Although ursodeoxycholic acid (UDCA) is not an alternative to surgery for treatment of gallstone disease, it may be a useful alternative, particularly in patients who are unable or unwilling to undergo surgery. The authors demonstrate their case successfully treated with UDCA to dissolve the gallstones in gall bladder. Conclusion: Careful case selection and follow-up determines the success of UDCA in dissolving gallstones.
Liver cirrhosis is common in Bangladesh. There has been a rise in acute viral E hepatitis in Bangladesh after the 2004 flood. At that time most of the country was under water for more than a month leading to sewerage contamination of water supply. The aim of this study was to assess the role of HEV infection in causing decompensation of cirrhosis.
Materials and Methods:
In this retrospective study, 69 patients with evidence of cirrhosis were included. They presented between January 2005 to January 2006 with features of decompensation for the first time. Anti-HEV IgM and anti-HAV IgM were tested and history of upper GI haemorrhage, drug and alcohol intake recorded.
Anti-HEV IgM was positive in 21.7% (15/69) patients. 4.3% (3/69) had history of upper GI haemorrhage and 4.3% (3/69) history of alcohol intake or diuretic overdose or anti-tuberculotic drugs. None tested positive for anti-HAV IgM. No cause for decompensation was found in others. It is likely that decompensation in these patients resulted from progression of the cirrhosis.
Acute HEV infection is a leading cause of decompensation of liver cirrhosis in Bangladesh. Sewerage contamination of water supply following flood contributed to the higher incidence of HEV infections.
Treatment of chronic hepatitis B has changed much since the introduction of interferon. Nucleosides have come to replace interferon in some situations like decompensated states. However, there is no clear cut guideline in many fields. Even end of treatment response is low in conventional treatments. This study describes a few scenarios where difficulties were faced. Unresolved questions in the management of chronic hepatitis B involve ‘who to treat, when to treat, how to treat?’ These should be clearly addressed.
Autoimmune hepatitis is defined as chronic liver disease of unknown aetiology with aberrant autoreactivity and genetic predisposition. It is characterized by female predominance, circulating auto-antibodies, hypergammaglobulinaemia and association with HLA DR3 and HLA DR4 . Differential diagnosis includes chronic viral hepatitis, drug induced hepatitis and alcohol. We present two patients with autoimmune hepatitis representing the two extremes of hepatic involvement in this condition. The first patient is a young lady who was diagnosed with autoimmune chronic hepatitis. The second patient, on the other hand, is an elderly gentleman who presented to us with autoimmune hepatitis-related decompensated cirrhosis of liver.
Acute hepatitis in pregnancy in not uncommon in Bangladesh. There has been a rise in acute viral E hepatitis in Bangladesh after the 2004 floods. At that time most of the country was under water for more than a month leading to sewerage contamination of water supply. The aim of this study was to see the aetiology of acute hepatitis in pregnant women in the third trimester in Bangladesh.
Materials and Methods:
In this retrospective study, 31 pregnant women in their third trimester with acute hepatitis were included. Only those patients who presented with prodromal features like icterus, nausea and vomiting, fever and raised serum bilirubin and raised serum transaminase levels were included in this study. They were all previously healthy and came to the Unit from all over Bangladesh. Patients were tested for markers for common hepatotrophic viruses. Relevant history was taken. Patient Record Book of the Unit was reviewed and patients who fulfilled the criteria were included in this retrospective study.
45.16% (14/31) had HEV infection. They were all anti-HEV IgM positive by ELISA. HBV infection was detected in 6.45% (2/31). All these later patients tested positive for either HBsAg or anti-HBs IgM by ELISA. Both anti-HEV IgM and HBsAg were positive in 9.38% (3/31) patients. No viral marker could be detected in 38.7% (12/31) patients. Overall 54.84% (17/31) patients had HEV and 16.12% (5/31) had HBV infection. No patient had history of drug or alcohol intake.
Acute viral E hepatitis is the leading cause of acute hepatitis in pregnancy in Bangladesh. Sewerage contamination of water supply following flood contributed to the higher incidence of HEV infections. Hepatitis B virus infection is also important.
The aim of this study is to compare Knodell and HAI scores in patients with wild type and precore/core promoter mutant CHB to see if there is any difference in severity of liver injury between these two types of HBV.
