Splanchnic Hemodynamics In Patients Research Articles

Portal and splanchnic hemodynamics after partial splenic embolization in cirrhotic patients with hypersplenism.

To assess the acute effects of partial splenic embolization (PSE) on portal and splanchnic hemodynamics in patients with cirrhosis. Ninety-five patients with hypersplenism were included in the study. Duplex examinations were performed before and 3 and 7 days after PSE. Portal and splanchnic hemodynamics including vessel cross-sectional area (CSA), mean flow velocities (cm/s), blood flows (mL/min), Doppler indices as portal congestion index (CI), liver vascular index, hepatic artery and superior mesenteric artery (SMA) pulsatility and resistive indices (PI and RI), were performed before and after PSE. In our study, 69 of 95 patients were males (72.6%) and 26 females (27.3%). Chronic hepatitis C virus infection was the main cause of cirrhosis (81.1%). PSE failed technically in six patients (6.3%). After PSE, both CSA and CI significantly decreased (p < 0.05 and <0.01). The portal vein velocity significantly increased (p < 0.01). The portal flow volume (892.4 ± 151 mL/min) did not show significant changes. The hepatic artery RI and PI showed a steady increase that became significant 7 days post-PSE (p < 0.05). The RI and PI of SMA increased significantly after 7 days of PSE (p < 0.05). PSE has an immediate portal decompression effect in patients with portal hypertension without reduction in portal flow. This effect on portal pressure should be investigated in future studies as a potential tool for management of acute variceal bleeding when other medical procedures fail.

Assessment of splanchnic hemodynamics in patients with cirrhosis after splenectomy in comparison with non-operated patients at the decompensated stage

Splenectomy in patients with cirrhosis presupposes an increase of blood inflow into portal system to decrease the portal pressure. At the same time there are different opinions about splenectomy. So it is actual to study the character of changes of blood flow in vessels of abdominal cavity in pre- and postsurgical periods and assessment of an influence of these changes on the clinical course of cirrhosis.Aim of research: To assess an influence of splenectomy on the character of changes of splanchnic hemodynamics in patients with cirrhosis comparing to non-operated patients with compensated and decompensated clinical course.Materials and methods: There were examined 190 patients with cirrhosis: gastrointestinal bleeding from oesophagus varicose veins took place in 133 patients, diuretic resistant ascites – in 57 ones. 19 patients underwent splenectomy: 7 – in association with sewing of the left gastric vein and artery, 6 – with “skeletonization” of the lesser curvature of stomach with Nessen’s operation, 2 – with Patsiora’s operation, 2 – with application of selective porto-caval shunt between the low mesenteric vein and the left vein of an ovary. 84 patients died during observation. The duration of observation was from 0.5 to 3.5 years. All patients underwent fibrogastroscopy every 3–4 month. Hemodynamics was assessed on the base of repeated ultrasound of abdominal cavity. There were assessed diameter of hepatic and splenic vessels; qualitative and quantitative characteristics of blood flow in hepatic and splenic arteries, portal and splenic veins.Results of research: Changes of hemodynamics in patients after splenectomy as opposed to non-operative patients are characterized with the decrease of diameter of portal vein at almost stable speed of the linear blood flow in it. The result is some decrease of the volume of portal blood and index of portal blood congestion that indirectly indicates the decrease of portal pressure after splenectomy. At the same time arterial hepatic blood flow stays without essential changes.At fibrogastroscopy there was noticed a decrease of esophageal varicose veins dilatation, its tension, elimination of «red signs” that is a prognostic marker of the menace of bleeding. There were noticed no one relapse of bleeding and the sign of refractory ascites during the period of observation.Conclusio: The changes of splanchnic hemodynamics after splenectomy are characterized with decrease of the volume of splanchnic blood. The result is a decrease of portal pressure that is proved with decrease of congestion index in portal vein, decrease of tension of varicose veins, elimination of “red signs” and consequently elimination of the menace of relapse of bleeding and development of resistant ascites. At the same time splectomy can be done in patients with decompensated clinical course of cirrhosis that is proved with an absence of lethality in postsurgical period

