Ultrasonic diagnosis and vasoactive substances examination in patients with cirrhosis

Mei Fan, Chun Su, Lin Lu, Jun-Chang Qin, Pei Li, Jia-Ying Yuan

1Department of Sonography, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China

2Department of Gynaecology and Obstetrics, the Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China

3Department of Radiology, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China

4Department of Pathophysiology, College of Basic Medical Sciences,Zhengzhou University,Zhengzhou,China

5Department of Sonography, the Affiliated Hospital of Henan Military Region, Zhengzhou, China

Ultrasonic diagnosis and vasoactive substances examination in patients with cirrhosis

Mei Fan1, Chun Su2, Lin Lu3, Jun-Chang Qin1, Pei Li4*, Jia-Ying Yuan5*

1Department of Sonography, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China

2Department of Gynaecology and Obstetrics, the Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China

3Department of Radiology, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China

4Department of Pathophysiology, College of Basic Medical Sciences,Zhengzhou University,Zhengzhou,China

5Department of Sonography, the Affiliated Hospital of Henan Military Region, Zhengzhou, China

Objective: To investigate hemodynamic change of patients with cirrhosis by using Color Doppler ultrasound technique and to explore the significance of change in the content of vasoactive substances-plasma endothelin-1 (ET-1) and calcitonin gene-related peptide (CGRP). Methods: A total of 178 cases with cirrhosis were regarded as study groups, and were divided into three degrees: A, B and C according to child-pugh and meanwhile 60 cases were regarded as normal control group. Portal vein and splenic vein of patients were explored by adopting Color Doppler ultrasound technique, related indexes were recorded and the blood flow as well as their ration in the two groups was calculated. Radio immunoassay was adopted to detect the content of plasma ET-1 and CGRP in both study group and contrast group. Results: Compared with the healthy cases in the contrast group, there was abnormal hemodynamics in the system of portal vein of patients with cirrhosis and the content of plasma ET-1 and CGRP was increased obviously. In the Child-Pugh liver function grades, the content of ET-1 and CGRP was increased as the degree of cirrhosis became more and more serious. There was no significant difference in the comparison between those without ascites and those in contrast group (P>0.05), the content of plasma ET-1 and CGRP in patients without ascites was increased remarkably. Besides, there was positive correlation between the content of plasma ET-1 and CGRP and Dpv, Dsv and Qsv. Conclusion: Detection of abnormal hemodynamics of portal vein and splenic vein by Color Doppler ultrasound technique can be one of the means for diagnosis of hypertension. Plasma ET-1 and CGRP of patients with cirrhosis reflect the serious degree of the damage in live function and play an important role in the formation and development of portal hypertension.

ARTICLE INFO

Article history:

Received 10 December 2013

Received in revised form 15 January 2014

Accepted 15 February 2014

Available online 20 April 2014

Cirrhosis

Color Doppler ultrasound technique

Venous hemodynamics

ET-1

CGRP

1. Introduction

Color Doppler ultrasound technique is a important way to diagnose cirrhosis and the standard of diagnosis of cirrhosis is that the diameters of the portal vein (PV) and splenic vein (SV) are respectively more than 13 mm and 8 mm[1]. Vasoactive substances mediate and participate in the formation of cirrhosis portal hypertension and the correlation between the content of vasoactive substances and cirrhosis as well as portal hemodynamics attracts a lot of attention[2]. Abnormal hemodynamics of cirrhosis is related to multiple vasoactive substances such as tumor necrosis factor, substance-P, vasoactive intestinal peptide, prostacyclin, endothelin (ET) and nitric oxide (NO) and so on[3]. Among these substances, ET is a kind of polypeptide consisting of 21 amino acids with a strong function of vascular contraction. ET-1 is synthesized by vascular endothelial cells[4] and plays an important biological role in liver and the portal system. The application of ET receptor antagonists can reduce the portal pressure[5]. Calcitonin gene-related peptide (CGRP) and calcitonin (Cal) come from a same gene and CGRP, consisting of 37 amino acids, isa kind of vasoactive peptide and can dilate the peripheral vessel remarkably[6]. Hemodynamic change of parameters in liver of patients with cirrhosis was detected by Color Doppler ultrasound technique and the change in the contents of vasoactive substances ET-1 and CGRP was checked by radioimmanoassay.

