Is liver biopsy necessary in the evaluation of a living donor for liver transplantation?

BACKGROUND

The role of liver biopsy in the evaluation of a candidate for living liver donation is controversial. Some authors suggest doing it routinely, but others do it only in selected cases. The aim of this work was to evaluate the usefulness of protocol liver biopsy in the evaluation of candidates for living liver donation.

METHODS

Ninety potential candidates for living liver donation were evaluated. In 46 cases donation was contraindicated without the need of liver biopsy. In the remaining 44 candidates, liver biopsy was done on a protocol basis. The usefulness of protocol biopsy was compared with the use of biopsy according to the recommendations of the Vancouver Forum.

RESULTS

Fifteen of the 44 biopsies were indicated according to the recommendations of the Vancouver Forum. Twelve of them were normal, and 3 had liver steatosis or steatohepatitis. Of the 29 biopsies done per protocol, 28 were normal and 1 showed liver steatosis. Donation was contraindicated according to liver biopsy findings in 3 of the 15 patients with liver biopsy done according to the Vancouver Forum recommendations and in none of the 29 patients with biopsy done per protocol (P = .034).

CONCLUSIONS

Protocol liver biopsy has a limited utility in the evaluation of the candidates for living liver donation.

Efficacy of transjugular intrahepatic portosystemic shunt to prevent total portal vein thrombosis in cirrhotic patients awaiting for liver transplantation

INTRODUCTION

Complete portal vein thrombosis (PVT) may complicate orthotopic liver transplantation (OLT), increasing its technical difficulty and the transfusion requirements and as well as affecting survival in some cases. Transjugular intrahepatic portosystemic shunt (TIPS) prevents total portal vein occlusion in patients with partial PVT.

OBJECTIVE

We aimed to assess the efficacy and safety of TIPS to prevent total portal vein occlusion among patients listed for OLT.

PATIENTS AND METHODS

We analyzed the clinical records of 15 consecutive patients with partial PVT who underwent TIPS before OLT. The control group consisted of 8 transplanted patients without TIPS but partial PVT diagnosed before OLT. Portal vein patency at surgery, ischemia time, and transfusion requirements during OLT, and survival thereafter were compared between both groups. The main complications were also compared: mortality after TIPS (from TIPS placement to OLT), intraoperative technical complications, and technical complications during the 6 months after OLT.

RESULTS

Clinical characteristics at the time of OLT were similar between the groups. No relevant complications were observed after TIPS; all patients underwent transplantation. One- and 5-year actuarial survival rates were similar in both groups (92% and 85% in TIPS-group versus 100 and 75% in the control group, respectively). No differences in transfusion requirement, duration of ischemia, and frequency of technical complications during and after OLT were observed between the groups. The portal vein was patent at surgery in all TIPS patients and 4 of 8 (50%) in the control group (P = .008).

CONCLUSION

TIPS may prevent PVT in liver transplantation candidates with partial PVT.

Increased liver stiffness values in patients with heart failure

BACKGROUND

Liver stiffness has been claimed to be increased in patients with heart failure.

AIMS

To determine the magnitude of this increase in liver stiffness, and to clarify whether it is related to the degree of heart failure or not.

METHODS

Twenty-six patients were prospectively collected, and divided in groups CHF (those with compensated chronic heart failure) and AHF (those with acute decompensated heart failure). Patients underwent routine blood chemistries, pro-BNP determination, echocardiography and transient elastography during outpatient care (group CHF) or at hospital admission (group AHF). Blood chemistries, pro-BNP and transient elastography were repeated in patients in group AHF before being discharged.

RESULTS

Correlation between liver stiffness and pro-BNP levels was statistically significant (Rho = 0.747, p = 0.001). Patients in group CHF had lower values of liver stiffness and pro-BNP when compared with patients in group AHF at admission. Median liver stiffness and pro-BNP values were 6.5 vs 14.4 kPa (p = 0.009) and 1511 vs 3535 pg/ml (p = 0.025) respectively. After clinical compensation, liver stiffness decreased in all patients in group AHF. Liver stiffness was 14.4 kPa at admission and 8.2 kPa at discharge (p = 0.008). Pro-BNP values also decreased from a median of 3535 pg/ml to a median of 1098 pg/ml (p = 0.025).

CONCLUSIONS

Patients with heart failure have increased liver stiffness, that appears to be related with the severity of heart failure.

