Different Approaches for Thyroid Surgery.

Introduction: Surgery remains main treatment of choice for thyroid nodule for diagnosis and treatment. Conventional thyroid surgery gives scar in the neck so many young patients particularly unmarried females demand thyroid surgery without visible scar in the neck for cosmetic reason. Extra cervical approaches have continued to evolve with an increasing body of research (Sarda AK, Bal S, Kapoor MM (1989) Near-total thyroidectomy for carcinoma of thyroid. Br J surg 76(90):2).majority of them presenting in 21-30 age So, here there is evaluation of minimally invasive or endoscopic thyroid techniques. Here, we have studied endoscopic approach and utilize it to minimize scar and scarless thyroid surgery. Aims and objectives: To evaluate optimal patient selection criteria. To study various surgical approaches and outcomes. To decide surgical approach according to size. To study patients satisfaction. Methodology: It was a prospective study of 50 patients with a duration of 3 years. All the Euthyroid cases with clinically palpable thyroid swelling in age group 15-60, after a detailed clinical history and examination, who required surgery and concern for visible neck scar are councelled and included in our study. Results: In our study 45 patients were females and 5 were males with majority of them presenting in 21-30 age group. All the patients in our study are presented with neck swelling. In most patients FNAC is suggestive of colloid goiter. Conclusion: Endoscopic thyroid surgery is mainly indicated for young patients having benign thyroid tumor less than 3 cm in size. Transaxillary and retroauricular are common approaches and is selected as per patient choice and surgeon expertise. Transaxillary thyroidectomy can be performed safely as conventional thyroidectomy.

Impact of diabetes mellitus on outcome of HCC.

BACKGROUND: Diabetes mellitus (DM) is recently identified risk factor for development and progression of chronic liver disease as well as hepatocellular carcinoma (HCC). We planned a prospective analysis to identify impact of DM in Indian patients with HCC. METHODS: During last 10 years, 160 consecutive patients of HCC were evaluated. Demographic profile like age of presentation, clinical features, etiology of HCC, tumor size at presentation, management and ultimate outcome was compared diabetic with non-diabetic HCC patients. RESULTS: During last 10 years, 160 consecutive patients of HCC were evaluated (Mean age = 59.6 +/- 12.9 years, sex ratio (M: F) = 5.4: 1). Etiology for HCC were hepatitis B in 45 (28.2%), hepatitis C in 18 (11.3%), alcohol in 27 (16.8%), alcohol with hepatitis B in 12 (7.5%), alcohol with hepatitis C in 1 (0.6%), non-alcoholic steatohepatitis in 4 (2.5%) and cryptogenic in 53 (33.2%) patients. Patients of HCC with DM (group-A, n =46, age = 62.6 +/- 9.5 years, sex (M: F) = 6.6:1) were compared with patient of HCC without DM (group-B, n =114, age = 66.7 +/- 13.7 years, sex (M: F) = 5.4:1). Duration of diabetes in group-A was 7.6 +/- 3.2 years. Patients in group-A had more advanced HCC (size of lesion > 5 cm and >3 lesions of 3 cm or more diameter, portal vein thrombosis or intra-hepatic bile duct involvement) than group-B [34 (73.9%) vs 72 (54.3%)]. Mortality with in one year was significantly more in group-A compared to group-B [36 (78.2%) vs 56 (49.1%)]. CONCLUSION: DM is associated with more advanced lesion and poor outcome in patient with HCC.

Hepatobiliary tuberculosis in western India.

