Clinical Profile and Outcome of Young Patients with Extrahepatic Biliary Obstruction at A High-Volume Tertiary Care Centre in Northern India

Background and Aim: The etiology of extrahepatic biliary obstruction (EHBO) ranges from benign disorders to pancreaticobiliary malignancy. We studied the demographic, clinical, laboratory, and endoscopic features of young patients with EHBO undergoing Endoscopic retrograde cholangiopancreatography (ERCP). Methods: We retrospectively analyzed one-year data of ERCP procedures performed on adult patients under 40 years of age. The diagnosis was based on a clinical and radiological basis with histopathological confirmation. Results: A total of 180 patients were included with a mean(±SD) age of 33.4(±5.8, range: 15-40) years, and 67.8% being female. Benign (67.2%) findings included choledocholithiasis (57.8%), benign biliary stricture (9.44%, post cholecystectomy stricture 82.3%), and malignant (32.8%) causes were gallbladder carcinoma (24.4%), cholangiocarcinoma (4.4%), periampullary carcinoma (2.8%), pancreatic head carcinoma (1.1%). Clinical presentation included jaundice (66.1%), pain abdomen (59.4%), pruritis (26.1%), weight loss (19.4%), anorexia, fever, and cholangitis (24.44%). Mean bilirubin levels (16.9 ±6.8 vs 4.6 ±4.1 mg/dl) and alkaline phosphatase (1170 ± 260.7 vs 439.3 ± 362.7 IU/mL) were higher in malignant causes, in comparison to benign. Stone retrieval using balloon during ERCP was successful in 79% of cases. Large (>15 mm) or impacted stones or those with biliary stricture failed stone extraction. In gallbladder carcinoma, adequate endoscopic biliary drainage was achieved in 68% of patients. Endoscopic biliary drainage was achieved in 75%, 80%, and 50% cases of cholangiocarcinoma, periampullary carcinoma, and pancreatic head carcinoma, respectively. Conclusion: Choledocholithiasis and gallbladder carcinoma are the most common benign and malignant causes of EHBO in young patients. The successful endoscopic therapeutic intervention could be achieved in most patients.

Relationship of serum vitamin D with hepatic fibrosis in patients with chronic hepatitis C

Background: Serum vitamin D concentration is proposed to have an important role on outcome in patients with chronic hepatitis C virus (HCV) infection. A few studies have shown an inverse association of vitamin D level with stage of fibrosis. The aim of the present study was to verify whether serum vitamin D level is an independent predictor of significant hepatic fibrosis.Methods: Seventy-two treatment naive chronic HCV subjects and 40 healthy age and sex matched controls were included in the study. A serum vitamin D level was assessed in both HCV subjects and controls, and liver biopsy was performed in all HCV subjects to assess for stage of fibrosis.Results: Serum vitamin D levels were significantly lower HCV patients in comparison to age and sex matched controls (18.04±6.92 versus 21.53±8.2, p<0.01). Most common genotype in HCV patients was genotype 3 (62.5%) and blood transfusion was the most common mode of transmission (28%) followed by intravenous drug user (IVDU) (17%). The HCV patients with vitamin D level <20 ng/ml had higher metavir score as compared to vitamin D≥20 ng/ml (1.67±0.66 versus 2.5±0.67, p<0.001). Both univariate and multivariate analysis performed using logistic regression revealed that vitamin D<20 ng/dl is a significant negative predictor of liver fibrosis (p<0.05).Conclusions: Chronic HCV patients had significantly lower vitamin D levels as compared to healthy controls. Serum vitamin D was a negative predictor of stage of fibrosis in patients with chronic hepatitis C.

A Study on the Role of Oxidative Stress and Prolidase Enzyme in the Clinical Evaluation of Irritable Bowel Syndrome (IBS)

Introduction: Irritable bowel syndrome (IBS), though abenign disorder is highly prevalent and imposes high costand substantial morbidity upon general population. Longconsidered as functional disorder, IBS pathogenesis carries anorganic basis at least in a subset of patients. Altered intestinalimmune response and low grade intestinal inflammation havebeen confirmed as pathophysiology of IBS in few studies.Oxidative stress indicates that there is inflammation and,markers of oxidative stress may be developed as diagnostictool for IBS in future. Study aimed to evaluate oxidativestress in form of total oxidant status (TOS), total anti-oxidantstatus (TAS), oxidative stress index (OSI) and serum prolidaseactivity (SPA) as a marker of intestinal inflammation in IBSpatients and healthy controls.Material and methods: In this case –control study done ata teaching medical institute in north India over a period ofone year, 120 IBS patients (cases) and 40 healthy volunteers(controls) were evaluated for TOS, TAS, OSI and SPA.Patients with IBS were sub-divided into 3 groups (40 each):diarrhea predominant, constipation predominant and mixedtype (IBS-D, C and M respectively). Student t-test, chi-squaretest and ANOVA tests were used for statistical analysis.Results: Mean TOS, TOS/TAS (OSI) and prolidase levelswere significantly higher in IBS group than control with pvalue of <0.001,< 0.001, and <0.01 respectively. Level ofTOS was highest in IBS-D subgroup followed by IBS-M andLowest in IBS-C subgroup showing a significant differencebetween IBS-D and IBS-C, IBS-D and IBS-M and IBS-Mand IBS-C with p values <0.001 for each comparison. OSIwas highest in IBS-D and lowest in IBS-C with significantdifferences between the subgroups (P<0.001). Only IBS-Msubgroup had significantly higher serum prolidase activitywhen compared to controls (p<0.001) IBS-D (P=0.013) andIBS-C (P=0.01). TAS level was significantly higher in controls(P<0.001) than cases. There were significant differencesbetween all four subgroups (p<0.001) except between IBS-Cand IBS-M subgroups (P=0.294).Conclusion: This study observed that there is increasedoxidative stress and decreased antioxidant capacity in patientwith IBS. To support our results further prospective andrandomized controlled trials are necessary.