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Open access

Sombat Treeprasertsuk, Piyawat Komolmit and Wiriya Tanyaowalak

Abstract

Background: Hypoadiponectinemia and hyperleptinemia, and reductions in the ratio of adiponectin to leptin (A/L ratio) are associated with the development of hepatic necroinflammation in nonalcoholic fatty liver, but the association of the adipokines with hepatic steatosis in chronic viral hepatitis is unclear.

Objective: To investigate the relationship between serum A/L ratio, insulin resistance, degree of hepatic steatosis, and necroinflammation in patients with chronic viral hepatitis.

Methods: We measured serum adiponectin, leptin, and resistin levels, insulin resistance, and analyzed the association between liver histopathology and the level of the adipokines in 44 patients with chronic viral hepatitis before they started treatment.

Results: We found that insulin resistance, leptin, and resistin levels tended to increase in the group with a greater degree of hepatic steatosis and necroinflammation, but that the increase was not significant. The adiponectin/leptin ratio (A/L ratio) in a group with a low degree of hepatic steatosis was significantly higher than it was in the group with a high degree of hepatic steatosis (3.1 ± 3.1 vs 1.2 ± 0.8; P = 0.008). The A/L ratio in a group with low histological activity index (HAI) scores was significantly higher than in the group with high HAI scores (3.7 ± 3.4 vs 1.1 ± 1.1; P = 0.006). Abdominal obesity was the only variable that showed a significant association with the HAI score (P = 0.03).

Conclusion: The serum A/L ratio in patients with chronic viral hepatitis showed a significant inverse association with their degree of hepatic steatosis and necroinflammation.

Open access

Yotsapon Thewjitcharoen, Sariyah Udae and Sombat Treeprasertsuk

Abstract

Background: Acute fatty liver of pregnancy (AFLP) is an uncommon complication in the third trimester of pregnancy. Differential diagnosis between severe cases of AFLP and others conditions remains challenging since there is no specific diagnostic test for this condition and the diagnosis is made by clinical and laboratory findings.

Objective: To evaluate the clinical presentation, laboratory findings, and clinical outcome in patients with acute fatty liver of pregnancy.

Material and Method: A retrospective study was carried out in all hospitalized pregnant patients who presented with hepatitis in the third trimester at King Chulalongkorn Memorial Hospital (KCMH), between January 2001 and March 2011. The diagnosis of AFLP had been made by clinical symptoms, laboratory evidence of acute hepatitis in the third trimester of pregnancy and by exclusion of other causes.

Results: Of 102,989 deliveries, there was five AFLP, giving an incidence of 1 in 20,598 pregnancies. The mean maternal age and gestational age was 33.6 years and 36 weeks, respectively. The mean length of stay in hospital was 12 days (range 8 to 20 days). Nausea and jaundice were the most common symptoms. It is of interest that one case of AFLP coexisted with the syndrome, which is a combined medical feature of “H” for hemolysis, “EL” for elevated liver enzymes, and “LP” for low platelet count (HELLP). Hypoglycemia was found in all patients requiring continuous infusion of dextrose solution. Acute renal failure was also found in all cases. Initial serum creatinine varied from 1.5 to 3.7 mg/dL. None of the patients required hemodialysis and renal function returned to normal at discharge. Two cases were associated with DIC, which caused postpartum hemorrhage. Liver function tests became normal within 7 to 43 days. There was one case of perinatal death of the fetus and no maternal deaths.

Conclusion: AFLP is an emergency. Multiple organ failures could develop even after delivery. In our experience, some cases of AFLP could overlap with HELLP syndrome or masquerade as TTP in the setting of pregnancy. Careful analysis of the clinical progression is important in the recognition of AFLP and prompt termination of the pregnancy is required to improve maternal and perinatal outcomes.

Open access

Sombat Treeprasertsuk, Kaewjai Thepsuthammarat, Bubpha Kitsahawong and Kamthorn Phaosawasdi

Abstract

Background

The burden of acute diarrheal diseases is a major problem in Thailand. The mortality rate is 0.5% of admissions in the 2010 Nationwide Hospital Admission Data. Data from the Global Burden of Diseases, Injuries, and Risk Factors Study in 2010 showed that the mortality rate of diarrheal disease was 2.65% of all deaths globally.

Objectives

To examine the burden of adult acute diarrhea in Thailand using nationwide data in 2010.

Methods

There were 820,735 admissions of patients aged ≥19 years with a diagnosis of digestive diseases (ICD10-K00-K93) and acute diarrhea (ICD10-A09). About one-third of admissions (214,722 admissions; 26%) were for acute diarrhea with a mean patient age 51.5 (SD 15.3) years.

