Computed virtual chromoendoscopy versus standard colonoscopy with targeted indigocarmine chromoscopy: a randomised multicentre trial.

OBJECTIVE: Colonoscopy is the accepted gold standard for screening of neoplastic colorectal lesions, but the substantial miss rate remains a challenge. Computed virtual chromoendoscopy with the Fujinon intelligent colour enhancement (FICE) system is a new dyeless imaging technique that might allow higher rates of adenoma detection. METHODS: This is a prospective randomised five tertiary care centre trial of colonoscopy in the FICE mode versus standard colonoscopy with targeted indigocarmine chromoscopy (control group) in consecutive patients attending for routine colonoscopy. Histopathology of detected lesions was confirmed by evaluation of endoscopic resection or biopsy specimens. RESULTS: 871 patients were enrolled, and 764 patients (344 female, mean age 64 years) were subjected to final analysis (368 in the FICE group, 396 in the control group). In total, 236 adenomas (mean of 0.64 per case) were detected in the FICE group and 271 adenomas (mean of 0.68 per case) in the control group (p = 0.92). There was no statistically significant difference in the percentage of patients with >or=1 adenoma between the control group (35.4%) and the FICE group (35.6%) (p = 1.0). For the differential diagnosis of adenomas and non-neoplastic polyps, the sensitivity of FICE (92.7%) was comparable with that of indigocarmine (90.4%) (p = 0.44). CONCLUSIONS: At colonoscopy, adenoma detection rates are not improved by virtual chromoendoscopy with the FICE system compared with white light endoscopy with targeted indigocarmine spraying. However, FICE can effectively substitute for chromoscopy concerning the differentiation of neoplastic and non-neoplastic lesions.

Association of primary biliary cirrhosis and blue rubber bleb naevus syndrome.

A 66-year old woman presented all the features of primary biliary cirrhosis and the blue rubber bleb naevus syndrome. This case represents a new association of primary biliary cirrhosis with an inherited disease.

[Hepatopulmonary syndrome]. / Das hepatopulmonale Syndrom.

The hepatopulmonary syndrome (HPS) is a functional process which is characterized by the triad of liver cirrhosis, intrapulmonary vascular dilatations, and arterial hypoxemia in absence of detectable intrinsic disease of the lung and the heart. The pathophysiological foundation is the presence of a ventilation-perfusion (VA/Q) inequality based on marked vasodilatation of the pulmonary vessels at the precapillary level. Only in critically ill patients limitations of the diffusion of oxygen from the alveolar gas to the capillary blood and intrapulmonary arterio-venous communications will contribute increasingly to the hypoxemia. For diagnosis of HPS arterial blood gases (under condition of room air and 100% oxygen), contrast echocardiography, pulmonary angiography, and multiple inert gas elimination techniques will provide important informations. Regarding recent studies, liver transplantation is the treatment of choice in patients with severe HPS.

[Pneumoretroperitoneum and bilateral pneumothorax after endoscopic biliary sphincterotomy]. / Pneumoretroperitoneum und beidseitiger Pneumothorax nach endoskopischer Sphinkterotomie.

HISTORY AND ADMISSION FINDINGS: A 39-year-old obese woman underwent endoscopic retrograde cholangiopancreatography with elective endoscopic biliary sphincterotomy (papillotomy) for symptomatic retained stones in the common bile duct which were extracted completely after added lithotripsy. Three hours later the patient developed profound subcutaneous emphysema of the face, neck and chest wall and shortness of breath, but had no abdominal pain. Physical examination revealed bilaterally diminished breath sounds and a distended and hyper-resonant abdomen, but no evidence of peritonitis. The patient was afebrile and hemodynamically stable. INVESTIGATIONS: An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen was performed. It demonstrated a bilateral pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum, in addition to extensive subcutaneous emphysema. There was no evidence of extraluminal leakage of contrast medium or intraperitoneal fluid on the CT. THERAPY AND CLINICAL COURSE: Because of the increasing respiratory distress an intercostal drain was placed in the left pneumothorax and broad-spectrum antibiotics were administered. No drain was placed in the right lung. A follow-up CT after three days showed decreasing pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum as well as resolution of the bilateral pneumothorax. The patient made an uneventful recovery and was discharged home seven days after the intervention. CONCLUSION: Pneumothorax after endoscopic biliary sphincterotomy is a rare but serious complication that should be kept in mind after postinterventional development of shortness of breath.

