Macrophages and platelets in liver fibrosis and hepatocellular carcinoma.

During fibrosis, (myo)fibroblasts deposit large amounts of extracellular matrix proteins, thereby replacing healthy functional tissue. In liver fibrosis, this leads to the loss of hepatocyte function, portal hypertension, variceal bleeding, and increased susceptibility to infection. At an early stage, liver fibrosis is a dynamic and reversible process, however, from the cirrhotic stage, there is significant progression to hepatocellular carcinoma. Both liver-resident macrophages (Kupffer cells) and monocyte-derived macrophages are important drivers of fibrosis progression, but can also induce its regression once triggers of chronic inflammation are eliminated. In liver cancer, they are attracted to the tumor site to become tumor-associated macrophages (TAMs) polarized towards a M2- anti-inflammatory/tumor-promoting phenotype. Besides their role in thrombosis and hemostasis, platelets can also stimulate fibrosis and tumor development by secreting profibrogenic factors and regulating the innate immune response, e.g., by interacting with monocytes and macrophages. Here, we review recent literature on the role of macrophages and platelets and their interplay in liver fibrosis and hepatocellular carcinoma.

Identification of potential metabolic biomarkers in predicting esophageal varices needing treatment in patients with liver cirrhosis.

The goal of this study was to determine the diagnostic performance of in vivo quantitative proton magnetic resonance spectroscopy (1H-MRS) to identify the presence of esophageal varices needing treatment (VNT), as well as investigate its correlation with clinical characteristics in patients with liver cirrhosis. Forty cirrhotic patients without VNT showing the negative red color sign, and 40 cirrhotic patients with VNT showing positive red color sign underwent laboratory tests, esophago-gastro-duodenoscopy, and 1H-MRS with single-voxel localization in the cirrhotic liver parenchyma. The levels of lactate + triglyceride (TG) and choline in cirrhotic patients with VNT were significantly higher than those in cirrhotic patients without VNT. In multivariate analysis, spleen diameter, platelet count, and platelet count/spleen diameter ratio, as well as lactate + TG, and choline were associated with the presence of VNT. Moreover, lactate + TG and choline levels were positively correlated with spleen diameter and negatively correlated with platelet count in the combined group of cirrhotic patients with and without VNT. Our study demonstrated that higher hepatic lactate + TG and choline levels in cirrhotic patients in conjunction with longer spleen diameter, lower platelet counts, and lower ratios of platelet count to spleen diameter were associated with the presence of esophageal VNT and the risk of developing variceal bleeding. Therefore, in vivo 1H-MRS might be an effective tool for diagnosing and predicting esophageal VNT in patients with liver cirrhosis.

Serum Mac-2-binding protein glycosylation isomer predicts esophagogastric varices in cirrhotic patients with chronic hepatitis C virus infection treated with IFN-free direct-acting antiviral agent: M2BPGi levels predict varices in SVR patients.

INTRODUCTION AND OBJECTIVES: We examined whether Mac-2-binding protein glycosylation isomer (M2BPGi) levels could be a predictive marker for the presence of esophagogastric varices (EGV) in cirrhotic patients after hepatitis C virus (HCV) eradication with direct-acting antivirals (DAAs). PATIENTS AND METHODS: A total of 102 cirrhotic patients with HCV infection treated with DAAs were enrolled. Esophagogastroduodenoscopy was performed in 84 of the patients before treatment (Cohort A), in 66 after treatment (Cohort B), and in 48 at both time points (Cohort C). We examined factors associated with EGV before and after DAA treatment. RESULTS: In Cohort A, M2BPGi levels and liver stiffness were significantly higher in the EGV-positive group than the EGV-negative group (p=0.034, and p=0.042, respectively). The proportion of EGV-positive patients with before-treatment levels of M2BPGi ≧ 7.3 C.O.I. was significantly higher than in patients with M2BPGi levels<7.3 C.O.I. (p=0.015). In Cohort B, M2BPGi levels were significantly higher in the EGV-positive group than EGV-negative group (p=0.003). The proportion of EGV-positive patients with after-treatment levels of M2BPGi ≧ 3.4 C.O.I. was significantly higher than in patients with M2BPGi levels<3.4C.O.I. (p=0.001). In Cohort C, M2BPGi levels decreased during DAA treatment regardless of EGV development, but there was no significant difference in the reduction of M2BPGi among the EGV-improvement, EGV-invariant, and EGV-exacerbation groups (p=0.659). CONCLUSIONS: M2BPGi levels may be a novel serum marker for the presence of EGV before and after DAA treatment.

