A case report of COVID-19 evoked cholangitic liver abscess

Background Lately, the humanity has been being threatened by the coronavirus disease (COVID-19). The virus-related destructive motives can damage not only the lungs but also the brain, blood vessels, kidneys, and the heart. Case presentation A middle-aged female presented with jaundice post-COVID-19 pneumonia. The patient had past history of cholecystectomy 20 years ago. Both laboratory and imaging data revealed a picture of cholestasis with right lobe liver abscess. Despite drainage and culture-based antibiotics, no improvement ensued. Endoscopic retrograde cholangiopancreatography was done revealing mildly dilated common bile duct (CBD), multiple large stones, mildly dilated central biliary radicals, and an old overlooked stent inside the dilated CBD. Papillotomy and papilloplasty were undertaken followed by stones’ extraction with insertion of 2 plastic stents (10 cm× 10 f), and a flow of thick dark bile was inspected. The patient was finally improved and safely discharged. Conclusion Herein, we present the first case of long-retained quiescent biliary stent which was over-headed by a cholangitic abscess in the vicinity of COVID pneumonia.

Late acute cellular rejection after switch to everolimus monotherapy at 11 months following liver transplantation

Background Acute cellular rejection beyond the 6th month posttransplant is an uncommon complication after liver transplantation. The inadequate immunosuppression (IS) remains the main risk factor. We report a case of acute cellular rejection after a switch to everolimus monotherapy at 11 months following liver transplantation. Case presentation This was a 69-year-old man who underwent liver transplantation after hepatocellular carcinoma. The initial immunosuppression was a combination of three immunosuppressive drugs (corticosteroids + tacrolimus + mycophenolate mofetil). The corticosteroid therapy was stopped at the 4th month posttransplant. Serious side effects of the immunosuppressive drugs (agranulocytosis and renal dysfunction), which occurred 4 months after transplantation, required a reduction and then a discontinuation of tacrolimus and mycophenolate mofetil. Everolimus was introduced as a replacement. The patient was consulted at 11 months after liver transplantation, 1 month after stopping the two immunosuppressive drugs, for liver function test abnormalities such as cytolysis and anicteric cholestasis. A moderate late acute cellular rejection was confirmed by a liver biopsy. A satisfactory biological evolution was observed following corticosteroid boluses and optimization of basic immunosuppressive drugs. Conclusion Late acute cellular rejection remains an uncommon complication, observed mostly in the first year after liver transplantation. The main risk factor is usually the decrease of immunosuppression.

Characterization of mesenchymal stem cells isolated from Wharton’s jelly of the human umbilical cord

Background Isolation of post-partum umbilical cord Wharton’s jelly stem cells has gained attention as an alternative source of the bone marrow. Because easy isolation, lack of ethical concerns, and the presence of both embryonic and adult stem cells have made them a valuable source for use in therapeutic applications and regenerative medicine. The study utilized a modified protocol using in-house human pooled cord blood serum for isolation and expansion of the mesenchymal stem cells obtained from the human umbilical cord Wharton’s jelly. Cell proliferation and population doubling time and tri-lineage differentiation were assessed, and the expressions of mesenchymal cell surface markers CD44, CD90, CD105, and CD34 were assessed by flow cytometry and RT-PCR. The genetic stability of the isolated cells was assessed by chromosomal karyotype. Results The isolated cells displayed fibroblastic-like morphology and tri-lineage differentiation into adipocyte, chondrocyte, and osteocyte. The isolated cells maintained the proliferative competence with a doubling time ranged from 38 to 42h and corresponded well with the standard positive and negative molecular markers (CD44+, CD90+, CD 105+, and CD34−). Cell senescence occurred at the later passage of the cells (P15) affecting, about 25% of the population. Metaphases spread of the cells showed normal diploid karyotypes, with typical chromosomal plates indicating genetic stability of the isolated cells. Conclusion The primary cultures exhibited success in isolating the umbilical cord Wharton’s jelly mesenchymal stem cells, which maintained their tri-lineage differentiation potential, phenotypes and karyotype characteristics on further passage and expansion.

