Volume 3 Naumber 1 March 2016 ISSN 2071-2324

BANGLADESH Jounrnal of HEPATOLOGY

Official Journal of

ASSOCIATION FOR THE STUDY OF LIVER Association for the Study of Liver Diseases Bangladesh

DISEASES BANGLADESH (National Association of Hepatologists of Bangladesh)

Bangladesh Journal of Hepatology

Bangladesh Journal of Hepatology Official Journal of Association for the Study of Liver Diseases Bangladesh (National body of Hepatologists of Bangladesh)

Correspondence

Room # 506, 4th floor Block # D Bangabandhu Sheikh Mujib Medical University Shahbag, Dhaka-1000 Email: [email protected], [email protected]

Vol. 3 No. 1 01 Bangladesh Journal of Hepatology

Bangladesh Journal of Hepatology

Editorial Board

Editor in Chief Professor Salimur Rahman Associate Editor Dr. Ayub Al Mamun Dr. Chitto Ranjan Debnath Dr. Faroque Ahmed Dr. K. M. J. Zaki Dr. Mamun-Al-Mahtab Dr. Md. Jasmshed Alam Khan Assistant Editor Dr. Harun Or Rashid Dr. Md. Fazal Karim Dr. Md. Izazul Haque Dr. Muhammad Mahbub Hossain Editorial Board Dr. Abu Saleh Md. Sadequl Islam Dr. Abul Barkat Muhammad Adnan Dr. Ahmed Lutful Moben Dr. Amalendu Bhattacharyya Dr. Arun Jyoti Tarafder Dr. Forhad Hossain Md. Shahed Dr. Golam Mashud Dr. Kutub Uddin Mollick Dr. Md. Abdur Rahim Dr. Md. Ashraful Alam Dr. Md. Dalil Uddin Dr. Md. Jahangir Alam Sarker Dr. Md. Zia Hayder Bosunia Dr. Mohammad Faiz Ahmad Khondaker Dr. Provat Kumar Podder Dr. Shamsul Kabir Dr. Sheikh Mohammad Noor-E-Alam Dr. Syed Abul Foez

02 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Volume 3 Number 1

Content Editorial Page Bangladesh Journal of Hepatology: Blown in the winds of heterogeneity and plurality 05 Sheikh Mohammad Fazle Akbar, Mamun Al Mahtab Original Articles Causes of jaundice in clinical practice: An observation at Brahmanbaria 07 Forhad Hossain Mohammad Shahed, Mamun Al Mahtab, Mohammad Fakhrul Islam Khaled, Mohammad Abul Fayaz, Ashiqur Rahman Khan Prevalence of Hepatitis B and Hepatitis C in Rural Population of Bangladesh 10 Mohammad Izazul Hoque, Mohammad Belalul Islam, Mostafa Kamal Azad Socio-demographic profile of non alcoholic fatty liver disease of 100 patients attended SBMCH Barisal 15 Golam Mashud, Jamsed Alom, Swapon Kumar Sarkar, Anwar Hossain, Amolendu Bhattacharia, Al Mamun Hossain Upper gastrointestinal endoscopic findings in adults at Comilla Medical College & Hospital, Bangladesh 20 Mohammad Forhad Abedin, Mohammad Asaduzzaman Lashkar, Mohammad Shah Jamal, Mohammad Belalul Islam, Mohammad Izazul Haque, Mohammad Abdur Rob Sarkar

Review Articles Hepatic hydrothorax: Challenge for Hepatologist 25 Syed Abul Foez, Mohammad Abdur Rahim, Sheikh Mohammad Noor-E-Alam, Mohammad Ashraful Alam, AKM Shoab, Swapan Kumar Singha, Joy Vargese, Chandan Kumar, Mamun-Al-Mahtab, Salimur Rahman, Ziaur Rahman Chowdhury

Brief Review Current strategies in the management of hepatocellular carcinoma 31 Premashish Kar

Case Reports A case of occult hepatitis B virus infection and hepatocellular carcinoma from Bangladesh 34 Ponkaj Kumar Naha, Mamun-Al-Mahtab, Sarkar Mohammad Shahadat Hossain, Rokshana Begum, Abul Hayet Manik, Debraj Malakar, Partho Pratic Roy, Ayub Al Mamun, Salimur Rahman

Vol. 3 No. 1 03 Bangladesh Journal of Hepatology

Abstracts of LIVERCON 2016 Association of portal vein tumor thrombus in hepatitis B related hepatocellular carcinoma 36 Abu Saleh Mohammad Sadequl Islam, Mamun Al Mahtab, Ayub Al Mamun, Sheikh Mohammad Fazle Akbar, Mohammad Kamal Hossain, Zia Hayder Bosunia, Salimur Rahman Metabolic syndrome is a good predictor for diagnosing non-alcoholic steatohepatitis. 37 Sheikh Mohammad Noor-E-Alam, Ahmed Lutful Moben, Zia Hayder Basunia, Amalendu Bhattacharyya, Abdur Rahim, Syed Abul Foez, Mohammad Shahed Ashraf, Faiz Ahmad Khandoker, Md. Jahangir Alam Sarker, Abu Saleh Mohammad Sadequl Islam, Mohammad Forhad Abedin, Utpal Das Gupta, Mohammad Jahangir Kabir, Mamun-Al-Mahtab, Salimur Rahman Upper gastrointestinal endoscopic findings in adults at Comilla Medical College & Hospital, Bangladesh 38 Mohammad Forhad Abedin, Mohammad Asaduzzaman Lashkar, Mohammad Shah Jamal, Mohammad Belalul Islam, Mohammad Izazul Haque, Mohammad Abdur Rob Sarkar Causes of jaundice in clinical practice: An observation at Brahmanbaria 39 Forhad Hossain Mohammad Shahed, Mamun Al Mahtab, Mohammad Fakhrul Islam Khaled, Mohammad Abul Fayaz, Ashiqur Rahman Khan Non favorable genotype is predominant at IL28B rs12979860 polymorphism in hepatitis B related hepatocellular carcinoma 40 Abu Saleh Mohammad Sadequl Islam, Mamun Al Mahtab, Ayub Al Mamun, Sheikh Mohammad Fazle Akbar, Mohammad Eunus Ali, Zia Hayder Bosunia, Salimur Rahman Life Sketch of Professor Baruch Samuel Blumberg 41 Email from Professor Baruch Samuel Blumberg 43 Brief Introduction of Dr. Nagaraja Rao Padaki: Blumberg Orator 2016 44 List of Blumberg Orators 45

04 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Editorial

Bangladesh Journal of Hepatology: Blown in the winds of heterogeneity and plurality Sheikh Mohammad Fazle Akbar1, Mamun Al Mahtab2 1Department of Medical Sciences, Toshiba General Hospital, Tokyo, Japan, 2Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Correspondence to Dr. Sheikh Mohammad Fazle Akbar Principal Investigator, Department of Medical Sciences, Toshiba General Hospital, Tokyo, Japan. Email

Transmission of knowledge, acceptance of new and about liver and allied disciplines of the world and novel ideas and discarding false but tempting concepts Asia-Pacific region with Bangladesh; thus it is acting as constitute the backbone of social and scientific media to translate all new information palatable to developments of modern-day society. This is especially Bangladeshi hepatologists and physicians of relevant in the context of liver and its pathologies as multidisciplinary positions. A journal is judged by its more than one halves of world population represent the longevity and also persistent improvement of its causality of different hepatotrophic viruses that infects qualitative inceptions. Bangladesh Journal of the liver, disrupt its microenvironments, and induce Hepatology has entered the stage of adolescence after long-term complications like the deadly term of liver crossing the steps of new born, infant and child. The cirrhosis and liver cancer. The impacts and implications future is waiting to accept it as an “ADULT” in the world of these diseases are more pronounced in developing of modern publication. countries, like Bangladesh with limited resources. The The uninterrupted publication of this journal has been primary responsibility of tackling liver and its diseases possible due enormous efforts of its leadership because in Bangladesh has been shouldered by Association for most of the journal of developing countries undergo the Study of Liver Diseases Bangladesh (ASLDB) with spontaneous apoptosis soon after their sailings. Now, it the assistance of its members and patrons. However, is the time to make qualitative improvement of the another major responsibility remains regarding the journal in global perspective. Various clinical researches means of transmitting evolving knowledges about liver and case-control studies have been accomplished in diseases to the members of ASLDB and also to other Bangladesh. Also, new and novel therapeutic allied physicians and medical service delivery approaches have been tested in Bangladesh in last one personnel. This noble responsibility has mainly been decade. ASLDB is also credited for being the sole accomplished by a publication named “Bangladesh sponsor of Single Topic Conference of The Asian Pacific Journal of Hepatology”. Association for the Study of the Liver (APASL) in 2012, Bangladesh Journal of Hepatology has dedicated its an act that has not been accomplished in most of the presence to compile the specific features of liver countries of Asia with better economical capabilities. diseases in Bangladesh. In addition, it has been acting Now, it is time for ASLDB to assess and act to induce as a bridge to connect knowledge and information qualitative improvement of their inherent heart,

Vol. 3 No. 1 05 Bangladesh Journal of Hepatology Bangladesh Journal of Hepatology. Although the quality of generic drugs for HCV infection in a ensuing task is not an easy one, but ASLDB is capable scientifically-amicable manner. This will boost the of taking this challenge to move forward. medical service delivery system of Bangladesh in the At present, the hepatologists have been facing a major context of management of HCV and these approaches challenge about treatment of HCV infection as drugs may reflect the future activities of ASLDB and its journal with potent capacities are now present in market. to move forward with other such medications. However, both aspirations and confusions have been Editors with leadership capabilities, an editorial board of prevailing about these drugs. In Bangladesh, the drugs multidisciplinary specialties and an innovative vision of are cheap and concerns remain if these are efficacious the ASLDB would make it possible to place Bangladesh or not? Bangladesh Journal of Hepatology may devote Liver Journal to its proper position in the field of medical its endeavor to make critical analysis about the journal. effectivity these drugs, especially the content and

06 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Original Articles

Causes of jaundice in clinical practice: An observation at Brahmanbaria Forhad Hossain Mohammad Shahed1, Mamun Al Mahtab2, Mohammad Fakhrul Islam Khaled1, Mohammad Abul Fayaz1, Ashiqur Rahman Khan1 1250 Bedded District Sadar Hospital, Brahminbaria, Bangladesh 2Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Corresponding author Dr. Forhad Hossain Mohammad Shahed Senior Consultant (Medicine) 250 Bedded District Sadar Hospital, Brahminbaria, Bangladesh. Email:

Abstract Background: Jaundice remains the commonest mode of presentation of liver disease. Identification of the cause at first medical contact is the basis of starting treatment. There is scarcity of study elaborating the common causes of jaundice in Bangladeshi people. We evaluated 100 patients presenting with jaundice at Brahmanbaria, a district of Bangladesh to know aetiologies. Methods: We performed this observational study on Patients attending with the complaint of jaundice to the private chamber of the only hepatologist at this district from January 2015 to September 2015. Data from 100 patients were collected and analyzed to know cause of jaundice and its relation with age & sex of these patients. Results: Mean±SD of age of the patients was 28.24±21.57, 57.6% were male. In 73% cases the cause was infectious, with hepatitis B virus (HBV) 44%, hepatitis C virus (HCV) 30%, hepatitis A virus (HAV) 30%, hepatitis E virus (HEV) 26%. Mean±SD of age was 19.7±2.7 in infectious group. Alcoholic liver disease was in 5% cases. Obstruction with gall stone was in 5% cases, Carcinoma of gall bladder (CaGB) in 5%, cholangiocarcinoma in 3%, Carcinoma liver in 1.6% and Carcinoma pancreas in 11.8% cases. Among the CaGB & cholangiocarcinoma patients 16% had gall stone. Mean±SD of age in malignant patients was 62.52±4.9 with 75% female. Conclusion: We observed that viral hepatitis was common in younger age and malignancy in older age. Most of the study subjects were male whereas malignancy was more common in female. HAV infection was more in pediatric age. Majority of hepatits were HBV related. Among the patients with CaGB & cholangiocarcinoma 16% had gall stone.

Background: hepatologist at Brahmanbaria district from January to Bangladesh is a densely populated country. Liver September 2015 with the complaint of jaundice were disease is the third leading cause of death in tertiary enrolled in this study. All patients were investigated to level hospital of this country [1]. Jaundice remains the know the cause and status of liver. Viral markers were commonest mode of presentation. Identification of the tested by ELISA, Sonographic evaluation was done by cause at first medical contact is the basis of starting ultrasonography machine. Demographic profiles and the treatment. There is scarcity of study elaborating the laboratory data were recorded in pre-formed data sheet. common causes of jaundice in Bangladeshi people. In Data were analyzed to detect the relative frequencies of this study we evaluated 100 patients at Brahmanbaria, causes of jaundice and there relation with age and sex. a district of Bangladesh to know aetiologies. Analysis was done by MS Excel software. Methods: Patients attending to the private chamber of the only

Vol. 3 No. 1 07 Bangladesh Journal of Hepatology Results: analysis. Mean±SD of age of the patients was Patients presented with the complaint of jaundice were 28.24±21.57, 57.6% were male. 80 % patients are in screened and total 100 patients were taken for 0-45 year age group.

% of Patients 40 34 35 30 27 25 19 20 % of Patients 15 11 9 10 5 0 0--15 16--30 31--45 46--60 >60

Age of patient

Fig. 1: Age distribution of patients Frequencies of different causes of jaundice and their relation with age and sex are shown in table I. Table I: Causes of jaundice in different age group. Age No. of HB HA HC HEV Gall Alcoholic Ca Ca HB group patient V V V (%) stone Liver GB pancr MA (Years) N=100 (%) (%) (%) (%) disease (%) eas with (%) (%) H/O Gall stone (%) 0—15 27 4 20 3 16—30 34 18 14 2 31—45 19 9 4 2 4 2 46—60 11 2 2 3 2 2 2 >60 9 5 4 5 In 76% cases causes were infectious, with HBV 44%, hepatitis. Rest 20% patients age was >45 of whom HCV 30%, HAV 30%, HEV 26%. Mean±SD of age was 75% were suffering from malignancy. HAV infection 19.7±2.7 in infectious group. Alcoholic liver disease was the dominant cause at 0—15 years age group, was in 6% cases. Obstruction with gall stone was in 5% HBV was common at age group 16-30 years and HEV cases, CaGB in 5%, cholangiocarcinoma in 3%, Ca liver was the second common cause at this age group. All in 1.6% and Ca pancreas in 11.8% cases. Among the the cases of >60years had malignancy involving CaGB & cholangiocarcinoma patients 16% had gall hepatobilliary system. Mean±SD of age in malignant stone. 80% of the patients were in 0-45 years age patients was 62.52±4.9 with 75% female. Sex group, of whom 90% were suffering from infectious distribution of patients is shown in the table II.

