Neonatal cholestasis in Kashmiri children

Neonatal cholestasis is prolonged elevation of conjugated serum bilirubin (more than 20% of total bilirubin) beyond first 14 days of life. After extensive evaluation a diagnosis of either biliary atresia or neonatal hepatitis is made in 70-80% of cases. Neonatal hepatitis and biliary atresia form a pathophysiologic process directed at various levels of the hepatobiliary tract. Inflammation in the bile duct epithelium may result in the sclerosis and obliteration of the bile ducts and manifest as biliary atresia. Primary hepatocellular inflammation is more likely to result in neonatal hepatitis. Half of the cases of neonatal hepatitis resolve without sequelae, while most of the biliary atresia cases require surgical intervention for repair or, ultimately, liver transplant.

Opportunistic hepatic infections in AIDS patients with fever of unknown origin

The clinical features and histopathologic manifestations of hepatic opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS) in Taiwan remain unexplored. We report 28 AIDS patients (25 men, 3 women; mean age, 34 years) with fever of unknown origin who underwent 31 liver biopsies from December 1995 to May 1997. In most cases, the biochemical tests showed moderate to markedly elevated alkaline phosphatase concentrations, but normal or mildly elevated aminotransferase concentrations. The most common histopathologic finding was macrosteatosis, which was noted in 15 of the 28 patients. Another important histopathologic finding indicating the etiology of hepatic opportunistic infection was granuloma, which was found in 11 patients. Histochemical stain and culture of liver specimens yielded Mycobacterium avium complex (MAC) in eight patients, Mycobacterium tuberculosis in two patients, Histoplasma capsulatum in one patient, and cytomegalovirus in one patient with concomitant MAC infection. Therefore, a definitive diagnosis in AIDS patients with fever of unknown origin was made in 11 of the 28 cases with the assistance of liver biopsy. During follow-up, late extrahepatic involvement by the same infectious agents was found in six patients. Thus, hepatic manifestations could be a harbinger of disseminated opportunistic infections in AIDS patients.

A prospective review of laparoscopic cholecystectomy in Brunei

Brunei has a small population and a unique medical setup: The number of laparoscopic cholecystectomies (LCs) performed in our institution represents the total number of cases performed in this country. A prospective analysis of all the LCs performed in Brunei is presented. All 220 LCs performed between February 1, 1992, and November 30, 1996, were prospectively recorded on a detailed protocol. Analyses were made with respect to preoperative patient demography, intraoperative complications, and postoperative morbidity and mortality. Symptomatic gallstone disease was found to be common among the ethnic Nepalese population. In this series, nine patients required conversion to open surgery (4%). Acute cholecystitis comprised 21% of cases, and the mean operating time was longer in these cases (144.1 min) than in elective cases (101.2 min; P = 0.002). The overall morbidity was 5% with one ductal injury (0.5%). The mortality rate in this series was 0.5%. Our results of LC are favorable and comparable with those of published series. We conclude that LC has been successfully introduced into our institution. This study also represents an unofficial audit of the state of development of LC in Brunei.

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a review of diagnosis and management

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia that threatens the gravida and her fetus. In this report, the diagnostic criteria and maternal and fetal risks of HELLP are defined. Prompt recognition and treatment in tertiary centers is emphasized, because the prognosis can be adversely affected by delayed or less than optimal diagnosis and treatment. Management guidelines are offered for treating this disorder. The potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Subsequent pregnancy outcome, contraception, and preventative strategies are considered.

Gabapentin does not interact with a contraceptive regimen of norethindrone acetate and ethinyl estradiol

Anticonvulsants that induce hepatic metabolism increase clearance of oral contraceptive hormones and thereby cause contraceptive failure. Gabapentin is not metabolized in humans and has little liability for causing metabolic-based drug-drug interactions. In healthy women receiving 2.5 mg norethindrone acetate and 50 microg ethinyl estradiol daily for three consecutive menstrual cycles, concurrent gabapentin administration did not alter the steady-state pharmacokinetics of either hormone. Thus, gabapentin is unlikely to cause contraceptive failure.

