Correlation Between the Degree of Esophageal Varices and Liver Stiffness in Liver Cirrhosis Patients

Background: Bleeding due to rupture of esophageal varices is one of main cause of death in liver cirrhosis, that endoscopy screening is recommended. However endoscopy is invasive and frequently cannot be performed due to contraindication, high-cost or uncomfortable effect to the patients, particularly on patients have not had any bleeding before. Consequently, it is necessary to find other assessment which can predict the presence of esophageal varices. Recent studies found liver stiffness measurement by the liver transient-elastography is one of non invasive measurement to evaluate liver fibrosis.This study was designed to know the correlation between degree of the esophageal varices and the degree of liver stiffness. Method: This was cross sectional study. Liver cirrhosis patients were consecutively enrolled in this study. They underwent endoscopy to determine esophageal varices and subsequently the liver transient- elastography by Fibroscan technique to determine liver stiffness. Degree of the esophageal varices based on OMED criteria. Liver stiffness are expressed in kilopascal (kPa). Correlation analysis was done to assess this study. Result: There were 13 subjects. Most subjectswere male, age > 50 years and Child-Pugh A or B. The mean value of liver stiffness was 35.55 ± 23.60 kPa and mean OMED was 5.61 ± 2.14. The coefficient correlation between degree esophageal varices and degree liver stiffnes was 0.492, p = 0.087. Conclusion: There is moderate correlation but not statistically significant between the degree of liver stiffness and the degree of esophageal varices. Larger sample size is necessary to find the correlation between the degree of liver stiffness and esophageal varices

Risk Factors for Recurrent Upper Gastrointestinal Tract Bleeding After Esophageal Varices Ligation on Patients with Liver Cirrhosis

Background: Upper gastrointestinal tract (GIT) bleeding on liver cirrhosis patients will increase morbidity and mortality. Recurrent bleeding\u27s risk rise after the first episode of variceal bleeding. The mortality risk also rises on each bleeding. Purpose: This study was done in order to identify the risk factors for the first episode of recurrent bleeding of upper GIT on liver cirrhosis patient. Evaluation of risk factors was based on preliminary data prior to ligation. Method: Evaluation of the upper GIT bleeding was done using anamnesis on the patients or their relatives by letter, home visits or telephone. The data on recurrent bleeding was obtained from medical records. They were evaluated on the 3rd month then 1st year after ligation. This study was a cross sectional study with retrospective data and a consecutive sampling method. Result: Bivariate analysis revealed the 3rd month\u27s risk factors for first episode of upper GIT bleeding were ascites, total bilirubin level of > 2 mg/dL, hepatoma, Child-Pugh C classification of the liver function and red color sign on esophageal varices. The risk factors for the first episode of upper GIT bleeding on first year were age £ 60 years old, hepatoma, and red color sign (RCS) on esophageal varices. The differences between risk factors on upper GIT bleeding on the 3rd month and 1st year were likely due to intervention, collateral para-esophageal varices, medication that irritated GIT, physical activities, and differences on variceal obliteration rate related to variceal ligation. Conclusion: Risk factors for recurrent upper GIT bleeding that could be minimized were ascites, total bilirubin level, Child-Pugh classification and RCS. It was expected with parascentesis, diuretics, hepatoprotector medications and drugs that lowers portal hypertension (such as propranolol and isosorbid mononitrate), might improve those risk factors thus decreasing the risk for recurrent upper GIT bleeding

Analisis Hubungan Kemampuan Pemecahan Masalah Matematis dan Self Confidence Siswa SMP

This study aims to analyze the achievement and improvement of problem solving skills of junior high school students through the application of guided inquiry method. This research is an experimental research with research design in the form of pretest-posttest Control Group Design, which is design of pretest-posttest control group involving two groups and sampling is done randomly class. Population in this research is all students in one of junior high school in Sukabumi Regency. The sample in this research is the students of class VIII SMPN 1 Sukaraja which has population characteristics. From all the existing classes VIII, two classes were chosen randomly to be sampled. The instrument used is the test of mathematical problem solving ability. Based on the result of the research, it can be concluded that the achievement of the problem solving ability of mathematical students in learning using guided inquiry method is better than the students who use ordinary learning. Then the improvement of students' mathematical problem solving skills in the learning using guided inquiry method is better than the students who use ordinary learnin

