Euroasian journal of hepato-gastroenterology

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2020 | July-December | Volume 10 | Issue 2

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COVID-19 and LIVER DISEASES: Pandemic, Epidemic and Endemic

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:1] [Pages No:00 - 00]

   DOI: 10.5005/ejohg-10-2-iv  |  Open Access |  How to cite  | 


Original Article

Dalip Alreja, Jyoti R Rao, Sakshi Kataria, Dhaval A Faterpenkar

Effect of Nonsurgical Treatment on Salivary HGF Levels in Population with Periodontal Disease: A Quasi-experimental Study

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:5] [Pages No:51 - 55]

   DOI: 10.5005/jp-journals-10018-1320  |  Open Access |  How to cite  | 


Aim: To assess the effect of nonsurgical treatment on salivary hepatocyte growth factor (sHGF) levels in a population with periodontal disease: a quasi-experimental study. Methods: Eighty-one patients (aged 30–70 years) were divided into three groups based on the gingival index, probing depth, clinical attachment loss, and radiographic evidence of bone loss: healthy (group I), gingivitis (group II), and chronic periodontitis (group III). Saliva samples were collected from these groups at baseline. At 8 weeks, saliva samples were collected again from group II and group III after the patients went through nonsurgical periodontal treatment. The levels of HGF were estimated using enzyme-linked immunosorbent assay (ELISA). The clinical parameters and HGF levels among all groups were analyzed using a one-way analysis of variance (ANOVA) using SPSS 17 version. Results: At baseline, the highest mean HGF concentration in saliva was observed for group III (3455.83 ± 1463.44 pg/mL), and the least in group I (469.43 ± 317.13 pg/mL). Following nonsurgical periodontal treatment, the mean HGF concentration decreased significantly in group III and group II (p < 0.05). A significant positive correlation between clinical parameters and HGF levels was also seen (p < 0.05). Conclusion: HGF concentration showed a positive correlation with the progression of periodontal disease. Clinical significance: Following nonsurgical periodontal therapy, the levels of HGF decreased significantly, suggesting that HGF could be useful for monitoring the response to periodontal therapy.


Original Article

Ioannis A Voutsadakis

A Systematic Review and Meta-analysis of PD-1 and PD-L1 Inhibitors Monotherapy in Metastatic Gastric and Gastroesophageal Junction Adenocarcinoma

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:8] [Pages No:56 - 63]

   DOI: 10.5005/jp-journals-10018-1321  |  Open Access |  How to cite  | 


Immune checkpoint inhibitors are new targeted treatments that harness the body's immune system to attack cancers. Drugs that are most extensively used among checkpoint inhibitors inhibit the PD-L1 or PD-1 (programmed death 1) ligand or receptor pair and are currently approved for many cancer indications. In gastric or gastroesophageal junction adenocarcinomas one inhibitor, pembrolizumab has regulatory approval for PD-L1 positive carcinomas. This meta-analysis investigates available data on the efficacy of PD-L1 or PD-1 inhibitors as a class in gastric or gastroesophageal junction adenocarcinomas. The literature was reviewed to identify clinical studies that included arms with PD-L1 or PD-1 inhibitors as monotherapy in gastric or gastroesophageal junction adenocarcinomas. Relevant patient characteristics, outcomes, and adverse effects were recorded. Summary estimates of response rates (RR) and survival were calculated using a random or fixed effect model, depending on heterogeneity. Six studies with a total of 1068 patients were included in the analysis. The summary RR was 10.63% (95% confidence interval (CI) 5.36–15.89%). The summary disease control rate (DCR) was 28.11% (95% CI 24.60–31.63%). Summary progression-free survival (PFS) was 1.59 months (95% CI 1.24–1.94 months). Summary overall survival (OS) was 5.72 months (95% CI 0–12.19 months). A subset of patients derived long-term benefits as seen in other cancer locations. The adverse effect rate was low and consistent with that in other disease locations. Low efficacy of immune checkpoint inhibitors as a class in gastric or gastroesophageal junction adenocarcinomas is observed in this analysis and stresses the need for effective biomarker use for the identification of most probable responders.


