Ultrasound detection of abdominal lymph nodes in chronic liver diseases. A retrospective analysis.

AIM: To retrospectively evaluate the prevalence of lymph nodes of the hepato-duodenal ligament in a group of patients with chronic liver disease of various aetiologies and to investigate what clinical, aetiological and laboratory data may lead to their appearance. MATERIALS AND METHODS: One thousand and three patients (554 men, 449 women) were studied, including 557 with chronic hepatitis and 446 with liver cirrhosis. The presence of lymph nodes near the trunk of the portal vein, hepatic artery, celiac axis, superior mesenteric vein and pancreas head was investigated using ultrasound. RESULTS: Lymph nodes were detected in 394 out of the 1003 study patients (39.3%); their number ranged from one to four, with a diameter ranging between 0.8 and 4 cm. The highest prevalence was in the subgroup of patients with primary biliary cirrhosis (87.5%), followed by patients with hepatitis C virus (HCV; 42%), patients with HCV and hepatitis B virus (HBV; 41.3%), autoimmune hepatitis (40%), and HBV alone (21.2%). In the alcoholic and idiopathic subgroups prevalence was 9.5%, while in the non-alcoholic steatohepatitis and haemochromatosis subgroups it was 0%. HCV RNA was present in 97 out of 103 lymph node-positive patients and in 141 out of 168 lymph node-negative HCV-negative patients (p<0.003). Lymphadenopathy frequency increased as the liver disease worsened (chi(2) MH=74.3; p<0.0001). CONCLUSION: Despite the limitations of a retrospective study, our data indicate a high prevalence of lymphadenopathy in liver disease patients; ultrasound evidence of lymph nodes of the hepato-duodenal ligament in a given liver disease may most likely suggest a HCV or an autoimmune aetiology and a more severe histological picture.

Evaluation by ultrasound of abdominal lymphadenopathy in chronic hepatitis C.

OBJECTIVE: Abdominal ultrasound has shown a frequent association between abdominal lymphadenopathy (LA) and chronic liver disease, but contradictory data have been reported on its relationship with the main parameters of hepatic function. The aim of this study was to correlate the prevalence of LA in patients who were chronic hepatitis-anti-hepatitis C virus positive prospectively followed-up over the last 3 years and its relationship with biochemical and histological data. METHODS: 136 RIBA II confirmed positive patients with ALT levels >2N were included. None of these had been or was at the time of study on interferon treatment. Ultrasound was performed using a Toshiba SSA 240 A apparatus with a 3.75 MHz convex probe; the operator was unaware of the other results. Diagnosis of chronic hepatitis in all cases was made on biopsy specimens; the histological activity index (HAI) score, according to Knodell, and the grading (G) and staging (S) scores, according to Desmet, were also evaluated. RESULTS: LA was found in 54 out of 136 patients (40%); accordingly, patients were divided into two groups: the LN + ve group included 54 patients (M 33, mean age 48.1+/-11.7 yr) and the LN-ve group included 82 patients (M 69, mean age 45.3+/-11.9 yr). LN + ve patients showed significantly higher serum levels of AST (p < 0.0005), ALT (p < 0.001), gammaGLO (p < 0.05) and gammaGT (p < 0.02) than LN - ve patients. There was a more severe degree of liver disease in LN + ve patients, expressed by the higher HAI (p < 0.002), G (p < 0.002), and S (p < 0.005). The chi2 test for linear association analysis confirmed the trend toward greater histological severity in LN + ve patients (chi2 MH = 10.2; p < 0.002). Logistic regression confirmed the association between the presence of LA and AST (p < 0.02), ALT (p < 0.03), G (p < 0.02), and S (p < 0.02). CONCLUSION: This study showed a moderate prevalence of LA in chronic hepatitis C, lower than that reported in other studies. LA was associated with serum parameters of cytolysis, and above all, with the severity of histological damage.

[Clinical and etiologic features of hepatocarcinoma in Sicily]. / Aspetti clinici ed etiologici dell'epatocarcinoma in Sicilia.

