Experience of fibrosing cholestatic hepatitis with hepatitis C virus in kidney transplant recipients

BACKGROUND

Fibrosing cholestatic hepatitis C (FCH-C) is a rare entity that occurs among immune-compromised patients resulting from the direct hepatotoxicity of a high intracellular viral load along with an ineffective immune system ultimately leading to a fatal outcome. We have describes herein 4 renal transplant recipients who were diagnosed with FCH-C at our institution in the last 8 months.

METHODS

Four renal transplant recipients presented with jaundice and deteriorating liver function tests. They were diagnosed to display FCH-C based on the presence of hepatitis C virus (HCV) RNA and characteristic liver biopsy findings; there was no evidence of any other cause of cholestasis or biliary obstruction.

RESULTS

The patients were men of ages 40, 25, 20, and 27 years. The durations after transplantation were 1.5, 10, 1.5 and 2.0 years, respectively. In all cases pretransplantation screening was negative for HCV antibody, HCV RNA, and hepatitis B surface antigen (HBsAg). All 4 patients were infected with genotype 1, whereas case 2 had coinfection with type 3. Cases 1 and 2 who were treated with interferon and ribavirin, showed improvement in cholestasis but did not achieve a rapid virological response. Case 1 developed graft dysfunction secondary to acute cellular rejection at 4 months after initiation of interferon treatment, which was treated with pulse steroids. Interferon-based therapy was stopped prematurely in both cases due to pancytopenia. Case 3 developed florid pyelonephritis and died without receiving therapy for hepatitis C. Case 4 was managed conservatively by decreasing the immunosuppression with regular monitoring.

CONCLUSION

FCH-C is difficult to treat and shows high morbidity and mortality rates. Treatment is associated with a risk of graft rejection.

Virulence markers of Helicobacter pylori in patients with diarrhoea-dominant irritable bowel syndrome

Recent studies suggest that irritable bowel syndrome (IBS) is associated with low-grade inflammation. This study aims to determine the distribution of Helicobacter pylori cytotoxin-associated gene A (cagA) and vacuolating cytotoxin A (vacA) alleles (e.g., s1 and s2) in patients with diarrhoea-dominant IBS (IBS-D) as the latter causes vacuolation in colonic epithelial cells in vitro. One hundred and seventy patients meeting Rome III criteria for IBS-D (mean age: 40 +/- 15 years) were enrolled. Gastric biopsy was assessed histologically and DNA extraction was performed by polymerase chain reaction (PCR) for H. pylori genus 16S ribosomal DNA (16S rDNA), cagA and vacA allele s1 and s2. There was no age- or gender-related difference in H. pylori positivity in IBS-D compared to the control group. H. pylori was positive in 116 (68%) with IBS-D compared to 88 (55%) in the control group (P=0.01). cagA was positive in 73 (63%) with IBS-D compared to 42 (48%) in the control group (P=0.03). vacA s1 was positive in 61 (53%) with IBS-D compared to 32 (36%) in the control group (P=0.02). cagA s1 was positive in 39 (34%) with IBS-D compared to 13 (15%) in the control group (P=0.002).

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Cytokine changes in colonic mucosa associated with Blastocystis spp. subtypes 1 and 3 in diarrhoea-predominant irritable bowel syndrome

We determined cytokines (e.g. interleukin-8, 10, 12 and TNF-α) expression by peripheral blood mononuclear cells (PBMCs) and in rectal mucosa in diarrhoea-predominant irritable bowel syndrome (D-IBS) with Blastocystis spp. Eighty patients with D-IBS and Blastocystis spp. infection were classified as 'cases' and 80 with D-IBS without Blastocystis spp. infection were classified as 'control'. Cases were subdivided into D-IBS and Blastocystis sp. defined type 1 (subtype-specific primer SB83) and type 3 (SB227). Stool microscopy and culture were performed. Rectal biopsies were obtained for histology and cytokines by real-time PCR for mRNA expression of cytokines. PBMCs IL-8 was similar in different groups but in type 1, IL-8mRNA was increased compared with type 3 (P = 0·001) and control (P = 0·001). In type 1, IL-10 by PBMCs had a low mean value (14·5±1·6) compared with (16·7±1·5) type 3 and (16±2·3) in controls (P<0·001 and P<0·001, respectively). In Blastocystis sp. type 1, low IL-10 was associated with lymphocyte and plasma cell infiltration (P = 0·015 and P = 0·002, respectively). In Blastocystis sp. type 1 and type 3, IL-12 was associated with goblet cell depletion 23 (85%) (P<0·001) and 8 (29%) (P = 0·037), respectively. In Blastocystis sp. type 1, low IL-10 was associated with a proinflammatory response characterized by IL-8.