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Table II: Sex distribution of patients. Age group No. of patient Sex P value N=100 Male Female 0—15 27 16 11 0.03 6—30 34 25 09 0.001 31—45 19 13 13 1.3 46—60 11 5 06 0.9 >60 9 0 09 0.001

Discussion: find the prevalence of different causes of jaundice in In this study, it was observed that age of most of the this country. patients presenting with jaundice was less than Reference: 45years. Majority of the patients at this age were male. 1. Abedin MF, Hoque MM, Islam ASMSM, Chowdhury Hepatotrophic viral infections were the most common MFI, Das DC, Begum SA, Mamun AA, Mahtab MA, causes in patients below 45 years age (91%). But less Rahman S, Saha AK. Chronic liver disease is one of common in patients with >45 years age (5%). HAV the leading causes of death in Bangladesh, infection was the dominant cause at 0—15 years age experience by death audit from a tertiary hospital. group, HBV was common at age group 16-30 years and Euroasian J hepato-Gastroenterology, 2014; HEV was the second common cause at this age group. 4(1):17-20 This is consistent with reports at home and abroad that 2. Jianhua Liu, Yanshan Cai, Jian Chen, et al. Analysis patients with viral hepatitis are more common in young of Viral Hepatitis B prevalence in the natural adults [2,3] but malignancy in adults. [4,5] Female sex population of Guang-zhou City, China Vaccines and was dominant in patients age >45years. All patients of Immunization, 2010,(05):438. ages > 60 were female and all were suffering from malignancy. 3. Bane A. Viral hepatitis: epidemiology, treatment, prevention. Ethiop Med J, 2008, 46(2):193. Conclusion: 4. Jizhou Wu, Guojian Li, Wuqing Cheng, et al. We performed this study in a private chamber of a Epidemiological studies liver cancer high point in hepatologist at Brahmanbaria district to find the causes Guangxi. Internal Medicain. 2009,(05):678. of jaundice in clinical practice. It was found that hepatitis was the dominant cause at younger age ad 5. Qua CS, Goh KL. Liver cirrhosis in malignancy in elderly. HAV infection was most common Malaysia-peculiar epide-miology in a multiracial cause for childhood jaundice and others were HEV, HBV Asian country. LID - & HCV. This finding may help the clinician for diagnosis 10.1111/j.1440-1746.2011.06732.x [doi]. J of cause of jaundice in out-patient service. Further large Gastroenterol Hepatol, 2011. scale study in different part of Bangladesh is needed to

Vol. 3 No. 1 09 Bangladesh Journal of Hepatology

Prevalence of Hepatitis B and Hepatitis C in Rural Population of Bangladesh Mohammad Izazul Hoque1, Mohammad Belalul Islam2, Mostafa Kamal Azad3 1Department of Hepatology, Comilla Medical College, Comilla, Bangladesh, 2Department of Medicine, Comilla Medical College, Comilla, Bangladesh, 3Department of Radiology, Comilla Medical College, Comilla, Bangladesh, Corresponding author Dr. Mohammad Izazul Hoque Associate Professor and Head Department of Hepatology, Comilla Medical College, Comilla, Bangladesh. E-mail:

Abstract Background: Prevalence of hepatitis B and hepatitis C in Bangladesh is not well documented. Several small studies from different parts show that Bangladesh is an intermediate prevalent area and very low hepatitis C prevalence. Methods: This cross-sectional study was carried out in two villages of Comilla district of Bangladesh. Serum samples were collected from both adult males and females and tested for HBsAg for hepatitis B and anti-HCV antibody for hepatitis C by ELISA. Prevalence rates were determined and correlated with different demographic and risk factors involved in the spread of these viruses. Result: 505 subjects were included in this study among which 160 males (31.7%) and 345 females (68.3%) with the mean age of 42.2 ± 15.04 years. HBsAg was positive in 8 person (1.6 %), Highest prevalence of HBV was among young adults and middle-aged individuals with a male predominance. Anti HCV was positive in 2 person (0.4%). Previous history of jaundice, blood transfusion, dental procedure and intravenous drug use were the main risk factors for acquiring the hepatitis B and C viruses. Conclusion: Prevalence of HBV was 1.6% and indicates an area of low endemicity for hepatitis B virus infection. Prevalence of HCV was 0.4% and indicates very low endemicity for hepatitis C virus infection in rural community of Bangladesh.

Introduction: of HBsAg varies greatly and countries can be defined as Hepatitis B virus (HBV) continues to be a global public having a high, intermediate and low prevalence of HBV health problem. 350-400 million people worldwide are infection based on a prevalence of HBsAg carriers of ≥ 3 chronic HBV surface antigen (HBsAg) carriers. Carriers 8%, 2-7% & <2% respectively . High prevalence areas of HBV are at increased risk of developing cirrhosis, are Sub Saharan Africa and part of Asia-Pacific and hepatic decompensation and hepatocellular carcinoma Low prevalence areas are North America and Europe. (HCC)1. Although most carriers will not develop hepatic Prevalence of hepatitis B among general population of complications from chronic hepatitis B, 15% to 40% Bangladesh not known. Different studies shows diverse will develop serious sequelae during their lifetime1. result. One study4 among 1018 general population HBV related end stage liver disease or HCC are shows the prevalence of 5.5%, 1.54% health care 5 responsible for over 0. 5-1 million deaths per year and workers were HBsAg positive in another study. currently represent 5-10% of cases of liver The hepatitis C virus (HCV) is a major public health transplantation2. problem and a leading cause of chronic liver disease. One third of world population have serological evidence The global prevalence of chronic hepatitis C is of present or fast HBV infection. The global prevalence estimated to average 3% (ranging from 0.1%-5%in

10 Vol. 3 No. 1 Bangladesh Journal of Hepatology different countries)6 and the highest number of infection villages of Comilla, Bangladesh during a 12-month reported in Egypt7. In western countries HCV accounts period in randomly selected sample of adult general for 20% cases of acute hepatitis, 70% cases of chronic population. All inhabitants older than 18 years were hepatitis, 40% cases of end stage cirrhosis, 60% cases invited to participate. Those who agreed to take part in of hepatocellular carcinoma and 30% of liver this study, made an appointment with the study team transplant6. for history and laboratory testing. Informed written The incidence of new symptomatic infections has been consent was taken from all the participants. Serum estimated to be 1-3 cases 100,000 persons annually. samples were collected from both adult males and The actual incidence of new infections is obviously females and tested for HBsAg for hepatitis B and much higher as the majority cases are asymptomatic6. anti-HCV antibody for hepatitis C by ELISA. Prevalence Intravenous drug use remains the main mode of rates were determined and correlated with different transmission. Other modes of transmission are demographic and risk factors involved in the spread of transfusion of blood and blood products, health care these viruses. related procedure, occupational exposure, sexual Statistical analyses was performed using the SPSS transmission and vertical transmission. software, version 16.0. The prevalence of Hepatitis B Hepatitis C virus is a parenterally transmitted virus that and Hepatitis C was calculated as a proportion of may pose an occupational hazard to the health care positive HBsAg and anti HCV subjects to included workers. Epidemiological evidence suggests that health subjects. The results were expressed as mean ± SD care workers are at an increased risk of Hepatitis C and proportions as appropriate. virus infection8, and episodes of hepatitis C virus Results: 9 infection after needle stick incidents and 505 subjects were included in this study among which transmissionlh of the virus in hospitals in developed were 160 males (31.7%) and 345 females (68.3%) 10 countries have also been reported . There are very few with the mean age of 42.2 ± 15.04 years. The studies from Bangladesh regarding the prevalence of demographic and socioeconomic status of the HCV infection in the high risk group of health care staff participants is summarized in Table I. Most of the working in hospitals. participants (52.5%) were categorized as mid income This study was designed to determine the while 239 (47.5%) patients where categorized as low seroprevalence of HBV and HCV infection among the income. 34% subjects were illiterate. rural population of Bangladesh. Methodology: This cross-sectional study was performed in two

Table I: Socio-demographic features of study population (n=505)

Variable N % Age (in years) • 18 – 40 256 50.7 • 41 – 60 195 38.6 • > 60 54 10.7 • Mean ± SD 42.21 ± 15.04 Gender • Male 160 31.7 • Female 345 68.3

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Variable N % Occupation • Farmer 14 2.8 • House wife 320 63.4 • Service 66 13.1 • Day labourer 33 6.5 • Business 30 5.9 • Stay abroad 4 0.8 23 4.6 • Student 15 3.0 • Others Socioeconomic condition • Low 239 47.5 • Middle 264 52.5 Education • Illiterate 171 34.0 • Primary 168 33.4 • Secondary 100 19.9 • Higher secondary 31 6.2 • Graduation 33 6.6 HBsAg was positive in 8 person(1.6%), mostly in the 18-40 age group with male predominance(75%).

Table II: Prevalence of Hepatitis B (HBsAg) (N=505) Test Positive, n(%) Negative HBsAg 8(1.6%) 497(98.4%)

Table III: Demographic characteristics of the HBsAg positive study population (n=8) Characteristics N % Age distribution 18 – 40 5 62.5 41 – 60 2 25 >60 1 12.5 Sex distribution Male 6 75 Female 2 25 Socio -economic Lower class 5 62.5 condition Middle class 3 37.5 Upper class 0 0

Table IV: Risk of exposure to HBV in the HBsAg-positive study population Risk factors N (%) H/O jaundice 3 37.5 Blood transfusion 1 12.5 Dental procedure 1 12.5 Surgery 0 0 I/V drug abuse 1 12.5 Family H/O HBsAg positive 1 12.5 Previous jaundice, blood transfusion, dental procedure and intravenous drug use were the main risk factors for acquiring the HBV infection.

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Table V: Prevalence of Hepatitis C (Anti HCV) Test Positive, n (%) Negative n (%) Anti -HCV 2(o.4%) 503 (99.4%)

Discussion: HBV.19,20 The same applies to Pakistan, where HBV is 21 HBsAg was positive in 8 persons (1.6%). This is lower responsible for 60% of cases of CLD. In Nepal, 60% than one study4 among 1018 general population which of cases of chronic hepatitis and 40% of cases of 22,23 shows the prevalence of 5.5%, but nearly same as in cirrhosis of the liver are due to HBV. another study where 1.54% health care workers were Anti HCV were positive in 2 person (0.4%). pointing to a HBsAg positive5. In our study population the highest low prevalence of the virus in our study population. This prevalence of HBV was among young adults and is lower than one study in general population of middle-aged individuals with a male predominance. Bangladesh where 0.88% were positive for anti-HCV24 HBV prevalence in our healthy adult population appears and was similar to another study where 0.5% subjects 25 to be on the decline. A study in 1984 reported HBV were positive for anti-HCV . Both of them were young prevalence in healthy Bangladeshi adults to be 7.2%.11 male with history of intravenous drug abuse. We found A similar figure, i.e. 7.5%, was revealed by another none to be co-infected with HBV and HCV. study carried out among healthy adult job seekers in Conclusion: 12 1996. The figure has dropped to 1.6%, as revealed by Prevalence of HBV was 1.6% and indicates an area of the present study. Several factors may have played a low endemicity for hepatitis B virus infection. Previous role, including introduction of HBV vaccination in the jaundice, blood transfusion, dental procedure and Expanded Programme of Immunization schedule and intravenous drug use were the main risk factors for equally importantly, public awareness, media-physician acquiring the HBV infection. Prevalence of HCV was partnership, health and family screening, mandatory 0.4% and indicates very low endemicity of hepatitis C screening of blood and blood products before donation, virus infection in rural community of Bangladesh. after which vaccination of negative individuals against Multicenter study with large group of people is HBV has become a popular exercise. recommended to get the real picture of prevalence of In a healthy adult Indian population, the prevalence of HBV and HCV infection in Bangladesh. HBV varies between 2% and 8%, being higher in South References: than in North and West India.13 The HBV carrier pool in 1. McMahon B J. The natural history of chronic India is estimated at approximately 40 million. From Hepatitis B virus infection. Semin Liver Dis Pakistan, a study reveals HBV prevalence in healthy 2004;24: 17-21 adults to be 10%.14 In Nepal, this prevalence varies between 0.9% and 1.6%, being higher in Kathmandu 2. Ganem D, Prince AM. Hepatitis B virus infection – valley than in rural Nepal. Sri Lanka has a reported 1% natural history and clinical consequences. N Eng J prevalence of HBV in the healthy adult population15. This Med 2004; 350: 1118-1129 study result is similar to prevalence of HBV in Nepal and 3. Lok ASF, McMahon B J. AASLD PRACTICE Srilonka GUIDELINES Chronic hepatitis B: Update 2009. HBV poses a huge burden on the health of Hepatology 2009; 50(3):1 Bangladeshis, being the leading cause of all forms of 4. Mahtab MA,Rahman S,Karim MF, Khan M. chronic liver diseases (CLD). HBV is responsible for Epidemiology of hepatitis b virus in Bangladeshi 76.3% of cases of chronic hepatitis16 and 61.15% of general population.Hepatobiliary pancreat dis int cases of cirrhosis.17 Things have changed very little 2008;7(6):595-600 over the years, as a Bangladeshi study in 1994 found 5. Latif MA,Hoque MI,Islam FMM. Seroprevalence HBV to be responsible for 40.5% of cases of CLD in the HBV infection among health care workers- study in country.18 In India >60% of cases of CLD is due to

Vol. 3 No. 1 13 Bangladesh Journal of Hepatology a tertiary care hospital of Bangladesh. Journal of 15. Shrestha SM. Seroepidemiology of Hepatitis B in comilla medical college teachers association Nepal. J Com dis 1990;22:27-32. 2011;13(2):12-14 16. Mahtab MA, Rahman S, Khan M, Kamal M, Karim 6. Akbar SMF, Hossain M, Hossain MF, Sarker S, MF, Ahmed F, et al. Aetiology of chronic hepatitis: Hossain SAS, Tanimoto K, Masumoto T, Michitaka Experience from a tertiary centre in Bangladesh. K, Horiike, Onji M. Seroepidemiology of hepatitis Indian JGastroenterol 2007;26(supple 2):142. viruses of chronic liver diseases in Bangladesh: 17. Afroz S, Mahtab MA, Rahman S, Khan M. Hepatitis high prevalence of HCV among blood donors and B virus is the leading cause of cirrhosis of liver in healthy persons. Hepatol Research 1997; 7: Bangladesh. Hepatol Int 2007;1:120. 113-120. 18. Khan M, Kiyosawa K, Yano M. HCV seroprevalence 7. Khan M, Yano M, Hashizume K, Yousuf M, Tanaka E, in liver disease in Bangladesh. IXth Biennial Matsumoto A, et al. Comparison of Scientific Meeting, Asian Pacific Association for the seroepidemiology of hepatitis C in blood donors Study of the Liver, Kuala Lumpur 1994 between Bangladesh and Japan. Gastroenterol Jpn (Abstract);128. 1993; 28(5): 28-31. 19. Sarin SK, Chari S, Sundaram KR, Ahuja RK, Anand 8. Zaman M. Khan M, Alam K, Williums I. Primary BS, Broor SL. Young v adult cirrhotics: a hepaioocellular carcinoma and viral hepatitis B and prospective, comparative analysis of the clinical C infection in Bangladeshi subjects. J Trop Med profile, natural course and survival. Gut Hyg 1995; 98: 64-68. 1988;29:101-107. 9. Khan M, Ahmed N, Rabtuan S, Zaki KMJ, Matin MA. 20. Acharya SK, Panda SK, Duphare H, Dasarathy S, Interferon therapy in chronic viral hepatitis in Ramesh R, Jameel S, et al. Chronic hepatitis in a Bangladesh: A preliminary report. Int Hepatol large Indian hospital. Natl Med J India Common 1995; 3 (suppl): 104. 1993;6:202-206. 10. Yen T, Keffe EB, Ahmed A. The epidemiology of 21. Zuberi SJ. Seroepidemiology of HBV/HCV in hepatitis C virus infection. J Clin Gastroenterol Pakistan. Int Hepatol Comm 1996;5:19-26. 2003; 36: 47-53. 22. Shrestha SM, Tsuda F, Okamoto H, Tokita H, 11. Islam MN, Islam KMN, Islam N. Hepatitis B virus Horikita M, Tanaka T, et al. Hepatitis B virus infection in Dhaka, Bangladesh. Bangladesh Med subtypes and hepatitis C virus genotypes in Res Council Bull 1984;X:1-6. patients with chronic liver disease in Nepal. 12. Khan M, Ahmad N. Seroepidemiology of HBV and Hepatology 1994;19:805-809. HCV in Bangladesh. Int Hepatol Comm 23. Shreatha SM. Incidence of HBsAg carrier rate in 1996;5:27-29. pregnant women in Kathmandu. J Inst Med 13. Tandon BN, Gandhi BM, Joshi YK. Etiological 1987;71-76. spectrum of viral hepatitis and prevalence of 24. Mahtab MA, Rahman S, Karim F, Foster G, markers of hepatitis A and B virus infection in north Solaiman S. Epidemiology of Hepatitis C virus in India. Bull World Health Organ 1984;62:67-73. Bangladeshi General Population. BSMMU J 2009; 14. Malik IA, Legters LJ, Luqman M, Ahmed A, Qamar 2(1):14-17. MA, Akhtar KA, et al. The serological markers of 25. Khan M, Mustafa MG, Ahmad N et al.Indian J hepatitis A and B in healthy population in northern Gastroenterol 2010(January Pakistan. J Pak Med Assoc 1988;38:69-72. –February);29(1):44-45

14 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Socio-demographic profile of non alcoholic fatty liver disease of 100 patients attended SBMCH Barisal Golam Mashud1, Jamsed Alom2, Swapon Kumar Sarkar3, Anwar Hossain4, Amolendu Bhattacharia1, Al Mamun Hossain1 1Department of Hepatology, Sher-E-Bangla Medical College, Barisal, Bangladesh 2Department of Hepatology, Shaheed Suhrawardi Medical College, Dhaka, Bangladesh, 3Department of Gastroenterology, Sher-E-Bangla Medical College, Barisal, Bangladesh, 4Department of Medicine, Sher-E-Bangla Medical College, Barisal, Bangladesh Corresponding author Dr. Golam Mashud Associate Professor Department of Hepatology, Sher-E-Bangla Medical College, Barisal, Bangladesh. E-mail:

Abstract Background: Non-alcoholic fatty liver disease (NAFLD) is an important cause of liver disease burden across the world. By definition, although the histopathologic features of NAFLD are identical to that of alcoholic liver disease, its diagnosis requires absence of significant alcohol use and absence of other causes of chronic liver disease. NAFLD is a metabolic disorder originally assumed to be largely confined to residents of affluent, industrialized Western countries4; however, obesity and insulin resistance, the common substrates of NAFLD, are not restricted to the west, as witnessed by their increasingly universal distribution. Methods: It is a prospective study conducted in Sher e-Bangla Medical College hospital Barishal during the time of 2013 to2015. Sonographically proved fatty liver disease patient were admitted into hospital or attended out patient department. Results: Majority of population belonged to >40 years in both groups. The mean age was found 38.86±10. (67.0%). Male female ratio was 0.49:1. Conclusion: In the next few years NFLD may be the principle cause of death due to liver disease and possibility the principal cause of liver transplant we suggest oto expand the number of prospective cohort study in general population44 years with a range from 18 to 70 years. Male was found 33(33.0%). Female was found 67.

