Characteristics of Newly Diagnosed Hepatocellular Carcinoma Patients Across Turkey: Prospective Multicenter Observational 3K Registry Study

AIMS

To evaluate patient profile for epidemiological and clinicopathological characteristics and potential risk/prognostic factors in newly diagnosed hepatocellular carcinoma (HCC) patients across Turkey.

METHODS

A total of 547 patients (mean (SD) age 62.6 (10.3) years, 81.9% were males) were included in this registry study. Data on patient characteristics, etiologies of HCC, laboratory values, and tumor characteristics and stages were recorded at study enrollment.

RESULTS

HBV infection (68.2%) was the leading etiology, followed by HCV infection (17.2%), HDV infection (5.5%), alcohol (6.4%), and NAFLD (3.5%), as the major etiologies. Considering that 51.6% of the patients had >5 cm HCC, 44% were Child-Pugh B/C and 57% were BCLC B-D, it appears that a significant group of HCC patients were diagnosed at advanced stages. Of 540 patients, 271 (50.2%) were referred or applied with the diagnosis of HCC. Patients with HCC at presentation had larger tumor size (median (min-max) 6.6 (0-30) vs. 4.8 (0-90) cm, P < .001) and more advanced BCLC stage (Stage C-D in 40.8% vs. 26.4%, respectively, P = .005), compared to patients who were diagnosed during follow-up.

CONCLUSIONS

Our findings revealed that HBV infection was the leading etiology and a moderate-to-advanced disease was evident in more than half of patients at the time of diagnosis. HCC patients diagnosed at follow-up had smaller tumor size and earlier BCLC stage.

Diagnostic performance of 2D shear wave elastography in predicting liver fibrosis in patients with chronic hepatitis B and C: a histopathological correlation study

PURPOSE

In this study, we investigated the diagnostic efficacy of 2D-Shear Wave Elastography (2D-SWE) in detecting stages of liver fibrosis and determining the disease-specific cut-off values in patients with chronic hepatitis B and C infection, using histopathological analysis as the reference method.

METHOD

Our study included 103 consecutive adult patients with chronic hepatitis B and C infection (CHB and CHC) who had liver biopsy within three months of elastography examination. A real-time 2D-SWE was performed using the LOGIQ E9 system (GE Medical Systems, Wisconsin, USA). The correlation between the liver stiffness measurements and the METAVIR scores was evaluated. The diagnostic performance of 2D-SWE was assessed, and cut-off values were set.

RESULTS

We found a statistically significant positive correlation between elastography values and the degree of liver fibrosis (Spearman's correlation coefficient = 0.76 and 0.83 for CHB and CHC; respectively) (p = 0.0001). The stiffness cut-off values were F ≥ 1: 5.92 kPa, F ≥ 2: 7.69 kPa, F ≥ 3: 8.97 kPa, F ≥ 4: 12.15 kPa in CHB; and F ≥ 1: 6.09 kPa, F ≥ 2: 7.81 kPa, F ≥ 3: 9.0 kPa, F ≥ 4: 12.47 kPa in CHC patients.

CONCLUSION

2D-SWE is reliable and accurate for the diagnosis of liver fibrosis. In selected patients, 2D-SWE may be useful in reducing the need for liver biopsy when staging fibrosis. Further studies in larger prospective series are needed to confirm these results and determine the most appropriate cut-off values for each stage of liver fibrosis.

Serum Biglycan as a Diagnostic Marker for Non-Alcoholic Steatohepatitis and Liver Fibrosis

BACKGROUND

Non-alcoholic steatohepatitis (NASH) has risen in prevalence substantially through the years. Although course and progression of the disease are variable, fibrosis is the most important factor. We intended to explore utility of serum biglycan (BGN) in NASH and its capacity in anticipating liver fibrosis.

METHODS

Serum tests of consecutive patients with biopsy-confirmed NASH and age, gender-matched healthy volunteers were utilized to evaluate serum BGN levels using ELISA kits. The correlation between BGN and histopathological highlights of NASH was examined. While patients with fibrosis scores < 2 were assembled in mild and scores of (≥ 2) were in significant fibrosis groups. Univariate/multivariate regression analyses were performed to assess the independent predictive variables of liver fibrosis. Receiver operating characteristics (ROC) were applied to locate the best cutoff values of BGN for NASH and fibrosis.

RESULTS

Seventy patients with NASH and 70 controls were recruited in the study. BGN levels were lower in NASH patients contrasted with controls 137.70 ± 33.12 pg/mL vs. 259.61 ± 187.34 pg/mL, respectively, and p < 0.001. In correlation, serum BGN was related to liver fibrosis and inflammation. The comparison between mild and significant fibrosis groups regarding BGN was as follows 155.92 ± 49.97 pg/mL vs. 390.07 ± 214.746 pg/mL, respectively, (p < 0.001). In multivariate analyses, BGN was an independent predictive factor of significant fibrosis (OR, 1.030; 95% CI: 1.011 - 1.048; p < 0.001). ROC analysis revealed that BGN was statistically significant in determination of significant fibrosis (AUROC, 0.955; 95% CI, 0.877 - 0.990; p < 0.001). Best cutoff value was 189.58 pg/mL with the best sensitivity (93.55%) and specificity (87.18%).

CONCLUSIONS

Serum BGN may be a new non-invasive indicative marker for the presence of NASH, significant fibrosis, and a treatment goal in the disease process.

The importance of serum biglycan levels as a fibrosis marker in patients with chronic hepatitis B

BACKGROUND

Liver biopsy is recommended in the majority of patients with chronic viral hepatitis for fibrosis evaluation. Because of the potential risks of liver biopsy, many studies related to non-invasive biomarkers of hepatic fibrosis have been performed. We aimed to assess the diagnostic value of serum biglycan as a non-invasive fibrosis marker in chronic hepatitis B patients.

METHODS

This study included 120 patients with biopsy-proven hepatitis B patients and 60 healthy controls. Fibrosis stage and necroinflammatory activity were assessed in liver biopsy specimens. Biglycan level was measured using an ELISA assay.

RESULTS

Serum biglycan levels of chronic hepatitis B patients were found to be significantly higher than those of healthy controls (337.3±363.0 pg/mL vs 189.1±61.9 pg/mL, respectively, P<.001). There was a statistically significant positive correlation between serum biglycan level and fibrosis stage (P=.004; r=.213). Besides, a statistically significant positive correlation was found between serum biglycan level and necroinflammatory activity (P<.001; r=.271). The AUROC of BGN levels was 0.702 for fibrosis stage, differentiating patients from healthy controls with statistical significance (P<.001). The AUROC of BGN levels was 0.632 for necroinflammatory activity score, differentiating patients from healthy controls with statistical significance (P=.004).

CONCLUSIONS

Serum biglycan might be used as a non-invasive marker of liver fibrosis. Further studies are needed to evaluate the usefulness of this marker.

Serum β-trophin level as a new marker for noninvasive assessment of nonalcoholic fatty liver disease and liver fibrosis

OBJECTIVE

Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease and evaluation of fibrosis is important. We aimed to investigate the utility of serum β-trophin in NAFLD and its ability to predict liver fibrosis.

