Non-invasive aspartate aminotransferase to platelet ratio index correlates well with invasive hepatic venous pressure gradient in cirrhosis.

BACKGROUND: Hepatic venous pressure gradient (HVPG) is the best recommended tool to measure portal pressure, but is invasive. HVPG helps in prognosticating cirrhosis and predict its complications. Aminotransferase to platelet ratio index (APRI) is a simple non-invasive marker of hepatic fibrosis. We aimed to correlate APRI with HVPG and to determine the usefulness of APRI in predicting complication of cirrhosis. METHODS: APRI and HVPG were measured in consecutive patients of cirrhosis aged 18 to 70 years. Spearman's rho was used to estimate their correlation; a cut-off value of APRI to predict severe portal hypertension (HVPG > 12 mmHg) was determined. RESULTS: This study, conducted between August 2011 and December 2014, included 277 patients, median age 51 (range: 16-90) years, 84% males. Etiology of cirrhosis was alcohol in 135 (49%), cryptogenic/nonalcoholic steatohepatitis (NASH) in 104 (38%), viral in 34 (12%), and others in 4 (1%). Median Child-Turcott-Pugh (CTP) and model for end-stage liver disease (MELD) scores were 7 (5-11) and 11 (6-33), respectively. Median HVPG was 17.0 (1.5-33) mmHg and median APRI was 1.09 (0.21-12.22). There was positive correlation between APRI and HVPG (Spearman's rho 0.450, p < 0.001). The area under the receiver operating characteristic (ROC) curve of APRI for predicting severe portal hypertension was 0.763 (p < 0.01). Youden's index defined the cut-off of APRI for predicting HVPG > 12 mmHg was 0.876 with a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 71%, 78%, 94%, 38%, and 73%, respectively. APRI also correlated well with CTP, variceal size, bleeding status, ascites but not with MELD. CONCLUSIONS: APRI score of 0.876 has an acceptable accuracy to predict severe portal hypertension (HVPG > 12 mmHg). High APRI also correlated with severity of cirrhosis and its complications. Thus, APRI may be used as a simple, bedside, non-invasive, and inexpensive tool for evaluating portal hypertension and complications of cirrhosis.

Dysphagia aortica: Emerging role of endoscopic ultrasound (with videos).

Dysphagia can occur due to extrinsic compression on esophagus. Dysphagia due to intrathoracic vascular causes is rare. Most reported cases of vascular etiology are due to dysphagia lusoria. Dysphagia due to any anomaly of aorta is called dysphagia aortica. In an emergency setting, endoscopic ultrasound (EUS) has been found to be superior and more sensitive for detection of abdominal aortic aneurysms over conventional radiological methods. We present a series of four cases of dysphagia aortica where the diagnosis was made by endoscopic ultrasound.

All ileo-cecal ulcers are not Crohn's: Changing perspectives of symptomatic ileocecal ulcers.

AIM: To investigated clinical, endoscopic and histopathological parameters of the patients presenting with ileocecal ulcers on colonoscopy. METHODS: Consecutive symptomatic patients undergoing colonoscopy, and diagnosed to have ulcerations in the ileocecal (I/C) region, were enrolled. Biopsy was obtained and their clinical presentation and outcome were recorded. RESULTS: Out of 1632 colonoscopies, 104 patients had ulcerations in the I/C region and were included in the study. Their median age was 44.5 years and 59% were males. The predominant presentation was lower GI bleed (55, 53%), pain abdomen ± diarrhea (36, 35%), fever (32, 31%), and diarrhea alone (9, 9%). On colonoscopy, terminal ileum was entered in 96 (92%) cases. The distribution of ulcers was as follows: Ileum alone 40% (38/96), cecum alone 33% (32/96), and both ileum plus cecum 27% (26/96). The ulcers were multiple in 98% and in 34% there were additional ulcers elsewhere in colon. Based on clinical presentation and investigations, the etiology of ulcers was classified into infective causes (43%) and non-infective causes (57%). Fourteen patients (13%) were diagnosed to have Crohn's disease (CD). CONCLUSION: Non-specific ileocecal ulcers are most common ulcers seen in ileo-cecal region. And if all infections are clubbed together then infection is the most common (> 40%) cause of ulcerations of the I/C region. Cecal involvement and fever are important clues to infective cause. On the contrary CD account for only 13% cases as a cause of ileo-cecalulcers. So all symptomatic patients with I/C ulcers on colonoscopy are not Crohn's.

