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BACKGROUND Metabolic risk factors may impact the severity and outcome of alcoholic liver disease. The present study evaluated this effect in patients with alcohol-associated acute-on-chronic liver failure (ACLF). METHODOLOGY One thousand two hundred and sixteen prospectively enrolled patients with ACLF (males 98%, mean age 42.5 ± 9.4 years, mean CTP, MELD and AARC scores of 12 ± 1.4, 29.7 ± 7 and 9.8 ± 2 respectively) from the Asian Pacific Association for the Study of the Liver (APASL) ACLF Research Consortium (AARC) database were analysed retrospectively. Patients with or without metabolic risk factors were compared for severity (CTP, MELD, AARC scores) and day 30 and 90 mortality. Information on overweight/obesity, type 2 diabetes mellitus (T2DM), hypertension and dyslipidaemia were available in 1028 (85%), 1019 (84%), 1017 (84%) and 965 (79%) patients respectively. RESULTS Overall, 392 (32%) patients died at day 30 and 528 (43%) at day 90. Overweight/obesity, T2DM, hypertension and dyslipidaemia were present in 154 (15%), 142 (14%), 66 (7%) and 141 (15%) patients, respectively, with no risk factors in 809 (67%) patients. Patients with overweight/obesity had higher MELD scores (30.6 ± 7.1 vs 29.2 ± 6.9, P = .007) and those with dyslipidaemia had higher AARC scores (10.4 ± 1.2 vs 9.8 ± 2, P = .014). Overweight/obesity was associated with increased day 30 mortality (HR 1.54, 95% CI 1.06-2.24, P = .023). None of other metabolic risk factors, alone or in combination, had any impact on disease severity or mortality. On multivariate analysis, overweight or obesity was significantly associated with 30-day mortality (aHR 1.91, 95% CI 1.41-2.59, P

Background and Aims: COVID-19 is a dominant pulmonary disease, with multisystem involvement, depending upon co morbidities. Its profile in patients with pre-existing chronic liver disease (CLD) is largely unknown. We studied the liver injury patterns of SARS-Cov-2 in CLD patients, with or without cirrhosis. Methods: Data was collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19. Result: Altogether, 228 patients [185 CLD without cirrhosis and 43 with cirrhosis] were enrolled, with comorbidities in nearly 80%. Metabolism associated fatty liver disease (113, 61%) and viral etiology (26, 60%) were common. In CLD without cirrhosis, diabetes [57.7% vs 39.7%, OR=2.1(1.1-3.7), p=0.01] and in cirrhotics, obesity, [64.3% vs. 17.2%, OR=8.1(1.9-38.8), p=0.002) predisposed more to liver injury than those without these. Forty three percent of CLD without cirrhosis presented as acute liver injury and 20% cirrhotics presented with either acute-on-chronic liver failure [5(11.6%)] or acute decompensation [4(9%)]. Liver related complications increased (p In decompensated cirrhotics, the liver injury was progressive in 57% patients, with 43% mortality. Rising bilirubin and AST/ALT ratio predicted mortality among cirrhosis. Conclusions: SARS-Cov-2 infection causes significant liver injury in CLD patients, decompensating one fifth of cirrhosis, and worsening the clinical status of the already decompensated. The CLD patients with diabetes and obesity are more vulnerable and should be closely monitored.

Background and Aim To compare the effect of telmisartan and vitamin E on liver histopathology of non‐alcoholic steatohepatitis (NASH) patients. Methods This noninferiority clinical trial was conducted for 1 year. Fatty liver patients with non‐alcoholic fatty liver disease (NAFLD) activity score (NAS) ≥ 5 (in liver biopsy) were selected. All methods were in accordance with the Declaration of Helsinki. Patients who received telmisartan and vitamin E were denoted as Group‐T and Group‐E, respectively. Forty patients >18 years old were assigned and divided into two groups (20 in each group). Histological improvements were primary outcome measures. Results Significant improvement in NAS score was noted in both groups (Group E [GE]: 6 ± 0.8 to 4.36 ± 1.4; P = 0.00 and Group T [GT]: 5.6 ± 0.7to 4.9 ± 1.2; P = 0.03). Fibrosis score improved from 1.6 ± 0.5 to 1.5 ± 0.5 in GE and from 1.7 ± 0.9 to 1.5 ± 0.7 in GT (P = 0.67 and 0.42, respectively). Steatosis improved in GE from 2.07 ± 0.6 to 1.14 ± 0.66 (P = 0.00) and in GT from 1.94 ± 0.57 to 1.56 ± 0.8 (P = 0.05). Lobular inflammation improved from 2.0 ± 0.4 to 1.6 ± 0.5 in GE (P = 0.02) and from 1.9 ± 0.3 to 1.8 ± 0.4 in GT (P = 0.58). Ballooning score in GE decreased from 1.9 ± 0.3 to 1.7 ± 0.5 (P = 0.03), and in GT, it reduced from 1.9 ± 0.1 to 1.5 ± 0.5 (P = 0.19). NAS improvement was similar in GE (1.6 ± 1.2) and GT (0.6 ± 1.1; P = 0.07) when controlled for weight reduction. Conclusion Telmisartan was similar to vitamin E in improving the histology of NASH patients., Vitamin E was thought to be effective for non‐alcoholic steatohepatitis (NASH), but this study proved that telmisartan is also comparable to vitamin E for NASH with few admitting limitations.

Nonalcoholic fatty liver disease (NAFLD) is a metabolic disorder characterized by excessive triglyceride accumulation in hepatocytes. NAFLD has a multifactorial etiology and a combination of environmental, genetic and metabolic factors play a role in the development of advanced disease. NAFLD consists of a wide spectrum of conditions, ranging from simple steatosis to nonalcoholic steatohepatitis (NASH) which can progress to cirrhosis and hepatocellular carcinoma (HCC). Despite the high prevalence and severity of hepatic illness, NAFLD remains underdiagnosed, because of few symptoms, lack of accurate laboratory markers. The accurate diagnosis of NASH remains dependent on specific histological parameters in liver biopsy. Although liver biopsy remains the ‘gold standard’, there are practical limitations, including costs and risks. There is an increasing requirement for simple, less invasive, highly accurate and affordable screening tools. Aspartate aminotransferase (AST) has been proposed as a noninvasive and available marker for assessment of NASH. A hospital based observational study was carried out for a period of two years in the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Data were analyzed by SPSS version 16. Qualitative and quantitative data were analyzed by Chi-square test and student’s t-test respectively. Fifty (50) patients were analysed. Twenty five were NASH and twenty five were non- NASH. AST in NASH group were 55.2 ± 30.1 IU/L and in Non-NASH group were 33.6± 20 IU/L. In NASH group significantly higher percentage of raised AST had NASH compared with normal AST (68% vs.32%).There was significant difference in the NAFLD activity score for diagnosing NASH between elevated and normal AST (P value 0.004). Higher AST values correlated with higher specificity. By multivariate analysis AST were found to be significant. Thus Aspartate aminotransferase (AST) is a good predictor for diagnosing non- alcoholic steatohepatitis (NASH). Bangladesh Med J. 2019 Jan; 48 (1): 44-49

