Effect of subcutaneous administration of octreotide on endogenous vasoactive systems and renal function in cirrhotic patients with ascites

Complete Heart Block due to Octreotide Infusion in Patient with Cryptogenic Cirrhosis

A 62-year-old man was admitted to the emergency department (ED) with the complaint of intense hematemesis. He was admitted to intensive care unit because of acute esophageal variceal hemorrhage. He underwent sclerotherapy followed by a slow infusion of intravenous octreotide. Complete heart block occured in the patient during octreotide infusion and infusion was stopped. Temporary pacemaker was placed in the patient's heart. Normal sinus rhythm was observed in the follow up one day later and the pacemaker was removed from patient. He was discharged upon recommendation.

Case report on intravenous octreotide for the treatment of intraoperative vasoplegia following thymoma resection

Octreotide is a somatostatin analog known for its role in the treatment of acute variceal bleeding, enterocutaneous fistula and carcinoid syndrome. The reduction of portal pressure from splanchnic vasoconstriction has been attributed to the inhibition of nitric oxide synthesis, guanylate cyclase and release of glucagon. Octreotide has many therapeutic applications as a result of the ubiquitous nature of somatostatin receptors throughout the body. The effects of octreotide on vascular tone make it potentially useful in the treatment of intraoperative vasoplegia, hypotension with low systemic vascular resistance with preserved cardiac output that is refractory to adrenergic agonists. We present a case in which a patient undergoing thymoma resection developed vasoplegia that was effectively treated with octreotide. We believe that this case illustrates the need for further investigation on the potential efficacy of octreotide as an adjunct for the treatment of vasoplegia and other forms of shock.

A somatostatin analog improves tilt table tolerance by decreasing splanchnic vascular conductance

Splanchnic hemodynamics and tilt table tolerance were assessed after an infusion of placebo or octreotide acetate, a somatostatin analog whose vascular effects are largely confined to the splanchnic circulation. We hypothesized that reductions in splanchnic blood flow (SpBF) and splanchnic vascular conductance (SpVC) would be related to improvements in tilt table tolerance. In randomized, double-blind, crossover trials, hemodynamic variables were collected in 14 women and 16 men during baseline, 70° head-up tilt (HUT), and recovery. A repeated-measures analysis of variance was used to compare changes from baseline with respect to sex and condition. HUT elicited an increase in heart rate and decreases in mean arterial pressure, cardiac index, stroke index, and systemic vascular conductance. Additionally, SpVC and non-SpVC were lower during HUT. Octreotide reduced SpBF and SpVC and increased systemic vascular conductance and non-SpVC. Changes in SpBF and SpVC between supine and HUT were smaller in women (P < 0.05). Tilt table tolerance was increased after administration of octreotide [median tilt time: 15.7 vs. 37.0 min (P < 0.05) and 21.8 vs. 45.0 min (P < 0.05) for women and men, respectively]. A significant relationship existed between change (Δ) in SpBF (placebo-octreotide) and Δtilt time in women (Δtilt time = 2.5-0.0083 ΔSpBF, P < 0.01), but not men (Δtilt time = 3.41-0.0008 ΔSpBF, P = 0.59). In conclusion, administration of octreotide acetate improved tilt table tolerance, which was associated with a decrease in SpVC. In women, but not men, the magnitude of reduction in SpBF was positively associated with improvements in tilt tolerance.

Somatostatin receptor subtype 2-mediated uptake of radiolabelled somatostatin analogues in the human kidney

PURPOSE

Renal irradiation is a dose-limiting factor in peptide receptor radionuclide therapy using radiolabelled somatostatin analogues. This irradiation is mainly caused by reabsorption of radiolabelled peptides in the proximal tubule. In the human kidney, somatostatin receptors are expressed in the vasa recta, tubuli and glomeruli. It is not clear to what extent these receptors contribute to the total kidney radioactivity uptake.

