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Background/aims: Endothelial dysfunction is an early and reversible feature in the pathogenesis of atherosclerosis. Coronary flow velocity reserve is a noninvasive test showing endothelial function of epicardial coronary arteries and coronary microcirculatory function. This study was designed to evaluate the carotid intima-media thickness and myocardial microvascular circulation in patients with non-alcoholic fatty liver disease. Materials and Methods: Twenty-four patients with non-alcoholic fatty liver disease and 28 healthy subjects were studied. Ac- cording to the pathology of liver biopsies, patients with non-alcoholic fatty liver disease were divided into non-alcoholic fatty liver and non- alcoholic steatohepatitis groups. Coronary diastolic peak flow velocities were measured at baseline, and then dipyridamole infusion was me- asured by transthoracic Doppler echocardiography. The ratio of hyperemic to baseline diastolic peak velocities was calculated and the inti- ma-media thicknesss of the carotid arteries were measured. Results: Baseline average diastolic peak and diastolic mean flow velocities we- re similar between non-alcoholic fatty liver disease patients and healthy subjects. However, hyperemic average diastolic peak and diastolic mean flow velocities were significantly lower in the patient groups compared to those in the controls (p=0.005 and p=0.002). Coronary flow velocity reserve was 1.65±0.36 and 2.67±0.81 in patients and healthy subjects, respectively (p

Levels of prohepcidin, a homeostatic regulator of iron absorption, are altered in chronic hepatitis C and liver cirrhosis. However, data on the potential alterations of prohepcidin in patients with HBV-related liver disease are scarce. We investigated whether serum prohepcidin is related to iron overload and perenchymal dysfuction in HBV-related liver disease. Three groups of subjects were studied: 66 patients with chronic hepatitis B, 32 patients with HBV-related cirrhosis, and 42 healthy controls without evidence of liver disease. Serum levels of prohepcidin were determined by enzyme-linked immunosorbent assay. Serum prohepcidin levels were significantly lower in patients with HBV-related cirrhosis (175.85 ± 71.5 ng/ml) than in patients with chronic hepatitis B (209.02 ± 62.7 ng/ml P

Background and Aims: Non-alcoholic fatty liver disease has long been accepted as benign; however, recent evidence suggests that the disease may progress to cirrhosis and hepatocellular carcinoma, although the natural course of the disease is still unclear. This study was designed to comparatively evaluate electron microscopic features of non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH). Methods: Quantitative and semi-quantitative ultrastructural evaluations were performed on liver biopsies from 23 patients, 10 with NAFL and 13 with NASH. Results: No statistically significant difference was noted between NAFL and NASH patients in ultrastructural features of hepatocytes including megamitochondria, intramitochondrial crystalline inclusions, mitochondrial matrix granules, foamy cytoplasmic appearance, electron-lucent and glycogen-containing nuclear regions, lipofuscin granules, or an increased frequency of vesicles containing electron-dense material in peribiliary Golgi zone; however, the mitochondrial diameter was significantly higher in the NASH patients. Intercellular distance and microvilli between hepatocytes, collagen and electron-dense material accumulation in the space of Disse, electron-dense material accumulation and microvillus density in bile canaliculi did not differ significantly between the groups. Conclusions: Our data show that, although NAFL and NASH can be distinguished by their distinct light microscopic features, ultrastructural characteristics are similar, which suggests that NAFL may also have the potential to progress to fibrosis and cirrhosis like NASH.

We aimed to determine the quality of life in treated and untreated hemodialysis patients with chronic hepatitis C virus infection.Ninety-five chronic renal failure patients with positive antiHCV/HCV-RNA were enrolled in this prospective study. All patients were questioned using the Short Form-36 (SF-36) health survey to evaluate life quality after the treatment. Fifty-five (ALT1.5 ULN) were treated with interferon-alpha-2b [3MU/tiw, sc, 6 (30 patients) and 12 (25 patients) months], and 40 (11 renal transplanted) were untreated. Fifteen patients had renal transplantation in a mean of 24.6+/-12.5 months after interferon-alpha treatment.The mean age of the patients was 37+/-10 years, and 58 were male. The mean durations of hemodialysis and renal transplantation were 6.4+/-3.8 and 5.9+/-4.6 years, respectively. Interferon treatment had a negative effect on general health perception, physical activity and anxiety about the disease (p0.05) when compared with the untreated patients. General health perception scores were positively slightly increased in interferon responder patients (p0.05). General health and physical activity were better in transplanted patients than patients undergoing hemodialysis (p0.05).General health perception slightly increased positively in interferon responder patients. However, general health perception and physical activity were affected negatively by interferon treatment in the whole group analysis. Renal-transplanted patients have a better life quality compared with those on hemodialysis.

