Entecavir 1 mg versus combined lamivudine/adefovir dipivoxil in chronic HBV Egyptian patients resistant to LAM monotherapy, non-randomised controlled study

The development of antiviral-resistant mutations with long-term treatment remains a major concern in the treatment of chronic hepatitis B virus [HBV] infection. The study aimed to compare the therapeutic efficacy of entecavir 1 mg versus combined lamivudine/adefovir dipivoxil [Lam/Adv] in chronic HBV patients resistant to lamivudine monotherapy. This study included two groups of lamivudine-resistant patients who received lamivudine 100 mg for 1-3 years. Group 1 was composed of 25 cases [52% HBeAg+ve] who received combined Lam/Adv, and group 2 was composed of 13 patients [30.8% HBeAg+ve] who received entecavir 1 mg. Pre-enrolment assessment included biochemical, serological and quantitative HBV-DNA testing as well as HBeAg and hepatitis B envelope antibody [HBeAb] assessment. Evaluation was done at 3, 6, 12, 24 and 36 months of treatment by the same parameters. Hepatitis B surface antigen and antibody [HbsAg and HBsAb] were assessed after each year of treatment. At the end of 36 months of treatment, 16 cases [69%] in group 1 completed the study period, versus 13 [100%] in group 2. Two cases in group 1 underwent HBeAg seroconversion, accompanied by HBV-DNA undetectability, at 6 and 12 months, respectively; no cases were seroconverted in group 2. Both treatments achieved improvement in alanine aminotransferase [ALT], bilirubin and alpha-foetoprotein equally at the end of the study. HBV-DNA undetectability was better achieved in group 2 when compared to group 1. HBeAg seroconversion was only achieved in two cases in group 1, whereas no cases lost HBeAg in group 2. None of our cases achieved HbsAg seroconversion or loss at the end of the study period. The entecavir I-mg monotherapy group achieved better HBV-DNA undetectability starting at 3 months of treatment when compared to the Lam/Adv group; however, both lines of treatment showed almost similar results over the rest of the study period. HBeAg seroconversion was only achieved in two cases in the combined Lam/Adv group, whereas no cases lost HBeAg in the other group

Erectile dysfunction in patients with chronic hepatitis C virus infection

Hepatitis C virus [HCV] infection is a major public health problem worldwide and in Egypt. Several studies have suggested that chronic HCV infection may be associated with erectile dysfunction [ED] in men. The aim of our study was to detect the prevalence of ED among male patients with chronic HCV infection. The study included 150 male patients with chronic HCV infection [124 patients with chronic hepatitis and 26 patients with HCV-associated liver cirrhosis]. The Child-Pugh score was used to assess the severity of cirrhosis. An Arabic validated version of the five-item International Index of Erectile Function [IIEF-5] was used to detect the presence and severity of ED. The patients' age ranged from 20 to 80 years with mean age +/- standard deviation [SD; 50 +/- 17.19] years. The prevalence of ED among patients with chronic HCV infection was found to be 29.3%. The prevalence was significantly higher in cirrhotic as compared to chronic hepatitis patients [p < 0.001] and the average ED score was significantly lower in patients with liver cirrhosis than in those with chronic hepatitis. There was a highly significant relation between the severity of ED and the severity of liver disease. There was a significant negative correlation between serum bilirubin and ED score and a significant positive correlation between serum albumin and ED score in patients with liver cirrhosis. About 30% of patients with chronic HCV infection were found to have ED: so, given the high prevalence of HCV infection in Egypt, chronic HCV infection may be considered in the differential diagnosis of ED. There was a highly significant relation between the severity of ED and the severity of liver disease and the majority of patients with liver cirrhosis proved to be suffering from ED, which may be related to the associated hypoalbuminaemia

Response and seroconversion rates among HBeAg-positive chronic HBV Egyptian patients treated with peginterferon alpha 2a [Pegasys], a single-centre experience

We aimed to evaluate the therapeutic efficacy of pegylated interferon alpha- 2a 180 micro g as a treatment for hepatitis B 'e' antigen [HBeAg]-positive genotype D chronic hepatitis B patients. Thirty patients attending the outpatient clinic at the National Hepatology and Tropical Medicine Research Institute were treated with peg.interferon alpha-2a [180 micro g] weekly for a period of 48 weeks. Pre-enrolment assessment was performed through biochemical, serological and quantitative HBV DNA testing. Liver biopsy was performed in all patients. Evaluation was done at weeks 12, 24 and 48 of treatment by liver enzymes, complete blood count [CBC], HBeAg /HBeAb and quantitative HBV DNA testing. At the end of 48 weeks of treatment only three cases [10%] of the study population showed HBeAg seroconversion and an undetectable HBV DNA level. None of responders exhibited hepatitis B surface antigen [HbsAg] loss. There were five [16.7%] primary non-responders, four [13.3%] relapses, four [13.3%] cases flared at week 12, and 14 [46.6%] cases who were non-responders. No specific predictors of response could be identified among patients. One year of peg. interferon alpha-2a 180 microgm weekly led to HBeAg seroconversion and an undetectable HBV DNA level in 10% of cases. Considering the privilege of a finite duration of treatment, tailoring of treatment and proper patient selection is of great importance in considering this therapy as a first line of treatment among HBeAg-positive chronic HBV Egyptian patients

