Vikas Singla

The usefulness of transient elastography by FibroScan for the evaluation of liver fibrosis

IntroductionLiver stiffness measurement (LSM) is used for the assessment of liver fibrosis. However, there is limited data in Indian patients.Aims and ObjectiveThe aim of this study was to find the correlation of LSM, aspartate transaminase to platelet ratio index (APRI) with fibrosis as assessed by liver biopsy (LB), and predictors of discordance between LB and LSM.MethodsOne hundred and eighty-five consecutive patients who underwent liver biopsy and transient elastography (TE) were enrolled. Fibrosis was graded by two independent pathologists using the METAVIR classification. Area under receiver operating curves (AUROC) was used to evaluate the accuracy of transient elastography and APRI in diagnosing significant fibrosis (F>2) and cirrhosis (F4).ResultsPredominant etiologies were hepatitis B (46xa0%) and hepatitis C (26xa0%). LSM was unsuccessful in ten patients (5xa0%) because of small intercostal space (nu2009=u20093) and obesity (nu2009=u20097). Fibrosis is significantly correlated with LSM (ru2009=u20090.901, pu2009=u20090.001) and APRI (ru2009=u20090.736, pu2009=u20090.001). There was a significant difference in median LSM value in patients with no fibrosis (F0) in comparison to patients having mild fibrosis [mild portal fibrosis (F1)u2009+u2009fibrosis with few septa (F2)] (4.5 vs. 7.5xa0kPa, pu2009=u20090.001) and advanced fibrosis [bridging fibrosis that is spreading and connecting to other areas that contain fibrosis (F3)u2009+u2009cirrhosis or advanced scarring of the liver (F4)] (4.5 vs. 19.4xa0kPa, pu2009=u20090.001). Similarly, there was a significant difference in mean APRI value in patients with F0 in comparison to patients having mild fibrosis (F1u2009+u2009F2) (0.55u2009±u20090.31 vs. 1.09u2009±u20090.81, pu2009=u20090.001) and advanced fibrosis (F3u2009+u2009F4) (2.3u2009±u20091.3, pu2009=u20090.001). AUROC for diagnosis of significant fibrosis was 0.98 (95xa0% confidence interval (CI) 0.963–0.999) for TE and 0.865 (95xa0% CI 0.810–0.920) for APRI. Optimal TE value was 10.0xa0kPa for diagnosis of significant fibrosis and 14.7xa0kPa for cirrhosis with specificity and sensitivity of 89xa0%, 98 % and 96xa0%, and 97xa0%, respectively. On multivariate analysis, total bilirubin and histological activity index (HAI) were identified as an independent predictor of TE inaccuracy.ConclusionLSM is a reliable predictor of hepatic fibrosis in Indian patients. LSM is superior to APRI for noninvasive diagnosis of hepatic fibrosis and cirrhosis, and high bilirubin (10.5xa0mg/dL) and Ishak HAI grade (>11) were independent predictors of discordance between LB and LSM.

Iatrogenic hypervitaminosis D as an unusual cause of persistent vomiting: a case report

IntroductionVitamin D is increasingly recognized to have several beneficial effects. Vitamin D deficiency is widely prevalent. Physicians often treat patients with high doses of vitamin D for various ailments without any monitoring for adverse effects and the prescribed doses often far exceed requirements resulting in toxicity. We present here a classic case of iatrogenic hypervitaminosis D, which presented with persistent vomiting and acute renal failure.Case presentationHere we present a case of a 45-year-old Asian Indian woman who presented to us with persistent vomiting the cause of which was iatrogenic hypervitaminosis D. She was treated with intravenous fluid, diuretics and calcitonin and had clinical improvement.ConclusionsWe suggest that in any patient presenting with persistent vomiting and hypercalcemia, particularly in the presence of normal parathyroid hormone, a diagnosis of overdose of vitamin D should be suspected. Its treatment not only alleviates symptoms but also prevents ongoing acute kidney injury.