Hepatitis B core antibody (Anti HBc) is currently considered the most sensitive serological marker for a patient’s history of hepatitis B virus (HBV) infection given its long-term persistence in the bloodstream. The serological pattern of isolated Anti HBc (IAHBc) has been of clinical interest over the past several years.,Thegrowing data of IAHBcsuggestingit as a marker for occult HBV infection (OBI). Occult HBV infection defined as HBV DNA detection in serum or the liver by sensitive diagnostic tests in HBsAg negative individuals with or without serologic markers of previous viral exposure. OBI is especially concerned in blood transfusion (BT), organ donation and reactivation of HBV infection following immunosuppressive therapy. HBV reactivation depends on viral and host factors. The important clinical implications of IAHBcis in the setting of co-infection with hepatitis C virus (HCV), reactivation risk of HBV during directly acting anti viral (DAA) therapy in HCV infection which may lead to progression of liver disease and hepatocellular carcinoma (HCC). Antiviral prophylaxis has been recommended in moderate to high risk of reactivation prior to immunosuppressive and biologics. The main goal of therapy is to improve survival and quality of life by preventing disease progression and to prevent consequent development of HCC. It is proposed to perform Anti-HBc test as a screening test prior to blood transfusion, HBVvaccination, DAA and immunosuppressive therapy in addition to HBsAg screening test. J Bangladesh Coll Phys Surg 2019; 37(4): 196-201

Background: Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of conditions ranging from simple steatosis to steatohepatitis, advanced fibrosis, and end stage liver disease. Despite the high prevalence and severity of hepatic illness, NAFLD remains underdiagnosed, because of few symptoms, lack of accurate laboratory markers. Objective: To evaluate a biochemical score for diagnosing non-alcoholic steatohepatitis. Methods: An observational, cross sectional study was carried out for a period of two years in the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. 43 patients of Non-alcoholic fatty liver disease (NAFLD) attending at department of Hepatology were selected and underwent for biochemical investigations and liver biopsy with NAFLD Activity Score (NAS). Results: A biochemical score (TAAG score) assigned 1 point for each parameter (fasting serum triglyceride >ULN, alanine aminotransferase >ULN, AST/ALT ratio (AAR) ≤1 and gamma-glutamyl transferase >ULN) was evaluated. TAAG score ≥3 was present in 32.5% of study population and 40% of NASH patients. It had a sensitivity of 40%, specificity 26% and AUROC 0.54. Conclusion: Biochemical scoring system comprising traditional biomarkers did not significantly predict NASH. Biopsy is the only way to estimate steatohepatitis and/or fibrosis. Bangladesh J Medicine July 2019; 30(2) : 58-62

The pathophysiology and risk factors of nonalcoholic fatty liver disease (NAFLD) among lean patients is poorly understood and therefore investigated. We performed a meta‐analysis of observational studies. Of 1175 articles found through searching from Medline/PubMed, Banglajol, and Google Scholar by two independent investigators, 22 were selected. Data from lean (n = 6768) and obese (n = 9253) patients with NAFLD were analyzed; lean (n = 43 398) and obese (n = 9619) subjects without NAFLD served as controls. Age, body mass index, waist circumference, systolic blood pressure, and diastolic blood pressure (DBP) had significantly higher estimates in lean NAFLD patients than in lean non‐NAFLD controls. Fasting blood sugar [MD(mean difference) 5.17 mg/dl, 95% CI(confidence interval) 4.14–6.16], HbA1c [MD 0.29%, 95% CI 0.11–0.48], and insulin resistance [HOMA‐IR] [MD 0.49 U, 95% CI 0.29–0.68]) were higher in lean NAFLD patients than in lean non‐NAFLD controls. All components of the lipid profile were raised significantly in the former group except high‐density lipoprotein. An increased uric acid (UA) level was found to be associated with the presence of NAFLD among lean. Cardio‐metabolic profiles of nonlean NAFLD patients significantly differs from the counter group. However, the magnitude of the difference of lipid and glycemic profile barely reached statistical significance when subjects were grouped according to lean and nonlean NAFLD. But DBP (slope: 0.19, P, A meta‐analysis of 22 articles comprising data from lean (n = 6768) and obese (n = 9253) patients with nonalcoholic fatty liver disease (NAFLD), and lean (n = 43398) and obese (n = 9619) subjects without NAFLD (healthy) revealed that both lean and obese patients shared similar risk factors associated with NAFLD including age, body mass index, waist circumference, systolic blood pressure, diastolic blood pressure, HbA1c, insulin resistance (HOMA‐IR), total cholesterol, low‐density lipoprotein, high‐density lipoprotein, triglycerides, and uric acid.

Metabolic associated fatty liver disease (MAFLD) is the principal worldwide cause of liver disease and affects nearly a quarter of the global population. The objective of this work was to present the clinical practice guidelines of the Asian Pacific Association for the Study of the Liver (APASL) on MAFLD. The guidelines cover various aspects of MAFLD including its epidemiology, diagnosis, screening, assessment, and treatment. The document is intended for practical use and for setting the stage for advancing clinical practice, knowledge, and research of MAFLD in adults, with specific reference to special groups as necessary. The guidelines also seek to improve patient care and awareness of the disease and assist stakeholders in the decision-making process by providing evidence-based data. The guidelines take into consideration the burden of clinical management for the healthcare sector.