Background Acquired hepatocerebral degeneration (AHD) and hepatic myelopathy (HM) are rare complications of chronic liver disease and are usually resistant to medical therapy. Materials and methods The clinical and laboratory findings of 14 male and 2 female patients with AHD or HM were evaluated. Results The prevalence of AHD and HM was 2% inpatient case series in the last 10 years. The median age of the patients (5 Child's B and 11 Child's C) was 48.7 years (28 to 66 y), and the mean known duration of the liver disease was 75 months (24 to 194 mo). The median time of onset of neurologic findings after diagnosis of the liver disease was 14.5 months. Eight patients who had marked spastic paraparesis or tetraparesis were included in the HM group and all others had AHD group. Sixty-nine percent of the patients had a spontaneous or surgical portosystemic shunts, and the remaining dense retroperitoneal collaterals. During the follow-up period of median 29 months (4 to 72 mo), 12 patients died while waiting for liver transplantation, and these patients suffered from the several complications of chronic liver disease more than the living patients. A marked improvement was observed in 2 of the patients (1 with AHD and the other with HM) at 6 and 8 months after the liver transplantation, respectively. Conclusions Our data suggest that liver transplantation had an important effect on the improvement in these patients.

OBJECTIVE To compare the frequency of intestinal metaplasia (IM) in patients with portal hypertensive gastropathy (PHG) to the control group with functional dyspepsia. METHODS Two-hundred and eighty-nine cases were prospectively evaluated in three groups (controls:group I--123 patients; cirrhotics: group II--135 patients; noncirrhotic portal hypertensives: group III--31 patients). Mucosal biopsies (three antrum, one angulus, two corpus) were taken and examined for atrophy, IM, dysplasia, Helicobacter pylori (Hp) and histologic PHG. RESULTS Frequencies of IM in groups I, II and III were 17.1% (type I, 3.3%; type II, 10.6%; type III, 3.3%), 34.3% (type I, 9.6%; type II, 17%; type III, 6.7%) and 33.3% (type I, 9.7%; type II, 12.9%; type III, 9.7%), respectively. In patients with PHG, frequency of IM was significantly higher than in control group (P

The risk factors for the transmission of hepatitis C virus (HCV) infection varies substantially between countries and geographic regions. The aim of this investigation was to determine the risk factors which may be involved in the transmission of HCV infection in the Turkish population. This study included patients who were admitted to the Department of Gastroenterohepatology, Istanbul Medical Faculty, Istanbul University, between 1996 and 2002 and found to be anti-HCV positive during hospitalization or during follow-up as outpatients. All patients were asked about risk factors for HCV transmission including transfusion, history of operation, hospitalization, hemodialysis, intravenous drug use, suspected sexual contact, tattooing, acupuncture, dental procedures, manicure and pedicure, blood brotherhood rituals, perinatal risk factors, common circumcision rituals, and history of abortion. In our study, total of 320 patients with anti-HCV seropositivity were involved. The numbers and percentages of male and female patients were 139 (43.4%) and 181 (56.6%), respectively. The mean age of the patients was 49.7+/- 12.4 years (range: 18-73 years). HCV-RNA was found to be positive in 297 (92.8%) patients. The most common risk factor was a history of surgery (305; 98%), and the second most common was blood transfusion (123; 39.7%). The numbers and percentages of patients for the other risk factors were as follows: dental procedure, 86 (27.5%); abortion, 66 (21.2%); long-term hospitalization, 37 (11.6%); hemodialysis, 31 (10%); history of jaundice, 15 (4.6%); history of intravenous drug abuse, 10 (3.1%); history of suspected sexual contact, 5 (1.5%); history of manicure and pedicure, 4 (1.2%); history of occupational transmission, 3 (0.9%); history of tattooing, 2 (0.6%); history of acupuncture, 2 (0.6%); circumcision in a common circumcision ritual, 1 (0.3%); and percutaneous needle puncture, 1 (0.3%). None of the patients had a history of blood brotherhood ritual or perinatal transmission. Only one risk factor was detected in 73 (22.8%) patients, two risk factors were detected in 122 (38.2%) patients, three risk factors were detected in 78 (24.5%) patients, and four risk factors were detected in 39 (12.2%) patients, however, in 8 (1.6%) patients no risk factors could be found. In Turkey, the most common risk factor for the transmission of HCV infection is surgery, which can be preventable.