Results

Approximately two-thirds of the 214,722 admissions were for acute diarrhea (59%) in patients 19–60 years old, and the remaining 41% were elderly patients >60 years old. Approximately 0.5% of admitted patients (1,048 patients) died. The complications during hospitalization were septicemia (2.2%), mechanical ventilation (0.6%), and renal failure requiring hemodialysis (0.14%). The predictors of mortality were patients >60 years old at admission, male sex, and the presence of complications. The total cost for management of acute diarrhea in Thailand in 2010 was 905,784,298 baht or 30,035,807 USD for 214,722 admissions.

Conclusions

Acute diarrheal diseases accounted for 26% of the digestive diseases in the 2010 Thai nationwide data with high expenditure.

Open access

Rapat Pittayanon, Sombat Treeprasertsuk, Kamthorn Phaosawasdi, Bubpha Kitsahawong, Kaewjai Thepsuthammarat and Pinit Kullavanijaya

Abstract

Background

Data on the incidence and burden of Clostridium difficile infection (CDI) in Asia is limited.

Objectives

To evaluate the incidence and burden of CDI in Thailand.

Methods

We used 2010 Nationwide Hospital Admission Data, which included the diagnosis of digestive disorders from various causes coded using the ICD-10. Patients with a diagnosis of Clostridium difficile (ICD10-A07) aged >18 years, were included. Their baseline characteristics, clinical outcomes, and risk factors for CDI were analyzed. Length of hospital stay (LOS), mortality rate, and hospital expenses were used as indicators to evaluate the burden of CDI in Thailand.

Results

Of 4,863,935 admissions in 2010, 554 patients in 570 admissions (0.01%) were diagnosed with CDI. Of these, 106 (19.1%) died during the index hospitalization, and 98.1% had at least one comorbidity. The mean LOS for patients with CDI was longer than with other colitis (P < 0.001) and was also significantly longer for those who died during the index admission, compared with those who survived during the index admission (P = 0.04). The hospital expense for those who died was significantly higher than for those who survived (P < 0.001). From a multivariate analysis, age ≥85 years old, comorbidity, and sepsis were risk factors for mortality during admission with adjusted odds ratios of 2.40, 7.4, and 5.14, respectively.

Conclusions

The calculated burden of CDI in Thais is high; although the incidence of CDI is lower in Thailand than in Western countries. The mortality relates to the elderly age-group and comorbidity, especially sepsis.

Open access

Puth Muangpaisarn, Kanisa Jampoka, Sunchai Payungporn, Naruemon Wisedopas, Chalermrat Bunchorntavakul, Pisit Tangkijvanich and Sombat Treeprasertsuk

Abstract

Background

MicroRNA-34a (miR-34a) contributes to liver injury through an apoptosis pathway.

Objective

To determine the correlation between serum miR-34a and liver inflammation as assessed by nonalcoholic fatty liver disease (NAFLD) activity score (NAS).

Method

We included a cross-selectional study of 50 patients with NAFLD in this observational study and confirmed diagnosis by liver biopsy, with NAS grading. A control group comprised 23 healthy individuals without chronic liver disease. Serum miR-34a was assayed using a real-time quantitative PCR (Applied Biosystems).

Result

The mean age of NAFLD patients was 46.0 ± 13.7 years, and 52% were female. Metabolic syndrome was found in 76%. Liver histopathology showed that 54% of patients had NAS ≥4 and significant fibrosis (≥2) was found in 22%. Serum levels of miR-34a were significantly correlated with NAS (r = 0.39, P = 0.005), and the degree of steatosis (r = 0.28, P = 0.049), ballooning (r = 0.30, P = 0.034), and fibrosis (r = 0.39, P = 0.005). Serum miR-34a in patients with NAS ≥4 was significantly higher than in those with NAS <4 (P = 0.011) and controls (P < 0.001). There was no significant correlation between serum miR-34a and other variables. The area under receiver operating characteristic curve for serum miR-34a comparing patients with NAS ≥4 and with NAS <4 was 0.67 (95% CI 0.52, 0.82).

Conclusion

Serum level of miR-34a has a significant fair to good correlation with NAS and may serve as a biomarker of liver inflammation and fibrosis in patients with NAFLD.

Open access

Sombat Treeprasertsuk, Panida Piyachaturawat, Tanassanee Soontornmanokul, Naruemon Wisedopas-Klaikaew, Piyawat Komolmit and Pisit Tangkijavanich

Abstract

Background

Liver biopsy is the criterion standard to assess liver fibrosis in patients with nonalcoholic fatty liver disease (NAFLD), which is important for prognosis, whereas noninvasive scoring systems showing promise for predicting fibrotic status include aspartate/alanine aminotransferase (AST/ALT) ratio, BARD score, fibrosis–4-score (FIB-4), and the NAFLD Fibrosis Score (NFS).

