Comparison of 12-hour with 72-hour terlipressin therapy for bleeding esophageal varices

Objective: To determine the efficacy of 12-hour of Terlipressin therapy as compared to 72-hour therapy in preventing rebleeding after endoscopic therapy

Study Design: Interventional study

Place and Duration of Study: Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from January to March 2016

Methodology: Cirrhotic patients presenting to our hospital with Gl [gastrointestinal] bleeding received Terlipressin 2 mg intravenous bolus, followed by 1mg 6-hourly until undergoing endoscopy.;Those with esophageal varices as the source of bleeding underwent band ligation and were recruited. Of the 93 enrolled patients, 90 remained and were randomized into 25 [27.8%] in control Group-A and 65 [72.2%] in test Group-B. Group-A received 72-hour of Terlipressin while Group-B received it for 12-hour. Both groups were monitored for rebleeding for 5 days

Results: Rebleeding occurred in 1 [4%] patient in Group-A and 3 [4.6%] in Group-B during the 5-day period. All 4 [4.4%] underwent repeat endoscopy. The Group-A patient and 2 [3%] of 3 Group-B patients showed ulcers over band ligation sites as source of bleed. The third Group-B patient showed varices requiring repeat banding. One [4%] patient [Group-A]

died due to persistent encephalopathy. No drug related adverse effects were seen

Conclusion: A 12-hour duration of Terlipressin as an adjunct to endoscopic band ligation shows similar results to 72-hour therapy

Changes in doppler ultrasound indices of hepatic circulation after treatment with beta blockers: a pilot study

Background: Portal hypertension is a serious complication of liver cirrhosis. Doppler ultrasound assessment may be a non-invasive and cost-effective means of evaluating portal hemodynamics in patients with portal hypertension

Aims and objectives: To assess efficacy of Doppler ultrasound in detecting changes in hemodynamics of hepatic circulation after beta-blocker administration

Methodology: 11 patients with liver cirrhosis and portal hypertension were included. All underwent Doppler assessment of portal vein velocity [PVV], spleno-portal index [SPI], congestive index [CI], liver vascular index [LVI], dampening index [DI], hepatic artery velocity [HAV], splenic artery velocity [SAV], hepatic artery resistive index [HARI] and splenic artery resistive index [SARI]. They were started on beta-blocker carvedilol 6.25 mg once daily and recalled after two weeks for repeat assessment

Results: Out of 13 enrolled, 4 were lost to follow up and one stopped carvedilol. 8 remained. The changes in parameters were: PVV: reduction in 3 [37.5%], no change in 1 and increase in 4[50%] patients; SPI: reduction in 3 [37.5%] and increase in 5 [62.5%]; CI: reduction in 3 [37.5%], no change in 1 and increase in 4 [50%]; LVI: decrease in 3 [50%], no change in 1 and increase in 2; DI: decrease in 5 [62.5%] and increase in 3 [37.5%]; HAV: increase in 4 [50%], no change in 1 [12.5%] and decrease in 3 [37.5%]; SAV: decrease in 4 [50%] and increase in 4 [50%]; HARI: increase in 7 [87.5%] and decrease in 1 [12.5%]; SARI: reduction in 3 [37.5%] and increase in 3 [37.5%]. 3 patients achieved reduction in 5 [PVV, LVI, DI, SARI and SAV] parameters. DI had the largest number of patients with observable reduction and HARI with the largest number showing observable increase in measured parameters

Conclusion: Doppler ultrasound represents a cost effective means of assessing the hemodynamics of hepatic circulation and any associated changes due to diseases and drugs

Pegylated interferon and ribavirin for post liver transplant HCV recurrence

Pakistan has a very high HCV prevalence[1] with majority being genotype 3. A high number of patients with cirrhosis undergo liver transplantation. HCV recurrence following transplant is universal[2]. Interferon free therapy has recently become available and preliminary studies show 70% SVR in post transplant patients[3]. Since genotype 3 has a high response to pegylated Interferon 3, it remains a competitive agent

Aims and Methods: The aim of this study was to determine the efficacy of pegylated interferon plus ribavirin in the treatment of recurrent hepatitis C following liver transplantation. 15 patients with recurrent hepatitis C following liver transplantation were included in the study, 13 males and 2 females. Mean age was 52 years. 13 had genotype 3 disease, one genotype 2 and one genotype 1.11 were living donor and 4 were cadaveric grafts. 13 were on tacrolimus and MMF, one on tacrolimus alone and one on cyclosporine and MMF. 6 patients were treated within 2 years of transplant and remaining 9 were treated 3-5 years after transplant. Liver biopsy was done prior to therapy in 6 patients. All patients received pegylated interferon a2a 180 g weekly plus ribavirin 15mg/kg daily for 48 weeks

