Hepatology Outpatient Clinic Research Articles

GALAD Score for the Diagnosis of Hepatocellular Carcinoma in Sub-Saharan Africa: A Validation Study in Ghanaian Patients.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide including sub-Saharan Africa. The GALAD score, derived from Gender, Age, Lens culinaris agglutinin-reactive fraction of alpha fetoprotein, Alpha fetoprotein, and Des-carboxy-prothrombin, has high accuracy in diagnosing HCC in Asia, Europe, and North America; however, it has not been validated in an African cohort. The aim of this study was to assess the performance of the GALAD score in the diagnosis of HCC in sub-Saharan Africa. Clinical data from patients with cirrhosis (n = 93) or HCC (n = 78) from outpatient hepatology clinics at three teaching hospitals in Ghana were abstracted, and serum samples were analyzed. A logistic regression model predicting HCC status based on the GALAD score was constructed to obtain the ROC curve for GALAD. The AUC with 95% confidence interval (CI) was calculated. The median GALAD score was higher among patients with HCC versus cirrhosis controls (8.0 vs. -4.1, P < 0.01). The AUC of the GALAD score for HCC detection was 0.86 (95% CI, 0.79-0.92). At a cut-off value of -0.37, the GALAD score had a sensitivity of 0.81 and a specificity of 0.86. The AUC (95% CI) was 0.87 (0.80-0.95) and 0.81 (0.67-0.94) in hepatitis B virus-positive and hepatitis B virus-negative patients, respectively. The GALAD score has a high accuracy for HCC detection. It has great potential to improve HCC surveillance in sub-Saharan Africa where imaging resources are limited. Significance: The GALAD score or its relevant modifications have the potential to aid in improving HCC surveillance efforts in low-resource settings in sub-Saharan Africa. This could enhance early detection rates of HCC and potentially improve survival rates in resource-limited settings.

Diagnostic and prognostic performance of the LiverRisk score in tertiary care

Diagnostic and prognostic performance of the LiverRisk score in tertiary care

Assessment of Accuracy of Blood Neutrophil to Lymphocyte Ratio (NLR) in Diagnosis of Spontaneous Bacterial Peritonitis (SBP) in Cirrhotic Patients

Abstract Background This was across-sectional study conducted on 40 Egyptian patients with decompensated cirrhosis and ascites selected from Internal Medicine and Hepatology outpatient clinics and wards at Ain-Shams University Hospitals. Aim of the Work The aim of this study is to compare accuracy of blood neutrophil lymphocyte ratio (NLR) to ascitic fluid neutrophil lymphocyte ratio (NLR) in diagnosis of SBP. Patients and Methods Patients in this study were divided into 2 groups: Group 1 (case):20 cirrhotic patients diagnosed with (SBP) on the basis of clinical manifestations (fever, abdominal tenderness, and pre-hepatic coma) and laboratory diagnostic criteria: ascitic fluid PMNs greater than 250/mm 3 and culture positive. Group 2 (control): 20 cirrhotic patients with ascites and were admitted with no evidence of (SBP) by clinical and laboratory evaluation. Results According to our results, we found that there was no statistically significant difference found between two groups regarding Age, Sex and Child Classification. There was no statistically significant difference found between two groups regarding WBCs, Platelets, ALT, Creat, Albumin, INR, Bilirubin and Adenosine deaminase, and there was statistically significant difference found between two groups regarding AST and Urea, and there was highly statistically significant difference found between two groups regarding HB. Also there was highly statistically significant difference found between two groups regarding MELD score, SERUM PMNLs, Ascitic PMNLs, Serum NLR and Ascitic NLR. Conclusion Spontaneous bacterial peritonitis is a serious complication in patients with liver cirrhosis and is associated with a considerable risk of mortality. The present study could be of clinical utility in predicting SBP, a major cause of mortality in patients with cirrhosis. NLR is considered an easy test that can be used to diagnose SBP.

Assessment of Sensitivity of Fib-4, Lok Score and Platelet Count / Spleen Diameter Ratio as Non-Invasive Indicator of Esophageal Varices in Egyptian Patients with Chronic Hepatitis C virus (HCV) Infection

