Hany Dabbous

Epidemiological aspects of Budd-Chiari in Egyptian patients: a single-center study.

AIM To describe the socio-demographic features, etiology, and risk factors for Budd-Chiari syndrome (BCS) in Egyptian patients. METHODS Ninety-four Egyptian patients with confirmed primary Budd-Chiari syndrome were presented to the Budd-Chiari Study Group (BCSG) and admitted to the Tropical Medicine Department of Ain Shams University Hospital (Cairo, Egypt). Complete clinical evaluation and laboratory investigations, including a thrombophilia workup and full radiological assessment, were performed to determine underlying disease etiologies. RESULTS BCS was chronic in 79.8% of patients, acute or subacute in 19.1%, and fulminant in 1.1%. Factor V Leiden mutation (FVLM) was the most common etiological cause of disease (53.1%), followed by mutation of the gene encoding methylene tetrahydrofolate reductase (MTHFR) (51.6%). Current or recent hormonal treatment was documented in 15.5% of females, and BCS associated with pregnancy was present in 17.2% of females. Etiology could not be determined in 8.5% of patients. Males had significantly higher rates of MTHFR gene mutation and Behçets disease, and females had significantly higher rates of secondary antiphospholipid antibody syndrome. A highly significant positive relationship was evident between the presence of Behçets disease and inferior vena caval occlusion, either alone or combined with occlusion of the hepatic veins (P < 0.0001). CONCLUSION FVLM is the most common disease etiology and MTHFR the second most common in Egyptian BCS patients. BCS etiology tends to vary with geographic region.

Safety, Efficacy, and Tolerability of Sofosbuvir and Ribavirin in Management of Recurrent Hepatitis C Virus Genotype 4 After Living Donor Liver Transplant in Egypt: What Have We Learned so far?

Background Recurrence of HCV after living donor liver transplant (LDLT) is nearly universal, with almost one third of recipients developing cirrhosis and graft failure within 5 years after LDLT. Different studies have been published on the effect of sofosbuvir after liver transplantation on recurrent HCV with different genotypes. Objectives The aim of this study was to evaluate the efficacy, safety, and tolerability of sofosbuvir and ribavirin in LDLT recipients with recurrent HCV genotype 4. Patients and Methods Thirty-nine Egyptian LDLT recipients were treated for recurrent HCV after LDLT with nucleos(t)ide analog NS5B polymerase inhibitor, sofosbuvir, and ribavirin without pegylated interferon for 6 months (November 2014 to June 2015) in this intention-to-treat analysis. Results One recipient died 1 week after starting the treatment, but the remaining 38 patients completed 24 weeks of treatment and were then followed for 12 weeks after end of treatment (EOT). The sustained virological response (SVR) at week 12 after EOT was achieved in 76% (29/38) of recipients. SVR was significantly higher in treatment-naïve patients and in recipients with a low stage of fibrosis. Only 2 (5%) recipients developed severe pancytopenia and acute kidney injury. Conclusions We recommend initiating treatment as soon as possible after liver transplantation with newer combinations, such as ledipasvir/sofosbuvir or sofosbuvir/simeprevir, rather than sofosbuvir with Ribavirin, to achieve higher rates of SVR.

Donor rejection before living donor liver transplantation: causes and cost effective analysis in an egyptian transplant center.

Background: In the living donor liver transplant setting, the preoperative assessment of potential donors is important to ensure the donor safety. Objectives: The aim of this study was to identify causes and costs of living liver-donors rejection in the donation process. Materials and Methods: From June 2010 to June 2012, all potential living liver donors for 66 liver transplant candidates were screened at the Ain Shams Center for Organ Transplantation. Potential donors were evaluated in 3 phases, and their data were reviewed to determine the causes and at which phase the donors were rejected. Results: One hundred and ninety two potential living liver donors, including 157 (81.7%) males, were screened for 66 potential recipients. Of these, 126 (65.6%) were disqualified for the donation. The causes of rejection were classified as surgical (9.5 %) or medical (90.5 %). Five donors (3.9 %) were rejected due to multiple causes. Factor V Leiden mutation was detected in 29 (23 %) rejected donors (P = 0.001), 25 (19.8 %) donors had positive results for hepatitis serology (P = 0.005), and 16 (12.7 %) tested positive for drug abuse. Portal vein trifurcation (n = 9, 7.1%) and small size liver graft estimated by CT volumetric analysis (n = 6, 4.8 %) were the main surgical causes which precluded the donation. Conclusions: Among potential Egyptian living liver donors, Factor V Leiden mutation was a significant cause for live donor rejection. A stepwise approach to donor assessment was found to be cost-effective.

Characteristics of hepatocellular carcinoma in Egyptian patients with primary Budd‐Chiari syndrome

Budd‐Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aimed at analyzing characteristics and factors associated with development of hepatocellular carcinoma (HCC) in patients with primary BCS.

