Ultrasound detection of abdominal lymph nodes in chronic liver diseases. A retrospective analysis.

AIM: To retrospectively evaluate the prevalence of lymph nodes of the hepato-duodenal ligament in a group of patients with chronic liver disease of various aetiologies and to investigate what clinical, aetiological and laboratory data may lead to their appearance. MATERIALS AND METHODS: One thousand and three patients (554 men, 449 women) were studied, including 557 with chronic hepatitis and 446 with liver cirrhosis. The presence of lymph nodes near the trunk of the portal vein, hepatic artery, celiac axis, superior mesenteric vein and pancreas head was investigated using ultrasound. RESULTS: Lymph nodes were detected in 394 out of the 1003 study patients (39.3%); their number ranged from one to four, with a diameter ranging between 0.8 and 4 cm. The highest prevalence was in the subgroup of patients with primary biliary cirrhosis (87.5%), followed by patients with hepatitis C virus (HCV; 42%), patients with HCV and hepatitis B virus (HBV; 41.3%), autoimmune hepatitis (40%), and HBV alone (21.2%). In the alcoholic and idiopathic subgroups prevalence was 9.5%, while in the non-alcoholic steatohepatitis and haemochromatosis subgroups it was 0%. HCV RNA was present in 97 out of 103 lymph node-positive patients and in 141 out of 168 lymph node-negative HCV-negative patients (p<0.003). Lymphadenopathy frequency increased as the liver disease worsened (chi(2) MH=74.3; p<0.0001). CONCLUSION: Despite the limitations of a retrospective study, our data indicate a high prevalence of lymphadenopathy in liver disease patients; ultrasound evidence of lymph nodes of the hepato-duodenal ligament in a given liver disease may most likely suggest a HCV or an autoimmune aetiology and a more severe histological picture.

Hemodynamic changes in splanchnic circulation after orthotopic liver transplantation in patients with liver cirrhosis.

BACKGROUND: Liver cirrhosis increases portal vein pressure and alters the splanchnic circulation. With Doppler sonography, we investigated the hemodynamic changes in the portal vein, superior mesenteric artery, hepatic and splenic arteries and spleen size in a group of patients with end-stage liver disease before and after orthotopic liver transplantation (OLT). METHODS: Ten patients (seven male, three female; mean age = 48.8 +/- 7.6 years) who underwent OLT for liver cirrhosis mainly associated with hepatitis C virus infection completed the study. The control group consisted of 10 patients matched by sex and age who had no gastroenterologic or vascular diseases. All patients underwent duplex Doppler sonography (Toshiba SSA 270A with a 3.5-MHz probe) after 24 h of fasting (baseline) and then 6 and 12 months after OLT. The following parameters, expressed as the mean of three measurements, were evaluated: portal flow velocity (PFV), pulsatility index of the superior mesenteric artery (MAPI), resistance indexes of the hepatic (HARI) and splenic (SARI) arteries, and longitudinal diameter of the spleen (LDS). RESULTS: PFV in the pre-OLT phase was significantly lower in the patients than in the controls ( p < 0.0001); it progressively and significantly increased over baseline levels at 6 and 12 months ( p < 0.0001), approaching control values. LDS in the pre-OLT phase was significantly higher than in controls ( p < 0.0001); after OLT, it decreased significantly compared with baseline values ( p < 0.005). The MAPI of patients in the pre-OLT phase was lower than that in controls ( p < 0.0001); post-OLT, it progressively increased and reached values that were significantly above baseline at 12 months ( p < 0.005). In the pre-OLT phase, the HARI and SARI were significantly higher than in controls ( p < 0.04); 6 and 12 months after OLT, those values were significantly below baseline values ( p < 0.001), and there was no significant difference from control values. CONCLUSION: These data show that many of the hemodynamic parameters typical of decompensated cirrhosis improve progressively within 12 months after transplantation.

Screening for autoantibodies to tissue transglutaminase reveals a low prevalence of celiac disease in blood donors with cryptogenic hypertransaminasemia.

