Post-transjugular Intrahepatic Portosystemic Shunt Hepatic Encephalopathy: Sarcopenia Adds Insult to Injury.

BACKGROUND: Hepatic encephalopathy, which is a serious complication, and sarcopenia are undesirable consequences in cirrhosis. Transjugular intrahepatic portosystemic shunt increases the risk of hepatic encephalopathy. We investigated the effect of sarcopenia on the incidence of post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy. METHODS: Clinical data of patients who underwent transjugular intrahepatic portosystemic shunt were extracted retrospectively. Computed tomography images at L3 level of scans performed prior to transjugular intrahepatic portosystemic shunt were analyzed to assess skeletal muscle index-expressed as skeletal muscle area (cm2)/ height (m2). RESULTS: Of 210 patients who underwent transjugular intrahepatic portosystemic shunt, complete information was available in 79 [male: 68 (86%); age: 50.5 ± 11.2 years; Child-Turcotte-Pugh score: 8.81 ± 1.23; etiology-alcohol: 44 (56%), non-alcoholic steatohepatitis: 16 (20%), others: 19 (24%); transjugular intrahepatic portosystemic shunt indication-ascites: 56 (71%); bleed: 23 (29%); sarcopenics: 42 (53%)]. Post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy developed in 29 (37%) patients. In patients who developed hepatic encephalopathy, both serum ammonia [177.6 ± 82.5 vs. 115.5 ± 40.5 µg/dL, P =.008] and prevalence of sarcopenia [69% vs. 44%; P =.02; odds ratio (95% CI): 2.8 (1.08-7.4), P =.02] were higher, with sarcopenics having 3 times higher risk of hepatic encephalopathy and 8 times higher risk of multiple episode of hepatic encephalopathy [31% vs. 5.4%; odds ratio (95% CI): 8.2 (1.68- 40.5), P =.009]. In multivariate analysis, age [odds ratio (95% CI): 1.05 (1.001-1.11), P =.047], serum albumin [odds ratio (95% CI): 0.162 (0.05-0.56), P =.004], and skeletal muscle index [odds ratio (95% CI): 0.925 (0.89-0.99), P =.017] were independently associated with post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy. CONCLUSIONS: Sarcopenia is present in nearly half of the cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt, which increases the risk of a single episode of hepatic encephalopathy by 3-fold and that of multiple episodes of hepatic encephalopathy by 8-fold after transjugular intrahepatic portosystemic shunt procedure. Increased skeletal muscle index is associated with decreased risk of hepatic encephalopathy.

Identifying critically ill patients with cirrhosis who benefit from nutrition therapy: the mNUTRIC score study.

Background and Aim: Malnutrition increases risk of mortality in critically ill patients with cirrhosis. Modified Nutrition Risk in Critically ill (mNUTRIC) score is a validated tool to identify at risk patients who may benefit from goal-directed nutrition therapy. We aimed to study the association between mNUTRIC score and 28-day mortality in critically ill patients with cirrhosis. Methods: A prospective study was conducted in the liver intensive care unit of a quaternary teaching institute. Baseline and follow-up data pertaining to mNUTRIC score, clinical, hemodynamic, biochemical, nutritional parameters, mechanical ventilation, length of ICU stay, and development of sepsis were collected. Correlation between mNUTRIC score and its modulation by nutritional adequacy was determined. Results: One hundred and fifty patients were enrolled. Out of these, 116 (77%) had a high NUTRIC score (HNS) and 34 (23%) had a low NUTRIC score (LNS). Patients with HNS had higher mortality (54% vs. 10%; P = 0.008), longer mechanical ventilation (P = 0.02), and high incidence of sepsis (32% vs. 2.6%; P = 0.002) compared to LNS. The probability of survival increased with increase in nutritional adequacy (P < 0.01) in patients with HNS. Conclusion: mNUTRIC score is a useful tool for identifying nutrition risk in critically ill patients with cirrhosis. Goal-directed nutrition therapy in patients with HNS can significantly improve survival. Relevance for Patients: Critically ill patients with cirrhosis who are at a higher nutritional risk as identified by the mNUTRIC score may have a better survival benefit if higher calorie and protein adequacy are achieved in the ICU.

