Sven Wallerstedt | University of Gothenburg (original) (raw)

Papers by Sven Wallerstedt

Research paper thumbnail of Short Answer Questions or Modified Essay questions – More Than a Technical Issue

International Journal of Clinical Medicine, 2012

Purpose, The present article was built on the assumption that the form of an examination may infl... more Purpose, The present article was built on the assumption that the form of an examination may influence learning, and may also reflect different kinds of knowledge. The aim of the study was to evaluate whether the results of an examination differ when short answer questions (SAQ) or modified essay questions (MEQ) are used. Method, Forty-nine students in the internal medicine course in Gothenburg, Sweden, performed a written examination in 2003, which included both SAQ and MEQ. Result, The correlation between the results of SAQ and MEQ was 0.59 (P < 0.001). The percentage correctly answered questions in the two types did not differ significantly. Some students had poor results in either SAQ or MEQ. Conclusion, The general outcome of the study indicates that results of SAQ and MEQ demonstrate a significant correlation. However, they may also reflect differences in mastery of the knowledge domain, which should be considered in relation to aspects of validity.

Research paper thumbnail of Scandinavian Journal of Gastroenterology. 2013; 48: 358–365 ORIGINAL ARTICLE

Moderate hyperkalemia in hospitalized patients with cirrhotic ascites indicates a poor prognosis

Research paper thumbnail of Moderate hyperkalemia in hospitalized patients with cirrhotic ascites indicates a poor prognosis

Scandinavian Journal of Gastroenterology, 2013

Objective. Development of ascites in patients with liver cirrhosis is an ominous sign with a poor... more Objective. Development of ascites in patients with liver cirrhosis is an ominous sign with a poor outcome. A liver transplantation must be considered, and it then becomes important to know if there are any factors indicating a worsened prognosis. Material and methods. We used official registers for a follow-up study of at least 5 years considering the prognosis of 155 prospectively recruited in-patients with cirrhotic ascites from medical units at nine Swedish university hospitals. All patients had undergone at least one diagnostic ascites tap, and had initially been questioned about background factors and physically examined according to a standardized case record form, followed by sampling of blood, urine, and ascites. Results. Death occurred within 1 year after inclusion in 53% of the cases, and was primarily liver-related in 70%. In a multivariable analysis, the two ordinary variables that showed the strongest correlation with risk of death were serum potassium and abdominal tenderness. All 22 patients with a serum potassium concentration of at least 4.8 mmol/L (maximum 5.8 mmol/L) died within 1 year after inclusion. Potassium concentration was related to renal function and potassium-saving drugs. Conclusion.This follow-up study of a prospectively recruited cohort of in-patients with cirrhotic ascites confirms their poor prognosis. Awareness of an elevated serum potassium value, which would reflect a threatened renal function, seems essential, because it may offer a simple way to identify cases with the worst prognosis. An area for further research should be to explore the significance of including serum potassium in prognostic models.

Research paper thumbnail of Registration of Liver Cancer Data—A Study on the Reliability of the Swedish Cancer Registry

Research paper thumbnail of Abdominal tenderness in ascites patients indicates spontaneous bacterial peritonitis

European Journal of Internal Medicine, 2007

Background: Spontaneous bacterial peritonitis (SBP), which has been reported to be present in 10-... more Background: Spontaneous bacterial peritonitis (SBP), which has been reported to be present in 10-30% of patients with cirrhotic ascites, may easily be overlooked. An important aim of our study was to determine whether there are any clinical signs which, in clinical practice, may predict or exclude SBP. Methods: We studied 133 patients with cirrhotic ascites from medical units at nine Swedish university hospitals where there had been at least one diagnostic ascites tap with analysis of polymorphonuclear leukocytes in the ascites fluid. The patients had initially been questioned about background factors and physically examined according to a standardized case record form. Samples of blood, urine, and ascites were then drawn for analysis according to a structured schedule. Results: SBP could be excluded in 80% of all the cases and was confirmed in 8% of the 133 patients in the final analysis. Abdominal pain and abdominal tenderness were more common in patients with SBP (p b 0.01), but no other physical sign or laboratory test could separate SBP cases from the others. Conclusions: SBP was present in about one-tenth of the hospitalized patients with cirrhotic ascites in this cohort. Performing repeated physical examinations and paying particular attention to abdominal tenderness may be the best way to become aware of the possible development of this complication.

Research paper thumbnail of Health check-ups and family screening allow detection of hereditary hemochromatosis with less advanced liver fibrosis and survival comparable with the general …

Scandinavian …, 2011

Objective. The information concerning the morbidity and mortality of hereditary hemochromatosis i... more Objective. The information concerning the morbidity and mortality of hereditary hemochromatosis is based primarily on clinical cohorts of symptomatic patients. The major aim of this study was to analyse the long-term prognosis for Swedish patients with this condition, with respect to both clinical features and survival, in relationship to the route by which the disease was detected. Material and methods. 373 patients with hemochromatosis detected through routine health checkups (n=153), family screening (n=44), symptoms of arthralgia (n=23), investigation of other diseases/symptoms (n=108) or signs of liver disease (n=45) were monitored for a mean period of 11.9±5.8 years. The degree of liver fibrosis and survival were analysed. Results. Overall survival among these patients was not significantly different from that of a matched normal population. The patients diagnosed through health checkups and family screening were detected at an earlier age and had the highest rate of survival. Liver biopsy at the time of diagnosis revealed cirrhosis in 9% of those detected through the health checkups and 5% in the case of family screening, compared with 13% for the group with arthralgia, 17% for other diseases/symptoms and 42% for liver disease. Conclusion. Health checkups and family screening allow detection of hereditary hemochromatosis at an earlier age and with less advanced liver fibrosis, although a few of these patients have already developed cirrhosis. Our study indicates that iron indices should be included in health checkups , and if abnormal, should lead to further investigation.

