Autonomic neuropathy in extra-hepatic portal vein thrombosis: evidence for impaired autonomic reflex arc

Background/Aims: Automatic dysfunction is common in cirrhosis, and may be associated with increased mortality and hyperdynamic circulatory changes. Our aim was to investigate whether autonomic disturbances occur in extrahepatic portal vein thrombosis and their correlation with hemodynamic abnormalities. Patients and Methods: Heart rate variation in response to standing, deep breathing, and Valsalva maneuver, and blood pressure response to sustained handgrip and to standing, were studied in 16 subjects with portal vein thrombosis (10 males, 30.8±2.8 years: mean±SE), 12 with cirrhosis (7 males, 52±2.3 years), and 10 healthy controls (7 males, 30.8±3.0 years). Supine resting, and 10- and 30-min standing epinephrine and norepinephrine levels were measured and results correlated with cardiac output. Results: Automatic dysfunction occurred in 62% of portal vein thrombosis and 75% of cirrhosis subjects, but in no controls (p<0.02). Similarly, postural hypotension occurred in portal vein thrombosis (−10.25±0.65 mmHg, p+0.003) and cirrhosis (−7.42±0.82 mmHg, p=0.007) but not in controls. All groups had similar baseline epinephrine and norepinephrine concentrations. Epinephrine increased significantly in controls (45%, p<0.01 and 49%, p<0.02) after 10 of 30 min standing but not in the portal vein thrombosis of the cirrhotic groups, and norepinephrine increased after 10 and 30 min standing in cirrhotics (128%, p<0.004 and 130%, p<0.008) and controls (129%, p<0.002 and 116%, p<0.004), but not portal vein thrombosis (34.5% and 39%, NS vs baseline). Portal vein thrombosis and cirrhosis groups had increased cardiac output (4441±509 and 3262±292) vs controls (1763±212 ml/min/m2, p<0.002), but there was no correlation with autonomic neuropathy or with catecholamine levels. Conclusions: Automatic dysfunction and impaired techolamine response to orthostatic stress occur commonly in portal vein thrombosis and suggest an impairment of the authonomic reflex arc, but changes do not correlate with hemodynamic abnormalities.