Euroasian Journal of Hepato-Gastroenterology

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2019 | July-December | Volume 9 | Issue 2

EDITORIAL

Sheikh Mohammad Fazle Akbar, Mamun Al-Mahtab

Editorial

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:1] [Pages No:0 - 0]

PDF  |  DOI: 10.5005/ejohg-9-2-iv  |  Open Access |  How to cite  | 

Original Article

Tomohiro Akao, Morikazu Onji, Keitarou Kawasaki, Takahide Uehara, Yukima Kuwabara, Takashi Nishimoto, Shinji Yamamoto, Jiro Miyaike, Masaki Oomoto, Teruki Miyake

Surveillance of Hepatitis Viruses in Several Small Islands of Japan by Ship: A Public Health Approach for Elimination of Hepatitis Viruses by 2030

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:6] [Pages No:57 - 62]

Keywords: Epidemiological survey, Hepatitis viruses, Islands, Japan, Ship-based survey

PDF  |  DOI: 10.5005/jp-journals-10018-1304  |  Open Access |  How to cite  | 

Abstract

Aim: In 1990, an epidemiological survey by ship in some Japanese islands revealed high prevalence of hepatitis viruses and human T cell leukemia virus (HTLV). A second prevalence study of these viruses were accomplished in 2018, 28 years after initial survey. Analysis of these studies provide insights about strategies of elimination of hepatitis viruses at remote areas. Materials and methods: In 2018, prevalence of hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), and HTLV was checked in 305 subjects in the islands those covered in 1990\'s survey. Hepatitis A virus was checked by the presence of anti-HAV IgG in sera; HBV was affirmed when hepatitis B surface antigen (HBsAg) in sera. Hepatitis C virus infection was evaluated by the presence of antibody to HCV (anti-HCV) and infection with HTLV was estimated by immunoassay. The methodology of assessment of different hepatitis viruses were optimized on the basis of present scientific knowhow. Results: In 1990, the prevalence of HAV (presence of anti-HAV), HBV (presence of HBsAg), HCV (positivity for anti-HCV), and HTLV was found in 79.3%, 11.1%, 2.2%, and 3.3% of apparently health subjects of the islands, respectively. The prevalence of HAV, HBV, HCV, and HTLV was 47.9%, 4.6%, 1.0%, and 3.0%, respectively, in 2018. A shift of age of infected persons tilted towards right as the days progressed. Conclusion: The study indicates a scenario of elimination of hepatitis viruses in Japan as lower trends of prevalence of HAV, HBV, and HCV have been recorded in 2018 compared with 1990, mainly by preventive measures. The most notable finding is that there are almost no new case below the age of 40 years, indicating an effective containment measure against these viruses.

Original Article

Md Abdur Rahim, Sheikh Mohammad Noor-E-Alam, Mohammad Ashraful Alam, Faiz Ahmad Khondaker, Ahmed Lutful Moben, Jhumur Ghosh, Md Sakirul Islam Khan

Treatment by Transarterial Chemoembolization and Sorafenib for Hepatocellular Carcinoma vs Advanced Hepatocellular Carcinoma in Bangladesh: A Real-life Situation

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:4] [Pages No:63 - 66]

Keywords: Hepatocellular carcinoma, Sorafenib, Transarterial chemoembolization

PDF  |  DOI: 10.5005/jp-journals-10018-1300  |  Open Access |  How to cite  | 

Abstract

Background: Although there are thousands of patients with hepatocellular carcinoma (HCC) in Bangladesh, almost there is no nationwide recommendations for therapeutic maneuver for HCC patients. As most of the HCC patients of Bangladesh are diagnosed late, patients with advanced HCC with large and multiple HCC nodules represent the usual presentation of HCC. The study is presented here to assess the effects of a combined therapy of transarterial chemoembolization (TACE) and sorafenib in advanced HCC patients. Materials and methods: A total of 77 patients with advanced HCC were enrolled in this study. All of them had advanced HCC with variable etiologies and clinical conditions. All patients were treated by TACE and also given systemic sorafenib at the same time. The patients were checked 1 and 3 months after therapy commencement. Results: Out of 77 patients, 18 patients died within 1 month and additional 15 patients died within 3 months after therapy commencement. Thus, there remains 44 surviving patients after 3 months. When different parameters of dead patients and survived patients were compared, no specific parameters dictated the factors about overall survival of more than 3 months. Discussion: This is the first approach to initiate an invasive and a systemic therapy for treatment of advanced HCC in Bangladesh. Further follow-up of patients and their long-term overall survival may cast some lights about the role of these therapies in Bangladeshi HCC patients.

