Interleukin Levels and Non-Alcoholic Fatty Liver Disease in Chronic Plaque Psoriasis: An Analytical Case Control Study.

Background: Psoriasis is a chronic, immune mediated inflammatory condition of the skin and imbalance in inflammatory mediators could result in insulin resistance, metabolic syndrome and facilitate the occurrence and progression of Non-alcoholic fatty liver disease (NAFLD). Objectives: Primary objectives: To study the frequency of NAFLD in cases of chronic plaque psoriasis and controlsTo study the interleukin levels in cases of chronic plaque psoriasis and controls. Secondary objectives: To study the BMI, lipid profile, waist circumference, FBS (fasting blood sugar), PPBS (post prandial blood sugar) and serum insulin in cases and controlsTo study the association of age, duration of psoriasis, PASI (psoriasis area severity index), BSA (body surface area) involved, BMI (body mass index), lipid profile, obesity, waist circumference, FBS (fasting blood sugar), PPBS (post prandial blood sugar) and serum insulin levels with NAFLD in patients of chronic plaque psoriasisTo correlate serum levels of IL1-ß, IL6 and TNF-α with NAFLD in patients of chronic plaque psoriasis. Methods: 50 clinically diagnosed cases of chronic plaque psoriasis with age ≥ 18years, diseases duration ≥ 6 months and 30 age and sex matched controls were recruited. PASI, BSA of cases was calculated and BMI, BP, WC of all subjects was measured. Serum lipid profile, FBS, PPBS, insulin level, IL1- ß , IL6, TNF- α , high frequency B-mode ultrasound, LFT and fibroscan were done in all subjects. Results: 28(56.0%) cases and 2(6.6%) controls had NAFLD with statistically significant difference. Significantly elevated WC, serum insulin, deranged lipid profile, fatty liver, transaminitis, fibroscan score, liver fibrosis, NAFLD and interleukins were found in cases vs controls. There was a significant association of NAFLD in psoriatic patients with increasing duration of psoriasis, BMI ≥23 Kg/m2, high WC, increasing BSA involved, deranged lipid profile, raised total cholesterol levels and increasing number of risk factors. Nonsignificant but positive association of NAFLD in cases was found with high levels of IL1 - ß, IL - 6, TNF-α, FBS and increasing PASI. Conclusion: Significantly increased interleukin levels and their weak positive correlation with the severity of psoriasis (PASI, BSA) in patients of chronic plaque psoriasis explains the possible role of inflammation in the causation of psoriasis. Screening may be considered in psoriatic patients with increasing duration of psoriasis, high WC, high BSA involved, high BMI, obesity, dyslipidemia and insulin resistance. Limitations: Small sample size. Conflict of Intrest: NONE.

EUS-guided jejuno-enterostomy in a patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy.

Video 1EUS-guided jejuno-jejunostomy in a 67-year-old male patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy.

AIH in HIV: A Very Much Possible Entity.

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

Demonstration of Gut-Barrier Dysfunction in Early Stages of Non-alcoholic Fatty Liver Disease: A Proof-Of-Concept Study.