Original Article

Md Nazmul Haque, Mamun Al-Mahtab, Noor-E-Alam Sheikh Mohammad, Md Sakirul I Khan, Sheikh MF Akbar, Salimur Rahman

Effect of Granulocyte Colony-stimulating Factor and Erythropoietin on Patients with Acute-on-chronic Liver Failure

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:4] [Pages No:64 - 67]

   DOI: 10.5005/jp-journals-10018-1330  |  Open Access |  How to cite  | 


Introduction: Patients with acute-on-chronic liver failure (ACLF) have low survival without liver transplantation. Granulocyte colony-stimulating factor (G-CSF) improves survival in ACLF and erythropoietin (EPO) promotes hepatic regeneration in animal studies. The aim of this study is to determine whether coadministration of G-CSF and EPO improves the outcome in ACLF. Methods: The study was conducted in the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka. Consecutive patients with ACLF were randomly assigned into group A and group B. Group A patients received subcutaneous G-CSF (5 mcg/kg/d) for 6 days and subcutaneous EPO (40 mcg/wk) for 4 weeks and group B patients received only standard medical care (control group). All patients were followed up for 3 months. The primary end point was to see survival at 3 months. Results: Patients had comparable baseline characteristics; hepatitis B virus infection was the commonest etiology of ACLF as both acute and chronic events. A higher proportion of patients were male in both groups. The survival was higher in group A than in group B at the end of 3 months (36.4% vs 29.4%; p = 0.457), but this was not statistically significant. Regarding complications, hepatorenal syndrome was higher in group B than in group A (36.7% vs 41.7%). In both the groups, Child–Turcotte–Pugh score and model for end-stage liver disease scores were similar before treatment and improved during follow-up. Conclusion: This is one of the early human studies that demonstrate potential hepatic regeneration using EPO in ACLF patients. Further study with a larger cohort will be needed to reproduce the results of the present work.


Original Article

Md Azizul Islam, Masudul A Mazumder, Neelima Akhter, AKM Faizul Huq, Mamun Al-Mahtab, Md Sakirul I Khan, Sheikh MF Akbar

Extraordinary Survival Benefits of Severe and Critical Patients with COVID-19 by Immune Modulators: The Outcome of a Clinical Trial in Bangladesh

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:8] [Pages No:68 - 75]

   DOI: 10.5005/jp-journals-10018-1327  |  Open Access |  How to cite  | 


Background: Coronavirus disease (COVID)-19 has devasted the healthcare delivery system as well as social establishments of almost all countries of the world. However, vaccines for containing new cases of COVID-19 are yet to be realized. Also, presently available antiviral drugs and other standard of care (SOC) management strategies could not satisfactorily control COVID-19-related mortality, which has crossed the one million mark during the last 9 months. These facts present an emergent need for developing new, novel, and evolving therapeutic strategies for the management of COVID-19. Aim and objective: This cohort study represents a clinical trial in real-life situations in Bangladesh where two immune modulators were applied in patients with severe and critical COVID-19 patients. Materials and methods: A total of 199 confirmed patients of COVID-19 were enrolled in this study. All of them had severe and critical COVID-19 and they were hospitalized at the intensive care unit (ICU) of the Combined Military Hospital (CMH), Dhaka, Bangladesh. All patients were positive for SARS-CoV-2 by polymerase chain reaction (PCR) of the nasal swab and they were endowed with severe pneumonia, multiple organ dysfunctions, and coagulopathy. The median percentage of lung involvement was 65%. The mean oxygen saturation was 83%. The patients received two immune modulators (tocilizumab and bevacizumab) in different combinations to retrieve broader insights about the safety and efficacy of immune modulators in COVID-19 management. Results: Out of the total 199 patients, 122 survived and 77 expired. A single dose of tocilizumab resulted in the survival of 71.5% (73 of 102 COVID-19 patients). On the other hand, a dramatic survival benefit was found in patients receiving bevacizumab (92%). Conclusion: The study indicates that active treatment should be started as early as possible for COVID-19 patients as moderate COVID-patients may progress to more severe illnesses with grave consequences. The safety of two immune modulators has been recorded in this cohort of severe and critical COVID-19 patients. In order to have a proper use of these immune modulators, there is a need to accomplish controlled, blinded, and large-scale prospective studies with at least two arms.



Sevgi B Altay, Gökhan Akkurt, Nisbet Yılmaz, Nuriye Özdemir

Clinicopathological Evaluation of Gastric Signet Ring Cell Carcinoma: Our Experience

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:9] [Pages No:76 - 84]

