[The efficacy of flower pollen in patients with rheumatoid arthritis and concomitant diseases of the gastroduodenal and hepatobiliary systems]

Kept under medical surveillance were 93 patients with rheumatoid arthritis (RA) of different degrees of activity, articular and visceral manifestations. Of these, 83 had apparent and latent afflictions of the gastroduodenal and hepatobiliary systems (gastritis, gastroduodenitis, peptic ulcer, cholecystitis, hepatitis). Floral pollen (FP) was used as a gastro- and hepatocytoprotectors. FP had a marked positive effect on disorders of the gastroduodenal and hepatobiliary systems and, to a lesser extent, on clinical manifestations and course of RA, as evidenced by clinical and biochemical, endoscopic, and ultrasonic investigations.

[37 so-called biliary cysts of the liver in adults]

Clinical manifestations, clinical course and therapeutic schemes were studied in 37 patients with a surgical indication for biliary cysts of the liver observed in a surgery unit over 25 years. Cyst size varied from 2 to 30 cm and was greater than 10 cm in 12 cases. Yellowish-clear contents were observed in 23 cases and purulent or hemorrhagic contents in 3 each. Twenty-three patients were asymptomatic, 14 had pain and/or complications (hemorrhage 3, infection 3, compression 3, rupture 1). Therapy was abstention in 7 cases, puncture in 5, resection of the protruding dome in 17, complete exeresis in 5, and hepatectomy in 3. There were no deaths and morbidity reached 7%. Biliary cysts of the liver can be discovered fortuitously at surgery or imagery or in patients with abdominal pain, an abdominal mass or complications including compression, intraperitoneal rupture, intracystic hemorrhage, hemobilia, acute infection, torsion, cancerization. Diagnosis requires sonography and computed tomography. Therapeutic indications are: abstention for small asymptomatic cysts. For voluminous cysts, with complications or confirmed during a supramesocolic operation, the risk of recurrence or aggravation of the complications excludes puncture or injection of a sclerosing agent. Wide resection of the protruding part of the cyst with histology resection can be performed although prospective assessment is needed. Cystectomy is not indicated if there is a diagnostic doubt. Hepatectomy is an exceptional indication retained for patients with uncontrolable hemorrhage, intra-cystic tumors or voluminous cysts destroying the lobe.

Cholestatic liver diseases in adults

Cholestatic liver diseases are a diverse group of disorders that are recognized by either increases in laboratory studies or the appearance of jaundice, fatigue, pruritus, and/or complications of cirrhosis. The etiologies for most forms of these diseases are unknown. In this paper, diagnostic and therapeutic strategies are reviewed for select forms of cholestatic disorders and for the management of shared complications of cholestatic illness.

Hepatobiliary and pancreatic infections in AIDS: Part one

Infections of the liver and biliary tract are common during the course of AIDS. A variety of viral, bacterial, fungal, and other opportunistic infections can present with hepatobiliary involvement as either the primary site of infection or secondary to a disseminated process. Coinfection with hepatitis B and C are particularly common due to the shared means of transmission of these viruses with HIV. The typical presenting features of hepatobiliary infections are right upper quadrant (RUQ) pain and abnormal liver function tests. Initial evaluation should include an RUQ ultrasonogram, which will usually identify abnormalities in the biliary tract and may demonstrate some parenchymal abnormalities as well. A liver biopsy is necessary to determine the etiology of focal hepatic lesions or opportunistic infections within hepatic parenchyma when other less invasive tests are negative or inconclusive. Special stains and culture techniques are required to identify specific organisms in the biopsy specimen. HIV-related biliary disorders include acalculous cholecystitis, which is a potentially serious condition requiring prompt recognition and gallbladder decompression. AIDS-cholangiopathy is a form of cholangitis involving the intra- and/or extrahepatic biliary tree. Endoscopic retrograde cholangio-pancreatography (ERCP) is the test of choice, demonstrating the stricturing, dilatation, and beading of bile ducts seen in this condition. Endoscopic sphincterotomy of the papilla of Vater may provide symptomatic relief for patients with papillary stenosis. Opportunistic infections of the pancreas have been reported. Evaluation should include a computerized tomogram of the abdomen and possible pancreatic tissue aspiration or biopsy. Management of pancreatitis is supportive.

Risks associated with conversion of stable patients after liver transplantation to the microemulsion formulation of cyclosporine

BACKGROUND

Neoral is a microemulsion formulation of cyclosporine that has a better pharmacokinetic profile than the standard formulation (Sandimmune). To prove the safety of converting stable liver transplant patients from Sandimmune to Neoral, we conducted a prospective trial involving 54 patients.