Background/Aims: Gut-barrier dysfunction is well recognized in pathogenesis of both non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD). However, comparison of components of this dysfunction between the two etiologies remains unexplored especially in early stages of NAFLD. Methods: Components of gut-barrier dysfunction like alterations in intestinal permeability (IP) by lactulose mannitol ratio (LMR) in urine, systemic endotoxemia (IgG and IgM anti-endotoxin antibodies), systemic inflammation (serum tumor necrosis factor alpha [TNF-α] and interleukin-1 [IL-1] levels), tight junction (TJ) proteins expression in duodenal biopsy and stool microbiota composition using Oxford Nanopore MinION device were prospectively evaluated in patients with NAFLD (n = 34) with no cirrhosis, ALD (n = 28) and were compared with disease free controls (n = 20). Results: Patients with ALD had more advanced disease than those with NAFLD (median liver stiffness -NAFLD:7.1 kPa [5.9-8.9] vs. ALD:14.3 kPa [9.6-24], P < 0.001]. Median LMR was significantly higher in NAFLD and ALD group when compared to controls (NAFLD 0.054 [0.037-0.17] vs. controls 0.027 [0.021-0.045] (P = 0.001)) and ALD 0.043 [0.03-0.068] vs. controls 0.027 [0.021-0.045] (P = 0.019)]. Anti-endotoxin antibody titer (IgM) (MMU/mL) was lowest in NAFLD 72.9 [3.2-1089.5] compared to ALD 120.6 [20.1-728]) (P = 0.042) and controls 155.3 [23.8-442.9]) (P = 0.021). Median TNF-α (pg/mL) levels were elevated in patients with NAFLD (53.3 [24.5-115]) compared to controls (16.1 [10.8-33.3]) (P < 0.001) and ALD (12.3 [10.1-42.7]) (P < 0.001). Expression of zonulin-1 and claudin-3 in duodenal mucosa was lowest in NAFLD. On principal co-ordinate analysis (PCoA), the global bacterial composition was significantly different across the three groups (PERMANOVA test, P < 0.001). Conclusion: While remaining activated in both etiologies, gut-barrier dysfunction abnormalities were more pronounced in NAFLD at early stages compared to ALD despite more advanced disease in the latter.

Cervical leiomyosarcoma in a teenage girl: A rare form of uterine leiomyosarcoma.

Sarcomas arising from the cervix are rare, and the reported prevalence is 0.20-0.55%. A 15-year-old Para 0+0 secondary school student presented to the emergency department in shock with a 1-year history of painless vaginal protrusion, vaginal bleeding, foul-smelling vaginal discharge, occasional passage of blood clots, fatigue, fainting episodes, and weight loss. She was resuscitated with intravenous fluids and blood transfusions. General examination revealed a young girl with a 16-week sized abdominal mass. Vaginal examination revealed a large mobile fleshy mass 14 cm by 10 cm with an offensive discharge and odour. It was externally friable, bled actively on contact, had areas of tissue necrosis, and was oedematous. It was difficult to determine the adnexa structures because of tenderness. Examination under anaesthesia showed that the mass was continuous with the cervix and was not attached to the vagina or vulva. The histology report of the biopsied specimens showed features consistent with cervical leiomyosarcoma (LMS). Cervical LMS was confirmed by immunohistochemistry and a total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed as definitive treatment. Postoperative hormone replacement therapy was initiated. The patient's postoperative condition was stable and there was no tumour recurrence for >2 years on follow-up. Making a diagnosis and instituting surgical and adjuvant treatments for LMS in a low-resource setting are challenging. This is due to lack of access to universal healthcare coverage. A multidisciplinary approach with early diagnosis and complete surgical resection of the tumour provides the most favourable possibility of an improved survival and quality of life.

Versatility of Anabolic Androgenic Steroid-Induced Hepatotoxicity.

The modified derivatives of testosterone, termed as androgenic steroids are indicated in the management of hypogonadism, visceral obesity and metabolic disorders. Anabolic androgenic steroids (AASs) however are surreptitiously used by athletes and body builders for cosmetic purpose owing to their anabolic effects on muscle mass and strength. The unsurveilled use of AASs subjects these users to various side effects involving multiple systems such as the endocrine, genitourinary, hepatobiliary, central nervous, musculoskeletal and psychosocial system. The liver is a hormone-sensitive organ owing to abundance of androgen receptors and is vulnerable to a wide array of hepatotoxicity ranging from asymptomatic liver enzyme elevation to life-threatening subacute liver failure. The type of drug-induced liver injury (DILI) due to AASs can be hepatocellular injury, cholestasis, fatty liver disease, chronic vascular injury and neoplastic disease. Herein, we report three cases of AAS-related DILI associated with AAS abuse.

