Applicability of Risk Scores to an Indian Cohort of Hepatitis B-Related Hepatocellular Carcinoma Patients.

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The Efficacy and Safety of Sofosbuvir and Daclatasvir Treatment in Children and Adolescents With Thalassemia and Hepatitis C Virus Infection.

Background/Aim: Thalassemia patients are susceptible to hepatitis C virus (HCV) infection due to blood transfusions. Currently, data on treating HCV in thalassemic children with direct-acting antivirals is lacking. This study was performed to determine the efficacy and safety of sofosbuvir-daclatasvir combination therapy in thalassemic children and adolescents. Methods: A nonrandomized, open-label, interventional study was carried out in a tertiary care hospital. Consecutive noncirrhotic treatment-naïve thalassemic patients with HCV infection with viremia, within the age group of 6-18 years, were treated with the combination of sofosbuvir-daclatasvir: 200 mg + 30 mg for age 6-11 years (Group A) and 400 mg + 60 mg for age 12-18 years (Group B). The primary endpoint was sustained virological response at 12 weeks (SVR12). Results: A total of 70 patients (Group A 45, 64% male; Group B 25, 40% male) were recruited. The mean age was 8.5 years and 13.9 years in the two groups. Mean HCV Ribonucleic acid (RNA) levels in Groups A and B were 446906.1 IU/ml and 256187.8 IU/ml, respectively. SVR12 was achieved in 43 of 45 (95.5%) patients on an intention-to-treat basis and 43 of 44 (97.7%) patients on a perprotocol basis in Group A, and all patients in Group B (100%). In both groups, there was a significant improvement in biochemical parameters. Among the two patients who did not achieve SVR12 in Group A, one required termination of therapy due to urticaria. Conclusion: Sofosbuvir-daclatasvir based treatment in noncirrhotic, treatment-naive thalassemic children and adolescents infected with HCV is effective and safe.

Differentiating biliary atresia from other causes of infantile cholestasis: An appraisal of the histomorphological changes on liver biopsy.

Background: Cholestatic disorders are a significant cause of morbidity and mortality in infants. Characterization of these disorders and differentiating biliary atresia (BA) from other causes of intrahepatic cholestasis is an age-old problem. Objectives: To study the spectrum of different infantile cholestatic disorders in our population, to differentiate BA from other causes of neonatal cholestasis (NC) on a liver biopsy, and validation of the available scoring system for the characterization of these disorders. Materials and Methods: This is an observational cross-sectional study performed over a period of 3 years between 2018 and 2021, done on neonates and infants presenting with cholestatic jaundice. The changes on liver biopsy were evaluated by different histological parameters and available scoring systems to differentiate BA from non-BA causes. Correlation with clinical, biochemical, and imaging findings was done in all cases. Results: This study included 87 cases of NC, of which BA comprised 28 cases (32%), whereas idiopathic neonatal hepatitis (INH) comprised only 12 cases (14%). Portal neutrophilic inflammation (P = 0.000053), ductal cholestasis (P < 0.001), neoductular bile plugs (P < 0.001) and bile ductular proliferation (P < 0.0001) were significantly more in BA, whereas lobular lymphocytic inflammation (P = 0.001) and giant cell transformation of hepatocytes (P = 0.0024) were more frequent in the non-BA group. Using the Lee and Looi scoring system, a histologic score ≥7 was helpful in identifying BA with 85.7% sensitivity, 92.6% specificity, and 90.6% accuracy. Conclusion: BA is the commonest cause of NC in neonates, whereas the frequency of INH is declining. Detailed histomorphologic analysis of liver biopsy, aided with IHC, is the cornerstone for the diagnosis of these disorders.

Long-term entecavir therapy of chronic hepatitis B in real-life setting-Importance of quantitative HBsAg level.

