Relation between non-alcoholic fatty liver disease and epicardial fat in metabolic syndrome

Background: Non-alcoholic fatty liver disease [NAFLD] is becoming recognized as a component of the metabolic syndrome and insulin resistance. There has been recent interest in the association between epicardial fat and atherosclerotic disease with increased risk of cardiovascular mortality and morbidity

Aim of the work: In this study we investigated the relationship between the metabolic syndrome with liver involvement and epicardial fat

Patients and methods: 85 patients who had the criteria of metabolic syndrome are subjected to thorough clinical evaluation. Abdominal circumference, body mass indexand waist/hip ratio were recorded for all patients. Laboratory investigations including urine, complete blood picture, fasting and postprandial blood glucose, uric acid, blood urea and creatinine,C-reactive protein [CRP], lipid profile, liver enzymes and bilirubin were done to all patients. Ultrasonography was used to grade fatty liver and measure the thickness of epicardial fat. Results: Patients with high ALT levels have significantly higher [p<0.01] AST, fasting blood glucose [FBG], uric acid, triglyceride [TG] level, more epicardial fat and waist circumference [p<0.05] compared to those with normal levels. Patients with high grade of fatty liver have significantly higher total cholesterol, TG, FBG, AST, ALT, uric acid levels, more epicardial fat and waist circumference [p<0.01] compared to those with mild and moderate. ALT, FBG and TG are significantly higher in patients with detectable epicardial fat than those without [p<0.01]. There were significant direct correlations between epicardial fat thickness with FBG [r= 0.324; p<0.01], TG [r= 0.217; p<0.05], AST [r= 0.493; p<0.01], ALT [r= 0.561; p<0.01], and grade of fatty liver [r= 0.479; p<0.01]. Also there were significant direct correlations between FBG with waist circumference [r= 0.422; p = 0.01], TG level [r = 0.370; p<0.01], HDL-C [r = 0.284; p<0.05] and grade of fatty liver [r = 0.533; p = 0.01]. There were significant direct correlations between grade of fatty liver with waist circumference [r= 0.264; p<0.05], TG [r= 0.407; p<0.01], uric acid [r= 0.288; p<0.05], and AST levels [r= 0.642 p<0.01]. CRP was found correlated only with liver enzymes [r = 0.481;p<0.05]. Simple logistic regression analysis revealed that epicardial fat thickness [mm] showed a trend in patients with NAFLD and metabolic syndrome

Conclusion: Echocardiographic assessment of epicardial adipose tissue, abdominal ultrasound assessment of NAFLD and transaminase level might serve as a reliable marker of visceral adiposity and more severe degree of metabolic syndrome

Frequent dose of peginterferon alfa 2a evaluation in treatment-naive chronic HCV, genotype 4 Egyptian patients

More frequent dosing with decreasing time intervals between injections of pegylated interferon in the treatment of HCV genotype 4, to our knowledge, was not tested before. The purpose of reducing the intervals between doses particularly in the first 12 weeks is to decrease the peak/trough ratio of the blood concentration of interferon in order to give no chance for the virus to recover. Therefore, the aim of this study is to explore the effect of such frequent dosing in the first 12 weeks as a trial to increase the response rates of our Egyptian patients with HCV genotype 4. This study includes 28 Egyptian patients, discovered to have chronic hepatitis C genotype 4 infection within 1-11 years before enrolling to study. They include 17 males and 11 females with mean age 41.57. Patients with active HCV infection without any vascular or parenchymatous decompensation were given pegasys 180 micro g every 5 days and ribavirin according the weight [800-1400 mg/day] for the first 4 injections. PCR is then done. Those with RVR [negative PCR after 4[th] injection] were treated in usual way with pegasys given every week. Those with detectable HCV RNA continued in the same way as first month for 12 injections. PCR was then repeated. Those showing EVR continued treatment in the usual way. Those with partial or slow EVR [detected HCV but viral load decreased at least 2 logs] continued as first month for 24 injections. Those with non EVR stopped treatment. All other patients continued treatment till 48 injections. Re-evaluation was done at end of treatment and after 6 and 12 months of end of treatment. Rapid virological response with disappearance of HCV RNA after 4 injections of treatment was detected in 14 cases [50%] in whom treatment in usual way continued till the end of 48 weeks. Additional 8 patients [28.6%] showed disappearance of HCV after 12 weeks of treatment to reach total of 22 cases [78.6%] in whom treatment in usual way continued till the end of 48 weeks. Three patients showed 2 log reduction of viral load continue treatment per protocol while 3 patients showed less viral load reduction were withdrawn from treatment. Additional 2 patients showed disappearance of HCV RNA at 24 weeks of treatment to reach a total of 24 patients [85.7%] the patient showing positive RNA stopped treatment. All those patients continuing treatment to 48 weeks remain negative for HCV RNA at end of treatment. Therefore, the ETR is 85.7% using this frequent dose administration of pegylated interferon. Only one patient relapse at week 72 [after 6 months of end of treatment]. Thus, the SVR occurred in 23/28 patient [82.14%]. Dose reduction was done for Ribavirin in 3 cases during treatment due to clinically significant decrease in the hemoglobin levels, all showed SVR. No reduction of interferon dose was commenced. General side effects were as usual and controlled with paracetamol. It is concluded that the use of more frequent peginterferon is associated with the best SVR in genotype 4, and whenever possible this strategy can be used particularly in patients with early disease as indicated by absence of sever hepatic or hematological abnormalities

