How confocal laser endomicroscopy can help us in diagnosing gastric lymphomas?

Primary gastric diffuse large cell lymphoma is one of the most common extranodal lymphomas of the gastrointestinal system. Diagnosing gastrointestinal lymphomas can be difficult, since there is no pathognomonic sign in endoscopy to distinguish it from other malignancies. In some cases biopsy can be non-diagnostic. Therefore, multiple endoscopic examinations and biopsies can be necessary. With using confocal endomicroscopy, histology of the tissue can be seen in vivo and a range of diseases can be identified by using this technique. We are presenting a case, which is diagnosed as primary gastric diffuse large cell lymphoma during the evaluation of erythema nodosum etiology. We want to emphasize the role of confocal laser endomicroscopy for in vivo diagnosis of gastric lymphoma and directing the endoscopist for sampling the diseased mucosa. Confocal endomicroscopy decreases non-diagnostic rates in endoscopic biopsy and can be performed successfully in cases of gastric lymphoma. Pit patterns of gastric lymphoma, ring cell gastric carcinoma and gastric adenocarcinoma are similar. To best of our knowledge, this case is the fifth case of confocal laser endomicroscopy aided in diagnosing gastric lymphomas (Tab. 1, Fig. 2, Ref. 13).

Prevalence of root dilacerations in Central Anatolian Turkish dental patients

OBJECTIVE

The aim of this study was to determine, retrospectively, the prevalence and distribution of the dilaceration of the root for each tooth-type in a sample of Central Anatolian Turkish population by using panoramic radiographs.

METHOD

Panoramic radiograhs of 6912 patients (3860 women and 3052 men, mean age 29.04 years, range, 15 to 50 years) were examined for the presence of root dilacerations. Chi-square test was also used to compare the prevalence of dilacerations between male and female subjects and upper and lower jaws.

RESULTS

Data showed that 1108 (16.0%) of these subjects had one or more teeth that were dilacerated and these were detected in 466 (15.2%) males and 642 (16.6%) females. Statistical analysis (chi2 test) showed a significant difference in the prevalence of dilaceration among male and female patients. Mandibular third molars were dilacerated most often (3.76%), followed by mandibular second molars (1.81%). Dilaceration was found in 1.23% of maxillary second premolars and 1.23% of mandibular second molars.

CONCLUSION

Root dilacerations are not uncommon among Turkish dental patients, and their early detection could be important in treatment problems associated with it. However further larger scale studies are required to assess its prevalence in the general population in order to compare it with other ethnic groups.

Abdominal tuberculosis leading to portal vein thrombosis, mimicking peritoneal carcinomatosis and liver cirrhosis

Abdominal tuberculosis is a rare infectious disease that can involve the peritoneum and lead to portal vein thrombosis and mimic peritoneal carcinomatosis. We report on a 43-year-old male patient with fatigue and progressive weight loss for two years. Ascites was the only pathologic finding in his physical examination and laboratory findings revealed only a mild anaemia with Ca-125 elevation. The ascitic fluid Adenosine deaminase (ADA) level was also elevated. Computed tomography revealed splenomegaly, a mesenteric mass measuring 3.5 cm and intra-abdominal lymphadenopathies at the hepatic hilum. Oesophagogastroduodenoscopy (EGD) revealed oesophageal varices which was also consistent with portal hypertension. Diagnostic laparotomy and biopsies obtained from the omentum and the lymph nodes revealed acid-fast staining tuberculosis bacilli.

Infection with Fasciola hepatica

Fascioliasis, caused by the liver fluke Fasciola hepatica, is an infection that occurs worldwide, although humans are accidental hosts. F. hepatica infection comprises two stages, hepatic and biliary, with different signs and symptoms. Stool examination and ELISA can be used for the initial diagnosis. Radiographic techniques, such as computerised tomography and ultrasonography, as well as magnetic resonance imaging, are used widely for confirmation and follow-up of the disease. Invasive techniques, such as percutaneous cholangiography, endoscopic retrograde cholangiography and liver biopsy, may aid in the diagnosis but are not essential. Triclabendazole is recommended as the first-line agent for the treatment of F. hepatica infection, with bithionol as an alternative.

The importance of serial measurements of cytokine levels for the evaluation of their role in pathogenesis in familial Mediterraean fever

Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by recurrent fever of unknown origin, renal amyloidosis, peritonitis, pleuritis and/or synovitis. There have been many studies to elucidate the etiopathogenesis of FMF. IL-6 is a cytokine that can induce the formation of serum amyloid A and C-reactive protein, both of which are important in development of amyloidosis. IL-6 was determined to be strongly associated in the etiopathogenesis of periodic fever in Chinese-pei dogs. The dogs with this syndrome experience periodic fever, arthritis, renal amyloidosis, a clinical picture very alike of human FMF. Here, we aimed to study mainly whether IL-6 had a similar etiopathogenetic role in human FMF as in Chinese-pei dogs syndrome. The median IL-6 blood levels were found to be higher in patients with acute (n=8) FMF attack (1.85 U/ml) compared to those (n=33) with asymptomatic ones (1.0 U/ml) (p=0.16). There are mainly two results: first; the study should be designed with a larger sample size of patients with acute attack in order to alleviate underestimation of significance, second; sampling time may give various results because of dynamic changes of cytokine levels during acute attack period.

Two common genetic thrombotic risk factors: factor V Leiden and prothrombin G20210A in adult Turkish patients with thrombosis

The prevalence of genetic risk factors for thrombosis varies greatly in different parts of the world, both in patients with thrombosis and in the general population. Factor V Leiden (FVL) and prothrombin G20210A (PT G20210A) mutations are the most common genetic defects leading to thrombosis. We have previously reported that those two thrombotic risk alleles are frequently found in Turkish children with thrombosis. The aim of the present study was to investigate the frequency of FVL and PT G20210A and their clinical manifestations in adult Turkish patients with thrombosis. Between January 1997 and February 2000, 146 patients with documented thrombosis were investigated in our center for the presence of the FVL and PT G20210A mutations. Forty-five of 146 patients with thrombosis (30.8%) were detected to have FVL mutation. Among those cases with the FVL mutation, seven (4.8%) had homozygote and 38 (26%) had heterozygote mutation. The PT G20210A mutation was detected in 10 of the 146 patients with thrombosis (6.8%). Another six cases (4.1%) had both FVL and PT G20210A mutations. The overall frequency of these two common risk alleles in our adult population with thrombosis was 41.6%. Our findings reveal that FVL and PT G20210A mutations are significant genetic risk factors contributing to the pathophysiology of thrombosis in the Turkish population.

Antiphospholipid syndrome presenting as portopulmonary hypertension

The association of pulmonary hypertension with portal hypertension, also called portopulmonary hypertension, is a well-described condition. The pathogenesis of this association remains unclear. We describe a 34-year-old female patient with "primary antiphospholipid syndrome" and portopulmonary hypertension. Our finding supports that in situ microthrombosis associated with the presence of anticardiolipin antibodies could be the pathophysiologic explanation for both portal and pulmonary hypertension.

Disappearance of "pseudocholangiocarcinoma sign" in a patient with portal hypertension due to complete thrombosis of left portal vein and main portal vein web after web dilatation and transjugular intrahepatic portosystemic shunt

The main portal vein web is probably a consequence of portal vein thrombosis, which is a very rare cause of portal hypertension. Principal manifestations are related to the degree of portal hypertension. In the literature, no data has been found for the treatment modality of portal vein web. We report, herein, the clinical and laboratory findings of a 38-year-old woman with angiographically proven incomplete main portal vein web and complete thrombotic occlusion of the left portal vein causing pseudocholangiocarcinoma sign (PCCS) on the common bile duct. She was treated by transjugular intrahepatic portosystemic shunt (TIPS) and membrane dilatation, which resulted in complete disappearance of collaterals and PCCS. It appears that TIPS and balloon dilatation of the portal vein web via transjugular approach was effective in decreasing portal pressure and its consequences.

