Minor role of hepatitis B virus in the causation of chronic liver disease in Somalia indicated by a case-control study

Chronic liver disease (CLD) is frequent in Somalia. In a case-control study, 116 in-patients with CLD were compared with the same number of age and sex matched controls. Demographic variables, use of drugs, symptoms and signs, serological markers for hepatitis B virus (HBV) and serum alpha-foetoprotein (AFP) were assessed. Hepatitis B surface antigen (HBsAg) was found in 44 cases of which 17 had antibodies to hepatitis D virus (anti-HD) and 7 had hepatitis B e antigen (HBeAg). Twenty-three controls were HBsAg-positive, of whom 3 had anti-HD and one HBeAg. Increased relative risks (95% confidence intervals in parentheses) were 2.5 (1.3-4.5) for HBsAg, 6.5 (1.7-21.5) for anti-HD, and 7.4 (0.9-66.5) for HBeAg. Despite the association between the presence of HBV markers and CLD, 62% of the cases had no markers indicating current HBV infection. This was reflected in the low risk attributable to chronic HBV infection (22.6%), which was lower than that in patients with CLD in other African populations with a high HBsAg carrier rate. The prevalence of HBV markers did not differ between cases with AFP greater than 100 ng/ml and those with AFP less than 100 ng/ml. The former were characterized by male predominance, shorter duration of symptoms, and larger mean liver size, indicative of malignancy. The mean age of HBsAg-positive cases with AFP greater than 100 ng/ml was significantly lower (by 7.7 years) than that of HBsAg-negative cases with AFP greater than 100 ng/ml. Among the CLD patients with AFP less than 100 ng/ml, 48 were HBsAg-negative. These cases differed significantly from the other 68 cases in that more were females (35% against 16%), more originated from an agricultural area (56% against 30%), and more were regular consumers of drugs (48% against 28%). In conclusion, factors as yet undefined play a considerable role in the causation of CLD in Somalia. The possibility of determining the role of hepatitis C virus (HCV) awaits the development of more specific assays for anti-HCV antibodies.

Treatment of hepatitis B virus infection with interferon. Factors predicting response to interferon

Several randomised controlled trials have been undertaken to evaluate the efficacy of alpha-interferon in the therapy of chronic hepatitis B. In patients with HBe antigen-positive disease acquired in adult life the response rates vary from 25-50%. In those infected at birth, response rates are lower. Twenty-one pretreatment variables were assessed for their significance in response prediction using data from 114 patients given alpha-interferon for chronic hepatitis B virus infection. In those patients who had received a minimum of 90 million units per m2 total dose over 12 weeks, a negative anti-human immunodeficiency virus antibody status (p less than 0.001), chronic active hepatitis on liver biopsy (p less than 0.005), high AST level (p less than 0.001), low hepatitis B virus DNA level (p less than 0.001) and a history of acute hepatitis (p less than 0.005) were all associated with an increased likelihood of response on univariate analysis. On stepwise logistic regression analysis, hepatitis B virus DNA, AST and a history of acute hepatitis predicted response independently (p less than 0.05). The most reliable combination of predictive factors was a negative anti-human immunodeficiency virus antibody status, with either a positive history of acute icteric hepatitis and AST greater than 45 IU per liter or no history of acute icteric hepatitis and AST greater than 85 IU per liter, which predicted response in 77% with a specificity of 79% (p less than 0.001). The loss of HBsAg in addition to HBeAg and hepatitis B virus DNA was more likely to occur in patients with chronic infection of less than 2 years duration (p less than 0.001).

Defects in the precore region of the HBV genome in patients with chronic hepatitis B after sustained seroconversion from HBeAg to anti-HBe induced spontaneously or with interferon therapy

Hepatitis B virus DNA clones were propagated from sera of six patients with chronic hepatitis B who seroconverted from HBeAg to antibody to HBeAg either spontaneously or after administration of alpha-interferon. Defects in the precore region blocking synthesis and secretion of HBeAg were detected in all 46 hepatitis B virus DNA clones from three patients who remained positive for antibody to HBeAg and in whom hepatitis resolved. Defective clones had point mutations from guanine to adenine at nucleotide 83 in the precore region, converting codon 28 from tryptophan (TGG) to a stop codon (TAG). In contrast, this defect was not found in any of 39 hepatitis B virus DNA clones from three patients who seroconverted to antibody to HBeAg but then redeveloped HBeAg with reactivation of hepatitis. Using these results, the G-to-A point mutation at nucleotide 83 in the precore region would predict sustained positivity for antibody to HBeAg and remission of hepatitis in patients who have seroconverted either spontaneously or with interferon therapy.

Prospective study of early detection of hepatocellular carcinoma in patients with cirrhosis

We prospectively monitored 140 cirrhotic patients for the development of hepatocellular carcinoma for 6 yr, using periodical screening by high-resolution convex-array ultrasonography and alpha-fetoprotein. Twenty-eight patients were positive for HBs antigen, 26 patients had received blood transfusions and were negative for HBs antigen and 26 patients had a history of heavy drinking. We detected hepatocellular carcinoma in 40 patients during this period. The overall cumulative incidence of hepatocellular carcinoma in the 6 yr was 39%; the cumulative incidence was 59% in patients with HBsAg, 53% in patients who had had blood transfusions and were negative for HBsAg and 22% in patients who had a history of heavy drinking and who were without HBsAg. Detection of the carcinoma in 85% of these 40 patients was based on results of ultrasonography. Twenty-six of the patients (65%) had a small hepatocellular carcinoma of 2 cm or less. alpha-Fetoprotein levels were lower than 100 ng/ml in 56% of these 40 patients. Patients with cirrhosis are at high risk of developing hepatocellular carcinoma, especially patients with HBsAg or with a history of blood transfusion who are negative for HBsAg. Periodic monitoring by use of ultrasonography in particular is recommended for early detection of hepatocellular carcinoma.

DNA measurements in chronic hepatitis, cirrhosis and hepatocellular carcinoma

It has been documented that chronic hepatitis may progress to cirrhosis and then develop hepatocellular carcinoma (HCC). To test whether abnormal cellular DNA increases along this line of development, liver tissues from 48 patients with chronic hepatitis, 17 with cirrhosis, and 8 with HCC were investigated for cellular DNA content with a scanning microdensitometer. Seven of 8 HCCs and 2 cirrhotic livers adjacent to HCC had abnormally increased cellular DNA content. Only 4 livers from patients with chronic liver diseases other than HCC had abnormal cellular DNA content. The cellular DNA content in livers not accompanying HCC was not related to the patient's age, histological diagnosis, and hepatitis inflammatory activity. The results confirmed the increase of cellular DNA content in HCC, but did not provide evidence of a progressively increasing DNA content from chronic hepatitis to liver cirrhosis. However, cirrhotic livers with abnormal hepatocytic DNA content deserve careful follow-up for the early detection of HCC.

