Virus-related Cirrhosis Research Articles

What is the benefit of computer-assisted image analysis of liver fibrosis area?

Liver fibrosis is usually semiquantitatively assessed in liver biopsy specimens by the numerical system of Scheuer [1], the Metavir group [2], or Ishak [3]. Fibrosis is staged as F0, no fibrosis; F1, portal fibrosis without septa; F2, portal fibrosis and few septa; F3, numerous septa without cirrhosis; and F4, cirrhosis. Staging mainly depends on the degree of the architectural changes of liver structure. Computer-assisted image analysis of the stained fibrosis area in liver biopsy specimens is a method for quantitatively measuring the amount of liver fibrosis [4]. It is not used for the clinical assessment of liver fibrosis in general, but is often used in the assessment of fibrosis in animal models. Its low popularity in clinical practice may be attributed to the complexity of the method. The fibrosis stage as determined by the numerical systems and the relative area of fibrosis measured by computer-assisted image analysis usually correlate well to each other. However, discrepancy between the two sometimes occurs. Which of the two is more useful in clinical practice may depend on the objectives of assessing liver fibrosis. The current study by Isgro et al. showed that collagen proportionate area (CPA) has a better relationship with liver stiffness measurement (LSM) and with hepatic venous pressure gradient (HVPG) compared with the Ishak stage. They also reported that CPA at 1-year post-transplantation in hepatitis C virus-infected patients predicts subsequent clinical decompensation more accurately than Ishak stage or HVPG [5]. They conclude that CPA should be the histological parameter with which to compare LSM and other non-invasive fibrosis markers and also be used to subclassify cirrhosis. Nitta et al. [6] also reported the good correlation between LSM and fibrosis area measured by image analysis in the patients with chronic hepatitis C, while LSM and Metavir score yielded better correlation. Xie et al. [7] reported that fibrosis area measured by image analysis significantly correlated with model for end-stage liver disease score, serum bilirubin levels and prothrombin time in the patients with hepatitis B virus-related decompensated cirrhosis. Arima et al. [8] reported that 42 % of chronic hepatitis C patients with pretreatment F3-4 who obtained sustained virological response by interferon (IFN) therapy had decreased fibrosis assessed by the numerical staging system, while the fibrosis area measured by image analysis decreased in 92 %. Thus the computer-assisted image analysis of liver fibrosis is more sensitive to measure the reduction of liver fibrosis after IFN treatment than the numerical system. In conclusion, the relative fibrosis area measured by computer-assisted image analysis is suitable for the comparison with newly developing non-invasive methods for fibrosis assessment, such as LSM. It is also useful to assess the degree of severe fibrosis in cirrhosis for predicting prognosis and to assess the change of fibrosis after antiviral treatment or in natural courses. It is better to add computer-assisted image analysis to the interpretation of liver biopsy in order to obtain valuable quantitative information in the specimens. The standardization and simplification of the method is needed in order that computer-assisted image analysis of fibrosis area will be widely used. This comment refers to the article available at doi:10.1007/s00535-012-0694-9.

Heavy alcohol consumption increases the incidence of hepatocellular carcinoma in hepatitis B virus-related cirrhosis

Taiwan has a high prevalence of hepatitis B viral (HBV) infection and hepatocellular carcinoma (HCC) with increasing consumption of alcohol. We investigated the impact of heavy alcohol consumption and HBV infection on HCC in cirrhotic patients. 966 cirrhotic patients (132 with HBV infection and alcoholism, 632 with HBV infection, and 202 patients with alcoholism) were enrolled between 2000 and 2009 and followed until 2011. The primary end point was newly developed HCC. Within the three patient groups (cirrhotic patients with HBV infection and alcoholism, HBV infection alone, and alcoholism alone) 38 (28.8%), 100 (15.8%), and 21 (10.4%) showed newly developed HCC, respectively. The 10-year cumulative (52.8% vs. 39.8% vs. 25.6%, p <0.001) and annual incidences (9.9%, 4.1%, and 2.1%) of HCC were significantly higher in cirrhotic patients with HBV infection and alcoholism than those in patients with HBV infection or alcoholism alone. For patients with HBV infection and alcoholism, baseline serum HBV DNA (OR=16.8, p=0.025), antiviral nucleos(t)ides analogues (NUCs) therapy (OR=0.01, p=0.035), and serum α-fetoprotein (OR=1.18, p=0.045) were risk predictors of HCC by multivariate logistic regression models. The cumulative incidence of HCC was higher in patients with higher baseline serum HBV DNA. Antiviral NUCs therapy reduced the incidence of HCC. Heavy alcohol consumption significantly increased the risk of HCC in HBV-related cirrhotic patients. Elevated baseline serum HBV DNA was a strong risk predictor of HCC and antiviral NUCs therapy reduced the incidence of HCC in cirrhotic patients with HBV infection and alcoholism.

