Non-alcoholic fatty liver disease among adult survivors of severe acute malnutrition

OBJECTIVE: To investigate whether malnutrition survivors had more liver fat than controls and whether marasmus survivors (Ms) had more liver fat than kwashiorkor survivors (Ks). SUBJECTS AND METHODS: We traced 726 of 1336 adults admitted to hospital as infants with a diagnosis of severe acute malnutrition. We used birthweight (BW) from hospital records and measured anthropometry, body composition (DEXA) and liver fat using single, crosssectional computed tomography (CT) scanning at T12/L1 vertebrae. Data were analysed using multivariate line arregression. RESULTS: We studied 45 Ms, 43 Ks and 84 age-, gender and body mass index (BMI)-matched controls (age 29.0 ±8.4 years, BMI 23.5 ± 5.0 kg/m2). Using LS ratio, malnutrition survivors had less liver fat than controls (1.3± 0.2 vs 1.2 ± 0.9, p = 0.03). Marasmus survivors had lower BW than Ks (-0.51 kg; p = 0.02), were younger (p =0.02), had smaller waists (p = 0.03), were thinner (p =0.01) and had less body fat (p = 0.05) compared to Ks.Marasmus survivors had more liver fat than Ks after adjusting for age, gender and BW (â = -2.62, SE = 1.23; p= 0.03). Lower BW infants had less liver fat after adjusting for diagnosis (â = -1.51, SE = 0.76; p = 0.04). CONCLUSION: Fatty liver occurs at lower BMI in Ms compared with Ks; this difference is likely due to both prenatal and postnatal factors acting independently. While further studies are needed to understand the mechanisms involved, our data suggest the need to monitor infants exposed to severe acute malnutrition beyond the acute episode.

Management of nonparasitic hepatic cysts

We congratulate Mazza and colleagues for a comprehensive article on their 17-year experience treating nonparasitichepaticcysts (NPHC). Although some mention was made of malignant cystic neoplasms in their reference to the use of tumor markers in the diagnostic workup, as well as the radiologic appearance of irregular, thickened cystic walls, we feel that this important component of cystic hepatic lesions was not sufficiently emphasized. After all, the title of the article is "Management of NPHC," and the consequence of missing a malignant lesion can be catastrophic. Intrahepatic biliary cystadenoma (IBCA) is one of the most common premalignant cystic hepatic lesions, accounting for approximately 5% of all symptomatic cystic lesions. The typical ultrasonographic feature of an IBCA is that of a solitary, multiloculated cyst; whereas the computed tomography scan appearance reveals thin, internal septae. Magnetic resonance imaging shows gadolinium enhancement of the septae. Elevated levels of CA 19-9 in the cystic fluid has also been shown to differentiate between benign and malignant lesions. It would therefore be quite interesting to know the radiologic features of the 7 patients diagnosed with cystic neoplasms by Dr Mazza and his team and what specific measures they would recommend to exclude malignancy prior to embarking on definitive management.

Management of Hepatic cysts by percutaneous drainage and instillation of tetracycline hydrochloride

This paper reports two cases of benign hepatic cysts successfully treated by the instillation of tetracycline hydrochloride. The patients presented with solitary large symptomic hepatic cysts and underwent ultrasound guided needle aspiration followed by the instillation of tetracycline hydrochloride. The cyst size diminished without complication and the patients have remained symptom free. We review the treatment of this uncommon entity and propose that injection of tetracycline hydrochloride is an effective non-operative treatment of symptomatic solitary hepatic cysts. (AU)

Medical admissions of oncology patients to the University Hospital of the West Indies

A prospective study of 80 oncology patients (42 men, 38 women; mean age 50.3 years) admitted to the University Hospital of the West Indies, Jamaica, was conducted over a six month period (August 1, 1995 to January 31, 1996). There were 103 admissions representing 8.7 percent of total admission to the medical wards. Solid tumours and haematological malignancies accounted for equal proportions of admissions. 62 percent were emergency admissions. Investigation of constitutional symptoms, abnormal physical findings, infection and chemotherapy were the commonest reasons for admission. Complications developed in 42.7 percent of admissions, the commonest being renal and/or hepatic impairment: anaemia, leukopaenia and thrombocytopenia; and nosocomial infections. 35 percent of the patients died during the study period. The mean length of stay was 12.9 days (SD 12.8). Mean hospital stay was significantly longer in admissions involving an initial diagnosis of cancer and in those resulting in complications (p < 0.001).(AU)

Congenital solitary non-parasitic cyst of the liver

Although non-parasitic cysts of the liver have often been described in adults, solitary non-parasitic cysts are rare in infants. We report a 17-month-old child with a large hepatic cyst(AU)

Extraction of an hyperglycaemic principle from the annatto (Bixa orellana)

