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Editor in chief
M.Y.Taher
Founder Editors
Hilmy Abaza
Seham Abdel Reheem
Co-Editors
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FathAlla Sidkey
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Mohamed Sharaf De Din
International Advisory Board
JP Galmiche France
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X Rogiers Belgium
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Des Verrannes France
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P Almasio Italy
National Advisory Board
Mohamed El Gendi
Moustafa El Henawi
Amira Shams Eldin
Nabil Abdel Baki
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M Essam Moussa
Ahmed Bassioni
Saeid Elkyal
Abdel Fataah Hano
Tarek Thabet
Ahmed Hussein
Khaled Madboli
Ezzat Aly
Contents Alexandria Journal of
Hepatogastroenterology, Volume IX ( III )
December 2011
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Disclaimer: The Publisher, the Egyptian Society of
Hepatology Gastroenterology and Infectious Diseases
in Alexandria, and Editors cannot be held responsible
for errors or any consequences arising from the use of
info-rmation contained in this journal; the views and
opinions expressed do not necessarily reflect the those
of the Publisher, the Egyptian Society of Hepatology
Gastro-enterology and Infectious Diseases in
Alexandria, and Editors, neither dose the publication
of advertisements constitute any endorsement by the
Publisher, society, and editors of the products
advertised.
-------------------------------------------
Original Article:
Occult Hepatitis B Virus infection in Egyptian Hepatitis
C Virus positive patients: Prevalence and impact on
Hepatocellular Carcinoma development
Ibrahim Baghdady*, Sabry Shoeib*, Ehab Abdel-atti*, Ashraf G. Dala*, Emad M. Eed** and Ashraf A.
Zytoon****Internal Medicine, **Bacteriology
-------------------------------------------
Original Article:
Open Splenectomy For Hypersplenism-induced
Thrombocytopenia In Egyptian Patients With HCV-
related Liver Cirrhosis
Mahmoud A. Hemidaa, Mohamed MShamseyab, Ahmed M.
L. Bedewyca)Department of clinical and expermintal
surgery,b) Department of internal medicine,c.
-------------------------------------------
Original Article:
Use of Anticyclic Citrullinated Peptide Antibodies to
Distinguish Hepatitis C Virus (HCV) – Associated
Arthropathy From Concomitant Rheumatoid Arthritis in
Patients with Chronic HCV Infection
Khaled Mahmoud Mohiedeen* ,Akram Deghedy **Tropical Medicine
-------------------------------------------
Original Article:
Prevalence of Non-Organ-Specific Autoantibodies and its
Effect on response to Antiviral Therapy in Patients with
Chronic Hepatitis C Virus Genotype 4
Mohamed Abd El-Maksoud1, Hatem Elalfy1, Maha Ragab
Habeeb2, Abd-Elmohsen E. El-desoky2
-------------------------------------------
Original Article:
Non-traumatic intramural hematomas in patients on
anticoagulant therapy: report of three cases.
Mohamed Bekheit.
-------------------------------------------
Original Article:
Comparative Study of the Efficacy of Rifaximin in
Comparison with Lactulose for the Treatment of Hepatic
Encephalopathy
Fathia E Asal1, Ahmed Khalid Tawfik1-
-------------------------------------------
Original Article:
Effect of Rebamipide on Portal Hypertensive
Gastropathy and Proliferating Cell Nuclear Antigen in
Patients with Liver Cirrhosis
Mohamed Y. El-Hasafi(a), Suzan M. Helal(b), Marwa A. Madkour(c), Ahmed S.
-------------------------------------------
Original Article:
Accidentally discovered patients with Antibody to
Hepatitis C Virus: Clinical, Biochemical, Virologic,
ultrasonic and Histologic Features
Ahmed Faisal MD1; Abdel-Naser Gad allah MD2 , Ashraf zytoon MD3 Infectious and endemic diseases unit1, Internal
Medicine department, Suez Canal university;
-------------------------------------------
Original Article
Occult Hepatitis B Virus Infection in Egyptian Hepatitis C Virus Positive Patients:
Prevalence and Impact on Hepatocellular Carcinoma Development
Ibrahim Baghdady*, Sabry Shoeib*, Ehab Abdel-atti*, Ashraf G. Dala*, Emad M. Eed** and Ashraf A. Zytoon***
*Internal Medicine, **Bacteriology and ***Radiology Departments, Faculty of Medicine, Menofiya University
ABSTRACT
Occult Hepatitis B Virus infection (OBI) is characterized by positivity for HBV DNA in HBsAg-negative patients with or
without serological markers of previous HBV infection. The prevalence of OBI in different studies has been reported between
zero and 52.3% among patients with diverse liver disease due to Hepatitis C Virus (HCV) infection. The aim of the present
work is to study the prevalence of OBI among HCV-positive Egyptian patients and its impact on hepatocellular carcinoma
(HCC) development. Patients and methods: The study included 100 chronic HCV positive patients. There were 57 male and
43 females ranged between 41-77 years old. Full history taking and complete clinical examination were done for all patients.
A blood sample was withdrawn for CBC, AST, ALT, albumin, bilirubin, prothrombin activity (PT%) and alpha fetoprotein.
Diagnosis was done clinically, by abdominal ultrasonography and by assessing viral markers (HBsAg, HBsAb, HBcAb and
qualitative PCR for HBV-DNA). HCC lesions were further confirmed by triphasic CT of the liver and AFP. Results: Out of
the 100 examined chronic HCV patients, only 16 patients (16%) had OBI. Dually infected patients (OBI/HCV) had
significantly lower platelet count and PT% than HCV monoinfected patients (P=0.001 and 0.03 respectively). HCC were
significantly more common in OBI/HCV dually infected (31%) than HCV monoinfected patients (7%) (P=0.01). Dually
infected patients (OBI/HCV) had significantly higher serum transaminases (AST, ALT) than HCV monoinfected patients
(P=0.01 and 0.03 respectively). The mean value of AST/platelet ratio is significantly higher among OBI/HCV dual infection
than HCV monoinfection (P=0.03). Out of the 100 examined chronic HCV patients, only 11 patients (11%) had HCC.
Presence of OBI was significantly more common in HCV patients with HCC (45%) than in HCV patients without HCC
(12%) (P=0.01). All chronic HCV patients with HCC had shrunken liver (100%) which was significantly more common than
in HCV patients without HCC (58%) (P=0.0001). On doing multiple logistic regression analysis of risk factors of HCC in our
patients, we found that OBI and presence of shrunken liver are independent risk factors of HCC (P=0.04 and 0.03
respectively). Conclusion, occult HBV infection may influence the outcome of HCV infection leading to more hepatic
fibrosis and development of HCC. The persistent HBV infection may have a critical role in the development of HCC in
HBsAg-negative patients. So, occult HBV should be considered and evaluated by more sensitive PCR among HCV-infected
patients.
Introduction
Human hepatitis B virus (HBV) is a compact,
partially double-stranded, enveloped, deoxyribo-
nucleic acid (DNA) virus; member of the
Hepadnaviridae family. HBV infection is
worldwide spread and is considered a major
public health problem, with an estimation of 350
million people chronically infected. The HBV
replicates in the liver leading to hepatic
dysfunction. Persistent HBV infection is assoc-
iated with the development of chronic liver
disease, including cirrhosis and hepatocellular
carcinoma (HCC) (1). Occult hepatitis B virus
infection (OBI) is one of the most challenging
topics in the field of viral hepatitis with its
virological and clinical relevance being debated
for more than 30 years. Initially described in the
late 1970s, this form of hepatitis B infection has
now been further characterized. In particular, in
the last 10 years the application of highly
sensitive molecular biology techniques has
resulted in the elucidation of its virological
features and possible clinical implications (2).
Occult hepatitis B virus infection is characterized
by the persistence of HBV DNA in the liver and
serum of individuals negative for HBV-surface-
antigen (HBsAg). Recent data demonstrated that
occult HBV may exist in the hepatocytes as a
free genome, its molecular basis being related to
the long-term persistence in the hepatocyte
nuclei of the viral covalently-closed-circular
DNA (HBVcccDNA), a replicative intermediate
that serves as template for gene transcription
(3). On the basis of the HBV antibody profile,
OBI may be distinguished as: seropositive-OBI
(anti-HBc and / or anti-HBs positive) or
seronegative-OBI (anti-HBc and anti-HBs
negative). In seropositive-OBI subjects, serum
HBsAg may become negative either following
the resolution of acute hepatitis B (thus, after a
few months of HBsAg carriage) or after years of
chronic HBsAg positive infection (4). The
seronegative-OBI cases might have either
progressively lost the hepatitis B specific
antibodies or theoretically, the individual may
have been hepatitis B specific antibody negative
from the beginning of the infection (5). There is a
fairly general agreement in considering HCV
infected patients as the category of individuals
with the highest prevalence of occult HBV (6).
Occult HBV infection may have a significant
impact in several clinical contexts, since it
might favor the progression of liver fibrosis and
the development of hepatocellular carcinoma in
patients with coexisting additional causes of
liver damage, such as chronic hepatitis C virus
(HCV) infection (7). Moreover, occult HBV may
acutely reactivate when an immunosuppressive
status occurs, and it may be transmitted in the
case of blood transfusion and organ transp-
lantation, causing classic forms of hepatitis B in
newly infected individuals (3). Mainly, carriers
of occult infection may be a source of HBV
transmission in the event of orthotopic liver
transplantation as an obvious consequence of
the fact that the hepatocytes are the site of the
virus reservoir (8). The aim of the present work
is to study the prevalence of occult hepatitis B
among HCV-positive Egyptian patients and its
impact on HCC development.
Patients and method
The study included 100 chronic HCV positive
patients (previously diagnosed by PCR for
HCV-RNA) selected from internal medicine
department in Menofya university hospital.
They were 57 males and 43 females ranged
between 41-77 years old. All patients gave their
written informed consent before participating in
the study. Exclusion criteria included, HBsAg
positive patients, patients with concomitant
causes of chronic liver diseases and history of
alcohol consumption and the use of potentially
hepatotoxic drugs. Full history taking and
complete clinical examination were done for all
patients. A blood sample was withdrawn by
sterile venipuncture and divided into three parts:
EDTA was added to the first sample which was
used for complete blood count (in cell counter,
Pentra 80,France) .The second sample was put
in plain vacutainer tube which was left to clot at
37ºC, centrifuged in a plain container. Serum
was used to estimate AST, ALT, albumin,
bilirubin (on Synchron CX5 autoanalyser).
Third sample with sodium citrate was used to
estimate prothrombin activity. Diagnosis was
done clinically, by abdominal ultrasonography
(liver and spleen status and degree of ascites)
and by assessing viral markers (HBsAg,
HBsAb, HBcAb and qualitative PCR for HBV-
DNA). HCC is further confirmed by triphasic
CT of the liver and AFP.
Statistical analysis
Data were processed and analyzed using a
computer based program (SPSS software
version 10). The results were expressed as mean
and standard deviation. For comparison of two
means, the paired Student t-test was used for
normally distributed variables and Mann- Whit-
ney test (U-test) for not normally distributed
variables. Fisher Exact analysis was also used to
compare proportions between groups. Multiple
logistic regression analysis was used to detect
the independent risk factors of HCC. A P-value
<0.05 was considered significant.
Results
The study population consisted of 100 chronic
HCV positive patients (previously diagnosed by
PCR for HCV-RNA). They were 54 males and
46 females ranged between 41-77 years old. Out
of the 100 examined chronic HCV patients, only
16 patients (16%) had OBI. Comparison
between OBI/HCV dually infected and HCV
monoinfected patients (table 1) showed that
there was no significant difference with regard
to age, gender, history of upper GIT bleeding,
history of encephalopathy, size of the spleen and
the liver, presence of ascites, Hb level, WBCs,
blood, serum albumin, serum bilirubin, Child-
Pugh score and AFP level (P>0.05). Dually
infected patients (OBI/HCV) had significantly
lower platelet count and PT% than HCV
monoinfected patients (P=0.001 and 0.03
respectively). HCC were significantly more
common in OBI/HCV dually infected (31%)
than HCV monoinfected patients (7%) (P=0.01).
Dually infected patients (OBI/HCV) had
significantly higher serum transaminases (AST,
ALT) than HCV monoinfected patients (P=0.01
and 0.03 respectively). The mean value of
AST/platelet ratio is significantly higher among
OBI/HCV dual infection than HCV mono-
infection (P=0.03). Out of the 100 examined
chronic HCV patients, only 11 patients (11%)
had HCC. Comparison between HCV patients
with and without HCC (table 2) showed that
there was no significant difference with regard
to gender, presence of ascites, Hb level, WBCs,
serum albumin and serum bilirubin (P>0.05).
Chronic HCV patients with HCC are
significantly older than HCV patients without
HCC (P=0.02). Presence of OBI was
significantly more common in HCV patients
with HCC (45%) than in HCV patients without
HCC (12%) (P=0.01). All chronic HCV
patients with HCC had shrunken liver (100%)
which was significantly more common than in
HCV patients without HCC (58%) (P=0.0001).
Chronic HCV patients with HCC had signi-
ficantly larger splenic size than HCV patients
without HCC (P=0.0001). All chronic HCV
patients with HCC had history of hepatic
encephalopathy and upper GIT bleeding (100%)
which was significantly more common than in
HCV patients without HCC (52% and 49%
respectively) (P=0.002 and 0.0001 respectively).
Chronic HCV patients with HCC had
significantly lower platelet count than HCV
patients without HCC (P=0.01). Chronic HCV
patients with HCC had significantly higher
serum transaminases (AST, ALT) than HCV
patients without HCC (P=0.003 and 0.002
respectively). Chronic HCV patients with HCC
had significantly higher Child-Pugh score and
lower PT% than patients without HCC (P=0.03
for both). On doing multiple logistic regression
analysis of risk factors of HCC in our patients
(table 3), we found that Occult HBV and the
presence of shrunken liver size are independent
risk factors of HCC (P=0.04, 0.03 and 0.03
respectively)
Table 1. Comparison between (occult HBV/HCV dual infection) and (HCV monoinfection) (data expressed as mean±SD):
P-value HCV monoinfection (n=84) OBI/HCV dual infection (n=16)
0.6 52.5±7.9 51.5±8.9 Age (years)
0.4 55% (n=46) 69% (n=11) Gender (male %)
0.3 52% (n=44) 69% (n=11) GIT bleeding (%)
0.2 54% (n=45) 75% (n=12) Encephalopathy (%)
1 63%(n=53) 63%(n=10) Shrunken liver (%)
0.8 14.4±2 14.6±2 Spleen size (cm)
0.7 90%(n=76) 94%(n=15) Ascites (%)
0.01* 7%(n=6) 31%(n=5) HCC (%)
0.9 10.3±1.2 10.1±1.3 Hemoglobin (gm/dl)
0.9 6.91±2.45 7.01±2.69 WBCs (×103)
0.001* 80.2±17.6 65.9±10. 6 Platelet count (×103)
0.01* 58±19 82±36 AST (U/L)
0.03* 55±16 66±20 ALT (U/L)
0.8 2.65±0.45 2.66±0.47 Serum albumin(gm/dl)
0.9 2.5±0.9 2.5±0.9 Total bilirubin(mg/dl)
0.9 1.5±0.7 1.6±0.8 Direct bilirubin(mg/dl
0.03* 49.3±10.9 41.4±7.3 PT (%)
0.03* 1.64±2.21 3.61±5.59 AST/platelet ratio
0.3 10±1.8 10.6±2.3 Child-Pugh score (points)
0.2 30.3±77.8 88.4±166.5 AFP (ng/ml)
*=Significant, GIT=gastrointestinal, PT%=Prothrombin activity, WBCs=White blood count,
AFP=Alfa fetoprotein
Table 2. Comparison between HCV patients with and without HCC (data expressed as mean±SD):
P-value HCV patients without HCC
(n=89)
HCV patients with HCC
(n=11)
0.02* 51.6±7.6 57.4±9.4 Age (years)
1 57% (n=51) 56% (n=6) Gender (male %)
0.002* 52% (n=46) 100% (n=11) Encephalopathy (%)
0.0001* 58%(n=52) 100%(n=11) Shrunken liver (%)
0.0001* 14.2±1.9 16.5±1.3 Spleen size (cm)
1 88%(n=83) 100%(n=11) Ascites (%)
0.0001* 49%(n=44) 100%(n=11) GIT bleeding (%)
0.01* 12%(n=11) 45%(n=5) Occult HBV (%)
0.2 10.2±1.3 9.8±1.5 Hemoglobin (gm/dl)
0.2 7.02±2.4 6.14±2.93 WBCs (×103)
0.01* 79.8±17.3 66.8±15. 6 Platelet count (×103)
0.003* 59.2±21.5 87±30.4 AST (U/L)
0.002* 54.7±16.9 71.9±15.1 ALT (U/L)
0.1 2.68±0.45 2.46±0.45 Serum albumin(gm/dl)
0.1 2.39±0.84 2.87±1.1 Total bilirubin(mg/dl)
0.1 1.48±0.7 2±1 Direct bilirubin(mg/dl
0.03* 48.7±10.5 40.7±7.2 PT (%)
0.03* 9.9±1.7 11.5±2.2 Child-Pugh score (points)
0.0001* 13.4±11.2 251.5±199.4 AFP (ng/ml)
AFP=Alfa fetoprotein, *=Significant, n=number, GIT=gastrointestinal,
PT%=Prothrombin activity, WBCs=White blood count
Table3. Multivariate regression analysis for risk factors of HCC in HCV+ve patients
Risk factors P-value R
Age 0.3 0.001
Shrunken liver 0.03* 0.33
Splenic size 0.5 0.001
Occult HBV 0.04* 0.32
AST 0.5 0.001
ALT 0.9 0.001
PT% 0.3 0.001
Child-Pugh score 0.8 0.001
AFP=Alfa fetoprotein, PT%=Prothrombin activity, *=Significant, n=number
Discussion
Occult HBV infection is characterized by
positivity for HBV DNA in HBsAg-negative
patients with or without serological markers of
previous HBV infection (6). The prevalence of
occult HBV in different studies has been
reported between zero and 52.3% among
patients with diverse liver disease due to HCV
infection (9). Occult HBV infection has been
commonly reported among immunocompromised
patients and in patients undergoing anti-cancer
chemotherapy (10). Also, occult HBV prevalence
was significantly high among patients under
hemodialysis (11). In Egypt, occult HBV
infection is 1.26% in the blood donors (12).
Occult HBV infection may occur after complete
clinical recovery from acute self-limited
hepatitis so; HBsAg seroclearance does not
necessarily imply HBV eradication (13).
Therefore in endemic areas, the anti-HBc IgG
and anti-HBs as well as HBsAg were not
sufficient markers to exclude HBV-DNA
carriers (14) The frequency of occult HBV
infection may differ geographically, depending
on HBV prevalence. It is ranged from 2-16%
among general population in different countries (15). Reported occult HBV infection frequencies
have been as high as 70-90% of anti-HBc-
positive individuals in areas of high prevalence
but as low as 5-20% in areas of low prevalence (16). It is known that occult HBV infection is
frequent in those with chronic hepatitis C. This
is probably because the route of transmission of
hepatitis B and C is similar (17). In present study,
we found that 16 out of 100 patients (16 %)
positive for HBV-DNA by qualitative PCR. Out
of those 16 patients, there were 12 patients
(75%) were positive for HBcAb and 4 patients
(4%) were negative for HBcAb. The prevalence
of occult HBV infection did not differ with age
or sex. Overall, the prevalence of occult HBV
among chronic HCV patients was 16%. This
appears near to the rate reported in a study done
to detect Occult hepatitis B virus infection in
Lebanese patients with chronic hepatitis C liver
disease (16.3%). Although Lebanon is an area of
low endemicity for both HBV and HCV, occult
HBV infection is common in HCV-infected
patients (18). In contrast, other studies reported a
low prevalence occult hepatitis B infection in
chronic HCV patients. In study done by Emara
et al., (19) in Egyptian chronic HCV patients on
Pegylated interferon/ribavirin therapy, the
prevalence of occult hepatitis B infection was
3.9%. Also in recent study in France, Levast et
al., (20) studied HBV-DNA in 140 sera and 113
liver biopsies of HCV positive/HBsAg negative
patients, the results showed that 4.4% (5/113)
prevalence of occult hepatitis B was recorded in
liver samples and in none of the sera. On the
other hand, other studies reported higher
prevalence of occult hepatitis B infection in
chronic HCV patients. The prevalence of occult
HBV among chronic HCV patients was 19.4%
in Iran (21), 28% in USA (22), 24% In Brazil (23)
and 37.7% In Japan (24). The discrepancy in the
reported prevalence of HBV DNA in HBsAg
negative chronic hepatitis C patients might be
due to differences in the sensitivity of the
methods used for detection of viral genome,
different quantity of HBV viremia, geographical
variation in prevalence of HBV infection and
severity of liver disease (9). Occult HBV is more
common in cirrhotics than in patients with
chronic hepatitis. Moreover, a high prevalence
of OBI (32%) was detected in cryptogenic liver
cirrhosis. This suggests that occult HBV
infection alone may cause pathological disorders (25). Occult HBV may contribute to liver
inflammation through episodes of increased
viral replication, increased immune activity and
subsequent liver injury (26). In chronic HCV
infection, the presence of Occult HBV has been
associated with liver enzymes flare (26),
increased severity of liver disease towards
advanced fibrosis and cirrhosis and poor
response to standard interferon (27). In contrast,
in study, done by Emara et al., (19) in Egyptian
chronic HCV patients on Pegylated interferon
/ribavirin therapy, OBI/HCV dual infected
patients had less hepatic fibrosis than HCV
monoinfected patients and tend to affect
younger age patients. Also Silva et al., (28)
reported that occult HBV was not associated
with more severe grades of inflammation, liver
fibrosis or cirrhosis development. In the present
study, platelet count is significantly lower
among occult HBV/HCV dual infection than
HCV monoinfection which agrees with
Matsouka et al., (29) and Branco et al., (30). In our
study, serum transaminases (ALT and AST)
were significantly higher among occult HBV/
HCV dual infection than HCV monoinfection.
Our results agree with Shavakhi et al., (21) and
Kannangai et al., (26). Moreover, Selim et al., (31)
who studied the role of occult HBV infection in
chronic HCV patients with flare of liver
enzymes. It reported that in patients with normal
or slightly high ALT, HBV DNA was detected
in 13.3% patients, while in those with ALT
flare; HBV DNA was detected in 63.3%
patients. Therefore, presence of occult hepatitis
B, with its added deleterious effect, must always
be considered in chronic hepatitis C patients
especially those with flare in liver enzymes (31).
In contrast, Branco et al., (30) reported that there
was no significant difference between occult
HBV/ HCV dual infection and HCV
monoinfection regarding serum AST and ALT
levels. Additionally, it has been reported that
liver cirrhosis in chronic hepatitis C patients is
more common in those with occult HBV
infection and that their serum ALT levels and
histological activity are high (32). This suggests
the possibility that occult HBV infection is
synergistic with chronic hepatitis C in terms of
development of liver disease. On the other hand,
some studies have reported no difference in
serum ALT levels, histological inflammatory
activity, or degree of fibrosis between patients
with chronic hepatitis C accompanied by occult
HBV infection and those infected with HCV
alone (33). Prothrombin activity was significantly
lower in occult HBV/HCV dual infection than in
HCV monoinfection in the present study.
Similar results were observed by Branco et al., (30). AST/platelets ratio index (APRI) is a
noninvasive marker that has satisfactory
sensitivity and specificity together with a high
predictive value and it can be useful in assessing
hepatic structural changes (34). APRI is
calculated by formula of (serum AST/upper
normal of AST)/platelets x 100. APRI has two
cut-off values, a lower one is 0.5, and a higher
one is 1.5. If the APRI score is less than or equal
to 0.5, there is no fibrosis or just a little. If the
APRI score is 1.5 or above, there is probably
cirrhosis. APRI scores between 0.5 and 1.5 are
related to progressive fibrosis stages, like
Metavir F1-to-F4 (35). In our study, AST/
platelets ratio was significantly higher among
occult HBV/HCV dual infection than HCV
monoinfection. An explanation to increased
APRI among occult HBV/HCV dual infection
that co-infection leads to more progression of
liver fibrosis which may reduce AST clearance,
leading to increased serum levels, in addition,
liver disease may be associated with
mitochondrial injury, resulting in further AST
release from the hepatocytes (36). The platelet
count decreases, in inverse proportion to
progressive liver fibrosis, due to worsening of
portal hypertension with consequent increased
platelet sequestration and destruction in an
enlarging spleen (37). Hepatocellular carcinoma
is one of the most common malignant tumors
worldwide ranging between 3% and 9%
annually (38). In Egypt, HCC reports to account
for about 4.7% of chronic liver disease patients (39). HBV and HCV infections are strongly
associated with liver cirrhosis and HCC. The
occult HBV infection has frequently been
identified in patients with chronic HCV
infection, and in such patients, this occult
infection may be associated with more severe
liver damage and even the development of HCC (40). In present study, 31% of patients with dual
infection OBI/HCV have HCC and only 7% of
HCV monoinfection have HCC. Occult HBV is
detected in 45% (5/11) of patients with HCC
and it is an independent risk factor of HCC.
