[Blood-pool-SPECT for imaging portosystemic collaterals in portal hypertension]. / Blutpool-SPECT zur Darstellung von portosystemischen Kollateralen bei portaler Hypertension.

In 46 patients, 26 male and 20 female, age from 32 to 71 years (mean 47.4 +/- 11 years) a bloodpool-scintigraphy (BPS) with SPECT (single photon emission computed tomography) was performed. The in-vivo labelling of the erythrocytes with pyrophosphate and Tc-99m was performed in the usual way. The SPECT investigations were performed with a digital Anger-Camera (Elscint; Apex 401). In 14 patients without collaterals BPS was performed to compare the method with patients with liver diseases and collaterals. 29 patients with liver cirrhosis and portal hypertension were investigated with the BPS and additionally a scintisplenoportography (SSP) was performed. In patients with only cephalad collaterals all the results were concordant. In just 1 patient with cephalad and caudad collaterals we found a discordant result. In 8 patients we performed BPS, SSP and a katheterangiography (KA). Taking the KA as the "golden standard" we found a concordant result with the 3 methods in all patients with cephalad collaterals. In patients with cephalad and caudad collaterals we once found a discordant result with the SSP and twice with the BSP. In 2 patients the patency of surgical shunts were proved. 2 patients after sclerosis of the oesophageal varices have been proved by BPS and SSP and both patients showed good therapeutical results.

[Percutaneous endoscopic gastrostomy--a possibility for enteral feeding of patients with severe cerebral dysfunctions]. / Perkutane endoskopische Gastrostomie--eine Möglichkeit der enteralen Ernährung von Patienten mit schweren zerebralen Funktionsstörungen.

Patients who are unable to be adequately nourished owing to cerebral dysfunction do not tolerate nasogastric tubes for enteral nutrition well. They are threatened by active or passive dislocation of the tube into the oesophagus with subsequent aspiration. Although these risks are minimized by percutaneous gastrostomy (PEG), aspiration cannot be completely prevented even when this method of feeding is employed. Enteral nutrition was provided by PEG in 33 patients with different cerebral disorders. PEG was indicated when adequate oral intake of food and fluids proved impossible 8 to 12 days after an acute hypoxaemic cerebrovascular event. 3 of 23 patients who had suffered a stroke, 2 of 8 patients with hypoxaemic brain damage and 3 of 5 patients with decompensated cerebral sclerosis regained the ability to eat between the 21st and 50th day of treatment, so that the gastrostomy could be dispensed with. The other patients died of their severe underlying disease. 6 patients aspirated. In 2 cases this complication occurred during acute aggravation of the underlying disease after several weeks of satisfactory enteral tube feeding. 2 patients aspirated after returning to oral nutrition, whereby feeding was certainly implicated in 1 patient and probable in the other patient. PEG enables adequate enteral nutrition of patients with severe neurological impairment. The advantages of PEG over parenteral nutrition are fewer complications, lower costs and, above all, its superiority in meeting physiological requirements.

[Early clinical diagnosis of stomach and large intestine cancer]. / Klinische Frühdiagnose des Magen- und Dickdarmkarzinoms.

