Exacerbation of hepatic encephalopathy by chronic renal failure: response to maintenance hemodialysis

The consequences of chronic renal insufficiency relevant to hepatic failure are not well appreciated. We describe a patient with chronic cirrhosis and marked porto-systemic shunting who, after the onset of chronic renal failure, developed intractable encephalopathy which improved markedly during an eight month period of maintenance hemodialysis.

The comparative survivals of alcoholics versus nonalcoholics after distal splenorenal shunt

Survival after distal splenorenal shunt in appreciably better in nonalcoholic patients than in alcoholics. This increase in survival does not appear to be dependent upon the state of biochemical liver function or the severity of changes in liver histology since these latter were similar for both groups. We suggest that the poorer survival of alcoholics may be related to continuing alcohol toxicity, and that a possible reason for the failure to demonstrate this difference in survival after portacaval shunts may be due to the harmful effects of total portal diversion on the liver.

Type B hepatitis after needle-stick exposure: prevention with hepatitis B immune globulin. Final report of the Veterans Administration Cooperative Study

Hepatitis B immune globulin (HBIG) and immune serum globulin (ISG) were examined in a randomized, double-blind trial to assess their relative efficacies in preventing type B hepatitis after needle-stick exposure to hepatitis B surface antigen (HBsAG)-positive donors. Clinical hepatitis developed in 1.4% of HBIG and in 5.9% of ISG recipients (P = 0.016), and seroconversion (anti-HBs) occurred in 5.6% and 20.7% of them respectively (P less than 0.001). Mild and transient side-effects were noted in 3.0% of ISG and in 3.2% of HBIG recipients. Available donor sera were examined for DNA polymerase (DNAP) and e antigen and antibody (HBeAg; anti-HBE). Both DNAP and HBeAg showed a highly statistically significant correlation with the infectivity of HBsAg-positive donors. Hepatitis B immune globulin remained significantly superior to ISG in preventing type B hepatitis even when the analysis was confined to these two high-risk subgroups. The efficacy of ISG in preventing type B hepatitis cannot be ascertained because a true placebo group was not included.

Intrahepatic hematoma resulting in obstructive jaundice. An unusual complication of liver biopsy

A patient who developed obstructive jaundice as a complication of a liver biopsy is presented. The jaundice was found to be attributable to obstruction of the biliary tree at the level of the bifurcation by an intrahepatic hematoma. The patient had a complete and spontaneous recovery.

Percutaneous aspiration liver biopsy using a large-caliber disposable needle: a preliminary report

A modification of the aspiration liver biopsy technique using a large-caliber disposable needle is described in an 18-month experience. One hundred forty liver biopsies were performed, obtaining adequate tissue in 98% of the patients. Complications occurred in 12 patients and were limited to pain at the biopsy site, epigastrium, or right shoulder; one instance of tachycardia and three of transient hypotension occurred. Thirty patients studied prospectively with liver scans and hematologic parameters failed to disclose subclinical complications. While the number of patients biopsied is still too small to provide definite conclusions , it appears that this technique is safe, similar and has a very high yield of excellent specimens. In addition, the needle offers the advantage of being disposable and easy to use by a single operator.

Survival after distal splenorenal shunt

These data support the conclusions that the distal splenorenal shunt is attended by the highest post-shunt survival as yet reported for patients with non-alcoholic cirrhosis, portal hypertension and bleeding varices; the procedure is safe, and in this series, the mortality has been nil for 66 consecutive operations. An analysis of the causes of death suggests that continued alcohol abuse plays an important part in the late mortality among those in the post-shunt alcoholic cirrhosis group.

Percutaneous transhepatic cholangiography with the "skinny" needle. A rapid, simple, and accurate method in the diagnosis of cholestasis

One hundred thirty-one cases of cholestasis were evaluated by "skinny" needle percutaneous transhepatic cholangiography. The biliary tree was seen in 129 patients (98.5%). When the biliary tree was dilated, a success rate of 100% was obtained. In the 45 patients with nondilated ducts, visualization was achieved in 95.6%. There was no mortality, early operation, or transfusion requirement associated with the procedure. This form of cholangiography is a simple, reliable, and extremely high-yield technique for evaluating patients with cholestasis.

