Jaundice as a misadventure of a green tea (camellia sinensis) lover : a case report

The case of a 76-year-old retired surgeon and lover of green tea (camellia sinensis) infusions who developed a clinical, sero-biochemical and histological picture of severe subacute hepatitis is reported. The clinical presentation was that of jaundice with asthenia and weight loss. Abnormal liver function tests were associated with hyper-gammaglobulinemia, and the transient presence of anti-smooth-muscle antibodies and ANCA. Liver histology showed mixed features of lobular hepatitis with central collapses, portal inflammatory cells infiltration and interface hepatitis. All other potential causes of hepatitis were excluded on the basis of clinical, biochemical and serological data. Herbal preparation withdrawal resulted in a slow and continuous improvement with a complete clinical and sero-biochemical resolution after 7 months.

Severe acute cholestatic hepatitis with prolonged cholestasis and bile-duct injury following atorvastatin therapy: a case report

We report the case of a patient who exhibited severe acute hepatitis with symptomatic cholestasis for more than 3 months and bile duct injury following the prescription of atorvastatin. After withdrawal the drug, the patient's wellbeing slowly improves and biological features normalize in 4 months. Therapy aimed at treating severe liver steatosis and hypercholesterolemia. Atorvastatin is a highly effective 3-hydroxy-3 methylglutamyl- coenzyme A reductase (statin) used to lower low-density lipoprotein. Reported frequent adverse events of the medication include nausea, depression, myalgia, abdominal pain and abnormal liver function tests. Although abnormal liver function tests is not an uncommon side effect of the medication, more serious liver injury is rare. In a recent literature review, about ten cases of serious hepatotoxicity have been documented. In the typical presentation, the duration of exposure prior to hepatic toxicity is variable. Liver injury is generally of the mixed type. A prolonged cholestasis for more than 3 months has been seldom reported. Morphological changes includes canalicular cholestasis, feathery degeneration but no cholangiolitis nor cholangitis under the form of cytological and inflammatory changes at the level of interlobular bile ducts. This case report provides further evidence that among statins, atorvastatin may be implicated in drug-induced liver injury and indicates for the first time that such liver injury may be followed by prolonged cholestasis and interlobular bile duct injury. Atorvastatin has thus to be added to the list of medication potentially responsible for bile duct injury.

Propylthiouracyl-induced severe liver toxicity: An indication for alanine aminotransferase monitoring?

Propylthiouracyl (PTU)-related liver toxicity is likely to occur in about 1% of treated patients. In case of acute or subacute hepatitis, liver failure may occur in about one third. We report two further cases of PTU-induced subacute hepatitis, in whom the delay between occurrence of liver damage after the initiation of treatment, the underestimation of its severity and the delayed withdrawal of the drug were all likely responsible for liver failure. The high incidence of liver toxicity related to PTU, its potential severity and delayed occurrence after initiation of treatment are in favor of monthly alanine aminotransferase monitoring, at least during the first six months of therapy.

Hypervitaminosis A-induced liver fibrosis: stellate cell activation and daily dose consumption

Hypervitaminosis A-related liver toxicity may be severe and may even lead to cirrhosis. In the normal liver, vitamin A is stored in hepatic stellate cells (HSC), which are prone to becoming activated and acquiring a myofibroblast-like phenotype, producing large amounts of extracellular matrix.

AIMS

In order to assess the relationship between vitamin A intake, HSC activation and fibrosis, we studied nine liver biopsies from patients belonging to a well-characterized series of 41 patients with vitamin A hepatotoxicity.

METHODS

Fibrosis was underlined by Sirius-red staining, whereas activated HSC were immunohistochemically identified using an antibody against alpha smooth muscle actin. The volume density (Vv) of sinusoidal and total fibrosis and of sinusoidal and total activated HSC was quantified by the point-counting method.

RESULTS

Morphology ranged from HSC hypertrophy and hyperplasia as the sole features to severe architectural distortion. There was a significant positive correlation between Vv of perisinusoidal fibrosis and the daily consumption of vitamin A (P=0.004).

CONCLUSION

The close correlation between the severity of perisinusoidal fibrosis and the daily dose of the retinol intake suggests the existence of a dose-effect relationship.

