Viral hepatitis in international travellers: risks and prevention

Viral hepatitis is caused by a number of unrelated hepatotrophic viruses, known and unknown. Five hepatitis viruses namely HAV, HBV, HCV, HDV and HEV have been well characterized and the epidemiology and disease pattern of each agent has been defined. In the West, HAV, HBV and HCV are major causes of viral hepatitis. In the East, HEV is the most common cause of viral hepatitis. HAV is ubiquitous in childhood in such countries and accounts for less than 4% of disease in adults. Viral hepatitis becomes a problem to an international traveller when he envisages a journey from low endemic to high endemic area and is susceptible to the infection endemic at his destination. Millions of such potentially susceptible travellers from Europe, the USA, Canada, Japan, Australia, and New Zealand visit endemic areas every year for various reasons. Viral hepatitis is the most common reported immunization-preventable disease among travellers to developing countries. Imported viral hepatitis incapacitates the incumbents for an average of 4-10 weeks. Considering the magnitude of the travel, the number of cases of viral hepatitis and case fatality of around 2%, the disease causes significant morbidity and mortality in such communities. It has been estimated that viral hepatitis occurs 100 times more frequently than typhoid fever and 1,000 times more often than cholera in travellers to developing countries. Hepatitis A is the most common form of viral hepatitis in travellers and cumulative data have shown a risk of 3-6 cases/1,000 persons/month of stay whereas the risk of acquiring hepatitis B is 10 times lower.

Aetiology, clinical course and outcome of sporadic acute viral hepatitis in pregnancy

Hepatitis E causes large-scale epidemics in endemic areas. The disease, during epidemics, has increased incidence and severity in pregnant women. Sporadic acute viral hepatitis (AVH) is common in endemic areas. The relationship of sporadic AVH and pregnancy has not been well studied. Over a 3-year period we prospectively studied 76 pregnant women and 337 non-pregnant women of childbearing age with sporadic acute viral hepatitis for aetiology, clinical course and outcome of disease. The aetiology in sporadic AVH was hepatitis A virus (HAV) in six (1.5%), hepatitis B virus (HBV) in 62 (15%), hepatitis C virus (HCV) in seven (1.7%), hepatitis D virus (HDV) co-infection in six (1.5%), hepatitis E virus (HEV) in 205 (49.6%), and hepatitis non-A-to-E (HNAE) in 127 (30.7%). Sixty-five (85.5%) pregnant women and 140 (41.5%) nonpregnant women had hepatitis E. The proportion of pregnant women was 31.7% in HEV group and 5.3% in non-HEV group [P < 0.001; OR=8.3 (95%C1 4.2-16.3)]. The prevalence of HEV in pregnant women in first trimester (76.9%), second trimester (88.9%), third trimester (83.8%) and puerperium (100%) did not differ significantly (P=0.09). Forty-seven (61.8%) of the 76 pregnant women developed fulminant hepatic failure (FHF), 69.2% in HEV group and 10% in non-HEV group (P < 0.001). Thirty-four (10.1%) nonpregnant women developed fulminant hepatic failure, 10% in HEV group and 9.7% in non-HEV group (P=0.86). FHF had occurred in four (40%) of 10 patients with HE in first trimester as against 41 (74.5%) of 55 patients in second trimester and beyond (P=0.015). Amongst the major complications of fulminant hepatic failure, cerebral oedema (53.2%) and disseminated intravascular coagulation (21.3%) occurred more often in pregnant women than in nonpregnant women (29.4% and 2.8%; P=0.03 and 0.016, respectively) while infections occurred more often in nonpregnant women (36.1%) than in pregnant women (10.6%; P=0.003). Fifty (61.7%) patients with FHF died [25 (53.2%) pregnant women and 25 (69.5%) nonpregnant women (P=0.06)]. Cerebral oedema and HEV aetiology were independent variables of survival in patients with FHF. Patients with cerebral oedema had worse prognosis and patients with HEV aetiology had best chances of survival. Hence HEV was the most common cause of sporadic AVH in this endemic area. High proportion of pregnant women and increased severity of disease in pregnancy were limited to patients with hepatitis E. Sporadic AVH caused by agents other than HEV did not show any special predilection to or increased severity in pregnancy. FHF in pregnant women caused by HEV was an explosive disease with short pre- encephalopathy period, rapid development of cerebral oedema and high occurrence of disseminated intravascular coagulation and may represent a severe manifestation of a Schwartzmann-like phenomenon.

Budd Chiari syndrome: experience at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

BACKGROUND

Budd-chiari syndrome (BCS) is rare disorder, varied in etiology, inconsistent in presentation, unpredictable in progression, and challenging in therapy.

