Non-malignant portal vein thrombosis in a cohort of cirrhotic patients: Incidence and risk factors

AIM

Non-malignant portal vein thrombosis (PVT) is a complication of liver cirrhosis. The aim of this study was to evaluate the annual incidence of PVT and related risk factors.

METHODS

We retrospectively reviewed clinical, laboratory, and radiological data collected prospectively from September 2016 to September 2017. A follow-up of 36 months was performed in a subset of patients to determine the cumulative incidence of PVT and related complications.

RESULTS

The study included 567 patients. The incidence of PVT at 12, 24, and 36 months was 3.7%, 0.8%, and 1.4%, respectively. Patients with PVT were compared with patients without PVT, and showed differences in albumin (p = 0.04), aspartate aminotransferase (p = 0.04), hemoglobin (p = 0.01), and prothrombin activity (p = 0.01). The presence of hydropic decompensation (57.1% vs. 30.1%; p 0.004), gastroesophageal varices (76.2% vs. 39.5%; p = 0.05), variceal bleeding (52.4% vs. 22.7%; p < 0.001), hepatic encephalopathy (38.1% vs. 9.9%; p = 0.01), spontaneous bacterial peritonitis (9.5% vs. 1.7%; p < 0.001), and use of beta-blockers (71.4% vs. 27.7%; p < 0.001) were significantly associated. In the multivariate analysis, use of beta-blockers and hepatic encephalopathy appeared as risk factors, and high albumin levels a protective factor.

CONCLUSIONS

The incidence of PVT was 3.7%. Beta-blockers and hepatic encephalopathy were risks factors. High albumin levels were a protective factor.

Validation of noninvasive methods to predict the presence of gastroesophageal varices in a cohort of patients with compensated advanced chronic liver disease

BACKGROUND AND AIM

The aim was to validate noninvasive methods to predict the presence of gastroesophageal varices (GEV) in patients with suspected compensated advanced chronic liver disease.

METHODS

We retrospectively reviewed clinical and radiological data collected prospectively between September 2013 and September 2015. We reviewed 442 consecutive patients with suspected compensated advanced chronic liver disease measured by transient elastography (TE) and a gastroscopy. We evaluated platelets, spleen diameter, TE, liver stiffness × spleen size/platelets (LSPS), variceal risk index (VRI), Baveno VI strategy, and Augustin algorithm.

RESULTS

One hundred sixty-one out of 442 patients were included. Patients with GEV were compared with patients without GEV and showed statistically significant differences in platelet count (117 SD 51 vs 149 SD 62; P = 0.02), spleen diameter (13.0 SD 1.9 vs 11.5 SD 2; P = 0.003), and TE (28 SD 15 vs 19 SD 10; P = 0.001). Single methods (platelet count and TE) diagnosed correctly 51% and 71.4% of patients. Combined methods (LSPS, VRI, Baveno VI, and Augustin algorithm) diagnosed correctly 78%, 83.6%, 45.3%, and 57.1% of patients. Patients with GEV misdiagnosed: platelets 5/161 (3.1%), TE 6/161 (3.7%), LSPS 16/159 (10%), VRI 18/159 (11.3%), Baveno VI 3/161 (1.8%), and Augustin algorithm 6/161 (3.7%). Rate of unnecessary gastroscopies: platelets 46%, TE 25%, LSPS 13%, VRI 6%, Baveno VI 53%, and Augustin algorithm 39.1%.

CONCLUSIONS

A significant number of patients were classified correctly using TE, LSPS, and VRI; however, LSPS and VRI had unacceptable rates of misdiagnoses. TE is the best noninvasive single method and the Baveno VI strategy the best combined method.

AM3, a natural glycoconjugate, induces the functional maturation of human dendritic cells

BACKGROUND AND PURPOSE

Dendritic cells (DCs) are dedicated antigen-presenting cells able to initiate specific immune responses and their maturation is critical for the induction of antigen-specific T-lymphocyte responses. Here, we have investigated the effects of Inmunoferon-active principle (AM3), the active agent of a commercial immunomodulatory drug, on human monocyte-derived DCs (MDDCs).

EXPERIMENTAL APPROACH

MDDCs derived from healthy and hepatitis C virus (HCV)-infected patients were stimulated with AM3. We analysed the expression of cell surface proteins by flow cytometry, that of cytokine production by ELISA, and the expression of chemokines and chemokine receptors by RNase protection assays. T-lymphocyte proliferation was assessed in mixed lymphocyte reactions, protein expression by western blot and luciferase-based reporter methods, and Toll-like receptor (TLR)-blocking antibodies were employed to analyse TLR activity.