METHODS

Retrospectively, [(111)In-DTPA(0)]octreotide scans of ten selected patients with carcinoids (well-differentiated gastrointestinal endocrine tumour) with liver metastases were evaluated. For each patient, two scans were obtained: one scan was performed without (control) and one during treatment with unlabelled octreotide. Kidney, tumour, spleen and liver uptake was measured in both scans.

RESULTS

The interval between the two scans per patient varied from 50 to 397 days. Octreotide treatment substantially lowered kidney [(111)In-DTPA(0)]octreotide uptake in eight out of ten patients. Kidney uptake in all patients was reduced to 82%+/-15% of control, (p < 0.01). A correlation between kidney uptake and spleen uptake was found (r=0.67, p < 0.05). Serum creatinine was unchanged. Surprisingly, tumour and liver [(111)In-DTPA(0)]octreotide uptake was not significantly influenced by unlabelled octreotide therapy, but spleen uptake was significantly lowered by treatment (30.6% of control, p < 0.002).

CONCLUSION

We conclude that the somatostatin receptor plays a role in the total renal uptake of radiolabelled somatostatin analogues. The long interval between scans might explain the finding that tumour and liver metastasis uptake of [(111)In-DTPA(0)]octreotide was unchanged. Further studies are needed to confirm and eludicate the results of this study.

Systematic review: renal and other clinically relevant outcomes in hepatorenal syndrome trials

BACKGROUND

Although reversal of pretransplant renal dysfunction in hepatorenal syndrome reduces post-transplant complications, the overall impact on morbidity and mortality requires clarification.

AIM

To review trials of pharmacologic interventions in hepatorenal syndrome, with specific assessment of trial quality and study endpoints, including patient survival and renal outcome measures.

METHODS

Literature search and selection was carried out by a single reviewer. Data extraction and quality analysis were carried out by two independent reviewers.

RESULTS

Of 848 identified articles, 36 were eligible for inclusion. Twenty-one were full-text. Only 19% were randomized-controlled trials. About 50% of studies included only Type 1 hepatorenal syndrome patients. Serum creatinine, urine output and urine sodium were the most common renal outcome measures. Only 42% defined a primary renal endpoint. About 88% of articles reported mortality rates.

CONCLUSIONS

Existing literature of pharmacologic agents for use in hepatorenal syndrome is limited by poor study design, including non-randomization, heterogeneous study populations, lack of power, and limited use of clinically relevant outcomes. There is insufficient information in most trials to judge the impact of pharmacologic therapy on mortality or rates of transplantation. The validity of renal outcome measures as surrogate markers of more clinically relevant endpoints has not been established.

Lanreotide on collateral response to endothelin-1 and vasopressin in cirrhotic rats

BACKGROUND

Portosystemic collaterals in cirrhosis are often complicated with hemorrhage. Endothelin-1 (ET-1) and arginine vasopressin (AVP) have been shown to directly constrict collaterals of portal hypertensive rats. Furthermore, octreotide, a long-acting somatostatin analog, enhances ET-1-related collateral vasoconstriction if administered in the perfusate before ET-1 incubation. However, long-term effects of somatostatin analogs on collateral response to ET-1 and AVP remain unclarified. This study investigated the effects of lanreotide (a longer-acting somatostatin analog when compared with octreotide) on the portosystemic collateral vascular reactiveness to ET-1 and AVP in cirrhotic rats.

METHODS

Liver cirrhosis was induced in Sprague-Dawley rats by common bile duct ligation (BDL). On the 33rd day after BDL, rats received 1 intramuscular injection with lanreotide (10 mg/kg) or distilled water. On the 43rd day after BDL, systemic, and portal hemodynamics were evaluated. By an in situ perfusion model, ET-1 (10(-10) - 10(-7) mol/L) and AVP (10(-10) - 3 x 10(-7) mol/L) were applied to assess the collateral responses.

RESULTS

Heart rate, mean arterial pressure, and portal pressure were not modified by lanreotide. Lanreotide pretreatment enhanced collateral vascular response to ET-1 and reached statistical significance at 10(-7) mol/L without inducing changes to AVP.

