutes was considered abnormal. Other measures were platelet count, prothrombin time, partial thromboplastin time, packed cell volume, and blood urea, serum bilirubin, and serum albumin concentrations, all measured on each subject at the same time by standard laboratory methods.

RESULTS

A weak but significant correlation existed between the bleeding time and the platelet count (rs = 0.483; p less than 0.001). There were significantly lower platelet counts, longer prothrombin times, and higher blood urea and serum bilirubin concentrations in the 42 patients with bleeding times of 10 minutes or more compared with the 58 patients with bleeding times less than 10 minutes. Multiple linear regression analysis showed that the bilirubin concentration as well as the platelet count was independently correlated with the bleeding time. The combination of a platelet count greater than 80 x 10(9)/l and a prothrombin time less than 17 seconds (usually taken as safe limits for performing routine liver biopsy) did not predict a normal bleeding time. Ten of 39 patients fulfilling these criteria had a prolonged bleeding time.

CONCLUSIONS

Prolonged bleeding time is common in patients with cirrhosis, even in those with prothrombin times and platelet counts within "safe limits" for invasive procedures. The severity of liver disease as assessed by the bilirubin concentration plays an important part in determining the bleeding time in cirrhosis. The bleeding time should be measured when assessing patients for invasive procedures who have a raised bilirubin concentration or poor hepatic function, even if the platelet count and prothrombin time are considered adequate.

Pancreatic pseudocyst causing portal vein thrombosis and pancreatico-pleural fistula

Portal vein thrombosis and pancreatico-pleural fistula are unusual complications of chronic pancreatitis. We describe a patient with chronic alcoholic pancreatitis in whom erosion of the splenic vein led to portal vein thrombosis and to the development of a pancreatico-pleural fistula. We suggest that fistula formation may occur over a considerable time period as the portal vein thrombosis was diagnosed three years before the amylase-rich pleural effusions.

Long-term pharmacologic therapy of portal hypertension

Beta-blockers modify splanchnic hemodynamics in cirrhotic patients. Nonselective beta-blockers are more effective than selective beta-blockers. Azygos blood flow, as a measure of collateral circulation, including that through varices, is always reduced, but the effects on portal pressure, whether measured directly or by the wedged hepatic venous pressure, are variable. The initial reported correlation between a 25% reduction of resting pulse rate and similar percentage reduction in the wedged free hepatic venous gradient has not been reproduced in subsequent studies. Therefore, to study the effect of changes in hemodynamic indices and the likelihood of variceal bleeding, direct measurements of such indices need to be made in clinical trials. At present, only one primary-prevention trial of propranolol suggests that a hemodynamic index can be used to identify patients given propranolol who will not bleed. Some clinical factors may be important in identifying nonresponders in trials of secondary prevention, but these are not universally recognized. The results of secondary-prevention studies are very heterogeneous, and it is difficult to understand why this is so. However, comparative studies versus sclerotherapy suggest that reductions in rebleeding and mortality are similar. Pharmacologic treatment, including beta-blockade, is ideal for primary prevention of variceal bleeding. The initial results from randomized studies are more homogeneous regarding the benefit of beta-blockers than in the secondary-prevention studies, although there is still doubt about the response in cirrhotics with ascites. No fatal complications due to propranolol administration have been reported in cirrhotic patients, and the complications are reversible. The future of pharmacologic therapy for portal hypertension lies in combination therapy. The addition of vasodilators to beta-blockers appears to potentiate their effect on portal pressure reduction. The results of clinical trials are awaited with great interest.

How to insert a Sengstaken-Blakemore tube

The Sengstaken-Blakemore (SB) tube is a valuable tool in the emergency treatment of patients with bleeding oesophageal varices. However, as its use may be associated with a number of serious complications it should be used judiciously and inserted with care. Once bleeding has been controlled with an SB tube, definitive treatment for the bleeding varices should be urgently considered.

Haemodynamic effect of triglycyl-lysine-vasopressin (glypressin) on intravascular oesophageal variceal pressure in patients with cirrhosis. A randomized placebo controlled trial

A double-blind random administration of 2 mg glypressin intravenously (i.v.) or placebo was given to 20 volunteer patients suffering from liver cirrhosis with portal hypertension and oesophageal varices. Experimental protocol required two basal intravascular oesophageal variceal pressure (IOVP) measurements, before and after bolus i.v. drug injection. The second measurement was taken as reference to determine whether the treatment was effective. Other measurements were taken 1, 3, 5 and 10 min after drug administration. The fall in IOVP at 3, 5 and 10 min in the patients who had been administered glypressin proved statistically significant (p less than 0.01) with mean percentage variations of -22.3%, -24.4% and -27.9%, respectively. In conclusion, the administration of glypressin in portal hypertensive patients brought about a marked reduction in transmural oesophageal variceal pressure in over 70% of the cases. This decrease may prove to be of clinical importance both as a first line therapy and as a possible aid to emergency sclerotherapy in the presence of active variceal bleeding.

