ca 19-9 is not a reliable test in patients with advanced cirrhosis and portosystemic shunt a. ochs,...

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HEPATOLOGY Vo]. 22, No. 4, Pt. 2, 1995 AASLD ABSTRACTS 467A 1441 CA 19-9 is not a reliable test in patients with advanced cirrhosis and portosystemic shunt. A. Ocns, K. HAAG, M. ROSSLE, H. E. BLUM. University Schoolof Medicine, Freiburg,Germany Aim: The concentration of CA 19-9, a sensitive serum marker for cholangio and pancreatic carcinoma may be influenced by severe liver disease due to impaired hepatic clearance or hepatic overexpression (Gut, 1994, 35: 707-708). Data on a greater number of patients are, however, lacking. Therefore, we determined the CA 19-9 concentrations in unselected patients with alcoholic (n=76), postnecrotic (n--9) and miscellaneous chronic liver diseases (n=15) who were previously treated with TIPS for variceal bleeding. The mean age was 56 :t: 12, 64% were male, Child Pugh's score 6.2 :t: 1.2. Routine liver tests, AFP, conventional and duplex sunography, physical examination were performed in 3 month intervals, and radiological or endoscopic procedures when indicated. Results: During follow-up, 5 rumors were detected: 2 hepetoeellular carcinomas (HCC), 1 cholangio-earcinoma (CC), one synchronous breast and ovarian carcinoma, one early gastric carcinoma. In one patient CC is likely, but diagnostic work-up is not completed. In 72 patients without cancer, CA 19-9 was elevated (normal range 0-20 kU/l). In 46 patients the CA 19-9 concentrations exeeded 50 and in 14 patients 100 kUfl. Patients with HCC and CC had CA 19-9 concentration between 60 and 108 kU/1. The concentration of CA 19-9 was correlated with serum bilirubin (p=0.015) and AFP (p<0.001) and inversely correlated with cholinesterase (p=0.017)(Spearman correlation). Conclusion:. Hepatocellular fimction and portosystemic shunting affect the plasma concentration of CA 19-9. Therefore, the use of CA 19- 9 as a tumor marker is limited in cirrhotic patients and may rather reflect hepatocellular function. 1442 Does TIPS induce mechanical hemolysis? A OCHS,K HAAG, I-[ E BLUM,M ROSSLE.University School of Medicine, Freiburg Germany. Aim: Severe hemolysis after TIPS is a rare complication which has been described previously. However, comparable to the situation after heart valve prosthesis, fragmentation of blood cells not resulting in clinical symptomes may be more frequent. It may be due to the turbulent blood flow through the metullic mesh protruding into the lumen of the portal and hepatic veins. To further investigate the incidence of hemolysis, we compared the concentrations of haptoglobin, bilirubin and thrombocytes of 84 patients with patent TIPS (age 56 ± 12, 64% male, 76 patients with alcoholic cirrhosis) with sixteen patients with occluded (n=8) or without TIPS (control group). Patency of the TIPS and intrahepatic portal perfusion was evaluated by duplex-sonography. Results: The shunt flow was 1734 ± 424 ml/min (mean + SD). In these patients the haptoglobin concentration was 32 ± 58 mg/100ml as compared to 69 ~: 51 mg/100ml in the control group (p=0.02), no difference was detected for platelet count. The haptoglobin concentration was correlated with the concentration of cholinesterase (p=0.007), intrahepatic portal flow (p<0.001) and thrombocyte count (p<0.001) and inversely correlated with shunt flow (p<0.001) and bilirubin concentration (p<0.001) (Spearman rank correlation). In 44 of 84 patients with patent TIPS but in none of the control group, haptoglobin was not detectable at all (p<0.001). Overt hemolytic anemia was not seen. Conclusion:. TIPS-induced hemolysis seems to be common but does not result in anemia. A higher platelet count may be protective by activation of neointima formation and reduction of turbulences. Low haptoglobin concentrations may reflect high shunt flow and poor intrahepatic portal perfusion. The clinical significance of TIPS-induced hemolysis regarding other diseases, e.g. gallstones, must be subjected to further studies. 1443 HEPATITIS C AND HEPATITIS B IN HIV INFECTED PATIENTS: PREVALENCE AND OUTCOME J Ocken~a 1 . IIL Tillmann 2_ S Herin~lake2. C Trantwein 2. M Stoll1. I Sehedel 1 MP Mann~2,. RE Schmidtl. 