Viral eradication is the primary goal in HCV Treatment-Wasim Jafari


 Gastroenterology conference proceedings-I

Viral eradication is the primary goal
in HCV Treatment-Wasim Jafari

Future of GI cancer lies in early diagnosis and treatment-Ho Khek Yu

KARACHI: Patient selection, timely diagnosis, timely availability of DAAS, effective measures to keep pace with the world are extremely important while viral eradication is the primary goal in HCV Treatment. This was stated by Prof. Wasim Jafri an eminent gastroenterologist from Aga Khan University Hospital Karachi. He was delivering a State of the Art lecture on “Hepatitis-C from 1989-2017 and Beyond” at the first plenary session during the recent held 33nd Annual congress of Pakistan Society of Gastroenterology and GI Endoscopy held from March 9-11, 2017. This session was chaired by Prof. M. Saeed Quraishy President of the Society along with Prof. Aamir Ghafoor Khan.

Tracing the history Prof. Wasim Jafri said that it was Choo and his colleagues who in 1989 found Hepatitis- C virus which was earlier used to be known as Non-A Non-B. This was a milestone in liver disorder and this was published in Journal of Hepatology in 1989. It was accompanied by a commentary by Patrizaia Farei. He then discussed the characteristics of Hepatitis-C in detail. It has a half-life of 2.7 hours. According to estimates there are about 30-35 Million patients in South East Asia. It has a chronicity of 70-90%. Almost 60% of liver cancer patients are suffering from Hepatitis-C while 51% of Thalassemia patients also suffer from it. Hepatitis-C accounts for 46% of chronic liver disease and 18% of cirrhotic patients. He himself wrote about it and published it in 1989.

Prof. Shahab Abid Chairman Scientific Committee presenting Mementoes to
Prof. Wasim Jafri and Prof. Greger Lindberg during the Plenary Session of
Gastroenterology Congress on March 10, 2017.

Continuing Prof. Wasim Jafri said that according to the PMRC survey the prevalence of Hepatitis-C in Pakistan is about 4.9%. The prevalence figures vary in different parts of the country. One of the reasons is the use of too many injections by patients in Pakistan which is reported to be fourteen per person annually which is too much. Studies have also shown that almost 1.6% of children below ten years of age are positive for HCV. Almost 80-90% of our Hepatitis-C patients are of Genotype-3. He then talked about major obstacles in developing vaccine for Hepatitis-C. After China, Pakistan also has too many patients of Hepatitis-C and it is estimated that we may be having about eight million patients of Hepatitis-C.

Treatment was started with Interferon in combination with Ribavirin. Later Peg Interferon was introduced. It was in 2013 that the first oral medication for Hepatitis-C Sovaldi was approved by FDA and now ten different oral medications for the treatment of Hepatitis-C have been marketed during the last three years. All of these ten are FDA approved but in Pakistan we have just one of them. SVR, Prof. Wasim Jafri stated means cure. The mortality from Hepatitis-C has also dramatically reduced from 26 to 10%. Mortality from liver disease was now 2% and there has been 5.1% reduction in the prevalence of HCC as well. The question arises what is next? At present we have just one oral medication for Hepatitis-C available in Pakistan and other oral medications have not yet been registered. Now three weeks treatment for Hepatitis-C is possible. Studies from China have showed 100% response to HCV treatment. It is important that the Generics available should have good bioequivalence.

Glecapivir Prof. Wasim Jafri stated was an excellent drug. With twelve weeks treatment is has sown 94-100% cure rates. In renal failure patients or those with renal impairment its response rate is 98%. Relapse cases are also responding better. He was of the views that if nurses, GPs, Specialists all are educated, practice ethical medicine, the results could be very good. He was of the view that we need to identify our priorities and we must have more oral medications available. WHO has now stated that with the availability of effective oral medications, Hepatitis-C should be eradicated from the World by 2030? He also laid emphasis on use of safe blood, safe blood products, and ensuring safe injection practices. In 2015 just less than 1% of people were getting Hepatitis-B vaccine and HCV treatment was also very disappointing. We need to ensure that almost 80% of these patients now must receive medications, he added.

