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Current Issue

January March, 2002

Vol. 1 Issue 1

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

FROM THE EDITOR

Welcome to The Annals of Hepatology from other Journal Editors

OBITUARY

CONCISE REVIEW

  • Treatment of nonalcoholic fatty liver disease Paul Angulo Page 12-19

    Treatment of patients with nonalcoholic fatty liver disease (NAFLD) has typically been focused on the management of associated conditions such as obesity, diabetes mellitus and hyperlipidemia. NAFLD associated with obesity may resolve with weight reduction, although the benefits of weight loss have been inconsistent. Appropriate control of glucose and lipid levels is always recommended, but not always effective in reversing the liver condition. Results of pilot studies evaluating ursodeoxycholic acid, gemfibrozil, betaine, N-acetylcysteine, vitamin E (α-tocopherol), metformin and thiazolidinedione derivatives suggest that these medications may be of potential benefit for patients with NAFLD. These medications, however, need first to be tested in well-controlled trials with clinically relevant end-points and extended follow up. A better understanding of the pathogenesis and natural history of NAFLD will help to identify the subset of patients at risk of progressing to advanced liver disease, and hence, those patients who should derive the most benefit from medical therapy.

  • Intrahepatic cholestasis of pregnancy: Changes in maternal-fetal bile acid balance and improvement by ursodeoxycholic acid Dora Brites Page 20-28

    Intrahepatic cholestasis of pregnancy (ICP) is a disease characterized by generalized pruritus and biochemical cholestasis that appears typically during the last trimester of gestation. The most predictive and accurate markers for diagnosis and follow-up of ICP are increased total bile acid levels (above 11,0 μmol/L), enhanced cholic acid percentage (above 42%) and decreased glycine/taurine bile acid ratio (below 1.0). Although essentially benign for the mother, evidence associates ICP with fetal poor prognosis resulting from increased transfer of bile acids from mother to fetus, who showed reduced ability to eliminate bile acids across the placenta. Those conditions lead to an accumulation of bile acids in the cord blood serum, meconium and amniotic fluid that may account for a diminished fetal well-being and sudden intra-uterine death by ICP. Ursodeoxycholic acid (UDCA) treatment was shown to reduce the bile acid content in the fetal compartment, while restoring the ability of the placenta to carry out vectorial transfer of these compounds towards the mother, decreasing bile acid levels in maternal serum and its passage to the fetus. In addition, UDCA administered to the mother also lowers the amount of bile acids present in colostrum without either increasing the UDCA concentration or causing major changes in lithocholic acid levels, further supporting the safety of UDCA in late pregnancy. Therefore, it is tempting to indicate UDCA as a first choice therapy for ICP as much as relevant aspects of fetal outcome may also be improved. This review focuses on the altered bile acid profiles in maternal and fetal compartments during ICP and its recovery by UDCA administration. Further elucidation of the precise mechanisms of action of UDCA and its therapeutic potential in improving fetal prognosis could result in the approval of UDCA for ICP treatment.

ORIGINAL ARTICLES

  • Treatment of cirrhotic tense ascites with Dextran 40 versus albumin associated with large volume paracentesis: a randomized controlled trial. Diego García Compean, Pierre Blanc, Dominique Larrey, Jean-Pierre Daures, Jacques Hirtz, Eduardo Mendoza, Héctor Maldonado, Henri Michel Page 29-35

    Intravenous albumin infusion prevents complications after large-volume paracentesis (LVP), particularly paracentesis-induced circulatory dysfunction (PCD), and improves patient survival. However, albumin is expensive. We compared a low-molecular weight dextran (Dextran-40) with albumin in treating LVP in cirrhotic patients with tense ascites. Sixty-nine cirrhotic patients were included and 96 LVPs were performed. Any repeat punctures on the same patient were at least three months apart. Patients were randomized to receive either i.v. Dextran-40 infusion (Group I, n = 48) or i.v. albumin infusion after LVP (Group II, n = 48). Clinical, biochemical, and hormonal evaluations were done before and after LVP. Patients were followed up for the detection of any recurrence of ascites or complications.The two groups were similar in age, sex, and etiology of cirrhosis, and in the volumes of ascites recovered. Significant decreases in mean arterial pressure were observed in both groups 24 and 48 h after LVP. Urine volumes increased significantly at 24 h in both groups (p < 0.05), but remained high only in Group I. Plasma renin activity and aldosterone concentrations increased in both groups 48 h after LVP, but they were more marked in Group I. Complications developed in 17 % of patients treated with Dextran-40 and in 23 % treated with albumin (p > 0.05). Ascites recurrence rates and survival were similar in the two Original Article Treatment of cirrhotic tense ascites with Dextran-40 versus albumin associated with large volume paracentesis: a randomized controlled trial. Diego García-Compean MD,1,4 Pierre Blanc MD,1 Dominique Larrey MD,1 Jean-Pierre Daures MD,2 Jacques Hirtz MD,3 Eduardo Mendoza MD,4 Héctor Maldonado MD,4 Henri Michel MD1 groups. In conclusion, Dextran-40 was thus not as efficacious as albumin for preventing PCD.

