Efficacy and safety of terlipressin and albumin vs. noradrenaline and albumin in adult patients with hepatorenal syndrome: A systematic review and meta-analysis.

INTRODUCTION AND OBJECTIVES: Hepatorenal syndrome (HRS) is a serious complication of cirrhosis treated with various medications. We aim to evaluate terlipressin and albumin's effectiveness and safety compared to albumin and noradrenaline in adult hepatorenal disease patients. MATERIALS AND METHODS: Clinical trials from four databases were included. Cochrane's approach for calculating bias risk was utilized. We rated the quality evaluation by Grading of Recommendations Assessment, Development, and Evaluation (GRADE). We included the following outcomes: serum creatinine (mg/dl), urine output (ml/24 h), mean arterial pressure (mmHg), reversal rate of HRS, mortality rate, blood plasma renin activity (ng/ml/h), plasma aldosterone concentration (pg/ml), urine sodium (mEq/l), and creatinine clearance (ml/min). RESULTS: Our analysis of nine clinical studies revealed that the noradrenaline group was associated with higher creatinine clearance (MD = 4.22 [0.40, 8.05]), (P = 0.03). There were no significant differences in serum creatinine levels (MD = 0.03 [-0.07, 0.13]), urinary sodium (MD = -1.02 [-5.15, 3.11]), urine output (MD = 32.75 [-93.94, 159.44]), mean arterial pressure (MD = 1.40 [-1.17, 3.96]), plasma renin activity (MD = 1.35 [-0.17, 2.87]), plasma aldosterone concentration (MD = 55.35 [-24.59, 135.29]), reversal rate of HRS (RR = 1.15 [0.96, 1.37]), or mortality rate (RR = 0.87 [0.74, 1.01]) between the two groups (p-values > 0.05). CONCLUSIONS: Noradrenaline is a safe alternative medical therapy for HRS.

Helicobacter pylori prevalence and histopathological findings in dyspeptic patients.

BACKGROUND: Helicobacter pylori (H. pylori) colonizes in half of the population of developed and nearly all inhabitants of developing countries. The infection is characterized by gastritis but can present more complicated disease states. We intended to report prevalence of H. pylori infection by histopathology and presence of gastritis, activity, atrophy and intestinal metaplasia in dyspeptic patients of Islamabad, Pakistan. METHODS: Ninety four patients identified to be dyspeptic on the basis of Rome-III criteria were included in the study and diagnosed for H. pylori status by Histopathology. The grading and severity of gastritis was documented as nil, mild, moderate or severe, based on the Sydney system. Activity was recorded as present when an increase in the number of neutrophils was observed. Atrophic changes and intestinal metaplasia were also determined. RESULTS: Eighty three out of total 94 (88.3%) patients were positive for H. pylori on histopathology. Out of total 94 patients, chronic gastritis was observed in 89 (94.6%), evidence of activity was found in 37 (39.4%), atrophic changes were observed in 66 (70%) and intestinal metaplasia was present in 4 (4.3%) patients. CONCLUSION: H. pylori infection in dyspeptic patients of Islamabad appears to be more related with gastritis.

Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia. METHODS: We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively. RESULTS: The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux. CONCLUSION: PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.

Factors Associated with Survival of Hepatocellular Carcinoma (HCC) Patients at a Safety Net Hospital in Arizona without On-Site Liver Transplant Program.

