Metabolites of arachidonic acid and linoleic acid in early stages of non-alcoholic fatty liver disease--A pilot study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of liver conditions related to fat infiltration. The role of liver triacylglycerol accumulation in NAFLD is not fully understood.

METHODS

Twenty-four patients, 12 in the first and 12 in the second stage of NAFLD, were prospectively enrolled in this study. Biochemical parameters and eicosanoids (HETE and HODE) were compared between the first and the second stage of hepatic steatosis and the effect of a 6-month dietary intervention on these parameters was evaluated. Eicosanoid profiles were extracted from 0.5 ml of plasma using solid-phase extraction RP-18 SPE columns. The HPLC separations were performed on a 1260 liquid chromatograph.

RESULTS

Patients with stage I NAFLD had a significantly higher level of HDL cholesterol and a lower level of 5-HETE. Patients with grade II steatosis had higher concentrations of 9-HODE. Following the six-month dietary intervention, hepatic steatosis resolved completely in all patients. This resulted in a significant decrease in the concentrations of all eicosanoids (LX4, 16-HETE, 13-HODE, 9-HODE, 15-HETE, 12-HETE, 5-oxoETE, 5-HETE) and key biochemical parameters (BMI, insulin, HOMA-IR, liver enzymes).

CONCLUSION

A significant reduction in the analyzed eicosanoids and a parallel reduction in fatty liver confirmed the usefulness of HETE and HODE in the assessment of NAFLD.

Prospective evaluation of PBC-specific health-related quality of life questionnaires in patients with primary sclerosing cholangitis

BACKGROUND & AIMS

Primary biliary cirrhosis and Primary sclerosing cholangitis are autoimmune cholestatic liver diseases sharing a lot in common, including a significant impairment of patients' health-related quality of life HRQoL HRQoL in PBC is assessed with disease-specific PBC-40 and PBC-27 questionnaires. A PSC-specific questionnaire has not been developed. Neither PBC-40 nor PBC-27s applicability for PSC has been evaluated. We applied these three questionnaires for HRQoL assessment in a large homogenous cohort of PSC patients.

PATIENTS AND METHODS

This cross-sectional study enrolled 102 Caucasian PSCs and 53 matched healthy controls and measured HRQoL using generic SF-36, and disease-specific (PBC-40/PBC-27) questionnaires.

RESULTS

(i) SF-36. Most SF-36 domains were significantly lower in PSCs than controls. Physical Functioning and Mental Component Summary scores were significantly lower in female patients and correlated negatively with age but not with concurrent inflammatory bowel disease. Cirrhosis was associated with lower Physical Functioning, Role Physical, General Health, Vitality and Physical Component Summary. (ii) PBC-40 and PBC-27. Both tools showed similar HRQoL impairment scoring. Fatigue and Cognitive were impaired in female patients. Several correlations existed between HRQoL and laboratory parameters, including cholestatic tests and Itch. Cirrhosis correlated with Other symptoms and Fatigue PBC-40. (iii) PBC-40 vs PBC-27. Strong correlations among most domains of both questionnaires were seen, as well as between (iv) SF-36 vs PBC-40 or SF-36 vs PBC-27.

CONCLUSION

This is the first study directly comparing PBC-40, PBC-27 and SF-36 in PSC. PSC patients, especially females, show HRQoL impairment. PBC-40 and PBC-27 questionnaires could be of potential use for HRQoL assessment in PSC.

Female Sex But Not Original Indication Affects Physical Activity After Liver Transplant: A Prospective, Single Center Study

OBJECTIVES

Physical activity has an effect on long-term recovery after major surgical operations including liver transplant. Seven-Day Physical Activity Recall Questionnaire is a semistructured survey that assesses an individual's time spent in physical activity, strength, and flexibility activities during the 7 days prior to the interview. In this study we applied the Seven-Day Physical Activity Recall Questionnaire in patients who underwent liver transplant in our center.

MATERIALS AND METHODS

We surveyed 107 consecutive patients (62 male and 45 female), who were ≥ 6 months after liver transplant. Patients were divided into 3 groups, depending on time after liver transplant: group A (n = 21), 6 to 12 months posttransplant; group B (n = 48), 13 to 36 months posttransplant; and group C (n = 38), > 37 months posttransplant. Relations were analyzed between physical activity and various factors including sex, age at procedure and survey, time after grafting, original diagnosis, and body mass index.

