Wesam A. Ibrahim

Role of Autologous Bone Marrow Stem Cell Transplantation in the Treatment of Active Ulcerative Colitis

Background: Stem cell therapy was suggested to improve the quality of life to patients of UC through its powerful immunomodulatory effects and its ability to stimulate regeneration of intestinal mucosa. Aim of the work: To evaluate autologous bone marrow stem cells transplantation as a treatment option for cases of active ulcerative colitis in comparison with the conventional treatment, and to evaluate its safety and feasibility. Patients and methods: 10 patients of active ulcerative colitis were intravenously injected with autologous bone marrow mononuclear layer containing stem cell and continued on their conventional treatment. Clinical, laboratory and endoscopic assessment of disease severity were done before and after 3 months after SCT. Results: There was statistically significant improvement in the number of diarrheal motions, heart rate, ESR, CRP, disease extent and severity after SCT with p value0.026, 0.009, 0.006, 0.012, 0.038 respectively with no recorded side effects or complications. Conclusion: Bone marrow stem Cell transplantation for patients of ulcerative colitis is a safe and feasible procedure. It can improve the quality of life of the patients as well as the disease activity assessed by clinical assessment, laboratory tests, endoscopic extent and severity.

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.

N-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and hypertonic glucose with 72% chromated glycerin in gastric varices.

AIM To compare n-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and a mixture of 72% chromated glycerin with hypertonic glucose solution in management of gastric varices. METHODS Ninety patients with gastric varices presented to Endoscopy Unit of Ain Shams University Hospital were included. They were randomly allocated into three groups; each group included 30 patients treated with intravariceal sclerosant injections in biweekly sessions till complete obturation of gastric varices; Group I (n-butyl-2-cyanoacrylate; Histoacryl(®)), Group II (iso-amyl-2-cyanoacrylate; Amcrylate(®)) and Group III (mixture of 72% chromated glycerin; Scleremo(®) with glucose solution 25%). All the procedures were performed electively without active bleeding. Recruited patients were followed up for 3 mo. RESULTS 26% of Scleremo group had bleeding during puncture vs 3.3% in each of the other two groups with significant difference, (P < 0.05). None of Scleremo group had needle obstruction vs 13.3% in each of the other two groups with no significant difference, (P > 0.05). Rebleeding occurred in 13.3% of Histoacryl and Amcrylate groups vs 0% in Scleremo group with no significant difference. The in hospital mortality was 6.6% in both Histoacryl and Amcrylate groups, while it was 0% in Scleremo group with no significant difference. In the first and second sessions, the amount of Scleremo needed for obturation was significantly high, while the amount of Histoacryl was significantly low. Scleremo was the less costly of the two treatments. CONCLUSION All used sclerosant substances showed efficacy and success in management of gastric varices with no significant differences except in total amount, cost and bleeding during puncture.

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.

Comparison between accuracy of different scoring systems in prediction of liver cirrhosis-related complications

Background Many scoring systems have been widely applied in recent years for assessing and predicting the mortality across a broad spectrum of liver diseases. The two most commonly used prognostic models are the Child–Turcotte–Pugh score and the more recently described the model of end-stage liver disease (MELD) score and its derivatives. Aim of the work The main objective of this work was to evaluate and compare the accuracy of the Child–Pugh score, the MELD score, and the new scores, MELD-Na, the integrated MELD (iMELD), and the MELD-to-sodium (MESO) index in the prediction of liver cirrhosis complications. Patients and methods This study was conducted on 60 patients with chronic liver disease. They were divided into two groups: group &Igr; consisted of 17 (28.3%) patients with uncomplicated liver cirrhosis. They were 10 (58.8%) male and seven (41.1%) female patients. Their mean age was 58.7±10.7 years. Group &Igr;&Igr; consisted of 43 (71.7%) patients with liver cirrhosis-related complications. They were 37 (86%) male and six (13.9%) female patients. Their mean age was 55.1±6.38 years. All were recruited from the Internal Medicine and Hepatology Department in Ain Shams University Hospitals. They were subjected to full medical history, clinical examination, lab investigations, upper gastrointestinal endoscopy, and imaging studies to assess the state of the liver disease and its complications. The MELD, its derivatives, and the Child–Turcotte–Pugh score were calculated for assessing their prognostic accuracy in relation to complications of chronic liver disease. Results In this study, the most common complication was portal hypertension (70%), which is the leading cause for ascites and hematemesis due to esophageal varices. In this study, there was a highly significant statistical difference between group &Igr; and group &Igr;&Igr; regarding albumin and International normalization ratio and a significant statistical difference between group &Igr; and group &Igr;&Igr; regarding total bilirubin, platelets, and the sodium level (Na). In this study, there was also a highly significant statistical difference between group &Igr; and group &Igr;&Igr; regarding Child, MELD, MELD-Na, MESO index, and iMELD scores. Regarding the comparison between Child, MELD, MELD-Na, MESO index, and iMELD scores as predictors for liver cirrhosis complications, our study showed that the Child–Pugh score was the most sensitive score with the highest predictive accuracy. The Child score at a cutoff greater than 7.5 has a sensitivity of 97.7%, a specificity of 70.6%, and an accuracy of 0.95 in predicting the occurrence of complications. MELD at a cutoff greater than 12.5 has a sensitivity of 93%, a specificity of 70.6%, and an accuracy of 0.913 in predicting the occurrence of complications. MELD-Na at a cutoff greater than 16 has a sensitivity of 90.7%, a specificity of 70.6%, and an accuracy of 0.867 in predicting the occurrence of complications. The MESO index at a cutoff greater than 0.95 has a sensitivity of 90.7%, a specificity of 70.6%, and an accuracy of 0.919 in predicting the occurrence of complications. iMELD at a cutoff greater than 30.6 has a sensitivity of 95.3%, a specificity of 41.2%, and an accuracy of 0.841 in predicting the occurrence of complications. For the detection of the most common complication, that is, esophageal varices, the MELD score was found to be the most specific, with a specificity of 100% and a sensitivity of 43% and the cutoff point greater than 18. This was followed by the MESO index, with a specificity of 100% and a sensitivity of 39.2% and the cutoff point greater than 1.4, whereas other scores could not be significantly related to the prediction of such complications. Conclusion This study concluded the superiority of the Child score over MELD, MELD-Na, MESO index, and iMELD scores in the prediction of liver cirrhosis-related complications, whereas the MELD score and the MESO index were the best for predicting the occurrence of esophageal varices.