BACKGROUND: With the rising incidence of hepatocellular carcinoma (HCC), ongoing efforts should be focused on providing equitable and state-of-the-art care to patients. PURPOSE: The aim of this study was to determine the survival of patients with HCC seen at a high-proportion Safety Net Hospital (h-SNH), where loco-regional therapy and hepatology services are available and liver transplantation (LT) is referred to outside facilities. PATIENTS AND METHODS: A retrospective cohort study was conducted on all patients with HCC seen at Valley Wise Health Center (VWHC) over a ten-year period. Clinical variables, treatment modalities, survival duration, hospice, and LT referrals of 161 patients were collected from the medical records. Survival analysis was used to determine the relationship of clinically relevant variables and survival among patients with HCC. A Log rank test was used to compare univariate variables. A Cox regression analysis was used to compare and control for multiple variables. RESULTS: Of the 161 patients included in the study, 33% were uninsured. The median age was 59 (21 to >89) years with 47% Hispanic, 31% Caucasian, 15% African American and 7% other races included for the analysis. The median survival for the cohort was 20.1 months. In the multivariate model, insurance status, final MELD, tumor within the Milan criteria and having received treatment for HCC were associated with survival. Surveillance for HCC was associated with HCC in the univariate analysis, but not in the multivariable model. Thirty percent of patients were referred for LT and 1.25% of the entire cohort received it. CONCLUSION: Despite the availability of treatment modalities available for HCC at VWHC and the option of liver transplantation for appropriate candidates at outside centers, OS was less than reported from programs with on-site liver transplant programs. Reasons for lower survival in centers without liver transplant programs should be further studied.

Continuous peritoneal drainage of large-volume ascites.

BACKGROUND: With the increasing population of individuals with cirrhosis, many of whom are not liver transplant candidates, large volume paracentesis as a medical therapy for ascites resistant to diuretic therapy has become increasingly utilized. AIM: To determine the safety and efficacy of continuous peritoneal drainage of large-volume ascites in Child Class-C cirrhosis. Subjects with no current clinical or laboratory findings of spontaneous bacterial ascites were studied. Each had a complete medical evaluation to document the etiology and severity of their liver disease as well as the identification of any confounding medical illness. A triple-phase abdominal CT of the abdomen was obtained in each individual to rule out any hepatoma. Upon completion of the above, a pericardiocentesis catheter was placed in the abdomen using the Seldinger technique and the ascites was drained continuously (to gravity) until no additional ascitic fluid could be removed or the total time of drainage was 72 h. The patient's weight, volume of ascitic fluid removed, ascitic fluid cell counts, ascitic fluid cultures, complete blood count and comprehensive metabolic profile were obtained immediately before and after the peritoneal catheter was removed. RESULTS: HCV cirrhosis accounted for 12 cases and alcoholic liver disease accounted for 8 cases (half the total of 40 cases), with 6 other diseases accounting for the remaining half. The ascitic fluid was drained continuously for 2.5 ± 0.08 days, with a removal of 13.3 ± 0.5 l of ascitic fluid. No clinically significant change in the serum creatinine or ascitic fluid cells count occurred as a result of the procedure. The adverse effects of the procedure were minimal. 63% of the patients experienced some mild discomfort at the catheter insertion site, or local abdominal pain just prior to the removal of the catheter. Two patients developed a small abdominal wall hematoma that required no therapy. No patients experienced peritoneal hemorrhage, infection or renal dysfunction. CONCLUSION: (1) Continuous large-volume peritoneal drainage by gravity is safe and effective; (2) if the procedure is limited 72 h, no cases of ascitic fluid contamination/infection occur; and (3) it reduces the time between subsequent paracentesis based upon historical data.

Predictors of depression in patients presenting with dyspeptic symptoms in a GI clinic.