Biochemical and Radiological Changes in Liver Steatosis Following Mifepristone Treatment in Patients With Hypercortisolism.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is the most common liver disorder in Western industrialized countries and may progress to liver injury. Cortisol is thought to play a role in the pathogenesis of NAFLD, and cortisol modulation has shown efficacy in preclinical models. However, published reports on the clinical effects of glucocorticoid receptor antagonism in these patients are limited. CASE REPORT: Two women (aged 66 and 60 years) with endogenous hypercortisolism presented with a history of hepatic steatosis, hypertension, type 2 diabetes mellitus, and dyslipidemia. Both patients declined adrenalectomy or pituitary tumor surgery, and treatment with mifepristone 300 mg daily was initiated. During mifepristone treatment (follow up durations ranging from 10 months to 5 years), improvements in hypercortisolism-related cardiometabolic abnormalities were observed, including the normalization of lipid levels and improvement of hyperglycemia. In both cases, findings on follow-up imaging revealed resolution of fatty liver, which was supported by a decrease in liver enzymes on liver function tests. No adverse events were reported. DISCUSSION: NAFLD is frequently observed in patients with endogenous hypercortisolism. Improvement in liver function tests has previously been demonstrated in patients with hypercortisolism treated with mifepristone. The present cases showed, for the first time, radiological improvement of liver steatosis following mifepristone use in patients with hypercortisolism and NAFLD. CONCLUSION: This case series demonstrated improvements in biochemical and imaging parameters of NAFLD in patients with hypercortisolism treated with mifepristone. Further research is needed to investigate the effects of glucocorticoid receptor modulation in fatty liver disease.

Human Fascioliasis: Report of Two Cases from Kashmir Valley.

Although few case reports of human fascioliasis have been reported from different parts of India, there is no case reported from the Kashmir valley to date. Herein we report two cases of human fascioliasis. Both patients presented with fever, marked eosinophilia, and liver lesions on imaging. Hepatobiliary imaging showed vague features like mild biliary dilatation and liver lesions representing burrows. A liver biopsy in one of the patients revealed eosinophilic granuloma. Both patients were diagnosed definitively with endoscopic retrograde cholangiopancreatography (ERCP) by demonstrating live adult fasciola worms. Any patient presenting with fever, marked eosinophilia, and liver lesions on imaging should be evaluated for fascioliasis.

Gall bladder Ascariasis: A rare entity.

Gall bladder ascariasis is a rare entity. The causative organism for gall bladder ascariasis is Ascaris lumbricoides It usually presents as acute acalculous cholecystitis. Conservative management with anti-helminthic drugs is preferred while sometimes the patient may need surgical intervention.

Quantification of Liver Fat by MRI-PDFF Imaging in Patients with Suspected Non-alcoholic Fatty Liver Disease and Its Correlation with Metabolic Syndrome, Liver Function Test and Ultrasonography.

BACKGROUND: Magnetic resonance imaging (MRI)-estimated proton density fat fraction (PDFF) has emerged to be a promising tool in quantification of liver fat. Aim of this study was to quantify liver fat using MRI-PDFF in patients with suspected non-alcoholic fatty liver disease (NAFLD) and to correlate it with the presence of metabolic syndrome (MetS), ultrasonography (USG) and liver function test (LFT). METHODS: We included 111 consecutive patients who were suspected to have NAFLD on the basis of clinical, laboratory or USG findings. A 3 Tesla Phillips MRI machine was used with a software named "mDixon Quant" for quantification of the liver fat. RESULTS: MRI-PDFF revealed hepatic steatosis grading as Grade 0 in 31 patients (28%), Grade I in 40 (36%), Grade II in 19 (17.1%) and Grade III in 21 patients (18.9%). MetS patients had higher proportion of advanced steatosis (Grades II and III) as compared to those without MetS (P < 0.001). ALT (alanine transaminase) was found to be significantly elevated (>1.5 times) in the patients with advanced steatosis as compared to patients with Grades I and 0 fatty liver on MRI-PDFF (P < 0.001). The Kappa measure of agreement between USG and MRI-PDFF was found to be 0.2, which suggests a low level of agreement between the two tests. CONCLUSION: MetS patients have higher proportion of advanced steatosis (Grades II and III) at MRI-PDFF as compared to those without MetS. Patients with advanced steatosis at MRI-PDFF had higher proportion of abnormal LFTs as compared to those with Grades 0 and I hepatic steatosis. There was a dis-correlation between MRI-PDFF and USG in the evaluation of NAFLD.

