Identification of human hepatocyte protein(s), which binds specifically to the recombinant envelope-2/non-structural-1 protein of hepatitis C virus.

Hepatitis C virus (HCV), which is the major pathogen responsible for human chronic liver disease, has special tropism for hepatocytes. Although, low-density lipoprotein receptor, CD81 and negatively charged glycosaminoglycans have been proposed as candidate receptors for HCV, no confirmed receptor(s) on the hepatocytes have been identified to date. It is also suggested that additional, yet unidentified, cellular proteins may be involved in the host-viral interaction. Therefore, this study was conducted with the main aim to identify hepatocyte protein(s) that may have affinity for the HCV structural protein, envelope-2/non-structural-1 (E2/NS1) protein. For the binding studies, hepatocytes were isolated from fresh normal human liver tissues. The hepatocyte proteins on the nitrocellulose paper were reacted with recombinant E2/NS1 protein and anti-E2 (rabbit). In another approach, to rule out the possibility of binding of rec-E2/NS1 with the hepatocyte cytoplasmic proteins, hepatocyte plasma membrane proteins were passed through CNBr-activated and recombinant E2/NS1 bound sepharose-4B column. The recombinant E2/NS1 binding hepatocyte plasma membrane protein(s) were eluted and were then analyzed. Altogether, our data suggest that E2/NS1 protein of HCV binds to two hepatocyte proteins of molecular weights 25-28 kDa and 59-60 kDa. These results indicate the possible role of the above proteins (25-28 kDa and 59-60 kDa) in the viral binding to the hepatocytes.

Clinical significance of patent paraumbilical vein in patients with liver cirrhosis.

A patent paraumbilical vein (PUV) is a frequent finding in patients with cirrhosis when studied by duplex Doppler ultrasound. There is controversy regarding the clinical significance of this finding. We studied 50 patients with cirrhosis and portal hypertension as evidenced by the demonstration of esophageal varices on endoscopy. All 50 patients were evaluated for a significant PUV (diameter of > or =3 mm) using duplex Doppler sonography. The patients were divided into two groups based on the size of esophageal varices (group A with small varices, N = 30; group B with large varices, N = 20). A significant PUV was seen in 21 (42%) patients. The patients with portosystemic encephalopathy had a significantly greater prevalence of PUV (70%) than those without (32%, P < 0.02). Of the group with large esophageal varices, 6 (30%) had a significant PUV, while in the group with small varices, 15 (50%) had a significant PUV (P > 0.05). In no patient with large varices did the PUV diameter exceed 6 mm, while in as many as six patients with small varices, the PUV diameter exceeded 6 mm. A significantly enlarged PUV seen on duplex Doppler ultrasound in cirrhotics may have important hemodynamic consequences. Besides predisposing the patient to portosystemic encephalopathy, it may also offer some protection against formation of large varices. In particular, a very large patent PUV (> or =6 mm) might identify a subgroup of patients with small varices and thus a lesser likelihood of variceal bleeding.

Efficacy of lactulose in cirrhotic patients with subclinical hepatic encephalopathy.

To investigate the role of lactulose in the treatment of cirrhotic patients with subclinical hepatic encephalopathy (SHE), 40 cirrhotic patients, 33 males and 7 females, were included in the study. The diagnosis of SHE was made by quantitative psychometric tests including the number connection test (NCT), figure connection test (FCT) parts A and B, and two performance subtests of Wechsler adult intelligence scale, ie, picture completion (PC) and block design (BD) tests. SHE was diagnosed in 26 (65%) of 40 patients. Of these 26 patients, 14 patients were randomized to treatment group (lactulose 30-60 ml/day for three months, SHE-L) and 12 patients to no treatment group (no lactulose, SHE-NL). Psychometric tests were repeated in all patients in both groups and in six patients with no SHE (group NSHE, N = 14) after three months. The mean scores and number of the abnormal psychometric tests at entry were significantly higher in patients in groups SHE-L and SHE-NL than in patients in group NSHE; however, there was no significant difference between SHE-L and SHE-NL. The mean number of the abnormal psychometric tests decreased in patients in group SHE-L after three months of treatment with lactulose (2.9 +/- 0.9 vs 0.8 +/- 1.2; P = 0.004); however, there was no change in patients in group SHE-NL after three months (3.7 +/- 1.5 vs 3.5 +/- 1.3; P = NS). While SHE improved in 8 of 10 patients in group SHE-L, none of the patients in group SHE-NL improved after three months of follow-up (P < 0.001). Two patients in group SHE-NL also developed overt encephalopathy during the study period. We conclude that lactulose treatment in cirrhotic patients with SHE is effective.