Handgrip strength: Best practice for a rapid nutrition screening and risk stratification in male patients with alcoholic liver cirrhosis, a classification and regression tree analysis study.

BACKGROUND: Rapid nutrition screening (NS) is vital for apt management in patients with alcoholic liver cirrhosis (ALC). AIM: To identify a quick method of NS having high reliability and prognostic significance. METHODS: NS of patients with ALC was assessed using mid-upper arm circumference (MUAC), handgrip strength (HGS), fat-free mass index (FFMI), and the Royal Free Hospital-Global Assessment (RFH-GA). Baseline clinical and biochemical information were recorded along with 90-day survival data. The classification and regression tree method was used to classify HGS, MUAC, and FFMI values as well nourished (WN), moderately malnourished (MM), and severely malnourished (SM), and their concordance with RFH-GA categories was assessed using Kendall tau-b coefficient. The prognostic proficiency of each method was tested by Cox regression analysis. RESULTS: According to the RFH-GA, of 140 male patients with ALC, 13 of 140 (9.3%) were WN, 93 of 140 (66.4%) were MM, and 34 of 140 (26.8%) were SM. HGS has the strongest association with the RFH-GA (Kendall tau-b = 0.772; diagnostic accuracy -81.4%). HGS was found to be the independent predictor of 90-day mortality (26 of 140 [18.6%]; hazard ratio, 0.93; 95% CI, 0.88-0.98; P = 0.002) after adjusting for age, body mass index, and disease severity. The hazard of mortality was 8.5-times higher in patients with ALC with HGS < 22 kg as compared with those with HGS > 29. CONCLUSION: HGS is a reliable tool for rapid NS. HGS < 22 kg suggests a high risk for severe malnutrition and is strongly associated with short-term mortality in male patients with ALC.

Effect of long-term aggressive nutrition therapy on survival in patients with alcohol-related cirrhosis: A randomized controlled trial.

BACKGROUND: The aim of this study was to assess the effect of long-term aggressive nutritional therapy on clinical outcomes and survival in patients with alcoholic liver cirrhosis (ALC). METHODS: Malnourished patients assessed by Royal Free Hospital-Subjective Global Assessment (RFH-SGA) were randomized to control group (CG) (35-40 kcal and 1.2 g protein/kg/day; diet alone) or intervention group (IG) (40-45 kcal and 1.5 g protein/kg/day; diet plus polymeric formula) for 3 months. Patients were followed up at 3 and 12 months. RESULTS: Malnourished patients (age 44.0 ± 9 years; M [100%]; Child A:B:C [%] = 11:39:50) were randomized to the CG (n = 50) or IG (n = 54); 21 patients in CG and 27 in IG completed 3 months of follow-up. The RFH-SGA improved in 7 (33.3%; p = 0.016) in IG vs. 3 (14.2%; p = 0.625) in CG. Over 3 months, increments (CG vs. IG) were seen in calories (1554 ± 972 to 1823 ± 398; p = 0.001 vs.1542 ± 603 to 2254 ± 372; p=0.001), protein (53.1 ± 18.4 to 72.5 ± 19.6; p = 0.001 vs. 53 ± 21 to 86.9 ± 18.8; p = 0.00), dry body weight (64 ± 10 to 66 ± 11; p = 0.04 vs. 60.8 ± 9.2 to 63.2 ± 10.7; p = 0.009), and mid-upper arm circumference (MUAC) (24.7 ± 3.3 to 25.5 ± 3.3; p = 0.116 vs. 23.5 ± 2.7 to 24.1 ± 2.9; p = 0.015), with better ascites resolution in IG (53.3%; p = 0.008) vs. CG (44.4%; p = 0.227). Median 12-month survival was comparable in both the groups (p = 0.864). Irrespective of the intervention group, energy intake > 25 kcal and protein > 0.8 g/kg/day significantly improved 12-month survival. CONCLUSION: Aggressive nutritional therapy improves nutritional status and resolves ascites, however fails to show long-term survival benefit, though higher calorie and protein intake has the potential to impact survival. TRIAL REGISTRATION: NCT02140294.

Omega-3 fatty acid lipid emulsions are safe and effective in reducing endotoxemia and sepsis in acute-on-chronic liver failure: An open-label randomized controlled trial.

