Fibrosis in Chronic Liver Disease: An Update on Diagnostic and Treatment Modalities.

Fibrosis is a common outcome of most chronic inflammatory diseases, characterized by the accumulation of excessive extracellular matrix components. Individuals with progressive liver fibrosis develop cirrhosis, are at risk of developing liver cancer, and may succumb to liver failure. Although a number of specific therapies for different diseases have been developed and successfully used, for example, direct antiviral agents in treatment for hepatitis C, effective and specific antifibrotic therapies are still not available. Liver biopsy remains the gold standard of staging liver fibrosis. However, transient elastography is increasingly being used in clinical trials and in hepatology clinics as part of standard-of-care evaluation because it is easy to use. Magnetic resonance (MR)-elastography is most accurate in evaluating fibrosis stage but is costly and time consuming and thus not readily available. Recent advances, however, have been made in areas of diagnostic and therapeutic modalities, with an increasing number of potential drugs currently in phase II and III trials, particularly in the field of non-alcoholic steatohepatitis-related liver fibrosis. These new drugs target multiple pathways involved in the pathogenesis of chronic liver disease, and we anticipate that some of them may soon be approved for use in patients.

[Viral Hepatitis: When to be Considered in Clinical Routine?] / Virushepatitis ­ wann daran denken?

Chronic viral hepatitis can remain unrecognized but may nevertheless lead to liver cirrhosis and hepatocellular carcinoma. Thus, patients with elevated liver enzymes as well as risk groups need to be screened and treated for viral hepatitis. These groups include, in particular, migrants from countries with high HBV or HCV prevalence, persons with previous or current intravenous drug use, and homosexual men. For HBV- or HCV-associated diseases, such as panarteriitis nodosa, cryoglobulinemic vasculitis or B-cell lymphoma, antiviral therapy may lead to remission. Prior to high-dose immunosuppressive therapy, especially with regimes containing rituximab, chronic or resolved HBV infection must be ruled out or antiviral prophylaxis may be required to avoid a potentially fatal HBV reactivation.

ACVIM consensus statement on the diagnosis and treatment of chronic hepatitis in dogs.

This consensus statement on chronic hepatitis (CH) in dogs is based on the expert opinion of 7 specialists with extensive experience in diagnosing, treating, and conducting clinical research in hepatology in dogs. It was generated from expert opinion and information gathered from searching of PubMed for manuscripts on CH, the Veterinary Information Network for abstracts and conference proceeding from annual meetings of the American College of Veterinary Medicine and the European College of Veterinary Medicine, and selected manuscripts from the human literature on CH. The panel recognizes that the diagnosis and treatment of CH in the dog is a complex process that requires integration of clinical presentation with clinical pathology, diagnostic imaging, and hepatic biopsy. Essential to this process is an index of suspicion for CH, knowledge of how to best collect tissue samples, access to a pathologist with experience in assessing hepatic histopathology, knowledge of reasonable medical interventions, and a strategy for monitoring treatment response and complications.

Factors associated with voluntary testing for HBV in the Upper West Region of Ghana.

This study examined the role of health facilities on testing for Hepatitis B virus in a policy context where screening is only available at a cost. We fitted multivariate multinomial logistic regression models to cross-sectional data (n = 1374) collected from Upper West Region of Ghana. The analysis showed that approximately 28% of respondents reported ever testing for HBV. Although source of healthcare influenced HBV testing, traders (RRR = 0.29, p ≤ 0.001) and farmers (RRR = 0.34, p ≤ 0.01) were significantly less likely to test voluntarily. Wealth generally predicted voluntary testing, although less so for mandatory testing. The findings highlight the need for free HBV services targeting the very poor, especially those who use community-level health facilities as their primary source of care.

Improving the hepatitis cascade: assessing hepatitis testing and its management in primary health care in China.

