Etiology and Impact of Hepatic Steatosis in Pakistan: Role of Hepatitis C Virus Genotype 3 Infection

Introduction: Hepatic steatosis has emerged as an important histological finding in patients with deranged liver function. It may be an important factor for the progression of hepatitis C virus-associated liver disease, particularly in genotype 3 infections. Aims: To determine the etiology and impact of hepatic steatosis in our patients presenting with chronic hepatitis. Methods: All liver biopsies performed at our hospital during 2010-2014 were analyzed by a single pathologist using histological activity index (HAI) scores and Brunt’s classification for steatosis. Patients were evaluated for factors reported to be associated with steatosis, including the prevalence of HCV. Results: Biopsies of 439 patients (284 male, mean ages 38.5 ± 11.2 years) were studied. Hepatic steatosis was present in 324 (73.8%) biopsies. It was mild in 190/439 (43.3%), moderate in 88/439 (20%) and severe in 46/439 (10.5%) cases. On univariate analysis, steatosis was associated with HCV infection (p=0.023), BMI >25 (p=0.008) and raised ALT (p=0.003), but not with diabetes, hypertriglyceridemia, HBV infection or alcohol intake. On multiple logistic regression HCV and BMI >25 were independent risk factors for steatosis. There was a linear ascending association of hepatic steatosis with grade and stage of liver disease (p ≤ 0.001). Among 369 HCV patients, 280 (76%) had steatosis. It was mild in 159/369 (43%), moderate in 82/369 (22.2%) and severe in 39/369 (10.6%) cases. There were only 32 non-alcoholic, non-viral hepatitis patients and 8/32 (25%) had moderate or severe steatosis. Conclusions: Significant hepatic steatosis is present in 30.5% of our patients with chronic hepatitis. HCV genotype 3 infection is the predominant factor for hepatic steatosis in Pakistan. Steatosis has a linear ascending correlation with hepatic inflammation and fibrosis.

Impact of a bleeding care pathway in the management of acute upper gastrointestinal bleeding.

Objectives Upper gastrointestinal (UGI) bleeding carries high morbidity and mortality. The use of a bleeding care pathway (BCP) may improve outcomes, but the results are inconsistent in various studies. Methods A BCP for patients with UGI bleed with admission in a bleeding care unit (BCU) has been in use at our hospital since 2005. Prior to this, a high dependency unit was used for management of all emergencies including UGI bleeding. We compared the length of stay in the bleeding care/high dependency unit, total hospital stay, time to UGI endoscopy after admission, and survival between pre-2005 and post-2005 patients. Results Five hundred and fifty-one patients were admitted with acute UGI bleed in the last 5 years; 121 belonged to pre- BCP (2004) period and 430 after implementation of the pathway (2005–2008). The mean (SD) time to UGI endoscopy improved from 21.3 (7.4) hours in the pre-BCU era to 9.4 (9.9) hours in BCU, p<0.001. BCU stay was shorter from 2.41 (1.4) days pre-BCP to 1.93 (1.32) days post-BCP, (p<0.001). The total hospital stay in pre-BCU (4.0 [2.08] days) as compared to BCU (4.13 [2.62] days; p=0.58) was similar; there was no impact of BCU on survival. Conclusion A BCU implementation showed improvement in time to UGI endoscopy, and did not reduce BCU stay or impact survival.

Factors determining the clinical outcome of acute variceal bleed in cirrhotic patients.

Variceal bleed is a severe complication of portal hypertension. We studied the predictors of failure to control variceal bleed and re-bleed in patients with cirrhosis. We reviewed the case records of 382 consecutive patients admitted with variceal bleed from January 2001 to December 2005. Diagnosis of cirrhosis was made on clinical, laboratory, and radiological parameters. Acute variceal bleeding, failure to control bleed, and re-bleeding were defined according to Baveno III consensus report. Failure to control bleed was observed in 39 (10.2%) patients while in hospital re-bleed occurred in 49 (12.8%) patients. Thirty-four patients died. Diabetes was present in 148 (39%) patients. On multivariate logistic regression analysis, predictors of failure to control bleed were presence of diabetes mellitus and active bleeding at the time of endoscopy; predictors of in-hospital re-bleed were diabetes mellitus and serum bilirubin >3 mg/dL. Diabetes mellitus, active bleeding at endoscopy and bilirubin >3 mg/dL are bad prognostic factors for initial control of variceal bleed, and recurrent bleed in patients with cirrhosis.

Factors predicting in-hospital mortality in patients with cirrhosis hospitalized with gastro-esophageal variceal hemorrhage.

AIM : To identify factors at the time of admission that predict in-hospital mortality in patients with gastro-esophageal variceal hemorrhage. METHODS : Case records of patients admitted with gastro-esophageal variceal hemorrhage between January 1998 and October 2003 were retrospectively analyzed. Relevant clinical and laboratory parameters and their relationship to mortality, were studied. Clinical parameters assessed included Child-Pugh class, ascites, portosystemic encephalopathy (PSE) and occurrence of rebleed within 24 hours of esophago-gastroduodenoscopy. The laboratory parameters assessed were: hemoglobin, prothrombin time, serum bilirubin, creatinine and albumin. RESULTS : Of the 343 patients admitted during the study period, 30 (8.7%) died in hospital. Serum bilirubin (2.4 versus 1.6 mg/dL) and serum creatinine (2.1 vs 1.1 mg/dL) levels were higher among non-survivors than among survivors. Non-survivors were also more likely to suffer from PSE (53%) than survivors (17%), while re-bleeding within 24 hours of endoscopy occurred in 40% and 5% of these groups, respectively. On multivariate analysis, serum creatinine > 1.5 mg/dL at the time of admission (p < 0.001), serum bilirubin > 3 mg/dL (p < 0.001), presence of PSE (p = 0.003) and rebleed within 24 hours of endoscopy (p < 0.001) were significant predictors of mortality. CONCLUSION : Serum creatinine and bilirubin levels, presence of PSE and re-bleeding within 24 hours of initial endoscopy are independent predictors of mortality in patients with gastro-esophageal variceal bleeding.