Experience with interferon in chronic hepatitis B in Egypt

Forty patients with compensated chronic active hepatitis B and elevated aminotransferases who were HBsAg and HBeAg positive were randomised to a treatment group receiving recombinant interferon alpha-2b (rIFN alpha-2b) or no treatment as a control group. The treated patients were divided into 2 groups, group I (n = 12) received IFN in a dose of 5 MU/m2 thrice weekly by subcutaneous injection for 16 weeks, and group II (n = 8) received the same dose daily for the same duration. Patients were followed up for 12 months after therapy ended. Initiation of IFN therapy was associated with an increase in aminotransferases, reaching a peak at 4-6 weeks in most patients, associated with clearance of HBeAg. At end of follow-up, 81% of the treated patients had cleared HBeAg vs 33% of the control group (p less than 0.01). Changes in other HBV markers were more frequent in the treated patients, though insignificantly. The type of response to therapy was significantly related to the duration of illness, being shortest in those who cleared HBsAg. A complete response to therapy with loss of HBsAg was associated with marked reduction in biochemical and histological activity. A partial response with clearance of HBeAg was associated with moderate improvement in biochemical parameters and ongoing activity in liver histology; whereas persistence of HBeAg was associated with elevated aminotransferases and histological deterioration in most cases. The rise in aminotransferases during seroconversion was associated with hepatic decompensation and death on 3 occasions: one during spontaneous seroconversion, and the other 2 during IFN therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatitis B virus replication in Chinese patients with hepatocellular carcinoma

We studied the frequency of hepatitis B virus replication in Chinese patients with hepatocellular carcinoma. Hepatitis B e antigen and hepatitis B virus DNA could be detected in the sera of 28% and 47% of 116 HBsAg-positive patients, but not in the sera of 15 HBsAg-negative patients. Replicative forms of hepatitis B virus DNA were detected in the neoplastic and nonneoplastic liver tissues from 34% and 62% of 29 HBsAg-positive patients and 0% and 20% of five HBsAg-negative patients by Southern blot hybridization analysis. Of the 10 patients with chronic hepatitis B virus infection in whom hepatocellular carcinoma developed during follow-up, hepatitis B e antigen and hepatitis B virus DNA were detected in the sera of seven and eight patients, respectively, at presentation, 13 to 43 mo before the diagnosis of hepatocellular carcinoma. In nine patients, hepatitis B virus DNA was persistently or intermittently detected in the serum during follow-up. Five patients remained hepatitis B e antigen-positive and seven were detectable for hepatitis B virus DNA in serum when hepatocellular carcinoma was diagnosed. Four patients had one or more episodes of exacerbations before the diagnosis of hepatocellular carcinoma; in three, the exacerbations were associated with changes in level of hepatitis B virus replication. Our study demonstrated that despite the long interval between the onset of hepatitis B virus infection and the development of hepatocellular carcinoma, hepatitis B virus replication persisted in most patients with hepatocellular carcinoma, albeit at a low level.

Clinical course of spontaneous reactivation of hepatitis B virus infection in patients with chronic hepatitis B

The purposes of this study were (a) to describe the clinical and biochemical manifestations associated with spontaneous reactivation of hepatitis B virus as defined by the reappearance of hepatitis B virus DNA in serum using dot-blot hybridization and (b) to determine whether the clinical and biochemical manifestations associated with hepatitis B virus reactivation were different in patients with and without human immunodeficiency virus-1 infection. During 1 yr, 110 French patients were admitted to Hôpital Beaujon for chronic hepatitis B. Fourteen were found to have hepatitis B virus reactivation; of these, three were anti-human immunodeficiency virus-1-positive. These 14 patients were HBsAg-positive for 60 mo (range = 6 to 180 mo). Clinical manifestations related to reappearance of hepatitis B virus DNA were present in 11 patients. HBeAg/anti-HBe status did not change in nine patients in whom hepatitis B virus reactivation would not have been recognized without hepatitis B virus DNA testing. Cirrhosis was present in nine patients. Four patients, of whom two were anti-human immunodeficiency virus-1-positive, had fulminant liver failure. Two patients died; one was anti-human immunodeficiency virus-1-positive. One patient was given an emergency transplant.

Hepatic arterial embolization with microencapsulated mitomycin C for unresectable hepatocellular carcinoma in cirrhosis

From 1986 to 1988, 35 patients with a hepatoma judged either inoperable or unresectable because of coexistent cirrhosis were treated with hepatic arterial embolization of mitomycin C microcapsules. Five of these 35 patients (14.5%) could not be treated because of inability to selectively cannulate the hepatic artery and were therefore excluded from the evaluation (feasibility rate, 86%). There were 24 men and six women with a median age of 57 years (range, 47 to 79) who could be classified as Okuda I (14 pts) or Okuda II (16 pts) and Child Class A:18 and Child Class B:12 in the remaining patients. A median dose of 0.5 mg mitomycin C/kg was administered to each subject and the treatment was repeated at 5 to 6 week intervals. Seventy courses were administered to these 30 patients (median, two courses/patient; range, 1 to 4). Minor complications were frequent (63%) but always either resolved spontaneously or after appropriate medical treatment. Neither severe renal nor hepatic toxicity was observed. No specific treatment related mortality was observed. When alpha-fetoprotein levels and tumor volume were assessed to evaluate the response to treatment using established criteria for identifying a response, an objective response was found in 43% of the cases treated. The actuarial median survival was 7 months and the 1-year actuarial survival was 36% (51% for those rated as Child Class A and 0% for those identified as Child Class B, P = 0.04 and 78% rated as Okuda Types I and 0% Okuda type II, P = 0.0001). The excellent quality of life and the increased survival rate experienced after mitomycin C microcapsule embolization suggest that this treatment modality can be used successfully in patients seen in the West who have unresectable hepatoma.

Relative risk of hepatocellular carcinoma in HBsAg positive vs alcoholic cirrhosis. A cross-sectional study

The etiological link between hepatitis B virus (HBV) infection and hepatocellular carcinoma (HCC) has been suggested on epidemiologic, serologic and molecular grounds. This link has, however, recently been questioned by prospective studies suggesting that HBV infection also causes cirrhosis and that whatever the cause of cirrhosis, the risk of developing HCC could be roughly similar. All male patients first admitted to Hôpital Beaujon with cirrhosis or HCC from 1983 to 1987 were included in a cross-sectional study. A total of 277 new patients with cirrhosis (but free of HCC) were admitted, of whom 55 were HBsAg positive, and 181 were alcoholic. During the same period, 117 new patients with HCC were admitted, 48 in association with alcoholic cirrhosis, 36 with HBsAg positive cirrhosis. The relative risk (odds ratio) of HCC was 2.5 (95% confidence interval, 1.46-4.37; p = 0.0011) in patients with HBsAg positive cirrhosis as compared to patients with alcoholic cirrhosis. HBsAg positive patients were significantly younger than their alcoholic counterparts (48 +/- 14 vs 54 +/- 10 years in the cirrhotic group; 49 +/- 12 vs 62 +/- 8 years in the HCC group). We conclude that, using the methodology of a cross-sectional study, the relative risk of HCC was about twice greater in HBV-associated than alcoholic cirrhosis. The results of longitudinal prospective studies examining this issue might be biased by selecting patients older than the mean age of HCC occurrence or excluding patients with HCC when present at first admission.

