Predictors of peri-opertative morbidity and liver dysfunction after hepatic resection in patients with chronic liver disease

BackgroundHepatic resection in patients with chronic liver disease (CLD) is associated with a risk of post-operative liver failure and higher morbidity than patients without liver disease. There is no universal risk stratification scheme for CLD patients undergoing resection.ObjectivesThe aim of the present study was to evaluate the association between routine pre-operative laboratory investigations, model for end-stage liver disease (MELD), indocyanine green retention at 15 min (ICG15) and post-operative outcomes in CLD patients undergoing liver resection.MethodsA retrospective review of patients undergoing resection for hepatocellular carcinoma (HCC) at the University Health Network was preformed. ICG15 results, pre- and post-operative laboratory results were obtained from clinical records. Adjusted odds ratios (AOR) were calculated for associations between pre-operative factors and post-operative outcomes using multivariate logistic regression adjusting for patient age and number of segments resected.ResultsBetween 2001 and 2005, 129 CLD patients underwent surgical resection for HCC. Procedures included 51 (40%) resections of ≤2 segments, 52 (40%) hemihepatectomies and 25 (19%) extended hepatic resections. Thirty- and 90-day post-operative mortality was 1.6% and 4.1%, respectively. Prolonged (>10 days) hospital length of stay (LOS) was independently associated with an ICG15 >15% {AOR [95% confidence interval (CI)]= 8.5 (1.4–51)} and an international normalized ratio (INR) > 1.2 [AOR (95% CI) = 5.0 (1.4–18.6)]. An ICG15 > 15% and MELD score were independent predictors of prolonged LOS. An ICG15 > 15% was also independently associated with MELD > 20 on post-operative day 3 [AOR (95% CI) = 24.3 (1.8–319)].ConclusionsElevated ICG retention was independently associated with post-operative liver dysfunction and morbidity. The utility of ICG in combination with other biochemical measures to predict outcomes after hepatic resection in CLD patients requires further prospective study.A possible role for ICG clearance in predicting outcome following hepatic resection for hepatocellular carcinoma     

Recurrent hepatocellular carcinoma after liver transplant: identifying the high-risk patient

BackgroundRecurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is rarely curable. However, in view of the advent of new treatments, it is critical that patients at high risk for recurrence are identified.MethodsPatients undergoing LT for HCC at a single centre between 2002 and 2010 were reviewed and data on clinical parameters and explant pathology were analysed to determine factors associated with HCC recurrence. All necrotic and viable tumour nodules were included in explant staging. All patients underwent LT according to the United Network for Organ Sharing (UNOS) Model for End-stage Liver Disease (MELD) tumour exception policies.ResultsLiver transplantation was performed in 122 patients with HCC during this period. Rates of recurrence-free survival in the entire cohort at 1 year and 3 years were 95% and 89%, respectively. Thirteen patients developed HCC recurrence at a median of 14 months post-LT. In univariate analysis the factors associated with HCC recurrence were bilobar tumours, vascular invasion, and stage exceeding either Milan or University of California San Francisco (UCSF) Criteria. Multivariate analysis showed pathology outside UCSF Criteria was the major predictor of recurrence; when pathology outside UCSF Criteria was found in combination with vascular invasion, the predicted 3-year recurrence-free survival was only 26%.ConclusionsExplant pathology can be used to predict the risk for recurrent HCC after LT, which may allow for improved adjuvant and management strategies.     

Longterm follow-up after transarterial chemotherapy for hepatocellular carcinoma in a Scandinavian centre

Background

Transarterial chemotherapy infusion (TAI) with lipiodol is a palliative treatment for hepatocellular carcinoma. The aim of this study was to describe the outcomes of TAI from a single scandinavian centre between 1995 to 2008.

Methods

The study is a retrospective analyse of prospectively collected data. TAI (doxorubicin, 50 mg with lipiodol) was administrated every 6 weeks. After 5 treatments, a CT scan was performed, and if the disease was stable, (RECIST score) treatment was continued.

