A 3 S T RA C T Carnitine is synthesized from lysine and metlhionine. In the rat, inade(quiate intake of either of these essential amino acids cauises carnitinie depletioIn 14 of' 36 hospitalized cirrhotics hald subnormal valtues for seruim carnitine. The creatinine/height index, midarm munscle circumference, and triceps skin-fold thickness indicated protein-calorie starvation in the 14 hypocarnitinemic liver patients. In six of the hypocarnitinemic cirrhotics (average seruim level 50% of normal), spontaneouis dietary intakes of' carnitine, lysine, and methionine were measuired and foulnd to be only 5-15% as great as in six normocarnitinemiic, healthy controls. When these six cirrhotic anuI six normnal stil)jects were given the same lysine-rich, methioninle-ricl, and carnitine-free nultritionaitl intake, the normaiitls mnain tained n oi-'matl serumiii camr iti ne levels and exeretedl 100 tLmol/day, wvhereas the cirrlhoties' sertum level fell to 25% of noimatl, and(l uirinary excretion dec ined to 15 Lmol/day. Seven lhypocarniitiniemic cirrhotics dlie(l. P'ostmlortemn concentratioons of' carnitine in liver, musele, heart, kidney, and brain averagedl only one-fouirtlh to onethir(d those in corresponding tisstues of eight normally noutrished nonhepatic patients who died after an actute illness of a 1-3-day duiration.These data show that carn-itine depletion is common in pattients hospitalized for advanced cirrhosis, and that it resuilts from three factors: stubstandard intake of dietary carnitine; substandard intake of lysine and methionine, the prectursors ftor endlogenouis carnitine synthesis; acnd loss of' cappacity to syntlhesize carnitine from lysine and methiioniine.

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Severe protein-energy undernutrition is a frequent finding among chronically ill patients. Its causes are anorexia, hypermetabolism, and malabsorption. Adverse consequences include impaired cell-mediated immunity increased susceptibility to infection, poor wound healing, weakness, and death. Spontaneous oral intake is inadequate in patients with this disorder, and therapeutic maintenance or repletion alimentation is needed. Enteral hyperalimentation is the method of choice, if tolerated. A successful treatment program usually requires a small-bore, flexible nasoenteral tube, appropriate feeding solution, and constant flow delivery of nutrient. If only partial dietary requirements are tolerated enterally, peripheral intravenous nutrient solutions can often supply the deficit. Although not suitable for all patients, enteral hyperalimentation is more physiologic, safer, easier, and more economical than central venous hyperalimentation. It would be well tolerated by many patients who now receive nutritional repletion by the latter method.

The concentrations of 23 plasma proteins were measured by radial immunodiffusion in the plasma and ascites of 17 patients with cirrhosis and four patients with intraperitoneal malignancies, to learn whether there is a selectivity in the movement of proteins from plasma into ascites, analogous to that of proteinuria. Additionally, since some of the proteins are involved in coagulation, we hoped to clarify the coagulopathy frequently seen following peritoneovenous shunting of ascites. Analysis was by groups: group 1 consisted of nine patients with cirrhosis with an ascites-total protein content less than 2.5 g/dl; group 2 consisted of eight patients with cirrhosis with ascites-total protein content greater than or equal to 2.5 g/dl; and group 3 consisted of four patients with malignant ascites. The ratio of the plasma concentration/ascites concentration ([P]/[A]) for each protein was calculated for each patient. In each group the median [P]/[A] for each protein was plotted against the natural logarithm of its molecular weight (In MW). For 21 of the 23 proteins, [P]/[A] showed a close linear relationship to In MW. Fibrogen and plasminogen showed significant (p < 0.0002) elevation above the regression line relating [P]/[A] to In MW. This indicates depletion of fibrinogen and plasminogen in ascites. The ascites in group 1 showed moderate selectivity, defined as the slope of the regression line (1.59), while groups 2 and 3 were essentialy nonselective (0.35 and 0.50). Fibrin-split products were elevated in all ascites but not in plasma, indicating either fibrinolysis or fibrinogenolysis within the ascites. A normal ratio for prothrombin suggests fibrinogenolysis may be the dominant mechanism. Thus the coagulopathy induced by LeVeen valve insertion may be in part secondary to the infusion of plasmin or a plasminogen activator into the circulation.

Analysis of 79 Dacron interposition shunts performed at Emory University from 1971 to 1977 identified a number of preoperative characteristics that correlate with short-term and long-term morbidity. Initial hospital mortality was related to the degree of elevation of the bilirubin and serum glutamic oxaloacetic transaminase (SGOT), to the presence of encephalopathy and to the urgency of the shunt procedure. Cumulative survival correlated best with the preoperative SGOT and bilirubin values, but other variables, including the Child's classification, preoperative encephalopathy, serum albumin, and the age of the patient at the time of operation, also exhibited significant associations. The hospital mortality of 13% and cumulative mortality of 48% in this series are in substantial agreement with similar reports in the literature. This experience differs widely from that described by most authors, however, in two other important respects: 1) significant hepatic encephalopathy has been observed in 45% of these hospital survivors, and 2) almost one-quarter of these patients have experienced spontaneous shunt closure. Thus, major shunt related complications have occurred in 70% of the patients to date. This incidence of undesirable consequences raises a serious question concerning the continued use of the Dacron interposition shunt for elective portal decompression.

Aortoenteric hemorrhage is the result of enteric erosion and necrosis of aortic wall or anastomotic site. Mechanical or bacteriologic causes may occur singly or in combination. The temporal sequence is such that warning symptoms, often including back pain, fever, hemotochezia, and anemia, are present long before exsanguinating hemorrhage occurs. Vigorous diagnostic efforts, including gallium-67 citrate nuclear scan and computerized axial tomography, lead to a correct diagnosis. This allows planned semielective corrective operation before severe hemorrhage begins. The ideal operation consists of extra-anatomic revascularization, excision of the infected prosthesis, bowel repair with decompression, and sump drainage. Appropriate antimicrobial therapy should be continued until healing is complete. With aggressive diagnostic and therapeutic intervention according to this plan, marked improvement in survival and limb preservation can be anticipated in patients having this complication of aortic surgery. In this series, 15 of 18 patiets having operation recovered, though delayed limb loss occurred in two.