Antimitochondrial antibody profiles in primary biliary cirrhosis distinguish at early stages between a benign and a progressive course: a prospective study on 200 patients followed for 10 years

In recent retrospective studies, it was shown that subtypes of antimitochondrial antibodies (AMA) can help to discriminate between a benign [only anti-M9 and/or anti-M2 positive by enzyme-linked immunosorbent assay (ELISA)] and a rather progressive course (anti-M2, -M4 and/or -M8 positive). According to different constellations of these AMA subspecificities in ELISA and complement fixation test (CFT), four AMA profiles (A-D) were defined. In 1984 we started a prospective study based on 200 PBC patients with known AMA profiles in order to correlate the antibody pattern with the clinical outcome. Progression was defined primarily as the necessity of liver transplantation and death due to hepatic failure or variceal bleeding. At entry, 18 (9%) of the 200 patients had AMA profile A (only anti-M9), 57 (29%) profile B (only anti-M2 with or without anti-M9), 74 (37%) profile C (anti-M2 in association with anti-M4/-M8 by ELISA), and 51 (26%) profile D (anti-M2/-M4/-M8 by ELISA and CFT). At the beginning of the study, 177 patients had PBC stage I/II. During the observation period of ten years, ten patients died and in 18 orthotopic liver transplantation (OLT) was performed; all these patients belonged to profile C/D. Furthermore, 44% of the patients with profile C and 31% of the patients with profile D progressed to late stages, as defined by histology and clinical manifestations such as portal hypertension and increase of bilirubin, while only one of the patients with profile B and none of the profile A-patients developed late stage PBC. A significant increase of bilirubin was observed only in C/D-patients. AMA profiles did not change during the follow-up. In conclusion, AMA profiles discriminate between a benign and a progressive course of PBC already at early stages.

[The effect of alcohol on portal vein hemodynamics in nutritional-toxic liver cirrhosis]

The influence of alcohol on portal vein haemodynamics was assessed prospectively in 30 patients (20 men, 10 women; mean age 54.3 [34-70] years) with nutritional-toxic cirrhosis of the liver (Child-Pugh stages A-C) and portal vein hypertension. During the period of observation hepatic vein occlusion pressure as an indirect measure of portal vein pressure was repeatedly determined. In addition, the size of oesophageal varices and the Child-Pugh stage were monitored. After complete alcohol abstinence of one year, portal vein pressure fell from 23.11 to 12.43 mm Hg (-46%, P < 0.001), the Child-Pugh score from 8.08 to 7.2 (-10.9%, not significant), and the size of oesophageal varices was reduced from grade 1.33 to grade 0.79 (-40%, P < 0.02). On resuming alcohol abuse, portal vein pressure increased by an average of 10 mm Hg (+60%, P < 0.001) to its previous level of 25 mm Hg. The portal vein pressure has thus proved to be a sensitive gauge of alcohol abstinence or abuse. Lasting, absolute alcohol abstinence is essential in nutritional-toxic liver cirrhosis.

Limited hepatic resection for selected cirrhotic patients with hepatocellular or cholangiocellular carcinoma: a prospective study

From 1 January 1983 to 1 January 1989 123 cirrhotic patients with hepatocellular cancer (n = 122) or cholangiocarcinoma (n = 1) were screened using liver function tests, alpha-fetoprotein determination, ultrasonography with biopsy (and in selected cases computed tomography or nuclear magnetic resonance), laparoscopy and angiography, Child-Pugh classification and urea-nitrogen synthesis rate. Twenty-three patients were selected for surgical resection because the tumour was smaller than 5 cm, not centrally located and at least 1 cm away from main structures; there was no evidence of multicentricity or metastatic disease; and the Child-Pugh classification was A or B and the urea-nitrogen synthesis rate at least 6 g/day. Upper gastrointestinal endoscopy was used routinely to identify oesophageal varices which were present in 17 cases; ten patients with a history of variceal haemorrhage (43 per cent) had preoperative endoscopic sclerotherapy. In cases with recurrent haemorrhage, surgery was used to prevent intraoperative and postoperative bleeding. Tumour resection was carried out using controlled hypotension and hepatoduodenal ligament clamping. Twelve bisegmentectomies, ten segmentectomies and one atypical resection were performed. The operative mortality rate was 13 per cent with liver failure and sepsis as the causes of death. The 'recurrence rate' was 26 per cent and the late mortality rate for the whole group up to 1 January 1990 was 30 per cent; 13 patients were still alive. The 12-month survival rate was 77 per cent and after 5 years it was 49 per cent. Thus, surgical resection of small liver tumours is the treatment of choice in this selected group of patients.

