Large Anorectal Venous Malformation Treated With Microfoam Therapy.

Deficiency of smooth muscle cells can lead to dysfunction and engorgement of blood vessels termed as hemangioma, arteriovenous malformations, and venous malformations (VMs). Anorectal VM is a rare disease. It can present with massive hematochezia. An optimal treatment of anorectal VMs has not been defined. Surgery is an option if the lesion can be resected completely. Endoscopic injection sclerotherapy has been reported to be effective in treating small colorectal VMs. However, it has rarely been described in the treatment of large VMs. In this study, we describe a rare case of large anorectal VMs treated with microfoam sclerotherapy.

Serum Gamma-Glutamyl Transpeptidase-to-Platelet Ratio as a Noninvasive Marker of Liver Fibrosis in Chronic Hepatitis B.

Background The gamma-glutamyl transpeptidase (GGT)-to-platelet ratio (GPR) is identified as a new model for the assessment of liver fibrosis in patients with chronic hepatitis B (CHB). We aimed to determine the diagnostic performance of GPR for the prediction of liver fibrosis in patients with CHB. Methods In an observational cohort study, patients with CHB were enrolled. The diagnostic performance of GPR was compared with transient elastography (TE), aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) scores for the prediction of liver fibrosis using liver histology as a gold standard. Results Forty-eight patients with CHB with a mean age of 33.42 ± 15.72 years were enrolled. Liver histology showed meta-analysis of histological data in viral hepatitis (METAVIR) stage F0, F1, F2, F3, and F4 fibrosis in 11, 12, 11, seven, and seven patients, respectively. The Spearman correlation of METAVIR fibrosis stage with APRI, FIB-4, GPR, and TE were 0.354, 0.402, 0.551, and 0.726, respectively (P value < 0.05). TE had the highest sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) (80%, 83%, 83%, and 79%, respectively), followed by GPR (76%, 65%, 70%, and 71%, respectively) for predicting significant fibrosis (≥F2). However, TE had comparable sensitivity, specificity, PPV, and NPV with GPR (86%, 82%, 42%, and 93%, and 86%, 71%, 42%, and 92%, respectively) for predicting extensive fibrosis (≥F3). Conclusion The performance of GPR is comparable to TE in predicting significant and extensive liver fibrosis. GPR may be an acceptable, low-cost alternative for predicting compensated advanced chronic liver disease (cACLD) (F3-F4) in CHB patients.

Torsion of spleen and portal hypertension: Pathophysiology and clinical implications.

The displacement of spleen from its normal location to other places is known as wandering spleen (WS) and is a rare disease. The repeated torsion of WS is due to the presence of long pedicle and absence/laxity of anchoring ligaments. A WS is an extremely rare cause of left-sided portal hypertension (PHT) and severe gastric variceal bleeding. Left-sided PHT usually occurs as a result of splenic vein occlusion caused by splenic torsion, extrinsic compression of the splenic pedicle by enlarged spleen, and splenic vein thrombosis. There is a paucity of data on WS-related PHT, and these data are mostly in the form of case reports. In this review, we have analyzed the data of 20 reported cases of WS-related PHT. The mechanisms of pathogenesis, clinico-demographic profile, and clinical implications are described in this article. The majority of patients were diagnosed in the second to third decade of life (mean age: 26 years), with a strong female preponderance (M:F = 1:9). Eleven of the 20 WS patients with left-sided PHT presented with abdominal pain and mass. In 6 of the 11 patients, varices were detected incidentally on preoperative imaging studies or discovered intraoperatively. Therefore, pre-operative search for varices is required in patients with splenic torsion.

Neurological manifestations of hepatitis E virus infection: An overview.

Hepatitis E virus (HEV) is an important cause of repeated waterborne outbreaks of acute hepatitis. Recently, several extrahepatic manifestations (EHMs) have been described in patients with HEV infection. Of these, neurological disorders are the most common EHM associated with HEV. The involvement of both the peripheral nervous system and central nervous system can occur together or in isolation. Patients can present with normal liver function tests, which can often be misleading for physicians. There is a paucity of data on HEV-related neurological manifestations; and these data are mostly described as case reports and case series. In this review, we analyzed data of 163 reported cases of HEV-related neurological disorders. The mechanisms of pathogenesis, clinico-demographic profile, and outcomes of the HEV-related neurological disorders are described in this article. Nerve root and plexus disorder were found to be the most commonly reported disease, followed by meningoencephalitis.

