Palpable Liver Research Articles

Mycobacterium gordonae bacteremia in an asymptomatic adolescent with acquired immunodeficiency syndrome.

Mycobacterium gordonae is historically viewed as an organism with low pathogenic potential, but it has increasingly become implicated in clinical disease in immunocompromised hosts. Illness related to M. gordonae infection ranges from localized infections to rare cases of disseminated disease. This report describes treatment of the first case of occult M. gordonae bacteremia in an adolescent with AIDS.

Pathologic Quiz Case: A 16-Year-Old Girl With a Palpable Liver Mass, Fever, and Vomiting

Pathologic Quiz Case: A 16-Year-Old Girl With a Palpable Liver Mass, Fever, and Vomiting

Transcutaneously measured near-infrared spectroscopic liver tissue oxygenation does not correlate with hepatic venous oxygenation in children

To compare transcutaneous near-infrared spectroscopic (NIRS) measured liver tissue oxygenation with hepatic vein oxygen saturation (SvhO2) in children undergoing cardiac catheterization. A NIRS optode (containing an emitter and a receiver of near-infrared light) was placed directly below the right costal arch above the palpable liver in 40 children aged 0.02 to 7.28 yr (median: 1.8 yr). Spatially resolved spectroscopic measured tissue oxygenation index (TOI) was recorded using the NIRO-300. Paired blood samples from the hepatic vein were taken under radiological control for determination of SvhO2 in a co-oxymeter. TOI values were compared with hepatic vein oxygenation, with simultaneously obtained arterial oxygen saturation (SaO2), inferior vena cava SO2 and hemoglobin concentration using simple linear and multi-regression analysis. TOI values ranged from 35% to 73% (58.6 +/- 8.4%); SvhO2 from 32% to 80% (58.4 +/- 14.4%), and arterial SO2 from 54% to 100% (90.0 +/- 11.4%). TOI and hepatic vein oxygen saturation failed to correlate (r = 0.052/P = 0.752). A regression model containing arterial saturation (Delta R2 = 0.177) and the ratio of pulmonary to systemic resistance (Delta R2 = 0.095) explained 27.3% of the observed variance in TOI. In this model, hepatic vein oxygen saturation was no longer significant; explaining only 3.4% of the variance. No other variable retained a significant association. Transcutaneously measured NIRS tissue oxygenation with an optode placed over the palpable liver does not correlate with SvhO2. The value is dominated by non-hepatic variables such as arterial saturation and vascular resistances.

Factors contributing to anemia after uncomplicated falciparum malaria.

The factors contributing to anemia in falciparum malaria were characterized in 4,007 prospectively studied patients on the western border of Thailand. Of these, 727 patients (18%) presented with anemia (haematocrit < 30%), and 1% (55 of 5,253) required blood transfusion. The following were found to be independent risk factors for anemia at admission: age < 5 years, a palpable spleen, a palpable liver, recrudescent infections, being female, a prolonged history of illness (> 2 days) before admission, and pure Plasmodium falciparum infections rather than mixed P. falciparum and Plasmodium vivax infections. The mean maximum fractional fall in hematocrit after antimalarial treatment was 14.1% of the baseline value (95% confidence interval [CI], 13.6-14.6). This reduction was significantly greater in young children (aged < 5 years) and in patients with a prolonged illness, high parasitemia, or delayed parasite clearance. Loss of parasitized erythrocytes accounted for < 10% of overall red blood cell loss. Hematological recovery was usually complete within 6 weeks, but it was slower in patients who were anemic at admission (adjusted hazards ratio [AHR], 1.9, 95% CI, 1.5-2.3), and those whose infections recrudesced (AHR, 1.2, 95% CI, 1.01-1.5). Half the patients with treatment failure were anemic at 6 weeks compared with 19% of successfully treated patients (relative risk, 2.8, 95% CI, 2.0-3.8). Patients coinfected with P. vivax (16% of the total) were 1.8 (95% CI, 1.2-2.6) times less likely to become anemic and recovered 1.3 (95% CI, 1.0-1.5) times faster than those with P. falciparum only. Anemia is related to drug resistance and treatment failure in uncomplicated malaria. Children aged < 5 years of age were more likely than older children or adults to become anemic. Coinfection with P. vivax attenuates the anemia of falciparum malaria, presumably by modifying the severity of the infection.

