Percutaneous treatment with the Örmeci technique for hydatid disease located in the spleen: Single center experience for twenty six years.

BACKGROUND/AIMS: Hydatid disease remains an important global socioeconomic health problem, particularly in the endemic areas. Although half of the patients show no symptoms, hydatid cysts should be treated because of their fatal complications. The aim of this study is to present the long-term results of percutaneous treatment of hydatid disease using the Örmeci technique. MATERIALS AND METHODS: Forty-nine patients with 54 cystic lesions were diagnosed with hydatid disease. Twenty-seven of the 54 hydatid cysts located in the spleen were punctured with a 22-gauge Chiba needle through the parenchyma of the spleen under sonographic guidance as a one-step procedure. For every 1 cm of the long diameter of the cyst lesion, 3 cc of fluid from the cysts was aspirated. For each centimeter of the long diameter, 2 cc of pure alcohol (96%) and 1 cc of polidocanol (1%) were injected into the cysts. Five out of 27 patients did not participate in the follow-up. RESULTS: The 22 patients who were treated using the percutaneous Örmeci technique were followed up for a mean±SD (median) of 50.32±65.30 (26.00) months (minimum 4 and maximum 298 months). All patients except one were successfully treated. No deaths or major complications were noted. Seven patients experienced minor complications. CONCLUSION: Percutaneous treatment with the Örmeci technique is a safe, effective, cheap, and reliable method that does not interfere with splenic functions, and this outpatient procedure should be the method of choice for a surgery alternative.

Comparison of three scoring systems for risk stratification in elderly patients with acute upper gastrointestinal bleeding.

AIM: Acute gastrointestinal bleeding is a potentially life-threatening condition that requires rapid assessment and dynamic management. Several scoring systems are used to predict mortality and rebleeding in such cases. The aim of the present study was to compare three scoring systems for predicting short-term mortality, rebleeding, duration of hospitalization and the need for blood transfusion in elderly patients with upper gastrointestinal bleeding. METHODS: The present study included 335 elderly patients with upper gastrointestinal bleeding. Pre- and post-endoscopic Rockall, Glasgow-Blatchford and AIMS65 scores were calculated. The ability of these scores to predict rebleeding, mortality, duration of hospitalization and the need for blood transfusion was determined. RESULTS: Pre- (4.5) and post-endoscopic (7.5) Rockall scores were superior to the Glasgow-Blatchford (12.5) score for predicting mortality (P = 0.006 and P = 0.015). Likewise, pre- (4.5) and post-endoscopic Rockall scores were superior to the respective Glasgow-Blatchford scores for predicting rebleeding (P = 0.013 and P = 0.03). There was an association between duration of hospitalization and mortality; as the duration of hospitalization increased the mortality rate increased. In all, 94% of patients hospitalized for a mean of 5 days were alive versus 56.1% of those hospitalized for 20 days, and 20.2% of those hospitalized for 40 days. CONCLUSIONS: In elderly patients with upper gastrointestinal bleeding, the Rockall score is clinically more useful for predicting mortality and rebleeding than the Glasgow-Blatchford and AIMS65 scores; however, for predicting duration of hospitalization and the need for blood transfusion, the Glasgow-Blatchford score is superior to the Rockall and AIMS65 scores. Geriatr Gerontol Int 2017; 17: 575-583.

Factors related to low serum vitamin B12 levels in elderly patients with non-atrophic gastritis in contrast to patients with normal vitamin B12 levels.