Fibroscan of chronic HCV patients coinfected with schistosomiasis

Both hepatitis C virus [HCV] and schistosomiasis are highly endemic in Egypt and coinfection is frequently encountered. Such coinfection is responsible for leading to a more severe liver disease. Hence, the aim of the study was to assess the fibroscan in chronic HCV patients coinfected with Schistosoma. This study included 231 chronic HCV patients. Routine pre-treatment work-up was done including anti-schistosomal antibodies. Liver stiffness measurements using fibroscan and reference needle-liver biopsy were done. Patients were categorised into two groups: HCV patients with positive schistosomal serology and HCV patients with negative schistosomal serology. Anti-schistosomal antibody was positive in 29% of the studied population. Positive schistosomal serology status was significantly associated with the disagreement between the results of liver biopsy [Metavir] and the fibroscan results [p value = 0.02], which was more obvious in F2 and F3 fibrosis stages. The sensitivity of fibroscan for the detection of the F2 stage decreased from 64% among negative schistosomal serology patients to 30.8% among positive schistosomal serology patients, and for the F3 stage it decreased from 43.8% to 21.4%, respectively. Multivariate logistic regression showed that fibrosis stages [FO-F1 and F4] were the most independent factors that were associated with the agreement between fibroscan and liver biopsy [odds ratio [OR] 3.4, 7.12 and p value <0.001, <0.001, respectively]. Although the sensitivity of fibroscan for the detection of fibrosis stages [F2 and F3] was impaired in patients with positive schistosomal serology, fibrosis stages [FO-F1 and F4] were the most independent factors associated with the agreement between fibroscan and liver biopsy

Quality of life of Egyptian donors after living-related liver transplantation

Quality of life after liver donation must remain a primary outcome measure when we consider the utility of living donor liver transplants. In making clinical decisions on the use of transplantation for chronic liver diseases, consideration should be given to the key factors likely to affect subsequent health related quality of life. It would be beneficial for donors, if factors predicting good quality of life are identified. The aim of this study was to assess the health related quality of life changes experienced by donors following living related liver transplantation using the Short Form 36 [SF-36] questionnaire. Between August 2001 and December 2006, 125 adults received liver grafts from living donors at Dar Al-Fouad Hospital, Cairo, Egypt. The SF-36v2 questionnaire was applied to 30 donors after at least 6 months following donation and maximally 4 years after donation [mean +/- SD:3.28 +/- 1.56 years]. Furthermore, 30 healthy volunteers were taken as a control group. None of the donors required re-surgery and no deaths were reported. Only 4 [13.3%] donors experienced minor complications, which did not affect their quality of life and had no long term effects. No significant difference was found between donors and control group when means of the Physical and Mental Component Summary were compared. The physical functioning domain was the only domain of health which showed a statistically significant difference between both groups. Health related quality of life of donors was not compromised after full recovery. All donors had good recovery and returned to regular activities within 2-4 months post donation

Histopathological features of chronic hepatitis C in Egyptian patients

Chronic liver disease including that caused by the hepatitis C virus progresses in stages. It can range from inflammation, to fibrosis to end stage liver disease or liver cancer. This work aimed to study the histopathological features of chronic hepatitis C infected Egyptian patients followed-up at National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt. The study included 4267 liver biopsies from patients with serological and virological diagnosis of chronic HCV with no other identifiable cause for liver disease, signs of hepatic decomposition, or other significant non-hepatic disease. All biopsies were fixed in formalin, embedded in paraffin, and sectioned by microtome with a thickness of 5 micro m. Routine specimen processing involved staining slides with hematoxylin and eosin [5 levels] and Masson's trichrome stain [5 levels], for a total of 10 levels per specimen. All levels were screened by two pathologists to ensure the histological abnormalities. Ishak scoring system was applied for assessment of fibrosis and necroinflammatory injury. The percentage of hepatocytes involved by fatty changes was used to score the grade of steatosis. The relations between the histopathological findings, age and sex of the patients were carried out. The studied group [n = 4267] involved 3268 males and 999 female, with age ranging from 21 to 60 years and a mean of 41.7 +/- 9.7 years. Necroinflammatory activity of the virus was minimal in 17.88%, mild in 56.41%, moderate in 22.24% and severe in 3.47%. No fibrous tissue deposition was seen in 21 patients [0.49%], 27.32% of the patients had portal and periportal fibrous expansion, 27.91% had fibrous extensions with occasional thin fibrous tissue bridge, 36.28% had frequent broad fibrous tissue septa, while 7.99% of the studied group of patients had cirrhosis. Steatosis was absent in 52.45% of cases, mild in 39.75%, moderate in 7.19% and severe in 0.61% of patients. Non-specific granulomatous reaction was detected in 11 liver biopsies [9 males and 2 females]. Fibrosis and necroinflammation were more frequent in older patients. No significant difference between males and females regarding fibrosis, but females were more exposed to higher grades of necroinflammation [p < 0.001]. Chronic hepatitis C infection is a common and serious health problem that progresses to fibrosis, cirrhosis, liver failure and hepatocelluar carcinoma. Portal lymphoid infiltrate and minor hepatocellular necrosis were present in almost all cases. Necroinflammatory activity was mild in nearly half of the cases. Steatosis was detected in 47.55% of the patients. Fibrosis and necroinflammation were more frequent in older patients. Non-specific granulomas were rarely encountered in association with hepatitis C