Non-Invasive Predictors of Gastro-Oesophageal Varices.

INTRODUCTION: The worldwide accepted tool for screening and monitoring gastro-oesophageal varices in patients with liver cirrhosis is upper gastrointestinal endoscopy. Endoscopy needs clinical expertise and has got its own procedure related complications. Repeated endoscopies may be expensive and patients tend to develop poor compliance. This study was undertaken to establish the role of noninvasive parameters in predicting gastro-esophageal varices. METHODS: Two hundred patients with clinical features, laboratory and sonological findings suggestive of cirrhosis of liver and endoscopic evidence of portal hypertension were included in the study. Blood parameters like serum albumin, international normalized ratio (INR), platelets count and ultrasonography assessments of portal vein diameter and spleen size were compared with presence of gastro-oesophageal varices. RESULTS: At cutoff point of 2.55g/dl, serum albumin had high specificity of 99% whereas platelets count <1,44,000/mm3 had 87.9% sensitivity for presence of oesophageal varices. Sensitivities of 92.72% and 94.5% while specificities of 90% and 75% were detected for presence of oesophageal varices when the cutoff values for portal vein diameter and spleen size were 12.25 mm and 13.9 cm respectively. CONCLUSIONS: Measurements of serum albumin, platelets count, portal vein diameter and spleen size by ultrasonography can be recommended as a non-invasive predictor for gastro-oesophageal varices in cirrhosis of liver. All these non-invasive parameters could be useful to patients with liver cirrhosis with portal hypertension in predicting presence of varices as well as in long-term clinical monitoring and management.

Two randomized controlled studies comparing the nutritional benefits of branched-chain amino acid (BCAA) granules and a BCAA-enriched nutrient mixture for patients with esophageal varices after endoscopic treatment.

BACKGROUND: The usefulness of branched-chain amino acid (BCAA) granules and BCAA-enriched nutrient mixtures for patients with liver cirrhosis is often reported. However, no randomized controlled studies have investigated the usefulness of these supplements in the nutritional intervention of cirrhotic patients receiving endoscopic treatment for esophageal varices. METHODS: Patients without BCAA before endoscopic treatment were divided into study 1, and those who received BCAA were divided into study 2. In study 1, 44 eligible patients were divided into a control group (n = 13), a general liquid nutrient (snack) group (n = 15), and a BCAA-enriched nutrient mixture (BCAA-EN) group (n = 16). In study 2, 48 eligible patients were divided into a BCAA group (n = 24) and a BCAA-EN group (n = 24). The nutritional status including non-protein respiratory quotient (NPRQ) levels, weight gain, and albumin were evaluated on days 0, 7, and 50. RESULTS: In study 1, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 as compared with the snack group. In study 2, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 and in weight levels on day 50 relative to the BCAA group, while the BCAA group showed improved serum albumin levels on day 7 compared to the BCAA-EN group. CONCLUSIONS: The BCAA-enriched nutrient mixture maintained NPRQ and weight in cirrhotic patients. Our findings suggest that supplements including both BCAA and a nutritional energy supplement would be beneficial for cirrhotic patients undergoing endoscopic treatment for esophageal varices.

Evaluation of correlation between high serum-ascites albumin gradient and the upper gastrointestinal endoscopic parameters in children presenting with portal hypertension with ascites.

