Spontaneous liver bleeding in a patient with congenital arterioportal fistulisation. Presentation of a casus princeps and review of the literature.

We present the first case reported in the literature describing spontaneous liver haemorrhage due to diffuse arterioportal fistulae. A 48-year old Caucasian woman was admitted to the hospital complaining of acute epigastric pain eradiating to the right shoulder. Patient never had any penetrating or blunt abdominal trauma in the past nor any intervention on the liver. CT scan of the abdomen revealed a subcapsular haematoma originating from two bleeding sites in the right liver lobe. Arteriography of the common hepatic artery showed opacification of the portal branches, indicative of an arterioportal fistula. A hypertrophic feeding branch of the right hepatic artery was then embolized, resulting in disappearance of the fistula. After complete resolution of the haematoma, investigations to detect underlying liver lesions were repeatedly negative. Therefore we conclude that a diffuse congenital arterioportal fistula was the cause of spontaneous bleeding. This is to our knowledge the first case in whom a spontaneous liver bleeding secondary to diffuse arterioportal fistulisation is reported. A review of the literature regarding arterioportal fistulas and regarding the possible aetiology of spontaneous liver haematomas is provided.

The effect of giving influenza vaccination to general practitioners: a controlled trial [NCT00221676].

BACKGROUND: No efficacy studies of influenza vaccination given to GPs have yet been published. Therefore, our purpose was to assess the effect of an inactivated influenza vaccine given to GPs on the rate of clinical respiratory tract infections (RTIs) and proven influenza cases (influenza positive nose and throat swabs and a 4-fold titre rise), while adjusting for important covariates. METHODS: In a controlled trial during two consecutive winter periods (2002-2003 and 2003-2004) we compared (77 and 100) vaccinated with (45 and 40) unvaccinated GPs working in Flanders, Belgium. Influenza antibodies were measured immediately prior to and 3-5 weeks after vaccination, as well as after the influenza epidemic. During the influenza epidemic, GPs had to record their contact with influenza cases and their own RTI symptoms every day. If they became ill, the GPs had to take nose and throat swabs during the first 4 days. We performed a multivariate regression analysis for covariates using Generalized Estimating Equations. RESULTS: One half of the GPs (vaccinated or not) developed an RTI during the 2 influenza epidemics. During the two influenza periods, 8.6% of the vaccinated and 14.7% of the unvaccinated GPs had positive swabs for influenza (RR: 0.59; 95%CI: 0.28 - 1.24). Multivariate analysis revealed that influenza vaccination prevented RTIs and swab-positive influenza only among young GPs (ORadj: 0.35; 95%CI: 0.13 - 0.96 and 0.1; 0.01 - 0.75 respectively for 30-year-old GPs). Independent of vaccination, a low basic antibody titre against influenza (ORadj 0.57; 95%CI: 0.37 - 0.89) and the presence of influenza cases in the family (ORadj 9.24; 95%CI: 2.91 - 29) were highly predictive of an episode of swab-positive influenza. CONCLUSION: Influenza vaccination was shown to protect against proven influenza among young GPs. GPs, vaccinated or not, who are very vulnerable to influenza are those who have a low basic immunity against influenza and, in particular, those who have family members who develop influenza.