Sahaj Rathi

Acute Liver Failure Due to Etodolac, a Selective Cycloxygenase- 2 (COX -2) Inhibitor Non-Steroidal Anti-Inflammatory Drug Established by RUCAM-Based Causality Assessment

Drug induced liver injury is a common cause of acute liver failure (ALF). While most of these cases are due to dose dependent hepa-totoxicity with acetaminophen, idiosyncratic drug-induced liver injury (DILI) is responsible for about 15% cases of ALF. Antibiotics are the most common cause of idiosyncratic DILI as well as DILI induced ALF. Etodolac is a selective cycloxygenase- 2 (COX -2) inhibitor non-steroidal anti-inflammatory drug used as an analgesic and anti-inflammatory in musculoskeletal diseases. Severe liver impairment is extremely rare. Till date, only 3 cases of ALF related to etodolac have been reported in the literature. Here we report two cases with a unique presentation of ALF occurring due to DILI caused by etodolac, as diagnosed by Roussel Uclaf Causality Assessment Method (RUCAM).Drug induced liver injury is a common cause of acute liver failure (ALF). While most of these cases are due to dose dependent hepatotoxicity with acetaminophen, idiosyncratic drug-induced liver injury (DILI) is responsible for about 15% cases of ALF. Antibiotics are the most common cause of idiosyncratic DILI as well as DILI induced ALF. Etodolac is a selective cycloxygenase- 2 (COX -2) inhibitor non-steroidal anti-inflammatory drug used as an analgesic and anti-inflammatory in musculoskeletal diseases. Severe liver impairment is extremely rare. Till date, only 3 cases of ALF related to etodolac have been reported in the literature. Here we report two cases with a unique presentation of ALF occurring due to DILI caused by etodolac, as diagnosed by Roussel Uclaf Causality Assessment Method (RUCAM).

Managing encephalopathy in the outpatient setting

Hepatic encephalopathy (HE) refers to brain dysfunction caused by liver insufficiency and/or portosystemic shunting, manifesting as a wide spectrum of neuropsychiatric abnormalities ranging from subclinical alterations to coma. It has traditionally been classified according to severity into minimal hepatic encephalopathy (MHE) and HE grades I to IV. MHE includes patients with mild neurocognitive decline apparent only on specialized testing. Grade I HE includes subtle behavioral changes such as inattention, mood changes, and sleep disturbances, which are often difficult to detect on routine clinical evaluation. Therefore, the new classification includes both grade I HE and MHE into covert hepatic encephalopathy (CHE). CHE is seen in 40% to 84% of patients with cirrhosis and is associated with poor quality of life (QOL), impaired driving skills, poor work performance, and reduced overall survival (Fig. 1).

Patient Acceptance of Lactulose Varies Between Indian and American Cohorts: Implications for Comparing and Designing Global Hepatic Encephalopathy Trials

Background Lactulose is the first-line drug for hepatic encephalopathy (HE), but its acceptance widely differs between Western and Eastern studies. Patient preference for lactulose between different parts of the world has not been examined systematically. Aim To define the preferences and reasons behind acceptance of lactulose in patients from USA and India. Methods A discrete-choice questionnaire with six hypothetical scenarios was constructed. Situations 1-3 studied preference for lactulose vs no-lactulose, while 4-6 studied preference for high-dose vs low-dose lactulose varying the overt HE prevention at 6 months and adverse event rates in each situation. This was administered to outpatient cirrhotics without prior/current experience with lactulose after dedicated education. Results 100 patients (50 Indian, 50 USA) with similar MELD scores were included. A significantly higher proportion of Indian respondents agreed to lactulose in all situations compared to Americans. While their acceptance of lactulose decreased in the situation with the least difference in overt HE prevention, it was consistently higher than Americans. In the high-dose vs low-dose scenario, the relative proportion of American respondents accepting high-dose increased with the higher presented protection against overt HE. On the other hand, Indian respondents remained largely consistent with low-dose lactulose option. Conclusions There are significant variations in the acceptance of lactulose in Indian and American populations. The acceptance increases with a more favorable perceived benefit/risk profile, which is strongly influenced by socio-cultural factors. These results have important implications when designing, comparing and interpreting HE trials from different parts of the world.