The success of alpha interferon (IFN-α) monotherapy for the treatment of chronic hepatitis D is very limited. In this study, the efficacy of IFN-α and ribavirin combination therapy for chronic hepatitis D was investigated. Nineteen patients (15 males; mean age ± standard deviation, 36.8 ± 12.8 years) with chronic hepatitis D who were treated with IFN-α2b (10 million U, three times/week, subcutaneously) and ribavirin (1,000 to 1,200 mg/day, orally) for 24 months were studied. All patients had compensated liver disease (15 were precirrhotic), elevated transaminase levels, and hepatitis D virus RNA positivity at baseline. Genotypic analyses revealed hepatitis D virus genotype I and hepatitis B virus genotype D. All patients completed the 24 months of treatment and at least 6 months (7 to 19 months) of a follow-up period. Biochemical responses were observed in eight patients (42.1%) at the end of treatment and in seven patients (36.8%) at the end of follow-up. Eight patients (42.1%) at the end of treatment and four patients (21%) at the end of follow-up had virological responses. In conclusion, combination treatment of IFN-α and ribavirin for chronic hepatitis D is not able to induce virological responses at a sufficient rate, despite its partial effectiveness in improving biochemical responses, and is not superior to IFN-α monotherapy.

Hepatopulmonary syndrome has yet not been sufficiently assessed in noncirrhotic portal hypertension. The prevalence of hepatopulmonary syndrome was determined in 31 consecutive patients with noncirrhotic portal hypertension (19 idiopathic portal hypertension, 7 portal vein thrombosis, 5 congenital hepatic fibrosis) and 46 patients with liver cirrhosis. Contrast echocardiography was carried out in all patients. Macroaggregated albumin lung perfusion scans were performed in patients with positive contrast echocardiogram. Hepatopulmonary syndrome was detected in 5 (10.8%) cirrhotic and 3 (9.7%) noncirrhotic portal hypertensive patients (2 idiopathic portal hypertension, 1 portal vein thrombosis). All patients with hepatopulmonary syndrome had an increased shunt fraction (13-62%) and a decreased diffusion capacity of carbon monoxide (40-79%), and 7 of them were hypoxemic (PaO2, 31.6-69.8 mm Hg). These findings show that hepatopulmonary syndrome may occur in both liver cirrhosis and noncirrhotic portal hypertension and that portal hypertension is the predominant etiopathogenic factor related to hepatopulmonary syndrome.

The contribution of hepatitis B, hepatitis C, and excess alcohol intake to the development of hepatocellular carcinoma in Turkey was assessed. The study was conducted through a questionnaire sent to seven major medical referral centers in different regions of Turkey and is based on 207 patients seen in the period 1994-1997. Of the seven centers, two were located in West Turkey (54 patients), two were in Central Turkey (85 patients), and two were in south and southeast Turkey (68 patients). In 196 of the 207 patients (94.7%), there was a history of chronic liver disease, and in 180 patients (87%) liver cirrhosis was documented. Of the 207 patients, 116 (56%) had hepatitis B, 48 (23.2%) had hepatitis C, and 33 (15.9%) had a history of excess alcohol intake. Anti-delta testing was available in 69 of 116 patients with hepatitis B, and anti-HDV was positive in 13 of these patients (13/69, 18.8%). Of the 33 patients with a history of heavy alcohol intake, 18 had concomitant chronic viral hepatitis infection, and alcohol alone was the etiology of hepatocellular carcinoma in only 15 cases (7.2%). The distribution of etiologic factors was not homogenous in different geographical regions in Turkey. In central, south, and southeastern Turkey, the predominant etiology of hepatocellular carcinoma was hepatitis B, whereas in western Turkey the impact of hepatitis B, hepatitis C, and alcohol was similar. This study indicates that hepatitis B virus infection is the leading cause of hepatocellular carcinoma in Turkey, followed by hepatitis C infection and alcoholic liver disease.

Eradication of Helicobacter pylori (Hp) infection is strongly recommended in duodenal and gastric ulcer. In developed countries the recurrence rate is low; however, in Turkey, the Hp recurrence rate is suspected to be high as the prevalence of Hp infection is--as high as 70-80% in the asymptomatic population. We planned this study to determine the relapse rate of Hp infection after successful eradication therapy in Turkey. Fifty-two cases including 24 patients with duodenal ulcer and 28 patients with nonulcer dyspepsia were examined in this study. The eradication regimen was omeprazole 20 mg twice daily, clarithromycin 500 mg twice daily, and metronidazole 500 mg three times a day for 1 week. All patients underwent upper gastrointestinal tract endoscopy. At least four samples from antrum and corpus were taken to enable histologic diagnosis of Hp infection. After the eradication therapy, endoscopy was repeated at 1, 3, 6, and 12 months, and Hp-positive patients were dropped from study. With the use of this regimen, the Hp eradication rate was 92.3% (48/52). After the eradication of Hp infection, relapse rates were 6.97%, 27.5%, and 11.11% at 3, 6, and 12 months, respectively. The cumulative relapse rate for 1 year was 41.46%. The results of this study revealed that after the eradication of Hp infection, recurrence is encountered very often as a problem in Turkey. We concluded that hygienic and environmental factors can affect these high relapse rates.

