Prognostic value of hepatic venous pressure gradient for in-hospital mortality of patients with severe acute alcoholic hepatitis.

BACKGROUND: Hepatic venous pressure gradient (HVPG) has prognostic value in complications and survival of patients with liver cirrhosis. However, the relationship between HVPG and the outcome of acute alcoholic hepatitis (AAH), as well as the specific features of portal hypertension syndrome in this setting, have not been defined. AIMS: To evaluate the prognostic value of HVPG and to analyse the degree of portal hypertension and hyperdynamic circulation in patients with severe AAH. METHODS: Early measurements of HVPG were performed in 60 patients with severe AAH, and compared with the haemodynamic findings of 37 and 29 liver transplantation candidates with alcoholic or viral end-stage cirrhosis respectively. RESULTS: Twenty-three patients (38%) died during hospitalization. Portal hypertension and hyperdynamic circulation were more severe in AAH patients. HVPG was greater in non-survivors [26.9 (7.4) vs. 19.4 (5.2) mmHg, P < 0.001]. Only 4/31 (13%) patients with HVPG 22 (P < 0.001). Encephalopathy (OR 9.4; CI 1.4-64.8), Model for End-Stage Liver Disease (MELD) score > 25 (OR 7.4; CI 1.4-39.9) and HVPG > 22 mmHg (OR 6.7; CI 1.1-39.9) were independently associated to in-hospital mortality. CONCLUSIONS: Early measurement of HVPG provides important prognostic information on the short-term outcome of patients with severe AAH. In addition, MELD score also seems to be a strong prognostic factor in these patients.

Increased intrahepatic and circulating levels of endoglin, a TGF-beta1 co-receptor, in patients with chronic hepatitis C virus infection: relationship to histological and serum markers of hepatic fibrosis.

Endoglin, a transforming growth factor (TGF)-beta1 co-receptor, has been associated with renal and cutaneous fibrosis, as overexpression of this protein has been observed in biopsies from patients with glomerulosclerosis and scleroderma, respectively. Our aim was to evaluate whether endoglin may be associated with hepatic fibrosis featuring chronic hepatitis C virus (HCV) infection. Fifty-two anti-HCV+ patients, five anti-HCV- patients and 27 healthy subjects were studied. Western blot and immunohistochemistry were used to quantify the expression levels of endoglin and TGF-beta1 in liver biopsy samples, and serum concentrations of endoglin and hyaluronic acid were determined by enzyme-linked immunosorbent assays (ELISAs). In patients with advanced fibrosis, intrahepatic expression levels of endoglin and TGF-beta1 were significantly higher than those in patients with early fibrosis (mean: 3- and 5.8-fold, respectively) and normal liver (mean: 3.9- and 12-fold, respectively). Interestingly, activated hepatic stellate cells as well as portal and septal myofibroblasts expressed endoglin. Serum levels of endoglin were also significantly higher in patients with advanced fibrosis than in those with early fibrosis (55.5 +/- 1.6 vs 47.5 +/- 0.9 ng/mL, P < 0.001), showing a positive correlation with serum hyaluronic acid concentrations (r = 0.57, P = 0.01). In conclusion, increased intrahepatic endoglin and TGF-beta1 expression is significantly associated with progressive hepatic fibrosis in chronic HCV infection. Circulating endoglin levels are elevated in HCV patients showing a significant correlation with histological and serum markers of hepatic fibrosis. These data suggest an active role for endoglin in the fibrotic process featuring chronic HCV infection.

[Liver failure due to mushroom poisoning: clinical course and new treatment perspectives]. / Toxicidad hepática por ingesta de setas: curso clínico y nuevas perspectivas de tratamiento.

Mushroom poisoning, mainly due to the Amanita genus, is an infrequent cause of liver failure in our environment. However, because of its high morbidity and mortality, it constitutes a medical emergency. The characteristic initial symptoms of vomiting, abdominal pain, and diarrhea are nonspecific and may be confused with gastroenteritis. If correct and early treatment is not given, renal and hepatic failure can develop, sometimes requiring liver transplantation. We present three cases of mushroom poisoning, which presented a different clinical course ranging from complete recovery with traditional medical treatment to severe acute liver failure requiring transplantation in one patient and albumin dialysis (molecular absorbent recycling system [MARS]) in another with favorable outcome. Although controlled clinical studies of the treatment of mushroom poisoning are lacking, recommendations based on the experience of various authors have been established. Penicillin G and silymarin seem to be useful. The development of new techniques of extracorporeal detoxification, mainly MARS, may represent an important support system in the treatment of these patients.

[Characterization of de novo malignancies in liver transplantation]. / Caracterización de los tumores malignos de novo en el trasplante hepático.

INTRODUCTION: The incidence of de novo malignancies after liver transplantation varies from 3-15%, and is greater than that in the general population. Immunosuppression may play a significant role in the development of most of these tumors. OBJECTIVE: To evaluate the incidence and clinical features of de novo tumors in liver transplant recipients in our center as well as to assess survival. PATIENTS AND METHODS: We retrospectively analyzed 437 liver transplantations (380 patients) performed from April 1990 to July 2001. The incidence of de novo malignancies was 7.4% (n = 28). Four patients presented two different tumors during their lifetime. The etiology of the underlying disease was alcoholic cirrhosis (45.8%), hepatitis C virus cirrhosis (20.8%), hepatitis B virus cirrhosis (12.5%), autoimmune disease (8.4%) and other causes (12.5%). The most frequent neoplasms were cutaneous and epidermoid tumors (21.4% of the malignancies both groups). All the patients with epidermoid tumors and adenocarcinomas were active smokers. The mean age at diagnosis was 58 9 years and this was a factor that influenced tumoral type (adenocarcinomas in older patients and epidermoid tumors in younger patients; p = 0.04). RESULTS: Sarcomas and adenocarcinomas appeared sooner after transplantation than epidermoid and cutaneous tumors (p = 0.04). Fifty percent of the malignancies developed in the second and third year after transplantation. The type of immunosuppression did not influence tumoral type, although most patients received cyclosporin A in combination with azathioprine and/or corticoids. The mean duration of follow-up after diagnosis of the tumor was 23.1 28 months (range, 1-81). Mortality was 58.4% with a median survival of 9 16 months. The actuarial probability of survival at 1, 3 and 5 years was 46.1, 27.7 and 27.7%, respectively. CONCLUSIONS: De novo malignancies are frequent after liver transplantation and their clinical course differs from that in the general population. Because their clinical course is more aggressive, regular follow-up of these patients is essential for early diagnosis.

