Pankaj Tyagi

Endoscopic Variceal Ligation plus Propranolol versus Endoscopic Variceal Ligation Alone in Primary Prophylaxis of Variceal Bleeding

BACKGROUND AND AIMS:The role of propranolol in addition to EVL in the prevention of first variceal bleed has not been evaluated. This prospective randomized controlled trial compared endoscopic variceal ligation (EVL) with propranolol and EVL alone in the prevention of first variceal bleed among patients with high-risk varices.PATIENTS AND METHODS:One hundred and forty-four consecutive patients with high-risk varices were randomly allocated to EVL plus propranolol (Gr I, n = 72) or EVL alone (Gr II, n = 72). EVL was done at 2-wk interval till obliteration of varices. In Gr I, incremental dosage of propranolol (sufficient to reduce heart rate to 55 beats/min or 25% reduction from baseline) was administered and continued after obliteration of varices. The endpoints of the study were bleeding and death.RESULTS:The two groups of patients had comparable baseline characteristics; follow-up (Gr I: 13.1 ± 11.5 months, Gr II: 11.2 ± 9.9 months), number of cirrhotic and noncirrhotic portal hypertension patients [Gr I 64 (88.6%) and 8 (11.4%), Gr II 63 (87.5%) and 9 (12.5%)], and frequency of Childs A (15 vs 18), B (38 vs 35), and C (19 vs 19). The mean daily propranolol dose achieved in Gr I was 95.6 ± 38.6 mg. Eleven patients had bleeds, 5 in Gr I and 6 in Gr II. All patients bled before the obliteration of varices, the actuarial probability of first bleed at 20 months was 7% in Gr I and 11% in Gr II (p = 0.72). Six patients died in the combination and 8 in EVL group. All deaths in Gr I were due to nonbleed-related causes, while in Gr II, 2 deaths were bleed related, the actuarial probability of death at 20 months was 8% and 15%, respectively (p = 0.37). The probability of bleed-related death was comparable (p = 0.15). At the end of follow-up, 4 patients in Gr I and 11 in Gr II had recurrence of varices (p = 0.03). Side effects on propranolol were seen in 22% patients, in 8% it had to be stopped. There were no serious complications of EVL.CONCLUSIONS:Both EVL plus propranolol and EVL alone are effective in primary prophylaxis of bleed from high-risk varices. Addition of propranolol does not decrease the probability of first bleed or death in patients on EVL. However, the recurrence of varices is lower if propranolol is added to EVL.

Spleen Stiffness in Patients With Cirrhosis in Predicting Esophageal Varices

OBJECTIVES:Screening for esophageal varices (EV) is recommended in patients with cirrhosis. Noninvasive tests had shown varying sensitivity (Se) and specificity (Sp) for predicting EV. Splenomegaly is a common finding in liver cirrhosis because of portal and splenic congestion. These changes can be quantified by transient elastography; hence, the aim of this study was to investigate the utility of spleen stiffness (SS) in evaluating EV in comparison with other noninvasive tests.METHODS:We measured SS and liver stiffness (LS) by using FibroScan in 200 consecutive cirrhotic patients who met the inclusion criteria. Patients were also assessed by hepatic venous pressure gradient (HVPG), upper gastrointestinal endoscopy, LS–spleen diameter to platelet ratio score (LSPS), and platelet count to spleen diameter ratio (PSR).RESULTS:Of 200 patients enrolled, 174 patients had valid LS and SS measurement, and 124 (71%) patients had EV (small, n=46 and large n=78). There was a significant difference in median LS (51.4 vs. 23.9 kPa, P=0.001), SS (54 vs. 32 kPa, P=0.001), LSPS (6.1 vs. 2.5, P=0.001), and PSR (812 vs. 1,165, P=0.001) between patients with EV and those without EV. LS ≥27.3 kPa had an Se of 91%, Sp of 72%, positive predictive value (PPV) of 89%, negative predictive value (NPV) of 76%, and a diagnostic accuracy of 86% in predicting EV. LSPS ≥3.09 had Se and Sp of 89% and 76%, respectively, and a PSR cutoff value of 909 or less had Se of 64%, Sp of 76%, and diagnostic accuracy of 68% in predicting EV. SS ≥40.8 kPa had Se (94%), Sp (76%), PPV (91%), NPV (84%), and diagnostic accuracy of 86% for predicting EV. SS was significantly higher in patients who had large varices (56 vs. 49 kPa, P=0.001) and variceal bleed (58 vs. 50.2 kPa, P=0.001). Combining LS+SS (27.3+40.8 kPa) had Se of 90%, Sp 90%, PPV 96%, NPV 79%, and a diagnostic accuracy of 90%. HVPG (n=52) showed significant correlation with SS (r=0.433, P=0.001), LSPS (r=0.335, P=0.01), and PSR (r=−0.270, P=0.05), but not with LS (r=0.178, P=0.20).CONCLUSIONS:Measurement of SS can be used for noninvasive assessment of EV and can differentiate large vs. small varices and nonbleeder vs. bleeder.

