Biological Appraisal of Liver Status in Adenocarcinomas

A prospective study of the ability of laboratory tests to detect or to exclude hepatic metastases was performed. Seventy-four patients who underwent liver biopsies were divided into 3 groups: 1) 33 patients with secondary liver involvement from adenocarcinoma; 2) 21 subjects suffering from a non-malignant hepatic disease, and 3) 20 cancerous patients free of overt hepatic metastases. They were investigated with 7 laboratory tests. No single test had a positive predictive value higher than 75%. This percentage was increased to 84% by combining the results of both CEA and rapidly migrating liver alkaline phosphatase isoenzyme ALP 1. More important was the fact that when those parameters were both normal, the negative predictive value was 93%, thus tending to exclude a liver metastatic involvement with an acceptable confidence limit.

[Outcome of patients after obliteration of esophageal varices by endoscopic sclerosis. Results of a prospective study]

The purpose of this prospective was study to investigate the course of patients after obliteration of bleeding esophageal varices by endoscopic sclerotherapy and to outline prognostic factors. Sixty-seven patients (45 men, 22 women, mean age: 53.3 +/- 14 years) were followed for a mean of 14 +/- 8 months median = 15 months-range: 1-33 months) from the time of obliteration. Etiology of portal hypertension was portal vein thrombosis in 3 patients and cirrhosis in 64, 44 of whom (65 p. 100) were due to alcoholism (Child-Pugh's class: A: 8 p. 100, B: 42 p. 100, C: 50 p. 100). Recurrence of varices was observed in 23 patients within 1.4 to 25 months (median: 6.6 months). The recurrence rate increased in a linear fashion with time. Reobliteration was achieved in one to three sessions of sclerotherapy. More than one bleeding episodes was observed more often, before sclerotherapy (p less than 0.05) and esophageal stenosis was seen less often during treatment (p less than 0.05) than in patients without recurrence. Variceal bleeding occurred in 14 patients (21 p. 100) within 0.1 to 23 months (median = 5.6), 6 of whom (43 p. 100) died. In the subgroup of alcoholic cirrhosis, absence of withdrawal was associated with a higher risk of rebleeding (p = 0.04). Fifteen patients (22 p. 100) died within 1 to 26 months (median = 12.3). They had a higher mean age (p less than 0.01) and a lower blood fibrinogen (p less than 0.05) than survivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of short-term prognosis after variceal bleeding in patients with alcoholic cirrhosis by early measurement of portohepatic gradient

Seventy-two consecutively admitted patients with biopsy-proven alcoholic cirrhosis and a bleeding episode endoscopically proven to originate from ruptured esophageal varices were studied. Hemodynamic assessment was performed within 48 hr of admission using the transjugular approach. Mean portal pressure was found to be significantly greater in the group of patients who died than in those who survived for 1 week, 2 weeks or 1 month after admission. We conclude that: The portohepatic pressure gradient and portal pressure have short-term prognostic value in patients with alcoholic cirrhosis bleeding from ruptured esophageal varices. Owing to a high early mortality, any delay between the occurrence of a bleeding episode and the measurement of portal pressure appears to select a sample of survivors with a significantly lower mean level of portal pressure than in those measured earlier. When evaluating portal pressure, the time of study is one of the most important variables which may affect the conclusions.

[Embolization of esophageal varices by the transjugular route in severe digestive hemorrhage in cirrhotic patients. Prospective study of 83 patients]

A prospective study was undertaken to assess the results of embolization of esophageal varices by the transjugular approach, in 83 patients with advanced cirrhosis (65 p. 100 Child's class C) admitted with severe bleeding (mean of 10 units of blood per patient). Embolization was successfully completed in 65 patients (78 p. 100) and complete obliteration was achieved in 50 (60 p. 100). Twenty-nine procedures were performed on actively bleeding patients. Cessation of bleeding was observed in 22 (76 p. 100). Excluding the 5 patients in whom embolization could not be achieved, the success rate was 92 p. 100. Embolization was attempted as an elective procedure in 54 patients who were not actively bleeding. Recurrent hemorrhage occurred in 18 patients (33 p. 100) during the first month of follow-up. Finally, 38 patients rebled and 57 died. No accident could be ascribed to the procedure. It is concluded that: (a) the transjugular approach proved to be safe in actively bleeding patients with severe cirrhosis; (b) variceal obliteration effectively controlled active bleeding. The efficacy of this procedure was limited in time. The use of embolization is further hindered by a consistent failure rate and by the development of new therapeutic modalities, such as sclerotherapy.