Gastrointestinal manifestations of Behcet's disease

Behcet's disease (BD) is a multisystem, chronic, relapsing vasculitis of unknown origin that affects nearly all organs and systems. While recurrent oral ulcerations are a "sine qua non" of BD, the frequency of extra-oral parts of the gastrointestinal involvement varies widely in different countries. The most frequent extra-oral sites of gastrointestinal involvement are the ileocecal region and the colon. The liver (except with Budd-Chiari syndrome), pancreas, and spleen are rarely involved. The symptoms associated with these extra-oral manifestations of BD are abdominal pain, nausea, vomiting, diarrhea with or without blood, and constipation. The lesions typically are resistant to medical treatment and frequently recur with surgical treatment. We review the literature regarding the gastrointestinal and hepatobiliary systems in BD. Also, we present a patient who had BD complicated with radiologically-proven hepatic veins involvement (Budd-Chiari syndrome) and complete occlusion of hepatic portion of inferior vena cava and who had a good response to colchicine and penicillin treatment.

A prospective randomized trial from Turkey comparing octreotide versus injection sclerotherapy in acute variceal bleeding

BACKGROUNDS/AIMS

Bleeding from gastroesophageal varices continues to be a life threatening complication of chronic liver diseases and portal hypertension. The purpose of this randomized prospective study is to compare the efficacy of octreotide administration and emergency injection sclerotherapy for the control of actively bleeding esophageal varices and prevention of early rebleeding in patients with cirrhosis.

METHODOLOGY

A total of 66 episodes of endoscopically proven active variceal bleeding in 52 patients were included in this study. Following admission to the hospital, the patients were resuscitated with blood and plasma, and fiberoptic endoscopy was performed within 2 hours. Thirty-six bleeds in 28 patients and 30 bleeds in 24 patients were randomized to endoscopic variceal sclerotherapy (1% polidocanol) and to octreotide infusion (at 50 micrograms/h for 12 hours following the initial 50 micrograms i.v. bolus), respectively.

RESULTS

Bleeding was initially controlled within 6 hours in 75% of episodes by endoscopic variceal sclerotherapy and in 73.3 by octreotide infusion (P > 0.05). There were no significant differences between the 2 groups in early rebleeding (within 72 hours of randomization) (22% vs. 22.7%), blood transfusion (4.2 +/- 1.8 units vs. 4.8 +/- 2.9 units), or hospital mortality (3.6% vs. 3.3%). Treatment failed in 9 episodes (25%) in the sclerotherapy group and in 8 episodes (26.7%) in the octreotide group.

CONCLUSIONS

We consider that Octreotide would appear to be as effective as sclerotherapy in both the early control of variceal hemorrhage and in the prevention of early recurrent bleeding and should therefore be considered the treatment of choice in those centers where 24-hour endoscopy is not available. Furthermore, even in hospitals that do have a 24-hour endoscopy service there is good evidence that octreotide therapy should be commenced as soon as a patient enters hospital with a suspected variceal bleed to achieve rapid homeostasis. When initial hemostasis is achieved, elective endoscopic therapies can be undertaken with greater success.

The role of natural anticoagulant deficiencies and factor V Leiden in the development of idiopathic portal vein thrombosis

One of the causes of portal hypertension is portal vein thrombosis (PVT). The aim of this study was to determine whether natural anticoagulant deficiencies, activated protein C resistance (APCR), and factor V Leiden play a role in the development of PVT, leading to cavernous transformation of the portal vein (CTPV). Twenty-three patients with idiopathic CTPV (group 1) seen at Hacettepe University Hospital during the past 12 years were identified and prospectively studied. These 23 patients underwent a detailed hematological evaluation including measurement of protein S, protein C, antithrombin III, activated protein C resistance (APCR), and factor V Leiden gene mutation. Additionally, all patients were tested for anticardiolipin antibodies (ACA), IgG, IgM, and lupus anticoagulant (LA). Natural anticoagulants and APCR were measured using available commercial kits, and factor V Leiden mutation (R506Q) was detected by Mnl I digestion of an amplified factor V DNA fragment. All parameters were measured at least 6 months after the diagnosis of CTPV was established. No patient was on anticoagulant or antiaggregant treatment while tested. The findings in these 23 patients were compared with those in 20 healthy control subjects (group 2), in whom all tests mentioned above were also performed. In 23 patients (group 1), who had no recognizable factor for portal vein thrombosis, considerably natural anticoagulant deficiencies and factor V Leiden mutation positivity were found when we compare them to those healthy controls (group 2). The protein C levels of six patients (26%), the protein S levels of 10 patients (43.5%), and the antithrombin III levels of five patients (26%) were lower than in control subjects. Two patients were found to have combined protein S and antithrombin III deficiency, and one had combined protein S and C deficiency and APCR. APCR was detected in seven of the 23 patients, and six of these seven patients were found to have R506Q factor V Leiden mutations. In group 1, ACA IgG levels were higher in four patients (17%) and ACA IgM level was higher in one (4%) compared with the control group. LA was positive in only one patient in group 1. Natural anticoagulant deficiencies and factor V Leiden mutation are strongly associated with PVT. The natural anticoagulant deficiencies and APCR (almost totally caused by R506Q mutation) produce a favorable medium for thrombus generation. PVT seems to be related to the natural anticoagulant deficiencies and factor V Leiden R506Q mutation. A combination of these defects increases the incidence of PVT and these factors should be evaluated carefully in patients with idiopathic CTPV.

Four cases with chronic intestinal pseudo-obstruction due to hollow visceral myopathy

BACKGROUND/AIMS

Chronic intestinal pseudo-obstruction is a rare clinical syndrome characterized by symptoms and signs of intestinal obstruction without any organic lesion obstructing the intestine. Visceral myopathy is one of the etiological causes and full thickness intestinal biopsy is essential for reaching a diagnosis. In this article we describe 4 cases of hollow visceral myopathy; our aim is to stress the importance of full thickness biopsy.

METHODOLOGY

Four cases of hollow visceral myopathy are studied herein. All the patients had recurrent abdominal pain and constipation. The onset of symptoms was early in life or in the second to third decade. A diagnosis was established in all cases by full thickness intestinal biopsy obtained during laparotomy. Associated disorders were noted in 2 cases. One patient had Axenfelt syndrome, non-descended testicles and primary hypogonadism, and another had a diagnosis of Kleinfelter syndrome.

RESULTS

All of the 4 cases were diagnosed to be suffering from hollow visceral myopathy by full thickness intestinal biopsy and 2 had additional disorders as well.

CONCLUSIONS

Patients with chronic intestinal pseudo-obstruction should be carefully evaluated as to whether there is an associated disorder and the diagnosis may be delayed unless full thickness intestinal biopsy is obtained.

Arterial thrombosis leading to intestinal infarction in a patient with Behçet's disease associated with protein C deficiency

Behçet's disease may be a possible cause of both occlusive and aneurysmal arterial involvement as well as recurrent venous thrombosis. A case of Behçet's disease complicated with vascular involvement leading to intestinal infarction is presented. A 41-yr-old man suffering from Behçet's disease for 15 yr presented with a 2-day history of severe abdominal pain and bloody diarrhea. Intestinal infarction secondary to thrombosis of the superior mesenteric artery had been diagnosed during surgical exploration 3 yr previously. He was started on anticoagulation with nutritional support. The patient was readmitted with severe diarrhea and malabsorption symptoms 3 yr after intestinal resection. A thrombus located in the posterior wall of the infrarenal portion of aorta was detected by aortography and ultrasonography. Although thrombosis is a relatively common complication of Behçet's disease caused by vasculitis, protein C deficiency, which is a pertinent laboratory finding in this case, might be a secondary factor in the thrombotic event. This is the first case reported of mesenteric artery thrombosis leading to bowel infarction and abdominal aorta thrombosis associated with protein C deficiency.

