Dual Impact of Chronic Hepatitis C and Schitosomal Hepatic Fibrosis on Gall
Bladder Disease
Fathia E Asal1, Abdelmonem N Darwish2, Ahmed Khalid Tawfik1& Raafat A
Salah1.
Tropical Medicine1 and Diagnostic Radiology2 Departments, Faculty of Medicine, Tanta University,
Egypt
Has been accepted to be published in Alexandria Hepatogastroenterology in December 2011.
Background/Aim: Hepatitis c virus is recognized as a major threat to global public health. An
estimated 200 million people worldwide are infected .Gall bladder disease represents one of
the most common and costly of all digestive diseases. The aim of the work is to study
gallbladder disease in chronic hepatitis c patients.
Patients & methods: This study included 180 patients and 40 healthy individuals. They were
classified into five groups namely: Group 1: included 78 patients associated with chronic
hepatitis C without cirrhotic changes. Group II: included 22 patients with chronic hepatitis c
patients with cirrhotic changes. Group III: included 40 patients without HCV infection but
associated with gallbladder disease. Group IV: included 40 patients with schistosomal
infection and pure hepatic periportal fibrosis without HCV infection. Group V: included 40
healthy individuals. All patients and controls were submitted to total serum cholesterol,
determination of serum estradiol (E2) and abdominal ultrasonogrophy for estimation of
gallbladder volume & periportal fibrosis. Fasting and postprandial volumes of GB and
ejection fraction were measured.
Results: Chronic HCV infection is an important risk factor for gall bladder disease in Egypt.
Among persons with HCV infection, the prevalence of gall bladder disease is highest among
those with more severe liver disease. This study also demonstrates that obesity represents one
of the most important risk factors for gallbladder stones formation in non hepatitis c patients.
This study also demonstrates that schistosomiasis represents a risk factor for gallbladder
stones formation.
Conclusion: Schistosomiasis represents a risk factor for gallbladder stones formation. Also,
People with chronic Hepatitis C are at a greater risk for developing gallbladder disease; so
those patients are strongly encouraged to practice gallstone prevention.
Assessment of Episodes of Sleep Apnea in Patients with Chronic HCV Related
Liver Cirrhosis
Raafat A. Salah * & Ayman H Abd El Zaher **
Tropical *& Chest Departments**, Faculty of Medicine, Tanta University
Tanta Medical Journal Vol. (38), October.2010 pp: 1173-1178
Background: Patients with obstructive sleep apnea (OSA) are at risk for the
development of fatty liver as a result being overweight. Several data suggest that OSA
per se could be a risk factor of liver injury; ischemic hepatitis during OSA has been
reported. Obstructive sleep apnea has been reported to be a new complication of liver
cirrhosis with ascites. Therefore we investigated the episodes of sleep apnea as a
complication of advanced liver cirrhosis.
Patients & Methods: Sixty patients with liver cirrhosis due to chronic hepatitis C
were divided according to the child-pugh score into 3 groups: Group A (20 patients
grade A cirrhosis), Group B (20 patients grade B cirrhosis), and Group C (20 patients
grade C cirrhosis). Portable sleep polygraph (ResMed corp., CA, USA) were attached
to the subjects, and oronasal respiration, tracheal sounds,
Respiratory movements of the chest, and percutaneous arterial oxygen saturation
continuously were recorded. A decrease in the mean airflow to 50% or less was
defined as hypopnea, and the number per hour of episodes of apnea and hypopnea
per hour lasting 10 seconds or longer (AHI) was counted.
Results: AHI was Results: AHI was significantly higher in Group C than in Groups A
and B (p<0.05). In Group C, 6 patients with 20 times or more AHI per hour,
obstructive sleep apnea, in which respiratory chest movements occur but oronasal
respiration decreases or disappears, was observed.
Conclusions: As the stage of liver cirrhosis advanced, sleep apnea appeared, and
changes in autonomic nervous activities were observed.
A Multicenter Pilot Study of the Effects of Ramadan Fasting on Patients
with Liver Cirrhosis
Asem Ahmed Elfert, SabryAbdelLatif AbouSaif, Nadiah AbdelAaty, Elsayed AbdelAal,
Ashraf Yousif Elfert, Amal Tohamy, Hasan Elbatae, Mohamed Samy Kohla, Raafat A Salah
Tanta Medical Sciences Journal Vol. (6), No. (3), July. 2011: PP 33-36
Background /Aim: Muslim patients with liver cirrhosis ask their doctors about
Ramadan fasting. Indirect hyper bilirubinemia has been found to increase during
fasting in Gilbert's syndrome. There are no available data on the effect of Ramadan
fasting on patients with liver cirrhosis. The aim of this study was to evaluate the
effects of Ramadan fasting on patients with liver cirrhosis.
