Hepatology Department Research Articles

Prevalence of Hepatitis B and C Viral Infections in Chronic Liver Disorder

Background and aim: Hepatitis is a liver infection caused by a variety of viruses and is a major public health issue worldwide. Hepatitis B and C are common liver infections caused by HBV and HCV that spread through sexual contact, contaminated blood product and contaminated needles. The present study aimed to determine the prevalence of hepatitis B and C in chronic liver disorders. Material and Methods: This prospective study was conducted on 136 chronic liver disease patients in the Department of Gastroenterology and Hepatology, Ayub Teaching Hospital Abbottabad from August 2021 to January 2022. Patients above 18 years age and clinically diagnosed with chronic liver disorder were enrolled. Chronic liver disorders were diagnosed based on clinical history, impaired liver function tests, and ultrasound. A questionnaire was used to accumulate possible related factors with virus infections from patients. Qualitative immunochromatographic method was used for screening out the serum for the presence of anti-hepatitis C virus antibodies and hepatitis B surface antigen. SPSS version 26 was used for data analysis. Results: Out of 136 chronic liver disorders, there were 88 (64.5%) male and 48 (35.5%) females. The overall mean age was 42.6±6.82 years with an age range from 15 to 75 years. Of the 136 CLD, the single, married, divorced, and widow were 34 (25%), 80 (58.8%), 12 (8.8%), and 10 (7.4%) respectively. The urban and rural dwellers were 98 (72.1%) and 38 (27.9%) respectively. The prevalence of Hepatitis B surface antigen and anti-HCV antibody was 52 (38.2%) and 34 (25%) respectively. The incidence of dual HBV and HCV coinfection was 6 (4.4%). Conclusion: The present study found that the prevalence of HBV and HCV infections were 38.2% and 25% among chronic liver disorders. HCV infections were 2.95 times higher in health facilities where dental extractions were provided compared to those who had no dental extraction facilities. All the CLD clinically diagnosed should be tested for HBV and HCV infections. Sterilization of surgical and dental instruments in proper way must be done along with public education regarding infections and transmission modes to prevent infections spreading. Keywords: HBV, HCV, Chronic liver disorders

The Impact of Hyponatremia on Severity of Decompensated Chronic Liver Disease

Introduction: Hyponatremia in cirrhosis is low sodium concentration in the blood. It has been additionally reported that hyponatremia occurs when serum sodium concentration in the blood is less than 135mmol/L, with severe hyponatremia being below 120 mmol/L. In general, two kinds of hyponatremia may be found in patients with cirrhosis, such as hypovolemic and hypervolemic hyponatremia. Complications may arise in case of correcting hyponatremia too quickly. The study aims to investigate the impact of hyponatremia on the severity of decompensated chronic liver disease. Methods: A Prospective cross-sectional study was carried out Department of Gastroenterology and Hepatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shabagh, Dhaka, from March 2014 to February 2015. A total of 100 patients (N=100) for one year were enrolled in this study following the inclusive criteria. Data were collected using the predesigned semi-structured questionnaire. Verbal consent was taken before recruiting the study population. Completed data forms were reviewed, edited, and processed for computer data entry. Result: Among hundred patients (N=100) with decompensated chronic liver disease observe the impact of hyponatremia with the severity of complications. Of them, it was observed that more than one-third of the patients (37, 37.0%) belonged to age 31-40 years. The mean age was found 42.2±SD years. It was observed that almost two-thirds of the patients (63, 63.0%) were male and thirty-seven (37,37.0%) patients were female. Among the study population, the majority of the patients (90, 90.0%) belonged to serum sodium ≤135 mmol/l (Hyponatremia). The mean serum sodium was found 124.7±SD mmol/l. The majority of patients (57,57.0%) had moderate ascites, nineteen patients (19,19.0%) had mild and about one-fourth of the patients (24,24.0%) had severe ascites. Conclusion: Hyponatraemia should be accomplished by dipping diuretics and increasing the plasma volume with fluid resuscitation.