Hepatocellular cancer in liver transplantation.

Hepatocellular carcinoma (HCC) is a malignant epithelial tumor that accounts for over 80% of primary liver tumors. It affects males more than females, and is responsible for over 1 million yearly deaths worldwide. HCC tends to be relentless in nature and of rapid evolution. Most cases of HCC are associated with cirrhosis, usually caused by chronic viral hepatitis or alcohol ingestion. In cases of established cirrhosis, HCC develops with an annual incidence of 3%-10%. Hepatocellular carcinoma may present in a generalized way with overall clinical deterioration and malaise, as a palpable liver mass, or as an asymptomatic lesion that is discovered incidentally. Alpha-fetoprotein (AFP) measurements allow for the differentiation of HCC in cirrhotics, and can act as predictive markers. Patients with cirrhosis and small tumors (up to 3 cm, or 5 cm if solitary), no more than three nodules, and no portal vein involvement were found to benefit more from orthotopic liver transplantation (OLTx) than from resection. Tumors under 3 cm in size were unlikely to recur, while those over 5 cm posed the greatest risk. An incidental HCC in a transplant patient should be treated as seriously and aggressively as if the transplant had been undertaken for HCC.

Radiation therapy for symptomatic hepatomegaly in myelofibrosis with myeloid metaplasia.

To describe the experience with liver irradiation in advanced cases of myelofibrosis with myeloid metaplasia (MMM). Over a 20-yr period, 14 patients with MMM were treated with a total of 25 courses of liver, abdominal, or abdominal and pelvic irradiation for symptomatic hepatomegaly with (5 patients) or without (9 patients) ascites. All 14 patients had advanced disease and 11 (79%) had previous splenectomy. The median radiation therapy (RT) dose per course was 150 cGy (range 50-1000) administered at a median of six fractions. Four patients received two to six courses. Twelve of the 14 patients (86%) had a transient (median 3 months) subjective response from RT. However, in only 35% of these was there a transient (median 3 months) decrease in palpable liver size. Four of the five patients with ascites experienced a short-term response from RT. Eight of the 13 patients suitable for evaluation (62%) had treatment-associated cytopenia, often in the form of anemia and/or thrombocytopenia. At last follow-up, 10 patients (71%) had died after a median of 7 months (range 0.1-23) and 4 were alive at 3, 20, 33, and 57 months after RT. Low-dose abdominal RT for symptomatic hepatomegaly or ascites associated with advanced-stage MMM is myelosuppressive and provides only temporary and mainly subjective and short-lived relief.

Hepatomegaly in neonates and children.

1. Ann D. Wolf, MD* 2. Joel E. Lavine, MD, PhD† 1. 2. *Chief Resident. 3. 4. †Associate Professor of Pediatrics and Chief, Joint Program in Gastroenterology and Nutrition, Department of Pediatrics, UCSD School of Medicine, San Diego, CA. After completing this article, readers should be able to: 1. Identify the possible causes of simultaneous hepatomegaly and splenomegaly. 2. List the important diagnostic considerations in patients who have hepatomegaly. 3. Delineate the most helpful initial radiographic test. 4. Describe what clinical findings occurring concomitantly in a patient who has hepatomegaly suggest metabolic or storage disease. 5. List the risk factors for infectious hepatitis. Hepatomegaly can represent intrinsic liver disease or may be the presenting physical finding of a generalized disorder. Early diagnosis and treatment of children who have liver disease is important because specific treatments are available for some diseases that can prevent disease progression or hepatic failure. The presence of a palpable liver does not always indicate hepatomegaly. Normal liver size is based on normative values of liver span by percussion, degree of extension below the right costal margin, or length of the vertical axis estimated from imaging techniques. In general, a liver edge greater than 3.5 cm in newborns and greater than 2 cm in children below the right costal margin suggests enlargement. Liver span is determined by measuring the distance between the upper edge, determined by percussion, and the lower edge, determined by palpation, in the midclavicular line. The lower border also may be determined by auscultation. With the stethoscope placed below the xiphoid, the examiner should gently scratch superiorly, starting in from the right lower quadrant, and listen for sound enhancement as the finger passes over the liver edge. Liver span increases linearly with body weight and age in both genders and correlates more with weight than with height. The normal range for liver span by percussion at 1 week of age is 4.5 to 5 cm. At 12 years, the normal value for boys is 7 to 8 cm and for girls is 6 to 6.5 cm. The liver …