Abstract Background The development of esophageal varices is one of the major complications of portal hypertension, which is considered a main complication of liver cirrhosis.Variceal bleeding occurs in 20–40% of cirrhotic patients with esophageal varices and The use of endoscopic prophylactic band ligation and non-selective beta blockers can decrease the risk of esophageal bleeding by 50%, so the current guidelines recommend screening all liver cirrhosis patients by endoscopy. Aim of the Work Assessment of sensitivity of fib-4, lok score and platelet count / spleen diameter ratio as non-invasive indicator of oesphageal varices in egyptian patients with chronic hepatitis c virus (hcv) infection. Patients and Methods This study will include 100 egyptian patients selected from internal medicine and hepatology outpatient clinics and inpatient wards at matria teaching hospital. Results Plt count/spleen diameter ratio, plt count and spleen diameter demonstrated a high statistically significant correlation with the presence and grade of esophageal varices. as according to sensitivity and specificity test the most accurate screening test for diagnosis of esophageal varicose is PLT/SD ratio as AUC (87.4%), also it is a good negative test as specificity (86.7%) with cutoff value (1026.7), but for suspect a case most sensitive test is PLT count as sensitivity (93.3%) with cutoff value (120.5). these tests followed by spleen diameter with accuracy (78.2%), and the least test is right lobe/ albumin ratio which cannot depend on it in diagnosis of esophageal varices as its accuracy is (52.2%),sensitivity 66.7% and specificity 48.3%. Conclusion The use of plt count/spleen diameter ratio, plt count and spleen diameter, especially the platelet count/spleen diameter ratio, can help physicians as noninvasive predictors of esophageal varices to restrict the use of endoscopic screening only to patients presenting a high probability of esophageal varices. This is especially useful in clinical settings where resources are limited and endoscopic facilities are not present in all areas.While rt liver lobe/albumin ratio can not be used as a non invasive predictor of esophageal varices.

Role of Α-L-Fucosidase as a Diagnostic Marker versus Α-Fetoprotein in HCC Post Viral Cirrhotic Patients

Abstract Background Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third cause of cancer-related mortality world- wide. The incidence of HCC is on the increase, and it is a major threat to our modern life. Epidemiological studies have indicated that HCC are related to chronic hepatitis B virus (HBV) and chronic hepatitis C virus (HCV) infection. Aim of the Work To evaluate the role of AFU as a diagnostic marker versus AFP in HCC post viral cirrhotic Egyptian patients. Patients and Methods This study had been carried out on 90 subjects, age range 21-75 year selected from Internal medicine and Hepatology outpatient clinics and inpatient wards at Ain shams university hospitals from January 2022 to June 2022. Results We found that serum levels of AFU were highest in patients of group A with HCC (129.867 ± 32.997 μl U/ml) compared to those with liver cirrhosis (33.433± 14.818 μl U/ml) with P value &amp;lt; 0.001 and the control groups (3.177 ± 1.199 μl U/ml) with P value &amp;lt; 0.001. Similarly alpha fetoprotein its serum levels were much higher in the HCC group (4688.223±11490.009 ng/ml) compared to the cirrhotic patients (4.407±3.107 ng/ml) with P value 0.02 Also, compared to healthy individuals (2.623±1.566 ng/ml) with p value 1.00. We found that there is No significant statistical correlation between serum AFP and AFU in our studied HCC and cirrhotic patients (R 0.332, P 0.073 for HCC and R 0.222, P 0.238 for cirrhotic). Regarding the negative correlation between serum AFU level and AFP level in order to predict the diagnostic value, sensitivity and specificity of both of them in term of tumor size, our study show that for AFU when the best cut off value was &amp;gt;52μl U/ml the sensitivity was 100% and specificity was 90% while for AFP when the best cut off value was &amp;gt; 10.5 ng/ml the sensitivity was 96.67% and specificity 96.67%. AFU is a promising serum tumor marker for HCC diagnosis and can be combined with AFP. Conclusion We concluded from this study that: Serum AFP was highly significant increase in HCC patients compared to cirrhotic and healthy controls, this is in agreement with many several reports that consider AFP in high serum levels as diagnostic for HCC combined with triphasic CT abdomen or dynamic MRI. Serum AFU levels were significantly higher in patients with HCC and mildly elevated in patients with liver cirrhosis compared to the control group. So it can be used as a tumor marker for HCC diagnosis. No correlation between AFU and laboratory data and child score. AFU was not influenced by clinical condition of the liver itself but with HCC. Around 40% of HCC patients have normal or low AFP level so AFU may be useful as a diagnostic marker in those patients. Serum AFP is the standard tumor marker used in clinical practice for diagnosis and surveillance of HCC in cirrhotic patients in spite of normal and low AFP HCC patients that may reach 40%. Sensitivity and specificity of AFU was nearly similar to sensitivity and specificity of AFP. Combined use of AFU with AFP or possibly other markers will improve the diagnostic field and can help in early detection of HCC in surveillance programms.

Association of Serum M2BPGi Levels with Nutritional Status (Using CONUT score) in Hepatitis C Virus Related Compensated Liver Cirrhosis Patients

