April 2000

1028LOCAL THROMBOLYTIC TREATMENT OF ACUTE, NON·CIR­RHOTIC PORTAL VEIN THROMBOSIS USING A TRANSJUGU­LAR APPROACH.Martin P. Rossie, Modjtaba Nazary, Volker Michael Siegerstetter, AndreasG. Ochs, Hubert E. Blum, Univ Hosp, Freiburg, Germany.

Acute portal vein thrombosis is a severe disease with early (ischemicnecrosis of the gut) and late complications (variceal bleeding). Systemicthrombolytic treatment or local treatment via the splenic or mesentericartery are not very effective. Local treatment via a transjugular approach tothe portal system is a new option which has been applied to 25 patients(45 :t 15 years, 15 male) with various etiologies e.g., protein C, S andAT-III defficiency, Factor V mutation, thrombocytemia, myelodysplasticsyndrom, and phospholipid antibodies. Twenty one patients had completeocclusion of the intra- and extrahepatic portal vein and of the splenic,superior and inferior mesenteric veins. Four patients had occlusion of theintra and extrahepatic portal vein but not of the tributaries. Treatmentconsisted of transjugular puncture of the (thrombotic) portal vein, dilatationof the tissue tract, placement of catheters in splenic, mesenteric and portalveins, and medication with urocinase (50 to 100,000 Ulhr) or r-TPA (50mg/l2 hrs) together with heparin or hirudoide. Control angiograms wereperformed daily and treatment was given until disappearance of the throm­bus, or complications forced discontinuation. Results: Portal puncture wassuccessfully performed in 21 patients who received thrombolytic treatment.In 12 patients, a stent was implanted to maintain portal outflow in theabsence of patent intrahepatic portal branches. Early response to treatmentwas achieved in 16 of the 21 patients treated, 9 of them had completeresolution of the thrombi. In 4 patients, treatment was discontinued becauseof complications (2 intraabdominal bleeding, 2 liver hematoma). Onepatient with a generalised vasculitis died from intraperitoneal bleeding and1 from septicemia. Late response with patent vessels or hemodynamicallyirrelevant thrombosis was seen in 9 and 3 patients, respectively. Conclu­sions: The transjugular local thrombolytic treatment of acute portal veinthrombosis is effective but severe complication can not be excluded inparticular during learning of the procedure.

1029EFFECTS OF PORTAL PRESSURE CHANGES ON LONG-TERMOUTCOME AFTER A VARICEAL HEMORRHAGE.Jose Minana, Candid Villanueva, Jose Sola-Vera, Jose M. Lopez-Balaguer,Montserrat Planella, Jordi Ortiz, German Soriano, Sergio Sainz, CarlosGuarner, Joaquin Balanzo, Hosp Sant Pau, Barcelona, Spain.

It has been suggested that changes of portal pressure, either spontaneous orinduced by treatment, offer better prognostic information than a singlemeasurement. Several studies have shown that these changes may correlatewith variceal rebleeding. A decrease of hepatic venous pressure gradient(HVPG) >20% from baseline value is associated with a lower rebleedingrisk, while a decrease to < 12 mmHg protecs against such risk. The aim ofthis study was to assess the influence of portal pressure changes on thelong-term outcome of different parameters related with rebleeding. METH­ODS: as a part of a randomized trial which compared endoscopic ligationvs combined drug therapy with nadolol and isosorbide mononitrate for theprevention of variceal rebleeding, 88 patients (46 treated with drugs) hadan hemodynamic evaluation at baseline and again 1 to 3 months later. Agood hemodynamic response, defined as a decrease of HVPG >20% frombaseline value or to <12 mmHg, was observed in 31 patients (24 treatedwith drugs). Outcome parameters were compared in hemodynamic re­sponders (N=31) and non-responders (N=57). RESULTS: the mean fol­lOW-Up was of 24:t 17 months. Rebleeding probability was significantlylower in responders group, both when considering all episodes (8% vs 52%at 1 year, P<O.OO1) and when considering only variceal rebleeding (4% vs44% at 1 year, P<O.ool). The probability of therapeutic failure (defined as1 rebleeding episode requiring ;::5units of blood or ;::2 episodes requiring;::2units) was also lower in responders (4% vs 28% at 1 year, P=O.OI).Child-Pugh score at the third month of follow-up was significantly better inresponders (6.9:t 1.9 vs 6:t 1.9, P=O.04). Survival probability was alsosignificantly higher in this group (93% vs 81% at 1 year, P<0.05). By Coxregression analysis, both HVPG at the follow-up measurement and theChild-Pugh score at the third month had independent prognostic value forsurvival. CONCLUSIONS: after a variceal bleeding episode, a relevantHVPG decrease (>20% from baseline or to <12 mmHg) either spontane­ous or induced by treatment, is associated with better long-term prognosis.Both rebleeding and survival probabilities, significantly improve in pa­tients with such a decrease of portal pressure.

