Hepatocellular Carcinoma. Part 2: Clinical Presentation and Diagnosis

Clinical presentation of hepatocellular carcinoma (HCC) can vary from asymptomatic patients to patients presenting variable symptoms such as pain, lethargy, jaundice, hepatic encephalopathy, anasarca, ascites, variceal bleeding, diarrhoea, paraneoplastic symptoms, cutaneous manifestations, and abnormal laboratory values. Diagnosis of HCC is based on computed tomography (CT), magnetic resonance imaging (MRI), and tumour markers. The most commonly used is alpha fetoprotein.1,2 MRI is the imaging method of choice, although it has decreased sensitivity in detecting lesions <2 cm.3 Other possibilities include biomarkers such as embryonic antigen, protein antigen, enzymes and isoenzymes, cytokines, and genetic biomarkers. Liver biopsy is used in selected patients who do not present typical features of HCC on CT or MRI. Surveillance by ultrasound is recommended every 6 months in cirrhotic patients. The Barcelona Clinic Liver Cancer (BCLC) scoring system has been proposed for staging of HCC, and numerous scoring systems have been developed to evaluate progression and determine treatment possibilities; they take into account the clinical as well as the laboratory and pathological criteria, biomarkers, biopsy, and imaging methods

Multiple-shower thromboembolism in an artificial mitral valve patient

BACKGROUND: Late acute left atrial thrombosis is a rare life-threatening complication that mostly appears with predisposing primary coagulopathy, such as Protein C, Protein S, antithrombin 3 deficiency, antiphospholipid syndrome or hyperhomocysteinemia. We present grave outcome due to lack of anticoagulation in a patient with artificial mitral valve. CASE PRESENTATION: A 47-year-old male known to have an artificial valve was hospitalized in another hospital due to an acute illness. Anti-coagulation therapy was not provided during that hospitalization. He was transferred to our hospital due to lower limb weakness and diagnosed by us as having extensive emboli disease with complete occlusion of the distal aorta. Multiple infarcts were found in the abdominal organs and leg muscles. He suffered from multiple organ failure and eventually died. CONCLUSION: Neglecting the common practice of anticoagulation to a patient with a mechanical heart valve may, in rare cases, lead to immediate catastrophic event caused by shower thrombemboli with disseminated vascular occlusion from the left atrium to the abdominal aorta causing complete occlusion, spleen, kidney and muscle infarcts

Hepatocellular Carcinoma. Part 3: Surgical and Medical Treatment

Hepatocellular carcinoma (HCC) treatment is variable and depends on the size, location, and presence of extra hepatic metastasis and vascular invasion. HCC treatment options have advanced significantly over the past few decades and include surgical and non-surgical methods. In the past, systemic chemotherapy was the non-surgical treatment and there was no significant increase in overall survival rate. Nowadays sorafenib, a molecular targeted drug, is the treatment of choice and has shown proven benefits in increasing survival time; other systemic therapies did not show longer statistical superiority. However, surgical treatments, such as liver transplantation and surgical resection, are still the only methods offering a curative opportunity; however, these are not free of adverse effects and recurrence of the tumour. Non-surgical techniques including ablative treatment, radiotherapy, transarterial chemoembolisation, and percutaneous ethanol injection also show some benefit in the survival of patients with HCC. Future molecular targeted drugs are currently under investigation in different stages of clinical trials, and there are positive expectations regarding their benefit in treating HCC

Angioimmunoblastic T-cell lymphoma presenting as giant kidneys: a case report

<p>Abstract</p> <p>Introduction</p> <p>Angioimmunoblastic T-cell lymphoma is a rare form of tumor of the lymph nodes or lymphoid tissue. In this report we describe an unusual presentation of angioimmunoblastic T-cell lymphoma consisting of giant kidneys with no nephrotic syndrome.</p> <p>Case presentation</p> <p>A 46-year-old Arabic man from Gaza was hospitalized in our ward due to abdominal pain and a weight loss of 20 kg during the preceding two months. The results of the physical examination and laboratory tests raised the possibility of neoplastic disease. A computerized tomographic scan of the abdomen showed huge kidneys, and a kidney biopsy showed infiltration by lymphocytes and eosinophils. The genetic examination revealed T-cell lymphoma. Diagnosis was made by a lymph node biopsy, which shows typical findings of angioimmunoblastic T-cell lymphoma.</p> <p>Conclusions</p> <p>Angioimmunoblastic T-cell lymphoma can present with huge kidneys without nephrotic syndrome.</p

The Role of Bile Acid Excretion in Atherosclerotic Coronary Artery Disease

The impact of cholesterol and different classes of lipoproteins on the development of coronary artery disease (CAD) has been investigated in extensively during the past 50 years. The cholesterol metabolism is dependent on numerous factors, including dietary fat, fractional absorption of dietary cholesterol, tissue stores of cholesterol, endogenous cholesterol synthesis, and fecal bile excretion. Several studies showed significantly lower amounts of bile acid secretion in adult patients with CAD compared to non-CAD patients. Could it be that the inability to efficiently excrete bile acids may lead to CAD development