PATIENTS AND METHODS

Serum samples of consecutive patients with biopsy-proven NAFLD and age-matched and sex-matched healthy controls were used to measure β-trophin using ELISA. Correlations between histopathological features of NAFLD and β-trophin were analyzed. Whereas patients with fibrosis scores less than 2 were grouped in the mild fibrosis group, patients with scores of 2 or more were grouped in the significant fibrosis group. Univariate/multivariate logistic regression analyses were carried out to evaluate the independent predicting factors of liver fibrosis. Receiver operating characteristics (ROCs) were assessed to determine the best cut-off values for NAFLD and fibrosis.

RESULTS

Sixty-nine patients with NAFLD and 69 healthy controls were enrolled in the study. Serum β-trophin levels were lower in NAFLD patients compared with the controls (2.34±0.06 vs. 1.94±0.09 ng/ml, respectively, P<0.001). In NAFLD, serum β-trophin was related to liver fibrosis and inflammation. The mild fibrosis group had higher serum β-trophin levels than the significant fibrosis group (2.11±0.12 vs. 1.72±0.11, respectively, P<0.001). In multivariate analysis, β-trophin remained an independent predictor of significant fibrosis (odds ratio, 0.237; 95% confidence interval, 0.059-0.949; P<0.001). ROC analysis showed that serum β-trophin was statistically significant in the identification of significant fibrosis (area under receiver operating characteristic, 0.844; 95% confidence interval, 0.718-0.970; P<0.001). The best cut-off value was 1.786, with the best sensitivity (71.43%) and specificity (95.65%).

CONCLUSION

Serum β-trophin may be a potential noninvasive marker for the identification of NAFLD and significant liver fibrosis.

Impact of hepatic immunoreactivity of angiotensin-converting enzyme 2 on liver fibrosis due to non-alcoholic steatohepatitis

BACKGROUND

We aimed to evaluate the hepatic immunoreactivity of angiotensin-converting enzyme 2 (ACE2) in non-alcoholic steatohepatitis (NASH) patients, elucidate its association with the clinicopathological characteristics and also determine its role in fibrosis progression.

METHODS

The consecutive biopsy proven NASH patients were subdivided into two groups according to their fibrosis score. Fibrotic stages<3 in mild fibrosis group and fibrotic stages ≥ 3 in advanced fibrosis depending on the presence of bridging fibrosis. Liver biopsy specimens were immunohistochemically stained for ACE2 immunoreactivity. Demographics and clinical properties were compared between the groups. Univariate and multivariate analysis were also performed to evaluate the independent predicting factors for the presence of advanced liver fibrosis caused by NASH.

RESULTS

One hundred and eight patients were enrolled in the study. Out of this, ninety-four patients representing 87% were classified as mild fibrosis group, whilst fourteen representing 13% were in advanced fibrosis group. We compared high hepatic immunoreactivity of ACE2 between mild and advanced fibrosis groups and found a statistically significant difference 65.9% vs 28.5%, respectively and P=0.008. Hepatic ACE2 immunoreactivity was inversely correlated with the fibrosis score (r: -0.337; P<0.001). The significant variables in the univariate analysis were then evaluated in multivariate logistic regression analysis and hepatic ACE2 immunoreactivity was an independent predicting factor of liver fibrosis [odds ratio (OR): 0.194; 95% confidence interval (CI): 0.082-0.897, P=0.036].

CONCLUSION

Hepatic immunoreactivity of ACE2 was inversely correlated with the liver fibrosis among biopsy proven NASH patients and it was also an independent predicting factor of advanced fibrosis.

Role of serum toll-like receptors 2 and 4 in non-alcoholic steatohepatitis and liver fibrosis

BACKGROUND AND AIM

Non-alcoholic fatty liver disease is a common cause of chronic liver disease, including non-alcoholic steatohepatitis (NASH). Our aim was to investigate whether serum toll-like receptors 2 and 4 (TLR2 and TLR4) levels are correlated with NASH and able to predict liver fibrosis, as well as to compare these markers with other non-invasive fibrosis scores (aspartate aminotransferase [AST] to alanine aminotransferase ratio, AST to platelet ratio index, fibrosis index, fibrosis 4, and fibrosis cirrhosis index).

METHODS

Serum samples were obtained from consecutive biopsy proven NASH patients and healthy controls. Serum TLR2 and TLR4 were measured using ELISA. Stage of fibrosis was evaluated using the Brunt Criteria. The different non-invasive fibrosis scores were compared using areas under the curve.

RESULTS

Fifty-seven patients with NASH and 57 healthy individuals were enrolled in the study. Serum TLR2 levels were not significantly different between the healthy controls and NASH patients. The medians were 3.88 ng/mL ± 0.29 versus 3.81 ng/mL ± 0.32, respectively (P = 0.587). In comparing the levels of TLR4 between groups, the medians were 1.05 ng/mL ± 0.13 versus 1.46 ng/mL ± 0.27, respectively (P < 0.001). In NASH patients, the levels of serum TLR4 increased with the stage of fibrosis: TLR4 medians were F0:1.01, F1:1.46, F2:2.14, F3:3.74, F4:5.83 (P < 0.001). TLR4 produced AUCs for ≥ F1, ≥ F2, and ≥ F3 of 0.862, 0.810, and 0.905, respectively (P < 0.001). TLR4 levels were more predictive than other non-invasive fibrosis scores in liver fibrosis.

CONCLUSION

Serum TLR4 levels but not TLR2 were elevated in NASH patients in comparison with healthy controls. And in NASH patients, serum TLR4 levels both correlated with and were able to predict liver fibrosis.

Can serum pin1 level be regarded as an indicative marker of nonalcoholic steatohepatitis and fibrotic stages?

BACKGROUND

We aimed to investigate serum Pin1 as an indicator of the presence of nonalcoholic steatohepatitis (NASH) and its association with the histopathological liver fibrosis stages.

METHODS

Serum samples were collected from consecutive biopsy-proven NASH patients and healthy controls, and then serum levels of Pin1 were measured. The correlations between clinical and histopathological features of NASH and Pin1 were evaluated. Patients who had fibrotic stages <2 were termed mild fibrosis group and those who had ≥ 2 as advanced fibrosis group. We performed univariate and multivariate logistic regression analyses to evaluate the independent predicting factors for the presence of liver fibrosis caused by NASH.

RESULTS

Fifty-six consecutive NASH patients and 56 age- and sex-matched healthy controls were enrolled in the study. Serum Pin1 levels were significantly higher in NASH patients (39.24 ± 30.94) than in controls (27.7 ± 9.56, p < 0.001). In NASH patients, serum Pin1 levels were correlated with the histopathological features. Patients with advanced fibrosis had higher serum Pin1 levels than the mild fibrosis group (53.42 ± 33.8 vs. 33.24 ± 20.90, respectively; p < 0.001). In multivariate analysis, Pin1 remained an independent predicting factor of advanced liver fibrosis (OR: 1.051, 95% CI: 1.013-1.089, p < 0.05).

