Biomarkers ; blood ; Diagnostic Techniques, Digestive System ; Elasticity ; Hepatitis C, Chronic ; complications ; Humans ; Liver ; pathology ; Liver Cirrhosis ; diagnosis ; etiology

Hepatocellular carcinoma (HCC) can be diagnosed based on characteristic findings of arterial-phase enhancement and portal/delayed "washout" in cirrhotic patients. Several countries and major academic societies have proposed varying specific diagnostic criteria for HCC, largely reflecting the variable HCC prevalence in different regions and ethnic groups, as well as different practice patterns. In 2014, a new version of Korean practice guidelines for management of HCC was released by the Korean Liver Cancer Study Group (KLCSG) and the National Cancer Center (NCC). According to the KLCSG-NCC Korea practice guidelines, if the typical hallmark of HCC (i.e., hypervascularity in the arterial phase with washout in the portal or 3 min-delayed phases) is identified in a nodule > or = 1 cm in diameter on either dynamic CT, dynamic MRI, or MRI using hepatocyte-specific contrast agent in high-risk groups, a diagnosis of HCC is established. In addition, the KLCSG-NCC Korea practice guidelines provide criteria to diagnose HCC for subcentimeter hepatic nodules according to imaging findings and tumor marker, which has not been addressed in other guidelines such as Association for the Study of Liver Diseases and European Association for the Study of the Liver. In this review, we briefly review the new HCC diagnostic criteria endorsed by the 2014 KLCSG-NCC Korea practice guidelines, in comparison with other recent guidelines; we furthermore address several remaining issues in noninvasive diagnosis of HCC, including prerequisite of sonographic demonstration of nodules, discrepancy between transitional phase and delayed phase, and implementation of ancillary features for HCC diagnosis.
Aged ; Aged, 80 and over ; Carcinoma, Hepatocellular/*diagnosis/pathology ; Contrast Media ; Female ; Hepatitis B, Chronic/complications ; Hepatitis C, Chronic/complications ; Humans ; Liver/*pathology ; Liver Neoplasms/*diagnosis/pathology ; Magnetic Resonance Imaging/*methods ; Male ; Middle Aged ; Practice Guidelines as Topic ; Republic of Korea ; Young Adult

OBJECTIVETo investigate the diagnostic value of magnetic resonance diffusion-weighted imaging (DWI) technique in assessing the disease activity and liver fibrosis of chronic viral hepatitis.

METHODSA total of 49 patients with chronic viral hepatitis who received liver biopsy and 10 healthy volunteers were included in this study. All of them underwent DWI on a 3.0 T magnetic resonance imaging system. When the gradient factor b value was set at 100, 200, 400, 600, and 800 s/mm2, the apparent diffusion coefficient (ADC) of the liver was measured respectively. Biopsy specimens were scored for necroinflammation and liver fibrosis according to the Knodell histological activity index.

RESULTSThe ADC values of the right lobe in both controls and patients were lower than those of the left lobe. When the b value was set at 400, 600, and 800 s/mm2, the differences of the ADC values between the fibrosis group (n = 36) and the non-fibrosis group (n = 23, including 10 cases of normal subjects) were statistically significant (P < 0.01). When the b value was set at 800 s/mm2, the ADC values among the different degrees of necroinflammation and grades of liver fibrosis were also significantly different (P < 0.05, P < 0.01).

CONCLUSIONDWI is a valuable method for in vivo and noninvasive assessment of the disease activity and liver fibrosis of chronic viral hepatitis.

Adolescent ; Adult ; Case-Control Studies ; Diffusion Magnetic Resonance Imaging ; methods ; Female ; Hepatitis B, Chronic ; complications ; pathology ; Hepatitis C, Chronic ; complications ; pathology ; Humans ; Liver Cirrhosis ; diagnosis ; etiology ; pathology ; Male ; Middle Aged ; Young Adult

OBJECTIVETo investigate the correlation between the stage of hepatic fibrosis and ultrasonographic findings of the liver, spleen and gallbladder and establish a sensitive ultrasonographic semi-quantitative scoring system for screening compensated liver cirrhosis.

METHODSTotalling 248 patients with chronic hepatitis B and hepatitis C virus infection underwent liver biopsy and ultrasonic examination. The images of the liver surface, parenchymal echo, intrahepatic vessels, gallbladder, spleen and diameter of portal vein were analyzed.

RESULTSThe stages of hepatic fibrosis were not correlated to ultrasonographic findings of the liver surface or diameter of portal vein, but hepatic fibrosis of different stages showed significant differences in parenchymal echo, intrahepatic vessels, gallbladder and splenomegaly. In cases with normal liver parenchymal, intrahepatic vessels, gallbladder and spleen, the negative predictive value of the ultrasonographic semi-quantitative scoring system for diagnosing compensated liver cirrhosis amounted to 96.3%. The sensitivity of a score not lower than 5 was 90% for detecting compensated cirrhosis. With a score not lower than 7, the diagnostic accuracy and specificity was 85.9% and 95.2%, respectively, but the sensitivity was lowered to 37.5%.