Hepatocellular carcinoma is a neoplasia with a high degree of malignancy and a quite unfavorable prognosis, and its frequency has tripled over the last 30 years. The aim of this study was to shed further light on some epidemiological and clinical aspects of hepatocellular carcinoma, on the basis of experience with a wide ranging patient population. We included 179 patients (127 males, 52 females, age range 31-86 years), diagnosed with hepatocellular carcinoma between January 1993 and December 1998. For each patient we recorded age, sex, coexistence and cause of cirrhosis, severity of cirrhosis, stage of hepatocellular carcinoma, serum markers of viral hepatitis (hepatitis B surface antigen and hepatitis C virus antibodies) and serum levels of alpha-fetoprotein. Hepatocellular carcinoma was associated with hepatitis C virus in 72% of patients, with hepatitis B virus in 10%, with combined infection in 3% and with negative viral markers in 15%. Mean age at diagnosis was significantly higher in the hepatitis C virus infection patients than in the combined infection patients (p < 0.04); the male/female ratio was 2.1:1 in the hepatitis C virus and 8:1 in the hepatitis B virus subjects. At hepatocellular carcinoma diagnosis, 175 out of 179 patients had liver cirrhosis with a significantly higher severity in patients with negative viral markers than in those with positive viral markers (p < 0.02). The stage of hepatocellular carcinoma at diagnosis was very advanced: in 103 out of 179 cases (58%) neoplasia was stage IV, with a stage I diagnosis in only 14 out of 179 (8%) cases. All the combined (hepatitis B and C virus) cases were diagnosed at stage IV, while hepatocellular carcinoma cases in patients with negative viral markers were diagnosed at earlier stages (66% stages I-II). Serum alpha-fetoprotein levels were above the normal limit (20 ng/mL) in 72% of patients; however, only 30% (54/179) had alpha-fetoprotein values > 400 ng/mL. These data confirm some previous epidemiological and clinical evidence concerning hepatocellular carcinoma (mean age at diagnosis, male/female ratio, severity of pre-existing liver disease, frequency of an associated hepatitis C and/or hepatitis B virus infection). Data based on such a large population, moreover, aid clarification of some still unresolved points such as the utilization of alpha-fetoprotein values in diagnosing hepatocellular carcinoma.

Ultrasound detection of abdominal lymphadenomegaly in subjects with hepatitis C virus infection and persistently normal transaminases: a predictive index of liver histology severity.

BACKGROUND/AIMS: The indications for liver biopsy in anti-HCV-positive patients with persistently normal alanine aminotransferase levels are not clearly established. Recent studies have correlated the presence of abdominal lymphoadenomegaly with disease severity in patients with chronic hepatitis C. Our study aimed to evaluate the frequency of abdominal lymphoadenomegaly in an anti-HCV positive blood donor population with persistently normal alanine aminotransferase and the relationship of abdominal lymphoadenomegaly with the severity of liver changes. METHODS: Eighty-six anti-HCV positive blood donors (58 M, 28 F) with normal alanine aminotransferase were followed up for a median of 31 months (range 12-50). To evaluate the frequency of abdominal lymphoadenomegaly, all patients underwent ultrasound scan. The common parameters of liver function as well as serum HCV RNA levels were determined. Histological changes were evaluated both in a conventional manner and using the numerical scoring systems of Knodell and Desmet. RESULTS: Of the 86 donors, 68 (79%) maintained persistently normal alanine aminotransferase levels during follow-up, and abdominal lymphoadenomegaly was present in 15 of them (22.0%). The remaining 18 donors (21%) showed rises in alanine aminotransferase above normal levels during the follow-up and seven of them (38%) had abdominal lymphoadenomegaly (p=n.s.). In the subjects with normal alanine aminotransferase, there were no significant differences in the common parameters of liver function and the serum presence of HCV RNA between those with or without abdominal lymphoadenomegaly. Normal liver was found in five patients without abdominal lymphoadenomegaly, but never in patients with abdominal lymphoadenomegaly. Analysis with the Mantel-Haenszel test showed a trend toward more serious changes in patients with abdominal lymphoadenomegaly (chi-square MH=9.5, p<0.003). Histological changes did not differ when Knodell's score was used; in contrast, staging, evaluated by Desmet's score, and periportal necrosis were significantly higher in subjects with abdominal lymphoadenomegaly (p<0.01 and p<0.004, respectively). Multiple logistic regression showed a significant relation between histological changes and the presence in serum of HCV RNA (p<0.004) and gamma-globulin (p<0.002), and abdominal lymphoadenomegaly p<0.003). CONCLUSION: Our study shows a prevalence of 22.0% of abdominal lymphoadenomegaly in anti-HCV positive subjects with normal alanine aminotransferase values and a relationship with the degree of liver histology change. Therefore, we suggest that the evidence of abdominal lymphoadenomegaly in these patients could be an indication to perform liver biopsy.

