Acute liver toxicity due to methylprednisolone: consider this diagnosis in the context of autoimmunity.

The occurrence of corticosteroid-induced hepatitis is a rare event that has been recently described in the literature. We report the case of an acute cytolytic hepatitis in a patient treated with methylprednisolone for multiple sclerosis associated with an autoimmune thyroid dysfunction. After ruling out other etiologies, we concluded that the acute liver injury was due to steroids, and we analyzed the specific circumstances in the literature where methylprednisolone may have been responsible for acute hepatitis.

Value of magnetic resonance cholangiography in the preoperative diagnosis of common bile duct stones.

OBJECTIVE: The aim of this study was to assess the performance of magnetic resonance cholangiography (MRC) in the preoperative diagnosis of choledocholithiasis. METHODS: A total of 147 consecutive patients underwent MRC for clinical and biological signs of common bile duct stones. ERCP was then carried out in 101 patients in whom there was a past history of cholecystectomy. The remaining 46 patients without a past history of biliary surgery underwent cholecystectomy and intraoperative cholangiography (IOC). The diagnosis obtained by MRC was compared with the final diagnosis established after endoscopic or surgical removal of calculi. RESULTS: A total of 113 patients had choledocholithiasis (single or multiple, including 15 cases of microlithiasis). There were no false-positive results with MRC. The false-negative results were caused mainly by small stones <3 mm in diameter, and to a lesser extent, cholangitis. Overall, the sensitivity was 93% and the specificity 100% for MRC in detecting common bile duct stones. The sensitivity and specificity of ERCP were respectively 94% and 100%, versus 93.5% and 93.3% for IOC. There was no statistically significant difference, however, between MRC and the other techniques. CONCLUSION: MRC is a key technique in the preoperative diagnosis of choledocholithiasis. Its diagnostic value is comparable to ERCP, but it appears to be more specific than IOC. Nevertheless, its diagnostic capability remains limited in cases of microlithiasis and cholangitis.

[Portal hypertension in a patient with hepatitic C revealing an iatrogenic arterioportal fistula]. / Hypertension portale chez un malade porteur d'une hépatite C, révélatrice d'une fistule artérioportale iatrogène.

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.

[Patients with alcoholic liver disease hospitalized in gastroenterology. A national multicenter study]. / Maladies alcooliques du foie hospitalisées en Hépato-Gastroentérologie. Enquête multicentrique nationale.

OBJECTIVES: To describe the characteristics of in-patients with alcoholic liver disease in Hepatogastroenterology and to evaluate whether geographic location was a risk factor for cirrhosis. METHODS: A French, national, multicenter, prospective investigation was performed in the last quarter of 1997. To be included in the study, patients had to have drunk at least 50 g of alcohol per day for the past year or to have cirrhosis. RESULTS: Seventeen centers included 802 patients, 20% had histologically proven cirrhosis or probable cirrhosis. Thirty-five percent had undergone liver biopsy. Twenty five percent of these patients had cirrhosis without acute alcoholic hepatitis and 37% had cirrhosis with acute alcoholic hepatitis. After dividing France along a Bordeaux-Strasbourg axis, there was more histologically proven or probable cirrhosis in the North (46%) than in the South (36%) (P<0.005) while daily alcohol intake was greater the South (150 +/- 6 g) than in the North (129 +/- 4 g) (P<0.0001). When the six variables (age, sex, daily consumption of alcohol over the past 5 years, presence of hepatitis B surface antigen and antibodies to hepatitis C virus, total duration of alcohol abuse) were considered together in stepwise logistic regression analysis, geographic location changed the prediction of cirrhosis. The odds ratio for cirrhosis in patients living to the North of the Bordeaux-Strasbourg axis was 1.9 (95% confidence interval range 1.1-3.2) (P<0.02), suggesting the role of nutritional factors.

Single-dose pharmacokinetics of amprenavir, a human immunodeficiency virus type 1 protease inhibitor, in subjects with normal or impaired hepatic function.

