MicroRNA signature in hepatocellular carcinoma patients: identification of potential markers

MicroRNAs (miRNAs) play important roles in liver pathologies and they are potential biomarkers for diagnosis of liver diseases progression. Changes in miRNA sera expression can be used as non-invasive biomarkers for hepatocellular carcinoma (HCC). The aim of the study was to identify the miRNome profiling of HCC and its diagnostic value in distinguishing HCC from healthy individuals. Expression profiles of miRNAs in serum samples of 20 HCC patients and 10 healthy controls were detected. Whole miRNome profiling was done using next generation sequencing. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic performance of the deregulated miRNAs for discriminating HCC cases from healthy controls. MiRNA 142 was highly expressed in HCC (P value = 0.023) while miRNAs 191, 22, and 126 were higher in the controls (P value = 0.005, 0.034, 0.010 respectively). We have identified 5 novel miRNAs and they were highly expressed in HCC than controls. Analysis of ROC curve demonstrated that these deregulated miRNAs can be used as a reliable biomarker for detection of HCC with high diagnostic accuracy (AUC = 0.93). We have detected a panel of serum miRNAs that can be used as a reliable noninvasive screening biomarker of HCC. The study recommends further research to shed light on a possible role of the newly discovered novel miRNAs in HCC pathogenesis.

Safety and Efficacy of Rifaximin in Prophylaxis of Spontaneous Bacterial Peritonitis: A Systematic Review and Meta-analysis

AIM

The role of rifaximin in the prevention of Spontaneous Bacterial Peritonitis (SBP) is not well studied. The aim of this meta-analysis was to evaluate the role of rifaximin in the prevention of SBP.

METHODS

A computerized literature search for relevant clinical trials was conducted during August 2017. Data on Frequency of SBP, the success rate of prevention of SBP, mortality rate, hepatorenal syndrome, septic shock, hepatic encephalopathy, and GIT bleeding were extracted and pooled as Risk Ratio (RR) with their 95% Confidence Interval (CI) in a meta-analysis model. Heterogeneity was assessed by Chi-square test.

RESULTS

Six studies involving 973 patients were included in the final analysis. The pooled effect estimate showed that the rifaximin plus norfloxacin group had less incidence of SBP (RR 0.58, 95% CI[0.37, 0.92], P=0.02) and hepatic encephalopathy (RR 0.38, 95% CI[0.17, 0.84], P=0.02) than the norfloxacin-based regimen group. No significant difference between rifaximin and norfloxacin in terms of frequency of SBP and success rate of primary prevention of SBP (RR 0.49, 95% CI [0.24, 1.01], P=0.05; RR1.21, 95% CI [0.95, 1.55], P=0.13, respectively).

CONCLUSION

Based on our analysis, Rifaximin is a promising drug and appears to be a good alternative to norfloxacin in the prevention of SBP.

Serum Alpha-fetoprotein Levels and Response to Direct Antiviral Therapy in Patients with Chronic Hepatitis C: Real-world Results from 1716 Patients in Egypt

BACKGROUND & AIMS

Direct Antiretroviral Agents (DAAs), sofosbuvir-based therapies, have opened a new era in the treatment of chronic HCV infection. The aim of the study was to investigate the potential use of baseline and in serial serum, AFP levels as a predictor for response to DAAs in patients with Chronic Hepatitis C.

METHODS

This multicenter observational study was carried out on 1716 chronic hepatitis C virusinfected patients who received direct anti-viral drugs for 12 weeks. The primary end point was sustained virological response at 12 weeks after the end of treatment determined by quantitative PCR for HCV RNA. Serum AFP was quantitatively assessed at baseline then after 12week after stoppage of treatment (SVR12).

RESULTS

SVR12 rate was 97.8%. Elevated serum AFP was significantly higher in non -SVR group p value (<0.001). There was a significantly marked decrease in AFP after treatment in comparison to pretreatment values. The multivariate logistic regression analysis on the resulting significant variable from the univariate analysis revealed that only AFP was significantly related to the response to direct antiviral therapy in patients with chronic hepatitis C with p <0.001, OR 1.10 (95% CI 1.07:1.12). Other sociodemographic (e.g. Age, gender, BMI, ..) or laboratory factors (Hb, ANC, WBCs, …) did not show any significant association with the patients' response to treatment.

CONCLUSIONS

Serum AFP levels were a predictor for response in patients with chronic HCV with the administration of direct antiviral drugs.

