Practice and complications of liver biopsy. Results of a nationwide survey in Switzerland

Studies on the complication rate of liver biopsy have hitherto been conducted in referral hospital centers. They are therefore not representative for general practice where liver biopsy is performed by specialists and nonspecialists. In a postal nationwide survey, we approached all gastroenterologists and hospital internists to assess the complication rate and practice (setting, needle type, use of ultrasonography) of percutaneous liver biopsy performed in 1989 in Switzerland for diffuse liver disease. Two hundred eighty questionnaires were mailed and 252 were returned (response rate 90.0%) 165 respondents (65.5%) performed 3501 biopsies while 87 respondents (34.5%) did not practice liver biopsy; 67.7% of biopsies were executed blindly and 32.3% were guided. Eight nonfatal and three fatal complications occurred. Hemorrhage was the most frequent complication (five cases) and was responsible for all three fatal outcomes. The overall complication rate was 0.31%, being distinctly lower in the group of gastroenterologists (0.11%) as compared to the group of internists (0.55%; P = 0.031). The complication rate was 1.68% in the group of internists performing fewer than 12 biopsies per year, while there was no complication in the group of internists performing more than 50 biopsies per year (P = 0.036). Complications were not related to the needle diameter or to the absence of ultrasonography before biopsy. In conclusion, this representative survey in Switzerland shows that the complication rate of liver biopsy is mainly related to the experience and training of the operator.

[Extracorporeal shockwave lithotripsy of the gallbladder: importance of selection criteria]

In recent years, a number of alternatives to surgery for gallstones have been developed. Among them, extracorporeal shock-wave lithotripsy (ESWL) was promising, being non-invasive and risk-free. Nevertheless, its results vary according to the size, number and composition of the stones and according to the bile acids treatment used for fragment dissolution. To better evaluate the importance of these factors, we have widened the selection criteria currently used (1 to 3 non-calcified stones with a diameter below 30 mm) by including patients with large stones (up to 40 mm in diameter), multiple stones (up to 10 stones) and calcified stones. We also compared, for efficacy of fragment dissolution after ESWL, treatment by ursodeoxycholic acid alone as opposed to a mixture with chenodeoxycholic acid. Our results were (1) significant lessening of the fragmentation rate and of the number of gallbladders free of stones 1 year after ESWL when selection criteria are widened; (2) a mixture of ursodeoxycholic and chenodeoxycholic acids may favour fragment dissolution after ESWL compared to treatment by ursodeoxycholic acid alone.

[Prevalence of anti-HCV (C100-3) antibodies in 20.373 blood donors]

The anti-HCV antibody (C100-3) is present in the serum of 70-90% of patients that are carriers of posttransfusion non-A non-B hepatitis. This marker appears to be associated with a viral replication and infectiousness state. Since 1st August 1990 the Swiss Red Cross Transfusion Service has operated a systematic search for anti-HCV antibodies for every blood donation. The aim of the study was to establish the prevalence of anti-HCV antibodies in a donor population, look for the risk factors in the anti-HCV positive group, look for biological symptoms and signs of chronic hepatitis, and compare the data with that from an anti-HCV negative control group. From August to March 1991, 20,373 donors were tested by EIA (Ortho). The presence of anti-HCV antibody was confirmed by a neutralization test (Abbott). The donors in which both tests were positive formed the group studied (55 subjects). Their data was compared with that of a control group of anti-HCV negative donors. The prevalence of anti-HCV antibody in the group of 20,373 donors was 0.29%. Possible parenteral exposure to hepatitis C virus was found in 47% of anti-HCV positive subjects (30% blood transfusion, 9% i.v. drug addiction, 8% tattooing). 42% of the anti-HCV positive donors had no risk factor presently known for hepatitis C. 27% of anti-HCV positive donors had elevated transaminase levels. Until more effective screening tests are introduced it appears necessary to stress the previous history of future blood donors in order to search for hepatitis C risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Low sodium solution for colonic cleansing: a double-blind, controlled, randomized prospective study

The standard polyethylene glycol electrolyte solution for colonic cleansing has a salty unpleasant taste resulting in limited patient acceptance. Introduced as a major advance allegedly providing a distinctly better taste, a new low sodium cleansing solution was recently described. In a double-blind controlled fashion, 66 colonoscopy outpatients were interviewed about general palatability and tolerance of the solution they had ingested for the preparation of endoscopy. Preparation quality was assessed endoscopically. Similar results were obtained for both solutions concerning palatability, tolerance, and cleansing quality. Furthermore, a small quantity of both solutions was tasted and directly compared for taste qualities before endoscopy. Fifty-one and one-half percent of patients preferred the new solution and 48.5% preferred the standard solution or had no preference (not significant). Of the patients, 39.2% were unable to differentiate between the more and the less salty solution. Moreover, 39.6% of patients preferred the solution they judged more salty. We conclude that the new low sodium lavage solution is not superior to the standard solution regarding patient acceptance, compliance, and cleansing quality. Thus, the reduction of salt concentration does not appear to be the appropriate approach to improve patients compliance with colonic cleansing solutions.