Assessment of splanchnic hemodynamics in patients with cirrhosis after separating operations in comparison with non-operated patients with compensated and decompensated clinical course

Separating operations are recommended for treatment and prophylaxis of bleeding from varicose veins of gullet as a result of portocaval (azygoportal) shunting at cirrhosis and directed to its elimination using azygoportal separation. At the same time the frequency of relapse of bleeding after operations remains rather high. And the formation of new varicose nodi as a result of disorder of hepatic and splanchnic hemodynamics that inevitably appears at different dates after operation is considered as the main cause of it. At the same time an assessment of hemodynamic changes after azygoportal separation is interpreted in different ways by different authors.Aim of research. To assess an influence of separating surgical interventions on the character of changes of splanchnic hemodynamics in patients with cirrhosis in comparison with non-operated patients with compensated and decompensated clinical course.Material and methods. There were examined 190 patients with cirrhosis: in 133 took place gastrointestinal bleeding from varicose veins of gullet, in 57 – diuretic resistant ascites. 16 patients underwent separating operations. 20 patients underwent endoscopic sclerotherapy of gullet veins. 84 patients died during observation (7 after surgical treatment). Duration of observation was from 2-3 weeks to 2,5-3 years. All patients underwent the repeated ultrasound of abdominal cavity. There were assessed diameter of hepatic and splenic vessels; quantitative and qualitative characteristics of blood flow in hepatic and splenic arteries, portal and splenic veins.Results of research. At assessment of splanchnic hemodynamics the changes of portal blood flow in first months after operation characterized with moderate dilation of portal vein and decrease of linear speed in it. At the same time the volumetric blood flow did not essentially change. It was noticed the decrease of volumetric blood flow in splenic vein at the expense of constriction of its lumen and decrease of linear speed in it. Arterial blood flow characterized with decrease of inflow to liver through hepatic artery and increase of blood flow through splenic artery. At later dates the character of changes of splanchnic hemodynamics after azygoportal separation was analogous on all indicators to non-operated patients at transfer from compensated to decompensated course of cirrhosis – decrease of blood flow through the portal vein and hepatic artery at relative increase of splenic blood flow. An increase of index of stagnation in the portal vein and splenic-hepatic portal index that took place in all operated patients and non-operated ones at the stage of decompensation was an unfavorable prognostic indication.Conclusion. The character of changes of splanchnic hemodynamics after gastroesophageal separation is analogous to non-operated patients at transfer from compensated course of cirrhosis to decompensated one. Decrease of the portal blood inflow through the splenic vein is a compensatory mechanism that must decrease the portal pressure. The quality of life in postsurgical period is determined by duration of compensation of hemodynamic disorders

Assessment of splanchnic hemodynamics in patients with cirrhosis after portocaval shunting in comparison with no-operated patients with the compensated and decompensated course of disease

