- Email: [email protected]
Prevalence and Spectrum of Biliary Abnormalities in Extrahepatic Portal Venous Obstruction—A Tertiary Centre Experience
MISCELLANEOUS
Table 1 Indications for Surgical Intervention (n = 110). Issues related to large spleen • Asymptomatic hypersplenism*, n = 90, 81% • Symptomatic hypersplenism*, n = 15, 14% a Spontaneous skin bleeds, n = 2 b Menorrhagia, n = 3 c Recurrent epistaxis, n = 4 d Severe unexplained anemia, n = 2 e Unconjugated hyperbilirubiinemia, n = 4 • Splenic infarction, n = 6, 5% • Dragging sensation, n = 49, 45% Non-esophageal varices • Large bleeding gastric fundal varices [secondaryˆ(n = 14) +primary# (n = 17)], 28% • Large non-bleeding gastric fundal varices [secondaryˆ(n = 15) +primary# (n = 19)], 31% • Bleeding duodenal varices, n = 2,2% • Non-bleeding duodenal varices, n = 1, 1% • Jejunal varices, n = 1, 1% • Ectopic bleeding source unidentified, n = 2,2% Growth retardation • Stunting (Ht z score < -2 SD), n = 70, 64% • Wasting (Wt z score <-2 SD), n = 79, 72% • Overall growth failure (stunting ± wasting), n = 74, 67% Symptomatic portal colopathy, n = 19, 17% Other rare indications, n = 4, 4% • Retroperitoneal dermoid cyst with EHPVO, n = 1 • Concomitant achalasia cardia with EHPVO, n = 1 • Pierre Robin syndrome with EHPVO, n = 1 • Geographical inaccessibility for regular endotherapy, n = 1 MISCELLANEOUS
evolved over 2 decades beyond EEEV requiring portosystemic shunt surgery (PSS) and their surgical outcome. Methods: We studied all EHPVO children who were referred for surgery (March 2000–April 2015). Baseline laboratory and last variceal status, indications of surgery, surgical details and its post-operative outcome were analysed. Post PSS, shunt patency was recorded at regular intervals by doppler-ultrasound. Patients with follow-up >12 months post PSS were analysed for long-term outcome. Results: Seven hundred and thirty five (735) EHPVO children were under endoscopic therapy and surveillance during the study period. After EEEV, 110 were referred for surgery for delayed sequelae. Surgical indications, types of PSS and post-operative outcome are shown in Table 1 and Figure 1. Age at surgery was 13(3.2–21) years. Duration between first symptom (variceal bleed or incidentally detected splenomegaly) to surgery was 7(0.1–18) years. Post-PSS portal pressures significantly dropped from the baseline pre-PSS pressures [22(13–34) and 34(17–50), P < 0.001]. In 89 follow-up PSS patients, 91% had shunt patency over 28(2–121) months. The rest seven with shunt block required repeat EEEV. 79 patients with follow-up >12 months were analysed for outcome. Among those with PCC (n = 29), symptoms persisted in 30% and biochemically in 47% post-PSS. Symptoms of portal colopathy S108
Figure 1. Outcome of portosystemic shunt surgery procedures in EHPVO.
resolved in all. Growth parameters improved [Pre and postPSS height z scores: −2.3(−4.9 to +1.3) and −1.01(−3.2 to +2.3); P < 0.001; pre and post PSS weight z scores: −2.5(−4.8 to +3.6) and −1.2(−3.1 to +2.8), P < 0.001]. Conclusion: Primary endoscopic therapy has resulted in a shift in indications and resurgence of portosystemic shunt surgery mainly for delayed sequelae of portal hypertension. Non-selective PSS has an overall favourable outcome in children with EHPVO.
CONFLICTS OF INTEREST The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.192
41 PREVALENCE AND SPECTRUM OF BILIARY ABNORMALITIES IN EXTRAHEPATIC PORTAL VENOUS OBSTRUCTION—A TERTIARY CENTRE EXPERIENCE Senthamizh Selvan 1,∗ , Pugazhendhi Thangavelu 2 , Mohammed Ali 2 1 Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India 2 Madras Medical College, Chennai, India
© 2017, INASL
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
E-mail address: [email protected] (S. Selvan).
