Richard E. Kessler

The portal pressure-blood volume relationship in cirrhosis

Portal pressure-blood volume curves were derived in 13 cirrhotic patients with portal hypertension and oesophageal or gastric varices by measuring portal pressure at two levels of blood volume. Portal pressure varied directly with blood volume. In seven patients where portal pressure was measured at three levels of blood volume separated by 500 ml or more the portal pressure-blood volume relationship was found to be approximately linear.

Effect of Portal Venous Blood Flow Diversion on Portal Pressure

To anticipate the hepatic vascular response to portacaval anastomosis, we studied portal pressure during diversion of portal blood through a temporary extracorporeal umbilical vein to saphenous vein shunt. The relationship of portal pressure to shunted flow was approximately linear. In five schistosomiasis patients (controls) portal diversion to 1,250 ml/min gave portal pressure-shunted flow curve slopes ranging from 0.13 to 0.57 cm water/100 ml per min (0.31+/-0.18, mean+/-SD). In 17 cirrhotic patients with portal hypertension a continuum of slopes was observed from within mean+/-2 SD of control (type A) to larger slopes (type B) indicating failure of portal pressure regulation. When portal flow was augmented by shunting from saphenous vein to portal vein, cirrhotic patients who had slopes less than mean+/-2 SD of controls during diversion (type A) exhibited a compliant system with small increases in portal pressure, whereas type B patients had significantly greater pressure increases. Selective investigations suggested that changes in portal pressure provoked compensatory changes in hepatic arterial blood flow that tended to maintain portal pressure at a set point. Type B patients demonstrated failure of this mechanism to varying degrees.After end-to-side portacaval shunt, seven type A cirrhotic patients maintained residual intrahepatic venous pressure unchanged from prior portal pressure, whereas six type B patients had a significant decrease. Residual intrahepatic venous pressure was measured after portacaval shunt in 40 cirrhotic patients who were followed for as long as 9 yr (median survival 4.0 yr). The 13 patients who developed chronic encephalopathy had significantly lower pressure (21.1+/-4.4 cm, mean+/-SD) and shorter survival (median 0.6 yr) than the other 27 patients (32.6+/-5.3 cm, 5.0 yr). The preoperative estimation of portal pressure-diverted portal flow curve slope anticipates the hepatic vascular response to portacaval anastomosis and identifies a group of patients in whom loss of portal blood flow results in a low residual intrahepatic venous pressure that is associated with early death and chronic encephalopathy.

Endoscopic Retrograde Cholangiopancreatography (ERCP) in the Diagnosis of Pancreatic Inflammatory Disease

The clinical value of endoscopic retrograde cholangiopancreatography (ERCP) was evaluated in 63 patients by comparing the initial clinical diagnosis with pancreatographic findings. ERCP was of considerable diagnostic value and permitted early and precise differentiation of pancreatic inflammatory disease.

Endoscopic retrograde cholangiopancreatography in the dog: a model for training and research

A canine model for training and research in endoscopic retrograde cholangiopancreatography is proposed. Similarities to human endoscopic appearance and anatomy allowed successful cannulation of duodenal papillae in 4 of 10 dogs.

Retrograde Flow of Portal Vein Blood in Patients with Cirrhosis

In 1907, Herrick demonstrated that hepatic arterial flow could reflux into the portal vein (1). Spontaneous reversal of portal vein flow in patients with cirrhosis can occur only when the hepatic outflow resistence exceeds the resistance through portal venous collaterals and probably represents an advanced stage of portal hypertension. This report confirms the occasional existence of hepatofugal flow of portal venous blood in patients with cirrhosis and describes the radiographic characteristics of umbilical vein portograms demonstrating this phenomenon. Angiograms obtained from 2 of 150 patients with cirrhosis of the liver who had umbilical vein portography form the basis of this communication. Method The technic of umbilical vein catheterization has been previously reported (2, 3). This approach to the portal venous system is used whenever splenic puncture fails to demonstrate a portal vein or cannot be carried out because of contraindications, technical difficulties, or prior splenectomy. Umbilical vei...

Umbilical vein angiography.

Radiographic visualization of the portal venous system by splenoportography has proved worthwhile in the evaluation of patients with portal hypertension. This technie, however, has serious technical limitations, is hazardous, and is frequently contraindicated in patients to whom it might be of great value. Furthermore, the hepatogram phase has been found disappointing when used to visualize space-occupying hepatic lesions. To overcome the disadvantages of splenoportography, we have approached the portal venous system through the umbilical vein remnant (1). This communication illustrates the superb radiographic quality of portal venography as performed through the umbilical vein and demonstrates the unique usefulness of this technic for the visualization of space-occupying hepatic lesions. Examples chosen from 60 umbilical vein catheterizations are presented. Method Umbilical vein portograms and hepatograms were obtained in patients with cirrhosis of the liver and/or suspected portal hypertension and in th...

Effect of Lymph Drainage on Portal Pressure and Bleeding Esophageal Varices

The effect of thoracic duct lymph drainage on portal pressure and bleeding esophageal varices in 7 patients with cirrhosis has been evaluated. Four control patients with cirrhosis and bleeding varices were monitored in similar fashion without lymph drainage. Significant reductions in portal pressure were associated with hypovolemia from inadequate lymph replacement or recurrent hemorrhage from esophageal varices. The portal, central venous, and arterial pressures, urine output, and body weight remain unchanged when lymph was reinfused at the same rate as withdrawal. The functional thoracic duct pressure approached the central venous pressure. lymph drainage did not appear to control hemorrhage from varices since bleeding continued or recurred in 4 patients while lymph was being drained.