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

Comparison of Renal Safety of Tenofovir and Telbivudine in Chronic Hepatitis B Patients: A Real World Study in Indonesia

Introduction. Tenofovir disoproxil fumarate (tenofovir) and telbivudine are two available nucleos(t)ide analogue (NA) for the treatment of chronic hepatitis B (CHB) patients. Tenofovir has been known as a nephrotoxic agent in HIV patients, but still controversy in CHB patients. On the other hand, telbivudine had a renal protective effect and increased estimated glomerular filtration rate (eGFR). This studi aimed to address the renal safety of tenofovir and telbivudine in Indonesian patients. Method. A retrospective cohort study design was conducted in CHB patients who prescribed with tenofovir or telbivudine from January 2013 to December 2016. Patients who met the inclusion and exclusion criteria were followed up for one year. The serial evaluation of creatinine serum was collected in week-24 and week-48 after the administration of tenofovir or telbivudine. Results. Among CHB patients, 68 and 62 patients that prescribed with tenofovir or telbivudine, respectively, were enrolled in this study. Serum creatinine level was increased in tenofovir group from 0.88 (SD 0.17) mg/dL at baseline to 0.93 (SD 0.22) mg/dL after 24 weeks (p = 0.02), but creatinine trend to reach plateau after 48 weeks. However, in telbivudine group, serum creatinine level was decreased from 0.85 (SD 0.21) mg/dL at baseline to 0.80 (SD 0.18) mg/dL after 48 weeks (p = 0.003). Conclusion. Tenofovir is associated with the increased of creatinine serum and decreased of eGFR in CHB patients with eGFR ≥60 mL/menit/1,73 m2

Mortality-related Factors in Patients with Malignant Obstructive Jaundice

Aim: to obtain survival rate and mortality-related factors of malignant obstructive jaundice patients. Methods: all medical records of obstructive jaundice inpatient at Cipto Mangunkusumo Hospital, Jakarta from January 2010 to December 2013 were reviewed retrospectively. The following factors were analyzed in terms of mortality: age, gender, sepsis, hypoalbumin, serum bilirubin level, serum CA 19-9 level, billiary drainage, non-ampulla Vateri carcinoma, and comorbid factors. Results: total 181 out of 402 patients were enrolled in this study with male proportion was 58.6%, and patients aged 50 years or above was 57.5%. Multivariate analysis showed that only sepsis, unsuccessful or no prior biliary drainage and Charlson comorbid score ≥4 were independent predictors of mortality. Patients with significant prognostic factors had median survival 14 days compared with overall median survival 26 days. Score ≥2 identified as the highest prognostic score threshold with sensitivity 68%, specificity 75%, and AUC on ROC curve 0.769. Conclusion: sepsis, unsuccessful or no prior bilirary drainage, and Charlson comorbid score ≥4 are factors significantly associated with shortened survival in malignant obstructive jaundice patients. Prognostic score  ≥2 was determined to classify patients into high risk mortality group. Mortality of patients with those significant prognostic factors can be predicted in 76.9%

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

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