AIM: Vitamin B12 deficiency is frequent in older patients, and the main reason is pernicious anemia. However, vitamin B12 deficiency can occur in patients who do not have atrophic gastritis. The aim of the present study was to investigate factors affecting serum vitamin B12 levels in older patients with non-atrophic gastritis. METHODS: A total of 1256 out of 1607 patients aged over 60 years who had undergone upper gastrointestinal endoscopy for various reasons, and who had serum vitamin B12 value and were diagnosed as having "non-atrophic gastritis" were analyzed by means of factors affecting low serum vitamin B12 levels. RESULTS: Non-atrophic gastritis patients were divided into two groups: patients with normal serum vitamin B12 (group I, n = 759) and patients with low serum vitamin B12 (group II, n = 497). The median serum vitamin B12 was 339 pg/mL (range 201-987 pg/mL) in group I and 180 pg/mL (range 50-200 pg/mL) in group II. Helicobacter pylori (n = 154 vs 325, P < 0.001), neutrophil activity (n = 176 vs 367, P < 0.001), intestinal metaplasia (n = 35 vs 14, P < 0.001) and inflammation (n = 230 vs 386, P < 0.001) were present significantly more often in group II compared with group I. A total of 785 patients were both negative for Helicobacter pylori and atrophy. Of these 785 patients, neutrophil activity (n = 56, [32.6%] vs 25, [4.4%], P < 0.001) and inflammation (n = 69, [40.1%] vs 82, [13.4%], P < 0.001) scores were present significantly more often in group II compared with group I. CONCLUSIONS: Helicobacter pylori was present significantly more often in older patients whose serum vitamin B12 levels were ≤200 pg/mL, and Helicobacter pylori density was inversely correlated with serum B12 level. Upper gastrointestinal endoscopic examination should be suggested for elderly patients with serum vitamin B12 level ≤200 pg/mL. Geriatr Gerontol Int 2015; ●●: ●●-●●.

Impact of Periampullary Diverticula on Bile Duct Stones and Ampullary Carcinoma.

INTRODUCTION: Periampullary diverticula (PD) is caused by extraluminal pouching of duodenal mucosa. Using a very common endoscopic procedure to diagnose or treat gastrointestinal disorders, we encountered duodenal diverticulum. MATERIALS AND METHODS: This is a retrospective, single-center study. Three thousand and sixteen patients on whom endoscopic retrograde cholangiopancreatography (ERCP) was performed at Ankara University Medical School, Department of Gastroenterology, from June 2009 to June 2014 were included to the study. RESULTS: Hundred and thirty patients (males 65, females 65) among the 3,016 had PD. Two hundred and sixty patients without diverticulum were randomly chosen from the 3,016 patients, as a control group [121 (47%) females, 139 (53%) males]. There was no statistical difference between the two groups. The mean age of the patients with PD was 69.9 years, while the mean age was 62.3 years for patients without PD (p < 0.001). Incidence for PD was 4.6%. The papilla of Vater was located in the inter-diverticular area (Type 1) in 9 patients (8.3%), at the edge of the diverticulum (Type 2) in 31 patients (28.4%), and at a distance of 2 to 3 cm from the papilla (Type 3) in 69 patients (63.3%). DISCUSSION: Although numerically more common bile duct stones occurred in patients with PD compared to those without PD, there was no statistical difference between the two groups. The rate of pancreato-biliary carcinomas was higher in patients without diverticulum. Cannulation was successful in both groups at the rate of 97.6 and 92% respectively, but cannulation failed more often in patients without PD. Duodenal perforation occurred in one patient with PD. Bleeding after sphincterotomy occurred in two patients without PD. HOW TO CITE THIS ARTICLE: Örmeci N, Deda X, Kalkan Ç, Tüzün AE, Karakaya F, Dökmeci A, Bahar DK, Özkan H, Idilman R, Çinar K. Impact of Periampullary Diverticula on Bile Duct Stones and Ampullary Carcinoma. Euroasian J Hepato-Gastroenterol 2016;6(1):31-34.

Association Between Level of Hepatitis D Virus RNA at Week 24 of Pegylated Interferon Therapy and Outcome.

BACKGROUND & AIMS: Interferon is the only effective treatment for chronic hepatitis D virus (HDV) infection. No rules have been set for stopping treatment based on viral kinetics. We analyzed data from an international study of hepatitis D treatment to identify factors associated with outcomes of pegylated interferon treatment, with and without adefovir. METHODS: We analyzed data from the Hep-Net-International Delta Hepatitis Intervention Trial on 50 patients with compensated liver disease who tested positive for anti-HDV and HDV RNA. Subjects received pegylated interferon α 2a, with adefovir or placebo, or only adefovir, for 48 weeks. Twenty-four weeks after treatment ended, 41 patients were evaluated for levels of HDV RNA and DNA, liver enzymes, and hepatitis B surface antigen (HBsAg); liver biopsy specimens were analyzed for fibrosis. Response to therapy was defined as end-of-treatment response or post-treatment week 24 virologic response. In both cases virologic response was associated with undetectable HDV RNA levels. Patients with less than a 1 log decrease in HDV RNA at the end of treatment were considered null responders. RESULTS: Based on univariate and multivariate analysis, the level of HDV RNA at week 24 of treatment was associated more strongly with response to therapy than other factors analyzed. The level of HBsAg at week 24 of treatment was associated with a response to therapy only in univariate analysis. Lack of HDV RNA at week 24 of treatment, or end of treatment, identified responders with positive predicted values of 71% and 100%, respectively. At 24 weeks after treatment, a decrease in HDV RNA level of less than 1 log, combined with no decrease in HBsAg level, identified null responders with a positive predictive value of 83%. A decrease in HDV RNA level of more than 2 log at week 24 of treatment identified null responders with a negative predictive value of 95%. CONCLUSIONS: Based on an analysis of data from a large clinical trial, the level of HDV RNA at week 24 of treatment with pegylated interferon, with or without adefovir for 48 weeks, can identify patients who will test negative for HDV RNA 24 weeks after the end of treatment. This information can be used to help physicians manage patients receiving therapy for chronic hepatitis D.

