XXXVI National Congress of Gastroenterology, Hepatology and Digestive Endoscopy
(Cluj-Napoca, 8-11 June 2016)
Editor Dan L. Dumitrașcu
FILODIRITTO INTERNATIONAL PROCEEDINGS
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INDEX
Foreword 12 Diagnostic and therapeutic management of non-alcoholic steatohepatitis ANTON Carmen, DIMACHE Mihaela, BISTRICEANU Sandina, SPATARU Vlad, HARTIE Codrina, ANTON Emil
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Nutritional deficiencies in adult patients with celiac disease 20 BALABAN Daniel Vasile, POPP Alina, ROBU Georgiana, CAZAN Andreea Ruxandra, COSTACHE Raluca Simona, NUȚĂ Petruț, IONIȚĂ-RADU Florentina, JINGA Mariana To treat or not to treat minimal hepatic encephalopathy? Ethical dilemmas and liability issues 25 BALAN G. Gheorghe, OLTEANU Andrei, TOADER Elena Preliminary results of the interferon-free treatment in patients with viral c liver cirrhosis 31 BATAGA Simona, FURNEA Cristina, TOROK Imola, NEGOVAN Anca, MACARIE Melania The Changing Pattern Of Celiac Disease Forms Of Presentation In A Pediatric Population From The Western Part Of Romania 35 BELEI Oana, SIMEDREA Ioan, MARCOVICI Tamara, OLARIU Laura, MARGINEAN Otilia Pre -, peri - and postnatal management of a fetus with Gaucher disease type II 42 BODEAN Oana, MUNTEANU Alexandra, CIRSTOIU Monica, BOHILȚEA Roxana, BRĂTILĂ Elvira, BERCEANU Costin, MEHEDINȚU Claudia, MUNTEANU Octavian Pregnancy after liver transplant - a case report in the context of hepatic transplant at reproductive age romanian achievements 49 BOHILTEA Roxana Elena, HERHORET Doina, GHEORGHE Liliana, CONSTANTINESCU Alexandrina, POPESCU Irinel, TOMESCU Dana, DROC Gabriela, TURCAN Natalia, BRATILĂ Elvira, MEHEDINTU Claudia, MUNTEANU Octavian, BODEAN Oana, CIRSTOIU Monica
Index Infection with Listeria monocytogenes in pregnant women in the third trimester of pregnancy - case report of a different therapeutic response and a review of the literature BOȚ Mihaela, VLĂDĂREANU Simona, PETCA Aida, ZVÂNCĂ Mona
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Intestinal symptoms in genital prolapse BRĂTILĂ Elvira, COMANDAȘU Diana, COROLEUCĂ Ciprian, MANTA Anca, CÎRSTOIU Monica, BOHÎLŢEA Roxana, MEHEDINŢU Claudia, VLĂDĂREANU Simona, BERCEANU Costin
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Gastrointestinal symptoms in endometriosis correlated with the disease stage BRĂTILĂ Elvira, COMANDAȘU Diana, COROLEUCĂ Ciprian, CÎRSTOIU Monica, BOHÎLŢEA Roxana, MEHEDINŢU Claudia, VLĂDĂREANU Simona, BERCEANU Costin
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Intrahepatic cholestasis of pregnancy: diagnosis, prognosis and complications BURNEI-RUSU Anca, VLADAREANU Simona, TRAISTARU Andrei, CRISTEA Carmen, ZAMFIRESCU Vlad, BOT Mihaela
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Severe atypical cases of HELLP syndrome BURNEI-RUSU Anca, VLADAREANU Simona, VLADAREANU Radu, BOIANGIU Andreea, ZAMFIRESCU Vlad, FILIPESCU Alexandru
