The extent of the collateral circulation influences the postprandial increase in portal pressure in patients with cirrhosis.

Background: In cirrhosis, repeated flares of portal pressure and collateral blood flow provoked by postprandial hyperaemia may contribute to variceal dilation and rupture. Aim: To examine the effect of the extent of the collateral circulation on the postprandial increase in portal pressure observed in cirrhosis. Patients and methods: The hepatic venous pressure gradient (HVPG), hepatic blood flow and azygos blood flow were measured in 64 patients with cirrhosis before and after a standard liquid meal. Results: Peak increases in HVPG (median+14.9%), hepatic blood flow (median+25.4%), and azygos blood flow (median+32.2%) occurred at 30 min after the meal. Compared with patients with marked postprandial increase in HVPG (above the median, n¿=¿32), those showing mild (<15%, n¿=¿32) increase in HVPG had a higher baseline azygos flow (p<0.01) and underwent a greater postprandial increase in azygos flow (p<0.02). Hepatic blood flow increased similarly in both groups. Postprandial increases in HVPG were inversely correlated (p<0.001) with both baseline azygos flow (r¿=¿¿0.69) and its postprandial increase (r¿=¿¿0.72). Food intake increased nitric oxide products in the azygos (p<0.01), but not in the hepatic vein. Large varices (p<0.01) and previous variceal bleeding (p<0.001) were more frequent in patients with mild increase in HVPG. Conclusions: Postprandial hyperaemia simultaneously increases HVPG and collateral flow. The extent of the collateral circulation determines the HVPG response to food intake. Patients with extensive collateralisation show less pronounced postprandial increases in HVPG, but associated with marked flares in collateral flow. Collateral vessels preserve their ability to dilate in response to increased blood flow.

Upper gastrointestinal bleeding in cirrhosis: clinical and endoscopic correlations

The clinical data of 180 episodes of upper gastrointestinal bleeding in 168 patients with cirrhosis of the liver are examined. The source of bleeding had been determined by early endoscopy in all cases. In men under the age of 50 years, and without symptoms of liver failure, bleeding was due to ruptured gastro-oesophageal varices in 84% of cases. Severe liver failure was associated with acute lesions of gastric mucosa in many cases. No presumptive diagnosis of the source of haemorrhage could be based on the examination of other clinical data (presence of ascites, mode of presentation and pattern of bleeding, history of ulcer disease, alcoholism, and previous medication.

Upper gastrointestinal bleeding in cirrhosis: clinical and endoscopic correlations

The clinical data of 180 episodes of upper gastrointestinal bleeding in 168 patients with cirrhosis of the liver are examined. The source of bleeding had been determined by early endoscopy in all cases. In men under the age of 50 years, and without symptoms of liver failure, bleeding was due to ruptured gastro-oesophageal varices in 84% of cases. Severe liver failure was associated with acute lesions of gastric mucosa in many cases. No presumptive diagnosis of the source of haemorrhage could be based on the examination of other clinical data (presence of ascites, mode of presentation and pattern of bleeding, history of ulcer disease, alcoholism, and previous medication.

Seguiment temporal de la reserva marina de les Illes Medes - I. Informe anual. Any 1995