Diagnosis of small bowel Crohn's disease: a prospective comparison of capsule endoscopy with magnetic resonance imaging and fluoroscopic enteroclysis.

BACKGROUND AND AIMS: The diagnostic yield of capsule endoscopy (CE) compared with magnetic resonance imaging (MRI) in small bowel Crohn's disease is not well established. We prospectively investigated CE, MRI, and double contrast fluoroscopy in patients with suspected small bowel Crohn's disease. METHODS: Fifty two consecutive patients (39 females, 13 males) were investigated by MRI, fluoroscopy and--if bowel obstruction could be excluded--by CE. In 25, Crohn's disease was newly suspected while the diagnosis of Crohn's disease (non-small bowel) had been previously established in 27. RESULTS: Small bowel Crohn's disease was diagnosed in 41 of 52 patients (79%). CE was not accomplished in 14 patients due to bowel strictures. Of the remaining 27 patients, CE, MRI, and fluoroscopy detected small bowel Crohn's disease in 25 (93%), 21 (78%), and 7 (of 21; 33%) cases, respectively. CE was the only diagnostic tool in four patients. CE was slightly more sensitive than MRI (12 v 10 of 13 in suspected Crohn's disease and 13 v 11 of 14 in established Crohn's disease). MRI detected inflammatory conglomerates and enteric fistulae in three and two cases, respectively. CONCLUSION: CE and MRI are complementary methods for diagnosing small bowel Crohn's disease. CE is capable of detecting limited mucosal lesions that may be missed by MRI, but awareness of bowel obstruction is mandatory. In contrast, MRI is helpful in identifying transmural Crohn's disease and extraluminal lesions, and may exclude strictures.

Concentrations of albendazole in serum, cerebrospinal fluid and hydatidous brain cyst.

A young girl with cerebral echinococcosis was treated with albendazole (13 mg/kg/d, p.o.). The concentrations of albendazole sulphoxide were determined in serum, cerebrospinal fluid and hydatidous cyst over a month. The mean ratios of concentration were: CSF/serum = 50%, cyst/serum = 40%, cyst/CSF = 80%.

[Hepatopulmonary syndrome]. / Das hepatopulmonale Syndrom.

The hepatopulmonary syndrome (HPS) is a functional process and is characterized by the triad of liver cirrhosis, intrapulmonary vascular dilatations, and arterial hypoxemia in absence of detectable intrinsic disease of the lung and the heart. The pathophysiological fundament is the presence of a ventilation-perfusion (VA/Q) inequality based on marked vasodilatation of the pulmonary vessels at the precapillary level. Only in critically ill patients limitations of the diffusion of oxygen from the alveolar gas to the capillary blood and intrapulmonary arteriovenous communications will increasingly contribute to the hypoxemia. For diagnosis of the HPS the arterial blood gases (under condition of room air and 100% oxygen), the contrast echocardiography, the pulmonary angiography, and the multiple inert gas elimination technique will give important informations. Regarding recent studies liver transplantation is the treatment of choice in patients with severe HPS.

[Acute upper gastrointestinal hemorrhage. Diagnosis and management]. / Akute obere Gastrointestinalblutung. Diagnostik und Management.

Upper gastrointestinal hemorrhage calls for a team approach. Early endotracheal intubation of unconscious patients helps to prevent aspiration. Erythromycin i.v. 20 min. before emergency endoscopy improves the diagnostic yield. Patients without increased risk of rebleeding may be treated on an outpatient basis. Band ligation is the gold standard for acute variceal bleeding. Terlipressin, somatostatin and octreotide are equally effective but require additional measures for prevention of late recurrence. Somatostatin and analogues used as adjunct to ligation slightly reduce the risk of rebleeding but not of death. Three to seven days of prophylactic antibiotics decrease the risk of uncontrolled or recurrent bleeding. Therapeutic failures are rescued by transjugular intrahepatic portosystemic shunting (TIPS). Patients with nonvaricose bleeding should only be treated when active hemorrhage or a "visible vessel" is found. First line treatment is endoscopic injection of diluted adrenalin or isotonic saline. Thermal coagulation is an alternative. Tissue-destructing sclerosants should be avoided. Clipping and injection of fibrin glue are second and third line measures. Proton pump inhibitors improve endoscopic hemostasis, however, it is unclear whether high i.v. doses are required. H. pylori must be eradicated to prevent late recurrence. Rebleeding is treated endoscopically with angiographic intervention or surgery as rescue measures.

