Evaluation of normal or minimally elevated alanine transaminase, age and DNA level in predicting liver histological changes in chronic hepatitis B.

BACKGROUND: Serum alanine transaminase (ALT), hepatitis B virus (HBV) DNA level and age are used in the evaluation of chronic hepatitis B (CHB). AIM: We designed this study to evaluate liver histology with ALT and its relation with age and HBV DNA. METHODS: During the period of October 2006 to July 2009, 499 CHB patients were included in this study with detectable HBV DNA at PCR. Of these, 181 had normal ALT, 200 had ALT [>(1 × ULN) < (2 ULN)] and 118 had ALT ≥ 2 ULN and were labelled as Group 1, 2 and 3 respectively. RESULTS: A strong positive correlation was found between ALT and histological activity index (HAI) and fibrosis. However, 29 (52.7%) and five (9.1%) in Group 1 with positive HBeAg status had HAI ≥4 and fibrosis ≥2 respectively. Among those with HBeAg-negative status, 66 (23.1%) had HAI >4 and 31 (10.8%) had fibrosis ≥2. In Group 2, 14 (15.7%) had moderate-to-severe HAI and 19 (21.2%) had fibrosis ≥2 when HBeAg was positive, in those with HBeAg negative 34 (30.6%) had moderate-to-severe HAI and 38 (34.2%) had fibrosis ≥2. An ALT value of ≥58.5 U/l had higher sensitivity than that of 80 U/l in predicting significant histological changes. Further, HAI and fibrosis were significantly greater in the age of >30 years. CONCLUSIONS: We recommend liver biopsy in HBeAg-negative CHB over 30 years of age regardless of ALT level and starting treatment at ALT 1.5 × ULN instead of 2 × ULN.

Percutaneous liver biopsy: technique and safety.

BACKGROUND/AIMS: Percutaneous liver biopsy is a commonly used procedure for management of patients with liver diseases. We studied 107 patients of liver diseases with percutaneous liver biopsy to assess the need and usefulness of post procedure abdominal binder, analgesics, antibiotics or blood transfusion, and safety of the procedure. METHODOLOGY: We selected 107 consecutive patients having clear indication for liver biopsy. Each and every patient underwent percutaneous liver biopsy under uniform technique. The study was performed at the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh during the period from July 2006 to December 2007. RESULTS: Mean age of the patients was 27.35 years with +/- 7.62 (SD) years. Eighty five of them were male and 22 were female. No abdominal binder or antibiotic was used after the procedure. No analgesic or blood transfusion was required after the procedure. CONCLUSION: Routine post procedure use of abdominal binder and antibiotic are needless. Analgesics and blood transfusion are not always needed after the procedure. Percutaneous liver biopsy is a safe procedure in expert hands.

HEV infection as an aetiologic factor for acute hepatitis: experience from a tertiary hospital in Bangladesh.

Acute hepatitis is seen sporadically round the year in Bangladesh. The incidence of acute viral hepatitis E increases after floods as this allows sewerage contamination of piped and groundwater. The aim of this retrospective study was to assess the burden of hepatitis E virus (HEV infection) in Bangladesh. Patients attending the Hepatology Unit III of the Bangabandhu Sheikh Mujib Medical University, during June 2004-December 2006, were included in the study. All viral markers were tested by enzyme-linked immunosorbent assay. The study population was divided in four groups. Group 1 included 144 patients with acute viral hepatitis. The inclusion criteria were: nausea and/or vomiting, loss of appetite, serum bilirubin >200 micromol/L, raised serum transaminases, and prothrombin time >3 seconds prolonged beyond control value. In Group 2, there were 31 pregnant women with acute viral hepatitis. All the patients had prodrome, icterus, raised serum bilirubin and raised serum transaminase levels. Group 3 included 23 patients presenting with fulminant hepatic failure. In Group 4, 69 patients with cirrhosis of liver were included. They presented with features of decompensation for the first time. The inclusion criteria were: patients with established cirrhosis with jaundice and/or ascites and/or hepatic encephalopathy. In Group 1, 58.33% of the 144 patients had acute viral hepatitis E. In Group 2, 45.16% of the pregnant women also had acute viral hepatitis E. HEV was responsible for 56.52% cases of fulminant hepatic failure in Group 3. In 21.7% cases in Group 4, decompensation of cirrhosis was due to HEV. Acute viral hepatitis E in the third trimester of pregnancy and HEV-induced fulminant hepatic failure were associated with 80% of mortality despite the best possible care. In this clinical context, acute viral hepatitis E is the leading cause of wide spectrum of liver disease ranging from severe acute viral hepatitis, fulminant hepatic failure, to decompensation of liver in cirrhotics in Bangladesh. Sewerage contamination of piped water following floods may contribute to the higher incidence of HEV infection.

