Neonatal cholestasis in Kashmiri children

Neonatal cholestasis is prolonged elevation of conjugated serum bilirubin (more than 20% of total bilirubin) beyond first 14 days of life. After extensive evaluation a diagnosis of either biliary atresia or neonatal hepatitis is made in 70-80% of cases. Neonatal hepatitis and biliary atresia form a pathophysiologic process directed at various levels of the hepatobiliary tract. Inflammation in the bile duct epithelium may result in the sclerosis and obliteration of the bile ducts and manifest as biliary atresia. Primary hepatocellular inflammation is more likely to result in neonatal hepatitis. Half of the cases of neonatal hepatitis resolve without sequelae, while most of the biliary atresia cases require surgical intervention for repair or, ultimately, liver transplant.

Opportunistic hepatic infections in AIDS patients with fever of unknown origin

The clinical features and histopathologic manifestations of hepatic opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS) in Taiwan remain unexplored. We report 28 AIDS patients (25 men, 3 women; mean age, 34 years) with fever of unknown origin who underwent 31 liver biopsies from December 1995 to May 1997. In most cases, the biochemical tests showed moderate to markedly elevated alkaline phosphatase concentrations, but normal or mildly elevated aminotransferase concentrations. The most common histopathologic finding was macrosteatosis, which was noted in 15 of the 28 patients. Another important histopathologic finding indicating the etiology of hepatic opportunistic infection was granuloma, which was found in 11 patients. Histochemical stain and culture of liver specimens yielded Mycobacterium avium complex (MAC) in eight patients, Mycobacterium tuberculosis in two patients, Histoplasma capsulatum in one patient, and cytomegalovirus in one patient with concomitant MAC infection. Therefore, a definitive diagnosis in AIDS patients with fever of unknown origin was made in 11 of the 28 cases with the assistance of liver biopsy. During follow-up, late extrahepatic involvement by the same infectious agents was found in six patients. Thus, hepatic manifestations could be a harbinger of disseminated opportunistic infections in AIDS patients.

A prospective review of laparoscopic cholecystectomy in Brunei

Brunei has a small population and a unique medical setup: The number of laparoscopic cholecystectomies (LCs) performed in our institution represents the total number of cases performed in this country. A prospective analysis of all the LCs performed in Brunei is presented. All 220 LCs performed between February 1, 1992, and November 30, 1996, were prospectively recorded on a detailed protocol. Analyses were made with respect to preoperative patient demography, intraoperative complications, and postoperative morbidity and mortality. Symptomatic gallstone disease was found to be common among the ethnic Nepalese population. In this series, nine patients required conversion to open surgery (4%). Acute cholecystitis comprised 21% of cases, and the mean operating time was longer in these cases (144.1 min) than in elective cases (101.2 min; P = 0.002). The overall morbidity was 5% with one ductal injury (0.5%). The mortality rate in this series was 0.5%. Our results of LC are favorable and comparable with those of published series. We conclude that LC has been successfully introduced into our institution. This study also represents an unofficial audit of the state of development of LC in Brunei.

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a review of diagnosis and management

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia that threatens the gravida and her fetus. In this report, the diagnostic criteria and maternal and fetal risks of HELLP are defined. Prompt recognition and treatment in tertiary centers is emphasized, because the prognosis can be adversely affected by delayed or less than optimal diagnosis and treatment. Management guidelines are offered for treating this disorder. The potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Subsequent pregnancy outcome, contraception, and preventative strategies are considered.

Gabapentin does not interact with a contraceptive regimen of norethindrone acetate and ethinyl estradiol

Anticonvulsants that induce hepatic metabolism increase clearance of oral contraceptive hormones and thereby cause contraceptive failure. Gabapentin is not metabolized in humans and has little liability for causing metabolic-based drug-drug interactions. In healthy women receiving 2.5 mg norethindrone acetate and 50 microg ethinyl estradiol daily for three consecutive menstrual cycles, concurrent gabapentin administration did not alter the steady-state pharmacokinetics of either hormone. Thus, gabapentin is unlikely to cause contraceptive failure.

The burden of viral hepatitis in Africa

The burden of viral hepatitis in Africa is difficult to quantify precisely because of inaccurate statistical data and under-reporting. Of the various agents causing viral hepatitis, data on hepatitis B virus have been relatively more available and suggest that 15 to 60 per cent of the normal population in many African countries may be positive for one or more of the serologic markers of hepatitis B virus infection, whilst the corresponding values for patients with PLCC ranged from 49 to 80 per cent. Liver disease was the third most common (12.1%) of all 4,568 deaths on the medical wards of the University College Hospital, Ibadan, Nigeria over a 14-year period. Of all causes of deaths from liver disease, PLCC alone accounted for 42.5% while liver cirrhosis accounted for 21.1% of the deaths and, in both disease, HBV was the commonest cause. PLCC, which accounted for 491 out of 100,000 admissions in that teaching hospital, was the commonest malignancy on the medical wards and was the commonest cause of deaths from cancers in middle-aged and elderly Nigerians. Recent reports suggest that the prevalence of Hepatitis C infection in normal Africans may be as high as 10.9% while the corresponding value for patients with PLCC would be about 18.7 to 38 per cent. There is a need for control of hepatitis particularly hepatitis B virus infection through health education, active immunization of all new-borns and other people at risk in Africa.

