Size and Number of Gastric Varices Decide Amount of Glue Injected during Endoscopic Therapy.

INTRODUCTION: Cyanoacrylate glue injection has become standard of care for acutely bleeding as well as for primary and secondary prophylaxis of high risk gastric varices. There is limited data on safe and effective amount of glue injected. Our study was aimed to fulfill the gap. MATERIALS: It was retrospective analysis of endoscopy laboratory chart, videos and corresponding case sheets of all consecutive endoscopies January to September 2022. Number, type and size of gastric varices, amount of glue injected and outcomes (technical success, intra procedural and post-procedural complications) were noted. RESULT: Among 337 upper gastrointestinal endoscopies performed during the study period, 12 patients had gastric varices. 3 had GOV1F1, 2 had GOV1F2, 8 had GOV2F2, 1 had GOV2F3 and one had isolated gastric varices, IGV2F1. 4 patients had history of upper GI bleed. 3 had one, 4 had two and 3 had three varices. 3 patients had <0.5 cm and 8 had >0.5 cm size varices. Cyanoacrylate glue was injected in 4 patients. Technical success was achieved in all (100%) patients. The amount of Cyanoacrylate glue injected was decided by the size and number of varices and varied between 1-4 ml depending on the above factors. Two patients had intra-procedural, self subsiding bleeding, one patient had severe abdominal pain needing intramuscular analgesic. None had fatal complication. CONCLUSION: Size and numbers of gastric varices are deciding factors for amount of glue injected during endotherapy. References Kumar A, Singh S, Madan K, et al. Undiluted N-butyl cyanoacrylate is safe and effective for gastric variceal bleeding. Gastrointest Endosc 2010;72(4):721-727. Saraswat VA, Verma A. Gluing gastric varices in 2012: lessons learnt over 25 years. J Clin Exp Hepatol 2012;2(1):55-69.

A comparative study of novel fibrosis index and transient elastography for predicting fibrosis in patients of chronic liver disease.

Progressive deterioration of liver functions for more than 6 months is considered Chronic liver disease (CLD). Hepatic fibrosis occurs in response to chronic liver injury. The gold standard for assessment of hepatic fibrosis is Liver biopsy, which is an invasive and painful procedure. and rarely can pass on potential life-threatening complications. Thus non-invasive tests that can correctly indicate the severity of liver fibrosis is essential. A number of non-invasive markers have been developed which are useful supplements to assess stages of fibrosis. These are biomarkers (aspartate transaminase (AST) to alanine transaminase (ALT) ratio (AAR), AST to Platelet Ratio Index (APRI), fibrosis index (FI), fibrosis-4 (FIB-4), Age Platelet Index (API), Pohl score, Fibrosis Cirrhosis Index (FCI)) and transient elastography. In our study, we will compare Novel Fibrosis Index (NFI) with other available noninvasive serum indices and transient elastography in predicting Liver Fibrosis Stages. NFI=[(bilirubin×(ALP)2)/ (platelet count (albumin)2)]-n, where n=2000 is a constant. MATERIAL: In this study, a total of 142 cases of confirmed Chronic liver disease were included. All the patients underwent transient elastography and routine hematological and biochemical investigations. Fibrosis staging was done according to Metavir staging (F0-F4) using the fibroscan score. Then the serum indices for predicting liver fibrosis were calculated and compared for various fibrosis stages with Novel Fibrosis index. OBSERVATION: Out of 142 patients, the majority of the patients belonged to age above 40 years and were males(65%). The majority of the patients belonged to F4 fibrosis stage(77.4%) and the most common etiology of Chronic liver disease was Viral hepatitis(47%), the most common being Hepatitis B.The optimum cutoff of NFI for F4 stage was ≥6670 with a sensitivity of 75.8% and specificity of 81.8%. The optimum cutoff of NFI for F3 stage was ≥2112 with a sensitivity of 63.6% and specificity of 72.7%.%. The optimum cutoff of NFI for F2 stage was ≥1334 with a sensitivity of 100% and specificity of 5.3%.The NFI had maximum area under the curve compared to other indices in predicting F2,F3 and F4 stage. CONCLUSION: NFI was the best index in predicting various fibrosis stages in chronic liver disease patients compared to other available serum indices and had maximum accuracy in predicting F4 stage.