Tuberculous involvement of liver as a part of disseminated tuberculosis is seen in up to 50-80% cases, but localized hepatobiliary tuberculosis (HBTB) is uncommonly described. During 6 years, a total of 280 consecutive patients with TB were evaluated prospectively for the presence and etiology of liver involvement. Cases with miliary TB or immunosuppression and cases receiving anti-tuberculosis drugs prior to presentation to our unit were excluded (38 cases). Details of clinical, biochemical and imaging findings and histology/microbiology were noted. Of 242 included cases, 38 patients (15.7%; age 38.1 +/- 12.5 years; sex ratio 2.5:1) had HBTB, whereas 20 patients (9%; age 39.3 +/- 16.3 years; sex ratio 2.1:1) had other liver diseases. Diagnosis of HBTB was based on caseating granuloma on histology (18/23 procedures), positive smear/culture for acid-fast bacilli (21/39 procedures) and positive polymerase chain reaction for Mycobacterium tuberculosis (28/29 procedures) when diagnostic procedures were guided by imaging results. Thirty-eight cases with HBTB were classified as follows [patients (n), (%)]: (A) hepatic TB [20 (52.6%)]: (1) granulomatous hepatitis - 10 (26.3%), (2) liver abscesses or pseudotumors - 10 (26.3%) and (3) calcified hepatic granuloma - 0 (0%); (B) biliary TB [15 (39.4%)]: (1) biliary strictures - 2 (5.2%), (2) gall bladder involvement - 1 (2.6%) and (3) biliary obstruction due to lymph node masses - 12 (31.5%); (C) mixed variety [3 (7.8%)]: (1) simultaneous granulomatous hepatitis and biliary stricture - 1 (2.6%) and (2) simultaneous lymph node involvement and calcified hepatic granuloma - 2 (5.2%). All the cases responded well to standard anti-tuberculosis therapy. HBTB forms an important subgroup in TB cases. It requires a combination of imaging, histological and microbiological procedures to define the diagnosis. HBTB responds well to treatment.

Changing spectrum of Budd-Chiari syndrome in India with special reference to non-surgical treatment.

AIM: To evaluate patterns of obstruction, etiological spectrum and non-surgical treatment in patients with Budd-Chiari syndrome in India. METHODS: Forty-nine consecutive cases of Budd-Chiari syndrome (BCS) were prospectively evaluated. All patients with refractory ascites or deteriorating liver function were, depending on morphology of inferior vena cava (IVC) and/or hepatic vein (HV) obstruction, triaged for radiological intervention, in addition to anticoagulation therapy. Asymptomatic patients, patients with diuretic-responsive ascites and stable liver function, and patients unwilling for surgical intervention were treated symptomatically with anticoagulation. RESULTS: Mean duration of symptoms was 41.5 +/- 11.2 (range = 1-240) mo. HV thrombosis (HVT) was present in 29 (59.1%), IVC thrombosis in eight (16.3%), membranous obstruction of IVC in two (4%) and both IVC-HV thrombosis in 10 (20.4%) cases. Of 35 cases tested for hypercoagulability, 27 (77.1%) were positive for one or more hypercoagulable states. Radiological intervention was technically successful in 37/38 (97.3%): IVC stenting in seven (18.9%), IVC balloon angioplasty in two (5.4%), combined IVC-HV stenting in two (5.4%), HV stenting in 11 (29.7%), transjugular intrahepatic portosystemic shunt (TIPS) in 13 (35.1%) and combined TIPS-IVC stenting in two (5.4%). Complications encountered in follow-up: death in five, re-stenosis of the stent in five (17.1%), hepatic encephalopathy in two and hepatocellular carcinoma in one patient. Of nine patients treated medically, two showed complete resolution of HVT. CONCLUSION: In our series, HVT was the predominant cause of BCS. In the last five years with the availability of sophisticated tests for hypercoagulability, etiologies were defined in 85.7% of cases. Non-surgical management was successful in most cases.

Diagnosis of Crohn's disease in India where tuberculosis is widely prevalent.