S1301 Understanding Barriers to Prescribing Pharmacotherapy for Alcohol Use Disorder: A Shared Responsibility

Introduction: Alcohol use disorder (AUD) is becoming more prevalent in the United States and has been accelerated by the global pandemic. It is essential to recognize AUD as a common precursor to the development of alcohol-related liver disease. This confers responsibility on all clinicians, especially those with specialty training in gastroenterology (GI) and hepatology, to mitigate this risk by offering any treatment that aids in abstinence. Pharmacotherapy, also known as medication-assisted treatment (MAT), for AUD is an underutilized but effective intervention that, unlike behavioral therapies, is within reach of most practicing physicians. This study aims to understand the barriers to initiating pharmacotherapy in AUD to help better inform quality improvement initiatives designed to increase the use of MAT. Methods: A survey was conducted using the RedCap platform and sent to internal medicine (IM) hospitalists and residents, primary care physicians, and attending GI and hepatologists at one urban academic tertiary medical center. We focused on naltrexone as it is the option with the strongest evidence, lowest cost, and fewest interactions of FDA-approved MAT. Results: The response rate was 19% (7/36) for the GI and hepatology department, 24% (29/120) for the IM residency, and 17% (5/30) for hospitalists. Within internal medicine, most (85.4%) had never prescribed naltrexone for AUD, but 89.6% would if they had more information about how to do so. The most popular barriers identified included: not knowing enough about the medication (70.8%), specifically not knowing the contraindications (56.3%), and prescribing did not occur to them (54.2%). Within GI and hepatology, 0% had prescribed naltrexone, 71.4% said they would be willing, but 85.7% said they didn’t know enough about the medication (Figure). Conclusion: Alcohol use is increasing in the US, and many patients may benefit from assistance with abstinence and reducing cravings by using FDA-approved MAT such as naltrexone. Initiating treatment in the inpatient setting may be a valuable opportunity to reach such populations. This study showed an apparent deficit among participants within IM, GI, and hepatology departments in prescribing naltrexone, primarily due to a lack of knowledge of available medications and their appropriate use. These findings will assist quality improvement initiatives at our institution aimed at increasing inpatient naltrexone initiation and may also help inform other institutions’ efforts.Figure 1.: Responses from gastroenterologists, hepatologists, and internal medicine residents and hospitalists, to questions regarding barriers to prescribing naltrexone. GI = gastroenterology; IM = Internal Medicine

Assessment of carotid atherosclerosis in Egyptian chronic hepatitis C patients after treatment by direct-acting antiviral drugs

BackgroundRecent studies suggested association between hepatitis C virus (HCV) infection and cardiovascular disorders, including carotid atherosclerosis with evidence of an effect of HCV clearance on carotid atherosclerosis.ObjectivesWe aimed to evaluate the impact of direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection on carotid atherosclerosis.Subjects and methodsThis is a prospective cohort study that was carried out in Internal Medicine and Hepatology Department, and outpatient clinics of the Ain Shams University hospitals included 80 Egyptian patients with chronic HCV infection who started treatment in the form of IFN-free DAA-based regimen and completed the course of treatment and 6-month follow-up period. All patients were subjected to detailed history taking, full physical examination, full laboratory investigations, radiological assessment by abdominal ultrasonography, and high-resolution B-mode ultrasonography of both the common carotid arteries.ResultsThe mean age of cases was 58.13 ± 7.56 years, 49 (61.25%) males and 31 (38.75%) females. IMT was significantly decreased after treatment 1.24 versus 1.57 mm p < 0.001. The number of patients with IMT ≥ 1 mm was significantly decreased after 6 months 45 (56.3%) versus 57 (71.3%). There was significant positive correlation between baseline carotid IMT and age, BMI, bilirubin, INR, CTP score, carotid plaques, and total cholesterol. Meanwhile, there was significant negative correlation between baseline carotid IMT and hemoglobin, platelets, albumin, and HDL. In patients who achieved SVR, total cholesterol, triglycerides, LDL, and HDL were significantly increased after treatment. IMT was significantly lower in SVR group compared to non-SVR group (p = 0.016).ConclusionHepatitis C virus eradication by DAAs improves carotid atherosclerosis by decreasing carotid intima-media thickening.

Editorial introductions.

Editorial introductions.