The effect of the distal splenorenal shunt on hypersplenism

Twenty-four patients with leukopenia and/or thrombocytopenia improved these deficiencies after distal splenorenal shunts. The average white blood cell count for 23 neutropenic patients increased by an average 1000 cells/cu.mm p less than .01. The average platelet count for 13 thrombocytopenic patients increased by more than 40,000, p less than .02. Analysis of the data showed that patients older than 50 years, with a history of alcoholic liver disease and sinusoidal hypertension greater than 15mm Hg were most likely to correct leukocyte and platelet defects after distal splenorenal shunts.

Noncirrhotic portal hypertension in Felty's syndrome

A case of Felty's syndrome with nodular regenerative hyperplasia of the liver, presinusoidal portal hypertension, and bleeding esophageal varices is reported. Increased splenic blood flow may be a contributing factor to the development of the regenerative nodules. The portal hypertension is postulated to be a result of intrahepatic vascular compression.

A randomized, double blind controlled trial of the efficacy of immune serum globulin for the prevention of post-transfusion hepatitis. A Veterans Administration cooperative study

A double blind, randomized, controlled trial has been conducted in 11 Veterans Administration hospitals during a 49-month period to compare the relative efficacies of immune serum globulin (ISG) and an albumin placebo for the prevention of post-transfusion hepatitis (PTH). A total of 2204 patients, of whom 1094 received ISG, participated in the study. The results indicate that ISG significantly reduced the incidence of icteric type non-B hepatitis only (inferred to be also type non-A hepatitis). Adverse reactions were rare, and the ISG did not significantly alter the incubation period or duration of the disease. The data suggest, however, that a similar reduction in type non-A, non-B hepatitis would have occurred had commercial blood been excluded from use. Analysis of the 241 patients who developed hepatitis indicates that type B hepatitis constituted less than 20% of the cases each year of the study. Furthermore, the efficacy of the ISG, manufactured in 1944, against apparent type non-A, non-B hepatitis suggests that this overlooked disease has existed from at least that time. Host- and transfusion-related factors that might have modified the development of PTH were examined. The use of commercial blood was observed to be the most important risk factor. It is concluded that the PTH incidence can be most effectively reduced by eliminating commercial donor blood, and continuing to screen volunteer donors for hepatitis B surface antigen (HBsAg) by sensitive procedures. Of prime importance is the need to define the agent(s) responsible for type non-A, non-B hepatitis.

Effect of acute uremia on arginine metabolism and urea and guanidino acid production by perfused rat liver

Since arginine is a precursor of urea and other guanidino derivatives, we have evaluated its metabolism in acute uremia using the isolated perfused rat liver. Female Sprague-Dawley rats underwent bilateral nephrectomy (n = 5) or sham operation (n = 5) 48 h prior to liver perfusion. Fifty microCi of L-[guanidino 14C] arginine and unlabelled arginine and aspartic acid were added to the recycling perfusate 15 min prior to liver perfusion. Perfusate concentrations of urea and other guanidino derivatives were measured with high-pressure liquid chromatography. After the initial 30 min of perfusion, net uptake of arginine was lower, and net release of guanidino-succinic acid (GSA) was higher in the livers of acutely uremic rats. Net release of urea was also higher in uremia but the results did not achieve statistical significance. In uremia, the percent conversion of 14C arginine to 14C urea was significantly higher (79 +/- 5 [SE]%) than in controls (58 +/- 7%). These results demonstrate increased GSA production by livers of acutely uremic rats and suggest that acute uremia may be associated with increased arginine utilization and increased production of urea.

Congenital hepatic fibrosis with dilation of intrahepatic bile ducts. A therapeutic approach

A case of congenital hepatic fibrosis with dilation of the intrahepatic ducts is presented. External drainage and lavage of the biliary tract through a prosthetic "Y" tube and internal drainage accomplished by a Roux en-Y cholangiojejunostomy resulted in prevention of the patient's recurrent bouts of cholangitis and sepsis. Surgical therapy for recurrent cholangitis in this disease is reviewed.

