BACKGROUND AND AIMS:Muscle cramps markedly affect the quality of life in cirrhotic patients with no available highly effective treatment. The aim of this study was to assess the safety and efficacy of orphenadrine in the treatment of muscle cramps in cirrhotic patients.METHODS:The study enrolled 30 liver cirrhosis patients complaining of frequent muscle cramps (≥3 per week), who were randomized to receive either orphenadrine 100 mg or calcium carbonate 500 mg twice daily as a control for one month. Severity, frequency, and duration of the muscle cramps were assessed before and after treatment as well as recurrence after washout of the drug for two weeks. Side effects were recorded.RESULTS:One month after treatment with orphenadrine; the frequency of muscle cramps decreased significantly to 0.6 ± 0.74 per week compared to 12.53 ± 6.01 at baseline (p < 0.001), the duration of muscle cramps decreased from 1 min to 0.1 min after treatment (p < 0.001). The pain score improved significantly from a score of 8/10 to 0/10 (p < 0.001). The side effects were few, such as dry mouth, drowsiness, and nausea, with no significant difference between their occurrences in the two groups.CONCLUSION:Orphenadrine is safe and effective in treatment of muscle cramps in patients with liver cirrhosis.

Hepatic steatosis is a frequent cause for elevated serum aminotransferase levels. The main screening method is ultrasonography. A combination of non-invasive tests may help in the diagnostic evaluation of a patient with suspected steatosis. Liver biopsy is the gold standard to precisely diagnose NASH. In this study we assessed the usefulness of hepatic steatosis index in comparison with ultrasonography and histopathological examination in the evaluation of steatosis associated with HCV infection. This study was carried out at Tropical medicine department (Tanta University Hospital). We studied fifty HCV patients who have bright liver in ultrasound. All patients were further studied with histopathological examination of liver biopsy as well as lab investigations. Hepatic steatosis index was also calculated. A significant positive correlation has been found between hepatic steatosis index (HSI) and Metavir staging of fibrosis assessed by histopathological examination. When the mean value of HSI = 35.5, the stage was F0 and when the mean value of HSI = 43.7, the stage was F3. A significant positive correlation has also been found between hepatic steatosis index and histopathological grading of steatosis. When the mean value of HSI = 31.7, the grade was G0 and when the mean value of HSI = 39.1, the grade was G3. Hepatic steatosis index may offer an economical noninvasive tool for predicting of hepatic steatosis with reasonable accuracy. In practice, the index could be used for the detection of risky patients in order to offer more advanced investigation, nutrition and life style counselling, as well as for the detection of severe steatotic patients requiring medical supervision and therapy.

Background Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent hemorrhage and thus, chronic anemia, in patients with cirrhosis. Treatment with argon plasma coagulation (APC) is an effective and safe method, but requires multiple sessions of endoscopic therapy. Endoscopic band ligation (EBL) was found to be a good alternative for APC as a treatment for GAVE, especially in refractory cases. The aim of this prospective randomized controlled study was to evaluate the safety and efficacy of EBL, as compared to APC, in the treatment of GAVE and gastric fundal vascular ectasia (GFVE). Patients and methods A total of 88 cirrhotic patients with GAVE were prospectively randomized to endoscopic treatment with either EBL or APC, every 2 weeks until complete obliteration was accomplished; then they were followed up endoscopically after 6 months, plus they had monthly measurement of hemoglobin levels during that period. Results We describe the presence of mucosal and submucosal lesions in the gastric fundal area that were similar to those found in GAVE in 13 patients (29.5%) of the EBL group and 9 patients (20.5%) of the APC group; we named this GFVE. In these cases, we treated the fundal lesions with the same techniques we had used for treating GAVE, according to the randomization. We found that EBL significantly decreased the number of sessions required for complete obliteration of the lesions (2.98 sessions compared to 3.48 sessions in the APC group (p < 0.05)). Hemoglobin levels increased significantly after obliteration of the lesions in both groups, compared to pretreatment values (p < 0.05), but with no significant difference between the two groups (p > 0.05); however, the EBL group of patients required a significantly smaller number of units of blood transfusion than the APC group of patients (p < 0.05). There were no significant differences in adverse events nor complications between the two groups (p > 0.05). Conclusions This study described and histologically proved the presence of GFVE occurring comcomitantly with GAVE in cirrhotic patients. We showed that GFVE can be successfully managed by EBL or APC. Our study revealed that EBL is more effective and is comparable in safety to APC, in the treatment of GAVE and GFVE in cirrhotic patients.

