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Current Issue

January March, 2006

Vol. 5 Issue 1

On the cover: Official Journal of the Mexican Association of Hepatology

EDITORIAL

CONCISE REVIEW

  • The use of TIPS in chronic liver disease Florence Wong Page 5-15

    The development of cirrhosis and portal hypertension in the natural history of chronic liver disease is associated with many complications. A transjugular intrahepatic portosystemic stent shunt (TIPS) is a metal prosthesis that has been shown to be very effective in lowering sinusoidal portal pressure, and therefore is effective in the management of complications of cirrhosis, especially those related to portal hypertensive bleeding and sodium and water retention. In patients with acute variceal bleeding not responding to pharmacologic and endoscopic treatments, a reduction of the hepatic venous pressure gradient to < 12 mmHg or by > 20% with TIPS has been shown to be effective in controlling the acute bleed and in preventing rebleeding. For stable patients whose acute variceal bleed is controlled, TIPS is equal to combined beta-blocker and band ligation in the prevention of recurrent variceal bleed. TIPS is also more effective than large volume paracentesis in the control of refractory ascites, and may confer a survival advantage over repeated large volume paracentesis. TIPS has also been used in the management of other complications related to portal hypertension including ectopic varices, hepatic hydrothorax, and hepatorenal syndrome with some success, but experience is still rather limited. Miscellaneous uses include treatment of Budd Chiari Syndrome, portal hypertensive gastropathy and hepatopulmonary syndrome. Careful patient selection is vital to a successful outcome, as patients with severe liver dysfunction tend to die post-TIPS despite a functioning shunt. All patients who require a TIPS for treatment of complications of cirrhosis should be referred for consideration of liver transplant.

  • Hepatocellular carcinoma. An overview Daniel Motola-Kuba, Daniel Zamora-Valdés, Misael Uribe, Nahum Méndez-Sánchez Page 16-24

    Hepatocellular carcinoma is a common malignancy affecting approximately one million people around the world every year. The incidence is low in the occidental world and high in locations such as Southeast Asia and sub-Saharan Africa. Hepatocellular carcinoma primarily affects old people, reaching its highest prevalence among those aged 65 to 69 years old. Chronic infection by the hepatitis B virus is the most common cause of this disease. Other important causes are cirrhosis, chronic viral hepatitis (hepatitis C virus, and hepatitis B plus D viruses), alcohol abuse, obesity, hemochromatosis, alfa1-antitripsin deficiency, and toxins similar to aflatoxin. In most cases, hepatocellular carcinoma is asymptomatic and has a low life expectancy. This article presents a review of the most important epidemiological, diagnostic and treatment data about this disease.

ORIGINAL ARTICLES

  • Pentoxifylline does not prevent neither liver damage nor early profibrogenic events in a rat model of non-alcoholic steatohepatitis Paula Vial, Arnoldo Riquelme, Margarita Pizarro, Nancy Solís, Juan Andrés Madariaga, Gloria Aguayo, Ignacio Duarte, Alejandro Soza, Luigi Accatino, Marco Arrese Page 25-29

    Background: Non-alcoholic steatohepatitis (NASH) is a metabolic disorder of the liver, which may evolve to fibrosis or cirrhosis. Pentoxifylline (PTX) has been postulated to act as an antifibrogenic agent able to inhibit hepatic stellate cell proliferation and collagen synthesis in vitro. Short-term studies suggest beneficial effects of PTX in experimental models of NASH. Aim: To study whether PTX can influence liver fibrogenesis in an animal model of NASH. Methods: To induce NASH, a choline-deficient diet (CDD) was given to Sprague- Dawley rats for 8 weeks. Rats were allocated to two experimental groups one receiving PTX (9 mg/kg/day) in drinking water. Control rats received a choline-supplemented diet. Biochemical and histological evaluation of fatty liver was performed by conventional techniques. In addition, mRNA levels of Pro-collagen I and transforming growth factor beta-1 were assessed by semi-quantitative RT-PCR and stellate cell activation by α-actin immunofluorescence stain. Results: After 8 weeks CDD induced a marked elevation of serum aminotransferases, a marked decrease in both hepatic and biliary glutathione and a severe fatty liver infiltration with mild histological inflammation and fibrosis. A significant increase in mRNA levels of both Pro-collagen I and TGFβ-1 was seen after CDD feeding. No differences were seen between rats receiving PTX and rats on CDD diet alone with regard to the biochemical, morphological or molecular alterations induced by the CDD. Conclusion: PTX does influence neither liver injury nor early profibrogenic events in the CDD model of NASH.