RESULTS

Female patients were significantly less active in daily and weekly measurements (981 ± 212 kcal vs 1267 ± 229 kcal; P < .0001) (6864 ± 1484 kcal vs 8866 ± 1607 kcal; P < .0001). There was a negative correlation between physical activity and age at transplant (P = .02) and survey (P = .02). Neither the time after liver transplant nor the original diagnosis before grafting affected physical activity.

CONCLUSIONS

Female patients, when assessed with Seven-Day Physical Activity Recall Questionnaire, were significantly less physically active than male subjects after liver transplant. Younger patients were more active, but primary diagnosis had no significant effect on physical activity after grafting.

Evolution Of The Results Of 1500 Liver Transplantations Performed In The Department Of General, Transplant And Liver Surgery Medical University Of Warsaw

Liver transplantation is a well-established treatment of patients with end-stage liver disease and selected liver tumors. Remarkable progress has been made over the last years concerning nearly all of its aspects. The aim of this study was to evaluate the evolution of long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw).

MATERIAL AND METHODS

Data of 1500 liver transplantations performed between 1989 and 2014 were retrospectively analyzed. Transplantations were divided into 3 groups: group 1 including first 500 operations, group 2 including subsequent 500, and group 3 comprising the most recent 500. Five year overall and graft survival were set as outcome measures.

RESULTS

Increased number of transplantations performed at the site was associated with increased age of the recipients (p<0.001) and donors (p<0.001), increased rate of male recipients (p<0.001), and increased rate of piggyback operations (p<0.001), and decreased MELD (p<0.001), as well as decreased blood (p=0.006) and plasma (p<0.001) transfusions. Overall survival was 71.6% at 5 years in group 1, 74.5% at 5 years in group 2, and 85% at 2.9 years in group 3 (p=0.008). Improvement of overall survival was particularly observed for primary transplantations (p=0.004). Increased graft survival rates did not reach the level of significance (p=0.136).

CONCLUSIONS

Long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery are comparable to those achieved in the largest transplant centers worldwide and are continuously improving despite increasing recipient age and wider utilization of organs procured from older donors.

The impact of fragility fractures on health-related quality of life in patients with primary sclerosing cholangitis

BACKGROUND

Osteoporosis occurs frequently in patients with chronic cholestatic liver diseases, yet data are scarce regarding the prevalence of osteoporosis and fragility fractures and their impact on Health-Related Quality of Life (HRQoL) in Primary Sclerosing Cholangitis (PSC).

OBJECTIVES

We aimed to assess Bone Mineral Density (BMD), physical activity and incidence of fragility fractures in patients with PSC. We also sought associations between prior fractures and HRQoL.

PATIENTS AND METHODS

The study was performed on 33 patients (11 females, 22 males) aged 35.3 ± 13 years. HRQoL was assessed by Short Form (SF)-36, Primary Biliary Cirrhosis (PBC)-40 and PBC-27 questionnaires. BMD was measured by densitometry in the lumbar spine and hip. Physical activity was assessed by questionnaire.

RESULTS

In 32% of patients, BMD measured in the hip or spine was below 1.0 Standard Deviation. A history of fragility fractures (distal forearm and ribs) was reported in six patients (18%). In SF-36 assessment, patients with fractures had lower scores in the role functioning, general health and vitality domains and Physical Component Summary (PCS) than those without fractures. Prior fractures adjusted for gender and PSC duration were associated with lower PCS and Mental Component Summary (MCS) scores. Symptoms and fatigue (assessed by PBC) and prior fractures were inversely associated with MCS (P = 0.007).

CONCLUSIONS

In middle-aged subjects with PSC, we found a high rate of non-vertebral fractures and a moderately decreased BMD in lumbar spine and hip. Fragility fractures had an impact on physical and mental aspects of HRQoL.

Fatty acid changes help to better understand regression of nonalcoholic fatty liver disease

AIM: To investigate whether liver steatosis reduction due to a six-month dietary intervention results in significant changes in the concentrations of fatty acids.

METHODS: A group of 35 Caucasian individuals diagnosed with different levels of steatosis were prospectively enrolled in the present study. Analysis of the fatty acid profiles was performed according to changes in liver steatosis (liver steatosis reduction by one or two degrees) after a six-month dietary intervention. The diet helped reduce body mass in obese and overweight patients, and stabilize both glycemia and dyslipidemia. Fatty acids were extracted according to the Folch method and analyzed by gas chromatography.