Objective: The study aimed to decentralize hepatitis testing and management services to primary care in China. Methods: A nationwide representative provider survey amongst community health centres (CHCs) using randomized stratified sampling methods was conducted between September and December 2015. One hundred and eighty CHCs and frontline primary care practitioners from 20 cities across three administrative regions of Western, Central and Eastern China were invited to participate. Results: One hundred and forty-nine clinicians-in-charge (79%), 1734 doctors and 1846 nurses participated (86%). Majority of CHCs (80%, 95% CI: 74-87) offered hepatitis B testing, but just over half (55%, 95% CI: 46-65) offered hepatitis C testing. The majority of doctors (87%) and nurses (85%) felt that there were benefits for providing hepatitis testing at CHCs. The major barriers for not offering hepatitis testing were lack of training (54%) and financial support (23%). Multivariate analysis showed that the major determinants for CHCs to offer hepatitis B and C testing were the number of nurses (AOR 1.1) and written policies for hepatitis B diagnosis (AOR 12.7-27.1), and for hepatitis B the availability of reproductive health service. Conclusions: Primary care providers in China could play a pivotal role in screening, diagnosing and treating millions of people with chronic hepatitis B and C in China.

Perfil clínico de pacientes portadores de hepatite B crônica / Clinical profile of patients with chronic hepatitis B

Objetivo: Conhecer as características e o perfil clínico dos indivíduos em tratamento de hepatite B crônica. Métodos: Participaram do estudo 65 pacientes com hepatite B crônica que iniciaram o tratamento entre os anos de 2010 a 2012. Resultados: Todos os pacientes eram da raça branca. Houve predomínio do sexo masculino (60%), e a maioria tinha entre 41 e 50 anos (32,8%). Grande parte dos pacientes (87,9%) não foi imunizada; 10,3% receberam as três doses da vacina e 43,1% possuíam familiar de primeiro grau ou parceiro com hepatite B crônica. A maioria (70,8%) relatou contato com algum fator de risco, sendo que 61,5% referiram ter realizado tratamento dentário. Conclusão: A implantação da vacina para toda população menor de 1 ano de idade, em 1996, pode ser uma explicação para a alta média de idade encontrada e pela inexistência de indivíduos menores de 23 anos no estudo. A vacinação completa, entretanto, ainda apresenta baixa adesão.(AU)

Objective: To get to know the characteristics and clinical profile of subjects being treated for chronic hepatitis B. Methods: Sixty-five patients with chronic hepatitis B who started treatment between the years 2010 to 2012 participated in the study. Results: All patients were white; there was a predominance of males (60%), and most of them were between 41 and 50 years (32.8%). Most patients (87.9%) were not immunized; 10.3% received all the three doses of the vaccine, and 43.1% had a first-degree relative or a partner with chronic hepatitis B. Most of them (70.8%) reported contact with a risk factor, with 61.5% reporting having had dental treatment. Conclusion: The implantation of the vaccine for all the population lower than 1 year of age, in 1996, can be an explanation for the high average age found, and the nonexistence of individuals younger than 23 years in the study. Complete vaccination, however, still presents low adherence.(AU)

Efficiency of Cell Therapy in Liver Cirrhosis.

We studied safety and clinical efficacy of transplantation of autologous bone marrow cell in complex therapy of 158 patients with chronic hepatitis and cirrhosis of the liver. The efficiency of cell therapy was assessed in 12 months after single injection of the cells. The positive response (alleviation of liver cirrhosis or stabilization of the pathological process) was observed in 70% cases. The efficacy of therapy correlated with the severity and etiology of the disease and was maximum in patients with Child-Pugh class A (in 82.5% cases) and class B liver cirrhosis (in 79% cases); in patients with class C liver cirrhosis, the positive response was achieved in 42.5% cases. In 39 patients, ultrasonic examination performed in 3 years after transplantation revealed no focal lesions or ectopic ossification foci.

Diagnosis and treatment challenges in a patient with splenic tumor and chronic viral hepatitis.

UNLABELLED: Non-Hodgkin lymphoma is a cancer of the lymphatic tissue located in various parts of the body: lymph nodes, spleen, thymus, adenoids, tonsils, and bone marrow. The disease occurs mainly in adults, with a higher incidence within the age range of 45 to 60 years. We present a clinical case of non-Hodgkin lymphoma diagnosed in a patient with chronic viral hepatitis B and D. The particularity of this case consists in the diagnosis of primitive spleen lymphoma, described in less than 1% of the cases, and also the difficult antiviral therapy recommendation for the liver disease, given the associated co-morbidity. ABBREVIATIONS: NHL = Non-Hodgkin lymphoma, HDV = Hepatitis delta virus, HCV = Hepatitis C virus, HBV = Hepatitis B virus, CT = Computerized tomography, CEUS = Contrast enhanced ultrasonography, CHOP = cyclophosphamide, doxorubicin, vincristine, prednisone, R-CHOP = cyclophosphamide, doxorubicin, vincristine, prednisone and rituximab.