Autologous dendritic cells pulsed with lysate from an allogeneic hepatic cancer cell line as a treatment for patients with advanced hepatocellular carcinoma: A pilot study

OBJECTIVES

This is a randomized trial adopted to evaluate the safety and efficacy of immunization with specific anti-hepatocellular carcinoma dendritic cells (DCs) in Egyptian patients with advanced hepatocellular carcinoma (HCC) as a treatment or adjuvant therapy in comparison with the traditional therapy.

METHODS

This study was conducted on 20 HCC patients who were assigned to four groups according to BCLC staging; group I: HCC patients (stage B) received trans-arterial chemoembolization (TACE) and DCs as an adjuvant therapy; group II: HCC patients (stage B) received TACE only; group III: advanced HCC patients (stage D) received DCs vaccine; group IV: advanced HCC patients (stage D) received supportive treatment. DCs were generated from peripheral blood monocytes and pulsed with a lysate of an allogeneic hepatic cancer cell line (HepG2). Toxicity and immunological response were reported as primary outcomes whereas clinical biochemical and radiological responses were reported as secondary outcomes.

RESULTS

Our study detected that patients who received DCs vaccine (group III) showed mild decrease in Child-Pugh score as well as AFP and PIVKA II levels and developed 20% partial response [PR] 40% stable disease [SD] and 40% progressive disease [PD] compared to the patients of group IV on supportive treatment who developed 100% PD. Although group I patients developed PR (60%) SD (20%) and PD (20%) no significant difference was detected in the clinical biochemical or radiological response between group I and group II patients. DCs vaccine had minimal adverse effects with no autoimmunity and elicited a better immunological response such as increased CD8 cells percentage and number as well as decreased TGFβ levels in the vaccinated patients.

CONCLUSION

DCs vaccine is safe as it is not associated with significant toxicity. However due to the small number of included patients the efficacy and immune response of using DCs vaccine in the treatment of advanced HCC patients need to be justified by testing of a large cohort.

Reuse of Biopsy Forceps may be Associated with Risk of Transmission of HCV in Egyptian Patients Undergoing Gastrointestinal Endoscopy

BACKGROUND AND AIMS

Hepatitis viruses are not transmitted via gastrointestinal endoscopy except if there are any mistakes in sterilization and disinfection of the endoscope that disrupt the infection control measures. So we aimed to measure the risk of transmitting HCV by GI endoscopy at department of Tropical Medicine and infectious Diseases, in a major University hospital in Egypt.

METHODS

Our study was conducted on four hundred patients with exclusion of those with HCV, HBV, and/or HIV positive antibodies. An ethical committee approval and a given consent were taken prior to enrollment on the study. Our patients are grouped into the following; 100 patients undergoing upper GI endoscopy without biopsy as group I; 100 patients undergoing upper GI endoscopy with biopsy as group II; 100 patients undergoing lower GI endoscopy without biopsy as group III and 100 patients undergoing lower GI endoscopy with biopsy as group IV. HCV antibodies were done 3 months after endoscopy with exclusion of other risks of HCV infection by a detailed questionnaire.

RESULTS

Only one case was reported positive after 3 months of procedure; it was after colonoscopy with biopsy using reusable forceps.

CONCLUSIONS

Strict infection control measures of the GI endoscopes despite being effective in preventing HCV transmission, the reuse of disinfected biopsy forceps may be associated with a risk of transmission. So, we recommend using disposable forceps for every patient to omit the risk of HCV transmission during endoscopy.

Evaluation of Different Sedatives for Colonoscopy

Background & Aims:

Sedation and analgesia are important elements of endoscopic examinations; sedation for colonoscopy aims to relieve patient discomfort and anxiety, improve the outcome of the examination, diminish the patient’s memory of the event and achieve comfortable and technically successful endoscopic procedure.

Methods:

Our prospective study was carried out on 150 patients who were referred for colonoscopy; they were divided into two groups based on the pre-endoscopic sedation given for them: propofol fentanyl or propofol ketamine. Detailed histories, thorough physical examinations, and routine laboratory investigations were performed for all patients, along with monitoring of their vital signs and oxygen saturation levels (before, during and after colonoscopy), to assess safety, efficacy, recovery times, complications of the sedative drugs, comfort of the patients and endoscopists.