Non-tumoral elevation of alpha-fetoprotein (AFP): a 10 year follow-up in two subjects

Elevation of serum alpha-fetoprotein (AFP) in the absence of any liver disease or malignancy, likely of genetic origin, is an uncommon observation which may be the source of diagnostic difficulties in routine clinical practice, especially in cases without available familial data. Animal studies suggest that the anomaly may be related to a mutation located in a regulatory gene different from that mapped for AFP. The transmission pattern of the defect is unknown with a strong suggestion for an autosomal dominant inheritance. We report the cases of two patients in whom a stable elevation of unknown origin of the tumoral marker for up to 10 years, has been observed in the absence of any detectable liver and/or malignancy and in whom the lack of familial data was the source of diagnostic difficulties.

Drug and toxin-induced bile duct disorders

Various drugs of toxins have been implicated in the development of a particular form of liver damage predominantly involving the bile ducts. Such liver toxicity is often associated with a clinical picture of prolonged cholestasis and may even evolve in rare instances, into the full picture of the vanishing bile duct syndrome, eventually complicated with biliary cirrhosis. Drug and toxins potentially responsible for bile duct injury are reviewed as well as the characteristics of its clinical presentation. The pathophysiologic aspects of the syndrome are also reviewed including recent data, which are strongly in favor of the role of a genetic predisposition.

HLA association of amoxicillin-clavulanate--induced hepatitis

BACKGROUND & AIMS

Drug-induced immunoallergic hepatitis typically affects a minority of patients exposed to a particular drug. Its rarity is believed to be due to metabolic or immunologic idiosyncrasy. The presence of an immunologic idiosyncrasy might imply an HLA association. Previous studies reporting an HLA association of drug-induced hepatitis included only small numbers of patients and used serological HLA typing.

METHODS

We studied 35 patients with biopsy-documented amoxicillin-clavulanate-induced hepatitis. HLA-A and -B were typed using alloantisera and compared with those of 300 controls (volunteer bone marrow donors). HLA-DRB and -DWB were typed by polymerase chain reaction-line probe assay, with 60 volunteer bone marrow donors serving as controls.

RESULTS

The study group was characterized by a higher frequency of DRB1*1501-DRB5*0101-DQB1*0602 haplotype (57.1% vs. 11.7% in controls, P < 0.000005; after correction for the large number of comparisons, P < 0.0002). Patients with DRB1*1501-DRB5*0101-DQB1*0602 haplotype were more likely than patients without it to have a cholestatic (70% vs. 60%) or mixed (30% vs. 13%) than a hepatocellular pattern of hepatitis (0% vs. 27%) (P < 0.05).

CONCLUSIONS

Amoxicillin-clavulanate-induced hepatitis is associated with the DRB1*1501-DRB5*0101-DQB1*0602 haplotype. The data support the view that an immunologic idiosyncrasy, mediated through HLA class II antigens, plays a role in the pathogenesis of drug-induced immunoallergic hepatitis. HLA association has a limited impact on the expression of hepatitis.

Dietary restriction of energy and sugar results in a reduction in human cytochrome P450 2E1 activity

Dietary habits are often considered as a pathogenic factor for fatty liver. The impact of dietary intake and steatosis on drug metabolism remains poorly investigated. Our aim was to assess the effect of dietary intake on in vivo cytochrome P450 (CYP) activities in eleven patients with abnormal liver function tests potentially due to fatty liver and associated with a high-sugar diet. Liver function tests, liver volume, aminopyrine breath test (ABT) and chlorzoxazone (CZ) pharmacokinetics (area under the curve, AUC) which are known to reflect CYP2E1 activity were evaluated before and after 2 months restriction of dietary sugar intake. Features at inclusion were an increased BMI (30.3 (SD 3.2) kg/m2), high hepatic volume (1.96 (SD 0.48) litres), hyperechogenic liver parenchyma, elevated liver enzyme activities (alanine aminotransferase (EC 2.6.1.2) 58.6 (SD 17.4) IU/1 with alanine aminotransferase: aspartate aminotransferase (EC 2.6.1.1) ratio > 1), together with a normal ABT value (0.68 (SD 0.21)% specific activity of administered dose of [14C]aminopyrine in breath after 1 h) and a high CYP2E1 activity (CZ AUC 20.3 (SD 7.1) micrograms/ml per h). A dietary sugar restriction was prescribed. On the basis of repeated interviews by the same dietitian, unaware of any clinical and biochemical data, six patients remained complaint to the diet and exhibited reductions in BMI (P < 0.001), serum alanine aminotransferase (P = 0.008), liver volume (P = 0.002) and CYP2E1 activity (P = 0.007), a significant increase in ABT (P < 0.001) together with the disappearance of liver hyperechogenicity at ultrasound. In contrast, the five non-compliant patients did not show any significant change in any of these variables. In conclusion, CYP2E1 activity is induced in patients with perturbations of liver function tests potentially due to fatty liver. In these patients, effective dietary sugar restriction is associated with a reduction in liver volume, a reduction in CYP2E1 activity and an increased aminopyrine metabolism rate.