There were high prevalence of HCC among our
patients with occult HBV/HCV dual infection.
Similar results were reported by Squadrito et al., (41) and Obika et al., (42). Therefore, the
evaluation of HBV genomes in chronic hepatitis
patients appears to be a powerful tool for the
identification of individuals at higher risk of
HCC development. Moreover, it has been
reported that in patients with primary liver
cancer caused by HCV infection, the anti-HBc-
positive rate was 69.6% (43). Also, Hassan et al., (44) showed that prevalence of serum HBV-DNA
was 22.5% and prevalence of intrahepatic HBV-
DNA was 62.5% among HCC patients. This
suggests that if occult HBV infection accom-
panies chronic hepatitis C infection, the risk of
liver cancer may increase. These data confirm
reports that most HBsAg- and anti-HCV-
negative primary liver cancer patients are anti-
HBc-positive and that intrahepatic HBV DNA is
detected in most of these individuals. (33). There
was an elevated risk in HCV patients because
this silent infection can affect the progression
and HCC development (45). Occult HBV has
associated with more advanced fibrosis/cirrhosis (46). Our study shows that all HCC patients had
cirrhosis and shrunken liver is an independent
risk factor of HCC. Similar results were
observed in previous studies (47,48). In addition,
occult HBV infection may favor neoplastic
transformation in HCV-infected patients
through its contribution to cirrhosis. Many
epidemiologic and molecular studies indicate
that persistent HBV infection may have a
critical role in the development of HCC in
HBsAg-negative patients (49). The reason for the
increasing interest in occult HBV infection is
the increasing evidence of its clinical relevance.
Occult HBV infection is linked to chronic liver
diseases and development of hepatocellular
carcinoma (32). It will be necessary to perform
larger studies on the frequency of HBV occult
infection in chronic hepatitis C patients to
determine its effect on development of chronic
hepatitis C or primary liver cancers.
Conclusion
occult HBV infection may influence the
outcome of HCV infection leading to more
hepatic fibrosis and development of hepato-
cellular carcinoma and may have a strong
association with HCV in the carcinogenesis of
liver. The persistent HBV infection may have a
critical role in the development of HCC in
HBsAg-negative patients. So, occult HBV
should be considered and evaluated by more
sensitive PCR among HCV-infected patients.
Recommendation, we must search for occult
HBV in HCV+ve patients with HBs Ag –ve to
slow the progression of liver fibrosis and
decrease risk of HCC. Vaccination against HBV
is important in HCV+ve patients as well as in
general population.
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Original Article
Open Splenectomy for Hypersplenism Induced Thrombocytopenia in Egyptian
Patients with HCV Related Liver Cirrhosis
Mahmoud A. Hemidaa,Mohamed MShamseyab, Ahmed M. L. Bedewyca) Department of clinical and expermintal surgery,b)
Department of internal medicine,c) Department of Hematology.Medical Research Institute, Alexandria University, Egypt.
ABSTRACT
Egypt has the highest prevalence of antibodies to hepatitis C virus (HCV) in the world, estimated nationally at 14.7%. An
estimated 9.8% are chronically infected. Although, Pegylated-interferon (IFN) plus ribavirin remains the most effective
therapeutic regimen for patients with chronic hepatitis C infection, there are several limitations of this treatment because of its
side effects. Thrombocytopenia is a frequent side effect of antiviral therapy, and unfortunately many patients with HCV
related liver cirrhosis have a base line thrombocytopenia due to hypersplenism making them a poor candidate for interferon
therapy. A number of surgical procedures are available to manage the hypersplenism related thrombocytopenia. Splenectomy
is one of the oldest procedures used for this purpose however; the procedure may be hazardous in patients with poor liver
function. TheAimof this work isto evaluate the safety and efficacy of open splenectomy in the management of hypersplenism
induced thrombocytopenia in selected patients with HCV- liver cirrhosis (patients of Child-Pugh score A), so that they can
receive Pegylated Interferon & ribavirin therapy. Methods: 20 patients with HCV-related liver cirrhosis (Child-Pugh A) &
hypersplenism-induced thrombocytopenia were subjected to open splenectomy with follow-up for 6 months to determineits
safety and efficacy in treating the hypersplenism induced thrombocytopenia. Results:20 patients with HCV related liver
cirrhosis of Child Pugh score A, all had hypersplenism induced thrombocytopenia were subjected to elective open
splenectomy. All patients included in the study had a significant improvement in platelets counts from a mean value of
62.8(10)3± 19.16/mm3 preoperatively to 215(10)3± 41.73 /mm3 after three months (P= 0.003 ) and to 293(10)3±
47.01/mm3after six months ( P = 0.007 ) there were no deaths, the mean hospital stay was 5.3 ±1.05 days, the blood loss was
accepted , the mean loss was 250 ±67.2ml ( range :100-850ml) and the complications were in the form of subphrenic
collection ( one patient) , basal atelectasis (two patients), high fever (three patients) ,and one patient had portal vein
thrombosis. Conclusion: open splenectomy is a safe and effective procedure for management of hypersplenism induced
thrombocytopenia in patients with HCV related liver cirrhosis especially those with good liver functions (Child Pugh score
A)
Introduction
HCV is currently the most significant public
health problem in Egypt, while it infects 2% of
the world's population. With the percentage
positive ranges from 0.01% in Scandinavia to
3% in North Africa, Egypt represents a single
unique Exception(1). In 1992, when HCV
antibody testing became widely available, the
prevalence of HCV in Egypt was reported to be
10.8% among first-time blood donors (2). Since
this discovery, many prevalence estimates of
HCV have been reported, mostly from rural
communities located in the northern Nile Delta.
Two more recent prospective studies estimating
the incidence rate of new HCV cases have also
been published, suggesting ongoing transmission
in their respective communities (3, 4). For more
than a decade, Egypt has been widely regarded
as having an epidemic, with the highest
recorded prevalence of HCV in the world (1).
The recently published Egyptian Demographic
Health Survey (EDHS) in 2009 was a national
probability sample of the resident Egyptian
population. This report estimated an overall
anti-HCV antibody prevalence of 14.7% (5). The
number of Egyptians estimated to be chronically
infected was 9.8%. This report provides a
precise national prevalence estimate and
includes additional data on patterns of HCV
prevalence by gender, age, urban versus rural,
and between different regions of the country.
Pegylated interferon (IFN) plus ribavirin
remains the most effective therapeutic regimen
for patients with chronic hepatitis C infection.
However, this treatment often leads to anemia,
neutropenia, and thrombocytopenia that prevent
safe application in patients with baseline pancy-
topenia, due to hypersplenism related to cirrh-
osis (6). The term hypersplenism was first introd-
uced by Chauffaud (7). It is characterized by
splenomegaly and a significant reduction in one
or more of the cellular elements of the blood in
the presence of normocellular or hyper-cellular
bone marrow. The incidence of hypersplenism is
variable. It has been described in between 11%
and 55% of patients with cirrhosis and portal
hypertension in different series(8). Thrombocyt-
openia is the most frequent manif-estation of
hypersplenism (9).Although recombinant erythro-
poietin and filgrastim granulo-cyte-colony
stimulating factor raise red and white cell
counts, little can be done for thrombocytopenia
before or during interferon treatment(6). A
number of therapies are available for treating
thrombocytopenia due to hyper-splenism inclu-
ding spleenectomy, partial spleen-ctomy, partial
splenic embolization, TIPS etc. Splenectomy is
the definitive treatment for hypersplenism.
How-ever, the operation may be hazardous in
patients with poor liver function(9).
Aim of the work
To evaluate the safety and efficacy of open
splenectomy in the management of hyper-
splenism induced thrombocytopenia in selected
group of patients with HCV-related liver
cirrhosis ( those with Child-Pugh score A), so
that they can receive Pegylated Interferon and
ribavirin therapy.
Patients & methods
From all patients with serologically proven
HCV attending the hepatology unit in Medical
Research Institute, only patients with the
following criteria were included in the study: -
Patients with chronic hepatitis C. - Patients with
Child Pough score A. - Patients with throm-
bocytopenia. - Liver biopsy stage F2 and F3. –
Negative antiplatelet antibody(assayed by direct
platelet suspension immunofluorescence test). In
the period from October 2009 to March 2011,
twenty patients were eligible for the study and
they were subjected to the following: - Detailed
history taking. - Clinical examination. Investi-
gations: Complete blood picture, blood urea,
serum creatinine and fasting blood glucose.
Liver profile: serum albumin, serum bilirubin,
serum transaminases, and prothrombin time and
activity. HBsAg, HCV antibodies ( 3 rd genera-
tion ELISA). - Quantitative HCV-RNA by PCR.
-Ultrasound abdomen. -U/S guided liver biopsy.
- UGIT endoscopy. - Anti-platelet antibodies
(assayed by direct platelet suspension immune-
fluorescence test). - Bone marrow trephine
biopsy. These patients were referred to general
surgery unit to perform open splenectomy.
Procedure
After informed written consent, polyvalent
peumococcal polysaccharide vaccine was admi-
nistered two weeks before surgery. Open spleen-
ectomy was performed through left paramedian
incision. After opening the lesser sac, the
splenic artery was identified and ligated in
continuity above the pancreas when possible.
The posterior attachments were divided and the
spleen was delivered then the short gastric
vessels were divided and the stomach retracted
to the right. Hilar dissection progressed. The
splenic artery and vein were divided and suture
ligated ,and the spleen removed. Left gastric
ligation was done only in patients with varices.
Haemostasis was done and rubber drain was
placed routinely which was removed before
discharge and sutures were removed on post –
operative day ten (POD 10). Platelets were
administered only after clamping the splenic
inflow. Doppler U/S was performed on two
weeks post-operative to detect portal vein
thrombosis. Data about blood & platelet trans-
fusion, duration of surgery, complications (intra-
& post-operative), & hospital stay were repor-
ted. Follow up of the patients at 3 & 6 months
was done.
Statistical analysis
Statistical analysis was performed using SPSS
version 17.0. Normality test was done for
quantitative variables. Normally distributed
variables were presented as the mean ±standard
deviation (SD), while qualitative variables were
presented as the number and percent. For
normally distributed quantitative variables the
independent t- test was done for pre- and post-
intervention comparison. A value of P< 0.05
was considered statistically significant.
Results
This study was conducted on 20 patients with
HCV - related liver cirrhosis and hypersplenism
induced thrombocytopenia .The age of the
patients ranged between 38-56 years with a
mean value 47.0 ± 5.40 years. As regards
gender, most of patients were males, 14
patients,(70%) and only six patients were
females (30%). (Table 1)
Table (1): Demographic data of the studied patients.
Patients
n=20
Age (years)
Range 38.0 – 56.0
Mean ± SD 47.0 ± 5.40
Sex
Male n (%) 14 (70.0 %)
Female n (%) 6(30.0 %)
All patients were positive to HCV-Ab testing,
but negative to HBsAg. Quantitative HCV-RNA
ranged between50,000-750,000 IU/ml with a
mean value 321,252 ± 267,659 IU/ml.Liver
cirrhosis and splenomegaly detected by U/S
were present in all patients. The longitudinal
diameter of the spleen ranged between 13-17cm
with a mean value 14.87 ± 1.71 cm. Portal vein
diameter was increased in 14 patients (70%). It
ranged between 11-15 mm with a mean value
13.33 ± 1.40 mm. All patients were of Child
Pough class A.The liver profile of patients is
shown in Table (2); ALT ranged between 35-50
u / l with a mean value 42.73± 7.20, AST ranged
between 39-60 u/l with a mean value 49.73 ±
6.71, serum albumin ranged between 3.3- 4.0
g/dl with a mean value of 3.8 ± 0.2 g/dl, serum
bilirubin ranged between 0.8- 1.5 mg/dl with a
mean value 1.2 ± 0.21 mg/dl, and INR ranged
between 1.1-1.5 with a mean value 1.27 ± 0.19.
Table (2): Liver profile of the studied patients.
Parameter
ALT (u/l)
Range 35-50
Mean ± SD 42.73 ± 7.20
AST (u/l)
Range 39-60
Mean ± SD 49.73 ± 6.71
Serum albumin (g/dl)
Range 3.3-4.0
Mean ± SD 3.8 ± 0.2
Serum bilirubin (mg/dl)
Range 0.8-1.5
Mean ± SD 1.2 ± 0.21
INR
Range 1.1-1.5
Mean ± SD 1.27 ± 0.19
As regards the hematological investigations of
studied patients, all patients had thrombocy-
topenia, the platelets counts ranged between 48×
(10)3-122×(10)3 / mm3 with a mean value 62.8×
(10)3± 19.16 / mm3, the hemoglobin levels
ranged between 10-12.5 g/dl with a mean
value10.83 ± 1.7 g/dl, and the leucocytic count
ranged between 2.8× (10)3–4.3× (10)3 /mm3
with a mean value 3.2 × (10)3 ± 1.1 /mm3,
(Table 3)
Table (3): Hematologicalinvestigations of studied patients.
Parameter Result
Hb (g/dl)
Range 10-12.5
Mean ± SD 10.83 ± 1.7
WBCs (cells/mm3)
Range 2.8×(10)3–4.3(10)3
Mean ± SD 3.2×(10)3 ± 1.1
Platelet count (cells/mm3)
Range 48×(10)3-122(10)3
Mean ± SD 62.8(10)3± 19.16
UGIT endoscopy was done for all patients to
detect esophgogastric varices. Esophageal
varices of F1 grade were detected in five
patients (25%); these varices had no risk signs
of bleeding. No gastric varices were detected in
any patient. Mild portal hypertensive gastro-
pathy was detected in two patients (10%).
Histopathological analysis of U/S guided liver
biopsy according to METAVAIR score revealed
that five patients (25%) had F2, while 15
patients (75%) had F3. The bone marrow biopsy
was hypercellular in 16 patients (80%) and
normocllular in four patients (20%) (Table 4)
Table (4): Results of UGIT endoscopy, liver biopsy, and bone marrow biopsy
Table (5) .shows the perioperative data, the
meanoperative time was 96.4±18.2 minutes
(range:75-130 minutes) and there were no
deaths. As regard the intraoperative complic-
ations, intraoperative bleeding occurred in one
case due to ooze from splenic bed and
controlled by pack which was removed after 48
hours. In another patient there were severe
adhesions between the spleen and the diaphragm
and during sharp dissection injury to the
diaphragm and diaphragmatic pleura occurred
with lung collapse, repair of the tear was done
and the lung was inflated by positive pressure
ventilation by the anesthetist and the air entery
was good by auscultation and post-operative
plain x ray showed normally inflated lung. The
mean blood loss in our study was 250±67.2ml
(range: 100- 850ml) and five patients were in
need for blood transfusion, while platelets were
given empirically to all patients after splenic
artery ligation. As regard the postoperative
complications, there was sub-diaphragmatic
collection in one patient (patient with packing),
guided aspiration was done and the patient
improved. Two patients developed basal atelec-
tasis and three patients developed high fever.
The mean postoperative hospital stay in our
study was5.3 ±1.05 days (range:3-12days).
Duplex study was done two weeks post-
operative, there was one case (5%) with partial
portal vein thrombosis, and this case passed
unnoticed clinically.
Table (5) Theperioperative data.
Estimated blood loss
Range
Mean± SD
1oo-850ml
250± 67.2ml
Blood transfusion
RBCs packs:
Range
Mean± SD
n= 5 patients
1-3 packs
1.2±0.96 packs
Operative time (minutes)
Range
Mean± SD
75-130 minutes
96.4±18.2
Intra-operative complications
No. ( %)
2 (10%)
Post-operative complications:
Sub- phrenic collection
Basal atelectasis
High fever
Portal vein thrombosis
1(5%)
2 (10)
3 (15%)
1 (5 %)
Hospital stay (days)
Range
Mean ± SD
3-12days
5.3 ±1.05
Mortality 0
Parameter Number of patients (%)
Esophageal varices
Grade I
Grade II
Grade III
Portal hypertensive gastropathy
5(25%)
-
-
2(10%)
Liver biopsy ( METAVAIR score)
F2
F3
5(25%)
15(75%)
Bone marrow biopsy
Hypercellular
Normocellular
16(80%)
4(20%)
CBC was done 3 and 6 months post-operative,
there was significant improvement in platelets
count in all patients. The count was raised from
a mean value of 62.8(10)3 /mm3preoperatively to
215× (10)3 /mm3 after three months (p=0.03)
and to 293× (10)3 /mm3 after six months ( p =
0.007 ) table (7)
Table (7) Hematological changes 3 and 6 months postoperative
Pre-operative 3 months post-operative 6months post-operative
Platelet count 62.8×(10)3±19.16 215×(10)3± 41.73
P= 0.003*
293×(10)3± 47.01
P=0.007*
WBC count 3.2×(10)3 ± 1.1 7.4×(10)3± 1.92
P= 0.04*
8.2×(10)3± 1.61
P= 0.02*
HB 10.83± 1.7 gm.
12.3± 0.91 gm.
P= 0.04*
12.8±0.84gm.
P= 0.01*
*= significant
Discussion
Thrombocytopenia is a common manifestation
of chronic hepatic disease, although the exact
mechanisms remain incompletely understood.
Portal hypertension from cirrhosis diverts the
flow of blood from the portal circulation toward
the enlarged spleen, resulting in hypersplenism
and platelet sequestration. In healthy patients,
45% of platelet destruction occurs in the splee
(10). Studies utilizing radiolabeled platelets in
patients with chronic liver disease demonstrate
an accelerated destruction of platelets by the
spleen (11). Thrombocytopenia carries a risk of
bleeding complications including hematuria,
hematemesis, melena, and intracranial hemor-
rhage. The risk of spontaneous bleeding varies
with platelet count and the individual patient’s
clinical risk factors for hemorrhage. Previous
reports have demonstrated a dramatic increase
in the frequency and severity of hemorrhage in
patients with platelet counts below20 × (10)3/ml
(12). Moreover thrombocytopenia prevents pati-
ents with hepatitis C virus from receiving
potentially curative antiviral therapy. So, num-
erous surgical procedures have been proposed to
correct cirrhosis-associated thrombocytopenia.
Early attempts focused on the diversion of portal
flow from the spleen through portocaval anast-
omoses. Although these interventions were eff-
ective in decreasing splenomegaly, they did not
correct thrombocytopenia in cirrhotic pati-ents
with hypersplenism(13). Other forms of portal
decompression such as transjugular intrahepati-
cportosystemic shunting (TIPS) have also been
unsuccessful (14). Selective shunting procedures
such as the distal splenorenal shunt have
demonstrated success in both resolving the
thrombocytopenia associated with cirrhosis as
well as reducing the incidence of variceal-
hemorrhage (8, 15). Partial splenic embolization
(PSE) has been developed hoping to be an
effective and less invasive alternative however
the procedure was found to be associated with
many complications, Sakai et al.(16) reported that
the most frequent complications of PSE were
abdominal pain (82.4%)and fever (94.1%). In
addition, severe complications including splenic
abscess were observed in 16% of the patients
who underwent PSE (17). Splenic abscess leading
to death was observed in 6%(16). N’Kontchouet
al (17)concluded that the indication for PSE
should bevery limited and the extent of necrosis
of the spleens hould be strictly controlled during
the PSE procedure. Splenectomy has been
performed for hypersplenism since the 1950s,
(18) and it has been shown to correct the
manifestations of hypersplenism in patients
with cirrhosis (15, 19). However the operation is
hazardous in patients with poor liver functions.
Recently laparoscopic splenectomy has been
used successfully by Kercher and colleagues in
patients with Child Pough score Ato reverse the
thrombocytopenia and allow continuation of
anti-HCV therapy (20). In this study we tried
open splenectomy to raise platelet counts in
patients with Child Pough score A (patients
with good liver functions) to enable anti-viral
therapy and fortunately those are patients who
are candidate for interferon therapy. All patients
included in the study had significant improve-
ement in the platelet counts after splenectomy,
the mean platelet count raised from 62.8
×(10)3±19.16/ml preoperatively to 215× (10)3 ±
41.73 / ml three months post operatively and to
293 ×(10)3±47.01/ ml-six months postoper-
atively. In our study there were no deaths, and
the mean blood loss was 250±6.7.2ml, blood
transfusion was needed only in five patients and
the mean transfusion requirement was 1.2 ± 0.96
packs of RBCs.The mean hospital stay was 5.3
± 1.05 days. Of primary concern, portal vein
thrombosis (PVT) is a major potential compli-
cation of spleenec-tomy and has been reported
in up to 8% to 10% of patients treated with open
surgery(21-23). in our study Portal vein throm-
bosis occurred in one patient (5%), and the
patient was clinically asymptomatic. Other
complications were in the form of sub phrenic
collection in one patient, fever in three patients
and basal atelectasis in two patients. Taking into
consideration that, all our patients were
discharged in good health and showed a100%
efficacy regarding the improvement in platelet
count, this in addition to the reasonable
operative time, hospital stay and the acceptable
blood loss of the operation,we can conclude that
open splenectomy offer a safe and effective
procedure for management of hypersplenism
induced thrombocytopenia especially in selected
group of patients with chronic hepatitis C
infection. (Patients with Child Pugh score A),
however the major limitations of our study are
its small size and relatively shorter duration of
follow up so a larger studies may be needed to
draw a firm conclusion regarding the wide
spread applicability of this technique.
References
1. Alter MJ. Epidemiology of hepatitis C virus infection.
World J Gastroenterol 2007; 13:2436–2441.
2. Kamel MA, et al. High HCV prevalence in Egyptian
blood donors. Lancet 1992; 340:427.
3. Mohamed MK, et al. Intrafamilial transmission of
hepatitis C in Egypt. Hepato-logy 2005; 42:683–687.
4. Saleh DA, et al. Incidence and risk factors for hepatitis
C infection in a cohort of women in rural Egypt. Trans R
Soc Trop Med Hyg 2008; 102:921–928.
5. El-Zanaty, Fatma and Ann Way. 2009. Egypt
Demographic and Health Survey 2008. Cairo, Egypt:
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International.
6. Hayashi PH, Mehia C, Joachim Reimers H, et al.
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744.
7. Chaufaud M. Apropos de la communication de M
Vaquez. Bulletins etMemoires de la SocieteMedicaledes
Hopitaux de Paris 1907; 24: 1201-1203.
8. El-Khishen MA, Henderson JM, MillikanWJ et al.
Splenectomy is contraindicated for throm-bocytopen-
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Obstetrics 1985; 160: 233-238.
9. McCormick AP, MurphyMK. Splenomegaly, hyper-
splenism and coagulation abnormalities in liver cirrhosis.
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Kinetics of 111In-labelled platelets in healthy subjects.
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11. Schmidt KG, Rasmussen JW, Bekker C, Madsen PE.
Kinetics and in vivo distribution of 111-In-labelled
autologous platelets in chronic hepatic disease:
Mechanisms of thrombocy-topenia. Scand J Haematol
1985;34:39–46.
12. Gaydos LA, Freireich EJ, Mantel N. The quantitative
relationbetween platelet count and hemorrhage in patients
with acuteleukemia. JAMA 1962;266:905–909.
13. Mutchnick MG, Lerner E, Conn HO. Effect of
portacavalanastomosis on hypersplenism. Dig Dis Sci
1980;25:929–938.
14. JabbourN,ZajkoA,Orons P, IrishW,FungJJ, Selby RR.
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15. Soper NJ, Rikkers LF. Effect of operations for
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partialsplenic embolization in cirrhotic patients. Dig Dis
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18. Lord JW Jr. The surgical management of secondary
hypersplenisms. Surgery 1951;29:407 –418.
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Shimabukuro R,Gotoh N, Ohta M, Sugimachi K. Effects
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in patients withesophageal varices. J Gastroenterol-
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Laparoscopicsplenectomy reverses throm-bocytopenia in
patients with hepatitis Ccirrhosis and portal hypertension.
J Gastrointest Surg. 2004;8:120–126.
21. Winslow ER, Brunt LM, Drebin JA, Soper NJ,
KlingensmithME. Portal vein thrombosis after
splenectomy. Am JSurg 2002;184:631–635; discussion
635–636.
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veinthrombosis following splenectomy. Br J Surg
2000;87:362–373.
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Sotto JJ.Portal vein thrombosis follo-wing splenectomy
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Original Article
Use Of Anti-Cyclic Citrullinated Peptide Antibodies to Distinguish Hepatitis C
Virus (HCV) – Associated Arthropathy from Concomitant Rheumatoid Arthritis In
Patients with Chronic HCV Infection
Khaled Mahmoud Mohiedeen and Akram Deghedy*Tropical medicine and clinical pathology departments*
Alexandria faculty of medicine
ABSTRACT
Differentiating those patients whose symptoms are an extrahepatic manifestation of HCV from patients who have
concomitant Rheumatoid arthritis (RA) is essential for appropriate management. Objectives: To investigate that Cyclic
Citrullinated Peptide Antibodies (CCP antibodies), in contrast to Rheumatoid factor (RF), might be a candidate biomarker for
concurrent Rheumatoid arthritis in chronic HCV patients. Methods: Fifty non arthritic patients with chronic viral hepatitis C
were included. Testing for autoantibodies was performed using ELISA kits for IgG anti-CCP, IgG-RF and IgM-RF. Results:
CCP antibodies were positive in only two patients (4%), whereas, RF was elevated in the serum of 60% of the patients. IgG-
RF was detected more frequently (56%), followed by IgM-RF (30%). There was no statistically significant correlation
between CCP antibody level and serum IgG-RF (R2 = 0.030), or IgM-RF (R2 = 0.016). Conclusion: Anti-CCP may be more
useful than RF for the diagnosis or literally the exclusion of Rheumatoid arthritis in patients with chronic HCV infection.
