Emergency treatment of variceal hemorrhage

The cirrhotic patient with acute bleeding from esophageal varices has less than a 50% chance of leaving the hospital alive; the outlook for survival is so poor that even desperate measures are worthwhile. Some traditional nonsurgical methods for the control of the bleeding are either ineffective at worst or temporary at best. Balloon tamponade is not recommended at all, but intravenously administered vasopressin may be helpful in allowing the necessary diagnostic investigations to be completed. Most important at this stage are the measures necessary to improve the general status of the patient--restoration of blood volume with fresh blood, prevention of ammonia intoxication, support of the liver, correction of metabolic alkalosis and treatment of the hyperdynamic state with digitalis and cardiotonic drugs. Controlling the bleeding is not the greatest problem--the greatest problem is achieving survival of a critically ill patient who undergoes a formidable operation (e.g., variceal ligation stops the bleeding, but is itself an operation of considerable magnitude). In our hands emergency shunting is the best treatment providing a definitive procedure with the highest 10-year survival rate and the lowest complication rate.

The intestinal phase hormone

The existence of a stimulatory intestinal phase of gastric acid secretion has been suspected, but largely ignored, for many years. Recently, however, it has become clear that the intestinal phase plays an important role in acid production during digestion. The intestinal phase is of additional interest in relation to the profound gastric acid hypersecretion associated with portacaval shunt (PCS). Substantial evidence indicates that PCS-related gastric hypersecretion is due to unmasking of the intestinal phase by hepatic bypass of a humoral stimulant in portal blood that is normally degraded to a considerable extent by the liver. Studies in our laboratory during the past 12 years have provided strong physiologic evidence for humoral mediation of both the intestinal phase of gastric secretion and of PCS-related hypersecretion by a hormone that arises in the small intestine, particularly in the jejunum. Furthermore, our studies have demonstrated that this intestinal phase hormone (IPH) exists in humans as well as in dogs, rats, and pigs. Additionally, recent work by a number of investigators, as well as by our group, has provided convincing evidence that IPH is different from any of the known gastric stimulatory hormones. With these physiologic observations as a background, we have used a classical method for extracting acidic peptides to prepare a hog intestinal mucosa extract (HIME) that has all of the known physiologic properties of an IPH. Specifically, HIME contains a potent stimulant of gastric acid secretion that acts according to a linear dose-response relationship; that is not gastrin in any of its immunoassayable forms; that significantly augments the maximal acid secretory responses to pentagastrin, gastrin, CCK, and histamine; and that is substantially degraded by the liver, in contrast to gastrin and CCK. Efforts at isolating the gastric stimulatory substance in HIME suggest that it is a peptide of low molecular weight. Work directed at isolating IPH in pure form and identifying it is in progress.

Heterotopic and orthotopic liver transplants in inbred rat strains

The functioning and survival of orthotopic liver allotransplants in toto were compared with heterotopic partial and whole allotransplants in inbred rats. In contrast to the rapid and aggressive rejection of the heterotopic allografts, the orthotopic whole-liver allografts survived for prolonged periods. These latter grafts were subjected to mild cellular attack 11 to 12 days following transplantation, but they survived without the massive cellular infiltration and hepatocytolysis seen in the heterotopic partial grafts. Biliary secretion by the orthotopic whole-liver allografts was functional throughout the survival period and was markedly increased during the final stages of survival, whereas the heterotopic liver grafts ceased to excrete normal bile by day 9, after which they were completely depigmented.

Treatment of Budd-Chiari syndrome by side-to-side portacaval shunt: experimental and clinical results

The Budd-Chiari syndrome caused by occlusion of the major hepatic veins, often of unknown etiology, is typically characterized by massive ascites, hepatomegaly and abdominal pain due to intense congestion of the liver. The outcome has almost always been fatal. This report describes an evaluation of side-to-side portacaval shunt in dogs with experimental Budd-Chiari syndrome and in six patients with hepatic vein thrombosis. In the animal studies, side-to-side portacaval shunt was very effective in relieving massive ascites, hepatomegaly, hepatic congestion and portal hypertension produced by ligation of the hepatic veins. Only one of 24 dogs with side-to-side anastomosis reformed ascites, 67% of the animals survived until the study was concluded after one year, and liver biopsies showed reversal of the severe pathologic abnormalities. In contrast, all 20 control dogs subjected to a sham laparotomy, and all 20 dogs that underwent end-to-side portacaval shunt reformed massive ascites and died within six months with continued hepatic congestion and necrosis. All six patients with the Budd-Chiari syndrome due to hepatic vein occlusion had massive ascites (4.4-15.9 l), hepatomegaly, abdominal pain and disturbed liver function. In all six, angiography demonstrated occlusion of the hepatic veins with a patent inferior vena cava (IVC) and a normal IVC pressure, and liver biopsy showed intense centrilobular congestion and necrosis. The most valuable diagnostic study was angiography of the IVC and hepatic veins with pressure measurements. Side-to-side portacaval shunt was performed from four to 14 weeks after the onset of symptoms, and produced dramatic and sustained relief of ascites in five of the six patients during follow-up periods of from eight months to seven years. Liver function returned to normal, hepatosplenomegaly disappeared, none of the survivors developed portal-systemic encephalopathy, and follow-up liver biopsies showed disappearance of congestion and necrosis, but mild to moderate fibrosis. One patient died following an emergency IVC thrombectomy and portacaval shunt, which was undertaken when, during the course of his workup, his condition deteriorated suddenly because the thrombotic process extended from the hepatic veins into the IVC. The everpresent risk of this complication, and the dangers associated with delaying operation were emphasized by this case. It is concluded that side-to-side portacaval shunt, which decompresses the liver by converting the portal vein into an outflow tract, provides effective treatment of the Budd-Chiari syndrome when the occlusive process is confined to the hepatic veins.

