Ultrasonically-guided percutaneous transcholecystic cholangiography--an alternative approach in cases of biliary obstruction and failure of percutaneous transhepatic cholangiography.

Fourteen ultrasonically-guided percutaneous transcholecystic cholangiographies (PTCC) were performed in subjects with biliary obstruction with different underlying diseases. No complication was observed, and the procedure permitted diagnosis in all cases, although the previously reported difficulty of visualizing proximal bile ducts was confirmed in two cases. PTCC can constitute a valid and safe diagnostic alternative in obstructive jaundice in which no dilation of intrahepatic bile ducts is revealed on US, in cases in which percutaneous trans-hepatic cholangiography fails.

Survey of delta infection in the Naples basin: a possible epidemiologic model for endemic areas.

The prevalences of delta co-infections and superinfections in 100 randomly selected subjects for each year from 1977 to 1982 and in all the subjects of subsequent years until April 1986, admitted to our Department with acute viral hepatitis B (AVHB), were evaluated and compared with the annual incidence of cases of AVHB reported in Naples during the same period. Moreover, anti-delta antibodies were determined in the sera of 25 consecutive cases of HBsAg-positive chronic active hepatitis and 25 consecutive cases of HBsAg-positive chronic active hepatitis and 25 consecutive cases of HBsAg-positive cirrhosis, respectively, for 1977, 1980, 1983 and 1986. Our data show a high, constant circulation of HDV and a decrease in its incidence in acute forms over the last 3 years, which coincides with the parallel lower incidence of AVHB, but which is not reflected in the delta prevalence in the chronic forms. They also indicate the possible existence of alternate cycles of increase and decrease in the infection, partly dissociated from HBV circulation, which present peculiar epidemiologic characteristics.

[Percutaneous therapy of hydatid cyst of the liver with ultrasound-guided double puncture-aspiration and alcoholization]. / Trattamento percutaneo delle cisti idatidee del fegato con doppia puntura-aspirazione ed alcolizzazione ecoguidata.

Fourteen patients (9 females, 5 males; age range: 22-80 years) with 16 univesiculated hydatid cysts of the liver (O ranging 4.2-14 cm) underwent two sessions of puncture-aspiration-alcohol injection (D-PAI) under real-time US guidance at 3-day intervals. Two patients had postoperative recurrences. One patient was pregnant (9 weeks' gestation): her cyst doubled its volume over 2 months. One patient had HBV chronic hepatitis treated by means of interferon: also in this case the cyst doubled its volume. The remaining were high-risk patients for surgery or had refused operation. At US follow-up (ranging 4-24 months) 6 cysts exhibited complete reconstitution of liver parenchyma. In the extant patients two different US patterns were observed: 1) liquid areas with detached inner membranes (4 cysts); 2) solid inhomogeneous areas (6 cysts). In these cases the volume was reduced by 50-80%. No allergic complication occurred either during or after the procedure. Two patients only were affected with vomiting and fever, which resolved in a few hours. Our results indicate D-PAI of univesiculated hydatid cysts of the liver to be an effective alternative to surgery.

Sonographic recognition of intraparenchymal regenerating nodules using high-frequency transducers in patients with cirrhosis.

In 38 patients with cirrhotic liver, an ultrasound examination was carried out by using 3/3.5-, 5-, and 7.5-MHz transducers sequentially in order to identify hypoechoic intraparenchymal regenerating nodules less than or equal to 20 mm. Twenty healthy subjects and 35 patients with noncirrhotic chronic liver disease were scanned as controls. Focal lesions were disclosed in five patients: one case turned out to be a small hepatocellular carcinoma; regenerating nodules were diagnosed as such in four cases by means of surgery, laparoscopy, and fine needle biopsy. At a follow-up needle biopsy one year later, one of these nodules proved to be malignant. Use of high-frequency transducers offered little aid to the diagnosis of small nodules. In only one case were multiple lesions revealed with a 7.5-MHz probe but not with 3- and 5-MHz probes. It seems that intraparenchymal regenerating nodules are rarely seen with the available technology, and their recognition cannot be recommended as a reliable ultrasound diagnostic marker of liver cirrhosis.

Ultrasound evaluation of uncomplicated and complicated acute viral hepatitis.

