Y. K. Chawla

Consensus on extra-hepatic portal vein obstruction

Abstract: The Asian Pacific Association for the Study of the Liver (APASL) had set up a working party on portal hypertension in 2002 with a mandate to develop consensus on various aspects of portal hypertension. The first of these consensuses has been developed on extra‐hepatic portal vein obstruction (EHPVO). It was discussed and prepared by the experts in this field from the Asian region and was presented at the annual meeting of the APASL, at Bali in August 2005. This article summarizes all the consensus statements approved by the APASL on various aspects of EHPVO.

Review article: the modern management of portal vein thrombosis.

Background  Portal vein thrombosis (PVT) is an important cause of portal hypertension. It may occur as such with or without associated cirrhosis and hepatocellular carcinoma. Information on its management is scanty.

Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment

The Asian Pacific Association for the Study of the Liver (APASL) Working Party on Portal Hypertension has developed consensus guidelines on the disease profile, diagnosis, and management of noncirrhotic portal fibrosis and idiopathic portal hypertension. The consensus statements, prepared and deliberated at length by the experts in this field, were presented at the annual meeting of the APASL at Kyoto in March 2007. This article includes the statements approved by the APASL along with brief backgrounds of various aspects of the disease.

The Clinicopathological Profile of Indian Patients with Nonalcoholic Fatty Liver Disease (NAFLD) is Different from That in the West

There are limited data on nonalcoholic fatty liver disease (NAFLD) from India. The clinicopathological profile of Indian patients with NAFLD may be different from that of Western patients. One hundred NAFLD patients with increased liver enzymes were prospectively evaluated for clinical presentation, associated diseases, overweight/obesity, central obesity (n=54), presence of diabetes mellitus, lipid abnormalities, insulin resistance (n=39), metabolic syndrome (n=54), serum iron, serum ferritin, and transferrin saturation (n=60), and HFE gene mutations (n=30). Risk factors for the grade and stage of the disease on histology were studied in 38 biopsy-proven patients. Patients were treated with lifestyle modifications and ursodeoxycholic acid (UDCA). Seventeen nonresponder patients were treated with metformin. The majority of patients were males (n=70). Twenty percent of patients were overweight, 68% had obesity, and 78% had central obesity. Abnormal cholesterol, HDL, and triglycerides were present in 36%, 66%, and 53% of patients, respectively. Twelve percent of patients had diabetes mellitus and 16% patients had various associated diseases. All 22 (100%) patients studied by ITT and all but 1 (98%) studied by HOMA-IR were found to have reduced insulin sensitivity and 50% were found to have metabolic syndrome by the modified ATP III criteria. Two (3%) patients were found to have high serum iron, 4 (7%) patients had high ferritin, 5 (8%) patients had increased transferrin saturation, and 4 (13%) patients were found to be heterozygotes for H63D HFE gene mutation. Twenty patients of 38 (53%) had histological evidence of NASH (class 3=6, class 4=14). The other 18 (47%) qualified for class I (n=1) or class II (n=17) NAFLD. Four (10.5%) patients had bridging fibrosis and none had evidence of cirrhosis liver. Seventy-four (74%) patients achieved a biochemical response to lifestyle modification and UDCA. All 17 patients treated with metformin had a reduction in ALT level and 10 (59%) of them had normalization of their enzymes. We conclude that the clinicopathological profile of NAFLD in Indian patients is different from that in the West.

Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

The Asian Pacific Association for the Study of the Liver (APASL) set up a Working Party on Portal Hypertension in 2002, with a mandate to develop consensus guidelines on various clinical aspects of portal hypertension relevant to disease patterns and clinical practice in the Asia-Pacific region. Variceal bleeding is a consequence of portal hypertension, which, in turn, is the major complication of liver cirrhosis. Primary prophylaxis to prevent the first bleed from varices is one of the most important strategies for reducing the mortality in cirrhotic patients. Experts predominantly from the Asia-Pacific region were requested to identify the different aspects of primary prophylaxis and develop the consensus guidelines. The APASL Working Party on Portal Hypertension evaluated the various therapies that have been used for the prevention of first variceal bleeding. A 2-day meeting was held on January 12 and 13, 2007, at New Delhi, India, to discuss and finalize the consensus statements. Only those statements that were unanimously approved by the experts were accepted. These statements were circulated to all the experts and were subsequently presented at the annual conference of the APASL at Kyoto, Japan, in March 2007.