CONCLUSIONThe ultrasonic images of the liver parenchyma, intrahepatic vessels, gallbladder and spleen in patients with compensated liver cirrhosis vary significantly in patients with hepatic fibrosis of different stages, and this ultrasonographic scoring system allows for a sensitive diagnosis of compensated cirrhosis.

Female ; Fibrosis ; Gallbladder ; diagnostic imaging ; Hepatitis B, Chronic ; complications ; Hepatitis C ; complications ; Humans ; Liver ; diagnostic imaging ; pathology ; virology ; Liver Cirrhosis ; complications ; diagnosis ; Male ; Reproducibility of Results ; Sensitivity and Specificity ; Spleen ; diagnostic imaging ; Splenomegaly ; diagnostic imaging ; Ultrasonography ; methods

Cryptococcus neoformans, an encapsulated fungus, is an important opportunistic pathogen that can cause meningitis in immunocompromised patients. Since patients with cryptococcemia have high mortality, it is essential to make an early diagnosis and promptly initiate antifungal therapy. However, it is often very difficult to differentiate between cryptococcal meningitis and hepatic encephalopathy in patients with liver cirrhosis, and there is delay in making the diagnosis. Therefore, these patients have a particularly grave prognosis and consequently many patients die before culture results become available. In one study, starting antifungal therapy within 48 hours of the blood culture was associated with improved survival, but patients with liver cirrhosis were significantly less likely to receive antifungal therapy within 48 hours compared to those without liver cirrhosis. Recently, the authors experience a case of a 68-year-old woman with liver cirrhosis who presented with fever and a drowsy mental status. She had a previous history of having been admitted for infection-associated hepatic encephlopathy. Cryptococcal meningitis and cryptococcemia were diagnosed by spinal puncture and culture of cerebrospinal fluid. In spite of adequate treatment, the patient developed multi-system organ failure and eventually expired. Herein, we report a case of cryptococcal meningitis mimicking hepatic encephalopathy in a patient with liver cirrhosis.
Aged, 80 and over ; Brain/radiography ; Cryptococcus/isolation & purification ; Female ; Hepatic Encephalopathy/complications/*diagnosis ; Hepatitis C, Chronic/complications/pathology ; Humans ; Liver Cirrhosis/etiology/pathology ; Meningitis, Cryptococcal/complications/*diagnosis/microbiology ; Tomography, X-Ray Computed

Facial nerve palsy due to temporal bone metastasis of hepatocellular carcinoma (HCC) has rarely been reported. We experienced a rare case of temporal bone metastasis of HCC that initially presented as facial nerve palsy and was diagnosed by surgical biopsy. This patient also discovered for the first time that he had chronic hepatitis B and C infections due to this facial nerve palsy. Radiation therapy greatly relieved the facial pain and facial nerve palsy. This report suggests that hepatologists should consider metastatic HCC as a rare but possible cause of new-onset cranial neuropathy in patients with chronic viral hepatitis.
Carcinoma, Hepatocellular/complications/*pathology ; Facial Nerve Diseases/diagnosis/etiology ; Facial Pain/etiology ; Facial Paralysis/diagnosis/etiology ; Hepatitis B, Chronic/diagnosis ; Hepatitis C, Chronic/diagnosis ; Humans ; Immunohistochemistry ; Liver Neoplasms/complications/*pathology ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Positron-Emission Tomography ; Skull Neoplasms/*diagnosis/pathology/secondary ; Tomography, X-Ray Computed

Hepatic myelopathy is a rare complication of chronic liver disease that is associated with extensive portosystemic shunts. The main clinical feature of hepatic myelopathy is progressive spastic paraparesis in the absence of sensory or sphincter impairment. Early and accurate diagnosis of hepatic myelopathy is important because patients with early stages of the disease can fully recover following liver transplantation. Motor-evoked potential studies may be suitable for the early diagnosis of hepatic myelopathy, even in patients with preclinical stages of the disease. Here we describe two patients who presented with spastic paraparesis associated with a spontaneous splenorenal shunt and without any previous episode of hepatic encephalopathy. One patient experienced improved neurologic symptoms after liver transplantation, whereas the other patient only received medical treatment, which did not prevent the progression of spastic paraparesis.
Adult ; Disease Progression ; Evoked Potentials, Motor/physiology ; Hepatitis B, Chronic/complications/diagnosis ; Hepatitis C, Chronic/complications/diagnosis ; Humans ; Liver Cirrhosis/*complications/diagnosis ; Liver Transplantation ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Paraparesis, Spastic/etiology/pathology ; Renal Veins/*radiography ; Spinal Cord Diseases/*diagnosis/etiology/radiography ; Splenic Vein/*radiography ; Tomography, X-Ray Computed ; Vascular Fistula/*radiography

