Alex Vianey Callado França

Frequency, Clinical Characteristics, and Respiratory Parameters of Hepatopulmonary Syndrome

OBJECTIVES To determine the frequency and the clinical characteristics of hepatopulmonary syndrome (HPS) in cirrhotic candidates for orthotopic liver transplantation and to identify the major respiratory parameters predictive of the presence of changes in arterial oxygenation. PATIENTS AND METHODS Patients underwent transthoracic contrast-enhanced echocardiography, pulmonary scintigraphy, pulmonary function test with diffusing capacity of lung for carbon monoxide (DLCO), and measurement of arterial blood gases. RESULTS Fifty-six patients were studied. Twenty-five patients (45%) presented with intrapulmonary vascular dilatations, but only 9 (16%) fulfilled the criteria for HPS. The clinical or demographic characteristics considered did not differ in the patients with and without HPS. The DLCO value was significantly lower in patients with HPS (P=.01). However, 32 (80%) of 40 patients with low DLCO values did not fulfill the criteria for HPS. An alveolar arterial oxygen gradient (AaPO2) of more than 20 mm Hg showed a higher diagnostic accuracy (91%) in the assessment of HPS than did the DLCO of less than 80% predicted (41%) and the AaPO2 of more than 15 mm Hg (71%). CONCLUSIONS The AaPO2 proved to be a more reliable index than PaO2 and DLCO for the determination of changes in arterial oxygenation in HPS. The DLCO does not seem to be a good marker for HPS screening. Intrapulmonary vascular dilatations were frequent, even in patients who did not fulfill the criteria for HPS.

Spontaneous hepatitis B surface antigen clearance in a long-term follow-up study of patients with chronic type B hepatitis. Lack of correlation with hepatitis C and D virus superinfection

We investigated the frequency of HBsAg clearance and the possible role of viral superinfection in a long-term follow-up of 184 patients with chronic hepatitis B (CHB). Our subjects were 184 patients with chronic hepatitis B and the follow-up was 12–216 months (mean 66.2±53.7 months). The investigative methods used were: immunoenzymatic assays for HBV, HCV, HDV, and HIV markers; polymerase chain reaction (PCR) for HBV DNA; and liver biopsy and immunoperoxidase. During the follow-up, 20 of the 184 patients cleared serum HBsAg. A comparison of patients with persistent HBsAg (group I) and of those who cleared this marker (group II) showed a significant difference in mortality (P=0.002) between the two groups and a tendency to a more severe exacerbation (flare) in group II (P=0.07). Antibodies to hepatitis C and D virus as well as antibodies to HIV were equally distributed in both groups. Thirteen patients (7.9%) from group I, but none from group II, subsequently developed hepatocellular carcinoma. These results suggest that the frequency of spontaneous clearance of HBsAg during chronic HBV infection is low. No determinant factor for the clearance was found, including the presence of liver cirrhosis. Serum HBV DNA was undetectable by PCR after clearance in 16 out of 17 patients.

Síndrome hepatopulmonar: patogenia, diagnóstico e tratamento

BACKGROUND The hepatopulmonary syndrome is characterized by a clinical triad consisting of: 1) hepatic disease and/or portal hypertension, 2) intrapulmonary vascular dilatations, and 3) abnormal arterial oxygenations (partial oxygen pressure <70 mm Hg or an alveolar-arterial oxygen gradient >20 mm Hg). Its frequency varies according to the diagnostic methods used. OBJECTIVES To review the literature about the pathogeny, diagnosis and treatment of the hepatopulmonary syndrome. METHODS A survey of the more relevant Brazilian and international publications on the hepatopulmonary syndrome in MEDLINE. RESULTS The prevalence of the hepatopulmonary syndrome ranges from 4% to 17.5% depending on the diagnostic criteria used. The most commonly associated liver disease is cirrhosis. The alveolar-arterial oxygen gradient seems to be the best parameter for the assessment of the abnormalities of arterial oxygenation. For the detection of intrapulmonary vascular dilatations, contrast echocardiography is the method of choice because it is of easy execution and it can differentiate between the intrapulmonary and intracardiac communications. In the treatment of hepatopulmonary syndrome, it was possible to reproduce and confirm few successful reports using pharmacological therapy and/or intervention radiology. At present, liver transplantation is considered to be the main therapeutic option for these patients, with encouraging results. CONCLUSIONS The hepatopulmonary syndrome is a frequent disease that requires blood gas measurements for diagnosis. Liver transplantation is the treatment of choice for patients with the syndrome.

