V. Moreira

Circulatory function and hepatorenal syndrome in cirrhosis

The pathogenic mechanism of hepatorenal syndrome is not well established. We investigated the circulatory function in cirrhosis before and after the development of hepatorenal syndrome. Systemic and hepatic hemodynamics and the activity of endogenous vasoactive systems were measured in 66 patients who had cirrhosis with tense ascites and normal serum creatinine levels; measurements were repeated at follow‐up in 27 cases in whom hepatorenal syndrome had developed. At baseline, mean arterial pressure and cardiac output were significantly higher, and hepatic venous pressure gradient, plasma renin activity, and norepinephrine concentration were significantly lower in patients who did not develop hepatorenal syndrome compared with those presenting with this complication. Peripheral vascular resistance was decreased to the same extent in the two groups. Plasma renin activity and cardiac output were the only independent predictors of hepatorenal syndrome. Hepatorenal syndrome occurred in the setting of a significant reduction in mean arterial pressure (83 ± 9 to 75 ± 7 mmHg; P < .001), cardiac output (6.0 ± 1.2 to 5.4 ± 1.5 L/min; P < .01), and wegded pulmonary pressure (9.2 ± 2.6 to 7.5 ± 2.6 mmHg; P < .001) and an increase in plasma renin activity (9.9 ± 5.2 to 17.5 ± 11.4 ng/mL · hr; P < .001), norepinephrine concentration (571 ± 241 to 965 ± 502 pg/mL; P < .001), and hepatic venous pressure gradient. No changes were observed in peripheral vascular resistance. In conclusion, these data indicate that hepatorenal syndrome is the result of a decrease in cardiac output in the setting of a severe arterial vasodilation. (HEPATOLOGY 2005.)

Diagnosis of hepatopulmonary syndrome with contrast transesophageal echocardiography: advantages over contrast transthoracic echocardiography.

The aim of this study was to study theprevalence of hepatopulmonary syndrome (HPS) incirrhotic patients, comparing the results obtained usingcontrast transthoracic echocardiography (CTTE) andcontrast transesophageal echocardiography (CTEE) in thedemonstration and grading of pulmonary vasodilatation(PV). We also analyzed the correlation betweengas-exchange abnormalities and PV when it wasdemonstrated with both techniques. The prevalence of PV andHPS with CTEE in the 88 cirrhotic patients was 28% and22%, respectively, and with CTEE, 42% (P < 0.05)(middle PV: 35% and significant PV: 7%) and 30% (P < 0.05), respectively. Fifty-six percentof patients diagnosed with PV and with CTTE presentedwith hypoxemia as did 49% using CTEE (83% of patientswith significant PV had hypoxaemia). PaCO and diffusing capacity of CO were significantly moredecreased in 2 patients with PV than in patients withoutPV when CTEE was employed. We conclude that CTEE issuperior to CTTE in the diagnosis and grading of PV in the diagnosis of HPS in cirrhotic patients,being more sensitive and presenting a better correlationwith gas-exchange abnormalities. Given its highsensitivity, CTEE should be carried out in all patients with suspicion of HPS and normal or uncertainCTTE.

The effect of liver transplantation on circulating levels of estradiol and progesterone in male patients: Parallelism with hepatopulmonary syndrome and systemic hyperdynamic circulation improvement

