Symptomatic hepatic cysts: treatment with single-shot injection of minocycline hydrochloride

PURPOSE

To assess the efficacy of percutaneous minocycline hydrochloride sclerotherapy in symptomatic hepatic cysts.

MATERIALS AND METHODS

From November 1992 to June 1994, seven of eight consecutive adults with large symptomatic hepatic cysts (diameter, 55-130 mm) were treated with a single intracystic injection of minocycline hydrochloride in an ambulatory procedure. Five patients had a solitary cyst, and two had polycystic liver disease. The target cyst was punctured under ultrasound guidance and local anesthesia with a 22-gauge Chiba needle. Half of the cyst content was aspirated before injection of 100-500 mg of minocycline hydrochloride diluted in 5-25 mL of saline. The minocycline hydrochloride was left in the cyst at the end of the procedure.

RESULTS

After a mean follow-up of 28 months (range, 24-42 months), all five patients with solitary cysts were asymptomatic and four had documented complete cyst regression; the two patients with multiple hepatic cysts showed only transient clinical improvement.

CONCLUSION

Single-shot injection of minocycline hydrochloride is an effective treatment for symptomatic solitary hepatic cysts but is less effective in polycystic liver disease.

Total parenteral nutrition-related liver disease

Administration of parenteral nutrition to the small infant has decreased morbidity but is associated with the development of cholestasis and liver dysfunction in a high proportion of infants. In this review, contributing factors of the etiopathogenesis of parenteral nutrition-associated liver disease will be outlined, forming the basis for a unifying theory of its pathogenesis. It is proposed that oxidant stress and stimulation of hepatic Kupffer cells by bacterial cell wall products absorbed from the injured intestine are major factors leading to cholestasis and liver injury during prolonged parenteral nutrition. Improved outcome in patients has been related to the early introduction of feedings. New proposed therapeutic modalities have included antibiotics and probiotics to prevent bacterial overgrowth of the small intestine, enterally-administered ursodeoxycholic acid and intravenous cholecystokinin. Improved understanding of the fundamental mechanisms producing liver injury and fibrosis during parenteral nutrition will lead to new preventative and treatment measures in the future.

Gastrointestinal disease and its management

Gastrointestinal (GI) diseases involving the alimentary tract and hepatobiliary system are common in geriatric dogs and cats. Inflammatory disorders predominate, but motility disturbances and degenerative lesions may also cause GI signs in affected animals. Treatment is directed at correction of the underlying cause and often requires tissue biopsy. The prognosis is good in many diseases with appropriate drug nutritional, and/or surgical therapy.

Inherited metabolic diseases of the liver

Since the time of Garrod, many of the intermediate steps of metabolism have been precisely characterized, defects pinpointed and genes identified. Certain liver diseases can be clearly attributed to mutations of genetic material resulting in alterations of metabolism or transport. Various types of metabolic disorders, each of which causes serious liver disease by quite different pathophysiologic mechanisms, are described in this paper. Metabolic disease can mimic any form of acute or chronic liver disease. Prompt recognition is crucial since some of these disorders are treatable, often dramatically so. Precise diagnosis is also imperative in order to inform the patient and their family of the genetic nature of the illness and the risk for recurrence.

Single-session alcohol sclerotherapy in benign symptomatic hepatic cysts

PURPOSE

To evaluate the results of single-session alcohol sclerotherapy in benign symptomatic liver cysts.

MATERIAL AND METHODS

Ten cysts (volume 200-4,800 ml) in 10 patients were treated by percutaneous catheterization and injection of 96% ethanol at a dose of 10% of the cyst volume but never more than 100 ml. The treatment was applied for a maximum of 20 min, after which the alcohol and catheter were removed.

RESULTS

A satisfactory reduction in cyst volume was achieved in all patients. In 8 patients there was a re-accumulation of fluid during the first period after therapy, followed by a significant reduction in volume on later follow-up examinations. Except for pain, there were no complications.

CONCLUSION

Sclerotherapy as a single-session procedure resulted in a significant reduction in cyst volume in all 10 patients. The postprocedural re-accumulation of fluid seen in 8 patients proved to be temporary. It was not necessary to repeat the sclerotherapy procedure in any patient.

Spontaneous subcapsular hepatic hemorrhage associated with pregnancy: report of a case

We report herein a case of spontaneous subcapsular hepatic hemorrhage which occurred in a 33-year-old woman 1 day after she had been delivered of her second child by cesarean section following an uneventful pregnancy. She complained of right upper quadrant pain on the 1st postoperative day, and computed tomography (CT) showed subcapsular low-density masses in both liver lobes, while extravasation was demonstrated by CO2 intraarterial digital subtraction angiography (IADSA). The hemorrhage was successfully controlled by transcatheter arterial embolization (TAE). However, on the 3rd day after TAE, an exploratory laparotomy was performed to establish an exact diagnosis to explain the persistent abdominal pain and abnormal liver function tests. Subcapsular hematomas in both lobes were confirmed and no visible laceration was present. The patient recovered gradually by spontaneous absorption of the hematomas and was discharged on the 22nd postoperative day. Spontaneous hepatic hemorrhage associated with pregnancy is a very rare complication, and establishing a correct diagnosis and initiating appropriate therapy are essential for this life-threatening disease.