Introduction
Chronic HCV infection is associated with extra
hepatic immune mediated conditions inclu-ding
vacuities, glomerulonephritis, thyroiditis, and
sialoadenitis(1, 2). Arthralgias are common, and
oligo or polyarthritis have been reported. (3, 4)
Arthralgia and arthritis in patients with chronic
hepatitis C can mimic rheumatoid arth-ritis
(RA), and discrimination is really difficult
without observing the erosions. (5) Differen-
tiating those patients whose symptoms are an
extra hepatic manifestation of HCV from
patients who have concomitant RA is essential
for appropriate management. Patients with virus
induced symptoms require antiviral therapy;
while patients with RA benefit from disease
modifying anti rheumatic drugs. (4) Fifty to
seventy percent of patients with HCV infection
may have rheumatoid factor (RF). The increased
prevalence of RF in patients with HCV infection
diminishes the diagnostic specificity of serum
RF for rheumatoid arthritis (RA) in this group of
patients. Therefore, the presence of RF mostly
does not help in distinguishing between RA and
HCV-associated rheumatic symptoms. (6)
Antibodies to cyclic citrullinated peptide (anti-
CCP) are recent serological marker available for
the diagnosis of RA. It is tested by commercially
available ELISA kit that has comparable sensit-
ivity and is more specific than Rheumatoid
factor for the diagnosis of RA. The clinical
usefulness of anti- CCP in diagnosis of early
arthritis is established and these antibodies
represent an important addition to the diagnostic
armamentarium in RA. (7, 8)
Patients and Methods
Patients. Fifty patients with chronic hepatitis C
infection were included in this study after
obtaining their consent. Patients who satisfied
the inclusion/exclusion criteria were recruited in
this study and selected from patients attending
the outpatient clinic or admitted to the inpatient
ward of Tropical Medicine Department, Alex-
andria Main University Hospital. Detailed
history taking and thorough clinical examination
were done for all patients. Patients were inclu-
ded after confirmation that HCV is the
etiological agent of their chronic liver disease
and obtaining an evidence of persistent infection
by either liver biopsy or abnormal transami-
nases. The exclusion criteria included concomi-
tant hepatitis B infection, known RA or the
presence of a history or clinically evident
arthritis, or current use of antiviral therapy.
Laboratory method: Serum samples were tested
for anti-hepatitis C antibodies by commercial
ELISA testing and were confirmed by HCV
RNA polymerase chain reaction amplification.
Testing for autoantibodies was performed using
ELISA kits for IgG anti-CCP, IgG-RF and IgM-
RF. All tests were performed according to the
manufacturer’s recommendations. Prediluted
control and diluted patient sera are added to the
microwell plates coated with the antigen.
Unbound sample was washed away and an
enzyme labeled anti-human IgG or IgM, was
added to each well to detect IgG-RFor IgM-RF
respectively, or enzyme labeled anti-human IgG
for CCP antibodies detection. The results of
anti- CCP ELISA were considered negative in
samples with results < 25 U/mL and are defined
as positive in samples with results ≥25 U/mL.
For RF, patients were considered to be
seropositive if serum RF was > 6 IU for all
isotypes. Comparison of CCP antibody and RF
concentrations was done. The study protocol
was approved by the ethics committee.
Results
Fifty HCV patients were included in the study.
The characteristics of the patients are presented
in Table 1. Subjects had a mean age of 45 years;
there were 34 men and 16 women. No patients
were receiving antiviral therapy. Sixty six
percent of patients were treatment-naive and
34% were treatment failures. RF was elevated
in the serum of 60% of the patients. IgG-RF
was detected more frequently (56%), followed
by IgM-RF (30%). CCP antibodies were
positive in only two patients (4%) (Figure.1).
Compared to CCP antibodies seropositivity,
there was a statistically significant increase in
the number of patients with elevations of IgG,
and IgM RF. Correlation of serum RF with
serum anti-CCP levels was examined by simple
regression. In this group of patients, there was
no statistically significant association between
CCP antibody level and serum IgG-RF (R2 =
0.306), IgM-RF (R2 = 0.016) (Figures 2,3).
Table.1 Patients demographic characteristics
Age Range: 39 - 54
Mean: 45 y
Sex Males: 34
Females: 16
Treatment
history
naive: 66%
Treatment failure: 34%
Figure 1 Prevalence of autoantibodies in HCV patients (% seropositivity)
0
10
20
30
40
50
60
IgG RF IgM RF ACCP
Figure 2: Correlation between ACCP and IgG RF
Figure 3: Correlation between ACCP and IgM RF
Discussion
Rheumatoid arthritis (RA) and hepatitis C virus
(HCV) infection are 2 distinct chronic diseases
that share several intriguing similarities. Each
illness is associated with immune system acti-
vation, autoantibody and cryoglobulin produ-
ction, secondary vasculitis and Sjögren’s
syndrome, and an increased risk of B cell lym-
phoma (9, 10) Although it is not always possible
to identify a specific pattern of HCV-related
arthropathy, two different clinical subsets of
arthritis have mainly been described; a mono
articular,oligoarticular intermittent arthritis aff-
ecting large and medium-sized joints and almost
invariably associated with the presence of mixed
cryoglobulinaemia and a polyarticular symm-
etrical arthritis closely resembling RA with met-
acarpophalangeal, proximal interphalangeal and
wrist joints involvement.(3,11) Arthritis associated
with mixed cryoglobulins or secondary to
immune complex deposition related to the
chronic viral infection might respond to
interferon- α. (4) However, induction or exace-
rbation of arthritis with interferon therapy in
some HCV patients has been noted. (12) These
patients might respond better to therapy directed
specifically to RA. Immunosuppressants are
generally avoided in chronic HCV infection due
to potential exacerbation of viral replication or
direct hepatotoxicity. (13) In this study, RF was
elevated in the serum of 60% of chronic HCV
patients. IgG-RF was detected more frequently
(56%), followed by IgM-RF (30%). This is in
accordance with other studies which reported
even higher percentages for the positivity of RF
in similar cohorts of patients.(14,15) This high rate
of RF seropositivity in patients with chronic
HCV infection presents diagnostic and thera-
peutic difficulties for the clinician. Recently,
Anti-cyclic citrullinated peptide (anti-CCP)
antibody testing was found to be particularly
useful in the diagnosis of rheumatoid arthritis,
with high specificity, presence early in the
disease process, and ability to identify patients
who are likely to have severe disease and
irreversible damage. (16) Unlike RF, CCP
antibody levels were not elevated in nonarthritic
patients with chronic hepatitis C included in this
study. In the two patients with CCP antibody
above the upper limit of normal, the level was in
the mild positive range. This is in agreement
with the results reported by Lienesch et al (17)
who detected a marginally elevated CCP
antibody in a single patient (2%). They also did
not find a correlation between anti CCP and RF
positivity which was also reported in the present
study. In a study on nonarthritic patients with
HCV, Orge et al(6) have found that, the
sensitivity, specificity and positive predictive
value of the anti-CCP test was superior to the
RF test and concluded that; Cyclic citrullinated
peptide antibody is a more useful test than RF
among patients with chronic HCV infection
without arthritis. Moreover, Ezzat et al (18)
reported that Anti-CCP antibodies were positive
in 4.5% in patients with HCV and poly-
arthropathy and in 83.3% of patients with RA.
RF was positive in 81.1% of HCV patients with
polyarthropathy and in 90% of RA patients.
They concluded that, anti-CCP antibodies are
reliable laboratory markers to differentiate
between RA and HCV-related polyarthropathy.
This observation may let us conclude that most
of the cases of chronic HCV associated poly-
arthropathy with positive RF testing are not
really due to Rheumatoid arthritis. Lienesch et
al explained that the HCV associated B cell
activity responsible for RF production does not
result in an increased production of antibodies
against CCP. Considering these data, a possible
interpretation of the presence of CCP antibodies
in HCV patients with arthritis could be that the
synovitis is secondary to concomitant RA.
Supporting this hypothesis is the lack of CCP
antibody production in other conditions ass-
ociated with inflammatory arthropathy.(18)
Similarly, measurement of anti-CCP antibodies
was also reported to be better than RF detection
to discriminate HBV-associated arthropathy
from concomitant RA in patients with chronic
HBV infection (19). The present study suggest
that, CCP antibodies unlike RF are not produced
in response to HCV infection, and therefore
Anti-CCP may be more useful than RF for the
diagnosis or literally the exclusion of Rheum-
atoid arthritis in this group of patients.
References
1. Ramos-Casals M, Trejo O, Garcia-Carrasco M, Font J.
Therapeutic management of extra-hepatic manifestations
in patients with chronic. hepatitis C virus infection.
Rheumatology 2003; 42: 818-28.
2. Pawlotsky JM, Roudot-Thoraval F, Simm-onds P, et al.
Extrahepatic immunologic manif-estations in chronic
hepatitis C and hepatitis C virus serotypes. Ann Intern
Med 1995;122:169-73
3. Lovy MR, Starkebaum G, Uberoi S. Hepatitis C
infection presenting with rheumatic manife-stations: a
mimic of rheumatoid arthritis. J Rhe-umatol 1996; 23:
979-83.
4. Zuckerman E, Keren D, Rozenbaum M, et al. Hepatitis
C virus related arthritis: characteristics and response to
therapy with interferon alpha. Clin Exp Rheumatol 2000;
18: 579-84.
5. Palazzi C, D'Angelo S, Olivieri I. Hepatitis C virus-
related arthritis. Autoimmunity Reviews 2008; 8: 48-51.
6. Örge J, Çefle A, Yazıcı A, Gürel-Polat N, Hulagu
S. The positivity of rheumatoid factor and anti-cyclic
citrullinated peptide antibody in nonarthritic patients with
chronic hepatitis c infection. Rheumatol Int 2010;30:485-
488
7. Jansen LM, van Schaardenburg D, van der Horst-
Bruinsma I, van der Stadt R, De Koning M, Dijkmans
BA. The predictive value of anti-cyclic citrullinated
peptide antibodies in early arthritis. J Rheumatol 2003;
30:1691-5
8. Khosla P, Shankar S, Duggal L. Anti CCP antibodies in
Rheumatoid arthritis. J Indian Rheumatol Assoc 2004 : 12
: 143 -46
9. Alter MJ. Hepatitis C virus infection in the United
States. J Hepatol 1999; 31 Suppl 1:88-91.
10. Lawrence RC, Hochberg MC, Kelsey JL, et al.
Estimates of the prevalence of selected arthritic and
musculoskeletal diseases in the United States. J
Rheumatol 1989; 16: 427-41.
11. Olivieri I., Palazzi C., Padula A. Hepatitis C virus and
arthritis. Rheum Dis Clin North Am 2003;29: 111–122
12. Nesher G, Ruchiemer R Alpha - interferon - induced
arthritis: clinical presentation, treatme-nt, and prevention.
Semin Arthritis Rheum 1998;27:360–5
13. Wener MH, Johnson RJ, Sasso EH, Gretch
DR.Hepatitis C virus and rheumatic disease. J
Rheumatol1996; 23: 953–9.
14. Clifford BD, Donahue D, Smith L, et al. High
prevalence of serological markers of autoi-mmunity in
patients with chronic hepatitis C. Hepatology
1995;21:613-9.
15. Nocente R, Ceccanti M, Bertazzoni G, Cammarota G,
Silveri NG, Gasbarrini G. HCV infection and extrahepatic
manifestations. Hep-atogastroenterology 2003; 50: 1149-
54.
16. Niewold TB, Harrison MJ, Paget SA Anti-CCP
antibody testing as a diagnostic and prog-nostic tool in
rheumatoid arthritis. QJM. 2007; 100 (4):193-201.
17. Lienesch D, Morris R, Metzger A, Debuys P,
Sherman K. Absence of Cyclic Citrullinated Peptide
Antibody in Nonarthritic Patients with Chronic Hepatitis
C Infection. J Rheumatol 2005;32:489–93
18. Niewold TB, Harrison MJ, Paget SA. Anti-CCP
antibody testing as a diagnostic and prognostic tool in
rheumatoid arthritis. QJM. 2007; 100(4):193-201.
19. Lim MK, Sheen DH, Lee YJ, Mun YR, Park M, Shim
SC. Anti-cyclic citrullinated peptide antibodies
distinguish hepatitis B virus (HBV)-associated
arthropathy from concomitant rheum-atoid arthritis in
patients with chronic HBV infection. J Rheumatol 2009;
36(4):712-6.
Original Article
Prevalence of Non-Organ-Specific Autoantibodies and Its Effect
on response to Antiviral Therapy in Patients with Chronic Hepatitis C Virus
Genotype 4
Mohamed Abd El-Maksoud1, Hatem Elalfy1, Maha Ragab Habeeb2, Abd-Elmohsen E. El-desoky2, Ziyad M. Tawhid3,
Basem S. Eldeek4
ABSTRACT
Immunological disorders have been frequently described in the course of hepatitis C virus (HCV)–related chronic hepatitis.
Our aim was to determine the prevalence of non-organ-specific autoantibodies (NOSAs) and to evaluate its impact on the
response to combined antiviral therapy in patients with chronic HCV genotype-4. Methods: A total of 134 adult patients with
chronic HCV genotype-4 were studied. Serum Antinuclear antibody (ANA), anti–smooth muscle antibody (SMA), and anti
liver/kidney microsomal antibody type 1 (LKM1) were detected by ELISA (Anova, Germany). 109 patients were treated
naive and received combined antiviral therapy (pegylated interferon–ribavirin). The presence of these autoantibodies was
related to patient’s characteristics and to the outcome of antiviral therapy. Result : Thirty-six (26.9%) patients were positive
for at least one autoantibody. Various autoantibodies were presented as follows: ANA in 29 (21.6%) patients, SMA in 9
(6.7%) and anti-LKM-1 in 2 (1.5%). In two patients, both ANA and anti-SMA were positive, and in other two cases both
ANA anti-LKM-1 were positive. Female patients had a higher prevalence of positive autoantibodies (P=0.005). Chronic
hepatitis C (CHC) patients with positive autoantibodies had higher serum ALT, AST and GGT levels. The rate of sustained
virological response to combined antiviral therapy was similar between autoantibody-positive and -negative groups (46.9%
vs. 53.2%). Conclusion: Autoantibodies can be induced in the course of CHC. Autoantibody-positive CHC patients are older
and have higher disease activity and severity. However, the presence of these autoantibodies did not influence the response to
combined antiviral therapy.
Introduction
Hepatitis C virus (HCV) is among the leading
causes of chronic liver disease worldwide and
affects approximately 170 million people (1).
Egypt has the highest prevalence of HCV infe-
ction in the world, ranging from 6% to 28%
with an average of approximately 13.8% in the
general population (2). Immunological disorders
have been frequently described in the course of
HCV-related chronic hepatitis, and non–organ-
specific autoantibodies (NOSAs) in particular
are common examples of autoreactivity associ-
ated with HCV infection (3). HCV has six major
genotypes according to its viral genome, num-
bered one to six. These viral types and sub-types
differ in their geographical distribution and anti-
genicity (4). Particular genotypes are associated
with different courses and outcome of liver
diseases, and also with different responsiveness
to interferon therapy. Results of the studies to
clarify the relationship between HCV genotype
and autoimmune manifestations are contrive-
rsial. A majority of them failed to confirm the
association between clinical course of HCV
infection, autoimmune disorders and particular
HCV genotypes. Genotype 4 is the predominant
genotype of HCV in Egyptian patients (up to
91%) (5). The currently recommended therapy
for chronic HCV infection is the combination of
pegylated interferon (PEG-IFN) and ribavirin (6).
The sustained virological response (SVR) rates
in patients treated with PEG-IFN and ribavirin
are 50% in HCV genotype 1 and 80-90% in
HCV genotype 2 or 3 (6- 9). The achievement of
the SVR in patients with chronic hepatitis C
(CHC) has been associated with improvements
in liver histology as well as a reduced risk of
hepatocellular carcinoma (HCC) and liver-
related mortality (10-12). However, several side-
effects have been published in patients treated
with IFN-α including the development or
exacerbation of underlying autoimmune
diseases and the development of a variety of
organ and non-organ specific autoantibodies
(NOSAs) .The association between these anti-
bodies and either HCV per se or IFN-a related
therapy is mainly based on epidemiological sur-
veys (13-18). Moreover, available data on the
relationship between autoantibody seropositivity
and the response to antiviral therapy in CHC
patients are limited and controversial (19, 20). In
this study, we aimed to assess the prevalence of
serum NOSAs in CHC patients. In addition, to
evaluate its impact on the response to com-bined
antiviral therapy (IFN or Pegylated IFN plus
ribavirin) in patients with HCV genotype 4-
related chronic hepatitis and to identify clinical,
biochemical, or immunological features predict-
ive of response to antiviral treatment.
Patients and Methods
The study was conducted into two stages: Stage
I: a comparative cross sectional study among
patients with chronic hepatitis C virus Genotype
4. Stage II: a case control study between patients
with chronic hepatitis C virus Genotype 4 and
healthy cross matched control. Sample size and
power of the study: The sample size was calcu-
lated by Medcalc program available at www.
Medcalc .be . At a level of 95% confidence
with alpha error 0.05. and the power of the
study was settled at 80 and beta error .02. The
prevalence of auto-antibodies was supposed to
be ranged from 20% to 10%. The estimated
sample is 86 patients. We try to increase the
sample of patients to 134 patients to increase the
power of the study. Limitation of our resources
enforce us to have a control group of 60
subjects. A total of 134 consecutive CHC pati-
ents were admitted to this study during the
period of July 2009 to January 2012 who visited
clinics of Tropical Medicine Unit (inpatients
and outpatients), Mansoura University Hospital.
They were 78 males and 56 females, with a
mean age of 48.4 ± 3.2 years and 60 healthy
controls with matched age and sex. All patients
had positive HCV antibody with enzyme-linked
immunosorbent assay (ELISA) ( Murex anti-
HCV (version 4.0) 7F51-06/-07, DiaSorin South
Africa (Pty) Ltd, Republic of South Africa) and
detectable HCV RNA ( Applied biosy stems,
Step One Real-time PCR system, USA) in the
serum. The exclusion criteria included human
immunodeficiency virus coinfection, hepatitis
other than hepatitis C (hepatitis B and autoim-
mune hepatitis), patients who showed evidence
of alcohol, illicit drug, or potentially hepatotoxic
medication use and major contraindications to
IFN or ribavirin therapy. Informed consent was
obtained from all patients, and the research
protocols were approved by the Medical Ethics
Committee of Mansoura University Hospital.
Detection of NOSA: Serum ANA was detected
by ELISA (ORG 538, ORGENTEC Diagnostika
GmbH, Germany), ASMA was detected by
ELISA (QUANTA LiteTM Actin IgG ELISA
708785, INOVA Diagnostics, Inc.USA) and
anti-LKM-1 was also detected by ELISA
(QUANTA LiteTM LKM-1 ELISA 708745,
INOVA Diagnostics, Inc.USA). Among the
laboratory parameters measured at baseline
serum levels of alanine- aminotransferase (ALT)
aspartate - aminotransferase (AST), total and
direct bilirubin, albumin, alkaline phosphatase,
γ-glutamyl transpeptidase (GGT) and α-
fetoprotein (AFP) were recorded and included in
the analysis. Samples positive for HCV-RNA by
real time PCR were subjected to genotyping of
HCV, by RT-PCR for the core domain using the
primers modified by Ohno et al. (21).
Histological assessment: Liver biopsy was done
for all patients before the initiation of therapy.
The histological evaluation was assessed using
the modified Knodell histology index and the
metavir scoring system reflecting the degree of
hepatic inflammation and fibrosis. Before
treatment, informed consent was obtained from
each patient. Treatment regimens and outcomes:
A total of 32 (88.9%) of 36 autoantibodies
positive patients and 77 (78.6%) of 98
autoantibodies negative patients had been
treated with a combination therapy ( either
Pegylated-IFN alfa-2a 180 µg subcutaneously
once a week or Pegylated IFN alfa-2b 1.5 µg/kg
subcutaneously once a week plus oral ribavirin
1000 or 1200 mg/day for subjects weighing <75
or ≥75 kg, respectively). According to HCV
genotype, the predetermined duration of
treatment was 48 weeks with a final efficacy
evaluation at week 24 of follow-up. Patients
were regularly followed–up for physical exam-
ination, blood tests and virological assays.
Treatment outcome was assessed as follows:
sustained virological response (SVR) was
defined as undetectable HCV RNA 24 weeks
after treatment discontinuation; relapse was
defined as HCV RNA clearance during treat-
ment and reappearance during follow-up; and
nonresponse was defined as a failure to clear
HCV RNA at any time during treatment (22.).
Statistical analysis: The data were collected and
entered the computer. The data were statistical
analyzed by using Statistical Package of Social
Science (SPSS). The qualitative data were pres-
ented in the form of number and percentage.
Chi-square with Yates correction was used as a
test of significance for qualitative data when the
expected cell less than 5. Chi-square test was
used as test of significance for qualitative data
when the expected cell more than 5. Signif-
icance was considered when p value less than
0.05. The quantitative data were presented in the
form of mean and standard deviation. Student t
test was used as a test of significance for
quantitative data of two groups. The fibrosis
score was presented in the form of median and
range. Mann Whitney u test was used as a test of
significance for fibrosis score. Significance was
considered when p value less than 0.05.
Result
Prevalence of NOSA in patients with chronic
hepatitis C: Table (1) shows the prevalence of
NOSAs in patients with chronic hepatitis C and
control groups. Among total of 134 patients
with chronic hepatitis C, thirty-six (26.9%) were
positive for at least one autoantibody. ANA was
present in twenty nine (21.6%) patients, anti-
SMA in nine (6.7%) patients , and anti-LKM-1
was found in two (1.5%) patients. In two of the
patients, both ANA and anti–SMA were
positive, and in other two cases both ANA anti-
LKM-1 were positive. The prevalence of serum
autoantibodies in patients with chronic hepatitis
C was significantly higher than in healthy
control (p < 0.05). Clinical significance of
NOSAs in patients with chronic hepatitis C:
Table (2) compares the clinical, laboratory and
histological parameters between CHC patients
with and without autoantibodies. As regard
demographic data, female patients had a higher
frequency of positive autoantibodies (P=0.005)
and age was significantly higher in the auto-
antibody-positive CHC patients (51.4 ±2.3) vs
(45.4 ±4.1) (P <0.001). The chronic hepatitis C
patients with and without serum autoantibodies
were analyzed with comprehensive clinical and
biochemical examinations: autoantibodies-
positive patients had significantly higher serum
levels of ALT (102±20.3) vs. (90±22.4)
(P=0.013), AST (96± 15.13) vs. (72±16.7)
(P=0.023), GGT (76.3± 15.2) vs. (50.9±12.7)
(P<0.001) and AFP (18± 4.5) vs. (13±3.9) (P=
0.012). Autoantibodies-positive patients had
also higher fibrosis scores and significantly
lower platelet counts (144 ±30.2) vs (186
±25.12) (P=0.004). No significant difference in
HCV viral load between both groups. Response
to combined antiviral therapy: Table (3) show
the response of chronic HCV- infected patients
to combined antiviral treatment (peg-IFN plus
ribavirin). In autoantibodies positive patients, 15
(46.9%) of 32 HCV-infected patients had a
sustained virological response (SVR), whereas 9
patients (28.1%) experienced nonresponse and 8
(25%) experienced relapse. In their counterpart,
autoantibodies negative HCV patients, the
response rate was as follow: 53.2% SVR, 24.7%
nonresponse and 22.1% relapse. The SVR rates
were comparable between autoantiboies positive
vs. autoantibodies negative patients (46.9% vs
53.2%). As regard the systemic autoimmune
manifestations, one patient with positive serum
autoantibodies developed hypothyrodism while
in autoantibodies negative group, one patient
developed diabetes mellitus, and another one
developed hypothyroidism. These complications
were con-trolled on therapy and did not required
withdrawal of combination therapy. Predictors
of response to antiviral therapy: In this study,
we compared patients with and without SVR
(Table 4) in order to predict the factors
associated with a favorable response to
combined antiviral therapy. Among the clinical,
biochemical, and histological parameters
studied, our results showed that younger age
(P<0.001), body mass index (BMI) (P<0.001),
higher serum ALT (P<0.001), lower GGT
(P<0.001), lower HCV viral load (P<0.001)
levels and lower fibrosis score were
significantly associated with SVR. In
comparison serum ANA, ASMA and LKM-1
were not significantly different between patients
with and without SVR.