Liver transplantation and HBsAg-positive postnecrotic cirrhosis: adequate immunoprophylaxis and delta virus co-infection as the significant determinants of long-term prognosis

BACKGROUND/AIMS

The place of liver transplantation in hepatitis B viral (HBV)-related diseases remains controversial because of the high rate of reinfection. The aim of this study was to define the determinants of long-term prognosis after transplantation.

METHODS

Fifty-eight patients were transplanted during the period February 1984-September 1996. Six patients died during the early (< 3 months) posttransplant period from causes unrelated to HBV infection. All 52 long-term (> 3 months) survivors were evaluated in relation to the mode of presentation, viral replication at time of transplantation, absence of hepatocellular cancer at time of transplantation and use of adequate immunoprophylaxis (IP). Adequate immunoprophylaxis, defined as maintenance of anti-HBs levels over 100 mUI/ml, was introduced in December 1989. Intention-to-treat IP analysis compared patients transplanted before and after this date. The median follow-up was 74 months (range 4 to 131). Forty-seven patients (90%) had a minimal follow-up of 3 years.

RESULTS

Five-year actuarial survival rates of 58 patients and of 52 long-term survivors were 72 +/- 6% and 80 +/- 6%, respectively. Univariate analysis showed that delta co-infection (n = 25) significantly improved survival (p < 0.001) [96 +/- 4% vs 63 +/- 10% in HBV patients (n = 27) at 5 years] as did absence of hepatocellular cancer (n = 36) (p = 0.020) [89 +/- 5% vs 61 +/- 12% in 16 non-cancer patients]. IP, however, significantly influenced 5-year survival in the HBV-patient group (n = 17) (p = 0.001) [85 +/- 10% vs 30 +/- 14% in 10 patients without IP). Multivariate analysis selected delta co-infection (p = 0.002) and IP (p = 0.01) as the significant determinants of prognosis independently influencing survival. Uni- and multivariate analyses showed that survival without reinfection was significantly influenced by IP (p = 0.002) [73 +/- 8% (n = 31) versus 33 +/- 12% in 15 non-treated patients).

CONCLUSIONS

Delta virus co-infection and immunoprophylaxis are the most important prognostic factors after transplantation for postnecrotic HBsAg-positive cirrhosis. Transplantation can be proposed as a therapeutic tool only if life-long adequate adjuvant therapy can be achieved. Under this condition good results can even be obtained if there is viral replication at the time of transplantation.

Severe exacerbation of liver disease during pregnancy in a thalassemic GBV-C/HGV-positive patient and neonatal hepatitis in offspring

The case of a young woman with GB virus C/hepatitis G virus (GBV-C/HGV) infection and with a severe exacerbation of chronic hepatitis of unknown etiology during pregnancy is described. In the offspring, severe neonatal hepatitis with subsequent mild chronic liver disease of at least 16-month duration was followed by the development of antibodies to the envelope protein (E2) of GBV-C/HGV, suggesting that the child was recovering from GBV-C/HGV infection. There was an improvement in clinical and biochemical parameters in the mother following delivery and alpha-interferon therapy was associated with a transient biochemical response.

Influence of body mass index, sex and age on serum alanine aminotransferase (ALT) level in healthy blood donors

BACKGROUND AND AIM

Serum alanine aminotransferase (ALT) level is the most common screening test as part of a routine evaluation of liver damage. In order to determine the factors influencing this liver function test in normal subjects, the relationship between ALT level and gender, age and body mass index (BMI) was studied in a large population of healthy blood donors.

METHODS

This population included 9,420 volunteer blood donors (4,488 men and 4,932 women aged from 18 to 70 years) selected on the basis of negative answers to a detailed medical questionnaire including past medical history, drug and alcohol consumption, on the absence of clinical signs of liver disease, on the negativity of serological testing for hepatitis B and C virus and HIV.