KEY RESULTS

In MDDCs, AM3 induced or enhanced expression of CD54, CD83, CD86, HLA-DR, chemokines and chemokine receptors, interleukin (IL)-12p70 and IL-10. Furthermore, AM3 stimulated MDDCs to increase proliferation of allogenic T cells. AM3 triggered nuclear translocation of NF-kappaB and phosphorylation of p38 mitogen-activated protein kinase. AM3 promoted NF-kappaB activation in a TLR-4-dependent manner, and blocking TLR-4 activity attenuated the enhanced expression of CD80, CD83 and CD86 induced by AM3. AM3 enhanced the expression of maturation-associated markers in MDDCs from HCV-infected patients and increased the proliferation of T lymphocytes induced by these MDDCs.

CONCLUSIONS AND IMPLICATIONS

These results underline the effects of AM3 in promoting maturation of MDDCs and suggest that AM3 might be useful in regulating immune responses in pathophysiological situations requiring DC maturation.

Transient elastography to assess hepatic fibrosis in primary biliary cirrhosis

BACKGROUND

Liver stiffness measurements may have potential for detecting and monitoring hepatic fibrosis in chronic liver disease.

AIM

To study the detection, quantification and progression of hepatic fibrosis in primary biliary cirrhosis by liver stiffness measurements.

METHODS

Liver stiffness measurements were generated in 80 patients with primary biliary cirrhosis by applying transient elastography; however, as there were 55 with liver biopsy, histological stage (METAVIR) and liver stiffness measurements were compared only in these 55 patients. The efficiency of liver stiffness measurements in predicting stage of fibrosis was determined from the area under receiver operating characteristics curve analysis.

RESULTS

Of the 80 patients included, 91, 4% were women and their mean age was 56 +/- 12 (s.d.) years. A significant correlation was found (P < 0.05) between histological fibrosis stage (METAVIR) and liver stiffness measurements. The values obtained from area under receiver operating characteristic curve analysis of liver stiffness measurement data were 0.89 for F > 2 and 0.96 for F = 4. Liver stiffness measurements were 9.0 +/- 5.3 and 7.9 +/- 6.0 kPa for patients followed up more than 5 years and less than 5 years, respectively (P > 0.05).

CONCLUSIONS

In patients with primary biliary cirrhosis, median values of liver stiffness measurements correlated with histological severity of hepatic fibrosis. Liver stiffness measurements appear to be promising for liver fibrosis detection and quantification, as well as monitoring its progression, in patients with primary biliary cirrhosis. The progression rate of hepatic fibrosis in our primary biliary cirrhosis patients appears to be slow.

Evaluation of 3 different tests for the detection of stool antigens to confirm Helicobacter pylori eradication after treatment. A pilot study

INTRODUCTION

Recently, several new diagnostic methods aimed to detect Helicobacter pylori stool antigens have been developed. Our aim was to evaluate the accuracy of 3 different stool tests to confirm H. pylori eradication.

PATIENTS AND METHODS

Twenty-six patients received H. pylori eradication treatment. Eradication was confirmed with 13C-urea breath test 6-8 weeks later, when stool samples were analyzed by polyclonal (Premier-Platinum-HpSATM), monoclonal (Amplified-IDEIATM-HpStARTM), and rapid test (ImmunoCard-STAT-HpSATM).

RESULTS

H. pylori was eradicated in 85% of the cases. Sensitivity, specificity, positive predictive value and negative predictive value with the polyclonal test were: 25%, 91%, 33% and 87%. Corresponding results with the monoclonal test, using the cut-off point recommended by the manufacturer, were 100%, 46%, 25% and 100%. However, the best cut-off point in our study had 100% sensitivity and 91% specificity. The area under ROC curve for the polyclonal and the monoclonal tests was 0.65 and 0.95. Diagnostic accuracy with the rapid test was 75%, 90%, 60% and 95%.

CONCLUSION

Neither the polyclonal stool antigen test nor the rapid stool antigen test can be recommended to confirm H. pylori eradication after treatment. The monoclonal test has better diagnostic accuracy, although more studies are necessary to definitively recommend its use for the confirmation of H. pylori eradication success.

Maintenance of T1 response as induced during PEG-IFNalpha plus ribavirin therapy controls viral replication in genotype-1 patients with chronic hepatitis C

OBJECTIVES

To analyze the T1/T2 cytokine profile in CD8 T cells from peripheral blood mononuclear cells from patients with genotype-1 CHC during treatment with pegylated interferon (Peg-IFN) alpha2a plus ribavirin (RBV). To correlate Th1/Th2 balance with virological response.

