- Email: [email protected]
Isolated hepatic tuberculosis: clinical presentation and diagnosis
AJG – September, Suppl., 2001
with elevated ALT and risk factor for infection, 2. with decompensated cirrhosis, 3. with normal ALT and no risk factors. Results: 110 residents participated in the survey. 61% were in Universitybased programs. Representation of residents at various levels from PGY I–IV was 32%,31%,35% and 2% respectively. 70% were planning on pursuing a career in primary care. 91% had cared for patients with HCV in the past year. 44% felt that they had not been adequately trained about HCV. 42% had not heard of the NIH consensus statement (1997) on HCV; only one had read the entire statement. 93% would screen persons with a history of iv drug use. 78% would appropriately screen if there had been a history of transfusion prior to 1990, while 21% would screen even if the transfusions were in 1994. Interestingly, 21% would not screen for HCV in patients with elevated ALT. 98% would recommend minimizing or stopping alcohol intake. Only 30% correctly identified licensed therapies and only 58% were aware of their limited efficacy. For patients with HCV, 93% and 69% would offer vaccination against HBV and HAV respectively. 52% would test patient 1 for HCV RNA by PCR, while only 15% would test for HCV genotype. 79% would appropriately consider patient 1 for treatment. Although 68% would refer patient 2 for liver transplantation, 25% would refer this patient for interferon therapy even in the setting of decompensated cirrhosis. Only 46% would perform RIBA on a patient with possible false positive HCV antibody test (patient 3) to confirm infection. Conclusions: Many IM residents do not screen for HCV when indicated and are unaware of the indications, contraindications and efficacy of currently licensed therapies. Few are aware of the existing guidelines. There is a considerable lack of knowledge in choosing the appropriate diagnostic tests and the feasibility of liver transplantation. Educational efforts should aim to improve knowledge of screening recommendations and treatment options for HCV among residents in IM and other primary care specialties.
398 Severe pulmonary toxicity of interferon (IFN) and ribavirin (RIBA) therapy in chronic hepatitis C K. Shiva Kumar MD1, Mark W Russo MD1, Stephen Esposito MD1, Alain Borczuk MD1, Ira Jacobson MD 1, Melissa Brown1 and Robert S Brown Jr MD1*. 1Center for Liver Disease & Transplantation, New York-Presbyterian Hospital, New York, NY, United States. Purpose: Side effects are common with IFN therapy in hepatitis C, though few are life threatening. Reported pulmonary complications include interstitial pneumonitis (IP) and sarcoidosis. One case of bronchiolitis obliterans organizing pneumonia (BOOP) has been reported. We report 4 cases of significant pulmonary toxicity with IFN and RIBA. Results: Case 1: A 41-year-old female received IFN a-2b 3 MU TIW and RIBA. Physical exam at 29 weeks revealed cervical adenopathy. CT scan showed an irregular subpleural density in left lower lobe. Open lung biopsy of the mass revealed BOOP. As the patient was asymptomatic, no therapy was given and the findings resolved with drug discontinuation. Case 2: A 48-year-old female received IFN a-2b 3 MU TIW and RIBA. After 24 weeks she developed fever and cough. PFT revealed a restrictive defect. Symptoms improved with stopping drugs. 6 months later she was enrolled in a trial of pegylated (PEG) IFN a-2a with RIBA and amantidine. Fever and cough recurred and therapy was stopped. CT revealed ground glass opacities in upper lung fields. Bronchoscopy with BAL was consistent with IP. Marked improvement was noted with steroid therapy and repeat CT showed complete resolution. Case 3: A 50-year-old female received IFN a-2b 5 MU daily and RIBA. She developed a severe cough and therapy was discontinued at week 24. CT showed bilateral interstitial opacities. Thoracoscopy with biopsy from the right lower lobe revealed BOOP. No treatment was given and symptoms improved upon stopping therapy. At last follow-up, the patient remains asymptomatic with resolution of radiographic findings. Case 4: A 50-year-old male received IFN a-2b 5 MU daily and RIBA. He developed cough and dyspnea after 3 weeks and treatment was discontinued. PFT revealed a restrictive defect. CT showed extensive sub-pleural
Abstracts
S127