[Liver transplantation. Initial Lausanne experiences]

This paper presents the results of the first 7 orthotopic liver transplants performed in Lausanne between December 1988 and September 1990. 6 patients are surviving; their rehabilitation is excellent.

Palatability of a new solution compared with standard polyethylene glycol solution for gastrointestinal lavage

The salty unpleasant taste of the standard polyethylene glycol electrolyte lavage solution constitutes a major drawback, which limits patient compliance. Recently, a new low-sodium cleansing solution was described and introduced as a major advance, allegedly providing a distinctly better taste and improving compliance. We compared the taste of both solutions, seeking a possible preference applying a double-blind randomized design. Twenty-eight healthy volunteers tasted one of the two solutions without a direct comparison. Both solutions were found to have a similar palatability and an equal salty taste. A different group of 50 volunteers compared the two solutions. Twenty-one preferred the standard solution, 25 preferred the new solution (not significant), and 4 subjects had no preference. Among the subjects basing their preference on the saltiness of the solutions, 18 estimated the standard solution to taste more salty than the new low sodium solution, while 18 volunteers found the new solution to taste more salty than the standard solution. This study does not confirm a taste preference for the new low-salt polyethylene glycol electrolyte lavage solution as compared with the standard solution for colonic cleansing. The difference in the salt concentrations of the two solutions could not regularly be distinguished by a group of healthy volunteers.

Reproducibility of ambulatory gastric pH recordings in the corpus and antrum. Effect of food, time, and electrode position

The reproducibility of simultaneous, long-term, ambulatory gastric pH recordings in the antrum and corpus was investigated in nine healthy subjects who underwent three separate, 27-h gastric double pH-metries. Intraindividual reproducibility for the entire 27-h recording period was good in the corpus (Kendall's concordance coefficient, W' = 0.6393, p less than 0.025) but not in the antrum (W' = 0.4806, NS). Analysis of predefined time periods showed that non-meal daytime pH was reproducible in the corpus (W' = 0.6531, p less than 0.025) but not in the antrum (W' = 0.3395, NS), whereas mealtime pH was reproducible in the antrum (W' = 0.7159, p less than 0.005) but not in the corpus (W' = 0.4954, NS); nocturnal pH was not reproducible in either the antrum or the corpus. These results reflect the functional separation of corpus and antrum and their differing responses to food. Thus, studies of gastric acidity over long periods should be conducted in the corpus, whereas studies of gastric acidity over shorter, meal-related periods should be conducted with a second electrode in the antrum.

[Gastroenterological problems in the elderly]

An increasing number of elderly patients presenting with gastroenterological problems is seen in hospital and private practice. It is therefore very important to be able to recognize the different clinical aspects of these diseases in this category of patients. Esophageal reflux and problems of motility can give rise to vague, atypical symptomatology, which does not orient the clinician to the esophagus. Unrecognized gastric ulcer is frequently complicated by hemorrhage or perforation leading to high mortality rates. Mesenteric infarction, even when diagnosed early still remains a serious complication. The prognosis of ischaemic colitis is more favorable than that of mesenteric infarction, thanks to the existence of a collateral circulation. Its evolution to gangrene is rare. 30% of patients 60-years or older suffer from diverticular disease which can remain asymptomatic or progress to diverticulitis, hemorrhage or fistulization. The prevalence of constipation, often aggravated by sedentary life style or drugs, increases in patients over 65 years. Fecal impaction is often unrecognized due to the poor specificity of its symptoms.

[Does Barrett's esophagus regress after effective treatment of gastro-esophageal reflux?]

Regression and disappearance of Barrett's esophagus are a rare event of which there are only three well documented cases in the literature. Two cases are described in this study.

