Ascitic Fluid Lactate Level as a Predictor of Mortality in Cirrhotic Patients Having Spontaneous Bacterial Peritonitis (SBP).

Introduction Limited studies are available for predicting mortality in patients with spontaneous bacterial peritonitis (SBP) based on ascitic fluid analysis. Recently, a proposition has been made regarding the role of ascitic fluid lactate as a better prognostic indicator of mortality in cirrhotic patients with SBP. Therefore, we aimed to evaluate the utility of ascitic fluid lactate in predicting mortality in cirrhotic patients with SBP. Methods This was a prospective, observational study that was conducted in the Hepato-Gastroenterology Department of Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1 January 2022 to 31 December 2022. All the patients having liver cirrhosis with ascites, aged between 18 and 65 years, and presenting with fever and/or abdominal pain were recruited in the study in the first six months (i.e., from 1 January 2022 to 30 June 2022) and were followed for six more months for the outcome. However, those patients on dialysis or those with hepatocellular carcinoma, any other malignancy as per a history of solid organ transplant, a history of HIV infection, or those underlying systemic sepsis or infections other than SBP were excluded from the study. The presence or absence of SBP was confirmed by doing the ascitic fluid analysis. Ascitic fluid lactate levels were also requested in each patient. Mortality was assessed at one, two, three, and six months, respectively. All the data were analyzed using SPSS version 23.0. The area under the receiver operating curve (AUROC) was obtained for ascitic fluid lactate for predicting mortality in SBP. At an optimal cutoff, the diagnostic accuracy of ascitic fluid lactate was obtained. Results The total number of cirrhotic patients included in the study was 123. The majority of the patients belong to Child Turcotte Pugh (CTP) class C (n = 88; 71%). Two third of the patients (65.8%; n = 81) had viral hepatitis i.e., hepatitis B, D, and/or C, as the cause of cirrhosis. Overall mortality was observed in 51(41.5%) patients. Ascitic fluid lactate was significantly raised in patients with SBP than in patients with non-SBP (p = 0.004). The AUROC of ascitic fluid lactate was highest at three months (AUROC = 0.88) followed by six months (AUROC = 0.84), two months (AUROC = 0.804), and one month (AUROC=0.773). At an optimal cut-off of more than or equal to 22.4 mg/dl, ascitic fluid lactate had a sensitivity of 84.9%, specificity of 85.7%, positive predictive value (PPV) of 97.3%, negative predictive value of 42.8% with diagnostic accuracy of 85% in predicting overall mortality in patients with SBP. On sub-analysis, the diagnostic accuracy of ascitic fluid lactate was highest at six months followed by at three, two, and one month, respectively. Conclusion Ascitic fluid lactate showed a good diagnostic utility in predicting the overall mortality in patients with SBP with the best diagnostic accuracy in predicting long-term (six months) mortality. However, further studies are required to validate our results.

Etiologies Associated With Elevated Liver Enzymes After Renal Transplant.

OBJECTIVES: One of the most important causes of morbidity and mortality in renal transplant recipients is liver disease. Liver dysfunction is shown in 7% to 67% of kidney transplant recipients. Liver insufficiency accounts for death in up to 28% of kidney transplant recipients. We stratified various etiological factors responsible for elevated liver enzymes in kidney transplant recipients. MATERIALS AND METHODS: We enrolled all patients who fulfilled inclusion criteria. The principal investigator obtained and recorded demographic and clinical information via a standardized form. We reviewed clinical records of kidney recipients with hepatotoxicity during the course of illness, and we analyzed data with SPSS statistical software (version 22). Descriptive statistics were used for continuous and categorical variables. RESULTS: All recipients of living related renal transplants from January 2015 to December 2016 were included in the study (n = 496). We excluded 64 patients with positive serology for hepatitis B or hepatitis C before transplant. Of the remaining 432 patients, 74 (17.1%) had deranged liver enzymes. Forty-one patients (55.4%) had deranged liver enzymes 3 to 4 years after transplant, whereas 23 patients (31.1%) had deranged liver enzymes 4 years after transplant. Liver parenchymal biopsy was performed in 17 patients (23%) to evaluate the etiology. The most common cause of deranged liver enzymes was sepsis, which was seen in 21 patients (28.4%), followed by viral hepatitis, ie, cytomegalovirus hepatitis in 7 (9.5%) and hepatitis C in 6 (8.1%) patients. Other causes included antituberculosis treatment-induced liver injury, autoimmune hepatitis, sinusoidal obstruction syndrome, and nonalcoholic steatohepatitis, observed in 4 patients each (5.4%). CONCLUSION: The most common cause of deranged liver enzymes in patients who received living related renal transplants in our population was sepsis, which can have a substantial effect on graft survival.