Abstract Background Protein-energy malnutrition (PEM), which is one of the most common complications seen in LC patients and associated with high morbidity and mortality. So, predicting the presence of PEM and providing appropriate nutritional support help improve the prognosis of those patients. Mac-2-binding protein glycosylation isomer (M2BPGi) was recently identified as a serum glycobiomarker for liver fibrosis. However, the relationship between M2BPGi and malnutrition in patients with chronic liver disease (CLD) is unclear. Aim of the Work The aim of this study is to evaluate the role of serum M2BPGi levels as a surrogate marker for malnutrition in HCV related cirrhotic patients, correlated with CONUT score as the nutritional status marker. Patients and Methods This is a Cross-sectional - Analytic study that included patients with chronic HCV infection and normal control group selected from patients attending to Hepatology Outpatient Clinics at Ain Shams University Hospital. This study was carried out from 30 patients (child A) attending to Hepatology Outpatient Clinics at Ain Shams University Hospital and 30 healthy individuals as a control. Results The M2BPGi levels increased with CONUT score. The correlation coefficient between M2BPGi and CONUT score was r = 0.315 (p = 0.05), indicating a positive weak correlation between M2BPGi and CONUT score. The cut-off for M2BPGi to predict CONUT low vs. moderate was 1.43 with a sensitivity 93.33% and specificity 100% when AUC =0.9 and CONUT moderate vs. severe was 1.7 with a sensitivity 91.67% and specificity 100% when AUC =0.9. Conclusion We found that there is correlation between M2BPGi and CONUT score and both can be useful as a marker for malnutrition in HCV related cirrhotic patients cut of point

Serum Ferritin and Cellular Reactive Protein (CRP) in Non Alcoholic Fatty liver Disease (NAFLD) and Non Alcoholic Steatohepatitis (NASH) Patients

Abstract Background Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the world, and it comprises a spectrum of hepatic abnormalities from simple hepatic steatosis to steatohepatitis, fibrosis, cirrhosis, and liver cancer. Simple steatosis (i.e., NAFL) rarely progresses to advanced disease whereas, in approximately 20% of patients with NASH, it progresses to fibrosis and cirrhosis and potentially to hepatocellular carcinoma over a 15-year time period. Aim of the Work To study the relation between serum ferritin and CRP levels and severity of non- alcoholic fatty liver disease NAFLD and non-alcoholic steatohepatitis NASH. Patients and Methods This case control study was conducted on patients attending the Hepatology Outpatient Clinic at Ain Shams University Hospital between December 2019 to May 2020. Results In group A there is significant correlation between ferritin and age, ALT, AST, albumin, CRP, LDL, BMI, cholesterol, triglycerides and NAFLD fibrosis score. But there is no significant correlation between ferritin and Hb, platelets, HDL and fasting blood sugar FBS in group A. In group B there is significant correlation between ferritin and ALT. Ferritin has cutoff point of &amp;gt; 168 with 80% sensitivy &amp; 80% specificity. In group A there is significant correlation between CRP and age, BMI, ALT,AST, albumin, LDL, cholesterole, triglycerides and NAFLD fibrosis score. In group A there is no significant correlation between CRP and Hb, platelets, FBS and HDL. While in group B there is significant correlation between CRP and BMI, ALT, albumin, LDL, cholesterole and triglycerides. CRP cutoff point of &amp;gt; 1.3 with specificity 90% but sensitivity 35%. Conclusion In conclusion, in this study we tried to find a relation between serum ferritin and CRP levels and severity of non-alcoholic fatty liver disease NAFLD and non-alcoholic steatohepatitis NASH. We found that s. ferritin and CRP are significantly elevated in NAFLD and more elevated in NASH with a link between serum ferritin and insulin resistance and the whole metabolic syndrome. Serum ferritin and CRP are related to disease progression with significant correlation with NAFLD fibrosis score.

BRIDGE to liver health: implementation of a group telehealth psychoeducational program through shared medical appointments for MASLD management

BackgroundMetabolic dysfunction-associated steatotic liver disease (MASLD) represents a significantly costly and increasingly prevalent disease, with treatment focused on lifestyle intervention. Integrating education and behavioral health into clinical care offers opportunities to engage and empower patients to prevent progression of liver disease. We describe the design and implementation of Behavioral Resources and Intervention through Digital Group Education (BRIDGE), a 6-session group telehealth program led by advanced practice providers (APPs) in 90-min shared medical appointments (SMAs) with small groups of MASLD patients in an academic outpatient hepatology clinic. The program contains multi-component group interventions, with didactic education and behavioral coaching, while leveraging peer-based learning and support.MethodsA mixed-methods exploratory pilot study was conducted. Feasibility and acceptability of the clinical intervention were assessed by tracking recruitment, attendance, and retention of BRIDGE participants, patient interviews, and debriefing of clinician and staff views of the clinical program. Implementation metrics included program development time, workflow and scheduling logistics, and billing compliance for sustainability. Finally, patient parameters including changes in liver enzymes, FIB-4, weight, and BMI from pre- to post-BRIDGE were retrospectively analyzed.ResultsWe included 57 participants (median age 57, interquartile range (IQR) 50 – 65 years), 38 (67%) female, 38 (67%) white, and 40% had public insurance. Thirty-three (58%) participants completed all six sessions, while 43 (75%) attended at least five sessions. Patients who completed all sessions were older (median age 61 vs 53.5; p = 0.01). Gender, race/ethnicity, and insurance type were not significantly associated with missed sessions, and patients had similar rates of completion regardless of weight, BMI, or stage of liver disease. Barriers to completion included personal illness, family reasons, work commitments, or insurance issues. Prior to BRIDGE, median BMI was 31.9 (SD 29 – 36), with a median weight loss of 2 pounds (IQR -2 – 6) after BRIDGE.ConclusionThe BRIDGE telehealth SMA program was feasible, well-attended, and positively reviewed. This pilot study informs future iterations of program development and evaluation of outcome measures.