Patients & Methods: 300 patients with liver cirrhosis had been studied.
Epidemiological, clinical, laboratory, and hemodynamic evaluation had been
compared before and after fasting Ramadan 1431 Hijri calendar.
Results: 216 patients completed the follow up period. BMI, serum glucose, ALT,
AST, GGT, and ALP decreased; while serum bilirubin increased significantly after
full Ramadan fast (p<0.05). Male gender, Child class A and absence of GI bleeding
had been independent factors in reduction of liver enzymes and serum glucose during
fasting (p<0.05, CI=95%). Increasing age, diabetes mellitus and Child class C had
been independent factors in elevation of bilirubin during fasting (p<0.05, CI=95%).
Conclusion: Patients with Child A liver cirrhosis and no history of GI bleeding may
benefit from fasting Ramadan. But, old patients with Child C cirrhosis associated with
GI bleeding or diabetes mellitus should be advised not to fast. Larger prospective
randomized controlled trials should be done to produce definite parameters for
cirrhotic patients who can fast.
Serum Systatin C and Doppler Ultrasound as a Predictor of renal Dysfunction in
Cirrhotic Patients with Normal Serum Creatinine
Atef E Awad ,Raafat A Salah ,Sabry A Abu Saif ,Mohamed K Zahra,Mohamed Amin
Departments of Tropical, Clinical Pathology and Diagnostic Radiology
Tanta Medical Sciences Journal Vol. (6), No. (4),Oct. 2011: PP:42 -54
Background/Aim: Renal and liver dysfunction often present together, either as part
of multiorgan failure in a critically ill patient, or as a result of failure of each organ
independently. Renal dysfunction begins early in cirrhosis, even before the patient
develops decompensated cirrhosis. This result from hemodynamic changes associated
with imbalance between vasodilators and vasoconstrictors leading to renal
vasoconstriction and low renal blood flows. Cirrhotic patients have several underlying
conditions that contribute to falsely low serum creatinine concentrations including
decreased creatinine production secondary to decreased hepatic creatine synthesis,
increased tubular creatinine secretion, and decreased skeletal muscle mass. Serum
creatinine level, measured creatinine clearance, and calculated creatinine clearance
may all significantly overestimate GFR; the degree of GFR overestimation was a
median of 95% in recent published studies. Cystatin C is being considered as a
potential replacement for serum creatinine as a filtration marker. Most studies show
that serum levels of cystatin C are more closely correlated with GFR than serum
creatinine. We aiming to analyze the renal dysfunction in cirrhotic patients with
normal serum creatinine based on serum cystatin C for estimation of glomerular
filtration rate and renal Doppler ultasonography for the kidney.
Patients & Methods: In the present study, serum creatinine, seum cystatin C,
Creatinine clearance, estimated GFR (eGFR) and renal Doppler ultasonography were
done for cirrhotic patients with normal serum creatinine as well as controls.
Results: Serum Cystatin C was elevated in patient groups. Also, Creatinine Clearance
was decreased in patient groups. Estimated GFR were below normal. Color Doppler
ultrasonograhy was done for assessment of Renal Resistive Index (RRI) of intrarenal
arteries of both kidneys. There was significant positive correlation between RRI and
serum creatinine in patients groups.
Conclusion: Our study shows that the sensitivity of serum cystatin C for detecting
reduced GFR is higher than that of creatinine in patients with liver cirrhosis.
Therefore, serum cystatin C measurements may be useful in these patients. However,
neither serum cystatin C nor creatinine reliably allows the prediction of the exact GFR
in these patients and cannot replace gold standard for measurement
Comparative Study of the Efficacy of Rifaximin in Comparison with Lactulose
for the Treatment of Hepatic Encephalopathy
Fathia E Asal1, Ahmed Khalid Tawfik1, Raafat A Salah1, Shaimaa M Mansour1 ,
Amal H Abed-El Hameed2
Tropical Medicine & Infectious Diseases1, Clinical Pathology2departments, Faculty of Medicine, Tanta
University, Egypt
Has been accepted to be published in Alexandria Journal Of Hepatogastroenterology in
August 2012.
