- Email: [email protected]
l -Ornithine l -Aspartate in Acute Overt Hepatic Encephalopathy
CIRRHOSIS AND COMPLICATIONS
Figure 1. This figure shows XPD Lys751Gln mutation represented by the presence of single band at 530 bp at lane 4 and 6 which is wild type. Presence of three bands at 192 bp, 338 bp, 530 bp respectively at lane no 2,5 represents heterozygous mutant allele while.
Table 1 Gender
N
%
Male Female P value
171 29
85.5 14.5
Xpdlys751gln Polymorphism (heterozygous) + (homozygous)
Xpdasp312asn Polymorphism (heterozygous) + (homozygous)
26 + 14 = 40 4 + 7 = 11 0.0967
9 + 7 = 16 4+0=4 0.5012
designed prospective studies are required to validate this association (Figure 1 and Table 1). CIRRHOSIS AND COMPLICATIONS
CONFLICTS OF INTEREST
samples were analyzed for WCC and ANC using standard laboratory techniques. Periscreen Strip was dipped in the same sample for 30 s and observed for 5 min. Color change on the strip was compared with cell count. Results: 72 patients with ascites underwent both Periscreen and laboratory analysis of WCC and ANC. Median age was 52 years, M:F, 4:1. Twenty four (33.3%) patients were diagnosed with SBP based on WCC ≥ 500 cells/mm3 . Sensitivity and specificity of Periscreen test was 70.8% and 100%, respectively. However, when ANC ≥ 250 cells/mm3 was defined as SBP (20.8% patients), the sensitivity increased to 100% and the specificity was 96%. AUROC score for excluding SBP with Periscreen was 0.93 Conclusion: Periscreen Strip test is a useful test for rapid diagnosis of SBP with excellent sensitivity and specificity. ANC has a better diagnostic value than WCC for diagnosing SBP. This test can be easily performed at the bedside for early initiation of treatment.
CONFLICTS OF INTEREST Periscreen Strips were supplied by Serim Research Corp, Indiana, USA. http://dx.doi.org/10.1016/j.jceh.2017.05.102
The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.101
14 PERISCREEN STRIP TEST—RAPID DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS Dinesh Jothimani ∗ , Ezhil Arasan, Vaibhav Patil, Mohamed Rela
15 L-ORNITHINE L-ASPARTATE IN ACUTE OVERT HEPATIC ENCEPHALOPATHY Sandeep S. Sidhu 1,∗ , Barjesh C. Sharma 2 , Omesh Goyal 2 , Harsh Kishore 2 , Navpreet Kaur 2 1 Dayanand Medical College and Hospital, Ludhiana, India 2 Institute of Liver and Biliary Sciences, New Delhi, India
E-mail address: [email protected] (S.S. Sidhu).
Gleneagles Global Health City, Chennai, India
E-mail address: [email protected] (D. Jothimani). Background and Aim: Delay in the diagnosis of spontaneous bacterial peritonitis (SBP) is associated with significant morbidity and mortality. Conventional diagnosis of SBP is based on the presence of ascitic fluid white cell count (WCC) ≥ 500 cells/mm3 or absolute neutrophil count (ANC) ≥ 250 cells/mm3 . Periscreen (Serim Research Corp, USA) is a new reagent strip specifically designed to test leukocyte esterase activity, an enzyme released by activated neutrophils. We prospectively evaluated the usefulness of Periscreen Strip test in the diagnosis of SBP. Method: All consecutive patients with ascites from June 2016 to March 2017 were evaluated for SBP. Collected S54
Background and Aim: High quality data on efficacy of l-ornithine l-aspartate (LOLA) in cirrhotics with acute overt hepatic encephalopathy (HE) is missing. We aimed to evaluate the efficacy of intravenous LOLA in reversal of acute overt HE in cirrhotics. This prospective doubleblind randomized placebo controlled trial was conducted at Gastroenterology department of two tertiary care institutes in India. Methods: Three hundred and seventy cirrhotics with acute overt HE were screened. After exclusion, 196 (52.97%) patients were randomized to receive either intravenous infusions of LOLA (n = 98), 30 grams daily or placebo (n = 98) for 5 days. Standard of care treatment (including lactulose) was given in both groups. Fasting venous ammonia levels were estimated daily from 0 to 5 days. Serum © 2017, INASL
Table 1 Results From a Linear Regression Analysis on Venous Ammonia and Interleukins at Day 5 Adjusted for Baseline and Center.