Endoscopic retrograde cholangiopancreatography in infants and children with cholestasis

Reports of ERCP in children are still limited. We present an experience with ERCP in 50 consecutive patients of the pediatric group. Children with obstructive jaundice indicated for ERCP are included in this study. ERCP was performed using the Olympus XPJ 230 in children older than one year, whereas in children less than one year old an Olympus PJF fiber duodenoscope was used. ERCP was able to diagnose 17 patients [34%] with choledochal cysts. Nine [18%] cases with choledocholithiasis either associated with hemolytic anemia or not were diagnosed and treated by ERCP [ES and stone extraction]. Fourteen cases with suspicion of EHBA were examined by ERCP and EHBA was diagnosed in 5 main out of 6 patients. In eight patients ERCP examination revealing normal biliary ductal system was very helpful and exploratory laparotomy to exclude EHBA was avoided. Two cases with parasitic worms obstructing the CBD were diagnosed by ERCP and treated also by ES and worm extraction by basket. Three cases of Caroli's disease [intrahepatic biliary radicles dilatation] were also diagnosed by ERCP and drainage of the IHBR also achieved by ES and internal biliary prosthesis placement in two of these patients. One case with sclerosing cholangitis was confirmed by ERCP. Biliary obstruction by thick inspissated bile was diagnosed and treated by ERCP in one case. Two postoperative obstruction of biliary system one case an old blocked stent was removed. The other case was diagnosed with ligated CBD and was sent back for revision of surgery. One case with congenital hepatic fibrosis and dilated IHBR on ultrasound was examined by ERCP which showed no IHBR dilatation and therefore excluding associated Caroli's disease. Only two cases with mild post ERCP, cholangitis and pancreatitis. ERCP is an important diagnostic modality in infants and children with cholestasis offering valuable detailed information on the biliary and pancreatic ductal system and it has the advantage over MRCP and CT in offering diagnostic as well as therapeutic capabilities, with very minimal complications

Acute upper gastrointestinal bleeding in Kasr El-Aini gastrointestinal endoscopy unit, Cairo, Egypt from the years 1991 to 2000

Acute upper gastrointestinal bleeding [UGIB] is a common and potentially serious problem in Egypt and worldwide. It remains a common cause for hospital admission with constant mortality despite advances in therapy and patient care. Endoscopy is the primary tool for diagnosis of UGIB. The present study aimed at investigating the etiology of UGIB in Egypt and whether any change has occurred in the period from 1991 to 2000. Files of patients undergoing upper GI endoscopy in one of the largest endoscopy units in Egypt [Kasr-El-Aini hospital, Cairo University, Cairo] during this period have been reviewed and analyzed. From 11567 patients who underwent upper GI endoscopy, 1763 [15.2%] had active or recent UGIB, mostly in the form of hematemesis and melena. Most of these patients were males [64.5%] with no age predilection. The commonest finding in bleeding cases was esophagogastric varices [53.3%]. The risk of bleeding increased with the grade of varices and was highest [odds ratio= 11] in the presence of gastric extension of varices. Varices was the commonest finding in all age groups in both males and females although significantly commoner in males [60% vs. 41 %]. Erosive and non-erosive gastritis were the second common finding followed by duodenal ulcer and esophageal erosions [15.8%, 21.1 %, 13.6% and 11.1 %, respectively]. Esophageal varices were associated with one or more other lesions in 31 % of cases and were the only finding in 650 cases with UGIB. Compared to cases presenting with hematemesis, patients with melena alone [n = 195] had significantly lower prevalence of varices and higher prevalence of gastritis and duodenal ulcer. Analysis of findings in 1991 and 2000 revealed a similar pattern of endoscopic findings in cases with UGIB indicating that no significant change has occurred in the underlying medical diseases predisposing to UGIB. Results were discussed in comparison with previous Egyptian and foreign studies