Erik Juhl

Aspects of the Natural History of Gastrointestinal Bleeding in Cirrhosis and the Effect of Prednisone

The natural history of gastrointestinal bleeding in cirrhosis has been studied using prospectively collected data of 532 patients included in a randomized clinical trial with a regular follow-up of up to 12 yr. Of the total 199 patients who experienced gastrointestinal bleeding, 95 (48%) bled from esophageal or gastric varices, 67 (34%) bled from peptic ulcer or gastritis, and 37 (18%) had either insufficient evidence of the source (33) or mixed sources (4). In the total group of patients the cumulative percentage of patients in whom varices had been demonstrated of patients in whom varices had been demonstrated by radiography increased from 12 to 90 in 10 yr, while that of bleeding from varices increased from 7 to 40. In 104 patients who bled for the first time during the trial period (trial bleeding patients) the median number of bleeding episodes was one (range 1-8). In these patients the fatality from bleeding from varices was 82%. The risk of rebleeding from varices was 81%, and 4 yr after the first bleeding the cumulative survival had decreased to less than 10%. Rebleeding was significantly less frequent and survival significantly higher in patients bleeding from sources other than varices. Prednisone reduced the occurrence rate of varices, bleeding from varices, and death from bleeding varices in nonalcoholic females without ascites, 40% of whom fulfilled the histologic criteria of chronic active hepatitis. Prednisone significantly increased the occurrence rate of varices inpatient with ascites and of bleeding from varices in alcoholic patients. Prednisone significantly increased the occurrence rate of peptic ulcer in males and in patients without chronic active hepatitis.

Accuracy of Direct Cholangiography by Endoscopic or Transhepatic Route in Jaundice—A Prospective Study

An exact anatomic diagnosis of bile-duct obstruction is a prerequisite for selecting the appropriate management. In a prospective study on patients with clinically suspected obstructive jaundice, the results of direct cholangiography--by endoscopic retrograde or, alternatively, by transhepatic route--were compared with operative findings or liver biopsy or both. Final diagnoses were based on autopsy, operative biopsy, and clinical course. The study included 105 patients, 90 of whom underwent surgery, and allowed a blind and independent comparison between cholangiography and operative findings. The predictive value of a positive test, i.e., cholangiographic visualization of obstruction, was 0.99 and the predictive value of a corresponding negative test was 0.90, with the final diagnoses as reference. For the operated patients the predictive values were calculated as to obstruction (positive test 0.99, negative test 0.89), malignancy (positive test 0.92, negative test 0.89), and common duct stones (positive test 0.96, negative test 0.98). Thus, laparotomy can be avoided in patients in whom direct cholangiography shows no obstruction or an appropriate nonoperative procedure, like transhepatic insertion of a stent or endoscopic biliary surgery elected.

Liver Morphology and Biochemistry in Eight Obese Patients Treated with Jejunoileal Anastomosis

Abstract Ten patients were treated for obesity with jejunoileal shunt operation. Liver biopsies were performed in seven both during and 10 to 27 months after operation. The degree of fatty infiltration showed no distinct trend. Steatosis increased in three, decreased in three and remained unchanged in one. Two liver specimens were entirely normal at follow-up examination. Serum aspartate transaminase and sulfobromophthalein retention tests showed a transient deterioration after surgery, but later improved as compared with preoperative values. Prothrombin values decreased, but remained within normal limits. All other liver-function tests were unchanged. The present investigation does not support the contention that jejunoileal shunt for obesity should be abandoned for fear of severe liver damage.

A Therapeutic Index That Predicts the Individual Effects of Prednisone in Patients With Cirrhosis

Our aim was to construct an index that accurately predicts the degree of benefit or harm that prednisone therapy holds for patients with liver cirrhosis. The admission and survival data of 488 patients with cirrhosis who participated in a controlled clinical trial of prednisone in a dosage of 10-15 mg daily (251 patients) versus placebo (237 patients) and who were observed for up to 12 yr were analyzed using Coxs multiple regression model. Four variables each provided significant therapeutic information: antinuclear factor (p = 0.02) and large piecemeal necroses (p = 0.02) were associated with a beneficial effect, whereas ascites (p = 0.0004) and large regenerative nodules (p = 0.0007) were associated with a harmful effect of prednisone. From these four variables a therapeutic index was constructed. For a given patient the therapeutic index is a measure of how big the effect will be if prednisone is given. The gain in survival time obtained by administering prednisone according to the therapeutic index was estimated to be 349 yr, mainly confined to 217 patients with a significant positive (121) or negative (96) therapeutic index. The therapeutic index may prove useful for the optimal administration of prednisone treatment in new patients with cirrhosis.