Chronic hepatitis B (CHB) is a major infectious disease which frequently involves liver injury and could be serious, even life threatening. Complications mainly include the development of chronic liver disease (CLD), cirrhosis, hepatocellular carcinoma (HCC), and liver failure. Liver function tests like determining the level of serum alanine aminotrasnferase (ALT), aspertate aminotransferase (AST) are orthodoxly used to assess the inflammatory activity and cirrhotic process in the liver. A total 2453 patients with an age range of 12-86 years with a positive HBsAg serostatus for more than six months was included in this study. Among them hepatic disease conditions were confirmed for 952 patients using visible symptoms, histological findings and precutaneous liver biopsy. Patients were examined for the serum ALT and AST level as biochemical markers, HBeAg and anti-Hbe level as serological markers, and HBV DNA level as molecular marker. In this study it was found that the probability to have a raised level of ALT and AST increases as the disease progresses from less severe to more severe conditions. Almost 80% of the CHB patients were documented to contain a raised level of ALT and the ratio was found to be increased to 93% for patients with CLD and 100% in patients diagnosed with HCC. For AST, elevated level was found for 61% of CHB patients without liver complication and 97% of CLD patients. Among CLD patients, 91.7% have raised level of both ALT and AST. And it was also found that the presence of serum HBe Ag and Anti HBe antibody have a significant relationship with raised level of serum ALT, and AST. Significant relations were also found for raised level of DNA with higher level of serum ALT and AST. This study shows that there is significant correlations of serum ALT, AST level with hepatic disease conditions and other diagnosing markers like serum HBe Ag, Anti-HBe antibody and HBV DNA level. Bangladesh J Microbiol, Volume 34 Number 1 June 2017, pp 39-42

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the “APASL ACLF Research Consortium (AARC)” was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the ‘Golden Therapeutic Window’, extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here., Article Highlights Updated on the basis of AARC data of >3300 cases enrolled into AARC registry prospectivelyACLF is distinct form Acute Decompensation of cirrhosisNewer sections on DILI-ACLF, AIH-ACLF, PVT/HVOTO–ACLFReversibility of Chronic Liver Disease in ACLFPortal and systemic hemodynamics and their relevance in ACLFAcute Portal Hypertension and Variceal progression in ACLFAARC score as a guide for treatment strategies in ACLFACLF in Children-first consensus on pediatric ACLF

Nonalcoholic Fatty Liver Disease (NAFLD) is the condition where fat accumulates in liver without significant ingestion of alcohol. NAFLD has become one of the most common liver conditions throughout the world. At the dawn of the history of NAFLD it was thought that NAFLD is disease of obese individual but lean patients are increasingly detected to have NAFLD. It seems that insulin resistance is central to the pathogenesis of NAFLD. In addition, oxidative stress and cytokines are important contributing factors, resulting in steatosis and progressive liver damage in genetically susceptible individuals. NAFLD varies considerably by ethnic group and Bangladeshi ethnicity is an independent risk factor for NAFLD. Prevalence of NAFLD in general population of Bangladesh is 4 - 18.4 %, which jumps up to 49.8% in diabetic patients. With the changes in socioeconomic condition and life style, aetiology of chronic liver disease is drifting from infectious to noninfectious diseases and the contribution of NAFLD is progressively increasing. Hepatitis B and hepatitis C have been the leading causes of mortality and morbidity from chronic liver disease in Bangladesh. But with increase in awareness and mass vaccination against HBV, prevalence of both the diseases has been decreasing in the country. The most alarming feature is that there is a high prevalence of NASH among the NAFLD patients. NAFLD is emerging as the largest contributor of chronic liver disease in Bangladesh. This warrants the attention of health policy makers and clinicians to explore this frontier and combat it from right now.J Bangladesh Coll Phys Surg 2017; 35(4): 184-191

Background and Objectives To observe the effect of Pentoxifylline for 1 year on hepatic histological activity and fibrosis of nonalcoholic steatohepatitis (NASH). Materials and Methods A single center, open label Randomized Control Trial. Patients were included if they had ultrasonographic evidence of fatty liver and nonalcoholic fatty liver disease activity score (NAS) ≥ 5 on liver histology. A total of 35 patients were selected; 25 of PL (Experimental) group and 10 of L (Control) group. PL group received 400 mg pentoxifylline thrice daily along with lifestyle modification and there was only lifestyle modification for the L group. After one year, NAS and fibrosis was compared in both groups. Results In PL group, NAS improved 2.10 ± 1.07; whereas in L group, NAS was 0.90 ± 0.99 (P = 0.006). As per the protocol analysis, NAS ≥ 2 improved in 15/20 (75%) in PL group and in 3/10 (30%) in L group (P = 0.018). In PL group, the individual component of NAS, steatosis improved from 2.30 ± 0.66 to 0.95 ± 0.76 (P = 0.000), lobular inflammation from 1.65 ± 0.59 to 1.05 ± 0.51 (P = 0.002) and hepatocyte ballooning from 1.50 ± 0.51 to 1.30 ± 0.57 (P = 0.258). In L group, steatosis improved from 2.30 ± 0.68 to 1.40 ± 1.08 (P = 0.01), lobular inflammation and hepatocyte ballooning did not improve. The fibrosis score did not improve in any group. In PL group, NAS improved significantly (P = 0.027; OR=22.76, CI=1.43-362.40) independent of weight reduction. Conclusion Pentoxifylline for 1 year improves the hepatic histological activity but not fibrosis of NASH patients.

The aim of this study was to determine the association of single nucleotide polymorphism (SNP) in patatin-like phospholipase domain-containing 3 (PNPLA3) at I148 with histological severity of non-alcoholic fatty liver disease (NAFLD). Patients were selected for the study if they had histological evidence of NAFLD and clinical evidence of non-alcoholic steatohepatits (NASH) cirrhosis. We included 50 NASH cirrhosis, 99 patients of NAFLD including 36 non-NASH fatty liver (NNFL) along with 63 NASH and 75 healthy controls. PNPLA3 genotyping was done by real-time PCR using a Taqman assay for rs738409. CC, CG, and GG frequencies were 45 (60.0%)/27 (36.0%)/3 (4.0%) in healthy control, 19 (52.8%)/14 (38.9%)/ 3 (8.3%) in NNFL, 18 (28.6%)/29 (46.0%)/16 (25.4%) in NASH, and 7 (14.6%), 25 (52.1%), 16 (33.3%) in cirrhosis. The frequency of G allele was significantly higher (62.6%) in NAFLD than in healthy control. The GG genotype had 20.25 times odds of NAFLD. The GG genotype had 6.53 times odds of having NASH. HOMA-IR > 1.6 had 3.81 times odds of having NASH. Regression analysis revealed that G allele odds of having cirrhosis was 3.9 times compared to C. The G allele was also significantly associated with steatosis, lobular inflammation, NAFLD activity score, and fibrosis. PNPLA3 genotype showed an association with NAFLD, NASH, fibrosis, and cirrhosis.

