Overlap of autoimmune hepatitis and primary sclerosing cholangitis: an evaluation of a modified scoring system

BACKGROUND/AIM

Recently, the scoring system for the diagnosis of autoimmune hepatitis (AIH) was modified by the International AIH Group. Our aim was to determine the prevalence of AIH in patients with cholangiographically proven primary sclerosing cholangitis (PSC) using this new scoring system.

METHODS

A total of 211 PSC patients were evaluated.

RESULTS

Three (1.4%) patients scored more than 15 points ('definite' AIH); 13 (6%) patients scored between 10 and 15 points ('probable' AIH); the remaining 195 (93%) patients had less than 10 points, allowing the exclusion of AIH. The separation of patients with PSC plus AIH from patients with PSC alone was based mostly on serum levels of total globulins (p=0.01), IgG (p=0.001), titers of autoantibodies (p<0.001) and histologic score (p<0.001). Using the older scoring system, four (2%) patients met the criteria for the diagnosis of PSC plus 'definite' AIH and 40 (19%) the diagnosis of PSC plus 'probable' AIH.

CONCLUSIONS

Overlap of PSC and AIH occurs rarely. The new scoring system seems to more precisely define the potential overlap syndrome between PSC and AIH, although further modification of the new scoring system may provide even better discrimination among these conditions.

Magnetic resonance cholangiography in patients with biliary disease: its role in primary sclerosing cholangitis

BACKGROUND/AIM

Magnetic resonance cholangiography (MRC) is a non-invasive diagnostic procedure whose role in the management of patients with primary sclerosing cholangitis (PSC) is unclear. The aim of this study was to determine the usefulness of MRC in the evaluation of the biliary tree in patients with suspected biliary disease, and in particular, PSC.

METHODS

MRC and invasive cholangiography (ERCP or PTC) were both performed in 73 patients, (33 male, 40 female, mean age 56 years) with clinical and/or biochemical evidence of cholestasis. Images were interpreted by two radiologists unaware of the results of other studies.

RESULTS

Forty-two patients (58%) had benign biliary disease, including 23 patients (32%) with PSC; 9 patients (12%) had malignant biliary disease; and 22 patients (30%) had a normal biliary tree. Diagnostic quality images were obtained in 73/73 (100%) of MRC, and in 70/73 (96%) of invasive cholangiography (68 ERCP's, 2 PTC's) procedures. Using ERCP/PTC findings as the reference standard, MRC had an accuracy greater than 90% in the diagnosis of normal bile ducts, biliary dilatation, biliary obstruction, bile duct stones, and PSC. Using the final diagnosis, MRC had an overall diagnostic accuracy of 90% in the detection of biliary disease compared to 97% for invasive cholangiography. Additional diagnostic/therapeutic interventions were performed during ERCP in 73% of patients with PSC and in 43% of patients without PSC (p=0.02).

CONCLUSIONS

MRC has excellent diagnostic accuracy in the presence of biliary disease. Because of its noninvasive nature, MRC may have advantages over invasive cholangiography when diagnosis is the major goal of the procedure.

Magnetic resonance cholangiography in patients with biliary disease: its role in primary sclerosing cholangitis

BACKGROUND/AIM

Magnetic resonance cholangiography (MRC) is a non-invasive diagnostic procedure whose role in the management of patients with primary sclerosing cholangitis (PSC) is unclear. The aim of this study was to determine the usefulness of MRC in the evaluation of the biliary tree in patients with suspected biliary disease, and in particular, PSC.

METHODS

MRC and invasive cholangiography (ERCP or PTC) were both performed in 73 patients, (33 male, 40 female, mean age 56 years) with clinical and/or biochemical evidence of cholestasis. Images were interpreted by two radiologists unaware of the results of other studies.

