[Histotopographic demonstration of hepatitis-B-surface-antigen (HBSAg) in liver-biopsies with the peroxidase-antiperoxidase (PAP)-method in symptomfree HBSAg-carriers]

In 241 paraffin-embedded liver-biopsies of HBSAg-positive, voluntary blood-donors hepacellular HBSAg was demonstrated with the immunomorphologic peroxidase-antiperoxidase (PAP)-method. In all sections, HBSAg-positive liver-cells were estimated, their distribution-pattern was assessed and different types of cytoplasmatic localisation of HBSAg were described. Despite high sensitivity of the PAP-method, 24% of seropostive cases were histologically negative. A correlation of HBSAg-content and histologic diagnosis was lacking. An association of high HBSAg-content with non-aggressive liver-disease and of low HBSAg-content with aggressive liver-disease in a single biopsy could not be found in our material in contrast to the literature. 34 patients were followed up through 4-6 years. Constant or improved liver-histology was associated with increased, deterioration with decreased HBSAg-tissue-content.

Screening for celiac disease: a prospective study on the value of noninvasive tests

OBJECTIVE

Celiac disease is frequently diagnosed in patients with nonspecific abdominal symptoms. Therefore, highly sensitive, specific, and simple noninvasive screening tests are needed.

METHODS

This study compared the usefulness of IgG- and IgA-antigliadin antibodies, IgA-endomysial antibodies, and intestinal permeability in diagnosing celiac disease in 102 adult patients with nonspecific abdominal symptoms. In addition, all patients underwent small bowel biopsy as a gold standard for the diagnosis of celiac disease.

RESULTS

Forty-nine patients were ultimately diagnosed as having celiac disease because of flat mucosa. Flatulence and signs and symptoms dating back to childhood were more frequent and abdominal pain less frequent (p < 0.05) in celiac disease but were not helpful for screening. IgA-endomysial antibodies showed a sensitivity and specificity of 100%; an altered intestinal permeability had also a 100% sensitivity, but only 55% specificity. IgG- and IgA-antigliadin antibodies' sensitivity (73% and 82%, respectively) and specificity (74% and 83%, respectively) were much lower. Combining the two antigliadin antibodies did not significantly improve the sensitivity and specificity.

CONCLUSIONS

Our data show the advantage of IgA-endomysial antibodies for screening of celiac disease except in the case of patients with IgA-deficiency or dermatitis herpetiformis. In these patients, the permeability test could improve noninvasive differential diagnosis.

[Ischaemic colitis (author's transl)]

Attention must be drawn to the fact that especially in elderly patients with acute onset of abdominal pain concomitant with haemorrhagic, mucous diarrhoea, ischaemic colitis must be considered in the differential diagnosis. Ischaemic colitis arises as a consequence of insufficient blood flow through the peripheral branches of the middle colic artery and inferior mesenteric artery and mostly strikes the left colonic flexure, the colon descendens or sigmoid. Because of the segmental involvement and the macroscopic appearance on X-ray and endoscopy the disease is sometimes indistinguishable from Crohn's disease or ulcerative colitis. In every day clinical life ischaemic colitis is a relatively rare phenomenon, in spite of the high incidence of arterial occlusive disease in the patients treated at this unit. The increasing frequency of ulcerative colitis in elderly patients, as reported in the literature, may be partly associated with unidentified cases of ischaemic colitis and this possibility is discussed.

[Clinical results with loperamide in the treatment of chronic diarrhoea of varied aetiology (author's transl)]

19 consecutive patients admitted with severe chronic diarrhoea which had failed to respond to standard therapeutic regimen were treated with 4 to 8 mg of loperamide daily for up to 50 weeks. A marked improvement was achieved in 13 out of the 19 patients (68%). The best results were observed in patients with ulcerative colitis and Crohn's disease. Patients with secretory diarrhoea did not improve. No major side effects were observed. It is concluded that loperamide is a highly effective and safe new drug in the treatment of patients with chronic inflammatory bowel diseases.

Portal hypertension and its prognostic implications in patients with Wilson's disease

BACKGROUND AND AIMS

Wilson's disease may progress to cirrhosis and clinically significant portal hypertension (CSPH). We aimed to assess the prevalence and prognostic impact of CSPH-related features on hepatic decompensation and transplant-free survival in patients with Wilson's disease.

