Epidemiology of chronic hepatitis B infection in France: risk factors for significant fibrosis--results of a nationwide survey.

BACKGROUND: Epidemiological data concerning hepatitis B are scarce in France. AIM: To describe epidemiological, clinical, virological and histological features of HBsAg-positive patients followed at non-academic hospitals in France. METHODS: Clinical, biological, virological and histological data of all HBsAg-positive consecutive patients observed from April 1, 2001 to May 31, 2002 in participating centres were recorded prospectively. Multivariate analyses of factors associated with significant fibrosis and cirrhosis were performed. RESULTS: Nearly 1166 HBsAg-positive patients were seen in the 58 centres: 671 males and 495 females from metropolitan France (32%) and from outside metropolitan France (68%); mean age 41 +/- 15 years. Twenty-nine percent of patients were probable HBsAg inactive carriers, while 50% had chronic hepatitis; 43% of these were HBeAg-positive and 57% HBeAg-negative. Liver biopsy had been performed in 558 (51%) patients; 205 (17.6%) patients had cirrhosis. By multivariate analysis, factors associated with significant fibrosis were: age >40 years (P < 0.05), HBeAg-negative status (P < 0.02) and histological activity (P < 0.0001). Factors associated with cirrhosis: age (P < 0.0001), platelet count <150 000/mm(3) (P < 0.0001) and viral co-infection (P < 0.03). CONCLUSION: HBV infection represents a significant workload for hepatogastroenterologists at non-academic hospitals in France.

Prolonged interferon-alpha therapy of hepatitis B virus-related decompensated cirrhosis.

Interferon alpha therapy of hepatitis B virus-related decompensated cirrhosis with the dose and the duration generally used is frequently associated with severe side-effects and reactivations. Between 1989 and 1996, 15 patients with hepatitis B virus-related decompensated cirrhosis received prolonged (3-48 months) low-dose (3 million units) IFN-alpha therapy. Ten patients (66%) had a sustained loss of serum hepatitis B virus DNA and hepatitis Be antigen (if present initially) associated with a decrease of aminotransferase levels into the normal range. During follow-up of these 10 patients, seven had a marked clinical improvement and are alive and fully active. One has an hepatocellular carcinoma, and two died without reactivation. Among the five other patients, two had a transient loss of serum HBV DNA followed by reactivation and three did not respond to therapy. During follow-up, one of these five patients died and one underwent liver transplantation. Severe complications, possibly related to interferon were uncommon and included bacterial infection in one case and variceal bleeding in two cases. Eleven of the 15 patients treated are alive after 1.5-7 years of follow-up. Hence, in patients with hepatitis B-related cirrhosis, prolonged low-dose IFN-alpha therapy is relatively well tolerated and may induce a sustained inhibition of hepatitis B virus replication with marked clinical improvement.

[Treatment of a hemorrhagic duodenal varice by endoscopic sclerotherapy]. / Traitement par sclérothérapie endoscopique d'une varice duodénale hémorragique.

We report the case of a duodenal varix rupture in a 37-year-old man revealing an alcoholic cirrhosis. Endoscopic diagnosis of this duodenal varix was difficult because of its atypical and changing appearance. Endoscopic sclerotherapy was completely successful and there was no recurrent bleeding. Although duodenal varix is rare, this case and the literature emphasize the importance of considering this diagnosis in all patients with duodenal tumoral lesions and suspected portal hypertension. In this context, duodenal biopsy can be dangerous and should be avoided. In case of duodenal varix rupture, endoscopic sclerotherapy appears to be a safe and efficient first-choice therapy.

[Endoscopic diagnosis of a biliodigestive fistula of tuberculous origin revealing acquired immunodeficiency syndrome]. / Diagnostic endoscopique d'une fistule bilio-digestive d'origine tuberculeuse révélatrice d'un syndrome d'immunodéficience acquise.