Background: the United States between 2011 and 2012.[3] Most Non-alcoholic fatty liver disease (NAFLD) is an people with NAFLD have few or no symptoms. Patients important cause of liver disease burden across the may complain of fatigue, malaise, and dull world. By definition, although the histopathologic right-upper-quadrant abdominal discomfort. Mild features of NAFLD are identical to that of alcoholic liver jaundice may be noticed although this is rare. More disease, its diagnosis requires absence of significant commonly NAFLD is diagnosed following abnormal liver alcohol use and absence of other causes of chronic function tests during routine blood tests. By definition, liver disease. Non-alcoholic fatty liver disease (NAFLD) alcohol consumption of over 20 g/day (about 25 ml/day [4] is one of the causes of fatty liver, occurring when fat is of net ethanol) excludes the condition. NAFLD is deposited (steatosis) in the liver due to causes other associated with insulin resistance and metabolic than excessive alcohol use. NAFLD is the most common syndrome (obesity, combined hyperlipidemia, diabetes [4][6] liver disorder in developed countries.[1][2] A recent study mellitus (type II), and high blood pressure). NAFLD is using the National Health and Nutrition Examination a metabolic disorder originally assumed to be largely Survey (NHANES) found a 30% prevalence of NAFLD in confined to residents of affluent, industrialized Western

Vol. 3 No. 1 15 Bangladesh Journal of Hepatology countries4; however, obesity and insulin resistance, the Methods: common substrates of NAFLD, are not restricted to the It is a prospective study conducted in Sher e-Bangla west, as witnessed by their increasingly universal Medical College hospital Barishal during the time of 5 distribution . In particular, there has been an upsurge in 2013 to 2015. Sonographically proved fatty liver obesity-related metabolic syndrome in the Asia-Pacific disease patient were admitted into hospital or attended region, so that in countries such as China, Japan, Korea out patient department. Properhistory was taken and and probably India, rates of NAFLD are between 12% examined thoroughly. Particulars of the patients and 7 and 24% of the general population . There are critical information regarding ace, sex occupation, food habit. differences with respect to the extent of adiposity physical and labrotory findings were documented in a 8 between Eastern and Western populations . In light of previously formed Case record form and data were these differences, we provide an Asia-Pacific regional analysed statistically. perspective of risk factors and settings for NAFLD.Most Results: people with NAFLD have few or no symptoms. Patients may complain of fatigue, malaise, and dull A total number of 100 patients who came to the right-upper-quadrant abdominal discomfort. Mild SBMCH,Barisal during the period of July 2013 to jaundice may be noticed although this is rare. More Decembar 2013, were enrolled in this study. Of them commonly NAFLD is diagnosed following abnormal liver 100 patients with fatty liver diagnosed on the basis of function tests during routine blood tests. By definition, USG were considering as NAFLD group. The present alcohol consumption of over 20 g/day (about 25 ml/day study findings were discussed and compared with of net ethanol) excludes the condition.[4]NAFLD is previously published relevant studies. associated with insulin resistance and metabolic syndrome (obesity, combined hyperlipidemia, diabetes mellitus (type II), and high blood pressure).[4][6] Table I: Socio-demographic variable of the study population (n=100).

NAFLD Socio -demographic (n=100) Age (in years) n % ≤25 12 12.0 26-30 13 13.0 31-35 14 14.0 36-40 20 20.0 >40 41 41.0 Mean±SD 38.86 ±10.44 Range (min -max) (18 -70) Sex Male 33 33.0 Female 67 67.0 Occupation House wife 49 49.0 Service 33 33.0 Day laborer 8 8.0 Businessman 5 5.0 Others 5 5.0 Socio -economic status Lower* 30 30.0 Middle** 65 65.0 Upper*** 05 5.0

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* Taka <5000 per month; ** Take 5000-60,000 per 67(67.0%). Male female ratio was 0.49:1. Muslim month; *** Taka >60,000 per month (Ref. State of population was found in 85 (85.0%). Hindu population children of the world 2007, UNICEF)27 was found 15(15.0%). Majority population i.e. The above table shows population were included in this 49(49.0%) were housewives, followed by 33(33.0%) study were divided into five groups according to age. service holder. Population came from urban area were Majority of population belonged to >40 years in both more frequent in both groups 96% and 55% groups. The mean age was found 38.86±10.44 years respectively. Majority population came from middle with a range from 18 to 70 years. class socio-economic status 65%. Male was found 33(33.0%). Female was found

Table II: Distribution of the study population according waist circumference, BMI and Blood pressure (n=100).

Variables NAFLD (n=100) Waist circumference (cm) n % Normal 33 33.0 ≥90 (men) ≥80 (women) (abdominal obesity) 67 67.0 Mean±SD 87.84 ±9.74 Range (min -max) (34 -112) BMI (kg/m 2) <23 (normal) 10 10.0 23-25 (over weight) 32 32.0 >25 (Obesity) 58 58.0 Mean±SD 26.9 ±2.9 Range (min -max) (20.0 -32.8) Systolic BP (mmHg) ≥130 mmHg 60 60.0 ≥140 mmHg 20 20.0 Mean±SD 133.94 ±9.74 Range (min -max) (110 -150) Diastolic BP (mmHg) ≥85 mmHg 60 60.0 ≥90 mmHg 20 20.0 Mean±SD 83.45 ±5.76

The above table shows regarding the waist overweight (BMI 23-25). The mean systolic BP was circumference, the mean waist circumference was found 133.94±9.74 mmHg. The mean diastolic BP was found in 87.84±9.74 cm. found 83.45±5.76 mmHg. Regarding the BMI, the mean BMI was found 26.9±2.9 Discussion: 2 kg/m . Maximum 58(58.0%) population were obese Although early studies emphasized that NAFLD was (BMI >25) and 10(10.0%) population were normal more common in women,10] recent studies have shown weight (BMI <23) and 32(32.0%) population were

Vol. 3 No. 1 17 Bangladesh Journal of Hepatology that NAFLD has a more even distribution between men studies have highlighted the positive association and women, or may even be more prevalent among between carbohydrate intake and NAFLD occurrence men. NAFLD can be found in all age groups; however and severity, others have underlined the effect of the prevalence appears to increase with age. A study different types of fat. Until relatively recently, NAFLD conducted in 1977 using liver biopsy found that the was considered a benign condition. However, an prevalence of fatty liver in the general population was increasing number of studies has demonstrated that 1% in people below 20 years, 18% between 20 and 40 NAFLD can lead to long-term complications such as years, and 39% among 60 and older.11] Several cryptogenic cirrhosis and hepatocellular carcinoma, as subsequent studies using different methods to define well as increased liver-related mortality. Additionally, NAFLD have shown similar findings. In a several studies conducted over the last decade have population-based study in the United States, Browning indicated that NAFLD is, by itself and concurrent with et al found that individuals with MRS defined-NAFLD other liver disease, a risk factor for diabetes and were slightly older (46 versus 45 years old, p = 0.003) cardiovascular disease. than those with normal HT.1`2, Browning et al found Conclusion: that African Americans have significantly less HT In NASH, steatosis is accompanied by intralobular (median 3.2%) and hepatic steatosis (24%) than inflammation and hepatocyte injury, usually in the form non-Hispanic whites (HT median 3.6% and hepatic of ballooning. Ongoing hepatic damage in NASH can steatosis 33%) or Hispanics (HT median 4.6% and lead to fibrosis and cirrhosis in some cases [6]. hepatic steatosis 45%) even after adjusting for obesity However, which conditions drive the progress of NAFLD and diabetes.[12] In another study, Caldwell et al towards NASH is not yet fully understood. As liver observed that, although there was overrepresentation biopsy is mandatory for diagnosis of NASH, larger of African Americans among patients seen with major epidemiologic studies are challenging;owing to risk factors for NAFLD and other liver diseases, a increased prevalence and incidence of obesity and disproportionately small fraction of patients with NAFLD diabetes, in the next few years NFLD MAY PRESENT were African Americans.13 Worldwide, obesity remains THE principle cause of death due to liver disease and the most important and well-described risk factor for possibility the principal cause of liver transplant we NAFLD (Fig. [1]). The results of several cross-sectional suggest oto expand the number of prospective cohort studies and case-control studies have shown that study in general population even they are more people with NAFLD have higher waist circumference expensive and difficulty to handle. (WC) or BMI than those without NAFLD, and have reported significant associations between abdominal Refererences: obesity (OR = 1.10-1.13; 95% CI, 1.02-1.22 per 1-cm 1. Shaker, Mina, et al. "Liver transplantation for increase in WC) and NAFLD14 In the Dionysos study, nonalcoholic fatty liver disease: New challenges NAFLD was present in 94%, 67%, and 24.5% of the and new opportunities." World journal of obese, overweight, and normal weight populations, gastroenterology: WJG 20.18 (2014): 5320. 15 respectively. Several studies have reported that 2. Rinella ME (June 2015). "Nonalcoholic fatty liver patients with obstructive sleep apnea (OSA) have a disease: a systematic review". JAMA (Systematic higher prevalence of NAFLD. Epidemiologic studies review) 313 (22): 2263–73. showing familial aggregation of NAFLD and insulin doi:10.1001/jama.2015.5370. PMID resistance further support a genetic basis for 26057287.3. Ruhl, C. E., and J. E. Everhart. "Fatty 16]-17 NAFLD. Additionally, studies have found interethnic liver indices in the multiethnic United States variations in the prevalence of NAFLD and National Health and Nutrition Examination Survey." NAFLD-related "cryptogenic" cirrhosis, suggesting that Alimentary pharmacology & therapeutics 41.1 [18 susceptibility to NAFLD has a genetic component. The (2015): 65-76. results of epidemiologic studies have been inconsistent and it has been difficult to distinguish the effect of 4. Angulo, P, 2002, ‘Non-alcoholic fatty liver disease’, N different components of diet per se. Although some Engl J Med, vol. 346, pp.1221-1331.

18 Vol. 3 No. 1 Bangladesh Journal of Hepatology 5. Williams, R 2006, ‘Global challenges in liver disease’, 12. Browning JD, Szczepaniak LS,Dobbins R, et al. Hepatology, vol.44, pp.521–526. Prevalence of hepatic steatosis in an urban 6. cardiovascular disease: a meta-analysis’, Am. J. population in the United States: impact of ethnicity. Med, vol.119, pp.81216.Galassi, A, Reynolds, K, Hepatology 2004;40(6):1387–1395 He, J 2006, ‘Metabolic syndrome and risk of –19. 13 .Caldwell SH, Harris DM, Patrie JT, Hespenheide EE. 7. Wu, YF 2006, ‘Overweight and obesity in China. The Is NASH underdiagnosed among African once lean giant has a weight problem that is Americans? Am J Gastroenterol increasing rapidly’, BMJ, vol.19, pp.362–3. 2002;97(6):1496–1500. 8 Adams LA, Angulo P (2006). "Treatment of 14 .Bellentani S, Bedogni G, Miglioli L, Tiribelli C. The non‐alcoholic fatty lidisease".PosMed J 82 (967): epidemiology of fatty liver. Eur J Gastroenterol 315–22. doi:10.1136/pgmj.2005.042200. PMC Hepatol 2004;16(11):1087–1093. 2563793. PMID 16679470. 15. Browning JD, Kumar KS, Saboorian MH, Thiele DL. 9. Clark JM, Diehl AM (2003). "Nonalcoholic fatty liver Ethnic differences in the prevalence of cryptogenic disease: an underrecognized cause of cryptogenic cirrhosis. Am J Gastroenterol cirrhosis". JAMA 289 (22): 3000–4. 2004;99(2):292–298. doi:10.1001/jama.289.22.3000. PMID 12799409 16. Toshimitsu K, Matsuura B, Ohkubo I, et al. Dietary 10 .Sheth SG, Gordon FD, Chopra S. Nonalcoholic habits and nutrient intake in non-alcoholic steatohepatitis. Ann Intern Med steatohepatitis. Nutrition 2007;23(1):46–52. 1997;126(2):137–145 17. Hui JM, Kench JG, Chitturi S, et al. Long-term 11. Hilden M, Christoffersen P, Juhl E, Dalgaard JB. outcomes of cirrhosis in nonalcoholic Liver histology in a ''normal'' population: steatohepatitis compared with hepatitis C. examinations of 503 consecutive fatal traffic Hepatology 2003;38(2):420–427. casualties. Scand J Gastroenterol 1977;12(5):593–597

Vol. 3 No. 1 19 Bangladesh Journal of Hepatology

Upper gastrointestinal endoscopic findings in adults at Comilla Medical College & Hospital, Bangladesh Mohammad Forhad Abedin1, Mohammad Asaduzzaman Lashkar2, Mohammad Shah Jamal3, Mohammad Belalul Islam1, Mohammad Izazul Haque4, Mohammad Abdur Rob Sarkar3 1Department of Medicine, Comilla Medical College Hospital, Comilla, Bangladesh, 2Department of Cardiology, Comilla Medical College Hospital, Comilla, Bangladesh, 3Department of Gastroenterology, Comilla Medical College Hospital, Comilla, Bangladesh, 4Department of Hepatology, Comilla Medical College Hospital, Comilla, Bangladesh Corresponding author Dr. Mohammad Forhad Abedin Resident Physician (Medicine) Comilla Medical College Hospital, Comilla, Bangladesh, Email: [email protected] Abstract Background: Endoscopy is a nonsurgical procedure used to examine a patient’s gastrointestinal tract. Fiber optic endoscopy is a highly efficient diagnostic tool, which is now being increasingly used in the diagnosis of GI diseases. This study has been carried out to demonstrate indications for and common findings of endoscopy in adults aging 15 years and above. Methods: We retrospectively reviewed the medical records for endoscopy indication and result of adults who had endoscopy between June 2014 and May 2005. Results: We analyzed 1283 adult aged 15 years or above who were referred for upper gastrointestinal endoscopy. There were 731 male and 552 female cases. Highest numbers of participants were in the age group of 25-34 (24.6%). The main indications comprised dyspepsia (49.66%), epigastric pain (29.63%), abdominal pain (7.025), hematemesis (6.12%), recurrent vomiting (3.67%), abdominal distension (2.26%) and others (1.64%). Endoscopic diagnoses included duodenal ulcer (9.6%), gastric ulcer (4.9%), Oesophagealvarices (6.8%), gastritis (5.6%), gastropathy (3.2%), Ca- stomach (2.7%),ca-oesophagus (1.3%), oesophagitis (1.5%), duodenitis (0.7%), pyloric stenosis (0.7%) and others (1.8%). Conclusion: Upper gastrointestinal endoscopy is a diagnostic procedure in adults, which is increasingly used in government medical college hospitals to explore the upper GI pathologies i.e.- duodenal ulcer, gastric ulcer, ca- stomach and oesophagus, gastritis, gastropathy and oesophagealvarices.