Portocaval shunting is recommended for decrease of the portal pressure and regression of the varicose veins in patients with cirrhosis. But the shunting surgery at cirrhosis is limited by the high risk of development of hepatic encephalopathy and the hepatocellular insufficiency in post-surgical period. And the disorder of the hepatic and splanchnic hemodynamics that inevitably appears at different dates after surgery is considered as the main cause of these states.Aim of research. To assess an influence of the shunting surgical interventions on the character of changes of splanchnic hemodynamics in patients with cirrhosis in comparison with no-operated patients with compensated and decompensated course of disease.Material and methods. 190 patients with cirrhosis were examined: 133 had gastrointestinal bleeding, 57 – diuretic-resistant ascites. 18 patients underwent surgery – portocaval shunting. 84 patients died during observation (10 after surgery). The duration of observation was from 2-3 weeks to 2,5-3 years.All patients underwent the repeated ultrasound examination of abdominal cavity. There were defined the diameter of hepatic and splenic vessels; quantitative and qualitative characteristics of the blood flow in hepatic and splenic arteries, in portal and splenic veins. Results of research. At assessment of splanchnic hemodynamics we noticed the differences of parameters depending on time that passed after surgery. The changes of portal blood flow in first 3-6 month were characterized by the moderate widening of portal and splenic veins at little decrease of its mean linear and volume speed so an inflow of the portal blood still stable. Arterial blood flow in hepatic artery was forced at the expense of both widening of diameter and increase of the mean speed of blood flow. The splenic arterial blood flow practically was not changed. The reliable decrease of the volume blood flow in portal vein at the expense of decrease of its linear speed was observed in all patients at later dates. An unfavorable sign was an increase of an index of haemostasia in portal vein and of splenic and hepatic portal index in dynamics that took place in all operated patients and in no-operated ones at the stage of decompensation.Conclusions. The character of changes of splanchnic hemodynamics after portocaval shunting is analogous to the one in no-operated patients at transition from the compensated course of cirrhosis to decompensated one. The compensatory mechanism that preserves the volume of the portal inflow to liver is the widening of the portal vein and preservation of the splenic blood flow. The quality of life in post-surgical period is determined by the duration of compensation of hemodynamic disorders

PTU-121 Monitoring changes in hepatic architecture and haemodynamics with quantitative magnetic resonance imaging (MRI) following directly-acting antiviral therapy in hepatitis C patients with decompensated cirrhosis

Introduction Directly-acting antiviral (DAA) therapy achieves sustained virological response (SVR) in over 90% of those with chronic hepatitis C (CHC), but even in those with SVR, the risk for liver related morbidity and mortality persists albeit at a lower level. It is hypothesised that the residual risk of liver related outcome in those with SVR is related to the progression or non-regression of structural and haemodynamic changes of advanced liver disease at the time of HCV therapy. Here, we investigate the effect of DAAs on the hepatic architecture and splanchnic haemodynamics in patients with decompensated cirrhosis, using quantitative MRI techniques. Method We prospectively recruited patients receiving DAAs for CHC related decompensated cirrhosis from the East Midlands hub of the Early Access Programme commissioned by NHS England. MRI was performed before and at the end of a 12-week treatment with Daclatasvir, Sofosbuvir and Ribavarin. A respiratory-triggered inversion recovery scheme was used to measure the longitudinal (T1) relaxation time of the liver employing a fat suppressed Echo Planar Imaging-acquisition. Phase-contrast (PC)-MRI was used to assess the velocity, area and bulk flow in the splanchnic circulation without any intravenous contrast agents. Results 9 patients have undergone baseline and post-treatment MR scans and end-of-treatment response (EOTR) was achieved in all 9 patients, but one patient has had virologic relapse. There was a significant reduction in the T1 relaxation time in patients with SVR (baseline T1: 765 ± 112 ms; post-treatment 737 ± 118 ms; p = 0.043) (Figure 1). There were no significant changes in the hepatic artery, portal vein, superior mesenteric artery and splenic artery flow. The changes in the Model for End-Stage Liver Disease (MELD) and United Kingdom Model for End-Stage Liver Disease (UKELD) score are shown in Table 1. Conclusion Treatment of decompensated CHC related cirrhosis with DAA is associated with early improvement in the MR markers of liver architecture. These early changes are likely to reflect the reduction in the inflammation associated with EOTR and is evident before any improvement in conventional liver function tests. This novel quantitative MR methodology will allow us to non-invasively monitor HCV related liver disease. Disclosure of interest None Declared.

205 Age-related changes of splanchnic hemodynamics in patients with liver cirrhosis

205 Age-related changes of splanchnic hemodynamics in patients with liver cirrhosis

Splanchnic haemodynamics in patients with coeliac disease: effects of a gluten-free diet.