Acute exacerbation in patients with liver cirrhosis: a clinicopathological study

The incidence, clinicopathologic features and etiology of acute exacerbation occurring in patients with liver cirrhosis were assessed prospectively among 332 hepatitis B surface antigen (HBsAg) positive and 71 HBsAg negative patients. During an 11-year period and a mean follow-up duration of 26.8 months, 148 acute exacerbation occurred in 107 HBsAg positive patients and 32 episodes occurred in 18 HBsAg negative patients. The calculated annual incidence was 11.5%. The clinical, laboratory and histologic features were similar to those in patients with chronic hepatitis. Confluent hepatic necrosis and alphafetoprotein elevation over 100 ng/ml occurred frequently, particularly in HBeAg positive patients. In general, acute exacerbations in HBsAg negative patients were less severe than their HBsAg positive counterparts. Of the exacerbations in HBsAg positive patients, 54.8% of the HBeAg positive ones and 38.6% of the HBeAg negative ones were attributable to hepatitis B virus reactivation, while 4.8% and 7.9%, respectively, were due to hepatitis delta virus superinfection. The others might be the results of hepatitis non-A, non-B virus superinfection or increased piecemeal necrosis. The immediate outcome of acute exacerbations in cirrhotic patients was usually good, although 13.8% developed hepatic decompensation and 4.4% died. Further follow-up study is required to evaluate the long-term effect of the frequent occurrence of bridging hepatic necrosis, high elevation of alphafetoprotein and hepatic decompensation during acute exacerbation in cirrhotic patients.

Hepadnaviruses in cirrhotic liver and hepatocellular carcinoma

Hepadnaviruses share properties of virion structure, genome structure and replication, epidemiologic behavior, and pathogenic effects, including an association with hepatocellular carcinoma (HCC). Epidemiologic evidence implicating hepadnavirus infection in HCC includes the observation that the geographic distributions of HBV infection and HCC are similar, that the incidence of HCC is much higher in hepadnavirus infected than uninfected hosts, and that viral DNA sequences are integrated in the cellular DNA of most (e.g., 80-90%) but not all hepadnavirus-associated HCC. Cirrhosis further increases the risk of HCC in HBV infected humans. The precise role of hepadnaviruses in development of most HCC is unclear, although the finding of viral integrations within or near protooncogenes in a few cases suggests the possibility that these integrations may play a direct role in these HCC. However, in the great majority of HCC associated with HBV infections, viral integrations are in different cellular DNA sites in different HCC, integrations are not within domains of known protooncogenes, and integrations are not found in some 10-15% hepadnavirus-associated HCC, suggesting that persisting viral sequences are not directly involved in the development of these HCC as viral sequences are for tumors caused by viruses with oncogenes or viruses that act by a "promoter-insertion" mechanism. It is possible, however, that oncogenic mutations could arise via other mutagenic mechanism that may operate in chronic hepatitis B and/or cirrhosis and which do not involve persisting viral integrations. For example, liver regeneration, which is a feature of the cirrhosis associated with chronic HBV infection (and sometimes with chronic hepatitis B) involves proliferation of many cells with HBV integrations, and such integrations have been shown to be unstable and may lead to mutations through post-integration rearrangements of cellular sequences at sites of viral integrations. Viral sequences appear to be lost or deleted at some such sites of rearranged cell DNA. Chronic HBV infection shares pathologic features of liver cell injury and reactive inflammation, liver regeneration, and in man sometimes cirrhosis with other important risk factors for HCC including chronic alcoholic liver disease, chronic non-A, non-B hepatitis, hemochromatosis, and crypogenic cirrhosis, suggesting that this common pathologic process may be carcinogenic by a mechanism that does not depend specifically on the factor which initiates liver cell injury. The pathogenetic role of chronic hepadnavirus infection in such a process would be in causing liver cell injury with reactive inflammation and hepatocyte proliferation (regeneration).(ABSTRACT TRUNCATED AT 400 WORDS)

Etiology of acute exacerbation in patients with severe chronic active hepatitis by in situ HBVDNA hybridization technique

To explore etiology of acute exacerbation in severe chronic active hepatitis, in situ HBVDNA hybridization was carried out combined with detection of HBV markers in the serum and the liver as well as intrahepatic HDAg in 15 cases. Four subgroups were identified based on the etiological evidence: 1) 9 cases were still undergoing HBV active replication or reactivation with cytoplasmic and membraneous HBcAg expression, often associated with the hepatic necrosis foci; 2) 3 cases showed HBsAg or/and HBVDNA positivity despite absence of HBcAg expression, the membranous and homogeneous HBsAg expression being closely related with hepatic necrosis; 3) 2 cases were HDAg positive; 4) the remaining case exhibited no HBV infection evidence. All findings suggested that HBV active replication or reactivation was the major cause of the exacerbation in severe chronic active hepatitis. In addition, HBV superinfection accounted for over 10% of cases with acute exacerbation. Hepatitis A or C may contribute to some episodes of exacerbation.

A lectin-based monoclonal enzyme immunoassay to distinguish fucosylated and non-fucosylated alpha-fetoprotein molecular variants

Purified alpha-fetoprotein (AFP), fucosylated AFP mixtures, and 40 sera from patients with AFP-producing hepatocellular carcinoma were analysed by monoclonal enzyme immunoassay (EIA) to distinguish fucosylated and nonfucosylated AFP molecular variants. FUC-AFP-25 was discriminated from FUC-AFP-75 by the EIA using monoclonal antibody 18H4 in the range of total AFP concentrations from 100 to 800 ng/mL. In addition, sera from 40 patients with hepatocellular carcinoma, with AFP concentrations from 100 to 1270 ng/mL and with fucosylated AFP from 0 to 100% by conventional cross immuno-affinoelectrophoresis, were also analysed by the present EIA. A statistically significant correlation was obtained between the data from the present EIA and from the conventional crossed immuno-affinoelectrophoresis in the range of fucosylated AFP more than 20% and the serum concentration of AFP more than 100 ng/mL. These results indicate that the present EIA is useful for clinical detection of hepatocellular carcinoma during the follow-up of patients with chronic liver diseases.

Intrahepatic expression of HBcAg and delta antigen in anti-HBe positive HBsAg carriers with acute exacerbation or chronic active liver disease

Intrahepatic expression of HBcAg and hepatitis delta antigen (HDAg) was studied in 43 patients with acute exacerbation AE and 37 with chronic active liver disease CALD, in order to evaluate the role of hepatitis B virus (HBV) replication and hepatitis delta virus (HDV) superinfection in development of AE or CALD in anti-HBe positive HBsAg carriers in Taiwan, and the results were compared with 37 patients with only minor hepatitic activity. Only 8.1% of patients with minor hepatitic activity were HBcAg positive, and none were HDAg positive. In contrast, 41.8% and 32.6% of patients with AE were positive for HBcAg and HDAg, respectively, and the other 25.6% were negative for both. The clinical features of AE showed no difference in relation to HBcAg and HDAg activity in the liver except that patients without HBcAg and HDAg were predominantly older adults. These patients might be supposed to have non-A, non-B hepatitis (NANB) virus superinfection, as many reports have shown a predominance of older patients in acute NANB hepatitis. Of the patients with CALD, 40.5% were HBcAg positive, 27.0% were HDAg positive, and 32.5% were positive for neither. Histological features of CALD were identified in 83.3% and 100% of patients with HBcAg and HDAg activity, respectively, but only in 26.1% of those without HBcAg and HDAg. The etiology of CALD in the latter group remains unclear. Furthermore, some of the anti-delta seropositive patients with AE or CALD expressed HBcAg rather than HDAg in the liver.(ABSTRACT TRUNCATED AT 250 WORDS)

Isoniazid-rifampin-induced hepatitis in hepatitis B carriers

From January 1984-December 1987, 1783 patients received combination therapy of isoniazid, rifampin, and ethambutol for the control of tuberculosis. Forty-two developed symptomatic hepatitis during the period of treatment. Fifteen were hepatitis B virus carriers, and the remaining 27 were noncarriers. The peak serum transaminase and bilirubin levels were higher in carriers. Seven carriers died of fulminant or subacute hepatic failure, and only 1 noncarrier died. Eleven carriers had detectable serum hepatitis B virus deoxyribonucleic acid during the acute stage of hepatitis. The roles of isoniazid-rifampin combination therapy and hepatitis B virus in the adverse outcomes of carriers were discussed.