The effect of interferon and desferrioxamine on serum ferritin and hepatic iron concentrations in chronic hepatitis B

BACKGROUND/AIMS

Recent reports indicate that an individual's iron status might affect the response rate achieved with Interferon therapy for the treatment of chronic viral hepatitis.

METHODOLOGY

Forty individuals, 29 men and 11 women, with chronic viral hepatitis B, who had elevated serum ferritin levels, were randomized to receive either Interferon (IFN) 5 MU TIW SQ for 6 months alone (n=21) or Interferon in combination with repetitive cycles of desferrioxamine infused at a dose of 80 mg/kg per cycle (n=19) over 3 consecutive days in an effort to reduce their metabolically active iron pool during the course of IFN treatment. These cycles were continued until a serum ferritin level of less than 250 ng/ml (normal values <220 ng/ml) was achieved. Additionally, all desferrioxamine treated subjects were placed on a low iron containing diet. An interferon response was defined as normalization of the serum ALT and seroconversion from eAg positive to eAb positive. All other responses were defined as failures.

RESULTS

The mean ages of the subjects in the 2 groups were 39+/-6 and 38+/-5 years. The initial serum ALT levels were 150+/-27 and 151+/-13 IU/l. The hepatic iron concentrations were 916+/-29 and 896+/-15 microg/g/dry liver weight. The serum ferritin levels were 386+/-12 and 393+/-18 ng/ml. None of these values differed significantly between the 2 treatment groups. The desferrioxamine treated group consisted of 14 men and 5 women. This group experienced a reduction in their serum ferritin to a level of 237+/-13 ng/ml as a result of the desferrioxamine treatment (p<0.05). Additionally, a reduction in their hepatic iron concentration, to a level 766+/-29 microg/g/dry liver weight, occurred with treatment (p<0.05). Twelve of the 19 (63%) desferrioxamine-treated subjects and 8 of the 21 (38%) control subjects experienced a normalization of their serum ALT levels with treatment (p<0.05). Thirteen of 19 (68%) of the desferrioxamine-treated subjects but only 8 of 21 (38%) of the IFN alone treated group seroconverted to anti-e positive (p<0.05). Moreover, a greater improvement in the hepatic histologic score and rate of HBV-DNA loss occurred in the desferrioxamine-treated group.

CONCLUSIONS

Based upon these data, it can be concluded that desferrioxamine infusion to achieve a normal serum ferritin level enhances the likelihood of an individual with chronic hepatitis B responding to IFN therapy. The precise mechanism responsible for this phenomenon is not clear, but would appear to be due to a reduction in the hepatic free iron pool as reflected by sequential changes in the serum ferritin and hepatic iron concentrations.

The usefulness of intra-operative endoscopy in Peutz-Jeghers syndrome: a case report

The Peutz-Jeghers syndrome is an autosomal dominant inherited disease manifested by a combination of mucocutaneous pigmentation and gastrointestinal hamartomatous polyps that usually cause intussusception and intestinal hemorrhage. We report a case in which the patient has been followed-up on for 14 years and who underwent surgical and endoscopic polyp removal several times as well as one intestinal resection. This time, with the use of combined surgery and perioperative endoscopy, 27 polyps were removed, performing only 3 enterotomies. This is the highest number in one session to be reported in the literature. The usefulness of this technique is providing a "clean small intestine" that allows the patient a longer time interval between laparotomies and reduces the complications associated with multiple laparotomies and resections.

What is the association of primary sclerosing cholangitis with sex and inflammatory bowel disease in Turkish patients?

BACKGROUND/AIMS

In the Western world, primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease that is associated with inflammatory bowel disease (IBD), particularly chronic ulcerative colitis and, to a lesser degree, Crohn's disease. The goal of this study was to determine the prevalence of PSC in Turkish patients with IBD and chronic amebic colitis, a disease that is endemic in Turkey.

METHODOLOGY

During a 10-year period, between 1986 and 1996, a total of 81 IBD (64 ulcerative colitis and 17 Crohn's disease) patients and 127 patients with chronic amebic colitis were seen and evaluated with radiologic, serologic, immunologic and pathologic tests. Whenever a clinical or biochemical finding suggested the presence of co-existent hepatic and/or biliary disease, the patient was further evaluated by liver biopsy, auto-antibodies and endoscopic retrograde cholangiopancreatography (ERCP) to determine whether they also had PSC or some other form of liver disease. As a disease control group, a total of 752 patients with clinical and/or laboratory evidence of pancreaticobiliary disease were also studied. In 86 of these 752 patients (10%), a primary disorder of the biliary tree was diagnosed by ultrasonography, computed tomography, peritoneoscopy, liver biopsy, ERCP and abdominal laparotomy. In addition, all 86 patients of the control group were evaluated endoscopically in order to determine whether they had any associated gastrointestinal condition of the upper or lower gastrointestinal tracts. After establishing final diagnoses of IBD, amebic colitis and PSC, these patients were evaluated with respect to their socio-economic status. A high protein diet (1.8 gram/kg/day) was administered to those patients with chronic amebic colitis and IBD during the active period of the disease.

RESULTS

Of the 208 patients (81 with IBD and 127 with chronic amebic colitis), no cases of PSC were identified. Of the 86 patients in the control group with primary biliary tract disease, 45 had a biliary system malignancy, 14 had primary biliary cirrhosis (PBC), 16 had PSC, 3 had Caroli's disease, 6 had a common bile duct cyst, and 2 had gallbladder adenomatosis. All but 1 of the 16 patients with PSC were female.

CONCLUSIONS

These data suggest that, in contrast to findings in Western Europe and the USA, in Turkey: 1) PSC is not regularly associated with idiopathic IBD; 2) most patients with PSC are female; 3) PSC accounts for only 18% of patients with a primary disorder of the biliary tree; 4) the incidence of small-duct primary sclerosing cholangitis is greater than that reported in the literature; and, 5) the incidence of IBD and PSC in Turkey is relatively lower than in other countries.

Superior vena cava thrombosis and obstructive sleep apnea in a patient with familial Mediterranean fever

Familial Mediterranean fever (FMF), a paroxysmal, self-limited, inflammatory disease of unknown etiology, may result in thrombotic complications after the development of nephrotic syndrome due to amyloidosis. It has been suggested that there is increased thrombogenic activity in the blood of patients with FMF who did not develop nephrotic syndrome. We describe a patient with FMF who presented with thrombosis in the superior vena cava (SVC) in the absence of nephrotic syndrome, and discuss the contributory role of increased procoagulant activity detected in this disorder. Moreover, the patient was proved to have obstructive sleep apnea (OSA) which we believe was secondary to SVC thrombosis that lead to soft tissue edema in the upper airways. To our knowledge, this is the second reported case in the literature in which OSA occurred secondary to the SVC thrombosis.

Does hepatic vein outflow obstruction contribute to the pathogenesis of hepatocellular carcinoma?