Original Article

Nuzhat Choudhury, Shamshad B Quraishi, AKM Atiqullah, Md Sakirul Islam Khan, Sheikh MF Akbar

High Prevalence of Wilson's Diseases with Low Prevalence of Kayser–Fleischer Rings among Patients with Cryptogenic Chronic Liver Diseases in Bangladesh

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:4] [Pages No:67 - 70]

Keywords: Chronic liver disease, Urinary copper, Wilson\'s disease

PDF  |  DOI: 10.5005/jp-journals-10018-1299  |  Open Access |  How to cite  | 

Abstract

Background: Chronic liver disease (CLD) is common in Bangladesh; however, a major bulk remains as cryptogenic CLD as they remain devoid of known pathological agents leading to have a check of Kayser–Fleischer (K–F) rings for possible Wilson\'s disease (WD) and many of these patients develop complications such as cirrhosis of liver and hepatocellular carcinoma. However, there remains considerable proportions of CLD patients with undefined etiology (cryptogenic CLD) and these patients cannot be provided effective therapy based on etiological factors. Here, the proportion of WD among cryptogenic CLD patients in Bangladesh has been evaluated to improve the management of CLD and reduce complications. Materials and methods: A total of 941 patients with cryptogenic CLD [negative for hepatitis viruses, alcohol, nonalcoholic fatty liver disease (NAFLD), drug, and autoimmunity] were enrolled in the study. To assess if they have been suffering from WD, the levels of copper in 24-hour urine were evaluated. Definitive WD was diagnosed when 24-hour urinary copper output was >100 μg and strongly indicative WD patients excreted >40 μg of copper in 24 hours. Results: Out of 941 patients with cryptogenic CLD, 212 patients were diagnosed as definitive WD and 239 patients as strongly indicative WD on the basis of 24-hours copper excretion. The age distribution ranging of the patients varied from 1 year to 90 years. There was a male predominance. Considerable numbers of WD patients had previous history of jaundice. Kayser–Fleischer rings were mostly uncommon and detected in five patients with WD only. Discussion: Wilson\'s disease is not a rare entity in Bangladesh; rather, it seems to be fairly common among CLD patients. A country-wide epidemiological survey should be conducted for diagnosis of WD in Bangladesh to provide a proper management strategy for these huge numbers of WD patients. In fact, most of the WD patients are unaware of their diagnosis and the general physicians are equally unaware of diagnosis and management of WD.

Original Article

Anurag Lavekar, Dhananjay Raje, Aarsha Sadar, Tanuja Manohar, Kavutharapu Sri Manjari, Pradeep T Satyanarayana

Predictors of Three-month Hospital Readmissions and Mortality in Patients with Cirrhosis of Liver

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:7] [Pages No:71 - 77]

Keywords: Cirrhosis, Liver disorders, Model for end-stage liver disease, Readmission

PDF  |  DOI: 10.5005/jp-journals-10018-1302  |  Open Access |  How to cite  | 

Abstract

Background: The rate of readmission to the hospital and mortality within 3 months is used as a quality measure for hospitalized patients with advanced liver disease; however, the topic has not been studied adequately under Indian context. Materials and methods: This study was a longitudinal study conducted from March 2017 to March 2018. Patients admitted with liver cirrhosis at inpatient hepatology service in Tertiary Health Care Centre, Mysore, India, were included for the study. A total of 232 patients were studied and their demographic, clinical, biochemical parameters along with readmission status and outcomes within 3 months of observation were recorded. The effect of these factors on readmission and mortality was studied through multivariate logistic regression. Results: The risk of readmission within 3 months was significantly associated with the presence of hydrothorax, hepatorenal syndrome (HRS), and portal vein thrombosis (PVT). Maddrey\'s discriminant function (DF), model for end-stage liver disease (MELD) score, and the Child–Turcotte–Pugh (CTP) C grade also significantly increased the odds of readmission. The area under curve (AUC) for DF and MELD were 0.927 and 0.928, respectively. Both DF and MELD significantly increased the odds of mortality. Conclusion: The present study revealed that the parameters such as MELD and DF score and complications such as hydrothorax, HRS, and PVT are the most predictive indicators of cirrhosis complication to ascertain the rate of readmission and mortality within 3 months of patient discharge.