Evaluation of Circular RNA SMARCA5 as a Novel Biomarker for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the fourth most prevalent type of cancer in Egypt and the sixth globally. Most patients with HCC are typically diagnosed during the advanced stages of the disease due to the absence of biomarkers for early detection. Consequently, these patients miss the optimal timeframe for receiving therapy. we aimed to assess the circular RNA SMARCA5 level and SMARCA5 mRNA gene expression as a potential biomarker for early detection of HCC. The present study utilized a case-control design comprising 159 participants. Participants were selected from both inpatient and outpatient hepatology and gastroenterology clinics at the National Liver Institute Hospital, Menoufia University. They were evenly distributed among three groups: Group I: 53 control subjects, Group II: 53 HCV cirrhotic patients, and Group III: 53 HCC patients. Tumor staging was done using BCLC staging system. Each patient underwent a thorough clinical examination, radiological examination, complete history taking, and serum Alpha-fetoprotein (AFP) assessment and detection of circular RNASMARCA5 and SMARCA5mRNA gene sutilizing quantitative real-time polymerase chain reaction. Statistically substantial differences were observed in the examined groups in terms of AFP, SMARCA5, and CircSMARCA5 (P-value = 0.001, 0.001 & 0.001). CircSMARCA5 and SMARCA5mRNA were markedly down regulated in the HCC group compared to HCV cirrhotic patients and controls. ROC analysis for early HCC diagnosis demonstrated that the CircSMARCA5 area under the curve (AUC) at cut-off point 4.55 yielded a specificity of 83.8% and sensitivity of 91.7%. The AUC for AFP at a cut-off point of 515ng/ml yielded a specificity of 89.2% and a sensitivity of 91.3%. CircSMARCA5 has the potential to be a more sensitive predictor of HCC disease compared to AFP.

Abstract 4802: Accuracy of the GALAD serologic model in the diagnosis of hepatocellular carcinoma in Ghanaian patients

Abstract Background: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. In sub-Saharan Africa, HCC is the second most common cancer in men and the sixth in women. African patients present with HCC at a young age and at advanced stage of disease. Improved surveillance can increase early HCC detection. The GALAD score has good sensitivity in the diagnosis of HCC in Asia, Europe and North America, however, it has not been validated in an African cohort. The aim of this study was to assess the performance of the GALAD score in the diagnosis of HCC in Ghanaian patients. Methods: Clinical data from patients with cirrhosis (n=93) or HCC (n=78) from out-patient hepatology clinics at 3 teaching hospitals in Ghana were abstracted, and serum samples analyzed. A logistic regression model predicting HCC status based on GALAD score was constructed to obtain the Receiver Operating Characteristics (ROC) curve for GALAD. The area under the curve (AUC) with 95% confidence interval was calculated and used to assess the performance of the GALAD score in surveillance for HCC. Results: The median AFP (5010.2 vs. 3.4), L3% (28.3 vs. 0.3) and DCP (507.6 vs. 0.2) levels were all significantly higher among HCC cases than the controls (p&amp;lt;0.0001). The median GALAD score was also higher among HCC patients (8.0 vs. -4.1, p&amp;lt;0.0001). The AUC of the GALAD score in the diagnosis of HCC was 0.86 (95% CI 0.79 - 0.92). At a cut-off value of -0.37, the GALAD score had a sensitivity of 0.81 and a specificity of 0.86. In a re-fit of the logistic regression model, the most significant factors in the GALAD model in our cohort were AFP-L3% and log(DCP). The AUC of the new GALAD model after model selection was 0.89. Conclusion: The GALAD score can be used to detect HCC in Ghana and has the potential to improve HCC surveillance in low-resource settings in sub-Saharan Africa. Citation Format: Yvonne Ayerki Nartey, Ju Dong Yang, Tyler Zemla, Joshua Ayawin, Shadrack Osei Asibey, Mohamed El-Kassas, Sally Afua Bampoh, Amoako Duah, Adwoa Agyei-Nkansah, Yaw Asante Awuku, Mary Yeboah Afihene, Hiroyuki Yamada, Jun Yin, Amelie Plymoth, Lewis Rowland Roberts. Accuracy of the GALAD serologic model in the diagnosis of hepatocellular carcinoma in Ghanaian patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4802.

Barriers to Exercise in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease: A Patient Survey.