Innovations in GI Endoscopy procedures

Prof. Lawrence Khek Yu Ho Vice Dean at National University of Singapore was the next speaker. His presentation was on Innovations in GI Endoscopy procedures. He pointed out that the surviving cancer in United States from Breast to uterine was 80-84% whereas GI cancer was not doing as good as the survival figures were just 7%. This is because we do not pick up these cancers early and they are also not easily accessible. The survival figures for liver cancer was 7% and for pancreases cancer it was 4%. He then spoke about evaluation of diagnostic endoscopy and pointed out that real time diagnosis for real time diseases are needed. His advice to his colleagues was not to do un-necessary biopsies, go for precise resection margins. NBI is operator dependent. He then depicted some laser endoscopy slides.

Prof. M. Saeed Quraishy President of PSG & GI Endoscopy, Prof.Shahab Abid, Prof.Wasim Jafri, Prof. Aamir
Ghafoor, Prof. Baddar Fayaz Zuberi, Prof. Zagham Abbas, Prof. Zahid Azam and others photographed

during the PSG’s 33rd Annual conference held at Karachi from March 9-11, 2017.

Continuing Prof. Yu Ho talked about molecular fingerprint, and also discussed the real time molecular diagnostic system. Each pathology, he stated, has a unique molecular finger print. Insertion of Raman probe can focal ranan diagnosis. For gastric cancer, endoscopic practices are changing fast. An ideal Endo surgical system uses Robots which is known as MASTER. He also disclosed that world’s first Endoscopic Robotic Gastric EST was done in 2011. Five patients suffering from gastric cancer were treated in Hong Kong. Now over the years the learning curve has also reduced. We can deal with complications. He also showed Robot assisted Robotic clipping. He then spoke about Endoluminal surgery, Natural Orifice Surgery and pointed out that two robotic arms can go in with the endoscope. He also demonstrated endoscopic suturing device and Robotic laparoscopy. He concluded his presentation by stating that future of GI cancer lies in early diagnosis and treatment.

Dr. Greger Lindberg from Sweden was the next speaker in this plenary session who spoke on  “ROME-IV: What is New” as related to future of GI diseases. There has been changes in terminology and scope. The word Function has been dropped from the new revised Guidelines and now it is just esophageal diseases, GI diseases, Gall Bladder and Sphincter etc. He then spoke about functional dyspepsia, post prandial distress syndrome. For chronic symptoms, we need adequate relief. Antidepressants, he said, may work. As regards Irritable Bowel Syndrome, its sub-classification remain unchanged. He also talked how one should treat a patient with FGID and also referred to IBS symptoms complex.

During the last forty years from 1976 to 2016, what has happened to IBS? He then mentioned about lactose malabsorption, Celiac Disease, Microscopic colitis. Sclerotherapy was started and it did cure the patient. IBS like symptoms, Dr. Greger Lindberg stated can arise from many other diseases. In the days to come improvement in diagnosis will take place. Environmental factors will be studied and we will know about the mechanism of quite a few unknown diseases, he remarked.

Prof. Prof. Saeed Quraishy in his introductory remarks said that now we have peace in Karachi. Previously there were lot of difficulties in organizing a conference here. For this meeting we have been able to attract lot of eminent faculty from abroad. Eminent experts from UK, USA, China, India, Singapore, Iran and a few other countries are here. We have had a number of pre-conference workshops which were very well attended. We have seen many now interventions which are not uncommon in many developing countries but are new to Pakistan. He thanked Prof.Badar Fayaz Zuberi, Prof.Shahab Abid, Prof.Aamir Ghafoor and others for making wonderful arrangements. He also congratulated the new President Prof. Masood Siddique and hoped he will strive further to promote this discipline.

Prof.Badar Fayaz Zuberi the moving spirit behind this congress traced the history of Pakistan Society of Gastroenterology and G. I. Endoscopy which was formed in 1960s. Now it has chapters in all the provinces besides a Federal Chapter. We have witnessed and introduced lot of innovations in teaching, training and treatment over these years in this specialty. Chairman of the Scientific Committee gave a brief overview of the scientific programme and also pointed out that they had over two dozen very interesting cases in the Workshop.

Advance Endoscopy workshop was organized on March 9th where the Course Director Dr.Saad Niaz gave a brief introduciton to the course. The programme included Mini Talks and procedures like EUS+FNA, ERCP and EMR. In the second session again there were mini talks and procedures which covered Use of spy glass digital, pancreatic ducdt stones removal and EUS-Celia plexus block. In the third session, the topics which were covered included Pancreatic Pseudo cyst drainage and Choledochogstrostomy. Detailed reports about other sessions will follow.