interstitial disease. Transbronchial biopsy was consistent with IP. After stopping therapy, marked improvement was noted with prednisone. 17 months later, the patient continued to have mild exertional dyspnea on Prednisone 15 mg qd. Conclusions: These cases illustrate serious pulmonary toxicity with combination therapy of IFN or PEG-IFN and RIBA. This is the first report of pulmonary toxicity with PEG-IFN. BOOP has been reported once with IFN and pulmonary toxicity of IFN and RIBA has not been reported except worsening of pulmonary sarcoidosis. Cough and dyspnea are common with RIBA and may make detection of IFN-related lung disease less likely. Most toxicity resolved with discontinuation of drugs, although one patient requires prednisone more than a year later. 399 Impact of a patient group education model on hepatitis C knowledge Stanley W. Lee, M.D., Jennifer K. Brennan, M.D., Anne Croghan, A.R.N.P., and Jason A. Dominitz, M.D. VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA. Purpose: to determine the effect of a patient group education class on knowledge about HCV. Methods: Eligible subjects were veterans with hepatitis C who attended a VA hospital-based hepatitis C education class. Subjects were divided according to whether they reported prior HCV education from a gastroenterologist (GI), a primary care provider (Primary Care), or other (Other). Each subject was given a self-administered, anonymous pre-test which included 41 true and false statements about HCV. Subjects responded to each statement by checking “yes”, “no”, or “don’t know”. Subjects then participated in an hour-long class after which they took a post-test consisting of the same questions as the pre-test. Baseline scores and improvement in test scores were compared for each group. Results: A total of 275 questionnaires were collected. Incomplete questionnaires were discarded (n ⫽ 34). Change in HCV knowledge was measured in subjects that completed both the pre- and post-tests. The table shows median number of correct responses according to prior education source. All groups showed significant improvement in their scores after attending the class (p ⬍ 0.0001). GI patients scored significantly higher on the pre-test compared to the other two groups using the Kruskal-Wallis test (p ⬍ 0.05). However, post-test scores were not significantly different among the three groups. Subjects had significant improvement in many areas, including modes of transmission, natural history, and treatment options. Prior Education (n) GI (36) Primary Care (106) Other (86)
Pre-test
Post-test
Change
28 21 17.5
38 36.5 37
9 14.5 17
Conclusions: Our patient group education class was an effective method in educating patients with HCV about their disease. All groups showed a benefit in attending the education class, even subjects that had previously seen a gastroenterologist. There was no significant difference in knowledge among the groups after attending the class. 400 Isolated hepatic tuberculosis: clinical presentation and diagnosis Jianjun Li MD, Abdolreza Abbassi MD, Carmela Monteiro MD and Louis Lambiase MD*. 1GI Division, Department of Medicine, University of Florida, Health Science Center, Jacksonville, FL, United States. Purpose: Findings of isolated hepatic tuberculosis are quite rare, particularly in the United State. From 1950 to 1990, only 23 cases of this form were reported in the worldwide literature. We report two rare cases of isolated hepatic tuberculosis; in order to emphasize the importance of
S128
Abstracts
obtaining a tissue diagnosis in all infected subjects with suspicious liver lesions to avoid missing this uncommon but curable entity. Methods: We reviewed all liver biopsies done in the last decade in our hospital. Two rare cases of hepatic tuberculosis were identified and are reported as followings: Results: The first case is 41 year-old black male who presented with fever, chills, malaise and diarrhea for 2 months. He was admitted and worked up for fever of unknown origin (FUO) in May 1997. He had a slightly enlarged liver and elevation of ALT and AKP. Other lab results including HIV, repeated blood culture and serum AFB were negative. Chest X- ray and CT were both negative. PPD with anergy panel was all negative. Multiple sputum collections were negative for AFB. He developed hypoxia and had a bronchoscopy which was unremarkable. A BAL was negative for AFB. Meantime, a bone marrow biopsy and liver biopsy were obtained. The bone marrow was negative for AFB, while the liver biopsy showed granulamatous hepatitis with noncaseating granulomas and AFB staining positive. He received INH, Rifampin and Pyrazinamide and Ethambutaol with the resolution of his early DIC and multiple organ failure. The second case is an 83 year-old black male who was admitted in March 2000 for the evaluation of FUO and 401b weight loss. The patient’s chest CT, bone marrow biopsy with culture, serum HIV, blood culture, sputum and skin AFB all were negative. ALT and AST were elevated. Liver biopsy showed multiple granulamatous lesions and AFB stain was positive. The patient expired from multiple organ failure one week after starting on the anti-TB medication. Conclusions: Local hepatic tuberculosis without active pulmonary or miliary tuberculosis is an uncommon diagnosis. It is rarely documented in the English literature. Since there is no consistent clinical pattern in patients with hepatic tuberculosis, the diagnosis should be considered in those patients with unexplained fever associated with hepatomegaly or persistent elevated LFTs. These two cases illustrate the importance of obtaining a liver biopsy, because it is the most valuable method to confirm the diagnosis of hepatic tuberculosis and avoid missing the uncommon but curable hepatic tuberculosis.