Conservative and semi-invasive modalities for treating bleeding esophageal varices

Although controversial, pharmacological therapy aimed at controlling acute variceal bleeding is widely used. A combination of intravenous vasopressin and nitroglycerin or glypressin alone with the aim of lowering portal pressure is currently recommended. Immediate endoscopy is mandatory to confirm that the patient is bleeding from varices. When variceal bleeding is detected, the patient should be immediately submitted to sclerotherapy, if expert treatment is available, or have the bleeding controlled by balloon tamponade or by pharmacological means, with subsequent performance of sclerotherapy with the use of a flexible endoscope within 6 to 24 hours, or transportation of the patient to a special center during this time. If bleeding has stopped, sclerotherapy can be performed immediately, or the patient can be observed while appropriate long-term management is planned. Patients who do not respond to immediate or delayed emergency sclerotherapy should be identified early and their suitability for a shunt or devascularisation procedure assessed. There is no question that at least after one or two early or even late recurrences of variceal hemorrhage, surgery should be planned and initiated. Although sclerotherapy is the favored form of emergency treatment, a nonshunting procedure or a portosystemic shunt operation should be recommended and thoroughly evaluated in order to determine whether this may be a preferable therapeutic option in a minority of patients, representing about 20% of all patients bleeding from esophageal varices referred to our institution.

Spontaneous regression of oesophageal varices after long-term conservative treatment. Retrospective study in 20 patients with alcoholic liver cirrhosis, posthepatitic cirrhosis and haemochromatosis with cirrhosis

Spontaneous regression of oesophageal varices in liver cirrhotics without sclerotherapy or shunt operation has only been known in alcoholic cirrhosis after alcohol abstinence. Therefore, 20 liver cirrhotics of different aetiologies were controlled over 13 years (six alcohol, nine hepatitis, five haemochromatosis). Under strict alcohol abstinence, all underwent treatment with lactulose and ammonia-reducing amino acids to improve the urea synthesis in the liver. Since gastrointestinal bleeding was not observed, neither sclerotherapy nor shunt operation were performed. Initially, all patients had oesophageal varices (nine stage III, three stage II-III, eight stage II). Following conservative therapy, eight cirrhotics showed total regression and twelve showed stage I-II. Their Child-Pugh index, and urea synthesis rate improved significantly. Possible causes for the spontaneous regression of oesophageal varices are strict abstinence from alcohol, spontaneous seroconversion in six posthepatic B-cirrhoses and consequent phlebotomy in haemochromatosis.

Analysis of a prospective series of 100 mesocaval interposition shunts for bleeding portal hypertension

The results of a prospective series using the mesocaval interposition shunt (MIS) over a period of 13 years is reviewed. One hundred patients were selected for the operation using strict criteria, and in 98 cases the operation was performed electively. Selection criteria included a liver volume of between 1,000 and 2,500 ml, portal perfusion of between 15-30%, no active liver disease and no stenosis of hepatic artery or celiac axis, as well as a good functional Child-Pugh classification (A-B). In all the cases preoperative sclerotherapy was performed as many times as needed with the aim of controlling the active bleeding at admission and of diminishing the pre- and postoperative bleeding probability. Intra-operative postshunt measurements showed residual portal perfusion in all patients studied. Early mortality was 10% and the follow-up mortality 38.8%. The main causes of death were liver failure and hepatocellular carcinoma. The five- and ten-year survival rates were 65% and 35%, respectively. The total encephalopathy rate was 12.2%. Rebleeding was observed in 5.5% of the cases, and the long term-shunt patency rate was 90%. Anigography and sequential scintigraphy showed residual portal perfusion in 75% of the cases soon after operation, in 60% after 6 months, and in 38% after 2 years, showing the tendency of the diversion to diminish the portal perfusion rate in the late postoperative period. The results show that MIS still has a place in the treatment of portal hypertension and that it is an excellent alternative choice to the selective shunts and the devasculariaztion procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

100 meso-caval interposition-shunts for recurrent variceal hemorrhage in portal hypertension. A prospective study

