Grading and staging systems for inflammation and fibrosis in chronic liver diseases

Liver biopsy is an important part of the evaluation of patients with a variety of liver diseases. Besides establishing the diagnosis, the biopsy is often used to assess the severity of the disease in terms of both grade and stage. The stage in most chronic liver diseases relates to the degree of scarring with the end stage being cirrhosis with its clinical complications. The grade relates to the severity of the underlying disease process, with features that vary with the pathogenetic mechanisms. Chronic viral hepatitis has been the object of the most extensive efforts at grading and staging, stimulated by the advent of new forms of therapy. Systems have also been developed for fatty liver disease, allograft rejection and chronic cholestatic diseases, but these have not been as widely used. Simple grading and staging systems for chronic hepatitis, including the IASL, Batts-Ludwig, and Metavir systems, are most appropriate for management of individual patients, while more complex systems such as the Histology Activity Index (HAI) are appropriate for evaluation of large cohorts of patients when statistical analysis is required.

Intraoperative transhepatic biliary catheter insertion technique for biliary reconstruction: early results

Biliary complications are critical problems in liver transplantation. Herein, we retrospectively analyzed the early results of an intraoperative transhepatic biliary catheter insertion technique for biliary reconstruction. Since November 2004, we have used this technique in 66 patients (32 children and 34 adults). In the new technique, a 5- F Kumpe catheter is inserted into the biliary system in 2 steps. One step is completed at the back table; the second step is completed during the recipient operation. Fourteen patients received whole-liver grafts, 25 received a right lobe, and 27 received a left-lateral or a left lobe. The mean graft weight-to-body weight ratio in the living-donor liver transplantations was 1.6% +/- 1.0% (range, 0.8%-4.1%). Intraoperative transhepatic biliary catheter insertion was performed with a duct-to-duct anastomosis in 60 patients and with a Roux-en-Y hepaticojejunostomy in 6 patients. Five biliary complications occurred in 4 patients. Two of these 4 patients had bile leakage from the anastomotic site during the early postoperative period. Biliary stenoses developed at the anastomotic site in 2 patients and from a nonanastomotic site in 1 patient in the late postoperative period. In conclusion, this new technique of biliary reconstruction with intraoperative biliary catheter insertion has significantly reduced our complication rate. Transhepatic biliary stenting seems to prevent biliary complications and makes it simple to maintain percutaneous access in the event that problems arise. Intraoperative transhepatic biliary catheter insertion at the back table is a safe means of providing good biliary drainage after liver transplantation.

[A study of the influences of blood sugar levels on the prognosis of fulminating hepatitis patients]

OBJECTIVE

To explore the possible relationship between hypoglycemia and the prognosis of fulminating hepatitis patients.

METHODS

Fasting blood sugar levels of 322 fulminating hepatitis patients were retrospectively analyzed. The blood sugar levels and their clinical significance were appraised together.

RESULTS

In all the samples, 173 were hypoglycemic (53.73%). The mortality rate of the hypoglycemia group was 48.55% (84/173), therefore the blood sugar level was lower and the mortality rate was higher.

CONCLUSION

A higher proportion of fulminating hepatitis patients have hypoglycemia. There is a close relationship between hypoglycemia and the prognosis of the fulminating hepatitis patients. Blood sugar level has an important clinical value in reflecting the degree of liver failure in early fulminating hepatitis patients.

The use of protein tyrosine phosphatase 1B and insulin receptor immunostains to differentiate nonalcoholic from alcoholic steatohepatitis in liver biopsy specimens

Nonalcoholic steatohepatitis (NASH) and alcoholic steatohepatitis (ASH) and typically are indistinguishable, histologically. The diagnosis relies on reporting of alcohol consumption. The metabolic syndrome involving insulin resistance is associated with nonalcoholic fatty liver disease (NAFLD). Protein tyrosine phosphatase 1B (PTP1B) negatively regulates the insulin receptor (IR). Increased PTP1B expression is seen in obesity and possibly is responsible for the insulin resistance seen in the metabolic syndrome. The study objective was to determine whether biopsy specimens with steatohepatitis could be classified accurately as alcoholic or nonalcoholic by immunohistochemical stains. We selected 241 cases of steatohepatitis, comprising 53 and 188 cases of alcoholic and NAFLD, respectively. Specimens were stained with PTP1B and IR (b subunit) and classified as NASH or ASH. The staining pattern predicted 60 cases of ASH and 181 cases of NASH. Results correlated with clinical diagnoses in 70% and 88% of ASH and NASH cases, respectively (odds ratio, 16.6; 95% confidence interval, 8.2-35.4).

