Spontaneous rupture of splenic hamartoma in a patient with hepatitis C virus-related cirrhosis and portal hypertension： A case report and review of the literature

Spontaneous rupture is a rare complication of splenic hamartoma. A review of the literature revealed only four such cases. To the best of our knowledge, this is the first report of spontaneous rupture of splenic hamartoma associated with liver cirrhosis and portal hypertension. A 53-year-old woman, who was followed up for aortic dissection and hepatitis C virus (HCV)-related liver cirrhosis, was referred with sudden left chest and shoulder pain. An abdominal ultrasound showed intraabdominal bleeding, and computed tomography indicated rupture of a splenic tumor. Emergent splenectomy was carried out. The postoperative course was uneventful, and the patient was discharged on the 13th postoperative day. Pathology revealed the tumor to be a ruptured splenic hamartoma. The non-tumorous splenic parenchyma revealed congestive changes. We consider that the presence of liver cirrhosis and portal hypertension are risk factors for spontaneous rupture of the splenic hamartoma.     

Effect of spleen operation on antiviral treatment in hepatitis C virus-related cirrhotic patients

AIM: To investigate the impact of spleen operation (SO) on interferon-α (IFN-α)-based antiviral treatment in patients with hepatitis C virus (HCV)-related cirrhosis.METHODS: Studies were systematically identified by searching electronic databases including MEDLINE, Cochrane Library, Elsevier, and Embase up to September 30, 2013, and relevant clinical studies were reviewed. Sustained virological response (SVR) rate and adherence to therapy were taken as the endpoints of interest.RESULTS: A total of 603 patients from 16 studies were included in the systematic review. Of 372 patients who underwent SO followed by antiviral treatment, the total SVR rate was 39.5%. SVR was associated with HCV genotypes 2/3 (OR = 10.84; 95%CI: 5.47-21.47; P < 0.00001). IFN-α dose needed to be reduced in 29.4%, and IFN-α-based therapy was discontinued in 11.5% of patients. Analysis of controlled studies showed that SVRs were achieved in 34.1% of patients with SO and 31.1% of patients without SO. SO had no effect on the SVR rate in cirrhotic patients with genotype 1 HCV infection (OR = 1.28; 95%CI: 0.51-3.22; P = 0.60), but improved the SVR rate in patients with genotypes 2/3 infection, though the difference was not significant (OR = 0.36; 95%CI: 0.13-1.02; P = 0.05).CONCLUSION: SO combined with IFN-α-based antiviral therapy may be suitable in cirrhotic patients with genotypes 2/3 HCV infection, but not in those with genotype 1 infection.     

Splenectomy prior to antiviral therapy in patients with hepatitis C virus related decompensated cirrhosis

Patients with hepatitis C virus-related decompensated cirrhosis can benefit from interferon-based antiviral therapy, but the common complication of cytopenia is a contraindication for this treatment. Splenectomy prior to interferon therapy may alleviate this problem. To investigate whether splenectomy improves the efficacy of antiviral therapy, 13 interferon-naïve hepatitis C virus decompensated cirrhotic patients underwent splenectomy between January 2008 and January 2011, followed 1–3 months later by an interferon-based therapeutic regimen (pegylated/standard interferon-α combined with ribavirin for 48 weeks). Ten (76.9%) of the patients developed postoperative complications, which included minor portal vein thrombosis (2/13, 15.4%) and transient ascites (8/13, 61.5%). At one-month post-splenectomy, the patients showed significantly increased platelet (pre-surgery: 48.2 ± 15.9 vs. 186.0 ± 70.6 × 10³ μL^?1, p < 0.001) and leukocyte (2.1 ± 0.5 vs. 5.7 ± 1.4 × 10³ μL^?1, p < 0.001) counts. Eight (61.5%) of the patients achieved sustained virological response, including all HCV genotype 2a-infected patients (4/4, 100%) and some of the genotype 1b-infected patients (4/9, 44.4%). Temporary interferon-α suspension was required for one patient to address severe intestinal infection. These results indicate that splenectomy prior to interferon-based therapy was safe and may facilitate adherence to subsequent antiviral therapy in selected HCV cirrhotic patients with portal hypertension and hypersplenism.     

Dermatomyositis associated with hepatocellular carcinoma in an elderly female patient with hepatitis C virus-related liver cirrhosis

A 79-year-old female patient with hepatitis C virus-related liver cirrhosis was diagnosed as having hepatocellular carcinoma (HCC) with a diameter of 2.0 cm. She refused therapy for HCC. Nine months after the diagnosis, she developed dermatomyositis when the HCC enlarged to a diameter of 6.0 cm. She underwent therapy for dermatomyositis, and then transcatheter arterial chemoembolization for HCC. Although the manifestations of dermatomyositis improved and entire tumor necrosis was achieved, she died of pneumonia 2 mo after the treatment of HCC. HCC and/or chronic hepatitis C virus infection might be involved in the pathogenesis of dermatomyositis.     

