Hidetaka Terabayashi

Portal hemodynamics in idiopathic portal hypertension (Banti's syndrome): Comparison with chronic persistent hepatitis and normal subjects

A comparative study of portal hemodynamics was made in 17 patients with idiopathic portal hypertension, 5 patients with chronic persistent hepatitis having no portal hypertension, and 21 healthy adults who served as the control for certain measurements. Venous pressures were measured by portal and hepatic vein catheterizations, blood flow by the pulsed Doppler flowmeter, organ volume by computed tomography, and intrahepatic shunt index by 99mTc-macroaggregated albumin instilled in the portal vein. The patients with idiopathic portal hypertension were divided into two groups: group A (n = 8) and group B (n = 9), consisting of those who respectively had portal venous flow per liver volume above and below the mean + 2 SD of healthy adults. In group A, portal vein pressure was moderately elevated, portal venous flow was significantly increased compared with the control, and portal vascular resistance was not much altered. In group B, portal vein pressure was markedly elevated above that of control, portal venous flow was comparable, and portal vascular resistance was significantly elevated. Splenic venous flow measured in the splenic vein between the left and short gastric veins was markedly increased in groups A and B, the increase being greater in the former. It was concluded that in some patients with idiopathic portal hypertension, increased portal venous flow, partly a result of increased splenic venous flow secondary to splenomegaly of an undetermined process, is the main contributor initially to the elevation of portal vein pressure; in others, possibly later, increased portal vascular resistance plays an important role.

Transformation of inferior vena caval thrombosis to membranous obstruction in a patient with the lupus anticoagulant

A 24-yr-old woman with hemolytic anemia developed multiple thrombosis of the hepatic vein and inferior vena cava. She was found to have circulating lupus anticoagulant that could have been causally related to the thrombosis and hence the Budd-Chiari syndrome. On her first admission to the hospital vena cava and hepatic vein catheterizations revealed partial thrombotic occlusion of the cava at the level of the diaphragm, which was subsequently transformed into complete membranous obstruction. The right hepatic vein, which was patent on the first admission, was also completely occluded. These observations support the theory that membranous obstruction of the inferior vena cava is a sequela to inferior vena caval thrombosis rather than a congenital anomaly.

Quantitative aspects of portal-systemic and arteriovenous shunts within the liver in cirrhosis

To estimate vascular changes in chronic liver disease, we quantitated intrahepatic arteriovenous and portal-systemic shunts in 12 patients with cirrhosis and arteriovenous shunts alone in 4 patients with cirrhosis. An index was obtained for intrahepatic arteriovenous shunts by instilling technetium 99m-macroaggregated albumin into the proper hepatic artery and portal-systemic shunts, by the same procedure done in the portal trunk, near the porta hepatis on different days. Counts were taken over the liver and both lungs in the anterior as well as the posterior view for calculation of the shunt index: cpm in lungs divided by cpm in liver and lungs X 100%. In the 12 patients with cirrhosis in whom both shunts were measured, intrahepatic arteriovenous shunting was significantly lower compared with intrahepatic portal-systemic shunting (1.4% +/- 1.1% vs. 36.0% +/- 29.0%, p less than 0.001). Thus, it seems that in patients with cirrhosis, the development of intrahepatic arteriovenous shunts is not as great as that of portal-systemic shunts, which were found in this study to be considerable and variable in degree.

Prospective controlled trial of elective endoscopic sclerotherapy in comparison with percutaneous transhepatic obliteration of esophageal varices in patients with nonalcoholic cirrhosis

The results of a prospective randomized controlled trial of elective endoscopic intravariceal sclerotherapy carried out over a 36-mo period in comparison with elective percutaneous transhepatic obliteration of varices (PTO) are presented. Sixty-six patients with nonalcoholic cirrhosis were randomized after they had stabilized, usually between 7 and 14 days after variceal bleeding had stopped following medical treatment (balloon tamponade and vasopressin infusion). Thirty-three patients were assigned to the sclerotherapy group and the other 33 patients were assigned to the PTO group. The mean follow-up period was similar in both groups. There was no significant difference in demographic, clinical, and laboratory data between the two groups. Six patients (18%) in the sclerotherapy group and 21 (64%) in the PTO group had at least one episode of gastrointestinal bleeding during the follow-up period (p less than 0.005). Three patients in the sclerotherapy group and 1 patient in the PTO group bled from lesions other than varices; therefore the incidence of variceal bleeding was 9% in the former and 61% in the latter (p less than 0.005). The cumulative variceal bleeding rate was significantly lower in the sclerotherapy group than the PTO group (p less than 0.05). Five patients in the sclerotherapy group died during the follow-up period but none died of recurrent variceal bleeding. Nineteen patients in the PTO group died and 10 of them died of bleeding from varices. The cumulative survival rate was significantly better in the sclerotherapy group (p less than 0.05). These results indicate that elective endoscopic intravariceal sclerotherapy is superior to elective PTO in the prevention of recurrent variceal hemorrhage and mortality in nonalcoholic cirrhosis.