Quantification of liver, pancreas, kidney, and vertebral body MRI-PDFF in non-alcoholic fatty liver disease.

PURPOSE: The purpose of the present study was to determine liver, pancreas, kidney, and vertebral fat deposition in NAFLD patients by proton density fat fraction (PDFF) using magnetic resonance imaging (MRI) and to evaluate the relationships among them. METHODS: A total of 41 biopsy-proven NAFLD patients underwent MRI-PDFF with IDEAL-IQ. MRI protocol included T1-independent volumetric multi-echo gradient-echo imaging with T2* correction and spectral fat modeling. The MR examinations were performed on a 1.5 HDx MRI system. MRI-PDFF measurements were obtained from liver, pancreas, renal cortex and sinus, and vertebral body. Liver biopsy specimens were retrieved from the archives and evaluated by one pathologist according to NASH CRN. RESULTS: The median age of the patients was 47 years. The median interval between liver biopsy and MRI examination was 16 days. Mean liver, pancreas, renal cortex, renal sinus, T12 and L1 vertebral body MRI-PDFFs were 18.7%, 5.7%, 1.7%, 51%, 43.2%, and 43.5%, respectively. No correlation between either liver MRI-PDFF or histological steatosis, and other organ MRI-PDFFs was observed. A good correlation between pancreas and vertebral body MRI-PDFFs, and pancreas and renal sinus MRI-PDFFs was observed. Diabetic patients had higher average pancreas MRI-PDFF compared to non-diabetics (12.2%, vs., 4.8%; P = 0.028). CONCLUSIONS: Pancreas and vertebral body MRI-PDFF is well correlated in NAFLD patients and both of them are higher in diabetic patients which may explain increased bone fractures in diabetics. MRI-PDFF can be used to demonstrate fat fractions of different organs and tissues and to understand fat metabolism.

Systemic Radiopharmaceutical Agents (Sm-153) may be Dangerous in Hepatacellular Carcinoma.

Palliation of bone metastases in hepatocellular carcinoma (HCC) is sometimes difficult. Systemic pharmaceuticals have been successfully used for the palliation of bone metastasis for many years. Safety of these agents in HCC is not known completely. We presented a male patient with decompensated liver cirrhosis with HCC. Multifocal bone metastases developed in this patient and he had refractory bone pain. We treated this patient with Sm-153 (samarium) after obtaining patient's consent. Two days after treatment, he experienced dyspnea and we detected a massive hemorrhagic pericardial effusion. He died due to this unexpected bleeding. We should use this radiopharmaceutical treatment cautiously in these cytopenic cirrhotic patients.

Efficacy of tenofovir in adefovir-experienced patients compared with treatment-naive patients with chronic hepatitis B.

BACKGROUND: Tenofovir (TDF) has similar antiviral efficacy in both treatment-naive and lamivudine-resistant chronic hepatitis B (CHB) patients. Data on TDF use in patients with adefovir (ADV) resistance is inconsistent. The aim of our study was to assess antiviral efficacy of TDF against nucleoside analogue-naive (NN) and ADV-resistant (ADV-R) CHB and suboptimal responders to ADV (ADV-S). METHODS: A database of 135 CHB patients treated with TDF was analysed. A total of 37 patients with incomplete data were excluded and analysis was performed in 98 (44 NN, 30 ADV-R and 24 ADV-S). Patients with primary ADV-R mutations had either A181T/V or N236T mutations or both. HBV DNA was measured at 3-month intervals until month 24. Primary outcome measures were comparison of the decline of HBV DNA between the three treatment groups. RESULTS: NN patients had higher baseline HBV DNA compared with ADV-R and ADV-S patients (6.08 log10 IU/ml versus 5.53 and 4.88, respectively; P=0.002). By exponential regression analysis, HBV DNA decline kinetics differed between the three groups. HBV DNA decline was faster in NN patients compared to ADV-R and ADV-S CHB patients (P=0.002 and P=0.004, respectively). Undetectable HBV DNA was achieved in 77.2%, 60% and 75% of NN, ADV-R and ADV-S CHB patients, respectively, at month 12 (P= not significant). CONCLUSIONS: HBV DNA decline is slower in ADV-experienced patients compared with treatment-naive patients. The clinical significance of this slow response may be important in patients with critical liver reserve and high viral load. Optimal combination treatment (TDF+ entecavir) could be considered in these patients.