Subsequent nonmelanoma skin cancer after liver transplantation

BACKGROUND

Liver transplant recipients have a high risk of developing nonmelanoma skin cancer (NMSC). Some develop multiple NMSC.

METHODS

Patients with a follow-up of >1 year have been prospectively followed to detect NMSC. We studied the risk of developing >1 NMSC.

RESULTS

After a follow-up of 2658 patient-years (mean, 8.5 years per patient), 59/312 (19%) patients were diagnosed with NMSC. Twenty-five had >1 NMSC. The 5-year risk of developing 1 NMSC, >1 NMSC, and a subsequent NMSC (a new NMSC after a first one) were 15%, 5.5%, and 46.5%, respectively. Age >60 years and transplantation for hepatocellular carcinoma were independently associated with a higher risk of developing >1 NMSC.

CONCLUSION

NMSC are frequent complications after liver transplantation and they may show a high rate of recurrence. Older age and hepatocellular carcinoma were related to the development of multiple NMSC.

Informed consent document in gastrointestinal endoscopy: understanding and acceptance by patients

OBJECTIVE

We wanted to know if patients read and understand the informed consent (IC) document used for endoscopic procedures, and to evaluate the readability of IC.

METHOD

During two months we gave patients studied in our endoscopy unit an anonymous questionnaire with different items concerning reading degree, knowledge of the technique, complications, sedation used, and information received. We evaluated IC readability using the Flesch index.

RESULTS

309 patients were included (mean age: 53 years, 55% males, 86% outpatients, 50% with basic education); 85% of patients read the IC, 96% considered they understood the exploration technique, 22% were not aware of severe complications, and 82% knew which kind of sedation would be used; 88% of patients received additional information from their doctors. Outpatients read the IC in a greater percentage versus inpatients (p < 0.05); patients with only basic education tended to ignore the possibility of complications (p < 0.05). Doctors gave more information to rural patients (p = 0.08), offered better information about complications to urban patients (p = 0.09), and offered more information on other diagnostic procedures to patients older than 50 years (p < 0.05). With the Flesch index we found that gastroscopy and colonoscopy ICs had a "standard" level of readability, while ERCP ICs were more complex.

CONCLUSIONS

The majority of our patients read and understands the IC. Doctors adapt information to patient characteristics. Our IC documents have an acceptable level of readability, but given that 50% of our patients have only a basic educational status, we should attempt to provide an easier IC document.

[Duodenal gangliocytic paraganglioma]

We present the case of an 85 year old male who was admitted to hospital with abdominal pain and jaundice. Different explorations were performed for this reason, with a mass observed in his 2nd duodenal portion. Histological study showed that it was a duodenal gangliocytic paraganglioma. The clinical characteristics of this infrequent tumour are described and we review the diagnosis and treatment.

[Isotretinoin and ulcerous colitis]

Isotretinoin is a drug obtained from retinoid acid, often used for the treatment of different types of acne. The way it acts on the dermo-epidermis has not been clearly described. Different studies reporting a relation, proportional or inverse, between isotretinoin and the occurrence or reactivation of an inflammatory bowel disease (IBD) have been found in the literature. Although there are several hypotheses about how this substance can affect the bowel mucous in the pathogenesis of the disease, none of them are definitive. We present a new case where the mentioned relation was evident. Therefore we suggest that when a patient treated with this isomer presents symptoms suggesting IBD, an endoscopic procedure should be performed in order to rule out inflammatory mucous changes.

[Treatment of chronic hepatitis C virus infection]

At present the treatment of chronic hepatitis C virus infection is based on the combination of pegylated interferon (PEG-INF) and rivabirin (RBV) and basically attempts to eradicate the viral infection (sustained viral response). The pattern depends above all on the viral genotype, hence, patients with genotype 1, 4 and 5 require 48 weeks of treatment and high doses of RBV, while those with genotype 2 and 3 require 24 weeks of treatment and low doses of RBV. All patients with chronic C infection are possible candidates for antiviral therapy. However, given that the response to treatment is variable, that the treatment has secondary effects and supposes a high economic cost, it is recommendable in patients with hypertransaminasemia and moderate-severe chronic hepatitis in the histological study, as long as there are no counter-indications. This does not exclude other groups of patients who should be evaluated individually. In those patients with compensated hepatic cirrhosis, treatment can stabilise the disease and reduce the risk of complications appearing, although the rate of response is lower and some adverse effects are more frequent. In patients who have received previous antiviral treatment with standard interferon, alone or in association with RBV, without response to this or with response but later relapse, the decision on treatment must be individual. In patients with coinfection by human immunodeficiency virus (HIV), special attention must be paid to the degree of evolution of the disease due to HCV and to HIV, as well as the possible hepatoxicity of the antiretroviral treatment and the risk of secondary effects.

