Questionnaire PLD-complaint-specific assessment identifies need for therapy in polycystic liver disease: A multi-centric prospective study

BACKGROUND AND AIMS

Polycystic liver disease (PLD) can lead to extensive hepatomegaly. Symptom relief is the primary goal of the treatment. The role of the recently developed disease-specific questionnaires for identification of the thresholds and the assessment of therapy needs further investigation.

METHODS

A five-year prospective multi-centric observational study in 21 hospitals in Belgium gathered a study population of 198 symptomatic PLD-patients of whom the disease-specific symptom questionnaire PLD-complaint-specific assessment (POLCA) scores were calculated. The thresholds of the POLCA score for the need for volume reduction therapy were analyzed.

RESULTS

The study group consisted of mostly (82.8%) women with baseline mean age of 54.4 years ±11.2, median liver volume expressed as height-adjusted total liver volume(htLV) of 1994 mL (interquartile range [IQR] 1275; 3150) and median growth of the liver of +74 mL/year (IQR +3; +230). Volume reduction therapy was needed in 71 patients (35.9%). A POLCA severity score (SPI) ≥ 14 predicted the need for therapy both in the derivation (n = 63) and the validation cohort (n = 126). The thresholds to start somatostatin analogues (n = 55) or to consider liver transplantation (n = 18) were SPI scores of ≥14 and ≥ 18 and the corresponding mean htLVs were 2902 mL (IQR 1908; 3964) and 3607 mL (IQR 2901; 4337), respectively. Somatostatin analogues treatment resulted in a decrease in the SPI score -6.0 versus + 4.5 in patients without somatostatin analogues (p < 0.01). Changes in the SPI score were significantly different between the liver transplantation group and no liver transplantation group, +4.3 ± 7.1 versus -1.6 ± 4.9, respectively, (p < 0.01).

CONCLUSION

A polycystic liver disease-specific questionnaire can be used as a guide on when to start a volume reduction therapy and to assess the effect of treatment.

Liver disease late in pregnancy without pre-eclampsia

We describe the case of a first twin pregnancy in a 27 year old patient, who experienced acute onset epigastric and right upper quadrant pain at a gestational age of 32 weeks and 2 days. She was diagnosed with acute liver and renal failure and possible disseminated intravascular coagulopathy (DIC) syndrome without pre-eclampsia. Early labor induction was mandatory to save both mother and foetuses. In this overview we describe the differential diagnosis of severe pregnancy related liver injury in the third trimester of pregnancy without pre-eclampsia. (Acta gastroenterol. belg., 2017, 80, 53-57).

Four patients with Amanita Phalloides poisoning

Mushroom poisoning by Amanita phalloides is a rare but potentially fatal disease. The initial symptoms of nausea, vomiting, abdominal pain and diarrhea, which are typical for the intoxication, can be interpreted as a common gastro-enteritis. The intoxication can progress to acute liver and renal failure and eventually death. Recognizing the clinical syndrome is extremely important. In this case report, 4 patients with amatoxin intoxication who showed the typical clinical syndrome are described. The current therapy of amatoxin intoxication is based on small case series, and no ran- domised controlled trials are available. The therapy of amatoxin intoxication consists of supportive care and medical therapy with silibinin and N-acetylcysteine. Patients who develop acute liver failure should be considered for liver transplantation.

Case report: Aortoduodenal fistula presenting as iron-deficiency anaemia

Aortoenteric fistulae are a rare cause of gastrointestinal bleeding. If undiagnosed, mortality is high. The outcome of aortoenteric fistula has improved significantly due to better diagnostic modalities, advances in anaesthesia and surgical techniques including endovascular aortic repair. Early diagnosis requires a high index of clinical suspicion. An aortoenteric fistula should be suspected in every patient with a history of surgical or endovascular repair of aortic disease who presents with gastrointestinal bleeding. Most patients present with massive gastrointestinal bleeding. Presentation with iron-deficiency anaemia on routine blood analysis, as in our case report, is extremely unusual.

Endoscopic trimming of metallic stents with the use of argon plasma

BACKGROUND

The endoscopic placement of metallic stents for palliation of malignant obstruction of the GI or biliary tract is an established practice and as such is often applied. Use of these stents, however, has its problems. Stent migration may cause obstruction of the bowel lumen. Migration of a biliary stent into the contralateral duodenal wall may cause difficulty in gaining access to the biliary tract, as will the placement of a duodenal stent across the ampulla.

OBJECTIVE

We report on 6 patients in whom trimming of the metallic nitinol stent was performed.

DESIGN

Single-center, retrospective case series.

SETTING

Secondary referral center.

PATIENTS

Of 6 patients included, 2 patients each had an uncovered duodenal stent, 2 had an uncovered biliary stent each, 1 had an uncovered colorectal stent, and 1 had a covered gastroduodenal stent.

INTERVENTIONS

Under direct endoscopic vision, an argon plasma beam was used to cut self-expandable metallic stents, as appropriate.

MAIN OUTCOME MEASUREMENT

The main objective was relief of the obstruction to the bowel lumen or bile duct, facilitating successful passage of an endoscope or biliary canulation, respectively.

RESULTS

In all 5 patients with uncovered metallic stents, we were able to re-establish access to the obstructed bowel lumen or the biliary tree, as indicated. An attempt to tailor the length of a covered metallic gastroduodenal stent failed. No complications were observed and no hemorrhage or perforation occurred.

LIMITATIONS

The study was limited by retrospective design and small sample size.

CONCLUSIONS

The endoscopic cutting and tailoring of an uncovered metallic prosthesis, by means of an argon plasma beam, is feasible, effective, and safe. Trimming of covered stents is not advocated.

Hepatitis C and insulin resistance: mutual interactions. A review

Worldwide approximately 200 million people are chronically infected with hepatitis C virus (HCV). Chronic HCV infection represents the leading cause of liver cirrhosis and the main indication for liver transplantation in the western world. In addition, chronic HCV infection is associated with numerous clinical manifestations, including type 2 diabetes. An obvious and frequently suggested explanation for the connection between HCV infection and type 2 diabetes is that cirrhosis by itself causes insulin resistance. However, the prevalence of type 2 diabetes in HCV cirrhosis is higher than in HBV cirrhosis (23.6% vs 9.4%). This suggests that HCV infection by itself can lead to insulin resistance and predispose to the onset of type 2 diabetes. First, HCV core protein induces hepatic steatosis by inhibition of microsomal triglyceride transfer protein and hepatic steatosis causes insulin resistance. Secondly, HCV core protein inhibits, through elevation of TNF-alfa and other factors, the insulin-signalling pathways causing insulin resistance. Moreover, recent data strongly suggest that insulin resistance is an important predictor of poor response to antiviral therapy in chronic hepatitis patients treated with peginterferon plus ribavirin.