AIM: To define the parameters that positively predict diagnosis of Crohn's disease (CD) and differentiate it from gastrointestinal tuberculosis (GITB). METHODS: This prospective study over 3 years was carried out in the consecutive Indian patients with definite diagnosis of CD and equal numbers of patients with definite diagnosis of GITB. Demographic, clinical, laboratory, morphological and histological features were noted in all the patients. Serological tests such as p-ANCA, c-ANCA, IgA ASCA and IgG ASCA, were performed. Endoscopic biopsy and/or surgical tissue specimens were subjected to smear and culture for acid-fast bacilli (AFB) and tissue polymerase chain reaction for tuberculosis (TB PCR). Diagnosis of CD and GITB was based on the standard criteria. Data were analyzed using univariate Chi-square test and multiple logistic regression (MLR). RESULTS: The study is comprised of 26 patients with CD (age 36.6 +/- 8.6 year, male:female, 16:10) and 26 patients with GITB (age 37.2 +/- 9.6 year, male:female, 15:11). The following clinical variables between the two groups (CD vs TB) were significant in univariate analysis: duration of symptoms (58.1 +/- 9.8 vs 7.2 +/- 3.4 mo), diarrhoea (69.2% vs 34.6%), bleeding per rectum (30.7% vs 3.8%), fever (23.1% vs 69.2%), ascites (7.7% vs 34.6%) and extra-intestinal manifestations of inflammatory bowel disease (61.5% vs 23.1%). Of these, all except ascites and extra-colonic manifestations were found statistically significant by MLR. Accuracy of predicting CD was 84.62% based on the fever, bleeding P/R, diarrhoea and duration of symptoms while it was 63.4% when histology was reported as inflammatory bowel disease and 42.3% when there was recurrence of disease after surgery. Accuracy of predicting GITB was 73.1% when there was co-existing pulmonary lesions and/or abdominal lymphadenopathy; 75% when tuberculosis was reported in histology; 63.4% when granuloma was found in histology; 82.6% when TB PCR was positive; and 61.5% when smear and/ or culture was positive for AFB. Serological test was not useful in differentiation of CD from GITB. Positivity rates for CD and GITB were: p-ANCA- 3.8% and 3.8%, c-ANCA- 3.8% and 0%, IgA ASCA- 38.4% and 23.1%, and IgG ASCA- 38.4% and 42.3%, respectively. CONCLUSION: Simple clinical parameters like fever, bleeding P/R, diarrhoea and duration of symptoms have the highest accuracy in differentiating CD from GITB.

Increased prevalence of type II diabetes mellitus in hepatitis C virus infection in western India.

BACKGROUND: Type II diabetes mellitus (DM) has been shown as more common in patients with hepatitis C virus infection (HCV). Similar data from India is not available. METHODS: This 3-year prospective study included consecutive Indian patients with HCV to detect the DM. In all patients, the presence of DM, duration of DM, probable duration of HCV, genotype of HCV, presence of steatosis and presence of cirrhosis were noted. Comparable numbers of consecutive patients with hepatitis B virus infection (HBV) and irritable bowel syndrome (IBS) were analysed for the presence of DM. RESULTS: A total of 200 patients with HCV were analysed: mean age = 45.9 +/- 9.8 years; male:female=1.3:1; genotype distribution (in 80 patients which included 17 patients of DM)--genotype 3 in 47 (58%), genotype 1 in 31 (39%) and genotype 2 in 2(3%) patients; probable duration (unknown in 40 patients) of HCV = 12.8 +/- 8.2 years; steatosis in 55(27.5%) patients; cirrhosis in 88 (44%) patients. Of these 200 patients, DM was present in 44(22%) patients with mean duration of DM of 6.1 +/- 2.3 years. HCV preceded DM in 29 patients by 10.8 +/- 2.3 years. Among HCV with genotype 3, DM was present in 11(23.4%) patients and with genotype 1, DM was present in 6(19.3%) patients. In patients with DM, cirrhosis and steatosis were present in 28(63.6%) and 20(45.4%) patients, respectively, as compared to 60 (38.4%) and 35 (22.4%) patients without DM. There was significantly lower presence of DM, 24 (12%) and 19 (9.5%), in 200 patients of HBV and 200 patients of IBS, respectively. CONCLUSION: There is increased prevalence of DM in patients with HCV. HCV precedes the development of DM by a decade.

Angiogenesis in chronic liver disease.