Results

57 patients with HCC were treated with TAI. Median age; 72 years (52–84), 41 (71%) men. 52 (91%) had Child-Pugh score A, and 5 (9%) had Child-Pugh B. Nine (16%) patients had a BCLC score A, 19 (33%) B, 29 (51%) C, while none was classified as BCLC D. Twenty nine (51%) patients had a tumour size ≥ 10 cm. In total 254 treatments were performed, a median of 4 (1–20) per patient. Treatment mortality was 0%. In 30 (53%) patients the treatment strategy was not completed due to deteriorating clinical conditions. Median survival was 17 months (2–108), 2, 3, and 5-years survival was 34%, 22%, and 13%, respectively. Patients that responded to treatment (n = 23) had a median survival of 26 (13–108) months compared to 8 (2–48) months for those not fulfilling the treatment plan, p < 0.05. Tumour size ≥ 10 cm, AFP ≥ 400 µg/l, and Child-Pugh class B or C were negative prognostic factors for survival, p < 0.05.

Conclusions

The 5 year survival was 13%, and median survival 17 months. Treatment mortality was 0%. Patients that responded to treatment (40%) had a median survival of 26 months. TAI provides good palliation but selection of patients is crucial.     

Focal nodular hyperplasia or focal nodular hyperplasia-like lesions of the liver: a special emphasis on diagnosis

Background and Aim: Focal nodular hyperplasia (FNH) and FNH‐like lesions are hypervascular masses that can mimic hepatocellular carcinoma (HCC). We have investigated the clinical, radiological and pathological features of FNH and FNH‐like lesions of the liver, with particular focus on the aspect of diagnosis. Methods: A total of 84 patients, 77 with pathologically‐proven FNH and seven with FNH‐like lesions of the liver, were analyzed retrospectively. Results: Of the 84 patients, seven had underlying liver cirrhosis, including two with Budd‐Chiari syndrome and one with cardiac cirrhosis. These cases were therefore classified as having FNH‐like lesions. Two of the remaining 77 patients without underlying liver cirrhosis were positive for hepatitis B surface antigen. Seven of 50 (14.0%) patients evaluated by four‐phase computed tomography (CT) showed portal or delayed washout, and three of 28 (10.7%) patients analyzed by three‐phase CT showed washout on the portal phase. Collectively, three of nine (33.3%) patients with risk factors for HCC could have been wrongly diagnosed with HCC based on the non‐invasive diagnostic criteria for HCC. A central scar was observed in 30 patients (35.7%) radiologically. Among 62 patients who underwent percutaneous needle biopsy, four patients (6.5%) were misdiagnosed as having HCC and two patients (3.2%) had inconclusive results by a first needle biopsy. Conclusions: The presence of a hepatic lesion with arterial hypervascularity and/or portal/delayed washout is not necessarily diagnostic of HCC, particularly in patients without risk factors for HCC. These radiological findings can also occur in cirrhotic patients with FNH‐like lesions, including those with hepatic outflow obstruction.     

Evolution of the surgical management of perihilar cholangiocarcinoma in a Western centre demonstrates improved survival with endoscopic biliary drainage and reduced use of blood transfusion