Predictors of Refractory Ascites Development in Patients with Hepatitis B Virus-Related Cirrhosis Hospitalized to Control Ascitic Decompensation

PurposeRefractory ascites (RA) is closely related to a high morbidity and mortality. In this study, we investigated predictors of RA development in patients with hepatitis B virus (HBV)-related cirrhosis who were hospitalized to control ascitic decompensation, and determined predictors for survival in patients who experienced RA.Materials and MethodsWe analyzed 199 consecutive patients with HBV-related cirrhosis who were hospitalized to control ascitic decompensation between January 1996 and December 2008.ResultsMultivariate analyses showed that only serum potassium at admission predicted RA development independently [p=0.013; hazard ratio (HR), 2.800; 95% confidence interval (CI), 1.166-6.722]. During the follow-up period, 16 (8.0%) patients experienced RA within 4.2 (range, 1.0-39.2) months after admission for controlling ascitic decompensation, and they survived a median of 8.7 (range, 3.9-51.3) months. Child-Pugh class and RA type were identified as independent prognostic factors affecting the survival in patients with RA (p=0.045; HR, 8.079; 95% CI, 1.231-67.984 and p=0.013; HR, 14.510; 95% CI, 1.771-118.874, respectively).ConclusionSerum potassium was an independent predictor of RA development in patients with HBV-related cirrhosis who were hospitalized to control ascitic decompensation. After RA development, Child-Pugh class and RA type were independent predictors for survival.

Improvement of Hypoxemia by Administering Inhaled Nitric Oxide after Living Donor Liver Transplantation for Adults with Hepatopulmonary Syndorome

Introduction: Hepatopulmonary syndrome (HPS) has been well known to be a good indication for liver transplantation. The hypoxemia can reverse with a high, but slow rate after liver transplantation, therefore the post-operative management for hypoxemia is important and effective treatment modalities are required. Inhaled nitric oxide (iNO) has been reported to be effective for hypoxemia of patients with pulmonary disease. There were a few reports describing the efficacy of iNO for patients with HPS after liver transplantation. We experienceed 2 adult cases in which iNO improved PaO2 during intensive ventilation support after liver transplantation for with the treatment of HPS. Procedure: Recipients were treated with mechanical ventilation support at the intensive care unit after living donor liver transplantation (LDLT). The iNO was added to the ventilator circuit at a concentration ranging from 1 to 10 ppm. The iNO concentration was tapered down eventually, and the mechanical ventilation support was terminated when supplemental oxygen sufficiently weaned down without iNO. Case presentation: Case #1 was a 56-year-old man with hepatocellular carcinoma (HCC) associated to hepatitis C virus-related liver cirrhosis. His preoperative resting PaO2 level in room air was 52.4 mm Hg, and intrapulmonary shunting was detected by echocardiogram with microbubbles. He underwent LDLT using a left hemi-liver graft donated by his son. The iNO was introduced immediately after LDLT, and PaO2 level was maintained above 80 mm Hg. The iNO concentration was uneventfully tapered down, and extubation was safely executed on postoperative day (POD) 3. He was discharged home from our hospital with home oxygenation treatment (HOT) on POD 57. He became free from HOT and the micro-bubble test turned out to be negative on POD 115. Case #2 was a 60-year-old woman with liver cirrhosis associated to non-alcoholic steatohepatitis (NASH). Her preoperative resting PaO2 level in room air was 48 mm Hg, and her intrapulmonary shunting ratio was calculated at 39% using technetium-99-labeled macroaggregated albumin scintigraphy. She underwent LDLT using a left hemi-liver graft donated by her son. The iNO was introduced immediately after LDLT and the PaO2 was maintained above 80 mmHg by 80% O2 supply with 7 ppm of iNO. Extubation was finally executed on POD 9 although it was difficult to taper iNO because of hypoxemia. She developed severe hypoxemia with 40 mm Hg of the resting PaO2 while breathing 100% O2 on POD 44. Although she required re-intubation, re-introducing iNO dramatically improved PaO2. She repeatedly develop hypoxemia when the iNO was tapered down to 0.5 ppm, however, we finally accomplished extubation on POD 55. She was discharged home from our hospital with HOT on POD 106. She became free from HOT and her intrapulmonary shunting ratio improved to 15% on POD 180. Conclusion: The iNO added to the ventilation circuit, improved hypoxemia after LDLT for adult patients with HPS. The iNO might be an alternative to support ventilation in post-operative periods when uncontrollable hypoxemia occurs in recipients with HPS.

