Search

Background: Recently, the role of aldosterone in metabolic syndrome (MS) has aroused interest and several reports have suggested that aldosterone blockade could be beneficial in reducing blood pressure (BP). Methods: To examine the add-on effects of eplerenone (EP) on BP in patients with MS, 54 hypertensive patients with MS and 44 without MS were recruited. Systolic and diastolic BPs in mmHg before the initiation of EP was 144/84 ± 13/12 (MS group) and 147/85 ± 12/14 (non-MS group). Before the start of EP, all patients in both groups were treated with at least one antihypertensive drug. BPs were checked on every visit (at least every 2 months) and serum chemistries were measured every 4 months. The levels of microalbuminuria and aminoterminal pro-brain natriuretic peptide (NT pro-BNP) were determined before the start of and at the end of the study. Patients were followed for 1 year. If adverse effects were reported by patients or found in laboratory studies, EP was withdrawn. Results: One month after the start of EP, BPs were decreased to 140/80 ± 12/12 mmHg (MS group) versus 142/82 ± 11/12 mmHg (non-MS group) and there was no difference between the two groups. Towards the end of the study, BPs of both groups gradually decreased. At the end of the study, BPs of both groups were 129/76 ± 15/13 mmHg (MS group) versus 133/78 ± 13/11 mmHg (non-MS group). There was a significant difference in reduction of systolic BP between the two groups (p < 0.05). Add-on EP significantly decreased the levels of urinary excretion of albumin in MS patients but not in non-MS patients (p < 0.05). There was a significant correlation between reduction of systolic BP and NT pro-BNP but not microalbuminuria in the MS group (p < 0.05). There were no serious adverse effects in both groups. Conclusion: EP may have some beneficial effects in lowering BP in patients with reduction of microalbuminuria.

症例は43歳の女性で, 2002年7月12日より腹痛および下痢があり, 7月22日当院初診となった. 腹部超音波検査およびCT検査にて腸重積と診断. しかし, 腹部単純X線上イレウス像を認めず, 臨床症状も重篤ではなく, 本人の希望もあって経過を見ていた. しかし, その後も症状改善せず初診から9日後に開腹手術を行った. 手術所見では盲腸内の粘膜下腫瘍が先進部となり回腸が上行結腸内まで重積していた. これを用手的に圧出, 解除後, 回盲部切除術にて病変を摘出した. 切除標本は5cm大の粘膜下腫瘍で, 病理学的検索にて盲腸子宮内膜症と判明した. 腸重積を合併した盲腸子宮内膜症の報告は少なく, 本邦においては本症例が2例目, 国内外を合わせても6例目となる.

Percutaneous transhepatic biliary drainage (PTBD) guided by color Doppler echography was performed on nine patients. By color Doppler echography, the segmental and subsegmental branches of both the portal vein and the hepatic artery could be identified and discriminated from the bile ducts because of their color flow mapping. We could select the safe pathway of needle advance, which did not injure the vessels. Thus, complication of bleeding did not occur in any of the patients. Color Doppler echography seems a very useful and safe method for the guidance of PTBD.

The main purpose of this paper is to clarify the meaningfullness of right anterior branch of portal vein (Pra) in evaluating portal venous flow by real-time two-dimensional Doppler echography (2-D Doppler). In normal persons, Frequency rate of observable main portal vein (mPV) and the umbilical portion (UP) of left portal vein were 45%, and 80%, respectively with anterior approach. Frequency rate of color flow imaging was low in mPV and in UP. They were 40% and 10%, respectively. However the Pra was well visualized with the right intercostal approach. Color flow imaging was obtained in 17 patients (85%) at Pra. Two patients related to thromboembolism of superior mesenteric artery (SMA-TE). One patient was suspected suffering from SMA-TE. Both SMA and mPV could not be observed due to intestinal gas. Pra was, however, well visualized and displayed by orange. That meant ample blood flow within mPV and SMA-TE was denied. Pra of another patient, whose intestine had been resected massively due to SMA-TE, was neither observable nor imaged in any color. It was considered that the portal flow decreased after SMA-TE. Two patients related the occlusion of mPV by cancer invasion. In these patients Pra was well observed. However, no color flow imaging was obtained due to the decreased portal flow. In another two patients, the flow of Pra increased. It was derived from the decreasing flow of another site, i.e., left portal vein. Hemodynamic changes of portal flow is well reflected in Pra. So, the observation of Pra may bring the information about the flow of mPV.

