A Simple Scoring Model Predicting the Outcome of COVID-19 Patients: Tanta COVID Score.

BACKGROUND: COVID-19 is a worldwide pandemic with high rates of morbidity and mortality, and an uncertain prognosis leading to an increased risk of infection in health providers and limited hospital care capacities. In this study, we have proposed a predictive, interpretable prognosis scoring system with the use of readily obtained clinical, radiological and laboratory characteristics to accurately predict worsening of the condition and overall survival of patients with COVID-19. METHODS: This is a single-center, observational, prospective, cohort study. A total of 347 patients infected with COVID-19 presenting to the Tanta University Hospital, Egypt, were enrolled in the study, and clinical, radiological and laboratory data were analyzed. Top-ranked variables were identified and selected to be integrated into a Cox regression model, building the scoring system for accurate prediction of the prognosis of patients with COVID-19. RESULTS: The six variables that were finally selected in the scoring system were lymphopenia, serum CRP, ferritin, D-Dimer, radiological CT lung findings and associated chronic debilitating disease. The scoring system discriminated risk groups with either mild disease or severe illness characterized by respiratory distress (and also those with hypoxia and in need for oxygen therapy or mechanical ventilation) or death. The area under the curve to estimate the discrimination performance of the scoring system was more than 90%. CONCLUSION: We proposed a simple and clinically useful predictive scoring model for COVID- 19 patients. However, additional independent validation will be required before the scoring model can be used commonly.

Tanta Protocol for Management of COVID-19: Perspectives from a Developing Country.

In late 2019, SARS-COV-2 disease was firstly discovered in Wuhan, China and then it infected millions of people worldwide. Later, the World Health Organization (WHO) described COVID-19 as the first pandemic invading the world in the 21st century. The WHO has declared that the emerging infection will last long enough to force adjustments not only in people's lifestyles but also in the health care system. This amendment is expected to spread through many medical practices and specialties. A lot of diagnostic and therapeutic modalities have been proposed for COVID-19 management. The best strategy for the management of patients requires a multi-disciplinary team approach with correct decisions regarding the right timing of each modality of treatment. The participating multidisciplinary team for COVID-19 management includes six infectious diseases experts in Tanta University; one critical care management expert, an emergency medicine expert and two pharmacists in Tanta University. In this review, we reported our multi-disciplinary team experience with up to date literature guidance to propose a valid protocol for the management of COVID-19 patients in a limited resources setting.

HCV and HEV: two players in an Egyptian village, a study of prevalence, incidence, and co-infection.

The highest recorded hepatitis C virus (HCV) prevalence worldwide is in Egypt. A high prevalence of hepatitis E virus (HEV) in chronic liver disease has been reported. The aim of this study was to study prevalence, incidence, and outcome of HCV infection in an Egyptian Nile Delta village and the relation between HEV infection and HCV-related chronic hepatic affection. This prospective cohort study included 2085 Nagreej village residents. Mass HCV screening was conducted and testing for HEV antibodies among HCV-infected patients performed. The annual incidence of HCV was recorded. Five hundred five (24.22%) of the tested villagers were positive for HCV RNA. Prevalence escalated with age and male sex. The main recorded risk factors were a history of surgery, dental procedures, hospitalization, blood transfusion, and antischistosomal treatment. HEV IgG antibody was positive in 71.4% of individuals with chronic HCV and 96.1% with advanced liver disease (cirrhosis ± hepatocellular carcinoma (HCC)). After 1 year, 29 of the 1390 HCV Ab negative villagers had a positive HCV PCR, placing an annual incidence of new HCV infections at 2.09%. The Egyptian HCV prevalence remains high with infection particularly among the elderly. The annual incidence in a small Nile Delta village is 2.086%. HCV-HEV co-infection may lead to a worse prognosis among Egyptians with chronic liver disease.

Efficacy of a non-invasive model in predicting the cardiovascular morbidity and histological severity in non-alcoholic fatty liver disease.

