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1.
J Viral Hepat ; 27(5): 466-475, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31785182

RESUMO

Asia has an intermediate-to-high prevalence of and high morbidity and mortality from hepatitis B virus (HBV) infection. Optimization of diagnosis and initiation of treatment is one of the crucial strategies for lowering disease burden in this region. Therefore, a panel of 24 experts from 10 Asian countries convened, and reviewed the literature, to develop consensus guidance on diagnosis and initiation of treatment of HBV infection in resource-limited Asian settings. The panel proposed 11 recommendations related to diagnosis, pre-treatment assessment, and indications of therapy of HBV infection, and management of HBV-infected patients with co-infections. In resource-limited Asian settings, testing for hepatitis B surface antigen may be considered as the primary test for diagnosis of HBV infection. Pre-treatment assessments should include tests for complete blood count, liver and renal function, hepatitis B e-antigen (HBeAg), anti-HBe, HBV DNA, co-infection markers and assessment of severity of liver disease. Noninvasive tests such as AST-to-platelet ratio index, fibrosis score 4 or transient elastography may be used as alternatives to liver biopsy for assessing disease severity. Considering the high burden of HBV infection in Asia, the panel adopted an aggressive approach, and recommended initiation of antiviral therapy in all HBV-infected, compensated or decompensated cirrhotic individuals with detectable HBV DNA levels, regardless of HBeAg status or alanine transaminase levels. The panel also developed a simple algorithm for guiding the initiation of treatment in noncirrhotic, HBV-infected individuals. The recommendations proposed herein, may help guide clinicians, to optimize the diagnosis and improvise the treatment rates for HBV infection in Asia.


Assuntos
Hepatite B/diagnóstico , Hepatite B/terapia , Ásia , Consenso , DNA Viral/sangue , Antígenos E da Hepatite B/sangue , Vírus da Hepatite B , Humanos
2.
Hepatology ; 70(3): 982-994, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30703853

RESUMO

Ammonia is thought to be central to the pathogenesis of hepatic encephalopathy (HE), but its prognostic role in patients with cirrhosis and acute decompensation is unknown. The aims of this study were to determine the relationship between ammonia levels and severity of HE and its association with organ dysfunction and short-term mortality. We identified 498 patients from two institutions as part of prospective observational studies in patients with cirrhosis. Plasma ammonia levels were measured on admission and Chronic Liver Failure-Sequential Organ Failure Assessment criteria were used to determine the presence of organ failures. The 28-day patient survival was determined. Receiver operating characteristic analysis was used to identify the cutoff points for ammonia values, and multivariable analysis was performed using the Cox proportional hazard regression model. The 28-day mortality was 43.4%. Plasma ammonia correlated with severity of HE (P < 0.001), was significantly higher in nonsurvivors (93 [73-121] versus 67 [55-89] µmol/L, P < 0.001), and was an independent predictor of 28-day mortality (hazard ratio, 1.009, P < 0.001). An ammonia level of 79.5 µmol/L had sensitivity of 68.1% and specificity of 67.4% for predicting 28-day mortality. An ammonia level of ≥79.5 µmol/L was associated with a higher frequency of organ failures (liver [P = 0.004], coagulation [P < 0.001], kidney [P = 0.004], and respiratory [P < 0.001]). Lack of improvement in baseline ammonia at day 5 was associated with high mortality (70.6%). Conclusion: Ammonia level correlates with not only the severity of HE but also the failure of other organs and is an independent risk factor for mortality; lack of improvement in ammonia level is associated with high risk of death, making it an important biomarker and a therapeutic target.


Assuntos
Amônia/sangue , Cirrose Hepática/sangue , Cirrose Hepática/patologia , Falência Hepática Aguda/sangue , Adulto , Biomarcadores/sangue , Biópsia por Agulha , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Hospitais Universitários , Humanos , Imuno-Histoquímica , Índia , Estimativa de Kaplan-Meier , Cirrose Hepática/mortalidade , Falência Hepática Aguda/mortalidade , Falência Hepática Aguda/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Estudos Retrospectivos , Medição de Risco , Papel (figurativo) , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Análise de Sobrevida , Reino Unido
3.
Hepatology ; 70(2): 621-629, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30194739