Transjugular intrahepatic portosystemic shunt: short-term and long-term effects on hepatic and systemic hemodynamics in patients with cirrhosis.

The aim of this prospective, nonrandomized study was to assess the short- and long-term effects of transjugular intrahepatic portosystemic shunt (TIPS) on hepatic and systemic hemodynamics and on gastroesophageal collateral flow in patients with cirrhosis and failure of chronic sclerotherapy. Cardiac output (CO), free and wedged pulmonary artery pressure (FPAP and WPAP), systemic vascular resistance (SVR), azygos venous blood flow (AzVBF), and the relative (portal minus vena cava) pressure in the portal vein (rel.PP) were determined immediately before, 30 minutes, 1 week, 3 months, and 1 year after TIPS implantation in 21 patients with alcoholic and biliary cirrhosis with repeated bleeding from esophageal varices despite chronic sclerotherapy. TIPS was inserted when patients were in a stable hemodynamic condition. Palmaz stents were dilated to a 10-mm to 14-mm diameter until gastroesophageal collaterals were no longer visible on direct splenoportography. Relative portal pressure decreased from 21 +/- 5 mm Hg to 11 +/- 5 mm Hg 30 minutes after the procedure (P <.001). CO increased from 7.1 +/- 1.5 L/min at baseline to 8.9 +/- 2.0 L/min (P <.005) at 30 minutes, 8.2 +/- 2.0 L/min (P <. 01) at 1 week, and 8.0 +/- 2.0 L/min (P <.01) at 3 months after TIPS, and returned to 7.2 +/- 1.3 L/min (ns) after 1 year. Before TIPS, SVR was 990 +/- 285 dyne. sec. cm-5 and decreased to 856 +/- 252 dyne. sec. cm-5 (P <.05) and 866 +/- 267 dyne. sec. cm-5 (P <.05) at 30 minutes and 1 week after the procedure, and increased again to 903 +/- 208 dyne. sec. cm-5 (ns) and 1,016 +/- 260 dyne. sec. cm-5 (ns) at 3 months and 1 year, respectively. AzVBF continuously decreased from 474 +/- 138 mL/min before TIPS to 335 +/- 116 mL/min, 289 +/- 147 mL/min, 318 +/- 157 mL/min, and 250 +/- 104 mL/min (all P <.005) at 30 minutes, 1 week, 3 months, and 1 year after TIPS. Portal decompression after TIPS is associated with a significant increase of CO for at least 3 months, which is only partly explained by a transient decrease of SVR. After 1 year, CO had returned to baseline levels. Despite an immediate decrease in portal pressure, the reduction of blood flow through gastroesophageal collaterals is delayed and not complete before 1 year after TIPS. In contrast to previous short-term observations, TIPS does not seem to cause long-term aggravation of the hyperkinetic circulation in patients with cirrhosis.

[Spontaneous bacterial peritonitis (SBP). Retrospective and prospective data from a multicenter study on prevalence, diagnosis and therapy in Germany]. / Spontane bakterielle Peritonitis (SBP). Retrospektive und prospektive Daten einer multizentrischen Studie zu Prävalenz, Diagnostik und Therapie in Deutschland.

BACKGROUND: Data regarding the prevalence of SBP in patients with ascites or the diagnostic and therapeutic management of SBP in Germany are lacking. PATIENTS AND METHODS: In a multicenter study (40 hospitals), retrospective, then prospective data were collected investigating the prevalence of SBP in patients with ascites and the pertinent diagnostic and therapeutic management. In 272 prospectively entered patients with ascites (cirrhosis/malignant ascites/other: n = 227/42/3) a diagnostic paracentesis was performed and SBP diagnosed using the ascitic neutrophil count. History, clinical symptoms and laboratory findings were recorded and potential risk factors analysed by univariate analysis and stepwise logistic regression. SBP was treated with a standard dose of a third-generation cephalosporin. RESULTS: In the retrospective study, SBP was diagnosed in 648 of 4,697 patients with ascites (14 %). Employed diagnostic and therapeutic pathways were not effective in several hospital departments. In the prospective trial, SBP was found in 134 of 272 patients with ascites (49,3 %). Frequency of symptoms was significantly different in patients either with or without SBP, as were macroscopic aspect of ascites, urine excretion and several biochemical parameters. However, their diagnostic precision was unsatisfactory. Predictive factors for SBP were previous paracentesis, endoscopic procedures and a history of abdominal pain. Treatment was effective in 83,5 % of cases. Inhospital mortality was 10 %. CONCLUSION: The prevalence of SBP in hospitalised patients with ascites in Germany is similar to that in southern Europe and USA. Symptoms alone lack sufficient diagnostic accuracy. Third-generation cephalosporin is an effective antibiotic in SBP. Pertinent diagnostic and therapeutic management calls for improvement.