BACKGROUND: Insulin resistance (IR) in cases of non-alcoholic fatty liver disease (NAFLD) is connected to remarkable liver cell inflammation and cardiovascular complications. Given the prevalence of NAFLD and its association with potential sequels, there is a strong need for an accurate non-invasive tool to monitor the progression of NAFLD. METHODS: 272 patients with NAFLD and cardio-metabolic risk factors were tested for HOMA-IR, mean platelet volume (MPV), neutrophil-lymphocyte ratio (NLR), uric acid, ferritin, lipid profile, liver stiffness measurement (LSM), controlled attenuation parameter (CAP) by fibroscan and carotid intima media thickness (CIMT). Liver biopsy was performed to validate the results.100 healthy controls were selected. A score was constructed and applied to a validation group (n = 61). RESULTS: Logistic regression revealed that significant fibrosis and cardiovascular risk in NAFLD were independently associated with AST/ALT ratio (p = 0.000), GGT (p = 0.000), CIMT (p = 0.001), uric acid (p = 0.000), VLDL (p = 0.000), HOMA-IR (p = 0.000), ferritin (p = 0.000) CAP (p = 0.000), LSM (p0.000). A non-invasive model was formulated by which a value > 15 was accurate in identification of advanced fibrosis and cardiovascular risk with a sensitivity of 97.3%, specificity 97%. CONCLUSION: The score correlated well with the results of liver biopsy and can be repeated with great flexibility to assess severity of NAFLD.

A Randomized Controlled Trial Comparing Nitazoxanide Plus Lactulose With Lactulose Alone in Treatment of Overt Hepatic Encephalopathy.

BACKGROUND AND AIMS: Hepatic encephalopathy (HE) is a reversible spectrum of neuropsychiatric abnormalities associated with liver dysfunction. Lactulose is a nonabsorbable disaccharide presently used to treat HE. Nitazoxanide (NTZ) has a broad-spectrum activity against urease-producing bacteria, so it decreases ammonia production and is therefore expected to reverse the symptoms of HE. A previous pilot study on HE patients given NTZ and lactulose had encouraging results with regard to amelioration of the clinical picture. Patients showed improvement in mental status and the drug was well-tolerated. Results such as these are encouraging larger studies. The aim of this study was to compare the safety and adequacy of NTZ plus lactulose versus lactulose and placebo in management of overt HE. METHODS: In total, 120 cirrhotic patients suffering from overt HE were randomly designated to take either NTZ plus lactulose (n=60) or lactulose and placebo (n=60). The Clinical Hepatic Encephalopathy Staging Scale (CHESS) score was assessed for all patients on inclusion to the study and 1 week from the start of treatment. RESULTS: Both groups evinced an improvement in CHESS score at 1 week, yet the improvement was significantly better in the NTZ group as the score decreased from 4.15±2.09 to 0.00±0.00 compared with 4.96±2.29 to 1.28±0.91 in patients receiving lactulose and placebo (P-value <0.001). CONCLUSIONS: NTZ significantly decreases the CHESS score and improves mental status in the form of patient alertness, orientation, response to stimulation, and ability to talk. NTZ is safe and well-tolerated apart from infrequent epigastric pain.

Evaluation of the blood ammonia level as a non-invasive predictor for the presence of esophageal varices and the risk of bleeding.

BACKGROUND/AIMS: The development of esophageal varices (EV) and resultant bleeding are the most critical complications of portal hypertension. Upper gastrointestinal endoscopy is the gold standard for diagnosis of EV. To find a non-invasive method for diagnosis of EV and to predict the bleeding risk is appealing and would decrease the cost and discomfort of upper endoscopy. The aim of our study was to evaluate the blood ammonia level as a predictor of the presence of EV and of a high risk of bleeding. MATERIALS AND METHODS: In this cross-sectional study, a total of 359 patients with cirrhosis were examined for the presence of EV by upper endoscopy. Abdominal ultrasonography, calculation of the Child-Pugh score, and measurement of blood ammonia were performed for each patient. RESULTS: The blood ammonia level was significantly higher in patients with EV than in those without it (p<0.001), and in patients with a high risk of variceal bleeding than in those with a low risk (p=0.026). CONCLUSION: An increased blood ammonia level and splenic vein diameter are predictors for the presence of EV and bleeding risk factors. The blood ammonia level may be clinically useful as it correlates with and is an independent predictor for both the endoscopic risk signs and risk factors of bleeding, and therefore, it could be used in patients with cirrhosis to decrease the number of screening endoscopies they are subjected to.

