Acute hepatitis: a prognostic study with observation time up to 37 years. A follow-up of the Iversen/Roholm liver biopsy material

Re-evaluation of 890 consecutive liver biopsies from 1939-59 gave the diagnosis of acute hepatitis in 147 patients. A follow-up study of these patients was performed 15-37 years after the diagnostic biopsy, based on repeated liver biopsies, biochemical liver tests, autopsy reports and death certificates. Two patients died from acute liver failure, and development of cirrhosis was documented or strongly suspected in 22 patients (15 percent). A comparison between these 24 patients with a malignant course of hepatitis and 86 patients with a well documented uncomplicated disease, revealed a significantly larger number of women, a higher age, and more cases with piece-meal necrosis, confluent necrosis and marked portal inflammation in the intitial liver biopsy in the group with the poor prognosis.

Ultrasound examination in jaundiced patients. Is computer-assisted preclassification helpful?

In this study we attempted to determine the diagnostic accuracy and reproducibility of ultrasonography (US) for jaundice and to see how US can best be combined with preliminary clinical-biochemical diagnoses to plan the invasive work-up. US proved reproducible in two diagnostic departments (127 agreements in 135 cases). But, since obstruction was underdiagnosed (15 double-false negatives), the predictive value of a negative result was only 0.83. By adding a term which represents the US conclusion, obstruction or not, to the Copenhagen pocket diagnostic chart score (based on the logistic model) we found that an obstructive conclusion increases the odds of obstruction by a factor of 25, and a non-obstructive conclusion decreases the odds by a factor of only 1.9. We conclude that the preliminary diagnosis is frequently sufficiently certain to be unalterable by US. This leaves only 40% of the jaundice cases in which US is necessary to plan invasive work-up. The US workload can even, it appears, be reduced to about 22% without appreciable penalty in terms of unrewarding invasive procedures. Using these strict indications, four US examinations seem to suffice to avoid one such error. Relying on either US or clinical-biochemical data alone is inferior to the combined strategy.

Determination of T1- and T2-relaxation times in the spleen of patients with splenomegaly

Twenty-nine patients with known splenomegaly and seven healthy volunteers were examined. The T1 and T2 relaxation times were read out from a region of interest centrally in the spleen. Even though different mean T1 and T2 relaxation times were found between the groups, the great scatter and the considerable overlap between the groups makes the contribution of relaxation time measurements to the differential diagnosis of splenomegaly of limited value.

Prolonged T1 in patients with liver cirrhosis: an in vivo MRI study

Fifteen patients with liver cirrhosis and two control groups were examined. The first control group consisted of 7 healthy volunteers, and the second group of 17 patients with nonfocal liver diseases. The T1 and T2 relaxation times were calculated from signal intensities read out from a region of interest centrally located in the liver. T1 relaxation time was longer in the patients with liver cirrhosis than in the two reference groups. Ten patients had a liver biopsy taken prior to the MRI study. No correlation was found between histopathology and the measured relaxation times.

Prognosis after the first episode of gastrointestinal bleeding or coma in cirrhosis. Survival and prognostic factors

Hepatic encephalopathy and gastrointestinal (GI) bleeding are the most serious complications in cirrhosis. The purpose of this study was to examine survival after the first episode of GI bleeding or coma, or both, and to identify variables associated with the subsequent survival in 284 consecutive patients with cirrhosis admitted to one division of hepatology over a period of 81 months. Patients who only bled had markedly longer survival than those who only had coma, whereas those who had both bleeding and coma had by far the poorest survival, only 15% being alive 1 year later. Several other variables showed a significant association with survival. In a Cox multiple regression analysis the following four variables showed significant association with a short survival: coma and bleeding at the episode, ascites, low prothrombin index, and high serum creatinine. The prognostic index derived from the Cox model, which was validated by a split-sample testing technique, may be used to refine prognostic estimation in this subgroup of severely ill cirrhotic patients.

A decision tree for early differentiation between obstructive and non-obstructive jaundice

We present a method for early differentiation between obstructive and non-obstructive jaundice. On the basis of 14 variables (clinical data and clinical chemical tests, all available within 48 h) a simple decision tree or flow chart has been constructed. The diagnostic yield was as follows: 857 of 982 consecutive jaundiced patients (87%) in a data base and 98 of 108 patients in an independent test sample (91%) were correctly classified. Decision trees for the differentiation between benign or malignant causes within the obstructive group and between acute or chronic causes within the non-obstructive group are also presented. The resulting four-way classification was correct for 77% of the patients in the data base and for 72% of the patients in the test sample. The decision trees are compared with previous methods founded on Bayes' rule and logistic discrimination. The decision trees enable a quick and reliable classification of jaundiced patients, thus providing a valid basis for rational planning of the further diagnostic study.

