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Fouad Y, Ghazinyan H, Alboraie M, Al Khatry M, Desalegn H, Al-Ali F, El-Shabrawi MHF, Ocama P, Derbala M, Barakat S, Awuku YA, Ndububa DA, Sabbah M, Hamoudi W, Ng'wanasayi M, Elwakil R, Ally R, Al-Busafi SA, Hashim A, Esmat G, Shiha G. Joint position statement from the Middle East and North Africa and sub-Saharan Africa on continuing to endorse the MAFLD definition. J Hepatol 2024; 80:e194-e197. [PMID: 38342440 DOI: 10.1016/j.jhep.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 01/27/2024] [Indexed: 02/13/2024]
Affiliation(s)
- Yasser Fouad
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt.
| | - Hasmik Ghazinyan
- Gastroenterology and Hepatology Service, Yerevan Medical Scientific Center, Yerevan, Armenia
| | - Mohamed Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
| | - Maryam Al Khatry
- Department of Gastroenterology, Obaidulla Hospital, Ras Al Khaimah, Emirates Health Services, Ministry of Health, United Arab Emirates
| | - Hailemichael Desalegn
- Department of Internal Medicine, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Fuad Al-Ali
- Department of Gastroenterology, Royal Hayat Hospital, Faculty of Medicine, Kuwait University, Kuwait
| | - Mortada H F El-Shabrawi
- Paediatric Hepatology Unit, Department of Paediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ponsiano Ocama
- School of Medicine, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moutaz Derbala
- Gastroenterology and Hepatology Department, Hamad Medical Corporation, Doha, Qatar
| | - Salma Barakat
- National Center for Gastrointestinal and Liver Diseases, Ibn Sina Hospital, Ministry of Health, Khartoum, Sudan
| | - Yaw Asante Awuku
- Department of Medicine and Therapeutics, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Dennis Amajuoyi Ndububa
- Department of Medicine, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Meriam Sabbah
- Department of Gastroenterology, Habib Thameur Hospital, Tunis, Tunisia
| | - Waseem Hamoudi
- Internal Medicine Department, Al-Bashir Hospital, Amman, Jordan
| | | | - Reda Elwakil
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Egypt
| | - Reidwan Ally
- Department of Gastroenterology, Univ of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Said A Al-Busafi
- Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Almoutaz Hashim
- Department of Internal Medicine, Jeddah University, Jeddah, Saudi Arabia
| | - Gamal Esmat
- Departement of Endemic Medicine and Hepatogastrenterology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Gamal Shiha
- Egyptian Liver Research Institute and Hospital, Mansoura, Egypt; Hepatology and Gastroenterology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Abou-Alfa GK, Afihene M, Capanu M, Li Y, Chou JF, Asombang A, Alatise OI, Bounedjar A, Cunha L, Mekonnen HD, Diop PS, Elwakil R, Ali MM, Ndlovu N, Ndumbalo J, Makondi PT, Tzeuton C, Biachi de Castria T, Agyei-Nkansah AA, Balogun F, Bougouma A, Atipo Ibara BI, Jonas E, Kimani S, Kingham P, Kurrimbukus R, Hammad N, Fouad M, El Baghdady N, Servais Albert Fiacre EB, Sewram V, Spearman CW, Yang JD, Roberts LR, Abdelaziz AO. Africa Guidelines for Hepatocellular Carcinoma Buildup Process. JCO Glob Oncol 2023; 9:e2300159. [PMID: 37944087 PMCID: PMC10645406 DOI: 10.1200/go.23.00159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/08/2023] [Accepted: 09/06/2023] [Indexed: 11/12/2023] Open
Abstract
PURPOSE Hepatocellular carcinoma (HCC), the fourth most common cancer in Africa, has a dismal overall survival of only 3 months like in sub-Saharan Africa. This is affected by the low gross domestic product and human development index, absence of coherent guidelines, and other factors. METHODS An open forum for HCC-experienced health care workers from Africa and the rest of the world was held in October 2021. Participants completed a survey to help assess the real-life access to screening, diagnoses, and treatment in the North and Southern Africa (NS), East and West Africa (EW), Central Africa (C), and the rest of the world. RESULTS Of 461 participants from all relevant subspecialties, 372 were from Africa. Most African participants provided hepatitis B vaccination and treatment for hepatitis B and C. More than half of the participants use serum alpha-fetoprotein and ultrasound for surveillance. Only 20% reported using image-guided diagnostic liver biopsy. The Barcelona Clinic Liver Cancer is the most used staging system (52%). Liver transplant is available for only 28% of NS and 3% EW. C reported a significantly lower availability of resection. Availability of local therapy ranged from 94% in NS to 62% in C. Sorafenib is the most commonly used systemic therapy (66%). Only 12.9% reported access to other medications including immune checkpoint inhibitors. Besides 42% access to regorafenib in NS, second-line treatments were not provided. CONCLUSION Similarities and differences in the care for patients with HCC in Africa are reported. This reconfirms the major gaps in access and availability especially in C and marginally less so in EW. This is a call for concerted multidisciplinary efforts to achieve and sustain a reduction in incidence and mortality from HCC in Africa.
