24Th Annual Scientific Meeting Abstracts

OUE6 UPEET1 UY21 JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY VOLUME 6, SUPPLEMENT 1, JULY 2016 Volume 6, Supplement 1, July 2016

24th Annual Scientiﬁ c Meeting Abstracts Indian National association for the Study of the Liver ELSEVIER IATION F C OR SO S S T A U L D A Y

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N I INASL

Journal of Clinical and Experimental Hepatology

Journal of Clinical and Experimental Hepatology (JCEH) is an international peer-reviewed journal of hepatology and is published by the Indian National Association for Study of the Liver (INASL). JCEH welcomes contributions from anywhere in the world. The Editorial Board comprises approximately 70 eminent hepatologists/gastroenterologists from all parts of the world. The Journal is published quarterly (March, June, September, December) by Elsevier, a division of Reed-Elsevier (India) Private Limited. It is circulated to all bonaﬁ de members of INASL and subscribers. JCEH publishes outstanding basic and clinical papers on all aspects of liver diseases, including both human and animal studies. JCEH is directed to gastroenterologists, hepatologists, liver transplant surgeons, pathologists, radiologists, and others involved in the research and treatment of a broad range of liver diseases. The Journal accepts original articles on clinical or laboratory research in the ﬁ eld of liver diseases and review articles on topics of current interest (mainly by invitation). In addition, the Journal features articles of educational value such as ‘Hepatology Quiz’, ‘Images in Hepatology’, ‘Reviews’, ‘Liver Transplant Forum’, ‘Seminar’, ‘Hepatology Elsewhere’, and ‘From Bench to Bedside’.

Subscription The journal is circulated to all bonaﬁ de members of the Indian National Association for Study of the Liver free of charge. For non-members (India), annual subscription is INR 1000 and USD 150 (outside India) by bank draft in favor of ‘Journal of Clinical and Experimental Hepatology’ payable at Chandigarh, India. For Institutional subscriptions, please write to [email protected]

INASL Governing Council (2015-2016)

President President Elect Past President Vinod K. Dixit, Varanasi Anil Arora, Delhi Vivek A. Saraswat, Lucknow

Secretary General Treasurer Radha K. Dhiman, Chandigarh Ajay Duseja, Chandigarh Members Aabha Nagral, Mumbai BS Satyaprakash, Bengaluru Manisha Bangar, Hyderabad A.V. Siva Prasad, Vizag Co-opted Members Radha K. Dhiman, Editor-in-Chief, JCEH Rakesh Kochhar, Honorary Secretary, Indian Society of Gastroenterology Vipulroy Rathod, Honorary Secretary, Society of Gastrointestinal Endoscopy of India

Copyright © 2016, Indian National Association for Study of the Liver No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without written permission from the Editor-in-Chief. Disclaimer: Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer. Please consult full prescribing information before issuing prescriptions for any products mentioned in this publication.

Printed at EIH Press, IMT Manesar (Haryana).

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J7.6-3.'#% th ! Vinod K Dixit!" Invitation to 24 INASL Annual Scientific Meeting #$%$&$'(" ! Dear Colleagues, J7.6-3.'#

" Aabha4%+-*&5.5 Nagral ! The 2016 Scientific program will focus on the discussion by prominent International and National Speakers on important topics including Hepatitis B, "! Hepatitis C, Nonalcoholic fatty Liver Disease, Alcoholic Liver Disease, Acute Liver Shivaram P. 6573*(Singh ! Failure, Acute on Chronic Liver Failure, Vascular Disorders of the Liver, HCC, Translational Hepatology, Pediatric Hepatology and Surgical Hepatology including "! Liver transplantation. An additional feature of this scientific meeting will be an )588*9:! J)6#%J7.6-3.'#% outstanding Postgraduate Course focused on issues related to the complications of ! Vivek A. Saraswat cirrhosis and Viral Hepatitis.

"!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!;59:+<=! Whether you are a Young Investigator, clinician, basic scientist, or a researcher, you will get the latest data in your specialty, and can broaden your horizons in ! %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% ! Hepatology at the INASL 2016. Take part in this exciting meeting and we are L//-,.%% looking forward to welcoming you at New Delhi.

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Journal of Clinical and Experimental Hepatology Ofﬁ cial Publication of the Indian National Association for Study of the Liver

Editor-in-Chief Radha K. Dhiman Postgraduate Institute of Medical Education & Research, Chandigarh, India

Associate Editors Anil C. Anand Paolo Angeli Sheikh Md. Fazle Akbar Army Research and Referral Hospital, University of Padova, Padova, Italy Toshiba General Hospital, Tokyo, Japan New Delhi, India Anil Dhawan Ajay Duseja, Alexander Gimson King’s College Hospital, Postgraduate Institute of Medical Addenbrookes Hospital, Cambridge, London, UK Education and Research, UK Chandigarh, India David Mutimer Vivek A. Saraswat Shivram P. Singh Queen Elizabeth Hospital, Sanjay Gandhi Postgraduate Institute SCB Medical College, Birmingham, UK of Medical Science, Lucknow, India Cuttuck, India Assistant Editor Sandeep Satsangi Postgraduate Institute of Medical Education & Research, Chandigarh, India

Liver Transplant Forum Sanjiv Saigal Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Delhi, India

From Bench to Bedside Harshad Devarbhavi St. John Hospital, Bangaluru, India

Hepatology Elsewhere Shalimar All India Institute of Medical Sciences, New Delhi, India

Statistical Consultant Ashutosh N. Aggarwal Postgraduate Institute of Medical Education & Research, Chandigarh, India

Editorial Board Subrat K. Acharya Roger F. Butterworth All Indian Institute of Medical Sciences, New Delhi, India University of Montreal, Montreal, Canada Guruprasad Aithal Dominique-Charles Valla Nottingham University Hospitals, Nottingham, UK Hôpital Beaujon, Clichy-la-Garenne, France Mamum Al-Mahtab Ashok Chauhan Bangabandhu Sheikh Mujib Medical University, Dhaka, South Carolina Medical University , Columbia, USA Bangladesh Chien-Jen Chen Catholic Fu –Jen University, Taipei, Taiwan Deepak Amarapurkar Bombay Hospital & Medical Research Centre, Gourdas Choudhari Mumbai, India Fortis Memorial Research Institute, Gurgaon, India Anil Arora Janak De-Silva Sir Ganga Ram Hospital, New Delhi, India University of Kelaniya, Ragama, Srilanka Pierre Bedossa Elwyn Elias Beaujon Hospital, Clichy, France Queen Elizabeth Hospital, Birmingham, UK Hubert E. Blum Scott Friedman University of Freiburg, Freiburg, Germany Mount Sinai Center, New York, USA Jacob George Bimal S. Sandhu University of Sydney, Sydney, Australia Virginia Commonwealth University , Richmond, USA Shibashish Giri Neeraj Saraf Universität Leipzig, Leipzig, Germany Medanta Institute of Liver Transplantation and Regenerative Subhash Gupta Medicine, Gurgaon, India Indraprastha Apollo Hospitals,, New Delhi, India Shiv K. Sarin Rakesh K. Gupta Institute of Liver and Biliary Sciences, New Delhi, India Fortis Memorial Research Institute, Gurgaon, India Rajan Saxena Saeed S. Hamid Sanjay Gandhi Postgraduate Institute of Medical Science, The Aga Khan University & Hospital, Karachi, Pakistan Lucknow, India Wasim Jafri Samir Shah The Aga Khan University & Hospital, Karachi, Pakistan Jaslok Hospital and Research Center, Mumbai, India Rajiv Jalan Barjesh C. Sharma Royal Free Hospital, London, UK GB Pant Hospital, New Delhi, India Ji-Dong Jia Praveen Sharma Capital Medical University, Beijing, China Sir Ganga Ram Hospital, New Delhi, India Patrick S. Kamath Sadiq Sikora Mayo Clinic, Rochester, USA Manipal Institute of Liver & Digestive Diseases, Dharmesh Kapoor Manipal, India Global Hospitals, Hyderabad, India Arvinder S. Soin Akinobu Kato Medanta Institute of Liver Transplantation and Regenerative Iwate Medical University, Iwate, Japan Medicine, Gurgaon, India Abraham Koshy Jose Sollano Lakeshore Hospital and Research Centre, Kochi, Kerala University of Santo Tomas, Manila, Phillipines Masatoshi Kudo Ajit Sood Kinki University School of Medicine, Osaka-Sayama, Japan Dayanand Medical College and Hospital, Ludhiana, India Ashish Kumar Anshu Srivastava Sir Ganga Ram Hospital, New Delhi, India Sanjay Gandhi Postgraduate Institute of Medical Science, Didier Lebrec Lucknow, India Centre de Recherche Biomédicale Bichat Beaujon, Paris, France Manav Wadhawan Hyo-Suk Lee Indraprastha Apollo Hospital, New Delhi, India Seoul National University College of Medicine, Seoul, South Korea Ian R. Wanless Stephen Locarnini The Toronto Hospital, Toronto, Canada Victorian Infectious Diseases Reference Laboratory, Melbourne, Surendra Yachha Australia Sanjay Gandhi Postgraduate Institute of Medical Sciences, Kaushal Madan Lucknow, India Medanta Institute of Liver Transplantation and Regenerative Ghulam N. Yattoo Medicine, Gurgaon, India Sher-i-Kashmir Institute of Medical Sciences, Sriprakash Misra Kashmir, India MLN Medical College, Allahabad, India Zobair M. Younossi Aabha Nagral Inova Fairfax Hospital, Virginia, USA Jaslok Hospital and Research Centre, Mumbai, India Shaukat A Zargar Frank Nevens Sher-e-Kashmir Institute of Medical Sciences, University Hospital Gasthuisberg, Leuven, Belgium Srinagar, India

Editorial Ofﬁ ce: Department of Hepatology, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh – 160012, India. E-mail: [email protected]. Manuscript submission: https://www.evise.com/evise/faces/pages/navigation/NavController.jspx?JRNL_ACR=JCEH

Publishing services by: Elsevier A division of Reed Elsevier (India) Pvt. Ltd. 14th Floor, Building No. 10B, DLF Cyber City, Phase-II, Gurgaon – 122002, Haryana, India. Phone: +91-124-4774444; Fax: +91-124-4774100; Website: www.elsevier.com Journal of Clinical and Experimental Hepatology Volume 6, Supplement 1, July 2016

CONTENTS

Acute Liver Failure and Acute on Chronic Liver Failure Study of Prevalence of Fatty Acid Oxidation Defects in Children and Adults With Acute Liver Failure: Signiﬁ cance of Carnitine/Acylcarnitine and Aminoacid Proﬁ le [Plenary Session] S1 V Sood, D Rawat, R Khanna, S Sharma, PK Gupta, S Alam, SK Sarin

Comparison of Acute-on-Chronic Liver Failure (ACLF): HBV Related Versus Non-Viral Cirrhotics in Coastal Eastern India S1 S Behera, P Nath, P Parida, P Padhi, J Narayan, G Pati, SP Singh

Predictors of Mortality at 3 Months and 6 Months Excluding 1 Month Mortality in Patients with Acute on Chronic Liver Failure (ACLF)—A Single Centre Experience S2 PT Sudheendran, C Govindaraju, R Cyriac, N Suraj, D Joseph, K Srijith, R Muraleedharan, S Abdul, S Sreesh, PK Sobhan, G Peter, SA Bahuleyan, S Noronha, K Devdas

Invasive Fungal Infections in Patients of Acute on Chronic Liver Failure S2 N Verma, S Singh, S Taneja, S Prakash, A Chakarbarti, V Singh, A Duseja, RK Dhiman, YK Chawla

Clinical Proﬁ le of Patients With Acute-on-Chronic Liver Failure S3 D Singh, M Gupta, S Dadhich, P Ranjan, S Vatsya

Acute on Chronic Liver Failure (ACLF)—Clinical Proﬁ le, Predictors of 1 and 3 Months Mortality from a South Indian Tertiary Care Center S4 SK Yadav, C Govindraju, S Narayanan, A Iyer, S Fathima, K Devdas, S Sreesh, S Satthar, Prasanth

Impact of Hepatic- and Extrahepatic-Insults on the Outcome of Acute-on-Chronic Liver Failure S4 T Gupta, RK Dhiman, S Rathi, S Agrawal, A Duseja, S Taneja, YK Chawla

Acute on Chronic Liver Failure and Acute Decompensation: Do They Behave Same on Long Term S5 C Govindaraju, P Sudheendran, N Suraj, R Joseph, G Peter, S Bahuleyan, S Sathar, P Sobhan, S Sreesh, S Noronha, D Krishnadas

New International Club of Ascites Deﬁ nition of Acute Kidney Injury Applied at Admission is not Independently Associated with Mortality in Patients with Acute-on-Chronic Liver Failure S5 H Singh, S Shetty, G Balaraju, A Shetty, CG Pai

Assess 28-Day Survival of Top Down Approach of Slow Low-Dose Continuous Albumin ϩ Furosemide ± Terlipressin (SAFI ± T) and N-Acetycystine Infusion and Probiotics in ACLF Patients with MELD Ն 35, Ascites and High CVP (Central Venous Pressure) ± Organ Failure S6 G Pande, K Kumar, P Sharma, VP Krishna, A Goel, A Verma, S Mohindra, P Rai, UC Ghoshal, R Aggrawal, VA Saraswat

Role of Procalcitonin in Early Detection of Infections in Acute on Chronic Liver Failure in Liver Intensive Care S7 S Dhampalwar, A Borkakoty, S Taneja, A Duseja, RK Dhiman, YK Chawla

Viral Hepatitis Liver Dysfunction in Thalassemic Children: More in Splenectomized Than Non-Splenectomized Cases S8 S Agarwal, S Gomber

Burden of Renal Dysfunction in Hepatitis C Virus Infection: An Important Unmet Treatment Need in the Sofosbuvir Era S8 AD Sonavane, D Amarapurkar

Real Life Experience of Sofosbuvir Based Therapy for Chronic Hepatitis C Patients From North East India S9 KS Prasanna, K Chetri, M Agarwala, P Roy, A Kelkar Circulating Bone Marrow-Derived Stem Cells in Patients With Chronic Hepatitis C: Relation to Hepatic Progenitor Cells and Hepatocyte Proliferation S9 HE Aggan, N Farahat, BE Sabaa, A Elyamany, RA Esa

HBx Hijacks Nuclear Body Protein Sp110 and Promotes Viral Pathogenesis S10 I Sengupta, C Das, D Das, R Chakravarty, S Adhikary, S Roy

Randomized Study of Interferon Based and Interferon Free Sofosbuvir Containing Regimens in Treatment of Patients With Hepatitis C Genotype 3 Infection S11 A Tiwari, S Shukla, A Nandmer, V Dixit

A Study on Clinical, Biochemical, Serological, and Histopathological Proﬁ le of Incidentally Detected Hepatitis B Infection S11 S Kadla, NA Shah, S Sharma, I Rehman, B Khan, A Shah, S Parveen, S Nazir

A Study on Prevalence of Hepatitis B Among Adult Population in South Kashmir S12 S Kadla, NA Shah, M Bhat, M Khan, B Khan, A Shah, S Parveen, S Nazir

Genotype Distribution of Hepatitis C Virus in Patients With Chronic Hepatitis C Infection in Kashmir: A Cross Sectional Study S12 NA Shah, S Parveen, S Kadla, A shah, M Querishi, S Farhat, B Khan, S Parveen

Safety and Effectiveness of Response-Guided Therapy Using Pegylated Interferon and Ribavirin for Chronic Hepatitis C Virus Infection in Patients on Maintenance Dialysis S13 A Goel, R Bhargava, D Bhadauria, A Kaul, N Prasad, A Gupta, R Sharma, P Rai, R Aggarwal

Upper Gastro Intestinal (UGI) Endoscopic Lesions in Patients with Hepatitis C S13 A Kumar, S Goyal, H Bhardwaj, B Bhardwaj, P Jain

Comparison of Sofosbuvir Plus Ribavirin Plus Peg-Interferon With Sofosbuvir and Ribavirin for Treatment of Genotype 3 Treatment Naive Indian Chronic Hepatitis C Patients: An Interim Analysis of Ongoing RCT S14 U Sonika

SVR12 Among 40 Patients of Chronic Hepatitis C Treated With SOF/RBVϩ/ϪpegIFN-Result From a Single Tertiary Center Kolkata, West Bengal S14 A Konar, JG Chatterjee

Sero Prevalence of Acute Hepatitis Caused by HAV and HEV in Gazipur, Bangladesh S15 MS Haque, S Sultana, MA Mahtab

Sofosbuvir and Ribavirin Combination is Safe and Effective in Renal Transplant Recipients with HCV Infection S15 S Taneja, A Duseja, A De, V Kumar, R Ramachandran, A Sharma, RK Dhiman, K Gupta, M Minz, YK Chawla

Knowledge and Attitude Regarding Care of Hepatitis B Virus (HBV) Positive Patients Amongst the Nurses of Tertiary Care Centre S16 S Kaur, RK Dhiman, S Satsangi, A Duseja, P Arora

Sofosbuvir Based Therapy is Useless in HCV Patients with CTP B and C Class of Cirrhosis With no Transplant Option S16 A Kumar, A Deep

Identiﬁ cation of a Microrna That Impedes Hepatitis C Virus Infection and Replication by Silencing Multiple Host Genes S17 S Ghosh, S Datta, A Chowdhury, G Dhali, S Banerjee

Hepatitis C Virus Infection in Patients on Hemodialysis in Tertiary Care Hospital S17 MI Abhilash, PS Kumar, MU Devi, R Macherla Oncogenic Potential of Hepatitis B Virus Subgenotype D1 Surpasses D3: Signiﬁ cance in the Development of Hepatocellular Carcinoma [Plenary Session] S18 D Dasgupta, S Datta, A Manna, S Datta, K Das, M Chatterjee, GK Dhali, A Chowdhury, S Banerjee

DAAs in Genotypes 1 and 4 of Chronic Hepatitis C—A Real World Experience S19 S Brugu, B Patel, N Joshi, R Yarlagadda, R Maidur, G Ratnaparkhi, A Kumar

DAAs in Genotypes 2 and 3 of Chronic Hepatitis C—A Real World Experience S19 B Patel, S Bhrugu, R Yarlagadda, N Joshi, R Maidur, G Ratnaparkhi, A Kumar

COOMBS: Continuous Overview of Mega Blood Donation of South India—A Five Year Study of Blood Borne Infectious Diseases S20 N Krishnasamy, C Annasamy, S Ramalingam, S Babu, K Premkumar, K Rajendran, JJ Jasmine

Viral Burden of HBsAg Among South Indians in a Tertiary Care Center—10 Year Survey S20 N Krishnasamy, JJ Jasmine, K Rajendran

Dual Treatment With Sofosbuvir Plus Ribavirin is as Effective as Triple Therapy With Pegylated Interferon Plus Sofosbuvir Plus Ribavirin in Predominant Genotype 3 Patients With Chronic Hepatitis C S21 S Satsangi, M Mehta, A Duseja, S Taneja, RK Dhiman, Y Chawla

Relationship of Severity of Hepatitis A With Genetic Polymorphisms in Hepatitis A Virus Cellular Receptor 1 (HAVCR1) Gene S21 M Benjamin, S Agnihotry, A Srivastava, M Peethambaran, R Bolia, A Koshy, T Grace, P Augustine, SK Yachha, R Aggarwal

Alcohol and Non-alcoholic Fatty Liver Disease A Study of Prevalence of Diabetes and Prediabetes in Patients with Non Alcoholic Fatty Liver Disease and Impact of Diabetes on Liver Histology S23 A Bansal, S Mourya, A Verma, B Khanam, R Bansal

Serum ALT is an Independent Predictor of Metabolic Syndrome and Insulin Resistance in Patients of Non-alcoholic Fatty Liver Disease S23 P Nath, PK Parida, J Narayan, PK Padhi, GK Pati, A Singh, B Misra, D Misra, SK Kar, MK Panigrahi, C Meher, O Agrawal, N Rout, K Pattnaik, P Bhuyan, M Swain, SP Singh

Check Point for Esophageal Variceal Bleeding Using Band Ligator – Outstanding Efﬁ cacy But at Low Cost? S24 AS Patil, A Balekuduru, L Locheruvapalli, R Kiran, BS Satyaprakash

Limited Implication of Serum Cholesterol for Diagnosing NASH S24 SM Noor-E-Alam, AL Moben, MZH Basunia, A Bhattacharyya, MA Rahim, SA Foez, FA Khondaker, MJA Sarker, MF Abedin, UD Gupta, MFI Chowdhury, MA Mahtab

Effect of Lifestyle Modiﬁ cation on Liver Enzyme and Fibroscan Score in Indian Patients with Non- alcoholic Fatty Liver Disease S25 J Paul, R Venugopal, L Peter, KNK Shetty, M Shetti

Association of NAFLD with Carotid Atherosclerosis and Serum Uric Acid Level S26 M-ur Ajmal, SN Afzal, N Abdali, I Ahmad

Validation Study to Predict Mortality in Alcoholic Hepatitis: Magic Score Versus Other Scoring Systems S26 A Iyer, C Govindaraju, S Sathar, S Sreesh, K Devadas

Can Alcoholic Liver Disease and Nonalcoholic Fatty Liver Disease Co-exist? S27 M Mehta, S Satsangi, A Duseja, S Taneja, RK Dhiman, YK Chawla

microRNA-124 Ameliorates Alcohol Induced Liver Injury by Restricting Multiple Components Involved in Intracellular Crosstalk S27 D Dasgupta, A Manna, S Datta, A Ghosh, A Ghosh, M Chatterjee, S Datta, G Dhali, A Chowdhury, S Banerjee Effect of GCSF on Mortality and Complications Viz Sepsis, Encephalopathy, HRS and GI Bleed in Severe Alcoholic Hepatitis – A Randomized Controlled Study [Plenary Session] S28 A Setia, R Rai

Predictors of 90 Day Mortality in Severe Alcoholic Hepatitis: Experience with 85 Patients at a Tertiary Care Center S28 R Daswani, A Kumar, S Anikhindi, P Sharma, N Bansal, V Singla, A Arora

Socioeconomic Impact of Alcohol in Patients with Alcoholic Liver Disease [ALD] in Odisha S29 SP Singh, P Padhi, J Narayan, P Nath, A Singh, G Pati, P Parida, S Mishra

Correlation of BMI with Subcutaneous Fat and Total Body Fat in Patients with NAFLD in South India S30 G Padsalgi, M Chooracken, R Mukkada, A Chettupuzha, J Francis, P Augustine, A Koshy

Cytokeratin 18 Fragment Level is a Useful Biomarker in Predicting Steatosis and NASH But Not Fibrosis S30 S Budhiraja, A Jain, V Dixit, S Shukla, P Asati, M Tripathi

Correlation of Insulin Resistance with Liver Histology in Obese Patients with NASH and in Lean NASH S31 MV L, R Gopalakrishna, M Eapen, HR Nair, I Siyad, S Sadasiv, RP Venu

Renal Dysfunction in Patients with Nonalcoholic Fatty Liver Disease is Related to the Presence of Diabetes Mellitus and Severity of Liver Disease S31 RV Nampoothiri, A Duseja, M Rathi, S Agrawal, N Sachdeva, M Mehta, RK Dhiman, YK Chawla

Cirrhosis and Complications Late Presentation of Autoimmune Hepatitis as Decompensation in a Diagnosed Case of Celiac Disease Associated Ataxia Telengectasia S33 S Agarwal, UR Gupta

Modiﬁ ed ‘Barrel Only’ Technique for Endoscopic Variceal Ligation (EVL): A Comparative Study S33 A Kumar, S Goyal

Relapse of Minimal Hepatic Encephalopathy in Cirrhotics After Short-Term Treatment—A Prospective Trial S34 O Goyal, S Sidhu, H Kashyap

Diabetes Mellitus Increases the Severity of First Episode of Overt Hepatic Encephalopathy in Decompensated Cirrhosis S34 S Kadavanoor, N Suraj, M Ramu, D Joseph, G Chethan, TS Prasanth, D Krishnadas

Endothelial Injury and Oxidative Stress in Patients With Hepatitis C Virus-Related Cirrhosis: Relation to Renal Function and Hemodynamics S35 HE Aggan, M Rashwan, S Abodeya, S Mahmoud

Therapeutic Plasma Exchange (TPE) as an Adjuvant to Supportive Management in End Stage Liver Disease Patients With High Meld (score >25) Awaiting Liver Transplantation [Plenary Session] S36 J Varghese, D Sachan, V Jayanthi, V Srinivasan, K Ilankumar, K Harika, M Jain, M Srinivas, GMM Reddy, M Rela

MELD vs MELD Na for Predicting Inhospital Mortality in Decompensated CLD S36 SS Fathima, P Gopalakrishnan, K Devadas, S Srijaya, KS Prasanth, A Shanid, GR Babu, A Iyer, SK Yadav, BK Bincy, G Peter

Efﬁ cacy of Talc Pleurodesis for the Management of Refractory Hepatic Hydrothorax in Patients With Liver Cirrhosis S37 A Chaudhary, O Patel

Factors Associated With in Hospital Mortality in Patients With Decompensated CLD S38 P Gopalakrishnan, SS Fathima, K Devadas, GR Babu, BK Bincy, S Srijaya, A Shanid, KS Prasanth Liver, Heart and Kidney—The Triology S38 KV Nagarajan, R Venugopalan

The Pattern of Treatment Response and Its Predictors in Cirrhotic Patients With Overt Hepatic Encephalopathy (HE) S39 SA Shemin, TM Ramachandran

To Study Upper Gastrointestinal Mucosal Changes in Patient With Portal Hypertension S39 PS Patel, D Amarapurkar

Predictors of in Hospital and 90-Day Mortality in Patients Admitted With Spontaneous Bacterial Peritonitis in a Tertiary Care Centre S40 GR Babu, M Ramu, P Krishnan, B Bincy, SK Yadav, SS Fathima, A Iyer, D Krishnadas, S Srijaya, A Shanid

Hidden From Endoscopic View Caught by Endosonography and Taken Care of Gastric Variceal Bleeding S41 A Shetty, A Balekuduru, L Locheruvapalli, R Kiran, SB Shetty

Inﬂ uence of Beta Blockers on Complications of Cirrhosis S41 K Rajini, R Solomon, A Arumugham, M Ananthavadivelu, B Rangachari, M Kalyanasundaram, R Govindarajan, V Priyaa, KS Kumar

Safety and Outcome of Protocol Based Injection of N-Butyl-2-Cyanoacrylate (GLUE) for Obliteration of Gastric Varix S42 B Shetty, A Balekuduru, L Locheruvapalli, R Kiran, BS Satyaprakash

Bone Mineral Density in Patients With Cirrhosis of Liver Awaiting Liver Transplantation S42 P Parikh, S Deshmukh, S Parameswaran, KR Palaniswami, N Murugan, AT Mohan, U Dhus, U Srinivas, P Piramnayagam, M Hariharan, VP Seshadri, M Preethi

Proﬁ le of Anemia in Cirrhosis With or Without Sepsis S43 A Srijayadeva, B Prashantha, S Gopal, S Shenoy, B Tantry

Prevalence of Driving Skill Impairment Due to Minimal Hepatic Encephalopathy (MHE) in Cirrhosis of the Liver S43 A Rajendran, V Thomas

A Study of Renal Function, Serum Sodium and Their Impact on Survival of Patients With End Stage Liver Disease S44 SK Korrapati, RK Allu, RS Girinadh Lekkala, MK Palakurthy

Silibinin Induced Cell Cycle Arrest in Human Hepatic Stellate Cells S45 E Devaraj

Cirrhotic Fundal Variceal Bleeders Have Lower Portal Pressure as Compared to Cirrhotic Esophageal Variceal Bleeders: A Comparative Analysis of 80 Patients S45 S Anikhindi, A Kumar, P Sharma, V Singla, N Bansal, A Arora

Comparison of Clinical and Laboratory Proﬁ le Between Alcoholic and Cryptogenic Cirrhosis in Coastal Odisha S46 S Parida, P Nath, A Singh, G Pati, S Singh, K Dash, S Behera, P Parida

Spontaneous Bacterial Peritonitis by Burkholderia Cepacia Complex: A Rare, Difﬁ cult to Treat Infection in Decompensated Cirrhotic Patients S46 P Kumar, S Taneja, V Gautam, A Duseja, V Singh, RK Dhiman, YK Chawla

Can Non-invasive Parameters Help Us to Predict Large Esophageal Varices? Results from a Tertiary Medical Centre of Rajasthan S47 D Vyas, RP Singh, G Gupta, S Nijhawan

Relationship of Serum Sodium With Complications of Cirrhosis Prospective Study in Tertiary Medical Center of Rajasthan S47 RP Singh, D Vyas, G Gupta, H Bharadwaj, S Nijhawan Granulocyte Colony Stimulating Factor Mobilizes CD34 Cells and Improves Survival of Patients With Decompensated Cirrhosis: A Randomized Controlled Trial [Plenary Session] S48 R Prajapati, A Arora, P Sharma, N Bansal, V Singla, A Kumar

Study of Common NOD2 Gene Polymorphisms as a Risk Factor for Development of Complications in Indian Patients of Liver Cirrhosis S49 M Tiwari, MT Noor, N Seehra, S Jain, R Kumar, BS Thakur

Normal Values for Psychometric Tests, for Kerala; and Its Evaluation in Cirrhotic Patients S49 J Jose, M Choracken, R Mukkada, A Chettupuzha, J Francis, A Koshy

Is Low Dose Synacthen Test Reliable in Detecting Adrenal Insufﬁ ciency in Cirrhosis S50 D Joseph, D Krishnadas, A Shanid, S Sreejaya, KS Prasanth, K Sreejith, R Muraleedaran, S Sandeep, R Cyriac, K Gaurav, S Varun

Factors Predicting Failure of 3rd Generation Cephalosporins in Treatment of Spontaneous Bacterial Peritonitis S50 M Ramu, GR Babu, K Sreejith, N Suraj, G Chethan, TS Prasanth, D Joseph, A Shanid, S Srijaya, S Noronha, D Krishnadas

Prospective Evaluation of Prognostic Factors in Cirrhotic Patients Requiring Intensive Care S51 R Maidur, S Brugu, N Joshi, R Yarlagadda, B Patel, K Vyawahare, G Ratnaparkhi, A Kumar

Prevalence of Malnutrition and Factors Associated With It, Among North Indian Cirrhotics Presenting to a Tertiary Care Centre S51 K Madan, E Gupta, L Saju, P Kumar, M Paliwal, R Dhingra, D Mehta, R Bhargava, M Yadav

Study on the Predictors of Response to Terlipressin Plus Albumin in Hepatorenal Syndrome (HRS) Type 1 S52 Manasa, Girinadh, M Manne, KR Dash

Inﬂ uence of Beta Blockers on Complications of Cirrhosis S52 K Rajini, TR Solomon, A Arumugham, M Ananthavadivelu, B Rangachari, M Kalyanasundaram, R Govindarajan, C Vaishnavi Priyaa, S Kavitha

Burden of Cirrhosis and Minimal and Past History of Overt Hepatic Encephalopathy on Patients and Caregivers S53 D Shrestha, RK Dhiman, S Grover, S Taneja, A Duseja, YK Chawla

Comparative Effectiveness of Different Pharmacological Interventions for the Treatment of Minimal Hepatic Encephalopathy: A Systematic Review With Network Meta-Analysis S54 RK Dhiman, KK Thumburu, M Chopra, U Dutta, M Singh, S Taneja, A Duseja, YK Chawla

Survival Beneﬁ t of Vitamin D Replacement on Deﬁ cient Decompensated Cirrhosis S54 SK Jha

Lactulose Tolerability and Adverse Effect Proﬁ le in Indian Patients With Chronic Liver Disease – A Knowledge, Attitude and Practice Study S55 S Rathi, M Chopra, S Taneja, A Duseja, YK Chawla, RK Dhiman

Prediction of Hepatic Encephalopathy by Liver Stiffness Measurement with Fibroscan in Patients with Cirrhosis of Liver S56 AL Moben, M Noor-E-Alam, MA Rahim, FA Khondoker, F Majid, MA Mahtab

Tadalaﬁ l, a Phosphodiesterase-5 Inhibitor, Improves Erectile Dysfunction in Patients with Liver Cirrhosis S56 J Thakur, S Grover, S Rathi, M Chopra, S Taneja, A Duseja, Y Chawla, A Bhansali, RK Dhiman

Prevalence of Infections in Acute Decompensation of Cirrhosis: A Tertiary Care Centre S57 T Gupta, D Lochan, S Rathi, A Duseja, S Taneja, YK Chawla, RK Dhiman Liver Transplantation Nocardia Liver Abscess – An Uncommon Infection Post Liver Transplant S59 P Hanchanale, M Jain, J Varghese, V Jayanthi, M Rela

Outcomes of Percutaneous Biliary Interventions in Bilioenteric Strictures After Living Donor Liver Transplant in Paediatric Patient Population S59 AK Kapoor, N Mohan, A Khandelwal, S Baijal

Effect of Pre-Transplant Malnutrition on Outcomes of Liver Transplantation S60 N Bakshi, K Singh, AS Soin

Progressive Fibrosis is Driven by Genetic Predisposition, Allo-Immunity, and Inﬂ ammation in Pediatric Liver Transplant Recipients S60 S Varma, J Ambroise, M Komuta, D Latinne, P Baldin, R Reding, F Smets, X Stephenne, E Sokal

To Evaluate Signiﬁ cance of Alpha Smooth Muscle Actin (ASMA) Expression on Liver Biopsy as Predictor of Future Graft Fibrosis in Pediatric Liver Transplant (LT) Recipients S61 S Varma, X Stéphenne, M Komuta, C Bouzin, J Ambroise, F Smets, R Reding, E Sokal

Adult Liver Transplantation – Initial Experience From a Tertiary Care Centre at North Kerala S61 R Rajan, A Kumar, K Biju, T Jose, S Janardhanan, T Rabia, G Ramakrishnan, R Babu, K Kanianchalil, S Natarajan, R Ravindran, R Nambiar, S Sahadevan

Retrospective Analysis of Post Transplant Liver Biopsies – From Diagnosis to Therapy – Can We Guide Further? Experience From a Tertiary Care Center in India S62 N Bansal, V Vij, M Rastogi, M Wadhawan, A Kumar

Neoplasms Combination of TACE and Sorafenib Improves Outcomes in BCLC Stages B/C of Hepatocellular Carcinoma: A Single Centre Experience S63 J Varghese, C Kedarisetty, J Venkataraman, K Harika, V Sreenivasan, T Deepashree, M Uthappa, K Ilankumaran, S Govil, M Reddy, M Rela

Lung Lesion With HCC—Not Always Metastasis S63 PB Hanchanale, D Jothimani, J Varghese, V Jayanthi, M Rela

Regression of Large Unresectable Hepatoma With Sorafenib S64 VV Reddy, PV Girish, T Joseph, G Balaji, VA Raju, M Patil, H Devarbhavi

Macrophage Inﬂ ammatory Protein-1Alpha/CC Chemokine Ligand 3 and Tumor-Associated Macrophages in Hepatitis C Virus-Related Hepatocellular Carcinoma: Relation to Tumor Progression and Angiogenesis S64 HE Aggan, M Helmy, NE Deeb, A Zeid, M Fawzy

Clinical and Etiological Proﬁ le of Hepatocellular Carcinoma in a North Indian Patient S65 PK Asati, S Shukla, A Jain, VK Dixit

Unusual Paraneoplastic Presentation of Hodgkins Lymphoma as Isolated Idiopathic Intrahepatic Cholestasis With Ascites S65 C Palanivelu, TS Ramesh, J Khan

Differential Expression of Circulating miRNAs Among Healthy, Diseased Controls and HCC Patients— Pilot Study S66 B Nayak, N Nadda, D Yadav, SB Paul, Shalimar, SK Acharya

Primary Malignant Melanoma of Liver–A Report of 2 Cases S67 GP Veeranna, VV Reddy, TS Joseph, B Gurappa, VA Raju, M Patil, HC Devarbhavi Does Diabetes Mellitus Alter the Clinical and Biochemical Characteristics of Hepatocellular Carcinoma Patients—A South Indian Experience S67 P Sudheendran, G Chethan, N Suraj, D Joseph, K Srijith, M Ramu, S Prasanth, A Shanid, S Sreesh, S Noronha, D Krishnadas

Non Favorable Genotype is Predominant at IL28B RS12979860 Polymorphism in Hepatitis B Related Hepatocellular Carcinoma S68 ASM Sadequl Islam

Does Preoperative Imaging Correlate With Explant Pathology in HCC? S69 J Varghese, M Jain, M Vij, S Govil, DM Reddy, V Jayanti, M Rela

A Case of Autoimmune—MIMIC Jaundice S69 JS Dhingra

Post-transarterial Chemoembolization Liver Failure is Associated With Poor Outcome in Hepatocellular Carcinoma S70 N Nadda, Shalimar, S Kedia, B Nayak, D Yadav, M Pathak, SB Paul, SK Acharya

Etiological and Clinical Characteristics of Hepatocellular Carcinoma at Presentation to Tertiary Care Hospital in South India S70 C Govindaraju, P Sudheendran, N Suraj, G Sudamrao, SA Pratap, G Peter, S Sathar, P Sobhan, S Sreesh, S Noronha, K Devadas

Factors Affecting Serum AFP in HCC S71 SS Fathima, G Chethan, TS Prasanth, K Devadas, S Noronha, S Srijaya, A Shanid, KS Prasanth, G Peter, A Iyer, BK Bincy, GR Babu, P Krishnan, S Yadav

Not All Peri-Ductal Plaque Like Enhancement Is Cholangiocarcinoma- Primer For Clinicians S71 S Krishan

Role of Volumetric Density Mapping in Differentiating Inﬁ ltrative HCC from the Residual Liver and its Affect on the Treatment Planning in Cirrhotic Liver S72 S Krishan, V Singh

Dual Energy CT- Surrogate Quantitative Marker of Response to Targetted treatment in HCC S72 S Krishan, H Lukhi

Miscellaneous Lane-Hamilton Syndrome: Atypical Presentation of Celiac Disease S74 S Agarwal, R Gupta

Concurrent Extrahepatic Autoimmune Disorders: Unexplored Dimension of Autoimmune Liver Disease in the Children S74 V Jain, S Yachha, E Bhatia, M Sarma, A Srivastava, U Poddar

Bacteriological Proﬁ le and Antibiotic Sensitivity in Acute Cholangitis S75 A Bale, A Shetty, G Balaraju, S Shetty, G Pai

Liver Function Test Abnormalities in an Epidemic of Dengue Viral Infection and its Correlation with Platelet Values—A Tertiary Care Experience S75 V Boopathy

Pilot Study to Access Safety and Efﬁ cacy of Granulocyte Colony Stimulating Factor Therapy in Decompensated Cirrhotics in Bangladesh S76 MH Uddin, MA Mahtab, MA Rahim, SM Noor-E-Alam, AL Moben, SA Foez, SMF Akbar, S Rahman Study to Compare HVPG with Endoscopy of UGIT to Assess Severity of Portal Hypertension in Cirrhotics in Bangladesh S77 MA Rahim, MA Mahtab, SM Noor-E-Alam, MA Alam, AL Moben, SA Foez, MH Uddin, SMF Akbar, S Rahman

Benign Recurrent Intrahepatic Cholestasis (Summerskill Walshe Tygstrup Disease)—A Case Report S77 GS Gurudath, C Palanivelu, JK Mohammad, KTS Ramesh, KGS Sharath, P Santhosh, D Suganya, S Nithyanand, M Piyush

Clinical Proﬁ le of Hepatic Wilson Disease in Tertiary Center S78 G Garg, V Dixit, S Shukla, P Asati, S Singh, S Sachan

Comparison of Transient Elastography and Shear Wave Elastography in the Evaluation of Liver Fibrosis S78 N Suraj, GR Babu, RC Joseph, K Srijith, S Sreesh, KS Prasanth, A Shanid, D Krishnadas

Diagnostic Conundrum of Infantile Glycogen Storage Disorder with Myopathy S79 A Chhikara, S Singh, B Gupta, M Ansari

Transarterial Chemotherapy (TAC) Versus Oral Chemotherapy in the Treatment of Unresectable Hepatocellular Carcinoma with Portal Vein Thrombosis: A Randomized Controlled Trial S79 SB Paul, SR Gamanagatti, V Sreenivas, DP Yadav, N Nada, B Nayak, Shalimar, SK Acharya

Shear Wave Elastography for Assessment of Liver Fibrosis in Chronic Hepatitis: Pilot Work S80 SB Paul, P Das, H Sharma, M Vijayvargiya, S Ghosh, R Vidyasagar, D Yadav, SR Gamanagatti, S Gupta, SK Acharya

Characteristics Of Congenital Hepatic Fibrosis and Caroli’s Disease: Experience of a Tertiary Care Center in the Ciliopathy of Childhood S80 B Gupta, P Das, R Yadav, Shalimar, SK Acharya, KS Madhusudan, SK Panda, SD Gupta

Seronegative Autoimmune Hepatitis Presents with More Severe Disease But Has Similar Outcomes as Compared to Seropositive Patients S81 N Sonthalia, P Rathi, S Jain, R Surude, A Mohite, S Pawar, Q Contractor

Proﬁ le of DILI in Patients with Chronic Liver Disease S82 S Shiraz, R Gopalakrishna, CM Neethu, P Nair, R Venu

Hepatorenal Fibrocystic Disease Spectrum in 2 Sisters S82 S Agarwal, R Gupta, A Bhandari, K Mangal

Seroprevalence of Schistosomiasis in CLD Cases from Upper Assam S83 T Arora, A Das, B Borkakoty, M Gohain

Enteral Parasites Detected by Fecal Exam, Colonoscopy, or Abdominal Imaging Studies in a Korean Health Checkup Center for 10 Years S83 JI Yang

Hepatobiliary Alterations in Ulcerative Colitis: A Report from a Tertiary Care Centre in Odisha S84 P Padhi, J Narayan, P Nath, P Parida, K Dash, S Behera, S Parida, G Pati, C Panda, S Singh

Utility of Tissue Elastography in Measuring Liver Iron Overload in Comparison to MRI T2 and Serum Ferritin in Patient with Thalassemia Major S85 K Shah, N Pipaliya, P Sawant

An Unusual Case of Chronic Hepatitis S85 KD Shinde, P kumar, D Srinivas, P Mathew, D Kazia, A Kokkat, P Kanni, M Patil, V Khalde, S Uppalapati, M Kilari

A Proﬁ le of AIH from India S86 S Taneja Collagen Rich Scaffolds for Liver Engineering: A Step Forward to an Artiﬁ cial Liver S86 C Martin, R Subathra, V Jayanthi, S Reddy, J Varghese, M Rela, N Kalkura

Pancreatic Exocrine Insufﬁ ciency in Diabetes S87 S Afzal, M-u-R Ajmal, A Dar, S Siddiqi

Granulomatous Hepatitis Complicating Intravesical Bacille Calmette-Guérin (BCG) Therapy for High- Risk Superﬁ cial Bladder Cancer S87 A Iyer, P Sudheendran, S Sathar, S Sreesh, K Devadas

A Rare Case of Budd Chiari Syndrome Secondary to Anti Phospholipid Antibody Syndrome and Inherited Thrombophilia S88 S Katepally

ADAMTS13 Mutations Associated with Defective ADAMTS13 Secretion in a Patient with Non- Cirrhotic Portal Hypertension S88 A Goel, V Raghupathy, GJ Amirtharaj, A Chapla, A Ramachandran, S Sureshkumar, KA Balasubramanian, A Ramachandran, B Ramakrishna, N Thomas, I Mackie, CE Eapen, E Elias

Hepatic Sarcoidosis S89 A Pal, A Sonawane, D Amarapurkar

Thromboelastography Analysis in Patients with Cirrhosis and its Correlation with Conventional Coagulation Parameters S89 R Agarwal, P Ranjan

Acoustic Radiation Force Imaging Elastography Correlation with Liver Biopsy in the Evaluation of Staging of Liver Fibrosis S90 U Goenka, C Bera, MDN Parvez, E Khan, M Goenka

Transient Elastography (Fibroscan) in Patients with Non-Cirrhotic Portal Fibrosis S90 R Agarwal, P Sharma

ARFI Elastography of Liver Can Predict the Presence of Clinically Signiﬁ cant Esophageal Varices S91 MDN Parvez, MK Goenka, C Bera, U Goenka

Clinical, Serological, Histological Characteristics and Treatment Outcome of Autoimmune Hepatitis in Elderly Indian Population S91 N Sonthalia, P Rathi, S Jain, R Surude, A Mohite, V Pawar, S Udgirkar, Q Contractor

To Determine the Utility of Thromboelastography in Comparison to Conventional Coagulation Tests in Cirrhotics Undergoing Invasive Procedure S92 V Somani, D Amarapurkar