Analyzing excess mortality from cancer among individuals with mental illness.

BACKGROUND: The objective was to compare patterns of site-specific cancer mortality in a population of individuals with and without mental illness. METHODS: This was a cross-sectional, population-based study using a linked data set comprised of death certificate data for the state of Ohio for the years 2004-2007 and data from the publicly funded mental health system in Ohio. Decedents with mental illness were those identified concomitantly in both data sets. We used age-adjusted standardized mortality ratios (SMRs) in race- and sex-specific person-year strata to estimate excess deaths for each of the anatomic cancer sites. RESULTS: Overall, there was excess mortality from cancer associated with having mental illness in all the race/sex strata: SMR, 2.16 (95% CI, 1.85-2.50) for black men; 2.63 (2.31-2.98) for black women; 3.89 (3.61-4.19) for nonblack men; and 3.34 (3.13-3.57) for nonblack women. In all the race/sex strata except for black women, the highest SMR was observed for laryngeal cancer, 3.94 (1.45-8.75) in black men and 6.51 (3.86-10.35) and 6.87 (3.01-13.60) in nonblack men and women, respectively. The next highest SMRs were noted for hepatobiliary cancer and cancer of the urinary tract in all race/sex strata, except for black men. CONCLUSIONS: Compared with the general population in Ohio, individuals with mental illness experienced excess mortality from most cancers, possibly explained by a higher prevalence of smoking, substance abuse, and chronic hepatitis B or C infections in individuals with mental illness. Excess mortality could also reflect late-stage diagnosis and receipt of inadequate treatment.

Non-invasive liver fibrosis markers: use of serum levels of cytokines IL 1α and TGF ß1 in management of chronic liver diseases.

AIM: To analyze the usefulness of specified immunological parameters, proinflammatory IL-1α and profibrogenic, antiinflammatory TGF-ß1, along with routinely used laboratory tests, in the differential - diagnostic procedure of chronic hepatitis of infectious and noninfectious etiology. METHODS: A total of 150 subjects were divided into two groups, depending on the infectious or noninfectious etiology of liver damage, and the control group. Apart from standard laboratory tests, the analysis included serum levels of cytokines: IL-1α and TGF-ß1. RESULTS: A high degree of correlation of serum level of IL-1α with viral hepatitis has been found, especially with active replication of genetic material ( HBV-DNA or HCV-RNA-PCR positive), p less 0.01. The highest mean concentration of TGF-ß1 was noted in the group of malignant and toxic hepatitis, p less 0.0001. A negative correlation between the concentration of IL-1α and TGF-ß1 has been found (-0.18). For IL-1 α significant predictive parameters included a previous infection of hepatitis B, lower serum level of TGFß, age, use of alcohol, lower MELD and Chilld-Pugh scores. For TGF-ß1 significant predictive parameters were age, lower MELD and Child-Pugh scores, history of receiving transfusions, lower serum level of IL-1α, higher serum level of fibrinogen. A predictive model has been delivered MELD = (TGF-ß1) x 0,001- (IL-1 α) x 0,085 + CTP x 1,771-2,052; ( ± 2.04, R2=0,61; p less 0,001). CONCLUSION: Inflammatory and immune parameters, analyzed together could significantly contribute to the understanding of chronic liver damage and thus differential diagnostic procedure. IL-1α and TGF-ß1 are important parameters of inflammatory activity and fibrosis evaluation in chronic liver damage.

Cryptogenic chronic hepatitis and its changing guise in adults.

