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1.  Can Helicobacter pylori infection influence human reproduction? 
Helicobacter pylori (H. pylori) infection could be associated with extra-digestive diseases. Here, we report the evidences concerning the decrease in reproductive potential occurring in individuals infected by H. pylori, especially by strains expressing CagA. This infection is more prevalent in individuals with fertility disorders. Infected women have anti-H. pylori antibodies in cervical mucus and follicular fluid that may decrease sperm motility and cross react immunologically with spermatozoa, conceivably hampering the oocyte/sperm fusion. Infection by CagA positive organisms enhances the risk of preeclampsia, which is a main cause of foetus death. These findings are supported by the results of experimental infections of pregnant mice, which may cause reabsorption of a high number of foetuses and alter the balance between Th1 and Th2 cell response. Infected men have decreased sperm motility, viability and numbers of normally shaped sperm and augmented systemic levels of inflammatory cytokines, such as tumor necrosis factor-α, which may damage spermatozoa. In countries where parasitic infestation is endemic, detrimental effects of infection upon spermatozoa may not occur, because the immune response to parasites could determine a switch from a predominant Th1 type to Th2 type lymphocytes, with production of anti-inflammatory cytokines. In conclusion, the evidences gathered until now should be taken into consideration for future studies aiming to explore the possible role of H. pylori infection on human reproduction.
doi:10.3748/wjg.v20.i19.5567
PMCID: PMC4024765  PMID: 24914316
Antigenic mimicry; Helicobacter pylori infection; Human sperm; Inflammatory cytokines; Preeclampsia; Reproductive disorders
2.  Helicobacter pylori: A chameleon-like approach to life 
Helicobacter pylori (H. pylori) is widely adaptable for colonization in human stomachs in more than half of the world’s population. The microorganism is characterized by an unusual capability of arranging itself in both genotypic and phenotypic ways. Stressing conditions, including antimicrobial agents in sub-inhibitory concentrations, facilitate entering the viable but nonculturable state in which bacterial cells acquire the coccoid form. This morphotype represents an important strategy for bacterial survival in unsuitable conditions and also allows escape from the immune system. H. pylori is capable of forming biofilm outside and inside the host. For the bacterial population, the sessile growth mode represents an ideal environment for gene rearrangement, as it allows the acquiring of important tools aimed to improve bacterial “fitness” and species preservation. Biofilm formation in H. pylori in the human host also leads to recalcitrance to antibiotic treatment, thus hampering eradication. These lifestyle changes of H. pylori allow for a “safe haven” for its survival and persistence according to different ecological niches, and strongly emphasize the need for careful H. pylori surveillance to improve management of the infection.
doi:10.3748/wjg.v20.i19.5575
PMCID: PMC4024766  PMID: 24914317
Helicobacter pylori; Viable But Non Culturable state; Route of transmission; Biofilm in vitro; Biofilm in vivo
3.  Immune responses to Helicobacter pylori infection 
Helicobacter pylori (H. pylori) infection is one of the most common infections in human beings worldwide. H. pylori express lipopolysaccharides and flagellin that do not activate efficiently Toll-like receptors and express dedicated effectors, such as γ-glutamyl transpeptidase, vacuolating cytotoxin (vacA), arginase, that actively induce tolerogenic signals. In this perspective, H. pylori can be considered as a commensal bacteria belonging to the stomach microbiota. However, when present in the stomach, H. pylori reduce the overall diversity of the gastric microbiota and promote gastric inflammation by inducing Nod1-dependent pro-inflammatory program and by activating neutrophils through the production of a neutrophil activating protein. The maintenance of a chronic inflammation in the gastric mucosa and the direct action of virulence factors (vacA and cytotoxin-associated gene A) confer pro-carcinogenic activities to H. pylori. Hence, H. pylori cannot be considered as symbiotic bacteria but rather as part of the pathobiont. The development of a H. pylori vaccine will bring health benefits for individuals infected with antibiotic resistant H. pylori strains and population of underdeveloped countries.
