Enfermedad hepática por alcohol / Alcoholic liver disease

Excessive alcohol consumption is an important cause of preventable morbidity and mortality. We have to bealert to chronic alcohol usage or abuse. Simple tests (AUDIT, CAGE) can be applied quickly on outpatientcare. We highlight advances in understanding the immune and molecular mechanisms; there is disruptionof the intestinal barrier with bacterial translocation, as well as endotoxins which activate the liver’s innateimmunity, causing apoptosis, necrosis, inflammation and fibrosis. Alcoholic hepatitis is most common inpatients between 40 and 60 years of age, preferably male with jaundice, fever, ascites, hepatomegaly. Thediagnosis is confirmed with a history of alcoholic consumption, mild to moderate AST and ALT values,a AST/ALT ratio > 2, hyperbilirrubinemia and prolonged prothrombin time. There are scores to evaluatethe severity and the need of corticoid therapy, such as modified Maddrey discriminating function andMELD score. Lille score assesses the response to treatment in the seventh day. The risks and benefits ofliver biopsy should be evaluated individually. The cornerstone of treatment remains alcohol abstinence.Nutritional management must be carefully monitored. Proteins requirements are standardized based onweight. The use of corticoids with 40 mg of prednisolone each day is the most widely accepted therapy,indicated on patients with MMDF higher than 32 or MELD score higher than 21. If Lille score is higherthan 0.45 at the seven day under corticoid therapy, treatment must be interrupted. The use of pentoxifyllinewould only be effective for prevention of hepatorenal syndrome...

El consumo excesivo de alcohol es una causa importante de morbimortalidad prevenible. Debemos estaratentos en detectar a pacientes con dependencia o abuso crónico de alcohol. Test sencillos (AUDIT, CAGE)pueden aplicarse rápidamente en consulta ambulatoria. Destacamos avances en el conocimiento moleculare inmunológico, existe disrupción de la barrera intestinal con translocación bacteriana y endotoxinas conactivación del sistema inmune innato del hígado, produciendo apoptosis celular, necrosis e inflamación yfibrosis. La hepatitis alcohólica se presenta principalmente en pacientes entre 40 y 60 años, preferentementeen varones con ictericia, fiebre, ascitis, hepatomegalia. El diagnóstico se confirma con antecedentes deingesta alcohólica, GOT y GPT elevadas en forma leve o moderada, relación GOT/GPT mayor de 2, hiperbilirrubinemiay tiempo de protrombina prolongado. Existen scores para evaluar la gravedad y necesidad demanejo con corticoides como función discriminante de Maddrey modificada y MELD. El puntaje de Lilleevalúa respuesta del tratamiento al séptimo día. El riesgo/beneficio de la biopsia hepática se evalúa caso acaso. La piedra angular del tratamiento sigue siendo la abstinencia. Manejo nutricional debe ser riguroso.Requerimientos proteicos están estandarizados por peso. La terapia con corticoides (prednisolona 40 mg/día) es la más ampliamente aceptada, con indicación en pacientes con FDMm mayor a 32 o MELD mayora 21. Si el puntaje de Lille es mayor de 0,45 a los 7 días con corticoides, deben suspenderse. Pentoxifilinasólo tendría efecto en prevenir el desarrollo de síndrome hepatorrenal (SHR). Hay nuevas terapias enevaluación, como el uso de G-CSF...

A Case of Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes / 대한소화기학회지

Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with ascites caused by advanced liver disease. While gram negative bacteria, such as Escherichia coli and Klebsiella pneumonia are the common pathogens, Listeria monocytogenes has been recognized as a very rare pathogen. Empirical treatment with third generation cephalosporins does not provide adequate antibiotics coverage against L. monocytogenes. Diagnosis is often delayed as it requires confirmation from ascitic fluid culture. Herein, we describe the first case of SBP caused by L. monocytogenes in a patient with advanced alcoholic liver cirrhosis in Korea. Clinicians should be aware of the atypical pathogens, especially in patients with inadequate response to empirical antibiotics.