Effects of antiviral nucleotide/nucleoside analogues and interferon on hepatitis B virus-related liver cirrhosis: a meta-analysis

To evaluate the effects of antiviral nucleotide/nucleoside analogues (NUCs) and interferon (IFN) on liver fibrosis and progression to cirrhosis in patients with hepatitis B virus (HBV) infection. The literature databases of PubMed (1966 to 2011), Embase (1966 to 2011), Wanfang database (1998 to 2011), Chinese National Knowledge Infrastructure (CNKI; 1997 to 2010), and Chinese Biomedical (CBMdisc; 1860 to 2011) were searched for studies that met the following criteria: (1) case-control phase III clinical trails that used only one kind of antiviral drug (NUCs or IFN), with the controls receiving placebo or no treatment; (2) analysis of biopsy specimens collected before and after treatment for both the cases and controls; (3) assessment of fibrosis as an outcome measure of the treatment's effect. The data from all 11 studies included in the meta-analysis were extracted and analyzed by the RevMan5.1 software. NUC treatment significantly regressed liver fibrosis, as compared with placebo treatment (33.7% vs. 19.2%, relative risk (RR): 1.82, 95% confidence interval (CI): [1.47, 2.25], P less than 0.01). NUC treatment significantly reduced the progression of fibrosis, as compared with placebo treatment (9.1% vs. 24.8%, RR: 0.33, 95% CI: [0.19, 0.58], P less than 0.01). IFN treatment significantly reduced progression of fibrosis, as compared with no treatment (23.8% vs. 30.7%, RR: 0.48, 95% CI: [0.34, 0.69], P less than 0.01). IFN significantly reduced progression to cirrhosis, as compared with no treatment (10.6% vs. 18.0%, RR: 0.62, 95% CI: [0.44, 0.88], P less than 0.01). One year of NUC treatment could partly regress liver fibrosis and partly reduce the progression of fibrosis, while one year of IFN treatment could reduce the progression of fibrosis and cirrhosis.

Coincidental Occurrence of Hepatocellular Carcinoma and Cholangiocarcinoma (Collision Tumors) After Liver Transplantation: A Case Report

Coincidental occurrence of hepatocellular carcinoma (HCC) and cholangiocarcinoma, known as “collision tumors”, within a cirrhotic liver is rare. Herein, we report a case of liver transplantation (LT) in a patient with such collision tumors. Our patient was a 56-year-old woman with hepatitis C virus-related cirrhosis and 2 focal hepatic lesions, measuring 1.5 and 3 cm, in the liver segments 8 and 5, respectively. The lesion on segment 8 showed the typical radiological characteristics of HCC; however, the lesion in segment 5 showed an atypical vascular pattern and was closely associated with the inferior vena cava. Serum alpha-fetoprotein level was normal and serum carbohydrate antigen 19-9 (CA19-9) level was slightly elevated (63 U/mL); the extrahepatic spread of HCC was ruled out. The patient underwent an uneventful deceased-donor LT. Histopathological examination of the explant confirmed that the lesion on segment 8 was an HCC, but surprisingly, the lesion on segment 5 was found to be a cholangiocarcinoma. Six months after LT, the serum CA19-9 level was markedly elevated (255 U/mL), and the patient began experiencing abdominal pain. Magnetic resonance imaging showed enlarged hilar and paraaortic lymph nodes that were suggestive of metastases; histopathological analysis using ultrasound (US)-guided biopsy confirmed recurrent cholangiocarcinoma. Unfortunately, the patient died because of tumor recurrence 9 months after LT.Collision tumor resulting from the co-existence HCC and cholangiocarcinoma in a cirrhotic liver is rare and has a negative impact on the outcome of LT. Atypical vascular pattern and elevated serum CA19-9 levels are suggestive of such tumors; patients with these findings should undergo a targeted biopsy to rule out the coincidental occurrence of HCC and cholangiocarcinoma.

