Blai Dalmau

Incidence, prevalence and clinical course of primary biliary cirrhosis in a Spanish community

Background and aims Primary biliary cirrhosis (PBC) is characterized by the autoimmune inflammatory response of small intrahepatic bile ducts. Prevalence in Spain is estimated as 61.9 cases per million inhabitants, whereas Northern Europe rates over 200 cases/million. Our objective was to determine the incidence and prevalence of PBC in our health area. Material and methods PBC was defined by the presence of abnormal liver tests (dissociated cholestasis) with positive antimitochondrial antibodies and/or compatible liver histology. Medical records from patients diagnosed between 1990 and 2002 were reviewed retrospectively. The following data were collected: diagnostic data, demographic and analytic data, liver histology and stage and treatment and disease outcome. Results In a population of 389 758 inhabitants, 87 patients were diagnosed with PBC. Mean age at diagnosis was 63.9±12.6 years. Eighty-four (96.6%) were women. Mean annual incidence was 17.2 per 106 inhabitants and the prevalence at the end of study was 195 per 106. Biopsy was performed in 71 (81.6%) patients, 61 of whom (86%) did not have fibrosis. Time of follow-up was 63.6±43.2 (2.28–153.9) months. Conclusion Incidence and prevalence in our reference area are higher than in some Spanish areas, as per the results previously published; however, they are comparable with those obtained in Northern Europe and the US.

Seroprevalence and epidemiology of Helicobacter pylori infection in patients with cirrhosis

BACKGROUND Helicobacter pylori infection is the major pathogenic factor for peptic ulcer disease. Its epidemiology is not fully known; few data are available in patients with chronic liver disease. AIMS To investigate the seroprevalence and factors associated with Helicobacter pylori infection in a series of liver cirrhosis patients. METHODS Two hundred and twenty consecutive patients were prospectively included in a study aimed to evaluate the effect of dietary intervention on cirrhosis complications and survival. At inclusion, an epidemiological and clinical questionnaire was completed. Sera were obtained and stored at -70 degrees C until analyzed. They were tested for Helicobacter pylori antibodies using a commercial ELISA kit. RESULTS Eleven out of 220 patients had borderline anti-Helicobacter pylori IgG titers. Of the remaining 209 patients, 105 (50.2%) showed positive titers of Helicobacter pylori IgG. Univariate analysis showed that Helicobacter pylori infection was more frequent in older patients, those born outside Catalonia, and in patients with a low educational level. Past ethanol consumption and current smoking correlated negatively with Helicobacter pylori infection. Multivariate analysis selected age (OR 3.1. 95% CI 1.46-6.45), educational level (OR 2.2. 95% CI 1.18-4.2) and alcohol consumption (OR 0.7. 95% CI 0.45-0.99) as the variables independently related to Helicobacter pylori infection. CONCLUSIONS Helicobacter pylori infection in cirrhosis has the same epidemiological pattern as in the general population. Suggestions that the etiology or the severity of the liver disease could be related to Helicobacter pylori infection were not confirmed by our study.

Usefulness of indirect noninvasive methods in predicting progression to cirrhosis in chronic hepatitis C.

Background and aims The ability of noninvasive methods to predict the development of cirrhosis has not been established. We evaluated the ability of three noninvasive methods [the Forns index, the aspartate aminotransferase-to-platelet ratio index (APRI), and the Non-Invasive Hepatitis-C-related Cirrhosis Early Detection (NIHCED) score] to determine the risk of developing cirrhosis in chronic hepatitis C. Methods Consecutive patients with chronic hepatitis C who had undergone liver biopsy between 1998 and 2004 were eligible. We used the three methods to evaluate patients at baseline and at follow-up (4–10 years later). When these methods yielded discordant or indeterminate results, a second liver biopsy was performed. Logistic regression models were fitted for each method to predict whether cirrhosis would appear and to predict long-term mortality from cirrhosis. Results We included 289 patients in our study. The mean scores at baseline and at follow-up, respectively, were as follows: Forns, 5.47±1.95 and 6.56±2.02; APRI, 1.1±2.33 and 1.4±1.53; and NIHCED, 7.79±11.45 and 15.48±15.28. The area under the receiver operating characteristic curve for predicting cirrhosis was 0.83 for Forns, 0.79 for APRI, and 0.76 for NIHCED. The sensitivity and specificity for predicting cirrhosis, respectively, were 75 and 71% for Forns (cutoff 4.7), 86 and 42% for APRI (cutoff 0.48), and 41 and 82% for NIHCED (cutoff 0). The area under the receiver operating characteristic curve for predicting mortality was 0.86 for Forns, 0.79 for APRI, and 0.84 for NIHCED. Conclusion Indirect noninvasive markers could help identify patients with chronic hepatitis C at risk of progression to cirrhosis.

