Hemobilia in hereditary hemorrhagic telangiectasia: an unusual complication of endoscopic retrograde cholangiopancreatography.

Hepatobiliary manifestations of hereditary hemorrhagic telangiectasia (HHT) are rare, but often involve cholestasis. We report here a case of HHT associated with cholestasis due to common bile duct stenosis. Attempted balloon dilation of the stenosis during endoscopic retrograde cholangiopancreatography (ERCP) resulted in hemobilia. Hemostasis was achieved by adjusting the nasobiliary drain. The aim of this report is to highlight the biliary manifestations of HHT and draw attention to an unusual complication of ERCP in this setting.

Spontaneous bacterial peritonitis in patients with hepatic cirrhosis: evaluation of a treatment protocol at specialized units.

INTRODUCTION: Spontaneous bacterial peritonitis is a common and severe complication in patients with cirrhosis and ascitis. Its prognosis clearly depends on its precocious clinical recognition and efficacious therapy. AIM: To optimize a treatment protocol, after auditing clinical efficacy and describe microorganisms implicated at our institution. MATERIAL AND METHODS: Retrospective study of clinical files of patients with hepatic cirrhosis with positive culture of ascitic fluid (AF) and/or an AF polymorphonuclear (PMN) count of more than 250/mm3, treated at our units between 1st January, 2000 and 31st December, 2001 (n = 38). Patients showed a median age of 49 years (30-76), 63% of which were male. Forty-eight percent were classified as belonging to Child-Pugh B class, and 52% to C. RESULTS: First, considering cases with PMN > 250/mm3 (n = 29), antibiotics were given to all patients (cefotaxime and ampiciline). Fifty-two percent had hepatic encephalopathy, 42% had fever, 66% abdominal pain. In 42% a microorganism was isolated. Although 24% of fatal cases (only two related to infection), we noted a 73% clinical and laboratorial response. Five patients (72%) that died, showed renal failure by the time of death. Second, in all cases with positive culture of ascitic fluid (n = 21), 42% of which with PMN > 250/mm3 and 9 monobacterial nonneutrocytic bacterascites' cases, one only agent was found: E. coli in 36%, Streptococci (37%), Staphylococci (14%), and other (14%): Klebsiella oxytoca, n = 1; Salmonella enteritidis, n = 1; Enterococcus faecium, n = 1, Acinectobacter anitratus, n = 1. Only one of the agents, E. faecium (3%) showed in vitro sensitivity exclusively to ampiciline; all other were cefotaxime sensitivite. CONCLUSIONS: Our protocol will be modified, to treat patients with spontaneous bacterial peritonitis with cefotaxime, as monotherapy. Albumin infusion will also be added to the protocol, as, we found renal failure to be an important negative prognosis factor.

Peritonitis bacteriana espontánea en pacientes con cirrosis hepática: evaluación de un protocolo de tratamiento en unidades especializadas / Spontaneous bacterial peritonitis in patients with hepatic cirrhosis: evaluation of a treatment protocol at specia lized units

Introducción: la peritonitis bacteriana espontánea es una complicación frecuente y grave en los pacientes con cirrosis y ascitis. Su pronóstico depende claramente de su reconocimiento clínico precoz y de que el tratamiento sea eficaz. Objetivo: optimizar un protocolo de tratamiento, después de auditar su eficacia clínica, y describir los microorganismos implicados en nuestra institución. Material y métodos: estudio retrospectivo de las historias clínicas de los pacientes con cirrosis hepática y cultivo positivo de líquido ascítico (LA), y / o un recuento de polimorfonucleares (PMN) en LA de más de 250/mm3, tratados en nuestras unidades entre el 1 de enero de 2000 y el 31 de diciembre de 2001 (n = 38). Los pacientes presentaban una mediana de edad de 49 años (30-76), siendo varones el 63 por ciento de ellos. El 48 por ciento se clasificaron como pertenecientes a la categoría Child-Pugh B, y el 52 por ciento a la C. Resultados: en primer lugar, considerando los casos con PMN > 250/mm3 (n = 29), se administraron antibióticos a todos los pacientes (cefotaxima y ampicilina). El 52 por ciento tenían encefalopatía hepática, el 42 por ciento fiebre y el 66 por ciento dolor abdominal. En el 42 por ciento se aisló un microorganismo. Aunque el 24 por ciento de los casos fueron fatales (sólo 2 en relación con infecciones), observamos un 73 por ciento de respuestas clínicas y analíticas. Cinco de los pacientes (72 por ciento) que fallecieron presentaban insuficiencia renal en el momento de morir. En segundo lugar, en todos los casos con cultivo positivo de líquido ascítico (n= 21), el 42 por ciento de los cuales presentaban PMN > 250 mm3, con nueve casos de ascitis monobacteriana no neutrocítica, sólo se halló un agente: E. coli en el 36 por ciento, estreptococos (37 por ciento), estafilococos (14 por ciento) y otros, como Klebsiella oxytoca, n = 1; Salmonella enteritidis, n = 1; Enterococcus faecium, n = 1, y Acinectobacter anitratus, n = 1. Sólo uno de los agentes, E. faecium (3 por ciento) mostró sensibilidad exclusivamente a la ampicilina in vitro. Todos los demás fueron sensibles a la cefotaxima. Conclusiones: nuestro protocolo se modificará para tratar con cefotaxima en monoterapia a los pacientes con peritonitis bacteriana espontánea. También se añadirán al protocolo las infusiones de albúmina, ya que encontramos que la insuficiencia renal suponía un importante factor pronóstico negativo. (AU)