  • Nonalcoholic steatohepatitis (NASH) with diabetes: predictors of liver fibrosis D.N. Amarapurkar, A.D. Amarapurkar, N.D. Patel, S. Agal, R. Baigal, P. Gupte, S. Pramanik Page 30-33

    Introduction: Nonalcoholic steatohepatitis (NASH) is common cause of chronic liver disease strongly associated with insulin resistance leading to fibrosis. No factors that determine increasing fibrosis have been well recognized. Liver biopsy is considered as gold standard for diagnosis and prognosis of this disease. Aim: To identify independent predictive factors of liver fibrosis in patients of NASH with diabetes. Material and methods: During the year 2001 and 2002 total 36 patients of NASH associated with diabetes were included in the study. The diagnosis of NASH was based on 1) presence of steatosis, inflammation and ballooning on liver biopsy 2) Intake of alcohol < 20 gm of ethanol per week 3) Exclusion of other liver diseases. Patients were labeled as diabetic if random glucose was > 200 mg/dL or fasting glucose more than 140 mg/dL on 2 occasion or having documented use of oral hypoglycemic medications or insulin. Clinical and biochemical variables such as age, sex, obesity, hypercholesterolemia, AST, ALT and AST: ALT were examined for predictors of fibrosis using univariate and multiple regression statistical analysis. Obesity was defined as BMI > 30 for both males and females. Hypercholesterolemia was considered when fasting cholesterol level was above 95th percentile of normal on at least 2 occasions. Fibrosis was noted as present or absent on histology. Results: Of 36 patients 17 were females and 19 males with age range of 25 to 75 years, mean age 50.8 years. Fibrosis was present in 11 (30.5%) and absent in 25 (69.4%) patients. Univariate and multiple correlations co-efficient failed to detect significant association of fibrosis with above mentioned variables. However multiple regression and logistic regression analysis (MLR) detected statistical significance for AST, ALT levels and AST: ALT ratio between fibrosis and no fibrosis in 80.6% patients. Conclusion: There is no definite noninvasive test that helps to predict liver fibrosis however AST, ALT levels and AST: ALT ratio may help to determine the fibrosis in patients of NASH with diabetes in majority of cases.

  • Occult hepatitis B in mexican patients with HIV, an analysis using nested polymerase chain reaction Rodrigo Torres-Baranda, Blanca E. Bastidas-Ramírez, Montserrat Maldonado-González, Laura V. Sánchez Orozco, Eduardo Vázquez-Vals, Eduardo Rodríguez-Noriega, Arturo Panduro Page 34-40

    Hepatitis B virus infection (HBV) with undetectable levels of HBsAg, has been named occult HBV infection and observed in immunosuppressed patients. The aim of this study was to determine the frequency of occult HBV infection in patients with HIV from the West of México, using a combination of serological markers and nPCR. Thirty eight HIV/AIDS patients, 32 men (84.2%) and 6 (5.8%) women, without liver damage related symptoms were studied. HBV coinfection was observed in 10 (26.3%) patients; while only 3 (7.9%) of them were positive to HBsAg. Thus, 7 (18.4%) occult HBV infected patients could be assessed in this population. One (10%) patient with occult HBV infection was positive to anti-HBs, in spite of the reinfection protection attributed to this serological marker. Anti-HBc was detected only in 2 (20%) patients with occult HBV infection. No significant association could be established between occult HBV infection and CD+4 cell count, biochemical, clinical parameters, AIDS stage, or any other risk factor. This study suggest that determination of HBV DNA utilizing highly sensitive techniques, as nPCR, should be performed to detect occult HBV infection, even in the absence of anti-HBc in HIV/ AIDS patients, in order to have a reliable diagnosis, prevent HBV dissemination and acute exacerbation of chronic hepatitis B or even fulminant hepatitis. To our knowledge this is the first study of occult HBV infection in Mexican patients with HIV. However, further studies are necessary in order to determine HBV genotypes and its relationship with evolution and clinical manifestation of the disease.

  • Hepatic tuberculosis in absence of disseminated abdominal tuberculosis Chirag S. Desai, Anand G Joshi, Philip Abraham, Devendra C. Desai, Ramesh B. Deshpande, Anita Bhaduri, Sudeep R. Shah Page 41-43

    Liver involvement in tuberculosis in absence of miliary tuberculosis is rare. This study was performed to analyse the spectrum and response to treatment of hepatic tuberculosis in the absence of miliary abdominal tuberculosis. Retrospective analysis of seven cases of hepatic tuberculosis without miliary abdominal tuberculosis who presented at the single tertiary referral center were analyzed. All patients presented with fever and hepatomegaly. Five of them had pain in upper abdomen and vomiting. HIV serology was positive in one patient. All patients had normocytic normochromic anaemia, raised erythrocyte sedimentation rate (Mean 65). Mild elevation of liver enzymes and low albumin (Mean 2.4 gm%) with reversal of albumin globulin ratio (Mean 0.6) were seen in all. Two had jaundice. Prothrombin time was normal in all and lactate dehydrogenase values were elevated in all (Mean 794 IU/L). On ultrasonography, 2 had multiple hypodense lesion, 1 had coarse echotexture of liver, 1had hyperechoic pattern and 3 had just hepatomegaly. Complete resolution of liver lesions on treatment with 4-drug anti-tuberculosis drug chemotherapy was seen. In conclusion, liver tuberculosis has protean manifestations with nonspecific alteration of liver function tests and is best diagnosed on liver biopsy. Overall response to therapy is satisfactory.