Endoscopic Mucosectomy: A Novel Technique for Management of Polypoidal Solitary Rectal Ulcer Syndrome.

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder often challenging to treat. Surgical treatment is associated with suboptimal outcomes and postoperative complications. Argon plasma coagulation helps control rectal bleeding and healing of ulcers, but more extended follow-up data are not available. The macroscopic appearance of SRUS can be polypoid in 17%-25% of cases. Here, we describe a novel endoscopic technique for treating symptomatic patients with polypoidal variant of SRUS after failed medical and endoscopic argon plasma coagulation treatments.

Baseline serum cystatin C as a marker of acute kidney injury in patients with acute-on-chronic liver failure.

BACKGROUND: A creatinine-based estimation of the renal function lags behind the onset of disease process. Cystatin C is a new marker for acute kidney injury (AKI). However, data are limited in patients with acute-on-chronic liver failure (ACLF). We evaluated serum cystatin C as an early predictor of AKI in patients with ACLF. METHODS: In a prospective observational study, patients with ACLF and normal serum creatinine level were included in the study. Serum cystatin C was analyzed with the development of AKI and the disease outcome. RESULT: Forty-seven patients (mean age: 43.26±16.34 years; male:female: 2.35:1) were included in the study. AKI developed in 34% of patients during the hospital stay. Receiver operating characteristic (ROC) curve analysis revealed that the best cutoff for baseline cystatin C was 1.47 mg/L with a sensitivity of 0.94 and specificity of 0.68. The cystatin C ((area under the curve [AUC]=0.853) performance was better than that of the creatinine (AUC=0.699), Child-Turcotte-Pugh (CTP) (AUC=0.661), and model for end-stage liver disease-sodium (MELD-Na) (AUC=0.641). In the univariate analysis, age, platelet count, creatinine, estimated glomerular filtration rate (eGFR)-modification of diet in renal disease (MDRD), cystatin C, and estimated glomerular filtration rate-serum cystatin C (eGFRcysC) were significantly associated with AKI in ACLF patients. Cystatin C was an independent positive predictor of AKI. Cystatin C was positively correlated with the MELD-Na scores (r=0.374 and p=0.009). CONCLUSION: Our study supports previous studies reporting that serum cystatin C is a better predictor for AKI development compared to serum creatinine. Cystatin C may be used as an early marker for new-onset AKI in hospitalized patients with ACLF.

Short-term mortality in patients with cirrhosis of the liver and acute kidney injury: A prospective observational study.

INTRODUCTION: Renal failure is a common and severe complication of cirrhosis and confers poor prognosis. Serum creatinine is the most practical biomarker of renal function. Serum creatinine estimation in cirrhosis of the liver is affected by decreased formation, increased tubular secretion, increased volume of distribution, and interference by elevated bilirubin. Studies on the prognosis of cirrhotic patients using creatinine kinetics as a definition of acute kidney injury (AKI) proposed by the International Ascites Club are limited. METHODS: In this single-center prospective observational study, decompensated cirrhotics with AKI defined by the International Ascites Club as the rise of serum creatinine ≥ 0.3 mg/dL within 48 h of admission or increase of serum creatinine ≥ 50% from stable baseline creatinine over the previous 3 months were followed and assessed for the development of complications during hospital course and in-hospital and 30-day mortality. RESULTS: AKI developed in 142 out of 499 (28.45%) patients with cirrhosis. Twenty patients were excluded. The most common etiology of cirrhosis was alcohol (n = 64, 52%), and ascites was present in 115 (94%) patients. Eighty-two (67.21%) patients presented with AKI at the time of admission. Thirty-day mortality was 46.72% (57/122 patients). Hepatorenal syndrome had the highest mortality followed by AKI related to infection. Presence of jaundice and hepatic encephalopathy (HE) was associated with poor survival with adjusted hazard ratio of 3.54 and 2.17, respectively. On bivariate logistic regression analysis, jaundice, HE, type of AKI, AKI stage at maximum creatinine, bilirubin, serum glutamic oxaloacetic transaminase (SGOT), international normalized ratio (INR), and Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were predictors of mortality (p < 0.05). Sensitivity, specificity, and accuracy of MELD > 29 and CTP score > 11 were 75.44%, 82%, and 78.70% and 66.67%, 81.54%, and 74.60%, respectively for predicting 30-day mortality. CONCLUSION: Development of AKI as defined by the International Ascites Club in cirrhosis confers high short-term mortality. Jaundice, HE, AKI stage, creatinine at enrollment, bilirubin, CTP, and MELD score were the predictors of mortality. Bullet points of the study highlights What is already known? • Renal failure is a common and severe complication of cirrhosis. • Serum creatinine is the most practical biomarker of renal function but it has many limitations in cirrhotic patients. • Creatinine kinetics-based definition of acute kidney injury (AKI) was proposed by the International Ascites Club. What is new in this study? • Short-term mortality (30 days) in decompensated cirrhotic patients with AKI as defined by the International Ascites Club using creatinine kinetics was high. • AKI due to hepatorenal syndrome (HRS) has the highest short-term (30 days) mortality followed by AKI due to infection in decompensated cirrhosis. • Detection of AKI using creatinine kinetics-based definition may prompt an early appropriate intervention. What are the future clinical and research implications of study findings? • Creatinine kinetics-based definition of AKI diagnose renal injury at an earlier stage; an appropriate intervention should be initiated at the earliest in these patients to improve patient survival.