Frequency of Upper Gastrointestinal Bleeding As Precipitant of Hepatic Encephalopathy among Patients with Liver Cirrhosis

Objective: To find frequency of upper gastrointestinal bleeding as precipitant of hepatic encephalopathy among patients with liver cirrhosis. Study design. Descriptive cross sectional study Setting: Gastroenterology and Hepatology Department, Lady Reading Hospital Peshawar. Duration: 6 months 20th December 2018 to 20th June 2019. Material and Methods: In this study a total of 271 patients were observed. History regarding the current illness was taken from the patient or the accompanying caregivers in case patient cannot respond adequately or at all. Emphasize was on the possible precipitant of current HE episode especially symptoms of upper gastrointestinal bleeding like hematemesis and malena. On examination; body temperature, stigmata of chronic liver disease such as hepatic flap, grading of HE and similarly presenting conditions was looked for. Results: In this study mean age was 45 years with SD ± 11.27. Fifty nine percent patients were male whle 41% patients were female. More over 10% patients had upper gastrointestinal bleed with hepatic encephalopathy among patients with liver cirrhosis. Conclusion: Our study concludes that the frequency of upper gastrointestinal bleed was 10% as precipitant of hepatic encephalopathy among patients with liver cirrhosis. Keywords: Upper Gastrointestinal Bleed, Hepatic Encephalopathy, Liver Cirrhosis.

Recent Findings in the Gut-Liver Axis and Associated Disease Therapy

Several presentations at the recent International Liver Congress™ (ILC), held in London, UK, from 22nd–26th of June 2022, addressed the role of the gut microbiome in chronic liver disease. Debbie L. Shawcross from the Department of Inflammation Biology, School of Immunology and Microbial Sciences, Institute of Liver Studies, King’s College London, UK, outlined the role of the gut-liver axis in the pathogenesis of cirrhosis, and how existing and novel therapies manipulate gut microbes. Emina Halilbasic from the Medical University of Vienna, Austria, and Benjamin H. Mullish from the Division of Digestive Diseases, Imperial College London, UK. Focused on the use of gut-based therapies in cholestatic liver disease. They explained the current understanding of the interplay between bile acids, microbiota, and the mucosal immune system, and the ways in which this may be manipulated for therapeutic gain. The role of gut barrier impairment in alcohol-related liver disease (ArLD) was presented by Shilpa Chokshi from the Roger Williams Institute of Hepatology, Foundation for Liver Research, London, UK, and School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, UK. Charlotte Skinner from the Department of Metabolism, Digestion, and Reproduction, Division of Digestive Diseases, Imperial College London, UK, described the role of gut proteases in this process, while Jasmohan S. Bajaj from the Virginia Commonwealth University, Richmond, USA, and Central Virginia Veterans Healthcare System, Richmond, USA, illustrated new therapies that target the gut-liver axis in this condition. Yue Shen from Zhongshan Hospital, Fudan University, Shanghai, China, and the Department of Gastroenterology and Hepatology, Shanghai Institute of Liver Diseases, China, described a combined microbiome-metabolome study to characterise the gut microbiome in hepatitis B virus infection-associated liver diseases (HBV-CLD), and how specific microbes might impact peripheral immunity. Finally, Bajaj outlined why the gut is a major target for hepatic encephalopathy (HE) treatment and described cutting edge research into therapies that show promise in this arena, such as soluble solid dispersion rifaximin, faecal microbiota transplantation (FMT), and rationally defined bacterial consortia. Overall, these presentations highlight an expanding knowledge of the gut-liver axis and promise an exciting future in liver treatment.

Hypermethylation of thymosin β4 predicts a poor prognosis for patients with acute-on-chronic hepatitis B liver failure

BackgroundIt has been demonstrated that thymosin β4 (Tβ4) could inflect the severity of acute-on-chronic hepatitis B liver failure (ACHBLF), but the relationship between its methylation status and the prognosis of liver failure is not clear. This study aimed to determine Tβ4 promoter methylation status in patients with ACHBLF and to evaluate its prognostic value. MethodsThe study recruited 115 patients with ACHBLF, 80 with acute-on-chronic hepatitis B pre-liver failure (pre-ACHBLF), and 86 with chronic hepatitis B (CHB). In addition, there were 36 healthy controls (HCs) from the Department of Hepatology, Qilu Hospital of Shandong University. The 115 patients with ACHBLF were divided into three subgroups: 33 with early stage ACHBLF (E-ACHBLF), 42 with mid-stage ACHBLF (M-ACHBLF), and 40 with advanced stage ACHBLF (A-ACHBLF). Tβ4 promoter methylation status in peripheral blood mononuclear cells (PBMCs) was measured by methylation-specific polymerase chain reaction, and mRNA was detected by quantitative real-time polymerase chain reaction. ResultsMethylation frequency of Tβ4 was significantly higher in patients with ACHBLF than in those with pre-ACHBLF, CHB or HCs. However, expression of Tβ4 mRNA showed the opposite trend. In patients with ACHBLF, Tβ4 promoter methylation status correlated negatively with mRNA levels. The 3-month mortality of ACHBLF in the methylated group was significantly higher than that in the unmethylated group. Also, Tβ4 promoter methylation frequency was lower in survivors than in non-survivors. When used to predict the 1-, 2-, and 3-month incidence of ACHBLF, Tβ4 methylation status was better than the model for end-stage liver disease (MELD) score. The predictive value of Tβ4 methylation was higher than that of MELD score for the mortality of patients with E-ACHBLF and M-ACHBLF, but not for A-ACHBLF. ConclusionsTβ4 methylation might be an important early marker for predicting disease incidence and prognosis in patients with ACHBLF.

