Search PubMed⌕ Search

Biomedical subjects

R Jalan

Publications and source records attributed to R Jalan.

At least 73 records · Page 4Linked to original sources
PubMed1996

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) insertion as a prelude to orthotopic liver transplantation in patients with severe portal hypertension.

OBJECTIVE: To investigate the impact of preoperative transjugular intrahepatic portosystemic stent-shunt (TIPSS) on patients undergoing liver transplantation. DESIGN: A retrospective non-randomized comparative clinical study. SETTING: Tertiary referral institution. PATIENTS, PARTICIPANTS: Twenty-four patients with liver cirrhosis, portal hypertension and gastro-oesophageal varices who underwent liver transplantation. INTERVENTIONS: TIPSS insertion had been performed preoperatively in 12 patients. MAIN OUTCOME MEASURES: Operative dissection times and blood transfusion requirements during liver transplantation. Postoperative complication rate. Cumulative patient and graft survival. RESULTS: There were no significant differences in outcome measures between patients with and without previous TIPSS insertion with respect to recipient hepatectomy times (mean 192 min (126-280) versus 196 min (145-254)), total operating time (mean 484 min (330-690) versus 486 min (370-580)), intraoperative blood transfusion (mean 11 units (2-29) versus 12 units (2-30)), intraoperative fresh frozen plasma transfusion (mean 9 units (1-16) versus 11 (2-23) units), patient survival (83% versus 92% cumulative 1-year survival), graft survival (80% versus 83% cumulative 1-year survival), or postoperative complication rates. CONCLUSION: TIPSS insertion is feasible and relatively safe as a 'bridge to transplantation' in patients who have had a variceal haemorrhage. There is little evidence that preoperative TIPSS insertion directly affects the performance of liver transplantation as TIPSS neither, hinders nor facilitates surgery or post operative survival. Although it is important that the potential hazards of TIPSS extension into the inferior vena cava or superior mesenteric vein be recognized, liver transplant surgeons need not be unduly concerned about the overall impact of TIPSS as it becomes more universally available in the management of variceal haemorrhage.

Blood Loss, Surgical↗
PubMed1996

Review article: renal circulatory changes in cirrhosis--pathogenesis and therapeutic prospects.

Renal dysfunction in cirrhosis describes a spectrum of abnormalities which lead to the clinical manifestations of ascites, peripheral oedema and hepato-renal failure. This article reviews the processes underlying this dysfunction with particular regard to the disturbance in the renal circulation. Renal haemodynamic changes occur early in cirrhosis prior to the development of ascites. However, as the liver disease progresses these changes become more profound and lead ultimately to severe cortical hypoperfusion. Renal blood flow and glomerular filtration rate do not appear to correlate well with the presence of ascites, and a separate defect in tubular sodium handling is likely to be present. The development of portal hypertension is a possible trigger of increased renal vascular resistance, whereas a deterioration in liver function may relate to the impaired tubular handling of sodium. The peripheral vasodilatation hypothesis seeks to relate these renal changes to the activation of vasopressor systems after the development of arteriolar vasodilatation. Correlations between systemic vascular resistance and renal blood flow have been difficult to establish. A variety of substances may mediate the renal circulatory changes. The likelihood is that the increase in systemic vasoconstrictors is compensatory, and that it is the locally active vasoactive substances, particularly those derived from the endothelium, which play a major role in the development of renal vasoconstriction. The management of ascites is fraught with complications, and the treatment of hepato-renal syndrome inadequate. Liver transplantation is currently the only therapy which gives any hope of long-term response and survival. Methods of improving the renal circulation by mechanically lowering portal pressure or by antagonizing locally active renal vasoconstrictors may be beneficial.

Animals↗
PubMed1996

Hepatic phosphorus-31 magnetic resonance spectroscopy in primary biliary cirrhosis and its relation to prognostic models.

