Primary biliary cirrhosis: clinical features and outcome, with special reference to asymptomatic disease

The clinical features and outcome of primary biliary cirrhosis (PBC) during long-term follow-up study (mean, 9 years; range, 1-20 years) was reviewed in 80 patients. Seventy per cent were asymptomatic at initial presentation. The mortality in the symptomatic group was 63%, compared with 20% in the asymptomatic group (p less than 0.001). The presence of hepatomegaly and histopathology consistent with stage 2-4 in asymptomatic cases was a prognostically ominous sign, as these patients often developed symptoms (p less than 0.001). The finding of histopathology consistent with stage 1, however, was correlated with an excellent prognosis with respect to both symptoms and mortality. Only 11% of these stage 1 patients became symptomatic, and none died (p less than 0.001). The mean age of symptomatic and asymptomatic patients did not differ. Moreover, the age distribution of asymptomatic patients with early histopathology and those patients with more advanced histopathology did not differ. This may indicate that asymptomatic PBC consists of subgroups with an active disease of various degrees.

The diurnal variation of serum hyaluronan in health and disease

The variation of the serum concentration of hyaluronan during the day and between days has been investigated. In a group of healthy volunteers, the mean hyaluronan level was very stable over time except for a moderate but significant elevation after rising from bed in the morning. Patients with rheumatoid arthritis showed markedly increased hyaluronan concentrations 0.5-2 h after leaving bed. Patients with primary biliary cirrhosis exhibited high and rather constant levels during the day. A reference group of hospitalized patients with other diseases did not show any diurnal variation. The best reproducibility in hyaluronan determinations is obtained if specimens are taken before the subjects rise from bed or a few hours later, i.e. after the morning elevation of serum hyaluronan has subsided. In rheumatoid arthritis valuable information can be obtained by repeated sampling during the morning hours.

Impaired release of vitamin A from liver in primary biliary cirrhosis

In 44 patients with primary biliary cirrhosis serum levels of vitamin A, retinol-binding protein and transthyretin (prealbumin) were found to be significantly lower than in 25 sex- and age-matched controls. Liver biopsies were available for chemical analyses in 28 of the patients. Their mean liver vitamin A concentration (2.8 +/- 2.0 mumoles per gm wet weight) did not differ significantly from that in 22 cases of sudden death which served as controls (2.0 +/- 1.5 mumoles per gm wet weight). Immunohistochemical investigation showed a normal distribution of serum retinol-binding protein in the patients' livers, whereas the staining pattern of cellular retinol-binding protein, believed to be involved in the intrahepatic transport of vitamin A, was abnormal. Thus, the number size and cellular retinol-binding protein staining intensity of fat-storing (Ito) cells were clearly higher in the patients as compared with controls. The results suggest that the low serum vitamin A levels in primary biliary cirrhosis are not a consequence of vitamin A deficiency but instead reflect a defective mobilization of vitamin A from the liver.

Serum hyaluronate in primary biliary cirrhosis--a biochemical marker for progressive liver damage

To evaluate serum hyaluronate as a marker for progressive liver injury in patients with primary biliary cirrhosis, a longitudinal study including 48 patients was conducted with a mean follow-up time of 40 months. The patients were examined every 6 months with a standardized set of conventional liver function tests, and a liver biopsy was performed every year. The hyaluronate concentration correlated significantly (p less than 0.001) with albumin, t1/2 galactose tolerance test, bilirubin and prothrombin time but not to serum variables reflecting inflammatory activity. Furthermore, there was a close correlation between serum hyaluronate levels and histopathological changes in the liver. The hyaluronate concentration increased significantly over time in all clinical stages of primary biliary cirrhosis (p less than 0.01), whereas the conventional liver function tests only changed in the advanced cases. The present data indicate that serum hyaluronate may be a sensitive marker for progressive liver damage in primary biliary cirrhosis. Serial determinations of hyaluronate are therefore of potential value for monitoring liver function during clinical management of the condition.