doi:10.3748/wjg.v20.i19.5583
PMCID: PMC4024767  PMID: 24914318
Helicobacter pylori; Vaccine; Immune response; Peptic ulcer; Gastric cancer
4.  Overview of the phytomedicine approaches against Helicobacter pylori 
Helicobacter pylori (H. pylori) successfully colonizes the human stomach of the majority of the human population. This infection always causes chronic gastritis, but may evolve to serious outcomes, such as peptic ulcer, gastric carcinoma or mucosa-associated lymphoid tissue lymphoma. H. pylori first line therapy recommended by the Maastricht-4 Consensus Report comprises the use of two antibiotics and a proton-pomp inhibitor, but in some regions failure associated with this treatment is already undesirable high. Indeed, treatment failure is one of the major problems associated with H. pylori infection and is mainly associated with bacterial antibiotic resistance. In order to counteract this situation, some effort has been allocated during the last years in the investigation of therapeutic alternatives beyond antibiotics. These include vaccines, probiotics, photodynamic inactivation and phage therapy, which are briefly revisited in this review. A particular focus on phytomedicine, also described as herbal therapy and botanical therapy, which consists in the use of plant extracts for medicinal purposes, is specifically addressed, namely considering its history, category of performed studies, tested compounds, active principle and mode of action. The herbs already experienced are highly diverse and usually selected from products with a long history of employment against diseases associated with H. pylori infection from each country own folk medicine. The studies demonstrated that many phytomedicine products have an anti-H. pylori activity and gastroprotective action. Although the mechanism of action is far from being completely understood, current knowledge correlates the beneficial action of herbs with inhibition of essential H. pylori enzymes, modulation of the host immune system and with attenuation of inflammation.
doi:10.3748/wjg.v20.i19.5594
PMCID: PMC4024768  PMID: 24914319
Helicobacter pylori; Alternative treatment; Phytomedicine; Herbal medicine; Phytotherapy; Botanical therapy; Herb medicine; Probiotics; Antibiotic resistance
5.  Factors that mediate colonization of the human stomach by Helicobacter pylori 
Helicobacter pylori (H. pylori) colonizes the stomach of humans and causes chronic infection. The majority of bacteria live in the mucus layer overlying the gastric epithelial cells and only a small proportion of bacteria are found interacting with the epithelial cells. The bacteria living in the gastric mucus may act as a reservoir of infection for the underlying cells which is essential for the development of disease. Colonization of gastric mucus is likely to be key to the establishment of chronic infection. How H. pylori manages to colonise and survive in the hostile environment of the human stomach and avoid removal by mucus flow and killing by gastric acid is the subject of this review. We also discuss how bacterial and host factors may together go some way to explaining the susceptibility to colonization and the outcome of infection in different individuals. H. pylori infection of the gastric mucosa has become a paradigm for chronic infection. Understanding of why H. pylori is such a successful pathogen may help us understand how other bacterial species colonise mucosal surfaces and cause disease.
doi:10.3748/wjg.v20.i19.5610
PMCID: PMC4024769  PMID: 24914320
Helicobacter pylori; Colonization; Infection; Gastric mucosa; Urease; Flagella; Polymorphisms; Adhesins; CagA; Type IV secretion system
6.  Blood pressure and stature in Helicobacter pylori positive and negative persons 
To evaluate vital signs and body indices in Helicobacter pylori (H. pylori) positive and negative persons. A total of 22 centres entered the study. They were spread over the whole country, corresponding well to the geographical distribution of the Czech population. A total of 1818 subjects (aged 5-98 years) took part in the study, randomly selected out of 38147 subjects. H. pylori infection was investigated by means of a 13C-urea breath test. Data on height, weight, systolic and diastolic blood pressure and heart rate were collected at the clinics of general practitioners. The overall prevalence of H. pylori infection was 30.4% (402/1321) in adults (≥ 18 year-old) and 5.2% (26/497) in children and adolescents (≤ 17 year-old). Once adjusted for age and gender, only a difference in body mass index remained statistically significant with H. pylori positive adults showing an increase of 0.6 kg/m2 in body mass index. Once adjusted for age and gender, we found a difference in height between H. pylori positive and H. pylori negative children and adolescents. On further adjustment for place of residence, this difference became statistically significant, with H. pylori positive children and adolescents being on average 3.5 cm shorter. H. pylori positive adults were significantly older compared to H. pylori negative subjects. Once adjusted for age and gender, H. pylori infection had no impact on body weight, body mass index and vital signs either in adults or children and adolescents. Chronic H. pylori infection appeared to be associated with short stature in children. H. pylori infection did not influence blood pressure, body weight and body mass index either in adults or children and adolescents.
