Critical flicker frequency is diagnostic of minimal hepatic encephalopathy.

Minimal hepatic encephalopathy may affect up to 80% of cirrhotic patients, in the absence of overt hepatic encephalopathy. The objective of the study is to evaluate the accuracy of diagnosis of minimal hepatic encephalopathy with critical flicker frequency (CFF). The study was conducted on 180 patients with post hepatitis C liver cirrhosis and on 60 healthy subjects as control. Patients and controls were divided into four groups: group 1 (60), healthy individuals as a control group; group 2 (60), patients with liver cirrhosis (Child class A); group 3 (60), patients with liver cirrhosis (Child class B); and group 4 (60), patients with liver cirrhosis (Child class C). All participants were subjected to estimation of CFF, line drawing test, complete blood picture, liver functions, viral markers, and abdominal ultrasound. CFF detected abnormality in 90% of patients. Accuracy of CFF in differentiation of Child A from normal is 100%, Child B from normal is 100%, Child C from normal is 100%, Child A from Child B is 80%, Child A from Child C is 100% and Child B from Child C is 100%, and it has higher accuracy than line drawing test. CFF is a simple, reliable and accurate method for the diagnosis of minimal hepatic encephalopathy. It is not influenced by the patient level of education.

Low-density lipoprotein receptor genetic polymorphism in chronic hepatitis C virus Egyptian patients affects treatment response.

AIM: To correlate a genetic polymorphism of the low-density lipoprotein (LDL) receptor with antiviral responses in Egyptian chronic hepatitis C virus (HCV) patients. METHODS: Our study included 657 HCV-infected patients with genotype 4 who received interferon-based combination therapy. Patients were divided into two groups based on their response to therapy: 356 were responders, and 301 were non-responders. Patients were compared to 160 healthy controls. All patients and controls underwent a thorough physical examination, measurement of body mass index (BMI) and the following laboratory tests: serum alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, albumin, total bilirubin, direct bilirubin, prothrombin time, prothrombin concentration, INR, complete blood count, serum creatinine, fasting blood sugar, HCV antibody, and hepatitis B surface antigen. All HCV patients were further subjected to the following laboratory tests: HCV-RNA using quantitative polymerase chain reaction (PCR), antinuclear antibodies, thyroid-stimulating hormone, an LDL receptor (LDLR) genotype study of LDLR exon8c.1171G>A and exon10c.1413G>A using real-time PCR-based assays, abdominal ultrasonography, ultrasonographic-guided liver biopsy, and histopathological examination of liver biopsies. Correlations of LDL receptor polymorphisms with HAI, METAVIR score, presence of steatosis, and BMI were performed in all cases. RESULTS: There were no statistically significant differences in response rates between the different types of interferon used or LDLR exon10c.1413G>A. However, there was a significant difference in the frequency of the LDL receptor exon8c.1171G>A genotype between cases (AA: 25.9%, GA: 22.2%, GG: 51.9%) and controls (AA: 3.8%, GA: 53.1% and GG: 43.1%) (P < 0.001). There was a statistically significant difference in the frequency of the LDLR exon 8C:1171 G>A polymorphism between responders (AA: 3.6%, GA: 15.2%, GG: 81.2%) and non-responders (AA: 52.2%, GA: 30.6%, GG: 17.2%) (P < 0.001). The G allele of LDL receptor exon8c.1171G>A predominated in cases and controls over the A allele, and a statistically significant association with response to interferon was observed. The frequency of the LDLR exon8c.1171G>A allele in non-responders was: A: 67.4% and G: 32.6 vs A: 11.2% and G: 88.8% in responders (P < 0.001). Therefore, carriers of the A allele exhibited a 16.4 times greater risk for non-response. There was a significant association between LDL receptors exon8 c.1171G>A and HAI (P < 0.011). There was a significant association between LDL receptors exon8c.1171G>A and BMI. The mean BMI level was highest in patients carrying the AA genotype (28.7 ± 4.7 kg/m(2)) followed by the GA genotype (28.1 ± 4.8 kg/m(2)). The lowest BMI was the GG genotype (26.6 ± 4.3 kg/m(2)) (P < 0.001). The only significant associations were found between LDL receptors exon8 c.1171G>A and METAVIR score or steatosis (P < 0.001). CONCLUSION: LDL receptor gene polymorphisms play a role in the treatment response of HCV and the modulation of disease progression in Egyptians infected with chronic HCV.