Clinical Proﬁ le and Survival Pattern of Wilson’s Disease S93 B Krishnan

Transient Elastography (Fibroscan) Assessment in Patients with Hepatic and Neurological Wilson’s Disease S93 T Joseph, V Reddy, PV Girish, G Balaji, V Raju, M Patil, H Devarbhavi

Autoimmune Hepatitis Associated with Autoimmune Hemolytic Anemia S94 I Suresh, HP Nandeesh, D Suvarna, D Chandrababu, HR Jeevan

Prognostic Scoring Systems and Outcome of Radiological Intervention of Chronic Budd-Chiari Syndrome in Children: A First Time Application S94 S Singh, M Sarma, R Yadav, S Kumar, R Gangwar, SK Yachha, A Srivastava, U Poddar

Langherhans Cell Histiocytosis with Sclerosing Cholangitis in Children: An Entity for Recognition S95 N Kumar, A Srivastava, S Yachha, U Poddar Dysphagia Lusoria due to Abberant Right Subclavian Artery in Twins S96 D Sharma, A Dey

Thromboelastography (TEG) does not Predict Thrombophilia in Hepatic Venous Outﬂ ow Tract Obstruction (HVOTO) S96 A Jain, S Bhatia, A Shukla

Is Non Cirrhotic Portal Fibrosis Actually Cirrhosis in Regression? A Histopathological Study of the “Hepatic Repair Complex” in Indian Patients S97 K Gaur, S Ali, P Sakhuja, K Majumdar, A Agarwal, A Puri

Esophageal Varices on Congenital Esophageal Stricture—Whom to Tackle First? S97 SS Sharma, L Bharadia

Do Nonselective Beta Blockers (NSBB) Increase the Risk of Acute Kidney Injury (AKI) in Decompensated Cirrhosis S98 S Kadavanoor, D Joseph, M Ramu, P Sudheendaran, C Govindaraju, N Suraj, K Devadas

A Case Report on Primary Hepatic Amyloidosis S98 R Reddy, S Kumar, U Devi, R Macherla

Spectrum of Congenital Hepatic Fibrosis (CHF) in Infants and Children from a Tertiary Care Centre S99 S Das, S Mitra, P Srikanth, J Menon, S Lal, A Das, BR Thapa

Safety and Outcome of Liver Biopsy in Infants and Children S99 P Srikanth, U Devi, J Menon, S Das, S Mitra, M Randhawa, S Lal, A Das, BR Thapa

ADAMTS13 Deﬁ ciency Predisposes to Systemic Macro and Microvascular Complications in NCIPH Patients S100 A Goel, GJ Amirtharaj, S Sarvanan, B Ramakrishna, A Ramachandran, KA Balasubramanian, U Zachariah, KG Sajith, I Mackie, E Elias, CE Eapen

Non-Invasive Markers: Fibrometer, Fibroscan vs Liver Biopsy in Detecting Liver Fibrosis in HBV Patients S100 N Krishnasamy, S Prabu, C Annasamy, S Ramalingam, JJ Jasmine, K Rajendran

Characterization of a Novel Microrna Identiﬁ ed by Small RNA Deep Sequencing and its Implication in the Development of Hepatocellular Carcinoma S101 S Ghosh, J Chakraborty, P Kumari, A Ghosh, A Ghosh, D Dasgupta, S Agarwal, S Gupta, S Datta, A Chowdhury, R Chatterjee, S Banerjee

Combination of TACE and Sorafenib Improves Outcomes in BCLC Stages B/C of Hepatocellular Carcinoma: A Single Centre Experience S102 J Varghese, CK Kedarisetty, J Venkataraman, V Srinivasan, T Deepashree, MC Uthappa, K Ilankumaran, S Govil, MS Reddy, M Rela 24th Annual Scientiﬁ c Meeting of the Indian National Association for Study of the Liver [INASL] 5Ð7 August 2016, New Delhi, India

JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY

Acute Liver Failure and Acute on Chronic Liver Failure

1 Conclusion: Metabolic liver diseases (FAODs) may not be an uncommon entity in cases of ALF with a STUDY OF PREVALENCE OF FATTY ACID prevalence of around 5%. CPT1 deficiency can cause OXIDATION DEFECTS IN CHILDREN AND ALF or modify the natural course of ALF caused by ADULTS WITH ACUTE LIVER FAILURE: other etiologies. Hyperaminoacidemia, as a marker of SIGNIFICANCE OF CARNITINE/ severity of hepatic damage, may predict poor outcome ACYLCARNITINE AND AMINOACID in ALF. PROFILE CONFLICTS OF INTEREST Vikrant Sood, Dinesh Rawat, Rajeev Khanna, Shvetank Sharma, Prem K. Gupta, Seema Alam, The authors have none to declare. Shiv K. Sarin Corresponding author: Seema Alam. Institute of Liver and Biliary Sciences, New Delhi, India E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.003 Background and Aim: Limited pediatric data suggests that fatty acid oxidation defects (FAODs) may underlie or modify the course of acute liver failure (ALF), but there is no adult data on this aspect. 2 Significance of carnitine/acylcarnitine and aminoacid COMPARISON OF ACUTE-ON-CHRONIC profile in patients with ALF is similarly undeter- mined. Thus this study was undertaken to study LIVER FAILURE (ACLF): HBV RELATED the prevalence of FAODs and significance of abnorm- VERSUS NON-VIRAL CIRRHOTICS IN ALF and ACLF alities in carnitine/acylcarnitine and aminoacid pro- COASTAL EASTERN INDIA fi le in ALF patients. Sambit Behera, Preeatm Nath, Prasanta Parida, Methods: A prospective study was performed includ- Pradeep Padhi, Jimmy Narayan, Girish Pati, ing all cases of acute liver failure (ALF) and detailed Shivaram P. Singh evaluation of subjects was done including metabolic testing (TMS/GCMS). S.C.B. Medical College, Cuttack, India Results: Out of a total of 55 patients (33 pediatric and 22 adult cases), 3 cases (a 1 year 6 month old child, a 13 year old pediatric patient and a 21 year old Background and Aim: Acute-on-Chronic Liver Fail- adult male patient) were confirmed to be of metabolic ure (ACLF) is an emerging entity. There is limited etiology (Carnitine Palmitoyl Transferase-1 or CPT-1 data on comparative analysis of ACLF cases in HBV deficiency). Three-fourths of patients (78%) had evi- related versus non-viral cirrhotics. The present study dence of serum hyperaminoacidemia while 31 was undertaken to compare HBV related versus non- patients (56%) had evidence of abnormal carnitine/ viral ACLF cases in coastal eastern India. acylcarnitine profile. Higher levels of serum tyrosine Methods: ACLF was defined as per Asian Pacific and lower levels of serum C0 in children and higher Association for the Study of Liver (APASL) consensus levels of serum phenyalanine in adults were predic- criteria 2014. Patients fulfilling the criteria were tive of poor outcome (death/LT). In the overall included and prospectively evaluated for three group, high serum methionine levels, high serum months or till death, whichever occurred earlier. phenyalanine levels and high serum tyrosine levels Results: Out of 197 patients with ACLF (mean age: were significantly associated with poor outcome. Pre- 45.56 Æ 11.29 years; male:female ratio 8:1), 23 sence of high tyrosine levels in children (20-fold (11.67%) and 174 (88.32%) cases had HBV related higher risk) could independently predict poor out- cirrhosis and cirrhosis due to non-viral causes [alco- come. But none of the factors were found to be holic liver disease (68.02%) and cryptogenic cirrhosis independently predictive of poor outcome in adult (20.3%)] respectively. 43.47% HBV related and 44.25% population. non-viral cirrhotics had history of prior acute

decompensation (P = 0.1). 13% HBV related and Gastroenterology Medical College Thiruvanantha- 32.75% non-viral cirrhotics had multiple acute insults puram (January 2012–December 2014). All consecu- (P = 0.06). 43.75% of HBV related and 71.31% of non- tive patients satisfying the APASL criteria and viral cirrhotics died within 3 months (early mortality) surviving for more than one month were taken for (P = 0.02). 17.39% HBV related and 26.43% non-viral analysis. cirrhotics had hepatorenal syndrome (P =0.34). Results: Of the 101 patients, 83.2% were males with 39.13% HBV related and 39.65% non-viral cirrhotics mean age 46.6 years. Ascites present in all with 35.6% had hepatic encephalopathy. Mean serum bilirubin having Spontaneous bacterial peritonitis. The major between HBV related viral and non-viral cirrhotics were chronic aetiologies were alcohol (60.4%) and hepa- 14.43 Æ 6.86 mg% and 11.15 Æ 6.89 mg% (P =0.03). titis B (19.8%). The acute insults were single in 73.3% Mean total leucocyte count in HBV related and non- and multiple in others. The major acute insults were viral cirrhotics were 8802.6 Æ 2337 and 9905.1 alcoholic hepatitis (52.5%) and chronic hepatitis B Æ 3736.1/cmm (P = 0.16). The prognostic markers flare (14.9%). The observed mortality at 3 months and (MELD, MELD-Na, CTP) were not significantly differ- 6 months were 21.4% and 32.1% respectively. Neither ent between HBV related and non-viral ACLF cases. the acute insult nor the chronic aetiology had signifi- Conclusion: ACLF cases with chronic hepatitis B cant association with outcome. But the presence of related cirrhosis had better early survival compared multiple acute insults correlated with outcome at 3 to non-viral cirrhotics despite having higher bilirubin months (P = 0.032). By ROC analysis, predictor of level. mortality at 3 months was age (P = 0.025) with cut off 45.8 years. The predictors of mortality at 6 months CONFLICTS OF INTEREST were age (P = 0.002) with cut off 47.5 years. Serum sodium level associated with mortality at 6 months The authors have none to declare. only (P = 0.009) with cut off 132.5. Corresponding author: Shivaram P. Singh. Conclusion: In this single centre study, the mortality L n ACLF and ALF E-mail: [email protected] was 21.4% at 3 months and 32.1% at 6 months excluding the first month mortality. At 3 months, http://dx.doi.org/10.1016/j.jceh.2016.06.004 age >45.8 years correlated with worst outcome. At 6 months age >47.5 years and serum sodium level <132.5 correlated with mortality. 3 CONFLICTS OF INTEREST PREDICTORS OF MORTALITY AT 3 MONTHS AND 6 MONTHS EXCLUDING 1 The authors have none to declare. MONTH MORTALITY IN PATIENTS WITH Corresponding author: Prasanth T. Sudheendran. ACUTE ON CHRONIC LIVER FAILURE E-mail: [email protected] (ACLF)—A SINGLE CENTRE EXPERIENCE http://dx.doi.org/10.1016/j.jceh.2016.06.005 Prasanth T. Sudheendran, Chethan Govindaraju, Rathan Cyriac, Nikhil Suraj, Deni Joseph, K. Srijith, Ramu Muraleedharan, Shanid Abdul, Srijaya Sreesh, Prasanth K. Sobhan, George Peter, 4 Suthanu A. Bahuleyan, Selwyn Noronha, Krishnadas Devdas INVASIVE FUNGAL INFECTIONS IN PATIENTS OF ACUTE ON CHRONIC LIVER Govt Medical College Trivandrum, Trivandrum, India FAILURE Nipun Verma, Shreya Singh, Sunil Taneja, Background and Aim: Acute on Chronic Liver Fail- Shiva Prakash, Arunaloke Chakarbarti, Virendra Singh, ure (ACLF) is a newly described clinical entity. Most Ajay Duseja, Radha K. Dhiman, Yogesh K. Chawla of the studies assess the 28 days mortality with SOFA, MELD and CTP scores correlating with outcome. We Post Graduate Institute of Medical Education and Research, Chandigarh, have taken only those patients who survived the first India 1 month. Our aim was to analyse the different variables and assess the predictors of mortality. Methods: This is a retrospective single centre Background and Aim: Invasive Fungal Infections cohort study from the department of Medical (IFI) are an emerging concern in patients of Acute

on Chronic Liver Failure (ACLF). Timely and accurate 5 diagnosis in patients is often difficult. The aim of the study is to study the impact of IFI in ACLF and assess CLINICAL PROFILE OF PATIENTS WITH the role of serum biomarkers for early diagnosis. ACUTE-ON-CHRONIC LIVER FAILURE Methods: A retrospective analysis of IFI in ACLF Dinesh Singh, Mayank Gupta, Sunil Dadhich, patients admitted in Liver ICU between November Prabhat Ranjan, Shubham Vatsya 2015 and April 2016 was done. Patients with clinical suspicion of IFI were diagnosed based on criteria M.G. Hospital, Dr S.N. Medical College, Jodhpur, India modified from the EORTC/MSG definitions for IFI. Demographic, clinical, laboratory data and the outcomes were reviewed and analyzed. Background and Aim: Acute on chronic liver failure Results: Out of 120 patients of ACLF, 27 [22.5%] were (ACLF) is defined as sudden deterioration of liver evaluated for IFI. Diagnosis of IFI was established in functions due to acute insult in patients with known 18 [15%] patients. In patients with IFI versus no IFI or unknown chronic liver disease. Its main feature is there were no difference in mean age [50.5 + 16.9 vs. the reversibility, and high short term mortality due to 49.6 + 7.9; P = ns] and gender [males 14 (77%) vs. 9 multi-organ failure (MOF). The aim of the study is to (100%); P = ns]. However, prior antibiotic use [16 study the clinical, laboratory and etiological profile of (89%) vs. 1 (11%); P = 0.00], lower platelet count patients with ACLF. [0.65 + 0.41 vs. 1.17 + 0.70 lac/mm3; P = 0.04], higher Methods: Out of 300 chronic liver disease patients CLIF-OF score [14 (9–18) vs. 11 (7–13); P = 0.004], admitted in department of gastroenterology, M.G. higher CLIF-C ACLF score [62 (39–80) vs. 50 (32–59); Hospital, Dr S.N. Medical College over the period P = 0.025] were noted in patients with IFI compared to of last 4 months, 58 met the criteria of ACLF (APASL no IFI. Those with IFI had higher Galactomannan consensus definition). Their clinical, laboratory, etio- index [0.9 (0.2–4.6) vs. 0.3 (0.1–0.4); P = 0.001] and logical profile and outcome were studied. higher BDG levels [341 (127–500) vs. 70 (30–446); Results: The most common etiology of underlying P = 0.004] and lower Procalcitonin levels [0.675 chronic liver disease was alcohol (81%). Most com- (0.02–100) vs. 14 (0.78–44) ng/ml; P = 0.00]. The sen- mon acute insult in patients with alcoholic liver dis- sitivity, specificity, PPV, NPV and AUROC of serum ease was severe alcoholic hepatitis (54%). Most BDG assay at a cutoff of >80 pg/ml for diagnosing IFI common (75.8%) type of patients were of decompen- ALF and ACLF was 100%, 67%, 86.5%, 100% and 0.824 respectively. sated cirrhosis. Remaining 24.2% of patients were not Higher mortality was noted in IFI vs. no IFI [12 (66%) decompensated before presentation. Seven days mor- vs. 2 (22%); P = 0.029]. Non-survivors were likely to tality was 13.7% (8 out of 58). Patients who died had have IFI [12 (86%) vs. 6 (46%); P = 0.029], higher CLIF- more than 2 organ failure and MELD >25. Two out of OF score [14 (11–18) vs. 11 (7–15); P = 0.001] and 8 patients who died, were not decompensated prior to CLIF-C ACLF score [63 (46–80) vs. 48 (32–61); illness. Fifteen required repeat admission within 1 P =0.002]. month. Conclusion: IFI constitutes an important cause of Conclusion: Most common cause of acute insult in mortality in patients with ACLF. Serum Galactoman- ACLF was alcohol which is preventable. Prognosis nan and BDG can be used as markers to guide pre- was worst in patients who were decompensated prior emptive antifungal therapy in ACLF patients at high to illness, had organ failure and high MELD score. risk. CONFLICTS OF INTEREST CONFLICTS OF INTEREST The authors have none to declare. The authors have none to declare. Corresponding author: Mayank Gupta. Corresponding author: Nipun Verma. E-mail: [email protected] E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.007 http://dx.doi.org/10.1016/j.jceh.2016.06.006

Journal of Clinical and Experimental Hepatology | July 2016 | Vol. 6 | No. S1 | S1–S7 S3 ACUTE LIVER FAILURE AND ACUTE ON CHRONIC LIVER FAILURE

6 CONFLICTS OF INTEREST ACUTE ON CHRONIC LIVER FAILURE The authors have none to declare. — (ACLF) CLINICAL PROFILE, PREDICTORS Corresponding author: Santosh K. Yadav. OF 1 AND 3 MONTHS MORTALITY E-mail: [email protected] FROM A SOUTH INDIAN TERTIARY CARE CENTER http://dx.doi.org/10.1016/j.jceh.2016.06.008 Santosh K. Yadav, Chethan Govindraju, Sandeep Narayanan, Arun Iyer, Shahna Fathima, Krishnadas Devdas, Srijaya Sreesh, Shanid Satthar, 7 Prasanth IMPACT OF HEPATIC- AND Govt. Medical College, Trivandrum, India EXTRAHEPATIC-INSULTS ON THE OUTCOME OF ACUTE-ON-CHRONIC LIVER FAILURE Background and Aim: ACLF is a new entity which is used for patients with acute complication of Tarana Gupta, Radha K. Dhiman, Sahaj Rathi, cirrhosis with organ failure(s). Defined differently Swastik Agrawal, Ajay Duseja, Sunil Taneja, by different associations, it lacks a consensus on Yogesh K. Chawla fi clinical pro le and precipitating event in different Post Graduate Institute of Medical Education and Research, Chandigarh, parts of world. In contrast to acute decompensation India of compensated cirrhosis, ACLF has a high 1 and 3 months mortality, with hope of reversibility after successful treatment of acute insult. The aims of the Background and Aim: Acute-on-chronic liver failure L n ACLF and ALF study were (1) to identify clinical profile of ACLF in (ACLF) is a clinical scenario wherein an acute insult our population and (2) predictors of 1 and 3 month leads to deterioration of underlying chronic liver mortality. disease. The aim of the present study to assess the Methods: This study, a single center prospective differences in outcome and predictors of mortality in observational study included 50 ACLF patients as ACLF precipitated by hepatic- or extrahepatic-insults. per APASL definition, admitted in department of Methods: Consecutive patients of cirrhosis with medical gastroenterology MCH Trivandrum. acute decompensation were prospectively included Result: Out of 50 patients, male 47 (94%) were and followed-up for 90-days from admission. predominant. Alcohol was most common etiology Acute-on-chronic liver failure (ACLF) was defined for chronic liver disease, 35 (70%) followed by based on CANONIC study criteria. Acute worsening chronic hepatitis B (CHB), 6 (12%). Active alcohol- due to acute viral hepatitis A and E, hepatitis B flare, ism was most common precipitating event 33 (66%), alcoholic hepatitis, autoimmune hepatitis flare or followed by sepsis in 15 (30%), CHB flare in 5 (10%), drug induced liver injury were categorized as hepa- acute hepatitis A in 3 (6%), ATT-DILI in 2 (4%). tic-ACLF and that due to sepsis, upper gastrointest- More than one precipitating event in 14 (28%). inal bleed or surgery as extrahepatic-ACLF. Patients Spontaneous bacterial peritonitis was present in with both hepatic and extrahepatic insults were 26%, hepatic encephalopathy in 40%, renal dysfunc- included in combined insult group. tion in 24%, UGI bleed in 18% cases. One month Results: Of 179 patients of acute decompensation, mortality was 20%. Three months mortality 122 had ACLF (hepatic-insults 47, extrahepatic-insults was 42%. For 1 month mortality younger age 51). Alcohol (64.8%) was the most common etiology of (<39 years), high INR (>3.07) and low hemoglobin cirrhosis while sepsis (36%) was the most common (<9.3 g/dL) were statistically significant. For 3 acute insult followed by alcoholic hepatitis (24.6%). months mortality total bilirubin (>21.65 mg/dL) Higher proportion of extrahepatic-ACLF patients had and low hemoglobin (<9 g/dL) were statistically history of prior decompensation than hepatic-ACLF significant. patients (62.7% vs. 27.7%, P < 0.001). There was no Conclusion: According to our study clinical profile difference in mortality among hepatic- and extrahe- of ACLF in our population is similar to western patic-ACLF groups at 28- and 90-days (53.2% vs. 56.9%, population with active alcoholism and sepsis being P = 0.715 and 85% vs. 74.5%, P = 0.193 respectively). most common precipitating event. ACLF carries a Area under receiver-operating curve (AUROC) for significantly high 1 and 3 months mortality. 28-day mortality in extrahepatic-ACLF group

was 0.788, 0.724, 0.718, 0.634, 0.726 and in hepatic- the most common precipitating event. At the end of 3 ACLF group was 0.786, 0.625, 0.802, 0.761, 0.648 for and 6 months, age and serum sodium as predictors CLIF-SOFA, MELD, iMELD, APACHE-II and CTP was statistically signiﬁcant. For age cut-off of 45.8 scores respectively. and 47.5 years at 3 and 6 months, and serum sodium Conclusion: There is no difference in mortality cut-off 132.5. Limitations—few cases were retrospec- among hepatic- and extrahepatic-ACLF groups at tive, lost to follow-up cases, and very long term (1 and 28- and 90-days. iMELD and CLIF-SOFA have high- 2 years) follow-up not analyzed. est AUROC to predict 28-day mortality in hepatic- Conclusion: AD had comparatively low mortality at and extrahepatic-ACLF groups respectively. the end of 3 and 6 months, but from 3 to 6 months AD group (8.6–25.7%) had more mortality compared CONFLICTS OF INTEREST to ACLF (21.4–32.1%). MELD, INR and CTP in AD whereas age and serum sodium was predictors of The authors have none to declare. mortality in ACLF group. Corresponding author: Radha K. Dhiman. E-mail: [email protected] CONFLICTS OF INTEREST http://dx.doi.org/10.1016/j.jceh.2016.06.009 The authors have none to declare. Corresponding author: Chethan Govindaraju. E-mail: [email protected] 8 http://dx.doi.org/10.1016/j.jceh.2016.06.010 ACUTE ON CHRONIC LIVER FAILURE AND ACUTE DECOMPENSATION: DO THEY BEHAVE SAME ON LONG TERM 9 Chethan Govindaraju, Prasanth Sudheendran, NEW INTERNATIONAL CLUB OF ASCITES Nikhil Suraj, Rathan Joseph, George Peter, DEFINITION OF ACUTE KIDNEY INJURY

Suthanu Bahuleyan, Shanid Sathar, Prasanth Sobhan, APPLIED AT ADMISSION IS NOT ALF and ACLF Srijaya Sreesh, Selwyn Noronha, Devadas Krishnadas INDEPENDENTLY ASSOCIATED WITH Govt Medical College Trivandrum, Trivandrum, India MORTALITY IN PATIENTS WITH ACUTE- ON-CHRONIC LIVER FAILURE Harneet Singh, Shiran Shetty, Girisha Balaraju, Background and Aims: We know acute on chronic Anurag Shetty, C. Ganesh Pai liver failure (ACLF) has high short-term mortality compared to acute decompensation (AD) but we Kasturba Medical College, Manipal, India do not have long-term data. So our aim was to assess the mortality and factors predicting it at the end of 3 and 6 months in AD and ACLF group. Background and Aim: The significance of the new Methods: Retrospective prospective study (2012– definition for acute kidney injury (AKI) proposed 2014) inclusion criteria—ACLF (according to APASL) by the International Club of Ascites (ICA) for patients and acute decompensation (not fitting into ACLF) withchronicliverdisease(CLD)hasnotbeenstudied patients who survived for 1 month after diagnosis. extensively in acute-on-chronic liver failure (ACLF). Results: Total 190 patients were included, ACLF 101 The aim of the study was to determine the association and AD 89 patients. ACLF group 17 and AD 19 between the different definitions of renal dysfunc- patients lost to follow-up. In AD alcohol 63 tion and short-term mortality in patients with (70.8%) was most common etiology. Alcoholic hepa- ACLF. titis 42 (47.19%) the most common precipitating Methods: Patients with ACLF as per the Asia Pacific event. At the end of 3 and 6 months, 6 (8.6%) and Association for the Study of the Liver (APASL) or 18 (25.7%) patients expired respectively. At 3 months European Association for the Study of Liver–Chronic MELD with a cut-off 22.5 as a predictor was statis- Liver Failure (EASL–CLIF) consortium criteria were tically significant. At 6 months MELD, CTP, INR was prospectively recruited, managed as per standard of statistically significant with a cut-off of 20.5, 12, 2.0 care and followed up for 28 days. Multivariate ana- respectively. In ACLF alcohol 61 (60.4%) was most lyses were done separately using six different mea- common etiology. Alcoholic hepatitis 61 (60.4%) is sures of renal dysfunction along with non-renal

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parameters found significant on univariate analysis protocol to achieve complete (clinically dry) ascites to assess their independent association with mortality mobilization and UNa > 80 mmol/L. for either group with ACLF. Methods: It was a retrospective analysis of prospec- Results: In the 76 (34.5%) and 78 (35.5%) patients tive accumulated data. Forty-one patients (20 study with ACLF as per the two definitions recruited from group (13:7; M:F)—Arm 1, 21 (15:6; M:F) standard 220 patients with CLD, the 28-day mortality was medical treatment (SMT)—Arm 2) fulfilling APASL 51.3% and 53.8% respectively. On multivariate ana- criteria for ACLF with ascites and high CVP (>10 cm lyses, none of the parameters of renal dysfunction in H2O) were included. All baseline lab tests (blood, patients with ACLF defined by the APASL criteria and urine, ascetic fluid) and timed 24-h urine collection only serum creatinine and the new ICA definition for urinary sodium (UNa), potassium (UK), creati- both as applied 48 h after admission were signifi- nine, albumin were done within initial 24 h. CVP was cantly associated with mortality. placed. Study arm group was initiated on furosemide Conclusion: AKI as per the ICA definition applied at infusion at 2 mg/h and albumin 2 g/h (20–40 g/d) admission is not significantly associated with mor- and N-acetylcystine infusion (as per dose of parace- tality in patients with ACLF diagnosed as per APASL tamol poisoning). Oral probiotic VSL #3 was added. and EASL–CLIF criteria. Blood and urine (electrolytes) samples were collected 12 hourly for UNa, UK and graded increase of fur- CONFLICTS OF INTEREST osemide was done by 1 mg/12 h if UNa < 80 meq/d with aggressive potassium supplementation wherever The authors have none to declare. required. At 48 h if UNa < 80 meq/d terlipressin infusion @4 mg/24 h was started after correcting anaemia Corresponding author: Harneet Singh. (8 g/dl) and baseline ECG (repeated 12th hourly) E-mail: [email protected] and response guided increase (1 mg/12th hourly) was http://dx.doi.org/10.1016/j.jceh.2016.06.011 done (maximum 8 mg/24 h) till ascites mobilization. L n ACLF and ALF Second group received SMT (albumin and all therapy as per guidelines). Both groups received aetiology specific treatment as per guidelines. 10 Results: Aetiology for cirrhosis in Arm I and II (alcohol (OH)—46% vs 46.2%, HCV—9.2% vs 5.5%, HBV— ASSESS 28-DAY SURVIVAL OF TOP DOWN 16.1% vs 20.9%, cryptogenic 27.6% vs 25.3%, autoim- APPROACH OF SLOW LOW-DOSE mune (AIH)—1.1% vs 2.2%) and acute insult (mainly CONTINUOUS ALBUMIN + FUROSEMIDE sepsis 46% vs 42.9%, OH 27.6% vs 25.3%; HBV reacti- — Æ TERLIPRESSIN (SAFI Æ T) AND N- vation 6.9 vs 14.3%; unknown 13.7 vs 9.9%; malena fi ACETYCYSTINE INFUSION AND 5.7% vs 7.7%) were not signi cant. All baseline parameters were not significantly different including in PROBIOTICS IN ACLF PATIENTS WITH — Æ Æ ARM I and II (creatinine 2.3 1.67 vs 2.4 1.68; MELD 35, ASCITES AND HIGH CVP — Æ Æ — Æ CTP 12.8 0.8 vs 12.7 1.38; median MELD 39.5 (CENTRAL VENOUS PRESSURE) ORGAN (36.2–40) vs 37 (35.5–39.5) (P = 0.03); number of FAILURE organ failure—2.9 Æ 1.4 vs 3.1 Æ 1.5; CLIF-SOFA— Æ Æ — Gaurav Pande, Kamlesh Kumar, Prabhat Sharma, 12.3 1.9 vs 12.2 2.3; urine output (UO) 523 Æ Æ V.P. Krishna, Amit Goel, Abhai Verma, Samir Mohindra, 78 vs 525 85 ml/day. Post-therapy in Arm I sig- fi Praveer Rai, Uday C. Ghoshal, Rakseh Aggrawal, ni cant difference from baseline was seen in urine Æ Æ Vivek A. Saraswat sodium 27.6 21 to 202 106 mmol/24 h, UO to 2152 Æ 815 ml/24 h (ARM II—810 Æ 150 ml/24 h), Sanjay Gandhi Institute of Medical Sciences, Lucknow, India serum creatinine 1.63 Æ 0.9; (ArmII—creatinine 1.99 Æ 1.7). Twenty-eight day survival in ARM I vs II was 65% (13/20) vs 47% (10/21) (P <0.05).Hemo- Background and Aim: Pathophysiology of ACLF dynamic assessment: baseline renal (RRI) and hepa- involves dysbalanced systemic inflammation and tic artery resistive index (HRI) was done in 10 worsened hyperdynamic circulation and altered gut patients only in Arm I pre- and post-therapy. Pre- permeability leading to multi organ dysfunction. A therapy the mean RRI was 0–806 Æ 0.078 and post- combination cocktail incorporating patho-physiolo- therapy changed to 0.67 + 0.04 (P = 0.001). For hepa- gical changes may impact survival. The aim is to study tic artery also the median differences were statisti- in ACLF patients the efficacy and safety of top-down cally significant. Side effect profiles were not therapy administered according to a response-guided significantly different.

Conclusion: Top down approach in extremely sick predictor of infection and outcome in patients with ACLF patients helps improve survival. ACLF. Methods: In this prospective study, total 120 CONFLICTS OF INTEREST patients of ACLF admitted in Liver Intensive Care from November 2015 to April 2016 were screened. The authors have none to declare. Thirty-ﬁve patients, who had suspected sepsis on presentation were included. Markers of sepsis includ- Corresponding author: Gaurav Pande. ing procalcitonin, C-reactive protein (CRP), galacto- E-mail: [email protected] mannan and b-D-glucan were evaluated. http://dx.doi.org/10.1016/j.jceh.2016.06.012 Results: Of the 35 patients analysed, the mean age of presentation was 45.86 years with a male predomi- nance (94.3%). Alcohol was the major etiological factor (77.1%) and majority of them had SBP (60%). 11 Procalcitonin on day 1 was not a predictor of infection, as well as CRP. A rising titre of procalcitonin on ROLE OF PROCALCITONIN IN EARLY day 5 (>0.745) had a sensitivity of 83.3%, speciﬁcity of DETECTION OF INFECTIONS IN ACUTE ON 87.5% and AUROC of 0.867 (0.695–1.039) to predict CHRONIC LIVER FAILURE IN LIVER infection. Nineteen out of 21 patients with stay of INTENSIVE CARE more than 7 days, had positive fungal work up and concomitant fungal sepsis with very high mortality Swapnil Dhampalwar, Aamritangsu Borkakoty, (78.8%). Four or more organ failures is a predictor of Sunil Taneja, Ajay Duseja, Radha K. Dhiman, mortality (P = 0.005). Yogesh K. Chawla Conclusion: Sequential measurement of procalcito- Postgraduate Institute of Medical Education & Research, Chandigarh, nin may help in predicting infection, but not one India point estimation. Threshold for preemptive antifungal therapy should be low in those with prolonged hospital stay.

Background and Aim: Infection is a major cause of ALF and ACLF mortality in Acute on Chronic Liver Failure (ACLF). CONFLICTS OF INTEREST Conventional scoring systems have limited prognostic accuracy ACLF. These scores fail to incorporate The authors have none to declare. ﬂ markers of sepsis and systemic in ammation and Corresponding author: Sunil Taneja. sequential organ failures. The aim of the study is E-mail: [email protected] to assess the role of biomarkers of sepsis and systemic inﬂammation on presentation and subsequently as http://dx.doi.org/10.1016/j.jceh.2016.06.013

Journal of Clinical and Experimental Hepatology | July 2016 | Vol. 6 | No. S1 | S1–S7 S7 JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY

Viral Hepatitis

1 CONFLICTS OF INTEREST LIVER DYSFUNCTION IN The authors have none to declare. THALASSEMIC CHILDREN: MORE Corresponding author: Sajan Agarwal. IN SPLENECTOMIZED THAN E-mail: [email protected] NON-SPLENECTOMIZED CASES http://dx.doi.org/10.1016/j.jceh.2016.06.015 Sajan Agarwal, Sunil Gomber

Guru Teg Bahadur Hospital, University College of Medical Sciences, New Delhi, India 2 Background and Aim: During recent year, liver disease has emerged as a major cause of mortality in BURDEN OF RENAL DYSFUNCTION IN patients with b thalassemia major. Multicenter cross- HEPATITIS C VIRUS INFECTION: AN sectional studies have reported that the development IMPORTANT UNMET TREATMENT NEED and the severity of liver fibrosis are strongly related to IN THE SOFOSBUVIR ERA the extent of liver iron overload and to the presence of Amey D. Sonavane, Deepak Amarapurkar chronic hepatitis infection. This study was conducted to find out the role of iron overload along Bombay Hospital and Medical Research Centre, Mumbai, India with concomitant chronic viral infection as a cause of ia Hepatitis Viral liver dysfunction in patients with b-thalassemia Background and Aim: The downstream metabolite major. GS-331007 of the potent NS5B inhibitor sofosbuvir Methods: Forty-one b-thalassemia major cases is exclusively eliminated renally (through combina- (divided into 2 groups—Group I: 12 splenectomized tion of glomerular filtration and active tubular secre- cases, Group II: 29 non-splenectomized cases) and 20 tion). Results of phase II and III clinical trials of apparently healthy subjects (Group III) were analyzed sofosbuvir have excluded patients with creatinine at the hour Thalassemic Centre for the assessment of clearance (CrCl) level less than 60 mL/min as its liver dysfunction. Hepatic dysfunction was defined by safety is not established in this population thus a ALT level of more than 55 IU/L. representing an unmet need in the treatment of Results: Thalassemic cases had significantly higher Hepatitis C virus (HCV) infection. The aim of the serum ALT and ferritin level with no significant dif- study was to assess the prevalence, risk factors and ference in serum albumin level between cases and burden of renal dysfunction in HCV patients. controls. ALT value was significantly higher in Group Methods: Medical records of 339 patients with HCV I than Group II. Serum ferritin level was higher in infection attending our clinic from January 2010 to Group I than Group II but it was not statistically June 2015 were scrutinized retrospectively. Patient significant. There was no significant correlation demographics, co-morbidities, HCV genotype, pre- between ALT and ferritin level. Hepatitis C infection sence of cirrhosis, decompensation and renal func- and hepatitis B infection had a prevalence of 24% (10/ tion were investigated. 41) and 2.4% (1/41) respectively among our cases. Out Results: Out of 304 records analysed (154 males; 150 of 10 hepatitis C infection cases, 7 were in Group I females), 184 (60.5%) had cirrhosis of liver. HCV Gen- and 3 were in Group II. Higher mean ALT value was otype 3 (64.1%) was the most prevalent followed by seen in HCV seropositive cases than HCV seronega- Genotype 1 (24.7%). 29.3% had hypertension, 23.4% tive cases. diabetes mellitus and 9.5% suffered from both co-mor- Conclusion: Hepatitis C infection lead to more hepa- bidities. 105 (34.5%) had decompensated with ascites, tic dysfunction in splenectomized thalassemic chil- 57 (18.8%) patients had jaundice, 39 (12.8%) had coa- dren. More hepatitis C infection cases in gulopathy (INR 1.5), 36 (11.8%) had at least one splenectomized group could be due to more frequent episode of gastrointestinal bleed and 17 patients blood transfusion requirement in these children (5.6%) had overt hepatic encephalopathy in the past. before splenectomy. However, Liver iron content, 58 (19.1%) patients had a baseline creatinine level fibrosis staging and cirrhosis should be evaluated 1.5 mg/dl. 7 (17.5%) of the 40 patients with severe by liver biopsy in these cases. renal dysfunction had decompensated liver disease.

42.4% were Interferon-experienced and 15.8% had (33%), one patient of genotype 6. 3 patients were experienced sofosbuvir. 7 patients had underwent renal treatment experienced (Peg INF), 4 patients were post transplantation and 39 patients were on maintenance renal transplant. Nine patients had completed ther- haemodialysis. The renal function is depicted in Table. apy till date, ETR was achieved in all 9 (100%) patients, SVR was documented in 6 of them. Two Severity eGFR/CrCl (mL/min/1.73 m2) Total (n) patients discontinued therapy due to severe fatigue Mild 50–80 89 (29.28%) and acute kidney injury while on therapy. One of the Moderate 30–50 25 (8.22%) INF experienced patient could not achieve ETR even <30 40 (13.15%) after 24 weeks of SOF + Ribavarin. Important thing Severe we noted in this study were one of the patients who >80 150 (49.35%) Normal had documented SVR developed hepatocellular carcinoma; post renal transplant patients tolerated ther- Conclusion: HCV infection is associated with signiﬁ- apy well and most of the patients did not have any cant renal dysfunction and was found in nearly 50% of major side effects and had good SVR rates. HCV infected population at our centre. A devoted Conclusion: In the real life setting also Sofosbuvir study to evaluate optimal dosage of sofosbuvir in based regimens for chronic hepatitis C treatment was patients with severe renal dysfunction is the need of well tolerated with good response rates without major the hour. adverse effects even in the setting of decompensated cirrhosis and post renal transplant. CONFLICTS OF INTEREST CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Amey D. Sonavane. The authors have none to declare. E-mail: [email protected] Corresponding author: K.S. Prasanna. http://dx.doi.org/10.1016/j.jceh.2016.06.016 E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.017 Viral Hepatitis 3 4 REAL LIFE EXPERIENCE OF SOFOSBUVIR BASED THERAPY FOR CHRONIC HEPATITIS CIRCULATING BONE MARROW-DERIVED C PATIENTS FROM NORTH EAST INDIA STEM CELLS IN PATIENTS WITH CHRONIC HEPATITIS C: RELATION TO HEPATIC K.S. Prasanna, Kamal Chetri, Mukesh Agarwala, PROGENITOR CELLS AND HEPATOCYTE Partha Roy, Arvind Kelkar PROLIFERATION International Hospital, Guwahati, India Hoda E. Aggan, Nahla Farahat, Basma E. Sabaa, Amany Elyamany, Rawhia A. Esa Background and Aim: Directly acting antivirals have changed the hepatitis C treatment drastically with University of Alexandria, Alexandria, Egypt good (>90%) sustained virologic response rates (SVR) in most patient groups in trials. We are presenting Background and Aim: Bone marrow-derived stem our real life experience with Sofosbuvir (SOF) based cells (BMSCs) are pluripotent cells that can be mobi- regimens in hepatitis C treatment. lized into circulation and recruited to sites of tissue Methods: All those patients who were hepatitis C injury where they promote local repair. The present virus RNA positive with or without anti hepatitis C work was designed to study circulating bone marrow antibody positivity with indication for therapy as per (BM)-derived hematopoietic stem cells (HSCs) and American association for study of liver diseases mesenchymal stem cells (MSCs) and serum stem cell (AASLD) guidelines were included in this study. factor (SCF) levels in patients with chronic hepatitis C Results: Thirty-nine patients with chronic hepatitis C (CHC) in relation to hepatic progenitor cells (HPCs) or compensated or decompensated cirrhosis {age 44 and hepatocyte proliferation. (18–72) years [median (range)], M:F—35:4, CTP A:B:C; Methods: Thirty treatment-naïve patients with CHC 26:10:3} were included in this study. Study popula- and 15 healthy subjects were included in the study. tion predominantly had genotype 3 (64%), genotype 1 The BM-derived HSCs and MSCs in fresh blood

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samples were identified as CD34+CD45+CD117+ and Background and Aim: Hepatitis B virus (HBV) is CD34CD45CD106+ cells respectively using flow the cause for chronic liver diseases such as hepatitis, cytometry. Serum SCF levels were measured using cirrhosis, and hepatocellular carcinoma (HCC). enzyme linked immunosorbant assay kit. Liver biop- HBx, a 17 kDa multifunctional protein, encoded sies were examined to assess METAVIR grade and by HBV, plays a crucial role in pathogenesis and fibrosis stage. Immunohistochemical staining was replication of HBV. HBx is known to interact with done using monoclonal antibodies against cytoker- many host factors, directly or indirectly, and thereby atin (CK)7 for HPCs, Ki-67 as proliferation marker alters their regular functioning for its own benefit. and alpha-smooth muscle actin for activated hepatic On the other hand, nuclear bodies (or PML bodies) stellate cells (HpSCs). are nuclear sub compartments that are involved in Results: Patients with CHC showed significant many cellular processes like transcription, DNA increases in the percentages of HSCs and MSCs in damage response and anti-viral response. Sp110 is peripheral blood and serum SCF levels compared a PML body protein, whose function in the cell is with healthy subjects (P < 0.05). Numerous CK7+ still not well characterized but its mutation is HPCs were detected mostly lining primitive bile ducts reported to cause hepatic veno-occlusive disease or as individual positive cells in the portal tracts. with immunodeficiency (VODI). A truncated iso- Hepatic proliferative activity was observed in prolif- form of Sp110 has previously been shown to inter- erated ductal profiles in portal tracts and within act with hepatitis C virus core protein and Epstein- hepatocytes and directly correlated with HPC expan- Barr virus (EBV) nuclear protein. The aim of the sion. The percentages of circulating HSCs and MSCs study the involvement of Sp110 in Hepatitis B viral showed positive correlation with serum SCF levels pathogenesis. and inverse correlations with HPC expansion, hepa- Methods: HepG2 (Human hepatoblastoma cells) tocyte proliferation, METAVIR grade and stage and and HepG2.2.15 (HBV stable HepG2 cells) were used intensity of activated HpSCs (P < 0.05). for the experiments which include standard methods ia Hepatitis Viral Conclusion: Chronic HCV infection is associated like siRNA silencing, transient transfection, qRT- with mobilization of BMSCs into the circulation, PCR, co-immunoprecipitation, Western Blot and particularly when HPC activation and hepatic prolif- immunofluorescence staining. erative activity are impaired. Although the mobilized Results: Sp110, which has a strong chromatin asso- BMSCs are not sufficient for hepatic repopulation, ciation, was found to be enriched in HBV infected they may play an important role in limiting HCV- cells at both RNA and protein level as compared to induced liver damage. the uninfected cell line. This was consistent with the patient samples where the level of Sp110 mRNA/ CONFLICTS OF INTEREST protein increases with the degree of infection. While Sp110 silencing in infected cells lowered the viral The authors have none to declare. load, it’s over expression caused reciprocal effect, implicating its involvement in promoting HBV infec- Corresponding author: Hoda E. Aggan. tion. Sp110 was found to interact with HBx protein of E-mail: [email protected] the virus. Gene expression profile of Sp110 silenced http://dx.doi.org/10.1016/j.jceh.2016.06.018 HepG2.2.15 cell became similar to that of HepG2 cells. Conclusion: Chromatin binding host-protein, Sp110, gets hijacked by viral protein HBx and pro- 5 motes viral pathogenesis.