Discussion
Patients chronically infected by HCV present
various immune mediated phenomena mainly
due to B lymphocyte dysfunction as mixed
cryoglobulinemia and non-organ-specific auto-
antibodies (NOSAs) production (23). Previous
studies have shown that serum autoantibodies
are commonly found in CHC patients (24). In this
study, the global prevalence of NOSAs among
patients with chronic hepatitis C was 26.9%.
ANA was the most commonly found
autoantibodies being present in 21.6% of
patients. The prevalence of ANA is higher than
that reported by studies from some countries (25),
while it is comparable to that reported from
some other countries. Lenzi et al., demonstrated
the occurrence of ANA in 16% of patients with
chronic hepatitis C(18). In Estonia, Zusinaite et
al., reported 14.4% prev-alence of ANA in
patients with chronic hepatitis C (26). As regard
the prevalence of ASMA in patients with
chronic hepatitis C, it was found to be 6.7%.
This result is lower than that reported in some
studies (18, 13, 26). Anti-LKM-1 autoantibodies are
detected worldwide in approximately 0-7% of
patients with chronic hepatitis C (27, 28).
Available data on the prevalence of anti-LKM-1
in Egyptian patients with CHC are relatively
uncommon. Here we reported that the positive
rate of anti-LKM-1 was 1.5%. These results
confirm that AIH related autoantibodies can
exist in CHC patients. Molecular mimicry
between the HCV polyprotein and "self"
proteins may account for the production of
autoantibodies in chronic HCV infection. A
sequence homology between the HCV
polyprotein and cytochrome p450 2D6 (CYP
2D6), the antigenic target of anti-LKM1, was
previously reported (29). The reactivity against
the viral protein would induce the production of
anti-LKM1 in HCV-related CLD. Gregorio and
colleagues documented molecular mimicry
between HCV polyprotein and three nuclear
host antigens including matrin, histone H2, and
replication protein as a mechanism for the
emergence of ANA (30). Polyclonal B cell
activation by persistent HCV infection has been
proposed as another mechanism for the prod-
uction of autoantibodies. In determining one of
the mechanisms for polyclonal B cell activation,
Pileri and colleagues documented that HCV
envelope protein (E2) represented a costimu-
latory signal to B cells by binding to CD 81
(tetraspanin) and thereby facilitated the produ-
ction of autoantibodies (31). B-lymphocyte acti-
vating factor (BAFF) appeared to play a crucial
role in HCV-induced autoimmunity (32). Varia-
tions in the prevalence of autoantibodies may be
attributed to several factors. First, there may be
differences in viral strains causing these differ-
ences (3). Secondly, the differences in detection
methods, ethnic background and geographic
distribution of the study cohort (33). In our study,
patients with positive autoantibodies were
significantly older. This is in agreement with the
findings of Squadrito et al., (13), who found that
NOSAs positive HCV patients were older than
those with negative autoantibodies. This phenol-
menon might result from functional defects in
suppressor T cells in older patients (34,35).
However, other studies found no age difference
between the two groups (36, 37). The positive
rate of autoantibodies was higher in females,
which is in accord with reports by other groups (25,38). This may reflect the difference in
autoimmune reactions between males and fema-
les after CHC infection, suggesting that horm-
ones, such as estrogen, may play an important
role in infection (39). As regard the biochemical
finding, this study showed that autoantibody-
positive CHC patients had significantly higher
serum ALT and AST levels than those without
autoantibodies. This is in agreement with
previous reports by Lenzi, et al., who reported
that NOSAs were significantly prevalent in
patients with HCV-related chronic liver disease,
and were especially so when the alanine aminot-
ransferase activity was higher (18). Moreover,
Cassani, et al., showed in a prospective series of
patients with HCV related chronic liver disease
who were positive for autoantibodies, a
biochemical and histological activity higher than
that of patients with no markers of autoim-
munity (40). In controversy, Stroffolini et al.,
showed no correlation between the positivity of
autoantibodies and liver damage (37). Muratori,
et al., showed that in the absence of active liver
disease the prevalence of non-organ specific
autoantibodies was similar in HCV positive
individuals and negative controls (3). This
suggests that the presence of non-organ-specific
autoantibodies is more likely associated with the
patient’s age and duration and severity of
chronic liver disease. Thus, reactivity against
self-antigens can be related to the severity of
liver damage without any independent patho-
genic role. Our finding also demonstrated that
NOSA-positive CHC patients had low platelet
count and more advanced fibrosis scores than
seronegative CHC patients. These finding are in
agreement with most published data, suggesting
that HCV-infected autoantibody- positive pati-
ents have higher disease activity and severity
than those who are autoantibody-negative ( 40,41).
IFN-alfa is the treatment of choice for patients
with chronic hepatitis C, but its imm-
unomodulatory activity may also favor the
appearance or amplification of autoimmune
reactions (42). The response to IFN-α in patients
with HCV infection and autoimmune markers
continue to be controversial (36). In our study,
we found that the presence of serum NOSA in
CHC patients did not influence the response to
combined antiviral therapy, which was similar
in both serum NOSA-positive and -negative
patients (46.9 % vs 53.2%). This results is in
agreement with other studies who reported that
the presence of autoantibodies such as ANA or
anti-LKM1 in patients with CHC is less likely to
affect the response to antiviral treatment (40,43).
In contrast, the favourable predictors of SVR
were younger age, body mass index (BMI),
higher serum ALT, lower GGT, lower HCV
viral load levels and lower fibrosis score. These
results are in agreement with other reports as in
all large prospective studies of (PEG) IFN and
RBV combination therapy younger age
correlated significantly with an SVR when
assessed by univariate and multivariate analyses
and patients younger than 40–45 years showed
the best response rates (44). GGT has been
identified as a prognostic factor in other studies (45,46). In this study, we found that low GGT
level had a favorable prediction of SVR. This is
in accordance with previous reports in which
low pre-treatment serum GGT levels were
significantly and independently associated with
SVR in multivariate regression analysis (47,48).
The pathogenetic background of GGT elevation
in chronic hepatitis C is not fully understood.
However a close relationship between serum
GGT levels and hepatic steatosis, advanced
fibrosis, and insulin resistance has been
described (49,50). Moreover, GGT levels are
related with an increased expression of TNFα in
the liver that seems to reduce the efficacy of
antiviral therapy (51). We also confirmed
previous reports signaling that a low viral load
is predictor of SVR. A low baseline viral load
(<600,000–800,000 IU/ ml or less) was shown
to be an independent predictor of SVR
regardless of genotype in numerous studies (44,47,52,53). In conclusion, serum NOSAS were
frequently found in HCV infected patients.
Patients with positive serum autoantibodies
were older, and have higher disease activity and
advanced fibrosis scores than their negative
counterparts. The positivity of autoantibodies
did not influence the response to combination
antiviral therapy. Combined antiviral treatment
is safe and effective in autoantibodies positive
patients with CHC. Routine testing of auto-
antiantibodies may be needed to monitors the
progress and severity of disease that might be
areas for further research. Limitation of the
study: Some limitations should be considered
when interpreting our findings. First, detection
of autoantibodies was based on ELIZA method,
and there was no record of the distribution type
of NOSAs. Whether the distribution type of
autoantibodies has clinical relevance is worthy
of future study. Second, the external validity of
this study is questionable, since the sample of
the patients may not be representative of all
Egyptian population due to cost variable, long
duration of follow up and the interferon therapy
is not available for most of Egyptian patients;
therefore, it is possible that our findings cannot
be extrapolated to all CHC patients in Egypt.
Table (1) Prevalence of NOSAs in patients with chronic hepatitis C
Case
(n)
Autoantibodies
(n (%))
ANA
(n (%))
ASMA
(n (%))
Anti-LKM-1
(n (%))
Patients with CHC 134 36 (26.9%) 29 (21.6%) 9 (6.7%) 2 (1.5%)
Control group 60 7 (11.7%) 7 (11.7%) 0 (0%) 0 (0%)
Test of significance 0.018* 0.098 .031* .47
Table (2) Clinical, laboratory and histological parameters of patients with chronic hepatitis C who did or not test positive for non-
organ specific autoantibodies
Parameters
Autoantibody positive
N= 36
Autoantibody negative
N= 98
P value
Gender
Male
Female
14
22
64
34
P=0.005**
Age (year) 51.4 ±2.3 45.4 ±4.1 <0.001***
Body mass index 26.1±2.1 27.2±2.4 .059
Hb level (g/dl) 13.6 ±1.2 13.9 ± 1.5 .28
WBCs 5.9±2.1 6.2 ±2.3 .19
/l)9(×10 Platlet count 144 ±30.2 186 ±25.12 0.004**
Albumin (g/dl) 4.03 ±0.75 4.2±0.32 .49
Total Bilirubin (mg/dl) 1.04±0.5 0.9±.41 .101
ALT (IU/ml) 102.3 ±20.3 90.5 ±22.4 0.013*
AST (IU/ml) 96.4 ± 15.13 72.9 ±16.7 0.023*
ALP (U/l) 247.08±42.3 238.67±36.8 .37
GGT (IU/l) 76.3±15.2 50.9±12.7 <0.001***
HCV RNA(×106 IU/ml) 0.58±.2 0. 66 ± .3 0.141
AFP 18.2 ±4.5 13.3 ±3.9 0.012*
Fibrosis score ( 0-2/3,4) 21/15
1(1-4)
70/28
2 (1-4)
<0.001***
*Significat p less than 0.05, ** highly significance less than .01, **** extremly significance less less than .001
Table ( 3) Response of chronic hepatitis C patients with and without autoantibodies to combined antiviral therapy
Autoantibodies positive
patients
N= 32
Autoantibodies negative patients
N=77 P value
SVR 15 (46.9%) 41 (53.2%)
.83 Non responder 9 (28.1%) 19 (24.7%)
Relapse 8 (25%) 17 (22.1%)
Table (4) Comparison between patients with SVR and Non-SVR
SVR
n= 56
Non-SVR
n= 53 P Value
Gender
Male/ Female
31/25
33/20
0.46
Age (year) 44±5.21 52±4.2 <0.001***
Body mass index 25.3±2.31 28.5±1.41 <0.001***
ALT (IU/ml) 116±25.7 86±50.1 <0.001***
AST (IU/ml) 17.2 87.7± 82.5±19.2 0.15
GGT (0-40IU/l) 47.7±5.7 82.3±6.2 <0.001***
ANA (+/-) 13/43 16/37 .41
ASMA (+/-) 4/52 5/48 .51
Anti-LKM-1 1/55 1/52 .96
HCV RNA (×106 IU/ml) 0.49±0.56 0.86±0.72 <0.001***
Fibrosis score 1
(1-3)
3
(2-4) 0.003**
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Original Article
Non-Traumatic Intramural Hematomas in Patients on Anticoagulant Therapy:
Report of Three Cases.
Mohamed Bekheit. MS, MSc, MRCS, MRCPS. a,b Mohamed Alaa Sallam. MS, FRCS. b
ABSTRACT
Non-traumatic intramural hematoma in the gastrointestinal tract is a rare event that could have diverse clinical presentation.
The small intestine is the site of predilection to this condition. Intestinal obstruction is the main presentation. Various degrees
of acute abdominal pain with peritoneal signs would make a cumbersome diagnosis. Patients and methods: Retrospective
review of the surgical emergency admissions database was conducted back to 1994. A literature overview was conducted.
Results: Three cases were retrieved and presented in this manuscript. More than 20 reports, with acute abdominal pain as a
main presentation, were found in the literature. Conclusions: Complete history taking is mandatory not to miss such an
uncommon complication. The INR level should be asked for in every case on oral anticoagulant presenting with acute
abdominal pain. CT scan is the main diagnostic tool. Conservative management is the standard therapeutic approach.
Introduction
In About 40% of the cases presenting with
abdominal pain; the diagnosis is uncertain. (1)
The primary goals of the management are to
diagnose the etiology of the abdominal pain and
then to ascertain the necessity for surgical inter-
vention. In order to avoid non indicated surgical
interference, meticulous workup is crucial. (2-4).
Meticulous differential diagnosis is not always
simple. Specific common patterns are usually
the guide for clinicians for further evaluation of
the patient condition. In at least third of the
cases the exhibited patterns are atypical, what
renders the diagnosis complex. (2,4). Accurate
history taking remains the most crucial initial
step in approaching these conditions. (5-10)
History of drug intake represents an essential
part of the history that might provide a direct
clue to the patient's problem. Anticoagulants are
commonly prescribed drugs for numerous surg-
ical and medical reasons. One of the rare repor-
ted complications of the drug is the occurrence
of intramural hematomas in the gastrointestinal
tract. (11). We report three cases of intramural
hematomas in various parts of the gastrointes-
tinal tract, who presented to the emergency dep-
artment with acute abdominal pain with or with-
out intestinal obstruction.
Cases presentations
Case 1: A 40 year-old male patient presented
with upper abdominal pain and food intolerance.
The patient had bronchial Asthma, COPD,
dilated cardiomyopathy, IHD and old MI, for
which he has been receiving the anticoagulant
therapy. The patient was on antihypertensive
medications plus the oral anticoagulant therapy.
His clinical examination showed minimal blee-
ding from the gum. The abdominal examination
revealed tender and rigid upper abdomen
(epigastric and Rt. Hypochondrium) with no
masses felt, bowel sounds were audible. Per
rectal examination (PR) showed normal color
stools. His admission profile showed mild
anemia (Hb 10 gm / dl), leucocytosis (WBCs
17,700 / dl), and deranged coagulation profile
(PT 163 sec and INR 17). An abdominal
ultrasound scan (U/S) revealed the presence of
18 mm thick hypoechoic gastric wall (Figure
1.a). UGI endoscopy (Figure 1.b) was done that
showed diffuse submucosal hemorrhage
involving the entire body and antrum of the
stomach down to the upper part of the
duodenum with no evidence of active bleeding.
CT scan of the abdomen confirmed the exact
extension of the hematoma (Figure 1.c). The
patient received fresh frozen plasma transfusion
and vitamin K. He was kept in the hospital for
13 days for correction of the coagulation deficits
and for stabilization of the heart condition.
Follow up ultrasound showed the reduced size
of the stomach thickness after five days of
admission. Follow up upper gastrointestinal
endoscopy after ten days of admission showed
significant improvement.
Case 2: A 62 year-old male patient presented to
the casualty complaining of abdominal pain
associated with constipation for two days. The
patient had ischemic heart disease and chronic
atrial fibrillation for which he required oral
anticoagulant therapy. His vital signs were
stable on presentation. His abdomen was
distended with diffuse tenderness, rebound
tenderness, sluggish intestinal sounds. His
digital rectal exam (P/R) was positive for mele-
na. Abdominal ultrasound scan (U/S) was done,
which reported thickened small bowel loops and
simple left renal cyst. Patency of the mesenteric
vessels was questioned by the U/S scan. Abd-
ominal CT scan with contrast showed thick-
ening of the proximal 20 cm of jejunum with
patent superior mesenteric artery and vein
(SMA and SMV) (figure 2). His initial laborato-
ry investigations demonstrated prolonged proth-
rombin time (PT 118 seconds) and an INR of
10.5. There were no significant derangements in
the rest of the laboratory work. There was a
dramatic cessation of pain on after correction of
the excessive anticoagulation with fresh frozen
plasma and fluids. The patient was discharged
after 4 days with adjusted dose of oral antico-
agulation.
Case 3: 65 year-old Male patient with diabetes
and ischemic heart disease for which he is on
regular warfarin treatment. The Pt. admitted to
our hospital through the E/R because of
abdominal pain. The pain was diffuse dull
aching with maximal tenderness at the Rt. Iliac
fossa. Clinical examination of the patient
showed tenderness in the right lower quadrant of
the abdomen, with no change in the stool color.
All laboratory investigations were within normal
except high blood sugar and abnormal
coagulation screening which showed elevated
INR 9. U/S abdomen was not conclusive. CT
scan of the abdomen with contrast showed
thickened terminal ileal loop about 10 cm with
normal mesenteric blood flow (figures 3.a, 3.b).
Fluid resuscitation and fresh frozen plasma were
given, the patient`s symptoms resolved by the
second day of admission. The patient was
discharged 2 days later.
Discussion and literature overview
Non-traumatic intramural hematoma of the
gastrointestinal tract complicating anticoagulant
therapy is mostly reported to take place with
Warfarin and less commonly reported with other
anticoagulants in the literature. (12,13) Warfarin
has a considerable variation in responsiveness
among patients. Factor VII polymorphism is
responsible for great portion of this variability. (14) Although the ambient temperature could be
another factor that would influence the response
to Warfarin, (15) the complete understanding of
the variability in responsiveness is not fully
elucidated. The high ambient temperature, where
our patients live, could be an implicated factor
in the development of excessive anticoagulation.
Intramural hematomas of the gastrointestinal
tract might have diverse presentations. Gastric
mural hematomas are very rare complications of
anticoagulant therapy that could present mainly
with upper abdominal pain and vomiting that
could be blood stained. (16,17) Jaundice and acute
pancreatitis have been reported as complications
of duodenal hematomas. (12,18-21) Intestinal
obstruction was the main presentation for
lesions occurring in the small intestine. (22-24)
Occasionally, these lesions could present with
bleeding from an orifice. (25,26) Acute abdominal
pain is not an uncommon presentation for the
Non-traumatic intramural hematoma. (27) All our
patients had acute abdominal manifestations on
presentation. Complete history taking remains
of paramount importance to the algorithm of
clinical diagnosis in patients with abdominal
pain. INR and bleeding profile would give direct
clue to the diagnosis. As a remarkably elevated
INR has been reported very often in the
published case reports, it is of benefit to screen
in anticoagulated patients presenting with
abdominal symptoms. (25,28) Despite that
endoscopy would allow direct visualization of
the mucosa; (28) the accessibility to the small
intestine is limited in most of the emergency
settings. CT scan would provide more discrete
information about the extent of the lesion and
the mural thickness. (29) Abdominal U/S usually
shows mural thickening of the affected region. (28). Bacterial translocation from the dysfun-
ctional mucosa due to the accumulation of blood
is related to the increase in the WBCs and septic
complications. (30) The increase in WBCs could
be as high as over 20 thousands, which could
hinder the diagnosis. The high WBCs count
could be related to the more extensive
hematomas. (30) Lethal out-comes occur if
extensive hematomas are associated with the
presence of significant comorbidities. (30)
Currently, the standard management for these
cases is the correction of the excessive
anticoagulation with resuscitation. (11, 12, 22, 28, 29,
31, 32). The necessity for surgical intervention in
these cases has diminished significantly and its
role now is reserved to those cases that do not
improve on resuscitative measures. The extent
of the mural hematoma, along with the WBCs
could predict those who might require surgical
intervention, (30) however, response to
resuscitation is governing factor for the decision
making. The importance of early recognition of
the condition is that surgical exploration could
be unnecessarily attempted with deleterious
outcomes. (33-35) Prevention of excessive
anticoagulation is a primary goal in patients who
require long term anticoagulant therapy. This
could be accomplished with tailored monitoring
approach.
Conclusions
Accurate detailed history taking is always
emphasized during assessment of acute abdo-
minal pain. Coagulation profile should be consi-
dered as a routine part of the evaluation of
patients on anticoagulant therapy who present to
with abdominal pain. The diagnosis of the
spontaneous intramural hematoma is achieved
through detailed history and clinical exami-
nation, abdominal CT scan along with the
deranged coagulation profile. The decision on
how to manage the clinical condition is
governed by the response to the conservative
management, which is the primary therapeutic
strategy for this clinical condition.
Acknowledgment
The authors would like to acknowledge the sincere efforts
of Prof. Khaled Katri FRCS, MD, professor of general
surgery, HBP surgery unit, department of surgery, faculty
of medicine, university of Alexandria, Egypt; in revising
the manuscript.
Figure 1.a: Abdominal ultrasound showing hypoechoeic
increased gastric mural thickness.
Figure 1.b: upper GI endoscopy demonstrating the swollen
congested mucosa of the stomach.
Figure 2: Abdominal CT scan showing increased thickness
of the proximal jejunum
Figure 3.a: Mural hematoma of the ileum.
Figure 3.b: mural hematoma of the ileum
Figure 1.c: Abdominal CT scan with thickened antrum of
the stomach.
Table1: Summary of cases presentations and management.
Case 1 Case 2 Case 3
Gender Male Male Male
Age 40 62 60
Presenting symptoms Upper abdominal pain Abdominal pain Diffuse abdominal pain
Associated symptoms Vomiting, constipation,
and fever
Constipation -
Indications for
anticoagulant
Ischemic heart disease Ischemic heart disease Ischemic heart disease
INR 17 10.5 9
Diagnostic tool U/S”, upper GI
endoscopy, CT
CT CT
Region Antrum of the stomach
and first part of
duodenum
Proximal jejunum Terminal ileum
Management FFP*, Vit K**, I.V***
Fluids
FFP, Vit K, I.V Fluids FFP, Vit K, I.V Fluids
*FFP: Fresh frozen plasma, **Vit K: Vitamin K, ***I.V: intravenous
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Original Article
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, Shimaa MMansour1, Amal H Abed-El Hameed2
Tropical Medicine & Infectious Diseases1, Clinical Pathology2departments, Faculty of Medicine, Tanta University, Egypt
ABSTRACT
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 and Methods :The study populationincluded50 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 and lactulose can decrease ammonia level by different mechanisms, but the response of patients regarding
improvement of symptoms of HE was more and 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.
Introduction
Hepatic encephalopathy is a spectrum of neuro-
psychiatric abnormalities in patients with liver
dysfunction after exclusion of other known
brain disease(1). A number of theories have been
proposed to explain the development of hepatic
encephalopathy in patients with cirrhosis.Some
investigators contend that hepatic encepha-
lopathy is a disorder of astrocyte function. Ast-
rocytes account for about one third of cortical
volume. They play a key role in the regulation
of the blood-brain barrier. They are involved in
maintaining electrolyte homeostasis and in prov-
iding nutrients and neurotransmitter precursors
to neurons. They also play a role in the detox-
ification of a number of chemicals, including
ammonia(2). The current management of HE
requires prompt recognition of the disease state
particularly in its earliest or mildest stages,
careful identification and amelioration of precip-
itating factors, and judicious prescribing of a
therapeutic arsenal that is often multifaceted and
must be tailored to each patient(3,4).In the United
States, Non-absorbable dissaccharide lactulose
remains the mainstay of therapy for the majority
of patients with episodic or mild persistent HE.
Non-absorbable antibiotics particularly rifax-
imin with or without DS have become the
standard-of-care treatment for patients with
recurrent or persistent HE, after removal of und-
erlying precipitating factors where possible (3,4).
Rifaximin is a novel antimicrobial agent with a
wide spectrum of activity that has shown
promise as an alternative antimicrobial treat-
ment option for HE. It is a derivative of rifam-
ycin, which acts by inhibiting bacterial ribbon-
ucleic acid (RNA) synthesis. Rifaximin is virtu-
ally unabsorbed after oral administration (5).
Rifaximin is a gut–selective antibiotic with
negligible systemic absorption and broad–
spectrum activity in vitro against both gram–
positive and gram–negative pathogens.
Rifaximin has a similar tolerability profile to
that of placebo. Rifaximin tablets 200 mg are
approved in over 30 countries worldwide (6). In
2004, rifaximin was approved by food and drug
administration (FDA) in the United States for
the treatment of travelers' diarrhea. In 2005, it
received orphan drug status as a treatment for
hepatic encephalopathy (7). In March 2010,
rifaximin was approved by the FDA to reduce
recurrence of hepatic encephalopathy (7). During
the past decade, several European studies have
proved the efficacy of rifaximin for the
treatment of HE in Caucasian patients (8).
Aim Of The Work
The purpose of this study is to evaluate the
efficacy of rifaximin in comparison to lactulose
for the treatment of hepatic encephalopathy
Patients and Methods
This study was carried out at Tropical medicine
department (Tanta University Hospital). The
study population included 50 patients who were
diagnosed to have signs of the first to third
degree HE, according to the criteria suggested
by Conn HO, et al. (9), and classified into two
groups: Group I: included 25 patients who had
hepatic encephalopathy and were treated with
rifaximin capsules 1200 mg daily divided into
3doses for 7 days. According to the dose
suggested by Festi D., et al (10) & Williams R ,et
al (11). Group II: included 25 patients who had
hepatic encephalopathy and were treated with
lactulose syrup (laxolac) 90ml daily divided into
3doses for 7 days.According to the dose sugg-
ested by Cash WJ, et al (12). No other measures
were done for the patients. Inclusion criteria: 1-
All patients affected by decompensated liver
cirrhosis. 2- Patients showing signs of the first
to third degree HE. Exclusion criteria: 1- The
presence of a major neuropsychiatric illness. 2-
Presence of intestinal obstruction or inflamm-
atory bowel disease. 3-Hypersensitivity to rifa-
mycin or disaccharides. 4-A serum creatinine
level > twice normal. 5-Patients with correctable
cause of HE as gasterointestinal bleeding. Infor-
med consent was obtained from all patients
enrolled in the study. All patients were
subjected to: A) Full history taking. B) Full
clinical examination; including: 1-General exa-
mination: to detect the grade of mental state
according to West Haven criteria (9) 2-Local
Abdominal examination: assessment of liver and
spleen state, detection of ascites. C) Laboratory
investigations including :Liver function tests,
Coagulation profile, renal functions, Serum
electrolytes, ascetic fluid analysis. Ammonia
level: blood samples were collected from a
stasis-free vein (that is, without using a
tourniquet and taking care not to cause
turbulence or hemolysis) and immediately
transported on ice to the laboratory to be
analyzed within 20 min. Norm-al ammonia
level was considered < 75 µmol/L (14). D)
Imaging evaluation: 1-Chest x-ray to exclude
chest infection. 2- Pelvi-abdominal ultrasono-
graphy. Conn score (grade of mental state) &
grade of flapping tremor & blood ammonia level
were done before beginning the treatment in the
first day and on days 3,5,7 of the trial period (13).