RESULTS: This study showed significant changes in fatty acid profiles in patients who had reduced liver steatosis by one as well as two degrees. A reduction in liver steatosis by one degree caused a significant increase in the level of the n-3 family: eicosapentaenoic acid (P < 0.055), docosapentaenoic acid-C 22:5 (P < 0.05) and docosahexaenoic acid (P < 0.05). A reduction in liver steatosis by two degrees caused a significant decrease in serum palmitoleic acid-C 16:1 (P < 0.05).

CONCLUSION: Liver steatosis reduction is associated with changes in fatty acid profiles, and these changes may reflect an alteration in fatty acid synthesis and metabolism. These findings may help better understand regression of nonalcoholic fatty liver disease.

Prospective evaluation of ursodeoxycholic acid withdrawal in patients with primary sclerosing cholangitis

Ursodeoxycholic acid (UDCA) is no longer recommended for management of adult patients with primary sclerosing cholangitis (PSC). We undertook a prospective evaluation of UDCA withdrawal in a group of consecutive patients with PSC. Twenty six patients, all treated with UDCA (dose range: 10-15 mg/kg/day) were included. Paired blood samples for liver biochemistry, bile acids, and fibroblast growth factor 19 (FGF19) were collected before UDCA withdrawal and 3 months later. Liquid chromatography/tandem mass spectrometry was used for quantification of 29 plasma bile acid metabolites. Pruritus and health-related quality of life (HRQoL) were assessed with a 10-point numeric rating scale, the Medical Outcomes Study Short Form-36 (SF-36), and PBC-40 questionnaires. UDCA withdrawal resulted in a significant deterioration in liver biochemistry (increase of alkaline phosphatase of 75.6%; P<0.0001; gamma-glutamyl transpeptidase of 117.9%, P<0.0001; bilirubin of 50.0%, P<0.001; alanine aminotransferase of 63.9%, P<0.005; and aspartate aminotransferase of 45.0%, P<0.005) and increase of Mayo Risk Score for PSC (change from baseline of +0.5 point; P<0.003). Bile acid analysis revealed a significant decrease in lithocholic acid and its derivatives after UDCA withdrawal, but no effect on concentrations of primary bile acids aside from an increased accumulation of their taurine conjugates. After UDCA removal cholestatic parameters, taurine species of cholic acid and chenodeoxycholic acid correlated with serum FGF19 levels. No significant effect on HRQoL after UDCA withdrawal was observed; however, 42% of patients reported a deterioration in their pruritus.

CONCLUSION

At 3 months, discontinuation of UDCA in patients with PSC causes significant deterioration in liver biochemistry and influences concentrations of bile acid metabolites. A proportion of patients report increased pruritus, but other short-term markers of quality of life are unaffected.

Synchronous and metachronous neoplasms in gastric cancer patients: a 23-year study

AIM

To determine the prevalence and characteristics of additional primary malignancies in gastric cancer (GC) patients.

METHODS

GC patients (862 total; 570 men, 292 women; mean age 59.8 ± 12.8 years) diagnosed at the Department of Gastroenterology at Pomeranian Medical University over a period of 23 years were included in this retrospective analysis of a prospectively maintained database. Mean follow-up time was 31.3 ± 38.6 mo (range 1-241 mo). The following clinicopathological features of patients with synchronous tumors were compared to those with metachronous tumors: age, sex, symptom duration, family history of cancer, tumor site, stage (early vs advanced), histology, and blood group. GC patients with and without a second tumor were compared in terms of the same clinicopathological features.

RESULTS

Of 862 GC patients, 58 (6.7%) developed a total of 62 multiple primary tumors, of which 39 (63%) were metachronous and 23 (37%) synchronous. Four (6.9%) of the 58 multiple GC patients developed two or more neoplasms. The predominant tumor type of the secondary neoplasms was colorectal (n = 17), followed by lung (n = 9), breast (n = 8), and prostate (n = 7). Age was the only clinicopathological feature that differed between GC patients with synchronous vs metachronous malignancies; GC patients with synchronous neoplasms were older than those with metachronous neoplasms (68.0 ± 10.3 years vs 59.9 ± 11.1 years, respectively, P = 0.008). Comparisons between patients with and without a second primary cancer revealed that the only statistically significant differences were in age and blood group. The mean age of the patients with multiple GC was higher than that of those without a second primary tumor (63.4 ± 11.4 years vs 59.5 ± 13.0 years, respectively, P = 0.026). GC patients with a second primary tumor were more commonly blood group O than those without (56.2% vs 31.6%, respectively, P = 0.002).