Patients with chronic cryptogenic hypertransaminasemia are at high risk of developing celiac disease (CD). In fact, among the various serological disorders, CD patients at onset frequently present hypertransaminasemia. In this study, we evaluated usefulness and reliability of the new test for antitissue transglutaminase (tTG) in screening for CD as well as in estimating the prevalence of CD in a population of blood donors presenting unexplained hypertransaminasemia at donation. Controls were 180 consecutive healthy donors without hypertransaminasemia and 20 CD patients with known antiendomysial antibody (EmA) positivity. Out of 22,204 blood donors over a period of 2 years, we found 258 subjects (1.2%) with cryptogenic hypertransaminasemia. Four of these subjects (1.5%) were positive for anti-tTG, but only 3 of them were positive for EmA. EmA were negative in all the remaining hypertransaminasemia subjects. In the control groups, anti-tTG antibodies were negative in all the 180 healthy donors without hypertransaminasemia, but positive in all the CD patients known to be EmA positive. 3 of the 4 subjects positive for anti-tTG, including 2 who were also EmA positive, underwent biopsy of the distal duodenal mucosa which showed a picture compatible with CD only in the 2 patients with concomitant EmA positivity. After 3 months of gluten-free diet, the serum transaminase values normalized in these 2 patients. In conclusion, the prevalence of CD in our blood bank population was lower than that reported in other similar studies, but the new test for anti-tTG showed a good sensitivity and reliability, and, therefore, it can be proposed as a first-level test in screening for CD in selected populations such as subjects with hypertransaminasemia.

Evaluation by ultrasound of abdominal lymphadenopathy in chronic hepatitis C.

OBJECTIVE: Abdominal ultrasound has shown a frequent association between abdominal lymphadenopathy (LA) and chronic liver disease, but contradictory data have been reported on its relationship with the main parameters of hepatic function. The aim of this study was to correlate the prevalence of LA in patients who were chronic hepatitis-anti-hepatitis C virus positive prospectively followed-up over the last 3 years and its relationship with biochemical and histological data. METHODS: 136 RIBA II confirmed positive patients with ALT levels >2N were included. None of these had been or was at the time of study on interferon treatment. Ultrasound was performed using a Toshiba SSA 240 A apparatus with a 3.75 MHz convex probe; the operator was unaware of the other results. Diagnosis of chronic hepatitis in all cases was made on biopsy specimens; the histological activity index (HAI) score, according to Knodell, and the grading (G) and staging (S) scores, according to Desmet, were also evaluated. RESULTS: LA was found in 54 out of 136 patients (40%); accordingly, patients were divided into two groups: the LN + ve group included 54 patients (M 33, mean age 48.1+/-11.7 yr) and the LN-ve group included 82 patients (M 69, mean age 45.3+/-11.9 yr). LN + ve patients showed significantly higher serum levels of AST (p < 0.0005), ALT (p < 0.001), gammaGLO (p < 0.05) and gammaGT (p < 0.02) than LN - ve patients. There was a more severe degree of liver disease in LN + ve patients, expressed by the higher HAI (p < 0.002), G (p < 0.002), and S (p < 0.005). The chi2 test for linear association analysis confirmed the trend toward greater histological severity in LN + ve patients (chi2 MH = 10.2; p < 0.002). Logistic regression confirmed the association between the presence of LA and AST (p < 0.02), ALT (p < 0.03), G (p < 0.02), and S (p < 0.02). CONCLUSION: This study showed a moderate prevalence of LA in chronic hepatitis C, lower than that reported in other studies. LA was associated with serum parameters of cytolysis, and above all, with the severity of histological damage.

[Clinical and etiologic features of hepatocarcinoma in Sicily]. / Aspetti clinici ed etiologici dell'epatocarcinoma in Sicilia.