RESULTS

In the overall population, the mean serum ALT value was 21.8 I.U./L and the mean BMI was 24.4 kg/m2. There was a positive significant correlation between serum ALT level and BMI (Pearson r = 0.54; p < 0.001) and between ALT and age (Pearson r = 0.25; p < 0.001). A major sex-difference in ALT value was observed, the mean ALT value being higher in men than in women (26.8 +/- 13.6 vs. 17.2 +/- 8.1 I.U./L, p < 0.0001). In both sexes, ALT level was significantly correlated with BMI (Pearson r = 0.45 in men and r = 0.37 in women; p < 0.001). In women a consistent rise in BMI and ALT value with increasing age was observed whereas in men BMI and ALT level only increased with age up to the fifth decade.

IN CONCLUSION

There was a significant positive correlation between ALT and BMI regardless the gender in a population of healthy volunteer blood donors. Moreover, at the same age and the same BMI, ALT was significantly lower in women than in men suggesting that the normal range for ALT value should be adjusted for gender. So gender and BMI have to be considered in the interpretation of ALT values.

Reduction in hepatic cytochrome P-450 is correlated to the degree of liver fat content in animal models of steatosis in the absence of inflammation

BACKGROUND/AIM

Fatty liver has been associated with an increased risk of primary graft non-function and drug toxicity. However, these effects have been observed mainly in fatty liver with inflammation, a situation characterized by an overall reduction in cytochrome P-450 (CYP)-dependent activities as well as a contrasting increase in CYP2E1 activity. Our aim was to examine the impact of liver-fat accumulation on CYP in two animal models of fatty liver without necroinflammation.

METHODS

Ducks were force-fed with a high-glucidic diet and male Wistar rats, after 48 h fasting, were refed a high-glucidic, fat-free diet for 48 h. Total CYP, aminopyrine- (AND), erythromycin-N-demethylase (END) and chlorzoxazone hydroxylase (CZOHase) activities as well as CYP2E1 and CYP3A proteins were quantified on microsomal proteins.

RESULTS

Livers from force-fed ducks exhibited significant decreases in total CYP, AND, END and CZOHase activities, inversely correlated with fat-liver content. Refeeding male Wistar rats a high-glucidic, fat-free diet after 48 h fasting, resulting in a 235% increased liver fat content, was associated with a decrease in total CYP (55%), AND (78%), END (55%) and CZOHase (62%) activities as well as in CYP3A (70%) and CYP2E1 (80%) protein content. A significant inverse correlation was observed between CYP and total lipid content.

CONCLUSIONS

In these models of steatosis induced by nutritional manipulations, fat liver accumulation was associated with a significant decrease in CYP activities and in CYP protein expression. Furthermore, the decreases in both CYP content and related activities were correlated with the degree of liver fat content.

14C-Propoxyphene demethylation in the rat. An example of differences between liver and intestinal drug-presystemic metabolism

Presystemic metabolism is believed to occur mainly in the liver with some minor intestinal participation. The aim of this study was to investigate the respective part of each of these two organs in the metabolism of the analgesic d-propoxyphene (DP). Pharmacological doses of DP were given in the duodenum (ID), the portal vein (IP), and the femoral vein (IV) of male Wistar rats. A tracer dose of 14C-DP was also administered either in IV, IP, or ID as well as in hepatectomized rats or rats with bile duct diversion. In vitro demethylation occurring in liver and intestinal microsomes was also studied. Absolute DP bioavailability obtained after oral administration was two times higher than that observed after portal administration (48.9% vs. 23.2%, respectively), an result opposite (i.e. a lower bioavailability) of that expected on the basis of the existence of a liver enzyme saturation phenomenon. The 14CO2 cumulative excretion after 14C-DP administration was significantly lower after IV or ID administration than after injection in the portal vein as a bolus or within 20 min. The biliary excretion of the labeled compound varied in the opposite direction, being greater after IV or ID than after IP administration, suggesting that the metabolism of DP in the liver is influenced by an extrahepatic transformation. This most likely occurs in the gut since the production of 14CO2 after IV administration was similar to that after ID administration. This transformation did not prohibit DP detection in the systemic blood but was sufficient to increase the part eliminated with bile and to decrease the part demethylated into NP. Demethylation mainly occurs in the liver since the production of 14CO2 was nearly abolished in hepatectomized rats. Furthermore, microsomes of hepatic but not of intestinal origin were able to demethylate DP. Our data suggest that the transformation of DP occurring in gut after oral administration is responsible for changes in the hepatic metabolism of the drug.