CONCLUSION

GC patients may develop other primary cancers; appropriate preoperative and postoperative diagnostic modalities are thus required, particularly if patients are older and blood group O.

Apolipoprotein E4 allele is associated with substantial changes in the plasma lipids and hyaluronic acid content in patients with nonalcoholic fatty liver disease

Fat may affect progression of liver damage in patients with non-alcoholic fatty liver disease (NAFLD). In this study we characterize the state of lipid metabolism in 22 patients with NAFLD and different Apo-E variants. Total concentration of plasma total fatty acids was quantified by gas chromatography, while their derivatives by liquid chromatography/tandem mass spectrometry (LC ESI MS/MS). The ratio of plasma saturated fatty acid to monounsaturated fatty acid increased, whereas the ratio of polyunsaturated fatty acids to saturated fatty acids was reduced in Apo-E4 carriers. Simultaneously, the levels of individual plasma linoleic, arachidonic, and alpha linolenic acids significantly increased in subjects with the Apo-E4 allele. The 15-lipoxygenase metabolite, 13-hydroxyoctadecadienoic acid, was significantly higher in Apo-E3 carriers (p<0.006). 5-oxo-6,8,11,14-eicosatetraenoic acid was significantly elevated in Apo-E4 carriers (p<0.009). A significant difference in hyaluronic acid concentration (p<0.0016) as well as predicted advanced fibrosis (using the BARD scoring system) was found in Apo-E4 carriers (p<0.01). We suggest that a distinct mechanism of fibrosis between Apo E alleles. In Apo-E4 carriers, an elevation in 5-oxo-6,8,11,14-eicosatetraenoic acid synthesis and fatty acid dysfunction may induce fibrosis, while an inflammatory process may be the main cause of fibrosis in Apo-E3 carriers.

Primary Budd-Chiari syndrome - a single center experience

BACKGROUND/AIMS

Budd-Chiari syndrome (BCS) is recognized as a clinical manifestation of various prothrombotic conditions which may be lethal within 3 years of the onset of symptoms if untreated. This study is a retrospective analysis of patients with BCS managed between 2004 and 2011.

METHODOLOGY

The diagnosis was confirmed with contrast CT-angiography and/or Doppler ultrasound.

RESULTS

BCS was diagnosed in 20 patients (11 females and 9 males), median age 38 years (ranging from 18 to 56). Twelve patients were referred as acute BCS for the liver transplant (LTx) assessment. Thrombosis of the hepatic veins was caused by myeloproliferative disorders (n=8), end-stage liver disease (n=4), protein C deficiency (n=3), paroxysmal nocturnal hemoglobinuria (PNH) (n=1), antiphospholipid syndrome (n=1) and secondary poliglobulia (n=1). In two patients the origin of BCS could not be established despite appropriate screening. Median follow-up was 29 months. Low molecular heparin with subsequent conversion to vitamin K antagonists was routinely applied in all patients. Two patients underwent TIPS procedure with good long term outcome and 10 subjects received LTx; 1 patient was lost to follow-up and 1 died of chest infection 9 years since the diagnosis of BCS was made; 14 patients, including those who received LTx, were alive and well at least one year after BCS diagnosis. All survivors remain stable and are followed-up on a regular basis.

CONCLUSIONS

Strict adherence to the diagnostic and therapeutic guidelines plays a crucial role in the management of BCS patients. Our results confirm the efficacy of anticoagulation as well as TIPS and/or OLT in treatment of this rare condition.