Hepatitis E virus is a leading cause of acute-on-chronic liver disease: experience from a tertiary centre in Bangladesh.

BACKGROUND: Acute-on-chronic liver failure (ACLF) is common in Bangladesh. Acute viral E hepatitis is sporadically encountered in this country each year, with a rising incidence in the rainy season. This study aimed to identify the etiology of ACLF in Bangladesh. METHODS: In this retrospective study, 69 ACLF patients were included. They presented to our department at the Bangabandhu Sheikh Mujib Medical University in Dhaka. History of diseases was recorded and appropriate investigations were conducted in all patients. RESULTS: Acute hepatitis E virus (HEV) infection was positive in 21.7% (15/69) of the patients, while 14.5% (10/69) had septicemia. Upper gastrointestinal tract hemorrhage was seen in 4.3% of the patients (3/69), while another 4.3% (3/69) had a positive history for alcohol or drugs. None of the patients tested positive for hepatitis A virus infection and no evidence of hepatitis B virus flare was found in any patient. No specific cause for ACLF could be identified. CONCLUSIONS: Acute HEV infection is a leading cause of ACLF in Bangladesh. Many patients were thought to have decompensation of cirrhosis, but subsequently were recognized as having ACLF by a retrospective review according to the definition of the Asian Pacific Association for the Study of the Liver Working Party Meeting on ACLF in New Delhi in early 2008.

Hepatitis B virus genotypes: an overview.

BACKGROUND: Hepatitis B virus (HBV) infection is a major cause of mortality and morbidity globally. The quest continues to identify viral factors that influence disease progression and severity as well as responses to treatment of HBV infection. Based on variations in HBV, the virus has been divided into a number of genotypes. DATA SOURCES: Review of published literature on HBV genotypes. RESULTS: HBV genotypes are likely to be important in determining the severity and progression of HBV-induced liver disease as well as responses to different anti-viral agents. CONCLUSION: Although HBV genotyping is not yet recommended for routine use in treating HBV infection, available data suggest that, as in hepatitis C virus infection, HBV genotyping is also likely to become a routine investigation for HBV treatment, perhaps in the not too distant future.

Etiology of fulminant hepatic failure: experience from a tertiary hospital in Bangladesh.

BACKGROUND: Fulminant hepatic failure (FHF) is not uncommon in our clinical practice in Bangladesh. There was a rise in acute hepatitis E virus (HEV) in Bangladesh after the 2004 floods. At that time, most of the country was under water for more than a month, leading to sewage contamination of the water supply. The aim of this study was to investigate the etiology of FHF in Bangladesh. METHODS: In this retrospective study, 23 patients with FHF who presented with severe impairment of hepatocellular function (i.e. encephalopathy, coagulopathy and jaundice) within 6 months of onset of symptoms were included. There were 17 men and 6 women, aged from 18 to 32 years. Four of the women were pregnant. Patients were tested for markers for common hepatotrophic viruses. A relevant history was taken and the Patient Record Book of the Unit was reviewed. RESULTS: 56.52% patients (13/23) had HEV infection, and all were anti-HEV IgM-positive tested by ELISA. HBV infection was detected in 34.78% patients (8/23), all of whom were tested positive for either HBsAg or anti-HBs IgM by ELISA. 8.7% patients (2/23) had a positive history for intake of alcohol and/or drugs. CONCLUSIONS: Acute HEV infection is the leading cause of FHF in Bangladesh. Sewage contamination of the water supply following floods contributes to a higher incidence of HEV infection. HBV infection is also important.

e-antigen-negative chronic hepatitis B in Bangladesh.