Definitive treatment of congenital liver cyst with alcohol

A full-term newborn boy presented with a palpable liver. Ultrasonography showed a solitary liver cyst. In 6 months the cyst grew 15-fold in volume. Intervention was deemed necessary because of large palpable abdominal mass in spite of the fact that the boy remained asymptomatic. Permanent resolution of the cyst was achieved by percutaneous ethanol injection-aspiration. At 7-year follow-up there has been no recurrence. The authors would like to draw attention to this minimally invasive alternative to surgery. J Pediatr Surg 35:1138-1139. Copyright © 2000 by W.B. Saunders Company.

Index of Suspicion

Index of Suspicion

Amyloidosis: Recognition, Confirmation, Prognosis, and Therapy

Amyloidosis: Recognition, Confirmation, Prognosis, and Therapy

Non-imaging-guided fine-needle aspiration of liver lesions: a retrospective study of 279 patients.

AIM:To determine the value of nonimaging-guided (direct) fine-needle aspiration cytology in diagnosing liver lesions.METHODS:Detection by technetium-99m, ultrasound or computed tomographic scanning of the liver was made in 279 patients with 332 aspirations.RESULTS:Based on histologic, cytologic and clinical findings, final liver diagnoses were reached in 265 patients, of whom 171 had malignant and 94 benign liver disease. Among the 171 patients with malignant liver disease, the cytologic findings indicated suspected malignancy in 8 patients, suggested definite malignancy in 130, but failed to disclose malignancy in 33 patients. In 93 of the 94 patients with benign liver disease, the cytologic findings were reported as benign, while in one patient the report of malignancy was false. The overall sensitivity, specificity, and positive and negative predictive values for cytologic results were 80.7%, 98.9%, 99.3% and 73.8%, respectively. The diagnostic accuracy of fine-needle aspiration cytology was 87.2%. The only major complication attributable to the procedure consisted of one case of pneumothorax.CONCLUSION:Direct fine needle aspiration of palpable liver mass and blind fine-needle aspiration of non-palpable liver lesions for cytodiagnosis are simple, safe,and cost effective diagnostic method for evaluating the nature of liver lesions.The aspiration procedure including potential complications could be cut short by early finding of abnormal cells.

Urban schistosomiasis: morbidity, sociodemographic characteristics and water contact patterns predictive of infection.

Schistosomiasis (Schistosoma mansoni) is classically described as a rural disease that occurs in areas with poor sanitary conditions. This cross-sectional study was undertaken in a suburban area of a large industrialized city in Brazil (Belo Horizonte), aiming at examining epidemiological characteristics of schistosomiasis in an urban setting. A simple random sample of 658/1896 dwellings was selected and 3049/3290 (92.7%) residents were submitted to stool examination. Of 518 eligible infected cases and 518 uninfected controls, 87.1% and 89.9% participated in the study, respectively. The prevalence of S. mansoni infection was 20%, predominantly low egg counts in stools; no cases of splenomegaly were found. Signs and symptoms associated with infection were bloody stools (odds ratio [OR] = 8.0) and hardened palpable liver at the middle clavicular and at the middle sternal life (OR = 5.5 and 8.0 respectively). Sociodemographic variables and water contacts predictive of infection were age (10-19 and > or = 20 yrs; OR = 7.1 and 3.3, respectively), gender (male; OR = 3.1), contacts for swimming and/or playing (twice a month or less and more than twice a month; OR = 2.2 and 3.0, respectively) and residence in Belo Horizonte (born in the City; OR = 2.5). Ninety per cent of dwellings had a piped water supply; no association between water supply and infection was found. Our results emphasize the need for schistosomiasis control measures focusing on water contacts for leisure purposes in this industrialized urban area.