Hepatocellular carcinoma is a neoplasia with a high degree of malignancy and a quite unfavorable prognosis, and its frequency has tripled over the last 30 years. The aim of this study was to shed further light on some epidemiological and clinical aspects of hepatocellular carcinoma, on the basis of experience with a wide ranging patient population. We included 179 patients (127 males, 52 females, age range 31-86 years), diagnosed with hepatocellular carcinoma between January 1993 and December 1998. For each patient we recorded age, sex, coexistence and cause of cirrhosis, severity of cirrhosis, stage of hepatocellular carcinoma, serum markers of viral hepatitis (hepatitis B surface antigen and hepatitis C virus antibodies) and serum levels of alpha-fetoprotein. Hepatocellular carcinoma was associated with hepatitis C virus in 72% of patients, with hepatitis B virus in 10%, with combined infection in 3% and with negative viral markers in 15%. Mean age at diagnosis was significantly higher in the hepatitis C virus infection patients than in the combined infection patients (p < 0.04); the male/female ratio was 2.1:1 in the hepatitis C virus and 8:1 in the hepatitis B virus subjects. At hepatocellular carcinoma diagnosis, 175 out of 179 patients had liver cirrhosis with a significantly higher severity in patients with negative viral markers than in those with positive viral markers (p < 0.02). The stage of hepatocellular carcinoma at diagnosis was very advanced: in 103 out of 179 cases (58%) neoplasia was stage IV, with a stage I diagnosis in only 14 out of 179 (8%) cases. All the combined (hepatitis B and C virus) cases were diagnosed at stage IV, while hepatocellular carcinoma cases in patients with negative viral markers were diagnosed at earlier stages (66% stages I-II). Serum alpha-fetoprotein levels were above the normal limit (20 ng/mL) in 72% of patients; however, only 30% (54/179) had alpha-fetoprotein values > 400 ng/mL. These data confirm some previous epidemiological and clinical evidence concerning hepatocellular carcinoma (mean age at diagnosis, male/female ratio, severity of pre-existing liver disease, frequency of an associated hepatitis C and/or hepatitis B virus infection). Data based on such a large population, moreover, aid clarification of some still unresolved points such as the utilization of alpha-fetoprotein values in diagnosing hepatocellular carcinoma.

Ultrasound detection of abdominal lymphadenomegaly in subjects with hepatitis C virus infection and persistently normal transaminases: a predictive index of liver histology severity.

BACKGROUND/AIMS: The indications for liver biopsy in anti-HCV-positive patients with persistently normal alanine aminotransferase levels are not clearly established. Recent studies have correlated the presence of abdominal lymphoadenomegaly with disease severity in patients with chronic hepatitis C. Our study aimed to evaluate the frequency of abdominal lymphoadenomegaly in an anti-HCV positive blood donor population with persistently normal alanine aminotransferase and the relationship of abdominal lymphoadenomegaly with the severity of liver changes. METHODS: Eighty-six anti-HCV positive blood donors (58 M, 28 F) with normal alanine aminotransferase were followed up for a median of 31 months (range 12-50). To evaluate the frequency of abdominal lymphoadenomegaly, all patients underwent ultrasound scan. The common parameters of liver function as well as serum HCV RNA levels were determined. Histological changes were evaluated both in a conventional manner and using the numerical scoring systems of Knodell and Desmet. RESULTS: Of the 86 donors, 68 (79%) maintained persistently normal alanine aminotransferase levels during follow-up, and abdominal lymphoadenomegaly was present in 15 of them (22.0%). The remaining 18 donors (21%) showed rises in alanine aminotransferase above normal levels during the follow-up and seven of them (38%) had abdominal lymphoadenomegaly (p=n.s.). In the subjects with normal alanine aminotransferase, there were no significant differences in the common parameters of liver function and the serum presence of HCV RNA between those with or without abdominal lymphoadenomegaly. Normal liver was found in five patients without abdominal lymphoadenomegaly, but never in patients with abdominal lymphoadenomegaly. Analysis with the Mantel-Haenszel test showed a trend toward more serious changes in patients with abdominal lymphoadenomegaly (chi-square MH=9.5, p<0.003). Histological changes did not differ when Knodell's score was used; in contrast, staging, evaluated by Desmet's score, and periportal necrosis were significantly higher in subjects with abdominal lymphoadenomegaly (p<0.01 and p<0.004, respectively). Multiple logistic regression showed a significant relation between histological changes and the presence in serum of HCV RNA (p<0.004) and gamma-globulin (p<0.002), and abdominal lymphoadenomegaly p<0.003). CONCLUSION: Our study shows a prevalence of 22.0% of abdominal lymphoadenomegaly in anti-HCV positive subjects with normal alanine aminotransferase values and a relationship with the degree of liver histology change. Therefore, we suggest that the evidence of abdominal lymphoadenomegaly in these patients could be an indication to perform liver biopsy.

Transmission of hepatitis C virus: a study of the main risk factors in a Sicilian population of volunteer blood donors.

