Budd-Chiari syndrome with thrombosis of the inferior vena cava: long-term patency of meso-caval and cavoatrial prosthetic bypass.

Portacaval or mesocaval shunts may relieve ascites that is caused by chronic forms of primary Budd-Chiari syndrome. When inferior vena cava stenosis is severe or is the site of thrombosis, another procedure has to be used. Portoatrial or cavoatrial shunting has been suggested, and a few reports have been made after only a short follow-up period. The case of a young woman with long-standing ascites caused by primary occlusion of the hepatic veins illustrates the incomplete relief of ascites after mesocaval shunt, which was caused by severe stenosis of the inferior vena cava. At 2 1/2-year follow-up, thrombosis of the retrohepatic inferior vena cava was documented and the mesocaval shunt remained patent. Cavoatrial bypass performed with the use of a long Dacron graft was successful as noted at a 4 1/2-year postoperative follow-up, and there was angiographic proof of patency. Budd-Chiari syndrome with stenosis or thrombosis of the inferior vena cava may be cured by prosthetic bypasses to the right atrium. Combined mesocaval and cavoatrial shunt should be encouraged in this specific situation.

Hepatoma after thorotrast. Morphological and autoradiographic data.

Two women, respectively given thorotrast 30 and 40 years ago, died of hepatoma. The spleen and liver of one and the liver of the other were studied by morphological, macro- and micro-autoradiographic methods. The part played by thorotrast in the neoplasic process and its effect on the mechanism of tumour induction are discussed.

[Histological and histoenzymological study of liver. II: In gallstone treated with chenodeoxycholic acid (author's transl)]. / Etude histologique et histoenzymologique du foie. II: Dans la lithiase vésiculaire traitée par l'acide chénodesoxycholique.

The histological and histochemical changes of liver from gallstones treated with ACDC are confronted with the same livers before treatment. There is few modification in histological patterns but the frequency of sinusoidal congestion increase. Numerous histoenzymological "injuries" are corrected by this treatment.

[Histological and histoenzymological study of liver. I: In gallstone without treatment (author's transl)]. / Etude histologique et histoenzymologique du foie. I: Dans la lithiase vésiculaire non traitée.

46 liver biopsies from gallstones and a control group have been studied by histological and histoenzymological technics. The most frequent injuries are in the portal tract, inflammatory infiltration and fibrosis; the most peculiar is a sinusoidal congestion. A brown pigment overload is seen in numerous livers. Lactic-, glyceric-, glutamic-, isocitric-, glucose-6-phosphate-deshydrogenase activities decrease but alkaline phosphatases-, transaminases activities are increased.

Comparison of six treatments of ascites in patients with liver cirrhosis. A clinical trial.

UNLABELLED: A national multicenter study (34 centers) compared six treatments in 328 patients with cirrhotic ascites. Excluded were patients with g.i. bleeding within the last six months, chronic encephalopathy, cancer, tuberculosis or the following complications persisting after three weeks: acute encephalopythy, fever greater than 38 degrees C, infected ascites or biochemical abnormalities: blood urea greater than 8 mmol/l, natremia less than 130 mmol/l, kaliemia less than 2.5 or greater than 5.5 mmol/l, WBC greater than 12000 mm3, total bilirubin greater than 85.5 mumol/l. In each center patients were randomized into two treatment groups, each center using 2 of 6 proposed treatments: (1) Spironolactone and 500 mg Na p.d (77 patients), (2) Spironolactone + furosemide or Moduretic (amiloride + hydrochlorothiazide) and 500 mg Na p.d (80 patients), (3) Spironolactone + Furosemide or Moduretic and unrestricted sodium diet (86 patients), (4) Concentrated ascites reinfusion and 500 mg Na p.d. (36 patients), (5) Unmodified ascites reinfusion and 500 mg Na p.d. (23 patients), (6) Slow ascites drainage and 500 mg Na p.d. (31 patients). Statistical analysis methods were X2, variance analysis and Spotvoll-Stoline and Dunn-Sidak tests. Before treatment, there was no significant difference between the 6 groups. RESULTS: After one month of treatment, no difference was found in the frequency of total or partial regression of ascites, complications of cirrhosis, mortality, acceptability of treatment. Mechanical treatments induced more rapid weight loss but more frequent recurrence; comparison of groups 2 and 3 did not confirm any benefit associated with unrestricted Na diet. Duration of treatment and hospitalization were shorter in group 4 than in groups 3 and 6.

