A. Alwmark

Evaluation of Splenic Embolization in Patients with Portal Hypertension and Hypersplenism

Twenty-five patients with hypersplenism caused by portal hypertension were treated by repeated partial splenic embolization. Fourteen surviving patients were followed for up to six years showing a good response on peripheral blood count and bleeding tendency. Three patients died in connection with the treatment and another eight died within half a year because of the underlying liver disease. The discomfort and complications of fever, pain, pleural effusion, and abscess formation and the possibility to avoid these by repeated partial embolization under antibiotic cover are discussed. The results are compared with reports in the reviewed actual literature and the splenic embolization is given a place among the means of a successful selective symptomatic treatment of partial hypertension.

IMPROVEMENT OF THE SPLENECTOMIZED RAT MODEL FOR OVERWHELMING PNEUMOCOCCAL INFECTION - STANDARDIZATION OF THE BACTERIAL INOCULA

Studies conducted on rats have shown an increased susceptibility after splenectomy to intravenously introduced pneumococci. One of the main obstacles in such experiments, as regards reproducibility, is the maintenance and handling of the bacteria. A procedure is described for the preparation of standardized inocula and preservation of the bacteria at -80 degree C. No change in viability or virulence was observed after storage for at least 6 months. A pronounced difference in susceptibility to type 1 pneumococci was found between sham-operated (LD100 greater than 2 X 10(4) colony-forming units) and splenectomized rats (LD100 less than 2 X 10(2) colony-forming units); in the latter group, the survival time was inversely correlated to the quantity of bacteria injected.

Endocrine tumors of the duodenum. Clinical characteristics and hormone content.

Nineteen patients with primary duodenal carcinoid were analysed retrospectively, and eight of the tumors were immunocytochemically examined. One tumor contained somatostatin, two tumors gastrin, two tumors both these peptides, and one tumor contained serotonin. In two tumors no peptide or amine could be demonstrated. Eight patients had ulcer symptoms and nine had gallstone disease. Only four patients had metastatic spread in spite of long delay. Five-year survival was 75% in 12 operated patients. No patient died of the tumor per se. It is concluded that a simple excision seems justified when the tumor is smaller than 2 cm, while probably more extensive surgery is needed when the tumor is larger or when there is local spread. Modern techniques of histofluorescence and immunocytochemistry facilitating a more precise classification will probably result in a better understanding as to symptomatology, prognosis, and making possible better treatment in the heterogenous group of carcinoid tumors.

Emergency and Long-Term Transesophageal Sclerotherapy of Bleeding Esophageal Varices: A Prospective Study of 50 Consecutive Cases

Fifty consecutive unselected patients with endoscopically proven bleeding esophageal varices were on 76 occasions during 3 years treated with transesophageal sclerotherapy. One-week hemostasis was obtained in 89%, with a hospital mortality of 14%. Three major complications (1.1%) occurred, with one fatal outcome. Long-term repeated sclerotherapy was instituted according to our protocol in all the survivors. During a mean follow-up period of 26 months 19 patients have been treated with sclerotherapy alone, 10 had elective and 2 had emergency operative procedures because of rebleeding. Six fatal bleedings occurred, four after sclerotherapy alone. The 3-year survival is calculated to be 49%. Sclerotherapy has proven to be effective and safe and can be recommended especially in the acute situation. It can also be used as long-term treatment, but rebleedings will in several cases necessitate operative procedures.

Phentolamine reverses NPY-induced inhibition of insulin secretion in isolated rat islets

It has been shown that the rodent pancreas is innervated by neuropeptide Y (NPY) nerves, some of which are adrenergic, and that NPY inhibits glucose-induced insulin secretion in vivo in the mouse and that from isolated rat islets in vitro. We now investigated whether the alpha-adrenoceptor antagonist phentolamine affects the inhibitory action of NPY on insulin secretion from isolated rat islets. It was found that NPY dose dependently inhibited insulin secretion stimulated by glucose (11.1 mM). At a concentration of 10(-7) M, NPY totally abolished the insulin secretory response to glucose. It was also found that incubation with the alpha-adrenoceptor antagonist phentolamine (10(-6) M) itself enhanced the insulin secretion at 3.3 mM but not at 16.7 mM glucose. Moreover, phentolamine counteracted the inhibitory action of NPY. Thus, at 10(-8) M, NPY could no longer inhibit insulin secretion when phentolamine (10(-6) M) was present, whether 3.3 mM or 11.1 mM glucose was present. In contrast, somatostatin (10(-7) M) could inhibit insulin secretion, both in the presence and absence of phentolamine (10(-6) M); this showed that phentolamine does not reverse all types of inhibition. However, when the dose of phentolamine was decreased to 10(-7) M, the inhibitory action of NPY on glucose-induced insulin secretion was retained indicating that the reversal of the NPY effect by phentolamine is a competitive effect. It is concluded that NPY inhibits glucose-induced insulin secretion by a direct action on the islets, and that phentolamine reverses this inhibitory action of NPY in a competitive manner.

