Prognosis of spontaneous bacterial peritonitis in patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the fourth leading cause of death from cancer worldwide. Spontaneous bacterial peritonitis (SBP) is associated with poor prognosis. This study aimed to evaluate risk factors, differences in clinical characteristics and prognosis of SBP in patients with HCC in comparison with non-HCC patients.

METHODS

This study was conducted on patients with cirrhosis who were admitted to hospital with SBP. The patients were divided into two groups: SBP group with HCC (n = 150) and SBP group without HCC (n = 250).

RESULTS

Men and women accounted for 72% and 28% (n = 108 and 42, respectively) of the population in SBP group with HCC with mean age 55.8 ± 13.1 years. They accounted for 68.4% and 31.6% (n = 171 and 79, respectively) in the SBP group without HCC with mean age 56.8 ± 10.5 years. In-hospital mortality was 25.3% in the SBP group with HCC and 18.8% in SBP group without HCC. Gastrointestinal bleeding was the most common cause of death in both groups. No significant difference was observed in patient outcomes between the two studied groups. The deceased patients had significantly higher levels of leukocytes and neutrophils in ascitic fluid as well as a higher frequency of positive culture results than in patients who survived (p < 0.001). However, there was no significant difference in protein level in ascitic fluid or causative organism between patients who survived and those who died (p = 0.63 and 0.19, respectively).

CONCLUSIONS

Prognosis of SBP in patients with HCC seemed similar to that in patients without HCC.

Hepatitis B Virus Infection in Eastern Libya: Current Efforts for Overcoming Regional Barriers for Its Elimination

Approximately 2.2% of Libyans have chronic hepatitis B (CHB) and are at the highest risk of developing end-stage disease complications. Several resource-limited countries, including Libya, may be far from achieving the WHO goal of hepatitis B elimination by 2030 as a result of several testing and linkage to care (LTC) barriers. In Libya, data about the current HBV infection situation is scarce. Therefore, our study aimed to evaluate the trends of HBV in eastern Libya, Tobruk region, and try to identify the region-specific gaps and barriers that could potentially delay the WHO goal of HBV elimination. An eighteen-year retrospective review of records of the main district medical center in the region was done to estimate the trends of HBV infection and qualitative interviews with the clinical staff of the CHB registry in the region were conducted to investigate the current status of HBV management. Out of 392,952 records, 371 (0.09%) HBV-positive were recorded and declining trends of the infection were noticed over the study period. Until late 2019, there was no linkage to care or follow-up for people with HBV infection. However, a CHB registry was established in late 2019 to manage HBV infections in the region, yet there are several barriers such as the lack of diagnostic infrastructure for liver function assessment and antiviral treatment. Despite the significant decline observed in the occurrence of HBV infection and introduction of important HBV management steps such as establishment of the CHB registry, there are still several barriers that could delay the elimination of the infection.

A multicentric and nationwide predictive study role of T cell sub-population in the prevalence and prognosis of cryoglobulinemia among genotype 4 chronic hepatitis C patients

The infection caused by the hepatitis C virus (HCV) is a significant global health concern. The prevailing genotype of HCV in Egypt is 4a, commonly referred to as GT-4a. A significant proportion exceeding 50% of patients infected with HCV experience extrahepatic manifestations (EHMs), encompassing a diverse range of clinical presentations. These manifestations, including essential mixed cryoglobulinemia (MC), can serve as initial and solitary indicators of the disease. The complete understanding of the pathogenesis of EHM remains unclear, with autoimmune phenomena being recognized as the primary causative factor. In this study, we examined the predictive significance of T-cell subpopulations in relation to the occurrence and prognosis of cryoglobulinemia in HCV patients. A total of 450 CHC genotype four treatment naïve patients were enrolled in this analytic cross-sectional study after thorough clinical, laboratory, and radiological examinations. All patients underwent laboratory investigations, including testing for cryoglobulin antibodies and measurements of CD4 and CD8 levels; two groups were described according to their test results: Group 1 consists of patients who have tested positive for cryoglobulin antibodies and Group 2 consists of patients who have tested negative for cryoglobulin antibodies. The exclusion criteria encompassed individuals with HIV infection or chronic HBV infection. Additionally, pelvi-abdominal ultrasonography was performed. Our study included 450 treatment naïve CHC patients (59% male, mean age 50.8 years). The patients were categorized according to their cryoglobulin antibodys test results into two groups: group A, CHC patients with cryoglobulin antibodies (Abs) negative (364 patients), and group B, CHC patients with cryoglobulin Ab positive (86 patients). Group B demonstrated a higher average age, elevated international normalized ratio, more prolonged duration of HCV infection, lower albumin, higher alanine aminotransferase, higher aspartate aminotransferase, higher bilirubin, lower CD8, lower CD4, and lower CD4:CD8 ratio. In contrast, 27 out of 86 (31.40%) patients in group B had symptoms; 85.8% had purpura and arthralgia, 74.3% had paresthesias, 86.7% had weakness, and 12.2% had non-Hodgkin's lymphoma. The levels of CD4 and CD8 were found to be decreased in chronic HCV patients with MC. T-cell subpopulation serves as a reliable indicator for assessing the prevalence and prognosis of MC in individuals with genotype 4 chronic hepatitis C. However, additional research is needed to further understand the development and spread of various emerging infectious diseases. Nevertheless, it is noteworthy that a critical threshold may exist beyond which EHM reaches a point of no return.

Vibration Controlled Transient Elastography in Screening for Silent Liver Diseases

OBJECTIVES

The objective of this study was to screen for significant hepatic fibrosis or steatosis in asymptomatic, apparently healthy subjects by using Vibration-controlled transient elastography and controlled attenuation parameter (CAP).

METHODS

Prospectively, 433 asymptomatic apparently healthy adults were included. Fibroscan/CAP examination was performed for all of them. Subjects with liver stiffness measurement > 6 kPa or CAP >248 dB/m were further evaluated to assess underlying chronic liver disease.

RESULTS

According to fibroscan/CAP examination, subjects were classified into four subgroups: normal (119) with CAP score of 215.85 ± 24.81 dB/m and fibrosis score of 4.47 ± 0.81 kPa, subjects with steatosis only 133 with CAP score of 309.41 ± 42.6 dB/m and fibrosis score of 4.74 ± 0.82 kPa, subjects with both steatosis and fibrosis 95 with CAP score of 318.20 ± 39.89 dB/m and fibrosis score of 7.92 ± 2.58 kPaand subjects with fibrosis only 86 with CAP score of 213.48 ± 22.62 dB/m and fibrosis score of 6.96 ± 1.11 kPa. S0 was present in 205 (47.3%), S1 in 48 (10.2%), S2 in 16 (3.7%) and S3 in 168 (38.8%) of studied subjects, whereas F0-1 was present in 371 (85.7%), F2 in 44 (10.16%), F3 in 16 (3.7%) subjects and F4 in only one (0.23%) subject. Subjects with both steatosis and fibrosis showed significantly higher transaminases, triglycerides and total cholesterol levels than other subgroups.

CONCLUSIONS

Most asymptomatic, apparently healthy subjects (72%) have significant steatosis and fibrosis. Liver stiffness measurement and CAP might represent promising first-line noninvasive procedures to screen for silent liver diseases in the general population.

Epidermal growth factor rs4444903 polymorphism and risk of cholangiocarcinoma. A case control study

Aim of the study

Cholangiocarcinoma (CCA) comprises a diverse group of malignancies that occur anywhere along the biliary tree. Gene polymorphisms are risk factors for CCA development. Expression levels of epidermal growth factor (EGF) are correlated with progressive tumor growth and metastasis by increasing tumor cell proliferation and migration. The EGF rs4444903 (G) allele seems to enhance carcinogenesis in several types of cancer. The aim was to study the association between epidermal growth factor EGF (rs4444903) gene polymorphism and risk of CCA in Egyptian patients.

Material and methods

This case-control study included 100 subjects, 50 CCA patients and 50 healthy individuals as controls. The EGF (rs4444903) genotyping was performed by real-time polymerase chain reaction (PCR).

Results

The risk of CCA increased more in subjects with GG and AG genotypes than in those with AA genotype compared to the control group (p = 0.009, 0.037, OR = 4.20, 2.83, 95% CI: 1.40-12.60, 1.05-7.60 respectively). The variant G allele showed a highly significant association with CCA risk in the dominant model (p = 0.009). However, in the recessive model the G allele showed a nonsignificant association with the risk of CCA (p = 0.075). There were no significant differences between the EGF rs4444903 SNP genotypes in terms of the size of foci and presence of chronic hepatitis C virus (HCV) infection in the CCA group (p = 0.220, 0.645, respectively).