Transplante de fígado: resultados de aprendizagem de pacientes que aguardam a cirurgia

This study aims to describe the learning results of the implementation of teaching strategies involving patients who will be submitted to liver transplantation. One of these strategies is to give the patients a manual with orientations and the subsequent application of a questionnaire related to the content of the manual. Authors analyzed 13 patients who were waiting for liver transplantation. With respect to the answers regarding the questionnaire, an average of 83.8% of correct responses was given and only one patient got all the questions right. During the correction and the time to clarify their doubts, authors concluded that the opportunity of reading the manual and applying the questionnaire allowed patients and families to get a better understanding about the surgerys most important aspects.O objetivo deste estudo e descrever os resultados de aprendizagem da experiencia de implementacao de estrategias de ensino com os pacientes que serao submetidos a transplante de figado. Uma delas e a entrega de um manual de orientacao aos pacientes que entram no programa, com posterior aplicacao de questionario relacionado ao conteudo do manual. Analisou-se 13 pacientes em lista de espera para transplante de figado, todos ocupando as primeiras posicoes no cadastro tecnico. Em relacao as respostas obtidas dos questionarios aplicados, a media de acertos foi de 80,6%, sendo que apenas um paciente acertou todas as questoes. Durante a correcao e esclarecimento das duvidas, concluiu-se que a leitura do manual de orientacao e a aplicacao do questionario proporcionam esclarecimento melhor dos pacientes e de seus familiares em relacao aos aspectos mais importantes da cirurgia.

Cryptococcosis in cirrhotic patients

The objective of the present study was to report on three distinct forms of presentation of Cryptococcus neoformans infection in three cirrhotic patients. One patient had disseminated cryptococcosis with detection of the fungus in ascitic fluid, cerebrospinal fluid and blood; the second patient had pleural involvement and the third had cutaneous infection caused by C. neoformans.

ACUTE ESOPHAGEAL NECROSIS

Acute esophageal necrosis (AEN) is defined as a diffuse blackened aspect of the esophagus observed by upper gastrointestinal endoscopy associated with the histopathological findings of necrosis of the esophageal mucosa. In general, the condition is present in severely compromised patients. Its cause remains unknown but is probably multifactorial. In the present case report we describe the clinical, endoscopic and histopathological characteristics of black esophagus observed in three patients and present a review of the literature.

Brain metastasis of hepatocellular carcinoma detected after liver transplantation

AIM We report the case of a patient with hepatocellular carcinoma submitted to liver transplantation, who subsequently manifested tumor recurrence initially as brain metastasis. CASE DESCRIPTION A 48-year-old male cirrhotic patient with hepatitis C infection, and two focal hepatic lesions, had a cytologic and histologic diagnosis of hepatocellular carcinoma. Before transplant, he was submitted to adjuvant treatment with a combination of arterial embolization and intratumoral ethanol injection. In the 3rd month post-liver transplantation, the patient developed headache, nausea and vomiting, without any neurological impairment. Brain computed tomography and magnetic resonance imaging identified an expansive hypervascular lesion with internal bleeding. Evaluation of the surgical explant revealed macroscopic invasion of portal vessels. CONCLUSION Brain metastasis of a hepatocellular carcinoma after liver transplantation may occur. This metastasis may have occurred before or soon after the transplant. Patients with hepatocellular carcinoma, awaiting liver transplant, should be screened for cerebral metastasis. Vascular invasion may indicate hematogenic dissemination of the tumor.