Coeliac disease is characterized by structural and functional changes in the small bowel which may also result in haemodynamic changes. To establish whether splanchnic haemodynamics can be modified by a gluten-free diet. Ten coeliac patients and 10 paired healthy subjects. Echo-Doppler measurements were made of splanchnic vessels both fasting and after a standard meal before and after 9 months of a gluten-free diet. In comparison to controls, coeliac patients had higher superior mesenteric artery blood velocity and flow, with lower resistance indexes and higher portal vein velocity and flow, particularly 3 h after a meal. Postprandial hyperaemia was reduced and delayed in time. Intrasplenic resistance indexes were also significantly lower both fasting and after a meal. After 9 months of a gluten-free diet, no significant differences were observed between coeliac patients and controls, both fasting and after a meal. Splanchnic haemodynamics is significantly changed in coeliac patients, mainly after a meal. On treatment with a gluten-free diet, both fasting and postprandial haemodynamics became normal.

Evaluation of the splanchnic circulation with indocyanine green pharmacokinetics in liver transplant patients.

Although indocyanine green (ICG) can be used to estimate cardiac output (CO) and blood volume independently, a recirculatory multicompartmental ICG model enables description of these and additional intravascular factors. This model was used to describe the effect of end-stage liver disease (ESLD) on systemic and splanchnic hemodynamics in patients undergoing orthotopic liver transplantation. ICG disposition was determined during the dissection phase in six patients with ESLD undergoing orthotopic liver transplantation and six healthy adult living liver donors. After injecting ICG, plasma concentrations were obtained for approximately 10 to 12 minutes by noninvasive pulse dye densitometry. The recirculatory model characterizes three distinct intravascular circuits: lumped parallel fast (presumably nonsplanchnic circulation) and slow peripheral (splanchnic) circuits and a central circuit (central blood volume). Mean transit time (MTT) in the fast peripheral circuit was not different in patients with ESLD and controls. However, ESLD resulted in a significant decrease in MTT in the central (0.11 +/- 0.028 [SD] v 0.24 +/- 0.094 minutes in controls; P <.001) and slow peripheral circuit (0.67 +/- 0.41 v 1.37 +/- 0.37 minutes in controls; P <.001) because of increased flows to the central and slow peripheral circuits. These findings are consistent with the described hyperdynamic systemic and splanchnic circulations in patients with ESLD. In conclusion, the ICG model is able to derive estimates of not only blood volume and CO, but also splanchnic hemodynamics under different physiological conditions. This model can be a useful tool to evaluate the effect of pharmacological manipulation of splanchnic hemodynamics.

Effects of spontaneous bacterial peritonitis (SBP) on systemic and splanchnic hemodynamics in patients with cirrhosis

Effects of spontaneous bacterial peritonitis (SBP) on systemic and splanchnic hemodynamics in patients with cirrhosis

Effects of spontaneous bacterial peritonitis (SBP) on systemic and splanchnic hemodynamics in patients with cirrhosis

Effects of spontaneous bacterial peritonitis (SBP) on systemic and splanchnic hemodynamics in patients with cirrhosis

Do fluid administration and reduction in norepinephrine dose improve global and splanchnic haemodynamics?

We studied global and splanchnic haemodynamics in patients with septic shock, while reducing norepinephrine doses by progressive fluid loading administration. Ten patients (six female, four male, aged 39-86 yr, mean 61 yr) were assessed using a transpulmonary thermo-dye dilution technique to measure cardiac output, intrathoracic blood volume and total blood volume. Splanchnic blood flow was measured by the steady state indocyanine green technique using a hepatic venous catheter. Gastric mucosal blood flow was estimated by regional carbon dioxide tension (PRCO2). Hydroxyethylstarch was infused in two stages while maintaining mean arterial pressure, allowing a reduction in norepinephrine dose from 0.54 to 0.33 to 0.21 microgram kg-1 min-1. Mean (SD) heart rate significantly decreased, from 104 (13) to 94 (15) beats min-1. Total blood volume index (mean (SD)) increased from 2650 (638) to 3655 (885) ml m-2, intrathoracic blood volume index from 888 (204) to 1050 (248) ml m-2 and cardiac index from 3.6 (1.0) to 4.0 (0.9) litres min-1 m-2. Splanchnic blood flow did not change significantly--either absolute (from 0.81 to 0.98 litres min-1 m-2) or fractional (from 22.3% to 23.9%). Gastric mucosal (PRCO2) increased from 7.5 (2.5) to 9.0 (2.8) kPa. The PCO2 gap, i.e. the difference between regional and end-tidal PCO2, increased from 3.1 (2.5) to 4.0 (2.9) kPa. Marked individual variation in responses suggests that norepinephrine dose reduction by fluid loading in patients with stabilized septic shock does not necessarily increase global or splanchnic blood flow.