doi:10.3748/wjg.v20.i19.5625
PMCID: PMC4024770  PMID: 24914321
Epidemiology; Helicobacter pylori; Czech Republic; 13C-urea breath test; Blood pressure; Heart rate; Weight; Stature; Body mass index
7.  Biofilm and Helicobacter pylori: From environment to human host 
Helicobacter pylori (H. pylori) is a Gram negative pathogen that selectively colonizes the human gastric epithelium. Over 50% of the world population is infected with H. pylori reaching up to 90% of infected individuals in developing countries. Nonetheless the increased impact upon public health care, its reservoir and the transmission pathway of the species has not been clearly established yet. Molecular studies allowed the detection of H. pylori in various aquatic environments, even forming biofilm in tap water distribution systems in several countries, suggesting a role of water as a possible reservoir of the pathogen. The persistence of human infection with H. pylori and the resistance of clinical isolates to commonly used antibiotics in eradication therapy have been related to the genetic variability of the species and its ability to develop biofilm, demonstrated both in vivo and in vitro experiments. Thus, during the last years, experimental work with this pathogen has been focused in the search for biofilm inhibitors and biofilm destabilizing agents. However, only two anti- H. pylori biofilm disrupting agents have been successfully used: Curcumin - a natural dye - and N-acetyl cysteine - a mucolytic agent used in respiratory diseases. The main goal of this review was to discuss the evidences available in the literature supporting the ability of H. pylori to form biofilm upon various surfaces in aquatic environments, both in vivo and in vitro. The results published and our own observations suggest that the ability of H. pylori to form biofilm may be important for surviving under stress conditions or in the spread of the infection among humans, mainly through natural water sources and water distribution systems.
doi:10.3748/wjg.v20.i19.5632
PMCID: PMC4024771  PMID: 24914322
Helicobacter pylori; Biofilm, Water; Infection
8.  Role of dental plaque, saliva and periodontal disease in Helicobacter pylori infection 
Helicobacter pylori (H. pylori) infection is one of the most common bacterial infections in humans. Although H. pylori may be detected in the stomach of approximately half of the world’s population, the mechanisms of transmission of the microorganism from individual to individual are not yet clear. Transmission of H. pylori could occur through iatrogenic, fecal-oral, and oral-oral routes, and through food and water. The microorganism may be transmitted orally and has been detected in dental plaque and saliva. However, the role of the oral cavity in the transmission and recurrence of H. pylori infection has been the subject of debate. A large number of studies investigating the role of oral hygiene and periodontal disease in H. pylori infection have varied significantly in terms of their methodology and sample population, resulting in a wide variation in the reported results. Nevertheless, recent studies have not only shown that the microorganism can be detected fairly consistently from the oral cavity but also demonstrated that the chances of recurrence of H. pylori infection is more likely among patients who harbor the organism in the oral cavity. Furthermore, initial results from clinical trials have shown that H. pylori-positive dyspeptic patients may benefit from periodontal therapy. This paper attempts to review the current body of evidence regarding the role of dental plaque, saliva, and periodontal disease in H. pylori infection.
doi:10.3748/wjg.v20.i19.5639
PMCID: PMC4024772  PMID: 24914323
Helicobacter pylori; Dental plaque; Saliva; Oral cavity; Periodontitis; Periodontal therapy
9.  Optimal treatment strategy for Helicobacter pylori: Era of antibiotic resistance 
Standard triple therapy, consisting of a proton pump inhibitor, plus amoxicillin and clarithromycin, has been the most commonly used first-line treatment regimen for Helicobacter pylori (H. pylori) eradication for many years worldwide. However, as a result of increased resistance to antibiotics, H. pylori eradication rates with use of standard triple therapy have been declining and recently reached < 80% in many countries. Several new strategies to enhance the eradication rate of H. pylori have been studied. Currently, among the alternative first-line eradication regimens, concomitant and hybrid regimens have shown excellent results and could be the optimal treatment option. Although clinical usefulness of rescue therapy for patients in whom eradication of H. pylori with non-bismuth quadruple regimen has failed is unclear, levofloxacin-based quadruple therapy has shown promise as a rescue treatment. The choice of third-line therapy depends on factors such as the local pattern of antibiotic resistance, drug availability, and previous treatment. We hope that a simple method for detection of antibiotic susceptibility using polymerase chain reaction would be a possible alternative to administration of “tailored treatment” in the era of increasing prevalence of antimicrobial resistance.