QT interval changes and reversibility of QT dispersion in patients with acute pancreatitis.

BACKGROUND/AIMS: QT dispersion is a sign of heterogeneity of ventricular myocardial wall and is associated with cardiac mortality and morbidity. Data regarding with the persistence of QT interval changes in cases with acute pancreatitis (AP) that required clinical follow-up, are insufficient. Therefore, in this study, we aimed to evaluate the QT interval changes during attack and after remission of the disease, in cases with AP. MATERIALS AND METHODS: The cases admitted to the Gastroenterohepatology Clinic with the diagnosis of AP were included into the study. Ranson's score parameters, electrocardiography and echocardiography of all patients included into the study were evaluated. Electrocardiographic changes were evaluated two times, during attack and after remission of the disease. RESULTS: A total of 134 subjects (F/M:54/80, 41/59%) diagnosed as AP were included into the study. Seventy two (54%) of the AP cases included into the study were biliary, 32 (24%) were alcohol dependant, 19 (14%) were idiopathic, 9 (7%) were hyperlipidemic and 2 (1%) were ERCP related cases. Mean age of the patents was 57.7±15 years old (range: 19-82 years old) and mean Ranson's score was 3.8±1.9 (range: 1-7), according to the numerical scoring system. We compared QT interval changes during the attack and after the remission of AP and found significant increase in QT dispersion levels during acute attack of AP (p<0,001). CONCLUSION: The most common electrocardiographic changes in AP patients are QT interval changes including QT dispersion. QT dispersion which was emerged during the attack recovered after the remission of the disease.

The predictive value of mean platelet volume, plateletcrit and red cell distribution width in the differentiation of autoimmune gastritis patients with and without type I gastric carcinoid tumors.

Autoimmune gastritis is an autoimmune and inflammatory condition that may predispose to gastric carcinoid tumors or adenocarcinomas. The early diagnosis of these tumors is important in order to decrease morbidity and mortality. Platelet indices such as mean platelet volume and plateletcrit levels increase in inflammatory, infectious and malign conditions. The primary aim of this study was to explore wheter platelet indices and red cell distribution width have any predictive role in the discrimination of autoimmune gastritis patients with and without gastric carcinoid tumors. Also secondary aim of this study was to investigate whether any changes exist betwenn autoimmune gastritis and functional dyspepsia patients by means of platelet indices. Plateletcrit (0.22 ± 0.06 vs. 0.20 ± 0.03%, p < 0.001) and red cell distribution width (16.11 ± 3.04 vs. 13.41 ± 0.95%, p < 0.001) were significantly higher in autoimmune gastritis patients compared to control group. Receiver operating curve analysis suggested that optimum plateletcrit cut-off point was 0.20% (AUC: 0.646), and 13.95% as the cut off value for red cell distribution width (AUC: 0.860). Although plateletcrit (0.22 ± 0.06 vs. 0.21 ± 0.04%, p = 0.220) and mean platelet volume (8.94 ± 1.44 vs. 8.68 ± 0.89 fl, p = 0.265) were higher in autoimmune gastritis patients without carcinoid tumor compared to patients with carcinoid tumors, these parameters were not statistically significant. Changes in plateletcrit and red cell distribution width values may be used as a marker in the discrimination of autoimmune gastritis and fucntional dyspepsia patients but not useful in patients with gastric carcinoid tumor type I.

Gamma-glutamyltranspeptidase in predicting sustained virological response in individuals with chronic hepatitis C.