Tissue Inhibitors of Metalloproteinase-1 and 2 and Obesity Related Non-Alcoholic Fatty Liver Disease: Is There a Relationship.

BACKGROUND/AIMS: Non-alcoholic fatty liver disease is a spectrum of clinical conditions, including simple steatosis and non-alcoholic steatohepatitis (NASH). The aim of the study is to evaluate the tissue inhibitors of metalloproteinase-1 and 2 (TIMPs) as noninvasive predictors of NASH. METHODS: Three groups were included in the study. Obese patients (n = 30) with normal liver enzymes were included in group I and obese patients (n = 30) with elevated liver enzymes with liver biopsy-based diagnosis of NASH were included in group II. Age-matched subjects (n = 30) formed the control as group III. The lipid profile, liver enzyme levels and levels of TIMPs were compared among all the patients and subjects. RESULTS: Comparison of groups I and II showed significantly elevated levels of TIMP-1 and TIMP-2 in group II as compared to group I (p < 0.05). Similarly, comparison between groups II and III showed significantly increased levels of TIMP-1 and TIMP-2 in group II as compared to group III (p < 0.05). TIMP-1 (sensitivity 96.7%, specificity 100%) and TIMP-2 (sensitivity 93.3%, specificity 100%) showed high accuracy in NASH diagnosis. CONCLUSION: TIMP-1 and TIMP-2 may be considered noninvasive markers for the diagnosis of NASH.

Molecular identification of giardia intestinalis in patients with dyspepsia.

BACKGROUND/AIMS: Giardia intestinalis triggers symptoms of functional dyspepsia. The aim of this study was to distinguish genotypes of G. intestinalis isolated from dyspeptic patients to evaluate their correlation with dyspeptic symptoms. METHODS: In total, 120 dyspeptic subjects were investigated by upper endoscopy, including gastric and duodenal biopsies for histopathological examination, and parasitological examination of their stools and duodenal aspirates was performed. The patients were classified into five groups: group I (G. intestinalis) included 19 patients, group II (Helicobacter pylori) included 36 patients, group III (coeliac disease) included 3 patients, group IV (mixed G. intestinalis and H. pylori infection) included 4 patients, and group V (unexplained aetiology) included 58 patients. Genotyping of G. intestinalis was performed for groups I and IV using PCR-RFLP. The urease test was performed for H. pylori. Serum anti-gliadin, anti-endomysial and anti-transglutaminase antibody estimation was performed for the diagnosis of coeliac disease. RESULTS: Genotype A of G. intestinalis was detected in the stool samples of 68.42% (13/19) and the duodenal aspirates of 42.1% (8/19) of dyspeptic patients harbouring the parasite. Genotype B was detected in 31.58% (6/19) of cases in stool samples and in 3 cases in duodenal aspirates. CONCLUSIONS: H. pylori, G. intestinalis and coeliac disease are common causes of dyspepsia. G. intestinalis genotype A demonstrated a greater association with dyspeptic symptoms.

Association of interferon-γ inducible protein-10 pretreatment level and sustained virological response in HCV-positive Egyptian patients.