Research paper thumbnail of Lack of Correlation Between Hepatitis B Virus Infection and the Increasing Incidence of Primary Liver Cancer in Sweden

Acta Oncologica, 1991

The incidence of primary carcinoma of the liver in Sweden has been reported to increase. In order... more The incidence of primary carcinoma of the liver in Sweden has been reported to increase. In order to study the role of chronic hepatitis B virus (HBV) infection for liver cancer development 40 cases with hepatocellular carcinoma (HCC) were examined for the presence of HBV surface antigen and HBV core antigen in the cancer and in the surrounding non-neoplastic liver tissue. It was not possible to demonstrate a single case with tissue HBV antigen, indicating that HBV plays a minor role in the etiology of HCC in Sweden and thus does not seem to be responsible for the increasing incidence of this cancer.

Research paper thumbnail of Acute liver failure in Sweden: etiology and outcome

Objective. To determine the causes and outcome of all patients with acute liver failure (ALF) in ... more Objective. To determine the causes and outcome of all patients with acute liver failure (ALF) in Sweden 1994-2003 and study the diagnostic accuracy of King's College Hospital (KCH) criteria and the model for end-stage liver disease (MELD) score with transplant-free deaths as a positive outcome. Research design and methods. Adult patients in Sweden with international normalized ratio (INR) of ‡1.5 due to severe liver injury with and without encephalopathy at admission between 1994-2003 were included. Results. A total of 279 patients were identified. The most common cause of ALF were acetaminophen toxicity in 42% and other drugs in 15%. In 31 cases (11%) no definite etiology could be established. The KCH criteria had a positive-predictive value (PPV) of 67%, negative-predictive value (NPV) of 84% in the acetaminophen group. Positive-predictive value and negative-predictive value of KCH criteria in the nonacetaminophen group were 54% and 63% respectively. MELD score >30 had a positive-predictive value of 21%, negative-predictive value of 94% in the acetaminophen group. The corresponding figures for the nonacetaminophen group were 64% and 76% respectively. Conclusions. Acetaminophen toxicity was the most common cause in unselected patients with ALF in Sweden. KCH criteria had a high NPV in the acetaminophen group, and in combination with MELD score <30 predicts a good prognosis in acetaminophen patients without transplantation.

Research paper thumbnail of Increased porphyrins in primary liver cancer mainly reflect a parallel liver disease

Recommended by Gianfranco D. Alpini Hepatic porphyries have been associated with an increased ris... more Recommended by Gianfranco D. Alpini Hepatic porphyries have been associated with an increased risk of primary liver cancer (PLC), which on the other hand may cause an increased porphyrin production. To evaluate the role of an underlying liver disorder we analyzed porphyrins in patients with hepatocellular carcinoma (HCC) (n = 65), cholangiocellular carcinoma (n = 3), or suspected PLC, which turned out to be metastases (n = 18) or a benign disorder (n = 11). None of the patients had a family history of porphyry or clinical signs of porphyry. Increased aminolevulinic acid or porphyrin values were common not only in patients with PLC (43%) but also in metastatic (50%) and benign (64%) liver disorders. The corresponding proportion for HCC patients with liver cirrhosis (55%) was higher (P < .05) than in those without cirrhosis (17%). We conclude that symptomatic porphyries are unusual in PLC, whereas elevated urinary and/or faecal porphyrins are common, primarily reflecting a parallel liver disease and not the PLC.

Research paper thumbnail of Natural history and prognostic factors in 305 Swedish patients with primary sclerosing cholangitis

Gut, 1996

Background/Aims-The course of primary sclerosing cholangitis (PSC) is highly variable and unpredi... more Background/Aims-The course of primary sclerosing cholangitis (PSC) is highly variable and unpredictable. This study describes the natural history and outcome of PSC. These data were used to construct a prognostic model for patients with PSC. Methods-A total of 305 Swedish patients with PSC were studied. The median follow up time was 63 (1-194) months and all patients could be traced for follow up. Some 79 patients died or had a liver transplant. The prognostic significance of clinical, biochemical, and histological findings at the time of diagnosis were evaluated using multivariate analysis. Results-The estimated median survival from time of diagnosis to death or liver transplantation was 12 years. Cholangiocarcinoma was found in 24 (8%) of the patients and 134 (44%) ofthe patients were asymptomatic at the time of diagnosis. The estimated survival rate was significantly higher in the asymptomatic group (p<0.001). However, 29 (22%) of the asymptomatic patients became symptomatic during the study period. It was found that age, serum bilirubin concentration, and histological stage at the time of diagnosis were independent predictors of a bad prognosis. These variables were used to construct a prognostic model. Conclusions-This prognostic model developed from a large homogeneous population of PSC patients should be of value for the timing oftransplantation and patient counselling in PSC.