BACKGROUND AND AIM: Sepsis is an important determinant of the outcome of acute-on-chronic liver failure (ACLF) patients. Omega-3 fatty acids (FAs) are known to suppress inflammation, reduce morbidity, and mortality in postoperative and critically ill patients. We aimed to evaluate the effect of intravenous omega-6 and omega-3 FA lipid emulsions in ACLF patients. METHODS: Ninety ACLF patients were randomly allocated to three groups: Gr. A received no lipid emulsions, Gr. B received omega-6 FAs, and Gr. C received omega-3 FAs. The primary and secondary aims were to compare the effects of lipid emulsions on immune modulation, the incidence of bacterial sepsis, and mortality at day 28. RESULTS: The baseline characteristics of the patients were comparable. Serum endotoxin levels remained suppressed by 22% in Gr. C compared with a 4% and 12% rise in Gr. B and A (P < 0.001). Omega-3 FAs also suppressed C-reactive protein levels and neutrophil-to-lymphocyte ratio in Gr. C. Compared with Gr. A, omega-3 FAs reduced sepsis by 86% (HR, 0.14; 95% CI 0.04-0.43; P < 0.001). Omega-3 FAs significantly increased the expression of TLR2 and TLR4 on both CD14+ and CD16+ monocytes, and TLR4, on macrophages and neutrophils. There were no serious adverse events, except transient flushing in 20% and 16.6% of patients receiving omega-6 FAs and omega-3 FAs, respectively. CONCLUSION: Omega-3 FAs are safe and effective in reducing systemic inflammation, endotoxemia, and sepsis in patients with ACLF. These lipid emulsions could also be considered as effective sources of immunonutrition in such sick patients.

Clinical and Endoscopic Management of Synchronous Amoebic Liver Abscess and Bleeding Colonic Ulcers.

BACKGROUND: Intestinal amebiasis is endemic in India, with myriad clinical presentations. The liver is the most common extra-intestinal organ to be involved in invasive amoebiasis up to 37% of cases. Synchronous presentation of hepatic and intestinal disease is unusual, and presentation as acute gastrointestinal bleed, or amoeboma even more atypical. GOALS: We aimed to assess the frequency of synchronous hepatic and colonic amebiasis and the efficacy of endoscopic management of colonic bleeding. RESULTS: We screened 52 consecutive patients with amebic liver abscess for synchronous intestinal amoebiasis and report the clinical course of 28 patients (mean age 48.3 years, all male) with amoebic liver abscess (ALA), (mean size, 7.2 ± 2.8 cm) who presented to us with lower gastrointestinal bleed requiring endotherapy. Patients with synchronous infection had higher bilirubin, liver enzymes and prothrombin time. Most needed percutaneous drainage of the liver abscess, and had prolonged hospital stay. They had ileocaecal ulcers with active bleeding; ulcer with adherent clot in 10(50%), and visible vessel in 8(37.5%), or active ooze in 4(12.5%). One patient had an ulcerated rectal mass, which appeared malignant on endoscopy, which was later found to be an amoeboma on microscopy. Hemostasis was achieved with dilute epinephrine injection, one patient required argon plasma coagulation, and 4 subjects required haemoclip placement at the site to control ooze from a visible vessel. CONCLUSION: Synchronous hepatic and intestinal amoebiasis is not uncommon, and often requires endoscopic haemostasis in case of gastrointestinal bleeding due to colonic disease. We report the successful endoscopic control of bleeding amoebic ulcers in all 24 patients.

Characterization of body composition and definition of sarcopenia in patients with alcoholic cirrhosis: A computed tomography based study.