From the Editor’s Desk…

From the Editor’s Desk…

Fecal Carriage of Escherichia coli Harboring the tet(X4)-IncX1 Plasmid from a Tertiary Class-A Hospital in Beijing, China.

The emergence of the mobile tigecycline-resistance gene, tet(X4), poses a significant threat to public health. To investigate the prevalence and genetic characteristics of the tet(X4)-positive Escherichia coli in humans, 1101 human stool samples were collected from a tertiary class-A hospital in Beijing, China, in 2019. Eight E. coli isolates that were positive for tet(X4) were identified from clinical departments of oncology (n = 3), hepatology (n = 2), nephrology (n = 1), urology (n = 1), and general surgery (n = 1). They exhibited resistance to multiple antibiotics, including tigecycline, but remained susceptible to meropenem and polymyxin B. A phylogenetic analysis revealed that the clonal spread of four tet(X4)-positive E. coli from different periods of time or departments existed in this hospital, and three isolates were phylogenetically close to the tet(X4)-positive E. coli from animals and the environment. All tet(X4)-positive E. coli isolates contained the IncX1-plasmid replicon. Three isolates successfully transferred their tigecycline resistance to the recipient strain, C600, demonstrating that the plasmid-mediated horizontal gene transfer constitutes another critical mechanism for transmitting tet(X4). Notably, all tet(X4)-bearing plasmids identified in this study had a high similarity to several plasmids recovered from animal-derived strains. Our findings revealed the importance of both the clonal spread and horizontal gene transfer in the spread of tet(X4) within human clinics and between different sources.

Study on clinical profile and therapeutic aspect of Wilson’s disease

Introduction: Wilson’s Disease is an autosomal recessive disease. It is characterized by degenerative changes in the brain, liver and Kayser-Fleischer Rings in the Cornea. It is observed with the prevalence of approximately 1:3000 among all ethnic groups. Aims &amp; Objectives: To study the clinical profile and therapeutic aspects of Wilson’s Disease. Material and Methods: It was a prospective observational study conducted in the department of Hepatology of SCB Medical College &amp; Hospital, in Cuttack city of Odisha. Patients were followed up after 6 month and response to treatment was observed. Results: Most patients were in age group 11-15 years (43%), male, female ratio being 2:1. 64% patients had hepatic presentations, 11% patients had neurological presentations and 25% of patients had both hepatic &amp; neurological presentations. The hepatic presentations were jaundice in 79% of cases followed by Ascites and pedal edema in 75% of cases each, 29% patients were having UGI bleeding. Among the 28 patients 68% presented with KF Rings, 16% patients had child A, 28% had Child B and 56% patients had Child C cirrhosis. Conclusion: The commonest presentation of Wilson’s disease was Chronic Liver Disease.

The Seroprevalence of SARS-CoV-2 IgG Antibodies in Children Hospitalized for Reasons Other Than COVID-19.