METHOD

The average time from transplantation to conversion was 48.5+/-21.6 months. Thirty of 54 patients (55%) required a dose reduction during the study for various reasons. Five of 30 patients had the first dose reduction because of increased levels of cyclosporine. Seven patients required more than one dose reduction.

RESULTS

Sixteen patients suffered serious adverse events. Six patients had a biopsy-proven rejection. Four of 6 patients had trough cyclosporine levels within 20% of baseline value immediately before developing rejection.

CONCLUSION

Converting patients from the standard formulation to the microemulsion formulation of cyclosporine seems to expose stable patients to unnecessary risks.

Liver hematoma and rupture in pregnancy

Liver hematoma and rupture is a rare but devastating complication of pregnancy. The majority of cases have been associated with severe preeclampsia, but unlike typical preeclampsia, it is a disease of older, multiparous patients. Although there are predictable findings on liver pathology, the underlying pathophysiology is poorly understood. Early recognition and prompt surgical intervention are crucial to reduce the high fetal and maternal mortality rate associated with this disease.

The liver in traditional Chinese medicine

Medical thinkers in China visualized the liver in microcosmal and macrocosmal terms. An anatomical tradition did not exist, hence the liver was described grossly in broad outline. It was recognized as being functionally important in the movement of qi (vital energy) and storage of xue ('blood'). The liver corresponded to various phenomena in both the natural and social orders, according to the scheme of yin yang and five phases. These interrelationships provided the basis for the diagnosis and treatment of liver dysfunctions. The disorders fell into three general groups: (i) hepatic qi stasis; (ii) hepatic yang excess with yin deficiency; and (iii) hepatic yin insufficiency. The signs and symptoms represented the logical outcomes of the disturbed physiology. Acupuncture, moxibustion and herbal drugs were used to redress the imbalance of hepatic qi and yin-yang. The impact of Western medicine led traditional authors to recognize the hepatobiliary role in bile secretion and in jaundice. The exchange between the Western and Chinese medical traditions revealed that active agents were included in the Chinese formulary, such as glycyrrhizin, which has recently been shown to be beneficial in chronic viral hepatitis.

[Puncture sclerosing treatment of nonparasitic liver cysts]

The article describes the method and results of the puncture sclerotherapy of nonparasitic liver cysts in 30 patients. Cooled to -28 degrees C 96% ethyl alcohol was used as a sclerosing agent. The total destructive effect of the agent was obtained due to the combination of its chemical and physical (temperature) factors. Complete recovery was obtained in 86.6% of the patients. The puncture sclerotherapy can be used as a medical alternative for nonparasitic liver cysts.

Coexistence of hereditary hemorrhagic telangiectasia and fibropolycystic liver disease

This is a case report of a 43-year-old woman who received a transplant for end-stage liver disease due to hereditary hemorrhagic telangiectasia and fibropolycystic liver disease. This is an uncommon association of two autosomal-dominant conditions with defined genetic and molecular defects. The liver showed extensive vascular malformations of arteries and veins as well as telangiectasia and fibrosis. In addition, there were cystically dilated ducts containing inspissated bile and extensive von Meyenburg complexes. This case raises interesting questions about the possible relationship of these genes and their gene products, both of which are related to cell-matrix interactions and are strongly associated with blood vessels, one of them being expressed on endothelial cells and the other being developmentally important in blood vessels.

Liver problems in pregnancy: part 2--managing pre-existing and pregnancy-induced liver disease

In distinguishing normal from abnormal hepatic changes, the author described the expected changes in liver tests that occur during complicated pregnancy. This article reviews the forms of pre-existing liver disease that may affect or be affected by pregnancy, as well as liver diseases that tend to arise during pregnancy. Among the pre-existing liver diseases are autoimmune chronic active hepatitis, which may be activated by pregnancy and tends to be associated with an increased risk of still and premature births. Worsening of chronic hepatitis B and C has occasionally been observed. While some women with cirrhosis can sustain a normal pregnancy without any worsening of hepatic function, others develop liver failure; plus, women with cirrhosis are less fertile and have higher rates of both stillbirths and premature infants. Other liver disorders that may or may not be affected by pregnancy include Dubin-Johnson syndrome, Gilbert syndrome, benign recurrent intrahepatic cholestasis, Wilson's disease, hepatic adenomas, and focal nodular hyperplasia. Among the hepatic disorders that occur during pregnancy in normally healthy women and then resolve after delivery is intrahepatic cholestasis of pregnancy (also known as pruritus gravidarum, recurrent intrahepatic cholestasis of pregnancy, and obstetric hepatosis). Others include acute fatty liver of pregnancy and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), which may be part of the spectrum of disorders associated with pre-eclampsia/eclampsia. Pregnancy may also trigger the dissemination of herpes infection to the liver.