HBX HIJACKS NUCLEAR BODY PROTEIN CONFLICTS OF INTEREST SP110 AND PROMOTES VIRAL PATHOGENESIS The authors have none to declare. Isha Sengupta 1, Chandrima Das 1, Dipanwita Das 2, Corresponding author: Mayank Gupta. Runu Chakravarty 2, Santanu Adhikary 3, E-mail: [email protected] Siddhartha Roy 3 http://dx.doi.org/10.1016/j.jceh.2016.06.019 1Saha Institute of Nuclear Physics, Kolkata, India, 2ICMR Virus Unit, Kolkata, India, 3Indian Institute of Chemical Biology, Kolkata, India

6 CONFLICTS OF INTEREST RANDOMIZED STUDY OF INTERFERON The authors have none to declare. BASED AND INTERFERON FREE Corresponding author: Anurag Tiwari. SOFOSBUVIR CONTAINING E-mail: [email protected] REGIMENS IN TREATMENT OF PATIENTS WITH HEPATITIS C http://dx.doi.org/10.1016/j.jceh.2016.06.020 GENOTYPE 3 INFECTION Anurag Tiwari, Sunit Shukla, Ajay Nandmer, 7 Vinod Dixit A STUDY ON CLINICAL, BIOCHEMICAL, Institute of Medical Sciences, Varanasi, India SEROLOGICAL, AND HISTOPATHOLOGICAL PROFILE OF INCIDENTALLY DETECTED Background and Aim: In India genotype 3 is HEPATITIS B INFECTION most prevalent (2/3rd) of total hepatitis C burden. Showkat Kadla, Nisar A. Shah, Sakshi Sharma, Sofosbuvir, a polymerase inhibitor is pangenotypic Inamu Rehman, Bilal Khan, Asif Shah, directly acting antiviral for hepatitis C. In this Shaheena Parveen, Shaheen Nazir study we evaluate two sofosbuvir containing regimens with or without pegylated interferon Govt. Medical College, Srinagar, India (PEGIFN) in patients with hepatitis C genotype 3 infections. Background and Aim: Incidentally detected Hepa- Methods: It was a prospective, single centre, rando- titis B is a common health problem in our commu- mized open label study. Thirty nine patients age 18 nity and common cause for referrals to a years or more with chronic hepatitis or compensated gastroenterologist but at the same time it has not cirrhosis infected with hepatitis C genotype 3 were been well studied. Our aim is to study the clinical, randomized into two groups Peg-IFN alpha 2b with biochemical, serological, nucleic acid (HBV DNA) and sofosbuvir and ribavirin for 12 weeks (A) and sofos- histological profile of incidentally detected HBV posi- buvir and ribavirin for 24 weeks (B). Patients with tive patients. Viral Hepatitis contraindications to Peg-IFN or ribavirin therapy, Methods: This prospective hospital based study with chronic kidney disease and with treatment included a total of 44 incidentally detected HBV experience were excluded. Primary and secondary positive patients. A detail clinical examination and end points were End of treatment response (ETR) laboratory value such as complete blood counts, kid- and rate of adverse effects respectively. ney function tests, coagulogram, liver function tests Results: Baseline characteristics in both groups were were done. Other investigations included ultrasono- comparable and any difference was statistically insig- graphy (USG) of hepatobiliary system, upper gastro- nificant. Two patients in group B did not complete intestinal endoscopy, HBeAg, HBeAb, and HBV DNA therapy and excluded from analysis. ETR in group A by PCR. Liver biopsy specimens from 33 patients were was 100%(18/18) and group B was 89.4%(17/19). Flu- studied and scored for activity and fibrosis stage by like symptoms after Peg-IFN injection was seen in modified Ishak score. almost all patients in group A for initial few injec- Results: 44 (100%) patients were asymptomatic with- tions. Non-specific adverse effects were more fre- out any liver disease or extrahepatic disease, clinical quent in group A than group B (94.4% versus examination was unremarkable in all the patients. 79%). Rates of hemoglobin decrease, neutropenia Out of the 44 studied patients 11 (25%) were HBeAg and thrombocytopenia were 100, 17 and 44.4 percent positive. Out of total of 18 patients with ALT level in group A and 94, 0 and 15.8 percent in group B <40 U/L, 7 (22.58%) had necroinflamatory score of 3 respectively. and 1 (3.22%) had necroinflammatory score of 5, 16 Conclusion: Peg-IFN with sofosbuvir and ribavirin (51.16%) patients were in stage 0 and 2 (6.45%) for 12 weeks achieves higher ETR rates as compared patients were in stage 1. HBV DNA <2000 IU/L to sofosbuvir and ribavirin for 24 weeks in treating was present in 25 (56.81%) of the 44 patients. Pre- patients infected with hepatitis C genotype 3 infec- dominantly histopathological finding was mild por- tions. Peg-IFN based treatment leads to higher hema- tal tract inflammation in 24 (72.7%) of patients with 2 tological as well as non hematological side effects but (6.06%) having portal tract fibrosis and 1 (3.03%) these are mild and easily manageable during 12 weeks having periportal fibrosis. None of them was treatment. cirrhotic.

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Conclusion: Majority of the patients were HBeAg Results: Out of 5533 subjects screened for HBsAg, negative and were in inactive phase and histopathol- 2976 were males and 2557 were females. Out of total ogy showing no evidence of cirrhosis. However good 5533 subjects, 133 tested positive for HBsAg consti- number of patients 24 (72.7%) had mild portal tract tuting a total prevalence of 2.40%. Out of 2976 males, inflammation and 2(6.06%) having portal tract fibro- 66 (2.21%) tested positive for HBsAg and among 2557 sis and 1(3.03%) having periportal fibrosis. females, 67 (2.62%) tested positive for HBsAg. Conclusion: Overall prevalence of hepatitis B is 2.4% CONFLICTS OF INTEREST in our setup, 2.21% in males and 2.62% in females. The authors have none to declare. CONFLICTS OF INTEREST

Corresponding author: Nisar A. Shah. The authors have none to declare. E-mail: [email protected] Corresponding author: Nisar A. Shah. http://dx.doi.org/10.1016/j.jceh.2016.06.021 E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.022

8 9 A STUDY ON PREVALENCE OF HEPATITIS B AMONG ADULT POPULATION IN SOUTH GENOTYPE DISTRIBUTION OF HEPATITIS C KASHMIR VIRUS IN PATIENTS WITH CHRONIC Showkat Kadla, Nisar A. Shah, Mudasir Bhat, HEPATITIS C INFECTION IN KASHMIR: Mohamad Khan, Bilal Khan, Asif Shah, A CROSS SECTIONAL STUDY ia Hepatitis Viral Shaheena Parveen, Shaheen Nazir Nisar A. Shah, Shagufta Parveen, Showkat Kadla, Govt. Medical College, Srinagar, India Asif shah, Mariya Querishi, Samina Farhat, Bilal Khan, Shaheena Parveen

Background and Aim: Hepatitis B virus is a small Govt. Medical College, Srinagar, India DNA virus that belongs to Hepadnaviridae family. Hepatitis B is a potentially life-threatening liver infec- Background and Aim: Hepatitis C virus (HCV), an tion caused by the hepatitis B virus. It is a major important cause of chronic hepatitis, cirrhosis and global health problem. It can cause chronic liver hepatocellular carcinoma shows a considerable disease and chronic infection and puts people at genetic heterogeneity among the patients infected high risk of death from cirrhosis of the liver and with hepatitis C virus from all over the world. At liver cancer. More than 240 million people have least six main groups of sequence variants are recog- chronic (long-term) liver infections. About nized. The natural history of disease and response to 600,000 people die every year due to the acute or treatment may be related to the genotype of HCV in a chronic consequences of hepatitis B. High rates of particular patient. Antigenic differences between gen- chronic infections are also found in the Amazon otypes also have implications for optimal design of and the southern parts of eastern and central Eur- serological sequencing and confirmatory assays for ope. In the Middle East and the Indian subconti- HCV. The present study was undertaken with the nent, an estimated 2–5% of the general population is objective to find out various genotypes of hepatitis chronically infected. Not many community based C virus prevalent in Kashmiri population with studies are available from our country and none chronic hepatitis C infection. from Kashmir valley. The study was aimed estimate Methods: This cross sectional study was conducted the prevalence of hepatitis-B among adult popula- by collecting and analyzing all the available information in South Kashmir. tion about the patients of hepatitis C registered and Methods: A community based, cross sectional study treated in the Department of Gastroenterology GMC was conducted in four districts of south Kashmir over Srinagar over last 4 years from February 2011 to June a period of one and half year by using Hepacard kit 2015. (immunochromatography method) product code Results: Out of 642 patients with hepatitis C infec- HB010020, HB010100 manufactured by J. Mitra & tion attending the department, genotype was avail- Co. Pvt. The hepacard kit has a sensitivity of 99% and able in 607 of them and only they were included in the specificity of 97.8%. final analysis. Data included males and females in the

ratio of 1.7:1 with 60% of them coming from south without such reduction (null responders), treatment Kashmir, 31% from central Kashmir and 9% from was discontinued. north Kashmir. Majority of the infected individuals Results: Of 26 non-cirrhotic patients (GT1 15, GT3 (90.8%) had infection with Genotype 3 followed by 11) treated, four (15%; GT1 3, GT3 1) were null type 1 in 8.1% of cases while as other genotypes found responders. Twenty-two (85%) patients had either here include Genotype 2 and 4 to a very less extent of rapid (n = 14 [54%]; GT1 10, GT3 4) or slow response 0.3% and 0.8% only. No case of Genotype 5 and 6 was (n = 8 [31%]; GT1 2, GT3 6), and had undetectable found in this study. RNA at end of treatment. One patient could not Conclusion: Most prevalent genotype of hepatitis C complete the treatment and was lost thereafter. There in Kashmiri population is type 3 (90.8%) followed by were no deaths during treatment. Three patients type 1 in 8.1% of cases. relapsed and three others died in 6 months after stopping treatment. Overall, 15/26 (58%) patients CONFLICTS OF INTEREST attained SVR24. Fourteen patients underwent transplantation beginning 1 month after treatment com- The authors have none to declare. pletion, and all were relapse-free after 13.5 (10–21) months of follow-up. Corresponding author: Nisar A. Shah. Conclusion: RGT using Peg-IFN and ribavirin was E-mail: [email protected] effective and safe in ESRD patients on maintenance http://dx.doi.org/10.1016/j.jceh.2016.06.023 dialysis. Renal transplant was safely done within 1 month of completing such treatment.

CONFLICTS OF INTEREST 10 SAFETY AND EFFECTIVENESS OF The authors have none to declare. RESPONSE-GUIDED THERAPY USING Corresponding author: Rakesh Aggarwal. PEGYLATED INTERFERON AND RIBAVIRIN E-mail: [email protected] FOR CHRONIC HEPATITIS C VIRUS http://dx.doi.org/10.1016/j.jceh.2016.06.024 INFECTION IN PATIENTS ON Viral Hepatitis MAINTENANCE DIALYSIS Amit Goel, Rajat Bhargava, Dharmendra Bhadauria, 11 Anupma Kaul, Narayan Prasad, Amit Gupta, Raj Sharma, Praveer Rai, Rakesh Aggarwal UPPER GASTRO INTESTINAL (UGI)

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, ENDOSCOPIC LESIONS IN PATIENTS WITH India HEPATITIS C Ashish Kumar, Sanjay Goyal, Harnoor Bhardwaj, Background and Aim: Treatment of hepatitis C Bachan Bhardwaj, Pallav Jain virus (HCV) infection in patients with end-stage renal disease (ESRD) is difﬁcult. Addition of ribavirin to Government Medical College, Patiala, India pegylated-interferon (Peg-IFN) may help to improve the treatment response. Further, treatment duration Background and Aim: Hepatitis C is a huge burden could be shortened using a response-guided treat- on health care system. This study describes different ment (RGT) approach. We aimed to assess the safety types of lesions encountered in patients with hepatitis and effectiveness of RGT with Peg-IFN and ribavirin C undergoing UGI endoscopy. in patients of chronic hepatitis C with ESRD. Methods: Thirty consecutive patients with hepatitis Methods: We retrospectively reviewed records of C who came for UGI endoscopy in the Endoscopy treatment-naïve adult patients with ESRD and Room, Government Medical College Patiala, from chronic HCV infection treated with Peg-IFN and January 1, 2016 onwards were included in this study. low-dose ribavirin using a RGT approach. Rapid Results: Patients consisted of 20 (66.67%) males and responders (undetectable HCV-RNA at 4 weeks) 10 (33.33%) females. Mean age was 51.36 years and received treatment for 12 weeks, and slow responders the range was 26–77 years. Analysis showed that 3 (HCV-RNA detectable at 4 weeks, but undetectable or (10%) patients were less than 40 years of age, 9 (30%) with >2.0 log10 reduction at week 12) for 24 (geno- patients were between 40 and 49 years, 9 (30%) patients type 3; GT3) or 48 (genotype 1; GT1) weeks. In those were 50–59 years, and 9 (30%) patients were above 60

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years of age. Esophageal lesions seen on UGI were: than >6,00,000 IU/ml. The median fibroscan value esophageal varices in 18 (60%) patients, CRS in 3 (10%), was 5.7 KPa. There were no significant differences RWS in 1 (3.33%), 1 (3.33%) eradicated varix, candi- between the baseline demographic characteristics, diasis in 1 (3.33%) patient and 1 (3.33%) patient had viral load and fibroscan values between the SRPeg concentric stricture measuring 8 cm. Gastric lesions and SR group. In the present interim analysis of were: PHG in 9 (30%), IGV in 1 (3.33%), GOV in 1 the 36 patients in whom SVR12 was available (20 (3.33%), antral gastritis in 1 (3.33%), gastritis in 2 in SRPeg; 16 SR), all patients achieved SVR12. Only (6.66%), gastric erosion in 2 (6.66%), 1 (3.33%) patient one patient in the SRPeg experienced low TLC (<1500/ had gastric volvulus. Duodenal lesions were seen as mm3) and low platelet count (<50,000/mm3), and was large duodenal ulcer in 1 (3.33%), decreased duodenal managed with dose reduction in Peg-Interferon. No folds in 1 (3.33%) and in 1 (3.33%) patient duodenum patient had haemoglobin <10 g/dl. No patient could not be reached (due to gastric volvulus). required treatment discontinuation. Conclusion: This study reveals that we may see vari- Conclusion: In the present interim analysis we found ety of lesions on UGI endoscopy that may or may not SRPeg and SR regimen to be equally efficacious in the be associated with portal hypertension. management of treatment naive genotype 3 chronic hepatitis C patients. CONFLICTS OF INTEREST CONFLICTS OF INTEREST The authors have none to declare. The author has none to declare. Corresponding author: Ashish Kumar. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.026 http://dx.doi.org/10.1016/j.jceh.2016.06.025 ia Hepatitis Viral 13 12 SVR12 AMONG 40 PATIENTS OF CHRONIC COMPARISON OF SOFOSBUVIR PLUS HEPATITIS C TREATED WITH SOF/RBV RIBAVIRIN PLUS PEG-INTERFERON WITH +/PEGIFN-RESULT FROM A SINGLE SOFOSBUVIR AND RIBAVIRIN FOR TERTIARY CENTER KOLKATA, WEST TREATMENT OF GENOTYPE 3 TREATMENT BENGAL NAIVE INDIAN CHRONIC HEPATITIS C Asokananda Konar, Jaya G. Chatterjee PATIENTS: AN INTERIM ANALYSIS OF ONGOING RCT Peerless Hospital and BK Roy Research Center, Kolkata, India

Ujjwal Sonika Background and Aim: Hepatitis C is a major cause All India Institute of Medical Sciences, New Delhi, India of liver related morbidity and mortality, with approx- imate global prevalence 122–185 million people. Bet- Background and Aim: Sofosbuvir plus Ribavirin ter understanding of HCV lifecycle and advent of plus peginterferon (SRPeg) for 12 weeks and Sofos- newer DAA has revolutionized its treatment and out- buvir and Ribavirin (SR) for 24 weeks are the recom- come. There are less available data on SVR12 response mended treatment regimens for treatment naive with DAA from India. The aims of the study were (1) genotype 3 chronic hepatitis C patients. There is to estimate SVR12 response in CHC; treatment-naive, sparse published data on the sustained virological treatment-experienced, cirrhotics and non-cirrhotics, response (SVR12) among Indian’s with either of these (2) to compare SVR12 among cirrhotics and non- 2 combinations. cirrhotics and (3) to assess overall adverse effects. Methods: We compared the efﬁcacy of SRPeg for 12 Methods: In an ongoing clinical prospective study. weeks with SR for 24 weeks in a randomized control Till date 40 patients between May 2015 and 2016, all trial in treatment naive genotype 3 patients. The aged >12 years, irrespective of sex, all CHC, with doses of drugs used were—Sofosbuvir 400 mg, Pegin- written consent were included. All were treated with terferon 1.5 mg/kg and Ribavirin 15 mg/kg. sofosbuvir 400 mg, wt based ribavirin (1000/ Results: A total of 79 patients were randomized (40 in 1200 mg), +/peg IFN (either 12 weeks with pegIFN; SRPeg and 39 in SR). The median age was 30 years, 53 or 24 weeks without IFN). HCV RNA measured with (67%) were males. All patients had HCV RNA more RTPCR with lower limit detection 15 IU/ml. Baseline

CBC, LFT, creatinine, TSH were checked. HCV RNA Methods: This cross-sectional study was conducted in measured at 4 weeks, 12 or 24 weeks (at the end 1118 patients presenting with acute viral hepatitis. All treatment), post treatment 12 weeks (SVR12). SVR patients were tested for anti-HAV IgM and anti-HEV 12 deﬁned by undetectable RNA after 12 weeks of IgM by Enzyme Linked Immunosorbent Assay (ELISA) treatment completion. Cirrhosis diagnosed on clin- method. The study population was divided into 7 ical/laboratory-low platelet, reversed alb-glob ratio, groups according to their ages with 10 years interval. APRI/imaging—USG/ﬁbroscan—>12.5 kPa. Results: Among 1118 patients, 571 (51.0%) and 203 Results: Total patients—40; M—24 (60%); cirrhotics— (18.2%) were found HEV IgM positive and HAV IgM 26/40 (65%), noncirrhotics—14/40 (35%); genotype 1— respectively. Rest 344 (30.8%) patients were negative 5/40 (12.5%), genotype 3—34/40 (85%), genotype 4—1/ for both HAV IgM and HEV IgM. 64.0% and 77.8% 40 (2.5%). Total 14/40 received pegIFN. SVR12 in male patients were positive for HAV and HEV infec- patients with cirrhosis—23/26 (88.5%); SVR12 in tion. In our study, it was found that 62.4% patients non-cirrhotic patients 13/14 (92.9%). Relapse was seen positive for Hepatitis A infection were less than 10 in 3 patients with cirrhosis 11% (1 child C, 1 child B years and 73.9% and 70.5% HEV positive patients were with HCC, 1 child B—nonadherent). Among noncir- in 31–40 years and 41–50 years age group. HAV and rhotics 1 patient discontinued, SVR12 among treat, HEV infections occur all year round with a peak naive cirrhotics—10/12 (83.3%), SVR12—13/14 (92%) during hot seasons with great number of rains. among treat.exp cirrhotics. Adverse effects—most com- Conclusion: It may be concluded with that both mon-anaemia 32/40 (80%), 7/40 (17.5%) required RBV HAV and HEV infection can occur at any age dose reduction, other 30% fatigubility, 15% anorexia, 1 throughout the year. But HAV affect more in children (2.5%) skin rash resolved. None with decompensation, and HEV affect more in adults with a peak during hot 1 (2.5%) discontinuation. 1 death unrelated—ICH. seasons with great number of rains. Conclusion: Limitation was small number of patients, but with DAA, SVR12 are impressive; among CONFLICTS OF INTEREST cirrhotics and noncirrhotics—88.5%, 92.5% respectively; 92%—treat-experienced cirrhotics. The authors have none to declare. Corresponding author: Sharmin Sultana.

CONFLICTS OF INTEREST E-mail: [email protected] Viral Hepatitis

The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2016.06.028 Corresponding author: Jaya G. Chatterjee. E-mail: [email protected] 15 http://dx.doi.org/10.1016/j.jceh.2016.06.027 SOFOSBUVIR AND RIBAVIRIN COMBINATION IS SAFE AND EFFECTIVE IN RENAL TRANSPLANT RECIPIENTS WITH 14 HCV INFECTION SERO PREVALENCE OF ACUTE HEPATITIS Sunil Taneja, Ajay Duseja, Arka De, Vivek Kumar, CAUSED BY HAV AND HEV IN GAZIPUR, Raja Ramachandran, Ashish Sharma, Radha K. Dhiman, BANGLADESH Krishan Gupta, Mukut Minz, Yogesh K. Chawla Mohammad S. Haque, Sharmin Sultana, Postgraduate Institute of Medical Education and Research, Chandigarh, Mamun A. Mahtab India

Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Background and Aim: Current DAAs have revolutionized the treatment of HCV. There is no substan- Background and Aim: Hepatitis A and E virus tial data addressing the safety and efficacy of the (HAV and HEV) are the most common causes of newer antivirals in renal transplant recipients. The acute hepatitis. Both of them are endemic in South combination antiviral therapy using Sofosbuvir and Asia; specially in the developing countries, like Ribavirin is an approved treatment option for chronic Bangladesh. This study was undertaken to determine HCV infection. However, the safety and efficacy of the prevalence, age-specific prevalence and seasonal this regimen in renal transplant recipients with HCV variation of Hepatitis A and Hepatitis E in Gazipur infection is unknown. Thus, we aimed to study the district. safety, efficacy and SVR rates with Sofosbuvir and

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Ribavirin for treatment of HCV infection in renal the prevention and spread of HBV infection. The transplant recipients. current study aims to assess the knowledge and atti- Methods: We studied fourteen HCV infected renal tude regarding hepatitis B amongst nurses. transplant recipients treated with Sofosbuvir and Methods: Using proportionate random sampling Ribavirin in this real life observational retrospective method, 400 bedside nurses working in various areas cohort analysis. of a tertiary care centre were studied. A prevalidated Results: Of the total 14 patients enrolled, 11 (78.5%) self administered questionnaire was used to collect patients in the cohort completed 24 weeks of treatment the data. All ethical aspects were kept in mind. with full dose Sofosbuvir and Ribavirin. One patient Results: Mean age of the subjects was 30.6 9.56 who was given modified doses in view of decompen- years with the range of 22–60. Majority (82.7%) were sated HCV cirrhosis with allograft dysfunction also females. The overall mean knowledge score was 25.7 completed 24 weeks of treatment. The baseline HCV 1.64 (56%) (maximum attainable score: 46). RNA concentration was 6.95 106 IU/ml (2.8 Around half (48%), each were in the good and average 105–3.5 107). A rapid virological response defined category of score. The subjects with lesser profes- as undetectable HCV RNA at 4 weeks was seen in 13 sional experience had significantly higher knowledge (93%) patients. HCV RNA remained undetectable at score. Regarding attitude of the subjects, majority end of treatment (at 24 weeks) in all 12 (86%) patients strongly agreed that their job put them at risk for who completed treatment. SVR 12 was achieved in 12 hepatitis B; the positive patients should be isolated (86%) out of 14 patients. 2 (14%) patients had to dis- from other patients; they should wear double gloves continue therapy due to development of severe anemia. while providing care to HBV positive patients and In all patients, liver fibrosis assessment was done by each patient should undergo testing for hepatitis B at transient elastography which revealed minimal or no the time of admission to the hospital. Regarding fibrosis (F0–F1) in 10 (71%) patients, moderate fibrosis vaccination, only 49% had taken all the three doses (F2) in 2 (14%) patients, severe fibrosis (F3) in none and of hepatitis B vaccine. 44% had experienced needle ia Hepatitis Viral cirrhosis in 2 (14%) patients. 12 (86%) patients achieved stick injury (NSI) with 23% experiencing 1–5 times. cure of hepatitis C post DAAs therapy. 17% had got their immunity checked after getting Conclusion: Sofosbuvir and Ribavirin combination vaccination. 56.5% were aware of what should be done has excellent efficacy, SVR rates and safety profile for after having NSI. treatment of HCV infection in renal transplant Conclusion: Ongoing in-service education programs recipients. are required to keep the nurses undated regarding the disease. Infection control practices must be super- CONFLICTS OF INTEREST vised regularly.

The authors have none to declare. CONFLICTS OF INTEREST Corresponding author: Ajay Duseja. The authors have none to declare. E-mail: [email protected] Corresponding author: Radha K. Dhiman. http://dx.doi.org/10.1016/j.jceh.2016.06.029 E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.030 16

KNOWLEDGE AND ATTITUDE REGARDING 18 CARE OF HEPATITIS B VIRUS (HBV) POSITIVE PATIENTS AMONGST THE SOFOSBUVIR BASED THERAPY IS USELESS NURSES OF TERTIARY CARE CENTRE IN HCV PATIENTS WITH CTP B AND C CLASS OF CIRRHOSIS WITH NO Sukhpal Kaur, Radha K. Dhiman, Sandeep Satsangi, Ajay Duseja, Pankaj Arora TRANSPLANT OPTION Ajay Kumar, Amar Deep Background and Aim: Owing to the nature of work, nurses are at high risk of acquiring and transmitting King George Medical University, Lucknow, India the blood borne infections. Hepatitis B is one of the most signiﬁcant occupational infectious risks Background and Aim: Hepatitis C virus (HCV) is amongst nurses. They need to be aware regarding one of the leading causes of liver cirrhosis. Since the

early 1990s, when interferon was first introduced for of a novel small molecule which efficiently prevents the treatment of HCV infection, the therapeutic goal viral entry into hepatocytes and its replication is has been viral suppression in chronic HCV viral era- urgently needed for proper management of HCV dication. With the introduction of new antiviral regi- patients. Aim of the study: This study aims to identify mens with 12 week course of a NS5A and NS5B a microRNA (miRNA) that can target multiple host polymerase inhibitor, we are able to achieve SVR rate and viral proteins required for infection and replica- of more than 95%. NS5B inhibitor combination are tion of HCV and its functional characterization in also highly effective for previously difficult to treat HCV infection. and or difficult to cure HCV subgroups including Methods: Bioinformatic tools were used to identify patients with cirrhosis. miRNA(s) which can target multiple host factors Method: We treated 92 HCV infected patients having which aid in the HCV life cycle. Luciferase assay no finances for transplant, with sofosbuvir based and qRT-PCR were performed to verify the binding triple drug regimen for 12 weeks. Among them 29 of miRNA to the targets. Inhibition of HCVcc infec- had cirrhosis with 16 CTP-A, 13 CTP B and C, and 63 tivity in presence of miRNA was studied in Huh7.5 cell without cirrhosis. after determining the cell viability by trypan blue Results: All 63 patients without cirrhosis achieved exclusion assay. SVR 12. In 9 patients with CTP B and C class, SVR Results: Bioinformatic tools identified mir-509-5p 12 was achieved but no improvement in CTP class. In that can target 6 host receptors and factors involved 4 patients, there was worsening in there CTP class. in HCV life cycle. Overexpression of miR-509-5p in Serious adverse events such as new onset ascites and Huh-7.5 showed decrease in expression of majority of hepatic encephalopathy was noted in 3 patients with the host receptors. In vitro luciferase assay along with CTP class B patients. One patient died during therapy. site directed mutagenesis of the miRNA binding sites Conclusion: These results show no benefitofsofos- has confirmed the binding of miR-509-5p to the buvir based anti HCV therapy with no transplant 30UTR region of CD-81 and CLDN1. HCVcc particle option. of genotype 3was used to determine TCID50 in Huh7.5 which was 1:1000 dilution. Infection in CONFLICTS OF INTEREST miR509-5p transfected cells showed significant low infectivity compared to that in vector control. The authors have none to declare. Conclusion: This data highlights that miR-509-5p Viral Hepatitis Corresponding author: Ajay Kumar. has a preventive role in HCV internalization by down- E-mail: [email protected] regulating the two host receptor genes like CD81 and CLDN1. Thus miR-509-5p may have a therapeutic http://dx.doi.org/10.1016/j.jceh.2016.06.032 potential.

CONFLICTS OF INTEREST 19 The authors have none to declare. IDENTIFICATION OF A MICRORNA THAT Corresponding author: Soma Banerjee. IMPEDES HEPATITIS C VIRUS INFECTION E-mail: [email protected] AND REPLICATION BY SILENCING MULTIPLE HOST GENES http://dx.doi.org/10.1016/j.jceh.2016.06.033 Suchandrima Ghosh, Simanti Datta, Abhijit Chowdhury, Gopal Dhali, Soma Banerjee 20 Institute of Post Graduate Medical Education and Research, Kolkata, India HEPATITIS C VIRUS INFECTION IN PATIENTS ON HEMODIALYSIS IN Background and Aim: In general, the therapeutic TERTIARY CARE HOSPITAL approaches of chronic hepatitis C (CHC) aim at the Mudumala I. Abhilash, P. Shravan Kumar, development of compounds targeting the virus and/ M. Uma Devi, Ramanna Macherla or host cell factors. But the monotherapy and genotype specificity often leads to drug resistance and Gandhi Medical College, Secunderabad, India difficulties in the treatment. As the processes of viral entry are the potential drug targets, targeting host Background and Aim: Hepatitis C virus is a major proteins would be a good option. Thus identification problem with an estimated global prevalence of 3%.

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The prevalence of HCV infection among dialysis Debanjali Dasgupta 1, Somenath Datta 1, Alok Manna, patients is generally much higher than healthy blood Simanti Datta, Kausik Das, Mitali Chatterjee, donors and general population. Studies held in dia- Gopal Krishna Dhali, Abhijit Chowdhury, lysis centers from different countries revealed that Soma Banerjee prevalence ranges from 1 to 84.6%. There is particular concern because it causes significant morbidity and Institute of Post-Graduate Medical Education and Research, Kolkata, India mortality among hemodialysis (HD) patients. The aim of the study was to study the prevalence of 1These authors have contributed equally to this work. HCV infection and its genotype in HD patients, fl HCV viremia by PCR, demographic profile and risk Background and Aim: In uence of HBV genotypes/ factors of HCV infection. subgenotypes on clinical outcome of liver diseases has Methods: This is a prospective cross-sectional study been documented from epidemiological studies but fi conducted in 225 patients undergoing HD at Gandhi the underlying mechanism is not well de ned. Thus, Hospital, Secunderabad. Patients were subjected to the present study aims to investigate the impact of screening for Anti-HCV antibody using ELISA, HCV two major circulating subgenotypes of HBV in RNA using RT PCR technique and genotyping. Eastern India, HBV/D1 and HBV/D3 on the disease Further comparison was done with healthy control progression to hepatocellular carcinoma (HCC). population and blood donor group. Statistical ana- Methods: HBV genotypes/subgenotypes were deter- lysis of the data was done by Chi-square test using mined using full-length genome sequences of HBV EPIINFO 2000 software with P < 0.001 highly signif- isolates from patients with chronic hepatitis B (CHB), icant and P > 0.05 insignificant. liver cirrhosis (LC) and HCC and the impact of HBV/ Results: Out of 225 hemodialysis patients 38 (16.8%) D1 and HBV/D3 on viral life-cycle and on the pro- patients were anti HCV positive. Duration of dialysis gression of liver diseases were assessed by several in was significantly longer in anti-HCV antibodies posi- vitro assays. ia Hepatitis Viral tive group with dialysis duration more than 2 years. Results: Phylogenetic tree analysis revealed that HBV/ Seropositivity is more in HD patients having dialysis D1 and HBV/D3 were dominating with almost equal more than one center. HCV RNA was detected in frequencies among HBV/D carrying patients in East- randomly selected 13/25 (52%) anti HCV positive ern India. While the frequency of HBV/D1 was pro- patients. The genotype distribution was as 3a (7) gressively increased from CHB to HCC through LC, 2a (2), 2b (1), mixed genotypes (3). the rising frequency of HBV/D3 suddenly dropped in Conclusion: Duration of dialysis, getting dialysis at HCC implicating HBV/D1 might have higher onco- more than one center is important association for genic potential than HBV/D3. In concordance with anti-HCV antibodies positivity. Genotype 3 was pre- higher viral load in HBV/D1 infected patients than dominant (61.11%). Detection of genotypes helps in HBV/D3, intracellular and extracellular viral DNA initiation of therapy and prediction of prognosis in and HBsAg level were found more in in vitro assay fi patients of chronic renal failure on hemodialysis. while insigni cant difference was observed in prege- nomic RNA level suggesting high replication capacity of HBV/D1. Subsequently, HBV/D1 was noted to be CONFLICTS OF INTEREST associated more with activation of endoplasmic reticulum stress markers, accumulation of reactive oxy- The authors have none to declare. gen species, DNA double strand breaks and abnormal Corresponding author: Mudumala I. Abhilash. genomic rearrangement which led to abandoned cel- E-mail: [email protected] lular proliferation, epithelial-mesenchymal transition, rapid migration and invasion of cancer cells. http://dx.doi.org/10.1016/j.jceh.2016.06.034 Conclusion: This study highlights the clinical importance of HBV subgenotypes in management of CHB patients.

21 CONFLICTS OF INTEREST

ONCOGENIC POTENTIAL OF The authors have none to declare. HEPATITIS B VIRUS SUBGENOTYPE D1 SURPASSES D3: SIGNIFICANCE IN THE Corresponding author: Soma Banerjee. DEVELOPMENT OF HEPATOCELLULAR E-mail: [email protected] CARCINOMA http://dx.doi.org/10.1016/j.jceh.2016.06.035

22 Corresponding author: Sukanya Brugu. E-mail: [email protected] DAAS IN GENOTYPES 1 AND 4 OF CHRONIC HEPATITIS C—A REAL WORLD http://dx.doi.org/10.1016/j.jceh.2016.06.036 EXPERIENCE Sukanya Brugu, Bubun Patel, Nayana Joshi, Raghavendra Yarlagadda, Rohit Maidur, 23 Gaurav Ratnaparkhi, Ajit Kumar DAAS IN GENOTYPES 2 AND 3 OF Nizam’s Institute of Medical Sciences, Hyderabad, India CHRONIC HEPATITIS C—A REAL WORLD EXPERIENCE Background and Aim: HCV infection is a major cause of liver disease throughout the world with Bubun Patel, Sukanya Bhrugu, Raghavendra Yarlagadda, global prevalence of 3%. In India, Hepatitis C preva- Nayana Joshi, Rohit Maidur, Gaurav Ratnaparkhi, lence is 1% and genotypes 1 and 3 are the common Ajit Kumar genotypes. Nizam’s Institute of Medical Sciences, Hyderabad, India Aims and Objective: To determine treatment outcome of DAAs in genotypes 1 and 4 with different Background and Aim: Direct acting antivirals have regimens. revolutionised treatment of Hepatitis C with Hepa- Methods: Prospective study of consecutive chronic titis C now being considered curable. However man- hepatitis C (CHC) patients from February 2015, who agement of genotype 3 remains challenging. completed at least 12 weeks of therapy were recruited. Aims and Objective: To determine treatment out- Results: 100 consecutive CHC patients were screened. come of DAAs in genotypes 2 and 3 with different 49, 1, 39, 9 patients were genotype 1, 2, 3, 4 respec- regimens. tively, 2 were not typable. 58 patients (33 M:25 F), Methods: Consecutive patients of genotype 2 and 3 mean age 52.5 11.8 were included. Among 58 from February 2015, who completed at least 12 weeks patients, 49 and 9 were genotypes 1 and 4 respectively. of therapy were included. Median baseline viral load was 5.3 105 IU/ml Results: 40 patients (32 M:8 F), mean age 54.3 9.8 Viral Hepatitis (range: 1.1 103–1 108). 39/58 completed 12 were included. Among 40 patients, 1 and 39 were weeks of therapy, 2 were lost to follow up, and 2 genotype 2 and 3 respectively. Median baseline viral did not complete treatment. Overall ETR and SVR load was 6.7 105 IU/ml (range: 6.6 103– rates were 89% and 83.3% in cirrhotics and 93.1% and 7.5 107). 27/40 completed at least 12 weeks of 94.4% in non-cirrhotics respectively. In genotype-1, therapy, 2 were lost to follow up, 1 underwent liver overall SVR rate was 95%; ETR and SVR rates were transplantation, 1 did not complete treatment, and 83.3% and 83.3% in cirrhotics and 100% and100% in 3 expired during treatment. Overall ETR and SVR non-cirrhotics respectively. In genotype-4, all were rates were 100% and 66.7% in cirrhotics and 94% non-cirrhotics and ETR and SVR rates were 75% and 93% in non-cirrhotics respectively. In genotype- and 75% respectively. In genotypes 1 and 4, ETR 3, overall SVR rate was 88%; ETR and SVR rates and SVR rates were 96% and 95% with triple therapy were 100% and 66.7% in cirrhotics and 94.1% and (n = 27), 75% and 67% with Sofosbuvir + Ribavirin 93% in noncirrhotics respectively. In genotype-2, (n = 4), 100% and 100% with Sofosbuvir + Ledipasvir ETR was 100%. In genotype 2 and 3, ETR and (n = 8). Overall ETR and SVR rates were 93% and 89% SVR rates were 91.7% and 89% with PegIFN + Sofos- in treatment naive and 100% and 100% in treatment buvir + Ribavirin (n = 12), 100% and 83.3% with experienced respectively. Sofosbuvir + Ribavirin (n = 14), 100% and 100% Conclusion: Genotype1 is the most prevalent geno- with Sofosbuvir + Daclatasvir (n =3).OverallETR type in South-India. Non-cirrhotics had a better SVR and SVR rates were 95.2% and 87.5% in treatment as compared to cirrhotics. Interferon based triple naive and 100 and 100% in treatment experienced therapy and Interferon free dual DAAs have compa- respectively. rable efﬁcacy. Conclusion: Genotype 2 is uncommon in our population. In genotype 3, SVR rates in cirrhotics CONFLICTS OF INTEREST remains low despite use of DAAs. Interferon based triple therapy and dual DAAs have comparable The authors have none to declare. outcomes.

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CONFLICTS OF INTEREST transfusion is still one of the main risk factor for the spread of BBID. Therefore, ELISA method should be The authors have none to declare. followed to screen for HIV, HBV and HCV infections Corresponding author: Bubun Patel. among blood donors to prevent the spreading of E-mail: [email protected] Blood Borne Infectious Diseases. http://dx.doi.org/10.1016/j.jceh.2016.06.037 CONFLICTS OF INTEREST

The authors have none to declare. Corresponding author: Narayanasamy Krishnasamy. 24 E-mail: [email protected] COOMBS: CONTINUOUS OVERVIEW OF http://dx.doi.org/10.1016/j.jceh.2016.06.038 MEGA BLOOD DONATION OF SOUTH INDIA—A FIVE YEAR STUDY OF BLOOD BORNE INFECTIOUS DISEASES Narayanasamy Krishnasamy, Chezhian Annasamy, 25 Senthilkumar Ramalingam, Shifa Babu, K. Premkumar, VIRAL BURDEN OF HBsAg AMONG SOUTH Karthick Rajendran, J. Janifer Jasmine INDIANS IN A TERTIARY CARE CENTER—10 Madras Medical College, Chennai, India YEAR SURVEY Narayanasamy Krishnasamy, J. Janifer Jasmine, Background and Aim: Blood Borne Infectious Dis- Karthick Rajendran eases (BBID) is any infection that is potential for ia Hepatitis Viral transmissible from individual to individual through Madras Medical College, Chennai, India parenteral administration of blood or blood products. The level of BBID varies from country to Background and Aim: To evaluate the viral burden country depending on BBID’s prevalence in that of HBsAg among South Indians in a tertiary care particular population. Our study aim was to estimate center. To estimate clinical correlation with HBV the seroprevalence of BBID among the South Indian and predictor marker of a HBV seropositive patients blood donors. and to know the role of family seropositivity. Methods: A Retrospective cross-sectional study was Methods: A retrospective cross sectional study was conducted in Rajiv Gandhi Government General conducted in Department of Hepatology, Rajiv Hospital, Chennai. The age, weight and seropositivity Gandhi Government General Hospital, Chennai. A of HIV, HBsAg and HCV data were collected from total of 72,287 patient’s age, weight, clinical, bio- blood donors records. chemical, socio-demographic and anthropometric Results: A total of 1,52,466 blood donor details were data were collected. collected in the 5 year study period. Overall seropre- Results: Total prevalence of HBV was 9.5% (6897). valence for HIV, HBsAg and HCV were detected in 712 (10.32%) in the age group of <20, 4037 (58.54%) in 1.03% (1571) of which prevalence for HIV, HBsAg, 20–40 age group patients were reactive for HBV and HCV was 0.030%, 0.98% and 0.020% respectively. HIV 2148 (31.14%) patients were above the age group of reactive donors had mean of age 29.7 8.2 and mean 40. Acute stage of liver abnormalities were observed in of weight 68.6 5.5, HCV reactive donors had mean 1530 (22.18%) patients whereas chronic stage of liver age of 30.6 10.1 and mean of weight 71.8 4.2, abnormalities were observed in 3461 (50.18%) HBsAg reactive donors had mean age of 28.6 7.7 patients. HBV were found in 912 (13.22%) pregnancy and mean of weight 70.3 6.2). Reactivity rate in cases and 994 (14.42%) patients have been referred rapid test was 30.6% and in ELISA 69.4%. Rh positive from other departments. Predictor marker in the was occurred in 95.7%, Rh negative was occurred in HBV reactive patients were studied and found that 4.3%. Prevalence of blood group ‘O’, ‘B’, ‘A’, ‘AB’ 915 (13.26%) patients were with a history of blood were observed in 40.2%, 34.5%, 19.4%, 5.9% transfusion, 1354 (19.63%) patients were with the respectively. history of tattooing and 4628 (67.11%) patients were Conclusion: HBsAg were more prevalent among with unknown means of their acquiring HBV. 17.3% South Indian blood donors than HCV, HIV. HIV of the HBV patients among the population were with reactive donors were higher in age with lesser weight. a family history of HBV reactivity either for the ELISA method detects more reactive donors. Blood mother or spouse or other blood relation.

Conclusion: Middle age patients were found in injections, inaccessibility to a facility, fear of injection higher number of HBV. Chronic liver abnormalities or its side effects and ﬁnancial constraints were the were found in higher number among the HBV reasons to refuse triple therapy. All patients in triple patients. Unknown reason were in higher number therapy group and all but 2 patients (98%) in the dual followed by HBV patients were with unknown reason therapy group attained ETR. All those who achieved of family history followed by history of tattooing. ETR, achieved SVR12 in both groups. But for anemia in 3 patients (2 in triple, one in dual therapy) there CONFLICTS OF INTEREST were no major side effects. Conclusion: Most patients with CHC prefer an oral The authors have none to declare. treatment with DAA’s. Both oral and interferon based regimens achieve high response rate. Corresponding author: Narayanasamy Krishnasamy. E-mail: [email protected] CONFLICTS OF INTEREST http://dx.doi.org/10.1016/j.jceh.2016.06.039 The authors have none to declare. Corresponding author: Ajay Duseja. E-mail: [email protected] 26 http://dx.doi.org/10.1016/j.jceh.2016.06.040 DUAL TREATMENT WITH SOFOSBUVIR PLUS RIBAVIRIN IS AS EFFECTIVE AS TRIPLE THERAPY WITH PEGYLATED INTERFERON PLUS SOFOSBUVIR PLUS 27 RIBAVIRIN IN PREDOMINANT GENOTYPE 3 PATIENTS WITH CHRONIC HEPATITIS C RELATIONSHIP OF SEVERITY OF HEPATITIS A WITH GENETIC Sandeep Satsangi, Manu Mehta, Ajay Duseja, POLYMORPHISMS IN HEPATITIS A VIRUS Sunil Taneja, Radha K. Dhiman, Yogesh Chawla

CELLULAR RECEPTOR 1 (HAVCR1) GENE Viral Hepatitis Postgraduate Institution of Medical Education and Research, Mercilena Benjamin 1, Shikha Agnihotry 1, Chandigarh, India Anshu Srivastava 1, Maya Peethambaran 3, Rishi Bolia 1, Abraham Koshy 2, Tony Grace 3, Philip Augustine 3, Background and Aim: Sofosbuvir (SOF) was the S.K. Yachha 1, Rakesh Aggarwal 1 ﬁrst directly acting antiviral (DAA) made available for chronic hepatitis C (CHC) in India. We describe 1Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 2 3 our ‘real life’ experience of using SOF with ribavirin India, Lakeshore Hospital, Kochi, India, School of Biological Sciences, (RBV) with or without pegylated interferon (PegIFN) Central University of Kerala, Kasargode, Kerala, India in predominant genotype 3 patients with CHC. HAVCR1 Methods: 158 patients [males 99 (62.6%), mean age Background and Aim: protein is the cel- 40.3 12.8 years) with CHC treated with dual ther- lular receptor for the hepatitis A virus (HAV). Genetic apy (SOF + RBV) for 24 weeks or triple therapy polymorphism in this gene may alter the outcome of (PegIFN + SOF + RBV) for 12 weeks were included HAV infection. A 6-amino acid insertion prospectively. Patients with co-infection, decompen- (157insMTTTVP) in it has been shown to be associated with more severe disease. sated liver disease and post organ transplantation HAVCR1 were excluded. Data was analysed for the preference Methods: We sequenced exon 4 of gene in of treatment regimen, end of treatment response patients with mild and severe hepatitis A disease, and (ETR), sustained virological response at 12 weeks healthy controls at two sites (Kochi and Lucknow). (SVR12) and side effects. Frequencies of different haplotypes of a region with Results: Genotype 3 was the predominant genotype two overlapping insertion-deletion polymorphisms [105 (66.4%)] followed by genotype 1 [40 (25.3%)] and (indels; rs141023871 and rs139041445) were com- genotype 4 [13 (8.2%)]. 48 (30.37%) patients had pared between groups. Results: The region of interest had three different cirrhosis (LSM 13 kPa) and 30 (19%) were treatment — experienced (TE) with PegIFN + RBV. 103 (65.18%) haplotypes a short form, an intermediate-form with patients received dual therapy and 55(34.81%) 5-amino acid 157insMTTVP insertion and a long- received triple therapy. Resentment to receive form with a 6-amino acid 157insMTTTVP insertion.