Prognostic markers in hepatitis A-related pediatric acute liver failure and validation of the Peds-hepatitis A virus prognostic model.

OBJECTIVES: Hepatitis A virus (HAV) is the commonest cause for pediatric acute liver failure (PALF) in India. The objective of the study was to identify the predictors of mortality and to evaluate the utility of Peds-HAV model in a cohort of non-LT HAV-PALF. METHODS: The study included HAV-related PALF from two non-transplant centers. The predictors of outcome were identified by univariate analysis followed by Cox regression analysis. The prognostic accuracy of Peds-HAV model, King's College Hospital (KCH) criteria and pediatric end-stage liver disease score (PELD) were evaluated. RESULTS: As many as 140 children with PALF were included, of whom 96 (68.6%) children had HAV-PALF. On Cox regression analysis, international normalized ratio (INR) (p < 0.001), jaundice to encephalopathy (JE) interval (p < 0.001) and hepatic encephalopathy (HE) grade 3/4 (p = 0.01) were independent predictors of mortality. The mortality rates were 0% (0/42), 14.3% (3/21), 60% (9/15) and 94.4% (17/18) when none, 1, 2 or 3 criteria of the Peds-HAV were met, respectively. Peds-HAV model at a listing cut-off of  ≥ 2 criteria predicted death with 89.7% sensitivity and 89.6% specificity. In contrast, KCH criteria had a lower sensitivity of 62.1%. PELD score had a sensitivity of 89.7% and specificity of 85.1% at a cut-off of 30. The overall prognostic accuracy of Peds-HAV model (89.6%) was higher than those of KCH (83.3%) and PELD (86.5%). CONCLUSION: INR, HE grade and JE interval were independent predictors of mortality. The study provides an external validation of Peds-HAV model as a prognostic score in HAV-PALF. CLINICAL TRIAL REGISTRY NUMBER: Not applicable as this is a retrospective study.

Comparison of Objectively Assessed Versus Patient-Reported Clarity of Last Rectal Effluent for the Prediction of Quality of Bowel Preparation for Colonoscopy: A Prospective, Case-Control Study.

INTRODUCTION: Colonoscopy is a crucial procedure for various clinical purposes, including screening for colorectal cancer. Adequate bowel preparation is essential for its success. Poor bowel preparation can lead to bad outcomes. An objective assessment of bowel preparation quality is typically only possible after the colonoscope is inserted. This study aimed to objectively correlate the clarity of last rectal effluent, directly collected in a transparent container, with the quality of bowel preparation, and compare it with patient-reported descriptions. METHODS: This prospective, single-centre, case-control study obtained ethical clearance and included patients aged >18 years undergoing colonoscopies. Cases included patients who collected the last rectal effluent and took photographs, while controls relied on verbal descriptions. Data collected included demographics, clinical information, bowel preparation quality, and lastly, stool clarity. A statistical analysis was performed to identify correlations and associations. RESULTS: Of the 70 included patients, 45 were male. The mean age was 35.8 ± 14.3 years. Cases had a higher mean age (37.8 ± 14.6). A higher number of cases had comorbidities (11, 68.8%). Photographic recording of the last rectal effluent was not associated with the adequacy of bowel preparation. Thin yellow fluid was the most common last-rectal effluent clarity (33, 47.1%). Thin, clear fluid was significantly associated with adequate bowel preparation. CONCLUSION: Objective assessment of last rectal effluent clarity correlates with the quality of bowel preparation. This can improve the quality of bowel preparation for colonoscopies and potentially reduce the need for repeat procedures, contributing to better patient outcomes and cost savings in healthcare systems.

Management of Gastric Variceal Bleed by Endoscopic Cyanoacrylate Injection: A Case Series.