Portal hypertension which usually leads to bleeding from oesophageal varices in children remain a difficult medical problem. The upper gastrointestinal endoscopy is currently considered as the best reliable method to diagnose oesophageal varices in portal hypertension. But endoscopic screening is an invasive procedure and is not easily available even in tertiary health care facilities of Bangladesh till now. Therefore an alternative noninvasive indicator is being looked for the diagnosis of portal hypertension. Patients with serum ascites albumin gradient (SAAG) values ≥1.1gm/dl have recently found to have presence of portal hypertension. The study was carried out to set up a diagnostic value of SAAG for the prediction of portal hypertensive changes (oesophageal and gastric varices, gastropathy) of upper gastrointestinal endoscopy in children. This cross sectional study was conducted at the Department of Paediatric Gastroenterology and Nutrition of Bangabandhu Sheikh Mujib Medical University. A total of 30 cases of portal hypertension were studied from November 2008 to February 2010. Oesophageal varices were found in 86.7% of cases. Significant association was found between high SAAG values and presence of oesophageal varices. Frequencies of oesophageal varices increased as the SAAG values increased. The cut off point of SAAG value was found to be 1.55gm/dl for the presence of oesophageal varices where sensitivity and specificity were found 84.6% and 100 % respectively. From this study, it can be concluded that SAAG value 1.6gm/dl is an indicator of portal hypertensive changes especially oesophageal varices in children.

Comparison of acoustic radiation force impulse imaging with transient elastography for the detection of complications in patients with cirrhosis.

BACKGROUND: Acoustic radiation force impulse (ARFI) imaging is a new non-invasive, ultrasound-based method for the evaluation of liver fibrosis and cirrhosis. AIM: To determine the diagnostic accuracy of ARFI imaging, transient elastography (TE) and Fibrotest for the evaluation of complications in patients with cirrhosis. METHODS: A total of 166 patients (109 male, mean age: 54 ± 11 years) with chronic liver disease and established cirrhosis were included in this study. ARFI-imaging of the liver and spleen, TE and Fibrotest were performed in all patients. In addition, clinical, laboratory and morphological parameters, including MELD/Child-Pugh scores, presence of oesophageal varices and hepatocellular carcinoma, history of variceal bleeding and history of hepatic encephalopathy were recorded. RESULTS: Acoustic radiation force impulse liver was significantly correlated with ARFI spleen (r = 0.48, P < 0.001), TE (r = 0.75, P < 0.001) and Fibrotest (r = 0.21, P = 0.006). The diagnostic accuracy (AUROC) for the diagnosis of large oesophageal varices was 0.58 (95% CI: 0.48-0.67), 0.58 (0.49-0.67), 0.53 (0.44-0.63) and 0.50 (0.41-0.59) for ARFI liver, spleen, TE and Fibrotest respectively (P > 0.20). The AUROC for the detection of hepatocellular carcinoma (HCC) was 0.54 (0.39-0.70), 0.58 (0.44-0.73), 0.56 (0.40-0.73) and 0.72 (0.60-0.84) respectively (P > 0.20). Multiple logistic regression analysis showed that ARFI spleen better predicted the presence of large oesophageal varices and HCC compared with ARFI liver. CONCLUSIONS: The diagnostic accuracy of ARFI liver and spleen was comparable to TE and Fibrotest for the detection of complications in patients with cirrhosis.

Portal hypertensive enteropathy before and after variceal obliteration: an endoscopic, histopathologic and immunohistochemical study.

AIM: To study portal hypertensive enteropathy (PHE) before and after the obliteration of esophageal varices. METHODS: 30 patients with portal hypertension and esophageal varices were included. Band ligation was performed for every patient until the obliteration of esophageal varices. Enteroscopy and biopsies from gastric, duodenal and jejunal mucosa were taken at the beginning of the study and after variceal obliteration. Morphometric measurement of mean vascular areas and estimation of tissue vascular endothelial growth factor (VEGF) were also completed. RESULTS: The number of patients with enteropathy increased from 6.6% before obliteration to 46.7% after variceal obliteration (p< 0.001). Angiogenesis, vascular ectasia and blood extravasation were the main histopathological findings and all increased significantly after variceal obliteration. The mean vascular area of ectatic vessels in the gastric, duodenal and jejunal biopsies also increased after variceal obliteration. The mean VEGF in the gastric, duodenal and jejunal biopsies increased after variceal obliteration. The mean corpuscular volume (MCV) and hemoglobin (Hb) concentration were significantly lower after variceal obliteration. CONCLUSION: the portal hypertensive enteropathic changes increased in frequency and severity after esophageal variceal obliteration with a probability of causing anemia.

Functional status of beta-2-adrenoceptor in isolated membranes of mature erythrocytes from patients with cirrhosis and oesophageal varices.

