Changes in lymph vessels and portal veins in the portal tract of patients with idiopathic portal hypertension: a morphometric study

Little is known about the effects of the pathological process associated with idiopathic portal hypertension (IPH) on hepatic lymph vessels or lymph flow. We used morphometric analysis to examine IPH-associated changes in lymph vessels and branches of the portal vein, with use of immunohistochemical staining for alpha smooth muscle actin. We also quantitated these changes using an image analysis system. The study was conducted with use of liver wedge biopsy material from 10 patients with advanced IPH and 10 control samples from patients with gastric carcinoma without liver disease. The number of lymph vessels, identified by a lack of smooth muscle layer in the wall, and the ratio of the total area of these vessels to that of the portal tract were higher in IPH samples than in the control samples, but the ratio of the area of a single lymph vessel to that of the portal tract in IPH samples was not different from control samples. The number of portal vein branches, characterized by hypertrophy of the smooth muscle layer in IPH samples was not different from control samples. The ratio of the total area of these branches to that of the portal tract, and the ratio of a single portal vein branch to that of the portal tract, were lower in IPH samples than in the control samples. Our results suggest that these morphometric changes in IPH may be associated with a reduction in portal blood flow and increased lymph flow, and that the latter may in turn reduce the high portal vein pressure in idiopathic portal hypertension.     

Are diuretics in the treatment of portal hypertension rational?]

When ascites develops in a patient with cirrhosis his probability to survive the following 2 years amounts to 50%. It is determined essentially by the residual functional capacity of the liver. In 80 to 90% of patients ascites due to portal hypertension can be managed by salt restriction and diuretics. Aldosterone-antagonists are more efficient and have fewer side effects than loop diuretics. They may lower portal tension by an additional direct effect on the vasculature. A daily reduction of body weight of 0.5 to 0.75 kg should not be exceeded because (prerenal) renal failure may become a threat. If diuretics are insufficient or when a rapid therapeutic success is needed paracentesis of 4-6.1 is a safe option if intravascular volume is substituted simultaneously. Albumin has proven superior to other plasma expanders (protection of renal function, survival). Only in the few patients whose ascites is intractable by the forementioned measures should alternatives such as peritoneo-, venous or porto-systemic shunts (nowadays mostly by interventional techniques via a transjugular catheter) be evaluated. The only treatment which not only attacks ascites symptomatically but also corrects the underlying disease is liver transplantation.     

Haemodynamic changes in portal hypertension: new insights in the pathogenesis and clinical implications

In man and experimental animals, portal hypertension with portal-venous collaterals, is associated with a hyperdynamic circulation, caused by peripheral vasodilatation, mainly in the splanchnic bed. This peripheral vasodilatation is clinically important, since it is thought to be responsible for the pathogenesis of complications of portal hypertension such as ascites, the hepatorenal syndrome and portal hypertensive gastropathy and colopathy. Many cirrhotic patients may not die primarily because of their hepatic dysfunction, but rather because of the consequences of the circulatory abnormalities which are secondary to the liver disease. Circulating hormonal vasodilators from intestinal origin such as glucagon, insufficiently cleared by the liver, are only partly responsible for these changes. Recent experimental data point to a role for an increased production of the locally acting potent vasodilator nitric oxide in the vascular wall, in the pathogenesis of the hyperdynamic circulation. Furthermore, nitric oxide seems to play an important role in the development of portal-venous collaterals. Modulation of the nitric oxide production might offer therapeutic options for the treatment of portal hypertension and its complications.     

The use of nitroglycerin in integral treatment of hemorrhage with portal hypertension

The pressure in portal vein had lowered by 28.2% in 36 patients with hepatic cirrhosis and portal hypertension influenced by nitroglycerin, applied in the dose 0.43 ml/kg in the course of the day. Under such conditions the central hemodynamics indexes did not change substantially, no hepatic functional state occurred. Nitroglycerin application in complex of therapy showed its efficacy in 32 patients.     

Transposition of the spleen in rats with portal hypertension

Portal hypertension was induced in rats by progressive occlusion of the portal vein or by dimethylnitrosamine (DMNA) cirrhosis. Portasystemic venous connections did not develop in relation to the spleen when this organ was intraperitoneal, but after subcutaneous transposition most of the collaterals were parasplenic and the portal venous pressure fell.     

Surgical treatment of Peyronie's disease: a new approach

We treated 12 patients with intractable Peyronie's disease with a new approach based on simple incision of the fibrotic plaque(s) and stenting of the corpora with penile implants. Infection in 1 case necessitated removal of the prostheses, while the remaining 11 patients had satisfactory functional and anatomical results. The procedure is indicated for patients with 1) Peyronie's disease and impotency, 2) normal potency and extensive disease and 3) normal potency and localized disease in selective cases. In this series insertion of the penile prostheses did not change sexual prowess in previously potent patients.     