Hydatid Disease of the Liver : Laparoscopic Approach , Initial Results in Egypt

This prospective study assessed the laparoscopic approach for treatment of HHC in Ain Shams University Hospitals from January 2010 to April 2012. Laparoscopic partial cystectomy was performed in all patients; no conversion to open technique or anaphylaxis was recorded. The mean operative time was 60 minutes with no perioperative mortality, while postoperative morbidity was recorded in 4 patients (36%). The mean length of hospital stay was 4.5 days. Radiological and serological tests showed no recurrences at a median follow up period of 18 months. Laparoscopic management of HHC is feasible gaining all the benefits of laparoscopy with no added morbidities or increased risk of recurrence. Careful patient selection is madrdatory to achieve successful results.

Efficacy of loco-regional treatment for hepatocellular carcinoma prior to living donor liver transplantation: a report from a single center in Egypt

Background and aim The number of loco-regional therapies (LRTs) for hepatocellular carcinoma (HCC) has increased dramatically during the past decade, bridging or downstaging patients on the waiting list for liver transplantation. This study aimed to analyze the outcomes of LRTs prior to living donor liver transplantation in patients with HCC. Methods Sixty-two HCC patients received living donor liver transplantation at Ain Shams Center for Organ Transplantation over a 2-year period. Data from 29 HCC patients were analyzed. Twenty patients (68.97%) met the Milan Criteria and 4 patients (13.8%) exceeded the Milan Criteria, but met the University of California, San Francisco Criteria. Five patients (17.2%) exceeded the University of California, San Francisco Criteria. All patients underwent preoperative LRTs. The protocol of bridging/downstaging, methods, duration of follow-up, the number of patients who were successfully downstaged before liver transplantation (LT), and their outcomes after LT were recorded. Results There was a decrease in the mean overall size of focal lesions (from mean 5.46 to 4.11 cm) in the last abdominal computed tomography (CT) scan after LRT (p=0.0018). Discrepancies between the radiological findings and histopathology were as follows: in 16 patients (55.17%) the CT findings were consistent with the histopathological examination of the explanted liver. Underestimated tumor stage was documented in 10 patients (34.48%), and was overestimated by CT scan findings in 3 patients (10.34%). The 1-year survival rate was 93%. No patient had HCC recurrence after median follow-up of 21 months (range 1–46 months). Conclusion These results encouraged tumor bridging/downstaging as a potential treatment option among carefully selected patients with HCC beyond conventional criteria for LT. Further studies on a large number of patients are necessary.

Pattern of Vascular Involvement in Egyptian Patients with Budd-Chiari Syndrome: Relation to Etiology and Impact on Clinical Presentation

INTRODUCTION AND AIM Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aims to analyze the pattern of vascular involvement in Egyptian patients with BCS, demonstrates its relation to etiology and shows its impact on clinical presentation. MATERIAL AND METHODS The current retrospective study was conducted at The Tropical Medicine Department, Ain Shams University on one hundred Egyptian patients with confirmed diagnosis of primary BCS who were presented to the Budd-Chiari Study Group (BCSG) from April 2014 to May 2016 by collecting clinical, laboratory and radiological data from their medical records. RESULTS Isolated hepatic vein occlusion (HVO) was the most common pattern of vascular involvement (43%), followed by combined HVO and inferior vena cava (IVC) compression by enlarged caudate lobe (32%), then combined HVO and IVC stenosis/webs (21%), and lastly isolated IVC occlusion (4%). Ascites was more significantly encountered in BCS patients with HVO than in those with isolated inferior vena cava (IVC) occlusion and patent HVs (P = 0.005). Abdominal pain was significantly encountered in patients with occluded three major HVs (P = 0.044). Behcets disease was significantly detected in isolated IVC occlusion. Protein C deficiency was significantly detected in patients with combined HVO and IVC compression. CONCLUSION Isolated HVs occlusion was the most common pattern of vascular involvement in Egyptian patients with primary BCS. Vascular pattern of involvement affected the clinical presentation and was related to the underlying thrombophilia in those patients.INTRODUCTION AND AIM Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aims to analyze the pattern of vascular involvement in Egyptian patients with BCS, demonstrates its relation to etiology and shows its impact on clinical presentation. MATERIAL AND METHODS The current retrospective study was conducted at The Tropical Medicine Department, Ain Shams University on one hundred Egyptian patients with confirmed diagnosis of primary BCS who were presented to the Budd-Chiari Study Group (BCSG) from April 2014 to May 2016 by collecting clinical, laboratory and radiological data from their medical records. RESULTS Isolated hepatic vein occlusion (HVO) was the most common pattern of vascular involvement (43%), followed by combined HVO and inferior vena cava (IVC) compression by enlarged caudate lobe (32%), then combined HVO and IVC stenosis/webs (21%), and lastly isolated IVC occlusion (4%). Ascites was more significantly encountered in BCS patients with HVO than in those with isolated inferior vena cava (IVC) occlusion and patent HVs (P = 0.005). Abdominal pain was significantly encountered in patients with occluded three major HVs (P = 0.044). Behcets disease was significantly detected in isolated IVC occlusion. Protein C deficiency was significantly detected in patients with combined HVO and IVC compression. CONCLUSION Isolated HVs occlusion was the most common pattern of vascular involvement in Egyptian patients with primary BCS. Vascular pattern of involvement affected the clinical presentation and was related to the underlying thrombophilia in those patients.