Research paper thumbnail of Incidence of primary liver cancer and aetiological aspects: a study of a defined population from a low-endemicity area

The prevalence of primary liver cancer (PLC) varies throughout the world. It has been attributed ... more The prevalence of primary liver cancer (PLC) varies throughout the world. It has been attributed to variations in incidence of the predominant histological type, hepatocellular carcinoma (HCC). The incidence of PLC types other than HCC such as cholangiocellular carcinoma (CCC) is far less known, especially in low-incidence areas. The aetiology of HCC and other PLC types is obscure, with the exception of the association between HCC and cirrhosis as well as chronic viral hepatitis. The present retrospective incidence and aetiology study concerns a well-defined population from a period with a high autopsy frequency. Preserved biopsy specimens were re-evaluated histopathologically and patient records were studied. Among 590 histologically verified cases of PLC, HCC constituted 90%, CCC 8% and a mixed form of these types 1%. At the end of the study period the annual age-standardised incidence rate of HCC was 3.6 cases per 100 000 inhabitants. Other PLC types were hepatoblastoma (n = 3), fibrolamellar carcinoma (n = 2), angiosarcoma (n = 1) and infantile haemangioendothelioma (n = 1), each constituting less than I % of the PLC cases. Comparing HCC with CCC we found that cirrhosis (70%) and alcoholism (21%) was significantly more frequent in HCC, and cholelithiasis was significantly more common (60%) in patients with CCC. In the majority of the PLC cases with liver cirrhosis this disorder was unknown before diagnosis of the tumour.

Research paper thumbnail of Incidence, Etiologic Aspects and Clinicopathologic Features in Intrahepatic Cholangiocellular Carcinoma: A Study of 51 Cases From a Low-Endemicity Area

Acta Oncologica, 1998

A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) f... more A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) from a low-endemicity area of primary liver cancer was analyzed during the periods from 1958 to 1979 and from 1984 to 1991. The mean annual age-adjusted incidence rate was 0.44 for males and 0.56 for females per 100 000 inhabitants. CCC was diagnosed before death in only 31%. There was a female predominance in patients over 70 years of age (p B 0.05). At presentation, malaise (85%), weight loss (73%), abdominal pain (50%) and hepatomegaly (80%) were common. The median survival time from diagnosis was 2 months. The mean age at the time of death was 72 years (range 41-92). At autopsy, cholelithiasis was found in 61% (81% in patients older than 70 years) and cirrhosis in 30% of patients. Cholelithiasis was more common in CCC (p B 0.01) than in hepatocellular carcinoma cases with the same mean age. Not one case of inflammatory bowel disease was found. The gross appearance of the tumor was predominantly massive (49%) or multinodular (35%). The most common histological features were tubular pattern of growth (82%) and abundant fibrous stroma. Metastases were particularly associated with the lymph nodes (41%), skeleton (26%) and lungs (16%).

Research paper thumbnail of Incidence, Etiologic Aspects and Clinicopathologic Features in Intrahepatic Cholangiocellular Carcinoma: A Study of 51 Cases From a Low-Endemicity Area

Acta Oncologica, 1998

A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) f... more A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) from a low-endemicity area of primary liver cancer was analyzed during the periods from 1958 to 1979 and from 1984 to 1991. The mean annual age-adjusted incidence rate was 0.44 for males and 0.56 for females per 100 000 inhabitants. CCC was diagnosed before death in only 31%. There was a female predominance in patients over 70 years of age (p B 0.05). At presentation, malaise (85%), weight loss (73%), abdominal pain (50%) and hepatomegaly (80%) were common. The median survival time from diagnosis was 2 months. The mean age at the time of death was 72 years (range 41-92). At autopsy, cholelithiasis was found in 61% (81% in patients older than 70 years) and cirrhosis in 30% of patients. Cholelithiasis was more common in CCC (p B 0.01) than in hepatocellular carcinoma cases with the same mean age. Not one case of inflammatory bowel disease was found. The gross appearance of the tumor was predominantly massive (49%) or multinodular (35%). The most common histological features were tubular pattern of growth (82%) and abundant fibrous stroma. Metastases were particularly associated with the lymph nodes (41%), skeleton (26%) and lungs (16%).

Research paper thumbnail of Autoimmune hepatitis among fertile women: Strategies during pregnancy and breastfeeding?

Scandinavian Journal of Gastroenterology, 2007

In published studies there is a lack of data about the risks, management and how women with autoi... more In published studies there is a lack of data about the risks, management and how women with autoimmune hepatitis (AIH) decide on and are advised about pregnancy. The aim of this study was to investigate how women with AIH consider pregnancies, are advised and pharmacologically treated, as well as the outcome. A questionnaire was mailed to 128 women with AIH diagnosed during their fertile period and data from the Swedish National Birth Register was also used for matched controls. There was an 83% response rate to the questionnaires. Sixty-three pregnancies were reported by 35 women. 48% did not consult their doctors before getting pregnant. More than half of the women reduced or stopped the immune suppression during pregnancy or breastfeeding. Some women were advised to abstain from pregnancy or even to have an abortion. Caesarean sections were performed more frequently in the AIH group (16% compared with 6.5% in the control group p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01). There were no significant differences in the number of stillborn infants or infants with malformations. However, 30% of the patients experienced flare-up after delivery. In general, the outcome of pregnancy in women with AIH seems to be good. Current pharmacological treatment appears to be safe, including azathioprine during pregnancy and lactation. After delivery an active preparedness to increase pharmacotherapy should be considered.