RESULTS

Forty-two patients (58%) had benign biliary disease, including 23 patients (32%) with PSC; 9 patients (12%) had malignant biliary disease; and 22 patients (30%) had a normal biliary tree. Diagnostic quality images were obtained in 73/73 (100%) of MRC, and in 70/73 (96%) of invasive cholangiography (68 ERCP's, 2 PTC's) procedures. Using ERCP/PTC findings as the reference standard, MRC had an accuracy greater than 90% in the diagnosis of normal bile ducts, biliary dilatation, biliary obstruction, bile duct stones, and PSC. Using the final diagnosis, MRC had an overall diagnostic accuracy of 90% in the detection of biliary disease compared to 97% for invasive cholangiography. Additional diagnostic/therapeutic interventions were performed during ERCP in 73% of patients with PSC and in 43% of patients without PSC (p=0.02).

CONCLUSIONS

MRC has excellent diagnostic accuracy in the presence of biliary disease. Because of its noninvasive nature, MRC may have advantages over invasive cholangiography when diagnosis is the major goal of the procedure.

Overlap of autoimmune hepatitis and primary sclerosing cholangitis: an evaluation of a modified scoring system

BACKGROUND/AIM

Recently, the scoring system for the diagnosis of autoimmune hepatitis (AIH) was modified by the International AIH Group. Our aim was to determine the prevalence of AIH in patients with cholangiographically proven primary sclerosing cholangitis (PSC) using this new scoring system.

METHODS

A total of 211 PSC patients were evaluated.

RESULTS

Three (1.4%) patients scored more than 15 points ('definite' AIH); 13 (6%) patients scored between 10 and 15 points ('probable' AIH); the remaining 195 (93%) patients had less than 10 points, allowing the exclusion of AIH. The separation of patients with PSC plus AIH from patients with PSC alone was based mostly on serum levels of total globulins (p=0.01), IgG (p=0.001), titers of autoantibodies (p<0.001) and histologic score (p<0.001). Using the older scoring system, four (2%) patients met the criteria for the diagnosis of PSC plus 'definite' AIH and 40 (19%) the diagnosis of PSC plus 'probable' AIH.

CONCLUSIONS

Overlap of PSC and AIH occurs rarely. The new scoring system seems to more precisely define the potential overlap syndrome between PSC and AIH, although further modification of the new scoring system may provide even better discrimination among these conditions.

Cetirizine-induce cholestasis

Cetirizine, a human metabolite of hydroxyzine, is a selective H1-receptor antagonist currently approved for the treatment of seasonal allergic rhinitis, perennial allergic rhinitis, and chronic urticaria. In U.S. clinical trials, transient reversible hepatic transaminase elevations were observed in <2% of patients during cetirizine therapy. We report a case of cetirizine-induced cholestasis in a 28-year-old man with no previous hepatobiliary disease after a 2-year period of taking cetirizine on a daily basis. The treatment of this patient included the use of ursodeoxycholic acid, as well as hydroxyzine, for symptomatic relief of pruritus. In light of the patient's clinical and biochemical improvement while using hydroxyzine, it appears that the hepatic metabolism of hydroxyzine to metabolites, including cetirizine, is not involved in the pathogenesis of this particular case of drug-induced hepatotoxicity. Cetirizine should be considered as a potential cause of drug-induced cholestasis.

Oral budesonide in the treatment of primary sclerosing cholangitis

OBJECTIVE

This study was designed to evaluate the safety and estimate the efficacy of oral budesonide in patients with primary sclerosing cholangitis (PSC).

METHODS

Twenty-one patients with PSC were treated with 9 mg daily of oral budesonide for 1 yr.

