瞬时弹性图诊断肝硬化:一项前瞻性研究

Background: Transient elastography (FibroScan) is a new, noninvasive, rapid, and reproducible method allowing evaluation of liver fibrosis by measurement of liver stiffness. In cirrhotic patients, liver stiffness measurements range from 12.5 to 75.5 kPa. However, the clinical relevance of these values is unknown. The aim of this prospective study was to evaluate the accuracy of liver stiffness measurement for the detection of cirrhosis in patients with chronic liver disease. Methods: A total of 711 patients with chronic liver disease were studied. Aetiologies of chronic liver diseases were hepatitis C virus or hepatitis B virus infection, alcohol, non-alcoholic steatohepatitis, other, or a combination of the above aetiologies. Liver fibrosis was evaluated according to the METAVIR score. Results: Stiffness was significantly correlated with fibrosis stage (r=0.73, p < 0.0001). Areas under the receiver operating characteristic curve (95% confidence interval) were 0.80 (0.75- 0.84) for patients with significant fibrosis (F >2), 0.90 (0.86- 0.93) for patients with severe fibrosis (F3), and 0.96 (0.94- 0.98) for patients with cirrhosis. Using a cut off value of 17.6 kPa, patients with cirrhosis were detected with a positive predictive value and a negative predictive value (NPV) of 90% . Liver stiffness was significantly correlated with clinical, biological, and morphological parameters of liver disease. With an NPV >90% , the cut off values for the presence of oesophageal varices stage 2/3, cirrhosis Child-Pugh B or C, past history of ascites, hepatocellular carcinoma, and oesophageal bleeding were 27.5, 37.5, 49.1, 53.7, and 62.7 kPa, respectively. Conclusion: Transient elastography is a promising non-invasive method for detection of cirrhosis in patients with chronic liver disease. Its use for the follow up and management of these patients could be of great interest and should be evaluated further.

超声内镜能否鉴别瘤性与非瘤性胆囊息肉

The present study aimed to clarify the endoscopic ultrasonography(EUS)features of nonneoplastic(cholesterol polyps and adenomyomatosis)and neoplastic(adenoma and adenocarcinoma)gallbladder polyps and to evaluate the effectiveness and limitation of EUS in the differential diagnosis of these lesions.We retrospectively compared EUS images with histologic findings in 29 surgical cases with gallbladder polyps with a diameter of 10 to 20 mm.Those cases were indicated for surgery based on the findings of a sessile appearance,a solitary lesion,low echogenicity,and/or a lobulated surface.Six of 10 cholesterol polyps were atypically seen as partially or completely hypoechoic due to predominant proliferation of glandular epithelia.Nine of 10 cholesterol polyps demonstrated an aggregation of hyperechoic spots,which represented multiple granules of cholesterosis.All adenomyomatoses(n = 10)showed multiple microcysts,which corresponded to proliferated Rokitansky-Aschoff sinuses.However,three of nine neoplastic lesions(three adenomas and six adenocarcinomas)showed one of these signs due to concomitant cholesterosis(n = 2)or proliferated Rokitansky-Aschoff sinuses(n = 1).In conclusion,69%(20/29)of gallbladder polyps larger than 10 mm that were preoperatively suspected of malignancy were nonneoplastic.An aggregation of hyperechoic spots and multiple microcysts are considered to be important predictive factors for cholesterol polyps and adenomyomatosis,respectively.However,we should caution that these findings can also occur in neoplastic polyps when they contain a concomitant nonneoplastic component(choleste-rosis or proliferated Rokitansky-Aschoff sinuses).

原发性胆汁性肝硬化伴系统性硬化症的临床特点与预后

Backgrounds and aims: To evaluate the prognosis of primary biliary cirrhosis (PBC) together with systemic sclerosis (SSc), as this is unknown. Methods and results: A PBC database of 580 patients identified 43 with PBC and SSc: two patients with PBC alone were matched to each PBC-SSc patient for serum bilirubin concentration at the initial visit. Forty (93% ) patients had limited cutaneous SSc. At diagnosis of PBC, median values were: 49.7 years, bilirubin 17 μ mol/l, and albumin 40.5 g/l. Liver diagnosis occurred a median 4.9 years after SSc in 24 (56% ) patients. In matched patients, median values at diagnosis were: 53.2 years, bilirubin 12 μ mol/l, and albumin 41 g/l. Median follow up was similar: 3.16 years (PBC-SSc) and 4.8 years (PBC alone). The risk of transplantation or death from diagnosis, adjusting for sex, age, log bilirubin, and alkaline phosphatase was significantly lower in PBC-SSc (hazard ratio 0.116, p = 0.01) due to less transplantation (hazard ratio 0.068, p = 0.006). The rate of bilirubin increase was less in PBC-SSc (p = 0.04). Overall survival was similar (hazard ratio 1.11, p = 0.948); there were nine deaths (21% ) in PBC-SSc (six SSc related and two liver related) and nine (11% ) in PBC alone (six liver related). Conclusions: Liver disease has a slower progression in PBC-SSc compared with matched patients with PBC alone.