BACKGROUND: The global burden of chronic hepatitis B remains high and the best possible treatment remains long-term viral suppression expecting cure. METHODS: Total 154 patients of chronic hepatitis B (48 HBeAg positive, e + ve) treated with oral entecavir (0.5 mg/1 mg per day) were recruited from June 2007 and followed prospectively until December 2022 for persistent HBV DNA negativity, HBeAg and HBsAg loss/seroconversion and other liver and drug-related events in real-life settings. RESULTS: The mean duration of therapy was 6.78 (2-14) years with 1364 person-years of follow-up. All patients were HBV DNA negative by 15 months and remained so until the last follow-up. As many as 16.7% lost HBeAg after eight to 13 years of therapy, but not HBsAg. The mean fall in serum HBsAg level per year was 0.158 log IU/mL, being significantly higher in e + ve patients at baseline and until two years of therapy. The decline was significant until six years in e + ve patients compared to two years in e - ve ones. None had biochemical or virological breakthrough (except eight defaulters), flares or any untoward effects. The incidence of liver-related events, hepatocellular carcinoma and death was 10.4%, 1.9% and 14.3%, respectively, and 5.2% deaths were liver-related whose predictors were presence of cirrhosis (log rank 46.5, p > 0.001) and higher HBsAg level > 4 log IU/mL (log rank 18.15, p < 0.001) at baseline. CONCLUSION: Long-term entecavir therapy provides additional benefits of continuous reduction of serum HBsAg levels beyond suppression of HBV DNA.

Propranolol Monotherapy in Multifocal/Diffuse Infantile Hepatic Hemangiomas in Indian Children: A Case Series.

Introduction: Infantile hepatic hemangioma (IHH) is the most common benign liver tumor in children, and multifocal and diffuse tumors often become life-threatening, necessitating therapy. Propranolol is now considered the first choice of therapy with ample data in Caucasian children. We present a series of nine Indian children with multifocal (n = 5) and diffuse (n = 4) IHH treated with propranolol monotherapy. Methods: This was a retrospective clinical data-based single-center study. Propranolol was used at a median dose of 3.2 mg/kg/day (range 3-3.3 mg/kg/day) for a median duration of 12 months (range 6-32 months). Results: The presentations of IHH (either in isolation or combination) were hypothyroidism in six patients (diagnosed by elevated serum TSH levels), heart failure in three (diagnosed based on clinical and echocardiographic features), and imaging evidence of macrovascular shunting in two patients. A good response to propranolol monotherapy (with a median dose of 3.2 mg/kg/day for a median duration of 12 months) was observed in eight patients, with a poor response in one. One patient experienced recurrence but responded adequately to propranolol retreatment. Conclusions: Our data reiterate the excellent response (88.9% responded) and safety profile with propranolol monotherapy in complicated IHH and strengthen the data in Asian (Indian) children. It includes the maximum proportion of complicated IHH treated with propranolol in East and South Asia, and the largest series from India.

Management of liver diseases: Current perspectives.

There is increasing incidence and prevalence of acute and chronic liver diseases (CLDs) all over the world which influence the quality of life and can give rise to life threatening complications. The burden of advanced liver disease due to hepatitis B has been controlled by antivirals but its eradication is difficult soon. Highly effective directly acting antiviral therapy has reduced the burden of hepatitis C but is partially offset by increasing IV drug abuse. Non-alcoholic fatty liver disease pandemic is on and there is recent alarming increase in alcohol related liver disease, both of which have no drug cure apart from control of the risk factors. Genetic factors have been identified in progression of all forms of CLD. Due to better management of complications of CLD, the life span of patients have increased spiking the number of hepatocellular carcinoma (HCC) and patients needing liver transplantation (LT). The present severe acute respiratory syndrome coronavirus pandemic has affected the outcome CLD including LT in addition to causing acute hepatitis. Better diagnostics and therapeutics are available for liver fibrosis, portal hypertension, HCC and post LT management and many drugs are under trial. The present review summarises the current scenario of the epidemiology and the advances in diagnosis and treatment of liver diseases including their complications like portal hypertension, HCC and LT.