Living donor liver transplantation for high model for end-stage liver disease score: What have we learned?

AIM To assess the impact of model for end-stage liver disease (MELD) score on patient survival and morbidity post living donor liver transplantation (LDLT). METHODS A retrospective study was performed on 80 adult patients who had LDLT from 2011-2013. Nine patients were excluded and 71 patients were divided into two groups; Group 1 included 38 patients with a MELD score < 20, and Group 2 included 33 patients with a MELD score > 20. Comparison between both groups was done regarding operative time, intra-operative blood requirement, intensive care unit (ICU) and hospital stay, infection, and patient survival. RESULTS Eleven patients died (15.5%); 3/38 (7.9%) patients in Group 1 and 8/33 (24.2%) in Group 2 with significant difference (P = 0.02). Mean operative time, duration of hospital stay, and ICU stay were similar in both groups. Mean volume of blood transfusion and cell saver re-transfusion were 8 ± 4 units and 1668 ± 202 mL, respectively, in Group 1 in comparison to 10 ± 6 units and 1910 ± 679 mL, respectively, in Group 2 with no significant difference (P = 0.09 and 0.167, respectively). The rates of infection and systemic complications (renal, respiratory, cardiovascular and neurological complications) were similar in both groups. CONCLUSION A MELD score > 20 may predict mortality after LDLT.

Prevalence of portal vein thrombosis in Egyptian patients with Budd-Chiari syndrome

Editor, Portal vein thrombosis (PVT) and Budd-Chiari syndrome (BCS) are caused by thrombosis and/or obstruction of the portal vein and the hepatic venous outflow tract, respectively [1, 2]. The mean survival of patients with PVT compared to patients without PVT may be shorter [3]. We evaluated the prevalence of PVT among Egyptian patients with BCS. All patients with BCS presenting to the Budd-Chiari Study Group (BCSG), Ain Shams University Hospital, Egypt, during the period from May 2005 to December 2011 were evaluated after signing an informed consent. One hundred and thirty-eight patients were included, and BCS and PVT were confirmed with color-pulsed Doppler ultrasonography. The mean age of the included patients was 26.6 years. The distribution of BCS cases was as follows: Cairo (n=60) followed by Delta (n=43) then upper Egypt (n=35). They mostly presented with the chronic BCS presentation (n=126) vs. 12 with acute presentation. Abdominal enlargement and abdominal pain were the most common symptoms (n=122, 113). The most common clinical signs were ascites and hepatomegaly (n=115, 114). The etiology could not be identified in 48 patients. Factor V Leiden mutation (FVLM) and methylene tetrahydrofolate reductase (MTHFR) gene mutation were the most common etiological factors being responsible for (n=26) and (n=25), respectively. Rare etiological factors include hemolytic uremic syndrome, Churg-Strauss disease, and congenital web and vasculitis (only one cause for each). One etiological factor was found in 60 patients, 2 factors in 21 patients, and 3 factors in 8 patients. Only one patient had four etiological factors (0.7 %). Esophageal varices were present in 97 cases, while gastric extensions (12 cases) and fundal varices (5 cases) were not common findings. Portal hypertensive gastropathy (PHG) was present in 63 cases. There was no significant difference between patients with (n=15) and without PVT (n=123) as regards sociodemographic data and the underlying etiology of BCS. Hepatic tenderness was more frequent in patients with PVT as well as increased direct bilirubin and white blood cells (p<0.05). Doppler ultrasound findings were similar in patients with PVT and others (Table 1). In our study, we identified a combined etiology in 21.7 % of the patients and FVLM was the most common. Denninger et al. documented combined etiology of BCS in at least 25 % of their patients [4]. Mohanty et al. concluded that FVLM was the most common risk factor in BCS (26 %) [5]. In our study, MTHFR gene mutation was documented in 18.1 % of patients. Others have reported high prevalence (45.1 %) of the MTHFR 677/T genotype in patients with BCS [6]. In the current study, Behcet’s disease (BD) was found in 8.7 %, like Turkey which reported 9 % prevalence in BCS [7]. As regards the frequency of PVT in Egyptian patients with BCS, we found that 10.9 % (15 of 138) of the studied patients had PVT including 10 males and 5 females (without significant difference) with median age of 26.93 years. In a multicenter European study in BCS patients [8], the estimated frequency of PVT was 14 %. In our cases, the etiology of combined BCS-PVT could not be defined in 4 patients (26. 7 %). Seven patients had unifactorial etiology (46.6 %), and the remaining 4 had multifactorial etiology (26.7 %), while in the European study, the etiology was unifactorial in 18 % and multifactorial in 58 % with no definitive etiology in 24 % of cases. The authors reported that three of the affected patients had a local cause of PVT, while none of our patients had such a cause. The main presenting sign in the studied patients was M. A. Sakr :N. Abdelkader :H. Dabbous (*) :A. Eldorry Tropical Medicine Department, Ain Shams University, Cairo, Egypt e-mail: drhdabbous@yahoo.com Indian J Gastroenterol (September–October 2014) 33(5):489–491 DOI 10.1007/s12664-014-0483-x