Defective C3b receptor-mediated phagocytosis of neutrophils in patients with primary biliary cirrhosis

Neutrophil function in patients with primary biliary cirrhosis (PBC) was studied by means of a kinetic particle uptake assay using IgG-coated and IgG + C3b-coated latex particles, enabling a differentiation between Fc and C3b receptor-mediated phagocytosis. C3b receptor-dependent phagocytic rate (delta C3b) in PBC was significantly decreased (PBC = 0.20, 0.08-0.51 min-1; reference = 0.37, 0.23-0.60 min-1; p less than 0.0005 (-x; +/- SD logarithmically transformed], whereas the Fc receptor-dependent phagocytic rate was normal. delta C3b was inversely correlated with complement factor C3 levels (r = -0.77, p less than 0.02) and C3b receptor-binding activity (r = 0.47, p less than 0.04) in PBC sera, indicating a possible relationship between serum components and neutrophil C3b receptor dysfunction. These observations are in accordance with previously reported defects of C3b receptor function in monocytes and lymphocytes, suggesting a generalized disturbance of C3b receptor-bearing cells in PBC. Furthermore, the effect of PBC sera on migratory function of normal neutrophils was investigated. PBC sera contained heat-labile, chemokinetic stimulating activity. The mean chemotactic activity of PBC sera did not differ from that of reference sera.

Is duodenal ulcer really a psychosomatic disease? A population-based case-control study

Risk factors for prepyloric and duodenal ulcer were analysed by means of a questionnaire in 132 patients and 132 population controls, pairwise matched for age and sex. Several factors associated with a lower socioeconomic status, such as short education, low income and low housing standard, and a job characterized by low satisfaction, low demands, and low autonomy, were more prevalent among the patients. The odds ratio (OR) with 95% confidence limits (CL) in smokers versus non-smokers was 2.9 (CL, 1.7-5.0). A trend emerged in relation to the daily number of cigarettes, with an OR of 4.1 (CL, 2.2-7.5) for those smoking more than 10 cigarettes. The risk of having peptic ulcer disease was virtually unrelated to other psychiatric and somatic morbidity, to marital status, personal worries, type-A behaviour, experience of a hectic or psychologically demanding job, and to consumption of coffee, alcohol, and drugs. Our data lend no support to the concept that peptic ulcer disease is a disorder related to psychologic stress. Causative agents other than smoking should probably be sought among factors characterizing the life style of low socioeconomic classes.

Psychological group counseling for the prevention of ulcer relapses. A controlled randomized trial in duodenal and prepyloric ulcer disease

The effect of psychological counseling on 1-year ulcer relapse rate of recurrent duodenal and prepyloric ulcer disease was evaluated in 148 patients randomly allocated into three treatment groups; psychological counseling group, maintenance cimetidine (400 mg at bedtime), and placebo cimetidine at bedtime. Ulcer relapses were monitored by endoscopy at 6 and 12 months after inclusion and at symptomatic recurrence. The estimated proportion of relapse-free patients after 12 months follow-up in the psychological counseling group (0.43 +/- 0.08) did not differ significantly from the placebo group (0.47 +/- 0.07), whereas the corresponding value for the cimetidine group (0.70 +/- 0.07) was significantly higher (p less than 0.01). The effect of cimetidine on ulcer recurrence, however, was confined to smokers; relapse risk among nonsmokers did not differ significantly between the treatment groups. The negative outcome of psychological counseling raises doubts as to whether duodenal or prepyloric ulcer recurrences can be prevented by such a therapeutic approach.

The "epigastric distress syndrome". A possible disease entity identified by history and endoscopy in patients with nonulcer dyspepsia

Nonucler dyspepsia lacks a clear definition, and probably conceals several entities under this heading. It seems appropriate to deal separately with symptoms likely to be elicited from the upper digestive tract. Therefore, we propose "epigastric distress syndrome" (EDS) as a designation for chronic or recurrent epigastric pain without any anatomical antecedents and without concomitant symptoms consistent with established criteria of the irritable bowel syndrome. In this study 185 dyspeptic patients with a tentative diagnosis of EDS, based on symptoms and negative upper endoscopy, underwent laboratory screening, peroral cholecystograms, ultrasound scanning of the liver, biliary tract, and pancreas, biopsies from the distal part of the duodenum, and acid secretory tests. There were very few pathological findings. Five patients had gallstones. No single case of chronic pancreatitis or celiac disease was disclosed. Thus, EDS seems to be a "safe" diagnosis, and it is not unreasonable to assume that it could represent a disease entity. Although many patients had symptoms closely similar to those in duodenal ulcer, the mean basal and maximal acid output in this patient category did not differ from that observed among healthy subjects.