Intravenous albumin infusion is an effective therapy for hyponatraemia in cirrhotic patients with ascites

The treatment of moderate to severe hyponatraemia in patients with decompensated liver disease is unsatisfactory. We report our preliminary experience using intravenous infusion of albumin to treat this condition. Three patients with cirrhosis, ascites, and hyponatraemia responded satisfactorily to treatment; one patient with fulminant hepatitis B did not respond. Intravenous albumin infusion is a safe and effective therapy for patients with cirrhosis complicated by hyponatraemia. Its main role may be in preparing patients for surgery, particularly liver transplantation.

Metabolism of exogenous S-adenosyl-L-methionine in patients with liver disease

S-Adenosyl-L-methionine (SAMe) is an important methyl group donor for many biochemical reactions. It is widespread in body tissues, including the liver, and is metabolised via 3 main metabolic pathways: transmethyltion, trans-sulphuration and amino-propylation. In chronic liver disease these pathways are impaired, the major abnormality being a reduction in SAMe-synthetase activity. Exogenous SAMe may overcome the effects of impaired SAMe-synthetase activity. Exogenous SAMe is stable in digestive juices and, although well absorbed orally, bioavailability is reduced because of a significant first pass effect in the liver. Dose-dependent peak plasma levels are achieved within 3 to 6 hours of oral administration and plasma levels approach baseline after 24 hours. Volumes of distribution are small. The metabolism of exogenous SAMe appears to follow the known pathways of endogenous SAMe metabolism and the initial data suggest that the process is largely unaffected in patients with chronic liver disease.

A comparison of sclerotherapy with staple transection of the esophagus for the emergency control of bleeding from esophageal varices

We compared two procedures for the emergency treatment of bleeding esophageal varices in patients who did not respond to blood transfusion and vasoactive drugs. We randomly assigned 101 patients with cirrhosis of the liver and bleeding esophageal varices to undergo either emergency sclerotherapy (n = 50) or staple transection of the esophagus (n = 51). Four patients assigned to sclerotherapy and 12 assigned to staple transection did not actually undergo those procedures, but all analyses were made on an intention-to-treat basis. Total mortality did not differ significantly between the two groups; the relative risk of death for staple transection as compared with sclerotherapy was 0.88 (95 percent confidence interval, 0.51 to 1.54). Mortality at six weeks was 44 percent among those assigned to sclerotherapy and 35 percent among those assigned to staple transection. Complication rates were similar for the two groups. An interval of five days without bleeding was achieved in 88 percent of those assigned to staple transection and in 62 percent of those assigned to sclerotherapy after a single injection (P less than 0.01) and 82 percent after three injections. In only 2 of the 11 patients who received a third sclerotherapy injection was bleeding controlled for more than five days, and 9 died. We conclude that staple transection of the esophagus is as safe as sclerotherapy for the emergency treatment of bleeding esophageal varices and that it is more effective than a single sclerotherapy procedure. We currently recommend surgery after two injection treatments have failed.

Antimitochondrial antibodies in primary biliary cirrhosis recognize both specific peptides and shared epitopes of the M2 family of antigens

Sera from patients with primary biliary cirrhosis exhibit variable autoantibody reactivity against mitochondria, the commonest antigen (designated M2) including three structures of approximate M.W. 70, 50 and 40 kD. The nature of these antigens has only recently been established; the 70 and 50 kD are the transacetylase E2 and component X, respectively, of the pyruvate dehydrogenase complex and are distinct polypeptides. We have demonstrated, by immunoblotting, elution and rebinding of antibodies, unequivocal cross-reactivity between the major bands of the M2 antigen. In addition, cross-reactivity has been shown between antibodies binding to each of the three M2 bands of mitochondria and two major antigenic bands of both Gram-negative and Gram-positive bacteria. Conversely, antibodies eluted from these two bands of Escherichia coli were found to bind all three M2 bands of mitochondria. These results suggest that the antibodies of primary biliary cirrhosis contain both peptide-specific and cross-reacting antibodies, the latter recognizing a common "M2 epitope" that might include nonprotein components of the peptides. However, direct and competitive enzyme-linked immunosorbent assays failed to implicate the coenzyme of the pyruvate dehydrogenase complex, lipoic acid or its amide, as the common antigenic moiety.

Significant bacteriuria has prognostic significance in primary biliary cirrhosis

Significant bacteriuria in women has been found to be associated with increased mortality in community-based studies. We have previously reported a high prevalence of significant bacteriuria with a high recurrence rate in females with primary biliary cirrhosis (PBC), particularly those with late stage disease on liver biopsy. During a 5-year period we prospectively screened for significant bacteriuria in 187 women with primary biliary cirrhosis, (median follow-up of 47 months, range 1-83). Significant bacteriuria was found in 30 (17%) in their first urine (index bacteriuria), 90 (48%) died and 15 (8%) had liver transplants. Cox's proportional hazard models showed that age, serum bilirubin, ascites and cirrhosis were independent prognostic variables. Index bacteriuria added significantly to this model (P = 0.069) being independent from other variables, with an increased relative hazard for death of 1.65 (65% increase in risk of death) compared to non-bacteriuric patients. This effect was due mainly to non-cirrhotic patients with significant bacteriuria as shown by using multiplicative variables for histological stage and significant bacteriuria. An index of recurrent bacteriuria was significantly increased in patients with index bacteriuria (P less than 0.001) and in those who died or underwent transplantation (P less than 0.001). In this study, significant bacteriuria defined a specific sub-group of PBC patients with an increased risk of death.

