Mallikarjun Patil

Drug‐Induced liver injury with hypersensitivity features has a better outcome: A single‐center experience of 39 children and adolescents

Drug‐induced liver injury (DILI) is rare in children and adolescents, and, consequently, data are remarkably limited. We analyzed the causes, clinical and biochemical features, natural history, and outcomes of children with DILI. Consecutive children with DILI from 1997 to 2004 (retrospective) and 2005 to 2010 (prospective) were studied based on standard criteria for DILI. Thirty‐nine children constituted 8.7% of 450 cases of DILI. There were 22 boys and 17 girls. Median age was 16 years (range, 2.6‐17). Combination antituberculous drugs were the most common cause (n = 22), followed by the anticonvulsants, phenytoin (n = 10) and carbamazepine (n = 6). All of the 16 children (41%) who developed hypersensitivity features, such as skin rashes, fever, lymphadenopathy, and/or eosinophilia, including the 3 with Stevens‐Johnson syndrome, survived. Those with hypersensitivity presented earlier (24.5 versus 35 days; P = 0.24) had less severe disease (MELD, 16 versus 29; P = 0.01) and had no mortality (0/16 versus 12/23; P < 0.001), compared to those without hypersensitivity. The 12 fatalities were largely the result of antituberculous DILI (n = 11). The presence of encephalopathy and ascites were associated with mortality, along with hyperbilirubinemia, high international normalized ratio, and serum creatinine. According to the Roussel Uclaf Causality Assessment Method, 18 were highly probable, 14 probable, and 7 possible. Thirty‐two children were hospitalized. Conclusion: DILI is not uncommon in children and accounts for 8.7% of all patients with DILI. Antituberculous drugs and anticonvulsants are the leading causes of DILI in India. Overall mortality is high (30.7%), largely accounted by antituberculous drugs. Children with DILI and hypersensitivity features present early, have less severe disease, and, consequently, a better prognosis, compared to those without, and are often associated with anticonvulsants or sulfonamides. (HEPATOLOGY 2011;)

Outcome and determinants of mortality in 269 patients with combination anti-tuberculosis drug-induced liver injury

Worldwide anti‐tuberculosis (TB) drug‐induced liver disease (DILI) is an important cause of hepatotoxicity, and drug‐induced acute liver failure (ALF). Reported series on anti‐TB DILI are limited by a mix of cases with mild transaminase elevation or adaptation. Our aim was to analyze the clinical features, laboratory characteristics, outcome, and determine predictors of 90‐day mortality.

Drug-induced liver injury associated with stevens-Johnson syndrome/toxic epidermal necrolysis: Patient characteristics, causes, and outcome in 36 cases.

The liver and skin are the organs most commonly involved in serious adverse drug reactions. Rarely a drug reaction can affect both organs concurrently. The association of drug‐induced liver injury (DILI) and Stevens‐Johnson syndrome (SJS) or toxic epidermal necrosis (TEN) is even rarer and not well studied. We describe our experience of DILI occurring in association with SJS/TEN including the etiologic agents, clinical and biochemical characteristics, and outcome. We identified patients who developed DILI in association with SJS/TEN from a registry of DILI patients from a single center. Causality assessment for DILI and SJS/TEN was carried out with the Roussel Uclaf Causality Assessment Method and the Algorithm for Drug Causality for Epidermal Necrolysis, respectively. Among 748 consecutive patients with DILI from 1997 to March 2015, 36 (4.8%) had associated features of SJS/TEN. The mean age was 32 years (females 19). Children and patients with human immunodeficiency virus constituted 25% (n = 9) and 22% (n = 8), respectively. Only a small number of “high‐risk” drugs such as antiepileptic agents, sulfonamides, and antiretroviral drugs accounted for the majority of cases. Overall mortality was 36% (n = 13), which rose to 45.5% in the presence of jaundice. Mortality was less in children 11% (n = 1) and human immunodeficiency virus patients 12.5% (n = 1). Conclusions: DILI associated with SJS/TEN is rare and associated with a high death rate, particularly in those with jaundice; however, children and human immunodeficiency virus–infected individuals have a favorable outcome; a small group of drugs contributed to a disproportionate number of cases, and causality with Roussel Uclaf Causality Assessment Method and the Algorithm for Drug Causality for Epidermal Necrolysis was highly probable or probable in all cases. (Hepatology 2016;63:993–999)

