Volume 66 - 2003 - Fasc.3 - Original articles
Influence of posture on haemodynam cirrhotic patients with and without as ics, sodium and hormonal homeostasis in cites
Background / Aims : Previous studies in preascitic cirrhosis demonstrated sodium retention during upright posture and sodi- um hyperexcretion during bed-rest. In patients with ascites, sodi- um excretion and creatinine clearance decreased during upright posture. Head-down tilting (HDT) accentuated the natriuretic effect of bed-rest in short term studies. The aim of this study was to evaluate the effects of prolonged change in posture on sodium homeostasis and on haemodynamics in cirrhotic patients.
Methods : Eighteen cirrhotic patients (9 with, 9 without ascites), were studied during 12 h upright, supine and HDT position (-10°). During each position, 12 h urine collections were performed and blood samples were obtained before and after change in position. Non-invasive systemic hemodynamic measurements were per- formed.
Results : There was no significant difference between HDT and supine position in both ascitic and preascitic groups for urinary volume, fractional sodium excretion, creatinine clearance, urinary and plasma hormones and hemodynamics. Urinary volume (in supine and HDT) and fractional sodium excretion (in supine) were significantly higher and urinary noradrenaline and plasma renin (in supine and HDT) significantly lower in the preascitic group compared with the ascitic patients. Cardiac output and heart rate decreased after 12 h supine and HDT, suggesting a deactivation of sympatic nervous system and catecholamines.
Conclusion : Our results demonstrate that prolonged HDT had no advantage over normal bed-rest in both patient groups. Possibly, a short-term beneficial effect of HDT was lost after several hours. (Acta gastroenterol. belg., 2003, 66, 206-212).
Management of portal hypertension in children : a retrospective study with longterm follow-up
Objectives : Data regarding the management of the portal hypertensive haemorrhage in the paediatric patients have yielded conflicting results. The purpose of this study was to evaluate the efficacy of b-blocker (propranolol) alone, sclerotherapy alone and b-blocker + sclerotherapy combination in the management of portal hypertension in the paediatric population. Methods : Medical information was retrieved from the records of 62 children with portal hypertension who were under treatment during at least two years of follow-up period. Data collected included diagnosis, type of portal hypertension, age at initiation of therapy, bleeding episodes before and during therapy. Results : Sixteen of 62 patients were diagnosed as extrahepatic portal hypertension, 46 as intrahepatic portal hypertension. The mean age of study population was 7.6 ± 4.2 years, 45 percent being females. The mean duration of follow-up under therapy was 5.2 ± 2.5 years. Among the patients with intrahepatic portal hypertension, 29 received propranolol + sclerotherapy, 12 received only propranolol and 5 received only sclerotherapy. There was no significant decrease in bleeding episodes during propranolol or sclerotherapy. However patients under propranolol + sclerotherapy, showed significant decrease in bleeding episodes during therapy (23/29 before therapy, 15/29 during therapy, p < 0.05). Rebleeding index in patients with IHPH was significantly long in the group treated by propranolol + sclerotherapy (p = 0.0001) compared with before therapy. Because the numbers of patients in the groups are small, Kaplan Meier estimation suggest that propranol treatment is more effective. But there isn't significant difference when the results were compared with those of before therapy, except in the combined treatment group Conclusion : The monotherapy is not sufficient for longterm follow-up of portal hypertensive patients. The combination therapy with propranolol + sclerotherapy appears more encouraging in the prevention of portal hypertensive haemorrhage, but this needs to be assessed in randomized trials. (Acta gastroenterol. belg., 2003, 66, 213-217).
A prospective comparative study of push and wireless-capsule enteroscopy in patients with obscure digestive bleeding
Objectives : To prospectively compare the global and specific diagnostic yields of push and wireless videocapsule enteroscopy for small bowel lesions in patients with obscure digestive bleeding after esogastroduodenoscopy and colonoscopy.
Methods : The patients studied had unexplained chronic iron- deficient anemia or digestive blood loss after routine investiga- tions. Small bowel investigation was performed first with the wire- less-capsule (M2A, Given Imaging) and then with the push-entero- scope (Olympus SIF100).
Results : Twenty-one patients were included in the protocol (14 females and 7 males), whose mean age was 60 years (range : 18 to 81). All patients had iron-deficient anemia with occult bleeding (n = 16) or overt bleeding (n = 5). A digestive lesion was observed in 14 of 21 cases (66%). Lesions were : esophageal varices (n = 2), reflux esophagitis (n = 1), upper gastrointestinal tract ulcerations (n = 9), intestinal angioectasia (n = 4), ileal varices (n = 1), cecal angioectasia (n = 1) and tumor-like angioma in the jejunum (n = 1). These 19 lesions were discovered by both methods in 10 cases (52%), by push-enteroscopy only in 6 (31%) and by wireless-cap- sule endoscopy only in 3 (17%). The global diagnostic yield was therefore slightly but not significantly higher for push wireless- capsule enteroscopy (61 vs 52% ; NS) and the specific diagnostic yield was similar (20%). Interobserver agreement on the wireless- capsule recordings reached 85% for detection of findings.
Conclusions : In patients with obscure digestive bleeding, no significant difference in diagnostic yield was evidenced between push and wireless-capsule endoscopy. The main advantage of the latter method versus the former was the detection of distal lesions in the small bowel. Wireless-capsule enteroscopy is mandatory for patients with active unexplained bleeding and negative push- enteroscopy, or for defining the extension of a disease involving, for instance, the presence of angioectasia. (Acta gastroenterol. belg., 2003, 66, 199-205).