[Prognostic indicators in patients with liver cirrhosis admitted to an intensive care unit]. / Indicateurs pronostiques chez les malades atteints de cirrhose admis en service de Réanimation.

OBJECTIVES: Assessment of prognosis in patients with cirrhosis admitted to an Intensive Care Unit remains unsatisfactory. The aims of this retrospective study were to determine the survival rates of patients admitted to an Intensive Care Unit, and to identify and validate prognostic indicators associated with a high mortality rate. METHODS: Two hundred and forty three patients with cirrhosis consecutively admitted to the Intensive Care Unit were studied. The main reasons for admission were upper gastrointestinal bleeding (n = 163), coma (n = 43), sepsis (n = 18), and liver failure (n = 13). Patients were divided into two groups: group 1 (n = 121) to identify prognostic indicators associated with a high mortality rate, and group 2 (n = 122) to validate these indicators. RESULTS: Intensive Care Unit and one year survival rates of patients with cirrhosis admitted for upper gastrointestinal hemorrhage were 76 and 50% respectively. These rates were 40 and 8% respectively for patients admitted for other reasons. In group 1, 4 predictive factors found at admission were identified to have independent significance by stepwise logistic regression: grade III or IV encephalopathy, prothrombin index, serum creatinine, and hypoxemia. On the other hand, the presence of shock on admission was associated with a 100% mortality rate. Two prognostic indicators were defined: shock requiring the administration of vasoactive drugs, and the presence of 3 out of the 4 following predictive factors: grade III or IV encephalopathy, mechanical ventilation, prothrombin index < 30%, and serum creatinine > 130 mumol/L. In group 2, the presence of at least one prognostic indicator at admission or during intensive care was associated with a 96% mortality rate. These indicators were present in 69% of patients who died. In 17 patients who died, but survived more than 24 hours in the Intensive Care Unit, indicators were present an average of 6.0 +/- 5.3 days before death. CONCLUSION: Common prognostic indicators may accurately predict death in patients with cirrhosis admitted to an Intensive Care Unit. These indicators could be helpful in identifying patients who will not benefit from intensive care.

[Cerebrovascular accidents after endoscopic obturation of esophageal varices with isobutyl-2-cyanoacrylate in 2 patients]. / Accidents vasculaires cérébraux après obturation endoscopique des varices oesophagiennes par l'isobutyl-2-cyanoacrylate chez deux malades.

We report 2 cases of cerebral stroke in cirrhotic patients following endoscopic obturation of esophageal varices with Isobutyl-2-Cyanoacrylate. In both cases, hemiplegia appeared several hours after the procedure. A brain CT scan showed radiodense material in the cerebral arteries due to dissemination of Isobutyl-2-Cyanoacrylate. One patient died, the other improved slowly. Different hypotheses may be raised: defectuous injection into the arterial circulation, systemic emboli via portopulmonary venous shunts, delayed polymerization of Isobutyl-2-Cyanoacrylate. Systemic emboli have been reported previously following percutaneous transhepatic obliteration of esophageal varices, suggesting portopulmonary venous shunts. In spite of these 2 complications, this procedure remains useful in stopping acute variceal bleeding and in preventing recurrent bleeding.

[Chylous ascites in cirrhosis. Retrospective study of 20 cases]. / Ascite chyleuse du cirrhotique. Etude rétrospective de 20 cas.