Results:

There was no statistically significant difference between the two groups in terms of age, sex and Body Mass Indexes (BMI). With respect to their Mean Arterial Blood Pressures (MAPs) and heart rates, there was high hemodynamic stability in the propofol ketamine group, and both the groups were efficacious, although the propofol fentanyl group had shorter recovery times than the propofol ketamine group (3±1.7 minutes and 4±2.8 minutes, respectively). However, nausea, vomiting and hypoxia were common in the propofol fentanyl group, while hallucinations were common in the propofol ketamine group. In propofol fentanyl group; there was a significant decrease in the heart rate more common in females (with age range 39-58 years) during and after colonoscopy [p value 0.01].

Conclusion:

Sedation with propofol ketamine during colonoscopy was found to be safe and efficacious to achieve hemodynamic stability with fewer complications than propofol fentanyl.

Relationship Between Helicobacter pylori Infection and Nonalcoholic Fatty Liver Disease (NAFLD) in a Developing Country: A Cross-Sectional Study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a very common disease that affects 25-30% of the population in western countries. Many studies have observed the importance of H. pylori infection in the development of insulin resistance, non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, and liver fibrosis and cirrhosis. However, the evidence from different studies was controversial. The present study aimed to investigate the relationship between H. pylori infection and NAFLD in a developing country.

PATIENTS AND METHODS

This cross-sectional study included all the attending outpatient clinics at four Major University hospitals and two research and clinical institutes in a developing country in the period between June and October 2019. Patients were assessed for the diagnosis of H. pylori infection as detected by H. pylori antigen in stool; they were also assessed for the diagnosis of NAFLD by ultrasound, fibroscan, and CAP.

RESULTS

The study was conducted on 646 patients; H. pylori infection was found to be present in 538 patients (83.3%). NAFLD (diagnosed by both U/S and Fibroscan with CAP), ALT, AST, hepatomegaly, hypertension, fasting blood sugar were significantly higher in H. pylori +ve group than H. pylori -ve group. After performing Linear regression of independent risk factors of NAFLD to prove or to refute the role of Helicobacter; H. pylori positivity, total cholesterol, degree of fatty liver by ultrasound, fasting blood sugar and diastolic blood pressure were independent risk factors for NAFLD.

CONCLUSION

Helicobacter pylori infection was independent risk factors for NAFLD and correlated with increased degree of steatosis.

Serum Dickopff 1 as a Novel Biomarker in Hepatocellular Carcinoma Diagnosis and Follow Up After Ablative Therapy

Background

This study aimed to evaluate the role of Dickopff 1 (DKK1) serum levels as a marker for early detection of hepatocellular carcinoma (HCC) and to compare it with alphafetoprotein (AFP) after non-surgical intervention (microwave ablation, radiofrequency ablation) in HCC.

Patients and methods

This prospective study was conducted in Al-Mahalla hepatology teaching hospital from June 2015 to June 2017. One hundred and twenty patients were included. They were classified into four groups: Group A: 40 patients with chronic liver disease; Group B: 40 patients with HCC which were divided into 2 main sub groups, group Ba which included HCC patients who were not eligible for ablative therapy and group Bb which included HCC patients who were eligible for ablative therapy; Group C: 20 healthy control subjects matched for age and sex; Group D: 20 HCC patients with negative AFP, DKK1 was done for them.

Results

There was a highly significant difference (p < 0.001) between groups regarding serum level of Dickpoff 1 with mean of 1 ng/mL in group A (cirrhotic), 2.38 ng/mL in group B (HCC), and 1.83 ng/mL in group D (AFP negative HCC) in comparison to control group C with mean of 0.54 ng/mL. There was a highly statistically significant difference (p value less =0.01) in the studied groups regarding serum Dickpoff 1 before and after intervention with a mean of 2.38 ng/mL before intervention and mean of 1.37 ng/mL after 1 month of intervention.

Conclusion

Serum Dkk-1 has higher sensitivity, specificity, and accuracy in early diagnosis of HCC than AFP.

Sofosbuvir, Pegylated Interferon and Ribavirin in the Treatment of an Egyptian Cohort with Hepatitis C Virus Infection in Real-Life Clinical Practice

BACKGROUND & AIMS

Hepatitis C virus infection is a major public health problem in Egypt with a risk for morbidity and mortality due to chronic liver disease complications. Worldwide, Egypt has the highest prevalence of HCV infection with the overall prevalence of about 14.7%. The aim of this study was to evaluate the antiviral efficacy, safety, and tolerability of sofosbuvir (SOF) plus Pegylated Interferon (Peg- IFNa) and Ribavirin (RBV) in Egyptian patients with chronic hepatitis C virus (HCV) infection.