Propranolol is a widely used drug for prophylaxis of variceal bleeding in patients with cirrhosis, but not all patients show an adequate clinical response. This variability may be in relation to beta adrenoceptor activity, but no information is available in this setting. Thirty-nine patients with advanced cirrhosis and presence of oesophageal varices were sequentially included. We studied the function of beta-2-adrenoceptor in isolated membranes of mature erythrocytes obtained from patients by measuring cyclic AMP (cAMP) production before and after isoproterenol. Blood samples obtained from 11 healthy volunteers were used as control. Patients showed a six-fold increase in the mean basal cAMP production as compared to healthy volunteers. Isoproterenol produced a small, non-significantly and highly variable increase in the AC activity in patients compared with controls. cAMP values remain stable after three months of continuous treatment with oral beta-blockers in both groups. Patients without antecedent of variceal bleeding or with an active alcohol intake showed a significantly higher isoproterenol effect. In conclusion, beta-receptor function in human erythrocytes membranes is altered in patients with cirrhosis and oesophageal varices.

[Usefulness of branched-chain amino acid (BCAA)-enriched nutrient mixture for nutritional treatment undergoing endoscopic treatment for esophageal varices].

We investigated the alteration of nutritional status in 144 patients who were treated for the first time with endoscopic sclerotherapy or endoscopic variceal ligation during their therapies. The serum levels of albumin, cholinesterase and total cholesterol were compared before and after treatment. The serum level of cholinesterase declined significantly. To investigate the impact of aging on the changes of nutritional status we divided all patients into two groups: (1) under 65 years, and (2) over 65 years. The decline of serum albumin of elderly patients (n=65) was significantly greater than that of younger patients (n=79). A branched-chain amino acid (BCAA)-enriched nutrient mixture for nutritional treatment significantly suppressed the decline of serum albumin in elderly patients. Nutritional treatment with a BCAA-enriched nutrient mixture should be considered during endoscopic therapy for esophageal varices, especially in elderly patients.

Expression of TNF-alpha and VEGF in the esophagus of portal hypertensive rats.

AIM: To investigate the expression of tumor necrosis factor-alpha (TNF-alpha) and vascular endothelial growth factor (VEGF) in the development of esophageal varices in portal hypertensive rats. METHODS: Thirty male Sprague-Dawley (SD) rats in the model group in which a two-stage ligation of portal vein plus ligation of the left adrenal vein was performed, were divided into three subgroups (M(7), M(14), and M(21)) in which the rats were kiued on the seventh day, the 14(th) d and the 21 d after the complete portal ligation. Thirty male SD rats, which underwent the sham operation in the control group, were also separated into three subgroups (C(7), C(14) and C(21)) corresponding to the models. The expression of TNF-alpha and VEGF in the esophagus of all the six subgroups of rats were measured with immunohistochemical SP technique. RESULTS: The portal pressure in the three model subgroups was significantly higher than that in the corresponding control subgroups (23.82+/-1.83 vs 11.61+/-0.86 cmH(2)O, 20.90+/-3.27 vs 11.43+/-1.55 cmH(2)O and 20.68+/-2.27 vs 11.87+/-0.79 cmH(2)O respectively, P<0.01), as well as the number (9.3+/-1.6 vs 5.1+/-0.8, 11.1+/-0.8 vs 5.4+/-1.3 and 11.7+/-1.5 vs 5.2+/-1.1 respectively, P<0.01) and the total vascular area (78 972.6+/-3 527.8 vs 12 993.5+/-4 994.8 mum(2), 107 207.5+/-4 6461.4 vs 11 862.6+/-5 423.2 mum(2) and 110 241.4+/-49 262.2 vs 11 973.7+/-3 968.5 mum(2) respectively, P<0.01) of submucosal veins in esophagus. Compared to the corresponding controls, the expression of TNF-alpha and VEGF in M(21) was significantly higher (2.23+/-0.30 vs 1.13+/-0.28 and 1.65+/-0.38 vs 0.56+/-0.30 for TNF-alpha and VEGF respectively, P<0.01), whereas there was no difference in M(7) (1.14+/-0.38 vs 1.06+/-0.27 and 0.67+/-0.35 vs 0.50+/-0.24 for TNF-alpha and VEGF respectively, P>0.05) and M(14) (1.20+/-0.25 vs 1.04+/-0.26 and 0.65+/-0.18 vs 0.53+/-0.25 for TNF-alpha and VEGF respectively, P>0.05). And the expression of TNF-alpha and VEGF in M(21) was significantly higher than that in M(7) (2.23+/-0.30 vs 1.14+/-0.38 and 1.65+/-0.38 vs 0.67+/-0.35 for TNF-alpha and VEGF respectively, P<0.01) and M(14) (2.23+/-0.30 vs 1.20+/-0.25 and 1.65+/-0.38 vs 0.65+/-0.18 for TNF-alpha and VEGF respectively, P<0.01), but there was no difference between M(7) and M(14) (1.14+/-0.38 vs 1.20+/-0.25 and 0.67+/-0.35 vs 0.65+/-0.18 for TNF-alpha and VEGF respectively, P>0.05). CONCLUSION: In the development of esophageal varices in portal hypertensive rats, increased TNF-alpha and VEGF may be not an early event, and probably play a role in weakening the esophageal wall and the rupture of esophageal varices.

