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Biomedical subjects

J Korula

Publications and source records attributed to J Korula.

At least 37 records · Page 2Linked to original sources
PubMed1993

Investigative studies in portal hypertension.

Portal hypertension usually results from progressive chronic liver disease and is manifested by the development of communications between portal and systemic circulation, termed collateral vessels. Bleeding from collateral vessels in the submucosa of the esophagus and stomach is a potentially fatal condition that is frequently treated with either endoscopic sclerotherapy or endoscopic variceal ligation; portal-systemic shunts are placed when these treatments fail. There are a wide range of investigative studies available to detect portal hypertension and to assess abnormalities in the portal circulation. These are helpful to determine treatment strategies for primary prophylaxis of variceal hemorrhage and to prevent rebleeding. A number of research investigations are designed to understand the mechanisms for bleeding from varices and to determine the pathophysiological basis for treatment.

Humans↗
PubMed1992

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices.

BACKGROUND: Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. METHODS: In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. RESULTS: Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections. CONCLUSIONS: Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.

Esophageal and Gastric Varices↗
PubMed1991

A simple and inexpensive method of removal or replacement of gastrostomy tubes.

The safety of removal or replacement of gastrostomy tubes by simply cutting the tube and allowing the inner components to be eliminated intestinally was prospectively studied in 64 patients. In only one patient was the internal component lodged at the pylorus; it required endoscopic removal. Abdominal radiographs obtained in 57 patients confirmed complete elimination of internal percutaneous endoscopic gastrostomy components in 48 patients (84%) and identified these components in the colon in eight (14%). In two patients, the internal components were identified in the stool, and in one, radiographs were not obtained. Six patients who did not have abdominal radiographs had no problems during a mean follow-up period of 153.3 +/- 37.2 days. This simple method is safe, inexpensive, can be offered to the large majority of patients with percutaneous endoscopic gastrostomy tubes, and avoids the need for endoscopic removal.

Adult↗
PubMed1991

Portal vein thrombosis complicating endoscopic variceal sclerotherapy. Convincing further evidence.

Portal vein thrombosis occurred in a patient who bled from gastric varices that developed after obliteration of esophageal varices by endoscopic sclerotherapy. This complication was recognized only at surgery when thrombectomy and endovenectomy preceded the successful placement of an end-to-side portocaval shunt. At histopathology, the presence of an amorphous, eosinophilic material staining negatively for fibrin and similar to sclerosant injected at sclerotherapy was observed within the clot. This latter finding, previously unreported, provides convincing evidence for the causal relationship of portal vein thrombosis to endoscopic sclerotherapy.

Esophageal and Gastric Varices↗
PubMed1991

Demonstration of two distinct subsets of gastric varices. Observations during a seven-year study of endoscopic sclerotherapy.

Over a seven-year period, assessment of gastric varices was made on 225 patients receiving endoscopic sclerotherapy for variceal hemorrhage. Of 170 patients with complete data, gastric varices were observed in 26 (15.3%). Importantly, two distinct subsets of gastric varices were identified: varices distal to the gastroesophageal junction without extension into the fundus, termed "junctional varices," occurred in 11.2%, and varices that were confined only to the fundus, termed "fundal varices," occurred less frequently in 4.1%. Although rebleeding was increased in both subsets of gastric varices, junctional varices were more amenable to sclerotherapy. Patients with fundal varices (N = 7) had a significantly higher rebleeding rate, increased complications with sclerotherapy, and significantly decreased survival (P less than 0.005) when compared to patients with esophageal varices alone (N = 87) who were followed for more than three months. Cumulative survival was not significantly different (P less than 0.08) in patients with junctional varices (N = 19) when compared with patients with esophageal varices alone. We conclude that not all patients with gastric varices have a poor result with sclerotherapy. Recognition of these subsets may improve treatment strategies in patients with gastric varices.

Esophageal and Gastric Varices↗
PubMed1991

The effects of chronic endoscopic variceal sclerotherapy on portal pressure in cirrhotics.

The effect of obliterating esophageal varices by endoscopic sclerotherapy on portal pressure was prospectively studied in 11 cirrhotic patients with variceal hemorrhage. Portal venous pressure gradient, determined as the difference between transhepatic portal and hepatic vein pressure, increased by a mean of 31.1% +/- 14.5% in 8 (73%) and decreased by a mean of 30.1% +/- 11.7% in 3 (27%) patients, with no statistically significant change overall (P = 0.1). These changes in portal venous pressure gradient occurred despite an improvement in the laboratory and clinical parameters of hepatic function. Deep abdominal sonography with color flow imaging at variceal obliteration showed patent paraumbilical veins in 6 (55%) patients, 3 of whom had decreases in portal venous pressure gradient (29%, 19%, 42.5%) at variceal obliteration. In 5 (45%) patients without patent paraumbilical veins, a statistically significant increase in portal venous pressure gradient between initial endoscopic variceal sclerotherapy and variceal obliteration was noted (P = 0.008). Rebleeding (single episode in all 4 patients, before obliteration in 3 patients) occurred in those with an increase in portal venous pressure gradient; all patients with portal venous pressure gradient decreases were nonbleeders. No correlation between changes in portal venous pressure gradient and time to variceal obliteration, number of sclerotherapy treatments, or rebleeding episodes was observed. Thus, an increase in portal venous pressure gradient was noted in the majority of patients at variceal obliteration. Although the portal venous pressure gradient decrease may be explained by a patent paraumbilical vein, the mechanism of portal venous pressure gradient increase is not clear. It is speculated that this portal venous pressure gradient increase may be caused by an increase in collateral resistance or flow or a combination of both, resulting from obliteration of esophageal varices by endoscopic sclerotherapy.

