Philip Augustine

Clinical outcomes, histopathological patterns, and chemical analysis of Ayurveda and herbal medicine associated with severe liver injury—A single-center experience from southern India

IntroductionAyurvedic and herbal medicines (AHM) are known to cause varying degrees of drug-induced liver injury (DILI). Clinical, biochemical, histological spectrum and outcomes of AHM linked to severe DILI are not well studied.MethodsOut of 1440 liver disease patients, 94 were found to have a severe liver injury and associated AHM intake. Thirty-three patients were suspected to have AHM-DILI on Roussel Uclaf Causality Assessment Scoring Method. Forty-seven and 30 of retrieved AHM samples were analyzed for heavy metals and hepatotoxic volatile organic compounds (hVOCs), respectively. Eleven patients ingested AHM from unregistered traditional healers (UTH). Clinicopathological outcomes were analyzed in 27 patients (who underwent liver biopsy) and outcomes with respect to chemical analyses were studied in 33 patients.ResultsMales predominated (70.4%) with mean age 46.9±15.8 years. Mean follow up was 119.2±81.4 days. The median duration of drug intake was 28xa0days (10 – 84). Five patients died (18.5%). Hepatic encephalopathy, hypoalbuminemia, and hepatic necrosis were significantly associated with mortality (pu2009<u20090.005). Arsenic and mercury ingestion was significantly associated with death (pu2009<u20090.005). hVOCs were detected in more than 70% of samples. AHM intake from UTH was associated with higher mortality.ConclusionAdequate regulation and scrutiny regarding AHM use among the general population is an unmet need. Early liver biopsy after clinical identification of at-risk patients can expedite definitive treatment with a liver transplant.

Partial splenic artery embolization for severe hepatic myelopathy in cirrhosis

Hepatic myelopathy (HM) is a devastating but rare complication of cirrhosis and portal hypertension that profoundly affects quality of life and improves only with liver transplantation. We present a case where progressive severe spastic paraparesis due to HM was substantially reversed with partial splenic artery emobilization (PSAE). (Hepatology 2018;67:1169–1171)

Shunt occlusion for portosystemic shunt syndrome related refractory hepatic encephalopathy—A single-center experience in 21 patients from Kerala

IntroductionLarge spontaneous portosystemic shunts (SPSS) are seen in a subset of patients with liver disease and medically refractory recurrent/persistent hepatic encephalopathy (MRHE). Shunt occlusion has been shown to improve clinical outcomes.MethodsWe retrospectively analyzed patient characteristics, SPSS attributes, procedural features, baseline clinical and investigational parameters, neurological outcomes, adverse effects (procedure and portal hypertension related), and risk factors predicting outcomes in liver disease patients undergoing shunt occlusion procedure for MRHE.ResultsBetween October 2016 and July 2017, 21 patients (Child-Pugh score, CTP 6 to 13) with mean model of end-stage liver disease (MELD) and MELD-sodium scores 15.7 and 19.3 respectively with MRHE [3-cirrhotic Parkinsonism (CP)] were diagnosed to have single or multiple large SPSSs. A total of 29 shunts were occluded (1 surgical, 20 non-surgical). Recurrent and persistent HE and CP markedly improved in the short (n=20, 1 to 3xa0months), intermediate (n=12, 3 to 6xa0months), and long (n=7, 6 to 9xa0months) follow up. None had spontaneous or persistent HE at a median follow up 105 (30 to 329) days (p<0.05). Motor, speech, sleep abnormalities, daily activities of living, and liver disease severity scores improved significantly on follow up. Baseline arterial ammonia showed a statistically significant reduction in all time periods of follow up after shunt occlusion (p<0.05). CTP >11 predicted mortality post shunt occlusion (p=0.04). Embolization of large SPSS in liver disease patients with MRHE and modestly preserved liver function is safe and efficacious and associated with improved quality of life and can function as a bridge to liver transplantation in accurately selected patients.

Multi-center prospective survey of inflammatory bowel diseases in Kerala: More than 2000 cases