BACKGROUND: Bangladesh is a densely populated country where about 10 million people are chronically infected with hepatitis B virus (HBV). The aim of the present study was to evaluate the biochemical, virological and histological characteristics of HBeAg-negative chronic hepatitis B (CHB). METHODS: Patients were included in this study if they were chronically infected with HBV with detectable DNA. The patients who were co-infected with human immunodeficiency virus, hepatitis delta virus or hepatitis C virus, and previously subjected to antiviral treatment, and those with hepatocellular carcinoma were excluded. The study was conducted during the period of January 2001 to December 2007. During this period 2617 patients with CHB were studied. HBeAg-positive cases were included to compare the characteristics. Among them, 237 cases underwent liver biopsy. RESULTS: 2296 patients (87.7%) were male, with a mean age of 28.9+/-13.7 years. 2375 patients (90.8%) had CHB, and 242 (9.2%) were cirrhotic. HBV DNA levels were 7.6+/-1.5 copies/ml, ALT was 111.3+/-212.5 U/L, and AST was 91.5+/-148.9 U/L. The number of HBeAg-negative CHB cases was 1039 (39.7%). HBeAg-negative patients with a lower DNA load were older, and they had more fibrotic changes in the liver than HBeAg-positive patients. The two groups did not differ in necroinflammatory activity, but the former had lower ALT and AST values. Cirrhosis was more common in e-antigen-negative patients. CONCLUSIONS: e-antigen-negative CHB patients are older and have more hepatic fibrosis patients than HBeAg-positive patients, although they have similar necroinflammatory activity.

Epidemiology of hepatitis B virus in Bangladeshi general population.

BACKGROUND: Hepatitis B virus (HBV) is encountered sporadically the year round in Bangladesh. It results in a wide range of liver diseases, with asymptomatic acute hepatitis at one end to hepatocellular carcinoma (HCC) at the other end of the spectrum. METHODS: All 1018 individuals of different age groups and sex with varied religious, educational and social backgrounds were tested for HBsAg by ELISA. The positive samples were further tested by ELISA for HBeAg. Before testing, blood samples were preserved at -20 degree centigrade. The study was conducted in a semi-urban location on the outskirts of Dhaka. RESULTS: Of the 1018 individuals, 5.5% tested positive for HBsAg. None were tested positive for anti-HCV. Among the HBsAg-positive population, 58.93% were HBeAg-positive and the rest 41.07% HBeAg-negative. There was a male predominance and those who were tested positive were mostly between 16 and 50 years of age. Major risk factors for exposure to HBV appeared to be injudicious use of injectable medications, treatment by unqualified, traditional practitioners, mass-vaccination against cholera and smallpox, barbers and body piercing. CONCLUSION: HBV remains a major cause of morbidity and mortality in Bangladesh and we have a long way to go before we may bid farewell to this deadly menace.

Study on ascitic fluid complement 3 level in cirrhotic patients with spontaneous bacterial peritonitis and without spontaneous bacterial peritonitis.

BACKGROUND/AIMS: Ascitic fluid Complement 3 (C3) concentration is the most important factor to offer local defense against infection of ascitic fluid. Hepatic synthesis of Complement 3 and its concentration in ascitic fluid is significantly reduced in patients with advanced cirrhosis. The aim of the study was to assess the level of Complement 3 in ascitic fluid in cirrhotic patients with and without spontaneous bacterial peritonitis (SBP) and to identify the group of cirrhotic ascites at risk of developing METHODOLOGY: A prospective case control study was carried out to compare the level of ascitic fluid Complement 3 concentration in patients with SBP (case-group) and without SBP (control-group). Ascitic fluid Complement 3 level was estimated in 15 patients with SBP (case) and another 15 patients without SBP (control). RESULTS: In the study, ascitic fluid Complement 3 concentration was 7.3+/-4.3 mg/dL in patients with SBP and 16.4+/-11.3 mg/dL in patients who did not develop SBP. CONCLUSIONS: Ascitic fluid Complement 3 level is significantly (P=0.009) reduced in cirrhotic patients who develop SBP.

Viral load speaks little about toll on liver.

