Control Of Gastrointestinal Bleeding Research Articles

Blastomycosis Diagnosed by EUS-FNA: An Unsual Modality of Diagnosis

Endoscopic ultrasound (EUS) has an essential role in diagnosis and staging of gastrointestinal and pancreatic malignancies. In addition to diagnostic utility, EUS is also valuable in therapeutic purposes such as drainage of pancreatic fluid collections, abscesses and control of gastrointestinal bleeding. We present a 25 year old healthy male with no significant past medical problems who was admitted with inter-scapular back pain and chest pain for several months along with night sweats. Patient also had decreased appetite, dry cough and denied any other associated symptoms. Patient has a 5 year history of smoking cigarettes, up to half pack per day. Physical exam was unremarkable. Laboratory work up revealed mild leukocytosis and elevated inflammatory markers with CRP of 12.0 and ESR of 90. CT scan of the chest was significant for a mass posterior to the esophagus, at measuring about 6.7 x 2.5 x 6 cm with anterior displacement of the esophagus. MRI of the cervical and thoracic spine showed a large prevertebral lesion extending into the posterior mediastinum with ventral shift of trachea and the esophagus, from C7-T5, 10.2 x 3.6 x 5.9 cm in size, with diffuse homogeneous enhancement. Esophagogastroduodenoscopy (EGD) revealed a hypoechoic ill-defined mass extending 18 cm from the incisors to 25 cm from the incisors with a size of around 30 mm. EUS with fine needle aspiration (FNA) and biopsy (FNB) of the mass revealed acute inflammatory debris with histiocytes and multinucleated giant cells including double refractile yeast forms with broad-based budding, morphologically compatible with Blastomyces. There was no evidence of malignant cells and AFB was negative. Blastomyces antigen and antibody were negative. Patient was started on itraconazole with which clinical improvement. Blastomycosis occurs from fungus Blastomycosis Dermatitis which is transmitted by inhalation of air-borne conidia. Diagnosis is usually by sputum analysis and bronchoalveolar lavage with washings or biopsy of the involved organ is obtained. Amphotericin B and Itraconazole are the drugs of choice in treatment of blastomycosis. Only one other case of pulmonary blastomycosis diagnosed by EUS with FNA has been reported in the literature. EUS can differentiate tissue densities with high accuracy. Thus, EUS-FNA is a not only a very effective tool in diagnosis of mediastinal masses and work up of lymphadenopathy but also in diagnosis of pulmonary infections with atypical presentation.2135_A Figure 1. EUS image of mediastinal mass2135_B Figure 2. Grocott Silver Methenamine stain showing double refractile broad based large fungal yeast forms2135_C Figure 3. H & E of the cell block

Endoscopic Therapy for Variceal Bleeding: from Patient Preparation to Available Techniques and Rescue Therapies

Gastrointestinal variceal bleeding (VB) is a frequent and severe complication in cirrhosis. Despite improvement in the last decades in the management of VB, the 6-week mortality after bleeding still ranges from 10 to 20%. Here, we review an up-to-date in the global management of VB. The endoscopic hemostatic treatment relies on band ligation for esophageal variceal bleeding and tissue adhesive injection for gastric variceal bleeding. In case of refractory bleeding, self-expanding metal stents or balloon tamponade can both be used as bridge to specific treatment. The use of covered TIPS provided a new step in the management of VB in severe patients, so-called “early-TIPS” in the setting of secondary prophylaxis or in all patients with refractory bleeding. The global management of patients with VB should include volume resuscitation, blood transfusion, and prevention of complications such as renal failure+/-sepsis+/-liver encephalopathy, as they drive the prognosis. Therefore, the rapid control of gastrointestinal bleeding and subsequent organ complications should be performed in specific intensive care units.

Should anti-inhibitor coagulant complex and tranexamic acid be used concomitantly?

