[Anti LKM-1 antibodies and cryoglobulinemia in autoimmune chronic hepatitis and virus C hepatitis]. / Anticuerpos anti LKM-1 y crioglobulinemia en hepatitis crónica autoinmune y por virus C de la hepatitis.

BACKGROUND: Anti liver kidney microsome antibodies (LKM-1) have been recently incorporated to the study and classification of chronic autoimmune hepatitis (HC-A1). The presence of anti LKM-1 antibodies and essential cryoglobulinemia is frequent in virus C associated chronic hepatitis (HC-VC). AIM: To study the frequency of anti LKM-1 antibodies and cryoglobulin levels in patients with HC-AI, HC-VC and cryptogenic cirrhosis. PATIENTS AND METHODS: Forty-two patients were studied. Nineteen adult women with classic HC-AI with positive antinuclear or anti smooth muscle antibodies. Five patients of less than 20 years old with HC-AI and negative antinuclear and anti smooth muscle antibodies. Ten adult women with cryptogenic cirrhosis, 4 women and 4 men with HC-VC. Serum samples were obtained at 37 degrees C. Antinuclear, anti smooth muscle and anti LKM-1 antibodies were measured by indirect immunofluorescence using Hep-2 cells and rat tissue slices as substrates. Cryoglobulins were determined by the traditional method and cryocrit. RESULTS: All studied patients were anti LKM-1 negative. All had significant circulating cryoglobulin levels. CONCLUSIONS: In this sample of patients with HC-AI or HC-VC, anti LKM-1 antibodies were not detected but all had cryoglobulinemia.

[Hepatitis C virus and resulting diseases]. / El virus C de la hepatitis y las enfermedades que produce.

In 1989, the main agent causing non A non B hepatitis was identified as a RNA virus of the flavivirus family, with several serotypes, and was denominated virus C. At the present moment, the knowledge about the infection features and diseases that it causes has expanded thanks to the availability of reliable laboratory techniques to detect the antibody and the virus. The prevalence of infection and the frequency of serotypes varies in different regions of the world. Chile is a country with a low prevalence. The detection of infected blood in blood banks has reduced the spreading of the disease. Other means of infection such as the use of intravenous drugs, hemodialysis and transplantation have acquired greater importance. Sexual, maternal and familial transmission is exceptional. Infected people develop an acute hepatitis, generally asymptomatic. Eighty percent remain with a chronic hepatic disease, that can be mild or progressive, evolving to cirrhosis or hepatic carcinoma. Chronic hepatitis, closely resembling an autoimmune disease, can be caused by the virus. Alcohol intake increases viral activity causing severe hepatic diseases, refractory to treatments. Several non hepatic diseases are associated to hepatitis C virus infection such as essential mixed cryoglobulinemia, mesangiocapillary glomerulonephritis, porphyria cutanea tarda, dysglobulinemias and probably type 2 diabetes mellitus. The only available treatment is interferon, that is successful in a minority of patients, frequently causing a transient improvement. The use of Ribaravine associated to interferon improve the effectiveness of therapy. Liver transplantation is the only therapy for severe hepatic disease. The use of new antiviral drugs should improve the prognosis of the disease.

[Gallbladder polyps. 2d Consensus Workshop of the Chilean Hepatology Association]. / Pólipos vesiculares. Segundo taller de consenso de la asociatión chilena de hepatología.

During a workshop, hepatologists analyzed and gave recommendations about gallbladder polyps. They arrived to the following agreements: gallbladder polyps of less than 10 mm should be followed with ultrasonography at 3, 6 and 12 months if there is no enlargement. If there is enlargement, a cholecystectomy should be performed. Polyps larger than 10 mm should be subjected to cholecystectomy.

[Prevention of digestive hemorrhage recurrence in hepatic cirrhosis with propranolol. A 4 years' follow-up study]. / Prevención de la recidiva de hemorragia digestiva en cirrosis hepática con propanolol. Seguimiento de cuatro años.

The aim of this study was to assess the effect of propranolol treatment on the recurrence of variceal bleeding and mortality in patients with hepatic cirrhosis. Fifty seven patients were studied; they were recruited within 15 days of an episode of variceal bleeding, assigned randomly to receive propranolol (n = 29) placebo (n = 28) and followed during 4 years. Three patients were lost from follow up and in 3 propranolol was discontinued due to secondary effects. Bleeding recurrence was less frequent in the treated patients (Kaplan Meier analysis p < 0.01). Ten patients on placebo and 1 receiving the active drug died. Life table analysis showed a significantly better survival in the group of patients treated with propranolol. It is concluded that propranolol decreases the recurrence of variceal bleeding and improves survival in patients with hepatic cirrhosis.