Immunological effects of ciclosporin in primary biliary cirrhosis: suppression of activated T cells and autoantibody levels

The effects of ciclosporin (CS) on liver immunohistology and peripheral blood T lymphocyte distribution were studied in 5 patients with primary biliary cirrhosis (PBC) receiving CS treatment for 6 months. Several significant immunological changes were seen during the course of treatment: the numbers of infiltrating T cells (Leu4+) and HLA-DR+ cells (mainly macrophage/dendritic-like) within the lobule parenchyma decreased; the total circulating T cell numbers increased and the percentage of activated, HLA-DR-expressing Leu2a+ ('suppressor/cytotoxic') T cells and Leu3a+ ('helper/inducer') T cells decreased. Moreover, using a highly sensitive enzyme immunoassay for antimitochondrial antibody (AMA), a selective decrease of IgM-type (but not IgG-type) AMA levels was observed in 4 patients. A reversal towards pretreatment values was observed for all these immunological parameters 3-6 months after withdrawal of therapy. We conclude that CS may inhibit both cell-mediated and antibody-mediated autoimmune mechanisms operating in PBC.

Absence of therapeutic benefit from antacids or cimetidine in non-ulcer dyspepsia

We randomly assigned 159 patients with non-ulcer dyspepsia, defined as chronic or recurrent epigastric pain without concomitant symptoms of the irritable bowel syndrome and with no evidence of organic disease, to treatment for three weeks with an antacid suspension one and three hours after meals, 400 mg of cimetidine twice a day, or placebo, according to a double-blind, double-dummy model. The intensity and duration of epigastric pain were recorded by the patients four times daily during a one-week period without therapy and during the three weeks of treatment. The mean reduction in pain intensity after three weeks in the placebo group was 25 percent. Neither antacid nor cimetidine treatment resulted in more than a 4 percent better effect. The reduction of pain was statistically significant (P less than 0.01) in all three groups. The time course of the pain scores in the groups receiving active drugs followed closely those in the placebo group, and there were no significant differences between the groups at any stage of the treatment. We conclude that the neutralization or suppression of gastric acid is of no clinical value in patients with this syndrome.

Symptomatic cimetidine treatment of duodenal and prepyloric ulcers

In a randomized trial, 75 patients with an endoscopically confirmed and symptomatic duodenal (N = 50) or prepyloric (N = 25) ulcer were allocated to cimetidine treatment (1 g/day) either regularly for four weeks (standard treatment group) or regularly for a minimum of one week and thereafter only until the symptoms were controlled (symptomatic treatment group). The four-week healing frequencies in the standard and symptomatic treatment groups were 72 and 67%, respectively. The difference +/- 95% confidence limits was 5 +/- 21%. Prospective recording of pain revealed that the two treatment regimens were about equally effective in relieving symptoms during weeks 2-4. Patients with unhealed ulcers reported pain during the day and night significantly more often than those with healed ulcers. In the symptomatic treatment group the average patient saved 11 days of cimetidine medication during weeks 2-4. We believe that disappearance of symptoms might be a valuable means of deciding when treatment for peptic ulcers can be discontinued. Provided its efficacy and safety can be further confirmed, symptomatic treatment might become a practical and possibly a money-saving mode of ulcer management, which should also be applicable to the ulcer regimens of tomorrow.

Removal of hyaluronic acid from the circulation in rheumatoid disease and primary biliary cirrhosis

Recent evidence from metabolic studies in animals and from measurement of plasma and serum hyaluronic acid (HA) levels in humans indicates that the liver is the organ mainly responsible for the clearance of circulating HA. The clearance of HA from the bloodstream was therefore studied with tritium-labeled material of high specific activity in patients with rheumatoid arthritis or primary biliary cirrhosis (PBC). In patients with rheumatoid arthritis, HA clearance was similar to that reported in normal subjects and approached the range of hepatic blood flow. HA metabolism was also rapid. In patients with PBC, clearance was inversely related to the preexisting plasma HA levels and severity of disease. Renal excretion of HA remained low despite the slower decay of plasma concentrations. Metabolic degradation was not significantly impaired. Most of the injected material was accounted for as tritiated water within 24 hours. Taken with data from other species and with the raised plasma HA levels observed in a variety of liver diseases, our findings indicate that the liver may also be the major site for the uptake of circulating HA in humans. High levels of plasma HA in the absence of hepatic dysfunction can be taken as evidence of an increased input from the tissues.

