Management of dyspepsia and Helicobacter pylori infection: the 2022 Indonesian Consensus Report

Dyspepsia still becomes a major challenge in upper gastrointestinal disease in Indonesia. This disease often correlated with Helicobacter pylori infection. However, the prevalence of this bacterium is generally low in Indonesia. Therefore, several considerations should be taken into consideration during the management of dyspepsia and H. pylori infection. "Management of dyspepsia and H. pylori infection in Indonesia: The Indonesian consensus report" comprises information gathered from 22 gastroenterology centers across Indonesia. The experts gathered to evolve a consensus, that consists of the statements, grades of recommendations, evidence levels, and rationales for the dyspepsia and H. pylori infection management for daily clinical practice. The report explains several aspects from the updated epidemiology information to comprehensive management therapy. After the experts worked together on all statements in the recommendations, the results are presented with the final agreement as a consensus to help clinicians in understanding, diagnosing, and treating dyspepsia and H. pylori infection patients in daily clinical practice in Indonesia.

The Expressions of NF−κB, COX−2, Sp1, and c−Jun in Pancreatic Ductal Adenocarcinoma and Their Associations with Patient Survival

Chronic inflammation is a crucial driver of carcinogenesis in pancreatic ductal adenocarcinoma (PDAC). Several studies have investigated the prognostic significance of cyclooxygenase−2 (COX−2) expression in PDAC patients, obtaining conflicting results. Nuclear factor kappa−B (NF−κB), specificity protein 1 (Sp1), and c−Jun are known as the transcription factors of the COX2 gene. This exploratory observational study investigated the association of the NF−κB, COX−2, Sp1, and c−Jun expressions with patient survival in PDAC. We used the immunohistochemical method to detect the PDAC tissue expressions of NF−κB (RelA/p65), COX−2, Sp1, and c−Jun. The expressions of these proteins were correlated with the overall survival (OS) and other clinicopathological characteristics of PDAC patients. We obtained 53 PDAC specimens from resections and biopsies. There were significant correlations between the four proteins’ expressions in the PDAC tissues. The expression of the cytoplasmic (aHR = 0.31; 95% CI 0.11–0.90; p = 0.032) or nuclear NF−κB (aHR = 0.22; 95% CI 0.07–0.66; p = 0.007) was independently associated with a better prognosis in the PDAC patients. COX−2, Sp1, and c−Jun showed no significant association with a prognosis in the PDAC patients. The PDAC patients who expressed NF−κB had a better prognosis than the other patients, which suggests that the role of inflammation in PDAC is more complex than previously thought.

Risiko Perdarahan Saluran Cerna pada Pasien COVID-19 berdasarkan Jenis Obat Antivirus di Rumah Sakit Umum Pusat Dr. M. Djamil Padang

Coronavirus disease 2019 (COVID-19) has become a global pandemic to date. Some studies reported gastrointestinal tract (GIT) bleeding occurs in several patients hospitalized with COVID-19. Medications known to be associated with an increased risk of GIT bleeding were not associated with GIT bleeding in COVID-19 patients. Objectives: To examined the risk of gastrointestinal tract (GIT) bleeding in COVID-19 patients based on antiviral drugs at Dr. M. Djamil General Hospital Padang. Methods: A nested cohort study was conducted in Dr. M. Djamil General Hospital Padang from May until October 2021. All COVID-19 patients who received antiviral drugs with GIT bleeding with onset days 0 - 7 were included. COVID-19 was confirmed by RT-PCR swab. Data entry and analysis were conducted by computerized. Results: 30 patients were involved in this study. 43,3% COVID-19 Moderate stage and 56,7% Severe stage. 63,3% were treated with remdesivir and 36,7% were treated with favipiravir. Onset on GIT tract bleeding at day 4 (23,3%), day 5 (26.7%), day 6 (30%), and day 7 (20%). The Chi-square test to determine the factors associated with GIT bleeding in COVID-19 patients including COVID-19 severity, type of antiviral drugs, anticoagulant, and corticosteroid revealed that none of all potential factors above related to GI bleeding. Conclusion: The type of antiviral drugs was not related to GIT bleeding in COVID-19 patients.Keywords: antiviral drugs,  COVID-19, gastrointestinal tract bleeding

