Background: Detecting early infection of chronic hepatitis C (CHC) can prevent late-stage complications including the need for transplant and death. However, screening hepatitis C virus for early detection of the disease has not been found to be beneficial in average risk individuals according to US Food and Drug Administration guidelines. Objectives: The primary aim of this study was to detect infection with hepatitis C antibodies using a rapid immunochromatographic assay in a community setting. The secondary aims included assessment of prevalence rate, disease characteristics and response to the standard treatment. Methods: A screening survey of 13,704 people (0.9% of the population) was conducted from December 2008 through July 2010. It was carried out in three phases involving 4000, 3212 and 6492 average and high risk people. Hepatitis C antibodies were detected using a colloidal gold enhanced rapid immunochromatographic assay. The diagnosis of CHC was confirmed by measuring the viral load using highl...

To the Editor: We read with great interest the article by Harwood et al published in issue 10 of J Clin Gastroenterol 2010. Authors retrospectively analyzed the results of 107 blind percutaneous liver biopsies (PLB) and compared their results in obese and nonobese children. They concluded that blind PLB could be safely carried out in obese children with no increase in complication rate compared with nonobese children. Similarly, there was no difference in number of passes, biopsy size, portal triads per biopsy, or biopsy success in obese children. However, there are several important points that need to be addressed. From our point of view, after a long experience in performing ultrasound (US) guidance PLB, we believe that direct US control of the needle pathway during the procedure represents the guarantee that hepatic fragment obtained by PLB is adequate for histologic analysis and additionally reduces complication rates. Several studies showed that complications appeared more often in “blind” than in “US-guided” biopsies. In this study, authors have presented similar statements in discussion section. In a prospective study, Riley reported that US examination before the PLB forced a change of the site of biopsy in 15.1% of the cases because of interposition of lung, gallbladder, large central vessel, ascites, colonic loop, and slim liver edge. Our main concern is based on the question whether blind biopsy (especially in children) would be ethical nowadays, with extensive use of US. Above all, many physicians consider US “the stethoscope of 21st century”. The opinion that the blind method of PLB (without visual inspection of the needle pathway) has the same chances for successful outcome is simply not realistic (especially regarding safety of the intervention and its complication rate). Therefore, we believe that blind biopsy is to a certain degree acceptable for clinicians (gastroenterologists/hepatologists) in the countries where only radiologists are allowed to perform US examination. In the countries where clinicians do perform US examination, we cannot recommend blind biopsy as US-guided method is likely to reduce the risk of complications and improves the quality of specimens obtained, as recommended by the American Association for the Study of Liver Diseases guidelines.

Summary.  Among individuals with chronic hepatitis C virus (HCV) infection, approximately 30% of patients show persistently normal alanine aminotransferase (PNALT). Individuals with PNALT have been historically excluded from antiviral treatment. However, some studies have reported sudden worsening of disease in patients with PNALT, suggesting the need to treat such individuals. To evaluate this further, we compared fibrosis severity and response to treatment in patients with PNALT to patients with abnormal ALT. In addition, we investigated whether liver histology and schistosomiasis affect response to treatment differently in those with PNALT and abnormal ALT. A retrospective cohort study of 176 HCV‐Genotype 4 (HCV‐G4) patients treated with pegylated interferon (PEG‐IFN) and ribavirin. Of 176 cases studied, 53 (30.1%) had normal ALT. Prevalence of pretreatment severe fibrosis, sustained virological response (SVR) and relapse were not significantly different in patients with PNALT (26%, 66% and 5.7% respectively) compared to those with abnormal ALT (32.5%, 60.7%, and 6.6% respectively). Multivariable logistic regression revealed that pretreatment ALT, pretreatment viral load, inflammation and schistosomiasis were not significantly associated with SVR [OR (95% CI), 0.75 (0.34–1.65); 0.92 (0.61–1.37); 1.64 (0.64–4.18); 0.90 (0.44–1.84) respectively]. Severe fibrosis was the only significant predictor of SVR [OR (95% CI), 0.38 (0.14–0.99)]. PNALT does not reflect the degree of fibrotic changes or predict SVR. Furthermore, schistosomiasis is a predictor of neither fibrosis nor poor response in patients with PNALT. Severe fibrosis is a strong and independent predictor of response to treatment. Therefore, it is important to treat individuals with PNALT levels regardless of schistosomiasis.

