Arab Journal of Gastroenterology

Editorial Board

2012-03-01

A note from the Editor’s desk

2012-03-01

Patterns of hepatitis B infection in Egyptian children in the era of obligatory hepatitis B vaccination

2012-03-26

Abstract: Background and study aims: Mass compulsory HBV vaccination was applied in Egypt in 1992. The first dose of vaccine is administered at 2months of age and routine screening of pregnant women for HBsAg is not applied. We aimed to evaluate the pattern of HBV infections after the implementation of HBV vaccination in Egyptian children.Patients and methods: Fifty-six children with HBV infection presented to the Paediatric Hepatology Unit, Cairo University Children’s Hospital, over the period from 1992 to 2006. Their data were reviewed for risk factors, clinical, serological and histopathological profiles. These cases were followed-up for 6.3±3.4years. The data of those born before 1993 (did not receive HBV vaccine) (group I) was compared to those who received the vaccine (group II).Results: Sixty percent of HBV infected cases were born before 1993. Comparison of data of both groups revealed: (1) A significant younger age of onset in group II (3.34±3.31years vs. 9.84+2.95years; p⩽0.01). (2) Vertical transmission was a significant risk factor in group II. (3) Chronic hepatitis developed in almost half of cases in both groups but cirrhosis was diagnosed only in 4 cases (all from group I) (p=0.04).Conclusion: Vertically transmitted HBV infection is becoming an important risk factor for acquisition of HBV among children born after the era of mass vaccination in Egypt. Mass screening for HBsAg of pregnant Egyptian women and/or giving a birth dose of HBV vaccine is becoming mandatory with the increased incidence of vertical transmission.

Cognitive function in patients with liver cirrhosis without overt hepatic encephalopathy: Assessment using an automated neuropsychological test battery

Taofiki A. Sunmonu, Olusegun Adekanle, Morenikeji A. Komolafe, Dennis A. Ndububa — 2012-03-14

Abstract: Background and study aims: A wide range of neuropsychiatric disorders occur in patients with liver cirrhosis without overt hepatic encephalopathy. Cognitive dysfunctions do occur and these tend to impair patients’ vocational and social life as well as activities of daily living. The aim of this study is to evaluate cognitive functions in patients with liver cirrhosis without overt HE in Nigeria.Patients and methods: Thirty-four patients with liver cirrhosis and 41 normal subjects as control were studied. Medical history and general physical/neurological examinations were carried out on all the subjects. Blood samples were obtained for viral serological markers and liver functions tests. The ‘Fepsy’ automated neuropsychological test battery was performed for the assessment of auditory reaction time (psychomotor speed). Recognition memory test (memory), binary choice reaction task (psychomotor speed/attention) and vigilance task were also administered. The data were analysed with the aid of Statistical Package for Social Sciences (SPSS) version 15.0 software.Results: The mean age of patients with liver cirrhosis was 45.00±13.83years, while that of control subjects was 41.88±139.49years. The visual/auditory reaction time, binary choice reaction time and computerised visual reaction time were prolonged in patients with liver cirrhosis when compared with control subjects. However, there were differences in the recognition memory test and vigilance performances between the two groups. The patients with liver cirrhosis who had hepatitis C virus infection had poor psychomotor speed when compared with patients who were hepatitis C virus negative, but there was no statistical significant correlation between other aspects of liver function tests and cognitive functions in patients with cirrhosis.Conclusion: Patients with liver cirrhosis had similar cognitive functions on measures of memory and vigilance when compared with normal control subjects. However, there were significant differences in other aspects of cognitive functions between the two groups.

Alpha-l-fucosidase as a tumour marker of hepatocellular carcinoma

Mohamed Fawzy Montaser, Mohamed Amin Sakr, Mohamed Omar Khalifa — 2012-04-09

Abstract: Background and study aims: Alphafoetoprotein (AFP) is not secreted in all cases of hepatocellular carcinoma (HCC) and may be normal in as many as 40% of patients with early HCC. Alpha-l-fucosidase (AFU), a lysosomal enzyme present in all mammalian cells, has been proposed as a tumour marker since many studies reported increased AFU serum levels in patients with cirrhosis and HCC.This study aimed at evaluation of the diagnostic value of AFU as a tumour marker of HCC and its prognostic role in follow-up after intervention.Patients and methods: This prospective case-control study was conducted on 80 patients (40 patients with HCC and 40 patients with chronic liver disease (CLD) as diseased controls) in addition to 40 apparently healthy individuals who served as a healthy control group. AFU serum levels in the three groups were measured and compared.Results: There was a statistically highly significant elevation (p<0.001) in the median values of serum AFU in the HCC group (0.99–26.59μmoll−1min−1) when compared with both the CLD (0.11–4.60μmoll−1min−1) and control (0.1–1.2μmoll−1min−1) groups. At a cut-off value of 2.3005μmoll−1min−1, AFU yielded a sensitivity and specificity of 90% and 97.5%, respectively. In HCC patients, AFU dropped significantly after successful intervention and can be used to follow-up therapy in these patients.Conclusion: AFU is a promising tumour marker in the diagnosis of HCC. It can be used also to follow up patients after interventional therapies.