Copper overload in the developing guinea pig liver: a histological, histochemical and biochemical study

The copper profile in Wilson's disease resembles that of human and guinea pig neonates. Microvesicular steatosis is characteristic of early histological damage in Wilson's disease. The aim of this study was to relate the histological, histochemical and ultrastructural changes seen in developing guinea pig liver to the developmental pattern of liver copper in these animals. Copper-stressed and control guinea pigs were studied. Liver biopsies were stained with haematoxylin and eosin, rhodanine (for copper), orcein (for copper-associated protein) and oil Red 0 (for fat). Selected specimens were examined by electron microscopy. Liver and serum copper levels and copper oxidase activity were also determined. Fetal liver copper increased during the last trimester of pregnancy, reaching five times the adult level in the perinatal period and falling rapidly in the 4 days after birth. Marked steatosis developed in both control and copper-stressed guinea pig liver. The fat score correlated strongly with liver copper concentration (r: 0.60; p less than 0.001). Orcein and rhodanine staining correlated with liver copper concentration (r: 0.52 and r: 0.40 respectively, p less than 0.01). Marked prenatal hepatic steatosis and its postnatal clearance correlates with changes in liver copper concentration. This experimental model provides an opportunity to study the pathogenesis of hepatic steatosis and the relationship between copper retention and steatosis.

Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates

The importance of variable time of entry for analysis of survival following variceal bleeding has recently been disputed. In a study of 194 cirrhotic patients with bleeding esophageal varices in whom 2-day mortality was 3%, statistically significant differences in both survival and rebleeding rates were obtained by shifting the starting point for analysis of survival by 2 weeks following admission to hospital or by 5 days for the analysis of rebleeding. In addition, the curve of hazard function for death or for failure to control bleeding following admission clearly showed that any change in entry time in a study of variceal bleeding would introduce bias and alter survival or rebleeding rates. Thus, the starting point for analysis following variceal hemorrhage is an important confounding variable when calculating both survival and rebleeding. It should always be taken into account, particularly in clinical trials, which are often performed in centers where patients are referred from other hospitals at different times following bleeding.

Carcinoma of the esophagus and long-term sclerotherapy

We report a case where a chronic non-healing esophageal ulcer which developed following a course of endoscopic sclerotherapy proved to be an esophageal carcinoma. In view of 2 similar previous reports we discuss the possibility that sclerotherapy may act as a carcinogen, and suggest that all such non-healing esophageal ulcers should be biopsied.

Inhibition of platelet aggregation by abnormal high density lipoprotein particles in plasma from patients with hepatic cirrhosis

ADP-induced aggregation of normal washed platelets was measured by nephelometry in the presence of plasma high density lipoprotein (HDL) from normal subjects and from 30 patients with hepatic cirrhosis. HDL, at one-eighth of its plasma concentration, inhibited platelet aggregation; the effect of cirrhotic HDL (40% [SD 29%] inhibition) was significantly greater than that of normal HDL (16% [11%]). The mean apolipoprotein E content of cirrhotic HDL was significantly higher than that of normal HDL, and strongly inhibitory HDL contained twice as many apolipoprotein-E-rich particles as weakly inhibitory HDL. Inhibition of platelet aggregation was correlated with the apolipoprotein E content of HDL from patients with cirrhosis.

Surgery and sclerotherapy for treatment of portal hypertension and oesophageal varices

Surgery and sclerotherapy are both used for the prevention of rebleeding from varices and for primary prevention. Prophylactic shunt surgery has been shown to be harmful, but devascularisation procedures are in use in Japan. Shunt surgery is the most effective therapy for the prevention of rebleeding and does not decrease survival rates in patients, compared with those not receiving therapy. However, the risk of encephalopathy, which may be severe, is increased. Sclerotherapy reduces the number of patients rebleeding by only a small proportion, but greatly diminishes the number of episodes of rebleeding. However, the value of emergency sclerotherapy in preventing rebleeding throughout the long term studies, as opposed to the solely elective component, has not been evaluated. The non-injection arm received neither emergency nor elective injection. Randomised studies comparing sclerotherapy and shunt surgery show surgery to be more effective and to have similar survival rates to sclerotherapy, with the exception of 1 study. Devascularisation, as practised by Sugiura, results in bleed-free rates equivalent to those achieved with shunts. These results have not been reproduced in the West. Since liver transplantation is a reality today, shunt surgery involving the portal vein and devascularisation should be avoided.