BACKGROUND: Alterations in body composition (BC) as loss of fat and muscle mass (sarcopenia) are associated with poor outcome in alcoholic cirrhosis (ALC). Prevalence of sarcopenia depends upon the method of assessment. Computed Tomography (CT) is a gold standard tool for assessing BC. AIM: To characterize BC and define sarcopenia in ALC patients using CT. METHODS: Single slice CT images at L3 vertebrae of healthy controls (HC) - organ transplant donors and ALC patients were analysed to give cross-sectional area of five skeletal muscles normalized for height -skeletal muscle index (SMI; cm2 /m2 ), area of subcutaneous (SAT;cm2 ) and visceral adipose tissue (VAT;cm2 ). Cut-offs for defining sarcopenia was established at 2SD below the mean of HC. HC were compared with Child A-compensated (C) and Child B+C-decompensated (DC) patients. RESULTS: Cut-offs of SMI derived from HC (n = 275; M: 50%; age 32.2 ± 9.8 years; BMI 24.2 ± 3.2 Kg/m2 ) were 36.54 in males and 30.21 in females. Sarcopenia was found in 12.8% of ALC patients [n = 148; C (31.8%): DC (68.2%); M: 100%; age 46.6 ± 9.7 years; BMI 24.5 ± 4.4]. Compared to HC, compensated patients had higher adiposity and comparable muscularity; decompensated patients had significantly lower muscle and also fat mass compared to both HC and compensated patients. HC vs C vs DC: SAT (140 ± 82 vs 177.3 ± 11 vs 112 ± 8.2); VAT (96.5 ± 6.5 vs 154.9 ± 8.7 vs 87.5 ± 6.5) and SMI (52.1 ± 0.9 vs 49.6 ± 1.2 vs 46 ± 0.9). CONCLUSIONS: Compensated ALC have increased adiposity and relatively preserved muscularity but decompensation leads to loss of both muscle and fat mass. Prevalence of sarcopenia, based on derived ethnic cut-offs was 12.8%.

Genetically Determined Chronic Pancreatitis but not Alcoholic Pancreatitis Is a Strong Risk Factor for Pancreatic Cancer.

OBJECTIVE: To study if chronic pancreatitis (CP) is a risk factor for pancreatic cancer. METHODS: Through a cohort and a case-control study design, CP and other important risk factors including smoking, diabetes, alcohol, obesity, and genetic mutations were studied for their association with pancreatic cancer. RESULTS: In the cohort study, 402 patients with CP were included. During 3967.74 person-years of exposure, 5 of the 402 patients (4 idiopathic CP, 1 hereditary CP) developed pancreatic cancer after 16.60 ± 3.51 years of CP. The standardized incidence ratio was 121. In the case-control study, 249 pancreatic cancer patients and 1000 healthy controls were included. Of the 249 patients with pancreatic cancer, 24 had underlying idiopathic CP, and none had alcoholic pancreatitis. SPINK1 gene mutation was present in 16 of 26 patients with idiopathic CP who had pancreatic cancer. Multivariable analysis showed CP (odds ratio [OR], 97.67; 95% confidence interval [CI], 12.69-751.36), diabetes (>4 years duration) (OR, 3.05; 95% CI, 1.79-5.18), smoking (OR, 1.93; 95% CI, 1.38-2.69) as significant risk factors for pancreatic cancer. The population attributable risk was 9.41, 9.06, and 9.50 for diabetes, CP, and smoking, respectively. CONCLUSIONS: Genetically determined CP but not alcoholic CP is a strong risk factor for pancreatic cancer.

Translation and validation of the Hindi version of chronic liver disease questionnaire (CLDQ) for the assessment of health related quality of life in patient with chronic liver disease in India.

Background: Chronic liver disease questionnaire (CLDQ) is an established disease specific tool to assess the health related quality of life (HRQOL) in patients with CLD irrespective of the etiology and severity. The objective of the study was to develop the Hindi language version of CLDQ and to assess the validity of the Hindi CLDQ. Methods: CLDQ was adapted into Hindi language by following a standard method of forward and back-translation by two bilingual translators, revision by expert panel and formulation of a consensual version followed by pilot testing and appropriate modifications before final administration. Hindi CLDQ along with short form 36 (SF-36) were administered in 494 patients with chronic liver disease (CLD) and 103 healthy controls (HC). To assess reproducibility, Hindi CLDQ was re-administered in a subsample of 20 patients. Internal consistency was assessed by Cronbach's alpha coefficient. Structural validity was assessed by exploratory factor analysis and construct validity was assessed with help of correlation of SF-36 scores and CLDQ pattern across disease severity groups. Results: The Cronbach's alpha coefficient was 0.93 and intra class coefficient correlation was 0.88 for the average CLDQ score, suggestive of good reliability. An inverse relationship of the average CLDQ score with the disease severity (CLDQ score of Child A vs. B vs. C = 5.2±1.10 vs. 4.73±1.24 vs. 4.15±1.19 respectively; p<0.001) and good correlation with SF-36 scores (average CLDQ score with PCS & MCS; r=0.63 & 0.55; p<0.001) was suggestive of good validity of Hindi CLDQ. The factor analysis identified 6 domains accounting for 62% of variability. The derived cut-off of 6 for the average CLDQ had the AUC of 0.826 with a sensitivity of 76.7. Conclusion: Hindi version of CLDQ is found to be a reliable and a valid tool comparable to the original English version. The HRQOL of patients with CLD is lower than healthy controls and HRQOL decreases with increase in disease severity.