Outcome of Tyrosinemia Type 1 in Indian Children.

AIM: The objective of this study was to determine the outcome of children with tyrosinemia type 1 from India. METHODS: A retrospective observational study was conducted on 11 patients diagnosed with type I tyrosinemia under our care. Age at symptoms, age at diagnosis, age at starting 2-nitro-4-trifluoromethylbenzoyl-1,3-cyclohexanedione (NTBC), duration between diagnosis and initiation of NTBC, dose given, total duration of NTBC, and outcomes were noted. RESULTS: Eleven children with a median age of 1.1 years (0.51-1.52) at onset of symptoms were included in the study. The median age at diagnosis was 1.76 years (0.95-2.43). Their current median age is 5.44 (2.36-8.80) years. Common clinical features at presentation were chronic liver disease in 8 (72.72%), rickets in 2 (18.18%), and fulminant liver disease in 1 (9.09%) patient. Hepatomegaly was observed in all children, growth retardation in 9 (81.81%), coagulopathy in 8 (72.72%), and abdominal distention in 6 (54.54%) patients. The median duration of NTBC therapy was 13.5 (7-21.25) months. The median dose of NTBC was 1 (0.77-1) mg/kg/day. One (9.09%) patient died due to liver cell failure. However, she had received NTBC only for a month. Another patient developed hepatocellular carcinoma (HCC) and underwent liver transplantation. He could receive NTBC only for 2 months, although he was diagnosed to have tyrosinemia for over a 1 year. Eight patients are on treatment with NTBC and are doing well, and 1 patient is not on NTBC and continues to have renal tubular acidosis. CONCLUSION: NTBC therapy is effective and improves the prognosis of tyrosinemia. A long-term follow-up is required to determine progression to HCC and need for liver transplantation.

Outcomes and Predictors of Mortality in Patients With Drug-Induced Liver Injury at a Tertiary Hospital in South India: A Single-Centre Experience.

INTRODUCTION: Drug-induced liver injury (DILI) is an important cause of acute liver failure with significant morbidity and mortality. The outcome of DILI varies widely according to the drug implicated and the type of liver injury. Owing to the heterogeneous nature of liver injury, knowledge on clinical course and prognosis of DILI is limited. We had undertaken this study to determine the clinical characteristics, outcomes, and predictors of mortality in patients with DILI. MATERIALS AND METHODS: This prospective study was conducted from January 2015 through December 2018. We analyzed the drugs implicated, clinical course, and the outcome. Causality assessment was performed by using Roussel Uclaf Causality Assessment Method scoring. Patients were followed for 6 months until recovery/death or liver transplantation. RESULTS: There were 133 cases with DILI. The mean age was 47.6 years, and 51.9% of them were men. Drugs causing DILI were antitubercular drugs (37.5%) followed by neuropsychiatric drugs (16.5%), antibiotics/antifungals (12%), complementary and alternative medicine (10.5%), immunomodulatory/chemotherapeutic drugs (10.5%), and nonsteroidal antiinflammatory drugs (7.5%). Eighty-two (61.6%) patients were classified as hepatocellular, 30 (22.5%) as mixed and 21 (15.7%) as cholestatic type of injury. There was no significant difference in the mortality and morbidity between the three types of liver injury. There were 18 deaths (13.5%), of which antitubercular drugs constituted the majority (55.5%) followed by neuropsychiatric drugs (27.7%) and complementary and alternative medicine (16.6%). Based on receiver operating characteristic curve analysis, model for end-stage liver disease (MELD) score >28, mean international normalized ratio (INR) >1.97, mean bilirubin level >15.6 mg/dl, and creatinine level >1.35 mg/dl were associated with mortality. CONCLUSION: Although DILI is uncommon, it has significant morbidity and mortality. Antitubercular drugs were the most common cause for DILI and DILI-related mortality in our study. Variables such as MELD, INR, bilirubin, albumin, and creatinine help in predicting severity of liver injury and may help in triaging the patient for referral for liver transplantation.

