The occurrence of asymptomatic and symptomatic simple hepatic cysts. A prospective, hospital-based study.

AIM: To examine the prevalence of asymptomatic and symptomatic liver cysts in a university hospital patient population using modern US equipment. METHODS: Abdominal US scans of 1541 cases referred during the period 21 January to 11 November 2000 were examined for hepatic cysts. RESULTS: Of 1541 cases, 174 (11.3%) were found to have hepatic cysts, i.e. 109 female (12.5%) and 65 (9.7%) male patients (9.7%). In 413 individuals younger than 40 years, no cysts were found. Above the age of 40 years, prevalence increased with age. CONCLUSION: By using modern US equipment, we found a higher prevalence of hepatic cysts than that reported in previous studies. Patient selection and the prevalence of liver cysts in the population from which the patients were referred may have influenced our results.

Biochemical and cytologic analysis of cystic contents in benign non-parasitic symptomatic hepatic cysts before and after ethanol sclerotherapy.

PURPOSE: To examine the fluid of liver cysts by cytologic and biochemical analysis before and after ethanol sclerotherapy in order to explore the etiology of cystic fluid reproduction after sclerotherapy. MATERIAL AND METHODS: The contents of 11 cysts in 11 patients were examined on the day of sclerotherapy, and 2-8 (mean 4.5) days later, and analysed for cytologic and biochemical parameters. RESULTS: Cytologic signs of acute or subacute inflammatory reaction were absent before and present in all cysts after sclerotherapy. Biochemical parameters reflecting the acute inflammatory reaction (CRP, orosomucoid and haptoglobine), changes in capillary permeability (protein, albumin), and the cystic epithelial function (bilirubin, alkaline phosphatase) were significantly elevated after sclerotherapy. CONCLUSION: The post-sclerotherapy fluid production is probably due to an inflammatory reaction. This may explain the success of performing sclerotherapy in one single session.

Complications and late outcome following percutaneous drainage of the gallbladder in acute calculous cholecystitis.

BACKGROUND: Acute septic cholecystitis (AC) remains a difficult problem in patients with coexisting severe illness, and ultrasonographically guided percutaneous puncture and drainage of the gallbladder (PTBD) may be an alternative treatment in this context. SETTING: University Hospital, Norway. METHODS: Retrospective study of the safety and efficacy of this approach in 86 consecutive patients treated from 1992 to 1999. RESULTS: Five patients died. Drainage did not seem to influence the condition in these patients, who were drained for a mean of 8 days after admission compared to 4 days for the survivors (p = 0.01), and had a higher S-bilirubin on the day of the drainage, 46 and 29 micromol/l (p = 0.05), respectively. Seven patients had an intraperitoneal bile leak and 2 had worsening septicemia. One of these patients had both, and the gallbladder was removed. An open cystic duct demonstrated at catheter cholangiography was associated with a bile leak in 3 (4%) of 76 patients as opposed to 4 (40%) of 10 patients with obstruction (p = 0.001). Only 60 patients survived another 6 months because of general debility and other diseases. Twenty-seven (45%) of these were asymptomatic during follow-up. Twenty-eight (47%) of the remaining patients had at least one recurrent episode of AC. One patient who was readmitted due to AC had urgent cholecystectomy and 8 others had elective cholecystectomy during follow-up for a total cholecystectomy rate of 12%. A common bile duct stone was demonstrated in 4 patients after ERCP and indicative signs were found in another 5 (10%). CONCLUSIONS: PTBD remains a good option in patients with septic AC who have severe coexisting disease and may be too ill to undergo an operation. It may not be necessary to remove the gallbladder in 45% or more of the patients as many remain asymptomatic after PTBD.

The value of ultrasonography in predicting autoimmune thyroid disease.

Ultrasonography (US) may demonstrate a diffuse reduction in thyroid echogenicity (low-amplitude echoes) in autoimmune thyroid disease (AITD), which includes chronic lymphocytic thyroiditis and Graves' disease, as well as in subacute thyroiditis. The reported occurrence of this finding in AITD varies from 19% to 95%. To assess the validity of diffuse reduction in thyroid echogenicity as a predictor of AITD, 3,077 patients referred for US of the thyroid were examined prospectively with regard to reduced versus normal thyroid echogenicity. The most frequent reasons for referral were goiter, thyroid dysfunction, neck discomfort, and/or difficulty in swallowing. Ultrasonography demonstrated diffuse reduction in thyroid echogenicity in 485 patients. Of these, 452 patients had available records of fine-needle aspiration biopsy (FNAB), and were included in the study. From the remaining patients, with normal thyroid echogenicity, 100 consecutive patients were selected as controls. In 411 of the 452 study patients (90.9%) there was at least one laboratory finding consistent with possible AITD: cytology indicating lymphocytic thyroiditis, 287 of 363 patients (79.1%) with diagnostic specimens; elevated levels of peroxidase antibodies (TPOAb), 225 of 337 (66.8%); elevated thyrotropin (TSH) levels, 290 of 450 (64.4%); or low TSH levels, 79 of 450 (17.6%). The final diagnosis was: chronic autoimmune (Hashimoto's) thyroiditis in 352 patients; Graves' disease in 47 patients; subacute (granulomatous) thyroiditis in 7 patients; toxic nodular goiter in 3 patients; and toxic adenoma in 2 patients. In the remaining 41 patients, those without laboratory results consistent with AITD, the final diagnosis was colloid goiter in 37 and thyroid cancer in 4 patients. In the 100 controls, laboratory results were consistent with possible AITD in 14 patients: elevated TPOAb levels in 5 of 49 patients with retrieved antibody results; lymphocytic thyroiditis in 2 patients; elevated TSH levels in 2 patients; and low TSH levels in 2 patients. In these controls, the final diagnosis was: chronic autoimmune thyroiditis in 7; toxic nodular goiter in 6 patients, and toxic adenoma in 1 patient. The corresponding positive and negative predictive values of reduced thyroid echogenicity as an indicator of AITD were 399 of 452 (88.3% [95% CI, 85% to 91%]), and 93 of 100 (93.0% [95% CI, 88% to 98%]), respectively. Thus, diffuse reduction in thyroid echogenicity was a valid predictor of AITD.