Clinical Profile of Hepatoblastoma: Experience From a Tertiary Care Centre in a Resource-Limited Setting.

Background Hepatoblastoma (HB) is a rare neoplasm of the liver, accounting for about 1% of all pediatric cancers. The aim of the present study is to report our experience with HBs over a period of five years from a tertiary center in Eastern India. Methodology This is a retrospective observational study. The data of all patients who were diagnosed with HB between August 2015 and December 2020 was reviewed. Results Twenty-three patients who were diagnosed and treated for HB at our center were included in the study. Sixteen (69.5%) of them were male. The median age of presentation was 14 (range, 3-58) months. An abdominal lump (n=23, 100%) and abdominal pain (n=11, 47.8%) were the most common presenting symptoms. The median level of serum alpha-fetoprotein at the time of initial evaluation was 8000 (878-1,280,000) ng/dL. The mean size of the largest focus in its largest dimension was 12.03±3.77 cm. The epithelial variant (n=22, 95.7%) was the most common histological subtype. One (4.3%), 10 (43.4%), 11 (47.8%), and one (4.3%) patient were found to have pre-treatment extent of tumor (PRETEXT) stages 1, 2, 3, and 4, respectively. Fifteen (65.2%) children were classified as standard risk and seven (34.7%) children as high risk. All the patients received neoadjuvant chemotherapy (NACT). The most commonly performed surgery was right hepatectomy (n=12, 52.1%). There were three (13%) cases of perioperative mortality. Four postoperative complications developed in three (13%) patients. Four (17.3%) patients developed chemotherapy-related complications. The median duration of follow-up was 31 (range, 0-58) months. Three (13%) patients developed relapses of the disease. Overall, five-year survival in our series was 73.9%. Conclusion This study shows that the overall outcomes of HB in a resource-limited setting such as ours are good with the adoption of multi-modality treatment. Managing chemotherapy-induced complications and making liver transplantation more feasible will improve the results further.

Interrelation of the Risk Factors of NAFLD at various Stages of Progression of the glycemic Status on long-term Follow-up.

BACKGROUND: Though the risk factors for nonalcoholic fatty liver disease (NAFLD) are the same in diabetic and nondiabetic patients, their exact interrelation and weightage in the pathogenesis are unclear Methods: A total of 130 nondiabetic and 170 diabetic patients with NAFLD [diagnosed on abdominal ultrasound and severity assessed by NAFLD fibrosis score (NFS)] were recruited from 2009 to 2018 and their baseline risk factors [body mass index (BMI), waist circumference (WC), blood pressure, presence of the metabolic syndrome (MS) and insulin resistance (IR) by Homeostasis Model of Assessment for Insulin Resistance (HOMA-IR), fasting blood glucose (FBG) and lipid levels, and hemoglobin A1c (HbA1c) levels] were noted and their interrelationship studied. The nondiabetic patients were prospectively followed up for alteration of glycemic status. RESULTS: There was presence of high BMI (>23) in 66%, central obesity in 86% (of whom 59% had normal body weight), low high-density lipoprotein cholesterol (HDL) in 51%, high triglyceride (TG) in 68%, high low-density lipoprotein cholesterol (LDL) in 46.7%, IR in 86%, hypertension in 54%, and the MS in 57%. Hemoglobin A1c was high in 42.3% of nondiabetics. The prevalence of the MS was significantly higher in patients having IR and vice versa but only the MS and its components as also increasing age determined advanced fibrosis. After mean follow-up 7.3 years, progression from prediabetes (PD) to diabetes mellitus (DM) occurred in 10%, from normal glucose tolerance (NGT) to PD in 6.25%, and progression of NFS occurred in 16.9%. Advanced age, low HDL and high TG were associated with IR and were involved in glycemic progression as also obesity in progression from NGT to PD and central obesity from PD to DM. CONCLUSION: Though IR and MS go hand in hand in the pathogenesis of NAFLD in both diabetic and nondiabetic patients as well as in the glycemic progression of nondiabetic patients with NAFLD, the MS or its components have more weightage in determining the severity.