Hepatocellular carcinoma (HCC) is one of the more common malignant diseases in the world. Here we have investigated role of hepatic venous outflow obstruction in the development of HCC. During a 10-year period from November 1986 to December 1996, 1,748 patients with clinical evidence of either portal hypertension, hepatic venous outflow obstruction, or inferior vena cava obstruction without Behçet's disease (BD) and 512 patients with Behçet's disease were examined at Hacettepe University Hospital. The presence of and the effect of hepatic venous obstruction on the subsequent development of HCC was assessed. In each case, hepatic vein thrombosis was assessed by hepatic venography and by digital subtraction angiography (DSA), computed tomography (CT), ultrasonography (US), and liver biopsy. Coagulation factors, including protein C, protein S, anti-thrombin III, and routine laboratory studies assessing the coagulability of blood were also investigated. The role of hepatic venous outflow obstruction on the subsequent development of HCC was determined by periodic laboratory investigations that included alpha-fetoprotein (AFP), ultrasonography, and when indicated liver biopsy. During the same time period all patients diagnosed as having HCC were investigated to identify all potential etiologic factors responsible for the HCC. Fifty-five (10.7%) of the 512 patients with BD were found to have one or more large vein thromboses. Sixteen of these 55 (29%) patients had hepatic vein thrombosis. During the follow-up period HCC developed in 2 of these 16 patients (12.5%), 34 and 21 months after a diagnosis of hepatic vein thrombosis was established. Forty patients from a total of 1,748 patients with clinical evidence of portal hypertension and cirrhosis, but without BD, were found to have evidence of hepatic vein thrombosis. Twenty-one of these 40 patients had an identifiable underlying disorder responsible for their hepatic vein thrombosis. Despite a full clinical and laboratory investigation in the other 19 patients, the etiologic factor responsible for the hepatic vein thrombosis remained obscure. Only one of these 19 patients, who also had portal vein thrombosis, developed HCC during a 9-year follow-up. Thus, a total of three of the 56 (5.36%) of cases of hepatic vein thrombosis developed an HCC. All of the hepatic tumors were of the multicentric, nodular, rapidly growing type. Despite the presence of hepatic vein thrombosis, there was no clear-cut histologic evidence for cirrhosis. Our experience suggests that hepatic vein thrombosis may be a contributing factor responsible for HCC development. Moreover, we advise that individuals with hepatic vein thrombosis should be assessed periodically for the development of HCC.

Determination of hepatic zinc content in chronic liver disease due to hepatitis B virus

BACKGROUND/AIMS

Zinc is an essential, mostly intracellular, trace element which participates in many physiologic mechanisms. Some liver functions like urea formation require the presence of zinc; thus the determination of hepatic zinc content may contribute to the understanding of probable zinc-related clinical consequences of chronic liver disease. In this study, we aimed to determine the hepatic zinc concentrations in patients with chronic liver disease due to the Hepatitis B virus and to ascertain the relationship between the severity of liver disease and hepatic zinc content, if one in fact exists.

METHODOLOGY

A total of 99 HBsAg positive subjects were included in the study. We performed a liver biopsy on all subjects. Hepatic zinc concentrations were determined by atomic absorption spectrophotometry.

RESULTS

The liver biopsies were normal in 25 subjects. There were 33 chronic active hepatitis (CAH), 34 cirrhosis and 7 chronic persistent hepatitis (CPH) patients in the study group. In the control group, CAH, cirrhosis and CPH groups, the mean liver zinc concentrations were 3.83 +/- 1.86, 1.86 +/- 0.92, 1.14 +/- 0.68 and 3.74 +/- 1.81 mumol/g dry weight, respectively. Hepatic zinc in the CAH and cirrhosis groups were lower than that of the control group (p < 0.05). We also found that liver zinc in the cirrhosis group was lower than in the CAH group (p < 0.05).

CONCLUSION

According to these results, as the severity of liver damage increases, the hepatic zinc concentration decreases. Therefore, it can be suggested that zinc supplementation may improve hepatic encephalopathy by increasing the efficiency of the urea cycle.

Peyronie's disease: intralesional treatment with interferon alpha-2A and evaluation of the results by magnetic resonance imaging

In this clinical study, to determine the therapeutic efficacy of interferon (IFN) treatment for Peyronie's disease, we applied interferon alpha-2A (IFN alpha-2A) intralesionally in the treatment of Peyronie plaques in 15 patients and results were evaluated by magnetic resonance imaging (MRI). Patients whose plaque sizes were 0.5 and 1 cm responded better to the treatment. There was about a 90% lessening in the sizes of the plaques of 1.5 cm, 83.3% of 2 cm, as the ones which were 0.5 cm and 1 cm disappeared completely after treatment. As a conclusion, the treatment of Peyronie's disease with IFN alpha-2A is effective and side effects are minimum.

Congenital hepatic fibrosis associated with cavernous transformation of the portal vein

BACKGROUND/AIMS

Congenital hepatic fibrosis (CHF), which is one of the fibropolycystic diseases, occurs in various forms. Portal hypertension, a very common clinical feature of this condition, has been attributed to the compression of portal vein radicles in the fibrous bands. We investigated whether there are any other contributing factors in the development of portal hypertension in patients with CHF.

METHODOLOGY

A total of 1285 patients with portal hypertension of different etiologies were studied using ultrasonography as the screening test. Forty-seven (including portal vein involvement and/or CHF) of these 1285 patients were prospectively studied to evaluate the etiology of the portal hypertension by portography, abdominal computed tomography, exploratory laparotomy, peritonoscopy, liver biopsy and laboratory tests. The patients with CHF were divided into two groups, according to whether or not they had portal vein involvement.

RESULTS

Eleven (0.8%) of the 1285 patients with portal hypertension had CHF, and 41 (3.2%) had cavernous transformation of the portal vein (CTPV), resulting from different or unknown etiologies. Five patients had both pathologies (CTPV and CHF). In the 11 patients with CHF, there was CTPV in 5 patients, Caroli's disease in 2 patients, cholangiocarcinoma in 1 patient, inferior vena caval obstruction in 1 patient, and CHF in only 2 patients. There were statistically significant differences in the age of the CHF patients at clinical onset, the incidence of bleeding from esophageal varices, and laboratory findings between the 2 groups with and without CTPV. Despite a thorough investigation, we could not distinguish any predisposing factor in 25 of the 41 patients with CTPV. The incidence of CTPV was 48% in patients with CHF and 3.2% in patients with portal hypertension.

CONCLUSIONS

These results suggest that the association of CTPV with CHF is not coincidental, but that CTPV may be associated with CHF and a new possible factor in portal hypertension, and that it can be a major factor in the manifestation of esophageal bleeding from varices.

Pregnancy complicated by congenital hepatic fibrosis with cavernous transformation of the portal vein: a case report

A 24-year-old primigravid woman with cogenital hepatic fibrosis associated with cavernous transformation of the portal vein is described. Although the neonate could not survive because of the ileal atresia, the pregnancy and delivery did not pose a significant threat to the mother.

Budd-Chiari syndrome: a common complication of Behçet's disease

OBJECTIVE

The Budd-Chiari syndrome is characterized by venous outflow obstruction of the liver, usually occurring as a consequence of thrombosis of the hepatic veins. Vasculitis is a major component of Behçet's syndrome. The aim of this study was to determine the incidence of hepatic vein thrombosis in patients with Behçet's disease and to estimate the effect of this entity upon the clinical features and course of Behçet's syndrome.

