Khairy H. Morsy

Outcomes and predictors of in-hospital mortality among cirrhotic patients with non-variceal upper gastrointestinal bleeding in upper Egypt.

BACKGROUND/AIMS Variceal bleeding is one of the most frequent causes of morbidity and mortality among cirrhotic patients. Clinical endoscopic features and outcomes of cirrhotic patients with non-variceal upper gastrointestinal bleeding (NVUGIB) have been rarely reported. Our aim is to identify treatment outcomes and predictors of in-hospital mortality among cirrhotic patients with non-variceal bleeding in Upper Egypt. MATERIALS AND METHODS A prospective study of 93 cirrhotic patients with NVUGIB who were admitted to the Tropical Medicine and Gastroenterology Department, Assiut University Hospital (Assiut, Egypt) over a one-year period (November 2011 to October 2012). Clinical features, endoscopic findings, clinical outcomes, and in-hospital mortality rates were studied. Patient mortality during hospital stay was reported. Many independent risk factors of mortality were evaluated by means of univariate and multiple logistic regression analyses. RESULTS Of 93 patients, 65.6% were male with a mean age of 53.3 years. The most frequent cause of bleeding was duodenal ulceration (26.9%). Endoscopic treatment was needed in 45.2% of patients, rebleeding occurred in 4.3%, and the in-hospital mortality was 14%. Hypovolemic shock was the most common cause of death (46.2%). Independent risk factors of in-hospital mortality among cirrhotic patients with NVUGIB in our study were bacterial infection during hospitalization [odds ratio (OR) =0.32, 95% confidence interval (CI) =0.03-0.89], shock (OR =1.12, 95% CI =0.68-1.54), early rebleeding (OR =2.26, 95% CI =1.85-3.21), low serum albumin (OR =3.81, 95% CI =2.35-4.67), low baseline hemoglobin (OR =0.714, 95% CI =0.32-1.24), and the need for endoscopic treatment (OR =2.96, 95% CI =0.62-3.63). CONCLUSION Bacterial infection during hospitalization, shock, early rebleeding, low serum albumin, low baseline hemoglobin, and the need for endoscopic treatment were independent risk factors of in-hospital mortality among cirrhotic patients with NVUGIB in Upper Egypt.

Variceal bleeding in cirrhotic patients: What is the best prognostic score?

BACKGROUND/AIMS To find the most accurate, suitable, and applicable scoring system for the prediction of outcome in cirrhotic patients with bleeding varices. MATERIALS AND METHODS A prospective study was conducted comprising 120 cirrhotic patients with acute variceal bleeding who were admitted to Tropical Medicine and Gastroenterology Department in Sohag University Hospital, over a 1-year period (1/2015 to 1/2016). The clinical, laboratory, and endoscopic parameters were studied. Child-Turcotte-Pugh (CTP) classification score, Model for end-stage liver disease (MELD) score, acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, and AIMS65 score were calculated for all patients. Univariate and multivariate analyses were performed for all the measured parameters and scores. RESULTS Of the 120 patients (92 male) admitted during the study period, eight patients (6.67%) died in the hospital. Advanced age, the presence of encephalopathy, rebleeding, and higher serum bilirubin were independent factors associated with higher hospital mortality. The largest area under the receiver operator curve (AUROC) was obtained for the AIMS65 score and SOFA score, followed by the MELD score and APACHEII score, then CTP score, all of which achieved very good performance (AUROC>0.8). AIMS65 score showed the best sensitivity, specificity, and negative and positive predictive values. Although the AIMS65 score was not significantly different from the MELD, SOFA, and APACHEII scores, it was the optimum among them in terms of the prediction of mortality. CONCLUSION AIMS65 score is the best simple and applicable scoring system for independently predicting mortality in cirrhotic patients with acute variceal bleeding.

Scoring Systems and Risk Stratification in Cirrhotic Patients with Acute Variceal Bleeding "Scoring in Variceal Bleeding"

Objectives: To find the most accurate, suitable and applicable scoring system used for prediction of outcome in cirrhotic patients with bleeding varices. Methods: This prospective study included 120 cirrhotic patients with acute variceal bleeding, admitted at Department of Tropical Medicine and Gastroenterology in Sohag University Hospital over a one-year period (1/2015 to 1/2016). Clinical, laboratory and endoscopic parameters were studied, Child–Pugh (CTP) classification score, Model for end-stage liver disease (MELD) score, Acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score and AIMS65 score were calculated for all patients, univariate, multivariate analysis and performance was performed for all taken parameters and the scores. Results: The 120 patients (92 male, 28 female) admitted during the study period, eight patients (6.67%) died in hospital. Higher age, presence of encephalopathy, rebleeding, and higher serum bilirubin were independent factors associated with higher hospital mortality. The largest area under the receiver operator curve (AUROC) was for AIMS65 score and SOFA score followed by MELD score and APACHEII score then Child score all of which achieved very good performance (AUROC > 0.8). AIMS 65 score has the best sensitivity, specificity negative and positive predictive values. Although AIMS65 score was not significantly different from MELD, SOFA, and APACHEII scores, it was the best among them in prediction of mortality. Conclusions: AIMS65 score is best simple and applicable scoring system to independently predict mortality in those patients.

