Staging of portal hypertension and portosystemic shunts using dynamic nuclear medicine investigations

AIM: To explore portal hypertension and portosys-temic shunts and to stage chronic liver disease (CLD) based on the pathophysiology of portal hemodynam-ics. METHODS: Per-rectal portal scintigraphy (PRPS) was performed on 312 patients with CLD and liver angio-scintigraphy (LAS) on 231 of them. The control group included 25 healthy subjects. We developed a new model of PRPS interpretation by introducing two new parameters,the liver transit time (LTT) and the circu-lation time between right heart and liver (RHLT). LTT for each lobe was used to evaluate the early portal hypertension. RHLT is useful in cirrhosis to detect liver areas missing portal in? ow. We calculated the classical per-rectal portal shunt index (PRSI) at PRPS and the hepatic perfusion index (HPI) at LAS. RESULTS: The normal LTT value was 24 ± 1 s. Abnor-mal LTT had PPV = 100% for CLD. Twenty-seven non-cirrhotic patients had LTT increased up to 35 s (median 27 s). RHLT (42 ± 1 s) was not related to liver disease. Cirrhosis could be excluded in all patients with PRSI < 5% (P < 0.01). PRSI > 30% had PPV = 100% for cirrhosis. Based on PRPS and LAS we propose the clas-sifi cation of CLD in 5 hemodynamic stages. Stage 0 is normal (LTT = 24 s,PRSI < 5%). In stage 1,LTT is increased,while PRSI remains normal. In stage 2,LTT is decreased between 16 s and 23 s,whereas PRSI is increased between 5% and 10%. In stage 3,PRSI is increased to 10%-30%,and LTT becomes undetect-able by PRPS due to the portosystemic shunts. Stage 4 includes the patients with PRSI > 30%. RHLT and HPI were used to subtype stage 4. In our study stage 0 had NPV = 100% for CLD,stage 1 had PPV = 100% for non-cirrhotic CLD,stages 2 and 3 represented the transition from chronic hepatitis to cirrhosis,stage 4 had PPV = 100% for cirrhosis. CONCLUSION: LTT allows the detection of early por-tal hypertension and of opening of transhepatic shunts. PRSI is useful in CLD with extrahepatic portosystemic shunts. Our hemodynamic model stages the evolution of portal hypertension and portosystemic shunts. It may be of use in the selection of patients for interferon therapy.

Spontaneous and antiviral-induced cutaneous lesions in chronic hepatitis B virus infection

AIM:To describe spontaneous,or interferon(IFN)-or immunization-induced skin lesions in hepatitis B virus(HBV)infection.METHODS:A comprehensive literature search of all the papers presenting case reports of dermatological lesions in patients with chronic HBV infection was carried out.We included only patients with histologically proven skin lesions that appeared in the normal course of hepatitis B infection,or after immunization for hepatitis B or antiviral treatment.RESULTS:We found 44 papers on this topic,reporting 151 cases.About 2%of patients with hepatitis B infection,mainly men,presented with skin lesions.Among patients with chronic hepatitis B,vasculitis and essential mixed cryoglobulinemia seemed to be the most frequent skin lesion(53.3%),followed by papular changes,rashes and Gianotti-Crosti syndrome,skin carcinoma and Henoch-Sch?nlein purpura were rare.IFN treatment seemed to be effective against HBV-associated and immunoglobulin-complex-mediated disease(vasculitis).Two cutaneous lesions(lichen planus andgranuloma annulare)were described after hepatitis B vaccination.Systemic lupus and lupus-like lesions were the most frequently encountered lesions after antiviral treatment.Immunosuppressive and steroid therapy ameliorates lichen planus lesions in 50%of cases.CONCLUSION:Vasculitis was the most frequent spontaneous skin lesion found in chronic hepatitis B.Lichen planus was most frequent after immunization and lupus/lupus-like lesions after IFN.