BACKGROUND: In vivo hepatic phosphorus-31 magnetic resonance spectroscopy (31P MRS) provides biochemical information about phosphorus metabolism. AIM: To assess 31P MRS as a prognostic marker in patients with primary biliary cirrhosis (PBC) in relation to the current clinical prognostic models. PATIENTS AND METHODS: Twenty three patients with PBC of varying functional severity and 16 matched healthy volunteers were studied using in vivo 31P MRS. Spectra were acquired using a 1.5 T spectroscopy system. Peak area ratios of phosphomonoesters (PME), inorganic phosphate (Pi), and phosphodiesters (PDE) and nucleotide triphosphate (NTP) were calculated. Pugh score, Christensen prognostic index, and R value according to the Mayo model were calculated from the clinical data. RESULTS: The PME/NTP, Pi/NTP, PME/PDE, and PME/Pi ratios and the PME signal height ratio (SHR) were significantly higher, while the PDE/NTP and PDE/SHR were significantly lower in PBC patients compared with healthy volunteers (p < 0.01). Significant correlations were seen between PME/Pi ratio and the prognostic index according to Christensen (r = 0.63, p < 0.001), R value according to the Mayo model (r = 0.45, p < 0.03), and with the Pugh score (r = 0.55, p < 0.007). CONCLUSIONS: This study shows that PME/Pi ratio obtained from 31P MRS correlates well with all three of the commonly used models of prognosis in patients with PBC. A longitudinal study with larger number of patients is required to confirm these findings and elucidate the biochemical changes underlying this phenomenon.

Adult↗
PubMed1996

Longterm follow up of transjugular intrahepatic portosystemic stent shunt (TIPSS) for the treatment of portal hypertension: results in 130 patients.

BACKGROUND: Transjugular intrahepatic portosystemic stent shunts (TIPSS) are increasingly being used to manage the complications of portal hypertension. This study reports on the follow up on 130 patients who have undergone TIPSS. PATIENTS AND METHODS: One hundred and thirty patients (81 male), mean (SD) age 54.7 (12.5) years underwent TIPSS. The majority (64.6%) had alcoholic cirrhosis and 53.2% had Childs C disease. Indications were: variceal haemorrhage (76.2%), refractory ascites (13.1%), portal hypertensive gastropathy (4.6%), others (6.1%). Shunt function was assessed by Doppler ultrasonography and two then six monthly portography and mean follow up for survivors was 18.0 months (range 2-43.5). RESULTS: The procedure was successful in 119 (91.5%). Sixty three episodes of shunt dysfunction were observed in 45 (37.8%) patients. Variceal rebleeding occurred in 16 (13.4%) patients and was always associated with shunt dysfunction. Twenty (16.8%) patients had new or worse spontaneous encephalopathy after TIPSS and 11 (64.7%) patients had an improvement in resistant ascites. Thirty day mortality was 21.8% and one year survival 62.5%. CONCLUSION: TIPSS is an effective treatment for variceal bleeding, resistant ascites, and portal hypertensive gastropathy. Rebleeding is invariably associated with shunt dysfunction, the frequency of which increases with time, therefore regular and longterm shunt surveillance is required.

Acute Disease↗
PubMed1995

Transjugular intrahepatic portasystemic stent-shunt in the treatment of variceal haemorrhage.

The transjugular intrahepatic portasystemic stent-shunt (TIPSS) is a side-to-side portocaval shunt, performed by interventional radiological methods, linking the hepatic and portal veins through the liver parenchyma with an expandable metal stent. The technique can be performed successfully in over 90 per cent of patients. The procedure-related mortality rate is about 1 per cent, mainly from intraperitoneal bleeding. The main indications for TIPSS insertion are control of acute variceal bleeding in patients with cirrhosis that is refractory to sclerotherapy and recurrent variceal haemorrhage despite sclerotherapy or band ligation. TIPSS insertion is followed by variceal rebleeding in about 10-20 per cent of cases, encephalopathy in 10-20 per cent, transient deterioration of liver function in 25-35 per cent and subsequent shunt dysfunction over a 6-12-month period in 15-60 per cent. The final place of TIPSS insertion in the management of portal hypertension is being evaluated in controlled studies, but its use in the treatment of uncontrolled variceal haemorrhage seems assured.

Esophageal and Gastric Varices↗
PubMed1995

A prospective evaluation of changes in neuropsychological and liver function tests following transjugular intrahepatic portosystemic stent-shunt.