The contraceptive choice for a Wilson's disease patient with chronic liver disease

Preserved fertility status is frequently encountered in patients with Wilson's disease, and contraceptive counseling may, therefore, be a relevant issue. Yet, several contraceptive methods can adversely influence the hepatic function, and the efficacy of others may be affected by the liver disease. We describe a patient with Wilson's disease manifested by cirrhosis, portal hypertension, and bleeding esophageal varices who underwent termination of pregnancy at 9 weeks' gestation. Following the procedure, contraceptive advice was sought in order to postpone conception until portal hypertension was controlled and hepatic function improved. Intramuscular depot medroxyprogesterone acetate was administered and tolerated well by the patient. A detailed discussion of the contraceptive options for patients with chronic liver disease, in general, and Wilson's disease, in particular, follows the case report.

Seroprevalence of hepatitis E virus in an adult urban population from Burundi

The prevalence of antibodies to the hepatitis E virus (HEV) was measured in a group of 129 adults from Bujumbura, Burundi, using an ELISA. The prevalence of anti-HEV IgG was 14%, much lower than that of hepatitis A virus (HAV) (97.7%). In addition to the lability of antibodies to HEV, this difference might be explained by the extensive availability of good-quality drinking water in the city. The presence of serologic markers of HBV (77.6%), HCV (27.1%), and human immunodeficiency virus (30.2%) was not associated with that of anti-HEV.

Spectrum of liver diseases in HIV infection

BACKGROUND

Most earlier reports on the spectrum of liver diseases in HIV-infected individuals originated from the West.

OBJECTIVE

To study the spectrum of liver diseases in HIV-infected individuals.

METHODS

Seventy four consecutive HIV-positive patients (57 men; age range 23-75 years, mean 34) were studied prospectively with clinical evaluation, liver function tests, ultrasonography, radioisotope liver scan, markers of hepatitis B (HBV) and C (HCV) viruses, and liver histology whenever necessary.

RESULTS

Thirty four patients (45%) were chronic alcoholics. Mean (SD) absolute lymphocyte count was 2521 (1271)/mm3; count < 2000/ mm3 was present in 20 patients. Serum bilirubin, transaminases and alkaline phosphatase levels were elevated in 13%, 13% and 24% of patients, respectively. Ultrasonography detected an abscess in two patients (tuberculous-1, amebic-1). Evidence of exposure to HBV was present in 81% (HBsAg-12, hepatitis B core and/or surface antibody-48); anti-HCV antibody was positive in 29.7%. Five patients with liver tuberculosis (granuloma-4, abscess-1) had AFB either in liver tissue or lymph nodes.

CONCLUSION

Chronic alcoholism, HBV and HCV infection, hepatic tuberculosis, and evidence of other liver disease were common in patients with HIV infection.

Hepatitis C (HCV) genotype and viral titer distribution among Argentinean hemophilic patients in the presence or absence of human immunodeficiency virus (HIV) co-infection

Hepatitis C (HCV) infection is frequent among hemophilic patients treated with non-inactivated factor-concentrates. Both HCV genotype and viral load have been suggested to be important prognostic markers of disease progression and treatment outcome. In addition, co-infection with the human immunodeficiency virus (HIV) has been associated with increased level of HCV replication and higher risk of developing liver failure. Thus, HCV genotype, viral load, and HIV co-infection are important factors in HCV infection. Using restriction fragment length polymorphism analysis (RFLP) and the branched-DNA (bDNA) assay, we retrospectively investigated the HCV genotypes and viral loads present in 59 Argentinean hemophiliacs, in the presence or absence of HIV infection. HCV genotype 1 was the predominant viral variant detected among HIV-negative (HIV-) (76%) and HIV-positive (HIV+) (82.5%) patients, followed by genotypes 3 (10.4%), 2 (2%) and a small proportion of multiply co-infected patients including genotypes 4 and 5 (6.25%). HIV+ patients had higher plasma HCV RNA levels than HIV- patients (88.4 +/- 16.5 x 10(5) Eq/ml vs. 24.7 +/- 10(5) Eq/ml) (P < 0.001); however, no correlation between HCV replication and level of immune suppression, evaluated by CD4+ T-cell measurement, was observed among HIV+ patients (r = 0.017). Abnormal and higher ALT levels were more frequently detected among HIV+ (93%; 123.6 +/- 15.7 U/liter) than HIV- (41%; 70.2 +/- 24.2 U/liter) patients (P < 0.001; P < 0.05). Although we were able to confirm previous reports suggesting the existence of increased HCV replication in HIV/HCV co-infected hemophiliacs, our data did not support the conclusion that HIV-induced immune suppression is directly responsible for this phenomena. It is possible that other factors induced by HIV are responsible for the increased levels in HCV replication observed.