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Affiliation(s)
- Ghassan K. Abou-Alfa
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
- Trinity College Dublin, Dublin, Ireland
| | | | - Marinela Capanu
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Yuelin Li
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | | | - Akwi Asombang
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Adda Bounedjar
- University Blida 1 Laboratoire de Cancérologie, Faculté de Médecine, Blida, Algeria
| | - Lina Cunha
- Hospital Privado De Maputo, Maputo, Mozambique
| | | | | | | | | | - Ntokozo Ndlovu
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | | | | | | | | | - Fiyinfolu Balogun
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Alain Bougouma
- Université de Ouagadougou UFR/SDS, Ouagadougou, Burkina Faso
| | | | - Eduard Jonas
- University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | | | - Peter Kingham
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | | | | | - Mona Fouad
- University of Alabama Birmingham, Birmingham, AL
| | | | | | | | - C. Wendy Spearman
- University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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3
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Elwakil R, Ocama P, Kayamba V, Fouad Y, Ojo O. Editorial: Global excellence in gastroenterology: Africa. Front Med (Lausanne) 2023; 9:1121276. [PMID: 36698811 PMCID: PMC9869266 DOI: 10.3389/fmed.2022.1121276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/26/2022] [Indexed: 01/12/2023] Open
Affiliation(s)
- Reda Elwakil
- Tropical Medicine Department, Ain Shams University, Cairo, Egypt,*Correspondence: Reda Elwakil ✉
| | - Ponsiano Ocama
- Internal Medicine Department, Makerere University, Kampala, Uganda
| | - Violet Kayamba
- Internal Medicine Department, Zambia University, Lusaka, Zambia
| | - Yasser Fouad
- Endemic Medicine Department, Minia University, Minia, Egypt
| | - Olusegun Ojo
- Department of Morbid Anatomy, Obafemi Awolowo University, Ife, Nigeria
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4
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Fouad Y, Esmat G, Elwakil R, Zakaria S, Yosry A, Waked I, El-Razky M, Doss W, El-Serafy M, Mostafa E, Anees M, Sakr MA, AbdelAty N, Omar A, Zaki S, Al-zahaby A, Mahfouz H, Abdalla M, Albendary M, Hamed AK, Gomaa A, Hasan A, Abdel-baky S, El sahhar M, Shiha G, Attia D, Saeed E, Kamal E, Bazeed S, Mehrez M, Abdelaleem S, Gaber Y, Abdallah M, Salama A, Tawab DA, Nafady S. The egyptian clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease. Saudi J Gastroenterol 2022; 28:3-20. [PMID: 35083973 PMCID: PMC8919931 DOI: 10.4103/sjg.sjg_357_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The landscape of chronic liver disease in Egypt has drastically changed over the past few decades. The prevalence of metabolic-associated fatty liver disease (MAFLD) has risen to alarming levels. Despite the magnitude of the problem, no regional guidelines have been developed to tackle this disease. This document provides the clinical practice guidelines of the key Egyptian opinion leaders on MAFLD screening, diagnosis, and management, and covers various aspects in the management of MAFLD. The document considers our local situations and the burden of clinical management for the healthcare sector and is proposed for daily clinical practical use. Particular reference to special groups was done whenever necessary.