Ammonia (g/dL) # (L = 81, P = 81) Interleukin 1 (pg/ml) # (L = 85, P = 78) Interleukin6 (pg/ml) # (L = 83, P = 79) Interleukin10 (pg/ml) # (L = 84, P = 79) TNF alpha (pg/ml) # (L = 84, P = 78)
LOLA (mean ± SD)
Placebo (mean ± SD)
Adjusted difference (95% confidence interval)a
P-value
40.3 ± 33.8
60.7 ± 35.1
20.9 (10.4–31.3)
0.0001
3.1 ± 19.5
2.4 ± 5.3
0.9 (−0.4 to 2.3)
0.15
37.8 ± 46.5
45.8 ± 54.4
3.3 (−8.8 to 15.4)
0.59
12.5 ± 32.0
19.1 ± 21.4
6.7 (−0.2 to 12.7)
0.06
11.33 ± 50.0
7.97 ± 13.1
−1.30 (−8.67 to 6.1) 0.73
a LOLA–placebo. #: Number of patients tested.
concentration of tumor necrosis factor ␣, interleukin 1, interleukin 6, interleukin10, hemogram, liver, renal function tests were performed at day 0 and 5. Primary outcome was mental state grade at day 5 of treatment. Results: After 5 days of treatment there was no significant difference in mental state grade between LOLA and placebo groups. However the mean time taken for recovery was 1.92 ± 0.93 days in LOLA group and 2.45 ± 1.06 days in placebo group, P = 0.002 (95% CI −0.852 to −0.202). Venous ammonia at day 5 and length of hospital stay were significantly lower in LOLA group. No significant change was seen in interleukins and tumor necrosis factor ␣ in both the groups. Conclusion: In patients with acute overt HE, intravenous LOLA decreases venous ammonia, decrease the time of recovery and shortens the length of hospital stay (Table 1).
CONFLICTS OF INTEREST The authors have none to declare.
skin tissue, is associated with a high mortality rate in cirrhosis. The study was done to assess the risk factors and the predictors of mortality in necrotizing fasciitis. Methods: A retrospective study was conducted at a tertiary care hospital between March 2016 and March 2017. Patients were categorized into two groups based on their in hospital outcome (survivors vs. non survivors). All patients with necrotizing fasciitis and cirrhosis were taken for the study. Results: 16 patients who were admitted in our hospital were taken for the study. Most common presentation was local swelling and erythema, fever and pain. All were males had lower limb involvement with a median age of 54 years. Most common etiology of cirrhosis was alcohol related. The mortality rate was 68.75%. Patients with Child C status, low albumin, renal failure, septic shock, coagulopathy, diabetes and late presentation to hospital had a high mortality rate. 14 patients underwent debridement. None underwent amputation. The common organisms were gram-negative bacteria Klebsiella and Escherichia coli. All patients who died had developed multi organ dysfunction syndrome including renal and lung involvement. Conclusion: Necrotizing fasciitis though a rare complication in cirrhosis has a high mortality rate. Early diagnosis and management with antibiotics and surgical debridement may reduce the mortality.
CONFLICTS OF INTEREST The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.104
17 SPECTRUM OF BACTERIAL INFECTIONS IN CIRRHOSIS OF LIVER IN A RESOURCE CONSTRAINED REGION
16
Subhendu Panigrahi ∗ , Kaibalya R. Das, Preetam Nath, Jimmy Narayan, Prasant K. Parida, Sambit K. Behera, Suryakant Parida, Debakanta Mishra, Chittaranjan Khatua, Shivaram P. Singh
NECROTIZING FASCIITIS IN CIRRHOSIS—PREDICTORS OF MORTALITY
E-mail address: [email protected] (S. Panigrahi).
http://dx.doi.org/10.1016/j.jceh.2017.05.103
Rony Thomas ∗ , Deepak Johnson, George C. Matteethra Believers Church Medical College Hospital, Thiruvalla, Kerala, India
E-mail address: [email protected] (R. Thomas). Background and Aim: Cirrhosis is associated with increase risk of infections resulting in sepsis and sepsis related mortality. Skin and soft tissue infection accounts for only minority of infections. However necrotizing fasciitis, a rare soft tissue infection manifesting as necrosis of
S.C.B. Medical College, Cuttack, India
Background and Aim: Patients with cirrhosis of liver are predisposed to bacterial infections and sepsis. Data on bacterial infections in cirrhosis of liver from India are scarce. The aim of this study was to study the spectrum of bacterial infections in hospitalized patients with cirrhosis of liver. Methods: This is a prospective cohort study including three hundred and twenty-six patients. All patients had an established diagnosis of chronic liver disease and were
Journal of Clinical and Experimental Hepatology July 2017 Vol. 7 No. S2
S55
CIRRHOSIS AND COMPLICATIONS
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Figure 1. This figure shows XPD Lys751Gln mutation represented by the presence of single band at 530 bp at lane 4 and 6 which is wild type. Presence of three bands at 192 bp, 338 bp, 530 bp respectively at lane no 2,5 represents heterozygous mutant allele while.
