Randomised controlled trials for variceal bleeding

The variceal bleeding episode represents several days of high risk of bleeding, thus therapy should be evaluated not only in terms of immediate cessation of bleeding but also in terms of providing a bleed-free interval of a few days. As the risk of continued bleeding or very early rebleeding from varices diminishes rapidly following admission, time is an important confounding variable when comparing therapies within and between trials. Cirrhotics with better liver function are more likely to stop bleeding with simple measures than those with worse liver function. Vasopressin, glypressin, vasopressin combined with nitroglycerin and somatostatin have all been used as splanchnic arteriolar vasoconstrictors thus reducing portal pressure. No trial has demonstrated increased survival with use of these agents. The efficacy of vasopressin is now disputed. Vasopressin combined with nitroglycerin and somatostatin have the fewest side-effects and may be more effective than vasopressin alone. Balloon tamponade arrests bleeding and prevents exsanguination, but should be used solely as a temporizing measure before the use of emergency sclerotherapy or surgery. Sclerotherapy is the only non-operative emergency technique which has been shown not only to stop variceal bleeding, but to reduce the frequency of very early rebleeding. Emergency oesophageal transection is equally if not more effective in arresting bleeding than sclerotherapy and has a lower early rebleeding rate and a similar mortality. Choice of treatment depends on expertise available. Further studies in the management of variceal bleeding should evaluate 3 main areas. Firstly improvement of existing therapies or new therapies. Secondly, investigation of therapies not related to bleeding, eg prophylaxis against infection, improvement in renal support. Lastly evaluation of predictive factors which may a priori determine a high risk of continued bleeding or early rebleeding thus justifying immediate sclerotherapy or surgery in a sub-group of patients.

Vitamin E deficiency and its clinical significance in adults with primary biliary cirrhosis and other forms of chronic liver disease

The vitamin E status of 146 adults with chronic liver disease was assessed by estimating both their serum vitamin E concentration and the ratio of serum vitamin E to serum cholesterol concentration. Low levels of vitamin E occurred most frequently in patients with primary biliary cirrhosis and other forms of chronic cholestatic liver disease. When a serum vitamin E concentration of 12.3 mumol/l (mean-2 SD of a control population) was taken as the lower limit of normal, 44% of patients with primary biliary cirrhosis and 32% with other chronic cholestatic liver disease had a reduced concentration, indicating a biochemical deficiency of vitamin E. If a vitamin E/total cholesterol ratio of 2.35 mumol/mmol was taken as the lower limit of normal, then 64% and 43% of patients with primary biliary cirrhosis and other chronic cholestatic liver disease, respectively, had a biochemical deficiency of vitamin E. Of the patients with chronic cholestasis and a serum bilirubin concentration greater than 100 mumol/l, 91% had a reduced vitamin E/cholesterol ratio. Twelve patients with primary biliary cirrhosis and severe vitamin E deficiency (serum vitamin E less than 5.0 mumol/l and a vitamin E/cholesterol ratio less than 1.0 mumol/mmol) underwent extensive neurological investigation. Five had a mild mixed sensorimotor peripheral neuropathy, which was not, however, typical of the neurological syndrome associated with vitamin E deficiency. In patients with severe biochemical deficiency of vitamin E (less than 5 mumol/l and less than 1 mumol/mmol total cholesterol), administration of large oral doses of vitamin E only increased serum concentrations to within the normal range in one patient; in the others even weekly parenteral administration over a 3-month period did not correct deficiency. In patients with less severe biochemical deficiency, the serum vitamin E concentration and vitamin E/total cholesterol ratio were restored to normal by oral or intramuscular supplements of the vitamin.

Bronchobiliary fistula due to acute cholecystitis in a suprahepatic gall bladder

We describe a patient presenting with painless jaundice, anorexia and pruritus. The gall bladder was found to be lying above and behind a hypoplastic right lobe of liver. There was no evidence of cholangitis or biliary obstruction. The patient subsequently developed a bronchobiliary fistula with severe wheeze, cough and bile-stained sputum. Emergency percutaneous drainage of the gall bladder led to immediate cessation of bronchospasm and biloptysis, rendering the patient fit for definitive surgery.