BackgroundInflammatory bowel disease (IBD) is considered uncommon in Asia. The aim of this study was to document the demographic characteristics and clinical aspects of ulcerative colitis (UC) and Crohn’s disease (CD) in Kerala, India.MethodsA survey of IBD in Kerala was performed. All gastroenterologists in the region were invited. From May 2013 to October 2015, data were collected in a standardized pro-forma.ResultsForty-seven doctors in 34 centers contributed data. A total of 2142 patients were analyzed. This is the largest state-wide survey of IBD in India. Ulcerative colitis was diagnosed in 1112 (38 new), Crohn’s disease in 980 (53 new), and 50 were unclassified (5 new). The district-wise distribution of IBD cases correlated with the District-wise Gross State Domestic Product (rxa0=u20090.69, pxa0<u20090.01). Three percent was below the age of 18. Patients with UC had more diarrhea (73% vs. 51%), bleeding PR (79% vs. 34%), and intermittent flares (35% vs. 13%) (all pxa0<u20090.01). Patients with CD had more abdominal pain (62% vs. 46%), weight loss (53% vs. 40%), fever (28% vs. 18%), and history of antituberculosis treatment (21% vs. 5%) (all pxa0<u20090.01). Compared to adults, children (below 18xa0years) were more likely to have extensive UC (58% vs. 34%, pxa0<u20090.01) and unclassified IBD (15% vs. 2%, pxa0<u20090.01).ConclusionInflammatory bowel disease is common in Kerala, India. The disease characteristics of patients with IBD are almost similar to those from other parts of the country. Both UC and CD were seen in equal proportion in Kerala.

Branch duct-type intraductal papillary mucinous neoplasm presenting as paraneoplastic small plaque para-psoriasis

To present and discuss a novel association between branch duct-type intraductal papillary mucinous neoplasm and paraneoplastic parapsoriasis. We present the case of a middle-aged male presenting with skin lesions that were suggestive of parapsoriasis, resistant to treatment, and in whom a diagnosis of branch-type intraductal papillary mucinous neoplasm of the pancreas was eventually made. A curative Whipples surgery led to complete resolution of the skin lesions within 3 weeks. Paraneoplastic parapsoriasis in association with intraductal papillary mucinous pancreatic neoplasm has never been reported before.

Strange case of dimorphic skin rash in a patient with cirrhosis: atypical herpes simplex and sweet’s syndrome

A middle-aged man with decompensated cirrhosis and a dimorphic multisite skin rash is diagnosed with rare atypical herpes simplex infection, manifesting Sweet’s syndrome (SS) in the absence of other described associations. SS, an acute febrile neutrophilic dermatosis, has three common forms—classical or idiopathic, malignancy associated and drug induced. Systemic autoimmune, connective tissue diseases and infections are also strong associations. The latter is commonly described in Gram-positive bacteria, salmonellosis and Yersinia. Herpes infections are a rare cause of SS, reported only thrice in literature, one with concomitant lupus, the second with associated mycobacterial infection and third, in metastatic breast disease in contrast to our patient. Atypical rash, especially if dimorphic, warrants histopathological evaluation to confirm underlying disease.

Isolated intraductal variant of hepatocellular carcinoma.

A 70-year-old male teetotaller, with a history of chronic obstructive lung disease and hypertension, presented to the emergencyxa0department with a 2-day history of right upper quadrant pain and melaena. Investigations revealed total bilirubin 6.8u2009mg/dL, aspartate and alanine transaminases 88 and 122 IU/L, respectively, alkalinexa0phosphatase 338 IU/L and gamma-glutamylxa0transpeptidase 223 IU/L. Tests for chronic hepatitis B, hepatitis C and HIV were negative. Serum alpha-fetoprotein was 22.8u2009ng/mL, whereasxa0carcino-embryonic antigen (CEA), CA 19–9, prostate specific antigen and chromogranin levels were normal. Contrast CT of the abdomen revealed fatty liver with moderate dilation of bilateral intrahepatic biliary radicles (figure 1A) and dilated common bile duct (CBD) with hyperdense contents, without identifiable mass lesions in the liver or biliary tree. Upper gastrointestinal …

Severe liver injury due to Epsom salt naturopathy.

A 38-year-old non-alcoholic, non-diabetic man with gallstone disease was prescribed three tablespoons of Epsom salt (magnesium sulfate crystals) with lukewarm water for 15 days for ‘stone dissolution’ by a naturopathy practitioner. He developed loss of appetite and darkening of urine from the 12th day on treatment and jaundice from the second day after treatment completion. The patient denied fevers, skin rash, joint pains, myalgia, abdominal pain, abdominal distension and cholestatic symptoms. Examination revealed a deeply icteric patient oriented to time, place and person without organomegaly or stigmata of chronic liver disease. Blood investigations revealed platelet count 190 (normal 150–450xa0xxa0109/L), total bilirubin 12.8 (39.3 mmol/L) (normal 0.3–1.0u2009mg/dL or 5.0–17.0u2009mmol/L), direct bilirubin 6.9 (21.7 mmol/L) (0.0–0.2u2009mg/dL or 0.0–3.4u2009mmol/L), aspartate aminotransferase 508 (<37u2009U/L), …