Effect of probiotic VSL#3 in the treatment of minimal hepatic encephalopathy: A non-inferiority randomized controlled trial.

AIM: Minimal hepatic encephalopathy (MHE) impairs daily functioning and health-related quality of life in chronic liver disease (CLD). Lactulose is the standard treatment but has side-effects. Probiotics have an encouraging role in MHE. The aim of the present study was to test whether probiotics are non-inferior to lactulose in improving MHE. METHODS: Patients with CLD (n = 227) were screened for MHE using neuropsychometric tests (number connection tests A and B [or figure connection tests A and B]) and/or neurophysiological test (P-300 auditory event-related potential), and 120 (53%) were diagnosed with MHE by abnormal tests. MHE patients were randomized to lactulose (30-60 mL/day) or probiotic (four capsules of VSL#3; total of 450 billion CFU/day) for 2 months. Response was defined as normalization of tests. Serum ammonia was measured by commercial kit. RESULTS: Of 120 patients randomized, 40 in the lactulose arm and 33 in the probiotic arm completed 2 months of intervention. MHE improved in 25 (62.5%) patients taking lactulose and 23 (69.7%) taking probiotics. The effect size of difference of improvement in MHE between lactulose and probiotic was 0.072 per per-protocol analysis and 0.040 as per intention to treat analysis (within -20% of non-inferiority margin). Serum ammonia was comparable between groups at baseline and 2 months; it decreased in patients in whom MHE improved, while increased in patients with no improvement in MHE. CONCLUSION: The probiotic VSL#3 was non-inferior to the standard therapy, lactulose in the treatment of MHE. Improvement in MHE correlated with reduction of ammonia levels.

Intestinal permeability and complications in liver cirrhosis: A prospective cohort study.

AIM: Increased intestinal permeability (IP) has been implicated as an important factor for bacterial translocation (BT), leading to bacteremia and endotoxemia, resulting in various septic complications, variceal bleeding (VB), hepatic encephalopathy (HE), hepatorenal syndrome (HRS) and death in patients with liver cirrhosis (LC). This study was planned to assess IP in patients with LC and follow them for the occurrence of complications. METHODS: Patients with Child B and C cirrhosis without a history of disease-related complications were followed up for 6 months. IP was measured by lactulose and mannitol excretion ratio (LMR) in patients and 50 healthy controls (HC). Serum endotoxin levels were also assessed in 48 patients and 20 HC. RESULTS: Eighty patients (74 male), 41 (51.3%) Child B and 56 (70%) Child C, with a mean age of 40.7 ± 9.8 years were enrolled. IP was increased in 28 (35%) patients. LMR of patients was higher than HC (patients vs HC = 0.0238 [0.0010-1.557] vs 0.0166 [0.0018-0.720]; P = 0.007]. No significant difference was seen in the LMR of patients among various Child classes and etiologies. Serum endotoxin levels (GMU/mL) were higher in patients than HC (patients vs HC = 1.42 [0.68-2.13] vs 0.994 [0.067-1.382]; P = 0.001), but comparable between patients with abnormal and normal IP. At follow up, there was no significant difference in the incidence of complications like spontaneous bacterial peritonitis, HRS, VB, HE and death between patients with abnormal and normal IP. CONCLUSION: IP was increased in 35% of patients with LC; however, it was not associated with a higher incidence of disease-related complications.

Laboratory evaluation of three regimens of treatment of chronic hepatitis B: tenofovir, entecavir and combination of lamivudine and adefovir.