Acetylcysteine therapy for chronic hepatitis C: are its effects synergistic with interferon alpha? A pilot study.

OBJECTIVE: This trial reports the 6-month results of a pilot study using lymphoblastoid interferon alpha (IFNalpha) and acetylcysteine (N-acetylcysteine) separately and in combination in patients with chronic hepatitis C, genotype 1b, who were nonresponders to previous treatment with recombinant IFNalpha alone. PATIENTS AND METHODS: 21 patients were randomly divided into three groups of seven each. Group A was treated with lymphoblastoid IFNalpha 6MU three times a week for 6 months; group B received the same schedule of lymphoblastoid IFNalpha as group A plus acetylcysteine 1200 mg/day per os in two administrations, and group C received only acetylcysteine 1200 mg/day per os in two administrations. RESULTS: Mean serum alanine aminotransferase (ALT) levels at 6 months in groups A and B, but not in group C, were significantly lower than baseline values (p < 0.05 and p < 0.03, respectively). Two patients in group A (28.6%) and three in group B (42.9%), but none in group C, had normalised ALT levels at 6 months. During follow-up, levels flared in one group A and in one group B patient. Thus, at the end of follow-up one group A and two group B patients were sustained responders. At the end of therapy and follow-up, hepatitis C virus (HCV)-RNA was negative in one patient in group A and two patients in group B. As no serious adverse effects were observed, therapy was never interrupted or suspended. CONCLUSION: Acetylcysteine alone had no effect on hepatic cytolysis and viral replication; lymphoblastoid IFNalpha showed a modest, but better, response than recombinant IFNalpha, and the combination therapy, although in a limited number of patients, appeared to be more efficient than lymphoblastoid IFNalpha alone.

[Wilson's disease]. / Morbo di Wilson.

Wilson's disease is a rare inherited metabolic disorder usually characterized by liver and/or neurological degeneration. Unlike most genetically transmitted diseases, it rapidly responds to pharmacological treatment in case of early diagnosis and treatment. Often, however, as this disease presents with aspecific symptoms, patients are wrongly diagnosed as psychiatric cases or as having generic chronic liver disease and the true cause of symptoms is only discovered at a much later stage. The authors give a detailed review of the literature with the aim of presenting the most recent research on the main aspects of this disease and offering a practical and simple approach to early diagnosis.

[Ultrasonographic assessment of gallbladder motility in obese subjects]. / Valutazione ecografica della motilità colecistica nei soggetti obesi.

The reduction in gallbladder motility could play an important role in the pathogenesis of cholesterinic lithiasis by favouring the precipitation of cholesterol crystals, especially in obese subjects who, as is well known, present a greater biliary secretion of cholesterol. In the present study we evaluated, by ultrasonography, the emptying capacity of gallbladder following a liquid meal in 20 obese subjects (BMI 37.8 +/- 11.8 kg/m2) and in 20 control subjects (BMI 23.2 +/- 1.7 kg/m2). The base and residual volume of the gallbladder, expressed in ml, were significantly higher in the obese group than in the controls: 30.7 +/- 11.8 vs 22.0 +/- 6.7 (t = 2.88 p < 0.001) and 14.6 +/- 7.14 vs 10.2 +/- 4.7 (t = 2.14 p < 0.04), respectively. However, there was no significant difference between the percentages of gallbladder emptying in the two study groups, although in the obese subjects the minimum volume was reached at the 60th minute, while in the controls it occurred at 40 minutes. Our data, in agreement with most reports in the literature, indicate that the volume of the gallbladder is greater in obese subjects and they do not present an intrinsic defect in gallbladder contractility; therefore this condition can be excluded from the risk factors of biliary lithiasis in obese subjects.