Original Article

Kouji Joko, Toshie Mashiba, Hironori Ochi, Ryo Yano, Kaori Sato, Yusuke Okujima, Michiko Aono, Nobuaki Azemoto, Shunji Takechi, Tomoyuki Yokota, Ryosuke Jinoka, Yasunori Moriyama, Masataka Nishiyama

Relation of Reduction of Antibodies against Hepatitis B Virus to Hepatocellular Carcinoma Recurrence in the Patients with Resolved Hepatitis B Virus Infection Following Direct-acting Antiviral Therapy for Hepatitis C Virus Infection

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:6] [Pages No:78 - 83]

Keywords: Direct-acting antiviral, Hepatitis B reactivation, Hepatitis C, Hepatocellular carcinoma, Recurrence risk

PDF  |  DOI: 10.5005/jp-journals-10018-1305  |  Open Access |  How to cite  | 

Abstract

Background: A possible interaction of hepatitis viruses at cellular and molecular levels has been suggested. Eradication of hepatitis C virus (HCV) has been reported to induce activation of hepatitis B virus (HBV)-related liver diseases. Materials and methods: The present study examined association of HBV markers with recurrence of hepatocellular carcinoma (HCC) in patients with resolved HCV infection by direct-acting antiviral (DAA) therapy. In a patient pool of 378 patients with sustained virologic response (SVR) by DAA, the antibody to the hepatitis B surface antigen (anti-HBs), the antibody to the hepatitis B core antigen (anti-HBc), and HBV-DNA levels were estimated before and at the end of DAA therapy. These patients were HBsAg negative. Eighty-nine patients had a history of curative treatment of HCC by resection or radiofrequency ablation. A Cox proportional hazards model was used to identify risk factors for HCC recurrence, including the change ratio of the antibody against HBV proteins. Results: Although 188 patients had resolved HBV infection, no patient showed HBV reactivation, but anti-HBs and anti-HBc levels decreased significantly. No significant difference in the HCC recurrence rate was evident between patients with and without resolved HBV infection. Changes of immune responses to HBV proteins did not affect HCC recurrence after DAA therapy for HCV infection in this cohort. Conclusion: The mechanisms underlying diverse roles of DAA-induced SVR of HCV on HBV kinetics need to be resolved in future.

RESEARCH ARTICLE

Sajib Chakraborty, Rajib Chakravorty, Saruar Alam, Yearul Kabir, Musarrat Mahtab, Md Atikul Islam, Md Abul Khair Yusuf, Ruksana Raihan, Sheikh Mohammad Fazle Akbar

A Dynamic Mathematical Modeling Revelation about the Impact of Vaccination on Hepatitis B Virus-induced Infection and Death Rate in Bangladesh

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:7] [Pages No:84 - 90]

