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Treatment of refractory anorectal variceal bleeding
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CORRESPONDENCE
Effect of Cholecystostomy on Gallbladder Motility Dear Sir: In the study by Vezina et ai.,: the authors have ignored the fact that a Foley catheter eholecystostomy was performed in all the transplant recipients; this procedure, we feel, would adversely affect gallbladder motility because of gallbladder wall fibrosis. The facts that a cholecystostomy is usually performed through the gallbladder fundus, the most expansile segment of the gallbladder wall, and that the cholecystostomy was left in place for a prolonged period of 3 months make it more than likely that the gallbladder wall would be locally scarred. This would prevent the gallbladder wall from being fully relaxed during the fasting state. Therefore, the conclusion that fasting donor gallbladder volume in transplant recipients is not increased compared with controls may be flawed. MADHUMITA SINHA, M.D. ANANYA DAS, M.D.
Suite 113, EZ Ship 818 Route 25A Northport, New York 11768 1. Vezina WC, McAlister VC, Wall JW, et al. Normal fasting volume and postprandial emptying of the denervated donor gallbladder in liver transplant recipients. Gastroenterology 1994; 107:847853.
GASTROENTEROLOGY Vo1.108, No. 4
when this intervention is used to treat other complications of portal hypertension. RAYMOND A. RUBIN, M.D. SANTIAGO J. MUNOZ, M.D.
Division of Gastroenterology and Hepatology Thomas Jefferson University Hospital Philadelphia, Pennsylvania 1. Yeh T, McGuire HH. Intractable bleeding from anorectal varices relieved by inferior mesenteric vein ligation. Gastroenterology 1994; 107:1165-1167. 2. Katz JA, Rubin RA, Cope C, Holland G, Brass CA. Recurrent bleeding from anorectal varices: successful treatment with a transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 1993; 88:1104-1107.
Reply. The long-term effect of inferior mesenteric vein ligation is undependable, and the procedure should rarely be needed. We reported it to illustrate the dynamics of anorectal varices. We agree with Drs. Rubin and Munoz that, for a patient with intractable bleeding, a better treatment would be TIPS followed by liver transplantation. If liver function were stable and too good for transplantation, a portacaval H-graft would be best. In our case, portacaval shunt was impossible and transplantation is contraindicated by recovery of normai liver function. Our patient appears healthy 18 months later but bled a small amount from an external anal varix on one occasion. THOMAS YEH, Jr. HUNTER H. McGUIRE, Jr.
Treatment of Refractory Anorectal Variceal Bleeding Dear Sir: The recent case report by Yeh and McGuire i describes an interesting approach for refractory anorectal variceal bleeding: inferior mesenteric vein ligation. Although the varices visibly disappeared in the patient described, follow-up venography would be essential to understand the postproeedural venous drainage for the distal colon and anorectum. Moreover, the effect of this procedure on the natural history of esophagogastric notices is not clear. We agree that this approach should be reserved for patients who require intervention and who are not candidates for transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunt procedures. We previously reported the first successful use of TIPS for the control of severe, recurrent anorectal variceal hemorrhage. 2 After TIPS, marked decompression of the anorectal varices was documented by magnetic resonance venography and flexible sigmoidoscopy within 1 and 7 days, respectively. Although Doppler ultrasonography confirmed TIPS' potency, venography could not be repeated before the patient's death of pneumonia 7 months after TIPS. While we agree that the long-term efficacy for treatment of refractory anorectal variceal hemorrhage is established for neither TIPS nor inferior mesenteric vein ligation, only the former treats underlying portal hypertension. Unlike TIPS, inferior vein ligation may actually exacerbate portal hypertension by eliminating a potential route for portal decompression. Furthermore, opposed to surgical shunting, TIPS may be ideally suited for patients with refractory anorectal variceal bleeding who are potential liver transplantation candidates. It is expected that the occlusion and postprocedural encephalopathy rates for TIPS for this indication would resemble the rates achieved
Department of Surgery Medical College of Virginia~Virginia Commonwealth University Richmond, Virginia
Bilitec to Quantitate Duodenogastric Reflux: Is It Valid? Dear Sir: A highly original paper by Champion et al. in a recent issue of GASTROENTEROLOGY: clearly showed that Barrett's esophagus was not related to alkaline reflux and that omprazole not only eradicated gastric acid secretion but also greatly decreased the quantity ofgastroesophageal reflux. However, the study used and endorsed the recently described Bilitec 2000 system (Synectics) for assessment of duodenogastroesophageal reflux. This system is being widely promoted commercially but, in my opinion, has not been validated. In fact, the data in the paper by Champion et al.,: as well as that in the original "validating" study by Bechi et al., 2 suggest that the Bilitec system is inherently unworkable and inaccurate. Therefore, the following points of concern are made. First, the model solutions used for validation and calibration of the instrument are irrelevant to in vivo conditions in the stomach and duodenum. The study by Bechi et al. 2 described neither the type of bilirubin used nor the method of dissolving it; as discussed below, unconjugated bilirubin (UCB) was probably used. Champion et al.: used bilirubin ditaurate (BDT). The pK~ values of the bilirubin glucuronide (BG) conjugates, which predominate in bile, are more than 4.0, 3 but pK~ values are more than 8.0 for UCB 4 and below 1.5 for B D T ) Thus, neither UCB nor BDT are appropriate to study the effects of pH on the solubility, spectra, and stability of the BG in bile. In the pH range of gastric juice, from 3.5 to 1.5, BDT is predominantly ionized
CORRESPONDENCE
Effect of Cholecystostomy on Gallbladder Motility Dear Sir: In the study by Vezina et ai.,: the authors have ignored the fact that a Foley catheter eholecystostomy was performed in all the transplant recipients; this procedure, we feel, would adversely affect gallbladder motility because of gallbladder wall fibrosis. The facts that a cholecystostomy is usually performed through the gallbladder fundus, the most expansile segment of the gallbladder wall, and that the cholecystostomy was left in place for a prolonged period of 3 months make it more than likely that the gallbladder wall would be locally scarred. This would prevent the gallbladder wall from being fully relaxed during the fasting state. Therefore, the conclusion that fasting donor gallbladder volume in transplant recipients is not increased compared with controls may be flawed. MADHUMITA SINHA, M.D. ANANYA DAS, M.D.