Clinical utility of linear endosonography in patients with unexplained biliary dilatation and negative MRCP, with predictors for detection of neoplastic lesions

Background and study aims Unexplained biliary dilatation (UBD) frequently represents a diagnostic dilemma. Linear endosonography (EUS), with its close proximity to the pancreaticobiliary system and the ability for tissue acquisition, could have a role in revealing etiologies of UBD particularly in the context of negative other non-invasive modalities. However, in such patients, the decision for this semi-invasive procedure is usually debatable and often needs justification. Thus, we aimed to evaluate the diagnostic utility of linear EUS in patients with UBD after negative magnetic resonance cholangiopancreatography (MRCP) and to delineate predictors for EUS ability to detect neoplastic lesions. Patients and methods This was a prospective diagnostic observational study between 2018 and 2021. Included patients with evidence of biliary dilatation on abdominal ultrasound and negative MRCP underwent linear EUS examination. Results were compared to the final diagnosis relied on histopathology after EUS-guided biopsy or surgery for neoplastic lesions, while ERCP, diagnostic EUS criteria plus histopathology for autoimmune pancreatitis, Rosemont criteria for chronic pancreatitis, and/or follow-up for 6 months were the gold standard tests for non-neoplastic etiologies. Logistic regression was conducted to reveal predictors of neoplasm detection by EUS. Results Sixty-one patients (mean age 60 years, 32 females) were enrolled; 13.1% of them were asymptomatic. The final diagnosis was categorized into 29 patients with and 32 without neoplasms. Sensitivity, specificity, positive, negative predictive values (PPV, NPV), and accuracy of EUS-positive findings were 98.3%, 100%, 100%, 66.7%, and 98.3%, respectively. Corresponding results for neoplasm identification were 100%, 93.8%, 93.5%, 100%, and 96.7%, respectively. The most common neoplastic etiologies were small pancreatic and ampullary masses. Common bile duct (CBD) diameter > 12.9mm and CA19-9 > 37.1 u/ML were independent predictors for pancreaticobiliary neoplasm at multivariate regression analysis. Conclusion Linear EUS appears to have a high accuracy in detecting etiologies of UBD, with higher sensitivity for small pancreatic, ampullary lesions, and CBD stones. CBD diameter > 12.9 mm and elevated CA19-9 > 37.1 u/ML should raise a concern about the presence of occult pancreaticobiliary neoplasm, and then, EUS may be warranted even in asymptomatic patients.

Etiology and outcome of neonatal cholestasis: an experience in a tertiary center of Bangladesh

Background Neonatal cholestasis (NC) is a major cause of morbidity and mortality in young infants. This study examines the etiology of NC and its outcome during 2 years of follow-up at a tertiary referral center in Bangladesh. Results Out of 80 cholestatic infants, 60% had intrahepatic cholestasis with a mean age of onset of 12.4±2.8 days and a mean age of admission of 82.4±29.0 days. The remaining 40% were extrahepatic with a mean age of onset of 6.7±2.3 days and a mean age of admission of 94.6±50.4 days. Biliary atresia (BA), idiopathic neonatal hepatitis (INH), and TORCH (Toxoplasma, rubella, cytomegalovirus, and herpes simplex) infection except rubella were the most common causes. After receiving treatment, 46.2% of the cases improved, 23.8% deteriorated with morbidity, and 30% died. The majority of the children with INH, TORCH, choledochal cyst, hypothyroidism, galactosemia, and urinary tract infection (UTI) with sepsis were improved. Significant mortality was found in BA (56.6%), intrahepatic bile duct paucity (PIBD) (100%), and progressive familial intrahepatic cholestasis (PFIC) (100%) whereas the rest of BA (43.4%) live with persistent morbidity. Significant clinical improvement was observed in 37 (46.2%) cases of cholestasis evidenced by decreasing jaundice, change of color of urine from dark to normal color, change of stool color from pale to yellow, and gradual decrease in liver size from hepatomegaly state. In addition, decreasing median total bilirubin, direct bilirubin, alanine transaminase, gamma-glutamyl transferase, and alkaline phosphatase showed biochemical improvement at 2 years follow-up. The age of admission, etiology, and presence of ascites are the predictors of outcomes. Conclusion BA was the most common cause of extrahepatic while INH and TORCH infection were the most common cause of intrahepatic cholestasis. Majority of children with intrahepatic cholestasis improved but deteriorated with BA and genetic causes. Prompt referral and early diagnosis as well as the etiology of NC were the main determinants of the favorable outcome.