Background and Aims: COVID-19 is a dominant pulmonary disease, with multisystem involvement, depending upon co morbidities. Its profile in patients with pre-existing chronic liver disease (CLD) is largely unknown. We studied the liver injury patterns of SARS-Cov-2 in CLD patients, with or without cirrhosis. Methods: Data was collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19. Result: Altogether, 228 patients [ 185 CLD without cirrhosis and 43 with cirrhosis] were enrolled, with comorbidities in nearly 80%. Metabolism associated fatty liver disease (113, 61%) and viral etiology (26, 60%) were common. In CLD without cirrhosis, diabetes [57.7% vs 39.7%, OR=2.1(1.1-3.7), p=0.01] and in cirrhotics, obesity, [64.3% vs. 17.2%, OR=8.1(1.9-38.8), p=0.002) predisposed more to liver injury than those without these. Forty three percent of CLD without cirrhosis presented as acute liver injury and 20% cirrhotics presented with either acute-on-chronic liver failure [5(11.6%)] or acute decompensation [4(9%)]. Liver related complications increased (p

Background and Objectives Weight reduction has evidenced benefit on attenuation of histological activity and fibrosis of nonalcoholic steatohepatitis (NASH), but there is scarcity of data for lean NASH subgroup. We have designed this study to compare the effects of weight reduction on histological activity and fibrosis of lean and non-lean NASH. Methods We have included 20 lean and 20 non-lean histologically proven NASH patients. BMI < 25 kg/m2 was defined as non-lean. Informed consent was taken from each subject. All methods were carried out in accordance with the Declaration of Helsinki. Moderate exercise along with dietary restriction was advised for both groups for weight reduction. After 1 year, 16 non-lean and 15 lean had completed second liver biopsy. Results Age, sex, alanine transaminase (ALT), aspartate aminotransferase (AST), gamma-glutamyltrasferase (GGT), Homeostasis model assessment insulin resistance (HOMA-IR), triglyceride and high density lipoprotein (HDL) was similar in both groups. Steatosis, ballooning, lobular inflammation, nonalcoholic fatty liver disease activity score (NAS) and fibrosis was similar in the two groups. In lean/non-lean group, any amount of weight reduction, ≥ 5% weight reduction and ≥ 7% weight reduction was found in respectively 8/11, 5/6 and 2/6 patients. In both lean and non-lean groups, weight reduction of any amount was associated with significant reduction of steatosis, ballooning and NAS, except lobular inflammation and fibrosis. In both groups, weight reduction of ≥ 5% was associated with significant reduction in NAS only. However, significant improvement in NAS was noted with ≥ 7% weight reduction in non-lean group only. Conclusion Smaller amount of weight reduction had the good benefit of improvement in all the segments of histological activity in both lean and non-lean NASH.

In case of non-alcoholic fatty liver disease, the ratio of serum aspartate aminotransferase (AST) level to platelet count index has been proposed as a non-invasive and readily available tool for the assessment of non-alcoholic steatohepatitis. The study was conducted on 50 non-alcoholic fatty liver disease patient (25 non-alcoholic steatohepatitis and 25 simple steatosis). The mean (± SD) serum AST level in the non-alcoholic steatohepatitis group was 55.2 ± 30.1 IU/L whereas in simple steatosis group it was 33.6 ± 20.0 IU/L. The mean platelet count in the non-alcoholic steatohepatitis group was 303.1 ± 68.7 x 109 /L whereas in the simple steatosis group it was 327.8 ± 66.8 x 109/L. The mean AST platelet ratio index (APRI) score in non-alcoholic steatohepatitis group was 0.5 ± 0.3 and in the simple steatosis group it was 0.3 ± 0.2. In conclusion, the APRI was significantly higher in the non-alcoholic steatohepatitis group than the simple steatosis group.

Background: Insulin resistance (IR) has largely been hypothesized as central in multifactorial pathogenesis of nonalcoholic fatty liver disease (NAFLD). This study was aimed to explore the association of IR with NAFLD and nonalcoholic steatohepatitis (NASH).Methods: We enrolled 219 patients of NAFLD with sonographic evidence of fatty changes in liver excluding patients with alcohol intake and other causes of fatty change during June 2012 to July 2014.Liver biopsy was done for 110 patients with elevated ALT of >30 U/L for male and >18 U/L for female. We have measured IR by homeostatic model assessment of insulin resistance (HOMA-IR).Results: Age of the study population was 40.6 ± 10.0 years, male and female was 83 (37.9%) and 136 (62.1%), ALT was 42.0 (16-861) U/L, AST was 32 (16-608) U/L and GGT was 39 (10-243) U/L. According to Asian criteria 54 (25.9%) were non-obese, 139 (64.1%) had metabolic syndrome, 163 (74.8%) were hypertriglyceridemic, 200 (91.3%) had low HDL and 170 (77.4%) had high waist. Hypertensive and diabetic were 58 (26.7%) and 57 (26.1%) respectively. IR was 1.9±1.3 with the range of 0.4 to 9.3 and only 87 (39.7%) were above normal. Of the 110 biopsied, 65 (59.1%) had NASH. Normal and raised IR was associated with 32 (50.8%) and 33 (70.2%) NASH respectively (p < 0.05). Correlation between IR and steatosis, ballooning and fibrosis was not significant except lobular inflammation. IR was similar in NASH (2.2 ±1.6) and non NASH (1.9±1.6).Conclusion: Large proportion of NAFLD patients had normal IR. IR had inconsistent association with histological activity.Bangladesh Crit Care J September 2016; 4 (2): 86-91

Interferon-gamma induced protein 10 (IP-10), a chemokine is suggested to be involved in liver injury during Hepatitis B virus infection (HBV). The increase of IP-10 is a critical step for recruitment of inflammatory cells to the local focus of the liver and hepatopathology. This study was designed to assess the correlation of IP-10 gene expression with HBV-DNA and serumAlanine transaminase(ALT) in patients with cirrhosis and HCC.The study was conducted among 60 patients. The study populationwere divided into four groups (15 in each groups)-HBV positive cirrhosis, HBV negative cirrhosis, HBV positiveHCC and HBV negative HCC. Expression of IP-10 gene was observed using real time PCR.IP-10 gene expressions in the above mentioned groups were correlated with serum ALT level and HBV viral load.IP-10 gene was significantly higher in HBV-positive patients with HCC than HBVpositive cirrhosis. Similarly, the expression of IP-10 was significantly higher in HBV-positive HCC than HBVnegative HCC patients. However, the expression of IP-10 was reduced in HBV-positive cirrhosis in comparison with HBV-negative cirrhosis.IP-10 gene expression in liver was not correlated with the serum levels of ALT in any of the study groups. HBV- DNA load also did not correlated with IP-10 gene expression in HBV positive HCC and HBV positive cirrhosis patients.This study shows that there was no significant change with the expression of IP-10 gene in any of the study groups with ALT level or viral load, though differential expression of IP-10 gene were observed in cirrhosis and HCC patients. Bangladesh J Med Microbiol 2016; 10 (2): 9-13