Although adequate physical activity is an essential component of treatment for metabolic dysfunction-associated steatotic liver disease (MASLD), the majority of people with MASLD do not engage in regular exercise and lead sedentary lifestyles. We aimed to identify perceived barriers to exercise and to examine awareness about the role of exercise in the treatment of MASLD. Individuals aged 18 years and above were recruited from a hepatology outpatient clinic. MASLD severity was assessed using controlled attenuation parameter (CAP) and transient elastography (TE) determined liver stiffness measurement (LSM) for the severity of hepatic steatosis and fibrosis, respectively. An online questionnaire was administered to record self-reported exercise patterns, barriers to exercise, and knowledge regarding effectiveness of different types of exercise for MASLD. Eighty-one participants (57% female) with a mean age of 55.3 ± 13.4 years and a mean body mass index (BMI) of 33.8 ± 6.4 answered the questionnaire. The mean CAP score was 335.7 ± 47.8 dB/m, and the median LSM was 12.45 kPa. While most patients (83%) considered MASLD to be a serious health concern, 73% did not achieve the recommended exercise levels of ≥ 150 min of moderate-intensity physical activity per week, and 54% were unsure about the role of exercise in the treatment of MASLD. Commonly reported barriers to exercise included physical and mental health issues (57%), lack of time (43%), lack of enjoyment in exercising (31%), fatigue caused by exercise (24%), and others (25%). Most participants with MASLD were unaware of the role of exercise as a potential treatment option and were not achieving recommended exercise levels. Inadequate time, physical and mental health problems, lack of enjoyment in exercise, and fatigue were major barriers.

Opportunistic screening using point-of-care testing leads to successful linkage to care of HBV-infected migrant populations in a low endemic country

Background and aimsIn low endemic countries, screening for hepatitis B surface antigen (HBsAg) in migrants is cost-effective in reducing the disease burden of hepatitis B virus (HBV) infections, but linkage to care (LTC) remains a challenge. This study aims to guide future screening initiatives, with 3 objectives: 1. to compare LTC between different ethnic groups screened for HBsAg with point-of-care testing (POCT) in an outreach setting; 2. to estimate the proportion of HBsAg seropositivity for ethnic minorities; and 3. to investigate the association between seropositivity and HBV risk factors. MethodsOpportunistic outreach screenings using finger prick HBsAg tests were performed at civic integration programmes between 11/2017 and 09/2022. If an individual tested positive, an appointment was given immediately at the outpatient hepatology clinic for follow-up and confirmation of HBsAg positivity in blood. Dedicated personnel contacted these individuals to motivate them for further LTC, which was defined as being assessed by a hepatologist, a blood test and an abdominal ultrasound. ResultsA total of 677 people from different ethnicities (Asian, Middle Eastern and African) were serologically screened using POCT. The observed positivity for HBsAg was 3.4 % (95% CI 2.17-5.05, 23/677). Apart from ethnicity and male sex, none of the surveyed HBV risk factors were associated with HBsAg seropositivity. All HBsAg positive individuals were linked to care and assessed by a hepatologist, despite the COVID-19 pandemic increase in time to follow-up of 82 days (95% CI 51–112 days) vs. 24 days (95% CI 5–43 days, p = 0.008)).Among HBV-infected patients, 31.8% (7/22), 100 % (22/22) and 26.1% (6/23) met the criteria for treatment indication, intrafamilial transmission risk and need for hepatocellular carcinoma surveillance, respectively. ConclusionThe proportion of HBsAg seropositivity in ethnic minorities was 3.4%. POCT and commitment of dedicated personnel can overcome previously identified barriers resulting in a 100% LTC.

A284 EVALUATING THE INCIDENCE OF MAJOR GASTROINTESTINAL BLEEDING IN PATIENTS WITH CIRRHOSIS ON ANTICOAGULATION THERAPY: A TERTIARY SINGLE CENTRE EXPERIENCE

Abstract Background Patients with chronic liver disease, especially those with cirrhosis, face an increased risk of bleeding and thrombosis due to hemostasis dysregulation. In such cases, prescribing anticoagulation therapy requires a cautious approach, given the inherent risk-reduction in thrombosis alongside a suspected elevated bleeding risk. Aims Perform a retrospective study to evaluate anticoagulation safety and gastrointestinal bleeding incidence in cirrhotic patients. Methods A retrospective study was conducted at the University Hospital of London Health Sciences Centre, involving patients who attended outpatient hepatology clinics between 2010 and 2022. To be eligible, patients had to be 18 years or older and have confirmed cirrhosis through imaging, radiology, or pathology. They were monitored for up to 5 years for the primary outcome, which was major gastrointestinal bleeding requiring hospitalization. Exclusions included patients with underlying hematologic or thrombotic conditions contributing to abnormal hemostasis beyond cirrhosis and those who underwent liver transplantation. Descriptive statistics were provided, such as means and standard deviations for continuous variables, and proportions/percentages for categorical ones. Group comparisons utilized the Student's t-test for continuous variables and chi-squared tests for categorical variables. Univariate and multivariate logistic regression were employed to calculate odds ratios and their associated 95% confidence intervals for the primary outcome Results We retrospectively enrolled 300 patients, with 34.0% having cirrhosis and anticoagulation history. The average age was 63.1 years [95% CI 61.7 – 64.6], and 43.7% were female. Atrial fibrillation was the primary reason for anticoagulation (53.9%). Cirrhotic patients on anticoagulation had a 13.1% bleeding rate, while those without had 18.6% (p-value = 0.207, not significant). Univariate analysis suggested a possible link between anticoagulation and bleeding risk (OR 1.51 [95% CI 0.79 – 2.89]). No covariates predicted bleeding in univariate logistic regression. In multivariate analysis adjusting for age and sex, the odds ratio remained at 1.50 [95% CI 0.78 – 2.88]. The study hints at a higher bleeding risk in cirrhotic patients on anticoagulation, but more statistical power is needed, either through a larger sample or a multicenter approach. Conclusions To further investigate the association between anticoagulation and bleeding risk in cirrhotic patients, a larger multicentre study with increased enrollment is required. Nonetheless, interim findings do suggest the potential existence of an associated bleeding risk in cirrhotic patients undergoing anticoagulation therapy, albeit with a small observed effect size and uncertain clinical significance. Funding Agencies None

