Impact of laparoscopic cholecystectomy on the complexity of endoscopic retrograde cholangiopancreatography.

BACKGROUND AND OBJECTIVES: A scarce number of researches discussed the impact of cholecystectomies on the anatomy of common bile duct (CBD) and intern if this will affect the difficulty of endoscopic retrograde cholangiopancreatography (ERCP). The objective of present study was to assess the impact of complicated cholecystectomy on the complexity and safety of the ERCP procedure. STUDY DESIGN: A total of 100 patients were enrolled after meeting the following inclusion criteria - study group (group A): 50 patients with previous history of complicated laparoscopic cholecystectomy and control group (group B): 50 patients with previous noncomplicated laparoscopic cholecystectomy. ERCP was performed and complexity was judged by a number of cannulation attempts, ERCP time, pancreatic cannulation and post-ERCP pancreatitis. RESULTS: The study revealed prolonged ERCP procedure duration in noncomplicated cholecystectomy (24.2 ± 8.5 min) and it was significantly more prolonged in complicated cholecystectomy (39.6 ± 10.7 min; P = 0.03). The trials of cannulation attempts were significantly higher in the study group with complicated cholecystectomy (P = 0.009). Pancreatic duct cannulation was frequently higher in the complicated cholecystectomy group (P = 0.03). Difficult or failed stone extraction was significantly prevalent in the complicated cholecystectomy group and the occurrence of post-ERCP pancreatitis (PEP) was significantly higher than the control group. CONCLUSION: ERCP after complicated laparoscopic cholecystectomy is more complex with increased duration liability of complications.

Residual hepatitis C virus in peripheral blood mononuclear cell as a risk factor for hepatocellular carcinoma after achieving a sustained virological response: a dogma or fiction.

BACKGROUND: Clinical worsening after achieving a sustained virological response (SVR) needs to be clarified and explained. Persistence of hepatitis C virus (HCV) core antigen interacts with the host proteins to interfere with signaling pathways and increases the susceptibility to hepatic carcinogenesis. OBJECTIVE: This study aimed to investigate the risk factors that increase the progression of liver disease and hepatocellular carcinoma in a subgroup of HCV patients who achieved a SVR. PATIENTS AND METHODS: Eighty-nine HCV patients with hepatic decompensation were selected 8.2 ± 1.8 months after achieving SVR24. HCV core antigen and HCV RNA were detected in peripheral blood mononuclear cells. Matched control (n = 100) and training (n = 200) groups were recruited. RESULTS: Eighty-five patients showed a progression of Child-Turcotte-Pugh and model for end-stage liver disease scores, with positive RNA in peripheral blood mononuclear cell (357.4 ± 42.1 IU/million cell) and positive hepatitis C virus core antigen (n = 73); four patients were excluded. Susceptibility to decompensation and hepatocellular carcinoma after direct-acting antiviral drugs increased with age [odds ratio (OD) = 1.87], and was associated with male sex (OD = 1.65), diabetes (OD = 3.68), thrombocytopenia (OD = 2.44), pretreatment Alfa-fetoprotein (OD = 3.41), and occult HCV (OD = 4.1). CONCLUSION: Clinical deterioration after SVR could be explained by occult HCV mainly in older male patients with diabetes and thrombocytopenia.

Impact of non-selective beta blockers on portal hypertension and hepatic elasticity in hepatitis C virus-related liver cirrhosis.

Portal hypertension and its complications are the leading causes of morbidity and mortality in patients with liver cirrhosis. Noninvasive assessment of liver stiffness had been an effective tool for assessment of fibrosis progression in chronic liver disease. It was intended to assess liver stiffness measurement (LSM), portal vein diameter (PVD), splenic bipolar diameter (SD), and the platelet count/spleen diameter (PC/SD) ratio in patients who test positive for the hepatitis C virus (HCV) and to study the impact of non-selective beta blockers (NSBB) on the grade of esophageal varices (EVs) and liver elasticity. Subjects were 80 patients with Child-Pugh grade A or B compensated cirrhosis who tested positive for HCV. All of the patients underwent a laboratory workup including AFP, HCV antibodies, HCV RNA, HBsAg, LSM according to real-time elastography, upper gastrointestinal endoscopy (UGIE) to detect and grade EVs, calculation of the PC/SD ratio, and measurement of the PVD and SD according to real-time abdominal ultrasonography. All patients were given the maximum tolerated dose of NSBB for three months, and UGIE, LSM, PC/SD, PVD, and SD were subsequently reassessed and reported. LSM and the PC/SD ratio were exceptional noninvasive tools for prediction of significant EVs (grade ≥ II, p < 0.001) with a sensitivity 82.4% and a specificity 82.6% at a cutoff point 18 kPa for LSM, and a sensitivity 94.1% and specificity 69.6% at a cutoff point 880 for the PC/SD ratio. LSM is highly correlated with PVD, the PC/SD ratio, SD, and the Child-Pugh score. NSBB significantly decreased PVD. The percent change in PVD significantly correlated with LSM, the grade of EVs, and SD. Findings indicated that LSM is a noninvasive, rapid, and reproducible tool with which to detect portal hypertension and EVs. NSBB therapy can effectively decrease PVD and may consequently improve the EV grade with no significant impact on LSM in patients with liver cirrhosis.

