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Current Issue

July - September, 2011

Vol. 10 Issue 3

On the cover: Right upper parietal peritoneum showing multiple small patches (1B) and a photomicrography of the liver biopsy (2A).

HEPATOLOGY HIGHLIGHTS

CONCISE REVIEW

  • Herb induced liver injury presumably caused by black cohosh: A survey of initially purported cases and herbal quality specifications Rolf Teschke, Alexander Schwarzenboeck, Wolfgang Schmidt-Taenzer, Albrecht Wolff, Karl-Heinz Hennermann Page 249-259

    Herb induced liver injury (HILI) is a particular challenge that also applies to purported cases presumably caused by black cohosh (BC), an herb commonly used to treat menopausal symptoms. We analyzed and reviewed all published case reports and spontaneous reports of initially alleged BC hepatotoxicity regarding quality of case details and causality assessments. Shortcomings of data quality were more evident in spontaneous reports of regulatory agencies compared to published case reports, but assessments with the scale of CIOMS (Council for the International Organizations of Sciences) or its updated version revealed lack of causality for BC in all cases. The applied causality methods are structured, quantitative, and liver specific with clear preference over an ad hoc causality method or the liver unspecific Naranjo scale. Reviewing the case data and the reports dealing with quality specifications of herbal BC products, there is general lack of analysis with respect to authentication of BC in the BC products used by the patients. However, in one single regulatory study, there was a problem of BC authentication in the analysed BC products, and other reports addressed the question of impurities and adulterants in a few BC products. It is concluded that the use of BC may not exert an overt hepatotoxicity risk, but quality problems in a few BC products were evident that require additional regulatory quality specifications.

ORIGINAL ARTICLES

Clinical Studies

  • Is pre-treatment liver biopsy necessary for all hepatitis C genotypes? Kevork M. Peltekian, Vincent G. Bain, Samuel S. Lee, Morris Sherman, Curtis L. Cooper, Eric M. Yoshida, Paul J. Marotta, Mel Krajden, Robert Balshaw, Marc Deschênes Page 260-269

    Background. Current practice guidelines recommend liver biopsy prior to treatment of hepatitis C genotype- 1 but not for genotype-2/3; this is based on expert opinion, not on published evidence. Methods. In retrospective analysis of a large trial database prior to the publication of recent guidelines, we compared outcomes in 985 treatment-naïve patients with hepatitis C who did or did not undergo liver biopsy before starting peginterferon alfa-2a plus ribavirin. Results. Physicians elected to treat 141/654 (21.6%) genotype-1 patients and 126/331 (38.1%) genotype-2/3 patients without liver biopsy. There were no differences in baseline characteristics among those with or without pre-treatment liver biopsy, except for female preponderance in genotype-1 patients with liver biopsy. The sustained viral response (SVR) rate was no different amongst genotype-2/3 patients who had a biopsy before treatment with 66.3% SVR vs. 69.8% of those treated without biopsy (p = 0.546), but significantly higher among genotype-1 patients with pre-treatment liver biopsy at 54.6 vs. 44.0% for those treated without a liver biopsy (p = 0.029). In genotype-1 patients with liver biopsy, more patients with cirrhosis had dose adjustments (p = 0.0057) rather than drug discontinuation. There was tendency for earlier discontinuation among patients without pre-treatment liver biopsy. Conclusions. Pre-treatment liver biopsy was associated with better SVR amongst genotype-1 patients. This improvement may reflect ongoing commitment to completing the treatment course by both patient and physician. In genotype-2/3 patients, pre-treatment liver biopsy may not be essential to maximize SVR rates. This study validates the recommendations of the most recent treatment guidelines for hepatitis C.

  • Sirolimus may be associated with early recurrence of biliary obstruction in liver transplant patients undergoing endoscopic stenting of biliary strictures James H. Tabibian, Hsin-Chieh Yeh, Vikesh K. Singh, Guldane Cengiz-Seval, Andrew M. Cameron, Ahmet Gurakar Page 270-276

