Assessment of malnutrition in alcoholic and non alcoholic cirrhotics.

OBJECTIVE: To study the nutritional status in patients with chronic liver disease using anthropometric techniques. METHODS: A total of 60 cirrhotic patients (30 Alcoholic (AC), 30 Non-alcoholic (NAC) and 30 control (CO) subjects were studied. Nutritional status was assessed using anthropometric measurements such as stature, body weight, body mass index, (BMI), skinfold thickness measurements and mid upper arm muscle circumference. Serum protein, serum albumin and globulin were measured. RESULTS: The skinfold thicknesses were significantly lower in NAC group of patients. In contrast the AC group of patients showed significantly lower mid upper arm muscle circumference values. Both groups of cirrhotic patients showed significantly lower total serum protein and serum albumin levels. CONCLUSION: Body fat is relatively more affected in NAC group of patients and muscle mass is more affected in AC group of patients.

Choledochal cysts in infants and children.

OBJECTIVE: To study the clinical spectrum and management of choledochal cyst in children below 12 years of age. DESIGN: Descriptive study. SETTING: Tertiary care hospital. METHODS: Twenty three children with choledochal cysts were managed between January 1991 to September 1997 and their clinical details, investigations and management were recorded. Choledochal cyst was diagnosed by ultrasonography and confirmed by ERCP or peroperative cholangioram (POC) Children were treated with antibiotics and/or percutaneous transhepatic biliary drainage if there was cholangitis and subsequently subjected to surgery (excision of the cyst and jejunal loop interposition hepaticoduodenostomy). RESULTS: The median age of these children was 3 years with an almost equal sex ratio. Predominant presentation was jaundice in 18, pain abdomen in 15, fever in 12, and lump abdomen in 9 cases. The classical triad of jaundice, pain and lump was present in only 4 cases. ERCP conducted in 7 and POC in 14 cases yielded positive findings in all. Clinically there were two distinct forms of presentation: (i) infantile form (< or = 1 year) comprised 9 infants which presented with jaundice in all, acholic stool in 6, lump abdomen in 4 but only one had classical triad; and (ii) childhood form (> 1 year) presented with pain abdomen in 12 and jaundice and cholangitis in 9 subjects each. Type I cyst was seen in 20 and type IVa in 3. Two children refused surgery, and the rest underwent surgery. Three infants died after surgery, the remaining 18 were alive and well on follow-up (median 25 months). Secondary biliary cirrhosis was seen in 6, extra hepatic biliary artresia in 2 and congenital hepatic fibrosis in 1 on histology. CONCLUSIONS: Choledochal cysts present in two clinically distinct forms. Infantile form is an important cause of cholestasis of infancy. Early diagnosis and referral is essential to prevent complications and death, and prognosis after surgery is good.

Assessment of effects of propranolol on portal hemodynamics in cirrhosis by duplex ultrasonography.

OBJECTIVE: To study the effect of propranolol on portal hemodynamics in cirrhotics using duplex ultrasonography. METHODS: Portal venous flow was measured by duplex ultrasonography in 12 healthy volunteers and ten men with cirrhosis. The cirrhotics were evaluated prior to and after ingestion of propranolol (60 mg twice daily for seven days) or placebo in a randomized cross-over fashion. Variations in heart rate, blood pressure, portal vein diameter, and portal venous flow and velocity were evaluated. RESULTS: The mean (SD) portal venous flow in the volunteers was 746 (280) mL/min, portal flow velocity was 18.5 (3.6) cm/s and portal vein diameter was 9.2 (1.4) mm. In cirrhotics, propranolol decreased portal blood flow from 586 (220) to 413 (120) mL/min (p < 0.03), the overall reduction being 29.5%. This effect was due to decrease in portal flow velocity, from 12.5 (3.3) to 9.7 (2.3) cm/s (p < 0.03) without significant change in portal vein diameter. No changes were observed with placebo. CONCLUSIONS: Propranolol decreases portal flow velocity and thus portal venous flow in cirrhotics.

Pulmonary function abnormality in patients with portal hypertension with or without chronic liver disease.

Pulmonary function (FVC, FEV1, PEFR, MMEF) and arterial blood gases (ABG) were analysed in 30 patients of portal hypertension. The aetiology of portal hypertension included cirrhosis of liver (n = 10), non cirrhotic portal fibrosis (NCPF, n = 10) and extrahepatic portal vein obstruction (EHPVO). Ten patients with chronic active hepatitis (CAH) without portal hypertension were also studied. Most pulmonary functions were abnormal (low) in portal hypertension and the most affected parameters, were FEV1, PEFR and MMEF (p < 0.05). The same was also observed in CAH, although in less number of patients. Hypoaxemia (26.7%) and wide alveolar--arterial oxygen gradient were observed most frequently in patients of portal hypertension. These patients also had a more alkaline blood pH. EHPVO patients had better lung function and arterial blood gas values. Patients with NCPF had greater impairment in pulmonary function.

Caroli's disease: a central dot means a lot.

We present here a patient of congenital non-obstructive focal dilatation of intrahepatic biliary radicles (Caroli's disease). The peculiar configuration of dilated intrahepatic biliary channels with central portal vein radicles was picked up sonologically as the 'central dot' sign. Awareness of this sign allows an accurate diagnosis without resorting to more invasive and expensive investigations.

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.

Multitransfused children with thalassemia major do not have gallstones.

Gall stones in children have been commonly described in hereditary spherocytosis and sickle cell anaemia. In North India thalassemia is the commonest haemolytic anaemia. We studied the incidence of gall stones sonographically in children with thalassemia major. Of the 64 multitransfused children with thalassemia major studied (age range 5-20 years) none had symptoms of biliary colic or evidence of gall stones on sonography. The study has demonstrated that patients with thalassemia major are not prone to develop gall stones.