doi:10.3748/wjg.v20.i19.5654
PMCID: PMC4024773  PMID: 24914324
Helicobacter pylori; Standard therapy; Bacterial eradication; Concomitant therapy; Hybrid therapy
10.  Helicobacter pylori eradication for preventing gastric cancer 
Helicobacter pylori (H. pylori) infection is a major risk factor for gastric cancer (GC) development, which is one of the most challenging malignant diseases worldwide with limited treatments. In the multistep pathogenesis of GC, H. pylori infection slowly induces chronic active gastritis, which progresses through the premalignant stages of atrophic gastritis, intestinal metaplasia, and dysplasia, and then finally to GC. Although eradication of H. pylori is a reasonable approach for the prevention of GC, there have been some contradictory reports, with only some long-term follow-up data showing efficacy of this approach. The inconsistencies are likely due to the insufficient number of participants, relatively short follow-up periods, poor quality of study designs, and the degree and extent of preneoplastic changes at the time of H. pylori eradication. This review analyzes recent high-quality studies to resolve the discrepancies regarding the eradication of H. pylori for GC prevention. The relationship between H. pylori eradication and GC/precancerous lesions/metachronous GC is examined, and the cost-effectiveness of this strategy in the prevention of GC is assessed. Although it is assumed that eradication of H. pylori has the potential to prevent GC, the feasibility and appropriate timing of this strategy for cancer prevention remain to be determined. As a result, additional well-designed trials with longer follow-up periods are needed to clarify this issue.
doi:10.3748/wjg.v20.i19.5660
PMCID: PMC4024774  PMID: 24914325
Helicobacter pylori; Gastric cancer; Cancer prevention
11.  Reduced genome size of Helicobacter pylori originating from East Asia 
Helicobacter pylori (H. pylori), a major pathogen colonizing the human stomach, shows great genetic variation. Comparative analysis of strains from different H. pylori populations revealed that the genome size of strains from East Asia decreased to 1.60 Mbp, which is significantly smaller than that from Europe or Africa. In parallel with the genome reduction, the number of protein coding genes was decreased, and the guanine-cytosine content was lowered to 38.9%. Elimination of non-essential genes by mutations is likely to be a major cause of the genome reduction. Bacteria with a small genome cost less energy. Thus, H. pylori strains from East Asia may have proliferation and growth advantages over those from Western countries. This could result in enhanced capacity of bacterial spreading. Therefore, the reduced genome size potentially contributes to the high prevalence of H. pylori in East Asia.
doi:10.3748/wjg.v20.i19.5666
PMCID: PMC4024775  PMID: 24914326
Helicobacter pylori; Genome; Mutation; Epidemiology; Recombination
12.  Treatment of early gastric cancer in the Western World 
The incidence rate of gastric cancer is much higher in Asia than in the Western industrial nations. According to the different screening programs in Japan and Korea about fifty percent of treated patients had an early tumor stage. In contrast, European and American patients with gastric cancer had an advanced tumor stage. Therefore, the experience for the various therapeutic options for gastric cancer may be different between these regions. In this review we tried to point out the treatment modalities in Western industrial countries for early gastric cancer.