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Intestinal inflammation and Spondylarthropathies - a frequent association CARDONEANU Anca, REZUS Elena, CIJEVSCHI PRELIPCEAN Cristina
85
Two different diseases, one treatment 92 CARDONEANU Anca, CIJEVSCHI PRELIPCEAN Cristina, MIHAI Catalina, GAVRILESCU Otilia, POPA Iolanda, UNGUREANU Irina, POPA Raluca, REZUS Elena Somatostatin analogues in digestive neuroendocrine tumors CAZAN Andreea, COSTACHE Cristina, ISPAS Maria, BALABAN Vasile, BARBU Mihaela, SMENGER Luiza, MĂNUC Teodora, DUȚEI Cătălin, SBURLAN Ioana, DICULESCU Mircea, CROITORU Adina, MĂNUC Mircea Solid Masses Of The Upper Gastrointestinal Tract And Endocrine Tumor Conditions: Any Link? CHIRA Ioan Romeo, CARSOTE Mara, MORAR Andra, BREABAN Maria, VALEA Ana
96
101
Gut Serotonin: Link Between Menopausal Osteoporosis And Breast Cancer? CHIRA Romeo Ioan, CARSOTE Mara, ALBU Simona Elena, GHEMIGIAN Adina, VALEA Ana
106
A rare type of hypereosinophilic disorder - eosinophilic enterocolitis CHIRA Romeo Ioan, HOTEA Ioana, CRIȘAN Doinița, VĂLEAN Simona, MIRCEA Petru Adrian
112
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Index Prevalence and clinical relevance of relative adrenal insufficiency in critically ill patients with liver disease 118 STEFAN Chiriac, IRINA Girleanu, OANA Stoica, ANA-MARIA Singeap, ANCA Trifan, CAROL Stanciu Management of Laryngopharyngeal Reflux in ENT Clinic of Cluj-Napoca CHIRILĂ Magdalena, LUCHOO Krishna, HAMMAMI Youssef, VEREŞ Ştefana, DINESCU Florina V, ŢIPLE Cristina
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Influencing the Consequences of Portal Hypertension. Endoscopic Treatment, Early Transjugular Intrahepatic Portosystemic Shunt COJOCARIU Camelia, STANCIU Carol, SINGEAP Ana Maria, SFARTI Catalin, NEGRU Dragoș, TRIFAN Anca
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Manic Episode With Psychotic Features During Therapy With Corticosteroids For Autoimmune Cirrhosis CRIŞAN Cătălina, CRUCEANU Oana, BLESNEAG Alina, DRAGOMIR Bianca-Iasmina, MĂRGINEAN Corina
137
Evaluation Of Atherothrombotic Cardiovascular Risk In Virus C Cirrhosis CUCIUREANU Tudor, CHIRIAC Stefan, GIRLEANU Irina, TRIFAN Anca, STANCIU Caro Aspects of Helicobacter Pylori Infection in a Pediatric Hospital - Retrospective Study Over a 7 Years Period DIACONESCU Smaranda, SAVESCU Cornelia, OLARU Claudia Adriana, GIMIGA Nicoleta, STANCA Raluca Cristina, BURLEA Marin
142
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Non-cirrhotic portal vein thrombosis associated with local pancreatic disease: 155 review of 25 patients DIACONU Cătălina, ILIE Madalina, SANDRU Vasile, TINCU Radu, Bogdan Popa, CONSTANTINESCU Gabriel, COSTACHE Raluca Simona Non-selective beta-blockers in patients with cirrhosis: “the therapeutic window” – where do we stand? DIMACHE Mihaela, ANTON Carmen, GÎRLEANU Irina, BISTRICEANU Sandina, FILIP Ana-Maria, TRIFAN Anca
160
Pancreatic Insulinoma With Dominant Neurological and Psychiatric Symptoms – Case Report DRAGOMIR Bianca-Iasmina, MĂRGINEAN Corina, BLESNEAG Alina, CRIŞAN Cătălina, ŞERBAN Ana Cristina