Do Hepatic Encephalopathy Patients Really Need a Low Protein in Their Diet

Hepatic encephalopathy (HE) is an extra hepatic complication of liver cirrhosis. The clinical manifestation of HE is a reflection of a low-grade cerebral edema due to astrocyte swelling as a consequence of hyperammonia. HE mostly is induced by precipitating factors. Correcting these identifiable precipitating factors can alleviate this complication. In the past, liver cirrhosis patients were recommended to lower their protein intake. It was assumed that by limiting protein intake, the ammonia production would lower, which can lead to HE recovery. This approach, on the other hand, had worsened the nutritional status that already present in most patients with HE. There are some ways to overcome these problems without restricting protein intake including balance diet, using Branch Chain Amino Acids (BCAA), and frequent small portion diet

Correlation Between Branched Chain Amino Acids to Tyrosine Ratio and Child Pugh Score in Liver Cirrhosis Patients

Background: The determination of branched chain amino acids (BCAA) to tyrosine ratio (BTR) was available in making differentiation of chronic hepatitis from liver cirrhosis, because there was a strong association between BTR and staging (fibrosis) scores. Branched chain amino acids to tyrosine ratio have a correlation with Fischer ratio and the examination is easier because it can be done by enzymatic assay. Materials and Methods: To evaluate the correlation between BTR and Child-Pugh score, we examined the amino gram of 52 liver cirrhosis patients consisted of 26 Child-Pugh A, 19 Child-Pugh B, and 7 Child-Pugh C. The examination of amino gram was done by High Pressure Liquid Chromatograph (HPLC) analyzer. Branched chain amino acids to tyrosine ratio were compared to Child-Pugh score, albumin, ammonia level, number connection test to Fischer ratio. Results: Significant differences in BTR among Child-Pugh A, B, C were observed (Child-Pugh A 7.75 + 1.2; Child Pugh B 6.0 + 1.23 and Child Pugh C 4.38 + 3.14 (p = 0.000)). Branched chain amino acids to tyrosine ratio had a weak correlation with albumin (r = 0.292; p = 0.036), ammonia level (r = 0.376; p = 0.006) and strong correlation with Fischer ratio (r = 0.818; p = 0.000). There was no significant correlation between BTR and number connection test. Conclusion: These results showed that the determination of the molar ratio of branched chain amino acids to tyrosine well reflected the severity of liver cirrhosis and it can be used as a substitute of Fischer ratio

The Role of Specific Cellular Immune System in Chronic Hepatitis C

Hepatitis C virus is a RNA virus with very high speed replication. The clinical course of chronic hepatitis C is frequently asymptomatic like other hepatitis viruses. Infection of hepatitis virus will activate the immune system specifically as well as non-specifically. Mechanism of the immune system regulation is controlled by tissues consisting of antibodies cells and cytokines. In the process, all of the immune systems integrate and coordinate with the main agent-lymphocytes. Lymphocytes recognize antigens through the specific-surface antigen receptors. Following exposure to viral chronic hepatitis virus, viremia takes place within 1-2 weeks. In immuno-competent hosts, viremia will be preceded with the increase in transaminase enzyme and delayed seroconversion of antibodies will occur. Unlike other immunologic processes, these established antibodies are not protective in nature but serve only as the sign that someone has been infected by hepatitis C. In most cases of hepatitis C virus infection, this virus cannot be eradicated in the acute phase. Approximately 80-90% of acute infection progresses to be chronic infection and in 50% of the cases, there is an increase in transaminase enzyme that reveals that there is still liver cell damage. The degree of liver tissue damage in hepatitis depends on the number of virus infecting and the activity of cytotoxic T cells

Effects of BCAA Enteral Nutrition to the Change of Nutritional Status and Hepatic Encephalopathy Parameters in Liver Cirrhosis Patient with Hepatic Encephalopathy