Single-session alcohol sclerotherapy in symptomatic benign hepatic cysts. Long-term results.

PURPOSE: To evaluate the long-term results of single-session alcohol sclerotherapy of symptomatic benign liver cysts. MATERIAL AND METHODS: 23 cysts in 19 patients were treated by single-session percutaneous catheterization and injection of 96% ethanol. Evaluation of long-term results was possible in 11 cysts (volume 200-2,700 ml, mean 1,317 ml) in 11 patients. Time of observation was 12-67 months, mean 38.3 months. RESULTS: The reduction of volume was 93-100% (mean 98%). The re-accumulation of fluid after therapy seen in 9 patients proved to be transitory. Except for pain there were no complications. CONCLUSION: Single-session sclerotherapy resulted in satisfactory cyst volume reduction in all 11 long-term follow-up patients.

Single-session alcohol sclerotherapy in benign symptomatic hepatic cysts.

PURPOSE: To evaluate the results of single-session alcohol sclerotherapy in benign symptomatic liver cysts. MATERIAL AND METHODS: Ten cysts (volume 200-4,800 ml) in 10 patients were treated by percutaneous catheterization and injection of 96% ethanol at a dose of 10% of the cyst volume but never more than 100 ml. The treatment was applied for a maximum of 20 min, after which the alcohol and catheter were removed. RESULTS: A satisfactory reduction in cyst volume was achieved in all patients. In 8 patients there was a re-accumulation of fluid during the first period after therapy, followed by a significant reduction in volume on later follow-up examinations. Except for pain, there were no complications. CONCLUSION: Sclerotherapy as a single-session procedure resulted in a significant reduction in cyst volume in all 10 patients. The postprocedural re-accumulation of fluid seen in 8 patients proved to be temporary. It was not necessary to repeat the sclerotherapy procedure in any patient.

Fine-needle aspiration cytology of focal liver lesions. Advantages and limitations.

Fine-needle aspiration cytology of focal liver lesions was performed 192 times in 175 patients over a 5-year period. Ultrasonic guidance was used for 153 punctures; the others were done peroperatively or on a palpable mass. A correct diagnosis of malignancy was obtained in 89/111 cases (80.2%), and of metastases (adenocarcinoma) to the liver in 71/84 (84.5%). The total of nonrepresentative aspirates was 26 (13.5%). The overall accuracy of cytologic evaluation was 87.5%, with 79.5% sensitivity and 100% specificity in malignant disease. The predictive values of positive and negative results were, respectively, 100% and 75.8%. There were no false positive tests, but 12.5% false negatives. No complications following the aspiration procedure were seen. Fine-needle aspiration biopsy is simple and safe, but the relatively high proportion of nonrepresentative aspirates is a problem. Possibly a more aggressive approach with multiple punctures may lessen this incidence and enhance the diagnostic accuracy in hepatic malignancy.

Ultrasonically and fluoroscopically guided therapeutic percutaneous catheter drainage of the gallbladder.

Percutaneous gallbladder drainage was performed in 16 poor surgical risk patients; 13 had acute cholecystitis, 1 had cholangitis and septicemia, 1 had undergone removal of a gallbladder calculus, and 1 had pancreatic carcinoma with bile duct occlusion. Catheterization and drainage of the gallbladder succeeded primarily in all patients. Catheter dislodgement occurred within 24 h in 1 patient without any side effects. One 87-year-old patient died 14 h after the insertion of the catheter from reasons unrelated to the drainage procedure. Percutaneous removal of gallbladder calculi failed in 3 patients, 2 of whom had been successfully treated for cholecystitis by catheter drainage. Percutaneous gallbladder drainage is a fast, low-risk, inexpensive procedure well suited for the treatment of acute, poor surgical risk patients.

Chronic pancreatitis in patients with sclerosing cholangitis and ulcerative colitis.

In the 4-year period 1980-83 sclerosing cholangitis was demonstrated in 7 out of 151 patients with ulcerative colitis hospitalized in our department. Total ulcerative colitis was demonstrated in all patients with sclerosing cholangitis, whereas abnormal pancreatograms compatible with chronic pancreatitis were seen in four of these patients. According to the criteria of Kasugai, one had minimal, two moderate, and one advanced changes of chronic pancreatitis. Although three of four patients had been treated with drugs known to induce pancreatitis (sulfasalazine and corticosteroids), it is tempting to assume that ulcerative colitis, sclerosing cholangitis, and pancreatitis, when seen in combination, are manifestations of autoimmune diseases with a genetic predisposition. A mechanical mechanism for the development of chronic pancreatitis in sclerosing cholangitis must also be considered.