Introduction: Laparoscopic cholecystectomy (LC) is a method of choice for chronic gallbladder calculus. Surgeon’s experience and sophistication of the work method itself have brought a number of advantages in comparison to open cholecystectomy (OC). Particularly, the advantage corresponds to decreased immune response of the organism on surgical stress. The aim of this study was to define the level of surgical stress through immune response of the organism on stress. Patients and Methods: One hundred patients were involved in the study, 50 of whom were treated by LC method and the other 50 by open method. The patients were of middle age group, between 47 and 57 years of age, mostly female. C-reactive protein was studied as one of the parameters of the organism’s immune response during LC and OC, and also a number of leucocytes, erythrocytes, haemoglobin and hematocrit after LC and OC procedures. C-reactive protein is a biochemical marker, as an organism’s response to stress and the aim of this study is to confirm the CRP values during surgical treatment of chronic calculus of the gallbladder through different surgical methods: conventional or open surgery and laparoscopic surgery which is considered less invasive. Number and frequency of intra-operative and post-operative complications during laparoscopic and open cholecystectomy were also compared. The erythrocytes, haemoglobin and hematocrit and leucocytes, were also determined in both groups of patients with the aim to confirm the hypothesis that the laparoscopic cholecystectomy is a less invasive method compared to the classic or open method. Results and Discussion: The results have confirmed the hypothesis that the laparoscopic cholecystectomy surgical method is less invasive and showed that the value of CRP is much less in post-operative period after LC than OC. In this way, decreased immunological response of the organism on the surgical laparoscopic procedure were confirmed in this study. Decreased value of leucocytes was determined in laparoscopic technique in the post-operative period in comparison to open technique. The number of erythrocytes, hematocrots and haemoglobin were not significantly different in the post-operative period during LC and OC. Complications such as bleeding, bile leakage, subphrenic abscess, post-operative pancreatitis, post-operative wound infection, hernias of post-operative sections and keloid were present more in OC than in LC. Conclusion: Inflammation of early protective homeostatic immune response on post-operative wound characterises the production of C-reactive protein as one of the activities of cellular and humoral mechanisms. This comparative study between laparoscopic and open cholecystectomy in light of immune response of the organism to stress, number and type of intra-operative and post-operative complications, confirmed advantages of laporascopic technique in comparison to open method.

Summary.  Kinetics of hepatitis C virus (HCV) during pegylated interferon (PEG‐IFN) and early monitoring of viral decline were recently described to predict treatment outcomes and in turn reduce the course of treatment, adverse effects and cost. However, there is limited (if any) information on the viral dynamics of HCV‐4. Our aim is to follow the HCV‐RNA kinetics during PEG‐IFN alpha 2a and ribavirin therapy and the best time for predicting sustained viral response (SVR) in genotype‐4 patients. Serum HCV‐RNA levels before initial dosing (baseline level) and at 24 h, week 1, week 4, week 12, week 24, week 48 and week 72 were assessed in 84 HCV genotype‐4 patients treated weekly by PEG‐IFN alpha 2a and daily ribavirin. At the end of treatment, out of the 84 treated patients, 19 (22.6%) were non‐responders while 65 (77%) showed end‐of‐treatment response (ETR). However, 8 patients relapsed (9.5%), thus the SVR was observed in 57 patients (67.9%). Younger patients were more likely to attain SVR, where the odds of SVR increased by a factor of 0.94 for each year increase in age (95% CI: 0.90–0.99, P = 0.019). Although a significant negative correlation between stage of fibrosis and rate of viral decline at weeks 1 and 4 (P < 0.005 and 0.001, respectively) was seen, neither fibrosis stage (χ2 = 3.4882, P > 0.1) nor grade of inflammation (χ2 = 0.0057, P > 0.1) significantly predicted response to treatment. Non‐responders had no or only a limited decline at week 1 and week 4, whereas sustained virological responders had a significant decline at both week 1 and week 4. Area under the (receiver operating characteristic) curve (AUC) revealed that week 12 is better than any other time point in predicting the SVR (AUC = 0.97; 95% CI: 0.94–1.01), (sensitivity 98.3%; 95% CI: 90.7–99.9), (specificity 88.5%; 95% CI: 71.0–96.0), positive predictive value of 94.9% and negative predictive value of 95.8%. A drop of more than 1.17 log viral load at week 1 and viral clearance or decline >3 log were considered as the earliest predictors of SVR. In genotype‐4 patients, while failure to achieve an EVR at week 12 predicts non‐response, an RVR at week1 and week 4 98% guaranteed SVR. These findings further re‐enforce the value of week 12 in the course of IFN treatment. Genotype‐4 patients who show significant viral clearance (>1.17log viral load) by the first week of treatment and viral clearance >3log by week 4 are expected to show SVR and should therefore be assigned to a shorter drug regimen lasting for 24 weeks. Those unfortunate cases who do not achieve viral clearance by week 1 or week 4 should not be deprived from the treatment but rather given more time till week 12 before being classified as non‐responders.