BACKGROUND: The association between dyspepsia, H. pylori and psychological distress has remained a topic of intense debate over the past several decades. In Pakistan, where depression is highly prevalent and dyspepsia is possibly present in a high percentage of population, little data exist about these common health problems. This study was conducted to determine the frequency and predictors of depression among patients presenting with dyspeptic symptoms in the Gastrointestinal (GI) Clinic of a tertiary care hospital in Pakistan. METHODS: Two hundred and sixty-nine consecutive patients were enrolled in the study based on their presenting symptoms in the GI clinic at Shifa International Hospital, Islamabad. Subjects with prior history of peptic ulcer disease (PUD), gallstones and HCV infections were excluded from the study. Demographic and socioeconomic variables as well as dyspeptic symptoms and important causes of dyspeptic symptoms were recorded. Depression was analysed based on the Urdu version of Beck's Depression Inventory-II (BDI-II). The data were analysed using SPSS-10 for univariate and multivariate analyses. RESULTS: Mild depression was associated with lower education status (p < 0.001), lesser income (p < 0.018), and lower socioeconomic status (0 < 0.009) as well as rural residence (p < 0.026). Smoking, alcohol-use, H. pylori infection, gender and dyspepsia were not found to have any association with depression. On multivariate analysis, education and income group remained significantly associated with mild depression. Clinically significant depression was found to be associated with lower education and rural residence. CONCLUSION: Depression among dyspeptic patients was found to be associated with socioeconomic status rather than dyspeptic symptoms or important risk factors associated with dyspeptic symptoms.

Frequency of peritoneal infections among patients undergoing continuous paracentesis with an indwelling catheter.

BACKGROUND: Ascites is a common clinical manifestation of advanced liver disease which can be managed with repeated large volume paracentesis. We sought to determine if continuous paracentesis via placement of an indwelling catheter for the management of ascites is safe and effective. METHODS: We placed 38 peritoneal drainage catheters in 30 patients for durations ranging from 1-10 days. Patients underwent ascites fluid culture and cell count determinations immediately before and after the completion of paracentesis. Serum WBC count, BUN and creatinine levels were available on all patients before and after paracentesis. The descriptive data were analysed to assess the rate of peritoneal infections, change in renal function and ultimate clinical outcome of patients. RESULTS: A mean 12.73 litres of peritoneal fluid was removed via continuous peritoneal drainage accomplished with the use of an indwelling abdominal catheter. Eight peritoneal cultures obtained after paracentesis grew out. The mean peritoneal cell count before and after paracentesis in each subject did not show evidence for spontaneous bacterial peritonitis. Five patients underwent successful liver transplantation (OLTX) and did not develop any peritoneal infections post OLTX. CONCLUSION: Continuous large volume paracentesis using an indwelling abdominal catheter for several days is effective in removing large volumes of peritoneal fluid in patients with endstage-liver-disease (ESLD). The peritoneal fluid can grow out bacteria if it is left in the abdomen for > or = 3 days.

Frequency and Associated Risk Factors of Hepatitis B Virus and Hepatitis C Virus Infections in Children at a Hepatitis Prevention and Treatment Clinic in Lahore, Pakistan.

Objective This study evaluated the frequency of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection and the associated horizontal risk factors in children being screened for viral hepatitis in Lahore, Pakistan. Methods Children aged 15 years or younger who were brought to a specialized outpatient viral hepatitis clinic affiliated with a tertiary hospital in Lahore, Pakistan, for viral hepatitis screening from March 2017 to March 2018 were enrolled. Children were screened for HBV and HCV infection by enzyme-linked immunosorbent assay; if results were positive, HBV and HCV concentrations were quantitatively assayed by polymerase chain reaction. Children positive for HBV or HCV infection were matched with 100 controls of the same age and sex. All subjects completed a questionnaire on viral infection and its associated risk factors. Results During the study period, 3500 children living in the Punjab Province of Pakistan were screened for HBV and HCV infection. Of these children, 28 (0.8%) were positive for HBV and 66 (1.88%) were positive for HCV. A comparison of the 94 (2.68%) children positive for HBV or HCV with 100 controls identified several risk factors associated with infection. Unexpectedly, ten (35.7%) of the 28 HBV-positive children were born of HBV-negative mothers and had been fully vaccinated for HBV during infancy. Conclusion The frequency of HCV infection was higher than that of HBV infection among Pakistani children aged ≤15 years. Several horizontal risk factors were found to cause viral hepatitis. Several children born of HBV-negative mothers and vaccinated for HBV during infancy later developed HBV infection.

Molecular epidemiology and genotype distribution of hepatitis C in Pakistan; a multicenter cross-sectional study.