Cryptogenic chronic hepatitis is a disease that is unexplained by conventional clinical, laboratory and histological findings, and it can progress to cirrhosis, develop hepatocellular carcinoma, and require liver transplantation. The goals of this review are to describe the changing phenotype of cryptogenic chronic hepatitis in adults, develop a diagnostic algorithm appropriate to current practice, and suggest treatment options. The frequency of cryptogenic hepatitis is estimated at 5.4%. Cryptogenic cirrhosis is diagnosed in 5-30% of patients with cirrhosis, and it is present in 3-14% of adults awaiting liver transplantation. Nonalcoholic fatty liver disease has been implicated in 21-63% of patients, and autoimmune hepatitis is a likely diagnosis in 10-54% of individuals. Viral infections, hereditary liver diseases, celiac disease, and unsuspected alcohol or drug-induced liver injury are recognized infrequently in the current cryptogenic population. Manifestations of the metabolic syndrome heighten the suspicion of nonalcoholic fatty liver disease, and the absence of hepatic steatosis does not discount this possibility. The diagnostic scoring system of the International Autoimmune Hepatitis Group can support the diagnosis of autoimmune hepatitis in some patients. Certain genetic mutations may have disease-specificity, and they suggest that some patients may have an independent and uncharacterized disease. Corticosteroid therapy is effective in patients with autoimmune features, and life-style changes and specific therapies for manifestations of the metabolic syndrome are appropriate for all obese patients. The 1- and 5-year survivals after liver transplantation have ranged from 72-85% to 58-73%, respectively.

Resultados del tratamiento médico combinado con Interferón alfa 2b recombinante y Ribavirina en pacientes con hepatitis crónica por virus C / Medical treatment results combined with Interferon alpha-2b recombinant and ribavirin in patients with chronic hepatitis by virus C

Se realizó un estudio descriptivo-retrospectivo, el cual incluyó todos los pacientes mayores de 20 años y de ambos sexos, a los cuales se les diagnosticó una hepatitis crónica por virus C y que fueron atendidos en la consulta especializada de hepatología del Hospital Provincial General Docente Dr. Antonio Luaces Iraola de Ciego de Ávila, durante el período comprendido de mayo del 2007 a noviembre del 2008. Fueron diagnosticados un total de 24 pacientes, de los cuales 13 (54.17 por ciento) fueron del sexo masculino y 11 (45.83 por ciento) del femenino, predominando fundamentalmente en pacientes relativamente jóvenes comprendidos entre los 30-39 años de edad con 10 casos (41.6 por ciento). El hallazgo histológico más frecuentemente encontrado fue la presencia de una hepatitis crónica ligera, con ausencia de fibrosis (FO-Escala de Metavir), observada en 19 pacientes (79.1 por ciento). De los 24 pacientes que llevaron tratamiento médico con interferón alfa 2 b recombinante y ribavirina por un año, en 17 (70.8 por ciento) se normalizaron las cifras de transaminasas (respondedores) al finalizar dicho tratamiento y en 13 de ellos (54.1 por ciento) las transaminasas se mantuvieron dentro de límites normales 6 meses después de haber finalizado el mismo (respuesta bioquímica sostenida) mientras que en los 11 pacientes restantes (45.8 por ciento) las transaminasas se mantuvieron elevadas, por lo que se clasificaron como no respondedores a la terapéutica.

A descriptive and retrospective study was carried out. This study included all the patients of both sexes bigger than 20 years which were diagnosed a chronic hepatitis by virus C. They were assisted in the specialized consultation of hepatology of the Educational General Provincial Hospital Dr. Antonio Luaces Iraola of Ciego de Ávila during the period of May 2007 to November 2008. A total of 24 patients were diagnosed, of those which 13 (54.17 percent) were from masculine sex and 11 (45.83 percent) from feminine one, prevailing fundamentally in patients relatively young understood among the 30-39 years of age with 10 cases (41.6 percent). The most frequently histological finding was the presence of a slight chronic hepatitis with fibrosis absence (FO-Metavir Scale), in 19 patients observed (79.1 percent). From 24 patients that took medical treatment with interferon alpha 2 b recombinant and ribavirin for one year, in 17 (70.8 percent) the aminotransferasas figures were normalized (responders) to conclude this treatment and in13 of them (54.1 percent) the aminotransferasas stayed inside the limits normal 6 months after having concluded the same one (sustained biochemical response) while in the 11 remaining patients (45.8 percent) the aminotransferasas stayed high, for what they were classified as non answers to the therapy.

Pancreaticoduodenectomy with radical lymphadenectomy is not contraindicated for patients with established chronic liver disease and portal hypertension.