Severe splenic rupture after colorectal endoscopic submucosal dissection

Splenic rupture (SR) after colonoscopy is a very rare but potentially serious complication. Delayed diagnosis is common, and may increase morbidity and mortality associated. There is no clear relation between SR and difficult diagnostic or therapeutic procedures, but it has been suggested that loop formation and excessive torquing might be risk factors. This is a case of a 65-year-old woman who underwent endoscopic submucosal dissection (ESD) for lateral spreading tumor in the descending colon, and 36 h afterwards presented symptoms and signs of severe hypotension due to SR. Standard splenectomy was completed and the patient recovered uneventfully. Colorectal ESD is usually a long and position-demanding technique, implying torquing and loop formation. To our knowledge this is the first case of SR after colorectal ESD reported in the literature. Endoscopists performing colorectal ESD in the left colon must be aware of this potential complication.     

Reduction of virus burden-induced splenectomy in patients with liver cirrhosis related to hepatitis C virus infection

AIM: To examine the hepatitis C virus (HCV) levels and immunological markers in cirrhotic patients after splenectomy. METHODS: HCV RNA titers as well as cellular and humoral immune markers were determined in 20 cirrhotic patients after splenectomy and in 32 cirrhotic controls with an intact spleen. RESULTS: Serum HCV RNA titers were lower in the splenectomized patients than in the controls (186±225×103 copies/ml vs 541±417×103 copies/mL, P<0.01). HCV RNA was judged to have been spontaneously eradicated in 4 splenectomized patients, but in none of the controls. Natural killer cell activity was higher in the splenectomized patients than in the controls (41.2±19.3% vs 24.7±15.3%, P<0.01), and natural killer cell activity was negatively correlated to HCV RNA titers in the splenectomized patients except in those with serotype 2-related infection. The CD4/CD8 ratio was significantly lower in the splenectomized patients than in the controls. CONCLUSION: The findings suggest that splenectomy may diminish virus burden in cirrhotic patients with HCV infection at least in part, through augmentation of natural killer cell activity.     

Portal vein thrombosis in a patient with hepatitis C virus-related cirrhosis complicated with antiphospholipid syndrome

We report a rare case of portal vein thrombosis (PVT) associated with antiphospholipid syndrome (APS) and hepatitis C virus-related cirrhosis. A 59-year-old woman with hepatitis C virus (HCV) infection was admitted because of coma. The blood test showed a typically cirrhosis pattern including an elevated serum ammonia level. Abdominal computed tomography showed liver cirrhosis and thrombus in the right branch of the portal vein. To elucidate the cause of PVT, antiphospholipid antibodies were examined. Both IgG anti-cardiolipin antibody (ELISA) and IgG anti-cardiolipin-β2 -glycoprotein I complex antibody (ELISA) were positive. When PVT is detected in a patient with cirrhosis, it might be necessary to examine antiphospholipid antibodies to clarify the cause of PVT.     

Chemokine system polymorphisms, survival and hepatocellular carcinoma occurrence in patients with hepatitis C virus-related cirrhosis

AIM： To explore the influence of polymorphisms in genes encoding for the chemokines Stromal cell-Derived Factor-1 （SDF-1）/CXCL12 and Monocyte Chemotactic Protein-1 （MCP-1）/CCL2, or for the chemokine receptor CCR5 on the risks of liver-related death and hepatocellular carcinoma （HCC） occurrence in hepatitis C virus （HCV）-infected patients.
METHODS： SDF-1 3＇A, MCP-1 （-2518） and CCRS-△32 polymorphisms, SDF-1α, Regulated upon Activation Normal T cells Expressed and Secreted （RANTES）/CCL5 and MCP-1 serum levels were determined in 120 HCV- infected patients, included at time of cirrhosis diagnosis and prospectively followed-up.
RESULTS： During follow-up, 23/120 （19.1%） patients died and 47/120 （39.1%） developed HCC. Carriers and noncarriers of each genetic marker had similar baseline characteristics estimating the severity of liver disease. The occurrence of death or HCC during follow-up was similar among carriers and noncarriers of each polymorphism. There was no association between the carriage of mutated alleles and chemokine serum levels and the latter were not associated with the risks of death or HCC.
CONCLUSION： This study suggests the lack of association of SDF-1 3＇A, MCP-1 （-2518）, CCRS-△32 polymorphisms with death and HCC occurrence in cirrhotic HCV-infected patients.     

