Nasser Mousa

De-novo portal vein thrombosis in liver cirrhosis: risk factors and correlation with the Model for End-stage Liver Disease scoring system.

Background and objectivesPortal vein thrombosis (PVT) is a potential lethal complication in late liver cirrhosis. There is a lack of knowledge of the clinical features and risk factors of PVT. We aimed to investigate the clinical and radiological characteristics, and biochemical markers of cirrhotic patients to determine the high-risk individuals for PVT attending our center. Patients and methodsOf 426 cirrhotic patients, only 120 consecutive patients were included. Clinical, biochemical, immunological, Model for End-stage Liver Disease (MELD) score, portal vein patency, and flow velocity were measured in all patients at baseline and every 6 months thereafter. Variables that could predict the development of PVT within 1 year were identified by multiple logistic regression. ResultsOnly 95 patients completed the study; PVT was found in 17 (17.9%) patients. PVT was observed mainly in the portal trunk, superior mesenteric vein, and splenic vein. Univariate analysis showed that diabetes mellitus, lower levels of hemoglobin, platelet counts, and portal vein flow velocity as well as increased MELD scores, platelet indices, portal vein diameter, and splenic thickness were associated with PVT patients than in non-PVT patients (all P<0.01). ConclusionThe incidence of PVT was 17.9%. PVT occurred mainly in the portal vein trunk, superior mesenteric vein, and splenic vein. Diabetes mellitus, lower levels of hemoglobin, platelet count and portal vein flow velocity as well as increased MELD score, platelet indices, portal vein diameter, and splenic thickening were associated with PVT. Splenic thickening, marked reduced of mean portal flow velocity, and diabetes mellitus may be risk factors for PVT.

Seroprevalence of subclinical HEV infection in asymptomatic, apparently healthy, pregnant women in Dakahlya Governorate, Egypt

Background and Aim: Hepatitis E virus (HEV) is a major public health problem in the developing countries. HEV infection in pregnant women is more common and fatal in the third trimester. The present study was designed to determine the seroprevalence of subclinical HEV infection in asymptomatic pregnant women. Materials and Methods: A total of 116 asymptomatic pregnant women divided into 2 groups: Group 1 included 56 pregnant women with HCV positive serology and group 2 included 60 pregnant women with negative HCV serology were included in this study. Prevalence of anti-HEV antibodies and anti-HCV were determined by an enzyme linked immunosorbent assay (ELISA) kit. Results: The overall prevalence of anti-HEV IgG was highly significant among pregnant women with chronic HCV infection 40/56 (71.42%) than pregnant women free from chronic HCV infection 28/60 (46.7%) (P = 0.006). Chronic HCV infection in pregnant women appeared to be a risk factor associated with HEV IgG seropositivity (OR = 2.86, CI = 1.24-6.6). The seropositivity of anti-HEV IgG was significantly high in rural areas than urban areas (62.5% vs. 37.5%) in group 1 and (78.58% vs. 21.42%) in group 2 (P = 0.15) and OR = 2.2, CI = 0.65-7.7). A decrease in albumin level (P = 0.047) and an increase in bilirubin (P = 0.025), ALT (P = 0.032), and AST (P = 0.044) in pregnant women with positive HCV and IgG anti-HEV than the second group with negative HCV serology. Conclusions: The seroprevalence of anti-HEV IgG in pregnant women is high in Egypt especially in rural areas. With chronic HCV coinfection, a marked increase in anti-HEV IgG seropositivity and significant worsening of the biochemical liver indices were noted. Increased public awareness about the sound hygienic measures for a less prevalence of HEV is strongly advised. The need for HEV vaccination for those at risk, especially pregnant ladies, should be considered.

A novel model using mean platelet volume and neutrophil to lymphocyte ratio as a marker of nonalcoholic steatohepatitis in NAFLD patients: multicentric study.