BackgroundPerihilar cholangiocarcinoma (PHCCA) remains a surgical challenge for which few large Western series have been reported. The aims of this study were to investigate the results of surgical resection for PHCCA and assess how practice has evolved over the past 15 years.MethodsA prospectively maintained database was interrogated to identify all resections. Clinicopathological data were analysed for impact on survival. Subsequently, data for resections carried out during the periods 1994–1998, 1999–2003 and 2004–2008 were compared.ResultsEighty-three patients underwent resection. Trisectionectomy was required in 67% of resections. Overall survival was 70%, 36% and 20% at 1, 3 and 5 years, respectively. Size of tumour, margin (R0) status, lymph node status, distant metastasis, tumour grade, portal vein resection, microscopic direct vascular invasion, T-stage and blood transfusion requirement significantly affected outcome on univariate analysis. Distant metastasis (P= 0.040), percutaneous biliary drainage (P= 0.015) and blood transfusion requirement (P= 0.026) were significant factors on multivariate analysis. Survival outcomes improved and blood transfusion requirement was significantly reduced in the most recent time period.DiscussionBlood transfusion requirement and preoperative percutaneous biliary drainage were identified as independent indicators of a poor prognosis following resection of PHCCA. Longterm survival can be achieved following the aggressive surgical resection of this tumour, but the emergence of a clear learning curve in our analyses indicates that these patients should be managed in high-volume centres in order to achieve improved outcomes.     

Hepatic artery reconstruction first for the treatment of hilar cholangiocarcinoma bismuth type IIIB with contralateral arterial invasion: a novel technical strategy

Background

En-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure.

Methods

The authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed.

Results

In both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months.

Conclusions

This new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.     

Splanchnic vein thrombosis in severe acute pancreatitis: a 2-year, single-institution experience

ObjectivesThis study aimed to determine current practice in the management and outcome of splanchnic vein thrombosis complicating acute pancreatitis (AP).MethodsAn audit of prospectively collected data for all patients presenting with AP was conducted. Patients with splanchnic vein thrombosis were grouped according to vessel involvement and whether or not systemic anticoagulation was administered.ResultsOf 127 consecutive patients admitted with AP, 20 had splanchnic venous thrombosis; in all cases the thrombosis was associated with a severe attack of AP. Involvement of the splenic vein (SV), portal vein (PV) and superior mesenteric vein (SMV) was observed in 14, 10 and three patients, respectively. Involvement of more than one vessel was observed in six patients (SV and PV in four patients; SMV and SV in one patient; all three veins in one patient). Thromboses were colocalized with collections in 19 patients. Only four patients received systemic anticoagulation. Resolution of thrombosis was observed in six patients over a median of 77 days. No significant differences were observed in recanalization rates following anticoagulation (P= 0.076). No complications associated with systemic anticoagulation occurred. One patient developed liver failure associated with progressive PV thrombosis and one patient died.ConclusionsSplanchnic vein thrombosis is a relatively common observation in severe AP and is associated with pancreatic necrosis and peripancreatic collections. Recanalization is observed in almost a third of patients, irrespective of whether or not they receive systemic anticoagulation.     

Expression of genes involved in rat liver angiogenesis after ischaemia and reperfusion: effects of ischaemic pre- and post-conditioning

Background

During surgery, ischaemic pre- (IPC) and post-conditioning (IPO) protects the liver against ischaemia/reperfusion injuries (I/R-injuries). The impact of ischaemic conditioning on liver regeneration has been less well studied. Angiogenesis is an important part of liver regeneration after hepatectomy. The aim of the present study was to investigate the effect of ischaemia/reperfusion and ischaemic conditioning on the expression of genes with angiogenic potential in a model of rat liver ischaemia.

Methods

A model of total liver ischaemia (30 min) and reperfusion (30 min) was employed using Wistar rats. Rats were randomized into five groups: (C) control (IRI) ischaemic, IPC, IPO and IPC + IPO. Liver enzymes were sampled at the end of reperfusion. Liver biopsies were analysed using cDNA microarrays.

Results

Alanine aminotransferase (ALT) increased significantly in all the ischaemic groups compared with controls (P = 0.000). Searching databases 99 genes involved in rat liver angiogenesis were identified. Compared with group (C) the number of genes significantly up-regulated was as follows: IRI (n = 5), IPC (n = 24), IPO (n = 33) and IPC + IPO (n = 18). No genes were down-regulated in the four groups compared with controls.