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At Kochi, the haplotype frequencies of the infection, in at least some populations. Further stu- 157insMTTTVP variant were more frequent in per- dies in other populations are needed to assess the sons with mild (31.0%) as well as severe (31.8%) clin- relation of this genetic variation with disease out- ical hepatitis A as compared to those with prior come, and the reason for differences in this relation- asymptomatic HAV infection (4.8%); genotype fre- ship between populations. quencies also showed similar difference. At Lucknow, no difference in haplotype frequencies were observed CONFLICTS OF INTEREST among persons with mild hepatitis A (18.5%), severe hepatitis A (20.0%) or controls (29.5%). Genotype The authors have none to declare. frequencies also showed similar results in the two Corresponding author: . sites. E-mail: [email protected] Conclusion: The 157insMTTTVP variant of HAVCR1 gene is associated with more severe outcome of HAV http://dx.doi.org/10.1016/j.jceh.2016.06.041 ia Hepatitis Viral

Alcohol and Non-alcoholic Fatty Liver Disease

1 CONFLICTS OF INTEREST A STUDY OF PREVALENCE OF DIABETES AND PREDIABETES IN PATIENTS WITH The authors have none to declare. NON ALCOHOLIC FATTY LIVER DISEASE Corresponding author: Aastha Bansal. AND IMPACT OF DIABETES ON LIVER E-mail: [email protected] HISTOLOGY http://dx.doi.org/10.1016/j.jceh.2016.06.043 Aastha Bansal, Sudhir Mourya, Abhyudaya Verma, Bushra Khanam, Rishu Bansal

Index Medical College Hospital and Research Centre, Indore, 2 MP, India SERUM ALT IS AN INDEPENDENT Background and Aim: NAFLD is one of the most PREDICTOR OF METABOLIC SYNDROME common chronic liver diseases with increasing pre- AND INSULIN RESISTANCE IN PATIENTS valence. There are limited studies on study of anthro- OF NON-ALCOHOLIC FATTY LIVER pometric, metabolic and histological parameters of DISEASE NAFLD patients. This study aims to determine the 1 1 fi Preetam Nath , Prasanta Kumar Parida , clinical and metabolic pro le of NAFLD patients and Jimmy Narayan 1, Pradeep Kumar Padhi 1, compare the liver histology of diabetic NAFLD Girish Kumar Pati 1, Ayaskanta Singh 2, Bijay Misra 1, patients with non diabetic NAFLD patients. Debasis Misra 2, Sanjib Kumar Kar 1, Methods: 50 patients diagnosed with NAFLD by Manas Kumar Panigrahi 2, Chudamani Meher 3, abdominal ultrasound and histology wherever possi- Omprakash Agrawal 3, Niranjan Rout 4, ble and 50 healthy controls were taken for study. Kaumudee Pattnaik 1, Pallavi Bhuyan 1, Measurements of fasting glucose, triglycerides, cho- Manorama Swain 1, Shivaram Prasad Singh 1 lesterol, liver function tests, insulin was done by ALD and NAFLD standard laboratory methods. Diabetes and predia- 1S.C.B. Medical College, Cuttack, Odisha, India, 2IMS and SUM Hospital, Bhubaneswar, Odisha, India, 3Beam Diagnostics Centre, betes was diagnosed by WHO criteria. Liver biopsy 4 was done in 21 patients who gave consent. Bajrakabati Road, Cuttack, India, Acharya Harihara Regional Cancer Center, Cuttack, Odisha, India Results: 12 (24%) patients with NAFLD were diabetics and 11 (22%) were prediabetics while only 1 Background & Aim: Aminotransferase assay is often of 50 controls had diabetes. Central obesity, hyper- used as a screening test as well as an endpoint for tension, fasting blood sugar, triglycerides, insulin resolution of disease in NAFLD. The aim of the study resistance was higher in diabetic NAFLD patients. was to evaluate the relationship of transaminase level fl On the contrary, necroin ammatory activity as mea- with metabolic variables and histology in NAFLD. fl sured by lobular in ammation was higher in non Methods: Single center observational study in a gas- diabetic NAFLD patients as compared to diabetic troenterology clinic at Cuttack in coastal Odisha. NAFLD patients. Subjects: Consecutive patients who had fatty liver on abdominal sonography without alcohol consump- Parameters NAFLD with NAFLD without P value* tion exceeding 20 g/day were included. Subjects with type 2 DM type 2 DM other liver diseases (hepatitis viruses A to E, autoim- Hypertension 6/12 4/38 0.000 mune disease, Wilson’s disease) and those on drugs FBS 124 46.3 90.8 10.2 0.000 which can induce fatty liver or insulin sensitization Investigations PPBS 201 8.7 122 5.1 0.000 were also excluded from the study. : All participants were evaluated for the presence of meta- HOMA IR 2.6 0.36 1.84 0.2 0.000 bolic syndrome, insulin resistance, liver function test and lipid profile. Various parameters were compared Conclusion: Prevalence of diabetes and prediabetes is between NAFLD subjects and controls. higher in NAFLD patients. Diabetes and prediabetes Results: Out of 939, 53.5% of NAFLD had normal patients do not have histologically severe disease, serum transaminases. NAFLD patients with high rather insulin resistance plays important role in serum ALT (>40 m/l) [n = 423] had significantly increasing severity and progression of disease. higher BMI (27.2 vs 26.4, P = 0.001), fasting plasma

glucose (103.4 vs 98.3, P = 0.009), serum insulin (11.0 cost (Rs. 1700/–) variceal band ligator (super clik- vs 9.4, P < 0.001) and lower HDL (42.3 vs 44.2, medenta) for VBL at our center. P = 0.034) than patients with normal ALT Methods: We retrospectively studied all the subjects [n = 516]. NAFLD patients who had transaminitis who underwent endoscopy for variceal bleed from had significantly higher incidence of metabolic syn- April 2015 to May 2016. The age, gender, etiology drome (311/423 vs 129/516, P < 0.001) and higher of varices, type of endotherapy, outcomes were sys- mean HOMA IR (2.81 vs 2.27, P < 0.001) than those tematically recorded. without. However, there was no significant difference Results: Endoscopy was performed in 237 subjects between waist circumference, blood pressure, serum with variceal bleed during the study period. The mean triglycerides and histopathological features between age was 64 8 years and 72% were men. Alcoholic NAFLD patients with and without transaminitis. liver disease was noted in 145 (61%) subjects. Endo- scopic VBL was the most common procedure in 193 Variables NAFLD with NAFLD without P value (81%) patients, endoscopic sclerotherapy in 24 (10%) transaminitis transaminitis patients, glue and hemoclip application in 5.4% and (ALT > 40) (ALT 40) [n = 423] [n = 516] 2.1% were noted respectively in dual etiology. Rebleed following VBL was noted in 18 (7.5%) subjects which BMI 27.2 4.0 26.4 3.4 0.001 was similar to the rate reported for standard ligator.2,3 FPG 103.4 31.6 98.3 23.4 0.009 Conclusion: VBL at a low cost with similar efficacy HOMA IR 2.81 1.73 2.27 1.67 <0.001 can improve the follow up VBL sessions especially in Metabolic 311 129 <0.001 subjects from low socioeconomic strata. syndrome CONFLICTS OF INTEREST Conclusion: Over half of NAFLD subjects do not have transaminitis. NAFLD patients with transami- The authors have none to declare. L n NAFLD and ALD nitis had a higher incidence of metabolic syndrome Corresponding author: Amol S. Patil. and insulin resistance than those without. However, E-mail: [email protected] there was no significant difference in histopathological features between these two groups. http://dx.doi.org/10.1016/j.jceh.2016.06.045

CONFLICTS OF INTEREST 4 The authors have none to declare. LIMITED IMPLICATION OF SERUM Corresponding author: Shivaram P. Singh. CHOLESTEROL FOR DIAGNOSING NASH E-mail: [email protected] Sheikh Mohammad Noor-E-Alam 1, http://dx.doi.org/10.1016/j.jceh.2016.06.044 Ahmed Lutful Moben 2, Md. Zia Hyder Basunia 3, Amalendu Bhattacharyya 4, Md. Abdur Rahim 5, Syed Abul Foez 6, Faiz Ahmad Khondaker 7, 3 Md. Jahangir Alam Sarker 7, Mohammad Forhad Abedin 8, Utpal Das Gupta 9, CHECK POINT FOR ESOPHAGEAL Md. Farhadul Islam Chowdhury 10, VARICEAL BLEEDING USING BAND Mamun A. Mahtab 11 LIGATOR – OUTSTANDING EFFICACY BUT 1 AT LOW COST? Shaheed Tajuddin Ahmad Medical College, Gazipur, Gazipur, Bangladesh, 2Kurmitola General Hospital, Dhaka, Bangladesh, Amol S. Patil, Avinash Balekuduru, 3Rangpur Medical College, Rangpur, Bangladesh, 4Shere-E-Bangla 5 Lokesh Locheruvapalli, Ravi Kiran, B.S. Satyaprakash Medical College, Barisal, Bangladesh, Abdul Malek Ukil Medical College, Noakhali, Bangladesh, 6Shahid Syed Nazrul Islam Medical 7 Ramaiah Hospital, Bangalore, India College, Kishorganj, Bangladesh, Shaheed Suhrawardy Medical College, Dhaka, Bangladesh, 8Comilla Medical College, Comilla, Bangladesh, 9Ali Hospital, Dhaka, Bangladesh, 10East-West Medical Background & Aim: Variceal band ligation (VBL) is College, Dhaka, Bangladesh, 11Bangabandhu Sheikh Mujib Medical recommended as the preferred endoscopic method University, Dhaka, Bangladesh for obliteration of esophageal varices.1 Multiple categories of band ligators were developed to manage Background & Aim: Nonalcoholic fatty liver disease variceal bleeding. The aim of the study is to assess (NAFLD) has become one of the most common the outcome of variceal bleed and the efﬁcacy of low chronic liver disease presenting with abnormal lipid

profiles. NAFLD ranging from simple steatosis to by liver fibrosis through liver biopsy. Liver fibrosis can nonalcoholic steatohepatitis (NASH), fibrosis, end also be assessed by fibroscan invasively in NAFLD. stage liver disease and hepatocellular carcinoma. This study has been designed to evaluate the effect of The aim of the study is to evaluate fasting serum lifestyle modification on liver enzymes and Fibroscan cholesterol (total) level for diagnosing NASH. value in population with NAFLD. Methods: An observational, cross sectional study was Methods: Initially there were 50 NAFLD patients carried out in the Hepatology Department, Banga- included in this prospective follow up study, however bandhu Sheikh Mujib Medical University, Dhaka. 43 after 6 months of lifestyle modification, only 39 patients of non-alcoholic fatty liver disease (NAFLD) participants were studied. During both 1st and attending at outpatient and inpatient department of 2nd consultation, fibroscan was carried out. All par- Hepatology were selected and underwent for liver ticipants underwent a careful interview, anthropome- biopsy with NAFLD activity score (NAS). Fasting try measurements, radiological and biochemical tests serum cholesterol (total) also analyzed. thereafter the data was analyzed by SPSS software Results: Serum cholesterol level above the upper limit (20th version). normal was 62.8% in our study population. Mean Results: Out of 50 NAFLD participants, 39 partici- serum cholesterol was 212.49 (43.68) mg/dl. In pants completed our study. After 6 months of lifestyle patients with hypercholesterolaemia (>200 mg/dl) modification, fibroscan value (P value = 0.009) and 48.1% were NASH. Serum cholesterol level above alanine aminotransferase (ALT) (P value < 0.001) the ULN had no significant relation (P = 0.78, chi- both showed significant improvements. square) to differentiate NASH from Non-NASH fatty Liver (NNFL). Conclusion: Serum cholesterol has very limited implication for diagnosing NASH.

CONFLICTS OF INTEREST

The authors have none to declare.

Corresponding author: Nipun Verma. ALD and NAFLD E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.046

5 EFFECT OF LIFESTYLE MODIFICATION ON LIVER ENZYME AND FIBROSCAN SCORE IN INDIAN PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE Conclusion: Measured by Fibroscan and ALT, it has Jayanta Paul, Raj Venugopal, Lorance Peter, been found that lifestyle modification is an effective K.N.K. Shetty, Mohit Shetti therapy to downgrade the hepatic injury in NAFLD Manipal Hospital, Bangalore, India patients. Fibroscan can be used to assess the treatment response in NAFLD. Background & Aim: Non-alcoholic fatty liver disease (NAFLD) is one of the hepatic manifestations of metabolic syndrome and a major burden to both CONFLICTS OF INTEREST the morbidity and mortality of the nation. NAFLD is remarkably increasing in developing countries like The authors have none to declare. India, parallel to the increasing incidence of obesity. Corresponding author: Jayanta Paul. Lifestyle modification is a recommended treatment E-mail: [email protected] for NAFLD. But in most of the previous studies, improvement after lifestyle modification was assessed http://dx.doi.org/10.1016/j.jceh.2016.06.047

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6 Corresponding author: Syed N. Afzal. ASSOCIATION OF NAFLD WITH CAROTID E-mail: [email protected] ATHEROSCLEROSIS AND SERUM URIC http://dx.doi.org/10.1016/j.jceh.2016.06.048 ACID LEVEL Masi-ur rehman Ajmal, Syed N. Afzal, Nasar Abdali, 7 Ibne Ahmad

J N Medical College, Aligarh Muslim University, Aligarh, India VALIDATION STUDY TO PREDICT MORTALITY IN ALCOHOLIC HEPATITIS: Background & Aim: NAFLD shares many features of MAGIC SCORE VERSUS OTHER SCORING metabolic syndrome, a highly atherogenic condition SYSTEMS and its presence could signify a substantial cardiovas- Arun Iyer, Chethan Govindaraju, Shanid Sathar, cular risk. High serum uric acid levels play a role in Sreejaya Sreesh, Krishnadas Devadas development of NAFLD. The aim of the study: (1) To assess the association of NAFLD with carotid athero- Government Medical College and Hospital, Thiruvananthapuram, India sclerosis and serum uric acid levels. (2) To assess association of various metabolic and lab parameters of Background & Aim: Alcoholic hepatitis (AH) is metabolic syndrome with NAFLD. (3) To assess how associated with high mortality. This study aimed at severity of NAFLD is related to above mentioned assessing the short term (up to 30 days) and 90 day parameters. mortality of severe alcoholic hepatitis and to compare Methods: 144 patients with incidentally USG con- various prognostic scoring systems viz Model For AH firmed NAFLD were compared with 98 age-matched To Grade The Severity In An Asian Patient Cohort (MAGIC) versus Maddrey’s Discriminant Function L n NAFLD and ALD and gender-matched controls for carotid intima media thickness and serum uric acid levels. Inclusion criteria: (mDF), age, bilirubin, international normalized ratio All patients with age >20 years without secondary and creatinine (ABIC) score, Glasgow alcoholic hepa- causes of steatosis. This study was a prospective case titis score (GAHS), model of end-stage liver disease controlled study. Carotid intima media thickness was (MELD) on a cohort of patients in our hospital. measured using high resolution B mode USG. Methods: This study was a retrospective observa- Results: Of the total 144 patients of NAFLD, 65.97% tional analysis of patients admitted between January had grade 1 disease, 25.69% grade 2 and 8.33% had 2012 and December 2015 in the Gastroenterology grade 3. Of the 144 patients, 43% had metabolic department of a tertiary care hospital. The total syndrome (P < 0.001). Mean serum uric acid was number of patients studied was 88. Clinical and 5.96 1.19 mg when compared to control 5.20 laboratory data of patients, on admission and at 0.82 mg (P < 0.001). The mean carotid intima med- day 7 of admission, were collected and analyzed. Patients treated with glucocorticoids or pentoxifyl- ial thickening was 0.86 0.23 mm in cases and 0.78 fi 0.14 mm in controls in right carotid artery line during the rst 7 days of hospitalisation were (P = 0.001). In left carotid artery it was 0.92 excluded. The mortality data were collected via tele- 0.41 mm in cases vs 0.73 0.12 mm in controls phonic contact. The ability of each score to predict (P < 0.001). mortality was evaluated using receiver operating char- Conclusion: NAFLD is more common in fourth and acteristic curves (ROC). The area under ROC was fifth decade. The order of prevalence of NAFLD grade used to compare the scores. fi Results: Eighty-eight patients were included aged is1>2>3.There exists a signi cant association of NAFLD and its severity with metabolic syndrome. 45.6 7.6 years with mean follow-up of 80.7 days. fi The 30 and 90 day mortality were 23.9% and 47.7% Uric acid though in normal range was signi cantly fi associated with NAFLD presence and severity. respectively. For risk strati cation, four risk groups were taken with cut-off scores of 0–28.9 (group A), Though age of the patient, triglyceride level, BMI – – independently affect carotid intima media thickness, 29 36.9 (group B), 37 45.9 (group C) and equal to or fi more than 46 (group D) based on the different sur- it is signi cantly associated with NAFLD presence P and severity. vival probabilities ( < 0.001). Different survival probabilities were 97.65 5.512%, 64.50 9.51%, 61.625 11.759%, 66.667 21.830% for group A, B, C and CONFLICTS OF INTEREST D respectively (P value = 0.023). Survival probabilities for mDF < 32 and mDF > 32 were 100% and 42.25 The authors have none to declare. 4.46%, respectively (P value = 0.0001). mDF had

the best predictive value AUROC 0.872, followed by Type II DM was present in 40 (25%) and 28 (34.5%) MELD 0.772, Glasgow 0.707, ABIC 0.663, and patients were hypertensive. Twenty two (27.2%) MAGIC 0.626 respectively. patients had hypertriglyceridemia and 52 (64.2%) Conclusion: mDF has a better predictive performance had low HDL. Eleven (13.6%) patients had Child’sA than other systems (MELD, Glasgow, ABIC, and cirrhosis, 46 (56.8%) had Child’s B and 24 (29.6%) MAGIC). patients had Child’s C cirrhosis. Even though not signiﬁcant statistically, patients with Child’s C cirrho- CONFLICTS OF INTEREST sis (17, 70.83%) had higher presence of MS in comparison to Child’s A (7, 63.6%) and B (19, 41.3%) cirrhosis. The authors have none to declare. Conclusion: Metabolic syndrome is common in Corresponding author: Arun Iyer. patients with AC. Presence of MS may be contributing E-mail: [email protected] towards severity of liver disease in these patients indirectly suggesting the co-existence of ALD and NAFLD. http://dx.doi.org/10.1016/j.jceh.2016.06.049 CONFLICTS OF INTEREST

8 The authors have none to declare. CAN ALCOHOLIC LIVER DISEASE AND Corresponding author: Ajay Duseja. E-mail: [email protected] NONALCOHOLIC FATTY LIVER DISEASE CO-EXIST? http://dx.doi.org/10.1016/j.jceh.2016.06.050 Manu Mehta, Sandeep Satsangi, Ajay Duseja, Sunil Taneja, Radha K. Dhiman, Yogesh K. Chawla 9 Postgraduate Institute of Medical Education and Research, Chandigarh, India MICRORNA-124 AMELIORATES ALCOHOL INDUCED LIVER INJURY BY RESTRICTING Background & Aim: Nonalcoholic fatty liver disease MULTIPLE COMPONENTS INVOLVED IN (NAFLD) by definition would require exclusion of INTRACELLULAR CROSSTALK ALD and NAFLD significant alcohol intake. Present study was aimed to assess the prevalence of various components of Debanjali Dasgupta, Alak Manna, Somenath Datta, metabolic syndrome (MS) in patients with alcoholic Alip Ghosh, Amit Ghosh, Mitali Chatterjee, cirrhosis (AC) and to study the affect of its presence on Simanti Datta, Gopal Dhali, Abhijit Chowdhury, the severity of liver disease, testing the hypothesis if Soma Banerjee alcoholic liver disease (ALD) and NAFLD could co- Institute of Post Graduate Medical Education and Research, Kolkata, exist. India Methods: In a retrospective study done over a period of one year, 81 patients with AC were analysed for the Background & Aim: Alcohol induced liver injury prevalence of MS. The diagnosis of AC was based on involves a complex array of derangements of intracel- the history of alcohol intake, exclusion of other lular crosstalk among liver residing parenchymal, non- causes of chronic liver disease, clinical examination, parenchymal and immune cells through myriad of serum biochemistry, hematological parameters, ima- signaling molecules. Chronic ethanol intake renders ging and upper gastrointestinal endoscopy. Severity liver macrophages, Kupffer cells (KCs) hyper-respon- of liver disease was assessed by Child–Turcotte–Pugh sive to endotoxin resulting production of inflamma- (CTP) score. Metabolic syndrome was assessed as per tory cytokines via TLR4 dependent pathway leading to the ATP III criteria and the affect of metabolic syn- apoptotic death ofhepatocytes and consecutive inflam- drome on CTP score was evaluated. mation. In this study the role of microRNA-124, which Results: All 81 patients with AC were male [mean age polarizes macrophages towards M2 phenotype, in alco- 50.9 9.5, mean CTP score 8.38 1.66]. But for hol induced inflammation has been investigated. three patients (3.7%) all other 78 patients (96.3%) Methods: Human hepatocellular carcinoma cell line with AC had at least one component of MS. Forty HepG2 and oncogenic human macrophage like three (53.0%) patients had full blown MS with three monocytic cell line (MCs) U937 were co-cultured in or more components of MS. Sixty one (75.30%) presence of miR-124 to assess the effect of the miRNA patients were either overweight [22 (27.1%)] or obese on regulation of crosstalk between hepatocyte and [39 (48.1%)], with a mean BMI of 25.35 3.86 kg/m2. KCs. Apoptosis and neutrophil migration assay

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through barrier of endothelial cells (ECs) was per- mortality, morbidity by CTP, MELD, and mDF scores formed to verify the functional contribution of and various complications viz. sepsis, GI bleed, ence- miRNA in vitro. Bioinformatics analysis/30UTR-luci- phalopathy, hepatorenal syndrome in comparison to ferase assay/qRT-PCR/ELISA were used for target SMT. We also studied the mobilising effect of GCSF prediction and validation. on bone marrow stem cells measured by counting Results: Over expression of miR-124 in MCs led to CD34+ cells from peripheral blood. downregulation of secretion of TNFa and IL1b, Methods: 50 patients with severe alcoholic hepatitis which subsequently restrained apoptosis in hepato- were randomly assigned to groups A and B (25 in cytes when co-cultured. Again restoration of miR-124 each). Both groups were given SMT, while in addition, in MCs showed reduced expression of stress response patients in group A were given 5 m/kg GCSF subcu- genes including ATF6, GRP78, PERK, IRE1 in hepa- taneous (10 doses for 5 days). We assessed survival, tocytes implicating its potential role to protect hepa- changes in CTP, MELD and mDF scores and the tocytes from endoplasmic reticulum stress by development of complications till 90 days. inhibiting MCs’s derived TNFa induced oxidative Results: The baseline parameters in both groups were stress. Furthermore, endothelial cells incubated with comparable. On day 6 group A had higher mean conditioned media of miR-124 transfected MCs also leukocyte and CD34 counts than group B, P < .001. arrested diapedesis of leukocytes through endothelial On 90 days follow up 17 patients in group A (68%) and barrier. In addition, bioinformatics analysis/30UTR- 9 in group B (36%) survived, P = .04. Mean changes for luciferase reporter assays revealed that miR-124 different scores were greater in group A then group B i. directly inhibited TNFa, IL1b production and secre- e. CTP (41.97 vs 8.84), MELD (50.89 vs 10.09) tion from MCs, expression of TRADD, Caspase8 on and mDF (74 vs 18), P < .001. The percentages of hepatocytes and ICAM1 on ECs. patients who developed HRS, HE, or sepsis were lower Conclusion: Thus this study highlights the emerging in group A than in group B (28% vs 64%, 32% vs 64%, anti-inflammatory therapeutic potential of miR-124. and 28% vs 68%, respectively), P < .001. There was no L n NAFLD and ALD Hence it could be a promising effective molecule for significant difference in GI bleed in both groups. therapeutic intervention least compromising with the Conclusion: In severe alcoholic hepatitis, GCSF ther- host immunity. apy significantly improves the survival. It also significantly reduces CTP, MELD, and mDF scores and CONFLICTS OF INTEREST prevents the development of complications.

The authors have none to declare. CONFLICTS OF INTEREST Corresponding author: Soma Banerjee. E-mail: [email protected] The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2016.06.051 Corresponding author: Ankur Setia. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.052 10

EFFECT OF GCSF ON MORTALITY AND 11 COMPLICATIONS VIZ. SEPSIS, ENCEPHALOPATHY, HRS AND GI BLEED IN PREDICTORS OF 90 DAY MORTALITY IN SEVERE ALCOHOLIC HEPATITIS – A SEVERE ALCOHOLIC HEPATITIS: RANDOMIZED CONTROLLED STUDY EXPERIENCE WITH 85 PATIENTS AT A Ankur Setia, Ramesh Rai TERTIARY CARE CENTER Ravi Daswani, Ashish Kumar, Shrihari Anikhindi, Fortis Escorts Hospital, Jaipur, India Praveen Sharma, Naresh Bansal, Vikas Singla, Anil Arora

Background & Aim: Severe alcoholic hepatitis has Sir Ganga Ram Hospital, New Delhi, India very high short term mortality. Compared to standard medical therapy (SMT), GCSF improves clinical Background & Aim: Severe alcoholic hepatitis (SAH) and biochemical proﬁles, morbidity and mortality in is a dreaded illness with high mortality. There are only these patients. We evaluated efﬁcacy of GCSF in few studies which have evaluated and compared the modulating the disease course of severe alcoholic various severity indices in SAH especially in Indian hepatitis over a period of 3 months in terms of population. We analysed patients with SAH admitted

to our Institute and compared various biochemical Shivaram P. Singh, Pradeep Padhi, Jimmy Narayan, and severity indices in predicting 90 day mortality. Preetam Nath, Ayaskanta Singh, Girish Pati, Methods: We retrospectively analysed patients with Prasanta Parida, Sunil Mishra SAH (defined as modified discriminant function [mDF] > 32) admitted from March 2015 to Febru- SCB Medical College, Cuttack, India ary 2016 to our Institute. All patients were administered standard treatment according to various Background & Aim: There is scarce information on established guidelines for SAH. 90 day mortality thesocio-economicimpactofalcoholuseinALD was determined in all patients with help of indoor patients and their families. The study was con- records, follow up visits or telephonic interviews. ducted to estimate the socioeconomic impact of Various hematologic, biochemical and severity alcohol use on patients with ALD and their families indices including mDF, Child Turcotte Pugh in Odisha. (CTP), Model for End Stage Liver Disease (MELD), Methods: The demographic and socioeconomic data Glasgow Alcoholic Hepatitis score (GAHS) and Age, were collected from hospitalized ALD patients (cases) Bilirubin, International Normalised ratio, Creati- and Chronic Liver Disease (CLD) patients of nonal- nine (ABIC) scores were compared between survi- coholic etiology (controls) using a self designed ques- vors and patients who died. tionnaire and analyzed. Results: A total of 85 patients (97% males, median Results: Study subjects included 400 consecutive age 39.8 years [range 19–62 years]) were included in CLD patients: 350 patients had ALD (cases) and our study. The median mDF, MELD and CTP scores 50 had CLD of nonalcoholic etiology (controls). were 73.7 (32–212), 28.2 (11.2–40) and 9.7 (6–14) Of the ALD patients, 60% were between 30 and respectively. 26 patients (31%) died within 90 days 50 years and 69% belonged to middle socioeconomic of admission among which 15 (58%) had in-hospital class. 90% cases started alcohol use before age 30 mortality. The patients with mortality had lower years and half before legal age of drinking (below 21 serum calcium (7.6 vs 8.2 mg/dl, P = 0.04) and albu- years). Family history of drinking was present in min (2.0 vs 2.5 mg/dl, P = 0.004). The mDF, ABIC 63% of ALD patients. Average expenditure on alco- and GAHS scores were comparable. However in the hol was INR 2000/month. Average hospitalizations mortality group MELD (28.6 vs 25.6, P = 0.05) and for ALD related problems were 4.9 times/year with CTP (12 vs 11, P = 0.01) scores were significantly average expenditure INR 30,000 during each hospi- ALD and NAFLD higher. talization. For treatment expenses, 86% ALD Conclusion: One third of patients with SAH suc- patients borrowed money from friends/relatives, cumb to their illness within 3 months of presenta- 36% used saving deposits, 28% utilized Odisha State tion; with majority among these having in-hospital Treatment Fund and 4% sold personal belongings. mortality. Among biochemical parameters, serum Children of 43% ALD patients and 14% of controls calcium and serum albumin; while among the severity were deprived of education. 52% of cases and 8% of indices CTP and MELD scores are of valuable pre- controls had disturbed social and family life. In dictors of 90 day mortality alcoholic group, 34% abused family members, 20% suffered accidents, 37% indulged in physical vio- CONFLICTS OF INTEREST lence, 5% got entangled in legal wrangles and 3% attempted suicide. The authors have none to declare. Conclusion: For patients with ALD, alcohol causes severe social disruption. Children suffered the most Corresponding author: Ashish Kumar. with disruption of education. There is a huge finan- E-mail: [email protected] cial burden on both the family and state. http://dx.doi.org/10.1016/j.jceh.2016.06.053 CONFLICTS OF INTEREST

12 The authors have none to declare. SOCIOECONOMIC IMPACT OF ALCOHOL IN Corresponding author: Shivaram P. Singh. E-mail: [email protected] PATIENTS WITH ALCOHOLIC LIVER DISEASE [ALD] IN ODISHA http://dx.doi.org/10.1016/j.jceh.2016.06.054

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13 Background & Aim: Non alcoholic fatty liver disease (NAFLD) is a spectrum of liver disease (from steatosis CORRELATION OF BMI WITH to cirrhosis). Differentiating various stages is impor- SUBCUTANEOUS FAT AND TOTAL BODY tant for therapeutic decision making. The gold stan- FAT IN PATIENTS WITH NAFLD IN SOUTH dard for the diagnosis and staging of NAFLD is liver INDIA biopsy. Cytokeratin 18 fragment (CK18-F) levels are a marker of hepatocyte apoptosis. This study was done Guruprasad Padsalgi, Mathews Chooracken, to evaluate the role of serum CK18-F levels in pre- Roy Mukkada, Antony Chettupuzha, Jose Francis, dicting steatosis, significant NASH and fibrosis when Philip Augustine, Abraham Koshy compared to the gold standard i.e. liver biopsy. VPS Lakeshore Hospital, Kochi, India Methods: 88 patients with biopsy proven NAFLD were enrolled. Histological findings were classified Background & Aim: Nonalcoholic fatty liver disease according to the NAFLD activity score (NAS) pro- (NAFLD) is increasing at alarming rates in south posed by the NASH CRN. In addition to basic serum Indian population, the correlation of BMI with skin biochemical profile, serum CK18-F level was mea- fold thickness and total body fat in patients with sured using M30 Apoptosense ELISA. Patients with NAFLD has less literature, we want to see how sig- diabetes mellitus and significant alcohol consump- nificantly they correlate. Aims: Correlation of BMI tion were excluded. with subcutaneous fat and total body fat in patients Results: Of the 88 patients, 59 (67%) had a NAS score with NAFLD. of 5 suggesting histopathological NASH and 33% Methods: A total of 118 patients were included in the patients had a score of <5. The mean level of CK18-F study. The following anthropometric measurements was significantly (P 0.024) higher (382 138 U/L) were collected: body mass (weight and height), waist when significant steatosis (steatosis grade 2 or 3 on NAS) was present as compared to no/mild steatosis

L n NAFLD and ALD circumference and skinfold thickness (triceps, biceps, sub scapular, anterior abdominal), total body fat (%) [(320 106.8 U/L) (steatosis grade 0 or 1)]. CK-18 F was measured by bio-impedance. level was significantly (P < 0.001) higher (395.82 Results: The correlation of BMI with skin fold thick- 135.83 U/L) in the group with NASH (NAS 5) ness at triceps – 0.619, biceps – 0.566, sub scapular – when compared to the group with no NASH 0.686, anterior abdominal –0.638, total body fat – (NAS < 5). CK18-F level was insignificantly higher 0.672. All of which are statistically significant with a P (P 0.087) in the group with fibrosis grade 1–2 value of <0.01. (381.9 139.22 U/L) as compared to the group with Conclusion: The correlation of BMI with skin fold no fibrosis (334.6 117.05 U/L). The AUROC for thickness and total body fat in patients with NAFLD detection of NASH for CK18-F was 0.82. A value of is statistically significant. 304 U/L was 83.1% sensitive and 82.8% specific for the diagnosis of significant NASH. The AUROC for fibro- CONFLICTS OF INTEREST sis detection using CK18-F was 0.62.

The authors have none to declare. Corresponding author: Guruprasad Padsalgi. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.055

14 CYTOKERATIN 18 FRAGMENT LEVEL IS A USEFUL BIOMARKER IN PREDICTING STEATOSIS AND NASH BUT NOT FIBROSIS Sanchit Budhiraja, Ashok Jain, Vinod Dixit, Sunit Shukla, Pankaj Asati, Manish Tripathi

Institute of Medical Sciences, Varanasi, India

Conclusion: Measurement of serum CK18-F was regard to HOMA IR levels in patients with Brunt useful in prediction of significant steatosis and grades, Brunt staging, Brunt grade 1 and 2, Brunt NASH but not fibrosis. score of <2 and 2, SAF scores, SAF score <3 and 3, CONFLICTS OF INTEREST NAS scores and NAS score of <4 and 4. Conclusion: Although IR was significantly higher in The authors have none to declare. obese patients with NASH as compared to lean NASH, there was no significant difference in the correlation of Corresponding author: Sanchit Budhiraja. IR with histology between these 2 groups. E-mail: [email protected] CONFLICTS OF INTEREST http://dx.doi.org/10.1016/j.jceh.2016.06.056 The authors have none to declare. Corresponding author: Rajesh Gopalakrishna. 15 E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.057 CORRELATION OF INSULIN RESISTANCE WITH LIVER HISTOLOGY IN OBESE PATIENTS WITH NASH AND IN LEAN NASH Mathew Vadukoot L, Rajesh Gopalakrishna, 16 Malini Eapen, Harikumar R. Nair, Ismail Siyad, Shine Sadasiv, Rama P. Venu RENAL DYSFUNCTION IN PATIENTS WITH NONALCOHOLIC FATTY LIVER DISEASE IS Amrita Institute of Medical Sciences, Kochi, India RELATED TO THE PRESENCE OF DIABETES MELLITUS AND SEVERITY OF LIVER Background & Aim: Insulin resistance (IR) plays a DISEASE central role in the pathogenesis of non-alcoholic steatohepatitis (NASH), especially in obese patients with Ram V. Nampoothiri, Ajay Duseja, Manish Rathi, Swastik Agrawal, Naresh Sachdeva, Manu Mehta, diabetes and related components of metabolic syn- ALD and NAFLD drome (MS). The aim of the study was to correlate Radha K. Dhiman, Yogesh K. Chawla histopathological grading and insulin resistance in Post Graduate Institute of Medical Education and Research, Chandigarh, obese patients with NASH as compared to lean NASH. India Methods: Patients with NASH who underwent liver biopsy between January 2012 and December 2012 Background & Aim: There is sparse data on the were included. Anthropometric, clinical and bio- prevalence of renal dysfunction in patients with non- chemical evaluation for MS was done. Histologic fl fi alcoholic fatty liver disease (NAFLD). The aim of the features, necroin ammatory grade, brosis stage on present study was to evaluate the presence of renal liver biopsies were scored according to Brunt, NAS dysfunction in patients with NAFLD and correlate it score. Categorical data was expressed as percentages with the severity of liver disease. and compared using chi-square test. Continuous data Methods: One hundred nonalcoholic patients with was expressed as mean standard deviation (SD) ‘t’ ultrasound showing hepatic steatosis were enrolled and compared by independent sample test. into the study after exclusion of other causes. Pre- Results: Out of 42 patients, there were 33 (78.57%) sence of renal dysfunction was estimated by glomer- 2 who had BMI of 23 kg/m while 9 had ular filtration rate and by evaluating 24 h urinary BMI < 23 kg/m2 (lean NASH). Mean FBS levels protein and microalbumin. Various risk factors (96.83 19.84 mg/dL) and HbA1c levels (5.93 including components of metabolic syndrome, sever- 0.68) in patients with obese NASH were found fi P ity of hepatic steatosis (as assessed on ultrasound), to be signi cantly high ( < 0.05). The mean HOMA hepatic necro-inflammation (as assessed by hepatic 2 IR among patients with BMI 23 kg/m were found transaminases) and hepatic fibrosis (as assessed by to be significantly higher than those with lean NASH vs P transient elastography) were correlated with the pre- (4.30 3.69 2.12 1.53; = 0.045) suggesting sence of renal dysfunction. higher prevalence of insulin resistance in obese Results: Twenty eight (28%) patients with NAFLD NASH. However, fasting insulin levels was compa- had evidence of impaired renal function with 5 (5%) rable among patients with lean and obese NASH. No fi fi having abnormal glomerular ltration rate, 18 (18%) statistically signi cant difference was observed with having significant proteinuria and 5 (5%) having

Journal of Clinical and Experimental Hepatology | July 2016 | Vol. 6 | No. S1 | S23–S32 S31 ALCOHOL AND NON-ALCOHOLIC FATTY LIVER DISEASE

both. Presence of type 2 diabetes mellitus, raised Prevalence of impaired renal function in patients hepatic transaminases and advanced fibrosis on tran- with NAFLD is dependent on the severity of liver sient elastography were found as independent pre- disease and presence of diabetes mellitus. dictors of impaired renal function with raised hepatic transaminases having the best sensitivity (89%) and CONFLICTS OF INTEREST presence of advanced fibrosis the best specificity (90%). A model comprising of these three parameters The authors have none to declare. had good accuracy (AUROC = 0.763) in predicting Corresponding author: Ajay Duseja. impaired renal function in patients with NAFLD. E-mail: [email protected] Conclusion: Asignificant proportion of patients with NAFLD have impaired renal functions. http://dx.doi.org/10.1016/j.jceh.2016.06.058 L n NAFLD and ALD

Cirrhosis and Complications

1 Corresponding author: Sajan Agarwal. LATE PRESENTATION OF AUTOIMMUNE E-mail: [email protected] HEPATITIS AS DECOMPENSATION IN A http://dx.doi.org/10.1016/j.jceh.2016.06.068 DIAGNOSED CASE OF CELIAC DISEASE ASSOCIATED ATAXIA TELENGECTASIA 2 Sajan Agarwal, Umesh R. Gupta ‘ ’ JK Lone Hospital, SMS Medical College, Jaipur, India MODIFIED BARREL ONLY TECHNIQUE FOR ENDOSCOPIC VARICEAL LIGATION Background: Celiac disease (CD) is frequently (EVL): A COMPARATIVE STUDY accompanied by a variety of extradigestive manifesta- Ashish Kumar, Sanjay Goyal tions, thus making it a systemic disease rather than a disease limited to the gastrointestinal tract. The hepa- Government Medical College, Patiala, India tic dysfunction presenting in CD ranges from asymptomatic liver enzyme elevations or nonspecific Background and Aim: EVL is an established proce- reactive hepatitis (cryptogenic liver disorders), to dure in managing variceal bleeding. In standard tech- autoimmune hepatitis (AIH) related chronic liver nique, ligator handle is attached over the biopsy disease (CLD). AIH are less common and are asso- channel and catheter is passed through its opening. ciated in the majority of cases with clinical signs and Catheter is retrieved from the tip of endoscope and symptoms of chronic liver disease, which need specific trigger cord is attached to it. Catheter along with trigger immunosuppressive therapy, rather than just GFD. cord is withdrawn from opening of control handle. Case Report: We report a 14 years old male child, Trigger cord is placed in a slot in the control handle. diagnosed case of celiac disease (based on positive The cord is pulled in the slot till the knot is seated into serology and DII biopsy) on strict gluten free diet it. The handle is rotated till and cord is taut. While (GFD) with ataxia telengiectasis (ataxia+, ocular winding one must be careful to avoid triggering of changes+) 8 years back, presented to our PICU in sick band. Modified barrel only method: Loading catheter Cirrhosis and Complications conditions as ascites since last 1 month without jaun- is passed directly into the biopsy channel through the dice. CLD stigmata and gross ascites were present on rubber cap with flap on without using ligator handle. examination. In work up, there was evidence of DCT End of trigger cord is attached to the loading catheter positive hemolysis, mildly increased liver enzymes, and catheter is withdrawn and retrievedfromthebiopsy hypoalbuminemia with reversal of A/G ratio, INR channel port. Endoscope loaded with barrel is inserted 1.75 and evidence of chronic liver disease with nodular into esophagus and varix is sucked into the barrel till liver in USG abdomen. Diagnosis of AIH was based on the red out. Trigger cord is pulled gently till there is positive anti-LKM-11:20 titer. Liver biopsy could not feeling of giveaway indicating release of band. Pull is be done because of hemodynamic unstability, gross ceased immediately (see figure). By avoiding control ascites and coagulopathy. Steroid was started but after handle, procedure time can be reduced significantly. few days, child condition further deteriorated and Aim of this study was to compare the procedure time in child could not be survived. modified method and standard method for EVL.1 Conclusion: Clinicians must remember that CD may debut with extraintestinal manifestations, and associated illnesses may appear both at the time of diagnosis, throughout the evolution of the disease and as a late presentation. Screening for liver involvement in celiac children should become routine practice. The early implementation and strict adherence to a GFD improves and slow down the evolution of the associated diseases. CONFLICTS OF INTEREST The authors have none to declare.