1Dept. Clinical Immunology, 2Dept. Gastroenterology& Hepatology, Medical School, Hannover, Germany Only limited information is available about the prevalence and clinical outcome of patients with coinfecfionof Hepatitis C (HCV), Hepatitis B (HBV) and Human immanodeficiency vims (HIV). Therefore this prospective study was set up to adress this question. Methods: I-IBVand HIV were diagnosed serological, while HCV infection was diagnosed serological and by PCR. 228 men and 52 women with proven HIV- infection were investigatedbetween January 1993 and December 1994 and followed up for survival (mean 625±19 days). In addition we compared the survival time since first AIDS defing event in those patients already with AIDS at the time of investigationor developing AIDS during follow up (N=62). Results: 65 of 280 patients (23%) were HCV positive and 24 of 280 patients (9%) were HBV positive, double infection with HCV and HBV occurred in 4 ( 1,5%) patients. Sources of HIV infection are shown in the table below. Homosexual Heterosexual Dmg addicts I Hemophiliacs* m f m f m f [ m f total 156 0 18 18 42 33 [ 12 1 HBvHCV 186 2 3 1 2 4 ~32IV I 1!'v anti-HBc § 73 6 6 30~' 17 'v HCV/HBV 2 1 m: male, f: female;~HBsAg neg.; "~ p< 0.05 vers homo- and heterosexuell, No significant difference in survival since evaluation of hepatitis serology and survival time since first diagnosis of AIDS in patients with HCV, HBV (HBsAG pos), and without viral hepatitis (698:1=30,586a:61, 609±20 days, and 1193±186, 1172±291,929-a:112,res.) could be observed. Condusioas: HCV and HBV infections are much more common among HIV positive patients compared to normal controls. Infection with all three viruses are rare according to the different routes of preferential transmission. The coinfeotion of HCV or HBV does not appear to influence survival of H1V infected patients. Further prospective studies are neccessary to evaluate those patients in which taxatmentof the viral hepatitis is beneficial. 1444 Clinical Features of Symptomatic non-B non-C non-Alcoholic Chronic Liver Disease in Japan. M Ohaua, K Hajiro~ and H Takakuwa. Department of Gastroenterology, Tenri Hospital, Nara, Japan. Objective:To clarify the clinical features of symptomatic chronic non-B non-C non-alcoholic liver disease (NBNCNALD) which has become important clinically since the introduction of hepatitis C (HCV) antibody testing. Methods: Three hundred and thirty-eight patients hospitalized for clinical manifestations associated with chronic liver disease were tested by hepatitis B surface antigen (HBsAg) by reversed passive hemagglutination (RPHA) and the second generation hepatitis C antibody by passive hemagglutination (PHA). The etiologies were classified into four groups; those with hepatitis B, hepatitis C, non-B non-C liver disease and others. Each group was divided into drinker, and non-drinker. NBNCNALD was evaluated clinically and compared with other close etiologies. Results: Twenty-two patients (6.5%, 15 men and 7 women) were diagnosed as having NBNCNALD. Their clinical manifestations and severity of liver disease such as the occurrences of hepatic encephalopathy, gastroesophageal varix, ascites, hypoalbuminemia and thrombocytopenia were similar to those of other etiologies. The average age was higher than hepatitis B (p<O.001), alcoholic (p<O.05), primary biliary cirrhosis (PBC, p<0,05), autoimmune hepatitis (AIH, p<O.05) and hepatitis C. None of them had a history of blood transfusion before the onset. Development of hepatoma was seen in 40.9%, being significant rare compared with hepatitis B (p<0.01) and hepatitis C (p<O.005). No significant difference of the survival rate was shown between NBNCNALD and other etiologies. Disappearance of HBsAg was seen in two patients during the follow-up period, suggesting some of "NBNCNALD" might have been hepatitis B, from frequent appearances of HBsAh (36.4%). Conclusions: Chronic NBNCNALD appeared to be a unique clinical entity in the elderly unrelated to blood transfusion, and resembled other types of viral hepatitis in mortality.