2. Materials and Methods

2.1. General Materials

A total of 178 patients who came to our hospital during Sep. 2009 to Sep. 2011 and were diagnosed with cirrhosis were chosen as study group, among whom there were 128 male cases and 50 female cases in the range of age 20-62 years old with the average age of (37.8±17.5) years. According to child-pugh grade of liver function, there were 55 cases with grade A, 89 cases with grade B and 34 cases with grade C. There were 106 cases with ascites and 72 cases without ascites. There were 144 cases with hepatitis cirrhosis, 13 cases with schistosomiasis cirrhosis, 8 cases with alcoholic cirrhosis and 13 cases with mixed cirrhosis. A total of 60 healthy persons were chosen as control group and they matched with the study group in terms of characters such as age fabric.

2.2. Ultrasonic diagnosis

Cases should be on fasting for 12 h before examination and be in resting in supine position. Toshiba Aplio500 Color Doppler ultrasound diagnostic apparatus was used with probe frequency 2.5-4.0 MHz to measure the diameter of portal vein (Dpv), velocity of portal vein (Vpv), diameter of splenic vein (Dsv), velocity of splenic vein (Vsv), quantity of portal vein (Qpv), quantity of splenic vein (Qsv). The calculation formula of venous quantity was Q=Vmin×(D/2)2×π×60 (Q was short for blood quantity, D symbolized the diameter of portal vein and Vmin symbolized the average velocity of blood).

2.3. Detection of vasoactive substances in serum

After cases who received examination finished their fast of 12 h, 8 mL blood was collected from them with empty stomach in the morning. And 4 mL was sent to be checked for liver function and the rest was divided into halves, stored in two test tubes respectively. Each tube contained 0.3 M anticoagulant EDTA-Na2 20 μL, 0.32 M dimercaprol dimercaptopropanol 10 μL and 0.34 M 8- hydroxyquinoline sulfate 20 μL. After they were fully mixed, the solution was centrifugal for 10 min at 2 000 rpm. The separated plasma was kept at -20 ℃ to detect ET-1 and CGRP. Radioimmunoassay kits of ET-1 and CGRP were bought from Beijing S & P Weiye Biological Technology Co. Ltd. and the operations were strictly under the guidance of instructions.

2.4. Statistical analysis

Software MATLAB 7.0 was used to analyze the statistics. Measurement data were symbolized by the means±standard deviations. The comparison of the differences in means of different samples was analyzed by variance and checked byt, regarding α=0.05 as checking standard. The difference was statistically meaningful when P<0.05.

3. Results

3.1. Results of color Doppler ultrasound diagnosis

Considering the final analyzed results, the Dpv and Dsv was wider than that in healthy group (P<0.05), Vsv was increased but the difference was not significant (P>0.05), Qsv was increased significantly (P<0.01) and the value of Qsv/Qpv was significantly larger than that in control group. From the perspective of Child-Pugh grade of liver function which reflected the degree of cirrhosis, in an ascending order A, B and C, Dpv and Dsv were increased gradually and there was significantly difference between adjacent groups (P<0.05). Vpv was gradually decreased (P<0.05). The change of Vsv in different groups wasn’t significant (P>0.05). The difference of Qpv between adjacent groups wasn’t significant either (P>0.05). Qsv was significantly in a increasing trend (P<0.01) and so it was same with the value of Qsv/Qpv, and the differences among groups were significantly (P<0.01) (Table 1).

3.2. Detection of ET-1 and CGRP

Radioimmunoassay was used to detect the content of ET-1 and CGRP in serum. The results showed the levels of them in study group were significantly higher than that in control group (P<0.01), the levels of them in group with ascites were significantly higher than that in group without ascites (P<0.05 or P<0.01). The difference between the levels of ET-1 and CGRP in group without ascites and that in control group wasn’t significant (P>0.05) (Table 2).