Inhibitor development in haemophilia patients is challenging especially when undergoing surgical procedures. The development of an inhibitor precludes using factor VIII (FVIII) therapy thereby requiring a bypassing agent (BPA) for surgical bleeding prophylaxis if the FVIII inhibitor titre >5BU. Concomitant use of anti-inhibitor coagulant complex (AICC) and tranexamic acid has been reported in the literature as a beneficial treatment for this population. Anti-inhibitor coagulant complex is known to cause an increase in thrombin generation and tranexamic acid inhibits fibrinolysis. Hence, the combined used of AICC and tranexamic acid has been limited due to safety concerns over possibilities of increased risk of thrombotic events and disseminated intravascular coagulation. However, the rationale for concomitant therapy is to obtain a potential synergistic effect and to increase clot stability. We conducted a literature review of past studies and individual case reports of concomitant use of AICC and tranexamic acid, which was extensively used during dental procedures. Evidence also exists for concomitant use of the combined therapy in orthopaedic procedures, control of gastrointestinal bleeding, epistaxis and cerebral haemorrhages. Some patients who received the combined therapy had failed monotherapy with a single BPA prior to combined therapy. There were no reports of thrombotic complications related to the concomitant therapy and haemostasis was achieved in all cases. Anti-inhibitor coagulant complex and tranexamic acid therapy was found to be safe, well-tolerated and effective therapy in haemophilia patients with inhibitors. Additional randomized controlled studies should be performed to confirm these findings.

Treatment of Pseudoaneurysm of the Ileocolic Artery with Microcoil Embolization in a Post-ileostomy Patient

Pseudoaneurysms arising from branches of the superior mesenteric artery (SMA) are very rare. It is important to recognize and treat a pseudoaneurysm because of the risk of bleeding and even death. Angiography is the standard means for detecting intestinal and mesenteric hemorrhage. Endovascular treatment is a prompt and effective method for control of gastrointestinal hemorrhage. Status post-ileostomy with pseudoaneurysm formation and active bleeding has not been reported in the literature. We present the first case of ileocolic artery pseudoaneurysm post-ileostomy successfully treated by transcatheter arterial microcoil embolization.

Richard F. Edlich, MD, PhDRecipient of Distinguished Alumni Award from the University of Minnesota Medical Alumni Society

On May 20, 2005, Dr. Richard F. Edlich, MD, PhD, was the recipient of the Distinguished Alumni Award from the University of Minnesota Medical Alumni Society. It is the purpose of this report to review his academic contributions, which have resulted in dramatic improvements in healthcare in our nation. Dr. Edlich began his general surgical training at the University of Minnesota under the guidance of his beloved mentor, Dr. Owen H. Wangensteen. During his 8-year surgical residency, Dr. Edlich spent 4 years in Dr. Wangensteen's multidisciplinary research laboratory. This unique research opportunity allowed him to initiate a wide variety of important clinical investigations involving the biology of wound repair and infection, the control of gastrointestinal hemorrhage, as well as the revascularization of the ischemic myocardium. After Dr. Edlich completed his 8-year surgical residency training, Dr. Wangensteen selected a 2-year plastic surgical residency at the University of Virginia Health Sciences Center for Dr. Edlich, which would allow him to complete his plastic surgical training. During his plastic surgical training and subsequent academic career at the University of Virginia, Dr. Edlich modeled his clinical and research training after that of Dr. Owen Wangensteen. Working with gifted scientists, Dr. Edlich championed the development of revolutionary advances in emergency medical care as well as burn care in our nation. He left the University of Virginia Health Sciences Center in 2001 to expand his research interest by participating in a unique multicenter evaluation of surgical products, to accept the special opportunity of being Editor-in-Chief of the Journal of Long-Term Effects of Medical Implants, and to assume a leadership position as Director of Trauma Research, Prevention and Education at Legacy Emanuel Hospital (Portland, Oregon). His academic journey that involves his beloved 2000 students is outlined in this report.

The Beginnings of the Society of Interventional Radiology (SIR, née SCVIR, SCVR)

