[Ascites]

Ascites means accumulation of fluid within the peritoneal cavity, usually in patients with cirrhosis. Diagnostic paracentesis (cell count, albumin, cell culture) is a must. Na-restriction remains the cornerstone of treatment (< 3 g NaCl/d). Spironolactone is the drug of choice, in some patients in addition with proximally acting diuretics. Minimum effective dosage is recommented to reduce side-effects. Pronounced ascites can be treated by large-volume paracentesis with concomitant albumin-infusion. Only very few patients suffer from refractory ascites. TIPS is a treatment modality for this group. However, TIPS may precipitate PSE in some patients with decompensated liver cirrhosis.

[Non-alcoholic steatohepatitis--a new epidemic]

Non-alcoholic steatohepatitis (NASH), the metabolic syndrome of the liver, characterised by the consequences of obesity (insulin resistance, production of free radicals, chronic inflammation) has become a new epidemic in the United States as in Europe. Diagnosis is suspected in patients with obesity, denying alcohol abuse, having typical co-morbitities (Hypertension, Diabetes mellitus, Hyperlipidemia). Liver histology confirms the diagnosis of NASH. Fatty liver without inflammation bears a good prognosis. Liver fibrosis, however, in NASH patients signalizes progression to liver cirrhosis and even HCC. Treatment modalities are limited. Reduction of body weight, physical activity, treatment of co-morbitities, specially Hypertension and Diabetes are of paramount importance. At the moment it remains unclear whether glitazone treatment could be introduced in the therapeutic armentarium.

[Diverticulosis--diverticulitis]

Diverticular disease is a common disorder in the western world. The course of the illness is benign: At least 75% of all patients with diverticular disease remain asymptomatic life long. 10-20% develop clinical symptoms, usually painful diverticulitis. Diverticular disease is diagnosed clinically in most cases. Computed tomography (CT) has replaced contrast enema as the diagnostic procedure of choice for acute diverticulitis. Most patients with uncomplicated diverticulitis can be treated as outpatients Bowel rest, intravenous fluid therapy, broad spectrum antibiotics are treatment modelities if a patient has been hospitalized. Close follow-up is mandatory, especially in patients treated as outpatients. Failure to improve with conservative medical therapy warrants a diligent search for complications and surgical consultation. Surgery may be nessasary in a few of hospitalized patients. Commonly, the operation is performed in a single-stage procedure. Once the acute setting has passed, a colonoscopy should be electively performed to exclude competing diagnoses particularly colonic cancer.

[Risk-classification in liver cirrhosis]

Prognostic models are useful in estimating disease severity and survivial and are used to make decisions regarding specific medical interventions. These models are developed using analytical methods that involve determining the effects of variables of interest (eg, laboratory values) on specific outcomes such as death. There are two models that are used commonly in the care of patients witch chronic liver disease: the Child-Pugh score and the recently described Model for End-Stage Liver Disease (MELD). MELD score is a prospectively developed and validated chronic liver disease severity scoring system that uses a patient's laboratory values for serum bilirubin, serum creatinine, and the international normalized ratio for prothrombin time (INR) to predict survival. The score was proposed as a the most promising alternative to Child-Pugh score. Weather Child-Pugh score should definitely be abandoned for MELD score remains uncertain. The aims of this paper are to summarize and to compare the characteristics, applications and limitations of Child-Pugh and MELD scores.

[Non-alcoholic liver disease (NASH)]

NASH, an increasingly recognized condition resembles alcohol-induced liver disease, but occurs in patients who do not abuse alcohol. Obesity, insulin resistance and oxidative stress have critical roles in the pathogenesis of NASH. Liver biopsy remains the only modality that can reliably distinguish steatosis from steatohepatitis. Simple steatosis may have the best prognosis. In patients with NASH liver enzymes are insensitive and can not be used reliably to confirm the diagnosis or stage the extent of fibrosis. Currently no effective medical therapy is available. Weight reduction may improve the disease. Liver-transplantation in end-stage liver disease is a potential therapeutic option also in patients with NASH.