A patient with rheumatoid factor positive symmetrical polyarthritis and fever. A.A. van de Loosdrecht1, M.K. Leijsma2, M. Posthumus2, M.H. van Rijswijk2. Departments of Internal Medicine1 and Rheumatology2, University Hospital, Groningen, Netherlands

CASE PRESENTATIONA 55-year-old Caucasian woman presented to her primary care physician with complaints of progressive fatigue for several months, dyspnea with minimal exertion, loss of appetite, 15-pound weight loss, and recurrent low-grade fevers. Past medical history was significant only for migraine headaches. The patient was taking no prescription or over-the-counter medications. There was no history of environmental toxin exposure, recent travel, smoking, excess alcohol consumption, or use of illicit drugs. She was empirically treated with a course of esomeprazole and amoxicillin.The patient returned 2 weeks later and reported no improvement in her symptoms. Laboratory studies revealed anemia, thrombocytopenia, hypercalcemia, and acute renal failure. The patient was admitted for further evaluation.Upon admission, physical examination revealed a well nourished but pale female in no acute distress. Her blood pressure was 156/70 mm Hg, pulse 96 bpm, temperature 98.6 F, respiratory rate 20 breaths/min, and pulse oximetry 100% on room air. Cardiac and pulmonary examinations were unremarkable. Abdominal examination revealed splenomegaly with a palpable liver edge 1–2 cm below the right costal margin. Laboratory testing (Table 1) was notable for a hemoglobin of 6.1 g/dl (normal range, 11.0–15.0 g/dl), platelet count 112 K/mm3 (nl 150–400 K/mm3), creatinine 3.7 mg/dl, BUN 34 mg/dl, and calcium 12.4 mg/dl (nl 8.5–10.1 mg/dl). Liver function tests, coagulation studies, and parathyroid hormone levels were normal. Urinalysis revealed 1+ protein, 1+ glucose, and trace blood. Negative serologies included anti-glomerular basement membrane antibody, proteinase-3 anti-neutrophil cytoplasmic antibodies, and myeloperoxidase anti-neutrophil cytoplasmic antibodies. Serum complement levels were mildly elevated with C3 179.0 mg/dl (nl 75–135 mg/dl) and C4 41.9 mg/dl (nl 9–36 mg/dl). Serum protein electrophoresis with immunofixation showed no monoclonal protein. A bone marrow biopsy revealed normocellular marrow with no evidence of lymphoma or a plasma cell dyscrasia. A non-contrast computed tomography scan of the chest, abdomen, and pelvis was notable for splenomegaly (18 × 15 × 10 cm) with a hypodense area measuring 7 × 7 × 4 cm and mild hepatomegaly. The kidneys measured 11.7 and 12 cm in length by ultrasound, without evidence of obstruction. A skeletal survey showed no abnormalities.The patient was treated with hydration and a single dose of pamidronate. At the time of discharge 6 days later, her creatinine had fallen to 1.9 mg/dl, and her calcium had normalized.The patient was seen in nephrologic consultation 1 week after discharge, at which time her creatinine had declined to 1.5 mg/dl. Computed tomography scan was repeated with contrast and revealed a 19 × 16 × 10 cm spleen with an ill-defined 11 × 11 × 13 cm mass with areas of probable necrosis. In light of the absence of a clear indication for splenectomy, a renal biopsy was performed to determine the cause of the patient's persistent renal dysfunction.

Clinical physiology - pharmacology: The wet brain: Drug-induced hyponatremia

A 72-year-old male has a history of hypertension, diabetes mellitus, ischemic cardiomyopathy and degenerative osteoarthritis. He is treated with digoxin 0.25 mg qd, hydrochlorothiazide 50 mg qd, chlorpropamide 250 mg qd, propranolol 120 mg bid, ibuprofen 400 mg qid and amitriptyline 25 mg tid. His past medical history is also significant for prostatism with overflow incontinence and endogenous depression. Over a four-week period he develops memory loss for recent and past events, occasional urinary incontinence, three episodes of falling and evidence of weight loss. Is there sufficient evidence in the history to implicate a reversible form of memory loss? If yes, does the index of suspicion point to (a) normal pressure hydrocephalus, (b) meningioma, (c) aneurysm, (d) multiple medications? First, it is necessary to understand that of all of the secondary or reversible forms of dementia, medications comprise the number one cause. In this person's history it is most likely that he has a secondary or reversible form of dementia due to at least one and, possibly, more medications. The physical exam revealed a cachectic and illappearing elderly male. He was lethargic but arousable. His mucous membranes, axillae and groins were moist. Blood pressure taken in the supine position was 150/80. His pulse was 77 and regular. The lungs were clear. His heart was enlarged percussion to the anterior axillary line and was associated with an $3S4 gallop. Examination of the abdomen revealed a palpable liver edge three centimeters below the right costal margin and a palpable liver edge three centimeters below the right costal margin and a palpable urinary bladder up to the umbilicus. The stool was heme positive. He had no edema. Neurological examination revealed the patient to be oriented to person and place but he was easily confused and occasionally replied incoherently. His strength was symmetrical and intact. The deep tendon reflexes were diffusely decreased but there was no B abinski reflex, tremor or asterixis. Do the physical findings confirm a dementia or an acute confusional state (delirium)? The physical exam points more to an acute confusional state which could be superimposed on a dementia process. One cannot ascertain this in the setting of delirium. One needs to find the cause of the delirium which in this case may be drugs or a surgically correctable lesion and then once rectified, neuropsychological testing could be performed to elucidate the presence of primary dementia, i.e. Alzheirner's, Binswanger's, etc. Laboratory evaluation revealed: Bicarbonate 34.5 mEq/L Sodium 102 meq/1 Chloride 51 meq/1 Bicarbonate 34.5 mEq/L Potassium 2.7 meq/1