CONCLUSION

Lanreotide augmented the collateral vascular responsiveness to ET-1 but not to AVP in cirrhotic rats.

The effects of treatment with octreotide, diuretics, or both on portal hemodynamics in nonazotemic cirrhotic patients with ascites

GOALS

To evaluate the effects of diuretic treatment, octreotide, or both on portal hemodynamics in nonazotemic cirrhotic patients with ascites.

BACKGROUND

Diuretics and octreotide have been associated with a decrease in portal pressure in cirrhotic patients, suggested to be mediated by plasma volume depletion and splanchnic vasoconstriction, respectively. However, liver cirrhosis is characterized by activation of the renin-angiotensin-aldosterone axis, which increases hepatic vascular resistance and is augmented or suppressed by diuretics or octreotide, respectively.

STUDY

Twenty nonazotemic cirrhotic patients with ascites were treated with furosemide and spironolactone. Of them, 10 (group 1) discontinued diuretic treatment for 7 days. Thereafter for 5 days, each patient received subcutaneous octreotide, 300 microg twice per day; ten of them (group 2) received the octreotide in addition to their usual diuretic treatment. Portal and systemic hemodynamics with Doppler ultrasound and endogenous vasoactive systems were evaluated while the patients received diuretics (both groups), after discontinuation of diuretics (group 1), and after octreotide administration (both groups).

RESULTS

The withdrawal of diuretics did not alter portal hemodynamics, but it impaired systemic hemodynamics and suppressed the renin-aldosterone axis. The addition of octreotide to diuretic treatment but not octreotide alone improved portal and systemic hemodynamics. In both groups the initiation of octreotide administration suppressed the renin-aldosterone axis and plasma glucagon levels.

CONCLUSIONS

In nonazotemic cirrhotic patients with ascites, the combination of diuretics and octreotide improves systemic hemodynamics and inhibits the diuretic-related component of the activated renin-aldosterone axis, which in turn augments the portal hypotensive effect of diuretic-induced plasma volume depletion.

Intrarenal octreotide treatment prevents sodium retention in liver cirrhotic rats: evidence for direct effects within the thick ascending limb of Henle's loop

We have previously shown that systemic treatment with the somatostatin analog octreotide has marked beneficial effects on renal function in rats with liver cirrhosis induced by common bile duct ligation (CBL; Jonassen TEN, Christensen S, Sørensen AM, Marcussen N, Flyvbjerg A, Andreasen F, and Petersen JS. Hepatology 29: 1387-1395, 1999). In the present study, we tested the hypothesis that octreotide has a direct effect on renal tubular function. Rats (CBL or Sham-CBL) were intrarenally treated with low-dose octreotide in a long-acting release formulation, which had no systemic actions (100 microg/kg body wt as a single dose). Rats receiving low-dose octreotide (sc) were used as controls. The rats were chronically instrumented, and renal function was examined 4 wk after CBL or Sham-CBL. Intrarenal octreotide administration (IROA) prevented sodium retention in CBL rats without changes in renal plasma flow, glomerular filtration rate, or circulating levels of aldosterone and vasopressin. Renal clearance studies revealed that IROA normalized the increased natriuretic efficacy of furosemide found in CBL rats. Furthermore, IROA protected against the development of hypertrophy of the inner stripe of the outer medulla and thereby the increased the volume of thick ascending limb of Henle's loop (TAL) epithelium found in CBL rats. Finally, Western blot analyses of outer medullary homogenates showed increased abundance of the furosemide-sensitive Na-K-2Cl (NKCC2) cotransporter. IROA did not affect the abundance of NCKK2 within the outer medulla. Together with the histological findings, these results indicate that IROA reduces the total number of NKCC2 within the outer medulla. In conclusion, the results indicate a direct intrarenal effect of octreotide on TAL function and morphology in cirrhotic rats.