168
Is there a Correlation Between the Biological and Radiological Modifications In Acute Pancreatitis 174 DRANGA Mihaela, DRUG Vasile Liviu, CUCUTEANU Bogdan, POPA Iolanda, DIDITA Ancuta, BARBOI Oana, PRELIPCEAN Cristina Cijevschi
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Index Evolutionary Features of Adalimumab Treatment in Patients with Inflammatory Bowel Disease 179 FRATILA Ovidiu, CIOCA Gabriela, ILIAS Tiberia “Sooner is better” in inflammatory bowel disease? GAVRILESCU Otilia, CIJEVSCHI PRELIPCEAN Cristina, CARDONEANU Anca, DIDIȚA Ancuța, CHIOSA Ana-Maria, BĂRBOI Oana Bogdana, DRANGA Mihaela Clinical Picture of Deep Vein Thrombosis in Patients With Liver Cirrhosis: A Rare Condition? GÎRLEANU Irina, TRIFAN Anca, STOICA Oana Cristina, COJOCARIU Camelia, SÎNGEAP Ana Maria, CHIRIAC Ștefan, CUCIUREANU Tudor, STANCIU Carol
187
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The Effect of Intrahepatic Cholestasis in Pregnancy on Maternal and Fetal Outcomes HANGAN L. Tony, VLADAREANU Simona, BADIU Diana, NICODIN Ovidiu, PANAITE Bogdan, VLADAREANU Radu, BIRSASTEANU Florin, CRACIUNESCU Mihaela, NAVOLAN Dan
199
Inflammatory Bowel Disease and Disturbances of Liver Function Tests HODISAN Eva, FRATILA Ovidiu
204
Quality Of Life In Patients With IBD Over Time: Importance Of Gender, Age, Disease Activity And Treatment IONITA Roxana Monica, VOIOSU Theodor, BENGUS Andreea, VOIOSU Andrei, BADIU Cristian, DINU Roxana, MATEESCU Bogdan
210
Endoscopic and histologic features of serrated polyps of the colon and rectum MACARIE Melania, MACARIE Ioan, TOROK Imola, GEORGESCU Dan, CIORBA Marius, OPASCHI Razvan, BATAGA Simona
216
The behavioural component of NASH 220 MACAVEI Bianca, BABAN Adriana, BABIN Alexandru, DUMITRASCU Dan Lucian The Accuracy of Endoscopic Markers of Suspected Celiac Disease in Adult Patients - Results from a Retrospective Study in a Tertiary Referral Center 226 MAXIM Roxana, TRIFAN Anca, PLESA Alina, CIORTESCU Irina, STANCIU Carol Viral Hepatitis B Infection Prevalence in Pregnancy – National Multicentre Study 233 MEHEDINTU Claudia, BRATILA Elvira, BERCEANU Costin, VLADAREANU Simona, PLOTOGEA Mihaela, IONESCU Oana, PITURU Silviu, CIRSTOIU Monica, BOHILTEA Roxana, BADIU Cristinel Dumitru, SECUREANU Adrian Florin Fitz-Hugh-Curtis Syndrome, Multidisciplinary Pathology, Often Underrated 240 MEHEDINTU Claudia, BRATILA Elvira, BOHILTEA Roxana, CIRSTOIU Monica, BADIU Dumitru Cristinel, PITURU Silviu, BERCEANU Costin, IONESCU Oana Maria, SECUREANU Adrian Florin
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Index The Management of Intrahepatic Cholestasis of Pregnancy – National Multicenter Study 246 MEHEDINTU Claudia, BRATILA Elvira, PITURU Silviu, BERCEANU Costin, VLADAREANU Simona, CIRSTOIU Monica, BOHILTEA Roxana, IONESCU Oana, ANTONOVICI Marina, SECUREANU Adrian Florin Steatosis in Patients with Genotype 1b Virus C Compensated Liver Cirrhosis MIHAI Catalina, CHIOSA Ana Maria, SAVIN Alexandra, BADEA Mircea, UNGUREANU Irina, CUCUTEANU Bogdan, MIHAI Bogdan, DRUG Vasile, TRIFAN Anca, STANCIU Carol, PRELIPCEAN CIJEVSCHI Cristina