Hepatobiliary cystadenocarcinoma without ovarian stroma and normal CA 19-9 levels. Unusually prolonged evolution

Hepatobiliary cystadenoma and cystadenocarcinoma are rare tumors of the liver. The differential diagnosis of cystadenoma includes other cystic neoplasms, nonneoplastic cysts, and even on some occasions parasitic liver involvement. It has been suggested that elevated serum level of the tumor marker CA 19-9 may be of value in distinguishing between cystadenoma with ovarian stroma and hydatid disease. We report the unique case of a male patient with a hepatobiliary cystadenocarcinoma without ovarian stroma of prolonged evolution characterized by a normal CA 19-9 serum level, low cyst fluid CA 19-9, and a very weak CA 19-9 expression on cyst epithelium.

Lactulose improves psychometric testing in cirrhotic patients with subclinical encephalopathy

BACKGROUND

Therapeutic trials suggest that lactulose is an effective treatment of acute and chronic encephalopathy in cirrhotic patients.

AIM AND METHODS

As it is likely that portal-systemic shunting and hepatocellular dysfunction are associated with some degree of neurological dysfunction, 14 patients with cirrhosis and documented portal-systemic shunting, but without detectable encephalopathy, were randomized to treatment with either lactulose 20 g t.d.s., or lactose 20 g t.d.s. as placebo, for a 15-day period. Monitoring included manually administered and computer-based psychometric testing, the results of which were correlated with a battery of biochemical and functional parameters.

RESULTS

There was no correlation between biochemical or functional parameters and psychometric testing. There was a close correlation between the time required to complete the number connection test and both the number of errors and the duration of errors at sinusoid testing. Lactulose therapy resulted in a significant improvement, assessed by the number connection test and the race track test.

CONCLUSION

Our data suggest that lactulose therapy might improve subclinical hepatic encephalopathy in patients with cirrhosis and portal-systemic shunting.

Serum and cystic fluid CA 19-9 determinations as a diagnostic help in liver cysts of uncertain nature

The distinction between hepatobiliary cystadenoma or cystadenocarcinoma and simple hepatic cyst complicated by intracystic hemorrhage may prove difficult to determine on the sole basis of clinical and radiological features because of the presence of intracystic structures and septations well-demonstrated by ultrasound examination in both situations. We investigated four patients with various types of hepatic cysts, in whom diagnostic difficulties led to further investigations. In this small group, CA 19-9 serum levels were abnormal only in the two patients with cystadenoma or cystadenocarcinoma. Cystic fluid CA 19-9 values were also five times higher in cystadenoma and cystadenocarcinoma than in other benign lesions. Our data thus suggest that the determination of serum and cyst fluid CA 19-9 may be of help in distinguishing between hemorrhagic simple cyst and cystadenoma or cystadenocarcinoma.

Long-term favourable outcome of portal hypertension complicating primary systemic amyloidosis

An unusual case of systemic amyloidosis complicated by portal hypertension is reported. In this condition, portal hypertension is a rare event associated with poor prognosis. In our patient, severe presymptomatic sinusoidal portal hypertension was demonstrated by hepatic vein catheterization and coincided with abundant perisinusoidal amyloid infiltration. Despite these features and the absence of objective response to 20 courses of melphalan and prednisone, the patient was still in good clinical condition 4 years after initial diagnosis. This observation suggests that in primary amyloidosis, the incidence of sinusoidal portal hypertension might be underestimated and also that it may be associated with a relatively good prognosis.

Microsomal function in hepatitis B surface antigen healthy carriers: assessment of cytochrome P450 1A2 activity by the 14C-caffeine breath test

The hepatitis B surface antigen (HBsAg) carrier state is associated with changes in hepatocellular function involving the cytochrome P450 (CYP) system. Among this system, CYP1A2 enzyme plays an important role in chemical carcinogenesis and in the metabolism of several drugs. We have thus investigated CYP1A2 function using two 14C-caffeine breath tests (3-methyl-14C; C3BT and 7-methyl-14C caffeine; C7BT) in 12 HBsAg healthy carriers and 8 healthy volunteers matched for 14C-aminopyrine breath test values. HBsAg carriers exhibited lower C3- and C7BT values than normal controls. This difference, however, did not reach statistical significance except for C7BT values normalised for aminopyrine breath test values. Our data thus do not support the association between viral presence and CYP1A2 dysfunction.