Method: We compared standard method and mod- Psychometric testing for diagnosis of MHE was per- ified method in 100 patients undergoing EVL. Fifty formed at baseline, 3 months and 9 months. patients were enrolled into each arm and time dura- Results: Of the 527 patients screened, 351 were found tion was noted from the point of passing of loading eligible and tested for MHE. Out of these, 112 (31.9%) catheter into biopsy channel till endoscope was ready patients had MHE (mean age 55.3 years; 75% males). for EVL. Release of multiple bands on single trigger They were randomized to receive rifaximin (n = 57; was also noted. 1200 mg/day) or lactulose (n = 55; 30–120 ml/day) Results: On an average modified method saved for 3 months. At 3 months, 73.7% (42/57) patients 129.5 s per procedure (see table). in rifaximin group experienced MHE reversal compared to 69.1% (38/55) in lactulose group (P = 1.0). Modified Standard Six months after stopping treatment, 47.6% (20/42) method arm method arm in rifaximin group and 42.1% (16/38) patients in Mean age (in years) 51.4 52.7 lactulose group experienced MHE relapse (P = 0.274). The overt hepatic encephalopathy devel- Male:female ratio 5:1 4.1:1 80.5 210 opment rate (7.1% vs 7.9%) and mortality rate (0.23% Mean procedure time (s) vs 0%) were similar in both groups. The Child–Tur- Release of multiple bands 54cotte–Pugh score and model for end stage liver disease (MELD) scores of patients who had MHE relapse were higher compared to those who did not. On Conclusion: Modified method for EVL is quick and multivariate regression analysis, MELD score was effective. Additionally it will reduce cost and biome- an independent predictor of MHE relapse. dical waste generation during procedure. Conclusion: Of the patients who became MHE nega- iroi n Complications and Cirrhosis tive after short-term (3 months) treatment with rifax- CONFLICTS OF INTEREST imin/lactulose, almost 50% had a relapse of MHE at 6 months follow-up. MELD score was an independent The authors have none to declare. predictor of MHE relapse. Corresponding author: Ashish Kumar. E-mail: [email protected] CONFLICTS OF INTEREST

http://dx.doi.org/10.1016/j.jceh.2016.06.069 The authors have none to declare. Corresponding author: Omesh Goyal. E-mail: [email protected] 3 http://dx.doi.org/10.1016/j.jceh.2016.06.070 RELAPSE OF MINIMAL HEPATIC ENCEPHALOPATHY IN CIRRHOTICS AFTER SHORT-TERM TREATMENT—A 4 PROSPECTIVE TRIAL DIABETES MELLITUS INCREASES THE Omesh Goyal, Sandeep Sidhu, Harsh Kashyap SEVERITY OF FIRST EPISODE OF OVERT D.M.C. and Hospital, Ludhiana, India HEPATIC ENCEPHALOPATHY IN DECOMPENSATED CIRRHOSIS Background and Aim: Minimal hepatic encephalo- Srijith Kadavanoor, Nikhil Suraj, M. Ramu, pathy (MHE) has been shown to reverse after short- Deni Joseph, G. Chethan, T.S. Prasanth, D. Krishnadas term treatment with ammonia lowering therapies. However, relapse rate of MHE after stopping treat- Govt Medical College, Trivandrum, India ment has not been studied so far. We aimed to evaluate long-term (9 months) efﬁcacy of a short- Background and Aim: Diabetes mellitus is asso- term (3 months) treatment of MHE with lactulose/ ciated with a state of increased inﬂammation as a rifaximin, for maintenance of remission from MHE. result of increased bacterial translocation due to Methods: In this prospective study, consecutive reduced intestinal transit time and SIBO. Diabetes patients with cirrhosis and MHE were treated with mellitus may alter the course of hepatic encephalo- lactulose/rifaximin for 3 months. After stopping pathy (HE) in decompensated cirrhosis. With the treatment, they were followed up for 6 months. increase in cases of NASH related cirrhosis it has

become important to study the relation of diabetes Background and Aim: Endothelial injury plays an with respect to HE as it is one of the main complication important role in the pathogenesis of chronic renal in decompensated cirrhosis which affects quality of diseases and may be related to oxidative stress. The life. The aim of the study was to identify the role of present work was designed to study markers of diabetes mellitus in the development of first episode of endothelial injury and oxidative stress in patients overt HE in patients with decompensated cirrhosis. with hepatitis C virus (HCV)-related cirrhosis in rela- Methods: We conducted a retrospective case control tion to renal function and hemodynamics. study in the study period January 2015 to December Methods: Thirty patients with HCV-related cirrhosis 2015. We enrolled consecutive patients with decom- and 15 healthy subjects were included in the study. pensated cirrhosis of any etiology with overt HE The severity of liver disease was assessed using Child– (grade 2–4) and divided them into two groups, those Pugh classification and Model for End Stage Liver with diabetes (Group I) and those without diabetes Disease (MELD) score. Glomerular injury was (Group II). Severe HE was defined as grade 3 HE and assessed by urinary albumin excretion rate and tub- above. ular damage was determined by 24-h urinary leucine Results: A total of 96 patients with overt HE were aminopeptidase (LAP) levels. Endothelial injury was enrolled of which 58 (60.41%) patients were diabetic evaluated by plasma von Willibrand factor (vWF) (Group I). Severe HE was seen in total of 34 (35.4%) activity and serum angiotensin converting enzyme patients of which diabetics were 29 (P < 0.001). The (ACE) levels. Serum malondialdehyde (MDA) levels mean serum albumin level in Group I was 2.78 were measured as a marker for oxidative stress. Renal Æ 0.32 g/dl and in Group II was 2.54 Æ 0.40 g/dl hemodynamics were assessed using duplex-Doppler (P = 0.002). The mean INR in Group I vs Group II ultrasonography by calculating the diastolic/systolic was 1.76 Æ 0.44 vs 2.02 Æ 0.57 (P = 0.011). Ammonia renal flow velocity ratio (d/s), intrarenal resistive levels were higher in Group I which was 87.33 index (RI) and hilar renal blood flow (RBF). Æ 21.72 as against 78.87 Æ 22.31 in Group II Results: Patients with HCV-related cirrhosis showed (P = 0.068). On multivariate analysis infections, sever- significant increases in plasma vWF activity, serum ity of HE, serum albumin and age were significant. levels of ACE and MDA, urinary LAP levels and RI and Conclusion: Diabetic patients had more severe significant decreases in d/s ratio and RBF compared grades of HE and it occurred at lesser biochemical with healthy subjects (P < 0.05). Plasma vWF activity decompensation. and serum ACE levels were positively correlated with serum MDA levels, urinary albumin excretion rate, Cirrhosis and Complications CONFLICTS OF INTEREST urinary LAP levels and RI and were inversely correlated with RBF (P < 0.05). No statistically significant The authors have none to declare. correlations were found between severity of liver disease and plasma vWF activity, serum ACE levels Corresponding author: Srijith Kadavanoor. and urinary LAP levels in patients with cirrhosis E-mail: [email protected] (P > 0.05) http://dx.doi.org/10.1016/j.jceh.2016.06.071 Conclusion: Endothelial injury, possibly due to oxidative stress, plays an important role in the pathogenesis of renal dysfunction and increased renovascular impedance in patients with HCV-related 5 cirrhosis. Pharmacological approaches to enhance endothelial function could improve renal function ENDOTHELIAL INJURY AND OXIDATIVE in these patients. STRESS IN PATIENTS WITH HEPATITIS C VIRUS-RELATED CIRRHOSIS: RELATION CONFLICTS OF INTEREST TO RENAL FUNCTION AND HEMODYNAMICS The authors have none to declare. Hayam E. Aggan, Magdy Rashwan, Safaa Abodeya, Corresponding author: Hayam E. Aggan. Sabah Mahmoud E-mail: [email protected]

University of Alexandria, Alexandria, Egypt http://dx.doi.org/10.1016/j.jceh.2016.06.072

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6 bilirubin and INR. Hence, it is an alternative support system to stabilize the patients while waiting for liver THERAPEUTIC PLASMA EXCHANGE (TPE) transplant. AS AN ADJUVANT TO SUPPORTIVE MANAGEMENT IN END STAGE LIVER CONFLICTS OF INTEREST DISEASE PATIENTS WITH HIGH MELD (SCORE >25) AWAITING LIVER The authors have none to declare. TRANSPLANTATION Corresponding author: Santosh K. Yadav. Joy Varghese 1, Deepti Sachan 1, V. Jayanthi 1, E-mail: [email protected] 1 1 1 Vijaya Srinivasan , K. Ilankumar , Kavya Harika , http://dx.doi.org/10.1016/j.jceh.2016.06.073 Mayank Jain 1, M. Srinivas 1, G.M.M. Reddy 2, Mohamed Rela 1

1Global Health City, Chennai, India, 2Chettinad Hospital & Research Institute, Chennai, India 7

Background and Aim: Patients with high MELD MELD VS MELD NA FOR PREDICTING score (>25) who are listed for liver transplantation, INHOSPITAL MORTALITY IN seek admission for jaundice, encephalopathy, coagu- DECOMPENSATED CLD lopathy, or multisystem organ dysfunction and mor- Shahna S. Fathima, Ponni Gopalakrishnan, tality rates are high without liver transplantation. Krishnadas Devadas, S. Srijaya, K.S. Prasanth, A. Shanid, Hence our aim of the study was to determine the Gopu R. Babu, Arun Iyer, Santosh K. Yadav, B.K. Bincy, iroi n Complications and Cirrhosis role of therapeutic plasma exchange (TPE) in ESLD George Peter patients with high MELD (25) awaiting liver transplant. Government Medical College Hospital, Thiruvananthapuram, India Methods: Patients with ESLD listed for LT with MELD score of 25 and more were offered either Background and Aim: MELD as prognostic score TPE with supportive treatment (cases) or supportive has several strengths compared with Child score. The treatment alone (controls). TPE was repeated when variables in MELD score are simple and more objec- there was worsening of biochemical parameters. tive. The incorporation of Na to the MELD (MELD- Response to TPE with supportive treatment was Na) has been shown to improve its predictive accu- assessed by change in MELD score, liver function racy in earlier studies. Aim of this study is to compare tests, platelet count and improvement in organ dys- meld and meld Na as predictors of inhospital function. These same parameters were compared mortality with control group. The primary end point was bio- Methods: Descriptive retrospective study. We col- chemical response and the secondary end point was lected data from case records of patients expired in liver transplant and overall survival without MGE Department Govt Medical College Hospital transplant. TVM from February 2015 to January 2016. Same Results: Both cases (39 patients) and controls number of patients were randomly selected of those (22 patients) were comparable for demography and who got discharged in a stable condition. Continuous clinical parameters. The median decline in MELD variables were described by mean and SD. Qualitative (P value 0.004), total bilirubin (P value <0.001) and variables were described by frequency distribution. INR (P value 0.002) was statistically significant in Association of continuous variables were analysed cases and not so for other parameters. The risk of by T test. Univariate analysis was used to find the mortality was 1.96 times higher in controls, when significance of association of MELD, MELD Na, compared to TPE (95% CI 1.03–3.79, P value 0.039). ALBI, NLR (neutrophil lymphocyte ratio) and PLR The cumulative survival was higher in TPE group, (platelet lymphocyte ratio) with mortality. ROC curve compared to the controls. This difference in the was used to predict optimum cut-off value for sig- survival function was statistically significant (P value nificant variables. 0.031). Four out of 39 patients on TPE and only one Results: 96 patients expired in this period. 88 were on supportive care underwent successful liver CHILD C and 8 were CHILD B. Comparison was transplant. done with those who were discharged stably. Signifi- Conclusion: TPE in ESLD patients temporarily cant difference was found in the MELD and MELD improves MELD score by reduction in serum Na between the 2 groups. AUROC was 0.707 for

MELD and 0.801 for MELD Na. Cut-off value of 21.5 Results: All five of our patients were male. The mean for MELD had sensitivity of 76 specificity of 56.3 age of the patients was 44 Æ 11.22 years (range 28–56 while cut-off of MELD Na at 23.04 had a sensitivity years). The median number of chemical pleurodesis of 84.5 and specificity of 67.7. sessions performed was 2 (range 1–3). The procedure Conclusion: Both MELD and MELD Na are good was effective in 4 out of 5 patients (80%) during 6- predictors of inhospital mortality. MELD Na is a month follow-up. In one patient (20%) there was slightly better predictor than MELD. Other score like recurrence with encysted pleural effusion. In one ALBI, NLR, PLR has no role in predicting in hospital patient initially there was fever and leucocytosis mortality (20%). There was no mortality during 6-month follow-up. CONFLICTS OF INTEREST

The authors have none to declare. Corresponding author: Shahna S. Fathima. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.074

8 EFFICACY OF TALC PLEURODESIS FOR THE MANAGEMENT OF REFRACTORY HEPATIC HYDROTHORAX IN PATIENTS WITH LIVER CIRRHOSIS Ashmeet Chaudhary, Onkar Patel

Apollo Hospitals, Indore, India Cirrhosis and Complications Background and Aim: Hepatic hydrothorax in patients with decompensated liver cirrhosis is a challenging complication. Chemical pleurodesis is an effective treatment for malignant effusion and pneu- Conclusion: The procedure appears to be effective in mothorax. Although this mode of therapy is less patients with refractory hydrothorax. Pleurodesis widely accepted in treatment of patients with hepatic with talc slurry was successful for control of hepatic hydrothorax. The need of palliative treatment in such hydrothorax in four of our ﬁve patients combined patients encouraged us to do this work as most of our with standard medical treatment. This treatment patient still are not willing for liver transplant. could be applied to patients with hydrothorax who Methods: Five consecutive patients with sympto- could not be submitted to or not willing for liver matic right sided hepatic hydrothorax not respond- transplantation. ing to medical therapy and repeated thoracocenthesis were enrolled in the study between January 2014 to April 2016. The medical records and radiologic ima- CONFLICTS OF INTEREST gings of these patients were thoroughly reviewed. Thorough general and systemic physical examination The authors have none to declare. done in all patients. Pleural ﬂuid examination done to Corresponding author: Onkar Patel. rule out any other suspicious cause. All underwent E-mail: [email protected] pigtail catheter drainage of pleural effusion followed by pleurodesis by talc slurry. http://dx.doi.org/10.1016/j.jceh.2016.06.075

Journal of Clinical and Experimental Hepatology | July 2016 | Vol. 6 | No. S1 | S33–S58 S37 CIRRHOSIS AND COMPLICATIONS

9 and hepatic encephalopathy at presentation has no signiﬁcance. FACTORS ASSOCIATED WITH IN HOSPITAL MORTALITY IN PATIENTS WITH CONFLICTS OF INTEREST DECOMPENSATED CLD Ponni Gopalakrishnan, Shahna S. Fathima, The authors have none to declare. Krishnadas Devadas, Gopu R. Babu, B.K. Bincy, Corresponding author: Ponni Gopalakrishnan. S. Srijaya, A. Shanid, K.S. Prasanth E-mail: [email protected] Govt Medical College Hospital, Thiruvananthapuram, India http://dx.doi.org/10.1016/j.jceh.2016.06.076

Background and Aim: The course of cirrhosis is extremely variable from patient to patient. It may be due to several factors, like hepatic synthetic func- 10 tion, the cause of cirrhosis, and the occurrence of liver — malignancy. Establishing prognosis in a given patient LIVER, HEART AND KIDNEY THE with cirrhosis remains a challenging issue. The aim of TRIOLOGY the study was to assess the clinical and biochemical Kayal V. Nagarajan, Ramakrishna Venugopalan factors associated with in hospital mortality in patients with decompensated CLD of different Amrita Institute of Medical Sciences, Kochi, India etiology. Methods: In this case control study we have retro- Background and Aim: Cirrhotic cardiomyopathy iroi n Complications and Cirrhosis spectively collected data from case records of patients (CCM) is a sub-clinical cardiac complication. The who were admitted with decompensated CLD with basic pathophysiology is related to hyperdynamic cir- complications and expired during in hospital stay in culation, splanchnic vasoconstriction and the resul- our department over a period from February 2015 to tant neurohormonal response. There is a probable January 2016. For assessing the factors associated association between CCM and hepato-renal syndrome with in hospital mortality we have taken randomly (HRS) in view of the common pathophysiology. The selected controls who were admitted following devel- aim of this study aims to assess the prevalence of CCM opment of complications, but discharged in a stable and correlate with severity of liver disease and etiology state during the same time period. Continuous vari- of cirrhosis. Also, assess the significance of the asso- ables were described by mean and standard deviation, ciation between CCM and HRS. Qualitative variables by percentage. Association of Methods: Prospective study of 210 patients under- continuous variables were analysed by t-test and qua- going pre-LT evaluation from June 2014 to May 2016 litative variables by chi-square test. Variables found to were evaluated for the prevalence of CCM using 2D- be significantly associated with mortality during uni- echocardiography with Doppler and Dobutamine variate analysis are subjected to multivariate analysis stress echocardiography. Statistical analysis was done by binary logistic regression. using SPSS software and significance calculated using Results: We had 88 Child C and 8 child B patients chi-square test. P value less than 0.05 was considered who expired during the study period (case group). significant. Same number of patients (n = 96) were there in con- Results: 210 patients were prospectively evaluated for trol group. On univariate analysis, gender, duration CCM and followed up. 6 patients were excluded from of hospital stay, upper GI bleed, AKI, hepatic ence- the study 2D-echocardiography could not assess for phalopathy, pneumonia and SIRS admission, total CCM. 30% (n = 62) of the 204 patients had CCM. count, ANC, total and direct bilirubin levels, SGOT, There was no statistical difference in the prevalence SGPT, ALP, total protein, blood urea and serum of CCM between alcoholic and non-alcoholics creatinine levels. Multivariate analysis showed that (P = 0.6). 85% (n = 53) of patients had Grade 1 dia- gender, upper GI bleed, AKI, pneumonia, duration of stolic dysfunction (DD), 13% (n = 8) had Grade 2 DD hospital stay, S. ALP levels and S. creatinine has and 3% (n = 2) had systolic dysfunction. Prolonged significant association with inhospital mortality. QT was noted in 73% of patients with CCM and pro- Conclusion: Our results suggest that female gender, BNP levels were elevated in 32% of patients. There was upper GI bleed, AKI, pneumonia, S. ALP levels, B. urea no correlation between CTP scores and CCM and S. creatinine at admission are important factors (P = 0.39). The correlation between HRS and CCM associated with inhospital mortality where as SBP was not significant (P = 0.16).

Conclusion: CCM is prevalent in 30% of patients in admission was 3.59 days (1–7 days). Grade of HE on our study. Despite the high prevalence, the degree of admission was grade II (32%), grade III (23%) and diastolic dysfunction was mild and systolic dysfunc- grade IV (25%). Identifiable precipitating factors were tion was very low. There is no correlation between the constipation (28%), variceal bleed (23%), infections severity of liver disease and CCM. There is no differ- (21%) and ACLF (8%). 20% patients had no obvious ence in the prevalence of CCM between alcoholics and precipitating factors. 26% had multiple precipitating non-alcoholics. HRS was not found to have an asso- factors. 53.8% patients had good response to treat- ciation with CCM. ment, 25% had no response and 21.2% patients were deteriorated. Factors significantly (P < 0.05) asso- CONFLICTS OF INTEREST ciated with good response were NAFLD, patients with adefinite precipitating factor, less duration of cirrho- The authors have none to declare. sis, less time lag between symptom onset and admission and low MELD score. Bad response (P < 0.05) Corresponding author: Ramakrishna Venugopalan. was associated with alcoholic cirrhosis, Wilson’s dis- E-mail: [email protected] ease, infections, long duration of cirrhosis, low albu- http://dx.doi.org/10.1016/j.jceh.2016.06.077 min, patients without a definite precipitating cause and previous history of HE. Conclusion: Majority (53.8%) of the patients with HE responded within 5 days of standard treatment and 11 non-responders had high mortality. Identifying the THE PATTERN OF TREATMENT RESPONSE prognostic factors on admission is important in man- AND ITS PREDICTORS IN CIRRHOTIC agement decision. PATIENTS WITH OVERT HEPATIC ENCEPHALOPATHY (HE) CONFLICTS OF INTEREST Shah A. Shemin, Thazhathu M. Ramachandran The authors have none to declare.

Govt. Medical College, Calicut, Kerala, India Corresponding author: Thazhathu M. Ramachandran. E-mail: [email protected] Background and Aim: HE is a common debilitating

http://dx.doi.org/10.1016/j.jceh.2016.06.078 Cirrhosis and Complications complication of cirrhosis liver which can be due to a precipitating event or progressive deterioration of hepatic functional reserve. The aims of the study were: (1) To assess the pattern of treatment response 12 to overt HE in cirrhotic patients. (2) To identify the factors influencing treatment response. TO STUDY UPPER GASTROINTESTINAL Methods: Prospective study. Patients admitted in MUCOSAL CHANGES IN PATIENT WITH Gastroenterology Department, Calicut Medical Col- PORTAL HYPERTENSION lege during April 2015 to March 2016 were included. The diagnosis of cirrhosis was done as per standard Pinakin S. Patel, Deepak Amarapurkar criteria and HE grading was done according to West Bombay Hospital & Medical Research Centre, Mumbai, India Haven criteria. Patients with HE grade II or more were included. HCC patients were excluded. Standard Background and Aim: Gastrointestinal bleeding treatment of HE and complications if any, were given accounts for up to 25% of overall mortality in patients to all the patients. Treatment response for first five with portal hypertension. Although variceal haemor- days post admission was recorded. The response was rhage and peptic ulcer disease account for a significant categorized as good response, no response and dete- portion of acute GI bleeding in cirrhotics, portal hyper- rioration, based on change in West Haven index of 2 tensive gastropathy (PHG) and gastric antral vascular or more on either side. ectasia (GAVE) represent important causes of chronic Results: 80 patients were included. 66 males and 14 gastrointestinal bleeding, responsible for chronic females with mean age of 53 years. The etiology of blood loss anaemia in 3–26% of patients. But their cirrhosis was alcohol 32 (40%), NAFLD 17 21.2%), incidence was underestimated as cause of chronic iron cryptogenic 15 (18.7%), viral 13 (16.2%) and Wilson’s deficiency anaemia in patient with portal hypertension. disease 3 (3.7%). Mean duration of cirrhosis was 29 Methods: 290 consecutive patient of portal hyper- months. Mean duration between symptom onset and tension (cirrhosis: 268, non-cirrhotic portal fibrosis

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(NCPF): 6, extra hepatic portal vein obstruction Background and Aim: Bacterial infections are com- (EHPVO): 16), were evaluated prospectively for upper mon in patients with cirrhosis. Spontaneous bacterial gastrointestinal mucosal changes over a period of 1 peritonitis (SBP) is the most prevalent infection in year. Out of 268 cirrhotic patients, 21 underwent cirrhosis. Incidence of SBP is 10–30% with mortality successful either band ligation or sclerotherapy, with ranging from 20% to 40%. The MELD was originally evaluation before and after same. created and validated in patients in whom an acute Results: Out of 268 cirrhotic patients, PHG was reversible complication like infection or azotemia was found in 203 patients [(75.7%) (mild 64.5%, severe not present and not to predict mortality. Of the 11.9%)], while its incidence was significantly higher in available models, MELD is the most commonly used patients with large oesophageal varies when com- to predict mortality in decompensated CLD. The aim pared with small and no varies (P < 0.05). Overall of the present study was to find the predictors of in incidence of GAVE, gastric varies, gatroduodenal hospital and 90-day mortality in patients admitted polyps, gastroduodenal ulcer in cirrhotic was 7%, with SBP. 12.6%, 7.8%, 7% respectively. Out of 268 patients 31 Method: This is a retrospective observational study (11.5%) having active oesophageal variceal bleed and 2 in the setting of Department of Medical Gastroen- patients having severe PHG bleed. 81 (30.2%) patients terology, MCH, Thiruvananthapuram. The study having iron deficiency anaemia from unexplained period ranged from January 2015 to December reasons. 21 patients underwent successful either band 2015. The inclusion criteria were patients with cir- ligation or sclerotherapy, of which 15 had PHG rhosis admitted with first episode of SBP. SBP was (severe—5, mild—10) before therapy. After successful defined as an ascitic fluid ANC 250 cells/mm3. either band ligation or sclerotherapy, 14 patients had Hospital based electronic discharge data and case PHG (severe—14, mild—4), but severity of PHG was records were reviewed. The demographic, clinical, iroi n Complications and Cirrhosis significantly (P < 0.05) increased. biochemical characteristics of patients were com- Conclusion: In cirrhosis incidence of PHG was sig- pared and analysed. nificantly higher with large oesophageal varies. PHG Results: 165 patients were admitted with SBP during GAVE and gastroduodenal ulcers are important cause the period of study. Mean age was 48.5 years. 84% of chronic iron deficiency anaemia of unexplained patients were male. ALD and NASH were predomi- reason in cirrhosis. Severity of PHG was significantly nant cause of decompensated cirrhosis. The mor- increased following successful either band ligation or tality rate was 20% for patients with SBP. About 66% sclerotherapy. of this death occurred during the in hospital period. On univariate analysis thrombocytopenia, serum CONFLICTS OF INTEREST creatinine, INR was found to predict in hospital mortality. Hyponatremia, prolonged INR and a The authors have none to declare. low ascitic fluid albumin was found to predict 90-day mortality. Corresponding author: Pinakin S. Patel. Conclusion: Elevated S. creatinine, prolonged INR E-mail: [email protected] and thrombocytopenia were factors which predicted http://dx.doi.org/10.1016/j.jceh.2016.06.079 the risk of IP mortality in patients with SBP. Those with hyponatremia and low ascitic fluid albumin needs to be followed up as they are at increased mortality risk during the first three months following 13 SBP. PREDICTORS OF IN HOSPITAL AND 90-DAY MORTALITY IN PATIENTS ADMITTED CONFLICTS OF INTEREST WITH SPONTANEOUS BACTERIAL The authors have none to declare. PERITONITIS IN A TERTIARY CARE CENTRE Corresponding author: Gopu R. Babu. Gopu R. Babu, M. Ramu, Ponni Krishnan, B. Bincy, E-mail: [email protected] Santosh K. Yadav, Shahna S. Fathima, Arun Iyer, Devadas Krishnadas, S. Srijaya, A. Shanid http://dx.doi.org/10.1016/j.jceh.2016.06.080

Govt Medical College, Thiruvananthapuram, India

14 Ramkumar Govindarajan, Vaishnavi Priyaa, Kavitha S. Kumar HIDDEN FROM ENDOSCOPIC VIEW CAUGHT BY ENDOSONOGRAPHY AND Kilpauk Medical College, Chennai, Tamilnadu, India TAKEN CARE OF GASTRIC VARICEAL BLEEDING Background and Aim: Non-selective beta blockers (NSBB) are said to be protective against spontaneous Athish Shetty, Avinash Balekuduru, bacterial peritonitis and worsen hepato renal syn- Lokesh Locheruvapalli, Ravi Kiran, drome, refractory ascites and hepatic encephalopa- Satyaprakash B. Shetty thy in liver cirrhosis. We aimed to study the association of beta blockers with these complications MS Ramaiah Medical College, Bangalore, India in our center. Methods: We performed a single center, retrospective Background: Gastric varices (GVs) are notorious to analysis of 82 patients with liver cirrhosis who did or bleed massively and often difﬁcult to manage with did not receive beta blockers and studied the occur- conventional techniques. GVs are known to bleed less rence of spontaneous bacterial peritonitis, refractory frequently than the esophageal varices (EVs), but ascites, hepato renal syndrome and hepatic encepha- bleed massively and difﬁcult to achieve primary lopathy at Department of Digestive Disease and hemostasis, with a mortality rate of 10%-30%. Once Health, Anna Nagar, Chennai. stabilised, an esophagogastroduodenoscopy (EGD) Results: Total of 82 patients were studied who were performed shows active bleeding/stigmata of recent registered from a period of January 2009 to January bleeding/type of GVs and concomitant presence of 2016. The group had more number of males which EVs or PHG 1. Endoscopic ultrasound (EUS) enables accounted for 79.3% of the whole group. Out of 82 the visualization of EVs, GVs and peri- and para- patients, 44 (55.2%) were on beta blockers and 38 esophageal collateral veins and perforating veins. (46.3%) were not on beta blockers. The most common Case Report: We present a case of ethanol related etiology for cirrhosis in our group was ethanol chronic liver disease and chronic pancreatitis present- (n = 61, 74.39%). Frequency of complications in NSBB ing with gastrointestinal bleeding requiring recurrent vs non-NSBB groups were as follows: spontaneous blood transfusions. Endoscopy done did not reveal bacterial peritonitis (NSBB = 34.1%, non- GVs. EUS combined with colour doppler enabled NSBB = 47.4%), refractory ascites (NSBB = 13.6%,

visualisation of multiple small GVs (<5 mm) with Cirrhosis and Complications non-NSBB = 13.2%), hepatorenal syndrome thickening of gastric mucosa, aided in glue injection (NSBB = 4.5%, non-NSBB = 15.8%) and hepatic ence- and obliteration of GVs during follow up. EUS is a phalopathy (NSBB = 15.9%, non-NSBB = 28.9%). The better tool to classify GVs and early signs of portal association of beta blockers with spontaneous bacter- gastropathy. ial peritonitis, refractory ascites, hepato renal syndrome and hepatic encephalopathy were analyzed CONFLICTS OF INTEREST and the P-values were 0.221, 0.949, 0.136 and 0.155 respectively. No statistically signiﬁcant association The authors have none to declare. between beta blockers use and any of these were Corresponding author: Athish Shetty. observed. E-mail: [email protected] Conclusion: This study indicates that non-selective beta blockers may have no role in the occurrence of http://dx.doi.org/10.1016/j.jceh.2016.06.081 spontaneous bacterial peritonitis, refractory ascites, hepato renal syndrome and hepatic encephalopathy in cirrhotics.

15 CONFLICTS OF INTEREST INFLUENCE OF BETA BLOCKERS ON COMPLICATIONS OF CIRRHOSIS The authors have none to declare. Corresponding author: Kayalvizhi Rajini. Kayalvizhi Rajini, Rajkumar Solomon, E-mail: [email protected] Aravind Arumugham, Murali Ananthavadivelu, Balamurali Rangachari, http://dx.doi.org/10.1016/j.jceh.2016.06.082 Muthukumaran Kalyanasundaram,

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16 Pallav Parikh, Sharad Deshmukh, Sarojini Parameswaran, K.R. Palaniswami, N. Murugan, SAFETY AND OUTCOME OF PROTOCOL A.T. Mohan, Ubal Dhus, Usha Srinivas, BASED INJECTION OF N-BUTYL-2- P. Piramnayagam, M. Hariharan, V.P. Seshadri, CYANOACRYLATE (GLUE) FOR M. Preethi OBLITERATION OF GASTRIC VARIX Apollo Hospital, Chennai, India Bhuvan Shetty, Avinash Balekuduru, Lokesh Locheruvapalli, Ravi Kiran, B.S. Satyaprakash Background and Aim: There is association between cirrhosis and low bone mineral density (BMD) and M.S. Ramaiah Hospital, Bangalore, India limited data regarding prevalence of low BMD in patients awaiting liver transplantation in India. Background and Aim: In patients with portal hyper- Aim of this study is to determine the prevalence tension at first endoscopy and of all variceal bleeds, of low BMD and factors associated with it in 20% occur from gastric varices but outcome is worse Indian patients with cirrhosis awaiting liver than with esophageal variceal bleeding 1–3. The tech- transplantation. nique of endoscopic glue injection in gastric varix is Methods: Patients with Child–Turcotte–Pugh (CTP) not standardized. The aim of the study is to assess the class B or C cirrhosis awaiting liver transplantation efficacy and outcome of protocol based injection of who fulfilled the inclusion criteria were included in glue injection at our center. study. BMD measurement at lumbar spine and Methods: We retrospectively studied all the subjects femoral neck were obtained by Dual Energy X-ray who underwent glue injection from March 2014 to Absorptiometry (DXA). Prevalence of low BMD February 2016. The age, gender, etiology and severity fi T À iroi n Complications and Cirrhosis (de ned as score below 1) among the study of liver disease, type of gastric varix, and outcome population was determined by using Hologic DXA were systematically recorded. database (Caucasian reference standards) and newly Results: Glue injection was done in 21 subjects dur- generated ICMR database. ing the study period. Their mean age was 41 + 10 Results: Study group comprised of 100 Indian cir- years and 15 (71%) were men. Ethanol was the most rhotic patients awaiting transplantation (79 males). common etiology in 11 (52%) subjects. Majority (62%) Mean age was 51.2 + 9.7 years with most common were Child–Turcott–Pugh score of A. The type of etiology of cirrhosis was alcohol (36%). Cirrhosis was gastric varix1 was 16 (76%) of GOV 1, 3(14.2%) of CTP class B in 42% and class C in 58%. By using IGV 1 and 2(9.5%) of GOV 1. Complications occurred Hologic DXA database and ICMR database preva- in four patients which included mortality in 1 and lence of low BMD was 82% (osteopenia 42% and rebleed requiring repeat injection in 3 (14.2%). osteoporosis 40%) and 62% (osteopenia in 43%; osteo- Conclusion: Glue injection is useful in active bleed porosis in 19%), respectively. Low BMD prevalence from gastric varices and the technique and dose of glue was high at the lumbar spine (82%) compared to injection needs to be standardized by larger studies. femoral neck (54%) (P < 0.05). Conclusion: Present study revealed high prevalence CONFLICTS OF INTEREST of low BMD in Indian patients with cirrhosis awaiting liver transplantation using both database. To The authors have none to declare. decrease complications, correction of osteopenia Corresponding author: Bhuvan Shetty. and osteoporosis in cirrhotic patients should be con- E-mail: [email protected] sidered, for which further studies are required. http://dx.doi.org/10.1016/j.jceh.2016.06.083 CONFLICTS OF INTEREST

The authors have none to declare. 17 Corresponding author: Pallav Parikh. E-mail: [email protected] BONE MINERAL DENSITY IN PATIENTS WITH CIRRHOSIS OF LIVER AWAITING http://dx.doi.org/10.1016/j.jceh.2016.06.084 LIVER TRANSPLANTATION

18 PROFILE OF ANEMIA IN CIRRHOSIS WITH OR WITHOUT SEPSIS Apoorva Srijayadeva, B. Prashantha, Sandeep Gopal, Suresh Shenoy, Bailur Tantry

Kasturba Medical College, Mangaluru, India

Background and Aim: Anemia is common in patients with cirrhosis and has been reported to be present in 75% of patients. Etiology of anemia in cirrhosis is multi factorial. Patients with cirrhosis have increased incidence of bacterial infections which could be associated with hematological abnormalities. Study was performed to identify the pattern Conclusion: The pattern of anemia in cirrhosis with of anemia in patients with cirrhosis and sepsis and sepsis is no different from those cirrhotic who had no its comparison with or without sepsis sepsis. However, microangiopathic haemolytic ane- Methods: Study type – prospective, single-centre, mia is a feature of sepsis and is seen very rarely in observational study was carried out in 200 patients cirrhosis without sepsis. of cirrhosis with anemia seen at KMC, Mangaluru from July 2014 to March 2016. All patients under- CONFLICTS OF INTEREST went detail clinical evaluation. Comprehensive hematological evaluation including CBC, peripheral smear, The authors have none to declare. iron studies, vitamin B12 levels, red cell folate and test for haemolysis were done. Relevant lab investiga- Corresponding author: Bailur Tantry. tions for liver disease were performed. Sepsis was E-mail: [email protected] diagnosed as per American College of Chest Physi- http://dx.doi.org/10.1016/j.jceh.2016.06.085 cians criteria. Results: 106 (53%) out of 200 were found to have Cirrhosis and Complications sepsis (group A) and 94 (47%) had no evidence of sepsis (group B). Severity of liver dysfunction (higher 19 MELD and CTP scores) was more in group A patients as compared to group B patients. Severity of anemia PREVALENCE OF DRIVING SKILL and red cell morphology in group A and B patients IMPAIRMENT DUE TO MINIMAL HEPATIC were similar. Patterns of anemia were found to be ENCEPHALOPATHY (MHE) IN CIRRHOSIS similar in both the groups. The most common type of OF THE LIVER anemia seen in both groups were anemia of chronic liver disease followed by iron deﬁciency anemia. How- Adarsh Rajendran, Varghese Thomas ever, microangiopathic hemolytic anemia was exclusively seen in Group A patients and was observed in Govt. Medical College, Calicut, Kozhikode, India 10/106 (9.4%). Only one patient in group B had microangiopathic hemolytic anemia. Background and Aim: Minimal hepatic encephalopathy (MHE) is present in more than half of patients with cirrhosis. MHE increases the risk of development of overt hepatic encephalopathy. Etiology Sepsis (n) No sepsis (n) P value MHE also causes impaired attention and precision Anemia of chronic 61 (57.5%) 48 (51.1%) 0.048 jobs like driving skills and have a higher risk of liver disease motor vehicle crashes. The aim of the study is to 13 (12.3%) 10 (10.6%) 0.231 Anemia of assess the prevalence of MHE and driving skill chronic disease impairment in cirrhotic patients who are regular 17 (16%) 26 (27.7%) 0.062 Iron deﬁciency drivers of four wheelers, using an electronic driving anemia simulator. Microangiopathic 10 (9.4%) 1 (1.1%) 0.002 hemolytic anemia Methods: All patients with cirrhosis liver (CHILD A & B) who are regular drivers of four wheelers with the

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inclusion criteria were enrolled. The study period was 20 from 1st January 2015 to 31st October 2015 and had a case control design. The assessment of MHE was A STUDY OF RENAL FUNCTION, SERUM done using NCT A&B, LDT A&B and CFF estima- SODIUM AND THEIR IMPACT ON tion. The driving performance was assessed with an SURVIVAL OF PATIENTS WITH END STAGE electronic driving simulator. The normal values for LIVER DISEASE psychometric tests and driving performance were Sravan K. Korrapati, Ravi K. Allu, R.S. Girinadh Lekkala, assessed with age and sex matched subjects. The data Murali K. Palakurthy were analysed with SPSS. Results: 23 patients were included. All were males. Andhra Medical College, Visakhapatnam, India The mean age of the cases was 48.1 Æ 7.3 years and that of controls was 44.4 Æ 11.2 yrs. 69% were CHILD Background and Aim: Serum creatinine is A and 31% were CHILD B status. MHE was present in considered to reflect renal function; however, it is 42.8% patients of CHILD A and all CHILD B patients. not a very accurate gauge, especially in detecting There was significant difference in NCT A, LDT A and early loss of renal function. To estimate the role CFF between normal subjects and patients. The sig- of serum creatinine, sodium, and estimated glomer- nificantly abnormal driving simulator parameters ular filtration rate (eGFR) as determinants of were lane deviation, map performance, reaction time survival in patients with end stage liver disease score, VDA response and collisions. Among the (CTP-C). patients who had MHE by bedside tests, 93.3% had Methods: Patients with decompensated cirrhosis driving simulator test abnormalities. (CTP-C) and serum creatinine 1.5 mg/dl were included in the study. Patients with diabetes, hyper- iroi n Complications and Cirrhosis tension, post-transplant candidates were excluded. Parameter Mean— Mean— Mean Mean P value MELD was calculated by MELD score. MELD Na patients healthy rank— rank— was calculated by MELD-Na = MELD + 1.59 (135- controls patients healthy Na). eGFR was calculated by the CKD-EPI (Chronic controls Kidney Disease Epidemiology Collaboration) for- CFF 38.27 41.18 13.07 23.50 0.004 mula. The primary event of interest in this study NCT (s) 59.8 35.28 18.48 5.71 0.000 was death within 6 months. LDT (s) 82.04 58.28 18.52 5.57 0.05 Results: Total 64 patients were included in the Lane deviation 7.39 2.14 19.4 6.01 0.000 study. 30 (46.8%) were having alcohol, 19 (29.6%) Map performance 1.65 0.28 18.57 5.43 0.000 patients had viral etiology as the cause of cirrhosis. Outof64patients18patients(28.12%)diedduring Collisions 1.69 0.3 17.11 6.93 0.002 1.16 0.91 17.46 9.07 0.025 6-month follow up. Hyponatremia was present in VDA response (s) 61.1% of dead patients and 21.7% of survived RT score 38.08 65.42 12.35 25.86 0.000 patients. eGFR was 90 ml/min/1.73 m2 in 12 Signal jumping 1.34 0 18.25 6.50 0.001 patients, 16% died. eGFR was 60–89 ml/min/ 2 Overspeeding 2.2 0.57 16.80 11.21 0.144 1.73 m in 32 patients, 25% died and eGFR was <60 ml/min/1.73 m2 in 20 patients, 40% died. Uni- variate analysis of baseline variables showed serum fi Conclusion: The prevalence of MHE in our creatinine had no signi cance in survival of patients study were 42.8% (CHILD A) and 100% (CHILD B). with end stage liver disease (CTP-C). MELD score, fi 93.3% of the patients with MHE had abnormalities eGFR, serum sodium and MELD-Na had signi - in the driving simulator test. 91.4% of the patients cance in the survival. Multivariate cox regression with CFF < 39 Hz had abnormal reaction time summaries for MELD, hyponatremia, and MELD score. plus serum sodium in predicting death considering 6-month follow-up data showed c-Static for MELD is0.75whereasc-StaticforMELD-Nais0.805and CONFLICTS OF INTEREST for a model comprising bilirubin, INR, eGFR and The authors have none to declare. sodium is 0.816. Conclusion: When compared to serum creatinine, Corresponding author: Varghese Thomas. eGFR is a better tool in estimating survival of patients E-mail: [email protected] with ESLD. As eGFR decreases percentage of mortal- http://dx.doi.org/10.1016/j.jceh.2016.06.086 ity increases.