3.3. Relation between the degree of damage to liver function and the levels of ET-1 and CGRP in plasma

The detected results showed that there was no significantdifference between the levels of ET-1 and CGRP in group with liver function damage in grade A and that in control group (P>0.05) and there were significant differences among groups with liver function damage in groups with grade A, B and C (P<0.05). The levels of ET-1 and CGRP increased significantly as the damage to liver function aggravated (Table 3).

Table 1 Index results of hemodynamics of portal and splenic vein by color doppler ultrasound diagnosis.

Table 2 Expression level of ET-1 and CGRP in serum (ng/L).

Table 3 Levels of ET-1 and CGRP in plasma of patients in different Child-Pugh Grades (ng/L).

3.4. Relation between levels of ET-1 and CGRP and venous hemodynamics of patients with cirrhosis

The levels of ET-1 and CGRP were in positive relation to the diameters of portal and splenic veins and quantity of splenic vein. The difference was statistically significant (P<0.01) (Table 4).

Table 4 Analysis of relation between vasoactive substances and hemodynamics of venous system.

4. Discussions

Hemodynamics in human body can change abnormally in the process of cirrhosis and such a change is relevant with two currently popular hypotheses-hypothesis of backward flow and hypothesis of forward flow[8, 9], both of which play an important role in the formation of cirrhosis portal hypertension[10,11]. So far, as to the measure of the blood flow of portal venous system, Color Doppler detection is of large value. In the study, through the detection of hemodynamics of portal vein by Color Doppler technique, it was found that as the Child-Pugh integral of liver function increased, the diameters of portal and splenic veins had the trend to dilate gradually while the blood flow in portal vein slowed down gradually and there were significantly differences in the degree of dilation among grade A, B and C. This is not totally same with the research results by Liu Mingtao and his colleagues[12]. In their study, they found that there were no remarkable differences in the degree of dilation of portal veins among grade A, B and C. Given the results that the values of Qsv/Qpv in group with cirrhosis in different grades were all higher than that in control group, the increase of blood flow in splenic vein plays an important role in the formation of portal hypertension of patients with cirrhosis. Therefore, the change in hemodynamics can be the index to assess the degree of hepatic parenchymal lesions as well as the effective index to diagnose portal hypertension[13,14].

Some studies showed that the level of plasma ET-1 in patients with cirrhosis increased remarkably[15,16]. Our study results also indicated that the level of plasma ET-1 grew remarkably with the increase of child-pugh grade (P<0.05), suggesting that the level of plasma ET-1 was related to the serious degree of cirrhosis-growing gradually with the aggravation of the damage in liver function. The increase of ET-1 in patients with cirrhosis can raise the intra-hepatic vascular resistance and the portal pressure[17,18]. The level of plasma ET-1 is significantly related to the diameters of portal and splenic vein, indicating that it plays a certain role in the formation of portal hypertension. In addition, the studyfound that the level of CGRP is similar to that of ET-1 and the content in patients with cirrhosis is obviously higher than that in control group. The increase of CGRP may contribute to hyper-dynamic circulatory state, resulting in the increase of splanchnic blood flow and portal pressure[19]. The dilation of peripheral vessel and the abnormal distribution of blood volume lead to water-sodium retention, which is consistent with related reports[20,21]. The result that the level of ET-1 and CGRP in patients with ascites is remarkably higher than that in cases without ascites indicates that high ET-1 and CGRP levels in patients with cirrhosis can lead to ascites through the dilation of peripheral vessels or the increase f portal pressure. Meanwhile, the level of CGRP is also related to the Child-Pugh grades of liver function. The above results show that ET-1 and CGRP may participate in the formation and maintenance of cirrhosis portal hypertension at the same time.

Conflict of interest statement

We declare that we have no conflict of interest.

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ment heading

10.1016/S1995-7645(14)60050-X

*Corresponding author: Pei Li, M.D. Basic Medical College of Zhengzhou University, Zhengzhou, China.

Jia-Ying Yuan, M.M., Department of Ultrasonography, Directly Affiliated Hospital of Henan Military Area, Zhengzhou 450003, Henan Province,China.

E-mail: peter_mails@126.com

Foundation project: The paper is supported by a grant of New Century Excellent Talents in University,Ministry of Education China(No.NCET-11-0949)