[Portal vein thrombosis in a patient with lowered protein S level]. / Pfortaderthrombose bei einem Patienten mit erniedrigtem Protein-S-Spiegel.

HISTORY AND CLINICAL FINDINGS: In a 39-year-old man with increasing spasmodic epigastric pain, nausea and vomiting, varices of the esophagus and the gastric fundus were found endoscopically. INVESTIGATIONS: A portal vein thrombosis and a consecutive thrombosis of the splenic vein were diagnosed by colour Doppler sonography and angio CT. A protein S deficiency (59 %) was found to be the underlying illness. TREATMENT AND COURSE: The thrombosis and the resulting clinical symptoms completely resolved shortly after starting therapeutic heparinization. For six months, the patient has been without complaints or clinical symptoms. CONCLUSION: Hence, an isolated protein S deficiency can be the cause for a portal vein thrombosis.

[Endoscopic therapy of cholangiolithiasis by percutaneous approach. Percutaneous gallstone therapy]. / Endoskopische Therapie der Cholangiolithiasis über perkutanen Zugang. Perkutane Gallensteintherapie.

PATIENTS AND METHODS: In a retrospective study, the results of percutaneous transhepatic therapy of bile duct stones under cholangioscopic control (PTCS) were evaluated in 32 patients in which a endoscopic retrograde stone removal was impossible or failed. RESULTS: Previous gastric surgery was the most common reason for choosing the percutaneous route (22 cases). Five patients had biliodigestive anastomosis, two pyloric obstructions, and in three patients the retrograde stone removal failed. Complete stone removal was obtained after 3 to 11 (median 5) percutaneous procedures in all cases, in 28 patients by electrohydraulic lithotripsy, and in the remaining 5 cases by mechanical extraction alone. There was no complication due to cholangioscopy and lithotripsy themselves. Two cases had major complications which needed laparotomy (4%, one case had capsular bleeding from the liver, another one had catheter perforation of the duodenum). In addition, three cases (7%) had minor complications which required no therapy during the percutaneous fistula procedure. Two elderly multimorbid patients (4%) died during hospitalisation after successful stone removal not related to the performed procedure. CONCLUSION: The percutaneous transhepatic cholangioscopy (PTCS) and lithotripsy are highly effective techniques for endoscopic treatment of bile duct stones. Because of an increased rate of complications during the fistula procedures, both methods should be restricted to cases with difficult anatomic situation and high risk of surgery.

Transjugular intrahepatic portosystemic shunt for bleeding angiodysplasia-like lesions in portal-hypertensive colopathy.

Portal-hypertensive colopathy has attracted interest in recent years because such lesions can cause life-threatening hemorrhage. In contrast to upper gastrointestinal bleeding from varices, there is no established therapy for bleeding from angiodysplasia-like lesions. This case report describes the first successful use of transjugular intrahepatic portosystemic shunt (TIPS) for long-term control of bleeding from angiodysplasia-like colonic lesions in a patient with cirrhosis caused by chronic hepatitis B infection. During an 18-month course after TIPS, angiodysplasia-like lesions disappeared without any further evidence of recurrent hematochezia. TIPS may be helpful as second-line treatment in patients with recurrent portal-hypertensive bleeding from colonic angiodysplasia-like lesions who do not tolerate or are unresponsive to treatment with beta-adrenergic blockers.

[Therapeutic results after papilloduodenal injuries following ERCP]. / Behandlungsergebnisse nach papilloduodenalen ERCP-Verletzungen.

