Correlation of global longitudinal strain with disease severity in liver cirrhosis

Funding Acknowledgements

Type of funding sources: None.

Introduction/purpose

Cirrhotic cardiomyopathy is characterized by high cardiac output, reduced peripheral resistance and diastolic dysfunction and has been correlated with cirrhosis severity and prognosis. Global longitudinal strain (GLS) is a sensitive marker of cardiac dysfunction which is considered relatively independent of preload and afterload conditions and thus may be of high diagnostic significance in this special population. We sought to investigate alterations of GLS relating to disease severity in cirrhotic patients.

Methods

Echocardiographic analysis of 51 consecutive cirrhotic patients was performed. Images were acquired and analyzed off-line. GLS was calculated with a semi-automatic way using dedicated software.  Clinical and biochemical examination were used to assess severity of liver disease by calculating Child-Pugh class (class C patients have more severe disease than class B and A patients) and MELD-Na score (increased score as the disease progresses).

Results

Mean age was 58.4 ± 8.7 years, 38 (74.5%) were males. Among patients, 22 (43.1%) were Child-Pugh class A, 17 (33.3%) Child-Pugh B and 12 (23.5%) Child-Pugh C and mean MELD-Na score was 15.3 ± 7.5. Mean left ventricular end-systolic volume (LVEDV) was 117 ± 29ml, mean stroke volume (SV) 72.5 ± 19.9ml , mean left ventricular ejection fraction (LVEF) 61.0 ± 5.0%, mean systolic blood pressure (SBP) 128 ± 13mmHg, mean ratio of peak transmitral to peak annular (septal) velocity during early diastole (E/e’ ratio) 10.4 ± 4.5, mean left atrial volume index (LAVI) 37.4 ± 11.8 ml/cm2  and mean GLS -21.6 ± 2.6%. GLS of Child-Pugh class A patients (-20.3 ± 2.4) was higher (less negative) than GLS of Child-Pugh class B (-22.2 ± 2.2) and class C (-23.0 ± 2.8) patients. Difference between groups B and C was non-significant (figure). Severity of cirrhosis as determined by higher MELD-Na score correlated with LAVI (r = 0.592, p < 0.001), SV (r = 0.554, p < 0.001), GLS (r=-0.441, p = 0.001) and LVEDV (r = 0.428, p = 0.002). GLS correlated with SV (r=-0.369, p = 0.008) but not with preload (LVEDV), or afterload (SBP). In a linear regression model, GLS was independently associated with Meld-Na score when adjusting for age, SBP, LVEDV and NASH etiology [B=-0.139 (-0.252; -0.025), p = 0.018].

Conclusions

GLS is lower (more negative) in patients with liver cirrhosis as disease progresses a relation not affected by preload and afterload conditions. Further research works are required to explain the underlying pathophysiology and to assess prognostic significance of reduced GLS values in patients with advanced cirrhosis.

Abstract Figure. GLS stratified by Child-Pugh score

P1768 The value of global longitudinal strain in non-alcoholic steatohepatitis-associated cirrhosis

Introduction

Non-alcoholic steatohepatitis (NASH) in patients with metabolic syndrome is a common cause of cirrhosis and has been associated with increased cardiovascular mortality. In patients with liver cirrhosis systolic or diastolic dysfunction can be observed and is independent of the cirrhosis etiology. Only few studies using newer echocardiography indices such as Global Longitudinal Strain (GLS) have been published in cirrhotic patients.

Purpose

To evaluate GLS in patients with NASH cirrhosis when compared to other etiologies.

Methods

A total of consecutive 36 cirrhotic patients aged 18-70 were included in our study. Standard speckle-tracking software was used for offline analysis of standard apical views and GLS was calculated. Stroke Volume Index (SVI) was calculated with the Simpson method and a standard 2D, Doppler and Tissue Doppler examination was performed in all patients.

Results

Median age of the study population was 58 (IQR 50-64) years, 78% were male and 17% had ascites. Cirrhosis was considered decompensated in 21 (58%) of patients. The 28%, 42% and 19% had NASH-associated, alcoholic and viral etiology of cirrhosis, respectively. Median ejection fraction (EF) was 60% (IQR: 57%; 65%) and GLS was -21.1% (-19.7%; -23.1%) in the total population. Absolute value of GLS was lower in patients with NASH cirrhosis compared to other etiologies (p = 0.009) (figure 1). EF, SVI, left atrial volume index (LAVI), E/e’ ratio and mitral annular velocity (e’) did not differ significantly between those with NASH associated cirrhosis and the rest. GLS values were significantly correlated with EF (r=-0.588, p = 0.002), SVI (r=-0.469, p = 0.016) and BNP levels (r=-0.571, p = 0.007), but not with age, left ventricular end diastolic volume, left atrial volume index, E/e’, mitral annular velocity and blood pressure. According to a multivariable linear regression model, NASH etiology [B = 2.1 (0.6; 3.7), p = 0.008)] and EF (per 10% increase) [B=-1.7 (-3.3; -0.2), p = 0.03)] were the only independent factors associated with GLS values in cirrhotic patients.

Conclusions

GLS values are within normal limits in cirrhotic patients but seem to be affected in patients with NASH associated cirrhosis. Further studies are needed to assess the prognostic implications of this finding.

Abstract P1768 Figure 1

Five-Years Outcome Analysis of 142 Consecutive Hepatocellular Carcinoma Patients Treated with Doxorubicin Eluting Microspheres 30-60 μm: Results from a Single-Centre Prospective Phase II Trial

PURPOSE

To assess prospectively long-term results of doxorubicin-loaded HepaSphere 30-60 μm in consecutive patients with hepatocellular carcinoma (HCC) not amenable to curative treatments.