BACKGROUND: Chronic liver disease is characterized by inflammation and fibrosis. As a consequence angiogenesis leading to new vasculature may have prognostic value in disease progression. Interfering with angiogenesis may be a potential target to avoid progression of liver disease. Hence we planned to evaluate the CD34 and vascular endothelial growth factor (VEGF), the markers for angiogenesis in chronic liver disease. METHOD: Liver biopsies from 79 patients of chronic liver disease and 21 cases of HCC (M: F = 4:1, age range 22 to 80) were stained for routine HE, CD 34 and VEGF immunostaining (Dako Corp & Santa Cruz respectively). Etiologies of chronic liver disease were alcoholic liver disease, HBV, HCV infection, NAFLD, autoimmune liver disease, and cryptogenic liver disease. Thirty biopsies from normal liver obtained at autopsy were taken as controls. Expressions of CD 34 and VEGF were compared with the stage of fibrosis. RESULTS: Out of 79 patients, angiogenesis was seen in 45.5% cases of chronic liver disease. None of the case with normal liver histology was CD 34 or VEGF positive. No significant correlation of angiogenesis was found between any etiologies of chronic liver disease. CD 34 was positive in 18/21 (85.7%) cases of hepatocellular carcinoma. CD 34 and VEGF positivity was 20.9% and 46.5% in stage 1 and 2 fibrosis while it was 75% and 80% in stage 3 and 4 fibrosis respectively. VEGF appeared more common as compared to CD 34 in early fibrosis. CONCLUSION: Angiogenesis was present in 45.5% cases of chronic liver disease. It was proportional to the increase in stage of fibrosis. Expression of VEGF was commonly found in early stages of fibrosis. Hence, therapeutic strategies of inhibiting VEGF expression may be of importance in preventing the progression of chronic liver disease in its early stage.

Monotherapy with peginterferon alpha-2b {12 kDa} for chronic hepatitis C infection in patients undergoing haemodialysis.

BACKGROUND: A combination of Peginterferon and Ribavirin is the standard treatment for patients with chronic hepatitis C viral infection (HCV). Ribavirin is contraindicated in patients with chronic renal failure (CRF). Conventional Interferon monotherapy is effective in around 30% of such patients. There is scanty data on the use of Peginterferon monotherapy in them. METHODS: We describe our preliminary experience of monotherapy with Peginterferon alpha- 2b {12 kDa} (Peg-IFN) for HCV patients undergoing haemodialysis for CRF. They were treated with Peg-IFN 1 microg/kg body weight subcutaneously once a week for 24 weeks. In all patients, clinical (age, sex, mode of acquiring HCV, pattern of haemodialysis) and virological (HCV RNA quantitative-PCR and genotype) profile was noted at baseline. Early virological response at 12 weeks (EVR), end-of-treatment virological response at 24 weeks (ETVR) and sustained virological response after 6 months of stopping treatment (SVR) were noted during the follow-up period. RESULTS: The clinical and virological characteristics of patients were as follows: Of a total number of 6 patients, 5 were male and 1 was female with an age range of 35 to 62 years. The duration of haemodialysis was from between 5 and 12 months before the start of treatment and its frequency lay between 1 and 3 times a week. The mode of acquiring HCV was blood transfusion (100%). All 6 cases suffered from chronic hepatitis. The genotype distribution was genotype 3 in 3 (50%), genotype 1 in 1 (16.7%) and genotype none of 6 in 2 (33.3%) patients. All the patients (100%) completed treatment. EVR was seen in all 6 patients (100%). ETVR was seen in 5 of 6 patients (83.3%). A follow-up period of more than 1 year was available in 4 patients. 3 of these 4 patients (75%) had SVR. A virological response was maintained in all 3 (100%) patients with SVR even after 6 months of renal transplantation. CONCLUSION: Peg-IFN monotherapy is safe and effective in patients with HCV who are on haemodialysis for CRF.

Primary mesenteric venous thrombosis: a study from western India.

