Haemodynamic adaptation two months after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients.

BACKGROUND AND AIMS: In portal hypertensive patients, transjugular intrahepatic portosystemic shunt (TIPS) acutely increases cardiac output and exaggerates peripheral vasodilatation. It has been suggested that the worsened hyperdynamic state may progress to high output heart failure. The aim was to evaluate the acute and short-term haemodynamic adaptation to this procedure. METHODS: Systemic, splanchnic, and pulmonary haemodynamics were studied in 15 cirrhotic patients under stable haemodynamic conditions before placement of TIPS, then 15-30 minutes after and two months later. For inclusion in the final analysis, an uneventful post-TIPS at two months follow up and a stable portacaval gradient were required. The following variables were measured or calculated: portacaval gradient; cardiac index (thermodilution); systolic and diastolic mean arterial, atrial, pulmonary arterial, and wedged pulmonary capillary pressures; heart rate; and total peripheral and pulmonary vascular resistances. Blood flow in the shunt was measured using duplex Doppler ultrasound. RESULTS: The portacaval gradient decreased by 56% and remained stable thereafter. Shunt blood flow was unchanged when measured immediately after TIPS and two months later. Immediately after TIPS there was a pronounced increase in cardiac index (+32%; p < 0.05) in association with a decrease in peripheral and pulmonary vascular resistance (-21%; p < 0.05 and -14%; NS). Two months later, whereas the initial rise in cardiac index was attenuated, peripheral vascular resistances remained similar and pulmonary vascular resistances decreased further (-33%; p < 0.05) compared with immediate post-TIPS values. CONCLUSIONS: Hyperdynamic circulation worsened immediately after TIPS, with a progressive adaptation during follow up. The mechanisms of post-TIPS induced haemodynamic changes include an abrupt volume load resulting from splanchnic decompression and an increased delivery of gut derived vasodilators to the systemic circulation. The persistence of decreased peripheral and pulmonary vascular resistances despite the reduction in high cardiac output two months after TIPS suggests that vasodilatation is not solely a compensatory response to a TIPS induced increased preload. Vasodilatory substances shunted away from the liver probably play an important part in this phenomenon.

The role of central blood volume in the development of sodium retention in portal hypertensive rats.

BACKGROUND & AIMS: In portal hypertension, peripheral vasodilatation (PVD) causes Na+ retention as a result of vascular underfilling. The central blood volume is responsible for the vascular filling signals to baroreceptors and volume receptors. The aim of this study was to determine the role of central blood volume in Na+ retention in portal hypertensive rats. METHODS: Mean arterial pressure, portal pressure, cardiac output, total peripheral resistance, central blood volume, and extracellular Na+ space were assessed daily in rats after portal vein ligation or sham operation until a hyperdynamic circulatory state developed. RESULTS: On day 1, portal vein-ligated rats had PVD and a diminished central blood volume (1.26 +/- 0.04 vs. 1.47 +/- 0.09 mL/100 g body wt; P < 0.05). On day 2, Na+ space increased in portal vein-ligated rats (38.1 +/- 0.5 vs. 33.1 +/- 0.5 mL/100 g body wt; P < 0.01). From day 2 on, normalization of central blood volume and cessation of Na+ retention were observed despite persistent PVD. On day 4, portal vein-ligated rats developed a hyperdynamic circulatory state with a normal central blood volume and persistent PVD. CONCLUSIONS: Although total peripheral resistance remains decreased, Na+ retention ceases after central blood volume is normalized. Central blood volume therefore appears to be the signal for Na+ retention. Although PVD persists after Na+ retention ceases, it may contribute to Na+ retention by decreasing central blood volume.

Autoimmune cholangiopathy: the result of consecutive primary biliary cirrhosis and autoimmune hepatitis?