A Case of Lateral Abdominal Wall Hematoma Treated with Transcatheter Arterial Embolization / 대한소화기학회지

Paracentesis is a diagnostic, therapeutic procedure performed in patients with ascites. It is generally thought to be a safe procedure and transfusion of platelet concentrate or fresh frozen plasma is not recommended before the procedure, because the incidence of clinically significant bleeding is very low. We report a case of lateral abdominal wall hematoma due to the injury of the deep circumflex iliac artery after paracentesis in patient with alcoholic liver cirrhosis who was treated with transcatheter arterial embolization.

A case of hypervascular hyperplastic nodules mimicking hepatocellular carcinoma in alcoholic liver cirrhosis / 대한간학회지

Benign hypervascular hyperplastic nodules (HHN) in liver cirrhosis are very rare. It is important to distinguish between regenerative nodules (hyperplastic nodules) and tumorous nodules (dysplastic or neoplastic nodules) in hepatocellular nodular lesions. The differential diagnosis between HHN and hepatocellular carcinoma on the basis of radiologic imaging is often difficult, and is clinically important when determining the therapeutic plan. Therefore, histological confirmation by needle biopsy sampling of the liver is necessary for a correct diagnosis of HHN. We report herein a case of benign HHN mimicking hepatocellular carcinoma in a 32-year-old male alcoholic liver cirrhosis patient without viral hepatitis infection.

Prevalência da pancreatite crônica em pacientes portadores de cirrose hepática alcoólica: estudo histopatológico / Prevalence of chronic pancreatitis in patients with alcoholic liver cirrhosis: histopathological study

INTRODUÇÃO: O abuso crônico do álcool é importante causa de cirrose hepática e de pancreatite crônica. OBJETIVO: Avaliar a frequência de pancreatite crônica (PC) em pacientes portadores de cirrose hepática alcoólica (CHA) por exame histopatológico. Casuística: Analisaram-se necropsias de 18 homens e sete mulheres portadores de CHA, com idade média e desvio padrão de 47,2 ± 13,8 anos (24 a 83 anos), que consumiam em média 239,6 ± 155,3 g de etanol/dia por um período médio de 16,7 ± 7,2 anos. MÉTODOS: O diagnóstico histopatológico de cirrose hepática baseou-se na fibrose sistematizada com formação de septos delimitando nódulos, associada à inflamação crônica inespecífica. O diagnóstico histológico de PC baseou-se na identificação de exsudato mononuclear (EM) em torno dos ductos e no tecido conjuntivo inter e intralobular, acompanhado de traves de fibrose. A PC foi classificada como leve quando havia discreto EM em região periductal, interlobular ou intralobular acompanhado por finas traves de fibrose; moderada, pelo aumento da intensidade do exsudato e da fibrose, ocasionalmente associado com pequena dilatação dos ductos; a forma grave caracterizou-se pelo EM, densa fibrose, presença de rolhas, dilatação dos ductos, atrofia glandular e, às vezes, calcificação. RESULTADOS: Observou-se PC em 20 pacientes portadores de CHA (80 por cento), que foi leve em 13 (52 por cento), moderada em dois (8 por cento) e grave em cinco (20 por cento). CONCLUSÃO: A pancreatite crônica está frequentemente associada à CHA, sendo histologicamente grave em aproximadamente 1/4 dos casos.

INTRODUCTION: The chronic alcohol abuse is an important cause of liver cirrhosis and chronic pancreatitis. OBJECTIVE: To evaluate the prevalence of chronic pancreatitis (CP) in patients with alcoholic liver cirrhosis (ALC) based on histopathological assays. Subjects: Autopsies of 25 patients with ALC, 18 men and seven women, age ranging from 24 to 83 years (mean ± standard deviation: 47.2 ± 13.8) were retrospectively analyzed. They ingested on average 239.6 ± 155.3 g ethanol/day for a mean period of 16.7 ± 7.2 years. METHODS: Liver cirrhosis histopathological diagnosis was based on the findings of systemized fibrosis with formation of septum-delimited nodules and nonspecific chronic inflammation. CP histopathological diagnosis was based on identification of mononuclear cell infiltration (MCI) around the ducts and in the inter- and intra-lobular connective tissue and presence of strands of fibrosis. CP was classified as mild (discrete MCI in the periductal, inter- or intra-lobular areas with thin strands of fibrosis), moderate (increased exudates and fibrosis, occasionally associated with small dilatation of ducts), and severe (evident MCI, dense fibrosis, presence of plugs in the ducts, irregular ductal dilatation, glandular atrophy and, sometimes, calcification). RESULTS: CP was observed in 20 patients (80 percent) with ALC, and was considered mild in 13 (52 percent), moderate in two (8 percent) and severe in five (20 percent) patients. CONCLUSION: CP is often associated with the ALC, and it can be histologically severe in approximately 1/4 of the cases.