Helicobacter pylori may be an initiating factor in newly diagnosed ulcerative colitis patients: A pilot study.

AIM: To directly visualize Helicobacter pylori (H. pylori) by the highly sensitive and specific technique of immunohistochemical staining in colonic tissue from patients newly diagnosed with ulcerative colitis (UC). METHODS: Colonoscopic biopsies from thirty patients with newly diagnosed UC and thirty controls were stained with Giemsa stain and immunohistochemical stain for detection of H. pylori in the colonic tissue. Results were confirmed by testing H. pylori Ag in the stool then infected patients were randomized to receive either anti H. pylori treatment or placebo. RESULTS: Twelve/30 (40%) of the UC patients were positive for H. pylori by Giemsa, and 17/30 (56.6%) by immunohistochemistry stain. Among the control group 4/30 (13.3%) and 6/30 (20 %) were positive for H. pylori by Giemsa and immunohistochemistry staining respectively. H. pylori was significantly higher in UC than in controls (P = 0.04 and 0.007). All Giemsa positive patients and controls were positive by immunohistochemical stain. Four cases of the control group positive for H. pylori also showed microscopic features consistent with early UC. CONCLUSION: H. pylori can be detected in colonic mucosa of patients with UC and patients with histological superficial ulcerations and mild infiltration consistent with early UC. There seems to be an association between UC and presence of H. pylori in the colonic tissue. Whether this is a causal relationship or not remains to be discovered.

Blood Ammonia Level Correlates with Severity of Cirrhotic Portal Hypertensive Gastropathy.

BACKGROUND: Portal hypertensive gastropathy (PHG) is a common anomaly with potential for bleeding found in portal hypertension. Blood ammonia levels correlate well with liver disease severity and existence of portosystemic shunts. Increased ammonia results in vasodilation and hepatic stellate cell activation causing and exacerbating portal hypertension. OBJECTIVE: To assess the relation of blood ammonia to the presence and severity of portal hypertensive gastropathy in cirrhosis. METHODS: This cross-sectional study included 381 cirrhotics undergoing screening for esophageal varices (EV) divided into a portal hypertensive gastropathy group (203 patients with EV and PHG), esophageal varix group (41 patients with EV but no PHG), and control group (137 patients with no EV or PHG). A full clinical examination, routine laboratory tests, abdominal ultrasonography, child score calculation, and blood ammonia measurement were performed for all patients. RESULTS: Blood ammonia, portal vein, splenic vein, and splenic longitudinal diameters were significantly higher and platelet counts lower in patients with EV and EV with PHG than controls. Patients having EV with PHG had significantly higher bilirubin and ammonia than those with EV but no PHG. Severe PHG was associated with significantly higher ammonia, EV grades, and superior location and a lower splenic longitudinal diameter than mild PHG. The PHG score showed a positive correlation with blood ammonia and a negative correlation with splenic longitudinal diameter. CONCLUSIONS: Blood ammonia levels correlate with the presence, severity, and score of portal hypertensive gastropathy in cirrhosis suggesting a causal relationship and encouraging trials of ammonia-lowering treatments for the management of severe PHG with a tendency to bleed.

Pilot study of orphenadrine as a novel treatment for muscle cramps in patients with liver cirrhosis.

BACKGROUND AND AIMS: Muscle cramps markedly affect the quality of life in cirrhotic patients with no available highly effective treatment. The aim of this study was to assess the safety and efficacy of orphenadrine in the treatment of muscle cramps in cirrhotic patients. METHODS: The study enrolled 30 liver cirrhosis patients complaining of frequent muscle cramps (≥3 per week), who were randomized to receive either orphenadrine 100 mg or calcium carbonate 500 mg twice daily as a control for one month. Severity, frequency, and duration of the muscle cramps were assessed before and after treatment as well as recurrence after washout of the drug for two weeks. Side effects were recorded. RESULTS: One month after treatment with orphenadrine; the frequency of muscle cramps decreased significantly to 0.6 ± 0.74 per week compared to 12.53 ± 6.01 at baseline (p < 0.001), the duration of muscle cramps decreased from 1 min to 0.1 min after treatment (p < 0.001). The pain score improved significantly from a score of 8/10 to 0/10 (p < 0.001). The side effects were few, such as dry mouth, drowsiness, and nausea, with no significant difference between their occurrences in the two groups. CONCLUSION: Orphenadrine is safe and effective in treatment of muscle cramps in patients with liver cirrhosis.