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Affiliation(s)
- Yasser Fouad
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Cairo, Egypt,Address for correspondence: Dr. Yasser Fouad, Professor of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Minia University, Minia 61519, Egypt. E-mail:
| | - Gamal Esmat
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Reda Elwakil
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Serag Zakaria
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ayman Yosry
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Imam Waked
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen El Kom, Egypt
| | - Maissa El-Razky
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wahid Doss
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Magdy El-Serafy
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Mahmood Anees
- Department of Gastroenterology and Hepatology, Tanta, Egypt
| | - Mohamed A. Sakr
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nadia AbdelAty
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ashraf Omar
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Samy Zaki
- Department of Hepatogastroenterology and Infectious Diseases, Al-Azhar University, Cairo, Egypt
| | - Amgad Al-zahaby
- Department of Hepatogastroenterology and Infectious Diseases, Al-Azhar University, Cairo, Egypt
| | - Hamdy Mahfouz
- Department of Hepatogastroenterology and Infectious Diseases, Al-Azhar University, Assuit, Egypt
| | - Maysaa Abdalla
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mahmoud Albendary
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Mansura University, Mansura, Egypt
| | - Abdel-Khalek Hamed
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Cairo, Egypt
| | - Ahmed Gomaa
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Adel Hasan
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Suez Canal University, Suez, Egypt
| | - Sherif Abdel-baky
- Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Medhat El sahhar
- Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Police Medical Academy, Cairo, Egypt
| | - Gamal Shiha
- Hepatology and Gastroenterology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Dina Attia
- Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt
| | - Ebada Saeed
- Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Benha University, Benha, Egypt
| | - Enas Kamal
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Cairo, Egypt
| | - Shamardan Bazeed
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Mai Mehrez
- Department of Hepatology, NTHMRI, Cairo, Egypt
| | - Shereen Abdelaleem
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yasmine Gaber
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohammed Abdallah
- Department of Medical Research Division Medicine, National Research Centre, Giza, Egypt
| | - Asmaa Salama
- Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt
| | - Doaa A. Tawab
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assuit University, Assuit, Egypt
| | - Shaymaa Nafady
- Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt
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5
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Marzouk D, Sharawy I, Nakhla I, El Hodhod M, Gadallah H, El-Shalakany A, Elwakil R, Moussa MM, Ismail A, Tash FM. Challenges During Review of COVID-19 Research Proposals: Experience of Faculty of Medicine, Ain Shams University Research Ethics Committee, Egypt. Front Med (Lausanne) 2021; 8:715796. [PMID: 34805197 PMCID: PMC8596560 DOI: 10.3389/fmed.2021.715796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
The COVID-19 pandemic resulted in an overwhelming increase in research studies submitted to research ethics committees (RECs) presenting many ethical challenges. This article aims to report the challenges encountered during review of COVID-19 research and the experience of the Faculty of Medicine, Ain Shams University Research Ethics Committee (FMASU REC). From April 10, 2020, until October 13, 2020, the FMASU REC reviewed 98 COVID-19 research protocols. This article addressed the question of how to face an overwhelming amount of research submitted to the REC while applying the required ethical principles. Ethical challenges included a new accelerated mode of review, online meetings, balance of risks vs. benefits, measures to mitigate risks, co-enrolment in different studies, protection of a vulnerable COVID-19 population, accelerated decisions, online research, how to handle informed consent during the pandemic, and justification of placebo arm.
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Affiliation(s)
- Diaa Marzouk
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Iman Sharawy
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Isabelle Nakhla
- Misr International University, US Naval Medical Research Unit No.3 (NAMRU-3), Cairo, Egypt
| | - Mostafa El Hodhod
- Faculty of Medicine, Ain Shams University, Cairo, Egypt.,Faculty of Medicine, October 6 University, Giza, Egypt
| | - Hoda Gadallah
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Reda Elwakil
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Alaa Ismail
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Fathy M Tash
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
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6
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Leddin D, Omary MB, Veitch A, Metz G, Amrani N, Aabakken L, Ali RAR, Alvares-da-Silva MR, Armstrong D, Boyacioglu S, Chen Y, Elwakil R, Fock KM, Hamid SS, Makharia G, Macrae F, Malekzadeh R, Mulder CJ, Piscoya A, Perman ML, Sadeghi A, Sáenz R, Saurin JC, Butt AS, Wu K, Lee YY. Uniting the Global Gastroenterology Community to Meet the Challenge of Climate Change and Nonrecyclable Waste. J Clin Gastroenterol 2021; 55:823-829. [PMID: 34617932 DOI: 10.1097/mcg.0000000000001619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Climate change has been described as the greatest public health threat of the 21st century. It has significant implications for digestive health. A multinational team with representation from all continents, excluding Antarctica and covering 18 countries, has formulated a commentary which outlines both the implications for digestive health and ways in which this challenge can be faced.
