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Early identification of patients at low risk for poor outcome after acute upper gastrointestinal hemorrhage would allow reduction of diagnostic and therapeutic interventions. We identified six early predictors of good outcome: age less than 75 years, no unstable comorbid illness, no ascites found on physical examination, normal prothrombin time, and, within an hour after presentation, systolic blood pressure of 100 mm Hg or greater and nasogastric aspirate free of fresh blood. Presence of all six predictors defined the low-risk population. Among 162 patients in the development and retrospective validation phases of our study, all 74 low-risk patients had good outcomes. A prospective validation study of 111 patients further established the accuracy of our predictive method; only two of 52 low-risk patients had poor outcomes. Application of our method should allow more selective management of patients with acute upper gastrointestinal hemorrhage.

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Sixty patients with advanced metastatic adenocarcinoma of the liver from a colorectal primary were treated by prolonged and continuous intra-arterial hepatic arterial infusion chemotherapy over a period of time from December 1969 through July 1976. A 10-day course of 5-FU was administered in the hospital, and patients were discharged receiving 5-FUDR by continuous arterial infusion through a chronometric infusion pump. Objective responses of 100% were obtained in 15% of patients, 50% response in 39% of patients, and 25% response in 21% of patients. The median survival from onset of treatment was 8.5 months, 6.9 months, and 7 months, respectively, for 100%, 50%, and 25% responders versus 3.6 months for nonresponders. Survivals from onset of treatment were generally less in those with no disease-free interval. No relationship of response to sex and age was found. Patients previously treated with 5-FU intravenously responded to intra-arterial chemotherapy; 13% had a 100% response, and 54% had a 50% response. No relationship of drug dose to response was observed. Drug toxicity was frequently systemic and mild to moderate. Numerous complications occurred due to the catheter, complete or partial thrombosis occurring in 18.6% and 20.8%, respectively, and 30% of patients had displacement of the catheter. The role of partial arterial occlusion in terms of response and survival may be significant. Future studies should involve comparison of direct surgical placement versus percutaneous placement of catheters.

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To exclude possible confounding effects of anesthesia on splanchnic hemodynamics, two different awake postanesthetic models (PAM), restrained and unrestrained, have been used. However critical analysis of the splanchnic hemodynamic state in these models is not available. We conducted experiments using chronically implanted pulsed-Doppler flow probes on the superior mesenteric artery (SMA) in ketamine-anesthetized and in postanesthetic restrained and unrestrained normal rats. Baseline values of mean SMA flow were compared with those under anesthesia (30 min), PAM (restrained or unrestrained at 90 and 150 min), and reanesthesia. Sham-anesthetized unrestrained animals provided control values. The same animals (n = 7) underwent the restrained, unrestrained, and control experiments at least 5 days apart. Ketamine anesthesia did not significantly alter mean SMA flow (89 +/- 9% of baseline) compared with sham-anesthetized controls (99 +/- 9%). Mean SMA flow in both PAM, restrained and unrestrained, had a significant (P less than 0.05) decrease at 90 min (78 +/- 8 and 83 +/- 12%) and at 150 min (68 +/- 14 and 78 +/- 14%) when compared with baseline and control. Reanesthesia returned SMA flows to baseline values (91 +/- 16%). The variability of mean SMA flow was significantly increased in both PAM. Maximum variability was observed in the restrained model (69 +/- 32%). These results indicate 1) that ketamine anesthesia does not significantly alter SMA flow and 2) that both the restrained and unrestrained PAM exhibit significant alterations of the splanchnic circulation for at least 2 h after complete recovery from anesthesia. Thus, in the absence of critical evaluation, results of splanchnic hemodynamic studies with these models should be questioned.(ABSTRACT TRUNCATED AT 250 WORDS)

Portal hypertension is accompanied by hyperdynamic systemic and splanchnic circulation. Serum bile acids (BAs), which are elevated in portal hypertension and have vasodilatory properties, have been proposed as mediators of this hyperdynamic circulation. In this study, portal hypertensive rats [accomplished by partial portal vein ligation (PVL)] were gavaged with cholestyramine (PVL-CH) to decrease circulating BA levels. A control group of rats was gavaged with an inert suspension of Metamucil (PVL-ME). The following hyperdynamic parameters were found to be similar in PVL-CH and PVL-ME: mean arterial pressure (119 +/- 6 vs. 124 +/- 5 mmHg), portal pressure (13.2 +/- 0.6 vs. 14.5 +/- 0.5 mmHg), cardiac index (0.33 +/- 0.04 vs. 0.34 +/- 0.03 ml.min-1.g body wt-1), splanchnic blood flow (1.4 +/- 0.13 vs. 1.6 +/- 0.1 ml.min-1.g body wt-1), portosystemic shunting (82 +/- 8 vs. 92 +/- 3%), peripheral arteriolar resistances (344 +/- 74 vs. 387 +/- 29 mmHg.min.ml-1.g body wt), and splanchnic arteriolar resistances (75 +/- 14 vs. 72 +/- 6 mmHg.min.ml-1.g splanchnic wt; 1,471 +/- 150 vs. 1,325 +/- 120 mmHg.min.ml-1.g body wt). BA in PVL-ME (84 +/- 9 microM/l) were similar to those previously observed in untreated PVL and significantly greater than those measured in PVL-CH (25 +/- 4 microM/l; P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)