Introduction: Departments of Gastroenterology and Hepatology, Upper gastrointestinal diseases are leading causes of Comilla Medical College Hospital from June 2014 to morbidity and mortality1, 2. Upper gastrointestinal May 2015. endoscopy (UGIE) has become a corner stone in the Objectives: diagnosis and treatment of many of gastrointestinal The objectives of the study were to determine the 3 disorders . The directvisualization of the entire demographic characteristics of adult who had upper GI oesophagus,stomach and duodenum with the facility endoscopy from June 2014 to May 2015 at Comilla toobtain material for analysis and to performvarious medical college & hospital as well as determine the therapeutic measures, make endoscopy superior to indications for upper GI endoscopy in the adults and 4, 5 other diagnosticprocedures . determine the prevalence of upper GI lesions in the Comilla medical college is the only government medical adults. college in Comilla district. This study was done in the

20 Vol. 3 No. 1 Bangladesh Journal of Hepatology Methods and procedures: fifteen years old and above are included in the study. Medical records of patients who underwent upper GI Cases with unclear medical records orthose with endoscopy in Comilla medical college hospital from missing values were excluded. The following data was June 2014 to May 2015 were retrospectively reviewed. collected from the patient: Age, Sex, Residences, Routine diagnostic and therapeutic endoscopies are Indication for the upper GI Endoscopy, Duration of carried out six days in a week in the Hospital. Symptoms, and Endoscopy findings. Data collected was Approximately 1000 patients undergo upper GI then analyzed using SPSS Version 17, result presented endoscopyper year. Gastrointestinal endoscopy at the in tables and Charts. hospital is under the department of gastroenterology, Results: and is performed by Gastroenterologist and A total of 1283 patients underwent upper GI endoscopy hepatologist with training and experience in endoscopy. during the period (June 2014 to May 201) were Under topical lidocaine, a Pentax FG-29W fiberoptic included in the study. Among the patient 56.9% were Upper GI scope is passed through the mouth of a male & 43.1% were female. Highest number of the patient in left lateral position through the patients (24.6%) underwent endoscopy at the age upperoesophageal sphincter into the oesophagus range between 25 to 34 years. stomach and duodenum (upper gut). Cases which were Table I: Age range and sex distribution

Age Sex Total range Male Female No Percent (%) No Percent (%) No Percent (%) 15-24 85 6.6 66 5.1 151 11.8 25-34 177 13.8 139 10.8 316 24.6 35-44 122 9.4 121 9.4 243 18.8 45-54 127 9.9 89 6.9 216 16.8 55-64 116 9.0 93 7.3 209 16.3 65-74 73 5.7 28 2.2 101 7.9 75-84 27 2.1 13 1.0 40 3.1 85-94 2 0.2 2 0.2 4 0.3 95-104 2 0.2 1 0.1 3 0.2 Total 731 56.9 552 43.1 1283 100.0 The three commonest indications for upper GI (7.02%).Miscellaneous causes included haematemesis endoscopy in adults were dyspepsia (49.66%), (6.12%), vomiting (3.67%), and abdominal distension epigastric pain (29.63%), and abdominal pain (2.26%).

Table II: Indications for endoscopy

Indication No of case Percent (%) Dyspepsia 637 49.66 Epigastric pain 380 29.63 Abdominal pain 90 7.02 Haematemesis 79 6.12 Vomiting 47 3.67 Abdominal distension 29 2.26 Others 21 1.64

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Approximately 61.2% of the upper GI endoscopy done (4.9%), Oesophageal varices were 6.8%.Among two in adults was negative. Of the 38.8% positive malignancies Ca-stomach(2.7%) was more prevalent endoscopies, duodenal ulcer were the most common than Ca-oesophagus (1.3%). 9.6%, followed by gastritis (5.6%) and gastric ulcer

Figure 1: Percentage of endoscopic findings

Duodenal ulcers (26.83%) were more prevalent at the Ca-oesophagus (47.06%) were occurred at the age 55 age range 55 to 64 years, whereas gastric ulcers were to 64 years. More Oesophageal varices (26.44%) were more prevalent relatively earlier age at 45 to 54 years. seen at the age 45 to 55 years. Highest prevalence of Ca-stomach (31.43%) &

Table III: Prevalence of endoscopic findings by age range

Endoscopic finding Highest prevalence Age range No Percentage (%) Normal 221 28.15 25-34 Pyloric stenosis 3 33.33 65-74 Duodenitis 4 44.44 25-34 Duodenal ulcer 33 26.83 55-64 Gastric ulcer 17 26.98 45-54 Ca - stomach 11 31.43 55-64 Ca - oesophagus 8 47.06 55-64 Gastropathy 15 36.59 25-34 Gastritis 15 20.83 25-34 Oesophagealvarices 23 26.44 45-55 Oesophagitis 6 31.58 55-64 Others 6 25.0 45-54 All the endoscopic positive findings are more in male than female except gastritis which is more in female than male.

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Figure 3: Prevalence of the findings according to sex

Discussion: so did Danbauchi et al, Aduful et al, Nkrumah et al, Gastrointestinal diseases affect adults worldwide and in Khurram in Pakistan, Onyekwere et al in Lagos and 8,17,16 18 patients with digestive complaints, endoscopy is the Cooper in USA . A study from India reported gold standard and often the primary exploration5. dyspepsia in 59%of patients undergoing OGD. Comilla medical college is the only government facility In our study normal Endoscopy was reported in 61.2% centre in Comilla district where endoscopic procedure (n=785), more common in males 51% (n=400) as can be done; beside these some private hospital also compared to females 49% (n=385), which is not have the facility for endoscopic procedure. consistent with the result of study by Khalid Mahmud et 12 In this study, there were more males 56.9% than al , showing more female preponderance (31.2% females 43.1%; similar to findings in majority of other females vs. 28.6% males). Rate of negative Endoscopy countries, probably because Upper GI tract diseases (61.2%) in our study was higher as compared to are more prevalent in males6, 7, 8, 9, 10. A study conducted reported rates in the study of Muhammad et al from 11 at Multan by Muhammad Innayatullah et al.11 shows Multan and was higher as compared to negative 12 12 more of male preponderance (50.6 % Males Vs. 49.4 Endoscopy 30% , as reported by Khalid Muhammad . 19 % Females). In the study conducted at Peshawar12 had This observation was also reportedby Shahetal . Strict an almost equal number of males and females, selection criteria required to reduce this rate will result however Nkrumah et al in Saudi Arabia and Khurram et in missing significant pathology in large number of al in Pakistan13, 14 noticed more females as compared to patients. males in their studies, probably more females are being The overall frequency of duodenal ulcer in the studied referred in the centers for endoscopy. population was 9.6% as compared to gastric ulcer The age pattern is closely similar to those of other which was 4.9% in our study, is concordance with the studies with very few presenting before the age of published by Khalid Muhammad et al12in which overall 20years, peaking in the 25 to 54 years, probably frequency of duodenal ulcer with that of gastric ulcer because Upper GI tract diseases are prevalent in the was 8.1% versus 3.7%. older population age group7, 9, 15. Gastric carcinoma was reported in 2.7 %(n=35) similar We noticed dyspepsia in (49.66%), being commonest to percentage of gastric carcinoma reported by indication for Upper GI Endoscopy in our study. This is Emmanuel jeje et al and esophageal carcinoma in similar to Malu et al (78.1 %) in their study at Zaria and 1.3% (n=17), which is less as compared to Emmanuel jeje et al which is 1.7%. Our findings were significantly

Vol. 3 No. 1 23 Bangladesh Journal of Hepatology high as compared to the percentage (1.17%) as 10. Aduful H, Naaeder S, Darko R, Baako B, reported by Khalid Muhammad12 and Muhammad Clegg-Lamptey J, Nkrumah K, et al. Upper Inayatullah et al11. gastrointestinal endoscopy at the korlebu teaching Conclusion: hospital, accra, ghana. Ghana Med J. 2007; 41(1): 12-6. Endoscopy is a very important investigative modality to identify the specific pathology in patients of Dyspepsia, 11. Muhammad Inayatullah, Zahra Nazish Muhammad Gastritis, Oesophagitis, Duodenitis, Duodenal ulcer, Saleem Akhtar, Abdul Hameed Anjum, Altaf Baqir Gastric ulcer, Gastric carcinomas and esophageal Naqvi. Dyspepsia and Upper Gastrointestinal malignancies were as the commonest endoscopic Endoscopy Professional Med J Mar diagnostic findings. Strict selection criteria required to 2008;15(1);143-147 reduce this rate will result in missing significant 12. Khalid Mahmood, Mohammad IlyasSaeedi, Riaz pathology in large number of patients. Mohammad, Zia ud Din upper gastrointestinal References: endoscopic findings in patients with dyspepsia jpmi 2006 vol.20 no:70-73 1. Spiller R. ABC of the upper gastrointestinaltract (Clinical Review). Anorexia, nausea,vomiting and 13. Nkrumah KN. Endoscopic evaluation of upper pain. BMJ 2001; 323: 1354-1357. abdominal symptoms in adult patients, Saudi Aramco-Ai Hasa Health Center, Saudi Arabia.West 2. Kolk H. Evaluation of symptom presentationin African Journal of Medicine. 2002; 21(1): 1-4. dyspeptic patients referred for uppergastrointestinal endoscopy in Estonia. 14. Khurram M, Khaar HT, Hasan Z, Umar M, Javed S, CroatMed J 2004; 45(5): 592-8. Asghar T, et al. A 12 years audit of upper gastrointestinal endoscopic procedures.Journal of 3. Editorial. Endoscopy in general practice. BMJ1995; the College of Physicians and Surgeons--Pakistan: 310: 816-817. JCPSP. 2003; 13(6): 321-4 4. Axon ATR, Bell GD, Jones RH, et al.Guidelines on 15. Onyekwere CA, Hameed H, Anomneze EE, appropriate gastrointestinal endoscopy. BMJ Chibututu C. Upper gastrointestinal endoscopy 1995; 310: 853-856. findings in Nigerians: a review of 170 cases in 5. Agbakwuru EA, Fatusi AO, Ndububa DA, etal. Pattern Lagos. The Nigerian Postgraduate Medical Journal. and validity of clinical diagnosis ofupper 2008; 15(2): 126-9. gastrointestinal diseases in south-west 16. Emmanuel Jeje Thomas Olajide, Bashir Akande Nigeria. Afr Health Sci 2006; 6(2): 98-103. Upper Gastrointestinal Endoscopy - Our Findings, 6. Olokoba AB, Bojuwoye BJ. Indications for Our Experience in Lagoon Hospital, Lagos, Nigeria oesophagogastroduodenoscopy in Ilorin, Macedonian Journal of Medical Sciences. 2013 Nigeria--a 30 month review. Nigerian Journal of June 1; 6(2):168-173 clinical Practice. 2010; 13(3): 260-3. 17. Cooper GS. Indications and contraindications for 7. Agbakwuru EA, Fatusi AO, Ndububa DA et al. Pattern upper gastrointestinal endoscopy.Gastrointestinal and validity of clinical diagnosis of upper Endoscopy Clinics of North America. 1994; 4(3): gastrointestinal diseases in south-west Nigeria. Afr 439-54. Health Sci. 2006; 6(2): 98-103. 18. Katelaris OH, Tippet GH, Norbu P, Lowe DG, Br e n n 8. Malu AO, Wali SS, Kazmi R, Macauley D, Fakunle a n R, F a t h i n g MJ Dyspepsia, Helicobacter YM.Upper gastrointestinal endoscopy in Zaria, pylori and peptic ulcer in a randomly selected northern Nigeria.West African Journal of Medicine. population in India. Gut 1992; 33: 1462-6. 1990; 9(4): 279-84. 19. Shah NH, Shah MS, Khan I, Hameed K An audit of 9. Danbauchi SS, Keshinro IB, Abdu-Gusau K. Fifteen diagnostic upper GI endoscopic and comparison of years of upper gastrointestinal endoscopy in Zaria booked vesus open access cases JCPSP (1978 - 1993). African journal of medicine and 1999;9(4);174 medical sciences. 1999; 28(1-2): 87-90.

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Review Articles Hepatic hydrothorax: Challenge for Hepatologist Syed Abul Foez1, Mohammad Abdur Rahim2, Sheikh Mohammad Noor-E-Alam3, Mohammad Ashraful Alam4, AKM Shoab1, Swapan Kumar Singha1, Joy Vargese5, Chandan Kumar5, Mamun-Al-Mahtab6, Salimur Rahman6, Ziaur Rahman Chowdhury7 1Department of Medicine, 250 Beded Hospital, Moulvibazar, Bangladesh, 2MATS, Noakhali, Bangladesh, 3Department of Hepatology, Shaheed Suhrawardhy Medical College Hospital, Dhaka, Bangladesh, 4Department of Hepatology, Cox’s Bazar Medical College, Cox's Bazar, Bangladesh, 5Institute of Liver Diseases & Transplantation, Global Health City, Chennai, India, 6Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 7Department of Paediatrics, 250 Beded Hospital, Moulvibazar, Bangladesh. Corresponding author Dr. Syed Abul Foez Resident Physician (Medicine) 250 Beded Hospital, Moulvibazar, Bangladesh. E-mail: Abstract Hepatic hydrothorax is an example of porous diaphragmatic syndrome which results from portal hypertension in patient with end stage liver disease. Commonly seen in conjunction with ascites, but isolated hydrothorax may also occur. Liver transplantation is the ultimate treatment of choice. Other management options may serve as a bridge to transplantation.

Introduction: Pathophysiology: Hepatic hydrothorax may be defined as a pleural Not fully elucidated so far. More than one mechanism effusion associated with portal hypertension without may coexist [2]. any cardiac, pulmonary and pleural disease. This Most of the studies suggested that transfer of “porous diaphragmatic syndrome” is not a common peritoneal fluid into the pleural space via diaphragmatic complication of end-stage liver disease (ESLD) [1]. defects is the predominant mechanism. Others are- There is no large randomized-controlled trial azygous vein hypertension, passage of fluid from establishing the best treatment options and other peritoneal to the pleural space via transdiaphragamtic management strategies [2]. HH thus represents a lymphatics, lymphatic leakage from the thoracic duct, formidable entity in the management of end-stage liver hypoalbuminemia resulting in decreased colloid disease [3]. This clinical review focuses on the recent osmotic pressure also play role [10]. developments in the pathogenesis as well as the Recently, these diaphragmatic defects associated with management strategies. the development of hydrothorax have been classified Incidence: into four morphologic types [11]: Occur in 4–6% of patients with cirrhosis in studies that Type 1: No obvious defect used chest x-ray to diagnose pleural effusion [4]. Type 2: Blebs lying in the diaphragm However, in a series of 862 cirrhotic patients from China that used ultrasonography to detect pleural Type 3: Fenestrations in the diaphragm effusion, the incidence was found to be 15% [5-8]. Type 4: Multiple gaps in the diaphragm Right-sided in majority (65–87 %), is left-sided in Discontinuties or gaps in the collagen bundles that 13–17 %, and could be bilateral in 3 % of cases [9]. make up the tendinous portion of the diaphragm.