BACKGROUND: Chronic liver disease has been considered a contraindication to radical surgery for intra-abdominal tumors because of the risk of decompensation. METHODS: In a retrospective analysis of all patients undergoing pancreaticoduodenectomy for cancer treated from January 2000 to December 2006 at our center, 4 patients were identified with operable pancreatic tumors and well-compensated chronic liver disease. The preoperative staging, decompression of the biliary tree, liver biopsy, Child-Turcot-Pugh and MELD scores were described. RESULTS: All patients underwent pancreaticoduodenectomy successfully with minimal blood loss, and no peri-operative blood transfusions or liver decompensation. There was no postoperative mortality. Two patients received adjuvant chemotherapy. One patient died with recurrent disease at 18 months, one is alive with disease recurrence, and two are alive and disease free. CONCLUSION: Patients with pancreatic cancer and well-compensated chronic liver disease should routinely be considered for radical surgery at specialist hepatobiliary centres with expertise available to manage complex liver disease.

Prophylaxis and treatment of recurrent viral hepatitis after liver transplantation.

Chronic hepatitis B or C can cause severe liver diseases such as liver cirrhosis and hepatocellular carcinoma (HCC). Both viral infections together especially hepatitis c virus infection (HCV) are the mayor indication for liver transplantation in Western Europe and the United States. Recurrence of hepatitis B virus (HBV) or HCV infection after orthotopic liver transplantation (OLT) plays a key role for the outcome after liver transplantation concerning patient and graft survival rates. Allograft dysfunctions, cirrhosis of the allograft and graft failure are major complications after recurrent viral hepatitis. The survival after liver transplantation for HBV-related liver disease changed dramatically during the last two decades with results today comparable with non-HBV-related liver transplantations. Availability of immunoprophylaxis with hepatitis B immunoglobulin (HBIG) as well as nucleoside/nucleotide analogues like lamivudine or adefovir in the pre- and post-transplant setting conferred to significant better results due to an efficient prophylaxis and the possibility of therapy of HBV reinfection of the allograft. New drugs such as entecavir, tenofovir and telbivudine for the treatment of chronic hepatitis B infections may offer even more opportunities in the transplant setting. In contrast, despite recent achievements in the treatment of HCV infection with pegylated interferons and ribavirin, patients with HCV cirrhosis or after liver transplantation are difficult to treat. Sustained virological response (SVR) rates in prophylactic and therapeutic approaches of HCV reinfection after OLT are only low compared to the pre-cirrhotic HCV infection. Moreover, best treatment duration and dosage of recurrent HCV infection with pegylated interferon in combination with ribavirin remains to be defined.

Interferon-alpha suppresses liver cell proliferation in patients with chronic hepatitis C virus infection.

SUMMARY: Interferon (IFN) therapy has been shown to reduce the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C, including virological nonresponders (NR). Whether IFN suppresses liver cell proliferation, i.e. the relevant risk factor for HCC, is unknown. The aim of the study was to evaluate the effect of IFN therapy on liver cell proliferation in chronic hepatitis C. The proliferating cell nuclear antigen-labelling index (PCNA-LI) was assessed prior to and at the end of therapy in the liver of 29 patients with chronic hepatitis C who received 3 MU IFN-alpha2b thrice weekly for 24-48 weeks. Overall, the median value of PCNA-LI was significantly reduced from 2.6% to 1.1% at the end of therapy (P < 0.0001). At baseline, PCNA-LI median values were similar in the 15 virological responders compared with the 14 NRs (2.3%vs 3.4%, P = 0.121) and at the end of therapy, median changes of PCNA-LI (-1.4%vs-1.1%, P = 0.089) were also similar although there was a higher decline of the proliferation index in responders with respect to NRs at the end of therapy (0.7%vs 1.6%, P = 0.004). In the two groups, the rate of fibrosis score reduction was also similar (7%vs 20%, P = 0.326). In contrast, the histological activity index was more often reduced in responders than in NRs both at the >or=2 and >or=4 points reduction level (80%vs 36%, P = 0.02 and 53%vs 14%, P = 0.03, respectively). The study showed a significant suppression of liver cell proliferation in IFN-treated patients with chronic hepatitis C. Although the strongest IFN effect was observed in virological responders, a reduction of proliferative activity was also seen in virological NRs.