CONCLUSION

Serum Pin1 level can be used as a potential independent marker of the presence of the NASH and advanced fibrotic scores.

The role of interleukin-6 and interleukin-8 gene polymorphisms in non-alcoholic steatohepatitis

BACKGROUND

Genetic polymorphisms may play role in the pathophysiology of nonalcoholic steatohepatitis (NASH).

OBJECTIVES

We purposed to assess the role of interleukin 6 (IL 6) and interleukin 8 (IL 8) gene polymorphisms in the pathogenesis of NASH.

PATIENTS AND METHODS

Consecutive patients with biopsy proven NASH and age- and gender-matched healthy individuals with normal liver function tests and normal ultrasonography were enrolled in the study. Histopathological findings were recorded according to nonalcoholic fatty liver disease activity score (NAS). Patients were classified according to fibrosis scores as fibrosis score < 2 (mild fibrosis group) and fibrosis score ≥ 2 (significant fibrosis group). Blood samples were collected and genomic DNA isolation kit was used to evaluate genetic polymorphisms.

RESULTS

Of thirty-eight patients, 27 (71%) were in mild fibrosis group and 11 (29%) in significant fibrosis group. Thirty-eight age- and gender-matched healthy controls were enrolled in the study. The frequencies of genotypes G/C and G/G of IL 6 among the NASH group and healthy controls were 39.5% and 60.5% vs. 53.6% and 46.4%, respectively (P = 0.32). The frequencies of the genotypes of IL 8 among the NASH group were 47.2%, 44.6%, and 8.2% for T/T, A/T, and A/A, and in healthy controls were 50%, 28.6% and 21.4%, respectively, (P = 0.568). The differences between IL 8 gene T/A and T/T genotypes were not significant statistically (P > 0.05). However, the frequency of A/A genotype in significant fibrosis group was higher than the mild fibrosis group (P = 0.0016). The differences of -251 A/T polymorphism in the IL 8 and -174 C/G polymorphism in the IL 6 were not statistically significant between fibrosis groups (P > 0.05).

CONCLUSIONS

IL6 and IL8 gene polymorphisms have no role in NASH pathogenesis and liver fibrosis process, but presence of the A/A genotype in the IL8 gene is associated with disease progression.

Estrogen receptor alpha expression and liver fibrosis in chronic hepatitis C virus genotype 1b: a clinicopathological study

BACKGROUND

Hepatic damage due to chronic hepatitis C virus (HCV) genotype 1b infection varies widely.

OBJECTIVES

We aimed to investigate whether estrogen receptor alpha (ERα) plays a role in liver fibrosis in patients infected with HCV genotype 1b.

PATIENTS AND METHODS

All the consecutive patients who received the same standard treatment protocol for HCV genotype 1b were subdivided into two subgroups according to their fibrosis scores as fibrotic stages < 2 in mild fibrosis group and fibrotic stages ≥ 2 in advanced fibrosis group, depending on the presence of septal fibrosis. ERα was stained in liver biopsy specimens. Demographics and clinical properties were compared between the groups. Multivariate logistic regression analysis was performed to predict advanced fibrosis.

RESULTS

There were 66 patients in the mild fibrosis group and 24 in the advanced fibrosis group. Among the mild and advanced fibrosis groups, 65.1% and 50%were female, respectively (P = 0.19). There was an inverse correlation between ERα and fibrotic stage (r: -0.413; P < 0.001). Age, platelet counts, neutrophil counts, Alanine aminotransferase (ALT), Aspartate aminotransferase (AST), Gamma glutamyl transferase (GGT) and ERα were statistically significant in the univariate analysis. In multivariate logistic regression analyses, ERα expression continued to be an independent predicting factor of liver fibrosis in patients infected with chronic HCV genotype 1b (OR: 0.10; 95% CI: 0.018-0.586; P < 0.001).

CONCLUSIONS

ERα expression in liver was inversely correlated with liver fibrosis among patients infected with chronic HCV genotype 1b.

The association between indirect bilirubin levels and liver fibrosis due to chronic hepatitis C virus infection

We proposed to evaluate the association between serum indirect bilirubin levels and liver fibrosis in patients with chronic hepatitis C (CHC) genotype 1b. Biopsy proven CHC genotype 1b patients' demographics, clinical and histopathological characteristics were evaluated. Logistic regression analysis was done to evaluate the clinical, laboratory and demographic features of the histologically proven liver fibrosis in CHC patients. A total of 112 biopsy proven CHC genotype 1b patients were enrolled into the study. Liver fibrosis scores were measured by using Ishak fibrosis scores and were divided into two groups; fibrosis scores ≤ 2 were categorized as mild fibrosis, 82 patients (73.2%), whereas fibrosis scores >2 were categorized as advanced fibrosis group, 30 patients (26.8%). Patients with advanced fibrosis had lower indirect bilirubin levels than the mild fibrosis group (0.28 ± 0.02 mg/dl vs. 0.44 ± 0.032 mg/dl, p<0.001, respectively). Indirect bilirubin level was negatively correlated with advanced fibrosis scores (r=-0.416 and p<0.001). In multivariate logistic regression analysis, low indirect bilirubin level was an independent predicting factor of advanced liver fibrosis (OR: 0.001, 95% CI: 0.0-0.005, p<0.001). There is an inverse relationship between indirect bilirubin levels and advanced liver fibrosis caused by CHC genotype 1b.

Vitamin E treatment in patients with nonalcoholic steatohepatitis: A six-month, open-label study of sixteen patients

BACKGROUND

Free radicals have a pivotal role in the pathogenesis of nonalcoholic steatohepatitis (NASH). Decreasing oxidative stress might have beneficial effects on the biochemical and histologic progression of this disease.

OBJECTIVE

We aimed to determine the therapeutic effect of vitamin E, a potent antioxidant, on liver enzymes and histology in NASH.

METHODS

This 6-month, open-label study was conducted at the Departments of Gastroenterology and Pathology, Gazi University School of Medicine (Ankara, Turkey). Patients aged 18 to 70 years with biopsy-proven NASH were included in the study. All patients received vitamin E 800 U/d in 2 divided doses, orally (capsules) for 6 months. Patients were not advised to change their exercise or dietary habits. Body mass index (BMI) was calculated at months 0 (baseline) and 6. Histologic scoring of steatosis, necroinflammatory grade, and fibrosis stage was performed at 0 and 6 months. Liver enzyme activities (alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], and gamma-glutamyltransferase [GGT]) were monitored monthly. Control biopsy specimens were obtained at the end of the treatment. All of the liver biopsies were read by a single pathologist (G.A.) who was blinded to the clinical, laboratory, and histopathologic data, as well as the sequence of liver biopsies. Assessments of compliance and tolerability of treatment were performed using a pill count and patient interview, respectively, at the end of each month.

