Degree Of Liver Involvement Research Articles

Use of Stent in Choledochocholedochostomy for Pediatric Liver Transplantation Secondary to Hepatoblastoma: A Case Report

BACKGROUND: Hepatoblastoma is a malignant tumor with an insidious clinical presentation, however, it is characterized by an increase in abdominal circumference. In addition, there is PRETEXT staging based on the degree of liver involvement, which ranges from I to IV, of these, for stage IV the treatment of choice is liver transplantation. In addition, the use of stents in the the choledocho – choledochostomy has been tried to reduce post-transplant complications, with variable results. THE CASE: A 18-month-old female with a diagnosis of PRETEXT IV hepatoblastoma and a history of receiving 11 cycles of chemotherapy (CTX) with SIOPEL-3HR scheme, subsequently initiates protocol to receive liver transplantation for being an ideal candidate and PRETEXT IV staging, received from a related living donor. During surgery, it was decided to place a biodegradable stent to perform the choledocho – choledochostomy. She also had hemorrhagic shock grade IV secondary to blood loss, which was successfully resolved. In her first two days post-transplantation she presented adequate flows by Doppler ultrasound and liver enzymes with a downward trend, which remained with the same trend, and she was discharged on day 26 post-transplantation. The following month, she received a cycle of adjuvant CTX with SIOPEL-3HR scheme, without complications. One month later she presented cholestasis and jaundice, so the stent was removed. Currently free of disease, functional graft, and adequate psychomotor development. CONCLUSION: Although the use of a stent was intended to prevent complications such as biliary obstruction, since it is the most feared complication during liver transplantation, this was not the case of the patient, so it could be considered that it continues to be a controversial technique. Also, the use of chemotherapy after transplantation is important to be free of disease since clinical studies have shown an increase in patient survival.

Shear wave elastography-based liver fibrosis assessment in patients with chronic hepatitis E displays elevated liver stiffness regardless of previous antiviral therapy.

Hepatitis E virus (HEV) infection especially in immunocompromised individuals can lead to chronic hepatitis. Aggressive courses of chronic hepatitis E leading to liver cirrhosis in a short period of time have been described, but evidence on the degree of liver involvement in chronic hepatitis E is rare. We therefore aimed to quantify liver fibrosis in patients with chronic active hepatitis E compared to patients with sustained virological response after ribavirin (RBV) treatment using 2D-shear wave elastography (2D-SWE) to measure liver stiffness. Patients with chronic hepatitis E underwent 2D-SWE, B-mode and Doppler ultrasound and laboratory testing in order to assess severity of liver involvement. In this cross-sectional study, we included 14 patients of whom 8 had ongoing chronic hepatitis E and 6 patients had been successfully treated for chronic hepatitis E. The most frequent cause for immunosuppression was prior kidney transplantation (n=12), one patient was a multivisceral transplant recipient, one had been treated for lymphoma. Five patients cleared HEV after RBV therapy, one patient reached viral clearance after reduction of his immunosuppressive medication. Using 2D-SWE measurement, 71.4% displayed increased stiffness indicative of liver fibrosis: 57.1% classified as significant fibrosis and 14.3% as severe fibrosis. Liver stiffness did not differ between patients with active chronic hepatitis E and in patients who had cleared HEV (1.59 and 1.54 m/s respectively). Compared with a control group of kidney transplant recipients without hepatitis E (1.44 m/s), the patients with a history of hepatitis E displayed a significantly higher liver stiffness (P=0.04). In our cohort of chronic hepatitis E patients, elevated liver stiffness indicating liver fibrosis was common and significantly higher than in controls. This is consistent with prior sparse reports of the presence of liver fibrosis or cirrhosis in chronic hepatitis E and emphasizes the need for HEV testing, therapy and research on new therapeutic options. As elevated liver stiffness was also present in patients after HEV treatment, continuous liver surveillance including elastography and ultrasound should be considered.

Currently available treatment options for neuroendocrine liver metastases.

Neuroendocrine neoplasms (NEN) are frequently characterized by a high propensity for metastasis to the liver, which appears to be a dominant site of distant-stage disease, affecting quality of life and overall survival. Liver surgery with the intention to cure is the treatment of choice for resectable neuroendocrine liver metastases (NELM), aiming to potentially prolong survival and ameliorate hormonal symptoms refractory to medical control. Surgical resection is indicated for patients with NELM from well-differentiated NEN, while its feasibility and complexity are largely dictated by the degree of liver involvement. As a result of advances in surgical techniques over the past decades, complex 1- and 2-stage, or repeat liver resections are performed safely and effectively by experienced surgeons. Furthermore, liver transplantation for the treatment of NELM should be anchored in a multimodal and multidisciplinary therapeutic strategy and restricted only to highly selected individual cases. A broad spectrum of interventional radiology treatments for NELM have recently been available, with expanding indications that are more applicable, as they are less limited by patient- and tumor-related parameters, being therefore important adjuncts or alternatives to surgery. Overall, liver-targeted treatment modalities may precede the administration of systemic molecular targeted agents and chemotherapy for patients with liver-dominant metastatic disease; these appear to be a crucial component of multimodal management of patients with NEN. In the present review, we discuss surgical and non-surgical liver-targeted treatment approaches for NELM, each complementing the other, with a view to assisting physicians in optimizing multimodal NEN patient care.

