Preventive strategies in chronic liver disease: part I. Alcohol, vaccines, toxic medications and supplements, diet and exercise.

Chronic liver disease is the 10th leading cause of death in the United States. Hepatitis C virus infection is the most frequent cause of chronic liver disease and the most common indication for liver transplantation. Preventive care can significantly reduce the progression of liver disease. Alcohol and hepatitis C virus are synergistic in hastening the development of cirrhosis; therefore, patients with hepatitis C infection should abstain from alcohol use. Because superinfection with hepatitis A or B virus can lead to liver failure, vaccination is recommended. Potentially hepatotoxic medications should be used with caution in patients with chronic liver disease. In general, nonsteroidal anti-inflammatory drugs should be avoided; acetaminophen in a dosage below 2 g per day is the safest choice. Many herbal remedies are potentially hepatotoxic, and only milk thistle can be used safely in patients who have chronic liver disease. Weight reduction and exercise can improve liver function in patients with fatty liver.

Lactulose-induced pneumatosis intestinalis and pneumoperitoneum.

A case of PI in a 57-year-old patient with colonic inertia treated with lactulose for PSE secondary to cirrhosis is described. The colonic inertia led to longer transit time. Retained lactulose and a build-up of carbon dioxide and hydrogen gas occurred in the setting of altered bacterial flora deficient in hydrogen metabolism. The increased gas pressure caused extravasation of air into the intestine, causing PI with pneumoperitoneum. They both resolved with discontinuation of lactulose.

Can one predict when ultrasound will be useful with percutaneous liver biopsy?

OBJECTIVE: We previously showed that ultrasound altered position of biopsy in 15% of cases by demonstrating intervening structures. This study was designed to test whether one could predict in which cases ultrasound would be useful. METHODS: A standard percussion technique was used. The site chosen was marked. Criteria were established to indicate whether a move might be predicted to be likely. If 10 or more points were assigned, then it was predicted that ultrasound would change position. A difficult percussion was assigned 10 points; obesity, 5 points; and chest deformity, 5 points. The ultrasound was then applied to the marked spot in every case. If an intervening structure was present within 6 cm, the biopsy site was moved. Otherwise, the biopsy was taken from the marked site. RESULTS: One hundred seventeen consecutive liver biopsies were included between January 1999 and January 2000. The criteria predicted the desirability of nine moves. No moves were made, however, in these cases. In 17 cases (14.5%), moves were made because of intervening structures. None of the cases were predicted. A move was made in 1 of 23 obese patients. There was no statistical difference in moves made between obese and nonobese patients. CONCLUSIONS: Using criteria of difficult percussion, obesity, and unusual chest shape, we could not predict when ultrasound would be useful. This is in contrast to the belief that ultrasound can be applied to selected liver biopsies considered in advance to be more difficult, as in the obese patients, and instead suggests that to avoid intervening structures, one should apply ultrasound to all cases.

Preventive strategies in chronic liver disease: part II. Cirrhosis.

Cirrhosis is a diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules. The modified Child-Pugh score, which ranks the severity of cirrhosis based on signs and liver function test results, has been shown to predict survival. Strategies have been established to prevent complications in patients with cirrhosis. Esophageal varices can be identified by endoscopy; if large varices are present, prophylactic nonselective beta blocker therapy should be administered. Alpha-fetoprotein testing and ultrasonography can be effective in screening for hepatocellular carcinoma. Vaccines should be administered to prevent secondary infections. The use of nonsteroidal anti-inflammatory drugs should be avoided, and patients should maintain a balanced diet containing 1 to 1.5 g of protein per kg per day. An extensive assessment should be performed before patients with cirrhosis undergo elective surgery. Before advanced liver decompensation occurs, patients should be referred for liver transplantation evaluation. If advanced cirrhosis is present and transplantation is not feasible, survival is between one and two years.

Is nausea associated with chronic hepatitis C infection?