AASLDA965

1030SYSTEMIC AND SPLANCHNIC HEMODYNAMICS IN CHRONICHEPATITIS C AND SCHISTOSOMIASIS COINFECTION.Sanaa M. Kamal, Mohamed A. Madwar, Mohamed K.El Naggar, Omar H.Omar, Jens W. Rasenack, Univ of Freiburg, Freiburg, Germany; Univ ofAin Shams, Cairo, Egypt; Univ of Freiburg, Freiburg, Egypt.

Background/Aims: HCV is prevalent in Egypt and 50% of cases progressto cirrhosis & intra-hepatic portal hypertension. Schistosomiasis is alsoendemic causing non-cirrhotic presinusoidal portal hypertension. Concom­itant infection is common, so systemic & splanchnic hemodynamics werestudied with long follow-up of coinfected patients. Patients & Methods:150 patients matched for age,sex & disease duration (50 with chronic HCV&/or cirrhosis: group A, 30 with schisto: group B & 70 with chronic HCV& Schisto:group C ) were enrolled and prospectively followed for 3 years.Besides endoscopy, liver biopsy,MAP & heart rate (HR), cardiac index(CI), systemic vascular resistance index (SVRI), portal flow & congestiveindex, Superior mesenteric artery (SMABF) & femoral artery flow(FABF), renal resistive index (RI) were assessed by Duplex Doppler.Results: Oesophageal variceal bleeding, refractory ascites, hepatorenalsyndrome, hepatic encephalopathy were significantly higher in coinfectedpatient. 22 (31%) patients in group C died of liver related causes vs 3 & 2patients in groups A & B. In group C non bleeders, grade of varices,cong.index, SVRI, SMABF; FABF were significantly different from othergroups being more accentuated in bleeders and cirrhotics. SMABF & renalhemodynamic changes were detected in pre-cirrhotic stage. Table showsresults: mean:tSD (**p<O.01,***p<O.OOI) Conclusion: Patients withchronic hepatitis C & schistosomiasis have more advanced disease, cirrho­sis, recurrent variceal bleeding, severe portal hypertension, splanchnicvasodilation & marked hyperkinetic syndrome.

Parameter Group A Group B GroupC

MAP 88.9±3.5 89.5±1.4 86.5±38*HR 73.3±4.2 71.6± 79.8±6.1**SVRI 1351.5±124 1391.9±102 1241±126**CI 2.5±06 3.6±03 4.3±04..'Portal Cong Index 0.07 0.09 0.12...SMABF 3422±85 450±427 546±98'"FABF 196±48 212±79 286±88"Renal RI 0.58±0.01 0.56+0.03 0.79±0.02**

1031ENDOSCOPIC HISTOACRYL OBTURATION VERSUS PRO·PANOLOL IN THE PREVENTION OF ESOGASTRIC VARICEALREBLEEDING : INTERIM ANALYSIS OF A RANDOMIZEDTRIAL.Sylvie Evrard, Jean-Marc Dumonceau, Myriam Delhaye, Philippe Gol­stein, Nadine Bourgeois, Michael Adler, Jacques Deviere, Olivier LeMoine, Erasme Hosp, Brussels, Belgium.

Aims: To compare endoscopic Histoacryl obturation versus propranolol inthe secondary prophylaxis of eso-gastric variceal bleeding. Methods: Be­tween Augustus 1995 and February 1999,41 patients with a first bleedingfrom eso-gastric varices were included in the study. Forty one percent hadgastric varices at the time of emergency endoscopy. The source of bleedingwas esophageal in 75% and gastric in 25% of the patients. The initialbleeding was controlled by endoscopic Histoacryl obliteration in 40/41(98%) of the patients. Thereafter, the patients were randomized either tocomplete endoscopic variceal Histoacryl obturation (group A, n=21) or topropranolol administration (group B, n=20) for the prevention of rebleed­ing. Results: The 2 groups were well matched and median follow-up was10.4 (2-45) and 18.1 (7-43) months for group A and B, respectively. Nosignificant difference was observed, concerning early rebleeding at 6 weeks( 4/21 and 3/20 for group A and B, respectively), bleeding related deathsat 6 weeks (3121 and 6120 for group A and B, respectively), and long-termrebleeding rate (9/21 and 4120 for group A and B, respectively) or deaths(6121 and 7/20 for group A and B, respectively). Complications weresignificantly more frequent and severe in group A (9121) than B(2/20)[p<O.03]. Conclusions: endoscopic Histoacryl obliteration is highly effec­tive to control acute eso-gastric variceal bleeding. However, iterativeinjections aiming to eradicate the varices are associated with more com­plications and a similar efficacy than beta-blockers administration in termsof rebleeding rate and survival.