Amprenavir (141W94) is extensively metabolized by P450 cytochromes, specifically, CYP3A4. Because hepatic insufficiency reduces P450-mediated metabolism, the concentrations in plasma of drugs metabolized through this pathway are often increased in subjects with liver disease. Following administration of a single, oral dose of 600 mg of amprenavir, pharmacokinetic parameters were determined for 10 subjects with severe cirrhosis, 10 subjects with moderate cirrhosis, and 10 healthy volunteers. Model-independent methods for determining the area under the plasma concentration-time curve (AUC) from time zero to infinity (AUC(0-infinity)) showed an increase in amprenavir AUC(0-infinity) of 2.5-fold in the group with moderate cirrhosis and 4.5-fold in the group with severe cirrhosis compared with that in the control group of healthy volunteers (P < 0.05). AUC(0-infinity) was linearly related to the severity of liver disease, as assessed by the Child-Pugh score. Of the laboratory data used to calculate the Child-Pugh score, only the mean total bilirubin concentration showed a significant relationship with AUC(0-infinity). The relationship between the total bilirubin concentration and the AUC(0-infinity) of amprenavir was well characterized by a simple E(max) model, suggesting that the total bilirubin concentration may be a useful parameter for predicting the amprenavir AUC in subjects with hepatic insufficiency. Finally, the sera of cirrhotic subjects showed significant decreases in the levels of alpha(1)-acid glycoprotein, the primary plasma binding protein for amprenavir. On the basis of the results of this study, for an exposure equivalent to a clinical dose of 1,200 mg twice daily in subjects without cirrhosis, subjects with Child-Pugh scores of 5 to 8 should receive a twice-daily 450-mg dose of amprenavir, and subjects with Child-Pugh scores of 9 to 15 should receive a twice-daily 300-mg dose of amprenavir.

Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases.

OBJECTIVE: The aim of this study was to evaluate magnetic resonance cholangiography (MRC) in the diagnosis of biliary tree obstruction. METHODS: Fifty-eight consecutive patients underwent MRC (GYROSCAN ACS II 1.5 Tesla, TSE T2 axial/coronal-MIP sequences) for clinical and biochemical signs of main bile duct obstruction. MRC images were interpreted by two radiologists and consensus was established according to presence or absence of main bile duct dilation, choledocholithiasis, and malignant or benign stricture. MRC was compared to a final diagnosis established by ultrasound and CT in 19 cases, endoscopic retrograde cholangiopancreatography (ERCP) in 25, intraoperative cholangiography and exploration in 14, and clinical, biochemical, and histological presentation when relevant. Included were single or multiple choledocholithiasis (28, including 11 < or = 3 mm), malignant (10) and benign (12) strictures, and intrahepatic cholestasis (9). RESULTS: Overall, MRC was sensitive (94%) and specific (92%) in detecting main bile duct dilation and choledocholithiasis (86 % and 97 %), but was less sensitive (64%) for small stones < or = 3 mm. Sensitivity for stones > 3 mm was 100%. For benign and malignant strictures, MRC was less sensitive (67% and 80%) but remained specific (98% and 96%). In the detection of normal main bile duct, MRC was highly sensitive (100%) and specific (94%). Diagnostic accuracy ranged from 91% to 98%. CONCLUSION: MRC appears to be specific for choledocholithiasis and sensitive except for small stones. Results for biliary stricture are less satisfactory, but remain specific. Our data confirm that MRC can be useful in the diagnostic workup of main bile duct obstruction.

[A case of digestive epilepsy with late diagnosis: a disease not to be disregarded]. / Un cas d"épilespie digestive de diagnostic tardif: une pathologie à ne pas méconnaître.

Digestive epilepsy is a rare disease, poorly recognized by gastroenterologists. Its diagnosis requires a compatible clinical presentation, the absence of concomitant organic digestive disease, and an effective and long-lasting response to specific anticonvulsant agents. We report a case of digestive epilepsy due to a meningioma of the right parietal lobe in a 79-year-old woman suffering from headaches, vertigo, sweating and abdominal pain for at least 14 years. Initial diagnosis was irritable bowel syndrome. A meningal syndrome led to neurological work-up showing cerebral meningioma. The recurrent paroxysmal abdominal pain was interpreted as manifestations of digestive epilepsy, and effective and long-lasting treatment was obtained with carbamazepine. After analysis of the determining elements in this case, the epidemiology, pathophysiology, diagnostic work-up, therapy, and differential diagnosis of digestive epilepsy are discussed.