Remission induction after pentoxifylline treatment in a patient with rheumatoid arthritis

Pentoxifylline (POF) has been shown to have anti-inflammatory and immunomodulatory effects. including suppression of TNF-alpha production by activated macrophages, Th-1 response of T cells, and fibroblasts' proliferation and metalloproteinase production. Pentoxifylline was also reported to possess therapeutic properties in 50% of severe refractory RA in an open study. We experienced a 64 year-old man with seronegative RA, stage 2, class 3. He showed 23 swollen joints, 32 painful joints, ADL score 37/40, and ESR 135 mm/h. All these parameters were dramatically improved 3 weeks after administration of POF 300 mg/d and prednisolone 5 mg/d. Discontinuation of POF resulted in rapid exacerbation of RA. POF was restarted and the patient showed complete recovery from arthritis with normalization of ESR within 3 months and was maintained a complete remission for another 1 year. This case further supports a potential antirheumatic effect of POF on some patients with RA.     

Percutaneous treatment of a congenital splenic cyst with alcohol: a new therapeutic approach

Percutaneous treatment of a huge congenital splenic cyst in a 23-year-old man is presented. The cyst had been catheterized and drained two times within a 3-month period without injecting any sclerosing agent into the cavity. On the third attempt, catheter drainage and injection of alcohol into the cyst cavity were performed because of insufficient response to drainage alone. He was discharged symptom-free after the procedure. The cyst diminished in size considerably 9 months after the treatment with alcohol. The volume of the cyst was reduced from 5200 to 8 ml. Although percutaneous treatment of a congenital splenic cyst with tetracyclin has been reported, to our knowledge this is the first case of a congenital splenic cyst treated with alcohol as a sclerosing agent. Percutaneous treatment of splenic cyst can obviate the need for partial or total splenectomy and may be an alternative to surgical treatment.     

Surgical treatment of portal hypertension with ascites using ileovesicopexy under experimental conditions

Experiments conducted with albino rats have evidenced that under the effect of an atherogenic ration the level of lipids and cholesterol in the blood plasma and hepatic tissue and of sillac acids in the blood plasma increased. In the aortic intima the content of acid mucopolysaccharides was rising, this being attended by a concurrent swelling of the main interstitial substance and of the collagen fibers in the subendothelial layer. An addition of apple pectin or of cellulose to the atherogenic ration deferred the development of the mentioned changes.     

Long-term treatment of bleeding caused by portal hypertension in children

We have compared the hypnotic requirements for i.v. thiopentone alone and in combination with i.m. lignocaine or bupivacaine. Ninety women, ASA I-II, undergoing minor gynaecological surgery were allocated randomly to nine groups of 10 patients to receive thiopentone combined with i.m. lignocaine, bupivacaine or saline, respectively. Thiopentone was administered in bolus doses of 0.5 mg kg-1 every 30 s until loss of response to verbal command. Lignocaine and bupivacaine significantly enhanced the hypnotic effect of thiopentone in a dose-dependent manner. The maximum doses tested (lignocaine 3.0 mg kg-1 and bupivacaine 1.0 mg kg-1) reduced the hypnotic dose of thiopentone by 39% and 48%, respectively. We conclude that if lignocaine or bupivacaine are injected into soft tissue before induction of anaesthesia by thiopentone, the i.v. dose of the latter should be modified accordingly.     

An approach to the treatment of essential hypertension

The efficacy and side effects of the combined administration of propranolol and phenoxybenzamine were examined in 19 patients with moderate and moderately severe essential hypertension. By titrating the dosage of both drugs against pulse rate and blood pressure response, propranolol was given between 80 and 160 mg. and phenoxybenzamine between 20 and 50 mg. per day in divided doses. There was a substantial reduction in both systolic and diastolic blood pressure in both recumbent and upright positions without orthostatic hypotension. Normal blood pressure (140/90 mm. Hg or less) or near normal (150/100 mm. Hg or less) was attained in 14 of the patients in the recumbent and 17 in the upright position. Pulse rate also decreased significantly, whereas body weight increased but not significantly so. Except for a reduction of ejaculation in three out of six male subjects, no symptomatic side effects were detected, and no changes in the liver or renal function or in blood count were observed. Despite the short duration of therapy, 3 to 10 weeks, this study clearly demonstrates that propranolol and phenoxybenzamine given together in individualized doses are very effective in lowering arterial blood pressure with minimal side effects.     

Effects on gastric circulation of treatment for portal hypertension in cirrhosis

We evaluated the gastric circulatory effects of the type of treatment administered for portal hypertension. Of 14 patients with cirrhosis, seven received a transjugular intrahepatic portosystemic shunt (TIPS; group T) and seven received percutaneous transhepatic portographic embolization (PTPE; group P). Patients were evaluated over the course of one year. After treatment, portal venous pressure was significantly reduced from 39 +/- 6 cm H2O to 32 +/- 5 (P < 0.001) in group T and was significantly elevated from 29 +/- 10 to 33 +/- 8 (P < 0.05) in group P. The portal flow velocity (Vmean) was significantly higher in group T vs group P (P < 0.0001). The congestion index was significantly lower in group T than in group P (P < 0.0001). The gastric mucosal blood flow was increased in group T but was unchanged in group P. Esophageal varices showed some improvement in both groups, but the portal hypertensive gastropathy was improved only in group T. These findings help to explain the differing effects on the gastric circulation related to the type of treatment used for portal hypertension.