Background: This study was also conducted to determine the effects of high-branched chain amino acid (BCAA) enteral supplementation on altered nutritional status parameters (including plasma prealbumin) and hepatic encephalopathy parameters in liver cirrhosis patients with hepatic encephalopathy. Method: Our study was a randomized, single-blinded experimental study comparing between control group of liver cirrhosis patients with standard hospital liver diet (40 kcal/kgBW/day for male and 35 kcal/kgBW/day for female; protein 1.25 g/kgBW/day) and experimental group of liver cirrhosis patients with liver diet modification high in BCAA supplementation, which had similar protein and calorie calculation as the control group. Results: Subclinical hepatic encephalopathy prevalence was 32%. In the experimental group, prealbumin plasma, arm circumference, body weight and body mass index (BMI) increased; whereas in the control group, prealbumin plasma, arm circumference, body weight and BMI decreased (p < 0.05). In experimental group, the ammonia level significantly decreased (p < 0.01). Clinical hepatic encephalopathy, flapping tremor, the number connection test (NCT) did not show significant changes between the two groups. However, there was worsening trend in the control group. Level of albumin, bilirubin, AST, ALT did not show any significant difference between both groups. Conclusion: High-BCAA enteral supplementation which is administered to liver cirrhosis patients with hepatic encephalopathy for 14 days could improve plasma prealbumin level, arm circumference, body weight, BMI and could decrease the plasma ammonia level. However, it does not improve Fischer ratio, psychometric test and electroencephalograph

Efficacy and Safety of In-Asia-manufactured Interferon Alpha-2b in Combination with Ribavirin for Therapy of Naïve Chronic Hepatitis C Patients: a Multicenter, Prospective, Open-Label Trial

Background: An open-label, multi center and non-comparative study was conducted to evaluate the efficacy and safety of a more affordable in-Asia-manufactured interferon á-2b product in combination with ribavirin to treat naïve chronic hepatitis C patients. Method: Thirty chronic naïve hepatitis C patients were treated with in-Asia-manufactured interferon a-2b subcutaneously 3 MIU thrice weekly and ribavirin 800-1,200 mg daily for 48 weeks. Follow-up was done until 24 weeks after the end of treatment. Efficacy was assessed by examining serologic and biochemical parameters at pre and post-treatment. Safety was assessed by evaluating clinical symptoms and laboratory parameters. Results: The virological response and sustained virological response rates of all Hepatitis C Virus (HCV) genotypes were 83.3% and 76.7% respectively. Post-treatment, 80% patients had significant alanine transaminase (ALT) decreased into normal level and remained normal in 76.7% patients at 24th week follow up period. At that time, the ALT level and sustained virological response were lower in HCV genotypes 1 and 4 than in non-1 and non-4 genotypes. The most frequent adverse event was flu-like syndrome. Conclusion: The efficacy and safety study on combination therapy of in-Asia-manufactured interferon a-2b and ribavirin has shown a good result based on the current standard of interferon alpha and ribavirin combination therapy

Abnormalities of the Small Bowel in Chronic Non-Infective Diarrhea: a Histopathological Study

Background: The incidence of chronic non-infectious diarrhea cases is increasing in line with the developments of medical technology and science. The objective of this study was to uncover the histopathologic abnormalities of the small bowel in cases of chronic non-infectious diarrhea. Methods: All chronic non-infectious diarrhea patients in Cipto Mangunkusumo Hospital from 1996 until 2000 were included in this study. For the control group, we used 37 endoscopically-normal patients with functional dyspepia with the same characteristics (sex and age). All of the patients underwent gastroduodeno-jejunoscopic and ileocolonoscopic examinations. Patients with infection were excluded from this study. Biopsies were taken from the duodenal bulb, descending duodenum, jejunum near the Treitz ligament, terminal ileum, and colon. Histopathological tests were performed on all of the biopsies. Result: Histopathological examination was carried out on 31 patients and 37 control patients. In the duodenal bulb, the width of villi, lymphocyte infiltration, eosinophil infiltration, stage of inflammation, and polymorphonuclear cells infiltration were all lower in the chronic non-infectious diarrhea group than in the control group (p < 0.01). In the descending part of duodenum and jejunum, lymphocyte infiltration, the stage of inflammation, and polymorphonuclear cell infiltration were found to be higher in the chronic non-infectious diarrhea group than in the control group (p< 0.01). Within the terminal ileum, lymphocyte infiltration, the stage of inflammation and lymphoid follicle hyperplasia were found to be higher in the chronic non-infectious diarrhea group than in the control group (p< 0.01). Conclusion: Histopathologically, increased lymphocyte infiltration, inflammation and lymphoid follicle hyperplasia were discovered in specified areas of small intestine in chronic non-infectious diarrhea patients