Managing Encephalopathy in the Outpatient Setting

In cirrhosis of liver, hepatic encephalopathy (HE) has an important impact on health-related quality of life. It is important to define whether HE is episodic, recurrent, or persistent; types A, B, or C; overt HE or covert HE; and spontaneous or precipitated. The overt HE is clinically evident and needs hospitalization. Nonabsorbable disaccharides, rifaximin, and probiotics are proven to be useful in the treatment of overt HE. Covert HE includes both minimal HE and grade I HE. It is not apparent on routine clinical examination. Presence of poor work productivity, increased accidental injuries on complex machinery and driving, etc., raise the suspicion of cognitive dysfunction. Specialized neurocognitive testing like psychometric HE, computerized tests like critical flicker frequency tests, inhibitory control tests, Stroop encephalopathy tests, and electroencephalography are needed to diagnose overt HE. Various studies have shown lactulose and rifaximin to be useful in overt HE. However, presence of persistent and recurrent HE in cirrhosis is an indication for liver transplant. Lactulose is effective both in improving reversal of minimal HE and in reducing the risk of development of overt HE. How to cite this article: Gupta T, Rathi S, Dhiman RK. Managing Encephalopathy in the Outpatient Setting. Euroasian J Hepato-Gastroenterol 2017;7(1):48-54.

Portal Hypertensive Vesiculopathy: A Rare Cause of Hematuria and a Unique Management Strategy

Portosystemic collaterals are common sequelae of portal hypertension. These often present as gastroesophageal varices. Ectopic varices can rarely be seen in duodenum, jejunum, rectum, and sites of surgical anastomoses. Bladder varices are extremely rare presenting with recurrent hematuria, with only a few reported cases. We report here a management of an unusual case of hematuria managed with blood transfusion, intravenous terlipressin, and endoscopic N-butyl cyanoacrylate glue injection.

Treatment Options for Covert Hepatic Encephalopathy

Hepatic encephalopathy, even in its mildest form, can lead to significant deterioration in quality of life, lower overall survival, and add to caregiver burden. However, due to a paucity of symptoms, covert hepatic encephalopathy (CHE) is often ignored or neglected by physicians as well as patients. The lack of consensus among experts for both diagnosis as well as treatment of CHE adds to this problem. Treatment options for CHE include lactulose, rifaximin, ammonia scavengers, branched-chain amino acids, and probiotics. In this chapter we review the existing evidence on these agents and explain treatment decisions using a case-based approach.

Primary Hepatic Leiomyosarcoma: Histopathologist's Perspective of a Rare Case

Primary hepatic leiomyosarcoma is a rare primary mesenchymal tumor of the liver requiring exclusion of any other primary site of origin and histological and immunohistochemical exclusion of other hepatic/extrahepatic tumors with spindle cell morphology. Only about 70 cases are reported in the English literature and many of these tumors have predisposing conditions in the form of immunosuppression or associated malignancies. The occurrence of this tumor in the immunocompetent individual is also known. Histomorphology of this tumor shows a spindle cell lesion which needs to be distinguished from other spindle cell lesions of this region. The main diagnostic challenge of this tumor lies in its rarity, lack of awareness and morphological mimickers in the given site. A complete range of immunohistochemical markers is required to distinguish the lesion from its close morphological mimickers. Here, we discuss a case of primary hepatic leiomyosarcoma in an adult female patient with detailed histomorphological differentials and respective immunoprofiles.

Subcentimetric Incidental Intrahepatic Cholangiocarcinoma in an Explant Liver: Diagnostic Difficulty of a Rare Entity

Incidental intrahepatic cholangiocarcinoma (iCCA) is a rare neoplastic lesion in the explant liver specimens with an approximate incidence of 0.7%. The detection of iCCA is associated with poor prognosis in the posttransplant setting. The occurrence of a subcentimetric iCCA is very rare and poses a major diagnostic challenge to the pathologist. This article presents a rare case of subcentimetric iCCA in a young male in the background of advanced stage chronic liver disease resulting from autoimmune hepatitis possibly with chronic cholangiopathy along with the histomorphological differentials.

Acute Portal Vein Thrombosis: Aetiopathogenesis, Diagnosis and Management

Portal vein thrombosis (PVT) refers to the occlusion of the trunk of the portal vein (PV) by formation of a luminal thrombus. This may extend into one or both of its intrahepatic branches, or its tributaries—the splenic and the superior mesenteric vein. The thrombus may be complete, occluding the whole lumen; or partial, sparing a peripheral stream to allow flow of blood. Occlusion of the PV by tumoral invasion is usually classified separately as a malignant thrombus.