Measurement of L-[1-14C]leucine kinetics in splanchnic and leg tissues in humans. Effect of amino acid infusion.

Although whole-body leucine flux is widely measured to study body protein turnover in humans, the contribution of specific tissues to the total-body measurement remains unknown. By combining the organ-balance technique with the systemic infusion of L-[1-14C]leucine, we quantitated leucine production and disposal by splanchnic and leg tissues and by the whole body, simultaneously, in six normal men before and during amino acid infusion. At steady state, disposal of arterial leucine by splanchnic and leg tissues was calculated from the percent extraction (E) of L-[1-14C]leucine counts: uptake = E x [Leu]a x flow. Tissue release of cold leucine (from protein turnover) into vein was calculated as the difference between leucine uptake and the net tissue leucine balance. In the postabsorptive state, despite substantial (P less than .01) extraction of L-[1-14C]leucine by splanchnic (23 +/- 1%) and leg (18 +/- 2%) tissues, net leucine balance across both tissue beds was small, indicating active simultaneous disposal and production of leucine at nearly equivalent rates. Splanchnic tissues accounted for approximately 50% of the measured total-body leucine flux. During amino acid infusion, the net leucine balance across splanchnic and leg tissues became positive, reflecting not only an increase in leucine uptake but also a marked suppression (by approximately 50%, P less than .02) of cold leucine release. This reduction in splanchnic and leg leucine release was indicated by a sharp decline in whole-body endogenous leucine flux.(ABSTRACT TRUNCATED AT 250 WORDS)

Splanchnic and peripheral disposal of oral glucose in man.

Oral glucose (92 g) was administered to 22 healthy, young volunteers undergoing hepatic vein catheterization, and net splanchnic glucose output (SGO) was measured during the basal period and for 4 h after glucose ingestion. In the basal state, SGO averaged 1.90 +/- 0.11 mg/min X kg. After glucose, SGO rose to a peak value of 6.65 +/- 0.83 mg/min X kg at 30 min and returned to baseline by 3 h. Total SGO over 4 h was 69 +/- 4 g; assuming complete absorption of the load, this amount represented 75% of the oral glucose. In a subgroup of six subjects, leg glucose uptake was simultaneously quantitated by femoral vein catheterization and leg blood flow measurement. In the postabsorptive state, glucose uptake by one leg was 24 +/- 8 mg/min and increased to a mean value of 76 +/- 7 mg/min during the 4 h after glucose ingestion. Overall, 18 +/- 2 g/4 h of glucose were taken up by one leg, which extrapolates to a total body muscle uptake of 65 +/- 4 g over 4 h. We conclude that in normal man, well over 2/3 of an oral glucose load escapes splanchnic removal, and that the peripheral tissues quantitatively play the dominant role in glucose disposal.

Splenic vein thrombosis in patients with a normal size spleen.

The frequency of splenic vein obstruction secondary to pancreatic or retroperitoneal diseases has been only recently appreciated. The diagnosis is important because it frequently results in development of gastric and duodenal varices. It is often assumed that the diagnosis should only be suspected in patients with splenomegaly. This report describes 19 patients in whom splenic vein thrombosis was diagnosed by angiography although clinically unsuspected. In 11, the spleen was normal in size although extensive gastric varices were present. In 3 patients the presenting problem was massive hematemesis. Review of the upper gastrointestinal examinations in these patients showed thickened gastric or duodenal folds although in the absence of esophageal varices, the diagnosis was not made prior to angiography. More liberal use of angiography in patients with an appropriate clinical background, such as a history of pancreatitis, may lead to earlier and more frequent diagnosis of splenic vein obstruction. Varices that result from splenic vein obstruction can be cured by splenectomy.

Hemodynamic and morphologic evaluation of the spleen after splenic vein ligation in the dog.

The splenic vein was ligated in ten dogs in order to evaluate the time course of changes in splenic size and to relate them to splenic arterial flow, splenic pressure and development of venous collaterals. Following ligation of the splenic vein, splenic size and venous pressure immediately rose in all dogs. Arterial flow to the spleen simultaneously fell in roughly inverse proportion to the elevation of venous pressure. During the following weeks, the splenic parenchymal pressure decreased to basline levels in all but one dog, as collateral veins developed through the gastric venous network to the portal vein. Splenic size gradually decreased toward normal in eight of the ten dogs. At the time of sacrifice, 8-16 weeks after splenic vein ligation, pathologic examination demonstrated fibrosis from healed infarction. Recent hemorrhage, indicating persistence of the congestive process, we also present, although difficult to explain in view of normal splenic parenchymal pressure.

