Liver biopsy in chronic hepatitis: 1968-78

Magnitude of contrast-enhanced ultrasonography as a noninvasive predictor for hepatic fibrosis: comparison with liver stiffness measurement and serum-based models

PURPOSE

To elucidate the efficiency of contrast-enhanced ultrasonography alone and in combination with other noninvasive models for grading hepatic fibrosis.

METHODS

This prospective study included 74 patients with four grades (F1-F4) of chronic liver disease (17, 20, 18, and 19 patients, respectively). Diagnostic performances of the contrast parameter (time to the maximum intensity ratio between the right portal vein and liver parenchyma from the onset of contrast enhancement in the right portal vein) assessed by ultrasonography, liver stiffness measurement (LSM), FIB-4 test, and type IV collagen 7s were compared with histological findings.

RESULTS

Greatest areas under the receiver operating characteristics curve (Az) with the single model were 0.83 (95 % confidence interval 0.71-0.91) for marked fibrosis (≥F2) by FIB-4 test; 0.85 (0.73-0.92) for advanced fibrosis (≥F3) by LSM, and 0.92 (0.83-0.96) by type IV collagen 7s for cirrhosis (F4). When combined, Az for marked fibrosis was ≥0.82; the best Az value was 0.87 (0.74-0.94) for the combination of contrast parameter with FIB-4. Similarly, the Az for advanced fibrosis was ≥0.82, and the best Az value was 0.89 (0.78-0.94) for the combination of contrast parameter with LSM. The Az for cirrhosis was ≥0.95, and the best Az was 0.99 (0.97-1.00) for the combination of contrast parameter with LSM.

CONCLUSIONS

The contrast parameter is a promising predictor for grading hepatic fibrosis when combined with LSM or FIB-4.

B alert: hepatitis B virus infection in children in Victoria

AIM

The aim of this study is to determine the demographic, clinical and serological patterns of hepatitis B in children in Victoria over a 17-year period.

METHODS

Retrospective analysis of medical records of all patients <18 years of age with positive hepatitis B surface antigen referred to the Gastroenterology, Immigrant Health and Infectious Diseases clinics between 1992 and 2009.

RESULTS

Of the 164 children identified, 76% were born overseas, with vertical transmission the most likely source in 84%. Most were asymptomatic, with no signs of chronic liver disease. Forty children infected with hepatitis B virus (HBV) were born in Australia prior to universal vaccination. There was poor documentation of vaccination or response to vaccination in siblings at risk within families where at least one child was infected. An increasing number of referrals was noted from 2006 to 2009 compared with the preceding 4 years (P < 0.001). Of an expected 200 follow-up visits from new referrals, 78% were attended.

CONCLUSION

These findings suggest that the number of children with HBV in our population is increasing and that models of health care designed to integrate primary with specialist care are required to minimise the overall health care burden of this chronic infection.

Do serum ALAT values reflect the inflammatory activity in the liver of patients with chronic viral hepatitis?

A retrospective study was carried out in 40 patients with chronic viral hepatitis, to assess whether serum alanine aminotransferase reflects the inflammatory process in the liver. Twenty liver biopsy specimens were included for each disease. Five histological aspects were scored: periportal inflammation, lobular inflammation, ballooning, Councilman bodies and lymphocyte follicles. Logarithmic values of alanine aminotransferase were correlated with each aspect using the Spearman correlation coefficient. For the hepatitis B cohort a statistical significant correlation was found between alanine aminotransferase and periportal inflammation (p = 0.0001), lobular inflammation (p = 0.0002) and Councilman bodies/area (p = 0.003). In the hepatitis C study population alanine aminotransferase correlates with both periportal inflammation (p = 0.007) and lymphocyte follicles/Area (p = 0.02). In conclusion, these results suggest that alanine aminotransferase can be used as an indicator of inflammatory activity. A prospective study is needed, to further analyze the use of alanine aminotransferase, as a monitor of disease activity in patients with chronic viral hepatitis.

The use of recombinant interferon alfa-2b in elderly patients with anti-HCV-positive chronic active hepatitis

OBJECTIVE

To compare efficacy and tolerance of recombinant interferon alfa-2b in the treatment of anti-HCV-positive chronic active hepatitis (CAH) in subjects aged 65 years and above with those less than 65.