BACKGROUND/AIMS: This study was designed to assess changes in: (a) neuropsychological tests, measures of memory, quality of life and scores for anxiety and depression; (b) liver function tests; and (c) the relationship between these following transjugular intrahepatic portosystemic stent-shunt. METHODS: Twenty-nine patients undergoing transjugular intrahepatic portosystemic stent-shunt for recurrent variceal haemorrhage, 12 matched patients with cirrhosis and variceal haemorrhage managed with variceal band ligation and 16 normal controls were studied. Patients in any of the groups who were clinically encephalopathic were excluded from the study. Serial changes in the conventional liver function tests and Indocyanine green clearance, and psychometric function (Hospital Anxiety Depression Scale, Rivermead Behavioral Memory Test, Quality of Life and the memory and reaction sub-tests of the Cambridge Automated Neuropsychological Test Assessment Battery) were measured prior to and 1, 3, 9 and 15 months following transjugular intrahepatic porto-systemic stent-shunt. RESULTS: Over a mean follow up of 9.1 months in the transjugular intrahepatic portosystemic stent-shunt group (range 3-28), one patient (3%) developed clinically detectable encephalopathy. Sixty-seven percent of patients with cirrhosis showed evidence of subclinical encephalopathy as compared with the control population. Significant deterioration occurred in the reaction sub-tests of the Cambridge Automated Neuropsychological Test Assessment Battery in patients, both in the transjugular intrahepatic portosystemic stent-shunt group and the controls with cirrhosis, during follow up. Transjugular intrahepatic portosystemic stent-shunt was followed by significant deterioration in levels of anxiety and psychological component of the quality of life. The Rivermead Behavioural Memory Test and the memory sub-test of the Cambridge Automated Neuropsychological Test Assessment Battery did, however, improve significantly at 1 and 15 months after transjugular intrahepatic portosystemic stent-shunt, respectively. Serum alanine aminotransferase, bilirubin and indocyanine green clearance deteriorated significantly following transjugular intrahepatic portosystemic stent-shunt (p <0.001, p <0.001 and p <0.0001, respectively). Significant correlation was observed between changes in the indocyanine green clearance and changes in the complex and simple reaction time subtests of the Cambridge Automated Neuropsychological Test Assessment Battery (r = 0.6 and r = 0.66, respectively). CONCLUSIONS: The results of this study showed that about 67% of patients with cirrhosis were subclinically encephalopathic and that temporary deterioration occurred in the Cambridge Automated Neuropsychological Test Assessment Battery during follow up, both in patients having transjugular intrahepatic portosystemic stent-shunt and in the controls with cirrhosis. These parallel the changes in the liver function tests and indocyanine green clearance. Temporary deterioration was also observed in the Quality of Life and Hospital Anxiety Depression Scale in the transjugular intrahepatic portosystemic stent-shunt group, although the measures of memory improved. Further studies should address the biochemical mechanisms of these changes and the role of prophylactic measures.

Adult↗
PubMed1995

Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage.

BACKGROUND/AIMS: The aim of this study was to analyse prognostic variables predicting mortality, shunt insufficiency, variceal rebleeding and encephalopathy following transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage. METHODS: Sixty-eight patients with cirrhosis who successfully underwent transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage were studied. Mean age was 54.8 years (s.e. 1.5); 41 were males and 27 were females. Mean Child score was 8.3 (s.e. 0.3). Cirrhosis was alcohol related in 47. The patients have been followed up for a mean of 10.8 (s.e. 1.1) months. The univariate association between 30 prognostic variables and post-treatment encephalopathy was tested by the Chi-squared or Wilcoxon rank-sum tests and multiple logistic regression was used to test the significance of factors adjusted for one another. Cox's proportional hazard regression was used to test the univariate and multivariate significance of the other three outcomes. RESULTS: Transjugular intrahepatic portosystemic stent-shunt was performed successfully in 89.5% of patients. Twenty-two patients have died and eight have been transplanted. Fourteen patients died within 30 days of transjugular intrahepatic portosystemic stent-shunt and death was predicted independently by hyponatraemia (p < 0.001) and by severe liver disease (Child C, p < 0.001). Eight patients died during follow up and survival in the long term was predicted independently by the presence of encephalopathy (p < 0.001) prior to transjugular intrahepatic portosystemic stent-shunt (p < 0.001). Shunt insufficiency was predicted by an initial portal pressure gradient of greater than 18 mmHg (p < 0.01). None of the variables analysed predicted variceal rebleeding. Encephalopathy following transjugular intrahepatic portosystemic stent-shunt was only predicted indepedently by its presence prior to transjugular intrahepatic portosystemic stent-shunt (p < 0.001). CONCLUSIONS: The results of this study suggest that patients with severe liver disease and hyponatraemia are liable to die early, and the presence of encephalopathy prior to transjugular intrahepatic portosystemic stent-shunt independently determines long-term survival. Patients in these groups should be considered high risk and worked up for orthotopic liver transplantation early. Shunt function in patients with an initial portal pressure gradient of > 18 mmHg requires close supervision. Encephalopathic patients should have smaller shunts and prophylactic measures to prevent worsening encephalopathy.