RESULTS

Significant, but marginally important, improvement in serum alkaline phosphatase (1,235 +/- 190 vs 951 +/-206 U/L, p = 0.003) and AST levels (119 +/- 14 vs 103 +/- 19 U/L, p = 0.02) was noted at the end of the treatment period. Serum bilirubin levels increased significantly in the 18 patients who completed 1 yr of treatment (1.1 +/- 0.1 vs 1.4 +/- 0.3, p = 0.01) and no significant changes in liver tests were noted 3 months after budesonide was discontinued. The Mayo risk score did not change significantly, and although a significant improvement in the degree of portal inflammation was noted at the end of the treatment period, the degree of fibrosis and stage of disease were not significantly affected. There was a marked loss of bone mass of the femoral neck (0.851 +/- 0.02 vs 0.826 +/- 0.02 g/cm2, p = 0.002) and lumbar spine (1.042 +/- 0.02 vs 1.029 +/- 0.02 g/cm2, p = 0.09) at 1 yr of treatment with budesonide. Two patients required evaluation for liver transplantation during treatment, and two patients developed cosmetic side effects.

CONCLUSIONS

Oral budesonide appears to be of minimal, if any, benefit and it is associated with a significant worsening of osteoporosis in patients with PSC.

The timing of liver transplantation in primary biliary cirrhosis

Primary biliary cirrhosis, the most common chronic cholestatic liver disease in adults, usually progresses to cirrhosis and its complications. Ursodeoxycholic acid therapy delays disease progression, but most patients will ultimately succumb. Liver transplantation is now accepted as the standard treatment for end-stage PBC. Development of major complications of portal hypertension and liver failure, poor quality of life and short survival without transplantation are the major indications for this surgical intervention in patients with primary biliary cirrhosis. Resource use is another key variable to be considered in the timing of liver transplantation. Prognostic models have been developed to predict survival and resource utilization with and without liver transplantation. Prognostic models aid the clinician in the selection and timing of liver transplantation in the patient with primary biliary cirrhosis.

Serum autoantibodies in patients with primary sclerosing cholangitis

BACKGROUND/AIM

Primary sclerosing cholangitis is a chronic cholestatic syndrome with a presumed autoimmune basis frequently associated with inflammatory bowel disease. The aim of this study was to determine the profile and significance of serum autoantibodies in patients with primary sclerosing cholangitis.

METHODS

Serum samples taken from 73 untreated patients (32 female and 41 male, median age 45 years) with well-defined primary sclerosing cholangitis, and from 75 healthy age- and sex-matched controls were assayed for 20 different autoantibodies.

RESULTS

Of 73 patients, 71 (97%) were positive for at least 1 autoantibody; whereas 59/73 patients (81%) were positive for > or =3 antibodies. Patients with primary sclerosing cholangitis had a significantly greater rate of positivity than controls for antinuclear, anticardiolipin, antineutrophil cytoplasmic, and antithyroperoxidase antibodies as well as rheumatoid factor. The rate of positivity and serum levels of any of these 20 autoantibodies were not significantly different between patients with primary sclerosing cholangitis and inflammatory bowel disease and those without inflammatory bowel disease. Anticardiolipins were the single group of antibodies that had a significant correlation with the Mayo risk score (r=0.49, p<0.001) and histologic stage of disease (r=0.30, p<0.01).

CONCLUSIONS

Primary sclerosing cholangitis is associated with a high proportion of non-organ specific autoantibodies. Anticardiolipin antibodies appear to be related to the severity of primary sclerosing cholangitis and may be a useful prognostic marker.

Oral budesonide in the treatment of patients with primary biliary cirrhosis with a suboptimal response to ursodeoxycholic acid

Ursodeoxycholic acid (UDCA) is a safe and effective medical therapy for most patients with primary biliary cirrhosis (PBC). However, some patients show an incomplete response to UDCA therapy. Treatment with corticosteroids may be of benefit although at the expense of systemic side effects. Budesonide, a corticosteroid with an extensive first-pass hepatic metabolism appeared promising for the treatment of PBC. The aim of this study was to evaluate the safety and estimate the efficacy of budesonide in patients with PBC, who have shown a suboptimal response to UDCA. Twenty-two patients with PBC, 16 women, median age of 50 who had been on UDCA (13-15 mg/kg/d) for a mean of 46 months (range 6-108 months) and had shown a persistent elevation of alkaline phosphatase activity at least 2 times the upper limit of normal were enrolled. Oral budesonide, 9 mg daily was administered for 1 year and patients continued on the same dosage of UDCA. There was a significant, but transitory improvement in serum levels of total bilirubin (P =.001) and a significant, but marginal improvement in serum alkaline phsophatase (P =.001) with combination therapy. The Mayo risk score increased significantly (P =.02) and there was a significant loss of bone mass (P <.001) of the lumbar spine. Budesonide-induced hyperglycemia and cosmetic adverse effects were noted in 2 patients. In conclusion, oral budesonide appears to add minimal, if any, additional benefit to UDCA, and it is associated with a significant worsening of osteoporosis in patients with PBC.