Research paper thumbnail of Budd-Chiari syndrome in Sweden: epidemiology, clinical characteristics and survival - an 18-year experience

Liver International, 2009

Background: The exact incidence and prevalence of Budd-Chiari syndrome (BCS) is unknown in the ge... more Background: The exact incidence and prevalence of Budd-Chiari syndrome (BCS) is unknown in the general population. Published reports differ in terms of the clinical characteristics, effects of therapy and survival. Aims: To investigate the epidemiology, clinical presentation and survival in patients with BCS. Methods: Retrospective multicentre study in Sweden reviewing the medical records of all patients with BCS 1986-2003, identified from the computerised diagnosis database of 11 hospitals, including all university hospitals and liver transplantation centres. Results: Forty-three patients with BCS were identified, of whom nine (21%) had concomitant portal vein thrombosis. The mean age-standardised incidence and prevalence rates in 1990-2001 were calculated to be 0.8 per million per year and 1.4 per million inhabitants respectively. Myeloproliferative disorders (38%), thrombophilic factors (31%) and oral contraceptives (30%) were common aetiological factors. Two or more risk factors were present in 44%. In 23%, no risk factor was evident. The median follow-up time was 2.7 years. Seventy-two percent were on anticoagulant therapy during follow-up. Transjugular intrahepatic portosystemic shunting, surgical shunting procedures and liver transplantation were performed in 4, 6 and 18 patients respectively. Nineteen patients died. The overall transplantation-free survival at 1, 5 and 10 years was 47, 28 and 17% respectively. Conclusions: Budd-Chiari syndrome is a rare disorder; the mean agestandardised incidence and prevalence rates in Sweden in 1990-2001 were calculated to be 0.8 per million per year and 1.4 per million inhabitants respectively. The presence of a myeloproliferative disorder was a common aetiological factor in our cohort and about half of the patients had a multifactorial aetiology. The transplantation-free survival was poor.

Research paper thumbnail of Abdominal tenderness in ascites patients indicates spontaneous bacterial peritonitis

European Journal of Internal Medicine, 2007

Background: Spontaneous bacterial peritonitis (SBP), which has been reported to be present in 10-... more Background: Spontaneous bacterial peritonitis (SBP), which has been reported to be present in 10-30% of patients with cirrhotic ascites, may easily be overlooked. An important aim of our study was to determine whether there are any clinical signs which, in clinical practice, may predict or exclude SBP. Methods: We studied 133 patients with cirrhotic ascites from medical units at nine Swedish university hospitals where there had been at least one diagnostic ascites tap with analysis of polymorphonuclear leukocytes in the ascites fluid. The patients had initially been questioned about background factors and physically examined according to a standardized case record form. Samples of blood, urine, and ascites were then drawn for analysis according to a structured schedule. Results: SBP could be excluded in 80% of all the cases and was confirmed in 8% of the 133 patients in the final analysis. Abdominal pain and abdominal tenderness were more common in patients with SBP (p b 0.01), but no other physical sign or laboratory test could separate SBP cases from the others. Conclusions: SBP was present in about one-tenth of the hospitalized patients with cirrhotic ascites in this cohort. Performing repeated physical examinations and paying particular attention to abdominal tenderness may be the best way to become aware of the possible development of this complication.

Research paper thumbnail of The epidemiology and clinical features of portal vein thrombosis: a multicentre study

Alimentary Pharmacology & Therapeutics, 2010

Reliable epidemiological data for portal vein thrombosis (PVT) are lacking.

Research paper thumbnail of Moderate hyperkalemia in hospitalized patients with cirrhotic ascites indicates a poor prognosis

Scandinavian Journal of Gastroenterology, 2013

Objective. Development of ascites in patients with liver cirrhosis is an ominous sign with a poor... more Objective. Development of ascites in patients with liver cirrhosis is an ominous sign with a poor outcome. A liver transplantation must be considered, and it then becomes important to know if there are any factors indicating a worsened prognosis. Material and methods. We used official registers for a follow-up study of at least 5 years considering the prognosis of 155 prospectively recruited in-patients with cirrhotic ascites from medical units at nine Swedish university hospitals. All patients had undergone at least one diagnostic ascites tap, and had initially been questioned about background factors and physically examined according to a standardized case record form, followed by sampling of blood, urine, and ascites. Results. Death occurred within 1 year after inclusion in 53% of the cases, and was primarily liver-related in 70%. In a multivariable analysis, the two ordinary variables that showed the strongest correlation with risk of death were serum potassium and abdominal tenderness. All 22 patients with a serum potassium concentration of at least 4.8 mmol/L (maximum 5.8 mmol/L) died within 1 year after inclusion. Potassium concentration was related to renal function and potassium-saving drugs. Conclusion.This follow-up study of a prospectively recruited cohort of in-patients with cirrhotic ascites confirms their poor prognosis. Awareness of an elevated serum potassium value, which would reflect a threatened renal function, seems essential, because it may offer a simple way to identify cases with the worst prognosis. An area for further research should be to explore the significance of including serum potassium in prognostic models.