Clastogenic factors as biomarkers of oxidative stress in chronic hepatitis C.

BACKGROUND/AIMS: Clastogenic factors (CFs) are composed of lipid peroxidation products, cytokines and other oxidants with chromosome-damaging properties. They are regularly observed after radiation exposure and in chronic inflammatory diseases, where they are supposed to be risk factors for carcinogenesis. It appeared of interest to investigate their presence in the plasma of patients with chronic hepatitis C. METHODS: CFs are detected by chromosomal breakage studies. They were compared to malondialdehyde (MDA), total plasma thiols (t-SH), alanine aminotransferase (ALT), viral load and histological data. RESULTS: CFs were increased in 19 of 20 patients, 16 had increased MDA levels and 15 had decreased t-SH levels. Mean values were significantly different from the 20 controls (p<0.001). After the first 3 months of interferon treatment, all three markers showed significant improvement, but were not completely normalized. There was a positive correlation between CFs and necroinflammatory activity (p<0.03), while MDA was correlated with fibrosis (p<0.03). Viral load was correlated with necrosis and inflammation (p<0.05). CONCLUSION: The presence of CFs in chronic hepatitis C confirms the occurrence of oxidative stress in this disease and could be useful in clinical trials for testing antioxidants. The CF test is a sensitive assay for the detection of oxidative stress and correlates with necroinflammatory activity.

Occurrence of hepatocellular carcinoma and decompensation in western European patients with cirrhosis type B. The EUROHEP Study Group on Hepatitis B Virus and Cirrhosis.

To examine the morbidity of compensated cirrhosis type B, a cohort of 349 Western European, white patients (86% men; mean age, 44 years) with biopsy-proven cirrhosis was followed up for a mean period of 73 months and was studied for occurrence of hepatocellular carcinoma (HCC) and decompensation. At entry into the study all patients were tested for hepatitis B e antigen (HBeAg; 34% of patients were HBeAg-positive) and antibody to hepatitis delta virus (anti-HDV; 20% of patients were anti-HDV-positive); 48% of 252 patients tested were hepatitis B virus (HBV)-DNA-positive. During follow-up HCC developed in 32 (9%) of the 349 patients and decompensation was observed in 88 (28%) of 317 tumor-free patients. Five years after diagnosis, the probability of HCC appearance was 6% and the probability of decompensation was 23%. After the first episode of decompensation the probability of survival was 35% at 5 years. Cox's regression analysis identified three variables that independently correlated with HCC: age, serum levels of platelets, and liver firmness on physical examination. HBV (HBeAg or HBV-DNA) and HDV (anti-HDV) markers at presentation had no prognostic value for the development of HCC. In conclusion, a high proportion of patients with HBsAg-positive compensated cirrhosis do not experience worsening of their condition for several years, but once decompensation occurs life expectancy is poor. European, white patients with compensated cirrhosis type B are at consistent risk for HCC. Prognostic factors for HCC reflect an advanced stage of cirrhosis and support the hypothesis that development of a tumor could be the likely consequence of long-standing hepatic disease.

Serum markers of hepatitis B virus replication, liver histology and intrahepatic expression of hepatitis B core antigen.