[Emergency colonoscopy in lower intestinal occlusion]

From March 1980 to June 1983, 23 patients presenting with clinical and or radiological manifestations of colonic obstruction and with uncertainty as to medical/surgical possibilities of management, underwent emergency colonoscopy in the intensive care unit of our Digestive Disease Department. The investigations were conducted without preparation (enema) or premedication, using an ordinary colonoscope. The endoscopic examination led to correct diagnosis in 21 patients out of 23 (91.3 p. 100). The main causes of occlusion were: colonic or rectal cancer (11 cases), Ogilvie's syndrome (6 cases), volvulus of the sigmoid colon (3 cases). Endoscopy contributed to treatment in eight patients with good results in six. It was unsatisfactory in two cases of volvulus of the sigmoid colon which recurred. In two instances complications occurred which were attributable to the method: one pneumoperitoneum without frank perforation and a transtumoral perforation in a case of sigmoid cancer, discovered at laparotomy. No septic complication or mortality resulted from endoscopy. Colonoscopy under normal conditions should not be advocated systematically, but can be used as a method of investigation and possibly of therapy in selected cases of colonic obstruction admitted into intensive care units.

[Comparison of 3 methods of recording esophageal pH in the diagnosis of gastroesophageal acid reflux]

The aim of this prospective work was to analyze the results of 3 methods of esophageal pH recording (i. e. short-term pH test, 3-hr postprandial recordings, and 12-hr nocturnal pH recording) in 47 patients with suspected gastroesophageal reflux. Nocturnal pH recording was used as a reference for evaluation of the diagnostic value of the 2 other pH tests. Normal ranges were established from 20 control subjects. Esophageal endoscopy with biopsies were performed systematically in order to evaluate the relationship between pH results and the grades of esophagitis. According to the results of nocturnal pH recordings, 32 patients were considered to suffer from acid gastroesophageal reflux and 15 patients as being free of reflux. The sensitivity and specificity of the pH measurements were 0.94 and 0.13 for the short-term pH test and 0.91 and 0.80 for 3-hr postprandial recordings respectively. The total duration of reflux (expressed as a percentage of total duration of the test) was the most discriminative parameter for the diagnosis of reflux and was simpler to determine than previously described pH scores. Because of the absence of lamina propria in the biopsy specimens obtained at endoscopy, histological diagnosis of esophagitis was possible in only 35 patients (74 p. 100). No relationship was found between the grade of esophagitis and the results of short-term pH tests. On the other hand, the mean duration of reflux episodes, the duration of the longest episode, the total duration of reflux measured by 12-hr nocturnal pH recording, and the number of low pH reflux episodes determined by postprandial tests were significantly higher in patients with macroscopic lesions than in those with normal endoscopic aspect or mild (histological) lesions of esophagitis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Granulomatous hepatitis. Apropos of 112 cases in adults]

In this series, the commonest aetiology was tuberculosis (24 cases), Hodgkin's disease (21 cases), sarcoidosis (14 cases) and Q fever (14 cases). Some morphological features such as number and size of granulomas seemed useful for aetiological diagnosis. A granuloma with a central fat vacuole surrounded by fibrinoid material was in favour of Q fever. A dense mononuclear sinusoidal infiltration was associated with granulomas in MNI or CMV infections. 19 cases were cryptogenetic.