Detection of hepatopulmonary syndrome in patients with liver cirrhosis using 3D contrast echocardiography

Rania Gaber, Dina H. Ziada, Nesreen A. Kotb, Gehan H. Abo El-Magd, Manal Hamisa — 2012-04-02

Abstract: Background and study aims: Hepatopulmonary syndrome (HPS) is characterised by the triad of advanced liver disease, arterial hypoxaemia and intrapulmonary vascular dilatation (IPVD). The present study aimed to evaluate HPS in patients with liver cirrhosis and the role of three-dimensional (3D) contrast echocardiography in the detection of this syndrome.Patients and methods: A total of 78 chronic liver disease patients aged 42±11years fulfilled the criteria for this study and were subjected to clinical examination, laboratory investigations, arterial blood gases measurement, pulmonary function tests, upper gastrointestinal endoscopy, 3D contrast echocardiography and computed tomography (CT) pulmonary angiography.Results: According to 3D contrast echocardiography results, we divided the patients into a positive group (n=26) in which patients showed a delayed appearance of contrast in left heart chambers and a negative group (n=52). Among 26 patients of the positive group, nine had hypoxaemia (partial pressure of oxygen (PaO2) <70mmHg) and were diagnosed as having hepatopulmonary syndrome (HPS), the other 17 who had shown echocardiographic evidence of IPVDs but without hypoxaemia were diagnosed as having sub-clinical HPS. This study showed significant correlation between positive contrast echocardiography findings and duration of liver disease, Child score, cyanosis, clubbing, orthodeoxia, portal vein diameter, spleen size and oesophageal varices grades. No significant correlation was found between 3D contrast echocardiography findings and age, sex, spider naevi and pulmonary function tests. Multivariate logistic regression showed that cyanosis, clubbing, orthodeoxia, Child score and portal vein diameter are independent predictors of HPS.Conclusion: Cyanosis, clubbing and platypnoea-orthodeoxia are suggestive indicators of HPS, which can be easily detected by 3D contrast echocardiography which can replace the trans-oesophageal echocardiogram (TEE) in cirrhotic patients.

Irritable bowel syndrome, gastro-oesophageal reflux disease and dyspepsia: Overlap analysis using loglinear models

2012-04-09

Abstract: Background and study aims: Irritable bowel syndrome (IBS), gastro-oesophageal reflux disease (GERD) and dyspepsia are three most important gastrointestinal disorders which occur frequently together in patients. This study aims to assess the association between IBS, GERD and dyspepsia by using loglinear model analysis.Patients and methods: This cross-sectional household survey, the purpose of which was to find the prevalence of gastrointestinal symptoms, disorders and the related factors, has been done from May 2006 to December 2007 in Tehran province, Iran. Subjects were interviewed by trained personnel. GERD was diagnosed as the experience of heartburn and/or acid regurgitation at least once a week for the last 3months. IBS and dyspepsia were diagnosed according to the Rome III criteria. Loglinear models were applied to investigate the simultaneous association between IBS, GERD and dyspepsia.Results: 77.9% of IBS patients had dyspepsia symptoms and 74.7% had GERD symptoms as well at the same time. As for the other two symptoms, 66% of GERD patients were also suffering from dyspepsia.Conclusions: These three symptoms frequently overlap; the overlap is systematic and not by chance or random.

Coeliac disease in irritable bowel syndrome (Rome III) in Southeast Iran

2012-04-06

Abstract: Background and study aims: Irritable bowel syndrome (IBS) is a common functional gastrointestinal (GI) disorder and coeliac disease (CD) is an auto-immune enteropathy that can mimic almost any functional GI disorder. Both IBS and coeliac disease share common symptoms. The aim of the present study was to estimate the prevalence of CD in patients with IBS and its sub-types.Patients and methods: In this cross-sectional study (2008–2010), all consecutive patients with IBS who fulfilled the Rome III criteria attending the GI units in Zahedan (Southeast Iran) were included. Patients based on the sub-type of IBS were classified as diarrhoea-predominant irritable bowel syndrome (D-IBS), constipation-predominant irritable bowel syndrome (C-IBS) and alternating symptoms (mixed type). Immunoglobulin A (IgA) tissue transglutaminase (anti-tTG) was used to screen patients for CD. In the case of positive serologic test, duodenal biopsies were taken to confirm the diagnosis.Results: A total of 364 (221 females and 143 males) patients with IBS were included. The mean±standard deviation (SD) age of patients was 37.4±12.4years. Twenty (5.5%) patients were found to have positive IgA anti-tTG. Main symptoms of patients were diarrhoea (11/20), bloating (10/20) and abdominal distension (6/20). Thirteen (10.5%) patients were found to have positive IgA anti-tTG among the D-IBS, two (1.6%) in the C-IBS and five (4.2%) in M-IBS groups.Conclusion: The prevalence of CD in IBS is high. IBS subjects whose main complaint is diarrhoea, bloating or even abdominal distension should be evaluated for CD.