[The patient with slightly increased liver function tests]

The availability of serum blood chemistries for screening both symptomatic and asymptomatic patients has resulted in a marked increase in the number of abnormal liver chemistry tests that must be interpreted by physicians. Usually the first step in the evaluation of a patient with elevated liver enzymes is to repeat the test to confirm the result. If the result is still abnormal, it seems wise to differentiate between a predominant "necrotic pattern" of liver chemistry, as indicated by an elevation of ALT- or AST-activity or a predominant "cholestatic pattern", as indicated by elevated activities of g-GT and alkaline phosphatase. In patients with elevated serum amino transferases hepatic diseases should be excluded primarily with non-invasive serologic tests. The most common causes of elevated amino transferase levels are chronic hepatitis B and C, autoimmunhepatitis, non-alcoholic steatohepatitis, hemochromatosis, Wilson-disease and (only recently recognized) celiac sprue. In the case of a dominant "cholestatic pattern", primary biliary cirrhosis, primary sclerosing cholangitis, but also drugs and granulomatose hepatitis must be excluded. If non-invasive serologic studies remain inconclusive, ultrasound, mini-laparoscopy and liver biopsy will help to establish the final diagnoses.

[Phenprocoumon-induced liver failure]

HISTORY

A 61-year-old woman was referred because of painless jaundice, laboratory tests having indicated hepatitis with impaired liver functions. For the past two years she had been taking phenprocoumon because she had atrial fibrillation.

INVESTIGATIONS

Serological tests largely excluded infectious, autoimmune or metabolic etiology, so that the diagnosis of drug-induced hepatic disease was made. Liver biopsy showed necrotic liver cells and mild inflammatory reaction.

TREATMENT AND COURSE

A perforating duodenal ulcer required urgent surgical intervention, after which liver functions further deteriorated. The patient having refused liver transplantation she was treated symptomatically (oral vitamin K. lactulose, diuretics), phenprocoumon was discontinued and her condition slowly improved. She was discharged after two months. At subsequent examination she was symptom-free, the INR was 1.41, transaminases were normal and ultrasound merely showed a slightly inhomogeneous internal structure.

CONCLUSION

Phenprocoumon can cause liver damage even when the drug has been taken for prolonged periods without any problems. A careful history about previously administered drugs should be taken in any case of hepatitis of uncertain etiology.

[Hepatitis: associated diseases. Risk groups -- prevention -- treatment]

Active vaccination against HBV-infection results in a very high protection rate. Therefore, all persons at risk should be vaccinated. Acute HBV-infection seems to progress to chronicity in a minority of adults. Unfortunately, treatment of chronic HBV-infection with interferon and Lamivudine is effective only in about 40% of patients, leading to a complete virus elimination. However, relapse-rates are high. Additionally, mutant viruses arise in the case of Lamivudine treatment (YMDD-mutants). Interestingly, Adefovir, a new nucleoside analogue, seems not to induce virus-mutants, at least after a therapy of 48 weeks. HBV-DNA declines rapidly, transaminases normalize in more than 2/3 of the patients, liver histology improves. As mentioned, active vaccination against HBV is very effective in preventing the infection. Unfortunately, this is not the case in HCV-infection. So far, the development of an HCV-vaccine is mainly hampered due to the variability of the HCV (RNA) virus. Untreated, more than 2/3 of the HCV-infected patients with acute HCV-positive hepatitis develop chronicity. Chronic hepatitis C can be treated preferably with a combination therapy (pegylated interferons + Ribavirin). Sustained response rates average 50 per cent (and more). However, treatment of non-responders as well as the treatment of relapsers remain an unresolved problem.

[Pantoprazole-induced hepatitis]

HISTORY

A 46-year-old woman presented for an emergency admission because of colic-like upper abdominal pain and markedly impaired general condition. Eight days before admission she had started and continued to take pantoprazole because of symptoms of gastroesophageal reflux.

INVESTIGATIONS

Clinical examination and laboratory tests indicated abnormal liver functions suggesting hepatitis. Serology largely excluded an infectious, autoimmunological or metabolic cause. Duplex sonography gave no evidence of bile obstruction or Budd-Chiari syndrome.