Esophageal and Gastric Varices↗
PubMed1995

Review article: quantitative tests of liver function.

The search continues for a single reliable test of liver function that provides accurate prognostic information in chronic liver disease, in acute liver failure, and about graft function following orthotopic liver transplantation. Although transaminases, the commonly used markers of hepatocellular injury, have a high sensitivity in screening for liver disease, they do not provide any information about prognosis. Rational assessment of liver function using bilirubin, serum albumin and prothrombin-time is limited by the relative lack of sensitivity of these measurements and their inability to identify the functional reserve of the liver. Dynamic liver function tests are an improvement on the static tests but are generally cumbersome. The ideal liver function test would be cheap, easy to perform and analyse, safe, have a simple pharmacokinetic profile with minimal drug interactions, have a high predictive value and provide quick results. Numerous quantitative liver function tests have been developed and have shown promise in some studies. The aim of this review is to assess the place of these tests in the practical management of liver disease.

Animals↗
PubMed1995

The role of duplex and colour Doppler ultrasound in the follow-up evaluation of transjugular intrahepatic portosystemic stent shunt (TIPSS).

Transjugular intrahepatic portosystemic stent shunt (TIPSS) is an effective means of controlling acute variceal haemorrhage. Shunt occlusion or stenosis occurs in up to 30% of patients within 6 months. It is important to detect these patients and intervene to prevent rebleeding. We have compared non-invasive Doppler ultrasound with the portal pressure gradient (PPG) at portography at 3 month follow-up in 23 patients. All patients with a shunt peak velocity greater than 90 cm s-1 (7 of 17 analysable results) had normal shunt function at portography (PPG < 12 mmHg). Portography may therefore be avoided in this group, although the majority of patients will still require portography for TIPSS follow-up assessment.

Blood Flow Velocity↗
PubMed1995

A comparative study of emergency transjugular intrahepatic portosystemic stent-shunt and esophageal transection in the management of uncontrolled variceal hemorrhage.

OBJECTIVES: Transjugular intrahepatic portosystemic stent-shunts (TIPSS) have been shown to reduce portal hypertension consistently and have recently been reported to arrest active variceal hemorrhage. This retrospective and nonrandomized study compares the results of TIPSS with esophageal transection (ET) and devascularization in patients with uncontrolled variceal hemorrhage admitted to a single center with an interest in variceal bleeding. PATIENTS AND METHODS: Two hundred and sixty cirrhotic patients have been referred with variceal bleeding over the past 7 yr. In 41 patients (15.8%), hemorrhage was uncontrolled despite two treatments with sclerotherapy. Thirty-eight patients were eligible for analysis. Nineteen were considered for ET and 19 for TIPSS. Patients in the two groups were well matched for age, sex, etiology of liver disease, and its severity and complications. They have been followed for 13 patient years (TIPSS-7, longest 20 months; ET-6, longest 23 months). Data for survival and rebleeding were analyzed by the Kaplan-Meier method on an intention-to-treat basis. RESULTS: Seven of the 19 were considered unfit for surgery, and 12 underwent esophageal transection and devascularization. TIPSS was undertaken successfully in 17 patients, the Palmaz stent being used in 4 and the Wallstent in 13. Successful TIPSS reduced the mean portal pressure gradient from 22.2 (SE 1.2) to 9.7 (SE 0.7) mm Hg (p < 0.001). Mortality within 30 days of the initial bleed was 42% in the TIPSS group compared with 79% in the ET group (p < 0.05). Rebleeding occurred in 15.6% patients with TIPSS, compared with 26.2% in the ET group. Encephalopathy in the two groups of patients was not significantly different (TIPSS 25% and ET 22%). TIPSS was followed by active infection in 20% compared with 36% after ET. CONCLUSIONS: This study shows that the overall mortality in this group of patients is high whatever the type of treatment used. TIPSS can be performed successfully on these patients who are often not suitable for surgery. Mortality rates were significantly lower in patients treated by TIPSS. Compared with ET, TIPSS should be regarded as the preferred mode of treatment for uncontrolled variceal hemorrhage in patients with cirrhosis.

