Viral nucleotide changes in asymptomatic hepatitis B carriers undergoing interferon treatment

BACKGROUND

Interferon might induce mutation in regions of hepatitis B virus DNA that encode for immunologic target of cytotoxic T lymphocytes.

AIM

To investigate the short-term effect of steroid priming and interferon therapy on hepatitis B virus, we followed the nucleotide changes in the precore and core region of hepatitis B virus DNA in seven healthy asymptomatic carriers who underwent steroid priming followed by recombinant alpha interferon for 3 months.

METHODS

Hepatitis B virus DNA from serial sera of the patients were polymerase chain reaction-amplified, and the precore and core region directly sequenced and analysed.

RESULTS

Analysis revealed no serial changes in the hepatitis B virus nucleotide sequence in any of the patients.

CONCLUSIONS

Steroid priming and short-term treatment with interferon in healthy asymptomatic patients does not select for hepatitis B virus with mutations in the precore and core region.

Serological profiles of hepatitis B carrier patients in Singapore with special reference to the frequency and significance of concurrent presence of HBsAg and anti-HBs

Hepatitis B serological markers were investigated in 1,132 consecutive Singaporean HBV carriers. Hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) were found concurrently in 234 carriers (234/1132 or 21%). Serum anti-HBs levels were more than 10 mIU/mL in 80 of these carriers (80/234 or 34%). There were no difference in HBeAg positive status, as well as HBV-DNA positive status in concurrent HBsAg/anti-HBs carriers compared to carriers without anti-HBs. Our results suggested that concurrent HBsAg and anti-HBs is a common serologic pattern in Singaporean HBV carriers.

Primary biliary cirrhosis--an uncommon disease in Singapore

Primary biliary cirrhosis (PBC) is uncommon in Singapore. Twelve consecutive patients with PBC were seen between 1987 and 1994 at the National University Hospital. Eleven were women and the mean age at presentation was 53 years. Three patients presented with pruritus and jaundice whilst three had decompensated cirrhosis. The remaining six patients had no symptoms attributed to their liver disease when first detected, three of them presented with associated conditions including sicca syndrome and interstitial lung fibrosis, lichen planus, and carcinoma of breast. All patients had elevated serum alkaline phosphatase and positive anti-mitochondrial antibodies. Liver histology (10/12) showed Stage II disease (2), Stage III (5) and Stage IV (3). Three patients also had co-existing gall bladder stones but their endoscopic retrograde cholangiograms were normal. The mean follow-up period was 32.6 months and four patients died during follow-up. The only male patient had liver transplantation, two patients had symptomatic treatment while the rest were treated with ursodeoxycholic acid. In conclusion, local patients tended to presented relatively early in the course of the disease with 50% being asymptomatic and in the precirrhotic Stages.

Hepatitis B virus infection in Singapore

Although Singapore is in an endemic region for hepatitis B infection, the hepatitis B carriage rate of 5-6% is relatively low. The highest positivity rates for hepatitis B surface antigen (HBsAg) are found in the paediatric age group, with another peak in 40-49 year olds. Studies suggest that, although perinatal transmission is an important route of infection, most children acquire the virus through horizontal transmission between family members. Viral replication continues at a high rate in young carriers and tends to slow down with increasing age. Up to 50% of hepatitis B carriers in Singapore have chronic hepatitis, shown by raised serum ALT values and liver histology, and about 10% are infected with the precore mutant virus. About 20% of carriers have cirrhosis. Among patients with HCC, up to 75% are HBsAg positive, of whom 45% are still viraemic. Mass vaccination against hepatitis B was introduced into Singapore on a voluntary basis in 1983, with compulsory vaccination of babies born to HBeAg positive mothers since 1985. The number of cases of acute hepatitis B has fallen by 60% between 1989 and 1995 although the problems of the longterm complications of chronic hepatitis B still need to be tackled.

The effect of polyunsaturated phosphatidyl choline in the treatment of acute viral hepatitis

BACKGROUND

Polyunsaturated phosphatidyl choline is a preparation often advocated for diseases of the liver.

METHODS

In a randomized open controlled trial, a preparation of polyunsaturated phosphatidyl choline, at a dose of 900 mg orally daily, was given to 22 patients with acute viral hepatitis. A control group of 25 patients was not treated.

