Extrahepatic complications of chronic cholestasis: current diagnosis and treatment

Pruritus, fatigue and osteoporosis are the main symptoms of the extra hepatic manifestations of chronic cholestasis that affect patients' quality of life. Pruritus affects more often female patients, varies as intensity during a day and for longer period of time, typically can be localized on the palms of hands and soles of feet or can be generalized. Pruritus can be treated with anions resines exchange--cholestiramine, the pregnanne X receptor agonist Rifampicine, Naltrexone. Liver transplantation can be considered if severe pruritus remains refractory to all medical treatments. Fatigue is the most disabling complain in chronic colestasis. No specific therapies are available for fatigue and liver transplantation doesn't improve it. Osteoporosis and the risk of fractures are more severe with the duration and severity of hepatic disease. For treatment are recommended regular physical exercise, vitamin D and Ca supplimentation and bisphosphonates (Alendronate 70 mg/week) in severe cases. Only patients with atherosclerotic risk and hyperlipemia can be treated with statines. Fat soluble vitamin supplementation can be administrated only in symptomatic and proved vitamin deficiency.

[Eosinophilic esophagitis--from a rare pediatric disease to the forefront of adult gastroenterology]

Eosinophilic esophagitis (EE) is a disease whose presence has exploded in clinical practice. Because of its relative novelty, the epidemiology, pathogenesis, clinical manifestations, diagnosis and treatment of EE are constantly evolving. EE was first recognized as a disease predominantly of children, but the publications in the last few years describe it like an adult disease, too. It is not known if its frequency is truly increasing in an antigen underexposed society or the disease was previously not recognized. The diagnosis requires the histologic finding of more than 20 eosinophils per high powered field in esophageal squamous mucosa. The specific antigens that initiate EE are unknown, but both food and aeroallergens are involved. The mechanisms by which EE induces esophageal dis-motility, chronic inflammation with fibrosis, and stricture formation are still unclear. The mucosa of the patients affected by EE contains increased numbers of CD8 lymphocytes, tumor necrosis factor alpha, I1-5 and eotaxin. The main symptoms in adult are: dysphagia and food impaction. Endoscopy commonly reveals strictures, mucosal rings, linear furrowing, corrugation, and white plaques. The common treatment regimens in children and adults involve the ingestion of topical corticosteroids.

Extragastric manifestations of Helicobacter pylori infection

The role of Helicobacter pylori (HP) in some digestive diseases (gastritis, ulcer, gastric cancer, MALT lymphoma) is well known. It has been suggested relatively recently that infection with HP can be involved in various extra-digestive conditions: respiratory disorders (chronic obstructive pulmonary disease, bronchiectasis, lung cancer, pulmonary tuberculosis, bronchial asthma); vascular disorders (ischaemic heart disease, stroke, primary Raynaud phenomena, primary headache); autoimmune disorders (Sjogren syndrome, Henoch-Schonlein purpura, autoimmune thrombocytopenia, autoimmune thyroiditis, Parkinson's disease, idiopathic chronic urticaria, rosacea, alopecia areata); other disorders (iron deficiency anaemia, growth retardations, liver cirrhosis). Case studies, small patient series and non-randomized trials that have shown a beneficial effect of HP eradication in different conditions are not convincing. According to Mastricht III the only conditions where HP eradication is indicated are immune thrombocytopenic purpura and iron deficiency anaemia.

[Variceal upper digestive bleeding--an ever new complication in liver cirrhosis]

Variceal bleeding in liver cirrhosis is a medical emergency with a high mortality. The therapeutic options in patients with portal hypertension are: treatment of acute bleeding from varices, prevention of the first bleeding episode and prevention of rebleeding. Treatment of acute bleeding from varices includes: blood volume restitution, use of antibiotics for preventing bacterial infections, vasoactive drug therapy (terlipressin, somatostatin, vapreotide, octreotide), endoscopic band ligation for acute esophageal bleeding and endoscopic therapy with tissue adhesive (cyanoacrylate) for acute gastric variceal bleeding. Endoscopic treatments are best used in association with pharmacological therapy. In primary prophylaxis non-selective beta- blocker therapy and endoscopic band ligation are useful. Beta blockers, band ligation or both should be used for prevention of recurrent bleeding. In patients who fail endoscopic and pharmacological treatment for prevention of rebleeding TIPS and transplantation should be considered.

[Under-evaluated extrahepatic manifestations of cholestasis]

Biliary stasis can occur in many different diseases. Pruritus, metabolic bone disease, deficiencies of fat-soluble vitamins, steatorrhea, hyperlipidemia and fatigue represent the major extra-hepatic manifestations of cholestatic liver disease that considerably affect the patient's quality of life. The present article reviews pathogenetic and clinical aspects of and current therapeutic approaches to extra-hepatic manifestations of cholestatic liver disease.

Osteoporosis in liver cirrhosis--overview

Osteoporosis can occur as a result of liver cirrhosis. The pathogenesis of reduced bone mineral density in liver cirrhosis is multifactorial. It can be caused by alterations in calcium and vitamin D homeostasis, as well as nutritional and dietary factors. Dual-energy X-ray absorptiometry (DXA) has become the gold standard in assessing bone mineral density in patients with liver cirrhosis. In such cases, patients can be treated with calcium and vitamin D supplements, bisphosphonates and hormonal replacement therapy (HRT).

Temporomandibular joint ankylosis. A possible complication in juvenile psoriatic rheumatism

The authors present a rare case of bilateral temporomandibular joint ankylosis secondary to polyarticular juvenile psoriatic arthritis in a 24 year-old man. The patient first presented with arthritis of his right elbow joint at the age of 9, followed by involvement of the distal inter-phalangeal joints of his right foot and both sacroiliac joints. Serum rheumatoid factor was not detected. At the age of 16 he developed psoriatic lesions affecting his nails and skin. By the age of 20, clinical and radiological evidence of arthritis was detected in his temporomandibular joint (TMJ). Subsequently, the patient developed bilateral TMJ ankylosis over a period of 4 years. The patient was managed by bilateral resection of the ankylosis bone blocks, mobilization of the mandible and interposition of Dacron material between the two neo-articular surfaces. 10 months postoperatively the patient maintained an inter-incisal distance of 3 cm. Postoperative mechano-therapy was hindered by the limited use of the patients' hands.

[Gastroesophageal reflux involvement in ENT disorders]

It is admitted that gastroesophageal reflux patients may presents ear, nose, and throat (ENT) symptoms and signs, condition known as laryngo-pharyngeal reflux. It is estimated that as many as 10% of patients presenting to an ENT specialist have a clinical condition that might be attributed to gastroesophageal reflux. The diagnosis is challenging since no laryngeal signs are pathognomonic. A combination of ENT and esophageal symptoms and signs may suggest the necessity of further investigations. Adapted 24h pH study or better an esophageal impedance study may reveal the involvement of gastroesophageal reflux. Alternatively, a short trial with omeprazole or another proton pump inhibitor may be the simplest way for diagnosis. The standard treatment for gastroesophageal reflux is the valid treatment for these patients.