Virendra Singh

Noradrenaline vs. terlipressin in the treatment of hepatorenal syndrome: A randomized study

BACKGROUND & AIMSnVarious vasoconstrictors are useful in the management of hepatorenal syndrome (HRS). Terlipressin is the drug of choice; however, it is expensive. In this study, we evaluated safety and efficacy of terlipressin and noradrenaline in the treatment of HRS.nnnMETHODSnForty-six patients with HRS type 1 were managed with terlipressin (group A, N=23) or noradrenaline (Group B, N=23) with albumin in a randomized controlled trial at a tertiary center.nnnRESULTSnHRS reversal could be achieved in 9 (39.1%) patients in group A and 10 (43.4%) patients in group B (p=0.764). Univariate analysis showed baseline Child Turcotte Pugh score (CTP), model of end stage liver disease (MELD), urine output on day 1(D1), albumin, and mean arterial pressure (MAP) were associated with response. However, on multivariate analysis only CTP score was associated with response. Fourteen patients in group A and 12 in group B died at day 15 (p>0.05). Noradrenaline was less expensive than terlipressin (p<0.05). No major adverse effects were seen.nnnCONCLUSIONSnThe results of this randomized study suggest that noradrenaline is as safe and effective as terlipressin, but less expensive in the treatment of HRS and baseline CTP score is predictive of response.

Midodrine Versus Albumin in the Prevention of Paracentesis-Induced Circulatory Dysfunction in Cirrhotics: A Randomized Pilot Study

OBJECTIVES:Intravenous albumin has been used to prevent paracentesis-induced circulatory dysfunction (PICD) in cirrhotics; however, its use is costly and controversial. Splanchnic arterial vasodilatation is primarily responsible for PICD. There are no reports of use of midodrine in the prevention of PICD. In this pilot study, we evaluated midodrine and albumin in the prevention of PICD.METHODS:Forty patients with cirrhosis underwent therapeutic paracentesis with midodrine or albumin in a randomized controlled trial at a tertiary center. Effective arterial blood volume was assessed by plasma renin activity.RESULTS:Plasma renin activity at baseline and at 6 days after paracentesis did not differ in the two groups (43.18 ± 10.73 to 45.90 ± 8.59 ng/mL/h, P= 0.273 in the albumin group and 44.44 ± 8.44 to 41.39 ± 10.21 ng/mL/h, P= 0.115 in the midodrine group). Two patients had an increase in plasma renin activity of more than 50% from baseline in the albumin group, and none in the midodrine group. A significant increase in 24-h urine volume and urine sodium excretion was noted in the midodrine group. Midodrine therapy was cheaper than albumin therapy.CONCLUSIONS:The study suggests that midodrine may be as effective as albumin in preventing PICD in cirrhotics, but at a fraction of the cost, and can be administered orally. Midodrine also resulted in an increase in 24-h urine volume and sodium excretion.

Midodrine in patients with cirrhosis and refractory or recurrent ascites: A randomized pilot study

BACKGROUND & AIMSnSplanchnic arterial vasodilatation plays an important role in cirrhotic ascites. The aim of this study was to evaluate the effects of long term administration of midodrine on systemic hemodynamics, renal function, and control of ascites in patients with cirrhosis and refractory or recurrent ascites.nnnMETHODSnForty cirrhotic patients with refractory or recurrent ascites were prospectively studied after long term administration of midodrine plus standard medical therapy (n=20) or standard medical therapy alone (n=20) in a randomized controlled trial at a tertiary centre.nnnRESULTSnA significant increase in urinary volume, urinary sodium excretion, mean arterial pressure, and decrease in plasma renin activity (p<0.05) was noted after 1 month of midodrine administration. There was also a significant decrease in cardiac output and an increase in systemic vascular resistance after midodrine therapy at 3 months (p<0.05). There was no change in glomerular filtration rate and model for end-stage liver disease (MELD) score. Midodrine plus standard medical therapy was significantly superior to standard medical therapy alone in the control of ascites (p=0.013) at 3 months. The mortality rate in the standard medical therapy group was significantly higher than the midodrine group (p<0.046). There was no significant difference in the frequency of various complications at the end of follow-up.nnnCONCLUSIONSnThe results of this randomized pilot study suggest that midodrine plus standard medical therapy improves the systemic hemodynamics without any renal or hepatic dysfunction in these patients and is superior to standard medical therapy alone for the control of ascites.

Noradrenaline vs terlipressin in the treatment of type 2 hepatorenal syndrome: a randomized pilot study.