Grain size dependent optical band gap of CdI2 films

The thermally evaporated stoichiometric CdI2 films show goodc-axis alignment normal to substrate plane for film thickness up to 200 nm. The optical absorption data indicate an allowed direct interband transition across a gap of 3.6 eV in confirmation with earlier band structure calculations. However, part of the absorption data near band edge can be fitted to an indirect band gap of 3 eV. The dependence of band gap on film thickness (> 200 nm) can be explained qualitatively in terms of decreasing grain boundary barrier height with grain size.

Addition of Propranolol and Isosorbide Mononitrate to Endoscopic Variceal Ligation Does Not Reduce Variceal Rebleeding Incidence

BACKGROUND & AIMS Endoscopic variceal ligation (EVL) and propranolol are standard secondary prophylaxis therapies for variceal bleeding. Addition of isosorbide mononitrate (ISMN) to propranolol improves its hemodynamic efficacy; we investigated whether a combination of EVL and propranolol/ISMN was more effective than EVL alone for secondary prophylaxis. METHODS Patients with a prior variceal bleed were randomly assigned to groups given a combination (n = 88) of EVL, propranolol (dose titrated to reduce heart rate to 55 beats per minute), and ISMN (40 mg/day) or EVL alone (n = 89). Primary end points were rebleeding or death; secondary end points were new complications of portal hypertension or serious adverse effects. RESULTS The actuarial probabilities of rebleeding 2 years after therapy were 27% in the combination group and 31% in the EVL alone group (P = .822). Two patients in the combination group and 3 patients in the EVL alone group died during the study period (P = .682); no deaths were caused by variceal hemorrhage. In cirrhotic patients, the actuarial probabilities of rebleeding were 24% and 30%, respectively (P = .720). Secondary end points were comparable between groups. In multivariate analyses, presence of ascites (P = .003), serum albumin < 3.3 g/dL (P = .008), and hepatic venous pressure gradients > or = 18 mm Hg (P = .009) were independent risk factors for variceal rebleeding. CONCLUSIONS EVL alone is sufficient to prevent variceal rebleeding in cirrhotic and noncirrhotic patients with history of variceal bleeding. Addition of propranolol and ISMN to EVL does not reduce the incidence of variceal rebleeding but increases severe adverse effects. Risk factors for rebleeding include ascites, low serum albumin, and high hepatic venous pressure gradients.

Prevention of hepatorenal syndrome in patients with cirrhosis and ascites: a pilot randomized control trial between pentoxifylline and placebo