Eosinophilic gastroenteritis presenting with colitis and cholangitis

Eosinophilic gastroenteritis (EG) is a rare condition that most commonly affects the stomach and intestine. Large bowel involvement has also been described. We report a case of EG presenting with colitis and cholangitis. This is the first case of associated cholangitis demonstrated radiologically and histologically. Simultaneous biliary and gastrointestinal tract involvement suggest a common link between EG and hypereosinophilic syndrome (HES). However, HES requires high peripheral hypereosinophilia and several organs including gastrointestinal tract, lung, heart, infiltrated with eosinophils. The patient's condition improved with corticosteroids.

Precore mutant chronic hepatitis B in an autochthonous Belgian population: a study of ten patients

The mode of contamination, presentation, clinical evolution and liver histology of 10 native Belgian patients with chronic hepatitis B likely due to a peculiar viral strain, the so called precore mutant hepatitis B virus were reviewed. This viral strain first described in Southern European regions is characterized by a mutation of a single base change at nucleotide 1896 in the preterminal codon of the precore region which creates a stop codon that prevents the production of HBeAg. In this setting, abnormal liver biochemistry and active viral replication as evidenced by HBV DNA positivity often coincides with a serological profile similar to that observed in healthy HBsAg carriers. Our data indicate that chronic hepatitis related to such a viral strain may be observed in a native Belgian population. This unusual presentation of chronic hepatitis B should thus be kept in mind when interpreting atypical sero-biochemical features, evaluating the risk of infectivity and the potential benefit of antiviral therapy.

Anti-hepatitis C virus positivity (HCV) in Belgian volunteer blood donors: source of contamination and HCV-testing among donors and related recipients

We investigated a group of Belgian HCV-100 Elisa positive volunteer blood donors for potential sources of contamination and the presence of liver biochemical abnormalities. In addition, results of serological testing and liver biochemistry of their related blood products recipients were also analysed. In blood donors, anti-HCV-100 repeat reactive rate was 0.77% with a 34% rate of abnormal liver function tests. A potential source of parenteral exposure was found in all donors with RIBA-confirmed HCV-100 positivity. Among recipients, anti-HCV-100 RIBA-2 positive blood product donations were associated with RIBA-2 seroconversion, a history of transfusion in donors being of high predictive value of infectivity.

Biliary cystadenoma of the liver with elevated CA 19-9

A case of intrahepatic biliary cystadenoma with mesenchymal stroma is reported. The tumor was associated with strikingly elevated serum and intracystic levels of the tumor-associated antigen CA19-9. Two months after surgical enucleation, serum CA 19-9 levels returned to normal.

D-propoxyphene and norpropoxyphene kinetics after the oral administration of D-propoxyphene: a new approach to liver function?

In an attempt to design a liver function test which takes into account both portal-systemic shunting and hepatocellular dysfunction, we investigated a group of patients with cirrhosis with or without surgical porta-caval shunt for d-propoxyphene and its major metabolite, norpropoxyphene kinetics. A small dose of d-propoxyphene (0.7 mg/kg body weight) was given orally to seven normal subjects, 15 patients with cirrhosis and seven patients with cirrhosis and surgical portacaval shunt. D-propoxyphene and norpropoxyphene areas under the plasma concentration-time from 0 to 4-h (AUC) were determined by the trapezoidal method. As d-propoxyphene is a high extraction drug and since the production of norpropoxyphene should reflect the amount of d-propoxyphene available to the hepatocytes, we tested the hypothesis that norpropoxyphene/d-propoxyphene AUC ratios should reflect both the degree of portal-systemic shunting and the severity of hepatocyte dysfunction. Norpropoxyphene/d-propoxyphene AUC ratios were significantly lower in patients with cirrhosis (mean +/- S.D.: 0.92 +/- 0.59) than in controls (2.51 +/- 0.45) and also significantly lower in patients with cirrhosis and a surgical shunt (0.53 +/- 0.23) than in patients with cirrhosis but without surgical shunt (1.10 +/- 0.63). Moreover, there was an overall statistically significant correlation between norpropoxyphene/d-propoxyphene AUC ratios and branched to aromatic amino acids ratios (rs = 0.91) and fasting venous NH4 (rs = -0.63). On the other hand, there was only a weak correlation between norpropoxyphene/d-propoxyphene AUC ratios and the 14C-aminopyrine breath test (rs = 0.43). These data suggest that the norpropoxyphene/d-propoxyphene AUC ratio reflects both shunting and reduced hepatocellular function.(ABSTRACT TRUNCATED AT 250 WORDS)