PATIENTS AND METHODS

Single-center study from June 2011 to December 2015 in 151 patients treated with 75 mg of doxorubicin per HepaSphere vial. Baseline: Barcelona Clinic Liver Cancer BCLC A/B was 49.3%/50.7%, and median diameter 6.1 cm (mean 6.7 ± 2.0). Liver function, local response (mRECIST), liver time to progression (LTTP), progression-free survival (PFS), overall survival (OS) and adverse events (AEs) were recorded.

RESULTS

Final analysis included 142 patients with median follow-up of 46.8 months (range 4-72) without grade 4/5 AEs, and 30-day mortality was 0%. Mean number of scheduled treatments was 2.6 (range 1-3) and on demand 3 (range 1-8). Complete response for single tumor ≤ 5 cm was 75.0% and 66.7% for Child A and Child B, while for > 5 cm was 28.6% and 11.8%, respectively. OS was 31.0 months (mean 33.3 ± 15.2; range 8-69), notably for BCLC A 41 months (mean 41.1 ± 15.3; range 13-69) and for BCLC B 26.0 (mean 26.0 ± 10.5; range 8-51). OS at 1, 3 and 5 years: 95.8%, 75.7% and 21.4% for BCLC A, and 94.4%, 36.1% and 2.7% for BCLC B. Median LTTP for BCLC A was 11 months (mean 11.9 ± 4.7; range 3-24) and 7.5 for BCLC B (mean 7.9 ± 2.9). Local response was significant for OS and LTTP (p < 0.0001), while size and lesion number affected LPFS and OS (p < 0.001).

CONCLUSIONS

HepaSphere 30-60 μm loaded with doxorubicin provides a safe and effective treatment option for patients with HCC.

Addressing barriers to the prevention, diagnosis and treatment of hepatitis B and C in the face of persisting fiscal constraints in Europe: report from a high level conference

In the WHO-EURO region, around 28 million people are currently living with chronic viral hepatitis, and 120,000 people die every year because of it. Lack of awareness and understanding combined with the social stigma and discrimination exacerbate barriers related to access to prevention, diagnosis and treatment services for those most in need. In addition, the persisting economic crisis has impacted on public health spending, thus posing challenges on the sustainable investment in promotion, primary and secondary prevention, diagnosis and treatment of viral hepatitis across European countries. The Hepatitis B and C Public Policy Association in cooperation with the Hellenic Center for Disease Prevention and Control together with 10 partner organizations discussed at the Athens High Level Meeting held in June 2014 recent policy developments, persisting and emerging challenges related to the prevention and management of viral hepatitis and the need for a de minimis framework of urgent priorities for action, reflected in a Call to Action (Appendix S1). The discussion confirmed that persisting barriers do not allow the full realisation of the public health potential of diagnosing and preventing hepatitis B and C, treating hepatitis B and curing hepatitis C. Such barriers are related to (a) lack of evidence-based knowledge of hepatitis B and C, (b) limited access to prevention, diagnosis and treatment services with poor patient pathways, (c) declining resources and (d) the presence of social stigma and discrimination. The discussion also confirmed the emerging importance of fiscal constraints on the ability of policymakers to adequately address viral hepatitis challenges, particularly through increasing coverage of newer therapies. In Europe, it is critical that public policy bodies urgently agree on a conceptual framework for addressing the existing and emerging barriers to managing viral hepatitis. Such a framework would ensure all health systems share a common understanding of definitions and indicators and look to integrate their responses to manage policy spillovers in the most cost-effective manner, while forging wide partnerships to sustainably and successfully address viral hepatitis.

Abnormalities in Cu and Zn levels in acute hepatitis of different etiologies

BACKGROUND

Copper (Cu) and Zinc (Zn) are essential trace elements which play an important role in various biological processes. Zn deficiency is common in liver diseases while Cu deficiency is rarely reported. To determine whether serum Cu and Zn concentrations differed in acute hepatitis, compared to controls and investigate possible correlations of Cu and Zn values with etiology and severity of liver diseases.

METHODS

Serum Cu and Zn concentrations were determined by air acetylene flame atomic absorption spectrometer in 40 patients (acute hepatitis A, B, C, autoimmune and drug induced hepatitis) and 150 healthy controls.

RESULTS

Compared to healthy controls, significantly higher Zn levels were found in patients (106.5 μg/dl, P <0.01). Abnormal levels of either Cu and/or Zn were found in 48% of patients vs 23.3% of the controls (P =0.01). Ten patients had abnormal Zn and fourteen had abnormal Cu levels. There was a trend for the severe hepatitis cases to have abnormal Cu values and in this subgroup Cu and Zn were positively correlated with prothrombin time and alanine aminotransferase (ALT) levels, respectively. Cu and Zn levels did not differ statistically across groups of different etiologies.

CONCLUSIONS

Abnormalities in Cu and Zn concentrations are common in acute hepatitis. Cu and Zn exhibited positive correlations with prothrombin time and ALT respectively, in severe cases.

Pegylated interferon plus ribavirin combination therapy for chronic hepatitis C in patients with congenital coagulation disorders

