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Jain P, Patel S, Simpson HN, Silver RM, Lewin DN, Campbell RC, Guimaraes M, Silver KC. Nodular Regenerative Hyperplasia of the Liver in Rheumatic Disease: Cases and Review of the Literature. J Investig Med High Impact Case Rep 2021; 9:23247096211044617. [PMID: 34514900 PMCID: PMC8436301 DOI: 10.1177/23247096211044617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/25/2021] [Accepted: 08/19/2021] [Indexed: 12/05/2022] Open
Abstract
Nodular regenerative hyperplasia (NRH) is a rare disease that is characterized by benign transformation of the hepatic parenchyma into small nodules with little to no fibrosis. Nodular regenerative hyperplasia is a cause of noncirrhotic portal hypertension. Symptoms can range from asymptomatic disease to more serious complications of portal hypertension such as esophageal varices and ascites. Nodular regenerative hyperplasia has been described in association with a variety of different rheumatologic, hematologic, and oncologic diseases, as well as in immune deficiency states and with exposures to certain toxins. Diagnosis is made by histology, and the treatment involves addressing the underlying disease. The first description of this rare disease was actually described in a patient with rheumatoid arthritis, neutropenia, and splenomegaly (Felty's Syndrome). We describe 2 cases of NRH associated with underlying rheumatic disorders, in one of which NRH was actually the presenting feature of the patient's underlying autoimmune condition. Subsequently, we provide a brief review of the literature of NRH in autoimmune disease with respect to epidemiology, cause, clinical manifestations, diagnosis, and treatment.
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Affiliation(s)
| | - Sagar Patel
- Medical University of South Carolina, Charleston, USA
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Barge S, Grando V, Nault JC, Broudin C, Beaugrand M, Ganne-Carrié N, Roulot D, Ziol M. Prevalence and clinical significance of nodular regenerative hyperplasia in liver biopsies. Liver Int 2016; 36:1059-66. [PMID: 26415006 DOI: 10.1111/liv.12974] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 09/17/2015] [Indexed: 02/13/2023]
Abstract
BACKGROUND Nodular regenerative hyperplasia (NRH) is a rare histological disorder associated with a wide variety of systemic diseases. AIMS We aimed (i) to report the prevalence of NRH in a database of liver biopsies (LBs) and the frequency of portal hypertension (PHT) at diagnosis, and (ii) to investigate whether associated diseases and/or specific histological lesions, including abnormalities of the microvasculature, were related to PHT. METHODS Patients with a histological diagnosis of NRH, referred by seven clinical departments, were retrospectively selected. Clinical, biological, radiological, haemodynamic and endoscopic data at diagnosis were recorded. LBs were reassessed for microvascular abnormalities. RESULTS NRH was diagnosed in 4.4% of LBs (n = 159, male: 52%, mean age: 54). Among patients referred for unexplained liver enzyme abnormalities, 15% had NRH. PHT was present at diagnosis in 45 patients (38%), including 13 with portal thrombosis; 65% of patients had an associated disorder. Obliteration of portal vein branches, observed in the LBs of 17 patients (11%), was significantly associated with PHT (P = 0.02). Periportal angiomatosis, observed in 101 patients (63%), was associated with the absence of PHT (P < 10(-4) ). CONCLUSION We suggest that NRH is a frequent histological lesion in the setting of unexplained liver enzyme abnormalities. PHT is present at the time of diagnosis in 1/3 of patients regardless of the presence of associated disease. The frequency of periportal angiomatosis in NRH without obliteration of portal vein branches, and its association with the absence of PHT suggest that obstructive portal venopathy would not represent the most frequent mechanism involved in NRH.
