Tandon Bn

An epidemic of veno-occlusive disease of liver in central India.

An outbreak of veno-occlusive disease which was probably caused by consumption of cereals mixed with seeds of a plant (Crotalaria sp.) containing pyrrolizidine alkaloids occurred in the Sarguja district of India in November-December 1975. 42% of the 67 recorded cases died.

Epidemiology of hepatitis B virus infection in India.

The average estimated carrier rate of hepatitis B virus (HBV) in India is 4%, with a total pool of approximately 36 million carriers. Wide variations in social, economic, and health factors in different regions may explain variations in carrier rates from one part of the country to another. Professional blood donors constitute the major high risk group for HBV infection in India, with a hepatitis B surface antigen positivity rate of 14%. Blood transfusions represent the most important route of HBV transmission among adults. However, most of Indias carrier pool is established in early childhood, predominantly by horizontal spread due to crowded living conditions and poor hygiene. Acute and subacute liver failure are common complications of viral hepatitis in India and HBV is reckoned to be the aetiological agent in 42% and 45% of adult cases, respectively. HBV is reported to be responsible for 70% of cases of chronic hepatitis and 80% of cases of cirrhosis of the liver. About 60% of patients with hepatocellular carcinoma are HBV marker positive. Small numbers of patients have been reported to be infected with the pre-core mutant virus but none with the S mutant. Coinfection with hepatitis C virus or hepatitis delta virus is comparatively uncommon. In conclusion, hepatitis B is a major public health problem in India and will continue to be until appropriate nationwide vaccination programmes and other control measures are established.

Recommendations of the International Association for the Study of the Liver Subcommittee on nomenclature of acute and subacute liver failure

Therefore, a nomenclature and classification was needed that would: (i) not detract widely from the spirit of the original definition of Trey and Davidson; (this is necessary because most of the studies and the accepted therapeutic options currently available are based on this description or its modifications; further, an altogether new nomenclature/classification would be an obvious source of confusion); (ii) be simple, concise and understood by primary care physicians world-wide, as patients are more likely to be first seen by such physicians rather than by hepatologists to whom these cases are referred; (iii) incorporate accepted changes (as far as possible) that have been described in the literature; (iv) try to clarify some of the confusions, especially regarding certain entities, such as SHF, that are found in some geographical areas; and (v) include terminologies that would be acceptable to a majority.

Effect of periodic deworming on nutritional status of ascaris-infested preschool children receiving supplementary food.

The weight for age of 154 undernourished preschool children in an ascaris-infested community receiving supplementary food was monitored for a year. 74 children were given tetramisole every 4 months, while 80 controls were given placebo. The prevalence of ascaris (roundworm) infection and the severity of protein-energy malnutrition were the same in the two groups at the onset of the study. Stool-positive rates for ascariasis came down significantly in the experimental group during the year, but eradication of the worm was not possible owing to constant re-exposure. Nutritional status remained unaltered in the controls but improved strikingly in the treated children 8 and 12 months after the start of the study. Periodic deworming should form a part of the supplementary feeding programme if malnutrition is associated with ascariasis in the community.

Acute liver failure. Experience with 145 patients.

Acute liver failure (ALF) is an uncommon but serious disease still carrying a high mortality. This report describes one of the largest series of cases of acute failure, managed on a simple intensive supportive therapeutic regimen. One hundred fifty-eight patients with ALF were admitted to the Rajgarhia Liver Unit of the All-India Institute of Medical Sciences (AIIMS) during the period July 1976 to December 1981. Data from 145 were completed and analyzed for this report. Of the patients, 85.4% were below the age of 40 years. The female-to-male ratio was 1.3:1. Of the 77 women in the reproductive age group, 59.7% were pregnant. All cases of ALF were secondary to viral hepatitis. Cerebral edema, bleeding, infection, and renal failure were seen in 57.2, 57.2, 39.3, and 16.5% of patients, respectively. Overall survival was 28.9% of patients. It was 33% below the age of 40 years and only 4.8% above this age. Pregnancy did not adversely affect the prognosis. Survival was related to grade of coma, being 22.8% for patients in Grade IV coma and 62% for patients in Grade I coma. In fatal cases the immediate complications resulting in death were cerebral edema (63%), bleeding (30%), renal failure (10.6%), and infection (8.7%). Presence of HBsAg, a serum bilirubin of over 20 mg%, and serum sodium less that 119 mEq/liter were indicators of poor prognosis. A simple, intensive, support therapy yielded results comparable to those reported by centers using a variety of complex therapeutic regimens.

Study of an epidemic of venoocclusive disease in India.