Sustained Virological Response Rates to Antiviral Therapy in Genotype 1 and 3 Chronic Hepatitis C Patients: A Study from North India

BACKGROUNDnIn India, both genotype 3 and 1 are predominant genotypes in patients with chronic hepatitis C (CHC). However, there is scanty data on sustained viral response (SVR) rate with conventionally recommended dual therapy with PEG-IFN and ribavirin.nnnMETHODSnIn this retrospective study, consecutive patients of CHC of genotypes 1 and 3, attending the single unit of Gastroenterology of our hospital, who received PEG-IFN and ribavirin therapy, were included. Patients who had co-infection with HIV or HBV were excluded.nnnRESULTSnA total of 114 patients were included in the study median age 44 (15-72) years, 79% males. Most common presentation was with chronic hepatitis, while 10 (9%) patients had compensated cirrhosis. Nine (8%) patients had associated diabetes, 16 (14%) patients gave history of significant alcohol abuse. The median baseline HCV RNA level was 3.0xa0×xa010(5) (1.7xa0×xa010(3)-1.8xa0×xa010(7))xa0IU/mL. The most common genotype was 3 (75%) followed by genotype 1 (25%). 70% patients received PegIFN-α2a (median dose 180xa0MIU/wk) and 30% patients received PegIFN-α2b (median dose 80xa0MIU/wk). The median ribavirin dose was 800 (range 800-1200)xa0mg. SVR in genotype 1 was 64% (18/28) while SVR in genotype 3 was 73% (63/86). The factors predicting SVR on univariate analysis were a lower baseline HCV RNA level (less than 3.0xa0×xa010(5)), higher hemoglobin levelxa0>xa011.8xa0g/dl, and achievement of rapid virological response (RVR), early virological response (EVR) and end of treatment response (ETR). In multivariate analysis the only baseline factor found independently correlating with SVR was low HCV RNA level (<3.0xa0×xa010(5)xa0IU/mL) (Pxa0=xa00.003).nnnCONCLUSIONnIn north India, HCV genotype 3 has a SVR rate of 73%, which is comparable to genotype 1 with SVR rate of 64% when treated with PEG-IFN and ribavirin therapy. A baseline HCV RNA level lower than 3.0xa0×xa010(5) best predicts SVR in addition to achievement of RVR, EVR or ETR.

Unusual Cause of Massive Upper Gastrointestinal Bleeding: A Pancreatic Arteriovenous Malformation

CONTEXTnUpper gastrointestinal bleeding is one of the most common emergencies in gastroenterology. The common causes of the upper gastrointestinal bleeding include peptic ulcer disease, gastric erosive mucosal disease and portal hypertension. Gastrointestinal arteriovenous malformation is a less common cause of gastrointestinal bleeding and these arteriovenous malformation are most commonly located in the large and small intestine. Pancreatic arteriovenous malformation is a rare condition in which there is tumor-like formation or vascular anomaly built up via an aberrant bypass anastomosis of the arterial and venous systems in the pancreas. Splenic artery is most commonly involved (42%), followed by gastroduodenal artery (22%) and small pancreatic arteries (25%). Clinically it may present as gastrointestinal hemorrhage which is occasionally fatal. Other presentations are abdominal pain, pancreatitis, duodenal ulcer, jaundice, and portal hypertension.nnnCASE REPORTnWe present a rare case of pancreatic arteriovenous malformation presenting as massive upper gastrointestinal bleeding.nnnCONCLUSIONnSince early surgery is a life saving treatment for such cases, hence, a high index of suspicion should be maintained especially when massive bleeding is detected from the medial wall of second part of duodenum.

Hepatitis B Virus Infection can Cause Hepatocellular Carcinoma in Less Advanced Liver Cirrhosis: A Comparative Study of 142 Patients from North India

BACKGROUND AND AIMSnThe clinical profile of patients with hepatocellular carcinoma (HCC) may differ depending on the etiology of HCC. There is no study from India comparing the clinical profile of patients of HCC due to hepatitis B virus (HBV) infection with other etiologies.nnnMETHODSnWe retrospectively reviewed the records of patients clinically diagnosed as HCC between Nov 2000 and Dec 2012 admitted under a single unit of Department of Gastroenterology at our hospital. We compared the clinical presentation of patients of Hepatitis B virus etiology (HBV group) with other etiologies (Non-HBV group).nnnRESULTSnOne hundred and forty-two patients were included (median age 60 years [range 30-83], 92% males). The etiology was HBV in 56 (39%) and among the non-HBV group (nxa0=xa086, 61%) the etiological spectrum was following: alcohol 31 (22%), cryptogenic 26 (18%), HCV 27 (19%), and miscellaneous 2 (1%). The median age of presentation was significantly less for HBV group than in non-HBV (56 [30-77] vs. 62 [42-83] years, Pxa0<xa00.01). Clinical evidence of cirrhosis was significantly less common in the HBV group than non-HBV group (74% vs 98%, Pxa0<xa00.01). HBV group had lower CTP score than non-HBV (median CTP score 7 vs 8,Pxa0<xa00.05). Ascites was more common in non-HBV group than HBV group (65% vs 43%, Pxa0=xa00.018). The BCLC staging was: A 13%, B 23%, C 35%, and D 29%, and there was no difference in tumor characteristics or BCLC staging between HBV or the non-HBV group.nnnCONCLUSIONSnHBV is a common cause of HCC in India, accounting for 39% of cases. The tumor characteristics of HCC due to HBV is similar to other etiologies, however, HBV causes HCC at an earlier age, and in less advanced or even absence of cirrhosis, thus further consolidating the directly carcinogenic potential of HBV.