401 Transcatheter chemoembolization for hepatocellular carcinoma: predictive factors of poor survival outcome Shilun D Li1, Wayne Lue1, Marc Borge2, Ellen Yetter2, Nikunj Shah1 and David H Van Thiel1. 1Gastroenterology and Hepatology, Loyola University Medical Center, Maywood, Illinois, United States; and 2 Radiology, Loyola University Medical Center, Maywood, Illinois, United States. Purpose: Hepatocellular carcinoma (HCC) has been treated by chemoembolization with variable results. The reported outcomes have measured survival in weeks to months. A retrospective analysis of the experience at Loyola University Medical Center was performed to identify factors that distinguish patients who did not benefit from this therapy. Methods: A retrospective chart review of 24 patients, who were treated with transcatheter chemoembolization consisting of 100mg cisplatin and 15 ml ethiodol with gelfoam pledgets embolizing agent between 1/97 and 11/99, was performed. All patients have histological diagnosis of cirrhosis, except for one who developed HCC from chronic hepatitis B. Factors assessed as part of the review consisted of histology of the tumor, tumor size and location, liver volume, background liver disease, wbc count, platelet count, total lymphocyte count, prothrombin time, total bilirubin, alkaline phosphatate, alpha-fetoprotein, albumin, and creatinine were collected prior to each session of chemoembolization. Patients were systematically receiving up to a total of 4 sessions of chemoembolization (one month apart) of the largest tumor in the liver. The patients were divided into 2 groups: one with a survival less than 2 weeks (Group A) and a second with a survival greater than 4 weeks (Group B). Results: Of the 24 patients records reviewed, 5 died within 2 weeks of chemoembolization, 5 died between 4 weeks to 10 months post-chemoembolization, 6 patients were transferred to other medical facilities, and 8
AJG – Vol. 96, No. 9, Suppl., 2001
survived during the study period. The only 3 factors that segregated these 2 groups were the initial serum total bilirubin prior to the chemoembolization 18.8 ⫹/⫺ 12.2 (Group A) vs. 1.8 ⫹/⫺ 0.9 (Group B), p ⫽ 0.03; initial total lymphocyte count 533 ⫹/⫺ 208 (Group A) vs. 1463 ⫹/⫺ 759 (Group B), p ⫽ 0.002; initial serum albumin 2.64 ⫹/⫺ 0.29 (Group A) vs. 3.06 ⫹/⫺ 0.48, p ⫽ 0.03. Conclusions: Patients with all three factors of low serum albumin levels, low total lymphocyte counts, and high total bilirubin levels have a statistically significant increased risk of death soon following transcatheter chemoembolization of cisplatin for HCC. This group of patients has the characteristics of advanced liver failure and malnutrition. Factors such as the number, size, and histology of the tumor do not increase the risk of death soon after transcatheter chemoembolization. Patients who have very advanced liver disease and HCC should not receive this mode of therapy.