[Use of a medium and long chain triglyceride mixture for parenteral nutrition in a university hospital: results of an internal audit]. / Utilisation d'un mélange de triglycérides à chaînes longues et chaînes moyennes pour la nutrition parentérale en hôpital universitaire. Résultats d'un audit interne.

OBJECTIVES: The aim of this study was to determine whether a medium and long chain triglyceride mixture for parenteral nutrition is used in accordance with indications and contraindications in hospital practice. METHODS: Patient data recorded in 30 consecutive patients included illness, nutritional status, laboratory findings before nutrition as well as indications and contraindications for parenteral nutrition. RESULTS: When expressed in g.kg-1.day-1 maximal recommended doses of the mixture were exceeded in 32% but there was no excess when expressed in g.kg-1.hr-1. Serious hepatic insufficiency was present in 11% of the patients, 38% had hypertriglyceridemia and one had serious coagulopathy. There were 3 contraindications for the mixture. CONCLUSION: Indications for using this emulsion were respected, but there were contraindications in 45% of the cases. These contraindications are however questionable as is the daily dosage. Because the mixture seems better for use in many cases of parenteral nutrition, it would appear best to discuss the prescription case by case.

Dual-energy CT in the diagnosis and quantification of fatty liver: limited clinical value in comparison to ultrasound scan and single-energy CT, with special reference to iron overload.

BACKGROUND/AIMS: It has been suggested that dual-energy CT could differentiate irregular fatty liver from other hypodense lesions. We compared dual-energy CT to ultrasound scan and single-energy CT in the diagnosis and quantification of fatty liver, with special reference to iron overload. METHODS: Twenty-seven patients were included according to ultrasound: fatty liver (n=16) and normal liver (n=11). Single and dual-energy CT were performed. Attenuation measurements of hepatic lobes and control tissues were taken at 140 kV and 80 kV CT-guided liver biopsy was done in fatty liver patients, the degree of infiltration was estimated, and the histologic iron overload determined (iron overload, n=11; iron-free, n=5). RESULTS: The mean changes in attenuation for the right hepatic lobe were: normal liver: -0.8 (ns); iron overloaded fatty liver: 1.5 (ns); and iron-free fatty liver: 7.7 (p<0.0053). A spleen-liver attenuation differential threshold of 12H (140 kV, single-energy CT) and a right hepatic lobe 140 kV to 80 kV attenuation differential threshold of 9 H (dual-energy CT) were specific for fatty liver. Histology confirmed all cases of fatty liver diagnosed by ultrasound, independently of iron overload. Ultrasound did not differentiate cases of irregular from diffuse fatty liver detected on CT. Iron overload produced a masking effect in CT, decreasing its sensitivity: fatty liver was diagnosed in 67% of cases by single-energy CT and in 20% by dual-energy CT. Degree of fatty infiltration correlated with single-energy CT. CONCLUSIONS: Ultrasound diagnosed fatty liver best. Single-energy CT quantifies fatty infiltration, and best differentiates the irregular from the diffuse forms. Dual-energy CT is limited by poor sensitivity, especially in iron overload.

Recurrence of biliary drug lithiasis due to dipyridamole.

The occurrence of drug-containing gallstones is not often observed. To our knowledge, three drugs have so far been incriminated-ceftriaxone, glaphenine, and dipyridamole. This report presents the case of an 85-year-old woman who developed a recurrent drug-containing gallstone caused by dipyridamole eighteen months after a previous stone had been removed endoscopically.

[Ultrasonographic aspect of the rectal wall in liver cirrhosis]. / Aspect échographique de la paroi rectale au cours de la cirrhose.