  • Obesity-related non-alcoholic steatohepatitis and TGF-β1 serum levels in relation to morbid obesity Ricardo N Sepúlveda-Flores, Lucio Vera-Cabrera, Juan P. Flores-Gutiérrez, Héctor Maldonado-Garza, Ricardo Salinas-Garza, Pablo Zorrilla-Blanco, Francisco J Bosques-Padilla Page 36-39

    Non-alcoholic steatohepatitis (NASH) can vary from mild hepatic inflammation and steatosis to cirrhosis, and is most frequently associated with obesity, Type 2 diabetes mellitus, hypertension, and the female gender. The prevalence of fatty liver and NASH in the general population is 20% and 3%, respectively. In Western countries, 15–20% of the population is obese and 74–90% of them exhibit fatty changes in liver biopsies. We assessed the prevalence of NASH in morbidly obese patients and evaluated serum TGF-β1 concentrations in different stages of liver fibrosis. Thirty-five obese patients were evaluated, nine male and 26 female. Their mean body mass index (BMI) was 43.62 ± 7.92 kg/m2. Liver biopsies were evaluated by light microscopy; graded and staged according to Brunt’s system. Serum obtained from patients was used to detect TGF- β1 concentrations by an ELISA method. Serum alanine transaminase (ALT) levels were elevated in four of the patients and the mean level was 49.98 ± 94.7 (8–65 IU/L). NASH was diagnosed in 32 (91%) of the biopsies, and the most common pattern seen was mixed, predominantly macrovesicular steatosis. Some degree of fibrosis was seen in 34 (97%) of the biopsies and 22 (63%) were at stage 2 (range 1–3). Serum concentrations of TGF-β1 had no relationship with the stages of fibrosis. In conclusion, NASH and fibrosis are common in our obese patients, as observed in other studies. TGF-β1 may play a key role in liver fibrogenesis.

  • Zinc sulfate inhibits the enterohepatic cycling of unconjugated bilirubin in subjects with Gilbert?s syndrome Nahum Méndez-Sánchez, Mariana Martínez, Verónica González, Ernesto Roldán Valadez, Miguel A Flores, Misael Uribe Page 40-43

    We have previously observed that UCB binds to ZnSO4 in vitro, and suppresed the biliary bilirubin secretion in the hamster. The aim of this study was designed to investigate whether Zn salts might inhibit the enterohepatic cycling of UCB in subjects with Gilbert´s syndrome. Fifteen patients with Gilbert´s syndrome and 5 normal healthy volunteers were included in this study according to the following criteria: fasting hyperbilirubinemia, no hemolysis, and free of any medication. Patients were randomly assigned to receive acute o chronic treatment. Subjects treated in acute form and normal healthy volunteers were treated with 40 mg of ZnSO4 in a single dose, where as patients treated in chronic form received 100 mg ZnSO4 in a single dose daily for 7 days. The serum UCB levels (mg/dL) decreased from 2.64 ± 1.04 to 2.02 ± 0.87 (p < 0.001) and 1.8 ± 0.36 to 1.48 ± 0.32 (p < 0.005) in subjects treated in acute an chronic form respectively, but not in the control group. Whereas, the serum Zn levels (?g/dL) increased from 96.3 ± 16.8 to 118.8 ± 19. 5, (p < 0.01) and from 117.6 ± 8.5 to 130.7 ± 6.6 (p < 0.03) in subjects treated in acute an chronic form and also in subjects in the control group (98.0 ± 7.3 to 128.0 ± 21.9) p < 0.03. This study showed that acute and chronic oral administration of ZnSO4 decreased serum UCB levels significantly in subjects with Gilbert´s syndrome. Most likely by the inhibition of the ?normal? enterohepatic cycling of UCB.

IMAGES IN HEPATOLOGY

CASE REPORTS

  • Amebic liver abscess Aldo Torre, David Kershenobich Page 45-47

    Amebic liver abscess (ALA) highly endemic in most developing tropical countries is being encountered more frequently in other geographical areas maybe secondary to increased travel to areas where the disease is endemic as well as in the homosexual population. We report a classical clinical case of ALA in a 44 years old man diagnosed by ultrasound and positive seroameba titers who responded to oral imidazole

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

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