Historical Aspects of Ascites and the Hepatorenal Syndrome

Abstract

Content available: Author Interview and Audio Recording.

Florence Wong.

Laurence Blendis.

FIG 1

Hollow figurine found at the necropolis of Jaina, Mexico, depicting a man with massive ascites and an everted umbilicus. Reproduced with permission from Annals of Internal Medicine.4 Copyright 1994, American College of Physicians. Inset: Hand‐drawn cartoon illustrating fluid leaking into the peritoneal cavity from a “hardened” (cirrhotic) liver.

FIG 2

Paracentesis via the umbilicus in an engraving from Scultetus “Armamentarium chirurgicum” Lugduni Batavorum 1693.

FIG 3

Paracentesis via a puncture in the left lower abdomen, as shown by Job van Meekereen in Heel‐ en Geneeskonstige Aenmerkingen. Original first edition, 1668. Facsimile edition, introduced by D. de Moulin.

FIG 4

Monitoring the patient’s pulse during paracentesis. This cartoon is a generous gift from Prof. Vincente Arroyo, who instructed his previous resident, the late Dr. Pablo Humbert, to draw it.

FIG 5

Modification by Paul Barbette of the puncture pin brought from Padua to Amsterdam by Jacob Block, drawn by Job van Meekereen in his book Heel‐ en Geneeskonstige Aenmerkingen, 1668.

FIG 6

(A) A patient with cirrhosis with ascites and edema being attended to by his “hepatologists.” From the series of satiric etchings known as “The Comforts of Bath” by the 18th‐century English caricaturist Thomas Rowlandson (1757‐1827), as described in a footnote to the text. (B) Bathers submerged, fully clothed, in the Roman baths in Bath. On the right, two men cling to pillars and another man is supported in the water by a servant in the foreground. The majority do not seem to enjoy the experience. Reproduced from “The Comforts of Bath” by Thomas Rowlandson. Published 1858 by W. Lewis Printer and Lithographer, 24 Union Passage, Bath.

FIG 7

The Manna Ash or Southern European Flowering Ash, Fraxinus ornus. Sap (from which a sugary extract may be derived), is obtained by making a cut in the bark. This sugary extract was compared in late medieval times (around 1400 CE) with the biblical manna, giving rise to the English name of the tree, and some of the vernacular names from its native area (e.g., fresno del maná in Spanish and frassino da manna in Italian). The sugar mannose and the sugar alcohol mannitol both derive their names from the extract. Photo was taken by Jean‐Pol Grandmont, CC BY 3.0: https://creativecommons.org/licenses/by‐sa/3.0/. Text: Wikipedia, CC BY 3.0.

FIG 8

The creation of an intrahepatic portosystemic tissue shunt for a patient with bleeding esophageal varices. (A) A Grüntzig catheter within the tissue tract joining a branch of the portal vein with a branch of the hepatic vein, with its balloon partially inflated; therefore, a ringlike stricture is present. The tip of the catheter is in the portal vein. (B) Balloon fully dilated within the tissue tract, and hence disappearance of the constriction. Reproduced from Canadian Medical Association Journal. Copyright 1982, Canadian Medical Association. CC BY‐NC‐ND.

FIG 9

Selective renal angiogram performed in patient with cirrhosis and HRS. (A) Premortem showing absence of blood flow in the arcuate and cortical vessels. (B) Postmortem refilling of the renal arterial system to the periphery of the cortex in the same patient. Reproduced with permission from The American Journal of Medicine. Copyright 1970, Elsevier.

FIG 10

Diagram showing increases in active arterial perfusion in the splanchnic and pulmonary circulations, a passive increase in cerebral perfusion in acute liver failure and reflex renal arterial vasoconstriction, in association with the systemic arterial vasodilatation of advanced liver disease. Reproduced with permission from Hepatology. Copyright 2006, American Association for the Study of Liver Diseases.

FIG 11

Schematic depiction of the changes in cardiac output with a progressive increase in systemic arterial vasodilatation, as exemplified by splanchnic vasodilatation. The upper panel shows the change in hemodynamics according to the original peripheral vasodilatation hypothesis, in which cardiac output increases to a plateau. The lower panel shows that cardiac output rises to a peak with increasing splanchnic vasodilatation only to fall thereafter, which explains the impaired renal function that is seen with the most advanced portal hypertension. Reproduced with permission from Seminars in Liver Disease. Copyright 2008, Thieme Medical and Scientific Publishers Private Limited.