The aim of this study was to assess the ultrasonographic abnormalities of the rectal wall and surrounding structures in patients with cirrhosis and to correlate these findings with endoscopy. From November 1992 to May 1993, 53 cirrhotic patients and 30 control subjects were examined by transrectal ultrasonography and rectoscopy. In addition to rectoscopy and transrectal ultrasonography, patients with cirrhosis underwent an upper gastrointestinal endoscopy. Ultrasonography abnormalities of the rectum were detected in 32 cases of cirrhosis (60.5%): a) in 21 cases the rectal wall thickness was greater than 5 mm and the sub-mucosa was thickened ( > or = 2 mm) and dissected by thin echo-free elements; b) the remaining 11 patients presented, in addition to the previously described abnormalities, rounded elongated echo-free structures surrounding the rectum which were not found in the control group. All these 11 patients had rectal varices at rectoscopy. In the group of cirrhotic patients, rectoscopy showed abnormal dilated veins in 23 cases (43.5%) and rectal varices in 11 cases. Ultrasonographic and endoscopic abnormalities of the rectum were more often visualized in the group of cirrhotic patients than in the control group (P < 0.001). In patients with cirrhosis, the demonstration of rectal varices was associated with transrectal ultrasound abnormalities (P < 0.01), and in particular peri-rectal vascular formations. In cases of cirrhosis the rectal wall abnormalities were not associated with gastric varices at endoscopic inspection but were linked with large esophageal varices or gastric mucosal abnormalities demonstrated on endoscopy (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Terlipressin plus transdermal nitroglycerin vs. octreotide in the control of acute bleeding from esophageal varices: a multicenter randomized trial.

We undertook a multicenter randomized trial to compare the efficacy of terlipressin combined with transdermal nitroglycerin and that of octreotide in the emergency control of acute variceal hemorrhage in cirrhosis. Over 16 mo, 87 patients with endoscopically proved active bleeding from esophageal or cardiac varices were enrolled in five centers in France and randomly assigned to receive intravenous terlipressin (2 mg and then 1 mg/4 hr over 24 hr) and transdermal nitroglycerin (10 mg/12 hr over 24 hr) (group 1) or octreotide (continuous intravenous infusion of 25 micrograms/hr over 12 hr and then 100 micrograms at hr 12 and hr 18 subcutaneously) (group 2). Initial control of bleeding was assessed at the end of 12 hr of treatment on the basis of stability of blood pressure and hematocrit level with no further transfusion requirements. At 12 hr, bleeding was controlled in 59% (24 of 41) in group 1 and 78% (36/46) of group 2 patients (Fisher's exact test, p = 0.064). Mean transfusion requirements over this 12-hr period were significantly greater in group 1 (three blood units; range = 0 to 13) than in group 2 (one blood unit; range = 0 to 5) (p = 0.002). After the first 12 hr, 20% of patients (5 of 24) had repeat bleeding in group 1 compared with 27% (10 of 36) in group 2. During the first 48-hr period, five patients (12%) died in group 1, compared with 3 (6%) in group 2. Few side effects were noted in either group. However, in group 1 two patients experienced severe bradycardia; it resulted in death in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Physicochemical and bacteriological analysis of the contents of occluded biliary endoprostheses.

The deposits obstructing 12 biliary endoprostheses were examined by scanning electron microscopy and analyzed quantitatively by Fourier transform infrared spectroscopy. Calcium palmitate and bilirubinate associated with proteins were found in all the deposits. Apart from the small amount of cholesterol, this composition closely resembled that of brown pigment gallstones and suggested an infectious cause. Facultative aero-anaerobic organisms were found on bacteriological investigation. beta-Glucuronidase activity was only detected in one sample, suggesting that the calcium bilirubinate may have been formed through tissue glucuronidases. In our study, deposit formation was thought to have been caused by the action of bacterial phospholipases (although not measured) rather than beta-glucuronidases.

[Recto-colonic and hepatic involvement in graft-vs-host disease after bone marrow transplantation]. / Atteinte recto-colique et hépatique lors de la réaction de greffon contre l'hôte aprés une greffe de moelle osseuse.

We report the case of a child suffering from a graft versus host disease after an allogenic bone marrow transplantation. He developed intestinal, hepatic and cutaneous symptoms. The outcome after treatment was favorable with a total normalization.