Biliary features in liver histology of children with autoimmune liver disease

OBJECTIVES AND STUDY

Various degrees of biliary changes are considered to be part of the histological picture of children with pediatrics autoimmune liver disease (AILD), but the literature is scarce and confusing. We aimed to describe the characteristics of children with AILD (autoimmune hepatitis, AIH, and autoimmune sclerosing cholangitis, ASC) focusing on the prevalence and type of biliary abnormalities on initial biopsy to see whether ASC was predictable on histological ground.

METHODS

The files of children diagnosed with AILD were reviewed. The Ishak score was used to grade inflammation and fibrosis on biopsy; a biliary score was built to grade bile duct injury. Demographic, laboratory and histological features at diagnosis were reported and compared between the two groups (AIH vs ASC).

RESULTS

Forty-one patients were diagnosed with AIH (n = 24), ASC (n = 13) and PSC (n = 4) between 2009 and 2018. Twenty-nine patients [F = 76%, AIH = 20, ASC = 9, median age at diagnosis 11.7 (range 2.2-17.8)] were included in the study; 12 (4 with PSC) were excluded. Prevalence of inflammatory bowel disease was higher in ASC group (56% vs 10% in AIH, p < 0.05). On histology 17% had cirrhosis. The grade of biliopathy with AILD was moderate in 72% and severe in 31%, and overall more prominent in ASC (p = 0.031). The inflammation of the bile ducts was classified as "multifocal" or "diffuse" mainly in ASC patients (89% vs 45% in AIH, p = 0.043). Periductular fibrosis was reported in 52% of AILD patients, with a higher mean score in ASC group (p < 0.05). However, ductular reaction, biliary metaplasia and granulomatous cholangitis were equally reported in AIH and ASC, providing no clear-cut for the distinction of the two entities in the global histological evaluation.

CONCLUSIONS

Majority of patients with pediatrics AILD have "moderate" or "severe" features of biliopathy; AIH and ASC are not easily distinguishable on histological ground at diagnosis, and therefore, the cholangiogram remains the only effective tool to differentiate patients with AIH from those with ASC. Further prospective studies are needed to better define histological biliary features in AILD, assess if the biliopathy responds to immunosuppressive treatment and evaluate its impact on long-term outcome.

Choose the best route: ultrasound-guided transbronchial and transesophageal needle aspiration with echobronchoscope in the diagnosis of mediastinal and pulmonary lesions

Nodal mediastinal staging is a crucial part of the diagnostic workup of patients with non-small-cell lung cancer (NSCLC) for planning optimal treatment. Transesophageal endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and real-time endobronchial ultrasounds transbronchial needle aspiration (EBUS-TBNA) are accurate, minimally invasive and safe diagnostic techniques for mediastinal staging. Because of the different accessibility to the mediastinum, they are considered complementary and their combination increases the diagnostic yield as compared with the either alone. Recent studies have shown that endosonography represents the best initial test for invasive mediastinal evaluation in NSCLC. Endoscopic ultrasound (with bronchoscope)-guided fine needle aspiration (EUS-B-FNA) is a recently introduced procedure consisting of a transesophageal needle aspiration using an ultrasound bronchoscope. It allows to perform both transbronchial and transesophageal needle sampling with the same instrument, in the same session and by one operator only, thus maximizing time and costs savings. In a recent study Oki et al. randomized 110 patients with hilar/mediastinal adenopathies or lung abnormalities adjoining both the esophagus and the bronchi, to undergo EBUS-TBNA or EUS-FNA performed by pulmonologists with an echobronchoscope. The Authors demonstrated that both procedures provide a high diagnostic yield, without any difference in the number of adverse events and a good comparable tolerance. Nevertheless, the transesophageal approach guaranteed a significantly lower dose of anesthetics and sedatives, a shorter procedural time, fewer oxygen desaturations, a significantly lower cough score and a higher operator satisfaction. In this review our aim was to discuss the findings by Oki et al. in the context of medical literature, highlighting the importance of the EUS-B needle aspiration technique in diagnosing mediastinal and lung lesions, when EBUS-TBNA is deemed less suitable. Finally, we pointed out the importance of interventional pulmonologists being trained to perform mediastinal sampling by the esophageal route, to choose the best solution in every technical and clinical occurence.

[TRH stimulation test in the diagnosis of hyperthyreosis]

After a review concerning the present knowledge on the hypothalamic peptide releasing hormones, the response of TSH to intravenous administration of TRH in man (Thyreotrophin Releasing Hormone Stimulation Test) is discussed, with regard to clinical endocrinology. Personal investigations with the TRH test were carried out in 3 groups of conditions correlated with thyroid hyperfunction: 1) suspected hyperthyroidism with equivocal routine tests (9 subjects); 2) autonomous thyroid decompensated adenoma, with or without clinical hyperthyroidism (5 subjects); 3) thyrotoxicosis (Graves' disease) in remission phase after pharmacological or surgical treatment (10 subjects). In these conditions the test provided useful diagnostic information for appropriate therapeutical decisions.

[Current management in the diagnosis and treatment of necrotic lesions of the diabetic foot]

A simplified classification for clinical pratical purposes of the diabetic foot necrotic lesions is proposed. Two types are considered both possibly with infection: 1. The angiopathic foot, as a manifestation of the diabetic macro- and microangiopathy. 2. The angioneuropathic foot, as an association of the preminent diabetic neuropathy with diabetic microangiopathy and macroangiopathy. This classification proved suitable to 63 personal observations during the last 7 years. Diagnosis and treatement, planned by a diabetological-orthopedic cooperation, are specified for the two headings. The measure of systolic peripheral blood pressure by means of the ultrasonic device Doplette 10 Danica is introduced.

[Evaluation of the antibody anti-insulin titer using Christiansen's radioimmunoelectrophoresis in clinical diabetology]

On the basis of personal experience concerning 2020 consecutive determinations, the radioimmunoelectrophoretic method of Christiansen for 125I-Insulin-Binding to IgG (= IB, significant limits = mU/ml) has been proved as a reliable tool for the evaluation of insulin antibody titer in clinical diabetology. After a critical review of the recent literature about insulin antibodies both without and after exogenous immunization, the following results are presented and discussed. 1) - In 163 diabetic subjects, never previously treated with insulin, the mean value of IB was X = 0,008 mUml (sigma = 0,023 . Sx = 0,002). 2) - In 221 longterm insulin-treated diabetics the mean value of IB was X = 1,50 mU/ml (sigma = 2,15 . Sx = 0,145). 3) -In 46 insulin-dependent diabetics, serial determinations of IB allowed to follow the insulin antibody production during a 5 years treatment with monocomponent insulin )Lente MC). No or slight antibody formation was observed in newly diagnosed patients, never previously treated with insulin. High antibody starting levels showed tendency to a gradual reduction, after switching from conventional insulin treatment to the monocomponent one. These modifications in the IB values have been studied in correlation with the clinical course of conditions possibly referred to an immunologic pathogenesis, such as: brittle diabetes, high insulin requirement, insulin allergy, insulin lipoatrophy, diabetic microangiopathy. No significant variations in IB values were observed after viral infections.