Non-invasive diagnosis of liver fibrosis and cirrhosis

The evaluation and follow up of liver fibrosis and cirrhosis have been traditionally performed by liver biopsy. However, during the last 20 years, it has become evident that this "gold-standard" is imperfect; even according to its proponents, it is only "the best" among available methods. Attempts at uncovering non-invasive diagnostic tools have yielded multiple scores, formulae, and imaging modalities. All are better tolerated, safer, more acceptable to the patient, and can be repeated essentially as often as required. Most are much less expensive than liver biopsy. Consequently, their use is growing, and in some countries the number of biopsies performed, at least for routine evaluation of hepatitis B and C, has declined sharply. However, the accuracy and diagnostic value of most, if not all, of these methods remains controversial. In this review for the practicing physician, we analyze established and novel biomarkers and physical techniques. We may be witnessing in recent years the beginning of the end of the first phase for the development of non-invasive markers. Early evidence suggests that they might be at least as good as liver biopsy. Novel experimental markers and imaging techniques could produce a dramatic change in diagnosis in the near future.

Normal vitamin D levels are associated with spontaneous hepatitis B surface antigen seroclearance

AIM: To investigate a possible association between serum vitamin D levels and spontaneous hepatitis B surface antigen (HBsAg) seroclearance. METHODS: Fifty-three patients diagnosed with chronic inactive hepatitis B and spontaneous HBsAg seroclearance were followed up in two Israeli liver units between 2007 and 2012. This retrospective study reviewed medical charts of all the patients, extracting demographic, serological and vitamin D rates in the serum, as well as medical conditions and current medical therapy. Spontaneous HBsAg seroclearance was defined as the loss of serum HBsAg indefinitely. Vitamin D levels were compared to all patients who underwent spontaneousHBsAg seroclearance.HBsAg seroclearance. RESULTS: Out of the 53 patients who underwent hepatitis B antigen seroclearance, 44 patients (83%) had normal levels of 25-hydroxyvitamin vitamin D compared to 9 patients (17%) who had below normal levels. Multivariate analysis showed that age (>35 years) OR = 1.7 (95%CI: 1.25-2.8, P=0.05), serum vitamin D levels (>20 ng/mL) OR = 2.6 (95%CI: 2.4-3.2, P=0.02), hepatitis B e antigen negativity OR = 2.1 (95%CI: 2.2-3.1, P=0.02), low viral load (hepatitis B virus DNA < 100 IU/mL) OR = 3 (95%CI: 2.6-4.2, P = 0.01) and duration of HBsAg seropositivity (> 8 years) OR = 1.6 (95%CI: 1.15-2.6, P=0.04) were also associated with spontaneous HBsAg seroclearance. CONCLUSION: We found a strong correlation between normal vitamin D levels and spontaneous HBsAg seroclearance.

Enzyme pattern of biliary colic: A counterintuitive picture

AIM To evaluate the diagnostic value of serial biochemical blood tests in the diagnosis of biliary colic.METHODS Files were reviewed of 1039 patients who were admitted to the Share'e Zedek Medical Center emergency department between the years 2012-2013, and received the coding of acute biliary disease. Of these, the first 100 cases were selected that met the following criteria:(1) a diagnosis of biliary colic or symptomatic cholelithiasis;(2) at least two biochemical blood tests performed; and(3) 18 years of age or older. Patients with other acute biliary diseases were excluded. The biochemical profile of the patients was analyzed as were their clinical and radiological findings.RESULTS Three-quarters of the patients were women, whose average age of 37 years was younger than the averageof the men, at 50 years. According to their histories, 47% of the patients had previously known cholelithiasis. Pain in either the right upper quadrant or the epigastrium was the presenting symptom in 93% cases. The greatest change in serum biochemical results was seen during the first day of the patients' admissions. Alanine aminotransferase(ALT) showed the highest initial rise above the reference range, followed by aspartate aminotransferase(AST), gamma-glutamyl transferase(GGT), bilirubin and alkaline phosphatase(ALKP)- all these increases were statistically significant(P < 0.05). AST showed the sharpest decline followed by bilirubin and ALT. GGT and ALKP did not fall. A sharp rise and fall in liver enzymes, especially during the first day, most prominently in AST and ALT, was seen in 70% percent of cases. In 65% of cases trans-abdominal sonography did not give diagnostic findings.CONCLUSION Serial serum liver enzyme measurements are helpful in the initial diagnosis of acute biliary colic.

Hepatitis C virus cures after direct acting antiviral-related drug-induced liver injury: Case report

The United States Food and Drug Administration recently warned that the direct acting antiviral(DAA) combination hepatitis C virus(HCV) treatment of Paritaprevir, Ombitasvir, Dasabuvir, Ritonavir, and Ribavirin(PODr + R) can cause severe liver injury in patients with advanced liver disease. Drug induced liver injury was observed in a small number of patients with decompensated cirrhosis treated with other DAAs, but has not been reported in patients with compensated cirrhosis. We report a case of a 74-year-old woman with chronic HCV and Child-Pugh class A cirrhosis(compensated cirrhosis) treated with PODr + R. The patient presented on day 14 of PODr + R therapy with jaundice and new-onset ascites. Her total bilirubin level increased to 23 mg/dL and international normalized ratio rose to 1.65, while aminotransferase levels remained relatively stable. Hepatitis C treatment was discontinued on day 24 and she gradually recovered. Follow-up testing showed that she achieved a sustained virologic response. In conclusion, hepatic decompensation developed within two weeks of starting treatment withPODr + R in a patient with Child-Pugh class A cirrhosis and was characterized by jaundice and ascites with stable aminotransferase levels. Careful monitoring is warranted in patients with HCV-related cirrhosis treated with PODr + R.