Dilatation of benign oesophageal strictures: 10 years' experience with Celestin dilators.

BACKGROUND: Endoscopic dilatation is the first line of treatment for benign oesophageal strictures. There are limited data available on the use of Celestin dilators. METHODS: The efficacy and safety of Celestin dilators was evaluated retrospectively in 61 patients with benign oesophageal strictures. Three hundred and ninety-three dilatations using Celestin dilators were performed over a period of 10 years on an outpatient basis in patients with corrosive, peptic and other causes of benign oesophageal strictures. RESULTS: Initial success was achieved in all patients in the peptic and miscellaneous group and in 91% in the corrosive group of patients. Patients with corrosive strictures required significantly more dilatations for initial success compared with the peptic group (mean 5.82 vs 1.62 P < 0.1). At 6 months follow up after the initial success, 29% of the patients had an excellent response, 56% a good response and 15% a fair response. No patient had a poor response. During the long-term follow up of 10 years, overall dilatation requirement decreased significantly. (72 vs 27 vs 14% of patients requiring dilatation at 1, 5 and 10 years P < 0.05). The dilatation requirement also decreased significantly within the groups (P < 0.05). Patients with corrosive stricture required more frequent dilatations on follow up compared with the other two groups. Complications in the form of oesophageal perforation occurred in only two patients. There was no mortality. CONCLUSION: Oesophageal dilatation with Celestin dilators is an effective and safe modality for managing patients with benign oesophageal strictures.

Duplex Doppler sonography in patients with Budd-Chiari syndrome.

BACKGROUND: Angiography has been the mainstay for diagnosis of Budd-Chiari syndrome even though other modalities are increasingly being used. We have evaluated our findings of duplex Doppler sonography (DDS) in patients with Budd-Chiari syndrome. METHODS: Duplex Doppler sonography was performed in 37 consecutive angiographically proven patients with Budd-Chiari syndrome. RESULTS: Real time ultrasonography showed abnormalities of right, middle and left hepatic veins (HV) in 21, 15 and 18 patients, respectively. Duplex Doppler sonography showed abnormal flow patterns in 37, 22 and 31 patients in the right, middle and left HV, respectively, thereby increasing the diagnostic yield by 40%. An abnormal waveform in one or more HV was present in all 37 patients. Uniphasic flow was the commonest abnormality and was seen in 22, nine and 14 patients, respectively, in the right, middle and left HV, while there was no flow in five, four and seven patients in the right, middle and left HV, respectively. Intrahepatic collaterals were seen in 35 of 37 patients (94.6%). Hepatopetal flow was found in the portal vein of 21 of 23 patients (91.3%), while flow was hepatofugal in one and portal vein thrombosis was found in another. CONCLUSION: Duplex Doppler sonography is a useful procedure which helps in the diagnosis of patients with Budd-Chiari syndrome.

Post-biopsy liver cyst: a rare complication of liver biopsy.

Liver biopsy rarely leads to complications in a non-cirrhotic liver. We describe here a case of a biliary cyst of the liver that developed after a liver biopsy. It was successfully treated with surgery.

Genetic variability of hepatitis E virus within and between three epidemics in India.

Hepatitis E virus (HEV) is an important cause of epidemic and sporadic acute viral hepatitis in many developing countries, including India. We evaluated the genetic variability within two regions (a 476-nt long ORF1 segment and a 304-nt long ORF2 segment) from specimens collected during three outbreaks in the cities of Karnal (1987), Yamunanagar (1989), and Meerut (1996), India, and from one patient, residing in Lucknow, India, who had a case of sporadic hepatitis (1996). Within an outbreak, sequences in the ORF1 and ORF2 regions were 99.3-100.0% identical. However, when strains were compared between outbreaks, identity in the ORF1 and ORF2 region was 97.1-99.2 and 96.4-100.0%, respectively. A comparison of these sequences to previously published Indian ORF1 and ORF2 sequences revealed even lower similarities, 95.2-98.5 and 95.1-98.7%, respectively. One patient in the Meerut outbreak had genomic sequences that differed substantially from the other patients affected during this outbreak and probably reflected a sporadic infection. The sporadic hepatitis E strain from Lucknow clustered with a previously described HEV strain from a patient with fulminant hepatic failure (FHF). Our data suggest that the ORF1 and ORF2 segments can be used to study the molecular epidemiology of HEV infection and indicate that much remains to be determined about the genetic variability of Indian HEV strains.

