Insulin tolerance test is comparable to homeostasis model assessment for insulin resistance in patients with nonalcoholic fatty liver disease.

INTRODUCTION: Insulin resistance (IR) is common in patients with nonalcoholic fatty liver disease (NAFLD). We compared the performance of insulin tolerance test and the homeostasis model assessment (HOMA) for measuring IR in such patients. METHODS: In a prospective study, IR was determined using both insulin tolerance test and HOMA in 22 patients with NAFLD. Rate constant for insulin tolerance test (KITT) was calculated using the formula KITT (%/min) = 0.693/t(1/2), where t(1/2) was calculated from the slope of plasma glucose concentration during 3-15 minutes after administration of intravenous insulin. IR was assessed using HOMA as the product of fasting insulin (microU/L) and fasting plasma glucose (mmol/L) levels divided by 22.5. RESULTS: All the 22 patients had IR. Results of KITT and HOMA-IR for determining IR showed a fair correlation (r = 0.55; p = 0.03). CONCLUSIONS: Insulin tolerance test may be a useful method for assessing IR in patients with NAFLD.

Prevalence & significance of hepatitis C virus (HCV) seropositivity in blood donors.

BACKGROUND & OBJECTIVES: The clinical significance of anti HCV antibodies in healthy blood donors remains uncertain. These donors are usually asymptomatic and it is difficult to elicit risk factors of acquiring HCV infection during pre-donation questioning. Limited information on donor recall and follow up studies on anti HCV positive blood donors have been reported from India. Paucity of data which is likely to have an impact on safe blood transfusion programme has prompted us to undertake this study to assess the significance of HCV seropositivity in blood donors with respect to their clinical, biochemical and virological profile. METHODS: A total of 16,250 blood units were screened for the mandatory tests using third generation ELISA (anti HIV 1&2, anti HCV, HBsAg), VDRL and peripheral smear for malaria. Donors reactive for anti HCV were informed. Repeat anti HCV reactive donors were subjected to detailed clinical history focusing on risk factors for HCV transmission. The blood tests included liver function tests (LFT), coagulation and autoimmune profile, qualitative serum cryoglobulins and HCV RNA detection. These donors were followed at 2-3 monthly intervals for a minimum period of six months by LFT. RESULTS: An overall seropositivity of 0.44 per cent (72/16,250) was observed in our donors which was significantly lower in first time, young voluntary donors as compared to replacement donors (0.27 vs. 0.60%). In contrast to drug abuse (6.4%) we found minor percutaneous routes like sharing of shaving kits or visit to a road side barber (32%) as the major risk factor for HCV transmission. There was no prior history of blood transfusion in any of these donors; however history of some surgical procedures was present in 25.8 per cent. Raised transaminases and HCV viraemia were observed in 87 and 71 per cent donors respectively. An association was observed between HCV RNA when the ELISA ratio was >5. INTERPRETATION & CONCLUSION: Voluntary donors form a safe source of blood supply and efforts should be made to increase this precious source to 100 per cent. Abbreviated behavioural donor screening questionnaire for repeat donors is not advisable. Awareness and education of donors is required regarding modes of HCV transmission. HCV positive donors should be informed about their disease, counselled and referred to hepatologist, and permanently deferred for future donations.

Gross anatomy of the retrohepatic segment of the inferior vena cava in northwest Indians.

BACKGROUND AND OBJECTIVES: Information regarding the size and position of the ostia of veins opening into the retrohepatic segment of inferior vena cava (HIVC) in northwest Indians is not available. Knowledge of gross anatomy of this segment is of importance in cases of segmental resection of the liver involving the groove for inferior vena cava (IVC) and when performing selective hepatic venography. We carried out this study to provide information on gross anatomy of HIVC in northwest Indians. METHODS: Livers were obtained from 500 adult autopsy subjects. The HIVC was opened posteriorly by a vertical cut and its circumference at the upper and lower cut ends was measured. To study the position of the ostia of the hepatic veins, HIVC was divided transversely into upper, middle and lower thirds. The anterior and anterolateral walls of HIVC were also divided into four equal parts longitudinally. The venous ostia were classified according to the size of their openings. In addition, in 100 livers the openings were injected with a 20 per cent solution of cellulose acetate butyrate (CAB) in acetone and veins were dissected. RESULTS: The HIVC extended upwards and to the left either obliquely (66.4%) or by describing a gentle curve (33.6%) in its upper half or upper third. Its average length was about 71 mm. Mean diameter at the upper cut end was about 19 mm. The posterior aspect of the upper half or upper one third of HIVC was covered by an extension of the caudate lobe completely (4%) or incompletely (7.4%). The ostia of the left, middle and right hepatic veins were large (>10 mm) and were located in the upper third segment of HIVC. In 87 per cent of specimens the left and middle hepatic veins had a common opening on the left anterior area. The ostium of the right hepatic vein was present in the right anterior area. INTERPRETATION AND CONCLUSION: In conclusion, our study provided gross measurements of HIVC in northwest Indians. A knowledge of the anatomy of HIVC and hepatic venous ostia will help the clinician interventional operator in planning the treatment by choosing a balloon of correct size and at correct site. The measurements helps in determining the fall in portal pressure with pharmacotherapy given for the prevention of variceal bleed.