42
Background and Aim: Portal cavernoma cholangiopathy (PCC) refers to abnormalities in extra hepatic biliary system including cystic duct and gallbladder with or without involvement of 1st and 2nd generation biliary ducts in a patient with portal cavernoma. The symptoms of PCC usually develop late in the course of portal hypertension. Magnetic resonance cholangiography (MRC) and portovenography is the non-invasive modality of choice for characterization of PCC. Portal decompression alone can change the natural history of PCC. The objective of present study was to find the prevalence and spectrum of biliary abnormalities in extra hepatic portal venous obstruction (EHPVO). Methods: Consecutive patients with EHPVO attending Gastroenterology department between January and December 2015 were included. Demographic details, clinical features at presentation, liver function tests, endoscopic findings and imaging features on MRC coupled with MR portovenogram were collected. The details of Endoscopic retrograde cholangiopancreatography (ERCP) in indicated patients were also recorded. Results: A total of 30 patients were analyzed during the study period. Their mean age was 34.2 years with a male preponderance (n = 20). Biliary symptoms were observed in only one third of our patients. Liver function test abnormalities were noted in 12 patients (40%). The imaging abnormalities on MRC were seen in 20 patients (66.67%). They included: pericholedochal plexus in 12, epicholedochal plexus in 8, gall bladder varices in 6, gall stones in 6 patients, biliary strictures in 9 and bile duct stones in four patients. ERCP was done in 10 patients (33.33%) for choledocholithiasis, bile duct strictures, persistent LFT abnormality and cholangitis. Conclusion: In conclusion, the prevalence of PCC was 67%. A majority of these patients were asymptomatic. Hence, an early diagnosis is essential for planning definitive therapy in PCC.
CLINICAL STUDY OF ASCITES WITH SPECIAL REFERENCE TO SERUM ASCITES ALBUMIN GRADIENT
CONFLICTS OF INTEREST The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.193
Kiran D. Shinde, Praveen Kumar ∗ , Praveen Mathew, Prashant Kanni, Vishakha Khalde, Suraj Ujjalapati, Mounika Killari, P. Manjunath, S. Shruthi, Nishant Dubey Vydehi Institute Of Medical Sciences and Research Centre, Bangalore, India
Background and Aim: Ascites is a common clinical problem with broad aetiology. Cost effective and widely available biochemical parameters are required to differentiate Ascites which can correlate with pathogenesis and pin point towards an aetiology with high sensitivity and significant accuracy. Aim of the study was to understand clinical profile and to determine the sensitivity, specificity and diagnostic efficacy of serum Ascites albumin Gradient (SAAG) in evaluating their diagnostic role in identifying the aetiology of Ascites. Method: It was observational cross sectional study conducted at VIMS & RC, Bangalore in department of medical gastroenterology. In this study, 100 patients of Ascites were evaluated for ascitic fluid total protein, albumin, TLC, SAAG along with ultrasound and other required investigations. Results: The distribution of Ascites among the males and the females was 83 and 17 respectively. Irrespective of sex maximum cases were in age group of 51–60 years contributing 28%. Major symptoms irrespective of aetiology were abdominal distension (100), anorexia (71), melena (56), fever (33), abdominal pain (20), Jaundice and decreased urine output 19 each and haematemasis (18). Major signs spider naevi 36 cases followed by icterus 28 cases, splenomegaly 22 cases, pallor 21cases, flapping tremors 15 cases and pedal oedema 10 cases. There were 72 exudative and 28 transudative cases of ascites, 73 found having portal hypertension. Sensitivity, Specificity, PPV and NPV of SAAG & AFP for Portal hypertension were 90.41%, 96.29%, 98.51% and 78.79% & 35.62%, 92.59%, 92.86% and 34.72% respectively. Mean SAAG were significantly elevated in Hepatocellular carcinoma and least was in Tb peritonitis. Conclusion: Estimation of SAAG does not give the diagnosis of Ascites but it can point out towards the underlying mechanism and hence helps in differential diagnosis. Sensitivity of SAAG is high (90.41) compared to Ascitic fluid total protein (35.62) which is routinely used to classify Ascites.