The aim of the study was to assess the seroprevalence of SARS-CoV-2 IgG antibodies in children hospitalized for reasons other than COVID-19. The study was conducted among 686 children, aged 2 weeks to 18 years, hospitalized in the Department of Paediatrics, Infectious Diseases, and Hepatology in Bydgoszcz, Poland, in the period from 1 June 2021 to 30 April 2022. The presence of anti-SARS-CoV-2 antibodies was detected in 392 (57%) children. Since December 2021, a significantly larger proportion of children with a positive titer of anti-SARS-CoV-2 antibodies has been observed, constituting as much as 87.5% of patients hospitalized in April 2022. In total, 69% of children with detected anti-SARS-CoV-2 antibodies were children under 5 years of age. The highest mean amounts of titers of anti-SARS-CoV-2 antibodies were observed in children over 10 years of age. The conducted studies showed the presence of anti-SARS-CoV-2 antibodies in a significant group of hospitalized children and an increase in the percentage of these children during the fourth and fifth wave of COVID-19 in Poland caused by the Delta and Omicron variants, respectively. The vast majority of parents of the studied children had no knowledge of the COVID-19 infection in their charges, which may indicate asymptomatic infection or mild course of the disease.

An evaluation of ascitic calprotectin for diagnosis of ascitic fluid infection in children with cirrhosis

BackgroundThe most common infection in children with the hepatic disease with or without cirrhotic ascites is spontaneous bacterial peritonitis (SBP), which occurs in the absence of an evident intra-abdominal source of infection. The present study aims to assess the value of calprotectin in ascitic fluid in the diagnosis of ascitic fluid infection in children with liver cirrhosis.Materials and methodsIn this cross-section study, 80 children with underlying liver disease who attended the Hepatology and Emergency Department in Shiraz University Hospitals were studied. All the patients were evaluated by a thorough history, clinical examination, laboratory investigations, diagnostic paracentesis with PMNLs count, and Calprotectin, which was measured in 1 mL ascitic fluid by ELISA.ResultsThirty-five patients (43.75%) were diagnosed with ascitic fluid infection. Of these children 6 cases had positive ascitic fluid culture (SBP). Calprotectin was high in AFI patients with a statistically significant difference in AFI patients compared to non-AFI patients. The cut-off levels were 91.55 mg /L and the area under the curve was 0.971. So it can serve as a sensitive and specific diagnostic test for detection of AFI in children with underlying liver disease.ConclusionElevated ascitic calprotectin levels in cirrhotic patients are a diagnostic and reliable marker for the detection of AFI and are considered a surrogate marker for PMN.

Improvement of early diagnosis of axial spondyloarthritis in intestinal infectious diseases

Introduction. Despite numerous fundamental clinical studies on the frequency, pathogenesis, clinical features of spondyloarthritis (SpA) in intestinal infectious diseases (IID) and intestinal damage in SpA, there are currently a number of unresolved problems, one of which is the problem of early diagnosis of arthropathies, especially associated with IID, which makes it necessary to continue the research in the scientific problem. Purpose of the study. Appreciation of the features of early manifestations of axial arthropathies in intestinal infectious diseases in order to improve their early diagnosis. Objectives of the study. Identification of clinical variants of axial arthropathies in patients with infectious intestinal diseases and instrumental description of axial lesion by conducting comparative analysis of clinical and laboratory parameters in these patients depending on the presence of axial arthropathies. Development of an algorithm for the early detection of axial spondyloarthritis in intestinal infectious diseases. Material and methods. During 2015-2021, 141 patients were analyzed retrospectively, out of which 50 patients with SpA from the Republican Clinical Hospital „Timofei Moşneaga” and 91 patients with infectious intestinal diseases from the gastro-enterology and hepatology departments of the Republican Clinical Hospital „Timofei Moşneaga”. Depending on the etiology of IID, subjects were divided into 2 groups: the first group included patients with Yersinia enterocolitica or Campylobacter jejuni (Y±C), the second with Salmonella enteritidis or Shigella flexneri (S±Sh). Results. In patients with IID, the following clinical variants of arthropathies have been identified: axial lesion (spinal inflammatory pain according to ASAS criteria (2009) in 42.9%, axial spondyloarthritis (axSpA) in 28.6%, AS in 15.4%), arthralgia - 38.5%, arthritis - 13.2%. Conventional radiography imaging and magnetic resonance imaging (MRI) of the sacroiliac joints (SI) increased the incidence of SpA from 6.6% (n = 6) to 28.6% (n = 26). Conclusions. In patients with IID, the following clinical variants of arthropathies have been identified: axial lesion (spinal inflammatory pain according to ASAS criteria (2009) in 42.9%, axSpA in 28.6%, ankylosing spondylitis in 15.4%), arthralgia – 38.5%, arthritis – 13.2%. Imaging in the form of conventional radiography and MRI of SI joints increased the incidence of SpA from 6.6% (n = 6) to 28.6% (n = 26). Axial arthropathies, arthralgia, arthritis, and uveitis are encountered more frequently. At the same time, the possibility of detecting axSpA is greater if arthritis, arthralgia, inflammatory back pain, uveitis is present. Patients with S±Sh have a higher chance of developing axSpA compared to patients with Y±C.