Factors that predict mortality in children with Wilson disease associated acute liver failure and comparison of Wilson disease specific prognostic indices

Wilson disease (WD) associated acute liver failure (ALF) affects children more than adults. The predictors of mortality and outcome in patients without encephalopathy are not clear. We investigated the ability of prognostic factors and various models including model for end‐stage liver disease (MELD) to predict mortality among children with WD and ALF.

An unusual experience with endoscopic retrograde cholangiopancreatography

The endoscopic retrograde cholangiopancreatography (ERCP) is known for its varied diagnostic and therapeutic utility for a variety of disorders. However it has greater likelihood of procedure related complications among the endoscopic procedures of gastrointestinal tract. The extraluminal hemorrhagic complications following ERCP are potentially life threatening though relatively rare. We present a 50 year patient with choledocholithiasis and cholelithiasis developing rare complication of subcapsular hepatic hematoma, following ERCP due to guide wire injury.

Drug-induced acute liver failure in children and adults: Results of a single-centre study of 128 patients

Drugs producing acute liver failure (ALF) are uncommon and vary geographically. Here we review the implicated drugs, clinical features, laboratory characteristics and outcome of patients with drug‐induced ALF (DIALF). We analysed the predictors of mortality and their relationship with MELD, Kings College criteria (KCC) and ALFSG prognostic index.

Duodenal gastrointestinal stromal tumor presenting as massive gastrointestinal bleed

Editor Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract, derived from the malignant transformation of the interstitial cells of Cajal or their precursors. GISTs are more common in the 50– 60 years age group and occur commonly in the stomach (60% to 70 %) and small intestine (25 % to 35 %) [1]. Duodenal GISTs are rare, comprising about 12 % to 18 % of small intestine GIST and less than 4 % of all GISTs. They usually present with anemia due to chronic GI blood loss, but duodenal GIST presenting as massive GI bleed with shock is rare. Duodenal GISTs most frequently involve the second portion of the duodenum in close relationship to the ampulla of Vater, followed by the third, fourth, and first portions. The relationship to the ampulla determines surgical treatment strategies. We have treated four patients of GIST presenting with massive upper GI bleed and shock in the last 18 months. Their clinical, laboratory, operative, and histopathology details are outlined in Table 1. All four were between 40–60 years of age. Three out of four presented with hematemesis, and all four were critically ill with hemodynamic instability. Laboratory evaluations revealed severe microcytic hypochromic anemia in all four patients with hemoglobin ranging from 5.6 to 6.8 g/ dL. Coagulation parameters were normal. Gastroduodenoscopy showed submucosal nodule with surface ulceration and active ooze in the second part of the duodenum in three patients and submucosal nodule with active spurt of blood in the third part of the duodenum in one patient (Fig. 1). Hemostasis was achieved with injection of the diluted adrenaline. Contrast-enhanced computed tomography of abdomen confirmed intramural mass in duodenum with distinct fat planes and no lymph node enlargement. All four were operated with limited resection and primary anastomosis. All patients had small size tumors which presented early due to endoenteric growth and had mitosis less than 5 per 50 high-power fields. Their small size, endoenteric growth, complete resection, and lower mitosis were good prognostic signs in our patients. Immunohistochemical analysis revealed a positive CD117 in all four patients, positive CD34 in three patients, and positive smooth muscle actin (SMA) in one. All are alive with no recurrence, with a mean follow up of 10 months ranging from 5 to 18 months. Massive GI bleeding, as in our patients, is unusual in duodenal GIST. In a large study of 156 duodenal GIST patients, 75 cases presented with anemia due to chronic GI loss, but massive GI bleed with hemodynamic instability was only occasional [2]. In the same study, occasional massive GI bleed presented with melena, but none had hematemesis [2]. The typical features of GISTs on duodenoscopy include gross ulceration in the mucosa or an intramural mass with central ulceration. The most specific diagnostic criterion is strong and diffuse positive staining for CD117. GISTs harbor positivity for vimentin in nearly all cases, CD34 in 50 % to 70 %, smooth muscle actin in 30 % to 40 %, and platelet-derived growth factor receptor alpha (PDGFR-α) in about 5 %, while desmin (intermediate filament typical for muscle) and S-100 (a neural cell marker) are usually negative [3]. Poor prognostic parameters of GISTs include extragastric location, size greater than 5 cm, central necrosis, extension into adjacent organs, M. Patil (*) :K. A. Sheth :C. K. Adarsh :H. Devarbhavi Department of Gastroenterology, St. John’s Medical College, Bangalore 560 034, India e-mail: drmalli_arjun@yahoo.co.in

