Evaluation of plasma soluble urokinase plasminogen activator receptor (SuPAR) levels in ulcerative colitis.

BACKGROUND AND STUDY AIM: Soluble urokinase plasminogen activator receptor (SuPAR), a soluble form of the urokinase-type plasminogen activator receptor, is a biomarker produced by macrophages, monocytes, neutrophils, active T cells, endothelial cells, and circulating tumor cells. SuPAR is a novel biomarker showing altered inflammation in many inflammatory diseases. This study aims to investigate the SuPAR level in ulcerative colitis (UC) patients, and to evaluate the SuPAR level in active, and remission patients. PATIENTS AND METHODS: Patient and healthy control SuPAR levels were analyzed by immunoassay method. SuPAR levels between UC patients and control group were compared. The difference between SuPAR levels in patients with active UC and UC in remission was analyzed. The relationship between C-reactive protein level, Total Mayo score, Mayo Endoscopic score used to predict disease activity, and amount of SuPAR were evaluated. RESULTS: SuPAR levels were determined in the UC patient group (2170,3 ± 121,0 pg/ml), and healthy controls (2130,7 ± 164,8 pg/ml) (p = 0. 805). Median SuPAR levels were determined in moderate UC (2479 pg/ml), mild UC (1944 pg/ml), and patients in remission (1774 pg/ml) (p = 0,207). There were no significant relationships between SuPAR levels and CRP levels, Total Mayo score, disease duration in the UC group (r = 0.177, r = 0.267, and r = 0,007; respectively p > 0.05). A slightly positive correlation was found between Mayo Endoscopic Score and SuPAR level (r = 0.303; p = 0.031). CONCLUSION: SuPAR is of limited value in the diagnosis of ulcerative colitis and in the assessment of disease activation.

Improvement of Work Productivity and Quality of Life with Anti-Tumor Necrosis Factor Treatment Used in Crohn's Disease in Routine Clinical Practice in Turkey.

BACKGROUND: Patients with Crohn's disease experience major deterioration in work productivity and quality of life. We aimed to provide the long-term effects of anti-tumor necrosis factor agents on work productivity and activity impairment and quality of life in patients with Crohn's disease using the Inflammatory Bowel Disease Questionnaire and the Short-Form Health Survey-36. METHODS: Patients with Crohn's disease and initiated an anti-tumor necrosis factor treatment were included and followed up for 12 months in this observational study. RESULTS: A total of 106 patients were included in this study, and 64.2% of the patients were males. Mean [± standard deviation] age was 36.8 [± 10.9] years. At baseline, mostly perianal fistulas [65.7%] were observed [n = 23]. Intestinal stenosis was detected in 34.9% of the patients [n = 37], and most of the stenosis was located in the ileum [70.6%] followed by the colon [20.6%]. Extraintestinal symp- toms were observed in 24 patients [22.6%]. Most frequent extraintestinal symptom was arthritis with 71.4% [n = 15]. Mean time from first symptom to initiation of anti-tumor necrosis factor treatment was 6.3 [± 5.0] years. Improvements in work productivity and activ- ity impairment scores throughout 12 months were -24.1% [P = .003] for work time missed, -18.0% [P = .006] for impairment at work, -8.5% [P = .160] for overall work impairment, and -17.0% [P < .001] for daily activity impairment. Similarly, significant improvements [P < .001] were detected in all components of the Inflammatory Bowel Disease Questionnaire when compared to baseline. Statistically sig- nificant improvements [P < .05] were detected for all components of Short-Form Health Survey-36 except for mental health [P = .095]. CONCLUSION: Our study indicates the significant improvement in work productivity and activity impairment and quality of life of patients with Crohn's disease who receive long-term anti-tumor necrosis factor treatment.

Evaluation of hydrogen peroxide-assisted endoscopic ultrasonography-guided necrosectomy in walled-off pancreatic necrosis: A single-center experience.

