High rate of portal thrombosis after splenectomy in patients with esophageal varices and idiopathic portal hypertension

Data on 126 consecutive patients who were admitted to our clinics from January 1979 to May 1989 were scrutinized to assess changes in portal hemodynamics following splenectomy. Two groups were classified: (1) a group of 106 patients with cirrhosis of the liver and (2) a group of 20 patients with idiopathic portal hypertension (IPH). Portal thrombosis was present in five (25.0%) of the 20 patients with IPH and in two (1.8%) of the 106 patients with cirrhosis of the liver. As seen on celiac arteriography, the mean (+/- SD) diameter of the trunk of the splenic artery and vein was 8.99 +/- 1.55 and 16.2 +/- 3.6 mm, respectively, in patients with IPH, while it was 7.94 +/- 1.28 and 14.2 +/- 3.1 mm, respectively, in patients with cirrhosis of the liver. Changes in portal venous pressure were 78.4 +/- 59.4 mm H2O in patients with IPH and 43.5 +/- 38.7 mm H2O in patients with cirrhosis of the liver. There were no significant differences in the maximum level of thrombocytes in patients with IPH or in those patients with cirrhosis of the liver. These events suggest that portal thrombosis can occur with a significantly higher incidence in patients with IPH than in those patients with cirrhosis of the liver after splenectomy, and a decrease in blood flow in the portal vein may be closely linked to the formation of portal thrombosis after splenectomy in patients with IPH. Preoperative examination of portal hemodynamics must be thorough.

Sulfadimethoxine residue in broiler-chicken skin

The disposition and elimination of sulfadimethoxine (SDMX) in the skin of broiler-chickens were investigated. The administration of SDMX, in drinking water, at a concentration of 1,000 ppm for 5 days demonstrated that the SDMX was eliminated much more slowly from the skin than from the other tissues or plasma. These results were duplicated and confirmed in another experiment, in which a single dose of 200 mg/kg BW of SDMX was administered via a stomach tube. No significant difference in the SDMX residue level was observed between the broiler-chickens that had their skin surface sealed versus the non-sealed animals and that had ingested SDMX in their drinking water. This illustrated the higher SDMX residue in the skin was not attributable to external SDMX contamination from the drinking water, feces or urine. In addition, there was no significant difference among the SDMX residue concentrations in the thoracic, dorsal and leg skin samples, following an intravenous injection of SDMX (30 mg/kg BW). This indicated that the SDMX was distributed evenly throughout the entire skin area of the broiler-chickens.

A rat model of esophageal varices

We have developed a new method for inducing portal hypertension and esophageal varices in rats--partial ligation of the portal vein after devascularization of the circumference of the left renal vein and complete ligation of the portal vein on the fifth day thereafter. Thirty rats were separated into groups of 10, control (sham operation), complete portal ligation only and complete portal ligation plus devascularization. Two weeks after the surgery, the presence of esophageal varices in rats with complete portal ligation plus devascularization was confirmed by portography and by the histological findings. The diameter (mean +/- SD) of the submucosal veins of the lower esophagus in the complete portal ligation plus devascularization group (219.4 +/- 86.6 microns) was significantly larger than that in the complete portal ligation group (99.8 +/- 53.4 microns) or in the control group (30.5 +/- 16.6 microns) (p less than 0.01). Vascular structures of the lower esophagus closely resembled those in humans with esophageal varices. This new technique is simple, rapid and reliable, and application can be made to various experimental studies on portal hypertension.

Platelet aggregability and prostacyclin/thromboxane A2 ratio after endoscopic injection sclerotherapy with different sclerosants

Platelet aggregability and coagulative and fibrinolytic systems were analyzed with regard to positive effects and for side effects of 5% ethanolamine oleate (EO) versus 5% sodium morrhuate (SM) used for endoscopic injection sclerotherapy (EIS). Twelve patients each were treated with each sclerosant. There was a temporary activation of coagulative and fibrinolytic systems within 1 h in both groups. Platelet aggregability was significantly suppressed to 78.6 +/- 8.9% of that before EIS in the EO group, but was activated to 110.0 +/- 10.5% in the SM group at 1 h after EIS. The ratio of concentrations of prostacyclin (PGI2) to thromboxane A2 (TXA2) increased in the EO group and decreased in the SM group after EIS. The clinical effect in the SM group after the initial session was weaker than that in the EO group with regard to endoscopic findings at the second session. As change in platelet aggregability after EIS is apparently induced by alterations in the ratio of PGI2/TXA2, there would be related effects concerning the sclerosants.