BACKGROUND: The response to antiviral therapy in HCV infected patients depends on several predictive factors; however, the ability to achieve sustained virological response is still limited to around 60% of the patients infected with the HCV-4 genotype. Increased serum and intrahepatic interferon -γ inducible protein 10 (IP-10) levels in patients with chronic hepatitis C have been described. The aim of the work was to study the impact of pretreatment serum IP-10 level on the antiviral treatment outcome in a group of Egyptian patients infected with HCV. MATERIALS AND METHODS: The study included 80 treatment naive HCV patients. Serum IP-10 levels were determined by an enzyme linked immunosorbent assay before therapy was introduced. Serum samples were examined twice by Real-Time PCR after complete course of therapy for detection of HCV RNA; at the end of the antiviral therapy and six months later to detect sustained virological response (SVR). RESULTS: 57 patients (71%) achieved SVR while 23 (29%) patients were non-responders (NR). Pretreatment serum IP-10 levels were significantly lower in patients who achieved SVR than in NR (p=0.000). CONCLUSION: Low pretreatment serum IP-10 is a favorable predictive of response to antiviral HCV therapy in Egyptian patients.

Prevalence of photosensitivity in chronic hepatitis C virus patients and its relation to serum and urinary porphyrins.

BACKGROUND & AIMS: HCV is a major cause of chronic liver disease in Egypt. The aim was to study the prevalence of photosensitivity among asymptomatic HCV-infected patients and its possible relation to porphyrins levels and whether it can be considered an alarm for early diagnosis of the disease, which is the most important goal in the management. METHODS: This study included 100 accidentally discovered HCV positive cases and 100 HCV negative healthy controls. All patients and controls were subjected to: Detailed history and clinical examination, dermatological examination including evaluation of reaction to solar exposure, measurement of serum AST, ALT, albumin, bilirubin, serum and urinary porphyrins levels. RESULTS: The prevalence of photosensitivity among HCV-positive cases (33%) was significantly higher compared to 10% in the control group. Serum porphyrins were positive in 46 cases (46%), twenty-three cases (23%) had positive urinary porphyrins, while only four controls (4%) showed positive serum porphyrins and one (1%) showed positive urinary porphyrins, the difference was statistically significant. Cases with photosensitivity showed significantly higher prevalence of serum and urinary porphyrins existence as well as serum porphyrins levels. Levels of viraemia showed statistically significant relation to levels of porphyrins. CONCLUSION: Asymptomatic chronic HCV infection cases showed significantly high prevalence of photosensitivity, which is related to the associated disturbance of porphyrins metabolism. Photosensitivity can thus be considered an early marker of HCV infection. Patients discovered to have recently acquired photosensitivity should be screened for HCV infection especially in endemic areas like Egypt.

Epidemiological and clinical characteristics of inflammatory bowel diseases in Cairo, Egypt.

AIM: To study the natural history, patterns and clinical characteristics of inflammatory bowel diseases (IBD) in Egypt. METHODS: We designed a case-series study in the gastroenterology centre of the Internal Medicine department of Cairo University, which is a tertiary care referral centre in Egypt. We included all patients in whom the diagnosis of ulcerative colitis (UC) or Crohn's disease (CD) was confirmed by clinical, laboratory, endoscopic, histological and/or radiological criteria over the 15 year period from 1995 to 2009, and we studied their sociodemographic and clinical characteristics. Endoscopic examinations were performed by 2 senior experts. This hospital centre serves patients from Cairo, as well as patients referred from all other parts of Egypt. Our centre received 24156 patients over the described time period for gastro-intestinal consultations and/or interventions. RESULTS: A total of 157 patients with established IBD were included in this study. Of these, 135 patients were diagnosed with UC (86% of the total), and 22 patients, with CD (14% of the total). The mean ages at diagnosis were 27.3 and 29.7, respectively. Strikingly, we noticed a marked increase in the frequency of both UC and CD diagnoses during the most recent 10 years of the 15 year period studied. Regarding the gender distribution, the male:female ratio was 1:1.15 for UC and 2.6:1 for CD. The mean duration of follow up for patients with UC was 6.2 ± 5.18 years, while the mean duration of follow up for patients with CD was 5.52 ± 2.83 years. For patients with UC we found no correlation between the severity of the disease and the presence of extraintestinal manifestations. Eleven patients had surgical interventions during the studied years: 4 cases of total colectomy and 7 cases of anal surgery. CONCLUSION: We observed a ratio of 6:1 for UC to CD in our series. The incidence of IBD seems to be rising in Egypt.