Combined oral contraceptives and liver disease

Although some information is available about the risk of liver tumors associated with combined oral contraceptive use, little is known about the relationship with other hepatic problems. Data from two large long-term observational studies, the Royal College of General Practitioners (RCGP) Oral Contraception Study and the Oxford-Family Planning Association (Oxford-FPA) Study, were used to examine this issue. Observations accumulated over a period of up to 27 years were available for each study. The incidence of liver disease in each study was low. There was no evidence of an increased risk of serious liver disease overall among current or former pill users. The RCGP study found a modest increased risk of mild liver disease associated with oral contraceptive use which declined after four years of use and after cessation of use. This increased risk occurred in women who had used oral contraceptives containing more than 50 micrograms of estrogen.

[Intestinal parasitosis and hepatic cirrhosis]

The authors describe their experience, in a prospective survey, with the prevalence rates of intestinal parasites in patients with hepatic cirrhosis admitted to the Gastroenterology Unit of University Hospital of Federal University in Juiz de Fora, Brazil, whose fresh stools were examined by Hoffman-Pons-Janner, Baermann-Moraes and Willis methods. They compare the results of stool exams with two control groups and look for a relation with cirrhosis' etiology. A higher prevalence of some parasites was observed in cirrhosis than in people with other digestive diseases (group I). mainly for the Strongyloides stercoralis, found in 40.2%, chiefly in alcoholic cirrhosis. Oddly no one of the group I admitted in the same period had strongyloidiasis. Another group including all the people who had stool samples examined in the same period at the hospital had 1.91% of that helmintic infection (group II). A comparison is also made with the prevalence in schoolchildren between the ages of 7 and 14 studies eight years before (13.16%). Other parasites were also observed in different incidence between those with cirrhosis and the other groups and the results are presented. They conclude that hepatic cirrhosis must be included in the list of conditions which increases the risk of Strongyloides stercoralis infection.

p53 mutations in hepatocellular carcinoma related to oral contraceptive use

Oral contraceptives (OCs) are implicated in the development of hepatocellular carcinoma (HCC). Mitogenic stimulation may be the primary mechanism of tumorigenesis, but other factors may also contribute. Mutational spectrum analysis can provide insights into pathogenesis, therefore we analyzed the p53 tumor suppressor gene in 10 HCCs from women with a history of OC use. All were non-Asians whose average OC use was 6.7 years (range 2 months-13 years) and whose mean age at HCC diagnosis was 48.8 years (range 21-67 years). Each tumor was analyzed by immunohistochemistry, DNA sequencing and allelic deletion analysis. Three tumors were positive by p53 immunohistochemistry; allelic deletion analysis identified loss of heterozygosity in one of four informative cases. Two p53 point mutations were found in one tumor containing moderately and well-differentiated components; this patient was negative for all serological markers of hepatitis B and C infections. Both components showed p53 protein accumulation and a GTTval-->GCTala mutation at codon 274. In addition, a silent mutation (ACCthr-->ACTthr) at codon 140 of the p53 gene was detected in the moderately differentiated component of the tumor. These preliminary data indicate that p53 mutations are uncommon in OC-related HCCs. One of the two detected mutations was a G:C-->A:T transition at a non-CpG site, which is characteristic of DNA damage by free radicals. These data support a model whereby estrogens contribute to HCC development primarily through mitogen stimulation and secondarily by mutagenesis via hydroxyl radicals produced during estrogen metabolism. Confirmational analysis of a larger series is warranted.

A young female with a cholangiocarcinoma in the past: is pregnancy allowed?

BACKGROUND

A 28-year-old woman developed a cholangiocarcinoma after using oral contraceptives for eight years. The common bile duct and the gallbladder were removed and four hepaticojejunostomies were performed.

RESULTS

Seven years after surgery no evidence of disease recurrence is detectable and the patient wants advice regarding her wish for pregnancy.

CONCLUSION

The possible role of oestrogens in the development of cholangiocarcinoma makes it difficult to give an adequate advice. As in patients with breast cancer in the past, it seems reasonable to admit pregnancy in our patient, because of a disease-free interval of longer than five years.

Hormonal oral contraceptives, urinary porphyrin excretion and porphyrias

The influence of hormonal oral contraceptives on the urinary porphyrin excretion of 40 healthy females has been studied. Two different hormonal oral contraceptives (combinations of gestoden or desogestrel, respectively, and ethinylestradiol) were applied for half a year. In each case twenty women received one of these two combinations. Porphyrin precursors delta-aminolevulinic acid and porphobilinogen were normal in all subjects as well as the mean of uroporphyrin and coproporphyrin. One healthy female developed a mild secondary coproporphyrinuria. In this case coproporphyrin isomer I was slightly enhanced and isomer III slightly lowered. Furthermore it could be shown that three females with repeated premenstrual clinical expression of an acute hepatic porphyria (acute intermittent porphyria and hereditary coproporphyria) could be treated successfully with a hormonal oral contraceptive or other exogenous hormones to stabilize the latent, subclinical phase of the disease.