Portal and splanchnic haemodynamics in patients with advanced post-hepatitic cirrhosis and in healthy adults. Assessment with duplex Doppler ultrasound.

To assess portal and splanchnic haemodynamics, and splanchnic vascular resistance in patients with advanced post-hepatitic cirrhosis and in healthy volunteers, by means of duplex Doppler ultrasound (US). The duplex Doppler US examination was performed in 16 patients with cirrhosis and in 24 healthy volunteers. We investigated vessel diameters, mean flow velocities, and mean blood flows in the portal vein, the superior mesenteric artery (SMA), and the splenic artery (SA), and measured the resistive index values of SMA and SA. The mean portal venous blood flow in patients with cirrhosis (829 +/- 264 ml/min) was not statistically different from those in the volunteers (734 +/- 194 ml/min). The ratio of the SMA and SA blood flows (621 ml/min) to the portal venous blood flow (734 ml/min) was 0.85 in the control subjects. The mean portal venous blood flow (1261 ml/min) and the portal venous velocity (14.6 cm/s) were higher in the patients with recanalized para-umbilical veins than in the volunteers and in the patients without recanalized para-umbilical veins. The SMA and SA blood flows were significantly increased in patients with cirrhosis compared with volunteers. Splanchnic inflow (the sum of the SMA and SA blood flows) was higher than the portal blood flow in patients with cirrhosis except in the subjects with recanalized para-umbilical veins. SMA and SA resistive index values were significantly higher in these patients than in the volunteers. Splanchnic blood flow and splanchnic vascular impedance increased significantly in patients with advanced post-hepatitic cirrhosis. Splanchnic inflow must not exceed portal venous blood flow in patients with recanalized para-umbilical veins. Portal vein velocity and portal venous blood flow measurements alone are not useful parameters for discriminating patients with cirrhosis from healthy subjects.

Neurohumoral fluid regulation in chronic liver disease

Impaired homeostasis of the blood volume, with increased fluid and sodium retention, is a prevailing element in the deranged systemic and splanchnic haemodynamics in patients with liver disease. In this review, some basic elements of the circulatory changes that take place and of neurohumoral fluid regulation are outlined in order to provide an update of recent investigations on the neuroendocrine compensation of circulatory and volume dysfunction in chronic liver disease. The underlying pathophysiology is a systemic vasodilatation in which newly described potent vasoactive substances such as nitric oxide and vasodilating peptides seem to play an important role. The development of central hypovolaemia and activation of potent vasoconstricting systems such as the renin-angiotensin-aldosterone system and the sympathetic nervous system lead to a hyperdynamic circulation with increased heart rate and cardiac output. Moreover, patients exhibit an autonomic dys- and hyperfunction with vascular hyporeactivity to pressor stimuli. The circulatory dysfunction may be part of a multiorgan failure with disturbed haemodynamics of various vascular beds, including those of the splanchnic system, kidneys, brain and lungs. It is still an enigma why patients with chronic liver disease are at the same time overloaded and functional hypovolaemic with a hyperdynamic, hyporeactive circulation. Further research is needed to find the solution to this apparent haemodynamic conflict concerning the abnormal neurohumoral fluid regulation in chronic liver disease.

Portal and splanchnic haemodynamics in patients with advanced post-hepatitic cirrhosis and in healthy adults

Portal and splanchnic haemodynamics in patients with advanced post-hepatitic cirrhosis and in healthy adults

Effects of endoscopic variceal ligation on systemic and splanchnic hemodynamics in patients with cirrhosis.