The burden of viral hepatitis in Africa

The burden of viral hepatitis in Africa is difficult to quantify precisely because of inaccurate statistical data and under-reporting. Of the various agents causing viral hepatitis, data on hepatitis B virus have been relatively more available and suggest that 15 to 60 per cent of the normal population in many African countries may be positive for one or more of the serologic markers of hepatitis B virus infection, whilst the corresponding values for patients with PLCC ranged from 49 to 80 per cent. Liver disease was the third most common (12.1%) of all 4,568 deaths on the medical wards of the University College Hospital, Ibadan, Nigeria over a 14-year period. Of all causes of deaths from liver disease, PLCC alone accounted for 42.5% while liver cirrhosis accounted for 21.1% of the deaths and, in both disease, HBV was the commonest cause. PLCC, which accounted for 491 out of 100,000 admissions in that teaching hospital, was the commonest malignancy on the medical wards and was the commonest cause of deaths from cancers in middle-aged and elderly Nigerians. Recent reports suggest that the prevalence of Hepatitis C infection in normal Africans may be as high as 10.9% while the corresponding value for patients with PLCC would be about 18.7 to 38 per cent. There is a need for control of hepatitis particularly hepatitis B virus infection through health education, active immunization of all new-borns and other people at risk in Africa.

The contraceptive choice for a Wilson's disease patient with chronic liver disease

Preserved fertility status is frequently encountered in patients with Wilson's disease, and contraceptive counseling may, therefore, be a relevant issue. Yet, several contraceptive methods can adversely influence the hepatic function, and the efficacy of others may be affected by the liver disease. We describe a patient with Wilson's disease manifested by cirrhosis, portal hypertension, and bleeding esophageal varices who underwent termination of pregnancy at 9 weeks' gestation. Following the procedure, contraceptive advice was sought in order to postpone conception until portal hypertension was controlled and hepatic function improved. Intramuscular depot medroxyprogesterone acetate was administered and tolerated well by the patient. A detailed discussion of the contraceptive options for patients with chronic liver disease, in general, and Wilson's disease, in particular, follows the case report.

Seroprevalence of hepatitis E virus in an adult urban population from Burundi

The prevalence of antibodies to the hepatitis E virus (HEV) was measured in a group of 129 adults from Bujumbura, Burundi, using an ELISA. The prevalence of anti-HEV IgG was 14%, much lower than that of hepatitis A virus (HAV) (97.7%). In addition to the lability of antibodies to HEV, this difference might be explained by the extensive availability of good-quality drinking water in the city. The presence of serologic markers of HBV (77.6%), HCV (27.1%), and human immunodeficiency virus (30.2%) was not associated with that of anti-HEV.

Spectrum of liver diseases in HIV infection

BACKGROUND

Most earlier reports on the spectrum of liver diseases in HIV-infected individuals originated from the West.

OBJECTIVE

To study the spectrum of liver diseases in HIV-infected individuals.

METHODS

Seventy four consecutive HIV-positive patients (57 men; age range 23-75 years, mean 34) were studied prospectively with clinical evaluation, liver function tests, ultrasonography, radioisotope liver scan, markers of hepatitis B (HBV) and C (HCV) viruses, and liver histology whenever necessary.

RESULTS

Thirty four patients (45%) were chronic alcoholics. Mean (SD) absolute lymphocyte count was 2521 (1271)/mm3; count < 2000/ mm3 was present in 20 patients. Serum bilirubin, transaminases and alkaline phosphatase levels were elevated in 13%, 13% and 24% of patients, respectively. Ultrasonography detected an abscess in two patients (tuberculous-1, amebic-1). Evidence of exposure to HBV was present in 81% (HBsAg-12, hepatitis B core and/or surface antibody-48); anti-HCV antibody was positive in 29.7%. Five patients with liver tuberculosis (granuloma-4, abscess-1) had AFB either in liver tissue or lymph nodes.

CONCLUSION

Chronic alcoholism, HBV and HCV infection, hepatic tuberculosis, and evidence of other liver disease were common in patients with HIV infection.