RESULTS

Serial serum bilirubin and alanine amino transferase levels were measured up to 12 weeks. The falls in their levels after 2 and 5 weeks, and the lengths of time to their normalization, were not significantly different in the treated group compared to the control group.

CONCLUSION

The results indicated that polyunsaturated phosphatidyl choline had no beneficial effect on the course of acute viral hepatitis.

Treatment of hepatitis B surface antigen carriers in the early stage of the infection using recombinant alpha-interferon with steroid priming

BACKGROUND

Alpha-interferon has been found to inhibit hepatitis B virus (HBV) replication in Chinese patients with chronic HBV infection although a sustained effect was rarely achieved in those with normal pretreatment serum alanine amino transferase (ALT) levels. Prednisolone priming has been found to be beneficial over treatment with interferon alone in these subjects. We studied the effect of steroid pre-treatment followed by recombinant interferon alpha-2a in the treatment of asymptomatic HBV carriers with positive hepatitis Be antigen (HBeAg), hepatitis B viral DNA (HBV-DNA) and minimal changes in liver histology.

METHODS

The treatment regimen included a 6-week prednisolone priming, a 2 week rest followed by 14 weeks of three times weekly 9 mega units of interferon alpha-2a injection and 52 weeks of follow-up. There were seven patients in the treatment group and seven controls.

RESULTS

The mean age, pre-treatment ALT (normal in all except for one in each of the treatment and control groups), HBV-DNA levels and histological scores were similar in the two groups. Serum HBV-DNA levels fell in six patients during treatment and became undetectable in two of them by the end. During follow-up, serum HBV-DNA returned to pre-treatment levels in all patients. None of the treated patients had HBeAg sero-conversion and none of the controls had spontaneous clearance of HBV-DNA or sero-conversion of HBeAg. No improvement of liver histology was observed in any of the treated patients. There were only mild flu-like side-effects noted and interferon alpha-2a was well tolerated at the doses given among treated patients.

CONCLUSION

Prednisolone priming followed by interferon alpha-2a treatment has no beneficial effect on HBV carriers in the early stages of chronic hepatitis B infection.

How does chili cause upper gastrointestinal symptoms? A correlation study with esophageal mucosal sensitivity and esophageal motility

Chili ingestion produces gastrointestinal symptoms in many subjects. Some of these symptoms, such as heartburn, might well arise from the esophagus, but the pathogenesis is unknown. We studied the effects of chili ingestion on esophageal motility in 16 healthy volunteers and correlated these with the production of chili-induced upper gastrointestinal symptoms. We also studied the effects of chili instillation into the esophagus in 15 of the subjects to determine whether typical symptoms were produced. There were no changes in esophageal manometric parameters in all 16 subjects after the ingestion of a chili suspension (5 g chili powder in 100 ml water), although half of them reported one or more symptoms. Direct instillation of the same chili suspension into the lower esophagus produced typical symptoms in all 15 volunteers tested. Chili-induced upper gastrointestinal symptoms were not accompanied by changes in esophageal motility. The esophageal mucosa itself was sensitive to chili, suggesting that at least some of the upper gastrointestinal symptoms produced by chili are mediated by direct stimulation of chili-sensitive afferent nerve endings in the esophageal mucosa.

Hepatitis C virus genotypes in Singapore and Indonesia

5' untranslated and partial core (C) region sequence of hepatitis C virus (HCV) in 21 Singaporean and 15 Indonesian isolates were amplified by reverse-transcription polymerase chain reaction and sequenced with the use of conserved primer sequences deduced from HCV genomes identified in other geographical regions. The HCV genotypes are predominantly that of Simmonds type 1 and less of type 2 and 3 with the latter genotype currently not detected in Indonesia. The 5' untranslated sequences are related to HCV-1. DK-7 (Denmark), US-11 (United States of America), HCV-J4, SA-10 (South Africa), T-3 (Taiwan), HCV-J6, HCV-J8, Eb-1 and Eb-8. When compared with the prototype HCV-1, insertions are found within the 5' untranslated region of Singaporean isolates and not in the Indonesians. There are Singaporean and Indonesian isolates that have sequences within the 5' untranslated region that differ slightly from each other. Microheterogeneity is observed in the core region of two Singaporeans and one Indonesian isolate. Finally, not all HCV isolates can be amplified with the conserved core sequence primers when compared with the ease with which these isolates can be amplified with 5' untranslated region conserved primers.