Results: 14 out of 15 patients [93.3%] achieved SVR. This included all 13 Genotype 3 patients [100%] and the single genotype 2 patient. One patient, genotype 1, was nonresponder to treatment. Treatment was stopped at 22 and 36 weeks in 2 patients due to anaemia. Both achieved SVR. 11 patients were administered erythropoietin for anemia. 7 patients required ribavirin dose reduction for anemia, and achieved SVR despite dose reduction

Conclusion: Pegylated interferon and ribavirin is an extremely effective combination for treatment of patients with recurrent genotype 3 hepatitis C after liver transplantation. The main side effect is anaemia, which can be managed with erythropoietin supplementation and ribavirin dose reduction without any reduction in response rate

High meld score and spontaneous bacterial peritonitis; a proven relationship

Almost a 3[rd] of patients with liver cirrhosis and ascites may develop spontaneous bacterial peritonitis [SBP]. SBP carries a high morbidity and mortality. Hence identifying predisposing factors that may cause a patient with ascites to develop SBP are of great interest. The Model for End-Stage Liver Disease [MELD] score is a measure of mortality risk in patients with end-stage liver disease7. Development of ascites and encephalopathy, two complications of end-stage liver disease that are not used in the MELD score calculation, have generally correlated with higher MELD scores

Aims and methods: The aim of this study was to determine the frequency of higher MELD score in patients of SBP with liver cirrhosis. Eighty-five patients fulfilling the inclusion criteria were selected. An informed consent was taken from all patients. Demographic data including age, sex etc. was obtained. All patients had MELD scoring on the basis of serum creatinine, serum bilirubin and INR. MELD scores were calculated according to the method used by the United Network of Organ Sharing [UNOS]

Results: A total of 85 patients were included in the study. It included 52 [61%] male patients and 33 [39%] female patients. Mean age was 48.88 years [SD +/-8.82], Serology for viral markers showed that 68[80 %] patients were positive for hepatitis C antibodies and 8[9.4%] patients were positive for hepatitis B while 3 [3.5%] patients were positive for both hepatitis B and C. In the remaining 6 patients, 2 [2.35%] patients had alcoholic cirrhosis and in 4 [4.7%] patients, etiology of liver disease could not be ascertained. MELD scores in these patients ranged from 9 to 36. Eight patients [9.41%] with SBP had a MELD score of below 15 while 15 [17.64%] patients had scores between 16 and 20. 32 [37.64%] patients had MELD scores between 21 and 25. 20 [23.52%] patients had scores between 26 and 30 while 10 [11.76%] patients had a MELD score higher than 30. Conclusion: A high MELD score [>16] is noted in a significant number of patients with spontaneous bacterial peritonitis [over 90%]

Comparison of rifaximin and lactulose with lactulose alone in the treatment of acute hepatic encephalopathy in patients with liver cirrhosis

Hepatic encephalopathy [HE] is one of the common complications of liver cirrhosis. Lactulose is conventionally used for the treatment of hepatic encephalopathy

Aims and methods: The aim of this study was to evaluate the combined efficacy of lactulose plus rifaximin versus lactulose alone in the management of hepatic encephalopathy. 80 patients with HE were given lactulose alone and another 80 were given a combination of lactulose and rifaximin. They were monitored for 7 days for response i.e., reversal of HE

Results: Initially 160 patients with HE, who met inclusion and exclusion criteria, were enrolled in this study [out of 183 screened]. 80 patients were randomized in lactulose plus rifaximin group [group A] while the other 80 were placed in lactulose alone group [group B]

Patients were given respective treatment and were monitored for improvement of HE by using West Haven [WH] criteria. Patients were assessed daily. Patients were monitored till recovery or death for 7 days, whichever occurred first. 62 [77.5%] patients in the rifaximin plus lactulose group showed reversal while 43[53.75%] patients in lactulose only group showed reversal of HE. Mortality was also less in the rifaximin plus lactulose group compared to lactulose alone group 17[21.25%] vs. 33 [41.25%] respectively [P<0.05]

Conclusion: Rifaximin and lactulose have different mechanisms of action and act synergistically in combination and show better response in treating HE. This can result in significant decrease in morbidity and mortality