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.

Preoperative bile salt administration versus bile refeeding in obstructive jaundice.

BACKGROUND: Endotoxaemia due to intraluminal bile salt depletion may be a cause of renal failure in patients with obstructive jaundice. Administration of bile salts to these patients has been reported to decrease portal and systemic endotoxaemia during surgery and improve renal function. However, such changes have not been shown with bile refeeding. We compared the effect of preoperative bile salt administration with preoperative bile refeeding on renal function in patients with obstructive jaundice. METHODS: Sixteen patients with obstructive jaundice underwent percutaneous transhepatic biliary drainage--eight received oral bile salts (500 mg of sodium deoxycholate 8-hourly for 48 hours preoperatively) and the other 8 were refed the total bile output for the entire period of biliary drainage (median 13 days). Blood endotoxin levels and renal function were assessed before, during and after the operation. RESULTS: The number of patients with intraoperative portal and postoperative systemic endotoxaemia decreased after both forms of therapy. Renal function also improved in both the groups--all 4 patients with renal failure recovered. There was a significant increase in creatinine clearance postoperatively after bile salt therapy (from 65 ml/minute preoperatively to 87 ml/minute postoperatively). CONCLUSION: Refeeding of bile obtained by percutaneous catheter drainage is an effective, cost-free substitute for oral bile salts in patients with obstructive jaundice.

Endoscopic nasobiliary drainage in acute suppurative cholangitis.

BACKGROUND: Acute suppurative cholangitis is associated with significant mortality. It is best managed by drainage of the biliary tree, endoscopic, percutaneous or surgical. AIMS: To study the effect of emergency endoscopic nasobiliary drainage (ENBD) in acute suppurative calculous cholangitis. METHODS: In 37 patients with calculous cholangitis, an endoscopic nasobiliary drain (7 F) was placed in the biliary tree above the site of obstruction to ensure continuous biliary drainage. RESULTS: Success rate was 100% and there was no mortality. ENBD was performed in 4 very sick patients without the aid of fluoroscopy. Cholangitis improved in 36 of 37 patients within 12-24 hours. When the clinical condition improved, all the 36 patients were taken up for elective biliary surgery or endoscopic sphincterotomy and stone extraction. CONCLUSIONS: Emergency endoscopic nasobiliary drainage is an effective method in managing patients with acute suppurative calculous cholangitis.

Hepatitis E virus: epidemiological, clinical and serological studies of north Indian epidemic.

BACKGROUND: A large waterborne epidemic of viral hepatitis occurred in the city of Karnal (Haryana) from February to April 1987. An attempt was made to study the epidemic clinically, serologically and etiologically. METHODS: A house-to-house search of the city was conducted for the detection of acute hepatitis cases. Patients willing to give blood samples for liver function tests were studied. RESULTS: A total of 1273 persons (0.79% of persons surveyed) were affected by viral hepatitis. Of the 477 clinically and biochemically documented cases, more than 75% were adults, while only 11% were less than 10 years old. Children below 15 years of age and females had a significantly higher incidence of anicteric hepatitis. Serological markers for acute hepatitis A and B viruses were absent in 85% of patients. Antibodies to hepatitis E virus (HEV) were detected in 84% of acute phase sera studied by indirect immunofluorescence assay. Liver biopsy showed characteristic features of cholangitic hepatitis. Three of 19 pregnant females who developed hepatitis died. No residual clinical or biochemical abnormality was detected in any of the patients followed up for 8 months. This epidemic correlated with the timing of unsupervised digging of lanes to provide new tap water connections to houses in the congested area of the city. This resulted in damage to the sewerage system and leakages which contaminated drinking water supply. CONCLUSION: HEV was transmitted by contaminated drinking water in this epidemic. Most affected individuals were adults, and recovered without sequelae. Affected pregnant women had a worse outcome.

Endoscopic removal of foreign bodies from gastrointestinal tract.

Forty-two children with ingestion of foreign bodies (FB) were managed conservatively. Thirty one (74%) of them were under 5 years of age. At presentation history revealed accidental ingestion in 95% and of being put in the oral cavity by elder sibs in 5% patients. Fifty seven per cent had respiratory distress, 38% had dysphagia and 12% had hematemesis. Foreign bodies were located in the gastrointestinal tract in the stomach (40%), esophagus (26%), small intestine (19%), duodenum (12%) and rectum (2%). A large majority of the FB were constituted by household objects. All the FB above the duodenojejunal junction and one in the rectum were retrieved successfully with fiberoptic endoscopes. In 19% patients, the FB had crossed duodenojejunal junction, and had come out in the stools during 4-5 days observation and these were mostly round in shape. Endoscopic procedures were carried out under intravenous diazepam or ketamine sedation. On endoscopic examination, 21% of them showed erosions in stomach and/or esophagus. No complications of endoscopic procedure or sedation were observed and none of the patients required surgical removal. Removal of FB with flexible fiberoptic endoscopes is less invasive and the best therapeutic option to avoid preventable complications of FB ingestion. In this procedure there is need of a trained and skilled Pediatric endoscopist with lot of patience and a good team work.

Emergency endoscopic nasobiliary drainage without the aid of fluoroscopy.

Endoscopic nasobiliary drainage without the aid of fluoroscopy, as an emergency procedure, was performed successfully in four patients with severe calculous cholangitis. There were no complications. All the patients improved and three were taken for definitive surgery later.