Incidence and outcome of gastrointestinal bleeding in patients receiving aspirin with or without clopidogrel over 10 years- An observational study.

Aims: To determine the long-term incidence and outcome of gastrointestinal (GI) bleeding in users of aspirin with (dual antiplatelet therapy, DAPT) or without clopidogrel. Settings and Design: Prospective hospital based 12-year study. Methods and Material: There were 1047 patients on either aspirin 150 md/day alone (n = 574, 54.8%) or aspirin 75 md/day + clopidogrel 75 md/day (n = 473, 45.2%) were followed up for any incident GI bleed, rebleed and mortality. Those simultaneously using other drugs known to cause GI bleeding were excluded. Comorbidities, concomitant use of proton pump inhibitors and statins were noted. Results: GI bleed occurred in 11.8% after 8,683 person years of follow up. 56 (45%) patients had lower GI source of bleed [colon 9 (7%), small gut 47 (38%)] and 68 (55%) had upper GI source [duodenum 39 (32.3%), stomach 28 (22.6%) and oesophagus 1 (0.1%)]. Whereas stomach and duodenum were the chief sites in the first year, small gut predominated in later years. The cumulative bleeding rate after 1, 5 and 10 years was 5%, 8% and 11%, respectively, higher in the DAPT group. Bleeding stopped spontaneously in 98% on drug withdrawal, and 7.3% patients rebled in the next 6.2 years. The overall mortality was 33.1% but only 1.6% was due to the bleed being significantly lower in the DAPT group. On multivariate analysis coronary interventions, diabetes mellitus, renal and multiorgan dysfunction were the significant predictors of GI bleed and mortality. Conclusions: Though the incidence and mortality are low, GI bleed increases with longer use of antiplatelet agents predominantly from the lower GI tract.

Guidelines on Diagnosis and Management of Cow's Milk Protein Allergy.

JUSTIFICATION: Cow's milk protein allergy (CMPA) is increasingly being diagnosed in the West, while there is scant data on the subject from India. There is low awareness among pediatricians about its diagnosis and management; leading to improper diagnosis. PROCESS: A group of experts from the pediatric gastroenterology sub-specialty chapter of Indian Academy of Pediatrics (Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition) met at Mumbai on 26 October, 2018 and discussed various issues relating to the subject. A broad consensus was reached and a writing committee was formed. They met again on 11 August, 2019 at Chennai for a detailed discussion. The statement was sent to the entire group by e-mail and their approval obtained. OBJECTIVE: To formulate a consensus statement enable proper diagnosis and management of Cow's milk protein allergy. RECOMMENDATIONS: Cow's milk protein allergy is most common in the first year of life. Gastrointestinal manifestations are usually non-IgE mediated and therefore skin prick test and specific IgE levels are not useful in diagnosis. Clinical response to elimination diet followed by a positive oral food challenge is diagnostic. In patients with only gastrointestinal manifestations, sigmoidoscopy and rectal biopsy may be considered as an alternative. Management involves strict avoidance of all forms of bovine milk protein. For infants who are artificially fed, an extensively hydrolyzed formula is the first choice. Soy formula is an alternative in those above six months of age. Since most infants outgrow the allergy, elimination diet is only for a limited period and re-evaluation should be done periodically.

Overlap Syndrome and Myasthenia Gravis: An Uncommon Association With Unusual Features.

The author presents a rare case of overlap syndrome associated with myasthenia gravis in the absence of acetylcholine receptor antibody and thymoma. Various liver autoantibodies developed at different times later in the disease course and myasthenia occurred 5 years after the diagnosis of liver disease. The importance of repeating antibody panel later in the disease course for proper diagnosis and timely treatment is highlighted. The exact mechanism of the development of myasthenia gravis in autoimmune liver disease also needs investigation for the possibility of new drug development that might be beneficial to both.