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Affiliation(s)
- Sandrine Barge
- Service d'Hépato-Gastro-entérologie, Groupe hospitalier Paris-Seine-Saint Denis, Hôpital Jean Verdier, France et Université Paris 13, Bobigny, France
| | - Véronique Grando
- Service d'Hépato-Gastro-entérologie, Groupe hospitalier Paris-Seine-Saint Denis, Hôpital Jean Verdier, France et Université Paris 13, Bobigny, France
| | - Jean-Charles Nault
- Service d'Hépato-Gastro-entérologie, Groupe hospitalier Paris-Seine-Saint Denis, Hôpital Jean Verdier, France et Université Paris 13, Bobigny, France.,Faculté de Médecine, INSERM UMR-1162, Génomique fonctionnelle des Tumeurs solides, IUH, France Université Paris Descartes, Paris, France
| | - Chloé Broudin
- Service d'Anatomie pathologique et Centre de Ressources biologiques, Groupe hospitalier Paris-Seine-Saint Denis, Hôpital Jean Verdier, France et Université Paris 13, Bobigny, France
| | - Michel Beaugrand
- Service d'Hépato-Gastro-entérologie, Groupe hospitalier Paris-Seine-Saint Denis, Hôpital Jean Verdier, France et Université Paris 13, Bobigny, France
| | - Nathalie Ganne-Carrié
- Service d'Hépato-Gastro-entérologie, Groupe hospitalier Paris-Seine-Saint Denis, Hôpital Jean Verdier, France et Université Paris 13, Bobigny, France.,Faculté de Médecine, INSERM UMR-1162, Génomique fonctionnelle des Tumeurs solides, IUH, France Université Paris Descartes, Paris, France
| | - Dominique Roulot
- UF Hépatologie, Groupe hospitalier Paris-Seine-Saint Denis, Hôpital Avicenne, AP-HP, France et Université Paris 13, Bobigny, France
| | - Marianne Ziol
- Faculté de Médecine, INSERM UMR-1162, Génomique fonctionnelle des Tumeurs solides, IUH, France Université Paris Descartes, Paris, France.,Service d'Anatomie pathologique et Centre de Ressources biologiques, Groupe hospitalier Paris-Seine-Saint Denis, Hôpital Jean Verdier, France et Université Paris 13, Bobigny, France
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Maiwall R, Goel A, Pulimood AB, Babji S, Sophia J, Prasad C, Balasubramanian KA, Ramakrishna B, Kurian S, Fletcher GJ, Abraham P, Kang G, Ramakrishna BS, Elias E, Eapen CE. Investigation into celiac disease in Indian patients with portal hypertension. Indian J Gastroenterol 2014; 33:517-23. [PMID: 25231910 DOI: 10.1007/s12664-014-0501-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 08/20/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is limited data on celiac disease in patients with cryptogenic cirrhosis or idiopathic noncirrhotic intrahepatic portal hypertension (NCIPH). Our objective was to evaluate for celiac disease in patients with portal hypertension in India. METHODS Consecutive patients with portal hypertension having cryptogenic chronic liver disease (cases) and hepatitis B- or C-related cirrhosis (controls) were prospectively enrolled. We studied tissue transglutaminase (tTG) antibody and duodenal histology in study patients. RESULT Sixty-one cases (including 14 NCIPH patients) and 59 controls were enrolled. Celiac disease was noted in six cases (including two NCIPH patients) as compared to none in controls. In a significant proportion of the remaining study subjects, duodenal biopsy showed villous atrophy, crypt hyperplasia, and lamina propria inflammation, not accompanied by raised intraepithelial lymphocytes (IELs); this was seen more commonly in cases as compared to controls. An unexpectedly high rate of tTG antibody positivity was seen in study subjects (66 %) of cases as compared to 29 % in controls (p-value < 0.001), which could indicate false-positive test result. CONCLUSION In this study, 10 % of patients with unexplained portal hypertension (cryptogenic chronic liver disease) had associated celiac disease. In addition, an unexplained enteropathy was seen in a significant proportion of study patients, more so in patients with cryptogenic chronic liver disease. This finding warrants further investigation.