CONFLICTS OF INTEREST CONFLICTS OF INTEREST

The authors have none to declare. The author has none to declare. Corresponding author: Sravan K. Korrapati. http://dx.doi.org/10.1016/j.jceh.2016.06.088 E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.087 22 21 CIRRHOTIC FUNDAL VARICEAL BLEEDERS SILIBININ INDUCED CELL CYCLE HAVE LOWER PORTAL PRESSURE AS ARREST IN HUMAN HEPATIC COMPARED TO CIRRHOTIC ESOPHAGEAL STELLATE CELLS VARICEAL BLEEDERS: A COMPARATIVE ANALYSIS OF 80 PATIENTS Ezhilarasan Devaraj Shrihari Anikhindi, Ashish Kumar, Praveen Sharma, Université Catholique de Louvain, Brussels, Belgium Vikas Singla, Naresh Bansal, Anil Arora Background and Aim: Proliferation of hepatic stel- Sir Ganga Ram Hospital, New Delhi, India late cells (HSCs) plays pivotal role in the progression of hepatic fibrosis consequent to chronic liver injury. Background and Aim: Variceal bleeding is a com- Silibinin (SBN), a flavonoid compound, has been mon manifestation of portal hypertension in liver shown to possess anti-fibrogenic effects in animal cirrhosis. There is inadequate data comparing portal models of liver fibrosis. This was attributed to an pressures in patients who bleed from esophageal (EV) inhibition of cell proliferation of activated HSCs. To or fundal varices (FV). We compared hepatic venous gain insight into the molecular pathways involved in pressure gradient (HVPG) in patients with EV and FV, SBN anti-fibrogenic effect, the current work was who were admitted to our institute with past or undertaken to evaluate the mechanisms behind the recent history of variceal bleeding. anti-proliferative and cell cycle arresting properties of Methods: Cirrhotic patients admitted from January SBN. 2015 to January 2016, with history of FV bleeding, Methods: The study was conducted on LX-2 human and who had undergone HVPG, were retrospectively Cirrhosis and Complications stellate cells treated with three concentrations of analyzed. Gastroesophageal varices type 2 (GOV2) SBN (10, 50 and 100 mM) for 24 and 96 h. Cell and isolated gastric varices (IGV1) were referred to death and viability was analyzed using Annexin as FV, together. These patients had none/small EV v/PI staining, cellular senescence was evaluated and the bleeding was attributed to GV. Patients with by b-galactosidase staining, expression of Akt, history of bleeding from EV (or GOV1), matched for p27, p53 was performed by Western blotting age, sex and MELD scores were included for com- and Ki-67 protein expression was evaluated by parison. All patients underwent standard evaluation immunocytochemisty. and management according to variceal status and Results: SBN inhibits dose and time-dependently LX- severity of underlying cirrhosis. HVPG was done 2 cell proliferation. SBN up regulated the protein after control of bleeding in admitted patients. expressions of p27 and p53. Such regulation was Beta-blockers were stopped for at-least 7 days prior correlated to an inhibition of both downstream to procedure. HVPG was compared between the two Akt and their phosphorylated protein signaling groups. and Ki-67 protein expression. Analysis of sirtuin Results: A total of 80 patients (84% males, median age activity also seems to be correlated to SBN-inhibited 51 [range 26–87]) years were included in our study. proliferation of LX-2 cells. Most common etiology of cirrhosis was cryptogenic/ Conclusion: Our data indicate that the anti-prolif- NASH (48%) followed by alcohol (37%) and viral (15%). erative effect of SBN measured in LX-2 human stellate The median MELD score was 11 (range 6–32). Twenty- cells is related to inhibition of the expression of three patients bled from FV and 57 patients bled from various cell cycle targets including p27, Akt and sir- EV. Both groups were comparable across demographic tuin signalling. and biochemical parameters. The median HVPG in FV

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group was 16.0 (range 11.0-26.5) mmHg, which was telephonically. The clinical, laboratory and survival significantly lower than median HVPG in EV group data were compared between the two groups and (19.0 [range 10.0–30.0] mmHg, P =0.05). analyzed. Results: Out of 211 patients with cirrhosis, 100 patients had AC and 49 patients had CC. Patients with AC were younger (45.32 Æ 9.6 years vs 51.9 Æ 12.38, P = 0.046), with higher incidence of high grade encephalopathy (24% vs 11%, P = 0.046), ascites (86% vs 71%, P = 0.030), higher values of serum bilirubin (4.69 Æ 3.97 vs 2.79 Æ 3.37 mg%, P = 0.005), INR (1.69 Æ 1.14 vs 1.34 Æ 0.31, P = 0.040), AST (149.25 Æ 115.77 vs 66.06 Æ 110.84, P = 0.001), ALT (55.67 Æ 35.47 vs 38.17 Æ 50.9, P = 0.010) than patients with CC. The mean serum sodium was lower in AC (132.42 Æ 6.02 vs 135.14 Æ 6.1, P = 0.010), whereas mean CTP (10.42 Æ 1.76 vs 9.71 Æ 1.83, Conclusion: Patients with FV bleeding have lower P = 0.020) and MELD (18.07 Æ 6.98 vs 14.18 HVPG compared to patients with EV bleeding. Æ 5.33, P = 0.001) were higher than patients with This implies that patients with FV may bleed even CC. 30% (n = 30) of alcoholic cirrhosis and 23% at lower portal pressures as compared to patients with (n = 11) (P = 0.4) of cryptogenic cirrhosis died during EV. Hence these patients require aggressive treatment. this period. On multivariate analysis, age and MELD score were found to be independent predictors for iroi n Complications and Cirrhosis CONFLICTS OF INTEREST survival in CC, whereas presence of upper GI bleeding and encephalopathy in AC patients. The authors have none to declare. Conclusion: The CC patients were older with com- Corresponding author: Ashish Kumar. paratively less severe liver disease (bilirubin, INR, CTP E-mail: [email protected] and MELD) than AC. Age and MELD score were independent predictors of survival in CC, whereas http://dx.doi.org/10.1016/j.jceh.2016.06.089 presence of upper GI bleeding and encephalopathy were independent predictors of survival in AC patients. 23 CONFLICTS OF INTEREST COMPARISON OF CLINICAL AND The authors have none to declare. LABORATORY PROFILE BETWEEN ALCOHOLIC AND CRYPTOGENIC Corresponding author: Suryakanta Parida. CIRRHOSIS IN COASTAL ODISHA E-mail: [email protected] Suryakanta Parida, Preetam Nath, Ayaskanta Singh, http://dx.doi.org/10.1016/j.jceh.2016.06.090 Girish Pati, Shivaram Singh, Kaibalya Dash, Sambit Behera, Prasanta Parida 24 Shri Ramachandra Bhanj Medical College, Cuttack, India SPONTANEOUS BACTERIAL PERITONITIS Background and Aim: Patients with cryptogenic BY BURKHOLDERIA CEPACIA COMPLEX: A cirrhosis (CC) have different clinico-biochemical pro- RARE, DIFFICULT TO TREAT INFECTION IN file and survival pattern than cirrhosis due to other etiologies. The aim of the study was to compare DECOMPENSATED CIRRHOTIC PATIENTS clinical and laboratory profile between hospitalised Pramod Kumar, Sunil Taneja, Vikas Gautam, alcoholic (AC) and CC cases in a tertiary care hospital Ajay Duseja, Virendra Singh, Radha K. Dhiman, in Coastal Odisha. Yogesh K. Chawla Methods: This was a case control study in which the data of alcoholic and cryptogenic cirrhotic patients Postgraduate Institute of Medical Education and Research, Chandigarh, India admitted in department of gastroenterology, SCB Medical College, from April 2015 to April 2016 were Background and Aim: Spontaneous bacterial peri- extracted from case sheets. Their survival was enquired tonitis (SBP) is a frequent and severe complication of

decompensated cirrhosis. Burkholderia cepacia com- Dhawal Vyas, Ram P. Singh, Gaurav Gupta, plex (Bcc) is non-fermenting Gram-negative bacillus Sandeep Nijhawan with high intrinsic antibiotic resistance and has been rarely reported to cause SBP in decompensated cir- SMS Medical College, Jaipur, India rhosis. This study was done to evaluate the clinical presentation of cirrhotic patients with SBP due to Bcc Background and Aim: Current consensus recom- and to determine its impact on clinical outcome. mend screening cirrhotics patients with endoscopy Methods: This is a retrospective, observational study to detect esophageal varices and to begin prophylactic management in patients having large esophageal conducted during the period from 1st January 2013 fi through 31st March 2015. Medical records and varices. This study was aimed at nding non-invasive microbiology laboratory files were reviewed to iden- parameters which could identify the presence of large tify all cases of Bcc associated spontaneous bacterial esophageal varices. peritonitis among patients hospitalized at the Liver Methods: In this prospective study 191 patients with Intensive Care Unit and analyzed. liver cirrhosis without a history of prior gastrointest- Results: During the study period, out of 252 SBP inal bleed were studied. Epidemiological, clinical, patients, 11 (4.3%) patients with a positive ascitic fluid laboratory, and ultrasound parameters were assessed. culture for Bcc were identified. Pain abdomen was the Esophageal varices were divided as small and large on endoscopy. Univariate and multivariate analysis using predominant symptom present in 9 (81%) patients fi followed by hepatic encephalopathy in 7 (63%) binary logistic regression was done to nd indepen- patients. Acute kidney injury (AKI) was universally dent predictors for the presence of large esophageal present, seen in 6 (54%) patients at the time of pre- varices. sentation and 4 (36%) patients developed AKI during Results: 191 patients (151 males; median age 43.5 yrs) hospital stay. The mean CTP score was 11.2 Æ 1.1 with liver cirrhosis, [135 had large and 56 had small (10–13), and the mean MELD was 24.3 Æ 5.9 (14– varices on multivariate analysis portal vein diameter >13 mm (odd’s ratio [OR] 62.495, 95% confidence 35). The mean SOFA and APACHE II score at pre- – P sentation were 11 Æ 4.2 (4–18) and 19.4 Æ 5.2 (11–28) interval [CI] 10.583 369.038), < 0.001S, AUC — — 0.929], splenic diameter >120 mm (OR 34.835, 95% respectively. A total of 8 (72%) patients (6 ACLF, 2 – P NASH) succumbed to the illness during hospitaliza- CI 8.791 138.032, < 0.001S, AUC 0.922) and platelet count <1 lakh/mm3 (OR 11.871, 95% CI 2.515– tion due to severe sepsis and multiorgan dysfunction P fi and 3 (27%) patients are doing well on follow-up after 56.036, = 0.002S, AUC 0.684) emerged as signi cant Cirrhosis and Complications 3months. risk factors in the present study. Conclusion: Low platelet count, spleen diameter, and Conclusion: Infections caused by Bcc should be confi sidered in patients requiring multiple admissions in portal vein diameter are signi cant predictors of large ICU and repeated use of antibiotics. Critically sick grade esophageal varices. They may be considered as ICU cirrhotic patients with SBP and non-response to non-invasive predictors for large grade varices. conventional antibiotics should be evaluated for such CONFLICTS OF INTEREST difficult to treat organisms because of their associated high mortality. The authors have none to declare. CONFLICTS OF INTEREST Corresponding author: Sandeep Nijhawan. E-mail: [email protected] The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2016.06.092 Corresponding author: Sunil Taneja. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.091 26 RELATIONSHIP OF SERUM SODIUM WITH COMPLICATIONS OF CIRRHOSIS 25 PROSPECTIVE STUDY IN TERTIARY MEDICAL CENTER OF RAJASTHAN CAN NON-INVASIVE PARAMETERS HELP US Ram P. Singh, Dhawal Vyas, Gaurav Gupta, TO PREDICT LARGE ESOPHAGEAL Hemendra Bharadwaj, Sandeep Nijhawan VARICES? RESULTS FROM A TERTIARY MEDICAL CENTRE OF RAJASTHAN SMS Medical College, Jaipur, India

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Background and Aim: Hyponatremia is an indepen- cirrhosis; however, it is limited by donor organ avail- dent predictor of mortality in patients of cirrhosis, ability, high cost, operative risk, and long-term com- but its clinical importance and prevalence is unclear. plications. Besides, many patients die while on liver In this study we aimed at identifying prevalence of transplant waiting list. The contribution of granulo- hyponatremia and relationship between serum cyte colony stimulating factor (GCSF) induced mobi- sodium levels and severity of ascites and complica- lization of bone marrow stem cells to tissue tions of cirrhosis. regeneration has been recognized and there is con- Methods: In this prospective study 191 patients with siderable interest in the potential benefits of GCSF liver cirrhosis were analyzed for demographic, clinical therapy in patients with advanced liver disease. We and biochemical parameters. evaluated the efficacy of GCSF therapy in patients Results: The prevalence of low serum sodium with decompensated cirrhosis, in an open-labeled concentration as defined by a serum sodium concen- randomized control trial. tration 135 meq/l, 130 meq/l was 12% and 40% Methods: Consecutive patients with decompensated respectively. Low serum sodium 135 was associated cirrhosis were randomized to receive either GCSF with severe ascites as assessed by frequent need for 5 mg/kg b.i.d. for 5 days plus standard medical ther- paracentesis and impaired renal function, compared apy (SMT) (GCSF + SMT group) or standard medical with normal serum sodium levels. Low serum sodium therapy alone (SMT alone group). The outcome was levels have also shown association with more frequent assessed at 6-month follow-up. episodes of hepatic encephalopathy, spontaneous Results: A total of 126 patients [median age 53 (range bacterial peritonitis, and hepato renal syndrome, 31–76) years, 85% males] received GCSF + SMT and but not gastrointestinal bleeding. These complica- 127 patients received SMT alone. The baseline med- tions were more frequently seen in patients with ian Child–Turcotte–Pugh (CTP) score and MELD iroi n Complications and Cirrhosis serum sodium less than 130 meq/l but the frequency scores were 10 (range 7–13) and 16 (range 4–34), was also increased with mild reduction in serum respectively. Baseline characteristics were similar in sodium (131–135 meq/l). both groups. All patients were able to successfully Conclusion: Hyponatremia in cirrhotics is associated complete the 5-day therapy with GCSF without any with severe ascites with repeated paracentesis and significant adverse effects. Compared to baseline increase frequency of hepatic encephalopathy, sponta- values, there was a significant increase in median neous bacterial peritonitis and hepato renal syndrome. CD34 count post therapy (1 Â 106/cumm versus 11 Â 106/cumm; P < 0.01). At the end of 6 months CONFLICTS OF INTEREST follow-up, 16 patients had died and 10 patients were lost to follow-up in the GCSF + SMT group; while 33 The authors have none to declare. patients had died and 12 patients were lost to follow up in SMT alone group. According to intention-to- Corresponding author: Sandeep Nijhawan. treat analysis survival was significantly higher in E-mail: [email protected] GCSF + SMT group (P = 0.02). At 6 months signifi- http://dx.doi.org/10.1016/j.jceh.2016.06.093 cantly more number of patients (66%) had showed improvement in CTP score or could maintain their baseline CTP score in GCSF + SMT group as compared to in SMT alone group (52%, P = 0.03). 27 Conclusion: A 5-day course of GCSF in decompensated cirrhosis leads to improvement in survival and GRANULOCYTE COLONY STIMULATING clinical outcome at 6-month follow up. Further stu- FACTOR MOBILIZES CD34 CELLS AND dies are needed to study whether repeated periodic IMPROVES SURVIVAL OF PATIENTS WITH GCSF courses can further increase the survival and DECOMPENSATED CIRRHOSIS: A decrease the mortality of patients on liver transplan- RANDOMIZED CONTROLLED TRIAL tation waiting list. Ritesh Prajapati, Anil Arora, Praveen Sharma, CONFLICTS OF INTEREST Naresh Bansal, Vikas Singla, Ashish Kumar

Institute of Liver, Gastroenterology, and Panceaticobiliary Sciences, Sir The authors have none to declare. Ganga Ram Hospital, New Delhi, India Corresponding author: Anil Arora. E-mail: [email protected] Background and Aim: Liver transplantation is the only curative treatment modality for decompensated http://dx.doi.org/10.1016/j.jceh.2016.06.094

28 29

STUDY OF COMMON NOD2 GENE NORMAL VALUES FOR PSYCHOMETRIC POLYMORPHISMS AS A RISK FACTOR FOR TESTS, FOR KERALA; AND ITS EVALUATION DEVELOPMENT OF COMPLICATIONS IN IN CIRRHOTIC PATIENTS INDIAN PATIENTS OF LIVER CIRRHOSIS Jeesemon Jose, Mathews Choracken, Roy Mukkada, Manish Tiwari, Mohd T. Noor, Nivesh Seehra, Antony Chettupuzha, Jose Francis, Abraham Koshy Sunil Jain, Ravindra Kumar, Bhagwan S. Thakur VPS Lakeshore Hospital, Cochin, India Sri Aurobindo Medical College and Post Graduate Institute, Indore, India Background and Aim: Normal values of tests used Background and Aim: Nucleotide-binding oligo- for minimal hepatic encephalopathy (MHE), is merization domain-containing protein 2 (NOD2) dependent on education and age. In addition, it needs gene polymorphism promotes bacterial translocation to be established for each society. Normal values for (BT), which plays a crucial role in the pathogenesis of Kerala, South India, has not been established. The many complications of cirrhosis. These polymorph- aim of the study is to establish normal values for each isms are recently identified as an important genetic psychometric test used as part of MHE assessment for risk factor for the development of spontaneous bac- Kerala, South India and to use these to determine the terial peritonitis (SBP) in western patients of liver prevalence of minimal hepatic encephalopathy in cirrhosis. Our aim was to see the association of these cirrhotic patients and to correlate with clinical polymorphisms with SBP and other major complica- parameters. tions of cirrhosis involving BT in Indian patients. Methods: MHE was assessed using Psychometric Methods: Ninety-seven consecutive patients of Hepatic Encephalopathy Score and critical flicker decompensated liver cirrhosis and 45 healthy con- frequency in 68 controls and 82 cirrhotics. Multi- trols were recruited. Baseline clinical and laboratory variate linear regression was used to establish age, parameters were analyzed. CTP (Child–Turcotte– sex and education adjusted normal values for con- Pugh) and MELD (model for end stage liver disease) trols. With the new cut off values, MHE was reas- score were calculated as a disease severity score. All sessed in cirrhotic patients. Clinical parameters patients and healthy controls underwent genetic test- (edema, ascites, bilirubin and varices) were correlated ing for three common NOD2 gene (R702W, G908R to MHE. Cirrhosis and Complications and 1007fs) polymorphisms. Association of these Results: Among controls, the psychometric tests, NOD2 gene polymorphisms with major complica- number connection test (NCT), figure connection tions of cirrhosis as well as with mortality of these test (FCT), digit symbol (DS), line tracing (LT) were patients was studied. dependent on age and education. None were inde- Results: Out of three common NOD2 gene poly- pendently correlated with sex. The linear correlations morphisms, only 1007fs gene variant was identified were: NCT = 42.5 + (age * 0.453) + (edu * À0.325), in six (6.18%) patients but none of the healthy con- FCT = 54.8 + (age * 0.137) + (edu * À0.337), trols showed any of three NOD2 gene polymorph- DS = 20.4 + (age * 0.532) + (edu * À0.289), LT = 112 isms. There was no statistically significant association + (age * 0.263) + (edu * À0.275). Serial dotting (SD) of common NOD2 gene polymorphisms with any and critical flicker frequency (CFF) were not depen- major complications of cirrhosis as well as with 6- dent on age or education. Upper limit of normal for month mortality. SD was 83 s (55 + (2 * 14), M + (2 * SD)). These Conclusion: Common NOD2 gene polymorphisms newly derived normal values were used to determine are not a significant genetic risk factor for develop- the presence of MHE in cirrhotics. ment of SBP and other major complications of cir- Conclusion: Normal values for psychometric tests rhosis as well as for poor prognosis in our cohort of are defined by this study, for Kerala. Indian population.

CONFLICTS OF INTEREST CONFLICTS OF INTEREST

The authors have none to declare. The authors have none to declare. Corresponding author: Mohd T. Noor. Corresponding author: Jeesemon Jose. E-mail: [email protected] E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.095 http://dx.doi.org/10.1016/j.jceh.2016.06.096

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30 CONFLICTS OF INTEREST

IS LOW DOSE SYNACTHEN TEST RELIABLE The authors have none to declare. IN DETECTING ADRENAL INSUFFICIENCY Corresponding author: Deni Joseph. IN CIRRHOSIS E-mail: [email protected] Deni Joseph, D. Krishnadas, A. Shanid, S. Sreejaya, http://dx.doi.org/10.1016/j.jceh.2016.06.097 K.S. Prasanth, K. Sreejith, Ramu Muraleedaran, S. Sandeep, Rathan Cyriac, K. Gaurav, S. Varun

Govt Medical College Trivandrum, Trivandrum, India 31 Background and Aim: To detect adrenal insufficiency in cirrhosis using low dose (1 mg) synacthen FACTORS PREDICTING FAILURE OF 3RD test and to compare it with, S. cortisol and salivary GENERATION CEPHALOSPORINS IN cortisol. Background adrenal insufficiency is very TREATMENT OF SPONTANEOUS common in CLD. Even in stable CLD patients various BACTERIAL PERITONITIS studies showed prevalence of cirrhosis varying from M. Ramu, Gopu R. Babu, K. Sreejith, Nikhil Suraj, 20 to 70%. Free cortisol is the most reliable method G. Chethan, T.S. Prasanth, Deni Joseph, A. Shanid, used for estimation of adrenal insufficiency. But it is S. Srijaya, Selwyn Noronha, D. Krishnadas expensive and time consuming. Salivary cortisol in various studies correlated well with free cortisol. Govt Medical College, Trivandrum, India Serum total cortisol may not be a reliable in detecting iroi n Complications and Cirrhosis adrenal insufficiency. Low dose (1 mg) synacthen test Background and Aim: Spontaneous bacterial peri- may be reliable and cost effective method in detecting tonitis (SBP) is the most prevalent bacterial infection adrenal insufficiency. in patients with cirrhosis. Cefotaxim has been con- Methods: Prospective observational study. 31 stable sidered the first choice of empirical antibiotic for the CLD patients admitted in medical gastro trivandrum treatment of SBP. Studies from different parts of were taken and S. total cortisol, salivary cortisol at world have reported significant rates of resistance 8 am was sent. Low dose (1 mg) synacthen was admi- to third-generation cephalosporins. The aim of the nistered i.v. to the patients at 8 am and S. total study is to find the factors predicting failure of 3rd cortisol at 8.30 am was also measured. Similar tests generation cephalosporins in treatment of SBP in were also done for 15 acute viral hepatitis patients. decompensated cirrhosis patients. Those with basal S. cortisol <4 mg/dl, post-synacthen Methods: Retrospective observational study by data <18 mg/dl were considered to have adrenal collection of all patients admitted with cirrhosis and insufficiency. SBP who were started on cefotaxim from January Results: Prevalence of adrenal insufficiency in stable 2015 to January 2016 were done. Multivariate logistic CLD using low dose synacthen was 40%. Prevalence of regression was used to determine independent pre- adrenal insufficiency in stable CLD using salivary dictors of third-generation cephalosporin resistance cortisol is 44%. Prevalence of adrenal insufficiency Results: 168 patients met the criteria for study inclu- in stable CLD using total was S. cortisol 12% which sion. 120 (71.42%) patients responded to cephalos- rose to 60% when higher cut off 10 mg/dl was used. porin therapy. 48 (28.57%) were non-responders. Similarly prevalence of adrenal insufficiency in a/c Alcoholic liver disease 113 (67%), NASH 36 (21%), viral hepatitis was 6%, 25% and 33% using S. cortisol, Hep B infection 26 (15%) were predominant cause low dose synacthen test and salivary cortisol. The of decompensated cirrhosis. 58 (48.3%) responders prevalence of adrenal insufficiency was more in those and 22 (44%) non-responders were on norflox pro- with alcohol as etiology of cirrhosis, MELD > 16 and phylaxis. H/o recent broad spectrum antibiotic usage Child C cirrhosis. was found in 24 (20%) responders and 17 (35.41%) Conclusion: Low dose synacthen test is a reliable test non-responders. On multivariate analysis MELD > 19 to detect adrenal insufficiency in cirrhosis. Prevalence P 0.001, OR 4.37 (95% CI 2.12–9.00), presence of of adrenal insufficiency in cirrhosis was 44%. Total hepatic encephalopathy P 0.014, OR 2.53 (95% CI serum cortisol at lower cutoff has high false negativity 1.2–5.3) and recent antibiotic usage P 0.01, OR 2.44 and higher cutoff has high false positivity. Low dose (95% CI 1.365–5.854) emerged as significant risk factor synacthen was found to have equally efficient com- for resistance to 3rd generation cephalosporins. pared to salivary cortisol in detecting AI in cirrhosis Conclusion: High MELD score, presence of encepha- and is very cost effective. lopathy and recent broad spectrum antibiotic usage

emerged as signiﬁcant risk factor for resistance to 3rd different (P < 0.001). ROC curve analysis demon- generation cephalosporins. These group of patients strated that serum ferritin 0.954, CLIF SOFA score with SBP should receive empirical treatment with 0.87, APACHE II 0.85, SOFA 0.80 calculated within higher antibiotics during admission. 24 hours of admission predicted 30 day mortality better than MELD (0.79), MELD Na (0.77), CTP CONFLICTS OF INTEREST (0.727). Conclusion: Oliguria, GI bleed, low MAP, platelet The authors have none to declare. count, bilirubin, lactate, pH serum creatinine and serum ferritin are good predictors of 30-day mortality. Corresponding author: M. Ramu. The CLIF SOFA should replace CTP and MELD to E-mail: [email protected] predict short term mortality in critically ill liver cir- http://dx.doi.org/10.1016/j.jceh.2016.06.098 rhotics. An ideal score may be the one which includes ferritin along with assessment of multi organ functioning

32 CONFLICTS OF INTEREST PROSPECTIVE EVALUATION OF PROGNOSTIC FACTORS IN CIRRHOTIC The authors have none to declare. PATIENTS REQUIRING INTENSIVE CARE Corresponding author: Rohit Maidur. E-mail: [email protected] Rohit Maidur, Sukanya Brugu, Nayana Joshi, Raghavendra Yarlagadda, Bubun Patel, http://dx.doi.org/10.1016/j.jceh.2016.06.099 Kunal Vyawahare, Gaurav Ratnaparkhi, Ajit Kumar

Nizam’s Institute of Medical Sciences, Hyderabad, India 33 Background and Aim: The mortality in subjects with critically ill liver cirrhosis ranges between 36 PREVALENCE OF MALNUTRITION AND and 86%. Various scoring systems and markers have FACTORS ASSOCIATED WITH IT, AMONG been used to predict mortality in this set of patients. NORTH INDIAN CIRRHOTICS PRESENTING Serum ferritin is a representative of consequence of TO A TERTIARY CARE CENTRE Cirrhosis and Complications cell stress and damage. The present study is intended Kaushal Madan, Esha Gupta, Leena Saju, to find the parameters that influence outcome in Pradeep Kumar, Maneesh Paliwal, Rajan Dhingra, cirrhotics requiring critical care. Divij Mehta, Richa Bhargava, Manju Yadav Methods: Consecutive liver cirrhosis patients admitted with critical illness in our ICU were enrolled Artemis Hospital, Gurgaon, India and followed for 30 days. Physiologic and lab parameters were obtained within 24 h of admission. Para- Background and Aim: Malnutrition is prevalent meters were compared among those who survived among cirrhotics. Limited data is available about the beyond 30 days and non-survivors. prevalence of and factors associated with malnutrition Results: Total of 84 subjects (females 7, males 77) among Indian cirrhotics. To study the prevalence of were studied. The mean age among survivors (45 malnutrition and factors influencing it, among cirrho- Æ 9.32) and non-survivors (50 Æ 8.067) was signifi- tics presenting to a tertiary care hospital in India. cantly different (P < 0.0001). The etiologies were alco- Methods: Consecutive cirrhotic patients presenting hol (76.1%), hepatitis B (8.3%), hepatitis C (4.7%), to Artemis Centre for Digestive and Liver diseases alcohol + viral hepatitis (n = 9). Main causes of hos- were enrolled. Nutritional status was assessed using, pitalization were ascites (n = 64), hepatic encephalo- BMI, mid-upper arm circumference (MUAC) and Tri- pathy (n = 53), AKI (n = 8), hematemesis (n = 8). ceps skin fold thickness (TSF). Patients with low Mortality rate at 30-day follow up was 66.7%. On MUAC (<23 cm) or low TSF (<11 mm for males multivariate analysis mean arterial pressure, platelet and <15 mm for females) were considered to be hav- count, pH, bilirubin, lactate, creatinine were signifi- ing malnutrition. Nutrient intake (adequacy of cal- cantly different (<0.05) among survivors and non- ories and protein) was assessed using food frequency survivors. Mean serum ferritin levels among survivors questionnaire and 24 h dietary recall. Factors (age, (368.17 + 113.8 ng/ml) beyond 30 days and those who sex, etiology, CTP class, MELD, food habits, ascites, did not (922 + 319.86 ng/ml) were significantly energy restriction and protein restriction) associated

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with malnutrition were analyzed using univariate and beta blocker usage were obtained before the analysis. initiation of treatment as well as changes in arterial Results: 44 patients with cirrhosis of liver between pressure during treatment were analyzed for their February and April 2016 were included. The mean age predictive value. was 52 (13.8) years and 81.8% (36) were males with a Results: Response to therapy (reduction in serum median BMI of 24 (16–36) kg/m2. HBV was the most creatinine <1.5 mg/dL at the end of treatment) was common etiology in 40.9% (18) cases. 18.2%, 59.1% and observed in 12 patients (40%) and was associated with 22.7% were in CTP class A, B and C respectively. Low an improvement in circulatory function. Independent MUAC was prevalent in 31.8% (14/44) and low TSF predictive factors of response to therapy were baseline was present in 71.7% (32/44) patients. Alcoholic etiol- serum bilirubin, baseline serum creatinine, and an ogy (57% vs 20%; P = 0.03) and protein restriction increase in mean arterial pressure of 5mmHgat (92.8% vs 63.3%; P = 0.06) were associated with low day 3 of treatment. The cutoff level of serum bilirubin MUAC. Vegetarian diet (68.6% vs 16.6%; P =0.005) that best predicted response to treatment was 8 mg/ was associated with low TSF. Proportion of patients dL (area under the receiver operating characteristic with low MUAC or low TSF were equally distributed in curve, 0.61; P < 0.001; sensitivity, 89%; specificity, the CTP categories (P = 0.15 and 0.70 respectively). The 61%). The cutoff level of serum creatinine that best nutrient intake was also similar between the CTP predicted response to treatment was 3 mg/dL (area categories. under the receiver operating characteristic curve, 0.72; Conclusion: Significant proportion of Indian cirrho- P < 0.012; sensitivity, 85%; specificity, 62%). Corre- tics, irrespective of severity have high prevalence of sponding values in patients with an increase in mean malnutrition. Alcoholic etiology, protein restriction arterial pressure 5mmHgor<5mmHgatday3 and vegetarian diet are associated with markers of were 64% and 23%, respectively. Previous use of beta iroi n Complications and Cirrhosis poor nutrition. blockers is not associated with response to treatment. Conclusion: Serum bilirubin, serum creatinine and CONFLICTS OF INTEREST an early increase in arterial pressure predict response to treatment with terlipressin and albumin in type 1 The authors have none to declare. HRS. No role of beta blockers in predicting response to treatment. Corresponding author: Kaushal Madan. E-mail: [email protected] CONFLICTS OF INTEREST

http://dx.doi.org/10.1016/j.jceh.2016.06.100 The authors have none to declare. Corresponding author: Kaibalya R. Dash. E-mail: [email protected] 34 http://dx.doi.org/10.1016/j.jceh.2016.06.101 STUDY ON THE PREDICTORS OF RESPONSE TO TERLIPRESSIN PLUS ALBUMIN IN HEPATORENAL SYNDROME 35 (HRS) TYPE 1 INFLUENCE OF BETA BLOCKERS ON Manasa, Girinadh, Muralikrishna Manne, COMPLICATIONS OF CIRRHOSIS Kaibalya R. Dash Kayalvizhi Rajini, T. Rajkumar Solomon, King George Hospital, Vishakapatnam, India Aravind Arumugham, Murali Ananthavadivelu, Balamurali Rangachari, Background and Aim: Terlipressin plus albumin is Muthukumaran Kalyanasundaram, an effective treatment for type 1 hepatorenal syn- Ramkumar Govindarajan, C. Vaishnavi Priyaa, drome (HRS), but approximately only half of the S. Kavitha patients respond to this therapy. The aim of this study was to assess predictive factors of response Kilpauk Medical College, Chennai, Tamilnadu, India to treatment with terlipressin and albumin in patients with type 1 HRS. Background and Aim: Non-selective beta blockers Methods: Thirty patients with cirrhosis and type 1 (NSBB) are said to be protective against spontaneous HRS were treated prospectively with terlipressin and bacterial peritonitis and worsen hepatorenal syn- albumin. Demographic, clinical, laboratory variables drome, refractory ascites and hepatic encephalopathy

in liver cirrhosis. We aimed to study the association of Postgraduate Institution of Medical Education and Research, beta blockers with these complications in our center. Chandigarh, India Methods: We performed a single center, retrospective analysis of 82 patients with liver cirrhosis who did or Background and Aim: Hepatic encephalopathy did not receive beta blockers and studied the occur- (HE) is associated with impaired health-related rence of spontaneous bacterial peritonitis, refractory quality of life in patients with liver cirrhosis. How- ascites, hepatorenal syndrome and hepatic encepha- ever, HE causing significant socioeconomic and lopathy at the Department of Digestive Health and emotional impact over the caregiver is not clearly Disease, Anna Nagar, Chennai. defined. This study was carried out to assess the Results: Total of 82 patients were studied who were overall emotional and socioeconomic burden of registered from a period of January 2009 to January minimal and overt HE over liver cirrhosis patients 2016. The group had more number of males which and their caregivers. accounted for 79.3% of the whole group. Out of 82 Methods: This cross-sectional study was conducted patients, 44 (55.2%) were on beta blockers and 38 at the tertiary health-care center, which included liver (46.3%) were not on beta blockers. The most common cirrhosis patients (n = 100) and their caregivers. etiology for cirrhosis in our group was ethanol (n =61, Demographic characteristics, socioeconomic data 74.39%). Frequency of complications in NSBB vs. non- (Kuppuswamy score), severity scores [Child–Tur- NSBB groups was as follows: spontaneous bacterial cotte–Pugh (CTP) score, model for end-stage liver peritonitis (NSBB = 34.1%, non-NSBB = 47.4%), disease (MELD) score], details of decompensations refractory ascites (NSBB = 13.6%, non-NSBB = 13.2%), were recorded and psychometric tests [psychometric hepatorenal syndrome (NSBB = 4.5%, non- hepatic encephalopathy score (PHES)] and question- NSBB = 15.8%) and hepatic encephalopathy naires for quantifying caregiver burden [perceived (NSBB = 15.9%, non-NSBB = 28.9%). The association caregiver burden (PCB) and Zarit burden interview of beta blockers with spontaneous bacterial peritoni- (ZBI)], assessing depression [Beck depression inven- tis, refractory ascites, hepatorenal syndrome and hepa- tory (BDI)], anxiety [Beck anxiety inventory (BAI)] tic encephalopathy were analyzed and the P-values and social support [interpersonal support evaluation were 0.221, 0.949, 0.087 and 0.155 respectively. No list-short form (ISEL-SF)] were carried out. statistically significant association between beta Results: One hundred cirrhotic patients (70% male, blockers use and any of these were observed. 23% with past HE, 53% with minimal HE, mean CTP Conclusion: This study indicates that non-selective

7.48, mean MELD 13.21) and their caregivers (66% Cirrhosis and Complications beta blockers may have no role in the occurrence of women, 81% spouse, 26.51 years mean relationship) spontaneous bacterial peritonitis, refractory ascites, were included. We demonstrated a statistically sig- hepatorenal syndrome and hepatic encephalopathy niﬁcant higher burden scores in caregivers of those in cirrhotics. patient who had past history of HE [PCB (74.63 vs. 66.15, P = 0.001), Zarit (27.93 vs. 21.11, P = 0.023), CONFLICTS OF INTEREST BDI (11.63 vs. 8.96, P = 0.082) and BAI (11.37 vs. 8.12, P = 0.027)]. Also the burden was higher in caregiver of The authors have none to declare. those patient who had minimal HE at time of study Corresponding author: Kayalvizhi Rajini. compared to those without [PCB (70.74 vs. 65.85, P P E-mail: [email protected] = 0.027) and ZBI (26 vs. 19.51, = 0.015)]. The caregiver scores correlated well with each other and http://dx.doi.org/10.1016/j.jceh.2016.06.102 with the severity scores (CTP and MELD) and nega- tively correlated with Kuppuswamy score. The variables associated with ZBI were PCB (<0.001), ISEL-SF (<0.001) and BAI (<0.024). Similarly, the variables 36 associated with PCB were ZBI (<0.001), BAI (<0.001), no of admissions in past (0.001), CTP BURDEN OF CIRRHOSIS AND MINIMAL (<0.001) and MELD (0.020). AND PAST HISTORY OF OVERT HEPATIC Conclusion: This cross-sectional study demon- ENCEPHALOPATHY ON PATIENTS AND strated the presence of higher caregiver burden in CAREGIVERS cirrhotic patients with past history of HE and those who had minimal HE at the time of study. This is the Deepa Shrestha, Radha K. Dhiman, Sandeep Grover, ﬁ Sunil Taneja, Ajay Duseja, Yogesh K. Chawla rst study to demonstrate the burden over the caregiver of patients with minimal HE.

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CONFLICTS OF INTEREST 95% PrI, 3.64–8.73), probiotics + lactulose (OR 4.72; 95% PrI, 1.22–18.28), LOLA (OR, 4.43; 95% PrI, 2.39– The authors have none to declare. 8.22), PPS (OR 4.37; 95% PrI, 2.66–7.19) and BCAA – fi Corresponding author: Radha K. Dhiman. (OR 2.16; 95% PrI, 1.03 4.56), showed signi cantly E-mail: [email protected] higher reversal of minimal HE compared to placebo or no intervention. Between the active treatments, http://dx.doi.org/10.1016/j.jceh.2016.06.103 rifaximin is superior to BCAA (OR 0.27; 95% PrI, 0.10–0.69), PPS (OR 0.54; 95% PrI, 0.28–1.03), LOLA (OR 0.54; 95% PrI, 0.26–1.14), probiotics + lactulose (OR 0.58; 95% PrI, 0.14–2.38, lactulose (OR 0.69; 95% 37 PrI, 0.38–1.25). Likewise, LOLA (OR 0.16; 95% PrI, 0.04–0.64), lactulose (OR 0.21; 95% PrI, 0.09–0.48), COMPARATIVE EFFECTIVENESS OF PPS (OR 0.25; 95% PrI, 0.11–0.59), but not rifaximin DIFFERENT PHARMACOLOGICAL (OR 0.44; 95% PrI, 0.09–2.04) significantly reduced INTERVENTIONS FOR THE TREATMENT OF the risk of development of overt HE when compared MINIMAL HEPATIC ENCEPHALOPATHY: A to placebo or no treatment. In the network metaa- SYSTEMATIC REVIEW WITH NETWORK nalysis, for reversal of minimal HE, moderate quality META-ANALYSIS evidence supported that rifaximin followed by lactulose were the most effective interventions. For pre- Radha K. Dhiman, Kiran K. Thumburu, Madhu Chopra, vention of overt the HE, lactulose (moderate quality) Usha Dutta, Meenu Singh, Sunil Taneja, Ajay Duseja, followed by LOLA (low quality) were the most effec- Yogesh K. Chawla tive interventions. iroi n Complications and Cirrhosis Postgraduate Institute of Medical Education & Research, Chandigarh, Conclusion: While rifaximin alone was the most India effective intervention for reversal of minimal HE, lactulose (moderate quality) is effective both in rever- Background and Aim: Minimal hepatic encephalo- sal of minimal HE and in reducing the risk of devel- pathy (HE) is associated with impaired quality of life opment of overt HE. and increased progression to overt HE. We assessed the comparative effectiveness of pharmacological CONFLICTS OF INTEREST interventions for the reversal of minimal HE and for prevention of development of overt HE through The authors have none to declare. network meta-analysis combining direct and indirect Corresponding author: Radha K. Dhiman. treatment comparisons of randomized clinical trials E-mail: [email protected] (RCTs). Methods: We performed a systematic search of the http://dx.doi.org/10.1016/j.jceh.2016.06.104 PubMed, EMBASE, OvidSP and CENTRAL databases for RCTs of adults with minimal HE that compared the effectiveness of active interventions [lactulose, 38 rifaximin, L-ornithine L-aspartate (LOLA), pre-/pro-/ synbiotics (PPS), branched chain amino acids SURVIVAL BENEFIT OF VITAMIN D (BCAA), alone or in combination] with each other REPLACEMENT ON DEFICIENT or placebo. We used Bayesian network metaanalysis DECOMPENSATED CIRRHOSIS to combine direct and indirect evidence to estimate Sharad K. Jha odds ratios (ORs) between treatments, and used grading of recommendations assessment, develop- Indira Gandhi Institute of Medical Sciences, Patna, India ment and evaluation criteria to appraise quality of evidence. Background and Aim: Low levels of vitamin D are Results: We identified 27 RCTs (2056 patients) com- associated with adverse outcome in various disorders. paring 5 different interventions for reversal of mini- However role of Vitamin D deficiency in prognosis of mal HE and 21 RCTs (1162 patients) comparing 4 decompensated cirrhosis has not been clearly estab- different interventions for the prevention of develop- lished. The purpose of this study was to assess the ment of overt HE. In network meta-analysis, in the levels of vitamin D in decompensated cirrhotic order of superiority, rifaximin [OR 8.14; 95% predic- patients and effect of vitamin D replenishment on tive interval (PrI), 4.49–14.74], lactulose (OR 5.64; the mortality.

Methods: 100 decompensated cirrhotic patients Background & Aim: Lactulose is a cornerstone of (CTP10) of any etiology having deficient vitamin treatment of hepatic encephalopathy (HE). However, D were randomly divided into two groups of 50 it is often poorly tolerated, over a third of patients patients each. One group received vitamin D replen- being non-compliant. This is one of the major rea- ishment (Intramuscular cholecalciferol 3,00,000IU as sons for its limited use for minimal HE(MHE) and loading dose. Maintenance dose 800IU/day oral) and primary prophylaxis of HE. Interestingly, Indian other group received placebo. The groups were com- patients tolerate lactulose very well with excellent pared for effect of treatment on mortality. compliance. We aim to understand the perception Results: The mean age of the patients in the treat- of Indian patients towards lactulose with a Knowl- ment group and control was 46.2 years (Æ14.93) and edge, Attitude and Practice(KAP) model. 43.28 years (Æ12.53) respectively. Most common Methods: We recruited 62 patients with cirrhosis on etiology of decompensated CLD was ethanol in both lactulose as primary or secondary prophylaxis for HE. treatment (n=19; 38%) and control (n=24; 48%) They were questioned regarding their KAP for lactu- groups. 80% of the patients in both groups had lose. Knowledge was assessed by their understanding history of jaundice at the baseline screening (p = of need of lactulose. Attitude constituted of their 0.579). Almost all patients of both groups had com- outlook towards the side effects, and Practice plain of ascites (p = 1.00). The proportion of survival involved their level of compliance with lactulose ther- in treatment group (69%) was higher as compared to apy as assessed by a medication adherence control group (64%), but the difference was not sta- questionnaire. tistically significant (p = 0.389). Also the mean survi- Results: Of the 62 patients surveyed, 46 were males. val days in treatment group was 155 days (95% CI; The mean age was 50.45. Median Child Pugh and 142–167, as compared to mean duration of survival in MELD scores were 7 and 14 respectively. 31 were on control group ie. 141 days (95% CI; 125–157. The primary prophylaxis for HE. 57 (92%) patients per- mean survival duration was not statistically signifi- ceived lactulose as an important part of their treat- cant (p = 0.1687). ment. 59 (95%) did not have a problem in continuing Conclusion: Vitamin D deficiency is very common in lactulose. 52 felt 2–3 stools/day was normal for them. cirrhotic patients regardless of etiology of liver dis- 7(11%) occasionally forgot to take lactulose, and 4 ease. Replenishment of vitamin D along with calcium confessed they were careless towards medication. 17 supplementation showed a trend towards survival (27%) stopped lactulose when they felt better. 12 improvement in cirrhotic patients. (29%)stoppedmedicationwhenpoorlytolerated, of which 8 were on primary prophylaxis. The fre- Cirrhosis and Complications CONFLICTS OF INTEREST quency of side-effects reported were similar in patients who received lactulose as primary or second- The author has none to declare. ary prophylaxis (P = 0.12). No patient on secondary prophylaxis reported stopping lactulose due to side Corresponding author: Sharad K. Jha. effects. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.178 Table 1 Side Effect Profile Of Lactulose. N = 62 No Bothersome Bothersome, Poorly bothersome but tolerable leading to tolerated, 39 symptoms missed wish to LACTULOSE TOLERABILITY AND ADVERSE doses discontinue EFFECT PROFILE IN INDIAN PATIENTS Frequency 44 14 4 0 of Stools WITH CHRONIC LIVER DISEASE – A Bloating/ 45 16 1 0 KNOWLEDGE, ATTITUDE AND PRACTICE Gas STUDY Taste 53 8 1 0 Sahaj Rathi, Madhu Chopra, Sunil Taneja, Ajay Duseja, Nausea 59 3 0 0 Yogesh K. Chawla, Radha K. Dhiman Abdominal 59 3 0 0 Pain Post Graduate Institute of Medical Education and Research, Chandigarh, India

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cirrhosis patients. Liver stiffness measurement (LSM) is tested for prediction of hepatic encephalopathy, so that preventive measure could be taken or enhanced. Methods: A cross sectional study has been done enrolling consecutive 50 patients having cirrhosis in which fibroscan is not contraindicated anyway. History of hepatic encephalopathy developed within last three months and patients got admitted with hepatic encephalopathy considered as hepatic encephalopathy positive case. Results: A total of 50 patients evaluated. Among them 31(62%) were male, mean age was 35.2 years (18–70 years). Hepatitis B was the leading cause (76%), NASH contributed 9% which was higher than HCV (6%). Irrespective of triggering factors 27(54%) patients had HE. Liver stiffness measurement corre- lates significantly (P < 0.05). ROC curve analysis reveals Area under the curve 0.897, sensitivity were 82.14%, specificity 81.82%, negative predictive value Figure 1 Overall Side Effect Profile. 78.26%, positive predictive value 85.19% taking liver stiffness 29.3kpa as cut off value. Conclusion: Socio-cultural differences in perception Conclusion: Liver stiffness measurement can be a iroi n Complications and Cirrhosis of normal stool frequency may be behind greater good predictor of hepatic encephalopathy and may acceptability of lactulose in our population. Thus, alarm attending physician and patients to combat lower threshold of prescribing lactulose may be jus- hepatic encephalopathy. tified in patients with MHE and as primary prophylaxis. CONFLICTS OF INTEREST

CONFLICTS OF INTEREST The authors have none to declare.