Recurrence Rate of Early Hepatitis C Virus Infection After Renal Transplantation Following Successful Treatment of Patients on Dialysis With Direct-Acting Antiviral Agents.

OBJECTIVES: Recurrence of hepatitis C virus after organ transplant has dreadful complications. An excellent response has been shown with direct-acting antiviral agents in transplant recipients. Although a sustained virological response is considered as the virological cure, it requires patients to be on dialysis for 3 months more before undergoing renal transplant, thus increasing the risk of hepatitis C virus reinfection and associated complications. We aimed to determine hepatitis C virus recurrence in renal transplant recipients who had achieved endof-treatment response before transplant. MATERIALS AND METHODS: Per our institutional dialysis protocol, patients who do not achieve rapid virological response are treated with 6 months of direct-acting antiviral agents. All patients who achieve end-of-treatment response are then referred for renal transplant. Our study included kidney transplant recipients who were treated with directacting antiviral agents and had a hepatitis C virus polymerase chain reaction test 3 months after renal transplant. We obtained demographic and clinical data of patients and used SPSS version 20.0 for statistical analyses. RESULTS: Our study included 48 transplant recipients; most were males (81.1%) with mean age of 28.7 ± 9.4 years. All patients received sofosbuvir, daclatasvir, and ribavirin combination before transplant. Most patients (70%) received treatment for 3 months. The polymerase chain reaction test for hepatitis C virus was conducted after a mean of 8.3 ± 3.3 months posttransplant. Laboratory parameters showed total bilirubin of 3.6 ± 17.5 mg/day, alanine aminotransferase of 51.5 ± 80.2 IU/L, and gammaglutamyltransferase of 133.9 ± 220 IU/L. Two recipients (4.2%) had posttransplant recurrence of hepatitis C virus infection. CONCLUSIONS: To our knowledge, this study is the first to document excellent response of direct-acting antivirals in renal transplant recipients who had been referred early for transplant. Thus, dialysis patients can undergo transplant after achieving end-oftreatment response.

Management of Tacrolimus-Induced Toxicity With Normal Serum Levels After Liver Transplant.

Drug-induced liver injury after liver transplant occurs in 1.7% of patients. Tacrolimus is an effective immunosuppressant that is used to treat acute rejection. Although rare, it can cause toxicity, which is demonstrated by cholestatic liver injury. Here, we present a case of a young male patient who was diagnosed with Wilson disease, had penicillaminechelating therapy, and underwent living related liver transplant. Within 1 month posttransplant, he developed deranged, predominantly cholestatic pattern liver function tests. Laboratory parameters showed total bilirubin of 1.12 mg/ dL, alanine aminotransferase of 553 IU/L, gammaglutamyltransferase of 624 IU/L, and tacrolimus level of 10.2 ng/mL. After thorough evaluation, a liver biopsy was performed. Liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. However, with normal level of tacrolimus, the biopsy was suggestive of drug-induced liver injury. Thus, tacrolimus dose was reduced, resulting in improved liver function tests and patient discharge from the hospital. Tacrolimus is an effective immunosuppressant after liver transplant and has the ability to treat early acute rejection. The patient's liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. Cholestatic liver injury after tacrolimus usually resolves after dose reduction or by switching to another agent. With demonstrated tacrolimus-induced toxicity in liver transplant recipients, despite normal serum levels, transplant physicians should keep high index of suspicion regarding toxicity in the posttransplant setting.

Correlation of Model for End Stage Liver Disease (MELD), MELD-Sodium (MELD-Na), and Child-Turcotte-Pugh (CTP) Score With Frailty in Patients With Hepatitis C Virus (HCV) Related Cirrhosis.