METHODS AND RESULTS

About 137 patients with Wilson's disease (Leipzig score ≥4), followed for a median observation period of 9.0 (3.9-17.7) years at the Vienna General Hospital, were included in this retrospective study. Overall, 49 (35.8%) developed features of CSPH: 14 (10.2%) varices, 40 (29.2%) splenomegaly, 20 (14.6%) ascites, 18 (13.1%) hepatic encephalopathy and 3 (2.2%) experienced acute variceal bleeding. Overall, 8 (5.8%) patients died, including three deaths caused by CSPH-related complications. Within 10 years, compensated patients with features of CSPH developed more decompensation events (8.3% vs. 1.5% in patients without CSPH, p = 0.3) and had worse transplant-free-survival (91.7% vs. 98.6%), which further declined in patients with hepatic decompensation (26.7%, log-rank: p < 0.0001). Patients with liver stiffness <15 kPa and normal platelets (≥150 G/L) were less likely to decompensate within 10 years (2.6% vs. 8.4%, p = 0.002) and had a better 10-year transplant-free-survival (97.7% vs. 83.9%, p = 0.006).

CONCLUSIONS

Patients with Wilson's disease developing features of CSPH are at an increased risk for hepatic decompensation and liver-related mortality, warranting for regular screening and timely initiation of effective CSPH-directed treatments.

[Parenteral nutrition in liver diseases]

A total parenteral nutrition may particularly be used in patients with liver diseases, for comatous patients or postoperatively. By using central venous catheterization the practical application of high osmolar solutions, fat emulsions and amino acid mixtures is easy to be performed. Partial parenteral nutrition is needed mainly for decompensation of metabolic disturbances of amino acids in liver diseases. As carbohydrates particularly glucose is used, but because of the deranged glucose tolerance also fructose and glucose substitutes are given in mixed solutions. The infusion of fat emulsions partly covers the need of energy and on the other side prevents a lack of essential fatty acids. Recent investigations demonstrated that fat emulsions may be tolerated by patients with liver diseases and fat is utilized for energy metabolism. The changes of plasma amino acids in blood in patients with chronic liver diseases, especially in the stage with liver insufficiency, demands for a special amino acid solution. For the accomplishment of a total as well as for partial parenteral nutrition principles are given and relevant clinical problems are discussed.

[NOD2/CARD15 mutations and genotype-phenotype correlations in patients with Crohn's disease. Hungarian multicenter study]

Recently mutations of the NOD2/CARD15 gene were identified as genetic markers for Crohn's disease (CD). It has also been suggested that the presence of mutation may influence the phenotype of the disease. The aim of this study was to determine the frequency of common NOD2/CARD15 mutations in Hungarian Crohn's patients.

PATIENTS AND METHODS

DNA was obtained from 142 pts with Crohn's disease (70 male and 72 female, mean age: 36.2 yrs) and of 115 healthy subjects. Clinical data were obtained by filling in a questionnaire by the physician. DNA was screened for possible mutations by denaturing HPLC (WAVE Nucleic acid fragment analysis systems, Cheshire, UK) using published primers (Lesage et al, Am J Hum Gen 2002) for SNP's 8, 12, and 13. Mutations were then confirmed by direct sequencing on a ABI Prism 310 Genetic Analyzer (Perkin Elmer; Norwalk, USA).

RESULTS

Mutations of NOD2/CARD15 were significantly more frequent in patients (n = 42, 29.6%) than in controls (11.3%, p = 0.0007, OR = 3.3, 95% CI = 1.7-6.5). R702W and 3020insC mutations were significantly more common in IBD compared to controls (4.3% and 2.6%); 18 patients had the R702W mutation (12.7%, p = 0.001, 13 homozygous, one homozygous for R703C) and 22 the 3020insC (15.9%, p = 0.001, 4 homozygous). 7 patients (4.9%) were heterozygous for the G908R, which was not different from the controls (4.3%). 5 patients were compound heterozygous. The allele frequency of R702W (11.6% vs. 4.3%, p = 0.0026, OR = 5.9, 95% CI: 2.3-14.9) and 3020insC (9.1% vs. 2.6% p = 0.004, OR = 7.6, 95% CI = 2.4-24.0) was significantly higher in Crohn's disease compared to the controls. Age at presentation was not different between carriers and non-carriers (26.7 +/- [SD] 10.3 yrs vs. 27.7 +/- 11.8 yrs). There was a tendency of ileal location to be more common in carriers of the mutation (40.5% vs. 29.0%), while colonic location was less frequent (16.7% vs. 44%). The presence of the mutation did not affect disease behaviour (carrier: inflammatory: 30.9%, stenosing: 26.2%, penetrating: 42.9%, non-carrier: inflammatory: 36%, stenosing: 27%, penetrating: 37%). Among the extraintestinal manifestations arthritis (30.1% vs. 47%, p = 0.05) and primary sclerosing cholangitis (0% vs. 9%, p = 0.047%) was significantly less frequent in carriers of the mutation.