RESUMO

Acute liver failure (ALF) caused by hepatitis A is a rare but fatal disease. Here, we developed a model to predict outcome in patients with ALF caused by hepatitis A. The derivation set consisted of 294 patients diagnosed with hepatitis A-related ALF (ALFA) from Korea, and a validation set of 56 patients from Japan, India, and United Kingdom. Using a multivariate proportional hazard model, a risk-prediction model (ALFA score) consisting of age, international normalized ratio, bilirubin, ammonia, creatinine, and hemoglobin levels acquired on the day of ALF diagnosis was developed. The ALFA score showed the highest discrimination in the prediction of liver transplant or death at 1 month (c-statistic, 0.87; 95% confidence interval [CI], 0.84-0.92) versus King's College criteria (KCC; c-statistic, 0.56; 95% CI, 0.53-0.59), U.S. Acute Liver Failure Study Group index specific for hepatitis A virus (HAV-ALFSG; c-statistic, 0.70; 95% CI, 0.65-0.76), the new ALFSG index (c-statistic, 0.79; 95% CI, 0.74-0.84), Model for End-Stage Liver Disease (MELD; c-statistic, 0.79; 95% CI, 0.74-0.84), and MELD including sodium (MELD-Na; c-statistic, 0.78; 95% CI, 0.73-0.84) in the derivation set (all P < 0.01). In the validation set, the performance of the ALFA score (c-statistic, 0.84; 95% CI, 0.74-0.94) was significantly better than that of KCC (c-statistic, 0.65; 95% CI, 0.52-0.79), MELD (c-statistic, 0.74; 95% CI, 0.61-0.87), and MELD-Na (c-statistic, 0.72; 95% CI, 0.58-0.85) (all P < 0.05), and better, but not statistically significant, than that of the HAV-ALFSG (c-statistic, 0.76; 95% CI, 0.61-0.90; P = 0.28) and new ALFSG indices (c-statistic, 0.79; 95% CI, 0.65-0.93; P = 0.41). The model was well-calibrated in both sets. Conclusion: Our disease-specific score provides refined prediction of outcome in patients with ALF caused by hepatitis A.


Assuntos
Hepatite A/complicações , Falência Hepática Aguda/etiologia , Falência Hepática Aguda/cirurgia , Transplante de Fígado/estatística & dados numéricos , Modelos Estatísticos , Adulto , Feminino , Humanos , Falência Hepática Aguda/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Fatores de Tempo
4.
Dig Dis Sci ; 65(9): 2719-2729, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-31897895

RESUMO

BACKGROUND AND AIM: There is a paucity of data on the clinical presentations and outcome of Budd-Chiari syndrome (BCS) patients presenting as acute-on-chronic liver failure (BCS-ACLF). We aimed to describe the profile and outcomes of endovascular interventions in patients with BCS-ACLF. METHODS: All BCS-ACLF patients presenting between October 2007 and April 2019 satisfying the Asian Pacific Association for the Study of the Liver (APASL) definition were studied. We compared 30- , 90- and, 180-day survival among BCS-ACLF patients who underwent endovascular intervention with those who did not, and with a historical cohort of Child-C BCS patients without ACLF who underwent endovascular intervention. RESULTS: Twenty-eight (5%) of 553 BCS patients presented as ACLF as per APASL definition. The majority (60.7%) were males, and mean age was 29.6 ± 11.2 years. The most common site of the block was isolated involvement of hepatic veins-HV (68%), followed by combined inferior vena cava (IVC) and HV block (25%) and isolated IVC block (7%). The acute precipitants were stent thrombosis (17.9%), acute HV thrombosis (10.7%), acute viral hepatitis (7.1%), and antituberculosis drug with hepatitis B virus reactivation (3.6%). In 60.7% patients, no acute precipitant could be identified. The 30- , 90- , and 180-day survival in BCS-ACLF post-endovascular intervention (n = 15), BCS-ACLF without endovascular intervention (n = 13), and Child-C BCS without ACLF who underwent endovascular intervention (n = 25) were (93%, 87%, and 87%), (46%, 28%, and 0%) and (96%, 92%, and 88%), respectively (log-rank test, p value < 0.001). On multivariate Cox proportional analysis, endovascular intervention and the presence of hepatic encephalopathy were independent predictors of mortality. CONCLUSION: Budd-Chiari syndrome can present as acute-on-chronic liver failure. Endovascular intervention is associated with an improved outcome.


Assuntos
Insuficiência Hepática Crônica Agudizada/etiologia , Síndrome de Budd-Chiari/terapia , Procedimentos Endovasculares , Insuficiência Hepática Crônica Agudizada/diagnóstico , Insuficiência Hepática Crônica Agudizada/mortalidade , Adolescente , Adulto , Síndrome de Budd-Chiari/complicações , Síndrome de Budd-Chiari/diagnóstico por imagem , Síndrome de Budd-Chiari/mortalidade , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
5.
Dig Dis Sci ; 62(4): 1058-1066, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28130708