Anatomical Resection of Segment 8 by Means of Ultrasound-Guided Vessel Compression

Anatomical resection is the gold standard for liver resection in patients with hepatocellular carcinoma (HCC). Bimanual hepatic vessel compression has been already described, although segmental and subsegmental resection of segment 8 (S8) remain challenging by this technique. We demonstrate how to obtain a S8 demarcation by means of ultrasound-guided vessel compression. Two patients with HCC with hepatitis C virus-related cirrhosis partially or fully located in S8 without portal thrombosis underwent liver resection. In the first patient with a HCC fed by subsegmental glissonian pedicles to S4 superior (P4sup) and S8 ventral (P8v), the resection area was disclosed by direct compression of the aforementioned feeding pedicles. A second patient had a HCC located in S8 ventral with a satellite in S8 dorsal; the patient had a pedicle to the right anterior sector originating from the left portal vein. The resection area was obtained by means of direct compression of the P8d and countercompression of the left portal vein (peripherally to the origin of the pedicle to the anterior sector), and P5. Countercompression was needed because of the peculiar trajectory of P8v passing across the middle hepatic vein. In neither case was there a congested area. In the first patient, hepatic veins were not exposed because it was a resection conducted in a subsegmental fashion. There was no morbidity, and no blood transfusions were needed. Patients were both discharged on day 8 after surgery. Disclosure of subsegmental portions of S8 by means of intraoperative ultrasound-guided compression technique is feasible and confirms the reliability of this approach.

An Unusual Cause of Rapidly Developing Massive Ascites in Early Stage Hepatitis C Cirrhosis and Celiac Disease

Introduction: Primary omental/peritoneal carcinomatosis is an unusual presentation of lymphomas. Epidemiologic studies have shown that hepatitis C has a strong association with lymphoproliferative disorders. Celiac disease is also a risk factor for malignancies. While T-cell lymphoma represents 50% of all malignancies in patients with celiac disease, very few cases of B-cell intestinal lymphomas have been reported. We present a rare case of a patient with chronic hepatitis C virus-related cirrhosis and celiac disease who developed B-cell omental/peritoneal lymphomatosis. Case: A 52-year-old Caucasian man with history of celiac disease, chronic hepatitis C (genotype 1B) and cirrhosis (MELD 9) presented with a 1-week history of abdominal distention and pain. He completed 1-year treatment of peg- interferon and ribavirin, with no response. Peripherally enhancing liver masses and a lesion in the liver were detected in an MRI of the abdomen which was performed three months prior to the admission. There was a concern for metastatic disease. Patient did not follow up at that time. He was admitted to Johns Hopkins Hospital. Physical exam revealed anicteric sclera, markedly distended and tense abdomen with ascites. No lymphadenopathy was noted. Colonoscopy revealed erythematous colonic mucosa and superficial ulcers. Biopsies were all normal. Repeated MRI of the abdomen showed increased numbers and sizes of peripherally-enhancing liver masses and omental nodularity, which was suspicious for metastatic disease. Tumor markers such as AFP, CEA and CA 19-9 were normal. Patient underwent exploratory laparotomy. Liver biopsy showed only cirrhotic features. The omental biopsy was consistent with diffuse, large B-cell lymphoma. Immunohistochemical studies were positive for CD45, CD20, CD-10, BCL-6 and BCL-2. Cytokeratin AE1/AE3, CAM5.2, pCEA and S100 and in-situ hybridization study for EBV were negative. He was given a cycle of R-CHOP chemotherapy and discharged. Unfortunately, he was later admitted to a local hospital with massive ascites and neutropenic fever. He eventually died from complications. Discussion: Although there is a link between hepatitis C infection and lymphoid malignancies, an association of B-cell lymphoma with celiac disease is very unusual. In this case, chronic hepatitis C infection might have played a role as a triggering factor for changes in cellular immune system, predisposing lymphoproliferative disorder. In conclusion, omental/peritoneal lymphomatosis can be the cause of rapidly growing ascites and it is vital to keep this entity in the differential diagnosis among HCV patients with ascites presenting with sudden deterioration of otherwise well-compensated disease state.