Els seguiments o monitoritzacions, com els empenys humans, tenen per tret diferencial els alts i baixos, les dents de serra. I aixó, no només és vàlid per al comportament de les variables monitoritzades, sino també per als avatars administratius i financers. Fins l'extrem que la continuitat temporal, i no sols l'antiguitat delsregistres, és la millor mesura de la seriositat en la gestió d'un país; en aquest sentit, és evident que els països anglo-saxons tenen molt que ensenyar als llatins (p.e. en els registres de dades metereològiques).Abans del que haguèssim volgut, els alts i baixos polítics i financers van tocar, fent trontollar l'any 1995, al Seguiment del Patrimoni Biològic de les Illes Medes. L'any 1994 s'acabà el primer cicle del Pla d'Usos de l'Àrea protegida de les illes Medes (sorgit de la llei 19/1990 de 10 de desembre del Parlament de Catalunya).Aquest havia d'obrir les portes a un segon cicle quatrienal en el que, de forma preceptiva segons l'esmentada llei, s'havien de continuar els controls biològics del seu patrimoni natural. Per tant, no calia recorrer al nostre reiterat argument que en ecologia hom precisa de períodes d'estudi relativament llargs per definir amb fiabilitat les tendències de canvi: l'administració havia assumit l'argument i el feia seu. Malgrat tot, no podem dir que causès sorpresa la notícia que, després de moltes dil.lacions, informacions contradictòries i canvis de titularitat en els òrgans de gestió, el seguiment de 1995 es veia desproveït de suport financer (ens apresurem a reconeixer que a nivell d'intencions, el suport de les administracions involucrades no es va veure mai compromés). Conscients de la ingenuïtat d'esperar un suport lliure d'entrebancs, el nostre equip de treball havia assumit, des de l'inici del seguiment en 1990, el risc d'aquesta eventualitat. I havia previst que, arribat el cas, caldria continuar el seguiment, omplint si calia el buit derivat de la manca del marcadministratiu (en aquest cas el nou conveni entre la conselleria d'Agricultura, Ramaderia i Pesca i la Universitat de Barcelona) que per motius diversos no es restablí en tot el curs del 1995. És així que el seguiment del patrimoni natural de l'Àrea protegida de les illes Medes al llarg de l'any 1995 es feu amb recursos propis, la qual cosa vol dir amb moltes estretors econòmiques. Afortunadament, la situaciós'ha redrecat, en renovar-se per tres anys més (1996-1998) el conveni que estableix el seguiment. La satisfacció per la signatura d'aquest nou conveni, em fa alimentar l'esperança que ens anys a venir els nous gestors de la Reserva Marina de les Illes Medes, conscients del paper capdavanter d'aquest espai en la gestió dels espais litorals mediterrànis, no permetràn que tals anomalies es repeteixin.

Increased anandamide induced relaxation in mesenteric arteries of cirrhotic rats. Role of cannabinoid and vanilloid receptors

Background and aims: Anandamide is an endocannabinoid that evokes hypotension by interaction with peripheral cannabinoid CB1 receptors and with the perivascular transient receptor potential vanilloid type 1 protein (TRPV1). As anandamide has been implicated in the vasodilated state in advanced cirrhosis, the study investigated whether the mesenteric bed from cirrhotic rats has an altered and selective vasodilator response to anandamide. Methods: We assessed vascular sensitivity to anandamide, mRNA and protein expression of cannabinoid CB1 receptor and TRPV1 receptor, and the topographical distribution of cannabinoid CB1 receptors in resistance mesenteric arteries of cirrhotic and control rats. Results: Mesenteric vessels of cirrhotic animals displayed greater sensitivity to anandamide than control vessels. This vasodilator response was reverted by CB1 or TRPV1 receptor blockade, but not after endothelium denudation or nitric oxide inhibition. Anandamide had no effect on distal femoral arteries. CB1 and TRPV1 receptor protein was higher in cirrhotic than in control vessels. Neither CB1 mRNA nor protein was detected in femoral arteries. Immunochemistry showed that CB1 receptors were mainly in the adventitia and in the endothelial monolayer, with higher expression observed in vessels of cirrhotic rats than in controls. Conclusions: These results indicate that anandamide is a selective splanchnic vasodilator in cirrhosis which predominantly acts via interaction with two different types of receptors, CB1 and TRPV1 receptors, which are mainly located in perivascular sensory nerve terminals of the mesenteric resistance arteries of these animals.

Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis

Hepatorenal syndrome (HRS) is a serious complication of end-stage liver disease, occurring mainly in patients with advanced cirrhosis and ascites, who have marked circulatory dysfunction,1 as well as in patients with acute liver failure.2 In spite of its functional nature, HRS is associated with a poor prognosis,3 4 and the only effective treatment is liver transplantation. During the 56th Meeting of the American Association for the Study of Liver Diseases, the International Ascites Club held a Focused Study Group (FSG) on HRS for the purpose of reporting the results of an international workshop and to reach a consensus on a new definition, criteria for diagnosis and recommendations on HRS treatment. A similar workshop was held in Chicago in 1994 in which standardised nomenclature and diagnostic criteria for refractory ascites and HRS were established.5 The introduction of innovative treatments and improvements in our understanding of the pathogenesis of HRS during the previous decade led to an increasing need to undertake a new consensus meeting. This paper reports the scientific rationale behind the new definitions and recommendations. The international workshop included four issues debated by four panels of experts (see Acknowledgements). The issues were: (1) evidence-based HRS pathogenesis; (2) treatment of HRS using vasoconstrictors; (3) other HRS treatments using transjugular intrahepatic portosystemic stent-shunt (TIPS) and extracorporeal albumin dialysis (ECAD); and (4) new definitions and diagnostic criteria for HRS and recommendations for its treatment.