[Characteristics of bleeding from esophageal-gastric varices in patients with HIV infection]. / Características de la hemorragia digestiva por varices esofagogástricas en pacientes con infección por el VIH.

AIMS: Coinfection with human immunodeficiency virus (HIV) and hepatotropic viruses (hepatitis B and C) is frequent because the routes of infection are similar. Liver disease appears earlier in these patients and progression to cirrhosis and its complications is faster. The aim of this study was to determine the incidence and clinical characteristics of bleeding from esophageal-gastric varices in patients with HIV. METHODS: We retrospectively analyzed 258 consecutive episodes of bleeding from esophageal-gastric varices in cirrhotic patients between January 1996 and January 2001, of which 20 episodes occurred in patients with HIV (7.8%). RESULTS: The mean age was significantly lower in patients with HIV infection and all presented hepatitis C infection. The hepatic venous pressure gradient was higher in patients with HIV (22.8 3.4 mmHg vs 19.6 5,4 mmHg; p = 0.05). No differences in the severity of liver disease (Child-Pugh), transfusion requirements, treatment performed, initial hemostasis, early recurrence, or rescue treatment with dipeptidyl peptidase I (DPPI) were found. The development of complications (bacterial infections, hepatic encephalopathy and ascites), hospital stay and mortality were also similar. Mortality was not influenced by HIV stage. Bleeding from esophageal-gastric varices in patients with HIV infection has a similar form of presentation and clinical course with treatment to that in non-cirrhotic patients, despite a higher degree of portal hypertension. CONCLUSIONS: The presence of HIV infection should not modify diagnostic or therapeutic attitudes to bleeding from esophageal-gastric varices.

Randomized controlled trial of aspiration needle versus automated biopsy device for transjugular liver biopsy.

PURPOSE: The efficacy and safety of transjugular liver biopsy used to obtain liver specimens in patients with coagulation disorders have been widely proven. However, histopathologic examination is not always possible because of fragmented samples provided by the aspiration technique. Recently, an automated device with a Tru-Cut-type needle was designed. In this randomized controlled trial, the use of this new device is compared with the traditional method in terms of efficacy and safety. METHOD: Fifty-six patients were included in the study; 28 were randomized to undergo the aspiration technique and 28 were randomized to undergo the automated biopsy technique. RESULTS: Correct positioning of the device was achieved in 93% of patients undergoing the aspiration technique and 96% of patients undergoing the automated biopsy technique (P = NS). Mean duration of the procedure and total number of passes were significantly higher in the aspiration needle group than in the automated device group (22.6 min +/- 12.6 vs 15.5 min +/- 9.4; P = .03, and 3.3 min +/- 1.9 vs 1.5 min +/- 0.63; P < .001, respectively). The number of portal tracts was significantly higher in the automated device group (4.7 +/- 2.5 vs. 2.7 +/- 3.4; P < .05). Adequate specimens for histopathologic evaluation were obtained in 26 patients in the automated device group and 24 patients in the aspiration needle group (92.8% vs 85.7%; P = NS), but a definite histopathologic diagnosis was more frequently obtained with the automated biopsy device (68% vs 43%; P = .05). No significant differences were observed in complication rates (7.14% vs. 10.7%; P = NS). CONCLUSION: The automated biopsy device for transjugular liver biopsy is more effective than an aspiration needle in obtaining good samples for a definite histologic diagnosis.

[The endoscopic placement of self-expanding metal prostheses as palliative treatment in colorectal stenosis of tumor origin]. / Colocación de prótesis metálicas autoexpandibles por vía endoscópica como tratamiento paliativo en estenosis colorrectales de origen tumoral.

BACKGROUND: The aim of this study was to retrospectively analyze the endoscopic placement of autoexpandible metallic prostheses of the colon carried out in our department as palliative treatment in patients with colorectal stenosis of tumoral origin. PATIENTS AND METHODS: From may, 1995 to august, 1998, autoexpandible metallic prostheses were placed in 14 patients (11 males and 3 females, mean age 64.5 years, range 41-92). All the patients presented tumoral stenosis by adenocarcinoma, 5 of which had been previously treated by surgery. RESULTS: All the stenoses were found in the rectum/sigma at less than 35 cm from the anal margin. In 7 patients endoscopic dilatation was performed prior to placement of the autoexpandible metallic prostheses. The prostheses used had a diameter of 18 mm and were of variable length. The placement of the prostheses was successfully achieved in all the patients except 2 (one due to technical difficulties and in the other because of early migration of the same, in both the autoexpandible metallic prostheses was placed without complications within 24 h). In two cases early complications were observed (14%): one case due to perforation and one to early migration. In two patients stenosis of the prostheses was observed during follow up and in a third patient late migration occurred. CONCLUSIONS: Endoscopic placement of autoexpandible metallic prostheses in patients with colorectal stenosis of tumoral origin is a simple technique with few complications and may be used as a definitive palliative treatment in these patients.