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Affiliation(s)
| | - M Bishr Omary
- Rutgers University, New Brunswick, NJ, United States
| | | | - Geoffrey Metz
- Monash University and University of Melbourne, Melbourne, Australia
| | | | | | - Raja A R Ali
- National University of Malaysia, Bandar Baru Bangi, Selangor, Malaysia
| | | | | | | | - Ye Chen
- Southern Medical University, Guangzhou, Guangdong Province, China
| | | | - Kwong-Ming Fock
- Duke-NUS Medical School and Changi General Hospital, Singapore, Singapore
| | | | - Govind Makharia
- All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Finlay Macrae
- Royal Melbourne Hospital, Parkville, Vic., Australia
| | | | | | | | | | | | - Roque Sáenz
- Universidad del Desarrollo, Concepción, Chile
| | | | | | - Kaichun Wu
- Xijing Hospital of Digestive Diseases, Xi'an, Shaanxi Province, China
| | - Yeong Yeh Lee
- Universiti Sains Malaysia, Gelugor, Penang, Malaysia
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7
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Leddin D, Omary MB, Veitch A, Metz G, Amrani N, Aabakken L, Raja Ali RA, Alvares-Da-Silva MR, Armstrong D, Boyacioglu S, Chen Y, Elwakil R, Fock KM, Hamid SS, Makharia G, Macrae F, Malekzadeh R, Mulder CJ, Piscoya A, Perman ML, Sadeghi A, Sáenz R, Saurin JC, Butt AS, Wu K, Lee YY. Uniting the Global Gastroenterology Community to Meet the Challenge of Climate Change and Non-Recyclable Waste. Gastroenterology 2021; 161:1354-1360. [PMID: 34629165 DOI: 10.1053/j.gastro.2021.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Desmond Leddin
- Dalhousie University, Canada Chair, WGO Clinical Research Committee
| | - M Bishr Omary
- Rutgers University, United States Past President, American Gastroenterological Association
| | - Andrew Veitch
- Royal Wolverhampton Hospitals, United Kingdom President Elect, British Society of Gastroenterology
| | - Geoffrey Metz
- Monash University and University of Melbourne, Australia Chair, Climate Change Working Group, WGO
| | | | | | | | | | | | | | - Ye Chen
- Southern Medical University, China
| | | | - Kwong-Ming Fock
- Duke-NUS Medical School and Changi General Hospital, Singapore
| | | | | | | | | | | | | | | | | | | | | | | | - Kaichun Wu
- Xijing Hospital of Digestive Diseases, China
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8
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Leddin D, Omary MB, Veitch A, Metz G, Amrani N, Aabakken L, Raja Ali RA, Alvares-Da-Silva MR, Armstrong D, Boyacioglu S, Chen Y, Elwakil R, Fock KM, Hamid SS, Makharia G, Macrae F, Malekzadeh R, Mulder CJ, Piscoya A, Perman ML, Sadeghi A, Saenz R, Saurin JC, Butt AS, Wu K, Yeh Lee Y. Uniting the global gastroenterology community to meet the challenge of climate change and non-recyclable waste. Gut 2021; 70:2025-2029. [PMID: 34620696 DOI: 10.1136/gutjnl-2021-325789] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 01/16/2023]
Affiliation(s)
- Desmond Leddin
- Gastroenterology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - M Bishr Omary
- Department of Medicine, Rutgers Robert Wood Johnson Medical School Camden, Piscataway, New Jersey, USA
| | - Andrew Veitch
- Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | | | | | | | | | | | | | | | - Ye Chen
- Southern Medical University, Guangzhou, China
| | | | - Kwong-Ming Fock
- Duke-NUS Medical School and Changi General Hospital, Singapore
| | | | | | - Finlay Macrae
- University of Melbourne, Melbourne, Victoria, Australia
| | | | - Chris J Mulder
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | | | | - Kaichun Wu
- Xijing Hospital of Digestive Diseases, Xi'an, China
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9
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Spearman CW, Desalegn H, Ocama P, Awuku YA, Ojo O, Elsahhar M, Abdo AA, Ndububa DA, Fouad Y, Borodo MM, Ng'wanasayi M, Ally R, Elwakil R. The sub-Saharan Africa position statement on the redefinition of fatty liver disease: From NAFLD to MAFLD. J Hepatol 2021; 74:1256-1258. [PMID: 33484771 DOI: 10.1016/j.jhep.2021.01.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 02/08/2023]
Affiliation(s)
- C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - Hailemichael Desalegn
- Medical Department, St. Paul's Hospital, Millennium Medical College, Addis Ababa, Ethiopia
| | - Ponsiano Ocama
- School of Medicine, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Yaw Asante Awuku
- Department of Medicine and Therapeutics, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Olusegun Ojo
- Gastroenterology and Liver Pathology Unit, Department of Morbid Anatomy, Obafemi Awolowo University and Teaching Hospital Complex, Ile Ife, Nigeria
| | - Medhat Elsahhar
- Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Police Medical Academy, Cairo, Egypt
| | | | - Dennis Amajuoyi Ndububa
- Department of Medicine, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Yasser Fouad
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt
| | | | | | - Reidwan Ally
- Departement of Gastroenterology, University of Witwatersr, Chris Hani Baraguanath Academic Hospital, Johansberg, South Africa
| | - Reda Elwakil
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Egypt.
