Laurie Blendis

Comparison of fatty liver index with noninvasive methods for steatosis detection and quantification

AIM To compare noninvasive methods presently used for steatosis detection and quantification in nonalcoholic fatty liver disease (NAFLD). METHODS Cross-sectional study of subjects from the general population, a subgroup from the First Israeli National Health Survey, without excessive alcohol consumption or viral hepatitis. All subjects underwent anthropometric measurements and fasting blood tests. Evaluation of liver fat was performed using four noninvasive methods: the SteatoTest; the fatty liver index (FLI); regular abdominal ultrasound (AUS); and the hepatorenal ultrasound index (HRI). Two of the noninvasive methods have been validated vs liver biopsy and were considered as the reference methods: the HRI, the ratio between the median brightness level of the liver and right kidney cortex; and the SteatoTest, a biochemical surrogate marker of liver steatosis. The FLI is calculated by an algorithm based on triglycerides, body mass index, γ-glutamyl-transpeptidase and waist circumference, that has been validated only vs AUS. FLI < 30 rules out and FLI ≥ 60 rules in fatty liver. RESULTS Three hundred and thirty-eight volunteers met the inclusion and exclusion criteria and had valid tests. The prevalence rate of NAFLD was 31.1% according to AUS. The FLI was very strongly correlated with SteatoTest (r = 0.91, P < 0.001) and to a lesser but significant degree with HRI (r = 0.55, P < 0.001). HRI and SteatoTest were significantly correlated (r = 0.52, P < 0.001). The κ between diagnosis of fatty liver by SteatoTest (≥ S2) and by FLI (≥ 60) was 0.74, which represented good agreement. The sensitivity of FLI vs SteatoTest was 85.5%, specificity 92.6%, positive predictive value (PPV) 74.7%, and negative predictive value (NPV) 96.1%. Most subjects (84.2%) with FLI < 60 had S0 and none had S3-S4. The κ between diagnosis of fatty liver by HRI (≥ 1.5) and by FLI (≥ 60) was 0.43, which represented only moderate agreement. The sensitivity of FLI vs HRI was 56.3%, specificity 86.5%, PPV 57.0%, and NPV 86.1%. The diagnostic accuracy of FLI for steatosis > 5%, as predicted by SteatoTest, yielded an area under the receiver operating characteristic curve (AUROC) of 0.97 (95% CI: 0.95-0.98). The diagnostic accuracy of FLI for steatosis > 5%, as predicted by HRI, yielded an AUROC of 0.82 (95% CI: 0.77-0.87). The κ between diagnosis of fatty liver by AUS and by FLI (≥ 60) was 0.48 for the entire sample. However, after exclusion of all subjects with an intermediate FLI score of 30-60, the κ between diagnosis of fatty liver by AUS and by FLI either ≥ 60 or < 30 was 0.65, representing good agreement. Excluding all the subjects with an intermediate FLI score, the sensitivity of FLI was 80.3% and the specificity 87.3%. Only 8.5% of those with FLI < 30 had fatty liver on AUS, but 27.8% of those with FLI ≥ 60 had normal liver on AUS. CONCLUSION FLI has striking agreement with SteatoTest and moderate agreements with AUS or HRI. However, if intermediate values are excluded FLI has high diagnostic value vs AUS.

Pulmonary Manifestations of Liver Diseases

Respiratory problems are common in patients with chronic liver diseases. The most common causes are disorders that are not related to liver diseases such as asthma and COPD. In addition certain liver diseases that are associated with specific pulmonary abnormalities, and conditions associated with end stage liver disease like tense ascites and intercostal muscular wasting are considered. Finally two unique disorders characterizing by vascular abnormalities independent of cardiorespiratory disorder-the hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are observed. These disorders have different pathogenesis, different clinical pictures, treatment and prognosis. This article reviews the epidemiology, pathophysiology, clinical features, evaluation and current therapy of these two disorders.

Sampling variability of transient elastography according to probe location

Background and Aims Heterogeneity of fibrosis throughout the liver has been reported. However, the need for several measurements when using transient elastography was not thoroughly investigated. The aim was to find out whether measurement of liver stiffness varies according to the probe location. Methods Six hundred and twenty-five consecutive patients with chronic liver diseases referred for transient elastography were enrolled. All patients underwent successive liver stiffness measurements at three different sites. Representative measurements were acquisitions with a success rate greater than 60% and an interquartile range lower than 30% of the median. Results The sample included 371 eligible patients with three representative measurements. Comparing the three successive measurements categorized to fibrosis stages F0–F4, 68.2% of patients had agreement between all three sites. Discordance of one stage was noted in 28.3% of the patients, in 7% for two stages, and in 1.4% for three stages. The &kgr; for comparing the maximal versus the minimal results was 0.43. There was no significant difference in the characteristics of patients with discordance and patients without discordance including age, sex, waist circumference, BMI, and etiology of liver disease. The stage of fibrosis was associated with discordance between measurements (P<0.001), demonstrating low discordance rate in patients with stages F0–F1 or F4 and high discordance rate in patients with stages F2 and F3. Conclusion Sampling variability according to probe location is seen in transient elastography in approximately 30% of patients. Therefore, it may be suggested to perform transient elastography from various sites to minimize the sample error.

Role of CYP2D6 polymorphism in predicting liver fibrosis progression rate in Caucasian patients with chronic hepatitis C.

Abstract: Objective: Previous studies have demonstrated that CYP2D6 polymorphism is associated with liver cirrhosis. The aim of the present study was to find out whether CYP2D6*4, the poor metabolizer allele can predict fibrosis progression rate.

Excess nitric oxide in preascites: another piece in the puzzle.

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Hepatocellular Carcinoma: New Strategies to Improve Prognosis

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. Most patients still present late in the course of the disease so that curative therapy is rarely possible. Strategies developed to improve the prognosis include primary prevention, directed at the underlying liver diseases, secondary prevention by cancer surveillance and early intervention, and more effective therapies. Only childhood vaccination against hepatitis B (HBV) infection has been clearly documented to reduce the incidence of HCC. Eradication of the hepatitis B and C viruses by interferon in noncirrhotic patients may reduce the incidence of HCC. Removal of iron by phlebotomy in noncirrhotic patients with genetic hemochromatosis will largely prevent HCC. Many physicians offer secondary prevention by surveillance and early intervention involving repeated abdominal ultrasound and serial serum α-fetoprotein estimations in order to identify early malignant lesions, but such strategies have yet to be proven to reduce mortality from HCC. Nonetheless, early detection would seem to offer a greater chance for application of potentially curative therapy. Different surveillance strategies may be necessary in different patient groups. For example, in chronic hepatitis C the increased risk of HCC seems to be confined to patients with established cirrhosis, whereas even noncirrhotic patients with HBV have a substantially increased risk of HCC.In high-risk patients, such as those with cirrhosis following chronic viral hepatitis, several factors can be identified which appear to confer additional risk. Examples are hepatocyte dysplasia found on biopsy, or non-neoplastic vascular nodules on computed tomography scanning. The management of such patients needs urgent resolution.Potentially curative treatment options include resection, liver transplantation, and alcohol injection or radiofrequency ablation. Resection in ideal candidates may provide up to 60% survival at 5 years. Liver transplantation may result in a 5-year survival of up to 70%. However, the shortage of organ donors means that tumor progression while on the waiting list will disqualify some patients, while others will die before an organ becomes available. Local ablation has been reported to be as effective as resection and is applicable to a larger proportion of patients.Of the palliative forms of therapy only chemoembolization has been shown to provide a significant improvement in life-span, although other forms of adjuvant and palliative therapy are under investigation.