Intolerance to tartrazine in aspirin-induced asthma: results of a multicenter study

One hundred and fifty-six German, Italian and Polish patients with confirmed aspirin-induced asthma underwent open oral challenges with increasing doses of tartrazine up to 25 mg. All positive challenges were repeated under double-blind conditions. Only 4 of 156 patients (all Polish) had positive reactions in a double-blind test, as evidenced by a fall in FEV1 greater than 25% from baseline and corresponding clinical symptoms. Sixty-five patients who tolerated 25 mg tartrazine well received 50-3,000 mg tartrazine and none showed adverse reactions. Thus, intolerance to tartrazine appears to be rare among Central-European and South-European patients with aspirin-induced asthma, its frequency amounting to about 2.6%.

Serum aminoterminal procollagen type III peptide in acute viral hepatitis. A long-term follow-up study

The development of chronic viral liver disease is associated with increased deposition of connective tissue in the liver. The aminoterminal propeptide of procollagen type III (P-III-NP) is considered to reflect the metabolism of collagen type III, one of the major collagen types in liver fibrosis. The purpose of the present study was to elucidate, whether S-P-III-NP in patients with viral hepatitis was related to injury and repair processes in the liver. S-P-III-NP was determined in a prospective longitudinal study of 63 patients with acute viral hepatitis followed to healing or development of chronic liver disease. Two assays were applied. The P-III-NP Ria-gnost assay, which measures mainly the intact propeptide, and the P-III-NP Fab-assay, in which the antibody exhibits equal affinity to the intact propeptide as well as the degradation product col 1. At the onset of viral hepatitis, S-P-III-NP determined in either assay was equally elevated in the two groups. From the second month of follow-up, significantly higher levels in both assays were observed in patients developing chronic disease. During follow-up, the highest P-III-NP RIA-gnost values were seen in patients with chronic active hepatitis, and active cirrhosis. S-P-III-NP decreased towards normal levels during development of inactive cirrhosis. In the individual patient, S-P-III-NP Ria-gnost was positively related to transaminases. During follow-up of uncomplicated hepatitis a normalization of transaminases occurred before normalization of S-P-III-NP RIA-gnost. Considering, that S-P-III-NP, in contrast to the conventional laboratory variables, reflects the metabolism of type III collagen, it is assumed that determination of S-P-III-NP may provide new information on fibrogenesis in viral liver disease.

Updating prognosis and therapeutic effect evaluation in cirrhosis with Cox's multiple regression model for time-dependent variables

A multivariate Cox regression analysis with time-dependent variables has been performed on the data of 415 patients with cirrhosis included in a controlled clinical trial of 10-15 mg prednisone daily versus placebo. The analysis showed that a poor prognosis was associated with a low prothrombin index, marked ascites, GI bleeding, high age, high daily alcohol consumption, high bilirubin and alkaline phosphatase and low albumin values, little liver connective tissue inflammation, and poor nutritional status. Prothrombin index and ascites showed significant interaction with the treatment in such a manner that high prothrombin index and absence of ascites were associated with a beneficial effect of prednisone, whereas low prothrombin index and presence of ascites were associated with a harmful effect of prednisone treatment. The final model was validated in independent patients by comparing their actual survival with that predicted from the model, using a split-sample testing technique. The prognostic factors were combined with an index that can be used to update prognosis whenever changes occur in the clinical status of a patient during the course of the disease. The probability of surviving the next 3 or 6 months can be estimated from the prognostic index at any time during the course. The index may be of value for the correct timing of special therapeutic procedures such as liver transplantation.