    Introduction. Recurrent biliary obstruction necessitating premature repeat endoscopic retrograde pancreatography (ERCP) remains a costly and morbid problem in patients undergoing treatment of post-orthotopic liver transplantation (OLT) biliary strictures. We evaluated the relationship between prednisone or sirolimus use and early recurrence of biliary obstruction given their negative effects on collagen production and cholangiocyte regeneration. Methods. Medical records of adult patients who underwent OLT from 1998-2008 and developed anastomotic (ABS) and/or nonanastomotic (NABS) biliary strictures requiring endoscopic plastic stent therapy were reviewed. Outcome was early recurrence of biliary obstruction requiring repeat ERCP. Univariate and multivariable logistic regression analysis, adjusting for age, sex, and time from OLT to ERCP, were performed. Results. 35 patients with ABS and 9 patients with NABS underwent a total of 157 ERCPs. Median patient age was 56 years, 68% were male, and hepatitis C was the most common OLT indication (52%). Early recurrence of biliary obstruction ocurred following 17.1% of ERCPs. In univariate analysis, neither prednisone nor sirolimus was associated with early recurrence of biliary obstruction. In multivariate analysis, however, sirolimus use was associated with increased incidence of early recurrent biliary obstruction (OR = 2.53; 95% CI: 0.77-8.32; p = 0.12); this was more pronounced at doses > 3 (OR = 4.27; 95% CI: 0.62-29.3; p = 0.14) than at ≤ 3 mg/day (OR = 2.24; 95% CI: 0.62-8.13; p = 0.22) and statistically significant in patients with ABS only (OR = 1.44 per mg increase in sirolimus dose; 95% CI 1.02-2.03; p = 0.037). Conclusions. Sirolimus use, particularly at higher doses and patients with ABS, may be associated with an increased risk of early recurrence of biliary obstruction requiring repeat ERCP for post-OLT biliary strictures. Additional studies are needed to further investigate these findings and elucidate other risk factors.

  • Pentoxifylline for the treatment of non-alcoholic steatohepatitis: a randomized controlled trial Lisa B. Van Wagner, Sean W.P. Koppe, Elizabeth M. Brunt, Jeanne Gottstein, Konstantina Gardikiotes, Richard M. Green, Mary E. Rinella Page 277-286

    Introduction. The burden of non-alcoholic steatohepatitis (NASH) is growing and current pharmacologic treatments are limited by side effects and inconsistent efficacy. Pilot studies suggest that pentoxifylline (PTX) can reduce liver injury in patients with NASH. Objective. We sought to determine the tolerability of PTX and its effect on aminotransferases and liver histology in patients with NASH. Material and methods. Thirty patients with biopsy proven NASH were randomized in a 2:1 fashion to receive 1,200 mg PTX or placebo for 12 months. Metabolic parameters, aminotransferases, liver histology and hepatic gene expression changes were compared. Results. At baseline the groups were similar. Adverse events were mild, most frequently headache and abdominal cramps, and did not differ between groups (p = NS). After 12 months, ALT and AST decreased from 92 ± 12 IU/L to 67 ± 13 IU/L and 67 ± 6 IU/L to 47 ± 6 IU/L (p < 0.05), respectively in patients treated with PTX. No significant effect was seen with placebo. Steatosis and cellular ballooning improved in the PTX group (p < 0.05), whereas no histological feature of steatohepatitis improved with placebo. However, between groups comparison of both biochemical and histological features were nonsignificant. Conclusion. Pentoxifylline is safe, well tolerated and improves transaminases and histology in patients with NASH when compared to baseline and may be a reasonable therapeutic modality for the treatment of NASH. However PTX failed to reduce transaminases compared to placebo and did not positively affect any of the metabolic markers postulated to contribute to NASH. Although animal data and small pilot studies in humans have suggested that PTX may be effective as a treatment for NASH, translating this therapy to clinical practice may prove challenging.

  • Nonvariceal upper gastrointestinal bleeding in patients with liver cirrhosis. Clinical features, outcomes and predictors of in-hospital mortality. A prospective study José Alberto González-González, Diego García Compean, Genaro Vazquez-Elizondo, Aldo Garza-Galindo, Joel Omar Jáquez-Quintana, Héctor Maldonado-Garza Page 287-295