Lipidic last breath of life in patients with alcoholic liver disease

Alcoholic liver disease (ALD) begins with the accumulation of lipid droplets in the liver. Lipids which accumulate in the liver can stimulate inflammation, and the fatty acid derivatives, hydroxyeicosatetraenoic acids (HETEs) and hydroxyoctadecadienoic acids (HODEs), may play an important role in this process. We evaluated the concentrations of linoleic and arachidonic acid derivatives in the plasma of patients with ALD, non-alcoholic fatty liver disease (NAFLD) and healthy individuals. The groups consisted of 173 subjects: 63 patients with ALD, 90 with NAFLD and 20 healthy volunteers. Plasma 12-, 15-, and 5-HETE as well as 9- and 13-HODE were assessed using HPLC and isoprostane 8-epi-PGF 2α III was evaluated with an ELISA. In addition the mRNA expression of lipoxygenases (5-LOX, 15-LOX-1, 15-LOX-2) in the liver samples of patients with ALD cirrhosis was measured. A significant difference between the plasma concentrations of the analyzed derivatives was found when divided according to gender. The most significant differences were found between healthy individuals and ALD patients, as well as ALD and NAFLD individuals regardless of gender. The increased plasma HODEs and HETEs concentrations were in line with the increase in 5- and 15-LOX-1 and 15-LOX-2 mRNA in liver samples from ALD cirrhosis patients. LOXs expression and peroxidation of polyunsaturated fatty acids by free radical-propagated chemical oxidation may be contributing factors in liver necroinflammatory injury in ALD.

[Wilson's disease]

Wilson's disease is caused by a P-type ATP-ase gene mutations with reduced biliary copper excretion and accumulation copper in the liver and other tissues. Clinical symptoms can be heterogeneous but in many cases on the first stage the only abnormalities is elevation of aminotransferase activity. In some cases the first fatal symptom of disease is acute liver failure, therefore early diagnosis and treatment is essential. We present an actual recommendations for diagnosis and treatment of patients with Wilson's disease.

Validation of the BARD scoring system in Polish patients with nonalcoholic fatty liver disease (NAFLD)

Abtract

Nonalcoholic fatty liver disease and HFE gene mutations: A Polish study

AIM: To describe a Polish population with nonalcoholic fatty liver disease (NAFLD) with regard to HFE gene mutations, as well as analyzing demographic and clinical data.

METHODS: Sixty-two consecutive patients with biopsy-proven NAFLD were included in the study. Demographic, clinical, and laboratory data were summarized in a database. C282Y and H63D mutations of the HFE gene were analyzed using polymerase chain reaction-restriction fragment lenght polymorphism.

RESULTS: The analyzed cohort consisted of 62 homogeneic Caucasian participants, 66.1% men and 33.9% women, with a median age of 48 years. The median body mass index was 29.05 kg/m². Hypercholesterolemia was observed in 74.2% of patients and hypertriglyceridemia in 32.2%; 16.1% had type 2 diabetes mellitus (DMt2). On liver biopsy, 22.6% of NAFLD patients were found to have severe fibrosis. There were no differences between frequencies of HFE gene mutations in subgroups of NAFLD patients with less and more severe liver fibrosis. Obesity, older age, female gender and DMt2 were associated with more advanced fibrosis in this Polish cohort, as well as higher glucose level, serum iron and transaminase aspartate aminotransferase/alanine aminotransferase ratio.

CONCLUSION: HFE mutations conferred no additional hepatic fibrosis risk in NAFLD, but higher serum iron was a risk factor for severe liver damage in NAFLD, regardless of HFE mutations.

[Portal biliopathy presenting itself as a massive vericeal bleeding--case report]

This article presents a rare case of portal biliopathy, a secondary cholangiopathy, in a young man whose first clinical manifestation was bleeding from esophageal varices. Portal biliopathy may mimic primary sclerosing cholangitis and it can develop secondary to portal vein thrombosis usually acquired in early childhood. Narrowing and dilatation of biliary tree develops as a consequence of compression of common bile duct by collaterals. Clinical symptoms are mainly cholestatic jaundice and abdominal pain. Complications include recurrent cholangitis and secondary biliary cirrhosis. The article provides information on the pathogenesis, clinical symptoms and treatment of portal biliopathy and problems related to differential diagnosis with primary sclerosing cholangitis (PSC).

HFE gene mutations in patients with alcoholic liver disease. A prospective study from northwestern Poland

INTRODUCTION

Hereditary hemochromatosis has been linked with C282Y and H63D mutations of the HFE gene encoding human hemochromatosis protein. It is genetic disorder of iron metabolism, leading to iron accumulation and increased liver fibrosis. The association between alcoholic liver disease (ALD) and HFE gene mutations remains unclear and requires clarification.