Delta hepatitis in Lebanon. Prevalence studies and a report on six siblings with chronic delta-positive active hepatitis

The prevalence of delta infection in Lebanon is reported for the first time. Delta antigen and antibody were screened for in serum of 43 patients consecutively seen in hospital, 22 with acute hepatitis B (anti-HBc IgM-positive), and 21 with histological evidence of chronic active hepatitis, 6 of whom were brothers in a sibship of eleven. Twenty asymptomatic HBsAg carriers without clinical or biochemical evidence of liver disease were similarly studied. None of the asymptomatic carriers or acute hepatitis B patients had markers of delta infection. In contrast, delta antibody in high titre (greater than 1:5000) was found in 12 (57%) of the patients with chronic active hepatitis, including all six brothers. Five sisters in the sibship were anti-HBs-positive without evidence of liver disease, suggesting a horizontal mode of transmission of the delta virus, as a superinfection on a hepatitis B carrier state. Excluding the sibship, delta infection was present in 6 of 15 (40%) chronic active hepatitis patients. This prevalence is similar to other Middle Eastern countries. Delta infection was associated with severe liver disease.

Review article: beta-adrenoceptor blockers for the treatment of portal hypertension

beta-Adrenoceptor blockers always change splanchnic haemodynamics in cirrhotic patients. Azygous 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 correlations between a 25% reduction of resting pulse rate and similar percentage reduction in the wedge-free hepatic venous gradient, has not been reproduced in subsequent studies. Therefore, to study the effect of changes in haemodynamic indices and the likelihood of variceal bleeding, direct measurements of such indices need to be made in clinical trials. At present there are no haemodynamic or clinical factors which can be used to select patients who will have a good therapeutic response to propranolol other than those documented in the first clinical trial of propranolol for the prevention of variceal re-bleeding from Paris. Thus the hypothesis that beta-adrenoceptor blockers may lessen the incidence of bleeding in cirrhotics, by partially reducing portal pressure or flow or both, needs testing in further clinical studies. The selection criteria of the first clinical trial of propranolol in Paris need to be confirmed. Two subsequent trials, in which patients were not selected but in which many patients had similar clinical characteristics to the Paris patients, could not confirm a therapeutic effect of propranolol. No fatal complications due to propranolol administration have been reported in cirrhotic patients. Complications are reversible. Pharmacological treatment including beta-adrenoceptor blockade appears ideal for trials of primary prevention of variceal bleeding. Some preliminary results including use in decompensated cirrhotics are encouraging. However, as for trials for prevention of re-bleeding, the design and analysis of such trials needs careful evaluation to take into account the outcome of patients who discontinue medication, whether due to simple noncompliance or due to side-effects, and also the influence of abstinence from alcohol on bleeding from varices.

The ontogeny of liver copper metabolism in the guinea pig: clues to the etiology of Wilson's disease

The normal human neonate has a copper profile indistinguishable from Wilson's disease, and we have previously postulated that this disease is caused by genetic failure to switch from the fetal to adult mode of copper metabolism. This study validates the developing guinea pig as a suitable animal in which to study copper ontogeny. At birth, liver copper concentrations are 7 times higher than in adults and serum copper and ceruloplasmin are 27 and 21% of adult values, respectively. A 53% fall in liver copper occurs in the 4 days after birth. This is associated with a marked increase in bile copper output, which does not parallel increasing bile flow. Liver copper falls, and serum copper and ceruloplasmin increase to near adult levels in the 30 days after birth. Until the sixtieth day of gestation, liver copper was significantly increased in copper-stressed littermates, although paradoxically at birth, concentrations were significantly lower. In copper-stressed fetal animals, bile copper output increased markedly before birth. Metallothionein was the dominant copper-binding protein in the fetal liver but a minor component in the adult. Superoxide dismutase activity only developed after birth. We conclude that the postnatal switch from the fetal to adult mode of copper metabolism involves activation of biliary excretion and ceruloplasmin export as well as changes in the association of copper with hepatic copper proteins. Similarities between the fetus and Wilson's disease suggest that this disease is caused by failure of this postnatal adaptation process.

Biliary lavage with corticosteroids in primary sclerosing cholangitis. A clinical, cholangiographic and bacteriological study

Bile duct perfusion with corticosteroids is reported to improve the cholangiographic and biochemical abnormalities in some patients with primary sclerosing cholangitis. In a randomised placebo controlled trial, thirteen consecutive patients received continuous bile duct irrigation with either normal saline (1 l/day) or normal saline plus hydrocortisone (100 mg daily) via a nasobiliary tube placed in a hepatic duct at endoscopic retrograde cholangio-pancreatography. Eleven patients completed lavage for 2 weeks but no cholangiographic changes were observed in either group. Liver function tests deteriorated during lavage, but later returned to pre-treatment levels. Although bile was sterile at start of lavage, a wide range of bacteria was isolated from bile in all patients during treatment, and cholangitis with septicaemia occurred in 2 patients. We conclude that nasobiliary lavage is not beneficial in treating primary sclerosing cholangitis.