Sofosbuvir and daclatasvir plus ribavirin treatment improve liver function parameters and clinical outcomes in Egyptian chronic hepatitis C patients.

BACKGROUND AND AIMS: Interferon-free direct-acting antivirals (DAA) combination therapies, including sofosbuvir (SOF) and daclatasvir (DCV) therapy, eradicate chronic hepatitis C virus (HCV) in a high percentage of patients, but its impact on improvements in liver function is unclear. The aim of this study was to investigate the changes in clinical and biochemical parameters reflecting liver function and general status in those who achieved HCV eradication by DAA. PATIENTS AND METHODS: From March 2016 to October 2016, 374 chronic hepatitis C patients were enrolled for this prospective, observational study and received SOF, DCV with ribavirin, to evaluate the changes in liver function parameters, international normalized ratio, complete blood count, model for end-stage liver disease, and Child-Turcotte-Pugh scores after achieving a sustained virological response 12 weeks after treatment. RESULTS: In those who achieved HCV clearance, liver function parameters, serum albumin, bilirubin, platelet count, and international normalized ratio improved significantly in the majority of patients; the reduction in the model for end-stage liver disease score was (-2.36, SE 0.15, P<0.001). 44% of the patients showed an improved Child-Turcotte-Pugh score, 51% showed no change, and only 5% showed deterioration. CONCLUSION: Successful HCV eradication by DAAs including SOF, DCV with ribavirin therapy improved liver function parameters and clinical outcomes in chronic hepatitis C patients.

Management of different types of gastric varices with band ligation: a 3-year experience.

BACKGROUND AND AIM: Gastric varices (GVs) occur with an incidence of 20% in patients with portal hypertension. The aim of this study was to evaluate the efficacy of endoscopic band ligation (BL) as an option in the management of small-to-moderate nonbleeding GVs in cirrhotic patients. PATIENTS AND METHODS: A total of 50 patients (GOV2; n=6, IGV1; n=34, IGV2; n=10) with nonbleeding small-to-moderate-sized GVs without local risk signs of bleeding, such as large size, red-colored elevated areas or red wales, and systemic factors of bleeding risk such as an international normalized ratio of at least 2 and a platelet count of 80 000/µl or less were subjected to endoscopic BL. The patients were followed up every 2 weeks for 1 month and then every 1.5 months for 6 months. The primary outcome was GV eradication, detection of complications such as postprocedural bleeding ulceration and mortality. RESULTS: The mean number of BL sessions was 2.2±0.8; post-BL ulceration occurred in two (4%) patients (n=2 in IGV1, P=0.61), bleeding occurred in one (2%) patient (n=1 in IGV1, P=0.79), and epigastric pain occurred in six (12%, n=4 in GOV2, n=2 in IGV1) patients. There was no mortality reported among patients treated with BL. CONCLUSION: Endoscopic BL resulted in better outcome and a lower incidence of complications when used to treat small-to-medium-sized nonbleeding GVs. Further, early eradication can save effort and cost, thus avoiding the future risk of treatment of large or risky GVs with sclerotherapy.

Rifaximin and midodrine improve clinical outcome in refractory ascites including renal function, weight loss, and short-term survival.