Etiologic and Laboratory Analyses of Ascites in Patients who Underwent Diagnostic Paracentesis / 대한간학회지

BACKGROUND/AIMS: Liver cirrhosis and malignant tumors are two major causes of ascites according to the reports from Western countries, 80% and 10% respectively. Assuming that there might be regional differences in etiologies and changes in their frequency over time, we investigated causes of ascites and the diagnostic usefulness of various laboratory tests. METHODS: Medical records of 366 patients, who underwent diagnostic paracentesis in the mid-1990s (1996 and 1997) and early 2000s (2001 and 2002), were retrospectively reviewed. The etiology was confirmed by histology, imaging studies, and ascites analyses. RESULTS: The frequency of cirrhotic ascites was 59.6%, cancer-related 25.7%, tuberculous peritonitis 6.6%, and others 8.1%. Among cirrhotics, the frequency of cases related to hepatitis B decreased significantly from 72% to 55% over time, and alcoholic cirrhosis increased from 18% to 34%. Among cancer-related ascites, peritoneal carcinomatosis type was 75.5% (primary sites: stomach 24.5%, pancreas 15.9%, colon 15.9%, lung 7.4%, etc), metastatic liver cancers 8.5%, hepatocellular carcinoma without cirrhosis 6.4%, etc. The sensitivity of serum-ascites albumin gradient for the diagnosis of cirrhotic ascites was 91.4%, and total protein in ascites also revealed a comparable diagnostic sensitivity, 90%. The diagnostic sensitivity of adenosine deaminase for tuberculous peritonitis was 94.2%, and its positive predictive value was 75%. CONCLUSIONS: Liver cirrhosis is the leading cause of ascites, especially alcoholic cirrhosis has significantly increased. The next common etiology is cancer-related, and its frequency in Korea is higher than in western countries. Tuberculous peritonitis is still prevalent, and adenosine deaminase could precisely differentiate it from other causes.

Status of blood antioxidant enzymes in alcoholic cirrhosis.

Chronic alcohol consumption is associated with increased incidence of variety of illnesses including cirrhosis. Studies have shown that ethanol consumption may result in increased oxidative stress with increased formation of lipid peroxides and free radicals. However, very few reports are available on their involvement in the toxicity of alcoholic cirrhosis. The present study was undertaken in 44 male subjects to evaluate the role of oxidative stress in liver injury with special reference to alcoholic or non alcoholic cirrhosis. It was observed that the parameters of liver function like total bilirubin, Alanine Transaminase (ALT), Aspartate Transaminase (AST), Alkaline Phosphatase (ALP), gamma Glutamyl transfarase (gammaGT) were increased in cirrhotic (alcoholic or non alcoholic) patients as compared to normal controls. However antioxidant enzymes like Superoxide dismutase (SOD) and Glutathine peroxidase (GPx) lipid peroxidation marker, Malondialdehyde (MDA) showed significant changes only in alcoholic cirrhosis and not in non alcoholic cirrhosis when compared with normal controls. The possibility of assessment of antioxidant enzymes to differentiate between alcoholic or non alcoholic or non alcoholic cirrhosis is postulated.