Endoscopic Ultrasound-Guided Fine Needle Aspiration versus Percutaneous Ultrasound-Guided Fine Needle Aspiration in Diagnosis of Focal Pancreatic Masses.

OBJECTIVE: Pancreatic carcinoma is one of the leading cancer morbidity and mortality world-wide. Controversy has arisen about whether the percutaneous approach with computed tomography/ultrasonography-guidance fine needle aspiration (US-FNA) or endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the preferred method to obtain diagnostic tissue. Our purpose of this study is to compare between the diagnostic accuracy of EUS-FNA and percutaneous US-FNA in diagnosis of pancreatic cancer. PATIENTS AND METHODS: A total of 197 patients with pancreatic masses were included in the study, 125 patients underwent US-FNA (Group 1) and 72 patients underwent EUS-FNA (Group 2). RESULTS: EUS-FNA has nearly the same accuracy (88.9%) as US-FNA (87.2%) in diagnosis of pancreatic cancer. The sensitivity, specificity, positive predictive value and negative predictive value for EUS-FNA was 84%, 100%, 100%, 73.3% respectively. It was 85.5%, 90.4%, 94.7%, 76% respectively for US-FNA. EUS-FNA had a lower complication rate (1.38%) than US-FNA (5.6%). CONCLUSION: EUS-FNA has nearly the same accuracy as US-FNA of pancreatic masses with a lower complication rate.

Noninvasive assessment of hepatic fibrosis in Egyptian patients with chronic hepatitis C virus infection.

AIM: To evaluate the accuracy of specific biochemical markers for the assessment of hepatic fibrosis in patients with chronic hepatitis C virus (HCV) infection. METHODS: One hundred and fifty-four patients with chronic HCV infection were included in this study; 124 patients were non-cirrhotic, and 30 were cirrhotic. The following measurements were obtained in all patients: serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, total bilirubin, prothrombin time and concentration, complete blood count, hepatitis B surface antigen (HBsAg), HCVAb, HCV-RNA by quantitative polymerase chain reaction, abdominal ultrasound and ultrasonic-guided liver biopsy. The following ratios, scores and indices were calculated and compared with the results of the histopathological examination: AST/ALT ratio (AAR), age platelet index (API), AST to platelet ratio index (APRI), cirrhosis discriminating score (CDS), Pohl score, Göteborg University Cirrhosis Index (GUCI). RESULTS: AAR, APRI, API and GUCI demonstrated good diagnostic accuracy of liver cirrhosis (80.5%, 79.2%, 76.6% and 80.5%, respectively); P values were: < 0.01, < 0.05, < 0.001 and < 0.001, respectively. Among the studied parameters, AAR and GUCI gave the highest diagnostic accuracy (80.5%) with cutoff values of 1.2 and 1.5, respectively. APRI, API and GUCI were significantly correlated with the stage of fibrosis (P < 0.001) and the grade of activity (P < 0.001, < 0.001 and < 0.005, respectively), while CDS only correlated significantly with the stage of fibrosis (P < 0.001) and not with the degree of activity (P > 0.05). In addition, we found significant correlations for the AAR, APRI, API, GUCI and Pohl score between the non-cirrhotic (F0, F1, F2, F3) and cirrhotic (F4) groups (P values: < 0.001, < 0.05, < 0.001, < 0.001 and < 0.005, respectively; CDS did not demonstrate significant correlation (P > 0.05). CONCLUSION: The use of AAR, APRI, API, GUCI and Pohl score measurements may decrease the need for liver biopsies in diagnosing cirrhosis, especially in Egypt, where resources are limited.

Serum mannan-binding lectin in egyptian patients with chronic hepatitis C: its relation to disease progression and response to treatment.

