Portal Hypertensive Gastropathy: the Twilight Zone

As one of the major complication of liver cirrhosis, portal hypertensive gastropathy (PHG) should be an interesting topic to study. Until now the exact mechanism on how this phenomenon happened is yet, not clear.1 The occurrence of PHG is quite high in patient liver cirrhosis and some relationship occurred between PHG and portal hypertension. In liver cirrhosis patients, PHG may be closely associated with hepatic vein pressure gradient(HVPG).2 However, PHG may not be directly associated with portal pressure because the mucosal damage not linearly correlated with portal hypertension, hence other mechanism involved in the etiopathogenesis of PHG. In this regards, the most important factor related to PHG is the pressure in the splanchnic vasculature. Based on histopathology study in PHG, vascular congestion resulted from increased portal pressure reduced oxygen for gastric mucosa, hence exposed mucosal layer to irritants.2 Moreover, the congestion somehow increased the production of nitric oxide, either through the shearstress locally or as the result of increase production of splanchnic vasculature due to portal hypertension

Artificial Ascites in Radiofrequency Ablation for Liver Cancer

Background: Radio Frequency Ablation (RFA) is one of the treatment modality for liver tumor either as primary tumor as well as secondary Malignancy. Occasionally, a good ablation can't be performed due to the tumor location. To assists the ablation in this particular case, some fluid can be deposited inside the abdomen which is called as artificial ascites. The aim of this study is to report and evaluate the method of artificial ascites in RFAMethod: This was a case series study consist of 19 consecutive patients that had been treated with ultrasound-guided RFA using artificial ascites from 2014 to 2017.Results: Artificial ascites was successfully performed in all 19 patients (100%) with total of 53 hepatocellular carcinoma (HCC) lesions in 34 RFA's sessions and tumor size ranges from 10mm to 50mm. Most of the tumors were primary tumor (14/19). 9 patients had single tumor and 10 patients had multiple tumors and most of the tumor were located in segment 5 (14/53). Artificial ascites was performed using 5% dextrose in water (D/W) solution ranging from 500ml to 1500ml. No adverse effect occurred during and after the procedure.Conclusion: Percutaneous RFA using artificial ascites technique was safe and effective for treating HC

Bacterial Infection in Liver Cirrhosis

Patients with liver cirrhosis frequently have infection which can deteriorate further the already impaired liver function. The most common form of infection in this particular patients are spontaneous bacterial peritonitis, urinary tract infection, and respiratory infection. Causative organism mostly Gram negative micro organism and originate from the gastrointestinal tract. The weaken of immune defense mechanism and also the altered gastrointestinal tract motility can explained most of these infection. This paper will review the bacterial infection in liver cirrhosis with some guidance in the management

Treatment of Chronic Hepatitis B

Chronic hepatitis B is still a major health problem in Indonesia. Unfortunately, to date, treatment of chronic HBV (Hepatitis B virus) infection had not shown satisfactory Result. Monotherapy with alpha interferon or lamivudine have been widely used as treatment of chronic HBV. However, treatment response to Alpha interferon in Asian people was not satisfactory (15% - 20%), while monotherapy with lamivudine was not sufficient to eradicate HBV in chronically infected patients and commonly induce drug resistance. The occurrence of chronic hepatitis B resistant to lamivudine had encouraged development of newer agents such as adefovir, entecavir, emtricitabine and nucleoside analog. New therapeutic strategy using combination therapy should be considered if there is no sufficient response to monotherapy

Treatment Response Monitoring of Chronic Hepatitis B Patients using Transient Elastography and Aspartate Aminotransferase-to-Platelet Ratio Index (APRI)