Conclusions

EGF rs4444903 polymorphism may have a role in the pathogenesis of CCA and the minor G allele may predispose to CCA, but it has no effect on severity of the disease.

Hypokalemia as a responsible factor related with the severity of hepatic encephalopathy: a wide multination cross-sectional study

Several precipitating factors of hepatic encephalopathy have been recognized and studied. Hepatic encephalopathy which is a frequent and grave complication of liver failure, is associated with multiple biochemical changes like high serum ammonia, mercaptan and phenol levels, low albumin levels and derangements in electrolytes. It is characterized by a range of neuronal and psychological aberrations mainly due to the inability of liver to metabolize different neurotoxic chemicals produced in the body. Hypokalemia is one of the most important findings in hepatic encephalopathy and postulated as a precipitating factor of the condition. The authors aimed to know the frequency of hypokalemia and its relation to the severity of hepatic encephalopathy.

Methods

After taking approval from the hospital ethical review committee, a total of 5000 patients with hepatic encephalopathy were recruited by consecutive sampling. They were interviewed, examined and investigated for serum potassium levels and other precipitating factors of hepatic encephalopathy.

Results

Total of 5000 patients including 3070 (61.4%) males and 1930 (38.6%) females, aging 13 years and above were studied. The frequency of hypokalemia was 78% (3900 patients). Relating the serum potassium level with the severity of hepatic encephalopathy, 1200 (60%) out of 2000 patients with serum potassium below 2.5 mEq/l were in grade 4 (40%) and 800 out of 2000 were in grade 3 encephalopathy. On the other hand, only 700 patients (6.4%) out 1100 with serum potassium above 3.4 mEq/l were in grade 4 encephalopathy.

Conclusion

Hypokalemia is a frequent finding in patients with hepatic encephalopathy and found to be directly related to its severity.

Bone morphogenic protein-7 (BMP-7) polymorphism: Susceptibility to cirrhosis and hepatocellular carcinoma after viral hepatitis in Egyptian patients

Aim of the study

Bone morphogenic proteins (BMPs) have both inhibitory and stimulatory effects on growth of a tumor that depend on the type of cells, the dosage and the tumor microenvironment. We aimed to investigate the impact of the bone morphogenic protein-7 (BMP-7) single nucleotide polymorphism (SNP) rs230205 [A/G] on susceptibility to hepatocellular carcinoma (HCC) progression from liver cirrhosis after viral hepatitis infection in Egyptian patients.

Material and methods

The amplification-refractory mutation system (ARMS)-polymerase chain reaction (PCR) method was used to genotype the rs230205 [A/G] SNP in 150 subjects (50 patients with post-hepatitis C or B cirrhosis, 50 HCC patients, and 50 controls). Expression level of BMP-7 protein was assessed using enzyme-linked immunosorbent assay (ELISA).

Results

The results revealed insignificant changes in distribution of all genotypes/alleles of the BMP-7 rs230205 [A/G] SNP between cirrhotic patients, HCC patients and controls. The AA genotype and A allele could be considered risk factors for cirrhosis (OR = 1.75, 1.50) and HCC (OR = 2.19, 1.74), respectively. The AA genotype (95% CI: 0.45-6.79) and A allele (OR = 1.50, 95% CI: 0.77-2.93) may be viewed as cirrhosis risk factors based on group segregation. Additionally, the A allele, AG and AA genotypes and their combined ORs of 2.19 (95% CI: 0.58-8.23), 1.74 (95% CI: 0.90-3.37), and 1.70 (95% CI: 0.68-4.29) could all be risk factors for HCC. No genotype or allele could be regarded as a risk factor for progression of cirrhosis to HCC, according to OR values.

Conclusions

The results showed no correlation between BMP-7 rs230205 [A/G] SNP and progression of cirrhosis to HCC. To confirm our findings, additional prospective large-scale research is required.

Susceptibility patterns and virulence genotypes of Helicobacter pylori affecting eradication therapy outcomes among Egyptian patients with gastroduodenal diseases

BACKGROUND

Helicobacter pylori (H. pylori) is a significant human pathogen that is responsible for a variety of illnesses, including mucosa-associated lymphoid tissue lymphoma, gastric cancer, peptic ulcers, and gastritis.

AIM

To investigate the frequency of H. pylori infection and its resistance patterns among Egyptian patients and to determine the influence of H. pylori virulence genetic determinants on the eradication success of 14-d triple therapy regimen.

METHODS

H. pylori infections were investigated in 72 patients with gastroduodenal complications suggestive of H. pylori infection. The cagA and vacA genotypes of cultured strains were studied using polymerase chain reaction. The patients underwent 14 d of triple-therapy treatment. The treatment response was examined using histology and a rapid urease test 6 wk after therapy discontinuation.

RESULTS

The intention-to-treat eradication rate was 59.2% (95%CI: 48.2%–70.3%). Rates of H. pylori resistance to clarithromycin, amoxicillin, and metronidazole were 52.8%, 81.9%, and 100%, respectively. Successful eradication of H. pylori was more significantly associated with vacA s1-positive strains [adjusted odds ratio (aOR) = 0.507, 95%CI: 0.175–0.822]. A significant association was found between failed eradication rate and H. pylori strains resistant to clarithromycin (aOR = 0.204, 95%CI: –0.005 to 0.412) and amoxicillin (aOR = 0.223, 95%CI: 0.026–0.537).

CONCLUSION

This study’s low H. pylori eradication rate following 14-d triple therapy is concerning and worrying. H. pylori pan-resistance to metronidazole followed by the high resistance to ciprofloxacin, amoxicillin, and clarithromycin in this research is challenging and of great concern.

A286 THE ROLE OF A GUT HORMONE VERSUS NUCLEAR FACTOR-KAPPA B IN PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE

NOT PUBLISHED AT AUTHOR’S REQUEST

A151 OSEPHAGEAL VARICEAL RECURRENCE 4 YEARS BEYOND ENDOSCOPIC BAND LIGATION IN HEPATITIS C PATIENTS WHO ACHIEVED SUSTAINED VIROLOGICAL RESPONSE WITH ORAL DIRECT ACTING ANTIVIRAL THERAPIES

NOT PUBLISHED AT AUTHOR’S REQUEST

Role of liver biopsy in management of liver diseases without hepatic nodules following end of the interferon era: experience of a tertiary referral center

Liver biopsy (LB) is the cornerstone in the management of patients with liver diseases. However, a lot of queries had emerged about its role following the end of the interferon era. The aim of this study was to re-evaluate the current role of LB in the diagnosis of liver diseases. All patients who had underwent LB at the Department of Hepatology, National Liver Institute, from January 2015 through December 2018 were recruited. Indications for LB, pathology reports and medical records of all cases were retrieved, reviewed and statistically analyzed. A total of 275 liver biopsies were collected, 191 males and 84 females with mean age 41.22 ± 13.36 years. Etiological diagnosis made by histopathological evaluation was 48 drug-induced liver injury (DILI), 42 nonalcoholic fatty liver disease (NAFLD), 34 chronic hepatitis B, or C with cholestasis, 29 autoimmune hepatitis, 34 primary sclerosing cholangitis, 13 primary biliary cholangitis, 7 autoimmune overlap syndrome, 13 active bilharziasis and 10 Wilson's disease. Minor number of cases was diagnosed by different other etiologies. Initial diagnosis was made by liver biopsy and confirmed by clinical response and laboratory findings. Liver biopsy is still considered as the gold standard diagnostic measure of different liver diseases representing an integral component of management decisions in hepatology.