Autoimmune cholangiopathy is a recently proposed entity that describes a specific group of patients presenting overlapping features of primary biliary cirrhosis and autoimmune hepatitis, i.e., clinical and/or biochemical cholestasis, high titer antinuclear antibody, negative antimitochondrial antibody, and elevated immunoglobulin G. Liver histology shows primary biliary cirrhosis coexisting with varying degrees of parenchymal inflammation. In addition, these patients achieve remission on corticosteroid therapy. The patient in this report fulfilled the above criteria. However, preceding the autoimmune cholangitis stage, a typical antimitochondrial antibody-positive primary biliary cirrhosis was documented with favorable response to ursodeoxycholic acid treatment. Twenty months later, the patient developed autoimmune hepatitis with elevated aspartate aminotransferase and immunoglobulin G and high titer antinuclear antibody as well as corticosteroid dependency, whereas the antimitochondrial antibody disappeared. The patient's sera initially showed reactivity to three mitochondrial proteins, the 74-, 64-, and 56-kilodalton autoantigens of the 2-oxo acid dehydrogenase complexes, which was characteristic of primary biliary cirrhosis. After developing autoimmune hepatitis, reactivity to the 74- and 64-kilodalton antigens disappeared, whereas reactivity to the 56-kilodalton antigen decreased to low levels. Autoimmune cholangitis and probably other forms of the overlap syndrome may result from the association of two diseases: primary biliary cirrhosis and autoimmune hepatitis.

Administration of N omega-nitro-L-arginine ameliorates portal-systemic shunting in portal-hypertensive rats.

BACKGROUND: Nitric oxide, a vasodilator synthesized from L-arginine by vascular endothelial cells, may play a role in the development of portal-systemic collaterals. This study investigated the effect of long-term inhibition of NO secretion on portal systemic shunting. METHODS: Systemic and splanchnic hemodynamics and the degree of portal-systemic shunting were evaluated in partial portal vein-ligated rats after administration of placebo (0.9% saline) or N omega-nitro-L-arginine (NNA) (approximately 2 micrograms.kg-1 x min-1) intravenously for 6 days. RESULTS: NNA treatment induced increases in splanchnic arterial resistance (P < 0.001) and portal-collateral resistance (P < 0.05) and a decrease in portal venous inflow (P < 0.05). Portal pressure was not changed (NS). The splenic-systemic shunting was significantly decreased from 81% +/- 5% in the placebo-treated group to 69% +/- 4% in the NNA-treated group (P < 0.05), paralleled by an insignificant reduction in the mesenteric-systemic shunting (64% +/- 7% vs. 50% +/- 6%, NS). The attenuation of portal-systemic shunting by NNA was further shown by an increase in the vascular resistance of portal-systemic collateral venous bed using an in situ portal-systemic collateral perfusion model (1.27 +/- 0.05 vs. 1.07 +/- 0.03 cm H2O.mL-1 x min-1; P < 0.001). CONCLUSIONS: The results show that in portal hypertensive rats, NNA reduces portal-systemic shunting without reducing portal pressure, suggesting that NO plays a role in the collateralization of the portal system. In addition, high flow through the portal-collateral bed is probably an important driving force that is independent of portal hypertension for the development of portal-systemic shunting in portal-hypertensive rats.

Octreotide ameliorates vasodilatation and Na+ retention in portal hypertensive rats.

BACKGROUND: Whether long-term octreotide treatment given to portal hypertensive rats could prevent or ameliorate peripheral vasodilatation and thereby modify sodium retention was investigated. METHODS: Starting at the time of partial portal vein ligation or sham operation, rats received a 4-day course of either octreotide (15 micrograms/kg in 5% dextrose in water) or placebo (5% dextrose in water) subcutaneously every 8 hours. RESULTS: In portal hypertensive rats, octreotide induced a 13% increase in mean arterial pressure (P < 0.01) and a 19% increase in total peripheral resistance (P < 0.01). Octreotide treatment induced a decrease in extracellular sodium space (22Na injection) (34.2 +/- 0.5 vs. 36.7 +/- 0.4 mL/100 g; P < 0.01) without changes in serum sodium level. In addition, octreotide treatment significantly reduced portal pressure as well as glucagon levels and plasma renin activity. In contrast, octreotide treatment had no effect on mean arterial pressure and extracellular sodium space in shamoperated rats. CONCLUSIONS: Long-term octreotide treatment ameliorated peripheral vasodilatation and sodium retention only in portal hypertensive rats. These findings suggest that in portal hypertension sodium retention can be modified by pharmacological agents that affect peripheral vasodilatation. The specificity of octreotide's effect sheds additional light into the vasodilatory syndrome associated with portal hypertension in liver diseases.

