Interrelation of the Risk Factors of NAFLD at various Stages of Progression of the glycemic Status on long-term Follow-up

Background: Though the risk factors for nonalcoholic fatty liver disease (NAFLD) are the same in diabetic and nondiabetic patients, their exact interrelation and weightage in the pathogenesis are unclear. Methods: A total of 130 nondiabetic and 170 diabetic patients with NAFLD [diagnosed on abdominal ultrasound and severity assessed by NAFLD fibrosis score (NFS)] were recruited from 2009 to 2018 and their baseline risk factors [body mass index (BMI), waist circumference (WC), blood pressure, presence of the metabolic syndrome (MS) and insulin resistance (IR) by Homeostasis Model of Assessment for Insulin Resistance (HOMA-IR), fasting blood glucose (FBG) and lipid levels, and hemoglobin A1c (HbA1c) levels] were noted and their interrelationship studied. The nondiabetic patients were prospectively followed up for alteration of glycemic status. Results: There was presence of high BMI (>23) in 66%, central obesity in 86% (of whom 59% had normal body weight), low high-density lipoprotein cholesterol (HDL) in 51%, high triglyceride (TG) in 68%, high low-density lipoprotein cholesterol (LDL) in 46.7%, IR in 86%, hypertension in 54%, and the MS in 57%. Hemoglobin A1c was high in 42.3% of nondiabetics. The prevalence of the MS was significantly higher in patients having IR and vice versa but only the MS and its components as also increasing age determined advanced fibrosis. After mean follow-up 7.3 years, progression from prediabetes (PD) to diabetes mellitus (DM) occurred in 10%, from normal glucose tolerance (NGT) to PD in 6.25%, and progression of NFS occurred in 16.9%. Advanced age, low HDL and high TG were associated with IR and were involved in glycemic progression as also obesity in progression from NGT to PD and central obesity from PD to DM. Conclusion: Though IR and MS go hand in hand in the pathogenesis of NAFLD in both diabetic and nondiabetic patients as well as in the glycemic progression of nondiabetic patients with NAFLD, the MS or its components have more weightage in determining the severity

Sociodemographic and Clinical Profile of Amoebic Liver Abscess observed at a Tertiary Referral Hospital over 10 Years

Aim: To study the sociodemographic factors, clinical features and treatment outcome of patients with amebic liver abscess. Methods: Prospective analysis of 163 consecutive patients with liver abscesses (mean age 39.5 years, 140 males). Amoebic aetiology was determined by various combinations of history of dysentery, radiological appearance, aspirated pus study, amebic serology, colonoscopy findingsand response to treatment. Sociodemographic factors associated with amoebic liver abscess included education, income, eating hygiene and alcohol consumption. All patients were treated with fine needle pus aspiration and intravenous metronidazole for at least 7 days. Results: 109(63.9%) abscesses were treated in the first 5 years. Antecedent diarrhoea was present in 27 (16.6%). 146 patients (89.6%) took nitroimidazoles frequently. Jaundice, mostly mild, occurred in 35%.E. histolytica was demonstrated in stool in 11 patients (6.7%) and in aspirated pus in 35 patients (21.5%). Serology was positive (>1:160) in 53(32.5%) patients and was related to abscess size > 10 cm, presence of amoeba in pus and stool and positive colonoscopy findingsbut not to the number of abscesses. Colonoscopy revealed colitis in 21(12.9%) and caecal mass in 7(4.3%). All patients had prompt symptom relief with treatment without recurrence. 80% belonged to the lower middle class hailing from rural areas. 128(78.5%), all males, consumed 60 – 80 ml indigenously brewed liquor daily and they had poor personal and eating hygiene with higher antibody levels. 32 patients (19.6%) drank potable water. Conclusion: Though decreasing, amebic liver abscess continues to afflict heavy alcohol drinkers of lower socioeconomic strata, living in unhygienic conditions. Alcohol might influence seropositivity. Aspiration irrespective of size gives a lasting cure.

Estudo de parâmetros metabólicos em pacientes não diabéticos com doença hepática gordurosa não alcoólica - importância da dislipidemia / A study of metabolic parameters in non diabetic patients with non alcoholic fatty liver disease - importance of dyslipidemia