Supervivencia de pacientes con cirrosis hepática en el Hospital General Regional del IMSS, Durango / Survival in patients with liver cirrhosis at the Durango, IMSS Regional General Hospital

INTRODUCTION: In Mexico, hepatic cirrhosis mortality exhibits important regional differences. AIM: To analyze global survival of cirrhotic patients, according to etiology and functional status. MATERIAL AND METHODS: Between March 1990 to August 1998, newly diagnosed patients with hepatic cirrhosis were included in a follow-up study. Subjects were analyzed monthly. Information on clinical evolution, complications, and dates of events (death) and complications were registered. Survival was estimated using Kaplan-Meier method. RESULTS: Ninety nine subjects were included in the survival analysis, 66 with alcoholic and 33 with viral cirrhosis (HCV and HBV in 24 and nine patients, respectively). Ninety seven percent of patients were decompensated at diagnosis, and 81 had ascites. Probabilities for survival in the entire series were 69.7, 37.6 and 23.6 at 24, 48, and 60 months, respectively. There were no significant differences in the survival of patients grouped according to etiology. When survival was analyzed by Child-Pugh score, it was slightly higher in the alcoholic cirrhosis group. CONCLUSIONS: In this study survival probability of patients with viral cirrhosis was lower than in patients with alcohol cirrhosis.

Inmunoglobulina A ¿un predictor de daño hepático crónico por alcohol? / Immunoglobulin A: predictor of alcoholic chronic liver damage?

La relación entre etiología, severidad del daño hepático y niveles aumentados de IgA ha sido motivo de controversia. Nuestros objetivos fueron a) analizar el efecto del alcohol sobre la concentración sérica de IgA en pacientes con cirrosis alcohólica, b) estudiar la relación entre IgA y severidad del daño hepático y c) evaluar el efecto de la suspensión del consumo de alcohol sobre sus niveles. Se estudiaron 48 pacientes cirróticos, 30 alcohólicos y 18 no alcohólicos. En todos se midieron inmunoglobulinas séricas (IgA, IgG, IgM) y se determinó la puntuación de Child-Pugh. En 16 pacientes alcohólicos se realizó una segunda determinación de inmunoglobulinas luego de al menos 7 meses de abstinencia. Los valores de la IgA fueron significativamente mayores en pacientes alcohólicos y cifras más elevadas se observaron en la medida que aumentó el grado de insuficiencia hepática, de acuerdo a los niveles de Child-Pugh. No se observó relación entre los valores de IgA y transaminasas. Estos valores aumentados de IgA se mantienen más allá de los seis meses

Determinaçäo sérica dos ácidos biliares na detecçäo da hepatopatia crônica e no seu estadiamento funcional / Serum determination of bile acids in the diagnosis of chronic liver disease and in the functional staging

Os valores séricos dos ácidos biliares totais foram dosados através de método enzimático-colorimétrico em 15 indivíduos dispépticos, sem doenças hepática (grupo controle) e em 52 portadores de hepatopatia crônica de etiologia alcoólica, subdivididos de acordo com a classificaçao funcional de Child-Pugh (Child A=17; B= 18 e C = 17) ou de acordo com o exame clínico em grupos compensado (n = 22) e descompensado (n = 30). A dosagem sérica dos ácidos biliares, particularmente as pós-prandiais, apresentaram elevado poder discriminativo na detecçao de hepatopatia crônica, separando o grupo controle de qualquer un dos grupos de etilistas portadores de hepatopatia crônica. Apresentaram também correlaçao significante com os testes bioquímicos mais diretamente relacionados à funçao hepatocelular, como albumina, bilirrubina total e atividade de protrombina, além da classificaçao de Child-Pugh numérica. No entanto, quando os pcientes cirróticos foram separados de acordo com a apresentaçao clínica, a dosagem plasmática dos ácidos biliares apresentou capacidade discriminativa inferior aos exames convencionais como a classificaçao de Child-Pugh numérica e o tempo de protrombina, demonstrando ter valor limitado na avaliaçao funcional e no acompanhamento evolutivo da hepatopatia crônica alcoólica.

Consumption of 'country liquor' and its relation to alcoholic liver disease in Mumbai.

The amount of alcohol intake required for the development of liver disease has been determined in Western populations; corresponding figures in Indians, many of whom consume locally brewed liquors, are not known. We studied 328 patients from a public hospital in Mumbai who admitted to regular alcohol consumption, to determine the pattern of alcohol consumption and its relation to liver disease. Liver disease was more common in those who consumed illicitly-brewed as compared to licit liquor. Daily drinking, volume of consumption > 200 ml per day, and duration of drinking > 14 years were each significantly more common in those with liver disease. A cumulative intake of > 2000 ml. years, calculated as the product of volume (ml per day) and duration (years), was a reliable cut-off level for association with liver disease (sensitivity 65%, specificity 77%) and cirrhosis (sensitivity 70%, specificity 59%). The content of alcohol in these liquors, estimated in 23 samples, ranged from 23-36.1 g/100 ml, being lower in the illicit liquors. Thus, in Mumbai, alcoholic liver disease occurs more commonly with consumption of illicit liquor (despite its lower alcohol content); liver involvement appears earlier and with lower consumption levels than in the West.