CONCLUSIONS

In concordance with European data we found a high number of NOD2/CARD15 R702W and 3020insC mutations in Hungarian patients with Crohn's disease. The G908R mutation was uncommon in Hungarian Crohn's patients. The presence of the mutation was associated with ileal but not with fibrostenosing disease and extraintestinal manifestations were less common in carriers of the mutation.

[Emergency endoscopy in patients with chronic alcohol abuse]

In this study we evaluated the findings of emergency endoscopy--carried out because of acute bleeding in the upper gastrointestinal tract--in 58 patients with chronic abuse of alcohol. These findings were compared with those bleeding sources which were seen within the emergency endoscopy of 199 patients without abuse of alcohol. Among the collective of the chronic alcoholics in 37,9% the bleeding lesion was found in the esophagus. In one third of the alcoholics with proved liver cirrhosis and esophageal varices another bleeding source than esophageal varices existed. In two patients of this collective, besides bleeding esophageal varices another more distally located bleeding source could be found. This shows the necessity to examine also stomach and duodenum in order to exclude an additional bleeding lesion, even when bleeding out of these varices is endoscopically proved. Erosive alterations in the area of the stomach and duodenum were observed very frequently when multiple lesions existed.

[Nutritional problems in diseases of the small and large intestine]

18 patients with inflammatory bowel disease, among them ten with ulcerative colitis and 5 with Crohn's disease, were treated with the combined enteral-parenteral synthetic hypercaloric nutrition. By use of Vivasorb the clinical results were rather good. However, it was impossible to normalize the serumalbumin until the application of the formula diet BSD, enriched in amino acids. These experiences with BSD reveal much better results. All patients recovered nearly completely from their complaints and the clinical parameters went back to normal. Furthermore, it is easier to improve the flavour. The typical mode therapy is demonstrated on one patient with ulcerative colitis and one with Crohn's disease.

[Therapy of chronic hepatitis C]

Interferon-alpha is still the only drug with antiviral activity against the hepatitis C virus. However, if the outcome of treatment is measured by highly sensitive virologic test, sustained response rates to interferon monotherapy are low, especially in patients infected with subtype 1 (3-10%). Therefore better therapies are needed. The combination of interferon with ribavirin is a major advance. Although the precise mode of action of ribavirin is unknown, it seems to decrease relapse rates after successful treatment. By combination therapy, 30% of patients with subtype 1 and 65% with subtype 3 had a sustained response. Further improvements can be expected from high-dose induction therapy and from long-acting pegylated interferons. Nonresponders may benefit from antifibrotic agents, like long-term interferon therapy, IL-10 or silymarin.

[Prognosis of liver cirrhosis: results of a 14-year-long clinical follow-up study]

The incidence of primary liver cancer (PLC) was assessed in 652 patients (429 male, 223 female) with liver cirrhosis. By the end of the study 64% of all patients had died. The autopsy rate was 65%. 138 patients (49%) died after acute gastrointestinal hemorrhage. PLC developed in 73 patients (11.3%). Histologically 67 cases were classified as hepatocellular, one as mixed hepatocellular-cholangiocellular, and 5 as cholangiocellular carcinoma. In 32 cases PLC was confirmed within a year of diagnosis of cirrhosis, while in the remaining 41 cases PLC developed 2 to 13 years later. At autopsy the frequency of PLC was twice as high in males (30%) as in females (15%) (p less than 0.025). This difference occurred in alcoholic and posthepatic cirrhosis but not in cryptogenetic cirrhosis. HBsAg was detected in 18.5% of male and 8.9% of female patients (p less than 0.01). Comparison of patients with and without PLC revealed no significant differences in the prevalence of HBsAg. These data indicate that PLC is common in Austrian patients with cirrhosis and represents 64% of all malignant tumors in this group. In view of the high HBsAg carrier rate and the prevalence of chronic alcoholism in patients with cirrhosis, it is suggested that both factors together lead to an increased risk of cirrhosis followed by an increased incidence of PLC. Survival curves show that that the prognosis of severe liver cirrhosis is the same as that of patients with malignant diseases. Therefore, it is important to detect these patients at an early stage of the disease.

HFE genotyping demonstrates a significant incidence of hemochromatosis in undifferentiated arthritis

OBJECTIVE

Hereditary hemochromatosis is a common autosomal recessive disorder of iron metabolism. Among Northern Europeans the carrier frequency is estimated to be 1 in 10, while up to 1 in 200 is affected by the disease. Arthropathy is one early clinical manifestation of this disease, but the articular features are often misdiagnosed. In this study the two frequent mutations of the HLA-linked hemochromatosis gene (HFE) were investigated in a rheumatology clinic population.