Factors related to survival in hepatocellular carcinoma in the geographic area of Sabadell (Catalonia, Spain)

BACKGROUND hepatocellular carcinoma (HCC) is a very frequent tumor. Screening for the disease is effective, but the prognostic factors are difficult to evaluate. OBJECTIVES 1. To determine epidemiological data and the clinical course of HCC in our setting. 2. To compare patient survival according to whether screening is performed or not. 3. To evaluate survival prognostic factors. PATIENTS AND METHODS data on the epidemiology and clinical course of patients diagnosed with HCC were collected on a prospective basis (January 2004-December 2006). Two groups were considered according to whether screening had been performed (group A) or not (group B). RESULTS a total of 110 patients were diagnosed with HCC (70% males). The most common etiology of cirrhosis was hepatitis C (56.1%), and 69% presented mild liver failure (Child-Pugh grade A). The median follow-up was 1.8 years. Fifty-one percent had been subjected to screening. The diagnosis of HCC was established by imaging techniques in 48.2% of the cases, and by histological criteria in 51.8%. The median tumor size was 23 mm in group A and 28 mm in group B (p = 0.005). Treatment with curative intent was provided in 72% of the cases in group A and in 48% in group B (p = 0.011). The median overall survival was 1.99 years -2.67 years in group A and 1.75 years in group B (p = 0.05). The multivariate analysis of overall survival showed the type of treatment (OR = 2.82 95%CI: 1.3-6.12, p = 0.009) and liver function (OR = 1.71 95%CI: 1.1-2.68, p = 0.020) to be independent predictors of survival. CONCLUSIONS screening allows the diagnosis of smaller lesions and a higher percentage of curative treatments. The degree of liver function and the provision of curative treatment are independent predictors of survival.

Historia natural del carcinoma hepatocelular en una cohorte de pacientes de un hospital comarcal

Background: hepatocellular carcinoma (HCC) is a cancer with high incidence and mortality. Objective: our aim was to describe the natural history of a pa tient cohort with HCC, and to identify the factors associated with survival. Patients and methods: a retrospective and descriptive study of patients diagnosed with HCC between 1995 and 2002. Quali tative variables were expressed as frequencies and percentages. Quantitative variables were expressed as medians and standard deviations. Survival was calculated using the Kaplan-Meier method and log rank. Results: a total of 154 patients were analyzed. The men-towomen ratio was 2.9/1. Mean age was 68 ± 9 years. 82% of pa tients died during a median follow-up of 28 months. Median sur vival was 21.5 months (95% CI: 16.98-26.04). Curative treatment was done in 40.3% of diagnosed patients, and 59.7% of patients received palliative treatment. Factors associated with survival were: ascites, number of lesions at diagnosis, and curative treatment. No statistical differences were found for the next fac tors: age, sex, etiology of cirrhosis, and Child-Pugh stage at diag nosis. Conclusions: factors associated with low survival in patients with HCC were ascites and number of lesions. Curative treatment is associated with a higher survival when compared to palliative treatment.