DIAGNOSIS AND COURSE

The patient's condition and laboratory tests after the drug had been discontinued gradually improved on symptomatic treatment, indicating pantoprazole-induced hepatitis.

CONCLUSION

Intake of proton pump inhibitors is a rare cause but should be considered in the differential diagnosis of hepatitis of uncertain etiology.

[Rare, but important chronic liver diseases]

The presence of steatosis and inflammatory infiltrate in liver biopsies is essential for the diagnosis of non-alcoholic steatohepatitis (NASH). These findings are similar to those with alcoholic liver disease. However, in the NASH-situation alcohol doesn't play an important role. Risk factors for the development of NASH are obesity and diabetes. Most of the patients are clinically asymptomatic. This means, that a diagnosis of NASH is a diagnosis of exclusion: Viral induced, autoimmune, metabolic and toxic liver disease have to be excluded. The disease has a benign clinical course. The risk of cirrhosis is low. So far, there is no established treatment. Preliminary reports suggest a positive effect of weight-loss and ursodeoxycholic acid. Wilson's disease, a copper storage disorder, in which biliary copper excretion is reduced, is inherited as an autosomal recessive trait. Most patients with Wilson disease become symptomatic between the ages of 6 and 15. In about 90% of patients serum ceruloplasmin levels and serum copper concentrations are reduced. Copper excreation is increased. Histologic examination of liver biopsy specimens reveals fatty infiltration, Mallory bodies and ballooned glycogen nuclei, abnormalities which are also found in alcoholic liver disease. The definitive diagnostic parameter is the quantitative determination of liver copper content (> 250 micrograms/g dryweight). Untreated Wilson disease is always fatal. Lifelong treatment with anti-copper drugs are essential, D-penicillamine being the firstline therapy. Hereditary hemochromatosis (HH) is an iron overload disease inherited as an autosomal recessive trait. The frequency of the disease is high. The first symptoms usually can be found at the age of 20-50 years. Arthralgia develops in up to 50% of the patients. Many organs are involved, most often the liver. The organ is usually enlarged, transaminases are always moderately elevated. Laboratory findings disclose a marked elevation in serum ferritin and transferrin saturation. More than 80% of HH-patients are homozygous for the C282Y-mutation in the HFE-gene. The firstline treatment of HH is phlebotomy. Treatment is lifelong. When serum ferritin drops below 50 micrograms/l, the frequency of phlebotomy should be reduced (4-12 per year). If the patient already has cirrhosis, the risk of HCC is very high.

[Hepatocellular carcinoma: risk groups--screening]

Cirrhosis of the liver has to be regarded as a premalignant condition independent of its etiology. The annual risk of developing HCC in cirrhosis is between 1% and 6%. Surveillance-programs have been introduced to detect early stages of HCC in order to improve mortality. However, only controlled trials will answer the question of the efficacy of such programs. Studies on the potential benefit of surveillance-programs comparing survival in surveilled and unsurveilled patients are so far lacking. It seems clear, however, that surveillance-programs can detect small tumors, often unfocal and potentially treatable by a curative approach. Moreover, the etiology (HBV, HCV, genetic hemochromatosis) and activity of liver cirrhosis as measured by serum-transaminases, liver histology (small-cell dysplasia and atypical regenerative nodules), Child-Pugh-stage and the concentration of alpha-fetoprotein at the beginning of a surveillance-program--all these factors reflect a high risk of developing HCC in an individual patient. Until programs are introduced on the basis of randomized, controlled trials of surveillance vs. usual care (with liver-related, specific deaths and all-cause-mortality as end-points) it seems reasonable to screen high-risk patients semi-annually by liver ultrasound and determination of AFP-concentration in the serum.