OBJECTIVES: Hepatitis C virus is a common chronic infection that is widely associated with symptoms of fatigue and pain in the right upper quadrant. Nausea may be an underrecognized symptom. This study was designed to study the frequency of nausea in patients with hepatitis C virus infection compared to controls. METHODS: A cross-sectional study design with consecutive outpatients was used. Three groups were administered a dyspepsia and a previously validated Nausea Profile questionnaire. Univariate and multivariate analysis was performed. RESULTS: A total of 64 hepatitis C virus (HCV) patients, 53 liver disease controls (LC), and 64 normal controls (NC) were studied. An increased period prevalence of nausea was found in HCV patients 43% versus 29.7% in NC and 18.9% in LC (p = 0.009). There was an increased frequency of fatigue and abdominal pain in HCV patients over 1 month compared to LC and NC combined (p = 0.0001 and 0.0065 respectively). The Nausea Profile score revealed statistically higher total scores and higher subscale scores in the HCV group compared to controls. The total NP score expressed as a percentage of the maximum was 27% in HCV versus 12.7% for LC and 9.2% for NC (p = 0.0005). The odds of nausea using logistic regression were 2.1 CI (1.0-4.5) in HCV patients compared to controls (p = 0.05). Using linear regression, higher Nausea Profile scores were found to be independently associated with the diagnosis of HCV (.0005), fatigue (p = 0.0003), and abdominal pain (p = 0.0001). CONCLUSIONS: HCV infection is associated with an increased risk for nausea. The strong association between abdominal pain and nausea may be a clue to the etiology of nausea in these patients. Further etiological studies are needed.

Preventive care in chronic liver disease.

OBJECTIVE: To identify preventive care measures that are appropriate for and specific to patients with chronic liver disease and to provide recommendations and information that can be shared with patients. MEASUREMENTS: A review of the literature was undertaken using MEDLINE from 1970 to present. Priority was given to randomized controlled studies, but case reports, case-control studies, and reviews were included. MAIN RESULTS: Evidence for the avoidance of alcohol and other toxic substances, immunizations, and dietary modifications for chronic liver disease is summarized. In addition, measures that are effective in the mitigation of the complications of cirrhosis are reviewed. CONCLUSIONS: Preventive care can play an important role in patients with chronic liver diseases. Based on the existing data, the preventive strategies of alcohol avoidance, hepatitis vaccination, avoidance of NSAIDs nonsteroidal anti-inflammatory drugs, iron supplementation when appropriate, and a low-fat diet are prudent in patients with chronic liver disease. Once cirrhosis develops, screening for hepatocellular cancer with alpha-fetoprotein testing and ultrasound, and screening for varices by endoscopy are justified.

How often does ultrasound marking change the liver biopsy site?

OBJECTIVES: The aim of this study was to answer the question: How often does ultrasound change the liver biopsy position, when a percussion technique is applied, because of intervening structures? A secondary objective is to compare the performance of the hepatologist to a radiology technician to demonstrate safety of a self-training technique. METHODS: One hundred sixty-five consecutive outpatient liver biopsies were studied. Using a standard percussion technique, a biopsy site was chosen and marked. Ultrasound was applied to the marked site. An adequate site was determined to be one without intervening structure within 6 cm of liver depth. If an intervening structure was found, an alternative site was chosen by ultrasound. Data recorded included reason for change of position, distance of moved site from original site, and complications. The first third of liver biopsies were done with assistance of a certified radiology technician performing ultrasound, the last two-thirds were done by the hepatologist after observing the first 64 biopsies. RESULTS: Ultrasound changed the position in 21 of 165 patients. The ultrasound caused an abortion of the procedure in 4 of 165 patients. Ultrasound changed management in 15.1% of patients. Reasons for change were lung (10 patients), gallbladder (6), large central vessel (4), >4-cm rim of ascites (2), colonic loop (1), slim liver edge (1), and focal liver lesions (1 patient). There was a 1.8% multiple pass rate. No serious complications occurred. CONCLUSIONS: Ultrasound changed management 15.1% of patients. A hepatologist could perform ultrasound marking after a period of observation, without compromising results. A low multiple pass rate was observed when applying ultrasound and percussion. Avoided structures could explain decrease in pain when ultrasound is applied.