Role of liver biopsy versus non-invasive biomarkers for diagnosis of significant fibrosis and cirrhosis: a web-based survey

Background Liver biopsy is the standard reference for staging hepatic fibrosis. Non-invasive methods for assessment of hepatic fibrosis and cirrhosis are becoming increasingly popular. Objective We aimed at exploring the change in practice regarding the use of liver biopsy and non-invasive methods for staging hepatic fibrosis and cirrhosis among hepatologists. Methods We performed a survey-based study that recruited hepatologists from various Egyptian institutions. Physicians were deemed eligible if they had a degree in internal medicine with hepatology as a subspecialty. We utilized an online-based survey that assessed the acceptability and reliability of liver biopsy, serum biomarkers, and radiological tools for evaluating liver fibrosis and cirrhosis. Results A total of 573 responses were retrieved (response rate = 80.3%). Out of them, 58% were having more than 15 years of experience as a hepatologist. Liver biopsy is still considered the gold standard for assessment of hepatic fibrosis and cirrhosis by 61% of participants. Liver biopsy was accepted by 44% of their patients. 84% reported the need for a more practical alternative to liver biopsy to assess disease progression or response to treatment. 78.34% of participants know serum biomarkers, 84.08% reported that they were acceptable by their patients, 37.79% thought they are reliable. 95.4% were familiar with radiological methods of non-invasive assessment of hepatic fibrosis, 89.1% reported that radiological methods were acceptable by their patients, 62% think that they are reliable and 78% reported they were applicable in clinical practice. Sixty-five percent think that combining non-invasive methods is better than using a single method. Forty percent of participants thought that radiological methods are easier to use for assessment of hepatic fibrosis followed by a combination of non-invasive methods, serum biomarkers, and liver biopsy respectively. Conclusion In conclusion, liver biopsy is still considered the most reliable method for evaluation and staging of liver cirrhosis by hepatologists in Egyptian institutions, despite the modest acceptance by the patients. Nonetheless, non-invasive methods are gaining acceptance by Egyptian physicians and patients, and most of them consider these methods as reliable and applicable tools for predicting the course of liver cirrhosis.

Resuming post living donor liver transplantation in the COVID-19 pandemic: real-life experience, single-center experience

Background Solid organ transplantation (SOT) service has been disrupted during the current coronavirus disease 2019 (COVID-19) pandemic, which deferred the service in most centers worldwide. As the pandemic persists, there will be an urgency to identify the best and safest practices for resuming activities as areas re-open. Resuming activity is a difficult issue, in particular, the decision of reopening after a period of slowing down or complete cessation of activities. Objectives To share our experience in resuming living donor liver transplantation (LDLT) in the context of the COVID-19 pandemic in the Liver Transplantation Unit of El-Manial Specialized Hospital, Cairo University, Egypt, and to review the obstacles that we have faced. Material and methods This study is a single-center study. We resumed LDLT by the 26th of August 2020 after a period of closure from the 1st of March 2020. We have taken a lot of steps in order to prevent COVID-19 transmission among transplant patients and healthcare workers (HCWs). Results In our study, we reported three LDLT recipients, once resuming the transplantation till now. All our recipients and donors tested negative for SARS-CoV-2 by nasopharyngeal RT-PCR a day before the transplantation. Unfortunately, one of them developed COVID-19 infection. We managed rapidly to isolate him in a single room, restricting one team of HCWs to deal with him with strict personal protective measures. Finally, the patient improved and was discharged in a good condition. The second patient ran a smooth course apart from FK neurotoxicity which improved with proper management. The third patient experienced a sharp rise in bilirubin and transaminases on day 14 that was attributed to drug toxicity vs. rejection and managed by discontinuing the offending drugs and pulse steroids. In addition, one of our head nurses tested positive for SARS-CoV-2 that was manageable with self-isolation. Conclusion Careful patient, donor, personnel screening is mandatory. Adequate supply of personal protective equipments, effective infection control policies, and appropriate administrative modifications are needed for a safe return of LDLT practice.

