Two cases with hepatic amyloidosis suspected of having primary sclerosing cholangitis

Hepatic amyloidosis: a prevalence study and clinical characterization of a rare and severe disease

BACKGROUND AND AIM

Amyloidosis is a systemic disease characterized by extracellular deposition of amyloid protein, most commonly in the heart and kidney. Hepatic amyloidosis is a rare form of presentation that ranges from mild hepatomegaly and altered liver biochemical tests to acute liver failure. The aims of this study were to evaluate the prevalence of amyloidosis in patients undergoing liver biopsy and describe its main clinical characteristics and prognostic impact.

METHODS

A retrospective analysis of all patients with a histological diagnosis of hepatic amyloidosis between January 2010 and December 2019 was performed.

MAJOR RESULTS

A total of 7 patients were identified from a total of 1773 liver biopsy procedures (0.4%), with a female predominance (6/7) and median age of diagnosis of 62 years. The most common clinical manifestations included hepatomegaly (4/7), jaundice (2/7) and peripheral edema (2/7), whereas 3/7 patients were asymptomatic. Every patient presented abnormalities in liver biochemical tests, more commonly cholestasis (6/7), but also cytolysis (4/7) or hyperbilirubinemia (2/7). Abnormal imaging findings included hepatomegaly, steatosis or parenchymal heterogeneity. In most patients (5/7), other organs were involved, most commonly with nephrotic syndrome (3/7) and infiltrative cardiomyopathy (3/7). The most common type was AA amyloidosis (3/7) followed by AL amyloidosis (2/7). The 1-year mortality rate was 43% and the median survival was 24 months.

CONCLUSIONS

We report a low prevalence (0.4%) of amyloidosis among patients undergoing liver biopsy. Although rare, hepatic amyloidosis is associated with a dismal prognosis and a high index of suspicion is crucial to achieve an early diagnosis. .

Secondary sclerosing cholangitis: mimics of primary sclerosing cholangitis

Sclerosing cholangitis is a chronic cholestatic disease characterized by stricturing, beading, and obliterative fibrosis of the bile ducts. Sclerosing cholangitis is considered primary (PSC) if no underlying etiology is identified or secondary (SSC) if related to another identifiable cause. In this article, we will review the clinical features, pathogenesis, diagnosis, and imaging findings of PSC and SSC, with an emphasis on features that may aid in the distinction of these entities. We will also discuss various etiologies of SSC including recurrent pyogenic cholangitis, other infectious etiologies, ischemic damage, toxic insults, and immunologic, congenital, and miscellaneous causes, highlighting the unique imaging findings and clinical context of each diagnosis.

Amyloidosis of the gastrointestinal tract and the liver: clinical context, diagnosis and management

Amyloidosis is a group of disorders that can manifest in virtually any organ system in the body and is thought to be secondary to misfolding of extracellular proteins with subsequent deposition in tissues. The precursor protein that is produced in excess defines the specific amyloid type. This requires histopathological confirmation using Congo red dye with its characteristic demonstration of green birefringence under cross-polarized light. Gastrointestinal (GI) manifestations are common and the degree of organ involvement dictates the symptoms that a patient will experience. The small intestine usually has the most amyloid deposition within the GI tract. Patients generally have nonspecific findings such as abdominal pain, nausea, diarrhea, and dysphagia that can often delay the proper diagnosis. Liver involvement is seen in a majority of patients, although symptoms typically are not appreciated unless there is significant hepatic amyloid deposition. Pancreatic involvement is usually from local amyloid deposition that can lead to type 2 diabetes mellitus. In addition, patients may undergo either endoscopic or radiological evaluation; however, these findings are usually nonspecific. Management of GI amyloidosis primarily aims to treat the underlying amyloid type with supportive measures to alleviate specific GI symptoms. Liver transplant is found to have positive outcomes, especially in patients with specific variants of hereditary amyloidosis.

