Prevalence of hepatic encephalopathy in patients with non-cirrhotic portal hypertension: A systematic review and meta-analysis.

BACKGROUND: Hepatic encephalopathy, (HE) although commonly associated with cirrhosis, has also been reported in non-cirrhotic portal hypertension (NCPH). The importance of identifying and treating HE in NCPH lies in the fact that many patients may be wrongly diagnosed as having psychiatric or neurologic disorders. Hence, we aimed to systematically review the prevalence of HE in NCPH. METHODS: A comprehensive search of three databases (Medline, Embase and Scopus) was conducted from inception to November 2022 for studies reporting on the prevalence of minimal HE (MHE) and overt HE (OHE) in patients with NCPH. Results were presented as pooled proportions with their 95% confidence intervals (CI). RESULTS: Total 25 studies (n = 1487) were included after screening 551 records. The pooled prevalence of MHE in NPCH was 32.9% (95% CI: 26.7-39.0) without any difference between adult (32.9%, 95% CI: 23.5-42.3) and pediatric patients (32.6%, 95% CI: 26.1-39.1) (p = 0.941). There was no significant difference in the prevalence between patients with NCPH and compensated cirrhosis with odds ratio of 1.06 (95% CI: 0.77-1.44). The pooled event rate for prior history of OHE in NCPH was 1.2% (95% CI: 0.3-2.1). CONCLUSION: Around one-third of the patients with NCPH have MHE, irrespective of age group. OHE is extremely rare in NCPH and is usually associated with a precipitating factor.

Assessment of portal system hemodynamics for the prediction of portal vein thrombosis in cirrhosis-A systematic review and meta-analysis.

BACKGROUND: The pathogenesis of portal vein thrombosis (PVT) in cirrhosis is multifactorial, with altered hemodynamics being proposed as a possible contributor. The present systematic review was conducted to study the role of assessment of portal hemodynamics for the prediction of PVT in patients with cirrhosis. METHODS: Three databases (Medline, Embase, and Scopus) were searched from inception to February 2023 for studies comparing portal venous system parameters in patients with cirrhosis developing PVT with those not. Results were presented as mean difference (MD) or odds ratio (OR) with their 95% confidence intervals (CIs). RESULTS: A total of 31 studies (patients with cirrhosis: 19 studies, patients with cirrhosis undergoing splenectomy: 12 studies) were included. On pooling the data from multivariable analyses of the included studies, a larger portal vein diameter was a significant predictor of PVT in patients with cirrhosis without or with splenectomy with OR 1.74 (1.12-2.69) and OR 1.55 (1.26-1.92), respectively. On the other hand, a lower portal vein velocity (PVV) was a significant predictor of PVT in cirrhotics without or with splenectomy with OR 0.93 (0.91-0.96) and OR 0.71 (0.61-0.83), respectively. A PVV of <15 cm/s was the most commonly used cut-off for the prediction of PVT. Patients developing PVT also had a significantly higher splenic length, thickness, and splenic vein velocity. CONCLUSION: The assessment of portal hemodynamic parameters at baseline evaluation in patients with cirrhosis may predict the development of PVT. Further studies are required to determine the optimal cut-offs for various parameters.

Natural history of portal vein thrombosis in cirrhosis: A systematic review with meta-analysis.