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10
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Fouad Y, Elwakil R, Elsahhar M, Said E, Bazeed S, Ali Gomaa A, Hashim A, Kamal E, Mehrez M, Attia D. The NAFLD-MAFLD debate: Eminence vs evidence. Liver Int 2021; 41:255-260. [PMID: 33220154 DOI: 10.1111/liv.14739] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 10/30/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022]
Abstract
Debates are inevitable in science and could be a powerful tool for addressing controversial topics as it promotes critical thinking and inspires individuals to consider alternate viewpoints. However, debates can help only to identify the issues that need to be clarified to address this question, but it can never help resolve the controversy itself. In the era of evidence-based medicine, the need for an evidence-based debate is mandatory. Polarising opinions and major debate have recently arisen in hepatology on the nomenclature and diagnostic criteria for fatty liver disease associated with metabolic dysfunction (non alcoholic fatty liver disease [NAFLD]-metabolic (dysfunction) associated fatty liver disease [MAFLD] debate). The aim of this viewpoint is to suggest a way to settle the debate through evidence. Descriptive review using PubMed to identify literature on the evidence and eminence-based medicine and studies comparing MAFLD and NAFLD criteria. The emerging studies comparing the performance of diagnostic criteria of NAFLD and MAFLD represent the dawn of a new era for reframing the ongoing debate by acquisition of the mandatory evidence that will both resolve the debate and lead to novel avenues of research. In conclusion, the time has come to hold debate and focus on gathering and building the evidence to settle it. It does not matter who wins the debate and once there is robust evidence, we should all follow it wherever it leads.
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Affiliation(s)
- Yasser Fouad
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt
| | - Reda Elwakil
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Egypt
| | - Medhat Elsahhar
- Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Police Medical Academy, Cairo, Egypt
| | - Ebada Said
- Department of Hepatology and gastroenterology, Faculty of Medicine, Banha University, Banha, Egypt
| | - Shamardan Bazeed
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Ahmed Ali Gomaa
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Almoutaz Hashim
- Department of Medicine, University of Jeddah, Jeddah, Kingdom of Saudi Arabia
| | - Enas Kamal
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mai Mehrez
- Department of Hepatology, NTHMRI, Cairo, Egypt
| | - Dina Attia
- Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
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11
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Hamed AE, Elwan N, Naguib M, Elwakil R, Esmat G, El Kassas M, Abd-Elsalam S, Moussa S. Diabetes Association with Liver Diseases: An Overview for Clinicians. Endocr Metab Immune Disord Drug Targets 2019; 19:274-280. [PMID: 30444204 DOI: 10.2174/1871530318666181116111945] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/24/2018] [Accepted: 10/04/2018] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
| | - Nadia Elwan
- Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Reda Elwakil
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Gamal Esmat
- Faculty of Medicine, Cairo University, Cairo, Egypt
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12
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Hamed AE, Elsahar M, Elwan NM, El-Nakeep S, Naguib M, Soliman HH, Aboubakr AA, AbdelMaqsod A, Sedrak H, Assaad SN, Elwakil R, Esmat G, Salh S, Mostafa T, Mogawer S, Sadek SE, Saber MM, Ezelarab H, Mahmoud AA, Sultan S, El Kassas M, Kamal E, ElSayed NM, Moussa S. Managing diabetes and liver disease association: Practice guidelines from the Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD). Arab J Gastroenterol 2019; 20:61-63. [PMID: 30852101 DOI: 10.1016/j.ajg.2019.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 02/16/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Abd Elkhalek Hamed
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt.