Hepatopulmonary syndrome (HPS) is a well-known complication characterized by abnormalities of arterial oxygenation in patients with chronic liver disease, with or without portal hypertension. There is no definitive treatment for HPS except liver transplantation. We report on a patient with HBV-related liver cirrhosis and HPS who received garlic and lamivudine for 3 years. Signs of liver failure and hypoxemia gradually improved, indicating that lamivudine may improve the functional reserve of the liver, while garlic may help to reduce the signs and symptoms of HPS.

We investigated the clinical and laboratory findings of hypogonadism and feminization in male patients with viral or alcoholic cirrhosis to determine whether chronic liver disease plays a primary role in the development of sexual dysfunction and hormonal changes. Two groups of male patients with liver cirrhosis (23 alcoholic, 33 viral) age- and Child's grade-matched, and 20 age-matched healthy men, as a control group, were included in this study. Clinical signs of hypogonadism and feminization were examined in the cirrhotic patients. Follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone, free testosterone, estradiol, androstenedione, dehydroepiandrosterone sulfate, and sex hormone-binding globulin were estimated in all groups. Seminal fluid was also analyzed in 7 alcoholic and 15 viral cirrhotics. Serum levels of estradiol, androstenedione, and sex hormone-binding globulin were significantly higher, and free testosterone and dehydroepiandrosterone sulfate levels were significantly lower in both groups of cirrhotics compared with the control group. Child's C patients in both groups of cirrhotics were found to have higher estradiol and lower free testosterone levels than child's A and B patients. Alcoholic and viral cirrhotics had markedly reduced sperm motility and density. The differences between alcoholic and viral cirrhotic patients in the clinical signs of hypogonadism, serum levels of sex steroids, and the results of seminal fluid analysis were not statistically significant. These findings suggest that liver cirrhosis per se, independent of etiology, causes hypogonadism and feminization, and that the degree of hypogonadism and feminization correlates well with the severity of liver failure.

SUMMARY. The aims of the study were to investigate the efficacy of rescue therapy with lamivudine (LAM) and adefovir (ADV) combination for 6 months followed by ADV monotherapy in lamivudine-resistant chronic hepatitis B (LAM-R CHB) patients, and to analyze the frequency of ADV resistance mutant development in such patients. A total of 170 consecutive LAM-R CHB patients (male/female: 130/ 40, mean age: 42.9 ± 13.4 years) with viral breakthrough under LAM therapy were analyzed. A total of 68 had HBeAg-positive. Patients received rescue therapy with LAM [100 mg (qd)]+ADV [10 mg (qd)] for 6 months after which LAM was discontinued. HBV-DNA was assessed with the HBV-DNA 3.0 bDNA assay. ADV-resistant mutations were identified by sequencing the reverse transcriptase region. The median duration of rescue therapy was 24 months. Cumulative probability of becoming HBV-DNA undetectable was 33.8%, 59.6% and 68.2% after 24, 48 and 96 weeks of treatment, respectively. These figures were 43.2%, 58.0% and 73.1% for ALT normalization. Among 68 HBeAg-positive CHB patients, 10 patients had an e-antigen seroconversion. Low baseline HBV-DNA level (

Background: There is little information about the prevalence of occult hepatitis B virus infection (OHBVI). We have investigated the prevalence and virological features of OHBVI among female sex workers (FSWs) in Istanbul. Methods: Hepatitis B surface antigen (HBsAg) was tested in FSWs who work uncontrolled and were admitted to Venereal Diseases Hospital. HBV DNA and anti-HBs were investigated in all the HBsAg-negative cases. Hepatitis B envelope (HBe) antigen, anti-HBe, anti-hepatitis B core (HBc) antigen, HBV genotype, S gene and precore (PC)/basic core promoter (BCP) mutations were determined in HBV DNA-positive sera. Results: Two hundred and eighty-six volunteers were enrolled and 32.5% (n=93) of them had anti-HBs positivity. HBV DNA (range 30–209 copy/ml) was positive in 11 anti-HBs-negative and two anti-HBs-positive cases. The prevalence of OHBVI was 4.5% (13/286). Anti-HBc was positive in 77% (10/13) of those with OHBVI and anti-HBe positivity was 53.8% (7/13). Only genotype D was present in all occult HBV-infected cases. One PC (G1896A) and one BCP (T1762/A1764) mutation was found, but S gene mutation was not detected in any of the samples. Conclusion: In this population, OHBVI may have a negligible role in the horizontal transmission because of a very low viral load, and PC and core promoter mutations are very rare.