Seven hundred ninety-one consecutive patients with acute viral hepatitis, 17 of whom had liver failure, and 97 healthy volunteers were examined by ultrasound. No specific patterns were found in either the uncomplicated or the complicated forms. Only 19 subjects showed a typical "bright liver" pattern, which is correlated with significant vacuolar hepatocellular degeneration. The increased brightness and clear visualization of portal vein radicle walls, previously described in this disease, were detected in only 32.2% of the hepatitis patients but were also seen in 30.9% of the normal controls.

[Clinical significance of hyperechogenic focal lesions of the cirrhotic liver]. / Significato clinico delle lesioni focali iperecogene nel fegato cirrotico.

A review was made of the ultrasonographic (US) examinations performed over the period 1981-1986; 27 cirrhotic patients with hyperechoic liver lesions were identified, whose diagnoses had been made by means of either US-guided percutaneous biopsy, or laparoscopy, or autopsy. In 24 patients hepatocellular carcinomas nodules (HCC) were found, associated with cirrhosis, while in 3 cases only cirrhosis was seen. In the above mentioned 3 cases, a 2-year US follow-up showed no variation in the size of the nodules. These data confirm the importance of US in the screening of risk HCC patients, and point out that--however small--hyperechoic lesions in a cirrhotic liver suggest the cancerization of the substanding cirrhosis.

Cirrhosis: value of caudate to right lobe ratio in diagnosis with US.

To verify the value of ultrasound (US) in the diagnosis of cirrhosis, the ratio of transverse caudate lobe width to right lobe width (C/RL) was determined with US in 25 healthy subjects and 156 consecutive patients with either histologically proved acute viral, chronic persistent, or chronic active hepatitis or cirrhosis. The C/RL ratio had a sensitivity of 43%, a specificity of 100%, and an accuracy of 79% in cirrhosis. The sensitivity was very low in alcoholic cirrhosis, low in cryptogenic cirrhosis, and high in hepatitis B virus related cirrhosis. In spite of its fairly low overall sensitivity, the C/RL ratio is a useful measurement in assessing chronic liver disease because of its high specificity in cirrhosis.

Morphologic and motility changes of the gallbladder in response to acute liver injury. A prospective real-time sonographic study in 255 patients with acute viral hepatitis.

In 255 patients with acute viral hepatitis and in 50 healthy controls, wall thickness, volume, and percentage of maximal contraction of the gallbladder were prospectively evaluated using real-time ultrasonography. A hypotonic, hypokinetic gallbladder was shown in 58.4% of the cases, expressed by normal parietal thickness, larger volume, and lower response to fat stimulation than the controls. In the remaining patients, wall thickening, decreased volume, and reduced contraction were compatible with a hypertonic gallbladder. Because the latter pattern was never observed in patients with disease onset dating back more than 9 days, it is conceivable that gallbladder hypertonicity in the early phase of the illness is followed by depression of tone and motor activity. However, such sonographic features turned out to be short-lived and reversible as they disappeared in all patients within 3 weeks of the first ultrasound examination. Moreover, none of the sonographic abnormalities correlated with either biochemical indices of acute disease or the patients' long-term outcomes.

Echo-guided percutaneous puncture: a safe and valuable therapeutic tool for amebic liver abscess.

To clarify the therapeutic role of echo-guided percutaneous puncture (EPP) in management of amebic liver abscess, 20 patients (24 abscesses) received metronidazole plus EPP. Fluid was aspirated through Chiba needles under real-time sonographic guidance so as to reduce cavity size to less than 3 cm. Not more than two EPPs were necessary in the majority of cases and no complication followed the procedure. This scheme resulted in a shortening of time of both hospitalization (less than or equal to 20 days) and liver lesion healing as assessed by ultrasound (less than or equal to 4 months). It is concluded that EPP is a valuable and safe therapeutic tool for hepatic amebic abscess.

Correlation between virus genotype and chronicity rate in acute hepatitis C.