Resectional surgery on rectum, finishing with continued colo-rectal anastomosis by the classical manual technique, were burdened by a great number of post surgery complications of dehiscentio over 60%. If we take into reconsideration a high number of mortality 5-20% then we have valid reasons for developing modern and safer methods of surgical intervention of these patients. Two groups of 60 patients each, have been analyzed. They have been operated at the Surgical clinic University Clinical Center Tuzla because of rectum malignancy. The first group of patients where the colo-rectal anastomosis was manually operated was done between 1995-1998. In the second group of the patients being operated, colorectal continuity was done by stapler. The patients were operated in time period 2001-2002. The medium evaluation time was 20 months, for each group. All the patients were operated in elective programme, after endoscopic treatment and ph diagnosis done. The patients from the both analyzed groups were operated by the same surgeons. Preoperational procedure and postoperational observation was fullfilled according to the unified protocol. The patients with their colo-rectal continuity having been by stapler had a shorter surgery time, and less transfusion of blood. They had less ureter lesion. Also they have got a shorter hospitalization time with less number of anastomotic complications. Dehiscenc as well as bleeding. The patients with colorectal anastomosis made manually had more repeated surgeries. The patients from the manual group of the surgeries had more anastomotic relapses. The difference in the number of post operational strictures in both analyzed groups was not noticed. The patients with stapler colorectal anastomosis had no mortality. The manual group had one lethal case. The important thing that is noticed is a larger number of stapler colorectal anastomosis, not because of the illnes incidence increase but decrease of abdominoperineal rectum amputation. The patients have been safely operated from the oncologic point of wiev. They have continuing anastomosis which was not burdened with a larger number of morbidity and mortality. This was possible to do by improving surgical strategy and technique and introduction of stapler in every day surgical practice.

AIM To evaluate pegylated interferon alpha2a (PegIFN-alpha2a) in Egyptian patients with HCV genotype 4, and the impact of pretreatment viral load, co-existent bilharziasis and histological liver changes on response rate. METHODS A total of 73 naive patients (61 with history of bilharziasis) with compensated chronic HCV genotype 4 were enrolled into: group A (38 patients) who received 180 mg PegIFN-alpha2a subcutaneously once weekly for a year and group B (35 patients) received IFN alpha-2a 3 MU 3 times weekly. Ribavirin was added to each regimen at a dose of 1200 mg. Patients were followed for 72 wk and sustained response was assessed. RESULTS Significant improvement in both end of treatment response (ETR) (P < 0.002) and sustained response (SR) (P < 0.05) was noted with pegylated interferon, where ETR was achieved in 29 (76.3%) and 14 patients (40%) in both groups respectively, and 25 patients in group A (65.8%) and 9 (25.7%) in group B could retain negative viraemia by the end of follow up period. Sustained virological response (SVR) showed a significant negative correlation with age and positive correlation with pretreatment inflammation in patients receiving PegIFN. Viral clearance after 3 mo of therapy was associated with high incidence of ETR and SR (P < 0.001), but without significant difference between both forms of interferon. Significant improvement in response was achieved in patients with high grade fibrosis (grade 3 and 4) with PegIFN-alpha2a, where SR was seen in 5 out of 13 patients in group A, but none in group B. There was no significant difference in response between bilharzial and non-bilharzial patients in both groups. In terms of safety and tolerability, neutropenia was the predominant side effect; both drugs were comparable. CONCLUSION PegIFN-alpha2a combined with ribavirin results in improvement in sustained response in HCV genotype 4, irrespective of history of bilharzial infestation.