Increased serum levels of hyaluronate in liver disease

Recent animal studies show that endothelial cells in liver sinusoids are the main site for removal of sodium hyaluronate from the circulation. Few data with respect to hyaluronate metabolism are available in man. Serum hyaluronate levels were measured in 119 patients with liver disease by a sensitive assay. The hyaluronate level was significantly increased in liver cirrhosis, in comparison with healthy controls and with patients with noncirrhotic liver disease. The results suggest a role for the human liver in elimination of hyaluronate from circulation. Quantification of serum hyaluronate may be a useful test of liver endothelial cell function.

Serum beta 2-microglobulin levels in primary biliary cirrhosis

Serum beta 2-microglobulin (beta 2 mu) was determined in 44 patients with primary biliary cirrhosis (PBC) and in 63 patients with other liver disorders. beta 2 mu levels were elevated in PBC when compared with chronic persistent hepatitis, primary sclerosing cholangitis and noncirrhotic alcohol liver disease, but not in comparison with chronic active hepatitis and alcoholic liver cirrhosis. With the exception of chronic persistent hepatitis, all liver disorders had significantly increased serum concentrations of beta 2 mu when compared with controls. A significant correlation between beta 2 mu and erythrocyte sedimentation rate (p less than 0.001) and beta 2 mu and serum IgG (p less than 0.05) was found in PBC. No significant difference in beta 2 mu levels was noted when PBC patients with early and late histopathological changes were compared. D-penicillamine treatment significantly (p less than 0.01) but transiently reduced beta 2 mu levels in PBC; this may reflect the presumed immunosuppressive action of this drug.

Social and economic effects of non-ulcer dyspepsia

An attempt was made to estimate the total costs of non-ulcer dyspepsia (NUD) in Sweden by extracting information from different available sources. After extrapolation of figures from the in-patient register of the University Hospital in Uppsala to the whole of Sweden, the total annual expenditure for in-patient care was estimated to be 10.3 million SEK. Calculations of costs for out-patient care and drugs were based on data from a nation-wide sample survey, and the total expenses were estimated to be 197.5 million SEK and 60 million SEK, respectively. Among indirect social costs, economic losses due to death and early retirement were found to be comparatively moderate. Production loss due to short-term sick-leave was by far the most dominant item among all social costs. In a study of 88 consecutive patients with NUD, it was revealed that the average NUD patient was responsible for 26 more days of lost production than the average employee. Thus, the total annual cost for short-term sick-leave was estimated to be 2,496 million SEK. The grand total of these calculations amounts to no less than 2,786 million SEK. Although affected by a considerable degree of uncertainty, the presented figures point to important economic consequences for society.

The Diagnosis and Therapy Survey October 1978-March 1983, health care consumption and current drug therapy in Sweden with respect to the clinical diagnosis of gastritis

Demographic epidemiology, current drug therapy and the health care resources required by patients clinically considered to have gastritis were studied during a four and a half year period-October 1978 to March 1983. The investigation was based on data from the Diagnosis and Therapy Survey, an on-going nation-wide sample study covering all out-patient care in Sweden. Gastritis was found to account for 1.9% of all out-patient consultations and for 30% of those for gastrointestinal disorders. The corresponding figures for peptic ulcer disease were 0.2% and 4%, respectively. The estimated minimum number of annual consultations for gastritis was 47 per 1,000 inhabitants. The majority of the consultations were dealt with in general practice, where gastritis was the fifth most common diagnosis. Drug therapy was considered to be indicated in 92% of the consultations. Antacids were prescribed in 77%, anticholinergic/spasmolytic drugs in 36% and histamine H2-receptor antagonists in 4%. The clinical diagnosis of gastritis was found to be the major indication for antacids and anticholinergic drugs and accounted for a substantial proportion of H2-receptor antagonist prescriptions. The patient groups with gastritis and duodenal ulcer showed a similar age distribution, with a mean age of about 50 years. In the gastritis group, the two sexes were equally represented, but in the duodenal ulcer group there was a predominance of men. The results of the Diagnosis and Therapy Survey indicate that the patient group with symptoms traditionally denoted as gastritis in clinical practice constitutes a major health care problem in our community.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical diagnosis of gastritis. II. Aspects of current therapy and drug consumption