We did percutaneous liver biopsies of 155 CHB patients. 102 (65.8%) of them were infected wild type HBV and the rest 53 (34.2%) were infected with precore/core promoter mutant CHB.
11/53 (20.8%) patients with precore/core promoter mutant CHB had moderate to severe CH (HAI score 8–18). In contrast, moderate to severe CH was seen in 19/102 (18.6%) patients with wild type CHB. Fibrosis score was >2 in 15/53 (28.3%) precore/core promoter mutant CHB as opposed to 20/102 (19.6%) patients with wild type CHB.
The study shows that precore/core promoter mutant HBV produces more severe histologic liver disease compared to wild type HBV.
Cirrhosis is a chronic liver disease characterized by diffuse fibrosis and nodule formation leading to distortion of normal liver architecture. The initial stimulus is hepatocyte necrosis. A wide variety of liver diseases can lead to cirrhosis, including viral hepatitis (B, C and D), alcohol, metabolic diseases (eg. haemochromatosis, Wilson’s disease, NASH, α1 anti-trypsin deficiency, type IV glycogenesis), cholestatic liver disease, auto-immune hepatitis, Budd-Chiari syndrome, drugs (eg. methotrexate, amiodarone), etc. The aetiology of cirrhosis remains unknown in a significant number of cases, giving rise to the entity of cryptogenic cirrhosis. In the UK, this figure stands between 5–10% . In Bangladesh, the common causes of cirrhosis remain viral hepatitis (B and C) and NASH .
Primary biliary cirrhosis (PBC) is a rare autoimmune liver disease, not infrequent in the West, but hardly reported from the East. We report a case of PBC for the first time from Bangladesh. The patient was an elderly woman presenting with vague complaints. The diagnosis was confirmed by antibody testing and histopathology, whereas other possible causes of cirrhosis were also excluded.
The aim of this study was to compare the histological activity index and viral load, which one response more with lamivudine, an anti-viral agent used for treating chronic hepatitis B infected patients.
Materials and methods
Following the defined case selection protocol a total of 39 CHB cases were enrolled in the study. After initial evaluation they received with lamivudine orally for 52 weeks. Repeat biopsy could be obtained in 16 cases. 16 patients were analysed in this study. All patients had a liver biopsy at the beginning of the study before starting the drug. Lamivudine was given orally at a dose of 100 mg once daily for 52 weeks. A second liver biopsy was taken for comparison at the end of week 52. Biopsy materials were stained with Haematoxylin and Eosin staining as a routine procedure. Immunohistochemical staining for both surface and core antigens by using antibodies against these antigens were done as special staining. In routine staining biopsies were scored according to Knodell's Histological Activity Index (HAI). Improvements in histological activity index were regarded in cases where Knodell's HAI improved by 2 points or more after treatment. Both Viral Load and staining intensity of each antigen were assessed by visual inspection of 300 hepatocytes randomly under light microscope.
68% (11/16) patients had a reduction of hepatic necroinflammatory HAI score (Components 1 through 3) by 2 points or more at the end of 52 weeks of lamivudine therapy compared to the pretreatment values. Improvement in viral load was found in 80% (12/15) cases. Staining intensity of both viral antibodies was also decreased following treatment.
One of the key objectives of treatment of chronic hepatitis B remains to improve hepatic histology in addition to clearing the virus. The quest continues in this regard and antivirals are potential tools at hand in achieving this goal.
Lamivudine causes significant improvement in viral load in the majority of patients treated for CHB.
Stevens-Johnson syndrome, otherwise known as erythema multiforme majus, was first described in 1922 by Stevens and Johnson as a febrile illness with stomatitis, purulent conjunctivitis, and skin lesions. Case report: We report a 28-year-old married woman who presented with fever and was advised ciprofloxacin tablet. After taking two doses of the tablet, she developed papulo-vesicular rash involving the trunk and the upper and lower limbs, including mucous membranes. She also developed a painful red eye. She eventually developed jaundice and her case was ultimately diagnosed as ciprofloxacin-induced Stevens-Johnson syndrome. Discussion: Medications appear to be the most common cause of Stevens-Johnson syndrome. It commonly affects multiple organs. Treatment for Stevens-Johnson syndrome is as diverse as the symptoms and it should be begun by withdrawing any offending agent identified. Conclusion: Stevens-Johnson syndrome is a potentially fatal multiorgan disease. This aspect of the condition is best addressed by early involvement of medical specialists.