Levofloxacin+Tetracycline Quadruple Regimen for Eradication of Helicobacter pylori: A Multicenter Multinational Randomized Controlled Trial

Background: The ideal combination regimen for Helicobacter pylori (HP) eradication has not yet been determined and the success rate of HP eradication has been extensively reduced worldwide due to increasing antibiotic resistance. So this multinational multi-center randomized controlled trial was designed to evaluate the efficacy of tetracycline +levofloxacin for HP eradication. Methods: During a 6-month period, all of the cases with HP infection in eight referral tertiary centers of three countries were included and randomly allocated to receive either tetracycline + levofloxacin or clarithromycin plus amoxicillin quadruple regimen for two weeks. For all of the participants, pantoprazole was continued for 4 more weeks and after one to two weeks of off-therapy, they underwent urea breath test C13 to prove eradication. Results: Overall 788 patients were included (358 male (45.4%), average age 44.2 years). They were diagnosed as having non-ulcer dyspepsia (516 cases, 65.5%), peptic ulcer disease (PUD) (234 cases, 29.69%), and intestinal metaplasia (38 cases, 4.8%). Racially 63.1% were Caucasian, 14.5% Arab, 15.6% African, and 6.1% Asian. The participants were randomly allocated to groups A and B to receive either tetracycline + levofloxacin or clarithromycin. Among groups A and B in intention to treat (ITT) and per protocol (PP) analysis, 75.2% & 82.1% (285 cases) and 67.5% & 70.1% (276 cases) of participants achieved eradication, respectively (P = 0.0001). The complete compliance rate in groups A and B were 84.4% and 83.6%, respectively. During the study, 33.5% of the participants in group A (127 cases) reported side effects while the complication rate among group B was 27.9% (114 cases, P = 0.041). The most common complaints among groups A and B were nausea and vomiting (12.6% & 9.3%) and abdominal pain (4.48% & 2.68%), respectively. The rate of severe complications that caused discontinuation of medication in groups A and B were 2.1% and 1.46%, respectively (P = 679). In subgroup analysis, the eradication rates of tetracycline+levofloxacin among patients with non-ulcer dyspepsia, PUD, and intestinal metaplasia were 79.4%, 88.1%, and 73.9%, respectively. These figures in group B (clarithromycin base) were 71.3%, 67.6%, and 61.5% respectively (P = 0.0001, 0.0001, and 0.043). Conclusion: Overall, the combination of tetracycline+levofloxacin is more efficient for HP eradication in comparison with clarithromycin+amoxicillin despite more complication rate. In areas with a high rate of resistance to clarithromycin, this therapeutic regimen could be an ideal choice for HP eradication, especially among those who were diagnosed with PUD.

Evaluation of Amino Acids Profile as Non-Invasive Biomarkers of Hepatocellular Carcinoma in Egyptians

BACKGROUND

Hepatocellular carcinoma (HCC) is the most dangerous complication of chronic liver disease. It is a multifactorial complicated disease. Hepatitis C and hepatitis B viruses (HCV and HBV, respectively) represent the main causes of HCC in Egypt. Early diagnosis is very important to aid in early intervention.

OBJECTIVES

The goal of this research is to evaluate the metabolic role of different amino acids as non-invasive biomarkers over the course of HCC.

METHODS

This study included 302 participants with 97 diagnosed, untreated HCC patients, 81 chronic HCV patients, 56 chronic HBV patients, 18 co-infected patients, and a control group of 50 normal age and gender-matched individuals. All participants provided complete medical histories and underwent complete clinical examinations, abdominal ultrasonography and/or computed tomography, routine laboratory investigations, estimation of serum α-fetoprotein, and determination of amino acid levels using ultra-performance liquid chromatography (UPLC MS/MS).

RESULTS

This work revealed a decline in branched chain amino acids (BCAA) and increase in aromatic amino acids (AAA) among infected groups (HCC, HBV, HCV, and co-infected patients) compared to control subjects and a marked change in Fisher's and the BCAAs/tyrosine molar concentration ratios (BTR) between controls and infected groups.

CONCLUSION

Different amino acids could be used as non-invasive markers to discriminate and follow chronic hepatitis patients to predict the course of HCC.

Acute Hepatitis A Virus Infection in Tobruk, Eastern Libya: Increasing Trends After 2017

Acute hepatitis A is a self-limited liver inflammation caused by hepatitis A virus (HAV) infection. The infection is transmitted by direct contact from person to person via fecal-oral routes, or through consuming contaminated food and water. This study aims to estimate the frequency of HAV infection from medical records of Tobruk Medical Center, eastern Libya and its distribution during 6 years. The medical records department of Tobruk Medical Center follows guidelines of the international classification of diseases-10 for coding the diseases. The research estimates the frequency and distribution of HAV infection based on age and sex during the period from January 2015 to December 2020. HAV screening assay was performed using commercially available enzyme-linked immunosorbent assays HAV IgM microwell. 245 cases were recorded, 53.5% of cases were males. HAV infection was the most prevalent (92.6%) in age groups of < 5-20 years. A significant rise in the occurrence of HAV infection in the last three years was reported (p < 0.05). More than half of the cases (68%) were reported in 2019 and 2020. No case fatality rate was reported in the present study. There is an increase in the frequency of HAV infection in the last 3 years and the younger age groups (under 20 years old) are more vulnerable to HAV infection. More prevention and control efforts towards this age group should be a top public health priority to avoid the possibility of HAV outbreaks in the future.

Hepatitis C Virus Infection in Eastern Libya: Efforts Needed to Improve HCV Testing and Linkage to Care in the Resource-Limited Setting

Hepatitis C virus (HCV) is a significant public health problem, and the elimination of its infection by 2031 is a global goal. However, due to insufficient testing, lack of linkage to care (LTC) and treatment, Libya may be far from achieving this goal. This study aimed to explore HCV testing, the care and treatment of infected people, and to assess the burden of the infection among individuals who visited the main Medical Centre in Tobruk region, eastern Libya, for various medical and surgical conditions. A research team interviewed public health officials in Tobruk Medical Center, inspected available equipment, and obtained data available for people who were positive for antibodies to HCV (anti-HCV) as part of their routine pre-invasive procedures and pre-donation screening tests from January 2005 to April 2020. HCV antibody tests were positive for 612 cases out of 368,392 (0.17%). Of those who tested positive for anti-HCV antibodies, no one had followed up by RNA test for identifying individuals with chronic HCV infection, and there are no links to outpatient care and treatment. Our findings highlight the critical need for an up-to-date HCV diagnosis and linkage to care guidelines, which includes a follow-up RNA test for anti-HCV positive patients and early linkage to care for confirmed cases to accelerate the elimination of HCV infection from the community.

Value of Bile Acids in Diagnosing Hepatitis C Virus-Induced Liver Cirrhosis and Hepatocellular Carcinoma

Background: Metabonomic studies have related bile acids to hepatic impairment, but their role in predicting hepatocellular carcinoma still unclear. The study aimed to examine the feasibility of bile acids in distinguishing hepatocellular carcinoma from post hepatitis C virus-induced liver cirrhosis.

Methods: An ultra-performance liquid chromatography coupled with mass spectrometry measured 14 bile acids in patients with noncirrhotic post hepatitis C virus disease (n = 50), cirrhotic post hepatitis C virus disease (n = 50), hepatocellular carcinoma (n = 50), and control group (n = 50).

Results: The spectrum of liver disease was associated with a significant increase in many conjugated bile acids. The fold changes in many bile acid concentrations showed a linear trend with hepatocellular carcinoma &gt; cirrhotic disease &gt; noncirrhotic disease &gt; healthy controls (p &lt; 0.05). Receiver operating characteristic curve analysis revealed five conjugated acids TCA, GCA, GUDCA, TCDCA, GCDCA, that discriminated hepatocellular carcinoma from noncirrhotic liver patients (AUC = 0.85–0.96) with a weaker potential to distinguish it from chronic liver cirrhosis (AUC = 0.41–0.64).

Conclusion: Serum bile acids are associated primarily with liver cirrhosis with little value in predicting the progress of cirrhotic disease to hepatocellular carcinoma.

The association between micro-RNA gene polymorphisms and the development of hepatocellular carcinoma in Egyptian patients

INTRODUCTION

The development and progression of hepatocellular carcinoma (HCC) is a multistage process involving the deregulation of genes that are crucial to cellular processes. Multiple risk factors are correlated with HCC. MicroRNA is differentially expressed in the development of different types of malignancies, including hepatic malignancy. Single nucleotide polymorphisms (SNPs) are the most common sequence variation in the human genome. SNPs in miRNAs may affect transcription, processing, or target recognition and result in malignant disease. The aim of the study was to determine the association between microRNA gene polymorphisms and the development of HCC in Egyptian patients.

MATERIAL AND METHODS

This study included 200 individuals who were matched in age and sex. Tumour staging was done using the BCLC staging system. Quantification and genotyping of microRNA were performed.

RESULTS

Among the 200 patients, 2 groups were described: group I included 90 HCC patients with a male majority (72.2%), and group II comprised 110 controls. Three microRNA SNPs were assayed in both patients and controls. There was a significant association between rs10061133 miR-499b and the risk of HCC. The genotypes GG or G allele were significantly associated with an increased risk of HCC (GG: OR = 2.91, 95% CI: 1.23-4.22, p = 0.013; G allele: OR = 1.79, 95% CI: 1.12-2.15, p = 0.026) compared with the genotype of AA or AG or A allele.

