Hepatobiliary and pancreatic manifestations in inflammatory bowel diseases: a referral center study.

BACKGROUND: Hepatobiliary and pancreatic manifestations have been reported in patients with Crohn's disease or ulcerative colitis. Our aim was to describe the prevalence of hepatobiliary and pancreatic manifestations in inflammatory bowel disease and their association with the disease itself and the medications used. METHODS: Data were retrospectively extracted from the clinical records of patients followed up at our tertiary IBD referral Center. RESULTS: Our study included 602 IBD patients, with liver function tests at regular intervals. The mean follow-up was 5.8 years (Std. Dev.: 6.72). Abdominal imaging examinations were present in 220 patients and revealed findings from the liver, biliary tract and pancreas in 55% of examined patients (120/220). The most frequent findings or manifestations from the liver, biliary tract and pancreas were fatty liver (20%, 44/220), cholelithiasis (14.5%, 32/220) and acute pancreatitis (0.6%, 4/602), respectively. There were 7 patients with primary sclerosing cholangitis. Regarding hepatitis viruses, one-third of the patients had been tested for hepatitis B and C. 5% (12/225) of them had positive hepatitis B surface antigen and 13.4% had past infection with hepatitis B virus (positive anti-HBcore). In addition, most of the patients were not immune against hepatitis B (negative anti-HBs), while 3% of patients were anti-HCV positive and only one patient had active hepatitis C. Furthermore, 24 patients had drug-related side effects from the liver and pancreas. The side effects included 21 cases of hepatotoxicity and 3 cases of acute pancreatitis. Moreover, there were two cases of HBV reactivation and one case of chronic hepatitis C, which were successfully treated. CONCLUSION: In our study, approximately one out of four patients had some kind by a hepatobiliary or pancreatic manifestation. Therefore, it is essential to monitor liver function at regular intervals and differential diagnosis should range from benign diseases and various drug related side effects to severe disorders, such as primary sclerosing cholangitis.

Systemic hemodynamic response to terlipressin predicts development of hepatorenal syndrome and survival in advanced cirrhosis.

BACKGROUND: The aim of this study was to predict the occurrence of hepatorenal syndrome (HRS) and death in patients with advanced cirrhosis and ascites. PATIENTS AND METHODS: We retrospectively evaluated 2-year data of 78 patients with cirrhosis and ascites (Child-Pugh B/C: 45/43). The mean arterial pressure (MAP) and cardiac output (CO) were measured in all patients just before administration of 2 mg of terlipressin and 30 min later. Systemic vascular resistance (SVR) was calculated as MAP/CO. ΔMAP, and ΔCO, and ΔSVR were defined as the percentage change of MAP, CO, and SVR, respectively, after terlipressin injection. Plasma renin activity (PRA) and plasma aldosterone were evaluated at baseline. Two multivariate models were used: one excluding (model 1) and one including (model 2) the Model of End-stage Liver Disease score. RESULTS: Higher ΔSVR, Model of End-stage Liver Disease score, and PRA were related independently to the severity of cirrhosis. Independent predictors of HRS at 12 and 24 months were ΔSVR (models 1/2: P=0.008/0.01 and 0.01/0.02, respectively), ΔCO (models 1/2: P=0.01/0.03 and 0.03/0.04, respectively), and PRA (models 1/2: P=0.04 and model 1: P=0.04, respectively). ΔSVR at 12 and 24 months (models 1/2: P=0.005/0.01 and 0.01/0.03, respectively) and ΔCO at 24 months (models 1/2: P=0.02/0.01, respectively) were related independently to survival. Patient groups with significantly higher probability of HRS and mortality were identified by certain cutoffs of ΔSVR (20.6 and 22.8%, respectively) and ΔCO (-10.6 and -11.8%, respectively). ΔSVR and ΔCO independently predicted survival in patients with the most advanced cirrhosis and infection-related survival. CONCLUSION: An increase in SVR by at least 20% and a decrease in CO at least 10% in response to terlipressin could predict HRS and mortality in patients with advanced cirrhosis.

von Willebrand factor and procoagulant imbalance predict outcome in patients with cirrhosis and thrombocytopenia.

