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Effect of L-ornithine-L-aspartate Therapy on Low-Grade Hepatic Encephalopathy in Patients with Liver Cirrhosis Martha Iskandar; Irsan Hasan; Unggul Budihusodo
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 12, NUMBER 1, April 2011
Publisher : The Indonesian Society for Digestive Endoscopy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24871/121201138-43

Background: Minimal hepatic encephalopathy (MHE) is an abnormal condition of psychometric testing before hepatic encephalopathy (HE) condition reducing quality of life and survival rate. Impractical instrument, the psychometric hepatic encephalopathy score (PHES), has been recommended in diagnosing MHE. The new critical flicker frequency (CFF) has good precision and accuracy for diagnosing MHE. Oral L-ornithine-L-aspartate (LOLA) may increase ammonia detoxification. The aim of this study was to recognize the effect of oral LOLA on low-grade HE by investigating the mean value of CFF. Method: We included 31 patients with liver cirrhosis and low-grade HE (MHE, HE grade 1 and 2) at the outpatient clinic of hepatology, Cipto Mangunkusumo hospital between November 2009 and March 2010. It was a double-blind, randomized, placebo-controlled clinical trial. Oral LOLA was administered in a dose of 18 g/day, 3 times daily for 14 consecutive days. At the end of the study, there were 27 cirrhotic patients with CFF value 38 Hz; 14 patients had received LOLA and 13 patients had placebo. Statistic analysis was performed by using the Mann-Whitney U test. Results: The mean value of CFF in LOLA group after treatment (39.3 Hz) was significantly different than the placebo group (36.04 Hz); (p = 0.027). Ammonia level decreased in LOLA group from 118.7 into 109.1 µ mol/L. In placebo group, it increased from 106.9 into 147.5 µ mol/L with p = 0.275 (before); p = 0.052 (after). Conclusion: Oral LOLA may improve the value of CFF and is likely to decrease blood ammonia level in patients with low-grade HE. Keywords: low-grade hepatic encephalopathy, oral LOLA, CFF improvement, ammonia detoxification

Update 2013: the Role of Probiotic in Non-alcoholic Fatty Liver Disease, an Evidence Based Approach Alvin Nursalim; Irsan Hasan
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 14, NUMBER 2, August 2013
Publisher : The Indonesian Society for Digestive Endoscopy

During the last two decades, non-alcoholic fatty liver disease (NAFLD) has been a topic in many discussions. The major risk factors for NAFLD is metabolic syndrome, which include obesity, insulin resistance andhypertension. Beside insulin resistance, oxidative stress has been linked with the disease. There is accumulating evidence that intestinal bacterial overgrowth plays an important role in NAFLD pathogenesis. Intestinal bacteria influence the progression of NAFLD through endogenous ethanol production and cytokine that would eventually induce hepatic oxidative stress. Probiotic intervene pathogenic intestinal flora so it is a potential treatment for NAFLD. Many animal studies documented the beneficial effect of probiotic in NAFLD. Probiotic reduce hepatic inflammation, reduce hepatic steatosis and improve insulin resistance. There is still limited human studies upon this topic. However, preliminary result showed potential role of probiotic in NAFLD treatment. Probiotic is safe, cheap and widely available therefore it is a promising new approach for NAFLD therapy. Upcoming study would hopefully provide firm foundation regarding the use of probiotic for NAFLD on human.Keywords: NAFLD, probiotic, metabolic syndrome

Non-endoscopic Examination as Predictor of Varices Degree in Liver Cirrhosis Patients Who have Experienced Esophageal Variceal Bleeding Paulus Kusnanto; Marcellus Simadibrata; Irsan Hasan
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 12, NUMBER 1, April 2011
Publisher : The Indonesian Society for Digestive Endoscopy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24871/121201115-22

Background: Standard diagnosis for determining the degree of varices is by endoscopy. However, sometimes there are obstacles in the implementation of endoscopy. Based on the factors, we need to know the parameters of non-endoscopic examination which include ascites, splenomegaly, thrombocytopenia, Child-Pugh, portal vein diameter as a predictor of the degree of liver cirrhosis patients with varices who have experienced esophageal variceal bleeding. Method: The study design was cross-sectional study. The study was conducted on hospitalized patients in Cipto Mangunkusumo hospital, Gatot Subroto hospital, and Kraton hospital from September 2008 to November 2009. The patients were liver cirrhosis patients with history of upper gastrointestinal bleeding, no present bleeding, and hemodynamically stable. Examination of predictor factors in the patients such as ascites, splenomegaly, thrombocytopenia, Child-Pugh and portal vein diameter were done. Statistical analysis was performed with student’s t-test, Mann-Whitney test, and stepwise multivariable logistic regression. Results: The study involved 44 patients with liver cirrhosis who have esophageal variceal bleeding. Based on the results of endoscopic examination, large varices (F3) were found in 21 (47.73%) patients, small varices (F1 F2) in 23 (52.27%) patients, located on the distal esophagus extending to the medial (86.4%), with red color sign present (54.5%). Results of non-endoscopic examination such as splenomegaly, ascites, thrombocytopenia, portal vein diameter and Child-Pugh score was known not to be associated with the degree of esophageal varices (p 0.05). Conclusion: Non-endoscopic examination was not related to the degree of varices in liver cirrhosis patients who have experienced esophageal variceal bleeding. Keywords: esophageal variceal bleeding, liver cirrhosis, predictor factors, endoscopic criteria