Octreotide in the treatment of refractory ascites of cirrhosis

Dietary sodium restriction and diuretic treatment have been shown to be effective in the treatment of ascites in the majority of cirrhotic patients. However, approximately 5 to 10% of patients develop refractory ascites, which is defined as ascites that does not respond to intensive diuretic therapy (diuretic-resistant) or ascites that cannot be controlled because the patient develops diuretic-induced complications that prevent the use of an effective diuretic dose (diuretic-intractable). Current therapeutic approaches for refractory ascites include repeated large-volume paracentesis and transjugular intrahepatic portosystemic shunting. In the present report, subcutaneous octreotide treatment improved renal function and hemodynamics and diuretic response in two patients with refractory ascites in line with a marked decrease in renin and aldosterone secretion. We consider that octreotide could be of value in the management of refractory ascites in cirrhotic patients.

Octreotide in liver cirrhosis: a salvage for variceal bleeding can be a gunshot for kidneys

BACKGROUND

The renal effects of octreotide, used for bleeding esophageal varices in cirrhosis, are controversial.

METHODS

Fourteen cirrhotic patients (Child-Pugh; A/B/C: 1/12/1) were enrolled. Plasma nitrite and endothelin (ET) levels, urinary nitrite output, free water clearance (FWC) and fractional excretion of filtered sodium (FENa) were measured and renal Doppler ultrasound was carried out. Octreotide was infused at a rate of 0.75 microg/kg/h for 3 h after a bolus of 0.75 microg/kg body weight. All the parameters were reevaluated during octreotide administration while the patients acted as their own controls.

RESULTS

Octreotide induced significant reductions in urinary nitrite, FENa and FWC. Plasma ET levels increased (baseline: 6.7 pg/ml, octreotide: 8.4 pg/ml), whereas the plasma nitrite level did not change significantly after octreotide infusion. Overall, no significant change in renal resistive index (RRI) could be demonstrated on Doppler after octreotide administration. However, patients with elevated baseline RRI values had significantly more deterioration in FWC and FENa compared with patients with normal RRI in response to octreotide.

CONCLUSION

A marked decrease in FENa, FWC and urinary nitrite output, together with a significant increase in plasma ET level in response to octreotide, may indicate renal dysfunction in cirrhotic patients. This deleterious renal effect of octreotide may be more enhanced in patients with elevated baseline RRI.

Renal effects of treatment with diuretics, octreotide or both, in non-azotemic cirrhotic patients with ascites

BACKGROUND

Diuretic-induced hyperreninaemia is associated with renal dysfunction in cirrhotic patients with ascites, and in turn prevents the use of high doses of diuretics. Furthermore, ample evidence suggests that octreotide can inhibit the activation of the renin-aldosterone axis. The present study investigated the renal effects of the addition of octreotide to furosemide and spironolactone in the treatment of non-azotemic cirrhotic patients with ascites.

METHODS

We studied 20 patients treated with furosemide and spironolactone. Of them, 10 (Group 1) discontinued diuretic treatment for 7 days. Thereafter, for 5 days each patient received subcutaneous octreotide 300 microg b.i.d., in 10 patients (Group 2) in addition to their usual diuretics. We collected data on the patients while they received diuretics (both groups), after discontinuation of diuretics (Group 1), and after octreotide administration (both groups).

RESULTS

We observed a trend to increase creatinine clearance and a significant reduction in plasma active renin and plasma aldosterone after the discontinuation of diuretics. The subsequent introduction of octreotide reduced glomerular filtration rate, although it significantly decreased plasma active renin and plasma aldosterone. In contrast, the addition of octreotide to diuretic treatment significantly increased glomerular filtration rate, urine volume and sodium excretion. The magnitudes of the decreases in plasma-active renin and aldosterone produced by the combination of octreotide and diuretics were similar to those produced by octreotide alone or by the discontinuation of diuretics.

CONCLUSIONS

Octreotide alone does not improve renal function in cirrhotic patients with ascites. On the contrary, adding it to diuretic treatment increases glomerular filtration rate and sodium and water excretion, mainly through the suppression of an activated renin-aldosterone axis.

