Daily variation in portal blood flow and the effect of propranolol administration in a randomized study of patients with cirrhosis

Abstract

A nocturnal increase in portal pressure and blood flow was demonstrated in patients with cirrhosis, suggestingPatients. Fourteen patients with cirrhosis (10 men and 4 women, that these hemodynamic changes may contribute to the mean age 53 { 6 years [mean { SEM]; range, 35-63 years) were triggering of the hemorrhagic episodes observed during included in this study. Diagnosis of the disease was made by liver the night in these patients. It is known that propranolol biopsy in nine patients and was based on clinical and biochemical reduces portal flow, thus reducing the risk of variceal data in five. The origin of cirrhosis was alcoholic in nine patients, posthepatitic in three, and cryptogenic in two. All of these patients bleeding. In a double-blind, placebo-controlled study, we fested by a significant reduction in heart rate (Ï21% { sured with a Toshiba Sonolayer SSA 270 (Tokyo, Japan), a duplex scanner consisting of a real-time, two-dimensional ultrasonic device 4%, P Ú .01) and cardiac output (Ï12% Ô 2%, P Ú .05). A and an attached 3.5-MHz pulse Doppler flowmeter. After a sampling significant decrease in portal blood flow (Ï20% Ô 4%, P marker had been set in the middle of the lumen of the portal vein Ú .01) was also observed in these patients. Propranolol along the beam axis, a second marker was positioned parallel to the administration blunted the time-related changes in cardirection of blood flow. Care was taken to maintain the angle formed diac output and portal blood flow. In contrast, patients by the ultrasonic beam and blood flow direction below 60Њ because the receiving placebo had a nocturnal peak of both parame-accuracy of the hemodynamic measurements decreases at increasing ters similar to that observed under basal conditions. Our angles. Measurements were carried out during expiration because study shows that chronic propranolol administration they can be easily standardized, allowing for a better visualization abolishes the nocturnal peak of portal blood flow in pa-of the portal vein for Doppler purposes, as the angle formed by the ultrasonic beam and blood flow direction is reduced to a minimum. duce the risk of variceal bleeding. [5][6][7][8] The purpose of the presTwenty-Four Hour Study. The patients were admitted to hospital ent randomized study was to evaluate the effect of propranotwo days before the study. During this time, they underwent an lol on the daily fluctuation of systemic and splanchnic acclimation period in a quiet room at 20Њ to 24ЊC. On the day of the hemodynamic parameters in patients with cirrhosis. baseline study, systemic and portal hemodynamic parameters were measured at 0800, 1600, 2400, and 0800 hours. During this period, the patients pursued ordinary activities within the room. HemodyFrom the 1 Seccion Ecografia and the 3 Unidad de Higado, Hospital Dr Bonorino Udaondo, namic studies were performed at least two hours after meals and tients with cirrhosis and indicates a preventive effect of

Circadian pattern of acute variceal bleeding among cirrhotic Egyptian patients

“…Another two studies may suggest the circadian variation of fi brinolytic activity [17,19]. Our results are also in agreement with a previous work in Argentina that found a nocturnal triggering factors of the hemorrhagic episodes observed at night [25]. Also the habit of most Egyptian people to go to sleep at the afternoon, beside the main sleeping hours at night, these two times of sleep may explain the two peaks because our observed two peaks coincided with the late hours of these two sleeping periods, these fi ndings go hand-in-hand with the fi ndings of Iwao et al who reported that the upright posture decreases esophageal variceal fl ow velocity in patients with liver cirrhosis [14].…”

“…However, some arguments that may suggest a possible role of hyperfi brinolysis in facilitating variceal bleeding should be considered. A role for local fi brinolysis of the esophagus as a cause of hemorrhage in cirrhosis was suggested about 27 years ago [25], and subsequently plasma hyperfi brinolysis was clinically found to be a risk factor for bleeding in patients with cirrhosis [15,[26][27][28][29]. Indeed patients with impaired liver functions have hyperfi brinolysis [29] and this may be a possible explanation for the contribution of the liver function estimate in predicting variceal bleeding [23,[30][31][32].…”

Effects of propranolol on the hepatic hemodynamic response to physical exercise in patients with cirrhosis

“…23 In that regard, it is of interest to note that propranolol therapy has been shown to attenuate or prevent the changes in HVPG and portal blood flow associated with meals, 24,25 as well as its circadian variation. 26 We have recently described how physical exercise significantly increases HVPG in patients with cirrhosis, 1 thus adding another factor to the list of circumstances that may modify the splanchnic hemodynamics in cirrhosis. However, the possible effects of physical exercise on gastroesophageal collateral blood flow (which includes blood flow through the esophageal varices) was not studied in our previous investigation.…”

Systemic and Portal Hemodynamic Response to Propranolol in Patients with Portal Hypertension Due to Hepatitis C Virus

“…First, daily variations in portal blood flow occur and propranolol may affect these variations [7]. Second, the portal pressure response to ß-blockade may be greater in cirrhotic patients without varices than in those with varices [5].…”