Hemodynamics In Cirrhotic Patients Research Articles

Effect of direct-acting antiviral drugs on portal circulation hemodynamics in cirrhotic patients infected with HCV

BackgroundLiver cirrhosis (LC) is the most common cause of portal hypertension. In chronic hepatitis C patients who are treated with direct-acting antiviral therapy (DAAS), the progression of cirrhosis can be reversed with treatment. Portal hypertension is also expected to improve with a virological response.AimTo evaluate the effect of direct-acting antiviral therapy on portal circulation hemodynamics in cirrhotic patients infected with HCV.MethodsThis study included 78 consecutive patients with chronic HCV-related liver disease. They were treated by a sofosbuvir-based regimen in combination with daclatasavir. All patients were subjected to routine investigations (complete blood count, liver and renal function tests), hepatitis B surface antigen, α feto protein, PCR of HCV RNA, imaging (abdominal ultrasound and colored Doppler and duplex examination for the assessment portal hypertension) before starting treatment and after 1 year.ResultsThere was a significant improvement in Doppler parameters such as portal vein (PV) diameter, PV velocity, PV cross-sectional area, portal congestive index, splenic vein diameter, and spleen span; the decrease in portal pressure occur in about 55% of the patients; several factors are associated with non-response as a history of bilharziasis, patients from a rural area, presence of splenomegaly and varices, low HB level, low platelet count, and high level of fibrosis.ConclusionSustained virological response to direct-acting antiviral therapy is associated with a reduction in portal pressure in patients with liver cirrhosis and clinically significant portal hypertension.

Analysis of Ultrasound as a Predictor of Renal Impairment in Patients with HCV Infection

Background: Renal arterial waveform analysis done via renal Duplex Doppler Ultrasound gives a safe, trustworthy, and real time assessment of renal hemodynamics without any delay and ambiguity as it removes various components that make estimation of renal function problematic. Objective: To evaluate the clinical validity of RI and to identify the relationship between RI and RFT’s for evaluation of renal function in patient. Analytical cross sectional examination was done at DHQ teaching hospital Sargodha from 2020 to 2021. The it had 158 hepatitis C positive patients and 79 healthy volunteers following approval of summary. After validation of inclusion and exclusion criteria, patients were broken in into 4 groups (A to D) according to stage of disease and controls were kept in Group E. Grey scale ultrasonography test for renal measurements and renal echogenicity was done. Sagittal and axial scans was done in supine posture from anterior approach utilizing liver and spleen as an acoustic window. The size and texture of liver was also assessed. Color Doppler was done to calculate Resistive Index (RI) using conventional curvilinear probe. Results: The serum creatinine and urea levels in the diseased groups were greater than those in the control group. It was individuals in Group-D who had the highest creatinine levels, which were followed by those in Groups C, B, and A, respectively. The greatest Urea level was found in Group-D, at 49.6714.19, while the lowest was found in Group-A. The mean RI in sick groups (the highest was in Group D, with values of 0.78 and 0.81 in the right and left kidneys, respectively) was similarly statistically substantially greater. Conclusion: An important connection exists between RI and RFT. The use of Doppler duplex ultrasonography for the study of renal hemodynamics in cirrhotic patients with HCV is a reliable, non-invasive, simple, immediate, and cost-effective method for examining renal hemodynamics in these patients. It is not essential to have clinical symptoms or deviations from RFTs for this test to be more accurate than RFTs at predicting disease development. Keywords: Renal Doppler Duplex Ultrasound, Renal Resistive Index (RI), Renal function tests, Urea, Creatinine, Cirrhosis, HCV

Hemodynamic response in cirrhotic patients with transjugular intrahepatic portosystemic shunt