RESUMO

BACKGROUND AND AIM: Hepatitis E virus (HEV) is a global disease and an important cause of acute liver failure (ALF) in the Indian subcontinent. The aim of this study was to assess the differences in the course of HEV-ALF as compared to other etiologies of ALF. METHODS: We compared the clinical course, complications, and outcomes of HEV-ALF with other etiologies. We assessed the prognostic factors and compared existing prognostic scores in HEV-ALF patients. RESULTS: One thousand four hundred and sixty-two ALF patients were evaluated between January 1986 and December 2015. HEV was the etiology of ALF in 419 (28.7%) cases, whereas non-A non-E hepatitis, HBV and anti-tuberculosis therapy (ATT) were the etiologies in 527 (36.0%), 128 (8.8%), and 103 (7.0%) cases, respectively. The frequency of cerebral edema in HEV-ALF (41.3%) was lower than that in non-A non-E ALF (52.9%; P < 0.001) and HBV-ALF (52.8%; P = 0.024). Infection and seizures were significantly less in patients with HEV-ALF compared to non-A non-E and HBV-ALF (P = 0.038 and 0.022, respectively). The survival of HEV-ALF patients was significantly better (55.1%, P < 0.001) than patients of other etiologies-including ATT (30.0%), non-A non-E (38.1%) and HBV (35.9%). In HEV-ALF patients, age, female sex, cerebral edema, prothrombin time >60 s, infection, and total bilirubin were observed as independent predictors of outcome on multivariate logistic regression analysis. Model for end-stage liver disease, acute liver failure study group model and King's College Hospital criteria had poor discriminative accuracy for outcome (area under receiver operator characteristic curve 0.63-0.64) in HEV-ALF. CONCLUSIONS: Hepatitis E virus-associated ALF has a better outcome than ALF of other etiologies.


Assuntos
Vírus da Hepatite E , Hepatite E/diagnóstico , Hepatite E/mortalidade , Falência Hepática Aguda/diagnóstico , Falência Hepática Aguda/mortalidade , Adolescente , Adulto , Feminino , Hepatite E/complicações , Humanos , Índia/epidemiologia , Falência Hepática Aguda/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Adulto Jovem
7.
J Gastroenterol Hepatol ; 31(4): 856-64, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26519215

RESUMO

BACKGROUND AND AIM: Acute on chronic liver failure (ACLF) because of precipitating factors (variceal bleed/infections) identifies cirrhotics at risk for high short-term mortality. Information on ACLF because of acute hepatic insults is lacking. The aim of the study was to evaluate acute hepatic insults in ACLF and their effect on the course and outcome. METHODS: In a prospective study, 213 consecutive patients of ACLF because of acute hepatic insults were included. Etiology of acute hepatic insult, frequency of silent, and overt chronic liver disease (CLD), organ failure (OF), and outcomes were assessed. Prognostic models such as model for endstage liver disease (MELD), acute physiology and chronic health evaluation (APACHE II), and chronic liver failure-sequential organ failure (CLIF-SOFA) were evaluated. RESULTS: Etiologies of acute hepatic insult were hepatitis virus(es)- 81 (38%; HBV-42, HEV-39), continuous alcohol consumption-77 (33.3%), antituberculosis drugs-11 (5.2%), autoimmune hepatitis flare-5(2.3%), cryptogenic-44 (20.7%). The common causes of CLD were alcohol (n = 85/40%), HBV(n = 52/24%), and cryptogenic(n = 50/20%). The MELD, APACHE II, and CLIF-SOFA scores were similar among silent and overt CLD and did not influence outcome. Predominant etiologies of ACLF were hepatitis virus(es) reactivation or superinfection in silent CLD(52/112, 46.4%) and alcohol among overt CLD(43/101, 43%). Independent predictors of mortality included hepatic-encephalopathy (early, HR: 4.01; advanced, HR: 6.10), serum creatinine ≥1.5 mg/dl (HR: 4.53), CLIF-SOFA ≥8(HR: 1.69), and etiology of acute hepatic insult (alcohol, HR: 4.08; cryptogenic, HR: 3.18). HEV-ACLF had lower mortality (12.8% vs. 33-54% in other etiologies;P < 0.001). OF was major determinant of mortality. With increasing number of OF, mortality increased linearly(P = 0.001). CONCLUSIONS: Hepatitis virus(es) and continuous alcohol consumption are important causes of ACLF caused by acute hepatic insults. HEV-ACLF has lower mortality. OF is an important prognostic predictor.