Hepatitis autoinmune: formas clínicas y factores relacionados con la respuesta al tratamiento / Hepatitis autoinmune: clinical forms and factors related to the answer to the treatment

La enfermedad hepática crónica es una entidad clínica que tiene varias causas; siendo la enfermedad viral y el consumo crónico de alcohol las más frecuentes. Las entidades de origen inmunológico son las que en conjunto ocupan el tercer lugar, incluyéndose la hepatitis autoinmune, la cirrosis biliar primaria, la colangitis esclerosante primaria, así como los síndromes de superposición. En el Perú hay escasos reportes en relación a la hepatitis autoinmune, y su frecuencia es desconocida. En la Unidad de Hígado del HNERM. La etiología autoinmune corresponde al 13 por ciento del total de casos hospitalizados por enfermedad hepática crónica en el año 2002. En este artículo reportamos 30 casos de hepatitis autoinmune con diagnóstico clínico y serológico, se hizo biopsia en el 97 por ciento de casos, demostrándose cirrosis en el 70 por ciento. La relación F/M fue de 5/1, la edad promedio fue 48.59 años, y en 6.7 por ciento de casos el debut del cuadro fue como insuficiencia hepática aguda. Se halló anticuerpos antinucleares en 73.33 por ciento, anticuerpos antimúsculo liso en 43.33 por ciento y antimitocondriales en 16.7 por ciento, habiendo coexistencia de autoanticuerpos en 40 por ciento. La endoscopía reveló la presencia de várices en 20 por ciento, pero solo 1 caso debutó con hemorragia variceal. La terapia instaurada fue a base de prednisona y azatioprina en la mayoría de casos. Recibieron tratamiento 26 casos, de los cuales el 80 por ciento tuvo remisión inicial, 2 tuvieron respuesta parcial y 3 no respondieron. En 16.7 por ciento de casos ocurrieron complicaciones relacionadas con el tratamiento inmunosupresor, sobre todo infecciones severas (3 casos). En conclusión, la Hepatitis autoinmune es una causa importante de enfermedad hepática crónica, que tiene características clínicas similares a las reportadas en la literatura internacional, responde al tratamiento inmunosupresor en la mayoría de casos, aunque debe hacerse un adecuado seguimiento del caso...

Chronic liver disease is a clinical entity of different origins. It is most frequently caused by viral infection and alcohol consumption. The entities of immunological origin are listed in third place including autoimmune hepatitis, primary biliar cirrhosis, primary sclerosing cholangitis, as well as superposition syndromes. In Peru report of cases relating to autoimmune hepatitis are very few and its frequency is unknown. In 2002, autoimmune etiology represented 13 per cent of all the cases admitted in the Hepathology Unit of Edgardo Rebagliati Martins National Hospital (“HNERM”) for chronic hepatic disease. In this article, 30 cases of autoimmune hepatitis clinically and serologically diagnosed are reported.Biopsy was performed on 97 per cent of the cases, of which 70 per cent showed cirrhosis. The relationship F/M was 5/1, the average age was 48.59 years, and in 6.7 per cent of the cases the initial picture was acute hepatic insufficiency. Antinuclear antibodies were found in 73.33 per cent, smooth antimuscle antibodies in 43.33 per cent, and antimitochondrial antibodies in 16.7 per cent, with a coexistence of autoantibodies in 40 per cent. The endoscopy performed revealed the presence of varices in 20 per cent of the cases, but only one case of variceal hemorrhage. In most cases, therapy was initiated based on prednisone andazathioprine. Of 26 cases that were treated, 80 per cent had an initial remission, 2 responded partially,and 3 did not respond. There were complications related to the treatment with immunosuppressants in 16.7 per cent of the cases, and especially severe infections in 3 cases. In conclusion, autoimmune hepatitis is a substantial cause of chronic hepatic disease that has similar clinical characteristics tothose reported in international medical journals. In most cases it responds to treatment with immunosuppressants. However, adequate follow-up is recommended to detect secondarycomplications in the treatment with...

Chronic viral hepatitis.

Although less common in childhood, hepatitis B virus (HBV) and hepatitis C virus (HCV) remain the most common causes of chronic hepatitis in the United States and worldwide. Children with chronic HBV or HCV are often asymptomatic, with normal or mildly elevated serum transaminases. Although chronic HBV and HCV are indolent diseases in childhood, they cause significant morbidity and mortality later in life. Because the dreaded complications of chronic HBV and HCV--cirrhosis with liver failure and hepatocellular carcinoma--can be seen in childhood, routine follow-up with a pediatric gastroenterologist or hepatologist is recommended. The most important role of the primary care physician and pediatric gastroenterologist or hepatologist is prevention of chronic viral hepatitis through education and screening programs.