Clinical, biochemical and histological features in 102 patients with chronic hepatitis C virus infection

The clinical, biochemical and histological features of 102 consecutively referred patients with chronic hepatitis C virus infection were analysed. Demographic, epidemiological, biochemical, haematological and histological details were catalogued for each patient. The mean follow-up was 49 +/- 6 months. Liver biopsies were obtained from 92 patients; a second biopsy was obtained from 35 patients. The average known duration of infection was 8.6 +/- 0.7 years. The most common risk factors that could be identified were past blood transfusion, surgery or intravenous drug abuse. Twenty-four of the 27 patients (85%) with past blood transfusion had received blood in countries outside of northern Europe. In contrast, 12 of the 16 former drug users were northern European. Patients were frequently diagnosed incidentally; one-quarter had no symptoms of liver disease and were generally asymptomatic or had presented with non-specific complaints and were found to have abnormal serum aminotransferase levels after routine screening. The mean serum aminotransferase levels were not significantly different in those presenting with fatigue compared to those diagnosed incidentally. The most common physical sign in these patients was a palpable liver, which was present in 52%. The mean serum albumin concentration in patients older than 40 years was significantly lower than that in younger patients. Splenomegaly and endoscopic evidence of varices was also more common in older patients. Cirrhosis was present in 37% of patients at presentation: 20% showed progression on rebiopsy, and 5% developed cirrhosis within 4 years of initial presentation. Of those treated, 27% showed histological improvement. Histological severity did not correlate with duration of disease, but did correlate with age.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiology of Schistosoma mansoni infection in a low-endemic area in Brazil: clinical and nutritional characteristics.

A cross-sectional case-control study designed to evaluate the role of malnutrition in the association between the intensity of Schistosoma mansoni infection and clinical schistosomiasis, was conducted in an area with both low frequency of infection and low morbidity of schistosomiasis in Brazil. Cases (256) were patients with a positive stool examination for S. mansoni; their geometrical mean number of eggs/gram of feces was 90. Controls (256) were a random sample of the negative participants paired to the cases by age, sex and length of residence in the area. The clinical signs and symptoms found to be associated with S. mansoni infection, comparing cases and controls, were blood in stools and presence of a palpable liver. A linear trend in the relative odds of these signs and symptoms with increasing levels of infection was detected. Adjusting by the level of egg excretion, the existence of an interaction between palpable liver and ethnic group (white) was suggested. No differences in the nutritional status of infected and non-infected participants were found.

Prognostic factors in patients with liver metastases from colorectal carcinoma treated with discontinuous intra-arterial hepatic chemotherapy