Pegylated interferon alfa 2a and small dose ribavirin in the treatment of HCV genotype 4 in end-stage renal disease

As hepatitis C virus [HCV] infection is a major health problem in patients with end-stage renal disease [ESRD]. Explore the response rate and adverse effects of pegylated interferon and ribavirin in treating HCV genotype 4 in patients withend stage renal disease [ESRD] waiting renal transplantation. This study included 24 patients with ESRD and active HCV infection as detected by clinical, sonographic, biochemical, serological, virological and histological examination with liver biopsy. All patients were under hemodialysis with HCV antibodies positive > 6 months. Viral genotyping and both qualitative and quantitative PCR were carried out before starting therapy. Treatment was continued for 48 weeks using pegasys 135 micro g weekly and ribavirin 200 mg daily. The biochemical and virological responses were evaluated regularly during and after treatment. The sustained virological response [SVR] being evaluated 24 weeks later. The side effects were monitored throughout the treatment period. Rapid virological response [RVR] after week 4 was achieved in 11/24 [46%] patients. The sustained virological response [SVR] was achieved in 16/24 [66.7%] patients. No break through or relapses were detected during and after treatment respectively. Correlation was found between the viral load before treatment and that at week 4 with p < 0.001and at 12 weekand between the reduction of hemoglobin and the reduction of viral load at week 12 with p < 0.045. Genotype 4 HCV patients with ESRD can be considered for therapy pre-operatively to overcome all the morbidities associated with persistence of HCV after renal transplantation provided that the general condition, the hematological parameters and all other factors of treatment allowed such therapy

Prognostic value of serum pepsinogen isoenzymes in H. pylor eradication and other treatment modalities on the course of congestive gastropathy

Portal hypertensive gastropathy [PRG] is a common finding in patients with liver cirrhosis. Reduced gastric mucosal defense caused by H pylon may account for the pathogenesis of GI lesions in liver cirrhosis. Pepsinogens are secreted by chief cells in the fundus and body, The ratio of pepsinogen isozymes I and II in serum has good correlation with presence of metaplastic atrophic gastritis Most of the studies showed no relationship between H. pylon infection and congestive gastropathy in Fiver cirrhosis. The aim of this work is to estimate the prognostic value of serum levels of pepsinogen isoenzymes I and II and their ratio in addition to investigate the role and the eradication of H. pylon in the treatment of portal hypertensive gastropathy in comparison with other suggested treatments such as Daflon, sucralfait, propranolol and verapamil. Our intimate aim is to find .a simple treatment; if possible, for such common gastro-intestinal disease. This study included 64 cirrhotic patients divided into three groups: Group I: included 21 patients with congestive gastropathy and H. pylon infection and were treated with eradication therapy for H. pylon. Group 11: included 20 patients without H. pylon infection and without history of injection sclerotherapy are treated with sucralfait and Daflon. Group III: 23 patients without H. pylon infection and with history of injection sclerotherapy are treated with propranolol and verapamil. Upper endoscopy and gastric biopsies for histopathology and H. pylon staining before and after treatment were done in all patients in addition to pepsinogen isoenzymes I and II, serology and other routine tests. The three types of therapy showed significant clinical improvement in these patients. Most of these patients are suffering from dyspeptic symptoms in the form of epigastric discomfort and pain after meals, flatulence and distension. This was more marked in patients with H pylon infection. Serum Pepsinogen I levels and PG I/lI ratio were significantly less in group I with H pylon infection than groups II and III [P<0.001]. There is substantial improvement after treatment in all patients that was most marked in patients of group I after eradication of H pylon. Serum Pepsinogen I levels and PG I/Il ratio in group I showed significant increase after eradication of H pylon [P<0.001]. PHG was improved significantly in all groups. Also, there were no differences in the response of PHG in the three groups. Comparison of the response of oesophageal varices to therapy between the three groups found that oesophageal varices improved significantly in group I in comparison to group II. It is concluded from this study that H pylon may aggravate this disease process as estimated by reduction of pepsinogen I level and PG I/lI ratio, and its eradication may be beneficial in patients with liver cirrhosis and portal hypertension, as estimated by normalization of pepsinogen level. Also, other treatment modalities were effective in decreasing the severity of this disease, which means that this disease process may be aggravated by other factors than H pylon