CONCLUSIONS

There is an association between the miRNA SNPs and the susceptibility to HCC, to explore some roles and mechanisms of SNPs within miRNAs in the occurrence and development of HCC.

Lymphoepithelioma-like Hepatocellular Carcinoma: a Case Report and Review of Literature

We report a case of hepatic lymphoepithelioma-like carcinoma-hepatocellular carcinoma subtype (LEL-HCC) in a 41-year-old man with chronic hepatitis C virus (HCV) infection. The patient presented with abdominal pain and further assessment revealed a hypoechoic mass on ultrasonography. Serum alpha-fetoprotein (AFP) was 13·6 ng/dl. The patient was diagnosed as hepatocellular carcinoma based on the established triphasic computed tomography (TCT) diagnostic criteria and he underwent a surgical resection of the mass. Microscopic examination showed sheets and cords of malignant epithelial cells intermixed with heavy lymphoid infiltrate, with more than 100 tumor-infiltrating lymphocytes (TILs) per 10 high-power-field (HPF). Based on immunohistochemical studies, the malignant cells were positive for Hep Par 1 and glypican 3, focally positive for cytokeratin 7 (CK7), and negative for cytokeratin 20 (CK20). TILs were diffusely positive for cluster of differentiation 3 CD3 with an approximately equal CD4/CD8 ratio. The patient was recurrence free at 25 months after surgery, as evident by CT and serum alpha-fetoprotein level. LEL-HCC is a rare variant of HCC with a relatively better prognosis. Exploring the potential for immune modulator-based therapy in this subset of tumors is highly recommended.

Role of bile acids in the prediction of hepatocellular carcinoma in HCV-induced liver cirrhosis

Background

Bile acids are essential organic molecules synthesized from cholesterol in the liver and regarded as indicators of hepatobiliary impairment; however, their role in the pathogenesis of hepatocellular carcinoma (HCC) is still unclear. The study aimed to examine the feasibility of bile acids in distinguishing HCC from post hepatitis C virus liver cirrhosis. A UPLC/MS was used to measure 14 bile acids in patients with noncirrhotic HCV disease (n = 50), cirrhotic HCV disease (n = 50), hepatocellular carcinoma (n = 50), and control group (n = 50).

Results

The progression of liver cirrhosis to HCC was associated with a significant increase in serum bile acids compared to the normal or the noncirrhotic HCV disease (p < 0.05). The fold changes in bile acids concentrations showed a trend that HCC > cirrhotic HCV disease > noncirrhotic HCV disease. Four conjugated acids GCA, GCDCA, GUDCA, and TCDCA steadily increased across the different groups. ROC curves analysis revealed that these bile acids discriminated noncirrhotic liver patients from HCC (AUC 0.850–0.963), with a weaker potential to distinguish chronic liver cirrhosis from HCC (AUC 0.414–0.638).

Conclusion

The level of serum bile acid was associated primarily with liver cirrhosis, with little value in predicting the progress of chronic liver cirrhotic disease into hepatocellular carcinoma.

Hyaluronic acid as a potential marker for assessment of fibrosis regression after direct acting antiviral drugs in chronic hepatitis C patients

INTRODUCTION

Fibrosis is an inevitable complication of chronic hepatitis C virus (HCV) infection. Direct acting antivirals (DAAs) radically treated HCV and were suggested to ameliorate fibrosis. Silymarin (a natural herbal remedy) was proposed to further decrease hepatic inflammation and fibrosis. Consequently, serial monitoring of liver fibrosis status by different biomarkers is needed.

AIM OF THE STUDY

To assess hyaluronic acid (HA) as a potential marker of fibrosis regression after DAAs in chronic HCV patients; in addition, to evaluate silymarin as an agent that, beside DAAs, could further improve fibrosis.

MATERIAL AND METHODS

Two groups were included (150 patients each). Group 1 received DAAs only, while group 2 received DAAs followed by silymarin. Hyaluronic acid and FIB4 score were assessed at baseline before treatment and 1 year after inclusion in the study.

RESULTS

We found that DAA therapy alone or in combination with silymarin resulted in a significant reduction in serum HA level. However, the latter case showed a statistically significantly greater reduction (p = 0.034). Mean ±SD of serum HA level was 211.8 ±179.9 and 143.3 ±123.9 µg/l before and one year after inclusion respectively in group 1 (p = 0.001) and also, its level decreased significantly in group 2 from 188.3 ±211.8 µg/l before receiving DAAs to 126.4 ±136.9 µg/l at one year after inclusion (p = 0.001). There was no significant difference between the 2 studied groups as regards FIB-4 at 1 year after inclusion (p = 0.103).

CONCLUSIONS

Hyaluronic acid might be a sensitive marker for monitoring fibrosis regression in treated chronic HCV patients. Adding silymarin to treatment protocols could ameliorate the fibrosis status.

Cancer incidence in the Tobruk area, eastern Libya: first results from Tobruk Medical Centre

OBJECTIVES

Cancer is a major cause of morbidity and mortality worldwide, and it is an increasing problem in developing countries. Estimation of the incidence of cancer is important, especially in regions with limited epidemiological data on cancer. Therefore, the aim of this study was to provide an updated report on the incidence of cancers in the Tobruk region in eastern Libya.

METHODS

Data on cancer patients from the records of the Department of Histopathology of Tobruk Medical Centre from January 2013 to June 2020 were included.

RESULTS

In total, 402 cases were recorded. Men patients accounted for 30.3% (n=122) of cases, and women patients represented 69.6% (n=280). The overall mean age at the time of the first diagnosis was 49.0±17.1 years. The most common malignancies were breast and uterine cancer in women (18.4%, n=74; 15.9%, n=64, respectively), colorectal cancer (11.6%, n=47; 26 in women and 21 in men), bladder cancer (8.2%, n=33; 8 in women and 25 in men), and thyroid cancer (8.0%, n=32; 23 in women and 9 in men).

CONCLUSIONS

Breast and uterine cancers were the most common cancers in women, and bladder and colorectal cancer were the most common cancers in men, followed by colorectal cancer in both genders. These data will help health authorities launch preventive plans for cancer in the region. Further studies to identify aetiological factors and cancer-related risk factors need to be conducted in the region.

The Putative Role of Natural Killer Cells in Patients with Hepatitis C Virus-Related Hepatocellular Carcinoma

BACKGROUND

Natural Killer (NK) cells have crucial roles in immune responses against malignant transformation including hepatocellular carcinoma (HCC). The NKG2D receptor has a critical role in the NK recognition of target cells.

AIM

We assessed NKG2D receptor expression as a diagnostic biomarker for HCC detection and progression in Egyptian patients with hepatitis C virus (HCV)-related HCC.

METHODS

We classified 81 patients into three groups: chronic hepatitis (21), cirrhotic (30) and HCC (30) patients, with 36 individuals enrolled to the control group. We analyzed NK levels in peripheral blood and NKG2D receptor expression in NK cells using flow cytometry.

RESULTS

We observed a significant decrease in NKG2D (CD314) expression on circulating NK cells and frequency of NK cells expressing NKG2D (CD314) in HCC patients. Also, in patients, larger foci lesions significantly correlated with decreased NK cell numbers. Multiple foci numbers and patients with a Child score C significantly correlated with decreased circulating NK cells expressing NKG2D and decreased NKG2D expression.

CONCLUSION

The percentage of NK cells in peripheral blood and NKG2D receptor expression could function as potential biomarkers for HCC detection and progression.

SARS-CoV-2-associated gastrointestinal and liver diseases: what is known and what is needed to explore

BACKGROUND

The pandemic of COVID19 which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first described in China as an unexplained pneumonia transmitted by respiratory droplets. Gastrointestinal (GI) and liver injury associated with SARS-CoV-2 infection were reported as an early or sole disease manifestation, mainly outside China. The exact mechanism and incidence of GI and liver involvement are not well elucidated.

MAIN BODY

We conducted a PubMed search for all articles written in the English language about SARS-CoV-2 affecting the GI and liver. Following data extraction, 590 articles were selected. In addition to respiratory droplets, SARS-CoV-2 may reach the GI system through the fecal-oral route, saliva, and swallowing of nasopharyngeal fluids, while breastmilk and blood transmission were not implicated. Moreover, GI infection may act as a septic focus for viral persistence and transmission to the liver, appendix, and brain. In addition to the direct viral cytopathic effect, the mechanism of injury is multifactorial and is related to genetic and demographic variations. The most frequently reported GI symptoms are diarrhea, nausea, vomiting, abdominal pain, and bleeding. However, liver infection is generally discovered during laboratory testing or a post-mortem. Radiological imaging is the gold standard in diagnosing COVID-19 patients and contributes to understanding the mechanism of extra-thoracic involvement. Medications should be prescribed with caution, especially in chronic GI and liver patients.

