Neutrophil Gelatinase-associated Lipocalin Predicts Short-term Outcomes in Decompensated Cirrhosis With Acute Kidney Injury.

Background and aims: Acute kidney injury (AKI) increases mortality in cirrhosis. Early identification of the cause of AKI helps in planning appropriate management. We aimed to find whether neutrophil gelatinase-associated lipocalin (NGAL) can be used to differentiate between different types of AKI in cirrhosis and predict short-term outcomes in patients with decompensated cirrhosis and AKI. Method: This was a time-bound study in which consecutive hospitalized patients with cirrhosis and AKI were prospectively recruited and managed as per standard care. Acute on chronic liver failure (ACLF) was diagnosed as per the EASL-CLIF Acute-on-Chronic Liver Failure in Cirrhosis (CANONIC) criteria. Urine NGAL was measured by enzyme-linked immunosorbent assay (ELISA) by Epitope Diagnostics Inc. kit (San Diego, USA.) in all patients on admission, and patients were followed up until hospital discharge or death. Results: A total of 110 consecutive patients (median [range] age: 44 [28-81] years;87.3%were male; ACLF: 71.8%; acute decompensation 28.2%; Model for end-stage liver disease (MELD) 27 [13-46]; Child-Turcotte-Pugh (CTP) 11 [7-15]) with cirrhosis and AKI were recruited. Alcohol was the most common etiology of cirrhosis(64.5%)). Pre-renal azotemia (PRA) was the most common cause of AKI (n = 56). Urine NGAL was significantly elevated in acute tubular necrosis (ATN) (1747 [6-6141] ng/ml than in hepatorenal syndrome (HRS) (379 [33.5-2320] ng/ml; P < 0.0001) and PRA (167 ng/ml [3.34-660]; P < 0.0001). Sixty-four percent patients with ATN, 27.6% patients with HRS, and none with PRA required dialysis. A total of 79.31% patients with HRS and 76% with ATN died. Urine NGAL was significantly higher in patients who required hemodialysis than in those who did not (1733 [243-6141] ng/ml vs 235 [3.34-2320] ng/ml; P < 0.0001). Both urine NGAL (n = 110) and plasma NGAL (n = 90) were significantly higher in patients who died (urine NGAL: -475 [6-6141] ng/ml vs 247 [3.34-2320] ng/ml; P = 0.002;plasma NGAL-950 [94-4859] ng/ml vs 608 [18-3300)]g/ml; P < 0.001). On multivariate analysis, urine NGAL and INR could predict mortality. Conclusion: NGAL can differentiate between different types of AKI in cirrhosis and predict the need for hemodialysis and mortality in decompensated cirrhosis with AKI.

Prospective observational study on clinical and epidemiological profile of adult patients presenting to the emergency department with suspected upper gastrointestinal bleed.

BACKGROUND AND OBJECTIVE: Bleeding from the upper gastrointestinal (GI) tract is one of the common medical emergencies. In this study, we assessed patients' socio-demographic and clinical characteristics and the association of clinical characteristics with treatment outcomes among patients with suspected upper gastrointestinal bleed (UGIB) presenting to the emergency department (ED). At present, there is a scarcity of data on UGIB in Northern part of India. MATERIAL AND METHOD: The study was a single-center, prospective observational study conducted at an urban tertiary care center. Consecutive patients with suspected UGIB were enrolled in the study from August 2020 to February 2022. A detailed history was obtained, including demographic data such as age and sex, presenting complaints, history of presenting illness, history related to co-morbidities, addiction, and drug history. Pre-endoscopic Rockall and Glasgow-Blatchford Score were calculated for each patient. The patients were subsequently followed up till discharge from the hospital. The final outcomes with regard to mortality, need for blood transfusion, length of emergency department stay, and discharge were noted. RESULT: 141 patients were included in the study. The mean age of the patients with suspected UGIB was 48 ± 14 years. 115 (81.6%) patients were male. The most common co-morbidity was chronic liver disease (40;28.4%). The most frequent presenting complaint in this study was hematemesis (96; 68.1%), followed by melena (76;53.9%). The mean (Standard Deviation, SD) of the Rockall Score was 2.46 ± 1.75. The mean (SD) of the Glasgow Blatchford Score was 12.46 ± 3.15 in patients with UGIB. CONCLUSION: In our study, hematemesis was the most prevalent symptom of suspected UGIB, followed by melena. Portal hypertension was the most common cause of UGIB. Most frequent comorbidities in patients suspected of UGIB were alcohol intake, Nonsteriodal Antiinflammatory Drugs (NSAIDs) abuse, and co-morbidities such as underlying chronic liver disease, hypertension, and diabetes. Early endoscopy can be of great utility to reduce morbidity and mortality.

