Jayant Kumar Ghosh

Assessment of the Model for End-stage Liver Disease (MELD) Score in Predicting Prognosis of Patients with Alcoholic Hepatitis

BACKGROUNDnTraditionally, Maddrey discriminant function (DF) score has been used for stratifying the prognosis of alcoholic hepatitis. Recently, the Model for end-stage liver disease (MELD) score has been applied to alcoholic hepatitis and some investigators consider MELD score as a better prognostic indicator. Another new prognostic approach, Lille model has been also suggested to accurately identify patients at high risk of death. Therefore, this prospective study was aimed to compare MELD, DF, Child-Turcotte-Pugh (CTP) scores and Lille model for predicting the short-term mortality in Indian patients with alcoholic hepatitis.nnnMETHODSnWe calculated the DF, CTP, MELD and Lille scores in patients hospitalized with alcoholic hepatitis & evaluated if the scores predicted in-hospital mortality.nnnRESULTSnA total of 104 patients were enrolled and thirty-two (30.7%) patients died during the hospitalization (2-30 days). Admission DF score (OR 1.1, Pxa0<xa00.04), CTP (OR 2, Pxa0<xa00.05) MELD score (OR 2.2, Pxa0<xa00.005) and first week MELD score (OR 1.1, Pxa0<xa00.05) were independently associated with in-hospital mortality. The area under the receiver-operating curve (AUROC) for the admission and day 7 MELD score was significantly higher than CTP scorexa0and was comparable to DF score and Lille model (AUC & 95% CI: 0.97 [0.95-1.0], 0.99 [0.99-1.0], 0.91 [0.83-0.91] and 0.92 [0.86-0.98] for MELD at admission & day 7, admission DF and Lille model, respectively). The MELD score >14 at admission and >12 at day 7 had high sensitivity and specificity in predicting short-term mortality (96%, 89% and 95%, 98% respectively). The cutoff of 0.45 for the Lille model was able to identify 79% of the observed deaths, whereas DF score ≥32 for DF were able to identify 85%.nnnCONCLUSIONnMELD score, as a predictive model for assessment of short-term mortality in alcoholic hepatitis is better than CTP and comparable to DF and Lille model.

HBsAg Level as Predictor of Liver Fibrosis in HBeAg Positive Patients With Chronic Hepatitis B Virus Infection

BACKGROUND AND AIMSnPreliminary data suggests lower serum hepatitis B surface antigen level is associated with more severe liver fibrosis in HBeAg positive patients. We evaluated the association of HBsAg level with biochemical, virological, and histological features in asymptomatic patients with chronic HBV infection.nnnMETHODSnHBsAg levels were measured at baseline in 481 asymptomatic, treatment naive patients with chronic HBV infection. Subjects were followed-up prospectively (median, 12; range, 8-36 months). Phases of HBV infection were defined after regular monitoring of HBV-DNA and transaminases. Liver histology was scored using the METAVIR system.nnnRESULTSnHBeAg positive (n, 126) patients were significantly younger than HBeAg negative (n, 355), median age 26 vs 30 years; Pxa0<xa00.01. HBV genotype could be determined in 350 patients, 240 (68.57%) had genotype D and 100 (28.57%) had genotype A. HBsAg level had modest correlation with serum HBV DNA(rxa0=xa00.6 vs 0.4 in eAg positive & negative respectively). HBeAgxa0+xa0ve patients with fibrosis scorexa0≥xa0F2 showed significantly lower median serum HBsAg levels and serum HBV DNA levels compared with patients with F0-F1 score (median, range; 4.51, 2.99-6.10 vs 5.06, 4.13-5.89, Pxa0<xa00.01) and (8.39, 3.85-10.60, Pxa0<xa00.01) respectively. Significant inverse correlation of HBsAg level was found with liver fibrosis in eAg positive group (rxa0=xa0-0.76; Pxa0<xa00.001). HBsAg level cut off value 4.7xa0log10xa0IU/ml predicted moderate to advance fibrosis (Fxa0≥xa02) with 92% sensitivity, 85% specificity & 91% negative predictive value.nnnCONCLUSIONnLower HBsAg level might reflect the status of advanced liver fibrosis in HBeAg positive chronic hepatitis B subjects.

Hydatid Cyst of Liver Presented as Obstructive Jaundice in Pregnancy; Managed by PAIR.

Incidence of Hydatid disease in pregnancy ranges from 1in 20,000 to 1 in 30,000. The most common site of hydatid cysts is the liver. The diagnosis of liver hydatid cysts is not difficult but the management during pregnancy is problematic. Both medical and surgical treatments are available but there is no consensus and each case has to be individualized. We present a case of liver hydatid cyst presented with obstructive jaundice during pregnancy which was managed by Puncture of the cyst under USG guidance; Aspiration of the cystic fluid, Injection of hypertonic saline, and Re-aspiration of solution without drainage (PAIR) and albendazole therapy. Very few cases of liver hydatosis were reported previously which had been managed by PAIR.

Polyarticular tuberculosis missed diagnosed as juvenile idiopathic arthritis

We report a child with multiple joint swellings, being treated as a case of poly-articular juvenile idiopathic arthritis subsequently turned out to be tubercular origin. Development of overlying sinuses, lytic lesions on radiographs, synovial fluid analysis showing tubercular infection and demonstration of epitheloid granulomas on bone biopsy confirmed the diagnosis of tubercular poly-arthritis with dactylitis. Child was asymptomatic after two months of starting antitubercular treatment. The case highlights the need to consider the possibility of tuberculosis as aetiology of poly-arthritis, at least in endemic areas, even in the absence of a tuberculosis contact history and overt pulmonary symptoms.

Intrauterine foreign body presenting as a rectal bezoar and causing chronic diarrhea.

A 32-year-old woman presented to us with a 7-month history of chronic low grade lower abdominal pain and diarrhea of large-bowel type, which had begun after the delivery of her baby by Caesarean section. She had been treated with antibiotics, probiotics, and anticholinergic drugs. A colonoscopy was performed, which showed what appeared to be a large bandage that was completely embedded in the rectal mucosa and could not be removedwith foreign-body removal forceps (● Fig.1). An ultrasound was performed, which revealed that anteriorly the bandage was embedded in the uterine wall and posteriorly it was eroding the rectal wall (● Fig.2). The patient then informed us that during her Caesarean section a swab had gone missing. Postoperativelya thoroughsearch had been undertaken using ultrasonography but nothing abnormal had been identified. She developed diarrhea and vague low grade lower abdominal pain 1 week later and was treated initially for infective diarrhea and then as irritable bowel syndrome (IBS). After the colonoscopic discovery of the missing swab, surgical removal of the foreign body and repair of the tear was undertaken at our institute. She was well on discharge and at a follow-up appointment 2 weeks later. The term “bezoar” originates from the Arabic term badzehar,meaning “antidote.” Bezoars most commonly form in stomach, but may occur in the small intestine and, rarely, in the colon or rectum [1]. Bezoars include phytobezoars (composed of indigestible food materials such as seeds and pips), trichobezoars (composed of hair), lactobezoars (composed of lactose), and pharmacobezoars (composed of medications). Common clinicalmanifestations include nausea, vomiting, anorexia, weight loss, constipation, and obstipation. Possible complications of bezoars include obstruction, ulceration, hemorrhage, and perforation [2]. There are rare cases reported in the literature of rectal bezoars being caused by watermelon seeds, sunflower seeds, and invading plant materials [3–5]. However, there are no previous reports of an iatrogenic intrauterine foreign body that has eroded into the rectal wall presenting as chronic diarrhea and being diagnosed colonoscopically as a rectal bezoar.