要旨:リアルタイム断層ドップラー血流映像装置(real-time tow-dimensional Doppler echography: 2-D-Doppler)により興味ある所見が得られたヘパトーマ症例4例を呈示し,同装置のヘパトーマ観察に於ける有用性について検討した.(1) 2-D-Dopplerは血流のカラー表示により腫瘍内外の脈管の同定と追跡を容易にした.(2) 腫瘍内外を走る脈管内の血流方向,速度を色調ないし輝度の違いとして把えることができた.(3) 2-D-DopplerはTAE前後の腫瘍内動脈血流の変化や腫瘍内のA-Pシャントの認知にも有用であった.(4) 肝硬変症のような遅い門脈血流のカラー表示は困難な場合が多く,今後改良すべき点と考えられた.

肝癌に対して肝切除前に肝動脈塞栓術transcatheter arterial embolization (TAE)を施行し,胆管壊死が手術によって確認された2例を報告した.肝切除前TAEは29例に施行されているので,胆管壊死の発生率は7%であった.ただし,これら2例はいずれもgelfoampowderが用いられており,gelfoam powder使用例に限定すると4例中2例,50%の発生率であった.Gelfoam powderは胆管壊死を高率に起こす危険があり,肝の一部分に限局したTAEでなければ,gelfoam powderの使用は禁忌と思われる.なお,塞栓物質につき若干の考察を加えた.

食道静脈瘤に対する内視鏡的硬化療法 (ST) 施行後死亡例について臨床的分析を行った.ST症例は50例であったが, 1ヵ月～3年1ヵ月の追跡期間中, 26例 (52%) がすでに死亡.このうち, 入院死亡は16例, 退院死亡が10例であった.入院死亡が多い理由の一つとして, 多臓器不全の状態のChildC症例が多かったことがあげられた.Child AまたはBの吐血例 (n: 10) にはST後に手術 (主として選択的シャント手術) が施行されたが, 入院死亡となった例はなく, 累積生存も2年で89%と良好であった.一方, STのみで退院した22例中9例 (40.9%) がすでに死亡し, 2年までの累積生存率は46%であった.退院後死亡例中, 3例は出血が死因となっており, ST後の内視鏡による定期的チェックがのぞまれた.

Conventional transcutaneous ultrasound examinations are often compromised by intervening intestinal or pulmonary gas and have limited resolution. Ultrasonic probes of frequencies greater than 5 MHz, which enhance resolution, cannot be used successfully on the skin surface, because they do not penetrate enough to to visualise intra-abdominal organs in most adults. To overcome these problems, we have used transoesophageal real-time two-dimensional Doppler echography. The ultrasonic probe, with a 5 MHz, curved array, was integrated into the end of a steerable insertion tube. Fifteen patients with oesophagogastric varices were examined. Oesophagogastric varices were visualised in colour in 10 patients. The direction of blood flow was determined in six patients. The flow velocity was measured quantitatively in five patients by the pulsed Doppler technique. The vessels in and around the liver were also visualised even when they could not be seen with transcutaneous ultrasonography. This technique is useful for the evaluation of both oesophagogastric varices and other abdominal vessels.

Radioisotopic angiography of the splenic vein was performed in six patients following a distal splenorenal shunt (Warren procedure). Under echographic guidance, the spleen was punctured with a 22-gauge needle, and Tc-99m pertechnetate was injected into the splenic pulp. In five patients whose esophageal varices had remained atrophic, the splenic vein, the left renal vein, the inferior vena cava, and the heart were clearly visualized within 8 seconds. In one patient, in whom recurrence of esophageal varices had been recognized, the splenic vein was not imaged. The injected material coursed mainly upwards through collaterals.