IT is hard for many of us who were around in the early days of the Society of Cardiovascular Radiology to realize that 30 years have passed since the first organizational meeting at the Massachusetts General Hospital in 1973. The introduction of the percutaneous Seldinger technique represented a major advance in diagnostic imaging. In the very early 1960s, the only way to be trained in percutaneous angiography was to go to Sweden and study at the side of radiologists at Lund or Stockholm or go to Herbert Abrams at Stanford University, Charles Dotter at the University of Oregon, or Kurt Amplatz at the University of Minnesota. All offered fellowships in Cardiovascular/Angiography. The trainees from these fellowships were recruited to various parts of the country, and, slowly, the practice of Cardiovascular/Angiography began to grow. As is true for all fledgling disciplines, there was a need to share experiences, describe some of our complications, and describe new techniques. During the 1960s, all of us immersed catheters in boiling water to give them the right shape, punched the proper number of side holes, and flanged the ends of the catheters so they could be attached to the adapters and injectors. To facilitate the sharing of information, “angio clubs” began to spring up in different parts of the country. On the East coast, we had the Philadelphia, New York, Boston, and Baltimore clubs. The West coast had the Western Angiography Society with members from all the western academic centers. These clubs were also important as a means of educating and alerting each other to the incidence and nature of complications. In the early days, most angiographers performed angiocardiography and selective coronary arteriography in addition to peripheral vascular studies. In 1965, the pharmaceutical company making the most widely used contrast material for selective coronary arteriography decided that the contrast material would be safer if its concentration of sodium was decreased. Those of us performing selective coronary arteriography with use of this new contrast material began noticing a significant increase in the number of procedure-related ventricular fibrillations. This was identified early through the monthly meetings of the angio clubs. The company was notified, the sodium level was brought back to where it was, and the number of ventricular fibrillations decreased. Frank discussions at the angio clubs played a critical role in the early development and acceptance of angiography as a safe diagnostic method. The establishment of the angio clubs fulfilled in part the need for members to share information and to learn from each other. Soon it became obvious that geographic expansion of the citybased angio clubs would be beneficial. Expansion would bring more angiographers together to share the latest advances in the new field. This led to the organization of “regional” meetings. On the East coast, once a year, angiographers from Philadelphia, Baltimore, Boston, and New York gathered in one city on an alternating basis. These regional angio club meetings were wellattended and well-received. Participants found the information and the learning experience extremely valuable. During coffee breaks, comments were often heard and opinions voiced about expanding these meetings beyond cities and regions, possibly to a national level. The seeds for the development of a new national society were planted there and then. The growth of angiography as a diagnostic tool was rapid, and in a very short time angiography was being used to diagnose a large variety of abdominal and thoracic abnormalities. The angiographer was being called on to be available 7 days a week so emergency studies could be performed. The work on catheter control of variceal bleeding and on the angiographic localization and control of gastrointestinal bleeding from arterial sources laid the foundation for the therapeutic applications of angiography for the control of bleeding from the gastrointestinal tract (1–3) and trauma (Fig 1). The specialty rapidly evolved into “interventional radiology” (a term coined by Alex Margulis in his attempt to describe this new field of radiology). Blood flow in vessels could now be increased by placing dilating catheters or expanding baskets across stenotic or occluded vessels and bleeding in the gastrointestinal tract or following trauma could be controlled by means of From the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Address correspondence to S.B., Department of Radiology, 3600 Market Street, Suite 370, Philadelphia, PA 19104; E-mail: baum@oasis.rad.upenn.edu

Endoscopic treatment of upper gastrointestinal tumors

The art and science of gastrointestinal endoscopy will continue to evolve at an amazing pace, with both endoscopists and industry providing new techniques and technologies for us to learn, investigate and apply to the benefit of our patients. It is not difficult to imagine that the next decade may see the maturation of a distinct specialty of gastrointestinal endoscopic surgery, currently in its adolescence, which crosses traditional boundaries. Practitioners will originate from a variety of backgrounds--gastroenterological, surgical or radiological--but must be trained specifically to perform the wide range of endoscopic procedures already in existence and those continually being introduced. Such 'endotherapists' will be an integral part of multidisciplinary units where optimal management strategies are planned based on available scientific evaluation of techniques irrespective of who performs them. Currently, numerous gastroinestinal diseases including both benign and malignant conditions have been managed using only endoscopic measurements. Control of gastrointestinal bleeding (variceal and non-variceal), dilation of benign and malignant strictures, antireflux management for esophagogastric reflux, endoscopic curative resection of premalignant and malignant lesions, treatment of submucosal tumors, percutaneous endoscopic gastrostomy or jejunostomy, stenting for malignant stricture of hollow viscus or pancreaticobiliary diseases, tumor ablation, and removal of biliary or pancreatic duct stones, etc. have been widely performed and various fascinating techniques and instruments have been continuously developed. It would be difficult to handle all of these various treatment modalities in a limited space. In this review we would like to discuss the fields of gastrointestinal tumors.

