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.

Auxiliary Partial Orthotopic Liver Transplant as a Rescue Procedure for Acute Liver Failure with Extra-Small-for-Size Grafts: A Report of 2 Cases.

Auxiliary partial orthotopic liver transplant is a complex technique whereby a partial liver graft is transplanted in the orthotopic position, leaving behind a portion of the native liver. In acute liver failure, auxiliary partial orthotopic liver transplant serves as a rescue therapy and bridge for the native liver to regenerate. Auxiliary partial orthotopic liver transplant was initially considered a technically challenging procedure with inferior results versus orthotopic liver transplant. However, advancements in surgical techniques have led to improved results with auxiliary partial orthotopic liver transplant. Auxiliary partial orthotopic liver transplant is now increasingly accepted as a valid treatment option for acute liver failure. We present 2 cases of acute liver failure treated with auxiliary partial orthotopic liver transplant using an extra-small-for-size graft. The first case was a 12-year-old female patient who presented with druginduced acute liver failure and required an auxiliary partial orthotopic liver transplant with an extra-small left lobe graft (graft-to-recipient weight ratio of 0.45). The second case was a 23-year-old male patient with acute liver failure of unknown etiology who underwent an auxiliary partial orthotopic liver transplant with a small right lobe graft (graft-torecipient weight ratio of 0.5). In both cases, computed tomography liver volumetry was performed to determine the appropriate graft size for the recipient. Both patients underwent successful auxiliary partial orthotopic liver transplants, with good postoperative recovery. Follow-up examinations showed satisfactory liver function without evidence of graft failure or rejection. Auxiliary partial orthotopic liver transplant using extra-small grafts can be an effective treatment option for acute liver failure when no other suitable option exists, including as a rescue procedure for small grafts. However, careful patient selection and surgical planning are essential to ensure successful outcomes.

Prevalence of splenic vein thrombosis and risk of gastrointestinal bleeding in chronic pancreatitis patients attending a tertiary hospital in western India.

BACKGROUND: Splenic vein thrombosis (SVT) is most commonly caused by acute and chronic pancreatitis (CP). Variceal gastrointestinal (GI) bleeding is a potentially life-threatening event in such patients. The aim of this study was to determine the prevalence of SVT in CP patients and the risk of variceal GI bleeding. MATERIALS AND METHODS: A total of 187 consecutive patients with a diagnosis of CP were assessed for the presence of SVT at the gastroenterology department of a tertiary care hospital. Thirty seven patients had evidence of SVT. Patients with portal vein thrombosis or cirrhosis were excluded. Potential factors associated with SVT were assessed. RESULTS: Of the 187 CP patients assessed, 37 patients (19.8%) (male 33; female 4; mean age 41.9 years) had evidence of SVT. Among patients with SVT, most common etiology of CP was alcohol abuse (70.3%). Seven patients (18.9%) with SVT presented with clinically significant upper GI bleeding. The source of GI bleeding was gastric varices in three patients (8.1%) and non-variceal source in four patients (10.8%). All three patients with gastric varices were managed by splenectomy. There were no new variceal bleeding episodes in other 33 patients (89.2%) during mean follow-up of 16.4 months. On comparison of patients with and without SVT, the factors associated with significantly higher incidence of SVT were smoking (P = 0.019, odds ratio 3.021, 95% confidence interval 1.195-7.633) and presence of pseudocyst (P = 0.008, odds ratio 3.743, 95% confidence interval 1.403-9.983). Complete resolution of SVT was seen in three patients (8.1%) after resolution of underlying pseudocyst. CONCLUSION: SVT is a common complication of CP, particularly in patients with pseudocysts and history of smoking. Most patients remain asymptomatic and the risk of variceal bleeding is low. Splenectomy is the treatment of choice in patients with variceal bleeding. Conservative approach is preferred in other patients. Resolution of pseudocysts may lead to resolution of SVT in some patients.

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.

Difficult colonoscopy: air, carbon dioxide, or water insufflation?