BACKGROUND: Bangladesh is situated in the intermediate prevalence region of hepatitis B virus (HBV). The lifetime risk of acquiring HBV infection in Bangladesh is greater than 40%. It has been estimated that this virus is responsible for 10%-35% cases of acute viral hepatitis, 35.7% cases of fulminant hepatic failure, 33.3%-40.5% cases of chronic hepatitis and 46.8% cases of hepatocellular carcinoma in Bangladesh. The aim of this study is to compare the correlation between HBV DNA load and grade and stage of liver disease in patients with chronic hepatitis B (CHB). METHODS: Percutaneous liver biopsies done in 159 CHB patients revealed 62.9% (100 patients) had wild type HBV infection and the rest 37.1% (59) had pre-core/core promoter mutant HBV infection. HBV DNA load was measured using PCR in all patients. RESULTS: In the wild type CHB group, 97% (97 patients) had moderate to high HBV DNA load and 3% (3) had low to moderate HBV DNA. In the pre-core/core promoter mutant group, 74.6% (44 patients) had moderate to high HBV DNA and the rest 25.4% (15) had low to moderate HBV DNA. The patients with moderate to high HBV DNA of the patients with wild type CHB, 78.4% (76 patients) had minimal to mild chronic hepatitis (HAI-NI 0-8) and 21.6% (21) had moderate to severe chronic hepatitis (HAI-NI 9-18). 66.6% (2 patients) and 33.3% (1) patients with low to moderate HBV DNA load had minimal to mild and moderate to severe chronic hepatitis respectively. In the moderate to high HBV DNA group, 77.3% (75 patients) patients had minimal to moderate fibrosis (HAI-F 0-2) and 22.7% (22) (HAI-F 3-4) had severe fibrosis to cirrhosis. These figures were 33.3% (1 patient) and 66.6% (2) respectively in the patients with low to moderate HBV DNA load. On the other hand in case of patients with pre-core/core promoter mutant type CHB, in the moderate to high HBV DNA group, 79.5% (35 patients) had minimal to mild chronic hepatitis (HAI-NI 0-8) and 20.5% (9) had moderate to severe chronic hepatitis (HAI-NI 9-18). 93.3% (14) and 6.7% (1) patients with low to moderate HBV DNA load had minimal to mild and moderate to severe chronic hepatitis respectively. In the moderate to high HBV DNA group, 68.2% (30 patients) had minimal to moderate fibrosis (HAI-F 0-2) and 31.8% (14) (HAI-F 3-4) had severe fibrosis to cirrhosis. These figures were 86.7% (13) and 13.3% (2) respectively in patients with low to moderate HBV DNA load. CONCLUSIONS: The study shows that high HBV DNA load does not correlate with necro-inflammatory activity or extent of fibrosis in the liver in patients with either wild type or pre-core mutant type CHB.

Presentation and endoscopic management of biliary ascariasis.

Ascaris lumbricoides is a common parasite and the most serious and dramatic presentation is hepatobiliary and pancreatic ascariasis (HPA). Therefore, this study was planned prospectively to elucidate the clinical presentation of HPA and evaluate the efficacy and safety of endoscopic intervention. In this study we documented 77 consecutive patients with HPA from January 2000 to November 2005. All the patients had endoscopically proven HPA. A total of 77 patients were included in the study. The age ranged from 6 to 80 years, with the third decade most commonly (28.6%) affected. Females were 6 times more likely to be affected than males. The commonest presentation was biliary colic (97.4%); other presentations were acute cholangitis (15.6%), obstructive jaundice (9.1%), acute pancreatitis (6.5%), choledocholithiasis (6.5%), acute cholecystitis (6.5%) and liver abscess (2.6%). In this report 51 (66.2%) had living, 10 (13%) had dead and 16 (20.8%) had both living and dead worms. Choledocholithiasis was associated only with dead worms. From one to 23 worms were found in the biliary tree. In 94.8% of cases we had to remove the worm by wide papillotomy followed by basket extraction. We did not experience any major complications during or following the procedures. Three patients had recurrent HPA during the course of follow-up (1 to 12 months). The majority of patients with HPA presented with biliary colic. This should be kept in mind in the management of an acute abdomen, especially in tropical countries. Endoscopic extraction is a safe and effective procedure for the treatment of HPA.

Relationship between Hepatitis B Viral Deoxyribonucleic Acid Load and Hepatocellular Carcinoma.