BACKGROUND AND AIM: Progression of liver disease in cirrhosis is associated with an increased incidence of portal vein thrombosis (PVT) in cirrhosis. However, evidence suggests that spontaneous recanalization of PVT may occur even without anti-thrombotic therapy. Thus, the present meta-analysis was conducted to study the natural history of PVT in cirrhosis, facilitating decisions regarding anticoagulation. METHODS: Three electronic databases were searched from 2000 to August 2022 for studies reporting the outcome of PVT in cirrhotics without anticoagulation. The pooled proportions with their 95% confidence intervals (CIs) were calculated using a random-effect model. RESULTS: A total of 26 studies (n = 1441) were included in the final analysis. Progression of PVT on follow-up was seen in 22.2% (95% CI 16.1-28.4), while 77.7% (95% CI 71.6-83.9) remained non-progressive (improved or stable). The most common outcome was a stable PVT with a pooled event rate of 44.6% (95% CI 34.4-54.7). The pooled rates of regression and complete recanalization of PVT in cirrhotics were 29.3% (95% CI 20.9-37.7) and 10.4% (95% CI 5.0-15.8), respectively. On follow-up after improvement, pooled recurrence rate of PVT was 24.0% (95% CI 14.7-33.4). MELD score, and presence of ascites had a negative association, while a longer follow-up duration had positive association with PVT regression. CONCLUSION: Approximately 25% of the cases of PVT in cirrhosis are progressive, 30% cases improve, and 45% remain stable. Future studies are needed to analyze the predictors of spontaneous regression.

AIH in HIV: A Very Much Possible Entity.

Autoimmune Hepatitis (AIH) is a chronic liver disease Characterized by interface hepatitis, lymphoplasmacytic infiltrate, and hepatic rosettes. HIV infection is a state of immunosuppression; hence, the possibility of AIH is relatively rare, especially in patients with low CD4 counts. Therefore, we present an interesting case series of four patients with autoimmune liver disease with myriad presentations for the first time from India. We propose that despite the rarity of this presentation with immunosuppression, one should never miss such a treatable cause of liver disease leading to good clinical outcomes.

When to Discharge a Patient After Endoscopy: A Narrative Review.

Video endoscopy is an important modality for the diagnosis and treatment of various gastrointestinal diseases. Most endoscopic procedures are performed as outpatient basis, sometimes requiring sedation and deeper levels of anesthesia. Moreover, advances in endoscopic techniques have allowed invasion into the third space and the performance of technically difficult procedures that require the utmost precision. Hence, formulating strategies for the discharge of patients requiring endoscopy is clinically and legally challenging. In this review, we have discussed the various criteria and scores for the discharge of patients who have undergone endoscopic procedures with and without anesthesia.

Elevated plasma ICAM1 levels predict 28-day mortality in cirrhotic patients with COVID-19 or bacterial sepsis.

BACKGROUND & AIMS: Endothelial injury and dysfunction play a detrimental role in the pathogenesis of infections. Endothelium-related molecules have been reported as potential diagnostic and/or prognostic biomarkers of infection. The prognostic value of these biomarkers in patients with cirrhosis and infections remains elusive. METHODS: In this study, we investigated the performance of key soluble endothelial injury biomarkers, including intercellular adhesion molecule 1 (ICAM1), von Willebrand factor (vWF), vascular endothelial growth factor receptor 1 (VEGFR1), and angiopoietin 1 and 2 (Ang1, 2) as mortality predictors in patients with cirrhosis and severe COVID-19 or bacterial sepsis. RESULTS: A total of 66 hospitalized patients (admitted to the COVID-19 ward or liver intensive care unit [ICU]) were included. Twenty-two patients had COVID-19 alone, while 20 patients had cirrhosis plus COVID-19. Twenty-four patients had cirrhosis plus bacterial sepsis. Among patients with cirrhosis, the most common aetiology of liver disease was alcohol. ICAM1 was increased (p = 0.003) while VEGFR1 (p <0.0001) and Ang1 (p <0.0001) were reduced in patients with COVID-19 and cirrhosis, compared to patients with COVID-19 alone. Endothelial biomarker levels did not differ significantly between patients with cirrhosis and severe COVID-19 or bacterial sepsis in the ICU. In these patients, ICAM1 levels significantly and independently predicted mortality (hazard ratio 3.24; 95% CI 1.19-8.86) along with model for end-stage liver disease (MELD) score, renal and coagulation failures. The AUC for ICAM1 was 0.74, MELD was 0.60 and combined ICAM1 and MELD was 0.70. ICAM1 also positively correlated with the composite organ failure scores recorded 3-5 days post ICU admission (CLIF-OF and SOFA) in this subgroup of patients. CONCLUSION: The study indicates that in patients with cirrhosis, elevated plasma ICAM1 serves as an independent predictor of severe COVID-19- or sepsis-associated 28-day mortality. LAY SUMMARY: Bacterial sepsis and COVID-19 lead to increased mortality in patients with cirrhosis. In this study, we demonstrate that high plasma levels of ICAM1, an endothelial injury biomarker, is one of the important factors predicting mortality in critically ill cirrhotic patients with severe COVID-19 or bacterial sepsis.