Criteria for selection of patients for emergency portacaval shunt

A computer program analysis of the effect on survival of 74 preoperative factors was performed as part of a prosepctive study of the emergency portacaval shunt in 146 unselected patients with bleeding esophageal varices due to alcoholic cirrhosis. Only ascites, a serum glutamic oxalacetic transaminase level of 100 units or more, and a requirement for 5,000 ml or more of blood transfusion were associated with a statistically significant decrease in survival. However, none of these factors are contraindications to operation because their presence permits a survival rate of 37 to 40%. The only contraindication to emergency portacaval shunt is the combined presence of ascites, jaundice, encephalopathy, and severe muscle wasting, a constellation that was incompatible with survival beyond one year.

En bloc transplantation of liver, pancreas, duodenum, and spleen in the rat. Description of technique and histological findings

En bloc transplantation involving liver, spleen, pancreas, and duodenum was successfully carried out in the rat. While operative mortality due to technical failure was 31%, of those that survived over 95% of the isografts had normal histology up to 4.5 months. Rejection reaction in the allografts first appeared in the liver and the spleen, followed by the pancreas and the duodenum, and was complete by day 14. No gross evidence of graft-versus-host reaction was observed.

Further evidence for an intestinal phase hormone that stimulates gastric acid secretion

The studies described in this report were directed at isolating the hormone responsible for the intestinal phase of gastric acid secretion. One hundred and ten extracts of hog intestinal mucosa, each representing the yield from about 3,000 hogs, were prepared by a method for isolating small peptides that involved heating, absorption on diethylaminoethylcellulose (DEAE), and acid precipitation. All extracts stimulated gastric acid secretion in acute gastric fistula rats, and 56 were highly active according to stringent criteria that required a greater than 50 percent increase in acid output above basal in at least 60 percent of rats. Increasing doses of extract stimulated increasing acid production according to a regular dose-response relationship. Twelve highly active extracts were tolerated without side effects when infused into dogs with Heidenhain pouches and produced a mean 22 fold increase in acid output above basal. The gastrin content of 73 extracts, measured by radioimmunoassay in two independent laboratories, averaged 5,80 ng. per rat dose of extract, which is approximately 1/500 of the minimal stimulating dose of hog gastrin. No extract contained sufficient gastrin to produce an acid secretory response. Administration of the extract together with a maximal stimulating dose of pentagastrin in rats significantly augmented the maximal acid secretory response. Finally, comparison of the acid secretory response to portal and systemic intravenous infusion of the extract in acute gastric fistula rats demonstrated significant inactivation by passage through the liver, in contrast to the results of similar studies of hog gastrin. It is concluded that the extract had all of the known physiologic properties of the intestinal phase hormone and very likely contained the intestinal phase hormone.

Long term studies of pancreas transplantation in experimental diabetes mellitus

Alloxan diabetes was induced in inbred rats that then were divided into four groups consisting of unoperated diabetic controls, sham-operated diabetic controls, rats given pancreaticoduodenal isografts, and rats given duct-ligated pancreas isografts. The animals were studied for from 18 months (controls) to two years (transplants) and the following important results were obtained: 1) In striking contrast to the diabetic controls, pancreas transplants of both types produced immediate and permanent relief of hyperglycemia, immediate and lasting elevation of serum insulin levels, a normal weight and growth curve, and good health for two years. Removal of the graft was followed by recurrence of severe diabetes. 2) Pancreas transplants of both types prevented the widespread and severe renal, ophthalmic and neural lesions of diabetes that were found in the diabetic controls. 3) The duct-ligated pancreas graft and pancreaticoduodenal transplant were equally effective in controlling diabetes. Ligation of the pancreatic duct was not followed by significant morphologic or clinical evidence of pancreatitis or by loss of endocrine function. 4) Portal venous drainage of the pancreas transplant was unnecessary for good endocrine function.