BACKGROUND: Chronic hepatitis B is a disease of concern due to its life-threatening complications like cirrhosis, and hepatocellular carcinoma (HCC) in 20-40% of patients. There are about 400 million people affected worldwide with HBV, and over 300,000 die every year from HBV-related diseases. Oral antivirals like lamivudine, adefovir, entecavir, and tenofovir are commonly used to treat chronic hepatitis B. In this study, we tried to evaluate the comparative efficacy of these drugs alone and in combination. MATERIALS AND METHODS: Chronic hepatitis B patients with HBV-DNA more than 104Copies/mL irrespective of their HBeAg status (n=60) were enrolled in a prospective study. 21, 20, and 19 patients were treated with lamivudine (100 mg/day) plus adefovir (10 mg/day) combination entecavir monotherapy (0.5 mg/day) and tenofovir monotherapy (300 mg/day), respectively and were followed up for 24 weeks with their virological, serological, and biochemical markers measured at 12 and 24 weeks. RESULTS: After 24 weeks of treatment, there was no significant difference between the 3 groups in suppressing HBV-DNA to undetectable levels. The median decrease in HBV-DNA levels from baseline was better with tenofovir and entecavir monotherapies than lamivudine and adefovir combination, which was statistically significant. There was no significant difference between the 3 groups in HBsAg and HBeAg seroconversion and normalization of biochemical parameters. CONCLUSION: Entecavir and tenofovir monotherapy were found to be more effective than lamivudine plus adefovir combination in reducing the HBV-DNA levels. However, lamivudine plus adefovir combination was not too inferior, especially when cost of treatment was taken into consideration.

Glutamine and whey protein improve intestinal permeability and morphology in patients with Crohn's disease: a randomized controlled trial.

BACKGROUND: Increased intestinal permeability (IP) has been implicated in the etiopathogenesis, disease activity and relapse of Crohn's disease (CD). Glutamine, the major fuel for the enterocytes, may improve IP. AIM: We evaluated the effect of oral glutamine on IP and intestinal morphology in patients with CD. METHODS: In a randomized controlled trial, consecutive patients with CD in remission phase with an abnormal IP were randomized to a glutamine group (GG) or active control group (ACG) and were given oral glutamine or whey protein, respectively, as 0.5 g/kg ideal body weight/day for 2 months. IP was assessed by the lactulose mannitol excretion ratio (LMR) in urine, and morphometry was performed by computerized image analysis system. RESULTS: Patients (age 34.5 ± 10.5 years; 20 males) were assigned to the GG (n = 15) or ACG (n = 15). Fourteen patients in each group completed the trial. The LMR [median (range)] in GG and ACG at 2 months was 0.029 (0.006-0.090) and 0.033 (0.009-0.077), respectively, with P = 0.6133. IP normalized in 8 (57.1%) patients in each group (P = 1.000). The villous crypt ratio (VCR) [mean (SD)] in GG and ACG at 2 months was 2.68 (1.02) and 2.49 (0.67), respectively, (P = 0.347). At the end of 2 months LMR improved significantly in GG from 0.071 (0.041-0.254) to 0.029 (0.006-0.090) (P = 0.0012) and in ACG from 0.067 (0.040-0.136) to 0.033 (0.009-0.077) (P = 0.0063). VCR improved in the GG from 2.33 (0.77) to 2.68 (1.02) (P = 0.001), and in ACG from 2.26 (0.57) to 2.49 (0.67) (P = 0.009). CONCLUSIONS: Intestinal permeability and morphology improved significantly in both glutamine and ACG.

Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial.

OBJECTIVE: This study aimed to determine the noninferiority of early enteral feeding through nasogastric (NG) compared to nasojejunal (NJ) route on infectious complications in patients with severe acute pancreatitis (SAP). METHODS: Patients with SAP were fed via NG (candidate) or NJ (comparative) route. The primary outcome was the occurrence of any infectious complication in blood, pancreatic tissue, bile, or tracheal aspirate. Secondary end points were pain in refeeding, duration of hospital stay, intestinal permeability assessed by lactulose/mannitol excretion, and endotoxemia assessed by endotoxin core antibody types immunoglobulin G and M. RESULTS: Seventy-eight patients were randomized to feeding by either the NG or the NJ route. During the hospital stay, the presence of any infectious complication in the NG and NJ groups was 23.1% and 35.9% (significantly different), respectively. The effect size of the difference of infectious complications was -12.8 (95% confidence interval, -29.6 to 4.0). The upper limit of the 95% confidence interval was 4.0 and was within the 5% limit set for noninferiority. The value of 8.0 for the number needed to treat implies that 8 patients should be treated with NG compared with the NJ group to prevent 1 patient from any of the infectious complications. CONCLUSIONS: Early enteral feeding through NG was not inferior to NJ in patients with SAP. Infectious complications were within the noninferiority limit. Pain in refeeding, intestinal permeability, and endotoxemia were comparable in both groups.