[Controlling complications in laparoscopic cholecystectomy: diffuse parenchyma hemorrhage in the liver parenchyma]

The inflammatory pericholecystic reaction to acute or subacute cholecystitis results in the involvement in the inflammatory process of connective tissue within the liver bed, with subsequent neovascularization. The inflamed wall of the gallbladder and the surrounding connective tissue also involved in the inflammatory process become fused together thus preventing dissection in this plane. As a result, the gallbladder affected by acute cholecystitis frequently has to be dissected directly out of the liver parenchyma. The resulting diffuse parenchymal bleeding proves difficult to control by cauterization. In addition, there is a danger of postoperative bile leakage occurring. Today, the use of fibrin sealing is accepted practice in the treatment of oozing haemorrhage from the resection surface of the liver following resective surgery, and for the prevention of postoperative biliary fistulae. Using special application systems, the two-component fibrin sealing can now also be employed under video-endoscopic control. Through direct application of the adhesive to the parenchyma in the liver bed using a flexible catheter, diffuse oozing bleeds can be effectively arrested. In addition, coagulation-related parenchymal necroses associated with the development of biliary fistulae can be avoided. The technique of video-endoscopic controlled fibrin sealing is an important method of preventing and controlling complications arising during video-endoscopic surgery.

Recent developments in autoimmune liver diseases

Several diseases are regarded as autoimmune liver diseases. Apart from the cholestatic liver diseases, primary biliary cirrhosis, primary sclerosing cholangitis, these include autoimmune hepatitis, hepatitis as part of the autoimmune polyendocrine syndrome type 1 (APS-1) and particular overlap syndromes such as autoimmune cholangitis (also called antimitochondrial antibody negative primary biliary cirrhosis [PBC]), overlap syndrome chronic active hepatitis (CAH)/PBC and the overlap syndrome primary sclerosing hepatitis (PSC)/CAH. In addition, auto-antibodies may be observed during the course of chronic viral hepatitis, in particular chronic hepatitis C and D. Finally, a small number of drug-induced liver diseases is immune mediated. The following article will review our recent progress in the field of autoimmune hepatitis including APS-1 and autoimmunity in viral hepatitis and immune-mediated drug-induced liver disease.

Review article: gene therapy in gastroenterology and hepatology

Gene therapy for diseases of the gastrointestinal tract is an exciting prospect because of the fundamental cure that is potentially available. The gastrointestinal system, and especially the liver, is an area that will be central to the development of gene therapy. Techniques for gene replacement include homologous recombination and gene augmentation. For the treatment of cancer antisense strategy, pro-drug activation systems and gene immunotherapy are being investigated. Gene-carrying vectors divide into viral- and non-viral-based vectors, each with advantages and limitations. The accurate delivery of these vectors to sufficient numbers of target cells in vivo is still a major barrier to clinical use. Diseases that may be helped by gene therapy include: gastrointestinal malignancies, viral hepatitis, the haemophilias, hypercholesterolaemia, alpha 1-antitrypsin deficiency, and metabolic diseases of the liver and cystic fibrosis. In this review we will outline the principles of gene therapy, delivery vectors under investigation, diseases that may benefit from this technology and some of the remaining problems to be overcome.

Care of the patient and management of complications after percutaneous coronary artery interventions

Certain aspects of patient management are common with conventional balloon angioplasty and newer coronary artery interventions. These aspects include the evaluation of chest pain or treatment of acute vessel closure shortly after the intervention, management of the vascular access site (especially if complications occur), prevention and treatment of contrast-induced renal dysfunction, and the use of anticoagulant or antiplatelet agents after the procedure. However, some aspects of management vary among techniques. Several different drug therapies are indicated after these procedures, but pharmacologic therapy for restenosis has been largely unsuccessful. Placement of an intracoronary stent decreases the frequency of restenosis and subsequent revascularization procedures, and functional testing may be of value in some patients after coronary artery interventions. It is important for the specialist in internal medicine to have a firm working knowledge of the various aspects of care that are required because their role in management is increasing.