Case-Control Studies↗
PubMed1995

Relationship between directly measured portal pressure gradient and variceal hemorrhage.

OBJECTIVE: It is commonly believed that variceal hemorrhage in patients with cirrhosis and portal hypertension does not occur below a portal pressure gradient (PPG) of 12 mm Hg. The aim of this study was to assess the relationship between directly measured portal pressure gradient and variceal hemorrhage. METHODS: The procedure of insertion of the transjugular intrahepatic portosystemic stent-shunt (TIPSS) for variceal hemorrhage provides access to the portal vein and allows direct measurement of the portal pressure. Right atrial, inferior vena caval, and portal pressure were recorded, and the PPG was calculated (portal pressure-inferior vena caval pressure) in 48 patients undergoing TIPSS for variceal hemorrhage. RESULTS: PPG was reduced from a mean of 21.4 (6.4) before TIPSS to 10.6 (3.1) mm Hg after the procedure. Seven patients (14.7%) had a baseline portal pressure gradient of < 12 mm Hg. CONCLUSION: The results of this study do not support the concept of a discrete bleeding threshold.

Atrial Function, Right↗
PubMed1995

Laparoscopy and histology in the diagnosis of chronic liver disease.

We compared laparoscopy with histology in identifying fatty change, fibrosis, the degree of inflammatory activity, cirrhosis and the cause of liver disease. Laparoscopic liver biopsy was performed in 145 consecutive patients. The laparoscopist and the histologist were provided with similar clinical and biochemical information. Both scored the appearances on respective examinations for the degree of fatty change, fibrosis and activity, presence or absence of cirrhosis; and provided a provisional diagnosis. The final diagnosis was determined by clinicopathological conference and clinical follow-up. Laparoscopy was successfully performed in 142 patients (97.9%). Compared with histology, the sensitivity and specificity of laparoscopy for identifying fatty change were 96.4% and 100%, 100% and 95% for fibrosis and 94% and 95% for inflammatory activity, respectively. For cirrhosis, laparoscopy was 100% sensitive and 97.1% specific. Histology missed 10 cases of cirrhosis (6.1%). Histology did, however, provide additional information in 9 patients (6.3%) which contributed to the final diagnosis. Overall, histology is required in addition to laparoscopy in cases where the aetiology is unclear. The sensitivity and specificity in identifying fatty change, fibrosis, activity and cirrhosis are similar for laparoscopy and histology. The combination of information gained on laparoscopy with histology provides the diagnosis in most patients. Laparoscopy may replace the need for liver biopsy in patients in whom the aetiological diagnosis is not in question and the biopsy is being performed to stage the disease. We used it as an integral part of the work-up of a patient with liver disease.

Adolescent↗
PubMed1994

A pilot study of indocyanine green clearance as an early predictor of graft function.

Primary graft dysfunction occurs in up to 10% of liver transplant recipients and is the major reason for early mortality and retransplantation. The conventionally used markers of early graft function--i.e., correction of acidosis, glucose requirement, consumption of potassium, serum alanine transaminase (ALT), prothrombin time (PT), bile flow, resolution of encephalopathy and haemodynamic instability can be very misleading as they are dependent on numerous other factors. The aim of this study was to assess the use of indocyanine green clearance (ICG) as a measure of graft function. Peripheral ICG clearance was measured 18-24 hr after liver transplantation in twenty-three consecutive patients (24 transplants). Doppler ultrasonography confirmed normal hepatic arterial blood flow. Correlations between ICG clearance and other markers of graft function and outcome were sought. The mean ICG clearance was 406 mls/min (SD 137.5). A threshold value of 200 ml/min reliably predicted outcome. Significant correlations were found between ICG clearance and times to normalization of PT (P < 0.02) and to the correction of acidosis (P < 0.05). No correlation was found with ALT, PT, bile flow, glucose requirement, or consumption of potassium. ICG clearance measured on the day after liver transplantation accurately reflects graft function and may be used to predict graft survival and final outcome.