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Page 1: CA 19-9 is not a reliable test in patients with advanced cirrhosis and portosystemic shunt A. Ochs, K. Haag, M. R�ssle, H. E. Blum. University School of Medicine, Freiburg, Germany

HEPATOLOGY Vo]. 22, No. 4, Pt . 2, 1995 A A S L D A B S T R A C T S 4 6 7 A

1 4 4 1 CA 19-9 is not a reliable test in patients with advanced cirrhosis and portosystemic shunt. A. Ocns, K. HAAG, M. ROSSLE, H. E. BLUM. University School of Medicine, Freiburg, Germany Aim: The concentration of CA 19-9, a sensitive serum marker for cholangio and pancreatic carcinoma may be influenced by severe liver disease due to impaired hepatic clearance or hepatic overexpression (Gut, 1994, 35: 707-708). Data on a greater number of patients are, however, lacking. Therefore, we determined the CA 19-9 concentrations in unselected patients with alcoholic (n=76), postnecrotic (n--9) and miscellaneous chronic liver diseases (n=15) who were previously treated with TIPS for variceal bleeding. The mean age was 56 :t: 12, 64% were male, Child Pugh's score 6.2 :t: 1.2. Routine liver tests, AFP, conventional and duplex sunography, physical examination were performed in 3 month intervals, and radiological or endoscopic procedures when indicated. Results: During follow-up, 5 rumors were detected: 2 hepetoeellular carcinomas (HCC), 1 cholangio-earcinoma (CC), one synchronous breast and ovarian carcinoma, one early gastric carcinoma. In one patient CC is likely, but diagnostic work-up is not completed. In 72 patients without cancer, CA 19-9 was elevated (normal range 0-20 kU/l). In 46 patients the CA 19-9 concentrations exeeded 50 and in 14 patients 100 kUfl. Patients with HCC and CC had CA 19-9 concentration between 60 and 108 kU/1. The concentration of CA 19-9 was correlated with serum bilirubin (p=0.015) and AFP (p<0.001) and inversely correlated with cholinesterase (p=0.017)(Spearman correlation). Conclusion: . Hepatocellular fimction and portosystemic shunting affect the plasma concentration of CA 19-9. Therefore, the use of CA 19- 9 as a tumor marker is limited in cirrhotic patients and may rather reflect hepatocellular function.

1 4 4 2 Does TIPS induce mechanical hemolysis? A OCHS, K HAAG, I-[ E BLUM, M ROSSLE. University School of Medicine, Freiburg Germany. Aim: Severe hemolysis after TIPS is a rare complication which has been described previously. However, comparable to the situation after heart valve prosthesis, fragmentation of blood cells not resulting in clinical symptomes may be more frequent. It may be due to the turbulent blood flow through the metullic mesh protruding into the lumen of the portal and hepatic veins. To further investigate the incidence of hemolysis, we compared the concentrations of haptoglobin, bilirubin and thrombocytes of 84 patients with patent TIPS (age 56 ± 12, 64% male, 76 patients with alcoholic cirrhosis) with sixteen patients with occluded (n=8) or without TIPS (control group). Patency of the TIPS and intrahepatic portal perfusion was evaluated by duplex-sonography. Results: The shunt flow was 1734 ± 424 ml/min (mean + SD). In these patients the haptoglobin concentration was 32 ± 58 mg/100ml as compared to 69 ~: 51 mg/100ml in the control group (p=0.02), no difference was detected for platelet count. The haptoglobin concentration was correlated with the concentration of cholinesterase (p=0.007), intrahepatic portal flow (p<0.001) and thrombocyte count (p<0.001) and inversely correlated with shunt flow (p<0.001) and bilirubin concentration (p<0.001) (Spearman rank correlation). In 44 of 84 patients with patent TIPS but in none of the control group, haptoglobin was not detectable at all (p<0.001). Overt hemolytic anemia was not seen. Conclusion:. TIPS-induced hemolysis seems to be common but does not result in anemia. A higher platelet count may be protective by activation of neointima formation and reduction of turbulences. Low haptoglobin concentrations may reflect high shunt flow and poor intrahepatic portal perfusion. The clinical significance of TIPS-induced hemolysis regarding other diseases, e.g. gallstones, must be subjected to further studies.