METHODS

This study was carried out in 1200 patients with chronic hepatitis C virus infection who were eligible for interferon therapy. They were treated with the triple therapy of sofosbuvir 400 mg once daily, Peg-INF subcutaneous injection weekly for 12 weeks in combination with oral weight-based ribavirin. The primary outcome measures were the number of patients with successful eradication of the virus evidenced by the sustained virologic response (SVR) at 12 Weeks. After discontinuation of Therapy (SVR12), the secondary outcome measures were the incidence of adverse effects associated with the tested HCV therapy.

RESULT

The mean age of the patients was 49.32 ± 6.97 years. 45.9% of them were males and 54.1% were females.70 patients (5.8%) had a history of previous HCV treatment. ''1077 (89.8%)'' of patients achieved successful eradication of virus while ''106 (8.8%)'' were resistant to treatment and ''17 (1.4%)'' stopped treatment. Good predictors of response to the triple therapy were female gender, treatment naive and non-cirrhotic patients.

CONCLUSION

The triple regimen of Pegylated interferon, sofosbuvir plus ribavirin is safe and effective in the treatment of Egyptian patients with hepatitis C virus and is associated with real-life SVR12 rates of 89.8%.

Diabetes Association with Liver Diseases: An Overview for Clinicians

BACKGROUND

There is a strong association between liver diseases and diabetes (DM) which is higher than expected by a correlation between two very common diseases. Liver diseases may occur as a result of diabetes, and the reverse is true as well.

AIM

To review the etiology of this association between liver diseases and diabetes and how to diagnose it.

METHODS

Studies that identified this association between liver diseases and diabetes and how to diagnose it was reviewed.

RESULTS

This association can be divided into the following categories: liver disease related to diabetes (Diabetic hepatopathy), hepatogenous diabetes (HD), and liver diseases that occur in conjunction with Diabetes mellitus. Two hours after glucose loading is the best screening test for HD. HbA1c may neither be suitable for diagnosis nor monitoring of diabetes that links liver disease.

CONCLUSION

NAFLD, hepatogenous diabetes, glycogenic hepatopathy and diabetic hepatosclerosis are the most important association between liver diseases and diabetes. The criteria for the diagnosis of diabetes associating liver disease are the same for primary diabetes. Two hours post glucose load is the best screening test for HD due to the fact that fasting glucose can be normal early in the disease. The tool used for diabetes monitoring depends on stage and severity of liver condition.

Impact of pre-transplant infection management on the outcome of living-donor liver transplantation in Egypt

Background and aim

Liver transplantation (LT) has emerged as an established therapeutic option for patients with chronic liver disease. Patients with end-stage liver disease are at high risk of infection with multidrug-resistant organisms, which may affect the outcome of LT. The aim of this study was to evaluate the impact of pre-transplant infection on the outcome of living-donor LT.

Methods

Prospective follow-up was done for 50 patients with chronic liver disease who had had LT performed from September 2013 to December 2017. We divided patients into group 1 (patients who had had infection within 3 months before transplantation with adequate treatment [n=20]), and group 2 (patients without infection [n=30]). Both groups were followed for 4 months post-operatively.

Results

Patients with high Model for End-Stage Liver Disease scores were more susceptible to infection pre- and post-operatively, and chest infection was the most common infection pre-transplant. There were no significant statistical differences regarding hospital and ICU stay and post-operative course between the groups, but the mortality rate was higher in group 1 (40%) than in group 2 (23.3%), and the causes of mortality in the group 1 were mainly due to medical causes (infections and sepsis, 75%) versus 28.6% in group 2.

Conclusion

Liver-cell failure and concomitant infection 3 months before LT with adequate treatment had no significant statistical differences regarding hospital, ICU stay, or medical complications, but post-operative infection and mortality rate were more frequent in group 1 and the causes of mortality were mainly medical.

Comparative Evaluation of Colon Cancer Specific Antigen-2 Test and Chromocolonoscopy for Early Detection of Egyptian Patients with Colorectal Cancer

Background: Effective screening of colorectal cancer (CRC) in early stage could reduce the advancement of CRC and therefore mortality. Effective screening is based on either stool dependent tests or colon dependent examination.

Aims: The aim of the study was a comparative evaluation of chromocolonoscopy and Colon Cancer-Specific Antigen-2 test for early detection of colorectal cancer in Egyptian patients.

Methods: This case control study was carried out on 55 patients classified into 3 groups: Group I consisted of twenty patients with precancerous lesions detected by colonoscopy, Group II consisted of twenty patients diagnosed with colorectal cancer and Group III consisted of fifteen individuals (who underwent colonoscopy for other indications) as a control group. All the subjects were subjected to measure occult blood in the stool, measurement of Colon Cancer-Specific Antigen-2 level in serum and tissue and chromo colonoscopy using Indigo Carmine stain.