Autoimmune chronic active hepatitis responsive to immunosuppressive therapy evolving into a typical primary biliary cirrhosis syndrome: a case report

The evolution from a characteristic picture of autoimmune chronic hepatitis type I to primary biliary cirrhosis is reported in a middle-aged woman. The initial diagnosis of autoimmune chronic liver disease was based on clinical, bio-serological and histological grounds. It was further confirmed by complete remission following immunosuppressive treatment and prompt relapses at the time of therapy withdrawal. After 7 years, the characteristics of liver disease were altered with increased biochemical cholestasis and serum IgM concentrations, positivation of previously negative anti-M2 antimitochondrial antibodies and the appearance of a typical histological picture of stage I primary biliary cirrhosis. We believe that this is the first reported case in which autoimmune chronic hepatitis highly responsive to immunosuppressive therapy has been followed by the development of a characteristic picture of primary biliary cirrhosis.

Short report: interferon-alpha decreases 14C-aminopyrine breath test values in patients with chronic hepatitis C

OBJECTIVE

To investigate the effect of interferon-alpha on cytochrome P-450 dependent microsomal function.

METHODS

The 14C-aminopyrine breath test was performed before, during and after a standard dose of interferon-alpha (3,000,000 units three times per week) was administered for at least six months (nine patients with chronic hepatitis C).

RESULTS

Mean aminopyrine breath test values obtained during therapy were significantly lower than either pre- or post-treatment, the degree of reduction varying widely between individuals. Pre- and post-treatment aminopyrine breath test values did not differ significantly.

CONCLUSION

Interferon therapy is associated with a significant and transient inhibition of cytochrome P-450 activity, which should be taken into account when prescribing concurrent therapy with drugs metabolized by this pathway.

Viral infections and liver transplantation

Viral infections after liver transplantation represent a major cause of morbidity and mortality. These agents may be introduced into the patient through the allograft, infusion of blood, blood products, and intravenous lines... Reactivation of latent viruses related to immunosuppression is also frequently observed after liver transplantation. Finally, a persistent infection due to hepatitis B, C or D viruses frequently occurs after liver transplantation and still presents serious problems when evaluating the therapeutic benefits of liver grafting. In this review, the clinical, biochemical, and histological characteristics of most frequent viral pathogens observed after liver transplantation are described. Particular features of each of these viruses are underlined.

Hepatic [14C]aminopyrine demethylation capacity after portocaval shunting. Comparative study in patients with and without arterialization of portal vein

The [14C]aminopyrine breath test (ABT) was used before and after surgical portocaval shunting in 29 cirrhotic patients, 15 with arterialization of the portal vein and 14 without. These two subgroups were comparable with regard to age, prothrombin time, serum albumin, serum total bilirubin concentrations, Child classification, and preoperative ABT. After portocaval shunt, a striking reduction in ABT values was observed after 6 and 12 months (90.7 +/- 8.0%, P < 0.05 and 77.3 +/- 7.5%, P < 0.005, respectively). No further decrease was observed between 12 and 24 months. The microsomal function was reduced to a greater extent in patients with postnecrotic cirrhosis (55 +/- 4.8%, P < 0.01) than in those with alcoholic cirrhosis (84.8 +/- 10.4%, P < 0.05). Arterialization of the portal stump of the portal vein did not prevent the reduction in hepatocellular function. No significant change in prothrombin time, serum albumin, or bilirubin concentrations was observed during the follow-up period in any of the groups. Overall, preoperative ABT was significantly higher in those surviving one year (0.29 +/- 0.12% administered dose) than in those who died within this time period (0.12 +/- 0.01%, P < 0.005). This observation suggests that portocaval anastomosis induces an early decrease in microsomal function that is not prevented by arterialization of the portal vein. It also suggests that ABT might be helpful in selecting patients for shunt surgery.