INTRODUCTION: The prevalence and clinical spectrum of mesenteric venous thrombosis (MVT) in India is largely unknown. METHODS: We retrospectively re-viewed the case records of patients with primary mesenteric venous thrombosis seen over a 10-year period and retrieved information on clinical picture, underlying hypercoagulable states and outcome. RESULTS: The 28 cases (mean age 41.2 [SD 10.2] years; 19 male) included 13 with acute MVT, 10 with subacute MVT and 5 with chronic MVT. Ten patients had past thromboembolic events (multiple events in five); four patients had isolated superior mesenteric vein involvement and 14 had multiple vessel involvement. Hypercoagulable state was identified in 17 patients, with multiple etiologies in 7 patients. Pre-operative diagnosis was made in all patients. Ten patients needed surgical management; the rest were managed medically initially, but 2 required surgery on follow up. Seven patients died during a follow up of up to 10 years, with in-hospital mortality during index admission in six. CONCLUSIONS: Most of the patients with MVT have multiple intra-abdominal vessel involvement and underlying hypercoagulable state. The policy of early treatment with anticoagulation in all and surgical treatment as per need, achieves low mortality.

Spectrum of autoimmune liver diseases in western India.

BACKGROUND AND AIM: The prevalence and spectrum of autoimmune liver diseases (AILDs) in India are rarely reported in comparison to the West. METHOD: During a study period of 7 years, all patients with chronic liver diseases (CLDs) were evaluated for the presence of AILDs on the basis of clinical, biochemical, imaging, serological, and histological characteristics. RESULTS: Of a total of 1760 CLD patients (38.1% females), 102 patients (5.7%) had an AILD. A total of 75 (11.2%) female patients had an AILD. Among males, 27 (2.4%) had an AILD. The prevalence of AILDs in women increased from 11.2% to 45.7% and in men from 2.4% to 10.3%, after excluding alcohol, hepatitis B virus, and hepatitis C virus as a cause of CLD. Of the AILDs, autoimmune hepatitis (AIH) was present in 79 patients (77.4%), followed in descending order by primary biliary cirrhosis (PBC) in 10 patients (9.8%), PBC/AIH true overlap syndrome in six patients (5.8%), primary sclerosing cholangitis (PSC) in five patients (4.9%), and PBC/AIH switchover syndrome in two patients (1.9%). None had PSC/AIH or PBC/PSC overlap syndrome. Associated known autoimmune diseases were found in 40 (39.2%) patients. CONCLUSIONS: AILDs are not uncommon in India. They should be suspected in all cases of CLDs, especially in middle-aged women who do not have problems with alcoholism and who are without viral etiology, as well as in all patients with known autoimmune diseases.

Do different hepatitis C virus genotypes behave differently?

BACKGROUND: The natural history of hepatitis C genotype III infection, the predominant form in India, is not wholly understood. This study attempted to compare the natural history of diseases due to genotypes III and I. METHODS: This 10-year prospective follow-up study (mean follow-up period = 3.6 +/- 1.4, range = 1-10 years) included 108 patients of hepatitis C. Group 1 comprised 65 patients with hepatitis C genotype III infection (mean age = 46.1 +/- 11.3 years, male: female = 1.8 : 1) and group 2 comprised 43 patients with hepatitis C genotype I infection (mean age = 44.2 +/- 8.2 years, male: female = 2.1 : 1). Demographic features, clinical presentation and course, response to treatment (either interferon-ribavirin or peginterferon-ribavirin combination) and complications were noted for all patients. Data were analysed using the chi-square test and Student's t-test. RESULTS: The number of steatosis cases was larger in group 1 (32.3%, 21/65 patients) than in group 2 (18.6%, 8/43 patients) although statistically not significant. There was no significant difference in the mode of infection, presence of diabetes, obesity or alcoholism, clinical presentation, extra-hepatic manifestations, stage of liver disease, complications like decompensation or hepatocellular carcinoma and mortality. Overall, the sustained treatment response was significantly greater in group 1 patients [(87.5%, 21/24 treated patients vs. 56.2%, 9/16 treated patients in group 2; p = 0.0001)]. CONCLUSION: HCV with genotype III was associated with better treatment response. Although statistically not significant, more number of patients in genotype III had steatosis.

Differential diagnosis of acute liver failure in India.