    Background. Clinical and endoscopic features of cirrhotic patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) have been rarely reported and clinical outcomes and predictors of mortality have not been evaluated. Aims. 1) To describe the clinical features; 2) To define the clinical outcomes; and 3) To identify the predictors of in-hospital mortality of cirrhotic patients with NVUGIB. Methods. One hundred sixty cirrhotic patients with NVUGIB were prospectively studied. Clinical features, endoscopic findings, clinical outcomes and in-hospital mortality rate were studied. Predictors of death were identified by means of univariate and multiple logistic regression analysis. Results. The mean age was 56.5 ± 14.4, male gender prevailed. Alcohol was the most frequent etiology. Hemodynamic instability was reported in 29.4%. Mean serum hemoglobin was 9.5 ± 3.3 g/dL and blood transfusions were required in 59.4%. Gastroduodenal ulcers were the most frequent source of bleeding (50.6%). In endoscopy "high-risk" bleeding stigmata (HRBS) at the ulcer base were found in 53.1%. All patients with HRBS received endoscopic treatment. Rebleeding occurred in 3 patients (1.9%) and mortality was of 13.8%. By univariate analysis: Cryptogenic etiology, BUN, hypoalbuminemia, active bleeding at ulcer base, and endoscopic treatment were predictors of mortality. However, only cryptogenic etiology, hypoalbuminemia and active bleeding at ulcer base were independent predictors of death in multivariate analysis. Conclusions. Gastroduodenal ulcers as a source of NVUGIB are frequent in cirrhotic patients. They were severe; half of them had HRBS, and required frequently endoscopic treatment. In-hospital mortality of these patients seemed to be greater than that of non-cirrhotic patients, and it was significantly related to cryptogenic etiology of cirrhosis, renal dysfunction, severe hepatic failure, and active bleeding ulcers on admission to the hospital.

  • Diagnostic significance of plasma osteopontin in hepatitis C virus-related hepatocellular carcinoma Mona A. Abu El Makarem, Ashraf Abdel-Aleem, Ahmed Ali, Rafet Saber, Mohammed Shatat, Doaa Abdel Rahem, Douaa Sayed Page 296-305

    Background and aim: Outcome of hepatocellular carcinoma (HCC) depends mainly on its early diagnosis. The performance of traditional biomarkers is not satisfactory. Osteopontin (OPN) is of potential importance. This study aim to assess the diagnostic value of plasma OPN compared with alpha-fetoprotein (AFP) for the diagnosis of HCV- related HCC. Methods: We recruited 113 HCC patients compared with 120 matched cirrhotic patients and 120 Controls. The plasma level of OPN and serum AFP for all participants were assessed. Results: The median plasma OPN level was significantly higher in the HCC group than in the cirrhotic patient group or in the normal control group (p-value < 0.001), while OPN levels were not differed significantly in correlation with the degree of liver function deterioration in terms of advanced Child-Pugh class (p-value < 0.9). The diagnostic efficacy of OPN were superior to AFP in terms of AUC, sensitivity, specificity, PPV and NPV either in diagnosis of early or late stages of HCC (0.88 vs. 0.56; P = 0.0001, 0.991vs. 0.899; p = 0.01; respectively). Conclusion: Plasma OPN level is a potential diagnostic marker for HCC, especially among high-risk group of patients. These values extend beyond the traditional tumor biomarkers as AFP, as it possesses good prognostic value.

  • Is gallbladder cancer decreasing in view of increasing laparoscopic cholecystectomy? My Di Le, Donald Henson, Heather Young, Jorge Albores-Saavedra Page 306-314

    Background. Gallstone disease affects over 20 million people in the U.S. and is a major risk factor for gallbladder cancer (GBC). In 1988, a less invasive, low-cost procedure, laparoscopic cholecystectomy (LC), was introduced and became the standard of care for management of gallstones. Methods. GBC incidence (1973-2007) and mortality rates (1969-2006) were calculated using SEER Program data. LC rates (1993-2008) were obtained from NAMCS, NHAMCS, and HCUP. Annual percent change was estimated by gender, age, and race, and the statistical significance was assessed at p < 0.05. Correlation analysis was performed on GBC and LC trends. Results. Since the early 1970s, GBC incidence and mortality rate have declined. Women and older age groups continue to have the highest risk for GBC, despite having greater declines. Incidence significantly decreased among whites, but did not among blacks. The number of inpatient LC procedures increased by 15% between 1994 and 2008; however, inpatient and outpatient LC rates remained stable. LC rate was not significantly correlated with either GBC incidence or mortality. Conclusions. The decline in incidence and mortality of GBC began decades before the introduction of LC and apparently has stabilized in the past decade. No temporal relationship existed between LC rate and the incidence and mortality rates of GBC. Our study suggests that prevention of a rare tumor may be extremely difficult if the surgical removal of a risk factor is involved.

