Diagnosis and Management of Hepatic Hydrothorax.

Hepatic hydrothorax is a pleural effusion (typically ≥500 mL) that develops in patients with cirrhosis and/or portal hypertension in the absence of other causes. In most cases, hepatic hydrothorax is seen in patients with ascites. However, ascites is not always found at diagnosis and is not clinically detected in 20% of patients with hepatic hydrothorax. Some patients have no symptoms and incidental findings on radiologic examination lead to the diagnosis of the condition. In the majority of cases, the patients present with symptoms such as dyspnea at rest, cough, nausea, and pleuritic chest pain. The diagnosis of hepatic hydrothorax is based on clinical manifestations, radiological features, and thoracocentesis to exclude other etiologies such as infection (parapneumonic effusion, tuberculosis), malignancy (lymphoma, adenocarcinoma) and chylothorax. The management strategy involves a stepwise approach of one or more of the following: Reducing ascitic fluid production, preventing fluid transfer to the pleural space, fluid drainage from the pleural cavity, pleurodesis (obliteration of the pleural cavity), and liver transplantation. The complications of hepatic hydrothorax are associated with significant morbidity and mortality. The complication that causes the highest morbidity and mortality is spontaneous bacterial empyema (also called spontaneous bacterial pleuritis).

High levels of fecal calprotectin and C-reactive protein in patients with colitis.

Inflammatory bowel disease (IBD) with a poor prognosis may be due to persistent colitis. According to the latest guidelines, monitoring has become a part of the treatment process for colitis. Adequate monitoring of the patient's condition is necessary to determine the course of the disease to prevent the worsening of the condition and suppress the subclinical inflammatory process. This analytical study with a cross-sectional design was conducted to evaluate the activity of colitis using the results of C-reactive protein (CRP) and fecal calprotectin (FC) assays. FC levels were analyzed by ELISA, while CRP levels were analyzed using Siemens Flex particle-enhanced turbidimetric immunoassay. In 30 subjects with endoscopy and biopsy of colitis, 16 men and 14 women had a median age of 52.5 (18-70) years. The median FC value increased by 67 (7.3-722 g/g) and was positive (≥50 g/g) in 20 subjects (66.7%), and the mean CRP value was 13.64 mg/L, positive (10-15 mg/L) in 13 subjects (43.33%), and negative (<10 mg/L) in 17 subjects (56.67%). This study demonstrated that FC had a significant relationship with CRP (r=0.57; p<0.001) in patients with colitis. Assessing the levels of FC and CRP among patients with colitis can be useful to assess the worsening of symptoms early and reduce mortality and morbidity.

Anti-tuberculosis drug-induced liver injury in patient with hepatitis B and cirrhosis: A case report.

Background: Pulmonary tuberculosis patients infected with hepatitis B are at high risk for drug-induced liver injury. Case presentation: A 42-year-old Indonesian female complained of sclera icterus, tea-colored urine, vomiting, dyspnea, and swollen stomach and legs. The patient experienced this condition after taking anti-tuberculosis drugs for five days. Her medical history showed hepatitis B and cirrhosis. Follow-up examination included chest X-ray and GeneXpert supported a diagnosis of pulmonary tuberculosis. However, abdominal ultrasonography indicated ascites and cirrhosis. We diagnosed the patient with anti-tuberculosis DILI, cirrhosis Child-Pugh C (score 12) related to hepatitis B, and pulmonary tuberculosis. We decided to stop the anti-tuberculosis drug. We treated the patient using tenofovir, hepatoprotective drug, diuretics, and albumin infusion. On the third day, the patient received new anti-tuberculosis drugs, including levofloxacin 750 mg, ethambutol 1000 mg, and streptomycin 1000 mg (LES). The patient's condition then gradually improved. Discussion: The dilemma of treating tuberculosis in liver disease is treating tuberculosis without ignoring hepatitis B and cirrhosis. Conclusion: Administration of anti-tuberculosis drugs based on liver tolerance of hepatotoxic drug in patients with hepatitis B and cirrhosis.

Role of fecal calprotectin as a hypoxic intestinal damage biomarker in COVID-19 patients.