BACKGROUND & AIMS: Several lines of evidence suggest that the hemostatic disorders of cirrhosis may have a significant clinical impact. We investigated the independent predictive value of components of the hemostatic system on the occurrence of ascites, variceal bleeding (VB), and survival. METHODS: One hundred and two patients with thrombocytopenia (Child-Pugh class A/B/C: 34/34/34) were enrolled. Platelet counts, factors (F) II, V, VII, and VIII, antithrombin, protein C (PC), FVIII-to-PC ratio as an index of procoagulant imbalance, von Willebrand factor antigen (vWF-Ag), and model for end-stage liver disease (MELD) were evaluated. Two multivariate analyses were performed: one excluding (model 1) and one including MELD (model 2). RESULTS: Higher vWF-Ag levels and FVIII-to-PC ratios were the most prominent hemostatic disorders in patients with cirrhosis. Increased levels of vWF-Ag and FVIII, and higher FVIII-to-PC ratios independently predicted the presence of ascites and varices at baseline. Independent predictors of ascites and VB during follow-up were vWF-Ag (model 1/2: p=0.001/p=0.009 and p=0.008/p=0.01, respectively) and FVIII-to-PC ratio (model 1/2: p=0.003/p=0.02 and p=0.01/p=0.03, respectively). vWF-Ag (model 1/2: p=0.007/p=0.002), FVIII-to-PC ratio (model 1/2: p=0.001/p=0.01), and MELD (p=0.02) independently predicted mortality. Patient groups with significantly higher probability of new-onset ascites, VB, and mortality were identified by certain cut-offs of vWF-Ag (213%, 466%, and 321%, respectively) and FVIII-to-PC ratio (1.99, 3.29, and 2.36, respectively). vWF-Ag and FVIII-to-PC ratio equaled MELD in mortality prediction. CONCLUSIONS: Advanced cirrhosis is characterized by increased thrombotic potential. vWF-Ag and FVIII-to-PC ratio independently predict new-onset ascites, VB, and mortality. Targeting hypercoagulability could improve the outcome of patients with cirrhosis. LAY SUMMARY: Higher von Willebrand factor antigen (vWF-Ag) levels and factor VIII-to-protein C (FVIII-to-PC) ratio are the prominent hemostatic disorders in patients with cirrhosis. vWF-Ag and FVIII-to-PC ratio independently predict new-onset ascites, variceal bleeding, and mortality in these patients.

Thrombin generation measured as thrombin-antithrombin complexes predicts clinical outcomes in patients with cirrhosis.

AIM: Hypercoagulability has been detected in patients with cirrhosis yet its clinical significance remains unclear. We investigated the association of hypercoagulability with clinical outcomes in patients with cirrhosis. METHODS: Thrombin-antithrombin (TAT) complexes as thrombin generation (TG) marker, D-dimer, antithrombin (AT), protein C, protein S, international normalized ratio (INR), activated partial thromboplastin time, fibrinogen, Child-Pugh class and Model for End-Stage Liver Disease (MELD) were evaluated. Two different multivariate analyses were performed: one not including MELD (model 1) and one including MELD and excluding INR (model 2). RESULTS: Eighty-one patients (Child-Pugh class A/B/C: 27/27/27) and 40 healthy subjects were enrolled. Only ΤΑΤ and AT were independently associated with increasing liver disease severity. Increased TAT levels and MELD score were significantly associated with ascites and varices at baseline. Independent predictors of follow-up events were: TAT and MELD score for new-onset ascites; TAT and AT for variceal bleeding (VB); TAT and AT for portal vein thrombosis (PVT); and TAT and MELD for mortality. TAT equaled MELD in mortality prediction at 12 and 18 months. TAT cut-offs at 5.35, 14.6, 13.5 and 9.25 ng/mL identified patient groups with significantly higher probability of new-onset ascites, VB, PVT and mortality, respectively. CONCLUSION: Increased TG is strongly correlated with portal hypertension-related complications, PVT and mortality in patients with cirrhosis. Measuring TG by TAT could enable risk stratification and institution of preventive strategies to improve clinical outcomes.

Red face, postendoscopy.

The authors present a case report of extensive facial petechiae following esophagogastroduodenoscopy (EGD). The patient was a previously healthy male who did not receive any medication predisposing to haemorrhage, nor did he suffer from any underlying disorder (as the subsequent diagnostic work-up demonstrated) that predisposed to the extensive facial capillary rupture. Increased intrathoracic pressure during EGD can rarely result in similar cases that are alarming to the patient and possibly the endoscopy staff, and awareness of their potential and their benign nature and prognosis can assist in reassuring patients.

Platelet IgG antibodies are significantly increased in chronic liver disease.

BACKGROUND: The aim of this study was to investigate the presence of IgG antiplatelet (anti-P) IgG antibodies in patients with chronic liver disease (CLD) of diverse but well defined etiology. METHODS: One-hundred fifty-six consecutive patients with CLD (65 with chronic hepatitis B, 57 with chronic hepatitis C, 23 with alcoholic liver disease and 11 with primary biliary cirrhosis), and 240 healthy blood donors were investigated for the presence of anti-P antibodies. RESULTS: Anti-P antibodies were present in 36.5% (57/156) of patients with CLD, and 2.9% (7/240) of controls (P=0.0001). In detail, anti-P antibodies were detected in 35.4% (23/65) of patients with chronic hepatitis B, 26.3% (15/57) of patients with chronic hepatitis C, 47.8% (11/23) of patients with alcoholic liver disease and 72.7% (8/11) of those with primary biliary cirrhosis. The study also demonstrated the significantly higher prevalence of anti-P antibodies in patients with cirrhosis (53.0%) than in non cirrhotic patients (26.4%, P=0.0018). The association of anti-P antibodies with thrombocytopenia was inconsistent. CONCLUSIONS: This study showed a high prevalence of anti-P IgG antibodies in patients with CLD compared to healthy controls.