Functional renal failure and haemorrhagic gastritis associated with endotoxaemia in cirrhosis

Forty-three patients with cirrhosis and ascites, 21 with normal renal function, 10 with a progressive functional renal failure (FRF), and 12 with a steady FRF, were investigated for the presence of endotoxaemia by the Limulus lysate test. Endotoxaemia was found in nine patients with FRF and in none of the 21 with normal renal function (P less than 0-01). A positive Limulus test was almost exclusively associated with a progressive FRF (eight of 10 patients) and all but one of them died. Renal function improved as endotoxaemia disappeared in the survivor. Endotoxaemia was also associated with haemorrhage due to acute erosions of the gastric mucosa, being present in six of the seven patients who had this complication. Intravascular coagulation was not found in any patient. The Limulus test was positive in the ascitic fluid in 18 of 21 patients tested, although only two of them had peritonitis. These results suggest that endotoxaemia may play a critical role in the development of progressive renal failure and haemorrhagic gastritis in cirrhosis, and emphasise the potential risk of procedures involving reinfusion of ascitic fluid.

Entre Catalunya i Polònia: Witold Gombrowicz i Gabriel Ferrater: correspondència inèdita (1965-1967)

En el present treball, he intentat respondre la pregunta sobre per què Gabriel Ferrater es va interessar tant per l’obra de Witold Gombrowicz. Segurament, havia conegut la seva literatura en una traducció francesa i més possible encara alemanya, ja que el traductor va estar treballant a Hamburg per l’editorial Rowohlt Verlag com a lector. Devia assabentar-se de l’èxit de les obres de Gombrowicz a França i Alemanya i potser va decidir que era l’hora d’introduir-lo al mercat espanyol. Com comenta Janet Rodney, en el correu electrònic adjunt als apèndixs del treball, potser Ferrater veia algunes semblances entre ell mateix i Gombrowicz. Tots dos tenien problemes per publicar la seva obra sencera als seus països d’origen i, tot i que Gombrowicz ja feia molt de temps que no vivia a Polònia, sempre havia conservat el desig de poder ser publicat, sense censura, al seu país natal. Potser també tots dos escriptors compartien el sentiment d’inferioritat de les seves cultures respecte les de l’Europa Occidental. Tots dos intentaven mostrar en la seva obra literària l’existència d’una realitat potser oculta però tan legítima com les altres, com la “realitat oficial” en la que havien de viure

Effect of meal ingestion on liver stiffness in patients with cirrhosis and portal hypertension.

BACKGROUND AND AIMS: Liver stiffness is increasingly used in the non-invasive evaluation of chronic liver diseases. Liver stiffness correlates with hepatic venous pressure gradient (HVPG) in patients with cirrhosis and holds prognostic value in this population. Hence, accuracy in its measurement is needed. Several factors independent of fibrosis influence liver stiffness, but there is insufficient information on whether meal ingestion modifies liver stiffness in cirrhosis. We investigated the changes in liver stiffness occurring after the ingestion of a liquid standard test meal in this population. METHODS: In 19 patients with cirrhosis and esophageal varices (9 alcoholic, 9 HCV-related, 1 NASH; Child score 6.9±1.8), liver stiffness (transient elastography), portal blood flow (PBF) and hepatic artery blood flow (HABF) (Doppler-Ultrasound) were measured before and 30 minutes after receiving a standard mixed liquid meal. In 10 the HVPG changes were also measured. RESULTS: Post-prandial hyperemia was accompanied by a marked increase in liver stiffness (+27±33%; p<0.0001). Changes in liver stiffness did not correlate with PBF changes, but directly correlated with HABF changes (r = 0.658; p = 0.002). After the meal, those patients showing a decrease in HABF (n = 13) had a less marked increase of liver stiffness as compared to patients in whom HABF increased (n = 6; +12±21% vs. +62±29%,p<0.0001). As expected, post-prandial hyperemia was associated with an increase in HVPG (n = 10; +26±13%, p = 0.003), but changes in liver stiffness did not correlate with HVPG changes. CONCLUSIONS: Liver stiffness increases markedly after a liquid test meal in patients with cirrhosis, suggesting that its measurement should be performed in standardized fasting conditions. The hepatic artery buffer response appears an important factor modulating postprandial changes of liver stiffness. The post-prandial increase in HVPG cannot be predicted by changes in liver stiffness.