[Hepatitis C virus antibodies in chronic non-alcoholic liver disease]. / Anticuerpos anti-virus C de la hepatitis (HCV) en enfermedad hepática crónica no alcohólica.

The presence of hepatitis C virus antibodies was studied in 64 patients with non alcoholic liver disease and found in 11 (17%). The greater frequency of positive antibodies was found among patients with cryptogenetic liver disease, specially those without serum auto-antibodies (32%). The antibody was unusually found (0 to 11%) in non alcoholic liver diseases of other etiologies. It is concluded that hepatitis C virus chronic infections may be the etiology of an important number of non alcoholic chronic liver diseases.

[Liver cirrhosis and portal hypertension: non-invasive measurement of blood flow in the portal vein with Doppler-duplex]. / Cirrosis hepática e hipertensión portal: medición no invasiva del flujo sanguíneo de la vena porta con Doppler-duplex.

Doppler-duplex has been widely used to quantify blood flow. Nevertheless, its usefulness in assessing portal vein flow (PVF) has been questioned due to technical problems: vessel cross sectional area measurements, interobserver variability, and PVF changes related to physiological events. This study was aimed to measure PVF in patients with cirrhosis and portal hypertension, to estimate changes in PVF during the respiratory cycle, and to evaluate intraobserver variability of Doppler-duplex technique. Twenty-two patients with liver cirrhosis and portal hypertension and 22 healthy subjects were included. One operator made 6 measurements of portal vein diameter (D) and mean flow velocity in inspiration and aspiration. Area of the vessel (A) and PVF were calculated by a microprocessor. Interobserver variability was estimated for each subject and a mean was determined for each group. In the control group, PVF was 901 +/- 39 ml/min in inspiration and 633 +/- 38 ml/min in aspiration; p < 0.001. In patients with cirrhosis PVF was 1303 +/- 121 ml/min in inspiration and 1003 +/- 96 ml/min in aspiration; p < 0.001. Intraobserver variability was 6.0 +/- 0.6% for D, 12.0 +/- 3% for MV and 18.3 +/- 1.6% for PVF in healthy subjects and 5.3 +/- 0.7% for D, 9.2 +/- 0.9% for MV and 15.2 +/- 1.5% for PVF in patients with cirrhosis and portal hypertension. In conclusion, PVF is significantly increased in cirrhotics. PVF was higher in inspiration than espiration in both groups. The Doppler-duplex method evaluation of PVF has an important intraobserver variability (18.3 +/- 1.6%). Then, changes in PVF less than 20% are not accurately measured by this technique.

Effects of nitroglycerin on forearm haemodynamics in patients with cirrhosis.

1. Basal forearm haemodynamics were studied by venous occlusion plethysmography in three groups of subjects: group I, healthy controls, group II, patients with cirrhosis age- and sex-matched with group I, and group III, an older group of patients with cirrhosis. Subsequently, responses to sublingual nitroglycerin were measured in group I and II subjects. 2. Controls responded to nitroglycerin with an increase in venous distensibility; group II patients had higher initial venous distensibility but did not respond to nitroglycerin. No other variables in either group were affected by nitroglycerin. 3. Group II and III patients differed in forearm blood flow and vascular resistance and venous distensibility. A significant inverse correlation was found between age and forearm blood flow (r = 0.57, P less than 0.001) in all patients with cirrhosis. 4. We conclude that (a) venous tone is reduced in cirrhosis, possibly as a result of chronic venodilatation; (b) this venodilatation impedes further dilatory response to a small dose of nitroglycerin; (c) cirrhosis is also associated with age-related decreases in peripheral haemodynamics.

Naloxone does not alter haemodynamics in cirrhosis. Studies in humans and rats.