BACKGROUND: Chronic hepatitis C virus (HCV) infection is a major worldwide public health problem. Egypt has the highest prevalence of adult HCV infection in the world, averaging 15%-25% in rural communities. Mannan-binding lectin (MBL) is a liver-derived pluripotent serum lectin that plays a role in the innate immune system of the host. It is an acute-phase protein that is involved in the activation of the classical complement pathway. MBL may play a defensive role in HCV infection. OBJECTIVES: To investigate the relationship between MBL concentration and HCV infection in Egyptian patients suffering chronic hepatitis C. PATIENTS AND METHODS: Serum samples obtained from 35 Egyptian hepatitis C patients and 30 normal controls were assayed for MBL. MBL concentrations were correlated to disease characteristics and treatment response. RESULTS: Serum MBL was significantly higher in HCV patients than in controls, but no relationship was found between MBL concentration and disease progression in terms of hepatic fibrosis and inflammation. Responders to interferon (INF)-based therapy had significantly higher serum MBL than non-responders. CONCLUSIONS: We found no association between serum MBL concentration and progression of HCV related liver disease. Responders to INF-based therapy had significantly higher serum MBL than non-responders.

Role of ultrasound elastography in prediction of malignancy in thyroid nodules.

BACKGROUND: Ultrasonography is considered useful to distinguish between solid and cystic thyroid nodules and to stratify a nodule's risk of cancer as low, medium, or high. Ultrasound (US) elastography has been applied to study the hardness/elasticity of nodules to differentiate malignant from benign lesions. Elastography possibly can solve the dilemma in reaching an accurate diagnosis for the cytologically known as indeterminate nodules. AIM: To evaluate the sensitivity and specificity of US elastography in the diagnosis of thyroid cancer. PATIENTS AND METHODS: This prospective study included 40 patients. The total number of nodules was 46, they were all euthyroid. Laboratory investigations were done including FT3, FT4, and TSH to exclude hot nodules. Neck US, US elastography, and fine-needle aspiration were done to all patients, and US elastography scoring system from 1 to 4 was used. RESULTS: Four out of the 46 studied nodules were malignant. The ROC curve for elastography score (E-score) showed high sensitivity, specificity for the diagnosis of malignant thyroid nodules with a cut-off value of E-score 4 and high significance (p<0.001), the area under curve was 0.92. The sensitivity was 75.0% and specificity was 100%. For E-score more than 2, the sensitivity was 100% and specificity was 85.37%. CONCLUSION: US elastography can be used to increase both the sensitivity and the specificity of US for the detection of malignant thyroid nodules, and so it seems to have great potential as a new tool for the diagnosis of thyroid cancer.

Can we consider the right hepatic lobe size/albumin ratio a noninvasive predictor of oesophageal varices in hepatitis C virus-related liver cirrhotic Egyptian patients?

BACKGROUND: The current guidelines recommend the screening of all cirrhotic patients by endoscopy, but repeated endoscopic examinations are unpleasant for patients and have a high cost impact and burden on endoscopic units. The aim of this study is to evaluate the optimal liver lobe size/albumin ratio and to compare this ratio with spleen size, platelet count and platelet count/spleen diameter ratio as potential noninvasive predictors of oesophageal varices in hepatitis C virus (HCV)-related liver cirrhosis in Egyptian patients. METHODS: This prospective study included one hundred patients with HCV-related liver cirrhosis. All studied subjects underwent a detailed clinical examination, biochemical workup, upper gastrointestinal endoscopy and abdominal ultrasound. The platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio for all patients were calculated. RESULTS: The 4 predictors demonstrated a high statistically significant correlation with the presence and grade of oesophageal varices (P values<0.001). The platelet count/spleen diameter ratio had the highest accuracy, followed by the right liver lobe/albumin concentration ratio, spleen size and then platelet count. CONCLUSION: The use of the studied noninvasive predictors, especially the platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio, can help physicians by restricting the use of endoscopic screening only to patients presenting a high probability of oesophageal varices. This is especially useful in clinical settings where resources are limited and endoscopic facilities are not present in all areas. Such is the case in Egypt, where there is a large number of patients who require oesophageal screening for oesophageal varices.