Results
The results showed that the both rifaximin and
lactulose can decrease ammonia level by
different mechanisms, but the response of
patients regarding improvement of symptoms of
HE was more and rapid in rifaximin group than
lactulose group. After the end of treatment 21
patients (84%) in rifaximin group became in
grade 0 but only 8 patients (32%) in lactulose
group became in grade 0. These results showed
that the response of patients regarding
improvement of mental status was more and
rapid in rifaximin group than lactulose group.
Table (1): Shows liver function tests, platelets count &base line ammonia (NH3) in group I & group II
Lab. Investigation Group I
Rifaximin (n=25)
Group II
Lactulose (n=25)
Pvalue
S e r u m a l b u m i n ( g / d l ) 2.788+0.3407 2.668+0.3326 0.214
T o t a l b i l i r u b i n ( m g / d l ) 3.844+5.6092 3.420+5.0661 0.780
P l a t e l e t s ( x 1 0 3 / µ l ) 89.64+37.443 99.68+88.464 0.604
H a e m o g l o b i n ( m g / d l ) 9.852+1.1399 9.436+0.7064 0.127
C r e a t i n i n e ( m g / d l ) 1.148+0.2275 1.400+1.0145 0.231
N H 3 ( µ m o l / l ) 182.4+36.436 162.2±60.4 0.279
Table (2): Shows Similar attacks of HE
Similar attacks of HE
GROUP I
Rifaximin (n=25)
GROUP II
lactulose (n=25) P value
no. of patients % no. of patients %
Present 20 80 21 84 0.713
Absent 5 20 4 16
Table (3): mean level of blood ammonia (µmol/l) pre & post treatment in both groups.
P r e - t r e a t m e n t Post treatment p v a l u e $
GroupIRifaximin (n=25) 182.4+36.436 120.8+44.8 <0.001*
Group IILactulose (n=25) 162.2±60.4 118.7±50.7 <0.001*
P v a l u e $ $ 0 . 2 7 9 0 . 8 8 1
P < 0.001** highly significant test.P value $pre treatmentVS post treatmentin the same group.
P value $$pre treatment and post treatment in group I VS group II.
Table (4): Shows changes in the grading of mental status in both groups in 1st&3rd&5th&7th days of treatment in both groups
Grade of
Mental status
Group I
Rifaximin(n=25)
Group II
Lactulose(n=25)
0 1 2 3 0 1 2 3
No of cases in the 1st day (before
treatment)
0
0%
6
24%
11
44%
8
32%
0
0%
3
12%
15
60%
7
28%
No of cases in the 3rd day
12
48%
10
40%
3
12%
0
0%
1
4%
10
40%
11
44%
3
12%
No of cases in the 5th day
19
76%
5
20%
1
4%
0
0%
1
4%
16
64%
7
28%
1
4%
N o o f c a s e s i n t h e 7 t h d a y 2 1
8 4 %
3
1 2 %
1
4 %
0
0 %
8
32%
1 4
5 6 %
2
8 %
1
4 %
Table (5): Shows changes in the grading of flapping tremors in both groups in 1st&3rd&5th&7th days of treatment
GroupI
Rifaximin(n=25)
GroupII
Lactulose(n=25)
0 1 2 3 4 0 1 2 3 4
No of cases in the 1st
day(before treatment)
0
0%
0
0%
9
36%
15
60%
1
4%
0
0%
1
4%
6
24%
16
64%
2
8%
No of cases in the
3rd day
9
36%
6
24%
10
40%
0
0%
0
0%
0
0%
3
12%
10
40%
12
48%
0
0%
No of cases in the
5th day
15
60%
5
20%
5
20%
0
0%
0
0%
1
4%
7
28%
12
48%
4
16%
1
4%
No of cases in the 7 t h day 1 8
7 2 %
4
1 6 %
3
1 2 %
0
0 %
0
0 %
3
1 2 %
1 2
4 8 %
7
2 8 %
2
8 %
1
4 %
Figure (1) mental status at the 1st day before beginning of treatment in both groups
Figure (2) mental status at the 7th day of treatment in both groups
Discussion
Hepatic encephalopathy (HE) is a metabolically
induced, potentially reversible, functional distu-
rbance of the brain. While HE may be a com-
plication of acute or chronic liver disease, it is
most commonly associated with cirrhosis (15).
Depending on its cause, HE can be categorized
as either type A, which occurs in patients with
acute liver failure; type B, which occurs in
patients with bypass shunts; or type C, which
occurs in patients with chronic liver disease(16).
In this study the cause of the liver disease was
HCV infection with percentage 100% in both
groups. In Egypt, the main cause of decom-
pensated liver disease is HCV infection, because
Egypt developed the world's highest rates of
HCV infection over a short period of time. The
majority of infections among individuals aged
30 years and older can be explained by
parenteral anti-Schistosomal therapy (PAT) and
other iatrogenic exposures. Since Schisto-
somiasis was a greater problem in rural regions,
these populations were more affected by the
PAT campaign, and consequently, HCV
transmission(17). Regarding laboratory investti-
gations (albumin level, Total bilirubin, Platelets
count, Haemoglobin level, and Serum creatinine
level) there was no significant difference
between both groups. In this study we found that
protein overload was the precipitating factor in
9/25(36%) patients in group I & 15/25(60%)
patients in group II. Infection like (spontaneous
bacterial peritonitis, chest infection, urinary tract
infection or gastroenteritis) was present in 9/25
patients in group I & 3/25 patients in group II.
Constipation was present in 3/25 patients in
group I & 2/25 patients in group II. Four from
25 patients in group I & 5/25 patients in group II
were presented with unknown precipitating
factor of hepatic encephalopathy, which means
that protein overload is one of the common
precipitating factor of HE. These data were in
agreement with Cash WJ., et al (12), Chung Rt et
al., 18)and Sundaram V., et al(19), who reported
that consumption of large amounts of protein
was one of the common precipitating factor of
HE as it led to increase ammonia level in blood
which is the most widely accepted theory of the
pathogenesis of H(20). Also Yong-Han Paik et al,
(13)reported in their study that 8/32(25%)
patients presented by HE which was precipitated
by protein over load. But Antoni Mas et al.
(21)reported in their study of comparison
between rifaximin and lactitol that only 1
(2%)in rifaximin group &1(1.9%) in lactitol
group were precipitated by protein overload .
Heyman JK et al. (22) showed that protein
restriction (0–40g protein/day) in all patients
with cirrhosis who developed encephalopathy
has no impact on encephalopathy grade and that
it may even worsen their nutritional status. The
consensus of opinion nowadays is that protein
restriction is avoided in all patients, and protein
be maintained between 1.2 and 1.5g of proteins
per kg of body weight per day. but in severely
protein intolerant patients, particularly in
patients in grades III-IV HE, protein may be
reduced for short periods of time (23). In this
study 4/25 (16%) patients in group I and 5/25
(5%) patients in group II were presented with
unknown precipitating factor of hepatic encep-
halopathy. That was similar to the findings of
Cash WJ. ,et al(12) who found that in some cases
, no clear cause for an attack can be found. Also
Yong-Han Paik et al, (13) concluded that
7(21.9%) patients in rifaximin group &
5(22.9%) patients in lactulose group were
presented by HE of unknown precipitating
factor. So, many patients suffer from episodic
HE, with episodes being either precipitated or
spontaneous(24). There was no significant
statistical difference between both groups as
regard presence of similar attacks. Hepatic
encephalopathy was presented for the first time
in 5/25(20%) in group I Vs 4/25(16%) in group
II. With no significant difference between both
groups. this finding means that the most of
patients presented by recurrent attacks of HE.
This meets the finding of Bajaj JS et al 2010(24)
who found that many patients suffer from
intermittent or “episodic HE,”. Episodes of HE
may be isolated events, but more commonly
they are recurrent, with patients having seem-
ingly normal cognitive functioning between
episodes. Regarding blood ammonia level,there
was significant statistical difference pretreatm-
ent and post treatment in group I(rifaximin)
with p value <0.001*. also there was significant
statistical difference pretreatment and post
treatment in group II (lactulose) with p value
<0.001*.but in rifaximin group the decrease in
ammonia level was faster than in lactulose
group as shown in the results figure. These
results were similar to results reported by Bucci
and Palmieri(25) who reported in their study that
ammonia concentrations decreased in both
groups. AlsoYong Han Paik et al 2005(13) found
that ammonia concentrations decreased in both
groups. Mas A, et al(15)in their study that comp-
ared between rifaximin and lactitol found that
ammonia concentrations decreased for rifaximin
superior to lactitol. This means that all patients
in both groups showed increase in ammonia
level before beginning of both treatment then
ammonia level decreases after treatment by
rifaximin & lactulose this support that increase
ammonia level in blood is the most widely
accepted theory of the pathogenesis of HE, and
it is thought to be a central player in the
development of HE (20). Both rifaximin and
lactulose can decrease ammonia level by
different mechanisms but rifaximin is more
rapid than lactulose. This can be explained by
the fact that rifaximin acts by inhibiting
bacterial ribonucleic acid (RNA) synthesis and
it is unabsorbed after oral administration and
exhibits broad spectrum antimicrobial activity
against both aerobic and anaerobic gram-
positive and gram-negative microorganisms
within the gastrointestinal trac(26), So rifaximin
lowers the bacterial load 100–1000-folds(27). As
regard grading of mental status, the result
showed that after 3 days, 12 patients became in
grade 0 in the group treated with rifaximin vs 1
patients only in the group treated with lactulose.
After the end of treatment 21 patients (84%) in
rifaximin group became in grade 0 but only 8
patients (32%) in lactulose group became in
grade 0. These results showed that the response
of patients regarding improvement of mental
status was more & rapid in rifaximin group than
lactulose. These data were in agreement with
Neff G et al(28) who reported in their study that
the response to rifaximin ranged from 80% to
90%, with a faster onset of action by up to 3
days. Also Loguercio et al(29) documented faster
improvement in hepatic encephalopathy and
higher percentages of normalized mental state in
patients treated with rifaximin. Alsothese
resultsare similar to that reported by Bucci and
Palmieri(25) who found in their study that the
improvement in the rifaximin group was
significantly superior to that of the lactulose
group as regard mental status. Mas A, et al(15)
reported in their study that improvement in
grading of mental status for rifaximin was
superior to lactitol. Two recent trials confirmed
that it is a useful alternative to disaccharides in
patients with grades I–III HE in improving
mental status(10,11). Also HinaYasmeen et al(30)
reported that rifaximin was effective in im-
proving behavioral, laboratory, mental status
and intellectual abnormalitiesassociated with
hepatic encephalopathy and patients treated with
rifaximin also required shorter duration of hosp-
italization ,compared with lactulose. It may be
due to rifaximin is unabsorbed by the gut,
thereby allowing the antibiotic to reach high
concentrations in the intestinal tract and to
remain in the feces in its active form. Due to
these properties (high antibacterial activity with
null absorption), rifaximin decreases ammonia
plasma levels and improves the symptoms relat-
ed to HE rapidly(31). Regarding the grading of
flapping tremors, the results showed that after 3
days of treatment with rifaximin 9 patients had
no flapping tremors and this number increased
to 18 patients after the end of treatment. But as
regard lactulose group no patients became in
grade 0 flapping tremors after 3 days of treat-
ment and only 3 patients had no flapping
tremors after end of treatment. These results
showed that the response of patients regarding
improvement of flapping tremors was more &
rapid in rifaximin group than lactulose
group.These data were in agreement with Neff
G et al(28)who reported in their study that the
response to rifaximin ranged from 80% to 90%,
with a faster onset of action by up to 3 days.
Loguercio et al (29) documented in their study
faster improve-ement of asterixis in patients
treated with rifaximin.As 80% to 90% of
rifaximin taken by mouth concentrates in the
gut. This accum-ulation enh-ances the
effectiveness of rifaximin in the treatment of
intestinal infections. Due to its distribution in
the gut, rifaximin is excreted almost entirely in
the feces and its half-life is approximately six
hours. so its action more rapid than lactulose. As
regard side effects in this study only one
patients (4%) developed mild abdominal pain
after treatment with rifaximin, 5 patients (20%)
developed abdominal discomfort and flatulence
& 2 patients (8%) developed nausea after
treatment with lactulose so rifaximin was better
tolerated than cathartics and these data were in
agreement with David C Wolf, (32)and Iadevaia
et al,(33) and Hina Yasmeen et al, who concluded
that rifaximin is generally well tolerated, and
has a better profile in terms of side effectswhen
compared with other systemic antibiotics &
cathartics and the adverse effects of rifaximin
were mostly minor gastro-intestinal complaints
and this is because rifaximin is a synthetic
antibiotic that has a very low rate of systemic
absorption (0.4%), and has an excellent safety
profile than neomycin and the non- absorbable
disaccharides(34).
Conclusion: So rifaximin can be used in the
treatment of episodic HE alone or in
combination with lactulose. Competing
Interests: None
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Original Article:
Effect of Rebamipide on Portal Hypertensive Gastropathy and Proliferating Cell
Nuclear Antigen in Patients with Liver Cirrhosis
Mohamed Y. El-Hasafi(a), Suzan M. Helal(b), Marwa A. Madkour(c), Ahmed S. Saher(a) (a) Internal Medicine Department,
Faculty of Medicine, University of Alexandria (b) Pathology Department, Faculty of Medicine, University of Alexandria (c) Clinical and Experimental Internal Medicine Department, Medical Research Institute, University of Alexandria
ABSTRACT
Portal hypertensive gastropathy (PHG) is a complication of advanced liver cirrhosis and portal hypertension, in the form of
mucosal and submucosal vascular ectasia without significant inflammatory changes. It is a frequent cause of acute and
chronic upper gastrointestinal hemorrhage. Another sequel of PHG is increased susceptibility of gastric mucosa to injury by
noxious factors, with impaired mucosal healing response. Rebamipide is a gastroprotective drug used for mucosal protection
and promoting healing of gastroduodenal ulcers. The proliferating cell nuclear antigen (PCNA) is an antigen expressed in the
nuclei of actively dividing cells, and is considered to be a useful tool for assessing the proliferative activity of gastric mucosa
during the ulcer healing process. Aim: To evaluate the effect of Rebamipide on PHG and on the gastric mucosal expression
of PCNA in patients with liver cirrhosis and portal hypertension. Methods: 60 patients with liver cirrhosis and endoscopic
evidence of PHG were divided into 3 groups: Group І patients with PHG and non-ulcerated gastric mucosa receiving
Rebamipide for 3 months, Group П patients with PHG and gastric mucosal ulcers receiving Rebamipide for 3 months and
Group Ш patients with PHG and intact non-ulcerated gastric mucosa receiving Placebo for 3 months. Clinical and laboratory
assessment, Doppler study of the portal vein, endoscopic examination of the stomach, histopathologic and
immunohistochemical assessment of mucosal biopsies for PCNA were all performed before and after drug therapy in all 3
groups. Results: Clinical and laboratory assessment and Doppler study of the portal vein showed no significant difference
after drug administration in all patients. The platelet count showed a significant drop after drug administration in patients’
Group П only, while in Groups І and Ш it showed no similar drop. Endoscopically, there was also no significant change in
PHG score after drug therapy in any of the three groups. In Group II, however, the gastric ulcer score showed significant
improvement after drug therapy (p<0.001). There was no significant difference in the histopathologic stomach score of PHG
after drug therapy in all groups. However, there was a significant rise in PCNA score of the stomach in Groups І and П
(Rebamipide groups, p<0.001), while there was no similar change in Group Ш (Placebo group). Conclusions: Rebamipide
has no effect on the grade of PHG. However, it significantly increases the healing capacity of the ulcerated as well as non-
ulcerated gastric mucosa in patients with PHG, as proved by the significant rise in the gastric mucosal expression of PCNA
after Rebamipide therapy. Further research is needed to clarify the effect of Rebamipide on platelet count in cirrhotic
patients.
Introduction
Liver cirrhosis is a consequence of chronic liver
disease characterized by loss of architecture
with replacement of liver tissue by fibrosis and
regenerative nodules, ultimately leading to loss
of liver function. Portal hypertension is an
increase in the blood pressure within the portal
venous system. Normal portal pressure is
generally defined between 5 and 10 mm Hg.
However, once the portal pressure rises to 12
mm Hg or greater, complications can arise.
These include ascites, spontaneous bacterial
peritonitis, hepatorenal syndrome, hepatopulmo-
nary syndrome, portopulmonary hypertension
and bleeding from ruptured esophageal varices. (1) Portal hypertensive gastropathy (PHG) has
emerged during the last two decades as a clin-
ical and pathological entity among the compli-
cations of advanced liver cirrhosis, in the form
of mucosal and submucosal vascular ectasia
without significant inflammatory changes.(2) The
pathogenesis of portal hypertensive gastropathy
has not been completely cleared up. Clinical and
experimental studies suggest that chronic inc-
rease of pressure in the portal vascular system is
the main prerequisite for this condition. How-
ever, the involvement of humoral and autocrinal
factors has been recently implicated in its path-
ogenesis, as nitric oxide, tumor necrosis factor
alpha and several growth factors.(3,4) The diag-
nosis of PHG is fundamentally endoscopic. The
classic mosaic-like pattern (MLP) of the gastric
mucosa consists of multiple rectangular or
diamond-shaped erythematous areas, outlined
by a delicate white or yellowish network. Red
marks in the form of red point lesions, cherry
red spots or black-brown spots can also be
found. These changes are prominent in the
gastric body and cardia, but can be present in all
parts of the stomach.(5) In a classification
proposed by the North Italian Endoscopic Club
(NIEC), PHG was categorized into mild and
severe grades. Mild PHG is diagnosed when
only mosaic-like pattern (MLP) lesions are
found. MLP can be mild, moderate or severe.
Severe PHG is diagnosed when any of the red
marks, with or without MLP, are found.(6) The
incidence of PHG fluctuates between 30% and
45% among patients with cirrhosis undergoing
endoscopy.(7) In fact, PHG is a frequent cause of
acute and chronic upper gastrointestinal (GI)
hemorrhage: 10-20% of bleeding episodes occu-
rring in cirrhotic patients are caused by this
condition, with high incidence of morbidity and
mortality.(8) Another sequel of PHG is increased
susceptibility of gastric mucosa to injury by
noxious factors as non-steroidal anti-inflamm-
atory drugs, alcohol and helicobacter pylori
infection. Experimental evidence has also demo-
nstrated an impaired gastric mucosal healing
response to such injuries.(9) Excessive nitric
oxide production, in addition to increased gene-
ration of reactive oxygen species and lipid
peroxidase in the portal hypertensive gastric
mucosa are the main mechanisms incriminated
for these phenomena.(10) At the moment, no
single line of pharmacotherapy is able to prevent
or cure PHG. Beta-blockers seem to be an
effective treatment for this condition, which act
by decreasing portal pressure, resulting in decre-
ased gastric blood flow and reduced bleeding
from gastric mucosa.(11) Rebamipide is a gastro-
protective drug used for mucosal protection,
healing of gastroduodenal ulcers, and treatment
of gastritis. It works by enhancing mucosal
defense, scavenging free radicals and stimuli-
ting prostaglandin generation in gastric mucosa,
which improves not only the speed but also the
quality of ulcer healing. In addition, it protects
the gastric mucosa against acute injury caused
by various noxious and ulcerogenic factors.
After being tested in several experimental and
clinical trials it is now approved in Japan for
therapeutic use in patients with gastric ulcers
and acute gastritis.(12) A recent study by Kinjo et
al. demonstrated a new application of Rebami-
pide in PHG, by achieving a significant decrease
in lipid peroxidase and nitrotyrosine (which are
both indicators of oxidative stress) in portal
hypertensive rats. In addition, this drug succeed-
ded in restoring the integrity of mucosal
enzymes and proliferating cell nuclear antigen
(which are both responsible for gastric mucosal
healing) back to normal state.(10) The prolif-
erating cell nuclear antigen (PCNA) is an
antigen expressed in the nuclei of cells during
the DNA synthesis phase of cell cycle. It was
also proved to be an important mediator of DNA
repair in response to damage.(13) Its particular
role in the process of gastric ulcer healing was
identified and proved in more than one study,
which lead some authors to consider the
immunohistochemical staining of PCNA in the
gastric mucosa to be a useful tool for assessing
the proliferative activity of gastric mucosa
during the ulcer healing process. (14-16) Intere-
stingly, a decreased expression of PCNA in the
gastric mucosa of portal hypertensive rats was
recently described by two studies and hence was
added to the possible mechanisms of impaired
healing power in portal hypertensive gastric
mucosa.(9,17) This finding was further confirmed
by Kinjo et al. who demonstrated an improved
PCNA labeling index back to normal levels and
enhanced ulcer healing in the portal hypert-
ensive gastric mucosa of rats after the use of
Rebamipide.(10) However, whether Rebamipide
can achieve similar results among human
subjects with PHG, this needed further eluci-
dation. Therefore, the aim of our study was to
evaluate the effect of Rebamipide on portal
hypertensive gastropathy (endoscopically and
histopathologically ) and on the gastric mucosal
expression of proliferating cell nuclear antigen
(PCNA) in patients with liver cirrhosis and
portal hypertension.
Patients and Methods
This prospective interventional, single-blind,
placebo-controlled study was carried out on 60
patients with liver cirrhosis and portal hyper-
tension (based on clinical, laboratory and
ultrasonographic findings) and with endoscopic
evidence of portal hypertensive gastropathy
(PHG). Patients were obtained from Hepatology
and Gastroenterology Unit of the Clinical and
Experimental Internal Medicine Department,
Medical Research Institute, Alexandria Univer-
sity during the period from January 2010 till
March 2011. The patients were divided into
three groups: Group І included 20 patients with
PHG and intact non-ulcerated gastric mucosa
receiving Rebamipide 100 mg tablets three times
daily (tds) before meals for a period of three
months, Group П included 20 patients with PHG
and gastric mucosal ulcers receiving Rebamipide
100 mg tablets tds before meals for a period of
three months and Group Ш included 20 patients
with PHG and intact non-ulcerated gastric mucosa
receiving Placebo tablets tds before meals for a
period of three months. Exclusion criteria of the
patients included those with a history of
hypersensitivity to any ingredient of the drug,
past history of sclerotherapy or band ligation of
esophagogastric varices (due to their potential
effect on the grade of PHG,(18,19) patients having
grade 2 or 3 esophageal varices with risk signs
of bleeding or with active variceal hemorrhage
(due to their need for immediate endoscopic
intervention by sclerotherapy or band ligation),
patients using β-blockers, mononitrates, proton
pump inhibitors or H2- blockers which may
affect the grade of gastropathy or ulcer healing (20), patients with gastric mucosal infection by
helicobacter pylori(21) and finally patients with
hepatocellular carcinoma. Therapeutic regimen:
After obtaining their written consent, patient's
Group І and П were instructed to blindly take
Rebamipide (Mucosta®; Otsuka pharmaceutical,
Tokushima, Japan) 100 mg tablets tds before
meals for a period of three months, while
patient's Group Ш was instructed to take place-
bo for a period of three months. Clinical and
laboratory assessment: All patients were
subjected to detailed history taking, clinical exa-
mination and Child-Pugh-Turcotte scoring to
assess the severity of liver disease before and
three months after continuous drug therapy.(22)
Routine laboratory investigations included
complete blood picture, blood urea, serum creat-
inine and fasting blood sugar. Liver profile was
assessed in the form of serum albumin, biliru-
bin, serum transaminases and prothrombin time
and activity. Also, baseline serum HBs antigen,
HCV antibodies (3rdgeneration ELISA) and
ocult blood in stool were tested.(23, 24) Abd-
ominal ultrasound was performed at the beg-
inning of the study using a Siemens G50
sonograph, equipped with a 3.5 mHz sector
transducer scanner to verify diagnosis of cirrh-
osis, diameter and patency of portal vein,
splenomegaly as well as the presence and grade
of ascites. Moreover, Doppler ultrasound of
portal circulation was performed before and
three months after drug therapy for assessing the
portal vein congestion index, which was
calculated as the ratio of cross-sectional area of
portal vein (cm2) and mean flow velocity
(cm/sec).(25) Upper gastrointestinal tract endo-
scopy: The procedure was performed for all
patients using a video-endoscopy system (Oly-
mpus GIF-240 and Olympus GIF-260) in two
sessions: before and three months after drug
therapy. In each of the two sessions, the follow-
ing was assessed: - The endoscopic grade
of portal hypertensive gastropathy, which was
classified according to the North Italian Endos-
copic Club (NIEC) classification into: mild
PHG (mosaic pattern of variable degrees but
with no red signs) and severe PHG (any degree
of mosaic pattern in addition to any of the three
red signs: red point lesions, cherry red spots and
black-brown spots).(6) - The presence or absence
of esophageal or gastric varices, their grade and
risk signs. - The presence or absence of gastric
mucosal ulceration and their stage according to
Sakita-Miwa classification as follows.(26) (table1)
Table (1): Sakita-Miwa classification of gastric mucosal ulceration(26)
Stages Manifestation
Active stage A1
(6 points)
The surrounding mucosa is edematously swollen and no regenerating epithelium is
seen endoscopically
Active stage A2
(5 points)
The surrounding edema has decreased, the ulcer margin is clear, and a slight
amount of regenerating epithelium is seen in the ulcer margin. A red halo in the
marginal zone and a white slough circle in the ulcer margin are frequently seen.