Acute variceal bleeding portends poor outcomes in patients with acute-on-chronic liver failure: a propensity score matched study from the APASL ACLF Research Consortium (AARC)

BACKGROUND AND AIMS

Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC).

METHODS

Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB).

RESULTS

Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort.

CONCLUSION

Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.

Hepatitis E: when to treat and how to treat

HEV generally causes a self-limited acute infection and treatment remains supportive. However, severe hepatitis or fulminant hepatic failure may occur, more so during pregnancy. It is an important cause of acute-on-chronic liver failure in endemic areas. Chronic HEV infection and progressive disease has been reported in recipients of solid organ transplants, haematological malignancies, HIV patients and those on haemodialysis. Clearance of HEV may occur after reducing immunosuppressive therapy, especially those targeting T-cells, in about one third of cases. Antiviral therapy should be considered for patients for whom immunosuppressive therapy cannot be reduced and for those who do not achieve viral clearance after reducing immunosuppression. For the patients with severe infection, fulminant hepatic failure and acute-on-chronic infection, ribavirin monotherapy should be considered to expedite the viral clearance and recovery. Although ribavirin therapy is contraindicated in pregnancy owing to teratogenicity, the risks of untreated HEV to the mother and fetus are high and treatment may be offered. A twelve-week course of pegylated interferon, ribavirin or a combination of the two agents leads to viral clearance in about two-thirds of patients with chronic hepatitis E. Three- to twelve-month treatment with pegylated interferon clears virus in liver transplant recipients and patients on haemodialysis. In kidney and heart transplant patients where interferon may lead to organ rejection, ribavirin may be given.

Helicobacter pylori: correlation of the virulence marker iceA allele with clinical outcome in a high prevalence area

The association of Helicobacter pylori virulence marker 'induced by contact with epithelium A' (iceA) allele types was determined in H. pylori-related diseases and virulence markers. Gastric biopsies were obtained at EGD from patients for culture, histopathology and polymerase chain reaction (PCR) for iceA types, cagA and vacA alleles. Two hundred and eighty-four H. pylori isolates were examined. iceA type 1 was positive in 177 (62%) and iceA type 2 in 158 (56%). In iceA type 2, gastric ulcer was present in 34 (21%) (P < 0.001) and carcinoma in 28 (25%) (P = 0.002), compared to nine (8%) and 2 (2%) in iceA type 2-negative cases. For iceA type 2, 139 (88%) were associated with chronic active gastritis compared to 95 (75%) (P = 0.006) in iceA type 2-negative. H. pylori cagA was positive in 101 (64%) iceA type 2 strains compared to 57 (45%) in negative strains (P = 0.002). H. pylori iceA type 2 was dominant and associated with cagA, chronic active inflammation, gastric ulcer and carcinoma.

A global survey on the use of the international classification of diseases codes for metabolic dysfunction-associated fatty liver disease

BACKGROUND

With the implementation of the 11th edition of the International Classification of Diseases (ICD-11) and the publication of the metabolic dysfunction-associated fatty liver disease (MAFLD) nomenclature in 2020, it is important to establish consensus for the coding of MAFLD in ICD-11. This will inform subsequent revisions of ICD-11.

METHODS

Using the Qualtrics XM and WJX platforms, questionnaires were sent online to MAFLD-ICD-11 coding collaborators, authors of papers, and relevant association members.

RESULTS

A total of 890 international experts in various fields from 61 countries responded to the survey. We also achieved full coverage of provincial-level administrative regions in China. 77.1% of respondents agreed that MAFLD should be represented in ICD-11 by updating NAFLD, with no significant regional differences (77.3% in Asia and 76.6% in non-Asia, p = 0.819). Over 80% of respondents agreed or somewhat agreed with the need to assign specific codes for progressive stages of MAFLD (i.e. steatohepatitis) (92.2%), MAFLD combined with comorbidities (84.1%), or MAFLD subtypes (i.e., lean, overweight/obese, and diabetic) (86.1%).