Keywords: Hepatitis B virus, Immunization, Mathematical model, Target

PDF  |  DOI: 10.5005/jp-journals-10018-1303  |  Open Access |  How to cite  | 

Abstract

Aim: Attainment of sustainable development goal (SDG) targets requires reducing the rate of new hepatitis B virus (HBV)-induced infection and mortality rate to 90% and 65%, respectively, by 2030. Therefore, it is important to investigate the feasibility of reducing the required rates of HBV-induced infection and death incidents at the current rate of vaccination coverage in Bangladesh. Moreover, factors influencing vaccination coverage like negative bias toward girls during immunization can affect the current vaccination program and ultimately hinder the efforts to reduce HBV-induced infection and death rates. To investigate the possibility of reducing HBV-induced infection and death rates with current vaccination coverage, we adopted mathematical molding-based approach. Materials and methods: We developed a mathematical model based on the susceptible–infectious–recovered model to simulate the HBV-induced infection in children under the age of five at three different vaccination rates: 80, 90, and 95%. Additionally the impact of current vaccination coverage was assessed on HBV-induced death rates in the future. Moreover, we took advantage of the mathematical model to investigate the impact of negative bias toward girls in vaccination program on HBV-induced infection and death rates. Results: The model simulations revealed that 10% increase in the vaccination rate from 80 to 90% can potentially contribute to the significant lowering (around 40%) of HBV-induced infection rate among children. When increased by 5% of vaccination rate from 90 to 95%, the HBV-infection rate is likely to be decreased by another 22%. Likewise, 44% reduction in HBV-induced death rate in the future (2050 onward) can potentially be achieved by 10% increase in the current vaccination rate from 80 to 90%, whereas 5% increase in the current vaccination rate (90–95%) may lead to 24% further reduction of death rate. These results underscored the significant impact of vaccination in reducing HBV-induced infection among children and future death rates in adults. Moreover, at 90% vaccination coverage, the negative bias of vaccination toward girls contributes to an increase of 15 and 12% of HBV-induced infection and death rates, respectively, in female subjects compared to their male counterparts. Conclusion: The current vaccination coverage (80–90%) is further aggravated by untimely vaccination, dropouts from vaccination program, and negative bias toward girls in vaccination program. Therefore, if the current situation persists, it will not be possible to accomplish the required reduction in HBV-induced infection and death rates by 2030, according to the SDG guidelines. Moreover negative bias in the vaccination program may intensify the HBV-induced infection and death rates in the future. Clinical significance: In light of the mathematical model, we suggest that the vaccination coverage should be increased to 95% without any negative bias toward girls. To accomplish this, the concerning authorities must ensure timely and full completion of the HBV vaccine schedules, reducing dropouts from vaccination program, and lastly preventing negative bias toward girls to uplift vaccination coverage to more than 95% with gender equality. Without these strategies, the necessary reduction in the HBV-induced infection and death rates in Bangladesh may not be attained per SDG directives.

RESEARCH ARTICLE

Deepa Jahagirdaar, Nitin Bomanwar, Sneha Joshi

A Prospective Clinicoendoscopic Follow-up Study in Young Patients with Peptic Ulcer Perforation at a Tertiary Institute in Central India

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:5] [Pages No:91 - 95]

Keywords: Endoscopy, Helicobacter pylori, Peptic, Perforation, Ulcer

PDF  |  DOI: 10.5005/jp-journals-10018-1306  |  Open Access |  How to cite  | 

Abstract

Background: Perforation peritonitis is one of the commonest encountered emergencies in the surgery casualty. This study was conducted with the aim of identifying risk factors in peptic ulcer disease (PUD) in young patients. Materials and methods: Seventy patients were evaluated in this study and were followed up with clinical examination and endoscopy at 8 weeks and 6 months. Results: Out of the total 70 patients, there was a mortality of 5 patients and 7 patients were lost to follow-up. Out of the remaining 57 patients, 56 were men and 1 was a woman. Maximum patients were from the age group of 35–40 years. The patients were categorized on the basis of their clinical symptoms and endoscopy results at the follow-up of 6 months in 4 categories—21 patients having an active ulcer and symptomatic, 15 patients having active ulcer but no symptoms, 16 patients who were asymptomatic and without an active ulcer and 5 patients nonulcer dyspepsia. Conclusion: Postoperative treatment with H2 blockers or proton pump inhibiters along with anti-Helicobacter pylori regimen should be prescribed for all patients with peptic ulcer perforation. Routine endoscopic examination of such patients should also form a part of the follow-up to look for ulcer healing postoperatively.

REVIEW ARTICLE

Burcak E Tasdogan, Michelle Ma, Cem Simsek, Behnam Saberi, Ahmet Gurakar

Update on Immunosuppression in Liver Transplantation

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:6] [Pages No:96 - 101]