   DOI: 10.5005/jp-journals-10018-1325  |  Open Access |  How to cite  | 


Aim: Gastric cancer is one of the most common cancers worldwide. In Turkey, stomach cancer is ranked 5th among men and 8th among women in all cancers and is located in the forefront in cancer-related deaths. Signet ring cell adenocarcinoma, which is the histopathological subtype of gastric cancer, has a poor prognosis. The incidence of signet ring cell adenocarcinoma is rising. In the present study, we aimed to describe the clinicopathologic features of signet ring cell adenocarcinoma. Materials and Methods: A total of 79 patients with 30 being female (38%) and 49 male (62%) who were diagnosed with gastric signet ring cell adenocarcinoma in the Medical Oncology Department of Ankara Numune Training and Research Hospital between January 2004 and October 2015 were retrospectively evaluated. Results: The baseline demographic characteristics of the patients, such as tumor localization, tumor stage, preoperative serum tumor markers, and treatment type (surgery and chemotherapy regimen), and the effects of these variables on survival and mortality were evaluated. Total surgery, stage III disease, moderate to poor grade, preoperative serum CA 19-9 and CEA levels were found as independent predictors of progression risk (p < 0.05). Each 1 ng/mL increase in preoperative serum CEA level was found to increase the risk of progression by 1.20 folds. Again, each 1 U/mL in preoperative serum CA 19-9 level was found to increase the risk of progression and mortality by 1.06 folds. Conclusion: The clinicopathologic features of signet ring cell stomach cancer were described. Tumor localization and disease, CA 19-9 and CEA levels, and treatment type (surgery and chemotherapy regimen) were effective on survival and mortality. However, further studies with larger patient groups are needed on this issue.



Mustafa C Senoymak

Evaluation of the Relationship between Insulin Resistance and HBV DNA Level in Patients with HBeAg-negative Chronic HBV Infection (Natural Course Phase 3)

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:7] [Pages No:85 - 91]

   DOI: 10.5005/jp-journals-10018-1329  |  Open Access |  How to cite  | 


Background and aims: Chronic hepatitis B (CHB) infection is an important cause of morbidity and mortality worldwide with an increased risk of liver failure, cirrhosis, and hepatocellular carcinoma. Hepatitis B virus (HBV) DNA level, the marker of viral load in the host, is a parameter affected by host factors. In this study, we investigated the relationship between HBV DNA level and insulin resistance as a host factor. Methods: In this study, 146 patients diagnosed with “HBeAg-negative chronic HBV infection” (natural course phase 3, inactive carrier) according to the European Association for the Study of the Liver (EASL) 2017 guidelines were retrospectively analyzed and demographic, anthropometric, histopathological, radiological and laboratory data of the patients were recorded. Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) levels of the patients were calculated, and according to the value, the patients were divided into two groups as insulin resistant and non-insulin resistant. All parameters, including HBV DNA, were evaluated and compared between the two groups. Results: 77 patients (52.7%) were insulin resistant with a HOMA-IR value of 2.5 or more. The remaining 69 patients (47.3%) whose HOMA-IR value less than 2.5 were non-insulin resistant. The median HBV DNA was 410 IU in the insulin-resistant group and 350 IU in the other group, and there was no statistical significance between the two groups (p: 0.537). HBV DNA level was only positive correlated with HBsAg level and negatively correlated with anti-Hbs level and age (p < 0.005). Compared to the non-insulin resistant group, body mass index (BMI), presence of hepatosteatosis on ultrasonography (USG), fasting blood sugar, fasting insulin, total protein, gamma glutamyl transferase (GGT), triglyceride (TG), very-low-density lipoprotein (VLDL), uric acid level, triglyceride/high-density lipoprotein (HDL) ratio were significantly higher and HDL levels were significantly lower in the insulin-resistant group (p < 0.005). GGT levels and TG/HDL ratio were found to be higher in patients with hepatosteatosis on ultrasonography than in patients without hepatosteatosis (p < 0.005). TG/HDL ratio was found to be an independent factor in predicting insulin resistance and every 1 unit increase of this ratio increases the risk of developing insulin resistance 2.1 times. Conclusion: In this study, no significant relationship was found between insulin resistance and HBV DNA levels in chronic inactive HBV carriers. In addition, insulin resistance was observed more frequently in these patients compared to the general population, and insulin resistance was found to be associated with high BMI, hepatosteatosis rate, VLDL, TG, GGT, total protein, uric acid, TG/HDL ratio, and low HDL. TG/HDL ratio was found to be successful in predicting insulin resistance.



Dinesh Meher

Artificial Intelligence in Gastrointestinal Endoscopy in a Resource-constrained Setting: A Reality Check

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:6] [Pages No:92 - 97]

   DOI: 10.5005/jp-journals-10018-1322  |  Open Access |  How to cite  | 


Artificial intelligence (AI) is being increasingly explored in different domains of gastroenterology, particularly in endoscopic image analysis, cancer screening, and prognostication models. It is widely touted to become an integral part of routine endoscopies, considering the bulk of data handled by endoscopists and the complex nature of critical analyses performed. However, the application of AI in endoscopy in resource-constrained settings remains fraught with problems. We conducted an extensive literature review using the PubMed database on articles covering the application of AI in endoscopy and the difficulties encountered in resource-constrained settings. We have tried to summarize in the present review the potential problems that may hinder the application of AI in such settings. Hopefully, this review will enable endoscopists and health policymakers to ponder over these issues before trying to extrapolate the advancements of AI in technically advanced settings to those having constraints at multiple levels.