Treatment of benign hepatic cysts by instillation of tetracycline hydrochloride

BACKGROUND/AIMS

Despite the high frequency of benign hepatic cysts, they rarely cause symptoms. Large cysts, however, may produce clinical manifestations. In these cases, ultrasonography-guided therapy has been proposed. We report the results of this therapy in patients with symptomatic benign hepatic cysts.

METHODOLOGY

Seven patients with non-parasitic, non-neoplastic benign hepatic cysts were submitted to fine-needle ultrasonography-guided aspiration, followed by injection of diluted tetracycline hydrochloride (1 g). In all cases, cytology, tumour markers and microbiology analysis of aspirates were performed. One patient required two sessions. The grade of patient satisfaction and ultrasonography changes were assessed 1, 3 and 6 months after the procedure.

RESULTS

Cyst size decreased in all patient, with total collapse in three. No major complications occurred. Cytology, alpha fetoprotein, CA19.9, CEA and microbiology of the cyst fluid confirmed the initial ultrasonographic diagnosis of simple biliary cysts. Clinical complaints improved in 2 cases, and 5 patients became asymptomatic. Ultrasonography evaluation 3 months after the procedure was more reliable in predicting successful treatment.

CONCLUSION

Intracystic instillation of tetracycline hydrochloride is an effective and safe technique and may become the first choice therapy for benign hepatic cysts.

Metabolic liver disease in the pediatric patient

Most metabolic liver diseases that affect pediatric patients present in the neonatal period with either cholestasis or acute liver failure. Metabolic liver disease in the older child has considerable overlap with adult patients. New diagnostic methods and therapy, including liver transplantation, has radically changed the outcome of many metabolic liver diseases.

Liver disease in cystic fibrosis

CF is a common hereditary disorder of ion transport, with increasing numbers of patients surviving beyond childhood and developing manifestations of hepatobiliary involvement. Inspissated secretions within the biliary tree result in obstruction and periductular inflammation that eventually progresses to focal and then multilobular cirrhosis. Fatty infiltration of the liver and hepatomegaly is common. Variceal hemorrhage and other findings of portal hypertension may be the initial presentation. At present, therapy with high-dose ursodeoxycholic acid should be considered standard, as it has been shown repeatedly to reduce the injurious effects of the cholestasis. Liver transplantation has been successfully performed on those with advanced disease and adequate pulmonary function. Innovative therapies for CF, including gene transfer, appear promising in preliminary studies, offering hope that earlier intervention in the course of hepatobiliary CF may soon be possible.

[Results of treating liver cysts]

In the years 1974-96, 27 patients aged 31-74 were treated for symptomatic pseudocysts. The duration of symptoms ranged from 3 months to 20 years. Patients were complaining for: pain in the upper abdomen (82%), feeling of fullness (59%), nausea and vomiting (41%), weight loss (23%). Diagnosis was confirmed by USG and CT except of two patients who were diagnosed during emergency surgery because of the cyst rupture. Multiple cysts were present in 4 patients others had single cysts. The treatment comprised: excision of the cyst in 13 patients, excision with partial right lobectomy in 4, fenestration in 5 (laparoscopically in two), marsupialisation of ruptured cyst in one and in remaining 4 puncturing or transcutaneous drainage. Good result of treatment was achieved in all cases. Histologic examination of the cysts revealed: serosal cyst in 18, echinococcal in 2, adenoma originating from bile ducts epithelium in the remaining. The follow up period is 3 months to 21 years. No recurrence of the cyst was noted.

Liver disease in the immunocompromised patient

This chapter reviews the most common diseases of the liver that are associated immunodeficiencies resulting from AIDS, chemotherapy and radiation, and bone marrow and solid organ transplantation. Conditions described include liver disease, infection, venoocclusive disease, graft versus host disease, and others.

[The characteristics of the clinical manifestations and treatment of chronic obstructive bronchitis in patients with hepatobiliary system diseases and pseudoallergy]

Routine clinical, laboratory, instrumental and immunological examinations in 105 patients have established that hepatobiliary disorders occur 2.2 times more frequently in patients with chronic obstructive bronchitis (COB) and pseudoallergy than in those without pseudoallergy. To correct negative effects of pseudoallergy, conventional therapy was combined with enterosorbent polyphepan, spasmolytic nospa and cholagogic allochol used alone or in different combinations. The highest benefit for COB patients was achieved in using combination of polyphepan + nospa + allochol.

Hepatobiliary diseases in women

Most diseases of the hepatic and biliary systems affect both women and men. There are several disorders, however, that affect women differently than they affect men. Gallstones, primary biliary cirrhosis (PBC), and autoimmune liver disease occur more often in women. The impact of alcohol on the liver is worse in women. Chronic liver disease from any cause can affect fertility. In addition, oral contraceptive use and pregnancy can have specific effects on the liver.