Successful treatment of Budd-Chiari syndrome with early gastric cancer

In a patient with Budd-Chiari syndrome associated with early gastric cancer, the membranous obstruction of the inferior vena cava was removed by Percutaneus Transluminal Angioplasty (PTA) without any complication. Due to continuous poor clinical status and hepato-renal dysfunction, her early cancer stomach lesion was treated with Nd: YAG laser. In follow-up biopsies, malignant change became evident three months after laser therapy. By that time hepatorenal function gradually improved, and a partial gastrectomy was performed successfully. PTA is a safe and effective procedure for clinical management of Budd-Chiari syndrome, and when there is concomitant early stage malignancy, PTA followed by laser therapy paves the way for major surgery.

Hypercoagulopathy after repeated injection of 5% ethanolamine oleate to sclerose esophageal varices

Hematological and coagulating parameters were examined in 53 patients in an attempt to find possible evidence of disseminated intravascular coagulation after intravascular injection of 5% ethanolamine oleate to sclerose esophageal varices. FDP-E in the peripheral blood measured by latex photometric immunoassay significantly increased from 111.2 +/- 112.9 to 234.2 +/- 178.3 ng/ml and 370.4 +/- 189.5 ng/ml one hour after the first and second sessions of sclerotherapy, respectively (p less than 0.01). The other parameters showed no significant change, except on the first day after sclerotherapy. The increase of FDP-E was closely related to fibrinopeptide A (r = 0.689, p less than 0.01) and fibrinogen (r = 0.585, p less than 0.05), before the sclerotherapy. As repeated intravariceal sclerotherapy over short time intervals can lead to a deterioration of the coagulating system, especially in patients with abnormal preoperative coagulopathy, latex photometric immunoassay for FDP-E is a rapid and useful method of monitoring alterations in the coagulating system.

Eradication of oesophageal varices recurring after portal non-decompressive surgery by injection sclerotherapy

The results of injection sclerotherapy for oesophageal varices which recurred after portal non-decompressive surgery were analysed retrospectively to evaluate its efficacy. We treated 60 consecutive patients with portal hypertension; 19 were treated on an emergency basis, seven electively and 34 on a prophylactic basis. All acute bleeding was controlled with one session of sclerotherapy using a transparent overtube. After eradication by sclerotherapy, no bleeding episodes occurred and there was no recurrence of the varices, except in three uncompliant patients, during a mean follow-up period of 33.1 months. Bleeding from a gastric ulcer and gastritis occurred in one patient each. Oesophageal stenosis occurred in nine (15 per cent) patients and gastric varices developed in two (3 per cent) patients. Twelve patients died, five from liver failure and six with hepatoma, but there was no bleeding from the gastrointestinal tract. The overall 4-year survival rate was 80 per cent. We recommend the use of sclerotherapy as the primary treatment for recurrent oesophageal varices.

[Clinical study on the inhibitory effect of AA-2414 on platelet function in asthmatic patients]

We studied the effect of AA-2414, a TXA2 receptor antagonist, on platelet function in 12 asthmatic patients, 6 males and 6 females, whose mean age was 43.6 years. AA-2414 was orally administered to each patient at 20 mg/day for two weeks and then at 40 mg/day for the following two weeks. Platelet aggregation, plasma concentration of TXB2, and serum concentrations of AA-2414 and its metabolites were measured before and after the administration of each dose. Platelet aggregation induced by U-46619 (an analogue of PGH2), STA2 (a stable analogue of TXA2) and arachidonic acid with the administration of AA-2414 was significantly inhibited. The degree of this inhibition was proportional to the serum level of the drug. Plasma concentration of TXA2 tended to be lowered by administration of AA-2414, but it was not statistically significant. Eight (75.0%) of the 12 patients showed clinical improvement. In the cases where the drug was ineffective, the inhibition of platelet aggregation after administration of AA-2414 was less than in those cases where it was effective. We conclude that AA-2414 might exert its antiplatelet and antiasthmatic effects through antagonism of the TXA2 receptor. Investigation of the response to AA-2414 may be useful in assessing the clinical effect of this compound.

Endoscopic classification of gastric varices

Endoscopic observations of gastric varices in 124 patients were classified according to form, location, and color. Form was classified into three types: tortuous (F1), nodular (F2), and tumorous (F3). Location was classified into five types: anterior (La), posterior (Lp), lesser (Ll) and greater curvature (Lg) of the cardia, and fundic area (Lf). Color was white (Cw) or red (Cr). Glossy, thin-walled focal redness on the varix was defined as red color spot (RC spot). Stepwise logistic regression analysis for multivariate adjustments was performed for all of the endoscopic covariates, and four risk factors (La, Lg, F2, RC spot) that affect bleeding from gastric varices were independently identified. This classification should aid in assessing gastric varices observed by fiberoptic endoscopy and help design appropriate treatment.