RESULTS

Sixteen patients (12 men, 4 women; mean [SD] age, 45.5 [6.9] years [range, 37-60 years]) were enrolled. All patients completed 6 months of treatment. Mean BMI did not change significantly from baseline. Significant improvements in mean (SD) serum liver enzyme activities were observed at 6 months compared with baseline (ALT: 38.6 [16.3] U/L vs 84.8 [22.1] U/L, respectively, P = 0.001; AST: 29.8 [15.4] U/L vs 46.0 [16.0] U/L, respectively, P = 0.001; ALP: 154.6 [64.1] U/L vs 211.5 [70.4] U/L, respectively, P= 0.011; and GGT: 49.8 [38.5] U/L vs 64.7 [54.4] U/L, respectively, P = 0.002), as well as in total cholesterol level (176.2 [42.0] mg/dL vs 199.6 [60.6] mg/dL; P = 0.02). Posttreatment liver biopsy was available in 13 patients (81%). Significant improvements in the mean (SD) scores of steatosis (1.46 [0.66] vs 2.43 [0.62]; P = 0.002) and necroinflammatory grade (0.84 [0.24] vs 1.31 [0.51]; P= 0.006) were observed at 6 months compared with baseline, respectively. However, no significant change was noted in the mean (SD) score of fibrosis stage (0.77 [0.33] vs 1.12 [0.59], respectively). None of the patients reported any adverse effects.

CONCLUSION

In this small, 6-month, open-label study, vitamin E treatment was safe and well tolerated and led to potential biochemical and histologic improvements (except in fibrosis) in patients with NASH.

The relationship between advanced oxidation protein products (AOPP) and biochemical and histopathological findings in patients with nonalcoholic steatohepatitis

OBJECTIVE

To investigate the correlation between advanced oxidation protein products (AOPP) levels and biochemical and histopathological findings in patients with nonalcoholic steatohepatitis (NASH).

METHODS

Sixty biopsy-proven NASH patients and 60 individuals with ultrasonographically healthy liver (the control group) were included in the study. AOPP levels were determined in all the participants and liver histopathological examination based on liver biopsy was performed in NASH patients. The NASH activity score (NAS), hepatosteatosis, liver inflammation and fibrosis were evaluated.

RESULTS

Serum AOPP level was significantly higher in the NASH group than that in the control group (461.8 ± 201.9 μmol/L vs 191.7 ± 152.5 μmol/L, P < 0.001). The receiver operating characteristic (ROC) curve revealed a sensitivity of 73.3% and a specificity of 88.3% for the diagnosis of NASH with an AOPP cut-off value of 332 μmol/L (the area under ROC curve 0.88, 95% confidence interval 0.82-0.94, P < 0.01). AOPP levels were positively correlated with NAS (r = 0.27, P = 0.035), fibrosis (r = 0.27, P = 0.037) and inflammation (r = 0.34, P = 0.008), but not the grade of steatosis (r = 0.02, P = 0.83) or ballooning (r = 0.02, P = 0.55).

CONCLUSIONS

AOPP levels are significantly higher in patients with NASH than in those with ultrasonographically healthy liver. AOPP levels are positively correlated with biochemical and histopathological findings (NAS, liver inflammation and fibrosis), indicating that AOPP may play a role in the development of liver fibrosis and inflammation and may predict liver histopathology in NASH.

Is increased red cell distribution width an indicating marker of nonalcoholic steatohepatitis and fibrotic stage?

AIM: To evaluate the red cell distribution width (RDW) as an indicator of the presence of non-alcoholic steatohepatitis (NASH) and its association with fibrotic scores.

METHODS: A retrospective study was carried out that included sixty-two biopsy proven NASH, 32 simple steatosis patients and 30 healthy controls. The correlation between the clinical and histopathological features of NASH patients and RDW values was evaluated. Liver fibrosis scores were measured using a 0 to 4 point scale and were divided in to two groups; fibrosis scores 0-1 were termed mild and fibrosis scores 2-4 were termed advanced fibrosis. RDW values were compared between NASH, simple steatosis and healthy controls. Univariate and multivariate analyses were performed to evaluate the independent predicting factors for the presence of liver fibrosis caused by NASH.

RESULTS: Patients with NASH had higher RDW values compared with simple steatosis and healthy control groups [14.28% ± 0.25% vs 13.37% ± 0.12%, 12.96% ± 0.14% (P < 0.01), respectively]. Patients with advanced fibrosis had higher RDW values than the mild fibrosis group (15.86% ± 0.4% vs 13.63% ± 0.67%, P < 0.01, respectively). RDW also correlated with fibrotic scores (r = 0.579 and P < 0.01). The variables that were significant in the univariate analysis were evaluated in multivariate logistic regression analysis, and RDW was an independent predicting factor of NASH (OR = 1.75, 95%CI: 1.129-2.711, P < 0.05).

CONCLUSION: RDW a new non-invasive marker that can be used to demonstrate the presence of NASH and indicate advanced fibrotic scores.

Lack of association of hepatic estrogen receptor-alpha expression with histopathological and biochemical findings in chronic hepatitis C

Estrogens exert a protective effect against hepatic steatosis and fibrosis. Loss of estrogen receptor-alpha (ER-α) in the liver is associated with hepatic steatosis and inflammation in animal models. We conducted a study in order to investigate the presence and extent of ER-α expression in HCV infection, and its relationship with histological and biochemical findings. Ninety biopsy-proven chronic hepatitis C (CHC) patients were enrolled in the study. Liver biopsy specimens were immunohistochemically stained for ER-α expression. Nuclear ER-α expression percentage was calculated. ER-α was positive in 69 of the patients (76%). ER-α positive and negative groups were not significantly different in terms of age, gender, necroinflammatory activity, fibrosis, steatosis, serum levels of AST, ALT, ALP, GGT, and bilirubin. ER-α expression percentage was not correlated with fibrosis, steatosis, necroinflammatory activity and biochemical findings. Although estrogens are known to be protective against fibrosis and steatosis in animal models, we did not find any significant correlation between ER-α expression and histopathological and biochemical findings in CHC patients. These findings should be verified in further large scale studies.

Presence and extent of estrogen receptor-alpha expression in patients with simple steatosis and NASH

Loss of estrogen receptor-alpha (ER-α) in the liver is associated with hepatic steatosis and inflammation. We conducted a study in order to investigate the presence and extent of ER-α expression in NASH, and its relationship with histological findings. Fifty-four patients with histologically confirmed NASH, 12 patients with simple steatosis (SS), and 6 patients with normal liver tissue (NLT) were included. NASH activity score and fibrosis score were calculated according to biopsy findings. Liver biopsy specimens were immunohistochemically stained for ER-α expression. Nuclear ER-α expression percentage (staining index) was calculated. Mean staining index was significantly different across the NASH, SS, and NLT groups (6.3±9.9 vs. 22.1±26.4 vs. 44.2±24.8, respectively, p<0.001 for all comparisons). Staining index was significantly higher in women than in men (19.4±22.2 vs. 7.9±15.3, respectively, p=0.003). Staining index negatively correlated with serum ALT (r=-0.240; p=0.04), fasting plasma glucose (r=-0.261; p=0.027), and fibrosis score (r=-0.312; p=0.011). As a conclusion, hepatic nuclear ER-α expression percentage (staining index) is lower in patients with NASH when compared to SS and NLT groups. Staining index is negatively correlated with serum ALT levels, plasma glucose, and fibrosis score. Further studies are required to clarify the significance of ER-α expression in NASH.

