Cholangiopathy in critically ill patients surviving beyond the intensive care period: a multicentre survey in liver units.

BACKGROUND: The outcome of cholangiopathy developing in intensive care unit (ICU) is not known in patients surviving their ICU stay. AIM: To perform a survey in liver units, in order to clarify the course of cholangiopathy after surviving ICU stay. METHODS: The files of the liver units affiliated to the French network for vascular liver disease were screened for cases of ICU cholangiopathy developing in patients with normal liver function tests on ICU admission, and no prior history of liver disease. RESULTS: Between 2005 and 2015, 16 cases were retrieved. Extensive burns were the cause for admission to ICU in 11 patients. Serum alkaline phosphatase levels increased from day 11 (2-46) to a peak of 15 (4-32) × ULN on day 81 (12-511). Magnetic resonance cholangiography showed irregularities or frank stenosis of the intrahepatic ducts, and proximal extrahepatic ducts contrasting with a normal aspect of the distal common bile duct. Follow-up duration was 20.6 (4.7-71.8) months. Three patients were lost to follow-up; 2 patients died from liver failure and no patient was transplanted. One patient had worsening strictures of the intrahepatic bile ducts with jaundice. Nine patients had persistent but minor strictures of the intrahepatic bile ducts on MR cholangiography, and persistent cholestasis without jaundice. One patient had normal liver function tests. CONCLUSIONS: In patients surviving their ICU stay, ICU cholangiopathy is not uniformly fatal in the short term or clinically symptomatic in the medium term. Preservation of the distal common bile duct appears to be a finding differentiating ICU cholangiopathy from other diffuse cholangiopathies.

Relevance of 3D Cholangiography and Transient Elastography to Assess Cystic Fibrosis-Associated Liver Disease?

Background. Cystic fibrosis-associated liver disease (CFLD) is a major cause of death. The objective of our retrospective study was to describe the relevance of magnetic resonance imaging (MRI) and liver stiffness measurement (LSM) for CFLD evaluation. Methods. All cystic fibrosis adult patients evaluated by MRI and LSM were included. MR signs of portal hypertension (PHT), dysmorphia, or cholangitis were collected and LSM expressed in kPa and Metavir. Results. Of 25 patients, 52% had abnormal MRI. Median LSM was 5.7 kPa (3.4-9.9). Three patients had F2 score and one had F3 score. In patients with PHT, LSM was 7.85 kPa (3.7-9.9) compared to 5 (3.4-7.5) in others, p = 0.02. In patients with abnormal liver function tests, 50% had increased LSM (≥F2), whereas 94% with normal tests had normal LSM (p = 0.04). Seven patients had abnormal MRI despite normal ultrasonography. Conclusions. MRI and LSM provide useful information on CFLD and may help to screen patients with PHT.

[Spontaneous intrahepatic hematoma: an unexpected etiology]. / Hématome intra-hépatique spontané : une étiologie inattendue.

INTRODUCTION: Diagnosis of AL amyloidosis can be complicated by the diversity and the absence of specificity of symptoms. CASE REPORT: We report a patient who presented with a non-traumatic hepatic hematoma, leading to the discovery of hepatic amyloidosis secondary to probable multiple myeloma. The originality of our report lies in the discovery of two acquired abnormalities of haemostasis: a factor X deficiency and an acquired von Willebrand syndrome, by a likely inhibitor. CONCLUSION: Our case report is a reminder of the importance of haemostasis analysis in AL amyloidosis.

Hepatic stellate cell proliferation is an early platelet-derived growth factor-mediated cellular event in rat cholestatic liver injury.

