Excessive loss of plasma protein into the gastrointestinal tract associated with primary myocardial disease

Abstract

The investigation of albumin metabolism in a seventy-nine year old man with primary myocardial disease associated with intractable edema and severe hypoalbuminemia showed that the diminution of plasma albumin was due to both an increase in plasma volume and a diminution in total exchangeable albumin. The synthesis of albumin was accelerated but its catabolism was markedly increased due to the loss of albumin into the gastrointestinal tract. Peroral biopsy of the jejunum showed slight edema of the villi, dilatation of the capillaries and moderate enlargement of the lymphatics of the lamina propria. The thoracic duct, internal jugular vein and subclavian vein were exposed under local anesthesia and it was found that the duct and its tributaries in the neck were markedly dilated and blood refluxed freely into the duct with each systolic venous pulsation. The pressure in the unopened duct was raised and lymph flowed from the cannulated duct at four times the normal rate. It is suggested that several factors are involved in the plasma protein loss that occurs in certain patients with congestive heart failure, namely, raised venous pressure with increased passage of plasma albumin into the interstitial fluid of the villi, impaired lymph drainage of the gastrointestinal mucosa due to impaired lymph flow in the thoracic duct and, in some cases, lymphangiectasia.