Chronic hepatitis C (CHC) and end-stage liver disease are becoming an increasingly common cause of mortality in patients with congenital bleeding disorders, especially in the HIV-coinfected group. Combination of pegylated interferon (Peg-IFN) and ribavirin has recently become the treatment of choice for CHC. In this study, we evaluated the safety and efficacy of combination therapy with Peg-IFN plus ribavirin for the treatment of CHC in human immunodeficiency virus (HIV)- and HIV+ patients with congenital bleeding disorders. Between 2000 and 2004, 50 (18-68 years old) patients with CHC (19 HIV+) from two hemophilia centers were included in the study. They were treated with weekly subcutaneous administration of Peg-INF-alpha combined with 800-1,200 mg ribavirin daily, for 24-48 weeks depending on viral genotype. Response was evaluated at weeks 12, 24, 48 (end of treatment response) and 72 had sustained virological response). Overall, 22/50 patients (43.8%) had end of treatment response and 20/50 (40%) sustained virological response. HIV- patients responded similarly to the general population (58.1%), while HIV+ patients had very low response rates (10.5%). The high rate of discontinuation (36.9%) as a result of side effects contributed to the observed low response rate in the HIV+ group. The only factor strongly associated with sustained virological response in the HIV- patients was the reduction of HCV RNA at 12 weeks (p = 0.001). Patients with viral genotypes other than 1 had higher SVR rates, but this was not found to be statistically significant. Peg-INF plus ribavirin is safe for the treatment of CHC monoinfected patients with inherited bleeding disorders, with similar response rates to nonhemophiliacs. On the contrary, in HIV coinfected hemophilic patients under highly active antiretroviral therapy it is associated with severe toxicity and very poor sustained virological response rates. Careful evaluation and several considerations are needed before starting treatment in this population.

Transarterial embolization of giant liver hemangiomas associated with Kasabach-Merritt syndrome: a case report

Of 22 patients with symptomatic giant liver hemangiomas referred for embolization, two females (52 and 74 years) had Kasabach-Merritt syndrome (KMS). Hematocrit values were observed to be 33% and 29%, platelets 4000 and 5400/mm(3), and fibrinogen 98 and 77 mg/dl, respectively. Lesion diameters were 7 and 14 cm, respectively. Hepatic angiography revealed excessive vascular lakes typical of cavernous hemangiomas. Microspheres of 40-300 microm were superselectively injected under fluoroscopic guidance until cessation of flow. Coil packing of the feeding hepatic artery was additionally used in one patient. The procedure was uneventful in both. Partial restoration of platelet count was observed immediately; fibrinogen levels and platelets were restored completely in one patient and partially in the other, without remissions at 2-year follow-up.

Hepatitis B virus reactivation in patients receiving chemotherapy for malignancies: role of precore stop-codon and basic core promoter mutations

Hepatitis B virus (HBV) strains carrying the precore stop-codon mutation (A1896) have been considered among the predisposing factors for reactivation during chemotherapy for malignancies. The role of the T1762/A1764 basic core promoter (BCP) mutations has not been fully evaluated. We aimed to record any changes in HBV serological markers after reactivation, detect the presence of A1896 and BCP mutations and evaluate the type of cytotoxic drugs involved. We retrospectively screened eight patients presenting with HBV reactivation following chemotherapy for malignancies. The chemotherapy regimens used included corticosteroids (CSs), fludarabine and cyclophosphamide/adriamycine. The INNO-LiPA HBV PreCore kit was used for the detection of the A1896 and BCP mutations. Six patients who were hepatitis B surface antigen (HBsAg)-(+)/hepatitis B e antigen (HBeAg)-(-) before chemotherapy, had disease reactivation following a mean of four cycles of chemotherapy. Four survived and two died of hepatic failure. At the time of reactivation, all six patients carried the A1896 and five of them the BCP mutations. The remaining two patients were HBsAg-(-)/anti-HBs-(+)/anti-hepatitis B core (HBc)-(+)/HBeAg-(-) before chemotherapy. One of them reverted to HBeAg-(+) status but remained HBsAg-(-), while the other became HBsAg-(+)/HBeAg-(+), following three and eight cycles of fludarabine treatment, respectively. The former carried the A1896 and the latter the wild-type virus. Both died from causes associated with their haematological disease. All but one of our patients with HBV reactivation during chemotherapy carried the precore stop-codon and BCP mutations. Whether this occurs more frequently in such patients than those carrying the wild-type virus needs further investigation. Fludarabine should be added to the list of drugs inducing HBV reactivation. HBV reactivation following fludarabine treatment occurred in HBsAg-(-) patients who had been anti-HBs-(+).

Genetic heterogeneity of hepatitis viruses and its clinical significance

The genetic heterogeneity of hepatitis B virus (HBV) (8 genotypes A-H) has been applied for tracing the route of HBV transmission and the geographical migration of HBV carriers but it also appeared to have clinical implications. The secondary structure of e encapsidation signal could explain why the precore mutant virus prevails in Mediterranean countries, where genotype D is most prevalent, while the wild type virus is frequent in Western countries, where genotype A is most prevalent. There is increasing evidence that patients infected with genotype C have more severe outcome of chronic liver disease than those infected with genotype B. Genotype B was associated with fulminant hepatitis and more severe episodes of acute exacerbation of chronic HBV infection. Patients infected with genotype B appeared to seroconvert earlier than those infected with genotype C. The hepatitis delta virus (HDV) has 3 genotypes (I, II, III) which are associated with different disease patterns. Genotype III is the most distantly related HDV genotype and is associated with the most severe outcome while genotype II with relatively mild liver disease. The most geographically widespread genotype is I and is associated with a broad spectrum of chronic liver disease. The hepatitis C virus (HCV) displays high genetic heterogeneity with six genotypes (1-6), multiple subtypes and quasispecies. This viral diversity has epidemiological and clinical implications and has been associated with the severity of liver disease, prognosis, response to treatment and failure to generate an effective protective vaccine. HCV genotype 1 is the predominant genotype in Western countries and has been associated with a low response rate to interferon-alpha (IFN-alpha) or to the combination of ribavirin and IFN-alpha. Consequently the duration of treatment has been tailored according to HCV genotype.