Portal vein thrombosis in a patient with Turner’s syndrome: A case report

Soad A. Shedeed — 2012-04-11

Abstract: This work aimed at reporting a case of Turner’s syndrome with portal vein thrombosis and elevated levels of factor VIII and von Willebrand factor. A 14-year-old Libyan girl was admitted for evaluation of infantilism and pallor; meanwhile, she was found to be of short stature, with webbing of the neck. Chromosomal studies showed monosomy pattern Turner’s syndrome (45XO). Abdominal ultrasound displayed a hugely enlarged spleen. Computed tomography (CT) imaging of the abdomen revealed portal vein thrombosis and dilated venous collaterals in porta hepatis. Thrombophilia screening demonstrated elevated levels of factor VIII (207IUdl–1) and von Willebrand factor (450IUdl–1). It was concluded that this was a case report on the unusual finding of portal vein thrombosis in a patient with Turner’s syndrome in whom high levels of factor VIII and von Willebrand factor were found. Detailed molecular epidemiological study is recommended to clarify this finding and its underlying factors.

Gastric adenocarcinoma associated with lymphangitis carcinomatosa, adrenal metastasis with ectopic ACTH syndrome and malignant common bile duct stricture

2012-02-03

Abstract: Ectopic adrenocorticotrophic hormone (ACTH) syndrome (EAS) commonly occurs secondary to neuroendocrine tumours and small cell carcinoma of lung. EAS has also been reported in association with gastric carcinoids. But, the occurrence of EAS secondary to gastric adenocarcinoma has rarely been reported. A 45-year-old male patient from Bangladesh presented with abdominal pain, jaundice and hyperpigmentation. Extensive work-up revealed poorly differentiating mucin-secreting adenocarcinoma of stomach with lymphangitis carcinomatosa of lung, bilateral adrenal metastasis and malignant common bile duct (CBD) stricture. Laboratory reports were suggestive for ectopic ACTH production. Most of these features are very rare in adenocarcinoma of stomach, and all these rare events occurring in a single patient is probably the rarest.

Intracellular cholestasis: A rare complication of malaria falciparum infection

Abdel Motaal Mohamed Ahmed, Mohamed B. Galib — 2012-03-15

Abstract: Background: Aside from acute viral hepatitides intracellular cholestasis is seen less often with the use of certain drugs, contrast media, leptospirosis and congenital hyperbilirubinaemias. Types of liver injuries complicating malaria usually take the form of acute hepatitis or haemolytic anaemias rather than cholestasis. We report here a rare presentation where a typical intracellular cholestatic picture complicated malaria falciparum in a patient residing in an endemic area.Patient and methods: A 55year old bank manager presented with malaria fever and deep jaundice for investigations. CBC, LFT, renal function, coagulation profile, liver function test, viral hepatitis markers for HBV and HCV including PCR, U/S liver, MRI liver, CT brain, full septic screen, thin and thick Giemsa-stained blood films and ICT for malaria, leptospira Abs and ANA.Results: Total bilirubin 22mg/dl, conjugated 19mg/dl, ALT 49, AST 65, alkaline phosphatase 176 (normal), serum albumin 3.5mg/dl, INR 0.9, urea 98mg/dl, creatinine 2.3mg/dl, Hb 8.8, platelet 263, WBC 11000, MCV 84, Coomb’s test negative, haptoglobulin levels: normal, blood culture: negative, HBVDNA and HCVRNA: negative, ANA: negative, blood film and ICT for malaria: positive then turned negative after artemether treatment, leptospira Abs titres for six species including L haeorragiae at days 7, 14 and 60, were: <1/10 negative. Liver U/S normal, MRCP: normal and CT brain: normal patient fully recovered with anti-malarial agent artemether and short course of renal support (haemofiltration).Conclusion: In cases of severe intracellular cholestasis malaria infection should be considered in the differential diagnosis particularly in malaria endemic localities. This rare complication of a common disorder is potentially treatable.

Pancreatic-pleural fistula in chronic pancreatitis

2012-04-06

Abstract: Pancreatic-pleural fistula is a rare condition and few data related to its diagnosis and treatment are available. A fistulous connection linking the pancreas with the pleura via the diaphragm or mediastinum through the retroperitoneal area is formed.We report on a case with pancreatic-pleural fistula at its early stages in an alcoholic male patient aged 45years with known chronic pancreatitis. The operation by Roux-en-Y jejuno-pseudocystostomy was followed by chest tube drainage.