Percutaneous cholangiography with the Chiba University needle: a new, safe, and accurate method in the diagnosis of cholestatic syndromes

A modified technique of percutaneous transhepatic cholangiography utilizing the Chiba University needle is described. This new technique employs injection of dye through a thin flexible 22 gauge needle with a short bevel while it is slowly withdrawn under a fluoroscopic monitoring. The results of several investigators are reviewed and indicate that failure to visualize the biliary radicals with the Chiba University needle virtually rules out extrahepatic obstruction. It is anticipated that this technique will replace the traditional sheathed needle cholangiography as a diagnostic modality in the evaluation of the jaundiced patient.

Percutaneous transhepatic cholangiography utilizing the Chiba University needle

Percutaneous transhepatic cholangiography with the Chiba University needle has been performed in 42 patients with cholestasis. The examination was successful in 100% of patients with dilated intrahepatic bile ducts and in 89% of those with normal-size ducts. Complications were minimal. The results of this study suggest that PTC with the Chiba needle is superior to the current conventional methods. The patients with intrahepatic cholestasis, which often simulates extrahepatic biliary obstruction, were spared an unnecessary laparotomy.

Bile duct carcinoma mimicking chronic liver disease

In a case of cholangiocarcinoma involving the bifurcation of the common duct, the association with striking intermittence of jaundice and with signs of chronic liver disease presented a diagnostic enigma. Disappearance of jaundice does not rule out the diagnosis of bifurcation tumors and may be misleading. Adequate demonstration of the biliary tree, best achieved with percutaneous transhepatic cholangiography, is essential for early diagnosis of this entity.

The fate of esophageal varices following selective distal splenorenal shunt

Esophagographic evaluation of the fate of esophageal varices after distal splenorenal shunt was obtained. The radiologist-observer was blinded as to the surgical status of the films under study. The results indicate that varices are likely to persist after surgery. However, the sizes of the varices are clearly diminished following selective distal splenorenal shunt. The incidence of postoperative bleeding has been low, 3.7% (2/54) or one episode for each 441 months of postoperative survival.

Efficacy of hepatitis B immune serum globulin after accidental exposure. Preliminary report of the Veterans Administration Cooperative Study

A randomised, double-blind, controlled trial has been undertaken to compare the efficacy of hepatitis B immune globulin (H.B.I.G.) with that of immune serum globulin (I.S.G.) for the prophylaxis of viral hepatitis. Participants in the trial were individuals exposed accidentally to material infectious for hepatitis (primarily viral B hepatitis). Preliminary evaluation of the first 302 of the 561 individuals entered into the study indicates that H.B.I.G. significantly reduced the frequencies of both clinical and subclinical hepatitis during the first 3--4 months after the injection. Less than 10% of H.B.I.G. recipients had detectable anti-HBs at the sixth month after the injection, suggesting that H.B.I.G. might need to be given every 3--4 months to continually exposed individuals. Further long-term evaluation is required in order to define more clearly those most likely to benefit from H.B.I.G.

67Gallium accumulation in hepatic actinomycosis

A case of actinomycosis involving the liver is reported. The liver scan with 99mTcS colloid showed multiple areas of focal abnormalities. 67Gallium citrate liver scan showed these areas to concentrate intensely. This pattern of differential hepatic scintigraphy is seen in pyogenic abscesses as well as malignancy of the liver. Actinomycosis may mimic the clinical picture of a malignant neoplastic process, making the differential diagnosis of 67Ga-positive lesions of the liver more difficult.

Hepatic disease in asymptomatic parenteral narcotic drug abusers: a Veterans Administration collaborative study