OBJECTIVES

The aim of the study was to determine the prevalence of C282Y and H63D mutations in patients with ALD and healthy individuals and to analyze laboratory data in the context of HFE gene mutation in ALD patients.

PATIENTS AND METHODS

We analyzed 119 patients with ALD. The control group comprised 1516 DNA samples obtained either from cord blood or healthy subjects from the records of general practitioners. HFE mutations were detected using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method.

RESULTS

Among the ALD patients, 0.84% were homozygous and 3.36% were heterozygous for the C282Y mutation, while 5.04% were homozygous and 21.85% heterozygous for the H63D mutation. There was 1 C282Y/H63D compound heterozygote in the ALD group. In the control group, 2 homozygotes and 117 heterozygotes for the C282Y mutation were identified. As for the H63D mutation, 2.5% homozygotes, 25% heterozygotes, and 1.4% compound heterozygotes were found. There was a trend towards a more common occurrence of ALD patients homozygous for the H63D mutation. Patients with H63D genotype had higher total and low-density lipoprotein cholesterol.

CONCLUSIONS

The prevalence of HFE mutations in ALD patients is similar to that observed in healthy subjects and comparable to the prevalence in other Central European countries. Our findings on lipid disturbances in the H63D heterozygotes are potentially interesting and require further studies on larger patient groups.

Assessment of a modified Child-Pugh-Turcotte score to predict early mortality after liver transplantation

OBJECTIVE

The Model for End-Stage Liver Disease (MELD) predicts mortality on the transplant list; however, it has not been of much use to predict posttransplant outcomes. Several prognostic models have been tested among patients with cirrhosis; nevertheless, their predictive value has not been established in the posttransplant setting. We recently modified the Child-Pugh-Turcotte (CPT) score by adding creatinine levels (CPT + Cr), which has proven useful for patients with alcoholic cirrhosis. This retrospective analysis sought to predict early (1 month) mortality using CPT + Cr versus 5 other prognostic models in patients who underwent orthotopic liver transplantation (OLT) at our center.

MATERIALS AND METHODS

We included 48 consecutive patients (30 males, 18 females, median age 51 years). The predictive values of CPT + Cr were compared with CPT scores without or with the Huo modification, CPT + Na, MELD, and MESO, which is the MELD to serum Na ratio. Pearson correlations and ROC curves as evidenced by the area under the curve (AUC) were determined for each index. P < .05 was considered to be significant.

RESULTS

CPT + Cr showed the highest correlation with the risk of death (r = .368, P = .01); MELD and MESO were the lowest (r = .204, P = NS; and r = .254, P = NS, respectively). ROC analysis showed the best predictive value of CPT and CPT-Crea with AUC of 0.758 (P = .010) and 0.748 (P = .011) respectively, as compared to 0.689 for MESO and 0.659 for MELD (both NS).

CONCLUSIONS

A modified CPT score with creatinine levels may be of value to predict early death after OLT. Its usefulness must be validated in a prospective study of a large patient cohort.

Modified Charlson Comorbidity Index in predicting early mortality after liver transplantation

BACKGROUND

The Charlson Comorbidity Index for orthotopic liver transplantation (CCI-OLT) is a modified clinical score recently proposed to be useful for the assessment of long-term survival after OLT. It includes 9 associated conditions selected upon a multivariate analysis of a large cohort of transplant recipients. Its role in predicting early mortality after OLT has not yet been investigated. We sought to CCI-OLT as a potential predictor of 1-month mortality after OLT.

MATERIALS/METHODS

One hundred ninety-seven OLT were performed in our center between March 2002 and February 2009. After exclusion of patients who underwent transplantation for fulminant hepatic failure or those who underwent regrafting, we included a group of 169 patients. Viral (39%) and alcohol-induced (23%) cirrhosis were the most common indications for OLT. The CCI-OLT index was assessed in all patients.

RESULTS

In total, 146 (86%) subjects survived and 23 (14%) died within 1 month after LT. Fifty-one (30%) patients suffered at least 1 comorbidity that was included in the CCI-OLT. Direct comparison between survivor versus nonsurvivor groups showed no significant difference in terms of the total frequency of comorbidities (30.1% vs 30.4%; P > .99) or the number or the type of comorbidity. The most commonly associated condition in both groups was diabetes mellitus.