Association between the HLA-DQB1 Gene Polymorphism and Chronic Progression of Hepatitis B in Indonesia

BACKGROUND: The progression of hepatitis B is affected by the activity of T lymphocytes. Activation of T lymphocytes requires a primary signal originating from the presentation of antigen by HLA molecules to T cell receptors. HLA-DQB1 gene polymorphisms can affect the ability of HLA to bind and present viral antigens to T cells, thus affecting T cell activation and potentially associated with the progression of chronic hepatitis B. AIM: We aimed to investigate the polymorphisms of the HLA-DQB1 gene and its influence on chronic hepatitis B progression of chronic hepatitis B patients in Indonesia. METHODS: This cross-sectional research studied chronic hepatitis B patients at the Internal Medicine Department, Arifin Ahmad Hospital, Pekanbaru, from January 2018 to December 2018. Subjects were grouped into three categories: (1) Inactive chronic hepatitis B, (2) active chronic hepatitis B, and (3) end stage liver disease (ESLD) which consisted of patients with liver cirrhosis and hepatocellular carcinoma. Examination of the HLA-DQB1 gene polymorphism was performed with the SSP-PCR method and sequenced to verify the PCR results. Analysis results of p < 0.05 were considered statistically significant. RESULTS: The most common allele in patients with chronic hepatitis B was the HLA-DQB1 0301. The HLA-DQB1 0301 allele found primarily in the inactive chronic hepatitis B group. The DQB1 0501 allele found to be more abundant in patients with active chronic hepatitis B. The HLA DQB1 0502 allele only found in patients with chronic hepatitis B with ESLD. CONCLUSIONS: The HLA-DQB1 gene polymorphism is associated with the progression of chronic hepatitis B in chronic hepatitis B patients in Indonesia.

Differences in MUC2 Gene Expression Based on the Clinical Severity of Colitis and the Degree of Histopathological Damage to the Colonic Mucosa in Colitis-induced Rat

BACKGROUND: Inflammatory bowel disease (IBD), such as Crohn’s disease (CD) and ulcerative colitis (UC), is characterized by intestinal inflammation and epithelial damage. Impaired mucosal cell barrier function mainly associated with thinning of the mucin layer may be the initial events underlying injury and inflammation in UC. Impaired expression of specific mucins is closely associated with IBD. MUC2 is a gene that produces mucin, which is predominant in the colon in humans and rats. METHODS: This study is an experimental study with a posttest-only design. The sample comprised 16 colitis-induced rats. Induction of colitis was done by giving a solution of dextran sodium sulfate (DSS) 2.5% 1 mL/day orally for 7 days. MUC2 gene expression was measured by rtPCR. The clinical severity of colitis was classified based on the disease activity index (DAI) score. The degree of histopathological damage was classified based on the score of colonic histology observations. The statistical analysis was done by the Shapiro–Wilk normality test and continued with an independent samples t-test. RESULTS: There were differences in MUC2 gene expression in mild and moderate colitis (1.81 vs. 2.99) but the difference was not significant (p > 0.05). MUC2 gene expression also differed in mild and severe histopathological damage degrees (2.32 vs. 2.1) but the difference was not significant (p > 0.05). CONCLUSION: It was concluded in this study that MUC2 gene expression did not have significant differences based on the clinical severity of colitis and the degree of histopathological damage to the colonic mucosa in colitis-induced rats.

The Effect of Mesenchymal Stem Cell Wharton's Jelly on ADAMTS-4 and iNOS Levels in Osteoarthritis Rat Model

BACKGROUND

Osteoarthritis (OA) is one of the most common diseases among the elderly. OA occurs due to an imbalance between degradation and synthesis in articular joint tissue, causing changes in joint components such as cells, matrices and molecular production. Therefore, knowledge of cartilage-degrading enzymes such as ADAMTS-4 and iNOS is needed.

AIM

This study aims to prove the effect of Mesenchymal Stem Cell Wharton Jelly on decreasing ADAMTS-4 levels as cartilage-degrading enzymes and increasing levels of iNOS which showed the immunosuppressive potential of MSC-WJ in cases of osteoarthritis in vivo.