Background and aim Pentoxifylline is effective in prevention of hepatorenal syndrome (HRS) in alcoholic hepatitis. The aim of this study was to assess the efficacy of pentoxifylline for prophylaxis of HRS in patients with cirrhosis and ascites. Materials and methods One hundred and seventy-six consecutive patients with cirrhosis and ascites were screened. Patients with creatinine clearance (Ccl) between 41 and 80 ml/min and serum creatinine of less than 1.5 mg/dl in absence of renal disease were randomized to receive either pentoxifylline (group A, 1200 mg/day) or placebo (group B) for 6 months. Patients were followed monthly for 6 months, and kidney function tests were carried out at baseline, 1, 3, and 6 months. Primary endpoint was the development of HRS within 6-month follow-up. Results Thirty-five patients each were randomized to group A and group B. Of the 70 patients, 61 completed follow-up (group A, n=30 and group B, n=31). In group A, serum creatinine remained stable at 1 month (0.94±0.2 vs. 0.90±0.4 mg/dl, P=0.43), at 3 months (0.94±0.2 vs. 0.80±0.3 mg/dl, P=0.10), and at 6 months (0.94±0.2 vs. 0.8±0.2 mg/dl, P=0.06). Improvement occurred in Ccl at 1month (61.7±16.0 vs. 82.0±30.0 ml/min, P=0.001) and at 3 months (61.7±16.0 vs. 86.2±30.7 ml/min, P=0.001). Serum sodium in group A showed progressive improvement at 1 month (134.7±4.4 vs. 137.0±5.3 mmol/l, P=0.006), at 3months (134.7±4.4 vs. 138.4±5.4 mmol/l, P=0.004), and at 6 months (134.7±4.4 vs. 137.6±4.9 mmol/l, P=0.009). Similarly, mean arterial pressure (MAP) also showed progressive improvement at 1 month (76.7±6.7 vs. 81.8±6.9 mmHg, P=0.001), at 3months (76.7±6.7 vs.82.3±6.2 mmHg, P=0.001), and at 6 months (76.7±6.7 vs. 82.6±6.1 mmHg, P=0.01). Tumor necrosis factor (TNF) level measured at baseline and at 3months (14.4±4.8 vs. 13.1±3.7 pg/ml, P=0.28) showed no difference in group A patients. In group B, serum creatinine increased gradually at 1 month (0.80±0.2 vs. 1.0±0.2 mg/dl, P=0.007), at 3 months (0.80±0.2 vs. 1.1±0.3 mg/dl, P=0.001), and at 6 months (0.80±0.2 vs.1.1±0.2 mg/dl, P=0.001). Ccl at 1 month (63.1±14.5 vs. 66.8±28.2 ml/min, P=0.37) decreased at 3months (63.1±14.5 vs. 54.4±18.3 ml/min, P=0.008). Serum sodium, in group B, showed progressive decline at 1month (136.2±5.0 vs. 132.7±3.2 mmol/l, P=0.02) and at 6months (136.2±5.0 vs. 132.7±3.4 mmol/l, P=0.002). MAPremained stable at 1 month (75.1±7.5 vs. 75.3.8±5.1 mmHg, P=0.86), at 3 months (75.1±7.5 vs. 73.2±4.6 mmHg, P=0.19), and at 6months (75.1±7.5 vs. 74.1±6.1 mmHg, P=0.06). TNF level also did not show any change at baseline and at 3 months (14.5±6.8 vs. 13.4±5.1 pg/ml, P=0.31). Of the 12 patients who developed HRS, 10 patients were in group B (type 1 HRS, n=9 and type 2 HRS, n=1) and two patients (type-1 HRS, n=2) were in group A (P=0.01). Patients with HRS had higher baseline TNF-&agr; (15.3±5.8 vs. 10.9±4.8 pg/ml, P=0.01), lower MAP (68.0±3.8 vs. 77.8±6.5 mmHg, P=0.01), and sodium level (131.2±3.0 vs. 135.6±4.7 mmol/l, P=0.003) than those whodid not develop HRS. Conclusion Pentoxifylline is effective in preventing HRS in patients with cirrhosis and ascites at risk of HRS.

Natural history of hepatic fibrosis progression in chronic hepatitis C virus infection in India.

Background and Aim:  The rate of fibrosis progression per year can predict the time for the development of cirrhosis in chronic hepatitis C (CHC). We assessed the rate of fibrosis progression and the predictors of disease severity in Indian CHC patients.

Ageing effect of Sb2Te3 thin films

Abstract Post deposition variation in film resistance of Sb 2 Te 3 films deposited on glass substrates at room temperature and an elevated temperature (110°C) are investigated. The resistance of films grown at room temperature shows a non-linear decrease with time which is thickness dependent as opposed to the increasing resistance of film grown at elevated temperature. The decreasing resistance with time can be attributed to the transformation of an amorphous phase of the as-grown film to a micro-crystalline phase as revealed by X-ray diffraction. The increasing resistance was found to be due to the surface oxidation (Sb 2 O 3 ) and a diffusion as a function of time. However, the underneath layer of Sb 2 Te 3 below the top Sb 2 O 3 layer remains amorphous even after 2 years from the date of fabrication.

Inhibitory control test, critical flicker frequency, and psychometric tests in the diagnosis of minimal hepatic encephalopathy in cirrhosis.

