Takatsune Nakayama

Formation of Hilar Collaterals or Cavernous Transformation After Portal Vein Obstruction by Hepatocellular Carcinoma: Observations in Ten Patients

A total of 155 patients with hepatocellular carcinoma were studied by celiac and superior mesenteric angiography. Complete (9 patients) or near complete (1 patient) obstruction of the portal vein and formation of hepatopetal collateral veins in the porta hepatis, or the so-called cavernous transformation of the portal vein, were seen in 10 patients. In 4 patients, the first angiogram did not show cavernous transformation, but on the follow-up angiograms cavernous transformation was present. The suggested interval between obstruction of the portal vein and formation of cavernous transformation was no more than 5 wk. The mechanism of cavernous transformation and its clinical implications are briefly discussed.

Experimental Portal Fibrosis Produced by Intraportal Injection of Killed Nonpathogenic Escherichia coli in Rabbits

An attempt was made to develop an animal model for the study of the etiology of noncirrhotic portal fibrosis or idiopathic portal hypertension based on the assumption that it is related to chronic abdominal infection. Rabbits were given killed nonpathogenic Escherichia coli intraportally or intravenously. The animals to which a mixture of killed E. coli and rabbit antiserum (aggregated E. coli) was given intraportally developed remarkable histologic changes in the liver. The early inflammatory reactions in the portal area and parenchyma were followed by rapid disappearance of inflammation and development of portal fibrosis with bile duct proliferation. Three intraportal challenges with aggregated E. coli were sufficient to produce pronounced portal fibrosis, although there was considerable variation in response among individual animals. This procedure also produced splenomegaly, and in some animals marked portal hypertension. Injection of nonaggregated killed E. coli into the portal vein or aggregated E. coli into the ear vein also caused similar hepatic changes, but they were milder in degree. These histologic changes resemble portal fibrosis seen in idiopathic portal hypertension and, less closely, pericholangitis associated with inflammatory bowel disease in humans.

Direction of splenic venous flow assessed by pulsed Doppler flowmetry in patients with a large splenorenal shunt

We studied the direction of blood flow in the splenic vein, using a combined ultrasonic system consisting of an electronic sector scanner and a pulsed Doppler flowmeter, in 21 patients with a large spontaneous splenorenal shunt demonstrated by angiography. Pulsed Doppler flowmetry revealed hepatofugal flow in the splenic vein in all 11 patients with chronic spontaneous hepatic encephalopathy, and hepatopetal flow in 10 patients without encephalopathy. In the former, hepatofugal flow of part of the superior mesenteric venous blood into the splenorenal shunt was corroborated by the venogram obtained after superior mesenteric arteriography. In 5 patients without a history of hepatic encephalopathy, superior mesenteric arteriography demonstrated hepatofugal flow of part of the superior mesenteric venous blood into the splenorenal shunt. Pulsed Doppler flowmetry, however, revealed hepatopetal flow in all of these patients, suggesting that the angiographic finding of hepatofugal flow may have represented an artifact.

Serum Cholinesterase in Patients with Fatty Liver

In search of a practical biochemical test that will reflect hepatic steatosis, we assessed the significance of serum cholinesterase activity in 48 patients with nonalcoholic fatty liver, 16 obese subjects without fatty liver, 30 cases of chronic persistent hepatitis, 38 cases of chronic active hepatitis, and 20 cases of liver cirrhosis. Increased cholinesterase activity was observed in nonobese as well as obese patients with fatty liver, whereas obese subjects without fatty liver showed levels in the upper normal range. When we set a cutoff level above the upper normal limit, half of the patients with fatty liver showed values above it, with only a few overlaps with other patients. When obese patients with fatty liver took a low-caloric diet, cholinesterase activity decreased, clearly reflecting improvement of hepatic steatosis. Thus, measurement of cholinesterase activity is of diagnostic value and an alternative to computed tomography in hepatic steatosis, and will provide a practical measure for the assessment of effects during follow-up.

Transhepatic obliteration of esophageal varices using stainless coils combined with hypertonic glucose and gelfoam.

A total of 63 patients with variceal bleeding were included in this study. Fifty-six attempts at percutaneous transhepatic variceal obliteration were made using stainless steel coils followed by 50% glucose and Gelfoam in 27 emergency cases, in whom bleeding did not stop by conventional medical treatment; and in 18 elective cases, in whom bleeding did stop by conventional medical treatment. The remaining 18 patients, whose bleeding was controlled by conventional medical treatment, were used as a control for the elective cases (conservative cases). The overall success rate was 93%. In 92% of the 37 acute bleeders, bleeding ceased as soon as the varices were obliterated. In emergency cases, the cumulative variceal rebleeding rate at 1, 2, 3, 6, 9, and 12 months after obliteration was 16%, 29%, 34%, 44%, 56%, and 56%, respectively. Its mortality within 1 month after the first bleeding was only 11%. In elective cases, the rebleeding rate at 1, 2, and 12 months was significantly lower; and the survival rate at 1 and 2 months was significantly higher compared with conservative cases. Follow-up portography in 10 active rebleeders and two nonrebleeders demonstrated new vessel formation in six, and recanalization of previously completely occluded varices in two. Complications included transient hemiparesis and partial stenosis of intrahepatic portal branches, but none was fatal. When compared with a conventional treatment, transhepatic variceal obliteration using steel coils followed by 50% glucose and Gelfoam proved to be an effective, safe emergency treatment for variceal hemorrhage. However, since the rebleeding rate was high, this procedure should be followed by an elective operation or other procedures for a lasting prevention of bleeding.

Reduction of portal vein pressure with the enlargement of portal-systemic shunts: Observation made in one patient

Whether portal vein pressure is reduced as spontaneous portal-systemic shunts are enlarged has long been disputed. We measured portal vein pressure directly by percutaneous transhepatic catheterization in one patient with cirrhosis at a 4-year interval, and demonstrated a significant reduction in portal vein pressure that had occurred along with enlargement of a collateral paraumbilical vein and splenorenal shunt during this period.

Direction of splenic venous flow assessed by pulsed doppler flowmetry in patients with a large splenorenal shunt. Relatin to spontaneous hepatic encephalopathy.

セクタ電子スキャンパルスドップラー複合装置を用いて,21例の巨大脾腎短絡路を有する患者の脾静脈の血流方向を調べた.肝性脳症を反復し,上腸間膜動脈造影の静脈相で上腸間膜静脈血の一部が脾腎短絡路に流入することを確認した反復性肝性脳症例全例(n=11)で,脾静脈血が脾腎短絡路へ流入する遠肝性血行を明らかにし得た.また上腸間膜動脈造影で遠肝性血行を示した5例と経皮経肝的上腸間膜静脈造影にて求肝性血行を示した5例の非脳症例全例(n=10)では脾静脈血が門脈へ流入する求肝性血行を明らかにした.以上より脾腎短絡路を有する患者でセクタ電子スキャンパルスドップラー複合装置を用いて,脾静脈の血流方向を測定することは,これら反復性肝性脳症群,非脳症群に分ける上で上腸間膜動脈造影に較べ非侵襲的でより正確であり,また脾静脈血流の逆流を示すものが近い将来脳症を発現するか否かを予測するのに有用と思われる.