[Chronic hepatitis C virus infection]

Following acute hepatitis C virus infection (HCV), a significant percentage of patients do not clear the virus and develop a chronic hepatitis C. The symptoms, when they exist, are usually unspecific. Besides, approximately one third of the patients present extrahepatic manifestations of the infection, basically due to the lymphotropism of HCV. Outstanding amongst these, due to their clear association with HCV, are mixed cryoglobulinaemia and the production of autoantibodies (autoAb). Other diseases such as non-Hodgkin lynphoma (NHL) or autoimmune thyroiditis do not have a clearly established association. Although the majority of patients with chronic hepatitis C have slight or moderately high levels and fluctuations of transaminases, as many as one third of those infected can show persistently normal levels of transaminases. The diagnosis of chronic HCV infection is based on serological tests, which detect the presence of antibodies against HCV, and on virological tests that detect RNA of the HCV, which confirm the existence of active infection. Finally, an important topic of chronic HCV infection, following diagnosis, is to ascertain the stage of fibrosis and the degree of inflammation, since both characteristics are very important for predicting the natural evolution and the need for treatment. Nowadays, this information can only be obtained through liver biopsy, which is recommended in patients with chronic HCV infection and high transaminases. Whether liver biopsy should be performed in patients with normal transaminases is still subject of controversy.

[Abdominal pain and infection by the varicella-zoster virus following bone marrow transplant]

Infection by the varicella-zoster virus (VZV) is an important cause of morbidity and mortality in patients who have received a bone marrow transplantation (BMT), both autologue and alogenic. Infection is generally produced in the first post-transplant year and, in its disseminated form, it can show itself through abdominal pain that translates the visceral affectation, pain that can precede the appearance of the characteristic cutaneous lesions by days, making diagnosis difficult. The clinical case described belongs to a patient who, 10 months after a bone marrow transplant, showed an infection by varicella-zoster virus, manifested through abdominal pain due to hepatic affectation, with an interval of 2 days between the start of pain and the appearance of cutaneous lesions. The diagnosis and treatment of these patients is discussed.

Digestive anisakiasis: clinical manifestations and diagnosis according to localization

OBJECTIVES

Digestive anisakiasis is a parasitic disease whose clinical manifestations depend on the effect of Anisakis simplex on the digestive tract wall. Larvae are acquired by eating raw or poorly cooked fish. It is estimated that this entity is currently under-diagnosed, although publications are becoming increasingly common. We analyse our series of digestive anisakiasis checking localization and studying its relationship with symptoms and method of diagnosis.

PATIENTS AND METHOD

We review 23 cases of digestive anisakiasis registered between 1989 and 2001, and confirmed by the measurement of specific serum Ig E antibodies. We analyse clinical symptoms and method of diagnosis according to whether localization was gastro-duodenal or intestinal, evaluating whether surgical intervention was needed for a correct diagnosis. The statistical analysis is made using Fisher's test.

RESULTS

23 patients were included between 1989 and 2001, 8 with gastro-duodenal localization and 15 with intestinal localization. All patients with intestinal localization had abdominal pain. Symptoms were less severe for gastro-duodenal cases, and diagnosis was made by clinical suspicion and subsequent gastroscopy, whereas more than a half of intestinal cases required histological examination of a surgical specimen for correct diagnosis. In the remaining half, diagnosis was made by abdominal ultrasonography. We also observed that the need for surgery has decreased with time from 6/6 cases in the 1989-1996 period of time to 2/9 in the 1997-2001 period of time.

CONCLUSIONS

Clinical manifestations of anisakiasis vary depending on localization, symptoms being more severe in intestinal forms. The diagnosis of gastro-duodenal anisakiasis did not need surgery and was based mainly on gastroscopy findings, whereas intestinal forms frequently required histological examination of the surgical specimen. In our hospital, a higher index of clinical suspicion allowed us to diagnose intestinal anisakiasis without examination of surgical specimens in the last years.