BACKGROUND/AIMS: Forty-two patients with the diagnosis of acute hepatitis C virus hepatitis were studied to investigate the relationship between hepatitis C virus genotype and progression to chronic infection. METHODS: The patients were followed for more than 1 year (mean age 29 years, male/female ratio 2.5). Intravenous drug use was documented in 15 cases, blood transfusion in four, surgical intervention, dental therapy or other parenteral exposure in 15, and unknown factors in the remaining eight. The evolution to chronicity was diagnosed on the basis of a persistent increase in transaminase levels, the presence of HCV-RNA and the histological pattern of chronic hepatitis. RESULTS: The majority of cases presented hepatitis C virus infection of subtype 1a (38.1%) or 1b (33.9%). Six cases showed the presence of genotype 3a (14.3%). Subtype 2c was observed in three out of four cases infected with genotype 2. No significant association was demonstrated with documented risk factors. The overall chronicity rate was 59.5%. This value increased to 92% in individuals infected with genotype 1b. By multivariate analysis the age-adjusted odds ratio for infection with genotype 1b as compared with all other genotypes was 14.4 (95% confidence interval; 1.52-137). Moreover, significant differences (p= 0.0002) were present in this group for histological activity index (8.7 as compared with 5-7). CONCLUSIONS: The results of this prospective study are consistent with an independent association between hepatitis C virus genotype 1b and a poor prognosis.

A histological study of hepatitis delta virus liver disease.

The histopathology of hepatitis delta virus disease was studied in carriers of HBsAg with chronic hepatitis delta antigen-positive hepatitis and in serial biopsies of patients with acute hepatitis delta virus hepatitis that progressed to chronicity. There was no histologic feature distinctive of hepatitis delta virus from other types of viral hepatitis. Biopsy specimens of patients with chronic disease exhibited portal and periportal inflammation with piecemeal necrosis, conforming to a picture of aggressive hepatitis often accompanied by cirrhosis. Characteristic was a marked intralobular infiltration by mononuclear cells and a degenerative eosinophilic change of the hepatocytic cytoplasms conducive to the formation of acidophilic bodies. Liver specimens from patients with hepatitis delta virus hepatitis exhibited aspects of focal, confluent and bridging necrosis. The disease progressed to chronicity irrespective of the original histological features. The expression of intrahepatic hepatitis delta antigen was reduced in the phase of the acute hepatitis but increased in parallel with the development of chronic active liver disease. In late-stage cirrhosis, expression of hepatitis delta antigen was usually low.

Delta infection in the Naples area. Epidemiologic and clinical significance.

To define the epidemiologic and clinical significance of delta infection in the Naples area, we sought anti-delta antibodies in all cases of HBV-associated liver diseases, hospitalized in our department during 1983 (234 acute hepatitis, 9 of which fulminant; 51 chronic hepatitis; 32 cirrhosis; 19 hepatocarcinomas) and in randomly selected acute hepatitis over the previous 6 years. Delta agent in acute forms and IgM anti-HBc in delta-positive acute forms were also tested. The acute cases were controlled for at least 9 months after dismissal. Delta infection showed a high prevalence in the Naples area (20% of all acute cases in 1983; similar prevalences in previous years; high rate of coinfections, 81%; no peculiar modalities of circulation) and a high pathogenicity, as proved by the greater prevalence in fulminant cases (66.7%) and severe chronic forms. Moreover superinfection appears a more dangerous event than coinfection as regards the diseases becoming chronic (77.8% vs 2.5%).

Efficacy of hepatitis A vaccine in prevention of secondary hepatitis A infection: a randomised trial.

BACKGROUND: Hepatitis A vaccination stops outbreaks of hepatitis A infection, but its efficacy against infection after exposure has not been proven. We investigated the use of hepatitis A vaccine to prevent secondary infections with hepatitis A virus (HAV). METHODS: We did a randomised controlled trial of hepatitis A vaccine in household contacts of people with sporadic HAV infection (index cases). Households (index cases and contacts) were randomly assigned to the vaccine group or unvaccinated group, according to the study week in which they were enrolled. All household contacts in the vaccine group received vaccination at the time of entry to the study. FINDINGS: During 45 days of follow-up, secondary infection had occurred in ten (13.3%) of 75 households (two families had two cases each) in the untreated group and in two (2.8%) of 71 households in the vaccine group. The protective efficacy of the vaccine was 79% (95% CI 7-95). The number of secondary infections among household contacts was 12 (5.8%) of 207 in the unvaccinated group and two (1.0%) of 197 in the vaccinated group. Therefore, 18 individuals needed to be vaccinated to prevent one secondary infection. INTERPRETATION: Hepatitis A vaccine is effective in the prevention of secondary infection of HAV and should be recommended for household contacts of primary cases of HAV infection.