CONCLUSION

GI manifestations are common in COVID-19 patients. Special care should be paid for high-risk patients, older males, and those with background liver disease.

Predictive Role of AURKA rs 1047972 Gene Polymorphism and the Risk of Development of Hepatocellular Carcinoma

ABBREVIATION

AFP: alpha-fetoprotein; ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; AURKA: aurora kinase A; BCLC: Barcelona- Clinic Liver Cancer; CBC: complete blood count; CT: computed tomography; DM: diabetes mellitus; DNA: deoxyribonucleic acid; EDTA: ethylene diamine tetraacetic acid; GGT: gamma-glutamyl transferase; HB: hemoglobin; HBV: hepatitis B virus; HBsAg: hepatitis B surface antigen; HCC: hepatocellular carcinoma; HCV: hepatitis C virus; INR: international normalized ratio; mRNA: messenger ribonucleic acid; OR: odds ratio; PVT: portal vein thrombosis; RT-PCR: real-time polymerase chain reaction; SNP: single nucleotide polymorphism; WBCs: white blood cells.

Outcomes of curative liver resection for hepatocellular carcinoma in patients with cirrhosis

BACKGROUND

Given the poor synthetic function of cirrhotic liver, successful resection for patients with hepatocellular carcinoma (HCC) necessitates the ability to achieve resections with tumor free margins.

AIM

To validate post hepatectomy liver failure score (PHLF), compare it to other established systems and to stratify risks in patients with cirrhosis who underwent curative liver resection for HCC.

METHODS

Between December 2010 and January 2017, 120 patients underwent curative resection for HCC in patients with cirrhosis were included, the pre-operative, operative and post-operative factors were recorded to stratify patients' risks of decompensation, survival, and PHLF.

RESULTS

The preoperative model for end-stage liver disease (MELD) score [odds ratio (OR) = 2.7, 95%CI: 1.2-5.7, P = 0.013], tumor diameter (OR = 5.4, 95%CI: 2-14.8, P = 0.001) and duration of hospital stay (OR = 2.5, 95%CI: 1.5-4.2, P = 0.001) were significant independent predictors of hepatic decompensation after resection. While the preoperative MELD score [hazard ratio (HR) = 1.37, 95%CI: 1.16-1.62, P < 0.001] and different grades of PHLF (grade A: HR = 2.33, 95%CI: 0.59-9.24; Grade B: HR = 3.15, 95%CI: 1.11-8.95; Grade C: HR = 373.41, 95%CI: 66.23-2105.43; P < 0.001) and HCC recurrence (HR = 11.67, 95%CI: 4.19-32.52, P < 0.001) were significant independent predictors for survival.

CONCLUSION

Preoperative MELD score and tumor diameter can independently predict hepatic decompensation. While, preoperative MELD score, different grades of PHLF and HCC recurrence can precisely predict survival.

Portal vein thrombosis in hepatitis C virus-related cirrhotic patients: Prevalence and clinical characteristics in an Egyptian cohort

Portal vein thrombosis is a catastrophe not uncommonly complicating hepatitis C virus-related liver cirrhosis. To estimate its prevalence and clinical characteristics, we investigated 1000 cirrhotic patients by abdominal ultrasound or Doppler study at least. Portal vein thrombosis was found in 21.6%, of whom 157 (72.7%) had malignancy. Complete portal vein thrombosis was found in 70.4%. Half of all these patients had at least one episode of portal hypertensive bleeding, a third had abdominal pain and a quarter presented with jaundice. Portal bilopathy was diagnosed in two cases (0.9%). There was significant association between severity of liver disease, ascites, male gender and site of segmental focal lesion and portal vein thrombosis.

The role of IL-4 gene polymorphism in HCV-related hepatocellular carcinoma in Egyptian patients

Background

Interleukin-4 (IL-4), a pleiotropic anti-inflammatory cytokine, is produced mainly by activated T helper 2 (Th2). Hepatocellular carcinoma (HCC) is a typical inflammation-related cancer. Alterations influencing IL-4 expression may disturb immune response and may be associated with HCC risk. We aimed to verify role of IL4 gene polymorphism (IL-4-589C/T (rs2243250)) in HCV-related hepatocellular carcinoma in Egyptian patients. IL-4-589C/T (rs2243250) polymorphism was examined in 50 patients with HCC on top of HCV, 40 patients with HCV-induced liver cirrhosis, and 30 healthy controls using the polymerase chain reaction- restriction fragment length polymorphism method.

Results

Overall IL-4 gene polymorphism (IL-4-589C/T (rs2243250)) showed significant difference between hepatocellular carcinoma group versus liver cirrhosis and healthy control groups. TT homozygous genotype was more prevalent in HCC group (24%) versus (5%) in liver cirrhosis and (3.3%) in control. TT homozygous genotype had 10 times more risk of hepatocellular carcinoma versus healthy control group and 6.33 times more risk versus cirrhotic patients group (p value = 0.018 and 0.016 respectively).

Conclusion

IL-4-589C/T (rs2243250) polymorphism, TT homozygous genetic model, may be a risk factor in HCV-related HCC in Egyptian patients.

Variceal recurrence 4 years post endoscopic band ligation in hepatitis C patients who achieved sustained virological response with oral direct-acting antiviral therapy

Oral Direct-acting antivirals (DAAs) are safe, highly effective altering disease burden and prognosis in hepatitis C patients. Sustained virologic response (SVR) is achieved nowadays in more than 90% of the treated patients and related to the improvements in functions of the liver, fibrosis plus survival. Furthermore, portal hypertension is thought to be improved with achievement of virological response, parallel to the improvements in hepatic inflammation and fibrosis. We aimed to assess the recurrence rate of oesophageal varices by long-term follow-up in patients treated with different DAAs regimens who had achieved SVR. We studied 176 Child A cirrhotic HCV patients who achieved SVR after DAAs treatment and had a history of endoscopic oesophageal varices obliteration and were on maximum tolerated propranolol dose. They were subjected to follow-up upper gastrointestinal endoscopy repeated every 6 months for 4 years. Fifty-two patients (29.5%) had recurrence of oesophageal varices observed during the 4-years follow-up upper GIT endoscopy. On multivariate analysis, platelet count was the only significant variable, P-value = .007*. HbA1C, HOMA IR, BMI 1 and BMI 2 showed non-significant differences between the studied groups. By ROC analysis, we identified baseline platelet count of 96 000/µL with 100% sensitivity (95% confidence interval [CI] [91%-100%]) and 74% specificity (95% CI [65%-81%]). Spearman correlation showed a positive correlation between AFP, age, AST, Bilirubin, creatinine, INR. Patients who achieved SVR post DAAs showed a significant decrease in oesophageal varices recurrence post endoscopic obliteration. Baseline platelet count was found to be a strong independent predictor for oesophageal varices recurrence.

Association between IFN-λ 3 Gene Polymorphisms and Outcome of Treatment with Direct Acting Antivirals in Chronic HCV-Infected Egyptian Patients

Background: Single nucleotide polymorphisms (SNPs) of the interferon lambda 3 (IFN-λ 3) gene are associated with viral clearance and treatment response in chronic hepatitis C virus (HCV) infection. Aim: to assess whether specific IFN-λ 3 gene SNP, known as rs12979860 (C > T), could predict the outcome of treatment with direct acting antivirals (DAAs) among Egyptian patients with chronic HCV genotype 4 infection. Methods: Tetra-primer (ARMS-PCR) and PCR-RFLP methods were used for SNP genotyping in 100 chronic HCV-infected patients and 50 healthy subjects as control group. Results: The CC (wild type) genotype of rs12979860 was identified in 20 patients, 50% of them achieved sustained virological response (SVR). SNP genotype TT was found in 17 patients and only 2 of them (11.76%) were responders. The frequency of CT genotypes was significantly higher in responders than in non-responders (p= .021). In contrast, the frequency of TT genotypes was significantly higher in non-responders (42.85%, p< .001). On univariate and multivariate logistic regression analyses of the significant predictors of SVR, there were six predictive factors (Age, diabetes mellitus, AST, albumin, type of therapy and IFN-λ 3 genotype). Conclusion: The TT genotype and T allele were significantly associated with failure to achieve SVR. However, CT genotype of IFN-λ 3 (rs12979860) may be considered as a predictor for SVR in patients who received DAAs.

