Clinical Indicators of Bone Deterioration in Alcoholic Liver Cirrhosis and Chronic Alcohol Abuse: Looking beyond Bone Fracture Occurrence.

Although previous studies indicated that chronic alcohol abuse (CAA) and alcoholic liver cirrhosis (ALC) are associated with increased bone fragility, understanding bone fragility determinants is still modest in these individuals. We used a comprehensive individualized clinical fracture risk assessment approach (vertebral osteodensitometry, femoral osteodensitometry and geometry, and serum bone turnover biomarkers) to compare adult male patients with ALC who have not previously had femoral or vertebral fractures (n = 39), patients with CAA (without liver cirrhosis, n = 78) who have not previously had femoral or vertebral fractures and healthy age- and sex-matched controls (n = 43). Our data suggested that intertrochanteric bone mineral density was significantly lower in ALC and CAA patients than in controls. Also, the trabecular bone score was considerably lower in ALC patients compared with CAA and control individuals. The most significant inter-group differences in femoral geometry were noted on the femoral shaft. Patients with ALC and CAA have a higher 10-year risk of major osteoporotic fractures compared to the controls. Analysis of bone turnover biomarkers showed increased osteoprotegerin and beta-C-terminal telopeptide serum concentrations and decreased insulin growth factor-1 concentrations in patients with ALC compared to CAA and control groups. Our data revealed that bone alterations are present in patients with ALC and CAA even if they did not sustain a nontraumatic bone fracture, but it is also indicative that current bone-assessing clinical methods are not entirely reliable. Thus, future studies should focus on developing a reliable integrative clinical tool that can be used to accurately predict and prevent bone fracture occurrences in patients with ALC and CAA.

Intrahepatic Cholestasis of Pregnancy: A Case Study of the Rare Onset in the First Trimester.

Intrahepatic cholestasis of pregnancy (ICP) is a gestation-specific liver disorder, defined most often as the onset of pruritus, usually from the third trimester of pregnancy, associated with abnormal liver test results and/or increased total serum bile acids and spontaneous relief after delivery. The 21-year-old patient was admitted to our ward in the 11th week of pregnancy due to raised liver enzymes. The first onset of pruritus and jaundice appeared a month before hospitalization. Immunology tests and Toxoplasma gondii were negative. We excluded viral etiology, while alpha-1-antitrypsin, serum and urine copper levels, and thyroid hormones were within the reference values. The patient denied she had taken any medicines and herbal preparations before and during pregnancy. Total bile acids in the serum were significantly elevated (242 µmol/L). The abdominal ultrasound revealed a regular finding. Liver biopsy suggested a cholestatic liver disorder. After a presentation of all risks, the patient decided to stop the pregnancy. After a month, the hepatogram was within the reference values. Very rarely an ICP can occur in early pregnancy (first trimester), which calls for close monitoring. The risk of serious adverse fetal outcomes and spontaneous preterm delivery is proportional with increased levels of maternal serum bile acid.

Primary amyloidosis presenting with cholestasis and hyperkinetic portal hypertension.

Amyloidosis is not a single disease, but a series of diseases in which there is extracellular deposition of a protein in an abnormal fibrillar form. We report a 48-year old woman with subicteric coloration of scleras and hepatomegaly. Functional liver tests evidenced a high level of alkaline phosphatase and serum gamma-glutamyl transpeptidase with mild increase of bilirubin level. Color Doppler ultra-sonography, showed a hyperkinetic portal hypertension. The liver biopsy found amyloid in sinusoids subendothelially. Immunohistochemical staining for anti lambda light chain immunoglobulin was positive. Bone marrow morphology and immunohistochemistry confirmed lymphoplasmocytic lymphoma with amyloidosis.

[Epoprostenol in the treatment of portopulmonary hypertension]. / Epoprostenol u terapiji portnoplucne hipertenzije.

Primary or non-hemodynamic pulmonary hypertension is characterized by the increased pulmonary arterial pressure, higher than 3.32 kPa, and normal pulmonary capillary pressure less than 1.99 kPa. Primary pulmonary hypertension is a rare complication of portal hypertension, which significantly increases surgical morbidity and mortality, and it is not reversible after liver transplantation. As a rule, clinical manifestations of pulmonary hypertension are disguised by complications of portal hypertension. The symptoms of chronic pulmonary heart, such as peripheral edema and ascites, are usually ascribed to liver insufficiency and/or portal hypertension. Clinical significance of portopulmonary hypertension follows from the fact that the failure of the right heart is most commonly the direct cause of death in these patients. The majority of authors concurs that the right heart catheterization is the most valid method for diagnosis of portopulmonary hypertension. Doppler echocardiography represents quite valuable non-invasive diagnostic method, especially in patients with extensive spontaneous and surgical porto-systemic collaterals, rendering the high risk group of cases. Epoprostenol (prostacyclin), administered via continuous infusion, diminishes the platelet aggregation and causes the intense pulmonary and systemic vasodilatation. Good hemodynamic effect of this substance was verified in patients with primary pulmonary hypertension. Several articles have reported that long-term, continual epoprostenol administration in dose of 10 to 28 ng/kg/min. Has significantly reduced pulmonary vascular pressure and pulmonary vascular resistance. Portopulmonary hypertension represented the absolute contraindication for liver transplantation. Huge clinical significance of epoprostenol reflects in the fact that, along with the improvement of pulmonary hemodynamics, it provides the prerequisite for liver transplantation in patients with portopulmonary hypertension.