Hepatitis delta virus superinfection among patients with chronic hepatitis B in southern Taiwan

To study the prevalence of hepatitis delta virus (HDV) superinfection among patients with chronic hepatitis in southern Taiwan, total and IgM anti-delta antibody (anti-HD) and delta antigen (HDAg) were determined in 85 histology-proven patients with chronic hepatitis. There were 12/85 (14.1%) cases with total anti-HD; 3 of them were also positive for IgM anti-HD. Another 9 (10.6%) cases were positive for HDAg. Thus, the prevalence of HDV superinfection was 21/85 (24.7%), which was significantly higher than previous reports in southern Taiwan. The difference was not seen if anti-HD was used as the only detector. It is concluded that, when other methods are used than previously, HDV infection is more common than previously thought and there is no difference between different parts of Taiwan.

Aetiology and pathophysiology of chronic liver disorders

The aetiology of chronic liver disease covers a wide range of congenital or acquired abnormalities of the hepatocellular biochemical network. Although our knowledge has considerably increased in recent years, the aetiology of chronic liver disease often remains obscure. Acquired irreversible disturbances of normal liver function can be mediated by hepatotrophic viruses, chemicals, chronic oxygen depletion, or interference with the immune system. Considerable progress has been made in the detection and characterisation of hepatitis B, C, and D viruses as causative agents of chronic active hepatitis. Alcohol abuse remains the predominant cause of chronic liver disease in the Western world. The targets of autoantibodies used to diagnose autoimmune diseases of the liver and primary biliary cirrhosis continue to be biochemically defined. Their significance for the aetiology of the disease, however, remains to be established. Nonparenchymal cells play an important role in the sequence of events following hepatocellular injury and ultimately leading to liver cirrhosis. They release vasoactive compounds, cytokines, and other important mediators, and participate in the modulation of the extracellular matrix that is characteristic of liver fibrosis and cirrhosis. The biochemical basis of liver cell necrosis remains poorly defined. In spite of recent progress, and the detection of some new pathogenic principles that help in the understanding of the complications of chronic liver disease such as portal hypertension, oesophagogastric variceal bleeding, portosystemic encephalopathy, ascites, and other metabolic disturbances, many questions concerning the aetiology and pathophysiology of chronic liver disease and its complications remain to be answered.

Acute exacerbations in Chinese patients with chronic hepatitis B virus (HBV) infection. Incidence, predisposing factors and etiology

Three hundred and eighty-six Chinese patients (262 men and 124 women), age 5-74 years, with chronic hepatitis B virus (HBV) infection were prospectively followed for 1-5 years to determine the incidence, predisposing factors and etiology of acute exacerbations that occurred during the course of chronic HBV infection. Group I consisted of 334 patients with serum alanine aminotransferase (ALT) levels below 200 IU/l at presentation. Of these, 29 (8.7%) patients developed 32 episodes of acute exacerbation during follow-up. The cumulative probabilities of developing exacerbations were 6.3% and 15% at the end of 1 and 4 years, respectively. Group II included 52 patients with ALT levels above 200 IU/l at presentation. Of these, 19 (37%) patients developed 26 episodes of exacerbation during follow-up. The cumulative probabilities of developing eacerbations were 24% and 47% at the end of 1 and 4 years, respectively. In both groups, the probability of developing exacerbations was slightly higher in men and significantly higher in those above the age of 20 and those who were HBeAg positive. Logistic regression analysis showed that HBeAg positivity (p less than 0.00001), elevated ALT levels (greater than 200 IU/l) at presentation (p less than 0.0001) and male sex (p = 0.03) were associated with a significantly higher probability of developing exacerbations. Twenty eight (48%) episodes of exacerbation were accompanied by symptoms of acute hepatitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute hepatitis delta virus superinfection in patients with liver cirrhosis

A clinicopathologic study in a total of 164 patients with acute hepatitis delta virus (HDV) infection showed that nine male patients (5.5%) had evidence of liver cirrhosis prior to or during the episode of acute hepatitis. All nine patients had typical clinical presentations and laboratory findings of acute viral hepatitis. Four of them had prolonged prothrombin time, three developed ascites and one finally died of hepatic failure. Clinical ascites occurred more frequently in cirrhotic patients with severe but non-fulminant hepatitis than their non-cirrhotic counterparts (p less than 0.05). In addition, histologic studies in five patients with cirrhosis disclosed diffuse lobular necrotizing inflammatory activity, with four showing bridging hepatic necrosis, which also occurs more frequently in cirrhotic than in non-cirrhotic patients (p less than 0.05). The data suggest that HBsAg positive patients with cirrhosis are susceptible to acute HDV infection which may lead to extensive necrosis or even decompensation and failure, simulating decompensation of the underlying liver disease. Therefore, careful clinicopathologic work-ups are required for accurate diagnosis and correct assessment of their outcomes.

Elevations in serum alpha-fetoprotein levels in patients with chronic hepatitis B

In a retrospective analysis of 166 patients with chronic hepatitis B followed for up to 8 years, 22 patients had 29 episodes of elevations in serum alpha-fetoprotein (AFP) levels. Twenty-five episodes were due to a transient exacerbation of the underlying hepatitis and 11 of these episodes were followed by a loss of hepatitis B e antigen (HBeAg) from serum and a remission in disease. Two patients were found to have hepatocellular carcinoma. No apparent cause could be found in a further two episodes of AFP elevation. In comparison to 144 patients with normal levels, the 22 with AFP elevations were more likely to have cirrhosis (61% versus 13%, P = 0.01), to die a liver-related death (27% versus 0.7%, P = 0.0007) and to have hepatocellular carcinoma (HCC) (9% versus 0%, P = 0.002). These findings confirm that AFP can be used to screen for HCC in high-risk patients with chronic hepatitis B. The majority of AFP elevations, however, will be found to be due to exacerbations of disease, with or without loss of HBeAg from serum, especially in white patients with severe disease and cirrhosis.