Keywords: Adverse effects, Immunosuppression, Liver transplantation

PDF  |  DOI: 10.5005/jp-journals-10018-1301  |  Open Access |  How to cite  | 

Abstract

The standard therapy for decompensated end-stage chronic liver disease of any etiology and acute fulminant hepatic failure is liver transplantation (LT). Advances in immunosuppressive therapy decreased the rates of acute and chronic rejections. Thus, graft and patient survivals have significantly improved. However, long-term adverse effects of prolonged use of immunosuppressive agents such as malignancies, opportunistic infections, metabolic disorders, and other organ toxicities have now become a major concern. Consequently, alternative approaches are needed to deescalate the customary drugs and their side effects. Therapy must be individualized and additional preventive measures should be taken by patients with particular risk factors or predisposed to certain adverse effects. Current opinion favors a combination of agents with different mechanism of actions and toxicity profiles. Corticosteroids are employed in immediate and early postoperative period. Although they have a pronounced side effect profile, calcineurin inhibitors (CNIs) are still the backbone of early and late phase immunosuppressive regimens because of their proved efficacy. Antimetabolites are frequent choices for steroid and/or CNI-sparing strategies. Studies also have established a role for mammalian target of rapamycin (mTOR) inhibitors in specific groups of recipients. Biologic agents are a hot topic of interest and made their way into current strategies for induction. Agents extrapolated from other transplantation or immunologic experience are being evaluated.

CASE REPORT

Tarana Gupta

Valproate-induced Drug Rash Eosinophilia with Systemic Symptoms Syndrome: An Unknown Hepatotoxicity

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:2] [Pages No:102 - 103]

Keywords: Drug rash eosinophilia with systemic symptoms syndrome, Hepatotoxicity, Sodium valproate

PDF  |  DOI: 10.5005/jp-journals-10018-1298  |  Open Access |  How to cite  | 

Abstract

Drug rash eosinophilia with systemic symptoms (DRESS syndrome) presents as an acute febrile illness with leukocytosis, eosinophilia, lymphadenopathy, skin rash with acute hepatitis, renal failure, myositis, or systemic organ involvement. Aromatic anticonvulsants like phenytoin, carbamazepine, and phenobarbital cause drug-induced hypersensitivity or DRESS syndrome. However, sodium valproate being nonaromatic compound although known hepatotoxic drug in preexisting chronic liver disease has never been reported to cause DRESS syndrome alone. Here we report an interesting case of DRESS syndrome caused by valproate, which presented as an acute hepatitis illness with rash, renal dysfunction, and typical hematological features of DRESS syndrome within 2 months of the introduction of the drug in an epileptic patient. Patient initially showed a good response to intravenous steroids with improvement in the liver and renal dysfunction. However, later on, developed pancytopenia either due to steroid-induced sepsis or DRESS syndrome-related secondary hemophagocytosis (HPS) due to involvement of bone marrow as a rare occurrence and succumbed to illness.

CASE REPORT

Ravi Thanage, Nikhil Sonthalia, Sanjay Chandnani

An Enigmatic Liver Mass in a Child

[Year:2019] [Month:July-December] [Volume:9] [Number:2] [Pages:4] [Pages No:104 - 107]

Keywords: Corticosteroids, Inflammatory pseudotumor, Liver abscess

PDF  |  DOI: 10.5005/jp-journals-10018-1307  |  Open Access |  How to cite  | 

Abstract

Hepatic space occupying lesions in childhood are a diagnostic challenge, as they are caused by a variety of malignant and nonmalignant disorders with a different prognosis and, of course, treatment. They are often misdiagnosed or diagnosed only after surgical resection. A 14-year-old boy presented with abdominal pain, evening-rise fever with loss of appetite and weight. The patient also developed jaundice after 2 months of above symptoms. Ultrasound of the abdomen showed an irregular infiltrative mass in segment IV of the liver. Gadobenate disodium magnetic resonance imaging done showed T1 hypointense and T2 hyperintense lesions in segment VIII of the liver with extension into porta with delayed enhancement suggestive of fibrous tumor. Liver biopsy showed extensive liver parenchymal fibrosis with a mixed inflammatory infiltrate with eosinophils. Bacterial, tubercular, and fungal culture of liver biopsy were negative. Although serum IgG4 levels were 7.88 g/L (N =1.9 g/L), IgG4 staining of liver biopsy was negative. The patient was started on prednisolone 1 mg/kg considering the diagnosis of inflammatory pseudotumor (IPT). Twenty days after starting the steroid, mass lesions were converted into multicystic abscess requiring antibiotics and pigtail drainage. On follow-up, patient had improved symptoms with mass lesions turned into small-sized abscess cavity. Hepatic IPTs are difficult to differentiate from malignant tumors, as they are rare and can have variable imaging findings. To avoid inadvertent surgery, histological confirmation of the hepatic mass is essential. Steroids should be used with caution with close follow-up to prevent iatrogenic complications, such as a chronic liver abscess.

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