Racial differences in the association between adiposity measures and the risk of hepatitis C-related liver disease.

African Americans have lower reported likelihood of hepatitis C virus-related cirrhosis than whites. It is unknown whether relative differences in the distribution of adipose tissue, lean mass, and other anthropometric measurements may explain these observed interethnic differences in disease risk. : To evaluate the association between anthropometric measurements and advanced liver disease in a cross-sectional study of African American and white male veterans. We used the validated FibroSURE-ActiTest to assess hepatic pathology, and direct segmental multichannel bioelectric impedance analysis for anthropometric measurements. Race-stratified logistic regression was employed to evaluate risk of high fibrosis progression rate (FPR) and advanced inflammation (A2 to A3). Among 330 eligible males (59% African American), there were 43 white and 57 African American males with high FPR, and 70 African American and 59 white with advanced inflammation. Percentage body fat (%BF) was a stronger predictor of high FPR risk than was a high body mass index in African Americans [odds ratio (OR)(adj)=2.08; 95% confidence interval (CI),0.83-5.23 for highest %BF vs. lowest tertile and OR(adj)=1.50; 95% CI,0.60-3.75 for obese vs. normal body mass index, respectively], but not in whites. Highest lean leg mass was associated with a nonsignificant increased risk of both high FPR and advanced inflammation in African Americans (OR(highFPRadj)=1.73; 95% CI, 0.73-4.10; OR(AdvancedinflammationAdj)=1.65; 95% CI, 0.76-3.56) versus a decreased risk of both in whites (OR(highFPRadj)=0.62; 95% CI, 0.21-1.79; OR(AdvancedinflammationAdj)=0.58; 95% CI, 0.22-1.48). Interethnic differences in nontraditional anthropometric measurements like %BF suggests their potential role in understanding interethnic differences in hepatitis C virus-related liver disease risk in males.

Endoscopic resection of a large colonic leiomyosarcoma

Leiomyosarcoma of the colon is a rare tumor (330 reported cases [1]) which can mimic an adenocarcinoma [2]. Contrastenhanced computed tomography (CT) is the imaging method of choice in the diagnostic work-up, though magnetic resonance imaging may be useful. Endoscopy and endoscopic ultrasonography (EUS) are also useful for further characterizing the lesion, and are helpful in distinguishing a benign lesion from a malignant one [3]. Positron emission tomography can be used to monitor the response to therapy or detect local recurrence [2]. The management of leiomyosarcomas involving the gastrointestinal tract depends on the confidence in the preoperative diagnosis, and the treatment of choice is radical surgical excision [4]. No data are available on endoscopic treatment in patients who cannot undergo surgery. A 64-year-old man affected with hepatitis C virus-related decompensated cirrhosis was admitted to our hospital because of rectal bleeding. At colonoscopy a large sigmoid polyp (diameter 2.5cm) was found (● Fig.1a). At EUS with a 20-mHz miniprobe the polyp was seen as rising from the second and third layers (● Fig.1b). At histopathology the diagnosis was true leiomyosarcoma. CT scan was negative for metastatic lesions. Taking into account the severe liver disease, and in agreement with the surgeon, an endoscopic mucosectomy was performed after injection with saline, epinephrine, and dilute methylene blue into the base, obtaining a complete lift. The polyp was resected en bloc with a snare, using coagulation current followed by Endo Cut current. At the end, clips were placed at the mucosectomy site to prevent delayed bleeding (● Fig.1c). The histopathology of the resected specimen confirmed the diagnosis (● Fig.1d). At 6-month distal endoscopy there was no local recurrence (● Fig.1e), and PET scan was negative. Although surgery is the treatment of choice in operable patients affected with leiomyosarcoma, this report shows that in selected inoperable patients with no metastatic disease, endoscopic excision of leiomyosarcoma can be an effective and safe nonsurgical approach.

