A remarkable presentation of a massive Budd-Chiari syndrome

A 59-year-old female presented to the emergency department with malaise, significant weight loss, abdominal discomfort, dyspnoea and severely swollen peripheral extremities. She had a past medical history of sickle cell anaemia, a latent tuberculosis infection and a chronic hepatitis B that was treated with PEG-interferon alpha-2 in 2008. Since 2018, she was lost to follow-up. The patient was critically ill, sarcopenic and lethargic. Clinical examination revealed icteric sclerae and a markedly distended and diffusely tender abdomen and peripheral oedemas. Her vital signs included a blood pressure of 105/64 mmHg, tachycardia of 130 bpm, hypothermia of 35.6°C and a SpO2 of 100% in ambient air. Laboratory workup demonstrated a total bilirubin of 12.9 mg/dL, AST 500 U/L, ALT 218 U/L, ALP 178 U/L and GGT 126 U/L, a thrombocytopenia of 34 x10E3/ μL, 16,01 x10E3/μL leukocytes, a CRP of 94.8 mg/L and a lactate of 10,12 mmol/L. The serum creatinine was 1.04 mg/dL, eGFR 54.1 ml/min. The INR was 2.77 and there was a severe hypoalbuminemia (22 g/L). D-dimers were >20 000 ng/ml. The patient presented also with spontaneous hypoglycaemia. A multiphasic contrast-enhanced thoracic and abdominal computed tomography (CT) was performed (figure 1). Given the results of the CT, a 2D echocardiogram was urgently requested (figure 2).

An unusual cause of portal hypertension

A 66-year-old male with a medical history of coronary artery disease presented with nonspecific symptoms of anorexia, lethargy and an increase in abdominal girth. He was diagnosed 3 months ago with chronic liver disease of undetermined aetiology. He did not smoke and was a social drinker till 4 months ago. He was taking tests showed progressive cholestatic liver enzymes (total bilirubin 1,09 mg/dL, AST 130 U/L, ALT 129 U/L, GGT 517 U/L and ALP 641 U/L) and a severe hypoalbuminemia. Laboratory workup made a metabolic, autoimmune, and viral aetiology of the suspected cirrhosis less probable. Urinalysis showed a rapidly progressive proteinuria in the nephrotic range accompanied by the presence of serum spike of monoclonal lambda light Furosemide, Aldactone, Pantoprazole, Acetylcysteine and Atorvastatin. He had no personal or familial history of liver diseases. Physical examination revealed a tender but distended abdomen and large ascites was present. The laboratory chain protein on electrophoresis with immunofixation. Doppler echocardiography revealed a hypertrophic cardiomyopathy based on diffuse left and right ventricular hypertrophy with relative apical sparing. A diagnostic paracentesis was undertaken and the results were consistent with portal hypertension (SAAG 1,6 g/ dL). Considering the concomitant presence of hypertrophic cardiomyopathy, nephrotic syndrome and a presentation of portal hypertension of undetermined aetiology in presence of a monoclonal IgG lambda light chain spike, a transjugular liver biopsy (figure 1 and 2) was performed with HVPG measurement consistent with significant portal hypertension (15 mmHg).

Hepatitis C virus (HCV) prevalence estimation in the adult general population in Belgium : a meta-analysis

BACKGROUND AND STUDY AIMS

Although multiple HCV prevalence studies were recently performed in the general population from Belgium, they suffer from a lack of geographical representativeness, an insufficient number of participants or a lack of inclusion of high prevalence groups. The aim of this study is to provide robust information on the HCV burden.

METHODS

Recently performed HCV prevalence studies in the general, adult population were included in this study, based on well-defined selection criteria. A meta-analysis was performed to estimate the seroprevalence, the prevalence of participants with viremia and the prevalence estimation for people with viremia which were unaware of their status.