Hemodynamic and morphological changes in the dog kidney after injection of 5% ethanolamine oleate into the superior vena cava

The effect of the sclerosant 5% ethanolamine oleate (EO) on renal circulation was evaluated in 20 mongrel dogs into which we injected 5% EO (0.5 ml/kg) into the superior vena cava. There was a marked hemolysis and a significant decrease in creatinine clearance from 104.4 +/- 17.1 (mean +/- SD) to 40.7 +/- 5.0 ml/min (p less than 0.01) at 120 min. The renal arterial blood flow (RAF) decreased biphasically; from 75.3 +/- 13.1 to 9.8 +/- 9.3 ml/min during an average of 2.3 min, immediately after the injection (p less than 0.01) and gradually decreased after reaching the pretreatment level to 43.2 +/- 8.6 ml/min at 120 min (p less than 0.01). Cardiac output significantly decreased from 1.86 +/- 0.08 to 1.54 +/- 0.08 l/min (p less than 0.01). Tubular necrosis was histologically evidenced in the tissues examined at 6 h after the injection of EO. Biphasic decrease in renal arterial blood flow can be explained by the possible occurrence of spasm of the peripheral renal arteries in the acute phase and tubular necrosis in the late phase. This study suggests to us that the tubular necrosis induced by decreases in RAF as well as hemolytic nephropathy play a significant role in cases of renal dysfunction following the endoscopic injection of 5% EO to sclerose esophageal varices.

A prospective randomized trial of schedules for sclerosing esophageal varices. 1-versus 2-week intervals

A prospective randomized trial was performed to compare the efficacy and complications of 1-week (20 patients) and 2-week (20 patients) interval schedules of endoscopic injection sclerotherapy for patients with esophageal varices; 6 were acute, 3 were elective and 31 were prophylactic cases. There were no significant differences between the 1-week and 2-week interval groups with regard to total number of sclerotherapy sessions, total volume of the sclerosant used (5% ethanolamine oleate) or rate of complications such as pyrexia, stricture and pleural effusion. The incidence of ulcer and/or slough formation after EIS was the same in the two groups. Neither early nor recurrent bleeding occurred in any patient in the two groups. Eradication of varices in the 2-week interval group was achieved significantly earlier (p less than 0.05) than in the 1-week interval group.

Platelet aggregability after endoscopic intravariceal injection of 5 per cent ethanolamine oleate into oesophageal varices

Platelet aggregability and the coagulative and fibrinolytic systems were examined in 45 patients who underwent endoscopic injection sclerotherapy for oesophageal varices. Five per cent ethanolamine oleate, the sclerosant used, was injected into the oesophageal varices. There were significant increases in the concentrations of fibrinopeptide A, fibrinopeptide B-beta-15-42 and fibrin degradation products-E after the sclero-therapy. At 1 h after the sclerotherapy the mean(s.e.m.) platelet aggregation was significantly suppressed to 71.9(4.2) per cent of that before the treatment (P less than 0.01). There was a gradual recovery within 1 week to the same level seen before the sclerotherapy. Thromboxane B2 and 6-keto-prostaglandin F1 alpha, both stable products of thromboxane A2 and prostacyclin respectively, showed significant temporary increases after the sclerotherapy (P less than 0.01). The peak increase in the level of thromboxane B2 was noted within 1 h after the sclerotherapy and earlier than that for 6-keto-prostaglandin F1 alpha. This increased ratio of prostacyclin and thromboxane A2 may be related to the marked limitation in platelet aggregation.

Angioarchitectural classification of esophageal varices and paraesophageal veins in selective left gastric venography

An improved radiographic classification of esophageal varices and paraesophageal veins was devised. Esophageal varices were divided into palisading and bar types. Paraesophageal veins were divided into intra-abdominal and thoracoabdominal types, with the latter being further subdivided into right-side-predominant and left-side-predominant types. The existence of the thoracoabdominal paraesophageal veins was significantly related to the preoperative endoscopic findings of the red sign and the form of the esophageal varices. Left-side-predominant paraesophageal veins were likely to drain the splanchnic blood flow to the hemiazygos vein. The largest grade of red sign was found in 88.9% of the patients with combination of bar type and intra-abdominal type and the largest form was in 88.9% of those with palisading and right-side thoracoabdominal types. The pressure gradients across the shunt were significantly lower in the right thoracoabdominal type than in others. Our study suggests that treatment be designed according to the vascular patterns of the lower esophagus.