Intrahepatic Cholangiocarcinoma Masquerading as Liver Abscess

Malignancy masquerading as liver abscess, and presenting with fever, is mainly described in patients with colorectal cancers with liver metastasis. Primary liver tumors such as hepatocellular carcinoma or intrahepatic cholangiocarcinoma presenting as non-resolving liver abscess is extremely uncommon and carries a dismal prognosis. We present a rare case of non-resolving liver abscess as a presenting manifestation of intrahepatic cholangiocarcinoma.

Melioidosis Presenting as Fever and Jaundice: A Rare Presentation

Melioidosis caused by the environmental Gram-negative bacillus Burkholderia pseudomallei is endemic in northern Australia and Southeast Asia and is being described increasingly from south and west coastal regions of India. Melioidosis is known to have high mortality (14-50%) and the risk factors associated with it are diabetes mellitus and heavy alcohol abuse. Melioidosis primarily presents as pneumonia, genitourinary infection and bacteremia. We present a case of Melioidosis from North India, a 56-year-old diabetic male, presenting with fever and jaundice. His blood culture was positive for the B. pseudomallei. The hepatic involvement was in the form of jaundice with serum bilirubin value of more than 12xa0mg/dL, hepatic enzymes more than ten times high and without hepatic abscess. He improved with intravenous antibiotics with complete normalization of liver function tests.

Clinical and biochemical profile of tuberculosis in patients with liver cirrhosis.

INTRODUCTIONnThere is paucity of data on tuberculosis and antituberculous therapy (ATT) induced hepatotoxicity in patients with chronic liver disease.nnnAIMnTo study demographic, clinical characteristics of tuberculosis, pattern of drug induced liver injury and treatment responses to ATT in patients with liver cirrhosis.nnnMATERIAL AND METHODnAll cases of liver cirrhosis diagnosed with tuberculosis (TB) between January 2010 and June 2013 were enrolled. Drug induced liver injury (DILI) was defined as follows (1) an aspartate aminotransferase (AST)/alanine aminotransferase (ALT) value exceeding 3 times the normal upper limit if the baseline level was normal (<40xa0IU/L), or an AST/ALT exceeding 2 times the baseline level if the baseline level was abnormal and an absolute increase in serum bilirubin >2xa0mg/dl from baseline.nnnRESULTSnSixty seven patients had confirmed TB with underlying cirrhosis and formed the study group. The mean age was 52xa0±xa012 years and M:F ratio was 57:10. Mean Child Turcotte Pugh (CTP) score 8.5xa0±xa01.5 (CTP A:B:C:7:44:16). The sites of TB included: pulmonary (25, 37%); pleural effusion (10, 16%) peritoneal (19, 29%); chest lymph nodes (3, 4%); liver (1, 1.5%); intestines (3, 4%), vertebra (3, 4%), brain (1, 1.5%) and disseminated (2, 3%). Thus, extrapulmonary TB was more common in the cirrhotic patients as compared to pulmonary TB. Patients with Childs status A (nxa0=xa07) received 4 drugs (R: rifampicin, H: Isoniazid, E: ethambutol, Z: pyrizinamide) and could tolerate well even during follow up without any drug induced toxicity. In rest of patients commonest regimen followed was combination of drugs (RHEO, nxa0=xa032) followed by RHE (nxa0=xa011). DILI occurred in 35% started with either RHEO, HEO and REO. Median time of onset of DILI was 12 days (4-34) days. There was no DILI related death during hospital stay or follow up.nnnCONCLUSIONSnExtrapulmonary TB is common in patients with cirrhosis and DILI is common in Child B and C with combination of rifampicin and isoniazid regimen.

A patient with unexplained ascites

Sixty-two-year old male presented with history of low-grade fever, progressive abdominal swelling, weight loss and anorexia from the last one year. Patient was evaluated for the ascites in the peripheral hospital but diagnosis could not be made. Patient underwent contrast-enhanced computed tomography (CECT) abdomen for the workup (Figurexa01A), which helped in the diagnosis. n n n nFigurexa01 n nA: Case investigation—imaging. n n n nWhat is the diagnosis? n n(Answer on the page 87)