Portal lymphadenopathy associated with lipofuscin in chronic cholestatic liver disease

The incidence of chylous ascites after liver transplantation and the proposal of a diagnostic and management protocol

BACKGROUND

No protocol has been established for the diagnosis and management of chylous ascites after liver transplantation (LT). In this study, we retrospectively reviewed our cases of posttransplant chylous ascites (PTCA) and aimed to propose a diagnostic and management protocol.

PATIENTS AND METHODS

We retrospectively reviewed the clinical records of 96 LT recipients who underwent LT at our department. The incidence of PTCA and the associated risk factors were analyzed and our protocol for chylous ascites was evaluated.

RESULTS

PTCA occurred in 6 (6.3%) patients (mean age: 10.7±11.0years) at a mean of 10.8±3.6days after LT. The primary disease in all of PTCA cases was biliary atresia (BA). The periportal lymphadnopathy was an independent risk factor for PTCA. In all cases PTCA successfully resolved according to our protocol. Octreotide was administered in 4 of our 6 PTCA cases. The mean postoperative hospital stay was 40.2±8.4days, which was similar to that of cases without PTCA.

CONCLUSIONS

The incidence of PTCA in LT patients, especially in those with BA, is relatively high. Our diagnostic criteria and our management protocol were helpful for patients with refractory ascites after LT.

TYPE OF STUDY

Diagnostic test: Level II. Treatment study: Level III.

The accumulation of regulatory T cells in the hepatic hilar lymph nodes in biliary atresia

PURPOSE

A proposed etiopathogenesis of biliary atresia (BA) involves T-cell-mediated inflammatory bile duct damage and progressive hepatic fibrosis. Pediatric surgeons often observe swelling of the hepatic hilar lymph nodes during the Kasai procedure. Given the importance of regulatory mechanisms in immune responses, the present study was designed to analyze the quantitative changes of regulatory T cells (T _reg cells) in the hepatic hilar lymph nodes (hepatic hilar LNs) and peripheral blood (PB) in BA.

METHODS

The hepatic hilar LNs and PB obtained during the Kasai procedure were analyzed by flow cytometry. The ratios of total and active Tregs to the total CD4⁺ cells in the PB and the hepatic hilar LNs were compared.

RESULTS

In patients with BA, the ratios of both the total and active T _reg cells in the hepatic hilar LNs were higher than those in the PB (total T _reg cells: PB vs. LN; P < 0.001; active T _reg cells: PB vs. LN; P = 0.001). In BA patients, the increase in the ratio of active T _reg cells to the CD4 + cells in the LNs in comparison to the PB was greater than that in control patients. The ratio observed in the BA patients was almost double the ratio observed in the control patients. The median LN/PB ratio in the BA patients was 3.1, while that in controls was 1.6 (P = 0.03).

CONCLUSION

The present study showed that the ratios of both total T _reg cells and active T _reg cells were higher in the hepatic hilar lymph nodes of BA patients. This finding could shed light on the pathogenesis of BA.

A combination of metallomics and metabolomics studies to evaluate the effects of metal interactions in mammals. Application to Mus musculus mice under arsenic/cadmium exposure

Arsenic and cadmium are toxic metals of environmental significance with harmful effects on man. To study the toxicological and biochemical effects of arsenic/cadmium in mammals a combined metallomic and metabolomic approach has been developed, complemented with the measurement of biochemical parameters in blood and histopathological evaluation of liver injury in mice Mus musculus under exposure to both xenobiotics. Size-exclusion chromatography (SEC) was combined with affinity chromatography (AF) and ICP-MS detection using species unspecific isotopic dilution analysis (SUID) to characterize the biological effects of As/Cd on selenium containing proteins in the bloodstream of exposed mice. On the other hand, both direct infusion mass spectrometry (DIMS) and gas chromatography-mass spectrometry (GC-MS) provided information about changes in metabolites caused by metals. The results show that As/Cd exposure produces interactions in the distribution of both toxics between organs and plasma of mice and antagonistic interactions with selenium containing proteins in the bloodstream. Interplay with essential metabolic pathways, such as energy metabolism and breakdown of membrane phospholipids were observed, which are more pronounced under As/Cd exposure. In addition, heavy metal and metalloid causes differential liver injury, manifested by steatosis (non-alcoholic fatty liver disease, NAFLD) and infiltration of blood cells into the space of Disse.

BIOLOGICAL SIGNIFICANCE

This work presents new contributions in the study of arsenic/cadmium interactions in mice Mus musculus under controlled exposure. With the combination of metallomic and metabolomic approaches the traffic of As and Cd from liver to kidney by means of blood was observed and excretion of As (as arsenic metabolites) or Cd (as MTCd) is inhibited with the simultaneous administration of As/Cd, and these toxic elements have important influence in the levels of seleno-proteins in the plasma. In addition, the metabolomic approach reveals inhibition of different metabolic cycles such as tricarboxylic acid and phospholipid degradation that causes membrane damage and apoptosis that is histopathologically confirmed. This article is part of a Special Issue entitled: Environmental and structural proteomics.