It has been shown that patients with cirrhosis and portal hypertension have hyperdynamic systemic and splanchnic circulation. This study was designed to assess how endoscopic variceal ligation may influence systemic and splanchnic hemodynamics. Sixteen patients with cirrhosis and esophageal varices were studied. Cardiac output and flow volume of the portal vein and the superior mesenteric artery were determined by means of duplex Doppler ultrasonography. Mean arterial pressure was also recorded. These hemodynamic measurements were performed before and after initial (3 days after initial session) and repeated (7 days after last session) variceal ligation. No significant changes in cardiac output and mean arterial pressure were found after either initial or repeated variceal ligation. Thus, systemic vascular resistance was not modified. In splanchnic hemodynamics, portal vein blood flow significantly increased after initial variceal ligation (27%, P < 0.01) but it returned to the baseline value after repeated variceal ligation. In contrast, superior mesenteric artery blood flow significantly decreased after initial variceal ligation (17%, P < 0.01) and it returned to the baseline value after repeated variceal ligation. Effect of variceal ligation on splanchnic hemodynamics is transient and variceal ligation has very little effect on systemic circulation. Thus, patients with cirrhosis underwent repeated variceal ligation still have abnormal systemic and splanchnic circulation.

Effect of verapamil on portal and splanchnic hemodynamics in patients with advanced posthepatitic cirrhosis using duplex Doppler ultrasound

Purpose: To assess the effect of verapamil (80 mg) oral administration on portal and splanchnic hemodynamics in patients with advanced posthepatitic cirrhosis using duplex Doppler ultrasound (US). Methods: Fourteen patients with post-hepatitic liver cirrhosis were included in the study. Duplex Doppler sonographic examinations were performed before, and 2–3 h after, 80 mg verapamil oral administration. Portal and splanchnic hemodynamics including vessel diameters (mm), mean flow velocities (cm/s), blood flows (ml/min), Doppler indices such as pulsatility and resistive indices (PI and RI), were investigated before and after verapamil administration. Results: After verapamil administration; diameter of portal vein, splenic vein, and superior mesenteric artery (SMA) showed increase of 8%, 10%, and 7% ( P < 0.05 to < 0.001), respectively. Increases of 20%, 38%, and 47% were found in blood flows ( P < 0.05 to < 0.0001) with respect to the above vessels. Decreases of 17%, 10%, 11%, and 7% were found in SMA PI, SMA RI, splenic artery (SA) PI, and SA RI, respectively ( P < 0.05 to < 0.0001). Conclusions: Verapamil appears to have splanchnic, portal, splenic, portocollateral and probably intrahepatic vasodilator effects in patients with advanced posthepatitic liver cirrhosis. Verapamil should be further investigated in the treatment of patients with advanced liver cirrhosis with prospective studies measuring portal and wedged hepatic pressure.

Effects of isosorbide-5-mononitrate on variceal pressure and systemic and splanchnic haemodynamics in patients with cirrhosis