The effects of nomegestrol acetate subdermal implant (Uniplant) on carbohydrate metabolism, serum lipoproteins and on hepatic function in women

This study was undertaken to assess possible variations in body weight, blood pressure, fasting glucose, HbA1C, insulin, total cholesterol, HDL-C, LDL-C, triglycerides, SGPT, SGOT, GGT and bilirubin in women bearing a single subdermal Silastic implant containing 55 mg (10%) of nomegestrol acetate during two years. A total of eighteen volunteers of reproductive age who desired to avoid conception were enrolled in this study. Subjects were healthy women with no contraindications to hormonal contraception. All women were investigated before starting treatment and were followed up for one year. At the end of one year the capsules were removed and a new capsule was inserted. Fasting blood samples were drawn at 8:00 to 8:30 am twice prior to implant insertion and then at the first, third, sixth and twelfth months and every six months thereafter. Body weight increased from 54.9 +/- 1.5 kg at admission to 55.3 +/- 2.0 kg at 12 months of use (p < 0.05) and to 56.0 +/- 2.7 kg at 24 months of use. A slight increase in both systolic and diastolic blood pressure was recorded at month 12 (p < 0.01). At month 24, blood pressure was not significantly different from admission values. All levels were within the normal range. Insulin, HbA1C, LDL-C and GGT remained unchanged during twenty-four months of Uniplant use. A significant decrease in total cholesterol (p < 0.05) was observed in the third month while a significant decrease in HDL-C (p < 0.01) was observed only in the sixth month of Uniplant use.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical contraindications and issues for consideration in the use of once-a-month injectable contraceptives

A number of once-a-month injectable contraceptives have been studied over the last 30 years and at least three different formulations are currently in use worldwide. Each of these formulations contains an ester of the natural estrogen, estradiol, and a synthetic progestin. This is in contrast to the combined oral contraceptives which contain synthetic analogs of both estradiol and progesterone. This paper considers medical contraindications or precautions related to the use of once-a-month injectable formulations and suggests some considerations for their programmatic use, particularly in the developing world. Because once-a-month injectables contain both an estrogen and a progestin, the precautions related to their use are similar to those of combined oral contraceptives; however, since the estrogen component is a natural estrogen, administration is parenteral and the circulating levels reach peaks that are in the range of those of the normal preovulatory phase of the menstrual cycle, some of these precautions may be very conservative. Absolute contraindications to the use of monthly injectables are current or suspected pregnancy, and estrogen-responsive tumors of the breast or genital tract. Other factors have been termed precautions for use rather than absolute or relative contraindications. Primary precautions are conditions under which a woman should probably not use monthly injectables, but if she does, she should be monitored closely. These include current or individual history of cardiovascular disease, current liver disease or liver tumors, and over age 40 if a smoker. Secondary precautions to use are those which should be considered very carefully and balanced against the risks of not using the particular method. These include suspicion of breast or genital tract cancer until cancer is ruled out, unexplained abnormal vaginal bleeding, use of drugs which might affect metabolism and decrease effective levels of circulating steroids, breastfeeding, and having combinations of several risk factors for cardiovascular disease. These precautions are categorized as proposed, based on the fact that most women in the developing world face a risk from pregnancy that is probably far greater than the risks from any of the present formulations of steroidal contraceptives. A key consideration during programmatic use of monthly injectables is attention to compliance with follow-up schedules to minimize the risk of pregnancy. Because little information on monthly injectables is available that is directly related to these precautions, additional research studies will be required in order to reconsider whether some of the listed precautions are valid or others should be considered.

[Transformation of hepatic adenoma into hepatocellular carcinoma in patients with prolonged use of oral contraceptives]

Liver cell adenomas were relatively rare until the use of oral contraceptives. Most of these tumors have occurred in otherwise healthy young women who have been exposed to oral contraceptives. The treatment of this condition remained controversial for a long time. However, bleeding is still a frequent complication and can lead to a significant mortality rate. The better surgical results in hepatic resection, due to technological advances, has contributed to the indication of surgical management as therapeutic option in hepatic cell adenoma. Some authors believe that liver cell adenomas were potentially premalignant and could degenerate into hepatocellular carcinoma but there is very few well documented reports of this transformation. We report our experience in the management of liver cell adenoma.

Liver damage from low-dose oral contraceptives

OBJECTIVE

To study whether the decrease in the content of oestrogen and gestagen in modern low-dose oral contraceptives (OC) has yielded a lower incidence of adverse liver reactions, and to describe the biochemical pattern of the adverse liver reactions from low-dose OC.

DESIGN

We surveyed all liver reactions from OC reported to SADRAC (Swedish Adverse Drug Reactions Advisory Committee) from 1966 to 1989.

MAIN OUTCOME MEASURE

Incidence of reported adverse liver reactions (number of reported adverse reactions/OC sales in defined daily dose [DDD]).

RESULTS

There was a sharp decline in the number of reports during the studied period, suggesting changes in reporting habits. However, there was also a significantly lower incidence of reports for medium-compared to high-oestrogen dose OC, and a further decrease, albeit non-significant, in incidence with low-oestrogen dose OC. Furthermore, in three comparisons of pairs of OC that differed only in the gestagen dose, there was a strong trend towards a higher reporting rate with higher gestagen dose. Cholestatic and hepatocellular liver enzyme patterns were equally frequent in patients with adverse reactions from low-dose oestrogen OC. There was no report of liver tumours related to use of low-oestrogen dose OC.

