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Three days later, he was admitted to the emergency department with complaints of abdominal pain, weakness, and dizziness, which had started after hemodialysis. On examination, the blood pressure was 90/55 mmHg and the pulse was 105 beats/min. On physical examination, he had tenderness in all abdominal quadrants. On laboratory examination, the Hb level was 8.2 g/dl. Ultrasonographic examination revealed abundant intraperitoneal free fluid, with a maximum depth of about 8 cm. Paracentesis was performed and hemorrhagic fluid was detected. Erythrocyte concentrates and fresh frozen plasma were transfused during hospitalization; the patient was again discharged 3 days later without surgical requirement. Severe bleeding is defined by radiological evidence of intraperitoneal bleeding and requires hospitalization, with the likelihood of a transfusion or even radiological or surgical interventions. It occurs in 1/2500–10 000 biopsies after the intercostal percutaneous approach for diffuse liver disease [3]. Management of antiplatelet and anticoagulant drugs before and after liver biopsy is still an important issue. Data addressing the use of intravenous or subcutaneous heparin or heparin-like compounds during the peribiopsy period are lacking. According to the American Association for the Study of Liver Diseases guidelines, patients on chronic hemodialysis should be well dialyzed before liver biopsy, and heparin should be avoided if at all possible [4]. However, there are no data on the postbiopsy period. Routine desmopressin use appears to be unnecessary in patients on stable dialysis regimens. In our case, the patient was dialyzed without heparin before and after liver biopsy. However, on the third day of biopsy, he took heparin during the hemodialysis, which probably caused premature clot dissolution at the biopsy area of the liver. In conclusion, intraperitoneal bleeding after liver biopsy may be a life-threatening, serious complication for patients on chronic hemodialysis because of heparin intake. Extension of the hemodialysis period without heparin after liver biopsy may be recommended to avoid major bleeding due to premature clot dissolution.

Acknowledgements Conflicts of interest

There are no conflicts of interest.

References 1 2

3

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Bedossa P. Liver biopsy. Gastroenterol Clin Biol 2008; 32:4–7. Huang JF, Hsieh MY, Dai CY, Hou NJ, Lee LP, Lin ZY, et al. The incidence and risks of liver biopsy in non-cirrhotic patients: an evaluation of 3806 biopsies. Gut 2007; 56:736–737. Firpi RJ, Soldevila-Pico C, Abdelmalek MF, Morelli G, Judah J, Nelson DR. Short recovery time after percutaneous liver biopsy: should we change our current practices? Clin Gastroenterol Hepatol 2005; 3:926–929. Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD. American Association for the Study of Liver Diseases. Liver biopsy. Hepatology 2009; 49:1017–1044.

Should we investigate retinopathy in chronic Letters to the Editor hepatitis C patients receiving treatment with interferon? Sami Aoufi Rabiha, Laura Blanca Alfaya Mun˜ozb, A´lvaro Fidalgo Broncanob, Rosanna Villanueva Herna´ndeza, Pedro Gonza´lez Carroa and Francisco Pe´rez Rolda´na, aDepartment of Gastroenterology and Hepatology, Hepatology Unit and bDepartment of Ophthalmology, La Mancha-Centro Hospital Complex, Alca´zar de San Juan, Spain Correspondence to Sami Aoufi Rabih, PhD, Department of Gastroenterology and Hepatology, Hepatology Unit, La Mancha-Centro Hospital Complex, Avda. de la Constitucio´n s/n, 13600 Alca´zar de San Juan, Ciudad Real, Spain Tel: + 34 638 227 755; fax: + 34 926 580 962; e-mail: [email protected] Received 15 May 2013 Accepted 18 May 2013