Ibuprofen-induced hepatotoxicity in patients with chronic hepatitis C: a case series.

Hepatitis C is a common chronic infection. Nonsteroidal anti-inflammatory drugs are commonly ingested both over-the-counter and by prescription. This case report describes three cases where ibuprofen use leads to a marked rise in hepatic transaminases with one case repeating on rechallenge. These cases support the recommendation of acetaminophen over nonsteroidal antiinflammatory drug use in patients with chronic hepatitis C.

Peloisis hepatis due to Bartonella henselae in transplantation: a hemato-hepato-renal syndrome.

BACKGROUND: Bacillary peliosis hepatis is an uncommon but well recognized disease due to disseminated Bartonella infections occurring predominantly in immunocompromised individuals infected with human immunodeficiency virus, type 1. A similar condition in the absence of Bartonella infection when described in organ transplant patients was felt to be secondary to azathioprine and/or cyclosporine. METHODS: Herein, we report the first case of bacillary peliosis hepatis due to systemic Bartonella henselae infection in a patient after kidney transplant. The patient presented with severe anemia, persistent thrombocytopenia, and hepato-renal syndrome. DNA-based polymerase chain reactions (PCR), which allowed direct detection of both B henselae and quintana DNA in patient's peripheral blood and liver tissue, were used. Indirect immunofluorescence assay for Bartonella serology was performed on peripheral blood. RESULTS: Histopathology of the liver biopsy demonstrated peliosis hepatis. Indirect immunofluorescence assay for Bartonella serology was positive, and B henselae DNA was identified by PCR in the peripheral blood and liver tissue. Treatment with a 3-month course of oral erythromycin resulted in an excellent clinical response. CONCLUSIONS: The present case suggests that although various anti-rejection therapies and opportunistic infections are associated with hepatic and renal dysfunction along with bone marrow suppression, the diagnostic evaluation in this situation should include liver biopsy and a careful search for evidence of systemic Bartonella infection, e.g., exposure to cats, Bartonella serology, and Bartonella DNA by PCR. A reduction in immunosuppression and prolonged therapy with antibiotics such as erythromycin will often result in early recovery.

A case series of transplant recipients who despite immunosuppression developed inflammatory bowel disease.

OBJECTIVES: We describe 14 patients who developed inflammatory bowel disease (IBD) after transplantation despite immunosuppression. METHODS: Using an electronic medical archival retrieval system, records of 6800 liver and kidney transplant patients were searched for evidence of IBD. The pathology was reviewed, and infectious etiologies were excluded. RESULTS: Fourteen patients developed IBD after transplantation. Twelve patients had undergone liver transplantation, and two kidney transplantation. Four had transplantation for autoimmune hepatitis; four for non-A, non-B, non-C hepatitis; two for primary sclerosing cholangitis; one for giant cell hepatitis; one for biliary atresia; one for polycystic kidney disease; and one for obstructive uropathy. Mean age at development of IBD was 38 yr. Mean time to development of IBD after transplantation was 4 yr. Endoscopically there were two cases limited to the left side, eight of pancolitis, of which one had terminal ileal disease, and four of patchy colitis. Histology was consistent with ulcerative colitis in nine patients and Crohn's disease in five. Patients with ulcerative colitis either responded and remained in remission on maintenance therapy (seven of nine) or were refractory and required a colectomy (two of nine). Patients with Crohn's disease continued to have flares despite treatment (five of five). CONCLUSION: 1) New onset IBD can develop after solid organ transplantation, despite use of immunosuppressive therapy. 2) A full spectrum of IBD can be seen after transplantation. 3) Study of these patients could shed light on why immunosuppression is not uniformly effective for IBD and provide clues to the inflammatory determinants of IBD.