Study of serum ghrelin changes and its correlation with malnutrition in liver cirrhosis in Egypt.

Egypt has the highest prevalence of hepatitis C virus (HCV) all over the world, with an estimated 8-10 million among a population of 68 million having been exposed to the virus and 5-7 million active infections (Frank et al., 2000). It is considered the most common aetiology of chronic liver disease (CLD) in Egypt, where prevalence of antibodies to HCV (anti-HCV) is 10-fold greater than in the United States and Europe (Goldstone et al., 2002; Strickland et al., 2002). We have studied the role of plasma ghrelin, an orexigenic hormone that was found to correlate with malnourishment in CLD depending on Child classification. Sixty patients were divided in three groups according to Child classification and were compared to normal healthy controls (20 subjects). There was a highly significant correlation of plasma ghrelin and body mass index (BMI), mid arm circumference (MAC), waist circumference (WC) and tricuspid skin fold thickness (TSF). Also plasma ghrelin was specific and sensitive by the ROC curve analysis to BMI, which would indicate a new marker for malnourishment and possibility of a novel therapeutic approach.

Long-term effect of argon plasma coagulation (APC) in the treatment of gastric antral vascular ectasia (GAVE).

BACKGROUND AND STUDY AIMS: Gastric antral vascular ectasia (GAVE) is a distinct vascular abnormality, mainly involving the gastric antrum. It is a rare but well-known cause of occult gastrointestinal bleeding. Various endoscopic treatment modalities have been tried in this condition. The aim of the study is to show the long-term effect of argon plasma coagulation (APC) on GAVE. PATIENTS AND METHODS: Twenty-nine patients with endoscopically proved GAVE were enrolled in the study. Clinical assessment of GAVE patients, haemoglobin (Hb) level and transfused blood units were recorded after APC using 60-80-W power setting. A second session was done 1month after the therapeutic procedure to ensure complete ablation of all lesions. RESULTS: The documented Hb levels and number of blood units transfused 3months after APC were recorded. At endoscopy, all patients had the classic type of GAVE. The mean Hb level increased from 7.5±1.7gdl(-1) before APC to 10.2±0.8gdl(-1) after APC (p value <0.001). The transfusion requirements significantly decreased to 0.2±0.5units/patient (p value <0.001). CONCLUSION: Endoscopic APC is a safe, effective and inexpensive modality in treating GAVE and could be an alternative to the currently available endoscopic methods.

A comparative study between three noninvasive predictors of oesophageal varices in post hepatitis C virus liver cirrhosis in Egypt.

BACKGROUND AND AIM: The prevention of variceal bleeding is very important. The current guide lines recommend screening of all cirrhotic patients by endoscopy, to identify patients at risk of bleeding in whom prophylactic treatment should be started. Repeated endoscopic examinations are unpleasant for patients, and carry a high cost impact and burden on endoscopic units, while only 50% of cirrhotic patients have esophageal varices, 30% of whom have large varices. The aim of this study is to evaluate prospectively the spleen size, platelet count and platelet count/spleen diameter ratio as noninvasive predictors of oesophageal varices in post hepatitis C virus liver cirrhosis in Egypt. PATIENTS AND METHODS: One hundred patients with post hepatitis C virus liver cirrhosis were included in the study. All studied subjects underwent a detailed history taking, clinical examination, biochemical workup, upper gastrointestinal endoscopy and abdominal ultrasound. The platelet count to spleen diameter ratio was calculated. RESULTS: All the 3 predictors showed high statistically significant correlation with the presence, size and the grade of oesophageal varices (P < 0.01). Among the 3 noninvasive predictors the platelet count/spleen diameter ratio gave the highest accuracy (94%) at a cut-off value of 1326.58 followed by the spleen size (89%) at a cut-off value of 131.5 mm and lastly the platelet count (84%) at a cut-of value of 131000/mm3. CONCLUSION: The use of the three studied predictors in this study can help the physicians to restrict endoscopy to those who are highly suspected to have oesophageal varices.