  • Hepatitis B virus infection has no significant role on lymphoproliferative disorders post liver transplantation: PTLD. int survey Morteza Izadi, Saeed Taheri Page 315-320

    Introduction. Based on very limited data, it has been recently suggested that hepatitis B virus infection can play significant roles in post transplantation lymphoproliferative disorders. In the current study pooling data of PTLD in HBV positive liver recipients gathered from the existing literature, we sought to analyze and compare characteristics, behavior and prognosis of PTLD arising in HBV positive liver graft recipients. Methods. A comprehensive search for the available data though PubMed and Google Scholar for reports of PTLD and HBV infection in liver recipients was conducted. Data of 18 different studies were pooled and analyzed. Results. Liver recipients with HBV positive-PTLD were comparable to their HBV negative counterparts in gender, age at transplantation, time from transplantation to PTLD development, lymphoma cell type, histopathology of lesions, remission episodes, mortality rate, multi-organ involvement, and disseminated PTLD (p > 0.1 for all). HBV positive PTLD patients were significantly less likely to complicate spleen (0 vs. 23%, respectively; p = 0.015). Survival of the two patient groups were comparable (p = 0.8). Conclusion. HBV infection has no significant impact on inducing some distinct types of PTLD and represents no survival effect in PTLD setting. Future prospective studies are needed for confirming our findings.

  • Anatomical cardiac alterations in liver cirrhosis: An autopsy study Nayeli X. Ortiz-Olvera, Guillermo Castellanos-Pallares, Luz M. Gómez-Jiménez, María L. Cabrera-Muñoz, Jorge Méndez-Navarro, Segundo Morán-Villota, Margarita Dehesa-Violante Page 321-326

    Background. It has been suggested that liver cirrhosis (LC), regardless of etiology, may be associated with anatomical cardiac alterations. Objective. To describe the frequency and type of macroscopical anatomic cardiac abnormalities present in alcoholic and non-alcoholic cirrhotic patients in an autopsy series. Material and methods. The autopsy records performed at our institution during a 12-year period (1990-2002) were reviewed. All cases with final diagnosis of LC were included, their demographic characteristics as well as cirrhosis etiology and macroscopic anatomical cardiac abnormalities (MACA) analyzed. Patients with any known history of heart disease prior to diagnosis of cirrhosis were excluded. Results. A total of 1,176 autopsies were performed, of which 135 cases (11.5%) were patients with LC. Two patients with cardiac cirrhosis were excluded. Chronic alcohol abuse (29%) and chronic hepatitis due to hepatitis C virus (HCV) infection (20%) were the most common causes of cirrhosis. The etiology was not identified in 35% of the cases, even after exhaustive clinical, serological and/or radiological assessment. In the postmortem analysis, 43% of the cases were informed to have MACA (47% in the group of patients with alcoholic cirrhosis and 41% in other types of cirrhosis); this rate increased to 62% in patients with ascites. The most frequent alterations were cardiomegaly and left ventricular hypertrophy (LVH). Conclusion. The results confirm the high frequency of cardiac abnormalities in patients with cirrhosis, regardless of cirrhosis etiology.

  • Novel cytochrome P450-2D6 promoter sequence variations in hepatitis C positive and negative subjects Martin T. Ho, Edward J. Kelly, Miklos Bodor, Tot Bui, Kris V. Kowdley, Rodney J.Y. Ho Page 327-332

    Introduction. CYP2D6 is a liver enzyme that metabolizes more that 25% of drugs and thus may play a pivotal role in drug-drug interactions. The promoter sequences of cytochrome P450 2D6 (CYP2D6) gene could impact metabolic activity. Methods. We analyzed genetic variations in the promoter sequence of CYP2D6 gene for 71 hepatitis C negative and 15 hepatitis C positive subjects. Results. We found two novel genetic variants -1822A→G; -1740C→T, only in two patients with hepatitis C. Also, two linked new promoter sequence variations at –2060 G→A and –2053 T→G nucleotide positions that present in both hepatitis C negative and positive subjects are identified. The -2060 and -2053 variations are confirmed to be in linkage disequilibrium. The individuals with -2060A/A, and -2053G/G variation appeared to be associated with significantly lower levels of liver CYP2D6 mRNA. Analysis of CYP2D6 enzymatic activity in *1/*1 (wild type) subjects revealed that hepatitis C positive subjects expressed about 2.6-fold lower activity (24.0 ± 1.5 vs. 62.6 ± 3.7 pmol/min/mg; p = 0.0061) relative to hepatitis C negative. Conclusion. These data suggest that promoter variations -1822A→G and -1740C→T are present only in hepatitis C infected subjects. Hepatitis C positive individuals were associated with a lower liver CYP2D6 enzyme activity.