Usually, converging mucosal folds can be followed right up to the ulcer margin
Healing stage H1
(4 points)
The white coating is becoming thin and the regenerating epithelium is extending
into the ulcer base. The gradient between the ulcer margin and the ulcer floor is
becoming flat. The ulcer crater is still evident and the margin of the ulcer is sharp.
The diameter of the mucosal defect is about one-half to two-thirds that of A1
Healing stage H2
(3 points)
The defect is smaller than in H1 and the regenerating epithelium covers most of the
ulcer floor. The area of white coating is about a quarter to one-third that of A1
Scarring stage S1
(2 points)
The regenerating epithelium completely covers the floor of ulcer. The white coating
has disappeared. Initially, the regenerating region is markedly red. Upon close
observation, many capillaries can be seen. This is called “red scar”
Scarring stage S2
(1 point)
In several months to a few years, the redness is reduced to the color of the
surrounding mucosa. This is called “white scar”
Gastric mucosal infection with helicobacter
pylori was screened among all patients by rapid
urease test kit, using a gastric mucosal biopsy,
and positive cases were excluded . (21) - Two
gastric mucosal biopsies were taken for histop-
athologic and immunohistochemical study from
gastric fundus and antrum before and three
months after drug therapy.
Histopathological examination of gastric
mucosal biopsies
The two biopsies from gastric mucosa (fundus
and antrum) obtained from each of the patients
before and three months after Rebamipide or
placebo intake were stained by Hematoxylin and
Eosin (H&E) for identification of inflammatory
infiltrate, whereas Periodic Acid Schiff stain
(PAS) was used for better visualization of
mucosal capillaries.(27) Microscopic examination
of the gastric mucosa was carried out by using a
computer-assisted image analysis system. The
severity of portal hypertensive gastropathy was
graded by counting the number of dilated ectatic
capillaries in three consecutive high-power
fields (X400) of the superficial and deep lamina
propria, and the mean of these values was taken
for statistical calculation. The grade of portal
hypertensive gastropathy was scored for the
antrum and the fundus biopsy separately
according to Misra et al(28) as follows: - No PHG
(0): No ectatic capillaries in superficial or deep
lamina propria. - Mild (1): 1-3 dilated ectatic
capillaries in the deep lamina propria - Moderate
(2): More than 3 dilated ectatic capillaries in the
deep lamina propria - Severe (3): Dilated ectatic
capillaries even in the superficial lamina propria
The histopathologic whole stomach score and
grade of PHG were calculated as the sum of
antrum and fundus score for each patient, so that:
score = 0 (No PHG), score 1-2 (mild PHG),
score 3-4 (moderate PHG) and score 5-6 (severe
PHG).
Immunohistochemical study of gastric
mucosal biopsies
Fundus and antrum mucosal biopsies obtained
before and three months after drug therapy were
stained and studied immunohistochemically for
assessing cellular proliferation. Primary mono-
clonal antibodies against proliferating cell nu-
clear antigen (PCNA) as a cell proliferation
marker were used. The antibody was provided
by Lab Vision Corporation (Neo Markers,
Fremont, USA). PCNA-labeled cells and the
total number of cells in standardized rectangles
were counted at 200x magnification. The PCNA
-labeling index (PCNA score) was expressed as
the percentage of labeled cells per all counted
cells.(29)
Statistical analysis
Qualitative data were analyzed using number,
percent and Chi-square test. When more than
20% of the cells had expected count less than 5,
correction for chi-square was conducted using
Monte Carlo correction. Quantitative data were
described using median, minimum, maximum,
mean and standard deviation. For normally
distributed data comparisons between more than
two populations were conducted by F-test
(ANOVA), while Paired t-test was used to
analyze paired data. For abnormally distributed
data, Mann-Whitney test was used to analyze
two independent populations, and Kruskal
Wallis test was used for more than two
populations. Correlations between two quantita-
tive variables were assessed using Spearman
coefficient. Significance test results were quoted
as two-tailed probabilities. Significance of the
obtained results was judged at the 5% level.
Results
The demographic data of patients showed male
predominance in gender, rural predominance in
residence and an age range from 36 to 71 years.
There was no statistically significant difference
between the three groups as regards sex, age or
residence. HCV was positive in 100% of
patients in Groups І and П, and in 95% of Group
Ш, while HBV was positive in 15% of patients
in Group І, 10% of Group П and 5% of Group
Ш. Occult blood in stool was positive in 55% of
patients in Group І, 35% of Group П and 25%
of Group Ш. Blood urea, serum creatinine and
fasting blood sugar values showed no
statistically significant difference from before to
after drug administration. There was a statist-
ically significant improvement of hemoglobin
level in Group І only, its mean value increased
from 8.76 g/dl before drug administration to
9.67 g/dl after drug administration. The platelet
count showed a statistically significant drop
from a mean value of 169.75x103/mm3 before
drug administration to a mean value of
165.05x103/mm3 after drug administration in
patients in Group П only. The platelet count in
Groups І and Ш, however, showed no
statistically significant difference (table 2).
Table (2): Comparison between the three studied groups according to complete blood picture laboratory results before and after
Rebamipide / Placebo
Group I Group II Group III
Hb
(g
/dl)
Before Rebamipide / placebo
Range 6.50 – 11.90 6.80 – 13.0 7.60 – 12.30
Mean ± SD 8.76 ± 2.11 9.99 ± 1.88 9.97 ± 1.43
Median 8.05 9.65 10.20
After Rebamipide / placebo
Range 7.20 – 12.60 7.30 – 113.0 8.0 – 12.60
Mean ± SD 9.67 ± 2.09 15.23 ± 23.08 10.30 ± 1.40
Median 9.05 10.40 10.40
pWX *<0.001 0.210 0.304
WB
C
)3
/mm
3(c
ou
nt
x1
0
Before Rebamipide / placebo
Range 3.60 – 9.30 2.60 – 8.40 2.30 – 9.60
Mean ± SD 5.56 ± 1.40 5.31 ± 1.83 6.08 ± 2.09
Median 5.60 5.15 6.40
After Rebamipide / placebo
Range 2.80 – 8.20 2.90 – 7.80 2.80 – 9.60
Mean ± SD 5.35 ± 1.29 5.61 ± 2.01 6.0 ± 1.91
Median 5.50 6.25 5.90
pt 0.310 0.328 0.783
Pla
tele
t
)3
/mm
3(c
ou
nt
x1
0
pide / placeboBefore Rebami
Range 63.0 – 345.0 88.0 – 397.0 67.0 – 314.0
Mean ± SD 121.90 ± 65.23 169.75 ± 79.82 153.35 ± 62.96
Median 97.0 145.50 138.50
After Rebamipide / placebo
Range 83.0 – 350.0 91.0 – 402.0 54.0 – 386.0
Mean ± SD 125.50 ± 62.31 165.05 ± 82.42 155.50 ± 72.34
Median 102.0 137.0 140.50
pWX 0.167 *0.038 0.925
Hb = Hemoglobin WBC = White blood cells tp:p value for Paired t-testWXp: p value for Wilcoxon signed ranks test between before and after
rebamipide/placebo in each group *: Statistically significant at p ≤ 0.05
Child-Pugh class C patients represented the
majority of all three groups before drug
administration; ranging from 50% to 80%, while
after drug administration it ranged from 45% to
85%. However, the results showed no
statistically significant difference in Child score
or class from before to after drug administration.
Also, the other liver profile parameters showed
no statistically significant difference from
before to after drug administration, (table 3). Table (3): Comparison between the three studied groups according to Child score and class before and after Rebamipide / Placebo
Group I Group II Group III
No % No % No %
Ch
ild
sco
re &
cla
ss Before Rebamipide / placebo
Class A (score 5 – 6) 0 0.0 0 0.0 0 0.0 Class B (score 7 – 9) 8 40.0 10 50.0 4 20.0 Class C (score 10 – 15) 12 60.0 10 50.0 16 80.0
After Rebamipide / placebo Class A (score 5 – 6) 0 0.0 0 0.0 0 0.0 Class B (score 7 – 9) 3 15.0 11 55.0 4 20.0 Class C (score 10 – 15) 17 85.0 9 45.0 16 80.0
P 0.063 1.000 1.000
p: p value for McNemar test *: Statistically significant at p ≤ 0.05
Doppler ultrasound of portal circulation reve-aled that the portal vein flow direction, portal vein diameter, cross sectional area, mean flow velocity and congestion index showed no statistically significant difference from before to
after drug administration. The congestion index of the portal vein ranged from 0.11 to 0.81 in all patients of the three groups before drug therapy, and ranged from 0.12 to 0.76 after drug therapy, (table 4).
Table (4): Comparison between the three studied groups according to Doppler study (PV diameter, cross sectional area, mean
velocity and congestion index of the portal vein) before and after Rebamipide / Placebo
Group I Group II Group III
PV
Dia
met
er (
mm
)
Before Rebamipide / placebo
Range 12.70 – 17.80 12.10 – 17.70 12.10 – 17.30
Mean ± SD 15.59 ± 1.82 14.41 ± 1.77 14.55 ± 1.52
Median 16.0 13.95 14.50
After Rebamipide / placebo
Range 12.80 – 17.70 12.30 – 18.10 12.40 – 17.0
Mean ± SD 16.56 ± 1.75 14.53 ± 1.83 14.46 ± 1.32
Median 15.85 14.25 14.30 tp 0.690 0.071 0.560
Cro
ss s
ecti
onal
are
a
(cm
2)
Before Rebamipide / placebo
Range 1.28 – 2.49 1.24 – 2.44 1.22 – 2.23
Mean ± SD 1.94 ± 0.44 1.67 ± 0.41 1.70 ± 0.32
Median 2.01 1.59 1.78
After Rebamipide / placebo
Range 1.31 – 2.56 1.28 – 2.60 1.28 – 2.19
Mean ± SD 1.93 ± 0.42 1.69 ± 0.42 1.70 ± 0.30
Median 1.98 1.59 1.79
P 0.672 0.339 0.525
Mea
n v
eloci
ty
(cm
/sec
)
Before Rebamipide / placebo
Range 3.10 – 6.50 3.20 – 7.40 2.90 – 7.30
Mean ± SD 4.60 ± 1.05 5.79 ± 1.37 4.96 ± 1.53
Median 4.30 6.10 4.70
After Rebamipide / placebo
Range 3.0 – 6.70 3.50 – 7.60 2.80 – 7.70
Mean ± SD 4.49 ± 1.16 5.79 ± 7.44 5.06 ± 1.47
Median 4.10 6.10 4.90
P 0.360 0.958 0.245
Co
nges
tio
n i
ndex
Before Rebamipide / placebo
Range 0.21 – 0.81 0.18 – 0.77 0.11 – 0.73
Mean ± SD 0.47 ± 0.20 0.33 ± 0.18 0.45 ± 0.21
Median 0.47 0.27 0.42
After Rebamipide / placebo
Range 0.19 – 0.74 0.18 – 0.76 0.12 – 0.75
Mean ± SD 0.47 ± 0.19 0.33 ± 0.19 0.47 ± 0.19
Median 0.48 0.27 0.43
P 0.614 0.525 0.263
PV = Portal vein,tp: p value for Paired t-testp: p value for Wilcoxon signed ranks test between before and after rebamipide/placebo in each
group*: Statistically significant at p ≤ 0.05
Upper gastrointestinal tract endoscopy at the
beginning of the study revealed that 15 patients
(75%) in Groups I and II, and 17 patients (85%)
in Group III had esophageal varices, all without
risk signs of bleeding. The number of columns
of esophageal varices showed no significant
change after drug therapy. There was a
significant rise in the grade of esophageal
varices from before to after drug in both Group І
and Group Ш, while there was no similar
change in Group П. There was also a significant
rise in esophageal varices risk signs only in
Group П after drug therapy, while the difference
was non-significant in both Groups І and Ш,
(table 5).
Table (5): Comparison between the three studied groups according to endoscopic study of varices before and after Rebamipide /
Placebo
Group I Group II Group III
No % No % No %
Eso
ph
agea
l v
aric
es
nu
mb
er
Before Rebamipide / placebo
Range 0.0 – 2.0 0.0 – 2.0 0.0 – 2.0
Mean ± SD 1.15 ± 0.81 0.95 ± 0.69 1.15 ± 0.67
Median 1.0 1.0 1.0
After Rebamipide / placebo
Range 0.0 – 3.0 0.0 – 3.0 0.0 – 2.0
Mean ± SD 1.30 ± 1.03 1.05 ± 0.76 1.50 ± 0.69
Median 1.0 1.0 2.0
P 0.257 0.157 0.439
Eso
ph
agea
l v
aric
es
gra
de
Before Rebamipide / placebo
Range 1.0 – 2.0 1.0 – 2.0 1.0 – 2.0
Mean ± SD 1.67 ± 0.49 1.87 ± 0.35 1.71 ± 0.47
Median 2.0 2.0 2.0
After Rebamipide / placebo
Range 1.0 – 3.0 1.0 – 3.0 1.0 – 3.0
Mean ± SD 2.0 ± 0.65 1.69 ± 0.79 2.0 ± 0.69
Median 2.0 1.50 2.0
P *0.025 0.527 *.0340
Eso
ph
agea
l
var
ices
ris
k s
ign
s
Before Rebamipide / placebo
No 15 100.0 15 100.0 17 100.0
Yes 0 0.0 0 0.0 0 0.0
After Rebamipide / placebo
No 14 93.3 9 60.0 14 82.3
Yes 1 6.7 6 40.0 3 17.7
pM 0.317 *0.014 0.0833
Mp: p value for McNemar test ,p: p value for Wilcoxon signed ranks test between before and after Rebamipide/placebo in each group,*: Statistically
significant at p ≤ 0.05
Endoscopic signs of portal hypertensive
gastropathy (mosaic pattern and mucosal red
signs) showed no significant change after drug
administration. Portal hypertensive gastropathy
NIEC grade was mild in the majority of patients
before drug therapy, ranging from 50% to 80%,
while after drug therapy 40% to 80% of all
patients had mild grade of PHG. There was no
significant change in PHG NIEC score from
before to after drug therapy in any of the three
groups, (table 6, figures 1, 3-5).
Table (6): Comparison between the three studied groups according to the endoscopic study of PHG before and after Rebamipide /
Placebo
Group I Group II Group III
No % No % No %
PH
G N
IEC
sco
re a
nd
gra
de
Before Rebamipide/ placebo
None (0) 0 0.0 0 0.0 0 0.0
Mild (1) 10 50.0 16 80.0 16 80.0
Severe (2) 10 50.0 4 20.0 4 20.0
Range 1.0 – 2.0 1.0 – 2.0 1.0 – 2.0
Mean ± SD 1.50 ± 0.51 1.20 ± 0.41 1.20 ± 0.41
Median 1.50 1.0 1.0
After Rebamipide / placebo
None (0) 2 10.0 0 0.0 0 0.0
Mild (1) 8 40.0 16 80.0 14 70.0
Severe (2) 10 50.0 4 20.0 6 30.0
Range 0.0 – 2.0 1.0 – 2.0 1.0 – 2.0
Mean ± SD 1.40 ± 0.68 1.20 ± 0.41 1.30 ± 0.47
Median 1.50 1.0 1.0
P 0.414 1.000 0.414
PHG = Portal hypertensive gastropathy ,NIEC = North Italian Endoscopy Club,p: p value for Wilcoxon signed ranks test between before and after
rebamipide/placebo in each group *: Statistically significant at p ≤ 0.05
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Group I Group II Group III
Mea
n o
f P
HG
NIE
C
Before rebamipide / placebo
After rebamipide / placebo
Figure (1): Comparison between the three studied groups according to PHG NIEC score of the stomach before and after
Rebamipide / Placebo
In patients’ Group II, 90% of gastric ulcers were
present in the antrum and 10% were in the body
of the stomach. The gastric ulcer score ranged
from 4 to 6 before drug therapy, with a median
value of 5.0. After drug therapy, the ulcer score
ranged from 1 to 5, with a median value of 2.0.
The drop in endoscopic ulcer score after drug
therapy was statistically significant. Active ulcer
stages represented the majority of presenta-
tionsat the beginning of the study; with 25% of
patients at stage A1 and 40% of patients at stage
A2. After drug therapy, most ulcers were classi-
fied as scarring stage; with 30% of patients at
stage S1 and 45% of patients at stage S2. The
drop in endoscopic ulcer stage after drug
therapy proved to be significant, (table 7, figures
2, 6-8).
Table (7): Comparison of the endoscopic gastric ulcer score and stage according to Sakita Miwa classification (26)
in study Group II before and after Rebamipide/Placebo
Group II
No %
En
do
sco
pic
Ulc
er s
tag
e (s
core
)
Before Rebamipide / placebo
A1 (6 points) 5 25.0
A2 (5 points) 8 40.0
H1 (4 points) 7 35.0
After Rebamipide / placebo
A1 (6 points) 0 0.0
A2 (5 points) 1 5.0
H1 (4 points) 1 5.0
H2 (3 points) 3 15.0
S1 (2 points) 6 30.0
S2 (1 point) 9 45.0
Before Rebamipide / placebo
Range 4.0 – 6.0
Mean ± SD 4.90 ± 0.79
Median 5.0
After Rebamipide / placebo
Range 1.0 – 5.0
Mean ± SD 1.95 ± 1.15
Median 2.0
P <0.001*
p: p value for Wilcoxon signed ranks test between before and after Rebamipide/placebo in each group
*: Statistically significant at p ≤ 0.05
0
5
10
15
20
25
30
35
40
45
50
A1 A2 H1 H2 S1 S2
Mea
n o
f E
nd
osco
pic
Ulc
er s
tage
Before rebamipide / placebo
After rebamipide / placebo
Figure (2): Comparison of the endoscopic gastric ulcer score and stage according to Sakita Miwa classification(26)
in study Group II before and after Rebamipide/Placebo
Figure (3): Upper gastrointestinal tract endoscopy
showing mild PHG (Mild mosaic pattern)
Figure (4): Upper gastrointestinal tract
endoscopy showing mild PHG (Moderate
mosaic pattern)
Figure (5): Upper gastrointestinal tract endoscopy
showing severe PHG -red spots of the fundal
mucosa on background of mosaic pattern
Figure (6): Upper gastrointestinal tract endoscopy
showing stage H1- multiple small gastric ulcers at the
antrum of the stomach
Figure (7): Upper gastrointestinal tract endoscopy
showing stage A2- large gastric ulcer surrounded
by multiple smaller linear ulcers at the body of the
stomach
Figure (8): Upper gastrointestinal tract
endoscopy showing stage H2- linear gastric
ulcer at the antrum of the stomach
Histopathologic examination of gastric mucosal
biopsies revealed that there was no significant
change in the histopathologic score or grade of
PHG from before to after drug therapy, neither
in the fundus, nor the antrum, nor in the “whole
stomach” score, which was calculated as the
sum of fundus and antrum, (table8, figures 9-12)
Table (8): Comparison between the three studied groups according to histophathologic all over stomach score and grade of PHG
before and after Rebamipide / Placebo
Group I Group II Group III
No % No % No %
His
top
atho
log
ic S
tom
ach
sc
ore
& g
rad
e
of
PH
G
Before Rebamipide/ placebo
Mild (score 1-2) 6 30.0 6 30.0 3 15.0
Moderate (score 3-4) 7 35.0 9 45.0 14 70.0
Severe (score 5-6) 7 35.0 5 25.0 3 15.0
After Rebamipide / placebo
Mild (score 1-2) 7 35.0 8 40.0 4 20.0
Moderate (score 3-4) 6 30.0 9 45.0 10 50.0
Severe (score 5-6) 7 35.0 3 15.0 6 30.0
Before Rebamipide/ placebo
Range 2.0 – 6.0 1.0 – 6.0 2.0 – 6.0
Mean ± SD 3.60 ± 1.35 3.30 ± 1.42 3.75 ± 1.02
Median 3.50 3.0 4.0
After Rebamipide / placebo
Range 1.0 – 6.0 1.0 – 6.0 1.0 – 6.0
Mean ± SD 3.55 ± 1.79 2.95 ± 1.47 3.75 ± 1.29
Median 3.50 3.0 4.0
P 0.977 0.244 1.000
p: p value for Wilcoxon signed ranks test between before and after Rebamipide/placebo in each group
*: Statistically significant at p ≤ 0.05
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Group I Group II Group III
Mea
n o
f H
isto
path
olo
gic
Sto
mach
sco
re o
f P
HG
Before rebamipide / placebo
After rebamipide / placebo
Figure (9): Comparison between the three studied groups according to histopathologic stomach score of PHG
Figure (10): Light microscopic picture (X 400) of
gastric mucosa with special stain (PAS) showing a
few ecstatic capillaries in the deep lamina propria, a
case of mild PHG.
Figure (11): Light microscopic picture (X 400) of
gastric mucosa with special stain (PAS) showing
multiple ectatic capillaries in the deep lamina
propria, a case of moderate PHG.
Figure (12): Light microscopic picture (X 400) of
gastric mucosa with special stain (PAS) showing
multiple ectatic capillaries in the superficial and
deep lamina propria, a case of severe PHG.
Immunohistochemical study of gastric mucosal
biopsies showed a significant rise in PCNA
scores of the antrum and the fundus mucosa in
Groups І and П, while there was no similar
change in Group Ш. The PCNA score of whole
stomach was calculated as the mean value of the
antrum and fundus PCNA scores for each
patient, demonstrating a significant rise in
PCNA expression by the stomach mucosa in
Groups І and П, while no similar change was
measurable in Group Ш, (table 9, figures 13-
17).
Table (9): Comparison between the three studied groups according to PCNA score of the antrum, fundus and whole stomach
before and after Rebamipide / Placebo
Group I Group II Group III
PC
NA
sco
re (
antr
um
)
Before Rebamipide / placebo
Range 24.0 – 98.0 0.0 – 89.0 24.0 – 86.0
Mean ± SD 67.75 ± 22.04 45.95 ± 27.44 50.0 ± 21.26
Median 72.50 47.50 41.0
After Rebamipide / placebo
Range 31.0 – 98.0 43.0 – 98.0 20.0 – 97.0
Mean ± SD 81.40 ± 20.99 75.85 ± 17.72 50.80 ± 19.90
Median 87.50 79.0 45.0
P 0.001* <0.001* 0.285
PC
NA
sco
re (
fund
us)
Before Rebamipide / placebo
Range 24.0 – 87.0 0.0 – 88.0 15.0 – 94.0
Mean ± SD 55.35 ± 20.98 44.40 ± 24.18 50.90 ± 26.02
Median 52.50 41.50 44.50
After Rebamipide / placebo
Range 22.0 – 98.0 26.0 – 98.0 18.0 – 96.0
Mean ± SD 76.40 ± 22.27 69.90 ± 21.73 56.20 ± 24.50
Median 86.0 68.0 58.50
P <0.001* <0.001* 0.073
PC
NA
sco
re (
sto
mac
h)
Before Rebamipide / placebo
Range 27.0 – 88.0 0.0 – 86.0 21.0 – 83.0
Mean ± SD 61.75 ± 20.15 45.35 ± 24.51 50.75 ± 21.02
Median 69.50 45.50 51.0
After Rebamipide / placebo
Range 27.0 – 98.0 35.0 – 98.0 20.0 – 97.0
Mean ± SD 79.05 ± 20.84 72.75 ± 18.27 53.90 ± 20.11
Median 87.0 78.50 52.50
P <0.001* <0.001* 0.150
p: p value for Wilcoxon signed ranks test between before and after Rebamipide/placebo in each group
*: Statistically significant at p ≤ 0.05
0
10
20
30
40
50
60
70
80
90
100
Group I Group II Group III
Mea
n o
f P
CN
A s
core
sto
ma
ch
Before rebamipide / placebo
After rebamipide / placebo
Figure (13): Comparison between the three studied groups according to PCNA score stomach
Figure (15): Light microscopic picture (X 400) with
PCNA immunostain showing rare positive (brown)
stain of nuclei before drug therapy (+ve), indicating
low mucosal cellular proliferation.
