Horace J. McCORKLE

The diagnosis and clinical management of hepatic coma in surgical patients

Abstract The diagnosis of hepatic coma and its response to treatment was studied in sixty-four surgical patients with (1) chronic liver disease associated with gastrointestinal hemorrhage, or (2) surgically constructed portal-systemic venous shunts. This syndrome should be suspected as a possible etiological factor when encephalopathy occurs in such patients. The clinical manifestations of hepatic coma have been described according to changes in the state of consciousness, motor activity and changes in deep tendon reflexes. These manifestations have been divided into three stages of encephalopathy including delirium, stupor and coma. The concentration of ammonia in the blood was found to correlate with the clinical progression of hepatic coma in over 90 per cent of these cases. In some patients electroencephalographic changes were found to be helpful in making the diagnosis of hepatic coma. Methods for decreasing the production of ammonia by the action of intestinal bacteria on nitrogenous substrates, as well as for the control of the concentration of this metabolite in the blood, were an important part of the clinical management of hepatic coma. When gastrointestinal hemorrhage was the precipitating cause of hepatic coma, control of bleeding and prompt removal of the accumulated blood from the gastrointestinal tract by catharsis, gastric lavage and enemas were found to be essential in controlling the production of ammonia. The oral administration of broad-spectrum antibiotics was also valuable in reducing the ammonia within the gastrointestinal tract. It was essential to withdraw the dietary protein completely during the acute phase of hepatic coma, and in order to avoid recurrence of this syndrome a limitation of protein intake often was necessary during the chronic state of ammonia intoxication. The amino acid arginine was used to enhance detoxification of ammonia within the body. In sixty-four patients with ammonia intoxication there was a prompt decrease in blood ammonia concentrations associated with clearing of the sensorium. Although over half of the patients were initially in deep coma, the over-all mortality rate was only 30 per cent.

THE PROBLEM OF NUTRITION FOLLOWING TOTAL GASTRECTOMY

Summary Clinical and laboratory studies made from the records of 36 patients undergoing total gastrectomy and experiments on 116 totally gastrectomized dogs indicate that 1.Alimentation time is decreased after complete gastrectomy. The amount of carbohydrate, fat and protein absorbed is considerably less than normal. 2.There is a tendency to regain some weight and maintain better nutrition when continuity is maintained between the esophagus and duodenum. This can be accomplished either by direct anastomosis between the esophagus and duodenum or by anastomosis isoperistaltically of a segment of jejunum or colon between the esophagus and duodenum. In human subjects digestion and nutrition appear to be better in patients who have isoperistaltic colon segment transplants and this procedure appears to be worthy of further trial even though it is technically more difficult to perform.

Effect of pancreatic secretions on the gallbladder in the absence of bile

Abstract An experimental method is described whereby bile was excluded from the gallbladder and pancreatic juice allowed to flow through the gallbladder of kid goats. Cholecystitis was produced but no gallstones were found.

A practical method of anesthesia for prolonged surgical procedures on the goat.

Summary Anesthesia for lengthy surgical procedures in goats was accomplished by the intermittent administration of sodium pentobarbital into a continuous intravenous (jugular) infusion. Adequate airway was maintained with a low tracheotomy.