Assuntos
Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/mortalidade , Insuficiência de Múltiplos Órgãos/etiologia , Adulto , Alcoolismo/complicações , Antituberculosos/efeitos adversos , Feminino , Previsões , Hepatite Autoimune/complicações , Hepatite Crônica/complicações , Hepatite Viral Humana/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto Jovem
8.
Indian J Med Res ; 143(3): 331-40, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27241647

RESUMO

BACKGROUND & OBJECTIVES: Standard of care for chronic hepatitis C (CHC) in India is peginterferon and ribavirin (RBV). The response to treatment in real life stetting is unclear. The objectives of this study were to evaluate the demographic profile and assess the virological response and predictors of response in CHC patients. METHODS: Consecutive patients with CHC were included in this study. Detailed clinical history, risk factors, and predictive factors of response were noted. Patients were treated with peginterferon α2b (1.5 µg/kg/wk) and RBV (12 mg/kg/day) for 6 to 18 months based on response. RESULTS: A total of 211 patients were included in the analysis, mean age 40.6±12.3 yr, 144 (68%) were males and 71 (34%) had compensated cirrhosis. Commonest risk factor for acquiring CHC was previous transfusion and surgery (51%). Genotype 3 (72%) was most common followed by genotype 1 (23%). Overall sustained virologic response (SVR) was 64 per cent [95% CI 57.1%-70.4%]. The SVR was 66.5 per cent [95% CI 58.34-73.89%] for genotype 3 and 61.2 per cent [95% CI 46.23 to 74.80%] for genotype 1. Non-cirrhotics had better SVR rates compared to cirrhotics (76 vs 41%, p<0.001). On multivariate analysis, BMI ≥23 kg/m2, HOMA-IR ≥2, compliance (≤80%), and fibrosis >2 were predictors of low SVR. INTERPRETATION & CONCLUSIONS: Genotype 3 was the commonest HCV genotype. The commonest source of infection was previous transfusion and surgery. SVR rates for genotypes 3 were better than genotype 1 patients. Predictors of non-response were high BMI, insulin resistance, significant fibrosis and inadequate compliance.


Assuntos
Hepacivirus/efeitos dos fármacos , Hepatite C Crônica/tratamento farmacológico , Interferon-alfa/administração & dosagem , Polietilenoglicóis/administração & dosagem , Ribavirina/administração & dosagem , Adulto , Idoso , Feminino , Hepatite C Crônica/epidemiologia , Hepatite C Crônica/virologia , Humanos , Índia , Interferon alfa-2 , Cirrose Hepática/tratamento farmacológico , Cirrose Hepática/epidemiologia , Cirrose Hepática/virologia , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/administração & dosagem , Resposta Viral Sustentada , Centros de Atenção Terciária
9.
10.
Indian J Gastroenterol ; 43(2): 296-311, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38722512

RESUMO

Acute liver failure (ALF) is an infrequent, but serious complication subsequent to severe acute liver injury (sALI) due to various hepatotoxic agents such as hepatotropic virus(es) and drugs such as anti-tubercular medications, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics and anti-cancer and anti-epileptic therapy and due to metabolic and autoimmune disease flares. ALF after sALI presents with encephalopathy associated with prolonged international normalized ratio (INR). Mortality in ALF is high and ranges between 50% and 80%. Due to severe liver damage, multiple sequels consequent to hepatic dysfunction result in complications such as hyperammonemia that culminates in encephalopathy associated with cerebral edema; innate immune paralysis resulting in increased frequency of infections and endotoxemia causing decrease in systemic vascular resistance (SVR) and tissue hypoperfusion and damage-associated molecular patterns (DAMPs) released from damaged hepatic parenchyma inducing pro-inflammatory cytokine storm, which may cause other organ dysfunctions. Certain etiologies such as hepatitis E virus and hepatitis A virus-related ALF or paracetamol-ALF (hyper-acute presentation) have better survival than remaining causes. In addition, if etiology-specific treatment (antivirals for ALF related to hepatitis B virus (HBV) or Herpes simplex virus (HSV) or N-acetylcysteine for paracetamol) is available, then the outcome with treatment is better. About half of the patients can be salvaged with medical therapy. All patients need intensive care and organ support to provide time for the liver to regenerate. Various prognostic models to predict high probability of mortality have been described, which should be used to select patient early during the disease for liver transplantation, which is associated with high long-term survival in these sick patients. The Indian National Association for Study of the Liver (INASL) recommends the ALF-Early Dynamic (ALFED) model as a preferred prognostic model in the Indian scenario, where hepatitis viruses are a dominant etiology of ALF and occur on a naïve liver with good regenerative capacity.