Conclusion

Ischaemic conditioning, as demonstrated in the present study, seems to be potent activators of angiogenic genes. This might be favourable to the regenerating liver.     

Detailed liver-specific imaging prior to pre-operative chemotherapy for colorectal liver metastases reduces intra-hepatic recurrence and the need for a repeat hepatectomy

Background

Neoadjuvant chemotherapy for colorectal liver metastases (CRLM) reduces the accuracy of liver imaging which may understage patients pre-operatively. Retrospective review of a prospective database to determine whether liver-specific magnetic resonance imaging (MRI) prior to pre-operative chemotherapy affects intra-hepatic recurrence and long-term outcome after hepatectomy.

Patients and methods

Between 2003 and 2009, 242 patients with CRLM underwent a hepatectomy after ≥3 cycles of oxaliplatin or irinotecan-based chemotherapy. All had a liver-specific MRI immediately pre-operatively. The outcome of patients who had a liver-specific MRI prior to chemotherapy (PCI group, n = 92) was compared with those who did not (non-PCI group, n = 150).

Results

A liver-specific MRI pre-chemotherapy changed the staging in 56% of patients. At a median (range) follow-up of 55 (6–94) months, there was a higher incidence of intra-hepatic recurrence at a new site in the non-PCI group (65% vs. 48% in the PCI group, P = 0.041) and an increased rate of recurrence in patients with the same number of lesions pre- and post-chemotherapy [hazard ratio (HR) 2.02, 1:10–3.37, P = 0.024]. The non-PCI group underwent more repeat hepatectomies than the PCI group (24.7% vs. 13%, P = 0.034), achieving similar long-term survival.

Conclusions

A liver-specific MRI prior to chemotherapy reduces intra-hepatic recurrence and avoids a repeat hepatectomy.     

Lymphadenectomy in the staging and treatment of intrahepatic cholangiocarcinoma: a population-based study using the National Cancer Institute SEER database

ObjectivesAlthough lymphatic spread is common in intrahepatic cholangiocarcinoma (ICC), lymphadenectomy is not widely performed as part of operative resection in this disease. The objectives of this study were to assess national trends for lymphadenectomy and its impact on survival in patients with ICC.MethodsThe National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) registry was queried to identify patients with ICC (n= 4893) reported during 1988–2007. Kaplan–Maier and Cox proportional hazards regression were used to analyse survival.ResultsFive-year overall survival (OS) was 5.2%. Lymph node (LN) status was available for 48.9% (n= 2391) of patients. Histologic LN evaluation was performed in 13.5% (n= 658) of patients for a median of two (interquartile range: 1–3) LNs. During the study period, the frequency of histologic LN assessment (P= 0.78) did not change in liver resection patients. In the 733 resected patients, positive vs. negative LN status was associated with worse 5-year OS of 8.4% vs. 25.9%, respectively (hazard ratio = 1.8; P < 0.001).ConclusionsNodal status is an important prognostic factor for survival in patients diagnosed with ICC. In the USA, few patients undergo hepatic resection with lymphadenectomy; therefore, the clinical benefit of formal lymphadenectomy in ICC remains unknown.     

Magnetic resonance imaging (MRI) and diseases of the liver and biliary tract. Part 1. Basic principles, MRI in the assessment of diffuse and focal hepatic disease