WOS: 000248523700056, PubMed ID: 17517832, Forty-eight hepatitis B virus (HBV) E antigen-negative chronic hepatitis B patients received pegylated interferon alfa-2b either alone or with lamivudine for 48 weeks and were followed for an additional 24 weeks. At the end of follow-up, virological response rates (HBV DNA levels of < 400 copies/ml) were similar in the monotherapy (24%) and combination therapy (26%) groups.

Background and study aims: Increased alanine aminotransferase (ALT) levels with negative hepatitis B virus (HBV) DNA by hybridization is a common problem in Turkey where is a mild endemic region. We aimed to evaluate the causes of elevated ALT levels in patients who are negative for hepatitis B e antigen (HBeAg) and HBV DNA (by hybridization) for at least 6 months.Patients-methods: Forty-nine patients were enrolled in this study. Histological changes [histological activity index (HAI), and the extent of fibrosis] were assessed according to the Knodell scoring system and steatosis were graded by Brunt’s classification for NAFLD in all patients.Results: A mean age of the patients was 34.9 ± 12.1 years (16-70). 43 (87.8%) of them were male. Mean ALT level was 95 ± 39.7 IU/L (50258). Hyperglycemia (>100 mg/dL) and hyperlipidemia were found in 12 and 24 patients, respectively. Hepatic steatosis (7 patients grade 1; 5 patients grade 2; and 7 patients grade 3), ground-glass hepatocyte, chronic hepatitis, and Wilson disease were found in liver biopsy in 38.8%, 32.6%, 26.6%, 2%, respectively. Mean HAI was 6.5 ± 3.6 (4-12) in chronic hepatitis. Seven patients (53.9%) were in stage 1 and 2 while 6 patients (46.1%) were in stage 3 and 4.Conclusions: Nonalcoholic fatty liver disease is the most common cause of elevated ALT levels in HBeAg negative/HBV DNA negative patients. Chronic hepatitis B was found in 26.6% of these patients.

We aimed to determine the relationships between iron overload and HFE gene mutation in chronic liver disease in Turkey. One hundred thirteen chronic liver disease patients and 138 healthy controls were evaluated regarding their clinical, biochemical, and genetic parameters. Each group was divided into two subgroups according to transferrin saturation (TS) (45% and >45%). HFE gene mutation was analyzed by the PCR-RFLP method. C282Y homozygote, heterozygote, and wild-type mutation rates were 1.7%, 0%, and 98.3% in patients and 0%, 1.4%, and 98.6% in controls, respectively. H63D homozygote, heterozygote, and wild-type mutation rates were 1.8%, 24.7%, and 73.5% in patients and 1.4%, 24%, and 74.6% in controls, respectively. Mutation rates were not statistically different in patients with high and normal TS. Iron overload was positively correlated with biochemical activity and Child-Pugh score (P < 0.05). In multivariate analysis, H63D homozygotic mutation was an independent factor for the development of hepatocellular carcinoma (P = 0.004). We conclude that C282Y mutation is very rare in Turkey. Iron overload is not related to H63D mutation but is positively correlated with biochemical activity and Child-Pugh score in chronic liver diseases.

Hepatic hydrothorax is a complication of cirrhosis that is uncommon and difficult to treat. Diuretic therapy, thoracentesis, transjugular intrahepatic portosystemic shunt and liver transplantation are the main therapeutic options. Here, we report on a 47-year-old man with decompensated liver cirrhosis related to hepatitis B and D virus infections and who had complications of hepatic hydrothorax and hepatorenal syndrome. In this case, the hepatic hydrothorax, which was refractory to thoracic tube drainage and octreotide treatment, could be controlled with 5 days of terlipressin therapy associated with albumin. Terlipressin administration resulted in both improvement in renal function and successful resolution of hepatic hydrothorax. Splanchnic vasoconstrictor agents that reduce splanchnic blood flow, increase both central volume and effective renal blood flow. Thus they improve renal function. In our case, terlipressin, known to be beneficial in hepatorenal syndrome, was also effective in the treatment of hepatic hydrothorax probably by similar mechanisms. This is the first case in the literature.