ABSTRACT: Hydrogen peroxide is a liquid that functions in mechanical removal of the necrotic tissue via the elimination of tissue debris.In this study, we aimed to evaluate the effectiveness of the use of hydrogen peroxide in necrosectomy treatment of walled-off pancreatic necrosis.Records of 24 patients who were diagnosed with pancreatic necrosis or walled-off pancreatic necrosis and underwent endoscopic necrosectomy (EN) were retrospectively assessed. Patients were divided into 2 groups; hydrogen peroxide used for treatment or not used, and these 2 groups were compared.A total of 24 patients underwent endoscopic intervention for walled-off pancreatic necrosis. Procedural success was comparable between the 2 groups. During the post-procedural follow-up, the duration of the hospital stay, recurrence, and complication rates were found to be similar in both groups. The mean number of the endoscopic interventions was significantly lower in the hydrogen peroxide group (4.2 ±â€Š1.4 vs 6.1 ±â€Š4.2; P = .01).The use of hydrogen peroxide for EN in walled-off pancreatic necrosis patients seems to have similar efficiency and safety. However, it can be said that the use of hydrogen peroxide could reduce the number of endoscopic procedures.

Serum Resolvin E1 Levels and Its Relationship with Disease Activity in Ulcerative Colitis.

BACKGROUND: Resolvins originate from ω-3 PUFA (polyunsaturated fatty acid) precursors and play a role in the resolution of inflammation. The aim of this study was to determine the serum Resolvin E1 levels in patients with ulcerative colitis (UC) and to evaluate the relationship between the serum Resolvin E1 levels and ulcerative colitis disease activity. METHODS: In this observational study, serum samples were collected from 51 patients with UC and 30 healthy controls for the determination of Resolvin E1 levels. Firstly, we compared the serum Resolvin E1 levels between the UC patients and the control group. Subsequently, Resolvin E1 levels were analyzed in patients with active UC and UC in remission. Finally, the correlation between Resolvin E1 and C-reactive protein (CRP) and partial Mayo score (p-MS) was analyzed to determine the efficacy of Resolvin E1 in predicting disease activity. RESULTS: Serum Resolvin E1 level was determined in the UC group (3126 ± 1413 ng/ml) and in the control group (2758 ± 1065 ng/ml) (p = 0.187). Serum Resolvin E1 levels were determined in patients with active UC (3114 ± 1166 ng/ml) and patients in remission (3132 ± 1520 ng/ml) (p = 0.749). In the UC group, a low-grade positive significant association was found between Resolvin E1 and CRP (r = 0.303, p = 0.031). There was no significant association between Resolvin E1 and partial Mayo score (r = -0.207, p = 0.146). CONCLUSIONS: There was no sufficient evidence that Resolvin E1 was an appropriate inflammatory marker to determine disease activity in UC.

Radial EUS Examination Can be Helpful in Predicting the Severity of Acute Biliary Pancreatitis.

We investigated the utility of noncontrast enhanced endosonography (EUS) in predicting the severity of acute pancreatitis (AP) during the first 72 to 96 h of admission.In total, 187 patients with acute biliary pancreatitis were included. The patients were classified into 2 groups as having severe and mild AP according to the Modified Glasgow scoring and computerized tomography severity index (SI). The 158 cases with mild and 29 cases with severe AP had a similar age and sex distribution.Although none of the cases with mild AP developed morbidity and death, of the cases with severe AP, 16 developed serious morbidities and 5 died. On EUS examination, we looked for parenchymal findings, peripancreatic inflammatory signs, free or loculated fluid collections, and abnormalities of the common bile duct and the pancreatic channel. Statistical analysis indicated a significant relationship between the severity of AP with diffuse parenchymal edema, periparenchymal plastering, and/or diffuse retroperitoneal free fluid accumulation, and peri-pancreatic edema. We also defined an EUSSI and found that the EUSSI had sensitivity of 89.7%, specificity of 84.2%, positive predictivity value (PPV) of 88.9%, negative predictivity value (NPV) of 91.2%, and an accuracy of 87.9% in the differentiation of mild and severe AP. We found that the EUSSI had an accuracy of 72.4%, sensitivity of 75.4%, specificity of 65.1%, PPV of 69.3%, and NPV of 73.1% for determining mortality.Our data suggest that EUS allowed us to accurately predict the severity and mortality in nearly 90% of cases with AP.

Can red cell distribution width be a marker of disease activity in ulcerative colitis?