Body composition in Indian patients with Crohn's disease during active and remission phase.

BACKGROUND: The alterations in the body composition (BC) in both the active and remission phase of Crohn's disease (CD) are poorly characterized. OBJECTIVE: To assess the BC of the patients with CD in active and remission phase, and compare with healthy controls (HC). METHODS: BC was assessed by bioelectrical impedance analysis using Tanita TBF-215 leg to leg portable impedance analyzer in 123 patients with CD and 100 matched HC. Diet intake was assessed by 24 hours diet recall method. RESULTS: The mean age of patients was 36.4 +/- 12.6 years and 56% were males. Patients in active phase as well as in remission phase had a lower BMI than HC (18.8 +/- 3.6 vs. 23.9 +/- 4.0; p = 0.001 and 18.8 +/- 3.6 vs. 21.6 +/- 5.0; p = 0.002). The fat mass (FM) in active phase was significantly lower than that in remission phase (8.2 +/- 5.9 vs. 13.4 +/- 10.6 kg; p = 0.005) and HC (8.2 +/- 5.9 kg vs. 14.1 +/- 7.5 kg; p = 0.001). FM did not differ between remission phase and HC. The fat free mass (FFM) of HC was significantly higher than that of both remission phase (48.9 +/- 7.4 kg vs. 43.3 +/- 10.4 kg; p = 0.001) and active phase (48.9 +/- 7.4 kg vs. 40.7 +/- 8.5 kg; p = 0.001). There was no difference in the FFM of patients in both phases; p = 0.356. The intake of macronutrients was comparable between the two phases; however lower than that of HC. CONCLUSION: Both FM and FFM were depleted in the active phase, while only FFM was deficient in the remission phase of CD, indicating a poor recovery of lean mass in remission.

Torque teno virus: its prevalence and isotypes in North India.

AIM: To investigate the prevalence and genotype distribution of Torque teno virus (TTV) in patients with different liver diseases and chronic renal failure treated at a referral hospital in North India. METHODS: Whereas prevalence of TTV was based on amplification of conserved region of ORF2 of TTV genome, the genotyping of TTV was carried out using restriction fragment length polymorphism (RFLP) procedure on the N22 region of ORF1. RESULTS: TTV-DNA was detected in 137 of 513 (26.7%) patients with liver diseases and 38 of 65 (58.5%) patients with chronic renal failure. TTV was also detected in 27% of healthy controls. The sequence analysis of the PCR product from 10 randomly selected cases failed to show a significant sequence divergence when compared with that of the TRM1 isolate of TTV genotype 1. The results of genotyping in 55 randomly selected patients showed the presence of genotype 1 (G1) in 53 (96.4%) and genotype 2 (G2) in 2 cases (3.6%), respectively. Other genotypes were not identified in this patient subgroup, suggesting that G1 is predominant in this area. The results of genotyping by RFLP were also supported by phylogenetic tree analysis, where G1 was found to be the major genotype. CONCLUSION: These results indicate that TTV is moderately present in Indian patients, with G1 to be the major genotype in North India. The pathogenicity and etiological role of TTV in different diseases is still a question mark and warrant further studies.

Cause and effect relationship of malnutrition with idiopathic chronic pancreatitis: prospective case-control study.