Control of gastrointestinal hemorrhage in the critical care unit

Gastrointestinal hemorrhage, despite improvements in pharmacology and endoscopic, radiologic, and surgical techniques, remains a diagnostic, therapeutic, and economic challenge to the clinician. There remains 250,000 to 300,000 admissions yearly for gastrointestinal bleeding, and despite endoscopic techniques, which may predict prognosis and shorten hospital stay, the mortality is still 8% to 10% unchanged over the past 3 decades. In the critical care unit, gastrointestinal hemorrhage has an extraordinary mortality.

Endoscopic injection of gelatin solution for severe hemorrhagic gastric cancer

Severe bleeding from end-stage gastric cancer is difficult to manage and often fatal. Surgical resection is one option for hemostasis, but many patients cannot tolerate an operation because of their poor condition. Recent advances in endoscopic treatment have introduced various methods to control gastrointestinal bleeding, including pure ethanol injection, hyperosmotic saline-epinephrine injection, and coagulation with a heat probe or laser irradiation. 1 Asaki S Nishiaki T Iwai S et al. Tissue solidification in coping with digestive tract bleeding-hemostatic effect of local injection of 95% ethanol. Gastroenterolical Endoscopy. 1981; 23: 792-798 Google Scholar , 2 Hirao M Kobayashi T Masuda K et al. Endoscopic local injection of hypertonic saline epinephrine solution to arrest hemorrhage from the upper digestive tract. Gastroenterolical Endoscopy. 1981; 23: 1097-1107 Google Scholar , 3 Matek W Fruhmorgen P Kaduk B et al. Modified electro-coagulation and control of gastrointestinal bleeding. Endoscopy. 1971; 11: 253-258 Crossref Scopus (24) Google Scholar , 4 Kiefhaber P Nath G Moritz K. Endoscopical control of massive gastrointestinal hemorrhage by irradiation with a high-power Nd:YAG laser. Prog Surg. 1977; 15: 140-155 Crossref PubMed Google Scholar Although effective for peptic ulcer bleeding, these endoscopic therapies have not been as effective as initially expected for malignancy.

Gastrointestinal Laser Endoscopy—Future Horizons

The laser, especially the neodymium:yttrium-aluminum-garnet device, has been a dominant influence on the development of gastrointestinal therapeutic endoscopy. More than 2,000 such procedures were performed in the first 5 years of experience with laser endoscopy at the Mayo Clinic. The major areas for future development are (1) the control of acute and chronic gastrointestinal bleeding, (2) the palliation of malignant gastrointestinal neoplasms, and (3) the management of benign and malignant obstructive lesions of the biliary tract. Refinements in laser devices, delivery systems, and techniques such as photodynamic therapy will be needed to achieve more selective tissue destruction. Improvements in the new adjunctive endoscopic methods of electronic (video) endoscopy and ultrasonography may enhance evolving laser applications by more accurately identifying diseased tissues and guiding their destruction.

Animal testing of endoscopic hemostasis with lasers and other devices.

A variety of animal models for testing endoscopic control of gastrointestinal hemorrhage are reviewed. Advantages and disadvantages of each are discussed. New types of mechanical devices for controllable injury are presented, and the efficacy of laser photocoagulators and other recently developed electronic devices on these new lesions is compared.

Anti-fibrinolytic therapy with aminocaproic acid for the control of bleeding in thrombocytopenic patients.

11 courses of EACA were given to 9 acutely ill, severely thrombocytopenic patients (platelet count less than 20 X 10(9)/l). 6 patients were being treated for acute leukaemia while 1 each had cyclical amegakaryocytic thrombocytopenia, dysmyelopoietic syndrome and advanced chronic lymphocytic leukaemia. 8 were refractory to HLA-matched platelets and 1 refused blood product transfusion. All had simultaneous major medical complications such as infection and granulocytopenia. The highest dose of EACA used was 24 mg/d. Improvement in haemostasis was noted in all patients with successful control of epistaxis in 1, control of gastrointestinal bleeding in 3 and lack of significant bleeding for 4-29 d in the remaining 5 patients. The only toxicity was dose-related nausea. Since this patient group was at extremely high risk for haemorrhage, we conclude that EACA is safe and useful in the management of thrombocytopenia including that occurring during leukaemic induction.