SUMMARY: After liver injury, hepatic stellate cells (HSC) undergo a pleiotropic response termed "activation" that also occurs in culture models and ultimately leads to the conversion of HSC into myofibroblasts expressing smooth muscle alpha-actin (alpha-SMA). The onset of HSC proliferation in primary culture coincides with the induction of platelet-derived growth factor receptor-beta (PDGFR-beta) expression, while platelet-derived growth factor (PDGF) is the most potent mitogen for culture-activated HSC. Yet, the mechanisms and the stage of activation required for HSC proliferation in the intact liver are still uncertain. In the present study, we analyzed the proliferative response of HSC to rat cholestatic liver injury and the role of PDGF in this response. After in vivo incorporation of bromodeoxyuridine (BrdU), pure vitamin A-containing HSC were isolated at different time points after bile duct ligation (BDL) or sham operation and were analyzed by means of flow cytometry. The induction of HSC proliferation, as ascertained by BrdU incorporation, occurred between 24 and 48 hours and reached a plateau as soon as 48 hours after BDL. Flow cytometry and immunoblot analyses of HSC indicated that the induction of proliferation in HSC coincided with the up-regulation of PDGFR-beta protein on their surface but preceded that of alpha-SMA. A dose-dependent inhibition of PDGF-BB-induced HSC proliferation by STI571, a PDGF receptor tyrosine kinase inhibitor, was documented in vitro. Daily intraperitoneal injections of STI571 (20 mg/kg) caused a 60% reduction in BrdU positive isolated HSC and in the amount of desmin-immunoreactive sinusoidal cells on liver tissue sections in 48-hour bile duct-ligated rats. These results indicate that cholestatic liver injury elicits an early proliferative response in HSC that is mainly mediated by PDGF, and which precedes HSC phenotypic conversion into myofibroblasts.

[Upper gastrointestinal bleeding in patients treated by low-dose aspirin]. / Hémorragies digestives hautes et aspirine à faible dose.

AIM OF THE STUDY: To estimate the number of people treated by low-dose aspirin (<330 mg daily) in France and to evaluate the risk of upper gastrointestinal bleeding associated with low-dose aspirin treatment. SUBJECTS AND METHODS: One thousand six hundred and two patients with upper gastrointestinal bleeding were included between January and June 1996 in 4 French areas. Data about patients characteristics, drugs recently used, and bleeding lesions were prospectively collected. Five hundred seventy five cases were matched for sex, age and area with control people without previous upper gastrointestinal bleeding. Low-dose aspirin intake in the population was estimated from the control group. Aspirin intake in the previous 7 days in cases and in controls was compared by logistic regression, adjusted for other gastrotoxic drugs intake. RESULTS: Low-dose aspirin is taken by about 1.2 millions adults in France. In 1 602 patients, gastrointestinal bleeding was related to a peptic ulcer in 34%. Aspirin was associated with higher risk of upper gastrointestinal bleeding: OR=1.68 (1.03-2.74) with low-dose, and OR 1.42 (0.91-2.21) with higher doses. CONCLUSION: About 2.8% of the population is exposed to low-dose aspirin in France. This treatment seems to be associated with a high risk of upper gastrointestinal bleeding.

Chronic hepatitis C with normal or abnormal aminotransferase levels: is it the same entity?

OBJECTIVE: The features of hepatitis C virus (HCV) infection with persistently normal serum alanine aminotransferase (ALT) activity levels are not well defined. This study evaluated the characteristics of HCV infection according to the presence or absence of elevated ALT. METHODS: Demographic data, liver histology and HCV genotype were studied in a group of 80 HCV-RNA-positive subjects with persistently normal ALT (PNALT) (group 1), and compared with a second group of 455 HCV-RNA-positive patients with elevated ALT (group 2). The annual progression of liver fibrosis was also calculated. RESULTS: A higher proportion of women was found in group 1:64% vs 42% in group 2 (P< 0.0002). The HCV genotype 1 was less frequent in group 1:49% vs 60% in group 2 and genotype 2 was more frequent: 16% in group 1 vs 4% in group 2 (P< 0.002). Cirrhosis was less frequent in group 1 (4% vs 13% in group 2 (P< 0.0001)). Normal liver was more frequent in group 1:9% vs 1% in group 2 (P< 0.0001). The Knodell score was significantly different between the two groups: 3.2 +/- 0.27 vs 7.15 +/- 0.22 (P< 0.0001). The progression of liver fibrosis was lower in group 1: 0.053 +/- 0.14 units/year vs 0.13 +/- 0.24 in group 2 (P < 0.007). CONCLUSION: HCV infection with PNALT is associated with less severe histological liver disease and a lower fibrosis progression rate. This suggests that the natural history of HCV infection in these patients is different from that in patients with abnormal ALT.