INTRODUCTION: The model for end stage liver disease (MELD), model for end stage liver disease-sodium (MELD Na), and Child-Turcotte-Pugh (CTP) score are independent predictors of mortality in cirrhotic patients. Approximately 43% of cirrhotic patients with advanced disease are frail and can have detrimental effects on the disease prognosis and survival including delisting from the transplant list and increased risk of post-transplant complications. Therefore, our aim was to determine the correlation of MELD, MELD-Na, and CTP score with frailty in patients with hepatitis C virus (HCV) related cirrhosis. METHODS:  This cross-sectional study was conducted at the Department of Hepato-gastroenterology, Sindh Institute of Urology and Transplantation from 1st January 2022 to 30th June 2022. All the patients of either gender aged between 18 and 70 years with serological evidence of HCV and features of cirrhosis on ultrasound abdomen were included in the study. Patients with conditions over estimating frailty were excluded from the study. Liver Frailty Index (LFI) was calculated using grip strength measured in kilograms, timed chair stands, and balance testing. CTP and MELD-Na scores for each patient were also recorded. All the data were analyzed using SPSS version 22.0 (IBM Corp., Armonk, NY). The correlation of MELD, MELD-Na, and CTP with LFI was analyzed using the Pearson correlation coefficient and a p-value < 0.05 was considered statistically significant. RESULTS:  A total of 274 patients were included in the study. Out of them, 185 (67.5%) were males. The mean CTP score was 8.1 + 2.1, MELD score of 13.6 + 7.1, MELD-Na score of 15 + 6.6, and LFI of 4.1 + 0.83. LFI was found to be weakly correlated with MELD (r = 0.278) (p < 0.001), MELD-Na score (r = 0.41) (p < 0.001), and CTP score (r = 0.325) (p < 0.001). CONCLUSION:  Weak correlation was noted between LFI, CTP, MELD, and MELD-Na scores in HCV-associated chronic liver disease. Therefore, frailty along with MELD, MELD-Na, and CTP must be assessed before considering the patients for liver transplantation.

Hepatic manifestations of coronavirus disease 2019 infection: Clinical and laboratory perspective.

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has become a global challenge of unprecedented nature since December 2019. Although most patients with COVID-19 exhibit mild clinical manifestations and upper respiratory tract involvement, in approximately 5%-10% of patients, the disease is severe and involves multiple organs, leading to multi-organ dysfunction and failure. The liver and gastrointestinal tract are also frequently involved in COVID-19. In the context of liver involvement in patients with COVID-19, many key aspects need to be addressed in both native and transplanted organs. This review focuses on the clinical presentations and laboratory abnormalities of liver function tests in patients with COVID-19 with no prior liver disease, patients with pre-existing liver diseases and liver transplant recipients. A brief overview of the history of COVID-19 and etiopathogenesis of the liver injury will also be described as a prelude to better understanding the above aspects.

Pancreatic Tuberculosis mimicking as a Pancreatic Mass Lesion.

Tuberculosis is a global health problem and commonly affects the respiratory system. The involvement of the pancreas in this disease is a rare event. We hereby report a case of a young male who presented with right hypochondrial pain along with significant weight loss. Further workup revealed a raised erythrocyte sedimentation rate along with a pancreatic mass lesion on the CT scan. Endoscopic ultrasound-guided biopsy of the pancreatic lesion revealed evidence of caseation necrosis along with epithelioid granuloma, findings suggestive of tuberculosis. He was started on anti-tuberculous therapy for 6 months and a repeat CT scan showed complete disappearance of the mass lesion and resolution of symptoms. Key Words: Tuberculosis, Pancreatic mass, Endoscopic ultrasound, Biopsy.

Primary Hepatic Sarcomatoid Carcinoma Presenting with Dysphagia: A Rare Presentation.

A 50-year male presented with vomiting and dysphagia for 2 weeks. Laboratory workup showed a positive serology for hepatitis C and normal serum α-fetoprotein (AFP) levels. CT abdomen revealed a large lesion in the right lobe of the liver extending upto the lower esophagus causing significant luminal narrowing and dysphagia. The enhancement pattern on the CT scan was not consistent with hepatocellular carcinoma. Liver lesion biopsy showed an infiltrating spindle cell lesion exhibiting fascicles of spindle cells with moderately hyperchromatic nuclei and perinuclear vacuolization. Mitotic count was 2-3/10 HPFs. Immunohistochemical markers were positive for CK AE1/AE3 and vimentin. Thus, a diagnosis of sarcomatoid carcinoma was made on the basis of morphological and immunohistochemical features. Due to unresectable disease and poor functional status, palliative care was opted for. Key Words: Dysphagia, Vomiting, Liver biopsy, Sarcomatoid carcinoma.