Comparative study of the safety and efficacy of liquid and dry monopolar electrocoagulation in experimental canine bleeding ulcers using computerized energy monitoring

The drawbacks of monopolar electrocoagulation in the control of gastrointestinal bleeding include tissue adherence, unpredictable energy deposition, and a high incidence of tissue damage. Introduction of a conductive interfacial film of liquid between the monopolar electrode and the bleeding point during electrocoagulation may overcome these drawbacks. A prospective, controlled study was undertaken to evaluate the efficacy and safety of a monopolar electrode in liquid and dry modes when used to coagulate experimental canine bleeding ulcers. All experiments were done in open fashion via a gastrotomy with hand-held electrodes. An analog computer, which could be connected between a standard electrosurgical generator and the electrode, was designed and built to monitor and control the energy delivered to the tissue. Both liquid and dry electrodes were highly effective in stopping bleeding. The liquid electrode was found to be superior to the dry electrode in that tissue adherence was eliminated and energy deposition was more predictable, varying less with angle of incidence. The liquid electrode caused less macroscopic serosal damage and less full-thickness histologic damage if the total energy or number of pulses was limited; however, both caused microscopic full-thickness damage in one-half of the experimental ulcers treated, although no perforations occurred.

Control of upper gastrointestinal bleeding with a microcrystalline collagen hemostat.

A microcrystalline collagen hemostat (MCH) widely used in general surgery was tested in the control of bleeding from experimentally produced gastric ulcers. Five dogs had a gastrotomy and were given heparin. Using the standard "ulcer maker," three sets of three ulcers were made in the gastric mucosa of each animal. Blood from each ulcer was collected for a 5-min period to allow for stabilization of bleeding. MCH powder or slurry or no MCH was placed directly on one ulcer of each set in random order. The bleeding rate for the next 10 min was measured. Mean decrements in the bleeding rate for slurry MCH and dry MCH-treated ulcers were 87% and 81%, respectively, compared with 51% for controls, P less than 0.05. Twelve MCH-treated ulcers, but no control ulcer, stopped bleeding completely, P less than 0.01. Preliminary observations show that MCH slurry can be applied through an endoscope and may be hemostatically effective in man. MCH may have a role in the endoscopic control of gastrointestinal bleeding.

Selective embolization for control of gastrointestinal hemorrhage

Transcatheter embolization using Gelfoam plugs or autologous clot is an alternative or adjunct to the conventional management of gastrointestinal hemorrhage. During a 12 month period we successfully treated 10 patients who had massive gastrointestinal hemorrhage with selective embolization; 6 patients had upper gastrointestinal hemorrhage and 4 had bleeding from the colon. Most of these patients were critically ill and were poor surgical candidates. Hemorrhage was controlled by selective catheterization of the bleeding vessel, followed by injection of Gelfoam pledgets. Since the procedure was accomplished with ease and prolonged hemostasis obtained, we recommend it for gastrointestinal hemorrhage, especially in patients who are poor surgical risks or are unresponsive to vasopressin infusion, or both. Operative intervention for the primary disease could subsequently be performed electively, if necessary, days or weeks after transcatheter embolization.

Modified Electrocoagulation and Its Possibilities in the Control of Gastrointestinal Bleeding

In acute experiments in the stomach of dogs electrocoagulation with simultaneous instillation of water (EHT-electrode i.e. electro-hydro-thermo-electrode) proved the most effective electrocoagulation method for controlling standardized bleeding: Optimal visibility at the bleeding site, extension of the therapeutic range as well as the avoidance of charring at the bleeding site are its major advantages. Disturbing adhesion of coagulated material on the electrode is also avoided. The electro-hydro-thermo-electrode is a cheap and portable means of controlling bleeding.

Potentiation of Epinephrine-induced mesenteric vasoconstriction with β-blockade

Reduction of splanchnic blood flow and the subsequent lowering of portal venous pressure are important adjuncts in the nonsurgical treatment of upper gastrointestinal hemorrhage from varices. At present, the most widely utilized therapy is intra-arterial infusion of vasopressin; however, as vasopressin becomes increasingly limited in supply this treatment may soon be unavailable to the clinician. Epinephrine is an alternate mesenteric vasoconstrictor which has received successful though limited use in control of gastrointestinal hemorrhage [7]. This report investigates the enhancement of epinephrine-induced splanchnic vasoconstriction with P-blockade by propranolol. The effect of intra-arterial infusion of epinephrine after p-blockade on superior mesenteric artery flow and jejunal submucosal perfusion was studied.