252
Diet particularities in patients with irritable bowel syndrome MOCAN Mihaela, CETEAN Coralia, CĂTINEAN Adrian
259
Predictive value of deep venous thrombosis for the later development of pancreatic cancer: a case report MOCAN Mihaela, CRIȘAN Ramona, CĂTINEAN Adrian, CHIRA Romeo, CRIȘAN Doinița, BLAGA Sorin
267
Surveillance of Intraabdominal Fetal Meconium Peritonitis by Sonography NAVOLAN Dan, HANGAN L. Tony, BADIU Diana, NICODIN Ovidiu, PANAITE Bogdan, VLADAREANU Radu, BIRSASTEANU Florin, CRACIUNESCU Mihaela, VLADAREANU Simona
272
First Trimester Pregnancy Exposure To Barium Sulphate Contrast Media Radiography For Gastric Disease: Case Report And Review Of Literature 276 NAVOLAN Dan, VLADAREANU Simona, BADIU Diana, VLADAREANU Radu, HANGAN L. Tony, BIRSASTEANU Florica Percutaneous transhepatic cholangio-drainage and biliary stent placement – a rendez-vous procedure in a patient with Billroth II anastomosis NEDELCU Cristian, ILIE Madalina, SANDRU Vasile, DIACONU Catalina, TINCU Radu, POPA Bogdan, CONSTANTINESCU Gabriel
280
The efficiency of various therapeutic methods in severe constipation in children OLARU Radian Alexandru, DIACONESCU Smaranda, GIMIGA Nicoleta, BURLEA Marin, OLARU Claudia
287
Benefits of synbiotic treatment in constipated children OLARU Radian Alexandru, DIACONESCU Smaranda, GIMIGA Nicoleta, BURLEA Marin, OLARU Claudia
291
Clinical, Biological and Ultrasonography Predictors of the Severity of NAFLD OLTEANU Vasile-Andrei, BĂLAN G. Gheorghe, TIMOHE-TUMAC Sandra, GOLOGAN Elena, MITRICĂ Dana-Elena, TOADER Elena, BĂLAN Gheorghe, ȘTEFĂNESCU Gabriela
296
7
Index Secondary giant inflammatory rectosigmoid polyps caused by Cronh’s deasease - a case presentation 302 ONISOR Danusia, BOERIU Alina, BRUSNIC Olga, DRASOVEANU Silvia, PETRUT Madalina, DOBRU Daniela Celiac Disease - Associated Vitamin D Deficiency Complicated With Secondary Hyperparathyroidism In A Patient With Primary Hyperparathyroidism OPRISOR Mariana Iuliana, CHIRA Romeo Ioan, CARSOTE Mara, MORAR Andra, VALEA Ana
308
Liver Involvement And Neuroendocrine Tumors 312 OPRISOR Mariana Iuliana, CARSOTE Mara, DUMITRASCU Anda, TERZEA Dana, VALEA Ana From Goitre to Fulminate Outcome Related To Oesophageal Cancer OPRISOR Mariana Iuliana, IOACHIM Dumitru, DUMITRASCU Anda, CARSOTE Mara, VALEA Ana Comparative analysis of two epidemic outbreaks of acute hepatitis A in Stara Zagora region, Bulgaria PEKOVA L., PAROUSHEVA P., FARTUNOVA M., CHAKAROV Sv., DIMITROV N., YOSIFOVA G., PETROV D. Approach of rebleeding in upper gi non-variceal haemorrhage PLOTOGEA Oana, ILIE Madalina, MOROI Iustin, CONSTANTIN Alina, TABACELIA Daniela, SANDRU Vasile, NEDELCU Cristian, TINCU Radu, POPA Bogdan, CONSTANTINESCU Gabriel
319
325
331
Is there a relationship between nonsteroidal antiinflammatory drug use and gastroesophageal reflux disease? POP-SILVĂŞAN Florina, CIOBANU Lidia, LEUCUŢA Daniel, ANDREICA Vasile