CONCLUSIONS

This global survey by a collaborative panel of clinical, coding, health management and policy experts, indicates agreement that MAFLD should be coded in ICD-11. The data serves as a foundation for corresponding adjustments in the ICD-11 revision.

Association of Helicobacter pylori and protozoal parasites in patients with chronic diarrhoea

Introduction An association of Helicobacter pylori and common protozoal parasites in patients with abdominal discomfort and chronic diarrhoea is unclear and may be pathological. Materials and methods One hundred and sixty-one patients with diarrhoea were compared to 114 age and sex matched controls. Stool samples were examined by microscopy and DNA extracted for PCR with specific primers for H. pylori and protozoal parasites Blastocystis sp., Entamoeba sp. (Entamoeba histolytica, Entamoeba dispar and Entamoeba moshkovskii) and Giardia duodenalis (G. duodenalis). Results There was a marked difference in the presence of parasites between patients and controls: no parasite 42/75%, one parasite 42/15%, two or more parasites 16/10%, respectively (p < 0.001). Patients with diarrhoea were more likely to be infected with Blastocystis sp (p < 0.001), E. histolytica (p = 0.027) and E moshkovskii (p = 0.003). There was no difference in the frequency of H. pylori (p = 0.528), G duodenalis (p = 0.697) or E dispar (p = 0.425). Thirty-three patients and 27 controls had H. pylori infection. Of these, 22 patients and 6 controls were infected with Blastocystis sp (p = 0.001), 6 patients and no controls were infected with E. histolytica (p = 0.02), whilst 7 patents and 9 controls were infected with E dispar (p = 0.292). Conclusion In this population, diarrhoea is linked to infection with Blastocystis sp, E. histolytica and E moshkoviskii. In H. pylori infection, diarrhoea is linked to Blastocystis sp and E. histolytica infection. These associations may be linked pathogenically.

Associations between the Plasticity Region Genes of Helicobacter pylori and Gastroduodenal Diseases in a High-Prevalence Area

BACKGROUND/AIMS

Genes associated with the Helicobacter pylori (H. pylori) plasticity region may play a role in the pathogenesis of H. pylori. We compared the genes jhp0940, jhp0947, and jhp0986 in H. pylori isolates from patients with different gastroduodenal diseases and in different age groups.

METHODS

The H. pylori hyperplasticity region genes jhp0940, jhp0947, and jhp0986 were studied by PCR. We also evaluated whether these genes were related to the cytotoxin-associated gene (cagA) and histology findings.

RESULTS

Of the patient cohort, 71 (62%) were positive for jhp0940, 67 (59%) for jhp0947, 12 (10%) for jhp0986, and 69 (60%) for cagA. jhp0940 (n=18, 67%) and jhp0947 (n=23, 85%) were found more frequently in duodenal ulcer (DU) patients than in gastritis patients (n=14, 39%; p=0.029 and p<0.001, respectively). Gastric ulcer (GU) was more frequently associated with jhp0940 (17 patients, 77%; p=0.003) than with gastritis (14 patients, 39%). Gastric carcinoma (GC) was more strongly associated with both jhp0940 (22 patients, 76%; p=0.003) and jhp0947 (22 patients, 76%; p=0.003) than was gastritis (14 patients, 39%). jhp0947 was more frequently associated with chronic active inflammation (58 patients, 87%; p=0.009) than with chronic inflammation (9 patients, 13%). Multivariate analysis demonstrated that jhp0947 was associated with DU (odds ratio, 6.1; 95% confidence interval, 1.87-20).

CONCLUSIONS

The genes jhp0947 and jhp0940 were identified in H. pylori isolates from patients with GC and DU, while jhp0940 was also isolated from patients with GU. jhp0947 was independently associated with DU.