Background/Aim: Minimal hepatic encephalopathy (MHE) impairs health-related quality of life and driving ability of the patient. Objective: We assessed the utility of the inhibitory control test (ICT), critical flicker frequency (CFF), and psychometry in the diagnosis of MHE. Patients and Methods: Consecutive patients with cirrhosis underwent number connection tests A and B (NCT-A, B), digit symbol test (DST), line tracing test (LTT), serial dot test (SDT), CFF, and ICT at baseline and after four hours. Fifty healthy subjects served as controls for the ICT test. Results: Fifty patients with cirrhosis (43.4 ± 10.2 yrs, M: F 42:8) underwent psychometric tests [NCT-A (48.3 ± 17.7 vs. 42.6 ± 17.3 sec, P = 0.001), NCT-B (85.7 ± 40.1 vs. 90.2 ± 37.0 sec, P = 0.18), DST (23.5 ± 9.3 vs. 23.0 ± 8.7, P = 0.45), LTT (96.6 ± 48.2 vs. 96.8 ± 46.8 sec, P = 0.92), SDT (88.0 ± 39.5 vs. 83.4 ± 37.2 sec, P = 0.02)] at baseline and after four hours. Target accuracy of ICT was lower in patients with cirrhosis compared with controls (88.4 ± 5.6 vs. 95.6 ± 2.1, P = 0.01), whereas ICT lures were higher (18.3 ± 4.2 vs 10.2 ± 2.8, P = 0.01). Patients with cirrhosis showed a reduction in lures in the second evaluation compared with the first (18.3 ± 4.2 vs. 17.1 ± 4.3, P = 0.003) but no change in target accuracy (88.4 ± 5.6 vs. 88.4 ± 5.3, P = 0.97). Control subjects did not show any change either in lures (10.2 ± 2.8 vs. 10.3 ± 2.1, P = 0.65) or target accuracy (95.6 ± 2.1 vs. 95.5 ± 2.2, P = 0.82). The sensitivity and specificity of ICT test for the diagnosis of MHE at lure rate >16.5 was 88.5 and 56%, respectively. CFF in patients with MHE (38.4 ± 1.8 vs. 38.6 ± 1.5, P = 0.3) and non MHE (40.6 ± 2.2 vs. 40.8 ± 2.2, P = 0.6) did not show any difference after four hours as in controls (41.9 ± 2.4 vs. 42.1 ± 2.0, P = 0.3). Thirty one (31%) patients preferred psychometric tests, 57 (57%) preferred CFF and only 12 (12%) preferred ICT (P = 0.001). Conclusions: ICT, CFF, and psychometric tests are useful tools to assess MHE, and CFF was preferred by this study cohort.

Pseudoaneurysm of the inferior phrenic artery presenting as an upper gastrointestinal bleed by directly rupturing into the stomach in a patient with chronic pancreatitis.

Pseudoaneurysms occurring in patients with chronic pancreatitis are associated with significant morbidity and mortality. These pseudoaneurysms occur more commonly in the splenic, pancreaticoduodenal, and gastroduodenal arteries. Upper gastrointestinal bleeding (UGIB) due to pseudoaneurysms in patients with pancreatitis with pseudocyst usually presents as hemosuccus pancreaticus. However, pseudoaneurysm directly perforating the gastrointestinal tract and presenting as UGIB is a rare complication. We report here the first case of UGIB from the inferior left phrenic artery pseudoaneurysm rupturing directly into the stomach of a patient with chronic pancreatitis.

Iatrogenic hypervitaminosis D as an unusual cause of persistent vomiting: a case report

IntroductionVitamin D is increasingly recognized to have several beneficial effects. Vitamin D deficiency is widely prevalent. Physicians often treat patients with high doses of vitamin D for various ailments without any monitoring for adverse effects and the prescribed doses often far exceed requirements resulting in toxicity. We present here a classic case of iatrogenic hypervitaminosis D, which presented with persistent vomiting and acute renal failure.Case presentationHere we present a case of a 45-year-old Asian Indian woman who presented to us with persistent vomiting the cause of which was iatrogenic hypervitaminosis D. She was treated with intravenous fluid, diuretics and calcitonin and had clinical improvement.ConclusionsWe suggest that in any patient presenting with persistent vomiting and hypercalcemia, particularly in the presence of normal parathyroid hormone, a diagnosis of overdose of vitamin D should be suspected. Its treatment not only alleviates symptoms but also prevents ongoing acute kidney injury.