Direct acting antivirals are associated with more liver stiffness regression than pegylated interferon therapy in chronic hepatitis C patients

OBJECTIVES

Extent of post-treatment fibrosis change in patients with different stages of fibrosis not fully known. We aimed to study changes in liver fibrosis in chronic hepatitis C patients who were treated with pegylated interferon/ribavirin (PEG/RBV) or direct acting antivirals (DAAs).

METHODS

Retrospective evaluation of results of transient elastography (TE) was done before and 1 year after end of treatment for patients treated with PEG/RBV (n = 268) and DAAs (n = 245).

RESULTS

The average age was 45.54 ± 10.64 years; mainly males. All patients in the DAAs group achieved sustained virological response (SVR), unlike 56.3% of the patients in the PEG/RBV group. F3-F4 fibrosis was predominant in the PEG/RBV nonresponder patients (51.3%) and DAAs responders (57.1%). TE decreased 1 year after end of treatment (p = 0.001) in the viral responders of the PEG/RBV group (7.44 ± 4.02 vs. 10.24 ± 7.29 kPa) and DAAs group (12.12 ± 9.21 vs. 16.81 ± 12.84 kPa) respectively. The delta TE change in the DAAs responders was higher than the PEG/RBV responders (p = 0.001) and PEG/RBV nonresponders (p = 0.001). The percentage of patients with liver fibrosis regression was higher in DAAs responders (52.5%) than in PEG/RBV responders (23.3%).

CONCLUSION

Treatment with DAAs is associated with fibrosis improvement more than treatment with PEG/RBV in chronic hepatitis C patients.

Matrix Metalloproteinase-11 Gene Polymorphisms as a Risk for Hepatocellular Carcinoma Development in Egyptian Patients

Background:

Chronic hepatitis C (CHC) virus infection is one of major risk factors of hepatocellular carcinoma (HCC) in Egypt, which is a major cause of cancer mortalityin the world. Matrix metalloproteinase-11 (MMP-11) has an important role in tumor migration and metastasis. Therefore, this study aimed to determine relation between MMP-11 gene polymorphisms and risk of HCC development among Egyptian cirrhotic patients. Subjects and methods: Two hundred and sixty patients were included, 140 of them with HCC on top of CHC and 120 patients with post CHC liver cirrhosis (LC) as well as 140 subjects were enrolled in the study as healthy controls. Two single nucleotide polymorphisms (SNPs) rs738791 and rs738792 for MMP-11 gene were done using real-time PCR.

Results:

Combination of CT and TT allele of rs738791 genotypes was more significantly frequent in HCC compared to LC patients and controls, however, a higher frequency of T allele was found in HCC patients compared to LC and controls. In spite of lake of significant difference between patient groups regarding the rs738792 genotypes, the CC genotype was considered a risk of developing portal vein thrombosis, and was associated with advanced tumor stage, increased tumor size, higher Cancer of the Liver Italian Program [CLIP] score, more advanced Barcelona stage [D] and with child Pugh class [C].

Conclusion:

Genetic variations in MMP-11 may be implicated in post HCV-HCC development and might be dependable biomarkers for HCC progression.

The role of serum bile acid profile in differentiation between nonalcoholic fatty liver disease and chronic viral hepatitis

Background

Bile acids are essential organic molecules synthesized from cholesterol in the liver. They have been utilized as indicators of hepatobiliary impairment because synthesis of BAs and their metabolism are influenced by liver diseases. We aimed to investigate the role of serum bile acid level and composition in differentiation between nonalcoholic fatty liver disease (NAFLD) and chronic viral hepatitis. An ultra-performance liquid chromatography coupled with mass spectrometry assay was used to measure the serum level of 14 bile acids in chronic viral hepatitis and NAFLD patients beside normal healthy control subjects.

Results

The mean serum levels of 11 out of the 14 bile acids (two primary, six conjugated, and three secondary) were significantly higher in viral hepatitis compared to control. Only 4 bile acids [2 primary, one glycine conjugated (GCDCA), and one secondary (LCA)] had statistically significant increase in their mean serum bile acid level in NAFLD compared to control. Comparing viral hepatitis group against NAFLD group revealed that the mean serum levels of five conjugated and one secondary bile acid (DCA) were significantly higher in viral hepatitis group. Receiver operating characteristic (ROC) curve analysis revealed that LCA had the best diagnostic performance for viral hepatitis followed by TCA and GCDCA. ROC curve for the combined three parameters had better sensitivity and specificity (70.55% and 94.87% respectively).

Conclusion

BA compositions including primary, secondary, and conjugated ones could differentiate between chronic viral hepatitis and NAFLD patients, and they might be potential distinguishing biomarkers for this purpose.

Liver biopsy is still needed in liver transplantation recipients: a single center experience

Background

Liver transplantation is a final treatment for decompensated liver disease.

Aim

Description of post-liver transplant histopathology. We enrolled 89 patients divided into two groups according to if they underwent on demand liver biopsy (n = 34; 38.2%) or not (n = 55; 61.8%). Albumin-bilirubin (ALBI) score and model for end-stage liver disease (MELD) assessed the degree of liver dysfunction.

Results

Patient underwent liver biopsy (LB) was 44.65 ± 8.46 years old, mainly males (88.2%) with average MELD of 8.74 ± 4.71. Most patients were positive pre-transplant for HCV (91.2%) and 29.4% had hepatocellular carcinoma on top of hepatitis C. Patients underwent LB had worse liver dysfunction by ALBI score (− 2.62 ± 0.6 vs. − 2.96 ± 0.5; p = 0.014) but comparable MELD. The time till first biopsy was 19.88 ± 11.22 (4-44) months. It was not different statistically with various histopathology (p > 0.05). Histopathology of first biopsy was viral chronic hepatitis (50%), acute rejection (20.6%), steatohepatitis (11.8%), chronic rejection (5.9%), chronic hepatitis (5.9%), biliary obstruction (2.9%), and cytomegalovirus hepatitis (2.9%). Most patients were F1 (38.2%) and A1 (35.3%). The immunosuppressive drug regimen had no impact on the histopathology (p > 0.05). Patients with hepatitis C pre-transplant had in a descending manner the following histological diagnosis (p = 0.001): viral chronic hepatitis 16 (51.6%), acute rejection 7 (22.6%), steatohepatitis 4 (12.9%), chronic rejection 2 (6.5%), biliary obstruction 1 (3.2%), and CMV hepatitis 1(3.2%). Some patients required on demand second (n = 9) and third biopsied (n = 5) that were the same as the first biopsy or completely different.

Conclusion

Liver biopsy is a useful tool for diagnosis of liver transplantation complications.

Barriers for resuming endoscopy service in the context of COVID-19 pandemic: A multicenter survey from Egypt

BACKGROUND

The current coronavirus disease 2019 (COVID-19) pandemic has affected routine endoscopy service across the gastroenterology community. This led to the suspension of service provision for elective cases.

AIM

To assess the potential barriers for resuming the endoscopy service in Egypt.

METHODS

A national online survey, four domains, was disseminated over a period of 4 wk in August 2020. The primary outcome of the survey was to determine the impact of the COVID-19 pandemic on the endoscopy service and barriers to the full resumption of a disabled center(s).

RESULTS

A hundred and thirteen Egyptian endoscopy centers participated in the survey. The waiting list was increased by ≥ 50% in 44.9% of areas with clusters of COVID-19 cases (n = 49) and in 35.5% of areas with sporadic cases (n = 62). Thirty nine (34.8%) centers suffered from staff shortage, which was considered a barrier against service resumption by 86.4% of centers in per-protocol analysis. In multivariate analysis, the burden of cases in the unit locality, staff shortage/recovery and the availability of separate designated rooms for COVID-19 cases could markedly affect the resumption of endoscopy practice (P = 0.029, < 0.001 and 0.02, respectively) and Odd's ratio (0.15, 1.8 and 0.16, respectively).

CONCLUSION

The COVID-19 pandemic has led to restrictions in endoscopic volumes. The staff shortage/recovery and the availability of COVID-19 designed rooms are the most important barriers against recovery. Increasing working hours and dividing endoscopy staff into teams may help to overcome the current situation.

DNA Methyltransferases as Potential Biomarkers for HCV Related Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a major health concern in many countries including Egypt. The alteration in DNA methylation that was observed in HCC patients suggests a possible role of DNA methyltransferases (DNMTs) in the disease pathogenesis in addition to potential role as a disease biomarker.

AIM

To study the change in DNMTs expression in chronic HCV infected patients as potential non- invasive biomarker for diagnosis of hepatocellular carcinoma.