Esophageal and Gastric Varices↗
PubMed1991

The effect of oral nitroglycerin on portal blood velocity as measured by ultrasonic Doppler. A double blind, placebo controlled study.

We studied the effect of oral nitroglycerin on portal blood velocity (PBV) in 20 cirrhotic patients by a double blind, placebo controlled method using noninvasive Doppler sonography. After we obtained baseline Doppler in the fasting state, 0.6 mg nitroglycerin or placebo was given orally and the mean of 3 s averaged mean PBVs was repeated at 5 min intervals for 60 min. Ten patients each received nitroglycerin or placebo. Portal vein flows were antegrade in all. Of the 10 patients receiving nitroglycerin, seven (P = 0.002) showed a greater than 10% fall in the mean PBVs for at least 15 min. Of these seven "responders," five patients had a 10% decrease in mean systemic blood pressure for at least 15 min. None of the "nonresponders" had systemic hypotension. Our study suggests that the PBV-reducing effect of nitroglycerin in cirrhotics may be explained in part by systemic hypotension.

Administration, Oral↗
PubMed1991

Portal venous system after portosystemic shunts or endoscopic sclerotherapy: evaluation with Doppler sonography.

We sought to determine the usefulness of duplex Doppler sonography in the assessment of blood flow and clot formation in the portal vein in 44 patients with portal hypertension and bleeding esophageal varices who had undergone either endoscopic sclerotherapy (28 cases) or portosystemic shunt procedures (16 cases). The main, left, and right portal veins (collectively referred to as intrahepatic portal veins), superior mesenteric vein, splenic vein, and shunt were assessed for flow direction, presence of thrombi, and collaterals. Patent shunts were visualized in 12 (75%) of the 16 cases. Clot was detected in 27 (69%) of 39 intrahepatic portal veins in patients with end-to-side shunts, in six (67%) of nine intrahepatic portal veins in patients with distal splenorenal shunts, and in five (5%) of 92 intrahepatic portal veins in patients who had had endoscopic sclerotherapy. Flow in the main portal vein was hepatopetal in two (15%) of 13 patients with patent shunts (one end-to-side portacaval shunt and one distal splenorenal shunt). Flow in the main portal vein was hepatopetal in 26 (93%) of 28 patients who had had endoscopic sclerotherapy. Our data suggest endoscopic sclerotherapy preserves antegrade portal flow and results in fewer portal vein clots than surgical portosystemic shunts do. Patterns of thrombosis and flow direction vary unpredictably from patient to patient. Shunt patency should not be inferred without direct visualization of the shunt.

Esophageal and Gastric Varices↗
PubMed1990

Cardiorespiratory effects of endoscopic esophageal variceal sclerotherapy.

Endoscopic variceal sclerotherapy (EVS) is an effective means of controlling variceal hemorrhage, which develops as a consequence of portal hypertension. While esophageal perforation, ulceration, strictures, and mediastinitis are potential complications associated with this procedure, it is not clear whether isolated pleuropulmonary events such as pleuritis, pneumonitis, and adult respiratory distress syndrome are causally related to the EVS. Endoscopy and sedation with the attendant risk of aspiration, particularly in the background of hepatic encephalopathy, may account for some of these events. Recent controlled studies of respiratory function demonstrate that EVS as such results in minor changes in gas exchange, lung volumes, and pulmonary and systemic hemodynamics. Most pulmonary complications have been reported with the use of sodium morrhuate sclerosant. Comparative studies among different sclerosants are necessary to evaluate relative safety. Finally, there have been rare reports of myocardial ischemia and pericarditis reported in association with EVS, but these are of a transient nature. Chest symptoms, roentgenographic pleuropulmonary changes, pulmonary hemodynamics, and cardiac perturbations are transient and should not preclude offering EVS to patients with variceal hemorrhage.

Esophageal and Gastric Varices↗
PubMed1989

Digoxin-like immunoreactive substances in chronic liver disease.