Research paper thumbnail of Short Answer Questions or Modified Essay questions – More Than a Technical Issue

International Journal of Clinical Medicine, 2012

Purpose, The present article was built on the assumption that the form of an examination may infl... more Purpose, The present article was built on the assumption that the form of an examination may influence learning, and may also reflect different kinds of knowledge. The aim of the study was to evaluate whether the results of an examination differ when short answer questions (SAQ) or modified essay questions (MEQ) are used. Method, Forty-nine students in the internal medicine course in Gothenburg, Sweden, performed a written examination in 2003, which included both SAQ and MEQ. Result, The correlation between the results of SAQ and MEQ was 0.59 (P < 0.001). The percentage correctly answered questions in the two types did not differ significantly. Some students had poor results in either SAQ or MEQ. Conclusion, The general outcome of the study indicates that results of SAQ and MEQ demonstrate a significant correlation. However, they may also reflect differences in mastery of the knowledge domain, which should be considered in relation to aspects of validity.

Research paper thumbnail of Scandinavian Journal of Gastroenterology. 2013; 48: 358–365 ORIGINAL ARTICLE

Moderate hyperkalemia in hospitalized patients with cirrhotic ascites indicates a poor prognosis

Research paper thumbnail of Moderate hyperkalemia in hospitalized patients with cirrhotic ascites indicates a poor prognosis

Scandinavian Journal of Gastroenterology, 2013

Objective. Development of ascites in patients with liver cirrhosis is an ominous sign with a poor... more Objective. Development of ascites in patients with liver cirrhosis is an ominous sign with a poor outcome. A liver transplantation must be considered, and it then becomes important to know if there are any factors indicating a worsened prognosis. Material and methods. We used official registers for a follow-up study of at least 5 years considering the prognosis of 155 prospectively recruited in-patients with cirrhotic ascites from medical units at nine Swedish university hospitals. All patients had undergone at least one diagnostic ascites tap, and had initially been questioned about background factors and physically examined according to a standardized case record form, followed by sampling of blood, urine, and ascites. Results. Death occurred within 1 year after inclusion in 53% of the cases, and was primarily liver-related in 70%. In a multivariable analysis, the two ordinary variables that showed the strongest correlation with risk of death were serum potassium and abdominal tenderness. All 22 patients with a serum potassium concentration of at least 4.8 mmol/L (maximum 5.8 mmol/L) died within 1 year after inclusion. Potassium concentration was related to renal function and potassium-saving drugs. Conclusion.This follow-up study of a prospectively recruited cohort of in-patients with cirrhotic ascites confirms their poor prognosis. Awareness of an elevated serum potassium value, which would reflect a threatened renal function, seems essential, because it may offer a simple way to identify cases with the worst prognosis. An area for further research should be to explore the significance of including serum potassium in prognostic models.

Research paper thumbnail of Registration of Liver Cancer Data—A Study on the Reliability of the Swedish Cancer Registry

Research paper thumbnail of Abdominal tenderness in ascites patients indicates spontaneous bacterial peritonitis

European Journal of Internal Medicine, 2007

Background: Spontaneous bacterial peritonitis (SBP), which has been reported to be present in 10-... more Background: Spontaneous bacterial peritonitis (SBP), which has been reported to be present in 10-30% of patients with cirrhotic ascites, may easily be overlooked. An important aim of our study was to determine whether there are any clinical signs which, in clinical practice, may predict or exclude SBP. Methods: We studied 133 patients with cirrhotic ascites from medical units at nine Swedish university hospitals where there had been at least one diagnostic ascites tap with analysis of polymorphonuclear leukocytes in the ascites fluid. The patients had initially been questioned about background factors and physically examined according to a standardized case record form. Samples of blood, urine, and ascites were then drawn for analysis according to a structured schedule. Results: SBP could be excluded in 80% of all the cases and was confirmed in 8% of the 133 patients in the final analysis. Abdominal pain and abdominal tenderness were more common in patients with SBP (p b 0.01), but no other physical sign or laboratory test could separate SBP cases from the others. Conclusions: SBP was present in about one-tenth of the hospitalized patients with cirrhotic ascites in this cohort. Performing repeated physical examinations and paying particular attention to abdominal tenderness may be the best way to become aware of the possible development of this complication.

Research paper thumbnail of Health check-ups and family screening allow detection of hereditary hemochromatosis with less advanced liver fibrosis and survival comparable with the general …

Scandinavian …, 2011

Objective. The information concerning the morbidity and mortality of hereditary hemochromatosis i... more Objective. The information concerning the morbidity and mortality of hereditary hemochromatosis is based primarily on clinical cohorts of symptomatic patients. The major aim of this study was to analyse the long-term prognosis for Swedish patients with this condition, with respect to both clinical features and survival, in relationship to the route by which the disease was detected. Material and methods. 373 patients with hemochromatosis detected through routine health checkups (n=153), family screening (n=44), symptoms of arthralgia (n=23), investigation of other diseases/symptoms (n=108) or signs of liver disease (n=45) were monitored for a mean period of 11.9±5.8 years. The degree of liver fibrosis and survival were analysed. Results. Overall survival among these patients was not significantly different from that of a matched normal population. The patients diagnosed through health checkups and family screening were detected at an earlier age and had the highest rate of survival. Liver biopsy at the time of diagnosis revealed cirrhosis in 9% of those detected through the health checkups and 5% in the case of family screening, compared with 13% for the group with arthralgia, 17% for other diseases/symptoms and 42% for liver disease. Conclusion. Health checkups and family screening allow detection of hereditary hemochromatosis at an earlier age and with less advanced liver fibrosis, although a few of these patients have already developed cirrhosis. Our study indicates that iron indices should be included in health checkups , and if abnormal, should lead to further investigation.