Objective: To discuss the effects of transjugular intrahepatic portosystemic shunt (TIPS) procedure on hemodynamics in cirrhotic patients. Methods: A total of 23 cirrhotic patients for TIPS insertion were enrolled from January 2018 to October 2018. Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP), transthoracic echocardiography and non-invasive cardiac output measurement based on impedance cardiogram were carried out before and 24h, 1 month, 6 months after TIPS in order to observe cardiac function and hemodynamic changes after TIPS. Results: Significant increases in right atrial area [(17.2±4.0) cm(2) vs. (15.0±3.4) cm(2), P<0.05], right ventricular area [(15.1±3.8) cm(2) vs. (13.7±3.5) cm(2), P<0.05] and left ventricular volume [(97.4±21.5) ml vs. (91.1±22.7) ml, P<0.05] were observed 24 h after TIPS. These changes were accompanied with significant reduction in collapsible index of inferior vena cava [(20.7± 8.1)% vs. (28.6±11.3)%, P<0.01] and elevation in pulmonary arterial systolic pressure [(36.0±8.4) mmHg (1 mmHg=0.133 kPa) vs. (31.8±5.4) mmHg, P<0.01]. There also existed significantly elevated serum NT-proBNP [(551.2±325.1) ng/L vs. (124.2±94.4) ng/L, P<0.01], cardiac output [(5.82±0.96) L/min vs. (5.12±1.28) L/min, P<0.01], cardiac index [(3.47±0.64) L·min(-1)·m(-2) vs. (3.05±0.78) L·min(-1)·m(-2), P<0.01], early diastolic filling rate [(59.0±14.3)% vs. (54.5±11.0)%, P<0.05], and reduced systemic vascular resistance index (SVRi) [(1 798.4±357.3) dyne·s·cm(-5)·m(-2) vs. (2 195.7±508.7) dyne·s·cm(-5)·m(-2), P<0.01] 24 h after TIPS. At the end of 6-month follow-up, all these parameters, but not SVRi, returned towards baseline values. Moreover, peak early to late diastolic tissue velocity ratio at the level of lateral mitral annulus (E'/A') was significantly higher at the end of 6-month follow-up than that at baseline (1.06±0.32 vs. 0.90±0.45, P<0.05). Neither the right ventricular fractional area changes nor the left ventricular ejection fractions during the follow-up period were different from those at baseline (P>0.05). Conclusion: Cirrhotic patients who had no cardiovascular pathologies had adequate adaptation and good compensation ability to reach a new hemodynamic homeostasis for the increased volume load after TIPS insertion.

APTR is a prognostic marker in cirrhotic patients with portal hypertension during TIPS procedure

Portal hypertension is a major cause of mortality and morbidity in cirrhotic patients. In this study, we aimed to analyze the clinical characteristics of Alu-mediated p21 transcriptional regulator (APTR) during transjugular intrahepatic portosystemic shunt (TIPS) procedure. Portal and hepatic venous blood was drawn from 84 patients with liver cirrhosis and portal hypertension before and after TIPS treatment. Then, we detected biochemical, hemodynamic parameters and APTR expression before and after TIPS treatment. Indeed, TIPS treatment could markedly ameliorate the serum blood urea nitrogen (BUN) level and portal vein hemodynamics in cirrhotic patients. We found that portal venous levels of APTR was significantly decreased after TIPS treatment and its aberrant expression levels were positively correlated with Model for End Stage Liver Disease (MELD), portal hepatic venous pressure gradient (PHPG) in patients. Higher APTR expression in portal vein was associated with poor prognosis. APTR level in portal vein was an independent predictors of mortality. Our data indicated that APTR may serve as a novel biomarker for cirrhotic patients with portal hypertension before and after receiving TIPS.

Cerebral Hemodynamics and Cognitive Function in Cirrhotic Patients with Hepatic Encephalopathy.

Aims. To investigate cerebral hemodynamics in cirrhotic patients with HE and to observe effects of treatment in cerebral hemodynamics and correlations among ammonia, cerebral hemodynamics, and cognitive function. Methods. There were four groups: healthy controls (group 1), cirrhosis without HE (group 2), cirrhosis with MHE (group 3), and cirrhosis with OHE (group 4). Ammonia and cerebral hemodynamics (by TCD) were assessed. Patients in group 3 were subsequently randomized to two subgroups: the control (group A) and the treated (group B, treated with lactulose for two months), and they were retested for ammonia and TCD after treatment. Results. Ammonia, Vm, Vd, PI, and RI were statistically different before treatment, and ammonia, PI, and RI levels paralleled the severity of HE (P < 0.05). In group B, Vd increased and ammonia, PI, and RI declined following treatment (P < 0.05), while there were no differences in group A (P > 0.05). Correlations were found between ammonia and Vd, PI, RI, NCT-A, and DST and also found between Vd, PI, RI, and NCT-A and DST (P < 0.05). Conclusions. This study revealed that cerebral hemodynamics were related to the severity of HE and cerebral autoregulation was impaired. There were tight correlations among ammonia, cerebral hemodynamics, and cognitive function, and, following treatment, cerebral hemodynamics improved.