Journal of Clinical and Experimental Hepatology July 2017 Vol. 7 No. S2
S109
MISCELLANEOUS
E-mail address: [email protected] (P. Kumar).
Table 1 Indications for Surgical Intervention (n = 110). Issues related to large spleen • Asymptomatic hypersplenism*, n = 90, 81% • Symptomatic hypersplenism*, n = 15, 14% a Spontaneous skin bleeds, n = 2 b Menorrhagia, n = 3 c Recurrent epistaxis, n = 4 d Severe unexplained anemia, n = 2 e Unconjugated hyperbilirubiinemia, n = 4 • Splenic infarction, n = 6, 5% • Dragging sensation, n = 49, 45% Non-esophageal varices • Large bleeding gastric fundal varices [secondaryˆ(n = 14) +primary# (n = 17)], 28% • Large non-bleeding gastric fundal varices [secondaryˆ(n = 15) +primary# (n = 19)], 31% • Bleeding duodenal varices, n = 2,2% • Non-bleeding duodenal varices, n = 1, 1% • Jejunal varices, n = 1, 1% • Ectopic bleeding source unidentified, n = 2,2% Growth retardation • Stunting (Ht z score < -2 SD), n = 70, 64% • Wasting (Wt z score <-2 SD), n = 79, 72% • Overall growth failure (stunting ± wasting), n = 74, 67% Symptomatic portal colopathy, n = 19, 17% Other rare indications, n = 4, 4% • Retroperitoneal dermoid cyst with EHPVO, n = 1 • Concomitant achalasia cardia with EHPVO, n = 1 • Pierre Robin syndrome with EHPVO, n = 1 • Geographical inaccessibility for regular endotherapy, n = 1 MISCELLANEOUS
evolved over 2 decades beyond EEEV requiring portosystemic shunt surgery (PSS) and their surgical outcome. Methods: We studied all EHPVO children who were referred for surgery (March 2000–April 2015). Baseline laboratory and last variceal status, indications of surgery, surgical details and its post-operative outcome were analysed. Post PSS, shunt patency was recorded at regular intervals by doppler-ultrasound. Patients with follow-up >12 months post PSS were analysed for long-term outcome. Results: Seven hundred and thirty five (735) EHPVO children were under endoscopic therapy and surveillance during the study period. After EEEV, 110 were referred for surgery for delayed sequelae. Surgical indications, types of PSS and post-operative outcome are shown in Table 1 and Figure 1. Age at surgery was 13(3.2–21) years. Duration between first symptom (variceal bleed or incidentally detected splenomegaly) to surgery was 7(0.1–18) years. Post-PSS portal pressures significantly dropped from the baseline pre-PSS pressures [22(13–34) and 34(17–50), P < 0.001]. In 89 follow-up PSS patients, 91% had shunt patency over 28(2–121) months. The rest seven with shunt block required repeat EEEV. 79 patients with follow-up >12 months were analysed for outcome. Among those with PCC (n = 29), symptoms persisted in 30% and biochemically in 47% post-PSS. Symptoms of portal colopathy S108
Figure 1. Outcome of portosystemic shunt surgery procedures in EHPVO.
resolved in all. Growth parameters improved [Pre and postPSS height z scores: −2.3(−4.9 to +1.3) and −1.01(−3.2 to +2.3); P < 0.001; pre and post PSS weight z scores: −2.5(−4.8 to +3.6) and −1.2(−3.1 to +2.8), P < 0.001]. Conclusion: Primary endoscopic therapy has resulted in a shift in indications and resurgence of portosystemic shunt surgery mainly for delayed sequelae of portal hypertension. Non-selective PSS has an overall favourable outcome in children with EHPVO.
CONFLICTS OF INTEREST The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.192
41 PREVALENCE AND SPECTRUM OF BILIARY ABNORMALITIES IN EXTRAHEPATIC PORTAL VENOUS OBSTRUCTION—A TERTIARY CENTRE EXPERIENCE Senthamizh Selvan 1,∗ , Pugazhendhi Thangavelu 2 , Mohammed Ali 2 1 Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India 2 Madras Medical College, Chennai, India
© 2017, INASL
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
E-mail address: [email protected] (S. Selvan).