BACKGROUND: Gastrointestinal manifestations of coronavirus disease 2019 (COVID-19) appear to be substantial. Fecal calprotectin is a promising biomarker in COVID-19 associated gastrointestinal inflammation; however, its role in the severity of COVID-19 remains limited. We conducted a study to analyze the relationship between the severity of COVID-19 and hypoxic intestinal damage. METHODS: We assessed the severity of 44 hospitalized COVID-19 pneumonia patients based on the PaO2/FiO2 (P/F) ratio. Inflammatory markers were measured from blood samples, and fecal calprotectin was obtained from stool samples. RESULTS: Median levels of fecal calprotectin in COVID-19 patients involved in this study (n = 44) were found to be markedly elevated along with the severity of hypoxemia, as seen in the non-acute respiratory distress syndrome (ARDS) group 21.4 µg/g (5.2-120.9), mild ARDS 54.30 µg/g (5.2-1393.7), moderate ARDS 169.6 µg/g (43.4-640.5), and severe ARDS 451.6 µg/g (364.5-538.6). We also found significant differences in fecal calprotectin levels based on the severity of ARDS (P < 0.001), and although the patients were divided into ARDS and non-ARDS groups (P < 0.001). Furthermore, we found a strong negative correlation between the P/F ratio and fecal calprotectin levels (r = - 0.697, P < 0.001). CONCLUSION: Our findings support the potential role of fecal calprotectin as a biomarker of intestinal inflammation in COVID-19 as a consequence of hypoxic intestinal damage and as suggested by the reduced P/F ratio.

Urease Levels and Gastritis Stage in Dyspeptic Patients.

BACKGROUND: Dyspepsia is a frequent main symptom of inpatients and outpatients scenario in Indonesia. However, the number of endoscopy facilities are still low, thus the use of non-invasive method to detect gastritis is necessary. We measured the relationship between urease levels and the stage of gastritis in dyspeptic adult patients. METHODS: A cross-sectional study included outpatient dyspepsia patient from November 2018 to February 2019. We examined 14C-Urea Breath Test (UBT) and determined the stage of gastritis based on the Updated Sydney System classification. RESULTS: The urease level of acute and chronic gastritis positive patients were higher than negative patients (p = 0.001, r = 0.353; p <0.0001, r = 0.433, respectively). The AUC value of 14C-UBT to detect acute, chronic, and atrophic gastritis are 0.889, 0.632 and 0.544, respectively. The best cut-off points of 14C-UBT to predict acute gastritis was ≥26.50δ‰ with sensitivity and specificity being 88.89% and 63.95%, respectively. Whereas the best cut-off points for chronic gastritis was ≥34.50δ‰ with 82.89% sensitivity, 63.16% specificity. As for atrophic gastritis, it showed very low AUC value, hence it is not a sufficient test modality to predict atrophic gastritis cases. CONCLUSION: 14C-UBT is sufficient for predicting acute or chronic gastritis but not for atrophic gastritis.

Acute management of caustic injury patient in low-resource settings.

BACKGROUND: Caustic ingestion causes high mortality and morbidity, so it is necessary to perform effective management for this case, especially in low-resource settings. CASE PRESENTATION: A 58-year-old male with caustic intoxication. The patient had acute complications in the form of hematemesis caused by gastric burns. The patient underwent immediate endoscopy and a Grade-IV Zargar gastric injury was noted. The patient was treated conservatively. He was given nutrition, proton pump inhibitors, antibiotics, and other supportive therapy during treatment. DISCUSSION: Insertion of a nasogastric tube in patients with caustic ingestion should be carried out after endoscopy or during endoscopy. CONCLUSION: Endoscopy plays an important role in the acute management of caustic ingestion.

Lower Number and Percentage of Activated Natural Killer Cells in Colorectal Cancer Patients.

BACKGROUND: Colorectal cancer is a type of cancer that begins in the colon and/or rectum tissue. Natural killer (NK) cells play a critical role in the first line of defense against infection and tumors, as well as in autoimmunity and hypersensitivity reactions. NK cells also play a role in regulating tumor cell growth and metastasis. The number and percentage of activated natural killer cells have been determined in patients with colorectal cancer and benign lesion. METHODS: This was a cross-sectional observational analytic study. The number and percentage of activated NK cells in peripheral blood were determined using the flow cytometry method in 50 samples from patients who underwent colonoscopy and obtained a mass as evidenced by histopathological examination. RESULTS: Among the 50 samples, 24 samples included in the colorectal cancer group and 26 samples from benign lesion group. The mean number of NK cells in colorectal cancer was 161.71 ± 62.666 cells/µL, benign lesion was 553.92 ± 269.173 cells/µL. The mean percentage of activated NK cells in colorectal cancer was 2.82 ± 1.19%, benign lesion was 5.10 ± 2.48%. There was a significant difference in the number of NK cells and the percentage of activated NK cells between colorectal cancer and benign lesion patients (p = 0.000). CONCLUSION: The number and activity of NK cells decreases in patients with colorectal cancer.