Plasma ADAMTS-13 protein is not associated with portal hypertension or hemodynamic changes in patients with cirrhosis

BackgroundActivated hepatic stellate cells synthesize the matrix metalloprotease ADAMTS13, which may be involved in the development of liver cirrhosis and portal hypertension. Plasma ADAMTS13 activity has been reported as both increased and decreased in cirrhosis, but ADAMTS13 protein has not previously been examined. AimTo evaluate ADAMTS13 protein in the hepatic circulation and the relation to disease severity, portal pressure, and systemic hemodynamics in cirrhotic patients. MethodsSixty-one cirrhotic patients (Child class: A=22; B=21; C=18) and nine healthy controls underwent a liver vein catheterization with measurement of splanchnic and systemic hemodynamics, and plasma ADAMTS13 protein concentration in a hepatic vein and the femoral artery. ResultsADAMTS13 protein concentrations were increased in cirrhotic patients compared with controls (774ng/ml [IQR: 585–955] vs. 538ng/ml [IQR: 484–631], p<0.03). There were no significant correlations to MELD score, Child Pugh score, portal pressure, nor systemic vascular resistance or cardiac output. ConclusionsThe increased concentration of ADAMTS13 protein in the hepatic circulation may reflect an increased number of active hepatic stellate cells in cirrhosis. However, ADAMTS13 was unrelated to portal hypertension and systemic hemodynamics. In conclusion, ADAMTS13 does not appear to be associated to disease severity or the hemodynamic derangement in patients with cirrhosis.

The Effect of Laser Revascularization of the Liver on Portal Hemodynamics in Cirrhotic Patients: Preliminary Study

Background and Aims: Portal hypertension leads to serious complications such as variceal bleeding and is responsible for significant morbidity and mortality in cirrhotic patients. The aim of this research was to study the influence of improving of the microenvironment within the liver through formation of new vessels and extracellular matrix remodelling using a high-intensity laser radiation on portal hemodynamics in cirrhotic patients.

The impact of large-volume paracentesis on renal haemodynamics in cirrhotic patients with ascites

Background and aim Ascites in liver cirrhosis is associated with a poor prognosis and impairment of the quality of life and may be complicated by hepatorenal syndrome. Renal functions and haemodynamic changes after large-volume paracentesis (LVP) in cirrhotic patients with tense ascites were evaluated. Patients and methods A total of 50 cirrhotic patients with tense ascites were divided into two groups: group I 25 patients without renal impairment and group II 25 patients with renal impairment (type II hepatorenal syndrome). Results In groups I and II, the serum creatinine decreased significantly 24 h after LVP (P Conclusion LVP causes a significant reduction of heart rate and mean arterial pressure, serum creatinine, blood urea nitrogen and RI with a significant glomerular filtration rate increase, but had no effect on the plasma renin activity.

Cerebral haemodynamics in cirrhotic patients with hepatic encephalopathy

Factors other than elevated levels of ammonia may be implicated in hepatic encephalopathy (HE) pathophysiology, including abnormal cerebral haemodynamics. Transcranial Doppler ultrasonography (TCD) evaluates cerebrovascular structural integrity and reactivity, through pulsatility index (PI) and breath-holding index (BHI) respectively. The aim of this study was to evaluate cerebral haemodynamics by TCD in patients with compensated and decompensated cirrhosis, and patients with and without HE. We studied 90 subjects by TCD measuring PI and BHI in the middle cerebral artery: 30 with cirrhosis and no HE, 30 with cirrhosis and low-grade HE and 30 healthy subjects. Critical flicker frequency, psychometric hepatic encephalopathy score and West-Haven criteria were performed to assess MHE and HE respectively. Pulsatility index increased in decompensated cirrhotics (Child≥7) when compared with compensated cirrhotics and healthy subjects [median (IQR) 1.07 (0.95-1.21) vs 0.90 (0.83-1.05) vs 0.87 (0.78-0.96); P<0.001]. A reverse relationship was observed for BHI among the three groups [0.82 (0.45-1.11) vs 1.20 (0.82-1.52) vs 1.28 (1.06-1.68); P<0.001]. Similar findings were observed in decompensation [model for end-stage liver disease (MELD) score ≥14]. Patients with HE showed higher PI and lower BHI [1.05 (1.00-1.16) and 0.89 (0.59-1.15)], when compared with patients without HE [0.96 (0.83-1.13) and 1.00 (0.60-1.53)] or controls [0.87 (0.78-0.96) and 1.28 (1.06-1.68)] (P<0.001 for PI, and P=0.007 for BHI). In multivariate regression models, only PI predicted HE, but it was outperformed by MELD-sodium and tumour necrosis factor-alpha. These results indicate that cerebral haemodynamics are altered in patients with cirrhosis, in relation to severity of disease and HE. Findings on impaired PI and BHI suggest that structural vascular damage and loss of vascular autoregulation are implicated in the pathophysiology of HE.