Background/Aim: Hepatic encephalopathy (HE) represents a broad spectrum of
neuropsychological dysfunction. In cirrhotic patients, HE may be clinically overt or
minimal.Overt HE (OHE) may be further divided into episodic or persistent. Both episodic
and persistent HE may beinduced by a precipitating event or may occur apparently
spontaneously.The most widely accepted theory of the pathogenesis of HE is that
nitrogenous substances derived from the gut adversely affect the cerebral function. The main
substance implicated is ammonia. Rifaximin is a derivative of rifamycin, which acts by
inhibiting bacterial ribonucleic acid (RNA) synthesis. Rifaximin is virtually unabsorbed after
oral administration and exhibits broad spectrum antimicrobial activity against both aerobic
and anaerobic gram-positive and gram-negative microorganisms within the gastrointestinal
tract.
Patients & Methods: The study population included 50 patients were diagnosed to have
signsof the first to third degree HE and classified into two groups: Group I: included 25
patients who had hepatic encephalopathy and were treated with rifaximin (1200 mg daily
divided into 3doses for 7 days).Group II: included 25 patients who had hepatic
encephalopathy and were treated with lactulose (90ml daily divided into 3doses for 7 days).
Results: The results showed that the both rifaximin& lactulose can decrease ammonia level
by different mechanisms, but the response of patients regarding improvement of symptoms
of HE was more & rapid in rifaximin group than lactulose group.
Conclusion: Patients treated with rifaximin required shorter duration of hospitalization
compared to lactulose, also rifaximin was better tolerated than other pharmacologic
treatments.
Interleukin 28B rs12979860 Polymorphism is a Useful Tool for Prediction of
Sustained Virological Response Outcomes in Hepatitis C Genotype 4 Egyptian
Patients Treated with Current Standard of Care Treatment : A Retrospective
Cohort Study
(1)
Yasser El-Sawaf , Gamal Kassem(1), Raafat Salah(1), Atef Taha(2), Abeer
Shahba(2), Hesham El-Sorogy(3) & Mohamed Attia Saad(3)
Tropical Medicine Department(1), Internal Medicine Department(2), Clinical Pathology Department(3),
Faculty of Medicine, Tanta University, Egypt.
Tanta Medical Sciences Journal Vol. (7) , No. (2), April 2012: PP: 11-21
Background/Aim: Hepatitis C virus infection is a global health problem, it is estimated that
there are between 120 and 130 million infected people worldwide. The prediction of
treatment outcomes for patients with chronic hepatitis C virus infection has
been revolutionized by the finding of a strong association between single-nucleotide
polymorphisms near the interleukin-28B (IL-28B) gene and sustained virological response
after pegylated interferon and ribavirin–based therapy for HCV genotype 1 infection.
Patients & Methods: A total of 93 unselected treated patients with chronic hepatitis C
genotype 4 were enrolled in the study. All these patients had samples available for IL28B
analysis, all are Egyptians.
Results: A total of 93 patients were enrolled in the study. SVR was achieved in 39 patients
(41.94%), 23 men and 16 women. When evaluating predictors of response we found that the
IL28B rs12979860 CC genotype was significantly associated with SVR in HCV genotype
4 infected patients (Odds ratio 5.15; 95%CI 2.43 - 13.37; p <0.001). In the multivariate analysis,
with age and EDD adjustment Odds ratio was 3.68; 95% CI 1.57 - 11.04. IL28B rs12979860 CC
genotype, which has been associated with better treatment response in several previous
studies, was identified in 33 patients, and 27 of them (81.82.2%) achieved SVR. In the other 60
patients with IL28B non-CC genotype, 12 (20%) achieved SVR.
Conclusion: Our results showed that IL28B host genotypes can be added to predictors of
treatment response to Peg-IFN and RBV in Egyptian patients with HCV genotype 4.
The Impact of Pegylated Interferon on Sexual Dysfunction in Male Patients with
Chronic HCV
Mohamed A Sharaf Eldin1, Raafat Salah1, El-Sayed S Hewedy2, Ahmed S
Shenawy2, Mohammad A Sweilam3
Departments of Tropical Medicine1, Dermatology & Venereology2, Clinical Pathology3, Faculty of
Medicine, Tanta University, Egypt M
Tanta Medical Sciences Journal Vol. (7), No. (3), July 2012: PP 11-17
Background/Aim: The frequency of sexual dysfunction is not very well known in patients
with chronic hepatitis C. Decrease of libido and erectile dysfunction are reported by male
patients with chronic hepatitis C and during pegylated interferon α 2a therapy of chronic
hepatitis C. The aim of this work was to evaluate sexual dysfunction in male patients with
chronic HCV.
Patients & Methods: This study was carried out on 30 adult male patients complaining of
chronic hepatitis C and 10 healthy males as a control. The patients were divided into 2
groups. The first group included 15 patients who were not treated by either interferon
therapy or other treatment for hepatic dysfunction. The second group included 15 patients
who were treated by fixed weekly subcutaneous injection of 160 μg pegylated interferon α-2a
(Rhein Minafarm Company, Egypt). These patients were just finished 12 weeks of treatment.