Background and aims Cyanoacrylate glue (CAG) is the standard of care for gastric varices (GVs) but has serious complications too. The literature is scarce on determining the safe and effective amount of glue before the procedure objectively. Our study aimed to fill this gap.  Methods It was an interventional case series, from January to December 2022. Patients with GVs, in whom CAG was injected, were included. Demographic, clinical, and endoscopic data with emphasis on cumulative variceal diameter (CVD, sum of maximum diameter of each varix), the total amount of glue injected (GTotal), outcomes (technical and clinical success), and complications intra- and post-procedural) were noted. Results Among 467, 18 (4%) patients had gastric varices. Glue was injected in six (1%) patients. Five had type 2 gastro-esophageal varices (GOV2) and one had type 1 isolated gastric varix (IGV1). Four had a history of upper GI bleed. Numbers of GVs ranged between 1 and 4, sizes 0.5-2.5 cm, and CVDs between 3.5 and 5.0 cm. GTotal ranged between 2 and 4 ml, the number of aliquots was one to two, and the maximum amount of glue in each aliquot was between 2 and 3 ml. The calculated relationship between CVD and GTotal ranged was CVD minus 0.5 to 1. Clinical and technical success was achieved in all. Two patients had intra-procedural, self-subsiding bleeding, and one patient had severe abdominal pain, which subsided with analgesics. None of them had fatal complications, transfusion requirements, or prolonged hospital stays. Conclusions CVD is a potential determinant factor for the total amount of glue injected during the endotherapy of GVs to achieve favorable clinical and technical outcomes.

A Comparative Study of Novel Fibrosis Index and Other Non-invasive Serum Indices for Predicting Fibrosis in Patients of Chronic Liver Disease.

Introduction Chronic liver disease progression leads to liver fibrosis/cirrhosis. Transient Elastography is used for staging liver fibrosis but ascites, obesity, and operator experience limit its applicability. In this study, we compared various non-invasive serum indices in predicting fibrosis in chronic liver disease patients. Materials and methods A total of 142 cases of confirmed Chronic Liver Disease were included. Quantitative determination of liver stiffness by Transient Elastography and relevant blood investigations was done. We compared the liver stiffness measurement by Transient Elastography and fibrosis indices, i.e., Aspartate Transaminase (AST) to Alanine Transaminase (ALT) Ratio (AAR), AST to Platelet Ratio Index (APRI), Fibrosis Index (FI), Fibrosis-4 (FIB-4) Index, Age-Platelet Index (API), Pohl score, and Fibrosis Cirrhosis Index (FCI) with Novel Fibrosis Index (NFI), to predict liver fibrosis stages. Results The optimum cutoff of NFI for the F4 stage was ≥ 6670 with a sensitivity of 75.8% and specificity of 81.8%, for the F3 stage was ≥ 2112 with a sensitivity of 63.6% and specificity of 72.7%, and for the F2 stage was ≥ 1334 with a sensitivity of 100% and specificity of 56.3%. The NFI had the maximum area under the curve compared to other indices in predicting fibrosis stages. Conclusion The Novel Fibrosis Index was the best in predicting fibrosis stages in Chronic Liver Disease patients, with good performance in predicting the F4 stage.

Comparison of a Novel Score "NOD-ACLF" to Other Established Prognostic Scores for Prediction of Mortality in APASL-ACLF Patients: A Cohort Study from a Tertiary Care Center of North India.

Background: Commonly used prognostic scores for acute on-chronic liver failure (ACLF) have complex calculations. We tried to compare the simple counting of numbers and types of organ dysfunction to these scores, to predict mortality in ACLF patients. Methods: In this prospective cohort study, ACLF patients diagnosed on the basis of Asia Pacific Association for Study of the Liver (APASL) definition were included. Severity scores were calculated. Prognostic factors for outcome were analysed. A new score, the Number of Organ Dysfunctions in Acute-on-Chronic Liver Failure (NOD-ACLF) score was developed. Results: Among 80 ACLF patients, 74 (92.5%) were male, and 6 were female (7.5%). The mean age was 41.0±10.7 (18-70) years. Profile of acute insult was; alcohol 48 (60%), sepsis 30 (37.5%), variceal bleeding 22 (27.5%), viral 8 (10%), and drug-induced 3 (3.8%). Profiles of chronic insults were alcohol 61 (76.3%), viral 20 (25%), autoimmune 3 (3.8%), and non-alcoholic steatohepatitis 2 (2.5%). Thirty-eight (47.5%) were discharged, and 42 (52.5%) expired. The mean number of organ dysfunction (NOD-ACLF score) was ->4.5, simple organ failure count (SOFC) score was >2.5, APASL ACLF Research Consortium score was >11.5, Model for End-Stage Liver Disease-Lactate (MELD-LA) score was >21.5, and presence of cardiovascular and respiratory dysfunctions were significantly associated with mortality. NOD-ACLF and SOFC scores had the highest area under the receiver operating characteristic to predict mortality among all these. Conclusion: The NOD-ACLF score is easy to calculate bedside and is a good predictor of mortality in ACLF patients performing similar or better to other scores.