| | - Medhat Elsahar
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Police Medical Academy, Egypt
| | | | | | | | | | - Ashraf Ahmed Aboubakr
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | | | | | | | - Reda Elwakil
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Ain Shams University, Egypt
| | - Gamal Esmat
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Kasr Al Aini, Egypt
| | - Samira Salh
- Department of Pharmacy, Cairo University, Egypt
| | | | | | - Sameh Emil Sadek
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | - Maha M Saber
- Department of Clinical Nutrition National Research Centre, Egypt
| | - Hanan Ezelarab
- Department of Clinical Nutrition National Research Centre, Egypt
| | - Asem Ashraf Mahmoud
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | | | | | - Ehab Kamal
- Medical Department, National Research Centre, Egypt
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13
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Hamed AE, Elsahar M, Elwan NM, El-Nakeep S, Naguib M, Soliman HH, Ahmed Aboubakr A, AbdelMaqsod A, Sedrak H, Assaad SN, Elwakil R, Esmat G, Salh S, Mostafa T, Mogawer S, Sadek SE, Saber MM, Ezelarab H, Mahmoud AA, Sultan S, El Kassas M, Kamal E, ElSayed NM, Moussa S. Managing diabetes and liver disease association. Arab J Gastroenterol 2018; 19:166-179. [PMID: 30420265 DOI: 10.1016/j.ajg.2018.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/26/2018] [Indexed: 02/05/2023]
Abstract
There is strong association between liver diseases and diabetes (DM) which is higher than expected by a chance association of two very common disorders. It can be classified into three categories: Liver disease related to diabetes, hepatogenous diabetes (HD), and liver disease occurring coincidentally with DM. The criteria for the diagnosis of diabetes associating liver disease are the same for primary diabetes. Two hours post glucose load is a better screening test for HD. HbA1c may not be suitable for diagnosis or monitoring of diabetes associating advanced liver disease. Apart from the increased cardiovascular risk in patients with type 2 DM (T2 DM) and NAFLD, the cardiovascular and retinopathy risk is low in HD. Patients with metabolic derangement should be screened for NAFLD which in turn may predict T2 DM development. Similarly, patients with established T2 DM should also be screened for NAFLD which further contributes to diabetes worsening. Diabetes is a significant risk factor for progression of the chronic liver disease. It is associated with poor patient survival. Treatment of diabetes associating liver disease appears beneficial. Metformin, if tolerated and not contraindicated, is recommended as a first-line therapy for patients with diabetes and chronic liver disease (CLD). If the hepatic disease is severe, insulin secretagogues should be avoided because of the increased risk of hypoglycaemia. Pioglitazone may be useful in patients with fatty liver disease. DPP-4 inhibitors showed effectiveness and safety for the treatment of T2 DM in CLD patients up to those with child B stage. GLP-1 receptor agonists and SGLT-2 inhibitors exhibit positive effects on weight and are associated with minimal risk of hypoglycaemia. Insulin must be used with caution, as hypoglycaemia may be a problem. Insulin analogues are preferred in the context of hypoglycaemia Statins can be used to treat dyslipidaemia in NAFLD, also the use of angiotensin II receptor antagonist for hypertension is safe and beneficial Given the clear association between diabetes mellitus and hepatocellular carcinoma, the strict control of glycaemia with insulin sensitizers can be essential in its prevention. The addition of DM to the currently used scores (Child-Pugh and MELD scores) may enhance the sensitivity and the specificity for prediction of morbidity and mortality rates in cirrhotic patients. In the new era of directly acting antiviral agents (DAAs) for HCV treatment, it is recommended to follow up lipid profile and blood sugar levels following SVR in order to adjust doses of medications used in diabetic (SVR is associated with reduction in insulin requirements) and dyslipidaemic patients (rebound increase in the lipid profile after clearing the virus may increase risk of cardiovascular disease (CVD)). The issues of post liver transplant diabetes and relation between DM and chronic HBV are highlighted. This narrative review and Consensus-based practice guidance (under revision and criticism) are based on a formal review and analysis of the recently published world literature on the topic (Medline search up to September 2017); and the experience of the authors and independent reviewers.