Vol. 3 No. 1 25 Bangladesh Journal of Hepatology Ascites raises the intra-abdominal pressure and tends mycobacterium, amylase, and cytology to exclude to stretch the diaphragm; thereby, creating or enlarging chylothorax, empyema, tuberculosis, pancreatitis, and these microscopic defects 12]. Herniation of malignancy respectively. Characteristics of pleural fluid peritoneum through these gaps in the pleural cavity in an uncomplicated HH are [20, 21]: leads to the formation of pleuro-peritoneal blebs • Cell count < 500 cells/mm3 (typically < 1 cm). Due to increasing intra-abdominal • Polymorphonuclear count < 250 cells/mm3 pressure these blebs tend to rupture. • Total protein < 2.5 g/dl The negative intrapleural pressure facilitates the one-way transfer of fluid [13]. Blebs tend to occur more • Serum to pleural fluid albumin gradient (SPAG) commonly in the right hemidiaphragm which may be >1.1 g/dl related to embryonic development; the left • Pleural fluid to serum total protein ratio <0.5 hemidiaphragm is more muscular, thicker and relatively • Pleural fluid LDH/serum LDH < 0.6 resistant to blebs formation. • Pleural fluid/serum bilirubin < 0.6 The negative intrathoracic pressure coupled with the increased intra abdominal pressure in the background • Glucose level similar to that of serum of diaphragmatic thinning due to chronic malnutrition • Pleural fluid amylase concentration < serum further form a gradient favoring cephalad transfer of amylase concentration fluid across these defects, possibly with a valvular • pH >7.4 mechanism [1] CT scan of the chest will exclude mediastinal, Clinical features: pulmonary or pleural lesions or malignancies. HH should be suspected in a patient of established Echocardiography and BNP should also be performed cirrhosis and portal hypertension, presenting with to evaluate cardiac function in proper clinical setting pleural effusion [1]. Clinical features depends on [1]. Demonstration of a peritoneal-pleural volume of the pleural fluid, the rapidity of accumulation communication by scintigraphy, contrast-enhanced of fluid and the presence of associated ultrasonography, MRI, or thoracoscopy is not necessary cardiopulmonary disease. Patients may be in clinical practice unless surgical repair is being asymptomatic or may present with dyspnea, cough, or contemplated [16, 17]. hypoxemia with or without ascites. Rarely acute tension SBEM/ SBPL: hydrothorax leading to respiratory failure due to sudden Spontaneous bacterial empyema (SBEM) may be rupture of a large pleuroperitoneal bleb [14, 15]. defined as bacterial colonization of a pre-existing sterile Diagnosis: hydrothorax without any concomitant pneumonia A diagnostic thoracentesis and chest radiograph should [22].The term SBEM itself is an oxymoron, implying that be performed in all patients with suspected HH [18]. In there is actually no pus or abscess in the pleural space. a cohort of cirrhosis patients 70% of pleural effusions Spontaneous bacterial pleuritus (SBPL) is a more were due to uncomplicated HH, 15% were due to appropriate term. SBPL develops in 10%-16% of infected HH, and 15% were due to causes other than cirrhosis patients with HH. It must be considered in any liver disease [4]. In another study 80% of right-sided patient with HH who develops fever, pleuritic pain, pleural effusions were found to be uncomplicated HH, encephalopathy or unexplained deterioration in renal while only 35% of left-sided pleural effusions were function [3]. Dignostic criteria of SBPL [22]: uncomplicated HH [19]. • PMN >250 cells/mm3 and positive pleural Pleural fluid analysis should include total and fluid culture OR differential cell count, Gram stain and culture, serum • PMN >500 cells/mm3 and negative pleural and fluid protein, albumin, LDH, ADA and bilirubin [12]. fluid culture AND Other tests depending on the appropriate clinical • Absence of pneumonia or contiguous infection circumstances include triglyceride, pleural pH, PCR for on chest imaging

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Pathogenesis remains speculative. Direct bacterial fashion: spironolactone up to 400 mg/day and spread from the peritoneal cavity or transient furosemide up to 160 mg/day every 3–5 bacteremia infecting the pleural space may be the days [1]. mechanism [23]. However, nearly 40% of episodes • Other investigational agents: terlipressin, were not associated with SBP. Escherichia coli, octreotide and midodrine. But there is not Streptococcus species, Enterococcus, and Klebsiella enough evidence to recommend routine use species are the usual pathogens [25]. Risk factors Refractory hydrothorax: includes low pleural fluid C3, low serum albumin, low pleural fluid total protein (<1.5 g/dL), high Child-Pugh Persistent hydrothorax despite fluid and sodium score/MELD and SBP [24]. restriction and use of maximal tolerable doses of diuretics. It is found in approximately 25% of cases Third-generation cephalosporins are the drug of choice [24]. Treatment options are [29]: (IV cefotaxime 2gm Q8h for 7-10 days). Carbapenems should be the treatment of choice in high-risk patients • Repeated thoracentesis ± Paracentesis with nosocomial episodes, diabetes and patients • Transjigular intrahepatic portosystemic treated with cephalosporin within the previous 3 shunt (TIPS) months [26]. Albumin therapy: 1.5 g/kg on day 1 and • Indwelling pleural catheter (IPC) 1.0 g/kg on day 3 may improve outcome. Lifelong antibacterial prophylaxis is recommended. Selective • Pleurodesis ± Contineous positive airway intestinal decontamination with norfloxacine appears to pressure (CPAP) be effective. Chest tube placement is contraindicated • Surgical repair of diaphragmatic by video except in case of frank pus or pH < 7.1 plus pleural assisted thoracoscopic surgery (VATS)/ fluid glucose < 40 mg/dl. An episode of SBPL warrants medical thoracoscopy (MT) ± Pleurodesis evaluation for LT [1]. Mortality associated with an • Liver transplantation (LT) episode of SBPL is 20% Thoracentesis ± Paracentesis: Management: Therapeutic thoracocentesis is a simple, effective, safe Immediate goal: relief of symptoms and prevention of and well-tolerated procedure for immediate relief of pulmonary complications and infections [3] symptoms. Paracentesis should be attempted prior to Cardinal aspect: prompt evaluation for liver thoracentesis to prevent the rapid accumulation of fluid transplantation [27] in the pleural space after thoracentesis. There is no There are three aspects of management: consensus for the maximal volume of pleural fluid to be drained in a single thoracentesis. It has been postulated • Pharmacologic/Medical that ≥ 2L of fluid should be removed so as to minimize • Radiological intervention the risk of hypotension or re-expansion of pulmonary • Surgical approach edema [30]. It is not advocated as a maintenance therapy in patients requiring more frequent Medical management: thoracentesis (>1in every 2 weeks) [7]. Chest tube • Aim: to induce and maintain a net negative insertions should be avoided at all costs [31]. sodium balance TIPS: • Restrict dietary sodium: upto 2,000 mg/day Should be considered as a bridge to transplant and only (88 mEq/day) [28] in carefully selected group such as age < 65 years, • Diuretics: typically furosemide 40 mg/day bilirubin < 3 mg/dL, absence of encephalopathy, CTP B and spironolactone 100 mg/day to produce and MELD<17 [32-34]. 40–50% reduction of the initial a renal excretion of sodium of at least HVPG should provide the optimal outcome of resolution 120mEq/day [28]. The doses may be of hydrothorax avoiding significant hepatic increased simultaneously in a stepwise encephalopathy [35].

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IPC (Pigtail): challenging and frequently associated with poor Indwelling pleural catheter (IPC) is emerging as a outcomes. Liver transplantation remains the definitive feasible alternative in patients with frequent therapeutic treatment of choice. Recurrent thoracocentesis, TIPS, thoracentesis, TIPS is contraindicated and awaiting for IPC, pleurodesis and VATS/MT advocated as a bridge to liver transplantation [36]. Small bore pigtail is safe, less transplantation. invasive, well tolerated and little chance of References: complications. 1. Krok KL, Cardenas A. Hepatic hydrothorax. Semin Pleurodosis ± CPAP: Respir Crit Care Med. 2012;33(1):3–10. Because of moderate degree of complications (fever, 2. Roussos A, Philippou N, Mantzaris GJ, et al. Hepatic chest pain, empyema, incomplete re-expansion, hydrothorax: pathophysiology diagnosis and pneumonia, wound infection) pleurodosis typically management. J Gastroenterol Hepatol. reserved for patients in whom no other options exist 2007;22(9):1388–93. [38]. CPAP appears effective in keeping the pleural 3. Cardenas A, Kelleher T, Chopra S. Review article: cavity dry after chemical pleurodesis [40]. CPAP will hepatic hydrothorax. Aliment Pharmacol Ther. reverse the peritoneal-pleural pressure gradient and 2004;20(3):271–9. thus prevent the shift of fluid form the peritoneal to the 4. Chen TA, Lo GH, Lai KH. Risk factors for spontaneous pleural space [37]. bacterial empyema in cirrhotic patients with VATS/MT: hydrothorax. J Chin Med Assoc. VATS considered a palliative alternative in patients 2003;66(10):579–86. requiring frequent thoracentesis [39]. It is also done as 5. Ladero JM. Recurring hepatic hydrothorax: a difficult an alternative to TIPS and used as a bridge to liver therapeutic challenge. Rev Esp Enferm Dig. transplantation. Medical thoracoscopy (MT) is a 2001;93(9):561–5. minimally invasive that may be used in complicated 6. Gur C, Ilan Y, Shibolet O. Hepatic hepatic hydrothorax (thorasic empyema) [41]. hydrothorax—pathophysiology, diagnosis and Administration of sclerosing agents for pleurodosis or treatment—review of the literature. Liver Int. repair of diaphragmatic defects are reported by these 2004;24(4):281–4. procedure [42-44]. 7. Garcia N Jr, Mihas AA. Hepatic hydrothorax: Liver transplantation: pathophysiology, diagnosis, and management. J It is the best definitive treatment. Indicated in refractory Clin Gastroenterol. 2004;38(1):52–8. hydrothorax, MELD >15 and after an episode of SBPL 8. Alagiakrishnan K, Patel PJ. Left-sided hepatic [18]. Presence of preoperative hepatic hydrothorax hydrothorax with ascites. Int J Clin Pract. does not have a significant negative influence on 1999;53(3):225–6. postoperative survival [45]. But uncontrollable hydrothorax is independent risk factors for the 9. Gurung P, Goldblatt M, Huggins JT, et al. Pleural fluid postoperative prognosis [46]. analysis and radiographic, sonographic, and echocardiographic characteristics of hepatic Prognosis: hydrothorax. Chest. 2011;140(2):448–53. Survival is limited. In one study median survival was 10. Zenda T, Miyamoto S, Murata S, et al. Detection of found 9.1 months [47]. But it is favorably affected by diaphragmatic defect as the cause of severe liver transplantation. hepatic hydrothorax with magnetic resonance Summary: imaging. Am J Gastroenterol. Hepatic hydrothorax is an infrequent but an important 1998;93(11):2288–9. complication of portal hypertension. Diagnosis involves 11. Huang PM, Chang YL, Yang CY, et al. The a high index of suspicion in a cirrhotic patient who morphology of diaphragmatic defects in hepatic presents with pleural effusion. Management is hydrothorax: thoracoscopic finding. J Thorac

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Cardiovasc Surg. 2005;130(1):141–5. 25. Chen CH, Shih CM, Chou JW, et al. Outcome 12. Lazaridis KN, Frank JW, Krowka MJ, et al. Hepatic predictors of cirrhotic patients with spontaneous hydrothorax: pathogenesis, diagnosis, and bacterial empyema. Liver Int. 2011;31(3):417–24. management. Am J Med. 1999;107(3):262–7. 26. Tu CY, Chen CH. Spontaneous bacterial empyema. 13. Strauss RM, Boyer TD. Hepatic hydrothorax. Semin Curr Opin Pulm Med. 2012;18(4):355–8. Liver Dis.1997;17(3):227–32. 27. Gines P, Cardenas A, Arroyo V, et al. Management of 14. Kaplan LM, Epstein SK, Schwartz SL, et al. Clinical, cirrhosis and ascites. N Engl J Med. echocardiographic, and hemodynamic evidence of 2004;350(16):1646–54. cardiac tamponade caused by large pleural 28. Runyon BA. Management of adult patients with effusions. Am J Respir Crit Care Med.1995;151(3 ascites due to cirrhosis: an update. Hepatology. Pt 1):904–8. 2009;49(6):2087–107. 15. Castellote J, Gornals J, Lopez C, et al. Acute tension 29. Kiafar C, Gilani N. Hepatic hydrothorax: current hydrothorax: a life-threatening complication of concepts of pathophysiology and treatment cirrhosis. J Clin Gastroenterol. 2002;34(5):588–9. options. Ann Hepatol. 2008; 7(4):313–20. 16. Foschi FG, Piscaglia F, Pompili M, et al. Real-time 30. Sherman SC. Reexpansion pulmonary edema: a contrastenhanced ultrasound—a new simple tool case report and review of the current literature. J for detection of peritoneal-pleural communications Emerg Med. 2003;24(1):23–7. in hepatic hydrothorax. Ultraschall Med. 31. Orman ES, Lok AS. Outcomes of patients with chest 2008;29(5):538–42. tube insertion for hepatic hydrothorax. Hepatol Int. 17. Nakamura A, Kojima Y, Ohmi H, et al. 2009;3(4):582–6. Peritoneal–pleural communications in hepatic 32. Spencer EB, Cohen DT, Darcy MD. Safety and hydrothorax demonstrated by thoracoscopy. Chest. efficacy of transjugular intrahepatic portosystemic 1996;109(2):579–81. shunt creation for the treatment of hepatic 18. Alonso JC. Pleural effusion in liver disease. Semin hydrothorax. J Vasc Interv Radiol. 2002;13(4): Respir Crit Care Med. 2010;31(6):698–705. 385–90. 19. Castellote J, Xiol X, Cortes-Beut R, et al. 33. Salerno F, Merli M, Cazzaniga M, et al. MELD score Complications of thoracentesis in cirrhotic patients is better than Child–Pugh score in predicting with pleural effusion. Rev Esp Enferm Dig. 3-month survival of patients undergoing 2001;93(9):566–75. transjugular intrahepatic portosystemic shunt. J 20. Xiol X, Castellote J, Cortes-Beut R, et al. Usefulness Hepatol. 2002;36(4):494–500. and complications of thoracentesis in cirrhotic 34. Wilputte JY, Goffette P, Zech F, et al. The outcome patients. Am J Med. 2001;111(1):67–9. after transjugular intrahepatic portosystemic shunt 21. Light RW. Diagnostic principles in pleural disease. (TIPS) for hepatic hydrothorax is closely related to Eur Respir J. 1997;10(2):476–81. liver dysfunction: a long-term study in 28 patients. Acta Gastroenterol Belg. 2007;70(1):6–10. 22. Xiol X, Castellote J, Baliellas C, et al. Spontaneous bacterial empyema in cirrhotic patients: analysis of 35.Dhanasekaran R, West JK, Gonzales PC, et al. eleven cases. Hepatology. 1990;11(3):365–70. Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in 23. AbbaAA, LaajamMA, Zargar SA. Spontaneous patients with cirrhosis. Am J Gastroenterol. neutrocytic hepatic hydrothorax without ascites. 2010;105(3):635–41. Respir Med. 1996;90(10):631–4. 36. Milanez de Campos JR, Filho LO, de Campos 24. Sese E, Xiol X, Castellote J, et al. Low complement Werebe E, et al. Thoracoscopy and talc poudrage in levels and opsonic activity in hepatic hydrothorax: the management of hepatic hydrothorax. Chest. its relationship with spontaneous bacterial 2000;118(1):13–7. empyema. J Clin Gastroenterol. 2003;36(1):75–7.