Liver transplantation: teaching strategies used with patients waiting for surgery

This study aims to describe the learning results of the implementation of teaching strategies involving patients who will be submitted to liver transplantation. One of these strategies is to give the patients a manual with orientations and the subsequent application of a questionnaire related to the content of the manual. Authors analyzed 13 patients who were waiting for liver transplantation. With respect to the answers regarding the questionnaire, an average of 83.8% of correct responses was given and only one patient got all the questions right. During the correction and the time to clarify their doubts, authors concluded that the opportunity of reading the manual and applying the questionnaire allowed patients and families to get a better understanding about the surgerys most important aspects.O objetivo deste estudo e descrever os resultados de aprendizagem da experiencia de implementacao de estrategias de ensino com os pacientes que serao submetidos a transplante de figado. Uma delas e a entrega de um manual de orientacao aos pacientes que entram no programa, com posterior aplicacao de questionario relacionado ao conteudo do manual. Analisou-se 13 pacientes em lista de espera para transplante de figado, todos ocupando as primeiras posicoes no cadastro tecnico. Em relacao as respostas obtidas dos questionarios aplicados, a media de acertos foi de 80,6%, sendo que apenas um paciente acertou todas as questoes. Durante a correcao e esclarecimento das duvidas, concluiu-se que a leitura do manual de orientacao e a aplicacao do questionario proporcionam esclarecimento melhor dos pacientes e de seus familiares em relacao aos aspectos mais importantes da cirurgia.

Long term follow-up and patterns of response of ALT in patients with chronic hepatitis NANB/C treated with recombinant interferon-alpha

The response to interferon treatment in chronic hepatitis NANB/C has usually been classified as complete, partial or absent, according to the behavior of serum alanine aminotransferase (ALT). However, a more detailed observation of the enzymatic activity has shown that the patterns may be more complex. The aim of this study was to describe the long term follow-up and patterns of ALT response in patients with chronic hepatitis NANB/C treated with recombinant interferon-alpha. A follow-up of 6 months or more after interferon-alpha was achieved in 44 patients. We have classified the serum ALT responses into six patterns and the observed frequencies were as follows: I. Long term response = 9 (20.5%); II. Normalization followed by persistent relapse after IFN = 7 (15.9%); III. Normalization with transient relapse = 5 (11.9%); IV. Temporary normalization and relapse during IFN = 4 (9.1%); V. Partial response (more than 50% of ALT decrease) = 7 (15.9%); VI. No response = 12 (27.3%). In conclusion, ALT patterns vary widely during and after IFN treatment and can be classified in at least 6 types.

Diagnosis and treatment of benign liver nodules: Brazilian Society of Hepatology (SBH) recommendations

Space-occupying lesions of the liver may be cystic or solid. Ultrasonography is an extremely useful method for initial screening, and suffices for diagnosis of simple hepatic cysts. Complex cysts and solid masses require computed tomography or magnetic resonance imaging for confirmation. Wide surgical excision is indicated in cystadenoma or cystadenocarcinoma. Clinical and epidemiological data are important, as nodules in noncirrhotic livers are more likely to be benign. Hemangiomas, the most common benign tumors, require no follow-up after diagnostic confirmation if they are small and asymptomatic. Patients with giant, symptomatic hemangiomas or compression of adjacent structures should be referred to hepatobiliary centers for potential surgery. The genetic heterogeneity of hepatocellular adenomas and their epidemiology and prognosis prompted classification of these tumors into four subtypes based on histology and immunohistochemistry. The major complications of hepatocellular adenomas are rupture with bleeding and malignant transformation. Rupture occurs in approximately 30% of cases. The main risk factors are tumors size >5 cm and inflammatory subtype. Hepatocellular adenomas may enlarge during pregnancy due to marked hormonal stimulation. As oral contraceptive pills and anabolic steroids have associated with hepatocellular adenomas growth, particularly of the hepatocyte nuclear factor-1alfa subtype, these drugs should be discontinued. Focal nodular hyperplasia is the second most common benign tumor of the liver. It is most frequent in women aged 20 to 60, and 70% to 90% of cases are asymptomatic. In the absence of a central scar and/or other hallmarks of Focal nodular hyperplasia, with uncertainty between this diagnosis and hepatocellular adenoma, liver-specific contrast agents are indicated.