Factors Found on the First Variceal-Bleeding Episode in Liver Cirrhosis Patients with Portal Hypertension Arnold Hasahatan Harahap; Dadang Makmun; Irsan Hasan
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 11, NUMBER 1, April 2010
Publisher : The Indonesian Society for Digestive Endoscopy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24871/111201015-18

Background: The dietary protein restriction that was commonly recommended to hepatic encephalopathy (HE) patients, often leads to malnutrition, whereas malnutrition can deteriorate cirrhosis prognosis. The aims of this study were to find out encephalopathy improvement that was measured by critical flicker frequency (CFF) test and nutritional status by measuring prealbumin level after L-Ornithine L-Aspartate (LOLA) treatment with adequate calories and protein intake in patients with HE. Method: Patients with liver cirrosis who visited Cipto Mangunkusumo hospital on June-October 2009 was evaluated by CFF test using HEPAtonormTM device. Encephalopathy was defined when CFF 39 Hz. Nutritional status was measured by the mid-arm muscle circumference (MAMC) and was stated as malnutrition when the MAMC was below the 15th percentile. Patients had been treated by 3 x 6 mg LOLA granules for 2 weeks, and adequate calories and protein intake with branched-chain amino acid (BCAAs) substitution. The change of encephalopaty was evaluated by the CFF test and the nutritional status by measuring prealbumin blood level. Results: There were 17 patients with liver cirrhosis who fulfilled the inclusion criteria. The mean CFF Result increased from 34.1 ± 2.5 Hz to 36.5 ± 2.9 Hz after LOLA treatment with the adequate calories and protein intake including BCAAs substitution, which was statistically significant (p 0.001) compared to before treatment. The prealbumin level also increased significantly compared before treatment, i.e. from 5.4 ± 2.1 mg/dL to 6.4 ± 2.6 mg/dL, p = 0.008. Conclusion: HE patients with malnutrition could be given adequate calorie and protein with BCAAs substitution to improve their nutritional status, and LOLA granules for the improvement of HE. Keywords: minimal hepatic encephalopathy, malnutrition, CFF, LOLA, prealbumin, BCAAs

Hepatitis B Virus Double Mutations is There any Role in Pathogenesis of Hepatocellular Carcinoma in Young Patients Andri Sanityoso Sulaiman; Rino Alvani Gani; Irsan Hasan; Andi Utama; Susan Tai; Griscalia Christine
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 10, NUMBER 3, December 2009
Publisher : The Indonesian Society for Digestive Endoscopy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24871/103200996-98

Background: The incidence of hepatocellular carcinoma (HCC) below age 40 years old in our institution were relatively high compared with other institutions in Asia. Hepatitis B virus (HBV) basal core promoter (BCP) double mutations correspond with increasing age. The aim of this study was to know if there was any role of HBV double mutations in young HCC patients. Method: A descriptive study was performed on HBV related HCC patients in Cipto Mangunkusumo Hospital in May 2006-November 2008. Patient were recruited consecutively and divided in to two groups, below 40 and above 40 years old. The genotypes were examined by polymerase chain reaction (PCR) method. The alpha feto protein (AFP) values were diagnosed based on ELISA method. The BCP A1762T/G1764A double mutations were examined by direct sequencing. Results: There were 49 HBV related HCC samples consist of 14 (28.5%) samples with age below 40 years old and 35 (71.5%) samples with age above 40 years old. We only found two genotype, genotype B was dominant in patients with HBV related HCC compare to genotype C, 43 (88%) and 6 (12%) respectively. The increasing of AFP level above 400 ng/mL was only found in about half of the samples, 7 (50%) 40 years old, 19 (54%) 40 years old. Double mutations of A1762T/G1764A in BCP occurred in 5 (36%) 40 years old, 15 (43%) 40 years old. Conclusion: The incidence of HBV related HCC in young patients were relatively high. The proportion of patients with AFP level 400 ng/mL in patients below 40 years old were higher compared to patients above 40 years. Keywords: hepatocellular carcinoma, BCP double mutation, HBV genotype