Hepatitis C (HCV) genotype and viral titer distribution among Argentinean hemophilic patients in the presence or absence of human immunodeficiency virus (HIV) co-infection

Hepatitis C (HCV) infection is frequent among hemophilic patients treated with non-inactivated factor-concentrates. Both HCV genotype and viral load have been suggested to be important prognostic markers of disease progression and treatment outcome. In addition, co-infection with the human immunodeficiency virus (HIV) has been associated with increased level of HCV replication and higher risk of developing liver failure. Thus, HCV genotype, viral load, and HIV co-infection are important factors in HCV infection. Using restriction fragment length polymorphism analysis (RFLP) and the branched-DNA (bDNA) assay, we retrospectively investigated the HCV genotypes and viral loads present in 59 Argentinean hemophiliacs, in the presence or absence of HIV infection. HCV genotype 1 was the predominant viral variant detected among HIV-negative (HIV-) (76%) and HIV-positive (HIV+) (82.5%) patients, followed by genotypes 3 (10.4%), 2 (2%) and a small proportion of multiply co-infected patients including genotypes 4 and 5 (6.25%). HIV+ patients had higher plasma HCV RNA levels than HIV- patients (88.4 +/- 16.5 x 10(5) Eq/ml vs. 24.7 +/- 10(5) Eq/ml) (P < 0.001); however, no correlation between HCV replication and level of immune suppression, evaluated by CD4+ T-cell measurement, was observed among HIV+ patients (r = 0.017). Abnormal and higher ALT levels were more frequently detected among HIV+ (93%; 123.6 +/- 15.7 U/liter) than HIV- (41%; 70.2 +/- 24.2 U/liter) patients (P < 0.001; P < 0.05). Although we were able to confirm previous reports suggesting the existence of increased HCV replication in HIV/HCV co-infected hemophiliacs, our data did not support the conclusion that HIV-induced immune suppression is directly responsible for this phenomena. It is possible that other factors induced by HIV are responsible for the increased levels in HCV replication observed.

Combined oral contraceptives and liver disease

Although some information is available about the risk of liver tumors associated with combined oral contraceptive use, little is known about the relationship with other hepatic problems. Data from two large long-term observational studies, the Royal College of General Practitioners (RCGP) Oral Contraception Study and the Oxford-Family Planning Association (Oxford-FPA) Study, were used to examine this issue. Observations accumulated over a period of up to 27 years were available for each study. The incidence of liver disease in each study was low. There was no evidence of an increased risk of serious liver disease overall among current or former pill users. The RCGP study found a modest increased risk of mild liver disease associated with oral contraceptive use which declined after four years of use and after cessation of use. This increased risk occurred in women who had used oral contraceptives containing more than 50 micrograms of estrogen.

[Intestinal parasitosis and hepatic cirrhosis]

The authors describe their experience, in a prospective survey, with the prevalence rates of intestinal parasites in patients with hepatic cirrhosis admitted to the Gastroenterology Unit of University Hospital of Federal University in Juiz de Fora, Brazil, whose fresh stools were examined by Hoffman-Pons-Janner, Baermann-Moraes and Willis methods. They compare the results of stool exams with two control groups and look for a relation with cirrhosis' etiology. A higher prevalence of some parasites was observed in cirrhosis than in people with other digestive diseases (group I). mainly for the Strongyloides stercoralis, found in 40.2%, chiefly in alcoholic cirrhosis. Oddly no one of the group I admitted in the same period had strongyloidiasis. Another group including all the people who had stool samples examined in the same period at the hospital had 1.91% of that helmintic infection (group II). A comparison is also made with the prevalence in schoolchildren between the ages of 7 and 14 studies eight years before (13.16%). Other parasites were also observed in different incidence between those with cirrhosis and the other groups and the results are presented. They conclude that hepatic cirrhosis must be included in the list of conditions which increases the risk of Strongyloides stercoralis infection.