Results: In group II, there was a statistically significant increase in CCSA2 in serum as compared to the other 2 groups. Cutoff >11.3 CCSA2 in serum showed 65% sensitivity, 85% specificity, 81.2% PPV, 70.8% NPV and 70.3% accuracy in the differentiation of group II with cancer colon from group I with premalignant colonic lesions. A cutoff > 9.1 CCSA2 in serum showed 95% sensitivity, 46.67% specificity, 70.4% PPV, 87.5% NPV and 73.5% accuracy in differentiating group II with cancer colon from normal controls (group III).

Conclusion: CCSA-2 level in serum was significantly higher in cancer colon. Chromoendoscopy has a role in the detection of polyps, both neoplastic and non-neoplastic.

Genetic Susceptibility in Family Members of Egyptian Hepatitis C Virus Infected Patients: Role of Interleukin-12 B Gene Polymorphism

AIM

The research was conducted to study 1188 A\C polymorphism of Interleukin (IL)-12B gene for C/C, A/C and A/A genotypes in families of Hepatitis C virus (HCV) infected patients in Egypt.

METHODS

Three hundreds HCV patients, 860 family members and 100 healthy subjects were studied. All family members were screened for HCV antibodies by enzyme-linked immunosorbent assay (ELISA). Positive cases were examined using Real-Time polymerase chain reaction (PCR) to confirm the presence of HCV ribonucleic acid (RNA) and detect the viral load. Molecular study of IL-12B gene was carried out on all patients, family members and controls using PCR and restriction enzyme analysis.

RESULTS

HCV infection was confirmed in 10.6% of family members. The distribution of IL-12B gene polymorphism in patients was 2.3%, 45.7% and 52% for C/C, A/C and A/A genotypes respectively, in infected family members was 3.3%, 41.7%, 55%, in noninfected family members was 4.5%, 43.5% and 52% for C/C, A/C and A/A genotypes respectively and in control was 5%, 36% and 59% for C/C, A/C and A/A genotypes respectively. The frequency of the C/C, A/C and A/A genotype was not significantly different between the studied groups.

CONCLUSION

IL-12B gene polymorphism has no role in intrafamilial susceptibility of HCV transmission. The distribution of the functional 1188 A\C polymorphism of Interleukin (IL)-12B gene for C/C, A/C and A/A genotypes was not significantly different among the studied groups.

Efficacy of a non-invasive model in predicting the cardiovascular morbidity and histological severity in non-alcoholic fatty liver disease

BACKGROUND

Insulin resistance (IR) in cases of non-alcoholic fatty liver disease (NAFLD) is connected to remarkable liver cell inflammation and cardiovascular complications. Given the prevalence of NAFLD and its association with potential sequels, there is a strong need for an accurate non-invasive tool to monitor the progression of NAFLD.

METHODS

272 patients with NAFLD and cardio-metabolic risk factors were tested for HOMA-IR, mean platelet volume (MPV), neutrophil-lymphocyte ratio (NLR), uric acid, ferritin, lipid profile, liver stiffness measurement (LSM), controlled attenuation parameter (CAP) by fibroscan and carotid intima media thickness (CIMT). Liver biopsy was performed to validate the results.100 healthy controls were selected. A score was constructed and applied to a validation group (n = 61).

RESULTS

Logistic regression revealed that significant fibrosis and cardiovascular risk in NAFLD were independently associated with AST/ALT ratio (p = 0.000), GGT (p = 0.000), CIMT (p = 0.001), uric acid (p = 0.000), VLDL (p = 0.000), HOMA-IR (p = 0.000), ferritin (p = 0.000) CAP (p = 0.000), LSM (p0.000). A non-invasive model was formulated by which a value > 15 was accurate in identification of advanced fibrosis and cardiovascular risk with a sensitivity of 97.3%, specificity 97%.

CONCLUSION

The score correlated well with the results of liver biopsy and can be repeated with great flexibility to assess severity of NAFLD.

Rescue therapy for chronic hepatitis C virus infection after repeated treatment failures: Impact on disease progression and risk of hepatocellular carcinoma

AIM

Retreatment after previous failure of direct-acting antivirals for hepatitis C virus (HCV) infection is a challenging decision. The importance of achieving viral eradication on modification of disease progression and outcome, including the risk of hepatocellular carcinoma (HCC), remains a critical issue to be evaluated.