Incidence of gallbladder lithiasis after ceftriaxone treatment

Ceftriaxone has potent activity against a broad range of Gram-positive and Gram-negative bacteria. While it is eliminated mainly by the kidney, 10-20% of the drug is eliminated in the bile and ceftriaxone salt precipitates have been described in the gallbladder of animals dosed with ceftriaxone. The purpose of the present study was to investigate the incidence of biliary lithiasis 6 and 12 months after treatment with ceftriaxone and to compare it with that in patients treated with amoxycillin/clavulanate. Biliary ultrasonography was performed at the start of treatment, at 6 months and at 12 months after the beginning of the study. One hundred patients were randomized and 74 were evaluable: 34 were given amoxycillin/clavulanate, 40 ceftriaxone. Gallbladder lithiasis developed in one patient 12 months after the amoxycillin/clavulanate treatment and in none in the ceftriaxone treatment arm. Biliary precipitate during ceftriaxone treatment was not looked for because this phenomenon was not known at the beginning of the study, but gallbladder precipitation that was seen in two patients given ceftriaxone during and at the end of treatment, respectively, resolved spontaneously. In conclusion, ceftriaxone treatment does not appear to lead to gallstone formation more often than an antibiotic that is not eliminated through the bile.

[Drug-induced esophagitis and its complications. Retrospective study of 30 case reports and review of 650 published cases (1970-1987)]

Prevalence and incidence of drug-related esophagitis are probably underestimated. The condition can often be diagnosed on the basis of history alone. Tetracyclines and emepronium bromide were implicated in most published cases. Endoscopy usually shows erosions in the upper two thirds of the esophagus. These esophageal lesions generally heal after the medication has been stopped. Complications such as stricture, hemorrhage or perforation are very rare.

[Refractory anasarca]

In a 68-year-old male hospitalized for a traffic accident physical examination revealed a left tibial fracture and an asymptomatic left pleural effusion. The evolution was characterized essentially by the appearance of oedema of the legs, ascites, and aggravation of the left pleural effusion with concomitant right effusion. Immediate therapy consisted of digitalis and diuretics. Several days later the patient suddenly complained of epigastric pain irradiating to his arms, followed by vomiting. ECG showed transitory elevation of ST segment in V3 to V5. Blood levels of CK and CK-MB were normal. An electrocardiogram showed extensive antero-septal-apical akinesis and a very small cardiac effusion. Pleural and abdominal tap revealed the presence of a milky liquid containing 40 g/l proteins, 8.6 mmol/l triglycerides and 2.5 mmol/l cholesterol, with no atypical or tumorous cells. CAT scan revealed the presence of a retroperitoneal mass extending from the diaphragm to the iliac crests and apparently enclosing the aorta and the vena cava and causing bilateral hydronephrosis. The development of chylous ascites and/or chylothorax indicates the presence of an extrinsic or intrinsic obstruction of lymphatic drainage or the existence of a laceration or rupture of the thoracic canal. Chylous ascites is not a frequent finding, since only 28 cases have been diagnosed in 20 years at the Massachusetts General Hospital and 71 in 30 years at the Mayo Clinic. In these 2 series a tumoral etiology was found in more than 85% of the cases. The most frequently encountered tumor was lymphoma followed by cancer of the pancreas, stomach, or other tumors.

CLINICAL DIAGNOSIS

Retroperitoneal tumor, most probably lymphoma; inferior vena cava compression syndrome; subacute antero-septal infarction. In spite of the poor general condition of the patient exploratory laparotomy was performed, and several specimens were taken from the lymphatic nodes located at the angle of Treitz, in the mesentery and the mesocolon and along the celiac axis. HISTOPATHOLOGICAL DIAGNOSIS: Non-Hodgkin B-cell malignant lymphoma, low-grade, lymphoplasmacytoid (immunocytoma) according to the Kiel classification, or small lymphocytic, plasmacytoid according to the International Working Formulation (abdominal lymph nodes, liver, epiploon, peritoneum, rectus abdominis muscle).

EVOLUTION

Chemotherapy was instored consisting of a combination of prednisone, vincristine, and cyclophosphamide. The patient's condition was complicated by peritonitis. Laparotomy revealed phlegmonous cholecystitis and a perforated colon. The post-operative course was characterized by septic shock, cardiac and respiratory insufficiency which resulted in the death of the patient. Autopsy confirmed the presence of a low-grade lymphoma stage IV (retroperitoneum, mesentery, cervical, axillary and abdominal lymph nodes, liver, spleen, pancreas, colon, rectum, kidneys, adrenal glands, bronchi, epicardium). No evidence of an infarctus or oth

[Screening for colorectal tumors using fecal occult blood studies]

Guaiac tests such as Hemoccult are widely used but are affected by several factors. Occult blood testing does uncover subclinical colorectal cancer often at early stage, but a favorable effect on survival remains to be proven. The sensitivity for the detection of malignancies is from moderate to good, but it is poor for benign polyps. Predictive value of a positive test for cancer ist about 8-12%. Thus, most of the individuals with a positive test would not need colonic investigations. Recommendations relating to the testing for of occult blood could change rapidly with the new immunologic techniques or with new data on mortality coming from controlled clinical trial now being conducted.