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Affiliation(s)
- Abd Elkhalek Hamed
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt.
| | - Medhat Elsahar
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Police Medical Academy, Egypt
| | | | | | | | | | - Ashraf Ahmed Aboubakr
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | | | | | | | - Reda Elwakil
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Ain Shams University, Egypt
| | - Gamal Esmat
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Kasr Al Aini, Egypt
| | - Samira Salh
- Department of Pharmacy, Cairo University, Egypt
| | | | | | - Sameh Emil Sadek
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | - Maha M Saber
- Department of Clinical Nutrition National Research Centre, Egypt
| | - Hanan Ezelarab
- Department of Clinical Nutrition National Research Centre, Egypt
| | - Asem Ashraf Mahmoud
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | | | | | - Ehab Kamal
- Medical Department, National Research Centre, Egypt
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14
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Elwakil R, Montasser MF, Abdelhakam SM, Ibrahim WA. N-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and hypertonic glucose with 72% chromated glycerin in gastric varices. World J Gastrointest Endosc 2015; 7:411-416. [PMID: 25901221 PMCID: PMC4400631 DOI: 10.4253/wjge.v7.i4.411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/06/2015] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To compare n-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and a mixture of 72% chromated glycerin with hypertonic glucose solution in management of gastric varices.
METHODS: Ninety patients with gastric varices presented to Endoscopy Unit of Ain Shams University Hospital were included. They were randomly allocated into three groups; each group included 30 patients treated with intravariceal sclerosant injections in biweekly sessions till complete obturation of gastric varices; Group I (n-butyl-2-cyanoacrylate; Histoacryl®), Group II (iso-amyl-2-cyanoacrylate; Amcrylate®) and Group III (mixture of 72% chromated glycerin; Scleremo® with glucose solution 25%). All the procedures were performed electively without active bleeding. Recruited patients were followed up for 3 mo.
RESULTS: 26% of Scleremo group had bleeding during puncture vs 3.3% in each of the other two groups with significant difference, (P < 0.05). None of Scleremo group had needle obstruction vs 13.3% in each of the other two groups with no significant difference, (P > 0.05). Rebleeding occurred in 13.3% of Histoacryl and Amcrylate groups vs 0% in Scleremo group with no significant difference. The in hospital mortality was 6.6% in both Histoacryl and Amcrylate groups, while it was 0% in Scleremo group with no significant difference. In the first and second sessions, the amount of Scleremo needed for obturation was significantly high, while the amount of Histoacryl was significantly low. Scleremo was the less costly of the two treatments.
CONCLUSION: All used sclerosant substances showed efficacy and success in management of gastric varices with no significant differences except in total amount, cost and bleeding during puncture.
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15
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Talaat RM, Esmail AA, Elwakil R, Gurgis AA, Nasr MI. Tumor necrosis factor-alpha -308G/A polymorphism and risk of hepatocellular carcinoma in hepatitis C virus-infected patients. Chin J Cancer 2011; 31:29-35. [PMID: 22200181 PMCID: PMC3777466 DOI: 10.5732/cjc.011.10258] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tumor necrosis factor-alpha (TNF-α) is an important cytokine in generating an immune response against infection with hepatitis C virus (HCV). The functions of TNF-α may be altered by single-nucleotide polymorphisms (SNPs) in its gene structure. We hypothesized that SNPs in TNF-α may be important in determining the outcome of an HCV infection. To test this hypothesis, we investigated the role of the polymorphism -308G/A, which is located in the promoter region of the TNF-α gene, in the progression of HCV infection in Egyptian patients using a quantitative real-time polymerase chain reaction (qRT-PCR). The distribution of this polymorphism and its impact on the serum level of TNF-α was compared between 90 HCV-infected patients [45 with HCV-induced cirrhosis and 45 with HCV-related hepatocellular carcinoma (HCC)] and 45 healthy Egyptian volunteers without any history of liver disease. Our results showed that at the TNF-α -308 position, the G/G allele was most common (78.5%) in the study population, with the G/A and A/A alleles occurring less frequently (13.3% and 8.1%, respectively). Frequencies of G/G, G/A, and A/A genotypes were 87%, 7%, and 6% in patients with liver cirrhosis and were 94%, 4%, and 2% in patients with HCC, respectively. Serum levels of TNF-α were significantly higher in HCV-infected patients than in healthy controls, indicating that the TNF-α -308 polymorphism does not influence the production of TNF-α. The serum level of TNF-α was positively correlated with HCV infection. Taken together, these findings suggest that the TNF-α -308 polymorphism may not be a host genetic factor associated with the severity of HCV infection, but may be an independent risk factor for HCC.