AIM: The current study aimed to investigate the association between disease activity and red cell distribution width (RDW) levels in ulcerative colitis and to determine whether RDW can be used as a marker of disease activity in non-anemic ulcerative colitis. METHODS: The RDW levels of 310 ulcerative colitis patients who underwent colonoscopy were analyzed retrospectively. The patients were divided into two groups (active disease and remission) according to the endoscopic activity index. In addition, the accuracy of RDW in determining disease activity in non-anemic patients was assessed. The efficacy of RDW in determining disease activity was compared to that of white blood cell count, platelet count, C-reactive protein, and erythrocyte sedimentation rate. RESULTS: Two hundred and six (66.5%) patients had active disease, and 104 (33.5%) were in remission. The mean RDW levels in patients with active ulcerative colitis and in those in remission were 16.8±2.9 and 15.5±1.4, respectively (P<0.001). Ninety-six (46.6%) patients in the active disease group and 89 (85.6%) in the remission group were non-anemic, and their respective RDW levels were 15.4±1.2 and 15.3±1.1 (P=0.267). The sensitivity and specificity of RDW in determining inflammation were 41% and 91%, respectively (AUC 0.65, P<0.001). CONCLUSIONS: This study demonstrated that RDW can be used as a marker for disease activity in ulcerative colitis, but it did not have the same efficacy in the non-anemic group.

Serum Syndecan-1 Levels and Its Relationship to Disease Activity in Patients with Crohn's Disease.

Background. Syndecan-1 (SDC-1), a member of the family of heparan sulfate proteoglycans, plays an important role in the resolution of inflammation. This study aimed to investigate the relationship between SDC-1 and disease activity in Crohn's disease (CD). Methods. Serum samples of 54 patients with CD and 30 healthy controls were obtained. First, SDC-1 levels of the CD patients were compared to the control group. Subsequently, SDC-1 levels were analyzed in patients with CD in active and remission periods. Finally, SDC-1 efficacy in predicting disease activity was evaluated by performing correlation analysis between SDC-1 and C-reactive protein (CRP) and Crohn's disease activity index (CDAI). Results. SDC-1 level was higher in the CD group (61.9 ± 42.6 ng/mL) compared with the control group (34.1 ± 8.0 ng/mL) (p = 0.03). SDC-1 levels were higher in active CD patients (97.1 ± 40.3 ng/mL) compared with those in remission (33.7 ± 13.5 ng/mL) (p < 0.001). A significant positive correlation was found between SDC-1 and CRP (r = 0.687, p < 0.001) and between SDC-1 and CDAI (r = 0.747, p < 0.001). Conclusion. Serum levels of SDC-1 are higher in CD compared to the normal population and can be an effective marker of disease severity.

Evaluation of factors associated with response to hepatitis B vaccination in patients with inflammatory bowel disease.

It is recommended to investigate the serology of hepatitis B virus (HBV) and vaccinate seronegative patients at the time of diagnosis in inflammatory bowel diseases (IBD). This study aimed to investigate the efficacy of HBV vaccine and factors affecting the response.In this retrospective, observational study, HBV-seronegative IBD patients were administered 3 doses (at months 0, 1, and 6) recombinant 20  µg HbsAg. Patients' demographics, IBD attributes, and treatment methods were investigated as the factors with potential impacts on vaccination outcomes.One hundred twenty-five patients with IBD were evaluated. The number of patients with Anti-HBs >10  IU/L was 71 (56.8%), and the number of patients with anti-HBs >100  IU/L was 50 (40%). Age, disease activity, Crohn disease subtype, and immunosuppressive treatment (IST) were found to have significant effects on immune response (P = 0.011, P < 0.001, P = 0.003, and P < 0.001, respectively). With multivariate analysis, age < 45 years (OR 3.1, 95% CI 1.2-8.3, P = 0.020), vaccination during remission (OR 5.6, 95% CI 2.3-14, P < 0.001), and non-IST (OR 11.1, 95% CI 2.9-43.2, P = 0.001) had favorable effects on the occurrence of adequate vaccine response.The likelihood of achieving adequate immune response with standard HBV vaccination protocol in IBD is low. Selecting vaccination protocols with more potent immunogenicity is a better approach to achieve effective vaccine response in patients with multiple unfavorable factors.

The last innovation in achalasia treatment; per-oral endoscopic myotomy.