Role of "HinCh Score" as a Non-invasive Predictor of Post-endoscopic Retrograde Cholangiopancreatography Cholangitis.

Introduction: Post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis (PEC) is associated with increased morbidity and mortality in patients ERCP. The aim of the present study was to analyze the predictors of PEC and to formulate a predictive model for early diagnosis and management. Materials and methods: It was a cross-sectional study that was carried out at the Sindh Institute of Urology and Transplantation from September 2019 to June 2021. All patients aged between 18 and 75 years and undergoing ERCP due to obstructive jaundice were included. Patients with altered biliary anatomy, history of hepatobiliary surgery, and concurrent sepsis were excluded. Endoscopic retrograde cholangiopancreatography intervention was performed by an expert gastroenterologist. Laboratory parameters (total leukocyte count, total bilirubin, alanine transaminase) and patient temperature were checked on admission, at 12 hours, 24 hours, and 36 hours after ERCP to document PEC. Results: A total of 349 patients were included in the study. Among them, 176 (50.4%) patients were males. Common bile duct (CBD) stricture was the most common indication of ERCP seen in 148 (42.4%) patients followed by CBD stone and cholangiocarcinoma in 108 (30.9%) and 48 (13.8%) patients, respectively. The most common presenting complaint was jaundice noted in 300 (86%) patients followed by right hypochondrial pain in 280 (80.2%) and weight loss in 194 (55.6%) patients, respectively. Post-ERCP cholangitis developed in 251 (71.9%) patients. On univariate analysis, age >50 years, female gender, right hypochondrial pain, fever, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, TLC of >10,000 cells/L at 12 hours, 24 hours, and 36 hours post-ERCP and rise in ALT >50 IU 24 and 48 hours post-ERCP were significantly associated with PEC. While on multivariate analysis, female gender, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, post-ERCP fever, and rise in TLC of >10000 cells/L at 24 hours post-ERCP were independently associated with PEC. HinCh score was formulated and was found to be significantly associated with the presence of cholangitis. Area under the receiver operating characteristics (AUROC) of HinCh score was 0.74 and at cutoff of ≥4, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HinCh were 81.67%, 59.18%, 83.67%, and 55.71%, respectively with a diagnostic accuracy of 75.36%. Conclusion: The performance of HinCh score in predicting PEC was accurate in 86% of the patients. However, further studies are needed to validate the score. How to cite this article: Ismail H, Yaseen RT, Danish M, et al. Role of "HinCh Score" as a Non-invasive Predictor of Post-endoscopic Retrograde Cholangiopancreatography Cholangitis. Euroasian J Hepato-Gastroenterol 2022;12(1):19-23.

Revolution in the diagnosis and management of hepatitis C virus infection in current era.

Chronic hepatitis C virus (HCV) infection is a major global public health problem, particularly in developing part of the world. Significant advances have been made in the early diagnosis and treatment of the disease. Its management has been particularly revolutionized during the past two decades. In this review, we summarize the major advances in the diagnostic and management armamentarium for chronic HCV infection. The focus of the present review is on the newer directly acting anti-viral agents, which have revolutionized the management of chronic HCV infection. Management of uncomplicated chronic HCV infection and of specific complications and special at-risk populations of patients will be covered in detail. Despite the advent and approval of highly effective and well tolerable oral agents, still many challenges remain, particularly the affordability, the equitable distribution and access to later drugs. The World Health Organization aims to eliminate viral hepatitis including HCV by 2030 since its poses a major public health threat. There is an urgent need to ensure uniform and early access to diagnostic and therapeutic facilities throughout the world if the later goal has to be realized.

Refactory Coeliac disease-a case series from Pakistan.

Coeliac disease or gluten intolerance is a frequent cause of chronic diarrhoea leading to malabsorptive symptoms. Refractory coeliac disease is a rare entity, which is not only harder to diagnose but managing it can be challenging. We hereby present three such cases.

Clinical Characteristics and Comparison of Different Prognostic Scores in Wilson's Disease.