Diagnostic Value of Serum Ascites Lipid Gradients in Patients with Ascites

Introduction: Differential diagnosis of ascites is a common clinical problem. Aim of the work: To study the value of Serum Ascites Lipid Gradients (SALG) of total cholesterol, triglyceride, HDL cholesterol, and LDL cholesterol in the diagnosis of ascites. Materials and methods: The study was conducted on patients with ascites admitted to Tropical Medicine and Gastroenterology Department, Assiut University. The study included 115 patients with ascites of different etiologies (liver cirrhosis, tuberculosis, and malignant ascites). Clinical evaluation, abdominal ultrasonography, and laboratory investigations were conducted as follows: Serum Ascites Albumin Gradient (SAAG), serum lipid profile, and SALG of total cholesterol, triglyceride, HDL cholesterol, and LDL cholesterol. Results: SAAG values were 1.87 ± 0.537 (>1.1), 0.58 ± 0.112 (<1.1), and 0.69 ± 0.201 (<1.1) gm/dL respectively for patients with liver cirrhosis, tuberculosis, and malignancy. The SALG levels for differentiating high SAAG (cirrhosis) from low SAAG (tuberculosis and malignancy) were 97.9 ± 28.6 versus 52.7 ± 32.35 and 49.4 ± 28.64 for SALG- total cholesterol, 74.7 ± 28.2 versus 56.9 ± 48.0 and 48.3 ± 29.23 for SALG- triglyceride, 28.67 ± 9.11 versus 18.53 ± 15.7 and 14.7 ± 14.8 for SALG- HDL cholesterol, 55.7 ± 26.1 versus 17.93 ± 38.5 and 28.5 ± 13.65 for SALGLDL cholesterol respectively. These values are significantly higher in cirrhosis than tuberculosis or malignancy. The cut-off SALG values being 67 mg%, 66 mg%, 26 and 49 mg% in cholesterol, triglyceride, HDL cholesterol, LDL cholesterol respectively in differentiating cirrhotic ascites from tuberculosis or malignant ascites A close relationship between the levels of SALG and severity of cirrhosis is found but it is not significant. Conclusion: SALG has important value in differentiation cirrhotic ascites from tuberculosis or malignant ascites but cannot differentiate tuberculosis ascites from malignant ascites.

Efficacy of ombitasvir/paritaprevir/ritonavir/ribavirin in management of HCV genotype 4 and end-stage kidney disease

BACKGROUND Till now, pooled data about the safety and efficacy of different direct-acting antiviral (DAAs) regimens in different renal situations are still under evaluation. AIM To evaluate a real-life experience of the efficacy and safety of ombitasvir/paritaprevir/ritonavir plus ribavirin (OBV/PTV/r plus RIB) in patients with end-stage kidney disease (ESKD). PATIENTS AND METHODS Between January 2017 and January 2018, an open-label multicenter prospective study was designed to enroll all consecutive patients with proven CHC genotype 4 infections and concomitant ESKD based on estimated glomerular filtration rate (eGFR) with (HD group) or without hemodialysis (non-HD group). Patients were given a co-formula of OBV/PTV/r (25/150/100 mg) once-daily plus RIB was given for 12 weeks. Sustained virologic response (SVR 12) was the primary endpoint. RESULTS A total of 110 patients were enrolled. An overall SVR 12 was reported in 104 (94.5%) patients, and treatment failure were reported in 6 patients [2 patients (1.8%) were relapsed, and 4 patients (3.6%) patients were non-responders]. SVR12 was 96% in HD and 91.4% in non-HD patients (P = 0.286). There were no reported serious adverse events. Anemia was reported in 66.6% (n = 50) in HD group and in 31.4% (n = 11) in non-HD group. CONCLUSION Although it is still challenging, achievement of SVR12 in patients with chronic HCV and concomitant end-stage kidney disease in the era of DAAs became possible with a 12 weeks course of a co-formula of ombitasvir/paritaprevir /ritonavir plus ribavirin. CLINICALTRIALS. GOV ID NCT03341988.