METHODS

Two hundred and six consecutive patients (mean age 57.7 years; 38 male/168 female) attending a rheumatology clinic over a period of 14 months were screened for HFE mutations (C282Y and H63D). All standard diagnostic procedures were used to identify the aetiology of the arthropathy. Mutations were evaluated by separation on PAGE of digested PCR amplificates of DNA (by SnapI and Bcl-I, for C282Y and H63D, respectively) obtained from PBMCs.

RESULTS

The C282Y and H63D allele frequencies were 4.5 and 12.8 in patients with rheumatic diseases. Five patients were homozygote for H63D (2.4%), and one for C282Y (0.5%). Five patients were compound heterozygous (2.4%). The observed C282Y allele frequency in rheumatic patients with undifferentiated arthritis was 12.9 and exceeded that of healthy subjects (p = 0.01).

CONCLUSIONS

Determination of the HFE genotype is clinically useful in patients with arthritis of unknown origin, to allow early diagnosis of hemochromatosis.

Rational use of polymerase chain reaction--based detection of viral genomes in patients with serologic markers of hepatitis B or C virus infection

We studied the value of additional diagnostic information obtained by detection of hepatitis B virus (HBV) DNA or hepatitis C virus (HCV) RNA using the qualitative polymerase chain reaction (PCR) in patients with serologic markers of hepatitis B or hepatitis C virus infection. In HBV infection, all HBsAg+HBeAg+ patients and all HBsAg+HBeAg- patients with alanine aminotransferase (ALT) levels > 100 U/L were positive for HBV-DNA by PCR, whereas in HBsAg+HBeAg- patients with ALT < 100 U/L 58% and in HBsAg+HBeAg- patients with normal aminotransferase 45% were found to be positive. In HBsAg+ patients no further clinically useful information can be obtained by PCR as the presence of HBsAg proves infection. However in three of 42 (7%) patients with markers of past HBV infection (antiHBs and/or antiHBc+) HBV-DNA was detected in the serum. Similarly, in some patients with acute hepatitis B HBV-DNA was demonstrable up to four months after the disappearance of HBsAg from serum, pointing to persistence of viremia despite the loss of serological markers of ongoing HBV infection. Demonstrating ongoing HBV infection in patients with serological markers of past infection is valuable additional information in only selected patients. In HCV infection, 10% of anti-HCV+ patients with increased ALT levels had a negative serum HCV-RNA. However, in 20% of those patients HCV-RNA was demonstrated in a serum sample collected later during follow-up, indicating that a single negative HCV-RNA determination cannot be taken as evidence for the resolution of infection.

Progress of Hepatitis C elimination in Viennese people living with HIV after two decades of increasing cure rates

BACKGROUND & AIMS

Interferon(IFN)-based hepatitis C virus (HCV) therapy has been replaced by direct-acting antivirals (DAAs). We assessed temporal trends in patient characteristics, transmission risks, treatment initiation, and cure rates in eras of IFN, restricted DAA-access, and unrestricted DAA-access in Viennese HCV/HIV-coinfected patients (HIV/HCV).

METHODS

Consecutive HIV/HCV-coinfected patients starting HCV treatment at the Vienna General Hospital between 2002 and 2020 were retrospectively enrolled.

RESULTS

Of all N = 508 HIV/HCV, 78% (398/508) were male and the mean age was 41.8 ± 9.5 years. 'People-who-inject-drugs' (PWID) accounted for 61% (311/508), while 31% (156/508) were 'men who have sex with men' (MSM). In the IFN-era, restricted DAA-era and unrestricted DAA-era, N = 152, N = 129, and N = 227 HCV treatments were started and 49% (74/152), 95% (122/129), and 88% (200/227) achieved sustained virologic response, respectively. Treatment during the IFN-era was a strong predictor for virologic non-response (aOR 12.69; 6.93-23.24) and loss-to-follow-up (aOR 6.12; 2.99-12.54), while virologic non-response was less common in 'MSM' (aOR 0.28; 0.13-0.62). Ninety three percent (50/54) of the observed HCV reinfections occurred in the unrestricted DAA-era. A substantial increase in 'MSM' transmission was observed since 2010 with 66% (107/161) in the DAA-era versus 15% (49/330) prior to the DAA-era.

CONCLUSIONS

HCV cure rates in Viennese HIV patients increased from 49% in the IFN-era to 88-95% in the DAA-era. MSM-related risk behaviour and reinfections became the key challenges towards HCV elimination in HIV-coinfected patients.