The Veterans Administration is currently conducting a collaborative study in three hospital-based drug treatment clinics to evaluate asymptomatic parenteral drug addicts for evidence of hepatic disease. Preliminary data are presented on 347 patients who have completed at least three months of follow-up evaluation. On admission, abnormal serum transaminase values were demonstrated in one half, HBs Ag in 7 per cent, and anti-HBs in 59 per cent. The frequency of these findings increased during the follow-up evaluation, only 19 (5.5 per cent) remaining entirely free of one or more of these abnormalities. Definable hepatologic disease (acute or chronic hepatitis, alcoholic hepatitis) developed in 46 per cent of the patients. However, among 60 of them subjected to liver biopsy, a poor correlation was noted between the clinical and histologic diagnoses. In particular, routine liver function and immunologic tests did not discriminate between histologically detected chronic active and chronic persistent hepatitis. However, HBs Ag was present significantly more frequently in those with chronic active hepatitis. Wide variability of histologic diagnoses was seen among patients subjected to more than one biopsy, apparent progression and regression of the lesion being noted. This demonstrates the hazard of attempting to assign a prognosis to the disease on the basis of a single liver biopsy specimen, and suggests that repeated biopsies should be mandatory for the evaluation of chronic liver disease in drug addicts.

Hepatitis in dental professionals

To characterize some epidemiologic characteristics of viral hepatitis among dentists, information was obtained with a mailed questionnaire from 434 dentists and 787 attorneys in Dade County, Florida. Dentists had a significantly higher incidence of hepatitis than did lawyers, 6.7% vs 2.4%, with the highest rate among oral surgeons (21%). The incidence of hepatitis B antigenemia among asymptomatic dentists was not significantly higher than that of volunteer blood donors. Twenty-two percent of dentists with hepatitis reported treating more than ten drug addicts per year, as compared with 10% of those dentists without hepatitis. No differences were noted between dentists with and without hepatitis in methods of sterilization, the wearing of gloves during procedures, or the use of disposable needles. The increased risk of hepatitis among dentists, however, may be related to the omission of adequate prophylatic measures, particularly when treating high-risk patients such as drug abusers.

Presence of serum alpha-1-fetoprotein in alcoholic hepatitis

Alpha-Fetoprotein was detected in a patient with alcoholic hepatitis during the acute phase of the illness. The alpha-fetoprotein was no longer detected as clinical improvement developed. No evidence of malignant disease was found after an extensive evaluation. This case represents another example of a non-neoplastic disease associated with the presence of increased serum levels of alpha-fetoprotein.

Clinical approach to jaundice

Jaundice, with and without hepatobiliary damage, has a wide spectrum of causes. In the initial evaluation, fractionation of the bilirubin facilitates differential diagnosis. Unconjugated hyperbilirubinemia most often is the result of pigment overload or Gilbert's disease. Most patients with jaundice seen by the clinician have underlying hepatobiliary disease. Liver biopsy usually establishes the etiology of hepatocellular forms of jaundice. In patients with cholestasis, visualization of the biliary tree by either transhepatic or endoscopic retrograde cholangiopancreatography provides the most direct means of differentiating mechanical biliary obstruction from intrahepatic cholestasis.

Characterization of the kinetics of the passive and active transport mechanisms for bile acid absorption in the small intestine and colon of the rat

Bile acid uptake occurs via passive diffusion in all regions of the intestine and via active absorption in the ileum. Determination of the passive permeability coefficient for ionized monomers ((*)P(-)) demonstrated that permeability decreased by a factor of 3.4, 6.8, and 8.1 for the addition of a hydroxyl, glycine, or taurine group, respectively, to the steroid nucleus. Removal of the negative charge increased permeation by a factor of 4.4; however, permeability coefficients for the protonated monomers showed the same relative decrease with addition of a hydroxyl group. The calculated incremental free energies of solution (deltaDeltaF(W-->1)) associated with these additions equaled + 757 (hydroxyl), + 1178 (glycine), and + 1291 (taurine) cal/mole. Passive permeability coefficients for the transverse colon showed the same relative relationships among the various bile acids. After making appropriate corrections for passive permeability across the ileum, apparent values for the maximal transport velocity ((*)V(max)) and Michaelis constant ((*)K(m)) of the active transport system were measured. (*)V(max) depended upon the number of hydroxyl groups on the steroid nucleus; values for the trihydroxy bile acids were high (1543-1906 pmoles/min per cm) while those for the dihydroxy (114-512 pmoles/min per cm) and monohydroxy (45-57 pmoles/min per cm) acids were lower. In contrast, (*)K(m) values were related to whether the bile acid was conjugated; unconjugated bile acids had values ranging from 0.37 to 0.49 mM, while values for the conjugated bile acids were approximately half as high (0.12-0.23 mM).