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Background & Aims: Equality of access to organ transplantation is a mandatory public health requirement. Referral from a local to a university hospital and then registration on the national waiting list are the two key steps enabling access to liver transplantation (LT). Although the latter procedure is well defined using the Model for End-stage Liver Disease score that improves equality of access, the former is mostly reliant on the practices of referring physicians. The aim of this study was to clarify the factors determining this initial step., Methods: This observational study included consecutive inpatients with cirrhosis of whatever origin in a cohort constituted between 2003 and 2008, using medical records and structured questionnaires concerning patient characteristics and the opinions of hospital clinicians. Candidates for LT were defined in line with these opinions., Results: Four hundred and thirty-three patients, mostly affected by alcoholic cirrhosis, were included, 21.0% of whom were considered to be candidates for LT. Factors independently associated with their candidature were: physician empathy [odds ratio (OR) = 10.8; 95% CI: 4.0-29.5], adherence to treatment (OR = 16.6; 95% CI: 3.7-75.2), geographical area (OR = 6.8; 95% CI: 2.2-21.3) and the patient's physiological age (OR = 2.3; 95% CI: 1.1-4.7)., Conclusions: Several subjective markers restrict the referral of patients from local hospitals to liver transplant centres. Their advancement to this second step is thus markedly weakened by initial subjectivity. The development of objective guidelines for local hospital physicians to assist them with their initial decision-making on LT is now necessary., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The authors describe a case of cirrhogenic hepatitis due to Pexid which was given for 8 months at 400 mg/day for a severe angina pectoris. We find here the anatomo-clinical profile of perhexiline maleate hepatiits already described in approximately 20 cases. There was a cirrhogenic evolution in our case as in 5 others : but here cirrhosis was revealing and seems stabilized since the treatment was stopped. The cirrhogenic evolution could be due to a cumulative effect of the drug and/or to an immuno-allergic mechanism as in alcoholic cirrhosis which is very similar, especially from an anatomical point of view. However cirrhogenic hepatitis differs by a characteristic lysosomal overload : brown pigment under microscopic observation and lipolysosomes with in some cases a lamellar structure under electron microscopic observation. The prescription of such a drug should be limited to cases of refractory angina pectoris and needed a regular clinical and biological survey.

Over 14 years the authors have observed 6 adults with a special form of portal hypertension revealed by massive gastrointestinal hemorrhages due to rupture of voluminous esophageal varices. Though first suggested by huge enlargement of the spleen (5 out of 6 cases), cirrhosis was eventually discounted by laparoscopy and laparotomy. The liver was of normal volume, smooth (never nodular) and above all soft to the touch, to the biopsy needle and to the surgeon's hand. The histologic lesions of the liver were minimal and heterogeneous: fibrosis without cirrhosis (2 cases), isolated and mild steatosis (2 cases), one non-specific lymphohistiocytic granuloma (2 cases), moderate myeloid metaplasia (2 cases), hepatic siderosis without fibrosis (1 case), sinusoidal congestion (3 cases). Normality of the portal vein was evidenced by angiography (5 cases) or inferred from the elevated porta-caval gradient (1 case), and was confirmed once on autopsy. Sus-hepatic catheterization was performed in every case and provided the following information: right atrial pressure always normal, sus-hepatic veins normal, porta-caval gradient normal or slightly elevated in 4 patients (suggesting presinusoidal block) and obviously elevated in the other two (as in post-sinusoidal block). The minimal histologic lesions of the liver, the normality of the portal vein, the lack of sus-hepatic obstruction, and the variable porta-caval gradient make it impossible to localize the obstacle (if any) and thus say what is the mechanism of portal hypertension with soft liver. In the absence of elevated splenic inflow, this hypertension has to be classified as essential or idiopathic. Soft consistency of the liver has never been reported before in such cases.

The diagnosis of proctated jaundice is done in 50% of all cases by clinical examination; in 30% of all cases by peritoneoscopy; in the other 20% instrumental opacification of the biliary tract is required (before the laparotomy) in order to determine the site and the nature of the cholestasis. Among these instrumental devices, a transhepatic cholangiography with the Okuda needle allows biliary tract opacification in 98% of all cases if the obstacle is extra-hepatic and in 69% of all cases if the obstacle is intra-hepatic. This technique is easy to perform, without danger, and readily available to any physician. It should be performed after the peritoneoscopy and before the retrograde cholangiography.