BACKGROUND: Acute liver failure (ALF) is a condition with rapid deterioration of liver function resulting in hepatic encephalopathy and/or coagulopathy in patients with previously normal liver. Complicated forms of certain infectious diseases like falciparum malaria, leptospirosis, dengue fever, ricketsial fever, typhoid fever, haemophagocytosis, herpes simplex virus, cytomegalovirus, tuberculosis or amoebic liver abscess can present with altered mentation and/or bleeding manifestations in presence of jaundice and mimic ALF due to acute viral hepatitis (AVH). METHODS: We describe our experience in last 2 years with 28 patients of ALF due to above mentioned conditions (ALF-ID) and compared them with 28 patients with ALF due to AVH (ALF-AVH). RESULTS: In ALF-ID, typhoid fever was present in 1, haemophagocytosis in 1, ricketsial infection in 4 (scrub typhus = 2, endemic typhus = 2), amoebic liver abscess in 4, leptospirosis in 5, dengue fever in 5 and falciparum malaria in 8 patients. In ALF-AVH, hepatitis E and B co-infection was responsible in 1, hepatitis A and E co-infection in 1 and hepatitis E, B and C co-infection in 1, hepatitis E in 18, hepatitis A in 2 and hepatitis B in 5 patients. Differentiation of various forms of ALF-ID from ALF-AVH depends on various clinical, haematological and biochemical parameters, in addition to specific diagnostic tests. Patients with ALF-AVH had mortality rate of 50% (14/28) and ALF-ID had mortality rate of 25% (7/28). CONCLUSIONS: In developing countries, ALF-mimicking infections should be looked for in differential diagnosis of ALF. Early identification and treatment of these infections is important in reducing mortality.

An experience with covered transjugular intrahepatic portosystemic shunt for refractory ascites from western India.

BACKGROUND: In refractory ascites/hydrothorax (RA), uncovered transjugular intrahepatic portosystemic shunt (TIPS) is shown to be superior to large-volume therapeutic paracentesis (LVP) for long-term control of ascites, but at a cost of increased risk of hepatic encephalopathy (HE). Use of covered TIPS has shown to improve shunt patency rate over uncovered TIPS. This retrospective analysis was performed on patients with RA to assess efficacy of TIPS, both covered and uncovered. METHODS: Over 10-year period, patients with RA, patients either required LVP at least 2 times in a month, or were intolerant to LVP, or were unwilling to undergo further LVP, were treated with TIPS (Group-A = 12 patients with uncovered TIPS {Wallstent = 10, Memotherm = 1, SMART = 1}, age = 56.1 +/- 4.5 years, male: female = 5:1; Group-B = 11 patients with e-PTFE-covered TIPS {Viatorr = 11}, age = 55.8 +/- 5.2 years, male: female = 8:3). They were followed-up with clinical and ultrasonography/ Doppler examination every monthly for 3 months and every 3 monthly thereafter (mean = 9.6 +/- 4.2 months). Clinical success (disappearance of ascites at 1-month), technical success (post-TIPS reduction of portosystemic pressure gradient {PPG} < 12 mmHg), appearance of encephalopathy, TIPS-dysfunction (> 50% reduction in flow-velocity, > 50% shunt stenosis or increase in PPG > 12 mmHg in presence of symptoms) and mortality were noted. Data were analyzed using chi-square test and t test. RESULTS: Baseline clinical and biochemical characteristics were similar in both groups. TIPS placement was possible in 11/12 group-A and 11/ 11 group-B patients. Fall in PPG after TIPS was similar in both groups. One patient in group-A was lost followup after the procedure. On comparison of group-A and group-B, clinical success (63.3% and 81.8%), technical success (90.9% and 100%), occurrence of HE (60% and 54.4%) and mortality at 1-year (70% and 63.3%) were not significantly different. TIPS-dysfunction requiring re-intervention was significantly more common in group-A (50%) than group-B (0%). CONCLUSIONS: Covered TIPS was superior to uncovered TIPS, because of less TIPS-dysfunction without increasing chances of HE; but failed to offer any survival advantage.

Combination of Peginterferon alpha-2b (12 kDa) and Lamivudine in difficult-to-treat chronic hepatitis B- an Indian experience.