Background and aim Nonalcoholic fatty liver disease (NAFLD) is a leading cause of progressive and chronic liver injury. Mean platelet volume (MPV) and the neutrophil–lymphocyte ratio (N/L ratio) may be considered cheap and simple markers of inflammation in many disorders. We aimed to investigate the clinical utility of MPV and the N/L ratio to predict fibrosis in NAFLD patients and the presence of nonalcoholic steatohepatitis (NASH). Materials and methods A total of 873 patients with biopsy-proven NAFLD and 150 healthy controls were included. Patients were divided into two groups: non-NASH group (n=753) and NASH group (n=120). Liver biopsy, MPV, lymphocyte, and neutrophil counts were registered; the N/L ratio was calculated. Proinflammatory cytokines (tumor necrosis factor-&agr; and interleukin-6) were measured by an ELISA. Results NASH patients had higher MPV compared with non-NASH patients (10.9±1.8 and 9.5±1.6 fl, respectively, P<0.001). MPV correlated positively with the NAFLD activity score, proinflammatory cytokines, and C-reactive protein (CRP) (P<0.001). Patients with advanced fibrosis (F3–4) had increased MPV (11.3±0.9 fl) compared with patients with early fibrosis (F1–2) (10.2±0.8 fl, P<0.001). NASH patients had an increased N/L ratio compared with non-NASH cases (2.6±1.1 and 1.9±0.7 fl, respectively, P<0.001). The N/L ratio correlated positively with NAFLD activity score, proinflammatory cytokines, and CRP (P<0.001). In addition, patients with advanced fibrosis (F3–4) had an N/L ratio (2.5±1.1) comparable with that of patients with early fibrosis (F1–2) (1.8±0.9) (P<0.001). Conclusion MPV and the N/L ratio were elevated in NASH patients versus non-NASH cases, and in patients with advanced fibrosis (F3–4) versus early fibrosis (F1–2). They can be used as noninvasive novel markers to predict advanced disease.

Ascitic Fluid Calprotectin and Serum Procalcitonin as Accurate Diagnostic Markers for Spontaneous Bacterial Peritonitis

Background/Aims The diagnosis of spontaneous bacterial peritonitis (SBP) is based on a polymorphonuclear leukocytes (PMNs) exceeding 250/μL in ascitic fluid. The aim of the study was to evaluate serum procalcitonin and ascitic fluid calprotectin as accurate diagnostic markers for detecting SBP. Methods Seventy-nine patients with cirrhotic ascites were included. They were divided into a SBP group, including 52 patients, and a non-SBP group of 27 patients. Serum procalcitonin, ascitic calprotectin, and serum and ascitic levels of tumor necrosis factor α (TNF-α) and interleukin 6 (IL-6) were measured using an enzyme-linked immunosorbent assay. Results Serum procalcitonin and ascitic calprotectin were significantly higher in SBP patients than in non-SBP patients. Significant increases in both serum and ascitic levels of TNF-α and IL-6 were observed in SBP patients versus non-SBP patients. At a cutoff value of 0.94 ng/mL, serum procalcitonin had 94.3% sensitivity and 91.8% specificity for detecting SBP. In addition, at a cutoff value of 445 ng/mL, ascitic calprotectin had 95.4% sensitivity and 85.2% specificity for detecting SBP. Both were positively correlated with ascitic fluid proteins, PMN count, TNF-α, and IL-6. Conclusions According to our findings, determination of serum procalcitonin levels and ascitic calprotectin appears to provide satisfactory diagnostic markers for the diagnosis of SBP.

Increased α-Fetoprotein Predicts Steatosis among Patients with Chronic Hepatitis C Genotype 4.

Background. The prognostic importance of α-fetoprotein (AFP) level elevation in patients with chronic hepatitis C and its clinical significance in steatosis associated with HCV infection remain to be determined. The present paper assessed clinical significance of elevated AFP in patients with CHC with and without steatosis. Methods. One hundred patients with CHC were divided into 50 patients with CHC and steatosis and 50 patients with CHC and no steatosis based on liver biopsy. Results. AFP was significantly increased in CHC with steatosis than patients without steatosis (P < 0.001). Highly significant positive correlation was found between serum AFP and necroinflammation as well as the severity of fibrosis/cirrhosis and negative significant correlation with albumin level in chronic HCV with steatosis (P < 0.001) but negative nonsignificant correlation with ALT and AST level (P ≤ 0.778 and 0.398), respectively. Highly significant increase was found in chronic hepatitis patients with steatosis than CHC without steatosis regarding necroinflammation as well as the severity of fibrosis/cirrhosis and AFP (P < 0.001). Conclusion. Patients with chronic HCV and steatosis have a higher AFP levels than those without steatosis. In chronic HCV with steatosis, elevated AFP levels correlated positively with HAI and negative significant correlation with albumin level.