Intestinal pseudo-obstruction and ureterohydronephrosis as the presenting manifestations of relapse in a lupus patient

Intestinal pseudo-obstruction (IPO) is a rare complication of systemic lupus erythematosus (SLE). We present a 32-year old female with SLE for seven years. She was admitted with profound fatigue, frequent vomiting, colicky abdominal pain, diarrhoea and intermittent dysuria for the past 12 months. Imaging studies revealed dilated small and large bowel loops with thickened intestinal wall and multiple fluid levels. Urinary tract involvement was also demonstrated. The patient responded well to immunosuppressive treatment. IPO in the context of SLE has been described only in anecdotal case reports. Half of the cases developed this complication during the course of lupus as in the present case. Concomitant ureterohydronephrosis was present in approximately two-thirds of the cases. Early recognition of the syndrome is necessary for the institution of the appropriate medical treatment and prevention of inappropriate surgical intervention.

Immune thrombocytopenic purpura in a patient treated with interferon alfacon-1

Immune thrombocytopenic purpura is an acquired disorder characterized by severe thrombocytopenia and caused by one or more antiplatelet autoantibodies. We present a case of a 20-year-old woman referred to our Unit for chronic hepatitis C virus (HCV) infection. At week 28 of treatment with interferon (alfacon-1), undetectable HCV RNA and transaminase levels within normal limits, the patient presented with immune thrombocytopenic purpura, which was successfully treated with immunoglobulin and methylprednisolone. Despite the high doses and long life of corticosteroid treatment HCV RNA remained undetectable.

The autoimmune lymphoproliferative syndrome (Canale?Smith) in adulthood

The autoimmune lymphoproliferative syndrome (ALPS) or Canale-Smith syndrome is a recently described clinical entity consisting of chronic, non-malignant lymphadenopathy and hepatosplenomegaly together with hypergammaglobulinemia, positive autoantibodies and/or overt autoimmune diseases. It is caused by a genetic defect in the mechanism of programmed cell death (apoptosis) and is characterized by the presence of double-negative (TCR alpha/beta CD4- CD8-) T lymphocytes (DNT). Although well known in pediatric patients, ALPS is an unusual diagnosis in adults. The oldest reported patient was aged 54. We describe another two adult patients in whom a presenting autoimmune disease led to the diagnosis of ALPS.

Pituitary non-secreting macroadenoma apoplexy in an adolescent. patient report and review of the literature

Pituitary macroadenomas are rare in children and adolescents, and when encountered are usually hormone secreting. Symptomatic pituitary non-secreting macroadenoma apoplexy in an adolescent is rare and potentially life-threatening. A 15 year-old patient is described, hospitalized due to headache, fever and photophobia 4 days prior to admission. A meningeal syndrome was postulated, based on clinical examination and cerebrospinal fluid testing. However, clinical examination and hormone testing revealed partial failure of the anterior pituitary. Computed tomography of the brain demonstrated a space-occupying lesion of the pituitary. Magnetic nuclear resonance imaging suggested the presence of a pituitary macroadenoma. Hypophysectomy was performed. Histological examination revealed an extensive infarction of a pituitary adenoma. Hormonal substitution with thyroxine and corticosteroids was administered. This report emphasizes that pituitary non-secreting macroadenoma apoplexy may rarely be the cause of headache and fever in an adolescent, thus causing difficulties in differential diagnosis from acute meningitis.

Autoimmune hepatitis associated with the antiphospholipid syndrome

The antiphospholipid syndrome has rarely been described in patients with autoimmune hepatitis. Two cases with type I autoimmune hepatitis and antiphospholipid syndrome are presented. The first case is that of a 53-year-old Caucasian female with a history of arterial thrombosis and fetal loss who was submitted to clinical and laboratory testing due to persistent transaminasaemia and was found to have autoimmune hepatitis. Antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant) were positive. The second case is that of a 31-year-old Caucasian woman with a history of autoimmune hepatitis who was submitted to laboratory testing due to a second-trimester fetal death, revealing an increased activated partial thromboplastin time and positive antiphospholipid antibodies. In conclusion, secondary antiphospholipid syndrome may accompany autoimmune hepatitis.

Pleural effusion and pulmonary injury as an unusual complication to chemotherapy in non-small cell lung cancer patients

We report the appearance of pleural effusion, or pulmonary failure after chemotherapy, followed by tumor reduction, in a small number of patients. Five hundred and fifty-four patients with lung cancer have undergone chemotherapy at our Institute during the last ten years. Three patients with non-small cell lung cancer (NSCLC), with locally advanced disease, exhibited an unusual consequence following cytotoxic drug treatment. Two patients with NSCLC had pleural effusion which improved within 2-3 weeks, together with tumor reduction, which allowed the continuation of treatment. One patient had pulmonary failure with pleural effusion and recovered within two weeks. Two of the three patients had positive cytology for cancer cells in the fluid. All three patients achieved partial remission with no repetition of the complication. The patients' recovery, response to treatment and the tumor reduction suggest that this complication was not due to disease progression.

A case of haemosuccus pancreaticus

Haemosuccus pancreaticus (Wirsungorrhagia or pseudohaemobilia) is a rare complication of chronic pancreatitis. We describe a 48-year-old patient with alcohol-induced chronic calcific pancreatitis and recurrent episodes of severe upper gastrointestinal bleeding but without abdominal pain. Upper gastrointestinal endoscopy revealed fresh blood oozing from the ampulla of Vater. No pseudoaneurysms or pseudocysts were detected by arteriography or computerized tomography. The bleeding was attributed to pancreatic lithiasis. Following conservative treatment, there was no evidence of recurrence during a 24-month follow-up period. In conclusion, although a rare occurrence, haemosuccus pancreaticus should be considered in the differential diagnosis of all cases of obscure upper gastrointestinal bleeding in patients with chronic pancreatitis, whether or not accompanied by pain. A highly suggestive clinical history or X-ray findings and an endoscopic visualization of blood coming from the ampulla of Vater may suffice for the diagnosis, thus avoiding diagnostic and therapeutic errors. When haemosuccus pancreaticus occurs in patients without pseudoaneurysms or pseudocysts, it can be treated conservatively, thus obviating the need for pancreatectomy or arteriographic embolization.