MATERIAL AND METHODS

This research is an experimental study with the design of Post-test-Only Control Group Design. The sample consisted of 16 OA rats as a control group and 16 OA rats treated with MSC-WJ as a treatment group. OA induction is done by injection of monosodium iodoacetate (MIA) into the intra-articular right knee. Giving MSC-WJ is done in the third week after MIA induction. The serum ADAMTS-4 and iNOS levels were measured after 3 weeks treated with MSC-WJ using the ELISA method. The statistical test used is an independent t-test. The value of p < 0.05 was said to be statistically significant.

RESULT

The result showed that serum ADAMTS-4 levels were lower in the group treated with MSC-WJ than in the control group, but not statistically significant (p > 0.05). Serum iNOS levels were higher in the group treated with MSC-WJ than in the control group (p < 0.05).

CONCLUSION

This study concluded that MSC-WJ significantly reduced ADAMTS-4 levels and increased the serum iNOS levels of OA rats.

The Effect of Mesenchymal Stem Cell Wharton's Jelly on Matrix Metalloproteinase-1 and Interleukin-4 Levels in Osteoarthritis Rat Model

BACKGROUND:

Osteoarthritis (OA) is generally considered a degenerative joint disease caused by biomechanical changes and the ageing process. In OA pathogenesis, the development of OA is thought to be regulated largely by excess matrix metalloproteinase (MMP), which contributes to the degradation of extracellular matrices such as MMP-1 and Interleukin-4.

AIM:

This study aims to prove the influence of Mesenchymal Stem Cell Wharton Jelly on decreasing MMP-1 levels and increasing IL-4 which is a specific target as a target component in cases of osteoarthritis in vivo.

MATERIAL AND METHODS:

This research is an experimental study with the design of Post-Test-Only Control Group Design. The sample consisted of 16 OA rats as a control group and 16 OA rats treated with MSC-WJ as a treatment group. OA induction is done by injection of monosodium iodoacetate (MIA) into the intra-articular right knee. Giving MSC-WJ is done in the third week after MIA induction. The serum MMP-1 and IL-4 levels were measured after 3 weeks treated with MSC-WJ using the ELISA method. The statistical test used is an independent t-test. The value of p < 0.05 was said to be statistically significant.

RESULTS:

The result showed that serum MMP-1 levels were higher in the group treated with MSC-WJ than in the control group (p < 0.05). Serum IL-4 levels were higher in the group treated with MSC-WJ than in the control group (p < 0.05).

CONCLUSION:

This study concluded that MSC-WJ increased MMP-1 levels and IL-4 levels in serum OA rats. MSC-WJ showed a negative effect on MMP-1 in the serum of OA rats.

Mesenchymal stem cells accelerate liver regeneration in acute liver failure animal model

Introduction: The massive hepatic necrosis of acute liver failure (ALF) results in a sudden loss of hepatic cells. Although most hepatocyte cells of ALF are completely lost, stem cell-derived circulating cells and endogenous progenitor cells rapidly regenerate them. Mesenchymal stem cells (MSCs) have a critical role in the regeneration of liver injury through regulating platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF) levels. However, their fluctuating levels in the healing process and correlation to the decrease of liver function markers remain unclear. The aim of this study was to analyze the effects of MSCs in accelerating liver regeneration of ALF by measuring VEGF and PDGF levels on day 2 and 7, as well as SGPT and SGOT levels, and assessing histopathology appearance. Methods: Using an ALF rat model, 12 animals were randomly assigned into two groups: umbilical cord (UC)-MSC injection (T1) and vehicle control (Veh). ELISA assay was employed to measure PDGF and VEGF levels, an automatic analyzer was used to assess serum glutamic pyruvic transaminase (SGPT) and serum glutamic oxaloacetic transaminase (SGOT), and hematoxylin and eosin (H&E) staining was used to evaluate morphological appearance. Results: The study showed an significant (P<0.001) increase of PDGF and VEGF levels on the 2nd day, followed by a decrease on the 7th day, along with a decrease of SGPT and SGOT levels as well as the normality of histology appearance. Conclusion: In conclusion, administration of MSCs may accelerate liver regeneration of ALF through PDGF and VEGF regulation.  