KGHeBTA (King George's Medical University Hepatitis B Therapeutic Algorithm): A New Diagnostic and Therapeutic Algorithm and Clinico-epidemiological Spectrum of Hepatitis B.

Background: Diagnostic and therapeutic algorithms given by various societies for hepatitis B are fragmented and complex. The clinico-epidemiologic spectrum of hepatitis B is not studied with large-scale data from our region. We aimed to develop a comprehensive algorithm for the treatment of hepatitis B and study its clinico-epidemiological spectrum. Methods: From 2014-2019, the clinico-laboratory data of hepatitis B surface antigen (HbsAg)-positive patients were prospectively recorded. King George's Medical University hepatitis B therapeutic algorithm (KGHeBTA) was developed on the basis of the standard existing guidelines. The prevalence of different clinical stages of HBsAg-positive patients was calculated and their treatment records reviewed. Testing circumstances and risk factors were noted. Results: Among 1,508 data record sheets, 421 were complete. According to the KGHeBTA algorithm, 221 had detectable hepatitis B virus DNA. 21% were cirrhotic and 79% non-cirrhotic. 72% were incidentally detected asymptomatic hepatitis B, 7% were hepatitis B with acute symptoms, 0.7% were acute hepatitis B, and 22% were chronic hepatitis B. 20% patients were eligible for antivirals and 80% patients were not eligible. 32% patients were actually treated with antivirals due to the inclusion of some special indications as pregnancy and family history. Screening during various medical illnesses (40%) was the most common and during health camps (0.2%), the least common testing approach. Road-side shaving (52%) was the most common and intravenous drug abuse (0.2%) and the least common risk factor for the detection of hepatitis B in our data pool. Conclusions: HBsAg-positive patients can be easily worked up and treated based on the proposed algorithm (KGHeBTA). About one fourth to one fifth of all HBsAg-positive patients were eligible and treated with oral antivirals. Most of the patients were incidentally detected asymptomatic hepatitis B screened during medical illnesses. Roadside shaving and intravenous drug abuse were the most and the least common risk factors.

Analysis of Government website for web-registration to assess pattern of the Covid pandemic.

Introduction: Covid-19 is an unprecedented challenge in our times leaving a trail of destruction and mayhem affecting almost all of us during the last 2 years. Various data sources are available around the globe to measure its impact using various yardsticks. Material and Methods: By carefully looking at data available at the website maintained by Government of India, we can draw some useful conclusions. Results: There is a dip in the number of online registrations at our hospital coinciding with second wave and resultant lockdown. Conclusion: Tracing digital footprints of an event as huge as the Covid pandemic may help us for future planning when we learn its lessons well.

Measuring impact of Covid-19 pandemic at a teaching hospital in north India.

Introduction: Government runs teaching hospitals to impart a high-quality medical education to budding medicos and paramedical students in training. The experiences these trainees at various tenure positions get then and there shape their worldview for rest of the life and have an indelible impression. The Covid-19 pandemic disrupted all the routines at the hospitals around the world-including ours-and we make an attempt to measure it in one dimension in this study. Materials and Methods: We obtained attendance data of patients at out patient department and in patient department of our hospital. During the pandemic for a certain duration offline (physical) registrations were closed and they were attended only by online ones. Hence that data (actually a part of it) got captured electronically and we analyzed it to get an idea of the traversed course of the scourge. Results: When the pandemic surged during the spring and summer of 2021, our hospital was turned into a Covid facility. Hence average routine attendance of patients got reduced to a significant extent, elective surgeries/interventions and procedures were postponed and this data is reflected in an electronic system, perhaps making a long-lasting effect on the budding trainees. This fact needs to be realized so as to take appropriate action. Conclusion: We need to realize that the effects of the viral communicable disease may be enduring, not only for the infected patients and their families but also for those who learn on those patients. Therefore, the transmissible diseases disabled not only our society, economy, and health care services when they ascended but pedagogy too. Online learning came to rescue but only up to a certain extent and with several caveats and limitations.