Prevalences of Giardia lamblia and Cryptosporidium parvum infection in adults presenting with chronic diarrhoea

Giardia lamblia and Cryptosporidium parvum are both waterborne pathogens associated with diarrhoea in developing countries. In a recent study based at the Aga Khan University in Karachi, 334 adults aged 16-83 years (178 patients with chronic diarrhoea and 156 diarrhoea-free volunteers who acted as controls) were checked for infection with these parasites, using stool microscopy and/or PCR. Overall, 21 (6.3%) and 29 (8.7%) of the subjects were found positive for G. lamblia by microscopy and PCR, respectively, while the corresponding values for C. parvum were 13 (3.9%) and 14 (4.2%). Although, compared with the diarrhoea-free controls, the patients with diarrhoea were not significantly more likely to be found infected with Giardia, either by microscopy [15 (8.4%) v. six (3.8%); P=0.085] or PCR [19 (10.7%) v. 10 (6.4%); P=0.167], they were significantly more likely to be found infected with C. parvum, both by microscopy [11 (6.2%) v. two (1.3%); P=0.024] and by PCR [12 (6.7%) v. two (1.3%); P=0.014]. The 19 patients found PCR-positive for Giardia comprised 10 (67%) of the 15 found smear-positive for the same parasite but only nine (5%) of the 163 found smear-negative (k=0.545; P<0.001). Similarly, the 12 patients found PCR-positive for Cryptosporidium comprised all 11 (100%) patients found smear-positive for the same parasite but only one (0.6%) of the 167 found smear-negative (k=0.954; P<0.001). Although C. parvum was associated with chronic diarrhoea in the present study, the carriage of G. lamblia often appeared asymptomatic.

Management of hepatitis delta: Need for novel therapeutic options

Hepatitis D virus (HDV) is the smallest single stranded RNA virus infecting humans. The hepatitis B surface antigen envelope protein protects the HDV nucleocapsid antigen and provides a means for the virus to enter and exit the hepatocyte. Hepatitis B and D viruses exploit the human sodium taurocholate co-transporting polypeptide (NTCP), a receptor, for their entry into hepatocytes. Prenylation of the large delta antigen is a critical determinant of HDV particle assembly. Treatment with pegylated interferon results in sustained virological response six months post-treatment in one fourth of the patients. Nucleos(t)ide analogs (NAs) have been widely tested in hepatitis delta, but they appear to be ineffective. Combination treatment of NAs with interferon also proved to be disappointing so there is a need for novel therapeutic options. The receptor function of NTCP is blocked by Myrcludex B, a synthetic N-acylated preS1 lipopeptide that competes with infectious virions for receptor binding. There are already some approved drugs available, including irbesartan, ezetimibe, and ritonavir and cyclosporin A, with documented inhibitory effects on NTCP's metabolic function. These drugs may have a role in HDV treatment. Interference with host-mediated post-translational changes of proteins that are crucial to the HDV life cycle, such as prenylation may become an important tool to control HDV infection and prevent replication. Lonafarnib, a prenylation inhibitor significantly reduces virus levels in hepatitis delta patients. Antisense oligodeoxynucleotides which are complementary to genomic HDV ribozyme self-cleavage site and stem I regions can inhibit genomic HDV ribozyme activity.

The diagnostic yield of various tests for Helicobacter pylori infection in patients on acid-reducing drugs

The diagnostic yield of various tests for Helicobacter pylori infection in patients on acid-reducing drugs, such as proton pump inhibitors (PPI) and histamine-2 receptor blocker (H2RB), was compared. Seventy-four consecutive patients on acid-reducing drugs were enrolled: 34 (46%) were on PPIs, 20 (27%) were on H2RBs and 20 (27%) were not on medications. For those patients on PPIs, RUT and histology results from antrum were negative in 28 (82%) and 17 (50%) patients, respectively (OR: 4.7; 95% CI: 1.4-16.6; P = 0.004), while those from the corpus were negative in was 28 (82%) and 18 (53%) patients, respectively (OR: 4.4, 95% CI: 1.3-15.5; P = 0.006). For patients on H2RBs, RUT and histology results from the antrum were negative in 12 (60%) and six (30%) patients, respectively (OR: 3.5; 95% CI: 0.8-16.1; P = 0.05), while those from the corpus were negative in 12 (60%) and nine (45%) patients, respectively (OR: 1.8; 95% CI: 0.4-7.8; P = 0.342). For those patients on PPIs, the diagnostic yield of both RUT and histology was reduced from both the antrum and corpus. In these patients, PCR for H. pylori is more sensitive than RUT and histology.

