Moataz M. Sayed

The prevalence of coeliac disease in patients fulfilling Rome III criteria for irritable bowel syndrome

BACKGROUND AND STUDY AIM The clinical presentation of coeliac disease can vary from a classical malabsorption syndrome to more subtle atypical gastrointestinal manifestations similar to irritable bowel syndrome (IBS). The aim of this study was to investigate the prevalence of coeliac disease in Egyptian patients with clinically diagnosed diarrhoea-predominant IBS (according to Rome III criteria). PATIENTS AND METHODS This study was conducted on 100 patients with clinically diagnosed diarrhoea-predominant IBS (fulfilling Rome III criteria). They were subjected to complete clinical evaluation, routine laboratory investigations, abdominal ultrasonography and serum anti-tissue transglutaminase antibody (anti-tTG) test as a predictor marker for coeliac disease. All patients who tested positive for serum anti-tTG underwent upper gastrointestinal endoscopy with four to eight biopsy samples collected from the second part of the duodenum. RESULTS All of the studied 100 patients presented with abdominal pain or discomfort, flatulence and diarrhoea. Eight patients (8%) exhibited high levels of serum anti-tTG, and their duodenal biopsy samples satisfied the histopathological criteria of coeliac disease. The studied patients were divided into two groups: Group I comprising 92 patients with IBS and negative anti-tTG results and Group II comprising eight patients with IBS and positive anti-tTG results. A non-significant difference was noted between the two groups in age, gender and duration of abdominal pain (p>0.05). The haemoglobin level was found to be significantly reduced in anti-tTG-positive patients (p<0.01), as was the Na level in anti-tTG-negative patients (p<0.05). A highly statistically significant inverse correlation was noted between anti-tTG and both serum total protein and serum albumin. CONCLUSION Some symptoms overlap between coeliac disease and IBS. A lack of awareness may lead to a diagnostic delay in these patients.

Association between Severity of Liver Disease, Frequency of Helicobacter pylori Infection, and Degree of Gastric Lesion in Egyptian Patients with Hepatitis B Virus Infection

The relationship between hepatitis B virus (HBV) infection, severity of liver disease, frequency of Helicobacter pylori infection, and degree of gastric lesions was not yet fully investigated in Egyptian patients. The present work was performed on 100 Egyptian patients with HBV from the National Hepatology and Tropical Medicine Institute and 70 healthy volunteers as control group. The participants were subjected to full medical history taking, clinical examination, and laboratory investigations. All patients were positive for HBV surface antigen (HBV sAg), HBV DNA, and negative for hepatitis C virus antibodies. The severity of the liver disease was assessed using Child-Pugh scoring system. Screening of all participants for H. pylori Ag in stool was performed. Biopsy specimens were taken from the gastric lesions of H. pylori-infected patients for histopathological examination. The mean age of the patients and control group were 34.9 and 33.4 years, respectively. The levels of the liver enzymes were statistically higher in HBV patients than the control group. Helicobacter pylori Ag in stool was detected in 45.7% of the control group, and a higher percentage (60%) was detected in the patients group. Chronic gastritis with glandular atrophy and metaplasia was found in 15.6% of patients of Child-Pugh A, 70% of Child-Pugh B, and 100% of Child-Pugh C. It could be concluded that the prognosis of the liver disease significantly influences the severity of the gastric pathology in H. pylori infection.

Can hepatitis C virus core antigen be used as a reliable marker of viral load for hepatitis C virus infection in genotype 4

Background Anti-hepatitis C virus (HCV) antibody assessment and viral nuclear acid measurement are important in the HCV infection diagnosis and follow-up. Aim The aim of this study was to analyze hepatitis C virus core antigen (HCV core Ag) positivity among anti-HCV antibody-positive patients with genotype 4 to determine the utility of testing of HCV core Ag for the diagnosis of HCV infection in comparison with HCV RNA levels. Patients and methods Ninety patients with positive anti-HCV antibody test were included in this study. HCV PCR quantitative and HCV core Ag tests were measured in all patients. HCV core Ag was assessed using WKEA HCV-Ag assay. Results HCV PCR was detectable in 78 patients. All patients were infected with genotype 4. Seventy-five patients with positive HCV PCR demonstrated HCV core Ag positivity. HCV core Ag was undetectable in all 12 patients with negative HCV RNA and was undetectable in three patients with positive HCV PCR. In this study, HCV core antigen sensitivity, specificity, positive predictive value, and negative predictive value were 96.15, 100, 100, and 80%, respectively, in relation to HCV RNA PCR results. There was a positive correlation between HCV RNA and HCV core Ag (r=0.916, P<0.0001). Conclusion The HCV core Ag is a rapid, cost-effective test with good correlation with the HCV PCR tests. It may have a role in HCV diagnosis and should be further evaluated for follow-up of the HCV infection.

Reversibility of minimal hepatic encephalopathy following liver transplantation in Egyptian cirrhotic patients

AIM To evaluate the reversibility of minimal hepatic encephalopathy (MHE) following liver transplantation (LT) in Egyptian cirrhotic patients. METHODS This prospective study included twenty patients with biopsy-proven liver cirrhosis listed for LT and twenty age- and sex-matched healthy control subjects. All underwent neuro-psychiatric examination, laboratory investigations, radiological studies and psychometric tests including trail making test A (TMT A), TMT B, digit symbol test and serial dotting test. The psychometric hepatic encephalopathy score (PHES) was calculated for patients to diagnose MHE. Psychometric tests were repeated six months following LT in the cirrhotic patient group. RESULTS Before LT, psychometric tests showed highly significant deficits in cirrhotic patients in comparison to controls (P < 0.001). There was a statistically significant improvement in test values in the patient group after LT; however, their values were still significantly worse than those of the controls (P < 0.001). The PHES detected MHE in 16 patients (80%) before LT with a median value of -7 ± 3.5. The median PHES value was significantly improved following LT, reaching -4.5 ± 5 (P < 0.001), and the number of patients with MHE decreased to 11 (55%). The pre-transplant model for end-stage liver disease (MELD) score ≥ 15 was significantly related to the presence of post-transplant MHE (P = 0.005). More patients in whom reversal of MHE was observed had a pre-transplant MELD score < 15. CONCLUSION Reversal of MHE in cirrhotic patients could be achieved by LT, especially in those with a MELD score < 15.

