Hepatitis B Reactivation in Immunosupressed Patients, Prophylaxis and Management

Hepatitis B virus (HBV) reactivation is a clinical problem associated with high morbidity and mortality rates. Currently, this incidence seems to be increasing around the world. The reactivation commonly developes in immunosuppressed individuals, although it may also occur spontaneously. Individuals who develop malignancy with chronic hepatitis B virus infection are at high-risk for hepatitis B virus reactivation, since they are closely related to immunosuppression, especially when undergoing chemotherapy. The loss of immune control in these patients may results in the reactivation of HBV replication within hepatocytes. This review article will focus on HBV reactivation related to immunosuppressed patients, immunosuppressive drug classes and corresponding risk estimates of hepatitis B virus reactivation, screening test recommended before getting this drugs, choice of antiviral drugs for prophylaxis, and duration of prophylaxis treatment based on EASL, AASLD and APASL guidelines

Surgery in Liver Diseases: Perioperative Evaluation & Management

Many patients with liver disease would have to undergo surgery. Surgery and anesthesia in patients with liver disease are associated with extremely high perioperative complications and mortality. Identification of the type of liver disease, stratification of risk factors, and management of preoperative, intraoperative, and postoperative complications are essential to reduce the morbidity and mortality. Surgical risk is increased in patients with liver cirrhosis. Child turchote pugh (CTP) and the model for end stage liver disease (MELD) are two scoring systems which are often used nowadays to stratify risk factors in patients with liver cirrhosis who will undergo surgery. Elective surgery is well tolerated in cirrhosis patients with CTP class A and permissible in patient with CTP class B with preoperative preparation, except for extensive liver resection surgery and cardiac surgery. Elective surgery is contraindicated in patients with CTP class C, acute viral hepatitis, alcoholic hepatitis, fulminant liver failure, and liver disease with severe extrahepatic complication such as hypoxemia, cardiomyopathy, and acute renal failure. Intensive monitoring in the postoperative period and early intervention of complications are also essential to reduce the morbidity and mortality

Perbedaan Profil Abses Hati Pyogenic dengan Amoebic pada Pasien Abses Hati Rawat Inap di RSUD Dr Soetomo Tahun 2016-2019

Abses hati dibagi menjadi dua berdasarkan penyebab, yaitu bakteri pyogenik dan amoebik. Abses hati yang terjadi pada Dr. Soetomo masih belum diketahui, tetapi protozoa atau bakteri yang menyebabkan abses hati ditemukan banyak di Indonesia. Tujuan: Menentukan perbedaan profil klinis pasien dengan abses hati amoebik dan pyogenik di RSUD Dr. Soetomo pada periode 2016 sampai 2019.  Metode: Studi ini adalah analitik observasional menggunakan pendekatan cross-sectional pada rekam medis, dengan kriteria inklusi tes seroamoeba dan USG. Data dianalisis menggunakan uji Chi-square untuk skala nominal, t-test dan Man-Whitney untuk skala interval. Hasil: Ada 58 pasien dengan abses hati, masing-masing terdiri dari 29 pasien pada kedua jenis abses hati. Abses hati terjadi lebih dari 85% pada pria dengan usia rata- rata 42 hingga 45 tahun. Manifestasi klinis yang paling umum adalah nyeri RUQ (Kuadran Kanan Atas) (93,1%), hepatomegali (70%), dan demam (69%). Hasil pemeriksaan USG adalah abses tunggal di lobus kanan. Tinjauan terapi menggunakan drainase perkutan lebih dari operasi. Komplikasi yang paling umum adalah efusi pleura (37,9%) dan sepsis (34,5%). Kematian hanya terjadi pada abses hati pyogenik sebesar 13,8%, sedangkan pada amoebik 0%. Dan rata-rata lama durasi abses hati (LOS) adalah 15 (sekitar 7 hari). Simpulan: Terdapat perbedaan karakteristik, gambaran klinis, dan angka kematian antara pasien abses hati amoebik dan pyogenik, dan terbukti secara statistika pada mortalitas.Kata kunci: abses hati amoebic, abses hati pyogenic, rawat ina

Diabetic Gastroenteropathy: A Complication of Diabetes Mellitus

Diabetic gastroenteropathy is a common complication in prolonged diabetic patients, particularly patients with poor glycemic control or other complications, including all form of diabetic complication on the gastrointestinal tract, which prompts various symptoms of heartburn, abdominal pain, nausea, vomiting, even constipation, diarrhea, and fecal incontinence. The underlying pathophysiology of this complication manifestations are different on each organ or symptom, but may include autonomic nervous system neuropathy, loss of Interstitial Cell of Cajal as gastric muscle pacemaker leading to dysmotility, impair of liquid transportation and motoric function, as well as hyperglycemia causing oxidative stress, and other factors like Insulin-Growth Factor I inducing smooth muscle atrophy. Diabetic gastroenteropathy is one of major morbidity on diabetes mellitus patients. Patients with this complication need to be well diagnosed and ruled out other diagnosis possibilities. Management of the complication includes resolving main symptoms and maintaining good glycemic control. With growing number of diabetes mellitus patients and the prevalence of diabetic gastroenteropathy complication not being well recorded, caused by lack of attention and knowledge of healthcare provider in identifying the complication; it is important to be able to identify and to give early treatment to diabetic gastroenteropathy patients, to increase quality of life and maintain glycemic control of the patient