INTRODUCTION: Hepatitis B virus (HBV) infection is an established cause of hepatocellular carcinoma (HCC) and is associated with poor prognosis. High HBV deoxyribonucleic acid (DNA) load has been identified in HCC and hepatitis B surface antigen-positive patients. MATERIALS AND METHODS: This study was done in the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, from January 2006 to December 2007. Thirty patients with HBV infection-related HCC were enrolled. Another 30 patients with HBV-related liver diseases without HCC were analyzed as controls. RESULTS: The HCC patients had a high viral load (>105 copies/mL), while all of the controls had low (<105 copies/mL) viral load. CONCLUSION: It seems that patients with HCC bear high HBV DNA loads in Bangladesh, but the causes underlying this remain to be resolved.How to cite this article: Hussain MM, Al Mahtab M, Islam S, Ahmed N, Rahman S, Khan M. Relationship between Hepatitis B Viral Deoxyribonucleic Acid Load and Hepatocellular Carcinoma. Euroasian J Hepato-Gastroenterol 2017;7(1):111-112.

Plasma Prothrombin Time and Esophageal Varices in Patients with Cirrhosis of Liver.

INTRODUCTION: Cirrhosis of the liver is a common complication of chronic liver disease and is associated with portal hypertension and esophageal varices. In this study, we checked the implication of prothrombin time, if any, in the genesis of esophageal varices. MATERIALS AND METHODS: Sixty patients with cirrhosis of the liver were randomly assigned into two groups: Group I - 30 cirrhotic patients with esophageal varices, and group II - 30 cirrhotic patients without esophageal varices. The prothrombin time was checked for both groups. RESULTS: A positive correlation was found between the prolonged plasma prothrombin time (> 4 seconds) and esophageal varices with a sensitivity of 56.67% and specificity of 73.33%. The Child-Pugh score showed a correlation; however, the size of varices did not exhibit any such relation. CONCLUSION: Prothrombin time may be cautiously used to assess portal hypertension in a field level and rural setting where endoscopy is not available or feasible. HOW TO CITE THIS ARTICLE: Islam MN, Khan M, Ahmad N, Al-Mahtab M, Karim MF. Plasma Prothrombin Time and Esophageal Varices in Patients with Cirrhosis of Liver. Euroasian J Hepato-Gastroenterol 2016;6(1):10-12.

Variant of Ascitic Fluid Bacterial Infections in Patients of Liver Cirrhosis.

BACKGROUND AND AIMS: Bacterial infections of ascitic fluid of cirrhotic patients are related to high morbidity and mortality. The aim of the study was to determine the variants of ascitic fluid bacterial infection in patients with advanced cirrhosis (Child Pugh Class C). MATERIALS AND METHODS: We analyzed 35 consecutive cirrhotic patients of Child Pugh Class C with ascites attending the outpatient department (OPD) of Hepatology Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2008 to December 2009. Clinical and laboratory parameters of these patients were recorded. RESULTS: Among the total 35 patients, eight patients were symptomatic and 27 patients were asymptomatic. Out of eight symptomatic patients, two had ascitic fluid bacterial infection (25%), whereas six of 27 asymptomatic patients (22.2%) had ascitic fluid bacterial infection. CONCLUSION: Bacterial infection should always be considered in patients with ascites with liver cirrhosis irrespective of their symptoms. HOW TO CITE THIS ARTICLE: Sarker JA, Alam MS, Khan M, Mahtab MA, Ashraf MS, Khondaker FA. Variant of Ascitic Fluid Bacterial Infections in Patients of Liver Cirrhosis. Euroasian J Hepato-Gastro-enterol 2015;5(2):131-133.

Frequent coinfection with hepatitis B virus strains of distinct genotypes detected by hybridization with type-specific probes immobilized on a solid-phase support.

A genotype-specific probes assay (GSPA) was developed for distinguishing the seven genotypes (A-G) of hepatitis B virus (HBV). Nucleotide (nt) sequences corresponding to preS1 region were amplified by PCR with a primer labeled with biotin, and delivered to eight wells on which complementary sequences specific to one or other genotype had been immobilized. Thereafter, hybridization of HBV DNA sequences amplified from the test serum was detected by colorimetry. When 256 sera from HBV carriers in Bangladesh, Cameroon, Japan, South Africa, USA and Uzbekistan were subjected to GSPA, genotypes were concordant with those of ELISA with monoclonal antibodies to epitopes on preS2-region products in 242 (94.6%) of them; 8 sera (3.1%) were not genotypeable by either method. Cloning analysis confirmed the presence of two distinct HBV genotypes in the seven selected sera with coinfection. There were 7 (2.7%) sera with discordant genotyping results between GSPA and ELISA. When HBV DNA clones propagated from these sera were sequenced and analyzed phylogenetically, the genotypes determined by GSPA were verified. Coinfection with HBV strains of two distinct genotypes was identified by GSPA in 28 (10.9%) sera, while it was suggested by ELISA in only 2 (0.8%) sera. The GSPA method would be particularly useful for detecting the coinfection with distinct HBV genotypes of any clinical relevance, which seems to be more frequent than reported previously.

