Fulminant hepatic failure in children: etiology, histopathology and MDCT findings

The qualitative and quantitative image analysis of MR imaging in patients with acute-on-chronic liver failure

PURPOSE

To evaluate the distinctive features of ACLF and chronic liver disease (CLD) on MR images using quantitative and qualitative analyses.

METHODS

Twelve patients with ACLF and 36 patients with CLD who had undergone MR images were included. MR imaging findings from both groups were assessed.

RESULTS

Gallbladder edema, esophageal varix, and ascites were significantly more prevalent in the ACLF group (all P-values <0.05). The liver to muscle SI ratio on T2-WI was significantly higher in the ACLF group (P=0.002).

CONCLUSION

MR imaging findings could be helpful in differentiating between patients with ACLF and those with CLD.

Oedema of gallbladder wall: correlation with chronic hepatitis B on MR imaging

PURPOSE

The aim of this study was to characterise gallbladder wall oedema and correlate it with chronic hepatitis B (CHB) on magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Sixty-seven patients who were clinically and histologically diagnosed with CHB and 18 healthy individuals without any history of liver disease underwent abdominal MR imaging. Hepatic inflammation (grade 0-4) and fibrosis (stage 0-4) for patients were assessed histologically. Gallbladder wall oedema was noted.

RESULTS

Twelve patients showed gallbladder wall oedema on MR imaging, including six with grade 3 and six with grade 4 disease. There was a statistically significant difference for the presence of gallbladder wall oedema among groups with grade 0-4 (p=0.000), but not between groups with grades 3 and 4 (p=0.729). Gallbladder wall oedema was related to moderate-severe inflammatory activity (p<0.05), alanine transaminase (ALT) (p=0.012) and aspartate aminotransferase (AST) (p=0.027) levels but not to fibrosis or other laboratory data, including serum quantitative DNA for hepatitis B virus (HBV), with the p=0.105-0.846. Sensitivity and specificity for the diagnosis of hepatic moderate-severe inflammation using gallbladder wall oedema were 33.33% and 100%, respectively.

CONCLUSIONS

Gallbladder wall oedema for patients with CHB can be specifically demonstrated on MR imaging and is correlated with hepatic moderate-severe inflammatory activity, elevated ALT and AST levels but not with fibrosis or other laboratory data, including viremia.

Acute and acute severe (fulminant) autoimmune hepatitis

Autoimmune hepatitis frequently has an abrupt onset of symptoms, and it can present with acute liver failure. The abrupt presentation can indicate spontaneous exacerbation of a pre-existent chronic disease, newly created disease, a superimposed infectious or toxic injury, or new disease after viral infection, drug therapy, or liver transplantation. Deficiencies in the classical phenotype may include a low serum immunoglobulin G level and low or absent titers of the conventional autoantibodies. The original revised diagnostic scoring system of the International Autoimmune Hepatitis Group can guide the diagnostic evaluation, but low scores do not preclude the diagnosis. Liver tissue examination is valuable to exclude viral-related or drug-induced liver injury and support the diagnosis by demonstrating centrilobular necrosis (usually with interface hepatitis), lymphoplasmacytic infiltration, hepatocyte rosettes, and fibrosis. Conventional therapy with prednisone and azathioprine induces clinical and laboratory improvement in 68-75 % of patients with acute presentations, and high dose prednisone or prednisolone (preferred drug) is effective in 20-100 % of patients with acute severe (fulminant) presentations. Failure to improve or worsening of any clinical or laboratory feature within 2 weeks of treatment or worsening of a mathematical model of end-stage liver disease within 7 days justifies liver transplantation in acute liver failure. Liver transplantation for acute severe (fulminant) autoimmune hepatitis is as successful as liver transplantation for autoimmune hepatitis with a chronic presentation and other types of acute liver failure (patient survival >1 year, 80-94 %). Liver transplantation should not be delayed or superseded by protracted corticosteroid therapy or the empiric institution of nonstandard medications.

Mushroom poisoning: a case report from Jordan

An eight years male child with his family ate fresh mushroom at lunch time from back garden at their home in a village in the North of Jordan. By the evening approximately six hours later all started feeling nausea, abdominal cramps and vomiting they rushed to nearest primary health care center. After getting general medical medication they were transfer to a referral hospital at city of Irbid. The boy got deteriorated with diarrhea in addition to the previous gastrointestinal complains and died on third day. The message from this case is to ascertain in the public opinion that unknown type of mushroom even eaten previously could be poisonous and fetal.

Specificity of unenhanced CT for non-invasive diagnosis of hepatic steatosis: implications for the investigation of the natural history of incidental steatosis

OBJECTIVES

To determine a highly specific liver attenuation threshold at unenhanced CT for biopsy-proven moderate to severe hepatic steatosis (≥30% at histology).

METHODS

315 asymptomatic adults (mean age ± SD, 31.5 ± 10.1 years; 207 men, 108 women) underwent same-day unenhanced liver CT and ultrasound-guided liver biopsy. Blinded to biopsy results, CT liver attenuation was measured using standard region-of-interest methodology. Multiple linear regression analysis was used to assess the relationship of CT liver attenuation with patient age, gender, BMI, CT system, and hepatic fat and iron content.

RESULTS

Thirty-nine subjects had moderate to severe steatosis and 276 had mild or no steatosis. A liver attenuation threshold of 48 HU was 100% specific (276/276) for moderate to severe steatosis, with no false-positives. Sensitivity, PPV and NPV at this HU threshold was 53.8%, 100% and 93.9%. Hepatic fat content was the overwhelming determinant of liver attenuation values, but CT system (P < 0.001), and hepatic iron (P = 0.035) also had a statistically significant independent association.

CONCLUSIONS

Unenhanced CT liver attenuation alone is highly specific for moderate to severe hepatic steatosis, allowing for confident non-invasive identification of large retrospective/prospective cohorts for natural history evaluation of incidental non-alcoholic fatty liver disease. Low sensitivity, however, precludes effective population screening at this threshold.

KEY POINTS

• Unenhanced CT liver attenuation is highly specific for diagnosing moderate/severe hepatic steatosis. • Unenhanced CT can identify large cohorts for epidemiological studies of incidental steatosis. • Unenhanced CT is not, however, effective for population screening for hepatic steatosis.