Introduction: Long-term outcome including the nutritional status was evaluated in cirrhotic patients receiving tolvaptan for refractory hepatic ascites.

Patients and Methods: 44 consecutive patients receiving tolvaptan at April 2011 and later were enrolled. The extents of abdominal distention at baseline and 3 weeks after the therapy were assessed by the Japanese version of the Support Team Assessment Schedule (STAS-J). Nutritional conditions were evaluated by Controlling Nutritional Status (CONUT), and peripheral lymphocyte counts and serum levels of albumin and total cholesterol were serially measured. The long-term outcome of patients was also evaluated.

Results: Abdominal bloated feeling was improved in 29 patients (65.9%). Peripheral lymphocyte counts as well as serum levels of albumin and total cholesterol were increased, and the COUNT scores (mean±SD) were decreased from 8.6±2.1 to 7.5±2.7 (p<0.01) ; the baseline counts were smaller in patients in whom abdominal bloated feeling was improved than in those without such improvement (p<0.05) and the scores were decreased in the former patients (from 8.2±2.2 to 6.8±2.7, p<0.01), while were unchanged in the latter patients (from 9.6±1.6 to 9.3±2.1). The mean survival time was 412 days and was longer in the former patients than in the latter patients (508 vs 234, p<0.05).

Conclusions: The long-term outcome of patients receiving tolvaptan for the treatment for refractory hepatic ascites differed depending on the baseline nutritional status. The nutritional status, however, was improved especially in those showing attenuation of abdominal bloating feeling during the therapy leading to improvement of their long-term outcome.

Balloon-occluded retrograde transvenous obliteration (B-RTO) was attempted in 19 cases of solitary gastric varices at our institution. Patients were divided based on the cause of the difficulty with closure of the collateral pathway to investigate how they affected the success or failure of the procedure. When left gastric venous reflux was imaged during B-RTO, the surgical success rate was lower than when reflux was not observed. Stratification based on the degree of reflux resulted in a positive correlation between surgical completion rates and the approximate ratio (left gastric vein diameter²/gastric varices diameter²) of left gastric venous flow into the gastric varices. Once this ratio exceeded approximately 0.45, closure of the collateral pathway became difficult, and B-RTO could not be completed. When the left gastric vein provides an alternative entry pathway, it may cause backflow during B-RTO forming a collateral pathway that cannot be closed off. The above ratio may provide an indicator to predict the difficulty of collateral pathway closure prior to B-RTO.

The pluero-peritoneal communication in the diaphragm provokes hepatic hydrothorax in patients with cirrhosis. Thus the usefulness of thoracoscopic diaphragmatic plication was evaluated in patients with hepatic hydrothorax following identification of the communication through injection of perflubutane in the ascites. Perflubutane solutions at a volume of 0.5 mL were intraperitoneally injected in 17 cirrhotic patients with refractory hepatic hydrothorax from October 2007 to December 2015, and the pluero-peritoneal communication was identified in 11 patients. Among them, thoracoscopic examinations were done in 5 patients and plication procedures were underwent in 4 patients except one patient in whom the communication was not identified thoracoscopically. In this patient, diaphragmatic reinforcing using polyglycolic acid and fibrin paste was done followed by pleurodesis. Consequently, pleural effusions disappeared in 4 patients and decreased in one patient, while peritoneal effusions were increased in 4 patients and transjugular intrahepatic portosystemic shunt procedures were done in 2 patients to improve dyspnea. Thoracoscopic diaphragmatic plication attenuated hepatic hydrothorax due to the pleural-peritoneal communication in safe, and may improve the quality of life in cirrhotic patients.

Objective: The relation between splenomegaly and hepatic blood flow assessed was evaluated in patients with chronic liver diseases due to hepatitis C virus infection

Patients and Methods: Subjects were 159 patients receiving perflubutane-enhanced ultrasonography during the recent 6 years. Contrast-enhanced images in the right hepatic segment-5 and segment-6 as well as right kidney were recorded through the right intercostal space for 30 seconds following intravenous injection of perflubutane. The Arrival time Parametric Images reflecting hepatic parenchymal blood flows were constructed as follows; blood flows until 5 seconds after the injection were shown as red pixels and those at 5 seconds and later as yellow pixels, and the ratios of red pixels among total pixels were calculated (ratio of red; ROR). Also, the splenic volumes were measured on ultrasonography.

Results: The ROR values did not differ between patients with and without splenomegaly (p=0.059), but a weak correlation (r=0.29) was found between the values and splenic volumes.

Conclusion: In general, blood flows in the portal vein decrease, while those in the hepatic artery increase along with the progression of liver fibrosis in patients with chronic hepatitis C. Such changes in the hepatic hemodynamics, however, showed a minimal relation with the extent of splenomegaly.