Magnetic resonance imaging (MRI) relies on the physical properties of unpaired protons in tissues to generate images. Unpaired protons behave like tiny bar magnets and will align themselves in a magnetic field. Radiofrequency pulses will excite these aligned protons to higher energy states. As they return to their original state, they will release this energy as radio waves. The frequency of the radio waves depends on the local magnetic field and by varying this over a subject, it is possible to build the images we are familiar with. In general, MRI has not been sufficiently sensitive or specific in the assessment of diffuse liver disease for clinical use. However, because of the specific characteristics of fat and iron, it may be useful in the assessment of hepatic steatosis and iron overload. Magnetic resonance imaging is useful in the assessment of focal liver disease, particularly in conjunction with contrast agents. Haemangiomas have a characteristic bright appearance on T2 weighted images because of the slow flowing blood in dilated sinusoids. Focal nodular hyperplasia (FNH) has a homogenous appearance, and enhances early in the arterial phase after gadolinium injection, while the central scar typically enhances late. Hepatic adenomas have a more heterogenous appearance and also enhance in the arterial phase, but less briskly than FNH. Hepatocellular carcinoma is similar to an adenoma, but typically occurs in a cirrhotic liver and has earlier washout of contrast. The appearance of metastases depends on the underlying primary malignancy. Overall, MRI appears more sensitive and specific than computed tomography with contrast for the detection and evaluation of malignant lesions.     

Over‐expression of glutamine synthetase in focal nodular hyperplasia: a novel easy diagnostic tool in surgical pathology

Background and Aims: Glutamine synthetase (GS) is a useful marker in tumour liver pathology, including hepatocellular adenomas and nodules in cirrhosis. We investigated the use of GS as a marker in various clinical situations, in which FNH diagnosis had been firmly established to determine its contribution to diagnosis. Methods: Seventy‐nine cases of resected FNH, all on normal (or occasionally steatotic) livers, were retrieved from our collection. The control group was composed of hepatocellular adenomas and well‐differentiated hepatocellular carcinoma. The following stains: H&E, Masson's trichrome, Gordon‐Sweet, PAS, perls and immunostains: CK7 and 19, and GS were carried out. FNH was diagnosed based on traditional pathological techniques. In case of uncertainty, particularly with hepatocellular adenoma, additional immunostainings including liver fatty acid‐binding protein, serum amyloid A and β‐catenin were performed. Results: Glutamine synthetase immunostaining was similar in all FNH cases. Positive GS staining of hepatocytic cytoplasms formed large areas, anastomosed in a ‘map‐like’ pattern, often surrounding hepatic veins, whereas GS was not expressed in hepatocytes close to fibrotic bands containing arteries and ductules. In comparison, hepatocellular adenoma staining was completely different, even in cases of fibrotic bands due to tumour remodelling related to necrosis or haemorrhage. In hepatocellular adenomas or well‐differentiated hepatocellular carcinoma presenting β‐catenin mutation, GS was positive but with a completely different pattern that appeared diffuse and not ‘map‐like’. Conclusion: Regardless of the FNH size or steatotic content, GS produced a similar and characteristic pattern and consequently represents a good marker for easily identifying resected FNH from other hepatocellular nodules.     

Serum amyloid A and C‐reactive protein positive nodule in alcoholic liver cirrhosis,hard to make definite diagnosis

We describe a case of serum amyloid A (SAA) and C‐reactive protein (CRP) positive nodule detected by immunohistochemical analysis in a 37‐year‐old woman with alcohol‐related cirrhosis. Imaging studies at first admission pointed to hepatocellular carcinoma (HCC), a dysplastic nodule, an inflammatory pseudotumor or focal nodular hyperplasia (FNH). Ultrasonography‐guided biopsy in Segment 2 showed minimal atypical changes, except for a slight increase in cell density and micronodular cirrhosis in the non‐nodular portion. gadolinium‐ethoxybenzyl‐diethylenetriamine pentaacetic acid‐enhanced magnetic resonance imaging carried out after a year and a half revealed hypervascularity in the arterial phase and isointensity in the hepatobiliary phase. Three years thereafter, however, the imaging displayed a change from isointensity to a defect in the hepatobiliary phase, and the nodule demonstrated minimal histological atypia. Immunohistochemical staining of the nodule was positive for SAA, CRP, liver fatty acid‐binding protein and glutamine synthetase, but negative for β‐catenin, heat shock protein 70 and Glypican 3. Organic anion transporter (OATP)8 staining was weaker in the nodule than in the non‐nodular portion of the alcohol‐related micronodular cirrhosis. The nodule was diagnosed as an SAA and CRP positive nodule, and HCC was ruled out. Despite the change from isointensity to a defect in the hepatobiliary phase, no evidence of HCC was found in the biopsy specimen. The change may be explained more by the weak OATP8 staining compared with that of alcohol‐related liver cirrhosis than by malignant transformation into HCC.     

