Spontaneous bacterial empyema in cirrhotic patients: complements 3 and 4, opsonic power and C-reactive protein as pathogenic mechanisms and diagnostic tools

Hepatic hydrothorax occurs in approximately 5-12% of patients with cirrhosis and portal hypertension and may be complicated by spontaneous bacterial empyema [SBE]. Pathogenic mechanisms of SBE still need to be investigated. The present work assesses the role of complement components [C3, C4], opsonizing power and C-reactive protein in the pathogenesis of SBE in cirrhotic patients. Twenty five cirrhotic patients with hepatic hydrothorax were randomly selected and 10 patients with hydrothorax secondary to heart failure were included as controls in the study. Pleural fluid [PF] and serum samples were analyzed for: total protein [TP], albumin, lactic dehydrogenase [LDH], glucose, polymorph nuclear leukocytic count [PMNL], complement components [C3, C4], opsonic activity [on the basis of log-kill] and high sensitive C-reactive protein [CRP]. SBE was diagnosed when pleural fluid PMNL was > 250 cells/mm[3] with a positive culture or >500 cells/ mm[3] with a negative culture after exclusion of pulmonary infections. Thirteen patients [52%] [Group I] were diagnosed as SBE and 12 patients [48%] had no SBE [Group II]. There was no significant difference between patients and controls [GIII] as regards age, gender, serum proteins, serum C3, serum WBC and effusion CRP. Levels of serum albumin, total pleural effusion proteins, PT% and opsonic activity of groups I and II were significantly lower than in GIII with no significant difference between groups I and II. Levels of serum bilirubin and C4 of groups I and II were significantly higher than group III with no significant difference between groups I and II. Level of pleural effusion C3 in group I was significantly lower than in groups II and III and level of C3 in group II was significantly lower than in group III. Level of pleural effusion C4 in group I was significantly lower than group III, but there was no significant difference between groups I and II. In hepatic patients, 7 patients [28%] belonged to Child's class B and 18 [72%] to class C. Spontaneous bacterial empyema was detected in 56% of hepatic patients with Child's class C and in 43% of Child's class B. There was no significant difference between hepatic patients with and without SBE with regard to Child-Pugh's score. In patients with SBE, levels of C3 and C4 were significantly less in pleural fluid than in serum but there was no significant difference with regard to opsonic activity. Local complement defects [especially C3] and opsonic activity in cirrhotic patients predispose to SBE. Serum CRP increases, but effusion CRP level should be reassessed as a cheap diagnostic tool

Significance of vascular endothelial growth factor in chronic liver disease and hepatoceliular carcinoma

Vascular endothelial growth factor [VEGF] is the most potent directly acting angiogenic growth factor that plays an important role in inducing tumor-associated angiogenesis. The aim of this study was to evaluate the clinical significance of the circulating VEGF in hepatocelluar carcinoma [HCC] and chronic liver disease [CLD]. The study included 13 with chronic viral hepatitis [CVH], 14 with liver cirrhosis [LC] and 13 with HCC, in addition to 15 age and gender- matched healthy subjects as controls. For each studied subject, detection of hepatitis viral markers, and assessment of liver function tests, alpha-fetoprotein [AFP] and VEGF were performed. Results of the study showed a highly significant [p < 0.001] increase of VEGF in sera of HCC patients as compared to other groups. VEGF serum level was significantly [p < 0.01] associated with portal vein thrombosis, however, it was not significantly associated with tumor size. There was no significant difference between the serum level of VEGF among either LC or CVH group compared to the controls. Moreover, no significant difference was detected between different Child-Pugh classes among LC patients. Furthermore, no correlation was found between serum level of VEGF and AFP, serum albumin, aminotransferases or prothrombin time among the studied groups. In conclusion, serum VEGF can be used as a tumor marker for diagnosis of HCC and as a prognostic marker for tumor invasion