Nuevas propuestas en el manejo de la enfermedad hepática por abuso de alcohol / New proposals in management of alcoholic liver diseases

Some recent proposals in management of alcoholic liver disease are discussed focusing on early diagnosis and treatment of alcohol abuse itself, alcoholic hepatitis early mortality, clinical meaning of nutrional therapy, serological approach and treatment of hepatic fibrosis, and problems in liver transplantation for end stage alcoholic liver cirrhosis. CAGE or similar systematized brief questionnaires, and desialylated transferrin/total transferrin ratio as serological marker, seeems to be interesting contributions to "hidden" alcohol abuse diagnosis and abstinence control while psyco-social support and voluntary incorporation to self-aid groups are the best weapons to reach persistent abstinence. Corticosteroids seems to improve survival in a selected group of patients with severe alcoholic hepatitis, specially in those presenting encefalopathy but free of Gl bleeding, decompensated diabetes, active infections, pancreatitis, and other contraindications or adverse effects of these drugs. Relationship between direct toxicity and nutritional deficiencies in pathogenesis of alcoholic liver injury are not clear enough, but malnutrition is generally present in patients requiring hospitalization, and related to clinical severity; oral, enteral or parenteral nutritional suplementation in this order of preference according to patients condition, associated or not with steroid anabolics, are useful in cases with moderate to severe alcoholic hepatitis or decompensated cirrhosis to eliminate the catabolic state, reaching a better nitrogen balance and liver function tests, without special adverse effects. A special role on liver regeneration is discussed...

Cirrosis y embarazo: presentación de un caso clínico y consideraciones sobre el tema / Cirrhosis and pregnancy: report of a case and considerations about the theme

Se presenta el caso de una mujer de 32 años de edad con cirrosis hepática diagnosticada antes de la gestación, que cursó con embarazo complicado con retardo en el crecimiento intrauterino del producto, habiéndo sospechado inicialmente en la vigésima semana de gravidez mediante ultrasonido y se ratifica en las exploraciones subsecuentes, para confirmarse finalmente con el peso subnormal del bebé al nacer. Se analiza la metodología diagnóstica de la cirrosis, su tratamiento y la evolución del embarazo

O vírus da hepatite B na doença hepática alcoólica: avaliaçäo clínica e bioquímica / The hepatitis B virus in alcoholic liver disease: its clinical and biochemical assessment

Foram estudados prospectiva e sequencialmente 107 pacientes com doença hepática alcoólica (DHA) crônica, sendo 83 casos de cirrose e 24 de hepatite alcoólica. Além do etilismo, ingestäo mínima de 70 gramas de etanol puro ao dia por período superior a sete anos, todos apresentaram disfunçäo hepatocelular. De acordo com o perfil sorológico para o VHB os pacientes foram alocados em quatro grupos a saber: grupo I infectados: AgHBs e anti-HBc positivos; grupo II imunes: anti-HBs e anti-HBc positivos; grupo III sem marcadores do VHB: AgHBs, anti-HBc e anti-HBs negativos; grupo IV IV anti-HBc positivo isoladamente. A prevalência de infecçäo pelo VHB na DHA foi alta: 42,06 por cento apesar dos índices elevados de imunidade: 26,17 por cento sugerindo que na DHA ocorre maior exposiçäo ao VHB com resposta imunológica deficiente. A análise dos parâmetros clínico-bioquímico, quando considerados isoladamente, näo mostrou diferenças estatisticamente significantes entre os grupos I, II, e III, entretanto a clasificaçäo de Child/Campbell, discriminou o grupo infectado, onde houve predomínio da classe C, de pior prognóstico