Diagnostic accuracy of fine-needle aspiration biopsy in patients with hepatocellular carcinoma

The present study was undertaken to investigate the diagnostic usefulness of fine-needle aspiration biopsy (FNAB) in a large series of patients with hepatocellular carcinoma (HCC) seen over a 1-year period. During 1986, ultrasonographically guided percutaneous FNAB was performed in 72 patients with suspected HCC. A final diagnosis of HCC was made in 58 patients. The presence or absence of HCC was ascertained by histological examination and/or by other diagnostic procedures (alpha 1-fetoprotein, computed tomography, arteriography) and by clinical follow-up (repeated ultrasonographic controls) and/or by surgery or necropsy. A total of 61 FNABs were carried out in these 58 patients. Only 42 (69%) of the 61 FNABs allowed the diagnosis of HCC. This moderate diagnostic sensitivity was not related to tumor size. Only one false positive result was observed in the non-HCC group. Therefore, the diagnostic specificity of FNAB for HCC was 93%, with a positive predictive value of 97% and a negative predictive value of 40%. These results show that FNAB is a useful diagnostic technique in patients with HCC. However, these data also show that there is a large proportion (31%) of subjects with false negative results. Therefore, we suggest that further efforts should be made to improve the diagnostic accuracy of this procedure.

Which patients with chronic hepatitis B virus infection will respond to alpha-interferon therapy? A statistical analysis of predictive factors

Twenty-one pretreatment variables were assessed for their significance in response prediction using data from 114 patients given alpha-interferon for chronic hepatitis B virus infection. In those patients who had received a minimum of 90 million units per m2 total dose over 12 weeks, a negative anti-human immunodeficiency virus antibody status (p less than 0.001), chronic active hepatitis on liver biopsy (p less than 0.005), high AST level (p less than 0.001), low hepatitis B virus DNA level (p less than 0.001) and a history of acute hepatitis (p less than 0.005) were all associated with an increased likelihood of response on univariate analysis. On stepwise logistic regression analysis, hepatitis B virus DNA, AST and a history of acute hepatitis predicted response independently (p less than 0.05). The most reliable combination of predictive factors was a negative anti-human immunodeficiency virus antibody status, with either a positive history of acute icteric hepatitis and AST greater than 45 IU per liter or no history of acute icteric hepatitis and AST greater than 85 IU per liter, which predicted response in 77% with a specificity of 79% (p less than 0.001). The loss of HBsAg in addition to HBeAg and hepatitis B virus DNA was more likely to occur in patients with chronic infection of less than 2 years duration (p less than 0.001).

Reappraisal of surgical treatment of small hepatocellular carcinomas in cirrhosis: clinicopathological study of resection or transplantation

Thirty-two patients with hepatocellular carcinoma (HCC) occurring in individuals with cirrhosis had a potentially curative surgical procedure. Twenty-two had segmental hepatic resections (HR), and 10 underwent orthotopic liver transplantation (OLTx). The diagnosis of hepatic malignancy was established in each case preoperatively, and each case was studied intraoperatively by means of sonography. Postoperatively each surgical specimen was examined pathologically with attention to the possibility of intrahepatic tumor spread. Twenty-three of the 32 patients had single small HCC lesion (less than 5 cm diameter) identified preoperatively. Sixteen of these underwent HR and seven underwent OLTx. Multiple additional neoplastic lesions were found in 19% of the 16 HR cases and in 14% of those undergoing OLTx when the resection specimens were examined pathologically. Vascular invasion was present in 43% of the OLTx patients and in 25% of the HR patients. Subtotal hepatic resection for small HCC occurring in cirrhosis has produced few long-term survivals. Both pre- and intraoperative sonography have been shown to underestimate the extent and distribution of these tumors. Based upon this experience that (1) vascular spread occurs often in HCC and (2) a high risk of postoperative hepatic failure can be expected after HR in cirrhotic individuals, OLTx is the most rational surgical procedure for such cases as it has the potential to cure.

Serial antipyrine clearance studies detect altered hepatic metabolic function during spontaneous and interferon-induced changes in chronic hepatitis B disease activity

The present study was performed to establish whether sequential determinations of antipyrine clearance, using a simplified two-point test, are sensitive and specific indicators of changes in chronic hepatitis B disease activity. Sixteen patients were studied on four or more occasions during 18 to 30 months. Eleven patients were treated with recombinant human alpha-interferon (2.5, 5.0 or 10 X 10(6) per m2, intramuscularly, three times per week, for 24 weeks), and five patients were untreated controls. Among seven patients, (six interferon-treated and one control) who lost hepatitis B e antigen from serum, antipyrine clearance improved by 46% (range: 20 to 160%) from 0.37 +/- 0.14 ml per kg per min (mean +/- S.D.) to 0.54 +/- 0.13 ml per kg per min, p less than 0.005. This change paralleled the loss of symptoms and reduction of serum ALT levels (from 206 +/- 189 IU per liter (mean +/- S.D.) to 38 +/- 12 IU per liter, p less than 0.005). Conversely, antipyrine clearance declined to previous levels when reactivation of chronic hepatitis B with reappearance of HBeAg in serum occurred. Regardless of changes in hepatitis B serology, when serum ALT values fluctuated by more than 20% (presumed to reflect fluctuations in necroinflammatory activity of the liver disease), antipyrine clearance also changed whereas serum albumin and bilirubin concentrations and prothrombin time did not. It is concluded that antipyrine clearance is a more sensitive and specific parameter than conventional indices for assessing hepatic metabolic function during changes in chronic hepatitis B disease activity. Remission in disease with loss of HBeAg from serum is associated with improved hepatic metabolic function as determined by the antipyrine clearance test.

Natural course after the development of cirrhosis in patients with chronic type B hepatitis: a prospective study

To examine the early stage of the natural course of liver cirrhosis, a prospective follow-up study was conducted in a series of 76 patients with recent development of cirrhosis during the course of chronic type B hepatitis. During a mean follow-up period of 34.4 months, 45 episodes of acute exacerbation were recorded; the majority of the episodes occurred within 2 years after entry. The calculated annual incidence of acute exacerbation was significantly higher in patients seropositive for hepatitis B e antigen (HBeAg) and/or hepatitis B virus (HBV)-DNA (25.9%) than in those without these markers (11.9%). Three-fourths of the acute exacerbations were attributable to the reactivation of HBV. Spontaneous HBeAg seroconversion to anti-HBe also occurred in the early phase, but less than 30% of the events were preceded by acute exacerbation. Late hepatitis B surface antigen clearance occurred in two patients. Hepatic decompensation, esophageal variceal bleeding and hepatocellular carcinoma developed relatively late in the course of the disease with a calculated annual incidence of 2.3%, 2.3% and 2.8%, respectively. Seven patients (9.2%) died of hepatic failure or variceal bleeding, usually more than 3 years after entry. The estimated 5-year survival rate was 80%. The results suggest that the natural events of chronic HBV infection, including exacerbation, seroconversion and its sequelae could occur after the development of cirrhosis. In addition, these events might be responsible for the clinicopathological changes and the outcomes of these cirrhotic patients.