In order to test the hypothesis that endogenous opioids may mediate some of the circulatory derangements in cirrhosis, we studied the haemodynamic effects of naloxone, an opioid antagonist, in patients and in a rat model of biliary cirrhosis. In 9 patients with alcoholic cirrhosis and 5 control patients without significant liver disease, cardiac output, systemic vascular resistance, mean arterial pressure, heart rate, hepatic venous pressures and O2 content, hepatic and azygos blood flows and serum catecholamines were measured before and 30 min after naloxone 3.2 mg i.v. bolus. No significant changes were observed in either group of patients. Similarly in 16 conscious rats, 8 sham-operated and 8 with cirrhosis due to bile duct ligation, cardiac output, systemic vascular resistance, mean arterial pressure, heart rate, and splanchnic organ blood flows were measured by radioactive microspheres, before and 20 min after naloxone 1 mg/kg i.v. bolus. No significant changes were observed in either group. We failed to detect any evidence that endorphins are involved in tonic haemodynamic control in cirrhosis.

Failure of haemodynamic measurements to predict recurrent gastrointestinal bleeding in cirrhotic patients receiving propranolol.

In an attempt to identify the haemodynamic factors predicting the recurrence of gastrointestinal bleeding in cirrhotic patients receiving propranolol, haemodynamic measurements were prospectively collected. Systemic and splanchnic haemodynamics were assessed before propranolol administration. Among 77 patients receiving propranolol, 24 re-bled and 53 did not re-bleed in a follow-up period of 30-730 days (median 540). There was no difference between patients with and without recurrent bleeding with regard to the initial value of heart rate, mean arterial pressure, cardiac index, and hepatic venous pressure gradient. A subgroup of 43 patients was further investigated for the haemodynamic response to one single dose of 40 mg of propranolol. No difference was observed in the propranolol-induced changes of heart rate, mean arterial pressure, cardiac index or hepatic venous pressure gradient, between patients with (n = 14) and those without (n = 29) recurrent bleeding while taking propranolol. In conclusion, systemic haemodynamics and hepatic venous pressure gradient have no predictive value in evaluating the risk of recurrent bleeding in cirrhotic patients receiving propranolol. Furthermore, therapeutic efficacy of propranolol cannot be predicted from the haemodynamic response to a single first dose of this substance.

Possible deleterious hemodynamic effect of nifedipine on portal hypertension in patients with cirrhosis.

The acute effects of nifedipine, 10 mg administered sublingually, were studied in 10 patients with alcoholic cirrhosis. Nifedipine significantly increased cardiac output and reduced systemic vascular resistance. Nifedipine also increased the hepatic venous pressure gradient by 15% (P less than 0.01). Hepatic blood flow and azygos blood flow did not change significantly. It is suggested that nifedipine increases portal pressure and thus may be deleterious to patients with portal hypertension.

Tru-cut and Menghini needles: different yield in the histological diagnosis of liver disease.

An evaluation of the information obtained by percutaneous liver biopsy performed with Travenol Tru-cut ("Tru-cut"), Menghini's 1.9 and 1.6 needles, was done using cadavers. All needles used had a similar, low number of "failures". Recognition of diffuse liver lesions, excluding fibrosis, was very high regardless of the needle used. Identification of cirrhosis was significantly more frequent in biopsies performed with the Tru-cut needle.

Effect of propranolol on hepatic blood flow in patients with cirrhosis.

The effect of propranolol on systemic and hepatic hemodynamics was studied in patients with cirrhosis. One hour after 40 mg propranolol by mouth as well as during continuous oral dosing at doses that reduced heart rate 25%, cardiac output and the hepatic venous pressure gradient fell significantly, whereas arterial pressure and hepatic blood flow did not change significantly. In six patients with cirrhosis and surgical end-to-side portacaval shunts, cardiac output and the hepatic venous pressure gradient also decreased 15 minutes after intravenous propranolol (5 mg), whereas hepatic blood flow did not change significantly. In the patients with surgical shunts, systemic vascular resistance rose significantly but hepatic arterial vascular resistance fell. Our data show that in patients with cirrhosis, propranolol induces an increase in the fraction of cardiac output reaching the liver.

Superior portosystemic collateral circulation estimated by azygos blood flow in patients with cirrhosis. Lack of correlation with oesophageal varices and gastrointestinal bleeding. Effect of propranolol.