The results of a prospective series using the mesocaval interposition shunt (MIS) over a period of 13 years is reviewed: 100 patients were selected for the operation using strict criteria and in 98 cases the operation was performed electively. Selection criteria included liver volume between 1000-2500 mL, portal perfusion between 15-30%, no active liver disease and no stenosis of hepatic artery or coeliac axis as well as a good functional CHILD-PUGH classification (A-B). In all the cases preoperative sclerotherapy was performed so many times as needed by each individual patient with the goal of controlling the active bleeding episodes at admission and of diminishing the pre and postoperative bleeding probability. Intraoperative postshunt measurements showed residual portal perfusion in all studied patients. Early mortality was 10% and the follow up mortality 38.8%. Main causes of death were liver failure and hepatocellular carcinoma. Five and ten years survival rates were 63.9% and 35.1% respectively. The total encephalopathy rate was 12.2%. Rebleeding was observed in 5.5% of the cases and long term shunt patency rate among survivors was 90%. Angiography and sequential scintigraphy showed residual portal perfusion in 75% of cases soon after operation, in 60% after 6 months and 38% after 2 years, showing the tendency of the derivation to diminish the portal perfusion rate in the late postoperative period. The results show that MIS still has a place in the treatment of portal hypertension and that it is an excellent alternative choice to the selective shunts and the devascularization procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

The antimitochondrial antibody anti-M9. A marker for the diagnosis of early primary biliary cirrhosis

The clinical relevance of a new antimitochondrial antibody, anti-M9, reacting with an outer membrane-associated antigen on liver mitochondria is described. Sera from 22 anti-M2-negative patients with histologically proven primary biliary cirrhosis (PBC) who had been followed for 5-15 years were tested for anti-M9 in the ELISA using a purified M9-fraction. 18 (82%) were anti-M9-positive, and 17 of them (94%) were in stage I/II. None of the 17 anti-M9-positive/anti-M2-negative patients with early PBC progressed to stage III/IV during the observation period of 5-15 years, and in all instances anti-M9 remained of the IgM-type. In one anti-M9-positive patient anti-M2 of the IgM type appeared 2 years after the first demonstration of anti-M9. Among 156 patients with anti-M2-positive PBC, 58 (37%) had anti-M9, and 39 of them (67%) were in stage I/II. 19 of these 39 stage I/II patients (49%) had anti-M9 exclusively of the IgM-type in contrast to none of the 19 stage III/IV patients. Using the purified M9-fraction in ELISA and Western blotting, anti-M9 antibodies were confined only to patients with PBC or overlap syndromes between PBC and autoimmune chronic active hepatitis (10% of 133 patients) and were not found in patients with other hepatic and non-hepatic disorders. We conclude that the determination of anti-M9 may be helpful for the diagnosis of early and asymptomatic PBC. From follow-up studies of anti-M9-positive but anti-M2-negative patients it emerges that this antibody type may be associated with a benign course of PBC.

Hepatic detoxification and hepatic function in chronic active hepatitis with and without cirrhosis

The detoxification capacity of the liver in chronic active hepatitis (CAH) without liver cirrhosis (LC) is not sufficiently known. Therefore, we examined, in 156 patients with morphologically proven CAH of different stages, plasma ammonia, free phenols, indican, glucuronic acid and urea synthesis rate as parameters for liver detoxification. We found a significant increase of ammonia, phenols, and indican and a significant decrease of glucuronic acid and urea synthesis rate parallel to the stage of CAH without LC. In 34 CAH patients with complete recovery, a retrospective 10-year follow-up was possible. Parallel to the normalization of liver morphology and general liver tests, detoxification parameters also normalized. However, the detoxification disorders in CAH without LC are mild in nature and do not produce hepatic encephalopathy. Probably, they are caused by a reduced synthesis of the urea-cycle enzymes and of glucuronyltransferase in the liver.