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37. Takayama T, Kurokawa Y, Kaiwa Y, et al. A new 42. Medford AR, Bennett JA, Free CM, et al. Current technique of thoracoscopic pleurodesis for status of medical pleuroscopy. Clin Chest Med. refractory hepatic hydrothorax. Surg Endosc. 2010;31(1):165–72. 2004;18(1):140–3. 43. Shaw P, Agarwal R. Pleurodesis for malignant 38. Ferrante D, Arguedas MR, Cerfolio RJ, et al. pleural effusions. Cochrane Database Syst Rev. Video-assisted thoracoscopic surgery with talc 2004;1:CD002916. pleurodesis in the management of symptomatic 44. Lin DJ, Zhang M, Gao GX, et al. Thoracoscopy for hepatic hydrothorax. Am J Gastroenterol. 2002; diagnosis and management of refractory hepatic 97(12):3172–5. hydrothorax. Chin Med J (Engl). 39. Northup PG, Harmon RC, Pruett TL, et al. 2006;119(5):430–4. Mechanical pleurodesis aided by peritoneal 45. Serste T, Moreno C, Francoz C, et al. The impact of drainage: procedure for hepatic hydrothorax. Ann preoperative hepatic hydrothorax on the outcome Thorac Surg. 2009;87(1):245–50. of adult liver transplantation. Eur J Gastroenterol 40. Drouhin F, Fischer D, Law Koune JD, et al. Hepatol. 2010;22(2):207–12. Treatment of hydrothorax in liver cirrhosis with 46. Xiol X, Tremosa G, Castellote J, et al. Liver chemical pleurodesis associated with continuous transplantation in patients with hepatic positive airway pressure ventilation. Preliminary hydrothorax. Transpl Int. 2005;18(6):672–5. results. Gastroenterol Clin Biol. 1991;15(3):271–2. 47. Porcel JM1, Mas E, Reñé JM, Bielsa S. Hepatic 41. Lee WJ, Kim HJ, Park JH, et al. Chemical hydrothorax: report of a series of 77 patients. Med pleurodesis for the management of refractory Clin (Barc). 2013;141(11):484-6 hepatic hydrothorax in patients with decompensated liver cirrhosis. Korean J Hepatol. 2011;17(4): 292–8.

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Brief Review

Current strategies in the management of hepatocellular carcinoma Premashish Kar, Department of Gastroenterology & Hepatology, Max Superspeciality Hospital, New Delhi, India Corresponding author Dr. Premashis Kar Retd Director and Professor of Medicine Maulana Azad Medical College, Dipu Bharali E-mail:

Introduction: (HBV)/Hepatitis C virus (HCV) infection which increases Hepatocellular carcinoma (HCC) is considered to be the the risk of HCC. HBV infection, HBV infection with 5th commonest cancer and also considered an Aflatoxin exposure, viral infection and alcohol important cause of death all over the world, more so in consumption leading to overt cirrhosis of the liver, Asia and Africa (1). The regions with hepatitis B and C alcohol consumption leading to cirrhosis of the liver virus infection are considered to be endemic areas and with viral infection are the predominant risk factor for are considered to be more prone to HCC where in those the development of HCC. HCV and alcohol are also areas HCC is extremely common (2). India belongs to an associated with HCC in India. Indians develop diabetes endemic zone for hepatitis B virus infection but the at younger age, Asians have strong genetic representative data on epidemiology of HCC in India is susceptibility for type II diabetes. Diabetes mellitus is very scanty. The cancer registries in India are mostly identified as a risk factor for HCC. Prevention of viral urban (3). Etiology: infection by universal vaccination against hepatitis virus, HCC surveillance program, preventing alcoholic The Comprehensive analyzed data for HCC occurrence liver diseases, fungal contamination of grains and in India has not been established yet. HCC occurs in the ground crops to prevent basically Aflatoxin exposure age range of 40- 55 years and above 60 years in India are important measures to prevent liver diseases and (3, 4). Eighty per cent of all HCCs occurring in India HCC among those at risk. In India, 70% to 80% of all occur with cirrhosis of liver in the background and 60% HCCs are related to the hepatitis B virus (HBV), of all these cases are hepatitis B positive carriers (5, 6). approximately 15% are related to hepatitis C virus The estimated number of cases as well as mo1iality per (HCV), and 5% to both HBV and HCV (3). Alcohol alone year in India is approximately close to 22,000 has been accounts for approximately 8% of all HCCs. In about suggested (3). 45 million people who are suffering from 10%, no direct etiology is seen. Iron overload and chronic Hepatitis B virus (HBV) infection and Aflatoxin may have a role to play in some geographical approximately 15 million people who are afflicted with areas in India (3, 6). The prevalence of hepatitis Bin chronic Hepatitis C virus (HCV) infection in India (7). India varies between 0.2 to 1.6 per 100,000; 2.77 for HBV and HCV infection is considered an important males and 1.38 for females. This relative low etiologic factor in HCC. Positive association between prevalence is due to an under-reporting of the disease, HCC and consumption of alcohol where alcohol thus India erroneously falls in the low incidence zone (3, contribute as a cofactor for hepatotoxins and hepatitis 8). The under-reporting of HCC is possibly due to viruses (7). Aflatoxin contamination in the diets, non-surveillance of chronic hepatitis B patients and Hepatitis B virus infection and liver cirrhosis in Andhra carriers, and cirrhotic patients (3, 8). This also attributes Pradesh, India and direct chronic exposure to aflatoxins to majority of cases being diagnosed at a late stage of was shown to cause liver cirrhosis. Cirrhosis of liver of the disease. The majority of patients with a viral etiology any cause lead to develop about 70%-90% of HCC. have a silent course, picked up by foeto-matemal Aflatoxin interacts synergistically with Hepatitis B virus transfusion.

Vol. 3 No. 1 31 Bangladesh Journal of Hepatology Clinical features: factors are cost, availability and patients' ability to The mean age of presentation of HCC was found in withstand (6). Radio frequency ablation (RFA) is higher age groups peaking around 45 to 55 years (5, 9). available in very few centers while RFA may have Hepatitis B positive patients in the age group below 14 similar results as hepatic resection in properly selected years were described to be present of HCC occurrence cases (6, 14). Use of trans-arterial chemoembolization (10). The duration of symptoms of HCC was usually (TACE) or RFA is available in some centers, but these detected from five months to almost a year of are extremely small in number. No organized data is occurrence. 90% of patients were symptomatic at available. Counseling and discussion of HCC with diagnosis and 15% of these patients were diagnosed experts might encourage in awareness of the HCC after one year of symptoms. The clinical presentations disease management and treatment in certain early commonly seen are anorexia, fever (11). Worldwide cases (4, 6). distribution of HCC is predominated by males compared There is no established standard chemotherapy for to females in the ratio of 5:1 (6). 10% to 15% cases are HCC for advanced HCC although sporadic use of found to have liver cirrhosis found during diagnosis. Out doxorubicin, interferon and thalidomide is available but of 70% of the total patient population was with liver not organized systematically and practically. There are cirrhosis in which 60% were found to be developed to options of targeted therapy for HCC. The drug HCC. 50% cases were found to be presence of hepatic commonly used is Sorafenib and the benefit of this drug decompensation while 5% of patients presenting with seems to be around four months more than the Best encephalopathy. Hematemesis and melena occur in Supportive Care (15). All patients are usually offered 25% (6, 10, 12) of patients. Best Supportive Care, which includes management of Weakness, anorexia, abdominal pain, weight loss, ascites, nutritional manipulation, treatment of ascites with jaundice, fever and gastrointestinal co-morbidities and prevention of deterioration of bleeding are common symptoms. Patients present hepatic functions which includes the anti-virals for commonly with hepatomegaly, pallor, edema, and hepatitis B and hepatitis C. Prevention of hepatitis B and clubbing (in about 20%). Massive hepatomegaly is seen hepatitis C, which are predominant causes of HCC, is in about 50% of patients. The enlarged liver is usually the primary prevention for HCC. Pegylated interferon firm to hard. Approximately 15% of patients do not have alfa and the anti-viral drug ribavirin based on the type of an enlarged liver. About 60% of patients present with HCV genotype is followed for management of hepatitis ascites while worsening of ascites occurs in about C. Most often single drug pegylated interferon is used 20%. Sometimes fever, leukocytosis and recurrent and viral control is seen in 80%. For hepatitis B hypoglycemia occur as a paraneoplastic syndrome (13, lamivudine is usually used as a single drug. 65% per 14). cent of the patients have control of hepatitis B proliferation (14, 16). Neonatal vaccination of HBV has Management decreased not only the prevalence of HBV carriers (17) Treatment management of HCC patients was different but also the incidence of HBV related HCC. Increasing for different conditions depend on to various factors awareness of blood bone infection control can also such as patient factors, socioeconomic factors, bring down the incidence of hepatitis B and hepatitis C. etiological and the disease status. All modern facilities Therapeutic use of interferon and antiviral in chronic required for the treatment and management of HCC infections of hepatitis can bring down the incidence of patients should be demanded basically in rural areas viral hepatitis induced HCC (18, 19). while in tertiary hospitals of urban areas those facilities Summary are available, but in rural areas such facilities are scanty. Resection and hepatic transplants are available Prognosis, diagnosis, treatment and management of for surgical therapy and only applicable in early stage of HCC in India is very critical and challenging. Since HCC disease in a few centers. Therapy occurs possibly routine tests for screening of HCC are not followed to in less than 1 in 10,000 patients and liver transplants perform in developing countries such as India therefore were done in five to six cases in India. The deterrent the advanced HCCs are common at diagnosis. It is

32 Vol. 3 No. 1 Bangladesh Journal of Hepatology imperative to develop effective and affordable therapy 9. Javid G, Khan BA, Shah A, et al. Hepatocellular and treatment strategies for such advanced disease. carcinoma mimicking liver abscess. Indian Pediatr There is no systemic chemotherapy other than 1998;35:1126-9. application of drug Sorafenib which has shown survival 10. Singh SV, Goyal SK, Chowdhury BL. Primary benefit. Multimodality approach is the need of the hour carcinoma of liver in Udaipur. J Assoc Physicians and has shown much better survival benefit, in single India 1971;19:693-5. modality, in developed countries. Researchers need to 11. Saini N, Bhagat A, Sharma S, et al. Evaluation of unravel the underlying hepato-carcinogenesis and key clinical and biochemical parameters in molecular targets for development of more effective hepatocellular carcinoma: experience from an chemotherapy agents to improve survival in advanced Indian center. Clin Chim Acta 2006;371:183-6. HCC. Vaccination against hepatitis B and antivirals for hepatitis B and hepatitis C in chronic state, screening 12. Agarwal AK, Manvi KN, Mehta JM, et al. Clinical program as well awareness program for early diagnosis diagnosis of hepatoma. J Assoc Physicians India of HCC are the challenging tasks in the field of 1966;14:465-8. hepatology science for developing countries. 13. Bruix J, Sherman M, Llovet JM, et al. Clinical References: management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL 1. S Ashtari, Md A Pourhoseingholi, A Sharifian, and conference. European Association for the Study of Md R Zali; Hepatocellular carcinoma in Asia: the Liver. J Hepatol2001;35:421-30. Prevention strategy and planning; World J Hepatol. 2015 Jun 28; 7(12): 1708-1717 14. Sarin SK, Thakur V, Guptan RC, et al. Profile of hep:;tocellular carcinoma in India: an insight into 2. H B El-Serag; Epidemiology of Viral Hepatitis and the possible etiologic associations. J Gastroenterol Hepatocellular Carcinoma; Gastroenterology. 2012 Hepatol2001;16:666-73. May; 142(6): 1264-1273.el. 15. G.S.Bhattacharyya, K.G. Babu, H. Malhotra, A. A. 3. Durga R, Muralikrishna P. Viral markers in Ranade, S. Murshed, D. Datta; Hepatocellular hepatocellular carcmoma. Indian J carcinoma in India; Chin Clin Onco/2013;2(4):41. Gastroenterol1994;13:A57. 16. Kumar A, Sreenivas DV, Nagarjuna YR. 4. Indian Association for Study of the Liver (INASL). Hepatocellular carcinoma. The Indian scenario. Hepatitis B in India: Therapeutic options and Indian J Gastroenterol1995;14:A95. prevention strategies - Consensus statements. Indian J Gastroenterol 2000;19:54-74. 17. Chadha MS, Arankalle VA. Ten-year serological follow up of hepatitis B vaccme recipients. Indian J 5. Melbye M, Skinh0j P, Nielsen NH, et al. Gastroenterol 2000;19:168-71. Virus-associated cancers in Greenland: frequent hepatitis B virus infection but low primary 18. Chang MH, You SL, Chen CJ, et al. Decreased hepatocellular carcinoma incidence. J Natl Cancer incidence of hepatocellular carcinoma in hepatitis Inst 1984;73:1267-72. B vaccinees: a 20-year follow-up study. J Natl Cancer Inst 2009;101:1348-55. 6. Kumar R, Saraswat MK, Sharma BC, et al. Characteristics of hepatocellular carcinoma in 19. Morgan RL, Baack B, Smith BD, et al. Eradication of India: a retrospective analysis of 191 cases. QJM hepatitis C virus infection and the development of 2008;101:479-85. hepatocellular carcinoma: a meta-analysis of observational studies. Ann Intern Med 7. KarP; Risk Factors for Hepatocellular Carcinoma in 2013;158:329-37. India; J CLIN EXP HEPATOL 20I4;4:S34- S42. 8. Parkin DM. The global health burden of infection-associated cancers in the year 2002. Int J Cancer 2006;118:3030-44.

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Case Reports

A case of occult hepatitis B virus infection and hepatocellular carcinoma from Bangladesh Ponkaj Kumar Naha1, Mamun-Al-Mahtab1, Sarkar Mohammad Shahadat Hossain1, Rokshana Begum1, Abul Hayet Manik1, Debraj Malakar1, Partho Pratic Roy1, Ayub Al Mamun1, Salimur Rahman1 1Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Corresponding author Dr. Mamun Al Mahtab Associate Professor Department of Hepatology, Bangabandhu Sheikh Mujib Medical university, Dhaka, Bangladesh. E-mail:

Abstract Hepatitis B virus (HBV) is the major causative agent of chronic hepatitis, hepatic decompensation, liver cirrhosis and hepatocellular carcinoma (HCC). HBV related serum markers are widely used in clinical diagnosis and prognosis of HBV infection. Serum HBsAg is regarded as the sole marker for HBV infection. But negative result for serum HBsAg test do not always represent a clearance or inactivating status of HBV infection, rather HCC can still develop in the absence of detectable HbsAg in serum. The situation is called occult HBV infection (OBI). Here we reported a case of 36 years old patient attended Hepatology OPD, BSMMU with abdominal pain for 3 month. After evaluation he was diagnosed as a case of HCC due to OBI based on high AFP (>20000ng/ml), suggestive triphasic CT scan of HBS and positive anti HBc(T), detectable HBV-DNA but negative HBsAg in serum.