  • Bile duct injuries related to misplacement of "T tubes" Miguel Angel Mercado, Carlos Chan, Héctor Orozco, Alexandra Barajas-Olivas, José Manuel Villalta, Ismael Domínguez, Javier Eraña, Fernando Poucel Page 44-48

    Introduction: T tubes can be placed in the bile ducts either open or laparoscopically for several reasons such as: extraction of stones, biliary reconstruction after liver transplant and in end-to-end anastomosis in iatrogenic injuries. Inadequate placement of the T tube, long term stay and technical difficulties that can affect the outcome, can lead to an injury that usually requires a biliodigestive reconstruction. Methods: In a 15-year period (1990?2005) a total of 343 patients have been referred to our university hospital for biliary reconstruction. Files of those patients in which the injury was due to misplacement of a T tube or associated with a long-term stay were reviewed. We evaluated the type of injury, technique used for the reconstruction, longterm staying of the T tubes (1?6 months), hospital in stay, long term outcomes as well as associated comorbidities. Results: In 42 cases a biliary injury related to a T tube was identified (13%). All the injuries were classified as Strasberg E, with demonstration of a fistula (internal or external); 18 to the duodenum, 5 to the jejunum ? ileum and 3 to the colon. A hepatojejunostomy was done to all patients; the duodenum and small gut fistulas were closed and in the 3 cases with colonic injury a right hemicolectomy was performed. The postoperative evolution was adequate without major complications but with a longer hospital stay. In 39 of the 42 patients (92%), good postoperative results were obtained. Only one case required a new surgery (22 months after the first one), due to recidivant cholangitis. Conclusion: Inadequate placement of the T tubes and long-term stay can produce complex biliary injuries with associated comorbidities such as fistulas to the adjacent viscera. Placement of T tubes need a careful surgical technique and their indication must be carefully assessed.

IMAGES IN HEPATOLOGY

CASE REPORTS

  • A 57 year old man with chronic renal failure and cardiac tamponade who developed ischemic hepatitis Eric López-Méndez, Eduardo López-Méndez, Iván López-Méndez, Pablo Hernández-Reyes, Jaime Galindo-Uribe, Vanessa Angulo-Ramírez, Lourdes Ávila-Escobedo, Misael Uribe Page 50-52

    Ischemic hepatitis is an infrequent entity, usually associated with low cardiac out put. We present a case of a 57 year-old man with chronic renal failure and cardiac tamponade who developed elevation of serum alanine transferase level of 5,054 U/L, aspartate transferase level of 8,747 U/L and lactate dehydrogenasa level of 15,220 U/L. The patient developed hepatic encephalopathy and hypoglycemia. Liver Doppler ultrasound was normal. He was seronegative for HBV and HCV, drugs list was scrutinized for the names of known hepatotoxins. Ischemic hepatitis was diagnosed. The hypoglycemia and encephalopathy were solved and the patient was discharged with normal transaminase levels. Ischemic hepatitis is typically preceded by hypotension, hypoxemia, or both. As one would expect, the most common cause of sustained systemic hypotension is cardiovascular disease. Liver biopsy is usually not necessary. The best treatment is support measures and correct the underlying condition.

  • Orthotopic liver transplantation in an adult with situs inversus: an easy way to fit the liver Sergio Hoyos, Carlos Guzmán, Gonzalo Correa, Juan-Carlos Restrepo, Hernán Franco, Andres Cardenas Page 53-55

    Situs inversus (SI) is a rare congenital disorder with a complete mirror image of thoracic and abdominal organs. In adults with SI and decompensated cirrhosis experience with liver transplantation is limited. Orthotopic liver transplantation (OLT) in an adult with cirrhosis using a technique where the recipient liver was placed using a 90-degree rotation of the graft was previously reported by Klintmalm et al, however no other reports using this technique have been described. We report a case of a 41 year-old man with situs inversus and decompensated cirrhosis who successfully underwent OLT using this technique. The donor liver was rotated 90-degrees towards the left and easily fitted into the recipients' fossa with the left lobe pointing toward the left lower quadrant. The patient had an uneventful recovery and has been followed for 21 months without any complications. This technique has the advantage of preventing compromise of the size of the donor liver, permits an easy reconstruction of vascular and biliary tree and in this case was associated with an excellent outcome.

  • Drug induced liver injury secondary to interferon-β (IFN-β) in multiple sclerosis V. Byrnes, N. Afdhal, T. Challies, P.E. Greenstein Page 56-59

    Post marketing studies of Interferon-β (IFN-β) therapy in multiple sclerosis (MS) have demonstrated surprisingly high rates of hepatotoxicity. Grade 3 hepatotoxicity (AST and ALT > 5 to 20 upper limit normal) or higher has been observed in as many as 1.4% of MS patients on IFN-β. We report three cases of IFN-β induced hepatitis in MS and discuss the pathology findings and possible mechanisms of drug-induced liver injury.

The Official Journal of the Mexican Association of Hepatology, the Latin-American Association for the Study of the Liver and the Canadian Association for the Study of the Liver

ALEH Hepatología CASL ACEF Médica Sur
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