p53 mutations in hepatocellular carcinoma related to oral contraceptive use

Oral contraceptives (OCs) are implicated in the development of hepatocellular carcinoma (HCC). Mitogenic stimulation may be the primary mechanism of tumorigenesis, but other factors may also contribute. Mutational spectrum analysis can provide insights into pathogenesis, therefore we analyzed the p53 tumor suppressor gene in 10 HCCs from women with a history of OC use. All were non-Asians whose average OC use was 6.7 years (range 2 months-13 years) and whose mean age at HCC diagnosis was 48.8 years (range 21-67 years). Each tumor was analyzed by immunohistochemistry, DNA sequencing and allelic deletion analysis. Three tumors were positive by p53 immunohistochemistry; allelic deletion analysis identified loss of heterozygosity in one of four informative cases. Two p53 point mutations were found in one tumor containing moderately and well-differentiated components; this patient was negative for all serological markers of hepatitis B and C infections. Both components showed p53 protein accumulation and a GTTval-->GCTala mutation at codon 274. In addition, a silent mutation (ACCthr-->ACTthr) at codon 140 of the p53 gene was detected in the moderately differentiated component of the tumor. These preliminary data indicate that p53 mutations are uncommon in OC-related HCCs. One of the two detected mutations was a G:C-->A:T transition at a non-CpG site, which is characteristic of DNA damage by free radicals. These data support a model whereby estrogens contribute to HCC development primarily through mitogen stimulation and secondarily by mutagenesis via hydroxyl radicals produced during estrogen metabolism. Confirmational analysis of a larger series is warranted.

A young female with a cholangiocarcinoma in the past: is pregnancy allowed?

BACKGROUND

A 28-year-old woman developed a cholangiocarcinoma after using oral contraceptives for eight years. The common bile duct and the gallbladder were removed and four hepaticojejunostomies were performed.

RESULTS

Seven years after surgery no evidence of disease recurrence is detectable and the patient wants advice regarding her wish for pregnancy.

CONCLUSION

The possible role of oestrogens in the development of cholangiocarcinoma makes it difficult to give an adequate advice. As in patients with breast cancer in the past, it seems reasonable to admit pregnancy in our patient, because of a disease-free interval of longer than five years.

Hormonal oral contraceptives, urinary porphyrin excretion and porphyrias

The influence of hormonal oral contraceptives on the urinary porphyrin excretion of 40 healthy females has been studied. Two different hormonal oral contraceptives (combinations of gestoden or desogestrel, respectively, and ethinylestradiol) were applied for half a year. In each case twenty women received one of these two combinations. Porphyrin precursors delta-aminolevulinic acid and porphobilinogen were normal in all subjects as well as the mean of uroporphyrin and coproporphyrin. One healthy female developed a mild secondary coproporphyrinuria. In this case coproporphyrin isomer I was slightly enhanced and isomer III slightly lowered. Furthermore it could be shown that three females with repeated premenstrual clinical expression of an acute hepatic porphyria (acute intermittent porphyria and hereditary coproporphyria) could be treated successfully with a hormonal oral contraceptive or other exogenous hormones to stabilize the latent, subclinical phase of the disease.

The effects of nomegestrol acetate subdermal implant (Uniplant) on carbohydrate metabolism, serum lipoproteins and on hepatic function in women

This study was undertaken to assess possible variations in body weight, blood pressure, fasting glucose, HbA1C, insulin, total cholesterol, HDL-C, LDL-C, triglycerides, SGPT, SGOT, GGT and bilirubin in women bearing a single subdermal Silastic implant containing 55 mg (10%) of nomegestrol acetate during two years. A total of eighteen volunteers of reproductive age who desired to avoid conception were enrolled in this study. Subjects were healthy women with no contraindications to hormonal contraception. All women were investigated before starting treatment and were followed up for one year. At the end of one year the capsules were removed and a new capsule was inserted. Fasting blood samples were drawn at 8:00 to 8:30 am twice prior to implant insertion and then at the first, third, sixth and twelfth months and every six months thereafter. Body weight increased from 54.9 +/- 1.5 kg at admission to 55.3 +/- 2.0 kg at 12 months of use (p < 0.05) and to 56.0 +/- 2.7 kg at 24 months of use. A slight increase in both systolic and diastolic blood pressure was recorded at month 12 (p < 0.01). At month 24, blood pressure was not significantly different from admission values. All levels were within the normal range. Insulin, HbA1C, LDL-C and GGT remained unchanged during twenty-four months of Uniplant use. A significant decrease in total cholesterol (p < 0.05) was observed in the third month while a significant decrease in HDL-C (p < 0.01) was observed only in the sixth month of Uniplant use.(ABSTRACT TRUNCATED AT 250 WORDS)