Desmopressin and bleeding time in patients with cirrhosis

Desmopressin acetate 0.3 microgram/kg was given intravenously to nine patients with chronic liver disease and to a further six such patients in a double blind controlled study versus placebo. Desmopressin acetate significantly shortened the bleeding time compared with basal values in both groups and compared with placebo. There was also a significant decrease in partial thromboplastin time (but not prothrombin time) and significant increases in factor VIII and its components, von Willebrand factor and ristocetin cofactor activity, but not in factors VII, IX, X, XI, or XII. Increased fibrinolysis could be blocked by concomitant administration of tranexamic acid. No important side effects were seen. The multimer pattern of von Willebrand factor was studied for the first time in chronic liver disease. It was normal, but after administration of desmopressin acetate the percentage of multimers of higher molecular weight increased significantly. This may be an important mechanism in the shortening of the bleeding time in cirrhosis, as has been shown in uraemia and other conditions after administration of desmopressin acetate. Desmopressin acetate may be useful in correcting defects in primary haemostasis in chronic liver disease.

Recurrent bacteriuria and primary biliary cirrhosis: ABO blood group, P1 blood group, and secretor status

Patients with primary biliary cirrhosis have an abnormally high incidence of urinary tract infection (35%). Susceptibility to urinary infection and other infectious diseases has been linked with certain blood group antigens and secretor status. We have therefore studied these characteristics in patients with primary biliary cirrhosis. We were unable to show any abnormal distribution in blood groups or secretor status in patients with primary biliary cirrhosis (compared with a normal population) which might reflect their predisposition to urinary infection. The distribution of blood groups and secretor status in patients with primary biliary cirrhosis with a history of urinary infections was not significantly different from patients without such a history. Escherichia coli strains isolated from patients with primary biliary cirrhosis did not bind in any greater numbers to the uroepithelial cells of primary biliary cirrhosis patients than to the cells of a normal healthy control. We therefore conclude that blood group distribution, abnormal secretor status, and epithelial cell type are not important factors in the predisposition of primary biliary cirrhosis patients to urinary infections.

Bacteriuria and primary biliary cirrhosis

Significant bacteriuria was found in 19% of 87 women with primary biliary cirrhosis, whereas in 89 women with other types of chronic liver disease bacteriuria was present in only 7%. In 74 women with rheumatoid arthritis 8% were bacteriuric. Midstream urine specimens obtained from 144 consecutive women with primary biliary cirrhosis attending hospital over a two year period showed that 50 (35%) developed bacteriuria during 12 months of follow up. Bacteriuria was unrelated to age, raised serum bilirubin, drug therapy or urinary pH but was more common in patients with late stage (fibrotic) disease as judged by histological criteria. Fifty seven per cent of bacteriuric primary biliary cirrhosis patients suffered more than one urinary infection. Fifty nine per cent of the 156 bacteriuric episodes were asymptomatic. The types of organism isolated, the antibiotic sensitivity patterns and cure rate were similar to those reported in bacteriuric women without other underlying disease. The reinfection rate (34%), however, was double that reported for bacteriuric episodes in 'problem' women with recurrent bacteriuria, indicating a special susceptibility to urinary infection. The most common isolates were E coli (70%), which did not show abnormal adhesiveness to uroepithelial or buccal cells of normal women, or to those of primary biliary cirrhosis patients. Patients with primary biliary cirrhosis have not been reported to be more susceptible to infection in general. Bacteriuria, however, was common throughout all clinical stages of primary biliary cirrhosis. Thus there may be a unique association between bacteriuria and primary biliary cirrhosis.

Controlled trial of propranolol for the prevention of recurrent variceal hemorrhage in patients with cirrhosis

We conducted a prospective randomized trial of propranolol for the prevention of recurrent variceal bleeding in 48 patients with cirrhosis of the liver. During a follow-up period of up to 21 months, 12 of 26 patients in the propranolol group and 11 of 22 in the control group had rebleeding from esophageal varices. There was no significant difference in rebleeding between the two groups. This contrasts with a previous report of the efficacy of propranolol in preventing recurrent gastrointestinal bleeding in alcoholic cirrhosis. The difference in results may be due to the inclusion in our study of patients with other causes of cirrhosis and more severe liver disease. Propranolol may not be indicated for the prophylaxis of variceal rebleeding in such patients, and we advocate that its use be limited at present to controlled clinical trials.