The effects of chronic treatment with octreotide versus octreotide plus midodrine on systemic hemodynamics and renal hemodynamics and function in nonazotemic cirrhotic patients with ascites

OBJECTIVES

The adrenergic agonist midodrine improved circulatory and renal dysfunction when acutely administered in nonazotemic cirrhotic patients with ascites while its combination with octreotide has recently been proposed as an effective treatment of type 1 hepatorenal syndrome (HRS). However, the effects of octreotide on systemic hemodynamics and renal function in cirrhotic patients are controversial. This study evaluated the effects of chronic treatment with octreotide versus octreotide plus midodrine on systemic hemodynamics and renal hemodynamics, and function in nonazotemic cirrhotic patients with ascites.

METHODS

Twenty-five patients were studied at baseline and 11 days after administration of subcutaneous octreotide 300 mug, b.i.d. alone (n = 12) or together with oral midodrine 7.5 mg, t.i.d. (n = 13).

RESULTS

Octreotide did not improve systemic hemodynamics whereas the addition of midodrine significantly decreased cardiac index (CI) and heart rate (HR), and increased mean arterial pressure (MAP) and systemic vascular resistance (SVR). Octreotide caused a decrease in renal vascular resistance (RVR) and increased renal blood flow (RBF) but significantly reduced glomerular filtration rate. The association of midodrine to octreotide did not modify renal hemodynamics and function as compared to baseline while it caused an almost significant minor increase in RVR and a significant minor decrease in RBF as compared to octreotide alone. Consequently, a significant minor increase in glomerular filtration rate was demonstrated. The plasma values of active renin, aldosterone, and glucagon were significantly reduced in either group.

CONCLUSIONS

Octreotide does not improve systemic hemodynamics in nonazotemic cirrhotic patients with ascites while it impairs renal function. On the other hand, the addition of midodrine can ameliorate the hyperdynamic circulation without inducing renal dysfunction in these patients.

Effect of somatostatin versus octreotide on portal haemodynamics in patients with cirrhosis and portal hypertension

OBJECTIVES

Elevated portal inflow is part of the pathogenesis of portal hypertension in patients with cirrhosis. Vasoactive substances appear to play a primary role in the regulation of portal flow. The aim of this study was to investigate the effects of somatostatin and octreotide on portal pressure and plasma levels of insulin-like growth factor (IGF-1), nitric oxide (NO), endothelin-1 (ET-1) and glucagon (GLU).

METHODS

Portal pressures of 14 cirrhotic patients with portal hypertension who underwent transjugular intrahepatic portosystemic shunt (TIPS) were directly measured via a catheter placed in the portal vein. Portal pressure and IGF-1, NO, ET-1 and GLU plasma levels were determined at baseline, and at 8 h and 24 h after administration of somatostatin or octreotide via portal vein catheter in a randomized, double-blind, cross-over design.

RESULTS

The average decrease in portal pressure after intravenous infusion of somatostatin and octreotide was 9.4 +/- 1.0 cmH2O and 5.0 +/- 1.0 cmH2O, respectively (P < 0.01). Plasma levels of GLU and IGF-1 decreased significantly 8 and 24 h after somatostatin and octreotide infusion (P < 0.05). However, there were no significant decreases in plasma NO or ET-1 levels. There was a significant difference between somatostatin and octreotide groups (P < 0.01).

CONCLUSION

Both somatostatin and octreotide can significantly reduce portal pressure, although somatostatin is more potent than octreotide. The underlying mechanisms may involve inhibition of the secretion of GLU, IGF-1 and other hormones as well as a decrease in hepatic metabolism and portal inflow leading to a reduction in portal pressure.