Research paper thumbnail of Lack of Correlation Between Hepatitis B Virus Infection and the Increasing Incidence of Primary Liver Cancer in Sweden

Acta Oncologica, 1991

The incidence of primary carcinoma of the liver in Sweden has been reported to increase. In order... more The incidence of primary carcinoma of the liver in Sweden has been reported to increase. In order to study the role of chronic hepatitis B virus (HBV) infection for liver cancer development 40 cases with hepatocellular carcinoma (HCC) were examined for the presence of HBV surface antigen and HBV core antigen in the cancer and in the surrounding non-neoplastic liver tissue. It was not possible to demonstrate a single case with tissue HBV antigen, indicating that HBV plays a minor role in the etiology of HCC in Sweden and thus does not seem to be responsible for the increasing incidence of this cancer.

Research paper thumbnail of Acute liver failure in Sweden: etiology and outcome

Objective. To determine the causes and outcome of all patients with acute liver failure (ALF) in ... more Objective. To determine the causes and outcome of all patients with acute liver failure (ALF) in Sweden 1994-2003 and study the diagnostic accuracy of King's College Hospital (KCH) criteria and the model for end-stage liver disease (MELD) score with transplant-free deaths as a positive outcome. Research design and methods. Adult patients in Sweden with international normalized ratio (INR) of ‡1.5 due to severe liver injury with and without encephalopathy at admission between 1994-2003 were included. Results. A total of 279 patients were identified. The most common cause of ALF were acetaminophen toxicity in 42% and other drugs in 15%. In 31 cases (11%) no definite etiology could be established. The KCH criteria had a positive-predictive value (PPV) of 67%, negative-predictive value (NPV) of 84% in the acetaminophen group. Positive-predictive value and negative-predictive value of KCH criteria in the nonacetaminophen group were 54% and 63% respectively. MELD score >30 had a positive-predictive value of 21%, negative-predictive value of 94% in the acetaminophen group. The corresponding figures for the nonacetaminophen group were 64% and 76% respectively. Conclusions. Acetaminophen toxicity was the most common cause in unselected patients with ALF in Sweden. KCH criteria had a high NPV in the acetaminophen group, and in combination with MELD score <30 predicts a good prognosis in acetaminophen patients without transplantation.

Research paper thumbnail of Increased porphyrins in primary liver cancer mainly reflect a parallel liver disease

Recommended by Gianfranco D. Alpini Hepatic porphyries have been associated with an increased ris... more Recommended by Gianfranco D. Alpini Hepatic porphyries have been associated with an increased risk of primary liver cancer (PLC), which on the other hand may cause an increased porphyrin production. To evaluate the role of an underlying liver disorder we analyzed porphyrins in patients with hepatocellular carcinoma (HCC) (n = 65), cholangiocellular carcinoma (n = 3), or suspected PLC, which turned out to be metastases (n = 18) or a benign disorder (n = 11). None of the patients had a family history of porphyry or clinical signs of porphyry. Increased aminolevulinic acid or porphyrin values were common not only in patients with PLC (43%) but also in metastatic (50%) and benign (64%) liver disorders. The corresponding proportion for HCC patients with liver cirrhosis (55%) was higher (P < .05) than in those without cirrhosis (17%). We conclude that symptomatic porphyries are unusual in PLC, whereas elevated urinary and/or faecal porphyrins are common, primarily reflecting a parallel liver disease and not the PLC.

Research paper thumbnail of Natural history and prognostic factors in 305 Swedish patients with primary sclerosing cholangitis

Gut, 1996

Background/Aims-The course of primary sclerosing cholangitis (PSC) is highly variable and unpredi... more Background/Aims-The course of primary sclerosing cholangitis (PSC) is highly variable and unpredictable. This study describes the natural history and outcome of PSC. These data were used to construct a prognostic model for patients with PSC. Methods-A total of 305 Swedish patients with PSC were studied. The median follow up time was 63 (1-194) months and all patients could be traced for follow up. Some 79 patients died or had a liver transplant. The prognostic significance of clinical, biochemical, and histological findings at the time of diagnosis were evaluated using multivariate analysis. Results-The estimated median survival from time of diagnosis to death or liver transplantation was 12 years. Cholangiocarcinoma was found in 24 (8%) of the patients and 134 (44%) ofthe patients were asymptomatic at the time of diagnosis. The estimated survival rate was significantly higher in the asymptomatic group (p<0.001). However, 29 (22%) of the asymptomatic patients became symptomatic during the study period. It was found that age, serum bilirubin concentration, and histological stage at the time of diagnosis were independent predictors of a bad prognosis. These variables were used to construct a prognostic model. Conclusions-This prognostic model developed from a large homogeneous population of PSC patients should be of value for the timing oftransplantation and patient counselling in PSC.