The role of protein metabolism in 204 liver cirrhotics with and without hepatic encephalopathy. I. Clinical and general biochemical findings

Alcohol, hepatitis B, and Non A Non B hepatitis were the main aetiologies of 124 patients with hepatic encephalopathy (HE) due to histologically proven liver cirrhosis. All had severe portal hypertension (PH) and usually increased inflammatory activity of the liver. In stage I (n = 27) 7.4% died, in stage II (n = 28) 14.3%, in stage III (n = 32) 50% and in stage IV (n = 37) 94.6%. Even in cirrhotics without PH, serum albumin, cholinesterase activity and prothrombin time (PT) were significantly decreased. But only in the case of PT did the magnitude of the decrease parallel the stage of HE. Hyperammonaemia and serum creatinine were increased in parallel with the stage of HE. Therefore, in liver cirrhosis a quotient derived from decreased PT and increased serum creatinine has a good prognostic value. Early diagnosis of HE is possible on the basis of writing tests and the determination of free or toxic ammonia.

The role of protein metabolism in 204 liver cirrhotics with and without hepatic encephalopathy. II. Amino acids, free phenols and indoles

Toxic protein metabolites are assumed to play an important role in the multifactorial pathogenesis of hepatic encephalopathy (HE). To investigate this, we examined the serum levels of free amino acids, free phenols and indoles in 100 healthy adults, and in 124 liver cirrhotics with HE and 80 without HE. We found a significant increase in free serum phenols and indican already in liver cirrhosis without portal hypertension (PH) and HE. In stage III and IV HE large amounts of p-hydroxy-phenyl lactic acid were detected, which was not the case in cirrhotics without HE. In HE the increase in free serum phenols and indican was much higher than that of the mother substances tyrosine and tryptophan. The quotient BCAA/AAA was decreased significantly already in PH without HE. In addition to the increased formation by intestinal bacteria, a diminished oxidative capacity of the cirrhotic liver seems to be one of the main causes of the increased serum levels of toxic protein metabolites in HE.

Treatment of chronic active hepatitis--present state

Nowadays, both Anglo-Saxon and Middle European pathologists define chronic active hepatitis as synonymous with chronic aggressive hepatitis (CAH) without cirrhotic transformation. For its treatment, an accurate determination of the histological stage is necessary. CAH with slight to moderate activity (type 2a) requires merely general treatment, while corticosteroids and/or immunosuppressives are contraindicated. The latter drugs are indicated only for HBs- and HBeAG-negative CAH of type 2b with marked inflammatory activity. Every case should, however, be carefully assessed to determine whether these drugs might not be contraindicated. Our own experience with more than 600 patients with CAH shows that the prognosis is most favourable in HBs- and HBeAg-negative patients, in whom pre-existing chronic infections have been quickly recognized and eradicated, and in whom corticosteroids and/or immunosuppressives were not required. In the meantime, 13% of the CAH patients without cirrhotic transformation have been cured, and 42.5% improved. In contrast, CAH treatment with interferon, Virazol, arabinoside and immunostimulation remain disappointing.

Polypectomy in the presence of portal hypertension--an increased risk of bleeding?

A report is presented on 58 polypectomies performed in the stomach and colorectum in 46 patients. Twenty-five patients had portal hypertension consequent on liver cirrhosis, while 21 patients had healthy livers. The question as to whether haemorrhage occurred immediately after polypectomy or within the next 24 hours, was investigated. Furthermore, either the stalk (of pedunculated polyps), or the polyp itself (when sessile) was investigated pathologically-anatomically, with respect to its vascularity pattern. The submucosal and intramucosal vascularity patterns were classified in 4 categories, I to IV. A tentative interpretation of the results obtained indicates, on the basis of their mucosal and submucosal vascularity patterns, that patients with portal hypertension developing from a cirrhosis of the liver, are not at any higher risk of haemorrhage than patients with no portal hypertension.

[Hepatic coma. Principles of pathogenesis and treatment. 2: Treatment, prognosis]

According to the multifactorial pathogenesis of hepatic coma, generally caused by the increased formation of toxic protein metabolites in the gut, the most important therapeutical measure is the cleaning and acidifying of the gut. This is possible very simply and cheaply by high enemas of sodium acetate buffers of pH 4,5 and lactulose. If necessary, neomycin or paromomycin must be administered in high doses of 6--8 gm/daily to reduce the pathogenic intestinal bacteria. The detoxification capacity of liver and brain can be improved by intravenous and later oral administration of ammonia reducing amino acids such as arginine, ornithine, and aspartic acid (10--20 gm/daily). They diminish also the elevated serum phenols. Very helpful are also branched chain amino acids which improve apparently the detoxification capacity of the muscle. Very important is the normalization of disturbances of the water and electrolyte balance, especially the normalization of hypokalemia. Very difficult is a successful treatment of cerebral edema and the disturbances of blood coagulation. In special cases of endogenous hepatic coma liver perfusions, hemodialysis, charcoal perfusions a.s.o. can eliminate successfully toxic protein metabolites, whilst this treatment is generally insufficient in the more frequent exogenous hepatic coma. In summary the prognosis of hepatic coma is also nowadays very serious and can only be improved by the early recognition and elimination of exacerbating factors.