Introduction: altered consciousness, oliguria, haematemesis and HBV infection remain a major public health problem melaena, altered bowel habit, any nodular swelling of worldwide with more than 350 million people body, fever, cough, breathlessness during his illness. He chronically infected and about 600000 related death had past H/O jaundice 15 years back. On examination, annually. HBV infection has five different clinical patient was non icteric, abdominal exam revealed categories; asymptomatic, acute, chronic, fulminant, tender hepatomegaly and ascites. Investigation report OBI. OBI is characterized by the presence of HBV viral revealed normal LFT, but enlarged coarse liver with mild genome in the patients liver, but no virus surface Ag ascites on USG. The triphasic CT scan of HBS showed (HBsAg) detected in serum by commonly used characteristic feature of HCC and AFP >200000 ng/ml. immunoassays. HCC may develop in HBsAg negative Regarding viral marker only Anti HBc(T) is positive, other patient accounted for 15.9% of all liver cancer patients. viral markers are negative. Ascitic fluid study showed A study in Bangladesh found that HBV DNA was high SAAG with low protein. Above all evidences were detected in several group of patients where HBsAg was suggestive of HCC on the back ground of cirrhosis of negative. liver. Case report: Discussion: Thirty six years aged Mr. Abdur Rahim, a garments The Hepatitis B virus is an enveloped and double strand product manager, normotensive, nondiabetic, smoker, relaxed circular DNA virus that belong to the family nonalcoholic, presented with upper abdominal pain Hepadna viridae. HBsAg is formed through several associated with anorexia and weight loss. He also had pathways in the life cycle of HBV and the virus abdominal swelling for 1 month, but no history of cccDNA(Covalently close circular DNA) is used as template. HBsAg level in serum are associated with the

34 Vol. 3 No. 1 Bangladesh Journal of Hepatology level of active cccDNA. 1HBV viruses in HBsAg negative 2. Lee KM, Kim YS, Ko YY, Yoo BM, Lee KJ, Kim JH, patients usually have higher genetic diversity and Hahm KB, Cho SW. Emergence of vaccine – higher mutation frequency than HBsAg positive induced escape mutant of hepatitis B virus with patients. Many type of mutation are only found in multiple surface gene mutation in a Korean child. J HBsAg negative patients, but not in HBsAg positive Korean Med Sci. 16(3):359-362, 2001. patients. So HBsAg specific antibody cannot recognize 3. Louisirirotchanakul S, Kanoksinsombat C, and bind to the surface antigen. The wide application of Theambooniert A, Puthavatana P, Wasi C, HBV vaccination and to antiviral treatment increase the Poovorawan Y. Mutation of the “a” determinant of 2 3 chance of viral mutation. The reason of negative HBsAg with discordant HBsAg diagnostic kits.Viral HBsAg in serum may be for low specificity and Immuunol 17(3):440-444, 2004. sensitivity of the reagents for detecting HBsAg, 4. Chen CY, Wu JR, Wang SY. [Occult hepatitis B virus co-infection with HCV and HIV, disruption of HBV gene infection] Zhonnghua Gan Zang Bing Za Zhi during integration into the chromosomal DNA in host 13(11): 873-875, 2005. hepatocyte, deamination and methylation of HBV genome.4 5 6 HBV DNA can present in the hepatocytes 5. Huang FY, Wong DK, Seto WK, Zhang AY, Lee CK, either by integration into host cell genome remaining a Lin CK, Fung J, Lai CL, Yuen MF. Sequence free epsomes. The integration itself could trigger variations of full-length hepatitis B virus genomes carcinogenesis by activating other genes.7 8 9 The occult in Chinese patients with HBsAg-nagative hepatitis virus infection may be mild but continuous B infection. Pios One 9(6):e99028, 2014. necroinflamation in the liver could provoke repeated 6. Raimondo A, Pollicino T, Romano L, Zanetti AR. A cycles of apoptosis, necrosis and complementary 2010 update on occult hepatitis B infection. Pathol regeneration. All these reaction in liver contribution to Biol 58(4):254-257.2010. the progression toward cirrhosis and HCC.7 7. Elmore LW, Hancock AR, Chang SF, Wang XW, Conclusion: Chang S, Collahan CP, Geller DA, Will H, Harris CC. OBI is attributing to the long lasting presence of HBV Hepatitis B virus X protein and p53 tumour cccDNA in the hepatocyte. So there is risk of cancer suppressor interaction in the modulation of development in OBI patients .There is a pressing apoptosis. Proc Nati Acad Sci U S A 94(26): demand for accurate diagnosis of OBI for effectively 14707-14712, 1997. prevent the development of HCC. 8. Mahmoud OA, Ghazal AA, Metwally Del S, Elnor References: AM,Yousif GE. Detetion of occult hepatitis B virus infection among blood in Sudan. J Egypt Public 1. Werie-Lapostolle B, Bowden S, Lacornini, Health Assoc 88(1), 2013. Wursthorn K, Petersen J, Lau G, Trep C, Mercellin P, Goodman Z, Delaney WET, Xiong S, Brosgart CL, 9. Ohba K,Kubo S, Tamori A, Hirohashi K, Tanaka H, Chen SS, Gibbs CS, Zoulim F. Persistence of Shuto T, Nishiguchi S, Kinoshita H. previous or cccDNA during the natural history of chronic occult hepatitis B virus infection in hepatitis B hepatitis B and decline during adefovir dipivoxil surface antigen-negative and anti hepatitis C therapy. Gastroenterology 126(7): 1750-1758, negative patients with hepatocellular carcinoma. 2004. Surg Today 34(10):842-848, 2004.

Vol. 3 No. 1 35 Bangladesh Journal of Hepatology

Abstracts of LIVERCON 2016

Association of portal vein tumor thrombus in hepatitis B related hepatocellular carcinoma Abu Saleh Mohammad Sadequl Islam1, Mamun Al Mahtab2, Ayub Al Mamun2, Sheikh Mohammad Fazle Akbar3, Mohammad Kamal Hossain1, Zia Hayder Bosunia4, Salimur Rahman2 1Department of Medicine, SZR Medical College Hospital, Bogra, Bangladesh. 2Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. 3Department of Medical Sciences, Toshiba General Hospital, Tokyo, Japan, 4Department of Hepatology, Rangpur Medical College Hospital, Rangpur, Bangladesh.

Background: mm slice thickness) multi-detector CT (MDCT). All CT The highest incidence of Hepatocellular carcinoma images were evaluated by 2 trained radiologists by (HCC) is in Asia, accounting for about 76% of all cases consensus after exclusion of hepatitis C virus infection worldwide. In South East Asia, hepatitis B is the most (Anti HCV+ve) and significant alcohol intake (>20 gm. common underlying cause.HCC is the sixth most /day). All patients were HBsAg positive done by ELISA common type of cancer and the third highest cause of test. cancerrelated mortality worldwide. HCC exhibits intense Results: neoangiogenic activity during its progression. In the A total 44 patients were included in this study. Among early stages the tumor is not highly vascularized and its them, 91% were male (n=40) and 09 % were female blood supply comes from the portal vein. However, as (n=4).The mean age was 48.2 (±12.9) years with the tumor grows the blood supply becomes range from 23 to 80. Maximum (50%) patient’s ages progressively arterialized.11% to 42% of patients with were belonged to 35-54 years. Urban was found 23 HCChave to invasion the portal venous system, which (52.3%). Cirrhosis was 79.5% (n=35) and no cirrhosis results in portal vein tumor thrombus (PVTT). To find out was found 20.5% (n=9).PVTT was found 40.9% the relationship ofportal vein tumor thrombus (PVTT) (n=18)and no PVTT was found 59.1% (n=26). Among with the hepatitis B-related hepatocellular carcinoma. cirrhosis and non-cirrhosis group, PVTT was 83% Methods: (n=15) and 17% (n=03) respectively.BCLC (Barcelona This observational study was carried out in the Cancer of the Liver Clinic) staging showed 100% Department of Hepatology, BSMMU from January 2012 (n=18) of patients were advanced and terminal stage to December 2013. The study was approved by the (Stage C & D).Conclusions:Median survival time of Ethical Institutional Review Board (IRB) of BSMMU, patients with PV invasion was 2.7 to 4 months if left Dhaka. The diagnosis of HCC was confirmed by untreated, whereas the median survival time of patients pathological examination or AFP elevation (400ng/ml) without PV invasion was 24.4 months if left untreated. combined imaging (CT/MRI) and diagnosis of PVTT was Detection of PVTT inHCC leads to extremely poor made by non-enhanced and contrast-enhanced (10 prognosis.

36 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Metabolic syndrome is a good predictor for diagnosing non-alcoholic steatohepatitis. Sheikh Mohammad Noor-E-Alam1, Ahmed Lutful Moben2, Zia Hayder Basunia3, Amalendu Bhattacharyya4, Abdur Rahim5, Syed Abul Foez6, Mohammad Shahed Ashraf1, Faiz Ahmad Khandoker1, Md. Jahangir Alam Sarker1, Abu Saleh Mohammad Sadequl Islam7, Mohammad Forhad Abedin8, Utpal Das Gupta9, Mohammad Jahangir Kabir2, Mamun-Al-Mahtab10, Salimur Rahman10 1Department of Hepatology, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh, 2Kurmitola General Hospital, Dhaka, Bangladesh, 3Rangpur Medical College, Rangpur, Bangladesh, 4Shere-E-Bangla Medical College Hospital, Barisal, Bangladesh, 5MATS, Noakhali, Bangladesh, 6250 Bed Hospital, Moulvibazar, Bangladesh 7SZR Medical College Hospital, Bogra, Bangladesh, 8Comilla Medical College Hospital, Comilla, Bangladesh, 9Ali Hospital, Dhaka, Bangladesh, 10Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh

Background: patients underwent liver biopsy and NAFLD activity Nonalcoholic fatty liver disease (NAFLD) is a metabolic score (NAS) was assessed. liver disease that has become a worldwide public health Results: concern. The conditions ranging from simple steatosis Metabolic syndrome was present in 79% of study to nonalcoholic steatohepatitis (NASH), fibrosis, population according to International Diabetes cirrhosis and end stage liver disease. To evaluate Federation 2006 criteria for South Asians and 55.9% metabolic syndrome for diagnosing non-alcoholic metabolic syndrome patients presented with NASH. steatohepatitis. 95% NASH patients presented with metabolic Methods: syndrome. In this study presence of metabolic An observational, cross sectional study was carried out syndrome significantly correlated (p=0.01, chi-square in the Department of Hepatology, Bangabandhu Sheikh test) NASH from non-NASH fatty liver. Mujib Medical University, Dhaka, Bangladesh. Patients Conclusion: of Metabolic syndrome having NAFLD on Metabolic syndrome can significantly predict NASH ultrasonography attending at outpatient and inpatient from non-NASH Fatty Liver. Departments of Hepatology were selected as cases. 43

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Upper gastrointestinal endoscopic findings in adults at Comilla Medical College & Hospital, Bangladesh Mohammad Forhad Abedin1, Mohammad Asaduzzaman Lashkar2, Mohammad Shah Jamal3, Mohammad Belalul Islam1, Mohammad Izazul Haque4, Mohammad Abdur Rob Sarkar3 1Department of Medicine, Comilla Medical College Hospital, Comilla, Bangladesh, 2Department of Cardiology, Comilla Medical College Hospital, Comilla, Bangladesh, 3Department of Gastroenterology, Comilla Medical College Hospital, Comilla, Bangladesh, 4Department of Hepatology, Comilla Medical College Hospital, Comilla, Bangladesh

Background: (24.6%). The main indications comprised dyspepsia Endoscopy is a nonsurgical procedure used to examine (49.66%), epigastric pain (29.63%), abdominal pain a patient’s gastrointestinal tract. Fiber optic endoscopy (7.025), hematemesis (6.12%), recurrent vomiting is a highly efficient diagnostic tool, which is now being (3.67%), abdominal distension (2.26%) and others increasingly used in the diagnosis of GI diseases. This (1.64%). Endoscopic diagnoses included duodenal study has been carried out to demonstrate indications ulcer (9.6%), gastric ulcer (4.9%), Oesophagealvarices for and common findings of endoscopy in adults aging (6.8%), gastritis (5.6%),gastropathy (3.2%), Ca- 15 years and above. stomach (2.7%),ca-oesophagus (1.3%), oesophagitis (1.5%), duodenitis (0.7%), pyloric stenosis (0.7%) and Methods: others (1.8%). We retrospectively reviewed the medical records for Conclusion: endoscopy indication and result of adults who had endoscopy between June 2014 and May 2005. Upper gastrointestinal endoscopy is a diagnostic procedure in adults, which is increasingly used in Results: government medical college hospitals to explore the We analyzed 1283 adult aged 15 years or above who upper GI pathologies i.e.- duodenal ulcer, gastric ulcer, were referred for upper gastrointestinal endoscopy. ca- stomach and oesophagus, gastritis, gastropathy There were 731 male and 552 female cases. Highest and oesophagealvarices. numbers of participants were in the age group of 25-34

38 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Causes of jaundice in clinical practice: An observation at Brahmanbaria Forhad Hossain Mohammad Shahed1, Mamun Al Mahtab2, Mohammad Fakhrul Islam Khaled1, Mohammad Abul Fayaz1, Ashiqur Rahman Khan1 1250 Bedded District Sadar Hospital, Brahminbaria, Bangladesh 2Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Background: infectious, with Hepatitis B Virus (HBV) 44%, Hepatitis C Jaundice remains the commonest mode of Virus (HCV) 30%, Hepatitis A Virus (HAV) 30%, Hepatitis presentation of liver disease. Identification of the cause E Virus (HEV) 26%. Mean±SD of age was 19.7±2.7 in at first medical contact is the basis of starting infectious group. Alcoholic liver disease was in 5% treatment. There is scarcity of study elaborating the cases. Obstruction with gall stone was in 5% cases, common causes of jaundice in Bangladeshi people. We Carcinoma of gall bladder (CaGB) in 5%, evaluated 100 patients presenting with jaundice at cholangiocarcinoma in 3%, Carcinoma liver in 1.6% Brahmanbaria, a district of Bangladesh to know and Carcinoma pancreas in 11.8% cases. Among the aetiologies. CaGB & cholangiocarcinoma patients 16% had gall stone. Mean±SD of age in malignant patients was Method: 62.52±4.9 with 75% female. We performed this observational study on Patients Conclusion: attending with the complaint of jaundice to the private chamber of the only hepatologist at this district from We observed that viral hepatitis was common in January 2015 to September 2015. Data from 100 younger age and malignancy in older age. Most of the patients were collected and analyzed to know cause of study subjects were male whereas malignancy was jaundice and its relation with age & sex of these more common in female. HAV infection was more in patients. pediatric age. Majority of hepatits were HBV related. Among the patients with CaGB & cholangiocarcinoma Result: 16% had gall stone. Mean±SD of age of the patients was 28.24±21.57, 57.6% were male. In 73% cases the cause was

Vol. 3 No. 1 39 Bangladesh Journal of Hepatology

Non favorable genotype is predominant at IL28B rs12979860 polymorphism in hepatitis B related hepatocellular carcinoma Abu Saleh Mohammad Sadequl Islam1, Mamun Al Mahtab2, Ayub Al Mamun2, Sheikh Mohammad Fazle Akbar3, Mohammad Eunus Ali4, Zia Hayder Bosunia5, Salimur Rahman2 1Department of Medicine, SZR Medical College Hospital, Bogra, Bangladesh, 2Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 3Department of Medical Sciences, Toshiba General Hospital, Tokyo, Japan, 4Department of Microbiology & Immunology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 5Department of Hepatology, Rangpur Medical College, Rangpur, Bangladesh.

