Hirofumi Koen

Clinical Study of Eighty-six Cases of Idiopathic Portal Hypertension and Comparison With Cirrhosis With Splenomegaly

The clinical features of 86 cases of idiopathic portal hypertension, the equivalent of hepatoportal sclerosis in the United States and of noncirrhotic portal fibrosis in India, are presented. This disease is characterized by overt splenomegaly with pancytopenia, portal hypertension, and relatively mild abnormalities in liver function tests. Although differential diagnosis from liver cirrhosis is not always easy, liver histology, laparoscopy, portography, hepatic venography, and measurement of wedged hepatic vein pressure are useful in diagnosis. Prognosis is relatively benign if variceal bleeding is controlled or prevented, and the disease does not progress to cirrhosis. The etiology is still undetermined, but the liver pathology characterized by occlusive changes of the intrahepatic portal radicles, portal and periportal fibrosis, and irregularly distributed parenchymal atrophies suggests some sort of portal venopathy that causes decreased portal perfusion of peripheral liver parenchyma. These patients with idiopathic portal hypertension were compared with 63 cases of cirrhosis with splenomegaly and 80 cases of cirrhosis without splenomegaly. There was some similarity in hematologic findings between idiopathic portal hypertension and cirrhosis with splenomegaly, but the basic disease process seemed distinctly different. The cause of marked splenomegaly does not seem to be simply congestion, and remains an enigma.

Direction of splenic venous flow assessed by pulsed Doppler flowmetry in patients with a large splenorenal shunt

We studied the direction of blood flow in the splenic vein, using a combined ultrasonic system consisting of an electronic sector scanner and a pulsed Doppler flowmeter, in 21 patients with a large spontaneous splenorenal shunt demonstrated by angiography. Pulsed Doppler flowmetry revealed hepatofugal flow in the splenic vein in all 11 patients with chronic spontaneous hepatic encephalopathy, and hepatopetal flow in 10 patients without encephalopathy. In the former, hepatofugal flow of part of the superior mesenteric venous blood into the splenorenal shunt was corroborated by the venogram obtained after superior mesenteric arteriography. In 5 patients without a history of hepatic encephalopathy, superior mesenteric arteriography demonstrated hepatofugal flow of part of the superior mesenteric venous blood into the splenorenal shunt. Pulsed Doppler flowmetry, however, revealed hepatopetal flow in all of these patients, suggesting that the angiographic finding of hepatofugal flow may have represented an artifact.

Serum Cholinesterase in Patients with Fatty Liver

In search of a practical biochemical test that will reflect hepatic steatosis, we assessed the significance of serum cholinesterase activity in 48 patients with nonalcoholic fatty liver, 16 obese subjects without fatty liver, 30 cases of chronic persistent hepatitis, 38 cases of chronic active hepatitis, and 20 cases of liver cirrhosis. Increased cholinesterase activity was observed in nonobese as well as obese patients with fatty liver, whereas obese subjects without fatty liver showed levels in the upper normal range. When we set a cutoff level above the upper normal limit, half of the patients with fatty liver showed values above it, with only a few overlaps with other patients. When obese patients with fatty liver took a low-caloric diet, cholinesterase activity decreased, clearly reflecting improvement of hepatic steatosis. Thus, measurement of cholinesterase activity is of diagnostic value and an alternative to computed tomography in hepatic steatosis, and will provide a practical measure for the assessment of effects during follow-up.

Hepatic Lymphatics as Opacified by Percutaneous Intrahepatic Injection of Contrast Medium: Analysis of Hepatic Lymphograms in 125 Cases

Hepatic lymph vessels were opacified in 125 patients with various hepatobiliary diseases during percutaneous transhepatic cholangiography or portography. Contrast medium deposited in the parenchyma flowed relatively quickly in winding channels, usually toward the hepatic hilus. No correlation was demonstrated between the locus of the intraparenchymal deposit and the direction of the flow. Contrast medium also opacified the lymphatics near the hepatic hilus and abdominal aorta. Neither jaundice nor liver disorder were prerequisite for the visualization of the hepatic lymphatics. The intrahepatic injection of contrast medium provides a safe and useful method for the study of hepatic lymph and its pathways.

A dynamic study of rectally absorbed ammonia in liver cirrhosis using [13N] ammonia and a positron camera

Abstract[13N] Ammonia produced by the cyclotron was instilled intrarectally in patients with cirrhosis and other liver diseases to study the turnover of rectally absorbed [13N] ammonia. A positron camera connected to an on-line computer system was used for the measurement of sequential changes of13N activity in blood and for coincidence positron imaging of the liver and heart.13N activity over the head was also recorded. Chromatographic analysis of13N-labeled substances in blood was carried out using a Dowex 50Wx8 column at varying times after the administration. In the control, [13N] ammonia was absorbed quickly and visualized the liver, whereas in patients with cirrhosis, the lungs and heart were first visualized, and13N activity over the head was also higher. It was suggested that a large proportion of absorbed [13N] ammonia bypassed hepatocytes and reached peripheral tissues in cirrhosis. The heart/liver ratio of13N and13N over the head were correlated with various indices of portal hypertension. The relative proportion of nonammonia13N metabolites in blood was lower at 5 and 15 min after administration in cirrhosis, suggesting a reduced capacity of the liver to remove and metabolize ammonia.

Reduction of portal vein pressure with the enlargement of portal-systemic shunts: Observation made in one patient

Whether portal vein pressure is reduced as spontaneous portal-systemic shunts are enlarged has long been disputed. We measured portal vein pressure directly by percutaneous transhepatic catheterization in one patient with cirrhosis at a 4-year interval, and demonstrated a significant reduction in portal vein pressure that had occurred along with enlargement of a collateral paraumbilical vein and splenorenal shunt during this period.

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.

Fundamental Studies on Clinical Application of 13N-ammonia

放医研の医療用サイクロトロンを利用して, 13N-アンモニアを製造し, これの家兎の腸管内および静注の2つの投与経路での肝および心の13N-放射能動態の観察を行った。これに基づき, アンモニア代謝モデルを設定し, その解を適当な近似式に変換し, これにより腸管からのアンモニア吸収能, 肝内門脈分布, 実質細胞分布などで規定される諸パラメータ抽出の理論を展開した。