Determinantes clínicos y bioquímicos del pronóstico a corto plazo en pacientes con cirrosis por alcohol

Se determinó el pronóstico a corto plazo en pacientes con cirrosis hepática por alcohol mediante la aplicación de la Escala de Orrego que valora parámetros clínicos y bioquímicos. Se estudiaron prospectivamente 50 pacientes con diagnóstico de cirrosis hepática por alcohol que ingresaron al departamento de clínica del hospital Vicente Corral Moscoso, entre el 1ro de Diciembre de 1987 al 31 de Mayo de 1988. Se demuestra que la hepatomegalia, encefalopatía hepática, tendencia hemorrágica, ascitis, además periféricos, astenia y anorexia, son datos significativos para valorar el pronóstico en el grupo de fallecidos (P<0.01); en cuanto a los datos de laboratorio la TGO, albúmina sérica y fosfatasa alcalina son los datos de laboratorio de mayor valor en el pronóstico a corto plazo (p<0.01). La aplicación de la escala de orrego es una manera útil y sencilla para determinar el pronóstico, pues demuestra que los pacientes con menor puntaje (lesión hepática moderada) tienen mejor pronóstico que aquellos cuyo puntaje es mayor (lesión hepática severa)(p<0.01). Las complicaciones determinaron una mortalidad del 38//similiar a la observada en otros países.

Formas clínicas e anatomopatológicas das hepatopatias alcoólicas / Clinic and anatomopathologic manifestations in alcoholic liver diseases

Os autores estudam e analisam aspectos clínicos, laboratoriais e anatomopatológicos em grupo de 50 pacientes alcoolistas. Inicialmente conceituam um espectro da doença em três formas anatomoclínicas e parâmetros que definem o que é "alcoolista". Säo discutidos os sinais e sintomas clínicos mais freqüentes nesses pacientes, os exames laboratoriais indicadores de alteraçöes, bem como os achados morfológicos. Os resultados estatisticamente mais significativos säo analisados separadamente, segundo as formas anatomoclínicas, procurando-se correlaçöes. O estudo de revisäo da literatura, 78 artigos no total, é cotejado com os achados

Tempo de alcoolismo no desenvolvimento de doenças orgânicas em mulheres tratadas no Hospital das Clínicas de Ribeiräo Preto, SP, Brasil / Time of alcoholism in the course of organic diseases in women treated in the Hospital das Clínicas of Ribeiräo Preto, SP, Brazil

Com o objetivo de conhecer o tempo de ingestäo freqüente de bebidas alcoólicas (ingestäo média de mais de 100 ml de etanol por dia, pelo menos três dias por semana), até o aparecimento de sinais e sintomas de doenças orgânicas conseqüentes ao hábito, estudamos 95 mulheres tratadas entre 1978 e 1982 no Hospital das Clínicas de Riberäo Preto, portadoras de doenças orgânicas associadas alcoolismo. Foi feito diagnóstico clínico e laboratorial de cirosse hepática em 32 pacientes, de pancreatite crônica em 13 e de outras doenças (pelagra, desnutriçäo, neurite periférica e hepatite alcoólica) em 50. Pacientes com apenas sintomas psiquiátricos näo foram estudadas. A obtençäo das informaçöes ocorreu após alguns dias de tratamento.Em média e idade em que começaram a ter sinais e sintomas das doenças que motivaram a procura de hospital para tratamento foi de 35,30 + ou - 7,72 anos na pancreatite crônica 36,53 + ou - 8,39 anos na cirrose hepática e de 33,90 + ou - 11,27 anos nas outras doenças. O tempo de ingestäo da bebida foi de 15,92 + ou - de 7,15 anos na pancreatite crônica, 14,62 + ou - 8,70 anos na cirrose hepática e 13,24 + ou - 9,58 anos nas outras doenças. Antecedentes familiares de alcoolismo estiveram presentes em 64,2% dos casos, geralmente marido ou companheiro. Nenhuma delas tinha outras mulheres na família com problemas de alcoolismo. A média do tempo de alcoolismo para o aparecimento de cirrose hepática nas mulheres (14,62 anos) foi menor do que a encontrada para homens da mesma populaçäo (21,10 anos), estudados em trabalhos anteriores