Various vasoconstrictors have shown promising results in the management of type 1 hepatorenal syndrome (HRS). However, there are very few studies on vasopressors in the management of type 2 HRS. Terlipressin has been used commonly; however, it is costly and not available in some countries. In this study, we evaluated the safety and efficacy of terlipressin and noradrenaline in the treatment of type 2 HRS.

Endoscopic management of traumatic hepatobiliary injuries

Background:u2002 Non‐surgical treatment has become the therapeutic method of choice in hemodynamically stable patients with liver trauma. There are a few reports of endoscopic management of traumatic hepatobiliary injuries in such patients; however, the optimal intervention is not known.

Amoebic liver abscess in the medical emergency of a North Indian hospital.

BackgroundAmoebic Liver abscess although fairly common in developing countries, yet, there is limited data on the clinical presentation to the emergency department. A retrospective analysis of 86 indoor cases of Amoebic Liver Abscess presenting to the emergency department over a 5-year period was carried out.FindingsThe mean age of patients was 40.5 ± 2.1 years (male-female ratio = 7:1). Fever, pain abdomen and diarrhea were seen in 94%, 90% and 10.5% respectively. Duration of symptoms less than 2 weeks was seen in 48% cases. Hepatomegaly was present in 16% cases only, a right sided pleural effusion in 14% cases and ascites in 5.7%. On ultrasound, a right lobe abscess was seen in 65%, a left lobe abscess in 13% and multiple abscesses in both the lobes in 22% cases. Seventy one cases underwent per-cutaneous pigtail catheter drainage for a mean period of 13.4 ± 0.8 days. The mortality rate was 5.8%. On multivariate regression and correlation analysis, a higher number of inserted pigtail catheters correlated to mortality.ConclusionsAmoebic liver abscess presents commonly to the emergency department and should be suspected in persons with prolonged fever and pain abdomen. Conservative management for uncomplicated amoebic liver abscess and insertion of single per-cutaneous pigtail catheter drainage for complicated amoebic liver abscess are efficacious as treatment modalities.

Contrast‐free unilateral endoscopic palliation in malignant hilar biliary obstruction: New method

Background:u2002 Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast‐free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast‐free unilateral metal stenting in type II malignant hilar biliary obstruction.

Dengue fever related acalculous cholecystitis in a North Indian tertiary care hospital.

Background and Aims:u2002 To document the clinical outcome and prognosis of acalculous cholecystitis in dengue fever.

Outcomes after multiple courses of granulocyte colony‐stimulating factor and growth hormone in decompensated cirrhosis: A randomized trial

Decompensated cirrhosis (DC) carries a high mortality. Liver transplantation (LT) is the treatment of choice; however, the limited availability of donor organs has resulted in high waitlist mortality. The present study investigated the impact of multiple courses of granulocyte‐colony stimulating factor (G‐CSF) with or without growth hormone (GH) in these patients. Sixty‐five patients with DC were randomized to standard medical therapy (SMT) plus G‐CSF 3 monthly plus GH daily (group A; n = 23) or SMT plus G‐CSF (group B; n = 21) or SMT alone (group C; n = 21). The primary outcome was transplant‐free survival (TFS) at 12 months. Secondary outcomes were mobilization of CD34+ cells at day 6 and improvement in clinical scores, liver stiffness, nutrition, episodes of infection, and quality of life (QOL) at 12 months. There was significantly better 12‐month TFS in groups A and B than in group C (P = 0.001). At day 6 of therapy, CD34+ cells increased in groups A and B compared to baseline (P < 0.001). There was a significant decrease in clinical scores, improvement in nutrition, better control of ascites, reduction in liver stiffness, lesser infection episodes, and improvement in QOL scores in groups A and B at 12 months as compared to baseline (P < 0.05). The therapies were well tolerated. Conclusion: Multiple courses of G‐CSF improved 12‐month TFS, mobilized hematopoietic stem cells, improved disease severity scores, nutrition, fibrosis, QOL scores, ascites control, reduced infections, and the need for LT in patients with DC. However, the use of GH was not found to have any additional benefit. (Hepatology 2017).

CONTRAST‐FREE BALLOON‐ASSISTED UNILATERAL PLASTIC STENTING IN MALIGNANT HILAR BILIARY OBSTRUCTION: A NEW METHOD

Background:u2002 Unilateral endoscopic drainage in unresectable type II malignant hilar biliary obstruction is effective. Contrast injection leads to cholangitis. Recently, contrast‐free unilateral metal stenting in malignant hilar biliary obstruction has shown encouraging results, however, it is costly.