ASSOCIATION BETWEEN ANXIETY AND DEPRESSION IN METABOLIC DYSFUNCTION-ASSOCIATED STEATOTIC LIVER DISEASE (MASLD).

This study aimed to assess the frequency and intensity of anxious and depressive symptoms in patients diagnosed with metabolic dysfunction-associated steatotic liver disease (MASLD). This is a descriptive and cross-sectional study, resulting from 106 patients from the Hepatology outpatient clinic at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil without a history of alcohol abuse, verified by the alcohol use disorders identification test (AUDIT). These were assessed using the sociodemographic data sheet, Hospital Anxiety and Depression Scale (HADS), Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Depression Scale (HAM-D). A total of 69.8% were women and 30.2% were men, with a mean age of 61 years. The majority (71.7%) discovered MASLD through routine exams, presenting as comorbidities: Type 2 diabetes mellitus (59.4%), Dyslipidemia (49.1%), Arterial hypertension (68.9%), Obesity (61.3%) and Metabolic syndrome [MetS (63.2%)]. The HADS scale indicates 34% probability of anxiety and 33% depressive symptoms. The Hamilton's scales of intensity indicates 63.9% severe anxiety and 54.3% severe depression. There is also a relationship between anxiety, depression and the female gender, as well as between depression and MetS. The findings point to the presence of anxiety and depression in more than one third of MASLD patients, most with severe symptoms. The group is concentrated in the elderly, with many comorbidities, including MetS. There was a positive correlation between anxiety, depression and being female; also, being significant between MetS and depression.

MYELOID-DERIVED SUPPRESSOR CELLS TWO YEARS AFTER HEPATITIS C VIRUS ERADICATION USING DIRECTLY ACTING ANTIVIRALS.

Myeloid-derived suppressor cells (MDSCs) have immature morphology, relatively weak phagocytic activity, as well as some immunosuppressive functions. The capacity of MDSCs to inhibit T-cell-mediated immunological responses is their most notable functional characteristic. Down-regulating antitumor immune surveillance is one way that the expansion and activation of MDSCs contribute significantly to the occurrence and progression of tumors. Increased levels of MDSCs in patients with chronic hepatitis C virus (HCV) infection could suppress T-cell responses, promoting viral escape and hepatitis progression. This may make HCV-infected individuals more vulnerable to severe infections, hepatic and extra-hepatic tumors, and a diminished capacity to react to immunization. It is still unknown if effective HCV eradication with directly acting antivirals (DAAs) can restore immune functions and immune surveillance capacity. The purpose of this study was to observe the frequency of M-MDSCs (CD33+, CD11b+, and HLA-DR) in patients with a previous history of HCV, 2-3 years after virus eradication using DAA therapy. This study was conducted on 110 subjects: fifty-five subjects without liver cirrhosis who were treated with HCV using DAAs and attained SVR for a period of 2-3 years and 55 age- and gender-matched healthy controls. The study was conducted during the period from January to July 2022. Patients were recruited from the National Viral Hepatitis Treatment Unit, Alexandria University Hepatology outpatient clinic, and the Alexandria University Tropical Medicine outpatient clinic. The frequencies of MDSCs (CD33+CD11b + HLA-DR-) by flow cytometry were assessed. Even after the virus had been eradicated for longer than two years, MDSC levels in HCV-treated individuals were found to be considerably higher. In the HCV-treated group, the median number of MDSCs was 5, with an interquartile range (IQR) of 3.79-7.69. In contrast, the median for the control group was 3.1, with an IQR of 1.4-3.2 (P˂0.001). Successful DAA therapy leads to slow and partial immunological reconstitution, as demonstrated by the failure to attain normal levels of MDSC's 2 years after successful HCV eradication despite the normalization of laboratory parameters as well as the absence of liver fibrosis. The clinical implications of these findings should be thoroughly studied.