Influence of Paraumbilical Vein Patency on the Portal Hemodynamics of Patients With Cirrhosis

The aim was to determine the influence of the paraumbilical vein (PUV) patency and its effect on the portal hemodynamics and clinical presentations in cirrhotic patients. In this prospective study of 181 cirrhotic patients (101 males, 80 females; aged 62.6±11.8 y), the portal hemodynamics were assessed using Doppler ultrasonography. The incidence of patent PUV was 26.0% (47/181). The mean flow volume in the portal trunk, the incidence of a left gastric vein with hepatofugal flow, and the grade of the esophageal varices were significantly higher in the patients with a patent PUV (908.2 mL/min, 70.2%, 9 with none to small, and 27 with medium to large, respectively) than in those without (771.7 mL/min, 48.5%, 57 with none to small, and 48 with medium to large, respectively). The hepatic venous pressure gradient and the wedged hepatic venous pressure (mm H2O) were significantly higher in the former group (268.0±89.7 and 389.5±99.9, respectively) than in the latter (203.5±63.2 and 317.7±67.7, respectively). The deterioration of ascites during the 2-year follow-up period was significantly more often in the patients with a patent PUV (4/12, 33.3%) than in those without. The cumulative survival rates at 1, 2, and 3 years were similar between the 2 groups: 92.5%, 92.5%, and 82.4%, respectively, in the former and 90.7%, 83.8%, and 76.3%, respectively, in the latter. A patent PUV seems to signify pressure-loaded portal hemodynamics in cirrhotic patients. However, it seems to have little effect on their prognoses.

The evaluation of haemodynamics in cirrhotic patients with spectral CT

To evaluate haemodynamics in cirrhotic patients with portal hypertension using spectral CT imaging. 118 cirrhotic patients with portal hypertension were included in the study group (further divided into Child-Pugh A, B and C subgroups). The control group consisted of 21 subjects with normal liver functionality. All subjects underwent three-phase spectral CT scans. Material decomposition images with water and iodine as basis material pairs were reconstructed. The iodine concentrations for the hepatic parenchyma in both arterial and portal venous phases were measured. The arterial iodine fraction (AIF) was obtained by dividing the iodine concentration in the hepatic arterial phase by that in the portal venous phase. AIF values from the study and control groups were compared using analysis of variance and between subgroups using a post-hoc test with Bonferroni correction, with a statistical significance of p<0.05. The AIF was 0.25±0.05 in the control group, and 0.29±0.10, 0.37±0.12 and 0.43±0.14 in the study group with Child-Pugh Grades A, B and C, respectively. The difference in AIF between the control and study groups was statistically significant. The differences were statistically significant between the subgroups with multiple comparisons except between the control group and the Child-Pugh A group (p=0.685). AIF measured in spectral CT could be used to evaluate the liver haemodynamics of cirrhotic patients. The AIF, provided by spectral CT, could be used as a new parameter to observe liver haemodynamics.

Altered Effective Connectivity Network of the Basal Ganglia in Low-Grade Hepatic Encephalopathy: A Resting-State fMRI Study with Granger Causality Analysis