Randomized trial of preoperative administration of oral pregabalin for postoperative analgesia in patients scheduled for radiofrequency ablation of focal lesions in the liver.

PURPOSE: The aim of this study was to evaluate the effect of preoperative pregabalin on postoperative analgesia in patients undergoing radiofrequency ablation (RFA) of hepatic focal lesions (HFLs). METHODS: This randomised controlled study was carried out on 70 adult patients for whom RFA was indicated to treat hepatocellular carcinoma. They were randomised into two groups: Group I: 35 patients who were given a placebo before the procedure and Group II: 35 patients who were given 150 mg of oral pregabalin one hour before the procedure. The primary outcome was the analgesic effect in the form of postoperative pain severity and the need for opioid analgesics. RESULTS: In the immediate postoperative period there was no significant difference between the two groups on pain assessment by the visual analogue pain scale (VAS Pain; p = 0.84). However, the medians of Group II VAS Pain were significantly (p < 0.001) less than Group I 3,2,1,1,1,0 vs. 4,3,3,2,2,2, respectively when measured every four hours until 24 hours. The number of required doses of rescue analgesia and total required dose of morphine in the first 48 hours postoperatively of Group II were significantly (p < 0.001) less than Group I. Side effects such as nausea and vomiting and delayed discharge were significantly less frequent in Group II when compared with Group I:20vs. 45.7%, 17.1 vs. 45.7% and 11.4 vs. 37.1%, respectively (p = 0.02, 0.01 and 0.01, respectively). CONCLUSION: Pre-emptive oral pregabalin is safe and effective for postoperative analgesia in patients scheduled for radiofrequency ablation of focal lesions in liver.

High numbers of myeloid derived suppressor cells in peripheral blood and ascitic fluid of cirrhotic and HCC patients.

BACKGROUND: Hepatocellular carcinoma (HCC) is the 3rd most common cause of cancer-related death worldwide. It has evolved different immune escape mechanisms, which might include emergence of lymphoid and myeloid regulatory cells. Aim of this work: To determine the numbers of Myeloid-derived suppressor cells (MDSCs) in peripheral blood and ascitic fluid in cirrhosis and HCC and their relation to IFN-γ and α-fetoprotein (α-FP). PATIENTS AND METHODS: Sixty individuals were enrolled in this study; forty cirrhotic patients with ascites; twenty without HCC (Group I), and twenty with HCC (group II) as well as twenty healthy individuals as a control group (group III). The phenotype and numbers of MDSCs were analyzed in peripheral blood of all the individuals and ascitic fluid of the patients using flow cytometry. Intracellular IFN-γ and serum alfa-fetoprotein were measured. RESULTS: Significant increases in the relative and the mean number of peripheral blood MDSCs were found in the cirrhosis and HCC groups than in the control group, with the HCC group showing the highest number. MDSC count was negatively correlated with IFN-γ levels, while α-FP was positively correlated with MDSC% in the HCC group. MDSC count was low in ascitic fluid of both HCC and cirrhosis groups with no significant difference between the 2 groups. CONCLUSION: A high frequency of MDSCs was detected in the peripheral blood of cirrhotic and HCC patients, indicating presence of immunosuppressive arms. These cells could be targeted to develop a new effective immunotherapy or an adjuvant to current therapies.

Anti-Nuclear Cytoplasmic Antibody-Associated Vasculitis: A Probable Adverse Effect of Sofosbuvir Treatment in Chronic Hepatitis C Patients.