Computer diagnosis in jaundice. Bayes' rule founded on 1002 consecutive cases

Extensive clinical and clinical chemical information was collected from 1002 consecutive jaundiced patients. Initial selection of variables based on Chi 2-tests or Mann-Whitney U-test allowed the removal of 64 of the 107 variables originally collected. A further selection of variables was carried out using a modified version of Bayes' rule thus reducing the number of variables from 43 to 22. Of the 982 patients with a final diagnosis 743 patients (76%) could be classified correctly into one of 13 diagnostic categories. The Bayes' rule was also applied to a test group of a further 110 jaundiced patients and found to perform equally well: of 108 patients with a final diagnosis 81 (75%) were correctly classified. A comparison between the clinician's diagnosis and the computer-aided diagnosis according to Bayes' rule demonstrated agreement with regard to one of the 13 diagnostic alternatives in 734 patients (75%), of whom 81 patients were wrongly diagnosed. In the test group agreement upon diagnosis was found in 80 patients (74%). By plausibly combining the computer-aided and the clinician's preliminary diagnoses, more correct classifications were obtained than with either method alone. Many diagnostic modalities such as ultrasound examination, CT-scan, and direct cholangiography are at hand today for the differential diagnosis of jaundice. Computer-aided diagnosis using Bayes' rule has proved a reliable tool for the clinician and can be used in the planning of a diagnostic strategy for the individual jaundiced patient.

Changes of laboratory variables with time in cirrhosis: prognostic and therapeutic significance

The time change of laboratory variables in cirrhosis was studied by analysis of data from 488 patients with cirrhosis included in a controlled clinical trial of long-term prednisone vs. placebo. In the placebo group, a marked regression towards normal was seen within 3 months of entry into the trial (increase in serum albumin, acetylcholinesterase, cholesterol, hemoglobin and decrease in erythrocyte sedimentation rate). The subsequent course did not show a clear pattern, except for a slight increase in serum bilirubin and decrease in albumin. When studied in relation to the time of death in patients dying from a "hepatic" cause, marked increase in bilirubin and decrease in prothrombin index, albumin and cholesterol were seen in the year prior to death with little change before that time. In the prednisone group, a more marked decrease in bilirubin, SGOT, alkaline phosphatase, gamma-globulin, sulfobromophthalein retention, erythrocyte sedimentation rate and increase in leukocytes, prothrombin index and cholesterol were seen during the first 3 months. In relation to time of death from a "hepatic" cause, similar changes were seen as in the placebo group except that alkaline phosphatase increased and cholesterol did not decrease. A beneficial effect of prednisone on survival, as expressed by a previously developed therapeutic index, was associated with decrease in SGOT, alkaline phosphatase and gamma-globulin within the first 3 months. An increase in SGOT during prednisone seemed to be associated with harmful effects of therapy.

Survival after jaundice: a prospective study of 1000 consecutive cases

A consecutive series of 1002 jaundiced adult patients covering 23 different causes of jaundice is presented. Patients were followed up for 2 to 7 years. The survival for the 784 patients included during their first episode of jaundice was calculated for each diagnostic category. Examples of decreased survival as compared with the general population were (figures indicate 3 months' and 5 years' survival, respectively): alcoholic cirrhosis 0.81, 0.35; cryptogenic cirrhosis 0.78, 0.32; pancreatic carcinoma 0.54, 0.04; cholangiocarcinoma 0.26, 0.00; and heart failure with liver congestion 0.47, 0.07. Ten of 172 patients with acute viral hepatitis died, 1 of fulminant hepatitis and 9 because of suicide or accidents. Of 105 patients with gallstones 37 died during the study period, but in only 9 of these could death be attributed to the gallstone disease. New diagnostic methods and types of treatment for jaundiced patients have been developed during recent years. To justify fully these diagnostic and therapeutic modalities, knowledge of the prognosis for the various causes of jaundice is essential.

A therapeutic index that predicts the individual effects of prednisone in patients with cirrhosis

Our aim was to construct an index that accurately predicts the degree of benefit or harm that prednisone therapy holds for patients with liver cirrhosis. The admission and survival data of 488 patients with cirrhosis who participated in a controlled clinical trial of prednisone in a dosage of 10-15 mg daily (251 patients) versus placebo (237 patients) and who were observed for up to 12 yr were analyzed using Cox's multiple regression model. Four variables each provided significant therapeutic information: antinuclear factor (p = 0.02) and large piecemeal necroses (p = 0.02) were associated with a beneficial effect, whereas ascites (p = 0.0004) and large regenerative nodules (p = 0.0007) were associated with a harmful effect of prednisone. From these four variables a therapeutic index was constructed. For a given patient the therapeutic index is a measure of how big the effect will be if prednisone is given. The gain in survival time obtained by administering prednisone according to the therapeutic index was estimated to be 349 yr, mainly confined to 217 patients with a significant positive (121) or negative (96) therapeutic index. The therapeutic index may prove useful for the optimal administration of prednisone treatment in new patients with cirrhosis.