Immunogenicity and safety of an inactivated hepatitis A vaccine amongst Singaporeans

The immunogenicity and reactogenicity of an inactivated hepatitis A virus (HAV) vaccine was studied in healthy Singaporean adult volunteers. One hundred and forty healthy volunteers with normal alanine (ALT) and aspartate (AST) transaminases and no previous exposure to HAV, received three 1 ml doses (720 ELISA units) of an inactivated HAV vaccine (Smithkline Beechams Biologicals) following a 0, 1, 6 months vaccination schedule. All subjects were asked to record and grade the severity of any reactions for three consecutive days after each dose. Serum ALT and AST as well as anti-HAV were measured at 0, 1, 2, 6 and 7 months after the first vaccine dose. Anti-HAV seroconversion occurred when levels rose above 40 mIU/ml. Eighty-five percent of vaccinees seroconverted after the first innoculation and 99% after the second injection. All vaccinees seroconverted after the third dose. Geometric mean anti-HAV titers (GMTs) were, respectively, 119, 391, 4406 mIU/ml one month after each of the three doses. The most common side effect was transient pain and tenderness at the vaccination site. No elevation of ALT or AST levels were noted during the study period. The inactivated hepatitis A vaccine used in this study is safe and highly immunogenic in the local adult population. Two doses one month apart appeared to give adequate protection.

Chili protects against aspirin-induced gastroduodenal mucosal injury in humans

Capsaicin, the pungent ingredient of chili, has a gastroprotective effect against experimental gastric mucosal injury in animals. Such an effect has not, however, been documented in humans to date. Eighteen healthy volunteers with normal index endoscopies underwent two studies four weeks apart. Each subject took 20 g chili orally with 200 ml water in one study and 200 ml water in another study. In each case this was followed half an hour later by 600 mg aspirin BP with 200 ml water. Endoscopy was repeated 6 hr later. Gastroduodenal mucosal damage was assessed by a previously validated scoring system. The median gastric injury score after chili was 1.5 compared to 4 in the control group (P < 0.05), demonstrating a gastroprotective effect of chili in human subjects.

Chili--protective factor against peptic ulcer?

The aim of the present study was to determine the frequency and amount of chili taken by peptic ulcer patients and control subjects. One hundred three Chinese patients with peptic ulcer and 87 control patients were interviewed using a standard questionnaire. Those subjects who deliberately avoided chili use because of symptoms or advice from friends or medical practitioners were excluded. The median number of times of chili use per month was eight in the ulcer group (25-75% quartiles 1-30) compared to 24 (8-56) in the control group (P < 0.001). The median amount of chili used per month was 312 units (25-75% quartiles 38-899) in the ulcer group compared to 834 units (274-1892) in the control group (P < 0.001). The odds ratio of having peptic ulcer disease, adjusted for age, sex, analgesic use, and smoking by multiple logistic regression, was 0.47 (95% confidence intervals: 0.25-0.89) for subjects who had a higher intake of chili both in terms of frequency as well as amount used compared to those who took less chili. Our data support the hypothesis that chili use has a protective effect against peptic ulcer disease.

Seroprevalence of antibodies against hepatitis A (anti-HAV) in Singapore: the NFDD experience

At the 4th National Foundation for Digestive Disease (NFDD) Day in 1991 where public lectures on prevention of hepatitis and early detection of hepatocellular carcinoma were given, screening of sera obtained from 364 registrants for antibodies to Hepatitis A (IgG) was undertaken. The overall sero-prevalence rate was 50%, with 55% for males and 46% for females with antibodies for HAV. None of the subjects below 20 years old had antibodies to HAV. This rose to 16% for those 21-30 years old and 92% for those above 61 years. This study shows that in Singapore, prevalence of anti-HAV antibodies rise with age and is approaching the low endemicity pattern that is seen in developed countries.