341
Dysplasia in Inflammatory Bowel Disease: Perspective From a Tertiary Centre in Northwestern Romania POPA Iolanda Valentina, DRUG Vasile Liviu, POPA Raluca, SAVIN Alexandra, CARDONEANU Anca, BĂRBOI Oana, ȘTEFĂNESCU Gabriela
346
351 Beta 2 - Microglobulin and Inflammatory Bowel Disease POPA Iolanda Valentina, MIHAI Cătălina, DRANGA Mihaela, GAVRILESCU Otilia, CARDONEANU Anca, CIJEVSCHI-PRELIPCEAN Cristina A particular case of sigmoid stenosis-updating informations POPA Raluca Cezara, BAR Camelia, COTEA Elena, LOZNEANU Ludmila, MIHAI Catalina, CIJEVSCHI PRELIPCEAN Cristina
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Index Association between Multiple Sclerosis and Ulcerative Colitis-Therapeutic Challenge: a Case Report 363 GEORGIANA CATALINA Robu, VASILE DANIEL Balaban, RALUCA SIMONA Costache, PETRUT Nuta, FLORENTINA Ionita-Radu, TUDOR GEORGE Gherasim, MARIANA Jinga 368 Synchronous Colonic Tumours with Primary Gastro-colic Fistula – Case Report SECUREANU Adrian Florin, BADIU Dumitru Cristine, MANEA Cristina Alexandra, NACEV Tudor Vlad, GRIGOREAN Valentin Titus, IONESCU Oana Maria, PITURU Silviu, BRATILA Elvira, MEHEDINTU Claudia Incidental Discovery of a GIST During a Laparoscopic Cholecystectomy – Case Presentation 374 SECUREANU Adrian Florin, STANESCU Diana, DIACONU Victor, BADIU Dumitru Cristinel, PITURU Silviu, MUNTEANU Octavian, BRATILA Elvira, MEHEDINȚU Claudia Surgical Treatment in a Complicated Case of Mendelson’s Syndrome 380 SECUREANU Adrian Florin, STANESCU Diana, DIACONU Victor, BADIU Dumitru Cristinel, PITURU Silviu, IONESCU Oana Maria, BRATILA Elvira, MEHEDINȚU Claudia Surgical indication in severe ulcerative colitis: are conventional criteria sufficient? SINGEAP Ana-Maria, TRIFAN Anca, CHIRIAC Stefan, CUCIUREANU Tudor, STOICA Oana Cristina, STANCIU Carol
385
Gastric glomus tumors Stavar Angelica Nela, Micu Luminita, Micu Dorian, Tofolean Tiberiu Ioan, Tofolean Doina Ecaterina, Dogaru Iuliana, Timurlenc Iusuf, Suceveanu Andra Iulia
390
Non-invasive Assessment of Liver Fibrosis in Patients with Chronic HCV Infection: Prediction Factors for Discordance between Fibromax and Transient Elastography ȘTEFĂNESCU Gabriela, GÎLCĂ Georgiana Emmanuela, BĂLAN Gheorghe jr, MIHAI Cătălina, BRĂILESCU Ramona, DRUG Vasile, CIJEVSCHI PRELIPCEAN Cristina
397
Cutaneous Manifestation In Ulcerative Colitis: Diagnostic And Therapeutic Challenge 405 STOICA Oana, TRIFAN Anca, TANASE Oana, CHIHAIA Catalin, STATESCU Laura, RAID Issa, STANCIU Caro Liver Nodules in Cirrhosis: Do We Need Contrast-Enhanced Ultrasonography? TIMOFTE Oana, ȘTEFĂNESCU Gabriela, GOLOGAN Elena, BĂLAN Gheorghe
410
The frequency of dyslipidemia in helicobacter pylori infected patients TOADER Elena, HORDILĂ Alexandra, NACLAD Andreea, BALAN G. Gheorghe
416