Teories de l’imperialisme. Un estat de la qüestió

El propòsit d’aquest treball és presentar i discutir les diferents teories sobre l’anomenat «imperialisme modern», delimitat cronològicament des de finals del segle XIX fins a l’inici de la Primera Guerra Mundial. A més a més, és també l’objectiu d’aquest article mostrar l’evolució de la discussió presentant aquestes teories en ordre cronològic i insistint en com els conceptes «imperialisme» i «colonialisme» han canviat de significat. Les teories marxistes i liberals de principis del segle XX consideraven l’imperialisme un procés fonamentalment econòmic mentre que la teoria sociològica de Schumpeter el veia com un atavisme. Algunes teories després de les guerres mundials han insistit en la importància de parar atenció en els territoris colonitzats i en com la seva relació amb Europa ha afectat la nova forma imperial. Les explicacions més recents n’han destacat aspectes molt diferents, des de la importància sobre com ha permès l’expansió del lliure-comerç fins a l’imperialisme com una perversió del nacionalisme.

Prevalence and clinical significance of isotype specific antinuclear antibodies in primary biliary cirrhosis.

with specific ANA, in particular of the IgG3 isotype, had significantly more severe biochemical and histological disease compared with those who were seronegative. None of the controls was positive.Conclusions: Disease specific ANA are present in the majority of patients with PBC when investigated at the level of immunoglobulin isotype. PBC specific ANA, in particular of the IgG3 isotype, are associated with a more severe disease course, possibly reflecting the peculiar ability of this isotype to engage mediators of damage.

Incidence, prevalence and clinical significance of abnormal hematological indices in compensated cirrhosis.

Background & Aims: Patients with cirrhosis develop abnormal hematologic indices (HI) from multiple factors, including hypersplenism. We aimed to analyze the sequence of events and determine whether abnormal HI has prog-nostic significance. Methods: We analyzed a database of 213 subjects with compensated cirrhosis without esopha-geal varices. Subjects were followed for approximately 9 years until the development of varices or variceal bleeding or completion of the study; 84 subjects developed varices. Abnormal HI was defined as anemia at baseline (hemoglo-bin,<13.5 g/dL for men and 11.5 g/dL for women), leuko-penia (white blood cell counts,<4000/mm 3 ), or thrombo-cytopenia (platelet counts, < 150,000/mm 3 ). The primary end points were death or transplant surgery. Results: Most subjects had thrombocytopenia at baseline. Kaplan-Meier analysis showed that leukopenia occurred by 30 months (95% confidence interval, 18.5-53.6), and anemia occurred by 39.6 months (95% confidence interval, 24.1-49.9). Baseline thrombocytopenia (P .0191) and leukope-nia (P.0383) were predictors of death or transplant, after adjusting for baseline hepatic venous pressure gradient (HVPG), and Child-Pugh scores. After a median of 5 years,a significant difference in death or transplant, mortality,and clinical decompensation was observed in patients who had leukopenia combined with thrombocytopenia at base- line compared with patients with normal HI (P < .0001). HVPG correlated with hemoglobin and white blood cell count (hemoglobin, r 0.35, P < .0001; white blood cell count, r 0.31, P < .0001). Conclusions: Thrombocy-topenia is the most common and first abnormal HI to occurin patients with cirrhosis, followed by leukopenia and anemia. A combination of leukopenia and thrombocytopenia at baselin predicted increased morbidity and mortality.

Management of varices and variceal hemorrhage in cirrhosis.

Variceal hemorrhage is a lethal complication of cirrhosis, particularly in patients in whom clinical decompensation (i.e., ascites, encephalopathy, a previous episode of hemorrhage, or jaundice) has already developed. Practice guidelines for the management of varices and variceal hemorrhage1 in cirrhosis are mostly based on evidence in the literature that has been summarized and prioritized at consensus conferences...