402 Successful treatment of giant cell hepatitis with Rebetron (interferon/ribavirin) Julia J. Liu, James Piper and Francis A. Farraye, FACG*. 1 Gastroenterology, Brigham and Women’s Hospital, Boston, MA, United States; 2Gastroenterology, Harvard Vanguard Medical Associates, Boston, MA, United States; and 3Gastroenterology, Boston Medical Center, Boston, MA, United States. Purpose: Giant cell hepatitis (GCH) is a rare form of hepatitis with a poor prognosis. Drug toxicity, autoimmune disorders and viral infection with paramyxovirus have been implicated as possible etiologies. We report a case of GCH successfully treated with Rebetron. Methods: Case report. Results: A 49-year-old male was found to have abnormal liver enzyme tests on a routine physical in 1993. His past medical history was significant for a self-limited episode of Guillian Barre syndrome, cholecystectomy in 1987 and vasectomy in 1989. He denied intravenous drug use or tattoo placement and never had a blood transfusion. There was no family history of liver disease. The patient rarely drank alcohol. He traveled to India in the 1980’s. His physical examination was entirely normal. Serologies for Hepatitis A, B, EBV and CMV were negative. Hepatitis C antibody by first generation testing was positive but HCV RIBA was negative as was HCV RNA on repeated testing. Laboratory investigation revealed AST 161, ALT 344, bilirubin 0.7. Iron, TIBC, ceruloplasmin, alpha-1 antitrypsin level, anti liver-kidney-muscle antibody, RF, ANA, and anti-smooth muscle antibody were negative. The patient underwent a liver biopsy in 1994, which revealed moderate inflammatory infiltrate with a multinucleated syncytial hepatocytes and ground glass appearing cytoplasm, without evidence of fibrosis. The patients LFTS remained elevated at greater than 5 times normal over the ensuing three years. A repeat liver biopsy done in 1997 showed mild fibrosis. Stains for HSV I, HSV II, EBV, CMV were negative. EM performed on the biopsy specimen revealed multinucleated syncytial hepatocytes with vesicular transformation of endoplasmic reticulum; no viral particles or cytopathic changes were identified. A 2 month course of steroids did not lead to any decrease in the LFTS. After extensive discussion with patient, interferon/ribavirin therapy was initiated. The patient was treated for one year. His enzymes fell to normal limits during treatment. Repeat liver biopsy at the culmination of therapy showed scattered multinucleated giant cells, but less inflammatory infiltrate and stable fibrosis. He did develop immune mediated arthritis, which improved on prednisone. His LFTS remained normal at one year follow up. Conclusions: GCH is an uncommon and often rapidly progressive liver disorder that has been postulated to be related to a paramyxoviral infection. There are several case reports in the literature of effective treatment of GCH with ribavirin. We report a case of successful treatment with Rebetron in an adult patient with GCH supporting the hypothesis that GCH is related to a viral infection.
with elevated ALT and risk factor for infection, 2. with decompensated cirrhosis, 3. with normal ALT and no risk factors. Results: 110 residents participated in the survey. 61% were in Universitybased programs. Representation of residents at various levels from PGY I–IV was 32%,31%,35% and 2% respectively. 70% were planning on pursuing a career in primary care. 91% had cared for patients with HCV in the past year. 44% felt that they had not been adequately trained about HCV. 42% had not heard of the NIH consensus statement (1997) on HCV; only one had read the entire statement. 93% would screen persons with a history of iv drug use. 78% would appropriately screen if there had been a history of transfusion prior to 1990, while 21% would screen even if the transfusions were in 1994. Interestingly, 21% would not screen for HCV in patients with elevated ALT. 98% would recommend minimizing or stopping alcohol intake. Only 30% correctly identified licensed therapies and only 58% were aware of their limited efficacy. For patients with HCV, 93% and 69% would offer vaccination against HBV and HAV respectively. 52% would test patient 1 for HCV RNA by PCR, while only 15% would test for HCV genotype. 79% would appropriately consider patient 1 for treatment. Although 68% would refer patient 2 for liver transplantation, 25% would refer this patient for interferon therapy even in the setting of decompensated cirrhosis. Only 46% would perform RIBA on a patient with possible false positive HCV antibody test (patient 3) to confirm infection. Conclusions: Many IM residents do not screen for HCV when indicated and are unaware of the indications, contraindications and efficacy of currently licensed therapies. Few are aware of the existing guidelines. There is a considerable lack of knowledge in choosing the appropriate diagnostic tests and the feasibility of liver transplantation. Educational efforts should aim to improve knowledge of screening recommendations and treatment options for HCV among residents in IM and other primary care specialties.