Larga supervivencia tras resección de metástasis craneal de hepatocarcinoma. Descripción de un caso y revisión de la literatura

The life expectancy of patients with hepatocellular carcinoma (HCC) has increased in the last few years due to recent treatment advances. However, extrahepatic metastases from tumors, previously described only occasionally, are becoming more frequent in clinical practice. The choice between an active or passive approach to these metastatic lesions can sometimes present clinicians with a difficult dilemma. We discuss the case of a male patient with multifocal HCC and cranial metastasis from a primary liver tumor and who, after surgery and radiotherapy over the metastatic lesion, has survived for more than 3 years.

Inter and intra-observer concordance for the diagnosis of portal hypertension gastropathy

INTRODUCTION At present there is no fully accepted endoscopic classification for the assessment of the severity of portal hypertensive gastropathy (PHG). Few studies have evaluated inter and intra-observer concordance or the degree of concordance between different endoscopic classifications. OBJECTIVES To evaluate inter and intra-observer agreement for the presence of portal hypertensive gastropathy and enteropathy using different endoscopic classifications. METHODS Patients with liver cirrhosis were included into the study. Enteroscopy was performed under sedation. The location of lesions and their severity was recorded. Images were videotaped and subsequently evaluated independently by three different endoscopists, one of whom was the initial endoscopist. The agreement between observations was assessed using the kappa index. RESULTS Seventy-four patients (mean age 63.2 years, 53 males and 21 females) were included. The agreement between the three endoscopists regarding the presence or absence of PHG using the Tanoue and McCormack classifications was very low (kappa scores = 0.16 and 0.27, respectively). CONCLUSIONS The current classifications of portal hypertensive gastropathy have a very low degree of intra and inter-observer agreement for the diagnosis and assessment of gastropathy severity.

Factores pronósticos de mortalidad en la cirrosis hepática tras un primer episodio de peritonitis bacteriana espontánea. Estudio multicéntrico

INTRODUCTION Spontaneous bacterial peritonitis is an infectious complication with a negative impact on survival of patients with cirrhosis. OBJECTIVE To analyze the short- and long-term survival after a first episode of bacterial peritonitis and the associated prognostic factors. PATIENTS AND METHODS This was a retrospective, multicenter study of patients admitted to hospital for spontaneous bacterial peritonitis between 2008 and 2013. Independent variables related to mortality were analyzed by logistic regression. The prognostic power of the Child Pugh Score, the Model for End-Stage Liver Disease (MELD) and the Charlson index was analyzed by ROC curve. RESULTS A total of 159 patients were enrolled, 72% were males with a mean age of 63.5 years and a mean MELD score of 19 (SD ± 9.5). Mortality at 30 and 90 days and one and two years was 21%, 31%, 55% and 69%, respectively. Hepatic encephalopathy (p = 0.008, OR 3.5, 95% CI 1.4-8.8) and kidney function (p = 0.026, OR 2.7, 95% CI 1.13-16.7) were independent factors for short- and long-term mortality. MELD was a good marker of short- and long-term survival (area under the curve [AUC] 0.7: 95% CI 1.02-1.4). The Charlson index was related to long-term mortality (AUC 0.68: 95% CI 0.6-0.77). CONCLUSIONS Short- and long-term mortality of spontaneous bacterial peritonitis is still high. The main prognostic factors for mortality are impairment of liver and kidney function. MELD and the Charlson index are good markers of survival.

Observación clínicaLarga supervivencia tras resección de metástasis craneal de hepatocarcinoma. Descripción de un caso y revisión de la literaturaLong survival after resection of cranial metastases from hepatocellular carcinoma. case report and review of the literature

The life expectancy of patients with hepatocellular carcinoma (HCC) has increased in the last few years due to recent treatment advances. However, extrahepatic metastases from tumors, previously described only occasionally, are becoming more frequent in clinical practice. The choice between an active or passive approach to these metastatic lesions can sometimes present clinicians with a difficult dilemma. We discuss the case of a male patient with multifocal HCC and cranial metastasis from a primary liver tumor and who, after surgery and radiotherapy over the metastatic lesion, has survived for more than 3 years.