Gliclazide-induced acute hepatitis

There are few reports in the literature related to sulfonylurea-induced hepatotoxicity. We describe the case of acute hepatitis induced by gliclazide, a second generation sulfonylurea. A 60-year-old woman with diabetes mellitus (type 2) developed an acute icteric hepatitis-like illness 6 weeks after the initiation of gliclazide therapy. Other causes of acute hepatocellular necrosis were excluded. Liver histology showed marked portal inflammation with lymphocytes, monocytes and eosinophils, associated with lobular inflammation (indicative of a histological pattern consistent with drug-induced hepatitis). The drug was immediately withdrawn and the patient was given glibenclamide. The patient recovered clinically and, in less than 4 weeks, her serum bilirubin and aminotransferases returned to normal levels. We believe that this is the first description of acute hepatitis caused by an idiosyncratic adverse reaction to gliclazide or to one of its metabolites. In conclusion, this case strongly suggests that gliclazide can induce acute icteric liver necro-inflammation which may be misdiagnosed clinically as acute viral hepatitis. In patients who show abnormal liver function tests, the immediate discontinuation of gliclazide is recommended.

Fulminant hepatic failure as a presenting paraneoplastic manifestation of Hodgkin's disease

Malignancies may uncommonly present as fulminant hepatic failure and, due to the rarity of such an occurrence, they may easily be overlooked as one of its possible causes. An unusual case of Hodgkin's disease presenting as a fulminant hepatic failure is reported. A 34-year-old man presented with an acute onset of liver failure characterized by jaundice, ascites, encephalopathy and bleeding diathesis. Chemotherapy was initiated, resulting in a dramatic improvement not only in the patient's level of consciousness, but also in prothrombin time. Unfortunately, he succumbed shortly after to disseminated candidiasis. A post-mortem needle liver sample revealed massive hepatocellular necrosis, but no liver infiltration by the neoplastic disease. We conclude that in Hodgkin's disease, involvement of the liver can be manifested as a syndrome of paraneoplastic fulminant hepatic failure. In such cases, liver transplantation is an absolute contraindication but urgent chemotherapy under antifungal surveillance can be life saving.

Sump syndrome: endoscopic treatment and late recurrence

OBJECTIVE

Biliary sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by food, stones, or debris after choledochoenterostomy. Endoscopic sphincterotomy has been recommended as the primary and definitive treatment modality. The aim of our study was to confirm the short and long term therapeutic efficacy of endoscopic treatment in a long follow-up period.

METHODS

The series include 31 patients with characteristic clinical illness after choledochoduodenostomy. All of them were successfully treated by endoscopic sphincterotomy and bile duct clearance with a balloon catheter or basket. The follow-up period ranged from 18 to 84 months (median: 51 months).

RESULTS

Clinical improvement was immediate in all patients. No complications were recorded. Recurrence of the syndrome, with restenosis of the sphincterotomy opening, was observed in six patients (19%) and was treated successfully and safely with a new papillotomy. Sump syndrome recurrence occurred 31-72 months (median: 58.5 months) after the initial treatment.

CONCLUSIONS

We report a considerably high recurrence rate of sump syndrome after initially successful endoscopic management and its effective endoscopic treatment with a new papillotomy. We still believe that the primary therapeutic approach in patients with sump syndrome should be endoscopic.

Flour contamination as a source of lead intoxication

CASE REPORT

A 43-year-old man was hospitalized because of severe anemia and recurrent bouts of abdominal pain over 20 days. There was no known occupational exposure to toxins. Concomitantly, the patient's father complained of having the same symptoms. Familial lead poisoning was diagnosed when all 6 family members tested had high blood leads (31-64 micrograms/dL).

RESULTS

Following detailed examination of the potential sources common to all members of the household, the cause of poisoning was determined to be corn flour containing 38.7 mg/g lead. Physicians are reminded to consider lead poisoning in the differential diagnosis of individuals with unexplained symptoms, particularly those of abdominal discomfort and anemia.

Splenic infarct as a late complication of liver transplantation

Splenic infarct is a rare complication of portal hypertension. It has been reported as an early complication after successful liver transplantation when portal pressure returns to normal and the splenic size progressively declines. It has not been reported as a late complication of liver transplantation. We describe the case of a 19-year-old patient with a splenic infarct which occurred 11 months after successful orthotopic liver transplantation for decompensated cryptogenic liver cirrhosis. Following transplantation, the patient was in excellent general health, liver function tests were normal, there was no clinical evidence of portal hypertension and the splenic size had decreased significantly compared to the pre-transplantation period, although it remained increased. The patient presented with high fever, left pleuritic pain and vomiting. The splenic size had not changed and left pleuritic exudate fluid collection was detected. A hypoechoic region of the spleen was demonstrated in the ultrasound examination corresponding to a hypodense lesion in the computerized tomography scanning. The patient recovered completely, with the disappearance of the infarct in the imaging studies in 2 months time. This case report indicates that a symptomatic splenic infarct can occur late following successful liver transplantation for liver cirrhosis despite lack of any evidence of residual portal hypertension at a time that splenomegaly has not yet regressed. The differential diagnosis from a splenic abscess in transplanted patients can be difficult but the final prognosis seems to be good.

Core variability does not affect response to interferon alpha in HBeAg negative chronic hepatitis B

BACKGROUND/AIMS

The pre-core stop codon variant (A 1896) of hepatitis B virus (HBV) has been associated with chronic active liver disease with acute exacerbations and a high relapse rate after an initial response to alpha-interferon (IFN-alpha) therapy. Poor sustained response has been correlated with a high prevalence of mutations in the core region, potentially enabling escape from the immune system. The aim of this study was to analyse the predictive factors of response to IFN-alpha in such patients.