[Causes and diagnostic criteria of hepatic coma--an analysis of 560 cases]

560 patients with hepatic coma were treated during the years 1958 to 1982 in Homburg and Bad Kissingen . 82 patients had an endogeneous and 478 an exogeneous hepatic coma. Endogeneous hepatic coma was caused most frequently by fulminant virus hepatitis, intoxication, and hepatorenal syndrome accompanying serum hepatitis. Exogeneous hepatic coma in patients with cirrhosis of the liver was caused in most cases by gastrointestinal bleeding, by a diet too high in protein, or by excessive diuresis. Early clinical symptoms are changes in writing tests and ability to concentrate, whereas hepatic foetor occurs in coma stage III and IV. Clinical chemistry findings pointing to imminent hepatic coma are increase of arterial ammonia in exogeneous hepatic coma, and increase of free phenols in endogeneous hepatic coma. The increase of prothrombin time is prognostic for imminent hepatic coma in both types. Prognosis of endogeneous hepatic coma is still rather bad; 87% of the patients suffering from it died; in exogeneous hepatic coma prognosis has improved for stage I and II in the last 23 years, whereas however the total prognosis for all 4 stages is still unchanged, letality being 55%.

[Chronic destructive non-suppurating cholangitis]

Initially liver morphology of chronic destructive non-suppurative cholangitis (CDNC) is rather atypical. Therefore, early morphological diagnosis is difficult. First symptoms are severe pruritus and an increase of IgM, AP and gamma-GT. Own investigation of 101 CDNC patients showed that antimitochondrial antibodies (AMA) are generally later present than the increase of the a/m enzymes. Also remarkable is the fact that among 101 patients are 13 men generally observed during the last 3 years. The most difficult problem is the treatment of CDNC. Here we have to differentiate between symptomatic basic treatment and so-called specific treatment. As basic treatment, ammonia-reducing amino acids, phenobarbital and finally cholestyramine are administered in order to diminish the severe pruritus. The diet must be rich on pectine. Lactulose and bifidum milk improve the diminished detoxication function of the liver. As specific treatment prednisolone and/or azathioprin have disappointed. D-penicillamine can influence CDNC at least temporarily. Because of the frequent side-effects D-penicillamine should be administered only in low doses (100-200 mg daily together with 300 mg vitaminee B6). Until not it is uncertain if the extremely bad prognosis of CDNC can be improved by medical treatment of its early stages.

[Oral gallbladder contrast agents in liver damage]

Jopron acid a new peroral cholangiographic agent and did not increase serum enzymes, bilirubin and some other parameters in 21 patients with active chronic liver diseases identified by laparoscopy and biopsy. For the patient the peroral radiographic examination of the biliary system in the ambulance seems to be quite safe.

[Eliciting factors and clinical picture of hepatic coma in 152 patients with cirrhosis of the liver (author's transl)]

Exogenous hepatic coma was found 102 times (group A) and a combination of exogenous and endogenous hepatic coma 50 times (group B) in 152 patients with hepatic coma. The most frequent eliciting factors in group A were too high a protein supply and gastrointestinal hemorrhage and diuretics, in group B necrotic exacerbations and infections, 2/3 of them having severe portal hypertension with ascites and esophageal varices at the same time. A typical fetor hepaticus was found in only 25% of group A and 50% in group B. 10% had a primary liver cell carcinoma. The prognosis depends largely on the stage of the coma and the treatment of the eliciting factors. Altogether 50 of the 152 hepatic coma patients died. The most frequent complication was a terminal renal failure which no longer responded to therapy.