BackgroundThe basal ganglia often show abnormal metabolism and intracranial hemodynamics in cirrhotic patients with hepatic encephalopathy (HE). Little is known about how the basal ganglia affect other brain system and is affected by other brain regions in HE. The purpose of this study was to investigate whether the effective connectivity network associated with the basal ganglia is disturbed in HE patients by using resting-state functional magnetic resonance imaging (rs-fMRI).Methodology/Principal FindingsThirty five low-grade HE patients and thirty five age- and gender- matched healthy controls participated in the rs-fMRI scans. The effective connectivity networks associated with the globus pallidus, the primarily affected region within basal ganglia in HE, were characterized by using the Granger causality analysis and compared between HE patients and healthy controls. Pearson correlation analysis was performed between the abnormal effective connectivity and venous blood ammonia levels and neuropsychological performances of all HE patients. Compared with the healthy controls, patients with low-grade HE demonstrated mutually decreased influence between the globus pallidus and the anterior cingulate cortex (ACC), cuneus, bi-directionally increased influence between the globus pallidus and the precuneus, and either decreased or increased influence from and to the globus pallidus in many other frontal, temporal, parietal gyri, and cerebellum. Pearson correlation analyses revealed that the blood ammonia levels in HE patients negatively correlated with effective connectivity from the globus pallidus to ACC, and positively correlated with that from the globus pallidus to precuneus; and the number connectivity test scores in patients negatively correlated with the effective connectivity from the globus pallidus to ACC, and from superior frontal gyrus to globus pallidus.Conclusions/SignificanceLow-grade HE patients had disrupted effective connectivity network of basal ganglia. Our findings may help to understand the neurophysiological mechanisms underlying the HE.

Changes of varicosis and hemodynamics in cirrhotic patients with portal vein hypertension after Hassab devascularization

Objective To analyze the changes of varicosis and hemodynamics in cirrhotic patients with portal vein hypertension at different stages after Hassab devascularization, and to evaluate the outcome.Methods Hassab devascularization was performed in 161 patients with portal vein hypertension, who were all evaluated by means of endoscopy, Doppler color imaging and Child-Pugh grading before and 6, 12, 18,24 months after the procedure, respectively.Results The rates of mild esophageal varicosis were 44.0%,34.8% and 28.3% at 6, 12 and 18 months after Hassab devascularization, respectively, which were all significantly higher than that before the operation（7.5%, P 〈 0.05）, while the rates of severe esophageal varicosis were 25.2%, 29.7% and 34.9% at 6, 12 and 18 months after the procedure, which were significantly lower than that before（65.2%, P 〈 0.05）.The incidence of varices in gastric fundus was correlated with the severity of esophageal varices.At 12 months after the operation, the inner diameters of portal vein and its right branch significantly decreased when compared with those before（P 〈 0.05）, the maximal flow rate,volume of portal vein and average flow rate of the left branch also significantly decreased（P 〈 0.05）.At 6 months after the operation, the average flow rate of the right branch slowed down（P 〈 0.05）.Child-Pugh Grade A accounted for 63.5%, 60.6% and 57.9% at 6, 12 and 18 months after the operation, respectively, which were significantly higher than that before（48.4%, P 〈0.05）.When evaluated at 24 months after the procedure, all variables were getting close to those before.Conclusion The severity of esophageal varices mitigates in 18 months after Hassab.Hemodynamics of portal vein system decreases in 12 months.The overall liver function improves in 18 months after the operation. Key words: Hypertension, portal; Splenectomy; Esophageal and gastric varices; Endoscopy

The use of β-adrenergic drugs improves hepatic oxygen metabolism in cirrhotic patients undergoing liver resection

Hepatic resection is associated with hemodynamic and oxygen metabolism disturbances of the residual liver resulting from liver regeneration. In underlying liver disease, the remnant liver responds inadequately to increased energy demands leading to a less efficient recovery process. The aim of this study was to assess the effect of vasoactive drugs on hepatic oxygen metabolism and hemodynamics in cirrhotic patients that have undergone liver resection. Thirty patients were randomly allocated to receive peri-operatively low doses (4 microg/kg/min) of dopamine (DaG, n=10), dobutamine (DbG, n=10) or saline (CG, n=10). Hepatic hemodynamics, hepatic oxygen metabolism and lactate uptakes were evaluated before drug administration and at the time of abdominal closure. Post-operative liver function and outcome were recorded. The peri-operative use of vasoactive drugs preserved total hepatic blood flow and hepatic compliance, even increasing in patients who received Db, whereas those parameters decreased in CG after liver resection. At this time, oxygen delivery and consumption decreased in CG patients, but were unchanged when vasoactive drugs were used. In all groups, lactate uptake decreased sharply and only DbG showed positive lactate extraction capacity. The peak of post-operative bilirubin, which resumed baseline values more quickly in DbG, inversely correlated with intra-operative hepatic compliance and hepatic oxygen extraction. Low doses of vasoactive drugs, especially dobutamine, improved hepatic oxygen supply and uptake preserving immediate function of the remnant cirrhotic liver.