Microsporidial infections due to Encephalitozoon intestinalis in non-HIV-infected patients with chronic diarrhoea

We determined the prevalence of microsporidia Enterocytozoon (Ent.) bieneusi and Encephalitozoon (E.) intestinalis infection in patients with chronic diarrhoea and hepatocellular carcinoma (HCC). A total of 330 stool samples were examined from 171 (52%) patients with chronic diarrhoea, 18 (5%) with HCC while 141 (43%) were controls. Stool microscopy, polymerase chain reaction (PCR) with species-specific primers for Ent. bieneusi and E. intestinalis and sequencing were carried out. Microsporidia were found by trichrome staining in 11/330 (3%) and E. intestinalis by PCR in 13/330 (4%) while Ent. bieneusi was not detected. PCR for E. intestinalis was positive in 8/171 (5%) stool samples from patients with chronic diarrhoea, 2/141 (1·4%) samples from healthy controls and in 3/18 (17%) samples from patients with HCC. In the chronic diarrhoea group, E. intestinalis was positive in 4/171 (2·3%) (P=0·69) stool samples compared to 2/18 (11%) (P=0·06) in the HCC group and 2/141 (1·4%) from healthy controls. E. intestinalis infection was significantly associated with chronic diarrhoea and HCC in these patients who were negative for HIV. Stool examination with trichrome or species-specific PCR for microsporidia may help establish the cause of chronic diarrhoea.

Incidence and predisposing factors for de novo post-COVID-19 irritable bowel syndrome

OBJECTIVE

Postinfectious irritable bowel syndrome (IBS) is a known entity. We evaluated the incidence of post-COVID-19 IBS in patients discharged from the hospital and analyzed its correlation with the clinical and laboratory parameters, and treatment during the hospital stay.

METHODS

Three hundred three COVID-19 hospitalized patients without prior history of IBS were prospectively followed after their discharge and were evaluated as per Rome-IV criteria for IBS.

RESULTS

One hundred seventy-eight patients were males (58.7%). The age range was 17-95 years (mean ± SD, 55.9 ± 15.8). A total of 194 (64%) had mild COVID-19, 74 (24.4%) had moderate COVID-19, whereas 35 (11.6%) had severe COVID-19 infection. Sixteen (5.3%) patients had concomitant GI symptoms during COVID-19 infection. IBS symptoms were found to be present in 32 (10.6%) patients, out of which 17 (53.13%) had diarrhea-predominant, 10 (31.25%) had constipation-predominant, and five (15.62%) had mixed-type IBS. Post-COVID-19 IBS was more common in the female sex (P < 0.001), concomitant GI symptoms with COVID-19 (P < 0.001), oxygen requirement (P = 0.015), deranged liver function tests at the time of admission (P = 0.002), high procalcitonin (P = 0.013), high C-reactive protein levels (P = 0.035); whereas negative correlation was found with remdesivir treatment (P = 0.047). After performing regression analysis, female sex (P < 0.001), oxygen requirement during hospital stay (P = 0.016), GI symptoms during COVID-19 infection (P < 0.001), and high procalcitonin levels (P = 0.017) were independently associated with post-COVID-19 IBS.

CONCLUSION

GI symptoms during active COVID-19 infection increase the chances of developing post-COVID-19 IBS. The risk of developing post-COVID-19 IBS increases in female patients, those requiring oxygen and having high procalcitonin levels during COVID-19 infection.

Furazolidone, co-amoxiclav, colloidal bismuth subcitrate, and esomeprazole for patients who failed to eradicate Helicobacter pylori with triple therapy

There is increasing evidence of Helicobacter pylori (H. pylori) resistance to the classical triple therapy consisting of a proton-pump inhibitor and clarithromycin with either amoxicillin or metronidazole. This study is aimed at establishing the efficacy and safety of a 14-day regimen to eradicate H. pylori in patients who have failed with the classical triple therapy given for 14 days. One hundred seventy-six patients diagnosed to have H. pylori infection were given triple therapy for 14 days. Fifty-two patients who failed to respond as evident from positive 14C-urea breath test (UBT) done 4-6 weeks after the completion of triple therapy were offered a combination regimen comprised of furazolidone 200 mg b.i.d, co-amoxiclav 1 g b.i.d., colloidal bismuth subcitrate 240 mg b.i.d., and esomeprazole 40 mg b.i.d. for 14 days. The mean age of these patients was 41 +/- 13 years (range 20-67). Thirty-four were males. To document eradication of H. pylori, UBT was repeated 4 weeks after the completion of treatment. On an intention-to-treat analysis, the eradication rate was 81% (42 out of 52) whereas on per-protocol basis, the eradication rate was 82.4% (42 out of 51). In conclusion, this new regimen represents a suitable second-line therapy.