Investigating Acute Hepatitis after SARS-CoV-2 Vaccination or Infection: A Genetic Case Series.

(1) Background: Despite the advantages of COVID-19 vaccination, rare cases of acute hepatitis developing after the administration of the COVID-19 vaccine or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported. The aim of the study is to describe a case series of patients who experienced the onset of acute hepatitis, with or without autoimmune features, following SARS-CoV-2 vaccination or infection and to hypothesize a genetic susceptibility in the pathogenesis. (2) Methods: A group of patients with acute onset hepatitis following SARS-CoV-2 vaccination or infection were evaluated in our hepatology outpatient clinic, where they underwent biochemical and autoimmune tests. Hepatitis A (HAV), B (HBV), and C virus (HCV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), and human immunodeficiency virus (HIV) infections were excluded. Patients with a diagnosis of autoimmune hepatitis (AIH) or drug-induced liver injury (DILI) underwent HLA typing and histological testing. (3) Results: Five patients experienced new-onset AIH after COVID-19 vaccination, one of which developed mild symptoms after vaccination that strongly worsened during subsequent SARS-CoV-2 infection. One patient had AIH relapse after COVID-19 vaccination while on maintenance immunosuppressive treatment. All of them had HLA DRB1 alleles known to confer susceptibility to AIH (HLA DRB1*03,*07,*13,*14), and in three of them, HLA DRB1*11 was also detected. Two patients developed acute hepatitis without autoimmune hallmarks which resolved spontaneously, both positive for HLA DRB1*11. (4) Conclusions: An association between AIH and COVID-19 vaccine or infection can be hypothesized in individuals with a genetic predisposition. In patients without autoimmune features and spontaneous improvement of hypertransaminasemia, the diagnosis of drug-induced liver injury (DILI) is probable. Further studies are needed to determine the presence of an actual association and identify a possible role of HLA DRB1*11 in the pathogenesis of acute liver injury after SARS-CoV2 vaccination or infection.

Efficacy and Safety of Probiotic versus Conventional Treatment of Irritable Bowel Syndrome

Abstract Background Irritable bowel syndrome is a gastrointestinal syndrome characterized by chronic abdominal pain and a change in intestinal habits without any organic cause. It affects 11% of the world-wide population. irritable bowel syndrome reduces health-related quality of life and leads to a significant economic healthcare burden. Aim of the Work The aim of this study is to investigate the efficacy of probiotics in irritable bowel syndrome (IBS) patients. Patients and Methods A randomized controlled clinical trial in Gastroenterology and Hepatology outpatient clinic at: Ain Shams University Hospitals for 6 months from November 2020 till April, 2021. 120 Person were included in this study divided into 2 group: Group 1:60 patient with irritable bowel syndrome received conventional treatment and and Lactobacillus Acidophilus probiotics. Group 2: 60 patient with irritable bowel syndrome received conventional treatment. Results There was a significant increase of passage of gas in group 1 than in group 2 but no significant difference in between group 1 and group 2 regarding stool consistency, mucus with stool, abdominal pain, Bloating and passage of stools. There was 46.7% in group 1 and 55% in group 2 had a very good treatment success with no significant difference in between. Regarding to the treatment success in group 1, there were 46.7% in group 1 had a very good treatment success, 33.3% had a good treatment success and 20% had poor response. There was 80% in group 1 had a very good overall tolerability to probiotic treatment. Conclusion This study shows moderate evidence for the use and safety of probiotics in irritable bowel syndrome. Probiotics provide a new strategy as a safer treatment for irritable bowel syndrome. In general, the use of Probiotics has been successful in practice, especially for symptom control and maintenance of remission in these entities. However, it is necessary to take into account the specific condition of the patient and their comorbidities to make informed decisions about management.

Assessment of Right Lobe Size/Serum Albumin Ratio as a Non-Invasive Marker for Esophageal Varices in HCV Patients