CONCLUSION

There seems to be a decrease in the incidence of adverse liver reactions related to lower contents of both oestrogen and gestagens in OC of the combined-preparation type.

The frequency of blood-born viral infections in a population of multitransfused Brazilian patients

The frequency of viral markers for hepatitis B (HBV) and C (HCV), human immunodeficiency virus-1 (HIV-1) and human T-lymphotropic virus-1 (HTLV-1) was evaluated in 32 Brazilian beta-thalassemia multitransfused patients. Additionally the serum concentrations of ferritin and alanine aspartate transaminase (ALAT) were determined. The results show a high prevalence of markers of infection by HBV (25.0%) and HCV (46.8%) and a low prevalence of markers for HIV-1 and HTLV-1. No correlations were demonstrated between the presence of the hepatitis markers and the number of units transfused or the serum concentrations of ferritin and ALAT.

Benefits and risks of oral contraceptive use

As a general rule, the lowest-dose oral contraceptive should be prescribed that minimizes side effects while maintaining contraceptive protection. A woman who experiences mild side effects should be encouraged to tolerate symptoms for three menstrual cycles before a decision is made to change the prescription. Compliance may also be improved by informing women of the noncontraceptive health benefits of oral contraceptives: less menstrual blood loss and a lower incidence of menorrhagia, irregular bleeding, benign breast disease, endometrial cancer, dysmenorrhea, ovarian cysts or tumors, and salpingitis. Adequate patient education and supportive counseling are key factors in patient satisfaction and hence compliance.

Pharmacokinetics of levonorgestrel and ethinylestradiol in 9 women who received a low-dose oral contraceptive over a treatment period of 3 months and, after a wash-out phase, a single oral administration of the same contraceptive formulation

The pharmacokinetics of levonorgestrel (LNG) and ethinylestradiol (EE2) were determined in 9 healthy women (age 23 to 42 years), during a treatment period of three months with a low-dose oral contraceptive, containing 0.15 mg LNG together with 0.03 mg EE2 (Microgynon). After a wash-out period of 3 months, 8 of these women received a single administration of the same formulation. The results showed that there was an increase in serum trough levels of LNG, reaching steady-state in the second half of each treatment cycle. The LNG levels achieved were about 3 to 4 times higher than anticipated on the basis of single dose administration. At the end of treatment cycles one and three, the terminal half-life of LNG was in the range of 24-26 h, while a mean value of 20 h was observed following single dose administration. An EE2-induced increase in the SHBG concentration of about 50% as compared to pretreatment values was observed during a treatment cycle. Pretreatment values were reached following the drug-free interval of 7 days between two cycles. After single dose administration, the free fraction of LNG was 1.3 +/- 0.2% and the fractions bound to SHBG and albumin were 64.1 +/- 4.2% and 34.6 +/- 4.0%, respectively. Serum protein binding of LNG did not change during chronic treatment. An about 50% reduction in total and unbound clearance of LNG was observed during chronic treatment, as compared to single dose administration. Increased SHBG binding capacity and a reduced hepatic metabolic capacity were discussed as possible causes of accumulating LNG concentrations in the serum. On the last day of treatment cycles one and three, the AUC(0-24h) values of EE2 were 728 +/- 314 and 778 +/- 318 pg x ml-1 x h, respectively, and were in keeping with data reported from others.

The interrelationship between HBV-markers and HIV antibodies in patients with hepatocellular carcinoma

To determine the interrelationship between hepatitis B viral markers (HBV), the human Immunodeficiency virus (HIV), and hepatocellular carcinoma (HCC) in HCC patients, a total of 282 subjects were included in the study. Out of 282 subjects, 182 were HCC patients as determined by raised alpha-feto-protein (AFP) of greater than 1,000 ng/ml. The other 100 control patients presented with other conditions and had detectable AFP of less than 1,000 ng/ml in their sera. On presentation, 10 ml of venous blood was drawn from each enrolled subject and taken to the laboratory. HBV markers were detected using commercial reagents; HIV antibodies were detected by the commercial ELISA tests and were confirmed by Western blot. AFP was detected using an RIA technique. Of 282 examined subjects 182 (64.5%) had detectable AFP of greater than 1,000 ng/ml. 113 (40.1%) and 103 (36.5%) had HBsAg and Anti-HBc respectively. However, HBeAg was found in 21 of 113 (18.6%) of the HBsAg positive only. Anti-HIV antibodies were present in 15 (5.3%) of the 282 tested individuals. Only 1 (1.0%) of the control group had detectable anti-HIV antibodies in the serum. Eleven percent and 4.0% of the same control group had HBsAg and anti-HBc in their sera respectively. The study shows a significant correlation between HCC and HBV-markers (P less than 0.0001). Similarly, a significant correlation between anti-HIV antibodies and HBV-markers, (P less than 0.0001) was found.

Perihepatic adhesions: not necessarily pathognomonic of pelvic infection

Perihepatic adhesions are often considered to be associated with pelvic inflammatory disease and subsequent infertility. Seventeen patients out of 100 undergoing elective laparoscopic sterilization had evidence of perihepatic adhesions. Four of the 17 showed evidence of old pelvic inflammatory disease, but only two gave a history of sexually transmitted disease. All patients had a negative gonorrhea culture and 50 also had a negative chlamydia culture before the procedure. These data suggest that perihepatic adhesions may be observed in otherwise normal fertile women, and its presence does not necessarily imply pelvic inflammatory disease or poor fertility.