Table 1 Gender
N
%
Male Female P value
171 29
85.5 14.5
Xpdlys751gln Polymorphism (heterozygous) + (homozygous)
Xpdasp312asn Polymorphism (heterozygous) + (homozygous)
26 + 14 = 40 4 + 7 = 11 0.0967
9 + 7 = 16 4+0=4 0.5012
designed prospective studies are required to validate this association (Figure 1 and Table 1). CIRRHOSIS AND COMPLICATIONS
CONFLICTS OF INTEREST
samples were analyzed for WCC and ANC using standard laboratory techniques. Periscreen Strip was dipped in the same sample for 30 s and observed for 5 min. Color change on the strip was compared with cell count. Results: 72 patients with ascites underwent both Periscreen and laboratory analysis of WCC and ANC. Median age was 52 years, M:F, 4:1. Twenty four (33.3%) patients were diagnosed with SBP based on WCC ≥ 500 cells/mm3 . Sensitivity and specificity of Periscreen test was 70.8% and 100%, respectively. However, when ANC ≥ 250 cells/mm3 was defined as SBP (20.8% patients), the sensitivity increased to 100% and the specificity was 96%. AUROC score for excluding SBP with Periscreen was 0.93 Conclusion: Periscreen Strip test is a useful test for rapid diagnosis of SBP with excellent sensitivity and specificity. ANC has a better diagnostic value than WCC for diagnosing SBP. This test can be easily performed at the bedside for early initiation of treatment.
CONFLICTS OF INTEREST Periscreen Strips were supplied by Serim Research Corp, Indiana, USA. http://dx.doi.org/10.1016/j.jceh.2017.05.102
The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.101
14 PERISCREEN STRIP TEST—RAPID DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS Dinesh Jothimani ∗ , Ezhil Arasan, Vaibhav Patil, Mohamed Rela
15 L-ORNITHINE L-ASPARTATE IN ACUTE OVERT HEPATIC ENCEPHALOPATHY Sandeep S. Sidhu 1,∗ , Barjesh C. Sharma 2 , Omesh Goyal 2 , Harsh Kishore 2 , Navpreet Kaur 2 1 Dayanand Medical College and Hospital, Ludhiana, India 2 Institute of Liver and Biliary Sciences, New Delhi, India
E-mail address: [email protected] (S.S. Sidhu).
Gleneagles Global Health City, Chennai, India
E-mail address: [email protected] (D. Jothimani). Background and Aim: Delay in the diagnosis of spontaneous bacterial peritonitis (SBP) is associated with significant morbidity and mortality. Conventional diagnosis of SBP is based on the presence of ascitic fluid white cell count (WCC) ≥ 500 cells/mm3 or absolute neutrophil count (ANC) ≥ 250 cells/mm3 . Periscreen (Serim Research Corp, USA) is a new reagent strip specifically designed to test leukocyte esterase activity, an enzyme released by activated neutrophils. We prospectively evaluated the usefulness of Periscreen Strip test in the diagnosis of SBP. Method: All consecutive patients with ascites from June 2016 to March 2017 were evaluated for SBP. Collected S54
Background and Aim: High quality data on efficacy of l-ornithine l-aspartate (LOLA) in cirrhotics with acute overt hepatic encephalopathy (HE) is missing. We aimed to evaluate the efficacy of intravenous LOLA in reversal of acute overt HE in cirrhotics. This prospective doubleblind randomized placebo controlled trial was conducted at Gastroenterology department of two tertiary care institutes in India. Methods: Three hundred and seventy cirrhotics with acute overt HE were screened. After exclusion, 196 (52.97%) patients were randomized to receive either intravenous infusions of LOLA (n = 98), 30 grams daily or placebo (n = 98) for 5 days. Standard of care treatment (including lactulose) was given in both groups. Fasting venous ammonia levels were estimated daily from 0 to 5 days. Serum © 2017, INASL
Table 1 Results From a Linear Regression Analysis on Venous Ammonia and Interleukins at Day 5 Adjusted for Baseline and Center.
