HEPATOLOGYVol, 34, No. 4, Pt.
2, 2001 AASLD ABSTRACTS
1459
MORTALITY OF GASTROINTESTINAL HEMORRHAGE IN CIRRHOTIC
PATIENTS HAS BEEN GREATLY REDUCED IN T%VO DECADES. Arnaud
Pauwels, Nicolas Carbonell, Olivier Fourdan, Victor Georges L~vy, Raoul Pou-
pon, Liver Intensive Care Unit, Paris France
]During the past two decades, management of gastrointestinal hemorrhage in
cirrhotic patients has been improved with new vasoactive drugs, endoscopic
sclerotherapy and variceal ligation, short-term antibiotic prophylaxis and
more suitable resuscitatives measures. Aim : To assess improvement of prog-
nosis in cirrhotic patients with gastrointestinal hemorrhage during the 1980-
2.000 period. Patients and methods : All cirrhotic patients admitted because of
gastrointestinal hemorrhage in our Liver Intensive Care Unit during the years
1L980, 1985, 1990, 1995 and 2000 were retrospectively studied. Results : In-
hospital mortality regularly decreased beetween 1980 and 2000 (Table). It was
even more evident when analyzed according to the Child-Pugh's classification
: in class A patients, mortality decreased from 14 % in 1980 to 0% in 2000; in
class B patients, from 44% to 0%; in class C patients, from 76% to 30%. It was
due to a reduction of both bleeding- and sepsis-related mortality (from 26% to
7.5% and from 10% to 0%, respectively). In patients with variceal hemorrhage,
reduction of bleeding-related mortality was associated with a more and more
systematic and combined use of vasoactive drugs (from 17% in 1980 to 100%
in 2000) and therapeutic endoscopy in first 24 h (from 0% to 73.5%), and with
a decrease in early rebleeding incidence. Decrease in bacterial infections was
mainly due to introduction of short-term antibiotic prophylaxis in 1990-92.
Conclusion : Mortality of gastrointestinal hemorrhage in cirrhotic patients has
been divided by three in two decades. This valuable result has been achieved by
a reduction of both bleeding- and sepsis-related mortality, concurrently a more
and more systematic and combined use of vasoactive drugs, early endoscopic
sclerotherapy or variceal ligation, and short-term antibiotic prophylaxis.
1980 1985 1990 1995 2000
% n=80 n=116 n=107 n=I06 n=t18
Mortality 4Z5 32.8 29 20.8 14,4
Rebleeding 36.2 19,8 17.8 17 11.9
infection 33.7 47,4 23.4 13.2 14.4
1461
CLINICAL CHARACTERIZATION FOR PORTAL HYPERTENSIVE GAS-
TROPATHY -EVALUATIONS FOR ITS SEVERITY AND LIVER FUNC-
TIONS IN PROGRESS OF CHRONIC LIVER DISEASES-. Yasuhiro Nish-
izaki, Masaru Itakura, Shigeyuki Motegi, Chikashi Muramatsu, Fuminori
Kobayashi, Tokai University Tokyo Hospital, Tokyo Japan; Syohei Matsuzaki,
Tokai University, Isehara Japan
Aim: Portal hypertensive gastropathy (PHG) is a major complication in chronic liver
diseases which causes upper abdominal complaints and hemorrhage. Several classi-
fications have been provided but endoscopic findings are not uniform in parts of the
gastric mucosa. To determine details in relation between endoscopic severity of the
PHG and liver functions including degree of portal hypertension in progress of
chronic liver diseases, 4 different findings of PHG were evaluated at 3 divided
portions of the stomach and were compared. Materials and Methods: 102 patients
with chronic liver diseases (12 chronic hepatitis (CH), 27 cirrhosis with Child A
(LC-A), 13 Child B (LC-B), 31 Child C (LC-C), 19 portal vein obstruction (PVO))
who underwent gastroendoscopy were included. Endoscopic findings of PHG were
classified according to McComacks classification, i.e. superficial reddening (SR),
snake skin appearance (SSA), cherry red spot (CRS), diffuse hemorrhage (DH), and
were evaluated separately in three portions of stomach, such as upper (U), middle
(M), lower (L). Liver functions were evaluated by Childs classification, prothrombin
time (PT%), cholinesterase (Ch-E), and degree of portal hypertension i.e. indocya-
nin green test (k-ICG) and spleen size measured by ultrasound. Patients with Heli-
cobacter pylori infection were eliminated. Logistic regression analysis was per-
formed. ANOVA, chi squre were used for statstical analysis. Results: Positive rate
PHG findings in CH, LC-A, LC-B, LC-C and PVO were 50, 85, 84, 93 and 100%
respectively. SR was frequently obsesrved at L (41-69%) but had no relation between
progress of liver disease. SSA was more frequently observed in M (25-55%) and U
(29--39%) than in L (0-16%) in CH, LC-A, LC-B, LC-C and PVO, however SSA in L
tended to be increased along to progress of liver diseases. Positive rate of CRS in U
was higher in CH (17%), LC-A (44%), LC-C (55%) than in L and M in each disease
group. DH in U with PVO (47%) was markedly higher than in all portion with and
without PVO. In comparison analysis between each PHG findings and liver func-
tions excluded patients with PVO showed that, PT% was lower in patients with CRS
and also CH-E and pit were lower in CRS and DH. Spleen index was larger than SSA,
and k-ICG was lower in DH when compared with patients with SSA. In Logistic
regression analysis, progress of liver damage (from CH to LC-C) had an independent
effect on the risk for appearances of SSA in L, CRS in U and DH in U in odds ratios
of 2.8, 1.6,10.9 respectively. Conclusions: The incidence of PHG was increased as
liver disease progressed. SR showed significantly higher in rates at L but had no
relation between progress of liver disease. SSA and CRS were appeared along to
progress of liver damage. DH was frequently observed at U in patients with PVO.