398 Severe pulmonary toxicity of interferon (IFN) and ribavirin (RIBA) therapy in chronic hepatitis C K. Shiva Kumar MD1, Mark W Russo MD1, Stephen Esposito MD1, Alain Borczuk MD1, Ira Jacobson MD 1, Melissa Brown1 and Robert S Brown Jr MD1*. 1Center for Liver Disease & Transplantation, New York-Presbyterian Hospital, New York, NY, United States. Purpose: Side effects are common with IFN therapy in hepatitis C, though few are life threatening. Reported pulmonary complications include interstitial pneumonitis (IP) and sarcoidosis. One case of bronchiolitis obliterans organizing pneumonia (BOOP) has been reported. We report 4 cases of significant pulmonary toxicity with IFN and RIBA. Results: Case 1: A 41-year-old female received IFN a-2b 3 MU TIW and RIBA. Physical exam at 29 weeks revealed cervical adenopathy. CT scan showed an irregular subpleural density in left lower lobe. Open lung biopsy of the mass revealed BOOP. As the patient was asymptomatic, no therapy was given and the findings resolved with drug discontinuation. Case 2: A 48-year-old female received IFN a-2b 3 MU TIW and RIBA. After 24 weeks she developed fever and cough. PFT revealed a restrictive defect. Symptoms improved with stopping drugs. 6 months later she was enrolled in a trial of pegylated (PEG) IFN a-2a with RIBA and amantidine. Fever and cough recurred and therapy was stopped. CT revealed ground glass opacities in upper lung fields. Bronchoscopy with BAL was consistent with IP. Marked improvement was noted with steroid therapy and repeat CT showed complete resolution. Case 3: A 50-year-old female received IFN a-2b 5 MU daily and RIBA. She developed a severe cough and therapy was discontinued at week 24. CT showed bilateral interstitial opacities. Thoracoscopy with biopsy from the right lower lobe revealed BOOP. No treatment was given and symptoms improved upon stopping therapy. At last follow-up, the patient remains asymptomatic with resolution of radiographic findings. Case 4: A 50-year-old male received IFN a-2b 5 MU daily and RIBA. He developed cough and dyspnea after 3 weeks and treatment was discontinued. PFT revealed a restrictive defect. CT showed extensive sub-pleural
Abstracts
S127
interstitial disease. Transbronchial biopsy was consistent with IP. After stopping therapy, marked improvement was noted with prednisone. 17 months later, the patient continued to have mild exertional dyspnea on Prednisone 15 mg qd. Conclusions: These cases illustrate serious pulmonary toxicity with combination therapy of IFN or PEG-IFN and RIBA. This is the first report of pulmonary toxicity with PEG-IFN. BOOP has been reported once with IFN and pulmonary toxicity of IFN and RIBA has not been reported except worsening of pulmonary sarcoidosis. Cough and dyspnea are common with RIBA and may make detection of IFN-related lung disease less likely. Most toxicity resolved with discontinuation of drugs, although one patient requires prednisone more than a year later. 399 Impact of a patient group education model on hepatitis C knowledge Stanley W. Lee, M.D., Jennifer K. Brennan, M.D., Anne Croghan, A.R.N.P., and Jason A. Dominitz, M.D. VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA. Purpose: to determine the effect of a patient group education class on knowledge about HCV. Methods: Eligible subjects were veterans with hepatitis C who attended a VA hospital-based hepatitis C education class. Subjects were divided according to whether they reported prior HCV education from a gastroenterologist (GI), a primary care provider (Primary Care), or other (Other). Each subject was given a self-administered, anonymous pre-test which included 41 true and false statements about HCV. Subjects responded to each statement by checking “yes”, “no”, or “don’t know”. Subjects then participated in an hour-long class after which they took a post-test consisting of the same questions as the pre-test. Baseline scores and improvement in test scores were compared for each group. Results: A total of 275 questionnaires were collected. Incomplete questionnaires were discarded (n ⫽ 34). Change in HCV knowledge was measured in subjects that completed both the pre- and post-tests. The table shows median number of correct responses according to prior education source. All groups showed significant improvement in their scores after attending the class (p ⬍ 0.0001). GI patients scored significantly higher on the pre-test compared to the other two groups using the Kruskal-Wallis test (p ⬍ 0.05). However, post-test scores were not significantly different among the three groups. Subjects had significant improvement in many areas, including modes of transmission, natural history, and treatment options. Prior Education (n) GI (36) Primary Care (106) Other (86)
