Ravindu S. Kumarasena

Intravenous N-acetylcysteine in dengue-associated acute liver failure

We read with interest the article by Mumtaz et al. [1] on the role of oral N-acetylcysteine (NAC) in adults with non-acetaminophen-induced acute liver failure. We agree that their findings are of particular relevance to many developing countries, where liver transplantation is neither available nor affordable. There has been another recent study in which intravenous NAC has been shown to improve transplant-free survival in early-stage non-acetaminophen-induced acute liver failure in adults [2]. We report our initial experience in treating acute liver failure caused by dengue infection with NAC. Use of NAC in this situation has not been previously described.

Usefulness of Routine Terminal Ileoscopy and Biopsy during Colonoscopy in a Tropical Setting: A Retrospective Record-Based Study

Introduction. Available evidence for routine terminal ileoscopy during colonoscopy is equivocal. We investigated the place of routine terminal ileoscopy and biopsy during colonoscopy, in a tropical setting. Materials and Methods. All consenting adults undergoing colonoscopy had routine TI and biopsy. Patients with right iliac fossa (RIF) pain, diarrhoea, anaemia, suspected inflammatory bowel disease (IBD), and raised inflammatory markers were defined as Group A and all others undergoing colonoscopy as Group B. Results. Caecal intubation and TI were achieved in 988/1096 (90.15%) and 832/1096 (75.9%) cases, respectively. 764/832(91.8%) patients were included in final analysis. 81/764 (10.6%) patients had either macroscopic (34/81) or microscopic (47/81) abnormalities of terminal ileum; 20/81 had both. These were CD (28/47), tuberculosis (TB) (6/47), ileitis due to resolving infection (8/47), and drug-induced ileitis (5/47). 27/81 with macroscopically normal ileum had CD (18/27), ileitis due to resolving infection (5/27) and drug-induced ileitis (4/27) on histology. 12/764 (1.57%) patients with macroscopically normal colon had ileal CD (8/12), drug-induced ileitis (2/12), and resolving ileal infection (2/12) on histology. 47/764 (6.15%) patients had ileal pathology that influenced subsequent management. These were significantly higher in Group A (43/555 (8%)) than in Group B (4/209 (1.9%)) (P = 0.0048, χ 2 = 7.968). Conclusion. TI and biopsy improve diagnostic yield of colonoscopy in patients with RIF pain, diarrhoea, anaemia, suspected IBD, and raised inflammatory markers.

Predicting acute liver failure in dengue infection

In a retrospective study involving 240 patients with dengue infection, we attempted to identify early predictors of acute liver failure (ALF). Sixteen out of 41 patients with serum AST more than 1000 IU/ml developed ALF compared to none with serum AST less than 1000 IU/ml. Among patients with serum AST more than 1000 IU/ml, presence of two of the three following phenomena, within the first 5 days of illness: elevated serum bilirubin, elevated alkaline phosphatise or persistent nausea and vomiting, predicted development of ALF (93.8% sensitivity, 98.7% specificity, 83.3% positive predictive and 99% negative predictive value). The presence of elevated serum bilirubin, alkaline phosphatase and persistent nausea and vomiting in patients with very high serum AST during the early phase of dengue infection should alert the physician of impending ALF.

Worsening cholestasis and possible cefuroxime-induced liver injury following “successful” therapeutic endoscopic retrograde cholangiopancreatography for a distal common bile duct stone: a case report

BackgroundCefuroxime very rarely causes drug-induced liver injury. We present a case of a patient with paradoxical worsening of jaundice caused by cefuroxime-induced cholestasis following therapeutic endoscopic retrograde cholangiopancreatography for a distal common bile duct stone.Case presentationA 51-year-old, previously healthy Sri Lankan man presented to our hospital with obstructive jaundice caused by a distal common bile duct stone. Endoscopic retrograde cholangiopancreatography with stone extraction, common bile duct clearance, and stenting failed to improve the cholestasis, with paradoxical worsening of his jaundice. A liver biopsy revealed features of drug-induced intrahepatic cholestasis. Although his case was complicated by an episode of cholangitis, the patient made a complete recovery in 4 months with supportive treatment and withdrawal of the offending drug.ConclusionsThis case highlights a very rare drug-induced liver injury caused by cefuroxime as well as our approach to treating a patient with paradoxical worsening of jaundice after therapeutic endoscopic retrograde cholangiopancreatography.

Bleeding from oesophageal ulceration induced by endoscopic variceal ligation for primary prophylaxis

In a recent issue of Gut Garcia-Pagan et al 1 describe a multicentre, randomised controlled trial investigating the benefit of adding endoscopic banding ligation (EBL) to pharmacological treatment in the prevention of recurrent oesophageal variceal bleeding. We were particularly interested in their finding of bleeding due to oesophageal ulceration caused by EBL. They report that bleeding requiring hospitalisation occurred in four out of 80 (5%) patients who underwent EBL in addition to receiving nadolol and mononitrate for secondary prophylaxis of oesophageal varices. This more or less negated the observed slight benefit of adding EBL to drug therapy in preventing rebleeding from varices per se. We wish to report a similar experience of bleeding from oesophageal ulcers after EBL for primary prophylaxis …