Research paper thumbnail of Incidence of primary liver cancer and aetiological aspects: a study of a defined population from a low-endemicity area

The prevalence of primary liver cancer (PLC) varies throughout the world. It has been attributed ... more The prevalence of primary liver cancer (PLC) varies throughout the world. It has been attributed to variations in incidence of the predominant histological type, hepatocellular carcinoma (HCC). The incidence of PLC types other than HCC such as cholangiocellular carcinoma (CCC) is far less known, especially in low-incidence areas. The aetiology of HCC and other PLC types is obscure, with the exception of the association between HCC and cirrhosis as well as chronic viral hepatitis. The present retrospective incidence and aetiology study concerns a well-defined population from a period with a high autopsy frequency. Preserved biopsy specimens were re-evaluated histopathologically and patient records were studied. Among 590 histologically verified cases of PLC, HCC constituted 90%, CCC 8% and a mixed form of these types 1%. At the end of the study period the annual age-standardised incidence rate of HCC was 3.6 cases per 100 000 inhabitants. Other PLC types were hepatoblastoma (n = 3), fibrolamellar carcinoma (n = 2), angiosarcoma (n = 1) and infantile haemangioendothelioma (n = 1), each constituting less than I % of the PLC cases. Comparing HCC with CCC we found that cirrhosis (70%) and alcoholism (21%) was significantly more frequent in HCC, and cholelithiasis was significantly more common (60%) in patients with CCC. In the majority of the PLC cases with liver cirrhosis this disorder was unknown before diagnosis of the tumour.

Research paper thumbnail of Incidence, Etiologic Aspects and Clinicopathologic Features in Intrahepatic Cholangiocellular Carcinoma: A Study of 51 Cases From a Low-Endemicity Area

Acta Oncologica, 1998

A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) f... more A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) from a low-endemicity area of primary liver cancer was analyzed during the periods from 1958 to 1979 and from 1984 to 1991. The mean annual age-adjusted incidence rate was 0.44 for males and 0.56 for females per 100 000 inhabitants. CCC was diagnosed before death in only 31%. There was a female predominance in patients over 70 years of age (p B 0.05). At presentation, malaise (85%), weight loss (73%), abdominal pain (50%) and hepatomegaly (80%) were common. The median survival time from diagnosis was 2 months. The mean age at the time of death was 72 years (range 41-92). At autopsy, cholelithiasis was found in 61% (81% in patients older than 70 years) and cirrhosis in 30% of patients. Cholelithiasis was more common in CCC (p B 0.01) than in hepatocellular carcinoma cases with the same mean age. Not one case of inflammatory bowel disease was found. The gross appearance of the tumor was predominantly massive (49%) or multinodular (35%). The most common histological features were tubular pattern of growth (82%) and abundant fibrous stroma. Metastases were particularly associated with the lymph nodes (41%), skeleton (26%) and lungs (16%).

Research paper thumbnail of Incidence, Etiologic Aspects and Clinicopathologic Features in Intrahepatic Cholangiocellular Carcinoma: A Study of 51 Cases From a Low-Endemicity Area

Acta Oncologica, 1998

A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) f... more A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) from a low-endemicity area of primary liver cancer was analyzed during the periods from 1958 to 1979 and from 1984 to 1991. The mean annual age-adjusted incidence rate was 0.44 for males and 0.56 for females per 100 000 inhabitants. CCC was diagnosed before death in only 31%. There was a female predominance in patients over 70 years of age (p B 0.05). At presentation, malaise (85%), weight loss (73%), abdominal pain (50%) and hepatomegaly (80%) were common. The median survival time from diagnosis was 2 months. The mean age at the time of death was 72 years (range 41-92). At autopsy, cholelithiasis was found in 61% (81% in patients older than 70 years) and cirrhosis in 30% of patients. Cholelithiasis was more common in CCC (p B 0.01) than in hepatocellular carcinoma cases with the same mean age. Not one case of inflammatory bowel disease was found. The gross appearance of the tumor was predominantly massive (49%) or multinodular (35%). The most common histological features were tubular pattern of growth (82%) and abundant fibrous stroma. Metastases were particularly associated with the lymph nodes (41%), skeleton (26%) and lungs (16%).

Research paper thumbnail of Autoimmune hepatitis among fertile women: Strategies during pregnancy and breastfeeding?

Scandinavian Journal of Gastroenterology, 2007

In published studies there is a lack of data about the risks, management and how women with autoi... more In published studies there is a lack of data about the risks, management and how women with autoimmune hepatitis (AIH) decide on and are advised about pregnancy. The aim of this study was to investigate how women with AIH consider pregnancies, are advised and pharmacologically treated, as well as the outcome. A questionnaire was mailed to 128 women with AIH diagnosed during their fertile period and data from the Swedish National Birth Register was also used for matched controls. There was an 83% response rate to the questionnaires. Sixty-three pregnancies were reported by 35 women. 48% did not consult their doctors before getting pregnant. More than half of the women reduced or stopped the immune suppression during pregnancy or breastfeeding. Some women were advised to abstain from pregnancy or even to have an abortion. Caesarean sections were performed more frequently in the AIH group (16% compared with 6.5% in the control group p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01). There were no significant differences in the number of stillborn infants or infants with malformations. However, 30% of the patients experienced flare-up after delivery. In general, the outcome of pregnancy in women with AIH seems to be good. Current pharmacological treatment appears to be safe, including azathioprine during pregnancy and lactation. After delivery an active preparedness to increase pharmacotherapy should be considered.