42
Background and Aim: Portal cavernoma cholangiopathy (PCC) refers to abnormalities in extra hepatic biliary system including cystic duct and gallbladder with or without involvement of 1st and 2nd generation biliary ducts in a patient with portal cavernoma. The symptoms of PCC usually develop late in the course of portal hypertension. Magnetic resonance cholangiography (MRC) and portovenography is the non-invasive modality of choice for characterization of PCC. Portal decompression alone can change the natural history of PCC. The objective of present study was to find the prevalence and spectrum of biliary abnormalities in extra hepatic portal venous obstruction (EHPVO). Methods: Consecutive patients with EHPVO attending Gastroenterology department between January and December 2015 were included. Demographic details, clinical features at presentation, liver function tests, endoscopic findings and imaging features on MRC coupled with MR portovenogram were collected. The details of Endoscopic retrograde cholangiopancreatography (ERCP) in indicated patients were also recorded. Results: A total of 30 patients were analyzed during the study period. Their mean age was 34.2 years with a male preponderance (n = 20). Biliary symptoms were observed in only one third of our patients. Liver function test abnormalities were noted in 12 patients (40%). The imaging abnormalities on MRC were seen in 20 patients (66.67%). They included: pericholedochal plexus in 12, epicholedochal plexus in 8, gall bladder varices in 6, gall stones in 6 patients, biliary strictures in 9 and bile duct stones in four patients. ERCP was done in 10 patients (33.33%) for choledocholithiasis, bile duct strictures, persistent LFT abnormality and cholangitis. Conclusion: In conclusion, the prevalence of PCC was 67%. A majority of these patients were asymptomatic. Hence, an early diagnosis is essential for planning definitive therapy in PCC.
CLINICAL STUDY OF ASCITES WITH SPECIAL REFERENCE TO SERUM ASCITES ALBUMIN GRADIENT
CONFLICTS OF INTEREST The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.193
Kiran D. Shinde, Praveen Kumar ∗ , Praveen Mathew, Prashant Kanni, Vishakha Khalde, Suraj Ujjalapati, Mounika Killari, P. Manjunath, S. Shruthi, Nishant Dubey Vydehi Institute Of Medical Sciences and Research Centre, Bangalore, India
Background and Aim: Ascites is a common clinical problem with broad aetiology. Cost effective and widely available biochemical parameters are required to differentiate Ascites which can correlate with pathogenesis and pin point towards an aetiology with high sensitivity and significant accuracy. Aim of the study was to understand clinical profile and to determine the sensitivity, specificity and diagnostic efficacy of serum Ascites albumin Gradient (SAAG) in evaluating their diagnostic role in identifying the aetiology of Ascites. Method: It was observational cross sectional study conducted at VIMS & RC, Bangalore in department of medical gastroenterology. In this study, 100 patients of Ascites were evaluated for ascitic fluid total protein, albumin, TLC, SAAG along with ultrasound and other required investigations. Results: The distribution of Ascites among the males and the females was 83 and 17 respectively. Irrespective of sex maximum cases were in age group of 51–60 years contributing 28%. Major symptoms irrespective of aetiology were abdominal distension (100), anorexia (71), melena (56), fever (33), abdominal pain (20), Jaundice and decreased urine output 19 each and haematemasis (18). Major signs spider naevi 36 cases followed by icterus 28 cases, splenomegaly 22 cases, pallor 21cases, flapping tremors 15 cases and pedal oedema 10 cases. There were 72 exudative and 28 transudative cases of ascites, 73 found having portal hypertension. Sensitivity, Specificity, PPV and NPV of SAAG & AFP for Portal hypertension were 90.41%, 96.29%, 98.51% and 78.79% & 35.62%, 92.59%, 92.86% and 34.72% respectively. Mean SAAG were significantly elevated in Hepatocellular carcinoma and least was in Tb peritonitis. Conclusion: Estimation of SAAG does not give the diagnosis of Ascites but it can point out towards the underlying mechanism and hence helps in differential diagnosis. Sensitivity of SAAG is high (90.41) compared to Ascitic fluid total protein (35.62) which is routinely used to classify Ascites.
Journal of Clinical and Experimental Hepatology July 2017 Vol. 7 No. S2
S109
MISCELLANEOUS
E-mail address: [email protected] (P. Kumar).