The presence and distribution of hepatitis B core antigen (HBcAg) was studied in the liver of 227 chronic carriers of hepatitis B surface antigen (HBsAg) to investigate its relationship with serum HBV-DNA, the status of hepatitis B 'e' antigen/antibody (HBeAg/anti-HBe) and the underlying liver disease. HBcAg was detected in 144 of the 227 (63%) liver specimens and HBV-DNA in 132 (58%) of the corresponding sera. Serum HBV-DNA showed a constant link with intrahepatic HBcAg. Out of 96 HBeAg-positive patients, 91 (95%) had HBcAg in the liver and 85 (89%) had HBV-DNA in serum. Overall there was a significant link between HBeAg and HBV-DNA in serum, but there was no correlation in 58 out of 227 (26%) cases. In HBeAg/HBV-DNA-positive carriers, HBcAg expression was predominantly nuclear. It was nuclear and cytoplasmic in patients with the highest levels of viremia. Eleven out of 13 (85%) HBV-DNA-positive patients who had only cytoplasmic HBcAg were HBcAg-negative and had low levels of HBV-DNA. Nine of 13 (69%) patients with exclusively cytoplasmic HBcAg had severe chronic liver disease. Neither the presence of HBV-DNA and HBeAg in serum nor the nuclear localization of HBcAg were associated with the severity of liver damage. In the group of HBV-DNA-positive patients (132), the presence of liver disease was significantly connected with the absence of HBeAg in serum (P less than 0.05; C.L. 3-35).(ABSTRACT TRUNCATED AT 250 WORDS)

Peripheral T-cell phenotypes in chronic active hepatitis B. Correlation with serum hepatitis B virus (HBV) markers and clinical features.

We have studied peripheral blood T-cell phenotypes using monoclonal antibodies in untreated heterosexual patients with chronic active hepatitis B (CAH-B) to investigate its relationship to HBV serological markers and clinical features. Compared to the controls, CAH-B patients formed three subgroups: one with low, one with normal and a third with high OKT4/OKT8 ratios. The CAH-B patients with an elevated OKT4/OKT8 ratio tended to be symptomatic, have a past history of acute hepatitis, a shorter disease duration and a more severe histological liver disease than patients with a low OKT4/OKT8 ratio. All cases with high OKT4/OKT8 ratio were HBeAg-positive and 88% HBV-DNA-positive by molecular hybridization. In contrast only 10% of the cases with low OKT4/OKT8 ratio were HBeAg-positive and 40% HBV-DNA-positive. Delta-positive cases were only found in the subgroups with low (40%) and normal (25%) ratios. Sequential studies were performed in the 12 HBeAg-positive cases: seroconversion of HBeAg to anti-HBe was observed in 3, all with high OKT4/OKT8 ratios. This study delineates two major subgroups in CAH-B using peripheral T-cell phenotypes. This classification may prove to be useful in the follow-up of patients with CAH-B and in predicting their responsiveness to anti-viral therapy.

[Histological aspects of the endometrium in users of intrauterine devices]. / Aspectos histológicos do endométrio em portadoras de dispositivos-intra-uterinos.

PIP: The large scale use of IUDs in Portugal is very recent. To evaluate their effects (Lippes Loop, Gynet, and Gravigard) on the histologic pattern of the endometrium, we have studied endometrial biopsies prior to insertion and following removal of the devices. The results of the histologic and, in some cases, cytologic study, are presented for 471 patients. 77.4% of the endometrial biopsies showed patterns of a normal menstrual cycle. 3.48% of the cases presented chronic and acute endometritis. Different patterns of endocrine dysfunction were present in 11.4% of the remaining cases. No case of foreign body reaction was detected. No clinical symptoms of pelvic inflammatory disease, ectopic pregnancy, or uterine perforation were seen. It is concluded that the use of IUDs may produce definite changes in the endometrium but they are often subtle ones. (author's)^ieng

[Churg-Strauss allergic granulomatosis]. / Granulomatose "alérgica" de Churg-Strauss.

A 65 year old female patient with a 2 year history of bronchial asthma disseminated petechial, papulopustular and ulceronecrotic eruption and an isolated episode of intestinal bleeding. Chest X rays showed bilateral pulmonary infiltrates and laboratory examination revealed eosinophilia (17%) leucocytosis (22.900) and a severe renal insufficiency. Cutaneous biopsy revealed a necrotizing, leucocytoclastic vasculitis of the small blood vessels in the dermis as well as the hypodermis. The patient died 2 days after diagnosis and corticosteroid therapy had been started. Necropsy showed granulomatous and/or vasculitic lesions of the lungs, spleen, kidneys and skin. The clinical and laboratory aspects are discussed and the relevant literature is reviewed.