doi:10.3748/wjg.v20.i19.5672
PMCID: PMC4024776  PMID: 24914327
Gastric cancer; Early cancer; Epidemiology; Diagnosis; Therapy; Western World
13.  Pathohistological classification systems in gastric cancer: Diagnostic relevance and prognostic value 
Several pathohistological classification systems exist for the diagnosis of gastric cancer. Many studies have investigated the correlation between the pathohistological characteristics in gastric cancer and patient characteristics, disease specific criteria and overall outcome. It is still controversial as to which classification system imparts the most reliable information, and therefore, the choice of system may vary in clinical routine. In addition to the most common classification systems, such as the Laurén and the World Health Organization (WHO) classifications, other authors have tried to characterize and classify gastric cancer based on the microscopic morphology and in reference to the clinical outcome of the patients. In more than 50 years of systematic classification of the pathohistological characteristics of gastric cancer, there is no sole classification system that is consistently used worldwide in diagnostics and research. However, several national guidelines for the treatment of gastric cancer refer to the Laurén or the WHO classifications regarding therapeutic decision-making, which underlines the importance of a reliable classification system for gastric cancer. The latest results from gastric cancer studies indicate that it might be useful to integrate DNA- and RNA-based features of gastric cancer into the classification systems to establish prognostic relevance. This article reviews the diagnostic relevance and the prognostic value of different pathohistological classification systems in gastric cancer.
doi:10.3748/wjg.v20.i19.5679
PMCID: PMC4024777  PMID: 24914328
Gastric cancer; classification; Laurén; World Health Organization classification; Pathohistology
14.  Sentinel lymph node navigation surgery for early stage gastric cancer 
We attempted to evaluate the history of sentinel node navigation surgery (SNNS), technical aspects, tracers, and clinical applications of SNNS using Infrared Ray Electronic Endoscopes (IREE) combined with Indocyanine Green (ICG). The sentinel lymph node (SLN) is defined as a first lymph node (LN) which receives cancer cells from a primary tumor. Reports on clinical application of SNNS for gastric cancers started to appear since early 2000s. Two prospective multicenter trials of SNNS for gastric cancer have also been accomplished in Japan. Kitagawa et al reported that the endoscopic dual (dye and radioisotope) tracer method for SN biopsy was confirmed acceptable and effective when applied to the early-stage gastric cancer (EGC). We have previously reported the usefulness of SNNS in gastrointestinal cancer using ICG as a tracer, combined with IREE (Olympus Optical, Tokyo, Japan) to detect SLN. LN metastasis rate of EGC is low. Hence, clinical application of SNNS for EGC might lead us to avoid unnecessary LN dissection, which could preserve the patient’s quality of life after operation. The most ideal method of SNNS should allow secure and accurate detection of SLN, and real time observation of lymphatic flow during operation.
doi:10.3748/wjg.v20.i19.5685
PMCID: PMC4024778  PMID: 24914329
Gastric cancer; Sentinel node navigation surgery; Infrared Ray Electronic Endoscopes; Indocyanine Green
15.  Role of microRNAs in gastric cancer 
Although gastric cancer (GC) is one of the leading causes of cancer-related death, major therapeutic advances have not been made, and patients with GC still face poor outcomes. The prognosis of GC also remains poor because the molecular mechanisms of GC progression are incompletely understood. MicroRNAs (miRNAs) are noncoding RNAs that are associated with gastric carcinogenesis. Studies investigating the regulation of gene expression by miRNAs have made considerable progress in recent years, and abnormalities in miRNA expression have been shown to be associated with the occurrence and progression of GC. miRNAs contribute to gastric carcinogenesis by altering the expression of oncogenes and tumor suppressors, affecting cell proliferation, apoptosis, motility, and invasion. Moreover, a number of miRNAs have been shown to be associated with tumor type, tumor stage, and patient survival and therefore may be developed as novel diagnostic or prognostic markers. In this review, we discuss the involvement of miRNAs in GC and the mechanisms through which they regulate gene expression and biological functions. Then, we review recent research on the involvement of miRNAs in GC prognosis, their potential use in chemotherapy, and their effects on Helicobacter pylori infections in GC. A greater understanding of the roles of miRNAs in gastric carcinogenesis could provide insights into the mechanisms of tumor development and could help to identify novel therapeutic targets.