METHODS

We studied the baseline clinical, biochemical, histological, serological and virological parameters in 30 hepatitis B s antigen positive (HBsAg-positive)/hepatitis B e antigen negative (HBeAg-negative) Greek patients with chronic liver disease. The patients were selected from a cohort who received IFN-alpha for 24 weeks. These were divided into three groups of ten sequential patients: those with no response to IFN-alpha treatment, those who relapsed after an initial response, and those with a sustained response. Serum HBV DNA was measured by a liquid hybridisation method, and the anti-HBc IgM was quantitated by the IMx analyser. The amino-acid sequence of core protein residues 40-89, a region where a clustering of mutations has been detected previously in severe hepatitis, was compared with a sequence from an HBeAg positive patient with chronic liver disease.

RESULTS

Multiple logistic regression analysis showed that the initial response to IFN-alpha could be predicted by pre-treatment absence of HBcAg staining in the liver and high ALT values, but no parameter could predict sustained response. The pre-treatment extent and pattern of aminoacid substitutions in the core region sequenced was similar in all groups studied and was not associated with IFN-alpha response.

CONCLUSIONS

In HBsAg-positive/HBeAg-negative patients with chronic liver disease, response to IFN-alpha therapy was not correlated with genomic variability of the core region. Other parameters such as pre-treatment HBcAg positivity in the liver and alanine aminotransferase values indicative of disease activity before treatment were associated with initial IFN-alpha response.

Sex hormonal preparations and the liver

The long-term use of oral contraceptives (OCs) may be associated with an increased, though quite small, risk of certain types of liver disease: acute intrahepatic canalicular idiosyncratic cholestasis, benign hepatic tumors (hepatic adenoma, focal nodular hyperplasia, hemangiomas), hepatocellular carcinoma, peliosis hepatis, hepatic vein thrombosis, and portal vein thrombosis. Estrogens have lithogenic properties, as shown by a rise in biliary cholesterol secretion and cholesterol saturation index, yet no substantial increase in the risk of gallstones among estrogen users has been found. Hormone replacement therapy (HRT), given after oophorectomy or menopause, is not associated with clinically significant liver injury. Generally speaking, synthetic sex hormones should not be used in patients with acute and chronic liver disease. A trial of a low-dose estrogen can be instituted under close monitoring for adverse reactions and HRT preparations are not contraindicated in patients with chronic liver disease. Moreover, OCs and HRT can be prescribed quite safely following successful liver transplantation. The incidence of hepatic abnormalities in patients taking androgen hormones is very high. Liver adenomas, cholestasis, peliosis, nodular regenerative hyperplasia and, particularly, hepatocellular carcinoma may complicate long-term use of C17-substituted testosterone and anabolic steroids.

Thyroid abnormalities in chronic viral hepatitis and their relationship to interferon alfa therapy

The prevalence of antithyroid peroxidase antibodies (ATPO) and/or of thyroid dysfunction was studied in 422 patients with chronic viral hepatitis C, B, and D. Baseline results were compared with those during and 6 months after interferon alfa (IFN-alpha) therapy. The overall prevalence of ATPO among untreated patients was 14.1%, with no significant differences between chronic hepatitis C, B, or D, as well as between males and females. However, high ATPO titers (> or = 18 IU/mL) clustered significantly among females (8.7% vs. 3.4%; P = .022), especially those with chronic hepatitis C (11.2% vs. 3.6%; P = .036). Before treatment, 3.7% of the patients had thyroid dysfunction, mostly hypothyroidism (3.5%), the latter increasing to 14.3% among patients with ATPO titers > or = 18 IU/mL. IFN-alpha treatment significantly increased overall thyroid dysfunction (9.7%; P = .001) and hypothyroidism (7.8%; P = .01), particularly among patients with high baseline ATPO (38.5%; P = .0002). Six months after stopping IFN-alpha treatment, the prevalence of thyroid dysfunction was 8.0%, still significantly higher than at baseline. By multivariate analysis, the only predictor positively associated with pre- or on-treatment hypothyroidism was the baseline titer of the ATPO antibodies (relative risk [RR], 3.0 and 3.8 per each log titer increase, respectively). In conclusion, patients with chronic viral hepatitis on IFN-alpha treatment exhibit an almost threefold increase of baseline thyroid dysfunction, persisting long after the end of therapy. High ATPO titers, clustering among females, particularly those with hepatitis C, represent the only predictor of pre- and on-treatment hypothyroidism by multivariate analysis. Patients with chronic viral hepatitis, especially females, should be tested for ATPO and thyroid function and monitored during and posttreatment for free thyroxin (FT4) and thyroid-stimulating hormone (TSH) levels.

Prolonged cholestatic jaundice after endoscopic retrograde cholangiography

The main complications of endoscopic retrograde cholangiography and sphincterotomy are bleeding, pancreatitis, perforation and sepsis. Two cases of unexplained prolonged cholestatic jaundice in patients who underwent endoscopic retrograde cholangiography (ERC) for biliary obstruction due to choledocholithiasis are reported. The patients were admitted because of right upper quadrant pain, vomiting and jaundice. Laboratory tests showed increased levels of total and conjugated serum bilirubin and increased alkaline phosphatase. Ultrasound examination showed cholelithiasis and choledocholithiasis with bile duct dilatation. ERC with sphincterotomy was performed and gallstones obstructing the common bile duct were removed endoscopically. Following ERC and despite complete patency of the biliary tree, a progressive increase of total and conjugated bilirubin and of alkaline phosphatase was noted, associated with itching and total stool discoloration. The insertion of nasobiliary drain did not improve the jaundice. Prednisolone treatment for 12 days was associated with progressive restoration of serum bilirubin alkaline phosphatase to normal levels. It was postulated that the radiocontrast material used may have acted toxically on the liver with disruption of the canalicular plasma membrane. It is proposed that intrahepatic cholestasis should be added in the list of complications of endoscopic retrograde cholangiography.