A STUDY OF METABOLIC PARAMETERS IN NON DIABETIC PATIENTS WITH NON ALCOHOLIC FATTY LIVER DISEASE - IMPORTANCE OF DYSLIPIDEMIA.

BACKGROUND: Metabolic risk factors of non alcoholic fatty liver disease (NAFLD) in non diabetic teetotallers who constitute a definite group are not well defined. OBJECTIVE: To identify the metabolic risk factors of NAFLD if any in non diabetic subjects who do not consume alcohol. METHODS: In a cross sectional study the effect of metabolic parameters (BMI, individual lipid levels, hemoglobinA1c (HbA1c), HOMA IR and the metabolic syndrome components) of 150 consecutive non diabetic teetotallers (90 with normal glucose tolerance and 60 prediabetics) on their NFS (quantifiable severity parameter of NAFLD) was studied by linear regression analysis. Similar study was done in the normal glucose tolerance and prediabetes groups separately. These parameters were then compared with those of 75 matched diabetic teetotallers with NAFLD. To analyse further the difference between normal glucose tolerance, prediabetic and overt diabetic groups, binary logistic regression of the factors was carried out taking prediabetes and diabetes as outcome variable. RESULTS: All the metabolic parameters were significantly higher in diabetics compared to non diabetics and in prediabetics compared to those with normal glucose tolerance except high-density lipoprotein cholesterol. Triglyceride, high-density lipoprotein cholesterol and BMI significantly predicted NFS in the overall (adjusted R2 68.7%, P=0.000) and normal glucose tolerance groups (adjusted R2 73.2%, P=0.000) whereas BMI, triglyceride, low-density lipoprotein cholesterol and HbA1c did in prediabetics (adjusted R2 89%, P=0.000). The metabolic syndrome was significantly associated with NFS in the overall and prediabetic groups. High triglyceride (odds ratio1.08), low-density lipoprotein cholesterol (odds ratio1.03) and HbA1c (odds ratio 11.54) were positively associated with prediabetes compared to normal glucose tolerance group. CONCLUSION: In nondiabetic teetotallers dyslipidemias are the prime contributors to the development of NAFLD.

Clinical Presentation and Mortality Determinants of Alcohol-Related Liver Disease: A Single-Center Experience of the Rising Menace from Eastern India.

OBJECTIVES: Recently, the incidence of alcohol-related liver disease has been rising alarmingly in India with late presentation and short survival. Better delineation of factors affecting mortality is needed for optimal utilization of constrained resources like liver transplantation. METHODS: Baseline data of 395 patients with alcohol-related liver disease including age, clinical presentation, alcohol parameters (amount, duration, type), laboratory parameters for detecting organ failure, and prognostic scores were compared between survivor and deceased groups. Further subgroup analysis of deceased patients was done to identify factors associated with early mortality in acute-on-chronic liver failure (ACLF) and cirrhosis groups by multivariate analysis and receiver operating characteristic (ROC) curves. Only best supportive medical therapy was offered to all. RESULTS: 80 (20.3%) patients had alcoholic hepatitis (without cirrhosis) and recovered completely with abstinence. 315 (79.7%) had evidence of either cirrhosis (n = 182, 46.1%) or ACLF (n = 133, 33.6%) at presentation and all died within the next 2 years of follow-up, earlier in the ACLF cases. All deceased patients had been heavy drinkers for long periods (>85 g/day for >17 years). Higher age, amount of alcohol consumption, number of organ failures and discriminant function score predicted severe disease and early mortality, the latter being the best predictor. The European Foundation for the study of chronic liver failure consortium (CLIF-C) score has good applicability in Indian ACLF cohorts. Serum glutamic pyruvic transaminase was normal in 73.8% of deceased patients compared to only 12.5% of survivors. Abstinence did not result in complete normalization of deranged laboratory parameters in those who died. CONCLUSION: Alcohol-related liver disease is serious with high short-term mortality, which has early identifiable but mostly irreversible factors. Urgent measures need to be taken to curb this rising menace.