Pakistan has second highest burden of hepatitis C virus (HCV) infected patients in the World. Little is known about the molecular epidemiology and risk factors for prevailing HCV genotypes in Pakistan. Considering this a multicenter cross-sectional study was conducted at 23different viral hepatitis control and prevention centers. A total of 175,897 patients were registered and screened for HCV, out of which 73,180 (41.6%) were found positive on Architect screening test. The screened positive patients were sequentially tested on RT-PCR; where 41,241 (56.35%) were detected positive. Molecular characterization results showed genotype 3 (73.9%) as the most prevalent type, followed by genotype 1 (9.7%), and genotype 4 (0.3%) was isolated for the first time in Pakistan. On regression analysis; risk factors associated with genotype 3 and 1 included; age group of 30-50 years, rural residence, exposure to >10 injections, barber shaving, circumcision by barbers, and low literacy rate. Phylogenetic analysis based on genotypes identified in this study and sequences isolated from Pakistan in last 10 years demonstrated that genotype 3 and 1 are endemic locally in Punjab province. The high prevalence rate of HCV is a threat for a generalized epidemic and genetic recombination with such variability of genotypes identified here is an alarming condition. More focused attention and resources should be spent in awareness of the population to prevent the spread of HCV among high risk population.

Imaging-Negative Hepatocellular Carcinoma Presents as an Intrabiliary Mass.

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death and one of the most prevalent cancers worldwide. HCC prognosis remains poor with an average survival rate between 6 and 12 months. Obstructive jaundice, as a main clinical feature, is uncommon in HCC. HCC with bile duct invasion is much rarer than HCC with vascular invasion. We present a case where a patient's HCC was diagnosed by endoscopic retrograde cholangiopancreatography and digital cholangioscopy because his HCC manifested as an obstructing lesion in the intrahepatic duct, but not in the liver.

Complex regional pain syndrome (reflex sympathetic dystrophy) in a patient with essential mixed cryoglobulinemia and chronic hepatitis C.

Essential mixed cryoglobulinemia (EMC) is a common extra-hepatic manifestation of hepatitis C virus (HCV). Complex Regional Pain Syndrome type I (CRPS) or Reflex sympathetic dystrophy (RSD) has never been reported in association with HCV. This is the first case report of RSD in a patient with HCV related cirrhosis and EMC.

Cryoglobulinaemia and autoimmune markers in hepatitis C virus infected patients on renal replacement therapy.

OBJECTIVE: To investigate the association of cryoglobulinaemia and autoimmune markers with hepatitis C virus (HCV) infection in patients on maintenance haemodialysis (HD) and post renal transplantation. METHODS: Serum samples of 103 HCV-antibody (anti-HCV) positive and 105 anti-HCV negative patients were investigated for cryoglobulins. These comprised 136 patients on HD and 72 renal transplant recipients. Serum creatinine and liver function tests were obtained on all patients. Rheumatoid factor (RF), anti nuclear antibodies (ANA), anti smooth muscle antibodies (ASMA), liver kidney microsomal antibodies (LKM), immunoglobulins (Igs) and complement levels were performed on all cryoglobulin positive (cryopositive) samples. HCV RNA and genotyping detection tests were done for cryopositive patients. RESULTS: The prevalence of cryoglobulins in patients on HD or after renal transplantation was found to be higher (57.6%) among anti-HCV positive patients compared to the anti-HCV negative patients (42.4%) (P=0.000). RF, ANA and ASMA were also higher in cryopositive HCV infected patients. HCV RNA was present in 84.2% of anti-HCV positive patients. Cryoprecipitable RF activity was found in a higher number of symptomatic patients with HCV genotype 1 compared to HCV genotype 3. CONCLUSION: There is an association of cryoglobulinaemia and autoimmune markers in HCV infected patients on HD, and in HCV positive renal transplant recipients. Also HCV genotype 1 is associated with symptomatic mixed cryoglobulinaemia.