Differential diagnosis of jaundice: a pocket diagnostic chart

Based on extensive clinical and clinical chemical information (107 different items) from 1002 jaundiced patients, we developed a diagnostic algorithm which was evaluated on a test sample of another 110 jaundiced patients. A primary classification into categories of obstructive jaundice (probability of obstruction greater than or equal to 0.80), non-obstructive jaundice (probability of obstruction less than or equal to 0.20), and of doubtful causes of jaundice (probability of obstruction: 0.20-0.80) was attempted. Among 234 patients in the data base who were classified as obstructive, 220 (94%) proved to be so, as did 36 (97%) of 37 in the test sample. The corresponding figures for non-obstructive jaundice were 463 (96%) of 483 patients correctly classified in the data base and 47 (92%) of 51 patients in the test sample. Altogether 69% of the patients in the data base and 75% of those in the test sample were correctly classified, in 27% and 20% the cause of jaundice was doubtful, and only 4% and 5%, respectively, were misclassified. A slight majority of the patients in whom the algorithmic diagnoses were doubtful proved obstructive. A close correlation was found between the preliminary diagnoses made by the algorithm and by the clinicians. A secondary classification of the patients by the algorithm into benign versus malignant causes of obstructive jaundice performed equally well in the data base and the test sample.

Prognostic value of Child-Turcotte criteria in medically treated cirrhosis

The Child- Turcotte criteria (CTC) (based on serum bilirubin and albumin, ascites, neurological disorder and nutrition) are established prognostic factors in patients with cirrhosis having portacaval shunt surgery. The objective of this study was to evaluate the prognostic value of CTC in conservatively treated cirrhosis. Patients (n = 245) with histologically verified cirrhosis from a control group of a controlled clinical trial were studied. Data at entry into the trial were used to classify patients according to CTC. Survival curves for up to 16 years were made, and survival rates were compared using the log-rank test. Survival decreased significantly with increasing degree of abnormality (A----B----C) of albumin (p less than 0.001), ascites (p less than 0.001), bilirubin (p = 0.02) and nutritional status (p = 0.03). Survival was insignificantly influenced by neurological status (p = 0.11) probably because none of the patients had hepatic coma at entry into the trial. The five variables in CTC were combined to a score. With increasing score, the median survival time decreased from 6.4 years (score 5) to 2 months (scores 12 or more). Furthermore, the mortality from hepatic failure, gastrointestinal bleeding or hepatocellular carcinoma increased significantly with increasing score. CTC provide valuable and easily obtainable prognostic information in cirrhosis. However, CTC are inferior to a prognostic index based on multivariate analysis of prognostic factors.

Prognostic factors in cirrhosis identified by Cox's regression model

In a controlled clinical trial in 488 patients with chronic liver disease treated with prednisone or placebo, survival data were analyzed using Cox's proportional hazards model. A total of 162 variables were screened separately for prognostic and/or therapeutic effect by log-rank analyses, whereby 46 clinical, biochemical, serological, and histological variables were isolated. Another five variables traditionally found to be important in patients with liver disease were included. After extensively checking the assumptions of the model, the 51 variables were, by a step-wise procedure, reduced to a final model. It comprised, besides a treatment indicator, 12 variables with significant (p less than 0.05) prognostic or therapeutic effect. The following eight variables had a significant prognostic effect: sex, age, prothrombin, acetylcholinesterase, eosinophil leucocytes in liver parenchyma, liver cell necrosis, inflammation in liver connective tissue, and efferent veins in parenchymal nodules. A prognostic index based on the final model is formed allowing calculation of 5 years survival probability. The usefulness of the prognostic index was tested by a cross-validation method, and no statistical significant difference was found between the estimated and observed survivorship functions.