[Therapy of hepatic insufficiency]

Hepatic insufficiency is generally caused by active liver cirrhosis with portal hypertension. The final stage is the exogenous hepatic coma. Much rarer is the endogenous hepatic coma caused by fulminant acute hepatitis or severe intoxications. In the treatment of hepatic insufficiency it is first necessary to eliminate all exacerbating factors such as too high protein-intake, gastrointestinal bleedings, abuse of alcohol and diuretics. Because hepatic encephalopathy is mainly produced by toxic intestinal protein metabolites no protein should be adminstered at the beginining of the disease. The production of toxic protein metabolites in the gut can be diminished as well by enemas with sodium acetate buffer (pH 4, 5) as by neomycin (6-8 gm daily). Because long-term treatment with neomycin reduces also the physiological intestinal bacteria combination with lactulose (70-100 gm daily) is better. Treatment with lactulose reduces not only significantly hyperammoniemia but also increases serum phenols. The same effect have so-called ammonia reducing amino acids such as arginine, ornithine and glutamic acid. In endogenous hepatic coma blood exchange transfusions, liver perfusions and charcoal perfusions are necessary. Nevertheless, the prognosis of hepatic insufficiency caused by fulminant hepatitis is very poor in the final stage of the disease. Therefore early diagnosis and treatment in special departments with intensive care is necessary.

[Clinical picture and therapy of portal-systemic encephalopathy (author's transl)]

The clinical syndrome of portal-systemic encephalopathy is caused by far advanced cirrhosis of the liver in most cases; it is characterized by increasing drowsiness, disturbances of mentation, flapping tremor and hyperreflexia. An early diagnosis can be established by testing writing and drawing abilities. Increased occurrence of spider nevi, a dry, deep red tongue, and hemorrhagic lesions of skin and mucous membranes are symptoms of incipient hepatic insufficiency. The syndrome is initiated in most cases by excessive intake of protein or alcohol, by intestinal bleeding, by diuretics, or by intercurrent infections. Therapy has to include elimination of causes, reduced intake of protein, enemas with acetate buffer solution and oral medication with lactulose, bifidum milk, and certain amino acids in order to lower hyperammoniemia; in serious cases neomycin has to be given. At the same time a normalization of fluid and electrolyte balance has to be achieved; replacement of potassium is especially important, when hypokalemia and alcalosis are present. In general prognosis of portal-systemic encephalopathy however is serious, depending primarily upon the fact, whether or not sufficient functional hepatic parenchyma is present.

[Effect of arginine ketoglutarate on the detoxifying capacity of the liver in cirrhosis of the liver (author's transl)]

According to the present studies it is shown that arginine ketoglutarate in sufficiently high dosage (3x3 g daily by mouth) produces a significant lowering of plasma ammonia and free serum phenols with a high-protein diet in patients with liver cirrhosis, compared to a previous day without this substance. The ammonia reduction can be explained by a significant increase in urea synthesis, measured by the urea nitrogen content of the 24-hour urine. The simultaneous lowering of pathologically raised serum levels of free phenols can be explained by an improved oxidative decomposition of these substances. No stimulation of insulin secretion worthy of note occurred after oral administration of 9 g arginine ketoglutarate.

[New aspects of the pathogenesis and therapy of alcoholic delirium (author's transl)]

Clinically, and especially biochemically, alcoholic delirium corresponds closely to an incipient but reversible exogenous hepatic coma. The blood levels of ammonia in particular, free phenols and lactate are greatly increased. These same metabolites increase slightly in the blood of persons with healthy livers after a single alcohol loading. The treatment of alcoholic delirium consists of optimal sedation with Distraneurin, which appears to have no side effects on the liver. There is even a lowering of the raised lactate level in the blood after a single administration of Distraneurin. Ammonia and phenols are reduced by ammonia-lowering aminoacids, lactulose and bifidum milk. Most important, however, is strict abstention from alcohol, which alone brings about a rapid improvement of pathological biochemical and morphological liver findings.

[Monomeric igM in acute and chronic liver diseases (author's transl)]

Monomeric IgM could be found rather frequently in acute hepatitis and chronic aggressive hepatitis and occasionally also in chronic persistent hepatitis. Earlier it was reported in lympho-proliferative-, autoimmune diseases, some infectious diseases and in cirrhosis of the liver. The occurence of monomeric IgM in chronic aggressive hepatitis correlates with the detection of several autoantibodies (ANA, SMA, RF). The 7S-IgM-test may be used as an easily measurable additional criterium for diagnosis and course of chronic liver diseases.