METHODS

During an 8-yr period from 1985 to 1994, from a total of 493 patients with Behçet's disease seen at Hacettepe University Hospital, the incidence and effect of hepatic vein thrombosis on the clinical course of Behçet's syndrome was investigated. The hepatic vein thrombosis in each case was documented by hepatic venography and confirmed by digital subtraction angiography, computed tomography, ultrasonography, and liver biopsy. Coagulation parameters including protein C, protein S, and anti-thrombin III levels were easured in each case. The survival of cases with Behçet's syndrome complicated by Budd-Chiari syndrome and the effect of the Budd-Chiari syndrome on the survival of individuals with Behçet's syndrome were determined using the Kaplan-Meier technique.

RESULTS

Of the 493 cases of Behçet's syndrome, 53 (10.8%) were found to have one or more large vessel thrombosis. Of these 53 patients, 14 (26.4%) had hepatic vein thrombosis. Of these 14 patients, 8 had an additional inferior vena cava thrombosis and 4 had portal vein as well as total inferior vena cava thrombosis. Only two patients with isolated hepatic vein thrombosis were identified. These two patients and two additional patients with hepatic vein thrombosis plus thrombosis of the hepatic portion of the inferior vena cava are currently alive. Of the 10 patients with total inferior vena cava and hepatic vein thrombosis (4 also had portal vein thrombosis), all 10 died with a mean survival of 10.3 months. During the same time period, 37 patients obtained from a total of 1494 patients with clinical evidence of either portal hypertension, hepatic venous outflow obstruction or inferior vena caval obstruction without Behçet's syndrome were found to have a Budd-Chiari syndrome. Of these 37 patients, 19 (51%) had an identifiable underlying disorder responsible for their hepatic vein thrombosis.

CONCLUSION

Based upon this experience, it appears as if Budd-Chiari syndrome is a relatively frequent complication of Behçet's disease. When individuals with Behçet's syndrome have BCS, concurrent thrombosis of the portal vein and inferior vena cava are often found, if the patency of these vessels is assessed. The clinical course of patients with Behçet's syndrome complicated by Budd-Chiari syndrome is poor. The extent of the vascular thrombosis within the inferior vena cava rather than the presence of the hepatic vein thrombosis per se is the major determinant of survival.

The cardiac evaluation of liver transplant recipients: a single center's experience

OBJECTIVE AND BACKGROUND

Orthotopic liver transplantation is both a difficult and a demanding surgical procedure. It is not unexpected that cardiovascular dysfunction is present in some individuals being evaluated for liver transplantation. Thus, all potential liver transplant recipients seen at this center undergo a full cardiac evaluation prior to being accepted for transplantation. The goal of this report was to review the components of the cardiovascular evaluation utilized at the Oklahoma Transplantation Institute and to determine their overall usefulness as well as the ability of the process to identify individuals at high risk for a cardiac misadventure during liver transplantation.

MATERIALS AND METHODS

Between June 25, 1993 and June 30, 1995, a total of 154 consecutive patients with chronic liver disease were evaluated. The primary liver disease of each was established utilizing specific serologic and biochemical tests, ultrasonographic and abdominal tomographic findings, as well as hepatic histology results and hepatic iron and copper level determinations. Each liver transplant candidate underwent a full cardiac evaluation consisting of the following: nuclear ventriculography to estimate the left ventricular ejection fraction (at rest and during exercise), right ventricular ejection fraction, cardiac output, stroke volume and cardiac index; uptake images using thallium and adenosine to identify foci of cardiac ischemic or fixed defects; echocardiography to define the dimensions of the various cardiac chambers, wall thicknesses, cardiac contractility and morphology of the cardiac valves. Finally, coronary arteriography was performed in 26 patients (16.9%) who were suspected of having clinically important coronary artery disease. It should be noted that all of the cardiac evaluations were performed by a single cardiologist.

RESULTS

Eight of the 154 potential liver transplant candidates (5.2%) were determined as not being eligible for liver transplantation because of an inadequate cardiac status based upon an initial history and physical examination. Forty-one of the remaining 146 patients (28.1%) underwent liver transplantation. The remaining 105 subjects have not been transplanted for reasons not related to the cardiac status. Eight of the 41 (19.5%) transplanted patients had a clinically advanced cardiac problem recognized prior to liver transplantation. Four of these eight required a specific cardiac intervention prior to liver transplantation consisting of coronary bypass surgery (n = 1), coronary artery balloon dilation (n = 2) or pericardiectomy (n = 1). The remaining four patients required no pretransplant cardiac intervention and were transplanted. None of these experienced any cardiac complications during, or in the 3 months following, the liver transplant procedure. Only one patient experienced a specific postoperative cardiac complication, consisting of an episode of high grave A-V block requiring transplant placement of a cardiac pacing device. This patient had hemochromatosis.

CONCLUSIONS

Based upon this experience, it can be concluded that coronary artery disease per se is not an absolute contraindication for liver transplantation. With appropriate treatment, liver transplantation can be performed safely in individuals with confounding cardiac disease. Nuclear ventriculography and echocardiography are essential procedures in evaluating potential liver transplant recipients in an effort to exclude those with occult cardiomyopathy. Coronary arteriography is indicated only in selected cases with evidence of cardiac ischemia or infarction.

A comparison of the prevalence of autoantibodies in individuals with chronic hepatitis C and those with autoimmune hepatitis: the role of interferon in the development of autoimmune diseases

BACKGROUND AND OBJECTIVES

Viral hepatitis due to hepatitis C virus results in chronic liver disease in more than 70% of individuals infected with the virus. Hepatitis C virus is also thought to be the cause of autoimmune chronic hepatitis, type II. The only treatment for chronic hepatitis C is interferon (IFN). IFN is both an antiviral agent and an up regulator of the cellular immune system. The latter effect is non-specific. Thus, IFN diffusely activates the cellular immune system and can initiate new autoimmune diseases in patients treated with it. To determine the prevalence of autoantibodies in patients with chronic hepatitis C and in patients with autoimmune hepatitis and to determine the incidence of new onset autoimmune disease in IFN-treated subjects with chronic hepatitis C, the records of 323 unselected patients with chronic hepatitis were reviewed.

MATERIAL AND METHODS

A total of 203 patients with a mean age of 45.7 +/- 0.8, ranging 18-81 with either HCV disease or autoimmune hepatitis, were identified and studied. One hundred sixty-two patients with chronic hepatitis C defined by elevations of serum alanine aminotransferase (ALT) for at least 6 months, the presence of detectable anti-HCV (HCV; second generation enzyme immunoassay [EIA2], a positive recombinant immunoblot assay [RIBA], the presence of HCV-RNA by PCR in serum and an abnormal biopsy consistent with chronic hepatitis C) were identified. Each was also negative for HbsAg, HbeAg and anti-Delta. Forty-one patients with a putative autoimmune chronic hepatitis (AIH) diagnosed on the basis of serologic positivity for classical autoantibodies (ANA and anti-smooth muscle antibodies), tissue typing (B8, Dr3 positive), characteristic liver biopsy findings and the absence of anti-HCV and HCV-RNA in serum were identified. The records of both of these groups of patients were reviewed for the following antibodies: anti-nuclear antibodies (ANA), antimitochondrial antibodies (AMA), anti-liver-kidney microsomal antibody (LKM), anti-smooth muscle antibodies (SMA), anti-microsomal antibodies (MSA).