Assuntos
Falência Hepática Aguda , Humanos , Índia/epidemiologia , Falência Hepática Aguda/etiologia , Falência Hepática Aguda/terapia , Doença Hepática Induzida por Substâncias e Drogas/etiologia , Acetaminofen/efeitos adversos , Transplante de Fígado , Antivirais/uso terapêutico , Encefalopatia Hepática/etiologia
11.
Indian J Gastroenterol ; 43(2): 312-324, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38451383

RESUMO

Viral hepatitis-induced acute liver failure (ALF) is a preventable cause for liver-related mortality worldwide. Viruses are the most common cause for ALF in developing nations in contrast to the west, where acetaminophen is largely responsible. Viruses may be hepatotropic or affect the liver secondary to a systemic infection. In tropical countries, infections such as leptospirosis, scrub typhus and malaria can mimic the symptoms of ALF. Differentiating these ALF mimics is crucial because they require etiology-specific therapy. Treatment of viral hepatitis-induced ALF is two-pronged and directed towards providing supportive care to prevent organ failures and antiviral drugs for some viruses. Liver transplantation (LT) is an effective modality for patients deteriorating despite adequate supportive care. Early referral and correct identification of patients who require a transplant are important. Liver support devices and plasma exchange have evolved into "bridging modalities" for LT. Preventive strategies such as hand hygiene, use of clean and potable water and inclusion of vaccines against viral hepatitis in the national program are simple yet very effective methods focusing on the preventive aspect of this disease.


Assuntos
Antivirais , Hepatite Viral Humana , Falência Hepática Aguda , Transplante de Fígado , Humanos , Falência Hepática Aguda/etiologia , Falência Hepática Aguda/terapia , Antivirais/uso terapêutico , Diagnóstico Diferencial , Troca Plasmática
12.
J Clin Exp Hepatol ; 14(6): 101436, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38882180

RESUMO

Introduction: During last few decades, radiological interventions have played crucial role in the management of the patients with chronic liver diseases. Various procedures including transjugualar intrahepatic portosystemic shunt (TIPS), transjugular liver biopsy (TJLB), transarterial chemoembilization (TACE)/transarterial radioembolization (TARE), balloon retrograde transvenous obliteration (BRTO) and plug-assisted retrograde transvenous obliteration (PARTO) are being performed safely and have significantly improved clinical outcomes in these patients. The technical and clinical success depend on appropriate patient selection along with thorough knowledge and experience to perform these procedures. On the other hand, few adverse events may also be associated with these procedures. The intervention radiologist and hepatologists should identify and treat these complications at the earliest so as to improve outcome of the patient. Materials and methods: About 25 hepatic intervention radiology procedures were performed in our center from January 2022 to 2023 May. Among these we have selected five patients who underwent TACE/TIPS/DIPS in our institute. We have selected these cases as in each of these cases we encountered some interesting outcomes/complications which were managed successfully. Results: The first case describes 33-year-old male with POEM syndrome and Budd Chiari Syndrome (BCS) who underwent TIPS and immediately had blockade of the stent. The second case is of a 43 years old male having BCS, refractory ascites with umbilical and inguinal hernia. The third case is of a 40 years old female with decompensated cirrhosis who underwent TIPS for portal hypertensive gastropathy. The fourth case is of a 51-years' female with decompensated cirrhosis with sarcopenia. Finally, the fifth case describes 24-year-old female with BCS and hepatocellular carcinoma. In this article we discuss the procedure and clinical course of the patients following the procedure. Conclusion: Hepatic radiological interventions though widely used can be associated with unusual albeit life threatening complications. Appropriate patient selection and thorough knowledge of procedure along with early diagnosis and management of these complications are key to obtain satisfying long term outcomes.

13.
World J Gastrointest Oncol ; 16(3): 699-715, 2024 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-38577460

RESUMO

BACKGROUND: There is scant literature on hepatocellular carcinoma (HCC) in patients with Budd-Chiari syndrome (BCS). AIM: To assess the magnitude, clinical characteristics, feasibility, and outcomes of treatment in BCS-HCC. METHODS: A total of 904 BCS patients from New Delhi, India and 1140 from Mumbai, India were included. The prevalence and incidence of HCC were determined, and among patients with BCS-HCC, the viability and outcomes of interventional therapy were evaluated. RESULTS: In the New Delhi cohort of 35 BCS-HCC patients, 18 had HCC at index presentation (prevalence 1.99%), and 17 developed HCC over a follow-up of 4601 person-years, [incidence 0.36 (0.22-0.57) per 100 person-years]. BCS-HCC patients were older when compared to patients with BCS alone (P = 0.001) and had a higher proportion of inferior vena cava block, cirrhosis, and long-segment vascular obstruction. The median alpha-fetoprotein level was higher in patients with BCS-HCC at first presentation than those who developed HCC at follow-up (13029 ng/mL vs 500 ng/mL, P = 0.01). Of the 35 BCS-HCC, 26 (74.3%) underwent radiological interventions for BCS, and 22 (62.8%) patients underwent treatment for HCC [transarterial chemoembolization in 18 (81.8%), oral tyrosine kinase inhibitor in 3 (13.6%), and transarterial radioembolization in 1 (4.5%)]. The median survival among patients who underwent interventions for HCC compared with those who did not was 3.5 years vs 3.1 mo (P = 0.0001). In contrast to the New Delhi cohort, the Mumbai cohort of BCS-HCC patients were predominantly males, presented with a more advanced HCC [Barcelona Clinic Liver Cancer C and D], and 2 patients underwent liver transplantation. CONCLUSION: HCC is not uncommon in patients with BCS. Radiological interventions and liver transplantation are feasible in select primary BCS-HCC patients and may improve outcomes.