12例丙型肝炎肝硬化患者脾切除术后抗病毒治疗的临床分析

目的 对部分符合外科脾切除术指征且有治疗意愿的失代偿期丙型肝炎肝硬化患者行脾切除术后给予小剂量干扰素联合利巴韦林抗病毒治疗,观察其疗效,并分析与疗效相关的可能影响因素. 方法 对部分符合外科脾切除术指征且有治疗意愿的失代偿期丙型肝炎肝硬化患者行脾切除术,术后给予个体化小剂量干扰素(普通干扰素3 ～ 5MU,隔日一次;或聚乙二醇干扰素50μg/周)联合利巴韦林0.6 ～ 0.9 g/d抗病毒治疗,基因1b型疗程≥72周,基因2a型≥36周.监测血常规、肝功能、凝血项、甲状腺功能、自身抗体等指标,处理不良反应;并监测HCV RNA水平,对病毒学应答进行评估.连续变量两组间比较采用t检验或秩和检验,计数资料采用x2检验.结果 12例患者均完成个体化治疗并随访6个月,其中3例患者因不能耐受聚乙二醇干扰素调整为普通干扰素,6例因溶血反应调整利巴韦林剂量.10例(83.3％)获得持续病毒学应答(SVR),1例无应答,1例复发.其中获得快速病毒学应答(RVR)者3例,占25.0％;获得完全早期病毒学应答(cEVR)者6例,占50.0％;24周获得应答的患者2例,占16.7％.RVR、cEVR对SVR率具有较好预测作用,获得RVR者SVR率为100％;获得cEVR者SVR率为83.3％;获得24周病毒学应答者SVR率为100％. 结论 对部分符合外科脾切除术指征且有治疗意愿的失代偿期丙型肝炎肝硬化患者可先行脾切除术,解决脾功能亢进,再行抗病毒治疗,以提高疗效;RVR、cEVR对SVR率具有较好预测作用;医师在抗病毒治疗早期与患者沟通、疗程中严密监测并给予患者足够的依从性教育和心理疏导是治疗得以维持的重要保证.     

Splenic rupture following colonoscopy

Colonoscopy is a safe and routinely performed diagnostic and therapeutic procedure for different colorectal diseases. Although the most common complications are bleeding and perforation, extracolonic or visceral injuries have also been described. Splenic rupture is a rare complication following colonoscopy, with few cases reported. We report a 60-year-old female who presented to surgical consultation 8 h after a diagnostic colonoscopy. Clinical, laboratory and imaging findings were suggestive for a massive hemoperitoneum. At surgery, an almost complete splenic disruption was evident, and an urgent splenectomy was performed. After an uneventful postoperative period, she was discharged home. Splenic injury following colonoscopy is considered infrequent. Direct trauma and excessive traction of the splenocolic ligament can explain the occurrence of this complication. Many times the diagnosis is delayed because the symptoms are due to colonic insufflation, so the most frequent treatment is an urgent splenectomy. A high index of suspicion needs an early diagnosis and adequate therapy.     

丙型肝炎肝硬化脾切除贲门周围血管离断术后的抗病毒疗效观察

我们对24例慢性丙型肝炎肝硬化合并脾功能亢进的患者进行了治疗,通过脾切除贲门周围血管离断术纠正外周血白细胞和血小板减少,术后2～4周开始聚乙二醇干扰素联合利巴韦林抗病毒治疗,疗程1年,随访24周,现报道如下.     

Significance of plasma osteopontin in diagnosis of hepatitis C virus-related hepatocellular carcinoma

Background and study aimsAlfa fetoprotein (AFP) is widely used as a surveillance test for hepatocellular carcinoma (HCC) among patients with liver cirrhosis (LC). However, the clinical use of AFP has been shown to present some important limitations in sensitivity and specificity. Osteopontin (OPN) is a secreted matrix glycoprotein that is emerging as a significant protein in the biology of HCC. The aim of this study was to assess the diagnostic value of plasma OPN compared with that of AFP in the diagnosis of HCC among hepatitis C virus (HCV)-related LC.Patients and methodsPlasma levels of OPN and AFP were measured in 69 Egyptian patients with HCV-related LC (35 with HCC and 34 without HCC) and 20 healthy controls.ResultsBoth median AFP and OPN levels were significantly higher in the HCC group compared to LC and healthy control groups (p < 0.001 in each) and in LC compared to the control group (p < 0.001). In the HCC group, both OPN and AFP levels were significantly higher in patients with Child–Pugh class C and B compared to class A (p < 0.05 in each). There was no correlation between OPN and AFP levels. The OPN level was significantly higher in patients with multiple focal lesions than in those with single lesions (p < 0.05) and in patients with portal vein invasion compared to patients without portal vein invasion (p < 0.05). Receiver operator characteristic (ROC) curves showed that the area under the curve (AUC) for OPN and AFP was 0.824 and 0.730, respectively.ConclusionOPN is a promising tumour marker which could be used as a screening test for the diagnosis of HCC in patients with LC and, hence, improves the prognosis and survival rate of these patients. The association of OPN with the multiplicity of focal lesions and portal vein invasion suggests an additional prognostic value.     