Development of Portal Vein Thrombosis Complicating Idiopathic Portal Hypertension

A 58-yr-old woman with biopsy-proven idiopathic portal hypertension presented with ascites and pretibial pitting edema. On admission, ultrasonic Doppler flowmetry demonstrated hepatopetal flow of a markedly reduced velocity in the portal vein, hepatofugal flow in the splenic vein, and a large spontaneous splenorenal shunt. The patient spontaneously developed hepatic encephalopathy 1 mo later. Percutaneous transhepatic portography demonstrated mural thrombi at the porta hepatis after the catheter had penetrated the mural thrombi without resistance; there was also a long retention of contrast medium in the portal vein. 99mTc-Macroaggregated albumin instilled into the superior mesenteric vein was caught in the lungs, and no activity entered the liver. Measurements of ammonia and immunoreactive insulin clearly indicated that superior mesenteric venous blood was shunted through the splenic vein and the splenorenal shunt. Subsequent ultrasonic examination with Doppler flowmetry suggested further growth of the thrombi and lack of blood flow in the portal vein. Although the procedure of percutaneous transhepatic catheterization could have contributed to the growth of thrombi, it is more likely that the thrombosis in the portal vein was a sequela to idiopathic portal hypertension, and was growing at the time of catheterization. This case may be of significance in the understanding of the relationship between idiopathic portal hypertension and extrahepatic portal obstruction.

Correlation between intrahepatic pressure and histomorphological changes of the liver.

ウイルス性肝疾患76例に,肝内圧の測定と肝の組織学的変化の検索を行なった.肝内圧と光学顕微鏡上の肝の線維化,炎症,壊死の程度ならびに電子顕微鏡上のDisse腔の膠原線維沈着の程度は,いずれも有意の一次相関(線維化:r=0.67,p<0.001,炎症:r=0.47,p<0.001,壊死:r=0.51,p<0.001, Disse腔の膠原線維:r=0.54,p<0.05)を認めたが,なかでも肝内圧と光学顕微鏡上の肝の線維化の程度が最も良い一次相関を認めた.

Familial occurrence of idiopathic portal hypertension: Observations in two sisters

Abstract Idiopathic (non‐cirrhotic) portal hypertension is one of the major problems in developing countries, but the aetiology is not known. Two sisters with idiopathic portal hypertension diagnosed by percutaneous transhepatic catheterization of the portal vein and liver biopsy are reported. Both patients had large spontaneous portal‐systemic shunts. This seems to be the first report of a familial aggregation of this disorder.

Direction of splenic venous flow assessed by pulsed doppler flowmetry in patients with a large splenorenal shunt. Relatin to spontaneous hepatic encephalopathy.

セクタ電子スキャンパルスドップラー複合装置を用いて,21例の巨大脾腎短絡路を有する患者の脾静脈の血流方向を調べた.肝性脳症を反復し,上腸間膜動脈造影の静脈相で上腸間膜静脈血の一部が脾腎短絡路に流入することを確認した反復性肝性脳症例全例(n=11)で,脾静脈血が脾腎短絡路へ流入する遠肝性血行を明らかにし得た.また上腸間膜動脈造影で遠肝性血行を示した5例と経皮経肝的上腸間膜静脈造影にて求肝性血行を示した5例の非脳症例全例(n=10)では脾静脈血が門脈へ流入する求肝性血行を明らかにした.以上より脾腎短絡路を有する患者でセクタ電子スキャンパルスドップラー複合装置を用いて,脾静脈の血流方向を測定することは,これら反復性肝性脳症群,非脳症群に分ける上で上腸間膜動脈造影に較べ非侵襲的でより正確であり,また脾静脈血流の逆流を示すものが近い将来脳症を発現するか否かを予測するのに有用と思われる.