Pre-test
Post-test
Change
28 21 17.5
38 36.5 37
9 14.5 17
Conclusions: Our patient group education class was an effective method in educating patients with HCV about their disease. All groups showed a benefit in attending the education class, even subjects that had previously seen a gastroenterologist. There was no significant difference in knowledge among the groups after attending the class. 400 Isolated hepatic tuberculosis: clinical presentation and diagnosis Jianjun Li MD, Abdolreza Abbassi MD, Carmela Monteiro MD and Louis Lambiase MD*. 1GI Division, Department of Medicine, University of Florida, Health Science Center, Jacksonville, FL, United States. Purpose: Findings of isolated hepatic tuberculosis are quite rare, particularly in the United State. From 1950 to 1990, only 23 cases of this form were reported in the worldwide literature. We report two rare cases of isolated hepatic tuberculosis; in order to emphasize the importance of
S128
Abstracts
obtaining a tissue diagnosis in all infected subjects with suspicious liver lesions to avoid missing this uncommon but curable entity. Methods: We reviewed all liver biopsies done in the last decade in our hospital. Two rare cases of hepatic tuberculosis were identified and are reported as followings: Results: The first case is 41 year-old black male who presented with fever, chills, malaise and diarrhea for 2 months. He was admitted and worked up for fever of unknown origin (FUO) in May 1997. He had a slightly enlarged liver and elevation of ALT and AKP. Other lab results including HIV, repeated blood culture and serum AFB were negative. Chest X- ray and CT were both negative. PPD with anergy panel was all negative. Multiple sputum collections were negative for AFB. He developed hypoxia and had a bronchoscopy which was unremarkable. A BAL was negative for AFB. Meantime, a bone marrow biopsy and liver biopsy were obtained. The bone marrow was negative for AFB, while the liver biopsy showed granulamatous hepatitis with noncaseating granulomas and AFB staining positive. He received INH, Rifampin and Pyrazinamide and Ethambutaol with the resolution of his early DIC and multiple organ failure. The second case is an 83 year-old black male who was admitted in March 2000 for the evaluation of FUO and 401b weight loss. The patient’s chest CT, bone marrow biopsy with culture, serum HIV, blood culture, sputum and skin AFB all were negative. ALT and AST were elevated. Liver biopsy showed multiple granulamatous lesions and AFB stain was positive. The patient expired from multiple organ failure one week after starting on the anti-TB medication. Conclusions: Local hepatic tuberculosis without active pulmonary or miliary tuberculosis is an uncommon diagnosis. It is rarely documented in the English literature. Since there is no consistent clinical pattern in patients with hepatic tuberculosis, the diagnosis should be considered in those patients with unexplained fever associated with hepatomegaly or persistent elevated LFTs. These two cases illustrate the importance of obtaining a liver biopsy, because it is the most valuable method to confirm the diagnosis of hepatic tuberculosis and avoid missing the uncommon but curable hepatic tuberculosis.
401 Transcatheter chemoembolization for hepatocellular carcinoma: predictive factors of poor survival outcome Shilun D Li1, Wayne Lue1, Marc Borge2, Ellen Yetter2, Nikunj Shah1 and David H Van Thiel1. 1Gastroenterology and Hepatology, Loyola University Medical Center, Maywood, Illinois, United States; and 2 Radiology, Loyola University Medical Center, Maywood, Illinois, United States. Purpose: Hepatocellular carcinoma (HCC) has been treated by chemoembolization with variable results. The reported outcomes have measured survival in weeks to months. A retrospective analysis of the experience at Loyola University Medical Center was performed to identify factors that distinguish patients who did not benefit from this therapy. Methods: A retrospective chart review of 24 patients, who were treated with transcatheter chemoembolization consisting of 100mg cisplatin and 15 ml ethiodol with gelfoam pledgets embolizing agent between 1/97 and 11/99, was performed. All patients have histological diagnosis of cirrhosis, except for one who developed HCC from chronic hepatitis B. Factors assessed as part of the review consisted of histology of the tumor, tumor size and location, liver volume, background liver disease, wbc count, platelet count, total lymphocyte count, prothrombin time, total bilirubin, alkaline phosphatate, alpha-fetoprotein, albumin, and creatinine were collected prior to each session of chemoembolization. Patients were systematically receiving up to a total of 4 sessions of chemoembolization (one month apart) of the largest tumor in the liver. The patients were divided into 2 groups: one with a survival less than 2 weeks (Group A) and a second with a survival greater than 4 weeks (Group B). Results: Of the 24 patients records reviewed, 5 died within 2 weeks of chemoembolization, 5 died between 4 weeks to 10 months post-chemoembolization, 6 patients were transferred to other medical facilities, and 8