N omega-nitro-L-arginine administration corrects peripheral vasodilation and systemic capillary hypotension and ameliorates plasma volume expansion and sodium retention in portal hypertensive rats.

In portal hypertensive states, peripheral vasodilation leads to sodium retention and plasma volume expansion. N omega-nitro-L-arginine, a specific biosynthesis inhibitor of the vasodilator nitric oxide, has been shown to acutely reverse peripheral vasodilation and the vascular hyporesponsiveness to endogenous and exogenous vasoconstrictors observed in portal hypertensive rats. This study investigated whether N omega-nitro-L-arginine treatment in portal hypertensive rats prevents peripheral vasodilation and therefore ameliorates plasma volume expansion and sodium retention. For 2 days before partial portal vein ligation or sham operation and then continuously for 4 days after the operation, animals received either placebo (0.9% saline) or N omega-nitro-L-arginine (approximately 2 micrograms/kg/min) intravenously through a subcutaneously implanted Alzet osmotic pump (model 2ML1; Alza, Palo Alto, CA). In portal hypertensive rats, N omega-nitro-L-arginine treatment significantly increased mean arterial pressure (placebo vs. N omega-nitro-L-arginine, 123 +/- 4 vs. 150 +/- 2 mm Hg, respectively; p < 0.001) and systemic vascular resistance (3.8 +/- 0.2 vs. 5.6 +/- 0.3 mm Hg/ml/min/100 gm body weight; p < 0.001), associated with a decrease in the cardiac index (33.5 +/- 1.0 vs. 27.0 +/- 1.1 ml/min/100 gm body weight; p < 0.001). N omega-nitro-L-arginine treatment also induced a decrease in plasma volume (4.6 +/- 0.1 vs. 4.1 +/- 0.1 ml/100 gm body weight; p < 0.001) and extracellular sodium space (39.4 +/- 0.7 vs. 37.4 +/- 0.4 ml/100 gm body weight; p < 0.05) without changes in serum sodium.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of nitric oxide in the vascular hyporesponsiveness to methoxamine in portal hypertensive rats.

This study examined whether an increased activity of the endothelium-derived relaxing factor, nitric oxide, may account for the hyporesponsiveness to vasoconstrictors in portal hypertension. We performed dose-response curves to methoxamine, an alpha-adrenoceptor agonist, with and without N omega-nitro-L-arginine, a specific inhibitor of nitric oxide synthesis, in experimental portal hypertension. Partial portal vein-ligated or sham-operated rats were pretreated with a continuous intravenous infusion of either N omega-nitro-L-arginine (50 micrograms.kg-1.min-1) or saline. Thirty minutes after starting the infusion of N omega-nitro-L-arginine or saline an infusion of methoxamine (10, 30 and 100 micrograms.kg-1.min-1) was added. Total peripheral resistance was calculated from mean arterial pressure and cardiac index. Repeated measurements of cardiac index were performed by a thermodilution technique. In portal vein-ligated rats pretreated with saline, the increase in total peripheral resistance after methoxamine infusion was significantly less than that of sham-operated rats (0.2 +/- 0.1 vs. 1.0 +/- 0.3, 0.6 +/- 0.1 vs. 1.6 +/- 0.3 and 3.7 +/- 0.5 vs. 6.1 +/- 0.7 mm Hg.ml-1.min.100 gm, p less than 0.05, methoxamine 10, 30 and 100 micrograms.kg-1.min-1, respectively). In the presence of N omega-nitro-L-arginine, the change in total peripheral resistance after methoxamine infusion was similar in both groups (p greater than 0.05). In conclusion, this study demonstrates that a vascular hyporesponsiveness to methoxamine is present in portal vein-ligated rats and that this hyporesponsiveness is reversed by blockade of nitric oxide.(ABSTRACT TRUNCATED AT 250 WORDS)

Sequence of morphological and hemodynamic changes of gastric microvessels in portal hypertension.