Aim: Wilson's disease (WD) is a rare autosomal recessive disease, that can involve any organ of the body, the main ones being the liver and the brain. These patients can have varied presentations, ranging from having no symptoms to having neurological manifestations to features of chronic liver disease (CLD). Those patients that end up having CLD are prognosticated via the Child-Turcotte-Pugh (CTP) score and the Model for End-stage Liver Disease (MELD) score. However, two specific scores exist for prognostication in patients having WD, namely, the Nazar score and the Dhawan score. However, these are yet to be validated nor has their use been implemented in clinical practice. Materials and methods: Our study involved 65 patients with WD, comprising both the pediatric and the adult population. We aimed at evaluating the clinical manifestations the lab parameters and the management of these patients. Furthermore, we tried validating the Nazar and the Dhawan score and later compared them with the CTP and the MELD score, which are well-known prognostic tools in CLD. Results: Our patients were subdivided into the pediatric (more than 50%) and the adult group. The most common presenting complaint noted in both groups was abdominal distension. Values of the urine copper and serum ceruloplasmin did not defer between the pediatric and adult patients. Hepatic involvement is frequently seen in the pediatric age-group. Also, CTP class C was chiefly seen in pediatrics 17/33 (51.5%), while CTP class B was in adults 13/32 (40.6%). The mean Nazar score was 3 ± 3, while the mean Dhawan score was 5 ± 4. The main treatment offered for both groups was zinc along with penicillamine. Conclusion: Our study showed the Dhawan score was comparable to the CTP and the MELD score in terms of predicting the disease severity of WD in our patient population. How to cite this article: Majid Z, Abrar G, Laeeq SM, et al. Clinical Characteristics and Comparison of Different Prognostic Scores in Wilson's Disease. Euroasian J Hepato-Gastroenterol 2022;12(2):69-72.

The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan.

Variceal hemorrhage is a serious consequence of patients having chronic liver disease (CLD). Various scores exist that predict the outcome for non-variceal bleed. However, only a few scores evaluate patients with variceal bleed. We, in our study, evaluated 48 cirrhotics who presented with variceal gastrointestinal (GI) bleed over a period of 3 months. Majority of these were males and the most common etiology was hepatitis C infection. The main presenting complaints were hematemesis seen in 39.6% followed by hematemesis and melena in 31.25%. Most bleeding episodes were secured via banding in 62.5% followed by injection of histoacryl in 12.5%. Finally, Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), albumin-to-bilirubin (ALBI), and the ABC score were applied and none correlated with the presence of esophageal varices. However, the ALBI score did correlate with the presence of tachycardia in our study, a pertinent sign of upper GI bleed. How to cite this article: Majid Z, Khan SA, Akbar N, et al. The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan. Euroasian J Hepato-Gastroenterol 2022;12(2):77-80.

Intestinal Spirochaetosis-A case series from the developing world.

Spirochaetes comprise a heterogenous group of gram negative, motile, spiral shaped bacteria. Some of these pathogens are known to cause numerous human diseases such as Lyme disease, relapsing fever, syphilis and leptospirosis. However, intestinal spirochetosis is a rare condition. Patients frequently present with long-term complaints of loose stools, abdominal pain and weight loss and rectal bleeding. Hence to establish a diagnosis an endoscopy with biopsy is required. In this article, we describe four such cases, having different ages and socio- economic background, successfully treated with a short course of metronidazole.

Successful response of intradermal hepatitis B vaccine in nonresponders of intramuscular hepatitis B vaccine in general and hemodialysis population.