Conversion of micronodular cirrhosis into macronodular cirrhosis

The conversion from micro- to macronodular cirrhosis is claimed to be a general phenomenon. In this study, the conversion was quantitated by means of liver needle follow-up biopsies and autopsy in 156 patients followed in a controlled clinical trial of prednisone treatment in cirrhosis. In the initial biopsy, 75 patients were classified as micronodular cirrhosis, and of them, 68 had macronodular cirrhosis at autopsy indicating a conversion ratio of about 0.9 in 10 years. This may overestimate the true conversion ratio slightly since conversion in many cases only was demonstrated at autopsy where the diagnosis of macronodular cirrhosis is made with greater certainty than from a needle biopsy. The median time interval between the diagnosis of micro- and macronodular cirrhosis was 2.25 years which is a maximum estimate of the conversion time due to irregular spacing between biopsies (or biopsy and autopsy). No significant difference was found between the conversion time in females and males. The conversion was faster in patients not drinking alcohol compared to patients drinking alcohol, but the difference was not significant. Prednisone treatment tended to accelerate the conversion, but not significantly.

Main causes of death in cirrhosis

The main causes of 436 deaths among 532 patients with cirrhosis followed up for up to 16 years constituted liver failure (24%), liver failure with gastrointestinal bleeding (13%), gastrointestinal bleeding (14%), primary liver cell carcinoma (4%), other liver-related causes (2%), infections (7%), cardiovascular diseases (22%), extrahepatic malignancies (9%), and other non-liver-related causes (5%). Totally, 57% died of liver-related causes. A high frequency of liver-related death was found among patients with a short observation time, high biochemical activity, pronounced change in liver architecture, ascites, and other signs of a poor prognosis at the time of diagnosis. The findings favoured the hypothesis that cirrhosis of the liver is a disease with an initial active and a subsequent inactive phase. Half of the patients were treated with prednisone, but this had no detectable influence on the distribution of causes of or on the frequency of single causes of death as infections or gastrointestinal bleeding. The group of patients responding favourably to prednisone treatment with regard to survival (non-alcoholic women without ascites) showed causes of death not different from those of the total material.

The accuracy of the clinical diagnosis in acute hepatitis and alcoholic liver disease. Clinical versus morphological diagnosis

Microfilms were prepared from the case histories of 357 consecutive patients submitted to liver biopsy for the first time so that all information after the time of the liver biopsy was erased. The microfilms were assessed by four clinicians, and the pre-biopsy diagnostic proposals were graded according to the degree of certainty and were compared with the results of the liver biopsies. Out of 357 patients, 200 had a history of alcoholism, of whom 172 had alcohol-induced changes in the liver biopsies: 80 cases of alcoholic cirrhosis, 84 cases of steatosis, and 8 cases of alcoholic hepatitis without cirrhosis. In 65 of the 80 patients with biopsy-verified alcoholic cirrhosis the clinical pre-biopsy diagnosis was in agreement with the histological findings. In 51 cases in which the clinical diagnosis of alcoholic cirrhosis was given as moderately certain or very certain, 4 clinically incorrect diagnoses occurred. No incorrect diagnoses occurred in the 35 cases in which the clinicians claimed the greatest diagnostic accuracy. In the 84 patients with steatosis in the liver biopsies the clinicians felt uncertain or moderately certain about all but 2 patients, and 14 incorrect diagnoses occurred. In none of the 8 patients with histological alcoholic hepatitis without cirrhosis was a correct clinical diagnosis made. The clinical pre-biopsy diagnosis of acute hepatitis was in agreement with the results of the liver biopsies in 52 out of 57 patients. In 51 cases in which the clinical diagnosis of acute hepatitis was given as moderately certain or very certain, 1 clinically incorrect diagnosis occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasonography, computed tomography, and cholescintigraphy in suspected obstructive jaundice--a prospective comparative study

In order to compare their capacity to visualize the bile ducts, ultrasonography, computed tomography, and cholescintigraphy were performed in 56 consecutive jaundiced patients in whom extrahepatic cholestasis was clinically suspected. The predictions as to the patency of the large bill ducts were compared with the final diagnoses made on the basis of direct cholangiography together with autopsy, biopsy, operative findings, and the clinical course. Thirty-nine patients (70%) had obstructed bile ducts, and 17 (30%) had patent large bile ducts. Using a simple scoring scale with 112 points as the maximum, ultrasonography obtained 72 points, computed tomography received 56 points, and cholescintigraphy totalled 37 points. Nonsignificant trends were found in favor of ultrasonography as compared with computed tomography and of computed tomography as compared with cholescintigraphy (p greater than 0.05), whereas ultrasonography was significantly better than cholescintigraphy (p = 0.01). However, because computed tomography is expensive and may imply a higher number of secondary direct cholangiographies than ultrasonography, we recommend ultrasonography as the first choice for noninvasive bile duct visualization. Computed tomography is an alternative method, whereas cholescintigraphy cannot be recommended.