Figure (14): Light microscopic picture (X 400) with
PCNA immunostain showing negative stain of all
nuclei before drug therapy, indicating absence of
mucosal cellular proliferation.
Figure (17): Light microscopic picture (X 400) with
PCNA immunostain showing diffuse strong positive
(brown) stain of all nuclei after drug therapy
(+++ve).
Figure (16): Light microscopic picture (X 400) with
PCNA immunostain showing positive (brown)
nuclear stain involving moderate amount of nuclei
(++ve), indicating moderate mucosal cellular
proliferation.
A strong negative correlation was found
between occult blood in stool and hemoglobin
level in Groups І and П. On the other hand,
there was a strong positive correlation between
endoscopic portal hypertensive gastropathy
NIEC score and occult blood in stool in all three
groups. Strong positive correlations were also
found between the Child score and portal vein
congestion index in the three groups, and
between the Child score and PHG NIEC score
in Groups І and П. In addition, significant
positive correlations were found between the
portal vein congestion index and portal
hypertensive gastropathy NIEC score in the
three groups, and between the portal vein
congestion index and histopathologic stomach
score of PHG in Groups І and П. Lastly there
was no correlation between the histopathologic
stomach score of PHG and the PCNA score of
the stomach in any of the three studied groups,
neither before nor after drug therapy except for
a weakly significant one in Group Ш before
drug therapy, (table 10).
Table (10): Correlation of portal vein congestion index with PHG NIEC score and histopathologic stomach score of PHG in the
different studied groups at the beginning of the study
Portal vein congestion index
Group I Group II Group III
Rho P Rho p rho p
PHG NIEC score 0.729 <0.001* 0.694 0.001* 0.488 0.029*
Histopathologic stomach score of
PHG 0.574 0.008* 0.567 0.009* 0.404 0.078
R : Spearman coefficient*: Statistically significant at p ≤ 0.05
A significant positive correlation was detected
between the inflammatory infiltrate and PCNA
score of the antrum and the fundus in all three
groups, both before and after drug therapy. The
higher the PCNA score, the higher was the value
of the inflammatory infiltrate, (table 11).
Table (11): Correlation between inflammatory infiltrate and PCNA score of the antrum and fundus in the different studied groups
before and after Rebamipide / Placebo administration
Inflammatory infiltrate
Group I Group II Group III
Rho P Rho p rho p
PC
NA
sco
re
Antrum
Before Rebamipide /
Placebo 0.773 <0.001* 0.576 0.008* 0.759 <0.001*
After Rebamipide /
Placebo 0.916 <0.001* 0.716 <0.001* 0.488 0.029*
Fundus
Before Rebamipide /
Placebo 0.746 <0.001* 0.520 0.019* 0.499 <0.001*
After Rebamipide /
Placebo 0.797 <0.001* 0.753 <0.001* 0.306 0.190
Rho ( : Spearman coefficient*: Statistically significant at p ≤ 0.05
Discussion
Portal hypertensive gastropathy (PHG) has
emerged as a new clinical and pathological
entity among the complications of advanced
liver cirrhosis. It has been identified as a frequ-
ent cause of acute and chronic upper gastro-
intestinal hemorrhage; 10-20% of bleeding
episodes occurring in cirrhotic patients are
caused by this condition, with high incidence of
morbidity and mortality.(8) The patients included
in the present work were chosen to have positive
endoscopic evidence of PHG. Occult blood in
stool was tested for all patients at the beginning
of the study; it was positive in up to 55% of
patients, and it showed a positive correlation
with the endoscopic score of PHG. Also, there
was a significant negative correlation between
occult blood in stool and hemoglobin level in
patients of Groups І and П. In other words; the
higher the severity of PHG, the more likely did
the patients test positive for occult blood in
stool, and the more severe was their anemia. In
accordance to these findings, Primignani et al.
stated in their study that the main clinical
presentation of PHG was in the form of severe
anemia and chronic gastrointestinal (GI) blood
loss, manifested by accidental discovery of
occult blood in stool, rather than frank GI
bleeding (incidence 12% versus 2.5% among
PHG patients, respectively).(30) Several factors
were suggested to affect the grade of PHG; like
the severity of the liver disease and the severity
of portal hypertension. In the present study, a
significant positive correlation was found betw-
een PHG NIEC score and Child-Pugh score in
all patients. The higher the Child-Pugh score,
the more severe was the grade of PHG. Another
significant positive correlation was found betw-
een portal hypertensive gastropathy NIEC score
and the portal vein congestion index in all our
patients. The higher the value of portal vein
congestion index, the more severe was the grade
of gastropathy. In the same context, Sarin et al.
investigated factors affecting the severity of
PHG in 107 patients with different etiologies of
portal hypertension. Their results demonstrated
a significant influence of liver disease severity
on the development and grade of gastropathy.(18)
Kim et al. also found that the hepatic venous
pressure gradient (HVPG), which is a classic
method for portal venous pressure determin-
ation, was significantly higher in patients with
severe PHG than in those with mild or no
PHG.(31) An important sequel of PHG is incre-
ased susceptibility of gastric mucosa to injury
by noxious factors as non-steroidal anti-inflam-
matory drugs, alcohol and helicobacter pylori
infection. Experimental evidence has also dem-
onstrated an impaired gastric mucosal healing
response to such injuries.(9) So far, beta-blockers
seem to be the only effective treatment for this
condition; acting by decreasing portal pressure. (32) Therefore, the aim of our work was to
evaluate (endoscopically and histopathology-
ically) the benefits and/or hazards of a new
therapeutic agent, Rebamipide, on PHG among
cirrhotic patients. The patients enrolled in our
study were divided into three groups: Patient's
Group І and П were instructed to take
Rebamipide, while patient's Group Ш was instr-
ucted to take placebo for a period of three
months. As regard the Child- Pugh score and
other liver profile parameters, our results
showed no significant change after drug admini-
stration, except for an isolated drop of ALT
level in Group П patients. Only few studies have
attempted to evaluate the effect of Rebamipide
on liver functions. Taniguchi et al. studied the
protective effect of anti-ulcer agents on ethanol-
induced gastric mucosal lesions and D-
galactosamine-induced hepatitis in rats, and
showed that Rebamipide had only little effect in
the form of some insignificant decline of serum
ALT and AST levels.(33) Other routine labo-
ratory results were also evaluated in the course
of our work. Baseline fasting blood sugar level,
blood urea and serum creatinine were measured
for all patients and showed no significant
change after drug administration. In comparison,
a study by Ha et al. investigated whether
Rebamipide could ameliorate the pathoph-
ysiology associated with experimental diabetes
in vivo. They found that Rebamipide showed no
effect on the glycemic level and that it atten-
uated high glucose-induced nephropathy by its
antioxidative properties.(34) Complete blood
picture of our patients demonstrated a signi-
ficant improvement of hemoglobin level after
drug administration in Group І only, while no
similar change was found in Groups П and Ш.
This isolated change in Group I could be
attributed to the fact that some patients received
blood transfusion over the course of the study
rather than the effect of Rebamipide itself. In
fact, the absence of similar hemoglobin level
improvement in Group II, who also received
Rebamipide for three months, suggests that this
hemoglobin level improvement is probably
Rebamipide independent. On the other hand,
thrombocytopenia was detected in most of our
patients at the beginning of the study, and a
statistically significant drop in platelet count
occurred after drug administration in patients’
Group П only (p=0.038). The platelet count in
Groups І and Ш, however, showed no similar
change. These results raise the important
question of whether the drop of platelet in
Group П was Rebamipide induced or not.
Indeed, thrombocytopenia has been reported as
an infrequent side effect of Rebamipide on
www.drugcite.com, a web site of the American
Food and Drug Administration (FDA) Adverse
Event Reporting System (AERS) which is
specialized in keeping a record on the adverse
effects of FDA approved drugs as reported by
customers.(35) However, no clinical studies have
been conducted so far to prove or deny the
significance of this finding. Besides, the absence
of similar drop of platelet count in patients’
Group І, who also received Rebamipide,
suggests that this drop might have been a
coincidental feature of liver disease progression
due to either hypersplenism, platelet-associated
immunoglobulins, or decreased serum thrombo-
poietin level, rather than the effect of Reb-
amipide itself.(36) Portal hypertension has been
agreed upon by most authors as a prerequisite
for the development of PHG.(37) In fact, the
reduction in portal pressure is the effective
mechanism behind the success of beta-blockers
in the treatment of PHG.(11) Therefore, we
assessed the portal vein hemodynamic para-
meters using pulse Doppler technique before
and after drug administration, where no
significant change was detected in any of the
three groups in response to drug administration.
These results seem to be expected, because
Rebamipide has never been reported to exert
any action on blood vessel wall or to affect the
hemodynamics of the portal circulation. Never-
the less, no comparable studies are available up
till now to prove or contradict these results.
Upper GI endoscopy revealed that esophageal
varices were a finding in many of our patients at
the beginning of the study. However, no patients
with variceal risk signs of bleeding were
included due to their need for urgent endoscopic
intervention. After three months of Rebamipide/
placebo administration, the grade of esophageal
varices showed significant rise in Groups І and
Ш, while Group П showed no change. Esop-
hageal varices risk signs of bleeding also
showed a significant rise in Group II only,
whereas Groups I and III showed no such
change. Again, no literature is available so far to
support or contradict these results. So, the
question is raised whether or not these findings
were Rebamipide induced. The significant rise
of variceal grade in Groups І and IП versus its
absence in Group II suggests that the drug is
probably innocent. Similarly, the appearance of
variceal risk signs of bleeding in Group П
versus their absence in Groups І and Ш suggests
that this might not be the effect of Rebamipide
but rather a coincidental feature of progressing
portal hypertension.(38) The endoscopic signs of
PHG were assessed in all patients before and
after drug administration, and they were
expressed in the form of PHG NIEC score. The
majority of patients had mild grade of PHG
before drug therapy, ranging from 50% to 80%,
while after drug therapy 40% to 80% of all
patients had mild grade of PHG. There was no
statistically significant change in PHG NIEC
score to after drug therapy in any of the three
groups. Similar to our results, a study by
Kijdamrongthum et al. was performed on eight
patients with endoscopic evidence of PHG.
Despite admitting the very small sample size,
they concluded that Rebamipide did not show
any improvement of PHG in this study. In fact,
their results actually demonstrated worse PHG
scores in the Rebamipide group compared to the
placebo group, but the difference was not
statistically significant. Also, no statistically
significant difference occurred in Child-Pugh
score or blood hemoglobin levels in the two
groups after Rebamipide administration for 12
weeks.(39) In the present work, study Group П
was chosen from patients with PHG and gastric
mucosal ulcers, which were endoscopically
assessed according to Sakita Miwa classify-
cation. Ninety percent of ulcers were present in
the antrum and ten percent were in the body of
the stomach. This finding was not different from
the results of Chiba et al, who stated in their
work that 60% of gastric disorders induced by
NSAIDs or other noxious agents affect the
antrum of the stomach.(40,26) The gastric ulcer
score according to Sakita-Miwa classification
showed a median value of 5.0 before drug
therapy, which significantly dropped to a
median value of 2.0 after Rebamipide therapy.
This beneficial effect of Rebamipide on gastric
ulcer healing is not novel; it has been already
well investigated and even compared to proton
pump inhibitors by various authors.(26,41,42)
However, almost no studies have attempted to
evaluate this effect microscopically. In our
work, a histopathologic evaluation of PHG was
performed before and three months after
Rebamipide/placebo intake. The histopathologic
whole stomach score of PHG was calculated as
the sum of antrum and fundus score for each
patient, and no significant change was recorded
in any of the three groups after drug admini-
stration. Similar to our endoscopic NIEC score
results of PHG, the histopathologic stomach
score of PHG showed a significant positive
correlation with the portal vein congestion index
at the beginning of the study. The higher the
value of congestion index, the higher was the
histopathologic stomach score of PHG. These
findings can be compared to the results of a
study by Madkour et al, who reported a
significant positive correlation between the
histopathologic and endoscopic grades of PHG,
with a specificity of 81.7% of the histopatho-
logic grading system.(43) Moreover, we perfo-
rmed immunohistochemical study of gastric
mucosal biopsies of our patients before and
three months after drug therapy for assessing the
proliferating cell nuclear antigen (PCNA)
expression in the gastric mucosa, which is
considered to be a useful tool for assessing the
proliferative activity of gastric mucosa during
the ulcer healing process.(16) In fact, studies
have shown a close relation between PCNA
score and both, inflammatory process and
gastric ulcer healing.(44) Similarly, our results
showed a significant positive correlation
between the inflammatory infiltrate and PCNA
score of the antrum and fundus in all three
groups, both before and after drug therapy. On
the other hand, there was no significant
correlation between histopathologic stomach
score of PHG and the PCNA score of the
stomach in any of the three studied groups,
neither before nor after drug therapy. From
these two findings we could conclude that the
PCNA score of the stomach is a good reflection
of the inflammatory process as well as healing
process of the gastric mucosa, whereas it is
completely irrelevant to the grade of PHG.
Interestingly, a decreased expression of PCNA
in the gastric mucosa of portal hypertensive rats
was recently described by two studies, and
hence was added to the possible mechanisms of
impaired healing power in portal hypertensive
gastric mucosa.(9,17) In our work, we assessed the
PCNA expression by the antrum, fundus and
whole stomach mucosa for all patients before
and after drug administration. After drug admin-
istration, there was a significant rise in PCNA
score in Groups І and П, while there was no
similar change in Group Ш. From these finding
we concluded that Rebamipide could achieve a
significant improvement of gastric epithelial
proliferation, as indicated by PCNA expression,
in both non-injured (Group І) and injured
(Group П) gastric mucosa of patients with PHG,
in contrast to failure of epithelial proliferation in
patients receiving placebo (Group Ш). Similar
results were demonstrated so far only on rat
models in a study by Kinjo et al. In their study,
the use of Rebamipide as a gastroprotective drug
and oxygen free radical scavenger succeeded to
normalize the oxidative state and to completely
reverse the impaired PCNA expression back to
normal, hence improving mucosal healing.(10)
From the results of the present work we
concluded that Rebamipide does not have a
significant effect on the grade of PHG, neither
endoscopically, nor microscopically. However,
Rebamipide significantly increases the healing
capacity of the ulcerated as well as non-
ulcerated gastric mucosa in patients with PHG,
as proved by the significant rise in the gastric
mucosal expression of PCNA after Rebamipide
therapy. The use of Rebamipide is, therefore,
recommended for the treatment of PHG-assoc-
iated gastric ulcers and mucosal injuries.
However, its use as monotherapy in the treat-
ment of PHG is not recommended, as it has no
effect on the grade of PHG. Further research is
also needed to clarify the effect of Rebamipide
on platelet count in patients with liver cirrhosis
and portal hypertension.
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Original Article
Accidentally Discovered Patients with Antibody to Hepatitis C Virus: Clinical,
Biochemical , Virologic , Ultrasonic and Histologic Features
Ahmed Faisal MD1; Abdel-Naser Gad allah MD2 , Ashraf zytoon MD3 ,Infectious and endemic diseases unit1, Internal
Medicine department, Suez Canal university; Internal Medicine department, Al Monofyia university,2 Radiology department3
Al Monofyia university.
ABSTRACT
To assess the clinical significance of antibody to hepatitis C virus (anti-HCV) in volunteer blood donors. Prospective cohort
study in blood bank of Suez general hospital and Menoyifia University Hospital. Patients: One hundred twenty four
accidentally discovered positive HCV-antibody, most of them are volunteer blood donors (identified as positive for anti-
HCV by first- or second-generation enzyme immunoassay (EIA-1 or EIA-2 according to availability they were followed up
for a minimum two years. Measurements: Medical history, results of laboratory and virologic testing, and percutaneous
liver biopsy findings. Results: Participants with normal alanine aminotransferase levels were older and more often female
than those with abnormal levels. The source of infection, duration of disease, symptom score, and amount of alcohol
consumed were similar in the three groups. Hepatitis C virus RNA was detectable in 85% of participants, more commonly in
the groups with elevated alanine aminotransferase levels (95%) than in the group with normal levels (65%); however, titers
were similar in all groups. Examination of liver biopsy specimens showed chronic hepatitis in 54 participants (90%) and
cirrhosis in 1 participant. The only normal liver biopsy specimens (n = 3) were those from participants who were HCV RNA
negative and had normal alanine aminotransferase levels. Conclusions : Most blood donors with anti-HCV antibodies have
chronic hepatitis C regardless of their serum alanine aminotransferase levels. Donors with normal alanine aminotransferase
levels and no HCV RNA in their serum generally have normal liver histologic findings or minimal changes and have
probably recovered from HCV infection.
Introduction
The discovery of hepatitis C virus (HCV) by
molecular techniques (1) was soon followed by
the development of sensitive and specific assays
for the detection of antibody to HCV (anti-
HCV) in serum (2).These assays have shown that
HCV causes most cases of post transfusion
hepatitis and that screening blood donations for
anti-HCV eliminates 80% to 90% of cases of
hepatitis C (3) . In the United States, approx-
imately 0.4% of blood donors and 1.4% of the
general population test positive for anti-HCV (4).
The initiation of routine screening of blood
donors for anti-HCV has led to a marked
decrease in the incidence of post-transfusion
hepatitis C (3) . The initiation of routine
screening of blood donors has also led to the
identification of many persons with anti-HCV
who are asymptomatic, have no history of liver
disease, and deny any risk factors for exposure
to viral hepatitis. These blood donors who test
positive for anti-HCV are informed by blood
bank personnel of their serologic status and are
advised to consult their private physicians for
evaluation . However, the clinical significance
of finding anti-HCV in these otherwise healthy
persons is unclear. Previous studies have shown
that 60% to 80% of blood donors with anti-HCV
have elevated serum aminotransferase levels; in
most cases, these elevations are persistent,
indicating the presence of chronic hepatitis.
Furthermore, most anti-HCV-positive blood
donors can be shown by molecular techniques to
harbor HCV RNA in serum and can transmit
hepatitis C regardless of whether serum
aminotransferases are elevated (5,6) . Studies of
liver histologic findings in healthy blood donors
with anti-HCV indicate that most of these
donors have chronic hepatitis, despite the
absence of symptoms or abnormal serum
aminotransferase levels (7). Thus, the clinical
significance of the presence of anti-HCV in
volunteer, apparently healthy blood donors
remains uncertain. To better define the natural
history of chronic hepatitis C in this population,
we have initiated a long-term study of volunteer
blood donors found to have anti-HCV on routine
testing. An initial cohort of these donors has had
extensive medical evaluation, including liver
biopsy.
Aim of work
Long-term, accurate natural history data are
needed to better understand the pathogenesis of
the disease and to determine which patients need
treatment now, which ones can wait for more
effective treatment, and which ones will pro-
bably never need treatment. The high prevalence
of HCV antibody among asymptomatic volun-
teer blood donors, and the contradictory views
about the outcome of HCV infection motivated
us to study the natural history of HCV infection
among this cohort group, to answer these ques-
tions: What is the significance of the presence of
anti-HCV antibodies in these asymptomatic
individuals? What are the risk factors associated
with the infection? What proportion of antibody
-positive individuals has viremia and chronic
infection? What proportion has significant liver
disease? What insights can be derived from
asymptomatic donors in assessing the natural
history of HCV infection? In the spectrum of
HCV associated disorders, what proportions are
associated with extrahepatic disorders? What
proportion are represented by relatively benign
disease seen in donors, what proportion progress
to severe disease?
Patients and Methods
Participants: The studied sample included one
hundred and twenty four accidentally discovered
positive HCV-antibody, most of them are
volunteer blood donors, of both sexes, at the age
group 15-50 years. Subjects who had evidence
of decompensated chronic liver disease, HBs Ag
positive, chronic exposure to hepatotoxic agents
in the last 6 months, or received anti-viral
therapy for HCV infection before one year of
follow up were excluded from the study. All
subjects who proved to have anti-HCV antibody
and agreed to enter the study were exposed to
the following baseline assessment; which
included complete history taking and clinical
examination . Abdominal U/S, liver function
tests, ALT, AST, prothrombin time, serum
bilirubin, serum albumin, random blood glucose
, and HCV-RNA by polymerase chain reaction
(PCR) were done. Every 3-4 months, clinical
history and examination, laboratory investti-
gation as ALT, AST, PT, serum bilirubin, and
serum albumin were done. Abdominal U/S was
done every 6 months. Liver biopsy was done in
86 patients, and repeated at least after one year
of follow-up in 31 patients. Biopsy specimens
were histopathologically evaluated to determine
the grade of necroinflammatory changes, acc-
ording to histologic activity scoring system, and
the stage of fibrosis, according to The META-
VIR scoring system. Mixed Cryoglobulins and
serum ferritin were done in 80 patients, and
bilharzial serology in 103 subjects. Statistical
Analysis: Continuous variables were analyzed
by one-way analysis of variance with post hoc
Student t-tests. Discrete variables were analyzed
by the chi-square test with Yates' correction and
by the Fisher exact test.
Results
The present study was done on 124 anti-HCV-
positive accidentally discovered subjects (about
90% of them discovered that during blood
donation) , None of the participants was aware
of having hepatitis before attempting to donate
blood. Basic demographic data: The demo-
graphic and clinical characteristics of the sub-
jects are shown in table 1. Out of them 88
(71.0%) male, and 36 (29.0%) female, their ages
ranged between (18-53y) with a mean of (36.3
+7.4y). Seventy-one of them live in urban area,
the rest live in rural areas. About 77.5% of
subjects were married, and 19.3 were single.
They were of different educational levels (16.1
% illiterates, 16.1% read and write, 41.9% basic,
16.9% secondary, and 8.9% university). Most of
them have sedentary work. About 31% of
subjects were smokers, and only 2.4% were
consuming alcohol. Medical history and
baseline clinical data & specialized tests: Table
1 shows medical history and baseline clinical
data in the study subjects, including some of risk
factors expected to be associated with HCV
infection. Among 124 subjects; positive history
of dental procedure or surgical intervention was
the most frequent risk factor as was present in
83 (66.6%), followed by past history of tartar
emetic injection 57(46 %), and family history of
HCV 24(19.4%). History of blood transfusion
was present in only 17(13.7%), while common
sharing of razors, and toothbrushes was the least
frequent risk factor 4(3.2)%. Past history of
schistosomiasis was present 72(58.1%), positive
history of exposure schistosomal infection in 40
(32.3%), past history of jaundice was present in
about 8%, 58.9%were asymptomatic, and high
body mass index (> 25) in 86 (69.4%). Although
all subjects denied any symptoms at time of
blood donation, or discovering anti-HCV anti-
body, many of them noted symptoms on inquiry
by the researcher after being tested positive for
HCV antibody, and during the subsequent
follow up. PCR for HCV RNA qualitatively was
positive in 102/111(91.9%) subjects, mixed
Cryoglobulins was positive in 5/80 subjects,
serum ferritin was high in 9/80subjects, bil-
harzial serology was positive in 36/103(35%).
Clinical manifestation & Extrahepatic mani-
festations: Table 2 shows the frequency of
different symptoms which elicited on the first
visit, The most common symptoms were hyper-
somnia in 25(20.1%) subjects, fatigue 23
(18.5%), bleeding per gum after teeth brushing
10(8.0%), right quadrant pain 16(12.9%), abd-
ominal distention after meals 16(12.9%), pass-
ing deep yellow urine 9(7.2%), weight loss 4
(3.2), anorexia 4(3.2%), dizziness 4(3.2%), and
Pruritus 3(2.4%). No one was complaining of
fever, lower limb edema, disturbed menstru-
ation, impotence, or clinical jaundice, and most
participants reported that the symptoms were
mild and did not interfere with daily activities or
work. None of these participants was seeing a
physician for these symptoms, and none had a
concurrent disease or were regularly taking any
medications. At the end of 24 months follow
up. The most common symptoms were hyper-
somnia 32 (25.8%), fatigue 30 (24.2%), blee-
ding per gum after teeth brushing 18 (14.5%),
right quadrant pain 18 (14.5%), abdominal
distention after meals 21(16.9%), passing deep
yellow urine 16(12.9%), weight loss 6 (4.8%),
anorexia 5 (4%). Fever, dizziness, and Pruritus
were uncommon, each 4(3.2%), and only one
subject was complaining of clinical jaundice,
and most participants reported that the symp-
toms were mild and did not interfere with daily
activities or work, and these symptoms had not
related to concurrent disease. Table 2 shows the
frequency of different signs in the study group;
on first presentation, pallor was present in
5(4.0%), the liver was found to be enlarged in
28(22.6%) of the subjects, splenomegaly in 4
(3.2%), and skin rash in 5 (4%), each of these
signs; lower limb edema, palmar erythema,
finger clubbing, spider naive, jaundiced sclera,
ascites , encephalopathy or flapping tremors
were not detected in the study subjects. After 24
months, pallor was present in 7 (5.6%), the liver
was found to be enlarged in 35(28.2%) of the
subjects, splenomegaly in 11(8.9%), and skin
rash in (5/124), each of these signs; lower limb
edema , palmar erythema, finger clubbing, spid-
er naevie, jaundiced sclera were present in less
than 4 (3.2%), no case of ascites , encephalo-
pathy or flapping tremors were detected in the
study subjects. Extrahepatic manifestations
appeared in the study group on first presentation
were; joint pain was the most frequent extra-
hepatic symptom present in 18(14.5%) subjects,
vasculitic skin lesions in 3(2.4%), each of,
vetiligo, and neuropathy in 2 (1.6%), and lichen
planus in only 1(0.8%) subjects. The extra-
hepatic manifestations appeared in the study
group after 24 months follow up: Thirty six out
of 124 subjects developed, one or more of
studied extrahepatic manifestations, as joint pain
was the most frequent extrahepatic symptom
present in 23(18.5%) subjects, vasculitic skin
lesions in 5 (4%), and each of lichen planus,
vetiligo, and neuropathy in 2 (1.6%) subjects.