Impact of basic lymphedema management and antifilarial treatment on acute dermatolymphangioadenitis episodes and filarial antigenaemia

Background: A major factor in the progression of lymphedema is acute dermatolymphangioadenitis (ADLA). Aims To study ADLA episodes and antigenaemia in patients with different grades of filarial lymphedema at pre- and two years post-treatment. Setting and Design: A prospectively conducted study from May 2008 through May 2010. Patients and Methods: Forty five patients complaining of limb swelling with present or past history of limb redness suggestive of ADLA attacks were included. Patients were clinically examined for lymphedema grading, detection of potential entry points and diagnosis of microfilaraemia. Wuchereria bancrofti antigen titer was estimated by “Trop-Ag W. Bancrofti” ELISA kit. Basic lymphedema management and treatment with antifilarial drugs were applied. Statistical Analysis Mann–Whitney test and Chi-square test were used. Results: The number of ADLA attacks in the pretreatment period, ranged from one to three per year. Mean duration of the attacks was 3.87±0.79 days. Entry points were detected in 82% of cases. The study revealed statistical significance between extension and grade of lymphedema and number of ADLA attacks per year (P=0.018 and 0.022, respectively). Microfilaraemia was detected in four cases and positive filarial antigenaemia were detected in 29 patients (64.4). The number of ADLA attacks per year significantly decreased from the pre-treatment period (mean: 2.05±0.560) to be 1.23±0.706 after one year and 0.89±0.575 after two years post treatment. There was a significant decrease in the mean antigen titer one year and two years after treatment. Conclusion: Basic lymphedema management is effective for controlling ADLA attacks in areas where lymphatic filariasis is endemic.

Is Combination Therapy Interferon and Ribavirin in Patients with Chronic Hepatitis C Infection Toxic for Eyes

BACKGROUND Many side effects of combination therapy using pegylated interferon (IFN) and ribavirin for treatment of chronic hepatitis C virus (HCV) infection have been well described. Ocular complications are fairly common. Diabetes mellitus (DM) and systemic hypertension are possible suggested risk factors for development of these complications. PURPOSE To determine the frequency of retinopathy and its risk factors in patients treated with combined pegylated IFN and ribavirin for chronic hepatitis C infection. METHODS Eligible 98 patients for HCV treatment with pegylated IFN a-2a, a-2b, and ribavirin between October 2011 and March 2012 were included. All patients underwent a baseline full ophthalmological examination, and any visual complaints during treatment prompted a repeat eye examination. RESULTS Out of the eligible 98 patients, 48 (48.78%) patients received pegylated IFN alpha-2a, and the other 50 (51.21%) patients were treated with pegylated IFN alpha-2b. Out of 98 patients, 21 (21.42%) had diabetes; 19 (19.38%) patients had hypertension and 16 (16.32%) patients had both diabetes; and hypertension. Only 8 patients (8.16%) had documented retinopathy [2 had DM; one had hypertension; 4 had both hypertension and diabetes; and one patient without DM or hypertension]. Univariate logistic regression analysis revealed that diabetic, hypertensive patients are at increased risk for development of IFN-associated retinopathy (IAR) (P=0.007, Odds ratio=6.5, 95% confidence interval=1.56-27. CONCLUSION Retinopathy in chronic HCV-infected patients undergoing treatment with combination of pegylated IFN-alpha and ribavirin therapy appears to be relatively low, and treatment cessation is rarely needed. Diabetic, hypertensive patients are at increased risk for IAR and are recommended to be ophthalmologically followed-up.

Diagnostic utility of interferon gamma-induced protein 10 kDa in spontaneous bacterial peritonitis: single-center study.