Ammonia (g/dL) # (L = 81, P = 81) Interleukin 1 (pg/ml) # (L = 85, P = 78) Interleukin6 (pg/ml) # (L = 83, P = 79) Interleukin10 (pg/ml) # (L = 84, P = 79) TNF alpha (pg/ml) # (L = 84, P = 78)
LOLA (mean ± SD)
Placebo (mean ± SD)
Adjusted difference (95% confidence interval)a
P-value
40.3 ± 33.8
60.7 ± 35.1
20.9 (10.4–31.3)
0.0001
3.1 ± 19.5
2.4 ± 5.3
0.9 (−0.4 to 2.3)
0.15
37.8 ± 46.5
45.8 ± 54.4
3.3 (−8.8 to 15.4)
0.59
12.5 ± 32.0
19.1 ± 21.4
6.7 (−0.2 to 12.7)
0.06
11.33 ± 50.0
7.97 ± 13.1
−1.30 (−8.67 to 6.1) 0.73
a LOLA–placebo. #: Number of patients tested.
concentration of tumor necrosis factor ␣, interleukin 1, interleukin 6, interleukin10, hemogram, liver, renal function tests were performed at day 0 and 5. Primary outcome was mental state grade at day 5 of treatment. Results: After 5 days of treatment there was no significant difference in mental state grade between LOLA and placebo groups. However the mean time taken for recovery was 1.92 ± 0.93 days in LOLA group and 2.45 ± 1.06 days in placebo group, P = 0.002 (95% CI −0.852 to −0.202). Venous ammonia at day 5 and length of hospital stay were significantly lower in LOLA group. No significant change was seen in interleukins and tumor necrosis factor ␣ in both the groups. Conclusion: In patients with acute overt HE, intravenous LOLA decreases venous ammonia, decrease the time of recovery and shortens the length of hospital stay (Table 1).
CONFLICTS OF INTEREST The authors have none to declare.
skin tissue, is associated with a high mortality rate in cirrhosis. The study was done to assess the risk factors and the predictors of mortality in necrotizing fasciitis. Methods: A retrospective study was conducted at a tertiary care hospital between March 2016 and March 2017. Patients were categorized into two groups based on their in hospital outcome (survivors vs. non survivors). All patients with necrotizing fasciitis and cirrhosis were taken for the study. Results: 16 patients who were admitted in our hospital were taken for the study. Most common presentation was local swelling and erythema, fever and pain. All were males had lower limb involvement with a median age of 54 years. Most common etiology of cirrhosis was alcohol related. The mortality rate was 68.75%. Patients with Child C status, low albumin, renal failure, septic shock, coagulopathy, diabetes and late presentation to hospital had a high mortality rate. 14 patients underwent debridement. None underwent amputation. The common organisms were gram-negative bacteria Klebsiella and Escherichia coli. All patients who died had developed multi organ dysfunction syndrome including renal and lung involvement. Conclusion: Necrotizing fasciitis though a rare complication in cirrhosis has a high mortality rate. Early diagnosis and management with antibiotics and surgical debridement may reduce the mortality.
CONFLICTS OF INTEREST The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.104
17 SPECTRUM OF BACTERIAL INFECTIONS IN CIRRHOSIS OF LIVER IN A RESOURCE CONSTRAINED REGION
16
Subhendu Panigrahi ∗ , Kaibalya R. Das, Preetam Nath, Jimmy Narayan, Prasant K. Parida, Sambit K. Behera, Suryakant Parida, Debakanta Mishra, Chittaranjan Khatua, Shivaram P. Singh
NECROTIZING FASCIITIS IN CIRRHOSIS—PREDICTORS OF MORTALITY
E-mail address: [email protected] (S. Panigrahi).
http://dx.doi.org/10.1016/j.jceh.2017.05.103
Rony Thomas ∗ , Deepak Johnson, George C. Matteethra Believers Church Medical College Hospital, Thiruvalla, Kerala, India
E-mail address: [email protected] (R. Thomas). Background and Aim: Cirrhosis is associated with increase risk of infections resulting in sepsis and sepsis related mortality. Skin and soft tissue infection accounts for only minority of infections. However necrotizing fasciitis, a rare soft tissue infection manifesting as necrosis of
S.C.B. Medical College, Cuttack, India
Background and Aim: Patients with cirrhosis of liver are predisposed to bacterial infections and sepsis. Data on bacterial infections in cirrhosis of liver from India are scarce. The aim of this study was to study the spectrum of bacterial infections in hospitalized patients with cirrhosis of liver. Methods: This is a prospective cohort study including three hundred and twenty-six patients. All patients had an established diagnosis of chronic liver disease and were
Journal of Clinical and Experimental Hepatology July 2017 Vol. 7 No. S2
S55
CIRRHOSIS AND COMPLICATIONS
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY