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Biomedical subjects

J L Riegler

Publications and source records attributed to J L Riegler.

10 recordsLinked to original sources
PubMed1999

Dissection of an iliac artery conduit to liver allograft: treatment with an endovascular stent.

Hepatic artery thrombosis remains one of the most serious complications after orthotopic liver transplantation. Sepsis, biliary leakage and strictures, and retransplantation are often the result of this devastating complication. Because retransplantation or reoperation is sometimes not possible or advisable, other means of reestablishing hepatic artery continuity are desirable. We describe a liver transplant recipient who developed a dissection of an iliac artery conduit after retransplantation that was treated with fibrinolytic therapy followed by successful placement of an endovascular stent.

Adult↗
PubMed1999

Spontaneous intrahepatic hemorrhage and hepatic rupture in the HELLP syndrome: four cases and a review.

Subcapsular hemorrhage and hepatic rupture are unusual catastrophic complications of the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. A high index of suspicion and prompt recognition are keys to proper diagnosis and management of affected patients. The optimal management of these patients is evolving. An aggressive multidisciplinary approach has considerably improved the morbidity and mortality associated with these complications. We present our experience with four cases of hepatic hemorrhage occurring in association with the HELLP syndrome and review the literature on this subject. All of our patients were multiparous, and three had a history of eclampsia/preeclampsia in a previous pregnancy. All four patients developed intrahepatic hemorrhage; two developed hepatic rupture requiring surgical intervention. Three patients developed disseminated intravascular coagulation and acute renal failure. Two patients developed pericardial effusion, pleural effusions, and ascites. One patient died of septic complications after multiple surgical interventions.

Adult↗
PubMed1998

Utility of endoscopic evaluations in liver transplant candidates.

OBJECTIVE: The aim of this study was to determine whether endoscopic evaluation of patients referred for liver transplant evaluation contributes significantly to patient selection or management. METHODS: Esophagogastroduodenoscopy (EGD) was performed in transplant candidates who had not undergone this examination within a previous 6-month period. Colonoscopy (CSP) was performed if the patient was >50 yr of age or had anemia, a history of colonic pathology such as adenomatous polyps, or a history suggesting gastrointestinal tract abnormalities. RESULTS: A total of 118 patients were studied. EGD was performed in 74 (63%) patients. Forty-seven patients had esophageal varices identified; in 26, this represented a new diagnosis. Other findings on EGD included portal gastropathy (21 patients), gastric varices (seven patients), peptic ulceration (10 patients), Barrett's esophagus (three patients), and one case each of esophageal and gastric carcinoma. CSP was performed in 56 patients. Findings included adenomatous polyps (24 patients) and one case of colon carcinoma. Overall, gastrointestinal pathology was discovered in 67 (57%) of the patients undergoing endoscopic evaluation as part of our study. Alterations in patient selection or management resulted from 44% of the procedures performed; 42% of the patients were affected by these management changes and 2.5% of patients were removed from further transplant evaluation because of the diagnosis of malignancy. CONCLUSION: Endoscopic evaluation of liver transplant candidates often identifies important gastrointestinal pathology and frequently impacts patient selection and management before OLT.

Adult↗
PubMed1997

Is melatonin associated with the development of autoimmune hepatitis?

Melatonin is a neurohormone produced by the human pineal gland that plays a role in the regulation of many physiologic processes and has been proposed as a therapy for everything from insomnia to metastatic carcinoma. Melatonin is available in the United States without prescription, and adverse effects appear to be uncommon. However, because melatonin appears to have immunomodulatory properties, the potential exists for the development of autoimmune-related side effects. We describe a patient in whom characteristic clinical and laboratory features of autoimmune hepatitis developed after beginning melatonin therapy for the treatment of insomnia. Liver biopsy demonstrated histologic features of autoimmune hepatitis. Rapid symptomatic and biochemical improvement resulted from the initiation of immunosuppressive therapy; however, hepatitis recurred after the withdrawal of steroid therapy. The temporal relation observed between melatonin use and the development of autoimmune hepatitis raises the possibility that the drug might be involved in the pathogenesis of this patient's autoimmune disease.

Adult↗
PubMed1996

Preneoplastic conditions of the liver.

Hepatocellular carcinoma (HCC) is one of the most common cancers in the world. The majority of patients who develop HCC have underlying cirrhosis, which suggests that cirrhosis itself represents a preneoplastic condition. Nevertheless, whereas patients with cirrhosis of any origin are at increased risk of developing HCC, those with chronic hepatitis B or C infection seem to be at greatest risk. Patients with cirrhosis resulting from chronic alcohol use, hemochromatosis, autoimmune hepatitis, or alpha-1 antitrypsin deficiency have less risk of developing this cancer, and some hepatic diseases, such as primary biliary cirrhosis and Wilson's disease, do not predispose affected persons to an appreciable risk of developing HCC. Certain histological features, such as liver cell dysplasia and macroregenerative nodules, may represent preneoplastic alterations of hepatocytes, but these changes do not seem to be a necessary step in the evolution of liver cancer. The pathogenesis of HCC is unclear, but seems to involve several steps. Hepatitis B virus infection may result in the malignant transformation of hepatocytes by some directly oncogenic mechanism, whereas other necroinflammatory conditions probably predispose to the development of HCC through the introduction of genetic alterations coupled with a reduction of genetic repair functions. Screening patients at risk for the development of HCC using alpha fetoprotein measurements and ultrasonography is widely practiced despite inconclusive evidence of efficacy. If screening is performed, the program used should be tailored to the perceived risk for a particular patient.