Shahinul Alam,1 Jhumur Ghosh,1 Golam Mustafa,1 Mohammad Kamal,2 Nooruddin Ahmad1 1Department of Hepatology, 2Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Background/purpose: Dipeptidyl peptidase 4 (DPP-4) expression is directly associated with hepatic lipogenesis and liver injury in nonalcoholic steatohepatitis (NASH). This study has been designed to elucidate the histological improvement of NASH with the DPP-4 inhibitor sitagliptin. Materials and methods: In this open-label randomized control trial, paired liver biopsy was taken from 40 NASH patients. Sitagliptin 100 mg was given once daily to the SL group and no sitagliptin was given to the L group for 1 year. Patients from both groups were encouraged to exercise moderately and advised to avoid saturated fat, excessive sugar, soft drinks, fast food, and refined carbohydrates to reduce weight. Results: Steatosis improved in the SL group (from 2.3±0.6 to 1.2±0.8; P=0.000) and the L group (from 2.1±0.6 to 1.6±0.9; P=0.008), ballooning decreased from 1.8±0.6 to 1.3±06 (P=0.002) in the SL group, but not in the L group. Nonalcoholic fatty liver disease activity score (NAS) attenuated in both groups: the SL group (from 5.8±0.9 to 3.9±1.4; P=0.000) and the L group (from 5.3±0.6 to 4.6±1.2; P=0.009). NAS improvement was much higher in the SL group (1.9±1.4) than in the L group (0.7±1.1) (P=0.006), with NAS improving by ≥2 in 13 patients from the SL group and five patients from the L group (P=0.01). Improvement was irrespective of diabetes. Regression analysis explored that sitagliptin had odds of 6.38 and weight reduction had odds of 4.51 for NAS reduction. Conclusion: Sitagliptin 100 mg once daily for 1 year ameliorates NAS by improving steatosis and ballooning, irrespective of diabetes. Sitagliptin has stronger efficacy than that of weight reduction. Keywords: fatty liver, NASH, sitagliptin, NAS, fibrosis, steatosis, ballooning, histological activity

Background/Aim: Telmisartan can attenuate two hit pathogenesis of non-alcoholic steatohepatitis (NASH). This study aimed to observe the effect of Telmisartan on non-alcoholic fatty liver disease (NAFLD) activity score (NAS) and fibrosis score in NASH patients. Patients and Methods: A total of 50 NASH patients were randomized; 35 of group 1 were treated with Telmisartan 40/80 mg once daily with life style modification (TL) and 15 of group 2 underwent only life style modification (L) for 1 year. At the end, 20 of TL group and 10 of L group were analyzed. Those who showed NAS improvement ≥ 2 or NAS improvement ≥ 1 with fibrosis improvement ≥ 1 were considered as responders. Results: Baseline alanine aminotransferase (ALT), aspartate aminotransferase (AST), insulin resistance index, components of metabolic syndrome, age, and sex were similar in both groups. At the end of study, NAS improvement in TL and L groups was 2.15 ± 1.66 and 1.10 ± 0.57 (P = 0.017) and fibrosis improvement was 0.65 ± 0.93 and -0.30 ± 0.48 (P = 0.001), respectively. NAS improved by ≥ 2 in 13 (65%) and 2 (20%) patients and fibrosis score improved by ≥ 1 in 8 (40%) patients and none of the patients in TL group and L group, respectively. Telmisartan and life style modification could improve steatosis, ballooning, lobular inflammation, and fibrosis. Life style modification could improve ballooning only, but fibrosis deteriorated. TL group showed improvement in NAS and fibrosis score [P value: 0.035; odds ratio (OR) =92.07, confidence interval (CI) =1.39-6106] to the level of response by regression analysis. Weight reduction and improvement of metabolic syndrome did not influence the response. There were similar minor adverse events in both groups. Conclusion: Telmisartan improved NAS and fibrosis score in NASH with insignificant adverse events.

Fatty liver is a common cause of chronic liver disease in developed as well as developing countries.We have designed this study to estimate the prevalence and predictors for non alcoholic steatohepatitis (NASH) in non alcoholic fatty liver disease (NAFLD). We have included 493 patients with sonographic evidence of fatty change in liver and 177 of them had done liver biopsy for histopathological study. Other causes of liver disease and alcohol consumption were excluded. Metabolic syndrome and biochemical and anthropometric evaluation was done. Females were predominating 250 (57.0 %). Centrally obese 422 (96.2 %) was more than over all obesity330 (75.1%). NASH was absent in 10 (5.6%) cases and diagnostic of NASH was 75 Journal of Bangladesh College of Physicians and Surgeons Vol. 32, No. 2, April 2014 (42.4 %).Presence of diabetes could significantly (p = 0.001) predicted NASH. Age, sex, BMI, waist circumference, Serum HDL,triglyceride, insulin resistance index, hypertension, metabolic syndrome could not predict NASH. Serum GGT level was significantly (p = 0.05) higher in NASHwith a sensitivity of 45 % and specificity of 68 % only. Serum ALT and AST level could not detect NASH. Females were predominant sufferer of NAFLD in Bangladesh. Prevalence of NASH was much higher42.4%. Diabetes was the main predictor of NASH. GGT was the only biochemical indicator of NASH. We recommend liver biopsy in NAFLD with diabetes and raised GGT.J Bangladesh Coll Phys Surg 2014; 32: 71-77

How to cite this article Noor-E-Alam M, Alam S, Alam AKMK, Al Mahtab M, Rahman S. Biochemical Scoring System for diagnosing Nonalcoholic Steatohepatitis. Euroasian J Hepato-Gastroenterol 2016;6(2):202-204.

Background and aims Bacterial infections of ascitic fluid of cirrhotic patients are related to high morbidity and mortality. The aim of the study was to determine the variants of ascitic fluid bacterial infection in patients with advanced cirrhosis (Child Pugh Class C). Materials and methods We analyzed 35 consecutive cirrhotic patients of Child Pugh Class C with ascites attending the outpatient department (OPD) of Hepatology Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2008 to December 2009. Clinical and laboratory parameters of these patients were recorded. Results Among the total 35 patients, eight patients were symptomatic and 27 patients were asymptomatic. Out of eight symptomatic patients, two had ascitic fluid bacterial infection (25%), whereas six of 27 asymptomatic patients (22.2%) had ascitic fluid bacterial infection. Conclusion Bacterial infection should always be considered in patients with ascites with liver cirrhosis irrespective of their symptoms. How to cite this article Sarker JA, Alam MS, Khan M, Mahtab MA, Ashraf MS, Khondaker FA. Variant of Ascitic Fluid Bacterial Infections in Patients of Liver Cirrhosis. Euroasian J Hepato-Gastro-enterol 2015;5(2):131-133.