We report the case of a 32-year-old Malian man with abdominal tuberculosis revealing acquired immunodeficiency syndrome. A gastroscopy was made for epigastric pain and showed caseum in a digestive fistula with acid fast bacilli. Mycobacterium tuberculosis infection was confirmed by sputum culture. An early antituberculous therapy was prescribed. Outcome was good with rapid fistula closing and slower mass diminution of the abdominal lymph nodes. This case report confirms nodal tuberculosis as a possible cause of digestive fistulae. Rapid endoscopic diagnosis of this tuberculous fistula led to diagnosis of acquired immunodeficiency syndrome and early adapted medical treatment without invasive diagnostic methods.

Adenine arabinoside 5'-monophosphate in patients with chronic hepatitis B: comparison of the efficacy in patients with high and low viral replication.

This study compared the response to adenine arabinoside 5'-monophosphate (ARA AMP) in 60 patients with chronic hepatitis B according to the pretreatment serum hepatitis B virus DNA concentration. The level of hepatitis B virus replication was defined as low (30 patients) or high (30 patients) when serum hepatitis B virus DNA concentration was below or above 100 pg/ml, respectively. Patients received a 28 day course of ARA AMP and a second course of ARA AMP was given six months later to patients with persistent hepatitis B virus replication. At the end of the first course of ARA AMP, 11 of the patients (37%) with low replication and one of the patients (3%) with high replication became negative for hepatitis B virus DNA (p = 0.0012); five of the patients (17%) with low replication and none of the patients with high replication had HBe seroconversion (p = 0.06). Two of these five patients lost HBsAg. Kinetics of serum hepatitis B virus DNA during treatment showed a considerable but transient antiviral effect of ARA AMP. Three of 32 retreated patients became negative for hepatitis B virus DNA and one patient had HBe seroconversion. In conclusion, ARA AMP exerts a considerable but transient antiviral effect on hepatitis B virus. Complete and sustained inhibition of hepatitis B virus replication was only obtained in the patients with low hepatitis B virus replication.

[Hyperthyroidism: a possible factor of cholestasis associated with hyperemesis gravidarum of prolonged evolution]. / L'hyperthyroïdie: un facteur possible de cholestase associée aux vomissements gravidiques incoercibles d'évolution prolongée.

We report two cases of hyperemesis gravidarum with hyperthyroidism and jaundice. The cessation of vomiting associated with supportive care was followed by complete recovery in 5 weeks. Hyperthyroidism occurs in 60% of hyperemesis gravidarum, but jaundice is uncommon. The association of jaundice and hyperthyroidism suggests that hyperthyroidism is a possible factor of cholestasis in patients with hyperemesis gravidarum.

[Bone condensation and enterocolitis: SAPHO syndrome. Apropos of a case]. / Condensation osseuse et entérocolite: un SAPHO. A propos d'une observation.

A new case of SAPHO syndrome with lesions confined to the spine and concomitant enterocolitis reported. Only eight cases of this rare combination have been published to date. Bone involvement consisted in sclerosis of vertebral bodies of T10 and T11, raggedness of the vertebral plateaux from T7 to T10, and thick syndesmophytes bridging the vertebrae from T7 to T11. Erythrocyte sedimentation rate was 108 in one hour. Systemic corticosteroids were given after failure of nonsteroidal antiinflammatory agents and recurrence of iritis. Pain resolved promptly and the erythrocyte sedimentation rate returned to normal. This case is unusual both because this combination of diseases is rare and because virtually complete resolution of vertebral sclerosis was noted after one year of corticosteroid therapy. Possible relationships between the SAPHO syndrome and the group of spondylarthropathies are suggested and discussed.

Coagulation assays as diagnostic markers of hepatocellular carcinoma.

With the aim of improving the biological diagnosis of hepatocellular carcinoma (HCC), alpha-fetoprotein (AFP), des-gamma-carboxyprothrombin (DCP) and factor V levels were assayed in 119 patients with HCC and 60 cirrhotic patients without HCC. Among the patients with HCC, increased levels of AFP (greater than 300 ng/ml) and of DCP (greater than 15 mU/ml) were observed in 36% and 69% of the cases, respectively. None of the 60 patients without HCC had increased AFP, and one had abnormal DCP; in this patient, DCP level returned to normal value after vitamin K1 injection. No significant correlation was found between increased AFP and DCP, thus indicating that the two tests complement each other for the diagnosis. A factor V level higher than expected from the reduced prothrombin time test of the patient was detected in 50% of patients with HCC and only 7% of those without HCC. No correlation was found between increased factor V and abnormal AFP or DCP. The thrombin time, fibrinogen activity to antigen ratio, and polymerization index failed to differentiate between cirrhosis and HCC. We conclude that AFP, DCP and factor V may give complementary informations in the diagnosis of HCC, one of these markers at least being positive in 88% of the patients.