Nucleoporin 88 expression in hepatitis B and C virus-related liver diseases

INTRODUCTIONHepatocellular carcinoma (HCC) ranks fifth of the most common cancers worldwide and its incidence is rising in the Western world[1]. Due to the high mortality associated with HCC it is the third leading cause of cancer death worldwide[1]. The …     

乙型肝炎肝硬化的抗病毒治疗

乙型肝炎肝硬化患者接受抗病毒治疗可以获得生化学缓解和组织学改善,部分患者甚至获得了肝硬化的完全逆转,显著降低了肝脏失代偿、肝癌以及肝病相关死亡的发生.干扰素可用于代偿期肝硬化有限疗程的抗病毒治疗,核苷(酸)类似物可用于代偿期和失代偿期肝硬化的长期抗病毒治疗.治疗期间需密切监测生化学和病毒学变化,及早发现病毒学突破,阻止...     

Previous hepatitis E virus infection,cirrhosis and insulin resistance in patients with chronic hepatitis C

Background

Hepatitis E virus (HEV) infection in patients with pre-existing liver disease has shown high morbidity and lethality. The consequences of HEV superinfection in patients with chronic hepatitis C virus (HCV) infection are not fully understood. This study aimed to evaluate the association between the presence of anti-HEV antibodies, liver cirrhosis, and insulin resistance.

Perihilar cholangiocarcinoma arising in hepatitis C virus-related liver cirrhosis with hepatocellular carcinoma

Liver cirrhosis is reportedly one of the conditions preceding peripheral-type intrahepatic cholangiocarcinoma but not hilar/perihilar cholangiocarcinoma. Herein, we report a case of perihilar cholangiocarcinoma arising in a hepatitis C virus-related cirrhotic liver. The patient was a 69-year-old man. He was diagnosed with hepatitis C virus-related chronic hepatitis at the age of 56 years, and 9 years later, multiple hepatocellular carcinomas were detected by imaging modalities. Despite treatments, including chemotherapy, he died of hepatic failure at the age of 69 years. At autopsy, in addition to multiple nodules of hepatocellular carcinoma, we found a white mucinous and fibrous tumor spreading from the hepatic hilum to the periphery along the left lateral segmental bile ducts in the advanced cirrhotic liver. This tumor was histologically a cholangiocarcinoma that involved mainly the peribiliary glands and showed variable cystic dilation, suggesting that it might have been derived from these peribiliary glands. Immunohistochemically, the cholangiocarcinoma cells were positive for cytokeratin 7 and mucin core protein 1, and negative for cytokeratin 20 and mucin core protein 2. Hilar/perihilar cholangiocarcinoma arising in hepatitis C virus-related liver cirrhosis has rarely been reported. This case warrants further studies to clarify the possible involvement of hepatitis C virus in tumorigenesis of hilar/perihilar cholangiocarcinoma.     

Comparison of outcomes between patients with alcoholic cirrhosis and those with hepatitis C virus-related cirrhosis

Background and Aim:  The natural history of alcoholic cirrhosis, especially in Asian countries, has not been completely understood thus far.
Methods:  We retrospectively compared the outcomes of compensated cirrhosis between Japanese alcoholic and hepatitis C virus (HCV)-infected patients.
Results:  A total of 227 patients (75 alcoholic and 152 HCV-infected patients) with compensated cirrhosis were enrolled. The median follow-up period was 4.9 years. The cumulative rates of hepatocellular carcinoma (HCC) development were significantly lower in the alcoholic patients than in the HCV-infected patients (6.8% vs 50.3% at 10 years, P  = 0.0003), while the cumulative rates of hepatic decompensation (37.4% vs 51.7% at 10 years) and survival (53.8% vs 47.4% at 10 years) did not significantly differ between the two groups (Kaplan-Meir analysis). The main causes of death were hepatic failure and non-hepatic diseases in the alcoholic patients and HCC and hepatic failure in the HCV-infected patients. Multivariate analyses using the Cox proportional hazard model revealed that the risk of HCC was lower in alcoholic cirrhosis than in HCV-related cirrhosis (hazard ratio (HR), 0.46), while the risk of hepatic decompensation and mortality was the same. Predictors of decreased survival were non-abstinence (HR, 2.53) in the alcoholic patients and low serum albumin level (1.58) in the HCV-infected patients.
Conclusions:  Survival of patients with alcoholic cirrhosis was similar to that of patients with HCV-related cirrhosis. The risk of HCC development was lower in alcoholic cirrhosis than in HCV-related cirrhosis. Abstinence from alcohol was important for improving the survival of patients with alcoholic cirrhosis.     