PROFIL RASIO NEUTROFIL TERHADAP LIMFOSIT PADA PASIEN DENGAN DUGAAN DEMAM TIFOID DI RSUD DR. SOETOMO SURABAYA

Demam tifoid merupakan penyakit multisistem akut yang disebabkan oleh Salmonella typhi dan bersifat endemis. Rendahnya sensitivitas alat diagnostik menyebabkan under diagnosed maupun over diagnosed. Beberapa studi menggunakan rasio neutrofil limfosit sebagai parameter status inflamasi. Studi ini untuk mengetahui gambaran rasio neutrofil limfosit pada pasien dengan dugaan demam tifoid. Sebuah studi deskriptif observasional dengan desain lintang potong menggunakan data sekunder dari rekam medis di Rumah Sakit Umum Daerah Dr. Soetomo Surabaya tahun 2016-2018. Teknik pengambilan sampel adalah total sampling dan diperoleh 64 sampel. Jumlah pasien dengan jenis kelamin laki-laki sebanyak 53,1% dan perempuan sebanyak 46,9% Perbandingan pasien laki-laki dan perempuan 1,3:1 dengan rentang usia terbanyak 17-25 tahun. Gambaran klinis rerata lama demam yaitu 6,95 hari dengan rentang lama demam terbanyak 1-7 hari. Demam ditunjukkan pada semua pasien (100%). Pemeriksaan hematologi kadar hemoglobin, leukosit dan trombosit dalam batas normal. Hasil neutrofil dan limfosit dalam batas normal. Gambaran rasio neutrofil limfosit memiliki median 3,97 dengan rentang nilai dalam batas normal

The Analysis of Mutation Profile on Pre-S1 and Pre-S2 Region of Hepatitif B Virus in Chronic Liver Disease

Objective: The purpose of this study was to complete the data frequency and mutation profile of Hepatitis B Virus (HBV) pre-S1 and pre-S2 in Indonesia. Methods: This cross-sectional study was used 32 blood serum samples of Chronic Liver Disease (CLD) patients with Hepatitis B surface antigen (HbsAg) at Endoscopy Outpatient Clinic, RSUD Dr. Soetomo Hospital, Surabaya. Polymerase Chain Reaction (PCR) of HBV DNA was performed on the samples based on pre-S1 and pre-S2 region. Then, electrophoresis was performed on the PCR product and followed by sequencing on samples with positive electrophoresis result. The sequencing results were analyzed by comparing them with the published sequences of HBV nucleotide. Results: The amplification results of nested PCR DNA HBV with primers based on HBV pre-S1 and pre-S2 region were positive at 21 serums. In patients with CLD in this study, pre-S1 and / or pre-S2 HBV mutations were found in 11 (84.62%) chronically infected HBV patients, 4 (100%) patients with liver cirrhosis, and 4 (100%) HCC patients. Dominant mutations were L101V (16.57%), M120I / T or pre-S2 start codon (10.82%), and F141L (10.81%). M120 and F141L mutations have been previously reported to be associated with CLD, while the dominant L101V mutation in this study as well as several other mutations has not been reported in previous studies. Conclusions: Mutations of pre-S1 and pre-S2 HBV regions were obtained in 90.48% of CLD patients in the form of substitution and deletion of amino acids

Distribution of Hepatitis B Virus Genotypes Among Patients at Internal Medicine Unit, Dr. Soetomo General Hospital, Surabaya