ABSTRACT BACKGROUND: Metabolic risk factors of non alcoholic fatty liver disease (NAFLD) in non diabetic teetotallers who constitute a definite group are not well defined. OBJECTIVE: To identify the metabolic risk factors of NAFLD if any in non diabetic subjects who do not consume alcohol. METHODS: In a cross sectional study the effect of metabolic parameters (BMI, individual lipid levels, hemoglobinA1c (HbA1c), HOMA IR and the metabolic syndrome components) of 150 consecutive non diabetic teetotallers (90 with normal glucose tolerance and 60 prediabetics) on their NFS (quantifiable severity parameter of NAFLD) was studied by linear regression analysis. Similar study was done in the normal glucose tolerance and prediabetes groups separately. These parameters were then compared with those of 75 matched diabetic teetotallers with NAFLD. To analyse further the difference between normal glucose tolerance, prediabetic and overt diabetic groups, binary logistic regression of the factors was carried out taking prediabetes and diabetes as outcome variable. RESULTS: All the metabolic parameters were significantly higher in diabetics compared to non diabetics and in prediabetics compared to those with normal glucose tolerance except high-density lipoprotein cholesterol. Triglyceride, high-density lipoprotein cholesterol and BMI significantly predicted NFS in the overall (adjusted R2 68.7%, P=0.000) and normal glucose tolerance groups (adjusted R2 73.2%, P=0.000) whereas BMI, triglyceride, low-density lipoprotein cholesterol and HbA1c did in prediabetics (adjusted R2 89%, P=0.000). The metabolic syndrome was significantly associated with NFS in the overall and prediabetic groups. High triglyceride (odds ratio1.08), low-density lipoprotein cholesterol (odds ratio1.03) and HbA1c (odds ratio 11.54) were positively associated with prediabetes compared to normal glucose tolerance group. CONCLUSION: In nondiabetic teetotallers dyslipidemias are the prime contributors to the development of NAFLD.

RESUMO CONTEXTO: Os fatores de risco metabólicos da doença hepática gordurosa não alcoólica (DHGNA) em abstêmios não diabéticos, que constituem um grupo distinto, não são bem definidos. OBJETIVO: Identificar os fatores de risco metabólicos da DHGNA em indivíduos não diabéticos e que não consumam álcool. MÉTODOS: Em um estudo transversal, o efeito dos parâmetros metabólicos (IMC, níveis de lipídios individuais, HbA1c, Homa IR e os componentes da síndrome metabólica) de 150 abstêmios não diabéticos consecutivos (90 com tolerância à glicose normal e 60 pré-diabéticos) em sua NFS (parâmetro de gravidade quantificável da DHGNA) foram estudados por análise de regressão linear. Um estudo similar em separado foi feito nos grupos normais da tolerância da glicose e do pré-diabetes. Esses parâmetros foram comparados com os de 75 abstêmios diabéticos pareados com DHGNA. Para analisar ainda mais a diferença entre a tolerância à glicose normal foi realizada a regressão logística binária dos fatores tomando pré-diabetes e diabetes como variável de desfecho, nos grupos diabéticos e pré-diabéticos. RESULTADOS: Todos os parâmetros metabólicos foram significativamente maiores nos diabéticos comparados aos não diabéticos e em pré-diabéticos comparados àqueles com tolerância normal à glicose, exceto HDL. Os índices TG, HDL e IMC previram significativamente o NFS no geral nos grupos de tolerância normal (R2 ajustado 68,7%, P=0,000) e de glicose normal (R2 ajustado 73,2%, P=0,000), enquanto o IMC, TG, LDL e HbA1c predisseram em pré-diabéticos (R2 ajustado 89%, P=0,000). A síndrome metabólica foi associada significativamente com o NFS nos grupos totais e pré-diabéticos. O TG elevado (odds ratio 1,08), o LDL (odds ratio 1,03) e a HbA1c (odds ratio 11,54) foram positivamente associados ao pré-diabetes em comparação com o grupo normal de tolerância à glicose. CONCLUSÃO: Em abstêmios não diabéticos as dislipidemias são os principais contribuintes para o desenvolvimento da DHGNA.

Trends of Chronic Liver Disease in a Tertiary Care Referral Hospital in Eastern India.

Background: There is scarce Indian data on time trends of hepatitis, an impediment to formulate an effective public health policy on the matter. Objective: The aim was to study secular trends and burden of hepatitis in a railway population. Materials and Methods: Outdoor, indoor, endoscopy unit and mortality records of patients attending this hospital from January 2003 to December 2011 were searched manually and relevant parameters of hepatitis patients were noted, especially etiology, clinical features, treatment, and mortality. Cochran-Armitage trend test was used to test signifi cance of any trend in these parameters. Binary logistic regression analysis of various factors was carried out to study their effect on the liver related mortality of hepatitis B and C cases and Kaplan-Meyer survival curves were generated for signifi cant factors. Two-sided P < 0.05 was considered to be signifi cant. Result: Chronic liver disease (CLD) due to alcohol showed a signifi cant rising trend with early age (mean 48.4 years) and high percentage of decompensated disease (75%) at presentation and high early mortality (63%). No trend was observed for hepatitis B and C, but signifi cant reduction in mortality was observed when defi nitive therapy was given. Cryptogenic CLD showed a decreasing trend though overall it still remained the most important etiology and survival was better compared with alcohol even with conservative therapy. Only 4% patients had hepatocellular carcinoma. Conclusion: A menace of alcohol related liver disease affecting young productive work force in this part of India is foreseen, which might impact the country’s economy and mandates immediate containment policy.

Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force.

AIMS: To study the profile of irritable bowel syndrome (IBS), and the frequency of such symptoms among the general population, in India. METHODS: In this prospective, multi-center study, data were obtained from 2785 patients with chronic lower gastrointestinal symptoms (complainants) with no alarm feature and negative investigations for organic causes visiting physicians at 30 centers, and from 4500 community subjects (non-complainants), using separate questionnaires. RESULTS: Most complainants were middle-aged (mean age 39.4 years) and male (1891; 68%). The common symptoms were: abdominal pain or discomfort (1958; 70%), abdominal fullness (1951; 70%); subjective feeling of constipation (1404 of 2656; 53%), or diarrhea (1252 of 2656, 47%), incomplete evacuation (2134; 77%), mucus with stools (1506; 54%), straining at stools (1271; 46%), epigastric pain (1364; 49%) and milk intolerance (906; 32%). Median stool frequency was similar in patients who felt they had constipation or those who felt they had diarrhea. Information to subtype symptoms using standard criteria was available in 1301 patients; of these, 507 (39%) had constipation-predominant IBS ( 3 <or= stools/week), 50 (4%) had diarrhea-predominant IBS (>3 stools/day) and 744 (57%) had indeterminate symptoms. Among non-complainants, most subjects reported daily defecation frequency of one (2520 [56%]) or two (1535 [34%]). Among non-complainants, 567 (12.6%) reported abdominal pain, 503 (11%) irregular bowel, 1030 (23%) incomplete evacuation, 167 (4%) mucus and 846 (18%) straining at stools; a combination of abdominal pain or discomfort relieved by defecation, and incomplete evacuation was present in 189/4500 (4.2%) community subjects. CONCLUSIONS: Most patients with IBS in India are middle-aged men, and have a sense of incomplete evacuation and mucus with stools. Abdominal pain or discomfort is frequent but not universal. Importantly, stool frequency was similar irrespective of whether the patients felt having constipation or diarrhea. Most (90%) non-complainant subjects had 1 or 2 stools per day; symptoms complex suggestive of IBS was present in 4.2% of community subjects.

Efficacy and tolerability of pegylated interferon alpha 2b and ribavirin in chronic hepatitis C--a report from eastern India.

AIM: To study the efficacy and tolerability of pegylated interferon alpha 2b and ribavirin therapy in a cohort of chronic hepatitis C patients. METHODS: In a prospective, open label, uncontrolled trial pegylated interferon alpha 2b (Viraferon Peg) 1.5 microgram/ kg subcutaneously weekly plus daily ribavirin 800mg for 24 weeks in genotypes 2 & 3 and 1000mg for 48 weeks in genotypes 1 and 4 was administered to 16 patients of chronic hepatitis C. The primary end point was the sustained viral response. Therapy was prolonged by 3 months if the end of therapy response was not attained. Drug dosage was modified or temporarily discontinued if anaemia or bone marrow suppression developed. RESULTS: Both virological end of therapy response and sustained viral response were seen in 75% cases but not every patient who achieved end of therapy response had a sustained viral response. Relapse was seen in 31% cases and a pattern of delayed response was seen in 2 patients who later experienced a sustained viral response. Biochemical and virological responses were similar. A lower baseline viral load, genotype 3, a high ALT and the parenteral mode of viral acquisition were associated with higher sustained viral response rates. A good response was also seen in men, those over 50 years of age and those with normal baseline ALT. Most relapses occurred in genotype 3 patients whose age was less than 50 years; however the relapsing viral load was very low. 66% of previous interferon and ribavirin non-responders achieved sustained viral response. Treatment was well tolerated; temporary dose modification was required in 3 patients. CONCLUSION: In Indian patients, a combination of peginterferon alpha 2b and ribavirin is safe and effective both as initial treatment of chronic hepatitis C and for use in previous non-responders.

Acute hepatitis B presenting as Guillain-Barré syndrome.

Guillain-Barré syndrome associated with acute hepatitis B virus infection is rare. We report a 56-year-old man who presented as Guillain-Barré syndrome in the absence of icterus and was subsequently shown to have acute hepatitis B. He improved on conservative therapy.

Severe acute pancreatitis in acute hepatitis E.

We report an 18-year-old boy with severe acute pancreatitis developing during acute hepatitis E and complicated by sepsis and acute renal failure. The patient recovered on supportive management.