Features and Treatment of Dapsone-Induced Hepatitis, Based on Analysis of 44 Cases and Literature Review

© 2017 by the AGA Institute 1542-3565/

Primary Gastric Lymphoma: Clinicopathological Profile

36.00 http://dx.doi.org/10.1016/j.cgh.2017.05.031 Dapsone (4,4’ diaminodiphenysulphone) was first synthesized in 1908. Aside from leprosy, it has been used for the treatment of many other dermatologic and nondermatologic conditions. Although adverse reactions such as methemoglobinemia, hemolytic anemia, agranulocytosis, and hypersensitivity reactions have been well recognized, the characteristics of as well as the mechanisms underlying the hepatic injury associated with the use of dapsone remain unclear. We systematically analyzed the diverse clinical and laboratory characteristics as well as outcomes of patients with dapsone related hepatotoxicity from a single center. In addition, we summarized the findings from published reports on dapsone-induced hepatitis (DIH).

Tumour of the lowest probability

Introduction Gastrointestinal tract (GIT) is the most common site of involvement of extranodal non-Hodgkin’s lymphoma (NHL). There is regional variation in anatomical distribution of extranodal NHL, stomach being the most common site followed by small intestine. Primary gastric lymphoma (PGL) predominantly involves the antrum and corpus of the stomach. It arises from mucosa-associated lymphoid tissue (MALT) and is of B-cell lineage and often associated with Helicobacter pylori infection. Primary gastric lymphoma often presents with nonspecific symptoms. The present study was undertaken to ascertain the clinicopathological characteristics of PGL at a tertiary care center in South India. Materials and methods It is a retrospective study from 2006 to 2016. Patient’s data were obtained from institutional medical records. The histopathology slides were reviewed. The relevant immunohistochemistry (IHC) markers done were leukocyte common antigen (LCA), CD3, CD20, CD79a, CD10, Bcl-2, Bcl-6, CD5, Cyclin D1, CD138, and Ki-67. Correlating with the immunoprofile, further subtyping was done. Results A total of 405 patients of NHL were seen during the study period, out of which 43 patients were PGL. There were 32 males and 11 females, with M:F of 2.9:1. The mean age at diagnosis was 58 years. Abdominal pain and new-onset dyspepsia were the commonly observed presenting symptoms. The common site of involvement was antrum (20). Diffuse large B-cell lymphoma (DLBCL) was the most common histological subtype. Helicobacter pylori infection was seen in 18 (41%) patients. Majority of the patients were in stages II and III. Conclusion In our study, the initial presentation of PGL was with nonspecific symptoms like abdominal pain and new-onset dyspepsia. High degree of suspicion of such symptoms and biopsy of all suspicious lesions is essential for early detection. Diffuse large B-cell lymphoma was the most common histological subtype seen in our study. How to cite this article: Malipatel R, Patil M, Rout P, Correa M, Devarbhavi H. Primary Gastric Lymphoma: Clinicopathological Profile. Euroasian J Hepato-Gastroenterol 2018;8(1):6-10.