Helicobacter pylori in diabetes mellitus: value of different diagnostic methods

Helicobacter pylori is one of the most common chronic bacterial infections in diabetic patients due to alteration of glucose metabolism, abnormal emptying of the stomach and autonomic neuropathy. So, this study was done to determine H. pylori infection in diabetes, to evaluate the different diagnostic methods of its infection and to estimate the efficacy of he current antimicrobial therapy to eradicate H. pylori. The study involved 40 patients with diabetes mellitus [12 with type 1 and 28 with type 2], and 20 non-diabetic patients as control group. Their sera were used for the assay of H. pylori specific lgG and IgA by enzyme immunoassay [EIA]. Biopsy specimens were tested by rapid urease test [RUT], stained by Gram's stain and cultured to isolate H. pylori. Antimicrobial susceptibility testing was performed using Epsilometer test [E-test]. Results showed that there was a significant increase in the incidence of H. pylori in diabetic patients, 77.5% by RUT, 75% by culture, 70% by lgG, 50% by IgA and 20% by direct smear. There was a significant association between age and smoking and the presence of IgG and IgA. The specificity of the direct smear and IgA was 100%, the sensitivity of RUT was 100%, positive predictive value [PPV] of direct smear and IgA was 100%, negative predictive value [NPV] of RUT was 100%. H. pylori was highly sensitive to tetracycline [93.3%] and amoxicillin [73.3%] and relatively resistant to metronidazol [70%]. We concluded that H. pylon infection is more common among diabetic patients. Culture is the method of choice in diagnosis of H. pylori as it allows testing for antimicrobial therapy. EIA for anti-H. pylori lgG could be of value in screening population and in excluding H. pylori negative infections. Anti-microbial sensitivity must be performed for better eradication of H. pylori in diabetic patients

Alternative to ovarian electrocauterization in the treatment of women with the polycystic ovary syndrome

To compare the efficacy of laparoscopic ovarian needle puncture versus laparoscopic ovarian electrocauterization in the treatment of the polycystic ovary syndrome and to assess the degree of postoperative adhesion formation after each procedure. Patients and methods: Forty women with anovulatory infertility due to polycystic ovary syndrome were enrolled in the study and were equally divided into 2 groups. Laparoscopic ovarian electrocauterization was performed for women in group I while laparoscopic ovarian needle puncture was performed for patients enrolled in group II. Blood samples were drawn before and 1 month after the laparoscopic procedures in both groups to determine levels of lutenizing hormone [LH], follicle stimulating hormone [FSH], LH/FSH ratio, testosterone, androstendione and insulin-like growth factor binding protein- 1. Doppler resistance index of the ovarian stromal vasculature was measured before surgery in both groups at days 11,13,15 and 17 of the menstrual cycle. All women enrolled in the study were followed up for a period of 1 2 months for regularity of the menstrual cycle, occurrence of ovulation and pregnancy. The hormonal profile and the Doppler resistance index of the ovarian stromal vasculature were reassesed 1 month after surgery at the same period of the menstrual cycle. There was no significant differences in the clinical characteristics of women enrolled in both groups. There was a highly significant postoperative improvement in cycle regularity, occurrence of ovulation and conception in both groups [p < 0.001]. There were a highly significant decrease in LH, LH/FSH, testosterone and androstendione levels after surgery in both groups [p< 0.0001]. FSH level increased significantly in both groups after surgery but the IGFBP showed a non significant increase [p > 0.05] in both groups. A significant rise in the Doppler resistance index of ovarian artery was noted at days 13, 15 and 17 of the cycle after both procedures. Second look laparoscopy for cases that did not get pregnant by the end of the 12 months follow up revealed a significant increase in the incidence of postoperative adhesion formation in group 1 compared to group II [p < 0.001]. laparoscopic ovarian needle puncture is an effective alternative to ovarian electrocauterization in the treatment of the polycystic ovary syndrome. In addition laparoscopic ovarian needle puncture results in statistically lower incidence of postoperative pelvic adhesions