Diagnostic potential of serum direct markers and non-invasive fibrosis models in patients with chronic hepatitis B

AIM

  Liver biopsy is recommended in the majority of patients with chronic viral hepatitis for fibrosis evaluation. Because of the disadvantages of liver biopsy, many studies related to non-invasive biomarkers and scores have been performed. In this study, we aimed to assess the diagnostic value of serum direct markers and non-invasive fibrosis models to predict liver fibrosis in the treatment-naive chronic hepatitis B (CHB) patients and to compare their diagnostic performance.

METHODS

  This study included 58 patients with a diagnosis of CHB virus infection and 30 healthy controls. Hyaluronic acid, tissue inhibitor of matrix metalloproteinase 1 and amino-terminal propeptide of type III procollagen were measured by enzyme-linked immunosorbent assay; and the Original European Liver Fibrosis panel, the Enhanced Liver Fibrosis (ELF) panel, PP score, aspartate aminotransferase to platelet ratio index (APRI) and FIB-4 indexes were calculated using the formulas taken from previous publications. Fibrosis stage was determined using Ishak's scoring system.

RESULTS

  The fibrosis stages identified upon liver biopsy was F0 in 12 patients (20.7%), F1-2 in 36 (62.1%) and F3-5 in 10 (17.2%). The diagnostic value of all the non-invasive indices was low to detect mild fibrosis. We demonstrated that the diagnostic accuracy of HA is the best for predicting fibrosis of F3 or more (area under the receiver-operator curve, 0.902). In our study, the results from a combination of tests showed that ELF and APRI had the highest diagnostic value sensitivity of 90%, specificity of 100%, positive predictive value of 100% and negative predictive value of 96.4% for detection of fibrosis of F3 or more.

CONCLUSION

  In CHB patients, combination of ELF and APRI has a better diagnostic value in predicting fibrosis of F3 or more.

A Case of Biliary Pancreatitis Which Subsided after Endoscopic Sphincterotomy during Pregnancy

A 24-year-old pregnant patient was referred to us because of pain and tenderness in the right upper quadrant. Her liver enzymes and bilirubin levels were elevated; an abdominal ultrasound examination revealed gallstones within the gallbladder. Diagnosis of biliary pancreatitis was established based on elevated amylase levels. Oral intake was withheld; intravenous antibiotic therapy and total parenteral nutrition were administered. An endoscopic sphincterotomy without the use of fluoroscopy was performed. Abdominal pain and elevated serum amylase levels subsided after this procedure. In our case, biliary pancreatitis, which developed during pregnancy, responded well to the endoscopic sphincterotomy, and this procedure obviated the need for surgical intervention and prevented the recurrence of pancreatitis.

Increased serum granulocyte colony stimulating factor in Turkish hepatocellular carcinoma patients

PURPOSE

To evaluate the serum levels of G-CSF in patients with hepatocellular carcinoma and to compare with values in healthy individuals.

PATIENTS AND METHODS

Thirty-three patients with hepatocellular carcinoma and 30 controls were included in the study. Histological confirmation of hepatocellular carcinoma (HCC) was performed by core needle biopsy and patients with cirrhosis were classified according to the Child-Pugh score. The serum G-CSF levels of individuals in both groups were calculated as pg/ml and compared for Child-Pugh Class A, B and C patients with HCC.

RESULTS

Median ages of patients with HCC and control group individuals were 58 (range:47-78) and 56 (range 45-70), respectively. Sex distributions were approximately equal. The mean serum level of G-CSF in patients with HCC was 199.4-/+112.2, as compared to 24.0-/+8.8 in the controls (p <0.001). In addition, on subgroup analysis, the serum levels of G-CSF were increased with Child-Pugh Class A, B and C, although without statistical significance (p= 0.253).

CONCLUSION

Increased levels of G-CSF are observed in patients with HCC. Further investigations are necessary to clarify the mechanism of G-CSF production and its effects on outcomes.

Serum and Ascitic Fluid Superoxide Dismutase and Malondialdehyde Levels in Patients with Cirrhosis

Summary

Serum and ascitic fluid superoxide dismutase (SOD) and malondialdehyde (MDA) levels were measured in 43 patients with cirrhosis and in a 10 healthy control group.

Compensated cirrhotic patients had no clinically detectable ascites, but decompensated patients had massive ascites. Cirrhotic patients were divided into three groups: patients with compensated cirrhosis (n = 16), patients with decompensated cirrhosis with Spontaneous bacterial peritonitis (SBP) (n = 14), and patients with decompensated cirrhosis without SBP (n = 13).

All cirrhotic patients in the experimental group had significantly higher serum SOD (p < 0.001) and MDA levels (p < 0.01) than those in the control group. There were no significant differences with respect to serum SOD and MDA levels among the three different groups of patients. There was no remarkable difference in ascitic fluid SOD and MDA levels between decompensated cirrhotic patients with and without SBP (p > 0.05).

These results suggest that the increase in serum SOD and MDA levels are not related to the presence of SBP and the status of liver cirrhosis. To sum up, clarifying the impact of increased serum SOD and MDA levels in cirrhotic patients needs further investigation.

The serum endothelin-1 level in steatosis and NASH, and its relation with severity of liver fibrosis

Endothelin-1 (ET-1) is known to play an important role in hepatic fibrosis. ET-1 is also a mediator that is elevated in conditions such as insulin resistance, hyperglycemia, oxidative stress, and endothelial cell dysfunction. In this study, we investigated whether ET-1 has a role in determining the severity of liver fibrosis in NASH. Also, the relation between ALT levels, obesity, diabetes, and AST/ALT ratio and fibrosis and ET-1 level was sought. A total of 92 patients were enrolled in the study. The patients were categorized into three groups: group 1, patients with elevated transaminase levels who were diagnosed as NASH by liver biopsy (n=40); group II, patients with only hepatosteatosis determined by biopsy but having elevated transaminase levels (n=12); and group III, patients with hepatosteatosis observed by ultrasonography, having normal transaminase levels (n=40). The serum ET-1 level was measured by an appropriate ELISA kit for all patients. Mean serum ET-1 level was statistically significantly higher in the NASH group compared to the other two groups (15.56+/-4.63 vs 6.75+/-2.46 and 5.74+/-2.34 micromol/L; P < 0.01). Mean serum ET-1 levels in NASH patients with grade I, grade II, and grade IV fibrosis were 14.06+/-0.92, 17.70+/-2.32, and 20.40+/-1.40 micromol/L, respectively. None of the patients were identified as grade III fibrosis. It was found that the serum ET-1 level showed a statistically significant increase as fibrosis severity increased in NASH patients (P < 0.05). In conclusion, the serum ET-1 level is higher in NASH patients compared to patients having only steatosis. There appears to be a correlation between severity of fibrosis and serum ET-1 level in NASH patients. It has been found that NASH patients having a twofold increase in their ALT levels had higher ET-1 levels and a more severe grade of fibrosis.