Periportal lymphadenopathy in patients without identifiable pancreatobiliary or hepatic malignancy

BACKGROUND & AIMS

Enlarged periportal lymph nodes often are noticed during imaging of the upper abdomen. Malignant infiltration and enlargement of periportal nodes occur in patients with cancers of the liver, gallbladder, biliary tree, and pancreas and lymphoma. However, there are no published data on the significance and differential diagnosis of enlarged periportal lymph nodes in patients without the above mentioned cancers.

METHODS

We searched our database for patients who (1) underwent endoscopic ultrasound for evaluation of enlarged periportal nodes or (2) were found to have enlarged periportal lymph nodes (> or =10 mm) during endoscopic ultrasound (EUS) examination. Patients with identifiable pancreatic, biliary, gallbladder, or liver cancers were excluded. EUS-guided fine-needle aspiration of one or more nodes was performed.

RESULTS

Sixty-four patients with periportal lymph nodes 10-40 mm in size met the inclusion criteria. In 24 patients, enlarged periportal nodes were noted in the computerized tomography or magnetic resonance imaging scans. Fifty-one patients had multiple enlarged periportal nodes. Concomitantly, enlargement was seen in peripancreatic nodes (n = 14), celiac nodes (n = 14), and mediastinal nodes (n = 11). Twelve of the 64 patients (18.8%; 95% confidence interval, 9.2%-28.4%) had a malignant cause of enlarged periportal lymph nodes: 5 with metastatic carcinoma and 7 with non-Hodgkin's lymphoma. Significant cytologic findings in benign nodes included granulomas (n = 4) and lipogranulomatosis (n = 8).

CONCLUSIONS

A significant number of patients with enlarged periportal lymph nodes without identifiable pancreatobiliary and liver cancer harbor malignancy and other identifiable pathologic processes. We recommend that these nodes be sampled with fine-needle aspiration at the time of EUS examination.

Sonographic detection of perihepatic lymphadenopathy is an indicator for primary sclerosing cholangitis in patients with inflammatory bowel disease

AIM

Primary sclerosing cholangitis (PSC) is a frequent complication in patients with inflammatory bowel disease (IBD). While hyperplasia of the perihepatic lymph nodes has been described in patients with PSC, its prevalence and cause in IBD patients remains obscure. In the present study we address the question of whether ultrasound (US) examination is useful to detect perihepatic lymphadenopathy and improve the diagnostic accuracy for PSC in patients with underlying IBD.

METHODS

A total of 310 consecutive IBD patients were prospectively evaluated by US for enlarged perihepatic lymph nodes, as well as serologic testing for cholestasis-indicating enzymes. In patients with positive test results, viral or autoimmune liver disorders were excluded by serum testing. Next, the presence of PSC was confirmed/excluded by endoscopic retrograde cholangiography (ERC).

RESULTS

Perihepatic lymphadenopathy was detected by US in 27 of 310 (9%) patients. In 9 (33%) of those, serologic testing identified an underlying autoimmune or viral hepatitis. In the remaining 18 patients, ERC confirmed PSC in 17 (94%) and excluded it in 1. Elevated cholestasis parameters were found in 43 of 310 (14%) patients and 5 (12%) of those were diagnosed with autoimmune or viral hepatitis. In the remaining 38 patients, ERC confirmed PSC in 15 (39%) and excluded it in 23 (61%). Therefore, when autoimmune or viral hepatitis was excluded, enlarged lymph nodes in US predicted PSC more accurately than conventional serum parameters alone (PPV 94 and 39%, respectively [ P<0.001]), and the sensitivity ratio increased by a factor of 1.13 in favor of the US examination.

CONCLUSION

In patients with IBD, detection of enlarged perihepatic lymph nodes is a highly predictive indicator for the presence of PSC. Alternative causes of perihepatic lymphadenopathy have to be excluded.

Ultrasound, hepatic lymph nodes and chronic active hepatitis

Thirty-two consecutive patients with a histological diagnosis of chronic active hepatitis were examined with liver biopsy, laboratory tests and ultrasonography of the hepato-duodenal ligament to investigate the possible correlation between enlarged lymph nodes in the hepato-duodenal ligament and biochemical activity, histological activity and/or humoral immunoreactivity. We found a significant correlation between lymph-node size and serum alkaline phosphatase in the total material. In the hepatitis C-virus-associated group of patients a significant correlation between the size of the lymph nodes and gamma-glutamyl transpeptidase was found. In the autoimmune group there was a trend towards a negative correlation between lymph-node size and albumin.

Ultrasound, hepatic lymph nodes and primary biliary cirrhosis

Thirty-five consecutive patients with primary biliary cirrhosis were examined using liver biopsy, laboratory tests and ultrasonography of the hepato-duodenal ligament to investigate the possible correlation between enlarged lymph nodes in the hepato-duodenal ligament and biochemical activity, histologic activity or stage and/or humoral immunoreactivity. We found a positive correlation between the size of the largest lymph node and laboratory values of cholestasis, hepatocellular damage and increased humoral immunoreactivity. On the other hand, we found a negative association between lymph node size and hepatocellular function. When twelve of the patients were reexamined after at least 10 months, in the majority of the patients changes in lymph node size were accompanied by similar changes in markers of cholestasis, hepatocellular damage and immunoreactivity. Prognostic index was also directly associated with lymph node size in most of these patients. No association between lymph node size and histologic stage was observed.