Background: Hepatitis B virus (HBV) infection is a major health problem worldwide, especially in developing countries. The study of HBV genotypes is important to find out the diversity of HBV genotypes related to the severity of the disease, response to therapy, and clinical symptoms. Objective: This study was aimed to detect HBV genotypes in patients at Hepatology Outpatient Clinic, Dr. Soetomo Hospital Surabaya. Methods: This study was conducted on new patients at Hepatology Outpatient Clinic of Dr. Soetomo General Hospital, Surabaya in one month. Nested PCR was performed by targetting HBV surface genes. Samples with positive HBV DNA were sequenced and analysed further. Results: In this study, a total of 27 samples were obtained. The prevalence of HBV infection shown by positive HBsAg in patients with symptoms of liver disease was 55.55% (15/27 patients). Based on the results of electrophoresis from PCR products, positive HBV DNA was obtained in these 15 patients (100%). After sequencing samples with positive HBV DNA, genotype B of Indonesian strain was found to be predominant genotype (100%). Subgenotype analysis showed that 7/15 samples had B3 subgenotype (46.67%). Conclusion: In patients at Hepatology Outpatient Clinic of Dr. Soetomo General Hospital, Surabaya, the prevalence of HBV infection was high (55.55%) and genotype B was predominant. In Surabaya, HBV genotype infection still remained like the previous pattern, although in Indonesia there have been many inter-island and ethnic migration. Further similar studies are needed to obtain the diversity of other HBV genotypes

Detection Of Hepatitis C Virus (Hcv) Infection And Its Genotype In Patients At Hepatology Outpatient Clinic, Dr. Soetomo General Hospital, Surabaya

Hepatitis C virus (HCV) is an RNA virus that can cause liver inflammation (hepatitis) and has the potential to become chronic and can progress to liver cirrhosis and hepatocellular carcinoma. Detection of HCV RNA infection, and genotype/subtype of HCV was performed on 70 blood sera of patients at the Hepatology Outpatient Clinic of Dr Soetomo General Hospital, Surabaya, Indonesia. Detection of HCV infection was carried out by Anti-HCV determination using enzyme immunoassay (EIA) technique, detection of HCV RNA by Reverse Transcription Polymerase Chain Reaction (RT-PCR) technique based on genome regions NS5b and 5'UTR, followed by electrophoresis with agarose gel. In positive PCR results, HCV genotype/subtype was determined by direct sequencing method using ABI 310 sequencer and sequencing results were analyzed by comparing the products with previously published HCV nucleotides. Sera were obtained from 41 (58.6%) male and 29 (41.4%) female patients. Anti-HCV was found positive in 17/70 (24.29%) patients and 16/17 (94.1%) was proved to contain HCV RNA when determined by RT-PCR technique. Patients with positive HCV RNA have the potential to transmit HCV infection. From the genotype/subtype analysis of sequencing results we obtained 2/16 (12,5%), 3/16 (18,75%) and 6/16 (37,5%), 1/16 (6,25%), 1/16 (6, 25%), 2/16 (12,5%), 1/16 (6,25%) HCV genotypes 1, 2, and HCV subtypes 1b, 1c, 2a, 3a, 3k respectively.Conclusion: In patients who went to the Hepatology Outpatient Clinic, Dr. Soetomo General Hospital Surabaya, we found positive Anti-HCV was 24,29%. In 94,1% of patients with positive Anti-HCV, HCV RNA was still detected and HCV genotype 1 with subtype 1b were still dominant HCV subtypes

Response Evaluation of Patients Undergoing Transarterial Chemoembolization (TACE) for Hepatocellular Carcinoma with Respect to Tumour Size, Number of Lesion, and Alpha-Fetoprotein (AFP) Level

Background: Transarterial chemoembolization (TACE) is widely used as a palliative treatment for unresectable hepatocellular carcinoma (HCC). TACE is also used as bridging therapy before liver transplantation to avoid tumour progression and considered for downstaging to fulfill tumour resection or liver transplantation criterias. This study aimed to evaluate response of TACE in unresectable HCC according to changing of tumour size, number of lesion, and AFP level.Method: Retrospectively, we evaluate 69 HCC patients who underwent TACE in Dr. Soetomo General Hospital in January 2012-June 2015, including their age, sex, aetiologies, and Barcelona Clinic Liver Cancer/BCLC staging. Laboratory examinations such as complete blood count (hemoglobin/Hb, leucocyte, thrombocyte), liver function test (aspartate aminotransferase/AST, alanine aminotransferase/ALT, bilirubin, albumin, international normalized ratio/INR), alpha-fetoprotein/AFP level, and abdominal CT-scan were performed before and 1 month post-TACE. Data was analysed using paired t-test.Results: 69 patients with mean age of 51.81 ± 12.8 years old, predominantly 76.8% males, the most common aetiology was hepatitis B 68.1%, 92.8% BCLC B, 64.3% with stable disease, none achieved complete response, 97.1% had tumour size > 5 cm, 69.6% had single tumour, and 55.7% had AFP level >1000 ng/mL. There was a significant increase in tumour size and number of lesions in 1 month post-TACE that were approximately 1.76 cm and 2.33, respectively, and there was no significant difference between AFP level before and 1 month post TACE.Conclusion: In 1 month post TACE evaluation, there was a significant increase of tumour size and number of lesion, but there was no significant alteration in AFP level. TACE might be performed repeatedly with shorter evaluation interval than 1 month to achieve better response