Assessment of chronic hepatitis C virus infection requires a liver biopsy in most circumstances. There is a reluctance to perform liver biopsy in haemophiliacs because of a perceived risk of ...haemorrhage, although with adequate factor concentrate replacement in patients without factor concentrate inhibitors it should be safe. We report a 4‐year experience of liver biopsy in patients with haemophilia infected with chronic hepatitis C virus. Of 55 patients seropositive for anti‐HCV, 35 have undergone liver biopsy; the median age of this group was 33 years (range 13–68). Seven patients had a normal liver. 22 had portal tract inflammation, four with lymphoid aggregates. Mild piecemeal necrosis was observed in only two and no bile duct injury was found. 11 patients had mild mixed micro‐ and macro‐vesicular fat. 19 patients had no evidence of fibrosis despite an estimated median duration of disease of 20 years (range 8–43). In the remaining 16 patients the maximum degree of fibrosis achieved was stage III. Patients with more significant fibrosis could not be identified on the basis of ALT or HCV RNA. There were no complications of liver biopsy in this series. Liver biopsy following a well‐defined protocol in chronic hepatitis C virus haemophiliac carriers is safe in the absence of factor concentrate inhibitors. In this young group of patients without HIV infection there was no evidence of significant liver disease despite a considerable duration of disease. Performing liver biopsy allows accurate information to be given to the patient and avoids unnecessary therapy. The relative youth of this group may be important in the light of the benign histology.
A case of a 63-year-old man with a long-standing history of portal hypertension secondary to hepatic sarcoidosis who developed hepatocellular carcinoma is reported.
Many clinicians appear to be concerned about the potential hepatotoxicity of the opiate antagonist naltrexone (NTX) and this may be one reason why it is not used more widely in treating both heroin ...and alcohol abusers. Some much‐quoted early studies noted abnormalities in liver function tests (LFTs) in very obese patients taking high doses, although there was no evidence of clinically significant liver dysfunction. These concerns may be reinforced by advice in the UK product information sheet to perform LFTs before and during treatment, by high infection rates with hepatitis C virus (HCV) among injecting heroin addicts and by the frequency of abnormal LFTs in alcohol abusers. We describe a heroin abuser in whom clinical and laboratory manifestations of acute hepatitis B and C appeared a few days after the insertion of a subcutaneous naltrexone implant. A decision was made not to remove the implant but the hepatitis resolved completely and uneventfully well within the normal time‐scale. A review of the literature indicates that even when given at much higher doses than are needed for treating heroin or alcohol abusers, there is no evidence that NTX causes clinically significant liver disease or exacerbates, even at high doses, serious pre‐existing liver disease. During the past decade, NTX has been shown to be safe and effective in the treatment of pruritus associated with severe jaundice caused by severe and sometimes life‐threatening cirrhosis and other liver diseases. Its safety, even in these extreme conditions, is particularly reassuring. We suggest that it may be more appropriate and economical to advise patients to report promptly any suspected side effects than to perform regular LFTs, which may be misleading.
Many people now seek alternative methods of weight loss. The internet provides a readily available source of weight reduction products, the ingredients of which are often unclear. The authors ...describe a case of acute hepatitis in a 20 year old woman caused by such a product purchased over the internet.
A 20-year old woman presented with a two day history of abdominal pain, vomiting and jaundice. There were no identifiable risk factors for chronic liver disease. Liver function tests demonstrated an acute hepatitis (aminoaspartate transaminase 1230 IU/L). A chronic liver disease screen was negative. The patient had started a weight loss product (Pro-Lean), purchased over the internet two weeks prior to presentation. The patient was treated conservatively, and improved. The sequence of events suggests an acute hepatitis caused by an herbal weight loss product.
This case report highlights the dangers of weight loss products available to the public over the internet, and the importance of asking specifically about alternative medicines in patients who present with an acute hepatitis.
