Hiroshi Kokawa

Effects of nifedipine on hepatic venous pressure gradient and portal vein blood flow in patients with cirrhosis

Abstract We investigated the effects of nifedipine on splanchnic haemodynamics in 13 patients with cirrhosis and portal hypertension, and in 10 control subjects using hepatic venous catheterization and pulsed Doppler ultrasound. There were no significant changes in systemic or splanchnic haemodynamics in control patients. In contrast, systemic vascodilatation, evidenced by significant decreases in mean arterial pressure and systemic vascular resistance, was observed in patients 20 min after sublingual application of 10 mg nifedipine. Moreover, hepatic venous pressure gradient and portal vein blood flow significantly increased after nifedipine administration. There was a significant correlation between the percentage increases in portal vein blood flow and in hepatic venous pressure gradient. However, no correlation was found between the percentage change in cardiac output and that in portal vein blood flow. Thus the increase in portal vein blood flow appears to be related to splanchnic arterial vasodilatation by nifedipine. Consequently, nifedipine has deleterious effects on portal haemodynamics in patients with cirrhosis. As nifedipine may potentially increase the risk of variceal haemorrhage in patients with less advanced varices, this drug should be used with caution in patients with chronic liver disease.

Combination of transileocolic vein obliteration and balloon-occluded retrograde transvenous obliteration is effective for ruptured duodenal varices

Abstract: Duodenal varices are a rare site of hemorrhage in patients with portal hypertension, but their rupture is a serious and often fatal event. We report a 65-year-old woman who presented with hematemesis and melena. She was admitted to our department because of prolonged shock, despite having received transfusion of a large volume of blood. Upper gastrointestinal endoscopy revealed nodular varices with active bleeding in the second portion of the duodenum. Endoscopic injection sclerotherapy (EIS) was performed using a tissue adhesive agent, α-cyanoacrylate monomer, with only temporary benefit. However, anemia continued to progress after the procedure. Therefore, we combined transileocolic vein obliteration (TIO) with balloon-occluded retrograde transvenous obliteration (B-RIO), using 5% ethanolamine oleate with iopamidol to obliterate the varices. Complete hemostasis was achieved without complications. Neither recurrence of varices nor further bleeding has occurred for over 3 years. We conclude that combined TIO and B-RTO, which can obstruct both the feeding and the draining vessels of duodenal varices to retain the sclerosing agent completely in the varices, is a safe and effective hemostatic measure for ruptured duodenal varices, when EIS has failed to accomplish complete hemostasis.

Effects of endoscopic variceal sclerotherapy on azygos vein blood flow and systemic haemodynamics

The present study was designed to determine the systemic haemodynamic effects of obliterating oesophageal varices by endoscopic sclerotherapy. We evaluated systemic and splanchnic haemodynamics before and after the first course of sclerotherapy in cirrhotic patients. The baseline cardiac index was significantly correlated with baseline azygos vein blood flow (r = 0.64; P< 0.01) and the azygos vein blood flow and cardiac index significantly decreased (‐33% and ‐16%, respectively; P< 0.01) following sclerotherapy. The systemic vascular resistance index was also increased significantly (+20%; P<0.01) in these patients. Moreover, the per cent change in azygos vein blood flow was directly correlated with that of the cardiac index (r=0.51; P< 0.03). We conclude from these findings that the obliteration of portosystemic collaterals by sclerotherapy significantly reverses hyperdynamic circulation in such patients via a decrease in cardiac preload. The blood flow of the portosystemic shunt per se is a leading contributor to the hyperdynamic circulation observed in patients with well‐developed portal systemic collateral vessels.

Combined Non-Surgical Treatment with Transileocolic Obliteration and Endoscopic Injection Sclerotherapy for Esophageal and Gastric Varices

Abstract: Clinical results associated with the combined treatment of endoscopic injection sclerotherapy (EIS) followed by transileocolic obliteration (TIO) for esophageal of gastric varices were evaluated in 31 patients. Twenty patients underwent emergency treatment, and 11 underwent non‐ememgency treatment. No fatal complications developed after this combined treatment.

Clinical Study on Treatment of Ruptured Varices on the Fornix of the Stomach.

胃穹窿部静脈瘤 (fmdic varices;FV) 破裂17例の治療成績を検討した. 内視鏡所見では腫瘤状FV12例, 結節状FV4例, 扁平状FV1例であった. 初回治療は内視鏡的硬化療法 (endoscopic injectionsclerotherapy;EIS) を4例, 経回結腸静脈的塞栓術 (transileocolic obliteration;TIO) を7例, Hassab手術 (HB) を6例に施行し, 止血率は25%, 43%, 100%であった. 初回治療後10例 (59%) で止血がえられた. 止血不能7例に対しEISを1例, TIOを4例, HBを2例に施行し, 止血率は0%, 50%, 100%であった. 7例中4例 (57%) で止血がえられ, 止血不能3例に対しEISを1例, HBを1例に施行し止血しえた. 延べ止血率はEIS33%, TIO45%, HB100%であった. HB施行例では治療後FVからの再出血は認めなかった. 今後, 特に腫瘤状または結節状FVに対し予防的手術療法を積極的に行うことが肝要と思われた. 同時に手術不能例に対する治療として, 確実な塞栓効果を有する硬化剤や治療手技の開発が必要と思われた.