Nonalcoholic fatty liver disease (NAFLD) is considered to be a disease of obese individuals, yet lean patients are increasingly susceptible to have NAFLD. The aim of this study was to evaluate the profile of nonobese patients by comparing with obese NAFLD patients. We have included 465 patients of NAFLD after exclusion of other diseases, and 220 with elevated alanine aminotransferase (ALT) were biopsied. Patients were biochemically and clinically evaluated: blood pressure, body mass index (BMI), and waist circumference (WC) were recorded for every patient. A BMI ≥ 25 kg/m2 was defined as obese, and those with a BMI of

Background & Aim Metabolic bone disease is common among patients with chronic liver disease and still it is underestimated complication in liver cirrhosis. The prevalence and presentation of bone disease in chronic liver diseases have been poorly described except for cholestatic liver diseases. This study aims at evaluation of the prevalence and degree of bone changes in patients with cirrhosis and to correlate severity of hepatic cirrhosis with the severity of bone changes. Patients and Methods Bone mineral density (BMD) was studied using dual energy X-ray absorptiometry (DEXA) in 60 subjects of 15-45 years old. Of them 30 subjects are patients with liver cirrhosis and rest of the 30 subjects were control group without having liver disease or any other chronic disease. The diagnosis of cirrhosis was based on clinical, biochemical, and ultrasonographic findings. Patients with renal impairment, cholestatic liver disease, chronic lung disease, prolonged bed ridden patients or deformity of spine, pelvis or wrist were excluded from the study. Results of BMD were then correlated with the Child score. Results Eighteen (60%) patients had decreased bone mineral density (BMD). Of which 15 (50%) patients have got osteopenia and 3 (10%) patients have got osteoporosis. No correlation was found between the T-score and Child Paugh score (p =0.236). Significant correlations were found between BMD and serum bilirubin. Conclusion Liver cirrhosis is a risk factor for the development of bone loss and there is a high prevalence of BMD disorders in cirrhotic patients. The severity of bone loss is not related to the severity of liver disease. Hyperbilirubinemia and low albumin is a contributing factor to altered bone mineral density in patients with liver cirrhosis DOI: http://dx.doi.org/10.3329/bjmed.v22i2.13588 Bangladesh J Medicine 2011; 22: 41-46

Background: Repeated endoscopy is required to detect & follow up of esophageal varices (OV) in cirrhotic patients. Objective: For discomfort and unwillingness lo do the endoscopy directed us to evaluate liver stiffness measurement (LSM) for lhe prediclion ofO V. Methods: A cross sectional observational study was conducted between July 2010 to July 2011. A total of 50 patients with cirrhosis were divided into three groups. Group-I patients had no varix (n=4), group-II had Grade-I OV (n=23) and group-UI had Grade-II/III OV (n=23 ) at endoscopy. Liver stiffness was measured by fibroscan & data was analyzed by SPSS.Results: Mean age were 35.20 ± 11.36 years with highest frequency 19 (38 %) in 21-30 years age group. Etiologies were different with leading causes includes HBV (76%) followed by HCV (6%), alcohol (2%) and 14% were unknown. Liver stiffness did not significantly differ from group-I & group-II, but was signifi­cantly higher in group III than group-II & group I. Liver stiffness was nol accurate in the prediction of grade-I oesophageal variees [Arca under the curve (AUC)] = 23.6%. Liver stiffness at a cut off value 32.52 kPa with sensitivity, specificity, positive predictive value, negative predictive value, accuracy respectively 82.6%, 77.8 %, 76 %, 84%, 80% can predict the Grade-II-Ill oesophageal varices (AUROC = 85.2%). Conclusion: Liver stiffness may be suitable for prediction of Grade-II-III oesophageal varices, not for the screening of the presence of oesophageal varices.

Background: Nonalcoholic steatohepatitis (NASH) and advanced fibrosis are the spectrum of nonalcoholic fatty liver disease (NAFLD) that may progress to cirrhosis.Objective: We aimed to determine the detecting capacity of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma glutamyl transpeptidase (GGT) for NASH and significant fibrosis.Methods: Demographic and laboratory data of 502 sonologically diagnosed NAFLD patients were retrospectively analysed. Area under receiver operating characteristics curve (AUROC) was performed for NASH and fibrosis score ≥2 (significant fibrosis) with ALT, AST and GGT of 233 biopsied patients.Results: Of 502 patients ALT, AST and GGT was elevated in 252 (50.1 %), 184 (36.7%) and 138 (27.4%) respectively. There was no difference in histological activity and fibrosis score between normal and elevated ALT and AST. Forty two (40.2%) NASH and 23(20.2%) significant fibrosis had normal ALT level. GGT was differed in NASH and Non NASH (p< .005) and between significant fibrosis (p< .01) and insignificant fbrosis. To detect NASH AUROC curve ofGGT was 67.5%, whereas of ALT and AST was 55.2% and 55.7%. For significant fibrosis AUROC curve of ALT, AST and GGT was 44, 50 and 68.4 % respectively. GGT level of39.5 U/L could detect NASH with a 63% sensitivity and 65% specificity irrespective of sex. GGT 40.5U/L had 60% sensitivity and 59 % specificity to detect significant fibrosis. For fibrosis ≥2 AUROC curve was 75.4% in male.Conclusion: No optimal ALT and AST level could detect NASH and fibrosis. GGT level of 40 U/L had a better detecting capacity for NASH and fibrosis especially in male.

Although insulin resistance (IR) is strongly associated with nonalcoholic fatty liver disease (NAFLD), the association of IR and NAFLD is not universal and correlation between IR and severity of NAFLD is still controversial. In this review, we summarize recent evidence that partially dissociates insulin resistance from NAFLD. It has also been reported that single-nucleotide polymorphisms in the diacylglycerol acyltransferase gene, rather than IR, account for the variability in liver fat content. Polymorphisms of the patatin-like phospholipase 3 gene have also been reported to be associated with NAFLD without metabolic syndrome, which suggests that genetic conditions that promote the development of fatty changes in the liver may occur independently of IR. Moreover, environmental factors such as nutrition and physical activity as well as small intestinal bacterial overgrowth have been linked to the pathogenesis of NAFLD, although some of the data are conflicting. Therefore, findings from both genetically engineered animal models and humans with genetic conditions, as well as recent studies that have explored the role of environmental factors, have confirmed the view that NAFLD is a polygenic disease process caused by both genetic and environmental factors. Therefore, IR is not the sole predictor of the pathogenesis of NAFLD.