High prevalence of haemosiderin accumulation in the cytoplasm of gastric glands in patients with liver cirrhosis.

AIMS: To investigate the presence of iron in biopsy and resection specimens from the stomach of patients with hepatic cirrhosis of various aetiologies. METHODS: Among 753 patients who had been admitted to the hospital with liver cirrhosis from 1984 to 2002, and 723 patients who underwent liver biopsy or liver resection from 1990 to 2003, 426 patients with concomitant gastric biopsy or gastrectomy were selected for study. Formalin fixed, paraffin wax embedded tissues of the stomach and the liver (when available) were retrieved from the pathology files of Kariya General Hospital, Japan. Haematoxylin and eosin staining and Perls' stain were performed for all the available tissues and haemosiderin and its localisation were examined. RESULTS: In total, 78 patients-72 of those with cirrhosis (26%) and six without cirrhosis (4%)-showed accumulation of haemosiderin. Regardless of aetiology, patients with clinical varices showed more frequent haemosiderin accumulation (40%) than patients without varices (19%). For patients with cirrhosis, there were no significant differences in the positive rate between those with (28%) or without (23%) hepatocellular carcinoma. CONCLUSION: The significant increase in haemosiderin deposition in the gastric glands of patients with cirrhosis suggests that the assessment of iron deposition in gastric biopsy specimens may have predictive value in controlling patients with cirrhosis.

Outcome of liver disease in children with Alagille syndrome: a study of 163 patients.

BACKGROUND AND AIMS: Various opinions have been expressed as to the long term prognosis of liver disease associated with Alagille syndrome (AGS). PATIENTS AND METHODS: We reviewed the outcome of 163 children with AGS and liver involvement, investigated from 1960 to 2000, the end point of the study (median age 10 years (range 2 months to 44 years)) being death, liver transplantation, or the last visit. RESULTS: At the study end point, of the 132 patients who presented with neonatal cholestatic jaundice, 102 remained jaundiced, 112 had poorly controlled pruritus, and 40 had xanthomas; cirrhosis was found in 35/76 livers, varices in 25/71 patients, and liver transplantation had been carried out in 44 patients (33%). Forty eight patients died, 17 related to complications of liver disease. Of 31 patients who did not present with neonatal cholestatic jaundice, five were jaundiced at the study end point, 17 had well controlled pruritus, and none had xanthomas; cirrhosis was found in 6/18 patients, varices in 4/11, and none underwent liver transplantation. Nine patients died, two of liver disease. In the whole series, actuarial survival rates with native liver were 51% and 38% at 10 and 20 years, respectively, and overall survival rates were 68% and 62%, respectively. Neonatal cholestatic jaundice was associated with poorer survival with native liver (p=0.0004). CONCLUSIONS: The prognosis of liver disease in AGS is worse in children who present with neonatal cholestatic jaundice. However, severe liver complications are possible even after late onset of liver disease, demanding follow up throughout life.

Correlation between serum-ascites albumin concentration gradient and endoscopic parameters of portal hypertension.

