Silvano Raia

Systemic and Hepatic Hemodynamics in Hepatosplenic Manson's Schistosomiasis with and Without Propranolol

Systemic and hepatic hemodynamics wereprospectively studied in 11 patients with Mansonsschistosomiasis and portal hypertension, as well asalterations resulting from the use of propranolol. Itwas decided that patients whose portal pressure was reducedby 30% with the use of the drug would not undergosurgery and that treatment would consist of the chronicuse of propranolol, associated with sclerosis of esophageal varices. This objective was not metby any of the patients whose portal pressure wasmeasured and the study was interrupted. Results showthat patients with Mansons schistosomiasis and portal hypertension have hyperdynamic circulation,mild pulmonary hypertension, greatly increased splenicblood flow, and preservation of total hepatic bloodflow. Administration of propranolol correctshyperdynamic circulation, aggravates pulmonary hypertension,does not alter portal pressure and reduces the sectorialportal blood flows, especially of the azygos vein, withmaintenance of total hepatic blood flow. These data favor the hypothesis of portaloverflow in the physiopathology of portal hypertensionof schistosomiasis.

Evaluation of predictive weaning indices for mechanical ventilation in liver transplantation

PATIENTS who have chronic liver disease, when in a terminal phase, often present ascitis, pleural effusion, and malnutrition. After liver transplantation these complications are associated with prolonged anesthesia, injury of the right diaphragm, infusion of blood-derived products, and surgical trauma, which result in alterations of gas exchange, reduction of pulmonary volume, and weakness of the respiratory muscles. This means that some parameters are required to ensure the successful weaning from mechanical ventilation immediately postoperative. Several indeces have been developed to predict successful weaning from mechanical ventilation. The indeces most often used are the spontaneous respiratory rate to tidal volume ratio (f/VT), 10 maximum inspiratory pressure (PImax), 11 and the partial arterial oxygen pressure to oxygen fraction inspired ratio (PaO2/FIO2). 12 In addition to these, our service has used maximum expiratory pressure (PEmax) measurements. These indeces are used for patients with chronic obstructive lung disease and healthy individuals. Unfortunately, no studies have been conducted to evaluate the efficacy of the method to wean patients from mechanical ventilation after liver transplantation. This study evaluates the efficacy of the f/VT, PaO2/FIO2, PImax and PEmax indeces as predictors for weaning from mechanical ventilation in liver transplantation patients.

Size of gastroesophageal varices: its behavior after the surgical treatment of portal hypertension

The size of gastroesophageal varices is one of the most important factors leading to hemorrhage related to portal hypertension. An endoscopic evaluation of the size of gastroesophageal varices before and after different operations for portal hypertension was performed in 73 patients with schistosomiasis, as part of a randomized trial: proximal splenorenal shunt (PSS n=24), distal splenorenal shunt (DSS n=24), and esophagogastric devascularization with splenectomy (EGDS n=25). The endoscopic evaluation was performed before and up to 10 years after the operations. Variceal size was graded according to Palmers classification: grade 1 - up to 3 mm, grade 2 - from 3 to 6 mm, grade 3 - greater than 6 mm, and were analyzed in four anatomical locations: inferior, middle or superior third of the esophagus, and proximal stomach. The total number of points in the pre-operative grading minus the number of points in the post-operative grading gave a differential grading, allowing statistical comparison among the surgical groups. Good results, in terms of disappearance or decrease of variceal size, were observed more frequently after PSS than after DSS or EGDS - 95.8%, 83.3%, and 72%, respectively. When differential grading was analyzed, a statistically significant difference was observed between PSS and EGDS, but not between proximal and distal splenorenal shunts. In conclusion, shunt surgeries were more efficient than devascularization in diminishing variceal size.

Systemic surgical shunts and splenomegaly as causes of haemolysis in portal hypertension in mansonic schistosomiasis: Evaluation through serum levels of haptoglobin, hemopexin and bilirubins

The haemolytic process in hepatosplenic schistosomiasis is often regarded as a result of splenomegaly that can be increased by spontaneous or surgical shunts. The importance of splenomegaly and/or shunt on the etiology of haemolysis was studied in a group of 74 patients with hepatosplenic schistosomiasis and portal hypertension. They were divided into 4 groups: Group I (22 cases) - pre-operative; Group II (15 cases) - classic splenorenal shunt; Group III (22 cases) - selective portal decompression and Group IV (15 cases) - azygoportal disconnection with splenectomy. The first group is characterized by the presence of splenomegaly and the absence of shunt; the second by the presence of shunt and absence of splenomegaly; the third, by the presence of both splenomegaly and shunt and the last by absence of both, shunt and splenomegaly. In all cases, the levels of sensitive markers of haemolysis, such as haptoglobin and hemopexin as well as non-conjugated and total bilirubins were determined. Biochemical and coagulation parameters, used to evaluate the hepatic function, were also studied. The data was initially analysed according to a factorial experiment of 2 and standard least squares techniques were used to evaluate the effects of splenomegaly, shunt and their interaction. The results showed that the shunts always provoked haemolysis, even in the absence of splenomegaly, but the presence of both, splenomegaly and shunt, always increased the process of haemolysis.

Hepatitis B and C in Patients with Hepatocellular Carcinoma in Brazil

The relative roles of hepatitis B (HBV) and hepatitis C (HCV) virus infections in primary liver cancer in Brazil have been established. In the present study, the prevalence of HBV and HCV infections was determined in 32 Brazilian patients with hepatocellular carcinoma (HCC), of whom 30 had elevated serum alpha-fetoprotein levels (median 285ng/ml, range 10–1380), but only 14 (44%) were found to have cirrhosis on liver biopsy. Fifteen (47%) had a history of excessive alcohol consumption (>80g/day). All patients were screened for serological markers of HBV (HBsAg, anti-HBe, anti-HBc, and anti-HBs) and of HCV (anti-HCV). Additionally, HBV-DNA was determined by a radiological molecular hybridization assay, and HCV-RNA was measured by nested polymerase chain reaction (PCR). Eight (25%) patients were found to be HBsAg- and anti-HBe- positive, five of whom were seropositive for HBV-DNA. Thirteen (41%) patients were found to have anti-HBs and/or anti-HBc. Anti-HCV was found in 8 (25%), of whom four were HCV-RNA-positive, and one had HBV coinfection (HBsAg- positive). Cirrhotic patients were significantly (P < 0.05) older (mean age 59 years, range 41–77 years) than noncirrhotic patients (mean age 43 years, range 22–68 years), but there was no significant difference between these two groups with respect to overall prevalence of HBV and HCV markers. Nine (28%) of the 32 patients had no markers of HBV or HCV infection and no history of heavy alcohol intake. These findings suggest that, in a significant proportion (56%) of Brazilian patients, HCC develops in noncirrhotic livers and in 50% of these is not related to either HCV or HBV infection or alcohol intake.