AIM OF STUDY

The aim of this study is to review experience of Budd-Chiari syndrome at KFSH, Riyadh; over a ten-year period.

METHODS

In a retrospective study using a computer data search of the medical records from May 1990 to May 2000, 43 patients' charts suspected of BCS were reviewed. 29 patients were found to have BCS, diagnosed by Doppler ultrasound, venography, MRI, or CT with or without liver biopsy.

FINDINGS

Of the 29 patients, 18 were male (62.1%) and I 1 were female (37.9%); mean age was 35.4 (range 17-69 years). Nine patients had Behcet's disease; seven patients had malignancy (five HCC, one melanoma and one hypernephroma). Eight patients had antiphospholipid syndrome, two patients had no known cause and three (one related to trauma, the other related to protein C deficiency and the third related nephrotic syndrome). Nineteen patients presented acutely with abdominal pain, progressive ascites and hepatomegaly. Ten patients had subacute presentation mimicking cirrhosis of liver. Five patients had web in the intrahepatic IVC or ostium HV and the remaining 24 patients had thrombosis of hepatic veins. Five patients received surgical shunts, three had balloon dilatation of webs, 11 had anticoagulant therapy and seven patients had symptomatic treatment. Eleven patients died, six of them had malignancy, two died while awaiting liver transplantation and three died with fulminant hepatic failure. Fourteen patients are still on follow-up.

CONCLUSION

Budd Chiari syndrome in Saudi Arabia is related to a defined cause in majority of patients (92%). Behcet's disease is a dominant cause of BCS in Saudi Arabia. This is in contrast to world literature where around 50% of patients are of unknown etiology.

Hepatobiliary and pancreatic ascariasis

Ascariasis is a helminthic infection of global distribution with more than 1.4 billion persons infected throughout the world. The majority of infections occur in the developing countries of Asia and Latin America. Of 4 million people infected in the United States, a large percentage are immigrants from developing countries. Ascaris-related clinical disease is restricted to subjects with heavy worm load, and an estimated 1.2 to 2 million such cases, with 20,000 deaths, occur in endemic areas per year. More often, recurring moderate infections cause stunting of linear growth, cause reduced cognitive function, and contribute to existing malnutrition in children in endemic areas. HPA is a frequent cause of biliary and pancreatic disease in endemic areas. It occurs in adult women and can cause biliary colic, acute cholecystitis, acute cholangitis, acute pancreatitis, and hepatic abscess. RPC causing hepatic duct calculi is possibly an aftermath of recurrent biliary invasion in such areas. Ultrasonography can detect worms in the biliary tract and pancreas and is a useful noninvasive technique for diagnosis and follow-up of such patients. ERCP can help diagnose biliary and pancreatic ascariasis, including ascaris in the duodenum. Also, ERCP can be used to extract worms from the biliary and pancreatic ducts when indicated. Pyrantel pamoate, mebendazole, albendazole and levamisole are effective drugs and can be used for mass therapy to control ascariasis in endemic areas.

Case report: Percutaneous drainage of the pancreatic head hydatid cyst with obstructive jaundice

We report a rare case of a patient with a primary hydatid cyst in the head of the pancreas who presented with obstructive jaundice caused by extrinsic compression of the intrapancreatic portion of the bile duct. The patient was treated successfully by ultrasound-guided percutaneous drainage of the cyst using hypertonic (20%) saline as the scolicidal agent and albendazole chemoprophylaxis before and after the drainage. The cyst was not visible on ultrasonography at 6 months follow up. Clinical, sonographic and serological follow up to 35 months showed no evidence of cyst recurrence or dissemination. In endemic areas of hydatid disease, hydatid cyst should be a differential diagnosis in cystic lesions of the pancreas in patients presenting with obstructive jaundice.

Haemosuccus pancreaticus: a clinical challenge

BACKGROUND

Haemosuccus pancreaticus is a rare complication of pancreatitis. It is a diagnostic problem for even the most astute clinician and a challenge for the expert endoscopist. We report a 25-year-old male patient who had all the features usually seen in haemosuccus pancreaticus patients: recurrent obscure upper gastrointestinal bleeding, pancreatitis, pseudocyst formation, ductal disruption, fistula and pancreatic ascites. The patient was treated by subtotal pancreatectomy, splenectomy and drainage of the pseudocyst. Although pancreatic duct communication with the surrounding vasculature could not be ascertained, we strongly believe the patient had haemosuccus pancreaticus because, over a follow-up period of 3 years, the patient was not only ascites free, but did not experience any further upper gastrointestinal bleeding. We believe that in evaluating patients with recurrent obscure gastrointestinal bleeding, one should always remember that the pancreas is a part of the gastrointestinal tract and, like other organs, is prone to blood loss.