BACKGROUND/AIMS: Per-oral endoscopic myotomy (POEM) is a minimally invasive endoscopic treatment option for patients with achalasia and has been performed since 2010. It is less invasive than Heller myotomy and its use is spreading rapidly worldwide. We present our results of POEM that, to the best of our knowledge, are the first cases in Turkey. MATERIALS AND METHODS: We enrolled patients between May 2014 and September 2014; 8 patients with achalasia whose complaints recurred after pneumatic balloon dilatation underwent POEM. The procedure was performed under general anesthesia at the endoscopy unit of the gastroenterology clinic. Demographic data was recorded before the procedure, and the results of the procedure were recorded prospectively. RESULTS: The median age of the patients was 42.5 (30-72) years. Preoperative and postoperative median Eckardt scores were 10 (8-12) and 1 (0-2), respectively. The median total duration of the procedure was 101 (71-158) min, and the median myotomy length was 13.5 (10-16) cm. Postoperative oral intake started on median day 1 (1-2) and the length of hospital stay was 4 (3-6) days. In 2 patients, capnoperitoneum developed during the procedure and was treated with a Veress needle. CONCLUSION: POEM is a safe endoscopic treatment modality for patients with achalasia in centers that are experienced in advanced endoscopic techniques.

Latent tuberculosis screening tests and active tuberculosis infection rates in Turkish inflammatory bowel disease patients under anti-tumor necrosis factor therapy.

BACKGROUND: Tumor necrosis factor (TNF)-α inhibitors increase the risk of tuberculosis (TB). The objective of the present study was to determine the rate of active TB infection in inflammatory bowel disease (IBD) patients receiving anti-TNF therapy and to determine the results of their latent TB infection (LTBI) screening tests during the follow up. METHODS: This is a retrospective observational study of IBD patients receiving anti-TNF therapy. Tuberculin skin test (TST), interferon-γ release assay (IGRA), and chest radiography were used to determine LTBI. Active TB infection rate during anti-TNF treatment was determined. RESULTS: Seventy-six IBD patients (25 with ulcerative colitis, 51 with Crohn's disease; 53 male; mean age 42.0±12.4 years) were included. Forty-four (57.9%) patients received infliximab and 32 (42.1%) adalimumab. Their median duration of anti-TNF therapy was 15 months. Forty-five (59.2%) patients had LTBI and received isoniazid (INH) prophylaxis. During the follow-up period, active TB was identified in 3 (4.7%) patients who were not receiving INH prophylaxis. There was a moderate concordance between the TST and the IGRA (kappa coefficient 0.44, 95% CI 0.24-0.76). Patients with or without immunosuppressive therapy did not differ significantly with respect to TST (P=0.318) and IGRA (P=0.157). CONCLUSION: IBD patients receiving anti-TNF therapy and prophylactic INH have a decreased risk of developing active TB infection. However, despite LTBI screening, the risk of developing active TB infection persists.

What is the most accurate method for the treatment of diminutive colonic polyps?: Standard versus jumbo forceps polypectomy.

Different methods such as standard, hot, and jumbo forceps are used in endoscopic treatment of diminutive colon polyps. In the current study, it was aimed to compare efficacy and safety of standard and jumbo forceps polypectomy methods in treatment of diminutive colon polyps of ≤5 mm. Polyps with ≤5 mm which were excised during colonoscopy by using standard or jumbo forceps were evaluated. Standard and jumbo forceps polypectomy methods were randomly performed in 212 consecutive patients with diminutive colorectal polyp. One-bite polypectomy and complete resection rates were also determined among polypectomy methods. Results of 161 standard forceps polypectomy and 102 jumbo forceps polypectomy were retrospectively evaluated. Both one-bite polypectomy and complete resection rates were significantly higher in the jumbo forceps polypectomy group than the standard forceps polypectomy group (P < 0.001). In the subgroup analysis performed according to polyp sizes, complete resection rate among polyps with 3-mm diameter was determined as 100%. However, numbers of bites in 4-mm and 5-mm polyps were higher in the standard forceps polypectomy group, and complete resection rate was lower than in the jumbo forceps polypectomy group (P < 0.001). Both endoscopic treatment methods may be employed in treatment of diminutive colon polyps with ≤5 mm. However, jumbo forceps polypectomy is a more effective treatment method in 4- to 5-mm polyps with high one-bite polypectomy and complete resection rate.

The effect of intravenous iron treatment on quality of life in inflammatory bowel disease patients with nonanemic iron deficiency.

