Pathik Parikh

Prevalence of hypothyroidism in nonalcoholic fatty liver disease in patients attending a tertiary hospital in western India

The aim of this study was to assess the prevalence of hypothyroidism in patients with nonalcoholic fatty liver disease (NAFLD). The patients visiting Gastroenterology outpatient clinic between September 2011 and September 2013 at our tertiary care center were investigated for NAFLD. Three hundred controls were selected on the basis of negative ultrasound examination. All patients above 18 years were included. All patients with alcohol intake greater than 20 g/day, HBsAg or anti-HCV positivity, and history of liver disease were excluded. Full thyroid profile was carried out in all patients and they were classified as follows: subclinical hypothyroidism (TSH >5.5 IU/mL but <10 IU/mL) and overt hypothyroidism (TSH >10 IU/mL). Eight hundred (500 NAFLD and 300 controls) patients were studied. The mean age of NAFLD patients was 44.3 years and of controls was 41.6 years, respectively. The female-to-male ratio of NAFLD patients was 1.8:1 and of controls was1.94:1, respectively (p>0.05). Hypothyroidism was significantly more common in NAFLD patients compared to controls. Eighty-four patients were detected to have hypothyroidism in NAFLD group compared to only four patients in control group (p<0.001). Mean ALT (55 vs. 21 IU), AST (44 vs. 18 IU), and BMI (29.17 vs. 25.14 kg/m2) were significantly higher in NAFLD hypothyroid group compared to nonhypothyroid NAFLD. Multivariate regression analysis showed that NAFLD was statistically significantly associated with hypothyroidism [odds ratio (OR) 14.94, 95 % confidence interval (CI), 3.5 to 62.6]. Steatohepatitis was more common in hypothyroid as compared to nonhypothyroid group [OR 3.9, 1.2 to 11.1 (95 % CI)]. The prevalence of hypothyroidism in NAFLD was 16.8 %. Hypothyroidism was closely associated with NAFLD independently of known metabolic risk factors, confirming a significant clinical relationship between these two diseases.

An open-label randomized control study to compare the efficacy of vitamin e versus ursodeoxycholic acid in nondiabetic and noncirrhotic Indian NAFLD patients.

Background/Aim: The study was carried out to compare the efficacy of Vitamin E versus Ursodeoxycholic acid (UDCA) in nondiabetic nonalcoholic fatty liver disease (NAFLD) patients. Patients and Methods: We randomized 250 non cirrhotic and non diabetic NAFLD patients diagnosed on ultrasound, with raised alanine aminotransferase (ALT) level. (>40 IU/L), to receive Vitamin E 400 mg twice a day (Group A) or UDCA 300 mg twice a day (Group B) for 52 weeks. Lifestyle modification to achieve at least 5% weight reduction and subsequent weight control and regular exercise was advised to both groups. The primary study endpoint was normalization of ALT. Secondary endpoints were the proportion of patients with reduction in ALT, relative reduction in the NAFLD Fibrosis score (NFS), symptomatic improvement and tolerability. Results: One hundred and fifty patients received UDCA as compared to 100 patients receiving Vitamin E. The treatment groups were comparable at entry with regard to age (44.1 vs 42.4 years), gender (67% vs 63% female), risk factors for nonalcoholic steatohepatitis, hypochondriac pain, serum liver biochemistries, and NAFLD Fibrosis score. The primary endpoint was achieved in 21 (14%) and 19 (19%) of patients in Group A and Group B, respectively (P = 0.2). The proportion of patients with reduction in ALT (56% vs 63%, P = 0.2), symptomatic improvement (78% vs 67%, P= 0.058), reduction in the NFS (44% vs 47%, P= 0.69), and tolerability (98% vs 95%, P= 0.2) were similar between Group A and Group B, respectively. Conclusion: UDCA is an effective and safe alternative to Vitamin E in nondiabetic–noncirrhotic Indian NAFLD patients.