Cholestatic jaundice as a paraneoplastic manifestation of renal cell carcinoma

Malignant diseases may cause cholestatic jaundice through either main bile duct obstruction or widespread hepatic metastasis. Renal cell carcinoma (hypernephroma, RCC) can cause a variety of paraneoplastic manifestations which can be the main presenting symptoms. Cholestasis, as a paraneoplastic syndrome, has been well described in patients with malignant lymphohyperplastic diseases. Non-metastatic nephrogenic hepatic dysfunction syndrome without jaundice has often been described in patients with hypernephroma (Stauffer's syndrome). Paraneoplastic cholestatic jaundice has not yet been described. We report, for the first time, two patients who presented with pruritus and cholestatic jaundice. During the diagnostic work-up, RCC was diagnosed. The renal tumour was an unexpected finding during computed tomographic (CT) scan. No clinical manifestations of hypernephroma, short of microscopic haematuria, were detected. Conjugated bilirubin, alkaline phosphatase and gamma-glutamyltranspeptidase were markedly increased. No hepatic metastasis or main bile duct obstruction were detected by appropriate investigations. After radical nephrectomy, liver abnormalities disappeared rapidly. We conclude that RCC should be included among neoplasms causing not only anicteric intrahepatic cholestasis but also frank jaundice as part of a paraneoplastic syndrome. The differential diagnosis from hepatic metastasis, main bile duct obstruction or other causes of jaundice is of clinical importance and of prognostic value. Patients with unexplained cholestasis should be investigated for malignant diseases including hypernephroma.

Immune thrombocytopenia and alpha-interferon therapy

Thrombocytopenia is often found in patients with liver diseases, especially due to congestive splenomegaly caused by portal hypertension. Immune thrombocytopenia has been described rarely, and it seems to be especially associated with hepatitis C virus, which has been described as having a particular interaction with the immune system contributing to the induction of autoimmunity. Interferons, on the other hand, because of their immunomodulatory properties, are able to induce or exacerbate autoimmune diseases. Mild thrombocytopenia is a common adverse effect of interferon therapy. Severe life-threatening thrombocytopenia is extremely rare. We report two cases of severe immune thrombocytopenia in patients with chronic hepatitis C, probably induced by alpha-interferon. Bone marrow aspirate and elevated platelet-associated IgG antibodies, determined by indirect immunofluorescence, were suggestive of immune thrombocytopenia. None of the patients had any clinical sign of autoimmune syndrome, including arthritis, serositis, Sicca syndrome, vasculitis, thyroid abnormalities and others. Cryoglobulins and rheumatoid factor were tested and were undetectable. The patients' histories of exposure to alpha-interferon and the exclusion of other causes are most consistent with drug-induced immune thrombocytopenia. After alpha-interferon withdrawal, thrombocytopenia was treated successfully with prednisolone and immunoglobulins. Response to treatment was consistent with the diagnosis of alpha-interferon-induced immune thrombocytopenia and peripheral consumption of platelets.

Polymyositis associated with primary biliary cirrhosis

The coexistence of polymyositis (PM) and primary biliary cirrhosis (PBC) is rare; only nine cases have been described in English literature. We report a case of a 46-year-old woman presenting with these two autoimmune diseases. The diagnosis of PM was based on the symmetrical, proximal limb muscle weakness, elevated muscle enzymes and was confirmed with the electromyography and muscle biopsy. The diagnosis of PBC was based on the increased serum levels of alkaline phosphatase, gamma glutamyltransferase, IgM immunoglobulin, the presence of antimitochondrial antibodies and diagnostic liver biopsy.

Fulminant hepatitis after flutamide treatment

Two cases of severe acute hepatitis in patients taking flutamide for metastatic prostatic carcinoma are reported. Jaundice and marked increase in aminotransferases occurred after 6-8 weeks of treatment. Continuation of flutamide administration was associated with the development of hepatic encephalopathy and a marked prolongation of prothrombin time. One of the patients died of acute liver failure and the other survived after prolonged hospitalization. Rechallenge was not performed because of the severity of the clinical picture. Liver histology showed extensive hepatic necrosis. These two cases strongly suggest that flutamide, in addition to its cholestatic side effects, can induce acute hepatitis potentially with a fulminant and lethal course. Journal of Hepatology.

Clinical significance of quantitative anti-HBc IgM assay in acute and chronic HBV infection

The applicability and clinical usefulness of anti-HBc IgM quantification in acute and chronic hepatitis type B by a single run of undiluted sera is largely unknown. Serum anti-HBc IgM concentrations were measured in 153 patients with various forms of acute and chronic HBV infection by a new commercially available qualitative ELISA/2-step capture assay applying streptavidin technology. The absorbance values were expressed in anti-HBc IgM U/ml using a calibration curve produced by a series of anti-HBc IgM standards. The results were compared with those obtained with another second generation qualitative anti-HBc IgM method also in undiluted sera applying the Microparticle Enzyme Immune Assay (MEIA). In acute hepatitis B, anti-HBc IgM was always > 600 U/ml (median: > 800 U/ml) declining to median values of 135 and 85 U/ml at months 3 and 6, respectively. Values above 600 U/ml were seen in 4 out of 20 (20%) HBsAg carriers with episodes of severe HBV-induced liver damage resembling acute hepatitis B (group 2) and in 2 out of 35 (5.6%) patients with HBV induced chronic active hepatitis (group 3). Values above 100 U/ml, representing the cutoff levels for the diagnosis of acute hepatitis B in the qualitative assays, were detected in 55% (11/20) and 45.7% (16/35) of the above patients of groups 2 and 3, respectively. Anti-HBc IgM was negative or under 20 U/ml in 96.7% (29/30) of HBsAg carriers with acute or chronic liver damage unrelated to HBV (HDV, HCV or drug-induced) and in 91% (41/45) of HBsAg carriers with persistently normal ALT levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Iron overload in multiply transfused patients who are HIV seropositive

AIMS

To assess histologically the amount of iron deposited in liver biopsy specimens from HIV positive patients; and to perform estimations of liver iron on tissue from patients with an increase in parenchymal stainable iron. To correlate the amount of blood transfused and the degree of iron overload.