Percutaneous drainage compared with surgery for hepatic hydatid cysts

BACKGROUND

In recent years percutaneous drainage has been used successfully to treat the hepatic hydatid cysts of echinococcal disease. We performed a controlled trial to compare the safety and efficacy of percutaneous drainage with those of surgical cystectomy, the traditional treatment.

METHODS

In a prospective study, we randomly assigned 50 patients with hepatic hydatidosis to treatment with percutaneous drainage (25 patients) or cystectomy (25). Albendazole (10 mg per kilogram of body weight per day for eight weeks) was administered to the patients who underwent percutaneous drainage. Serial assessments included clinical and biochemical examinations, ultrasonography, and serologic tests of echinococcal-antibody titers.

RESULTS

The mean (+/-SD) hospital stay was 4.2+/-1.5 days in the drainage group and 12.7+/-6.5 days in the surgery group (P<0.001). Over a mean follow-up period of 17 months, the mean cyst diameter decreased from 8.0+/-3.0 to 1.4+/-3.5 cm (P<0.001) after percutaneous drainage and from 9.1+/-3.0 to 0.9+/-1.8 cm (P<0.001) after surgery. The final cyst diameter did not differ significantly between the two groups (P=0.20). The cysts disappeared in 22 patients (88 percent) in the drainage group and in 18 (72 percent) in the surgery group (P=0.29). After an initial rise, the echinococcal-antibody titers fell progressively and at the last follow-up were negative (<1:160) in 19 patients (76 percent) in the drainage group and 17 (68 percent) in the surgery group (P=0.74). There were procedure-related complications in 8 patients (32 percent) in the drainage group and 21 (84 percent) in the surgery group, 17 of whom had fever postoperatively (P<0.001).

CONCLUSIONS

Percutaneous drainage, combined with albendazole therapy, is an effective and safe alternative to surgery for the treatment of uncomplicated hydatid cysts of the liver and requires a shorter hospital stay.

Comparative evaluation of therapeutic approaches in stage III and IV squamous cell carcinoma of the thoracic esophagus with conventional radiotherapy and endoscopic treatment in combination and endoscopic treatment alone: a randomized prospective trial

PURPOSE

To define the role of endoscopic dilatation/intubation and radiotherapy in squamous cell carcinoma of esophagus patients to improve their quality of life.

METHODS AND MATERIALS

One hundred and four patients with squamous cell carcinoma of the thoracic esophagus having Stage III and IV disease were enrolled in the present study, with 90 patients in Group 1 (nonesophagorespiratory fistula group) and 14 patients in Group 2 (esophagorespiratory fistula group). From Group 1 patients, 47 were subjected to radiotherapy (conventional) and had endoscopic dilatation and/or intubation whenever and wherever required (Group 1a), and 43 patients were allowed to follow the natural course of the disease except palliation with endoscopic dilatation and/or intubation whenever and wherever required (Group 1b). From Group 2, 4 patients received radiotherapy in addition to endoscopic intubation, while 10 patients received only endoscopic intubation.

RESULTS

The median survival for Group 1a was 7 months, for Group 1b--3 months, for Group 2a--4.25 months, and Group 2b--3.6 months. Only three patients from Group 1a survived more than 18 months, while no patient from Groups 1b, 2a, or 2b survived for more than 1 year. The difference in survival between Group 1a and 1b was statistically significant.

CONCLUSION

The addition of radiotherapy to endoscopic treatment definitely prolongs survival as well as improves the quality of life of these patients. We recommend both for the adequate palliation of patients with this disease.

A comparison of omeprazole and placebo for bleeding peptic ulcer

BACKGROUND

The role of medical treatment for patients with bleeding peptic ulcers is uncertain.

METHODS

We conducted a double-blind, placebo-controlled trial in 220 patients with duodenal, gastric, or stomal ulcers and signs of recent bleeding, as confirmed by endoscopy. In 26 patients the ulcers showed arterial spurting, in 34 there was active oozing, in 35 there were nonbleeding, visible vessels, and in 125 there were adherent clots. The patients were randomly assigned to receive omeprazole (40 mg given orally every 12 hours for five days) or placebo. The outcome measures studied were further bleeding, surgery, and death.