Gastric and colonic cancer, which affect alarmingly also younger age groups to a growing extent, are developing into a serious problem of public health. Not recognized in time, the survival probability is low. The 5-year survival time is 10% with a manifest gastric carcinoma, with colonic cancer it is 30%. If these neoplasias are recognized in a stage in which they correspond to the criteria of an early carcinoma, the chance of recovery will be 90% for the patients. The early gastric carcinoma does not occur without any symptoms, but in more than 80% of the cases it causes differently intensely pronounced symptoms in the epigastric region, with pain, dyspepsia, haemorrhage and loss of weight prevailing. Therefore, epigastric, complaint for more than 4 weeks should give reason for a thorough gastroenterological examination, with endoscopy being superior to radiological examination, even when using advanced methods of examination. Special control is needed for patients of the various risk groups. Patients with a morbus Ménétrie, a pernicious anaemia and a chronic-atrophic gastritis with intestinal metaplasia of the colonic type are exposed to a particularly high risk of carcinoma. Of a special practical importance is the circumstance that a peptic ulcus of the stomach may develop in an already carcinomatously changed mucosa and thus the carcinoma continues growing below a healed peptic lesion. Thus, a gastric ulcer requires a regular and short-term endoscopic control until its final macroscopic and histological healing. The malignant diseases of stomach and large intestine show an inverse behaviour over the past 20 years. The colonic carcinoma develops from an adenoma in 90% of the cases. In most of the cases, this development from the precursors is without any symptoms. Symptoms such as blood in the stools, abdominal pain, change in the action of the bowels, loss of weight, decrease in power and the like indicate already an advanced carcinoma. Among the laboratory tests, only the examination of the faeces for concealed haemorrhage is of some importance as a diagnostic test. The CEA test in not suitable therefore. As also larger adenomas bleed intermittently, there is the chance of recognizing also these prestages of carcinomas by regular examinations of the faeces. In contrast to the simple barium enema, the radiological examination in double contrast reveals changes of the mucosa of the colon up to a size of 1 cm in more than 80% of the cases. Coloscopy, however, is superior to X-ray examination, regarding both expressiveness and efficiency.(ABSTRACT TRUNCATED AT 400 WORDS)

[Functional assessment of the hepatic arterial blood flow by pharmacoradiography (author's transl)]. / Funktionelle Beurteilung der arteriellen Leberdurchblutung mittels Pharmakoradiographie.

By means of celiacography it was possible to demonstrate that parenteral medication with parathormone creates a selective dilatation of the liver vessels in man, provided that they are dilatable. This hemodynamic hormone effect could not be traced in the other mesenteric vessels. The increase of portal hypertension resulting from cirrhosis leads to a loss of the dilating ability of liver vessels. This regressive reaction is well demonstrated on the parathormon-celiaco-gram. Thus a functional assessment of the hepatic blood flow is possible. The extent of the dilatability of the liver artery seems to be of great importance for the prognosis and indication of the porto-systemic shunt-operation. Moreover we could show that an increase in the liver perfusion demonstrates pathologic liver processes in a better way.

[Angiographic investigation with parathyroid hormone administration as functional gauge of liver blood flow (author's transl)]. / Angiographische Untersuchung unter dem Eimfluss von Parathormon zur funktionellen Beurteilung der Leberdurchblutung.

Parenteral administration of parathyroid hormone causes dilatation of the main hepatic artery adn the intrahepatic branches, as demonstrable on coeliacography. This applies to healthy persons as well as to patients suffering from cirrhosis of the liver. When hormone is given intraarterially, i.e. into the coeliac trunk, the effect on the hepatic arteries is stronger than after intravenous administration. No effect can be be shown on the splenic, upper mesenteric or gastroduodenal arteries. The reaction of the hepatic arteries to parathyroid hormone seems to be a good parameter of the degree of dilatory capacity of these vessels in cirrhosis. Relevant conclusions can probably be drawn as to the prognosis of porto-systemic shunt operations and their indication. This haemodynamic hormone effect, the cause of which is still unknown enabled better visualisation of primary liver tumours on coeliacography.

[The influence of parathormone on blood flow of the hepatic artery after portocaval end to side shunt (author's transl)]. / Der Einfluss bon Parathormon auf die Durchblutung der Leberarterie nach Anlegen einer portokavalen End-zu-Seit-Anastomose.

Compensatory increase of hepatic artery blood flow follows protosystemic shunt surgery. Parathormone stimulates significantly blood circulation through the hepatic artery. This stimulating effect is used to test vasodilative capability of the hepatic artery prior to shunt surgery. We report our findings on a additional increase of the hepatic artery blood flow under Parathormone. A portal-caval end-to-lateral shunt surgery caused an increase in blood flow 71 percent on an average compared to the basic value. After administration of Parathormone we observed an additional increase of 13,5 percent. This result indicates, that the hepatic artery will be dilated by Parathormone after a portocaval shunt too.

[Estimation of hepatic blood flow with 133-Xenon (author's transl)]. / Bestimmung der Leberdurchblutung mit Xenon 133.