Background: done at the Department of Hepatology, Bangabandhu The highest incidence of HCC is in Asia, accounting for Sheikh Mujib Medical University (BSMMU), Dhaka from about 76% of all cases worldwide. In South East Asia, January 2012 to December 2013.The polymorphism of hepatitis B is the most common underlying cause. IL28B rs12979860 was analyzed by a genotyping Although numerous associations between technique, based on polymerase chain reaction (PCR) environmental factors (e.g. cigarette smoking, heavy followed by restriction enzyme analysis at the alcohol drinking, male gender, older age), viral factors Department of Microbiology & Immunology, BSMMU. (e.g. viral load, active replication, genotype, core Results: promoter mutations) and the development of HCC in The frequency of CC homozygosity was 70% in healthy chronic HBV infection have been identified, a clear controls and 45.5% in HCC, the difference being understanding of the role of host genetics remains statistically significant (χ2=4.35, P=0.03). Statistically illusive. Bangladesh is a densely populated country with significant difference was also seen between non-HCC about 160 million populations, where HBsAg positivity patients with chronic hepatitis B (CHB) (69%) and HCC in the healthy population is 5.4%. To evaluate the role of (45.5%) (χ2=4.35, P=0.03). However, this significant host IL28B (interleukin 28B; interferon lambda 3) single finding was not seen between non-HCC patients with nucleotide polymorphism (SNP) in predicting hepatitis B chronic hepatitis B (CHB) and healthy controls. Carriers virus (HBV)-related hepatocellular carcinoma (HCC) of the minor T allele in rs12979860 had a higher risk of susceptibility. HCC compared with non-carriers (χ2=4.78, P=0.02). Methods: Conclusions: Our results suggest that, T allele and Single SNP in the IL28B gene (rs12979860C/T) were non-CC genotypes have strong predictive effect of examined in 116 subjects (including 44 HBV-related developing HCC and IL28Brs 12979860 C/T HCC patients, 42 non-HCC patients with chronic polymorphism might influence susceptibility to HCC. hepatitis B and 30 healthy controls). The study was

40 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Life Sketch of Professor Baruch Samuel Blumberg

Blumberg then attended Far Rockaway High School in the early 1940s, a school that also produced fellow laureates Burton Richter and Richard Feynman. Blumberg served as a U.S. Navy deck officer during World War II. He then attended Union College in Schenectady, New York and graduated from there with honors in 1946. Originally entering the graduate program in mathematics at Columbia University, Blumberg switched to medicine and enrolled at Columbia's College of Physicians and Surgeons, from which he received his M.D. in 1951. He remained at Columbia Presbyterian Medical Center for the next four years, first as an intern and then as a resident. He then began graduate work in biochemistry at Balliol College, Oxford and earned his Ph.D there in 1957. Scientific career

Professor Baruch Samuel Blumberg Baruch Samuel "Barry" Blumberg (July 28, 1925 – April 5, 2011), was an American doctor and co-recipient of the 1976 Nobel Prize in Physiology or Medicine (with Daniel Carleton Gajdusek), and the President of the American Philosophical Society from 2005 until his death. Blumberg received the Nobel Prize for "discoveries concerning new mechanisms for the origin and dissemination of infectious diseases." Blumberg 1999 press conference at which Blumberg was identified the Hepatitis B virus, and later developed its introduced as the first director of the NASA Astrobiology diagnostic test and vaccine. Institute Early life and education Throughout the 1950s, Blumberg traveled the world Blumberg was born in Brooklyn, New York. He first taking human blood samples and studying the inherited attended the Orthodox Yeshivah of Flatbush for variations in human beings, focussing on why some elementary school, where he learned to read and write people contracted diseases in similar environments that in Hebrew and to study the Bible and Jewish texts in others did not. In 1964, while studying yellow jaundice, their original language. (That school also had among its he discovered a surface antigen for hepatitis B in the students a contemporary of Blumberg, Eric Kandel, who blood of an Australian aborigine. Blumberg and his is another recipient of the Nobel Prize in medicine.) team were able to develop a screening test for the virus

Vol. 3 No. 1 41 Bangladesh Journal of Hepatology to prevent its spread in blood donations and developed McCall Elementary on Sept. 29, 2010 as part of the a vaccine. Blumberg later freely distributed his vaccine program. patent in order to promote its fielding by drug In an interview with the New York Times in 2002 he companies. Deployment of the vaccine reduced the stated that "[Saving lives] is what drew me to medicine. infection rate of hepatitis B in children in China from There is, in Jewish thought, this idea that if you save a 15% to 1% in 10 years. single life, you save the whole world". Blumberg became a member of the Fox Chase Cancer In discussing the factors that influenced his life, Center in Philadelphia in 1964, and held the rank of Blumberg always gave credit to the mental discipline of University Professor of Medicine and Anthropology at the Jewish Talmud, and as often as possible he the University of Pennsylvania starting in 1977. attended weekly Talmud discussion classes until his Concurrently, he was Master of Balliol College from death. 1989 to 1994. He was elected a Fellow of the American Death Academy of Arts and Sciences in 1994. From 1999 to 2002, he was also director of the NASA Astrobiology Blumberg died on April 5, 2011, shortly after giving the Institute at the Ames Research Center in Moffett Field, keynote speech at the International Lunar Research California. Park Exploratory Workshop held at NASA Ames Research Center. At the time of his death Blumberg was In November 2004, Blumberg was named Chairman of a Distinguished Scientist at the NASA Lunar Science the Scientific Advisory Board of United Therapeutics Institute, located at the NASA Ames Research Center in Corporation, a position he held until his death. As Moffett Field, California. Chairman he convened three Conferences on Nanomedical and Telemedical Technology, as well as Jonathan Chernoff, the scientific director at the Fox guiding the biotechnology company into the Chase Cancer Center where Blumberg spent most of development of a broad-spectrum anti-viral medicine. his working life said, "I think it’s fair to say that Barry prevented more cancer deaths than any person who’s Beginning in 2005, Blumberg also served as the ever lived." In reference to Blumberg's discovery of the President of the American Philosophical Society. He had Hepatitis B vaccine, former NASA administrator Daniel been first elected to membership in the society in 1986. Goldin said, "Our planet is an improved place as a result In October of 2010 Blumberg participated in the USA of Barry's few short days in residence." Science and Engineering Festival's Lunch with a His funeral was held on April 10, 2011 at Society Hill Laureate program whereby middle and high school Synagogue, where he was a long time member. The students of the Greater Washington D.C., Northern eulogy was delivered by his son-in-law Mark Virginia and Maryland area get to engage in an informal Thompson, the Director-General of the BBC. conversation with a Nobel Prize winning scientist over a brown bag lunch. Blumberg came to General George A.

42 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Email from Professor Baruch Samuel Blumberg

Email received from Professor Baruch Blumberg endorsing “Blumberg Oration” introduced by Association for the Study of the Liver, Dhaka, Bangladesh

Delivered-To: [email protected] Subject: RE: Blumberg Lecture in Dhaka on World Hepatitis day 2010. Date: Mon, 17 May 2010 00:32:29 -0400 From: "Blumberg, Baruch"

To Dr. Mamun-Al-Mahtab Secretary General Association for the Study of the Liver, Dhaka, Bangladesh

Dear Dr. Mamun-Al-Mahtab, I am very pleased to know that the first Blumberg Lecture will be presented on World Hepatitis Day 2010 in Dhaka It is a great honor to have been selected by the Association for the Study of the Liver, Dhaka, Bangladesh and the Viral Hepatitis Foundation Bangladesh to have this important event include my name. The research that resulted in the discovery of the hepatitis B virus and the invention of the vaccine conducted by my colleagues and me at the Fox Chase Cancer Center in Philadelphia. USA, started as an exercise in basic clinical research. We did not set out with the goal of finding HBV but rather to understand the nature of human protein genetic and environmental variation and how it relates to susceptibility to disease. However, we had the conviction, the faith, that we would in time find means to prevent and treat disease. When we recognized that we had discovered an important pathogenic virus, methods of detection, and a vaccine, we dedicated ourselves to these applications. Basic science is an effective means to discover new natural phenomenon and new medical applications. HBV is prevalent world wide and the field work that was essential to the research was conducted in Asia, Africa, Europe, the Islands of the Pacific, the sub-Arctic as well as North and South America. In all of these places we had excellent cooperation with our international colleagues; the success of the project was dependent on them. Following our initial publications, scientists and physicians in many parts of the world greatly extended the understanding of the virus and the applications of research. It is gratifying that the results of all this research have benefited people worldwide. Disease does not know boundaries and cooperation between many nations has been effective in achieving widespread relief from sickness and death. World Hepatitis Day will greatly extend the benefits to those not yet included in effective programs, improve projects already in place, and increase knowledge about HBV and other infectious agents. Congratulations to your organization in achieving this national and international campaign to help control HBV infection worldwide.

Sincerely yours, Baruch Blumberg

Vol. 3 No. 1 43 Bangladesh Journal of Hepatology

Brief Introduction of Dr. Nagaraja Rao Padaki: Blumberg Orator 2016

at CARE hospitals Hyderabad with before taking up the current position of Chief of Hepatology and Nutrition at Asian Institute of Gastroenterology. He served as Governing Council Member for Indian Society of Gastroenterology, Indian Association for Study of Liver Diseases and Editorial Board Member for Indian Journal of Gastroenterology in the past. He is a visiting faculty at National Institute of Nutrition, Hyderabad. He is one of the founding members of Coalition for Eradication of Viral Hepatitis in Asia Pacific (CEVHAP) an NGO with members from all over the globe. He is currently the founder and Honorary Secretary of Indian National Association for Study of the Liver (INASL) Andhra Pradesh chapter. He has contributed chapters in API textbook, INASL monograms and original articles in basic research of HBV,HCV and NAFLD in peer reviewed journals His fields of interest in Hepatology include non alcoholic fatty liver disease, alcoholic liver disease, hepatic Dr. Nagaraja Rao Padaki hemodynamic studies, drug induced liver injury and Dr. Nagaraja Rao Padaki was best outgoing student of nutrition. Kurnool Medical College. He was recipient of merit certificates and gold medals during undergraduate career. He was Sri Venkateswara University first in the final M.B.B.S. Dr.P.N.Rao is an alumnus (M.D and D.M.) of prestigious postgraduate medical institution in our country, the Post Graduate Institute of Medical Education and Research (PGI), Chandigarh. He served as Assistant Professor in Gastroenterology at Osmania Mediacl College, Hospital before becoming Professor of Gastroenterology at Nizams Institute of Medical sciences (NIMS) Hyderabad. Subsequently he was chief of Gastroenterology at Medwin Hospitals & Mediciti Hospitals, Hyderabad. He was Chief Gastroenterologist

44 Vol. 3 No. 1 Bangladesh Journal of Hepatology

List of Blumberg Orators

Blumberg Orator, 2010 Professor Mahmud Hasan Former Vice Chancellor, Bangabandhu Sheikh Mujib Medical University President, Bangladesh Medical Association President, Bangladesh College of Physicians & Surgeons Chairman, Bangladesh Medical Research Council President, Bangladesh Gastroenterology Society Topic: Management of Hepatitis B: An Update

Blumberg Orator, 2011 Professor Salimur Rahman Professor of Hepatology, Bangabandhu Sheikh Mujib Medical University Executive Council Member, Asia Pacific Association for the Study of the Liver President, Association for the Study of the Liver, Dhaka, Bangladesh Chairman, Viral Hepatitis Foundation Bangladesh Senior Vice President, Association of Physicians of Bangladesh Editor in Chief, Euroasian Journal of Hepato-Gastroenterology Topic: Hepatitis B: from Blumberg to Bangladesh

Blumberg Orator, 2012 Professor George K. K. Lau Clinical Trial Center LKS Faculty of Medicine, The University of Hong Kong Humanity and Health GI and Liver Clinic, Hong Kong, SAR Topic: Hepatitis B research in Asia-Pacific region-past 5 decades and future

Vol. 3 No. 1 45 Bangladesh Journal of Hepatology

Blumberg Orator, 2013 Professor Subrata K. Acharya Head, Department of Gastroenterology All India Institute of Medical Sciences (AIIMS) New Delhi, India Topic: Ammonia in acute liver failure: It’s role in pathogenesis, prognosis and implication in medical therapy

Blumberg Orator, 2015 Dr. Pietro Lampertico Assistant Professor Gastroenterology and Hepatology Division University of Milan, Italy Topic: HBV-An overview

46 Vol. 3 No. 1 Bangladesh Journal of Hepatology

Guideline for Authors

Submission of Papers

Manuscripts for Bangladesh Journal of Hepatology are 5. Short communication: Short communications of to be submitted by e-mail. This is the preferred method upto 3500 words, describing works that may be of of submission and facilitates early processing of a preliminary nature, but which merits immediate manuscripts. In exceptional cases where there is no publication. email access, authors may submit one original copy of 6. Letter to the Editor: Letters will be considered for the manuscript with a soft copy on disk. publication from time to time. Authors may submit, their manuscripts on 7. Book review: Review of books on Hepato-Pancreato-Biliary diseases with their names Hepato-Pancreato-Biliary diseases will be and full contact details, including e-mail address. published. It is the author’s responsibility to ensure that papers are Manuscript Preparation written in clear and comprehensible English. Authors whose native language is not English are strongly General: Manuscripts must be type-written, advised to have their manuscripts checked by an double-spaced with wide margins on one side of white English speaking colleagues prior to submission. paper. Each page must be numbered. Font size of 12 point is required. The corresponding author should be Submission of a paper implies that it has not been identifi ed including fax number and email address. published previously (except in the form of an abstract Institutional affi liation must be given for all co-authors. or as part of a published lecture or academic thesis), The Editors reserve the right to adjust style to certain that it is not under consideration for publication standards of uniformity. Authors should retain a copy of elsewhere, that it’s publication is approved by all their manuscript since we cannot accept responsibility authors and that, if accepted, it will not be published for damage or loss of papers. Original manuscripts will elsewhere in the same form, in English or in any other be discarded one month after publication. language, without the written consent of the Publisher. Abstracts: Each paper should be provided with an Types of Contributions abstract of 100-150 words. Original research paper, review article, case report, Keywords: 3-5 words characteristic of the manuscript. rapid communication, short communication, letter to Text: Please follow this order when typing manuscripts: Editor and book review. title, authors, affi liations, abstract, keywords, main text, 1. Research paper: Original full length research acknowledgements, appendix, references, fi gures and papers not exceeding 8,500 words (including then tables. Please do not import fi gures or tables into allowance for no more than 6 tables and your text. The corresponding author should be identifi illustrations). ed with an asterisk and footnote. The title of the paper 2. Review article: - With focus on literature published should unambiguously refl ect its contents. A over the previous fi ve years and not exceeding suggestion for an abbreviated running title should be 12,000 words (including allowance for no more given. than 6 tables and illustrations). Units: The SI system should be used for all scientific 3. Case report: Interesting case reports of and laboratory data; if in certain instances, it is Hepato-Pancreato-Biliary diseases. necessary to quote other units, these should be added 4. Rapid communication: Original research papers in parentheses. Temperatures should be given in reporting signifi cant scientifi c results or findings degrees Celsius. with signifi cant implications. Symbols: Abbreviations for units should follow the suggestions of the British Standards publication (BS

Vol. 3 No. 1 47 Bangladesh Journal of Hepatology

1991). The full stop should not be included in number cited. The list of references should be arranged abbreviations, e.g. ppm (not p.p.m.), % and / should be according to the citation by author’s names and should used in preference to ‘per cent’ and ‘per’. Where be as full as possible, listing all authors, the full title of abbreviations are likely to cause ambiguity or may not articles and journals, publisher and year. be readily understood by an international readership, References should be given in the following form: units should be put in full. Mahtab MA, Kumar S, S Rahman, Aggarwal R. Current recognized chemical nomenclature should be Genotypes of hepatitis B virus: fi rst report of coinfection used, although commonly accepted trivial names may between genotypes C and D from the Indian be used where there is no risk of ambiguity. The use of sub-continent. Arab J Gastroenterol 2006; 7(3): 35-37. proprietary names should be avoided. Papers Mahtab MA, Kumar S, Rahman S, Khan M, Aggarwal R. essentially of an advertising nature will not be accepted. Genotypes of hepatitis B virus in Bangladeshi References: All publications cited in the text should be population. Proceedings of the 16th Conference of the presented in a list of references following the text of the Asian Pacifi c Association for the Study of the Liver, manuscript. No more than 50 references should be Manila, Philippines, 2006; 45-48. cited in the manuscript. In the text please refer to the

Correspondence to Bangladesh Journal of Hepatology: Dr. Mamun-Al-Mahtab Associate Professor of Heptology Bangabandhu Sheikh Mujib Medical University Secretary General, Association for the Study of the Liver, Dhaka, Bangladesh Address: Room # 506 (4th fl oor), Bangabandhu Sheikh Mujib Medical University, Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000, Bangladesh. Tel. +880-2-8621142, Email: [email protected], [email protected]

48 Vol. 3 No. 1 List of Sponsors

• LabAid Pharma • Incepta Pharmaceuticals Ltd • Square Pharmaceuticals Ltd. • Healthcare Pharmaceuticals • Opsonin Pharma Limited • Aristopharma Ltd • Beacon Pharmaceuticals Ltd. • Beximco Pharma • Julphar Bangladesh • General Pharmaceuticals Ltd. • Eskayef Bangladesh Limited • ACI Pharmaceuticals • Renata Limited • Drug International Limited • The ACME Laboratories Ltd. • Sun Pharmaceutical Bangladesh Ltd • M/s Swadesh • Mundipharma (Bangladesh) Pvt. Ltd • Ziska Pharmaceuticals Ltd • Popular Pharmaceuticals Ltd • NIPRO JMI Pharma Ltd • Welhealth Pvt. Limited ASSOCIATION FOR THE STUDY OF LIVER Association for the Study of Liver Diseases Bangladesh

DISEASES BANGLADESH (National Association of Hepatologists of Bangladesh)