Hepatic parenchymal calcifications--differentiation from intrahepatic stones

Intrahepatic hyperechoic lesions with acoustic shadows could be stones or nonspecific calcifications. To verify this, 9 patients with hepatic parenchymal calcifications were compared with 40 patients with intrahepatic stones. A set of criteria are proposed for the diagnosis of intrahepatic stones: (A) dilated intrahepatic duct; (B) pneumobilia; or (C) 2 or more of the following: (1) common hepatic duct more than 6 mm in diameter, (2) multiple lesions in one lobe, (3) left lobe involvement, and (4) elevated serum alkaline phosphatase. The sensitivity, specificity, and overall accuracy were 97.5%, 88.9%, and 95.9, respectively. The criteria help in the selection of patients for evaluation of intrahepatic stones.

Natural course of patients with chronic type B hepatitis following acute hepatitis delta virus superinfection

A 6-96-month prospective follow-up study on the natural course of chronic type B hepatitis after contracting acute hepatitis delta virus (HDV) superinfection was conducted in 30 patients with clear-cut onset of acute HDV superinfection (HDV group). Thirty patients with acute exacerbation without evidence of HDV infection, and well matched in terms of age, sex and hepatitis B e antigen/antibody status, served as the control group. The clinical and biochemical presentations tended to be more severe in the HDV group. More patients in the HDV group had persistent abnormal liver biochemical tests (69% vs 47%) and progressed to chronic active hepatitis (46% vs 20%) or cirrhosis (9.4%/year vs 5.2%/year), but the differences were not significant statistically. The results suggest that HDV superinfection induces slow progression of liver disease. However, in the early stage, the impact of HDV superinfection is not particularly different from that of the acute exacerbation unrelated to HDV in patients with chronic type B hepatitis.

The prevalence and incidence of cholecystolithiasis in patients with chronic liver diseases: a prospective study

To investigate the prevalence and incidence of cholecystolithiasis in hepatitis B surface antigen-positive chronic liver diseases, a prospective study using hepatobiliary ultrasonography was conducted in 933 "healthy" persons and four groups of HBsAg-positive patients: 226 asymptomatic carriers, 73 patients with chronic active hepatitis, 77 patients with early liver cirrhosis and 124 patients with advanced liver cirrhosis. Patients with hepatocellular carcinoma or alcoholism were excluded. The prevalences of cholecystolithiasis increased along with the increasing duration and severity of chronic liver diseases, with a significant linear trend (p less than 0.001). The prevalences of cholecystolithiasis in patients with liver cirrhosis (18.5% in males, 31.2% in females) were 4 to 5.5 times higher than that of the healthy population (p less than 0.005). In addition, the linear trend of increasing prevalence with increasing age in the healthy population was not observed in patients with chronic liver diseases. On the other hand, five of the 69 patients with early liver cirrhosis were found to develop cholecystolithiasis during a mean follow-up period of 32 months. The calculated annual incidence of cholecystolithiasis was 2.6%. The results suggest that chronic liver disease, particularly liver cirrhosis, is a risk factor for cholecystolithiasis.

The etiology of acute hepatitis superimposed upon previously unrecognized asymptomatic HBsAg carriers

To study the etiology of acute hepatitis superimposed upon previously unrecognized asymptomatic HBsAg carriers, paired sera were collected in acute and convalescence phases for measurement of HBeAg, anti-HBe, hepatitis B virus DNA and anti-delta from 76 adult patients with acute hepatitis who were HBsAg positive but IgM anti-HBc negative or positive only at low titer. None of them were IgM anti-hepatitis A virus positive on admission. Of the 34 patients who were HBeAg positive initially, two (5.9%) were diagnosed as having delta superinfection, and another two (5.9%) were suspected to have non-A, non-B virus superinfection because of a transient decrease of serum hepatitis B virus DNA. The remaining 30 (88.2%) cases were hepatitis B virus DNA negative with or without anti-HBe seroconversion on follow-up. The episodes of acute hepatitis in these cases may represent "immune clearance of HBeAg" or "immune clearance of hepatitis B virus with delayed anti-HBe seroconversion," respectively, in the natural course of chronic hepatitis B virus infection. Of the patients who were anti-HBe positive initially, 23 (54.8%) were diagnosed as having delta superinfection, including eight with de novo seroconversion of anti-delta and 15 with a rising titer of anti-delta; 10 (23.8%) were positive for hepatitis B virus DNA and were considered as reactivation of hepatitis B virus, and the other nine (21.4%) were suspected as having non-A, non-B virus superinfection.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of short-term prednisolone therapy in patients with severe chronic type B hepatitis

Ten patients with severe chronic type B hepatitis confirmed by liver biopsy were treated with prednisolone for eight weeks and followed up for more than one year. The patients were comprised of 6 males and 4 females, ages 17 to 45 (mean 32) yrs. Serum alanine aminotransferase (ALT) was elevated more than one month before the treatment in all (mean: 379 U/L, range: 87 to 772 U/L). Initial serological tests showed hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) in all and hepatitis B virus DNA (HBV-DNA) in 7/10 (70%). Liver biopsy showed severe chronic active hepatitis with confluent necrosis or acinar hepatitis in all. Prednisolone, 60 mg/day, was administered initially and the dose was tapered every 2 weeks over the 8 weeks period. Two to six months after cessation of treatment, 5 of 10 patients showed a disappearance of HBeAg and serum HBV-DNA and return of serum ALT level to normal (responders). The initial serum ALT level in responders was slightly higher than that of non-responders (mean: 404 vs. 355 U/L), but there was no statistical significance. Among 5 responders, serum HBV-DNA was detected in three patients initially and was transiently detected in one patient during treatment. In non-responders, HBeAg persisted during and after the treatment and serum HBV-DNA persisted in three, but serum ALT was decreased in all. One patient who did not show any clinical or serological improvement, died of jaundice, ascites and hepatic encephalopathy 4 months later.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcatheter arterial chemoembolization for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) was treated with transcatheter arterial chemoembolization (TACE) in a sample of 129 patients. The cumulative survival rate was 49% at 1 year and 22% at 2 years. The median survival time was 11.9 months. The survival rates at 1 year of 84 patients in Child's group A and 27 in Child's group B were 56% and 40%; out of 52 HCC patients with portal vein patent and 77 with portal vein invasion 75% and 40% survived, and the 1-year survival rates for 33 HCC patients with capsule intact, 14 with capsule broken and 82 with no capsule were 85%, 65% and 40% respectively. From the above results there were statistically significant differences in survival time in those with good clinical performance status by Child's classification, those showing patency of the portal vein and those where the capsule was present. Therefore, we would like to recommend, TACE of HCC in well-selected patients presenting with good clinical status, patency of the portal vein and without broken capsule, in order to achieve better clinical results.

alpha-Fetoprotein monitoring in Chinese patients with chronic hepatitis B virus infection: role in the early detection of hepatocellular carcinoma