doi:10.3748/wjg.v20.i19.5694
PMCID: PMC4024779  PMID: 24914330
MicroRNA; Gastric cancer; Reverse transcription-polymerase chain reaction; Chemosensitivity; Helicobacter pylori; Circulating MicroRNA
16.  miRNA polymorphisms and risk of gastric cancer in Asian population 
miRNAs are endogenous 19- to 25-nt noncoding RNAs that can negatively regulate gene expression by directly cleaving target mRNA or by inhibiting its translation. Recent studies have revealed that miRNA plays a significant role in gastric cancer development either as a tumor suppressor gene or oncogene. miRNA-single-nucleotide polymorphisms (SNPs), as a novel class of functional SNPs/polymorphisms, have been identified as candidate biomarkers for gastric cancer susceptibility. On the basis of recent data, the present review summarizes current knowledge of the functional effects of miRNA-SNPs and their importance as candidate gastric cancer biomarkers. Additionally, this review also includes a meta-analysis of the most frequently studied miRNA-SNPs in gastric cancer.
doi:10.3748/wjg.v20.i19.5700
PMCID: PMC4024780  PMID: 24914331
miRNA; Polymorphism; Gastric cancer; Risk
17.  Molecular diagnosis and treatment of drug-resistant hepatitis B virus 
Oral antiviral agents have been developed in the last two decades for the treatment of chronic hepatitis B (CHB). However, antiviral resistance remains an important challenge for long-term CHB therapy. All of the clinically available oral antiviral agents are nucleoside or nucleotide analogues that target the activity of viral reverse transcriptase (RT), and all are reported to have resistant mutations. Since the hepatitis B virus (HBV) RT, like other viral polymerases, lacks proofreading activity, the emergence of drug-resistance occurs readily under selective pressure from the administration of antiviral agents. The molecular diagnosis of drug-resistant HBV is based on sequence variations, and current diagnostic methods include sequencing, restriction fragment polymorphism analysis, and hybridization. Here, we will discuss the currently available molecular diagnosis tools, in vitro phenotypic assays for validation of drug-resistant HBV, and treatment options for drug-resistant HBV.
doi:10.3748/wjg.v20.i19.5708
PMCID: PMC4024781  PMID: 24914332
Hepatitis B virus; Drug-resistance; Molecular diagnosis; Antiviral treatment; Chronic hepatitis B
18.  Hepatitis B virus infection and intrahepatic cholangiocarcinoma 
Intrahepatic cholangiocarcinoma (ICC) is a devastating malignant tumor arising from the peripheral intrahepatic bile duct epithelium. The incidence and mortality of ICC is markedly increasing over the past two decades worldwide, though the cause for this rise in incidence is unclear, thus intensifying the search for alternative etiological agents and pathogenetic mechanisms. Hepatolithiasis, primary sclerosing cholangitis, parasitic infection (Opisthorchis viverrini or Clonorchis sinensis), fibropolycystic liver disease, and chemical carcinogen exposure are thought to be the risk factors for ICC. Nevertheless, the majority of ICC patients do not have any of these risk factors, and none of the established risk factors can explain the recent increasing trend of ICC. Therefore, identifying other risk factors may lead to the prevention and early detection of ICC. Chronic hepatitis B virus (HBV) infection is the predominant cause of hepatocellular carcinoma in HBV-endemic areas. This review discusses the evidence implicating chronic HBV infection as a likely etiology of ICC and the pathogenetic mechanisms that might be involved.
doi:10.3748/wjg.v20.i19.5721
PMCID: PMC4024782  PMID: 24914333
Hepatitis B virus; Intrahepatic cholangiocarcinoma; Epidemiology; Etiopathogenesis
19.  Optimization therapy for the treatment of chronic hepatitis B 
Chronic hepatitis B (CHB) is currently medically managed with either interferon-alpha or one of the five nucleos(t)ide analogs. However, there are still a large number of CHB patients whose response to the above therapies remains less than satisfactory, and their incomplete or non-response to antiviral therapies has plagued clinicians worldwide. In recent years, a newly proposed optimization therapy has provided us with a new approach to solve this problem. The key points in this optimization therapy are to initiate antiviral therapy with an appropriate agent at the correct time point, and to adjust treatments in patients with poor early responses by adding a second agent or switching to another more potent agent. In this review, we summarize recent developments in optimization therapy for the treatment of CHB, and provide an outlook for future research in this field.
