[Hemoperitoneum supporting difficult diagnosis of diffuse hepatocarcinoma in liver cirrhosis]. / L'emoperitoneo quale supporto di una diagnosi non agevole di epatocarcinoma diffuso su cirrosi epatica.

The cases of two patients with liver cirrhosis HCV-related, admitted in our Department in consequence of the development of ascites, anemia and clinical deterioration, are reported. Both patients had all major risk factors for hepatocellular carcinoma and anamnestic and physical findings suggesting this diagnosis; nevertheless, the alpha-1-fetoprotein serum levels and the ultrasonographic findings were not diagnostic for primary hepatic neoplasm. Explorative paracentesis was diagnostic, demonstrating the presence of hemoperitoneum (the hematocrit ratio in the ascitic fluid was 12 and 10, respectively). Magnetic resonance revealed extensive diffuse hepatocellular carcinoma on both cases. Hemoperitoneum, in patients with liver cirrhosis, in face of non diagnostic levels of alpha-1-fetoprotein and ultrasonographic findings, can be indicative of the spontaneous rupture of a diffuse type of hepatocellular carcinoma.

[Spontaneous bacterial peritonitis in liver cirrhosis. What tests to perform on the ascitic fluid?]. / La peritonite batterica spontanea nella cirrosi epatica. Quali esami sull'ascite?

Spontaneous bacterial perionitis (SBP) is a relatively frequent complication of liver cirrhosis and is associated with a high mortality if not early recognized and immediately treated. The text-books of Medicine available in Italy suggest the use of traditional laboratory tests (gravity, total protein concentration, Rivalta's test) to whom add white blood cell count for the assessment of the nature transudative (not infected) or exudative (infected) of ascitic fluid; nevertheless, in every day clinical practice, the association between total protein concentration and type of ascitic fluid may be misleading with respect to the diagnosis of SPB. The aim of this retrospective study, undertaken on 86 patients with liver cirrhosis consecutively admitted and separated in two groups, one without and the other with PSB (white blood cell count > 500/mm3), was to identify criteria for diagnosis of PSB. The traditional laboratory tests were significantly different in the two groups but Rivalta's test. Yet, none of them showed a diagnostic measurement sufficient for the use in the diagnosis of PSB (positive predittive value: gravity 41%, Rivalta's test 36%, total protein concentration 40%). The results of this work show the traditional laboratory tests unable to define the nature of the ascitic fluid. For the diagnosis of PSB the only reliable parameter is the white blood cell count.

[Roxatidine in the treatment of gastroduodenal mucosal lesions in hepatic cirrhosis]. / La roxatidina nel trattamento del danno mucoso gastroduodenale in corso di cirrosi epatica.

In about 50% of patients with liver cirrhosis, upper digestive bleeding is not due to oesaphageal varices rupture, but to a group of peculiar mucosal lesions usually referred as "congestive gastropathy" and "hepatogenic ulcer". The pathogenesis of such mucosal damage is still unclear: an important causative role is commonly thought to be played by portal hypertension, but the role of peptical pathway and of the mucosal barrier impairment must not be underscored as well. Aim of this study was to evaluate the effect of roxatidine in the long-term treatment of mucosal damage in 19 patients with liver cirrhosis. Patients showed a good tolerance and no side effects. The improvement of endoscopic pattern after a three months period of roxatidine therapy was statistically significant; moreover there was no occurrence of digestive bleeding. In conclusion, H2 antagonist may be considered as the drug of choice for the treatment of mucosal damage in patients with liver cirrhosis, for both its safety and effectiveness.

Impairment in dating and retrieving remote events in patients with early Parkinson's disease.