Chronic HCV infection affects about 500 million people world-wide and 450 000 people in UK. There is no evidence of immunity to this infection. Chronic infection occurs in the majority although a ...small proportion of infected individuals become sero-negative and appear to be free from disease. About 5-20% of patients develop cirrhosis within 20-30 years. No therapy is curative although alpha-interferon can restrict viral replication. Chronic HCV is a silent disease clinically with variable established or on-going underlying liver fibrosis. Conventional methods for assessment of patients with chronic liver disease are unreliable in detecting fibrosis. 136 chronic HCV carriers were assessed prospectively. A novel scoring system for assessing fibrosis was developed. Serum hyaluronic acid proved a useful surrogate marker of liver fibrosis. The factors governing the fibrotic process leading to cirrhosis are unknown. A statistical model was developed which explored the interrelationships of the necro-inflammatory activity and fibrotic changes. Piecemeal necrosis, lobular inflammation and steatosis were important features signalling the progressive development of fibrosis. Subclinical cryoglobulinaemia, with no association with any clinical features, was found in 20% of HCV patients. Type III cryoglobulins predominated, containing immune complexes of mainly IgG / IgM as well as HCV-RNA. Whether these antibodies are directed towards the E1/E2 regions was unclear. Neutralising antibodies are likely to be directed towards epitopes within the envelope. Epitope mapping with selected synthetic peptides from conserved regions of core, E1/E2 and HVR across different HCV genotypes using an ELISA technique was developed. IgG anti-core was commonly detected but was unrelated to replication, inflammation or fibrosis. IgA anti-core was rarely present. IgG anti-HVR was found in 3.4-53.6 % and was associated with viral replication and inflammation but not fibrosis. IgA anti-HVR was found rarely. In contrast, IgA anti-El or anti-E2 were found commonly and more frequently than the corresponding IgG antibodies. IgA antibody against a small selection of El and more particularly E2 peptides (W1399, S74, S76, S77 and S79) was associated with a reduced stage of fibrosis, although there was no link with inflammation or replication. IgG antibody to El or E2 was found to be protective from fibrosis with a small number of peptides; however, the infrequent identification of these antibodies precluded adequate statistical analysis. The recognition of antibodies to peptides of El and E2 conserved across different genotypes requires confirmation in a further series of patients prospectively, but suggests the exciting possibility that induction of immunity to these regions might prevent progressive fibrosis.
Helicobacter pylori (HP) testing in young patients with uncomplicated dyspepsia has been recommended. A test and treat strategy for dyspeptics positive for HP is recommended by the European H. pylori ...Study Group and the American Gastroenterology Association.
To assess the rates of re-referral for upper GI endoscopy (OGD) and outpatient (OPD) attendance in uncomplicated dyspeptic patients following assessment of HP status.
190 patients under 50 years of age with uncomplicated dyspepsia (without alarm symptoms) referred from general practitioners (GPs) to the gastroenterology department underwent HP urea breath test (UBT). GPs were informed of the results of UBT and recommended eradication therapy if positive, and if negative advised symptomatic treatment with an acid suppressant with/without a prokinetic. The patients were analysed for subsequent attendance at OGD or OPD in the following two years.
HP was present in 93 of 190 patients. Twenty of 190 (10.5%) patients subsequently were re-referred and underwent OGD for continuing dyspeptic symptoms; a further 6 were seen in OPD but not endoscoped as they have been judged to have uncomplicated gastro-oesophageal reflux disease. At time of OGD all patients were negative on Campylobacter-like organism (CLO) test for HP. Findings at OGD were normal (9), hiatus hernia (6), gastritis (4) and duodenitis (1). No case of peptic ulcer disease or gastric cancer has been identified.
In this group of dyspeptic patients, adopting a test and treat policy after initial analysis of HP resulted in 10.5% being re-referred for subsequent OGD; findings in those endoscoped were normal or minimal. A test and treat strategy for H. pylori in uncomplicated dyspeptics therefore saves endoscopies and outpatient consultations without missing significant underlying pathology.
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