Adrenal insufficiency predicts early mortality in patients with cirrhosis.

BACKGROUND: Adrenal insufficiency (AI), also known as hepato-adrenal syndrome, is a well-known entity in cirrhotic patients. However, factors associated with AI and its effect on survival are still not clear. We determined the prevalence of AI in patients with cirrhosis who had no hemodynamic instability or any acute deterioration, and studied its influence on short-term survival. PATIENTS AND METHODS: In consecutive cirrhotic patients, presence of AI was determined either by total serum cortisol <18 µg/dl, 60 minutes after 250 µg synacthen injection, or when the delta-fraction (post-synacthen serum cortisol minus basal serum cortisol) was <9 µg/dl. RESULTS: A total of 120 patients were included in the study (median age 50 years (range 27-73), males 87%). The median CTP and MELD scores were 10 (range 6-13) and 20 (range 6-40). The etiology of cirrhosis was alcohol (51%), cryptogenic (28%), viral (19%) and autoimmune (2%). Sixty-nine patients (58%) had AI and the remaining 51 (42%) had normal adrenal function. Serum bilirubin was significantly higher (p < 0.05) in the AI group, and total cholesterol, HDL, LDL and hemoglobin were significantly lower (p < 0.05) in the AI group. CTP score, MELD score, and basal cortisol levels were not different between those with and without AI (p = NS). By 120 days of follow-up, 41 patients had died. Thus, the 120-day survival was 66%, and this was higher in patients without AI than in patients with AI (78% vs 56%; p = 0.019). On multivariate analysis absence of AI, low WBC and low CTP score independently predicted 120-day survival. CONCLUSIONS: AI is present in more than half of cirrhotic patients but does not parallel the severity scores of cirrhosis. Its presence predicts early mortality in these patients, and this prediction is independent of CTP or MELD scores.

Multipurpose use of the 'bear claw' (over-the-scope-clip system) to treat endoluminal gastrointestinal disorders.

BACKGROUND AND AIM: The 'bear-claw' or over-the-scope-clip system (OTSC; Ovesco Endoscopy, Tübingen, Germany) is a new clipping device developed for closure of large luminal gastrointestinal (GI) defects. The aim of the present study was to evaluate the clinical outcomes of patients treated with the OTSC. METHODS: The present study was an observational, open-label, retrospective, single-arm case series conducted at two hospitals with tertiary care endoscopy. It involved 20 clip applications in 16 patients (median age 65.8 years [range 51-90 years], seven women) with GI defects from fistulas and anastomotic dehiscence and peptic ulcer bleeding. RESULTS: The range of indications included gastrointestinal bleeding (n=6), gastrocutaneous fistulas (n=3), esophagotracheal and/or esophagopleural fistulae (n=3), resection ofsubmucosal tumor (n=2), stent fixation (n=1), and anastomotic leak after esophagectomy (n=1). The overall success rate for the OTSC device was 75% (12 out of 16 patients). The overall per case success rate was 70% (14 of 20 applications). Mean follow up was 10 months (range 1-10). There were no complications (0%) related to endoscopy, sedation or application of the clipping device. CONCLUSIONS: The OTSC system is a useful device in a variety of clinical scenarios including the management of larger GI leaks and fistulas, GI bleeding, full-thickness resection of tumors, and stent anchoring, even in very old and frail patients.

Low eosinophil count predicts in-hospital mortality in cirrhosis with systemic inflammatory response syndrome.