Simplified technic for orthotopic liver transplantation in the rat

A new surgical procedure has been developed to simplify the difficult, complex technic of orthotopic liver transplantation in the rat that we previously described. This procedure eliminates the hepatic artery anastomosis and specifically changes the sequence of anastomoses of the vena cava and portal vein to minimize splanchnic congestion and hepatic ischemia. This has simplified and shortened the operation and has eliminated the need for an extracorporeal portosystemic shunt. Seventy-two per cent operative survival was achieved in fifty-seven orthotopic liver transplantations. This simplified technic of orthotopic liver transplantation in the rat can be applied widely to studies of liver physiology, immunologic rejection, and liver preservation.

Portacaval shunt as emergency procedure in unselected patients with alcoholic cirrhosis

A prospective evaluation of emergency portacaval shunt has been conducted during a 12 year period in 138 unselected, consecutive patients with alcoholic cirrhosis and bleeding esophageal varies. An extensive diagnostic evaluation was completed within seven hours of hospital admission, and the shunt operation was undertaken within a mean of 8.5 hours. Follow-up study was conducted in a special clinic, and the current status of 97.1 per cent of the patients had jaundice, ascites or encephalopathy alone or in combination on admission. Systemic intravenous administration of posterior pituitary extract temporarily controlled the hemorrhage in 94 per cent of the patients, and the emergency portacaval shunt promptly and permanently controlled the varix bleeding in 96 per cent of the patients. Contrary to recent proposals, patients with the highest portal perfusion pressure and, presumably, the largest hepatopetal portal flow had the highest survival rate and those who were presumed from pressure measurements to sustain the smallest portal flow diversion from the shunt had the lowest survival rate. The operative survival rate was 51 per cent, the predicted seven year survival rate for those operated upon seven or more years ago was 42.5 per cent. Encephalopathy requiring dietary protein restriction developed at some time in 17 per cent of the survivors. Sixty per cent of the survivors abstained from alcohol, and 53 per cent resumed gainful employment or full time housekeeping. Preoperative factors that adversely influenced survial rate were ingestion of alcohol within one month of bleeding, ascites, severe muscle-wasting and a small liver. Postoperatively, the single most important factor that compromised long term survival was resumption of alcoholism. In comparisons with our previous prospective studies, emergency portacaval shunt resulted in a significantly greater long term survival rate than did either emergency medical therapy or emergency varix ligation, followed by elective shunt. It is concluded that emergency portacaval shunt is the most effective treatment of bleeding esophageal varices in patients with alcoholic cirrhosis. Criteria for exclusion of those patients who are unlikely to derive long term benefits from portacaval shunt remain to be defined by further studies.

Long-term exocrine function of the pancreas transplant

The long-term exocrine function of fifty-nine pancreaticoduodenal isografts was evaluated in rats for up to one year post transplantation. At one, three, six, nine, and twelve months after transplantation the grafts were cannulated and the exocrine secretion was collected. The volume, protein content, pH, amylase and trypsin concentrations, and electrolyte composition of the secretion were compared with those obtained from the host pancreas in nineteen control rats. Twenty-four hour secretion studies demonstrated normal basal function of the pancreas transplant when compared with that of the host. Pancreozymin stimulation caused an increase in volume, trypsin concentration, and amylase concentration of the graft pancreas secretion that was similar to those seen in the host. These studies indicate that there is normal exocrine secretion of pancreas transplants in the absence of rejection and that denervation of the gland has little direct effect on over-all pancreatic function.

Liver regeneration after portacaval transportation in rats

General recognition of the presence of a specific hepatotrophic factor in portal blood that is necessary for liver regeneration was delayed by two major problems. First, there was a long period of confusion regarding liver atrophy, liver hypertrophy, and cellular hyperplasia. Second, because only exposure to other liver tissue destroys the hepatotrophic activity, all of the studies that were based on bypassing the portal blood into the systemic circulation merely diluted the active substance, which still was available to the hepatocytes by recirculation through the hepatic artery. These problems have been resolved by the development of more sophisticated methods by which to assay liver regeneration and by the introduction of the double liver model to study regeneration. During the time when liver weight alone was used to assess regeneration, the regenerative capacity of the liver was reported to be much greater after portacaval transposition than after end-to-side portacaval shunt, a finding that is inconsistent with current knowledge of the hepatotrophic portal blood factor. To re-evaluate the effect on liver regeneration of providing a compensatory systemic venous inflow after complete portal diversion, 40 partially hepatectomized inbred rats which had previously undergone either a sham operation and end-to-side portacaval shunt or a portacaval transposition were compared on the basis of six separate criteria of regeneration. All of the livers actively regenerated and no significant advantage of providing a substitute systemic venous inflow to the liver could be detected by any of the criteria.