The red powdery extract from the seeds of the annatto, Bixa orellana, is a well known food colouring. In an oil suspension it is used as a folk remedy (bush tea) in the West Indies, for diabetes mellitus. Detailed investigations on this extract, yielded a methyl ester, trans-bixin, molecular weight 394 and molecular formula C24 H30 O4. This purified substance was demonstrated, in anaaesthetised mongrel dogs, to cause hyperglycaemia. Concomitant electron microscopy of tissues biopsies, revealed damage to mitochrondria and endoplasmic reticulum mainly in liver and pancreas. When dogs were fed on a diet fortified with riboflavin, there was neither demonstratable tissue damage nor associated hyperglycaemia. These findings point to: (i) the potential dangers of informal medications such as 'bush teas'; (ii) the possible role of plant extracts/food additives in the development of diabetes mellitus especially in the undernourished state. (AU)

Drug-induced acute liver disease

Fifty three patients with drug-induced acute liver disease are reported. There were 35 females and 18 males with a mean age of 41 years. All but one patient had jaundice or hyperbilirubinaemia and 51 had abnormal liver enzymes. Histologically 38 patients (72 percent) had cholestatic injury while 15 had cytotoxic parenchymal damage. Methyldopa, chlorpropamide, chlorpromazine, halothane and the contraceptive pill accounted for 60 percent of cases. Fifty one patients recovered after drug withdrawal while 2 died of hepatic failure. Drug-induced liver injury must be considered in patients presenting with evidence of hepatic disease as the majority will recover on withdrawal. (Summary)

Ultrasonic demonstration of portal vein occlusion

The ultrasonic detection of pre-sinusoidal portal vein obstruction is described in a patient with clinical features of alcoholic liver disease. The case illustrates the advantages of ultrasound in the evaluation of the portal circulation, including some unusual radiological observations of the portal circulation (AU)

Actinomycosis of the liver

We present our first case of actinomycosis in Trinidad and we believe this is also the first reported case of hepatic actinomycosis in the West Indies.(AU)

Hepatic artery ligation for spontaneous hepatic rupture in pregnancy

Spontaneous rupture of the liver is a rare complication of pregnancy. Although hepatic artery ligation has been suggested as a possible line of management for these patients, less than five cases of its successful utilization have been documented. A case is reported of a patient with spontaneous rupture of the liver in pregnancy who survived following right hepatic artery ligation. (AU)

Prevalence of liver abnormality in early syphilis

Hepatic structure and function of 22 unselected patients with early syphilis was assessed. In 20 (91 percent) routine hepatic tests or bromsulphalein retention showed mild non-specific abnormalties. Minor changes in hepatic structure were present in 12 (55 percent), in three of whom intrahepatic spirochaetes were found. The only patient who had hepatomegaly also had splenomegaly. Observed changes in hepatic structure correlated with neither physical signs nor results of biochemical tests. Hepatic changes in early syphilis are common but frequently subclinical (AU)

Drugs and the liver

Damage to the liver from exposure may be direct or indirect. Direct drug toxicity embraces a wide group of drugs of which the commonest are tetracyclines, alcohol, perhexidine maleate, carbon tetrachloride, methotlrexalte, isoniazid and paracetamol, but could include most poisons and insecticides. These all produce similar toxic changes in the liver, viz. fatty change of hepatocytes with centrizonal fibrosis. Indirect toxicity is an immunological type-related drug toxicity produced by way of toxic metabolites which bind with P450 enzyme systems to produce toxic acetylating agents, the toxicity of which is genetically determined. Prevention is always the preferable course. If direct type sensitivity occurs the offending drug should be discontinued. Support glutathione levels early by L-acetyl-cysteine. Anesthetists must monitor allergic reactions to anesthetics, particularly Halothane, and refrain from frequent unnecessary repetition of the drug otherwise tragic consequences could result. When investigating damage to the liver, renal consequences are often far more important for the patient's survival. (AU)

Laparoscopic liver biopsy

The value of laparoscopy in the evaluation of the surface appearance of the liver is described in 21 patients. Observed abnormalities may be biopsiedunder guidance and this is particularly helpful in suspected neoplastic involvement of the liver where disease of only the left lobe of the liver exists or when percutaneous needle biopsy has failed. Liver biopsy under laparoscopic vision usefully increases our diagnostic capacity (AU)

Herbal teas and toxins: novel aspects of pyrrolizidine poisoning in the United States

This article reviews the discovery of pyrrolizidine alkaloid poisoning in United States caused by the drinking of herbal tea and describes some of the difficulties involved in establishing a causal relationship between exposure to these alkaloids and the delayed appearance of toxic symptoms. In addition, some of the more general problems presented by the widespread use of herbs in various forms are addressed. First, however, a brief overview is given of the toxicity of this class of alkaloids. (AU)

Absence of liver toxicity in 2723 patients treated with hycanthone in St. Lucia

This report is submitted not to refute the occurence of any toxicity but to record that in St. Lucia, given reasonable care in administration and careful follow-up, we have not yet encountered jaundice, liver necrosis or other serious side effects.(Summary)

Spontaneous rupture of the liver in pregnancy

A case of spontaneous rupture of the liver is presented, including the first English Language report of hepatic resection for this condition. The aetiology, pathogenesis, diagnosis, and treatment is reviewed. Hepatic artery ligation, evacuation of the subcapsular haematoma, excision of Glisson's capsule and drainage is suggested as the best initial approach. Hepatic resection is reserved for patients in whom this fails (AU)