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Affiliation(s)
- Roba M Talaat
- Molecular Biology Department, Menofia University, Sadat, Egypt.
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16
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Elwakil R, Reda MA, Abdelhakam SM, Ghoraba DM, Ibrahim WA. Causes and outcome of upper gastrointestinal bleeding in Emergency Endoscopy Unit of Ain Shams University Hospital. J Egypt Soc Parasitol 2011; 41:455-467. [PMID: 21980783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This prospective follow-up study was designed to analyze the causes and outcome of upper gastrointestinal bleeding among patients presenting by hematemesis and/or melena to Emergency Endoscopy Unit, Ain Shams University Hospitals. One thousand patients presented by upper GIT bleeding were subjected to complete clinical evaluation, emergency upper gastrointestinal endoscopy and therapeutic interventions as indicated. Follow up was done for occurrence of re-bleeding or mortality. Variceal causes of bleeding were the most common, representing 70.1% followed by non-variceal causes (26.1%) and obscure causes (3.8%). Esophageal varices (EV) alone represented 17.8% of causes of variceal bleeding, while combined esophageal and gastric varices represented 39.5% and isolated gastric varices 12.8%. Gastric lesions were the most common causes of non variceal bleeding. Recurrence of bleeding occurred in 19.4% of variceal group in comparison to 6.1% of non variceal group, while mortality was found in 4.3% of variceal group in comparison to 1.5% of non variceal group with very highly significant difference (P <0.001). Hypertension, ascites, EV columns, EV grade IV, presence of gastric varices and associated respiratory disorder were independent factors associated with recurrence of bleeding in variceal group. In non variceal group, recurrence of bleeding was significantly related only to the presence of gastric ulcers (P=0.035). Independent factors associated with mortality in studied patients were age, associated diabetes, presence of esophageal varices and associated duodenal ulcer.
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Affiliation(s)
- Reda Elwakil
- Department of Tropical Medicine, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
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17
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Shiha G, Sarin SK, Ibrahim AE, Omata M, Kumar A, Lesmana LA, Leung N, Tozun N, Hamid S, Jafri W, Maruyama H, Bedossa P, Pinzani M, Chawla Y, Esmat G, Doss W, Elzanaty T, Sakhuja P, Nasr AM, Omar A, Wai CT, Abdallah A, Salama M, Hamed A, Yousry A, Waked I, Elsahar M, Fateen A, Mogawer S, Hamdy H, Elwakil R. Liver fibrosis: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL). Hepatol Int 2008; 3:323-33. [PMID: 19669358 DOI: 10.1007/s12072-008-9114-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Accepted: 10/30/2008] [Indexed: 12/14/2022]
Abstract
Liver fibrosis is a common pathway leading to cirrhosis, which is the final result of injury to the liver. Accurate assessment of the degree of fibrosis is important clinically, especially when treatments aimed at reversing fibrosis are being evolved. Liver biopsy has been considered to be the "gold standard" to assess fibrosis. However, liver biopsy being invasive and, in many instances, not favored by patients or physicians, alternative approaches to assess liver fibrosis have assumed great importance. Moreover, therapies aimed at reversing the liver fibrosis have also been tried lately with variable results. Till now, there has been no consensus on various clinical, pathological, and radiological aspects of liver fibrosis. The Asian Pacific Association for the Study of the Liver set up a working party on liver fibrosis in 2007, with a mandate to develop consensus guidelines on various aspects of liver fibrosis relevant to disease patterns and clinical practice in the Asia-Pacific region. The process for the development of these consensus guidelines involved the following: review of all available published literature by a core group of experts; proposal of consensus statements by the experts; discussion of the contentious issues; and unanimous approval of the consensus statements after discussion. The Oxford System of evidence-based approach was adopted for developing the consensus statements using the level of evidence from 1 (highest) to 5 (lowest) and grade of recommendation from A (strongest) to D (weakest). The consensus statements are presented in this review.
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Affiliation(s)
- Gamal Shiha
- GI and Liver Unit, Internal Medicine Department, Almansoura Faculty of Medicine, Almansoura University, Almansoura, 35516, Egypt,
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