Liver Transplantation Is a Potential Treatment Option for Systemic Light Chain Amyloidosis Patients with Dominant Hepatic Involvement: A Case Report and Analytical Review of the Literature

Systemic light chain (AL) amyloidosis is caused by abnormal plasma cell clones producing amyloidogenic light chains. The standard treatment is therefore chemotherapy targeting these clones, however, some patients are ineligible due to liver dysfunction. For these patients, preceding liver transplantation (LT) and following chemotherapy is a possible treatment option. We herein report a 58-year-old man with advanced hepatic AL amyloidosis who was successfully treated using this strategy. Previously reported cases treated with LT for this condition were reviewed, however, the outcomes were not favorable. We additionally investigated potential prognostic factors of this treatment approach to improve the outcome of these patients.

Treatment of hepatic amyloid light-chain amyloidosis with bortezomib and dexamethasone in a liver transplant patient

Hepatic amyloid light-chain (AL) amyloidosis is characterized by abnormal deposition of amyloid fibrils in the liver. As this precursor protein is produced by a proliferative plasma cell clone in the bone marrow, liver transplantation (LT) does not affect the disease's progression. Here, we describe the successful treatment using bortezomib- and dexamethasone-based chemotherapy, following LT, of hepatic AL amyloidosis in a 65-year-old woman with progressive liver failure. The patient presented with progressive hepatic dysfunction accompanied by hepatorenal syndrome requiring hemodialysis, and living donor LT was successfully performed. Histology revealed amyloid deposits in the liver and stomach, and serum immunofixation revealed AL amyloidosis (κ-type). The patient began chemotherapy on day 45 after the LT, and remission was achieved after one course. She was subsequently discharged 83 days after the LT, with normal liver and renal function, and no clinical evidence of recurrent disease was observed at the latest follow up (22 months post-LT).

Hepatic amyloidosis: Clinical characteristics and follow-up

AIM: To summarize the clinical features and outcomes of patients with hepatic amyloidosis to improve its diagnosis and treatment and decrease the misdiagnosis rate.

METHODS: A total of 4 patients who were diagnosed with hepatic amyloidosis at General Hospital of Chengdu Military Region were retrospectively analyzed in terms of clinical features, laboratory tests, liver biopsy, treatment and follow-up data.

RESULTS: All the 4 patients had hepatomegaly, increased ALP and γ-glutamyl transferase, and some patients had decreased serum albumin, proteinuria and hyperlipidemia. The liver biopsy pathology showed significant amyloid deposition between hepatocytes and mesh scaffolds. After oral steroids and symptomatic treatment, all patients had improved symptoms and were discharged. During follow-up, two patients died because of liver function failure, and 1 patient died due to kidney function failure.

CONCLUSION: Hepatic amyloidosis is a rare disease, which can be diagnosed by liver biopsy pathology. Steroid hormone drugs can temporarily control the disease, although the prognosis is still poor.

Extensive loculated ascites in hepatic amyloidosis

CONTEXT

Amyloidosis is a disease of extracellular deposition of misfolded proteinaceous subunits, which could be systemic or localized disease. Though hepatic amyloidosis was not uncommon in autopsy series, most cases of hepatic amyloidosis were asymptomatic. Ascites, jaundice, portal hypertension, and gastrointestinal bleeding from esophageal varices were reported in literature.

CASE REPORT

A 42-year-old man with end-stage renal disease on hemodialysis and recent small bowel obstruction presented with chronic abdominal pain. Computed tomography of abdomen and pelvis showed extensive loculated ascites and multiple small bowel loops tethered to adhesions and hepatomegaly. Finally, hepatic venography and liver biopsy confirmed hepatic amyloidosis with portal hypertension. The patient was waiting for liver transplant for definite treatment.

CONCLUSION

We report a rare case of hepatic amyloidosis with prior small bowel obstruction presented with extensive loculated ascites and multiple small bowel loops tethered to adhesions.