INTRODUCTION: Treatment strategies for chronic hepatitis B (CHB) using either interferon or Lamivudine can achieve sustained response in 30-40 % in HBeAg positive CHB. Retreatment of treatment failure in CHB and treatment of HBeAg negative patients pose major therapeutic challenge. Because of success story of Peginterferon in hepatitis C and some preliminary data in CHB, we undertook this open-labeled prospective study to study the response of Peginterferon alpha-2b (PegIFN) and Lamivudine combination in patients of CHB. MATERIALS AND METHODS: Following 4 groups of patients of CHB with persistently elevated transaminases were treated with Lamivudine 100 mg PO daily and PegIFN 1.5 microg/kg SC once a week- 1) HBeAg negative treatment naive patients- for 12 months 2) HBeAg negative patients who were nonresponsive to at least two treatment regimens for 12 months, 3) HBeAg positive treatment naive patients- for 6 months 4) HBeAg positive patients who were treatment failure at least with two regimens- for 6 months. Patients were tested for LFT, HBeAg, antiHBe, quantitative HBVDNA (only in HBeAg negative CHB) and liver biopsy when possible at inclusion. During treatment period, LFT was tested at monthly interval and HBeAg, antiHBe and HBVDNA (in HBeAg negative CHB) at 3 monthly intervals. End of treatment response (EOR) was assessed at end of treatment period and sustained response (SR) at 6 months post treatment. Treatment response was defined in HBeAg positive patients with normalization of enzymes and disappearances of HBeAg & in antiHBe positive patients with normalization of enzymes and loss of detectable HBVDNA. RESULTS: Total 25 patients with CHB were included in this study with mean age of 37.9 +/- 4.6 years (range 20-56) and male: female= 11.5:1. 1) In HBeAg negative treatment naive patients, 4/6 patients achieved EOR (66.6%), whereas in 3/6 patients (50%) had SR. 2) In HBeAg negative treatment failure group, 4/5 patients had EOR (80%) and 3/5 patients achieved SR (60%), of which 1 patient lost HBsAg. 3) In HBeAg positive treatment naive patients, 4/5 patients achieved EOR (80%) and 3/5 patients obtained SR (60%). One patient in this group lost HBsAg. 4) In HBeAg positive treatment failure group, 5/9 patients achieved EOR (55.5%), whereas 3/9 patients (33.3%) obtained SR. CONCLUSION: Overall, in difficult-to-treat patients (considering groups 1, 2 & 4- total 20 patients) with combination of PegIFN and Lamivudine, EOR was seen in 13 patients (65%), SR was obtained in 9 patients (45%) and loss of HBsAg was seen in 1 patient (5%).

Antiviral therapy of decompensated cirrhosis due to hepatitis C viral infection.

BACKGROUND: For decompensated HCV cirrhosis, liver transplantation is the only available treatment. Only a few studies in world literature have used antiviral therapy in this situation. METHODS: During a 4-year period, we gave closely monitored antiviral therapy to all consecutive patients of HCV-related cirrhosis with episodes of decompensation. Patients who were excluded from the standard Interferon trials were treated. Patients were started on low dose Interferon alpha-2b (1 MIU tiw) and Ribavirin (800 mg/day) combination therapy or low-dose Interferon alpha- 2b (1 MIJ tiw) monotherapy (in the presence of renal failure) for 6 months to 1 year. Dose of Interferon was escalated gradually to a maximum dose of 3 MIU tiw according to clinical follow-up. RESULTS: A total of 18 patients (mean age = 51.6 +/- 9.8 years; male: female ratio= 10: 8) were treated. At baseline, mean Child-Pugh score was 9.4 +/- 0.8 (range = 7-12). Interferon monotherapy was given to 4 (22.2%) and combination therapy to 14 (77.8%) patients after clinical recovery from an episode of decompensation. Though 16 (88.9%) patients noticed some adverse events, 15 (83.3%) patients completed the treatment schedule. Premature discontinuation was warranted in 3 (16.7%) patients. Out of the 15 patients who completed the treatment schedule, mean maximum tolerated dose of Interferon was 1.73 +/- 0.6 MIU tiw, 10 patients had genotype II or III and 2 patients had genotype I. Of these, end-of-treatment virological response was seen in 11 (73.3 %) and sustained virological response (at 6 months) in 7 (46.6 %) patients. All these patients were followed up for a mean duration of 1.3 +/- 0.6 years (6 month to 3.5 years). During follow up, 7 non-responders had further episodes of decompensation, of whom 4 died. CONCLUSION: Although there is high intolerance to the treatment, closely-monitored low dose escalating Interferon and/ or Ribavirin therapy achieves good results.