Independent predictors of liver fibrosis in patients with nonalcoholic steatohepatitis

Nonalcoholic steatohepatitis (NASH) may present with increased hepatic fibrosis progressing to end-stage liver disease. No factors that determine increasing fibrosis and histologically advanced disease have been recognized, thus, liver biopsy is recommended in all patients for diagnosis and prognosis. Our aim was to identify independent predictors of severe hepatic fibrosis in patients with NASH. One hundred and forty-four patients were studied. All patients underwent liver biopsy. Clinical and biochemical variables were examined with univariate and multivariate analysis. Thirty-seven (26%) patients had no abnormal fibrosis, 53 (37%) had mild fibrosis, 15 (10%) had moderate fibrosis, 14 (10%) had bridging fibrosis, and 25 (17%) had cirrhosis. In multivariate analysis, older age (P =. 001), obesity (P =.002), diabetes mellitus (P =.009), and aspartate transaminase/alanine transaminase (AST/ALT) ratio greater than 1 (P =.03) were significant predictors of severe liver fibrosis (bridging/cirrhosis). Body mass index (P =.003) was the only independent predictor of the degree of fat infiltration. Increased transferrin saturation correlated positively with the severity of fibrosis (P =.02) in univariate analysis, and there was a trend for more female patients among those with more advanced fibrosis (P =. 09). However, iron studies or gender were not significant when controlled for age, obesity, diabetes, and AST/ALT ratio. In conclusion, older age, obesity, and presence of diabetes mellitus help identify those NASH patients who might have severe liver fibrosis. This is the subgroup of patients with NASH who would be expected to derive the most benefit from having a liver biopsy and considering investigational therapies.

Time course of histological progression in primary sclerosing cholangitis

OBJECTIVE

The aim of this study was to determine the time course over which patients with primary sclerosing cholangitis (PSC) progress through the histological stages of the disease.

METHODS

One hundred seven patients with PSC who had at least two liver biopsies were identified. The stage information from two consecutive biopsies formed one observation and a continuous time Markov model was used to describe the rate of progression between biopsies.

RESULTS

Three hundred seven liver biopsies were performed in the 107 patients giving a total of 200 observations. At 1 yr, 42% of patients in stage II disease progress, 66% at 2 yr, and 93% at 5 yr; whereas 14% of patients in stage III progress at 1 yr, 25% at 2 yr, and 52% at 5 yr. The frequency of progression of stage I disease could not be determined because of the small number of patients in stage I. Regression of histological stage was observed in 30 of 200 total observations (15%), and in 30 of 85 observations (35%) in which there was a change in stage.

CONCLUSIONS

These data regarding histological progression in PSC may be potentially helpful in determining the number of patients and length of time necessary to appreciate a treatment effect in clinical trials. However, the high degree of sampling variability in PSC may restrict the usefulness of serial liver biopsies as a means of evaluating treatment efficacy.

Primary biliary cirrhosis and primary sclerosing cholangitis

Primary biliary cirrhosis and primary sclerosing cholangitis are the most common chronic cholestatic liver diseases in adults that lead to biliary cirrhosis and its inherent complications such as portal hypertension and liver failure. Although important advances in the understanding of the pathogenesis of these conditions have been accomplished in the last two decades, much work is needed to uncover the interaction of genetic and immunologic mechanisms involved in their pathogenesis. Ursodeoxycholic acid at dosage of 13 to 15 mg/kg/d is the only agent that can currently be recommended in the treatment of PBC. No medical therapy aimed at disrupting disease progression is available for patients with primary sclerosing cholangitis, although several agents with different properties are currently under evaluation. Liver transplantation is the treatment of choice for patients with primary biliary cirrhosis and primary sclerosing cholangitis with end-stage liver disease.