To evaluate whether the cytokine responses in liver and serum differ in chronic hepatitis C patients with normal and high alanine aminotransferase (ALT) levels.Thirty-three (16 with normal ALT level as group 1 and 17 with elevated ALT level as group 2) patients infected with genotype 1b hepatitis C virus (HCV) were examined. Liver infiltrating lymphomononuclear cells (LILMCs) were isolated from liver biopsy by collagenase type 1 and stimulated with phytohemagglutinin and interleukin 2 (IL-2). IL-10, IL-12, interferon gamma (IFN-gamma) and tumor necrosis factor alpha (TNF-alpha) were determined in serum and LILMCs by ELISA.Serum cytokine levels were similar in both groups (P0.05). Stimulated IFN-gamma and TNF-alpha levels in LILMCs were increased in both groups. IL-12 and IL-10 levels stimulated with IL-2 were higher in group 1 than in group 2 (P = 0.023). Histological activity index (HAI) and stage had a negative correlation with TNF-alpha and IFN-gamma levels in group 2.Increased T-helper type 2 (Th2) cytokine response may regress inflammatory and biochemical activity. Progression of histological abnormalities in persons with elevated ALT probably depends on insufficient Th2 cytokine response, which does not balance Th1 cytokine response.

Our aim was to evaluate effects of metformin, rosiglitazone, and diet with exercise in nonalcoholic fatty liver disease. Forty-seven patients (mean age, 44+/-10 years; 17 female) whose ALT levels had been high for at least 6 months and with hepatosteatosis detected by liver biopsy and/or USG were enrolled in this study. Of these, 12 were treated with 850 mg/day metformin (group 1), 11 with 4 mg/day rosiglitazone (group 2), and 24 with diet and exercise (group 3) for 1 year. ALT normalization at months 6 and 12 was accepted as treatment response. Liver biopsy was performed in all patients in groups 1 and 2 before treatment and 12 patients (4 in group 1, 8 in group 2) after treatment; but in group 3 it was performed only in patients who approved this procedure (12 patients). Body mass index did not change in groups 1 and 2, but it decreased significantly in group 3 (30+/-3 to 28+/-2 kg/m(2)) at month 12. Treatment response rate was 33.3, 54.5, and 54.2% in groups 1, 2, and 3, respectively, at month 6. This rate was 22.2, 37.5, and 41.2 in groups 1, 2, and 3, respectively, at month 12. Rate of steatosis and stage of fibrosis did not change after treatment. Diet with exercise seems to be superior to metformin and rosiglitazone. Decreasing treatment response at month 12 compared to month 6 may be due to fluctuations of ALT levels. Treatment response should be evaluated histologically.

Background/Aims : End-stage renal disease patients on chronic hemodialysis are at risk for both hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. Although the prevalence is unknown in hemodialysis patients, occult HBV infection is frequent in subjects with chronic HCV infection. We aimed to investigate (1) the prevalence and clinical impact of occult HBV infection in hemodialysis patients with chronic HCV infection, and (2) the frequency of YMDD variants (tyrosine-methionine-aspartate-aspartate amino acid motif of HBV polymerase) in this setting. Methods : Thirty-three anti-HCV and HCV-RNA-positive, HBsAg-negative hemodialysis patients (mean age 36.9±10.4 years, 22 male) were admitted to this study. HBV-DNA (Innogenetics kit) and HCV-RNA (Cobas Amplicor HCV kit) were investigated by polymerase chain reaction technique (PCR). YMDD mutation was studied in all HBV-DNA-positive patients by the BOOM method. Results : HBV-DNA was detected in 12 of 33 patients (36.4%) by PCR. Their mean age was 33.0±9.0 years. Age, dialysis period (years) and biochemical parameters were not significantly different in patients with and without occult HBV infection. YMDD variants were identified in six of 12 (50%) patients with occult HBV infection. Conclusions : Occult HBV infection is frequent in hemodialysis patients with chronic HCV infection. YMDD variants are common in this setting.

Intestinal bacterial overgrowth in liver cirrhosis: is it a predisposing factor for spontaneous ascitic infection?

In this study, two cases of biopsy-proven pancreatic tuberculosis are reported. The patients presented with fever, anorexia, fatigue, abdominal pain and weight loss. A differential diagnosis of fever of unknown origin was conducted. Computed tomography (CT) revealed a cystic mass image in the pancreatic head in one patient, and a hypodense lesion in the pancreatic head in the other. The first patient was diagnosed by a wedge biopsy specimen obtained in the exploratory laparotomy. The other patient was diagnosed by percutaneous fine-needle aspiration biopsy. Both patients were successfully treated with quadruple antituberculous therapy for 12 months. We concluded that especially in young patients who present with a mass in the pancreas, pancreatic tuberculosis should be considered among the differential diagnoses, particularly in developing countries and immunosuppressed individuals.