Objectives

To determine the accuracy of noninvasive scoring systems to predict advanced fibrosis in Thai patients with NAFLD.

Methods

A prospective cross-sectional study of Thai patients with liver biopsy-proven NAFLD during January 2009-October 2012 at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Baseline NFS, BARD, and FIB-4 calculations were used to distinguish patients with NAFLD with and without advanced liver fibrosis, using cutoffs for NFS ≥ -1.455, BARD ≥ 2, and FIB-4 >1.3 (http://gihep.com/calculators/hepatology/).

Results

We included 139 patients mean age 40.95 (SD 13.3) years (47% male). Impaired fasting glucose or diabetes mellitus was found in 75, 9 showed advanced fibrosis (≥F3) by liver histology. NFS with cutoff ≥ -1.455 was determined as the best system with the highest sensitivity for identifying patients with advanced fibrosis, followed by BARD ≥2, FIB-4 >1.45, and AST/ALT ratio >0.8. Liver biopsy could potentially be avoided in >38% of patients with BARD, 46% with NFS, 64% with AST/ALT ratio, and 81% with FIB-4.

Conclusions

Advanced fibrosis was prevalent in 6% of our Thai patients with NAFLD. NFS had the highest negative predictive value for excluding patients with advanced fibrosis. At least 38% of patients with NAFLD could avoid liver biopsy by using the BARD system.

Open access

Pakkapon Rattanachaisit, Paweena Susantitaphong, Kessarin Thanapirom, Roongruedee Chaiteerakij, Piyawat Komolmit, Pisit Tangkijvanich and Sombat Treeprasertsuk

Abstract

Background

Non-alcoholic fatty liver disease (NAFLD) is one of the major causes of chronic liver disease. The primary treatment of NAFLD by statins has not been clearly elucidated.

Objectives

To evaluate the effectiveness of statin use in patients with biopsy-proven NAFLD or non-alcoholic steatohepatitis on the change in liver histology.

Methods

We searched MEDLINE, Scopus, Google Scholar, and the Cochrane Central Register of Controlled Trials for clinical trials and observational studies investigating the effects of statins on histological change regardless of type or dosage from inception to December 2015. Random-effect model meta-analyses were used to compute changes in outcomes of interest. The study protocol was registered in advance with the International Prospective Register of Systematic Reviews (PROSPERO 2016 CRD42016033132).

Results

We identified 6 studies (111 patients), representing 5 cohort studies and 1 randomized controlled clinical trial. There was significant decrease in steatosis grading with a standardized mean difference of –2.580 (95% confidence interval [CI] –4.623 to –0.536; P = 0.013) and NAFLD activity score standardized mean difference of –1.488 (95% CI –2.506 to –0.471; P = 0.004). However, there was no significant change in fibrosis stage (0.156; 95% CI –0.553 to 0.865; P = 0.667).

Conclusions

Statin use can possibly reduce the extent of steatohepatitis but not the stage of fibrosis. Further randomized controlled studies to assess histological evidence with adequate sample size and duration are required in order to establish the role of statin as a primary treatment of NAFLD.

Open access

Sombat Treeprasertsuk, Emmanouil Sinakos, Jill Keach and Keith D. Lindor

Abstract

Background: The American Association for the Study of Liver Disease (AASLD) guideline recommends cholecystectomy for GB polyps of any size in patients with PSC without strong supporting evidence.

Objective: Evaluate the predictors of malignancy and outcomes of PSC patients with GB polyps.

Methods: We identified 86 patients with PSC and GB polyps at the Mayo Clinic, Rochester, MN between January 1, 2000 and August 31, 2009 using a computerized record system. Twenty-six patients were excluded due to indefinite diagnosis or inadequate follow up data.

Results: Of the 2281 patients with PSC, 60 patients (2.6%) were diagnosed as having GB polyps with a median age of 49.8 years; 67% were male. The median follow up from the diagnosis of GB polyps to the last follow-up was 3.5 years. Thirty-one patients (52%) subsequently underwent cholecystectomy and eight of 31 patients (25.8%) developed malignant GB lesions. Low-grade dysplasia of the GB was seen in two (6.4%). Twenty-nine patients without cholecystectomy had a median follow up of 4.8 years and none of them developed a malignant GB lesion during follow-up. By multivariable logistic analysis, the size of GB polyps at baseline was associated with malignant GB lesions or GB dysplasia (OR = 7.0; 95%CI 2.0-25.1).

Conclusions: One third of GB polyps in patients with PSC who underwent cholecystectomy become malignant or developed dysplasia. A GB polyp at first diagnosis of at least 1 cm in size was a good predictor for malignant lesions of GB or GB dysplasia. In PSC patients with comorbidities who had GB polyp size at first diagnosis less than 1 cm, careful monitoring of the progression of GB polyp size over time with periodical assessment by ultrasound may be an option.

