Hepatic granulomas: a 10 year single centre experience

BACKGROUND: Epithelioid granulomas have been reported in 2-15% of unselected liver biopsies, with numerous underlying aetiologies described. However, all UK series were reported before identification of hepatitis C virus (HCV). AIM: To evaluate the current aetiologies of hepatic granulomas and to assess the prognosis for the "idiopathic" group, in which all investigations for a recognised cause were negative or normal. METHODS: A retrospective review of patient case notes between 1991 and 2001; all patients who had a liver biopsy at Glasgow Royal Infirmary revealing epithelioid granulomas had their case notes and liver biopsies reviewed and a standard proforma completed. RESULTS: Over the study period, 1662 liver biopsies were performed. Hepatic granulomas were found in 63. Of those identified, 47 were female, with a mean age of 42 years (range, 17-81). Underlying aetiologies were as follows: primary biliary cirrhosis (PBC; 23.8%), sarcoidosis (11.1%), idiopathic (11.1%), drug induced (9.5%), HCV (9.5%), PBC/autoimmune hepatitis (AIH) overlap (6.3%), Hodgkin lymphoma (6.3%), AIH (4.8%), tuberculosis (4.8%), resolving biliary obstruction (3.2%), and other single miscellaneous causes (9.5%). Of the seven patients with idiopathic hepatic granulomas, one was lost to follow up, one died of stroke, and the remaining five were well with no liver related morbidity at a mean follow up of 6.2 years. CONCLUSIONS: The aetiology of hepatic granulomas is broad ranging, with HCV an important cause in this population. Despite extensive investigations, a 10-15% of patients still had "idiopathic" hepatic granulomas. However, the prognosis for this last group appears to be excellent.     

Obstructive hyperinflation treated by use of self-expandable stent

A self-expandable metal stent was used in the management of a young woman who developed respiratory failure as a result of obstructive hyperinflation caused by a bronchogenic tumour.     

Percutaneous Real-Time Ultrasonic Guided Biopsy in the Diagnosis of Deep-Seated,Non-Palpable Intra-abdominal Masses (Initial Experience)

The accuracy of detecting and assessing the nature of deep seated non-palpable lesions by ultrasonically guided biopsy has not been well established. Although various authors have reported the accuracy of this technique in large mass lesions^1,2 the accuracy in non-palpable lesions has not been emphasized. A real-time sector scanner with a biopsy guide attached to a 3 MHz transducer was used for guiding 23 gauge fine needles into 24 patients with deep seated non-palpable masses, detected on ultrasound studies, with a view to diagnose or exclude malignancy, and to establish the exact nature of these lesions, either benign or malignant. Aspiration biopsy accurately diagnosed the lesions in 18 patients (75%). No complications occurred in any case.     

Radiologically guided balloon dilation of gastrointestinal strictures. Part II. Results of long-term follow-up

Balloon dilation catheters were used to treat 94 gastrointestinal strictures in 92 patients over a 6-year period. Long-term follow-up data were obtained for 80 of these patients, with a mean follow-up period of 389 days. Overall, of the patients who underwent a successful dilation procedure, 83% remained symptom free after 1 year, and 69% after 2 years. The location of the stricture did not significantly influence the long-term outcome, nor did procedure characteristics, aside from primary technical failure. Both patients with malignant strictures and those whose strictures were associated with an anastomosis were more likely than other patients to have recurrent symptoms.     

Accessory breast tissue in the axilla: mammographic appearance

Mammographic features of normal accessory axillary breast tissue were analyzed in 13 women, 54% of whom had positive findings on physical examination. Radiographically the accessory tissue resembled the remaining normal glandular tissue but was separate from it. The mean radiographic dimension of the accessory tissue, which was best seen on oblique or exaggerated craniocaudal views, was 3.9 cm. In most cases the accessory tissue was either bilateral or confined to the right side. When found on mammography, accessory axillary breast tissue should be recognized as a normal developmental variant rather than considered a pathologic lesion, although carcinoma can develop in the accessory tissue. A specific, radiography-aided diagnosis of accessory axillary breast tissue can eliminate unnecessary biopsy.     

Effect of d-fenfluramine on basal glucose turnover and fat-feeding-induced insulin resistance in rats

There is evidence that fenfluramine improves insulin action independently of its anorectic and weight-loss-inducing properties. Chronic d-fenfluramine also reduces hypothalamic noradrenergic tone, which correlates highly with hepatic glucose output. We report that chronic d-fenfluramine (5 mg.kg-1.day-1) ameliorates insulin resistance induced by high-fat feeding. Insulin action was assessed in adult male rats at basal insulin levels and at hyperinsulinemia (approximately 140 mU/L with the euglycemic clamp technique). Hepatic glucose production, peripheral glucose disposal, and individual tissue glucose metabolism were determined from bolus injections of [3H]-2-deoxyglucose and [14C]glucose. Food intake was matched between groups. Basal glucose turnover was reduced 28% (P less than .05) in fat-fed rats receiving d-fenfluramine (fat + fen). The glucose infusion rate to maintain euglycemia was 22.0 +/- 1.1 mg.kg-1.min-1 in the high-carbohydrate-fed rats, 8.2 +/- 1.0 in fat-fed rats, and 15.1 +/- 0.5 in the fat + fen group. Peripheral glucose disposal, reflecting measured skeletal muscle changes, was reduced by fat feeding (from 23.5 +/- 1.0 to 13.8 +/- 0.6 mg.kg-1.min-1) but was improved by d-fenfluramine (16.9 +/- 0.5, P less than .05 vs. fat fed). Impaired suppression of hepatic glucose output by insulin, caused by fat feeding, was totally reversed by d-fenfluramine. Thus, d-fenfluramine counteracted diet-induced insulin resistance, with the predominant effect on the liver. We hypothesize that d-fenfluramine improves insulin action by reducing hypothalamic noradrenergic tone, which in turn reduces the neural drive to hepatic glucose output and improves the hepatic response to insulin.