Bleeding after invasive procedures is rare and unpredicted by platelet counts in cirrhotic patients with thrombocytopenia.

BACKGROUND: In cirrhotics with low circulating platelets (PLT), restoration of normal cell counts has been traditionally recommended before invasive procedures. However, there is neither consensus on the PLT transfusion threshold nor evidence of its clinical efficacy. PATIENTS: In order to fill this gap of knowledge, we prospectively collected and analyzed data on circulating PLT counts [and International Normalized Ratio (INR)] values in a case series of 363 cirrhotics scheduled to undergo invasive investigations. PLT and/or fresh-frozen plasma (FFP) units were infused at the discretion of the attending physician, and the occurrence of post-procedural bleeding was related to pre-and post-infusion results. RESULTS: 852 Procedures were carried out in 363 cirrhotics sub-grouped according to the Child-Pugh-Turcotte (CPT) classification (class A/B/C: 124/154/85). The infusion of PLT and/or FFP improved only marginally circulating PLT counts and INR values. Ten post-procedural bleeds occurred in the whole case series, i.e. 1 episode every 85 procedures or every 36 patients. Post-procedural bleeding was unrelated to the PLT counts, to the degree of INR abnormalities, nor to the CPT classes, but was more frequent in patients who underwent repeated investigations. In the 10 patients with the most profound alterations in PLT and/or INR values, no post-procedural bleeding occurred. CONCLUSIONS: In cirrhotic patients with low PLT and/or abnormal INR values undergoing invasive investigations, post-procedural bleeding was rare and unpredicted by PLT counts or abnormal INR values. In particular, the recommendation to infuse platelets when counts are <50×103/L is not substantiated by this case series of cirrhotic patients.

Hepatocellular carcinomas <2 cm in diameter complicating cirrhosis: ultrasound and clinical features in 153 consecutive patients.

PURPOSE: To determine the frequencies of various echogenicity patterns in 153 consecutive unifocal hepatocellular carcinomas (HCCs) <2 cm detected in cirrhotic livers and to identify their relationships with clinical, laboratory, and microscopic features. PATIENTS AND METHODS: The tumors were classified as hypoechoic, hyperechoic, isoechoic, or nodule-in-nodule. Correlation was evaluated between hypoechoic and hyperechoic patterns and the following variables: age, gender, serum alphafetoprotein (AFP), tumor size, ultrasound features of liver parenchyma, cirrhosis etiology, and cyto/histological tumor grading. RESULTS: One hundred and seventeen tumors (76.4%) were hypoechoic, 26 (17.0%) were hyperechoic, 5 (3.3%) were isoechoic, and 5 (3.3%) had nodule-in-nodule patterns. The hyperechoic pattern was more common in patients under 69 years (25.0% vs. 11.3% in those under 69 years or older, P=0.033). Patients with a hyperechoic pattern displayed a trend towards lower AFP levels and higher prevalence of hepatitis C-related cirrhosis. The prevalence of well-differentiated tumors was identical (56.6% and 56.5%) in the hypoechoic and hyperechoic subgroups. AFP was higher than 400 ng/ml in only 11/153 cases (7.2%). CONCLUSIONS: The hyperechoic pattern of HCC is by no means uncommon, particularly in patients under 70. Hyperechogenicity is not related to an increased frequency of well-differentiated tumors. AFP shows limited value as a confirmatory test of small HCC.

Diagnosis of liver nodules observed in chronic liver disease patients during ultrasound screening for early detection of hepatocellular carcinoma.

OBJECTIVES: The aim of our study was to evaluate the nature of focal liver lesions detected during the ultrasound follow-up of a population (prevalently anti-hepatitis C virus [anti-HCV] positive) with chronic liver disease. METHODS: The study population consisted of 1827 consecutive newly diagnosed chronic liver disease cases without liver nodules at enrollment. Patients were screened at 4-month intervals by ultrasound and serum alpha-fetoprotein assessment. All lesions detected on imaging studies (except those accompanied by diagnostic a-fetoprotein levels) were subjected to biopsy (histology and cytology). RESULTS: During the 7-yr follow-up period (mean = 43.1 months), one or more solid focal lesions were found in 287 patients. a-Fetoprotein was diagnostic for hepatocellular carcinoma in 51 patients. Ultrasound-guided fine-needle biopsy was performed in the remaining 236 patients, yielding a diagnosis in 214: 198 hepatocellular carcinomas, 11 dysplastic nodules, and five B-cell non-Hodgkin's lymphomas (all confined to the liver and all in patients with chronic HCV infection). Twenty-two patients with nondiagnostic biopsies received diagnoses of hepatocellular carcinoma (20) or dysplastic nodules (two) based on arteriography or surgical biopsy. CONCLUSIONS: Focal lesions arising in patients with HCV-related chronic liver disease can be other than hepatocellular carcinoma, and ultrasound-guided fine-needle biopsy plays an important role in their diagnosis. The prevalence of non-Hodgkin's lymphoma in this selected population was 0.31%. The fact that all five lymphoma patients had cirrhosis related to hepatitis C strengthens the hypothesis of an etiological correlation between the latter infection and B-cell lymphoproliferative disorders.