BACKGROUND/AIMS: The Hepatitis C virus (HCV) is quite widespread in Sicily, and in the absence of a vaccine, prophylaxis is important. In order to determine the most effective means of prophylaxis, we must first understand the main vectors of transmission. METHODOLOGY: We performed a case control study on 274 consecutive anti-HCV virus positive subjects and compared them with 548 anti-HCV negative subjects, matched for sex and age and selected from voluntary blood donors. The modes of transmission were investigated by means of a detailed questionnaire focused on the common risk factors of HCV contagion. RESULTS: Univariate analysis showed associations between HCV infection and transfusions (OR 23.0), surgery (OR 2.2), family history of chronic liver disease (OR 4.54), and drug addiction (OR 5.74). Multiple logistic regression indicated that transfusions (p < 0.0001), surgery (p < 0.002), family history (p < 0.0001), drug addiction (p < 0.002) and alcohol consumption (p < 0.002) are related to the development of HCV infection. CONCLUSIONS: The modes of transmission of HCV in an endemic area of Sicily do not greatly differ from those in other Italian regions; the subjects at greatest risk were those who had received blood transfusions or underwent surgery, alcoholics, drug abusers and those with a family history of chronic liver disease, who are probably more exposed to contracting the infection by non-conventional ways of transmission.

[Wilson's disease]. / Morbo di Wilson.

Wilson's disease is a rare inherited metabolic disorder usually characterized by liver and/or neurological degeneration. Unlike most genetically transmitted diseases, it rapidly responds to pharmacological treatment in case of early diagnosis and treatment. Often, however, as this disease presents with aspecific symptoms, patients are wrongly diagnosed as psychiatric cases or as having generic chronic liver disease and the true cause of symptoms is only discovered at a much later stage. The authors give a detailed review of the literature with the aim of presenting the most recent research on the main aspects of this disease and offering a practical and simple approach to early diagnosis.

[Ultrasonographic assessment of gallbladder motility in obese subjects]. / Valutazione ecografica della motilità colecistica nei soggetti obesi.

The reduction in gallbladder motility could play an important role in the pathogenesis of cholesterinic lithiasis by favouring the precipitation of cholesterol crystals, especially in obese subjects who, as is well known, present a greater biliary secretion of cholesterol. In the present study we evaluated, by ultrasonography, the emptying capacity of gallbladder following a liquid meal in 20 obese subjects (BMI 37.8 +/- 11.8 kg/m2) and in 20 control subjects (BMI 23.2 +/- 1.7 kg/m2). The base and residual volume of the gallbladder, expressed in ml, were significantly higher in the obese group than in the controls: 30.7 +/- 11.8 vs 22.0 +/- 6.7 (t = 2.88 p < 0.001) and 14.6 +/- 7.14 vs 10.2 +/- 4.7 (t = 2.14 p < 0.04), respectively. However, there was no significant difference between the percentages of gallbladder emptying in the two study groups, although in the obese subjects the minimum volume was reached at the 60th minute, while in the controls it occurred at 40 minutes. Our data, in agreement with most reports in the literature, indicate that the volume of the gallbladder is greater in obese subjects and they do not present an intrinsic defect in gallbladder contractility; therefore this condition can be excluded from the risk factors of biliary lithiasis in obese subjects.

[Procollagen III and laminin in chronic viral hepatopathies]. / Procollagène III et laminine dans les hépatopathies chroniques d'origine virale.

OBJECTIVES: We measured serum concentrations of the N-terminal peptide of type III procollagen (PIIIP) and laminin (Lam-P1) in patients with chronic viral liver disease in the various stages of the clinical course, to judge their value in assessing liver fibrogenesis, and also compared them with a number of liver function tests and histological scores of inflammation and fibrosis. METHODS: Twenty-nine patients with chronic persistent hepatitis, 39 with chronic active hepatitis and 42 with liver cirrhosis were studied. The control group was composed of 45 healthy blood donors. Serum PIIIP and Lamp-P1 were determined by radioimmunoassay; hepatic function was measured by routine assay; liver fibrosis and inflammation were graded on a 0-3 score scale. RESULTS: A significantly higher increase in serum levels of PIIIP and Lam-P1 was found in the liver cirrhosis group compared with the other groups (p < 0.05). Serum PIIIP correlated with transaminase levels in the chronic active hepatitis group and with gammaglobulin and total bilirubin in the liver cirrhosis group. A positive correlation was found only with gammaglobulin and total bilirubin in the cirrhosis group. A positive correlation was found between serum PIIIP levels and the rating scale of liver necrosis. In contrast, for Lam-P1 values, a correlation with the rating scale of necrosis and fibrosis was found. CONCLUSION: Our findings confirmed the increase of PIIIP and Lamp-P1 in chronic viral liver disease, but because of the frequent overlap values, they cannot be used as substitutes for liver biopsy for diagnosis. The correlations with the histological findings indicate that these two markers can be used during the follow-up of patients receiving anti-inflammatory or anti-fibrotic treatment.