Hepatitis C virus (HCV) is one of the main viral causes of hepatocellular carcinoma (HCC) and is associated with lymphoproliferative disorder such as non-Hodgkin's lymphoma (NHL). However, there are only few case reports on concomitantly induced NHL and HCC by HCV. Herein, we report a case of synchronous NHL and HCC in a patient with chronic hepatitis C which was unexpectedly diagnosed during liver transplantation surgery. This case suggests that although intrahepatic lymph node enlargements are often considered as reactive or metastatic lymphadenopathy in chronic hepatitis C patients with HCC, NHL should also be considered as a differential diagnosis.
Antineoplastic Agents/therapeutic use ; Carcinoma, Hepatocellular/complications/*diagnosis/radiotherapy ; Drug Therapy, Combination ; Embolization, Therapeutic ; Fluorodeoxyglucose F18 ; Gadolinium DTPA ; Genotype ; Hepatitis B virus/genetics ; Hepatitis C, Chronic/complications/*diagnosis/*virology ; Humans ; Liver Neoplasms/complications/*diagnosis/radiotherapy ; Lymph Nodes/pathology ; Lymphoma, Non-Hodgkin/complications/*diagnosis/drug therapy ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Positron-Emission Tomography ; Tomography, X-Ray Computed

BACKGROUND/AIMS: We investigated the frequency of occult hepatitis B virus (HBV) infection in anti-hepatitis C virus (HCV)-positive individuals and the effects of occult HBV infection on the severity of liver disease. METHODS: Seventy-one hepatitis B virus surface-antigen (HBsAg)-negative patients were divided according to their HBV serological status into groups A (anti-HBc positive, anti-HBs negative; n=18), B (anti-HBc positive, anti-HBs positive; n=34), and C (anti-HBc negative, anti-HBs positive/negative; n=19), and by anti-HCV positivity (anti-HCV positive; n=32 vs. anti-HCV negative; n=39). Liver biopsy samples were taken, and HBV DNA was quantified by real-time PCR. RESULTS: Intrahepatic HBV DNA was detected in 32.4% (23/71) of the entire cohort, and HBV DNA levels were invariably low in the different groups. Occult HBV infection was detected more frequently in the anti-HBc-positive patients. Intrahepatic HBV DNA was detected in 28.1% (9/32) of the anti-HCV-positive and 35.9% (14/39) of the anti-HCV-negative subjects. The HCV genotype did not affect the detection rate of intrahepatic HBV DNA. In anti-HCV-positive cases, occult HBV infection did not affect liver disease severity. CONCLUSIONS: Low levels of intrahepatic HBV DNA were detected frequently in both HBsAg-negative and anti-HCV-positive cases. However, the frequency of occult HBV infection was not affected by the presence of hepatitis C, and occult HBV infection did not have a significant effect on the disease severity of hepatitis C.
Adult ; Aged ; Cohort Studies ; DNA, Viral/analysis ; Female ; Genotype ; Hepatitis B/*complications/*diagnosis ; Hepatitis B Core Antigens/blood/immunology ; Hepatitis B Surface Antigens/blood/immunology ; Hepatitis B virus/*genetics ; Hepatitis C, Chronic/*complications/genetics/*pathology ; Humans ; Liver/virology ; Male ; Middle Aged ; Polymerase Chain Reaction ; Severity of Illness Index

Variceal bleeding and hepatorenal syndrome (HRS) are serious and life-threatening complications of advanced liver disease. Terlipressin is widely used to manage both acute variceal bleeding and HRS due to its potency and long duration of action. The most severe (though rare) adverse event is ischemia. The present report describes the case of a patient with gangrene and osteomyelitis secondary to terlipressin therapy. A 71-year-old male with alcoholic liver cirrhosis (Child-Pugh B) and chronic hepatitis C was admitted due to a drowsy mental status. The patient had several experiences of orthopedic surgery. His creatinine level had gradually elevated to 4.02 mg/dL, and his urine output decreased to 500 mL/24 hr. The patient was diagnosed as having grade III hepatic encephalopathy (HE) and type II HRS. Terlipressin and albumin were administered intravenously to treat the HRS over 11 days. Although he recovered from the HE and HRS, the patient developed peripheral gangrene and osteomyelitis in both feet. His right toes were cured with the aid of rescue therapy, but his left three toes had to be amputated. Peripheral gangrene and osteomyelitis secondary to terlipressin therapy occur only rarely, and there is no specific rescue therapy for these conditions. Thus, attention should be paid to the possibility of ischemia of the skin and bone during or after terlipressin therapy.
Aged ; Creatinine/blood ; Foot/pathology ; Gangrene/*etiology ; Hepatitis C, Chronic/complications ; Humans ; Liver Cirrhosis/complications/diagnosis ; Liver Diseases/*diagnosis/drug therapy ; Lypressin/adverse effects/*analogs & derivatives/therapeutic use ; Male ; Osteomyelitis/*etiology ; Severity of Illness Index ; Toe Phalanges/radiography ; Vasoconstrictor Agents/*adverse effects/therapeutic use