Carcinoma, Hepatocellular↗
PubMed1996

Outcomes of patient disengagement policies: implications for managed care.

The gastroenterology division at Wilford Hall Medical Center (WHMC) refers approximately 70% of outpatient consultations to civilian providers, a policy known as disengagement. This policy was implemented in the hope of reducing waiting times for appointments and testing. We conducted a telephone survey to determine whether disengaged patients eventually obtained health care and, if they did not, the reasons for this. We also attempted to determine the level of patient satisfaction with this policy. The results demonstrated that many patients did not obtain care within the 6-month follow-up period, largely because of financial considerations. Most patients were also dissatisfied with the policy and disappointed at not having obtained care at WHMC. The results of this study have important implications for Tricare, which might result in impaired access to care through out-of-pocket patient expenses related to cost-shares and membership fees.

Gastroenterology↗
PubMed1995

Transjugular intrahepatic portosystemic shunt improves oxygenation in hepatopulmonary syndrome.

Hepatopulmonary syndrome is a complication of chronic liver disease in which arterial hypoxemia results from abnormalities in pulmonary blood flow. Severe hypoxemia can lead to clinical deterioration and death. Although the etiology is unknown, portal hypertension seems to be an important factor in the development of hepatopulmonary syndrome. No effective pharmacological therapy has been identified, but liver transplantation may be curative. Arterial hypoxemia may complicate transplant surgery, however, and resolution of the syndrome after liver transplantation is performed may be delayed. In addition, it seems that complete reversal of oxygenation abnormalities after liver transplantation is performed is unpredictable. We described a patient with hepatopulmonary syndrome who noted improvement in symptoms of dyspnea after the placement of a transjugular intrahepatic portosystemic shunt. Arterial oxygenation and calculated shunt fraction improved significantly during the follow-up period, and liver transplantation was subsequently performed without difficulty. Portal decompression using transjugular intrahepatic portosystemic shunt may represent a palliative therapy for hepatopulmonary syndrome in patients awaiting liver transplantation.

Female↗
PubMed1995

Hepatic encephalopathy after transjugular intrahepatic portosystemic shunts: incidence and risk factors.

OBJECTIVES: The aim of this study was to determine the incidence of new or worsened hepatic encephalopathy after transjugular intrahepatic portosystemic shunts (TIPS) and to ascertain which clinical characteristics are associated with this complication. METHODS: At the University of California, San Francisco, over 22 months, TIPS were placed successfully in 108 adults. Seventy-seven patients in whom it was possible to assess the development of encephalopathy comprised the study population. Clinically significant encephalopathy was assessed at protocol clinic follow-up and, in some cases, by phone contact with the patient and the referring physician. Post-TIPS encephalopathy was defined as new onset of clinical encephalopathy requiring treatment or worsening of preexisting encephalopathy within 1 yr of TIPS. RESULTS: The overall incidence of new or worsened encephalopathy was 23% (18/77). Post-TIPS encephalopathy was well controlled with lactulose in 78% of cases and was progressive in 22%. Multivariate analysis showed that an increased risk of encephalopathy was associated with an etiology of liver disease other than alcohol [relative risk (RR) 9.2, p = 0.0052], female gender (RR 3.0, p = 0.029), and hypoalbuminemia (RR 2.2 for each 1 g/dl decrease, p = 0.044). CONCLUSIONS: Hepatic encephalopathy is a common complication of TIPS that can be controlled medically in most patients. The identification of clinical variables associated with an increased risk of encephalopathy may be useful in the selection of appropriate candidates for this procedure.

Adult↗
PubMed1993

Fulminant hepatic failure.

FHF is an uncommon but devastating condition affecting otherwise healthy persons which causes significant morbidity and mortality. The etiologic factor is most commonly viral infection, with drugs and metabolic disorders being relatively less common causes. Hopefully, newer diagnostic techniques such as PCR will increase our understanding of the causes and pathogenesis of this disorder. Medical management at the present time must focus on anticipating, preventing, and rapidly identifying and treating complications that may affect every major organ system. Encouraging research continues on the clinical application of hepatotrophic drugs and artificial liver support systems, both as potentially definitive therapies and as maintenance for patients awaiting transplantation. Consultation with physicians at a transplant center should be sought early in the course of the patient's hospitalization when OLT is being considered. Liver transplantation has dramatically changed the outlook for patients with FHF, with current survival rates in the 55% to 75% range. The continuing challenge for the transplant team is to allocate available donor organs to those patients who would not otherwise survive, but also to provide OLT in a timely fashion to ensure the best chance of post-transplantation recovery. Newer techniques such as heterotopic liver transplantation, reduced-size organ transplantation, and the utilization of living related donors may further improve the survival of these patients.

Artificial Organs↗