Comparative study on presentation of biliary ascariasis with dead and living worms.

BACKGROUND/AIM: Ascariasis is a common parasitic infestation in Asia and Latin America. The most serious presentation is biliary and pancreatic ascariasis (BPA). The aim of the present study was to compare the clinical presentation of BPA with dead worms with that with living worms. MATERIALS AND METHODS: We included 138 consecutive cases of BPA that occured during the period January 2005 to July 2009. All the patients had endoscopically proven BPA consisting of living or dead worms. Comparison was done by chi-square and independent t tests. RESULTS: The age (mean +/- SD) of the patients was 36.8 +/- 16.1 years. Prevalence ratio between male and female patients was 1:5. Ninety eight patients contained living worms and 40 had dead worms. Males were more prone to develop dead worm BPA. The commonest presentation was biliary colic (131; 94.9%); others were acute cholangitis (30; 21.7%), obstructive jaundice (19; 13.8%), choledocholithiasis (20; 14.5%), acute pancreatitis (10; 7.2%), acute cholecystitis (6; 4.3%), liver abscess (2; 1.4%), hepatolithiasis (3; 2.2%), stricture of common bile duct (2; 1.4%), pancreatic abscess (1; 0.7%) and cirrhosis of liver (1; 0.7%). Choledocholithiasis, hepatolithiasis, liver abscess and cirrhosis were associated only with dead worms. We could successfully remove all the worms with endoscopic interventions, but 5 patients required surgical intervention as there were strictures and stones within the biliary tree or Ascaris were in gallbladder. Recurrences of stone and cholangitis occurred only in those with dead worms. CONCLUSION: Biliary ascariasis with dead worms is more dangerous than that with living worms. Endoscopic or surgical intervention may be required repeatedly in those with dead worms.

Natural course of fulminant hepatic failure: the scenario in Bangladesh and the differences from the west.

BACKGROUND/AIM: Fulminant hepatic failure (FHF) is a devastating complication of acute viral hepatitis, leading to death in most cases. The etiology and predictors of outcome differ according to the geographical region. This study was conducted with the aim of evaluating the etiology, complications, and outcome of FHF in Bangladesh. PATIENTS AND METHODS: In this prospective study, we included 67 consecutive cases of FHF presenting to the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, between November 2003 and May 2008. Thirty-nine of the patients were male and 28 were female. Data was analyzed using SPSS, version 13.0. RESULTS: The mean age of the subjects was 31.9 +/- 11 .7 years. Hepatitis E virus (HEV) was the commonest etiological factor for FHF (50 cases, 74.6%); of the 50 cases with HEV infection, 43 (64.2%) were not coinfected with any other virus, four cases were Hepatitis B virus (HBV) carriers, and three had coinfection with hepatitis A virus (HAV). HBV was the cause of FHF in nine (13.4%) patients. HCV, paracetamol, and alcohol were not responsible for any of the cases. Most of the patients (57 patients, 85%) developed FHF within 2 weeks of the onset of jaundice. Of the 67 patients, 49 (73.1%) died. Cerebral edema was the single most common cause of death (48 patients, 71.6%). Other complications were renal failure (23 patients, 34.3%), sepsis (15 patients, 22.4%), electrolyte imbalance (12 patients 17.9%), and bleeding tendency (7 patients, 10.4%). Occurrence of cerebral edema, longer prothrombin time, higher grade of encephalopathy, and longer jaundice-to-encephalopathy interval had significant negative influence on outcome. CONCLUSIONS: The etiology of FHF in Bangladesh is different from that in the West. Prolongation of prothrombin time and occurrence of cerebral edema are predictors of the worst prognosis.