Portal Hypertension

The Control of Gastro‐intestinal Hemorrhage in Cirrhosis by Combined Adrenocortical and Estrogenic Therapy

“…Although the degree of bromsulphalein retention is generally a safe and reliable diagnostic guide, it is well to bear in mind that abnormal BSP retention can occur in the presence of a normal liver as a result of anoxia caused by loss of blood. While elevation of the arterial blood ammonia level suggests that a patient may have esophageal varices, this sign cannot be relied upon since it can occur in the presence of gastro‐intestinal hemorrhage from various causes (3). The cessation of bleeding following institution of balloon tamponade is not diagnostic of variceal bleeding inasmuch as it may be a peptic ulcer that has stopped bleeding; on the other hand, hemorrhage can continue following tamponade for esophageal varices, either from a gastric varix or a concomitant peptic ulcer.…”

“…Should variceal hemorrhage continue in spite of all conservative measures, emergency ligation of the varices or immediate portacaval shunt may be in order; many authorities favor the former procedure (3). In the occasional case of variceal hemorrhage in portal hypertension due to an extrahepatic cause, however, the postoperative course may be complicated by gradual deterioration of hepatic function and clinical evidence of ammonium intoxication.…”

“…The virtually unchanged prognosis following venous‐shunt operations in patients who have bled from these varices, the operative mortality of 20 per cent even in experienced hands, and the fact that selected cases often do as well with purely medical therapy, has disenchanted a number of gastro‐enterologists with the results of such surgery (2). In a recent authoritative review of the treatment of bleeding esophageal varices, Leevy, Cherrick and Davidson (3) state: “It is quite clear that variceal hemorrhage in many patients with cirrhosis cannot be treated by shunt surgery, for they are unable to tolerate the operation. Indeed, in a large segment of patients with cirrhosis, the bleeding episode is only one of several clinical abnormalities incident to liver failure and a fatal termination.” The magnitude of the mortality in cases of cirrhosis with hemorrhage from varices continues to be so high that prophylaxis by means of shunt surgery is advocated in some centers (4).…”

“…The problem assumes even greater proportions when considered in the light of the clinician's frequent inability to ascertain the mechanism and site of the massive hemorrhage, and the dynamic capacity for constant change in esophageal varices. Even with the use of esophagoscopy and special roentgenologic technics (including splenoportography), esophageal varices are demonstrable in less than one‐fourth of these patients (3). Furthermore, in some instances neither intrahepatic nor extrahepatic portal‐vein obstruction can be demonstrated as the cause of portal hypertension and massive bleeding from esophageal varices (5a); the cause may be increased blood flow through the portal vein.…”

“…Several additional aspects of such hemorrhage serve to emphasize certain shortcomings in our present approach to the problem. Balloon tamponade with the Sengstaken tube or the Linton tube unquestionably has been life‐saving in many instances of persistent variceal bleeding, yet the introduction of this procedure has had little influence on the mortality rate for the majority of poor‐risk patients with bleeding esophageal varices and liver failure who are seen in large municipal hospitals (3). The gastric balloon has to be properly and skillfully fitted in order to restrict entry of blood into the esophagus, and certain complications are inherent in such tamponade, viz , tearing, ulceration or rupture of the esophagus, reflux of blood from the esophagus of obtunded patients, obstruction of the airway caused by displacement of the balloon, and cardiac arrhythmias associated with distention of the esophagus.…”