BACKGROUND AND STUDY AIMS:Bleeding internal haemorrhoids are common and used to be treated surgically with too many complications. Endoscopic therapy is trying to take the lead. Sclerotherapy and rubber band ligation are the candidates to replace surgical therapy especially in patients with liver cirrhosis. The aim of this study was to compare endoscopic injection sclerotherapy (EIS) to endoscopic rubber band ligation (EBL) regarding effectiveness and complications in the treatment of bleeding internal haemorrhoids in Egyptian patients with liver cirrhosis. PATIENTS AND METHODS:One hundred and twenty adult patients with liver cirrhosis and bleeding internal haemorrhoids were randomised into two equal groups; the first treated with EBL using Saeed multiband ligator, and the second with EIS using either ethanolamine oleate 5% or N-butyl cyanoacrylate. All groups were matched as regards age, sex, Child score and pre-procedure Doppler values. Patients were followed up clinically and with abdominal ultrasound/Doppler for 6 months. Endoscopic and endosonography/Doppler was done before and one month after the procedure. Pre and post-procedure data were recorded and analysed. RESULTS:Both techniques were highly effective in the control of bleeding from internal haemorrhoids with a low rebleeding [10% in the EBL group and 13.33% in the EIS group] and recurrence [20% in the EBL group 20% in the EIS group] rates. Child score had a positive correlation with rebleeding and recurrence in EIS group only. Pain score and need for analgesia were significantly higher while patient satisfaction was significantly lower in EIS compared to EBL [p<0.05]. No significant difference between ethanolamine and cyanoacrylate subgroups was found [p>0.05]. CONCLUSIONS:Both EBL and EIS were effective in the treatment of bleeding internal haemorrhoids in patients with liver cirrhosis. EBL had significantly less pain and higher patient satisfaction than EIS. EBL was also safer in patients with advanced cirrhosis.

Endoscopic band ligation (EBL) is a safe and effective method for treating symptomatic second and third degree hemorrhoids [1El Nakeeb Ayman M. Fikry Amir A. Omar Waleed H. et al.Rubber band ligation for 750 cases of symptomatic hemorrhoids.World J Gastroenterol. 2008; 14: 6525-6530Crossref PubMed Scopus (49) Google Scholar].Takahiro et al. [2Sato Takahiro Yamazaki Katsu Toyota Jouji et al.The value of endoscopic therapies in the treatment of rectal varices: a retrospective comparison between injection sclerotherapy and band ligation.Hepatology Research. 2006; 34: 250-255Crossref PubMed Scopus (21) Google Scholar], in their retrospective study, concluded that endoscopic injection sclrotherapy (EIS) is superior to EBL with regard to long-term effectiveness and complications. The aim of our study was to evaluate the effectiveness and complications of EBL compared to EIS in the treatment of bleeding internal hemorrhoids in Egyptian patients with liver cirrhosis. 60 adult Egyptian patients with liver cirrhosis and bleeding internal hemorrhoids were randomized into two equal groups; the first treated with EBL using Saeed multiband ligator, and the second treated with EIS using either ethanolamine oleate 5% or N-butyl cyanoacrylate. Patients were followed up clinically and with abdominal US/Doppler for 6 months. Endoscopic and EUS/Doppler was done before and one month after the procedure. Pre and post-procedure data were recorded and analysed. All groups were matched as regard age, sex, Child score, and pre-procedure doppler values. Both techniques were highly effective in the control of bleeding from internal hemorrhoids with a low rebleeding [10% in the EBL group and 13.33% in the EIS group] and recurrence [20% in the EBL group and 20% in the EIS group] rates. Child score had a positive correlation with rebleeding and recurrence in the EIS group only. Pain score and need for analgesia were significantly higher while patient satisfaction was significantly lower in EIS compared to EBL [p<0.05]. No significant difference between ethanolamine and cyanoacrylate subgroups [p>0.05]. Figure 1 shows EUS/Doppler before EBL. Figure 2 shows EUS/Doppler one month after EBL with complete obliteration of hemorrhoidal collatrals.View Large Image Figure ViewerDownload Hi-res image Download (PPT) EBL was as effective as EIS in the treatment of bleeding internal hemorrhoids in Egyptian patients with liver cirrhosis. EBL had significantly less pain and higher patient satisfaction than EIS.