Chylous ascites is a rare complication of cirrhosis. We report 20 cirrhotic patients with chylous ascites seen between 1976 and 1989. Hepatocellular carcinoma was associated in 2 cases and, in 5 cases, chylous ascites followed surgery (portosystemic shunt in 4 cases). Chylous ascites was spontaneous in the 13 other cases. Prevalence of chylous ascites was 1.1 p. 100 in the cirrhotic population with ascites observed between 1983 and 1988. Chylous ascites, whether spontaneous or postoperative, was almost always refractory to medical treatment (16 of 18 patients). Treatment by Le Veen shunt was unsuccessful in 4 patients and lead to infection in 2 cases. Four of 6 patients treated by portocaval shunt died during the first postoperative month. Repeated paracentesis should be preferred, but this can be complicated by malnutrition. Seven of 10 alcoholic cirrhotics with spontaneous chylous ascites and 2 of 4 patients with postoperative chylous ascites died during the year following diagnosis. In view of this poor prognosis, hepatic transplantation should be considered early in selected patients.

[Fibrolamellar carcinoma of the liver: hepatocellular carcinoma with favourable prognosis]. / Carcinome fibro-lamellaire du foie: un carcinome hépatocellulaire de pronostic favorable.

The authors report a case of fibrolamellar carcinoma of the liver in a young woman with bilateral lung metastases. This tumour was surgically unremovable. Presently, after a chemotherapy with adriamycin and mitomycin, this patient is in good health, two years after initial diagnosis. Review of the literature shows that fibrolamellar carcinoma of the liver occurs mainly in young patients. This tumor is characterised by large polygonal eosinophilic hepatocytes and an abundant fibrous stroma. It can be confused with focal nodular hyperplasia. Resection of the tumor and the methodical, repeated resections of metastases must be performed when possible. Prognosis of this tumor is better than that of the other variants of hepatocellular carcinoma.

[Budd-Chiari syndrome and membranous obstruction of the suprahepatic inferior vena cava. Treatment by percutaneous intraluminal angioplasty]. / Syndrome de Budd-Chiari et obstruction membraneuse de la veine cave inférieure sus-hépatique. Traitement par angioplastie intra-luminale percutanée.

A 38-year-old woman, suffering from a Budd-Chiari syndrome due to membranous obstruction of the inferior vena cava, has been treated by percutaneous trans-luminal angioplasty. The result is excellent six months after. The permeability of the vena cava has been studied by manometry and cavography. This innocuous procedure seems worth while in the treatment of Budd-Chiari syndrome with membranous obstruction of the inferior vena cava.

[Acute hepatitis caused by wild germander. Hepatotoxicity of herbal remedies. Two cases]. / Hépatite aiguë à la Germandrée petit-chêne. Hépatotoxicité d'une plante médicinale. Deux observations.

While interest in herbal therapy is clearly increasing in Western countries, there are few available data about hepatotoxicity of herbal remedies. We report on two women who had severe acute hepatocellular liver injury occurring within one to two months of treatment with Wild Germander (Teucrium chamaedrys L.), a herbal medicine for losing weight. Clinical course was favorable after the treatment was discontinued. Involuntary rechallenge in one case resulted in reappearance of symptoms of liver injury. When a patient presents with unexplained hepatic abnormalities, it may be worthwhile to consider non-orthodox self-treatment with herbal remedy as a potential cause. Only systematic observation will provide a clear picture of the incidence of liver injury caused by herbal medicines.

[Treatment of alcoholic hepatitis with silymarin. A double-blind comparative study in 116 patients]. / Traitement de l'hépatite alcoolique par la silymarine. Une étude comparative en double insu chez 116 malades.

A randomized double-blind trial of silymarin versus placebo was carried out in 116 patients with histologically proven alcoholic hepatitis, 58 of them with cirrhosis. Patients were not included in case of hepatic encephalopathy, contraindication to percutaneous liver biopsy, hepatocellular carcinoma, evident lack of discipline or refusal to enter the trial. Fifty-seven patients received silymarin orally 420 mg/day and 59 received placebo during 3 months. Biologic parameters were assessed in the serum, and a percutaneous liver biopsy was obtained at the start of the trial and 3 months later. Histologic scores of alcoholic hepatitis and fibrosis were established on each biopsy specimen by two independent pathologists. The 2 groups were comparable at inclusion; 26 p. 100 of patients were lost to follow-up at 3 months, abstinence was obtained in 46 p. 100 of patients at the end of the trial. These percentages were similar in the two groups. Four patients died of hepatic failure during the trial, 3 in the placebo group. Significant improvement in the score of alcoholic hepatitis and serum amino transferase activity, was noted in both groups during the trial, irrespective of treatment with silymarin or placebo. No side-effects were noted. Our results suggest that silymarin 420 mg/d is not clinically relevant in the treatment of moderate alcoholic hepatitis.