Splanchnic Hemodynamics in Cirrhotic Patients: Relationship to Esophageal Varices and the Severity of Hepatic Failure

Purpose: The relationship between splanchnic hemodynamics, liver function, and esophageal variceal grading in cirrhosis remains unclear. The aim was to determine the value of quantitative Doppler parameters of splanchnic hemodynamics in assessing esophageal variceal (OV) grading, severity of liver insufficiency and presence of ascites. Methods: The following parameters were performed for 153 cirrhotics and 30 controls: portal vein (PV) and splenic vein (SV) – cross sectional area (CSA), mean velocity (MV), flow volume (FL), PV congestive index; hepatic artery, splenic artery (SA) and superior mesenteric artery (SMA) pulsatility index (PI) and resistive index (RI); liver vascular index (LVI), modified LVI (M-LVI), portal hypertension index (PHI), portal inflow (P-flow) and collateral inflow (C-flow). Results: All parameters differentiated between control and cirrhotics except PV-FL and SV-FL which were significantly lower only in advanced cirrhosis (Child C). SMA-PI, PHI, P-flow and C-flow were significantly different among various Child classes. PV-MV was significantly lower in small OV compared to other groups. All parameters were significantly different in large OV except PV-FL, SMA-PI and –RI. PV-FL, SA-PI, SMA-RI, LVI, M-LVI, P-flow and C-flow were significantly different in gastric varices group compared to other groups. All parameters were significantly different in ascitic than non-ascitic except PV-CSA, SMA-PI and -RI. Conclusion: Splanchnic Doppler parameters are significantly related to stages of liver damage, grade of portal hypertension and presence of ascites, and may therefore be used as surrogate markers. We recommend an optimal scoring system with Doppler parameters integrated for diagnosis and staging of cirrhosis and portal hypertension.

Effects of Nitric Oxide Inhibition by Methylene Blue in Cirrhotic Patients with Ascites

Increased endogenous nitric oxide production has been proposed as an important mediator of the peripheral arterial vasodilation and the hyperdynamic circulation in cirrhosis, whereas a decreased intrahepatic production of nitric oxide has been implicated in the pathogenesis of portal hypertension. The present study investigated the possible beneficial effects of methylene blue, which is a potent inhibitor of guanylate cyclase and nitric oxide synthase, on hyperdynamic circulation and renal function in cirrhotic patients with ascites together with the effects on portal hemodynamics. Twenty patients were evaluated at baseline and during 2 consecutive 4-hr periods after the administration of methylene blue at a dose of 3 mg/kg (10 patients) or placebo (10 patients). Mean arterial pressure, heart rate, cardiac output, systemic vascular resistance, plasma active renin, plasma aldosterone, plasma antidiuretic hormone, serum urea, serum creatinine, serum sodium, urinary flow rate, glomerular filtration rate, effective renal plasma flow, portal flow volume, and portal vein velocity were not modified by methylene blue or placebo. Urinary sodium excretion, fractional sodium excretion and serum nitric oxide levels were significantly decreased 4 hr after methylene blue administration (P < 0.05), to return toward basal levels over a further 4-hr period. It is concluded that methylene blue, at the dose used in the present study, has no effect on systemic and portal hemodynamics in cirrhotic patients with ascites. The reduction in renal sodium excretion, in the absence of changes in renal function and hemodynamics, suggests, at least partly, a direct antinatriuretic effect of methylene blue.

Portal and splenic hemodynamics in cirrhotic patients: relationship between esophageal variceal bleeding and the severity of hepatic failure.

The relationship between portal and splenic vein hemodynamics, liver function, and esophageal variceal bleeding in patients with cirrhosis remains unclear. The aim of the present study was to investigate quantitative Doppler parameters of splanchnic hemodynamics in cirrhotic patients and to determine the value of the Doppler parameters in predicting esophageal variceal bleeding. With the help of pulsed Doppler ultrasonography, we investigated portal and splenic hemodynamics in 18 healthy controls and in 45 patients with liver cirrhosis, in whom the relationship of splenic hemodynamics with esophageal variceal bleeding and the grade of cirrhosis was examined. Portal flow velocity was decreased in cirrhotic patients with Child's C cirrhosis, as compared to those with Child's A cirrhosis ( P < 0.001). The portal blood flow volume in Child's C cirrhosis were also significantly low compared to patients with Child's A and Child's B cirrhosis ( P < 0.001 and P < 0.05, respectively). There was a significant increase in the portal vein congestion index and splenic vein congestion index in patients with Child's C cirrhosis as compared to patients with Child's A cirrhosis ( P < 0.001). Among cirrhotic patients, the group with esophageal variceal bleeding had significantly greater splenic blood flow volume and splenic vein congestion index ( P < 0.001). Patients with ascites had significantly lower portal flow velocity ( P < 0.001) and higher portal vein congestion index and splenic vein congestion index ( P = 0.003 and P = 0.05, respectively) as compared to those without ascites. In this report we have shown that the decrease in blood flow and increased congestion indexes in the portal vein and splenic vein are related to the impairment of liver function in cirrhotic patients; these indexes may be valuable factors for predicting esophageal variceal bleeding.