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Index The Prevalence of Gallstone Disease and Cholecystectomy, a Follow-up After 15 years 421 TÖRÖK Imola, BĂŢAGĂ Simona, MACARIE Melania, GEORGESCU Dan, CIORBA Ilie-Marius, FARKAS Hunor, LACZKÓ-DÁVID Zsófia Pancreatic neuroendocrine tumors - from enucleation to liver transplantation 426 TROFIN Ana-Maria, ANDRIESI-RUSU Delia, ZABARA Mihai, VORNICU Alexandra, TARCOVEANU Eugen, URSULESCU – LUPASCU Corina, PALAGHIA Madalina, TRIFAN Anca Victorita, LUPASCU Cristian Multi-Criteria Soft-Computing based System for Medical Diagnosis applied to ulcerative 432 colitis TULBURE Ildiko, GRAD Cosmin, DUMITRASCU Dan Isolated tracheoesophageal fistula- case report VLADAREANU Simona, BURNEI-RUSU Anca, ALI Saphia, KADAR Anna, VATRA Lorena, OANCEA Marcel
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Gallstone and Biliary Sludge Formation in Pregnancy VLADAREANU Simona, TRAISTARU Vlad Andrei, BURNEI-RUSU Anca, ZAMFIRESCU Vlad, VLADAREANU Radu
445
ERCP procedures involving trainees do not carry an additional risk of procedure failure 449 or adverse events: interim results from the QUASIE2 cohort VOIOSU T, BENGUŞ A, VOIOSU A, MATEESCU B Appendicitis During Pregnancy 454 ZAMFIRESCU Vlad, VLĂDĂREANU Simona, VLĂDĂREANU Radu, MARIN Alina, TRAISTARU Andrei, BURNEI-RUSU Anca Secular and New Trends in The Treatment of Hyperemesis Gravidarum ZAMFIRESCU Vlad, VLĂDĂREANU Simona, VLĂDĂREANU Radu, MARIN Alina, TRAISTARU Andrei, BURNEI-RUSU Anca Assessment of Metabolic Changes in Pregnancy and Their Correlation with Fetal Development BODEAN Oana, ARAMĂ Ștefan, CIRSTOIU Monica, BOHILȚEA Roxana, BRĂTILĂ Elvira, BERCEANU Costin, MEHEDINȚU Claudia, MUNTEANU Octavian
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Foreword
FOREWORD
We have the pleasure to present to you the proceedings volume of the Romanian Congress of Gastroenterology and Hepatology held in Cluj-Napoca between 8-11 June 2016. The Romanian Society of Gastroenterology and Hepatology is one of the founding members of the World Gastroenterology Organization, in 1958, and has organized since than annual meetings with international participation. This year the meeting was larger than ever, bringing together 1600 attendants (including the section for nurses). A main attraction was the United European Gastroenterology course which offered to participants the possibility to listen to high quality lectures under the title: What is changing, what is challenging? Beside this update, the congress included plenary sessions, symposia on specific topics, presentations of endoscopy and ultrasonography. A selection of the papers accepted to the congress is now published in this proceedings volume with the commitment of the publisher. In this volume the readers will find beside updated information in most fields of digestive diseases, a cross-sectional profile of our scientific research. Most authors are of course from Romania but we have contributors from other countries. Of course, the responsibility of the content belongs to the contributors. We are confident that the readers will find this book useful and welcome.
