Prevalence of Arterial Hypertension in Cirrhosis of Liver

Sir, 
 
Systemic hypertension is a common disorder. Cirrhotic patients have hyperdynamic circulation with a decrease in effective circulatory blood volume, which has been attributed to the underlying vasodilatory state in these patients. 
 
On this background, we conducted a study to evaluate the prevalence of essential hypertension among patients with cirrhosis and the related cardiovascular changes among them. We prospectively evaluated 260 cirrhotic patients at the Stanley Medical College, Chennai, India, regularly attending the Liver Clinic, of whom alcohol was the cause in 140 cases. All patients underwent blood pressure (BP) recording in supine and sitting posture, ECG, and echocardiogram. Among the 260 cases, 23 (8.8%) patients with arterial hypertension were identified, of whom four patients were excluded because of secondary hypertension. Among the remaining 19 (7%) patients with hypertension, the mean age was 51 ± 14.46 years, M:F ratio was 3.1:1, and the mean BMI was 25.8 kg/m2. The mean arterial pressure (MAP) was 120 mmHg. Ten patients (52.6%) were categorized as Child's A, six (31.5%) as Child's B, and three (15.7%) as Child's C. Abnormalities in ECG were noted in seven patients (36.8%), and abnormalities in echocardiogram were observed in six (31.6%) patients. In the normotensive group, comprising 237 patients, the mean age was 53 ± 13.56 years, M:F ratio was 1.8:1, mean BMI was 24.2 kg/m2, and the MAP was 83 mmHg; abnormalities in ECG were present in four (1.6%) patients, and none had abnormalities in echocardiogram. 
 
There has been a relatively low prevalence of hypertension among patients with hepatic cirrhosis.[1] Cirrhosis is a state of hyperdynamic circulation with increased cardiac output and low systemic vascular resistance.[2] This is mainly due to the abnormal distribution of increased blood volume with decreased effective circulatory blood volume, neurohumoral activation, and abnormal sodium and water handling.[3] There is also evidence that the static and dynamic properties of the large arteries are changed.[4] These factors probably account for the relatively low incidence of hypertension in patients with cirrhosis. 
 
In the current study, the prevalence of hypertension among cirrhotic patients was 7%, which is less than that among the general population (10–15%). Incidence of hypertension was found to be higher in patients with Child's A cirrhosis and showed a decreasing trend on worsening of liver disease. The study has shown the relatively low incidence of hypertension and cardiac events among the patients with cirrhosis, thereby postulating the possible protective effects of cirrhosis on the cardiovascular system.


Prevalence of Arterial Hypertension in Cirrhosis of Liver
Sir, Systemic hypertension is a common disorder.Cirrhotic patients have hyperdynamic circulation with a decrease in effective circulatory blood volume, which has been attributed to the underlying vasodilatory state in these patients.
On this background, we conducted a study to evaluate the prevalence of essential hypertension among patients with cirrhosis and the related cardiovascular changes among them.We prospectively evaluated 260 cirrhotic patients at the Stanley Medical College, Chennai, India, regularly attending the Liver Clinic, of whom alcohol was the cause in 140 cases.All patients underwent blood pressure (BP) recording in supine and sitting posture, ECG, and echocardiogram.Among the 260 cases, 23 (8.8%) patients with arterial hypertension were identified, of whom four patients were excluded because of secondary hypertension.There has been a relatively low prevalence of hypertension among patients with hepatic cirrhosis. [1]Cirrhosis is a state of hyperdynamic circulation with increased cardiac output and low systemic vascular resistance. [2]This is mainly due to the abnormal distribution of increased blood volume with decreased effective circulatory blood volume, neurohumoral activation, and abnormal sodium and water handling. [3]There is also evidence that the static and dynamic properties of the large arteries are changed. [4]These factors probably account for the relatively low incidence of hypertension in patients with cirrhosis.
In the current study, the prevalence of hypertension among cirrhotic patients was 7%, which is less than that among the general population (10-15%).Incidence of hypertension was found to be higher in patients with Child's A cirrhosis and showed a decreasing trend on worsening of liver disease.The study has shown the relatively low incidence of hypertension and cardiac events among the patients with cirrhosis, thereby postulating the possible protective effects of cirrhosis on the cardiovascular system.
Department of Gastroenterology, Stanley Medical College, Chennai, India. 1 Heavy Vehicles Factory -Health Unit, Avadi, Chennai, India.E-mail: p.rajeshprabhu@gmail.com Are All Surgical Referrals for Endoscopic Retrograde Cholangiopancreatography Necessary?
Sir, Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the diagnosis of biliary obstruction. [1]e objective of this study was to evaluate the necessity of emergency ERCPs in the acute phase (first 72 h) regardless of the trend of the liver function tests, thus exposing acutely ill patients to the risks of an invasive procedure [2] in the post magnetic resonance cholangiopancreatography (MRCP) era. [3,4]ere is no doubt that ERCP is a valuable and useful tool in management of hepatobiliary conditions.With less invasive diagnostic modalities, such as MRCP being available, the dogma of ERCP as a "gold standard" had to be re-evaluated.Our study shows that a percentage of our patients did indeed need ERCP; all of group II had calculi that required removal.
It was however only 28% of patients (26 of 73) that had stagnant or deteriorating liver function tests, thus warranting an emergency ERCP in the acute setting (first 72 h), while the patients were acutely unwell.
The outcome and conclusion of this study is that a supervised delay, with stringent monitoring of the trend of liver markers, will give many patients time to recuperate from their acute illness before an invasive procedure.This will also allow less invasive procedures, e.g., MRCP, play a role in selecting candidates for more invasive forms of management.