BACKGROUND: Absolute eosinophil count (AEC) and procalcitonin (PCT) level may have a prognostic value in critically ill patients. However, their role in cirrhotic patients has never been studied. We evaluated the role of AEC and PCT, obtained at admission, in predicting in-hospital mortality in cirrhotic patients with systemic inflammatory response syndrome (SIRS). PATIENTS AND METHODS: In consecutive cirrhotic patients with SIRS (with or without sepsis), the levels of AEC and PCT were estimated at admission. Their outcome was correlated with these baseline parameters. RESULTS: One hundred patients were enrolled [median age 52 (range 17-78) years, 84% men]. The etiology of cirrhosis was alcohol (47%), cryptogenic (35%), viral (13%), and others (5%). Their median model for end-stage liver disease (MELD) and Child-Turcotte-Pugh scores were 24 (range 6-40) and 11 (range 5-15), respectively. Infection was present in 59 patients and the rest of the 41 patients had SIRS without infection. There was a significant difference between the median levels of AEC and PCT between patients who had infection and those who did not have infection (P<0.01). Sixty-three patients recovered from SIRS and were discharged, 33 patients died, and four patients received orthotopic liver transplantation during the same admission. Baseline AEC and PCT levels were significantly different between patients who recovered and died. On multivariate analysis, baseline AEC values could independently predict in-hospital mortality, in addition to MELD and serum sodium. The area under receiver operating characteristic curve of AEC for predicting mortality was 0.785, and the best cutoff of AEC, obtained by Youden's index, was 104 cells/cumm, indicating that patients with baseline AEC values less than 104 cells/cumm had higher in-hospital mortality (sensitivity 78%, specificity 70%, positive predictive value 60%, negative predictive value 85%, and accuracy 73%). CONCLUSION: In critically ill cirrhotic patients with SIRS, a baseline AEC value of less than 104 cells/cumm accurately predicts in-hospital mortality. The prediction of mortality by AEC is independent of the MELD score and serum sodium.

Hepatitis B Virus Infection can Cause Hepatocellular Carcinoma in Less Advanced Liver Cirrhosis: A Comparative Study of 142 Patients from North India.

BACKGROUND AND AIMS: The clinical profile of patients with hepatocellular carcinoma (HCC) may differ depending on the etiology of HCC. There is no study from India comparing the clinical profile of patients of HCC due to hepatitis B virus (HBV) infection with other etiologies. METHODS: We retrospectively reviewed the records of patients clinically diagnosed as HCC between Nov 2000 and Dec 2012 admitted under a single unit of Department of Gastroenterology at our hospital. We compared the clinical presentation of patients of Hepatitis B virus etiology (HBV group) with other etiologies (Non-HBV group). RESULTS: One hundred and forty-two patients were included (median age 60 years [range 30-83], 92% males). The etiology was HBV in 56 (39%) and among the non-HBV group (n = 86, 61%) the etiological spectrum was following: alcohol 31 (22%), cryptogenic 26 (18%), HCV 27 (19%), and miscellaneous 2 (1%). The median age of presentation was significantly less for HBV group than in non-HBV (56 [30-77] vs. 62 [42-83] years, P < 0.01). Clinical evidence of cirrhosis was significantly less common in the HBV group than non-HBV group (74% vs 98%, P < 0.01). HBV group had lower CTP score than non-HBV (median CTP score 7 vs 8,P < 0.05). Ascites was more common in non-HBV group than HBV group (65% vs 43%, P = 0.018). The BCLC staging was: A 13%, B 23%, C 35%, and D 29%, and there was no difference in tumor characteristics or BCLC staging between HBV or the non-HBV group. CONCLUSIONS: HBV is a common cause of HCC in India, accounting for 39% of cases. The tumor characteristics of HCC due to HBV is similar to other etiologies, however, HBV causes HCC at an earlier age, and in less advanced or even absence of cirrhosis, thus further consolidating the directly carcinogenic potential of HBV.