Review of 31 Cases of Morphologic Hepatitis in Liver Transplant Patients Not Related to Disease Recurrence

AIMS

We examined the clinical and pathologic features of morphologic hepatitis occurring after liver transplantation (LT) that is unrelated to disease recurrence.

METHODS

Between February 1998 and December 2003, 704 primary LTs were performed at our center. Patients transplanted for diagnoses with low risk of disease recurrence were considered for our study (n = 282). Those with hepatitis C (HCV), hepatitis B (HBV), primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and autoimmune hepatitis (AIH) were excluded. Those with morphologic hepatitis comprised our case series and had medical records reviewed for clinical associations, duration, and outcome.

RESULTS

Thirty-one cases were identified. They were transplanted for cryptogenic cirrhosis (n = 13), steatohepatitis (n = 12), alpha-1-antitrypsin deficiency (n = 3), tumor (n = 2), and acetaminophen toxicity (n = 1); 22 cases (67%) presented within the first 8 months post-LT (range, 0.5-72 months). Histological activity was mild in 19 and moderate in 12. Associated conditions were identified in 19 patients (57%) with 3 categories being identified: probable drug toxicity (n = 7), systemic infection (n = 4), and mechanical or hemodynamic abnormalities (n = 8). Of the 25 cases that underwent follow-up biopsy 2 to 32 months (mean, 15.5 months) after the index biopsy, 10 cases had resolution and 15 cases had persistence of the infiltrate. One patient had evidence of de novo HBV infection.

CONCLUSIONS

Morphologic hepatitis occurred in 11% of patients at low risk for disease recurrence. Associated conditions could be grouped into three categories: drug toxicity, systemic infection, and mechanical or hemodynamic factors. Most cases did not appear to progress or improved over time, with no allograft loss occurring as a result of chronic hepatitis.

Mechanisms of liver injury: an overview

Liver cirrhosis, an end-result of a wide variety of the liver diseases, is a world wide health problem. Because of its unique organ system, i.e., portal blood supply, bile formation and enterohepatic circulation, drug metabolism system, and sinusoidal lining cells such as Kupffer, endothelial and stellate cells, the liver is a target of a variety of hepatotoxic insults. Current data suggest that hepatocyte apoptosis is an essential feature contributing to liver injury in a wide range of acute and chronic liver diseases. With an improved understanding of the pathophysiological role of apoptosis in liver diseases, we are now entering an era where regulation of liver cell apoptosis is becoming a therapeutic possibility. Inhibition of hepatocyte apoptosis using a variety of different strategies may be therapeutically beneficial in liver injuries, such as alcoholic hepatitis, non-alcoholic steatohepatitis (NASH), viral hepatitis, and cholestatic liver diseases. Considering the link between hepatocyte apoptosis and liver fibrosis, inhibition of hepatocyte apoptosis may also be an anti-fibrotic therapeutic strategy. Moreover, selective induction of apoptosis of activated stellate cells would be a unique approach to induce the resolution the phase of liver fibrosis. These concepts merit further clinical and basic investigation.

[Cut-off period of subclassification and pathological features of severe hepatitis based on clinical and pathological analyses]

BACKGROUND

To explore the cut-off period of subclassification and pathological features of severe hepatitis (SH).

METHODS

Based on combined clinical and pathological analyses, the complete clinical and biopsy or autopsy liver tissues data from 196 cases of patients with severe hepatitis were investigated. Meanwhile, proliferative hepatocytes, cholangioepithelia and collagens were identified by a panel of monoclonal antibodies such as those against albumin, cytokeratin 18,19 and collagen I, III with immunohistochemical method.

RESULTS

The clinical and pathological analyses indicated the cut-off periods of acute, subacute and chronic SH (ASH,SSH and CSH) were (13.4+/-7.2) d, (77.4+/-69.3) d and (80.5+/-63.2) d, respectively. Among all SH cases, one case of ASH patient presented clinical manifestation and pathological changes of ASH for 21 days, however, one patient with SSH was demonstrated 12 day course by histological examination. The time of cut-off period between ASH and SSH in child cases was shorter than that in adult cases. Histologically, ASH liver tissues showed massive and/or submassive necrosis caused by one attack, with congestive sinusoid frameworks and proliferative cholangioepithelium-like hepatocytes, while SSH liver tissues presented combined fresh and old submassive or massive necrosis caused by multiple attacks, accompanied by obviously proliferative bile ducts and sinusoid framework collapse.However, the pathological changes of CSH showed ASH- or SSH-like lesions on the background of chronic liver injury.