Diagnostic Value of 14C Urea Breath Test for Helicobacter pylori Detection Compared by Histopathology in Indonesian Dyspeptic Patients.

PURPOSE: Histopathology method is often used as a gold standard diagnostic for Helicobacter pylori infection in Indonesia. However, it requires an endoscopic procedure which is limited in Indonesia. A non-invasive method, such as 14C Urea Breath Test (UBT), is more favorable; however, this particular method has not been validated yet. PATIENTS AND METHODS: A total of 55 dyspeptic patients underwent gastroscopy and 14C-UBT test. We used Heliprobe® UBT for UBT test. As for the histology, May-Giemsa staining of two gastric biopsies (from the antrum and corpus) were evaluated following the Updated Sydney System. RESULTS: The Receiver Operating Characteristics analysis showed that the optimum cut-off value was 57 with excellence Area under Curve = 0.955 (95% CI = 0.861-1.000). By applying the optimum cut-off value, Heliprobe® UBT showed 92.31% for sensitivity, 97.62% for specificity, 92.31% for positive predictive value, 97.62% for negative predictive value, 38.77 for positive likelihood ratio, 0.0788 for negative likelihood ratio, and 96.36% for the accuracy. CONCLUSION: The 14C-UBT is an accurate test for H. pylori diagnosis with excellent sensitivity, specificity, and accuracy. The different optimum cut-off points suggested that a validation is absolutely necessary for new test prior application to the new population.

Diabetic Gastroenteropathy: A Complication of Diabetes Mellitus.

Diabetic gastroenteropathy is a common complication in prolonged diabetic patients, particularly patients with poor glycemic control or other complications, including all form of diabetic complication on the gastrointestinal tract, which prompts various symptoms of heartburn, abdominal pain, nausea, vomiting, even constipation, diarrhea, and fecal incontinence. The underlying pathophysiology of this complication manifestations are different on each organ or symptom, but may include autonomic nervous system neuropathy, loss of Interstitial Cell of Cajal as gastric muscle pacemaker leading to dysmotility, impair of liquid transportation and motoric function, as well as hyperglycemia causing oxidative stress, and other factors like Insulin-Growth Factor I inducing smooth muscle atrophy. Diabetic gastroenteropathy is one of major morbidity on diabetes mellitus patients. Patients with this complication need to be well diagnosed and ruled out other diagnosis possibilities. Management of the complication includes resolving main symptoms and maintaining good glycemic control. With growing number of diabetes mellitus patients and the prevalence of diabetic gastroenteropathy complication not being well recorded, caused by lack of attention and knowledge of healthcare provider in identifying the complication; it is important to be able to identify and to give early treatment to diabetic gastroenteropathy patients, to increase quality of life and maintain glycemic control of the patient.

Association between host TNF-α, TGF-ß1, p53 polymorphisms, HBV X gene mutation, HBV viral load and the progression of HBV-associated chronic liver disease in Indonesian patients.

In developing countries, including Indonesia, there is a high mortality rate associated with the progression of hepatitis B virus (HBV)-associated chronic liver disease (CLD). The pathogenesis of HBV infection is influenced by viral and host factors. To determine potential associations between these factors, host single nucleotide polymorphisms (SNPs) on TNF-α, TGF-ß1 and p53, HBV X gene mutation and HBV viral load were investigated in patients with HBV-associated CLD in Surabaya, Indonesia. Sera were collected from 87 CLD patients with HBV infection. TNF-α, TGF-ß1 and p53 SNPs were genotyped by PCR restriction fragment length polymorphism. The HBV X gene was sequenced and compared with reference strains to determine mutations and the viral load was measured using reverse transcription-quantitative PCR. In Indonesian patients, no association between TNF-α, TGF-ß1 and p53 SNPs and CLD or X gene mutation were identified. A total of 23% (20/87) of samples had HBV X gene mutations, including ten substitution types, one deletion and one insertion. Multinomial regression analysis revealed that the K130M/V131I mutations were correlated with CLD progression (OR, 7.629; 95% CI, 1.578-36.884). Significant differences in viral load were found in HBV-infected patients who had X gene mutations, such as R87W/G, I127L/T/N/S and K130M/V131I mutations (P<0.05). The presence of K130M and V131I mutations may be predictive for the progression of HBV-associated CLD in Indonesia.