Background: Egypt has the largest hepatitis C virus (HCV) epidemic worldwide. Sofosbuvir is an antiviral drug acting by inhibition of the HCV NS5B polymerase. It has shown high efficacy in combination with several other drugs and has a low reported rate of side effects. Objective: The aim of this prospective cohort study was to assess the safety of sofosbuvir-based treatment regimens used to treat chronic hepatitis C infections and to detect any side effects of sofosbuvir not previously reported. Methods: We studied treatment side effects in 3,000 patients with chronic HCV infection treated with sofosbuvir and ribavirin for 24 weeks or treated by pegylated interferon, sofosbuvir, and ribavirin triple therapy for 12 weeks. The endpoint of the study was the end of treatment. Results: Hyperbilirubinemia occurred frequently during treatment in both groups. Treatment was discontinued in 72 cases due to hepatic decompensation and drug complications; 8 of the cases had deep vein thrombosis (DVT) and 7 had cerebral ischemia. Surprisingly, 177/3,000 (5.9%) patients presented with abnormal bleeding, 85 of whom had a vasculitic skin rash. Conclusion: We report the occurrence of previously nonrecorded side effects with sofosbuvir, namely DVT and bleeding disorders associated with anti-nuclear cytoplasmic antibody (ANCA)-associated vasculitis (AAV).We believe this to be the first report of sofosbuvir-induced AAV skin lesions and bleeding disorders.

Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices.

BACKGROUND AND AIMS: Gastric varices develop in 5% to 33% of patients with portal hypertension. Their most common form is concomitant gastroesophageal varices. Scleroligation (combined sclerotherapy and band ligation) has been used successfully in management of esophageal varices but has not been evaluated previously in the management of gastroesophageal varices. The aim of this work was evaluation of a new scleroligation technique for management of bleeding gastroesophageal varices regarding efficacy, adverse events, variceal recurrence, and survival. METHODS: This study was conducted on 120 cirrhotic patients with bleeding gastroesophageal varices, whom we divided randomly into 2 groups of 60 patients each-a band ligation group and a scleroligation group. RESULTS: The mean number of sessions was lower in the scleroligation group than in the band ligation group (2.22 ± 0.92 and 3.43 ± 0.67, respectively) (P < .001), as were the duration of treatment and total number of bands used. Cost and survival were comparable in the 2 groups. There was no significant difference between the 2 maneuvers regarding adverse events, recurrence rates, or rebleeding rates after obliteration. Recurrence was significantly higher in patients with larger varices, ulceration, and postprocedure pyrexia. Rebleeding was significantly higher among those who experienced postprocedure pyrexia and developed or had worsening of gastric antral vascular ectasia. CONCLUSIONS: Scleroligation appears to achieve a faster rate of eradication with fewer treatment sessions and total number of bands deployed to achieve variceal obliteration than band ligation and is comparable in cost and in adverse event and recurrence rates. (Clinical trial registration number: NCT02646202.).

Comparison of single-session transarterial chemoembolization combined with microwave ablation or radiofrequency ablation in the treatment of hepatocellular carcinoma: a randomized-controlled study.

BACKGROUND: Globally, hepatocellular carcinoma (HCC) is the third most frequent cause of cancer-related mortality. In recent years, transarterial chemoembolization, radiofrequency ablation, and microwave ablation (MWA) have been accepted as treatment modalities for patients with surgically unresectable HCC. AIM OF THIS WORK: This study aimed to compare combination treatment with radiofrequency or MWA, followed by transarterial chemoembolization, and performed in a single session. PATIENTS AND METHODS: This study was carried out on 50 patients with nonresectable single-lesion HCC, who were divided into three groups: group A included 20 patients treated by transcatheter hepatic arterial chemoembolization, group B included 20 patients treated by radiofrequency thermal ablation combined with transcatheter arterial chemoembolization, and group C included 10 patients treated by MWA combined with transcatheter arterial chemoembolization. The combined treatments were performed in a single session, with the ablation performed first. RESULTS: The total success rate in this study at 6 months following the procedure was 50% in group A, 70% in group B, and 80% in group C. Major complications were recorded in 22% of patients. The number of complications was the highest in group A. CONCLUSION: Combined ablation with chemoembolization is superior in the treatment of nonresectable single masses larger than 4 cm. Transcatheter arterial chemoembolization and ablation can be performed safely and successfully during a single session, which has not been found to decrease the response rates to treatment. Combined treatment with MWA is more effective in terms of tumor response, and results in the same complication rate as with radiofrequency, but less than chemoembolization alone.