CRS and DH reflected liver dysfunction and portal hypertension in progress of liver
diseases.
537A
1460
THE INFLUENCE OF SPLEEN ON PORTAL HEMODYNAMICS: A NON
INVASIVE STUDY W I T H DOPPLER ULTRASOUND IN CHRONIC LIVER
DISEASE AND HEMATOLOGICAL DISORDERS. Fabio Piscaglia, Gabriele
Donati, Natascia Celli, Laura Cecilioni, Patrizia Pini, Barbara Stagni, Stefano
Gaiani, Filippo Gherlinzoni, Luigi Bolondi, Univ of Bologna, Bologna Italy
BACKGROUND AND PURPOSE. Portal hemodynamic changes related to
splenomegalies of different etiology are largely unknown. In particular the
contribute of spleen enlargement to portal hypertension is still controversial.
Aim of the present study was therefore to investigate the influence of the spleen
on portal hemodyanamics by assessing splenic and portal Doppler ultrasound
parameters in chronic liver diseases and hematological disorders. SUBJECTS
AND METHODS. Study groups were made by: 1) patients with chronic liver
disease (89 with cirrhosis, 35 with chronic hepatitis), 2) patients with spleno-
megaly without relevant portal hypertension (14 patients with hematological
splenomegaly and 25 liver transplant recipients for cirrhosis without compli-
cations at 6-24 months after surgery), c) 15 patients with arterial hypertension,
d) 22 healthy controls. In all subjects spleen size, portal flow parameters and
splenic artery resistance index (RI) were measured by duplex-Doppler ultra-
sound. RESULTS. Splenic artery RI resulted significantly and selectively in-
creased in patients with cirrhosis (0.63, whereas all other groups ranged be-
tween 0.53 and 0.56, p<0.01). Portal flow velocity was significantly decreased
in cirrhosis (p<0.01). The combination of these two parameters provided an
accuracy of 87.5% in distinguishing portal hypertensive from hematological
splenomegaly. In patients with cirrhosis the degree of spleen enlargement was
associated with increasing portal flow volumes, portal vein diameter and
variceal size, whereas splenic RI and portal velocity did not differ in connection
to spleen size. CONCLUSION. Splenomegaly of portal hypertensive or hema-
tological origin can be differentiated with high accuracy by spleno-portal
Doppler parameters. In patients with cirrhosis, the presence of splenomegaly
suggests a more severe condition, probably due to a more pronounced "for-
ward" component of portal hypertension.
1462
PLASMA ENDOTHELIN-I (ET-I) LEVELS IN CHILDREN WITH CIRRHO-
SIS AND THEIR RELATIONSHIP TO RENAL FUNCTION AND THE SE-
VERITY OF PORTAL HYPERTENSION. Ahmed F Abdalla, Mohammed Ezz
el-Regal, Ashraf M Bakr, Hala El-Marsafa~w, Talal Amer, lkbal Abu-Hashem,
Mansoura Univ, Mansoura Egypt; Mohammed K Abdel-Khalik, Cairo Univ,
Cairo Egypt; Hassan H A-Kader, Upstate Medical Univ, Cairo Egypt
Plasma Endothelin-I (ET-I) is a potent vasoconstrictor peptide, which is in-
volved in the pathogenesis of several disorders. ET-I levels are increased in
adult patients with cirrhosis. However, little is known about ET-I levels in
children with cirrhosis. Therefore, we measured ET-I levels in 19 children with
cirrhosis (8 patients with ascites, and 11 without ascites), and 1l age and
sex-matched normal children by radioimmune assay. We also correlated the
ET-I levels with mean blood pressure, creatinine clearance, and severity of
portal hypertension as measured by portal flow volume and portal flow veloc-
ity. Patients with cirrhosis and ascites had higher plasma ET-I levels compared
to patients without ascites (6.8 --- 0.62 pg/ml vs. 4.6 + 0.35 pg/ml; p < 0.01)
and controls (3.6 -+ 0.27 pg/ml; p < 0.005). Plasma ET-I levels were higher in
cirrhotic patients without ascites compared to controls (p < 0.005). Plasma
ET-I levels correlated positively with the mean blood pressure (r = 0.58; p <
0.05), and negatively with renal function as measured by creatinine clearance
(r = - 0.7; p <0.005). However, no correlation was detected between ET-I
levels and portal flow volume (r = - 0.02; p = 0.4) or portal flow velocity (r =
- 0.16; p = 0.4). We conclude that plasma ET-t levels are increased in children
with cirrhosis, with or without ascites, compared to controls. Patients with
cirrhosis and ascites have higher plasma ET-I levels compared to those without
ascites. The degree of elevation is not related to the severity of portal hyper-
tension. This increase tends to maintain systemic blood pressure, but is asso-
ciated with decline in renal function.