14.
J Gastroenterol Hepatol ; 28(6): 1010-4, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23301629

RESUMO

BACKGROUND AND AIM: In patients with extrahepatic portal venous obstruction (EHO), death is usually due to variceal bleeding. This is more so in developing countries where there is a lack of tertiary health-care facilities and blood banks. Prophylactic operations in cirrhotics have been found to be deleterious. In contrast, patients with EHO have well-preserved liver function, and we therefore investigated the role of prophylactic surgery to prevent variceal bleeding. METHODS: Between 1976 and 2010, we operated on selected patients with EHO, who had no history of variceal bleeding but had "high-risk" esophagogastric varices or severe portal hypertensive gastropathy and/or hypersplenism, and came from remote areas with poor access to tertiary health care. Following surgery, these patients were prospectively followed up with regard to mortality, variceal bleeding, encephalopathy, and liver function. RESULTS: A total of 114 patients (67 males; mean age 19 years) underwent prophylactic operations (proximal splenorenal shunts 98 [86%]; esophagogastric devascularization 16). Postoperative mortality was 0.9%. Among 89(79%) patients who were followed up (mean 60 months), hypersplenism was cured, and six (6.7%) developed variceal bleeding. The latter were managed successfully by endoscopic sclerotherapy. No patient developed overwhelming post-splenectomy sepsis or encephalopathy, and 90% were free of symptoms. CONCLUSION: In patients with EHO, prophylactic surgery is fairly safe and prevents variceal bleeding in ∼ 94% of patients with no occurrence of portosystemic encephalopathy. Patients with EHO who have not bled but have high-risk varices and/or hypersplenism, and poor access to medical facilities should be offered prophylactic operations.


Assuntos
Varizes Esofágicas e Gástricas/prevenção & controle , Hemorragia Gastrointestinal/prevenção & controle , Veia Porta/cirurgia , Doenças Vasculares/cirurgia , Adolescente , Adulto , Criança , Varizes Esofágicas e Gástricas/etiologia , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doenças Vasculares/complicações , Adulto Jovem
15.
Indian J Med Res ; 138(3): 329-39, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24135177

RESUMO

BACKGROUND & OBJECTIVES: Non-detection of hepatitis B virus (HBV) envelope protein (hepatitis B surface antigen, HBsAg) in a chronically HBV infected individual has been described as occult infection. One possible reason for this phenotype is alteration in large (L-HBsAg) to small (S-HBsAg) envelope protein ratio associated with reduced or non secretion of HBsAg. This results in quantitative levels of serum HBsAg below the detection limit of enzyme immunoassays. Genotype D of HBV has a characteristic 33 nucleotide (nt) deletion upstream of the pre-S2/S promoter. This deletion may reduce HBsAg secretion in occult infection patients infected with genotype D HBV. Additional deletions in the pre-S2/S promoter may further aggravate reduced HBsAg secretion in patients infected with genotype D HBV. Thus, the aim of the present study was to determine the role of genotype D specific 33nt deletion and additional pre-S2/S promoter deletions in causing reduced or no secretion of HBsAg, in occult infection. Since these deletions overlap virus polymerase, their effect on virus replication was also investigated. METHODS: We examined the in vitro expression of HBsAg, ratio of cure and 'e' antigen (HBcAg/HBeAg), their secretion and virus replication, using overlength 1.3 mer/1.86 mer genotype A replicons, and genotype D replicons with and without additional pre-S2/S promoter deletions from cases of occult infection. RESULTS: Genotype D replicon showed a decrease in HBsAg secretion compared to the wild-type genotype A. Genotype D replicons carrying additional pre-S2/S promoter deletions, showed further reduction in HBsAg secretion, demonstrated presence of intracellular HBcAg/HBeAg, virus replication intermediates and 'e' antigen secretion. INTERPRETATION & CONCLUSIONS: The characteristic 33 nt deletion of genotype D HBV reduces HBsAg secretion. Additional pre-S2/S promoter deletions may further diminish HBsAg secretion, leading to occult infection. Pre-S2/S promoter deletions do not affect HBV replication.