Hepatic cavernous haemangioma: a 10 year review

Between January 1981 and July 1991, 61 patients with hepatic haemangiomata were examined at Westmead Hospital. There were 14 males (22%) and 47 females (78%). The age range was 26-85 years with a median of 49 years. Forty-one had abdominal symptoms but these could be attributed to a haemangioma in only seven cases. There was at least one subcapsular lesion in 17 (28%). Six of the seven symptomatic lesions were subcapsular and five of these were giant haemangiomata (i.e. more than 4 cm in greatest diameter). One large symptomatic lesion was intrahepatic. No association was observed between hepatic haemangiomata and other hepatic or extrahepatic diseases. Haemangiomata were resected from six patients, four of whom were symptomatic. Symptoms improved in all four but did not resolve completely in any. Follow-up ranged from nil in five patients to 108 months in one. The median follow-up was 12 months after initial diagnosis. Ten patients showed evidence of change in their lesions or symptoms while under observation. Only three had worsening symptoms or suspected change in size of a haemangioma. This study highlights the benign, static nature of most hepatic haemangiomata. When this lesion is suspected, the diagnosis should be confirmed with ultrasound (US) and labelled red blood cell scanning (RBCS). Referral for evaluation by a specialist hepatobiliary surgery unit is necessary when symptoms are intolerable, increasing size is definitely demonstrated or the diagnosis is uncertain and cannot be established without specialized investigations. Bleeding into or from these lesions is rare.

Disseminated Penicillium marneffei infection in HIV-infected subject

Penicillium marneffei is a rare human pathogen predominantly affecting residents of South-east Asia. We report four fatal cases from Hong Kong in human immunodeficiency virus-infected patients. The diagnosis was established by histological examination and confirmed by isolation of the fungus. The infection was disseminated with involvement of lymph nodes, liver, spleen, lung, intestine and bone marrow. The involved organs showed an exclusively anergic tissue reaction characterized by a diffuse infiltrate of fungi-laden macrophages, multiple co-existing opportunistic infections and lymphoid cell depletion. This organism has to be distinguished from Histoplasma capsulatum and Pneumocystis carinii. Establishment of the diagnosis is important not only because this infection is potentially curable, but also it is a likely indicator disease of AIDS in South-east Asia. Penicilliosis marneffei should be suspected in any symptomatic HIV-positive patient who comes from or has visited endemic areas of South-east Asia.

Serum bile acids and the bile acid tolerance test under oral contraception

Oral contraceptives (OC) have lithogenic properties as shown by a rise in biliary cholesterol secretion and cholesterol saturation index. Since we noted not only a rise in saturation index, but also a reduction in chenodeoxycholate (CDC) pool size and an increase in cholate (C) pool size during oral contraception (30 micrograms ethinylestradiol + 150 micrograms desogestrel), we investigated the endogenous bile acid tolerance test as a potential predictor of this effect on bile acid pool sizes using a cholecystokinin infusion of 55 min duration (1.2 U.kg-1.hr-1) as stimulus of the enterohepatic bile acid circulation in 12 healthy females before and during oral contraception for 3-5 months. Serum C and CDC conjugates were measured at 5-10 min intervals over a period of 150 min and analysed by two specific RIA's. Although no significant correlations between the serum CDC and C measurements and CDC and C pool sizes were found, a significant reduction of nearly 40% for both serum peak levels and the integrated area under the serum curve of CDC conjugates during oral contraception, but not of C conjugates was found. The reduction in serum levels of CDC conjugates during OC using the present model is best explained by both a reduction in CDC pool size and more efficient hepatic uptake of CDC conjugates (consisting of considerably more taurine conjugates during OC use), as well as by an intestinal effect on bile acid absorption under OC.

Hepatobiliary complications of oral contraceptives

Complications secondary to the use of oral contraceptive agents are rare. Hepatobiliary complications, while often dramatic in presentation, occur infrequently. In a patient without predisposing conditions to complications, the benefits achieved with estrogen/progesterone products outweigh the risks. Those conditions that would absolutely and relatively contraindicate the use of oral contraceptives are listed in Table 4. Patients with a past history of liver disease in whom liver function tests have returned to normal may tolerate the introduction of oral contraceptives. They need to be monitored closely for adverse reactions. Patients who have experienced cholestatic jaundice of pregnancy should avoid all contraceptives because of a high risk of disease recurrence. Women whose first-degree relatives have experienced cholestasis of pregnancy or oral contraceptive-induced cholestasis may be at increased risk and should be closely monitored while taking birth-control pills. Women with current or previous benign or malignant hepatic tumors should not take oral contraceptives. Active hepatitis is an absolute contraindication to using birth control pills, although patients with a past history of hepatitis and no evidence of active disease can have a trial of these drugs with close follow-up. A final group of women who should avoid oral contraceptives is those with familial defects of biliary excretion, including the Dubin-Johnson syndrome, Rotor's syndrome, and benign intrahepatic recurrent cholestasis. Dubin-Johnson syndrome is often asymptomatic and may manifest only during pregnancy or during the use of oral contraceptives. The reduction in hepatic excretory function induced by the sex steroids can transform the mild hyperbilirubinemia into frank jaundice. Oral contraceptive agents are the most widely used reversible means of birth control currently available. Fortunately, the complications associated with these drugs are infrequent and may be decreasing due to lower-dose products. Complications still occur, however, and need to be recognized by the general internist as medication-induced problems so the offending drugs can be discontinued and appropriate treatment and follow-up initiated. In addition, patients at risk for the development of complications need to be recognized and advised prior to the introduction of oral contraceptives.