Digoxin-like immunoreactive substances, which cross-react with digoxin antibody, have been found to have natriuretic effect and Na+,K+-ATPase inhibitory effect. The role of digoxin-like immunoreactive substances in chronic liver disease was studied by radioimmunoassay in 63 serum and 60 urine samples from 58 patients with chronic liver disease and compared with 16 controls. Although the mean serum digoxin-like immunoreactive substances level of compensated chronic liver disease patients (0.06 +/- 0.05 ng per ml, p less than 0.01) was higher than that of controls (0.02 +/- 0.03 ng per ml), only four patients had serum digoxin-like immunoreactive substances higher than 0.10 ng per ml. Mean serum digoxin-like immunoreactive substances level was much higher in patients with decompensated chronic liver disease who had ascites (0.32 +/- 0.17 ng per ml, p less than 0.001), hepatorenal syndrome (0.57 +/- 0.20 ng per ml, p less than 0.001) and hepatic encephalopathy (0.43 +/- 0.20 ng per ml, p less than 0.001). Five patients with recent variceal hemorrhage requiring transfusions and saline infusion had significantly increased serum digoxin-like immunoreactive substances (mean: 0.16 +/- 0.06 ng per ml, p less than 0.001) before the development of clinically detectable ascites.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic Disease↗
PubMed1989

Perforation of esophagus after endoscopic variceal sclerotherapy. Incidence and clues to pathogenesis.

To determine the true incidence of endoscopic variceal sclerotherapy (EVS)-related esophageal perforation, a retrospective analysis of 900 EVS procedures using sodium tetradecyl sulfate performed on 170 patients during a five-year period (1980-1985) was carried out. Autopsy data of all patients who received EVS and who died (32 patients, 100%) during this period were available to confirm the diagnosis of perforation. Esophageal perforation was confirmed in 5 (2.9%) and was seen in patients with advanced alcoholic liver disease. Importantly, most patients did not manifest features of an esophageal leak, but presented instead as a deterioration in condition and died after a mean (+/- SD) 14 +/- 5.2 days. Analysis of the clinical and EVS data reveals that the risk of developing perforation is high when EVS is performed during active bleeding. The extravariceal location of sclerosant and microabscesses may be important predisposing factors. In our experience large-dose injection, deep ulceration, and balloon tamponade are less likely predisposing factors of this complication.

Adult↗
PubMed1989

Frequent endoscopic variceal sclerotherapy increases risk of complications. Prospective randomized controlled study of two treatment schedules.

In an effort to determine the optimal dose and frequency of chronic endoscopic variceal sclerotherapy, a prospective randomized controlled study comparing two treatment schedules of sclerotherapy was carried out over a 21-month period. Patients with variceal hemorrhage were randomly assigned to receive sclerotherapy at weekly intervals using injection volumes of greater than 15 cc at each treatment or at mean intervals of three days using volumes of less than 10 cc per treatment. Esophageal perforation occurred in three patients (15%) in the small-dose, frequent-injection group as compared to none in the large-dose weekly treatment group (P = 0.07), leading to premature termination of the study. The mean time to rebleeding was significantly shorter in the small-dose, frequent-treatment group (P = 0.05). Variceal obliteration was achieved in a mean of 66% of patients in both groups with no difference in the time to obliteration or the frequency of other complications. Sclerotherapy offered at less than weekly intervals is less effective and is associated with an increased frequency of serious and life threatening complications.

Adult↗
PubMed1989

Fatal hemorrhage from an arterio-portal-peritoneal fistula after percutaneous liver biopsy.

Exsanguinating hemorrhage complicated a percutaneous needle biopsy in a 64-yr-old woman with a probable collagen vascular disease. Angiography performed before Gelfoam embolization demonstrated a hepatic arterio-portal venous-peritoneal fistula, a lesion not previously described, to be a cause of the hemorrhage. Although surgery remains the treatment of choice, the role of selective hepatic arteriography and Gelfoam embolization in patients with serious hemorrhage who are poor surgical risks needs evaluation.

Arteriovenous Fistula↗
PubMed1989

A review of donor alanine aminotransferase testing. Implications for the blood donor and practitioner.

To reduce the incidence of post-transfusion non-A, non-B hepatitis, the American Association of Blood Banks has required that serum alanine aminotransferase activity be used to screen blood donors. Consequently, approximately 2% to 3% of all blood donations will be discarded owing to an elevated alanine aminotransferase level. In addition, approximately 0.7% of blood donors will be notified of an abnormal alanine aminotransferase result. While some of these donors may have viral hepatitis, factors such as the donor's age, gender, body weight, ethnic background, alcohol intake, diet, and exercise must also be considered when interpreting an elevated alanine aminotransferase level. Donors with significant or persistently elevated alanine aminotransferase levels should have their conditions evaluated so that treatable diseases can be recognized and/or treated.

Alanine Transaminase↗
PubMed1988

Failure of ketoconazole as anti-androgen therapy in nonresectable primary hepatocellular carcinoma.

Lacking a treatment for nonresectable hepatocellular carcinoma (HCC), we have utilized the androgen antagonist properties of ketoconazole in treating eight patients, seven men and one woman, with HCC, which, in view of a higher prevalence of HCC in men, seems to be androgen dependent. Response to treatment was determined by grading symptoms, serum alphafetoprotein, alteration in tumor size, and duration of survival. No patient had any significant side-effects from ketoconazole. No symptomatic improvement occurred, percent tumor size increased from 38.6 +/- 12, mean +/- SEM, to 44.4 +/- 12, and mean survival in six patients who were followed until death was less than 8 weeks from diagnosis. Anti-androgenic therapy with ketoconazole was not effective in any of these patients.

Adult↗