Chromogranin A assessment in patients with neuroendocrine neoplasm of the small bowel and carcinoid syndrome treated with somatostatin analogues.

Chromogranin A (CgA) is one of the non-specific markers measured in the biochemical diagnostics of neuroendocrine neoplasms (NENs). To analyze the CgA levels of patients with carcinoid syndrome who are being treated with somatostatin analogues (SSAs), depending on the histologic maturity of the neoplasm, the degree of liver involvement and the stage of the disease. The study group comprised of 41 patients, including 29 women (70.7%) and 12 men (29.3%). All of the patients had undergone surgical removal of the primary site. Hepatic metastases were found in all patients and they all were treated with SSAs. Chromogranin A concentration was determined using the enzyme-linked immunosorbent assay (ELISA). Among the patients with grade 1 tumors, the mean CgA value was 298.83 ng/mL, whereas in the group with grade 2 tumors, the CgA value was 1498.44 ng/mL, which was a statistically significant difference (p < 0.001). In the group of patients with 10% liver involvement, the mean CgA value was 394.44 ng/mL, whereas in the group of patients with 25% liver involvement, this value was 1,770.63 ng/mL, demonstrating significantly higher values (p < 0.001). Among the patients with a progressing disease, the mean CgA concentration value was 1,620.78 ng/mL, whereas in the group of patients with a stable disease, these were considerably lower, amounting to 230.36 ng/mL (p < 0.001). Assessing CgA level in patients with carcinoid syndrome is helpful in the diagnostics and monitoring of treatment because CgA values depend on the tumor grade and the severity of the disease.

Biochemical Profile and Degree of Liver Involvement in Dengue Fever

Dengue disease has emerged globally as the most frequent and medically relevant viral infection transmitted by mosquito bite. Acute hepatitis is a manifestation of dengue virus infection. This study shows the impact of dengue on liver function was studied by biochemical tests on 80 patients out of them 53 male (age 42±12 yrs) and 27 female (age 39±13 yrs). The patients were diagnosed as dengue fever and were admitted in Holy Family Red Crescent Medical college Hospital from June 2014 to December 2016. All the patient were diagnosed by anti-dengue IgM positive by ELISA method. Abnormal level of aspartate aminotransferase (ASV, alanine aminotransferase (ALT), bilirubin, alkaline Phosphatase (Alp), gamma-glutamyl transferase (G-GT) and albumin and urinary albumin were observed in 82.5%, 82.5%, 47.5%, 38.75%, 71.25% ,66.25% and, 76.25% of the patients respectively. It is concluded that dengue fever may cause hepatic injury and transaminase elevation similar to that in patients with conventional viral hepatitis. In epidemic or endemic areas, dengue fever should be considered in the differential diagnosis of acute hepatitis.

GEP-NETS UPDATE: Interventional radiology: role in the treatment of liver metastases from GEP-NETs

Neuroendocrine tumors from gastro-pancreatic origin (GEP-NET) can be responsible for liver metastases. Such metastases can be the dominant part of the disease as well due to the tumor burden itself or the symptoms related to such liver metastases. Intra-arterial therapies are commonly used in liver only or liver-dominant disease and encompass trans-arterial chemoembolization (TACE), trans-arterial embolization (TAE), and radioembolization (RE). TACE performed with drug emulsified in Lipiodol has been used for the past 20 years with reported overall survival in the range of 3-4 years, with objective response up to 75%. Response to TACE is higher when treatment is used as a first-line therapy and degree of liver involvement is lower. Benefit of TACE over TAE is unproven in randomized study, but reported in retrospective studies namely in pancreatic NETs. RE provides early interesting results that need to be further evaluated in terms of benefit and toxicity. Radiofrequency ablation allows control of small size and numbered liver metastases, with low invasiveness. Ideal metastases to target are one metastasis <5 cm, or three metastases <3 cm, or a sum of diameter of all metastases below 8 cm. Ablation therapies can be applied in the lung or in the bones when needed, and more invasive surgery should be probably saved for large-size metastases. Even if the indication of image-guided therapy in the treatment of GEP-NET liver metastases needs to be refined, such therapies allow for manageable invasive set of treatments able to address oligometastatic patients in liver, lung, and bones. These treatments applied locally will save the benefit and the toxicity of systemic therapy for more advanced stage of the disease.