Nodular regenerative hyperplasia of the liver diagnosed by needle biopsy of the liver: Report of a case and review of the literature

The authors report the case of a 45 year old woman in whom the diagnosis of nodular regenerative hyperplasia of the liver was made by needle biopsy of the liver, laparoscopy and hepatic venography. The patient did not have any underlying disorders and had not ingested any of the many drugs and chemicals which may produce the lesion. Clinical manifestations were hepatosplenomegaly, portal hypertension and iron deficiency anaemia, and her condition remains unchanged 5 years after diagnosis.     

Coexistence of focal nodular hyperplasia and pseudotumor caused by focal spared lesion in the liver of a young man

We report a case of 19-year-old male with an underlying case of chronic hepatitis C infection who suffered from two types of benign liver tumor: focal nodular hyperplasia (FNH) and pseudotumor due to focal fatty spared area in a fatty liver. These two kinds of lesions rarely occur simultaneously. The spectral Doppler ultrasound (US) images of these lesions were also provided. We suggest that spectral Doppler US provides an alternative diagnostic tool for the differentiation of liver tumors regarding their vascular pattern, which might help ensure a correct diagnosis.     

Liver disease in Viet Nam: screening, surveillance, management and education: a 5-year plan and call to action

Despite a high prevalence of liver disease in Viet Nam, there has been no nationwide approach to the disease and no systematic screening of at-risk individuals. Risk factors include chronic hepatitis B (estimated prevalence of 12%), chronic hepatitis C (at least 2% prevalence), and heavy consumption of alcohol among men. This combination of factors has resulted in liver cancer being the most common cause of cancer death in Viet Nam. There is a general lack of understanding by both the general public and health-care providers about the major risk to health that liver disease represents. We report here the initial steps taken as part of a comprehensive approach to liver disease that will ultimately include nationwide education for health-care providers, health educators, and the public; expansion of nationwide screening for hepatitis B and C followed by hepatitis B virus vaccination or treatment of chronic hepatitis B and/or hepatitis C; education about alcoholic liver disease; long-term surveillance for liver cancer; reduction of infection transmission related to medical, commercial, and personal re-use of contaminated needles, syringes, sharp instruments, razors, and inadequately sterilized medical equipment; and ongoing collection and analysis of data about the prevalence of all forms of liver disease and the results of the expanded screening, vaccination, and treatment programs. We report the beginning results of our pilot hepatitis B screening program. We believe that this comprehensive nationwide approach could substantially reduce the morbidity and mortality from liver disease and greatly lessen the burden in terms of both lives lost and health-care costs.     

Hepatocyte senescence in end-stage chronic liver disease: a study of cyclin-dependent kinase inhibitor p21 in liver biopsies as a marker for progression to hepatocellular carcinoma.