The Severity of COVID 19 Pneumonia in Vaccinated vs. Non-vaccinated Patients in the Second Wave: An Experience From a Tertiary Care Center in India.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel infectious disease caused by SARS CoV-2 that emerged in Wuhan, China, and has rapidly spread worldwide. The mortality rate of critically ill COVID-19 patients is high. OBJECTIVE: To assess the severity, different clinical symptoms, and comorbidities of COVID-19 pneumonia in vaccinated vs. non-vaccinated patients. METHODS: In this single-center, cross-sectional study, 142 patients with COVID-19 were enrolled. The clinical characteristics, comorbidities, severity, and outcomes were also assessed. RESULTS: Of the 142 patients, 92 (64.8%) were males, with a mean age of (56.00±14.81) years. Among them, 62 (43.7%) were aged above 60 years. Of these, 92 (64.7%) had comorbidities. The patients were divided into two groups: unvaccinated and those who received at least one dose of the vaccine within six months. The demographic characteristics of the two groups were similar except for gender. In the vaccinated group, most of the patients were males. Most patients in the non-vaccinated group had a severe illness, whereas most patients in the vaccinated group had mild to moderate disease. Only 26% of the vaccinated group experienced severe illness compared to 71.5% in the unvaccinated group. In addition, the all-cause 30-day mortality in the non-vaccinated population was higher than that in the vaccinated population. However, this difference was not statistically significant (12.5% vs. 7.1%). On the contrary, there was no difference in the length of the intensive care unit or total hospital stay between the two groups. CONCLUSION: Severe COVID-19 had the worst outcome in the unvaccinated patients. Most partially vaccinated patients got infected before developing immunity, and a small percentage of completely immunized patients who were infected were likely non-responders. Receiving at least one vaccination dose significantly reduced illness severity.

Fulminant acute fatty liver of pregnancy presenting with multi-organ failure: A case series.

Liver disease in pregnancy can be classified into pregnancy-related, liver disease coincident with pregnancy or preexisting liver disease. Acute fatty liver of pregnancy (AFLP) is a rare liver disorder that is caused by defects in mitochondrial beta (ß) oxidation of fatty acids. In view of its fulminant presentation and rapid progression to multiple organ failure (MOF), AFLP carries high maternal and fetal mortality. These patients are commonly present in the third trimester of pregnancy with gastrointestinal symptoms and complications such as hypoglycemia, lactic acidosis, hyperammonemia, leukocytosis, liver dysfunction, coagulopathy, and renal dysfunction. Diagnosis is mostly based on the Swansea diagnostic criteria and by excluding other etiologies of liver dysfunction. Liver biopsy is rarely performed owing to underlying coagulopathy and thrombocytopenia. In this case series, we intend to share our experience of managing four cases of AFLP that were admitted to the intensive care unit with fetal demise and MOF.

Tinospora Cordifolia (Giloy)-Induced Liver Injury During the COVID-19 Pandemic-Multicenter Nationwide Study From India.

Tinospora cordifolia (Giloy) is an herbal supplement commonly used in the Indian alternative medicine system Ayurveda. This herb has been promoted to the public in India as an immune booster to prevent novel coronavirus disease 2019. However, small reports have recently shown an association between Giloy use and the development of herb-induced liver injury (HILI) with autoimmune features in some patients. This large retrospective Indian multicenter study spanning 13 centers at nine locations was designed to identify features and outcomes of HILI temporally associated with Giloy use. Chemical and toxicological analyses of retrieved Giloy samples using state-of-the-art methods were also performed. We report 43 patients, of whom more than half were female, with a median time from initial Giloy consumption to symptom onset of 46 days. Patients presented with acute hepatitis, acute worsening of chronic liver disease (CLD, the most common clinical presentation), or acute liver failure. Causality assessment revealed probable liver injury in 67.4%. The most common autoantibody detected was anti-nuclear antibody. Liver biopsy in a subset revealed HILI associated with autoimmune features and hepatocyte and canalicular cholestasis and neutrophilic and eosinophilic infiltration. Conclusion: Giloy is associated with acute hepatitis with autoimmune features and can unmask autoimmune hepatitis (AIH) in people with silent AIH-related CLD. Further studies on the safety (and efficacy) of untested but heavily promoted herbals in alternative systems of medicine are an unmet need in the interests of public health and are especially important during this global health emergency.