Suite 113, EZ Ship 818 Route 25A Northport, New York 11768 1. Vezina WC, McAlister VC, Wall JW, et al. Normal fasting volume and postprandial emptying of the denervated donor gallbladder in liver transplant recipients. Gastroenterology 1994; 107:847853.
GASTROENTEROLOGY Vo1.108, No. 4
when this intervention is used to treat other complications of portal hypertension. RAYMOND A. RUBIN, M.D. SANTIAGO J. MUNOZ, M.D.
Division of Gastroenterology and Hepatology Thomas Jefferson University Hospital Philadelphia, Pennsylvania 1. Yeh T, McGuire HH. Intractable bleeding from anorectal varices relieved by inferior mesenteric vein ligation. Gastroenterology 1994; 107:1165-1167. 2. Katz JA, Rubin RA, Cope C, Holland G, Brass CA. Recurrent bleeding from anorectal varices: successful treatment with a transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 1993; 88:1104-1107.
Reply. The long-term effect of inferior mesenteric vein ligation is undependable, and the procedure should rarely be needed. We reported it to illustrate the dynamics of anorectal varices. We agree with Drs. Rubin and Munoz that, for a patient with intractable bleeding, a better treatment would be TIPS followed by liver transplantation. If liver function were stable and too good for transplantation, a portacaval H-graft would be best. In our case, portacaval shunt was impossible and transplantation is contraindicated by recovery of normai liver function. Our patient appears healthy 18 months later but bled a small amount from an external anal varix on one occasion. THOMAS YEH, Jr. HUNTER H. McGUIRE, Jr.
Treatment of Refractory Anorectal Variceal Bleeding Dear Sir: The recent case report by Yeh and McGuire i describes an interesting approach for refractory anorectal variceal bleeding: inferior mesenteric vein ligation. Although the varices visibly disappeared in the patient described, follow-up venography would be essential to understand the postproeedural venous drainage for the distal colon and anorectum. Moreover, the effect of this procedure on the natural history of esophagogastric notices is not clear. We agree that this approach should be reserved for patients who require intervention and who are not candidates for transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunt procedures. We previously reported the first successful use of TIPS for the control of severe, recurrent anorectal variceal hemorrhage. 2 After TIPS, marked decompression of the anorectal varices was documented by magnetic resonance venography and flexible sigmoidoscopy within 1 and 7 days, respectively. Although Doppler ultrasonography confirmed TIPS' potency, venography could not be repeated before the patient's death of pneumonia 7 months after TIPS. While we agree that the long-term efficacy for treatment of refractory anorectal variceal hemorrhage is established for neither TIPS nor inferior mesenteric vein ligation, only the former treats underlying portal hypertension. Unlike TIPS, inferior vein ligation may actually exacerbate portal hypertension by eliminating a potential route for portal decompression. Furthermore, opposed to surgical shunting, TIPS may be ideally suited for patients with refractory anorectal variceal bleeding who are potential liver transplantation candidates. It is expected that the occlusion and postprocedural encephalopathy rates for TIPS for this indication would resemble the rates achieved
Department of Surgery Medical College of Virginia~Virginia Commonwealth University Richmond, Virginia
Bilitec to Quantitate Duodenogastric Reflux: Is It Valid? Dear Sir: A highly original paper by Champion et al. in a recent issue of GASTROENTEROLOGY: clearly showed that Barrett's esophagus was not related to alkaline reflux and that omprazole not only eradicated gastric acid secretion but also greatly decreased the quantity ofgastroesophageal reflux. However, the study used and endorsed the recently described Bilitec 2000 system (Synectics) for assessment of duodenogastroesophageal reflux. This system is being widely promoted commercially but, in my opinion, has not been validated. In fact, the data in the paper by Champion et al.,: as well as that in the original "validating" study by Bechi et al., 2 suggest that the Bilitec system is inherently unworkable and inaccurate. Therefore, the following points of concern are made. First, the model solutions used for validation and calibration of the instrument are irrelevant to in vivo conditions in the stomach and duodenum. The study by Bechi et al. 2 described neither the type of bilirubin used nor the method of dissolving it; as discussed below, unconjugated bilirubin (UCB) was probably used. Champion et al.: used bilirubin ditaurate (BDT). The pK~ values of the bilirubin glucuronide (BG) conjugates, which predominate in bile, are more than 4.0, 3 but pK~ values are more than 8.0 for UCB 4 and below 1.5 for B D T ) Thus, neither UCB nor BDT are appropriate to study the effects of pH on the solubility, spectra, and stability of the BG in bile. In the pH range of gastric juice, from 3.5 to 1.5, BDT is predominantly ionized