Partho P Roy, Md Sakirul I Khan, Sheikh MF Akbar

Nobel Prize for the Discovery of Hepatitis B and C: A Brief History in Time

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:3] [Pages No:98 - 100]

   DOI: 10.5005/jp-journals-10018-1328  |  Open Access |  How to cite  | 


In 2020, the Noble Prize for Medicine jointly went to three scientists for hepatitis C virus-related discoveries. Earlier in 1976, an American scientist won this award for the discovery of hepatitis B virus. The Noble Prize, constituted as per the will of Alfred Noble, is awarded every year for achievements that benefit human beings in the best possible way. Although humans have known hepatitis as a deadly disease for hundreds of years, it was the discovery of hepatitis B and C viruses that changed the way we knew the hepatitis viruses forever and paved the way for saving millions of lives all over the world, the reason why the Noble Committee has on two different occasions picked up the great minds behind the discovery of these two hepatitis viruses and recognized them by conferring them with the highest recognition that one dreams of.



Iyad Khamaysi, Eisa Hajj

Drug-induced Pancreatic Atrophy (“The Vanishing Pancreas”)

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:2] [Pages No:101 - 102]

   DOI: 10.5005/jp-journals-10018-1323  |  Open Access |  How to cite  | 


Immune checkpoint inhibitors have become the therapeutic mainstay in a rapidly growing number of cancers. Immune checkpoint inhibitor-related diarrhea is attributed mainly to inflammatory colitis, with no other drug-related differential diagnosis. However, other causes of diarrhea should be considered. Pancreatic atrophy (and exocrine pancreatic insufficiency) is a relatively rare complication of immune checkpoint inhibitors. Herein we bring a set of striking computed tomography (CT) images that demonstrate a drug-related-progressive pancreatic atrophy until complete vanishing of pancreatic tissue. Exocrine pancreatic insufficiency (EPI) was diagnosed. Pancreatic enzyme replacement therapy was initiated with an excellent clinical response.



Unique Endoscopic Presentation of “Reversed Reflux”-type Cameron Lesions

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:2] [Pages No:103 - 104]

   DOI: 10.5005/jp-journals-10018-1324  |  Open Access |  How to cite  | 


As typical complications of hiatal hernias, Cameron lesions often go unnoticed in clinical practice, in particular, in patients with presumed overt and/or obscure upper gastrointestinal bleeding. However, albeit not yet systematically studied, Cameron lesions might be highlighted by novel image-enhanced endoscopic technologies, such as linked color imaging (LCI). Reminiscent of erosive reflux lesions, these lesions may present as reddish streaks, frank ulceration, and/or any other variation within this spectrum. However, an endoscopic presentation as “reverse reflux”-type Cameron lesions, mirroring typical erosive reflux lesions at the Z line, may represent a unique, novel endoscopic presentation.



Hemshankar Laugi

Discovery of Hepatitis C Virus: 2020 Nobel Prize in Medicine

[Year:2020] [Month:July-December] [Volume:10] [Number:2] [Pages:4] [Pages No:105 - 108]

   DOI: 10.5005/jp-journals-10018-1326  |  Open Access |  How to cite  | 


Hepatitis C virus (HCV) accounts for hepatitis, liver cirrhosis, hepatocellular carcinoma, and liver transplantation. This virus is a single-stranded RNA virus that belongs to the Flaviviridae family. According to the WHO, about 71 million people have chronic HCV infections around the globe in 2020, and hence, it is a plague of humankind. The credit of discovery of HCV goes to Michael Houghton, Harvey Alter, and Charles Rice for which they are awarded 2020 Nobel Prize in Medicine. Their contribution has given better hope to mankind to cure HCV for the first time in the history. With the use of pegylated interferon and ribavirin jointly, higher SVR has been found comparatively, even in patients with chronic liver diseases. However, due to excessive pain tolerated by patients, interferon (IFN)-based therapy is rapidly being replaced with IFN-free DAA regimens. With the onset of resistance to DAA drugs, CRISPR-Cas system can be used to modify the viral genome to impair their ability to develop resistance.


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