Blind-Loop Reflux in Relation to Weight Loss in Obese Patients Treated with Jejunoileal Anastomosis

In 10 patients operated on with jejunoileal anastomosis for obesity, rate and degree of weight loss showed no significant correlation to the following roentgenological parameters: gastric emptying time, small bowel transit time, and degree and duration of reflux to the excluded ileum. A predominant feature in all patients was a slowness of gastrointestinal passage. The absolute size of the weight loss was approximately the same in all patients irrespective of their initial weight. This means that the most obese patients (150 kg and more) stabilized their weight at a too high level. It is concluded that a more effective treatment of patients with extreme obesity should consist in shortening the intestine left in function, and not in an extended surgical procedure aiming at avoiding reflux into the blind loop.

Effect of jejunoileostomy on glucose and insulin metabolism in ten obese patients

Abstract Ten subjects underwent a jejunoileostomy in the treatment of obesity. The blood glucose and serum immunoreactive insulin response to oral and intravenous glucose was determined ten days before, and with varying intervals up to 18 months after the operation. The reduced intestinal glucose absorption was compensatorily improved without reaching the preoperative capacity. Fasting blood sugar levels tended to be low for a long time after the operation but rose later on. The intestinal insulinotropic action remained preserved. A generally improved glucose tolerance and normalization of hyperinsulinism was correlated to weight reduction. We conclude that none of the reported effects of jejunoileostomy on glucose and insulin metabolism contraindicate this surgical treatment of obesity.

Fatal outcome after jejunoileal bypass for obesity

A review of all literature on jejunoileal bypass for obesity disclosed 282 deaths, corresponding to a mortality rate of 4.2 percent. This rate has been fairly constant through the last 8 years. The causes of death and the postoperative duration are quantified. Pulmonary embolism, mostly early, and liver disease, sometimes late, dominate among the numerous causes of death. Details are too scarcely reported to allow guidance to better results.

Morphological Changes in Liver Biopsies from Patients with Rheumatoid Arthritis

Oxphenisatin is known to induce liver damage and is suspected to cause or perpetuate chronic liver disease. In order to evaluate the hepatotoxic effect of long-term therapy with oxyphenisatin 26 consecutive patients with rheumatoid arthritis were investigated for the presence of liver disease. In all cases, liver biopsy, biochemical liver function tests and determination of Hepatitis-B antigen were performed. Ten patients showed no pathological changes in the liver biopsy and a further 2 had only non-specific changes. Seven patients had fatty liver, 5 passive congestion, one haemosiderosis and only one had cirrhosis of the liver. No correlation was found between the activity of rheumatoid arthritis, and duration of the disease, the drug therapy given, and the liver damage.

Carbohydrate metabolism in alcohol-induced fatty liver. Evidence for an abnormal insulin response to glucagon in alcoholic liver disease.

An intravenous glucose tolerance test and an intravenous glucagon test were performed in 21 alcoholics with fatty liver. The effect on insulin secretion and blood glucose concentrations was compared with the effect in 21 normal subjects and 21 patients, of the same age and weight, with alcoholic cirrhosis. The average glucose tolerance in patients with fatty liver was lower than normal. Forty-eight per cent had a diabetic glucose tolerance. The glucose tolerance in cirrhosis was significantly lower, and it was impaired in 86% of the patients with alcoholic cirrhosis. In both cirrhosis and fatty liver the concentrations of insulin were above normal before and during the two tests. The insulin-glucose ratio was increased in the liver patients during glucagon stimulation, and there was no significant difference between the two types of liver disease. During glucose stimulation the insulin-glucose ratios were equal in liver patients and normal subjects. It is concluded that the carbohydrate metabolism in alcoholic fatty liver is impaired as in alcoholic cirrhosis, although to a lesser degree. The abnormal response to glucagon is suggested to be due to an increased β-cell sensitivity in fasting chronic alcoholics.

Regular paperUltrasound examination in jaundiced patients: Is computer-assisted preclassification helpful?

In this study we attempted to determine the diagnostic accuracy and reproducibility of ultrasonography (US) for jaundice and to see how US can best be combined with preliminary clinical-biochemical diagnoses to plan the invasive work-up. US proved reproducible in two diagnostic departments (127 agreements in 135 cases). But, since obstruction was underdiagnosed (15 double-false negatives), the predictive value of a negative result was only 0.83. By adding a term which represents the US conclusion, obstruction or not, to the Copenhagen pocket diagnostic chart score (based on the logistic model) we found that an obstructive conclusion increases the odds of obstruction by a factor of 25, and a non-obstructive conclusion decreases the odds by a factor of only 1.9. We conclude that the preliminary diagnosis is frequently sufficiently certain to be unalterable by US. This leaves only 40% of the jaundice cases in which US is necessary to plan invasive work-up. The US workload can even, it appears, be reduced to about 22% without appreciable penalty in terms of unrewarding invasive procedures. Using these strict indications, four US examinations seem to suffice to avoid one such error. Relying on either US or clinical-biochemical data alone is inferior to the combined strategy.