Computed tomography virtual oesophagography for the grading of oesophageal varices in cirrhotic liver disease patients with upper gastrointestinal endoscopic examination as the gold standard: a diagnostic validation study.

Purpose: Virtual endoscopy is a postprocessing method using three-dimensional computed tomography (CT), which produces views of the inner surfaces of the human body like those produced by fibreoptic endoscopy. To evaluate and categorise patients who require medical or endoscopic band ligation to prevent oesophageal variceal bleed, a less invasive, less expensive, better tolerated, and more sensitive modality is required, as well as to reduce the use of invasive procedures in the follow-up of patients who do not require endoscopic variceal band ligation. Material and methods: A cross-sectional study was conducted in the Department of Radiodiagnosis in association with the Department of Gastroenterology. The study was conducted over a period of 18 months from July 2020 to January 2022. The sample size was calculated as 62 patients. Patients were recruited on the basis of inclusion and exclusion criteria after giving informed consent. CT virtual endoscopy was performed through a dedicated protocol. Classification of variceal grading was done independently by a radiologist and endoscopist who were blinded to each other's findings. Results: The diagnostic performance of oesophageal varices detection by CT virtual oesophagography was good, with sensitivity: 86%, specificity: 90%, PPV: 98%, NPV: 56%, and diagnostic accuracy: 87%. There was substantial agreement between the 2 methods, and this agreement was statistically significant (Cohen's k = 0.616, p ≤ 0.001). Conclusions: Based on our findings, we conclude that the current study has the potential to change the way chronic liver disease is managed, as well as generate similar medical research endeavours. A multicentric study with a large number of patients is needed to improve the experience with this modality.

Prevalence and impact of infections in acute on chronic liver failure in Rishikesh, India: a prospective cohort study.

Introduction: infection in Acute on chronic liver failure (ACLF) is associated with poor outcomes. There is limited prospective data on microbiological and resistance profile of infections in ACLF and their impact on in-hospital mortality. Methods: the study was conducted in the Gastroenterology department of a tertiary care hospital. The study population consisted of patients hospitalized with ACLF. 123 ACLF patients were included into the study and followed till hospital discharge. Data was collected prospectively in prespecified case-record forms. The aim was to prospectively study the prevalence of bacterial infection in ACLF, compare outcomes between patients with and without infection, microbiological profile and its impact on in-hospital mortality in ACLF. Predictors of presence of infection and mortality were estimated using univariable and multivariable regression. Results: of the 123 patients included [Mean ± SD age 45.5 ± 11.8 years, Males 89%(n=110); Mean ± SD MELD: 32±8], infection was noted in 62% (n=77) patients on admission, but microbiological confirmation was present in only 35 of these who yielded 41 isolates. Spontaneous bacterial peritonitis (SBP) was the most common cause of infection, although most isolates were obtained from blood cultures. 58.5% (n=24) isolates were resistant to multiple drugs. In-hospital mortality was noted in 53% (n=65). Factors associated with in-hospital mortality on multivariable analysis were serum creatinine (aOR: 2.89, 95% CI 1.79-4.65; p < 0.01), international normalized ratio (aOR: 3.169, 95% CI 1.66-6.04; p < 0.001), infection at admission (aOR: 3.81, 95% CI 1.39-10.44, p 0.009). Conclusion: ACLF is associated with high prevalence of infection by drug-resistant organisms. Infection at admission is an independent predictor of in-hospital mortality.

Hypereosinophilic syndrome presenting as eosinophilic gastroenteritis disorder and splinter hemorrhages: A case report.

BACKGROUND: Eosinophilia and related organ damage are extensively studied hot topics among rare disorders. Any addition to the cohort of available case reports of the same will be adding knowledge for better management of this less known entity. CASE SUMMARY: In this article, we describe a 27-year-old Indo-Aryan man who presented with abdominal pain, abdominal distension, and loose stools for variable days. He had splinter hemorrhages in the majority of fingernails. He was diagnosed with predominant eosinophilic gastrointestinal involvement with bowel obstruction and ascites, and was managed with intravenous immunoglobulin. He was subsequently treated with oral low dose steroid therapy and responded completely. CONCLUSION: Our experience is evidence that prompt management of this hypereosinophilic lethal gastrointestinal (all three layers) infiltrative disease provides a cure and avoids complications. Splinter nail hemorrhages may be seen in the same disease.