Paracetamol hepatotoxicity

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Molecular biological methods in diagnosis and treatment of liver diseases

Molecular biology is making a tremendous impact on the diagnosis and treatment of liver diseases. Methods such as the polymerase chain reaction are changing the way physicians diagnose and monitor patients with viral hepatitis. Assays based on recombinant protein antigens allow for detection of specific autoantibodies in diseases such as primary biliary cirrhosis. The diagnosis of inherited metabolic diseases, such as hemochromatosis and Wilson disease, is being revolutionized by discovery of the defective genes involved and the development of methods to rapidly sequence DNA and identify mutations. Treatments and preventive measures are now possible with use of drugs and vaccines produced by recombinant DNA technology. Gene therapy and nucleic acid-based therapeutics are also realistic future treatment options for individuals with liver diseases.

Inhibition of nitric oxide modulates the effect of oral arginine supplementation in acute liver injury

BACKGROUND

Arginine possesses numerous unique and advantageous biochemical and pharmacologic properties. We have previously shown that arginine supplementation in an acute liver injury model reduces both the extent of the liver injury and bacterial translocation. We therefore studied the role of nitric oxide on the effects of oral arginine supplementation in acute liver injury, bacterial translocation, ileal and cecal mucosal nucleotides, and RNA and DNA, to investigate pathogenetic mechanisms.

METHODS

Sprague-Dawley rats were divided into normal, liver injury control, N-nitro-L-arginine methyl ester (L-NAME), arginine, and L-NAME + arginine supplementation groups. Oral supplementation was performed daily through a nasogastric tube for 8 days. Acute liver injury was induced on the 8th day by intraperitoneal injection of D-galactosamine (1.1 g/kg body weight). Twenty-four hours after the liver injury, liver function tests, bacterial translocation, and ileal and cecal mucosal nucleotides, RNA, and DNA were evaluated.

RESULTS

Bilirubin and liver enzymes increased significantly in the L-NAME group compared with the arginine group, whereas the liver enzymes increased significantly compared with the liver injury control group. In the L-NAME group the number of bacteria translocated to the portal and arterial blood increased significantly compared with all groups. In the arginine group the bacteria translocated to the liver and mesenteric lymph nodes decreased significantly compared with the liver injury control and L-NAME groups. The ileal and cecal mucosal nucleotides, RNA, and DNA in the arginine group increased significantly compared with the normal, liver injury, and L-NAME groups.

CONCLUSIONS

Nitric oxide plays a role in the beneficial effect of the arginine supplementation in acute liver injury. It significantly improves the liver damage indicated by the increase of liver enzymes when its production was inhibited by L-NAME. Nitric oxide has a role in bacterial translocation since the number of bacteria significantly increased in arterial and portal blood when L-NAME was used to inhibit its production. Furthermore, arginine supplementation improved mucosal nucleotides, RNA, and DNA in ileum and colon.

Transfusion requirements are correlated with the degree of proteolysis of von Willebrand factor during orthotopic liver transplantation

During orthotopic liver transplantation (OLT) excessive bleeding is the main cause of death and graft failure. The acute bleeding tendency that accompanies OLT, particularly during the anhepatic period and after reperfusion of the graft, is due to the depletion or functional abnormalities of several hemostasis components caused by the enhanced activity of enzymes such as plasmin, trypsin and leukocyte proteases. We surmised that enhanced proteolysis might also cause abnormalities of von Willebrand factor (vWF), and that these abnormalities are implicated in the bleeding tendency that develops during OLT. Therefore, the pattern of vWF proteolysis was studied with 16 patients with chronic liver disease, in serial blood samples obtained before OLT, during the anhepatic stage, after graft reperfusion and at the end of the surgical procedure. vWF became markedly degraded during the anhepatic and reperfusion stages, as shown by the partial loss of high molecular weight multimers, the relative decrease of the intact 225 kD subunit and the increase of the native proteolytic fragments of 176 and 140 kD. Novel proteolytic fragments also became detectable. Using monoclonal antibody epitope mapping, it could be demonstrated that some of the proteolytic fragments corresponded in apparent molecular mass to those produced in vitro by incubating purified vWF with plasmin or elastase, but other fragments could not be attributed to these proteases. During the anhepatic and reperfusion stages there was a significant correlation between the degree of vWF degradation and the total amount of blood components transfused to replace blood losses. To evaluate whether or not vWF degradation could be controlled by the administration of a broad-spectrum protease inhibitor such as aprotinin, 5 patients were given a bolus dose of 500,000 U before surgery followed by 100,000 U/h during surgery, 5 were given a 2,000,000 U bolus followed by 500,000 U/h, and no aprotinin was given to the remaining 6 patients. There were no differences in the patterns or degrees of vWF degradation between patients treated with aprotinin or not. In conclusion, there is a marked degradation of a key hemostasis protein during OLT. These alterations may be of clinical significance, because they are correlated with the transfusion requirements.