Estudo de parâmetros metabólicos em pacientes não diabéticos com doença hepática gordurosa não alcoólica - importância da dislipidemia / A study of metabolic parameters in non diabetic patients with non alcoholic fatty liver disease - importance of dyslipidemia

ABSTRACT BACKGROUND: Metabolic risk factors of non alcoholic fatty liver disease (NAFLD) in non diabetic teetotallers who constitute a definite group are not well defined. OBJECTIVE: To identify the metabolic risk factors of NAFLD if any in non diabetic subjects who do not consume alcohol. METHODS: In a cross sectional study the effect of metabolic parameters (BMI, individual lipid levels, hemoglobinA1c (HbA1c), HOMA IR and the metabolic syndrome components) of 150 consecutive non diabetic teetotallers (90 with normal glucose tolerance and 60 prediabetics) on their NFS (quantifiable severity parameter of NAFLD) was studied by linear regression analysis. Similar study was done in the normal glucose tolerance and prediabetes groups separately. These parameters were then compared with those of 75 matched diabetic teetotallers with NAFLD. To analyse further the difference between normal glucose tolerance, prediabetic and overt diabetic groups, binary logistic regression of the factors was carried out taking prediabetes and diabetes as outcome variable. RESULTS: All the metabolic parameters were significantly higher in diabetics compared to non diabetics and in prediabetics compared to those with normal glucose tolerance except high-density lipoprotein cholesterol. Triglyceride, high-density lipoprotein cholesterol and BMI significantly predicted NFS in the overall (adjusted R2 68.7%, P=0.000) and normal glucose tolerance groups (adjusted R2 73.2%, P=0.000) whereas BMI, triglyceride, low-density lipoprotein cholesterol and HbA1c did in prediabetics (adjusted R2 89%, P=0.000). The metabolic syndrome was significantly associated with NFS in the overall and prediabetic groups. High triglyceride (odds ratio1.08), low-density lipoprotein cholesterol (odds ratio1.03) and HbA1c (odds ratio 11.54) were positively associated with prediabetes compared to normal glucose tolerance group. CONCLUSION: In nondiabetic teetotallers dyslipidemias are the prime contributors to the development of NAFLD.

RESUMO CONTEXTO: Os fatores de risco metabólicos da doença hepática gordurosa não alcoólica (DHGNA) em abstêmios não diabéticos, que constituem um grupo distinto, não são bem definidos. OBJETIVO: Identificar os fatores de risco metabólicos da DHGNA em indivíduos não diabéticos e que não consumam álcool. MÉTODOS: Em um estudo transversal, o efeito dos parâmetros metabólicos (IMC, níveis de lipídios individuais, HbA1c, Homa IR e os componentes da síndrome metabólica) de 150 abstêmios não diabéticos consecutivos (90 com tolerância à glicose normal e 60 pré-diabéticos) em sua NFS (parâmetro de gravidade quantificável da DHGNA) foram estudados por análise de regressão linear. Um estudo similar em separado foi feito nos grupos normais da tolerância da glicose e do pré-diabetes. Esses parâmetros foram comparados com os de 75 abstêmios diabéticos pareados com DHGNA. Para analisar ainda mais a diferença entre a tolerância à glicose normal foi realizada a regressão logística binária dos fatores tomando pré-diabetes e diabetes como variável de desfecho, nos grupos diabéticos e pré-diabéticos. RESULTADOS: Todos os parâmetros metabólicos foram significativamente maiores nos diabéticos comparados aos não diabéticos e em pré-diabéticos comparados àqueles com tolerância normal à glicose, exceto HDL. Os índices TG, HDL e IMC previram significativamente o NFS no geral nos grupos de tolerância normal (R2 ajustado 68,7%, P=0,000) e de glicose normal (R2 ajustado 73,2%, P=0,000), enquanto o IMC, TG, LDL e HbA1c predisseram em pré-diabéticos (R2 ajustado 89%, P=0,000). A síndrome metabólica foi associada significativamente com o NFS nos grupos totais e pré-diabéticos. O TG elevado (odds ratio 1,08), o LDL (odds ratio 1,03) e a HbA1c (odds ratio 11,54) foram positivamente associados ao pré-diabetes em comparação com o grupo normal de tolerância à glicose. CONCLUSÃO: Em abstêmios não diabéticos as dislipidemias são os principais contribuintes para o desenvolvimento da DHGNA.