Study on the comparative immunogenicity of a recombinant DNA hepatitis B vaccine containing pre-S components of the HBV coat protein with non pre-S containing vaccines

A new recombinant hepatitis B vaccine (SCI-B-VAC), derived from Chinese hamster ovary (CHO) cells and consisting of both the major S protein and the minor pre-S1 and pre-S2 proteins of the viral coat were compared with two yeast-derived vaccines containing only S proteins (B-Hepavac II and Engerix-B) for immunogenicity in human volunteers in a randomized controlled study. Two hundred and ninety-five healthy subjects completed the 12 month follow up. There was no difference in the mean age and sex distribution among the three study groups. Seroconversion rates for all the three groups were similar at months 6, 9 and 12. However, hepatitis B surface antibody (anti-HBs) geometric mean titres (GMT) were significantly higher with 10 micrograms SCI-B-VAC and 20 micrograms Engerix-B than with 10 micrograms B-Hepavac-II at months 6, 9 and 12. SCI-B-VAC at month 6 also showed a significantly higher anti-HBs GMT than Engerix-B (295 vs 143 miu/mL, P < 0.02).

Closure of a benign gastrocolic fistula on medical management

Gastrocolic fistulae secondary to un-operated benign gastric ulcers are rare. We report a case of a large benign gastrocolic fistula diagnosed by colonoscopy, which was found to have healed over a short period of 3 weeks, while the patient was being prepared for surgery. He was on parenteral nutrition and intravenous cimetidine. The available literature is reviewed and an attempt is made to explain the closure of the fistula on medical treatment. A trial of medical management may be justified in patients with benign gastrocolic fistulae who are poor surgical risks.

Transjugular intrahepatic portosystemic shunt: a case report

Of the various methods currently available to manage potentially life threatening bleeding from oesophagogastric varices, surgical portosystemic shunts are recognised to have the lowest incidence of rebleeding though surgery is associated with high morbidity and mortality. Recently, a promising non-surgical technique has been developed to create an intrahepatic portosystemic shunt via a percutaneous transjugular route. This paper presents a case report of this region's first transjugular intrahepatic portosystemic shunt procedure and briefly reviews the development and preliminary results of this technique.

Hepatitis B virus infection in patients with systemic lupus erythematosus

Sera from 76 patients with systemic lupus erythematosus (SLE) were examined for HBsAg, anti-HBsAb and total anti-HBcAB by radioimmunoassay. Fifteen patients (19.7%) had one or more of these serological markers of HBV infection. This is comparable to the sero-prevalence in 100 sex- and age-matched healthy individuals (19%). There was no significant difference in the prevalence of HBV infection in patients who had received immunosuppressants compared with those who had not. Patients who had received transfusion of blood or blood products had a higher prevalence of serological markers but this was not statistically significant.

Pill-induced esophageal ulcer

We describe nine cases of esophageal injury associated with the ingestion of prescribed medications. Antibiotics were the most commonly implicated drugs. Odynophagia, retrosternal chest pain and dysphagia were the usual presenting symptoms. The typical endoscopic finding was that of discrete ulcers in the mid-esophagus. All patients recovered uneventfully with discontinuation of the offending drug and symptomatic treatment. Drug induced esophageal injury should be considered in patients presenting acutely with the above mentioned symptoms and having discrete esophageal ulcers on endoscopy.

Hepatitis A sero-epidemiology in Singapore: a changing pattern

Sera from 896 healthy volunteers between 15 and 56 years old were tested in 1987-1991 for immunoglobulin G antibody against the hepatitis A virus (IgG anti-HAV). The overall seroprevalence rate of IgG anti-HAV was 27%: it increased from 0.9% in the 10-19 years age group to 48.1% in the 40-49 years age group and was 100% in subjects over 50 years. There was no difference in anti-HAV seroprevalence between the sexes (29% among men and 26% among women) and races. A downward trend in anti-HAV seroprevalence was seen from 1987 (33%) to 1991 (21.4%). The level of exposure to the hepatitis A virus has decreased when compared with data obtained in 1975 and 1984-1985. Hepatitis A virus infection is no longer an infection of children and adolescents locally.