Retinopathy secondary to interferon (IFN) was described in 1990. Its incidence is uncertain. Published studies include clinical cases and short series of patients, between 18 and 86% with monointerferon and much lower with pegylated IFN [1,2]. There seems to be a direct relationship between the dose of IFN and the duration of treatment [1]. It may appear from week 8 of treatment initiation. Patients with retinopathy secondary to IFN are usually asymptomatic and do not have loss of visual acuity. It disappears completely in most patients after the discontinuation of antiviral treatment [1,3]. There have also been some cases caused by hepatitis C virus with the formation of a variety of thrombogenic antibodies [4], causing retinal damage [1]. IFN has been associated with the occurrence of subconjunctival hemorrhage, choroidal neovascularization, vasospasm, neovascular glaucoma, retinal vascular occlusion, ischemic optic neuropathy, and Vogt– Koyanagi–Harada-like syndrome [3]. It must be discontinued if there is decreased visual acuity or intense retinal ischemia [1]. Pathogenesis has been classically attributed to immune complex deposition in retinal vessels and the increase in leukocyte adhesion to the vascular endothelium caused by the IFN [2,4]. Ribavirin may contribute toward the retinopathy by its synergistic action in combination with IFN [3]. A fundus of the eye usually indicates a cottony exudate, as does the optical coherence tomography. Diabetes mellitus and arterial hypertension may cause retinal damage and, therefore, facilitate the progression of retinopathy secondary to IFN or to hepatitis C virus [2]. The aim of this study was to determine the prevalence of retinopathy in a cohort of chronic hepatitis C patients receiving or not antiviral treatment with IFN and ribavirin. We consecutively enrolled chronic hepatitis C patients from the Hepatology Consultation in La Mancha-Centro Hospital Complex, Alca´zar de San Juan, Ciudad Real, Spain. We excluded patients older than 75 years of age and those with ocular pathology caused by other diseases (arterial hyperten-

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Letters to the Editor 243

Fig. 1

Overlay Circle

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Axial section of optical coherence tomography, which shows an exudate at the superior temporal area. Involvement of the outer layers of the retina can be seen.

sion, diabetes, etc.). Patients underwent a fundus of the eye performed by a single ophthalmologist. We recruited 219 chronic hepatitis C patients of all genotypes, of whom 81 were excluded because of concomitant eye diseases. In all, 63.4% of patients were men, mean age 54 years (18–74). Seventy-three percent of patients were infected with genotype 1. We performed a fundus of the eye in 138 patients; 18 were receiving treatment with pegylated IFN and ribavirin. Of the 138 patients studied, pathological changes were found in one patient, who was treated with IFN (prevalence 5.5%). The characteristics of the lesions were attributed to antiviral treatment by the ophthalmologist (Fig. 1). None of the patients studied showed visual symptoms during the study. The prevalence of ophthalmic disorders in chronic hepatitis C patients is zero in our series and very low in those receiving antiviral treatment with IFN. However, because the fundus is inexpensive, noninvasive, easy to perform, and accessible at all sites, it seems advisable to indicate it in patients undergoing treatment with IFN. Our series is the largest in the literature and highlights not only the type of retinal changes associated with treatment with IFN but also the prevalence of this disease in this population.

Acknowledgements Conflicts of interest

There are no conflicts of interest.

References 1

2

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Cuthbertson FM, Davies M, McKibbin M. Is screening for interferon retinopathy in hepatitis C justified? Br J Ophthalmol 2004; 88: 1518–1520. Okuse C, Yotsuyanaqi H, Nagase Y, Kobayashi Y, Yasuda K, Koike K, et al. Risk factors for retinopathy associated with interferon-2b and ribavirin combination therapy in patients with chronic hepatitis C. World J Gastroenterol 2006; 12:3756–3759. Se`ne D, Touitou V, Bodaghi B, Saadoun D, Perlemuter G, Cassoux N, et al. Intraocular complications of IFN-alpha and ribavirin therapy in patients with chronic viral hepatitis C. World J Gastroenterol 2007; 13:3137–3140. Helal J Jr, Zacharias LC, de Alencar LM. Central vein occlusion in a patient using interferon and ribavirin: case report. Arq Bras Oftalmol 2006; 69:601–604.

Letters to the Editor

Active Helicobacter pylori infection on colorectal mucosa – adenomatous polyp – adenocarcinoma sequence Jannis Kountouras, Nikolaos Kapetanakis, Christos Zavos, Stergios A. Polyzos and Iordanis Romiopoulos, Department of Medicine, Second Medical Clinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece Correspondence to Jannis Kountouras, MD, PhD, 8 Fanariou St, Byzantio, 551 33 Thessaloniki, Macedonia, Greece Tel: + 30 2310 892238; fax: + 30 2310 992794; e-mail: [email protected] Received 6 July 2013 Accepted 17 July 2013

In their meta-analysis, Rokkas et al. [1] showed a modest relationship between Helicobacter pylori (Hp) infection (Hp-I) and colorectal cancer (CRC) and adenomas (CRA), although the authors mentioned some limitations: the majority of the studies used serology, which detects past rather than active Hp-I [1]. On the basis of histology, the practical diagnostic gold standard for active Hp-I, our studies on 50 CRC patients,

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Should we investigate retinopathy in chronic hepatitis C patients receiving treatment with interferon?

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