Advantage of intraarterial over intravenous vasopressin infusion in gastrointestinal hemorrhage

Recent laboratory data have suggested equivalent therapeutic value of selective intraarterial or peripheral intravenous infusions of vasopressin in the control of gastrointestinal bleeding. However, recent experience in two clinical cases continues to support a therapeutic advantage of the selective intraarterial route and casts doubt on the applicability of the laboratory results to man. Until further data is accumulated, it is premature to discard the presumed therapeutic advantage of the selective intraarterial infusion of vasopressin.

Clinical experience with selective intra-arterial infusion of vasopressin in the control of gastrointestinal bleeding from arterial sources

Eight patients with massive arterial gastrointestinal hemorrhage whose source of bleeding was demonstrated by selective mesenteric arteriography underwent subselective intra-arterial infusion of vasopressin with complete control of their bleeding. Seven of these eight patients left the hospital without requiring surgery. The eighth patient underwent right colectomy while still in the hospital in order to correct vascular ectasia of the cecum. The technic of this procedure and some of its pitfalls have been described.

Hepatic Coma

Hepatic coma is a treatable condition often in contrast with the underlying hepatic disease. The treatment, to a large extent, rests on known physiologic or biochemical abnormalities. Understanding these altered mechanisms aids in providing rational treatment. The treatment of hepatic coma involves at least the following:o1.Recording and graphing, when appropriate, a large number of observations and measurements so that the physician may learn at a glance the state of consciousness, the functioning of homeostatic mechanisms and the condition of the liver.2.Elimination or treatment, where possible, of all factors which might have precipitated the state. These include: (a) control of gastrointestinal bleeding, (b) attention to fluid and electrolyte balance, (c) avoidance of surgical procedures, (d) prevention and prompt treatment of infection and (e) discontinuance of certain diuretics (ammonium salts, chlorothiazide, acetazolamide).3.Oral administration of an antibiotic; broad-spectrum drugs such as neomycin, kanamycin and paramomycin are preferred, unless uremia is present, at which time chlortetracycline may be given.4.If the patient is in coma, the insertion of a stomach tube for feeding and the administration of an antibiotic.5.Moderate protein feeding during the prodrome or precoma, but elimination of protein if the condition progresses or coma ensues. When protein is climinated, calorie feeding must be continued with partially hydrolyzed starch by tube and glucose parenterally.6.“Cleansing the gastrointestinal tract” if blood or much protein is present or if the patient has been constipated.7.Provision for the intake of vitamins, including folic acid and choline, if food restriction is undertaken.8.Consideration of glutamic acid and arginine therapy.9.Consideration of colectomy or ileosigmoidostomy for patients difficult to control for long periods.10.Continuous attention to the treatment of the basic liver disease and its other complications: gastrointestinal bleeding, ascites and renal failure. Recording and graphing, when appropriate, a large number of observations and measurements so that the physician may learn at a glance the state of consciousness, the functioning of homeostatic mechanisms and the condition of the liver. Elimination or treatment, where possible, of all factors which might have precipitated the state. These include: (a) control of gastrointestinal bleeding, (b) attention to fluid and electrolyte balance, (c) avoidance of surgical procedures, (d) prevention and prompt treatment of infection and (e) discontinuance of certain diuretics (ammonium salts, chlorothiazide, acetazolamide). Oral administration of an antibiotic; broad-spectrum drugs such as neomycin, kanamycin and paramomycin are preferred, unless uremia is present, at which time chlortetracycline may be given. If the patient is in coma, the insertion of a stomach tube for feeding and the administration of an antibiotic. Moderate protein feeding during the prodrome or precoma, but elimination of protein if the condition progresses or coma ensues. When protein is climinated, calorie feeding must be continued with partially hydrolyzed starch by tube and glucose parenterally. “Cleansing the gastrointestinal tract” if blood or much protein is present or if the patient has been constipated. Provision for the intake of vitamins, including folic acid and choline, if food restriction is undertaken. Consideration of glutamic acid and arginine therapy. Consideration of colectomy or ileosigmoidostomy for patients difficult to control for long periods. Continuous attention to the treatment of the basic liver disease and its other complications: gastrointestinal bleeding, ascites and renal failure.