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Affiliation(s)
- Rakhi Maiwall
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, 632 004, India
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Hartleb M, Gutkowski K, Milkiewicz P. Nodular regenerative hyperplasia: Evolving concepts on underdiagnosed cause of portal hypertension. World J Gastroenterol 2011; 17:1400-9. [PMID: 21472097 PMCID: PMC3070012 DOI: 10.3748/wjg.v17.i11.1400] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 02/06/2023] Open
Abstract
Nodular regenerative hyperplasia (NRH) is a rare liver condition characterized by a widespread benign transformation of the hepatic parenchyma into small regenerative nodules. NRH may lead to the development of non-cirrhotic portal hypertension. There are no published systematic population studies on NRH and our current knowledge is limited to case reports and case series. NRH may develop via autoimmune, hematological, infectious, neoplastic, or drug-related causes. The disease is usually asymptomatic, slowly or non-progressive unless complications of portal hypertension develop. Accurate diagnosis is made by histopathology, which demonstrates diffuse micronodular transformation without fibrous septa. Lack of perinuclear collagen tissue distinguishes NRH from typical regenerative nodules in the cirrhotic liver. While the initial treatment is to address the underlying disease, ultimately the therapy is directed to the management of portal hypertension. The prognosis of NRH depends on both the severity of the underlying illness and the prevention of secondary complications of portal hypertension. In this review we detail the epidemiology, pathogenesis, diagnosis, management, and prognosis of NRH.
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Non-cirrhotic intrahepatic portal hypertension: associated gut diseases and prognostic factors. Dig Dis Sci 2011; 56:227-35. [PMID: 20499175 DOI: 10.1007/s10620-010-1278-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 04/30/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS Non-cirrhotic intrahepatic portal hypertension (NCIPH) is generally regarded to have a benign prognosis. We have studied a cohort followed-up at a tertiary referral center and postulate that gut-derived prothrombotic factors may contribute to the pathogenesis and prognosis of NCIPH. METHODS We retrospectively analyzed prognostic indicators in 34 NCIPH patients. We also searched for associated gut diseases. RESULTS Transplant-free survival in NCIPH patients from first presentation with NCIPH at 1, 5, and 10 years was 94% (SE: 4.2%), 84% (6.6%), and 69% (9.8%), respectively. Decompensated liver disease occurred in 53% of patients. Three (9%) patients had ulcerative colitis while five of 31 (16%) tested had celiac disease and on Kaplan-Meier analysis, celiac disease predicted reduced transplant-free survival (p=0.018). On multivariable Cox regression analysis, independent predictors of reduced transplant-free survival were older age at first presentation with NCIPH, hepatic encephalopathy, and portal vein thrombosis. Prevalence of elevated initial serum IgA anticardiolipin antibody (CLPA) was significantly higher in NCIPH (36% of patients tested), compared to Budd-Chiari syndrome (6%) (p=0.032, Fisher's exact test) and celiac disease without concomitant liver disease (0%) (p=0.007). CONCLUSIONS We have identified prognostic factors and report progression to liver failure in 53% of NCIPH patients followed-up at our center. Our data supports a role for intestinal disease in the pathogenesis of intrahepatic portal vein occlusion leading to NCIPH.
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Prasad KK, Debi U, Sinha SK, Nain CK, Singh K. Hepatobiliary disorders in celiac disease: an update. Int J Hepatol 2011; 2011:438184. [PMID: 21994857 PMCID: PMC3170807 DOI: 10.4061/2011/438184] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 09/02/2010] [Accepted: 10/06/2010] [Indexed: 12/30/2022] Open
Abstract
This communication reviews recent literature and summarizes hepatobiliary abnormalities that may complicate the clinical course of celiac disease. A wide spectrum of hepatobiliary diseases has been described, including asymptomatic elevations of liver enzyme levels, nonspecific hepatitis, nonalcoholic fatty liver disease, and autoimmune and cholestatic liver disease. Moreover, in the majority of patients, liver enzyme levels will normalize on a gluten-free diet. In addition, celiac disease may be associated with rare hepatic complications, such as hepatic T-cell lymphoma. Because many celiac patients do not have overt gastrointestinal symptoms, a high index of suspicion is required. Simple methods of detecting celiac disease such as serum antibody tests help in the early identification of the disease, thus preventing serious complications of the disorder. The IgG DGP antibody test and IgA tTG antibody test used in combination are an excellent screening test for suspected cases of celiac disease.
