Portal hypertension in primary biliary cholangitis: prevalence, natural history and histological correlates.

OBJECTIVES: The histopathological mechanisms underlying portal hypertension in primary biliary cholangitis (PBC) are poorly understood, as is its natural history. We have therefore determined the prevalence, severity and progression of portal hypertension in PBC and investigated whether its presence is related to specific histological lesions. METHODS: Hepatic venous pressure gradient (HVPG) was measured in 86 patients, with 186 assessments over up to 7 years of follow-up and the results correlated with a semiquantitative grading of 8 histological features and nodular regenerative hyperplasia (NRH). RESULTS: Portal hypertension (HVPG >5 mmHg) was present in 88% of all assessments (86% at baseline), and in 45% of patients at baseline was >12 mmHg (high-risk portal hypertension). The rise in portal pressure occurs early in the disease, since 45% of patients with normal serum bilirubin had a raised HVPG, as did 72% of patients with early (Ludwig stages 1 and 2) disease. After baseline, there was a small increase in HVPG over the next 5 years in most patients. In patients with precirrhotic PBC, 82% had portal hypertension and in 34% this was >12 mmHg. Portal pressure correlated significantly with a semiquantitative grading of cholestasis, interface hepatitis and portal tract and sinusoidal fibrosis. NRH was present in only 20% of wedge biopsies. CONCLUSIONS: Portal hypertension commences in the early stages of PBC, long preceding both rises in serum bilirubin and the development of cirrhosis. Around 34% of precirrhotic PBC patients have 'high-risk' portal hypertension, which is associated with lesions in the portal tracts and sinusoids rather than with NRH.

Pelvic radiation therapy: Between delight and disaster.

In the last few decades radiotherapy was established as one of the best and most widely used treatment modalities for certain tumours. Unfortunately that came with a price. As more people with cancer survive longer an ever increasing number of patients are living with the complications of radiotherapy and have become, in certain cases, difficult to manage. Pelvic radiation disease (PRD) can result from ionising radiation-induced damage to surrounding non-cancerous tissues resulting in disruption of normal physiological functions and symptoms such as diarrhoea, tenesmus, incontinence and rectal bleeding. The burden of PRD-related symptoms, which impact on a patient's quality of life, has been under appreciated and sub-optimally managed. This article serves to promote awareness of PRD and the vast potential there is to improve current service provision and research activities.

Lymph node harvest in colon and rectal cancer: Current considerations.

The prognostic significance of identifying lymph node (LN) metastases following surgical resection for colon and rectal cancer is well recognized and is reflected in accurate staging of the disease. An established body of evidence exists, demonstrating an association between a higher total LN count and improved survival, particularly for node negative colon cancer. In node positive disease, however, the lymph node ratios may represent a better prognostic indicator, although the impact of this on clinical treatment has yet to be universally established. By extension, strategies to increase surgical node harvest and/or laboratory methods to increase LN yield seem logical and might improve cancer staging. However, debate prevails as to whether or not these extrapolations are clinically relevant, particularly when very high LN counts are sought. Current guidelines recommend a minimum of 12 nodes harvested as the standard of care, yet the evidence for such is questionable as it is unclear whether an increasing the LN count results in improved survival. Findings from modern treatments, including down-staging in rectal cancer using pre-operative chemoradiotherapy, paradoxically suggest that lower LN count, or indeed complete absence of LNs, are associated with improved survival; implying that using a specific number of LNs harvested as a measure of surgical quality is not always appropriate. The pursuit of a sufficient LN harvest represents good clinical practice; however, recent evidence shows that the exhaustive searching for very high LN yields may be unnecessary and has little influence on modern approaches to treatment.

The malignant adenoma: when to operate and when to watch.

BACKGROUND: Adenomas are the precursors to colorectal cancer. Malignant adenomas represent an early form of colorectal cancer, in which cancer has invaded by direct continuity through the muscularis mucosa into the submucosa. The management of these malignant adenomas depends upon their histological risk factors and the patient's general condition. METHODS: A literature review of publications regarding the malignant adenoma/polyp using Medline was performed. RESULTS: The three main histological characteristics associated with an increased risk of residual disease and the potential for metastases are completeness and margin of excision, degree of differentiation and Haggitt level of invasion. CONCLUSION: The dilemma as to which course of action is in the best interest of the patient with high-risk adenoma, be it either therapeutic polypectomy alone or surgical resection, is best resolved by a multidisciplinary team involving the surgeon, pathologist and endoscopist, taking the patient's condition and wishes into account.

Pseudohepatic tumour associated with secondary syphilis in an HIV-positive male.

Inflammatory pseudohepatic tumours are unusual tumour-like conditions which can easily be mistaken for malignant lesions or liver abscesses. Patients usually present with fever, abdominal pain and loss of weight. The aetiology is unclear but the predominant inflammatory pattern of pathology and the associated systemic reactions suggest an underlying infectious agent. In the majority, microorganisms are not detected. As even routine imaging procedures usually fail to distinguish hepatic pseudotumours from liver neoplasms, biopsy is the definitive means of diagnosis. Until now, no case of pseudohepatic tumour has been reported as being associated with secondary syphilis. We believe secondary syphilis is the cause of this pseudohepatic tumour in our HIV-positive male.