METHODS

26 patients with HCC, 45 patients with liver cirrhosis, 20 chronic HCV patients and 20 apparently healthy individuals as a control group were enrolled in this study. Real-Time Quantitative Reverse Transcription PCR (qRT-PCR) was performed for all study participants.

RESULTS

A significant difference in DNMTs expression was observed among the studied groups. Receiver operating characteristics (ROC) curve analysis revealed that with a cutoff value of 3.16 for DNMT 3A expression, sensitivity and specificity were 80.8 and 95.6% respectively and area under curve (AUC) was 0.958, p < 0.001 for discriminating hepatocellular carcinoma among post hepatitis C cirrhotic patients. Besides DNMT 3B relative expression cutoff value of 3.10 showed 84.6% sensitivity and 77.8% specificity and AUC was 0.888, p < 0.001. On the other hand, cutoff value 0.65 for DNMT1 relative expression showed 92.3% sensitivity and 44.4% specificity and AUC was 0.72, p= 0.002. DNMT1, DNMT 3A and DNMT 3B have significant positive correlation with the level of AFP (p-value = 0.003, 0.004 and 0.008 respectively). The relative expression of DNMT3B was significantly correlated to focal lesion size (p-value = 0.015). High DNMTs expression was significantly associated with the presence of multiple focal lesions but not with the Child Pugh grade (p> 0.05).

CONCLUSION

The mRNA levels of DNMTs could be a potential biomarker for early detection of HCC development.
.

Anti-HBc and hepatitis B virus DNA among HBsAg-negative blood donors from the main central blood bank units in Eastern Libya

BACKGROUND

Post-transfusion hepatitis B virus (PTHB) infection is still a public health problem in the world. In many developed countries, nucleic acid testing (NAT) for detection of Hepatitis B Virus (HBV)-DNA has been implemented to enhance blood donation safety. In Libya, however, the testing for HBV infection is limited to the detection of HBV surface antigen (HBsAg) only.

OBJECTIVES

To determine the frequency of anti-Hepatitis B core antibody (HBc) and HBV-DNA in HBsAg-negative, anti-HBc-positive blood donors in the main Central Blood Bank Units (CBBUs) in eastern Libya.

METHODS

One thousand blood samples were obtained from healthy blood donors at the five main CBBUs in eastern Libya. The samples were screened for HBsAg and anti-HBc. Real-time polymerase chain reaction (PCR) was carried out to detect HBV-DNA in all anti-HBc-positive samples.

RESULTS

A total of 94 (9.4%) donors were positive for anti-HBc. Of the 94 anti-HBc-positive samples, 9 samples (9.5%) tested positive for HBV-DNA by real-time PCR.

CONCLUSION

The rate of anti-HBc among blood donors in this study (9.4%) was similar to that reported from other regions in the country. In the absence of advanced tests for the detection of HBV infection in blood donors, such as NAT, anti-HBc should be routinely tested for, at least for first-time donors.

Value of IFNL3 genetic polymorphism in the prediction of HCV treatment response to direct-acting antiviral drugs versus interferon therapy

Background: Despite the outstanding results of direct-acting antiviral therapies (DAAs) of Hepatitis C infection (HCV), non-responders had to be more defined. Aim: assess the outcome of DAAs in linkage with Interferon lambda 3 (IFNL3) in HCV patients. Methods: This case-control-study was conducted on 495 chronic-HCV (genotype-4a), previously treated Egyptians by either DAAs (responders 195, 120 relapsers) or interferon/ribavirin (IFN/RBV) (140 responders, 60 relapsers), and 98 healthy controls. IFNL3 distribution, clinical and laboratory data were assessed. Results: CT was the most predominant genotype in Egyptians (51%). All genotypes were sensitive to DAAs mainly CT genotype (60%), even TT genotype (resistant to IFN/RBV 40%) had 29.2% sensitivity. CT genotype was predominant in sofosbuvir/Daclatasvir responders (67.6%) (OR = 0.66), while non-CT prevailed in relapsers (56.7%). TT genotype may respond to SOF/Ledi better than other regimens (66.7%). In IFN/RBV relapsers; CT genotype was commoner (50%) than others, while CC genotype predominated in responders (54.3%). The c allele was the commonest in responders to IFN/RBV (71.4%), while the T allele was resistant to treatment (65% in relapsers). Addition of RBV to SOF/DCV reported higher resistance with CT genotype (42.2%-50%) and TT genotype (17.8%-27.8%). Conclusion: This study recommended IFNL3 genotyping to be a prerequisite before stratifying treatment for HCV-4a Egyptians.

Urine Neutrophil Gelatinase-Associated Lipocalin a Possible Diagnostic Marker for Egyptian Hepatocellular Carcinoma Patients

BACKGROUND

Most effective method for reducing mortality from hepatocellular carcinoma (HCC) is early diagnosis. Despite its lack of adequate sensitivity, ultrasound is considered fundamental for HCC screening.

AIM

to evaluate urinary neutrophil gelatinase-associated lipocalin (NGAL) as non-invasive marker for HCC diagnosis in Egyptian patients.

METHODS

One hundred and twenty patients were divided into three groups (40 patients each): patients with chronic viral hepatitis (HCV or HBV), cirrhotic patients and HCC patients and 40 healthy age and gender matched subjects were enrolled as control group. After clinical assessments, urinary NGAL was measured by enzyme-linked immunosorbent assay.

RESULTS

Our results revealed that median level of urinary NGAL was 290, 834, 1090 and 1925 pg/ml in control, chronic hepatitis, cirrhotic and HCC groups respectively among studied groups (p<0.001). Receiver operating characteristics (ROC) analysis showed that urinary NGAL cutoff value of 1255 ng/ml could discriminate between HCC and cirrhosis. The area under curve (AUC) was 0.95 with 90% sensitivity, 87.5% specificity (p-value <0.001). In HCC group, urine NGAL level didn`t show significant correlation with Child Pugh score, MELD score or Barcelona Clinic Liver Cancer (BCLC) stage.

CONCLUSION

Urinary NGAL could be a simple, non-invasive test for diagnosis of HCC in chronic liver disease patients.<br />.

XRCC1 Gene Polymorphism Increases the Risk of Hepatocellular Carcinoma in Egyptian Population

Section Title

Several major risk factors for hepatocellular carcinoma (HCC) have been identified, including chronic infection of hepatitis B virus (HBV) and hepatitis C virus (HCV). Nevertheless, only a fraction of infected patients develops HCC during their lifetime suggesting that genetic factors might modulate HCC development. X-ray repair cross complementing group1 (XRCC1) participates in the repair pathways of DNA.

Aim:

to investigate the association between XRCC1 gene polymorphism and HCC in Egyptian chronic hepatitis C patients.

Methods:

This study was assessed on 40 patients with HCC secondary to chronic HCV infection who were compared to 20 cirrhotic HCV patients and 40- age and gender- matched healthy control group. After collection of relevant clinical data and basic laboratory tests, c.1517G>C SNP of XRCC1 gene polymorphism was performed by (PCR-RFLP) technique.

Results:

A statistically higher frequency of XRCC1 (CC, GC) genotypes and increased (C) allele frequency in patients with HCC was found in comparison to cirrhotic HCV patients as well as control group. In addition, patients with the XRCC1 (CC, GC) genotypes had significantly higher number and larger size of tumor foci and significantly higher Child Pugh grades. Multivariate analysis showed that the presence of c.1517G>C SNP of XRCC1 gene is an independent risk for the development of HCC in chronic HCV patients with 3.7 fold increased risk of HCC development.

In conclusion:

XRCC1 gene polymorphism could be associated with increased risk of HCC development in chronic HCV Egyptian patients.

Platelet-albumin-bilirubin score - a predictor of outcome of acute variceal bleeding in patients with cirrhosis

BACKGROUND

The albumin-bilirubin (ALBI) score was validated as a prognostic indicator in patients with liver disease and hepatocellular carcinoma. Incorporating platelet count in the platelet-albumin-bilirubin (PALBI) score improved validity in predicting outcome of patients undergoing resection and ablation.

AIM

To evaluate the PALBI score in predicting outcome of acute variceal bleeding in patients with cirrhosis.

METHODS

The data of 1517 patients with cirrhosis presenting with variceal bleeding were analyzed. Child Turcotte Pugh (CTP) class, Model of End-stage Liver Disease (MELD), ALBI and PALBI scores were calculated on admission, and were correlated to the outcome of variceal bleeding. Areas under the receiving-operator characteristic curve (AUROC) were calculated for survival and rebleeding.