Regional hepatic blood flow was measured by two methods using 133-Xenon washout technique: 1. "portal method" (injection of 133-Xenon into the spleen), and 2. "arterial method" (direct application of 133-Xenon into the A. hepatica propria by an indwelling catheter after celiacography). The portal method was performed in 38 patients (30 patients with cirrhosis of the liver, 4 patients with chronic hepatitis, 4 controls with normal liver function). The results show that using this method regional liver blood flow can be measured accurately. Patients with cirrhosis of the liver had a highly significantly decreased hepatic blood flow in comparison to the control group. The advantage of this method is that extra- and intrahepatic shunts can be visualized simultaneously. However, using this method in patients with hemodynamically very effective extrahepatic collaterals the tracer does not reach the liver. In these patients regional hepatic blood flow can be estimated by the arterial method (12 patients with cirrhosis of the liver, 2 with normal liver function). However, no information about the morphology of the portal circulation can be obtained using this method. Direct comparison of the quantitative estimation of regional hepatic blood flow was performed in 6 patients. The data obtained by the 2 methods correlated highly significantly (r = 0.91).

[Diagnosis of liver and biliary diseases with 99mTc-Hepatobida (author's transl)]. / Hepatobiliäre Diagnostik mit 99mTc-Hepatobida.

Application of 99mTc-Hepatobida has turned out to be a convenient diagnostic screening method in liver and biliary disease. Side effects are unknown, thus patients with iodine allergy or other forms of allergy, as well as patients harboring autonomous adenomata of the thyroid, and severely ill patients will tolerate this substance well. 99mTc-Hepatobida may be applied even in the presence of highly elevated levels of plasma bilirubin and thus will yield diagnostic results in all forms of hepatic disease if findings are monitored repeatedly. In addition screening with 99mTc-Hepatobida will in some cases suffice to establish the diagnosis and thus forgo more complicated diagnostic procedures.

[Testing the dilatation capacity of the hepatic artery with parathyroid hormone]. / Prüfung der Dilatationsfähigkeit der Arteria hepatica mit Parathormon.

In portosystemic shunt surgery, there still is a lack of correlation between various preoperative hemodynamic measurements and the postoperative clinical course of patients. The magnitude of post-shunt increment in hepatic arterial flow was found to be directly related to long term prognosis. To predict the arterial response for selecting patients for shunting, we tried to use a new non invasive method: Arterial and portal components of total liver blood flow were determined quantitatively by "Sequential hepato-splenic scintigraphy". Dilatation capability of the hepatic artery, was tested by means of the hemodynamic action of Parathyroid hormone (PH). PH has been found to induce a large and exclusive augmentation of hepatic arterial blood flow. We were able to document a statistically highly significant increase in hepatic arterial flow following i. v. applications of PH. The extent of arterial increment appears to be dependent upon the degree of entrapment of the hepatic arterioles by the fibrous tissues of cirrhosis.

[Clinical and experimental investigations of the effect of dopamine on haemodynamics and function of kidney and liver (author's transl)]. / Klinische und experimentelle Untersuchungen über die Wirkung von Dopamin auf die Hämodynamik und Funktion von Niere und Leber.