Low frequency of endoscopic esophagitis in Asian patients

The aim of this study was to determine the frequency of endoscopic esophagitis in patients seen for upper gastrointestinal complaints in an Asian center. We studied a consecutive series of 11,943 patients undergoing diagnostic esophagogastroduodenoscopy at our unit over a 10-year period. Three hundred and eighty-nine patients (3.3%) had endoscopic esophagitis with no other significant lesion (primary esophagitis), whereas 143 (1.2%) had esophagitis associated with peptic ulcer or gastric or duodenal malignancy (secondary esophagitis). In contrast, peptic ulcer was diagnosed in 2,787 patients (23.3%) and gastric carcinoma in 286 (2.4%). The reported frequency of endoscopic esophagitis among patients undergoing endoscopy in Western countries varied from 9 to 23%. Our data therefore show that endoscopic esophagitis is much less common in Singaporean patients.

Inflammatory bowel disease: an uncommon problem in Singapore

Fifty patients with inflammatory bowel disease (ulcerative colitis, 40; Crohn's disease, seven; indeterminate colitis, three) treated in one gastroenterology unit in Singapore over a 10 year period were reviewed. Clinical features were similar to those described in Western patients. Of the three main races of Singapore it was found that Indians are more susceptible to these diseases than Chinese or Malays. A survey of all gastroenterologists in Singapore indicated a possible prevalence of 8.6 per 100,000 people for ulcerative colitis and 1.3 per 100,000 people for Crohn's disease. These prevalence rates are much lower than those reported for Western populations.

Chronic upper abdominal pain: site and radiation in various structural and functional disorders and the effect of various foods

Pain site and radiation and the effect of various foods were studied prospectively in a consecutive series of patients with chronic upper abdominal pain. Patients followed for less than one year were excluded unless peptic ulcer or abdominal malignancy had been diagnosed or laparotomy had been carried out. A total of 632 patients were eligible for the first study and 431 for the second. Gastric ulcer pain was more likely to be left hypochondrial (17%) compared with pain from duodenal ulcer (4%) or from all other conditions (5%). It was less likely to be epigastric (54%) compared with duodenal ulcer pain (75%). Oesophageal pain was more likely to be both retrosternal and epigastric (25%) compared with non-oesophageal pain (2%). Radiation to the back was more common in peptic ulcer (31%) and biliary pain (35%) compared with functional pain (20%). Pain precipitation by fatty foods was commoner in biliary disease (40%) than in duodenal ulcer (11%), peptic ulcer (9%), or non-ulcer dyspepsia (19%). Orange, alcohol, and coffee precipitated pain more frequently in duodenal ulcer (41%, 50%, and 43% respectively) than in biliary disease (17%, 0%, and 14% respectively). Chilli precipitated pain in one quarter to one half of subjects regardless of diagnosis. Approximately one tenth of all subjects avoided chilli, curry, coffee, and tea because of medical or other advice.

Recombinant DNA hepatitis B vaccine containing Pre-S components of the HBV coat protein--a preliminary study on immunogenicity

A novel recombinant hepatitis B vaccine, trademarked Sci-B-Vac, was evaluated for safety, tolerability and immunogenicity in an open label trial performed in Singapore. The experimental vaccine, derived from Chinese hamster ovary (CHO) cells, consists of hepatitis B surface antigen (HBsAg) particles harbouring all three viral envelope polypeptides, the major S protein and the minor Pre-S2 and Pre-S1, in their glycosylated and non-glycosylated forms. The vaccine was administered intramuscularly at 0, 1 and 6 months. No unexpected adverse effects were observed. A high level anti-HBs response to Sci-B-Vac was indicative of its immunogenicity. Subsequent to the third injection, 100% and 92% of the 10 micrograms and 5 micrograms dose recipients, respectively, were seroprotected (anti-HBs titres greater than or equal to 10 mIU ml-1). Moreover, the geometric mean titres (GMT) of the anti-HBs response were very high: 2687 and 1473 mIU ml-1, respectively. An immunogenic advantage of Sci-B-Vac was also suggested by the rapid onset of antibody response: 96% of the 10 micrograms dose recipients were seroprotected with a GMT of 159 mIU ml-1, prior to the third injection.