BACKGROUND: Histologic markers to predict hepatocellular carcinoma (HCC) include small cell change and dysplastic nodules. Hepatocyte senescence is noted in chronic liver disease and may or may not be important in progression to HCC. AIM: The study was undertaken to compare standard histologic features of chronic liver disease as well as markers of senescence and proliferation in two groups of biopsies from patients followed for at least a year. Methods: Standard histologic evaluation of necroinflammatory activity, fibrosis, steatosis, and iron, internationally accepted criteria of dysplasia, and immunohistochemical markers for proliferation and hepatocyte senescence were compared in 47 liver biopsies from noncholestatic chronic liver disease patients who subsequently either underwent transplant (the Control group, n=19) or had biopsy-proven (HCC group, n=28) over a similar time period of 34.9 months (mean) and 42.5 months (mean) respectively. RESULTS: Both groups were predominantly men; the MELD score was higher, and mean age was less in the Control group (46.9 vs 53.8 years, P=0.01). Small cell change was not significantly different in the biopsies between the two groups; neither were grade, stage (Ishak scores), nor presence or location of iron. Steatosis was more common in the group that subsequently developed HCC (P=0.04). The MIB-1 proliferation index was greater in the biopsies from the Control group. The senescence marker p21, and the ratio of p21:MIB-1 were not statistically different between the two groups. However, a Spearman's rank correlation showed a linear correlation of p21/MIB-1 with a greater amount of dyplasia in the explant livers of Controls. CONCLUSIONS: These findings suggested the Control groups' livers maintained effective removal of cells from the cell cycle by overexpression of p21 and, while not 'protected' from significant involvement by dysplasia, may have been precluded from development of HCC.     

CASE REPORT: Radiotherapy in the treatment of duodenal bleeding due to hepatocellular carcinoma invasion

Haemorrhage from an hepatocellular carcinoma (HCC) directly invading the gastrointestinal (GI) tract is uncommon. A 58-year-old man was admitted with upper gastrointestinal (UGI) bleeding and panendoscopy on examination revealed a large duodenal ulcerative bleeding mass. The mass was eventually diagnosed as HCC by pathological examination. The bleeding failed to respond to conventional management of haemostasis, but resolved with an external beam of radiotherapy with a total dose of 6000 cGy over a 5 week period. This unusual presentation of UGI bleeding, due to HCC invading the duodenum and treated by radiotherapy, has not been previously reported.     

Successful management of acute liver failure in Italian children: A 16-year experience at a referral centre for paediatric liver transplantation

BackgroundIdentifying the causes of acute liver failure (ALF) and predictors of death or liver transplantation (LTX) is crucial to decide its management. We aimed to describe features and outcome of ALF in Italian children.MethodsRetrospective review of cases presenting between 1996–2012. ALF was defined by high transaminases, INR ≥2.0 regardless of hepatic encephalopathy (HE), no evidence of underlying chronic liver disease.Results55 children (median age 2.6 years, range 0.1–15.1; M/F = 31/24) had ALF due to autoimmune hepatitis (AIH) in 10 (18%), metabolic disorders in 9 (17%), paracetamol overdose in 6 (11%), mushroom poisoning in 3 (5%), viral infection in 1 (2%), indeterminate in 26 (47%); 25/55 recovered with supportive management (45%); 28/55 underwent LTX and 2 died on the waiting list (55%). On multivariate analysis severity of HE grade 3–4 and bilirubin ≥12 mg/dl were independent predictors of death or LTX (p < 0.05). After a median follow up of 4 years (range 2–15.0 years) the overall survival rate was 93%.ConclusionChildren with ALF can be managed successfully with combined medical treatment and transplantation, warranting a survival rate similar to children transplanted because of chronic conditions. In our cohort of patients severe HE and high bilirubin on admission were independent predictors of the need of LTX.     

Non‐alcoholic fatty liver disease: a review of epidemiology,risk factors,diagnosis and management

Due to the rising prevalence of obesity and type II diabetes mellitus, non‐alcoholic fatty liver disease is becoming the leading cause of chronic liver disease in the Western world. In some patients, simple steatosis can result in non‐alcoholic steatohepatitis which over time can lead to liver cirrhosis and its associated sequelae, including hepatocellular carcinoma. Early identification and management of patients at risk with intensive dietary and lifestyle modification are essential to prevent the development of advanced liver disease and its complications. In this review, we will discuss the epidemiology of non‐alcoholic fatty liver disease, pathogenesis, diagnosis, management and surveillance strategies to offset the morbidity and mortality of this disease, as well as liver and non‐liver‐related complications.