Tongue thickness in health vs cirrhosis of the liver: Prospective observational study.

BACKGROUND: Malnutrition affects 40%-90% of patients with cirrhosis of the liver. L3 skeletal muscle index (L3SMI) is presently accepted as the most objective and quantitative measure available for sarcopenia, a surrogate marker of malnutrition. L3SMI application is, however, limited by non-availability of computed tomography scanning in remote areas, cost, need for extensive training, and the risk of exposure to radiation. Therefore, an alternative dependable measure with wider availability is needed. Malnutrition causes sarcopenia not only in skeletal muscles but also in other muscular structures such as the psoas muscle, diaphragm and tongue. We therefore hypothesised that the tongue, being easily accessible for inspection and for measurement of thickness using ultrasonography, may be used to document sarcopenia. AIM: To measure and compare tongue thickness in healthy individuals and in patients with cirrhosis of the liver and to study its correlation with conventional prognostic scores for patients with cirrhosis of the liver. METHODS: Tongue thickness was measured using ultrasonography. One hundred twenty subjects of either gender aged 18 to 65 years were studied, with 30 subjects in each group. The tongue thickness was compared between groups based on "Child Turcotte Pugh" (CTP) scores. The correlations between measured tongue thickness and "Model for end stage liver disease" (MELD) score and between age and measured tongue thickness were also assessed. RESULTS: Mean tongue thickness (mean ± SD) in patients with CTP class A, B and C was 4.39 ± 0.39 cm, 4.19 ± 0.53 cm, and 3.87 ± 0.42, respectively, and was 4.33 ± 0.49 cm in normal healthy individuals. Significant differences were seen in tongue thickness between patients with CTP class C and those with CTP class A and B (P < 0.05). Patients with CTP class C also had a significantly reduced tongue thickness than normal individuals (P < 0.05). However, no significant difference was seen in tongue thickness between patients with CTP class A and B and normal individuals. A statistically significant, negative correlation was found between MELD score and tongue thickness (r = -0.331) (P < 0.001). No correlation was observed between L3SMI and MELD score (r = 0.074, P = 0.424). L3SMI (mean ± SD) in healthy subjects was 39.66 ± 6.8 and was 38.26 ± 8.88 in patients with CTP class C, and the difference was not significant. No significant correlation was found between age of the patients and tongue thickness. Intra-class correlation coefficient was used to determine the reliability of the tongue thickness measurements. The intra-class correlation coefficient was 0.984 (95%CI: 0.979-0.989) and was indicative of good reliability. CONCLUSION: Tongue thickness measured by ultrasonography, correlates significantly with the severity of liver disease, as assessed by CTP and MELD scores. The patients with a CTP score ≥ 10 have significantly reduced tongue thickness as compared to normal individuals and those with less severe liver disease and CTP scores of 5-9. No significant difference in tongue thickness was found between healthy individuals and CTP class A and B patients.

Intractable hepatic encephalopathy in cirrhotic patients: mid-term efficacy of balloon-occluded retrograde portosystemic shunt obliteration.

PURPOSE: To evaluate the efficacy and intermediate-term outcome of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hepatic encephalopathy (HE) secondary to portosystemic shunt (PSS) in cirrhotic patients. MATERIALS AND METHODS: Institutional review board (IRB) approval was obtained for this study and hospital records of patients who underwent BRTO, from August 2011 to August 2015, were analyzed. Based on the inclusion and exclusion criteria, 39 patients (age, 54.07 ± 9.1 years (37-67 years); 33 males and 6 females) with cirrhosis and spontaneous PSS were included. Clinical and laboratory parameters and HE grade were evaluated in all patients before and after the procedure. RESULTS: Forty sessions of BRTO were attempted in 39 patients. Follow-up imaging revealed complete obliteration of the treated PSS in all patients with clinical success in 37 patients (94.9%). The 1-, 2-, 3-, 4-, 5-, 6-, and 7-year HE-free survival rates among responders were 91.7%, 91.7%, 88.8%, 85.5%, 80.8%, 80.8%, and 80.8% respectively and overall survival rates were 89.7%, 82.1%, 76.9%, 74.4%, 74.4%, 64.8%, and 64.8% respectively. Logistic regression highlighted Child-Turcotte-Pugh (CTP) score at 6 months as a positive predictive factor of HE recurrence with a cutoff of ≥ 9. Five patients (12.8%) had fever and leukocytosis and 1 (2.6%) patient developed spontaneous bacterial peritonitis after the procedure. CONCLUSION: BRTO is an effective treatment for refractory HE in cirrhotics secondary to large PSS with a few possible complications. KEY POINTS: • BRTO is an effective and safe treatment for refractory HE, arising from PSS in cirrhotic patients. • Patients with preserved liver function show better outcome and CTP score is the most important predictor of relapse during follow-up.

Safety and efficacy of early image-guided percutaneous interventions in acute severe necrotizing pancreatitis: A single-center retrospective study.

BACKGROUND: Acute necrotizing pancreatitis is managed conservatively in early phase of the disease. Even minimally invasive procedure is preferred after 21 days of onset and there is a paucity of data on decision and outcomes of early radiological interventions. This study aimed to evaluate efficacy and safety of early image-guided percutaneous interventions in management of acute severe necrotizing pancreatitis. METHODS: A single-center retrospective study was performed after obtaining Institutional review board approval for analyzing hospital records of patients with acute necrotizing pancreatitis from January 2012 to July 2017. Seventy-eight consecutive patients with necrotizing pancreatitis and acute necrotic collections (ANC) were managed with percutaneous catheter drainage (PCD) and catheter-directed necrosectomy, in early phase of the disease (< 21 days). Clinical data and laboratory parameters of the included patients were evaluated until discharge from hospital, or mortality. RESULTS: Overall survival rate was 73.1%. Forty-two (53.8%) patients survived with PCD alone, while the remaining 15 (19.2%) survivors needed additional necrosectomy. The timing of intervention from the start of the hospitalization to drainage was 14.3 ± 2.4 days. Significant risk factors for mortality were the presence of organ system failure, need for mechanical ventilation, renal replacement therapy, and the acute physiology and chronic health evaluation II (APACHE II) score. An APACHE II score cutoff value of 15 was a significant discriminant for predicting survival with catheter-directed necrosectomy. CONCLUSION: An early PCD of ANC in clinically deteriorating patients with acute necrotizing pancreatitis, along with aggressive catheter-directed necrosectomy can avoid surgical interventions, and improve outcome in a significant proportion of patients with acute necrotizing pancreatitis.