Medicinal plants with hepatoprotective potentials against carbon tetrachloride-induced toxicity: a review

Background Carbon tetrachloride (CCl4) is a well-characterized hepatotoxic agent. With rising cases of liver diseases, the identification, assessment, and development of hepatoprotective agents from plants source has become imperative. Main body With arrays of literature on plants with hepatoprotective potentials, this review sourced published literatures between 1998 and 2020 and systematically highlighted about 92 medicinal plants that have been reported to protect against CCl4-induced liver injury in animal models. The results show that herbal plants provide protection for the liver against CCl4 by downregulation of the liver marker enzymes and activation of antioxidant capacity of the liver cells with the restoration of liver architecture. We also provided the traditional and accompanying pharmacological uses of the plants. A variety of phytochemicals mostly flavonoids and polyphenols compounds were suggested to offer protection against liver injuries. Conclusion It can be concluded that there are a variety of phytochemicals in plant products with hepatoprotective activity against CCl4-induced toxicity in animal models.

Health care resources utilization and costs associated with different clinical stages of chronic hepatitis B in Egypt

Introduction Chronic hepatitis B (CHB) is associated with many serious clinical and social consequences. Despite Egypt being classified as a country of low endemicity, the infection is associated with a 15–25% risk of premature death from liver cancer or end-stage liver disease. The national committee of treatment and control of viral hepatitis has already offered a high-quality service for the diagnosis and treatment of CHB on a free basis. The current study aims to estimate the health care resources utilization and the annual direct medical cost associated with different clinical stages of CHB-related disease in Egypt. Methodology The data was retrieved through record review for three months in the General Administration of Hepatitis Viruses Control, Egypt. Then, the data was extrapolated to the population level by multiplying the prevalence in Egypt with a focus on the productive age groups (25–59 years). Results The cost and utilization of different health care resources increase with disease progression. The total annual direct medical costs due to CHB in Egypt is 21.3 L.E. Billion (4.7 Int$ billion/year) for the management of estimated 1,420,700 CHB patients. The direct medical costs among the productive age group (25–59 years) constitute more than half of the total cost (57%). The highest disease burden is encountered among (25–29 years) age group; 2.695 L.E. billion (0.59 Int$ billion/year). Despite liver transplantation phase being associated with the highest annual cost/patient, the number of patients in this stage is the lowest. Then, it only constitutes 0.04% of the disease direct medical cost in the country. The chronic hepatitis clinical stage constitutes 57.26% of the disease direct medical cost in Egypt’s working age group. Conclusion Strengthening the preventive and control measures is mandatory to alleviate the disease’s direct medical costs. Close monitoring of the chronic hepatitis stage is mandatory to prevent disease progression. Enhancement of vaccination efforts will lower the disease prevalence and its cost. The universal health insurance system which is gradually implemented in Egypt nowadays will be a cornerstone in relieving the economic stresses by allowing more access to high-quality health care services.

Role of plasma von Willebrand factor antigen in prediction of esophageal varices in pediatric and adolescent patients with portal hypertension

Background Ruptured esophageal varices (EVs) are a leading cause of death in Portal hypertension (PHT), it has been a big concern of research to screen EVs through non-invasive approaches. This study aimed to evaluate the role of plasma von Willebrand factor antigen (VWF-Ag) assay for early detection of EVs in patients with portal hypertension. This was a cross-sectional study, done on 47 portal hypertensive children and adolescents who were collected from the Pediatrics Hepatology Clinic, Children Hospital, Ain Shams University. All patients were subjected to comprehensive history taking, thorough clinical examination, routine investigations, abdominal ultrasound, upper GI endoscopy, and measurement of plasma VWF-Ag level. The patients were divided based on their endoscopic findings into two groups; a varices group which included 37 patients, and a non-varices group which included 10 patients. Results VWF-Ag rise significantly in patients with EVs, revealing a direct positive association with the degree of EVs. Conclusion The plasma VWF-Ag can be applied as a non-invasive evidence of the presence and grading of EVs.