Interplay between Gut Microbiota and T Lymphocytes in Colorectal Cancer

Colorectal cancer is one of the third leading causes of cancer mortality worldwide. There is increasing evidences about the involvement of gut microbiota in colorectal carcinogenesis. Several recent studies have shed light on the cross talk between gut microbiota and mucosal T cell subsets, specifically intraepithelial lymphocytes and lamina propria CD4+ T cells including T-helper cells and Tregulatory (Treg) cells which may be responsible for development of colorectal cancer through creating imbalance between proinflammatory and antiinflammatory immune cells and their cytokines. In this review, we will focus on the influence gut microbiota on the development of mucosal T cells and their role in promoting colorectal cancer.

Can eicosapentaenoic acid maintain the original ribavirin dose or affect the response during the treatment course of chronic hepatitis C virus (HCV) patients

BACKGROUND/AIMS Combination therapy with peginterferon (PEG-IFN) and ribavirin (RBV) has been recommended as a standard therapy for patients with chronic hepatitis C virus (HCV). Our aim was to evaluate the efficacy of eicosapentaenoic acid (EPA) against RBV-associated hemolytic anemia. MATERIALS AND METHODS Two hundred and forty HCV patients included in the study were randomized to either the EPA group (n=120) or non-EPA group (n=120), and they received combination therapy with or without EPA. We compare changes in hemoglobin levels with RBV dose reduction rate in each group as well as treatment response. RESULTS Of 120 patients randomized to receive combination therapy with EPA, 15/86 (17.5%) patients required RBV dose reduction, whereas 71/86 (82.5%) patients did not require RBV dose reduction; in the non-EPA group, 22/80 (27.5%) patients required RBV dose reduction and 58/80 (72.5%) patients did not require RBV dose reduction. There was no significant difference between the two groups in the rates of virologic response. CONCLUSION EPA can decrease the rate of RBV dose reduction and RBV-induced hemolysis during the course of combination treatment. Further trials are required to investigate the role of EPA in the current regimens of HCV treatment that include ribavirin.

Wandering spleen in the pelvic region in an adult man with symptoms of acute abdomen.

UNLABELLED Wandering or ectopic spleen is a condition characterised by migration of spleen in the abdomen or pelvis. This anomaly is rare, with a reported incidence of <0.2%. It occurs mostly in women between 20 and 40years of age. Clinical diagnosis is difficult because of lack of precise signs, symptoms, and nonspecific laboratory data. Diagnosis of a wandering spleen highly depends on the results of imaging studies such as abdominal ultrasound and abdominopelvic computed tomography (CT) scanning. Treatment includes surgery with the choice between splenopexy in a noninfarcted spleen and splenectomy when infarction has occurred. We report a rare case of wandering spleen in a 27-year-old man with infarction due to torsion of its pedicle, which was diagnosed by CT and treated by splenectomy. CONCLUSION Despite the rarity of wandering spleen, the possibility of torsion of its long pedicle with acute splenic infarction should be considered in the differential diagnosis of acute abdomen.

Clinical, laboratory, and virological characteristics of patients with positive hepatitis B surface antigen in Upper Egypt

Aim The aim of the study was to determine the clinical, laboratory, and virological characteristics of patients with chronic HBV infection in Upper Egypt. Patients and methods This descriptive, cross-sectional study included 252 patients with positive hepatitis B surface antigen (HBsAg). It was conducted in the Tropical Medicine and Gastroenterology Department and Outpatient Clinic, Assiut University Hospital (Egypt), from May 2012 to May 2014. All patients underwent clinical evaluation, were administered a questionnaire about risk factors for transmission of HBV, underwent liver function tests, abdominal ultrasonographic examination, and complete blood count, evaluation of serological markers of HBV, and quantitative detection of HBV-DNA. Results Of the 252 patients included, 88.5% were male with a mean age of 35.4 years. Arthralgia was the most common complaint (15.5%) and hepatomegaly was the most common finding (8.3%). As regards imaging results (ultrasonographic) the following were found: normal liver in 83.3%, coarse liver in 11.9%, hepatomegaly in 7.5%, splenomegaly in 6.3%, and cirrhosis in 5.9%. As regards laboratory results normal alanine aminotransferase was found in 79.8%, normal aspartate aminotransferase in 85.7%, reduced serum albumin in 4.4%, and low platelet count in 9.9%. The majority of patients (91.7%) were hepatitis B envelope antigen negative; 65.9% of patients were positive for HBV on PCR. No significant differences were found between positive HBV-DNA status (by PCR) and negative HBV-DNA status as regards clinical, imaging, and laboratory characteristics of patients. Conclusion Most of the patients had normal liver on ultrasonographic examination and normal liver function tests. No significant difference was found between positive HBV-DNA status (by PCR) and negative HBV-DNA status as regards clinical, imaging, and laboratory characteristics of patients.