Assessment of interleukin-28B (interferon λ3) rs12979860 C/T gene polymorphism and the risk for hepatocellular carcinoma in chronic hepatitis C cirrhotic patients

Introduction Hepatitis C virus (HCV) infection endemicity in Egypt is an important risk factor for the high prevalence of hepatocellular carcinoma (HCC). This mandates an exploration of the underlying genetic factors linking both diseases, thus predicting the risk for HCV-related HCC. Aim The aim of the study was to evaluate and compare the interleukin-28B (IL-28B) gene polymorphism in HCV cirrhotic patients with and without HCC. Patients and methods This case–control study included 40 HCV-infected patients, divided into two equal groups. The first group included 20 cirrhotic patients with HCC and the second group included 20 cirrhotic patients without HCC. IL-28B genotyping was done by using the TaqMan allelic discrimination kit using 7500 Real-Time PCR System (Applied Biosystems). Results In the present study, the frequencies of CC, CT, and TT genotypes in chronic hepatitis C (CHC) cirrhotic patients with hepatoma were shown to be 15, 30, and 55%, respectively, and 40, 20, and 40 in CHC cirrhotic patients without hepatoma. The prevalence of heterozygous CT and homozygous TT genotypes in CHC cirrhotic patients with hepatoma with allele frequencies among the entire study of the C allele was 30 and 50%, and for the T allele it was 70 and 50%, respectively, in both patients group. A major contribution of the T allele with an increased risk for developing hepatoma cannot be ruled out; CT or TT genotypes and the T allele frequency were 4.00, 3.67, and 2.33 (P>0.05). Although the difference was statistically nonsignificant due to small sample size, it may be achieved with larger sample size. Conclusion Our study concluded that IL-28 C/T gene polymorphism may contribute to risk for developing hepatoma in CHC cirrhotic patients.

Relation between hepatitis B viral load and liver fibrosis assessed using transient elastography in patients with chronic hepatitis B virus infection

Background Several hepatitis B (HB) viral factors such as viral load and genotype were shown to anticipate clinical outcomes. Noninvasive tests assessing liver fibrosis are widely preferred. Aim The aim of this study was to find the relation between HB viral load and liver fibrosis stage assessed using transient elastography in chronic HB patients. Patients and methods This study included 60 chronic HB patients who were divided into two groups. Thirty patients with fibrosis stages F1–F2 constituted group 1, and 30 patients with fibrosis stages F3–F4 constituted group 2. The stage of liver fibrosis was assessed using FibroScan. HB viral load was measured with PCR. Results The median (interquartile range) of HB virus PCR in groups 1 and 2 was 33.5 (16.0–515.5) and 82.5 (16.0–535.0), respectively, with a nonsignificant difference between the two groups (P=0.834). It was 220.0 (16.0–1014.0) and 77.0 (16.0–335.0) in patients with and those without cirrhosis, respectively, with a nonsignificant difference (P=0.552). Receiver operating characteristic analysis showed area under curve of 0.516 for differentiating between the two groups. Conclusion HB viral load was nonsignificantly higher in patients with higher grades of liver fibrosis and cirrhosis with weak diagnostic performance in differentiation between different fibrosis stages.

Clinical significance of the dipstick test to detect empyema in hepatic hydrothorax with and without spontaneous bacterial peritonitis

Background Hepatic hydrothorax is a frequent finding in cirrhotic patients with ascites. Spontaneous bacterial empyema (SBEM) represents a distinct complication of hepatic hydrothorax, with high associated mortality. Aim of the study We studied the presence of SBEM in cirrhotic ascitic patients with hydrothorax, both in the presence and in the absence of spontaneous bacterial peritonitis (SBP). We also showed the value of the dipstick test in the diagnosis of SBEM. Patients and methods Fifty cirrhotic patients with evidence of ascites and right-sided pleural effusion were recruited for this study. The patients were assigned into two groups: group I, comprising 25 patients with SBP; and group II comprising 25 patients without SBP. The presence or absence of SBP was diagnosed on the basis of the ascitic fluid neutrophil count, with a cutoff level of at least 250 neutrophils/ml to diagnose the infection. All patients underwent an abdominal ultrasound to confirm the diagnosis of chronic liver disease and to document the presence of ascites, its extent and aspect, and a chest radiograph to verify the presence of pleural effusion. Cytological analysis and culture and sensitivity for ascetic and pleural samples were carried out. The pleural fluid sample was tested using the leukocyte esterase dipstick test (Combur Test UX). Results SBEM was diagnosed in 12 patients with hepatic hydrothorax (24%). In nine (36%) patients it was associated with SBP and in three (12%) it was not associated with SBP. The sensitivity and specificity of the dipstick test were 92 and 88%, respectively, for the diagnosis of SBEM, using a cutoff grade of 2 and above. Conclusion Reagent strips are a rapid, easy to use, and inexpensive tool for the diagnosis of pleural fluid infection. A positive result should be an indication for empirical antibiotic therapy, and a negative result may be useful as a screening test to exclude SBEM.