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.

Predictors of 1-month and 3-months Hospital Readmissions in Decompensated Cirrhosis: A Prospective Study in a Large Asian Cohort.

INTRODUCTION AND AIM: Considered as a healthcare quality indicator, hospital readmissions in decompensated cirrhosis predispose the patients and the society to physical, social and economic distresses. Few studies involving North American cohorts have identified different predictors. The aim of this study was to determine and validate the predictors of 1-month and 3-months readmission in an Asian cohort. MATERIAL AND METHODS: We prospectively studied 281 hospitalised patients with decompensated cirrhosis at a large tertiary care public hospital in India between August 2014 and August 2016 and followed them for 3 months. Data regarding demographic, laboratory and disease related risk factors were compiled. We used multivariate logistic regression to determine predictors of readmission at 1-month and 3-months and receiver operating curves (ROC) for significant predictors to obtain the best cut-offs. RESULTS: 1-month and 3-months readmission rates in our study were 27.8% and 42.3%, respectively. Model for End stage Liver Disease (MELD) score at discharge (OR:1.24, p < 0.001) and serum sodium (OR:0.94, p-0.039) independently predicted 1-month and MELD score (OR:1.11, p-0.003), serum sodium (OR:0.94, p-0.027) and male gender (OR:2.19, p-0.008) independently predicted 3-months readmissions. Neither aetiology nor complications of cirrhosis emerged as risk factors. MELD score >14 at discharge and serum sodium < 133 mEq/L best predicted readmissions; MELD score being a better predictor than serum sodium (p - 0.0001). CONCLUSIONS: High rates of early and late readmissions were found in our study. Further, this study validated readmission predictors in Asian patients. Structured interventions targeting this risk factors may diminish readmissions in decompensated cirrhosis.

Correlation of Computed Tomography of Colonic Wall Thickening with Colonoscopy.

INTRODUCTION: Computed Tomography of abdomen frequently shows bowel wall thickening with different grades and characteristic of thickening. The correlation of bowel wall thickening (BWT) with endoscopic findings is not well described in Indian population. Therefore we did this study to determine the correlation of BWT with endoscopic findings. METHODS: Its Prospective single center study with 85 Consecutive patients with age group more than 12 years with CT scan abdomen showing bowel wall thickening were included in the study. Colonoscopy was done subsequently within a span of 15 days with appropriate bowel preparation. Colonoscopic correlation was done in relation to site, degree and characteristic of thickening. Biopsies were taken at the site of visible abnormalities on endoscopy and from normal appearing mucosa in case of strong suspicious of disease. RESULTS: Total of 85 (37 men) consecutive symptomatic patients with colonic wall thickening on computed tomography underwent colonoscopy. The mean age group was 34.2 (SD±17.35) years. Endoscopy was normal in 20 patients (24%) and abnormal in 65 patients (76.5%). Patients with mild thickening were more likely to have normal endoscopy than those with moderate/severe thickening (19 versus 1 patient; p<0.001). The abnormality rate was similar across different bowel segments (left vs right side; 85.7% versus 76.5%, p< 0.57). Out of 65 patients with endoscopic abnormality, 41 (62.12%) had tuberculosis, 10 (15.16%) had malignancy. Most common cause of IC thickening was secondary to tuberculosis (n=40, 95.2%). CONCLUSION: A proportion of patients with thickening on CT scan, especially mild, may have normal colonoscopy. Patients should be counseled about the same prior to colonoscopy. However, colonoscopy should be done to rule out abnormality even when CT shows mild thickening.

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.

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.