Delayed Graft Dysfunction due to Invasive Hepatic Mucormycosis After Living Donor Liver Transplantation.

Mucormycosis is a rare but emerging fungal infection complicating solid organ transplantation. It is associated with a high mortality rate. We describe an unusual case of hepatic mucormycosis in a living donor liver transplant recipient presenting as delayed graft dysfunction, which was successfully treated with combination of liposomal amphotericin B and oral posaconazole therapy, without surgical resection. The patient had clinical improvement with normalization of liver function tests.

Toxicity profile of honey and ghee, when taken together in equal ratio.

Honey and ghee are an essential component of our diet. They play an important role like anti-inflammatory, antioxidative, antimicrobial, etc. It is written in Charak Samhita that an equal mixture of honey and ghee turn into a harmful component for health. This study was designed to explore the mechanism of toxicity through the biochemical and histological parameters in Charles foster rats (24 rats were used). We have divided these rats into four groups (n = 6) - normal, honey (0.7 ml/100 g bw), ghee (0.7 ml/100 g bw), and honey + ghee (1:1) (1.5 ml/100 g bw). Treatment was given orally for 60 days. All rats were sacrificed on 61 days. Biochemical parameters like liver function test, kidney function test, Oxidative stress, Glycemic, and some protein modification parameters were done in blood plasma. We found weight loss, hair loss, red patches on ear, and increased liver function test, oxidative stress, Amadori product formation, advanced glycation end-product formation, dipeptidyl protease (DPP-4) and decreased incretins (glucagon-like peptide-1(GLP-1) and gastric inhibitory polypeptide (GIP)) in honey + ghee group. H&E and immunohistochemistry results showed mild inflammation in liver tissue but no changes in the kidney, intestine and, pancreas. Thus it concluded that the increased formation of Amadori product, DPP-4 activity and low incretins (GLP-1, GIP) activity resulting high postprandial hyperglycemic response could be collectively responsible for oxidative stress-mediated toxicity of honey and ghee in the equal mixture.

Rhabdomyolysis in the Setting of Concomitant Use of Tafamidis, Atorvastatin, and Amiodarone.

An 85-year-old women with transthyretin cardiac amyloidosis presented with generalized weakness, elevated liver function test levels, and creatinine kinase consistent with rhabdomyolysis 1 week after starting tafamidis. She was already taking atorvastatin and amiodarone, raising the possibility of a drug-drug interaction inhibiting the breakdown and excretion of atorvastatin, causing drug-induced rhabdomyolysis. (Level of Difficulty: Intermediate.).

Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy.

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.

Budd-Chiari Syndrome With Spontaneous Intrahepatic Portosystemic Shunts: A Case Series.

Intra-hepatic portal-venous collaterals are characteristic of Budd-Chiari syndrome (BCS) and are usually of small caliber and seen on Doppler. Creation of large portal-systemic shunt, either radiologically (Transjugular intrahepatic porto-systemic shunt) or surgically results in excellent long term outcomes in BCS. Here, we report a series of three rare cases of asymptomatic BCS, who had spontaneous large intra-hepatic portal-systemic shunts.

Redefining the Normal Values of Serum Aminotransferases in Healthy Indian Males.