Prof Dan L Dumitrascu Editor President of the congress
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© Filodiritto Editore - Proceedings
Diagnostic and therapeutic management of non-alcoholic steatohepatitis ANTON Carmen1,2, DIMACHE Mihaela1,2, BISTRICEANU Sandina2, SPATARU Vlad3, HARTIE Codrina2, ANTON Emil1 University of Medicine and Pharmacy “Gr.T. Popa”,Iasi, Romania Institute of Gastroenterology and Hepatology “St.Spiridon” Hospital, Iasi, Romania 3 Clinic of Diabetes, Nutrition and Metabolic Disorders “St. Spiridon” Hospital, Iasi, Romania
[email protected],
[email protected] [email protected], volod_
[email protected],
[email protected],
[email protected] 1 2
Workcode A608F5001
Abstract Non-alcoholic fatty liver disease (NAFLD) represents the most common hepatic pathology in the Western World, progressing from non-alcoholic simple steatosis to non-alcoholic steatohepatitis (NASH), with or without fibrosis. It has an established connection with other comorbidities such as obesity, insulin resistance, type 2 diabetes mellitus and dyslipidemia. Clinically, patients are oligosymptomatic. Mild to moderate increase in serum liver enzymes can be found in NAFLD. Some studies demonstrated a very promising biochemical diagnosing procedure using adipokines and serum proinflammatory cytokines. Imagistic diagnosis consists of ultrasonography, computed tomography and magnetic resonance imaging. Treatment of NAFLD is complex and starts with optimizing the lifestyle through exercise and diet. Pharmacologic therapy in NASH is indicated in patients with comorbidities or with high risk of advanced fibrosis. It includes: insulin sensitizers, antioxidants, lipid lowering drugs, N-3 polyunsaturated fatty acids, ursodeoxycholic acid, pentoxifylline, probiotics and synbiotics. Surgical forms of treatment are bariatric surgery and liver transplantation. Keywords: nonalcoholic steatohepatitis, diagnosis, treatment, management
Introduction Non-alcoholic fatty liver disease (NAFLD) represents the most common hepatic pathology in the Western World, characterized by fat accumulation more than 5% of the liver weight, without the context of excessive alcohol drinking or any secondary cause.[1] NAFLD slowly progresses from non-alcoholic fatty liver (NAFL), also called non-alcoholic steatosis (NAS), to non-alcoholic steatohepatitis (NASH). The major difference between these two stages of disease is the hepatocyte injury (ballooning), which is absent in NAFL and present in NASH, accompanied by intralobular inflammation, with or without fibrosis.[2] NASH developes gradually towards cirrhosis and hepatocellular carcinoma (HCC). NASH is considered to be the third most common risk factor for HCC, the first two places being occupied by viral infection and alcohol.[3] Of all patients with NASH, almost 20% of them will most likely develop cirrhosis and 30-40% from these patients die because of NASH-cirrhosis.[4] NASH exists not by itself, but is closely linked with other comorbidities, such as obesity, insulin resistance(IR), type 2 diabetes mellitus and dyslipidemia. In fact, NASH is one of the many faces of the metabolic syndrome.[5] It is estimated that NAFLD has a median prevalence of 20-30% in the general population of
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© Filodiritto Editore - Proceedings Western Countries. 3-5% of NAFLD patients develop early NASH.[6] Because obesity has the biggest role in the physiopathology of NAFLD, almost 74% of obese individuals suffer from this form of fatty liver disease. 84-96% of patients with morbid obesity undergoing bariatric surgery have NAFLD and 2-12% of them suffer from cirrhosis.The development of NAFLD is also influenced by age, sex, race and ethnicity, increasing with age, both in children and adults and being more frequent in men than women. [7]