Serum level of free and total testosterone was determined for the patients and controls.
Results: There was a significant decrease in libido and erectile dysfunction in chronic
hepatitis C patients when compared to controls. This significance was more in patients
treated by pegylated interferon α 2a. Also, there was a significant decrease in the serum level
of free and total testosterone in the patients when compared to controls. This decrease was
more significant in patients treated with pegylated interferon alfa 2a. No correlation could be
detected between the state of libido, erectile dysfunction and the serum level of free and total
testosterone.
Conclusion: Sexual impairment is common among men with chronic hepatitis C, especially
those undergoing therapy with PEG-IFN. Sexual dysfunction should be considered as a
potential side effect of IFN therapy
Propiotic can improve Neurometabolites in patients with minimal hepatic
encephalopathy?
Dina H. Ziada1, Hanan H. Soliman1, Raafat A. Salah1, Manal F.Hamisa2Azza
M. Hasan3&Ahmed El Shamy4
Tropical Medicine and Infectious Diseases1, Radiology2, microbilogy3, and neuropsychatry4
Departments, Faculty of Medicine Tanta University-Egypt
Tanta Medical Sciences Journal Vol.(7), No. (2), April 2012: 1-10
Background/Aim:Minimal hepatic encephalopathy (MHE) is a term that describes patients
with chronic liver disease who have no clinical symptoms of brain dysfunction, but perform
substantially worse on psychometric tests compared to healthy controls.This study aimed to
evaluate probiotic as alternative therapy in MHE
Patients &methods: This is an open labeled randomized controlled trial, performed in
Tropical medicine and infectious disease department, Tanta university hospitals, between
March 2010 and January 2012. Ninety Patients with MHE diagnosed by psychomotor testing
were allocated by simple randomization into 3 parallel equal groups. Group A received
lactulose, group B probiotic(lactobacillus acidophilus) and group C as control. After
informed consent, patients were tested for gut micrecology, fasting blood ammonia level, and
liver function tests, followed by MRS examination to study brain metabolites mainly
choline(Cho), myo-inositol(mI), and glutamine-glutamate(glx).Patients who developed overt
encephalopathy were excluded from analysis.The whole battery of investigations were
repeated in same order after 4 weeks.
Results: probiotic was better tolerated than lactulose. And psychometric tests were improved
in both therapies. RRR of developing overt encephalopathy was 60% in Lactulose, and 80% in
probiotic,and NNT were 2.4, and 2.3 respectively. The differential but not total microecology
count was significantly shifted toward sacrolytic rather than proteolitic bacteria. mI/Cre, and
(Cho+mI)/Glx ratios were significantly increased and Glx/Cre, ratio was significantly
reduced after one month follow up in probiotic compared to lactulose, and in both treatment
groups compared to control group.
Conclusion: Both probiotic and lactulose therapy were effective in MHE patients causing
improvement in their blood ammonia levels, psychometric tests, and reduce risk of
developing overt encephalopathy. MRS showed more improvement in levels of brain
neurometabolites with probiotic group.
Risk Factors for Recurrence of Hepatocellular Carcinoma (HCC) after
Radiofrequency Ablation (RFA) in a Cohort of Egyptian Patients with HCVinduced Cirrhosis: A Multi-Center Analysis.
Mohamed A. Sharaf-Eldin(1), ,Sahar A. El-Yamany(1), Raafat A Salah(1),
Mohamed Kohla(3) ,Eslam Heba (1) ,Hisham AbdelFattah(4) and Mohamed
Shaker Ghazy(2),
Tropical Medicine (1) and Radiology Department (2), Liver Institute (3) , Faculties of Medicine,
Tanta (1) , Ain Shams (2), Menofiya (3) and MUST(4) Universities
Tropical Medicine (1) and Radiology Department (2), Faculty of Medicine, Tanta (1) and Ain
Shams (1) University
Has been accepted in Falk Symposium Germany October 2012
Background/Aim: Hepatocellular carcinoma (HCC) is one of the major
complications of liver cirrhosis. Radiofrequency ablation is the treatment of choice for
patients with an early stage HCC who are not candidates for surgical management;
however, it is associated with a recurrence rate as high as 15-30% after one year. The
aim of this work was to analyze the risk factors for HCC recurrence in Egyptian
patients after Radiofrequency ablation.