The authors have none to declare. Corresponding author: Ahmed Lutful Moben. E-mail: [email protected] Corresponding author: Radha K. Dhiman. http://dx.doi.org/10.1016/j.jceh.2016.06.180 E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.179 41

TADALAFIL, A PHOSPHODIESTERASE-5 40 INHIBITOR, IMPROVES ERECTILE PREDICTION OF HEPATIC DYSFUNCTION IN PATIENTS WITH LIVER ENCEPHALOPATHY BY LIVER STIFFNESS CIRRHOSIS MEASUREMENT WITH FIBROSCAN IN Jitender Thakur, Sandeep Grover, Sahaj Rathi, PATIENTS WITH CIRRHOSIS OF LIVER Madhu Chopra, Sunil Taneja, Ajay Duseja, Ahmed Lutful Moben 1, Mohammad Noor-E-Alam 2, Yogesh Chawla, Anil Bhansali, Radha K. Dhiman 3 2 4 M.A. Rahim , Faiz Ahmad Khondoker , Farjana Majid , Departments of Hepatology, Psychiatry and Endocrinology, 5 Mamun Al Mahtab Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India 1Kurmitola General Hospital, Dhaka, Bangladesh, 2Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh, 3Abdul Malek Ukil Medical college, Noakhali, Bangladesh, 4Taerunnessa Memorial Medical College, Background and aim: Erectile dysfunction (ED) is Tongi, Gazipur, Bangladesh, 5Bangabandhu Sheikh Mujib Medical common in patients with liver cirrhosis. Though ED University, Dhaka, Bangladesh leads to a signiﬁcant deterioration in the quality of life, it is often neglected by most caregivers as well as Background & Aim: Hepatic encephalopathy (HE) is researchers. This study evaluates the prevalence of ED a very common and detrimental complication of liver in patients with cirrhosis, associated factors, and

response to treatment with Tadalafil, a phosphodies- a significant improvement in IIEF scores after the terase-5 inhibitor. treatment for 4 weeks with Tadalafil (baseline 15.1 Methods: Sixty male patients with Child-Turcotte- Æ 5.6, 4 weeks 22.0 Æ 3.4; P < 0.001; Figure); 11 Pugh (CTP) score between 5 and10 and no evidence of (44%) patients demonstrated resolution. There was overt hepatic encephalopathy (HE) were studied. ED no significant difference in the testosterone levels was assessed by International Index of Erectile Func- between patients with or without ED. tion (IIEF) questionnaire, and the patients were Conclusion: ED is common among patients with divided into 2 groups on the basis of presence (ED liver cirrhosis. Tadalafil is effective in improving +) or absence (ED-) of ED. Minimal HE was diagnosed ED in these patients. by Psychometric Hepatic Encephalopathy Score À (PHES 5). Patients who had IIEF score < 25 were CONFLICTS OF INTEREST given Tadalafil, a Phosphodiesterase-5 inhibitor, 10 mg daily for 4 weeks. The authors have none to declare. Results: The mean age of the participants was 45.2 Æ 7.8 yrs. Mean CTP score was 6.4 Æ 1.7 and median Corresponding author: Radha K. Dhiman. MELD score was 11 (Range 7–30). 27 (45%) patients E-mail: [email protected] had compensated cirrhosis and 45 (75%) patients had http://dx.doi.org/10.1016/j.jceh.2016.06.181 alcohol as etiologic factor. 21 (35%) patients were found to have minimal HE. 25 (41.7%) patients had an IIEF score of <25, suggestive of ED. Patients with ED were more likely to be smokers (P = 0.07), 42 had ascites (P = 0.04), had more use of diuretics (P = 0.03) and had a higher serum creatinine PREVALENCE OF INFECTIONS IN ACUTE (P = 0.03). Multivariable analysis demonstrated that DECOMPENSATION OF CIRRHOSIS: A only smoking (P = 0.04, OR 3.75) was independently TERTIARY CARE CENTRE associated with the presence of ED (Table). There was Tarana Gupta, Dibya Lochan, Sahaj Rathi, Ajay Duseja, Table Multivariable analysis. Sunil Taneja, Yogesh K Chawla, Radha K. Dhiman Predictors Odds ratio 95% CI p-value Department of Hepatology, Postgraduate Institute of Medical Education

CTP score 1.44 0.93–2.24 0.10 and Research, Chandigarh 160012, India Cirrhosis and Complications Ascites 0.70 0.14–3.61 0.67 Serum Sodium 1.10 0.91–1.34 0.35 Background and Aim: Infections are the most com- Serum Creatinine 0.12 0.01–1.09 0.06 mon cause of acute decompensation of cirrhosis. The Diabetes 2.93 0.47–18.05 0.24 present study was conducted to evaluate incidence of 3.75 1.27–11.10 0.04 bacterial infections in acute decompensation of cir- Smoking rhosis, pathogens involved and their impact on 7.35 0.58–91.75 0.12 Use of Beta blocker prognosis. Use of Diuretics 2.08 0.35–12.35 0.49 Methods: It was a prospective study, which enrolled 179 inpatients of acute decompensation of cirrhosis admitted between July 2013 and October 2015. Clin- ical and microbiological data were recorded. Results: Out of 179 patients, 102 (56.9%) patients were found to have bacterial infections. Out of these, SBP was most common infection in 65 (36%) followed by pneumonia, UTI, SBE and cellulitis in 9 (5%), 8 (4.5%), 4 (2.2%) and 2 (1.1%) respectively. Community acquired infections and nosocomial infections were present in 85 (83.3%) and 17 (16.6%) patients at admission respectively. Low serum albumin (mean 2.7 g/dLvs 2.9 g/dL; P = 0.015) and low serum sodium (129.8 mEq/L vs 132.4 mEq/L; P = 0.015) were present in patients with infection than without infection indicating more advanced liver disease. Escherichia coli Figure 2 Improvement in IIEF scores. was the most common causative

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organism for SBP (14; 21.5%), UTI (5; 45.5%) and Conclusion: Infections are most common cause of bacteremia (3; 20%) followed by Acinetobacter in blood acute decompensation. SBP is most common infec- and sputum and Enterococcus in blood and urine. tion and E coli is most common causative agent at Other causative organisms were Streptococcucs pneumo- admission. nia, Klebsiella pneumonia, Aeromonas hydrophila Staphy- lococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia Crysobacterium. and There was no difference CONFLICTS OF INTEREST in 28- and 90-day mortality due to presence or absence of infection at admission. Multivariate ana- The authors have none to declare. lysis demonstrated that the severity of liver disease was independent factor of mortality. http://dx.doi.org/10.1016/j.jceh.2016.06.182 iroi n Complications and Cirrhosis

Liver Transplantation

1 trimethoprime-sulfamethoxazole for up to 6 months improves survival. NOCARDIA LIVER ABSCESS – AN UNCOMMON INFECTION POST LIVER TRANSPLANT CONFLICTS OF INTEREST Pavan Hanchanale, Mayank Jain, Joy Varghese, The authors have none to declare. Venkataraman Jayanthi, Mohamed Rela Corresponding author: Joy Varghese. Global Health City, Chennai, India E-mail: [email protected]

Background: Nocardiosis is a rare, localised or dis- http://dx.doi.org/10.1016/j.jceh.2016.06.061 seminated, bacterial infection caused by aerobic acti- nomyces. It commonly affects immunocompromised hosts. With increasing load of post transplant patients the world over, this infection has been 2 reported with increasing frequency. OUTCOMES OF PERCUTANEOUS BILIARY Case Report: A 59-year-old gentleman underwent living donor liver transplant for ethanol related ESLD INTERVENTIONS IN BILIOENTERIC in our hospital. Immediate post OP period was STRICTURES AFTER LIVING DONOR LIVER uneventful. After 6 weeks post transplant he presented TRANSPLANT IN PAEDIATRIC PATIENT with abdominal pain and low grade fever. General POPULATION examination was unremarkable except for minimal Abhay K. Kapoor, Neelam Mohan, tenderness over right hypochondrium. His baseline Anubhav Khandelwal, Sanjay Baijal laboratory evaluation revealed hemoglobin 8.7 gm%, leukocyte count 7170/cumm, platelets 176,000/cmm. Medanta-The Medicity, Gurgaon, India Liver function revealed total bilirubin 0.46 mg/dL, Liver Transplantation AST 14 m/L, ALT 25 m/L, albumin 2.6 g/L, alkaline Background and Aim: Biliary complications (BC) in phosphatase 74 m/L, GGT 78 m/L and INR 1.2. Tacro- paediatric population after living donor liver trans- limus level 6 mg/dL. Ultrasound abdomen revealed plantation (LDLT) are responsible for significant well-defined thin walled hypoechoic lesion in segment morbidity and can lead to graft rejection. The overall VII measuring 53 mm Â 58 mm liver abscess. CT scan BC incidence in transplanted children varies from of abdomen showed a 6.2 cm Â 6cmÂ 5.9 cm size 15% to 40% of which 2% to 35% are anastomotic multiloculated hypodense collection in segment VII strictures (AS). As majority of the biliary reconstruc- of right lobe with perilesional edema. He underwent tion in children is a bilioenteric (BE) anastomosis percutaneous drainage of collection, which revealed performed by a Roux-en-Y, the AS have to be man- purulent aspirate. Microbiological examination of aged by percutaneous transhepatic biliary drainage aspirates showed pus cells and occasional gram-posi- (PTBD). The aim was to study the outcome of success tive branching filaments. Modified acid-fast stain was of treatment in biliary strictures in paediatric LDLT positive. Culture revealed Nocardai spp. MALDI-TOF recipients. test was positive for Nocardia farcinica. He was treated Methods: From 2011 to 2016 LDLT was done in 140 with trimethoprime-sulfamethoxazole, amikacin and paediatric patients. Of these 16 (11.4%) developed imipenem for 2 weeks. He was kept on low immuno- biliary strictures, of which 5 patients with duct-to- suppression. His fever subsided over next few days. duct AS underwent retrograde chlangio-pancreato- Repeat ultrasound scan revealed collapsed abscess graphy (ERCP) while 11 had bilio-enteric anastomo- cavity with small remnant collection. He was dis- sis and were dealt with PTBD. Post PTBD internal– charged on oral antimicrobials and is under regular external drainage catheter is placed from the bile duct follow up. into the jejunum across the AS and the catheter is Conclusion: Nocardiosis should be suspected as a exchanged over wire every 3 months for a year after likely cause of liver abscess in the setting of immu- which if no evidence of obstruction is seen on cho- nocompromised patients. Long-term treatment with langigram, the catheter is removed.

Results: Of the 5 patients who underwent ERCP (2 the patients were severely malnourished and only for early and 3 for late AS), 2 were successfully dilated about 17.8% of the patients were normal. The prog- and were disease free at 1 year follow-up. Three of nostic scores, CTP and MELD significantly had these patients had non-AS which could not be crossed higher scores in moderately and severely malnour- on ERCP and required PTBD. Of the 11 patients who ished patients (p < 0.001, 0.003). Among the biochem- were directly taken up for PTBD, 4 had early stricture ical parameters haemoglobin, albumin and sodium while 7 had presented with late strictures. Two of the showed significantly lower levels in moderate and early strictures and 3 late strictures were treated suc- severe malnutrition (p < 0.001, p 0.02 and p 0.01) than cessfully while 2 in each category are undergoing normal patients. Also, malnutrition was related to catheter exchange programme. Two late strictures higher usage of PRBC units (p 0.005) during the were successfully treated but had to undergo re-trans- surgery, and higher hospital stay (p 0.014) after transplant due to chronic rejection. plant. However, the present study did not show any Conclusion: Interventional radiology plays a major significant difference in outcomes like post-trans- role in salvaging patients with biliary complications plant ICU stay and mortality. post LDLT with bilio-eneteric anastomosis giving Conclusion: Pre-Transplant malnutrition is asso- 100% success in managing AS. ciated with higher hospital stay and blood usage during surgery. Hence, the present study suggests CONFLICTS OF INTEREST that addressing malnutrition in pre-LT phase may improve outcomes after LT. The authors have none to declare. CONFLICTS OF INTEREST Corresponding author: Abhay K. Kapoor. E-mail: [email protected] The authors have none to declare. ie Transplantation Liver http://dx.doi.org/10.1016/j.jceh.2016.06.062 Corresponding author: Neha Bakshi. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.063 3 EFFECT OF PRE-TRANSPLANT MALNUTRITION ON OUTCOMES OF LIVER 4 TRANSPLANTATION PROGRESSIVE FIBROSIS IS DRIVEN BY Neha Bakshi, Kalyani Singh, Arvinder S. Soin GENETIC PREDISPOSITION, ALLO- Lady Irwin College, University of Delhi, New Delhi, India IMMUNITY, AND INFLAMMATION IN PEDIATRIC LIVER TRANSPLANT Background & Aim: Malnutrition is universally pre- RECIPIENTS valent in ESLD (End Stage Liver Disease) patients Sharat Varma, Jerome Ambroise, Mina Komuta, undergoing Liver Transplantation (LT) and is asso- Dominique Latinne, Pamela Baldin, Raymond Reding, ciated to various clinical factors. The present study Francoise Smets, Xavier Stephenne, Etienne Sokal focuses on the effect of pre-Transplant nutrition status on various outcomes of LT. Sharat Varma, Jerome Ambroise, Mina Komuta are the Methods: 90 LT recipients were recruited in study co-first authors. period of January 2013 to October 2013 undergoing Université Catholique de Louvain, Cliniques Universitaires St Luc, elective LDLT and were grouped into normal, mod- Brussels, Belgium erate and severe malnutrition using Subjective Global Assessment (SGA) as a nutrition assessment tool. Background & Aim: Protocol biopsies (PB) from Information regarding prognostic factors (CTP, stable liver transplant (LT) recipient children fre- MELD scores), biochemical parameters (Haemoglo- quently exhibit idiopathic fibrosis. The relation bin, TLC, Platelets, Bilirubin (T), SGOT, SGPT, Albu- between allograft inflammation, humoral immune min, Creatinine and sodium) and outcomes (hospital response and fibrosis is uncertain. Also the role of stay, ICU days, blood units usage during surgery and HLA-DRB1 genotype has not been evaluated though dead and alive status) were gathered. it’s associated with fibrosis in autoimmune hepatitis. Results: The recipient evaluation showed 54.4% of Methods: This observational study, included 89 the patients were moderately malnourished, 27.8% of stable LT recipient transplanted between 2004-2012

with mean follow-up of 4.3 years, 281 serial PBs (3.1 quantification of ‘‘ASMA positive area percentage’’ biopsy/child) and human leukocyte antigen (HLA) was performed on the baseline biopsy. Histological antibody data. PBs were taken 1-2, 2-3, 3-5, 5-7, and 7- and fibrosis assessment using Metavir and liver allo- 10 years post-LT, and evaluated for inflammation and graft fibrosis scores (LAFSc), was performed on all fibrosis using liver allograft fibrosis score (LAFSc). biopsies. The difference of fibrosis severity between The evolution of fibrosis, inflammation and related the ‘‘baseline’’ and ‘‘follow-up’’ was termed ‘‘pro- predisposing factors were analysed. spective change in fibrosis’’. Results: HLA-DRB1*03/04 allele and Class II DSA Results: Significant association was seen between were significantly associated with portal fibrosis extent of ASMA positivity on baseline biopsy and (p = 0.03; p = 0.03, respectively). Portal inflammation ‘‘prospective change in fibrosis’’ using Metavir (p was predisposed by Class II DSA (p = 0.02) and non- value = 0.02), cumulative LAFSc (p value = 0.02), HLA antibody presence (p = 0.01). Non-portal fibrosis and portal LAFSc (p value = 0.01) values. ASMA posi- wasn’t predisposed by inflammation. Lobular inflam- tive area percentage >1.05 predicted increased fibrosis mation was associated with non-HLA antibodies. on next biopsy with 90.0% specificity. Additionally an Conclusion: We conclusively demonstrated that allo- association was observed between extent of ASMA graft inflammation results in fibrosis and is asso- positivity and concomitant ductular reaction ciated with post-LT Class II DSA and non-HLA (p = 0.06) but not with histological inflammation antibodies. The HLA-DRB1*03/04 allele caused in the portal tract or lobular area. genetic predisposition for fibrosis. Conclusion: ASMA quantification can predict the future course of fibrosis after liver transplantation. CONFLICTS OF INTEREST CONFLICTS OF INTEREST The authors have none to declare. The authors have none to declare. Corresponding author: Sharat Varma. E-mail: [email protected] Corresponding author: Sharat Varma. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.064 http://dx.doi.org/10.1016/j.jceh.2016.06.065 Liver Transplantation 5 6 TO EVALUATE SIGNIFICANCE OF ALPHA SMOOTH MUSCLE ACTIN (ASMA) ADULT LIVER TRANSPLANTATION – EXPRESSION ON LIVER BIOPSY AS INITIAL EXPERIENCE FROM A TERTIARY PREDICTOR OF FUTURE GRAFT FIBROSIS CARE CENTRE AT NORTH KERALA IN PEDIATRIC LIVER TRANSPLANT (LT) Rajneesh Rajan, Anish Kumar, K. Biju, Tony Jose, RECIPIENTS Sujith Janardhanan, Tajimal Rabia, G. Ramakrishnan, Sharat Varma, Xavier Stéphenne, Mina Komuta, Rakesh Babu, Kishore Kanianchalil, Caroline Bouzin, Jerome Ambroise, Francoise Smets, Seethalekshmy Natarajan, Rohit Ravindran, Raymond Reding, Etienne Sokal Rajesh Nambiar, Sajeesh Sahadevan

Université Catholique de Louvain, Cliniques Universitaires St Luc, Malabar Institute of Medical Sciences, Calicut, India Brussels, Belgium Background & Aim: This study retrospectively ana- Background & Aim: Activated hepatic stellate cells lyses the initial experience of liver transplantation express cytoplasmic alpha-smooth muscle actin (LT) from a tertiary care centre. We are presenting (ASMA) prior to secreting collagen and consequent data from our centre which started off with combined liver ﬁbrosis. We hypothesized that quantifying LDLT and DDLT programme. Its important for each ASMA could predict severity of future ﬁbrosis after transplant centre to analyze the success rate of their liver transplantation (LT). transplant programme and ours is one centre which Methods: 32 pairs of protocol biopsies i.e. ‘‘baseline’’ started both LDLT and DDLT programme together. and ‘‘follow-up’’ biopsies taken at 1-2 year intervals The aim of the study was to assess the success rate, from 18 stable pediatric LT recipients, transplanted intraoperative blood transfusion and hemodialysis between 2006 and 2012 were selected. Morphometric requirement, postoperative infectious, vascular and

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biliary complications and mortality related to Live Nalini Bansal, Vivek Vij, Mukul Rastogi, and deceased donor transplantation. Manav Wadhawan, Ajay Kumar Results: Between September 2013 and June 2016, we performed total 37 liver transplantations (18 DDLT Fortis Hospital, Delhi, India and 19 LDLT). There were 2 patients with acute liver failure, 2 with acute on chronic liver failure, 2 with Background & Aim: Post transplant liver biopsies HCC and 31 patients with decompensated cirrhosis form a critical part of management of complications liver. Mean MELD score was 24. Average duration of arising post transplant. The objective of this study ICU stay was 7 days and average duration of hospital was to analyze the Indian experience in pathologic stay was 18 days. Average blood transfusion require- diagnosis of liver biopsies after orthotopic liver trans- ment was 2 units/transplant. Five patients required plantation (OLTx) cases with special emphasis on intraoperative hemodialysis and three patients (8.1%) cases presenting with intrahepatic cholestasis IHC. required vascular interventions postoperatively. Type, incidence and timing of major complications Among the infectious complications, one had tuber- were analyzed All cases with IHC were retrospectively culosis and one had hepatitis B ﬂare and one had analyzed with clinical inputs for to look for cryptic cholangitis. 9 patients (24.32%) were treated for CMV clues in sub classifying such cases. infections. Three patients had preoperative complex Methods: 45 post-transplant liver biopsies from 39 biliary anatomy requiring three duct anastamosis and OLTx patients from Fortis Hospital Delhi, and Noida only one patient (2.7%) sufferred from post trans- were retrospectively analyzed from May 2015 to May plant biliary complication requiring biliary enteric 2016. The biopsies were stained with H&E and MT. anastamosis. Explant liver showed HCC in 2 patients. Results: The number of liver biopsies performed for each patient ranged from 1 to 3. The timing of these Out of 37, four patients died (10.8%). Among the 4 ﬁ who died, two patients were having advanced cirrho- biopsies varied from the ve days to >4 year post- ie Transplantation Liver sis, and two had ALF. There were no donor related transplant. Of the 39 patients who underwent post complications or mortality. transplant liver biopsies most common etiology of Conclusion: The overall survival and morbidity in liver transplant was HCV CLD in 66.6% cases. The this study is comparable to those from other centres. common complications were acute cellular rejection Complication rates are minimal due to patient selec- (33.3%), biliary stricture (13.3%), HCV recurrence tion criteria, good intensive care management and (11.1%), plasma cell hepatitis (4.4%), chronic hepatitis timely interventions. (4.4%), and intrahepatic cholestasis (22.2%). Cases with IHC were further being analyzed and results will follow. CONFLICTS OF INTEREST Conclusion: This study evaluated the types, incidence and timing of major complications occurring The authors have none to declare. after OLTx. Cases of IHC will be analyzed further to Corresponding author: Rajneesh Rajan. give new insight into the understanding of liver dis- E-mail: [email protected] eases in post transplant patients. http://dx.doi.org/10.1016/j.jceh.2016.06.066 CONFLICTS OF INTEREST

The authors have none to declare. 7 Corresponding author: Nalini Bansal. E-mail: [email protected] RETROSPECTIVE ANALYSIS OF POST TRANSPLANT LIVER BIOPSIES – FROM http://dx.doi.org/10.1016/j.jceh.2016.06.067 DIAGNOSIS TO THERAPY – CAN WE GUIDE FURTHER? EXPERIENCE FROM A TERTIARY CARE CENTER IN INDIA

Neoplasms

1 CONFLICTS OF INTEREST COMBINATION OF TACE AND SORAFENIB The authors have none to declare. IMPROVES OUTCOMES IN BCLC STAGES Corresponding author: Joy Varghese. B/C OF HEPATOCELLULAR CARCINOMA: E-mail: [email protected] A SINGLE CENTRE EXPERIENCE http://dx.doi.org/10.1016/j.jceh.2016.06.106 Joy Varghese, Chandan Kedarisetty, Jayanthi Venkataraman, Kavya Harika, Vijaya Sreenivasan, Tiruchunapalli Deepashree, Mangerira Uthappa, Kaliamurthy Ilankumaran, 2 Sanjay Govil, Mettu Reddy, Mohamed Rela LUNG LESION WITH HCC—NOT ALWAYS Global Health City, Chennai, India METASTASIS Pavan B. Hanchanale, Dinesh Jothimani, Joy Varghese, Background and Aim: Transarterial chemoemboli- Venkataraman Jayanthi, Mohamed Rela zation (TACE) or sorafenib is recommended for hepatocellular carcinoma BCLC stages B and C Global Health city, Chennai, India respectively. We studied the role of TACE + sorafenib in BCLC stages B/C. Background: We present a unique case of synchro- Methods: We performed a retrospective analysis on a nous cancers—primary HCC and primary pulmonary cohort of cirrhotics with HCC from August 2010 carcinoid tumor. through October 2014. Patients in BCLC stages B/ Case Report: A 65-year-old lady, case of HCV related C who had received TACE and/or sorafenib were decompensated cirrhosis with HCC was referred to

included. mRECIST criteria were used to assess our hospital for liver transplant. On examination she Neoplasms tumor response. The primary end point was overall was pale and had a firm, non tender nodular liver survival. palpable 2 cm below right costal margin. Baseline Results: Out of 124 patients, 47.6% were in BCLC-B laboratory evaluation revealed total Bilirubin- and 52.4% in BCLC-C. Baseline characteristics were 0.86 mg%, Albumin-2.3 gm/dL, AST-160 m/dL, ALT- comparable in the groups. The predominant etiology 134 m/dL and INR-1.28. Her AFP was elevated of cirrhosis was NASH in both groups (37.2% and (29.8 IU/ml). CECT abdomen showed cirrhosis with 38.5%, P = NS). 49.1% in BCLC-B and 56.9% in BCLC- arterial enhancing lesions with delayed washout C had received TACE + sorafenib. In BCLC-B, the noted in segment 2 (14 mm Â 14 mm), segment 5/ overall survival improved from 9months (95%CI 6 (14 mm Â 15 mm) & segment 6 (10 mm Â 8 mm, 6.3–11.7) using TACE only to 16months (95%CI 10 mm Â 7 mm) without vascular invasion and pre- 12.9–19.1) using TACE + sorafenib (P < 0.05). In sence of right lower lobe subpleural nodule. HRCT BCLC-C, addition of TACE to sorafenib improved thorax revealed 7.2 mm nodular soft tissue density the overall survival from 4months (95%CI 3–5) to 9 seen in superior basal segment of right lower lobe. months (95%CI 6.8–11.2) (P < 0.0001). As per mRE- Bone scan revealed no bone metastasis. As liver CIST criteria, patients on TACE + sorafenib had lesions were less than 2 cm in size without vascular reduced progressive disease (37.8% vs. 83.3%), invasion, she underwent biopsy of lung lesion with improved partial response (43.2% vs. 3.3%) and one excision of right lower interlobar lymphnodes to rule had complete response compared to those on sora- out lung metastasis. Biopsy revealed well differen- fenib alone (P < 0.0001) in BCLC-C but not in BCLC- tiated neuroendocrine tumor without necrosis and B group. Hand foot syndrome was noted in 27.7% surgical margin free of tumor. Lymphnode biopsy patients on sorafenib and post TACE syndrome in revealed metastatic well differentiated carcinoid 80.2% patients, but both were reversible. No major (IHC—HepPar-1 and Glypican-3 negative, Chromo- adverse events were noted. granin, synaptophysin, CD-56, TTF-1 positive with Conclusion: TACE + sorafenib was more effective Ki67 of 5%). She underwent Tc-99m-HYNIC-TOC than TACE or sorafenib alone in HCC BCLC stages (Octerotide) scan along with SPECT imaging revealed B or C with a significant survival benefit and improved no distant metastasis. The multifocal liver lesions in tumour regression especially in BCLC-C patients. both lobes of liver did not show radiolabelled

octreotide uptake. Biopsy from liver lesion revealed treatment, however in our case there is a near com- well differentiated hepatocellular carcinoma (IHC— plete regression of hepatoma with sorafenib alone. Glutamine synathase, CK7, CD34, Glypican 3, HSP70 Further prospective studies might pave way for use of positive). In view of HCC with lung NET she was not a Sorafenib as a curative treatment options for HCC candidate for liver transplant and underwent TACE irrespective of the stage of the disease. with soraﬁnib. Conclusion: Atypical lung lesions in patient with CONFLICTS OF INTEREST HCC without vascular invasion will require evaluation as not all lung lesions are metastatic. The authors have none to declare. CONFLICTS OF INTEREST Corresponding author: Vishnu V. Reddy. E-mail: [email protected] The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2016.06.108 Corresponding author: Pavan B. Hanchanale. E-mail: [email protected]

http://dx.doi.org/10.1016/j.jceh.2016.06.107 4 MACROPHAGE INFLAMMATORY PROTEIN- 1ALPHA/CC CHEMOKINE LIGAND 3 AND 3 TUMOR-ASSOCIATED MACROPHAGES IN REGRESSION OF LARGE UNRESECTABLE HEPATITIS C VIRUS-RELATED HEPATOMA WITH SORAFENIB HEPATOCELLULAR CARCINOMA: RELATION TO TUMOR PROGRESSION AND Neoplasms Vishnu V. Reddy, P.V. Girish, Tarun Joseph, G. Balaji, ANGIOGENESIS Vishnu A. Raju, Mallikarjun Patil, Harshad Devarbhavi Hoda E. Aggan, Myriam Helmy, Nevine E. Deeb, St Johns Medical College, Bengaluru, India Ahmed Zeid, Mohamed Fawzy

Background: Hepatocellular carcinoma (HCC) is the University of Alexandria, Alexandria, Egypt most common primary malignant tumor of the liver. Currently, Sorafenib is the only systemic treatment Background and Aim: Hepatitis C virus (HCV) is a modality approved for unresectable or metastatic major risk factor for hepatocellular carcinoma (HCC). HCC, which has demonstrated efficacy in improving Chemokines induce leukocyte migration and activate Progression-Free Survival (PFS). Complete response inflammatory response and have recently been impli- of the tumor to sorafenib has never been cated in tumor growth. The present work was designed documented. to study the role of macrophage inflammatory protein- Case Description: 51-year-old gentleman presented 1alpha/CC chemokine ligand 3 (MIP-1alpha/CCL3) in in October 2013 with history of mild upper abdom- the pathogenesis of HCV-related HCC in relation to inal pain abdomen for two weeks No other abdom- tumor progression and angiogenesis. inal complaints were noted. His past and personal Methods: Thirty patients with HCV-related cirrhosis history was unremarkable. Physical examination (15 patients with HCC and 15 patients without showed hepatomegaly and icterus. CECT abdomen HCC) and 15 healthy subjects were enrolled in the showed 10 cm Â 9 cm mass in the right lobe of liver study. Serum levels of MIP-1alpha/CCL3 were mea- with portal vein thrombosis. AFP levels were 438 ng/ sured using enzyme linked immunosorbant assay dl. HCV antibodies were positive. He was diagnosed and its sensitivity and specificity in the diagnosis to have chronic HCV infection with HCC in BCLC of HCC was determined. Histological tumor grading stage C. Patient was started on Sorafenib. Repeat was evaluated and the surrounding liver tissue was CECT after 1 year showed regression of the lesion examined to assess histological activity index (HAI) to 1.7 cm with patent portal vein. Patient received and steatosis grade. Expressions of MIP-1alpha/ treatment for genotype 1. As of May 2016, patient is CCL3, CD68 [for tumor-associated macrophages asymptomatic, compensated and doing well. (TAM)] and endoglin (CD105) [for determination Conclusion: Sorafenib has only been a palliative of microvessel density (MVD)] were studied in treatment modaility for HCC. Radiologically evident HCC and adjacent non-neoplastic liver tissues by partial or complete response is rare after sorafenib immunohistochemistry.

Results: Serum MIP-1alpha/CCL3 levels were signif- phase CECT scan) and enrolled in the study. Demo- icantly higher in cirrhotic patients with and without graphics, etiology, symptoms and risk factors were HCC than in healthy subjects and in HCC patients analyzed. than in patients without HCC (P < 0.001). By plotting Results: The mean age of the patients was 61 Æ 4.04 receiver-operating characteristic curve, the sensitivity years. According to BCLC classification 3, 5, 11, 32 and specificity of serum MIP-1alpha/CCL3 in the and 89 patients were belongs in BCLC STAGE 0, A, B, diagnosis of HCC were 100% and 93.3% respectively C and D respectively. Six patients had HCC without at a cut-off value of 17.5 pg/ml. HCV-related HCCs underlying liver cirrhosis. Patients presented with showed significant increases in MIP-1alpha/CCL3 abdominal pain, abdominal swelling, weight loss, expression, TAM count and MVD compared with and jaundice was seen in 92%, 64%, 33% and 11% adjacent non-neoplastic liver tissues (P < 0.001). respectively. Results showed that 77% and 3% of The MIP-1alpha/CCL3 expression in HCCs showed patients were found to be HBV related and HCV positive correlations with serum MIP-1alpha/CCL3 related CLD respectively. On the basis of history levels, tumor size, stage and histological grade, TAM 82% patients were chronic alcoholics and 64% count and MVD (P < 0.05). patients were smokers. On the basis of imaging Conclusion: The CC chemokine MIP-1alpha/CCL3 (USG Abdomen or CECT Abdomen) portal vein inva- plays an important role in the development and sion was seen in 42% patients. Biochemical analysis progression of HCV-related HCC possibly, through revealed that raised Serum AFP (>400 ng/ml, range migration of macrophages to tumor microenviron- 334–2119 ng/ml) was found in 87% patients. ment and enhancement of angiogenesis. MIP-1alpha/ Conclusion: HBV related CLD was the most com- CCL3 may serve as a potential serum biological mar- mon cause of HCC. Majority Patients were present ker and a useful therapeutic target for HCC. BCLC stage D.

CONFLICTS OF INTEREST CONFLICTS OF INTEREST

The authors have none to declare. The authors have none to declare. Corresponding author: Hoda E. Aggan. Corresponding author: Vinod K. Dixit. E-mail: [email protected] E-mail: [email protected] Neoplasms http://dx.doi.org/10.1016/j.jceh.2016.06.109 http://dx.doi.org/10.1016/j.jceh.2016.06.110

5 6 CLINICAL AND ETIOLOGICAL PROFILE OF UNUSUAL PARANEOPLASTIC HEPATOCELLULAR CARCINOMA IN A PRESENTATION OF HODGKINS NORTH INDIAN PATIENT LYMPHOMA AS ISOLATED IDIOPATHIC Pankaj K. Asati, Sunit Shukla, Ashok Jain, INTRAHEPATIC CHOLESTASIS WITH Vinod K. Dixit ASCITES C. Palanivelu, T.S. Ramesh, Junaid Khan Institute of Medical Science, Varanasi, India GEM Hospital and Research Centre, Coimbatore, India Background and Aim: Hepatocellular carcinoma (HCC) is a primary malignancy of the liver. HCC is Background: Intrahepatic cholestasis presenting as the leading cause of cancer related death worldwide. paraneoplastic manifestation is a rare form of pre- HCC is the 5th most common cancer in the world sentation in Hodgkin’s lymphoma (HL). and the third most common cause of cancer related Case Report: We present a diagnosis of mixed type death. HCC have varied clinical presentations. The Hodgkins lymphoma-related idiopathic intrahepatic aim of the study was to assess the etiological and cholestasis in a 85-year-old man who presented with clinical proﬁle of Hepatocellular Carcinoma. fever and evening rise of temperature, malaise, fati- Methods: We performed a study of clinical and etio- gue, jaundice, abdominal distension with swelling in logical proﬁle of Hepatocellular carcinoma in The both legs who was on antituberculous drug therapy Dept. of Gastroenterology, IMS, BHU, Varanasi, from for more than three months in a outside hospital and July 2013 to Dec 2015. A Total of 146 HCC patient since patient did not show improvement was (Male—124, Female—22) diagnosed (by HPR OR triple admitted and further evaluation showed multiple

Journal of Clinical and Experimental Hepatology | July 2016 | Vol. 6 | No. S1 | S63–S73 S65 NEOPLASMS

lymph nodes in the neck, axillary region, inguinal mortality worldwide. Hepatitis B or C is the most region, isolated elevation of alkaline phosphatase common cause of HCC. Majority of the patients of value more than 900 with CT thorax showed med- HCC have advanced disease at the time of diagnosis iastinal lymph nodes and patchy consolidation in the for which locoregional therapy remains the mainstay left lower lobe lung and celiac with para aortic lymph of treatment. Assessment of post treatment response nodes noted in the CT ABDOMEN. We proceeded is based on the imaging modalities like computed with cervical lymph node biopsy which is indicative of tomography or magnetic resonance imaging. There is mixed cellular type HL and liver biopsy consistent a need to identify a novel diagnostic and prognostic with intrahepatic cholestasis, following several diag- biomarker for HCC. Circulatory microRNAs (miR- nostic interventions after excluding extrahepatic NAs) are considered to be potential biomarkers for obstructive cholestasis. this purpose due to its ease of detection and high stability in circulation. The aim of the study was to identify the circulatory miRNAs and their differential expression in patients of HCC with Chronic hepatitis B/C (CHB/CHC) patients, diseased (CHB/CHC) and healthy controls. Methods: Serum miRNA proﬁling was carried out using miScript miRNA PCR Array. This array proﬁles the expression of a focused panel of 84 miRNAs that differentially expressed in serum. Six endogenous and two exogenous miRNAs were used for normalization. The miRNAs were isolated from serum of HCC patients with CHB/CHC (n = 6), diseased (n = 6) and healthy control (n = 6). These were poly-

Neoplasms adenylated, reverse transcribed and amplified by real time PCR using universal and miRNA specificpri- Conclusion: Our case report explains the value of mer. PCR array data analysis for differential miRNA early liver biopsy and lymph node excision biopsy expression was carried out using SAbioscience soft- with consideration of HL-related idiopathic intrahe- ware for scatter plot, heat map, P-value that uses delta patic cholestasis as a diagnosis of exclusion in chole- Ct values. static jaundice with isolated alkaline phosphatase Results: Out of 84 circulatory miRNAs, we detected elevation with ascites and splenomegaly. 79 miRNAs in healthy and 73 miRNA in serum of CONFLICTS OF INTEREST HCC patients at cut off of 35 Ct value. Endogenous small nucleolar C/D Box 95 RNA (SNORD95) detec- The authors have none to declare. tion was consistent in serum among six endogenous controls. For normalization, exogenous Cel miR39 Corresponding author: C. Palanivelu. and SNORD95 was used. Differential expression E-mail: [email protected] between HCC vs healthy and disease control vs http://dx.doi.org/10.1016/j.jceh.2016.06.111 healthy had shown down-regulation of 17 and 24 miRNAs; and up-regulation of 10 and 8 miRNAs respectively. A total of 9 serum miRNAs (miR-20a, 885, 148, 30e, 22, 223, 224,130 and 191) were sig- 7 nificantly deregulated in HCC patients compared to healthy and disease controls. The fold change of DIFFERENTIAL EXPRESSION OF these miRNA expressions varies from 2.06 to 2.44 CIRCULATING MIRNAS AMONG HEALTHY, for upregulation and À2.34 to À2.02 for down DISEASED CONTROLS AND HCC regulation. — PATIENTS PILOT STUDY Conclusion: These deregulated miRNAs target genes Baibaswata Nayak, Neeti Nadda, Dawesh Yadav, such as Rho b, mTOR, PTEN, MTPN, MAPK14, fi Shashi B. Paul, Shalimar, Subrat K. Acharya cyclin D1 which have signi cant role in HCC tumor progression and metastasis. The above proposed All India Institute of Medical Sciences, New Delhi, India miRNAs panel including up-and down-regulated miRNAs need validation in large prospective cohort Background and Aim: Hepatocellular carcinoma for their utilities as the diagnostic and prognostic (HCC) is the third leading cause of cancer-related markers in HCC patients.

CONFLICTS OF INTEREST immunotherapy in treatment of PHM has potential for further research. The authors have none to declare.

Corresponding author: Baibaswata Nayak. CONFLICTS OF INTEREST E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.112 The authors have none to declare. Corresponding author: Girish P. Veeranna. E-mail: [email protected]

8 http://dx.doi.org/10.1016/j.jceh.2016.06.113 PRIMARY MALIGNANT MELANOMA OF LIVER–A REPORT OF 2 CASES Girish P. Veeranna, Vishnu Vardhan Reddy, 9 Tarun Sabastian Joseph, Balaji Gurappa, DOES DIABETES MELLITUS ALTER THE Vishnu Abishek Raju, Mallikarjun Patil, CLINICAL AND BIOCHEMICAL Harshad C. Devarbhavi CHARACTERISTICS OF HEPATOCELLULAR St John’s Medical College and Hospital, Bengaluru, India CARCINOMA PATIENTS—A SOUTH INDIAN EXPERIENCE Background: Malignant melanoma is extremely Prasanth Sudheendran, G. Chethan, Nikhil Suraj, aggressive cancer arising from melanocytes. 90% of Deni Joseph, K. Srijith, M. Ramu, S. Prasanth, all melanomas are of cutaneous origin, although liver A. Shanid, Srijaya Sreesh, Selwyn Noronha, is a frequent site of metastasis from melanoma. Pri- D. Krishnadas mary hepatic melanoma (PHM) is rare. Case Report: In this case report, we present 2 patients Govt. Medical College, Thiruvananthapuram, India

of PHM, who came with jaundice, ascites, abdominal Neoplasms pain, for a short duration (1–2 months) and progres- Background and Aims: Recent studies suggested a sively worsened in a short span and finally suc- strong association between diabetes mellitus and cumbed. CT scans of both patients revealed Hepatocellular carcinoma (HCC) in males and diffusely distributed nodules of varying sizes in both females independent of the geographic location, alco- the lobes of liver with no evidence of portal hyperten- hol consumption, Hepatitis B or C (HBV or HCV) sion. Liver biopsy showed tumour cells with poor infection. We tried to find out if diabetes mellitus differentiation, which were in nests with prominent alter the clinical and biochemical characteristics of melanin deposits. The pigmentation distributed sinu- HCC patients. soidally, which was heavy enough to obscure cell Methods: We did a retrospective study of 170 cir- morphology. Pigment could be bleached with potas- rhotic HCC patients attending our department from sium permanganate. Immunohistochemical stain 2011 to 2015. The various clinical and biochemical showed, tumour cells were positive for HMB-45, factors like age, sex, aetiology, serum alphafetopro- s100, melanin A. Comprehensive dermatologic, tein (AFP), Portal vein thrombosis (PVT) were ana- ophtholmological examination revealed no evidence lysed and correlated with diabetes mellitus by of cutaneous or ocular primary lesion. Other sites like univariate and multivariate analysis with P value brain, respiratory tract, lung, GIT, were not involved. <0.05 taken as statistically significant. Our case report showed that, primary malignant mel- Results: We had a total of 170 patients with 152 males anoma of liver has a histological diversity and immu- (89.4%) and 18 females (10.6%) with mean age of nohistochemical staining may aid in differential patients 56.4 years with a minimum age of 17 years diagnosis from other hepatic neoplasms. Both of and maximum age of 88 years. Most of the patients the above patients died in a short duration after belong to CHILD B (38.8%), 42.4% belong to BCLC C diagnosis, which confirms PHM are extremely aggres- status. The most common aetiology was Hepatitis B sive tumours associated with short life span (months). 25.8%, Alcohol 19.4%, Hepatitis B + Alcohol 17.6%, Conclusion: The rare occurrence and aggressive nat- NASH 12.9% HCV alone 6.4% and others in 17.6% ure of PHM eludes the development of optimal treat- (Fig. 1). By univariate analysis and multivariate ana- ment regimen and study of natural history of tumor. lysis age and aetiology were having significant associa- The usefulness of chemotherapy, radiation, and tion with diabetes. Analysing the aetiology further we

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found that NASH related, HBV + Alcohol, HCV alone Background and Aim: The highest incidence of were having signiﬁcant association with Diabetes at HCC is in Asia, accounting for about 76% of all cases the time of diagnosis of HCC. Aetiology of cirrhosis worldwide. In South East Asia, hepatitis B is the most like Alcohol alone, Hepatitis B alone are having nega- common underlying cause. Although numerous asso- tive correlation with the presence of diabetes mellitus. ciations between environmental factors (e.g. cigarette smoking, heavy alcohol drinking, male gender, older age), viral factors (e.g. viral load, active replication, genotype, core promoter mutations) and the development of HCC in chronic HBV infection have been identiﬁed, a clear understanding of the role of host genetics remains illusive. Bangladesh is a densely populated country with about 160 million populations, where HBsAg positivity in the healthy population is 5.4%. The aim is to evaluate the role of host IL28B (interleukin 28B; interferon lambda 3) single nucleotide polymorphism (SNP) in predicting hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) susceptibility. Methods: Single SNP in the IL28B gene (rs12979860C/T) were examined in 116 subjects (including 44 HBV-related HCC patients, 42 non- HCC patients with chronic hepatitis B and 30 healthy controls). The study was done at the Department of Hepatology, Bangabandhu Sheikh Mujib Medical

Neoplasms University (BSMMU), Dhaka from January 2012 to Fig. 1 Clinical characteristics of HC patients with respect to diabetes December 2013. The polymorphism of IL28B mellitus. rs12979860 was analyzed by a genotyping technique, based on polymerase chain reaction (PCR) followed Conclusion: In HCC patients, diabetes mellitus has by restriction enzyme analysis at the Department of significant association with the aetiology of cirrhosis Microbiology & Immunology, BSMMU. like NASH, Alcohol + Hepatitis B and HCV alone. So Results: The frequency of CC homozygosity was 70% Diabetic patients with Cirrhosis aetiology like NASH, in healthy controls and 45.5% in HCC, the difference Hepatitis B + Alcohol and Hepatitis C alone should being statistically significant (x2 = 4.35, P = 0.03). Sta- be screened for HCC at frequent intervals than their tistically significant difference was also seen between non-diabetes mellitus counterparts. non-HCC patients with chronic hepatitis B (CHB) (69%) and HCC (45.5%) (x2 = 4.35, P = 0.03). How- CONFLICTS OF INTEREST ever, this significant finding was not seen between non-HCC patients with chronic hepatitis B (CHB) The authors have none to declare. and healthy controls. Carriers of the minor T allele in rs12979860 had a higher risk of HCC compared with Corresponding author: Prasanth Sudheendran. x2 P E-mail: [email protected] non-carriers ( = 4.78, = 0.02). Conclusion: Our results suggest that, T allele and http://dx.doi.org/10.1016/j.jceh.2016.06.114 non-CC genotypes have strong predictive effect of developing HCC and IL28Brs 12979860C/T polymorphism might influence susceptibility to HCC. 10 CONFLICTS OF INTEREST NON FAVORABLE GENOTYPE IS PREDOMINANT AT IL28B RS12979860 The author has none to declare. POLYMORPHISM IN HEPATITIS B RELATED HEPATOCELLULAR CARCINOMA Corresponding author: Abu Saleh Mohammmad Sadequl Islam. Abu Saleh Mohammmad Sadequl Islam E-mail: [email protected] Shaheed Ziaur Rahman Medical College Hospital, Bogra, Bangladesh http://dx.doi.org/10.1016/j.jceh.2016.06.115

11 Corresponding author: Mayank Jain. E-mail: [email protected] DOES PREOPERATIVE IMAGING CORRELATE WITH EXPLANT PATHOLOGY http://dx.doi.org/10.1016/j.jceh.2016.06.116 IN HCC? Joy Varghese, Mayank Jain, Mukul Vij, Sanjay Govil, Deepashree M. Reddy, V. Jayanti, Mohamed Rela 12 Global Health City, Chennai, India A CASE OF AUTOIMMUNE—MIMIC Background and Aim: To assess the correlation of JAUNDICE fi ndings noted on preoperative CT scan with patho- Jasmeet Singh Dhingra logical examination of liver explants in patients who underwent liver transplant (LT) for hepatocellular Tata Memorial Hospital, Mumbai, India carcinoma (HCC). Methods: This retrospective study was based on Background: In AIH, auto-antibodies can be preoperative CT scan examination of HCC patients detected in up to 95% patients. Our report describes who underwent LT. Study group was classified into 2 a case of 46-year-old woman with an ovarian mass groups. Group I (Gp I) was HCC patients within and unremitting jaundice with biopsy features of UCSF criteria and Group II (Gp II) was HCC patients early AIH and with both initial CA-125 and ANA beyond UCSF criteria. The validity, predictive values negative which finally turned out be metastatic cause and reliability of CT scan in rightly classifying the of jaundice. participants based on UCSF criteria as compared to Case Report: A 46-year-old woman presented direct pathological examination of explant liver (con- with history abdominal bloating and pelvic pain since sidered as gold standard) was analysed. The validity last 3 months was found to have anemia. Clinically was assessed by sensitivity, specificity, false positive there was no icterus or lymphadenopathy, abdominal and false negative rates. Reliability was assessed by distension was seen but no palpable lump/hepatos- P calculating the kappa statistic and its -value. plenomegly. She was non smoker/non alcoholic/ Neoplasms Results: A total of 86 patients (71 males, mean age non diabetic. Laboratory findings showed Hb = 55.1 years) over 5 years formed the study group. Fifty 8.3 mmol/L, WBC = 8900/dl, platelet 2.28 lac/dl, four patients (62%) underwent chemoembolisation creatinine 0.69 mg/dl. LFT showed normal bilirubin prior to surgery. Eight patients had vascular inva- and albumin with raised liver enzymes, negative viral sion on preoperative imaging. The mean size and markers, normal tumor markers Ca 125, hCG, AFP & number of tumors assessed preoperatively were CEA. CT scan (abdomen and pelvis) done outside 2.74 cm (0.8–10 cm) and 2.70 (1–10). On explants showed ovarian mass 7 cm Â 8 cm with no ascites. evaluation, the mean size and number of tumors Rest was normal. UGI endoscopy was normal. Sus- were 5.97 cm (0.7–11 cm) and 5.9 (1–10) respec- pecting Ca Ovary, she was planned for NACT but tively. The sensitivity of the CT scan in identifying due to deranged LFT she was investigated. She had patients with UCSF score beyond was very poor no h/o NSAID use. ANA/ASMA were negative. Total (53.2%, 95% CI 38.93–67.475), hence the rate of false Core IgG anti HBc was negative. Repeat viral mar- negative reporting was high (46.8%, 32.53–61.06%). kers for HAV/HEV were negative. FBS/PPBS/Lipid The CT scan had good specificity (84.6%, 73.27– profile was normal. LFT’sshowedAST/ALT>3Â 95.93%) in identifying people with UCSF criteria ULN and ALP > 5Â ULN. With clinical suspicion of within range. The positive and negative predictive both AIH Æ PBC/PSC, she underwent liver biopsy values of the test were 80.6% and 60% respectively. which was suggestive of early AIH. However repeat The kappa statistic of agreement between CT scan imaging was done in view of predominant chole- findings and explant examination was very poor static picture and MRI showed enlarged periportal (K = 0.117, P < 0.001). metastatic nodes. Fresh tumor markers revealed a Conclusion: Preoperative imaging has a good high CA125. specificity in patients with lesions within UCSF Conclusion: In patients with known underlying criteria. malignancy, cause of uninvestigated jaundice should be considered a metastatic parenchymal liver CONFLICTS OF INTEREST disease and same looked for and investigated thoroughly before attributing jaundice to secondary The authors have none to declare. causes.