RESULTS

Mean age was 52.6 years; 1176 were male (77.5%), 69 CTP-A (4.5%), 434 CTP-B (29.2%), 1014 CTP-C (66.8%); 306 PALBI-1 (20.2%), 285 PALBI-2 (18.8%), and 926 PALBI-3 (61.1%). Three hundred and thirty-two patients died during hospitalization (21.9%). Bleeding-related mortality occurred in 11% of CTP-B, 28% of CTP-C, in 21.8% of PALBI-2 and 34.4% of PALBI-3 patients. The AUROC for predicting survival of acute variceal bleeding was 0.668, 0.689, 0.803 and 0.871 for CTP, MELD, ALBI and PALBI scores, respectively. For predicting rebleeding the AUROC was 0.681, 0.74, 0.766 and 0.794 for CTP, MELD, ALBI and PALBI scores, respectively.

CONCLUSION

PALBI score on admission is a good prognostic indicator for patients with acute variceal bleeding and predicts early mortality and rebleeding.

MicroRNA-215 as a Diagnostic Marker in Egyptian Patients with Hepatocellular Carcinoma

Background: MicroRNAs are mentioned as a small non-coding RNAs groups and aberrant miRNA expression was found in hepatocellular carcinoma (HCC) patients. Aim: To evaluate role of plasma MicroRNA-215 as a diagnostic tool in HCC patients. Methods: A prospective study included 195 subjects: healthy controls (group I), cirrhotic patients (group II), and patients with HCC (group III). Clinical examination, radiological and laboratory investigations which included quantification of miR-215 by Real-time qPCR were done for all cases. Results: Spearman’s rank correlation revealed that in HCC group, there was a negative correlation between MiRNA-215 and serum AFP levels and focal size lesion (cm) (rs = -0.72, - 0.94 respectively, p<0.001). Receiver operating characteristics analysis for discrimination between cirrhosis and HCC groups regarding microRNA-215 displayed 78.3% sensitivity, 88.0% specificity at cutoff value of ≤ 1.90. Area under the curve (AUC) was 0.87 (p< 0.001). As regards AFP, it had a sensitivity of 81.7%, a specificity of 66.7 at cutoff value of ≥ 11.50 (ng/mL). Conclusions: Plasma level of miR-215 may be a promising biomarker in HCC diagnosis. Moreover, if miR-215 combined with AFP, it can be used as a diagnostic biomarker, for early detection of HCC.

Upper gastrointestinal bleeding in Egyptian patients with cirrhosis: Post-therapeutic outcome and prognostic indicators

BACKGROUND AND AIM

Upper gastrointestinal bleeding (UGIB) is a serious complication of portal hypertension in cirrhotic patients. The objective of this study is to identify the risk factors for morbidity and mortality occurring after an UGIB attack.

METHODS

A total of 1097 UGIB attacks in 690 patients with liver cirrhosis were studied. Their clinical, laboratory, and endoscopic data were reviewed.

RESULTS

Mean age 53.2 ± 10.6 (20-90) years, 78% men and the main cause of liver disease was hepatitis C (94.9%). Complications occurred after 467 attacks (42.6%): hepatic encephalopathy 31.4%, spontaneous bacterial peritonitis 18%, renal impairment 13.2%, and re-bleeding in 7.8%, while 199 patients (18.1%) died. Complications followed 78.4% of bleeding from gastric varices, 75% of post-interventional ulcers, 10.8% of peptic ulcers, and 5.9% of telangiectasias. By univariate analysis: packed red blood cells units transfused, transaminases, Child-Pugh (CP), model of end-stage liver disease (MELD), and albumin-bilirubin (ALBI) scores, beside the presence of hepatocellular carcinoma (HCC), previous hemorrhage in the previous 6 months, and the source of bleeding, were associated with occurrence of complications. By multivariate analysis, independent predictors of complications were CP, MELD, and ALBI scores (odds ratio, 95% confidence interval: 5.63, 3.55-8.93; 1.15, 1.11-1.19; and 2.11, 1.4-3.19, respectively) beside the presence of HCC (4.89, 2.48-9.64). Mortality predictors were packed red blood cells units transfused (1.11, 1.01-1.24), CP (5.1, 1.42-18.25) MELD (1.27, 1.21-1.32) scores, and presence of HCC (6.62, 2.93-14.95).

CONCLUSION

High CP, MELD, and ALBI scores beside the presence of HCC could predict poor outcome of UGIB. In the absence of these risk factors, early discharge could be considered if the source of bleeding is peptic ulcer or telangiectasia.

On-treatment improvement of an emerging psychosomatic depressive disorder among salmonella carriers: a multicenter experience from Egypt

Background

As physicians in a referral hospital, we observed the association between history of enteric fever and somatic disorders associated with low mood. At the Al-Hussein University Hospital, Cairo and the National Liver Institute Hospital, Menoufia, we receive patients from all over Egypt, including rural areas where enteric fever is endemic.

Aim

Here in, 60 Egyptian patients referred to us for evaluation of different somatic disorders are reported.

Methods

After extensive evaluations, the patients' symptoms were function-related. Also, their typhoid carrier states were documented, and the severity of depression using Hamilton-D (HAM-D) questionnaire was evaluated and recorded. All patients were treated with ceftriaxone, 2 gm, IV, daily for 15 days. The clinical evaluation and Hamilton score were reassessed at the end of the treatment and 6 weeks thereafter. The patients did not receive any anti-depressant nor anti-anxiety treatment during their course. Typhoid carrier was defined by documenting the history of typhoid fever that was diagnosed by culturing the Salmonella species, and not by serology, isolated from stool culture along with febrile condition, plus the absence of fever in the past 3 weeks. The Widal test was not accepted as a criterion for enrollment.

Results

Patients showed clinically significant improvement in the somatic complaints, and their HAM-D score immediately post-treatment that was consolidated for 6 weeks post-treatment completion.

Conclusion

In this study, the typhoid carrier was associated with the psychosomatic depression that improved by antibiotic therapy.

Urinary neutrophil gelatinase-associated lipocalin for diagnosis of spontaneous bacterial peritonitis

Cirrhotic patients with ascites are at high risk of developing spontaneous bacterial peritonitis (SBP). After exclusion of patients with acute kidney injury (AKI) or other infections, urinary neutrophil gelatinase-associated lipocalin (NGAL) levels were compared between two matched groups of Egyptian cirrhotic patients with ascites, mostly secondary to hepatitis C infection (98%). Group 1 had SBP (n = 41) and group 2 did not (n = 45). By univariate analysis, urinary-NGAL, high total bilirubin, serum creatinine, international normalised ratio and the Model of End-Stage Liver Disease (MELD) score and low platelet count were all significantly correlated with the presence of SBP, but only urinary-NGAL could independently predict development of SBP ( P = 0.001). Urinary-NGAL at a cut-off value of 1225 pg/mL, showed a sensitivity of 95% and a specificity of 76%, and is therefore a most useful tool.

Predictors of Spontaneous Bacterial Peritonitis in Patients with Cirrhotic Ascites

Background and Aims: Spontaneous bacterial peritonitis (SBP) is a serious complication of liver cirrhosis and a prognostic model to predict it is needed. This study was designed to test the ability of different laboratory tests and the new scoring system by Wehmeyer and colleagues (consisting of age, C-reactive protein (CRP) and platelet count) to predict it. Methods: Three-hundred patients admitted to the National Liver Institute, University of Menoufia, Egypt (2015-2016) with liver cirrhosis and ascites were included in our study. SBP was diagnosed if ascetic neutrophil count was ≥250/µL with no sign of secondary peritonitis. Results: The patient population had age range of 29-81 years old, was 60% men and showed a majority (91.7%) with primary cause of liver disease being hepatitis C. By univariate analysis, associations with age, total bilirubin, aspartate aminotransferase level, creatinine level, international normalized ratio, model for end-stage liver disease score, total leucocytic count, platelet count and CRP level were significant. By multivariate analysis, independent predictors were age, platelet count and CRP level (p = 0.004, 0.013 and <0.001, respectively). CRP at a cut-off point ≥13.5 mg/L could predict SBP (sensitivity of 86.4% and specificity of 66.0%). Wehmeyer's SBP scoring system was predictive (p < 0.001); only 4% of patients with 0 score developed SBP (CRP cut-off of 30 mg/L), while 92.8% with score of 3 or 4 developed SBP. By using our modified Wehmeyer score with CRP cut-off value of 13.5 mg/L, no patient with 0 score developed SBP. Conclusions: Age, CRP level and platelet count are independent predictors for SBP and a scoring system including them could easily predict the condition. SBP diagnosis could be excluded in patients with 0 score, using CRP cut-off value of 13.5 mg/L.