CONCLUSION

Our data indicated that the cut-off period between ASH and SSH is in accordance with the Scheme of Viral Hepatitis Prevention and Therapy, China, published in 2000, but excluded a part of child SH cases. In our study, the authors found a few pathological features in ASH and SSH.

[Validation of international autoimmune hepatitis group scoring system for diagnosis of type 1 autoimmune hepatitis in Korea]

BACKGROUND/AIMS

There are no pathognomonic features of autoimmune hepatitis (AIH). Its diagnosis requires the exclusion of various other conditions. The aim of this study was to validate indirectly the International Autoimmune Hepatitis Group (IAHG) scoring system in diagnosing AIH.

METHODS

Twenty-six patients with Type 1 AIH and female patients with chronic hepatitis B (n=34), chronic hepatitis C (n=25), or toxic hepatitis (n=13) were evaluated according to 9 categories of pretreatment minimum required parameters proposed by IAHG. Aggregate scores of AIH to those of non-AIH groups, which were assessed before and after extracting the proportions of etiologic factors, were also compared and evaluated.

RESULTS

While aggregate scores of non-AIH groups, before extracting the proportions of etiologic factors, were 5.2+/-1.8, 5.6+/-1.1, and 7.4+/-1.2 in that order, those of AIH groups were 12.8+/-1.7. These were significantly higher than those of non-AIH groups (p<0.01). All patients in AIH groups and only 1 patient in a non-AIH group showed aggregate scores of more than 10. Aggregate scores after extracting the proportions of etiologic factors were more than 4 in all, except 2, patients. These should have been consistent with 10 if there were no etiologic factors in non-AIH groups.

CONCLUSION

The IAHG scoring system might have a relatively excessive importance to the scores of categories excluding distinct etiologies from AIH. It might be difficult to differentiate AIH from chronic liver diseases of indistinct cause based on the IAHG scoring system.

Circulating soluble vascular adhesion protein 1 accounts for the increased serum monoamine oxidase activity in chronic liver disease

BACKGROUND & AIMS

Vascular adhesion protein 1 (VAP-1) is an endothelial glycoprotein that supports adhesion of lymphocytes to hepatic endothelium and has sequence homology with semicarbazide-sensitive amine oxidases (SSAOs). We investigated whether soluble VAP-1 (sVAP-1) displays SSAO activity and thereby accounts for increased monoamine oxidase activity in the serum of patients with liver diseases.

METHODS

sVAP-1 concentration and SSAO activity were measured in peripheral, hepatic, and portal blood and in bile from patients with liver disease and in peripheral blood of control subjects, using enzyme-linked immunosorbent assay and enzymatic assays.

RESULTS

sVAP-1 concentration (mean [+/-SE], 143. 67 [34.97-92.67] ng/mL) and SSAO activity (18.8 [12.0-24.6] nmol. mL(-1). h(-1)) were significantly increased in chronic liver diseases compared with healthy controls (87.1 [53.5-127] ng/mL [P<0.001] and 10.7 [6.5-12.7] nmol. mL(-1) x h(-1) [P<0.05]) but not in massive necrosis caused by paracetamol poisoning (109 [80.3-140] ng/mL and 8.9 [5.7-12.3] nmol. mL(-1) x h(-1)). sVAP-1 correlated with serum transaminase and bilirubin but not with creatinine. In 5 paired samples, sVAP-1 concentration was higher in hepatic (median, 113 [range, 53-122]) than in portal vein (102 [42-109]; 2P<0.05), and was not detected in bile. There was a highly significant correlation between serum sVAP-1 and SSAO activity in normal subjects, patients with acute liver failure, and those with chronic liver disease (r = 0.895; P<0.001). When serum was depleted of sVAP-1 by immunoaffinity chromatography, SSAO activity was eliminated.

CONCLUSIONS

sVAP-1 levels are increased in chronic liver disease, and sVAP-1 is likely derived from the liver. Serum sVAP-1 displays SSAO activity and accounts for most of the monoamine oxidase activity in human serum.

[Reevaluation of the nomenclature and diagnostic criteria in 477 patients with severe hepatitis]

OBJECTIVE

To explore the possibility of establishing more reasonable nomenclatures and diagnostic criteria for patients with severe hepatitis (SH) through analyzing clinical data of 477 cases of SH.

METHODS

The clinical characteristics and outcomes of SH were analyzed according to different criteria.

RESULTS

Chronic severe hepatitis (CSH) made up 88.5% of total cases of SH. The survival rate in the patients with hepatic encephalopathy was much lower than that without hepatic encephalopathy. About 1/5 of cases of subacute severe hepatitis (SSH) and CSH had neither ascites nor hepatic encephalopathy. When the period of 2 weeks was used in replace of 10 days for the diagnosis for acute severe hepatitis (ASH), the newly added cases were consistent with the characteristics of ASH.