The role of capsule endoscopy in etiological diagnosis and management of obscure gastrointestinal bleeding

Background/Aims To investigate the various etiologies, yields, and effects of capsule endoscopy (CE) on management and complications, along with follow up of patients with obscure gastrointestinal (GI) bleeding. Methods The study group of patients included those having obscure, overt, or occult GI bleeding. The findings were categorized as (A) obvious/definitive, (B) equivocal, or (C) negative. Any significant alteration in patient management post CE in the form of drug or surgical intervention was noted. Results Total patients included in the study were 68 (48 males and 20 females). The ratio of male:female was 2.4:1. The age ranged between 16 years to 77 years. Mean age for males was 62±14 years, for females 58±16 years. The total yield of CE with definitive lesions was in 44/68 (65.0%) of patients. In descending order (A) angiodysplasia 16/68 (23.53%), (B) Crohns disease 10/68 (14.70%), (C) non-steroidal anti-inflammatory drug enteropathy 8/68 (11.76%), (D) small bowel ulcers 4/68 (5.88%), (E) jejunal and ileal polyps 2/68 (2.94%), (F) intestinal lymphangiectasis 2/68 (2.94%), and (G) ileal hemangiomas 2/68 (2.94%) were followed. Equivocal findings 12/68 (17.65%) and negative study 12/68 (17.65%) was found. Complications in the form of capsule retention in the distal ileum were noted in 2/68 (2.94%) subjects. Statistically, there was a higher probability of finding the etiology if the CE was done during an episode of bleeding. Conclusions CE plays an important role in diagnosing etiologies of obscure GI bleeding. Its role in influencing the management outcome is vital.

CROSS SECTIONAL STUDY OF PREVALENCE AND RISK FACTORS OF HEPATITIS B AND HEPATITIS C INFECTION IN A RURAL VILLAGE OF INDIA

BACKGROUND Hepatitis B virus and hepatitis C virus are among the principal causes of severe liver disease. There is limited data of epidemiology of Hepatitis B in community, more so in rural population. OBJECTIVE To find the prevalence of hepatitis B and C infection in community and study the risk factors for their transmission. METHODS This was a community based cross sectional study. A total of 1833 randomly selected subjects from a rural area were interviewed for risk factors for transmission and tested for markers of hepatitis B and hepatitis C infection. All the positive card tests were confirmed by ELISA. RESULTS Out of 2400 subjects, rate for participation was 76.38%. None of the subjects was positive for anti hepatitis C virus antibody. Point prevalence for HBsAg positivity was 0.92. Being healthcare worker and having tattoo were significantly associated with HBsAg positive results. Nose and ear piercing was reported by almost. History of blood or blood product transfusion, I/V drug abuse, multiple sexual partners, unsafe Injections, hemodialysis and any h/o surgery was not associated with HBsAg positivity. CONCLUSION Health care workers are at high risk for transmission of hepatitis B. Educating common people regarding mode of transmission of Hepatitis B and C will help to reduce their transmission.

Total and Segmental Colon Transit Time Study in Functional Constipation: Comparison With Healthy Subjects

Background Constipation is a common problem worldwide. Constipation can be primary or secondary. Primary constipation is subdivided in slow transit constipation, normal transit constipation, and dyssynergic defecation. Colon transit time (CTT) is the most basic and primary tool in evaluating disorders of colonic motility. CTT helps to differentiate between types of constipation and plan the treatment. Methods Fifty functional constipation patients and 25 healthy controls were asked to ingest four gelatin capsules (each containing five radio-opaque markers) at 0, 12 and 24 hours. An abdominal X-ray was taken at 36 hours. Total or segmental CTT was measured after calculating the number of markers remaining in each segment at 36 hours on abdominal X-ray. Results Mean CTT in healthy controls in our study was 15.4 hours which is shorter than western population. Total CTT is significantly higher in constipation group (23 hours) compared to healthy subjects (15.4 hours). Transit time in right segment was significantly high in constipation group than healthy population (14.2 vs. 8.3 hours). Total as well as segmental transit times are slightly higher in females as compared to males in both the groups, however not statistically significant. To the best of our knowledge, there are no studies from India that compared the CTTs in functional constipation and healthy controls. Conclusion Radio-opaque marker study for CTT is a simple and reliable technique for evaluation of constipation. Patients with functional constipation have significantly longer CTT than healthy population. Total CTT is much less in this study population compared to west. There is need to establish standards for slow colon transit.