A 2-week Nitazoxanide-based quadruple treatment as a rescue therapy for Helicobacter pylori eradication: A single center experience.

As there are increasing reports of fluoroquinolone resistance on use as a first- or second-line treatment for Helicobacter pylori (H pylori), we aimed at evaluation of the efficacy and safety of nitazoxanide-based regimen as a rescue regimen in Egyptian patients whose previous traditional treatment for H pylori infection failed.In total, 100 patients from the outpatient clinic of the Tropical medicine department, Tanta University hospital in whom the standard triple therapy (clarithromycin-based triple therapy) failed were enrolled in the study. Nitazoxanide (500 mg bid), levofloxacin (500 mg once daily), omeprazole (40 mg bid), and doxycyclin (100 mg twice daily) were prescribed for 14 days. Eradication was confirmed by stool antigen for H pylori 6 weeks after the end of treatment. Among the patients enrolled in the study, 44% of patients were men and the mean age for the participants in the study was 46.41 ±â€Š8.05, 13% of patients were smokers, and 4% of patients had a previous history of upper gastro-intestinal bleeding. A total of 94 patients (94%) completed the study with excellent compliance. Only 1 patient (1%) discontinued treatment due to intolerable side effects and 5 patients (5%) did not achieve good compliance or were lost during follow up. However, 83 patients had successful eradication of H pylori with total eradication rates 83% (95 % CI 75.7-90.3%) and 88.30% (95 % CI 81.8-94.8%) according to an intention-to-treat and per-protocol analysis, respectively. Adverse events were reported in 21% of patients: abdominal pain (6%), nausea (9%) and constipation (12%), (2%) headache, and (1%) dizziness. A 2-week nitazoxanide-based regimen is an effective and safe rescue therapy in Egyptian patients whose previous standard triple therapy has failed.

Correlation of platelets count with endoscopic findings in a cohort of Egyptian patients with liver cirrhosis.

Screening endoscopy is recommended for early detection of esophageal varices (EVs) in cirrhotic patients with portal hypertension. However, this approach is limited by its invasiveness and cost. The aim of the study was to determine if platelet count can predict the presence of EVs, especially large (grade III, IV) EVs in need of prophylactic therapy, in a cohort of Egyptian patients with liver cirrhosis. In all, 110 patients with cirrhosis were prospectively analyzed. The presence of medium or large EVs was correlated with patients' platelet count and FIB-4. Esophageal varices were present in 87 (79.09%) patients. Among those with thrombocytopenia (platelet level below 150,000), 25.97% (20 patients) and 27.27% (21 patients) had EV grade II and EV grade III or IV, respectively. Whereas in patients in whom the platelet count was above 150,000, only 21.21% (7 patients) and 9.09% (3 patients) of patients had grade II EV and EV grade III or IV, respectively. A platelet count cut-off value of 149,000 was found to have specificity of 82% and sensitivity 39% for detection of presence of varices. A FIB-4 cut-off value of 3.175 was found to have an 83.3% sensitivity and 39.5% specificity in detecting large (grade III, IV) EVs. Platelet count is a noninvasive parameter with high accuracy for prediction of EVs. Cirrhotic patients with normal platelet counts (above 150,000), especially in financially deprived developing countries, can avoid screening endoscopy as they are at a low risk for variceal bleeding, and presence of large EVs in these patients is much less common than in those with thrombocytopenia. A 3.175 cut-off value of FIB-4 could be useful as a noninvasive predictor of large varices requiring prophylactic banding in cirrhotic patients.

Pigtail Catheter: A Less Invasive Option for Pleural Drainage in Egyptian Patients with Recurrent Hepatic Hydrothorax.