ORIGINAL ARTICLES

Basic studies

  • Hepatoprotective effect of stem of Musa sapientum Linn in rats intoxicated with carbon tetrachloride Piyush Dikshit, Mool Kumar Tyagi, Kirtikar Shukla, Sonal Sharma, Jasvindar Kaur Gambhir, Rimi Shukla Page 333-339

    Methods. The study was designed to evaluate the hepatoprotective activity of aqueous extract of central stem of Musa sapientum (AqMS) against carbon tetrachloride induced hepatotoxicity in rats. Animals were divided into six groups. Group I served as normal control. Group II, III, IV, V & VI were administered CCl4 mixed with olive oil 1:1 (1.5 mL/kg) I.P., twice a week for 5 weeks. Group II was maintained as CCl4 intoxicated control. Group III, IV and V received AqMS at a dose of 25, 50 and 100 mg/kg. Group VI received silymarin 100 mg/kg for 5 weeks orally once daily. Marker enzymes of hepatic functions estimated in serum were AST, ALT and ALP. Antioxidant parameters estimated were MDA and GSH in blood and liver and SOD in blood, after fifth week, animals were sacrificed, livers dissected out and evaluated for histomorphological changes. Results. There was significant rise in AST, ALT and ALP in CCl4 intoxicated control group II. Treatment with AqMS prevented rise in levels of these enzymes. There was significant rise in MDA and fall in GSH in blood and liver in group II, indicating increased lipid peroxidation and oxidative stress upon CCl4 administration. Treatment with AqMS prevented rise in MDA & increased GSH in treated group. SOD levels were decreased in group II while groups treated with AqMS showed significant rise (p < 0.05). Maximum hepatoprotective effect was observed with 50 mg/kg dose. Hepatoprotective effect observed with this dose was comparable to standard hepatoprotective drug silymarin. The results of pathological study also support the results of biochemical findings. Conclusion. the results of the present study indicate that stem of Musa sapientum possess hepatoprotective effect and probably it is due to it's antioxidant property.

  • Prophylactic and curative effects of purslane on bile duct ligation-induced hepatic fibrosis in albino rats Sousou I. Ali, Mostafa M. Said, Ehsan Khedre Mohammed Hassan Page 340-346

    Introduction. Hepatic fibrosis is a common pathological process of chronic liver injury. Oxidative stress and inflammation may have prognostic value in disease progression. Objective. To examine the implication of both aforementioned factors in hepatic fibrosis progression and whether, the antioxidant effect of various biological active constituents such as phenolic, flavonoids and fatty acids of purslane hydro-ethanolic extract can represent a potential target for therapy. Methods. Purslane exhibited a considerable antioxidant potential in DPPH assay compared to α-tocopherol. Consequently, the current study was designed to examine the prophylactic and curative effects of purslane extract on bile duct ligation (BDL)-induced liver fibrosis in rats in comparison with silymarin as a reference hepatoprotective agent. Purslane (400 mg/kg/ day) or silymarin (50 mg/kg/day) were administered orally for 4 weeks, immediately after surgery in order to evaluate the prophylactic effect and for 3 weeks starting 3 weeks after BDL in order to evaluate the curative effect. BDL significantly increased liver enzymes, total bilirubin (TB) and tumor necrosis factor-alpha (TNF-α) in serum along with malondialdehyde (MDA) in liver tissues. Results. Significant decrease in hepatic antioxidant defense system was noted in BDL-rats. Conversely, administration of purslane reversed all these biochemical parameters which were previously induced by BDL. Considerably, purslane effect was more pronounced in the prophylactic study than that in the curative one. Conclusion. The present work suggested that purslane had prophylactic and curative value on cholestasis-induced liver fibrosis through inhibition of oxidative stress, decreasing the expression of profibrogenic cytokines, collagenolytic activity and activation of hepatic stellate cells.