Hepatic hydrothorax after blunt chest trauma

We report a successful treatment result in a rare case of hepatitis C virus-related cirrhosis, who had sustained hydrothorax after blunt thoracoabdominal trauma. This was a female patient with liver cirrhosis, Child–Turcotte–Pugh class A, without ascites before injury. She sustained blunt thoracoabdominal trauma with a left clavicle fracture dislocation and right rib fractures. There was no hemopneumothorax at initial presentation. However, dyspnea and right pleural effusion developed gradually. We inserted a chest tube to relieve the patient's symptoms, and the daily drainage amount remained consistent. Hepatic hydrothorax was confirmed by the intraperitoneal injection of radioisotope 99mTc-sulfur colloid that demonstrated one-way transdiaphragmatic flow of fluid from the peritoneal cavity to pleural cavities. Finally, the hydrothorax was treated successfully by minocycline-induced pleural symphysis. To the best of our knowledge, this is the first case of hepatic hydrothorax developed after thoracoabdominal trauma.

Fever and rhomboid target lesion in decompensated cirrhosis

A 53-year-old woman with Child-Pugh B, hepatitis C virus-related cirrhosis presented with a 3 day history of high fever (peak 39·5°C) and a non-itchy rash. On admission, physical examination showed mild ascites, and a temperature of 38·5°C, a pulse rate of 88 beats per min, and a respiratory rate of 18 breaths per min were recorded. Many large (about 15 cm diameter) target lesions were present on the patient’s trunk and arms and legs, seen as concentric rings of a dull red, pink, or violet colour surrounding a clear centre (fi gure). No mucosal lesions were noted. Laboratory tests recorded a white-blood-cell count of 12×109 cells per L and a C-reactive protein concentration of 3·4 mg/L. Abdominal ultrasound confi rmed the presence of ascites, and echocardiography did not indicate endocarditis. Treatment with oral levofl oxacin was started; 2 days later, the patient’s fever was reduced, all lesions gradually ameliorated acquiring a rhomboid aspect, and liver decompensation diminished progressively. Meanwhile, two blood cultures yielded Grampositive bacteria identifi ed as Erysipelothrix rhusiopathiae. The patient attended the outpatient’s clinic at the Clinical and Molecular Hepatology Unit of the University Hospital of Messina 1 month after discharge from hospital and every 3 months thereafter. At the last visit (January, 2012) no signs of worsening liver disease were noted and the skin lesions had not reappeared. E rhusiopathiae is a common commensal or pathogen of many vertebrate and invertebrate species. Pigs are a major reservoir. Human disease is mainly an occupationally acquired zoonosis. The portal of entry is typically a puncture wound or abrasion on the hand; however, it can also be acquired from eating contaminated food. The patient does not work with animals and denied any injuries while preparing food. However, the week before she became unwell she ate raw pork meat. Liver dysfunction could be associated with E rhusiopathiae bacteraemia because of the noted impairment of reticuloendothelial function in the patient. Three clinical forms of infection with E rhusiopathiae have been reported in human beings: a localised cutaneous form, or erysipeloid of Rosenbach; a diff use cutaneous form; and a bacteraemic form that occurs with or without endocarditis. The diff use cutaneous form constitutes a rare situation in which violaceous cutaneous lesions can arise at remote areas as widespread urticaria with the rhomboid pattern characteristic of swine erysipelas. In our patient, the pattern was associated with bacteraemia without endocarditis.

Cryptococcal meningitis in a patient with hepatitis C virus related decompensated cirrhosis: coincidental or immunologically related?

Cryptococcal meningitis in a patient with hepatitis C virus related decompensated cirrhosis: coincidental or immunologically related?