AJG – Vol. 96, No. 9, Suppl., 2001
survived during the study period. The only 3 factors that segregated these 2 groups were the initial serum total bilirubin prior to the chemoembolization 18.8 ⫹/⫺ 12.2 (Group A) vs. 1.8 ⫹/⫺ 0.9 (Group B), p ⫽ 0.03; initial total lymphocyte count 533 ⫹/⫺ 208 (Group A) vs. 1463 ⫹/⫺ 759 (Group B), p ⫽ 0.002; initial serum albumin 2.64 ⫹/⫺ 0.29 (Group A) vs. 3.06 ⫹/⫺ 0.48, p ⫽ 0.03. Conclusions: Patients with all three factors of low serum albumin levels, low total lymphocyte counts, and high total bilirubin levels have a statistically significant increased risk of death soon following transcatheter chemoembolization of cisplatin for HCC. This group of patients has the characteristics of advanced liver failure and malnutrition. Factors such as the number, size, and histology of the tumor do not increase the risk of death soon after transcatheter chemoembolization. Patients who have very advanced liver disease and HCC should not receive this mode of therapy.
402 Successful treatment of giant cell hepatitis with Rebetron (interferon/ribavirin) Julia J. Liu, James Piper and Francis A. Farraye, FACG*. 1 Gastroenterology, Brigham and Women’s Hospital, Boston, MA, United States; 2Gastroenterology, Harvard Vanguard Medical Associates, Boston, MA, United States; and 3Gastroenterology, Boston Medical Center, Boston, MA, United States. Purpose: Giant cell hepatitis (GCH) is a rare form of hepatitis with a poor prognosis. Drug toxicity, autoimmune disorders and viral infection with paramyxovirus have been implicated as possible etiologies. We report a case of GCH successfully treated with Rebetron. Methods: Case report. Results: A 49-year-old male was found to have abnormal liver enzyme tests on a routine physical in 1993. His past medical history was significant for a self-limited episode of Guillian Barre syndrome, cholecystectomy in 1987 and vasectomy in 1989. He denied intravenous drug use or tattoo placement and never had a blood transfusion. There was no family history of liver disease. The patient rarely drank alcohol. He traveled to India in the 1980’s. His physical examination was entirely normal. Serologies for Hepatitis A, B, EBV and CMV were negative. Hepatitis C antibody by first generation testing was positive but HCV RIBA was negative as was HCV RNA on repeated testing. Laboratory investigation revealed AST 161, ALT 344, bilirubin 0.7. Iron, TIBC, ceruloplasmin, alpha-1 antitrypsin level, anti liver-kidney-muscle antibody, RF, ANA, and anti-smooth muscle antibody were negative. The patient underwent a liver biopsy in 1994, which revealed moderate inflammatory infiltrate with a multinucleated syncytial hepatocytes and ground glass appearing cytoplasm, without evidence of fibrosis. The patients LFTS remained elevated at greater than 5 times normal over the ensuing three years. A repeat liver biopsy done in 1997 showed mild fibrosis. Stains for HSV I, HSV II, EBV, CMV were negative. EM performed on the biopsy specimen revealed multinucleated syncytial hepatocytes with vesicular transformation of endoplasmic reticulum; no viral particles or cytopathic changes were identified. A 2 month course of steroids did not lead to any decrease in the LFTS. After extensive discussion with patient, interferon/ribavirin therapy was initiated. The patient was treated for one year. His enzymes fell to normal limits during treatment. Repeat liver biopsy at the culmination of therapy showed scattered multinucleated giant cells, but less inflammatory infiltrate and stable fibrosis. He did develop immune mediated arthritis, which improved on prednisone. His LFTS remained normal at one year follow up. Conclusions: GCH is an uncommon and often rapidly progressive liver disorder that has been postulated to be related to a paramyxoviral infection. There are several case reports in the literature of effective treatment of GCH with ribavirin. We report a case of successful treatment with Rebetron in an adult patient with GCH supporting the hypothesis that GCH is related to a viral infection.