Changes in gastric microvasculature and blood flow at different phases of portal hypertension were studied in rats 1, 2, 3, 4, and 15 days after induction of portal hypertension or sham operation. Vessel lumen and vessel wall thickness were expressed as a ratio referred to the vessel size. On day 2 after constriction of the portal vein, gastric blood flow was decreased (0.57 +/- 0.06 vs. 0.99 +/- 0.20 mL.min-1.100 g-1; P less than 0.05), and gastric vessels had a distended lumen (0.42 +/- 0.02 vs. 0.28 +/- 0.03; P less than 0.01) and a thin wall (2.11 +/- 0.2 vs. 3.82 +/- 0.4; P less than 0.01). On day 4, the gastric blood flow of portal hypertensive animals was increased (1.15 +/- 0.14 vs. 0.71 +/- 0.07 mL.min-1.100 g-1; P less than 0.05), whereas gastric vessels had a reduced lumen (0.27 +/- 0.02 vs. 0.33 +/- 0.02; P less than 0.01) and a thick wall (4.19 +/- 0.52 vs. 3.16 +/- 0.30; P less than 0.05). By day 15, vessels with the largest lumens (0.45 +/- 0.01 vs. 0.29 +/- 0.01; P less than 0.01) and the thinnest walls (1.78 +/- 0.26 vs. 3.58 +/- 0.62; P less than 0.01) were observed in portal hypertensive animals. In conclusion, the gastric vessels of the 15-day portal vein-ligated rat resemble the structural abnormalities described in human portal hypertensive gastropathy.

Vasodilatation and sodium retention in prehepatic portal hypertension.

Sodium retention and peripheral vasodilatation are common consequences of portal hypertension secondary to cirrhosis. Although peripheral vasodilatation has been extensively documented in prehepatic portal hypertension, it is not known whether sodium retention is also a feature of this entity. The aim of this study in portal vein-constricted rats was to evaluate (a) whether sodium retention is a feature of prehepatic portal hypertension and (b) if sodium retention is present in this model, what its temporal relationship with peripheral vasodilatation might be. It was proposed that an understanding of the temporal interplay between peripheral vasodilatation and sodium retention could shed light on the current theories of sodium retention in portal hypertension. Rats were studied 1, 2, 3, and 4 days after partial portal vein ligation (n = 80) or sham operation (n = 63). Sodium retention was evaluated by changes in the size of the sodium space measured by the volume of distribution of 22Na. Systemic vascular resistance was calculated from mean arterial pressure (measured by arterial catheterization) and cardiac index (measured by thermodilution). A decrease in systemic vascular resistance was already observed on day 1 after constriction of the portal vein (4.2 +/- 0.2 vs. 5.2 +/- 6.1 mm Hg.min.mL-1.100 g; P less than 0.01). However, an expansion of the sodium space, which indicates sodium retention, was not observed until day 2 after induction of portal hypertension (37.1 +/- 0.8 vs. 32.6 +/- 0.7 mL.100 g-1; P less than 0.01). Therefore, sodium retention should be considered along with peripheral vasodilatation among the characteristic features of prehepatic portal hypertension. Because the reduction in systemic vascular resistance preceded the expansion of the sodium space by at least 24 hours, the finding of this study indicates that sodium retention follows peripheral vasodilatation.

Temporal relationship of peripheral vasodilatation, plasma volume expansion and the hyperdynamic circulatory state in portal-hypertensive rats.