Fractured T Tube Fragment in Common Bile Duct during Retrieval: An Unforeseen Mishap.

Common bile duct (CBD) exploration by surgical method-open or laparoscopic, traditionally involved using a T tube to take care of postoperative intraluminal pressure and edema. The complications of T tube include bile leak after removal, formation of biliary fistula, excoriation of the skin, dehydration, saline depletion, retained T tube fragment, CBD obstruction, cholangitis, pancreatitis, and duodenal erosion. Here, we report a case of retained T tube fragment after an attempted removal in an operated case of choledocholithiasis, which was managed by endoscopic retrograde cholangiopancreatography and balloon catheter removal of the remnant.

COVID-19 Vaccines in Patients With Chronic Liver Disease.

The COVID-19 pandemic has caused mayhem globally since the beginning of 2020. Owing to the immune dysfunction inherent to cirrhosis and the poor general condition, patients with chronic liver disease (CLD) are at higher risk of mortality and morbidity due to COVID-19. Recently, a number of vaccines against SARS-Cov-2 have been approved for emergency use around the globe. Although the phase 2/3 trials of these vaccines show them to be safe and effective in the general population, data in patients with CLD are scarce. The number of patients with CLD enrolled on these trials is small, and no liver-related adverse effects have been reported yet. Various liver societies have come up with guidelines on vaccination in this population and recommend vaccination on a priority basis. Trials to assess the safety and efficacy of the COVID vaccines are underway and are likely to provide valuable insight into this matter.

Therapeutic plasma exchange in acute fatty liver of pregnancy: a case report and literature review.

Acute fatty liver of pregnancy (AFLP) is characterised by acute liver failure that occurs most commonly in the third trimester of pregnancy. Emergent delivery of the foetus reverses liver failure in most cases. Rarely, termination of pregnancy may not reverse liver failure, and adjunct interventions may be required. Therapeutic plasma exchange (TPE) has been described in AFLP in very few reports. We describe a patient in whom liver failure and extrahepatic organ failure persisted four days after delivery. She underwent TPE for persistent liver failure which resulted in prompt clinical improvement. We propose that TPE be considered as a measure to salvage AFLP patients with liver failure that does not reverse after termination of pregnancy.

Retained biliary plastic stents - lest we forget.

Prolonged indwelling of endoscopically placed biliary plastic stents may lead to complications. We conducted a retrospective analysis of patients who underwent endoscopic retrograde cholangio-pancreaticography (ERCP) at our centre in 2017 and were noted to have retained biliary plastic stents ( > 3 months after an index ERCP). A total of 127 patients had previously placed biliary plastic stents, out of which 45 (35.4%) were retained. The median age of the latter was 52 years (range = 22-79 years) with 27 (60%) patients being men. The median duration of the retained stents was 144 days (range = 94-3292 days). The majority of the patients were asymptomatic. However, 9 (20%) patients had cholangitis, 2 (4.4%) had choledocholithiasis, 2 (4.4%) had cholangitic abscess and 1 (2.2%) developed septicaemia. Fortunately, all these complications could be managed medically and endoscopically. Retention of biliary plastic stents is a problem often overlooked and underestimated in clinical practice. Various measures need to be instituted to create awareness of this entity to prevent undesirable outcomes.

Coronavirus disease 2019 and the pancreas.

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has led to a world-wide pandemic since its onset in December of 2019. Although, a primary respiratory pathogen, over the ensuing period, its extra-pulmonary effects have come to the forefront. The virus, having multi-organ tropism, has been shown to affect a host of other organs beyond the lung, including the pancreas. The data on pancreatic involvement by COVID-19, however, have been limited. Moreover, whether the effects on the pancreas are due to the direct effects of the virus or is just an epi-phenomenon is debatable. The prevalence of pancreatic injury and degree of injury are the other issues that need to be addressed. Pancreatic cancer has a dismal prognosis and the management of the same in the COVID era needs to be tailored assessing the risk-benefit ratio for the same. Additionally, pancreatic surgery increases not only the morbidity of the patient, but also the risk of the operator and burden on the health care system. Hence, the decision for such major procedures needs to be rationalized for optimum benefit during this pandemic. Similarly, for the endoscopist, pancreatic endoscopy needs to be carefully regulated to reduce risk to both the patient and the physician and yet deliver optimum patient care. This review gives a concise summary of various aspects of pancreatic involvement and pancreatic disease management during this pandemic.