DUPLEX DOPPLER ULTRASOUND OF HEPATIC SCHISTOSOMIASIS JAPONICA: A STUDY OF 47 PATIENTS

This study describes the ultrasound (US) appearances of the liver with hepatic schistosomiasis japonica (HSJ), and studies the portal hemodynamics in 47 patients with HSJ using duplex Doppler US over a period of 15 years. All patients but two were Chinese war veterans seen in Taiwan about 35-55 years after their presumed infection in Mainland China. The US presentations were reviewed. The data from Doppler portal flow studies were available for 39 patients with HSJ, and compared to data from Doppler portal flow studies in 40 normal healthy volunteers and to this data in 40 patients with postnecrotic cirrhosis. A typical "coarse reticular pattern" due to fibrosis in the whole liver was noted in 40 patients (85%). Other findings included periportal fibrosis (15%), septum-like fibrous bands extending to the liver capsule (32%), and an apparent nodular liver surface (19%). Splenomegaly was noted in seven patients. While coexisting hepatocellular carcinomas (HCC) were evident in three patients, and esophageal varices were found in three others, yet both conditions were found only in patients with positive hepatitis-B-surface antigen (HBsAg). Doppler flowmetry of the portal veins in HSJ patients showed a mean flow rate of 15.34 +/- 6.82 cm/sec, and a mean flow volume of 993.21 +/- 290.63 ml/min, both showed no significant difference from those in normal adults (p > 0.5). HSJ can be confidently diagnosed in patients with hepatic fibrosis when the hepatic pathology is presented as a coarse reticular pattern. The portal hemodynamics in HSJ patients who have been isolated from the infection site (for more than 35 years) are significantly different from portal hemodynamics in cirrhotic patients and are similar to those in healthy volunteers.

A randomized study of losartan vs propranolol: Effects on hepatic and systemic hemodynamics in cirrhotic patients

Background & aims: The potential use of losartan, an angiotensin II type 1 receptor blocker, in the treatment of portal hypertension is still under debate. This randomized controlled trial compared the effects of losartan vs. propranolol on portal and systemic hemodynamics in patients with cirrhosis. Methods: Twenty-seven compensated patients were randomized to receive losartan 25 mg/day (n = 17) or propranolol (n = 10). Hepatic venous pressure gradient (HVPG), portal blood flow (Doppler duplex ultrasound) and systemic hemodynamics were measured at baseline and after 12-week treatment. Portal resistance was calculated as HVPG/portal blood flow. Results: Propranolol induced a reduction in cardiac output (p 0.002), heart rate (p 0.0001) and HVPG [from 16.4 (± 4.1) to 13.1 (± 3.6) mmHg (p 0.07)]; six patients showed a reduction equal or greater than 20% and were considered responders. Losartan caused a decrease in HVPG [from 15.6 (± 4.2) to 11.8 (± 3.5) mmHg (p 0.002)], without changes in portal blood flow and systemic hemodynamics. Changes in HVPG correlated with variations in portal resistance (r 0.88, p < 0.0001). Losartan induced a reduction in HVPG between 10 and 19% in 5/17 patients, and 20% or more in 8/17. Five out of eight patients who respond to losartan showed severe portal hypertension, with higher baseline HVPG (equal or greater than 16 mmHg). Conclusions: the administration of losartan in a doses of 25 F per day may be effective in lowering portal pressure in patients with compensated cirrhosis, particularly in those with more severe portal hypertension

Effects of total volume paracentesis on variceal and portal hemodynamics in cirrhotic patients with tense ascites: relation to serum nitrite and nitrate levels

Effects of total volume paracentesis on variceal and portal hemodynamics in cirrhotic patients with tense ascites: relation to serum nitrite and nitrate levels