Assuntos
Genótipo , Vírus da Hepatite B/genética , Hepatite B/virologia , Mutação , Ensaio de Imunoadsorção Enzimática , Antígenos de Superfície da Hepatite B/sangue , Vírus da Hepatite B/imunologia , Humanos
16.
Trop Gastroenterol ; 34(1): 7-13, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23923368

RESUMO

Spontaneous bacterial peritonitis (SBP) is the most frequent infection in patients with cirrhosis. It is associated with high mortality at admission and its occurrence alters the natural course with a high 1 year mortality. Presence of > 250 polymorphonuclear cell (PMN)/mm3 in the India ascitic fluid is diagnostic of SBP. SBP is usually treated with IV antibiotics using third generation cephalosporins and fluoroquinolones. However, despite effective initial treatment subsequent recurrence of SBP with its accompanying mortality has resulted in use of long term antibiotic prophylaxis and such patients are recommended for liver transplant. An increased frequency of multidrug resistant bacterial SBP has recently been recognised with use of prophylaxis and is associated with enhanced mortality. Further, cirrhotics get repeated hospitalisation and ICU care leading to nosocomial infection causing SBP. Therefore, frequency of multidrug resistant bacteria induced SBP among the above settings has increased and the relative risk (RR) of mortality with bacterial resistance has been estimated to be 4 times higher than in patients with SBP without bacterial resistance. Therapeutic approach in such patients at present is a clinical challenge and they are difficult to treat patients. Therefore, SBP can be categorized into community acquired and nosocomial! multidrug resistant SBP.


Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas , Infecção Hospitalar , Cirrose Hepática/complicações , Peritonite , Líquido Ascítico/microbiologia , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/etiologia , Infecções Bacterianas/mortalidade , Infecção Hospitalar/complicações , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/mortalidade , Saúde Global , Humanos , Peritonite/tratamento farmacológico , Peritonite/etiologia , Peritonite/mortalidade , Taxa de Sobrevida/tendências
17.
Gut ; 61(7): 1068-75, 2012 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22337947

RESUMO

OBJECTIVE: It is difficult to predict the outcome in patients with acute liver failure (ALF) using existing prognostic models. This study investigated whether early changes in the levels of dynamic variables can predict outcome better than models based on static baseline variables. DESIGN: 380 patients with ALF (derivation cohort n=244, validation cohort n=136) participated in a prospective observational study. The derivation cohort was used to identify predictors of mortality. The ALF early dynamic (ALFED) model was constructed based on whether the levels of predictive variables remained persistently high or increased over 3 days above the discriminatory cut-off values identified in this study. The model had four variables: arterial ammonia, serum bilirubin, international normalised ratio and hepatic encephalopathy >grade II. The model was validated in a cohort of 136 patients with ALF. RESULTS: The ALFED model demonstrated excellent discrimination with an area under the receiver operator characteristic curve of 0.91 in the derivation cohort and of 0.92 in the validation cohort. The model was well calibrated in both cohorts and showed a similar increase in mortality with increasing risk scores from 0 to 6. The performance of the ALFED model was superior to the King's College Hospital criteria and the Model for End stage Liver Disease score, even when their 3-day serial values were taken into consideration. An ALFED score of ≥4 had a high positive predictive value (85%) and negative predictive value (87%) in the validation cohort. CONCLUSION: The ALFED model accurately predicted outcome in patients with ALF, which may be useful in clinical decision-making.


Assuntos
Amônia/sangue , Falência Hepática Aguda/mortalidade , Adolescente , Adulto , Idoso , Análise de Variância , Feminino , Humanos , Falência Hepática Aguda/sangue , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Adulto Jovem
18.
Diagnostics (Basel) ; 13(6)2023 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-36980341

RESUMO

Viral infections are among the major causes of acute liver failure (ALF) worldwide. While the role of agents such as hepatitis A, B, C, D and E viruses in precipitating ALF are well known, improvements in serological assays have led to the detection of viral agents such as Epstein Barr virus, cytomegalovirus etc. as atypical causes of ALF. Despite the plethora of literature available on viral hepatitis and ALF, there is very limited large-scale epidemiologic data on the prevalence, risk factors of progression and outcomes in ALF of viral causes. This is important as viral infections remain the leading cause of ALF in the East and in developing countries, while the impact of viral ALF in the West has largely been ameliorated by effective vaccination and sanitization programs. This review focuses specifically on the available prognostic scores that aid in the management of ALF of viral etiologies while also briefly reviewing the current literature on newer viral agents known to cause ALF, risk factors of progression, outcomes and how management algorithms can be developed by incorporation of prognostic scoring systems for referral and transplant listing.