Patients & Methods: This study was carried out on a cohort of HCC patients
presented to 2 large referral centers for management of HCC in Egypt from
November 2009 till January 2011. Only patients with an early stage HCC (BCLC
stage A), eligible for RFA ablation were included in the analysis, and followed up for
a period of one year. Patient and tumor –related risk factors associated with
recurrence were studied. Statistical analysis was done using SPSS software. A total of
45 patients were included in this study and classified into 2 groups: Group I: Patients,
who developed recurrence during follow up, (n=30, 66.6%). Group II: Patients who
did not show any recurrence during follow up (n=15, 33.3%).
Results: The risk factors associated with recurrence included, smoking (70% in
group I versus 40% in group II, p = 0.015), hepatolomegaly (50% in group I versus
40% in group II, p =0.001) splenomegaly (90% in group II versus 53.3% in group II p
= 0.001), heterogenous liver (30% in group I versus 6.66% in group II, p = 0.001),
bilobar involvement (20% in group I versus 6.66% in group II, p = 0.001) and tumors
in contact with hepatic capsule (20% in group I versus 6.66% in group II, p= 0.017) .
Conclusion: among various patient factors, only smoking, hepatomegaly, liver
heterogeneity, and splenomegaly (a sign of portal hypertension) together with the
tumor factors; bilobar involvement and proximity to liver capsule were the factors that
showed a significant association with tumor recurrence in this study.
The Value of Hepatitis B Core Antibody in Screening Blood Donors in Tanta
University Hospital
Elshazly Sheta1, Sabry A. Abou-Saif1, Mohammad Sweilam2, Raafat A. Salah1, Sahar A.
El-yamany1, Mohammed Yusif1, and Mahmoud Abdel-Samea1
Departments of Tropical Medicine1 and Clinical pathology2, Tanta University, Tanta, Egypt
Tanta Medical Sciences Journal Vol. (6), No. (4), October 2011: PP25-33
Background /Aim: Blood containing antibodies to hepatitis B core (HBcAb) might be
infectious. Therefore, screening blood for anti-HBc is implemented in some countries
resulting in a decrease in the risk of post-transfusion HBV infection. The aim of this study
was to determine the prevalence of HBV among the blood donors at Tanta university
hospital.
Patients & Methods: A total of 180 serum samples were collected from HBsAg negative
blood donors and were tested for the presence of anti-HBc. Anti-HBc positive samples were
subjected to real time polymerase chain reaction (PCR) to confirm the presence of HBV DNA.
Results: 10% of HBsAg negative blood donors were found to be HBcAb positive. PCR for
HBV DNA was positive in 5.6% of HBcAb positive samples. So, the risk of HBV infection in
HBsAg negative blood is 0.56%.
Conclusion: This study shows the incomplete effectiveness of HBsAg screening in protecting
blood recipients from HBV infection. Inclusion of anti-HBc testing should be considered in
the screening of blood donors especially in patients needing multiple transfusions or elective
surgeries needing massive transfusion.
Impact of fever stress due to extra-hepatic infections on the progress of chronic
hepatitis C
1
Abdel Raouf Abou El Azm , Hassan El Batae 1, Raafat A Salah 1,. Asem Elfert 1,
Safinaz Shalaby 2 and Nagwa Mansour 3
Departments of Tropical Medicine and Infectious Diseases 1, Public Health 2 and
Clinical Pathology 3 Faculty of Medicine, Tanta University, Egypt
Tanta Medical Journal Vol. (40) ,January 2012;pp:141-147
Background: Fever is a prominent sign of acute-phase response induced by microbial
infection. Hepatic involvement is due to elevated body temperature resulting in
oxidative stress.
Aim: to investigate the risk of fever stress due to extra-hepatic common infections on
chronic HCV.
Patients & Methods: A case series study included 70 patients with chronic HCV.
Thirty two were evaluated for HCV treatment. Liver functions and viraemia were
evaluated within 3 months and re-assessed when developed fever > 38.5 C as a sequel
to common extra-hepatic infections which have no direct liver affection; acute
tonsillitis, seasonal influenza or urinary tract infection and 38 patients with chronic
HCV during episode of fever and were re-assessed after one month of recovery from
fever before interferon therapy. 34 healthy liver volunteers with fever due to these
infections were included as control.
Results: liver functions and HCV viraemia showed significant increase p<0.05 in
both groups of hepatitis C during fever irrespective of the etiology as compared to
before or after fever while insignificant (p>0.05) between both in absence of fever.
Increased intensity of fever carries more risk. Non-hepatitis control showed
insignificant difference in liver functions during, or in absence of fever but significant
as compared to hepatitis C patients.
Conclusion: fever stress could deteriorate liver functions and elevate HCV viral load
requiring early management of fever and its etiology.