OBJECTIVE: We sought to determine the correlation between the level of serum-ascites albumin concentration gradient (SAAG) and the complications of portal hypertension (PHTN), manifested by the presence and grade of esophageal varices (EV). METHODS: Our study included 31 patients with ascites, demonstrated by ultrasonography, who had measurement of the SAAG. All had upper gastrointestinal endoscopy with assessment of the presence and size of EV. High SAAG was considered to be present when the SAAG was > or = 1.1 g/dl and Low SAAG when it measured < 1.1 g/dl. RESULTS: We found that 25 of 31 (80.6%) patients had High SAAG and six of 31 (19.4%) had Low SAAG. Esophageal varices were present in 17 of 25 (68%) patients with High SAAG and in none of six (0%) patients with Low SAAG (p = 0.028). In patients with alcoholic liver disease (ALD), 14 of 14 (100%) had EV. Otherwise, in patients with nonALD, only three of 11 (27.3%) had EV (p < 0.05). The presence of EV was associated with the Child-Pugh Score (p = 0.039). Among patients with High SAAG, EV were present in four of 10 (40%) with SAAG values of 1.10-1.49 g/dl; in four of 6 (66.7%) with SAAG values of 1.50-1.99 g/dl; and in nine of nine (100%) with SAAG values of > or =2.0 g/dl (p = 0.049). The size of the EV had no association with the level of SAAG in patients with High SAAG (p = 0.788), with a Pearson correlation coefficient of R = 0.54 (p = 0.005). Using the Receiver-Operating-Characteristic Curve a SAAG value of > or =1.435 +/- 0.015 g/dl was an accurate indicator of the presence of EV (cutoff point for the higher predictive value: positive = 87.5% and negative = 66.7%). CONCLUSIONS: In patients with ascites the presence of EV is associated only with patients with High SAAG. The presence of EV in patients with ascites and High SAAG is directly related to the degree of SAAG. The size of the EV in patients with ascites and High SAAG is not associated with the degree of SAAG. A SAAG value of > or =1.435 +/- 0.015 g/dl is a useful means to predict the presence of EV in patients with ascites. Finally, in patients with ascites, EV were more prevalent in those with ALD.

Fatal liver cirrhosis and esophageal variceal hemorrhage in a patient with type IIIa glycogen storage disease.

A 45-year-old woman with type IIIa glycogen storage disease (GSD IIIa) died of variceal hemorrhage secondary to liver cirrhosis. The postmortem examination disclosed increased intracellular glycogen in the liver as well as in the heart and skeletal muscle. Although most liver injuries in GSD IIIa have been considered to be non-progressive in adulthood, liver cirrhosis can be a cause of death in some patients.

Systemic dissemination of ethanolamine oleate after injection sclerotherapy for esophageal varices.

Sclerotherapy for esophageal varices was performed on six patients for a total of 16 injections. The sclerosant contained 5% ethanolamine oleate and technetium Tc 99m sodium pertechnetate solution at the volume ratio of 9:1. At each injection session 5 to 20 mL of this solution was injected into one varix. The distribution of the injected material was observed by a scintillation camera. Systemic dissemination of the sclerosant through the portal vein was demonstrated in five procedures, in which the injections were correctly intravenous. In three dogs 4 mL of 5% ethanolamine oleate made from oleic acids labeled with iodine 131 was injected into the gastric coronary vein. Most of the substance injected was washed out within five minutes, and systemic dissemination became evident.

[A method to transmucosal transport in the human esophagus (author's transl)]. / Ein Verfahren zur Messung transmuköser Transportvorgänge im menschlichen Osophagus.

A modified 9-luminal manometric tube served to perfuse the esophagus with 3.2 mmolar hydrochloric acid containing 2% polyethylene glycol (PEG) and to aspirate the esophageal contents. The esophageal secretion was calculated from the PEG dilution in the aspirates. Neutral red injected intravenously reddened selectively gastric juice. Red esophageal aspirates were discarded., In 6 health subjects esophageal secretion was 1.0/+-0.2 ml/min after 1 hour perfusion. It contained 38 /+-11 mmol/l na+, 3.3/+-1.4 mmol/l K+, 27/+-6 mmol/l Cl-, and 50/+-13 mumol/l N-acetylneuraminic acid (NANA). Thus this method allows measurement of the barrier function of the esophageal mucosa.