Background: Serum alanine transaminase (ALT), hepatitis B virus (HBV) DNA level and age are used in the evaluation of chronic hepatitis B (CHB). Aim: We designed this study to evaluate liver histology with ALT and its relation with age and HBV DNA. Methods: During the period of October 2006 to July 2009, 499 CHB patients were included in this study with detectable HBV DNA at PCR. Of these, 181 had normal ALT, 200 had ALT [>(1 × ULN) 4 and 31 (10.8%) had fibrosis ≥2. In Group 2, 14 (15.7%) had moderate-to-severe HAI and 19 (21.2%) had fibrosis ≥2 when HBeAg was positive, in those with HBeAg negative 34 (30.6%) had moderate-to-severe HAI and 38 (34.2%) had fibrosis ≥2. An ALT value of ≥58.5 U/l had higher sensitivity than that of 80 U/l in predicting significant histological changes. Further, HAI and fibrosis were significantly greater in the age of >30 years. Conclusions: We recommend liver biopsy in HBeAg-negative CHB over 30 years of age regardless of ALT level and starting treatment at ALT 1.5 × ULN instead of 2 × ULN.

Cirrhosis of liver is characterized by the replacement of normal liver tissue by scar tissue. The Child-Turcotte-Pugh (CTP) score is used to assess the prognosis of cirrhosis and included five factors: total bilirubin level, serum albumin, prothrombin time, ascites and hepatic encephalopathy. CTP score depends on clinical assessment which may result variation in scoring. Recently a new score is introduced, Albumin-Bilirubin (ALBI) score which may be done instead of CTP scoring in cirrhotic patient. This cross sectional study was conducted at the Department of Laboratory Medicine in collaboration with the Department of Hepatology, BSMMU, Dhaka, from March 2018 to February 2019. Blood samples were assayed from eighty one diagnosed cirrhotic patients. For all statistical analysis SPSS version 22 was used. The mean age of the study group was 46.1±16.0 years. 64.2% were male and 35.8% were female. Kappa (k) value was 0.759 between ALBI and CTP score. Pearson's correlation coefficient (r) test showed significant strong positive correlation between CTP score and ALBI score (r=+0.853, p

Background/Aim: Fulminant hepatic failure (FHF) is a devastating complication of acute viral hepatitis, leading to death in most cases. The etiology and predictors of outcome differ according to the geographical region. This study was conducted with the aim of evaluating the etiology, complications, and outcome of FHF in Bangladesh. Patients and Methods: In this prospective study, we included 67 consecutive cases of FHF presenting to the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, between November 2003 and May 2008. Thirty-nine of the patients were male and 28 were female. Data was analyzed using SPSS, version 13.0. Results: The mean age of the subjects was 31.9 ± 11 .7 years. Hepatitis E virus (HEV) was the commonest etiological factor for FHF (50 cases, 74.6%); of the 50 cases with HEV infection, 43 (64.2%) were not coinfected with any other virus, four cases were Hepatitis B virus (HBV) carriers, and three had coinfection with hepatitis A virus (HAV). HBV was the cause of FHF in nine (13.4%) patients. HCV, paracetamol, and alcohol were not responsible for any of the cases. Most of the patients (57 patients, 85%) developed FHF within 2 weeks of the onset of jaundice. Of the 67 patients, 49 (73.1%) died. Cerebral edema was the single most common cause of death (48 patients, 71.6%). Other complications were renal failure (23 patients, 34.3%), sepsis (15 patients, 22.4%), electrolyte imbalance (12 patients 17.9%), and bleeding tendency (7 patients, 10.4%). Occurrence of cerebral edema, longer prothrombin time, higher grade of encephalopathy, and longer jaundice-to-encephalopathy interval had significant negative influence on outcome. Conclusions: The etiology of FHF in Bangladesh is different from that in the West. Prolongation of prothrombin time and occurrence of cerebral edema are predictors of the worst prognosis.

Nonalcoholic fatty liver disease (NAFLD) is one of the most common forms of chronic liver diseases worldwide. The prevalence of NAFLD was 15% in the Asian population. In a study, NASH was observed in 42.4% of NAFLD cases in Bangladesh. It is a serious clinical problem because of its worldwide distribution and potential adverse sequel. Cytokeratin-18 fragment is a marker of hepatocyte apoptosis. Measurement of serum cytokeratin-18 fragment concentration is a noninvasive, quick and simple procedure that can be carried out easily in peripheral hospital. It can be very much helpful for early detection and frequent monitoring of disease progression and response to therapy. This cross sectional study was conducted in the Department of Clinical Pathology in collaboration with Department of Hepatology and Department of Pathology, BSMMU, Dhaka from March 2014 to February 2015. Forty patients who fulfilled the criteria of NAFLD were determined in our study. The concentration of serum CK-18 fragment was measured to evaluate its association in different types of NAFLD by enzyme linked immune sorbent assay (ELISA). In this study, we observed that the serum CK-18 fragment concentration was increased in relation to Nonalcoholic fatty liver disease Activity Score (NAS) (r=+0.7134, P

DOI: http://dx.doi.org/10.3329/medtoday.v23i2.13112 Medicine TODAY Vol.23(2) 2011 pp.109-111

There are remarkable advances in the treatment of chronic hepatitis B (CHB) in the last few years. Unfortunately, prolonged antiviral treatment is associated with increasing risk of drug resistance/viral breakthrough (VBT), which may lead to flare-up and rapid decompensation. We have designed this study to predict the pretreatment and on-treatment factors responsible for development of VBT.This study was conducted during the period of February 2000 to November 2007. We have included 423 patients who received lamivudine (LAM) therapy for at least 1 year and at least 2 follow-ups at 6 months' interval. Follow-up period was 12-78 months. Chi-square test, student's t test, and logistic regression analysis were performed to prove the validity.Of the 423 study cases, 367 (86.8%) were of male patients and 261 (61.7%) patients were HBeAg positive; the age of the patients was 30.8 +/- 12.9 years. Development of VBT was 4.4, 22.8, 45.3, and 74% at 1, 2, 3, and 4 or more years, respectively. Pretreatment high HBV DNA (P = 0.005) and female sex (P = 0.01) were associated with VBT and pretherapy ALT (P = 0.698), HBeAg status (P = 0.273), and age (P = 0.059) were not associated. Duration of treatment, failure to lose HBeAg at 1 year, and HBV DNA nonresponder at 6 months were significantly (P = 0.001) associated with development of VBT.Persistence of HBeAg at 1 year and HBV DNA nonresponder at 6 months are good predictors of development of VBT.