Whipple's disease: a non-invasive approach for suspected diagnosis. Case report.

A case is presented of Whipple's disease with mild gastrointestinal symptoms. Abdominal ultrasonography and breath test after lactose load were of great help in the diagnostic phase and follow-up. Ultrasonography showed dilated and thickened ansae and abdominal lymph nodes which were considerably increased in volume and markedly hyperechoic; this latter aspect would seem to be typical of lymph adenomegalia secondary to Whipple's disease and is linked to the accumulation of fats. The breath test showed two H2 peaks, the first being early (30 min after lactose intake) suggesting high seated bacterial colonization. Intestinal biopsy confirmed the diagnosis of Whipple's disease. After 40 days of antibiotic treatment the clinical and laboratory pictures were almost normal and the breath test showed complete disappearance of H2 production, thus confirming the effectiveness of the treatment in eradicating the intestinal bacteria.

[Effects of cyclosporin A on various indices of cholestasis in kidney transplant recipients]. / Effetti della ciclosporina A su alcuni indici di colestasi nei trapiantati renali.

A cholestatic syndrome has been reported as one of the main side effects of CyA therapy. The aim of the present study was to evaluate frequency and degree of severity of the cholestatic syndrome in a group of patients with renal transplant treated with CyA. In 55 patients we evaluated both clinical: jaundice, pruritus, presence of biliary lithiasis and biochemical parameters: total serum biliary salts (TBS), total bilirubin (TB), alkaline phosphatase (AP), gammaglutamyl transpeptidase (GGT), transaminase (AST, ALT), cholesterol (CT), triglycerides (TG), HDL-cholesterol (HDL-C) and compared them with a control group matched for sex and age. In the transplant patients significantly higher values of TBS, TB, AP (p < 0.05) were found; 55% of the patients had above mean values of at least one of the classical parameters of liver function and an higher frequency of biliary lithiasis was also found, in the absence of the classical risk factors. However, none of the patients presented severe signs of hepatic disease and to date it has never been necessary to stop treatment. In conclusion, our study shows that the dosage of CyA used at present is quite safe; however, it is necessary to monitor in these patients some parameters of liver function to prevent the minor side effects we observed from progressing into more serious damage.

[Incidence of anti-HCV positivity in a Sicilian population with liver diseases]. / Frequenza di positività per anti-HCV in una popolazione di epatopatici siciliani.

The discovery of virus C as an etiological agent of chronic liver disease (CLD) has modified previously-held concepts concerning the etiology of this disease. In a study of 581 consecutive patients with CLD, we confirmed that virus C was the sole agent responsible for it in 64.2% of all cases. Moreover, virus C was characteristically associated with virus B, alcohol consumption, and autoimmunity. When the various CLD were separated into subgroups, i.e., chronic persistent hepatitis (CPH), chronic active hepatitis (CAH), and liver cirrhosis (LC), virus C continued to be the main etiological agent, varying from 60.5% to 68.3%: this suggested constant evolution from milder to more severe forms of liver disease. Virus B alone was found less frequently, probably thanks to the virtual elimination of post-transfusion hepatitis B and the anti-B virus vaccination which is now widely administered. Frequency was 15.2% in the CPH group but lower in the LC and CAH groups (7.4% and 6.3% respectively), suggesting that evolution from the milder to the more severe forms of liver disease may not occur. Finally, we confirmed a statistically significant difference in mean age between hepatitis C virus positive men and women (p < 0.0001): in men, frequency was higher in the 20- to 50-year-old group; in women it was higher in the 50+year-old group.