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The Ministry of Health (MOH) publishes clinical practice guidelines on Chronic Hepatitis B Infection to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Chronic Hepatitis B Infection, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=26108). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Introduction: Minimal hepatic encephalopathy (mHE) has been reported in up to 84 percent of cirrhotics. The natural history of mHE has not been well-described. We designed a three-year prospective cohort study to determine the prevalence and natural history of mHE among cirrhotic patients., Methods: The patient cohort comprising 62 consecutive outpatients with cirrhosis were assessed at baseline and followed-up with a repeat assessment three years later. The assessments include: (1) Neuropsychometric analysis (digit-symbol substitution test, block-design test, number-connection test A); (2) Clinical, biochemical assessment; and (3) Quality of life (QOL) assessment (abbreviated sickness impact profile)., Results: Baseline characteristics were: age 52.9 +/- 11.0 years; Child's A:B:C was 46:14:2. mHE was detected in 33.9 percent of the cohort. Older age, a higher Child-Pugh score and female gender were independently associated with mHE. mHE was associated with a poorer QOL. Follow-up assessment three years later showed that seven patients had died, while six were lost to follow-up; these patients had significantly higher baseline Child's scores. Of the remaining patients, 36/49 (73 percent) agreed to a repeat evaluation. In this group, none had mHE. QOL remained impaired despite the resolution of mHE., Conclusion: It has been shown for the first time that mHE can revert to a normal state in a significant proportion of patients with well-compensated cirrhosis.

Imatinib mesylate (Gleevec) is widely-used in the treatment of chronic myeloid leukaemia (CML) and gastrointestinal stromal tumour. Up to four percent of patients treated with imatinib may develop hepatotoxicity, which usually resolves with discontinuation of the drug. We report a 45-year-old Chinese man with CML and chronic hepatitis B virus infection, on imatinib treatment, presenting with herpetic rash and acute liver failure. This case illustrates the diagnostic challenges in the management of such a patient, as well as the need for greater vigilance in the monitoring of liver function tests for patients treated with imatinib. A short review on imatinib-related hepatotoxicity is also presented.

Introduction: To characterise the anthropometrical and metabolic parameters of a group of non-diabetic and non-obese patients who had histologically-proven nonalcoholic steatohepatitis (NASH)., Methods: During September 1997 to November 1999, consent for liver biopsies were sought from a consecutive series of patients, whose body mass index (BMI) were equal to or less than 30 kg per square metres, and who had persistently elevated serum alanine transaminase (more than 2.5 times upper limit of normal for more than six months), with no associated viral hepatitis, alcohol or drug-induced liver disease, hereditary liver disease and diabetes mellitus. Patients who were found to have steatohepatitis histologically were further studied. Their body weight, height, waist and hip circumferences were taken, and fasting serum lipid and glucose measured. Serum insulin was measured in six patients and insulin resistance (IR) was calculated by homeostasis model assessment. Oral glucose tolerance tests were done if fasting glucose levels were greater than 6 mmol/L. All liver biopsies were reviewed by a single histopathologist. Three age- and sex-matched controls were randomly selected for each patient., Results: 11 of 12 patients who underwent liver biopsies were found to have NASH. All 11 were Chinese: eight males and three females. 73 percent of them had hepatic fibrosis. Overall, compared to controls, they had significantly higher body weight, BMI, IR and triglyceridaemia. The female patients also had a higher waist-hip ratio than controls. None had diabetes mellitus, and one had impaired glucose tolerance/fasting glycaemia. Nine out of 11 had BMI between 25 and 30 kg per square metres., Conclusion: Significant histological changes of NASH with hepatic fibrosis were found in Singaporean Chinese non-diabetic patients with BMI of less than 30 kg per square metres.

Non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (cox-2) inhibitors are structurally heterogeneous drugs that share similar therapeutic actions and adverse effects. Hepatotoxicity, although a relatively rare adverse effect of this class of drugs, can be severe. This has led to the withdrawal of some NSAIDs from the market. Nimesulide is an NSAID, with cox-2 preference, which has been reported to cause death from hepatic failure. However, most reports have been from European countries. Asian reports include that from Israel and India. We report three patients who presented with acute hepatitis after being prescribed nimesulide, one of whom died from fulminant hepatic failure.

The prevalence of hepatitis G virus (HGV) infection in patients with liver diseases in Singapore and its pathogenic role in these patients was studied. One hundred and forty-eight patients who had chronic hepatitis or acute non A-E hepatitis were studied. Presence of HGV RNA was determined by nested polymerase chain reaction of the 5'non-coding region of the virus in all the patients. Hepatitis G IgG antibody to the envelope (E2) antigen was tested with an enzyme immunoassay (Boehringer Mannheim, Singapore) in 76 of them. Most patients (93%) were ethnically Chinese, predominantly males (74%) and chronic hepatitis B (72%) patients. Others had chronic hepatitis C (19%) or cryptogenic cirrhosis (6%). Four patients had acute non A-E hepatitis. HGV RNA and anti-HGenv were present in 3.5% and 8.3% of those with chronic liver disease. HGV infection did not account for any of the acute non A-E hepatitis and most of the cryptogenic cirrhosis.

The seroprevalence of anti-HEV IgG was determined in a hospital-based population in a general medical unit. Patients who were otherwise well but admitted for acute, non-hepatological conditions represent the "healthy" general population, and those admitted primarily with liver disorders were studied. The seroprevalence of anti-HEV IgG was found to be 10.5% in the "healthy" population and 14.7% amongst those with liver diseases. The lack of travel history and past history of jaundice suggests presence of local cases and subclinical manifestation in some of the infected patients. There is an association between seroprevalence of hepatitis A and E, suggesting common predisposing factors for both infections. Anti-HAV IgG has a higher seroprevalence. Retesting of anti-HEV IgG in those who were initially positive found persistence of antibodies beyond twelve months. Both anti-HAV IgG and anti-HEV IgG were found more commonly in the older age groups.