Peripheral vasodilatation and plasma volume expansion are required to generate the hyperdynamic circulatory state observed in portal hypertension. To determine which of these factors is the initial event and to assess their temporal relationship with the development of hyperdynamic circulation, we sequentially measured plasma volume (by 125I-albumin dilution), cardiac index (by thermodilution), mean arterial pressure (by catheterization), superior mesenteric and iliac arterial flows (by Doppler flowmetry) and calculated total and regional peripheral resistances in portal-hypertensive rats. Experimental groups were studied from day 1 through day 4 after partial portal-vein ligation (n = 110) or sham operation (n = 111). Decreased total peripheral resistance was detected within a day of portal-vein ligation (4.18 +/- 0.21 mm Hg.min.ml-1 x 100 gm vs. 5.19 +/- 0.16 mm Hg.min.ml-1 x 100 gm; p less than 0.01). Plasma volume increased significantly on day 2 (4.31 +/- 0.07 ml.100 gm-1 vs. 3.86 +/- 0.04 ml.100 gm-1; p less than 0.05). Cardiac index and regional blood flows increased in parallel with plasma volume elevation. On day 4, maximum values of plasma volume (4.49 +/- 0.08 ml.100 gm-1 vs. 3.73 +/- 0.03 ml.100 gm-1) coincided with fully developed hyperdynamic circulation, as shown by a significant elevation in cardiac index (32.3 +/- 0.6 ml.min-1 x 100 gm-1 vs. 25.5 +/- 1.2 ml.min-1 x 100 gm-1), iliac and mesenteric blood flow. On day 1, vasodilatation was present in the iliac arterial circulation. In contrast, the superior mesenteric artery vascular bed showed vasoconstriction in response to the protal outflow block.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of anesthesia, postanesthetic state, and restraint on superior mesenteric arterial flow in normal rats.

To exclude possible confounding effects of anesthesia on splanchnic hemodynamics, two different awake postanesthetic models (PAM), restrained and unrestrained, have been used. However critical analysis of the splanchnic hemodynamic state in these models is not available. We conducted experiments using chronically implanted pulsed-Doppler flow probes on the superior mesenteric artery (SMA) in ketamine-anesthetized and in postanesthetic restrained and unrestrained normal rats. Baseline values of mean SMA flow were compared with those under anesthesia (30 min), PAM (restrained or unrestrained at 90 and 150 min), and reanesthesia. Sham-anesthetized unrestrained animals provided control values. The same animals (n = 7) underwent the restrained, unrestrained, and control experiments at least 5 days apart. Ketamine anesthesia did not significantly alter mean SMA flow (89 +/- 9% of baseline) compared with sham-anesthetized controls (99 +/- 9%). Mean SMA flow in both PAM, restrained and unrestrained, had a significant (P less than 0.05) decrease at 90 min (78 +/- 8 and 83 +/- 12%) and at 150 min (68 +/- 14 and 78 +/- 14%) when compared with baseline and control. Reanesthesia returned SMA flows to baseline values (91 +/- 16%). The variability of mean SMA flow was significantly increased in both PAM. Maximum variability was observed in the restrained model (69 +/- 32%). These results indicate 1) that ketamine anesthesia does not significantly alter SMA flow and 2) that both the restrained and unrestrained PAM exhibit significant alterations of the splanchnic circulation for at least 2 h after complete recovery from anesthesia. Thus, in the absence of critical evaluation, results of splanchnic hemodynamic studies with these models should be questioned.(ABSTRACT TRUNCATED AT 250 WORDS)

Bile acids do not mediate the hyperdynamic circulation in portal hypertensive rats.