[Hepatitis probably caused by Plethoryl. Apropos of 7 cases]. / Hépatites probablement dues au Pléthoryl. A propos de 7 observations.

Seven patients developed acute hepatitis after receiving Plethoryl for obesity for 4 to 16 weeks. Jaundice was generally associated with or preceded by asthenia, nausea and pruritus. Serum aminotransferase activities were markedly increased whereas alkaline phosphatase and gamma-glutamyltransferase activities were moderately elevated. There was no hepatic failure. In all cases, Plethoryl administration was promptly discontinued. In 6 cases, jaundice disappeared within 2 to 4 weeks, and recovery occurred within 2 to 5 months. In one case, however, jaundice disappeared within 12 weeks and recovery took 10 months.

Specificity of increased des-gamma-carboxyprothrombin in hepatocellular carcinoma after vitamin K1 injection.

The des-gamma-carboxyprothrombin (DCP) level was found to be increased in the majority of hepatocellular carcinomas (HCC). This increase has to be distinguished from an increased DCP level linked to a vitamin K deficiency. We studied the evolution of increased DCP level in 6 patients with histologically proven HCC and in 10 without HCC after slow injection of 20 mg of vitamin K1. The DCP assays performed subsequent to the vitamin K1 injection showed: first, a durable normalisation of the DCP level in the patients without HCC, suggesting that the increased DCP was linked, in them, to an underlying vitamin K deficiency; second, a transitory decrease followed by a return to the abnormal level in the patients with HCC. We can conclude that an increased DCP level which persists following vitamin K1 injection is specific for HCC. The minimal delay for the DCP assay after vitamin K1 injection seems to be 15 days.

[Intrahepatic collections of fluid of pancreatic origin. A case]. / Collections liquidiennes intra-hépatiques d'origine pancréatique. Une observation.

A case of intrahepatic liquid collections of pancreatic origin is reported. A search in the literature yielded 8 cases of pancreatic pseudocysts which developed in the liver left lobe. The present case was original owing to its localization in the right hepatic lobe, to the large volume of the intrahepatic effusions and to the scarcity of underlying pancreatic symptoms. Ultrasonography and computerized axial tomography were useful aids to the diagnosis as well as to the therapeutic procedures. Surgery, which usually is a matter of discussion in chronic pancreatitis, was necessary to obtain the favourable outcome expected in such diseases.

Myeloid metaplasia, perisinusoidal fibrosis, and nodular regenerative hyperplasia of the liver.

We describe two patients with myeloid metaplasia in whom portal hypertension resulted, not from infiltration of the liver sinusoids by myeloid cells, but from perisinusoidal fibrosis and nodular regenerative hyperplasia of the liver. We hypothesize that myeloid metaplasia induced the development of perisinusoidal fibrosis, which resulted in heterogeneous hepatic tissue blood perfusion, with atrophy of the liver cells in the underperfused areas and nodular regenerative hyperplasia in the normally perfused areas.

[Irregular hepatic steatosis. Ultrasonic and computed x-ray tomographic aspects]. / Stéatose hépatique irrégulière. Aspects échographiques et tomodensitométriques.

A 39-year-old moderately obese and alcoholic man complained of abdominal pain and nausea. An ultrasound examination of the liver showed large hyperechoic areas surrounding a limited pseudotumorous zone of relatively decreased echogenicity. CT scan showed a decreased density (35 UH) in the hyperechoic areas, suggesting fatty liver which was confirmed histologically; conversely, the hypoechoic area appeared normal on CT scan. Six months later, after reduction of caloric intake and cessation of alcohol ingestion, ultrasound examination and CT scan of the liver were normal.