John B. Price

Characterization of the syndrome of small and large intestinal variceal bleeding.

SummaryMassive bleeding from jejunal varices in a young alcoholic with cirrhosis and portal hypertension ceased following a portocaval shunt. Although rare, bleeding from small or large bowel varices has a high mortality. In 62 cases, small or large bowel varices are almost always associated with a predisposing condition including previous abdominal surgery and portal hypertension from cirrhosis or other causes. Hematochezia without hematemesis and nonbleeding esophageal varices generally occur. Angiography is the best diagnostic test.

Portasystemic shunting procedures for portal hypertension. Twenty-six year experience in adults with cirrhosis of the liver.

Abstract 1. 1. The results of the 404 cases of portal hypertension in adults with portal cirrhosis treated by portasystemic shunts are reviewed. 2. 2. The over-all operative mortality was 12 per cent. 3. 3. The five year survival rate was 58 per cent. 4. 4. Incidence of moderate and severe encephalopathy combined was 34 per cent in the follow-up period. 5. 5. Control of portasystemic encephalopathy is still imperfect but colon bypass offers hope when conservative therapy has failed. 6. 6. The incidence of shunt failure ranged between 5 and 50 per cent depending on the type of shunt performed. 7. 7. The most important factor in determining the clinical results of any shunting procedure is the underlying liver function status.

Epidermoid cysts of the liver.

To the four recorded cases of epidermoid cysts of the liver are added two cases recently seen in children. One was in a 4-yr-old girl and associated with biliary cirrhosis. The other was in a 5-mo-old boy. The former was treated by roux-en-y cystjejunostomy, the latter by enucleation. The origin of these cysts is unknown. One theory suggests derivation from accessory foregut buds. Because of their malignant potential, treatment should be by excision. Where this is impossible, roux-en-y cystjejunostomy offers satisfactory palliation.

Clinical significance of intraluminal pH in intestinal ammonia transport

Abstract 1. 1. In the canine small intestine the ammonia furnished by the relatively alkaline ammonium acetate (pH 7.1) is absorbed at a faster rate than is ammonia from a comparable quantity of the relatively acid dibasic ammonium citrate (pH 4.8). 2. 2. In the canine and human colon ammonia can be dialyzed more efficiently by an acid medium (Impersol) than by saline and much more efficiently than by an alkaline medium (THAM). 3. 3. Passive non-ionic diffusion appears to be the mechanism of ammonia transport in the colon and canine small bowel. 4. 4. Acid dialysis by Impersol in the acute situation or by lactulose for chronic use is suggested for the management of portasystemic encephalopathy.

SURGICAL, TREATMENT OF HEPATIC ENCEPHALOPATHY*

Over the past 15 years portal systemic encephalopathy has attracted increasing attention since it is a common and disabling complication in a growing number of patients with cirrhosis of the liver who have bad a surgically created portal-systemic venous shunt. Furthermore, as the varied neuropsychiatric syndrome becomes more accurately recognized, its presence is noted in patients with hemodynamically significant, naturally formed portal-systemic venous shunts-again in the presence of cirrhosis.’ The metabolic mechanism of portal-systemic encephalopathy is the subject of much investigative interest. In the words of Websteriz it “. . . has no explanation but it is unlikely the subtleties of hepatic coma wiil reveal themselves through a single experiment or discipline.” In spite of the complexities of the underlying mechanism, a growing body of clinical observations is being profitably used in the therapy of this incapacitating condition, and in tempering the judgment of the surgeon who contemplates creating a portal-systemic shunt where the condition may attenuate his therapeutic achievement. In recent reviews, Chalmers * and Webster * have summarized the growing body of clinical and laboratory observations concerning the three basic prerequisites of portal-systemic encephalopathy: hepatocellular impairment, functional portal-systemic shunting, and bacterial degradation of protein in the gastrointestinal tract. Therapeutic efforts based on these emerging concepts have utilized one or more of the following general approaches: (1) Suppression of bacterial action on the mixed protein substrate of the gastrointestinal tract. (2) Reduction of the quantity of the protein substrate on which the bacteria will act. (3) Reduction of the interaction time of the bacteria on the protein by decreasing the transit time of the intestinal content. (4) Suppression of the transport mechanism across the bowel wall. ( 5 ) Exclusion, by surgery, of the site where bacterial degradation of protein takes place. (6) Dilution of the toxic substances already absorbed. (7) Extraction of the toxic substmc&? already absorbed by extracorporeal perfusion extraction. (8) Stimulation of the body’s intrinsic mechanisms of detoxification. (9) Suppression of the cell membrane transport mechanism.