Increased incidence of renal insufficiency is observed in severe damage of liver parenchyma such as fulminant hepatitis, decompensated cirrhosis of the liver, septic cholangitis and the different forms of obstructive jaundice. Functional circulatory disturbances of the kidney, especially of the renal cortex, are of importance in the aetiology of this condition. Dopamine, at a dosage as low as 3 gamma/kg/min leads to an improvement in renal blood flow and also to an increase in hepatic blood flow. These observations are of therapeutic importance. Some important circulatory and functional parameters of both these organs, which influence each other under normal and pathological conditions, were studied in the presence of dopamine and the following results were obtained: 1. An investigation of the intrarenal haemodynamics with 133 Xenon in patients with severe cirrhosis of the liver and in patients with obstructive jaundice resulted in an increase of 91% in the mean renal blood flow. The blood flow in the renal cortex increased by 36.2% and in the renal medulla 18.5%, whereas the renal fat tissue showed no change. Compartment I, which was diminished as compared with the control value, also increased. The percentage contribution of the mean renal blood flow and the blood flow of the renal cortex towards the cardiac output was greater under the influence of dopamine; hence a greater part of the cardiac output flows into the kidney under dopamine. 2. The glomerular filtrate and the renal plasma flow increased under dopamine (13.5% and 43.1%, respectively). The increase was greater in compensated than in decompensated cirrhosis. In patients with obstructive jaundice there was a smaller increase in both these parameters than in patients with cirrhosis in the presence of dopamine. No connection was found between the increase in renal plasma flow with dopamine and the blood levels of bilirubin, cholinesterase, GOT and the Normotest. 3. The urinary output of sodium increased by 191.4% with dopamine. Patients with an initial renal plasma flow value of over 300 ml/min had a higher sodium output. These patients also eliminated more sodium under the influence of dopamine than those with an initial renal plasma flow value of under 300 ml/min. 4. Blood flow determinations in the portal vein and the hepatic artery in man, obtained during operation, showed an increase in portal flow of 28.5% and hepatic artery flow of 6.3% in response to dopamine. The percentage contribution of portal blood flow towards the cardiac output increase on dopamine administration. The functional hepatic blood flow, analyzed with 131-J-BSP, did not change. The wedged hepatic vein pressure, which is a good measure of portal pressure, increased on average by only 7% with dopamine at a dosage of 3 gamma/kg/min, but by 20.3% with twice the dosage. Dopamine did not cause a change in hepatic blood volume; hence, blood sequestration in the liver can be excluded in response to the dopamine-evoked increase in portal blood flow. 5...

[The effect of dopamine on the renal function in dogs with chronic ligation of the common bile duct (author's transl)]. / Das Verhalten der Nierenfunktion unter Dopamin nach Choledochusligatur beim Hund

The influence of dopamine on glomerular filtration rate (GFR), renal plasma flow (ERPF) and urinary sodium excretion was investigated in dogs before and after a chronic bile duct ligation for a period of 16 days. 1. Dopamine (4 microgram/kg/min.) leads to an increase of GFR, ERPF and urinary sodium excretion. 2. There was no change of GFR and ERPF after bile duct ligation. Urinary sodium excretion was decreased. The decrease was, however, not significant (0.05 less than p less than 0.1). 3. After bile duct ligation dopamine induced increase of GFR and ERPF was of the same order as observed in the preoperative period. Compared with the preoperative values for sodium excretion the dopamine effect was lower (p less than 0.05). The present investigation shows that dopamine is worth trying in cases of obstructive jaundice accompanied by acute renal failure.

[The influence of dopamine on the regional blood volume in liver, abdomen, chest and extremities (author's transl)]. / Der Einfluss von Dopamin auf die regionalen Blutvolumina in Leber, Abdomen, Thorax und Extremitäten.

The influence was studied of 3 and 6 gamma/kg/min. dopamine on the blood volume in the liver, abdomen, chest, arms and legs in ten volunteers with healthy livers, and a comparison was made between the effect of dopamine and the blood volume changes caused in these body regions by inflatable whole-leg boots at a pressure of 40 mm Hg. Regional blood volumes and any induced changes were studied by means of 99 m Tc labelled autologous erythrocytes. A gamma camera with a pinhole collimator and a small computer was used, the field of vision of the camera being 148 cm in diameter. Changes in regional activity reflect changes in the regional blood volume. 1. Whole-leg compression at 40 mm Hg led to an increase in the blood volume of the liver, abdomen and chest, but to a reduction in the legs, while no significant change was observed in the arm blood volume. 2. On infusion of 3 gamma/kg/min. dopamine for 15 minutes no significant change occurred in the blood volume of the liver and abdomen. The chest blood volume increased, while the blood volume of the upper and the lower extremities showed a statistically significant decrease. 3. On infusion of 6 gamma/kg/min. dopamine for 10 minutes no significant change occurred in the blood volume of the liver, while the chest blood volume continued to rise and that of the upper and lower limbs continued to fall. 4. Ten minutes after the end of the infusion there was no significant change in liver and abdominal blood volume as compared with the last value measured during infusion of 6 gamma/kg/min. dopamine. By that time the chest blood volume had already fallen and the blood volume of the arms and legs increased. The possible action mechanisms via dopamine-specific and other catecholamine receptors are discussed in this paper.