A Randomized Comparative Study of Efficacy of Lamivudine and Adefovir Combination versus Tenofovir versus Entecavir in Decompensated Cirrhotic Patients of Hepatitis B

Decompensation is a frequent presentation of Hepatitis B related liver disease. In India transplantation is not easily available. Hence antiviral drugs form the backbone of management. Lamivudine and Adefovir, either as alone or as combination has been useful, Entecavir and tenofovir have good efficacy. These drugs have different side effect, resistance and cost profile which is important considering long term treatment

Autoimmune Hepatitis Triggered by Treatment With Pegylated Interferon α-2a and Ribavirin for Chronic Hepatitis C.

Hepatitis flare is rarely observed during treatment with pegylated interferon alpha for hepatitis C virus (HCV) infection. A 49-year-old man receiving pegylated interferon α-2a for HCV infection had icterus and hyperbiliru-binemia in the 14th week of therapy, with HCV RNA undetectable after the 12th dose. Liver biopsy was suggestive of chronic hepatitis with cirrhosis without interface pattern. Pegylated interferon was discontinued; a few weeks later, his aminotransferases and immunoglobulin levels increased significantly. Antibody to cytosolic liver antigen-1 was positive, and liver biopsy revealed lymphoplasmacytic infiltrate with intense interface hepatitis, consistent with autoimmune hepatitis.

Range of Normal Liver stiffness and Predictors of Suspected Advanced Fibrosis in Apparently Healthy Individuals: A Pooled Analysis of 16,082 Participants