1 4 4 3 HEPATITIS C AND HEPATITIS B IN HIV INFECTED PATIENTS: PREVALENCE AND OUTCOME J Ocken~a 1 . IIL Tillmann 2_ S Herin~lake2. C Trantwein 2. M Stoll 1. I Sehedel 1 MP Mann~2,. RE Schmidtl. 1Dept. Clinical Immunology, 2Dept. Gastroenterology & Hepatology, Medical School, Hannover, Germany Only limited information is available about the prevalence and clinical outcome of patients with coinfecfion of Hepatitis C (HCV), Hepatitis B (HBV) and Human immanodeficiency vims (HIV). Therefore this prospective study was set up to adress this question. Methods: I-IBV and HIV were diagnosed serological, while HCV infection was diagnosed serological and by PCR. 228 men and 52 women with proven HIV- infection were investigated between January 1993 and December 1994 and followed up for survival (mean 625±19 days). In addition we compared the survival time since first AIDS defing event in those patients already with AIDS at the time of investigation or developing AIDS during follow up (N=62). Results: 65 of 280 patients (23%) were HCV positive and 24 of 280 patients (9%) were HBV positive, double infection with HCV and HBV occurred in 4 ( 1,5%) patients. Sources of HIV infection are shown in the table below.

Homosexual Heterosexual Dmg addicts I Hemophiliacs* m f m f m f [ m f

total 156 0 18 18 42 33 [ 12 1

HBvHCV 186 2 3 1 2 4 ~ 3 2 I V I 1! 'v

anti-HBc § 73 6 6 30 ~' 17 'v HCV/HBV 2 1 m: male, f: female; ~ HBsAg neg.; "~ p< 0.05 vers homo- and heterosexuell, No significant difference in survival since evaluation of hepatitis serology and survival time since first diagnosis of AIDS in patients with HCV, HBV (HBsAG pos), and without viral hepatitis (698:1=30, 586a:61, 609±20 days, and 1193±186, 1172±291,929-a:112, res.) could be observed. Condusioas: HCV and HBV infections are much more common among HIV positive patients compared to normal controls. Infection with all three viruses are rare according to the different routes of preferential transmission. The coinfeotion of HCV or HBV does not appear to influence survival of H1V infected patients. Further prospective studies are neccessary to evaluate those patients in which taxatment of the viral hepatitis is beneficial.

1444 Clinical Features of Symptomatic non-B non-C non-Alcoholic Chronic Liver Disease in Japan . M Ohaua, K Hajiro~ and H Takakuwa. Department of Gastroenterology, Tenri Hospital, Nara, Japan.

Objective:To clarify the clinical features of symptomatic chronic non-B non-C non-alcoholic liver disease (NBNCNALD) which has become important clinically since the introductio n of hepatitis C (HCV) antibody testing. Methods: Three hundred and thirty-eight patients hospitalized for clinical manifestations associated with chronic liver disease were tested by hepatitis B surface antigen (HBsAg) by reversed passive hemagglutination (RPHA) and the second generation hepatitis C antibody by passive hemagglutination (PHA). The etiologies were classified into four groups; those with hepatitis B, hepatitis C, non-B non-C liver disease and others. Each group was divided into drinker, and non-drinker. NBNCNALD was evaluated clinically and compared with other close etiologies. Results: Twenty-two patients (6.5%, 15 men and 7 women) were diagnosed as having NBNCNALD. Their clinical manifestations and severity of liver disease such as the occurrences of hepatic encephalopathy, gastroesophageal varix, ascites, hypoalbuminemia and thrombocytopenia were similar to those of other etiologies. The average age was higher than hepatitis B (p<O.001), alcoholic (p<O.05), primary biliary cirrhosis (PBC, p<0,05), autoimmune hepatitis (AIH, p<O.05) and hepatitis C. None of them had a history of blood transfusion before the onset. Development of hepatoma was seen in 40.9%, being significant rare compared with hepatitis B (p<0.01) and hepatitis C (p<O.005). No significant difference of the survival rate was shown between NBNCNALD and other etiologies. Disappearance of HBsAg was seen in two patients during the follow-up period, suggesting some of "NBNCNALD" might have been hepatitis B, from frequent appearances of HBsAh (36.4%). Conclusions: Chronic NBNCNALD appeared to be a unique clinical entity in the elderly unrelated to blood transfusion, and resembled other types of viral hepatitis in mortality.