CONCLUSION

Unlike the case of long-term survival, CCI-OLT did not seem to predict early (1-month) mortality after OLT.

Ligation of oesophageal varices may increase formation of "deep" gastric collaterals

BACKGROUND/AIMS

Endosonography (EUS) is rarely used in the routine diagnostic of portal hypertension in patients with cirrhosis even though it has significantly higher sensitivity for detection of varices than gastroduodenoscopy. The aim of this cross-sectional study was to assess the features of portal hypertension identified with EUS and to analyze the effect of variceal ligation on the prevalence of "deep" varices in subjects with cirrhosis.

METHODOLOGY

A cohort of 121 patients was divided into 2 groups depending on whether they had a history of variceal bleeding treated with ligation or not.

RESULTS

"Deep" oesophageal varices and large (> 5 mm) gastric varices occurred significantly more common in patients with previous banding. Also, large "deep" gastric varices occurred significantly more common in the banded group with no or small varices than in the not-banded group with similar endoscopy. Sixty percent of banded patients who had grade II/III oesophageal varices on endoscopy had large "deep" gastric varices comparing to 20% of not-banded with the same endoscopical findings (p = 0.04).

CONCLUSION

Previous banding may increase the risk of the development of large "deep" oesophageal and gastric varices. Thus potential new indication for EUS in patients with cirrhosis could be a follow-up examination after successful eradication of varices.

Partington-rochelle pancreaticojejunostomy for chronic pancreatitis: analysis of outcome including quality of life

BACKGROUND/AIMS

Obstruction of the main pancreatic duct in chronic pancreatitis (CP) leads to an increased intraductal and intraparenchymal pressure causing pain. In this study we evaluated the outcome of surgical treatment of CP including the quality of life following Partington-Rochellepancreaticojejunostomy (PRP) performed for intractable pain.

METHODOLOGY

Between July 2002 and May 2008, PRP was performed in 17 patients in whom the diameter of the main pancreatic duct exceeded 7mm and there was no inflammatory tumor in the pancreatic head. Perioperative morbidity and mortality were analyzed in all patients. The long term outcome including the quality of life (Karnofsky index) was evaluated in 9 patients who were followed with a mean 28 (range 13-60) months since surgery.

RESULTS

Complications in the postoperative period were found in 3 (18%) patients including 1 death due to a myocardial infarction shortly after surgery. All patients submitted to the long-term evaluation reported a significant (p < 0.0001) pain reduction by an average of 6.2 (5-8) points in a 10-points visual analogue scale. The Karnofsky index increased significantly from a mean 52% (40-70%) before surgery up to 82% (70-90%) following surgery and long-term.

CONCLUSIONS

PRP leads to a substantial quality of life improvement in patients with CP.

[Benign solid tumors of the liver--review of current knowledge]

Benign solid tumors of the liver may be one of the great diagnostic difficulties among the hepatic problems. The most common of them are: haemangiomas, adenomas, nodular regenerative hyperplasia (NRH) and focal nodular hyperplasia (FNH). There are several useful ways of imaging for those lesions (USG, CT, MR), which are helpful in decision-making and further management. This article presents a summary of the main information on benign solid tumors of the liver based on internet database MEDLINE. Also, it contains some proceedings of treatment and control for patients with those lesions, which can help to differentiate benign and malignant hepatic tumors.

[Recurrent variceal bleeding in a patient with portal and splenic vein thrombosis secondary to complex thrombophilia]

Thrombophilia in adults is one of main causes of portal vein thrombosis. Esophageal and gastric varices, ascites and hypersplenism are well known complications of portal hypertension. There are controversial issues on the management, especially anticoagulant therapy and surgical treatment of these patients. We present a 42-years old woman with a history of three acute coronary episodes suffering from recurrent variceal bleeding due to portal and splenic vein thrombosis in the course of myeloproliferative disorder and protein C deficiency. It was 10 months delay of diagnosis. She was successfully treated with medical and surgical treatment (esophageal stapler transection, cardial devascularization, and splenectomy). In the paper we discuss complexity of diagnosis and surgical treatment.