Twenty-five cases of rapidly developing ascites occurring in an epidemic form were observed in a tribal district in Central India during August 1972-May 1973. Eleven of the patients died. Six patients were brought to hospital and studied for periods of two to 17 months. Necropsy was performed on one patient who died. The clinical features suggested an outflow tract obstruction such as a Budd-Chiari-like syndrome or venoocclusive disease. Radiographic and haemodynamic studies demonstrated a combination of post and perisinusoidal blocks. Liver dysfunction was indicated by the presence of a marked bromsulphthalein retention and mild to moderate hypoalbuminaemia. Histological examination of the liver biopsies showed changes that ranged from centrizonal haemorrhagic necrosis to an extensive centrilobular fibrosis associated with central vein occlusion. The disease was apparently caused by a food toxin, and the possible nature of this is discussed.

Large volume paracentesis and intravenous dextran to treat tense ascites

Surgicalorty patients with cirrhosis of the liver and tense ascites were randomized to receive either aldactone 400 mg/day and furosemid 80 mg/day (n = 20) or repeated large volume paracentesis (LVP) and infusion of low molecular weight dextran (n = 20). Both treatment groups were similar in clinical and laboratory parameters. Complete mobilization of the ascitic fluid was achieved in all receiving LVP and dextran therapy within 1 week of the treatment, in contrast to the minimal mobilization of the ascitic fluid in patients receiving diuretics even after 2 weeks of therapy. Renal function, the clinical parameters of systemic hemodynamics, serum electrolytes, and hepatic function remained stable in patients receiving LVP and dextran and were similar to those in the diuretictreated patients. We found no deterioration of these functions in the nonedematous patients treated by LVP and dextran even though the protective effect of edema against LVP was lacking in them. Plasma volume estimation in six nonedematous cirrhotic patients treated by LVP and dextran did not reveal any hypovolemia after complete mobilization of ascites. The frequency of complications and death were similar in the two groups. Dextran infusion is a safe, effective, and low-cost replacement therapy in patients with cirrhotic ascites treated by LVP.

Subacute hepatic failure; is it a distinct entity?

We prospectively studied patients with subacute hepatic failure due to subacute hepatitis to find out 1) its relative prevalence compared to acute liver failure due to fulminant hepatitis and chronic liver failure due to chronic active hepatitis; 2) its clinical, biochemical, and morphological hepatitis; 3) the role of virus B in its etiology; and 4) its prognosis and whether there were any predictors of bad prognosis. Thirty-three patients with subacute hepatic failure were registered during a 3-year period. Persistent or progressively deepening jaundice of 8 weeks duration and development of moderate to sever ascites in patients starting otherwise typical features of acute viral hepatitis, defined the subacute hepatic failure group. The characteristic features included moderate to deep icterus, ascites, and peripheral edema; encephalopathy and gastrointestinal bleeding were infrequent. Liver function tests were abnormal but not diagnostic. Submassive and bridging necrosis of the liver were the main histological findings. Virus B etiology was recorded in 42% of the patients. Mortality was 66%. This condition is highly fatal and not infrequent in India.

Acute sporadic non‐A, non‐B viral hepatitis of adults in India—Epidemiological and immunological studies

On the basis of tests for specific IgM class antibodies in the serum, infections by hepatitis A virus, hepatitis B virus and hepatitis non‐A, non‐B virus accounted for 7%, 37.8% and 54.2% respectively of 286 cases of acute sporadic viral hepatitis in adults from three different regions of India. Epstein‐Barr virus and cytomegalo virus were insignificant (0.5–1%) aetiological agents. Approximately one‐quarter of all non‐A, non‐B (NANB) cases were additionally HBsAg carriers; there were significant differences in regional frequencies. NANB hepatitis commonly affected individuals in the mid‐fourth decade and occurred throughout the year with small peaks in different seasons. No antigen‐antibody reaction could be demonstrated in various immunological tests including radioimmunobinding using acute and convalescent phase sera. Neither were virus‐like particles visualized in acute phase sera on electron and immuno‐electron microscopy. However, rhesus monkeys inoculated with acute phase serum from a case of NANB hepatitis developed distinct hepatocellular changes at 43–55 days after inoculation, which had some features of similarity with experimental NANB hepatitis of other simian species. Sporadic NANB hepatitis is a major health problem throughout India and intensive study is needed on its epidemiology and aetiology.

Enzyme linked protein-A: An ELISA for detection of amoebic antibody

Enzyme linked protein-A was used to develop an enzyme linked immunosorbent assay (ELISA) system for the detection of circulating antibodies to amoebic antigen. The specificity of protein-A to bind IgG only through Fc receptors, makes the test more specific for the detection of IgG antibodies to amoebic antigen. The ELISA system was used to detect amoebic antibody in control subjects (56), patients with amoebic liver abscess (79) and Entamoeba histolytica cyst-passers (10) and the results compared with those of indirect haemagglutination assay (IHA). The ELISA was more sensitive and detected 74.7% of cases with amoebic antibody in amoebic liver abscess compared with 66.7% detected by IHA. The test was more specific, sensitive and easy to perform and is recommended as a test of choice for the serological diagnosis of amoebic liver abscess.