doi:10.3748/wjg.v20.i19.5730
PMCID: PMC4024783  PMID: 24914334
Chronic hepatitis B; Nucleos(t)ide analog; Interferon; Suboptimal response; Optimization therapy
20.  Deep vein thrombosis and pulmonary embolism in cirrhotic patients: Systematic review 
Patients with liver cirrhosis were traditionally believed to be protected against development of blood clots. Lately, studies have shown that these patients may probably be at an increased risk of venous thrombotic complications. Although the hemostatic changes in the chronic liver disease patients and the factors that may predict bleeding vs thrombotic complications remains an area of active research, it is believed that the coagulation cascade is delicately balanced in these patients because of parallel reduced hepatic synthesis of pro and anticoagulant factors. Thrombotic state in cirrhotic patients is responsible for not only portal or non-portal thrombosis [deep vein thrombosis (DVT) and pulmonary embolism (PE)]; it has also been associated with progression of liver fibrosis. The use of anticoagulants in cirrhosis patients is a challenging, and often a scary situation. This review summarizes the current literature on the prevalence of venous thrombosis (DVT and PE), risk factors and safety of prophylactic and therapeutic anticoagulation in patients with chronic liver disease.
doi:10.3748/wjg.v20.i19.5737
PMCID: PMC4024784  PMID: 24914335
Deep venous thrombosis; Chronic liver disease; Cirrhosis; Thrombosis; Anticoagulation; Pathogenesis; Portal vein thrombosis
21.  Pathogenic role of oxidative and nitrosative stress in primary biliary cirrhosis 
Primary biliary cirrhosis is a multifactor autoimmune disease characterized by hepatic and systemic manifestations, with immune system dysregulation and abnormalities in the hepatic metabolism of bile salts, lipids, and nutrients, as well as destruction of membrane lipids and mitochondrial dysfunction. Both oxidative and nitrosative stress are associated with ongoing manifestations of the disease. In particular, abnormalities in nitric oxide metabolism and thiol oxidation already occur at early stages, thus leading to the hypothesis that these biochemical events play a pathogenic role in primary biliary cirrhosis. Moreover, the association of these metabolic abnormalities with the progression of the disease may indicate some biochemical parameters as early diagnostic markers of disease evolution, and may open up the potential for pharmacological intervention to inhibit intra- and extra-cellular stress events for resuming hepatocellular functions. The following paragraphs summarize the current knowledge by outlining molecular mechanisms of the disease related to these stress events.
doi:10.3748/wjg.v20.i19.5746
PMCID: PMC4024785  PMID: 24914336
Aquaporins; Bile salts; Chronic cholestasis; Glutathione; Mitochondria; Nitrosothiols; Nitrotyrosine; Protein sulfhydryls; Thioredoxin
22.  Antitubercular therapy in patients with cirrhosis: Challenges and options 
Tuberculosis (TB) has been a human disease for centuries. Its frequency is increased manyfold in patients with liver cirrhosis. The gold standard of TB management is a 6-mo course of isoniazid, rifampicin, pyrazinamide and ethambutol. Although good results are seen with this treatment in general, the management of patients with underlying cirrhosis is a challenge. The underlying depressed immune response results in alterations in many diagnostic tests. The tests used for latent TB have many flaws in this group of patients. Three of four first-line antitubercular drugs are hepatotoxic and baseline liver function is often disrupted in patients with underlying cirrhosis. Frequency of hepatotoxicity is increased in patients with liver cirrhosis, frequently leading to severe liver failure. There are no established guidelines for the treatment of TB in relation to the severity of liver disease. There is no consensus on the frequency of liver function tests required or the cut-off used to define hepatotoxicity. No specific treatment exists for prevention or treatment of hepatotoxicity, making monitoring even more important. A high risk of multidrug-resistant TB is another major worry due to prolonged and interrupted treatment.
