John Moschos

Leucocyte esterase reagent strips for the diagnosis of spontaneous bacterial peritonitis : a systematic review

The reported incidence of spontaneous bacterial peritonitis (SBP) is 7–30% per annum in cirrhotic patients. Timely diagnosis and treatment is crucial to reduce mortality owing to this infection. Recently, leucocyte esterase reagent strips have been tested in the diagnosis of infection in the ascitic fluid. The objective was to evaluate the diagnostic value of leucocyte esterase reagent strips in SBP in cirrhotic patients with ascites, by systematically reviewing the evidence from prospective clinical studies. We performed a comprehensive literature search in Medline up to July 2007 for adult human prospective clinical studies. Two reviewers independently checked all identified studies for fulfillment of predefined inclusion criteria, extracted data and assessed methodological quality of included studies. We had decided a priori to pool the studies via meta-analysis, only if statistical heterogeneity was found to be nonsignificant (P>0.10). Seventeen studies were included. Statistical heterogeneity among studies was found to be highly significant (P<0.001) in all analyses, precluding pooling of data for meta-analysis. Compared with the manual polymorphonuclear count (‘gold standard’), leucocyte esterase reagent strips were found to have sensitivity ranging from 45 to 100%, specificity ranging from 81 to 100%, positive predictive value ranging from 42 to 100% and negative predictive value ranging from 87 to 100%. Despite the wide variation in sensitivity and positive predictive value between studies, the consistently high negative predictive value of leucocyte esterase reagent strips in SBP diagnosis should gain it a place in the ascitic tap diagnostic algorithm.

Idiopathic portal hypertension complicating systemic sclerosis: a case report

BackgroundPatients with systemic sclerosis may develop mild abnormalities of liver function tests. More serious hepatic involvement has been well documented but is rare. Idiopathic portal hypertension had been reported only in a few female patients with systemic sclerosis.Case presentationAn 82-year-old man with known systemic sclerosis presented with melaena. Urgent gastroscopy revealed oesophageal varices, which re-started bleeding during the procedure and were treated ensocopically, with Sengstaken tube and glypressin. Liver function tests and coagulation were normal. Non-invasive liver screen (including hepatitis viral serology and autoantibodies) was negative. Ultrasound scan of the abdomen revealed a small liver with coarse texture and no focal lesion. Hepato-portal flow was demonstrated in the portal vein. The spleen was enlarged. A moderate amount of free peritoneal fluid was present. A CT scan confirmed the absence of portal vein thrombosis. One month following discharge the patient had a liver biopsy. Histological examination showed essentially normal liver tissue; there was no evidence of any excess inflammation and no features to suggest cirrhosis or drug-induced liver disease. Taking into account the above evaluation we concluded that the patient had idiopathic portal hypertension.ConclusionBoth male and female patients with systemic sclerosis may – rarely – develop idiopathic portal hypertension.

Large mesenteric gastrointestinal stromal tumor in a patient with familial adenomatous polyposis syndrome

ZusammenfassungWir stellen den Fall eines 30-jährigen männlichen Patienten vor, der eine ausgeprägte Schwäche, Anämie und Diarrhoe seit 2 Monaten hatte. Bei der Koloskopie fanden sich viele (> 100) Polypen (Familiäres Adenomatöses Polyposis-Syndrom – FAP-Syndrom). Das Abdomen-CT zeigte einen großen Tumorim linken oberen Bauchraum, in der Nähe der linken oberen Kolonflexur. Wir führten eine totale Kolektomie mit Entfernung des mesenterialen Tumors und des angrenzenden Dünndarms mit einer Ileostomie durch. Die Untersuchung des resezierten mesenterialen Tumors zeigte einen stromalen Tumor (GIST) mit seltenen Mitosen und Infiltration des anliegenden Dünndarms. Der vorliegende Fall ist die in der medizinischen Literatur erstmalige Beschreibung der gleichzeitigen Existenz von FAP-Syndrom und GIST bei einem 30-jährigen männlichen Patienten.SummaryWe report a case of a 30-year-old man who presented with severe debilitation, anemia and diarrhea over two months. Colonoscopy revealed many (>100) polyps (familial adenomatous polyposis syndrome). Abdominal CT scan showed a large mass at the left upper abdomen in conjunction with the splenic flexure. Total colectomy with mesenteric mass and adjacent small bowel removal and ileoanal pouch was performed. Examination of the resected mesenteric mass showed a gastrointestinal stromal tumor (GIST) with scarce mitosis and infiltration of the adjacent small bowel. We describe for the first time in medical literature the coexistence of familial adenomatous polyposis syndrome and GIST in a 30-year-old man.

Dipsticks for spontaneous bacterial peritonitis: Comments on a long-awaited study report†

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