Open access

Sombat Treeprasertsuk, Taweesak Tanwandee, Teerha Piratvisuth, Chutima Pramoolsinsap, Anuchit Chutaputti, Kanchana Pornpininworakij, Lily Ingsrisawang and Varocha Mahachai

Abstract

Background: Data regarding the natural history and outcome of treatment of chronic hepatitis B (CHB) patients in Thailand remain inconclusive.

Objective: We aimed to examine the natural history and outcome of therapy in Thai CHB patients treated with nucleoside analogues (NAs) monotherapy or interferon (IFN) monotherapy.

Method: CHB patients without clinical evidence of cirrhosis and alanine aminotransferase (ALT) levels >1.5 times of normal for at least 6 months were enrolled from 6 hospitals (2002 to 2005). Treatment included NAs and IFN. Treatment response was defined as ALT normalization and an HBV DNA level <10,000 copies/ml (or <2,000 IU/ml) and/or HBeAg seroconversion at the end of follow up. The study was approved by the institutional review board of each hospital.

Result: A total of 567 patients with mean age of 46.8 ± 11.9 y were included. The ratio of HBeAg positive to HBeAg negative patients was 1.3:1. Nineteen percent of patients had no HBeAg status. There were 262 HBeAg positive patients (46%) and 197 HBeAg negative patients 35%. Sixty-one percent received NAs while 20% received IFN as a first line treatment and the remaining 19% received no specific medication. For the HBeAg positive patients, HBeAg seroconversion and undetectable HBV-DNA were achieved in 32.8% and 50.5%, respectively in NAs group (on therapy), and HBeAg seroconversion and undetectable HBV-DNA were achieved in 24.3% and 21.4%, respectively in the IFN-treated group (off treatment). For the HBeAg negative patients, undetectable levels of HBV-DNA occurred in 68.8% in the NAs group while undetectable levels of HBV-DNA occurred in 37.5% of patients in the IFN-treated group. HBsAg loss was not found in the NAs group, but 2.8% of patients in IFN group had HBsAg loss. HBV DNA reappeared in the IFN group (off treatment) and NAs groups (on therapy) in 26.6% and 24.3% of patients, respectively. Minor adverse events of therapy were found in 9% of patients. Five percent of patients progressed to Child A cirrhosis and one patient in the NAs group (0.18%) died from causes unrelated to liver disease, during a 3-year follow-up.

Conclusion: The treatment response of Thai CHB patients from multicenter study showed the results similar to previous studies. However, higher durability of treatment with lower rate of reappearance of HBV DNA was observed in Thai CHB patients.

Open access

Thirada Thongbai, Kessarin Thanapirom, Wiriyaporn Ridtitid, Rungsun Rerknimitr, Rattikorn Thungsuk, Phadet Noophun, Chatchawan Wongjitrat, Somchai Luangjaru, Padet Vedkijkul, Comson Lertkupinit, Swangphong Poonsab, Thawee Ratanachu-ek, Piyathida Hansomburana, Bubpha Pornthisarn, Varocha Mahachai and Sombat Treeprasertsuk

Abstract

Background

Acute upper gastrointestinal bleeding (UGIB) is a common gastrointestinal disease emergency and a cause of morbidity and mortality.

Objectives

To assess the clinical outcomes and explore predictive factors for mortality of elderly patients with acute UGIB.

Methods

During the study period from January 2010 to September 2011, we prospectively enrolled 981 patients presenting with UGIB from 11 hospitals (mean age ± standard deviation (SD), 59.4 ± 14.9 years; range, 17–94 years; including 661 men). Of these 981 patients, 499 (50.9%) were elderly. Basic demographic data and clinical findings, and Rockall scores were collected and calculated.

Results

We studied 499 elderly patients. Their mean age ± SD was 71.63 ± 7.65 years. The 30-day mortality rate was 9% and rebleeding was just 1%. Regression analysis showed a pulse rate >100 beats per min at first visit, red blood in a nasogastric aspiration, comorbidity with coronary artery disease, and creatinine >1.5 mg/dL were independent predictive factors of 30-day mortality.

Conclusions

Peptic ulcer bleeding is a major cause of acute UGBI in the elderly. We recommend patients with predictive factors of mortality, pulse rate >100 beats per min at first visit, red blood in nasogastric aspiration, comorbidity with coronary artery disease, and creatinine >1.5 mg/dL be closely monitored and treated promptly. Reducing mortality from peptic ulcer bleeding should focus on preventing peptic ulcer occurrence as a result of ulcerogenic medications.