Mohammad Sultan Khuroo

Vertical transmission of hepatitis E virus

Little is known about vertical transmission of hepatitis E virus from infected mothers to their infants. We studied eight babies born to mothers infected with hepatitis E in third trimester. One baby was icteric at birth with elevated transaminases and four babies had anicteric hepatitis. Two babies were born with hypothermia and hypoglycaemia and died within 24 h; one had massive hepatic necrosis. Hepatitis E virus RNA was detected by PCR in cord or birth blood samples of five infants. Six infants had evidence of hepatitis E infection. We conclude that hepatitis E virus is commonly transmitted from infected mothers to their babies with significant perinatal morbidity and mortality.

Hepatobiliary and pancreatic ascariasis in India

500 patients with hepatobiliary and pancreatic disease due to Ascaris lumbricoides infection were studied. 274 patients had duodenal ascariasis, 171 biliary ascariasis, 40 hepatic ascariasis, 8 gall bladder ascariasis, and 7 pancreatic ascariasis. Five clinical presentations were recognised: acute cholecystitis (64 patients), acute cholangitis (121), biliary colic (280), acute pancreatitis (31), and hepatic abscess (4). Ascarides in the duodenum (which were seen to invade only the ampullary orifice) induced either severe biliary colic or episodes of acute pancreatitis. 27 patients had pyogenic cholangitis and were managed by surgical (2) or endoscopic (25) biliary decompression and drainage. Removal of worms from the ampullary orifice and their extraction by mouth led to rapid relief of biliary colic (214 patients) and acute pancreatitis (16). 4 patients died (acute pancreatitis 2, pyogenic cholangitis 1, hepatic abscess 1). In 12 patients worms persisted in the biliary tree at 3 weeks; dead worms were removed from the biliary tree by surgery (5 patients) or with an endoscopic basket (7). Worms moved out of the ductal system in 211 patients. During a mean follow-up of 48 months (SD 14), 76 patients had worm re-invasion of the biliary tree due to ascaris re-infection. Intrahepatic duct and bile duct calculi developed in 7 patients in whom dead worms formed the nidus of stones.

Biliary ascariasis: A common cause of biliary and pancreatic disease in an endemic area

We prospectively evaluated the incidence, clinical features, radiographic findings, and course of biliary and pancreatic disease caused by ascariasis in an endemic area in India. Ascariasis was an etiologic factor in 40 (36.7%) of the 109 patients studied who had biliary and pancreatic diseases. Disease was prevalent in adult women and was associated with recurrent biliary colic in 38 patients (95%), recurrent pyogenic cholangitis in 27 patients (68%), acalculous cholecystitis in 9 patients (23%), and pancreatic disease in 6 patients (15%). Vomiting of roundworms during biliary colic occurred in 19 patients (48%) and often led to confirmation of biliary ascariasis by direct visualization of the biliary tree. Endoscopic retrograde cholangiopancreatography was an excellent diagnostic tool and often demonstrated worms in the dilated common bile duct and intrahepatic ducts. The worms moved actively into and out of the biliary tree from the duodenum. Thirty-six (90%) patients recovered on symptomatic treatment followed by anthelmintic therapy once acute symptoms subsided. Surgery was needed in 4 patients, as the worms were trapped in the ducts and had led to the formation of common bile duct and intrahepatic duct stones with the worm fragment as the nidus.

Aetiology and prognostic factors in acute liver failure in India

Summary.u2002 The early prognostic indicators for acute liver failure in endemic zones for hepatitis E virus have not been determined. All consecutive patients with acute liver failure from a geographically defined region endemic for hepatitis E virus were studied over the period April 1989–April 1996. Demographic, clinical and biochemical parameters were recorded at presentation and serum samples were analysed for known viral hepatitis (A–E) markers. Multiple parameters were compared in survivors and non‐survivors in a univariate analysis. All significant factors on univariate analysis were entered into a stepwise logistic regression analysis to identify independent variables of prognosis. The sensitivity and specificity of significant prognostic factors was then assessed.

Hepatitis E: an emerging global disease – from discovery towards control and cure

Hepatitis E is a systemic disease affecting the liver predominantly and caused by infection with the hepatitis E virus (HEV). HEV has marked genetic heterogeneity and is known to infect several animal species including pigs, boar, deer, mongoose, rabbit, camel, chicken, rats, ferret, bats and cutthroat trout. HEV is the sole member of the family Hepeviridae and has been divided into 2 genera: Orthohepevirus (mammalian and avian HEV) and Piscihepevirus (trout HEV). Human HEVs included within the genus Orthohepevirus are designated Orthohepevirus A (isolates from human, pig, wild boar, deer, mongoose, rabbit and camel). Hepatitis E is an important public health concern, and an estimated one‐third of the world population has been infected with HEV. In recent years, autochthonous hepatitis E is recognized as a clinical problem in industrialized countries. Several animal species especially domestic swine, wild boar and wild deer are reservoirs of genotype HEV‐3 and HEV‐4 in these countries. Human infections occur through intake of uncooked or undercooked meat of the infected animals and pig livers or sausages made from these livers and sold in supermarkets. HEV can be transmitted through blood and blood component transfusions, and donor screening for HEV is under serious consideration. Chronic hepatitis E resulting in rapidly progressive liver cirrhosis and end‐stage liver disease has been described in organ transplant patients. Ribavirin monotherapy attains sustained virological response in most patients. HEV 239 vaccine has been marketed in China and its long‐term efficacy over four and a half years reported.

Haemosuccus pancreaticus: a clinical challenge.

Background: Haemosuccus pancreaticus is a rare complication of pancreatitis. It is a diagnostic problem for even the most astute clinician and a challenge for the expert endoscopist. We report a 25‐year‐old male patient who had all the features usually seen in haemosuccus pancreaticus patients: recurrent obscure upper gastrointestinal bleeding, pancreatitis, pseudocyst formation, ductal disruption, fistula and pancreatic ascites. The patient was treated by subtotal pancreatectomy, splenectomy and drainage of the pseudocyst. Although pancreatic duct communication with the surrounding vasculature could not be ascertained, we strongly believe the patient had haemosuccus pancreaticus because, over a follow‐up period of 3 years, the patient was not only ascites free, but did not experience any further upper gastrointestinal bleeding. We believe that in evaluating patients with recurrent obscure gastrointestinal bleeding, one should always remember that the pancreas is a part of the gastrointestinal tract and, like other organs, is prone to blood loss.

Enteric Hepatitis Viruses: Hepatitis A Virus and Hepatitis E Virus

Hepatitis A is an infectious disease of the liver caused by hepatitis A virus. Hepatitis A has a global distribution with endemicity inversely proportional to higher socioeconomic conditions and standards of sanitation and hygiene. Hepatitis A virus infection is predominantly spread directly from one person to another through orofecal transmission and through contaminated food and water. The clinical outcome is strongly correlated with age, being mostly subclinical in young children and symptomatic in older children and adults. Hepatitis A vaccine is safe, highly immunogenic and protective against clinical hepatitis A.