IMAGES IN HEPATOLOGY

  • Hepatic endometriosis Federico Roesch-Dietlen, Alejandra Jiménez-García, Alfonso Pérez-Morales, Peter Grube-Pagola, Karen Lizzette Ramírez-Cervantes, José María Remes-Troche Page 347-348

CASE REPORTS

  • Trans-arterial 90yttrium radioembolization for patients with unresectable tumors originating from the biliary tree Joost W. Wijlemans, Karel J. Van Erpecum, Marnix G.E.H. Lam, Beatrijs A. Seinstra, Maarten L.J. Smits, Bernard A. Zonnenberg, Maurice A.A.J. Van Den Bosch Page 349-354

    Patients with malignant tumors originating from the biliary tree have a poor prognosis, since only a minority of tumors can be resected and most palliative regimens have shown only limited success. We present two patients with unresectable tumors, who were treated with trans-arterial 90yttrium radioembolization: a patient with an infiltrating gallbladder carcinoma and a patient with an extensive intrahepatic cholangiocarcinoma. In both cases the treatment was technically feasible, effective in controlling tumor growth, and without significant side effects. In conclusion, the presented cases demonstrate the potential of 90yttrium radioembolization as a palliative treatment option for malignant tumors of the biliary tree.

  • Course of a HBsAg positive liver transplantation in a hepatitis B and D virus coinfected recipient Ralf Bahde, Jens P. Hölzen, Heiner H. Wolters, Hartmut H. J. Schmidt, C. Thomas Bock, Andreas Lügering, Tilmann Spieker, Norbert Senninger, Jens G. Brockmann Page 355-360

    The increasing demand for transplantation has led to consideration of liver grafts from donors exposed to hepatitis B virus (HBV). Six transplantations of liver grafts from hepatitis B surface antigen (HBsAg) positive donors have been reported; two recipients suffered from HBV/HDV (hepatitis Delta virus) coinfection and were followed up for 10-12 months. Here, we report a 56 months follow-up of a HBV/HDV-coinfected recipient of a HBsAg positive liver graft. Posttransplant combination prophylaxis consisted of hepatitis immunoglobulin, lamivudine and adefovir dipivoxil. HBsAg remained positive during stable posttransplant follow-up and subclinical HDV reinfection with low replication rate was detected at 1 month. Pegylated interferon therapy was introduced after documentation of histological evidence of mild chronic hepatitis, but without virological response after 48 weeks. Finally, antiviral treatment was switched to tenofovir disoproxil fumarate. More than 50 months posttransplant the recipient revealed clinical symptoms of decompensated liver cirrhosis and has been relisted for liver transplantation. In conclusion HBsAg positive liver grafts in HBsAg positive recipients with HDV coinfection may result in virological recurrence and rapid development of liver cirrhosis.

  • Operational tolerance after liver transplantation, more common than we think: A case report Carlos Benítez, Juan Pablo Arancibia, Marco Arrese, Alejandro Soza, Pilar Domínguez, Nicolás Jarufe, Jorge Martínez, Rosa María Pérez-Ayuso Page 361-364

    Operational tolerance after liver transplantation has been described in around 20% of the recipients. These patients are able to maintain a normal graft function in the absence of immunosuppressive drugs, thus being free of adverse effects that are common and frequently severe. Here we present a well-documented case of operational tolerance after liver transplantation and discuss current concepts on this topic with emphasis on recent findings that will potentially allow for identifying graft-tolerant patients.

  • Multiple venous and arterial thromboses of the gallbladder causing acute cholecystitis. A previously undescribed complication of essential thrombocythemia Gabriela Picón-Coronel, Fredy Chablé-Montero, Arturo Ángeles-Ángeles, Jorge Albores-Saavedra Page 365-369

    Well established complications of essential thrombocythemia are multiple thrombohemorrhagic phenomena in various abdominal organs. We describe the case of a 22 year old man with essential thrombocythemia and thrombosis of the mesenteric and splenic veins as well as cavernomatous transformation of the portal vein. The patient also had a splenic infarction and a subphrenic hematoma. Additionally, he developed signs and symptoms of acute cholecystitis which in turn led to an open cholecystectomy. The gallbladder had a markedly thickened wall due to multiple recent and recanalized thrombi predominantly in subserosal veins. Only a few arteries were occluded by thrombi. A marked vascular proliferation in the subserosal connective tissue mimicking a hemangioma was most likely the result of collateral circulation. There was also a mild acute and chronic inflammatory infiltrate and edema in the lamina propria of the gallbladder. Hyperplasia of interstitial cells of Cajal in the lamina propria and between smooth muscle cells and proliferation of nerve trunks in the subserosal connective tissue adjacent to the thrombosed veins and arteries was also noted. To our knowledge this unique gallbladder thrombotic complication of essential thrombocythemia has not been previously reported.

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