BACKGROUND: Hepatitis B infection is one of the most common infections worldwide, with its vaccination being an effective preventive measure. Nonresponse to hepatitis B vaccination increases population susceptibility to virus dissemination along with detrimental complications. Despite twice intramuscular vaccination series, 14.3% in the general population and 50% in hemodialysis patients fail to mount a response against hepatitis B. We aimed to evaluate the effectiveness of intradermal (ID) vaccination in the nonresponders amongst the general and hemodialysis population. METHODS: A total of 5 doses of 10 µg of hepatitis B vaccine was given intradermally, 2 weeks apart, to both the study groups: patients who were on hemodialysis and the general population group who previously had failed to achieve satisfactory antibody titers with the IM administration of the vaccine. A hepatitis B surface antibody (HBsAb) titer of ≥10 IU/mL and ≥100 IU/mL were considered "responder" and "good responder," respectively. RESULTS: Out of a total of 95 participants, 49 (51.6%) were hemodialysis-dependent. Most of the participants were females 49 (51.6%). The mean age of all the participants was 39.02 ± 13.5 years (range: 18-70 years). Overall, 75.8% of the participants responded to the ID vaccination with a mean HBsAb titer of 263.5 ± 350.1 IU/L. Almost similar vaccination response was observed in both the hemodialysis and general population i.e., 75.5% and 76.1%, respectively (P = 1.00). In the hemodialysis group, the absence of hypertension (P = 0.04) and age ≥36 years (P = 0.016) were associated with an ID vaccination response. CONCLUSION: For those not responding to the conventional IM route of the hepatitis B vaccine, the ID route is an effective way of immunization in this group and this approach would lead to a decrease in infection rates in the vulnerable population such as those on hemodialysis.

Intrahepatic Portosystemic Shunt in a Young Female: Views from a Developing Country.

A young female presented to us with abdominal distension along with pedal edema. She had no prior medical or surgical history apart from a caesarean section done a few years prior. Initial workup showed low hemoglobin, low serum albumin and slight raised ESR. Her LFTs were slightly deranged. Ultrasound abdomen had evidence of portal hypertension along with splenomegaly. While ultrasound hepatic Doppler revealed a portosystemic shunt between the portal vein and the left hepatic vein, with a shunt ratio of 7.1%. CT scan abdomen confirmed these findings and a diagnosis of Type III intrahepatic portosystemic shunt and spleno-renal shunt was made. Since the patient was currently asymptomatic, she was advised regular follow-ups and was managed conservatively.

To determine the prognostic value of the albumin-bilirubin grade (ALBI) in patients underwent transarterial chemoembolization for unresectable hepatocellular carcinoma.

AIM: We aimed at determining the prognostic value of the albumin-bilirubin grade (ALBI) in patients undergoing transarterial Chemoembolization for unresectable Hepatocellular carcinoma. BACKGROUND: Various noninvasive liver reserve markers are used to predict the severity of liver injury. The role and probability of these markers in predicting the prognosis of patients with hepatocellular carcinoma (HCC) is still unknown. METHODS: Patients who underwent TACE from 2013 to 2017 were included. Patient's age, gender, cause of cirrhosis, ALBI Grade along with the site, size and number of tumors were recorded. Radiological response to TACE was assessed by CT scan at 1 and 3 months after the procedure, respectively. Survival assessment was performed and all patients were assessed for survival until the last follow-up. RESULTS: A total of 71 patients were included. Majority of them were male (80.3 %). The mean tumor size of 6 ± 3.9 cm. Majority of patients (54.9 %) had a single lesion and it was mostly localized to the right lobe (60.5 %). The most common cause of chronic liver disease was HCV (65.3%). Median Child class score (CTP) and MELD score were 7 and 10, respectively. Ascites was treated prior to TACE in 12 patients (16.9 %).Mean ALBI score in the study population was -1.59 ± 0.69, with the majority (49. 2 %) falling in grade 2. The mean duration of survival at the last follow up was of 12.1 ± 12.14 months (1- 49).Univariate analysis showed serum albumin (p = 0.003), serum bilirubin (p = 0.018), CTP score (p = 0.019), ALBI grade (p = 0.001) and presence of varices (p = 0.04) to be the main predictors of 6 months survival after TACE. On Cox analysis, only ALBI score (p = 0.038) showed statistical significant association. CONCLUSION: ALBI grade may serve as a surrogate marker in predicting the prognosis of HCC patients undergoing Transarterial Chemoembolization.

Non alcoholic fatty liver disease in a young male with celiac disease.

A young emaciated male, known case of celiac disease came with complaints of diarrhea along with 5kgs of weight loss in 3 months' time. He had severe electrolyte abnormalities along with low albumin, low calcium and a high phosphate with deranged liver function test. Ultrasound abdomen had shown fatty liver. Nutrition consult was sought and he was found to have a BMI of 6.8kg/m2. He was started on nutrition support along with supportive therapy, which resulted in weight gain and improvement in his condition.