Risk of liver cancer among US male veterans with cirrhosis, 1969–1996

Background:Liver cancer incidence rates in the United States have increased for several decades for reasons that are not entirely clear. Regardless of aetiology, cirrhosis is a strong risk factor for liver cancer. As mortality from cirrhosis has been declining in recent decades, it is possible that the risk of liver cancer among persons with cirrhosis has been affected.Methods:Data from the US Veterans Affairs medical records database were analysed after adjustment for attained age, race, number of hospital visits, obesity, diabetes, and chronic obstructive pulmonary disease. Hazard ratio (HR) and 95% confidence interval (95% CI) were calculated using Cox proportional hazards modelling. Survival analyses were conducted using age as the time metric and incidence of cirrhosis as a time-dependent covariate.Results:Among 103 257 men with incident cirrhosis, 788 liver cancers developed. The HR of liver cancer was highest among men with viral-related cirrhosis (HR=37.59, 95% CI: 22.57–62.61), lowest among men with alcohol-related cirrhosis (HR=8.20, 95% CI: 7.55–8.91) and intermediate among men with idiopathic cirrhosis (HR=10.45, 95% CI: 8.52–12.81), when compared with those without cirrhosis. Regardless of cirrhosis type, white men had higher HRs than black men. The HR of developing liver cancer increased from 6.40 (95% CI: 4.40–9.33) in 1969–1973 to 34.71 (95% CI: 23.10–52.16) in 1992–1996 for those with cirrhosis compared with those without.Conclusion:In conclusion, the significantly increased HR of developing liver cancer among men with cirrhosis compared with men without cirrhosis in the United States may be contributing to the increasing incidence of liver cancer.

Hepatectomy for hepatocellular carcinoma patients with macronodular cirrhosis

Patients with hepatocellular carcinoma (HCC) presenting with nonmicronodular or micronodular cirrhosis are usually treated by hepatectomy. The value of resection for patients with hepatitis B virus-related macronodular cirrhosis, however, remains unknown because of potentially fatal complications of this procedure. Clinicopathological data were analyzed for 85 resected HCC patients with hepatitis B virus-related macronodular cirrhosis. An additional 255 patients with nonmicronodular and micronodular cirrhosis were randomly selected during the same period as the control group. Compared with nonmicronodular and micronodular cirrhosis patients, macronodular cirrhotic patients exhibited elevated alanine aminotransferase, aspartate aminotransferase, and γ-glutamyltransferase levels, higher Child-Pugh classification, higher indocyanine green retention rate at 15 min (ICG R15), and more number of total complications. No significant differences were observed between the two groups with regard to major complications, mortality, overall survival, and recurrence-free survival. The morbidity rate was relatively low in patients exhibiting low ICG R15 (<10%). Cox analysis identified small tumors (≤ 5 cm) and radical resection as independent prognostic factors that could predict long-term overall survival. Radical resection can result in high recurrence-free survival in macronodular cirrhotic patients. Resection is safe for macronodular cirrhotic HCC patients, and radical resection provides a positive outcome. Small-sized patients are good candidates for hepatectomy. Macronodular cirrhosis should not rule out hepatectomy in patients with low ICG R15.

Viral Hepatitis in Liver Transplantation

Liver transplantation is the only alternative for patients with end-stage liver disease. Viral hepatitis B and C are among the most common causes of cirrhosis and hepatocellular carcinoma and a frequent indication for liver transplantation. Hepatitis B virus immunoglobulin and nucleot(s)ide analogues have facilitated the management of patients with hepatitis B who have received liver transplants and resulted in excellent long-term outcomes. On the contrary, recurrence of hepatitis C is the main cause of graft loss in most transplant programs. Current therapeutic approaches are far from optimal, because sustained virologic responses are only achieved in one-third of treated patients, and adverse effects are common and severe. However, the rapid development of direct-acting antivirals against hepatitis C virus will change the management of this disease and in a few years prevent graft infection with this virus.

Diabetic complications in Egyptian patients with and without hepatitis C virus-related liver cirrhosis

Diabetic complications in Egyptian patients with and without hepatitis C virus-related liver cirrhosis

Partial Splenic Artery Embolization for Thrombocytopenia and Uncontrolled Massive Ascites After Liver Transplantation