Clinical spectrum and natural history of non-alcoholic steatohepatitis with normal alanine aminotransferase values.

Non-alcoholic fatty liver disease (NAFLD) including nonalcoholic steatohepatitis (NASH) is a well-established cause for chronic liver disease. In most studies on NASH, elevation in alanine aminotransferase (ALT) is taken as one of the diagnostic criteria. However, the clinical and histological spectrum and natural history of NAFLD with normal ALT are not well explored. This study was planned to define the clinical spectrum and natural history of patients with NAFLD with normal ALT, and to compare them with NAFLD with abnormal ALT. A prospective study including 81 consecutive patients with ahistological diagnosis ofNAFLD was planned during the period from 1999 to 2003. Consecutive (n=81) patients with the histological diagnosis of NAFLD were included in the study. In all the patients, clinical, anthropometric, laboratory, histological and imaging features were noted at the baseline. All these patients were followed up regularly at 6-month intervals. Of the 81 cases, 25 patients (including 60% cirrhotics) had persistently normal enzyme, whereas 56 (including 23% cirrhotics) had abnormal ALT. Both the groups were comparable with respect to distribution of age, gender, ethnicity, clinical features, imaging features, histological severity and laboratory features; except a higher incidence of diabetes and higher occurrence of advanced liver disease at baseline in NAFLD with normal ALT. Natural history of NAFLD was better in patients without cirrhosis irrespective of baseline ALT levels than in patients with cirrhosis; except for a higher incidence of decompensation in cirrhotics with normal ALT. The entire clinical and histological spectrum of NAFLD is seen in patients with normal ALT and is not different from patients with abnormal ALT. In patients with diabetes and hepatomegaly in the absence of other obvious liver diseases, even normal ALT may not rule out advanced liver disease, and liver biopsy may be necessary to identify the severity of liver disease.

Prevalence of metabolic syndrome in non-diabetic and non-cirrhotic patients with non-alcoholic steatohepatitis.

Recently, insulin resistance (IR) was proposed as a primary pathogenic mechanism in non-alcoholic steatohepatitis (NASH). The prevalence of IR and metabolic syndrome remains largely unstudied in patients with NASH and without diabetes and cirrhosis, both being conditions associated with IR. During a 1-year period, all non-diabetic and noncirrhotic patients seen in our institute with a diagnosis of NASH were subjected to anthropometric measurements, clinical examination, lipid profile and glucose tolerance test to define metabolic syndrome. All the patients underwent test for fasting glucose and insulin levels to define the insulin resistance by HOMA-R (homeostasis model assessment) method. Of the 25 patients with NASH, the metabolic syndrome was present in 17 (68%) and at least one criterion for the metabolic syndrome was present in all the patients. IR was present in 20 patients (80%). All the patients were either overweight (8%) or obese (92%). Because of the high prevalence of the metabolic syndrome and IR in patients with NASH, it is pertinent to test for IR and metabolic abnormalities in all patients with NASH. Also, all patients with metabolic syndrome should undergo liver function tests and, in the presence of abnormal transaminases, a liver biopsy to define NASH.

Primary gastric tuberculosis--report of 5 cases.

BACKGROUND: Gastric tuberculosis is rare, and usually associated with pulmonary tuberculosis or an immunodeficient state. Here, we report five cases of gastric tuberculosis in immunocompetent patients without evidence of pulmonary involvement. CASE PRESENTATION: Three patients presented with gastric outlet obstruction that required surgery to relieve the obstruction as well as to confirm the diagnosis. The remaining two had involvement of gastroesophageal junction. All of them responded well to standard antitubercular treatment. CONCLUSION: Though gastric tuberculosis is rare, it should be considered a possibility when patients present with gastric outlet obstruction or with endoscopic evidence of diffuse chronic inflammatory activity, particularly in areas endemic for tuberculosis.