Oral budesonide and ursodeoxycholic acid for treatment of primary biliary cirrhosis: results of a prospective double-blind trial

BACKGROUND & AIMS

Ursodeoxycholic acid (UDCA) is used for treatment of primary biliary cirrhosis. Previous studies showed that, compared with UDCA monotherapy, bile salts plus prednisolone had no further effect on laboratory data but improved liver histology. Thirty percent of these patients had prednisolone-related side effects. Budesonide is a glucocorticoid with a high receptor affinity and a high first-pass metabolism. In this study we investigated whether budesonide and UDCA are superior to UDCA monotherapy.

METHODS

A 2-year prospective, controlled double-blind trial was performed. Twenty patients (mainly with early-stage disease) were treated with UDCA at a dose of 10-15 mg/kg daily in addition to 3 mg budesonide 3 times daily (group A), and 19 patients (1 dropped out for personal reasons) were treated with UDCA plus placebo (group B). Liver biopsy specimens were taken before, after 12 months, and at the end of study. Glucose tolerance tests, serum cortisol levels, and adrenocorticotropin-stimulated cortisol secretion were assessed at regular intervals. Bone mass density was measured by dual-energy photon absorptiometry.

RESULTS

Compared with pretreatment values, liver enzyme and immunoglobulin M and G levels decreased significantly in both groups. Improvement in group A was significantly more pronounced (P < 0.05) than in group B. Titers of antimitochondrial antibodies did not change. In group A, the point score of liver histology improved by 30.3%; in group B, it deteriorated by 3.5% (P < 0.001). Changes in bone mineral density after 2 years were -1.747% in group A and -0.983% in group B (P = 0.43). Budesonide had little influence on the hypothalamic-pituitary-adrenal axis. One patient in group A had budesonide-related side effects; in 3 patients in group B, complications of liver disease developed.

CONCLUSIONS

Combination therapy with UDCA and budesonide is superior to UDCA and placebo.

[Necrotizing hepatitis after taking herbal remedies]

HISTORY AND CLINICAL FINDINGS

Two unrelated women, aged 39 and 42 years, had been admitted (at different times) to hospital because of "recurrence of an aetiologically uncertain acute hepatitis". Both patients had a history of acute hepatitis with GPT concentration of 796 and 755 U/l, respectively. Each of them had experienced recurrences of hepatitis, each of them preceded by taking herbal remedies as alternative medication, containing kava or common (or lesser) celandine, respectively. In each patient physical examination had been unremarkable.

INVESTIGATIONS

Maximal values of GPT in the two patients were 422 and 350 U/l, respectively. Viral, autoimmune and metabolic causes of the hepatitis were excluded. In each of them liver biopsy revealed the picture of acute necrotizing hepatitis.

DIAGNOSIS, TREATMENT AND COURSE

As it was suspected that the hepatitis was medication-induced, the intake of the mentioned herbal preparations was stopped. The liver function tests quickly became normal.

CONCLUSION

In view of the rapid response to their withdrawal, a causal connection between intake of the herbal preparations and the recurrences of acute hepatitis is the most likely explanation in both cases.

[Cirrhosis of the liver as a precancerous condition]

Cirrhosis of the liver can be regarded as premalignant state, since more than 80 percent of hepatocellular carcinoma (HCC) in the western world develop in a cirrhotic liver. The risk to develop this malignancy depends on the activity of the underlying cirrhosis, its etiology and the duration of the disease. Patients suffering from cirrhosis of the liver due to HBV-, HCV- or HDV-infection and patients with genetic hemochromatosis exhibit a high risk for HCC. This risk is further increased by cocarcinogens, such as alcohol, nicotine and toxins. Ultrasound and AFP-studies aim to diagnose HCC early. The sensitivity of AFP in the serum is remarkably low (about 64%). In contrast a normal AFP-concentration (< 20 ng/ml) carries a high negative prognostic value (> 90%). Patients suspected to suffer from HCC according to the results of screening procedures should be subjected to additional radiologic investigations, such as CT-arterioportography or lipiodol-angiography.