48 patients with colorectal cancer metastatic to the liver were implanted with a subcutaneous access system allowing hepatic intra-arterial perfusion. Regional chemotherapy used 5-fluorouracil, while 17 patients also received low-dose mitomycin at the beginning of the study. Responses to the treatment occurred in 29 patients (60%) and median survival was 14.4 months. Toxicity included gastroduodenal erosions in 12.5% of the patients, leucopenia in 20.8%, catheter thrombosis in 42% and arterial thrombosis in 50%. 2 patients died of digestive haemorrhage probably related to treatment. When individually analysed, four factors were found to significantly affect survival: presence of hepatomegaly (defined as palpable liver edge exceeding the right costal margin by more than 5 cm) ( P = 0.006), percentage of hepatic replacement superior to 50% ( P = 0.003), more than four metastases ( P = 0.025) and hypovascularised metastases at radionuclide liver scan with 99mtechnetium-labelled macroaggregate albumin (MAA) ( P = 0.04). The effect of the four variables on the observed survival time was analysed using a Cox regression model. Two variables were found to have simultaneously influenced survival. Presence of hepatomegaly emerged as the more significant ( P = 0.0001), the other being hypovascularised metastases at 99mTc-MAA.

Validity of selected clinical signs and symptoms in diagnosis of Schistosoma mansoni infection

Sensitivity, specificity and positive predictive values of selected clinical signs and symptoms in the diagnosis of Schistosoma mansoni infection were evaluated in 403 individuals (69% of inhabitants over 1 year of age) in an endemic area in Brazil (Divino). Highest sensitivity (13%) was found for blood in stools. Specificity over 90% was found for blood in stools, palpable liver with normal consistency and palpable hardened liver at middle clavicular (MCL) or middle sternal lines (MSL). Hardened liver at MSL (83%) or MCL (75%), and blood in stools (78%) presented higher positive predictive values for S. mansoni infection, while palpable liver with normal consistency at MCL (45%) or MSL (48%) presented smaller values. Enlarged liver without specification of its consistency has been traditionally used as an indicator of the infection in areas where malaria or Kala-azar are not endemic. Our results demonstrate that the probability that a person with blood in stools or hardened palpable liver is infected is higher than among those with palpable liver with normal consistency.

帯状ほう疹にて入院し貧血，片麻ひをきたした高齢者ＳＬＥと思われる１例

An elderly case of systemic lupus erythematosus (SLE) with suspected hemolytic anemia was experienced. A 70 year-old female was admitted to our hospital on December 31 with complaints of herpetic eruption. She complained of arthralgia since 3 month prior to her admission. The positive findings on examination were skin eruption in the left chest, a systolic heart murmur and a palpable elastic hard liver. Laboratory data showed raised erythrocyte sedimentation rate of 149 mm per hour, decreased Hb (10.1 g/dl), decreased hematocrit (30.0%), increased reticulocytes (33%1000), decreased thrombocytes (73,000/mm3), increased gamma-globulin (33%) and positive rheumatoid factor. During admission, she developed anemia. A stool test for occult blood was negative. The haptoglobin was 38.8 mg/dl and bone marrow aspiration showed increased erythropoiesis, suggesting features of immune hemolytic anemia, except she was negative on Coomb'test. Eye fundi were similar to case of typical bleeding observed in SLE. Concerning immunological findings, the antinuclear factor was x 1280 and the anti-dsDNA antibody was x 80, on which a diagnosis of SLE was based. She experienced numbness of the left arm and developed left hemiparesis 2 days later. Therapy with 15 mg/day prednisone obtained a good response and anemia, abnormal immunological findings and hemiparesis disappeared.

Hepatic Dystychoma: A Five Year Experience

In 5 years, 64 solid hepatic lesions have been referred for diagnosis and management which have been found unexpectedly on organ imaging in well patients. We have called this lesion a “dystychoma”. Patients have undergone a two phase investigation programme which allows a diagnosis without admission to hospital in about 50% of cases. About three quarters of patients (47/64) have had nonneoplastic lesions, and about half (33/64) have had haemangiomas. About one patient in four (17/64) has had a neoplasm, and the neoplasm has been malignant in about one in six (11/64) of all patients. We stress the need to pursue the diagnosis in these patients. There were no reliable clinical, biochemical or imaging characteristics which individually distinguished benign from malignant lesions. Age over 55 years, an enlarged liver or a palpable liver mass and a raised serum alkaline phosphatase were all significantly more frequent with malignant tumours. The risk of malignancy rose with the number of risk factors, and all patients with all three risk factors had malignant tumours. Only 11 of the 64 patients were judged to have benefited by significant increase in quality or quantity of life as a result of what was frequently inappropriate organ imaging. There is no strong argument for replacing history taking and physical examination by CT scanning, ultrasound examination or other organ imaging.