Effect of chronic intake of arsenic-contaminated water on liver

The hepatotoxic effect of arsenic when used in therapeutic dose has long been recognized. We described the nature and degree of liver involvement and its pathogenesis due to prolonged drinking of arsenic-contaminated water in West Bengal, India. From hospital-based studies on 248 cases of arsenicosis, hepatomegaly was found in 190 patients (76.6%). Non cirrhotic portal fibrosis was the predominant lesions in 63 out of 69 cases who underwent liver biopsy. The portal fibrosis was characterized by expansion of portal zones with streaky fibrosis, a few of which contained leash of vessels. However, portal hypertension was found in smaller number of cases. A cross-sectional epidemiological study was carried out on 7683 people residing in arsenic-affected districts of West Bengal. Out of these, 3467 and 4216 people consumed water-containing arsenic below and above 0.05 mg/l, respectively. Prevalence of hepatomegaly was significantly higher in arsenic-exposed people (10.2%) compared to controls (2.99%, P < 0.001). The incidence of hepatomegaly was found to have a linear relationship proportionate to increasing exposure of arsenic in drinking water in both sexes ( P < 0.001). In an experimental study, BALB/C mice were given water contaminated with arsenic (3.2 mg/l) ad libitum for 15 months, the animals being sacrificed at 3-month intervals. We observed progressive reduction of hepatic glutathione and enzymes of anti-oxidative defense system associated with lipid peroxidation. Liver histology showed fatty infiltration at 12 months and hepatic fibrosis at 15 months. Our studies show that prolong drinking of arsenic-contaminated water is associated with hepatomegaly. Predominant lesion of hepatic fibrosis appears to be caused by arsenic induced oxystress.

SPECTRUM OF LIVER DAMAGE AND CORRELATION WITH CLINICAL AND LABORATORY PARAMETERS IN HCV INFECTED HEMODIALYSIS PATIENTS

There are conflicting results in studies concerning the best marker for liver histopathological features of HCV infection in HD patients. We planned a prospective study to follow HCV viremia and laboratory parameters of HD patients and correlate these with clinic features and histopathological findings. We included 68 HCV infected patients (45 male, 23 female, age: 39.8 ± 11.9 years, HD duration: 58.2 ± 36.4 months) in our study. The follow-up period after the biopsy was 33.2 ± 20.3 months. Patients liver enzyme (alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyl transferase (GGT)) levels were determined monthly and ferritin levels every three months, and the mean value was recorded. We also screened patients for HCV RNA. During the follow-up period, 22 (32.4%) of the patients had positive RNA, 26 (38.2%) negative RNA, 20 (29.4%) had intermittent RNA positivity. The patients with high grade of portal necroinflammatory activity had significantly higher AST and ALT levels. In addition patients with high grade lobular activity had significantly shorter HD and HCV infection duration and higher AST, ALT and ferritin levels. AST levels were negatively correlated with duration of HD and HCV infection, and positively correlated with GGT and ferritin levels. Additionally, we found that ALT levels were negatively correlated with HD duration and positively correlated with GGT levels. ALT levels higher than 30 U/L were reflected necroinflammatory activity more significantly than levels higher than 40 U/L. Cirrhosis was detected in 5.9% of the patients, and we could not find any laboratory parameter that was correlated with stage of fibrosis. Although there is a high degree of liver involvement, cirrhosis is a relatively less frequent finding in HD patients. Serum aminotransferases and ferritin levels but not the pattern of HCV viremia are predictors of necroinflammatory activity in liver biopsy specimens. Liver biopsy obligatory to assess the disease activity in HD patients.

The Impact of Dengue on Liver Function as Evaluated by Aminotransferase Levels

Objective: To evaluate the impact of dengue virus infection on liver function by measuring aminotransferases in blood samples from patients serologically diagnosed as Dengue Fever. Background: Dengue, presenting as classical or haemorrhagic fever, also has some effect on liver function. This evaluation should be done for the management and deterination of prognosis of dengue with altered liver function. This study was done to find out the impact of dengue on liver function by evaluation of aminotransferase levels. Methods: Serologically confirmed 100 cases of dengue were included for the study. The patients were treated in the indoor. Informations were collected in a preformed revised structured questionnaire. Degree of liver involvement was classified in four grades according to Aminotransferase levels. Grades are as follows: Grade A - normal enzyme levels; Grade B - increased levels of at least one of the enzymes; Grade C - increased, with at least one of the enzymes being at levels higher than three times the upper reference values; Grade D - acute hepatitis, with aminotransferase levels at least ten times or more their upper limit of normal values. Results: Out of the confirmed dengue cases, 58% were female and 42% were male. Mean age was 34.5. 70% cases were classified as classic dengue and 30% as Dengue Haemorrhagic fever (DHF). Liver functions involvements were classified as Grade A in 34% cases, Grade B in 44% cases, Grade C in 20% cases and Grade D in 2% cases. High level of aminotransferases was 60% in classic dengue cases while it was 80% in DHF cases. Conclusion: Many of the dengue cases have abnormal liver function which are usually overlooked. This must be taken into account for risk stratification, management and prognosis of dengue cases. Keywords: Dengue, Classic Dengue, Dengue Haemorrhagic Fever, Dengue Shock Syndrome, Liver function, Aminotransferase. DOI = 10.3329/jom.v9i2.1432 Â Â J MEDICINE 2008; 9 : 66-68