Definition and classification of acute-on-chronic liver diseases.

Patients with chronic liver diseases (CLDs) develop acute liver injury and/or acute decompensation under the attack of various precipitants and present with significantly elevated alanine aminotransferase and/or total bilirubin levels, liver failure, or acute decompensation of liver cirrhosis, which is called acute-on-CLD (AoCLD). AoCLD accounts for the majority of patients hospitalized in the Department of Hepatology or Infectious Diseases. AoCLD is complicated by various clinical types, the severity of the disease, and may pose a high risk of death. To date, the definition of AoCLD is still vague, and a consensus concept of the clinical classification is lacking. This review aimed to define the concept and clinical types of AoCLD based on related studies and the literature.

Surgical treatment of acute aortic dissection in a patient with SLE and prior antiphospholipid syndrome on therapy for over 30 years: a case report

BackgroundIn patients with systemic lupus erythematosus (SLE), lengthy treatment and long-term steroid use are the main risk factors for developing aortic aneurysms or aortic dissections. In patients with cardiac tamponade, hemodynamic collapse may lead to acute renal and hepatic failure.Case presentationWe report the successful treatment of a 55-year-old woman with SLE since the age of 21. She suddenly felt chest pain approximately 2 weeks before developing fever and vomiting and was admitted to our hospital. Initially, she had severe liver dysfunction and was admitted to the hepatology department, where treatment for fulminant hepatitis was initiated. However, computed tomography (CT) showed an acute aortic dissection (DeBakey type II) and severe bloody pericardial effusion. Therefore, we performed emergency pericardial drainage. Plasma exchange therapy was initiated as emergency aortic surgery was deemed impossible due to impaired liver function tests and coagulation. Ten days later, the patient developed peritonitis due to small bowel perforation, and laparotomy was performed for abscess drainage and perforation closure. She had received steroid pulse therapy at the age of 21. At 40 years of age, she developed deep vein thrombosis due to antiphospholipid antibodies and was prescribed prednisolone. She was ambulatory at 3 months after the onset of acute aortic dissection, and CT revealed a rapidly enlarging true aneurysm in the distal arch. We performed elective aortic surgery. Although there were no antiphospholipid antibodies, surgery could have led to a devastating antiphospholipid syndrome. Therefore, we decided to treat the patient with triple therapy. Methylprednisolone was intravenously administered intraoperatively and at 1 day postoperatively. The patient was discharged without complications after returning to her usual oral prednisolone regimen.ConclusionsThe patient described herein had a systemic circulatory failure due to cardiac tamponade, accompanied by liver failure. This condition is a significant cause of death in patients with aortic dissection-associated SLE and is extremely dangerous. However, multi-specialty intervention helped the patient recover, and she has been attending the outpatient clinic. Aortic surgery requiring hypothermia in SLE patients with antiphospholipid syndrome and a history of thrombocytopenia or thrombosis requires a multi-disciplinary treatment team, including cardiac surgeons and medical experts.

Whether Screening for Non-alcoholic Fatty Liver Disease in Patients With Psoriasis Is Necessary: A Pilot Quality Improvement Project.