In patients with cirrhosis, superior portosystemic collateral circulation was evaluated by the continuous thermodilution method in the azygos vein. Azygos blood flow was 5 times higher in a group of patients with cirrhosis (alcoholic in 27, cryptogenic in 8, post-hepatitic in 2 and primary biliary cirrhosis in 1), than in a group of patients without portal hypertension (steatosis in 2, granulomatous hepatitis in 2, persistent chronic hepatitis in 2 and Hodgkin's disease in 1). Azygos blood flow was not different in cirrhotic patients with no visible, in those with small-sized, and in those with large sized oesophageal varices. Azygos blood flow was not different in cirrhotic patients with and without a previous episode of gastrointestinal bleeding. Fifteen min after intravenous administration of 15 mg of propranolol, azygos blood flow significantly decreased whereas azygos blood flow did not change after placebo. The decrease in azygos blood flow was significantly more marked than the reduction in cardiac output. It is concluded that superior portosystemic collateral blood flow is elevated in patients with cirrhosis and that the reduction in this collateral circulation might explain the efficiency of propranolol in the prevention of recurrent gastrointestinal bleeding.

Relationship between dose, blood level and haemodynamic response in patients with cirrhosis receiving propranolol.

Fifty-two patients with cirrhosis receiving continuous administration of propranolol in doses reducing the heart rate by 25% were studied. The doses and plasma levels varied widely - 185 +/- 98 mg/day (mean +/- SD) and 208 +/- 153 ng/ml, respectively. These values were significantly correlated. No significant correlation was found between the dose of the drug or plasma level and the liver function tests. Although propranolol significantly decreased cardiac output and the hepatic venous pressure gradient, no correlation was found between drug dose or plasma level and these haemodynamic effects.

Massive pleural effusions in cirrhotic patients with ascites.

A method is described based on the passage of air across the diaphragm to detect pathological diaphragmatic orifices in autopsies. This method was used in 65 post-mortem studies; orifices were detected in 7 cases. Only one of these appears histologically to be a real spontaneous orifice. This was found in the post-mortem study of a cirrhotic patient with ascites and massive and recurrent hydrothorax. In eight patients with cirrhotic ascites and pleural effusions, radioisotopes were introduced into the ascites fluid, and only in two of them, both with right massive and recurrent pleural effusion, was radioactivity detected in the pleural cavity within the 1st h after injection. The radioisotopic method for detecting in vivo these orifices avoids the repeated taps that are necessary when dyes are used.

[Evaluation of the blood flow of superior portacaval anastomoses by the measurement of azygos blood flow in patients with alcoholic cirrhosis]. / Estimation du débit sanguin des anastomoses porto-caves supérieures par la mesure du débit sanguin azygos chez les malades atteints de cirrhose alcoolique.

In patients with portal hypertension the azygos system collects the main part of superior portosystemic shunts; accordingly, azygos blood flow might be a reflection of this collateral circulation. Azygos blood flow, estimated by the continuous thermodilution method with a catheter inserted into the azygos arch, was measured in 20 patients with cirrhosis. The variability of baseline measurements was 6.9 +/- 3.0 p. 100 and the reproducibility was 5.7 +/- 5.8 p. 100. In patients with cirrhosis, azygos blood flow ranged from 0.22 to 1.25 l/min (0.64 /+- 0.30 l/min; mean +/- SD) and was significantly higher than in patients without portal hypertension (0.13 +/- 0.04 l/min). In this series of patients, azygos blood flow was significantly correlated with the hepatic venous pressure gradient but neither with hepatic blood flow nor with cardiac output. This study shows that azygos blood flow may be estimated with the continuous thermodilution method and that azygos blood flow is approximately six times higher in cirrhotic patients than in controls. This result suggests that blood flow through the superior portosystemic shunts is very high.

Ecografia abdominal con equipo de tiempo real en el diagnostico diferencial de las ictericias. / Abdominal echography with real time equipment in the differential diagnosis of jaundice

En este estudio se describe el resultado del uso de la ecografia abdominal practicada con maquina ADR-1977, del tiempo real en el diagnostico diferencial de las ictericias. Se hizo diagnostico definitivo en 63 pacientes, 31 de los cuales habian hecho unna ictericia obstructuva. La via biliar se encontro dilatada en el 93,5% de los pacientes obstruidos.Hubo 2 falsos positivos.La dilatacion de la via biliar fue de mas facil identificacion cuando el tiempo de evolucion de la ictericia o el nivel de la bilirrubina eran mayores.Dificulto el diagnostico de la obstruccion de la via biliar la tendencia al descenso de la ictericia. Se concluye que las maquinas de tiempo real destinadas en 1979 a las maternidades a lo largo de Chile, podrian ser utilizadas con buen rendimento en el estudio de pacientes ictericos