BACKGROUND: The normal range for Aspartate and Alanine Aminotransferases (AST and ALT) levels (<40 IU/L) were set in 1950s. Recent data from certain countries suggest lower levels of AST and ALT. Aim of the study was to redefine the normal values of aminotransferases in healthy Indian adults. METHODOLOGY: In a cross sectional prospective study, 1002 blood donors were evaluated to isolate a healthy cohort. Four and 9 subjects positive for HBsAg and anti-Hepatitis C Virus (HCV) respectively and three females were excluded. 986 male subjects were evaluated for levels of serum aminotransferases. RESULTS: Of total 986 subjects (Group I), 543 (55.1%) had fatty liver on ultrasound [15 (1.5%) alcoholic fatty liver and 528 (53.5%) Nonalcoholic Fatty Liver Disease (NAFLD)]. Median AST and ALT in total group (Group I) were 27.69 (Interquartile Range (IQR) 22.33-37.04) and 34.19 IU/L (IQR 23.12-54.87) and in NAFLD (Group II) were 35.67 (IQR -27.49-47.43) and 50.36 (IQR 37.70-76.58) IU/L. Of remaining 443 subjects without fatty liver, 288 had one or more components of metabolic syndrome. Out of 155 patients with no fatty liver and no component of metabolic syndrome (Group III), 103 subjects had normal Body Mass Index (BMI) and normal cholesterol and Low Density Lipoprotein (LDL) (Group IIIB). Median AST and ALT in Group IIIB were 22.56 (IQR 20.23-26.91) and 21.36 (IQR 17.49-27.21) U/L respectively with a 95th percentile of 34.28 and 36.57 U/L for AST and ALT, respectively. CONCLUSION: Levels of AST and ALT in healthy men are lower than the conventional values in India.

Results of Sofosbuvir Plus Ribavirin in Patients With Hepatitis C Related Decompensated Cirrhosis.

BACKGROUND: Sofosbuvir (SOF), a direct acting antiviral, has revolutionized the treatment of chronic Hepatitis C Virus (HCV) infection. However, data is scarce about efficacy of SOF plus Ribavarin (RBV) in Indian patients with decompensated cirrhosis. We evaluated the efficacy of SOF plus RBV in decompensated cirrhosis, and compared the outcome with compensated cirrhosis and non-cirrhotics. PATIENTS AND METHODS: Consecutive decompensated cirrhotic patients of chronic HCV with detectable HCV RNA were treated with 24-week course of SOF (400 mg) plus weight based RBV. Sustained Virological Response (SVR), Child Turcotte Pugh (CTP) and Model for Endstage Liver Disease (MELD) scores were assessed at 36 weeks (i.e. 12 weeks after completion of therapy). Non-cirrhotic chronic hepatitis C patients and patients with compensated cirrhosis treated with SOF plus RBV during the same period were used as controls. During the period of this study ledipasvir and daclatasvir were not available in India. RESULTS: A total of 47 patients [median age 50 (29-82) years, 64% males] with decompensated cirrhosis were included as 'cases' in the study; while, 27 patients with compensated cirrhosis and 29 patients with chronic hepatitis were included as 'controls'. Age, gender, HCV RNA levels, and genotype distribution were similar in cases and controls. The median CTP and MELD scores of cases were 8 (7-12) and 13 (6-25), respectively. Among cases 39 (83%) could complete the therapy, while 1 (2%) was intolerant and 7 (15%) died before completion of therapy. End of Treatment Response (ETR) was achieved in 37/39 (95%) cases. Of these, another 3 died before SVR, and 7 failed to achieve SVR, thus 27/34 (79%) could achieve SVR. Thus according to intention-to-treat analysis, only 27/47 (57%) cases could achieve SVR. In comparison, 24/28 (86%) compensated cirrhotics and 27/28 (96%) of chronic hepatitis achieved SVR. There was a significant improvement in mean CTP score in cases who achieved SVR (P < 0.01) compared to those who did not achieve SVR/ETR. On multivariate analysis the only independent factor influencing successful outcome patients was a serum albumin >3.5 g/dL. CONCLUSIONS: A 24-week course of SOF plus ribavirin in decompensated HCV cirrhosis could lead to SVR in only 57% of patients. The failure of therapy in 43% patients was either due to non-response, intolerance, or death. A serum albumin of more than 3.5 is associated with success of antiviral therapy. Thus an early initiation of antiviral therapy is recommended before decompensation sets in as it precludes successful outcome.