Two hundred ninety patients (203 men, 87 women), age 7 to 74 years (mean: 39.1 years), with chronic hepatitis B virus infection, were prospectively followed for a period of 1 to 4 years to determine the value of alpha-fetoprotein monitoring in the early detection of hepatocellular carcinoma. At presentation, 66% of the patients were asymptomatic, 19% had chronic hepatitis and 15% had established cirrhosis. Forty-four (15%) patients had elevated alpha-fetoprotein levels on one or more occasions during the study period. Twenty patients with normal alpha-fetoprotein levels at presentation developed elevated alpha-fetoprotein levels during the course of follow-up, whereas 24 patients had elevated alpha-fetoprotein levels at presentation. Six (14%) of these 44 patients (five men and one woman), age 23 to 66 years, had persistent or progressive increase in alpha-fetoprotein levels and were confirmed to have hepatocellular carcinoma. In four patients, the alpha-fetoprotein levels were below 500 ng per ml at the time of tumor localization. Only three patients had resectable tumors. All six patients would have been missed if alpha-fetoprotein screening was restricted to men above the age of 40 with cirrhosis and anti-HBe. Of the remaining 38 patients, elevation in alpha-fetoprotein levels in 18 patients was associated with exacerbations of the underlying liver disease and/or significant changes in level of hepatitis B virus replication, but in 20 patients, no apparent cause could be identified. The elevation in AFP levels exceeded 200 ng per ml in 26% and persisted beyond 6 months in 15% of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum alphafetoprotein levels in subjects infected with hepatitis B virus

Serum alphafetoprotein (AFP) levels were measured using a sensitive radioimmunoassay in 108 hepatitis B surface antigen (HBsAg)-positive subjects and 695 controls. The concentrations were significantly higher in the HBsAg-positives. Within this group, the highest levels were found in those with active HBV infection. In those without evidence of acute infection, the levels were higher in the high-risk than in the low-risk subjects. It is concluded: 1) that measurement of serum AFP might be a useful additional index of infectivity and prognosis in HBsAg-positive subjects; and 2) that in the light of the association between chronic HBV infection, hepatocellular carcinoma, and raised AFP in non-European populations, consideration should be given to regular monitoring of AFP levels in HBsAg-positive subjects in the United Kingdom.

Changes of serum HBV-DNA in relation to serum transaminase level during acute exacerbation in patients with chronic type B hepatitis

To examine the relationship between changes of serum hepatitis B virus-dexoyribonucleic acid (HBV-DNA) and transaminase levels during acute exacerbation of chronic type B hepatitis, serial serum specimens from 74 patients were assayed for HBV-DNA by slot blot hybridization with 32P-labeled cloned HBV-DNA as probe. Of these patients, serial serum specimens were obtained with an interval of 2-7 days in 22 patients (Group I), 8-14 days in 30 patients (Group II) and 15-30 days in 22 patients (Group III). The peak of serum HBV-DNA was reached shortly before or simultaneously with the maximum elevation of serum alanine transaminase (ALT) in most (greater than 90%) of the acute exacerbations. In contrast, the peak of serum ALT was reached before maximum elevation of serum HBV-DNA in only 13.6% of Group I, 3.3% of Group II and 13.6% of Group III (9.5% of whole series). The results suggest that the increase of serum HBV-DNA is an event preceding, rather than the result of, hepatocytolysis in most of the acute exacerbations occurring in patients with chronic type B hepatitis.

The development of cirrhosis in patients with chronic type B hepatitis: a prospective study

The incidence and contributing factors of cirrhosis developing in patients with chronic type B hepatitis were assessed prospectively in 684 clinicopathologically verified patients, of which 509 were HBeAg positive and 175 were anti-HBe positive at entry into the study. During an average follow-up period of 35.3 months, cirrhosis occurred 6 to 64 months after entry in 35 HBeAg-positive and 7 anti-HBe positive patients with a calculated annual incidence of 2.4 and 1.3%, respectively (p greater than 0.05). The incidence increased significantly with the increasing age at entry. Patients who had experienced (a) hepatic decompensation, (b) repeated episodes of severe acute exacerbation (with alpha-fetoprotein greater than 100 ng per ml and/or bridging hepatic necrosis), (c) severe acute exacerbation not accompanied by subsequent HBeAg seroconversion and (d) hepatitis B virus reactivation (particularly those with HBeAg reappearance) were found to develop cirrhosis much more frequently (p less than 0.001). Contrary to general belief, patients who had hepatitis delta virus superinfection and patients with chronic active hepatitis were not particularly prone to develop cirrhosis. We conclude that in addition to age factor, the extent, severity, duration, frequency and etiology of the hepatic lobular alterations are important factors for the development of cirrhosis in patients with chronic type B hepatitis.

Diagnosis of hepatic lesions: ultrasonically guided fine needle biopsy or laparoscopy?

We compared the results of ultrasonically guided fine needle aspiration biopsy and laparoscopy in 63 patients who underwent both procedures. In this series, fine needle biopsy showed a sensitivity of 75.6% with a 84.1% overall accuracy. Laparoscopy demonstrated a 74.3% sensitivity with an overall accuracy of 82.7%. The combination of both procedures achieved an overall accuracy of 98.4% with a sensitivity of 97.5%. In one case only (hepatic involvement by Hodgkin's lymphoma), both laparoscopy and ultrasonically guided fine needle biopsy failed to establish the diagnosis. In small and deeply located lesions, ultrasonography is the most useful guide for biopsy. Laparoscopy is irreplaceable in the diagnosis of cirrhosis and in hepatic biopsies requiring larger bore needles. With the increasing use of ultrasonically guided fine needle biopsy, laparoscopy finds new indications, particularly in the preoperative staging of small hepatocellular carcinoma.

Plasma abnormal prothrombin (des-gamma-carboxy prothrombin) as a marker of hepatocellular carcinoma

Des-gamma-carboxy prothrombin [DCP], a protein induced by vitamin K absence or antagonist-II and also abbreviated PIVKA-II, was evaluated as a serologic marker for hepatocellular carcinoma (HCC). Its plasma levels were measured by enzyme immunoassay (E-1023) using an anti-DCP monoclonal antibody in 514 patients with various diseases. Of 120 patients with HCC, 76 (63%) had abnormal DCP levels greater than 0.1 arbitrary unit (AU)/ml and 58 (48%) showed levels greater than 0.3 AU/ml. When a diagnostic minimum level of 0.3 AU/ml was applied for DCP, false-positive cases of HCC were virtually eliminated. In some patients with HCC, plasma DCP levels normalized after surgical resection of the tumor. However, they rose again later with recurrence of the disease. The sensitivity of DCP in the diagnosis and monitoring of HCC was increased by serial and simultaneous determinations of alpha-fetoprotein (AFP), because high DCP levels were observed more often in low AFP-producing HCC patients. Elevated plasma DCP levels were not related to low vitamin K concentration in the serum. In fact, in many patients vitamin K administration resulted in only a moderate reduction of DCP levels. These results suggested strongly that DCP was synthesized by the hepatoma cells.

Hepatic arterial embolization in patients with unresectable hepatocellular carcinoma--a randomized controlled trial

A randomized controlled trial of hepatic arterial embolization was conducted in 63 consecutive patients who had unresectable but still embolizable hepatocellular carcinoma. Patients were randomized into three groups. Patients in group 1 received multiple hepatic arterial embolizations; patients in group 2 were given hepatic arterial embolization once, followed by monthly chemotherapy with high doses of 5-fluorouracil; and patients in group 3 received only monthly chemotherapy with high doses of 5-fluorouracil. Complete response was achieved in only 1 patient who received multiple hepatic arterial embolizations. Partial responses were observed in 13 patients (61.9%) in group 1, 10 patients (47.6%) in group 2, and 2 patients (9.5%) in group 3. The survival rates of patients in group 1 at the end of the ninth, 12th, 15th, 18th, and 21st months were 53.2%, 42.2%, 42.2%, 42.2%, and 42.2%, respectively, which were not significantly different from those of patients in group 2 but were better than the survival rates of patients in group 3. The results suggest that hepatic arterial embolization is an effective palliative treatment that prolongs survival of patients with unresectable hepatocellular carcinoma.