The effect of ranitidine on the plasma clearance and hepatic extraction of indocyanine green in patients with chronic liver disease

Since hepatic clearance of ICG is reduced by H2-receptor antagonists in normal subjects, it has been suggested that they reduce liver blood flow. We have studied the effect of intravenous ranitidine on ICG clearance in twelve patients with chronic liver disease. Wedged and free hepatic venous pressure were measured before and after intravenous ranitidine in nine of the patients, and the hepatic extraction of ICG was determined in six patients. ICG clearance fell by 22 +/- 11% (s.e. mean) 60 min after ranitidine. In patients in whom ICG clearance fell after intravenous ranitidine the hepatic extraction of ICG was also reduced. There was no significant change in the gradient between wedged and free hepatic venous pressure after ranitidine. It is therefore unlikely that ranitidine lowers liver blood flow.

Randomised, controlled study of transhepatic obliteration of varices and oesophageal stapling transection in uncontrolled variceal haemorrhage

Percutaneous transhepatic obliteration and surgical stapling transection of the oesophagus with the EEA gun were compared prospectively in the treatment of uncontrolled oesophageal variceal haemorrhage unresponsive to conservative measures. Twenty patients with cirrhosis, with a patient portal vein and who were considered suitable for general anaesthesia and surgery, were randomised to two treatment groups (10 patients each). Immediate arrest of haemorrhage was achieved in 17 patients (nine surgery, eight obliteration). In one other patient, stapling transection succeeded where attempted transhepatic obliteration failed, and in another patient obliteration succeeded where attempted transection had failed. One patient continued to bleed and died following attempts at both procedures. Two other patients also died in hospital, without rebleeding following surgery. Variceal rebleeding during the same hospital admission occurred in two patients in the obliteration group and in none after surgery. Oesophageal stapling transection compares very favourably with a non-surgical technique such as transhepatic obliteration of varices in the emergency treatment of uncontrolled variceal haemorrhage in patients with moderate liver failure.

Chronic intrahepatic cholestasis due to sarcoidosis

Two West Indian patients with Kveim-biopsy proven sarcoidosis developed chronic cholestatic liver disease, clinically and biochemically similar to primary biliary cirrhosis. Liver histology revealed multiple granulomas with reduction in bile ducts and, in one patient, progression to biliary cirrhosis. Portal hypertension was present in both patients leading to severe variceal haemorrhage in one. Mitochondrial antibody was negative in both patients and when used in conjunction with the Kveim-Siltzbach skin test serves to differentiate chronic intrahepatic cholestasis secondary to sarcoidosis from primary biliary cirrhosis.

Effect of cimetidine on portal hypertension in cirrhotic patients

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The effect of porta-systemic shunting on liver, brain and kidney zinc concentrations in the rat

Patients with alcoholic cirrhosis have subnormal liver zinc concentrations, and excessive urinary zinc excretion. It has been suggested that diversion of dietary zinc into the systemic circulation through porta-systemic shunts may be a major factor influencing the organ distribution of zinc in these patients. To test this hypothesis, we randomized Sprague-Dawley rats into a sham-operated group, and a group subjected to partial portal-vein occlusion (PPVO), which induces the formation of extensive porta-systemic collaterals. Three months after the operation, liver, brain and kidney zinc concentrations were measured in 8 sham-operated and 8 PPVO rats. Mean liver zinc concentrations were significantly higher in the PPVO group when compared to sham-operated controls (P less than 0.05). Brain and kidney zinc concentrations were similar in the 2 groups. This short-term study indicates that liver zinc concentrations are maintained and even increased in rats with porta-systemic shunting, and that diversion of portal blood into the systemic circulation is not a major cause of the low liver zinc concentration observed in alcoholic cirrhosis.

Long-standing asymptomatic primary sclerosing cholangitis: report of three cases

Three patients, two males and one female, with asymptomatic primary sclerosing cholangitis (PSC) are described. The diagnosis was made in each case by endoscopic retrograde cholangiography after investigation of persistent elevation of the serum alkaline phosphatase. All three have remained completely well without any medical or surgical treatment for 3, 7, and 15 years, respectively, despite extensive involvement of the biliary tree. Follow-up liver biopsies in two have shown no histological evidence of progression to secondary biliary cirrhosis. PSC may occur more frequently and may follow a less severe clinical course than previously recognized.

Polymyositis and acute onset systemic sclerosis in a patient with primary biliary cirrhosis: a clinical syndrome similar to the mixed connective tissue disease

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