METHODS

One hundred patients with repeated failure of sofosbuvir and ribavirin or triple therapy with sofosbuvir, ribavirin, and daclatasvir were divided into a study group (n = 50) given rescue therapy (sofosbuvir, daclatasvir, simeprevir, and ribavirin) or a control group (n = 50) matched for age, sex, and pretreatment variables (Child-Turcotte-Pugh score and Fibrosis-4 score). Follow-up was undertaken after the last non-response to detect serious adverse events, such as hepatic decompensation and development of HCC.

RESULTS

The study group achieved sustained virologic response (SVR) in 47 of 50 (94%) patients. The control group had significantly higher HCC rates than the study group (7 vs. 1 patients), with an odds ratio of 5.44. The rescue therapy was associated with significantly longer time to the occurrence of adverse events. Repeated treatment failures were associated with progression of FibroScan values in the control group (21 ± 4.5 vs. 10 ± 1.5 kPa, P = 0.001); achieving SVR in the study group stopped fibrosis progression despite non-significant increase from baseline (13.2 ± 3.2 vs. 10.6 ± 0.6, P = 0.12).

CONCLUSIONS

Rescue treatment for HCV infection was highly effective in achieving SVR, less expensive than the newer agents, and is associated with diminished risk of serious adverse events, mainly HCC in these patients.

Randomized-controlled trial of methocarbamol as a novel treatment for muscle cramps in cirrhotic patients

BACKGROUND

Muscle cramps occur in 29-88% of patients with liver cirrhosis. They adversely affect quality of life. This study aimed to evaluate the efficacy and safety of methocarbamol as a novel therapy in controlling muscle cramps in cirrhotic patients.

PATIENTS AND METHODS

This study was carried on 100 patients with liver cirrhosis in addition to chronic hepatitis C who presented with frequent muscle cramps (≥three cramps per week). Half of these patients received methocarbamol and the other half received placebo. This was done through equal randomization. Questionnaires on muscle cramp were answered. Patients were evaluated before, after 1 month of treatment, and 2 weeks after washout of treatment in terms of severity, duration, and frequency of cramps. Liver, renal functions, and electrolytes were analyzed. Also, any side effect was detected.

RESULTS

Patients who were treated with methocarbamol showed a significant decrease in the frequency and duration of cramps. Also, the pain score improved significantly. However, no significant changes were observed in the placebo group. Few side effects of methocarbamol were recorded, including dry mouth and drowsiness.

CONCLUSION

Methocarbamol seems to be a promising safe and well-tolerated medication, and plays a role in the treatment of muscle cramps in patients with liver cirrhosis.

A Randomized Controlled Trial Comparing Nitazoxanide Plus Lactulose With Lactulose Alone in Treatment of Overt Hepatic Encephalopathy

BACKGROUND AND AIMS

Hepatic encephalopathy (HE) is a reversible spectrum of neuropsychiatric abnormalities associated with liver dysfunction. Lactulose is a nonabsorbable disaccharide presently used to treat HE. Nitazoxanide (NTZ) has a broad-spectrum activity against urease-producing bacteria, so it decreases ammonia production and is therefore expected to reverse the symptoms of HE. A previous pilot study on HE patients given NTZ and lactulose had encouraging results with regard to amelioration of the clinical picture. Patients showed improvement in mental status and the drug was well-tolerated. Results such as these are encouraging larger studies. The aim of this study was to compare the safety and adequacy of NTZ plus lactulose versus lactulose and placebo in management of overt HE.

METHODS

In total, 120 cirrhotic patients suffering from overt HE were randomly designated to take either NTZ plus lactulose (n=60) or lactulose and placebo (n=60). The Clinical Hepatic Encephalopathy Staging Scale (CHESS) score was assessed for all patients on inclusion to the study and 1 week from the start of treatment.

RESULTS

Both groups evinced an improvement in CHESS score at 1 week, yet the improvement was significantly better in the NTZ group as the score decreased from 4.15±2.09 to 0.00±0.00 compared with 4.96±2.29 to 1.28±0.91 in patients receiving lactulose and placebo (P-value <0.001).

CONCLUSIONS

NTZ significantly decreases the CHESS score and improves mental status in the form of patient alertness, orientation, response to stimulation, and ability to talk. NTZ is safe and well-tolerated apart from infrequent epigastric pain.