RESULTS

Eight studies fulfilled the criteria for inclusion of the quantitative prevalence estimation. Based on the meta-analysis on these 8 studies, we estimated an HCV seroprevalence of 1.01% [95% CI : 0.66-1.42%], representing a total of 90,722 adult, HCV seropositives of which 64,412 individuals (0.71%) were confirmed seropositive. Based on the RNA presence, an estimated viremic prevalence of 0.33% [95% CI : 0.21-0.47 %] was determined, corresponding with 29,642 individuals. This is 46,0% of the true HCV seropositive residents. Further, based on the availability of patient information in 5 out of the 8 studies, a prevalence of 0.18% [95% CI : 0.07-0.33] representing 16,168 individuals from the adult Belgian population are unaware of their HCV status.

CONCLUSIONS

We believe that the quantitative measurement by the meta-analysis will be more reliable for their use in the design of a screening strategy or in the development of prevention campaigns as compared to the prevalence estimations performed at local level.

Update on liver transplantation for cholangiocarcinoma : a review of the recent literature

Cholangiocarcinoma (CC) represent 3% of all gastrointestinal tumours and can be classified anatomically in 3 types: intrahepatic (ICC), perihilar (PCC) and distal (DCC) cholangiocarcinomas. Resection is the treatment of choice but is only achieved in a few cases (<20%) because of invasion of the biliary tract and/or vascular structures. The outcome of advanced CC is poor with an overall survival (OS) of maximum 15 months with chemotherapy. In the 1990s, CC was regarded as a contraindication for liver transplantation (LT). LT has recently been proposed as potentially curative option for ICC and PCC. Careful patient selection has changed OS. This article provides an update on current status of LT for patients with unresectable CC.

The potential of glycomics as prognostic biomarkers in liver disease and liver transplantation

The study of glycomics is a novel and fascinating approach for the development of biomarkers. It has become clear that in the field of liver disease specific glycomic patters are present in specific disease states, which has led to the development of diagnostic biomarkers. In this manuscript, we will describe two new applications of this technology for the development of prognostic biomarkers. The first biomarker is associated with the risk of hepatocellular carcinoma development in patients with compensated cirrhosis. The second biomarker is present in perfusate and is related to the risk of primary non function occurrence after liver transplantation. The technology used for these biomarkers could easily be implemented on routine capillary electrophoresis equipment.

Association of recently described adipokines with liver histology in biopsy-proven non-alcoholic fatty liver disease: a systematic review

The prevalence of non-alcoholic fatty liver disease (NAFLD) is rising, as is the prevalence of obesity and type 2 diabetes. It is increasingly recognized that an impaired pattern in adipokine secretion could play a pivotal role in the development of NAFLD. We performed a systematic review to evaluate the potential link between newly described adipokines and liver histology in biopsy-proven NAFLD patients. A computerized literature search was performed in PubMed, EMBASE and Web of Science electronic databases. Thirty-one cross-sectional studies were included, resulting in a total of seven different investigated adipokines. Studies included in this review mainly had a good methodological quality. Most adipokines were suggested to be involved in the inflammatory response that develops within the context of NAFLD, either at hepatic or systemic level, and/or hepatic insulin resistance. Based on literature, clinical studies suggest that chemerin, resistin and adipocyte-fatty-acid-binding protein potentially are involved in NAFLD pathogenesis and/or progression. However, major inconsistency still exists, and there is a high need for larger studies, together with the need of standardized assays to determine adipokine levels.

IgG4-related cholangitis: Case report and literature review

CASE PRESENTATION

We describe a case of a patient who presents with jaundice, elevated cholestatic liver enzymes, an extreme weight loss and a midcholedochal stricture very suspect for a cholangiocarcinoma. In the conviction of malignancy, although the absence of anatomopathological prove, the patient underwent a choledochal resection. The anatomopathological specimen revealed no malignancy. In the year following resection, the patient keeps presenting with bile duct strictures and further weight loss. Ultimately the diagnosis of Ig G4-related cholangitis is withheld. Therapy with corticosteroids is initiated with a spectacular clinical, biochemical and radiographical result.