RESULTS

The rate of ANA positivity was 63% in both groups; the rate of SMA positivity was 65% in patients with HCV infection (group I) and 63% in patients with AIH (group II). AMA was positive in 4% of the subjects in group I and 50% of the subjects in group II; anti-LKM antibodies were absent in all 91 HCV cases and were present in 4% of the cases in group II; MSA positivity was present in 17% of group I and 10% of group II. Eighty-one of the one hundred sixty-two patients (50%) with chronic hepatitis C received IFN treatment at a dose of 5 MU SQ daily for 6 months. Thirty-two of these eighty-one patients (42 females and 39 males with a mean age of 45.0 +/- 1.3, ranging from 18 to 81 yr.) had at least two autoantibodies detectable prior to the IFN therapy (subgroup 1) and 49 had one or no identifiable autoantibodies (subgroup 2) present prior to IFN therapy. No significant differences in the interferon response rate defined by HCV-RNA negativity and normalization of serum ALT levels at the end of therapy was noted between those with autoantibodies and those without autoantibodies. Fifteen of the interferon-treated patients developed a clinical manifestation of a new onset autoimmune disease during the course of their interferon treatment. Six of the fifteen patients belonged to subgroup 1 (n = 32) and the remaining 9 patients to subgroup 2 (n = 49) (p > 0.05). None were managed by discontinuing the interferon. Most required some form of specific treatment.(ABSTRACT TRUNCATED)

Pharmacotherapy of benign prostatic hyperplasia: inhibitor of 5 alpha-reductase

We studied the effects of 5 alpha-reductase inhibitor (finasteride) in the treatment of benign prostatic hyperplasia (BPH). This study is a randomized controlled trial. Sixty-two patients were treated with 5 alpha-reductase (finasteride 5 mg/day) and 61 patients (control group) with placebo for one year. Prostatic volume, maximal urine flow rate, AUA symptom scoring, residual urine volume and prostate-specific antigen (PSA) levels were evaluated at 3, 6, 9 and 12 months. In the first 6 months prostatic volume decreased rapidly (20.5%), in the second 6 months it decreased slowly and reached the maximal rate (23.3%). Maximal urine flow rate increased in the second 6 months. AUA symptom scores decreased first at 3 months and were 4.6 points lower at the end of the 12th month. There were no significant changes in residual volume. The 5 alpha-reductase inhibitor caused a 50% decrease in PSA levels, like in other studies. Because of the prolonged use of the drug, treatment with 5 alpha-reductase inhibitor is not tolerated by many patients and being expensive its future in the pharmacotherapy of BPH is unclear.

Iatrogenic injuries to ureter, bladder and urethra during abdominal and pelvic operations

Abdominal and pelvic operations at Departments of Obstetrics and Gynaecology, and General Surgery play an important role in ureteral, bladder and rarely urethral injuries. Fifty-nine patients with iatrogenic ureteral, bladder and urethral injuries were treated at the Department of Urology, Atatürk University Research Hospital, between 1985 and 1995. These injuries were urinary vaginal fistulas in 43 patients (vesicovaginal 33, ureterovaginal 7, urethrovaginal 2 and vesicovaginal plus urethrovaginal 1), ureteric ligation in 9, bladder laceration in 7. These injuries were treated by different methods. All patients were followed up by intravenous urography (IVU) and urine culture three months later. It must be borne in mind that iatrogenic urinary tract injuries are not rare. Bladder and ureteral catheterization must be performed to prevent these complications.

Periampullary carcinoma detected after sphincterotomy

BACKGROUND/AIMS

Although periampullary carcinoma can often be diagnosed at an early stage because of its strategic location, in a substantial number of cases (23% to 25% of periampullary carcinoma cases), the papilla can be prominent, but without an identifiable mass or ulceration. As a result, duodenoscopy alone can miss the tumor. In this series, the usefulness of sphincterotomy in establishing a diagnosis of periampullary carcinoma is documented.

MATERIALS AND METHODS

A total of 664 patients, who had clinical, biochemical and/or sonographic evidence of pancreaticobiliary disorders underwent endoscopic retrograde cholangiopancreaticography (ERCP) at Hacettepe University Hospital between March 1985 and September 1994. All identified lesions were biopsied.

RESULTS

In sixty-six of the 664 patients, a specific periampullary or pancreatic diagnosis could be made. These included 30 cases of pancreatic carcinoma (14 in the head, 15 in the corpus, and 1 in the tail), 10 cases of chronic pancreatitis, 15 cases of periampullary carcinoma and 11 miscellaneous. None of the 15 periampullary carcinomas was demonstrable by abdominal computed tomography, sonography or pancreatic angiography. In 12, the diagnosis was established immediately by endoscopic visualization of the tumor and biopsy. In the remaining 3, the tumor was visualized as a protruding mass only after a papillatomy was performed. All cases were treated surgically with a pylorus preserving pancreaticoduodenectomy. No symptoms of dumping were experienced postoperatively. The survival of these 15 patients was good with a mean survival of 24.2 months.

CONCLUSIONS

Careful endoscopic examination of the periampullary mucosa before and after sphincterotomy is required to identify periampullary carcinoma. A pylorus preserving pancreaticoduodenectomy revealed excellent post-surgical outcome with no post operative symptoms of the dumping syndrome.

Hepatitis C and the controversies it creates relative to liver transplantation and autoimmune hepatitis

The paradox of hepatitis C. An agent that persists in tissue for years by escaping the immune system and not killing but only damaging its host while simultaneously being associated with autoimmune hepatitis as well as other putative autoimmune diseases is presented. Liver transplantation necessitates immune suppression and is associated with progressive HCV disease albeit at a rather slow rate. Diagnosis and treatment concerns are raised and discussed.

Cavernous transformation of the portal vein is associated with pancreatic duct atrophy

BACKGROUND/AIMS

To determine whether or not portal venous obstruction affects pancreatic duct size.

MATERIAL AND METHODS

The ERCP findings of 43 of 51 subjects with cavernous transformation of the portal vein (CTPV) were studied prospectively. In three, the ERCP failed to demonstrate the pancreatic duct (PD) for technical reasons and in 8 of the original 51 subjects, the ERCP was not attempted because of a lack of indications and unwillingness of the subject to undergo the procedure. The ERCP findings of the remaining 40 subjects were compared with those of 23 normal concurrent controls and those of reference controls.

RESULTS

In 21 of the 51 patients, an underlying disorder responsible for portal vein thrombosis and cavernous transformation was identified. Despite a full clinical, radiologic, hematologic and biochemical evaluation, no etiology for CTPV was found in the remaining 30 patients. The pancreatic duct diameter was measured at the widest portion of the duct where it traverses the head of the pancreas. In 34 of the 40 patients with CTPV and a successful ERCP, the pancreatic duct was smaller (less than 2.28 mm in diameter) than that of concurrent control subjects and a reference control group (p < 0.05). In only 6 subjects with CTPV was the pancreatic duct size within normal limits. In 3 of these 6, a confounding common bile duct stone was shown to be present and may have accounted for the pancreatic duct enlargement as compared to the other 34 subjects with CTPV.

CONCLUSIONS

These results indicate that a smoothly narrowing pancreatic duct hypoplasia or atrophy can be demonstrated in 85% of cases with CTPV. It is speculated that this finding is a consequence of the obstructed pancreatic venous drainage that occurs with CTPV.

A comparison of chemoembolization with conventional chemotherapy and symptomatic treatment in cirrhotic patients with hepatocellular carcinoma

BACKGROUND/AIMS

The results of transcatheter arterial chemoembolization (TACE) in 28 cirrhotic patients with advanced hepatocellular carcinoma (HCC) were compared to those obtained in 15 cirrhotic patients with HCC treated with systemic chemotherapy, and 14 patients with HCC receiving no specific anti-cancer treatment.

MATERIALS AND METHODS

From November, 1986 through May 1994, 235 patients with HCC were seen by the investigators. Twenty eight of these patients actually received TACE. The chemotherapeutic agent used was mitomycin C mixed with Lipiodol and arterial embolization was achieved using Gelfoam. In 19 of 28 cases treated with TACE, the embolization was limited to an artery feeding the tumor, thereby avoiding liver cell injury in non-tumor tissue. In 9 others, the main left or right hepatic artery was embolized. The results obtained in these 28 cases were compared to those obtained in 15 patients with HCC larger than 5 cm. who received systemic mitomycin C and doxorubicin chemotherapy and with those obtained in 14 patients who received no specific anti-tumor therapy.