[Hepatocellular carcinoma: interdisciplinary treatment concept]

In most cases hepatocellular carcinoma develops in a cirrhotic liver. The stage of the cirrhosis and the number and size of the liver tumors are decisive for the prognosis and the individual treatment possibilities. For each therapeutic procedure there are specific contraindications which have to be considered. In a prospective comparative study of different established methods of treatment, i.e. hepatic resection, percutaneous ethanol instillation, transcatheter arterial embolisation and tamoxifen therapy, tumor response, survival time, complications and factors, determining prognosis are analysed. The therapeutic concept of the study can thereby be used as a model for the interdisciplinary treatment of hepatocellular carcinoma.

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.

[Current diagnosis of chronic nonviral hepatitis]

Apart from viruses, hepatotoxins, hereditary metabolic disorders, immunological factors and cholestasis may cause chronic hepatitis both clinically and histologically. As far as the etiology is concerned, a complete history can be very helpful. The clinical examination, however, is rarely diagnostic. Nevertheless, some clinical signs (e.g. ascites, splenomegaly, spider naevi) are suggestive of cirrhosis. The activities of gammaglutamyl transferase and ALT in the serum are augmented in most of the patients with chronic hepatitis independent of its etiology. Electrophoresis reveals disturbance of serum albumin and globulin ratios. "Basic' laboratory tests are supplemented by carefully selected additional investigations (e.g. immunological tests) according to the history and clinical data of the individual patient. Retrograde cholangiography is diagnostic in the majority of patients suffering from primary-sclerosing cholangitis. Liver histology, best obtained during laparoscopy, allows classification (and prognosis) of the underlying liver disease in many patients. Results of iron and copper determination in liver tissue are diagnostic in cases of congenital liver disease (hemochromatosis, M. Wilson).

[Portal hypertension-induced stomach disease]

After esophageal and fundus varices, portal hypertensive gastropathy (PHG) is the second most frequent cause of bleeding in cirrhotic patients. It accounts for 1-8% of primary upper gastrointestinal hemorrhage and 30-60% of secondary acute or chronic bleeding in the first 12 months, mainly after sclerosing therapy of varices. Endoscopy is diagnostic by showing either a typical "mosaic pattern" (mild form) or single or confluent "cherry red spots" (severe form). Helicobacter pylori or NSAID-induced gastropathy are to be distinguished. The therapeutic principles are the same as in drug therapy of esophageal varices. Secondary prophylaxis with propranolol, especially after sclerosing therapy, is recommended, but not primary prophylaxis.

[Treatment of chronic virus hepatitis with acetylsalicylic acid]

The treatment of chronic hepatitis B and C with recombinant interferon (IFN) has only poor durable response rates. In the past only the lack of any prior effective therapy regimen could justify the use of this expensive agent. Dose escalating or prolonged treatment courses did not enhance the rate of sustained remissions. Pre- or cotreatment with antiviral (e.g. acyclovir, ribavirin, isoprenosin) or immunomodulating (e.g. prednisone, gamma IFN) drugs have not influenced the resistance to exogenous (IFN) of many patients. The mechanisms underlying resistance to this drug remain unknown. Some hypotheses focus on IFN antibodies, down regulation of IFN receptors or defects in the postreceptor response of cells to IFN. In 1991 Hannigan and Williams (Science 1991; 251: 204-207) described a synergistic signal transduction effect in human fibroblasts after exposure to IFN. Arachidonic acid (AA) activation from membrane phospholipid pools is common to many receptors and can be followed by metabolization of AA by cyclooxygenase to prostanoids, thromboxanes and eicosanoids and by lipoxygenase to leukotrienes; inhibition of these AA oxidation pathways by addition of inhibitors of these enzymes (e.g. indomethacin) resulted in marked amplification of the IFN signal, possibly by using the epoxygenase enzyme family as an alternative pathway. Our data are taken from the pretreatment part of a current study for evaluation of pre- and combination treatment with acetylsalicylic acid (ASA) as cyclooxygenase inhibitor and IFN in chronic hepatitis C. 27 patients with histologically proven chronic active hepatitis C were divided into two groups. Group A (16 patients) were treated with a daily dose of 100 mg ASA orally, and the 11 patients in group B served as untreated controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Association of primary biliary cirrhosis with the allele HLA-DPB1*0301 in a German population