Octreotide-induced bradycardia and heart block during surgical resection of a carcinoid tumor

Octreotide may be a life-saving treatment in the case of an acute carcinoid crisis, but when given as an i.v. bolus in larger doses, it may cause significant effects on the cardiac conduction system. We describe cardiac conduction impairment observed during octreotide administration in a patient undergoing carcinoid tumor surgery. In this patient, i.v. boluses of 100 microg of octreotide resulted in symptomatic bradycardia, Mobitz type II atrioventricular block, and complete heart block. Perioperative physicians especially need to be aware of these potential effects because they may be more likely to occur during surgery because of the larger doses and boluses that are used to treat acute symptoms secondary to tumor manipulation.

IMPLICATIONS

In some susceptible patients, i.v. bolus administration of octreotide may cause significant bradycardia and cardiac conduction defects. Therefore, when octreotide is administered as a bolus, it may be advisable to give it slowly while monitoring the electrocardiogram.

Octreotide in hepatorenal syndrome: a randomized, double-blind, placebo-controlled, crossover study

The hepatorenal syndrome (HRS) is related to vasoconstriction of the renal cortex induced by systemic hypovolemia that follows splanchnic vasodilatation as the primary event in the cascade of hemodynamic changes associated with portal hypertension. We evaluated the effects of octreotide, a splanchnic vasoconstrictor, on HRS in cirrhotic patients. We compared the effects of octreotide infusion (50 microg/h) to placebo using a randomized, double-blind, cross-over design over 2, 4-day periods. Nineteen patients were included, and 14 patients could complete the 2 phases of the study (group 1: placebo first; n = 8 and group 2: octreotide first; n = 6) The end point of the study was to evaluate improvement in renal function as defined by a 20% decrease in serum creatinine value after a 4-day treatment as compared with baseline. In all the patients, a normal central venous pressure was maintained by daily intravenous administration of 2 units of albumin. The 2 groups were similar with regard to demographic data and liver and kidney function parameters at baseline. Improvement in renal function was observed in 2 patients after the placebo and 1 patient after octreotide infusion in group 1 and in 2 patients after octreotide infusion and 1 patient after placebo in group 2 (P = not significant). In addition, treatment with octreotide infusion did not result in significant changes in creatinine clearance, daily urinary sodium, plasma renin activity, plasma aldosterone and glucagon levels, or renal and mesenteric artery resistance indices as measured by Doppler ultrasonography. In conclusion, the present study demonstrates that, under our experimental conditions, octreotide infusion combined with albumin is not effective for the treatment of HRS in cirrhotic patients.

Clinical management of ascites and its complications

Development of ascites is a poor prognostic sign with a 1 year mortality rate of up to 50%. Cirrhotic patients who develop ascites should therefore be evaluated for liver transplantation. Even though current therapies of ascites are not associated with a survival benefit, the elimination of ascites will improve quality of life and prevent the development of lethal complications such as SBP and HRS. Therapy of ascites should be directed at correcting the pathophysiologic abnormalities that lead to ascites formation, namely sodium retention, reduced effective arterial blood volume, and sinusoidal hypertension.

Bolus somatostatin but not octreotide reduces hepatic sinusoidal pressure by a NO-independent mechanism in chronic liver disease

BACKGROUND

Evidence exists that somatostatin and octreotide might have different effects on hepatic haemodynamics.

AIM

The investigation of the effects of somatostatin and its octapeptide analogue, octreotide, on sinusoidal pressure measured by the wedged hepatic venous pressure in patients with cirrhosis or chronic hepatitis and the correlation with the levels of hepatic vein NO.

METHODS

Patients were randomly assigned to receive an injection of either 250 microg somatostatin (n=14: cirrhosis six, chronic hepatitis eight) or an injection of 125 microg octreotide (n=19: cirrhosis nine, chronic hepatitis 10) during hepatic vein catheterization. Baseline wedged hepatic venous pressure was measured, followed by measurements at 2, 5, 10 and 15 min after the injection of the drug. Nitrites/nitrates of the hepatic vein were measured before the injection and after 15 min.