Editor’s Pick: Hepatocellular Carcinoma. Part 1: Epidemiology, Risk Factors, Pathogenesis, and Pathology

This review will cover the epidemiology, risk factors, pathogenesis, and pathology of hepatocellular carcinoma (HCC). HCC is the fifth most commonly diagnosed cancer in males and second most frequent cancer-related cause of mortality worldwide. In females, it is the seventh most frequently diagnosed malignancy and sixth leading cause of death. The incidence of HCC is higher among males in less developed countries and reaches a peak around the age of 70 years. The rates of liver cancer are twice as high in males compared to females.1,2 Various risk factors, including environmental, infectious, nutritional, and metabolic, are associated with HCC; among them viral infection has been linked to being the highest risk factor for developing HCC. HCC is a highly vascular tumour and its pathogenesis consists of increasing angiogenesis by overexpression of various growth factors. Another cause of HCC development is thought to be mutations in different signalling pathways that lead to proliferation of the tumour cells

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Abstract Background: Earlier studies on hypertension demonstrated seasonal variations in different age groups. However, slightly greater fluctuations were found in the hypertensive elderly. Objective: We conducted a prospective 5-year study from January 1997 to December 2001 to evaluate the seasonal variation in blood pressure and the variables of age, gender, body mass index and related complications in elderly Israeli patients with essential hypertension. Methods: Blood pressure was measured in four seasons in 182 patients (98 men and 84 women; age range 65-91 years) treated for hypertension in our outpatient clinic. Results: Both systolic and diastolic mean blood pressures were higher during winter compared to summer (165 B 11.6 and 90 B 13.7 and 134 B 47.3 and 74 B 8.5 mm Hg, respectively; p ! 0.001). There were no significant seasonal differences between spring and autumn or any correlation between the seasonal winter-summer difference in blood pressure and other studied parameters. Patients aged 65-75 years were unexpectedly more sensitive to winter-summer changes than older patients. There was a correlation between a large winter-summer difference in systolic blood pressure and a body mass index between 20 and 30, but there was none in lower or higher ranges. Supplementary antihypertension treatment was required during winter in 38% of these selected patients. Complications such as myocardial infarctions and strokes occurred twice as frequently in winter than in any other season (p ! 0.0001). Conclusions: Both systolic and diastolic blood pressures were highest during winter. Hypertension complications were more frequent in winter. Our results refute those of earlier studies that failed to find significant seasonal variations in blood pressure among the elderly

A Meteorological Paradox: Low Atmospheric Pressure-Associated Decrease in Blood Pressure Is Accompanied by More Cardiac and Cerebrovascular Complications: Five-Year Follow-Up of Elderly Hypertensive Patients

Background: Variations in atmospheric pressure (AP) are known to affect blood pressure (BP). We assessed the effect of AP on BP, and the major fatal and nonfatal complications thereof (i.e., stroke, myocardial infarction, and pulmonary emboli). Methods: In this observational cohort study, 250 hypertensive patients (aged 65–92 years old) were followed for 3.5–5.4 years in a primary care clinic. Cox proportional hazard regression was performed to define the associations between AP, clinical, demographic and environmental factors, and major complications such as stroke, myocardial infarction, etc. Results: AP fluctuated between 1007 and 1024 millibars (MB). A total of 132 patients (53%) developed various complications, of which 13 (9.8%) were fatal. Among all fatalities, 93 of 119 nonfatal cases and 7 of 13 fatal cases occurred at AP < 1013 MB. A Cox regression analysis showed that low AP (AP < 1013 MB) had a higher hazard ratio (HR) on hypertension (HTN) complications among all demographic, clinical and environmental parameters. Conclusions: Most major complications were associated with very low APs. Low AP was the best predictive risk-factor for major complications of HTN

Diminished bile acids excretion is a risk factor for coronary artery disease: 20-year follow up and long-term outcome

Background: Patients with coronary artery disease (CAD) had significantly lower bile acid excretion (BAE) compared with non-CAD patients, leading to the hypothesis that the inability to efficiently excrete bile acids leads to coronary atherosclerosis development. We investigated the long-term role of BAE in CAD development and related mortality in 50 patients with proven CAD compared with that of 50 patients with chest pain and no CAD (controls) matched for clinical and laboratory characteristics. Methods: All subjects received a 4-day standard diet that included ~500 mg of cholesterol. Fecal bile acids from 24-h stool collections were measured by gas liquid chromatography. Results: CAD patients excreted lower amounts of total bile acids than controls ( p < 0.001), less deoxycholic acid ( p < 0.0001) and less lithocholic acid ( p < 0.01). BAE was the best significant independent laboratory factor that predicted CAD ( p < 0.05). Mortality and CAD development rates were significantly lower for the controls at the 20-year follow up. Conclusions: These results showed that CAD patients had markedly decreased BAE levels compared with non-CAD controls. BAE <415 mg/day was associated with increased CAD long-term mortality. Impaired ability to excrete cholesterol might be considered an additional independent risk factor for CAD development