DESIGN

A randomized controlled trial.

SETTING

Outpatients in two hospitals.

PATIENTS

65 consecutive outpatients with anti-HCV-positive CAH for 1 to 30 years, having basal aminotransferase levels at least twice the normal value. Those 65 and over were randomized to an interferon group (A, n = 22) or a no-treatment group (B, n = 22). All those under 65 received interferon (group C, n = 21).

INTERVENTION

Interferon at a dose of 3 mU 3 times a week for a 6-month period. A normalization of serum aminotransferase levels was considered a positive response to therapy.

RESULTS

Response to therapy was positive in 62% of the treated elderly compared to 57% of the adults (P = 0.85). The two groups of responders showed a common highly significant reduction of aminotransferase (P < 0.001). Side effects were similar in elderly and young. Two untreated elderly showed spontaneous normalization of aminotransferase.

CONCLUSION

Interferon in anti-HCV-positive CAH is useful in the elderly, allowing normalization of aminotransferase, improvement of the histology and remission of the disease in 62% of the cases. Side effects seem to be independent of age. Further studies are required to assess both duration of remission and usefulness of cyclic therapy in previous responders.

Natural history of chronic persistent hepatitis B. Relationship between hepatitis B virus replication and the course of the disease

The status of viral replication at diagnosis and its relationship to the changes occurring during the natural history of the disease have been investigated in 26 patients with chronic persistent hepatitis (CPH) type B. Liver HBcAg and serum HBeAg were found in 73% of patients. During follow-up, serum transaminases normalized in 13/17 HBeAg-positive patients 1-6 years after diagnosis and 11 of them developed anti-HBe. HBe seroconversion was closely preceded by a transient elevation of transaminases in 5 patients in whom a repeated liver biopsy showed prominent lobular hepatitis and marked reduction of liver HBcAg. Such changes resulted in long-lasting biochemical normalization but only 1 patient became HBsAg-negative. These observations indicate that prolonged viral replication occurs in type B CPH. Termination of replication frequently implies a transient worsening caused by lysis of HBcAg-containing hepatocytes which leads to inactivation of the disease and to development of a healthy HBsAg carrier state.

A quantitative ultrastructural analysis of the leukocytes in contact with hepatocytes in chronic active hepatitis, with a cytochemical detection of mononuclear phagocytes

In an attempt to characterize in vivo the immune cells cytotoxic to hepatocytes in patients with chronic active hepatitis (CAH), a quantitative ultrastructural analysis of leukocytes in close contact with hepatocytes was performed in 13 patients with untreated HBsAg-negative CAH. Mononuclear phagocytes were identified by detection of endogenous peroxidase. Of the leukocytes, 8.3-4.1% were mononuclear phagocytes, 12.5-25.8% were large lymphocytes with a prominent secretory apparatus, assumed to represent mostly killer cells (T-cytotoxic cells and/or null cells), 12.2-56.8% were small lymphocytes poor in cytoplasmic organelles, and 0-45.8% were plasma cells. Patients with high serum transaminase levels had significantly more mononuclear phagocytes (P less than 0.001) and significantly fewer plasma cells (P less than 0.001) and small lymphocytes (P less than 0.001) than patients with lower disease activity. The profile of the leukocytes in contact with hepatocytes in these CAH patients suggests that mononuclear phagocyte-mediated mechanisms play an important role in hepatocyte necrosis in vivo.

Formulation and application of a numerical scoring system for assessing histological activity in asymptomatic chronic active hepatitis

A Histology Activity Index has been developed which generates a numerical score for liver biopsy specimens obtained from patients with asymptomatic chronic active hepatitis. Biopsies are graded in four categories: periportal necrosis, intralobular necrosis, portal inflammation, and fibrosis. Under code, three pathologists and three hepatologists evaluated 14 liver biopsy specimens obtained from five patients with asymptomatic chronic active hepatitis. Good correlation was seen between severity of liver biopsy lesions as judged by conventional histological descriptions and Histology Activity Index scores. Significant differences in Histology Activity Index score occurred in only 2 or 28 duplicate scorings of biopsy specimens by two observers. This system provides definitive endpoints for statistical analysis of serial changes in liver histology and offers an alternative to the use of conventional pathological descriptions in following the natural history and treatment responses of asymptomatic chronic active hepatitis.