Portal hypertension is accompanied by hyperdynamic systemic and splanchnic circulation. Serum bile acids (BAs), which are elevated in portal hypertension and have vasodilatory properties, have been proposed as mediators of this hyperdynamic circulation. In this study, portal hypertensive rats [accomplished by partial portal vein ligation (PVL)] were gavaged with cholestyramine (PVL-CH) to decrease circulating BA levels. A control group of rats was gavaged with an inert suspension of Metamucil (PVL-ME). The following hyperdynamic parameters were found to be similar in PVL-CH and PVL-ME: mean arterial pressure (119 +/- 6 vs. 124 +/- 5 mmHg), portal pressure (13.2 +/- 0.6 vs. 14.5 +/- 0.5 mmHg), cardiac index (0.33 +/- 0.04 vs. 0.34 +/- 0.03 ml.min-1.g body wt-1), splanchnic blood flow (1.4 +/- 0.13 vs. 1.6 +/- 0.1 ml.min-1.g body wt-1), portosystemic shunting (82 +/- 8 vs. 92 +/- 3%), peripheral arteriolar resistances (344 +/- 74 vs. 387 +/- 29 mmHg.min.ml-1.g body wt), and splanchnic arteriolar resistances (75 +/- 14 vs. 72 +/- 6 mmHg.min.ml-1.g splanchnic wt; 1,471 +/- 150 vs. 1,325 +/- 120 mmHg.min.ml-1.g body wt). BA in PVL-ME (84 +/- 9 microM/l) were similar to those previously observed in untreated PVL and significantly greater than those measured in PVL-CH (25 +/- 4 microM/l; P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Liposarcoma de pancreas descripción de un caso clinico y revisión del tema / Liposarcoma of the pancreas: report of a clinical case and review of the literature

Los liposarcomas son tumores poco frecuentes cuya localización ocurre predominantemente en las extremidades. Puede hallárselos también en el retroperitoneo. El hallazgo de liposarcoma en un órgano específico es de extrema rareza. La revisión de literatura indica la ocurrencia de un sólo caso localizado en el páncreas

Liposarcoma de pancreas descripción de un caso clinico y revisión del tema / Liposarcoma of the pancreas: report of a clinical case and review of the literature

Los liposarcomas son tumores poco frecuentes cuya localización ocurre predominantemente en las extremidades. Puede hallárselos también en el retroperitoneo. El hallazgo de liposarcoma en un órgano específico es de extrema rareza. La revisión de literatura indica la ocurrencia de un sólo caso localizado en el páncreas (AU)

[Liposarcoma of the pancreas. Report of a clinical case and review of the literature]. / Liposarcoma de páncreas, Descripción de un caso clínico y revisión del tema.

Pancreatic liposarcoma are tumors frequently located in extremities and retroperitoneum. Visceral located tumors of this histology are exceptional. We present a clinical case of nonresectable pancreatic liposarcoma. A general review is made on this subject.

Liposarcoma de páncreas, Descripción de un caso clínico y revisión del tema. / [Liposarcoma of the pancreas. Report of a clinical case and review of the literature]

Pancreatic liposarcoma are tumors frequently located in extremities and retroperitoneum. Visceral located tumors of this histology are exceptional. We present a clinical case of nonresectable pancreatic liposarcoma. A general review is made on this subject.

Cell-mediated immunity in alcoholic liver cirrhosis

Se efectuaron estudios de inmunidad mediada por células en 25 pacientes con cirrosis hepática alcohólica (CA) activa e inactiva. Fueron observadas diversas alteraciones inmunológicas: aumento de los linfocitos B y disminución de los linfocitos T. Sólo en los enfermos con CA activa la relación H/S era más baja que los valores normales. Los linfocitos NK (Leu 7 +) y la función citotóxica natural killer estaban aumentados; sin embargo el índice NK/Leu 7 estaba disminuido. En los enfermos con CA activa la proliferación blástica a la PHA estaba descendida. Se observó un déficit de la función supresora inducida por Con A en los pacientes con CA. En los cocultivos alogeneicos de linfocitos supresores de los pacientes y células efectoras normales, se observó un descenso de la función supresora T-T con respecto a los cultivos autólogos normales. No se encontraron diferencias cuando los linfocitos de normales fueron inducidos con Con A y se cocultivaron con linfocitos efectores de los enfermos. Estos resultados indican que los linfocitos de los pacientes con CA presentan anomalías en la inducción de supresión por Con A