BACKGROUND AND AIM: Patients with chronic pancreatitis are often malnourished. The role of malnutrition in the pathogenesis of chronic pancreatitis is unclear. The aim of the present article was to study prospectively the cause and effect relationship of malnutrition with idiopathic chronic pancreatitis in a case-control study. METHODS: Consecutive patients with chronic pancreatitis underwent anthropometry, nutritional and dietary assessments. For dietary assessment, food frequency questionnaire and 24-hour dietary recall methods were used. Primary outcome measure was cause and effect relationship of malnutrition with idiopathic chronic pancreatitis. RESULTS: Of 201 patients with chronic pancreatitis, 120 had idiopathic chronic pancreatitis (mean age 29.60 years, 74 males) who formed the study group. None of the patients consumed cassava. The nutritional status and dietary intake of the patients before the onset of chronic pancreatitis were comparable with those of controls with 20.6% of patients and 22.5% of controls being malnourished (body mass index [BMI] < 18.5). After the onset of chronic pancreatitis, 56.5% of patients lost weight and significantly more patients became malnourished compared with controls (45.8% vs 22.5%; P < 0.001). The causes of weight loss were diabetes, higher calories from proteins, and pseudocyst. CONCLUSION: Malnutrition was not a cause of idiopathic chronic pancreatitis and weight loss occurred as an effect of chronic pancreatitis. Cassava was not found to be a cause of idiopathic chronic pancreatitis.

Dietary counseling versus dietary supplements for malnutrition in chronic pancreatitis: a randomized controlled trial.

BACKGROUND & AIMS: Up to 50% of patients with chronic pancreatitis (CP) are malnourished. There are limited data on the role of dietary intervention in improving the nutritional status of such patients. The aim was to compare the efficacy of medium chain triglyceride (MCT)-enriched commercial dietary supplements with dietary counseling for homemade food in the management of malnutrition in patients with CP. METHODS: In a randomized controlled trial, consecutive undernourished patients with CP (body mass index [BMI] <18.5 kg/m(2)) at a tertiary care hospital were randomized to receive either dietary counseling for regular homemade food or commercial MCT-enriched dietary supplements for a period of 3 months to compensate for the dietary calorie deficit. All patients received standard management for CP including pancreatic enzyme supplements. Primary outcome measure was improvement in BMI. RESULTS: Sixty malnourished patients with CP were randomized to counseling group (n = 29; mean age, 32 +/- 10 years; male, 83%) and supplementation group (n = 31; mean age, 28 +/- 10 years; male, 84%). BMI increased in both the counseling group and supplementation group (17.2 +/- 1.7 vs 18.1 +/- 1.8 kg/m(2), P = .001; 16.7 +/- 1.6 vs 18.2 +/- 1.6 kg/m(2), P = .001). There were similar improvements in triceps skinfold thickness, dietary intake, fecal fat, and pain score during a period of 3 months in both groups. There was, however, no significant difference between the counseling and supplementation groups with regard to any of the outcome measures. CONCLUSIONS: Dietary counseling for a balanced homemade diet is as good as commercial food supplements in improving malnutrition in patients with CP.

Comparative redox status in alcoholic liver disease and nonalcoholic fatty liver disease.

PURPOSE: Altered redox status has been implicated in pathogenesis of alcoholic liver disease (ALD) as well as in nonalcoholic fatty liver disease (NAFLD). This study was planned to find the relative role of redox status in these two diseases. METHODS: A total of 44 patients with ALD and 32 patients with NAFLD and 25 apparently healthy controls were included in the study. Redox status was estimated by measuring oxidative stress (superoxide dismutase (SOD) and lipid peroxidation products as thiobarbituric acid reactive substances (TBARS)) and antioxidant status (ferric reducing ability of plasma (FRAP) and vitamin C). RESULTS: TBARS level was raised significantly in both ALD (3.5 (2.3-9.4) vs. 1.8 (0.5-4.1) nmol/ml; P = 0.0001) and NAFLD (5.1 (1-10.2) vs. 1.82 (0.51-4.1) nmol/ml; P = 0.0001) as compared with controls, but was not different between ALD and NAFLD. SOD was significantly higher in ALD as compared to NAFLD (2.4 (1.3-7.8) vs. 0.68 (0.05-19.1) U/ml; P = 0.0001) and controls (1.12 (0.01-3.5) U/ml; P = 0.001). FRAP was lower in ALD as compared with NAFLD (345.4 (56-615.9) vs. 434.1 (197.6-733.3) mumol of Fe(+2) liberated; P = 0.001) but similar to that of controls (340.9 (141.5-697.5) mumol of Fe(+2) liberated). CONCLUSIONS: ALD patients have a higher degree of redox imbalance as compared with NAFLD patients.