mon in the aged (>40 years) population. There are reports suggesting that older patients have more severe disease compared to younger population. The present study was aimed to compare the characteristics of old versus younger NAFLD patients. Materials and Methods: The anthropometric, biochemical and histological parameters of 270 old and 243 young NAFLD patients were compared. Results: The old NAFLD cases (mean age: 50.09 7.26) compared to younger patients (mean age: 33.48 4.8) had higher anthropometric indices (waist circumference: 97.64 10.79 vs. 94.4 7.87; P = 0.0007, waist–hip ratio: 0.98 0.07 vs. 0.95 0.05; P 0.05), fasting insulin (11.31 6.29 vs. 10.7 5.46; P = 0.41), triglyceride (204.33 143.17 vs. 201 110.53;P = 0.8),HDLCholesterol (42.94 17 vs. 44.16 15.93; P = 0.47), prevalence of metabolic syndrome (50.44% vs. 41.3%; P = 0.19) and histological activity [Definite NASH: 47% vs. 41%; P = 0.41, Hepatic Fibrosis: 36.47% vs. 25.26%; P = 0.1] were not statistically different between the old and young NAFLD patients. Conclusion: The older NAFLD patients did not have more severe disease, despite higher anthropometric indices and metabolic risk factors compared to younger patients.

AIM: To explore the prevalence and risk factors for nonalcoholic steatohepatitis (NASH) in nonalcoholic fatty liver disease (NAFLD) patients. METHODS: We have included 493 patients with sonographic evidence of a fatty change, and 177 of these individuals were evaluated and confirmed after liver biopsy. The exclusion criteria consisted of significant alcohol abuse (< 20 g daily), evidence of hepatitis B and C, evidence of drug-induced fatty liver disease and other specific liver diseases such as hemochromatosis, Wilson’s disease or autoimmune liver disease. The patients were assessed for metabolic syndrome, and biochemical, anthropometric and histopathological evaluations were carried out. The degree of disease activity in the NAFLD patients was evaluated using the NAFLD Activity Score. The data were analyzed by SPSS, version 16.0. RESULTS: Females predominated among the study participants (250, 57.0%), and the mean age was 40.8 ± 10.2 years. The numbers of overweight, obese Ⅰ and obese Ⅱ patients were 58 (13.2%), 237 (53.9%) and 93 (21.2%), respectively. However, there were 422 (96.2%) centrally obese patients. NASH was absent in 10 (5.6%) cases, borderline in 92 (52.6%) cases and present in 75 (42.4%) cases. The presence of diabetes could significantly ( P = 0.001) differentiate NASH from simple steatosis. The following parameters did not influence the development of NASH: age, sex, basal met abolic index, waist circumference, serum high-density lipoprotein, triglyceride, insulin resistance index, hypertension and metabolic syndrome. The serum gammaglutamyl transpeptidase (GGT) level was significantly higher (P = 0.05, 51.7 ± 32.8 and 40.4 ± 22.6 U/L) in the NASH patients, with a sensitivity of 45% and a specificity of only 68%. The serum alanine aminotrans ferase and aspartate aminotransferase levels were not able to predict NASH. CONCLUSION: Females were the predominant sufferers of NAFLD in Bangladesh. The prevalence of NASH was high. Diabetes was found to be the main culprit in developing NASH. GGT was the only biochemical marker of NASH. We recommend liver biopsy in NAFLD patients who have diabetes and elevated GGT.

Background/Aim: Ascariasis is a common parasitic infestation in Asia and Latin America. The most serious presentation is biliary and pancreatic ascariasis (BPA). The aim of the present study was to compare the clinical presentation of BPA with dead worms with that with living worms. Materials and Methods: We included 138 consecutive cases of BPA that occured during the period January 2005 to July 2009. All the patients had endoscopically proven BPA consisting of living or dead worms. Comparison was done by chi-square and independent t tests. Results: The age (mean ± SD) of the patients was 36.8 ± 16.1 years. Prevalence ratio between male and female patients was 1:5. Ninety eight patients contained living worms and 40 had dead worms. Males were more prone to develop dead worm BPA. The commonest presentation was biliary colic (131; 94.9%); others were acute cholangitis (30; 21.7%), obstructive jaundice (19; 13.8%), choledocholithiasis (20; 14.5%), acute pancreatitis (10; 7.2%), acute cholecystitis (6; 4.3%), liver abscess (2; 1.4%), hepatolithiasis (3; 2.2%), stricture of common bile duct (2; 1.4%), pancreatic abscess (1; 0.7%) and cirrhosis of liver (1; 0.7%). Choledocholithiasis, hepatolithiasis, liver abscess and cirrhosis were associated only with dead worms. We could successfully remove all the worms with endoscopic interventions, but 5 patients required surgical intervention as there were strictures and stones within the biliary tree or Ascaris were in gallbladder. Recurrences of stone and cholangitis occurred only in those with dead worms. Conclusion: Biliary ascariasis with dead worms is more dangerous than that with living worms. Endoscopic or surgical intervention may be required repeatedly in those with dead worms.

Background and aims: Parenteral route is the principal mode of transmission of Hepatitis C Virus (HCV). Health care workers are at risk of infection with HCV. Aim of study was to estimate seroprevalence of HCV amongst health care workers and identify possible risk factors of HCV infection. Materials and Methods: 355 health care workers were selected from July 2005 to June 2006 working in different departments of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Among them 43.5% were doctors, 32.1% nurses, 11.8% ward boys, 5.9% operation theatre staffs (OT staffs), and 6.8% others. Sera were tested for HCV antibodies by ELISA. Data analyzed by SPSS 10.0 version. Results: Mean age was 31.56±7.4 years. Males were 51.4% and females 48.6%. Anti-HCV was positive in 5(1.4%) cases out of 355. Most prone to HCV infection were nurses (3) followed by doctor (2). No ward boy or OT staff was affected. Previous surgical (80%) and dental procedures (60%) were the main risk factors than recipients of blood transfusion (20%), intravenous drug users (20%), and multiple sexual exposures (20%). Conclusions: Nurses are more prone to HCV infection. Surgical procedures are the main risk factors for acquiring HCV infection. Proper sterilization of surgical instruments is recommended. (J Bangladesh Coll Phys Surg 2007; 25 : 126-129)