Impact of compensated cirrhosis on survival in patients with acute-on-chronic liver failure

BACKGROUND AND AIMS

Acute-on-chronic liver failure (ACLF) is considered a main prognostic event in patients with chronic liver disease (CLD). We analyzed the 28-day and 90-day mortality in ACLF patients with or without underlying cirrhosis enrolled in the ACLF Research Consortium (AARC) database.

METHODS

A total of 1,621 patients were prospectively enrolled and 637 (39.3%) of these patients had cirrhosis. Baseline characteristics, complications and mortality were compared between patients with and without cirrhosis.

RESULTS

Alcohol consumption was more common in cirrhosis than non-cirrhosis (66.4% vs. 44.2%, p < 0.0001), while non-alcoholic fatty liver disease/cryptogenic CLD (10.9% vs 5.8%, p < 0.0001) and chronic HBV reactivation (18.8% vs 11.8%, p < 0.0001) were more common in non-cirrhosis. Only 0.8% of patients underwent liver transplantation. Overall, 28-day and 90-day mortality rates were 39.3% and 49.9%, respectively. Patients with cirrhosis had a greater chance of survival compared to those without cirrhosis both at 28-day (HR = 0.48; 95% CI 0.36-0.63, p < 0.0001) and 90-day (HR = 0.56; 95% CI 0.43-0.72, p < 0.0001), respectively. In alcohol CLD, non-cirrhosis patients had a higher 28-day (49.9% vs. 23.6%, p < 0.001) and 90-day (58.4% vs. 35.2%, p < 0.001) mortality rate than cirrhosis patients. ACLF patients with cirrhosis had longer mean survival than non-cirrhosis patients (25.5 vs. 18.8 days at 28-day and 65.2 vs. 41.2 days at 90-day). Exaggerated systemic inflammation might be the reason why non-cirrhosis patients had a poorer prognosis than those with cirrhosis after ACLF had occurred.

CONCLUSIONS

The 28-day and 90-day mortality rates of ACLF patients without cirrhosis were significantly higher than those with cirrhosis in alcoholic CLD. The presence of cirrhosis and its stage should be evaluated at baseline to guide for management. Thai Clinical Trials Registry, TCTR20191226002.

Helicobacter pylori outer membrane protein Q allele distribution is associated with distinct pathologies in Pakistan

Helicobacter pylori (H. pylori) strains expressing outer membrane protein Q (HopQ) promote adherence to the gastric epithelial cell. We characterized HopQ alleles in relation to H. pylori-related disease, histology and virulence markers. Gastric biopsies were obtained at esophagogastroduodenoscopy from patients with upper gastrointestinal symptoms. H. pylori culture, histology and polymerase chain reaction (PCR) for HopQ types, cagA, cagA-promoter and vacA alleles were performed. DNA extracted was used for PCR. Sequencing of PCR products of HopQ types 1 and 2 was followed by BLAST query. We examined 241 H. pylori isolates. HopQ type 1 was positive in 70 (29%) isolates, type 2 in 60 (25%) isolates, while both type 1 and type 2 in 111 (46%) H. pylori isolates, respectively. Nonulcer dyspepsia (NUD) was associated with HopQ type 2 in 48 (41%) isolates, while gastric carcinoma (GC) in 37 (53%) (P<0.001) with type 1 isolates. Gastric ulcers (GU) were 39 (46%) (P<0.001) in H. pylori infection with multiple HopQ alleles compared to 6 (23%) in HopQ type 1. Multivariate analysis demonstrated that multiple HopQ alleles were associated with GU OR 2.9 (1.07-7.8) (P=0.03). HopQ type 1 was associated with cagA 58 (84%) (P<0.001) and cagA-promoter 58 (83%) (P<0.001) compared to 14 (23%) and 17 (28%) respectively, in type 2. VacAs1a was associated with HopQ type 1 in 59 (84%) isolates compared to HopQ type 2 in 35 (58%) (P=0.002) isolates. VacAm1 was associated with HopQ type 1 in 53 (76%) isolates compared to HopQ type 2 in 32 (53%) (P=0.004) isolates. H. pylori infection with multiple HopQ alleles was predominant. H. pylori infection with single HopQ type 1 was associated with GC in the presence of other H. pylori virulence markers.