[Interferon alpha-2a treatment of 26 patients with chronic non-A non-B hepatitis. Predictive factors of response]. / Traitement par l'interféron alpha-2a de 26 cas d'hépatites chroniques non A-non B. Etude des facteurs prédictifs de réponse.

The type and predicting factors of response to alpha interferon therapy have been studied in 26 patients with chronic non-A non-B hepatitis. Interferon was administered three times weekly during 6 months at a dose of 3 millions units/day. Eleven patients (42 percent) had serum alanine aminotransferase levels below 1.5 times the upper limit of normal range at the end of treatment. Only eight (31 percent) patients had persistent normalization of seric alanine aminotransferase value, 6 months after the end of the interferon treatment. The main factors involved in the response to therapy were age, apparent duration of the disease, and mode of contamination: patients who responded to interferon were younger, had a shorter duration of hepatitis and a parenterally transmitted disease.

[Gastric protein loss and alcoholic cirrhosis. Study by measurement of gastric clearance of alpha 1-antitrypsin]. / Pertes protéiques gastriques et cirrhose alcoolique. Etude par la mesure de la clairance gastrique de l' alpha 1-antitrypsine.

OBJECTIVE: The aim of the study was to assess gastric protein loss in alcoholic cirrhotic patients, and to determine its role in the low serum albumin levels frequently observed in these patients. METHODS: Twenty-six alcoholic cirrhotic patients with ascites and serum albumin levels < 30 g/L were studied and compared to 6 healthy volunteers. Gastric protein loss was determined by measuring gastric clearance of alpha 1-antitrypsin. RESULTS: Gastric clearance of alpha 1-antitrypsin was 0.96 +/- 1.42 mL/h (median : 0.52; range: 0.11-6.54) in cirrhotic patients and 0.48 +/- 0.20 mL/h (median: 0.51) in healthy volunteers. Values in cirrhotic patients were not significantly different from healthy volunteers. However, 3 cirrhotic patients had high values of gastric clearance of alpha 1-antitrypsin (2.84, 3.99 and 6.54 mL/h). Their serum albumin and protein levels were significantly lower than those in the 23 other patients (P < 0.05 and < 0.03, respectively). Severe portal hypertensive gastropathy was present in two out of these 3 patients and in two out of the 23 other patients. CONCLUSION: Gastric protein loss is not significantly increased in liver cirrhosis. However, in a few patients, this loss is high and may play a role in low serum albumin levels.

[Immunoallergic complication induced by rifampicin with disseminated intravascular coagulation]. / Accident immunoallergique à la rifampicine avec coagulation intravasculaire disséminée.

In a 48-years old woman, intermittent rifampicin treatment induced an immunoallergic reaction with digestive disorders, haemolysis, acute renal failure and prolonged prothrombin time. The reintroduction of rifampicin, 17 days later, resulted in a similar, though more severe, reaction associated with diffuse haemorrhages from disseminated intravascular coagulation, this association being exceptional. The responsibility of rifampicin was demonstrated by the chronological relationship between clinical symptoms and administration of the drug, and by the presence in the patient's serum of anti-rifampicin antibodies. The antigen-antibody reaction with complement activation and haemolysis probably explains the disseminated intravascular coagulation.

[Hypoxemia in liver cirrhosis]. / Hypoxémies au cours des cirrhoses du foie.

Hypoxaemia is observed in almost 30 per cent of patients with cirrhosis of the liver, irrespective of the cause of cirrhosis. Two main physiopathological mechanisms can be described: hypoxaemia may be secondary to intrapulmonary vascular abnormalities or due to a regional disequilibrium of the ventilation/perfusion ratio. In the first case, the severity of hypoxaemia often requires complex and invasive investigations, while in the second case, by far the most frequent, hypoxaemia is moderate, usually asymptomatic and in practice only needs a few investigations.