Optimal cut-off value of fecal calprotectin for the evaluation of ulcerative colitis: An unsolved issue?

INTRODUCTION: There is variability in the fecal calprotectin (FCP) cut-off level for the prediction of ulcerative colitis (UC) disease activity and differentiation from irritable bowel disease (IBS-D). The FCP cut-off levels vary from country to country. AIMS: We aimed to assess FCP as a marker of disease activity in patients with UC. We determined the optimal FCP cut-off value for differentiating UC and IBS-D. METHODS: In a prospective study, we enrolled 76 UC and 30 IBS-D patients. We studied the correlation of FCP with disease activity/extent as well as its role in differentiating UC from IBS-D. We also reviewed literature regarding the optimal FCP cut-off level for the prediction of disease activity and differentiation from IBS-D patients. RESULTS: Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut-off level, 158 µg/g) for the prediction of complete mucosal healing (using Mayo endoscopic subscore) were 90, 85, 94.7, and 73.3%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut-off level, 425 µg/g) for the prediction of inactive disease (Mayo Score ≤ 2) were 94.3, 88.7, 86.2, and 95.4%, respectively. We also found a FCP cut-off value of 188 µg/g for the differentiation of UC from IBS-D. CONCLUSIONS: The study reveals the large quantitative differences in FCP cut-off levels in different study populations. This study demonstrates a wide variation in FCP cut-off levels in the initial diagnosis of UC as well as in follow-up post-treatment. Therefore, this test requires validation of the available test kits and finding of appropriate cut-off levels for different study populations.

Comparison of continuous versus intermittent infusions of terlipressin for the control of acute variceal bleeding in patients with portal hypertension: An open-label randomized controlled trial.

BACKGROUND: Continuous infusion of terlipressin causes more stable reduction in portal venous pressure than intermittent infusion. The aim of the study was to compare the efficacy of continuous infusion vs. intermittent boluses of terlipressin to control acute variceal bleeding (AVB) in patients with portal hypertension. METHODS: Eighty-six consecutive patients with portal hypertension and AVB were randomized to receive either continuous intravenous infusion (Group A, n = 43) or intravenous boluses of terlipressin (Group B, n = 43). Group A received 1 mg intravenous bolus of terlipressin followed by a continuous infusion of 4 mg in 24 h. Group B received 2 mg intravenous bolus of terlipressin followed by 1 mg intravenous injection every 6 h. Upper gastrointestinal (UGI) endoscopy was done within 12 h of admission. Endoscopic variceal ligation (EVL) was done using a multi-band ligator. In both groups, treatment was continued up to 5 days. The primary endpoint was rebleeding or death within 5 days of admission. RESULTS: Patients in group A had lower rate of treatment failure (4.7%) as compared to patients in group B (20.7%) (p = 0.02). Within 6 weeks, four and eight patients died in group A and B, respectively (p = 0.21). Model for end-stage liver disease sodium (MELD-Na) score and continuous infusion of terlipressin showed significant relationship with treatment failure on multivariate analysis. CONCLUSIONS: Continuous infusion of terlipressin may be more effective than intermittent infusion to prevent treatment failure in patients with variceal bleeding. There is significant relationship between MELD-Na score [Odd ratio = 1.37 (95% CI-1.16 - 1.62), p-value < 0.001] and continuous infusion of terlipressin [Odd ratio = 0.18 (95% CI-0.037 - 0.91), p-value - 0.04] with treatment failure.