Anti-neutrophil antibodies in chronic hepatitis and the effect of alpha-interferon therapy

In 34 patients with non-A non-B, 28 with type B and 11 with autoimmune chronic hepatitis, anti-neutrophil antibodies were investigated using indirect immunofluorescence and anti-myeloperoxidase antibodies by enzyme-linked immunosorbent assay. Granulocyte-specific antinuclear antibodies, were detected in 14 patients with advanced stages of non-A, non-B hepatitis (41%). Their presence correlated with histological features of disease activity but not with response to interferon therapy. Within 24 h after the first dose of interferon, 9 of these became negative and 3 more became negative after 1, 3 and 5 months. Myeloperoxidase-positive perinuclear neutrophil cytoplasmic antibodies were detected in a single patient and increased reaching a peak level after 8 weeks of interferon, decreasing thereafter. In type B, all were negative before and during the 6 months of therapy. In 6 patients with autoimmune hepatitis (55%), myeloperoxidase-negative perinuclear neutrophil cytoplasmic antibodies were detected in high titers. The association of granulocyte-specific anti-nuclear antibodies with non-A, non-B hepatitis support the hypothesis that hepatitis C virus infection might trigger humoral autoimmune response. In chronic autoimmune hepatitis, perinuclear neutrophil cytoplasmic antibodies appear as another marker of autoimmunity.

Vitamin A abuse: development of cirrhosis despite cessation of vitamin A. A six-year clinical and histopathologic follow-up

We report the case of a 35-year-old man who contracted vitamin A-induced liver cirrhosis. Five years before, he had been investigated for vitamin A-induced non-cirrhotic portal hypertension. In this case, the clinical and histopathologic evolution from non-cirrhotic portal hypertension to cirrhosis was documented. In spite of the cessation of pharmaceutical vitamin A intake, the disease progressed. Therapy with colchicine and phenobarbital apparently did not influence evolution to cirrhosis. This suggests that vitamin A can trigger largely unknown mechanisms of liver fibrosis which seem to be self-perpetuating.

Liver damage caused by therapeutic vitamin A administration: estimate of dose-related toxicity in 41 cases

Clinical presentation, changes in liver function test results, and liver morphology were examined in 41 consecutive patients with vitamin A hepatoxicity. The cause of liver disease was suspected at initial interview in only 13 instances, whereas histological evidence of fat-storing cell hyperplasia with fluorescent vacuoles led to the diagnosis in the remaining cases. Cirrhosis was found in 17, mild chronic hepatitis in 10, noncirrhotic portal hypertension in 5, and "increased storage" alone in 9 cases. During a mean follow-up period of 4.6 years, 6 patients died of causes related to the liver disease. A precise appraisal of drug consumption was obtained in 29 cases. Among them the total cumulative intake was the highest in patients with cirrhosis (423 +/- 103 x 10(6) IU) and significantly lower in those with noncirrhotic liver disease (88.5 +/- 41; P less than 0.02). The smallest continuous daily consumption leading to cirrhosis was 25,000 IU during 6 years, whereas higher daily doses (greater than or equal to 100,000 IU) taken during 21/2 years resulted in similar histological lesions. It was concluded that at least in some western countries chronic vitamin A consumption might represent an appreciable cause of chronic liver disease, the recognition of which mainly relies on expert liver biopsy interpretation. The data also indicate that prolonged and continuous consumption of doses in the low "therapeutic" range can result in life-threatening liver damage.

Reversible cholestasis with bile duct injury following azathioprine therapy. A case report

A 67-year-old patient, with primary polymyositis and without previous evidence of liver disease, developed clinical and biochemical features of severe cholestasis 3 months after initiation of azathioprine therapy. Liver biopsy showed cholestasis with both cytological and architectural alterations of interlobular bile ducts. Azathioprine withdrawal resulted after 7 weeks in the resolution of clinical and biochemical abnormalities. It is believed that this is the first reported case of reversible azathioprine-induced cholestasis associated with histological evidence of bile duct injury.

Antimitochondrial and antinuclear antibodies in primary biliary cirrhosis: an update in relation to their biochemical characterization and clinical significance

Antimitochondrial antibodies are found in 85 to 95% of patients with primary biliary cirrhosis. Nine different patterns have been identified but only four are associated with primary biliary cirrhosis. Anti-M2 antibodies are specific for the disease. The M2 antigen was found to be composed of five antigen determinants and related to the E2 component of three multienzyme complexes located within mitochondria. Anti-M4 and M8 antibodies appear invariably associated with anti-M2 and are markers for the "overlap syndrome" between primary biliary cirrhosis and chronic active hepatitis as well as for poor prognosis. Anti-M9 antibodies are preferentially associated with early and/or asymptomatic disease. Antinuclear antibodies are found in 24 to 58% of patients with primary biliary cirrhosis. Six various patterns have been reported. Antibodies directed to the 200 kD polypeptide of the nuclear pore and giving a perinuclear fluorescence are specific for primary biliary cirrhosis. Patients with such antibodies exhibit a less symptomatic disease and lower titers of anti-M2 than those without.