Acute Haemophilus parainfluenzae endocarditis: a case report.

INTRODUCTION: Numerous pathogens can cause infective endocarditis, including Haemophilus parainfluenzae. H. parainfluenzae is part of the H. aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae group that may cause about 3% of the total endocarditis cases, and is characterized by a subacute course and large vegetations. CASE PRESENTATION: Acute H. parainfluenzae endocarditis developed in a 54-year-old woman, with no underlying predisposing factors. The patient presented with fever of 3 days duration and a severe headache. Magnetic resonance imaging of the brain revealed multiple cerebral emboli with hemorrhagic foci. Upon suspicion of endocarditis, cardiac transesophageal ultrasonography was performed and revealed massive vegetations. The patient underwent emergency mitral valve replacement, and was further treated with ceftriaxone. Blood cultures grew H. parainfluenzae only after valve replacement, and a 6-week course of ceftriaxone was prescribed. CONCLUSION: We underline the typical presentation of large vegetations in H. parainfluenzae endocarditis, which are associated with embolic phenomena and resulting severity. Although the majority of the few cases reported in the literature are subacute in progress, our case further underlines the possibility that H. parainfluenzae endocarditis may develop rapidly. Thus, awareness of the imaging characteristics of the pathogen may enhance early appropriate diagnosis and therapeutic response.

Weil's disease in a patient with chronic viral hepatitis and history of alcohol abuse.

Clinical and laboratory diagnosis of severe leptospirosis (Weil's disease) may be difficult when other pathological processes that may cause similar clinical syndromes or affect immune response to infections coexist. In addition, the optimal management of the disease remains to be defined. We report on a case of Weil's disease, in which concurrent chronic hepatitis B virus infection and alcohol abuse caused diagnostic and therapeutic difficulties.

The globalization of leptospirosis: worldwide incidence trends.

OBJECTIVES: Leptospirosis continues to be a significant zoonosis of the developing world. Globalization, in the context of international travel, particularly for recreational activities and military expeditions, has led to increased exposure of individuals from the developed world to the disease, as recent outbreaks show. METHODS: We evaluated the trends in annual leptospirosis incidence for individual countries worldwide through reports from national and international organizations, the published medical literature on the subject, and web searches with the terms 'leptospirosis' and the individual country names. Inter-country variations in leptospirosis incidence, when relevant official data were available, were also analyzed. RESULTS: The Caribbean and Latin America, the Indian subcontinent, Southeast Asia, Oceania, and to a lesser extent Eastern Europe, are the most significant foci of the disease, including areas that are popular travel destinations. CONCLUSIONS: Leptospirosis is a re-emerging zoonosis of global importance and unique environmental and social correlations. Attempts at global co-ordination and recognition of the true burden of an infectious disease with significant mortality should be encouraged.

Baseline cholesterol is associated with the response to antiviral therapy in chronic hepatitis C.

BACKGROUND: Hepatitis C virus (HCV) partially interacts with low-density lipoprotein (LDL) receptors, suggesting a role for lipids in regulating HCV clearance. Our aim was to study if baseline lipids can discriminate responders from non-responders among patients with HCV infection. METHODS: A total of 109 HCV patients were studied. Laboratory measurements included serum lipids, aminotransferases and viral load, as well as HCV genotype determinations. RESULTS: Responders (n = 53) had significantly higher serum baseline levels of total cholesterol, LDL cholesterol and apolipoprotein B compared to non-responders (n = 56). Multivariate logistic regression analysis showed that a 10 mg/dL increase in total cholesterol was associated with 3.02 higher odds of responding to treatment (95% CI 1.74-5.32, P < 0.001), while a 10 mg/dL increase in apolipoprotein B levels was associated with 1.81 higher odds of responding to treatment (95% CI 1.37-2.54, P < 0.001), after adjustment for age, sex, body mass index (BMI), smoking habits, baseline viral load, liver histology and administration of pegylated interferon. An inverse association between BMI and response to treatment was also evident (adjusted odds ratio 0.73, 95% CI 0.55-0.96; P = 0.03). CONCLUSION: Baseline serum total cholesterol levels and BMI could be helpful in discriminating responders to antiviral therapy among patients with HCV infection.

Treatment of neurobrucellosis: what is known and what remains to be answered.

Neurological involvement is one of the most perplexing and diverse presentation complications of brucellosis, a worldwide prevalent zoonosis. This review presents the current knowledge available from medical literature and discusses the shortcomings of the existing data. A proposed regimen should include doxycycline and rifampicin and, with the benefit of doubt, ceftriaxone, since its high concentration in the cerebrospinal fluid may offer significant efficacy against the pathogen. Corticosteroids have been used in specialized situations. The use of streptomycin is discouraged owing to its questionable ability to penetrate into the cerebrospinal fluid and its potential neurotoxicity that may perplex the clinical presentation. Treatment duration should be individualized in the absence of an adequate cut-off index.