[Non invasive markers of non-alcoholic steatohepatitis]

Non-alcoholic steatohepatitis (NASH) is a part of the spectrum of non-alcoholic fatty liver disease (NAFLD), which can progress to hepatic cirrhosis and end-stage liver disease or hepatocellular carcinoma (HCC). Its pathogenesis is associated with insulin resistance (IR) and the metabolic syndrome. Hepatic steatosis has also been considered an early marker of IR. It is now accepted that NASH is a multistep process with a prominent role for IR, where oxidative stress and cytokines retain a central role. Markers for predicting NAFLD with advanced fibrosis are needed. Once considered irreversible, liver fibrosis is now recognized a dynamic process with significant prospects for remission. The liver biopsy is still a gold standard in assessment of liver fibro-inflammatory activity in the injured liver, but has its own limitations: invasiveness, small tissue sample and inter- and intra-observer error. The lack of non-invasive tests limits the ability of monitoring progression of hepatic fibrosis and response to treatment. Therefore, clinical trials focused on finding of new non-invasive diagnostic tools giving possibilities of frequent, more accurate and reproducible assessment of hepatic fibrosis are constantly conducted.

[Non-alcoholic fatty liver disease--new view]

Non-alcoholic fatty liver disease (NAFLD) covers a wide spectrum of liver pathology--from steatosis alone, through the necroinflammatory disorder of non-alcoholic steatohepatitis (NASH) to cirrhosis and liver cancer. NAFLD/NASH is mostly related with visceral adiposity, obesity, type 2 diabetes melitus (DM t.2) and metabolic syndrome. Pathogenetic concepts of NAFLD include overnutrition and underactivity, insulin resistance (IR) and genetic factor. The prevalence of NAFLD has been estimated to be 17-33% in some countries, NASH may be present in about 1/3 of such cases, while 20-25% of NASH cases could progress to cirrhosis. NAFLD is now recognized as one of the most frequent reason of liver tests elevation without clinical symptoms. Insulin resistance is considering as having a central role in NAFLD pathogenesis. In hepatocytes, IR is related to hyperglycaemia and hyperinsulinaemia, formation of advanced glycation end-products, increased free fatty acids and their metabolites, oxidative stress and altered profiles of adipocytokines. Early stages of fatty liver are clinically silent and include elevation of ALT and GGTP, hyperechogenic liver in USG and/or hepatomegaly. Among clinical symptoms, abdominal discomfort is relatively common as well as chronic fatigue. NAFLD/NASH is not a benign disease, progressive liver biopsy have shown histological progression of fibrosis in 32%, the estimated rate of cirrhosis development is 20% and a liver--related death is 12% over 10 years. No treatment has scientifically proved to ameliorate NAFLD or to avoid its progression. The various therapeutic alternatives are aimed at interfering with the risk factors involved in the pathogenesis of the disorder in order to prevent the progression to end-stage liver disease. The most important therapeutic measure is increasing insulin sensitivity by an attempt to change a lifestyle mostly by dieting and physical activity in order to loose weight. The most used agent is metformin, the others are under controlled trials or their effectiveness is low. NASH is not a common indication for liver transplantation because of the older age distribution of patients and high prevalence of comorbidity, related to metabolic syndrome. Recurence of NASH in the grafted liver is also a relatively frequent complication.

[Novel aspects of pathogenesis of hereditary hemochromatosis]

Patients with hereditary hemochromatosis (HC) may present a plenty of clinical symptoms, thus are referred to various specialists and may prone a significant diagnostic dillema. The molecular basis of hemochromatosis is more complex than expected. In 1996 HFE gene was identified and its main mutations (C282Y and H63D) were described as well as their high frequency in population of European descent. Them: Most patients with clinical symptoms of hemochromatosis are homozygous for C282Y but it is also clear that some families are linked to rarer conditions, named "non-HFE hemochromatosis". Between 2000-2004 other genes involved in iron homeostasis were intensively studied, leading to recognition of hepcidin (HAMP) - the most important iron hormone, hemojuvelin (HJV), transferin receptor 2 (TfR2) and ferroportin. Recent findings led to novel hypothesis on potential digenic modes of inheritance or the involvement of modifier genes. Hepcidin plays a central role in mobilization of iron, HFE, TfR2 and HJV playing a modulating role in its production, related to the body's iron status. It has also been demonstrated that HAMP negatively regulates cellular iron efflux by affecting the ferroportin cell surface availability. The result of such a wide investigations is OMIM classification of hereditaty hemochromatosis, typing four types of the disease.