Non invasive tools for the diagnosis of liver cirrhosis

Liver cirrhosis (LC), the end stage of many forms of chronic hepatitis of different etiologies is a diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules surrounded by annular fibrosis. This chronic progressive clinical condition, leads to liver cell failure and portal hypertension, which can favour the onset of hepatocellular carcinoma. Defining the phase of the natural history is crucial for therapeutic choice and prognosis. Liver biopsy is currently considered the best available standard of reference but it has some limits, so alternative tools have been developed to substitute liver biopsy when assessing liver fibrosis. Serum markers offer a cost-effective alternative to liver biopsy being less invasive and theoretically without complications. They can be classified into direct and indirect markers which may be used alone or in combination to produce composite scores. Diagnostic imaging includes a number of instruments and techniques to estimate liver fibrosis and cirrhosis like ultrasound (US), US Doppler, contrast enhanced US and Elastography. US could be used for the diagnosis of advanced LC while is not able to evaluate progression of fibrosis, in this case Elastography is more reliable. This review aims to revise the most recent data from the literature about non invasive methods useful in defining liver fibrosis

Ultrasound as first line step in anaemia diagnostics

This review covers the role of ultrasonography as an essential non-invasive diagnostic approach when facing patients with anaemia, a common clinical problem. Abdomen ultrasound is well recognised as a first-line examination in the setting of blood loss, both acute and chronic. Less is clear about the additional opportunities, given by ultrasound in anaemia, due to the many other possible causes. Here we provide information on the utility of ultrasound in different contexts and a practical guide for clinicians facing anaemic patients

A phenobarbital overdose: a case report

Background: Phenobarbital is a long-acting barbiturate, responsible for many cases of poisoning, from unintentional overdose or attempted suicide. We report a case of phenobarbital overdose in a patient with history of depression. Patients and Methods: A 60 year old woman was admitted to our Internal Medicine Unit for drowsiness, irritability, difficulties in the maintenance of an upright position, dysphasia and weakness. She was suffering from depression and epilepsy and treated with phenobarbital 150 mg/die. Results: At the admittance, she had high fever and neck stiffness; phenobarbital serum levels were 71.2 mcg/ml (3 times u.n.l.); aminotransferases were 12-17u.n.l. Arterial blood pressure was 80/50 mmHg. An inflammatory meningeal process was excluded by lumbar puncture; a brain and spinal cord CT scan excluded spine bone lesions and ischemic stroke. In the suspect of an overdose, a protocol of urine alkalinization was applied resulting in a reduction of phenobarbital levels below the therapeutic range in about 6 days, with state of consciousness, cognitive and behavioral functions improvement. A rapid normalization in aminotransferases levels was noted and serology for hepatitis viruses (HAV, HBV, CMV, EBV, HSV) resulted negative. Conclusions: In our patient phenobarbital was responsible for stupor, hypotension, hypertonicity and aminotransferases elevation, whereas fever was due to a concomitant pulmonary inflammatory process resolved after antibiotic therapy. Despite the use of these drugs has been progressively reduced, the number overdose reports remains still hig

An unusual Erdheim-Chester disease with orbital involvement: A case report

Erdheim-Chester disease is a rare non-Langerhans cell histiocytosis with multiorgan involvement and a specific tropism for perivascular and fatty connective tissue, of unclear origin, with poor response to therapy. Its identification is difficult because of the variable clinical presentation and its lack of knowledge. We report the case of a 63-years-old woman, with a history of bilateral orbital pseudotumor, who comes to our attention because of progressively worsening asthenia, vomiting and systemic inflammation. Total body computerized tomography scan showed a volumetric increase of choroid plexus of the temporal horn of the left lateral ventricle, presence of solid retrobulbar tissue at the level of both maxillary sinuses, lung fibrosis, and retroperitoneal and peri-aortic infiltration. The association of these signs addressed to a diagnosis of Erdheim-Chester disease. Thus, although extremely rare, the diagnosis of Erdheim-Chester disease must be considered in the case of bilateral retro-orbital tumors and multisystemic involvement

The role of vitamin deficiency in liver disease: To supplement or not supplement?

Over the past few years, growing interest has been shown for the impact of dietary requirements and nutritional factors on chronic diseases. As a result, nutritional programs have been reinforced by public health policies. The precise role of micronutrients in chronic liver disease is currently receiving particular attention since abnormalities in vitamin levels are often detected. At present, treatment programs are focused on correcting vitamin deficiencies, which are frequently correlated to higher rates of comorbidities with poor outcomes. The literature reviewed here indicates that liver diseases are often related to vitamin disorders, due to both liver impairment and abnormal intake. More specific knowledge about the role of vitamins in liver disease is currently emerging from various results and recent evidence. The most significant benefits in this area may be observed when improved vitamin intake is combined with a pharmacological treatment that may also affect the progression of the liver disease, especially in the case of liver tumors. However, further studies are needed

Benign and malignant mimickers of infiltrative hepatocellular carcinoma: tips and tricks for differential diagnosis on CT and MRI