Background: Hepatitis B is endemic in Indonesia and treatment response need to be monitored during and after antiviral therapy. Liver stiffness measurement and alanine aminotransferase-to-platelet ratio index (APRI) are noninvasive method to detect liver fibrosis available in Indonesia. However, little is known about their ability to evaluate treatment response in chronic hepatitis B (CHB) patients in Indonesia. This study aimed to investigate liver stiffness changes by transient elastography (TE) and APRI before and after one-year oral antiviral treatment in CHB patients and the correlation between TE and APRI. Methods: this study was retrospective cohort on CHB patients in CiptoMangunkusumo Hospital, Jakarta who uderwent treatment between January 2012 and December 2014. Patients received oral antiviral treatment with newer nucleoside analogues (entecavir or telbivudine) for at least one year. TE and APRI were obtained before and after treatment. TE and APRI reductions were analyzed statistically with Spearman’s test. Results: a total of 41 patients were enrolled in this study. Median liver stiffness value was significantly reduced from 10.8 to 5.9 kPa after oral antiviral treatment (p<0.001, Wilcoxon’s test). Median APRI was also significantly reduced from 1.13 to 0.43 after treatment (p<0.001, Wilcoxon’s test). The correlation between liver stiffness and APRI before treatment was weak (r=0.40), but it was strong after treatment (r=0.73). Conclusion: the liver stiffness measured with transient elastography and APRI significantly decreased after one year of antiviral treatment in chronic HBV patients. There was a significant correlation between TE and APRI after one year of treatment

Association Between HBV DNA Level and Intrahepatic HBcAg Protein Expression of Hepatocytes in Patients with Chronic Hepatitis B

Background: Correlation between serum Hepatitis B viral deoxyribonucleic acid (HBV DNA) and hepatitis B core antigen (HBcAg) protein expression in the liver regarding hepatitis B e-antigen (HBeAg) status have not been well studied. This study was aimed to demonstrate association between serum HBV DNA and HBeAg levels with HBcAg expressions in the liver. Method: A total of 55 naive chronic hepatitis B (CHB) patients were enrolled. All samples were tested for HBeAg serum by serological test enzyme-linked immunosorbent assay (ELISA) and HBV DNA was determined by polymerase chain reaction (PCR) HBsAg and HBcAg were evaluated immunohistochemically in the liver tissue Results: Of 55 patients, 44 (80%) were HBeAg positive and 11 (20%) were HBeAg negative. There was a positive correlation between serum HBV DNA and HBcAg expression in the nuclei (r: 0.383; p = 0.004). There was association between HBcAg expression in the nucleus and qualitative HBeAg (p = 0.017). Conclusion: In the patient with chronic HBV, there is a very significant positive correlation between the level of viral replication and HBcAg expression in the nucleus of hepatocytes. Moreover, there is association between HBcAg expression in the hepatocytes nucleus and HBeAg serum level. These finding lead to the proposition that nucleus localization of HBcAg protein function to amplify the pool of cccDNA in the replication cycle of HBV.

Relationship Between Vascular Endothelial Growth Factor and Severity of Hepatocellular Carcinoma

Background: Severity of hepatocellular carcinoma (HCC) that is assessed using Barcelona Clinic Liver Cancer (BCLC) classification is a main prognostic factor of hepatocellular carcinoma. Assessment of the serum level of Vascular Endothelial Growth Factor (VEGF) is considered to reflect the severity of HCC. However, there is still no fundamental basis of the association of severity of HCC with the serum VEGF level. The objective of this study is to know the relationship between serum VEGF levels with the severity of HCC by assessing the average difference of serum VEGF level in various severity of HCC.Method: This study was a cross sectional study to identify the association between serum VEGF levels with the severity of HCC based on BCLC classification. This study was performed in Cipto Mangunkusumo Hospital between January and May 2015. Statistical tests used to evaluate the association between serum VEGF level with BCLC classification was one-way ANOVA analysis, and continued with post hoc Tukey Schaffe analysis.Results: A total of 61 subjects with HCC were included into this study. In this study, we did not find subjects with stage 0 BCLC. The average of serum VEGF level in stage A BCLC was 288.26 ± 156.6 pg/mL; stage B BCLC: 434 ± 164.8 pg/mL; stage C BCLC: 785.57 ± 194.25 pg/mL; stage D BCLC: 1537.97 ± 660.62 pg/mL. One-way ANOVA analysis showed significant difference (P &lt; 0.001) between serum VEGF level and HCC severity based on BCLC classification. Post hoc Tukey Schaffe analysis showed the presence of significant difference between stage A and C BCLC (p &lt; 0.05) and stage A and D BCLC (p &lt; 0.001), stage B and D BCLC (p &lt; 0.001), and stage C and D BCLC (p &lt; 0.001). There was no significant difference between stage A and B BCLC, and between stage B and C BCLC.Conclusion: It was found that serum VEGF level increased in accordance to the HCC severity based on BCLC classification, particularly for stage B BCLC and above