19.
Indian J Gastroenterol ; 42(5): 658-667, 2023 10.
Artigo em Inglês | MEDLINE | ID: mdl-37639195

RESUMO

BACKGROUND AND AIM: Non-specific isolated terminal ileum abnormalities (NSITIA) namely erosions, ulcer and nodularity are frequent findings on ileal examination during colonoscopy. Their clinical significance and management are uncertain. METHODOLOGY: A pilot randomized clinical trial comparing combination antimicrobial therapy (oral Rifaximin 550 mg twice daily for two weeks; Albendazole 400 mg orally as a single dose; Tinidazole 1 gm twice daily for three days i.e. Group A) with symptomatic treatment (Group B) was performed in patients with NSITIA, which was diagnosed on the basis of colonoscopy and histopathology features. The primary outcome measure was mucosal healing on follow-up ileocolonoscopy at three months of randomization. Additionally, clinical, endoscopic and histological findings were noted at baseline and after a follow-up of three months. RESULTS: Total 60 patients with NSITIA were randomized. The most prevalent symptoms were abdominal discomfort (n = 37, 61.6%), diarrhea (n = 25, 41.6%) and constipation (n = 24, 40%). The incidence of ulcers, nodularity and erosions were (n = 18, 62.1%), (n = 8, 27.6%) and (n = 3, 10.34%) in group A and (n = 18, 58%), (n = 9, 29%), (n = 4, 13%) in group B, respectively. After a mean follow-up duration of 3.36 ± 0.27 months, both groups showed comparable resolution in clinical symptoms (n = 24, 92.4% vs. n = 24, 88.8%, p = 0.954), ileocolonoscopic findings (n = 23, 88.5% vs. n = 22, 81.5%, p = 0.765) and histological characteristics (n = 20, 76.5% vs. n = 19, 70.4%, p = 0.806). CONCLUSION: The clinical, endoscopic and histopathological remission occurs in most patients with NSITIA. The use of antimicrobials including antibiotic, antiprotozoal and anthelminthic therapy did not have any impact on the rate of mucosal healing in these patients. Our study is a pilot study and has some limitations such as small sample size and lack of complete small bowel workup in all patients, which leaves a possibility of undetected ulcers proximal to the terminal ileum. CLINICAL TRIAL REGISTRATION: This study has been registered in India's clinical trial registry under the registration number CTRI/2020/02/023459 ).


Assuntos
Anti-Infecciosos , Úlcera , Humanos , Projetos Piloto , Íleo/patologia , Colonoscopia
20.
Clin Gastroenterol Hepatol ; 10(8): 925-31, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22521861

RESUMO

BACKGROUND & AIMS: Patients admitted to the hospital with acute liver failure (ALF) and high arterial levels of ammonia are more likely to have complications and poor outcomes than patients with lower levels of ammonia. ALF is a dynamic process; ammonia levels can change over time. We investigated whether early changes (first 3 days after admission) in arterial levels of ammonia were associated with complications and outcomes and identified factors associated with persistent hyperammonemia. METHODS: We performed a prospective observational study that measured arterial ammonia levels each day for 5 days in 295 consecutive patients with ALF. We analyzed associations of changes in ammonia levels during the first 3 days with complications and outcomes. RESULTS: Patients with persistent arterial hyperammonemia (≥122 µmol/L for 3 consecutive days), compared with those with decreasing levels, had lower rates of survival (23% vs 72%; P < .001) and higher percentages of cerebral edema (71% vs 37%; P < .001), infection (67% vs 28%; P = .003), and seizures (41% vs 7.7%; P < .001). Patients with persistent hyperammonemia had greater mortality, with an odds ratio (OR) of 10.7, compared with patients with baseline levels of ammonia ≥122 µmol/L (OR, 2.4). Patients with persistent hyperammonemia were more likely to progress to and maintain advanced hepatic encephalopathy than those with decreasing levels. Patients with persistent, mild hyperammonemia (≥85 µmol/L for 3 days) were also more likely to have complications or die (P < .001) than patients with serial ammonia levels <85 µmol/L. Infections (OR, 4.17), renal failure (OR, 2.20), and decreased arterial pH (OR, 0.003) were independent predictors of persistent hyperammonemia. CONCLUSIONS: Patients with ALF and persistent arterial hyperammonemia for 3 days after admission are more likely to develop complications and have greater mortality than patients with decreasing levels or high baseline levels. Infection, renal failure, and decreased arterial pH are independent predictors of persistent hyperammonemia.


Assuntos
Hiperamonemia/complicações , Hiperamonemia/mortalidade , Falência Hepática Aguda/complicações , Falência Hepática Aguda/mortalidade , Adolescente , Adulto , Idoso , Amônia/sangue , Análise Química do Sangue , Edema Encefálico/epidemiologia , Criança , Doenças Transmissíveis/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Convulsões/epidemiologia , Análise de Sobrevida , Resultado do Tratamento , Adulto Jovem
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