RESULTS

One patient died of liver failure related to the TACE and three patients died of bleeding from esophageal varices within weeks of the TACE procedure. Two of the remaining 24 patients are alive with a follow-up of 6 and 22 months. Twenty-six of the 28 patients treated with TACE died within 1 and 28 months of the initiation of the TACE therapy. The mean survival of those receiving TACE was 13.0 months. Chemotherapy without embolization yielded a mean survival of 7.2 months. The mean survival of the patients receiving no specific anti-cancer treatment was only 6.9 months. There was no statistical differences between the survival of those receiving systemic chemotherapy and those receiving no specific treatment. In contrast, the mean survival of the group receiving TACE was significantly greater than that of either of the other two groups (p < 0.005).

CONCLUSIONS

These data suggest that TACE provides the best survival for individuals with larger hepatocellular carcinomas (> 5 cm) not eligible for surgery or percutaneous ethanol injection (PEI).

Percutaneous drainage of hepatic abscesses: therapy does not differ for those with identifiable biliary fistula

BACKGROUND/AIMS

Surgical drainage of pyogenic and amoebic hepatic abscesses has been an accepted therapy for decades. Modern imaging modalities have changed both the diagnostic and therapeutic management of many hepatic lesions, particularly abscesses. Specifically, percutaneous aspiration and drainage with either ultrasound or computed tomography guidance has been reported as an alternative treatment for hepatic abscesses in recent years. Little is known about aspiration of hepatic abscesses that communicate with the biliary tree.

MATERIAL AND METHODS

Fifteen patients with hepatic abscesses treated by percutaneous aspiration and drainage are herein reported. Six had a demonstrable fistulous communication between the abscess and the biliary tree.

RESULTS

During a four year period of follow-up, only two of these 15 patients experienced a recurrence. Neither had a biliary fistula complicating their abscess initially.

CONCLUSIONS

Based upon this experience, it is suggested that percutaneous aspiration and drainage should be the initial treatment of choice of both pyogenic and amoebic liver abscesses even when large. Abscesses with demonstratable biliary fistulas have a larger mean volume than do those without fistulous involvement. The finding of a communication between the abscess and the biliary tree should not change this treatment approach.

The use of deferoxamine infusions to enhance the response rate to interferon-alpha treatment of chronic viral hepatitis B

An individual's iron status may affect the response rate achieved with the use of interferon (IFN) as therapy for chronic viral hepatitis. A total of 27 patients with chronic hepatitis B viral infection, who had elevated serum ferritin levels, were randomized to receive either IFN 5 MU, three times weekly by subcutaneous injection alone (n = 14) or in combination with cycles of deferoxamine at a dose od 80 mg kg-1 per cycle (n = 13) administered over 3 consecutive days, to reduce their iron and maintain a serum ferritin level less than 250 ng ml-1. All deferoxamine-treated patients were on a low iron-containing diet. An IFN response was defined as a normalization of the serum alanine aminotransferase (ALT) level and seroconversion from hepatitis B e antigen (HBeAg) positivity to hepatitis B e antibody (HBeAb) positivity. The deferoxamine-treated group experienced a reduction in their serum ferritin level to 226 +/- 73 ng ml-1 as a result of the deferoxamine treatment. Six of the 13 (46%) deferoxamine-treated patients and two of the 14 (14%) control patients normalized their ALT levels. Seven of the 13 (54%) deferoxamine but only 14% of the IFN-treated group seroconverted to HBeAb positivity. A greater rate of histological improvement and loss of hepatitis B virus (HBV) DNA was seen in the deferoxamine-treated group. Two of the deferoxamine-treated patients were treated only once, two were treated twice, seven were treated three times and two were treated four times to achieve a ferritin level below 250 ng ml-1. Based on these data, we conclude that deferoxamine infusion enhances the rate of response to IFN in subjects with chronic hepatitis B. The precise mechanism of this phenomenon is not clear.

Relationship between the serum alanine aminotransferase level at the end of interferon treatment and histologic changes in wild-type and precore mutant hepatitis B virus infections

Unravelling the role of interferon (IFN) in the treatment of chronic hepatitis B compliance by many factors. Several mutant forms of hepatitis B virus (HBV) have recently been discovered; the most common of these is the precore mutant, characterized by hepatitis B e antigen (HBeAg) negativity and hepatitis B e antibody (HBeAb) positivity in an individual with an active HBV infection. The aim of this study was to compare the response rate to IFN therapy in patients with wild-type HBV infection and in individuals infected with the precore mutant. A second aim was to evaluate the role of an increased serum ferritin in terms of the IFN response rate in these two different types of HBV infection. IFN therapy was administered at a dose of 5 MU subcutaneously three times weekly for 6 months to 41 individuals with a chronic wild-type hepatitis B infection and 16 individuals with a precore mutant chronic HBV infection. An IFN response was defined as normalization of the serum alanine aminotransferase (ALT) level and an HBeAb to HBeAb seroconversion (in wild-type hepatitis infection), and a normalization of the serum ALT in individuals infected with a precore mutant infection. At entry, the two groups were matched for age, gender, serum ALT, serum iron, total iron binding capacity (TIBC), serum ferritin and liver histology. Forty-six per cent of the subjects with wild-type disease responded to IFN therapy. By contrast, only four of the 16 cases (25%) of the precore mutant cases responded (p < 0.05). Ferritin levels correlated well with the type of IFN response; as the serum ferritin level increased, the response rate to IFN declined. Hapatic infection caused by a precore HBV mutant is more resistant to IFN therapy than wild-type infection. The serum ferritin level appears to influence the type of IFN response achieved. Individuals with a serum ferritin level greater than 300 ng ml-1 failed to respond to IFN in 93% of the cases studied.

Is portal hypertension due to liver cirrhosis a major factor in the development of portal hypertensive gastropathy?

OBJECTIVES

The gastric mucosa of patients with portal hypertension frequently manifests changes in its appearance that are readily identifiable by endoscopy. Many of these can be sources of bleeding, and some imply the presence of systemic disease. Although portal hypertension is critical in development of portal hypertensive gastropathy (PHG), the role that other factors might play in its pathogenesis is uncertain.

METHODS

Four groups of subjects were studied prospectively: 37 with portal hypertension due to cirrhosis, 26 noncirrhotic subjects with portal hypertension due to extrahepatic portal vein obstruction (PVO), nine cirrhotic patients with extrahepatic PVO, and 57 control subjects. The diagnosis in each case was based on a combination of clinical data, needle liver biopsy, ultrasonography, splenoportography, and upper GI endoscopy.

RESULTS

Snake skin, scarlatina rash, diffuse hyperemia, and diffuse bleeding were frequent endoscopic gastric findings in cirrhotic patients. These findings were seen less frequently in noncirrhotic patients with portal hypertension due to PVO than in cirrhotic patients (p< 0.0001). The highest incidence was seen in cirrhotic patients with PVO (P< 0.001). Positive correlations existed among the endoscopic findings, the clinical estimate of the cirrhosis severity (Child-Pugh grade), and the size and appearance of esophageal varices (Beppu score). No endoscopic findings of the gastric mucosa enabled one to distinguish between groups. Hypergastrinemia was present in cirrhotics with and without PVO but not in noncirrhotic patients with portal hypertension resulting from isolated PVO.