Human thrombin plus 5 per cent ethanolamine oleate injected to sclerose oesophageal varices: a prospective randomized trial

Fifty cirrhotic Japanese patients with oesophageal varices underwent sclerotherapy in a prospective randomized trial carried out to examine the effects of human thrombin given concomitantly with the sclerosant 5 per cent ethanolamine oleate. The two groups (25 patients each) were comparable with regard to size of the oesophageal varices, and the aetiology and severity of the liver disease. Twenty-five patients, 13 and 12 in the thrombin + and - groups, respectively, had at least one episode of variceal bleeding. The remaining 25 were given prophylactic injections. There was a significantly lower rate of occurrence of bleeding from injection sites when the injection needle was removed at the initial session of sclerotherapy in the thrombin + group, where human thrombin was injected (0.2-0.3 ml, 100-150 units per injection) just before removal of the injection needle. Endoscopy at 1 week after the initial session showed a significantly (P less than 0.05) higher rate of disappearance of red colour signs on varices in the thrombin + group (96 per cent) than in the thrombin - group (72 per cent). Fibrin degradation product E-fraction (FDP-E) values increased 1 h, 1 day and 6 days after the initial session of sclerotherapy in the two groups. The rate of increase in FDP-E values 1 h after sclerotherapy was significantly larger (P less than 0.001) in the thrombin + than in the thrombin - group. There was no clinical sign of disseminated intravascular coagulation. Administration of human thrombin plus a sclerosant seems to be useful and efficacious, especially for patients with huge oesophageal varices.

Sclerotherapy superior to surgery for longer survival and less rebleeding in 103 cirrhotics with variceal bleeding

In the ten years period from 1976-1986, 103 cirrhotic Japanese with acute variceal bleeding underwent either surgical treatment (48) or endoscopic injection sclerotherapy (55) at Kyushu University Hospital. We retrospectively analysed the clinical records of these patients. The two groups were comparable with regard to clinical condition and liver function, except for the higher rate of Child's C patients in the sclerotherapy group than in the surgical group (29 vs. 16; P less than 0.05). Control of variceal bleeding was attained in all of the 48 surgical patients and in 54 (98.2%) of the 55 sclerotherapy patients. Bleeding recurred in five (10.4%) of the surgical group and in one (1.8%) of the sclerotherapy group, resulting in four and one deaths, respectively, during the hospital stay. Mortality rates at 30 days and six months were 16.7% (8/48), 43.8% (21/48) in the surgical group, and 9.1% (5/55), 14.5% (8/55) in the sclerotherapy group. The five-year cumulative survival rate was significantly higher (P less than 0.01) in the sclerotherapy group (53.3%) than in the surgical group (29.4%). Therefore, in our patients sclerotherapy led to a longer survival with fewer rebleedings, as compared to other patients who underwent conventional surgical treatment.

The effects on central dopamine function of chronic L-dopa (methyl ester hydrochloride) treatment of mice

Mice were treated for 28 days with drinking water containing L-DOPA methyl ester hydrochloride (DME) plus carbidopa, carbidopa alone, or with the vehicle. All mice were then given the vehicle for 1 day and behavioural and biochemical assessments made on the 29th day. On average, mice consumed between 181 and 302 mg/kg of DME (expressed as the base) each day. In behavioural experiments DME- and carbidopa-treated mice were subsensitive to the locomotor stimulating effects of apomorphine, after their pretreatment with reserpine plus alpha-methyl-p-tyrosine to remove endogenous stores of dopamine and to stop its synthesis. Even mice pretreated for only one day with chronic DME or carbidopa displayed some subsensitivity to apomorphine challenge, but the effect was more marked the longer the chronic treatment. Other mice were chronically treated for 28 days with alpha-methylDOPA or vehicle, and these mice when challenged with apomorphine after dopamine depletion (as described above), were also markedly subsensitive to the locomotor activating effects of apomorphine. There were no changes in sensitivity of drug-treated mice to the hypothermic effects of apomorphine, to the stereotypy-inducing effects of apomorphine or d-amphetamine, or to the locomotor activating effects of L-DOPA itself or to bromocriptine. There were, however, some changes in the basal grooming behaviour of both DME- and carbidopa-treated mice, and in their response to SKF38393 challenge. Striatal binding studies with [3H]-spiperone and [3H]-SCH23390 indicated that there were no marked changes in Kd or Bmax of either D-1 or D-2 receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of chronic renal hemodialysis and intracranial hypertension--a study on CSF dynamics]