BackgroundPsoriasis is a chronic inflammatory skin disease that is strongly associated with non-alcoholic fatty liver disease (NAFLD). Both conditions are associated with excess cardiovascular and liver-related morbidity and mortality. The severity of psoriasis correlates with the degree of liver inflammation and scarring, which can be further exacerbated by systemic immunomodulators such as methotrexate.Currently, no clinical pathway exists to screen psoriasis patients for NAFLD in our Trust. We aimed to develop a shared clinical pathway between our hepatology and dermatology departments to allow early identification and management of NAFLD in this patient group.MethodsA multidisciplinary team was assembled to identify patient priorities, management goals, and screening criteria. We identified gaps in our service and reviewed current clinical best practice guidelines. A clinical pathway was developed using a process map and revised according to feedback received. We piloted this pathway on a prospective cohort of psoriasis patients identified by our dermatology department. Patients were invited for transient elastography if fatty liver was identified on an ultrasound scan. Baseline demographics, biochemistry and imaging results were collected and analysed.ResultsOf 57 psoriasis patients, 30 (52.6%) had sonographic evidence of hepatic steatosis. The median age was comparable between groups with 56 and 55 years in the psoriasis-NAFLD (Ps-NAFLD) and no-NAFLD groups respectively. There were more males in the Ps-NAFLDgroup (56.7%) compared to the no-NAFLD group (37%). Fifteen out of 30 patients were eligible for transient elastography (two were excluded due to body habitus). Seven (53.8%) patients had no-to-mild fibrosis indicated by liver stiffness measurement (LSM) ≤7kPa, while six (46.1%) had moderate-to-severe fibrosis. Three (23.0%) patients had scores suggestive of cirrhosis (LSM>13kPa).ConclusionsThe introduction of a new shared-care pathway at our Trust has resulted in a streamlined way in which psoriasis patients can be screened and treated for NAFLD.

Frequency of Celiac Disease Diagnosed on Endoscopic Duodenal Biopsy in Patients of Functional Dyspepsia

Objective: To determine the frequency of celiac disease diagnosed on endoscopic duodenal biopsy in patients presenting with functional dyspepsia. Methods: This was a cross-sectional study was conducted at the Department of Gastroenterology and Hepatology, Shalamar Medical and Dental College, Lahore. A total 160 patients of either gender, aged 20-70 years and diagnosed with functional dyspepsia were included. The study was conducted during a period of six months from September 2021 to February 2022. The informed consent of patients was obtained. All the basic demographic information of each patient was noted and all the patients underwent endoscopic duodenal biopsies and specimens were sent to the department of histopathology for the histopathological assessment of celiac disease. The collected data were analyzed statistically by using SPSS version 12. Results: Average age of male and female patients was 45.61±14.41 and 39.83±14.91 years. Among 160 patients 60(37%) were male and 100(63%) were females. There were 90(56.3%) patients who had dysmotility like dyspepsia, 54(33.8%) patients diagnosed with an ulcer like dyspepsia and 16(10%) patients were having unspecified dyspepsia. According to the Marsh classification, 140 patients were diagnosed with type-0, 7 patients with Type-1, 2 patients with type-2, 9 patients with type-3a and 2 patients with type-3b. Celiac disease was diagnosed with the help of Modified Marsh classification. Among 160 patients 13(8%) were diagnosed with celiac disease. Conclusion: The results of the current study show a high frequency of celiac disease in patients with functional dyspepsia. Keeping this fact in mind, silent/subclinical CD should be kept in mind as a cause of functional dyspepsia during clinical activities Keywords: Celiac disease, Endoscopic duodenal biopsy, Functional dyspepsia

Small Intestinal Bacterial Overgrowth among Patients with Cirrhosis

Introduction: Acute chronic liver failure, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome are a few of the grave complications of liver cirrhosis that may result in death. For years, small-intestinal bacterial overgrowth (SIBO) has been considered a predisposing factor for these complications in cirrhotic patients. However, data regarding SIBO in cirrhosis patients remain less focused in our country. Therefore, the study was designed to evaluate the risk of SIBO in patients with liver cirrhosis attending a tertiary care hospital, in Bangladesh. The aim of the study was to find out the association of small intestinal bacterial overgrowth (SIBO) with cirrhosis. Methods: This case-control study was carried out in the departments of Gastroenterology and Department of Hepatology, Dhaka medical college hospital during the period from September 2018 to October 2019 with a total of 136 patients equally divided into case and control groups. The case group consisted of patients with cirrhosis, while the control group comprised of healthy age-matched volunteers. Result: Among SIBO positive cases and control most common age group was 41-50 years of age. The majority were males observed in both the case (83.3%) and the control (66.7%) groups. The risk of SIBO was more in the cirrhotic patient as the odds ratio was &gt; 1(OR= 7.8) with 95% CI 2.18-27.96. Overall frequency of SIBO was more among patients with higher CTP score {CTP-B (72.2%), CTP-C (27.8%)} with a p-value &lt;0.05. Conclusion: Cirrhosis is associated with small intestinal bacterial overgrowth (SIBO). The frequency of SIBO also increases in cirrhotic patients with higher CTP scores.

From the Editor’s Desk...

From the Editor’s Desk...