Effect of Norplant implants on liver, lipid and carbohydrate metabolism

In this study involving 100 women, the metabolic changes seen with Norplant use were evaluated. Besides a significant increase in serum bilirubin, there were no other changes in liver function to suggest possible hepatocellular dysfunction at the end of five years. Even the raised mean levels of bilirubin remained within the normal clinical range for the local population. As regards lipid metabolism, total triglycerides, cholesterol and LDL-cholesterol were decreased through the five years of Norplant use. The HDL-cholesterol showed a significant increase in the first year; it then decreased over the years to its preinsertion level at the end of five years. As a result, the HDL-cholesterol/Total cholesterol - HDL-cholesterol showed a significant increase in the first year and then decreased to almost its preinsertion value at the end of five years. The findings appear to indicate Norplant use not to be contributory to cardiovascular risk. The use of Norplant was not associated with any significant effect on carbohydrate metabolism.

[Treatment of infantile hepatitis syndrome with injection of yin zhi huang]

The infantile hepatitis syndrome is defined as a liver disease which occurs during the infantile period with the clinical manifestation of jaundice, hepatomegaly and hepatic dysfunction. The cause of disease is complex and the treatment is difficult. From March 1987 to June 1988, 55 patients (treatment group) were treated with injection of yin zhi huang, and 15 cases (control group) with injection of Inosine, vitamin C and glucose. The course of treatment lasted 15 days. At the beginning and the end of the treatment, serum bilirubin level, sALT level, duodenal juice bilirubin level, liver size and T cell subsets in peripheral blood had been detected separately. The results showed that among the treatment group, serum bilirubin level was significantly lower at the end of the treatment than that of the control group. The sALT, and hepatomegaly were also reduced or lessened, while the duodenal juice bilirubin level was increased. But there was no difference in T cell subsets between the two groups.

Early anti-HBs antibody response to accelerated and to conventional hepatitis B vaccination regimens in healthy persons

A significantly higher prevalence of a protective concentration of anti-HBs was achieved at 1 and 2 months among 132 healthy medical students who received an accelerated vaccination schedule with a recombinant hepatitis B vaccine (Engerix-B) than among 120 medical students who received a conventional regimen. With the accelerated schedule, however, 60% students at 1 month and 27% at 2 months were still unprotected (anti-HBs titre less than 10.0 IU/l). Additional passive immunisation should therefore continue to be offered if the accelerated schedule is adopted for post-exposure prophylaxis.

Oral contraceptives, sex steroid-induced antibodies and vascular thrombosis: results from 1318 cases

The role of antiethinyl estradiol antibodies (anti EE Ab) and associated risk factors was evaluated in 1318 cases of venous or arterial thrombosis in oral contraceptives (OC) users, and compared to 61 non-users and 124 healthy current users. Anti EE Ab were absent in non-users and present in 33% of healthy users and 72% of those with thrombosis, either arterial or venous. Age, duration of use, hyperlipidaemia and smoking were factors associated with thrombosis only in women with an arterial disease. While the two predominant factors, anti EE Ab and smoking may be risk factors in their own right, the combination of both was found in 47.7% of women with thrombosis. It is proposed that thrombosis associated with OC use may be explained by an immunological disease in which anti EE Ab and their complexes with the circulating synthetic hormones may be harmful to the vessels, as also suggested by the type of lesions already described in OC users. The determination of anti EE Ab in healthy users may identify a group at risk of thrombosis.

Hepatocellular carcinoma coexisting with hepatic adenoma. Incidental discovery after long-term oral contraceptive use

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Response to hepatitis B vaccine in relation to the hepatitis B status of family members

The influence of the hepatitis B status of family members on the response to hepatitis B vaccine of an infant has been examined in 395 families. The presence of one or more HBsAg-positive family members did not appear to have any effect on the vaccine response. This is an encouraging finding as children born into carrier families are at an increased risk of becoming carriers themselves. That the vaccine response of such children is as good as for those born into non-carrier families means that they are likely to be protected against the carrier state by the vaccine.

Oral contraceptives and skin neoplasia

A possible association between oral contraception and the development of cutaneous melanoma has been raised largely because of the hyperpigmentation of pregnancy and the effect pregnancy may have on the outcome of established disease. Present evidence suggests there is no causal link between oral contraceptive (OC) use and melanoma (or with benign melanocytic nevi), nor has a specific subgroup of women or subtype of melanoma been consistently implicated as being at increased risk of this disease due to use of OCs.