Is vaccination against hepatitis A virus required in patients with cirrhosis of the liver?

Hepatitis A virus (HAV) superinfection can cause decompensation in patients with chronic liver disease. The risk of HAV superinfection depends on the endemicity of HAV in that particular population. Recommendations of vaccination against HAV in patients with cirrhosis of the liver in India are lacking. Our aim was to assess the seroprevalence of anti-HAV antibodies in our population of patients with cirrhosis of the liver. In a retrospective analysis, the serum of 55 patients with cirrhosis of the liver was tested for total anti-HAV antibodies by ELISA. In the 35 patients who presented with acute decompensation, the serum was also analysed for IgM anti-HAV antibodies. Fifty-four of the 55 cirrhotics (99%) were positive for total anti-HAV antibodies. All 35 patients with decompensated liver disease were also positive for total anti-HAV antibodies, and none of them tested positive for IgM anti-HAV antibodies. Most of the patients with cirrhosis of the liver in the population studied were already exposed to HAV. Routine vaccination against HAV cannot be recommended in these patients.

Helicobacter pylori and hepatic encephalopathy.

Several extra-intestinal diseases have been associated with Helicobacter pylori infection. Hepatic encephalopathy has been linked to H. pylori infection because of the ammonia produced by the organism in the stomach. H. pylori infection is commoner in cirrhotic patients with hepatic encephalopathy than in those without. Increased ammonia levels have been observed in the gastric juice and blood more commonly in cirrhotics with H. pylori infection than in those without. Though the amount of ammonia produced by H. pylori may be too small to contribute to hepatic encephalopathy, eradication of H. pylori has been shown to improve the blood ammonia levels and hepatic encephalopathy.

Hepatic veins in northwest Indian subjects.

Formation, position, course and areas of drainage by hepatic veins were studied in 153 adult autopsy specimens. There were three major hepatic veins; left, middle and right. The middle hepatic vein (MHV) joined the left hepatic vein (LHV) in 88.2% specimens before the latter opened into inferior vena cava (IVC). Each major hepatic vein was joined by a superior vein. An intersegmental vein was present in the septum between the medial and lateral segments; it either joined the LHV or MHV. Formation and course of posterior hepatic veins (small veins) have been described and a nomenclature has been suggested. The right suprarenal vein either opened directly into IVC or joined the superior or inferior posterior hepatic veins.

Hepatitis B and C virus--prevalence and prevention in health care workers.

BACKGROUND: Hepatitis B and C viruses are important causes of liver related morbidity and mortality. We aimed at determining the presence of hepatitis B and C virus infections in the health care workers (HCWs) and their compliance for the HBV vaccination. METHODS: Three thousand five hundred and fifty six health care workers were screened for HBsAg and 115 for anti-HCV by ELISA. HBsAg negative individual were offered HBV vaccination and record of their compliance was kept. Anti-HBs titers were determined one month after 2nd or 3rd dose of vaccine in 273 subjects. RESULTS: Out of 3556 health care workers, 61 (1.7%) were found to be positive for HBsAg. One out of 115 HCWs (0.87%) was found to be positive for anti-HCV. Fifteen percent of HCWs received only one dose, 26% received two doses 59% received three doses and 2.5% also received the booster dose of the HBV vaccine. All those tested had anti-HBs titers more than 10 mUI/ml. CONCLUSION: In HCWs, HBsAg and anti-HCV prevalence was found to be 1.7% and 0.87% respectively. HCWs in our hospital, despite the awareness on HBV and HCV infection are noncompliant for HBV vaccination.

Pharmacokinetics of ciprofloxacin in patients with liver cirrhosis.

BACKGROUND: Bacterial infections are common in patients with cirrhosis of liver and are frequently treated with ciprofloxacin. Literature on pharmacokinetics of ciprofloxacin in patients with cirrhosis of the liver is scanty. The present study compared the pharmacokinetics of ciprofloxacin in cirrhotic patients with that in healthy volunteers. METHODS: In 20 patients with cirrhosis of liver (all Child-Pugh class B) and 10 healthy volunteers, plasma levels of ciprofloxacin were measured using high-performance liquid chromatography at several time points after a 500-mg oral dose. Various pharmacokinetic parameters were calculated. RESULTS: No significant differences were observed in maximum plasma levels reached (mean [SD] 2.6 [0.6] vs 2.6 [1.3] microg/ml), time taken for maximum plasma levels to be reached (1.3 [0.6] vs 1.5 [0.9] h), t1/2a (0.7 [0.3] vs 0.4 [0.9] h), elimination half-life (3.6 [1.2] vs 3.2 [1.8] h), and area under the curve (19.3 [3.8] vs 21.9 [4.5] microg/mL x h) in healthy volunteers and cirrhotic patients, respectively. CONCLUSIONS: Pharmacokinetics of ciprofloxacin is unaltered in patients with liver cirrhosis. Ciprofloxacin can be safely administered in the usual doses in such patients.

