No abstract

Since 1971, 70 patients have been seen at Emory University Hospital with gastroesophageal varices secondary to extrahepatic portal vein thrombosis (PVT). Thirty-seven of these patients had had prior major operative therapy. In only three patients (8%) was shunt surgery successful, and there was a high incidence of rebleeding, other morbidity, and mortality. Of especial note are the serious consequences of simple splenectomy; splenomegaly and thrombycytopenia should rarely, if ever, be used as indication for splenectomy in portal hypertension. In 1977, the use of selective distal splenorenal shunt (DSRS) was begun at Emory in this population and a selective shunt has been possible in 24 of 29 patients (83%) who had had no prior operative therapy. Results have been excellent with a greater than 90% patency rate, long-term portal perfusion in all, no encephalopathy, and late rebleeding in one patient. Quantitative studies at 3-6 years show stability of liver function, significant decrease in spleen size, and rise in platelet count. However, long-term follow-up (greater than 15 years) is required in PVT patients before definitive assessment can be obtained. A specific problem of the PVT patient is late shunt stenosis which requires close observation; dilatation of the shunt was performed in six of the 24 patients with a patent shunt. Poor results with non-shunt operative procedures in PVT were again documented. The proper role of endoscopic variceal sclerotherapy is not yet clear, but appears to be an excellent addition to the therapeutic options. In conclusion, for patients with a patent splenic vein, initial therapy should be a selective shunt; for patients without a patent splenic venous system, endoscopic sclerotherapy is the procedure of choice.

Fourteen patients with sclerosing cholangitis underwent percutaneous cholangioplasty and stent placement with balloon-angioplasty and biliary-drainage catheters. There was initial clinical improvement in 13 of the 14 patients; one patient did not improve and died 1 month after the procedure. One of the 13 survivors developed encephalopathy and received a liver transplant 9 months after cholangioplasty; during the 9 months before transplantation, serum bilirubin and alkaline phosphatase levels returned to normal, and pruritus decreased. Restenosis of a duct following stent removal prompted repeat cholangioplasty in five of the 13 patients. Four of these five patients benefited from repeat cholangioplasty, and the fifth underwent liver transplantation 10 months after the second cholangioplasty. The other seven of the 13 survivors became either asymptomatic (n = 3) or less symptomatic than before cholangioplasty (n = 4) and did not require repeat cholangioplasty or liver transplantation during 10-42 months of follow-up.

A rare case of renal actinomycosis with bilateral necrosing papillitis resulting in uraemia is reported. The part played in the process by the infection with Proteus vulgaris and the additional role of acute pancreatitis are discussed.