Primary eosinophilic gastroenteritis: A case series from western India.

Primary eosinophilic gastroenteritis is a rare inflammatory disorder of gastrointestinal tract characterized by symptoms like abdominal pain, diarrhea, vomiting, weight loss, and eosinophilic infiltration of the intestinal wall with or without peripheral eosinophilia. We found four cases with different causes of eosinophilic enteritis with varying manifestations ranging from chronic diarrhea with malabsorption, dysphagia, and gastric outlet obstruction due to mass-like lesions.

Lactate-free AARC ACLF Score (LaFAS) - A Simple Userfriendly Score is the Best Prognostic Marker for Patients with Alcohol Induced ACLF in Western Indian Population in a Nontransplant Resource-limited Setting.

INTRODUCTION: Acute-on-Chronic liver failure (ACLF) is a disease with a distinct spectrum of liver injury, with a rapid downhill course Here we describe three new scores - Albumin Bilirubin Index (ALBI), platelet albumin bilirubin index (PALBI) and Lactate-free AARC ACLF score(LaFAS), in predicting short-term mortality in patients with alcohol induced ACLF when compared to standard validated scores. METHODS: Consecutive patients diagnosed as alcohol induced ACLF as per the APASL 2014 definition were included in the study. Standard scores - MELD, MELD-Na, Maddreys' discriminant function, CLIF-OF and CLIF-C ACLF scores, APACHE II, ALBI, PALBI and LaFAS were calculated. The endpoints of the study were to predict short term mortality in alcohol induced ACLF patients using ALBI, PALBI and LaFAS and finding the cut-offs of these new scores and comparing it with standard validated scores. RESULTS: 67 patients were studied with 97% being male. Mean age was 45.78 + 8.15 years.44 patients died. The cut-offs, area under the ROC curve; sensitivity and specificity, positive and negative predictive values of the new prognostication scores were, respectively: ALBI (-0.57; 0.948; 90.9% and 82.6%; 77.69% and 93.15%),LaFAS(7; 0.968; 95.5% and 96.7%; 95.075 and 96.99%), PALBI(-0.28; 0.59; 61.4% and 52.2%; 46.13% and 66.98%). LaFAS and ALBI outnumbered the valid prognostic scores in predicting short-term mortality. PALBI underperformed when compared to all other scores. CONCLUSION: Thus incorporating albumin and bilirubin in a mathematical equation (for ALBI) or combining it with creatinine and grade of hepatic encephalopathy (for LaFAS) would help in prognosticate the patients with ACLF on admission in a resource limited setting thus enabling them to be transferred to a transplant center.

Esophageal carcinoma: An epidemiological analysis and study of the time trends over the last 20 years from a single center in India.

BACKGROUND AND AIMS: Esophageal carcinoma is a common gastrointestinal malignancy. There is a paucity of literature about the time trends from India. The aim of the study was to evaluate the time trends over 20 years and observe how they differ from the West. MATERIAL AND METHODS: We retrospectively evaluated the data of 552 patients from the gastroenterology database (single department, single-center) over a period of 20 years from 1996 to 2015. The study period was split into two groups, namely, Group A (1996 to 2005) and Group B (2006 to 2015). RESULTS: There were 263 patients in Group A and 289 patients in Group B. The mean age was 54.83 years (range 25-89 years). There were 345 males and 207 females, with the ratio being 1.67. The most common histological type was squamous cell carcinoma (SCC) with 443 patients (80.25%). The most common location was mid esophagus with 229 patients (41.48%) followed by 208 patients (37.68%) in the lower esophagus. There was no significant increase in the lower esophageal malignancy. However, there was a significant increase in the gastroesophageal junction (GEJ) and adenocarcinoma (AC). There were no other time trend changes in gender, location, or histology. CONCLUSION: SCC is still far more common than AC in India. The mid esophagus is the most common site. There is no evidence of an increase in the lower esophageal malignancy in our study for over 20 years. However, the rates of GEJ-AC were found to be increasing.