The prognostic significance of bridging hepatic necrosis in chronic type B hepatitis: a histopathologic study

A histopathologic follow-up study was conducted in 207 consecutive patients to examine the prognostic significance of bridging hepatic necrosis (BHN) in chronic type B hepatitis. One hundred and eight patients showed BHN and the other 99 intralobular spotty necrosis (SN) on initial biopsy. A higher proportion of patients with BHN healed (45.4% vs 26.4%) or developed cirrhosis (18.3% vs 3%) than the patients with SN. In contrast, intralobular inflammation persisted or recurred more frequently in the SN than in the BHN group (40.4% vs 5.6%). These figures were statistically significant (P less than 0.001). Alternatively, 87% of the patients who developed cirrhosis had had BHN as their initial histologic presentations. The estimated relative risk of cirrhotic progression for the BHN group compared to the SN group was 4:1. We conclude that BHN is a paradoxical prognostic factor, either for healing, or cirrhotic progression.

Alpha-fetoprotein Monoclonal Assay: Preliminary Clinical Findings in a High Risk Population

A two-site solid phase immunoradiometric assay was developed for measurement of human alpha-fetoprotein, utilizing two high-affinity monoclonal antibodies directed against distinct and separate epitopes on the proteic structure. The analytical sensitivity of the assay is 0.5 ng/ml. The clinical sensitivity was evaluated by comparison of patients with cirrhosis and patients with hepatocellular carcinoma with cirrhosis. This assay gave good diagnostic discrimination. In a preliminary clinical trial, the specificity of the assay was 92.3%, the clinical sensitivity 88.2%. and predictive values were 78.9% in the clinically positive stage and 96.0% in the negative stage. The diagnostic efficacy of the assay was 91.3%.

Primary liver cancer in Alaskan natives. 1980-1985

The authors reviewed the cases of 19 Alaskan Natives (15 men, four women) with primary hepatocellular carcinoma (HCC) diagnosed during 1980-1985. Of these 19 patients, 16 were seropositive for hepatitis B surface antigen (HBsAg). Alpha-fetoprotein (AFP) was elevated in 15 patients (all were HBsAg positive). The patients ranged in age from 8 to 80 years old. Of the 19 patients, 16 were Eskimo, 13 of whom were Yupik. The annual age-adjusted (world standard) incidence of HCC for all Alaskan Natives was 9.3/100,000 for men and 2.2/100,000 for women. The tumor was resected in seven patients; six showed no recurrence of cancer 1 to 4 years after surgery. Histologic evaluation in 18 patients revealed trabecular type of HCC in 15 and acinar HCC in two others. In 16 specimens in which nontumorous liver could be studied, only six had evidence of cirrhosis; ten others showed variants of chronic persistent hepatitis.

Prediction of the prognosis of liver cirrhosis in Japanese using Cox's proportional hazard model

Data on 155 patients with liver cirrhosis were analyzed, using Cox's proportional hazard model. Twenty variables were screened, using a multiple linear regression analysis in a stepwise manner and 6 were considered to reflect the prognosis of cirrhotics. Three of the 6 variables were significantly prognostic, i.e. ascites, atrophy of the right lobe of the liver seen on liver scintigram and the concentration of serum albumin. The prognostic index (PI) for each patient was calculated by adding all the products of scores of these three variables with the corresponding coefficient: PI = 0.895 X ascites (absent = 0, present = 1) + 0.983 X atrophy of right lobe of the liver on the liver scintigram (absent = 0, present = 1) + (-0.561) X serum albumin (g/dl). According to the PI, the subjects were separated into three groups; group 1: PI less than -1.9, group 2: -1.9 less than or equal to PI less than -0.6, group 3: PI greater than or equal to -0.6. The global 5- and 10-year survival rates of each group were 80% and 65% in group 1, 50% and 30% in group 2 and 12% and 0% in group 3, respectively. Four of the 14 deaths in group 1, 8 of 47 in groups 2 and 10 of 24 in group 3 were caused by hepatocellular carcinoma. Our observations suggest that advanced stage cases of cirrhosis are at a high risk concerning development of hepatocellular carcinoma.

Spontaneous reactivation of hepatitis B in Chinese patients with HBsAg-positive chronic active hepatitis

Eleven patients of Chinese origin experienced spontaneous reactivation of chronic active hepatitis B. Eight HBsAg-positive patients were followed for an average of 15 months prior to, while three others presented during reactivation. Fatigue, hepatomegaly and jaundice were frequent findings. Elevation of both serum ALT (average = 1,212 units per liter) and hepatitis B virus DNA levels were noted in all patients, and reactivation lasted an average of 4.4 months. During resolution, clinical symptoms abated, serum ALT levels reverted toward normal, and in nine patients, the hepatitis B virus DNA values became undetectable. All patients lacked evidence for acute hepatitis A, Epstein-Barr Virus, cytomegalovirus or hepatitis delta virus infection. Histologic findings of liver tissue from eight patients showed piecemeal necrosis and fibrosis. Within the parenchyma, varying degrees of hepatocytolysis with cuffing, perivenular necrosis and acidophilic bodies were noted. Ground-glass cells and regenerative changes also were observed. Cirrhosis was not present in any of the liver biopsies. These findings suggest that spontaneous reactivation of hepatitis B occurs in heterosexual patients with chronic active hepatitis B and contributes to chronic inflammation and to the progression of their liver disease.

Relation of the hepatitis B virus carrier state to hepatocellular carcinoma

The attempt to divide the large group of chronic HBsAg carriers into "healthy" vs. those with chronic hepatitis of various intensities is sometimes difficult. The major problems are overlap in clinical manifestations, hepatic test results and histologic as well as virologic features. Nevertheless, this separation is not only conceptually important, but may also be useful in patient management, particularly because of the risk of transition to cirrhosis and HCC. Although at least 75% of patients with HCC associated with HBV have cirrhosis, the time point at which the cirrhosis developed is not established, particularly since the vast majority of chronic HBsAg carriers fall into the "healthy" category. Important unanswered questions are, therefore: how often do "healthy" carriers develop cirrhosis and/or HCC, including the time relations between the two? Does the transformation to HCC result from one or several identifiable acute events in the "healthy" carrier (or in mild CPH) or is it a gradual process of progressing chronic hepatitis B in which intercurrent exacerbations may still play a role? Do the quantitative observations as to the relation between persistent HBV infections and HCC in the East apply to Western countries? Our hypothesis concerning pathogenesis is based on pathologic, molecular, clinical and epidemiologic observations and concepts, and is supported by studies of hepadna virus-infected animals. This thesis proposes that integration of HBV DNA into host chromosomes in acute or chronic hepatitis or during the "healthy" carrier state corresponds to an initiation event similar to that described in chemical carcinogenesis.(ABSTRACT TRUNCATED AT 250 WORDS)