Report of a case showing a recovery from liver cirrhosis to chronic hepatitis, type C, after glycyrrhizin injection for 2 years and a sustained response by the following interferon therapy

TO THE EDITOR: We read with great interest the article recently published by Schepke et al. (1), which demonstrates that Doppler assessment of portal vein flow velocity allows an accurate distinction between responders and nonresponders to propranolol acute administration compared with hemodynamic assessment. This is an important step in the field of treatment of portal hypertension, because hemodynamic evaluation is a relatively safe but still invasive technique and not as available as Doppler. At the end of the article the authors advocate the need for studies correlating Doppler parameters with clinical endpoints such as variceal bleeding. We here remark on our experience in this field. On the basis of a previous study, demonstrating a peak effect on portal flow velocity between 2 and 4 h after administration of 40 mg p.o. of propranolol (2), we conducted a prospective study on cirrhotic patients with esophageal varices at high risk of bleeding. This study, presented in the 49th ASSLD meeting in 1998 and published in 1999 (3), demonstrated that the portal flow velocity test was a safe and feasible method to predict the efficacy of b blockers in the prevention of a first variceal bleeding. A $12% decrease in maximal portal flow velocity after propranolol acute administration was the best cutoff value with respect to efficacy of subsequent chronic treatment in preventing variceal bleeding, with a sensitivity of 69% and a specificity of 70%. Notwithstanding some methodological problems, our findings, also discussed by Garcia-Tsao (4), are clinically relevant and find further scientific support in Schepke et al.’s data. The slight difference between the cutoff point values reported in the two studies may be the consequence of the different endpoints and of operator and technical factors. It should be mentioned that the mean acute variation in portal flow velocity after the administration of b blocker reported in the literature ranges from 211.2% to 220.4% (5). We propose that the portal flow velocity test be used for response to propranolol administration before starting chronic therapy. If there is not a significant decrease in maximal portal flow velocity, the patient is a nonresponder and will not derive any clinical benefit, so the clinician should supplement or change the therapeutic approach.