合并乙型肝炎病毒感染对丙型肝炎病毒核心抗原检测的影响

目的 探讨合并HBV感染对慢性HCV感染者血清丙型肝炎病毒核心抗原(HCVcAg)检出情况的影响. 方法 收集2005年12月-2009年10月慢性丙型肝炎患者和HBV/HCV合并感染者资料,检测血清HCVcAg和HCV RNA,对后者血清进行HBV DNA、HBeAg检测,分析HCVcAg检出率与HBeAg、HBV DNA定量检测的关系.用独立两组多分类的X2检验方法进行统计学分析. 结果 共收集88例慢性丙型肝炎患者和62例HBV/HCV合并感染者资料,血清HCVcAg的检出率分别为72.7％(64/88)和38.7％ (24/62),两者比较,x2= 17.358,P＜0.01,差异有统计学意义.HCV RNA检出率分别为81.8％ (72/88)和53.2％ (33/62),两者比较,x2=20.110,P＜0.01,差异有统计学意义.62例HBV/HCV合并感染者血清中,HBeAg阳性和HBeAg阴性感染者HCVcAg检出率分别为28.6％ (12/42)和60.0％ (12/20),两者比较,x2=5.641,P=0.011,差异有统计学意义.HCV RNA阳性率分别为42.9％ (18/42)和80.0％ (16/20),两者比较,X2=7.547,P＜ 0.01,差异有统计学意义.HBV DNA阳性和阴性时HCVcAg检出率分别为39.1％ (18/46)和37.5％ (6/16),两者比较,P＞0.05,差异无统计学意义.与单纯HCV感染者血清HCVcAg检出率72.7％ (64/88)比较,HBeAg阴性合并感染者为60.0％ (12/20),x2=1.266,P=0.261,差异无统计学意义;HBV DNA阴性合并感染者为37.5％ (6/16),x2=7.635,P＜0.01,差异有统计学意义.结论 HBV/HCV合并感染时HCVcAg检出率较低,可能是由于HBeAg抑制HCV的复制,从而减少HCVcAg的表达所致.     

Multivariate analysis of risk factors for hepatocellular carcinoma in patients with hepatitis C virus-related liver cirrhosis

To elucidate the risk factors for hepatocellular carcinoma (HCC) in hepatitis C virus (HCV)-related liver cirrhosis (LC), we examined 204 cirrhotic patients negative for hepatitis B surface antigen and positive for HCV antibodies. The independent influence of various clinical characteristics in these patients was analyzed by multiple logistic regression, and the risk factors for HCC were identified. Multiple logistic regression analysis identified and ranked the following four risk factors: male sex (P<0.001), habitual heavy drinking (P<0.005), hepatitis B virus antibody positivity (anti-HBs and/or anti-HBc,P<0.05), and age greater than 60 years (P<0.05). The odds ratio of HCC was 4.20 (95% confidence interval; CI, 1.80–9.78) in male patients, 3.27 (95% CI, 1.46–7.30) in habitual heavy drinkers, 2.01 (95% CI, 1.01–3.99) in patients positive for hepatitis B virus antibodies, and 2.06 (95% CI, 1.00–4.23) in patients older than 60 years. The cumulative occurrence rates of HCC after blood transfusion were significantly higher in habitual heavy drinkers (4.8%, 49.4%, and 74.7% at 10, 20, and 30 years, respectively) than in non-drinkers (0%, 21.0%, and 23.3% at 10, 20, and 30 years, respectively,P<0.0003). The mean interval for progression to LC after blood transfusion was significantly shorter in the habitual heavy drinkers than in the non-drinkers (22.4±4.4 years vs 28.4±3.9 years;P<0.0003). This multivariate analysis revealed that habitual heavy drinking and hepatitis B virus antibody positivity are significant risk factors for HCC in HCV-related liver cirrhosis. This work was presented in preliminary form at the annual meeting of the American Association for Study of Liver Diseases, New Orleans, May 16, 1994 and published as an abstract inGastroenterology 14: A875, 1994.