INTRODUCTION: Our goal was to compare operative vs. conservative therapeutic strategies after injuries following ERCP. METHODS: Eight patients with ERCP-induced injuries were surveyed retrospectively. Four of them were treated operatively, four conservatively. Criteria for an operative therapy were clinical and radiological findings and laboratory data. RESULTS: The four patients that were treated conservatively had an uncomplicated course whereas three of four patients treated operatively had long and complicated stays. In these patients the operation was performed more than 24 hours after injury. All of them showed advanced biliary peritonitis. One patient was operated on within 24 hours. He was discharged after a short stay without complications. All injuries were located in the retroperitoneum. Five patients showed anatomical abnormality of either duodenum, papilla or common bile duct. In five cases the duodenum was involved in the injury. CONCLUSIONS: The course of disease of the operated patients was longer and more complicated compared to those treated conservatively. According to our data the timing of the operation seems to be an important criterion with respect to the prognosis. Due to the small number of patients, whether conservative therapy should be preferred cannot be determined. The role of the location of injury is also not clarified.

Decreased and variable systemic availability of zidovudine in patients with AIDS if administered with a meal.

The systemic availability of oral zidovudine has been studied in 13 patients with the acquired immunodeficiency syndrome (AIDS) dosed either fasting or with breakfast. The mean peak plasma concentration and AUC of zidovudine were significantly 2.8- and 1.4-times higher in fasting patients than in those treated during meal. In both conditions the mean half-life was about 1.5 h and the period of plasma zidovudine concentrations greater than 1 mumol.l-1 was 2 h (NS). It is concluded that if zidovudine is taken on an empty stomach, high peak plasma concentrations and decreased variation in pharmacological parameters may be expected. Whether or not this will influence toxicity and efficacy remains to be shown.

The 13C-urea breath test--detection of Helicobacter pylori infection in patients with partial gastrectomy.

The 13C-urea breath test (13C-UBT) for diagnosis of Helicobacter pylori (Hp) infection was evaluated in 41 patients after partial gastrectomy and was used for determination of the Hp-prevalence after two different procedures of reconstruction of the gastrointestinal tract, i.e. Billroth's II operation and Roux-en-Y anastomosis. Breath samples were taken at various time points within 30 minutes after a motility inhibiting liquid test meal with citric acid followed by 75 mg of 13C-urea. The 13CO2/12CO2-ratio (delta-value) was measured using isotope ratio mass spectrometry and the recovery of tracer in the exhaled breath was calculated (UBT-value). In all patients and in the corresponding control groups comparison of established reference methods (culture, CLO test, and Fuchsin staining) with the 4 point breath analysis for detection of Hp was investigated. In patients with partial gastrectomy, the sensitivity of the 13C-UBT to detect the presence of Hp and the negative predictive values were 100%, whereas the specificity and the positive predictive values were about 80%. In patients without gastric surgery quality control parameters were not significantly different. Hp-prevalence in postoperative patients was about 45%. All results were independent of their expression either as delta-value or as UBT-value and were not significantly different between the patients with Billroth's II operation and the patients with Roux-en-Y anastomosis. In conclusion, the 13C-UBT is a suitable method for diagnosis and therapeutic monitoring of Hp-status in patients after partial gastrectomy.

Ursodeoxycholic acid in primary biliary cirrhosis: no evidence for toxicity in the stages I to III.

In an open, exploratory study, the safety of ursodeoxycholic acid (UDCA) in the treatment of primary biliary cirrhosis (PBC) was investigated. Seven patients in stages I to III and two patients in stage IV were treated for 1 year with 1 g/day of UDCA. Clinical symptoms, and alkaline phosphatase, gamma-glutamyltransferase, alanine aminotransferase (GOT) and aspartate aminotransferase (GTP) levels improved significantly within three months and remained at the lower levels for the period of observation. Results of the galactose elimination capacity (4.7 +/- S.D. 1.4 mg/min per kg) and the aminopyrine breath test (0.60 +/- 0.33% dose/kg per mmol CO2) remained unchanged for 1 year. In all patients total serum bile acids increased and quantitatively UDCA became the most important bile acid. In patients in stages I to III this increase, however, was modest, whereas in patients in stage IV, total serum bile acids reached levels of 140 and 157 mumol/l and UDCA, levels of 90 and 103 mumol/l, respectively. It is concluded that UDCA appears to be safe only in stages I to III and that prognostic stratification based on bile acid levels or on the histological stage of the disease should be an important aspect of controlled clinical trials.

Quantitative liver function tests as surrogate markers for end-points in controlled clinical trials: a retrospective feasibility study.