Background and aims Spontaneous bacterial peritonitis (SBP) is an important cause of mortality and morbidity in cirrhotic patients with ascites. The diagnosis of SBP is mainly made on the basis of a polymorphonuclear leukocyte cell count exceeding 250/&mgr;l in ascitic fluid. However, this procedure is subjective. We aimed to evaluate serum and ascitic fluid interferon-&ggr;-induced protein (IP-10) as accurate diagnostic markers for detecting SBP. Methods A total of 425 consecutive patients with ascites were included. Serum and ascitic fluid of IP-10, tumor necrosis factor-&agr; (TNF-&agr;), and interleukin-6 (IL-6) were measured using an enzyme-linked immunosorbent assay. Results Patients were divided into an SBP group, including 61 patients, and a non-SBP group, including 364 patients. Serum and ascitic IP-10 were significantly higher in SBP patients than in patients without SBP (1855±825 vs. 955±510 pg/ml; P<0.001 and 2160±994 vs. 1110±623 pg/ml; P<0.001), respectively. There was a significant increase in both serum and ascitic levels of TNF-&agr; and IL-6 in SBP patients than in patients without SBP. At a cut-off value of 1915 pg/ml, serum IP-10 had 91% sensitivity and 89% specificity for detecting SBP (area under the curve: 0.912). Also, at a cut-off value of 2355 pg/ml, ascitic IP-10 had 92.5% sensitivity and 87% specificity for detecting SBP (area under the curve: 0.943). Both were correlated with ascitic fluid proteins, polymorphonuclear count, TNF-&agr;, and IL-6. Conclusion Serum and ascitic IP-10, TNF-&agr;, and IL-6 are significantly increased in SBP patients versus patients without SBP. Serum level of IP-10 is more specific and sensitive, such as ascites. Thus, it seems to represent a satisfactory diagnostic marker for the diagnosis of SBP.

The role of antioxidants and zinc in minimal hepatic encephalopathy: a randomized trial.

Background: Minimal hepatic encephalopathy (MHE) has a far-reaching impact on quality and function ability in daily life and may progress to overt hepatic encephalopathy. There is a synergistic effect between systemic oxidative stress and ammonia that is implicated in the pathogenesis of hepatic encephalopathy. The aim of this study is to investigate the effectiveness of oral supplementation of antioxidants and zinc gluconate on MHE versus lactulose. Methods: Our study included 58 patients with cirrhosis diagnosed as having MHE by neuropsychometric tests, including number connection test part A (NCT-A), digit symbol test (DST) and block design tests (BDTs). Patients were randomized to receive 175 mg zinc gluconate, 50,000 IU vitamin A, 500 mg vitamin C and 100 mg vitamin E once daily plus lactulose, dose 30–60 ml/day for 3 months [group A (n = 31)] or initiated and maintained on lactulose dose 30–60 ml/day for 3 months [group B (n = 27)]. Neuropsychometric tests and laboratory investigations were repeated after 3 months of therapy. Results: Compared with the baseline neuropsychometric tests, a significant improvement was reported in patients with MHE after 3 months of antioxidant and zinc therapy (group A) versus patients with lactulose therapy (group B) (NCT-A, p <0.001; DST, p = 0.006; BDT, p < 0.001). Antioxidant and zinc supplementation significantly decreased arterial ammonia level, alanine aminotransferase (ALT), aspartate aminotransferase (AST) (p < 0.001) and improved Child–Pugh score in MHE after 3 months of therapy (p= 0.024). Conclusion: Antioxidant and zinc supplementation can improve MHE in patients with liver cirrhosis.

Can combined blood neutrophil to lymphocyte ratio and C-reactive protein be used for diagnosis of spontaneous bacterial peritonitis?

Abstract Background and objective: Spontaneous bacterial peritonitis (SBP) is diagnosed by the presence of ≥250 polymorphonuclear neutrophils (PMN)/mm3 in the ascites and the absence of surgically treatable cause of intra-abdominal infection. Blood neutrophil lymphocytic ratio (NLR) is an inexpensive and simple test for inflammation. C-reactive protein (CRP) is an inflammatory marker used for the diagnosis and follow-up of many diseases and morbidities. We aimed to evaluate the clinical utility of combined blood NLR and CRP as a non-invasive test for SBP diagnosis. Methods: Blood NLR was calculated, and CRP value determined in 180 cirrhotic patients with ascites (126 with and 54 without SBP). Sensitivity and specificity of combined blood NLR and CRP values for SBP diagnosis were estimated by receiver operator characteristic curve. Results: Both blood NLR and CRP values were significantly higher in SBP (p < 0.001). For SBP diagnosis, a blood NLR of >2.89 had a sensitivity 80.3% and specificity 88.9%. CRP >11.3 mg/dL had a sensitivity 88.9% and specificity 92.6%. In logistic regression analysis, combined blood NLR and CRP had a sensitivity 95.1% and specificity 96.3% at the same cut off values. Conclusions: Combined NLR and CRP could be used as a novel, simple, low-cost, non-invasive test for SBP diagnosis.