Sarfaraz Jasdanwala

Non-Alcoholic Fatty Liver Disease (NAFLD) in Obesity

BACKGROUND AND OBJECTIVES Limited studies have been undertaken to characterize Non-Alcoholic Fatty Liver Disease (NAFLD) in the Indian population. The main objective of our study was to document the prevalence of NAFLD amongst a cohort of obese Indian patients and demonstrate its relationship with other components of the metabolic syndrome. METHODS A total of 60 adult obese patients were subjected to a detailed history, clinical exam, anthropometric study and laboratory workup. Focus was on liver function and components of the metabolic syndrome like blood pressure, glycemic status and lipid profile. Subjects enrolled were divided into two groups Group A (n=48), with NAFLD and Group B (n=12) without NAFLD. The two groups were then compared amongst themselves as well as with data from previous similar studies. RESULTS A comparison of the anthropometric measurements revealed a statistically significant difference between the Body mass index (BMI) and Waist Hip Ratio of the two groups and in the mean triglyceride values between the two groups. Although the mean bilirubin levels measured in the serum were not statistically different the mean levels of SGOT and SGPT in the two groups was found to be statistically significant. On the contrary no significant difference in the values of alkaline phosphatase and synthetic liver functions could be discerned. A statistically highly significant difference in the mean liver span is seen. INTERPRETATION AND CONCLUSIONS NAFLD is common in Indian obese populations and is associated with significant differences in anthropometric, clinical, laboratory and ultrasonographic aspects as compared with obese individuals not affected with liver disease.

Crohn's Disease and Acute Pancreatitis. A Review of Literature

Crohns disease, a transmural inflammatory bowel disease, has many well-known extra-intestinal manifestations and complications. Although acute pancreatitis has a higher incidence in patients with Crohns disease as compared to the general population, acute pancreatitis is still relatively uncommon in patients with Crohns disease. Patients with Crohns disease are at an approximately fourfold higher risk than the general population to develop acute pancreatitis. The risk of developing acute pancreatitis is higher in females as compared to males. Acute pancreatitis can occur at any age with higher incidence reported in patients in their 20s and between 40-50 years of age. The severity and prognosis of acute pancreatitis in patients with Crohns disease is the same as in general population. Acute pancreatitis can occur before onset of intestinal Crohns disease, this presentation being more common in children than adults. It can also occur as the presenting symptom. However, most commonly it occurs after intestinal symptoms have manifest with a mean time interval between the initial presentation and development of acute pancreatitis being 2 years. There are several etiological factors contributing to acute pancreatitis in patients with Crohns disease. It is not clear whether acute pancreatitis is a direct extra-intestinal manifestation of Crohns disease; however, majority of the cases of acute pancreatitis in patients with Crohns disease are due to GS and medications. Drugs used for the treatment of Crohns disease that have been reported to cause acute pancreatitis include 5-ASA agents, azathioprine and 6 mercaptopurine, metornidazole and corticosteroids. Recent evidence has emerged correlating both type 1 and 2 autoimmune pancreatitis with Crohns disease. Understanding the association between the two disease entities is key to effectively manage patients with Crohns disease and acute pancreatitis.

Portal vein Doppler: a tool for non-invasive prediction of esophageal varices in cirrhosis.

BACKGROUND AND OBJECTIVES Esophageal varices (EV), a major complication of liver cirrhosis, can lead to life threatening gastrointestinal (GI) bleeding. Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosis and management of esophageal varices. However, it is not always available in resource-constrained settings.This study was aimed at evaluating portal vein indices (PVI) using Doppler on ultrasound abdomen, which is more widely available, as tools to predict the presence of EV. METHODS A total of 50 adult patients with cirrhosis were included in the study. All subjects underwent a percutaneous liver biopsy, abdominal ultrasound and EGD along with other tests as part of the work up for cirrhosis. The portal vein indices that were studied included hepatic congestion index (HCI), portal vein diameter (PVD) and portal vein velocity (PVV). Their sensitivity, specificity and predictive values were calculated using EGD as a gold standard. RESULTS Association of PVD, PVV and HCI with presence of EV was statistically significant (p-value <0.01). PVV had the highest sensitivity 84% (95% CI 66.45%- 94.10%) for detecting the presence of EV. PVD and HCI had the highest specificity of 55% (95% CI 0.31-0.77) and the highest negative predictive value of 38%(95% CI 0.24-0.52). Positive predictive value was highest PVV at 76%. (95% CI 0.61-0.86). CONCLUSION In resources- constricted settings where EGD is not available, PVI (PVV, PVD and HCI) on ultrasound abdomen can be used as non-invasive parameters to predict the presence of EV. Although EGD remains the gold standard for the diagnosis and management of EV, when this is not possible due to scarcity of resources, PVV may be used a tool to triage patients for referral for an EGD as it has the highest sensitivity of 84% (95% CI 66.45%-94.10%) and positive predictive value of 76% (95% CI 61.51%-86.47%) amongst the PVI studied for detecting the presence of EV.