Comparison of three doses of ursodeoxycholic acid in the treatment of primary biliary cirrhosis: a randomized trial

BACKGROUND/AIM

Ursodeoxycholic acid in doses of 13-15 mg x kg(-1) x day(-1), is a safe and cost-effective treatment for patients with primary biliary cirrhosis. However, very limited information exists regarding the most appropriate dose of ursodeoxycholic acid. The aim of the study was to compare three dosages of ursodeoxycholic acid with respect to changes in liver biochemistries, Mayo risk score, biliary enrichment with ursodeoxycholic acid and side effects over at least a 1-year period.

METHODS

A total of 155 patients were randomized to receive low- (5-7 mg x kg(-1) x day(-1)), standard-(13-15 mg x kg(-1) x day(-1)), and high- (23-25 mg x kg(-1) x day(-1)) doses of ursodeoxycholic acid.

RESULTS

The improvements in alkaline phosphatase (p = 0.0001), aspartate aminotransferase (p = 0.0001), Mayo risk score (p = 0.002), and ursodeoxycholic acid enrichment (p = 0.0001) were significantly greater in the standard- and high-dose groups compared to the low-dose group, but not between the standard- and high-dose groups. Changes in serum bilirubin were similar between the three groups (p = 0.07). No significant effects on symptoms were noted with any dose. No patients discontinued ursodeoxycholic acid because of side effects or toxicity.

CONCLUSIONS

Ursodeoxycholic acid in doses of 5-25 mg x kg(-1) x day(-1) is safe and well tolerated. The dose of 13-15 mg x kg(-1) x day(-1) appears to be the preferred dose for patients with primary biliary cirrhosis.

Utilization of the Mayo risk score in patients with primary biliary cirrhosis receiving ursodeoxycholic acid

BACKGROUND/AIMS

Ursodeoxycholic acid (UDCA) is an effective therapy for most patients with primary biliary cirrhosis (PBC). During the management of these treated patients, a number of clinically important issues arose including which patients might be candidates for combined therapy, which patients require endoscopy for variceal bleeding, and how survival can be predicted during treatment. Our aims were: 1) to identify factors associated with a suboptimal response to UDCA in patients with PBC; 2) to define a simple, non-invasive method to predict those PBC patients most apt to have esophageal varices; and 3) to determine the reliability of the Mayo survival model in predicting the course of UDCA treated patients.

METHODS

We analyzed the prospectively collected data of 180 patients, who we continue to follow, with PBC who participated in a randomized, placebo-controlled trial of UDCA.

RESULTS

After six months of UDCA therapy, patients with serum alkaline phosphatase levels less than twice normal (p < 0.04), and/or a Mayo risk score < 4.5 (p < 0.04) were more likely to respond favorably to treatment over a two year period. The Mayo risk score was the single risk factor independently predictive of development of varices (p < 0.01); 93% of patients who developed varices had a Mayo risk score > or = 4. The Mayo survival model, recalculated after 6 months on UDCA therapy accurately predicted patient survival.

CONCLUSIONS

Suboptimal responders to UDCA can be identified by assessment of serum alkaline phosphatase levels, and/or Mayo risk score. A Mayo risk score above 4 helps in selecting patients for endoscopic surveillance for varices and the Mayo survival model accurately predicts the clinical course in patients with PBC receiving UDCA.