Remote memory has been studied in a group of 25 non-demented patients with Parkinson's disease and their performance has been compared with that of 22 healthy control subjects. Only patients who scored > or = 27 on the mini mental state examination and with no anticholinergic treatment were included in the sample. A remote memory questionnaire was given, to evaluate memory for public events that occurred from 1966 to 1990. Each event was probed with five questions concerning its content and one for the date. Compared with healthy subjects, patients with Parkinson's disease were significantly impaired both in recalling the content and in dating remote events. These results support the claim that remote memory in patients with Parkinson's disease is disrupted independently of dementia. This impairment might result from a dysfunction at the level of the circuit connecting the basal ganglia to the frontal lobes.

Value of the measurement of portal flow velocity in the differential diagnosis of asymptomatic splenomegaly.

AIM AND METHODS: This prospective study was carried on 20 patients (10 with liver cirrhosis and 10 with myelo-lymphoproliferative disorders), consecutively admitted to our ward for splenomegaly and thrombocytopenia, with the aim of evaluating the ability of Duplex-Doppler ultrasonography (DDUS) to discriminate between congestive splenomegaly and enlarged spleen caused by haematological disorders. RESULTS: Comparing the clinical/laboratory and DDUS findings for the two groups, it emerged that maximum-portal flow velocity (PFV) values revealed the most statistically significant differences: 17.31 SD 2.48 vs. 28.27 SD 3.53 (cm/s, P < 0.001). Discriminant analysis showed that max-PFV is the variable which by itself maximizes the separation between the two groups (F = 71.56; P < 0.0001). The patients with congestive splenomegaly exhibited lower max-PFV than the controls (17.31 SD 2.48 vs. 26.29 SD 2.38 cm/s, P < 0.001), unlike those with haematological diseases, whose max-PFV values were greater, albeit not significantly so (28.27 SD 3.53 vs. 26.29 SD 2.38 cm/s, P = 0.161). CONCLUSIONS: DDUS assessment of portal haemodynamics thus proved useful in the differential diagnosis of splenomegaly in asymptomatic patients since it distinguishes rapidly and non-invasively between congestive and haemotological splenomegaly. A lower-than-normal max-PFV value indicates congestive splenomegaly; a highish value, on the other hand, suggests a splenomegaly of haematological origin.

A case of hepatocellular carcinoma that resisted identification.

The case of a 70-year-old man with clinically-compensated alcoholic liver cirrhosis is illustrated. His serum alpha-fetoprotein level was on the increase but Ultrasonography and Magnetic Resonance detected no focal lesion of the liver. Five months after Ultrasonography, Computed Tomography and Magnetic Resonance were performed because the patient's alpha-fetoprotein level indicated hepatocellular carcinoma, but none of these tests succeeded in locating the neoplasm. Digital subtraction angiography was performed and only then was a small hepatocellular carcinoma revealed under the diaphragm. The patient underwent transcatheter arterial chemo-embolization with the result that the alpha-fetoprotein level dropped immediately and is still normal after 15 months. The case described is a model of what the ideal function of a marker of neoplasia should be, namely early detection, and subsequent precise confirmation of the continuing efficacy of the treatment adopted.

MRI of hepatocellular carcinoma before and after transcatheter chemoembolization.