Gastritis profunda cystica presenting as gastric outlet obstruction and mimicking cancer: A case report

Gastritis cystica profunda (GCP) is a rare, benign lesion of the stomach characterized by polypoid hyperplasia and/or ulcerated mucosal lesion and cystic dilatation of the gastric glands extending into the submucosa or muscularis propria of the stomach. Its etiology and pathogenesis are still incompletely understood. The most important factor is assumed to be a history of prior gastric surgery. We herein present a case of a young adult female with upper gastrointestinal (GI) symptoms. She underwent upper GI endoscopy twice, which revealed pyloric narrowing and intramural mass. Gastric endoscopic mucosal biopsies were performed, but no tumor was identified and her symptoms persisted. Imaging studies also revealed a mass lesion. Open laparotomy and partial gastrectomy with histopathology of the resected specimen revealed the true nature of the lesion. Surgery also improved her symptoms. GCP should be kept in the differential diagnosis of gastric mural mass lesions.

Efficacy of L-ornithine-L-aspartate as an adjuvant therapy in cirrhotic patients with hepatic encephalopathy

OBJECTIVE

To evaluate the efficacy of L-ornithine-L-aspartate (LOLA) as an adjuvant therapy in cirrhotic patients with hepatic encephalopathy (HE).

STUDY DESIGN

Randomized placebo controlled study.

PLACE AND DURATION OF STUDY

The Aga Khan University Hospital, Karachi in the year 2003-2004.

METHODOLOGY

Patients with HE were randomized to receive LOLA or placebo medicine as an adjuvant to treatment of HE. Number connection test-A (NCT-A), ammonia level, clinical grade of HE and duration of hospitalization were assessed.

RESULTS

Out of 120 patients, there were 62 males with mean age of 57 ± 11 years. Improvement in HE was higher (n=40, 66.7%) in LOLA group as compared to the placebo group (n=28, 46.7%, p=0.027). In patients with grade I or less encephalopathy, improvement was seen in 6 (35.3%) and 3 (20%) patients in LOLA and placebo groups respectively (p=0.667). Patients with HE grade II and above showed improvement in 34 (79.1%) and 25 (55.6%) cases in LOLA and placebo group respectively (p=0.019). On multivariate analysis patients with HE of grade II and above showed prothrombin time, creatinine level and use of LOLA influencing the outcome. Duration of hospitalization was 93.6 ± 25.7 hours and 135.2 ± 103.5 hours in LOLA and placebo groups respectively (p=0.025). No side effects were observed in either groups.

CONCLUSION

In cirrhotic patients with advanced hepatic encephalopathy treatment with LOLA was safe and associated with relatively rapid improvement and shorter hospital stay.

Distribution of gastric carcinoma in an area with a high prevalence of Helicobacter pylori

BACKGROUND/AIMS

South Asia is an enigma for gastric cancer (GC) because it is a low risk region with a high prevalence of Helicobacter pylori (H. pylori) infections. We evaluated the trend of GC clinical presentation and risk factors in patients with dyspeptic symptoms.

MATERIALS AND METHODS

The medical records of patients, coded by the international classification of diseases (ICD-10-CM, 2015, Diagnosis Code C16.9) for malignancies of stomach diagnosed by esophagogastroduodenoscopy (EGD) and histopathology, were studied.