Oral testosterone load related to liver function in men with alcoholic liver cirrhosis

The relation between liver function and an oral testosterone load was examined in 42 consecutive patients with alcoholic liver cirrhosis. Administration of an oral load of 400 mg micronized free testosterone increased the serum concentration of testosterone (range, 31.9-694.4 nmol/l; median, 140.8 nmol/l) in male patients with alcoholic liver cirrhosis to significantly (P less than 0.01) higher levels than in male subjects without liver disease (range, 25.4-106.6 nmol/l; median, 61.5 nmol/l). The increase of testosterone after the load (log delta testosterone) in patients correlated inversely with galactose elimination capacity (r = 0.54; P less than 0.001), serum albumin (r = -0.53; P less than 0.001), plasma factor II + VII + X (r = 0.62; P less than 0.001), indocyanine green clearance (r = -0.71; P less than 0.001), and hepatic blood flow (r = -0.61; P less than 0.01) and correlated directly with wedged-to-free hepatic vein pressure (r = +0.54; P less than 0.01). The increase of testosterone after the load did not correlate significantly with sex hormone-binding globulin (r = +0.35; P greater than 0.05). It is concluded that the hepatic extraction of testosterone is significantly decreased in patients with alcoholic cirrhosis. This decrease seems to be due to decreased liver function, decreasing hepatic blood flow, and increased portosystemic shunting. Oral testosterone loading may therefore be of prognostic significance in patients with alcoholic liver cirrhosis.

Peritoneovenous shunt in treatment of ascites in patients with cirrhosis. A preliminary report with special reference to pathophysiology

Peritoneovenous shunts (LeVeen type) were implanted in seven patients with cirrhosis complicated by ascites refractory to diuretic treatment. Three patients died of gastrointestinal bleeding and hepatic coma 1 to 7 weeks after the shunt implantation. The patients who died were those with the most severely impaired liver and kidney function. In two of the four surviving patients (observation time, 5-24 months) the shunt was patent during the observation time, and ascites disappeared. In the other two the shunt closed, in one patient repeatedly following several re-implantations. Enhanced urinary sodium excretion was observed in patients with patent shunts. After disappearance of ascites, the splanchnic venous pressures became less deranged. Long-term change in plasma volume or circulating albumin mass could not be detected. A patent shunt increases the drainage from the peritoneal cavity, but detectable increment in the overall lymph drainage was only found in a patient with a very low pre-shunt value. The findings do not support the 'overflow' theory of ascites formation but rather the 'lymph imbalance' theory. For clinical evaluation of peritoneovenous shunting in the treatment of ascites a controlled clinical trial is essential.

The significance of the HBe system in an area highly endemic for hepatitis B virus

A group of 164 consecutive patients with chronic liver disease and 60 healthy HBsAg carriers were investigated in an area highly endemic for hepatitis B virus (HBV). Eighty-two of the 164 patients (50%) were found to be HBsAg-positive and only 39 (24%) had no HBV markers. A statistically significant correlation was found in the HBsAg-positive patients between the HBe system, their age and the time which had elapsed since their acute episode. Thus, the prevalence of HBeAg decreased with increasing age and with increasing time since their acute episodes. Furthermore, a statistically significant correlation was found between the presence of HBeAg and active chronic liver disease. Of the patients with chronic active hepatitis with or without cirrhosis, all patients below the age of 13 years were HBsAg-positive and 72% were also HBeAg-positive. The data suggest that the HBeAg-positivity in HBsAg carriers is of limited duration and that the seroconversion from HBeAg to anti-HBe is related to a histologically less active or inactive stage of the disease.

Endoscopic retrograde cholangiopancreatography and transhepatic cholangiography in patients with suspected obstructive jaundice. A randomized study

To establish principles for choosing between endoscopic retrograde and percutaneous transhepatic cholangiography, we randomized 52 consecutive jaundiced patients with clinically suspected obstructive jaundice. The bile ducts were visualized in 85% by the endoscopic and in 84% by the transhepatic route. A conclusive diagnosis was reached in 89% and 68% of the patients, respectively, but the difference is not significant (0.10 less than P less than 0.20). If the planned type of cholangiography failed, the other method was tried. By comparing the total numbers of investigations, a conclusive diagnosis was achieved in 91% by endoscopic and 69% by transhepatic route, which is significantly different (P less than 0.05). We therefore prefer to do endoscopic cholangiography initially with transhepatic cholangiography as the complementary method.