Serum kallistatin as a marker of severity of liver fibrosis in cirrhosis: A cross-sectional observational study.

Background: Liver cirrhosis is among the leading causes of morbidity and mortality worldwide. Although liver biopsy is the gold standard for the assessment of liver fibrosis in cirrhosis, it has its own limitations. Therefore, noninvasive methods to detect liver fibrosis are widely preferred. However, they also have their own limitations. Thus, there is always a need to extend the battery of serum-based assays. Kallistatin is a protein synthesized primarily in the liver. As it is a negative acute-phase protein, its blood level decreases with a decline in liver function. In our study, we explored the relationship between serum kallistatin and radiological evidence of liver fibrosis by transient elastography to determine if kallistatin levels can be used as a diagnostic marker of liver fibrosis. Materials and Methods: A cross-sectional study of 1-year duration was conducted at a leading tertiary care hospital in northern India. Patients between 15 and 75 years of age having evidence of chronic liver disease were enrolled. All enrolled patients were evaluated by detailed history, physical examination, and relevant investigations. Serum kallistatin levels were quantified using the ELISA method. Grading of liver fibrosis was done using transient elastography. A FibroScan scoring card was used to convert FibroScan results measured in kPa into the Metavir scale F1-F4. Results: A total of 128 subjects, including 64 patients with cirrhosis and 64 healthy controls, were enrolled. Our study suggested that FibroScan values were significantly higher in cases as compared to controls. The kallistatin level of cases was significantly lower than that of controls. An inverse correlation was found between FibroScan value and kallistatin level among cases. Conclusion: We conclude that serum kallistatin levels are low in patients with liver fibrosis and can be used as a potential marker of liver fibrosis.

Previous history of surgery in females and roadside shaving in males are the commonest risk factors for hepatitis C infection: A cross-sectional retrospective study.

BACKGROUND AND OBJECTIVES: Hepatitis C virus (HCV) is a causative agent of hepatitis C disease of the liver. We have analysed the major risk factors including demographic, clinical and genotypic distribution among HCV seropositive patients and their distribution in Uttar Pradesh, India. METHODS: This study was conducted by a questionnaire-based proforma, filled in Hepatobiliary Clinic, Department of Medicine, King Georg's Medical University, Lucknow, from 2014 to 2017. Demographic, clinical and laboratory data were recorded. Seropositivity was demonstrated through an anti-HCV IgG ELISA kit. Positive patients were further examined for HCV RNA by RT-PCR. RESULTS: A total of 31,440 patients attended the hepatobiliary clinic. Among these, 310 (0.99%) patients were confirmed for HCV infection and there was no significant difference between males and females (50.3% vs. 49.7%). Previous surgery (49.0%), dental extraction (41.0%) and roadside shaving (38.1%) were the major risk factors for HCV infection. We also observed that previous surgery 143/154 (92.9%) in female and roadside shaving 118/156 (75.6%) in male was the commonest factor for HCV, however; dental extraction was comparable among male and female (65 [51.8%] vs 62 [48.2%], P value = 0.818). HCV RNA genotype 3 (81.6%) was the most frequent followed by 3a (11.3%), 3b (5.8%), 1 (0.7%) and 4 (0.7%). In the district-wise analysis, frequent cases were included from Lucknow with previous surgery and dental extraction as the commonest risk factor. INTERPRETATION AND CONCLUSIONS: Previous surgery among female and roadside shaving among males are the commonest risk factors for HCV. This study suggests a powerful and strict guideline, to avoid HCV infection.