Predictors for eltrombopag response in patients with hepatitis C virus-associated thrombocytopenia

Background and aims

Thrombocytopenia is a common hematological abnormality observed in patients infected with hepatitis C virus (HCV). The use of eltrombopag has been approved for HCV-associated thrombocytopenia. This is the first study aiming to determine the predictive factors of response to eltrombopag therapy in patients with HCV-associated thrombocytopenia.

Patients and methods

This prospective study was carried out on 130 patients with chronic HCV-associated thrombocytopenia (<50,000×10⁹/L) that precludes the initiation of HCV therapy. Eltrombopag was initiated at a dose of 25 mg once daily; the dose was adjusted with 25 mg increments every 2 weeks to achieve the target platelet count. The primary end point was to achieve stable target platelet count (50,000-100,000×10⁹/L) required to initiate antiviral therapy.

Results

Treatment response was achieved in 111 (85.38%) patients. This prospective study showed that megakaryocyte hypoplasia or aplasia and splenectomy were independent risk factors for eltrombopag nonresponse in chronic HCV-associated thrombocytopenic patients.

Conclusion

Eltrombopag is safe and effective for patients with HCV-associated thrombocytopenia. Bone marrow examination should be considered before initiating treatment with eltrombopag in chronic HCV-associated thrombocytopenic patients, especially in patients with splenectomy.

Impact of Helicobacter pylori Infection on Gastric Variceal Bleeding among Patients with Liver Cirrhosis

BACKGROUND AND AIMS

Currently, it is well known that Helicobacter pylori- (H. pylori-) related peptic ulcer is one of the main causes of nonvariceal bleeding in cirrhotic patients. However, there is a lack of data to identify the exact effect of H. pylori infection on variceal bleeding. This study was conducted to identify the impact of H. pylori infection on gastric variceal bleeding in cirrhotic patients.

PATIENTS AND METHODS

76 cirrhotic patients with gastric varices were included in this prospective study and divided into 2 groups: nonbleeding gastric varices (32 patients) and bleeding gastric varices (44 patients). The fasting serum gastrin level was measured. Mucosal biopsies from the gastric body and antrum were examined to determine the patterns of gastritis and the presence of H. pylori.

RESULTS

The frequency of H. pylori infection in the studied patients was 59.2%. There were significant differences between both groups regarding liver decompensation (P = 0.001), red color sign over gastric varices (P = 0.0011), prevalence of H. pylori infection (P = 0.0049), histological patterns of gastritis (P = 0.0069), and serum gastrin level (P = 0.0200). By multivariate analysis, Child C cirrhosis, red color sign over gastric varices, and H. pylori-induced follicular gastritis were independent risk factors for bleeding from gastric varices.

CONCLUSION

H. pylori-induced follicular gastritis is considered as an additional risk factor for bleeding from gastric varices.

Overexpression of Hepassocin in Diabetic Patients with Nonalcoholic Fatty Liver Disease May Facilitate Increased Hepatic Lipid Accumulation

Methods:

The study enrolled 60 patients plus 20 healthy controls that were divided into 4 groups: Group I: included 20 patients who were diagnosed as diabetes mellitus type 2, Group II: included 20 patients who were diagnosed as nonalcoholic fatty liver disease (NAFLD), Group III: included 20 patients who were diagnosed as diabetes type 2 and NAFLD, and Group IV (control group): included 20 healthy person or controls who were matched in age and sex with patients group. All patients and controls were subjected to full history taking, thorough clinical examination, laboratory investigations including measurement of serum hepassocin in peripheral blood by ELISA technique.

Results:

There was a significant overexpression of serum hepassocin in patients with type 2 diabetes and NAFLD patients (Group 3) more than diabetic patients (Group 1) and even more than non-alcoholic fatty liver disease (Group 2).

Conclusion:

This study provides evidence that increased HPS may facilitate increased hepatic lipid accumulation with NAFLD and type 2 diabetes.

Endoscopic injection sclerotherapy versus N-Butyl-2 Cyanoacrylate injection in the management of actively bleeding esophageal varices: a randomized controlled trial

Background

The management of acute esophageal variceal bleeding remains a clinical challenge. Band ligation is the main therapeutic option, but it may be technically difficult to perform in active bleeders. This may necessitate an alternative therapy for this group of patients. This study was conducted to assess the safety and efficacy of sclerotherapy versus cyanoacrylate injection for management of actively bleeding esophageal varices in cirrhotic patients.

Methods

This prospective study included 113 cirrhotic patients with actively bleeding esophageal varices. They were randomly treated by endoscopic sclerotherapy or cyanoacrylate injection as banding was not suitable for those patients due to profuse bleeding making unclear endoscopic visual field. Primary outcome was incidence of active bleeding control and secondary outcomes were incidence of six weeks rebleeding, complications, and mortality among the studied patients.