Prevalence of coeliac disease in adult patients with symptoms of irritable bowel syndrome: a pilot study

The aim of this work is to estimate the prevalence and the potential clinical consequences of coeliac disease testing in adult Arab patients with IBS, and estimating the efficacy of IgA and IgG anti-gliadin antibodies, anti endomysial antibodies [EMA] IgA and anti-TG2 [IgA and IgG] on diagnosing celiac disease. As few recent studies have found higher prevalence of coeliac disease among patients diagnosed as irritable bowel syndrome [IBS] than general population [3-11% vs. 0.2-0.6%]. Similar studies showed that coeliac disease is as common in Middle Eastern countries as in Europe; in both the general population and at-risk groups. This is a prospective pilot study including 320 Arab patients with features compatible with IBS as defined by Rome III criteria without any other co-morbidity. The age of patients ranged between18-70 years. All patients were subjected to good history taking, clinical examination, and some investigations if needed such as stool, urine, CBC, liver enzymes, kidney function tests, ECG, electrolytes, H pylori serology, upper and lower endoscopy when indicated. Those diagnosed as having persistent criteria of IBS were tested for coeliac disease by IgA and IgG anti-gliadin antibodies, anti endomysial antibodies [EMA] IgA and anti-TG2 [IgA and IgG]. Upper endoscopy and duodenal biopsies were done and gluten free diet was implemented for only those with positive serological test. The same tests were repeated after period of about 6 months. Anti-gliadin antibodies were found positive in 15/320[4.69%] patients [14 with IgA and 13 IgG], EMA IgA in 13/320 [4.06%], anti-TG2 IgA in 12/320 [3.76%] and anti- TG2 IgG in 13/320 [4.06%]. Abdominal pain, diarrhea, dyspepsia, postprandial distress, epigastric pain, distension and chronic diarrhea were significantly higher and more common in combinations in those with positive serology in comparison to serologically negative patients [P < 0.05]. Haemoglobin level, serum iron, albumin and calcium were found to be significantly lower in those with positive serology in comparison to serologically negative patients [P < 0.05]. All these parameters improved significantly after gluten free died [GFD] for about 6 months [P< 0.05]. Only 11 patients [74.44% of those with positive serology and 3.49% of total patients] were diagnosed by biopsies as compatible with coeliac disease of which, two patients have family history of coeliac disease in first degree relatives. After gluten free died [GFD] for about 6 months, seroconversion to negative tests occurred in 6 patients for AGA-IgA, 4 for AGA- IgG, 3 for EMA IgA, 5 for Anti-TG2 IgA and 5 for Anti-TG2 IgG. Also, the grade of histopathology showed complete healing in 4 patients and improvement to lower grades in 4 patients after GFD. Worsening occurred in one case and still 7 cases showed the same grade of the disease. It is concluded from this study that minimally symptomatic coeliac disease can easily be mistaken for IBS. The presence of many persistent gastrointestinal symptoms in addition to the lower serum levels of some nutritional parameters must alert the physicians to screen for coeliac disease. The efficacy of IgA and IgG anti-gliadin antibodies, anti endomysial antibodies [EMA] IgA and anti-TG2 [IgA and IgG] were nearly the same. So any serological test can be used for the screening, especially EMA TG2 as they are easier and cheap. But this must be confirmed by tissue diagnosis which is the gold standard for diagnosis. Finally, screening for coeliac disease among patients with IBS must be considered to offer better prognosis to those patients simply by gluten free diet