Quantitative liver function tests such as the determination of galactose elimination capacity (GEC) or the aminopyrine breath test (ABT) may have the potential to serve as refined entry criteria and surrogate markers for end-points in controlled clinical trials. The magnitude of a statistically detectable difference in test results and the period of observation required to document such a difference must be known to properly design such trials. Therefore, we explored retrospectively the time course of changes in GEC and ABT and their reproducibility from a cohort of patients with alcoholic cirrhosis followed for 12 to 42 months, with a median of 34 months. In 15 patients who stopped drinking, GEC improved significantly by 0.64 mg/min/kg within 1 year (mean; 95% confidence interval [CI]: 0.42; 0.86). In contrast, it deteriorated by 0.53 mg/min/kg within 1 year (95% CI: 0.32; 0.74) in another 17 patients who continued to drink (P < .01). The residual standard deviation of the changes in GEC with respect to the patients' initial values was 0.43 mg/min/kg (95% CI: 0.32; 0.52). In addition, ABT improved significantly by 0.14% dose x kg/mmol CO2 (95% CI: 0.09; 0.18) in the abstinent group, and deteriorated by 0.09% dose x kg/mmol CO2 (95% CI: 0.06; 0.13) in the nonabstinent group (P < .01). The residual standard deviation in the above sense for ABT was 0.08% dose x kg/mmol CO2 (95% CI: 0.06; 0.10). These data indicate that clinical trials with a sample size of n = 20 in each group must achieve absolute differences (ADs) in GEC of 0.6 mg/min/kg and of 0.7 mg/min/kg to reach statistical significance at the 5% and 1% level, respectively. In the present study, a period of 11 and 12 months was necessary to observe such differences. The corresponding results for the ABT are 0.11% dose x kg/mmol CO2 (9 months of follow-up; 5% level) and 0.13% dose x kg/mmol CO2 (11 months of observation; 1% level), respectively. Provided that patients with liver diseases treated with drugs are similar to the abstinent and nonabstinent patients with alcoholic liver disease investigated in this study, such numbers could serve for the planning of controlled clinical trials, in which the control group is likely to deteriorate and the treated group is expected to improve. Trials based on GEC or ABT would require only 37 or 30 patient years of observation compared with a median of 444 patient years (range, 50-2,100 patient years) reported for various published controlled clinical trials using survival analysis.

Urinary sodium balance in patients with cirrhosis: relationship to quantitative parameters of liver function.

The relationship between the impairment in hepatic and renal function in cirrhosis has not been well established. This study investigated urinary sodium excretion in comparison with quantitative parameters of liver function in 75 patients with various degrees of cirrhosis kept on a constant salt diet of 120 mmol/d for 5 days before the start of the study. The aminopyrine breath test (ABT), indocyanine green (ICG) elimination, galactose elimination capacity (GEC), and hepatic sorbitol elimination (HSE) served as quantitative parameters of liver function. Results for the quantitative tests were compared with those for the Child-Pugh score. Urinary sodium excretion showed a significant nonlinear relationship to ABT (r = .70; P < .0001). Less-significant correlations were observed for ICG (r = .60), the Child-Pugh score (r = -.57), GEC (r = .44), and HSE (r = .34). Because a number of significant correlations were observed between the different liver function tests, multivariate analysis was used to further elucidate the relationship between hepatic function and sodium excretion. Only one independent predictor of urinary sodium excretion could be identified, and that was the ABT (P < .02). More than half of the nonascitic patients showed a urinary sodium excretion of less than 80% of dietary sodium intake, indicating impaired renal sodium handling in preascitic cirrhosis. Based on the 95% confidence interval (CI) for ABT of nonascitic patients with normal (mean ABT 0.56% dose x kg/mmol CO2; 95% CI: 0.44 to 0.69) and reduced urinary sodium excretion (mean ABT 0.26% dose x kg/mmol CO2; 95% CI: 0.18 to 0.35), a threshold level of ABT of about 0.4 (% dose x kg/mmol CO2) for conservation of normal urinary sodium excretion in cirrhosis can be defined. This ABT value reflects an approximate 50% reduction in function compared with the mean of cirrhotic patients with normal liver and kidney function (0.81% dose x kg/mmol CO2). The presence of ascites was also associated with a reduction in ABT to below 0.4 (% dose x kg/mmol CO2), while, for all other parameters, either the cut-off point was close to the lower limit of normal or no cut-off level could be detected. In conclusion, the results of the present study provide further evidence that the impairment in urinary sodium excretion in cirrhosis is related to hepatic function. The data suggest a nonlinear relationship. Because ABT has been shown to reflect functional hepatocellular mass, the occurrence of sodium retention and ascites appears to be related to a threshold of an approximate 50% reduction in functional liver cell mass.