Hideaki Mizumoto

Hemodynamics of the left gastric vein in portal hypertension

BACKGROUND Esophageal varices reflect the hemodynamics of the left gastric vein, which can now be studied by Doppler ultrasonography. The purpose of this study was to elucidate the hemodynamic features of the left gastric vein in portal hypertension. METHODS Flow direction and velocity in the left gastric vein were examined by the pulsed Doppler flowmeter in 53 healthy adults and 216 patients with liver cirrhosis. RESULTS Flow direction was hepatopetal in all healthy controls, whereas it was hepatofugal in 72% of the patients with esophageal varices. In the early stage of mild esophageal varices, flow direction was still hepatopetal. However, in portal pressure > 250 mm H2O, hepatofugal flow was highly frequent (56 of 59 patients, 95%). Hepatofugal flow velocity in patients with varices was 8.5 +/- 2.5 cm/s in mild varices, 11.6 +/- 2.4 cm/s in intermediate varices, and 13.8 +/- 3.4 cm/s in marked varices. Variceal bleeding was frequent in patients with a flow velocity > 15 cm/s (7 of 14 patients, 50%). Flow velocity in the left gastric vein increased after ingestion of glucose in 43 of 56 patients with esophageal varices. CONCLUSIONS In portal hypertension, as the size of varices enlarged, hepatofugal blood flow in the left gastric vein increased in parallel. High flow velocity in the left gastric vein was strongly associated with variceal bleeding. Increase of blood flow after ingestion of glucose suggests postprandial increase in variceal flow.

Hemodynamics in the left gastric vein after endoscopic ligation of esophageal varices combined with sclerotherapy

Background and Methods: We examined the changes in portal hemodynamics after endoscopic variceal ligation (EVL) combined with endoscopic injection sclerotherapy (EIS) in relation to post‐treatment relapse. The present study included 93 patients who underwent EVL–EIS combination therapy. Portal hemodynamics were examined by Doppler ultrasonography and percutaneous transhepatic portography (PTP).

Study of hemodynamic changes in portal systemic shunts and their relation to variceal relapse after endoscopic variceal ligation combined with ethanol sclerotherapy

BackgroundAmong the factors influencing variceal relapse after endoscopic treatment, portal hemodynamic changes, especially in portal systemic shunts, could be the most important factor because hemodynamics are directly related to the development of esophageal varices. We aimed to clarify the influence of endoscopic treatment for esophageal varices on portal systemic shunts as well as its predictive value for variceal relapse.MethodsFifty patients who underwent combined endoscopic variceal ligation and injection sclerotherapy were examined with sonography and portography.ResultsDecrease of diameter, hepatopetal flow direction in the left gastric vein, or the presence of non-varices portal systemic shunt were sonographic findings related to a low incidence of variceal relapse. The presence of blood flow in and around the esophagus on venograms was highly predictive for variceal relapse. In patients with such venograms, non-varices portal systemic shunts did not develop.ConclusionsSonographic assessment of hemodynamic changes in portal systemic shunt could be useful for estimating the results of endoscopic treatment for esophageal varices.

White ball appearance in endoscopic ligation of bleeding esophageal varices

BACKGROUND Endoscopic variceal ligation is useful in the control of bleeding from esophageal varices. However, confirmation of ligation precisely at the site of bleeding is usually difficult when treating massive variceal bleeding. Characteristic endoscopic findings that appeared when ligation was performed at the site of bleeding are reported in this article. METHODS Emergency endoscopic variceal ligation was performed in 14 patients with active bleeding from esophageal varices. Endoscopic findings after variceal ligation at the site of bleeding were compared with those at sites without bleeding. RESULTS Active bleeding ceased just after endoscopic ligation at the site of bleeding in all patients. After ligation of the bleeding site of the varix, an unusual white-colored ball-like appearance (white ball appearance) was observed in all patients. This finding was markedly different from the purple-colored ball-like appearance that is usually observed after ligation of a varix at a site without bleeding. CONCLUSIONS White ball appearance was a characteristic finding that appeared after ligation of a varix at the site of bleeding. This finding may be useful in the confirmation of successful ligation of a varix at its bleeding site.

Hemodynamic response of the left gastric vein to glucagon in patients with portal hypertension and esophageal varices

Flow direction and flow velocity of the left gastric vein (LGV) and the portal vein (PV) were examined by a Doppler sonographic machine in 33 patients with esophageal varices, before and after venous injection of glucagon (1 mg). In two patients with hepatopetal blood flow in the LGV, the flow direction changed to hepatofugal after injection of glucagon. In 31 patients with hepatofugal blood flow in the LGV, a significant increase of flow velocity was observed in the LGV in 18 patients (58.1%) and the changes (26.4 +/- 24.6%) were significantly larger than those in the PV (7.9 +/- 16.0%). The changes in flow velocity decreased in the LGV as the diameter of the LGV and the size of varices increased. In conclusion, glucagon increased collateral blood flow in the LGV in portal hypertension. However, the grade of the response decreased as the grade of portal hypertension increased.

To-and-fro waveforms in the left gastric vein in portal hypertension.

Unusual to-and-fro waveforms were demonstrated in the left gastric vein on Doppler sonograms in four patients with liver cirrhosis. The patterns of the to-and-fro waveforms were diverse in each of the patients: both hepatopetal and hepatofugal flow occurred in a single waveform in case 1, changes in the flow direction with flow interruption were noted in case 2, and changes in flow direction without observation of flow interruption and changes after meals were noted in cases 3 and 4, respectively. These waveforms may represent a transitional phase during the development of a portal systemic shunt in patients with portal hypertension.

Aneurysm of the left gastric vein in a patient with portal hypertension

varices in 1998: hemoglobin, 10.7 g/dl; platelet count, 9.0 × 10/mm; aspartate transaminase, 58 U/l; alanine transaminase, 53 U/l; serum albumin, 4.4 g/dl; total bilirubin, 1.1 mg/dl; and blood ammonia, 110 μg/ml. The most recent data were: hemoglobin, 12.1 g/dl; platelet count, 4.3 × 10/ mm; aspartate transaminase, 57 U/l; alanine transaminase, 36 U/l; serum albumin, 2.9 g/dl; total bilirubin, 5.2 mg/dl; and blood ammonia, 61 μg/ml. The grade of liver dysfunction changed from A to C according to the Child classifi cation over the period 1998–2008.