BACKGROUND/AIMS: Serum gamma-glutamyltranspeptidase (GGT) levels often increase in chronic hepatitis C. We aimed to identify whether GGT levels can predict sustained virological response (SVR) in patients with chronic hepatitis C and to investigate other potential predictive factors associated with SVR in patients with chronic hepatitis C treated with pegylated interferon and ribavirin at a single center. METHODOLOGY: We evaluated 112 consecutive patients with histologically proven chronic hepatitis C who were treated with pegylated interferon and ribavirin. As potential predictors of SVR to combination therapy, we analyzed age, gender, body mass index, pretreatment GGT and alanine transaminase levels, diabetes mellitus, receiving of anti-viral therapy before beginning combination therapy, viral load, and liver histology by use of a multivariate logistic regression model. RESULTS: SVR to combination therapy was seen in 57.2% of the patients. Variables associated with lower rates of sustained response were liver steatosis (p=0.026), diabetes mellitus (p=0.027), receiving anti-viral therapy before beginning combination therapy (p=0.016), higher GGT levels before therapy (>50IU/mL, p<0.001), and advanced fibrosis stage (p=0.017). On logistic regression analysis, the only independent predictor of SVR was the GGT level before therapy (p=0.003). CONCLUSIONS: Low serum levels of GGT before treatment are associated with higher rates of SVR in patients with chronic hepatitis C treated with pegylated interferon and ribavirin.

Adjuvant therapeutic plasma exchange in liver failure: assessments of clinical and laboratory parameters.

BACKGROUND: Therapeutic plasma exchange (TPE) seems to be an effective approach for clearing toxins, immune-mediated antigens, and other particles from the circulation. The aim of this study was to analyze the positive effects of TPE on clinical and biochemical parameters of liver failure. PATIENTS AND METHODS: Between January 2001 and March 31, 2005 individuals (men/women, 17/14; median age, 42.7+/-15.8 y) with acute and chronic liver failure who underwent a total of 113 TPEs (median session 3.7) were retrospectively reviewed. TPE was performed using the Fresenius AS-TEC 204 cell separator (Fresenius AG, Germany). The indication for TPE was severe coagulopathy (prothrombin time >20 s), severe hepatic encephalopathy, hyperbilirubinemia, and candidacy for liver transplantation. All patients were examined before and immediately after the last TPE session. RESULTS: When compared with baseline, there was significant improvement in hepatic encephalopathy stage (from median score 3.0 to 1.0, P=0.001), serum prothrombin time (from median 26.0 to 20.0 s, P=0.003), aminotransferases (P<0.001), and total bilirubin levels (from median 35.0 to 23.3 mg/dL, P<0.001) after TPE. Thirteen of the thirty-one individuals (41.9%) died in the hospital. The mean follow-up period of 18 survival patients was 35.9+/-5.6 months and 10 of those survived (55.6%, 10/18). No serious adverse effect of TPE was observed in any of the patients during or after completion of TPE. Only 6 patients experienced minor transfusion reactions. CONCLUSIONS: TPE seems to be effective in improving hepatic encephalopathy stage and liver tests in individuals with acute and chronic liver failure. The data suggest that TPE is safe and tolerable in such individuals, however, overall survival remains poor despite TPE.

The usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae.

Hydatid disease is an important health problem in areas where it is endemic. There are several therapeutic modalities, the most important being surgery, antibiotherapy, and percutaneous treatment. In recent years percutaneous treatment has become popular, and for this method or surgery it is sometimes lifesaving to know the relation between the biliary ducts and the cyst cavity. The aim of this study was to examine the usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae before percutaneous or surgical treatment. A total of 72 patients diagnosed with hepatic hydatid disease via ultrasound and serologic tests were enrolled in the study. Endoscopic retrograde cholangiopancreatography was successfully performed in all patients. (99m)Tc-labeled albumin macroaggregates also were injected into cysts at a dose of 1.5-2 mCi just before the treatment. All but three patients were treated percutaneously. Scintigraphy of abdominal and thoracic areas was performed with a GE Starcam 3200 XC/T gamma camera at 30 and 120 min after Tc-labeled albumin macroaggregate injections. Endoscopic retrograde cholangiopancreatography revealed communications between biliary ducts and cyst cavities in nine patients (12.5%). However, (99m)Tc-labeled albumin macroaggregates showed not only leakage into the systemic circulation in nine patients but also into the biliary ducts in two (15.4%). In one patient, mild acute pancreatitis occurred as a complication of endoscopic retrograde cholangiopancreatography. No complications of (99m)Tc-labeled albumin macroaggregates injection were seen. Three patients were surgically treated because of clinically manifested cystobiliary fistulae. We conclude that endoscopic retrograde cholangiopancreatography is a gold standard technique for the diagnosis of communication between the biliary duct and the cyst cavity, and (99m)Tc-labeled albumin macroaggregate injection is useful for revealing leakage into the systemic circulation. The diagnosis of biliary fistulae before percutaneous treatment of hydatid disease may enable planning of the optimal therapy.