Clinical diagnosis As mentioned earlier, NAFLD is the hepatic manifestation of the metabolic syndrome. According to the American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI)-criteria, metabolic syndrome is diagnosed when at least 3 of the following components are present: 1. waist circumference >88 cm for women and > 102 cm for men; 2. low HDL-cholesterol values: < 1.29 mmol/l for women and < 1.03 mmol/l for men; 3. high triglycerides values ≥ 1.7 mmol/l; 4. blood pressure ≥130/85 mmHg or an antihypertensive treatment; 5. impaired fasting glucose ≥ 5.6 mmol/l or drug treatment for high glucose levels. [8] Almost 85% of patients with NAFLD have at least one of these five metabolic components. The metabolic syndrome can be found in 30% of the individuals with NAFLD. [9] Aside the clinical features of the metabolic syndrome, patients with NAFLD are asymptomatic, until the onset of cirrhosis. Some patients may experiment non-specific symptoms such as: a slight discomfort or pain in the right upper quadrant, due to hepatomegaly that stretches the hepatic capsule, or fatigue.[10] Obesity and hepatomegaly are the main clinical traits found at the physical examination. Often, subjects with NAFLD are diagnosed incidentally. [11] It is very important to mention that NAFLD is a diagnosis of exclusion. The clinician must exclude other causes of liver disease, such as: excessive intake of ethanol, infection with hepatic virus B and/or C, drug abuse, Wilson’s disease, haemochromatosis or autoimmune liver disease. [9]
Biochemical diagnosis Mild to moderate increase in serum liver enzymes can be found in NAFLD. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) can be elevated 1.5 to 4 fold than normal in about 50% of patients.[12] NAFLD can be characterized by a greater ALT serum concentration than AST (AST/ALT1) as the fatty liver disease progresses from the steatohepatitis stage to fibrosis.[14] Antinuclear antibodies may be found in about 25% of NAFLD patients, in low titers (less than 1:320). [15] In a study of 628 patients with NAFLD diagnosed via liver biopsy, it was found that serum ferritin levels were elevated 1.5 fold than normal in advanced stages of NAFLD (NASH and development of hepatic fibrosis), meaning that serum ferritin is linked to fibrosis. [16] New perspectives in biochemical diagnosis of NAFLD were investigated. A case-control study evaluated the connection between adipokines (adiponectin and visfatin) and serum proinflammatory cytokines (interleukin-6, interleukin-8 and tumor necrosis factor-alpha) and NAFLD/NASH.[17,18]This evidence sustains that anti TNF-α medication can be included in the NASH treatment protocol.[19] The findings of this study need to be investigated in future studies. NAFLD is generally diagnosed and monitored using metabolic parameters and liver function tests. Using this new panel of serum markers (adipokines, cytokines) for diagnosing
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© Filodiritto Editore - Proceedings NAFLD and discerning between simple liver steatosis and steatohepatitis is very important for the medical world. [20]
Imagistic diagnosis Hepatic steatosis can be diagnosed with the help of imaging techniques, transabdominal ultrasonography being the most frequently used. [21] Because of fatty infiltration, the liver parenchyma appears more echogenic than the adjacent renal cortex and spleen. This echogenicity may be focal, with areas surrounded by straight borders, or diffuse.[22] There are 3 grades of steatosis, established visually, by analyzing the intensity of the liver parenchyma echogenicity. Grade 1 refers to an increased echogenicity. In grade 2, the echogenic walls of the portal vein branches are masked by the echogenic liver. Grade 3 means the diaphragmatic outline is obscured by the echogenic liver.[23] Ultrasonography can detect hepatic steatosis with a sensitivity of 60% - 94% and a specificity of 84% - 95%. Fibrosis can be detected by ultrasounds with a sensitivity of 77% and a specificity of 89%.[24] Sonoelastography can estimate the liver stiffness that is affected by fat accumulation.Transient elastography is a newly developed noninvasive imaging technique, very useful in detecting advanced fibrosis. [25,26] Computed tomography (CT) is another imaging technique that can detect steatosis. Moderate to severe steatosis can be diagnosed with 100% specificity when the liver-to-spleen attenuation ratio is