Abstract Background Viral hepatitis was estimated to be the 7th leading cause of mortality globally. HCVassociated disease is one of the leading causes of HCC and the main indications for liver transplantation. Approximately 71 million people are chronically infected worldwide, with a total global HCV prevalence estimated at 2.5%. Egypt has the highest world prevalence of hepatitis C virus (HCV) infection, which is associated with substantial disease and economic burden. Chronic HCV infection can result in hepatic fibrosis, cirrhosis, HCC and death. One of the major complications of cirrhosis is gastroesophageal varices, the incidence of which ranges from 35% to 80%). Current guidelines recommend that all cirrhotic patients should undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. Noninvasive identification of patients at highest risk for esophageal varices would limit investigation to those most likely to benefit. Aim of the Work The aim of our study is to determine the predictive value of noninvasive parameters (Rt. lobe diameter/ serum albumin ratio) in the prediction of esophageal varices. Patients and Methods It is a cross-sectional study carried on 100 patients collected from the Hepatology outpatient clinics and from Hepatology and Gastroenterology unit, Internal medicine department at Ain Shams University Hospital over 6-month period, with inclusion and exclusion criteria aiming at the elimination of other factors that might affect the study results. All patients were divided into 3 groups: 30 patients with Child-Pugh A, 30 patients with Child-Pugh B, and 40 patients with Child-Pugh C. patients were subjected to the following: Clinical assessment: including; Full medical history and clinical examination, laboratory investigations: (AST, ALT, Bilirubin, Albumin, INR, Alpha feto-protein, CBC), abdominal ultrasonography and doppler ultrasonography: performed after overnight fasting and the patient in supine position with emphasis on the liver right lobe diameter (cm), splenic bi-polar diameter (long axis) (cm), ascites, presence of periportal thickening, portal vein diameter (mm) and patency, upper GI endoscopy. Results Our study showed that regarding platelet count, INR, serum albumin, Liver size, liver size / serum albumin ratio there was a significant difference among esophageal varices grades. Liver size / serum albumin ratio had non-significant diagnostic performance in differentiating esophageal varices grade-I from grade-0, had significant moderate diagnostic performance in differentiating other esophageal varices grades from each other. Liver size / serum albumin ratio cutoff points had high specificity &amp; PPV but low sensitivity&amp; NPV in differentiating grade-I from grade-0, had high sensitivity&amp; NPV but moderate specificity &amp; PPV in differentiating other grades from each other. Conclusion Our study showed that there was significant moderate agreement between endoscopy and liver size / serum albumin ratio regarding esophageal varices grades. Our study stresses on the use of some of the non-invasive parameters in predicting the grade of esophageal varices in cirrhotic patients without submitting them to the invasive, time consuming and expensive procedure of endoscopy.

Role of Circulating Ectodysplasin A as a Biomarker in Non-Alcoholic Fatty Liver Disease

Abstract Background The liver is a dynamic organ that plays critical roles in many physiological processes, including the regulation of systemic glucose and lipid metabolism. Dysfunctional hepatic lipid metabolism is a cause of nonalcoholic fatty liver disease (NAFLD), the most common chronic liver disorder worldwide, and is closely associated with insulin resistance and type 2 diabetes. Objective To study serum level of Ectodysplasin A in patients with non-alcoholic Fatty Liver disease (NAFLD) to detect its relation to the incidence and severity of non-alcoholic Fatty Liver Disease (NAFLD). Patients and Methods Type of Study: Case-Control clinical study. Study Setting: Internal medicine and hepatology outpatient clinic at Ain Shams University Hospital Study period: this is a 6-month study period starting from July 2020 till January, 2021. Results There was a significant difference in between the two groups regarding to platelet, ALT, AST, GGT and albumin. The mean Ectodysplasin A was 337.54 ± 196.63 (pg/ml) in NAFLD group and 221.43 ± 115.89(pg/ml) in control group with high statistical significant difference in between. There was a significant positive correlation in between Ectodysplasin A and Weight, BMI, WC (cm), FPG, HbA1c and LDL-C in NAFLD group. Conclusion Ectodysplasin A level is elevated in NAFLD patients than in control. Ectodysplasin A level could be used as an inflammatory biomarker for the prognosis of patients NAFLD. Therefore, measurement of Ectodysplasin A level provides a new strategy to more aggressive treatments for high-risk groups.

Role of Circulating Vascular Cell Adhesion Protein – 1 as a Biomarker in Non-alcoholic Fatty Liver Disease

Background As a result of the obesity pandemic, non-alcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease worldwide. NAFLD is the hepatic manifestation of obesity and a precursor of and independent risk factor for type 2 diabetes Aim of the Work To assess the level of vascular cell adhesion molecule 1 (VCAM-1) as noninvasive diagnostic tools for diagnosis of NAFLD degree of fibrosis. Patients and Methods A Case-Control clinical study in the Internal medicine and hepatology outpatient clinic at Ain Shams University Hospital for 6-month on 60 persons that were included in this study divided into 2 groups: Group A: 30 patient with NAFLD as a study group. Group B: 30 healthy subjects as a control group. Results In the present study, the mean VCAM-1 was 2.392 ± 0.3 in NAFLD group, 9.893 ± 2.3 in NASH group and 1.983 ± 0.3 in control group with high statistical significant increase in NASH followed by NAFLD than in control group. Regarding to ROC curve, VCAM-1 had excellent Diagnostic performance with an AUC of 0.994. A best cut-off criterion of VCAM-1 &amp;gt; 7.7 ng/mL could discriminate between patients with NASH from control group with a sensitivity of 95% and specificity of 100% In our study, there was no significant correlation in between VCAM-1 and age, AST, ALT In the present study, the significant predictors of bad outcome in patients with NAFLD and NASH were higher VCAM-1 level, GGT and higher AST levels Conclusion The significant predictors of bad outcome in patients with NAFLD and NASH were higher VCAM-1 level, GGT and higher AST levels.