[Prospective study of the clinical signs, diet, and radiologic changes of the small intestine and the colon in 106 patients with functional intestinal disorders]

A prospective statistical study of clinical symptoms, radiological modifications of the colon and small bowel as judged by a morphometric method and dietary habits was performed in 106 patients who presented with functional intestinal disorders. Four different associations of symptoms and signs were found: a) pain, sometimes heavy, in the left upper quadrant and the ombilical region was associated with morphometric modifications of the small bowel: increased diameter of the upper part, decreased diameter and increased number of folds in the lower part of ileum; b) slight pain of the two upper quadrants and the two flanks was associated with flatulence, and was not correlated with modifications of the radiological aspect of the small bowel and colon; c) constipation and diarrhea were not correlated with any type of morphometric modifications of the colon; d) constipation was significantly correlated with low fiber diet.

[Esophageal pHmetry: comparison with clinical, endoscopic and histological data. Prospective study in 43 patients with suspected gastroesophageal reflux]

In order to evaluate the relationship between gastro-oesophageal acid reflux, as defined by pH recording, and clinical, endoscopic and histological findings, 43 patients with suspected gastro-oesophageal reflux (21 with typical and 16 with atypical symptoms) underwent endoscopy with biopsy and post-prandial oesophageal pH recording with a calculated acid reflux score. The history of each patient was carefully recorded. An acid reflux score higher than the mean +/- S.D. normal values was taken as diagnostic of gastro-oesophageal reflux. This level was reached in 30 out of the 43 patients. History taking gave 13 false-positive results (3 in the typical symptoms group, and 10 in the atypical symptoms group). The sensitivity and specificity of fiberoptic endoscopy as a means of diagnosing gastro-oesophageal reflux were 47% and 77% respectively. Histological data were available from only 77% of the patients; their diagnostic sensitivity and specificity values were 73% and 82% respectively. The absence of correlation between the intensity of the gastro-oesophageal reflux, as measured by pH recordings, and the severity of symptoms and endoscopic findings deserves to be noted.

[Familial autoimmune pathology comprising 2 cases of primary biliary cirrhosis]

Two cases of primary biliary cirrhosis (PBC) were observed in two brothers. Clinical, biochemical, immunological and genetic investigations (in particular by HLA typing) were systematically undertaken in nine subjects of this family (including the two above mentioned cases) in two generations. One case of granulomatous hepatitis associated with auto-immune thyroiditis was discovered in a sister. Immunological abnormalities were observed in six out of nine members of the family: anti-nuclear (four cases), anti-mitochondrial (two cases), anti-thyroid (two cases), auto-antibodies and rheumatoid factors (two cases). Six subjects (including the three with hepatic disease) had the same HLA haplotype (with in particular HLA DR4, which has been previously associated with sporadic PBC). However, the role of this haplotype in the transmission of PBC in a family could not be demonstrated. Biochemical and immunological survey might be of importance in the kindred of patients with PBC, thereby contributing to the screening of asymptomatic hepatic disease.

Clinical and prognostic significance of portohepatic gradient in patients with cirrhosis

As the clinical significance of hemodynamic parameters remains controversial, the portohepatic gradient has been measured in 89 patients with cirrhosis by a transjugular approach. Relationships between portohepatic gradient and clinical, roentgenologic and prognostic patterns were studied with a maximum follow-up period of 36 months. Portohepatic gradient was not related to the rate of occurrence or rate of recurrence of digestive tract bleeding. Portohepatic gradient was related to the size of esophageal varices, p less than 0.01. Observation of large varices at endoscopy was associated with a higher risk of digestive tract bleeding. Portohepatic gradient was related to the number of portosystemic shunts opacified at portography, p less than 0.01. Portohepatic gradient was found to be related to these aspects of prognosis: the mean portohepatic gradient was higher in patients who died than it was in survivors, p less than 0.05. When patients were separated into two groups according to portohepatic gradient values--greater than or equal to 20.8, less than 20.8 millimeters of mercury--the actuarial survival rate was inversely related to portohepatic gradient at one, p less than 0.02, and at 12, p less than 0.02, months of follow-up study. This relationship could be demonstrated in the entire group of patients with cirrhosis and in the group of patients with digestive tract bleeding. This pattern seemed to be related to the risk of hemorrhage. In groups of patients and within a 24 month observation period, the survival rate was significantly related to the range of portohepatic gradient in each group.