RESULTS

Both agents showed a similar qualitative but a different quantitative haemodynamic profile. No change in the wedged hepatic venous pressure was observed during the first 2 min after the injection of both drugs. This was followed by a decrease: 18% at 5 min (N.S.), 23% at 10 min (P < 0.01) and 24% at 15 min (P < 0.01) for somatostatin. Octreotide induced a relatively smaller decrease in the wedged hepatic venous pressure: 8% at 5 min (N.S.), 20% at 10 min (P < 0.01) and 16% at 15 min (N.S.). Further analysis of the sub-groups of cirrhotic and chronic hepatitis patients revealed a different effect. In the sub-group of cirrhotic patients, somatostatin caused a maximum decrease of 34% at 15 min post-injection (P < 0.01), but octreotide failed to produce a significant change on the wedged hepatic venous pressure. In contrast, no change was observed in chronic hepatitis patients with either drug. No change in the hepatic vein concentration of NO after treatment was observed with either somatostatin or octreotide. Moreover, no correlation of the levels of NO with the wedged hepatic venous pressure values was found.

CONCLUSIONS

This study shows that somatostatin is more effective than octreotide in acutely reducing the wedged hepatic venous pressure after bolus injection and the observed change is probably mediated by a NO-independent mechanism.

Long-term haemodynamic effects of octreotide on postprandial splanchnic hyperemia in humans: a placebo-controlled echo-doppler study

BACKGROUND

Octreotide is a potent splanchnic hypotensive somatostatin analogue effective in the treatment of acute variceal bleeding.

AIM

To study the effects of octreotide on basal and postprandial splanchnic and systemic haemodynamics, and hormonal changes in humans.

METHODS

Twenty-four healthy volunteers were randomized to receive a liquid meal and either octreotide (OCT, 100 microg bolus) or placebo repeatedly every 4 h for 48 h. Splanchnic (Doppler ultrasound) and systemic haemodynamics (non-invasive cardiac monitoring) were assessed for 2 h on four consecutive days: one control day and after doses 1 (0 h), 7 (24 h) and 13 (48 h).

RESULTS

The maximum postprandial increases in mean blood velocity of the superior mesenteric artery (SMA-Vmean +72%), portal (PBF +52%) and total hepatic blood flow (HBF +50%) observed in the placebo group, were abolished after the first dose of octreotide (SMA-Vmean -23%, P<0.01; PBF -22%, P<0.01; HBF -21%, P<0.01). Postprandial hyperemia was restored at the end of the 48-h study period, but baseline SMA-Vmean (placebo 40+/-12, OCT 29+/-11 cm/s, P<0.05) and PBF (placebo 1200+/-971, OCT 743+/-449 mL/min, P<0.05) remained significantly lower in the octreotide group. The postprandial decrease of systemic vascular resistance and increase of cardiac index were prevented by octreotide for 48 h.

CONCLUSIONS

Repeated 4-hourly bolus injections of octreotide reduce splanchnic blood flow for at least 48 h, but the prevention of food-induced splanchnic hyperemia is short-lasting.

Portal hypertension

Cirrhosis represents the end stage of any chronic liver disease. Two major syndromes result from cirrhosis: portal hypertension and hepatic insufficiency. Additionally, vasodilatation and the hyperdynamic circulation are hemodynamic abnormalities typical of cirrhosis and portal hypertension. Complications of cirrhosis occur as a consequence of a combination of these factors. Gastroesophageal varices result almost solely from portal hypertension, although the hyperdynamic circulation contributes to variceal growth and hemorrhage. Ascites results from sinusoidal hypertension and sodium retention, which is, in turn, secondary to vasodilatation and activation of neurohumoral systems. Hyponatremia and the hepatorenal syndrome result from water retention and renal vasoconstriction, respectively, both of which are also consequences of peripheral vasodilatation. Vasodilatation that occurs in the pulmonary circulation leads to the hepatopulmonary syndrome. Another complication of cirrhosis, portosystemic encephalopathy, is a consequence of both portal hypertension (shunting of blood through portosystemic collaterals) and hepatic insufficiency. This paper reviews the recent advances in the pathophysiology and management of the complications of cirrhosis and portal hypertension.