Uterine embolization in a patient with postabortal hemorrhage.

A case of postabortal hemorrhage in a patient with von Willebrand's disease was controlled by arteriographic embolization of the uterine branch of the internal iliac artery. Selective internal iliac artery embolization has been effectively used to control postpartum hemorrhage and hemorrhage resulting from pelvic malignancy. A discussion is presented for expanding the use of selective embolization for controlling uterine hemorrhage to patients suffering from postabortal bleeding as a means of controlling hemorrhage without sacrificing fertility.

Ureteral injuries at laparoscopy: insights into diagnosis, management, and prevention.

The increasing use of laparoscopy as a therapeutic method mandates a reappraisal of the risks involved. Complications frequently described include injuries to the large and small bowels, bladder, and blood vessels. The world literature reports only eight cases of ureteral injury at laparoscopy. In this report, we present five additional cases of ureteral injury occurring at laparoscopy, in addition to a summary of those previously reported. Patients tend to present in the early postoperative period (48-72 hours) with low back pain, abdominal pain, leukocytosis, and peritonitis. The diagnosis should be made by intravenous pyelography; if possible, the injury should be stented by either the retrograde or percutaneous route. The injuries, except for one apparent trocar injury, involved the use of electrocoagulation, both unipolar and bipolar. The injuries occurred most commonly near the uterosacral ligaments. In 38% (five of 13) of the cases, the laparoscopy was performed for treatment of endometriosis. Three of the 13 patients eventually lost renal function of the affected side; two of these underwent a nephrectomy. Because visualization of the ureter near the cervix at the time of laparoscopy is difficult, especially in the presence of disease, laparoscopic procedures in this area must be carried out with caution.

Embolization of bleeding esophageal varices via umbilical vein. An alternative approach.

Embolization of bleeding esophageal varices via the umbilical vein can be used as an alternative technique to percutaneous transhepatic coronary vein occlusion (PTCVO). Both techniques can stop acute bleeding from esophageal varices and allow the cirrhotic patient with portal hypertension to be prepared for an elective rather than an emergency shunt. Embolization via the umbilical vein can be performed with a patient under local anesthesia, can be effective when other methods fail, and can be done safely in the presence of both ascites and a bleeding diathesis, which are two contraindications to PTCVO.

Technical aids in investigation and management of urethral diverticula in the female.

Three aids in the diagnosis and management of urethral diverticula are described. First, the technique of double-balloon urethrography has been modified. Diluted contrast medium is used to inflate the intravesical and external balloons so that improved delineation of the anatomy of the diverticular pouches is obtained with undiluted contrast medium. Second, for identification and irrigation with antibiotic solution of the nondraining pouches of compound diverticula, an angiographic catheter is placed in the most distal pouch using fluoroscopically guided manipulation, and then this catheter is replaced with a pigtail-shaped nephrostomy drainage catheter. Third, a 7 F Foley catheter balloon is placed in thin-walled and friable diverticular pouches to facilitate dissection.

Problems in noninvasive imaging of pulmonary embolism.

The V/Q scintigram is the mainstay of pulmonary embolism diagnosis, but there are limitations, such as the need for sophisticated interpretation, the production of indeterminate readings, and the lack of specificity. The authors discuss these problems and the emerging techniques that may be more of a help to the radiologist faced with diagnosing pulmonary embolism.

Duodenal varices in extrahepatic portal obstruction.

Duodenal varices were angiographically demonstrated in 18 cases of extrahepatic obstruction of the portal vein or obstruction of the splenic vein. In 11 cases, barium examination of the upper gastrointestinal tract revealed prominent filling defects in the duodenal bulb and the duodenal sweep. These abnormalities share common characteristics and differ in their appearance from more commonly diagnosed duodenal lesions; their demonstration should raise the suspicion of extrahepatic portal or splenic vein obstruction, which may be verified by angiography.

Angiographic diagnosis of intrinsic duodenal inflammatory disease.

Duodenal tumors are rare but duodenal inflammatory disease occurs frequently. In most cases it can be accurately diagnosed without angiography but in the occasional case that presents a diagnostic problem, angiography is required. Seven cases of duodenal inflammatory disease are reviewed. Careful attention to the shape and direction of vascular displacement and to separate evaluation of pancreatic and duodenal arteries accurately distinguished duodenal from pancreatic disease. This distinction can significantly influence subsequent therapy.