Long-term ursodeoxycholic acid delays histological progression in primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a progressive cholestatic liver disease frequently leading to development of cirrhosis and its complications. Ursodeoxycholic acid (UDCA) is a beneficial medical therapy for patients with PBC. Improvement in some histological features, but not in histological stage, has been reported after 2 years of UDCA therapy. Thus, longer follow-up may be necessary to determine whether UDCA has a favorable effect on histological stage of disease and progression to cirrhosis. Our aim was to determine the long-term effects of UDCA therapy on histological stage and progression to cirrhosis in patients with PBC. Sixteen unselected patients with noncirrhotic PBC who had been on long-term UDCA therapy (13-15 mg/kg/d) for 6.6 +/- 0.4 years (range, 5-9 years) were identified and their histological finding during treatment compared with that of 51 noncirrhotic patients with PBC who had received ineffective therapy (D-penicillamine [DPCA] or placebo) for 5.6 +/- 0.07 years (range, 5-8 years). Histological stage was determined using the Ludwig classification. The rate of progression to cirrhosis (stage 4) was significantly less in the UDCA group than in the control group (13% vs. 49%; P =.009). Although the overall rate of progression of histological stage was less in the UDCA group than in the control group (50% vs. 71%), this difference was not significant (P =.1). A marked improvement in liver biochemistries and Mayo risk score was noted in all patients during UDCA therapy; however, this improvement was not significantly different between patients who progressed and those who did not. In conclusion, long-term UDCA therapy appeared to delay the development of cirrhosis in PBC.

Oral nicotine in treatment of primary sclerosing cholangitis: a pilot study

Currently, no accepted medical therapy for patients with primary sclerosing cholangitis (PSC) is available. Case-control studies have shown an inverse association between PSC and smoking behavior, suggesting that nicotine might have a beneficial effect in PSC. The aim of this study was to evaluate the safety and estimate the efficacy of oral nicotine in the treatment of PSC. Eight PSC patients who had never smoked received oral nicotine at a maximum dose of 6 mg four times a day for up to one year. Liver biochemistries and plasma cotinine levels were determined at entry and at three-month intervals during the study duration. Five patients completed one year of treatment, but three of them had to temporarily reduce the dose due to side effects. One patient completed only four months of treatment due to dizziness and heart palpitations. Two patients completed only one month of treatment due to reactivation of colitis requiring corticosteroid therapy. No significant changes in liver biochemistries were noted during the treatment period despite a significant increase in plasma cotinine levels. In conclusion, oral nicotine seems to have no beneficial effects in the treatment of PSC, and it is frequently associated with side effects necessitating permanent drug cessation.

Bone disease in patients with primary sclerosing cholangitis: prevalence, severity and prediction of progression

BACKGROUND/AIMS

Osteopenia is a common complication in some chronic cholestatic liver diseases. Our aims were to determine the prevalence and severity of bone disease in patients with primary sclerosing cholangitis; and identify risk factors to predict the presence and progression of osteopenia.

METHODS

Eighty-one patients involved in a randomized trial of ursodeoxycholic acid were analyzed. Bone mineral density of the lumbar spine was determined at entry and at annual intervals.

RESULTS

Bone mineral density of the lumber spine in primary sclerosing cholangitis patients was significantly lower than expected when compared to normal values adjusted for age, sex and ethnic group at entry (p<0.005), and after 1 year (p<0.05), 2 years (p<0.05), 4 years (p<0.005) and 5 years of follow-up (p<0.005). Seven patients (8.6%) had bone mineral density of the lumber spine below the fracture threshold at entry. These patients were significantly older, had a longer duration of inflammatory bowel disease and more advanced primary sclerosing cholangitis. The rate of bone loss in primary sclerosing cholangitis patients and expected in normal controls was 0.01+/-0.02 g x cm(-2) x year(-1) and 0.003+/-0.003 g x cm(-2) x year(-1), respectively (p = NS), and was similar in patients receiving placebo and ursodeoxycholic acid. Age was the only variable inversely related with baseline bone mineral density of the lumber spine (p<0.0001). None of the variables predicted progression of the bone disease.