Importance of cytokines, oxidative stress and expression of BCL-2 in the pathogenesis of non-alcoholic steatohepatitis

OBJECTIVE

Non-alcoholic steatohepatitis (NASH) is a form of chronic hepatitis. The pathogenesis of NASH has been dealt with in only a few studies and so it has not been clearly identified yet. The purpose of this study was to investigate the roles of TNF-alpha, TGF-beta, IL-6, IL-8, malondialdehyde (MDA), nitric oxide (NO) and the expression of Bcl-2 and Bax in the pathogenesis of NASH.

MATERIAL AND METHODS

The study included 92 patients, 57 of whom were diagnosed with biopsy-proven NASH, 13 with biopsy-proven hepatosteatosis and 22 with ultrasonography-diagnosed hepatosteatosis. Serum levels of TNF-alpha, TGF-beta, IL-6 and IL-8 were measured using the ELISA method. The plasma levels of NO were studied using the Griess method. Expressions of Bcl-2 and Bax were examined in paraffin blocks of liver biopsy materials by means of immunohistochemical-staining. MDA levels were measured using the thiobarbituric acid method.

RESULTS

No significant difference was found in the levels of TNF-alpha, TGF-beta, IL-6 or NO between the three groups (p>0.05). No difference was found in expression of Bcl-2 and expression of Bax between the biopsy-proven NASH and biopsy-proven hepatosteatosis groups (p>0.05). In the NASH group, the levels of IL-8 and MDA were found to be higher than those in the hepatosteatosis groups (p<0.05).

CONCLUSIONS

The elevated levels of MDA may indicate the relationship between oxidative stress and NASH. Furthermore, IL-8 was found to be higher in the NASH group than in the hepatosteatosis group, demonstrating the importance of inflammation in the pathogenesis of NASH.

A patient with primary biliary cirrhosis accompanied by Graves disease and Hurthle cell adenoma

A case of Hurthle cell adenoma and Graves disease associated with primary biliary cirrhosis is reported in a 51-year-old woman, who developed elevated liver enzymes and hyperthyroidism. Thyroid disorders accompanying primary biliary cirrhosis, especially hypothyroidism, are well documented. Concomitance of primary biliary cirrhosis and hyperthyroidism is rare. Moreover, there has been no previous report of a case with Hurthle cell adenoma accompanied by Graves disease and primary biliary cirrhosis.

Pegylated interferon Alfa-2b monotherapy and pegylated interferon Alfa-2b plus lamivudine combination therapy for patients with hepatitis B virus E antigen-negative chronic hepatitis B

Forty-eight hepatitis B virus (HBV) E antigen-negative chronic hepatitis B patients received pegylated interferon alfa-2b either alone or with lamivudine for 48 weeks and were followed for an additional 24 weeks. At the end of follow-up, virological response rates (HBV DNA levels of <400 copies/ml) were similar in the monotherapy (24%) and combination therapy (26%) groups.

Effects of vitamin E treatment on peroxisome proliferator-activated receptor-? expression and insulin resistance in patients with non-alcoholic steatohepatitis: results of a pilot study

BACKGROUND

Insulin resistance (IR) is commonly associated with non-alcoholic steatohepatitis (NASH). Peroxisome proliferator-activated receptor-alpha (PPAR-alpha) may also play a role in the pathogenesis of NASH. A pivotal role in NASH pathogenesis depends on the hypothesis of increased oxidative stress. The aim of our study was to evaluate the effects of supplemental oral vitamin E, a potent antioxidant, on liver functions, PPAR-alpha expression and IR in patients with NASH.

METHODS

Nine patients with biopsy-proven NASH were given oral vitamin E 800 mg daily for 24 weeks. Liver functions, lipid parameters, IR index with homeostatic metabolic assessment and liver histology and PPAR-alpha staining index in biopsy specimens were detected before and after the treatment.

RESULTS

Seven patients (78%) had IR initially. After 6 months of therapy in nine patients, fasting insulin improved (P = 0.01), but serum cholesterol, triglyceride, fasting blood glucose levels and body mass index remained unchanged. Aspartate aminotransferase and alanine aminotransferase levels decreased (P = 0.01 and P = 0.01, respectively). IR index with homeostatic metabolic assessment resistance improved (P = 0.01), but PPAR-alpha staining index did not change (P = 0.37). Although the histological grade of steatosis decreased (P = 0.01), necroinflammation and fibrosis remained unchanged. In seven patients with IR, however, necroinflammation and PPAR-alpha staining index were improved (P = 0.04 and P = 0.02).

CONCLUSION

Vitamin E treatment, in addition to its previously shown beneficial effect by suppressing oxidative stress, may also achieve improvement by reducing IR and PPAR-alpha expression in NASH.

The expression of bcl-2 in chronic liver diseases

OBJECTIVE

Bcl-2 is an oncogene that prevents apoptosis (programmed cell death). Expression of bcl-2 protein has been reported in association with a variety of human tumors.

METHODS

This study was conducted in the Department of Gastroenterology and Pathology, Faculty of Medicine Gazi University, Ankara, Turkey during the period 1996 to 2000 on formalin-fixed paraffin embedded tissue specimens of 69 liver biopsy with chronic liver disease. To evaluate the clinical importance of bcl-2 expression in chronic liver disease and its correlation with biochemical parameters, underlying liver disease types and histopathological parameters; we studied the bcl-2 expression in 69 biopsy proven patients. These were diagnosed with chronic liver disease, and had no other disease or had not received any treatment. Of these patients, 30 were diagnosed as having hepatitis C, 20 with hepatitis B, 19 with liver cirrhosis.

RESULTS

The bcl-2 expression was significantly higher in the hepatitis C group when compared with the hepatitis B group (p<0.001). No significant correlation was found among serum transaminase, bilirubin, albumin, hepatitis C virus-RNA, hepatitis B virus-DNA levels, prothrombin time and bcl-2 expression (p>0.05).

CONCLUSIONS

The reason for the increased expression of bcl-2 in hepatitis C is unclear and may be related to difference in the injury mechanism of the virus, differences in the infection period, and immunology.

Polymyositis and hepatitis concurrent with breast cancer

OBJECTIVE

To present a rare case of breast cancer associated with both inflammatory muscle disease and liver disease as a paraneoplastic syndrome.

CLINICAL PRESENTATION AND INTERVENTION

A woman with breast cancer presented with elevated liver enzymes and progressive proximal muscle weakness. Liver biopsy was consistent with hepatitis and muscle biopsy revealed myositis. The start of corticosteroid therapy was followed by relief of the myopathic symptoms and regression of hepatitis histopathologically.

CONCLUSION

A case of polymyositis and hepatitis associated with breast cancer and their flare-up with recurrence of malignancy is presented. In this case, the temporal relation with malignancy following its concurrent remission and relapse suggests a paraneoplastic mechanism.