Biochemical findings: Table 3- shows baseline
Liver functions tests, and after 24 months follow
up among 124 subjects:. seventy five (60.5%)
subjects has normal level (AST >48u/l), 31
(25%) subjects has mild elevation (AST= >
48:100u/l), and 18(14.5%) has moderate elev-
ation (AST=>100: 400 u/l). ALT levels ranged
from 3-290u/l. seventy one (57.3%) subjects has
normal ALT level, 36(29%) has mild elevation,
and 17(13.7%) has moderate elevation, 8(6.5%)
has total serum bilirubin > 1.1mg/dl, no one has
serum albumin < 3.5mg/dl, and 4 (3.2%)
subjects has prothrombin <80%. After 24
months of follow up; it was found that AST
level ranged from 8- 400u/l. seventy seven
(62.1%) subjects had normal levels, 30(24.2%)
subjects had mild elevation, and 17(13.7%) has
moderate elevation. ALT levels ranged from
10-290 u/l, 73(58.9%) subjects had normal
level, 35(28.2%) had mild elevation, and 16
(12.9%) had moderate elevation, 10/124(8.1%)
has total serum bilirubin > 1.1mg/dl, and only
one had serum albumin < 3.5 mg / dl, and 5/124
(4%) subjects had prothrombin <80%. Table 3
shows the pattern of liver transaminases through
the 24 months of follow up, ALT level was
persistently normal in 51(41.1%) subjects,
Fluctuating in 36(29.1%), and persistently in
37(29.8%), while AST level was persistently
normal in 50/124(40.3%) subjects, Fluctuating
in 36(29.1%), and persistently in 38(30.6%)
subjects. Blood picture of study group: Table 2-
shows the baseline blood profile among study
group (n.109), it was found that WBCs ranged
from 2550-12900 with mean value = 5480.2
±1713, leucopoenia (WBCs < 4000) was present
in 19(17.4%) subjects. Neutrophils ranged from
25%-67% with mean value = 51.8 %±9.8%,
lymphocytes ranged from 24%-68% with mean
value = 40.2%+9.9%, basophiles ranged from 0-
5% with mean value = 0.4±0.7, platelets count
ranged from 12000-342.000 with mean value=
173.558 ± 7133. Thrombocytopenia ( platelet
count> 150.000 ) was present in 30(27.5%),
hemoglobin level ranged from 8.2-16.9; anemia
( hemoglobin > 13g/dl ) was present in 37
(33.9%) subjects. Abdominal ultrasound find-
ings: Table 4- shows the baseline U/S findings
among 124 subjects, it was found that the liver
size ranged from 9.4-16.5cm with mean value =
11.4±2.6cm. Twenty - eight (22.6%) subjects
has hepatomegally (liver right lobe span >
13cm), the liver texture was normal in 29
(27.4%) subjects, bright texture in 83(66.9%)
subjects, and coarse texture in 12(9.7%)
subjects. Intra-hepatic veins were attenuated in
10(8.1%) subjects. The portal vein diameter
ranged from 9-17mm with mean value =
11.0±2.2, and dilated in 3(2.9%) subjects. The
splenic vein diameter ranged from 5-13mm with
mean value = 6.6±1.6, splenic vein diameter
was dilated in 4(3.2%). splenomegaly
(longitudinal splenic span >13cm) was found in
4(3.2%) subjects. According to suggested
criteria of CLD evide-nce by abdominal
ultrasonic examination, there was no evidence
of CLD in 84(67.7%); possible evidence of
CLD in 24(19.4%), and probable evidence of
CLD in 15(12.1%) subjects, and only one has
definitive evidence of CLD. U/S findings among
124 subjects after 24 months of follow up: It
was found that the liver size ranged from 8-17.5
cm with mean value = 11.8±3.2 cm, 35(28.2%)
subjects had hepatomegaly, the liver texture was
normal in 9(7.3%)subjects, bright texture in
85/124(68.5) subjects, and coarse texture in
30(24.2%) subjects. Intrahepatic veins were
attenuated in 31(25%) subjects. The portal vein
diameter ranged from 10-16cm with mean value
= 10.3±2.1, and dilated in 16 12.9% subjects.
The splenic vein diameter ranged from 4-13cm
with mean value = 6±1.3. Splenic vein dilated in
14(11.3%). Splenomegaly ( longitudinal splenic
span >13cm) was found in 11(8.9%) subjects.
According to suggested criteria of CLD
evidence by abdominal ultrasonic examination,
there was no evidence of CLD in 59 (47.6%),
possible evidence of CLD in 15 (12.1%), and
probable evidence of CLD in 31 (25%) subjects,
and 19(15.3) had definitive evidence.
Histopathologic findings: Table 5- shows
baseline histopathological activity according to
Knodell’s scoring system in 86 patients
underwent liver biopsy on start of follow up, it
was found that the hepatitis activity index of
subjects ranged from 0-18 with mean value =
8.2±5.3, piecemeal/bridging hepatic necrosis
ranged from 0-10 with mean value = 4.5±3.5,
Intralobular degeneration and focal hepatic
necrosis was not present in 10(11.6%) subjects,
mild in 28(32.6%), moderate in 24(27.9%),
severe in 16(18.6), and marked in 8(9.3%).
Portal inflammation was not present in 8(9.3%)
subjects, mild in 30(34.9%) pt., moderate in
21(24.4%), severe in 19(22.1%), marked in
8(9.3%). the hepatic fibrosis was not present in
50(58.1%), stage one (Fibrous Portal Expa-
nsion) in 16(18.6%pt., stage 2 ( Minimal Bridg-
ing Fibrosis) in 4(4.7%), stage 3 (marked Porto-
portal, or central linkage fibrosis) in 3(3.5%)pt.,
and stage 4 (Cirrhosis in 13(15.1%). Histologic
activity (intensity of necroinflammatory lesion)
was classified according to the new classify-
cation proposed by Desmet and colleagues for
chronic hepatitis(8), it was found that normal or
minimal active hepatitis was present in 18
(20.9%)pt., mild active hepatitis was present in
32(37.2%), moderate active hepatitis in 11
(12.8%), and severe active hepatitis in 25
(29.1%).
Table 1 Characteristics of the study sample (n=124)
333 Frequency Percent Frequency Percent
Age (years) Age (years)
Range 18.0-53.0 Range 18.0-53.0
Mean ± SD 36.3±7.4 Mean ± SD 36.3±7.4
Residence: Gender:
Urban 88 71.0 Male 88 71.0
Rural 36 29.0 Female 36 29.0
Marital status: Education:
Single 19 15.3 Illiterate 20 16.1
Married 96 77.4 Read / write 20 16.1
Widow 5 4.0 Basic 52 41.9
Divorced 4 3.2 Secondary 21 16.9
University 11 8.9
Special habits: Job:
None 83 66.9 Not working 36 29.0
Smoking 38 30.9 Sedentary 82 66.1
Alcohol/smoking 3 2.4 Manual 6 4.8
Table 2 Baseline and after 24 months clinical manifestations.
Symptoms 1st month 24th month Signs
1st month 24th month
Freq. % Freq. % Freq. % Freq. %
Hypersomnia 25 20.1 32 25.8 Hepatomegaly 28 15.0 35 28.2
Fatigue 23 18.5 30 24.2 Pallor 5 4.0 7 5.6
Abdominal distension 16 12.9 21 16.9 Skin rash 5 4.0 5 4.0
Right quadrant pain 16 12.9 18 14.5 Splenomegaly 4 3.2 13 10.5
Bleeding gum or nose 10 8.0 18 14.5 Jaundiced sclera 0 0.0 1 0.8
Deep yellow urine 9 7.2 16 12.9 L.L oedema 0 0.0 3 2.4
Dizziness 4 3.2 4 3.2 Muscle wasting 0 0.0 3 2.4
Weight loss 4 3.2 6 4.8 Pulmar erythema 0 0.0 3 2.4
Anorexia 4 3.2 5 4.0 Spider naevi 0 0.0 2 1.6
Pruritis 3 2.4 4 3.2 Clubbing finger 0 0.0 1 0.8
Fever 3 2.4 3 2.4 Shrunken liver 0 0.0 1 0.8
Hypersomnia 25 20.1 32 25.8 Ecchymosis 0 0.0 3 2.4
Table 3. Baseline and 24-month follow-up liver function tests of study subjects (n=124)
Baseline 24-month
Freq. % Freq. %
AST grade:
Normal (<48 IU) 75 60.5 77 62.1
Mild (48-<100 IU) 31 25.0 30 24.2
Moderate (100-400 IU) 18 14.5 17 13.7
ALT grade:
Normal (<48 IU) 71 57.3 73 58.9
Mild (48-<100 IU) 36 29.0 35 28.2
Moderate (100-400 IU) 17 13.7 16 12.9
Total bilirubin (>1.1) 8 6.5 10 8.1
Direct bilirubin (>0.4) 5 4.5 5 4.5
Prothrombin time (<80%) 4 3.2 5 4.5
Serum albumin (<3.5) 0 0.0 1.0 0.8
Table 4. Baseline U/S findings of study subjects (n=124)
Baseline
24-month
follow-up
No. % No. %
Hepatomegaly(Rt.Lobe span>13cm) 28 22.6 35 28.2
Liver texture:
Normal 29 23.4 9 7.3
Bright 83 66.9 85 68.5
Coarse 12 9.7 30 24.2
Intra-hepatic veins attenuation:
No 114 94.4 93 75.0
Yes 10 8.1 31 25.0
Dilated portal vein (>13 mm) 3 2.9 16 12.9
Splenomegaly 4 3.2 11 8.9
Dilated splenic vein diameter (>8 mm) 4 3.2 14 11.3
Ultrasonographic diagnosis:
Normal 84 66.7 59 47.6
Probable CLD 24 19.4 15 12.1
Possible CLD 15 12.1 31 25.0
Definitive CLD 1 0.8 19 15.3
Table 5. Baseline liver biopsy data of study subjects (n=87)
Frequency Percent
Intralobular degeneration and HC necrosis:
None 10 11.6
Mild 28 32.6
Moderate 24 27.9
Severe 16 18.6
Marked 8 9.3
Portal inflammation:
None 8 9.3
Mild 30 34.9
Moderate 21 24.4
Severe 19 22.1
Marked 8 9.3
Fibrosis by Metavir:
None 50 58.1
Mild 16 18.6
Moderate 4 4.7
Severe 3 3.5
Marked 13 15.1
Cirrhosis:
None 73 84.9
Cirrhosis 13 15.1
Desmet’s classification:according to knodell score
Normal/minimal (1-3) 18 20.9
Mild (4-8) 32 37.2
Moderate (9-13) 11 12.8
Severe (14-18) 25 29.1
Discussion
Community-acquired HCV infection makes up
the bulk of all HCV infections. However, kno-
wledge of the natural history in this setting
remains limited, primarily as a result of the
methodological difficulties associated with con-
ducting these studies. Such difficulties include
the problems of accurately identifying those
with incident infections. In this study, we traced
and followed up a cohort of volunteer blood
donors and accidentally discovered subjects who
were testing positive for HCV antibody by
second generation ELISA. The present study
was carried on 124 subjects who were acid-
entally discovered to be anti-HCV seropositive,
most of them during screening for blood
donation at the blood bank of Suez general
hospital. They were apparently healthy, and
denied any disease at that time. Initial liver
biopsy was done in most of patients, as a gold
standard for staging HCV-related liver disease
in terms of fibrosis and cirrhosis. Additionally,
the entire cohort did not take any specific anti-
viral treatment throughout the follow-up. The
selection of HCV seropositive patients in this
study was based on 2nd generation ELISA test,
which offered much greater sensitivity, and
remains the most commonly used assay used in
blood donation centers for detecting anti-HCV.
The second-generation test reduces the "wind-
ow phase" to seroconversion, with a dramatic
reduction in the number of false positive reac-
tions seen with the first-generation test (9). The
fact that PCR for HCV-RNA qualitatively was
positive in 91.9% of subjects tested provides
confidence that the vast majority of them had
HCV infection, but also indicates that some of
them might not be vireamic. Nonetheless, it
does not preclude the possibility of inclusion of
few false positive anti-HCV subjects. Baseline
Chronic Liver disease in asymptotic accidentally
discovered HCV antibody positive cases:
Symptoms and signs: Although the patients
included in this study were apparently healthy
and denied any diseases at the time of
screening, the questionnaire elicited that Just
over 40% had one symptom or more.. The most
frequent symptoms were hypersomnia, fatigue,
right quadrant pain, abdominal distention after
meals, with less frequent symptoms as passing
deep yellow urine, weight loss, anorexia,
dizziness, and pruritus. However most of these
symptoms are considered subjective, non-
specific, and common in the general population.
Meanwhile, none of our patients had specific
liver symptoms like jaundice, lower limb
edema, or ascites. These foregoing findings are
in agreement with Martinot et al (10) who
documented that most patients with chronic
hepatitis C have few if any symptoms; the most
common being fatigue, which is typically
intermittent, and hypersomnia. Right upper qu-
adrant pain, nausea, and poor appetite do occur
in some patients. In this respect, Shakil et al (11)
have evaluated a cohort of over 100 patients
with chronic HCV infection and no clinical
signs of cirrhosis and in 100 healthy blood
donors without HCV using self administered
symptom. Fatigue was the most common
complaint in both groups and occurred with
similar frequency (62 percent in those with
HCV versus 70 percent of controls). Abdominal
pain, itching, and dark urine were the only
complaints that were significantly more com-
mon among the HCV group members, although
they were present in only a small number of
patients. None of the participants studied in the
present work, including a participant with
cirrhosis, had symptoms that were obviously
related to liver disease. All through the follow-
up, most of the participants reported that the
symptoms were fluctuating, mild, and did not
interfere with daily activities or work. At the
end of follow-up, only one subject was
complaining of clinical jaundice. These findings
underscore the silent nature of chronic hepatitis
C, and the absence of symptoms and history of
liver problems in many patients with this
disease. As regard clinical sings, like other
investigators (12,13,14,15) hepatomegaly was the
most frequent sign observed on physical
examination, as it was detected in 22.6%
increased to 28.2% of our subjects. Splen-
omegaly was observed in 3.2% increased to
10.5% of our subjects , after 24 months of
follow up, this was in line with (15-18) who found
splenomegaly in (5%) of 756 anti-HCV positive
blood donors, no cases of ascites, encepha-
lopathy, or flapping tremors have been found in
the physical examination, indicating a low
degree of hepatic compromising in accidentally
discovered HCV patients
Risk factors
At least one or more risk factor was found in
each patient in the present study. The most
frequent risk factor was dental procedures,
which was reported by 66% subjects. The mode
by which HCV is transmitted during dental
procedure is through contaminated blood or
saliva. The role of saliva in HCV transmission
was verified by (19). These authors have
respectively reported that HCV-RNA was found
in 30% and 52.4 % of saliva specimens. It was
unknown whether these traces of genetic
material in the saliva could infect another
individual, but that it was not impossible. The
presence of HCV-RNA in saliva might make the
toothbrushes infected after brushing, as (19-33)
have reported that forty percent of the rinsing
water of the toothbrushes tested positive for the
virus. This makes the common sharing of
toothbrushes a risk factor for HCV transmission
frequent. The second most frequent risk factor
was previous tartar emetic injection, which was
also reported The EDHS study estimated that
29.6% of anti-HCV antibody positives (25.3%
of women and 31.5% of men) received injec-
tions to treat schistosomiasis (34). The Egyptian
HCV epidemic could be the result of a wide-
spread treatment campaign against schistose-
miasis, From the 1920s to the 1980s, the
government administered parenteral antischis-
tosomal therapy (usually 6-12 injections) with
reusable syringes. With a course of injections
taking two to four weeks, an individual infected
early in treatment could then spread HCV on a
sub-sequent injection to others who used the
same syringe. Current risk factors for acquiring
or having acquired hepatitis C in blood donors
include illegal intravenous drug use, which was
found only in two subjects in our study. The
finding in the present study that only 14% of
subjects reported a history of blood transfusion,
is in agreement with what was reported by (35,36),
claimed that , blood transfusion was identified
in 24.3% and needle reuse in 20.6% of the
HCV-positive cases in this nationwide sample.
It is clear that the identification of a certain
practice as a risk factor is related to the
frequency of exposure to that practice in the
community. Extrahepatic manifestation:
Chronic hepatitis C virus can directly or
indirectly affect a number of organs other than
the liver. A minority of patients with chronic
hepatitis develops clinically extrahepatic
features of disease. The specific viral and host
features that predispose patients to extrahepatic
expressions of disease have not been elucidated.
In studying extrahepatic manifestations in the
present work, the most common symptoms
involved the joints and skin. HCV infection was
associated with joint pains (19%), skin changes
(17%), dry mucous membranes (12%), and
sensory nerve changes (9%). Serum transami-
nase levels: Baseline measurement of serum
transaminases levels in our study revealed that
57.3% of subjects had normal ALT level, while
60.5% had normal AST level. At the 24-month
follow up, only 40.1%, 40.3% remained
persistently normal for ALT, AST respectively.
These results are similar to those reported by
Jamal (1999) who concluded that a single
normal ALT at the time of first evaluation is
common in volunteer blood donors with chronic
HCV patients. However, most of them did not
have persistently normal values on serial
assessment. Only 39% of normal ALT patients
at first assessment had persistently normal ALT.
Moreover, (37) have reported that serum alanine
aminotransferase (ALT) levels were elevated in
approximately 60 to 70% of chronic patients,
but these levels are highly variable and may
fluctuate over time. The remaining 30-40% of
patients had persistently normal ALT values,
with positive anti-HCV and HCV-RNA results.
In the present study, fluctuating transaminases
over serial determinations occurred mostly in
those with normal or mildly elevated levels at
initial measurement. Those with moderately
elevated levels remained unchanged. None of
the patients had ALT level >400u/l. In this
respect, (38) found that ALT level rarely exceeds
5 folds in asymptomatic blood donors.
Unexpectedly, mixed Cryoglobulins (CG+) in
this study were found in only 5/80 (6.25%) in
the text of the study subjects. In contrast, (39)
found (CG+) in 42.5% of 207 patients with
CHC. This can be explained by the fact that
CG+ might be present in more advanced stages
of the disease, as it is documented from many
studies (40,41). Mixed Cryoglobulins are often
seen in patients who have advanced histologic
lesions of bridging fibrosis or cirrhosis in liver
biopsy specimens, with hepatomegaly, and
splenomegaly (42). Other studies have shown that
mixed cryoglobulinemia was associated with
female gender, older age, longer disease
duration, and liver cirrhosis. The stage of
fibrosis was significantly higher in CG+
patients, whereas the activity grades and mean
ALT levels did not seem to be associated with
CG+. Mixed cryoglobulinemia was also
associated with the titer of rheumatoid factor,
and the prevalence of extrahepatic manife-
stations such as CG-related vasculitis, and some
hematological and autoimmune syndromes (39).
Blood picture: Study of blood profile among
109 subjects revealed presence of anemia,
thrombocytopenia, and leukopenia, in 33.9%,
27.5%, and 17.4% consequently, confirming the
haemocytopathic effects of HCV infection. The
pathogenic role of HCV in hepatitis-associated
aplastic anaemia develop-ment has not been
confirmed. The thrombocytopenia has been
observed more frequently during chronic
hepatitis C than during infections with other
hepatotropic viruses (43). However, a direct viral
megakaryocyte infection or an immune
mechanism could explain this thromb-
ocytopenia, as this disorder may be associated
with antiplatelet autoantibodies production, low
thrombopoietin production may play a role,
along with hyper-splenism, in the development
of thrombocytopenia in patients with liver
cirrhosis (44), Histopathological findings: In the
present work, hepatitis activity index (HAI) for
liver biopsy was studied in 86 accidentally
discovered HCV antibody positive patients.
Normal or minimal chronic hepatitis (HAI: 0-3)
was found in 20.9% of patients, mild chronic
hepatitis (HAI: 4-8) in 37.2%, moderate chronic
hepatitis (HAI: 9-12) in 12.8%, and severe
chronic hepatitis (HAI: 13-18) in 29.06% of the
cases. Meanwhile, assessment of fibrosis stagi-
ng resulted in fibrosis stage 0 in 58%, stage 1 in
18.6%, stage 2 in 4.7%, stage 3 in 3.5%, and
cirrhosis or stage 4 in 15.1% of the cases. These
results are near to those were reported by (43)
This author applied the histological evaluation
based upon the new class, the hepatitis activity
index (HAI) for liver biopsy, in 106 patients
who were positive for HCV antibody by a
second-generation ELISA. Minimal chronic
hepatitis (HAI: 1-3) was found in 13.2%, mild
chronic hepatitis (HAI: 4-8) in 65.09%, and
moderate chronic hepatitis (HAI: 9-12) in
21.69% of the cases. Meanwhile, assessment of
fibrosis (staging) resulted in fibrosis 0/1 in
41.5%, fibrosis 2 in 13.2%, fibrosis 3 in 34.9%,
and cirrhosis or fibrosis 4 in 10.37% of the cases
(43). The anti-HCV-positive subjects in the
present study were categorized into three groups
according to levels of serum ALT levels prior to
liver biopsy for analysis of the relation of
histopathologic activity to ALT levels. Althou-
gh most of the subjects with minimal or mild
histologic activity had normal ALT, and most
subjects with severe histologic activity had
elevated ALT levels, there was no statistically
significant association between ALT level and
severity of histopathologic activity by using
Desmet’s classification of chronic hepatitis.
This might be due to the small number of
subjects in certain categories, especially the
severe one. Nonetheless, the results might point
to the utility of the measurement of serum ALT
levels as a readily available way to assess
chronic hepatitis disease activity. However, it is
clear from this study and others, that the
presence of normal serum ALT levels even on
multiple occasions does not rule out the
presence of chronic hepatitis. Indeed, 40.1% of
participants with repeatedly normal serum ALT
levels in our study had chronic hepatitis on liver
biopsy. Six of these participants had cirrhosis,
but several (39) subjects, had chronic hepatitis
with minimal and mild inflammatory activity
(HAI: 0-8). These findings are similar to those
reported by other groups who have studied anti-
HCV-positive blood donors in Europe, Aus-
tralia, and Asia (27,43,44). Abdominal Ultra-
sonographic findings: Abdominal ultrasound at
baseline assessment of patients in the present
study revealed the presence of hepatomegaly in
22.6%, while splenomegaly was present in only
3.2%. After 24 months of follow-up, hepatom-
egaly was present in 28.2%, and splenomegaly
in 10.5%. Ultrasound assess-ment was similar
to that elicited by clinical examination. (44,45,36)
Ultrasound assessment revealed presence of
hepatomegaly in 23.4%, and splenomegaly in
10.5% throughhout the 24 months of follow-up.
Splenomegaly was parallel to dilated splenic
vein diameter, which occurred in 3.2% of
subjects, and/or dilated portal vein diameter.
This might support the view that splenomegaly
is not an early sign of the disease, and its
presence means complication rather than
activity of the disease. Abdominal imaging at
baseline revealed no evidence of CLD in 67.7%
of the total cohort, inspite of presence of
histologic or biochemical evidence of liver
insult. Hence, abdominal U/S at early stages of
HCV disease does not offer an advantage in
early detection of liver insult. Meanwhile, all
patients with evidence of CLD by U/S had
severer histologic activity. Nonetheless, it is
important to bear in mind that the interpretation
of these tests depends on probabilities and
likelihoods. Thus, it is more likely that a patient
will have more advanced liver disease if they
have if they have ultrasonographic evidence of
chronic liver disease. However, there are still
probabilities, although smaller, of not having
such grade of the disease. This is why it still is
generally accepted among hepatitis specialists
that liver biopsy is the only way to most
accurately assess a person's stage of liver
disease. It is well established that liver biopsy is
the most reliable way to assess the activity and
stage of liver disease, and should be
recommended in anti-HCV-positive subjects
who are HCV-RNA positive and have elevated
ALT levels. Nonetheless, the resulting data
might support the view of liver biopsy should be
routinely recommended also in those who are
HCV RNA - positive and have persistently
normal ALT levels. The aim is to evaluate them,
and to provide a base for assessment of
progression and eligibility to antiviral treatment.
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