CONCLUSIONS

Severe osteoporosis occurs in few patients with primary sclerosing cholangitis, but it should be suspected in patients with longer duration of inflammatory bowel disease and more advanced liver disease. Its presence, severity and progression cannot be accurately evaluated by routine clinical, biochemical, or histological variables. Ursodeoxycholic acid does not affect the rate of bone loss in primary sclerosing cholangitis.

The diagnostic and predictive value of ascites nitric oxide levels in patients with spontaneous bacterial peritonitis

Nitric oxide (NO) is a messenger molecule involved in pathogen suppression. Cirrhosis is characterized by an increased risk for infections, including spontaneous bacterial peritonitis (SBP). The role of NO in the infections that develop in cirrhosis has not been clearly established. The aim of this study was to investigate the utility of measuring ascites NO in the diagnosis of SBP and/or in determining the predisposition of cirrhotic patients to develop this infection. Nitric oxide metabolites (nitrites + nitrates [NOx]) were measured by chemiluminescence in 105 ascites samples obtained from 87 cirrhotic patients and in 87 simultaneously obtained serum samples. Ascites NO levels were not significantly different among ascites from patients with SBP (n = 39; median, 48 micromol/L), patients with sterile ascites (n = 54; median, 42 micromol/L), and samples obtained after patients with SBP had been treated (n = 12; median, 62 micromol/L). No differences in ascites NO levels were observed between culture-positive and culture-negative peritonitis. Among 50 patients with sterile ascites on initial paracentesis, 7 patients developed peritonitis during follow-up; no differences in baseline NO levels were observed between patients who developed peritonitis (median, 46 micromol/L) and those who did not (median, 41 micromol/L). Among patients with SBP, mortality was significantly higher in those with NO levels >60 micromol/L. A very significant direct correlation was found between ascites and serum NO levels (r2 = .86). In conclusion, ascites NO levels in cirrhotic patients are not useful either to diagnose or to determine predisposition to SBP. Rather, ascites NO levels reflect serum levels, are higher in cirrhotic patients with more severe liver disease, and may be a useful prognostic marker.

Management of primary biliary cirrhosis and autoimmune cholangitis

Several drugs have been evaluated in the treatment of primary biliary cirrhosis over a number of years. These drugs have immunosuppressive, antiinflammatory, cupruretic, antifibrotic and bile acid properties. Ursodeoxycholic acid has been shown to improve survival free of transplantation in a conclusive fashion. This drug is the single agent that can be recommended for the treatment of primary biliary cirrhosis. Corticosteroid therapy and ursodeoxycholic acid have been evaluated in a few patients with autoimmune cholangitis. This article reviews a large number of studies that have been published assessing different drugs in the treatment of these two entities, particularly in the treatment of primary biliary cirrhosis.

[Cor triatriatum with interventricular communication: Doppler color ultrasonography and magnetic resonance diagnosis. Repair in the first months]

We report a case of left cor-triatrial with ventricular septal defect and patent ductus arteriosus in a lactant of six months of age. It was diagnosed using color-coded Doppler echocardiography and magnetic resonance imaging. The intracardiac defects were successfully corrected through right atriotomy.

[Hodgkin's disease. Our 9-year experience with the 1980 protocol]

The purpose of this work was to evaluate the therapeutic results attained with our 1980 protocol for Hodgkin's disease. The usefulness of staging laparotomy was also analysed. Along a 9-year period, 94 patients were diagnosed (stages IA and IIA: 26 cases, IB, IIB and IIIA: 24 cases, and IIIB and IV: 44 cases). The complete remission (CR) rate, as a whole, was 85%; there were 14 relapses, of whom a new CR was attained in 9 instances. The overall actuarial survival is 64% at 47 months. The appearance of 3 cases of acute non-lymphoblastic leukaemia is noteworthy. Laparotomy induced changes of the patient's staging in 49% of cases (rise in 43% and descent in 6%). In account of this, laparotomy seems an adequate procedure in staging, although the criteria for selecting the patients who will undergo this, procedure should be perhaps restrictive.