[A comparative study of the kinetics of 131I-bromsulphthalein and 125 I-biligrafin (author's transl)]. / Vergleichsuntersuchungen der Kinetik von 131J-Bromsulphalein und 125J-Biligrafin

The kinetics of 131I-Bromsulphthalein (BSP) and 125I-Biligrafin were compared with one another. 131I-BSP is taken by the liver ten times faster than 125I-Biligrafin. The distribution volumes of these two tracers are identical. The maximum transport capacities (Tm) of BSP and Biligrafin are inversely proportional to the elimination constant k of the blood. The Tm of BSP is 8.6 +/- 1.9 mg/min., of biligrafin is 35.8 2.2 mg/min. Biligrafin leaves the liver cells without prior metabolization, which could account the higher Tm of this preparation. In conformity with theoretical considerations, 131I-BSP and 125I-Biligrafin differ in the following important respects: 131-I-BSP leads to a high activity in the liver against a low background activity. With labelled Biligrafin, on the other hand, on account of the slow activity in the liver and the high Tm, a striking contrast is demonstrable between liver and bile duct. This could, perhaps, be of diagnostic value in localizing a bile fistula.

[First clinical experiences with scintiphotosplenoportography]. / Erste klinische Erfahrungen mit der Szintiphotosplenoportographie

This paper reports on the clinical applicability and efficiency of Scintiphotosplenoportography (SPSP) by means of 99mTc Pertechnetate. This diagnostic process permits obtaining the following data: actual route and patency of the portal vein, localizing of collaterals, as well as information on the actual speed of portal flow. By determining the time of transit of the radionuclid via the collateral pathways into systemic circulation, additional assessments as to the hemodynamic functional importance of these collaterals can be made. This process is of particular value for the speedy assessment of the patency of a surgically effected portocaval shunt in cases of shunt-bleeders. In patients without cirrhosis, a stop in the filling along the course of the portal vein indicates portal thrombosis. In cases of manifest cirrhosis, however, the lack of an SPSP image for the proximal portal vein and the liver itself, merely points to the existence of extensive caudal collaterals. Traumatization as the result of intrasplenal application of a volume of less than 1 ml (of tracer) remains minimal. In contrast with radiological splenoportography this methods entails practically no risks. However, as a result of the restricted field of view and the relatively coarse power of resolution, the quality obtainable by szintiphotosplenoportography is somewhat inferior to that of X-ray splenoportography.

[The simultaneous investigation of liver and kidney function in the presence of dopamine (author's transl)]. / Simultane Untersuchung von Funktionsparametern der Leber und Niere unter dem Einfluss von Dopamin

The effect of dopamine on liver function and on renal blood flow and the glomerular filtration rate was studied in 13 patients suffering from liver cirrhosis. Hence, the BSP retention and 131I BSP clearance was determined and also the clearance of 99mTc DTPA and of 125I hippuran in decreasing concentrations, as well as under steady state conditions. Methodological problems arising from the application of the slope clearance technique in cirrhotic patients are discussed. Dopamine did not affect the BSP clearance and BSP retention, but a significant increase in renal plasma flow was observed. The glomerular filtration rate was not significant altered.

[Effect of dopamine on the portal pressure]. / Der Einfluss von Dopamin auf den Lebervenendruck

1. An infusion of 3 gamma/kg/min dopamine causes a significant increase in the renal plasma flow and the glomerulum filtration rate. This dosage does not cause a change of the mean systolic and arterial pressure. This effect may also be observed in patients with hepatic cirrhosis. 2. The wedged hepatic vein pressure, an indicator for the portal pressure, only shows a slight increase (9,46 +/- 9,41%) as compared to the initial pressure produced by the mentioned dose. Measurements of the spleen pulpa pressure, which likewise indicates the portal pressure, showed an increase of pressure up to 100% due to pressing or coughing. 3. If in the case of bleeding oesophageal varices acute renal failure might develop, the advantage of the effect of dopamine in stimulating the blood flow through the kidneys may be considered more important than the minute danger of a slight increase of the portal pressure, which might provoke haemorrhage.