Spectrum of drug-induced liver injury in a tertiary hospital in southern India.

Background Anti-tuberculosis drugs are thought to account for about 50% of drugs that cause liver injury in India. We show that the spectrum of drugs is much wider than previously reported. Methods We evaluated all patients with unexplained acute liver injury presenting during 2006-2016 using a structured proforma for drug-induced liver injury (DILI). The Roussel Uclaf Causality Assessment Method was used to assess causality. Results DILI was found in 143 of 2534 patients with acute liver injury. Nineteen patients had probable ayurvedic DILI. The other common causes of DILI were statins (16 patients) and anti-tuberculosis drugs (11 patients). Eight patients had DILI post-liver transplant. Fluconazole was the most common cause of post-liver transplant DILI. Chronic DILI (abnormal liver function test after 12 months of stopping the suspected drug) was found in 2 patients. Conclusion In otherwise unexplained acute liver injury, DILI due to ayurvedic drugs should be sought. DILI should be considered in post-liver transplant patients. Patients with DILI should be monitored for at least 12 months to exclude progression to chronic DILI.

Hemochromatosis in India: First Report of Whole Exome Sequencing With Review of the Literature.

BACKGROUND: Primary hemochromatosis is unusual in India. The homeostatic iron regulator (HFE) gene C282Y mutation, a common cause for hemochromatosis in Europe, is considered almost nonexistent in India. We are reporting a case of hemochromatosis with the HFE gene C282Y mutation and two other adult cases with a novel hemojuvelin (HJV) mutation from Kerala. METHODS: Of 434 cases with chronic liver disease, 3 cases were identified with the serum ferritin level of more than 1000 ng/mL and primary hemochromatosis after excluding secondary causes. Whole exome sequencing, including genes HFE, HJV, SLC40A1, TFR2, FTH1, HAMP, SKIV2L, TTC37, and BMP2, was performed for blood samples in all 3 cases. RESULTS: One patient with hemochromatosis had a homozygous HFE gene C282Y mutation, and two other adult cases had a novel homozygous HJV D355Y mutation. This is the first report of hemochromatosis associated with the HFE C282Y mutation from Kerala and the second report in India. This is the second report of hemochromatosis associated with an HJV mutation from India. CONCLUSION: HJV mutations may explain some of the adult onset primary hemochromatosis in India.

Endoscopic ultrasound-guided coil or glue injection in post-cyanoacrylate gastric variceal re-bleed.

BACKGROUND AND AIMS: N-butyl-cyanoacrylate injection is recommended in bleeding/recently bled gastric varices. However, cyanoacrylate injection is associated with re-bleed in 25% to 50% of patients. Endoscopic ultrasound (EUS)-guided coil application is an emerging treatment modality for bleeding gastric varices. The aim of this study was to compare EUS-guided coil application combined with or without cyanoacrylate glue injection to injection alone in post-glue gastric variceal re-bleed. METHODS: A retrospective analysis of a prospectively maintained database was performed. Thirty patients who re-bled after cyanoacrylate injection and who had EUS-guided coil application to gastric varices were included. The comparison was done with data of 51 patients who had only repeat cyanoacrylate injection. Both groups had a follow up for 12 months. EUS-guided coil application was done under endosonographic guidance. A single coil was placed in 7, two coils in each of 13 patients, three in 5, four in 3, five in one, and 6 coils in one patient. In addition, cyanoacrylate glue injection was given in 15 patients. Eight patients had repeat EUS-guided coil application 1 month later. Re-bleed and mortality were assessed. RESULTS: Coilng: Six out of 30 (20%) patients re-bled during follow up of 9 to 365 days. Three out of 30 (10%) died. One patient died 9 days after the procedure due to acute respiratory distress syndrome, one died 4 months after the procedure due to a re-bleed and one 5 months after the procedure due to spontaneous bacterial peritonitis. Glue only: 26/51 (51%) re-bled during follow up of 45 to 365 days. EUS-guided coil application resulted in significantly less re-bleed than glue-only (Kaplan-Meir survival analysis with log-rank test, z = 5.4, p < 0.001). Two out of 51 (4%) died 59 and 186 days after the procedure. CONCLUSION: EUS-guided coil application with/without cyanoacrylate injection for the obliteration of gastric varices is effective for post-cyanoacrylate gastric variceal re-bleed.

Bronchobiliary fistula treated successfully with endoscopic microcoils and glue.

A 29-year-old male developed bronchobiliary fistula after surgery for blunt abdominal trauma with liver laceration. Despite repeated endoscopic retrograde cholangiopancreatogram (ERCP) with stenting and surgeries, the fistula did not resolve. It was successfully sealed endoscopically, using microcoils and cynoacrylate glue. This is the first report of bronchobiliary fistula managed with ERCP using microcoils and cyanoacrylate glue.