BACKGROUNDS AND AIMS: The occurrence of refractory ascites in nearly 17% of patients with decompensated cirrhosis is an unresolved issue. Advanced liver disease, functional renal impairment, and vascular insensitivity to vasopressors are the main causes of its refractoriness. Therefore, the aim of this study was to evaluate the impact on diuresis, weight loss, and short-term survival if midodrine and rifaximin were added to the diuretic therapy (DT). MATERIALS AND METHODS: The study evaluated the eligibility of 650 patients with cirrhosis and refractory ascites who were selected during the period from November 2011 to May 2015. A total of 50 patients were excluded and finally 600 were selected and divided into the following groups: patients exposed to DT (n=200) as a control group, or DT with midodrine and rifaximin group (n=400). Body weight, mean arterial pressure, and glomerular filtration rate were determined. Plasma renin and aldosterone were also determined. Follow-up was performed after 2, 6, and 12 weeks, and then every 2 months for 24 months. RESULTS: The mean arterial pressure was significantly higher in the midodrine and rifaximin group (P=0.000), and there was a highly significant weight loss after 12 weeks (12.5 kg) (P=0.000), a highly significant increase in serum sodium, urine output, and urinary sodium excretion (P=0.000), and creatinine clearance was more reduced in the control group. With rifaximin and midodrine, a complete response occurred in 310 (78%) patients, a partial response in 72 (18%), and no response in 18 (4%) versus 30 (15%), 110 (55%), and 60 (30%) in the control group, respectively (P=0.000). Midodrine and rifaximin significantly reduced paracentesis needs when compared with the controls (18 study patients vs. 75 DT-only patients, P=0.000). CONCLUSION: Adding rifaximin and midodrine to DT enhanced diuresis in refractory ascites with improved systemic, renal hemodynamics and short-term survival.

The role of ascitic fluid viscosity in differentiating the nature of ascites and in the prediction of renal impairment and duration of ICU stay.

BACKGROUND AND AIM: Serum-ascites albumin gradient (SAAG) has been used in the classification of ascites for the last 20 years but it has some drawbacks. This study searches for possible correlations between ascitic fluid viscosity and the etiology of ascites, renal impairment, and length of ICU stay. MATERIALS AND METHODS: The study was conducted in Zagazig University Hospital, Egypt. It included 240 patients with ascites due to various causes. The patients were divided into two groups: the cirrhotic ascites group, which included 120 patients, and the noncirrhotic ascites group, which included 120 patients. Ascitic patients on medical management with diuretics, antibiotics, paracentesis, and infusion of plasma or albumin were excluded.The laboratory analysis included routine investigations to detect the cause of ascites as well as specific investigations such as ascitic fluid viscosity using a falling ball viscosimeter (microviscosimeter) at 37°C. RESULTS: The mean ascitic viscosity of patients with SAAG at least 1.1 was 1.16±0.56, which was associated with serum creatinine 1.35±0.52 mg/dl and ICU stay of 3.3±1.2 days. In patients with SAAG less than 1.1 g/dl, the mean ascitic viscosity was 2.98±0.87, with serum creatinine 2.1±0.56 mg/dl and ICU stay of 7.1±1.3 days. Ascitic viscosity can discriminate ascites due to portal hypertension from those associated with nonportal hypertension at a cut-off value of 1.65; it can predict renal impairment in hepatic patients at a cut-off of 1.35 and long ICU stay at a cut-off of 1.995 using receiver operating characteristic analysis. CONCLUSION: Ascitic viscosity measurement is rapid, inexpensive, and requires small sample volumes. Ascitic viscosity can discriminate ascites due to portal hypertension from those associated with nonportal hypertension at a cut-off value of 1.65. It can predict renal impairment in hepatic patients at a cut-off of 1.35 and long ICU stay at a cut-off of 1.995.

Association of thrombogenic genes polymorphisms with hepatocellular carcinoma in HCV Egyptian patients.

The rate of development of fibrosis varies among HCV patients and affected by many variables. We aimed to investigate the association between mutations in Factor V, prothrombin gene and thrombospondin 1 polymorphisms with hepatic fibrosis progression rate and development of HCC in patients infected with HCV and if they are potential markers for early prediction of disease progression. A total of 280 HCV-infected patients (70 with mild fibrosis, 70 with advanced fibrosis, 70 cirrhotic patients and 70 HCC patients) and 100 healthy controls were included. Factor V Leiden G1691A, prothrombin G20210A and thrombospondin 1 mutations were analyzed by restriction fragment length polymorphism. We observed that there were no significant differences between Factor V Leiden (G1691A) or TPS-1 (A2210G) polymorphisms in the four patient subgroups and control group. In HCC patients, the frequencies of GA genotype were significantly increased compared with control subject. HCV patients carrying GA genotype were more likely to develop hepatocellular carcinoma (OR=5.4, 95% CI=1.09-27.05; P=0.026).We concluded that the risk of HCC was increased 5-fold in subjects carrying GA genotype of prothrombin G20210A gene. However, there was no evidence for a significant association between thrombogenic genes polymorphisms and progression of fibrosis in HCV Egyptian patients.