The correction of hepatopulmonary syndrome (HPS) after liver transplantation (LT) remains controversial. The aims of our study were to: 1) analyze whether LT reverses HPS; 2) note any relationship between HPS and the systemic hemodynamic disturbance; and 3) note changes in circulating sex hormones and the possible association with pulmonary and systemic hemodynamic changes. Systemic hemodynamic parameters, cardiac output and systemic vascular resistance (SVR), sex hormones, and intrapulmonary vasodilatation assessed by contrast transesophageal echocardiography, and gas exchange abnormalities were investigated in 19 patients with advanced cirrhosis prior to and 6 months (176.8±30 days) after LT. LT was followed by a marked reduction in cardiac output (6.6±1.7 vs 3.5±0.5 l/min; plt0.001) and SVR (1039±460 vs 1978±294 dyn⊙sec⊙cm−5; plt0.005). Before LT, circulating estradiol and progesterone levels were invariably elevated (66±22 pg/ml and 1.8±1.1 ng/ml, respectively, normal values lt31 pg/ml and 0.35 ng/ml, respectively), and dropped after LT (28±12 pg/ml plt0.001 and 0.38±0.2 ng/ml; plt0.001, respectively). Seventeen of 19 patients had intrapulmonary vasodilatation and increased alveolar-arterial oxygen difference, thereby fulfilling diagnostic criteria for HPS. Patients with HPS presented higher cardiac output (plt0.05), lower SVR (plt0.01), and higher progesterone and estradiol levels than patients without HPS (plt0.05). LT produced normalization of intrapulmonary vasodilatation in all patients. LT normalized hyperdynamic circulation and is a useful therapeutic option in patients with HPS. Normalization of sex hormone levels after LT suggests that they could play a pathogenic role in the development of HPS.

Diagnosis and grading of intrapulmonary vascular dilatation in cirrhotic patients with contrast transesophageal echocardiography

BACKGROUND/AIMS The use of transesophageal contrast echocardiography (TOCE) in the diagnosis of intrapulmonary vascular dilatation (IVD) and hepatopulmonary syndrome (HPS) needs to be studied. We tested the specificity of TOCE using traditional criteria and the value of a new method based on TOCE, a grading scale and a selected contrast. METHODS 1) Several solutions were tested and two were selected: 20% mannitol and 0.9% saline. 2) 71 cirrhotic patients and 20 controls were studied. Left atrium opacification with contrast was classified into 6 degrees by TOCE. Mild and significant IVD were considered in relation to results in controls. Patients were studied with saline and mannitol-TOCE. Results were compared to transthoracic contrast echocardiography (TTCE), to gas exchange abnormalities and to Child class. RESULTS The reproducibility of TOCE grading was excellent, (Kappa >0.9). IVD detection using TTCE, mannitol-TOCE and saline-TOCE was 29.5%, 55% (25% mild and 30% significant), and 45% (38% mild and 7% significant), respectively. The best agreement with TTCE (reference method) was obtained with mannitol-TOCE, using significant IVD as the cut point. By this criterion, 18% reached the criteria of HPS using TTCE and 22% using mannitol-TOCE. Patients with IVD by TTCE had non-significant changes in gas exchange determinations. Patients with significant IVD by saline TOCE had lower mean PaO2 levels (67.3+/-14 vs. 79.5+/-11 mm Hg, p<0.05) than patients without IVD. Patients with significant IVD by mannitol TOCE had higher mean AaPO2 (29.3+/-14 vs. 19.7+/-9 mm Hg; p<0.005) and lower mean PaCO2 levels (30.1+/-4.4 vs. 33.4+/-4.8 mm Hg; p<0.05) than patients without IVD. Severity of IVD by TOCE correlated to Child class (r = 0.43; p<0.001). CONCLUSIONS The presence of contrast in the left atrium cannot be a criterion of IVD when TOCE is used. Our semi-quantitative scale has proved to be feasible and reproducible, presenting a good agreement with TTCE, and has shown better correlation with gas exchange abnormalities and Child class. Saline TOCE appears to be more specific in the detection of hypoxemic patients with IVD, but mannitol TOCE adds sensitivity.