Efficacy and Safety of In-Asia-manufactured Interferon alpha-2b in Combination with Ribavirin for Therapy of Naïve Chronic Hepatitis C Patients: A Multicenter, Prospective, Open-Label Trial Nurul Akbar; Ali Sulaiman; Rino Alvani Gani; Irsan Hasan; Laurentius Lesmana; Andri Sanityoso; Sjaifoellah Noer; FX Pridady; Soemarno Soemarno
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 10, ISSUE 1, April 2009
Publisher : The Indonesian Society for Digestive Endoscopy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24871/10120097-13

Background: An open-label, multi center and non-comparative study was conducted to evaluate the efficacy and safety of a more affordable in-Asia-manufactured interferon á-2b product in combination with ribavirin to treat naïve chronic hepatitis C patients. Method: Thirty chronic naïve hepatitis C patients were treated with in-Asia-manufactured interferon a-2b subcutaneously 3 MIU thrice weekly and ribavirin 800-1,200 mg daily for 48 weeks. Follow-up was done until 24 weeks after the end of treatment. Efficacy was assessed by examining serologic and biochemical parameters at pre and post-treatment. Safety was assessed by evaluating clinical symptoms and laboratory parameters. Results: The virological response and sustained virological response rates of all Hepatitis C Virus (HCV) genotypes were 83.3% and 76.7% respectively. Post-treatment, 80% patients had significant alanine transaminase (ALT) decreased into normal level and remained normal in 76.7% patients at 24th week follow up period. At that time, the ALT level and sustained virological response were lower in HCV genotypes 1 and 4 than in non-1 and non-4 genotypes. The most frequent adverse event was flu-like syndrome. Conclusion: The efficacy and safety study on combination therapy of in-Asia-manufactured interferon a-2b and ribavirin has shown a good result based on the current standard of interferon alpha and ribavirin combination therapy. Keywords: interferons, combination drug therapy, chronic hepatitis C, treatment efficacy, safety

Non-invasive Markers for Diagnosis of Liver Cirrhosis in Chronic Hepatitis B Jeffry Beta Tenggara; Irsan Hasan; Andri Sanityoso; Murdani Abdullah
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 12, NUMBER 3, December 2011
Publisher : The Indonesian Society for Digestive Endoscopy

Background: Indonesia is an endemic country for hepatitis B viral infection. Thus, early diagnosis of cirrhosis is important to be established with regard to prompt treatment and to determine the patients’ prognosis. Liver biopsy which is a gold standard in diagnosing liver cirrhosis has several limitations, such as expensive and invasive. The objective of this study was to identify the accuracy of non-invasive markers: aspartate/alanine transaminase ratio (AAR), age-platelet index (API), aspartate transaminase to platelet ratio index (APRI), spleen to platelet ratio index (SPRI), and age-spleen-platelet ratio index (ASPRI) in predicting cirrhosis in chronic hepatitis B patients. Methods: A diagnostic study was performed in Division of Hepatology and Hepatology Outpatient Clinic, Depatment of Internal Medicine, Cipto Mangunkusumo Hospital between January 2009 and July 2010, with the participation of 71 chronic hepatitis B patients who had undergone liver biopsy consecutively. Stage of fibrosis was determined based on the METAVIR scoring system. Five non-invasive markers: AAR, API, APRI, SPRI, and ASPRI were compared with liver biopsy Results. Statistical analysis was performed by using T-test and Spearman correlation test using SPSS version 13. Results: API, APRI, SPRI, and ASPRI had significant correlation with the incidence of liver cirrhosis in hepatitis B infection (p 0.05). However, AAR had no correlation with the incidence of cirrhosis. Using the cut-off point of 1.19, APRI was the best marker with area under curve (AUC) 0.91, sensitivity 83.3%, and specificity 89.2%. Conclusion: Non-invasive markers were suitable in predicting cirrhosis and have the potential to decrease the number of liver biopsy in chronic hepatitis B patients. Keywords: non-invasive markers, chronic hepatitis B, liver cirrhosis

Correlation between Branched Chain Amino Acids to Tyrosine Ratio and Child Pugh Score in Liver Cirrhosis Patients Irsan Hasan; Rino A Gani; Nurul Akbar; Sjaifoellah Noer
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 6, ISSUE 1, April 2005
Publisher : The Indonesian Society for Digestive Endoscopy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24871/6120051-3