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.

Coagulation abnormalities in idiopathic portal venous thrombosis.

BACKGROUND: Portal vein thrombosis, usually idiopathic, is the cause of portal hypertension in 46% of Indian patients, who present with a variceal bleed. The presence of lupus anticoagulant (LA) and antithrombin III deficiency have been reported to be associated with an increased tendency to venous thrombosis. METHODS AND RESULTS: We studied 30 patients with portal venous thrombosis diagnosed by ultrasound. Two patients were positive for a lupus anticoagulant and both had very prolonged partial thromboplastin time with kaolin. None of the patients had antithrombin III deficiency.

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.

Spontaneous bacterial peritonitis in fulminant hepatic failure.

Ascites may be associated with fulminant hepatic failure (FHF), but spontaneous bacterial peritonitis (SBP) is an extremely rare complication. We report on two patients with FHF who developed SBP. One patient died and the other recovered.

Prognostic evaluation of early indicators in fulminant hepatic failure by multivariate analysis.

Viral hepatitis is the commonest cause of fulminant hepatic failure (FHF) in developing countries. We evaluated the early indicators of prognosis in these patients by multivariate analysis. The records of 204 consecutive patients with acute liver failure admitted with hepatic encephalopathy over five years were studied. The etiology of these patients included virus related in 186 (91.1%), drug induced in 15 (7.4%), Wilson's disease in one (0.5%), acute Budd-Chiari syndrome in one (0.5%), and malignant infiltration in one (0.5%). Patients with FHF complicating viral hepatitis were analyzed by univariate and multivariate analysis. These patients were further subclassified depending upon the interval between the onset of jaundice and the onset of encephalopathy into hyperacute (HALF; interval 0-7 days), acute (ALF; interval 8-28 days) and subacute liver failure (SALF; interval 4-12 weeks). Sixty (32.3%) patients with viral hepatitis survived. Univariate analysis showed that the interval between onset of encephalopathy and onset of jaundice, grade of encephalopathy, raised intracranial pressure, prothrombin time, and serum bilirubin levels on admission were related to outcome in these patients. Multivariate logistic regression analysis showed that the presence of raised intracranial pressure at the time of admission, prothrombin time >100 sec on admission, age (>50 yr), and onset of encephalopathy seven days after onset of jaundice were associated with poor prognosis. Forty seven (37.0%) of 129 patients with HALF survived compared with 9 (22.5%) of 40 with ALF and 4 (21.1%) of 19 with SALF (P = NS). Raised intracranial pressure was more frequent in patients with HALF (48.8%) than in patients with ALF (32.5%) and SALF (15.8%; P = 0.01), while clinically detectable ascites was more frequent in patients with SALF (78.9%) compared with HALF (19.7%) and ALF (37.5%; P < 0.0001). The factors adversely affecting the outcome in our patients with FHF complicating viral hepatitis include presence of overt clinical features of raised ICP at the time of hospitalization, prothrombin time (>100 sec) on admission, age (>50 yr), and onset of encephalopathy seven days after onset of jaundice.

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.

Role of long-persisting human hepatitis E virus antibodies in protection.

The role of long-persisting HEV antibodies in humans was investigated. A well-characterized human volunteer anti-HEV (IgG) after 4 years of the recovery of the disease was passively immunized (200 mg kg-1 body wt) intramuscularly into three rhesus monkeys (nos 7, 8 and 9), while two monkeys (nos 5 and 6) were injected with normal immunoglobulin preparation (negative for anti-HEV IgG). At 16 h later all the animals were challenged intravenously with live HEV, as 10% stool extract prepared from the volunteer (positive for HEV by solid-phase immune electron microscopy). It was seen that transaminases (ALT/AST) were elevated in immunized monkeys on day 49 (no. 8), 60 (no. 7) and 86 (no. 9) after the virus challenge. On serological examination, all immunized (nos 7, 8 and 9) and one unimmunized (no. 6) monkeys were found positive for HEV IgM on day 10 post-challenge, while monkey no. 5 was negative. Further, all the animals from the immunized and unimmunized group seroconverted to HEV-IgG when tested on days 25 and 55 post-challenge. This has clearly shown that there is no protection. Therefore, these long-persisting HEV antibodies alone in humans, may not be protective in passive immunization.