CONCLUSION

We suggest dividing SH into 2 types: encephalopathy and non-encephalopathy by using the nomenclature of fulminant hepatitis and severe type hepatitis, respectively. The late-onset form should be added besides of acute form and subacute form. It seems to use the period of 2 weeks as the new definition of onset time for ASH. The criteria of dividing SH into 3 forms, i.e. ascites, encephalopathy and ascites plus encephalopathy, and the nomenclature recommended by the International Association for the Study of the Liver Subcommittee are not satisfactory when used in clinical cases. The typing of CSH remains to be clarified.

Sequence variability in the putative coding region of TT virus: evidence for two rather than several major types

Recently a new human virus, TT virus (TTV) was identified in the serum of a patient with post-transfusion hepatitis of unknown aetiology. Comparative sequence analysis of a 222 nt fragment of ORF 1 of TTV was performed to assess the genomic variability of this virus. Phylogenetic analysis of the nucleotide sequences of 76 TTV isolates collected in 17 countries segregated them into two major groups: TTV 1 and TTV 2. The TTV 1 group comprised two distinct subgroups, which corresponded to previously described TTV subtypes 1a and 1b. The TTV 2 group was separated into four main branches, two of which included sequences previously provisionally attributed as TTV types 2 and 3. Bootstrap resampling, however, did not support the reliability of this grouping, suggesting that the isolates in the TTV 2 group should be considered as subtypes of a single type rather than different TTV types.

Nomenclature of chronic hepatitis: the new look

The new recommendations for nomenclature, grading, and staging of chronic hepatitis and related biliary and other disorders are attempts to standardize the criteria and simplify the terminology used in making these diagnoses. It is hoped that an emphasis on the etiology as part of the diagnosis will eliminate the previous association with poor prognosis that was implied with a diagnosis of CAH. The inclusion of a system of grading and staging, whether it is numerical or descriptive, simple or complex, matters less than the need for it to communicate important information about the degree of necroinflammatory activity (grade) and the extent of the disease (stage of fibrosis) that are likely factors of prognostic and therapeutic significance.

Present status of autoimmune hepatitis in Japan--correlating the characteristics with international criteria in an area with a high rate of HCV infection. Japanese National Study Group of Autoimmune Hepatitis

BACKGROUND/AIMS

A nationwide survey of autoimmune hepatitis (AIH) was carried out in Japan.

METHODS

Four hundred and ninety-six patients were enrolled by questionnaires sent to 101 hospitals with hepatology specialists.

RESULTS

The clinical features of Japanese AIH were as follows: most patients were middle-aged women; serum autoantibodies, especially antinuclear antibody, were frequently positive, serum IgG level was high, and HLA-DR4 was the major HLA allotype. Liver-kidney microsomal type 1 antibody was positive in nine of 79 patients tested. Eight of these antibody positive patients were also positive for antinuclear antibody and five for anti-smooth muscle antibody. Ninety-two percent of the patients showed piecemeal necrosis and 60% bridging necrosis; plasma cell infiltration in the portal areas was observed in 50% of the patients. Only 12.3% were diagnosed as having liver cirrhosis. A favorable effect of corticosteroid, normalization of serum transaminases, was observed in 89% of 317 patients, who were treated with an initial dose of over 30 mg/day. Sixty-two patients were positive for hepatitis C virus (HCV) markers. In these patients, however, only one patient was liver-kidney microsomal type 1 antibody positive. Corticosteroid was effective in 30 (81%) of 37 HCV-marker-positive patients treated with this agent. Thus the efficacy of corticosteroid did not differ from that in AIH patients without HCV infection (90%). Similarly, interferon treatment was used in 20 patients, all of whom were positive for HCV-RNA, and resulted in 50% efficacy as determined by normalization of the serum transaminase level 6 months after treatment. The International Diagnostic Scoring System for the diagnosis of AIH worked well in these patients, except for HCV-infected individuals, that is, approximately 10% of the total of AIH patients.

Hepatitis

Hepatitis is a diagnosis that can easily be missed by the physician. The morbidity of this disease is significant when one takes into account all the cases that either do not have a typical presentation or are misdiagnosed. The emergency physician bears substantial responsibility in the diagnosis and intervention of patients with hepatitis, and needs to develop a systematic way of approaching the patient with a viral syndrome or other vague complaints that will allow appropriate consideration of this diagnosis.