J. Textor

Transjugular intrahepatic portosystemic stent-shunt for hepatorenal syndrome

According to a consensus recommendation, six patients had severe (type-I: serum creatinine >220 μmol/L or creatinine clearance 130 μmol/L or creatinine clearance <40 mL/min). Three of the six type-I patients required haemodialysis. In all patients, we measured renal function indices, urine volume, and sodium excretion before the intervention and 1, 2, 4, 8, 12, and 26 weeks after TIPS. Survival was analysed by Kaplan-Meier. Within 2 weeks of TIPS insertion there was a striking reduction in serum urea and creatinine together with a doubling in creatinine clearance (figure). Baseline sodium excretion increased spontaneously about 1 week after TIPS and was stimulated 2 weeks after TIPS by diuretics (100–200 mg of spironolactone and 40–80 mg frusemide per day). Glomerular filtration rate gradually improved over the next 6–8 weeks and creatinine clearance averaged around 60 mL/min 3 months after TIPS. Haemodialysis could be withdrawn in two patients (on days 12 and 18). Five patients died from progressive liver disease (at weeks 3, 4, 6, 13, 45) and two patients died from non-liver related events (at week 22 from cancer and at week 45 from sepsis). 3-month survival rate was 75% and the estimates of a six-month and a 1-year survival were 68% and 56% with little difference between type-I and type-II hepatorenal syndrome. While the majority of patients (81%) showed a rapid and sustained improvement, all three non-responders (unchanged GFR and severe ascites) died within 6 weeks after TIPS. Beneficial results even in patients already requiring haemodialysis but without subsequent transplant rescue may be due to improved filling of the central venous system decreasing neurohumoral vasoconstrictive activities (eg, plasma renin or noradrenalin), and a reduced sinusoidal pressure can relieve sodium retention by decreasing the direct symphathetic nervous effects on the proximal tubule. The observed 3-month and estimated 6-month and 1-year survival of our high-risk patients was substantially better than with medical management alone.

Detectability and detection rate of acute cerebral hemisphere infarcts on CT and diffusion-weighted MRI.

Abstract Our purpose was to compare the detectability and detection rate of acute ischaemic cerebral hemisphere infarcts on CT and diffusion-weighted MRI (DWI). We investigated 32 consecutive patients with acute hemisphere stroke with unenhanced CT and DWI within 6 h of stroke onset. The interval between CT and DWI ranged from 15 to 180 min (mean 60 min). Infarct detectability on CT and DWI was determined by comparing the initial CT, DWI and later reference images in a consensus reading of five independent examiners. The “true” detection rate was assessed by analysing all single readings. Two patients had intracerebral haematomas on DWI and CT and were excluded. There were 27 patients with ischaemic infarcts; all were visible on DWI and proven by follow-up. DWI was negative in three patients without a final diagnosis of infarct (100 % sensitivity, 100 % specificity, χ2 = 30, P < 0.0001). Ischaemic infarcts were visible on 15 and not seen on 12 CT studies (55 % sensitivity, 100 %specificity, χ2 = 1.48, P = 0.224). With regard to the single readings (30 examinations × 5 examiners = 150 readings), 63 CT readings were true positive and 72 false negative (sensitivity 47 %, specificity 86 %, χ2 = 2.88, P = 0.089). Of the DWI readings 128 were true positive and 7 false negative (sensitivity 95 %, specificity 87 %, χ2 = 70.67, P < 0.0001). Interobserver agreement was substantial for CT (ϰ = 0.72, 95 % confidence interval, 0.6–0.84) and DWI (ϰ = 0.82, 95 % confidence interval, 0.46–1). Taken together, detectability and detection rate of acute (< 6 h) hemisphere infarcts are significantly higher with DWI than with CT.

Prospective evaluation of a clinical score for 60-day mortality after transjugular intrahepatic portosystemic stent-shunt: Bonn TIPSS early mortality analysis.

Objective Transjugular intrahepatic portosystemic stent-shunt (TIPSS) is increasingly used to treat complications of portal hypertension, but proven tools for risk assessment of early mortality are lacking. Design The prospective evaluation of a new 60-day mortality score. Patients and methods In a tertiary medical centre, 30 consecutive TIPSS patients were analysed for early mortality predictors, such as Child–Pugh score, TIPSS urgency (elective:⩾ 36 h or emergency:< 36 h after variceal bleeding), comorbidity (Acute Physiology and Chronic Health Evaluation [APACHE]-II) and clinical data. Main predictors (P< 0.01) in this group (group-1: Child–Pugh score 10A, 10B, 10C) were graded (1, 2 or 3 points representing low, medium and high risk, respectively) and summarized as a Bonn TIPSS early mortality (BOTEM) score. This score was then tested prospectively in the next 73 TIPSS patients (group-2: Child–Pugh score 14A, 42B, 17C). Results Group 1 early mortality (30%) depended primarily on bilirubin (P< 0.005), APACHE-II (P < 0.001) and TIPSS urgency (P< 0.001). Added risk points (1, 2, 3) for bilirubin (< 3 mg/dl, 3–6 mg/dl, > 6 mg/dl, respectively), APACHE-II (< 10, 10–20, > 20 points, respectively) and urgency (elective, emergency, active bleeding, respectively) represented individual BOTEM score points. BOTEM was the best mortality predictor (P< 0.001);⩽/ > 6 score points was the optimal cut-off, with 56% sensitivity, 100% specificity, 100% positive predictive value, 84% negative predictive value and 87% accuracy. In group 2, early mortality (8.2%) was again best predicted by BOTEM (P < 0.01) with the same cut-off and 67% sensitivity, 99% specificity, 80% positive predictive value, 97% negative predictive value and 96% accuracy. Conclusion BOTEM score based on bilirubin, comorbidity and TIPSS-urgency predicts rather reliably post-TIPSS 60-day mortality and might optimize TIPSS treatment.