METHODS

Liver biopsy specimens (n = 120) from 109 HIV positive patients, 74 of whom had AIDS, were examined retrospectively and the amount of iron, as visualised with Perls's stain, was graded. Fibrosis was assessed using connective tissue stains. Estimations of liver iron were performed on tissue retrieved from paraffin wax blocks in cases with histological grade 3 or 4 iron overload. The amount of blood transfused before liver biopsy was determined from the notes for each patient.

RESULTS

Fifteen of the 120 liver biopsy specimens had significantly increased amounts of iron in their hepatocytes, as assessed histologically, and this was confirmed in seven cases by measurement of liver iron. There was a close correlation between the amount of blood transfused and the degree of iron overload. In the initial biopsy specimens only one case showed portal tract expansion. Three of the five patients who had repeat biopsies, however, showed progressive fibrosis.

CONCLUSION

Multiply transfused HIV positive patients may develop clinically important iron overload and are at risk of developing progressive fibrosis. Superimposed liver disease, especially viral hepatitis, in these high risk patients may exacerbate the effects of the iron overload.

Hepatitis C virus infection in Greece and its role in chronic liver disease and hepatocellular carcinoma

The aim of this study was to evaluate the prevalence of hepatitis C virus infection (HCV) in Greece, to estimate its frequency in chronic liver disease and to explore the role of HCV infection in the aetiology of hepatocellular carcinoma. A series of 1034 patients with chronic liver disease of various aetioloigies and 299 patients with hepatocellular carcinoma allocated to two case-control studies was tested for anti-HCV. Twelve recent reports on HCV infection in Greece were reviewed and analyzed. The results of the present study indicate the existence of a large pool of HCV infection in Greece and an impressive spread of the virus in high-risk groups. Chronic HCV infection was found to account for 83.6% of patients with chronic non-A, non-B hepatitis parenterally transmitted, 56.5% of cases of sporadic community-acquired disease and for almost 1/4 of all patients with chronic liver disease. The relative risks for development of hepatocellular carcinoma of patients with chronic HCV infection was 6.3 in the first and 13.7 in the second case-control study, increasing to 20.0 and 18.7, respectively, when hepatitis B surface antigen (HBsAg) was positive. Serum HBV-DNA was positive and/or anti-HBc IgM levels were high in 12 of 15 (80%) patients with hepatocellular carcinoma positive only for HBsAg, and in 7 of 15 (47%) positive both for HBsAg and antibodies to HCV. The present data support the view that hepatitis B and C virus have an interacting role in the origin of hepatocellular carcinoma.

Serological response and detection of viraemia in acute hepatitis C virus infection

The serological response during acute hepatitis C virus (HCV) infection was examined by enzyme-linked immunosorbent assay (ELISA) in sequential serum samples from 13 haemophiliacs following their first exposure to factor VIII concentrates contaminated with HCV. The commercially available C100-3 peptide and a new 22 kDa recombinant protein (p22) encoded by the nucleocapsid region of the viral genome were used for antibody detection, whilst a nested polymerase chain reaction (PCR) method was used for the detection of viraemia. In addition, eight sporadic cases of acute HCV infection were studied. The results in haemophiliacs demonstrated that seroconversion to the C100-3 antigen occurred in only one-third of the patients within 12 weeks of disease onset, but all of the patients had a diagnostic serological response to p22 during this phase of the disease. The new test was positive in all the sporadic cases at a time when the commercially available test was negative. Although PCR offers a sensitive method for the detection of recent HCV infection, the complex methodology makes it unsuitable for diagnostic laboratories. The new ELISA test with p22 may therefore have a useful diagnostic role in acute disease.

Seroprevalence of hepatitis C virus nucleocapsid antibodies in patients with cryptogenic chronic liver disease

The serological responses to two different hepatitis C virus antigens were studied by enzyme-linked immunosorbent assay in a variety of chronic liver diseases and in healthy blood donors. The study population comprised 97 cases of cryptogenic chronic liver disease (40% with a history suggestive of parenterally transmitted non-A, non-B hepatitis and 60% without such a history), 87 cases of other well-characterized chronic liver diseases and 96 voluntary blood donors. The commercially available C100-3 assay and a new assay utilizing a 22 kD recombinant protein (c22) from the nucleocapsid region of the virus were used for antibody detection. Overall in the non-A, non-B hepatitis group, 77% were positive for anti-c22, 55% were positive for anti-C100-3 and 24% were negative by both tests. In the parenterally transmitted chronic liver disease group, 82% were positive for anti-C100-3 and 90% were positive for anti-c22 (not significant). In the cryptogenic chronic liver disease cases 36% were positive for anti-C100-3 and 67% were positive for anti-c22 (p less than 0.001). Only in one case (a patient with hepatitis B virus infection) was anti-C100-3 detected without concomitant anti-c22. None of the voluntary blood donors had detectable hepatitis C virus antibodies. The new enzyme-linked immunosorbent assay test for anti-c22 would appear to be a more sensitive indicator of chronic hepatitis C virus infection than the existing commercial test, suggesting a useful diagnostic role in both cases of cryptogenic chronic non-A, non-B hepatitis liver disease and for the screening of blood products for prevention of hepatitis after transfusion.