A Study of Hormonal Abnormalities in Chronic Liver Disease.

BACKGROUND: The liver, being involved in multiple metabolic processes, not only impacts the endocrine system normally but also become an inevitable target during the course of endocrine disorders. The effects of this intricate relationship which may be disrupted in CLD can only be addressed by simultaneously studying all hormone profiles in such patients and also their relation to etiology and severity of CLD. METHODS: Serum fasting cortisol, insulin, prolactin, testosterone, estradiol, FSH, LH and thyroid hormones (TSH, free T4 & T3) were measured for any abnormality in 100 randomly selected patients of CLD in a cross sectional observational study and their relation to etiology and severity of CLD (estimated by MELD and CTP score) were studied. RESULTS: Cortisol, estradiol and insulin levels were significantly higher in alcoholics, the former two also increased with severity of CLD. There was overt hypothyroidism in 19% and subclinical hypothyroidism 43% patients, especially those with chronic hepatitis C and autoimmune hepatitis. Testosterone levels were lower in males. Other hormonal changes were independent of severity or etiology of CLD. Cortisol and insulin levels were significantly higher in diabetics with CLD. CONCLUSION: Significant alterations of hormonal profile starting early in the development of CLD of any etiology occur which may need treatment or close follow up. ALD may have worse outcome due to disturbed metabolism of sex hormones, cortisol and insulin. The normal endocrine homeostasis of the body may become disrupted in presence of CLD which may also influence outcome.

Long-term outcome of endoscopic variceal band ligation of esophageal varices in patients with chronic liver disease.

BACKGROUND: There are scanty data on the long-term outcome of endoscopic variceal band ligation (EVL) for esophageal varices. METHODS: Adult patients suffering from a chronic liver disease (CLD) undergoing EVL of esophageal varices of grade 2 and above between January 2006 and December 2015 were followed up for the recurrence of varices, worsening of portal hypertensive gastropathy (PHG), rebleeding, and mortality. EVL was done as primary prophylaxis of bleeding in 72 and as secondary prophylaxis in 175 patients. All received propranolol after EVL if there was no contraindication. RESULTS: Two hundred and forty-seven CLD patients (mean age 51.83 ± 11.28 years, 179 males) underwent 306 EVL sessions. The most common etiology was alcohol (53%). Sixty-eight percent of patients had grade 3 esophageal varices 76.5% had PHG. There was no immediate post-EVL bleeding or 30-day mortality. Variceal obliteration was achieved in 100% with 19% recurrence within a mean period of 53.74 ± 27.2 months. PHG worsened in 49.7%. Overall, rebleeding occurred in 13.8%, 4.3% from recurrent varices. There was no difference in variceal recurrence (16.7% vs. 20%) and incidence of rebleeding (9.7% vs. 13.7%) between patients undergoing EVL for primary and secondary prophylaxis. Cumulative rebleeding rates after 1, 5, and 9 years were 1.6%, 9.2%, and 11.4%, respectively. The overall mortality was 85%, mostly from progressive CLD, and only 8.6% was due to rebleeding. On subgroup analysis, the factors significantly associated with rebleeding was Child-Pugh class C and worsened PHG those with mortality were alcohol and Child-Pugh class C. CONCLUSION: EVL is effective in the long-term for both primary and secondary prophylaxis of esophageal variceal bleeding.

Long-term maintenance treatment of ulcerative colitis in eastern India: a 15-year follow-up.