Of 95 randomly selected patients using a percutaneous gastrostomy tube (PEG), 20 required tube replacement at least six months after the initial placement In order to study the possible histopathological changes that might develop in the gastric mucosa with the prolonged use of PEG, gastric biopsies were taken during the replacement procedure. The overall procedure-related minor complication rate was 16.84%; the predominant complication was superficial peristomal wound infection. Other minor complications were tubal migration into the small bowel, surgical emphysema and stomal leak. Histopathological changes seen in six patients showed mild chronic nonspecific gastritis, the predominant cells being lymphocytes and plasma cells. There was no dysplasia or metaplasia. PEG is a safe method of feeding that does not predispose to significant gastric mucosal changes with long-term use. It has a low rate of morbidity even with markedly debilitated patients

Most attacks of acute pancreatitis are self limiting, and the patients recover completely within days or weeks. In a few cases, however, the course is severe, with development of organ failure (single or multiple) and local complications such as necrosis, abscesses, and pseudocist. Between 01.01.2001-01.06.2004, 286 cases of acute pancreatitis were treated in our clinic. The purpose of this study is to represent indication for operative treatment of acute pancreatitis and its complications, according to the Atlanta classification. According to our date, the most frequent cause are changes on biliary tract. Of these 286 patients, 247 suffered from a mild or moderate type of acute pancreatitis and responded fully to medical treatment (215 patients) or to biliary tract surgery (32 patients). The hospital mortality of this group of patients was 2.4%. Surgery was indicated when the patients developed signs of an acute abdomen (9 patients), pancreatic pseudocyst (7 patients), progressiv icterus (2 patients), infection of pancreatic necrosis (10 patients), and pancreatic abscess (7 patients). Four patients with pancreatic necrosis were stable, and they had conservative treatment. The most difficult decision in the management of these patients is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. The hospital mortality of patients with severe acute pancreatitis was 28.2%. Multiple organ failure was the predominant cause of death.

Locally advanced colorectal canter may require an intraoperative decision for the block resection of surrounding organs or structures to achieve complete tumour removal. This decision must weigh the risk of complications and death of multivisceral resection against a potential survival benefit. Little is known about the prognostic factors and their influence on the outcome of multivisceral resection for colorectal cancer. We demonstrate our experience with multivisceral resections for the primary colorectal cancer. Patients undergoing multivisceral resection for primary colon or rectal cancer between I-I.2000-I-VII.2003 were identified from retrospective database. Multivisceral resection was performed in 41 of 378 patients with a median age of 61 years. Postoperative rates of complications and death in 41 patients were 30.9% and 12.1%. Histologic tumour infiltration was shown in 58.3% of patients with curative resection. Multivisceral resection is safe, and long-term survival after curative resection is similar to that after standard resection. As the palliative resections cannot be predicted accurately at the time of surgery, every effort should be made to achieve complete tumour resection.

Current treatment regimens with either long-term interferon (IFN) monotherapy or interferon-ribavirin combination achieve a sustained response of 6-21%. To improve the efficacy of IFN several strategies have been devised, including the use of higher doses of IFN, prolonged courses or pegylated IFN. Some recent reports have suggested that daily administration of IFN in the early phase of therapy (induction dose) may be more efficacious than the classic thrice-weekly regimen. There is no available data about the combination of induction dose regimen of IFN and ribavirin. Our objective was to evaluate prospectively the efficacy and safety of a 5mu IFN induction dose in combination with ribavirin in HCV patients. End treatment response (ETR) was 36.7% of the 30 patients included in the study, while 81.1% ofresponders could remain viral negative for one year after discontinuation of treatment (sustained response). Though responders had higher pretreatment levels of viraemia and ALT, it was still without statistical signficance. Also, there was no statistical histological difference between both groups. There was a significant correlation between response rate and post induction viraemia level (p < 0.05) but no similar relation to post-induction ALT level. We conclude that induction dose regimen seems to have no effect on ETR but may improve sustained response. Also, post-induction viral load level is a good predictor for both ET and sustained responses.