Prednisone and chronic liver disease. II. Clinical versus morphological criteria for selection of patients for prednisone treatment

A prospective, unblinded, randomized trial of treatment of cirrhosis and chronic aggressive hepatitis (CAH) with prednisone included 484 patients who were divided using both the clinical criteria: non-alcoholic females without ascites, and the morphological criterion: presence of a liver biopsy showing CAH. A total of 164 patients (34%) satisfied the three clinical criteria and biopsies from 95 patients (20%) showed CAH. By a cross-tabulation method between the two sets of criteria, four groups were formed. Evaluation of the treatment effect by means of relative death rate showed that the clinical criteria identified both a group of patients with a beneficial effect of prednisone (p less than 0.05) and a group with a harmful effect of the treatment (p less than 0.05). Patients with CAH also had a significant beneficial treatment effect, but patients without CAH showed only an insignificantly harmful effect of treatment. Patients fulfilling both sets of criteria had a beneficial effect of prednisone (p less than 0.05) and patients lacking both sets had a significantly harmful treatment effect. A significantly better survival was found in patients satisfying the clinical criteria without CAH in the biopsy than in patients with CAH and not fulfilling the clinical criteria (p = 0.03). In both the groups of patients with disagreement between the two sets of criteria, a trend towards a beneficial effect of prednisone was found. It is concluded that the simple clinical criteria in comparison with the histological criteria identify a larger group of patients with a beneficial effect of treatment.

Prednisone treatment of chronic liver disease. I. Chronic aggressive hepatitis as a therapeutic marker

A liver biopsy material comprising 477 biopsies from 477 patients included in a prospective, unblinded, randomized trial of treatment of cirrhosis with prednisone has been re-evaluated using new and more restrictive histological criteria for the diagnosis of cirrhosis and chronic aggressive hepatitis (CAH). The material was divided according to the likelihood of cirrhosis being present: (A) cirrhosis (287 patients), (B) probably cirrhosis (101 patients) and (C) compatible with but not diagnostic for cirrhosis (89 patients). Each group was further divided according to the presence (I) or absence (II) of CAH. A total of 98 patients fulfilled the histological criteria for CAH. The effect of prednisone concerning survival was evaluated in each group. In the total group of patients with CAH a significant beneficial effect of prednisone was found (p = 0.04). Among these patients the subgroup with cirrhosis in addition (group I A) also showed a significant effect of prednisone, while groups I B and I C only had a trend towards a beneficial effect (p = 0.44 and p = 0.36, respectively). In patients without CAH in the biopsy (Group II, A + B + C), no effect of prednisone was seen although a trend towards a harmful effect was found in patients with cirrhosis (Group II A). Control patients with CAH in all three subgroups had an insignificantly shorter survival than patients without CAH. All the CAH groups significantly more often included female patients with no history of alcoholism and a lower frequency of spider naevi. In addition, the CAH groups were more active as judged by biochemical and histological variables. It was further disclosed that the presence of large piecemeal necroses indicated a favourable effect of prednisone treatment, while alcoholism, ascites and male sex acted as indicators for an unfavourable treatment effect.

Fatal outcome after jejunoileal bypass for obesity

A review of all literature on jejunoileal bypass for obesity disclosed 282 deaths, corresponding to a mortality rate of 4.2 percent. This rate has been fairly constant through the last 8 years. The causes of death and the postoperative duration are quantified. Pulmonary embolism, mostly early, and liver disease, sometimes late, dominate among the numerous causes of death. Details are too scarcely reported to allow guidance to better results.