There are many reports on the disequilibrium syndrome due to dialysis in patients with chronic renal failure. However, they do not mention the findings of CT cisternography and MRI. We intend to investigate the mechanism of CSF dynamics in a patient with disequilibrium syndrome by means of these radiological examinations. A 31 year-old woman who had suffered from renal failure for 18 years was found to have prominent increase of serum creatinine (18.1 mg/dl) and BUN (127 mg/dl) 3 years ago. At that time, digital marking of the skull was already present by X-ray examination without other destruction in bone survey of the whole body. She was hemodialysed by the hollow fiber kidney three times weekly (dialysis time 4.5 hours, dialysate osmotic pressure 270 mOsm/kg H2O). Three months ago, she began to complain of severe headache, nausea and vomiting 2 hours after the beginning of dialysis, so that she was referred to Kosei Hospital. On admission, she showed exophthalmus, concentric narrowing of the visual field, optic atrophy and hyperreflexia in jaw and four extremities. After admission, she received hemodialysis therapy thrice weekly (dialysis time 5 hours, dialysate osmotic pressure 290 mOsm/kg H2O). At the same time, 200 ml of glycerol (contents of glycerin 10, fructose 5, NaCl 0.9%) was administered intravenously during dialysis, which ameliorated the symptoms of intracranial hypertension. Laboratory studies revealed marked decrease of serum creatinine, BUN and uric acid levels and osmotic pressure, and increase of blood pH at the time of postdialysis compared with predialysis. Manometric CSF pressure increased up to 310 mmH2O at the day without dialysis before the glycerol administration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diabetic ophthalmoplegia--a clinico-pathological study of the first case in Japan]

Many reports of diabetic ophthalmoplegia have been published from the clinical points of view. However, there have been only three autopsied cases in which the ocular nerves were investigated histopathologically. A 72-year-old housewife was diagnosed to have glycosuria at the age of 67, but no medical treatment was done. She admitted to the hospital, because of acute onset of right eyelid drooping and diplopia for previous four days. She showed complete eyelid ptosis, moderate dilatation of right pupil, loss of light reaction, and extraocular muscle palsy except abduction on the right. Blood pressure was normal. A glucose tolerance test was diabetic and HbA1c was moderately increased. Her diabetes was fairly well-controlled with a diet therapy and injection of lente insulin. Two and a half months after admission, the course of illness became regressive. Seven months later, external ophthalmoplegia was disappeared and only slight anisocoria was seen. She readmitted to the hospital one year and eleven months later, because of anorexia and emaciation. She died of adenocarcinoma of the stomach without chemotherapy. The duration from onset of ocular symptoms to death was two years and one month. At postmortem examination, stomach cancer infiltrated extensively to the abdominal and pelvic viscera, but no metastasis to the nervous system or intraorbital tissues was found. There were mild to moderate atherosclerotic changes in the small-and middle-sized arteries of the kidneys, pancreas and adrenal glands corresponding to her age. Moderate atherosclerosis was found in all of the major arteries including Willis ring, siphon of the right internal carotid artery and Vertebro-basilar one.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphological and hemodynamic changes of the lung after injection of 5% ethanolamine oleate into dogs

We examined the pulmonary hemodynamics and morphology after injection of a sclerosing solution of 5% ethanolamine oleate (EO) into 24 normal dogs. EO of 0.5 ml/kg (n = 5), 1.0 ml/kg (n = 6), and 3.0 ml/kg (n = 7) was injected through the jugular vein into the right atrium for pathological examination and gravimetric study of the lung, while monitoring the pulmonary hemodynamics for 12 h. Normal saline of 3.0 ml/kg was injected into the remaining 6 control dogs, using the same method. Cardiac output significantly decreased immediately after injection of the sclerosant in all dogs given 0.5 ml/kg, 1.0 ml/kg and 3.0 ml/kg injections of EO; however, there was a tendency toward recovery from 6 h after injection in dogs given 0.5 ml/kg and from 9 h in dogs given 1.0 ml/kg. Pulmonary hypertension just after injection and hypoxia at 9-12 h occurred only when 3.0 ml/kg was injected. Irreversible pulmonary hemorrhage was present in the excised lungs in 4 of 7 dogs given 3.0 ml/kg, while there were no significant lesions in the other dogs. The lung water content in cases of 1.0 and 3.0 ml/kg injections was significantly higher than that in the controls, while there was no significant difference between those given 0.5 ml/kg and of the controls. The findings obtained in this study suggest that EO less than 0.5 ml/kg used for sclerosing esophageal varices seems to have little untoward influence on pulmonary hemodynamics and morphology.