BACKGROUND/AIMS: This study aimed to compare tolerance to air, carbon dioxide, or water insufflation in patients with anticipated difficult colonoscopy (young, thin, obese individuals, and patients with prior abdominal surgery or irradiation). METHODS: Patients with body mass index (BMI) less than 18 kg/m2 or more than 30 kg/m2, or who had undergone previous abdominal or pelvic surgeries were randomized to air, carbon dioxide, or water insufflation during colonoscopy. The primary endpoint was cecal intubation with mild pain (less than 5 on visual analogue scale [VAS]), without use of sedation. RESULTS: The primary end point was achieved in 32.7%, 43.8%, and 84.9% of cases with air, carbon dioxide and water insufflation (P<0.001). The mean pain scores were 5.17, 4.72, and 3.93 on the VAS for air, carbon dioxide, and water insufflation (P<0.001). The cecal intubation rate or procedure time did not differ significantly between the 3 groups. CONCLUSIONS: Water insufflation was superior to air or carbon dioxide for pain tolerance. This was seen in the subgroups with BMI <18 kg/m2 and the post-surgical group, but not in the group with BMI >30 kg/m2.

Anemia in patients with ulcerative colitis in remission: A study from western India.

BACKGROUND: Anemia is common in patients with active ulcerative colitis. We aimed to study the anemia profile in patients with ulcerative colitis in clinical remission. METHODS: Sixty-four patients with ulcerative colitis and with a clinical Mayo score less than 3 for at least 3 months were evaluated for anemia. Initial screening was done by hemogram and only patients with anemia were evaluated further for the cause of anemia. We also screened a control population for anemia. Patients with mild anemia were given oral iron, moderate anemia were given intravenous iron and severe anemia were given blood transfusion. RESULTS: The mean hemoglobin in ulcerative colitis patients was 11.75 g/dL and in controls was 13.1 g/dL (p=0.011). The prevalence of anemia was 53.1% in the ulcerative colitis patients and 13.3% in the controls (p=<0.001). 58.8% had mild anemia, 29.4% had moderate anemia and 8.8% had severe anemia. Iron deficiency was the most common cause of anemia (70.5%) followed by anemia of chronic disease combined with iron deficiency in 23.5%. Ferritin levels did not correlate with hemoglobin levels. Oral iron increased the hemoglobin by 1.4 g/dL and intravenous iron by 2.2 g/dL at 1 month. CONCLUSION: Anemia was seen in more than half of patients with ulcerative colitis in clinical remission, iron deficiency being the most common cause.

Renal Vein and Inferior Vena Cava Thrombosis: A Rare Extrasplanchnic Complication of Acute Pancreatitis.

Acute pancreatitis is an inflammatory disorder often associated with various complications. Approximately one fourth of patients with acute pancreatitis develop vascular complications, of which venous thrombosis forms a major group. Extrasplanchnic venous thrombosis is less common, and simultaneous renal vein and inferior vena cava thrombosis is reported only twice. We report a case of alcohol-related acute pancreatitis complicated by simultaneous renal vein and inferior vena cava thrombosis.

Management of pregnancy in Crigler Najjar syndrome type 2.

Crigler Najjar syndrome is associated with indirect hyperbilirubinemia due to a deficiency of enzyme Uridine Di Phospho Glucoronosyl Transferase (UDPGT). Presented here is a case of a female in the first trimester of pregnancy, who was diagnosed to have type 2 Crigler Najjar syndrome. We also discuss the management of this rare disease especially in pregnancy. Unconjugated bilirubin can cross the placental barrier causing neurological damage in the newborn. Patient was carefully monitored during pregnancy and treatment with phenobarbitone in low doses was adjusted such that the serum bilirubin levels were below 10 mg/dL. Crigler Najjar syndrome being rare needs to be diagnosed early in pregnancy to avoid adverse fetal outcomes. Phenobarbitone being an inducer of enzyme UDPGT is used as the first line of treatment and is not teratogenic in the low doses used. Treatment protocol followed was on the basis of previous reported cases and successful perinatal outcome was achieved.

Post Colonoscopy Ischaemic Colitis in a Patient without Risk Factors for Colon Ischemia: A Case Report.

Ischaemic colitis is the most common form of intestinal ischaemia and is more common in the elderly and in the people having risk factors for colonic ischaemia. Colonoscopy procedure itself is a rare cause of ischaemic colitis. Fewer than 20 cases of ischaemic colitis caused by colonoscopy procedure have been reported in the english literature till date. This patient presented to us within hours of routine colonoscopy with rectal bleeding and lower abdominal pain. On repeat colonoscopy, the patient had mucosal oedema and ulcerations in the descending colon and sigmoid colon. Computed tomography of abdomen and biopsy of the involved segment confirmed ischaemic colitis. The patient recovered with conservative management.