Improving the detectability of focal liver lesions on T2‐weighted MR images: Ultrafast breath‐hold or respiratory‐triggered thin‐section MRI?

The purpose of this study was to determine whether a respiratory‐triggered (RT) T2‐weighted turbo spin‐echo (TSE) sequence with thin section can improve the detectability of focal liver lesions compared to a breath‐hold (BH) T2‐weighted TSE sequence. In 25 patients an RT TSE with 8‐mm sections (8‐TSE RT) and 5‐mm sections (5‐TSE RT) and a BH TSE sequence with 8‐mm sections (8‐TSE BH) were performed. Forty‐one focal liver lesions (mean: 1.8 ± 1.2 cm; 14 lesions ≤1 cm; 27 lesions >1 cm) were evaluated. The 5‐TSE RT was significantly better in lesion detection compared to the 8‐TSE BH sequence for all sizes of lesions (40/41 vs. 33/41; P = 0.014). For lesions >1 cm no relevant differences in the detection rate of the sequences were found (8‐TSE RT, 26/27; 5‐TSE RT, 26/27; 8‐TSE BH, 25/27), for lesions ≤1 cm the 5‐TSE RT provided significantly better sensitivity than the 8‐TSE BH (14/14 vs. 8/14, P = 0.015). The results of this study suggest that lesion detection could be significantly improved by using an RT TSE sequence with thin sections compared with a BH TSE sequence. J. Magn. Reson. Imaging 2001;14:128–133.

Acute Budd-Chiari syndrome: Treatment with transjugular intrahepatic portosystemic shunt

The case of a 28-year-old man with acute Budd-Chiari syndrome due to veno-occlusive disease is reported. Transjugular intrahepatic portosystemic shunt (TIPS) was performed after upper gastrointestinal endoscopy, duplex sonographic and abdominal computed tomographic examination, inferior cavogram with hepatic venous catheterization, and transvenous biopsy. A 10-mm parenchymal tract was created. The patient did well after the procedure; ascites resolved and liver function improved markedly. The shunt has remained patent up to now for 6 months.

Endoscopic manometry of esophageal varices: evaluation of a balloon technique compared with direct portal pressure measurement

BACKGROUND/AIMS Recently, a non-invasive endoscopic balloon technique for esophageal manometry was published. In the present study, we assess its methodological aspects together with the relationship to portal pressure. METHODS In 20 patients with liver cirrhosis who had received an intrahepatic portosystemic stent-shunt (TIPS), we evaluated portal and variceal pressure before and after balloon occlusion of TIPS (random order). Portal pressure was measured continuously via a portal venous catheter, and variceal pressure was determined at the same time independently by two endoscopists using two balloon techniques (inflation until varix collapses; deflation until varix reappears). RESULTS Overall, mean (+/-SD) portal pressure (28.5+/-7 mmHg) was significantly higher (p<0.001) than mean variceal pressure (24.4+/-6 mmHg). Balloon manometry-determined variceal pressure values were 10+/-15% higher with the inflation technique (26.2+/-7 mmHg) than with the balloon deflation technique (22.6+/-6 mmHg, p<0.001). Portal pressure and variceal pressure correlated significantly (p<0.001; balloon inflation: r=0.61, balloon deflation: r=0.66, mean values of inflation and deflation: r=0.68). Short-term TIPS occlusion led to mean increases of 52% and 35% in portal pressure and variceal pressure, respectively. The manometry results of both endoscopists correlated well with either balloon technique (r> or =0.93; p<0.001) and we saw no adverse effects. CONCLUSIONS Variceal balloon manometry provides non-invasive variceal pressure data which correlate to portal pressure assessed prior to and after short-term TIPS occlusion. However, probably due to variance in collateral anatomy, variceal pressure does not exactly predict portal pressure and its acute changes in the individual patient. The averaged variceal pressure of the inflation and deflation balloon technique provides the best relation to portal pressure combined with a good interobserver reliability and warrants further clinical evaluation.

Transjugular Portal Venous Stenting in Inflammatory Extrahepatic Portal Vein Stenosis

We report the case of a 37-year-old man with necrotizing pancreatitis associated with inflammatory extrahepatic portal vein stenosis and progressive ascites. Four months after the acute onset, when no signs of infection were present, portal decompression was performed to treat refractory ascites. Transjugular transhepatic venoplasty failed to dilate the stenosis in the extrahepatic portion of the portal vein sufficiently. Therefore a Wallstent was implanted, resulting in almost normal diameter of the vessel. In follow-up imaging studies the stent and the portal vein were still patent 12 months after the intervention and total resolution of the ascites was observed.