Aspects of the natural history of gastrointestinal bleeding in cirrhosis and the effect of prednisone

The natural history of gastrointestinal bleeding in cirrhosis has been studied using prospectively collected data of 532 patients included in a randomized clinical trial with a regular follow-up of up to 12 yr. Of the total 199 patients who experienced gastrointestinal bleeding, 95 (48%) bled from esophageal or gastric varices, 67 (34%) bled from peptic ulcer or gastritis, and 37 (18%) had either insufficient evidence of the source (33) or mixed sources (4). In the total group of patients the cumulative percentage of patients in whom varices had been demonstrated of patients in whom varices had been demonstrated by radiography increased from 12 to 90 in 10 yr, while that of bleeding from varices increased from 7 to 40. In 104 patients who bled for the first time during the trial period (trial bleeding patients) the median number of bleeding episodes was one (range 1-8). In these patients the fatality from bleeding from varices was 82%. The risk of rebleeding from varices was 81%, and 4 yr after the first bleeding the cumulative survival had decreased to less than 10%. Rebleeding was significantly less frequent and survival significantly higher in patients bleeding from sources other than varices. Prednisone reduced the occurrence rate of varices, bleeding from varices, and death from bleeding varices in nonalcoholic females without ascites, 40% of whom fulfilled the histologic criteria of chronic active hepatitis. Prednisone significantly increased the occurrence rate of varices inpatient with ascites and of bleeding from varices in alcoholic patients. Prednisone significantly increased the occurrence rate of peptic ulcer in males and in patients without chronic active hepatitis.

Accuracy of direct cholangiography by endoscopic or transhepatic route in jaundice--a prospective study

An exact anatomic diagnosis of bile-duct obstruction is a prerequisite for selecting the appropriate management. In a prospective study on patients with clinically suspected obstructive jaundice, the results of direct cholangiography--by endoscopic retrograde or, alternatively, by transhepatic route--were compared with operative findings or liver biopsy or both. Final diagnoses were based on autopsy, operative biopsy, and clinical course. The study included 105 patients, 90 of whom underwent surgery, and allowed a blind and independent comparison between cholangiography and operative findings. The predictive value of a positive test, i.e., cholangiographic visualization of obstruction, was 0.99 and the predictive value of a corresponding negative test was 0.90, with the final diagnoses as reference. For the operated patients the predictive values were calculated as to obstruction (positive test 0.99, negative test 0.89), malignancy (positive test 0.92, negative test 0.89), and common duct stones (positive test 0.96, negative test 0.98). Thus, laparotomy can be avoided in patients in whom direct cholangiography shows no obstruction or an appropriate nonoperative procedure, like transhepatic insertion of a stent or endoscopic biliary surgery elected.

Gamma-glutamyltransferase, aspartate aminotransferase and alkaline phosphatase as markers of alcohol consumption in out-patient alcoholics

Serum activity of gamma-glutamyltransferase, aspartate aminotransferase and alkaline phosphatase were determined in 316 patients attending an out-patients clinic for treatment of alcoholism. The activity of gamma-glutamyltransferase was raised in 34% and that of aspartate aminotransferase and alkaline phosphatase in 18% and 7%. Neither the activity of gamma-glutamyltransferase, aspartate aminotransferase nor alkaline phosphatase showed any significant (P greater than 0.05) correlation with the history of alcohol consumption. The activities of gamma-glutamyltransferase and aspartate aminotransferase were raised significantly more often in patients with recent alcohol consumption than in patients who had abstained for more than 9 days. The concentration of alkaline phosphatase was not significantly (P greater than 0.05) different in these groups. The predictive value of raised and normal activities of gamma-glutamyltransferase, in deciding whether a patient had had recent alcohol consumption or not, was not superior to the predictive value of raised and normal activities of aspartate aminotransferase.

Clinical relevance of restrictive morphological criteria for the diagnosis of cirrhosis in liver biopsies

Material obtained by needle biopsy of the liver from 532 patients with cirrhosis who had previously been examined has been re-evaluated using new and more restrictive histological criteria for the diagnosis of cirrhosis. The material was divided into four main groups: (A) cirrhosis, 287 biopsies; (B) probably cirrhosis, 101 biopsies; (C) compatible with but not diagnostic for cirrhosis, 89 biopsies; and (D) probably not cirrhosis, 11 biopsies. Group E consisted of 44 cases where no or insufficient material was available. The survival curves of the groups were significantly (P less than 0.05) different, with group D having the best survival followed by C, B and A. Clinical and laboratory manifestations of cirrhosis (more than five spider naevi, presence of ascites, daily alcohol intake of more than 50 g) were found significantly (P less than 0.05) more often among patients from group A, followed by patients from groups B, C and D. It is concluded that the more restrictive histological criteria for the diagnosis of cirrhosis in liver biopsies have clinical relevance, due to the prognostic and therapeutic implications of the diagnosis. The study also underlines the importance of specifying the criteria used when studies of patients with cirrhosis are reported.