Analyzing Determinant Factors for Pathophysiology of Functional Dyspepsia Based on Plasma Cortisol Levels, IL-6 and IL-8 Expressions and H. pylori Activity

BACKGROUND

there are many determinant factors that may play roles in pathophysiology of functional dyspepsia. One of them is psychological stress that can increase plasma cortisol levels, alter inflammation process and affect Helicobacter pylori activity. No study has been conducted to find out the dominant factor among them. This study aimed to find the dominant factor among plasma cortisol levels, IL-6 and IL-8 expressions and H.Pylori activity, as the determinant factors in the pathophysiology of functional dyspepsia.

METHODS

a cross-sectional study was conducted in 80 patients with dyspepsia syndrome at M. Djamil General Hospital, Padang, West Sumatera, Indonesia. The patients were categorized into two groups, i.e. the stress and non-stress group, which were identified using DASS 42 questionairre criteria. The inflammatory expressions (IL-6 and IL-8 expressions) as well as H. pylori activity were determined using immunohistochemistry of gastric biopsy specimens; while plasma cortisol levels was measured from peripheral blood samples. Data were analyzed using binary multivariate logistic regression.

RESULTS

there were 80 patients with functional dyspepsia with mean age of 38.9 years old. The morning cortisol levels was found significantly higher in the stress group. Higher IL-6 and IL-8 expressions were found in patients of non-stress group compared to those in the other group (IL-6: 73.28 (SD 16.60) vs. 72.95 (SD 19.49; and IL-8: 18.45 (SD 17.32) vs. 14.80 (SD 12.71)); although stastically not significant. There was greater Helicobacter pylori activity in the group with psychological stress compared to those in the non-stress group since there was antigen-antibody reaction invading the submucosa. The dominant determinant factor was the afternoon plasma cortisol levels.

CONCLUSION

many factors can become the determinant factors for gastric mucosal damage; however, our study has demonstrated that the dominant factor is afternoon plasma cortisol levels.

High prevalence of hepatitis B virus genotype C/C1 in the Minangkabau ethnic group in Indonesia

Background

The Minangkabau is one of the major ethnic groups in Indonesia. Previous studies with a limited number of samples have shown a different prevalence of HBV/C in the Minangkabau compared to the Indonesian population in general. The aim of this study was to assess the HBV genotype distribution pattern and the prevalence of pre-S, T1753V and A1762T/G1764A mutations among the Minangkabau HBV carriers. The samples were collected from Padang, West Sumatera and from western Java. Mixed primers for specific genotypes were used to determine the HBV genotype. Pre-S or S genes were amplified, sequenced and aligned with reference sequences from GenBank to derive a phylogenetic tree for subgenotyping. Pre-S genes were also analyzed for mutations. The basal core promoter (BCP) region was amplified and directly sequenced to analyze T1753V and A1762T/G1764A mutations.

Results

The predominant HBV genotype among the Minangkabau HBV carriers (n=117) was C (72.6%) followed by B (24.8%) and co-infection with B and C (2.6%). The prevalence of pre-S mutations, including both the pre-S deletion and pre-S2 start codon mutation, was 41.0%, and the T1753V and A1762T/G1764A mutations were found in 51.9% and 71.2% respectively. HBV/C1 was the predominant HBV subgenotype in the Minangkabau HBV carriers, and was found in 66.2%, followed by B3, B7, C8, B2, B9, C2, and C10 (18.3%, 7.0%, 2.8%, 1.4%, 1.4%, 1.4%, and 1.4% respectively). From samples that were found to be co-infected with HBV B and C, two samples were successfully cloned and subgenotyped, including one with mixed subgenotypes of B3 and C1, and another one with mixed subgenotypes of B7, C1, putative intergenotypic of B/A, and C/A. Furthermore, three samples from donors of non-Minangkabau ethnicity from Padang were found to be infected with an intragenotypic recombination form, including a putative recombinant of B8/B3 and B9/B7.

Conclusion

HBV/C with subgenotype C1 was the predominant HBV genotype among HBV carriers of Minangkabau ethnicity. The prevalence of pre-S, A1762T/G1764A, and T1753V mutations was higher among the Minangkabau compared to Indonesian HBV carriers in general.