CONCLUSION

These findings suggest that the endoscopic findings of PHG are affected by the severity of the underlying liver disease and the presence or absence of coexisting PVO. There is no association between PHG and the presence of gastric varices. Thus, the development of the gastric lesions characteristic of PHG requires not only portal hypertension but also some other consequence of parenchymal liver disease.

The effects of thiotepa, mitomycin C, BCG and interferon instillation on urothelium

The effects of Thiotepa, Mitomycin C, BCG and Interferon on urothelium were researched in rabbits. Early changes of a contracted bladder such as fibroblastic atypia and sub-epithelial plaque were seen in all groups in different rates. This rate in the Thiotepa and BCG groups was 100% and in the Mitomycin C and Interferon groups 60%. There was no urothelial dysplasia in the BCG and Interferon groups, whereas in the Thiotepa group 100% and in the Mitomycin C group 40% were seen. In conclusion, urothelial dysplasia or fibroblastic atypia in random biopsies were criteria to prevent further complications in intravesical therapies.

The "pseudo-cholangiocarcinoma sign" in patients with cavernous transformation of the portal vein and its effect on the serum alkaline phosphatase and bilirubin levels

OBJECTIVES

The goal of this study was to identify the underlying disorder responsible for portal venous thrombosis and cavernous transformation of the portal vein (CTPV). All patients with this finding underwent a thorough medical examination with intent to determine the cause and biochemical consequences of CTPV.

METHODS

During an 8-yr period, a total of 1247 patients with clinical evidence of portal hypertension were examined using ultrasonography. Forty four of these 1247 patients were found to have CTPV. In each case, the finding of CTPV was confirmed by portography using either splenoportography or arterial portography, with digital subtraction angiography. These 44 patients were studied in an effort to determine the etiology of the cavernous transformation. In addition, the specific reason for the increased serum bilirubin and alkaline phosphatase levels in 35 of the 44 cases was evaluated by endoscopic retrograde cholangiopancreatography (ERCP) (34 patients), percutaneous transhepatic cholangiography (one patient), and by CT in 19. The surgical findings in 10 of these 44 patients, who ultimately underwent splenectomy and portal venous decompression for bleeding, were reviewed in light of the ultrasonographic, portographic, and ERCP findings in the same 10 patients.

RESULTS

The underlying disorder responsible for cavernous transformation was found to be Behcet's disease in seven patients, chronic liver disease in four, congenital hepatic fibrosis in five, congenital protein C deficiency in one, and a prior abdominal operation for cholelithiasis in one patient. Despite a full clinical, radiological, hematological, and chemical evaluation, no etiology for CTPV was found in the remaining 26 patients. All of these later cases had no indication for liver biopsy or evidence for parenchymal liver disease. In these 26 patients, the serum levels of bilirubin and alkaline phosphatase ranged from mild to moderately increased compared with the moderately to markedly increased levels present in the 18 patients having an identifiable underlying liver disease. Irregular, undulating narrowing and nodular extrinsic defects, the so-called "pseudo-cholangiocarcinoma sign" was present in 33 of the 35 patients who underwent either ERCP or percutaneous transhepatic cholangiography. No such findings were observed in 10 control cirrhotic patients with portal hypertension but without CTPV, who also underwent ERCP.

CONCLUSION

The results of this study indicate that mildly increased serum alkaline phosphatase and direct reacting bilirubin levels occur in cases with CTPV associated with a pseudo-cholangiocarcinoma sign. Presumably, these enzyme elevations are a result of compression of the biliary tree by the venous collaterals that run along the extrahepatic biliary tree. None of the 33 cases with this sign had cholangiolar carcinoma. Thus, when a patient with splenomegaly but without documentable parenchymal liver disease demonstrates an increase in the serum direct reacting bilirubin and alkaline phosphatase levels, CTPV and the presence of large extrahepatic venous collaterals partially obstructing the biliary tree should be suspected.

Cavernous transformation of the portal vein: a common manifestation of Behçet's disease

Behçet's disease (BD) is a chronic, multisystem inflammatory disorder of unknown etiology, which is characterized by recurrent aphthous ulcers of the mouth and genitalia, uveitis with hypopyon, and a diffuse vasculitis that involves the arterial and venous systems. From January 1968 to July 1993, 66 of 844 patients with BD seen at the Hacettepe University Hospital, Ankara, Turkey, experienced a vascular complication other than peripheral thrombophlebitis. The vascular complication in each case was identified based upon a combination of clinical data, digital subtraction angiography, CT, and ultrasonography findings. Six of these 66 (9.1%) had cavernous transformation of the portal vein. Five of these six had additional large vein involvement resulting in the Budd-Chiari syndrome with or without inferior vena caval obstruction. Based upon this experience, it can be concluded that portal vein thrombosis is not a rare complication of BD. When patients with BD are found to have or develop splenomegaly, portal vein thrombosis should be suspected and investigated. If hepatomegaly and ascites are detected, Budd-Chiari syndrome due to hepatic vein thrombosis should be suspected. Finally, if hepatosplenomegaly, ascites, and dependent edema of the lower body are present, thrombosis of the inferior vena cava should be suspected.

Urinary retention after renal and ureteric surgery

A retrospective study was carried out on 200 patients who underwent surgery between January 1989 and September 1991. The aim was to investigate the development of urinary retention following renal and ureteric surgery. The incidence of urinary retention was 55% for patients in the renal group and 26% for those in the ureteric group. In a control group of 100 patients undergoing cholecystectomy the incidence was 5%. The results showed that bladder function was inhibited greatly after renal surgery. Catheterisation in the pre-operative period may help to prevent post-operative urinary retention.

Budd-Chiari syndrome: analysis of 30 cases

The authors report their experience with 30 adult patients with Budd-Chiari syndrome (BCS), which is a rare and serious disorder, characterized by hepatic outflow obstruction caused by many different conditions. The diagnosis was based on the clinical data, ultrasonography (US), vena cavography and hepatic venography, computed tomography (CT), and liver biopsy. Behçet's disease (BD) was found in 10 patients with BCS as an underlying disease. Two patients used oral contraceptive drugs, 2 had liver tumor hepatocellular carcinoma and liver lymphoma, and 1 patient had chronic lymphocytic leukemia. Despite full investigation, the authors could not find any obvious underlying cause in the other 15 patients. The results suggest that (1) BCS must be considered as a possible complication in patients with Behçet's disease when they have hepatomegaly even if there were no cardinal manifestations of the disease at the time of admission, and BD is the most common etiologic factor in BCS (33%) in Turkey, where the incidence of Behçet's disease is relatively high. (2) Anti-aggregant treatment seems to be effective in many instances. (3) There were space-occupying lesion-like appearances in the liver of 7 cases by CT and US examination in the acute stage, and these disappeared on the follow-up CT and US in 5 patients but continued in 2. BCS should thus be differentiated from other liver lesions. (4) There were other great-vessel involvements in 43% of the cases, mostly venous, but only 1 pulmonary arterial occlusion.

Effects of recombinant alpha interferon on chronic active hepatitis B: preliminary results

This paper presents the preliminary results of a study designed to evaluate the effects of alpha interferon in chronic hepatitis B. After six months' treatment with interferon alfa-2b (5 million units (MU), three times weekly) 15 of 25 (60%) patients achieved seroconversion of hepatitis B e antigen, 17 (68%) normalised alanine aminotransferase (ALT) activity, and 15 (60%) showed a decrease in the inflammatory reaction on liver histology. No seroconversions occurred in the control group (n = 10), and none of the control patients achieved a normal ALT or showed a reduction in the inflammatory reaction. Adverse effects were experienced by most patients who received interferon but none warranted stopping the treatment.