Background: The determination of branched chain amino acids (BCAA) to tyrosine ratio (BTR) was available in making differentiation of chronic hepatitis from liver cirrhosis, because there was a strong association between BTR and staging (fibrosis) scores. Branched chain amino acids to tyrosine ratio have a correlation with Fischer ratio and the examination is easier because it can be done by enzymatic assay. Materials and Methods: To evaluate the correlation between BTR and Child-Pugh score, we examined the amino gram of 52 liver cirrhosis patients consisted of 26 Child-Pugh A, 19 Child-Pugh B, and 7 Child-Pugh C. The examination of amino gram was done by High Pressure Liquid Chromatograph (HPLC) analyzer. Branched chain amino acids to tyrosine ratio were compared to Child-Pugh score, albumin, ammonia level, number connection test to Fischer ratio. Results: Significant differences in BTR among Child-Pugh A, B, C were observed (Child-Pugh A 7.75 + 1.2; Child Pugh B 6.0 + 1.23 and Child Pugh C 4.38 + 3.14 (p = 0.000)). Branched chain amino acids to tyrosine ratio had a weak correlation with albumin (r = 0.292; p = 0.036), ammonia level (r = 0.376; p = 0.006) and strong correlation with Fischer ratio (r = 0.818; p = 0.000). There was no significant correlation between BTR and number connection test. Conclusion: These results showed that the determination of the molar ratio of branched chain amino acids to tyrosine well reflected the severity of liver cirrhosis and it can be used as a substitute of Fischer ratio. Keywords: Branched chain amino acids, tyrosine, liver cirrhosis

Prolonged QTc-Interval in Liver Cirrhotic Patient: Prevalence and Its Relationship with Severity of Liver Dysfunction Iman Firmansyah; Irsan Hasan; Laurentius Lesmana; Idrus Alwi; Pudji Rahardjo
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 5, ISSUE 1, April 2004
Publisher : The Indonesian Society for Digestive Endoscopy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24871/5120041-6

Background: The aim of the study was to determine the prevalence of prolonged QTc -interval and it’s relationship with the severity of liver dysfunction in liver cirrhotic patient in the outpatient clinic of Hepatology, Dr. Cipto Mangunkusumo General National Hospital Methods: cross sectional study. Eighty one subjects was recruited and being followed as a consecutive non random sampling. The patient was divided according to the modified Child-Pugh classification and undergo to the ECG examination (with minimal 2 leads have measured QT-interval; one of these is II, aVL, V2 or V3 lead). Result: The prolonged QTc-interval prevalence in liver cirrhotic patient was found in 55 subjects (67,9%) with the mean 448.6 msec (SD = 28,9; 95% CI = 442.2 - 454.8). Using the Forward Stepwise Method in multivariate analysis to the independent variables (p 0.05) was found only the modified Child-Pugh classification had strongly correlation with the prolonged QTc-interval (OR = 11.2; 95% CI = 3.57-35.47; p = 0.000) Conclusion: The prolonged QTc-interval prevalence in liver cirrhotic patient is 67.9%. The prolonged QTc-interval were strongly associated with the severity of liver dysfunction. Keywords: The prolonged QTc-interval, liver dysfunction, liver cirrhosis

The Discrepancy of Colonoscopical and Histopathological Findings in Infectious Colitis: Focus on Amebic Colitis Salius Silih; Marcellus Simadibrata; Murdani Abdullah; Abdul Aziz Rani; Irsan Hasan
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 10, NUMBER 3, December 2009
Publisher : The Indonesian Society for Digestive Endoscopy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24871/1032009105-109

Background: Result of colonoscopic examination in infectious colitis was varying. The aim of this study was to recognize the correlation between colonoscopical and histopathological findings in patients with infectious colitis at Cipto Mangunkusumo hospital, Jakarta. Method: A cross-sectional study had been conducted. There were 227 patients with infectious colitis with unidentified etiology and 17 patients with amebic colitis. In both groups, several variables had been studied including sex, age group and indication of colonoscopy by using Chi-square test. The relationship between hematochezia and amebic colitis event was also studied by using Chi-square test. To recognize the ability of colonoscopy test in diagnosing amebic colitis, we conducted diagnostic test by searching the sensitivity and specificity. Result: In both groups of infectious colitis, we found male more frequent than female. There was a significant difference mean of age in both group of infectious colitis (p = 0.04). The mean age of amebic colitis group was younger (35.86 ± 14.36 years) than the other infectious colitis group (45.34 ± 15. 90 years). The incidence of amebic colitis was more frequent in hematochezia than in non -hematochezia (p 0.001). The sensitivity and specificity of colonoscopy in diagnosing amebic colitis were 35% and 97%, respectively. Conclusion: There was a tendency of developing amebic colitis in patients with hematochezia than non-hematochezia. In diagnosing the presence of amebic colitis, colo noscopy examination has lo w sensitivity and high specificity. Keywords: discrepancy, infectious colitis, amebic colitis, colonoscopy, histopathological finding

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