Cephalexin Induced Cholestatic Jaundice

Cephalexin is a very commonly prescribed orally administered antibiotic which has many potential side effects. Amongst these cholestatic jaundice has been infrequently reported as an adverse reaction. We present a case of a 57-year-old male who exhibited features of cholestatic jaundice including elevated liver function tests (LFTs) after taking cephalexin and showed improvement on removal of the offending agent. During this time he was symptomatically treated with cholestyramine. Complete resolution of LFTs was seen in four weeks. Cephalexin induced cholestasis is rare and hence requires a high degree of clinical suspicion for prompt diagnosis and treatment.

Fatal Waterhouse-Friderichsen syndrome due to Serotype C Neisseria meningitidis in a young HIV negative MSM (men who have sex with men).

Waterhouse-Friderichsen syndrome (fulminant meningococcaemia) is a fulminating infection, often leading to mortality in a matter of hours. In the past 3 years there has been a rise in cases of Neisseria meningitis in the men who have sex with men (MSM) population in the USA and sporadic cases over the world especially in those who are HIV positive. We describe a case of a 34-year-old Caucasian man who presented with acute fulminant meningococcaemia, which proved fatal over a period of hours. This case report emphasises the need for further vigilance, prompt diagnosis and treatment of fulminant meningococcaemia without signs of meningitis especially in the MSM population and the need to expand vaccination recommendations of Meningococcaemia in the MSM population across the USA in both HIV positive and negative males.

Cirrhosis: An Unusual Presentation of Sickle Cell Disease

Hepatobiliary complications of sickle cell disease are relatively rare but well recognised in literature. Clinical syndromes range from mild intrahepatic cholestasis and gallstones to life threatening sequestration crisis. Most patients, homozygous for sickle cell anaemia, present before adolescence. We report a case of an adult man with no prior symptoms who presented for the first time with decompensated cirrhosis, which was found to be due to underlying previously unrecognised sickle cell anaemia.

Non-Alcoholic Fatty Liver Disease as a Risk Factor for Acute Pancreatitis: A Case Control Study

Objective: Visceral obesity is an etiological factor and a marker of poor prognosis in acute pancreatitis (AP). Non-Alcoholic Fatty Liver Disease (NAFLD), a marker for visceral obesity, has also been recognized to have a stronger correlation to poor outcomes. With this study, we aim to assess the role of NAFLD as an etiologic factor in patients with AP. Materials and Methods: In this retrospective electronic medical record (EMR) based case control study of 530 non-alcoholic adults were classified into cases with acute pancreatitis and controls without pancreatitis. Further subgroup was classified based on gallstone formation as an etiology of pancreatitis. Data was evaluated with McNemar’s Test. Results: Results showed that patients with AP due to Gallstones had a higher incidence of NAFLD as seen on abdominal imaging [OR=1.688, p=0.0235 (CI: 1.070-2.701)], but Patients with AP due to unclear etiology did not have statistically significant higher rates of NAFLD [OR: 1.400, CI: 0.688 – 2.919]. Patients with AP due to all etiologies combined had higher incidence of NAFLD [(OR: 1.596, CI: 1.094-2.349, P-value 0.0145)]. Conclusion: We conclude from this study shows that NAFLD may be an independent risk factor for development of acute pancreatitis. It is also possible that NAFLD may have pathophysiologic interplay with formation of gallstones that is a known risk factor for acute pancreatitis.

Ganglioneuroma Masquerading as Rectal Polyp: Clinical Significance and Literature Review

Ganglioneuroma (GN) of colon is a rare tumor of gastrointestinal (GI) tract. GNs of GI tract are usually confined to colon particularly rectum. GNs are usually found incidentally but can be associated with MEN IIb, von Recklinghausen’s neurofibromatosis or Cowden syndrome. A 21-year-old female with past medical history of bulimia, bipolar disorder and hypothyroidism, who presented with complaints of hematemesis and hematochezia. Her physical exam was unremarkable. She subsequently underwent an EGD and colonoscopy for further evaluation. EGD reveled mild gastritis. Colonoscopy revealed two 5 mm sessile polyps in the sigmoid colon and the rectum. Biopsy of the rectal polyp showed ganglioneuroma. This represents a case of polypoid ganglioneuromatosis. These polyps are endoscopically small sessile or pedunculated polyp indistinguishable from hyperplastic and adenomatous polyps. They are not associated with increased risk of colon cancer and don’t require additional screening. On the other hand, ganglioneuromatous polyposis and diffuse ganglioneuromatosis can be associated with increased risk of colon and other cancers, and may require further work up.

Tracheobronchitis as an extraintestinal manifestation of ulcerative colitis

Respiratory involvement is a rare extraintestinal manifestation of ulcerative colitis (UC). It commonly presents as bronchiectasis and rarely as tracheobronchitis. It can occur before or after the presentation of gastrointestinal symptoms. Only rarely does it occur after the patient undergoes colectomy. Diagnosis should be considered in any patient with UC who presents with unexplained upper respiratory symptoms and a negative work up for infectious aetiologies. It responds well to immunosuppressive therapy. We present a case of a 21-year-old woman who underwent colectomy for ulcerative colitis and later presented with new onset severe reversible inflammation of the upper respiratory tract.