Serum hepatocyte growth factor and interleukin-6 levels can distinguish patients with primary or metastatic liver tumors from those with benign liver lesions

Hepatocyte growth factor (HGF) is a potent stimulator of angiogenesis and cancer metastasis. Interleukin-6 (IL-6) is a pleiotropic cytokine that can act as an autocrine or paracrine growth factor in various tumor cells. In this study, we investigated the role of serum HGF and IL-6 levels to distinguish primary or metastatic liver tumors from benign liver lesions. Serum HGF and IL-6 levels were measured in 64 cancer patients and 12 healthy controls. Patients were divided into 5 groups: Group-1 (n=24): Breast cancer patients in complete remission without any liver lesion, Group-2 (n=8): Breast cancer patients in complete remission with benign liver lesion, Group-3 (n=10): Breast cancer patients with liver metastasis, Group-4 (n=11): Metastatic breast cancer patients without liver metastasis, Group-5 (n=11): Patients with hepatocellular carcinoma. Group-6 (n=12): Healthy controls. Serum HGF levels were found to be higher in group-5 (606.4+/-255.8 pg/ml) than those in group-1 (*305.6+/-42.3 pg/ml), group-2 (*293.9+/-44.8 pg/ml), group-4 (**358.4+/-81.9 pg/ml) and group-6 (*305.8+/-24.9 pg/ml) (*p<0.001, **p<0.05). Patients in group-3 (448.9+/-157.3 pg/ml) had higher serum HGF levels than those in group-1, group-2 and group-6 (p<0.05). Serum IL-6 levels were found to be higher in group-5 (54.9+/-37.4 pg/ml) than those in group-1 (9.7+/-6.4 pg/ml), group-2 (9.5+/-4.8 pg/ml), group-4 (17.6+/-19.6 pg/ml) and group-6 (12.6+/-5.2 pg/ml, p<0.05). Patients in group-3 (32.5+/-36.9 pg/ml) had higher serum IL-6 levels than those in group-1, 2 and group-6, but these were not statistically significant (p>0.05). This study showed that primer and metastatic liver tumors had higher serum HGF and IL-6 levels than other patients and controls. Measurements of these markers in serum may be used to distinguish patients with primer liver tumors or breast cancer patients with liver metastasis from those with benign liver lesions or non-metastatic patients.

The protective effect of taurine pretreatment on carbon tetrachloride-induced hepatic damage--a light and electron microscopic study

The results regarding taurine pretreatment on CCl(4)-induced hepatic injury are controversial. To assess the therapeutic efficacy of taurine on rat liver injury, hepatic malondialdehyde, glutathione, and hydroxyproline levels together with morphologic alterations in the liver following CCl(4) administration were investigated. The rats were divided into three groups. Taurine-treated animals received 15 ml/kg/day of a 5% taurine solution by a gastric tube for 5 days before administering CCl(4) (2 ml/kg, intraperitoneally, in a single dose). CCl(4)-treated rats received the same amount of saline solution. Control animals received no treatment. The increase of hepatic malondialdehyde formation in the CCl(4)-treated group was partially prevented by taurine pretreatment, but taurine had no significant effect on the glutathione and hydroxyproline content in the CCl(4)-treated rats. Taurine pretreatment induced a marked beneficial effect regarding the prevention of hepatocellular necrosis and atrophy as demonstrated morphologically. In conclusion, these results suggest that taurine pretreatment might not significantly change the biochemical parameters, but prevents the morphologic damage caused by CCl(4) in the early stages.

Sulfasalazine decreases acute gastrointestinal complications due to pelvic radiotherapy

BACKGROUND

Radiation-induced gastrointestinal toxicity is a significant concern for patients who are treated with this modality for pelvic malignancies. Eicosanoids and free radicals are thought to be among the reasons for this effect. Sulfasalazine is an inhibitor of their synthesis in the mucosa. OBJECTlVE: To determine whether sulfasalazine can reduce the radiation-induced acute gastrointestinal complications.

METHODS

In this prospective, double-blind study, 31 patients receiving pelvic radiotherapy were randomized to receive two sulfasalazine 500-mg tablets twice daily or placebo, administered orally from the first day of irradiation. Patients were evaluated weekly, and gastrointestinal toxicities were graded according to the Late Effect of Normal Tissue-Subjective Objective Management Analytic (LENT-SOMA) toxicity table during pelvic radiotherapy. On the last day of week 5, the subjects were graded endoscopically, and biopsies taken from the rectum were classified histopathologically.

RESULTS

Groups did not differ in age, gender, tumor site, or irradiation procedure. During radiotherapy, grade 2 or higher gastrointestinal toxicity occurred in 20% (3/15) and 63% (10/16) of the sulfasalazine and placebo groups, respectively. This difference was significant (p = 0.017). No statistically significant differences were found in endoscopic and histopathologic evaluations.

CONCLUSIONS

Sulfasalazine is effective in decreasing clinically acute gastrointestinal toxicities. Long-term follow-up with the subjects will help to determine the net effect of sulfasalazine on the radiation-induced gastrointestinal injuries.

Risk factors for hepatocellular carcinoma in Turkey

The contribution of hepatitis B, hepatitis C, and excess alcohol intake to the development of hepatocellular carcinoma in Turkey was assessed. The study was conducted through a questionnaire sent to seven major medical referral centers in different regions of Turkey and is based on 207 patients seen in the period 1994-1997. Of the seven centers, two were located in West Turkey (54 patients), two were in Central Turkey (85 patients), and two were in south and southeast Turkey (68 patients). In 196 of the 207 patients (94.7%), there was a history of chronic liver disease, and in 180 patients (87%) liver cirrhosis was documented. Of the 207 patients, 116 (56%) had hepatitis B, 48 (23.2%) had hepatitis C, and 33 (15.9%) had a history of excess alcohol intake. Anti-delta testing was available in 69 of 116 patients with hepatitis B, and anti-HDV was positive in 13 of these patients (13/69, 18.8%). Of the 33 patients with a history of heavy alcohol intake, 18 had concomitant chronic viral hepatitis infection, and alcohol alone was the etiology of hepatocellular carcinoma in only 15 cases (7.2%). The distribution of etiologic factors was not homogenous in different geographical regions in Turkey. In central, south, and southeastern Turkey, the predominant etiology of hepatocellular carcinoma was hepatitis B, whereas in western Turkey the impact of hepatitis B, hepatitis C, and alcohol was similar. This study indicates that hepatitis B virus infection is the leading cause of hepatocellular carcinoma in Turkey, followed by hepatitis C infection and alcoholic liver disease.

Serum and ascitic fluid nitrate levels in patients with cirrhosis

BACKGROUND

Increased nitric oxide level may play a critical role in the hemodynamic disturbances in patients with cirrhosis. There are few reports investigating the factors related to this increase and their results are controversial. The purpose of this study was to reveal the clinical importance of nitric oxide levels and the possible factors related to this increase in patients with cirrhosis.

METHODS

Serum and ascites nitrate levels were studied in 50 patients with cirrhosis and 10 control subjects.

