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BACKGROUND Non-invasive tests (NITs), such as Fibrosis-4 index (FIB-4) and the aspartate aminotransferase-to-platelet ratio index (APRI), developed using classical statistical methods, are increasingly used for determining liver fibrosis stages and recommended in treatment guidelines replacing the liver biopsy. Application of conventional cutoffs of FIB-4 and APRI resulted in high rates of misclassification of fibrosis stages. AIM There is an unmet need for more accurate NITs that can overcome the limitations of FIB-4 and APRI. PATIENTS AND METHODS Machine learning with the random forest algorithm was used to develop a non-invasive index using retrospective data of 7238 patients with biopsy-proven chronic hepatitis C from two centers in Egypt; derivation dataset (n = 1821) and validation set in the second center (n = 5417). Receiver operator curve analysis was used to define cutoffs for different stages of fibrosis. Performance of the new score was externally validated in cohorts from two other sites in Egypt (n = 560) and seven different countries (n = 1317). Fibrosis stages were determined using the METAVIR score. Results were also compared with three established tools (FIB-4, APRI, and the aspartate aminotransferase-to-alanine aminotransferase ratio [AAR]). RESULTS Age in addition to readily available laboratory parameters such as aspartate, and alanine aminotransferases, alkaline phosphatase, albumin (g/dl), and platelet count (/cm3 ) correlated with the biopsy-derived stage of liver fibrosis in the derivation cohort and were used to construct the model for predicting the fibrosis stage by applying the random forest algorithm, resulting in an FIB-6 index, which can be calculated easily at http://fib6.elriah.info. Application of the cutoff values derived from the derivation group on the validation groups yielded very good performance in ruling out cirrhosis (negative predictive value [NPV] = 97.7%), compensated advance liver disease (NPV = 90.2%), and significant fibrosis (NPV = 65.7%). In the external validation groups from different countries, FIB-6 demonstrated higher sensitivity and NPV than FIB-4, APRI, and AAR. CONCLUSION FIB-6 score is a non-invasive, simple, and accurate test for ruling out liver cirrhosis and compensated advance liver disease in patients with chronic hepatitis C and performs better than APRI, FIB-4, and AAR.

Chronic hepatitis B virus (HBV) infection is a common infectious disease in the world. Two percent of the patients with chronic HBV infection will develop cirrhosis each year, and will die prematurely from cirrhosis or hepatocellular carcinoma. So far interferon alfa and lamivudine are the only effective drugs. Interferon alfa can be used at the dosage of 9-10 million units thrice a week for 4-6 months either intramuscularly or subcutaneously for standard treatment. Interferon provides sustained response in 1/3 of the patients when HBe Ag is (+). Response rate to interferon therapy in HBe Ag(-) patients was similar to that reported in HBe Ag(+) ones. However the responses were not sustained in many patients, serum HBV-DNA reappear in most after stopping the treatment. Extension of therapy to 1 year may be needed in patients who are unresponsive to therapy and having HBV-DNA levels10 pg/ml and ALT100 IU. Establishment of unresponsiveness in early phases of the therapy is important and careful follow up of serum HBe Ag may be helpful. Interferon alfa treatment of chronic HDV infection may result in temporary normalization of ALT values. Disappearance of HBV-DNA and HBs Ag from the serum upon completion of therapy dictates sustained response in chronic HDV infection. The long term effect of interferon with respect to virological and histopathological responses is poor in HDV infection and longer periods of therapy in higher doses may be beneficial.

Cyanoacrylate injection has been found in large series to be a remarkably safe and efficient treatment of gastric variceal bleeding. Dysphagia is a common local side-effect of endoscopic intravariceal histoacryl injection. A 49-year-old woman with diagnosis of cirrhosis and portal hypertension related to hepatitis B virus infection was admitted to the Ibni Sina hospital due to dysphagia that started after injection of N-butyl-2-cyanoacrylate (histoacryl) for gastric varices. She had undergone endoscopic gastric intravariceal histoacryl injection 2 years previously and again 1 month before the admission. There were no complications related to injection of the histoacryl or the endoscopy procedure itself. Dysphagia started immediately after the second endoscopy and was refractory to prokinetic and analgesic medication. She did not have any other complaint of medical significance. A diagnostic endoscopy revealed a heterogeneous foreign body stuck in the distal esophagus. Dysphagia resolved after endoscopic removal of the foreign body by endoscopic biopsy forceps. The heterogeneous material, which was mixed with food particles and tissue debris, was analyzed via infrared spectrophotometer and was found to be cyanoacrylate glue. In the present case, extrusion of the glue occurred earlier then expected and retching or vomiting might have dislodged the extruded glue from the stomach to the esophagus. If prolonged and intractable dysphagia starts after the endoscopy procedure, impaction of glue to the esophagus should be considered.