Eosinophilic Cholangiopathy—A Case Report

Eosinophilic cholangiopathy is a rare benign disorder of the biliary tract occurring in a setting of peripheral or tissue eosinophilia. It is a broader term and comprises eosinophilic cholecystitis when it involves only the gallbladder (GB) and eosinophilic cholangitis when it involves the bile ducts (1, 2). There are only a few case reports in the literature and most often they describe the combination of GB and bile duct involvement (Table 1). Isolated involvement of bile ducts without involvement of GB is very rare. Eosinophilic cholangiopathy occurs most often in patients with idiopathic hypereosinophilic syndrome, and to our knowledge, there are only two previous reports of bile duct involvement (eosinophilic cholangitis) in patients with eosinophilic gastroenteritis (3, 4). We report a patient who had eosinophilic gastroenteritis with eosinophilic cholangitis.

Serum Iron Levels and Hepatic Iron Overload in Patients with Nonalcoholic Steatohepatitis

To the Editor: We read with interest the article by Uraz et al. [1] on the serum iron levels and hepatic iron overload in patients with nonalcoholic hepatitis (NASH) and chronic hepatitis. They studied 25 patients, each with biopsy-proven NASH and chronic viral hepatitis, and found higher serum iron and ferritin levels in patients with chronic viral hepatitis in comparison to those with NASH. Five (20%) patients with chronic viral hepatitis showed positivity for iron on Perls’ Prussian blue staining on liver biopsy compared to none in patients with NASH. We agree with Uraz et al. [1] that patients with nonalcoholic fatty liver disease (NAFLD) do not show evidence of iron overload [2]. We studied iron parameters in 59 patients with NAFLD (38 biopsy proven) (Table 1). Only two (3%) patients had high serum iron (>150 μg/dl), five (8%) had high transferrin saturation (>55%), and four (7%) had high serum ferritin (>250 ng/dl). In contrast to Uraz et al. [1], even though the Perls’ Prussian blue staining for iron on liver biopsy was positive in 10 of 30 (33%) patients in whom this information was available

Pregnancy outcome in Budd Chiari Syndrome-a tertiary care centre experience

BackgroundPregnancy management is a crucial issue in women with Budd-Chiari Syndrome (BCS) and there are no established guidelines on the management.AimTo report our experience of pregnancy outcome with BCS.Material and MethodsWe report outcome of 13 pregnancies in three women, with favourable outcome after the diagnosis of the condition and its treatment using intervention to bypass obstruction and anticoagulant therapy during pregnancy.ResultsThree women had a total of 13 pregnancies; three after the diagnosis and decompressive treatment of the disease. Disease was diagnosed during index pregnancy in two women. Anticoagulation was given in all the three pregnancies (Robertson et al., Br J Haematol, 132:171–196, 2006).Pregnancies prior to diagnosis and treatment resulted in a live birth.ConclusionPregnancy does not seem to be a contraindication in well treated and controlled BCS. Maternal outcome is good with close multidisciplinary surveillance. Foetal outcome, however, may still be poor due to underlying prothrombotic condition.

Primary Leiomyosarcoma of Gallbladder: A Rare Diagnosis

Leiomyosarcoma of the gallbladder is a rare entity, constituting about 1.4 per 1000 gallbladder malignancies. Literature review shows female preponderance in sixth decade of life, due to unknown reasons. We report one such rare case of a 50-year-old female admitted with pain in right upper abdomen. On examination, mass was felt in right hypochondrium. The ultrasound abdomen showed mass with loss of interface with liver and cholelithiasis. CECT abdomen showed polypoidal gallbladder malignancy with ill-defined interface with liver. She was operated upon with diagnosis of carcinoma gallbladder; extended cholecystectomy was done. Histopathological examination revealed spindle-cell proliferation and possibility of malignant tumor of mesenchymal origin was kept. This was later confirmed on immunohistochemistry.

Dilatation of benign oesophageal strictures: 10 years’ experience with Celestin dilators

Background : Endoscopic dilatation is the first line of treatment for benign oesophageal strictures. There are limited data available on the use of Celestin dilators.