RESULTS

All cirrhotic patients (groups 2, 3, 4, 5, 6) showed significant increase in serum nitrate levels in comparison with that in control subjects (group 1) (p<0.001). Serum nitrate levels were significantly higher (282.4+/-111.3 micromol/l; p<0.05) in patients with spontaneous bacterial peritonitis (group 2) when compared with those in cirrhotic patients without spontaneous bacterial peritonitis (group 3) (186.4+/-87.6 micromol/l). Ascitic fluid nitrate levels were significantly higher (302.4+/-66 micromol/l; p<0.001) in patients with spontaneous bacterial peritonitis (group 2) when compared with those in cirrhotic patients without spontaneous bacterial peritonitis (group 3) (135.4+/-65.8 micromol/l). Serum nitrate levels were significantly lower in cirrhotic patients without ascites (group 5) when compared with those in cirrhotic patients with ascites (group 3) (98.8+/-52.6 vs. 186.4+/-87.6 micromol/l; p<0.05). No significant differences were found among patients with severe anemia (groups 4, 6) and other cirrhotic patients (group 3) (174.5+/-54.5, 168.8+/-63.8 vs. 186.4+/-87.6 micromol/l; p>0.05). Cirrhotic patients with Child--Pugh B and C scores showed higher serum nitrate levels (179.4+/-81.1, 222.5+/-101.7 micromol/l; p<0.001) than did cirrhotic patients with Child--Pugh A score (85.8+/-59.7 micromol/l).

CONCLUSION

Our findings suggest that overproduction of nitric oxide in cirrhotic patients may be related to the severity of liver damage and spontaneous bacterial peritonitis but not related to their anemia.

Double-blinded, randomized, placebo-controlled study to evaluate the effectiveness of sulphasalazine in preventing acute gastrointestinal complications due to radiotherapy

BACKGROUND AND PURPOSE

Acute radiation-induced diarrhea occurs in approximately 80% of the patients receiving pelvic radiotherapy. It is caused by gastrointestinal irritation and inflammation. Eicosanoids are thought to be one of the mechanisms of this. Sulphasalazine is an inhibitor of their synthesis in the mucosa. This randomized clinical trial was undertaken to evaluate its effect in preventing acute radiation enteritis (ARE).

MATERIALS AND METHODS

Prospectively, 87 patients receiving pelvic radiotherapy were randomized, in a double-blind fashion. Two tablets twice daily of sulphasalazine (500 mg) or placebo were administered orally. Patients were evaluated weekly according to diarrhea grading for the primary study endpoint and according to late effect of normal tissue-subjective objective management analytic (LENT-SOMA) criteria for the secondary endpoint during irradiation.

RESULTS

Groups did not differ for age, gender, tumour site or irradiation procedure. Diarrhea occurred in 55 and 86% of the sulphasalazine and placebo groups, respectively (P=0.001). Gastrointestinal toxicity was seen in 80 and 93% of the sulphasalazine and placebo groups according to the maximum LENT-SOMA score (P=0.07). According to the maximum LENT-SOMA score between the two groups, significant differences in favor of sulphasalazine were found for each week.

CONCLUSION

Sulphasalazine (2 g/day) was found to be effective in decreasing the symptoms of ARE.

The protective effect of Ginkgo biloba extract on CCl4-induced hepatic damage

The aim of this study was to evaluate the protective effect of Ginkgo biloba extract on CCl4-induced hepatic damage in rats. Hepatic malondialdehyde, glutathione and hydroxyproline levels and histopathologic alterations in liver specimens were assessed. 200 mg/kg/day Ginkgo biloba extract were given orally to the animals for 10 days, then a single dose of 2 ml/kg b.w. carbon tetrachloride was, administered intraperitoneally. Ginkgo biloba extract treatment reduced hepatic malondialdehyde levels significantly (p < 0.05), but did not alter glutathione (p > 0.05) and hydroxyproline levels (p > 0.05). The light and electron microscopic findings showed that Ginkgo biloba extract limited the CCl4-induced hepatocyte necrosis and atrophy. These results suggest that this extract may protect the hepatocytes from carbon tetrachloride-induced liver injury.

Long-term efficacy of interferon-alpha and ursodeoxycholic acid in treatment of chronic type C hepatitis

Interferon-alpha (IFN) and ursodeoxycholic acid (UDCA) combined have a controversial role in the treatment of chronic type C hepatitis. We studied the long-term efficacy of both drugs alone or in combination. In a three-year period, 108 patients were randomized into three treatment arms: (1) IFN alone 3 MU three times a week (N = 49), (2) IFN 3 MU three times a week + UDCA 250 mg twice a day (N = 45), and (3) UDCA alone 250 mg twice a day (N = 14). Response was defined as complete normalization of serum ALT. For the responders at the end of six months, the treatment was run to 12 months. Nonresponders (NRs) of the first group were crossed over to combination and NRs of the combination received 6 MU three times a week IFN+UDCA for the next six months. The enrollment to the UDCA alone arm was stopped early, since only 1/14 normalized serum ALT at the end of third month. However, 12/14 completed six months and 11 NRs received IFN 3 MU three times a week alone for the next six months. Twelve discontinued treatment due to side effects. Responders were followed-up untreated for 18 months. Sustained response (SR) was defined as persistence of normal serum ALT levels in this period. At the end of six months, 22/45 (48%) from the IFN-alone and 23/39 (58%) from the combination group responded. Twenty NRs from former and 15 of latter group were crossed over. While none of the 20 from the IFN-alone group responded to the combination, 1/15 NRs of the combination group responded to dose escalation. SR was achieved in 9/45 (20%) of the IFN alone and 7/39 (18%) of the combination group. The mean time form the end of the treatment to the relapse was not different between the groups. Five of 11 UDCA NRs responded to IFN with SR in 2. It was concluded that UDCA as a single agent is ineffective in achieving response in the treatment of chronic type C hepatitis. Combined with IFN, it increases response rate insignificantly although this is not sustained.

Activities of superoxide dismutase in erythrocyte of nonalcoholic chronic liver diseases

1. Superoxide dismutase (SOD) activity was studied in erythrocyte (RBC) of 42 patients with chronic liver disease. 2. Erythrocyte SOD activities in chronic active hepatitis (CAH) and active liver cirrhosis (ALC) groups were not significantly different from that of the control. 3. Erythrocyte SOD activity in the inactive liver cirrhosis (ILC) group was significantly lower than that of the control. 4. No differences of erythrocyte SOD activity were found between CAH, ALC and ILC groups. 5. The reason underlying this finding is obscure and can probably be related to a decrease in the synthesis of SOD.

Association of HLA class I and class II antigens with rheumatic fever in a Turkish population

The distribution of class I and class II HLA antigens of 100 Turkish patients with rheumatic fever, 77 of whom had cardiac involvement, was examined. We compared the results with a control group of identical origin. The frequency of HLA A10 and HLA B35 antigens were found significantly higher in patients with rheumatic fever (p < 0.05, p < 0.01, respectively). The frequency of HLA A10 and HLA DRw11 in patients with cardiac involvement were significantly higher than in those without cardiac involvement (p < 0.05, p < 0.01, respectively). On the other hand, HLA Cw2 antigen frequency was found significantly higher in patients without cardiac involvement than in those with rheumatic heart disease (p < 0.05). We support the concept that rheumatic fever is an immunological reaction to group A, beta hemolytic streptococci in individuals who have genetic predisposition.