Hepatocellular carcinoma (HCC) may have an infiltrative appearance in about 8–20% of cases. Infiltrative HCC can be a challenging diagnosis and it is associated with the worst overall survival among HCC patients. Infiltrative HCC is characterized by the spread of multiple minute nodules throughout the liver, without a dominant one, ultimately resulting into macrovascular invasion. On CT and MRI, infiltrative HCC appears as an ill-defined, large mass, with variable degree of enhancement, and satellite neoplastic nodules in up to 52% of patients. On MRI, it may show restriction on diffusion weighted imaging, hyperintensity on T2- and hypointensity on T1-weighted images, and, if hepatobiliary agent is used, hypointensity on hepatobiliary phase. Infiltrative HCC must be differentiated from other liver diseases, such as focal confluent fibrosis, steatosis, amyloidosis, vascular disorders of the liver, cholangiocarcinoma, and diffuse metastatic disease. In cirrhotic patients, the identification of vascular tumor invasion of the portal vein and its differentiation from bland thrombosis is of utmost importance for patient management. On contrast enhanced CT and MRI, portal vein tumor thrombosis appears as an enhancing thrombus within the portal vein, close to the main tumor and results into vein enlargement. The aim of this pictorial review is to show CT and MRI features that allow the diagnosis of infiltrative HCC and portal vein tumor thrombosis. A particular point of interest includes the tips and tricks for differential diagnosis with potential mimickers of infiltrative HCC

Increased leptin/leptin receptor pathway affects systemic and airway inflammation in COPD former smokers

Background: Leptin, a hormone produced mainly by adipose tissue, regulates food intake and energy expenditure. It is involved in inflammatory diseases such as chronic obstructive pulmonary disease (COPD) and its deficiency is associated with increased susceptibility to the infection. The leptin receptor is expressed in the lung and in the neutrophils. Methods: We measured the levels of leptin, tumor necrosis factor alpha (TNF-a) and soluble form of intercellular adhesion molecule-1 (sICAM-1) in sputum and plasma from 27 smoker and former smoker patients with stable COPD using ELISA methods. Further we analyzed leptin and its receptor expression in sputum cells from 16 COPD patients using immunocytochemistry. Results: In plasma of COPD patients, leptin was inversely correlated with TNF-a and positively correlated with the patient weight, whereas the levels of sICAM-1 were positively correlated with TNF-a. In sputum of COPD patients leptin levels were correlated with forced expiratory volume in 1 second/forced vitality capacity. Additionally, increased levels of sputum leptin and TNF-a were observed in COPD former smokers rather than smokers. Further the expression of leptin receptor in sputum neutrophils was significantly higher in COPD former smokers than in smokers, and the expression of leptin and its receptor was positively correlated in neutrophils of COPD former smokers. Conclusion: Our findings suggest a role of leptin in the local and systemic inflammation of COPD and, taking into account the involvement of neutrophils in this inflammatory disease, describe a novel aspect of the leptin/leptin receptor pathway in the regulation of host defense after smoking cessation

PROTOCOLLO ECOGRAFICO DEL PAZIENTE CON SCOMPENSO CARDIACO: RISULTATI AGGIORNATI DELLO STUDIO MULTICENTRICO SIUMB ABCDE 2018-2022

Lo scompenso cardiaco è una sindrome clinica caratterizzata da specifici segni e sintomi causati da anomalie cardiache di tipo strutturale e/o funzionale. La prevalenza dello scompenso cardiaco è di circa 1-2% nella popolazione adulta dei paesi industrializzati, aumenta fin oltre il 10% oltre i 70 anni ed è la maggiore causa di ospedalizzazione oltre che di disabilità. L’approccio ecografico al paziente con scompenso cardiaco è ad oggi pratica comune, sia per la valutazione della funzionalità cardiaca, sia per il monitoraggio dello stato di volemia che per la quantificazione del liquido interstiziale. Dal 2018 è in corso uno studio multicentrico italiano (“ABCDE”) patrocinato dalla SIUMB che ha come centro promotore il reparto di Medicina Generale e Malattie Aterotrombotiche e Degenerative dell’Università di Verona. L’ approccio ecografico proposto comprende le valutazioni di: A: ABI (Ankle Brachial Index), indice caviglia-braccio; B: linee B all’ecografia polmonare; C: CIMT (Carotid Intima Media Thickness), spessore intima-media carotideo; D: Diametro dell’aorta addominale e della vena cava inferiore; E: stima ecocardiografica della frazione di eiezione ventricolare sinistra. Questa presentazione riporta i risultati aggiornati a poco più di un anno dall’avvio dello studio riportando i dati provenienti dal centro promotore (Verona) e dai centri partecipanti. Dai primi risultati dello studio "ABCDE", la metodica ecografica nel paziente con scompenso cardiaco, intesa sia come “bedside” che come approccio ecografico integrato appare essere uno strumento essenziale di valutazione cardiovascolare globale, e di accorciamento della durata della degenza nei reparti medici