与短期塞来考昔应用相关的持续性胆汁淤积症

Drug-induced liver injury due to celecoxib, a first generation Cox-2 inhibitor, has been rarely reported. We describe one case of severe and prolonged cholestasis after treatment with celecoxib for 12 days in a young woman with no evidence of other causes of liver disease or allergy. Jaundice lasted for 3 months, pruritus and abnormal liver biochemistries persisted for 18 months after stopping the drug. Liver biopsy specimens showed a cholestatic pattern of liver injury with only minimal mononuclear infiltrate in the portal tracts. This case report supports the notion that celecoxib may cause bland, long term cholestasis.

与塞来考昔治疗密切相关的急性大肠炎

Selective inhibitors of cyclooxygenase-2 have less gastroduodenal toxicity than non selective anti-inflammatory drugs. However, there is little information on their effect on the distal gut. A 91 year old woman presented with acute diarrhoea 5 weeks after beginning celecoxib treatment. Laboratory results showed an inflammatory syndrome and increased alanine aminotransferase (ALT) to 13 N. Endoscopic examination of the colon showed diffuse erythematous lesions of the sigmoid and of part of the right colon. No aetiology has been found for colitis or hepatitis. Diarrhea and blood test anomalies disappeared one week after celecoxib was stopped. The role of celecoxib in the etiology of colitis was considered plausible but not for liver damage. This report and a few other cases in the literature suggest that cyclooxygenase-2 selective non-steroidal anti-infla-mmatory drug inhibitor toxicity should be investigated in case of unexplained acute colitis.

食管与贲门腺癌切除术后早期复发的术前预测因素分析

Objectives-To determine pre-operative predictive factors of early recurrence in patients with esophageal and cardial adenocarcinoma. Patients and methods-We retrospectively analyzed consecutive patients who underwent resection for esophageal and cardial adenocarcinoma in our institution between October 1992 and October 2001. Patient files were studied and classified according to the occurrence of early recurrence (within one year) (group A) and patients without recurrence (group B). Pre-operative clinical, biological and radiological parameters were recorded. Both groups were compared in univariate and multivariate analysis. Results-One hundred patients underwent surgical resection. Tumor was located in lower esophagus in 71 cases and at the cardia in 29 cases. R0 resection was feasible in 95 cases. Hospital mortality was 2%. Survival rate at 3 years was 56%. Recurrence before 1 year occurred in 28 patients (group A) and not in 72 (group B). In univariate analysis, younger age (P = 0.01), dysphagia (P = 0.04) and percentage of weight loss (P < 0.0004) were significantly different between both groups. Weight loss more than 10%was observed in 2 patients of group B, and in 9 patients of group A. In multivariate analysis, weight loss more than 10%was the only pre-operative factor associated with early recurrence (P = 0.018). Conclusion-Important weight loss could be a preoperative predictive factor of early recurrence after resection of esophageal and cardial adenocarcinoma and surgery as first line treatment could be avoided in these patients.

专科会诊中与痔疮有关的危险因素分析

Epidemiology and risk factors of hemorrhoidal disease are not well defined. Aims and methods-Past history and events occuring during the last two weeks before a medical visit for acute hemorrhoidal symptoms were analyzed and compared with controls consulting for any other diagnosis without exclusion. Results-Among complete inquiries returned by 931 private gastroenterologists, files from 1033 patients (542 males) and 1028 controls (504 males) were randomly selected. Hemorrhoidal disease patients were younger (47 ±14.5 vs. 52 ±16.5 yrs; P < 0.0001);sex ratio was not different from controls. Factors significantly associated with hemorrhoidal crisis were: past history of hemorrhoidal symptoms, age < 50 yrs, past history of anal fissure, occupational activity (OR 5.17; 1.95; 1.72; 1.43; P < 0.1) and recent unusual events : spicy diet, constipation, physical activity, alcohol intake (OR 4.95; 3.93; 2.79; 1.99; P < 0.1). Stress protected against hemorrhoids (OR 0.49; P < 0.0001). For women aged less than 40 yrs, no significant risk factor related with genital activity was found for hemorrhoidal disease. Conclusion-For young patients, especially those with a past hemorrhoidal history, spice or alcohol intake and constipation are risk factors for hemorrhoidal crisis. For young women, prevention is essentialy based on treatment of constipation associated with genito-obstetrical events.