doi:10.3748/wjg.v20.i19.5760
PMCID: PMC4024786  PMID: 24914337
Antitubercular therapy; Drug hepatotoxicity; Multidrug-resistant tuberculosis; Immune dysfunction
23.  Autophagy in hepatitis C virus-host interactions: Potential roles and therapeutic targets for liver-associated diseases 
Autophagy is a lysosome-associated, degradative process that catabolizes cytosolic components to recycle nutrients for further use and maintain cell homeostasis. Hepatitis C virus (HCV) is a major cause of chronic hepatitis, which often leads to end-stage liver-associated diseases and is a significant burden on worldwide public health. Emerging lines of evidence indicate that autophagy plays an important role in promoting the HCV life cycle in host cells. Moreover, the diverse impacts of autophagy on a variety of signaling pathways in HCV-infected cells suggest that the autophagic process is required for balancing HCV-host cell interactions and involved in the pathogenesis of HCV-related liver diseases. However, the detailed molecular mechanism underlying how HCV activates autophagy to benefit viral growth is still enigmatic. Additionally, how the autophagic response contributes to disease progression in HCV-infected cells remains largely unknown. Hence, in this review, we overview the interplay between autophagy and the HCV life cycle and propose possible mechanisms by which autophagy may promote the pathogenesis of HCV-associated chronic liver diseases. Moreover, we outline the related studies on how autophagy interplays with HCV replication and discuss the possible implications of autophagy and viral replication in the progression of HCV-induced liver diseases, e.g., steatosis and hepatocellular carcinoma. Finally, we explore the potential therapeutics that target autophagy to cure HCV infection and its related liver diseases.
doi:10.3748/wjg.v20.i19.5773
PMCID: PMC4024787  PMID: 24914338
Autophagy; Hepatitis C virus; Steatosis; Cirrhosis; Hepatocellular carcinoma
24.  Laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension 
Since the first laparoscopic splenectomy (LS) was reported in 1991, LS has become the gold standard for the removal of normal to moderately enlarged spleens in benign conditions. Compared with open splenectomy, fewer postsurgical complications and better postoperative recovery have been observed, but LS is contraindicated for hypersplenism secondary to liver cirrhosis in many institutions owing to technical difficulties associated with splenomegaly, well-developed collateral circulation, and increased risk of bleeding. With the improvements of laparoscopic technique, the concept is changing. This article aims to give an overview of the latest development in laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension. Despite a lack of randomized controlled trial, the publications obtained have shown that with meticulous surgical techniques and advanced instruments, LS is a technically feasible, safe, and effective procedure for hypersplenism secondary to cirrhosis and portal hypertension and contributes to decreased blood loss, shorter hospital stay, and less impairment of liver function. It is recommended that the dilated short gastric vessels and other enlarged collateral circulation surrounding the spleen be divided with the LigaSure vessel sealing equipment, and the splenic artery and vein be transected en bloc with the application of the endovascular stapler. To support the clinical evidence, further randomized controlled trials about this topic are necessary.
doi:10.3748/wjg.v20.i19.5794
PMCID: PMC4024788  PMID: 24914339
Laparoscopy; Splenectomy; Liver cirrhosis; Portal hypertension; Hypersplenism
25.  Acute pancreatitis: The stress factor 
Acute pancreatitis is an inflammatory disorder of the pancreas that may cause life-threatening complications. Etiologies of pancreatitis vary, with gallstones accounting for the majority of all cases, followed by alcohol. Other causes of pancreatitis include trauma, ischemia, mechanical obstruction, infections, autoimmune, hereditary, and drugs. The main events occurring in the pancreatic acinar cell that initiate and propagate acute pancreatitis include inhibition of secretion, intracellular activation of proteases, and generation of inflammatory mediators. Small cytokines known as chemokines are released from damaged pancreatic cells and attract inflammatory cells, whose systemic action ultimately determined the severity of the disease. Indeed, severe forms of pancreatitis may result in systemic inflammatory response syndrome and multiorgan dysfunction syndrome, characterized by a progressive physiologic failure of several interdependent organ systems. Stress occurs when homeostasis is threatened, and stressors can include physical or mental forces, or combinations of both. Depending on the timing and duration, stress can result in beneficial or harmful consequences. While it is well established that a previous acute-short-term stress decreases the severity of experimentally-induced pancreatitis, the worsening effects of chronic stress on the exocrine pancreas have received relatively little attention. This review will focus on the influence of both prior acute-short-term and chronic stress in acute pancreatitis.
doi:10.3748/wjg.v20.i19.5801
PMCID: PMC4024789  PMID: 24914340
Pancreatitis; Acute stress; Chronic stress; Heat shock proteins; Tumor necrosis factor alpha

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