OBJECTIVE: Magnetic resonance imaging of hepatocellular carcinomas (HCCs) was performed before and after transcatheter arterial chemoembolization (TACE). The changes of tumor signal intensity were compared to residual tumor or tumor recurrence in the follow-up period. MATERIALS AND METHODS: Fifteen cirrhotic patients with HCC were studied. All patients were examined with MRI both before and 3 months after TACE. Requirement for the study was that all lesions were detectable by MR before TACE. RESULTS: Magnetic resonance imaging detected 31 tumors. The changes of tumor signal intensity were compared to residual tumor or tumor recurrence in the follow-up period. On T1-weighted (T1W) images before TACE, 16 tumors were hyperintense, 11 were isointense, and 4 were hypointense; on T2W images, 26 tumors were hyperintense, 5 were isointense, and none were hypointense. On T1W images 3 months after TACE, 8 tumors were hyperintense, 18 were isointense, and 9 were hypointense; on T2W images, 11 were hyperintense, 11 were isointense, and 9 were hypointense. All the tumors that became hypointense on T2W images after TACE did not recur on follow-up. All lesions that were still hyperintense on T2W images after TACE showed residual tumor during the follow-up. Among 11 tumors that were isointense on T2W images after TACE, 7 were hyperintense on T2W images before TACE; 6 of these did not recur. Four tumors were isointense on T2W images before and after TACE; 2 of these showed residual tumor in the follow-up. On T2W images after TACE, 15 of 16 HCCs that decreased in signal intensity did not recur on follow-up. On T1W images no correlation was seen between the changes of the signal intensity of the lesion and tumor recurrence in the follow-up; however, 9 of 17 HCCs that did not recur after TACE showed decreased signal intensity. All the tumors (10 of 10) with decreased signal intensity on both T1W and T2W images after TACE did not show tumor recurrence on follow-up. CONCLUSION: The results suggest that MRI is useful in the assessment of the therapeutic effect of TACE in HCC.

Does the measurement of portal flow velocity have any value in the identification of patients with cirrhosis at risk of digestive bleeding?

Upper gastrointestinal bleeding is a leading cause of death in patients with liver cirrhosis. In most cases haemorrhage originates from oesophageal varices or from congestive gastropathy, and the evaluation of the bleeding risk is based on oesophagogastroduodenoscopic data. The aim of this prospective study was to determine whether the measurement of portal flow velocity by Duplex-Doppler, compared with endoscopic data, can help in detecting patients with cirrhosis at risk of bleeding. One hundred and seventy-three patients underwent endoscopy to ascertain the size of the varices and the severity of congestive gastropathy. For each patient maximal portal flow velocity measurements were obtained. No difference in portal flow velocity was observed between patients with or without oesophageal varices or congestive gastropathy. During a 2-year observation period, 27 patients (15.6%) had at least one episode of acute digestive bleeding. Stepwise multiple logistic regression analysis demonstrated a correlation between oesophageal varices and congestive gastropathy endoscopic grading and the incidence of bleeding; only the former was entered into the final regression equation (p < 0.001). No relationship between the max portal flow velocity value and incidence of bleeding was found. This study shows that portal flow velocity is unrelated to the degree of the endoscopic abnormalities in patients with liver cirrhosis and that it has no value in the identification of patients with cirrhosis at risk of upper gastrointestinal bleeding.

Hereditary hemochromatosis in adults without pathogenic mutations in the hemochromatosis gene.

BACKGROUND AND METHODS: Hereditary hemochromatosis in adults is usually characterized by mutations in the HFE gene on the short arm of chromosome 6. Most patients have a substitution of tyrosine for cysteine at position 282 (C282Y). We studied a large family from Italy that includes persons who have a hereditary iron-overload condition indistinguishable from hemochromatosis but without apparent pathogenic mutations in the HFE gene. We performed biochemical, histologic, and genetic studies of 53 living members of the family, including microsatellite analysis of chromosome 6 and direct sequencing of the HFE gene. RESULTS: Of the 53 family members, 15 had abnormal serum ferritin levels, values for transferrin saturation that were higher than 50 percent, or both. Thirteen of the 15 had elevated body iron levels, diagnosed on the basis of the clinical evaluation and liver biopsy, and underwent iron-removal therapy. The other two, both children, did not undergo liver biopsy or iron-removal therapy. None of the 15 members had the C282Y mutation of the HFE gene; 5 of the 15 (as well as 5 healthy relatives) had another mutation of this gene, a substitution of aspartate for histidine at position 63, but none were homozygous for it. No other mutations were found after sequencing of the entire HFE gene for all family members. Microsatellite analysis showed no linkage of the hemochromatosis phenotype with the short arm of chromosome 6, the site of the HFE gene. CONCLUSIONS: Hereditary hemochromatosis can occur in adults who do not have pathogenic mutations in the hemochromatosis gene.