Portal hemodynamics by duplex Doppler sonography in different grades of cirrhosis.

Not much is known about the relationship between portal hemodynamics and the grades of cirrhosis. Using pulsed Doppler ultrasonography, we studied portal vein diameter, portal flow velocity, and portal blood flow rate in 37 patients with liver cirrhosis (11 Child's A, 13 Child's B, and 13 Child's C) and 10 healthy controls. There was no difference in the maximum inner diameter of the portal vein in cirrhotics and controls. However, there was a significant decrease in the portal flow velocity in patients with Child's C cirrhosis, as compared to controls and patients with Child's A and Child's B cirrhosis. The portal blood flow rate in Child's B and Child's C cirrhosis was also significantly less as compared to controls and patients with Child's A cirrhosis. Patients with ascites and encephalopathy had significantly lower portal flow velocities and blood flow rate as compared to those without ascites and encephalopathy, respectively. This study indicates that portal flow significantly decreased in cirrhotic patients with worsening Child's grade of cirrhosis.

Extrahepatic portal hypertensive gastropathy in Wistar rats: modulation of acid secretion in isolated parietal cells.

Stimulated acid secretion in portal hypertensive gastropathy is blunted and could be due to defective signal transduction in the parietal cell. Therefore, an attempt was made to study the levels of second messengers in parietal cells in experimental extrahepatic portal hypertensive gastropathy. Our aim was to measure acid secretion, intracellular free calcium, calcium transport, cyclic AMP, and ATP levels in the parietal cells isolated from the gastric mucosa of portal hypertensive rats. Acid secretion using acridine orange, intracellular free calcium using Fura-2/AM, calcium influx and efflux by 45CaCl2 and cyclic AMP by RIA kits were measured in unstimulated and histamine- and carbachol-stimulated isolated parietal cells in rats with partial portal vein ligation and sham operation. ATP was measured by HPLC. In portal hypertensive gastropathy, stimulated acid secretion was blunted, and there was a decrease in basal intracellular free calcium. Calcium influx and efflux were at a higher level, and there was a decrease in elevation of intracellular free calcium and cyclic AMP levels with secretagogues. There was also a decrease in ATP. In conclusion, there exists a low energy state in addition to multiple aberrations at the second messenger level in parietal cells in portal hypertensive gastropathy.

Genetic polymorphism of CYP2D6 in North Indian subjects.

OBJECTIVES: CYP2D6 polymorphism of clinical relevance occurs with variable frequency in different ethnic groups. Since this polymorphism has not been studied in a North Indian population, the present study was undertaken. METHODS: One hundred healthy unrelated North Indian subjects received 30 mg dextromethorphan (DM) orally at bed-time. The amounts of DM and its metabolite, dextrorphan (DR), excreted in 8 h urine were estimated by high performance liquid chromatography. Metabolic ratio (DM/DR excreted in 8 h) was used as an index of the metabolic status of an individual. RESULTS: The analysis of the data by frequency distribution histogram, probit and NTV plots demonstrated bimodal distribution of the North Indian subjects with respect to hepatic CYP2D6. Out of 100 subjects, 97 were extensive metabolizers (EMs), whereas three were poor metabolizers (PMs). EMs and PMs excreted 29.82 and 2.67 micromol DR (mean value) and 2.59 and 8.82 micromol DM (mean value) in 8 h, respectively. MR and log MR was 197- and 2.2-fold higher in PMs versus EMs. The antimode value of zero was determined by visual observation in frequency distribution histogram and inflection point in probit plot. CONCLUSION: From this study, it can be concluded that the PM phenotype of CYP2D6 occurs with a frequency of 3% (95% confidence interval of 0.33%-6.33%) in North Indians.

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.