Background. Iron deficiency is the prevalent complication of inflammatory bowel disease (IBD). Herein, we investigated the effect of intravenous iron treatment on quality of life (QoL) in nonanemic and iron deficient IBD patients. Methods. Eighty-five IBD patients were recruited for this study. The patients were intravenously administered 500 mg iron sucrose in the first week of the study. Hematologic parameters and QoL were evaluated before to iron treatment and during the 12th week of treatment. The Inflammatory Bowel Disease Questionnaire (IBDQ) and the Short Form-36 (SF-36) Health Survey were used to assess QoL. Results. Prior to intravenous iron administration, the IBDQ, SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were 152.3 ± 30.6, 46.7 ± 7.3, and 45.7 ± 9.8, respectively. In the 12th week of iron administration, those scores were 162.3 ± 25.5 (P < 0.001), 49.3 ± 6.4 (P < 0.001), and 47.6 ± 8.9 (P = 0.024), respectively, which were all significantly different from the scores prior to iron administration. The mean changes in the IBDQ scores for ulcerative colitis and Crohn's disease were 8.7% and 3.0% (P = 0.029), were 6.4% and 4.7% (P = 0.562) for the SF-36 PCS, and were 4.6% and 3.2% (P = 0.482) for the SF-36 MCS, respectively. Conclusion. Intravenous iron treatment may improve QoL in nonanemic, but iron deficient, IBD patients.

Endoscopic submucosal dissection in gastric lesions: the 100 cases experience from a tertiary reference center in West.

OBJECTIVE: Endoscopic submucosal dissection (ESD) is an endoscopic treatment method widely used in premalignant and malignant lesions in countries of the Far East. This method, which is difficult technically and has a high complication risk rate, has rarely been performed in the West, because of the fewer number of upper gastrointestinal lesions. In the present study, we aimed to present our results of gastric ESD procedures in respect to the learning curve. METHODS: A total of 100 ESD procedures, which were performed in the stomach between April 2012 and September 2014, were recorded prospectively before and after the procedure. Patient data were analyzed retrospectively. ESD procedures were numbered chronologically; the first 30 patients constituted group 1, whereas the rest were classified as the group 2. ESD results were compared between the groups. RESULTS: In a total of 95 patients, 100 gastric ESDs were performed. The overall en-bloc and complete resection rates were 93% and 92%, respectively. In respect of the learning curve, there were significant differences in the sizes of lesions and tissues obtained, procedure duration and dissection rate, snare use and knife preferences between groups (p = 0.002, p < 0.001, p = 0.003, p < 0.001, p = 0.009, and p < 0.001, respectively). No significant difference was detected in the en-bloc and complete resection rates and complications between the groups. CONCLUSION: According to guideline recommendations and masters for ESD, if ESD training is initiated and continued, successful ESD may be performed in localized lesions in the stomach.

An Evaluation of the Correlation between Hepcidin Serum Levels and Disease Activity in Inflammatory Bowel Disease.

Aim. While there are many well-defined serological markers for inflammatory bowel disease (IBD), there is limited evidence that they positively affect clinical outcomes. This study aimed to evaluate the correlation between hepcidin serum levels and disease activity in IBD. Materials and Methods. Eighty-five consecutive IBD patients were enrolled in the study. Hepcidin serum levels were assessed using an enzyme-linked immunosorbent assay (ELISA) and were compared with disease activity as well as the interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Results. The mean hepcidin serum levels in Crohn's disease (CD) patients in remission and in the active phase were 3837 ± 1436 and 3752 ± 1274 pg/mL, respectively (P = 0.613). The mean hepcidin serum levels in ulcerative colitis (UC) patients in remission and in the active phase were 4285 ± 8623 and 3727 ± 1176 pg/mL, respectively (P = 0.241). Correlation analysis between inflammatory markers and hepcidin serum levels indicated that there was no correlation between hepcidin levels and IL-6 (P = 0.582) or CRP (P = 0.783). Conclusion. As an acute-phase protein, hepcidin seems to have a lower efficacy than other parameters in the detection of activation in IBD.

The usage of overtube has a favorable effect on endoscopic submucosal dissection.