Iron status of Zairean pregnant women with and without serological markers of hepatitis B virus infection

We assessed the iron status of 203 Zairean pregnant women: 38 with chronic hepatitis B virus (HBV) infection (HBsAg(+)), 94 with antibodies to the surface antigen (Anti-HBs(+)) and 71 without HBV markers (HBsAg(-)/Anti-HBs(-)). Participants, age range 15-42 years and parity 1-12, were recruited from Mama Yemo Hospital in summer 1983. Haemoglobin (Hb), serum iron, total iron binding capacity and transferrin saturation (TS) were determined by standard techniques and serum ferritin (FERR) by radioimmunoassay. To rule out inflammation and/or infection which increase FERR levels, C-reactive protein (CRP) and alpha 1-acid glycoprotein (AGP) were also measured. There was no significant difference in the mean levels of any of the haematologic measurements, FERR, CRP and AGP between the three HBV groups. Women who took iron supplements had slightly higher mean levels of Hb but not serum FERR or TS than those who did not. Women with inflammation and identical HBV markers had higher mean FERR levels than those without inflammation. Neither the prevalence of anaemia, which varied between 32 and 35%, nor that of iron deficiency, which varied between 52 and 59%, differed significantly between the three groups of women. We conclude that in pregnant women, chronic asymptomatic HBV infection is not associated with a lower prevalence of iron deficiency and/or anaemia.

Effect of the progestogens, gestodene, 3-keto desogestrel, levonorgestrel, norethisterone and norgestimate on the oxidation of ethinyloestradiol and other substrates by human liver microsomes

A number of different progestogens, levonorgestrel (LNG), norethisterone (NET), gestodene (GSD), desogestrel (DG) and norgestimate (NORG) are used in combination with the oestrogen ethinyloestradiol (EE2) in oral contraceptive steroid preparations. All the progestogens are acetylenic steroids and previous studies have indicated the potential of acetylenic steroids to cause mechanism-based or "suicide" inactivation of cytochrome P-450. We have compared the effects of the different progestogens on EE2 2-hydroxylation (a reaction catalyzed by enzymes from the P-450IIC, P-450IIIA and P-450IIE gene families) and also the oxidative metabolism of other drug substrates (cyclosporin, diazepam, tolbutamide) by human liver microsomes. On coincubation with EE2 as substrate, GSD, 3-keto desogestrel (3-KD, the active metabolite of desogestrel) and LNG produced some concentration-dependent inhibition of EE2 2-hydroxylation (maximum 32% inhibition at 100 microM 3-keto desogestrel). Ki values determined for GSD and 3-KD were 98.5 +/- 12.3 and 93.2 +/- 10.3 microM (mean +/- SD; n = 4), respectively. Preincubation of progestogens in a small volume (50 microliters) incubation for 30 min in the presence of an NADPH-generating system enhanced the inhibitory potential of all the steroids (at 100 microM, inhibition was for GSD 39%, 3-KD 46%, LNG 46%, NET 51% and NORG 43%). Inhibitory effects were therefore comparable and also similar to the macrolide antibiotic troleandomycin. The most marked inhibition seen was of diazepam N-demethylation and hydroxylation by GSD (71 and 57%, respectively) and 3-KD (62 and 50%, respectively). In preincubation studies involving cyclosporin as the substrate, the order of inhibitory potency was GSD greater than 3-KD greater than NET greater than LNG for production of both metabolite M17 and M21. The results of the study indicate that all the progestogens in common use have the propensity to inhibit a number of oxidative pathways but there is little evidence for one progestogen being more markedly inhibitory than others.

Serological and epidemiological studies of hepatitis B and human immunodeficiency virus in a dialysis unit of Africa

Hepatitis B infection is endemic in the tropics. Human immunodeficiency virus infection might also be endemic in parts of Africa. Blood transfusion is a major risk factor in the transmission of either virus. Patients with end stage chronic renal failure undergoing dialysis receive multiple blood transfusions. Three of twelve haemodialysed patients in a renal unit were found to carry the hepatitis B surface antigen. No patient on continuous ambulatory peritoneal dialysis, no patient with a Kidney transplant bore that antigen. Five out of twelve haemodialysed patients and only one out of seven patients on continuous ambulatory peritoneal dialysis were positive for the hepatitis B surface antibody. No transplanted patient bore this antibody. This status remained unchanged for a year. Only one patient who initially was H.I.V. negative converted to positivity a year after.

Oral contraceptives stimulate the excretion of clofibric acid glucuronide in women and female rats

1. Glucuronidation of clofibric acid, the pharmacologically active form of the hypolipidemic drug clofibrate was investigated in a human population, either in vitro with liver homogenates from biopsies, or after ingestion of the drug and determination of the urinary metabolite. No difference in the glucuronidation rate according to age of the patients was observed. Bilirubin but not clofibric acid glucuronidation was significantly higher in women (106% increase), when expressed per gram of tissue. 2. The excretion of clofibryl glucuronide in women who took oral contraceptives was significantly enhanced by 25%. 3. In female rats, treatment with the contraceptive agent norethindrone also stimulated by 48% the formation of clofibrylglucuronide in liver microsomes.