The major histocompatibility complex class II alleles at the HLA-DPB1 locus were investigated in 32 German Caucasoid patients with primary biliary cirrhosis (PBC) and compared with those from 47 normal control patients using molecular genotyping techniques. The second exon of the HLA-DPB1 gene was amplified by polymerase chain reaction (PCR) and hybridized with 25 sequence-specific oligonucleotides (SSOs) to assign the HLA-DPB1 alleles on the basis of known sequence variations, according to the protocols of the Eleventh International Histocompatibility Workshop. A strong association of PBC was found with the allele HLA-DPB1*0301. The allele HLA DPB1*0301 was present in 50% (16 of 32) of the patients with PBC compared with 13% (6 of 47) of normal controls (P corrected < .015), whereas the other HLA-DPB1 alleles showed no significant differences in both groups. The relative risk (RR) estimate for the allele HLA-DPB1*0301 was 6.8 (95% confidence limits: 2.27 to 20.57). In summary, this study clearly demonstrates an association of PBC with the HLA-DPB1*0301 allele in German Caucasoids and may add new data to the immunogenetic background of PBC, suggesting a contribution of the HLA-DPB1 gene to the genetic susceptibility of the disease.

[Clinical aspects of giant cell hepatitis]

Giant-cell hepatitis in adults is a rare event resembling either chronic non-A, non-B or autoimmune chronic active hepatitis. The etiology is unknown. Paramyxoviruses may be implicated. The clinical picture varies remarkably from mild chronic liver disease to subacute hepatic failure. Liver biopsy is diagnostic, showing giant cells as the common pathological finding. Due to the unknown cause of the disease, treatment is symptomatic. Steroids are applied, as in the case of autoimmune disease, with remarkable results in some patients. In fulminant cases, however, liver transplantation is the only option for cure.

[Hepatitis C: clinical aspects, course and therapy]

Clinically, acute hepatitis C is an asymptomatic disease in up to 90% of cases. Transaminases fluctuate characteristically. Anti-HCV (RIBA-II) and HCV-RNA (PCR) are diagnostic early in the course of the disease. The risk of chronification is high, exceeding 50% of cases, irrespective of disease transmission (parenterally or sporadic). Alpha-interferon is applicated in pilot-studies to reduce the risk of chronification, with varying results. Chronic hepatitis C is an insidious disease. Again, most cases are asymptomatic. Bilirubin is normal. GPT-activity tends to fluctuate during the course. Anti-HCV and HCV-RNA can be detected in serum. About 20% of cases progress to cirrhosis (and HCC) after a long-lasting disease (20 to 30 years after infection). Alpha-Interferon therapy is successful in about 25% of patients.

[Therapy update 1994]

In carefully selected patients with viral hepatitis B, C (and D?), alpha-interferon (IFN) treatment is associated with a reduction of active viral replication. In chronic hepatitis B, HBeAg clearance rates approximate 40%. About 25% of patients with chronic hepatitis C will profit from a long-lasting (six to twelve months) IFN therapy. Treatment of chronic hepatitis D remains unsatisfactory, since only a minority of patients (less than 10%) finally will clear the virus, even if IFN is administered for one year. Due to the lack of data, IFN therapy cannot be recommended in the moment for patients at special risks, e.g. in the post-transplant situation, during immunosuppressive or hemodialysis therapy.

[Clinical significance of cholestatic viral hepatitis]

Modern serologic methods permit the classification of the particular course a virus hepatitis takes into individual types of pathogenesis. This is the case with hepatitis A in which only cholestatic courses have been proved for sure. Cholestatic courses are observed in 5-10% of all cases of acute hepatitis A, with variations from country to country. The duration of the disease is considerably longer than in non-cholestatic hepatitis A. It is between 80 and 130 or even more days! The diagnostic difficulty consists in the clear delimination to other diseases, particularly to intrahepatic cholestasis by drugs or to posthepatic stenosis. Sonography and ERCP are useful technological methods in this situation. Specific therapeutical measures are not available due to the lack of knowledge of the pathogenesis of this type of acute virus infection. The prognosis of cholestatic hepatitis A is good. Short-term glucocorticoid therapy is recommended by some authors in long-term cases, which are associated with pruritus, general weakness, loss of weight and distinct icterus. The course of the disease is obviously not changed by this therapy, but the sometimes agonizing symptomatology is relieved.