Background and Aims. Treatment of hepatic hydrothorax is a clinical challenge. Chest tube insertion for hepatic hydrothorax is associated with high complication rates. We assessed the use of pigtail catheter as a safe and practical method for treatment of recurrent hepatic hydrothorax as it had not been assessed before in a large series of patients. Methods. This study was conducted on 60 patients admitted to Tanta University Hospital, Egypt, suffering from recurrent hepatic hydrothorax. The site of pigtail catheter insertion was determined by ultrasound guidance under complete aseptic measures and proper local anesthesia. Insertion was done by pushing the trocar and catheter until reaching the pleural cavity and then the trocar was withdrawn gradually while inserting the catheter which was then connected to a collecting bag via a triple way valve. Results. The use of pigtail catheter was successful in pleural drainage in 48 (80%) patients with hepatic hydrothorax. Complications were few and included pain at the site of insertion in 12 (20%) patients, blockage of the catheter in only 2 (3.3%) patients, and rapid reaccumulation of fluid in 12 (20%) patients. Pleurodesis was performed on 38 patients with no recurrence of fluid within three months of observation. Conclusions. Pigtail catheter insertion is a practical method for treatment of recurrent hepatic hydrothorax with a low rate of complications. This trial is registered with ClinicalTrials.gov Identifier: NCT02119169.

Higher Grades and Repeated Recurrence of Hepatic Encephalopathy May Be Related to High Serum Manganese Levels.

Hepatic encephalopathy is a serious complication of liver failure. Until now, the precise pathophysiologic mechanisms are not fully determined. It has been demonstrated that manganese plays an important role in the pathogenesis of hepatic encephalopathy. Therefore, we studied manganese levels in serum of cirrhotic patients with hepatic encephalopathy in relation to grading and recurrence of hepatic encephalopathy. One hundred persons were enrolled in the study, 80 cirrhotic patients with or without encephalopathy and 20 healthy controls. Hepatic encephalopathy was diagnosed clinically and by laboratory findings. Serum manganese levels were measured in all participants. The grading of hepatic encephalopathy was significantly correlated to the severity of liver dysfunction. The mean serum manganese level was significantly higher in cirrhotic patients than in controls and in cirrhotic patients with encephalopathy than in those without encephalopathy. It was also significantly higher in patients with advanced grading of hepatic encephalopathy. Serum manganese level was positively correlated to number of recurrences of encephalopathy during a 6-month follow-up period. Serum manganese levels were able to predict recurrence of hepatic encephalopathy within 6 months following the episode. Serum manganese levels are positively correlated to the modified Child-Pugh score of cirrhosis as well as grading and number of recurrences of hepatic encephalopathy. Higher manganese levels seem to be related to worsening of the condition, and its measurement may be used as a predictor of repeated recurrences.

Gastroenterologists and interventional radiologists: friends or foes? A multidisciplinary approach for solving gastrointestinal problems.

While endoscopy used to have more therapeutic abilities than radiology, interventional radiology is now racing to lead the minimally invasive diagnostic and therapeutic techniques in medicine as well as surgery. Expecting the new epidemic of hepatocellular carcinoma, radiologists and gastroenterologists are on the run competing in many procedures that are needed. While some radiologists worry about non-radiologists who "intervene" in radiology, many gastroenterologists defend their specialty. Both gastroenterologists and radiologists are invited to collaborate in diagnosing and treating many diseases. Treatment of upper gastrointestinal bleeds should be multidisciplinary involving a team of gastroenterologists, radiologists and surgeons. The role of the interventional radiologist and surgeon arises only after the failure of the endoscopic treatment. Transjugular intrahepatic portosystemic shunt (TIPS) is the preferred treatment for variceal bleeding after failed endoscopy. As the entire field of gastroenterology continues towards less invasive, safer and more effective means of diagnosing and treating diseases, digestive endoscopy will continue to expand the ways in which this unique and minimally invasive technology can be applied to the benefit of patients. In line with this trend, there will be a decline in simple diagnostic standard endoscopies. Development of new techniques, such as CT colonography and capsule endoscopy will actually increase the demand for digestive endoscopy. The trend of future digestive endoscopy will continue to move from diagnostic to therapeutic modalities. Future gastroenterologists will be trained and expected to become micro-surgeons of the gastrointestinal tract working in multispecialty teams along with their colleagues: surgeons and radiologists.