DISCUSSION

IgG4-related cholangitis is the biliary presentation of IgG4-related disease, a recently discovered entity of fibroinflammatory masses which can affect virtually every organ in the body. It is characterized by a dense lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phlebitis and a presence of > 30 IgG4-positive plasma cells per high power field. Main differential diagnosis contains cholangiocarcinoma and primary sclerosing cholangitis. Corticoids are cornerstone of therapy, with azathioprine frequently used as a maintenance in case of relapse.

CONCLUSIONS

With this case we want to draw the attention to a rather uncommon cause of biliary obstruction, easily mistaken for a cholangiocarcinoma.

Cutaneous infection by Alternaria infectoria in a liver transplant recipient: a case report

We report the case of a 65-year-old man who developed multiple crusty ulcerative skin lesions on both lower extremities six months after liver transplantation. The causative pathogen was identified as Alternaria Infectoria, an opportunistic fungal agent. The patient was successfully treated with fluconazole for 27 weeks, with complete regression of the lesions. Due to the lack of well-designed clinical studies it is difficult to determine the best treatment course regarding solid organ transplant recipients presenting with invasive fungal infections. And for now, the clinician must lean upon case-reports or retrospective analyses to compose the most suited therapy for his patient. Based upon literature, it seems that the combination of a broad spectrum azole and reducing the dose of immunosuppressive drugs is the cornerstone of treating invasive fungal infections in solid organ transplant patients.

Pathophysiology and management of post resection liver failure

Post resection liver failure (PRLF) is defined by the occurrence of jaundice, coagulopathy and encephalopathy after liver resection. When PRLF is present, it has a high morbidity and mortality. The incidence of PRLF ranges between 0-30%. For having a healthy regeneration of the liver remnant an adequate number of hepatocytes and nonparenchymal cells, a normal functional and regenerative capacity and also a good accommodation of haemodynamic changes without congestion are needed. To avoid the presence of PRLF ongoing parenchymal damage after the liver resection should be avoided. So, ischemia reperfusion injury should be minimalized, infection and sepsis should be treated immediately and small for size syndrome should be avoided.

Acute hepatitis after treatment for hair loss with oral green tea extracts (Camellia Sinensis)

Nutritional additives based on green tea have been claiming various beneficial health effects. However, several case reports on hepatotoxicity after the intake of green tea derivatives containing Camellia Sinensis have been published. We report a patient with an acute hepatitis after intake of an oral green tea derivative claiming protection against hair loss, showing a histological image compatible with drug induced hepatitis. Other important causes of hepatitis were excluded. After cessation of this nutritional additive there was a rapid and sustained recovery. We raise concern about the safety of nutritional additives with few proven beneficial effects and want to emphasize the importance of accurate and thorough history taking, with attention for over the counter drugs and herbal products.

Rheumatoid factor, but not anti-cyclic citrullinated peptide antibodies, is modulated by infliximab treatment in rheumatoid arthritis

OBJECTIVES

To analyse the effect of infliximab on IgM rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies, and determine whether baseline autoantibody titres (IgM RF and anti-CCP antibodies) are associated with changes in acute phase reactants.

PATIENTS AND METHODS

62 patients with refractory RA were treated with infliximab combined with methotrexate. At baseline and week 30, serum samples were tested for IgM RF by two agglutination assays, and for anti-CCP antibodies by an ELISA. Percentage change in C reactive protein (CRP) and erythrocyte sedimentation rate (ESR) was calculated.

RESULTS

At baseline and week 30 RF titres were reduced significantly during infliximab treatment (p<0.001 and p = 0.038, respectively), whereas anti-CCP antibodies were unchanged (p = 0.240). Baseline IgM RF titres, but not anti-CCP antibodies, correlated inversely with changes in CRP and ESR during treatment. Patients with a marked decrease in acute phase reactants had lower IgM RF titres than those with a smaller decrease in CRP and ESR; no significant differences were found for anti-CCP antibodies.

CONCLUSION

The differential effect of infliximab treatment on IgM RF and anti-CCP antibodies, and the different predictive value on changes in acute phase reactants during infliximab treatment support the existing evidence that RF and anti-CCP antibodies are independent autoantibody systems in RA.