Thrombocytopenia (platelet < 60,000/mm3) and uncontrolled massive ascites (ascitic fluid > 1000 mL/d over 10 days) after liver transplantation (OLT), although uncommon, usually represent serious complications. Splenectomy is a useful treatment despite its many side effects. Recently, partial splenic artery embolization (PSAE) is considered to be a nonsurgical, less invasive treatment. In this study, we retrospectively reviewed the results of PSAE after OLT. Between October 2008 and February 2010, 11 patients underwent PSAE after OLT due to thrombocytopenia (n = 6) or refractory ascites (RA; n = 5). Six patients (54.5%) were males and 3 (27.3%) were children. The primary liver disease was virus-related liver cirrhosis (n = 6), biliary atresia (n = 3), fulminant hepatitis (n = 1), or alcoholic liver cirrhosis (n = 1). Seven grafts were from living and four from deceased donors. The major axial size of spleen was 12.1 to 23.4 cm and its average embolized volume, 76.4% (range = 70%–80%). As the result, the platelet count significantly increased after PSAE in all patients maintaining values greater than 100,000/mm3 in four thrombocytopenic patients (66.7%). Cases of RA showed marked decreases after PSAE (100%). The follow-up was 6 to 28 months. After PSAE, patients experienced abdominal pain (n = 9, 81.8%), fever (n = 2, 18.2%), and abdominal distension (n = 2, 18.2%). However, there was no serious complication after PSAE such as splenic abscess, rupture, pancreatic infarction, sepsis, or death. In conclusion, PSAE was effective and safe and can be the choice for thrombocytopenia or RA related to hypersplenism after OLT.

All-in-one sleeve patch graft venoplasty for multiple hepatic vein reconstruction in living donor liver transplantation

ObjectivesThis paper presents an innovative technique to address complex multiple hepatic vein (HV) reconstruction in right lobe graft living donor liver transplantation (RL-LDLT). MethodsA patient with hepatitis C virus-related cirrhosis underwent RL-LDLT. The graft had seven HVs, including: the right HV (17mm); one segment VII HV (11mm); two segment VI HVs (6mm and 16mm), and three segment V HVs. The graft weighed 663g (53% of standard liver volume; ratio of graft weight to recipient body weight: 0.96). Each HV had significant drainage territory requiring reconstruction. A cryopreserved iliac vein graft was used to create a sleeve patch to incorporate the HV openings. The holes were anastomosed to their corresponding HV tributaries using continuous 6–0 polydioxanone (PDS) sutures. Two of the three segment V HVs were combined using a smaller iliac vein patch, which was anastomosed in an end-to-side fashion to a previously harvested recipient umbilical vein interposition graft. The other end of the umbilical vein graft was anastomosed to the larger iliac vein sleeve patch. ResultsOverall, six HV openings were incorporated in one sleeve patch to allow a single wide anastomosis with the recipient inferior vena cava. Doppler ultrasound after reconstruction showed adequate flow patterns in all the HVs. ConclusionsAll-in-one sleeve patch graft venoplasty simplifies the reconstruction of multiple HVs and reduces warm ischaemia time in RL-LDLT with excellent outcomes.

Isolated Dissection of the Superior Mesenteric Artery After Living Donor Liver Transplantation: A Case Report

Isolated dissection of the superior mesenteric artery (SMA) not associated with aortic dissection is rare, particularly after living donor liver transplantation (LDLT). We experienced a case of isolated dissection of the SMA after LDLT performed in a 56-year-old man diagnosed with hepatitis B virus–related cirrhosis and hepatocellular carcinoma within the Milan criteria. He had no past history of hypertension or diabetes mellitus. At 6 days after LDLT, the patient underwent an emergency portal vein thrombectomy with ligation of a huge left gastric vein shunt. Thereafter anticoagulant and antiplatelet therapy were initiated. At 12 days after LDLT, a contrast-enhanced computer assisted tomography (CT) scan revealed the presence of a thrombus in a false lumen and a thin flap enlarged in the SMA. Because he presented neither abdominal pain nor biochemical data suggesting mesenteric ischemia, he was treated with antihypertensive agents in addition to anticoagulant and antiplatelet therapy. The thrombus in the false lumen was reduced and the intimal flap in the SMA disappeared according to the results of a CT scan 4 months after LDLT. He has remained free of symptoms for 4 years. The strategy to treat isolated SMA dissection is not well established. Urgent surgery is indicated for acute symptomatic forms with a suspicion of mesenteric ischemia; conservative treatment is indicated for patients with minimal, resolving, or no pain, but requires close follow-up.