RESULTS

394 GC cases with a mean age of 54±15 years, range of 18 to 88, were analyzed. 256 (65%) were male. Distal non-cardiac and cardiac tumors were 302 (77%) and 92 (23%) cases, respectively. The WHO classification of GC defined 222 (56%) cases as intestinal type adenocarcinoma, 68 (17%) cases as signet ring cell carcinoma (SRC), 62 (16%) cases as diffuse type and 42 (11%) cases as B cell non-Hodgkin lymphoma. The co-morbid conditions associated with GC were H. pylori infection (positive in 246 (62%) cases), diabetes mellitus type 2 (in 90 (23%) cases), and cigarette smoking (in 94 (24%) cases). Of the male patients, 88 (34%) (p<0.001) were smokers. Body mass index was abnormal in all age groups and in both sexes. Cardiac regions for GC were more common in the 46- to 60-year old age range and in males. Diffuse GC was seen in all age groups but there were significantly more common in the 18- to 45-year old age range. Gastric non-Hodgkin's lymphoma was seen at an early age of 18-45 years in 14(12%) and a later of 61-88 years in 20 (15%).

CONCLUSION

Intestinal type GC is common at all ages but SRC and diffuse GC are more common in patients less than 50 years old. SRC and diffuse GC were not specific to the elderly in our study population.

Noninvasive predictors of large varices in patients hospitalized with gastroesophageal variceal hemorrhage

AIM

To identify noninvasive factors predicting the presence of large varices (LV) in patients hospitalized with gastroesophageal variceal hemorrhage (GEVH).

METHODS

Case records of patients admitted with GEVH between January 1998 and June 2005 were retrospectively analyzed. Relevant clinical parameters assessed included Child-Pugh class, ascites (clinical and/or on ultrasound), portosystemic encephalopathy (PSE), splenomegaly (clinical and/or on ultrasound), and hemodynamic instability. The laboratory parameters assessed were hemoglobin level, platelet count, prothrombin time, serum bilirubin, and albumin. The ultrasonographic characteristics noted were splenic size, presence of splenic varices, and portal vein diameter.

RESULTS

A total of 420 patients (264 men) presented with GEVH during the study period. The mean age, gender distribution, and presence of cirrhosis were similar in the two groups. Liver cirrhosis with hepatocellular carcinoma (HCC), Child-Pugh class C, presence of clinically detectable ascites, grade 3-4 PSE, detectable splenomegaly, previous history of GEVH, hemodynamic instability and platelet count <91,000 were more common in the LV group. The frequency of radiologically detected ascites, splenomegaly, and portal vein diameter were similar in both groups. On multivariate analysis, the independent predictors for the presence of LV were cirrhosis with HCC, clinically detectable splenomegaly, hemodynamic instability, a previous history of GEVH, platelet count <91,000, and splenic size >/=158 mm.

CONCLUSION

Cirrhosis with HCC, clinical splenomegaly, hemodynamic instability, a previous history of GEVH, thrombocytopenia (i.e., platelet count <91,000), and splenic size >/=158 mm are independent noninvasive predictors of large varices in patients hospitalized with gastroesophageal variceal hemorrhage.

Non-alcoholic fatty liver disease among visitors to a hepatitis awareness programme

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is rapidly becoming the most common liver disease worldwide. The present study aimed to evaluate the prevalence of NAFLD among the visitors screened on World Hepatitis Day 2010 and 2011.

METHODS

Attendees of the hepatitis awareness programme (n = 928) were offered screening to rule out liver ailments. The participants were evaluated on history, body mass index (BMI) measurement, blood tests for hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (anti-HCV), alanine aminotransferase (ALT) levels and abdominal ultrasound (US).

RESULTS

On ultrasonography, fatty liver was present in 142 of 806 subjects who were found negative for viral serology and had no history of regular alcohol intake. This accounted for 15.3% of all the visitors. Comparing them with the rest of the serology-negative alcohol-negative subjects, there were more housewives (p = 0.005) with fatty liver. They were older with mean age 43.3 +/- 12.1 years compared to 33.1 +/- 16.1 years (p = 0.000) in patients without fatty liver and had a higher BMI 28.6 +/- 6.0 kg/m2 vs. 22.2 +/- 5.3 kg/m2 (p = 0.000). Regression analysis suggested BMI as the only significant independent risk factor (p = 0.000). However, 32 subjects with fatty liver had BMI < 25 kg/m2 and 6 of them had diabetes mellitus. Thirty-one subjects (21.8%) with fatty liver had raised ALT level (p = 0.000) and possible non-alcoholic steatohepatitis (NASH) which accounts for 3.34% (31/928) of the total visitors.

CONCLUSIONS

This analysis reveals that our general population is at risk of having NAFLD and NASH and these should be looked into even in non-obese persons.