Patients with a clinical diagnosis of 'gastritis' or non-ulcer dyspepsia were studied as to the extent and pattern of drugs prescribed from October 1978 through September 1981. This was permitted by the Diagnosis and Therapy Survey, an ongoing nationwide sample study, covering all outpatient care in Sweden. In 98% of the consultations a drug was considered to be indicated. Antacids were prescribed in 76%, an anticholinergic drug in 40%, and a histamine-H2-receptor antagonist (cimetidine) in 3%. The latter figure seemed to increase during the 3-year study period, concomitant with a decrease in the prescription rate of anticholinergic drugs. Gastritis was the major indication not only for antacids and anticholinergic drugs but also for cimetidine, accounting for 35% of all cimetidine prescriptions. Total sales of these drugs in 1981 amounted to about SKR 150 million. Antacids comprised 57%, anticholinergic/spasmolytics 22%, and cimetidine 21% of this amount. The extensive drug use is remarkable considering the lack of convincing data from randomized controlled clinical trials supporting a therapeutic effect of any drug regimen in gastritis. More such trials in well-defined patient groups are therefore greatly needed.

The clinical diagnosis of 'gastritis'. Aspects of demographic epidemiology and health care consumption based on a nationwide sample survey

The health care resources required by patients clinically considered to have gastritis were studied during a 3-year period. The assessment was based on data from a nationwide sample study covering all outpatient care in Sweden. Gastritis, the fourth commonest diagnosis in general practice, accounted for 2% of all outpatient consultations and for 31% of those for gastroenterological disorders. The estimated minimal number of annual consultations for gastritis was 4500 per 100,000 inhabitants. Seventy-two per cent of the patients with gastritis had previously sought medical advice for similar symptoms. Our results indicate that the patient group traditionally denoted as gastritis constitutes a major health care problem in our community, which should be met by a thorough epidemiological, clinical, and laboratory characterization.

External quality assessment of serum drug determinations in the Nordic countries

A system for external quality assessment of serum drug determinations in the five Nordic countries has been established, and results of several surveys of antiepileptic drug determinations are described. The work was started as a pioneer work of NORDKEM at the time when NORDKEM was founded and was carried out during the years 1977-1979. The problems concerning methodology of drug analyses and, consequently, the problem of setting up quality assessment systems differ clearly from those in connection with the common analyses of clinical chemistry. Especially the quality of control materials is very important. An expert panel of drug specialists is necessary to plan and interpret an external quality assessment program of drug analyses, but it can very well be carried out in connection with other quality assessment programs. The state of the art of antiepileptic drug determinations in the Nordic countries at the time of the surveys was very good. The level of inaccuracy was well below 5%, and the level of imprecision was mainly in the range of 15-20%, although no outliers were excluded during the statistical treatment of the data.

Primary biliary cirrhosis--phenotypic characterization of immunocompetent cells in peripheral blood and liver tissue

Circulating T-cell subsets have been characterized in 18 patients with primary biliary cirrhosis (PBC) using a simple immunoenzymatic staining method on stored and prefixed cell samples. Furthermore, a double immunoenzymatic method was used to study T-cell subsets and their relationship to HLA-DR+ cells in frozen sections of liver biopsies from 12 patients with PBC. In 10 cases blood and liver samples were taken simultaneously from the same patient. Patients with PBC of early histological stage showed an elevated absolute number of helper/inducer T-cells (Leu 3a+) and reduced relative percentages of suppressor/cytotoxic T-cells (Leu 2a+) compared with healthy subjects resulting in an elevated helper/suppressor ratio. Liver biopsies in PBC were dominated by helper inducer phenotype T-cells in all cases irrespective of histological stage, penicillamine treatment or the relative levels of circulating T-cell subsets. A relatively high amount of HLA-DR+ cells were seen, several of these in close approximation to T-cells.