Hepatitis aguda E en Madrid: descripción de 18 casos

Resumen Introduccion En paises subdesarrollados, el virus de la hepatitis E (VHE) es el principal causante de las hepatitis no-A no-B no-C epidemicas de transmision enterica. Sin embargo, en estos ultimos anos se han descrito casos de hepatitis esporadicas en Europa, sin que se encuentre como antecedente epidemiologico el viaje a paises endemicos. Objetivo y pacientes Presentamos 12 casos de hepatitis E esporadicas autoctonas (no se encontro ningun factor de riesgo epidemiologico) y 6 importadas (antecedente de viaje a Nepal, Santo Domingo, China, Brasil y Ecuador) estudiados entre junio de 1999 y diciembre de 2005. Resultados El diagnostico de hepatitis E se realizo en pacientes con sintomas de hepatitis aguda que presentaban anticuerpos IgG e IgM anti-VHE en sangre. El VHE es la causa de algunas hepatitis agudas en paises desarrollados que antes se etiquetaban como de etiologia desconocida. Conclusiones La hepatitis E debe incluirse en el diagnostico diferencial de hepatitis aguda incluso en pacientes sin antecedentes de viajes a zonas endemicas.

Implications of estradiol and progesterone in pulmonary vasodilatation in cirrhotic patients

The derangement of sex hormone serum levels in cirrhotic patients is well-delineated, and increased levels of progesterone and estradiol have been associated to hyperventilation in cirrhotic patients. These hormones have a well-known role in the regulation of vascular tone. The aim of this study was to evaluate whether sex hormone levels contribute to pulmonary vasodilatation (PV) and gas exchange abnormalities in cirrhosis. Contrast transesophageal echocardiography, arterial blood gases, parameters of liver function, pulmonary function test, estradiol and progesterone levels were determined in 45 male cirrhotic patients. Nineteen of 45 patients (42.2%) presented PV. Hyperventilation (pressure arterial of CO2≤35 mmHg) was correlated to progesterone levels (p<0.05) and pressure arterial of CO2 was high in patients with PV (p<0.005) and Child class B and C (p<0.01). Hypoxemia (pressure arterial of O2<80 mmHg) had inverse correlation with progesterone (p<0.05) and estradiol (p<0.05) levels and pressure arterial of O2 was low in patients with Child class B and C (p<0.05). PV was present in patients with high estradiol levels (p<0.05), high progesterone levels (p<0.005) and Pugh class B and C (p<0.05). Logistic regression analysis identified progesterone as the sole independent factor associated to PV (p<0.0005). Multivariate linear regression showed that PV was the sole independent factor related to both pressure arterial of CO2 (p<0.05) and pressure arterial of O2 (p<0.01) levels. PV was independently associated to gas exchange abnormalities in cirrhosis. Progesterone and estradiol were related with PV in cirrhotic patients.

Optimized Protocol for Diagnosis of Acute Ileitis

BACKGROUND & AIMS Suspected acute ileitis (AI) is a poorly defined clinical condition with multiple causes; its diagnostic protocol has not been standardized properly. We performed a prospective evaluation of the incidence and causes of AI to create a standard protocol for diagnosis. METHODS The definition of AI included abdominal pain, diarrhea, fever, and at least 1 confirmatory imaging method (abdominal computed tomography scan or ultrasound) showing pathologic changes in the terminal ileum that indicated ileal inflammation. We studied all patients with a presumptive diagnosis of AI seen in the Emergency Room at the Ramón y Cajal Hospital in Madrid, from March 2005 to May 2007, according to a pre-established protocol. Sixty-six patients with primary AI were followed up for at least 6 months. RESULTS An infectious cause was found in 33.3% of cases; the most frequently detected microorganism was Yersinia spp. A gynecologic condition was identified in 9.1% of cases initially diagnosed as AI, representing 13.95% of the cases among female patients. Crohns disease was identified in 12.1% of patients. The diagnostic protocol led to negative results in 33.4% of the patients; 6.1% of patients did not complete the study. The initial diagnosis did not change among any of the patients during the follow-up period. CONCLUSIONS This protocol led to a definitive diagnosis of AI in more than 60% of potential cases. The most common cause was acute infection. About 10% of cases were of gynecologic origin and about 12% of patients presented with Crohns disease.