Non-cirrhotic portal fibrosis in a patient with rheumatoid arthritis.

A 53-year-old man suffering from rheumatoid arthritis for 15 years presented with bleeding esophageal varices, hepatosplenomegaly and normal splenoportal venous axis. Liver biopsy revealed mild fibrosis, suggestive of non-cirrhotic portal fibrosis (NCPF). There are reports of the association of idiopathic portal hypertension, a condition similar to NCPF, with progressive systemic sclerosis, Hashimoto's thyroiditis and systemic lupus erythematosus.

Prescribing drugs for patients with liver disease.

BACKGROUND: Adverse reactions to prescribed drugs are a common cause of morbidity in patients receiving medical care. Pre-existing or underlying liver dysfunction is one of the commonest factors that enhance the risk of such adverse events in medical practice. Most textbooks of medicine contain no guidelines on special precautions to be taken in prescribing to a patient with pre-existing liver disease. METHODS: To provide a ready reckoner for modifying drug dosage in liver diseases, a literature search was carried out. All papers related to human studies were reviewed and relevant material extracted for preparing the guidelines. RESULTS: Most adverse drug reactions in the presence of liver disease are related to altered pharmacokinetics, pharmacodynamics and susceptibility to drugs. The influence of hepatic disease on various drugs is highly variable. However, many such adverse events are predictable and preventable. Ideally, drug dosage should be modified with the help of serum drug concentrations, which unfortunately, are not available in most Indian hospitals. Hence, some broad guidelines are presented to assist the treating physician to be aware of the risk of adverse drug reactions and modify drug dosage empirically to avoid such events. CONCLUSION: The altered metabolism of pharmacological agents in patients with liver disease may induce several undesirable effects. A large number of adverse drug reactions can be prevented by modifying drug prescribing habits for patients who have pre-existing liver disease.

Combined percutaneous-endoscopic approach for biliary endoprosthesis placement.

A nonoperative method of palliation was used in four patients with malignant obstructive jaundice in whom biliary endoprosthesis could not be placed endoscopically. A guide wire was manipulated through the lesion by a percutaneous transhepatic route and retrieved from the duodenum through an endoscope. A 10 Fr stent was then passed through the endoscope over the guide wire across the stricture. The procedure was successful in all four patients, with no complication.

T cell rich and histiocyte rich B cell lymphoma--a case report.

We report one case of Non Hodgkin's Lymphoma which was classified as Histiocyte Rich B cell lymphoma on immunocytochemistry. The diagnosis was difficult on fine needle aspiration cytology and routine histopathological examination as the infiltrate was composed of reactive lymphocytes and numerous histiocytes obscuring the lymphoma cell population. The neoplastic cells were positive for CD20(L26-A Pan B marker) and negative for CD15(Leu M1), CD3(Ber H2) and pan T cell markers. The histiocytes were positive for CD3(UCHL-1). The patient had a rapid downhill course and died. The autopsy showed infiltration in the axillary, cervical, mesenteric, para aortic, peri pancreatic and hilar lymph nodes. The liver, spleen, bone marrow and kidney also showed lymphomatous infiltration.

Sexual behaviour, drug use and hepatitis B infection in Chandigarh students.

BACKGROUND: The relationship of hepatitis B virus infection with drug use and sexual activity in Indian college students has not been studied earlier. METHODS: We studied this relationship in Chandigarh, using a prospective, cross-sectional questionnaire-based survey and blood tests for hepatitis B markers. The responders were assured of the confidentiality of their responses and blood test results. RESULTS: Of the 1311 students who participated, 192 (15%) were sexually active. Eight-four per cent of them were heterosexual, 7.3% homosexual and 8.7% bisexual. Thirty-seven per cent of heterosexuals and 36% of homosexuals had more than one partner. Condoms were used by 24% heterosexuals, 11% bisexuals and 7% homosexuals. Of the sera tested, 2.9% were hepatitis B surface antigen positive and 10.4% were positive for the antibody to hepatitis B surface antigen. Fifteen per cent consumed alcohol, but only 1.6% were addicted to other drugs. Two students were intravenous drug users. Eleven per cent had donated blood at least once and a third of these had suffered from jaundice in the past. CONCLUSION: The pattern of sexual behaviour, low condom use and the small but definite prevalence of hepatitis B virus infection in this population of students suggests that the human immunodeficiency virus infection may spread rapidly when it enters this community.