Objective To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis. Methods Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features. Results The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment. Conclusion Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.

The prevalence of anti-HCV among patients on hemodialysis is consistently higher than in the general population, indicating that patients on hemodialysis programs are at risk of acquiring HCV infection. The response to interferon alpha 2b (IFN -α 2b) therapy in chronic C hepatitis depends on viral and host factors. We treated 22 chronic C hepatitis uremic patients with IFN- α 2b (3 MU three times a week) and compared interferon responsive and unresponsive patients with regard to HLA II genes. HLA II genes were investigated by PCR-SSP low resolution, anti-HCV with ELISA II and HCV-RNA with reverse transcriptase “nested” PCR. Findings: HLA DRB1*13 is 50% positive in the non-responder group (four women, four men, mean age; 28.8±11.9 years) and 7% in the responder group (five women, nine men, mean age; 32.2±7.8 years) (p*13 is 28% and 22% positive, respectively). We conclude that major histocompatibility complex class II genes influence the outcome of chronic C hepatitis treatment with IFN -α 2b.

Background: The operations with proven effects on survival in Budd-Chiari syndrome are shunt operations and liver transplantation. Patients and methods: Between 1993 and 1999 (June), 13 cases of Budd-Chiari syndrome have been treated surgically. Four cases had concomitant thrombosis of the inferior vena cava; the others had marked narrowing of the lumen due to the enlarged caudate lobe. Mesoatrial (n = 12) or mesosuperior vena caval (n = 1) shunts were constructed with ringed polytetrafluoroethylene grafts. Results: The median portal pressure fell from 45 (range 32 to 55) to 20 (range 11 to 27) cm H2O (P

Background/Aims: It has been reported that severe cryptogenic chronic hepatitis may be a subgroup of autoimmune hepatitis. The aims of this study were to investigate the clinical features, liver function tests, human leukocyte antigens and response to immunosuppressive therapy in severe cryptogenic chronic hepatitis, and to compare the findings in such patients with those in patients with autoimmune hepatitis. Methods: History of alcohol and hepatotoxic drug intake, markers of metabolic liver disease, autoantibodies (antinuclear antibody, smooth muscle antibody, antibody to liver/kidney microsome type 1), and viral markers (HBsAg, HBV DNA, anti-HCV, HCV RNA) were negative in all severe cryptogenic chronic hepatitis patients (histological activity index >9 and alanine aminotransferase level >2×normal). Fifteen cryptogenic patients (13 women; mean age, 33±16 years) and seven autoimmune patients (seven women; mean age, 28±3.9 years; five type 1; two type 2a) received prednisolone and azathioprine for at least 2 years. Results: Cryptogenic chronic hepatitis patients were similar to patients with autoimmune hepatitis with respect to age, sex, clinical presentation, liver function tests and Knodell scores at admission. HLA phenotype frequencies were comparable between cryptogenic and autoimmune groups: BW6 (77% vs. 100%), DR4 (62% vs. 57%), and HLA B8 (15% vs. 43%). The rates of complete and partial remissions achieved during therapy were 87% vs. 57% and 13% vs. 29%, respectively ( p >0.05). Conclusions: The clinical, biochemical and HLA phenotypic features, and the responsiveness to immunosuppressive therapy in severe cryptogenic chronic hepatitis support the idea that it may be an autoimmune liver disease similar to autoimmune hepatitis.

Objective: To investigate the prevalence of spontaneous ascitic infection (SAI) in different cirrhotic groups, the risk factors for development of SAI, and the efficacy of cefotaxime therapy. Design: A prospective study. Setting: In-patient clinic of a university hospital. Patients: Eighty cirrhotic patients with ascites were assigned to four groups: hepatitis B or D virus-related 34, alcoholic 18, hepatitis C virus-related 14, miscellaneous 14. Interventions: Paracentesis was performed on 80 patients during 92 consecutive hospitalizations. Ascitic fluid was cultured by the method of bedside inoculation of blood culture bottles with ascites. The patients with SAI were treated with cefotaxime (2 g, three times daily, intravenously) for 5 days. Main outcome measures: Frequency of SAI in cirrhotic groups; clinical, bacteriological and biochemical findings of SAI ; rate of recovery from infection. Results: Twenty SAI episodes (22%) were found in 16 patients; 8 episodes were spontaneous bacterial peritonitis, 2 bacterascites, and 10 culture-negative neutrocytic ascites. SAI occurred more frequently in patients with hepatitis B or D virus-related liver cirrhosis (32%) than in the alcoholic (6%, P