BACKGROUND & AIMS: Transient elastography (TE) is a noninvasive technique used to measure liver stiffness to estimate the severity of fibrosis. The range of liver stiffness measurements (LSMs) in healthy individuals is unclear. We performed a systematic review to determine the range of LSMs, examined by TE, in healthy individuals and individuals who are susceptible to fibrosis. METHODS: We collected data from 16,082 individuals, in 26 cohorts, identified from systematic searches of Embase, Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for studies of liver stiffness measurements. Studies analyzed included apparently healthy adults (normal levels of liver enzymes, low‐risk alcohol use patterns, and negative for markers of viral hepatitis). The presence of diabetes, hypertension, dyslipidemia, or steatosis, based on ultrasound examination, was known for most participants. We performed a meta‐analysis of data from individual participants. The cohort was divided into 4 groups; participants with a body mass index <30 kg/m2 were examined with the medium probe and those with a body mass index ≥30 kg/m2 were examined with the extra‐large probe. Linear regression models were conducted after adjusting for potential confounding factors of LSMs. We performed several sensitivity analyses. RESULTS: We established LSM ranges for healthy individuals measured with both probes—these did not change significantly in sensitivity analyses of individuals with platelets ≥150,000/mm3 and levels of alanine aminotransferase ≤33 IU/L in men or ≤25 IU/L in women. In multivariate analysis, factors that modified LSMs with statistical significance included diabetes, dyslipidemia, waist circumference, level of aspartate aminotransferase, and systolic blood pressure at examination time. Significant increases in LSMs were associated with the metabolic syndrome in individuals examined by either probe. Diabetes in obese individuals increased the risk of LSMs in the range associated with advanced fibrosis. CONCLUSIONS: In a systematic review and meta‐analysis of data from individual participants, we established a comprehensive set of LSM ranges, measured by TE in large cohorts of healthy individuals and persons susceptible to hepatic fibrosis. Regression analyses identified factors associated with increased LSMs obtained by TE with the medium and extra‐large probes.Background & Aims Transient elastography (TE) is a noninvasive technique used to measure liver stiffness to estimate the severity of fibrosis. The range of liver stiffness measurements (LSMs) in healthy individuals is unclear. We performed a systematic review to determine the range of LSMs, examined by TE, in healthy individuals and individuals who are susceptible to fibrosis. Methods We collected data from 16,082 individuals, in 26 cohorts, identified from systematic searches of Embase, Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for studies of liver stiffness measurements. Studies analyzed included apparently healthy adults (normal levels of liver enzymes, low-risk alcohol use patterns, and negative for markers of viral hepatitis). The presence of diabetes, hypertension, dyslipidemia, or steatosis, based on ultrasound examination, was known for most participants. We performed a meta-analysis of data from individual participants. The cohort was divided into 4 groups; participants with a body mass index Results We established LSM ranges for healthy individuals measured with both probes—these did not change significantly in sensitivity analyses of individuals with platelets ≥150,000/mm3 and levels of alanine aminotransferase ≤33 IU/L in men or ≤25 IU/L in women. In multivariate analysis, factors that modified LSMs with statistical significance included diabetes, dyslipidemia, waist circumference, level of aspartate aminotransferase, and systolic blood pressure at examination time. Significant increases in LSMs were associated with the metabolic syndrome in individuals examined by either probe. Diabetes in obese individuals increased the risk of LSMs in the range associated with advanced fibrosis. Conclusions In a systematic review and meta-analysis of data from individual participants, we established a comprehensive set of LSM ranges, measured by TE in large cohorts of healthy individuals and persons susceptible to hepatic fibrosis. Regression analyses identified factors associated with increased LSMs obtained by TE with the medium and extra-large probes.

A Rare Case of an Intraductal Papillary Mucinous Neoplasm of Pancreas Fistulizing Into Duodenum With Adult Polycystic Kidney Disease

Intraductal papillary mucinous neoplasm (IPMN) accounts for 20-50% of all cystic neoplasms of the pancreas. Rarely, IPMN, whether benign or malignant, can fistulize into adjacent organs like duodenum, stomach or common bile duct. IPMN can be associated with other diseases like Peutz-Jeghers syndrome and familial adenomatous polyposis. Association with adult polycystic kidney disease (ADPKD) is extremely rare. We report a case of a 60-year-old male with a large IPMN in the head of the pancreas diagnosed by magnetic resonance imaging, endoscopic ultrasound and cyst fluid analysis. It was complicated by fistula formation into the second part of the duodenum. Patient was simultaneously having adult polycystic kidney disease. There is only one case report of uncomplicated IPMN with ADPKD in the literature so far. And even rarer, there is no any case report of fistulizing IPMN with ADPKD reported so far, to the best of our knowledge.

Primary pancreatic lymphoma in a human immunodeficiency virus-positive patient

Primary pancreatic lymphoma (PPL) is a rare occurrence. Lymphoma involving the pancreas may be seen more often. The incidence of non-Hodgkin′s lymphoma (NHL) is expected to increase in patients suffering from acquired immune deficiency syndrome (AIDS) and also as age increases that is beyond sixth decade. NHL involving the pancreas is often seen in AIDS patients; however, PPL in a human immunodeficiency virus patient is uncommon and consists of a handful of case reports. Obstructive jaundice as a presentation is unusual. Histological diagnosis is often required to differentiate it from pancreatic adenocarcinoma, though there are certain features on computerized tomography and magnetic resonance imaging that favor lymphoma. We here describe a case of PPL in a young patient of AIDS who presented with obstructive jaundice and a palpable lump. Radiological features suggested it to be an adenocarcinoma. However, biopsy and immunohistochemistry helped to get the final diagnosis.