Hepatitis B virus pre-S2 start codon mutations in Indonesian liver disease patients

AIM: To identify the prevalence of pre-S2 start codon mutations and to assess their association with liver disease progression.

METHODS: The mutations were identified by direct sequencing from 73 asymptomatic carriers, 66 chronic hepatitis (CH), 66 liver cirrhosis (LC) and 63 hepatocellular carcinoma (HCC) patients. Statistical significances were determined using Fisher’s exact test, χ² test, and t-test analyses whenever appropriate. Pre-S mutation as a risk factor for advanced liver disease was estimated by unconditional logistic regression model adjusted with age, sex, and hepatitis B e antigen (HBeAg). P < 0.05 was considered significant.

RESULTS: Mutation of the hepatitis B virus (HBV) pre-S2 start codon was found in 59 samples from 268 subjects (22.0%), with higher prevalence in patients with cirrhosis 27/66 (40.9%) followed by HCC 18/63 (28.6%), chronic hepatitis 12/66 (18.2%) and asymptomatic carriers 2/73 (2.7%) (P < 0.001). Logistic regression analysis showed that pre-S2 start codon mutation was an independent factor for progressive liver disease. Other mutations, at T130, Q132, and A138, were also associated with LC and HCC, although this was not statistically significant when adjusted for age, sex, and HBeAg. The prevalence of pre-S2 start codon mutation was higher in HBV/B than in HBV/C (23.0% vs 19.1%), whilst the prevalence of T130, Q132, and A138 mutation was higher in HBV/C than in HBV/B. The prevalence of pre-S2 start codon mutation was higher in LC (38.9%) and HCC (40.0%) than CH (5.6%) in HBeAg(+) group, but it was similar between CH, LC and HCC in HBeAg(-) group.

CONCLUSION: Pre-S2 start codon mutation was higher in Indonesian patients compared to other Asian countries, and its prevalence was associated with advanced liver disease, particularly in HBeAg(+) patients.

Association of core promoter mutations of hepatitis B virus and viral load is different in HBeAg(+) and HBeAg(-) patients

AIM: To identify the prevalence of hepatitis B e antigen (HBeAg) and to assess the association of hepatitis B virus (HBV) core promoter mutations and viral load in Indonesian patients.

METHODS: Sixty-four patients with chronic hepatitis, 65 with liver cirrhosis and 50 with hepatocellular carcinoma were included in this study. HBeAg and hepatitis B e antibody (HBeAb) tests were performed using enzyme-linked immunosorbent assay and the mutations were analyzed by sequencing. Viral load was measured by real-time polymerase chain reaction.

RESULTS: Of 179 patients, 108 (60.3%) were HBeAg(-) and 86 (79.6%) of these HBeAg(-) patients had been seroconverted. The A1896 mutation was not found in HBeAg(+) patients, however, this mutation was detected in 70.7% of HBeAg(-) patients. This mutation was frequently found when HBeAg was not expressed (87.7%), compared to that found in HBeAg seroconverted patients (65.1%). The A1899 mutation was also more prevalent in HBeAg(-) than in HBeAg(+) patients (P = 0.004). The T1762/A1764 mutation was frequently found in both HBeAg(+) and HBeAg(-) patients, however, the prevalence of this mutation did not significantly differ among the two groups (P = 0.054). In HBeAg(+) patients, the T1762/A1764 mutation was correlated with lower HBV DNA (P < 0.001). The A1899 mutation did not correlate with HBV DNA (P = 0.609). In HBeAg(-) patients, the T1762/A1764 mutation alone was not correlated with HBV DNA (P = 0.095), however, the presence of either the T1762/A1764 or A1896 mutations was associated with increased HBV DNA (P < 0.001).

CONCLUSION: The percentage of HBeAg(-) patients is high in Indonesia, and most of the HBeAg(-) patients had been seroconverted. The A1896 mutation was most likely the major cause of HBeAg loss. The T1762/A1764 mutation alone was associated with lower viral loads in HBeAg(+) patients, but not in HBeAg(-) patients.