RESULTS

Twelve of the 110 patients treated with omeprazole (10.9 percent) had continued bleeding or further bleeding, as compared with 40 of the 110 patients who received placebo (36.4 percent) (P<0.001). Eight patients in the omeprazole group and 26 in the placebo group required surgery to control their bleeding (P<0.001). Two patients in the omeprazole group and six in the placebo group died. Thirty-two patients in the omeprazole group (29.1 percent) and 78 in the placebo group (70.9 percent) received transfusions (P<0.001). A subgroup analysis showed that omeprazole was associated with significant reductions in recurrent bleeding and surgery in patients with nonbleeding, visible vessels or adherent clots, but not in those with arterial spurting or oozing.

CONCLUSIONS

In patients with bleeding peptic ulcers and signs of recent bleeding, treatment with omeprazole decreases the rate of further bleeding and the need for surgery.

Ascariasis

Ascariasis is a helminthic infection of global distribution with more than 1.4 billion persons infected throughout the world. The majority of infections occur in the developing countries of Asia and Latin America. Of 4 million people infected in the United States, a large percentage are immigrants from developing countries. Ascaris-related clinical disease is restricted to subjects with heavy worm load, and an estimated 1.2 to 2 million such cases, with 20,000 deaths, occur in endemic areas per year. More often, recurring moderate infections cause stunting of linear growth, cause reduced cognitive function, and contribute to existing malnutrition in children in endemic areas. Ascaris infection is acquired by the ingestion of the embryonated eggs. The larvae, while passing through the pulmonary migration phase for maturation, cause ascaris pneumonia. Intestinal ascaris is usually detected as an incidental finding. Ascaris-induced intestinal obstruction is a frequent complication in children with heavy worm loads. It can be complicated by intussusception, perforation, and gangrene of the bowel. Acute appendicitis and appendicular perforation can occur as a result of worms entering the appendix. HPA is a frequent cause of biliary and pancreatic disease in endemic areas. It occurs in adult women and can cause biliary colic, acute cholecystitis, acute cholangitis, acute pancreatitis, and hepatic abscess. RPC causing hepatic duct calculi is possibly an aftermath of recurrent biliary invasion in such areas. Ultrasonography can detect worms in the biliary tract and pancreas and is a useful noninvasive technique for diagnosis and follow-up of such patients. ERCP can help diagnose biliary and pancreatic ascariasis, including ascaris in the duodenum. Also, ERCP can be used to extract worms from the biliary and pancreatic ducts when indicated. Pyrantel pomoate, mebendazole, albendazole, and levamisole are effective drugs and can be used for mass therapy to control ascariasis in endemic areas.

Vertical transmission of hepatitis E virus

Little is known about vertical transmission of hepatitis E virus from infected mothers to their infants. We studied eight babies born to mothers infected with hepatitis E in third trimester. One baby was icteric at birth with elevated transaminases and four babies had anicteric hepatitis. Two babies were born with hypothermia and hypoglycaemia and died within 24 h; one had massive hepatic necrosis. Hepatitis E virus RNA was detected by PCR in cord or birth blood samples of five infants. Six infants had evidence of hepatitis E infection. We conclude that hepatitis E virus is commonly transmitted from infected mothers to their babies with significant perinatal morbidity and mortality.

Spectrum of hepatitis E virus infection in India

A solid phase enzyme linked immunosorbent assay (ELISA) that detects IgM and IgG to hepatitis E virus (HEV) was used to study seroepidemiology in 40 healthy subjects and 227 consecutive patients with liver diseases in an endemic area. Fifty-two of the liver diseases patients (22.9 percent) had acute hepatitis E. In contrast, none of the 40 healthy subjects were positive for IgM anti-HEV, validating the ELISA assay. Twenty-three of 25 (92%) patients with epidemic non-A, non-B hepatitis were confirmed as having acute hepatitis E. Only 1 of the 10 patients with sporadic, fulminant hepatic failure of non-A, non-B, non-C etiology was positive for IgM anti-HEV. Five (31.2%) of the 16 patients with acute hepatitis in HBsAg carriers were positive for IgM anti-HEV. One patient with acute hepatitis B was coinfected with acute hepatitis E. Acute hepatitis was a disease of the adult population, with peak attack rates in the second and third decades of life. This disease was seen in only 4 (16%) of the 25 patients with acute viral hepatitis occurring below 14 years of age. Cholestasis was predominant in 25% of patients, enzyme elevation was monophasic, and all patients had clinical and biochemical recovery from the disease. The data suggest that the majority of patients with acute sporadic non-A, non-B, non-C hepatitis in India have hepatitis E. However, fulminant hepatic failure to sporadic nature is rarely from hepatitis E.