Background: Isosorbide-5-mononitrate is a long-acting nitrovasodilator which was introduced for the treatment of portal hypertension because of its capacity to reduce portal pressure. In contrast to vasoconstrictors, isosorbide-5-mononitrate acts primarily by decreasing portal-collateral resistance without deleterious effects on liver function, although at high doses, a reflex splanchnic vasoconstriction elicited by the fall in arterial pressure may further decrease portal pressure. However, there is no information on the effects of isosorbide-5-mononitrate on variceal pressure, which is thought to be a major determinant of variceal haemorrhage. Methods: We investigated the effects of isosorbide-5-mononitrate (40 mg, orally; in=12) or placebo ( n=10) on variceal pressure (non-invasive endoscopic gauge) and hepatic haemodynamics in 22 patients with cirrhosis. Results: Placebo administration had no significant effects. In contrast, isosorbide-5-mononitrate significantly reduced variceal pressure (from 13.5±3.6 to 9.8±3.2 mmHg, p<0.005). This was associated with a fall in wedged hepatic venous pressure (from 28±5.8 to 25.9±6.2 mmHg, p<0.005), hepatic venous pressure gradient (from 20±4 to 18±4.7 mmHg, p<0.005) and azygos blood flow (from 668±197 to 597±160 ml/min, p<0.05), suggesting that the decrease in variceal pressure caused by isosorbide-5-mononitrate could be caused by both reductions in collateral resistance and collateral blood flow. Isosorbide-5-mononitrate moderately reduced mean arterial pressure (−13±16%; p<0.005), its fall being directly related to the fall in hepatic venous pressure gradient ( r=0.6, p<0.01). Conclusions: The results of this study show that isosorbide-5-mononitrate markedly and significantly reduces variceal pressure in patients with cirrhosis and provide further support for its clinical use in the pharmacological treatment of portal hypertension.

The effects of chronic endoscopic variceal sclerotherapy on systemic and splanchnic hemodynamics in patients with cirrhosis.

The aim of this study was to determine whether endoscopic variceal sclerotherapy affects systemic or splanchnic hemodynamics. We measured hemodynamic parameters before and after the first course of sclerotherapy in 35 patients with cirrhosis. Following sclerotherapy, there was a significant decrease in cardiac index and a significant increase in systemic vascular resistance. Changes in hepatic venous pressure gradient varied from patient to patient with no statistically significant change in the group overall. However, all 20 patients with a decline in the hepatic venous pressure gradient had a concomitant decrease in cardiac index and/or a large extravariceal shunt. The multivariate analysis disclosed that the decrease in cardiac index was a statistically significant contributor for the decline in hepatic venous pressure gradient. We conclude that the obliteration of esophageal varices by sclerotherapy significantly reverses the hyperdynamic circulatory state in patients with cirrhosis. Spontaneous changes in systemic hemodynamics and the interaction with hepatic hemodynamics must be taken into account when evaluating hepatic hemodynamics in patients undergoing variceal sclerotherapy.

Effects of isosorbide-5-mononitrate on variceal pressure and systemic and splanchnic hemodynamics in patients with cirrhosis. A double-blind controlled study versus placebo

Effects of isosorbide-5-mononitrate on variceal pressure and systemic and splanchnic hemodynamics in patients with cirrhosis. A double-blind controlled study versus placebo

Low dose of nitroglycerin failed to improve splanchnic hemodynamics in patients with cirrhosis: Evidence for an impaired cardiopulmonary baroreflex function

High doses of nitroglycerin may decrease portal pressure in patients with cirrhosis with untoward effects such as arterial hypotension and a decrease in systemic O2 uptake. In the present study, low doses of nitroglycerin (7 to 15 micrograms per min, i.v.) were administered in 11 patients with cirrhosis in order to unload cardiopulmonary baroreceptor--one of the possible mechanisms by which nitroglycerin may improve splanchnic hemodynamics--and moreover to avoid deleterious systemic effects. Nitroglycerin significantly decreased right atrial pressure (-35%) and pulmonary wedged pressure (-27%) with significant increase in plasma norepinephrine concentration (+23%), which indicated that cardiopulmonary baroreceptor unloading was achieved. Changes in systemic hemodynamics were slight, although significant, with a decrease in arterial pressure (-8%) and an increase in heart rate (+8%); this indicates a minimal effect on high-pressure baroreflexes. In contrast, no significant change was observed in hepatic venous pressure gradient, hepatic blood flow and azygos blood flow. However, the fraction of cardiac output reaching the azygos system significantly increased by 18%. Plasma renin activity did not change significantly. Moreover, O2 transport and uptake were significantly decreased. These findings show that low doses of nitroglycerin failed to improve splanchnic hemodynamics in patients with cirrhosis. These results suggest an impaired cardiopulmonary baroreflex function which is probably located on the efferent arch.