Radiological signs of osteitis around extramedullary metal implants A radiographic-microbiological correlative analysis in rabbit tibiae after local inoculation of Staphylococcus aureus

Abstract Radiographic changes in the early stages of osteomyelitis may be subtle and, especially after plate osteosynthesis, frequently missed. A previously described experimental model of local bacterial infection was used in an attempt to determine the reliability of specific changes on conventional radiographs for the diagnosis of osteitis after metal-plate implantation and subsequent inoculation of Staphylococcus aureus in rabbit tibiae. Roentgenograms of the treated limbs were evaluated, and seven radiographic parameters, to which numerical scores were assigned, were determined for each bone. Our results substantiate the conclusion that a radiographically verified periosteal reaction is a constant and early skeletal feature of acute osteomyelitis and has the strongest association to the microbiological results (P < 0.05), emphasising its high predictive value. Plate implantation does not notably impede the diagnosis of osteomyelitis. An association between the amount of inoculated bacteria and the extent of radiographic changes could be found. The results of this present study closely resemble those described in man and suggest that this model may be useful for future experimental investigations in determining a score judging the severity of osseous involvement in local bacterial infection after plate osteosynthesis.

Tips for severe hepatorenal syndrome in non-transplant cirrhotics: a new option?!

TIPS FOR SEVERE HEPATORENAL SYNDROME IN NON-TRANSPLANT CIRRHOTICS: A NEW OPTION?! KA Brensin¢,. J Textorg*), J Perz, P Schiedermaifr, P Rash, H Strunk(*). FlU Klehr, HJ Kramer. U SDenaler. H Schild(*), T Sauerbruch, Depts. of Medicine & Radiology(*), University of Bonn, 53105 Bonn, Germany. Without urgent transplantation (LTx), only 10% of cirrhotics with hepatorenal syndrome (HRS) survive three months (l). Recent HRS data (2) suggest benefits after TIPS, but long-term data in non-transplant patients with severe HRS is missing. Method: We studied 16 non-transplantable Child-C cirrhotics with typed HRS (creatinine >2.5 mg/dl or GFR 12 Child-pts or bilirubin >15 mg/dl) were excluded and received best medical support. Patients were followed for at least 13 weeks (wks; median: 14; 0.2-120). We analysed renal function and survival (Kaplan-Meier). Results: Renal function (+SD) deteriorated without TIPS, but improved (p < 0.001) within 2 wks after TIPS (creatinine: 4.5+1.9 vs. 2.7+1.1 mg/dl; GFR: 9.0+9 vs. 29+ 24 ml/min; urine-Na: 7.1+7 vs. 54+51 mmol/24h). At 13 wks clearance was 45 ml/min and 4/5 patients were off hemodialysis. After TIPS, survival was 76% and 39% at 6 and 12 months (median: 48+5 wks), but only 12 % at 6 months without T! PS (median: 2+0.3 wks; p < 0.0001 vs. TIPS). Total cohort survival at 6 and 12 months was 55% and 19%. In multivariate analysis assignment to TIPS correlated independently to survival. Conclusions: About half of non-transplant cirrhotics with severe HRS may qualify for small TIPS. TIPS can improve renal function and provide favourable 6month survival, which may even offer the chanc~ for LTx reevaluation to some patients. (1) Gines et al. Gastroenterology 1993; 105: 229-236. (2) Brensing et al. Lancet 1997; 349: 697-698.

Definitionen, Epidemiologie, natürlicher Verlauf und klinisches Erscheinungsbild der Divertikelkrankheit

Die Haufigkeit einer Divertikulose und assoziierter Komplikationen nimmt mit dem Lebensalter zu. Eine Divertikelkrankheit liegt vor, wenn es zu Symptomen oder Komplikationen wie Divertikulitis oder Divertikelblutung gekommen ist. Die Divertikulitis ausert sich mit abdominellen Schmerzen und Entzundungszeichen. Es werden drei Typen mit Unterformen unterschieden: 1. die akute unkomplizierte Divertikulitis ohne Perforation, 2. die akute komplizierte Divertikulitis mit gedeckter Perforation, Mikro- oder Makroabszess oder freier Perforation mit begleitender Peritonitis und 3. die chronisch-rezidivierende Divertikulitis, die zu Komplikationen wie Stenose, Fistelung oder der Ausbildung eines Konglomerattumors fuhren kann. Die Divertikelblutung wird durch eine Ruptur der Vasa recta des Divertikels verursacht und ausert sich klinisch als schmerzlose untere Gastrointestinalblutung, die mit Zeichen des Volumenmangels einhergehen kann. Eine Sonderform stellt die segmentale Kolitis assoziiert mit Divertikulose dar, bei der sich entzundliche Veranderungen finden, die histologisch einer chronisch-entzundlichen Darmerkrankung ahneln.