Polyethylene glycol plus bisacodyl: A safe, cheap, and effective regimen for colonoscopy in the South Asian patients.

BACKGROUND AND AIM: Data regarding the comparison of colonoscopic preparation regimens are still variable. We aimed to assess the adequacy and tolerability of two bowel preparation regimens for afternoon colonoscopy. METHODS: In a randomized, investigator-blinded trial, two preparation regimens [4-L split-dose polyethylene glycol-electrolytes (PEG-ELS) and 2-L PEG-ELS plus bisacodyl) were compared in terms of bowel cleansing efficacy and adverse effects. RESULTS: The mean (±SD) age (years) of the 4-L split-dose PEG-ELS group (N = 147) and the 2-L PEG-ELS plus bisacodyl (N = 155) were 44.09 (±15.62) (M:F : 2:1) and 44.12 years (±15.61) (M:F : 1.7:1), respectively. Percentage of patients with excellent and good preparation was higher in the 4-L split-dose PEG-ELS regimen compared with the 2-L PEG-ELS plus bisacodyl regimen (22.44 vs 17.41 and 44.21% vs 36.12%). Percentage of patients with fair and poor preparation was lower in 4-L split-dose PEG-ELS regimen compared with the 2-L PEG-ELS plus bisacodyl regimen (21.08% vs 27.74% and 12.24% vs 18.70%). In comparison with the 2-L PEG-ELS plus bisacodyl group, the incidences of abdominal pain (11% vs 15%), bloating (9% vs 12.24%), nausea/vomiting (8.38% vs 9.52%), and sleep disturbance (11% vs 12%) were slightly more common in the 4-L split-dose PEG-ELS group. There were no statistically significant differences between the two regimens with regard to bowel cleansing efficacy and adverse events. CONCLUSIONS: The 2-L PEG-ELS plus bisacodyl (10 mg) preparation is as efficacious as the 4-L split-dose PEG-ELS regimen for afternoon colonoscopy. Optimal preparation for colonoscopy can be achieved with the 2-L PEG-ELS plus bisacodyl regimen with slightly fewer adverse events and lower cost compared to the 4-L split-dose PEG-ELS regimen.

Effect of replenishment of vitamin D on survival in patients with decompensated liver cirrhosis: A prospective study.

AIM: To assess the vitamin D (VD) deficiency as a prognostic factor and effect of replenishment of VD on mortality in decompensated cirrhosis. METHODS: Patients with decompensated liver cirrhosis were screened for serum VD levels. A total of 101 VD deficient patients (< 20 ng/mL) were randomly enrolled in two groups: Treatment group (n = 51) and control group (n = 50). Treatment group received VD treatment in the form of intramuscular cholecalciferol 300000 IU as loading dose and 800 IU/d oral as maintenance dose along with 1000 mg oral calcium supplementation. The VD level, clinical parameters and survival of both the groups were compared for 6-mo. RESULTS: Prevalence of vitamin D deficiency (VDD) in decompensated CLD was 84.31%. The mean (SD) age of the patients in the treatment group (M:F: 40:11) and control group (M:F: 37:13) were 46.2 (± 14.93) years and 43.28 (± 12.53) years, respectively. Baseline mean (CI) VD (ng/mL) in control group and treatment group were 9.15 (8.35-9.94) and 9.65 (8.63-10.7), respectively. Mean (CI) serum VD level (ng/mL) at 6-mo in control group and treatment group were 9.02 (6.88-11.17) and 29 (23-35), respectively. Over the period of time the VD, calcium and phosphorus level was improved in treatment group compared to control group. There was non-significant trend seen in greater survival (69% vs 64%; P > 0.05) and longer survival (155 d vs 141 d; P > 0.05) in treatment group compared to control group. VD level had no significant association with mortality (P > 0.05). In multivariate analysis, treatment with VD supplement was found significantly (P < 0.05; adjusted hazard ratio: 0.48) associated with survival of the patients over 6-mo. CONCLUSION: VD deficiency is very common in patients of decompensated CLD. Replenishment of VD may improve survival in patients with decompensated liver cirrhosis.