Hepatic Wedge Pressure, Blood Flow, Vascular Resistance and Oxygen Consumption in Cirrhosis Before and After End-to-Side Portacaval Shunt12

Abstract

flow, found an average fall of 22 per cent in five patients after this operation (4). Hepatic oxygen consumption did not appear to be decreased. Nardi, using a less widely accepted technique for liver blood flow determination (the disappearance rate of radioactive colloidal chromic phosphate), noted a fall in six of nine patients after splenorenal shunt (5). The mean change in the nine patients was a fall of 24 per cent.In the end-to-side portacaval shunt, the portal vein is ligated and divided, and its distal end is implanted into the vena cava. Diversion of portal blood from the liver is therefore complete, and hepatic hemodynamic changes would be expected to be even greater than after a splenorenal shunt. Published studies on hemodynamic changes are limited to three cases included in the report of Bradley, Smythe, Fitzpatrick, and Blakemore (4), and in these three, hepatic blood flow fell an average of 36 per cent. In the clinic from which our patients are drawn, end-to-side portacaval shunt is the procedure of choice for the relief of portal hypertension in cirrhosis (6). In 10 such patients, we have made pre-and postoperative comparisons of the standard liver function tests, and the data obtainable from hepatic vein catheterization, namely, hepatic blood flow and oxygen consumption, wedged hepatic venous pressure, and postsinusoidal hepatic vascular resistance. This communication details our findings and discusses their implications on the therapy and pathologic physiology of portal hypertension. MATERIALS AND METHODSTen patients with end-to-side portacaval anastomoses were the subjects of the study. All were chronic alcoholics and in each, a surgical liver biopsy confirmed the diagnosis of cirrhosis. Esophageal varices were visualized by X-ray in seven cases and by esophagoscopy in 606

A study of factors influencing drug disposition in chronic liver disease, using the model drug (+)‐propranolol.

“…With increasing severity of chronic liver disease the clearance of (+)-propranolol fell in proportion to the decrease in clearance of ICG. This suggests a decrease in the common rate limiting factor of the liver blood flow, either in association with a reduction of hepatic parenchymal tissue or following surgical portocaval anastomosis (Redeker, Geller & Reynolds, 1958;Redeker, Kunelis, Yamamoto & Reynolds, 1964). There was no evidence of drug metabolizing enzyme inhibition which would have been expected to cause a disproportionate decrease in the clearance of (+)-propranolol compared to the clearance of ICG.…”

Albumin synthesis in cirrhotic subjects with ascites studied with carbonate-14C

“…Change in colloid osmotic pressure, pressure alterations within the liver, thyroid and cortisone metabolism, as well as changes in the nutritional state, all could influence albumin synthesis (29,32,33,(38)(39)(40)(41)(42)(43)(44).…”

Assessment of Portal and Hepatic Hemodynamics after Side-to-Side Portacaval Shunt in Patients with Cirrhosis*

“…Probably their patients were not a representative sample, since in preoperative pressure measurements by our surgical colleagues, evidence for reversed flow was found in only 7 of 61 patients (10). We have consistently (18 of 19 patients) found falls in hepatic blood flow after portacaval shunt, suggesting that portal blood does flow into the liver in most patients with cirrhosis (8,12). From our data the functional contribution of the blood leaving the liver in the portal vein appears quite variable.…”

“…The patient with the largest backflow measurement (R.R., 1,110 ml per minute) actually had definite forward flow at the time of the postoperative catheterization. It is interesting to compare the average value for potential backflow obtained in the patients in this study with the previously reported falls in hepatic blood flow (HBF) seen after ES and SS shunt (8,12). Mean preoperative HBF in 19 patients undergoing portacaval shunt was 1,439 ml per minute with no significant difference between the ES patients (1,493 ml per minute) and the SS patients (1,380 ml per minute).…”