Standardized Intraabdominal Abscess Formation with Generalized Sepsis: Pathophysiology in the Rat

Gelatine capsules containing Escherichia coli and Bacteroides fragilis in a standardized mixture with rat colonic content and barium sulfate were implanted intraabdominally into rats. Capsules of 0.75 g gave approximately 50% mortality whereas 0.35 and 1.10 g caused no or 100% mortality, respectively. In subsequent experiments, using the 0.75 g capsule, all animals became ill with signs of tachypnea, piloerection, low physical activity and hypersecretion of saliva 6-8 h after the implantation. The animals reduced their water and food intake substantially and the body weight decreased. A significant reduction in blood pressure, glucose and leukocyte and platelet counts was found 12 h after challenge. Blood cultures obtained at 12, 24, 48 and 60 h all grew E. coli but none B. fragilis. Succumbed animals revealed diffuse peritonitis with growth of E. coli and B. fragilis at autopsy, whereas surviving animals showed abscess formation at investigation on day 8 after challenge. It was concluded that the model closely resembled intraabdominal abscess formation with sepsis in man.

SPLENIC RESECTION OR HETEROTOPIC TRANSPLANTATION OF SPLENIC TISSUE AS ALTERNATIVES TO SPLENECTOMY - REGENERATION AND PROTECTIVE EFFECT AGAINST PNEUMOCOCCAL SEPTICEMIA

In 82 male Sprague-Dawley rats, divided into eight groups according to surgical procedure performed (total splenectomy, sham operation and six different modes of splenic conservation), resistance to intravenous injection of 4 X 10(3) CFU of Streptococcus pneumoniae type I was evaluated 16 weeks after the surgical procedures. Significant regeneration of the spleen and almost normal resistance to pneumococci was seen 16 weeks after a two-thirds resection. Pieces of the spleen, implanted subcutaneously or into the greater omentum, also showed marked regeneration; though survival time was prolonged, the mortality among these animals following injection with pneumococci did not, however, differ from that of totally splenectomized animals. Dispersed splenic tissue, injected subcutaneously, intramuscularly, or retroperitoneally, showed less sign of regeneration and had no effect on mortality or survival time in partially vis-à-vis totally splenectomized rats.

Portal-Systemic Encephalopathy: Influence of Shunt Surgery and Relations to Serum Amino Acids

Fifty patients with liver cirrhosis, portal hypertension, and a history of bleeding oesophageal varices underwent 15 different cognitive psychometric tests to evaluate the presence of subclinical portal-systemic encephalopathy. None of the patients were clinically encephalopathic. The patients were compared with 50 healthy control subjects. Twenty-three patients showed definite signs of encephalopathy in the psychometric tests, 17 were normal, and 10 were borderline cases. The most pronounced abnormalities were seen in tests reflecting logic inductive capacity, visual spatial performance, cognitive flexibility, perceptual speed, spatial perceptive ability, and psychomotor performance. Tests reflecting word memory were less affected. Serum liver function tests did not differ between patients with deranged and normal brain functions. The serum isoleucine concentration was, however, significantly lower in the encephalopathic patients. The psychometric test results did not differ between patients with alcoholic and nonalcoholic liver cirrhosis, and no change was noted 2 years after shunt surgery.

Pattern of Serum Amino Acids in Patients with Liver Cirrhosis: Influence of Shunt Surgery and Transesophageal Sclerotherapy

The serum amino acid pattern was studied in 30 patients with alcoholic liver cirrhosis, in 15 patients with non-alcoholic cirrhosis, and in nine healthy controls. Patients with alcoholic liver cirrhosis had significantly increased serum levels of aspartic acid, proline, methionine, tyrosine, phenylalanine, and tryptophan compared with controls. Valine was significantly decreased. Patients with non-alcoholic liver cirrhosis differed from patients with alcoholic liver cirrhosis only in having significantly greater serum levels of glycine. The serum amino acid pattern of nine cirrhotic patients who underwent mesocaval interposition shunt surgery because of bleeding esophageal varices was prospectively compared with that of nine matched patients treated with transesophageal sclerotherapy. A further significant increase in methionine and tyrosine serum levels was noted after shunt surgery. It is concluded that sclerotherapy influences serum amino acids less, which might be an advantage in relation to the development of hepatic encephalopathy.

PATTERN OF SERUM BETA-HEXOSAMINIDASE IN LIVER-CIRRHOSIS

The activity of the primarily lysosomal hydrolase, beta-hexosaminidase (EC 3.2.1.30), was studied in serum from 53 patients with bleeding esophageal varices, portal hypertension, and liver cirrhosis (31 alcoholic, 13 cryptogenic, and 9 primary biliary). The serum enzyme activity was determined on 89 occasions and was increased in 93%. There was no difference in the distribution between the three patient groups, but in patients who underwent portal-systemic shunt surgery there was a significant increase after 9-12 months. Serum beta-hexosaminidase activity correlated significantly with other biochemical tests known to be influenced by portal-systemic shunting. It is concluded that determination of this enzyme might become a useful liver test, since it sensitively detects liver disease and also might be specific, since besides liver disease only pregnancy and lysosomal disorders are known to show considerable elevations in serum activity.