• Sclerotherapy for esophageal varices was performed on six patients for a total of 16 injections. The sclerosant contained 5% ethanolamine oleate and technetium Tc 99m sodium pertechnetate solution at the volume ratio of 9:1. At each injection session 5 to 20 mL of this solution was injected into one varix. The distribution of the injected material was observed by a scintillation camera. Systemic dissemination of the sclerosant through the portal vein was demonstrated in five procedures, in which the injections were correctly intravenous. In three dogs 4 mL of 5% ethanolamine oleate made from oleic acids labeled with iodine 131 was injected into the gastric coronary vein. Most of the substance injected was washed out within five minutes, and systemic dissemination became evident. (Arch Surg1985;120:833-836)

Die ersten Versuche, mit Hilfe des Ultraschalldopplerverfahrens den Blutflus nichtinvasiv nachzuweisen, bezogen sich uberwiegend auf die Untersuchung der A. carotis. So konnte Hokanson [2] 1971 erstmals mit dem gepulsten Dopplerverfahren den Blutflus in der A. carotis nachweisen. Im Jahre 1972 folgten die Untersuchungen von Reid und Spencer [6] an der A. carotis mit dem Dauerschalldopp-lerverfahren (CW-Doppler). Curry und White [1] konnten erstmals den Blutflus der A. carotis mit dem CW-Doppler farbig, jedoch nicht in Echtzeit abbilden.

The effect of spontaneous respiration on esophageal variceal flow was evaluated using 5 MHz color flow Doppler echography. Twenty-one patients with esophageal varices, of whom 19 had liver cirrhosis (95%), were examined with a convex array transesophageal transducer. The direction and velocity of the variceal flow during inhalation and exhalation could be inferred from the color, its brightness or the Doppler time-velocity spectrum. The mean intravariceal flow velocity was significantly higher during inhalation (20.6 cm per sec) than in exhalation (11.5 cm per sec; p less than 0.01). The direction of intravariceal flow at any given point did not change throughout the respiratory cycle. However, a combination of real-time color flow imaging and the doppler time-velocity spectrum revealed that, when the sampling point was near the peak of the curve of the varix, the spectrum falsely indicated reversal of direction between inhalation and exhalation. This semiinvasive method, which yields anatomical and physiological information simultaneously, appears to be very useful for the study of variceal flow.

A patient with downhill azygos venous flow is reported. This reverse flow was due to an obstruction in the superior vena cava and the azygos entry due to Behcet's disease. Color flow mapping of the azygos vein, using transesophageal real-time two-dimensional Doppler echography, was used for both anatomic and hemodynamic analysis. (Chest 1988; 94:1308-09)

A 41-year-old woman with cirrhosis of the liver was admitted to our hospital because of a severe melena. Blood pool scanning with labelled red blood cells showed a high concentration in the right upper quadrant of the abdomen. Endoscopy of the second portion of the duodenum revealed fresh blood on the first examination and varices with overlying erosion were evident in the second study. Co-existent esophageal varices were present but were apparently not associated with the bleeding. Because of the continuous hypotension even with blood replacement, ligation and sclerotherapy were performed. To evaluate the efficacy of the procedures, intraoperative two-dimensional Doppler echography was used and the transducer was applied directly to the viscera. Blood flow was visualized in the serosal and submucosal varices. After ligation and sclerosing of the veins, the blood flow velocity signals disappeared. This woman died of multiple organ failure on the ninth postoperative day.

Using a convex array transducer, the advantages and shortcomings of transesophageal real-time two-dimensional Doppler echography (TE2DD) were assessed in a study of the vessels around the esophagus and the stomach in 67 adult patients with (n = 56) or without (n = 11) liver cirrhosis. In most cases, all but the upper- and lowermost margins of the azygos vein could be visualized. The more caudally the portion located, the smaller its diameter and flow velocity became. The average number of intercostal veins visualized by TE2DD was 4 per person. The observable esophagogastric varices seemed to be limited to deeply located ones around the esophagogastric junction. In five patients who had undergone distal splenorenal shunt, splenic venous flow, or shunt flow could be seen from the stomach over a length of about 5 cm. The azygos venous flow in cirrhotic patients was significantly greater than that of patients without cirrhosis. TE2DD appears to be very useful for evaluating flow in the cephalad collateral veins and other vessels around the esophagus and the stomach.