[Hepatitis C infection and liver cell carcinoma]

Epidemiological data disclose that the incidence of hepatocellular carcinoma (HCC) is increasing world-wide, whereas the number of cases positive for HBV-marker has remained almost stable, at least in Japan. Data from Europe show positivity of antibodies against hepatitis C virus (anti-HCV) in 72% of HBsAg negative cases with HCC and in 28% of patients positive for HBsAg. Nearly 90% of HBsAg negative patients with HCC showed a histology of cirrhosis or chronic active hepatitis in the noncancerous liver. Almost every third patient had a history of blood transfusion. These results suggest an increasing incidence of HCV - associated HCC's, as it already has been shown for patients suffering from chronic HBV infection.

[Acute liver failure: current hepatological-surgical therapy strategies]

Patients with acute liver failure, characterized by deep jaundice, hepatic encephalopathy within eight weeks from the start of symptoms, are subjected to intensive care treatment. New drugs (Interferons, Prostaglandins) have been applied to these patients, with variable results. Mortality of fulminant hepatic failure is high in patients who don't respond to intensive therapy. These patients are characterized by progressive hepatic encephalopathy, decrease of clotting factors, especially of factor 5 and constantly increased serum bilirubin. Results of a multivariate analysis disclosed a poor prognosis in the individual patient more then 40 years old or under 11 years, with a prothrombin time below 10% of control, serum bilirubin over 300 mmol/l and with a late onset of hepatic encephalopathy after long standing jaundice.

One-year treatment of chronic non-A, non-B hepatitis with interferon alfa-2b

Thirty patients with chronic non-A, non-B hepatitis (24 male, six female; median age 38 years, range: 15-68 years) were treated with recombinant interferon alfa-2b for 1 year. Treatment was started with 5 million units interferon alfa-2b daily for 2 weeks followed by 2 million units daily for another 2 weeks. Further doses were titrated according to alanine aminotransferase values. After 1 year, treatment was stopped and a follow-up biopsy was obtained. Thereafter, patients were followed for 6 months. Of the 24 patients who completed the 1-year treatment period, 14 (58%) had normal alanine aminotransferase values at the end of the study, eight of whom showed transient increases while on treatment. In another seven (29%), alanine aminotransferase levels decreased by more than 50% of pre-treatment values but remained above the normal range. Biopsies at the end of treatment showed a complete disappearance of inflammatory activity in four and a marked improvement in eleven other patients. The results of this study indicate that a 1-year treatment with recombinant interferon alfa-2b of patients with non-A, non-B hepatitis was very effective at normalizing or improving serum transaminases and liver histology. However, the overall relapse rate was 57%, with relapse occurring in a greater proportion of patients with temporary breakthroughs during therapy (requiring dosage increase), and particularly of patients with only a partial response to treatment (serum transaminases decreased by greater than or equal to 50%). Thus, further studies are needed to establish the optimal dose and duration of treatment to induce a complete resolution of the disease.

Hepatocellular carcinoma in alcoholic liver disease: no evidence for a pathogenetic role of hepatitis B virus infection

Hepatocellular carcinoma tissues from HBsAg-negative patients with chronic alcoholic liver disease were investigated for the presence of hepatitis B virus DNA. Southern blot analyses of DNA extracted from the hepatocellular carcinomas were negative for hepatitis B virus DNA in all 17 patients examined, at a level of sensitivity of less than 0.01 genome equivalent per cell. Similarly, in liver tissues from another 30 patients with alcoholic cirrhosis without hepatocellular carcinoma, no hepatitis B virus DNA was detectable. We conclude that in our patients there is no molecular evidence for a contribution of hepatitis B virus infection to the development of hepatocellular carcinoma in alcoholic liver disease.