PATIENTS AND METHODS

In this prospective longitudinal study, a total of 28 naïve genotype-1 CHC patients received Peg-IFNalpha2a (180 microg/week) plus RBV (1-1.2 g/day) for 48 weeks. All patients (mean age 45 +/- 8 years) completed treatment and follow-up: 12 (43%) achieved a sustained virological response (SVR), 13 relapsed after end of treatment (47%), and only 3 (10%) were non-responders. Sixteen healthy controls were also analyzed (mean age 39 +/- 17 years). The production of IL-4, IFNgamma, and TNFalpha by CD8 T cells was measured by intracytoplasmic detection using flow cytometry in both resting and stimulated cells with a phorbol ester.

STATISTICS

Student's t test for independent values, chi2 test, and ANOVA test were used; relapsers and non-responders were joined to achieve a higher statistical power.

RESULTS

At third month during treatment, phorbol ester-stimulated-IL-4 levels tend to be lower in patients who presented with SVR versus those who did not (0.97 vs 2.58; p = 0.1). No statistically significant differences were found in IFNgamma and TNFalpha levels at month 3. At EOT, the stimulated-IFNgamma production was significantly higher in patients with SVR (20 vs. 8; p < 0.05). Conversely, IL-4 production was higher in NR patients although these data did not reach statistical significance (p < 0.1). No significant differences were found in TNFalpha (14 vs. 7; p < 0.2).

CONCLUSIONS

Cytokine T1 induced-response maintenance during combination treatment, measured as IFNgamma production by CD8+ T lymphocytes, is associated with SVR and suggests the replication control and later clearance of patients infected by genotype-1 HCV.

A pilot study on the endoscopic surveillance of colorectal dysplasia and cancer in long-standing ulcerative colitis

INTRODUCTION

Patients with ulcerative colitis (UC) have a greater risk of developing colorectal cancer (CRC) when compared to the general population. Epithelial dysplasia comes before this neoplasm, and thus endoscopic surveillance is recommended to these patients. This pilot study aims at establishing the incidence of dysplasia and CRC in patients with long-standing UC in our hospital.

MATERIAL AND METHODS

This is a prospective observational study performed in patients with a definite diagnosis of UC for more than 8 years. These patients were encouraged to enroll in an endoscopic surveillance program for CRC. All patients underwent colonoscopy and multiple biopsies every 18 to 24 months in order to detect epithelial dysplasia.

RESULTS

Thirty-nine patients were included from January 1994 to December 2003. Half of them were males. Mean age was 52 +/- 13 years. Mean duration of UC was 15 +/- 8 years. Thirteen (35%) patients had left colitis, and 26 (65%) had pancolitis or extensive colitis. The presence of mild dysplasia was detected in four patients, on two occasions in one of them (13%; 95% CI: 6.1-33.5); the incidence of mild dysplasia was 1.3% patients per surveillance year. No severe dysplasia or CRCs were identified.

CONCLUSION

The incidence of dysplasia in our area is lower than expected, and does not support surveillance programs for these patients. However, no definite conclusions may be drawn from such a small number of patients.

Evaluation of three different tests for the detection of stool antigens to diagnose Helicobacter pylori infection in patients with upper gastrointestinal bleeding

AIM

To evaluate the accuracy of several methods aimed to detect Helicobacter pylori stool antigens in patients with upper gastrointestinal bleeding.

METHODS

Thirty-four patients with upper gastrointestinal bleeding because of peptic ulcer were included. The first stool sample during hospitalization was collected, and stool antigens were determined with: polyclonal enzyme-linked immunosorbent assay (Premier-Platinum-HpSA); monoclonal enzyme-linked immunosorbent assay (Amplified-IDEIA-HpStAR); and rapid monoclonal immunochromatographic test (ImmunoCard-STAT HpSA). A patient was considered infected when H. pylori was diagnosed with invasive tests (rapid urease test or histology) or with (13)C-urea breath test. When all tests were negative, a new breath test was repeated after stopping proton pump inhibitors.

RESULTS

All patients were infected and, therefore, only sensitivity of the tests could be calculated: polyclonal enzyme-linked immunosorbent assay (74%), monoclonal enzyme-linked immunosorbent assay (94%), and rapid monoclonal immunochromatographic test (60%; concordance between the two observers was high, kappa = 0.9). Neither the presence of maelena nor the delay in obtaining stool samples explained false negatives.

CONCLUSIONS

Neither the polyclonal enzyme-linked immunosorbent assay stool antigen test nor the rapid immunochromatographic stool antigen test can be recommended to diagnose H. pylori infection in patients with upper gastrointestinal bleeding. However, the monoclonal enzyme-linked immunosorbent assay stool antigen test is highly sensitive for detecting the infection in patients with this complication, although more studies are necessary to evaluate the specificity of the method.