Research paper thumbnail of Budd-Chiari syndrome in Sweden: epidemiology, clinical characteristics and survival - an 18-year experience

Liver International, 2009

Background: The exact incidence and prevalence of Budd-Chiari syndrome (BCS) is unknown in the ge... more Background: The exact incidence and prevalence of Budd-Chiari syndrome (BCS) is unknown in the general population. Published reports differ in terms of the clinical characteristics, effects of therapy and survival. Aims: To investigate the epidemiology, clinical presentation and survival in patients with BCS. Methods: Retrospective multicentre study in Sweden reviewing the medical records of all patients with BCS 1986-2003, identified from the computerised diagnosis database of 11 hospitals, including all university hospitals and liver transplantation centres. Results: Forty-three patients with BCS were identified, of whom nine (21%) had concomitant portal vein thrombosis. The mean age-standardised incidence and prevalence rates in 1990-2001 were calculated to be 0.8 per million per year and 1.4 per million inhabitants respectively. Myeloproliferative disorders (38%), thrombophilic factors (31%) and oral contraceptives (30%) were common aetiological factors. Two or more risk factors were present in 44%. In 23%, no risk factor was evident. The median follow-up time was 2.7 years. Seventy-two percent were on anticoagulant therapy during follow-up. Transjugular intrahepatic portosystemic shunting, surgical shunting procedures and liver transplantation were performed in 4, 6 and 18 patients respectively. Nineteen patients died. The overall transplantation-free survival at 1, 5 and 10 years was 47, 28 and 17% respectively. Conclusions: Budd-Chiari syndrome is a rare disorder; the mean agestandardised incidence and prevalence rates in Sweden in 1990-2001 were calculated to be 0.8 per million per year and 1.4 per million inhabitants respectively. The presence of a myeloproliferative disorder was a common aetiological factor in our cohort and about half of the patients had a multifactorial aetiology. The transplantation-free survival was poor.

Research paper thumbnail of Abdominal tenderness in ascites patients indicates spontaneous bacterial peritonitis

European Journal of Internal Medicine, 2007

Background: Spontaneous bacterial peritonitis (SBP), which has been reported to be present in 10-... more Background: Spontaneous bacterial peritonitis (SBP), which has been reported to be present in 10-30% of patients with cirrhotic ascites, may easily be overlooked. An important aim of our study was to determine whether there are any clinical signs which, in clinical practice, may predict or exclude SBP. Methods: We studied 133 patients with cirrhotic ascites from medical units at nine Swedish university hospitals where there had been at least one diagnostic ascites tap with analysis of polymorphonuclear leukocytes in the ascites fluid. The patients had initially been questioned about background factors and physically examined according to a standardized case record form. Samples of blood, urine, and ascites were then drawn for analysis according to a structured schedule. Results: SBP could be excluded in 80% of all the cases and was confirmed in 8% of the 133 patients in the final analysis. Abdominal pain and abdominal tenderness were more common in patients with SBP (p b 0.01), but no other physical sign or laboratory test could separate SBP cases from the others. Conclusions: SBP was present in about one-tenth of the hospitalized patients with cirrhotic ascites in this cohort. Performing repeated physical examinations and paying particular attention to abdominal tenderness may be the best way to become aware of the possible development of this complication.

Research paper thumbnail of The epidemiology and clinical features of portal vein thrombosis: a multicentre study

Alimentary Pharmacology & Therapeutics, 2010

Reliable epidemiological data for portal vein thrombosis (PVT) are lacking.

Research paper thumbnail of Moderate hyperkalemia in hospitalized patients with cirrhotic ascites indicates a poor prognosis

Scandinavian Journal of Gastroenterology, 2013

Objective. Development of ascites in patients with liver cirrhosis is an ominous sign with a poor... more Objective. Development of ascites in patients with liver cirrhosis is an ominous sign with a poor outcome. A liver transplantation must be considered, and it then becomes important to know if there are any factors indicating a worsened prognosis. Material and methods. We used official registers for a follow-up study of at least 5 years considering the prognosis of 155 prospectively recruited in-patients with cirrhotic ascites from medical units at nine Swedish university hospitals. All patients had undergone at least one diagnostic ascites tap, and had initially been questioned about background factors and physically examined according to a standardized case record form, followed by sampling of blood, urine, and ascites. Results. Death occurred within 1 year after inclusion in 53% of the cases, and was primarily liver-related in 70%. In a multivariable analysis, the two ordinary variables that showed the strongest correlation with risk of death were serum potassium and abdominal tenderness. All 22 patients with a serum potassium concentration of at least 4.8 mmol/L (maximum 5.8 mmol/L) died within 1 year after inclusion. Potassium concentration was related to renal function and potassium-saving drugs. Conclusion.This follow-up study of a prospectively recruited cohort of in-patients with cirrhotic ascites confirms their poor prognosis. Awareness of an elevated serum potassium value, which would reflect a threatened renal function, seems essential, because it may offer a simple way to identify cases with the worst prognosis. An area for further research should be to explore the significance of including serum potassium in prognostic models.