[Evaluation of spontaneous peri-transfusional screening for HVC and HIV at the Rouen University Hospital Center]. / Evaluation du dépistage spontané péri-transfusionnel des virus VHC et VIH au CHU de Rouen.

INTRODUCTION: Since October 1996, French hospitals have been instructed to introduce screening for hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in all patients before and 3 months after each blood transfusion. The aim of this study was to assess the degree to which this recommendation had been taken into account in a university hospital via a pre- and post transfusion screening comparison. PATIENTS AND METHODS: A retrospective study on the use or non-use of screening tests for HCV and HIV was carried out in 2 groups of 150 randomly selected patients who had received blood transfusions in 1996 and in 1998. RESULTS: The coverage by pre-transfusion screening tests for HCV and HIV varied from 23% in 1996 to 20% in 1998 (not significant). The post-transfusion screening tests were performed by the hospital in 6% of the cases in 1996 and in 3% of the cases in 1998 involving blood transfusion. CONCLUSION: This study suggests that in the majority of patients, screening (particularly post-transfusion screening) for HCV and HIV was not carried out, and that over the 2-year period considered no noticeable improvement was observed. However, these results only concerned one hospital in which no specific screening program had been introduced. It is therefore possible that these findings are not representative of the situation in other hospitals; further studies would be useful in this regard.

[Intrahepatic portocaval shunt: review of the literature, apropos of 1 case]. / Shunt porto-cave intra-hépatique. Revue de la littérature, à propos d'un cas.

We report a case of portal-hepatic shunt which was detected fortuitously by ultrasonography in a 66-year-old patient. This abnormality, mainly described in cirrhotic liver and rarely in healthy liver, is usually revealed by hepatic encephalopathy or glycoregulation disorders. We propose a diagnostic and therapeutic approach based on a review of the literature.

[Risk factors of contamination by hepatitis C virus. Case-control study in the general population]. / Facteurs de risque de contamination par le virus de l'hépatite C. Etude cas-témoins en population générale.

UNLABELLED: In 30% of patients with hepatitis C virus, the source of infection is unknown. OBJECTIVE: To identify the risk factors of infection by hepatitis C virus in a case-control study. METHODS: Cases had positive hepatitis C virus serology, and were living in Fecamp (Normandy, France). Controls (2 for each case) were age and sex-matched subjects with negative hepatitis C virus serology, living in Fecamp. Demographic, medical, professional, and environmental data were collected. Statistical analysis included chi 2 or Fisher's exact test and multiple logistic regression. RESULTS: The risk factors of hepatitis C virus by univariate analysis were: history of transfusion, high number of sexual partners, hepatitis C virus infection in a relative, history of digestive or genitourinary surgery, an invasive medical procedure, digestive endoscopy, biopsy, lumbar or pleural puncture, medical care after an accident, injections, multiple deliveries or abortion. Risk factors of hepatitis C virus infection by multivariate analysis: hepatitis C virus infection in a relative (Odds ratio: 4.58), history of transfusion (Odds ratio: 2.32), of a surgical procedure (Odds ratio: 2.50), of medical care after an accident (Odds ratio: 1.51), of injections (Odds ratio: 2.24). CONCLUSION: Our results suggest the possible nosocomial transmission of hepatitis C virus. Intrafamilial transmission is also possible.