Results

Initial bleeding control was significantly higher in cyanoacrylate versus sclerotherapy groups (98.25, 83.93% respectively, P = 0.007). No significant differences between sclerotherapy and cyanoacrylate groups regarding rebleeding (26.79, 19.30% respectively, P = 0.344), complications, hospital stay or mortality rate were observed.

Conclusions

Based on this single-center prospective study, both of these therapies appear to have relatively favorable outcomes, although cyanoacrylate injection may be superior to sclerotherapy for initial control of active bleeding.

Trial registration

[ClinicalTrials.gov Identifier:NCT03388125]–Date of registration: January 2, 2018 “Retrospectively registered”.

Randomized controlled trial of rivaroxaban versus warfarin in the management of acute non-neoplastic portal vein thrombosis

BACKGROUND AND AIM

Anticoagulation therapy is the main line of treatment for acute portal vein thrombosis (PVT) in the absence of cirrhosis. However, the use of this therapy in cirrhotic PVT is still with doubtful evidence. We aimed to evaluate the efficacy and safety of rivaroxaban compared to warfarin for the management of acute non-neoplastic PVT in Hepatitis C virus (HCV)-related compensated cirrhosis.

METHODS

Out of 578 patients with chronic HCV infection, 80 patients with acute PVT who had undergone splenectomy due to hypersplenism and 4 patients with acute PVT due to portal pyemia were selected. The patients were randomly assigned (1:1) to the study group (n = 40), in which the patients received rivaroxaban 10 mg/12 h, or the control group (n = 40), in which the patients received warfarin.

RESULTS

In the rivaroxaban group, the resolution of PVT was achieved in 34 patients (85%) within 2.6 ± 0.4 months and delayed, partial recanalization after 6.7 ± 1.2 months (n = 6.15%). Complications such as major bleeding, abnormal liver functions, death, or recurrence did not occur during treatment, and patients in this group showed improved short-term survival rate (20.4 ± 2.2 months) compared to the survival rate in the control group (10.6 ± 1.8 months) in which warfarin achieved complete resolution in 45% of patients. Complications such as severe upper GI tract bleeding (43.3%), hepatic decompensation (22.5%), progression to mesenteric ischemia (12.5%), recurrence (10%), and death (20%) were observed in the control group. The duration until complete resolution of thrombus correlated with age, the extent of the thrombus, creatinine level, and MELD score. The recurrence after complete resolution of thrombus correlated with age, the extent of the thrombus, thrombogenic gene polymorphism, and the use of warfarin.

CONCLUSION

Rivaroxaban was effective and safe in acute HCV-related non-neoplastic PVT with improved short-term survival rate; ClinicalTrials.gov Identifier: NCT03201367.

Helicobacter pylori infection and risk of salmonella infection

Helicobacter pylori (H pylori) infection is the most frequent infection worldwide and it has been postulated that it predisposes to multiple enteric pathogens and diarrheal diseases. Salmonella infection is common in tropical and under developed communities and is associated with wide range of diseases from gastroenteritis to typhoid fever. This study aimed at detecting the impact of H pylori infection on the incidence of salmonella infections.The study participants were sampled from cohorts of patients in four university hospitals in different Egyptian Governorates. Their age ranged from 20 to 59 years and followed up for a rising Widal test. Case patients (n = 109) were subjects who visited the outpatient clinic because of diarrhea and typhoid like illness. They were either positive for H pylori stool antigen (n = 53) or negative to it (n = 56). All patients were subjected to thorough history taking, clinical examination, routine laboratory investigations, abdominal ultrasonography, H pylori stool antigen detection, and serial Widal test assay.The proportion of salmonella-infected subjects was lower among case patients with H pylori infection (22.6%) than among those negative for H pylori (33.9%) albeit not statistically significant (adjusted odds ratio [OR], 0.57; 95% confidence interval [CI], 0.24-1.33; P = .21). The association persisted nonsignificant after adjusting for sociodemographic variables (adjusted OR, 0.5; 95% CI, 0.18-1.39; P = .18). In a multivariate analysis that adjusted for sex, dietary habits, socioeconomic status, and educational level subjects who eat outdoors were associated with a significantly greater risk of salmonella typhi infection.Our findings suggest that there is no association between H pylori infection and salmonella infection in patients presented with typhoid fever or typhoid like illness.