Alanine Transaminase↗
PubMed1994

Multiple pancreatic abscesses due to Candida albicans following ERCP.

A report is presented of a patient who developed multiple abscesses of the pancreas due to Candida albicans following an Endoscopic retrograde chole-pancreatography (ERCP) for acute pancreatitis. He was not immunocompromised, debilitated and had not had recent surgery. There was complete radiological and clinical resolution of the abscess on prolonged treatment with amphotericin alone. Only a few cases of candidal abscess of the pancreas have been reported, none of them having occurred after an ERCP.

Abscess↗
PubMed1994

Transjugular intrahepatic portosystemic stent-shunt (TIPSS): long-term follow-up.

We assessed the long-term efficacy of transjugular intrahepatic portasystemic stent-shunt (TIPSS) in 64 patients. Insertion was successful in 56 patients (87.5%). The reasons for its use were: variceal bleeding (49); ascites (6); portal hypertensive gastropathy (6); hypersplenism (2); and embolization of a spontaneous shunt (1). Fourteen patients were Childs A, 20 Childs B and 28 Childs C cirrhotics. Two patients were non-cirrhotic; one with amyloidosis and one with non-cirrhotic portal fibrosis. Patients were followed clinically and radiologically (Doppler ultrasonography and routine portography at 6 months). During 33 patient-years of follow-up, 22 died, 12 during index admission (two were procedure-related) and nine were transplanted. Twenty-five patients are alive, with a mean survival of 7.1 (SD 7) months. Variceal rebleeding occurred in 10 patients (22.7%), one of whom died, and was always associated with shunt insufficiency (shunt thrombosis 2, hepatic vein stenosis (HVS) 1, intimal hyperplasia (IH) 4, dislocated stent 1, inadequate stent 2). Clinical encephalopathy was induced in seven patients (17.1%) following TIPSS. All responded to medical therapy, but two required reduction in shunt size. Ascites improved after TIPSS in 36 patients (87.8%), but reaccumulated in seven (17.5%), associated with shunt dysfunction in five (SBP 2, IH 3, HVS 2). Fatal sepsis occurred in two patients, and 14 other episodes of infection required antibiotics. TIPSS is a useful treatment for variceal bleeding, resistant ascites and portal hypertensive gastropathy. Shunt dysfunction and sepsis occur frequently, and regular surveillance is necessary.

Female↗
PubMed1993

Studies of human zinc kinetics using the stable isotope 70Zn.

1. The short-term (120 min) kinetics of Zn turnover has been studied in control subjects and patients with alcoholic liver disease after intravenous injection of 0.5 mg of 96.5% enriched 70ZnCl2. 2. The 70Zn enrichment of plasma was found closely to obey two-compartment kinetics and the derived two-component decay equation has been used to calculate the size and turnover of the initial two rapidly exchanging pools of body Zn. 3. In normal subjects isotopic Zn appears initially to equilibrate with the whole of the plasma Zn which comprises the first metabolic compartment, pool a. This has a size of 0.72 +/- 0.1 mumol/kg. 70Zn equilibration then occurs with a second compartment, pool b, consistent with a rapidly exchanging liver Zn pool of size 3.60 +/- 0.93 mumol/kg. The fractional turnover rate of pool b was found to be fivefold slower than that of pool a. 4. In the alcoholic group an expansion of pool a was observed (1.63 +/- 0.39 mumol/kg), but the size of the second pool was not significantly different from that of control subjects (5.55 +/- 1.0 mumol/kg), although its fractional turnover was significantly increased (Kab: control subjects, 0.018 +/- 0.002 min-1, alcoholic patients, 0.031 +/- 0.006 min-1). 5. These data therefore demonstrate that kinetic studies using stable isotopes of Zn can provide novel information on exchangeable Zn pools in man, but provide no support for the possibility of an underlying Zn depletion in patients with alcoholic liver disease.

Adult↗