BACKGROUND: Endoscopic submucosal dissection (ESD) may be very time consuming, and depending on the anesthesia, the contents of the stomach may reflux to the esophagus and cause the patient to aspirate. To prevent these situations, many practitioners suggest using an overtube, but no study has been done to evaluate the effect of the use of an overtube while performing the ESD procedure. Our aim was to investigate the effects of performing an upper gastrointestinal ESD with and without overtube. METHODS: Records of patients who underwent ESD were evaluated for histopathological results, complications, speed of dissection, dosages of anesthetic medications, and number of suctions performed during the procedure. The patients were classified into two depending on whether an overtube was used or not. RESULTS: There were a total of 58 patients on which 63 upper gastrointestinal ESD procedures were performed. Regarding age, gender, localization of the lesions, duration of the procedures, dosage of propofol, histopathological results, rate of complete resection, and rate of en-bloc resection, there was no difference between the two groups (p > 0,05). But the size of the lesions, the size of the resected specimen, and the speed of dissection were statistically different in two groups (p = 0.018, p < 0.001, p < 0.001, respectively).The need for suction during the procedure was much lower in the overtube group than those with no overtube (p < 0.001). CONCLUSIONS: We conclude that using an overtube during an upper gastrointestinal ESD decreases the need for suction, favors the speed of dissection, and eases the comfort of the procedure.

Evaluation of the relationship between serum ghrelin, C-reactive protein and interleukin-6 levels, and disease activity in inflammatory bowel diseases.

BACKGROUND/AIMS: Ghrelin is a 28 aminoasid peptide hormone, have generally focused upon this peptide's role upon growth and energy metabolism. Recently, studies investigating ghrelin's effect upon inflammation and immune response have gained importance. We aimed to compare the effectiveness of ghrelin levels, Creactive protein and interleukin-6 levels in establishing disease activity. METHODOLOGY: 52 cases with ulcerative colitis and 33 with Crohn's disease, total 85 patients, were included in this study. The serum ghrelin levels of the patients in remission and of those with active disease were compared. RESULTS: The mean serum ghrelin level in active patients (1243 ± 648 pg/ml), was found to be higher than those in remission (466 ± 214 pg/ml) (p<0.001). In establishing the disease activity, CRP is a the most effective marker compared to the other two inflammatory markers. AUC values were established as; CRP: 0.947 (95% CI,0.903-0.992),ghrelin:0.934(95% CI, 0.884-0.984) and interleukin-6: 0.756 (95% CI, 0.648- 0.864). DISCUSSION: Serum ghrelin level can be used with CRP as an important marker in establishing the mucosal damage in inflammatory bowel diseases.

Clinical utility of hepatitis B surface antigen levels during the natural history and treatment of chronic hepatitis B infection.

INTRODUCTION: Hepatitis B surface antigen (HBsAg) level quantitation may be helpful for understanding the natural history of the disease and its response to treatment. AIM: To determine the serum HBsAg levels during the different phases of chronic hepatitis B (CHB) infection and HBsAg levels of patients who are on treatment with oral antiviral drugs. MATERIAL AND METHODS: PATIENTS WERE CATEGORIZED IN FOUR GROUPS: 9 patients in the immune clearance (IC) phase, 46 patients in the inactive carrier (INC) phase, 25 patients in the reactivated HBeAg negative disease (END) phase and 60 HBeAg negative patients who were on treatment with oral antiviral drugs. HBsAg levels were compared between all groups. HBsAg and HBV DNA levels were compared in three phases of HBV infection. Patients on treatment were divided into two groups, taking lamivudine (L) and taking tenofovir (T). HBsAg levels were compared between END, L and T groups. RESULTS: The HBsAg levels were different between each phase of CHB (p < 0.0001). HBsAg levels were highest in the IC phase and lowest in the INC phase. The HBsAg/HBV DNA ratio was significantly higher in the INC phase than the END and IC phases (p < 0.0001). HBsAg levels were higher in the END phase than the INC phase (p < 0.0001) and higher than the treatment group (p = 0.007). The HBsAg levels had a good correlation with HBV DNA in the natural course of CHB (r = 0.72, p < 0.0001). HBsAg levels were higher in the END group than the L and T groups (p < 0.05). HBsAg levels were higher in the L than the T group (p < 0.05). CONCLUSIONS: This study demonstrates that HBsAg levels vary during the natural history of chronic hepatitis B infection. Also, the monitoring of HBsAg levels may help us to determine the best management strategy and to decide future treatment algorithms.