[Is the measurement of carcinoembryonic antigen still indicated in digestive cancers?]

Carcinoembryonic antigen (CEA) is not useful for detecting asymptomatic cancer. Its sensitivity and specificity are not high. For some cancers, antigen levels at the time of diagnosis provide more precise prognosis than staging alone. Regular determination of CEA is useful as a method of surveillance after surgery for cancer in the colon and in the rectum. Unfortunately the clinical gain of detecting postoperative relapses is low since curative surgical treatment is usually impossible.

[Pathogenic heterogeneity of Barrett's ulcers. Apropos of 38 case reports]

Barrett's ulcer is thought to develop in the columnar epithelium of Barrett's esophagus. In our series there is evidence that at least some Barrett's ulcers develop in squamous epithelium which may correspond to islets within Barrett's esophagus; in other cases Barrett's mucosa may surround a preexisting reflux-induced ulcer and thus transform it into Barrett's ulcer. In some individual cases of Barrett's ulcer development of the ulcer primarily in the columnar epithelium could not be ruled out. These ulcers may be produced by local acid secretion, by acid or alkaline gastroesophageal reflux in patients with reduced resistance of the columnar epithelium. Exceptionally, Barrett's ulcer may result from local irritation by medication (pill-induced ulcer) or by nasogastric intubation.

Atrial natriuretic peptide administered as intravenous infusion or bolus injection to patients with liver cirrhosis and ascites

The effect of a synthetic atrial natriuretic peptide (h-ANP, 25 amino acids, Wy-47.663) on blood pressure, renal electrolyte excretion, plasma catecholamines, and plasma renin activity was studied in nine patients with cirrhosis of the liver and ascites. The peptide was infused intravenously at 24-h intervals for 2 h in groups of four patients each in two different doses (0.015 and 0.075 micrograms/kg/min or 0.06 and 0.3 micrograms/kg/min). A control experiment with the vehicle was performed in all patients. In three patients h-ANP (1 and 2 micrograms/kg i.v.) was administered as an intravenous bolus injection. Consistent falls in blood pressure were observed during h-ANP infusion only with the two higher doses. The two lower infused doses induced a consistent natriuresis; this renal response was abolished when the two larger doses were used. When given as a bolus, h-ANP had a natriuretic effect comparable to that of the two lower doses of infused h-ANP. Plasma catecholamines and plasma renin activity increased during infusion of the two higher doses of h-ANP. It thus appears that in patients with cirrhosis and ascites, the natriuretic effect of infused h-ANP decreases rather than increases when the doses are raised. Bolus administration of h-ANP may be less prone to trigger counterbalancing responses and side-effects.

[Savary's ulcer: a new complication of gastroesophageal reflux? Apropos of 32 endoscopically observed cases]

Savary's ulcer is a rare and little known peptic ulcer situated just above Barrett's esophagus. It is predominant in elderly women, bleeds less than Barrett's ulcer and is almost always associated with peptic stenosis. It is, like Barrett's and Wolf's ulcers, a complication of gastroesophageal reflux and not of Barrett's esophagus.

[Current role of biopsy in the diagnosis of hepatic disease]

The criteria for the use of liver biopsy as a diagnostic tool were retrospectively analyzed over a ten-year period in 390 consecutive patients. The four principal conditions in which this procedure was employed were alcoholism (33%), hepatitis (18%), abnormal hepatic tests (16%) and tumors (10%). The development of new, "non-invasive", investigative methods such as echography and tomodensitometry has led to an decrease in the number of liver biopsies performed annually, but no change in the relative frequency of the various indications. In this paper, evidence is presented which demonstrates that hepatic biopsy confirmed the clinical diagnosis in 62.4% of the cases reviewed and fundamentally modified the diagnosis in 20.2%. Based upon these findings, it can be concluded that liver biopsy remains an indispensable diagnostic procedure in the field of hepatology, since it can result in modification of the clinician's diagnosis in one out of five cases.