Accessible online at: www.karger.com/dsu Chronic hepatitis C infection, which is common in patients with chronic renal failure on hemodialysis, is also an important cause of morbidity and mortality after renal transplantation. Immunosuppressive medications given in the post-transplant period may hasten damage to the liver and increase hepatitis C virus (HCV) replication [1]. Interferon-· can be used in chronic hepatitis C, but is not appropriate in the post-transplant period because it can cause rejection of the transplanted kidney [2]. To date, there is no medication that can be used to treat chronic hepatitis C in the post-transplant period. In this study, we investigated ribavirin, in renal transplantation patients with hepatitis C. We investigated 5 HCV-infected patients (3 males) between the ages of 25 and 50 years who had undergone renal transplantation. They had persistently elevated transaminase levels. Four of the patients had living-donor transplants and 1 had a cadaveric-donor transplant. All of the patients were on cyclosporine-based immunosuppressive treatment. Anti-HCV (by UBI EIA 4.0; Organon Teknika) and HCV RNA (with PCR) were positive in all patients. Genotypes were 1b in all cases. After the diagnosis of chronic hepatitis C infection had been established by liver biopsy, ribavirin was given 800 mg p.o. daily. In the first month of the therapy, the patients were examined weekly for side effects including hemolysis. Transaminase levels were checked monthly. Normalization of the transaminase levels was accepted as a biochemical response, and HCV RNA negativity was accepted as a virological response. Ribavirin therapy was given for 3–30 months. Preand post-treatment median aspartate aminotransferase, alanine aminotransferase, hemoglobin, and hematocrit levels were 84–49 U/l, 83–65 U/l, 12.5–10 g/dl, and 36–32%, respectively. None of the patients cleared HCV RNA. In 1 patient the transaminase level decreased to the normal range. In 3 patients, treatment was ceased because their hemoglobin and hematocrit levels decreased gradually despite decreasing their ribavirin dose to 400 mg daily. One patient was given packed red blood cells. In Turkey, hemodialysis and renal transplantation patients are the groups among whom HCV is the most common [3]. Interferon increases the risk of rejection in renal transplant patients because it is a strong immunomodulatory drug enhancing T lymphocyte-related cytotoxicity and natural killer functions. We obtained no virological response to ribavirin monotherapy, contrary to what is reported in the literature [4]. However, there was a tendency to a decrease in transaminase levels compared to the values at the beginning of therapy, and in only 1 patient did they decrease to the normal range. In these patients, although ribavirin was used at lower doses, signs of hemolysis were evident and symptomatic. In conclusion, ribavirin treatment in patients with chronic hepatitis C infection who have undergone renal transplantation is ineffective and its hemolytic effect is predominant and dose limiting.

Background and aims The sexual transmission of hepatitis C virus (HCV) is debated. By excluding other risk factors, the role of sexual intercourse in the transmission could be detected more accurately. We screened HCV prevalence and risk factors in the spouses of chronic hepatitis C (CHC) patients and followed the seroconversion rate of anti-HCV negative spouses. Patients and methods Six hundred spouses of CHC patients were recruited. The spouses' HCV risk factors were questioned and the spouses were tested for anti-HCV. The 216 spouses who were anti-HCV negative were checked annually for anti-HCV. Results Anti-HCV was positive in 12 of 600 (2%) of the spouses. Of the 12 anti-HCV positive spouses, 11 were HCV-RNA positive. Of anti-HCV positive and negative spouse groups, mean age was 52.3 +/- 9.8 and 49.8 +/- 12.4 yr; duration of marriage was 1521 +/- 506.7 and 1532.4 +/- 670.2 wk (p > 0.05); and the number of total sexual intercourse was 434 +/- 295 and 307 +/- 333 (p= 0.055), respectively. In our prospective study, none of the spouses developed anti-HCV seroconversion in mean 35.7 +/- 6.3 months and 257.9 +/- 72.2 sexual intercourse. Conclusions Anti-HCV was found positive in 2% of the spouses. None of the seronegative spouses developed seroconversion in the 3-yr follow-up period. This is the first study that stresses the importance of the total number of sexual intercourse in sexual transmission (p= 0.055). Our results of special monogamous group with very limited risk factors support the role of number of total sexual intercourse in HCV transmission. However, the seroprevalence rate of the spouses was still within the upper limit of our country population.