Clinical data of 65 histologically documented ulcerative colitis patients from January 2001 to December 2013 were prospectively recorded till June 2017 and analysed to determine the outcome of long-term maintenance treatment. Drugs used were 5-aminosalicylates, steroids and azathioprine. Primary outcome measure was relapse. Though 73.8% patients relapsed, most occurred within the first five years with mild to moderate severity and were easily controlled with the same medicines. None had progressive disease; drug discontinuation was possible in six cases. Side effects of drugs were negligible. Rates of surgery, colon cancer, complications and disease-related death were very low. Longer disease duration, azathioprine discontinuation and 5-aminosalicylate use in dose < 2.4 g/d were positively associated with relapses. Biologics were not used in any patient. We conclude that long-term effective use of low-cost drugs in India may obviate the need for newer more expensive drugs.

Indian consensus on chronic constipation in adults: A joint position statement of the Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology.

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.

Current Scenario of Hepatitis B and Its Treatment in India.

Hepatitis B is a significant public health problem in India, yet disease awareness is very low among the general population. The disease is mostly acquired horizontally, but the role of vertical transmission should not be underestimated. In spite of the fact that the majority of cases are e negative disease, most patients present in the advanced stage and even with hepatocellular carcinoma, the leading cause of which is hepatitis B. High-risk groups (especially tribals) also harbour significant disease burden and have a high prevalence of occult infection, supporting the potential of unknowingly spreading the disease. Findings on the relation of genotypes with disease severity or drug action have been conflicting. Though recently, oral antivirals with high genetic barrier to resistance have shown good viral suppression in the long term, e and s seroconversion is poor and relapse is universal upon therapy discontinuation. As no cure is possible with the currently available therapy, the target is long-term viral suppression by prolonged administration of oral antivirals; unfortunately, this leads to poor treatment adherence, which along with the high cost of therapy results in disease progression and spread of infection. At present, therefore, emphasis should be put on health education of the general and high-risk populations, along with health care workers to increase knowledge on such preventive measures as avoiding unsafe injection practices, high-risk sex, performing unnecessary injection and blood transfusion and providing proper screening of blood products; these efforts should be combined with intensive screening and aggressive vaccination programs, especially in high-risk groups and areas of high endemicity. Vaccination strategies are still below par and logistics should be developed for wider coverage; in addition, further research should be carried out on the efficacy and mode of usage for different types of vaccine.

Inflammatory bowel disease in India - Past, present and future.

There is rising incidence and prevalence of inflammatory bowel disease (IBD) in India topping the Southeast Asian (SEA) countries. The common genes implicated in disease pathogenesis in the West are not causal in Indian patients and the role of "hygiene hypothesis" is unclear. There appears to be a North-South divide with more ulcerative colitis (UC) in north and Crohn's disease (CD) in south India. IBD in second generation Indian migrants to the West takes the early onset and more severe form of the West whereas it retains the nature of its country of origin in migrants to SEA countries. The clinical presentation is much like other SEA countries (similar age and sex profile, low positive family history and effect of smoking, roughly similar disease location, use of aminosalicylates for CD, low use of biologics and similar surgical rates) with some differences (higher incidence of inflammatory CD, lower perianal disease, higher use of aminosalicylates and azathioprine and lower current use of corticosteroids). UC presents more with extensive disease not paralleled in severity clinically or histologically, follows benign course with easy medical control and low incidence of fulminant disease, cancer, complications, and surgery. UC related colorectal cancer develop in an unpredictable manner with respect to disease duration and site questioning the validity of strict screening protocol. About a third of CD patients get antituberculosis drugs and a significant number presents with small intestinal bleed which is predominantly afflicted by aggressive inflammation. Biomarkers have inadequate diagnostic sensitivity and specificity for both. Pediatric IBD tends to be more severe than adult. Population based studies are needed to address the lacunae in epidemiology and definition of etiological factors. Newer biomarkers and advanced diagnostic techniques (in the field of gastrointestinal endoscopy, molecular pathology and genetics) needs to be developed for proper disease definition and treatment.