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Affiliation(s)
- Kaushal K. Prasad
- Department of Superspeciality of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India,Division of GE Histopathology, Department of Superspeciality of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India,*Kaushal K. Prasad:
| | - Uma Debi
- Department of Radiodiagnosis, Government Medical College & Hospital, Sector 32, Chandigarh 160030, India
| | - Saroj K. Sinha
- Department of Superspeciality of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
| | - Chander K. Nain
- Department of Superspeciality of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
| | - Kartar Singh
- Department of Superspeciality of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
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Leggio L, Cadoni G, D'Angelo C, Mirijello A, Scipione S, Ferrulli A, Agostino S, Paludetti G, Gasbarrini G, Addolorato G. Coeliac disease and hearing loss: preliminary data on a new possible association. Scand J Gastroenterol 2007; 42:1209-13. [PMID: 17852854 DOI: 10.1080/00365520701327377] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Coeliac disease (CD), an autoimmune gluten-dependent enteropathy, can be associated with several extra-intestinal manifestations, including neurological disorders. At present, no data are available on the presence of hearing loss disorder in coeliac patients. The aim of the present study was to investigate the prevalence of hearing loss in coeliac patients compared with that in healthy controls. MATERIAL AND METHODS Twenty-four adult coeliac patients and 24 healthy subjects matched for gender, age, smoking and drinking habits were enrolled in the study. Among the coeliac patients, 6 were newly diagnosed and 18 patients were on a gluten-free diet for at least one year. RESULTS A hearing loss was found in 10 (47.1%) coeliac patients and 2 (9.1%) healthy controls. All CD patients with hearing loss presented a sensorineural hearing loss. The prevalence of hearing loss was significantly higher in coeliac patients than in healthy controls (p = 0.01) but it was not significantly different between untreated (33.3%) and treated (44.4%) coeliac patients (p: NS). CONCLUSIONS Despite the low number of subjects evaluated, the present study showed a higher prevalence of hearing loss in coeliac patients than in healthy controls, suggesting an association between CD and hearing loss. Immunological processes such as ear-specific and non-specific autoantibodies and vasculitis could be the basis of this association. Further longitudinal investigations on a larger sample size will be necessary to confirm the present data.
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Affiliation(s)
- Lorenzo Leggio
- Institutes of Internal Medicine, Catholic University of Rome, Rome, Italy
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Abstract
PURPOSE OF REVIEW Recent papers on disorders of the liver and biliary tract which clarify their pathogenesis and attendant morphologic changes are highlighted. RECENT FINDINGS The concept of 'bystander hepatitis' was cited in studies showing hepatic infiltration of CD8-positive T cells in the setting of extrahepatic infections such as influenza virus and severe acute respiratory syndrome. Diabetic liver lesions include glycogenic hepatopathy (in which poor diabetic control leads to swollen, glycogen-filled hepatocytes without fat, steatohepatitis or fibrosis) and diabetic hepatosclerosis in which there is diffuse perisinusoidal fibrosis (type IV collagen) without zonal predilection. Ground-glass hepatocellular inclusions (positive with periodic acid-Schiff stain for glycogen) were reported in three separate series of patients who were hepatitis B virus-negative, often transplant recipients, immunosuppressed and on multiple medications. A Banff consensus paper expertly compared and contrasted the histologic features which characterize the various causes of late liver allograft dysfunction. SUMMARY Informative papers emerged this past year concerning collateral damage to the liver in extrahepatic infections, diabetic lesions and causes of liver dysfunction after transplantation, among other topics.
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Affiliation(s)
- Jay H Lefkowitch
- Department of Pathology, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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