Long-term prognosis of nonalcoholic fatty liver disease: is pharmacological therapy actually necessary?

BACKGROUND AND AIM: Nonalcoholic fatty liver disease (NAFLD) comprises a wide spectrum of liver injury, ranging from steatosis and steatohepatitis to cirrhosis. Reasons for the different natural course in individuals with NAFLD are still unclear. The aim of this study was to describe the natural course of disease in individuals with NAFLD who did not receive pharmacological therapy. METHODS: A total of 27 individuals with NAFLD (male/female ratio: 10/17, mean age 49.7 years) were prospectively enrolled. Management after diagnosis consisted of establishment of an appropriate diet and exercise (walking and jogging) program, treatment of associated metabolic conditions such as diabetes and dyslipidemia, and discontinuation of potentially hepatotoxic drugs if the patient was taking these. Liver tests were performed at diagnosis and at 3-month intervals during the follow-up period. Mean follow-up period was 43.3 months (range 36-49 months). RESULTS: From baseline to the end of the follow-up period, although there was no significant difference observed in terms of the mean body mass index, serum aminotransferase levels significantly improved (48.8+/-29.9 U/L to 31.6+/-16.0 U/L for aspartate aminotransferase [AST] and 66.3+/-38.3 U/L to 39.6+/-22.9 U/L for alanine aminotransferase [ALT]; P<0.05). No significant differences in platelet counts, serum albumin level or prothrombin time were observed (P>0.05). No patient developed signs of advanced liver disease during the follow-up period. CONCLUSION: A treatment strategy comprising diet, exercise and management of associated metabolic conditions is associated with improvement in aminotransferases among patients with NAFLD. Further investigation is needed to examine the long-term efficacy of this approach on liver histology and clinical outcomes.

A new percutaneous approach for the treatment of hydatid cyst of the kidney: long-term follow-up.

Renal hydatid disease is an uncommon benign parasitic infestation compared to liver hydatid disease. Although the treatment of hydatid cysts depends on surgery which is related with high morbidity and an overall local recurrence rates, the following case reports describing two patients with renal hydatid cysts were successfully treated with this new percutaneous method.

Lamivudine treatment in HBeAg-negative chronic hepatitis B patients with low level viraemia.

BACKGROUND: Our aim was to determine the short-term natural course of viraemia and the response to lamivudine treatment in HBeAg-negative chronic hepatitis B patients with a persistently low hepatitis B virus (HBV)-DNA level. METHODS: A total of 55 patients were included. Group 1 consisted of 37 patients with low-level viraemia and high serum alanine aminotransferase (ALT) levels and further randomized to two groups: group 1a (n=19) patients received 1 year of lamivudine therapy and group 1b (n=18) patients were untreated controls. Group 2 consisted of 18 inactive carriers who were followed as controls of untreated low viraemic chronic hepatitis B patients. HBV DNA was longitudinally determined by real-time polymerase chain reaction assay. RESULTS: A female predominance in group 2 was observed while males were predominant in group 1. Mean age and baseline HBV-DNA levels did not differ between group 1 and 2 patients while group 1 patients had a higher histological score (P<0.01). Of group 1a patients, 44% had complete ALT normalization at end of treatment, whereas 21% untreated group 1b patients had normal ALT at the end of the follow-up. No change in histological activity was observed in group 1a patients at the end of treatment. HBV-DNA levels did not significantly change from baseline to end-of-treatment/observation period in patient groups. The viraemia course was not different across the groups. CONCLUSIONS: Low viraemic HBeAg-negative patients with high ALT present with minimal/mild histological activity. Inactive carriers cannot be differentiated from low viraemic patients with high ALT based on HBV DNA determination. Although lamivudine treatment can be effective in some cases, observation rather than a prompt treatment attempt seems to be more logical because of mild histological changes and low response rate to treatment in these patients.