Accuracy of Leukocyte Esterase Reagent Strip (LERS) test for rapid bedside screening of spontaneous bacterial peritonitis: An observational study.

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm3) and positive culture. Usually fluid analysis and culture take time and precious hours are lost in starting therapy. Leukocyte Esterase Reagent Strips (LERS) have consistently given a high negative predictive value (>95% in the majority of the studies). AIMS AND OBJECTIVES: Aim was to evaluate the diagnostic utility of leukocyte esterase reagent strip for rapid diagnosis of SBP in patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative predictive values. METHODOLOGY: The study was carried out on 64 patients with ascites. Cell count of AF as determined by colorimetric scale of Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥250 cells/mm3 was considered positive). RESULTS: Of the 64 patients SBP was diagnosed in 17 patients, 47 patients were negative for SBP by manual cell count. At cut off of 2+; sensitivity to diagnose SBP was 100%; specificity of 94%; PPV being 57% and NPV of 94%. at the cut off level of 3+; sensitivity decreased down to 76%; specificity increased to 100%; PPV of 100% and NPV of 93.75%. Overall accuracy at 2 + and 3 + was respectively 94.5% and 93.75%. CONCLUSION: In this study we have found good sensitivity and specificity for the prompt detection of elevated polymorphonuclear neutrophil count. A negative test result excludes SBP with a high degree of certainty. Thus, it represents a convenient, inexpensive, simple bedside screening tool for SBP diagnosis.

Aspartate transaminase to platelet ratio index (APRI) but not FIB-5 or FIB-4 is accurate in ruling out significant fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) in an urban slum-dwelling population.

BACKGROUND AND AIMS: Non-invasive assessment of fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) is challenging, especially in resource-limited settings. MR or transient elastography and many patented serum scores are costly and not widely available. There are limited data on accuracy of serum-based fibrosis scores in urban slum-dwelling population, which is a unique group due to its dietary habits and socioeconomic environment. We did this study to compare the accuracy of serum-based fibrosis scores to rule out significant fibrosis (SF) in this population. METHODS: Histological and clinical data of 100 consecutive urban slum-dwelling patients with NAFLD were analysed. Institutional ethics committee permission was taken. Aspartate transaminase (AST) to platelet ratio index (APRI), fibrosis-4 index (FIB-4) and FIB-5 scores were compared among those with non-significant fibrosis (METAVIR; F0 to F1; n=73) and SF (METAVIR; F2 to F4; n=27). RESULTS: AST (IU/mL) (68.3±45.2 vs 23.9±10.9; p<0.0001), alanine transaminase (IU/mL) (76.4±36.8 vs 27.9±11.4; p<0.0001), FIB-4 (2.40±2.13 vs 0.85±0.52; p<0.0001) and APRI (1.18±0.92 vs 0.25±0.16; p<0.0001) were higher and platelets (100 000/mm3) (1.8±0.8 vs 2.6±0.7; p<0.0001), albumin (g/dL) (3.4±0.50 vs 3.7±0.4; p<0.0001), alkaline phosphatase (IU/L) (60.9±10.2 vs 76.4±12.9; p<0.0001) and FIB-5 (-1.10±6.58 vs 3.79±4.25; p<0.0001) were lower in SF group. APRI had the best accuracy (area under the receiver operating characteristic curve=0.95) followed by FIB-4 (0.78) and FIB-5 (0.75) in ruling out SF. CONCLUSIONS: APRI but not FIB-5 or FIB-4 is accurate in ruling out SF in patients with NAFLD in an urban slum-dwelling population.