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CONFLICTS OF INTEREST HCC. Better objective tests are required to predict its occurrence. The author has none to declare. Corresponding author: Jasmeet Singh Dhingra. CONFLICTS OF INTEREST E-mail: [email protected] The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2016.06.117 Corresponding author: Subrat K. Acharya. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.118 13 POST-TRANSARTERIAL CHEMOEMBOLIZATION LIVER FAILURE IS 14 ASSOCIATED WITH POOR OUTCOME IN HEPATOCELLULAR CARCINOMA ETIOLOGICAL AND CLINICAL CHARACTERISTICS OF HEPATOCELLULAR Neeti Nadda, Shalimar, Saurabh Kedia, CARCINOMA AT PRESENTATION TO Baibaswata Nayak, Dawesh Yadav, Mona Pathak, TERTIARY CARE HOSPITAL IN SOUTH Shashi B. Paul, Subrat K. Acharya INDIA All India Institute of Medical Sciences Delhi, New Delhi, India Chethan Govindaraju, Prasanth Sudheendran, Nikhil Suraj, Gunjal Sudamrao, Singh Anirudha Pratap, Background and Aim: Transarterial chemoemboli- George Peter, Shanid Sathar, Prasanth Sobhan, zation (TACE) is the recommended treatment of Srijaya Sreesh, Selwyn Noronha, Krishnadas Devadas

Neoplasms BCLC-A and B stages of hepatocellular carcinoma (HCC), when curative options are not feasible. Govt Medical College Trivandrum, Trivandrum, India Post-TACE decompensation is common. In this analysis of a prospectively acquired database, we aimed to Background and Aim: To analyze the etiology, clin- determine the predictors of post-TACE liver failure ical presentation and tumor characteristics of Hepa- (LF), and its effect on natural course of HCC. tocellular carcinoma (HCC) presenting to tertiary Methods: Consecutive HCC patients with Barcelona care hospital. clinic liver cancer (BCLC) staging A/B were included Methods: This is an observational retrospective between August 2012 and December 2015. Post- descriptive study. All patients data who were diag- TACE LF was defined as occurrence of any of the nosed to have HCC from 2008 to 2014 were included. following: new onset hepatic encephalopathy, HCC diagnosis was based on EASL & AASLD guide- increase in ascites, or increase in bilirubin > 0.9 mg/ lines. Detailed clinical presentation, etiological dl within 2 weeks of TACE. Survival in patients with workup data, laboratory parameters, child status were and without post-TACE LF was compared with analyzed. BCLC staging was done. Kaplan-Meier graphs. Results: One hundred and seventy two patients (172) Results: Of the total 111 patients; 102(91.9%) were were diagnosed to have HCC during this period, out males; median age was 56 years. A total of 139 ses- of which two patients were non cirrhotic. One hun- sions of TACE were performed—39 (28.1%) in BCLC dred and fifty four patients (89%) were male, 18 class A and 100 (71.9%) in class B cases. Of the total (10.4%) were females. Mean age was 56.3 years (17– 139 sessions of TACE, post-TACE LF developed in 31 86 yrs). Hepatitis B alone was seen in 44 patients (22.3%). On multivariate analysis, baseline serum (25.8%), with alcohol in 30 patients (17.6%). alcohol bilirubin (P = 0.01), serum creatinine (P = 0.01), alone in 33 patients (19.4%), NASH in 22 patients aspartate aminotransferase levels (P = 0.03) and (12.9%), HCV in 1 patients (6.4%). HCC presenting as serum alkaline phosphatase (P = 0.02) were asso- first presentation in nearly half the patients. AFP was ciated with development of post-TACE LF. The 1- >200 in 107 patients (62.9%), while it was normal in 4 and 2-year survival in patients with and without post- patients (8.2%), PVT was present in 100 patients TACE LF was 33.6% (16.2–51.9%) vs 69.3% (56.5– (58.8%), About 72 (42.2%) patients belong to BCLC 79.1%) and 24.0% (9.3–42.4%) vs 31.8% (16.3– C, 52 patients (30.53%) to D. 48.5%), respectively (P = 0.001, log rank test). Conclusion: Hepatitis B was the most common cause Conclusion: Post-TACE liver failure is common and of HCC followed by alcohol in our population. Almost is associated with poor outcome in patients with all the patients had underlying cirrhosis. Nearly in half

the patients it was first presentation. More than two CONFLICTS OF INTEREST third of patient present in advanced stage. The authors have none to declare. CONFLICTS OF INTEREST Corresponding author: Shahna S. Fathima. E-mail: [email protected] The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2016.06.120 Corresponding author: Chethan Govindaraju. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.119 16 NOT ALL PERI-DUCTAL PLAQUE LIKE 15 ENHANCEMENT IS FACTORS AFFECTING SERUM AFP IN HCC CHOLANGIOCARCINOMA- PRIMER FOR CLINICIANS Shahna S. Fathima, G. Chethan, T.S. Prasanth, Krishnadas Devadas, Selwyn Noronha, S. Srijaya, Sonal Krishan A. Shanid, K.S. Prasanth, George Peter, Arun Iyer, Medanta, Gurgaon, India B.K. Bincy, Gopu R. Babu, Ponni Krishnan, Santosh Yadav Background and Aim: The early diagnosis of peri- Government Medical College Hospital, Thiruvananthapuram, India ductal infiltrating cholangiocarcinoma can be very difficult because this entity may begin as a benign- Background and Aim: Previous studies on Alpha looking stricture. The correct diagnosis of peribiliary FetoProtein (AFP) and (Hepato Cellular Carcinoma) cholangiocarcinoma depends on differentiating the HCC are heterogeneous as far as stage and etiology of benign focal stricture from a true malignancy. The liver disease is concerned. Consequently AFP is con- aim of this retrospective review was differentiating sidered to have suboptimal performance as a diag- periductal plaque like cholangiocarcinoma from the Neoplasms nostic and surveillance marker. This study aims to benign stricture and identifying any discriminant find factors affecting serum AFP in HCC so as to find CT/MR findings. why AFP level varies in HCC. Methods: All histopathologically proven cases of Methods: Observational retrospective study from benign lesions/malignant periductal infiltrating data collected from discharge records between 2008 cholangiocarcinoma presenting at our institution and 2014.117 cirrhotic HCC patients with single from January 2012 to 1st January 2015 were retro- etiology for CLD were included. Factors affecting spectively analysed by two blinded readers. Cases AFP levels in HCC were analysed with univariate were evaluated for length of stricture, intra/ and multivariate analysis. Patients were grouped into extrahepatic stricture, multifocality, regularity of those with high and low AFP using the cut off 200. margin, asymmetric narrowing, ductal enhance- Association of age, gender CHILD status, BCLC stage, ment, and lymph node enlargement as well as etiology, diabetes with AFP levels were assessed. any periductal soft-tissue lesion. Simple descriptive Results: 117 patients were included. Chronic HBV statistics was used to describe the findings. Spec- (37.6%) was the most common cause for HCC closely trum of imsging of benign pathologies was also followed by alcohol (28.2%). Etiology of HCC signifi- evaluated. cantly affected AFP levels. HBV and alcohol asso- Results: Isolated short segment asymmetric irregular ciated HCC had higher levels when compared to stricture with small soft tissue was most predictive of NASH and HCV associated HCC (P < 0.01). Other malignancy. Multifocal long segment stricture with- factors which affected same was age, gender, diabetes out marginal irregularity or soft tissue was most (P < 0.01). predictive of benign findings. Conclusion: Alcohol and HBV related HCC tends to Conclusion: Not all cases of peri-ductal plaque have higher AFP (>200) values compared to HCV & like enhancement are cholangiocarcinomas the radi- NASH related HCC. Diabetics had lower AFP com- ologist in tandem with the referring clinician must pared to nondiabetics in HCC. Males had higher AFP also evaluate the pattern and morphology of the than females in HCC. Increased age was associated stricture for distinguishing benign from malignant with higher AFP levels. strictures.

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CONFLICTS OF INTEREST were most predictive of extent of tumour. Arterial phase images were least predictive of the tumour The author has none to declare. volume. Corresponding author: Sonal Krishan. Conclusion: Whole liver volumetric enhancement ﬁ E-mail: [email protected] quanti cation on dynamic MRI/CT is a promising tool for evaluating tumour volume and response in http://dx.doi.org/10.1016/j.jceh.2016.06.175 inﬁltrative HCC.

CONFLICTS OF INTEREST

17 The authors have none to declare. ROLE OF VOLUMETRIC DENSITY MAPPING Corresponding author: Sonal Krishan. IN DIFFERENTIATING INFILTRATIVE HCC E-mail: [email protected] FROM THE RESIDUAL LIVER AND ITS http://dx.doi.org/10.1016/j.jceh.2016.06.176 AFFECT ON THE TREATMENT PLANNING IN CIRRHOTIC LIVER Sonal Krishan, Vikram Singh 18 Medanta, Gurgaon, India DUAL ENERGY CT- SURROGATE Background and Aim:Infiltrative HCC is being QUANTITATIVE MARKER OF RESPONSE TO increasingly seen in patients with cirrhosis. Patients TARGETTED TREATMENT IN HCC present often present late with portal vein tumour Sonal Krishan, Hitesh Lukhi Neoplasms thrombus. However the tumour is difficult to distin- guish from the surrounding hetergenous cirrhotic Medanta Hospital, Gurgaon, India liver. Evaluating the precise volume and true extent of the intrahepatic disease in these patients and the Background and Aim: Dual energy CT (DECT)– viability of the thrombus if any is essential to guide novel CT imaging technique at two different energies, any non surgical treatment planning such as TACE/ can be used to discriminate between different materi- TARE/EBRT. Our preliminary study investigates the als (e.g., fat, calcium, iodine, and water), which are not feasibility of whole liver volumetric enhancement allowed by conventional CT. The images recon- quantification to measure tumour extent evaluate structed from these differential data, including iodine treatment response. concentration maps, may provide diagnostic infor- Methods: 20 patients with proven infiltrative HCC mation beyond that obtainable with conventional CT were retrospectively. We evaluated the temporal Aim: To evaluate the supplementary value of dual change in volumetric enhancement in arterial, portal, energy CT to assess response in cirrhotic patients with hepatic and delayed phases as well as changes in the HCC following targeted therapy. diffusion coefficient as compared to the non infil- Methods: 20 patients with targeted therapies for dual trated liver parenchyma to see if these changes in energy CT (TACE/TARE/RFA) were evaluated. Iodine density/signal intensity can be utilised as an estab- uptake(IU), derived from the iodine-based material- lished means for evaluating tumour volume, evaluat- decomposition image and the iodine concentration ing response. We further interrogated if colour coded ratio on the dual energy CT acquired during early maps can be generated based on these density thresh- portal venous phase was calculated by drawing olds. For each session separately the whole liver was regions of interest within the treated lesion, at the segmented and pre-contrast and post contrast images edge and within the surrounding liver parenchyma. were subtracted. Viable tumor was identified in voxels Quantification of IU (absolute value for total IU (mg) enhancing above 2 times the standard deviation of and volume-normalized IU (mg/ml)) was based on enhancement inside a region of interest (ROI) placed semi-automatic tumor volume segmentation com- in non-tumorous liver parenchyma. A threshold at pared to the background liver. The decrease com- 35% reduction between baseline and follow-up CT/ pared with baseline was calculated. MRI was used to separate responders. Results: The mean normalized IU per patient within Results: Diffusion weighted imaging and delayed the treated lesion compared to the cirrhotic liver equilibrium as well hepatocyte specific phase images parenchyma -31%. Total IU per patient, combining

both normalized IU and volume, showed the most CONFLICTS OF INTEREST pronounced decrease. Conclusion: DECT enables objective, easy and fast The authors have none to declare. parameterization of tumor size and contrast medium Corresponding author: Sonal Krishan. uptake. DECT provides a quantitative method with E-mail: [email protected] which to analyze the treated lesions in the cirrhotic liver. http://dx.doi.org/10.1016/j.jceh.2016.06.177 Neoplasms

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Miscellaneous

1 2 LANE-HAMILTON SYNDROME: ATYPICAL CONCURRENT EXTRAHEPATIC PRESENTATION OF CELIAC DISEASE AUTOIMMUNE DISORDERS: UNEXPLORED Sajan Agarwal, Raj Gupta DIMENSION OF AUTOIMMUNE LIVER DISEASE IN THE CHILDREN JK Lone Hospital, SMS Medical College, Jaipur, Rajasthan, India Vikas Jain, Surender Yachha, Eesh Bhatia, Background and Aim: Celiac disease (CD) is defined Moinak Sarma, Anshu Srivastava, Ujjal Poddar as a chronic, immune-mediated enteropathy of the Sanjay Gandhi Postgraduate Institute, Lucknow, India small intestine, caused by exposure to dietary gluten in genetically predisposed individuals. Idiopathic Pul- Background and Aim: No comprehensive and pro- monary Hemosiderosis (IPH) is a rare cause of alveo- spective data is available on concurrent extrahepatic lar hemorrhage, which is seen primarily in childhood. autoimmune disorders (CEAIDs) in children with Association of CD with idiopathic pulmonary hemo- autoimmune liver disease (AILD). The aim of the siderosis (IPH) is known as Lane-Hamilton syndrome study was to evaluate CEAIDs in AILD and evaluate and is somewhat a rarely seen condition. There are their effect on AILD outcome. limited numbers of case reports of this syndrome in Methods: Enrolled AILD and CEAIDs patients were literature. diagnosed on the basis of simplified and standard Case Report: We report a case of an adolescent male diagnostic criteria respectively. Clinico-pathological Miscellaneous child who presented with exertional dyspnoea, inter- profile, treatment response and outcome were com- mittent hemoptysis, severe anemia and lung infiltrates pared between AILD with CEAIDs (Group A) and but no gastrointestinal complaints. After extensive AILD without CEAIDs (Group B). work-up, he was diagnosed with Lane-Hamilton syn- Results: Out of 62 AILD children, CEAIDs were drome based on a diagnosis of IPH made from spu- found in 42% (n = 26) [vitiligo (42%), celiac disease tum cytology and concomitant celiac disease (CD) (CD) (15%), potential CD (15%), autoimmune hemo- because of positive serology and duodenum biopsy. lytic anemia (AIHA) (15%)]. CEAIDs were asympto- He was initially managed with packed red cell transfu- matic in 75%. Single CEAID found in 81% (21/26) and sion (PRBC) and subsequently kept on gluten-free diet multiple in 19% (5/26). Significantly less biochemical with resolution of his symptoms and lung infiltrates. remission (BR) (46.1% vs. 74.2%, P =0.03),more Conclusion: We conclude that celiac disease must be treatment failure (23% vs. 3.2%, P = 0.04) and higher screened in patients diagnosed with IPH especially in mortality (15.3% vs. 3.2%, P = 0.04) were seen in presence of severe anemia despite having no gastro- Group A as compared to Group B. On multivariate intestinal symptoms. These patients may benefit from analysis of AILD cases (n = 57), less BR in vitiligo gluten free diet and IPH symptoms may disappear. (P =0.04);moretreatmentfailureinAIHA (P = 0.004) and vitiligo (P =0.04);andhighmortal- CONFLICTS OF INTEREST ity in AIHA (P = 0.02) subgroups. CD treatment has good impact on AILD outcome. We showed steroid The authors have none to declare. therapy was the cause of DM in AILD rather than autoimmunity as anti-islet cell antibody (ICA) and Corresponding author: Raj Gupta. anti-glutamic acid decarboxylase (GAD) antibody E-mail: [email protected] werenegativeandC-peptidelevelwaselevatedin http://dx.doi.org/10.1016/j.jceh.2016.06.122 allchildrenwithDM.

Methods: We retrospectively reviewed the medical case records of patients with acute cholangitis admitted under the Department of Gastroenterology, Kasturba Medical College, Manipal between January 2012 and January 2016 to analyze their clinical and bacteriological proﬁle. Results: 58 patients (male:female = 35:23) who developed 72 episodes of cholangitis were included. Peri- ampullary carcinoma (29.3%), choledocholithiasis (15.5%) and hilar cholangiocarcinoma (12.1%) were the main causes of obstruction. While the most common presenting complaints were fever followed by jaundice, the classically described Charcot’s triad was found in only 29 (40.2%). Bile and blood cultures were positive on 39 (84.7%) and 23 (36%) occasions. Poly- microbial growth was noted in 7 (18%) and 3 (13%) cholangitic episodes respectively. Escherichia coli and Conclusion: All AILD children should be screened Klebsiella together made up 87% of the organisms for CEAIDs as majority are asymptomatic. AILD out- isolated. The two organisms were resistant to third come was favourable in CD but poor in vitiligo and generation cephalosporins in 45 (70.3%) cultures and AIHA. Children on steroid therapy should be closely ﬂuroquinolones in 44 (68.75%), but were sensitive to monitored for DM. We suggest incorporation of imipenem in 53 (82.8%) cultures. CEAIDs in the pediatric AILD scoring system. Conclusion: Escherichia coli and Klebsiella are the major contributors to acute cholangitis and have a CONFLICTS OF INTEREST high incidence of resistance to third generation cephalosporins and quinolones. The authors have none to declare.

CONFLICTS OF INTEREST Miscellaneous Corresponding author: Vikas Jain. E-mail: [email protected] The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2016.06.123 Corresponding author: Abhijith Bale. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.124 3 BACTERIOLOGICAL PROFILE AND ANTIBIOTIC SENSITIVITY IN ACUTE 4 CHOLANGITIS LIVER FUNCTION TEST ABNORMALITIES Abhijith Bale, Anurag Shetty, Girisha Balaraju, IN AN EPIDEMIC OF DENGUE VIRAL Shiran Shetty, Ganesh Pai INFECTION AND ITS CORRELATION WITH Kasturba Medical College, Manipal University, Manipal, India PLATELET VALUES—A TERTIARY CARE EXPERIENCE Background and Aim: Acute cholangitis usually Vinoth Boopathy complicates biliary obstruction or stasis and carries a mortality rate as high as 30%. Antibiotic therapy Aarupadai Veedu Medical College, Puducherry, India plays a major role, as an adjunct to adequate biliary drainage in cholangitis. The changing antibiotic sen- Background and Aim: Liver function test (LFT) sitivity pattern of bacterial infections in general, abnormalities are commonly seen in patients with effects cholangitis too and knowledge of bacterial dengue viral infection, though the role of variation in epidemiology in cholangitis helps choose antibiotic the levels of liver enzymes in the pathogenesis of wisely. The aim of the study was to analyze the clinical dengue severity is not known yet. In this context and bacteriological proﬁle, in acute cholangitis. we conducted a retrospective study to analyse the

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1 2 clinical spectrum of dengue with regard to LFT Clinical Research Organization, Dhaka, Bangladesh, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 3Noakhali abnormalities in patients with dengue fever and its 4 Medical College, Noakhali, Bangladesh, Shaheed Tajuddin Ahmed association with disease severity from a recent epi- Medical College, Dhaka, Bangladesh, 5Kurmitola General Hospital, demic in a tertiary care centre of south India. Dhaka, Bangladesh, 6Shaheed Syed Nazrul Islam Medical College, Methods: It is a retrospective descriptive study, were Kisgoregonj, Bangladesh, 7Toshiba General Hospital, Tokyo, Japan in the data of patients with NS1 positive dengue viral infection between September and November of 2012 Background and Aim: Currently there is no specific were collected from the medical records department treatment for decompensated cirrhosis, excluding and their LFT, PTINR (Prothromin time) and platelet liver transplantation, which is available in limited values were analyzed. The severity of LFT and PTINR centres and is also is restricted by shortage of donor abnormalities were also graded to better understand organs, limited expertise and cost. Stimulation of the severity of LFT derangement in dengue infection. stem cells with GCSF injection may help hepatic Results: Out of 268 patients with dengue infection, regeneration in such patients and thus delay the LFT derangement was found in 80% of patients. need for liver transplantation. Aim of study is to SGOT was the commonest parameter abnormal assess safety and efficacy of granulocyte colony (80%), followed by SGPT (69%), albumin (53.5%), stimulating factor (GCSF) therapy in decompen- total protein (52.4%), GGT (46.9%), alkaline phospha- sated cirrhosis as GCSF is known to stimulate stem tase (8.6%%) and total bilirubin (3.5%). PT INR level cells humans. >1.3 was seen only in 2.8%. SGOT levels were more Methods: 10 patients with decompensated cirrhosis elevated than SGPT levels in patients with deranged were included. There were 5/10 (50%) males and rest LFT (97% vs 3%). It was also found that LFT when females. 3/10 (30%) had hepatitis B-related, 3/10 abnormal correlated well with the reduced platelet (30%) hepatitis C-related and 4/10 (40%) had cryp- count, an indicator of disease severity (P < 0.05). togenic cirrhosis. They were given injection GCSF Conclusion: LFT derangement is very common in (30IU) sub-cutaneously weekly for 6 weeks plus Miscellaneous dengue viral infection (80%). In an endemic area in a standard of care. In all 12 injections were patient with acute febrile illness, one has to suspect administered. dengue infection if LFT is abnormal with an SGOT Results: At baseline, all had decompensated cirrhosis level more than SGPT. Also the LFT levels have been 7/8 (87.5%) had clinical jaundice (serum bilirubin associated with disease severity and thus may serves as 0.8–11.4 mg/dl), 3/8 (37.5%) detectable ascites (serum an early indicator of severity of dengue infection. albumin 25–38 g/L). Their serum ALT was 28–73 IU/ L, INR1.04-3.2, serum creatinine 0.6–1.6 mg/dl and – CONFLICTS OF INTEREST total leucocyte count (TLC) 2500 16,000/cmm at point of inclusion. No ALT flair documented in The author has none to declare. any patient. At end of 12 weeks of treatment, 8/10 (80%) were alive. None had ascites. Analysis at the end Corresponding author: Vinoth Boopathy. of 12 weeks showed, serum bilirubin 5.2 mg/dl, E-mail: [email protected] serum albumin 30 g/L, serum ALT 350 U/L, http://dx.doi.org/10.1016/j.jceh.2016.06.125 INR1.4, serum creatinine 1.5 mg/dl and TLC 5600/ cmm. Conclusion: GCSF therapy was found to be safe in decompensated cirrhosis. It however failed to show fi 5 signi cant improvement in liver function test, although absence of ascites was important. Larger PILOT STUDY TO ACCESS SAFETY AND study with longer follow up is recommended to reach EFFICACY OF GRANULOCYTE COLONY definite conclusion. STIMULATING FACTOR THERAPY IN DECOMPENSATED CIRRHOTICS IN BANGLADESH CONFLICTS OF INTEREST Mohammad Helal Uddin 1, Mamun A. Mahtab 2, The authors have none to declare. Mohammad Abdur Rahim 3, Corresponding author: Mayank Gupta. Sheikh Mohammad Noor-E-Alam 4, E-mail: [email protected] Ahmed Lutful Moben 5, Syed Abul Foez 6, Sheikh Mohammad Fazle Akbar 7, Salimur Rahman 2 http://dx.doi.org/10.1016/j.jceh.2016.06.126

6 Corresponding author: Santosh K. Yadav. E-mail: [email protected] STUDY TO COMPARE HVPG WITH ENDOSCOPY OF UGIT TO ASSESS SEVERITY http://dx.doi.org/10.1016/j.jceh.2016.06.127 OF PORTAL HYPERTENSION IN CIRRHOTICS IN BANGLADESH 1 2 Mohammad Abdur Rahim , Mamun A. Mahtab , 7 Sheikh Mohammad Noor-E-Alam 3, Mohammad Ashraful Alam 4, Ahmed Lutful Moben 5, BENIGN RECURRENT INTRAHEPATIC Syed Abul Foez 6, Mohammad Helal Uddin 7, CHOLESTASIS (SUMMERSKILL WALSHE Sheikh Mohammad Fazle Akbar 8, Salimur Rahman 2 TYGSTRUP DISEASE)—A CASE REPORT

1Abdul Malek Ukil Medical College, Noakhali, Bangladesh, G.S. Gurudath, C. Palanivelu, J. Khan Mohammad, 2Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, K.T.S. Ramesh, K.G.S. Sharath, Palve Santhosh, 3 Shaheed Tajuddin Ahmed Medical College, Gazipur, Bangladesh, Dhinakaran Suganya, Sharma Nithyanand, 4Cox’s Bazar Medical College, Cox’s Bazar, Bangladesh, 5Kurmitola 6 Murudawar Piyush General Hospital, Dhaka, Shahid Syed Nazrul Islam Medical College, Kishorganj, Bangladesh, 7Clinical Research Organization, Dhaka, GEM Hospital and Research Centre, Coimbatore, India Bangladesh, 8Toshiba General Hospital, Tokyo, Japan Background: Benign Recurrent Intrahepatic Choles- Background and Aim: Aim of the study was to tasis (BRIC) is a rare form of hereditary cholestasis compare the utility of hepatic venous pressure gra- syndrome characterized by self limiting episodes of dient (HVPG) and endoscopy of upper gastrointest- pruritis and cholestasis. inal tract (UGIT) for the assessment of severity of portal hypertension in liver cirrhosis. Methods: Forty-five patients with cirrhosis of liver were included. There were 33/45 (73.3%) males and 12/45 females (26.7%). Four patients had past history of gastrointestinal (GI) bleeding. Miscellaneous Results: On endoscopy of UGIT, 20/45 (44.4%) patients had features of portal hypertension. Of them, 14/20 (70%) had esophageal varices (OV), 2/ 20 (10%) had portal hypertensive gastropathy (PGH) and 4/20 (20%) had both OV and PHG. On the contrary, portal hypertension was diagnosed in 32/ Case Report: Here we report a case of young male 45 (71.1%) patients at HVPG (7 mm of Hg). OV patient aged 28 years who had recurrent 5 episodes of needing therapeutic intervention (F2 and F3) was intrahepatic cholestatic jaundice associated with found in 10/45 (22.2%) patients at endoscopy of pruritis and symptom free intervals lasting for UGIT compared to 14/45 (31.1%) at HVPG months to years between two episodes of jaundice. (13 mm of Hg). Of the 4 patients with past history Patient was evaluated extensively for etiology with of GI bleeding, 3 had F3 OV, but on HVPG all had viral markers, MRCP, 24 h urinary copper, transfer- significant portal hypertension. ring saturation, autoimmune workup which found to Conclusion: Portal hypertension is not only an be normal. Liver biopsy revealed chronic cholestasis important cause of upper GI bleeding in cirrhosis, with few lymphocytic infiltration. Diagnosis of BRIC but also contributes significantly to the development was made based on clinical, laboratory parameters of ascites. The study demonstrates a comparable and diagnostic criteria. better implication of HVPG over endoscopy of UGIT for assessment of portal hypertension in liver cirrho- CONFLICTS OF INTEREST sis. This may aid profoundly in the long term management and prognosis of these patients. The authors have none to declare. Corresponding author: G.S. Gurudath. CONFLICTS OF INTEREST E-mail: [email protected] The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2016.06.128

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8 Corresponding author: Gaurav Garg. E-mail: [email protected] CLINICAL PROFILE OF HEPATIC WILSON DISEASE IN TERTIARY CENTER http://dx.doi.org/10.1016/j.jceh.2016.06.129 Gaurav Garg, Vinod Dixit, Sunit Shukla, Pankaj Asati, Sudhir Singh, Shivam Sachan

IMS BHU, Varanasi, India 9 COMPARISON OF TRANSIENT Background and Aim: Wilson disease is a rare auto- ELASTOGRAPHY AND SHEAR WAVE somal recessive inherited disorder of copper metabolism that is characterized by excess deposition of ELASTOGRAPHY IN THE EVALUATION OF copper in the liver, brain, and other tissues. Hepatic LIVER FIBROSIS dysfunction is the presenting feature in more than Nikhil Suraj, Gopu R. Babu, Rathan C. Joseph, half of patients. In this study we assess the clinical K. Srijith, Srijaya Sreesh, K.S. Prasanth, A. Shanid, profile of Wilson’s disease in hospitalized liver disease Devadas Krishnadas related patients. Methods: A total 38 (male 24, female 14) Wilson Government Medical College, Thiruvananthapuram, India disease patients (diagnosed by low serum ceruloplasmin, high 24 h urinary copper and D-pennicilamine Background and Aim: Several non-invasive methods challenge test) were enrolled in study conducted have been developed for the evaluation of liver fibro- between January 2015 and December 2015 in Depart- sis. Our primary aim was to compare the efficacy of ment of Gastroenterology, IMS BHU Varanasi. shear wave elastography (SWE) and transient elasto- Results: Mean age of patients was 27.2 Æ 13.21 years. graphy (TE) in determining liver fibrosis among Miscellaneous 24 patients presented with decompensated CLD (10— patients with chronic liver disease. ascites with variceal bleeding, 8—ascitis with jaundice, Methods: We enrolled 24 consecutive patients with 6—hepatic encephalopathy with variceal bleeding) various chronic liver diseases who underwent liver baseline CTP 8.6 Æ 2.11, MELD 20.25 Æ 7.34. 10 biopsy (BX) from September 2015 to November patients presented with acute hepatitis and 4 patients 2015, three months prior in Medical Gastroenter- present with fulminant hepatic failure. 52.63% ology Dept. of Super Specialty Hospital at Trivan- patients had KF ring on slit lamp examination. On drum Medical College. All the patients were investigations: 24 h urinary Cu was 488.89 subjected to evaluation with TE and SWE simulta- Æ 233.23 mg/day, serum ceruloplasmin was 13.23 neously over two days within three months of the Æ 4.34 mg/L. 7 patients were diagnosed by D-penicil- biopsy. TE was carried out in all patients with a lamine challenge test. On liver function tests, total FibroScan® (ECHOSEN FIBROSCAN 502) and the bilirubin was 17.49 Æ 15.11 mg/dl, AST 287 SWE measurement, was done using Aixplorer Æ 257 U/L, ALT 144 Æ 133 U/L, ALP 229 Æ 175 U/ (SuperSonic Imagine, France). Fibrosis staging L and other biochemical parameters were within nor- wasscoredonanF0–F4 using the Metavir staging mal limit. On hemogram, Hb was found low in 23 system. Statistical analysis was done using standard patients with mean of 9.45 Æ 2.95 g/dl. 4 patients AUROCs. with decompensated CLD also had HBsAg positive. Results: Main characteristics: 75% males, median age 3 patients of acute hepatitis and 1 of fulminant 36 years (24–51). Etiology: NASH—10, CHB—9, AIH— hepatic failure had IgM anti-HEV positive. All these 3, MTX—2. Fibrosis stages (n): F1—16.67% (4), F2— patients were treated with chelators and Zn therapy. 37.5% (9), F3—25% (6) and F4—20.83% (5). Standard Conclusion: Most patients of Wilson’s disease in this AUROCs (95% CI) for SWE, and Fibroscan were, study were presented with decompensated CLD in respectively: Stage 2 VS Stage 1—0.924 and 0.903, young age group, followed by acute hepatitis with for Stage 3 VS Stage 1-2—0.921 and 0.893 and for simultaneous acute HEV infection and third presen- Stage 4 VS Stage 1-3—0.994 and 0.988. Correlation tation was fulminant hepatic failure. between SWE score and FS score Spearman’s rho = 0.651, P = 0.001. Correlation between SWE CONFLICTS OF INTEREST score and Biopsy score Spearman’s rho = 0.849, P < 0.001. Correlation between FS score and Biopsy The authors have none to declare. score Spearman’s rho = 0.817, P < 0.001.

Conclusion: In our study shear wave elastography, Trichrome stains were positive in these fibrotic areas. and transient elastography showed good correlation Few muscle fibres showed PAS positivity in the with histologic fibrotic stages. Sensitivity and speci- vacuoles. Based on these findings a diagnosis of gly- ficity of both shear wave elastography, and transient cogen storage disorder was made. However, the child elastography increased the severity of liver fibrosis. expired and enzyme studies and further typing could not be performed. fi CONFLICTS OF INTEREST Conclusion: Glycogen storage disorders are dif cult to diagnose and cure. They present with a conun- The authors have none to declare. drum of features involving heart, liver or muscles. Early identification of this group of disorders is Corresponding author: Gopu R. Babu. important to improve the survival and outcome of E-mail: [email protected] these patients. http://dx.doi.org/10.1016/j.jceh.2016.06.130 CONFLICTS OF INTEREST

The authors have none to declare. 10 Corresponding author: Aruna Chhikara. DIAGNOSTIC CONUNDRUM OF INFANTILE E-mail: [email protected] GLYCOGEN STORAGE DISORDER WITH http://dx.doi.org/10.1016/j.jceh.2016.06.131 MYOPATHY Aruna Chhikara, Sarika Singh, Brijnandan Gupta, Mariya Ansari 11 Lady Hardinge Medical College, New Delhi, India TRANSARTERIAL CHEMOTHERAPY (TAC) VERSUS ORAL CHEMOTHERAPY IN THE Background: Glycogen storage diseases (GSD) are

TREATMENT OF UNRESECTABLE Miscellaneous inherited metabolic disorders of glycogen metabo- HEPATOCELLULAR CARCINOMA WITH lism. The overall GSD incidence is estimated 1 case PORTAL VEIN THROMBOSIS: A per 20,000–43,000 live births. There are only a few RANDOMIZED CONTROLLED TRIAL case reports about GSD in India. There are over 12 types of GSD and they are classified based on the Shashi B. Paul, Shivanand R. Gamanagatti, enzyme deficiency and the affected tissue. Disorders Vishnubhatla Sreenivas, Devesh P. Yadav, Neeti Nada, of glycogen metabolism may affect primarily the liver, Baibaswata Nayak, Shalimar, Subrat K. Acharya the muscle, or both. Case Report: We present a case of two month old All India Institute of Medical Sciences, New Delhi, India female who presented with lethargy and late onset neonatal sepsis at 15 days of life. The patient Background and Aim: Majority of the HCC patients improved with antibiotics. However one month later report to the hospital in an advanced stage when no she again developed lethargy and vomiting. She had curative therapies can be offered. Vascular involve- hepatosplenomegaly, peeling of skin and generalized ment (main portal vein thrombosis) limits their ther- erythema. She did not respond to antibiotics. Her two apeutic options. Palliative treatment in the form of siblings died with similar complaints at 1½ and 2½ chemotherapy becomes the main stay of treatment in months of life. Keeping inborn error of metabolism in such advanced cases. Transarterial chemotherapy mind brain, liver and muscle biopsy were sent for (TAC) has been tried by few researchers. Currently, histopathological examination. Sections from the radioembolization is recommended for such patients. brain were unremarkable. Liver biopsy showed micro- However, it is costly and has limited availability. vesicular and macrovesicular steatosis with mild peri- Whether TAC is better than oral chemotherapy portal fibrosis. The cytoplasmic vacuoles of (OC), this information needs exploration. This study hepatocytes showed PAS positivity. Sections from was undertaken to ascertain the efficacy of TAC in muscle biopsy showed atrophy, vacuolar degenera- comparison to OC in advanced HCC. tion and necrosis of muscle fibres. At places muscle Methods: Consecutive patients of unresectable HCC fibres were replaced by fibrotic tissue containing few reporting to liver clinic AIIMS, were studied. Patients hyalinised blood vessels. Von Gieson and Masson above 12 years of age, performance status 0–2, Child’s

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A/B cirrhosis, main portal vein thrombosis and will- Methods: CH patients scheduled for liver biopsy, ing to enroll after informed written consent were underwent SWE on the same day. SWE was per- included. Randomization into group-1 (TAC) and formed on Supersonic-Imagine Ultrasound (US) group-2 (OC) was done. For TAC, patients were machine with patient lying supine, right arm in max- admitted a day prior and intra-arterial chemotherapy imum abduction. B-Mode US image of right lobe liver was administered through the hepatic artery supply- was acquired through the right intercostal space. ing the tumor after transfemoral picture. In OC SWE mode was turned on and SWE box was placed group, Thalidomide and Capecitabine was used with in the liver at a depth of 3–5 cm from the liver capsule, blood test monitoring every fortnight. Clinical/ima- avoiding the intrahepatic vessels. After ensuring ging follow-up (FU) was done at one, three and six image stabilization, a color image of different types months’ interval and data recorded. of stiffness was obtained. Increasing fibrosis was Results: Of the 135 patients screened, 30 were found depicted by deep blue color to red. Quantification suitable and randomized (TAC-16, OC-14). Their clin- was then performed by choosing a circle (15–20 mm ical, biochemical parameters and symptomatology diameter) preferably in the central area of the SWE were comparable. The median FU was—TAC group box, exhibiting a homogeneous color map display. Six 7 months (range 1–48 months) in the TAC group and liver stiffness values (maximum, minimum, mean) 4.4 months (range 1–16 months) in the OC group. The per patient were taken at different segments of the cumulative survival rate at 12 months was significantly right lobe. Mean stiffness value was correlated with better in the TAC group compared to OC group Metavir histological grading (F0–F4). (43.7% vs 15.4%, P—0.03). Tumor response was compa- Results: Ten CH patients (9CHB, 1CHC) were eval- rable and could be ascertained in very few patients. uated. On SWE, qualitative and quantitative assess- Conclusion: Transarterial chemotherapy is useful ment, different mean values of liver stiffness were and provides a better survival than oral chemotherapy recorded (range 4.7 kPa to 18.7 kPa). On correlation in advanced HCC patients. with Metavir score, F0, F1, F2, F3 and F4 grade of liver Miscellaneous fibrosis was diagnosed in two patients each CONFLICTS OF INTEREST respectively. Conclusion: SWE is a reliable diagnostic tool for the The authors have none to declare. evaluation of liver fibrosis. Larger studies are required for establishing SWE cut off values for diagnosing Corresponding author: Shashi B. Paul. different grades of fibrosis in Indian patients of CH. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.132 CONFLICTS OF INTEREST

The authors have none to declare. Corresponding author: Shashi B. Paul. 12 E-mail: [email protected] SHEAR WAVE ELASTOGRAPHY FOR http://dx.doi.org/10.1016/j.jceh.2016.06.133 ASSESSMENT OF LIVER FIBROSIS IN CHRONIC HEPATITIS: PILOT WORK Shashi B. Paul, Prasenjit Das, Hanish Sharma, Maneesh Vijayvargiya, Shouriyo Ghosh, R. Vidyasagar, 13 Dawesh Yadav, Shivanand R. Gamanagatti, CHARACTERISTICS OF CONGENITAL Siddhartha Gupta, Subrat K. Acharya HEPATIC FIBROSIS AND CAROLI’S All India Institute of Medical Sciences, New Delhi, India DISEASE: EXPERIENCE OF A TERTIARY CARE CENTER IN THE CILIOPATHY OF Background and Aim: Shear wave elastography CHILDHOOD (SWE) is a novel ultrasound technique used for detecting liver ﬁbrosis in patients of chronic hepatitis Brijnandan Gupta 1, Prasenjit Das 2, Rajni Yadav 2, (CH). Assessment of ﬁbrosis is based on the liver Shalimar 2, S.K. Acharya 2, K.S. Madhusudan 2, stiffness assessed both in qualitative and quantitative S.K. Panda 2, Siddhartha Datta Gupta 2 manner. We evaluated CH patients [hepatitis B (CHB), hepatitis C (CHC)] and compared the results 1Lady Hardinge Medical College, India, 2All India Institute of Medical with the reference method of liver biopsy. Sciences, New Delhi, India

Background and Aim: Congenital hepatic fibrosis Nikhil Sonthalia, Pravin Rathi, Samit Jain, (CHF) is considered as variant of autosomal recessive Ravindra Surude, Ashok Mohite, Sunil Pawar, polycystic kidney disease (ARPKD) affecting children Qais Contractor and adolescents. Inheritance pattern is autosomal Topiwala National Medical College and BYL Nair Ch Hospital, Mumbai, recessive and affected gene is PKHD1 located on India chromosome 6p21, which encodes protein fibrocystin present on cilia of renal tubules and intrahepatic bile Background and Aim: Severe acute presentation is ducts. CHF may be associated with Caroli disease. We an uncommon manifestation of autoimmune hepa- aimed at characterizing the histopathological fea- titis (AIH) and it remains poorly characterized. The tures of these rare diseases and tried to correlate with aim was to study natural history and treatment out- radiological features, wherever available. comes of AIH variants presenting with severe-AIH. Methods: Retrospective study was done. Eight cases Methods: Out of 1153 patients with acute or chronic were retrieved from the archives of pathology depart- liver disease who were screened from January 2011 till ment, AIIMS. Detailed analysis of the histopatholo- December 2015, 125 (10.84%) were diagnosed as AIH. gical features was done. We tried to correlate the Of them 101 patients where finally recruited. Patients histopathological features with clinical and radiolo- were classified as Seropositive and Seronegative-AIH gical features. based on pre-specified diagnostic criteria. Patients Results: We included total 8 cases (3 males and 5 with acute liver failure (ALF), acute on chronic liver females). Age range varied from 3months to 13 years. failure (ACLF) and severe acute hepatitis were defined Two out of 8 cases had concomitant Caroli disease. as severe-AIH. Clinical, biochemical, serological, his- CHF is usually associated with juvenile type of tological parameters and treatment outcomes with ARPKD. On histopathology, portal tracts were fi follow up till 12 months were analyzed between dif- expanded by brosis and marked bile duct prolifera- ferent groups. tion was noted around portal tract. In 4/8 cases there Results: Out of 101, 24 (23.76%) had severe-AIH. Of were presence of mild to moderate mixed inflamma- fi them 9 (37.5%) were severe acute hepatitis, 3 (12.5%) tory in ltrate comprising of lymphocytes, histiocytes, ALF and 12 (50%) ACLF. Seronegative-AIH patients plasma cells and neutrophils. Individual hepatocytes presented as severe-AIH, significantly more than Ser- were unremarkable in all the cases. opositive-AIH (50% vs. 20.27%, P = 0.022). However, Miscellaneous Conclusion: Caroli disease and CHF are rare diseases response to treatment were not significantly different associated with ductal plate malformation. Liver between the two groups (P > 0.05). Severe-AIH had enzyme levels are usually normal. These are generally 50% non-responder. Jaundice (88.88% vs. 68.7%, suspected on USG and MR cholangiography. Porto- P = 0.048), encephalopathy (55.55% vs. 6.66%, systemic shunt surgery gives good result in patient P = 0.014) and higher INR values (2.17 Æ 0.60 vs. having patent portal vein and well preserved liver 1.82 Æ 0.14, P = 0.038) were factors associated with function. So, early diagnosis is of utmost importance non-response rather than presence or absence of in CHF and Caroli disease for planning further autoantibodies in severe-AIH. Kaplan–Meier analysis management. showed that probability of remission over 12 months was no different in Seronegative-AIH and Seroposi- CONFLICTS OF INTEREST tive-AIH patients who had severe-AIH (log rank test = 2.013, P = 0.156). The authors have none to declare. Corresponding author: . Characteristic N (%) or Mean W SD N (%) or Mean W SD P-value E-mail: [email protected] Type of AIH Severe AIH—24 Non-severe (23.76%) AIH—77(76.23%) http://dx.doi.org/10.1016/j.jceh.2016.06.134 Jaundice/ 24 (100%)/6 51 (66.2%)/3 0.018*/ encephalopathy/ (25%)/17 (70.8%) (3.8%)/34 (44.2%) 0.005*/ ascites 0.034* ANA positive/ 10 (41.7%)/6 56 (72.7%)/6 0.006*/ Seronegative-AIH/ (25%)/ (7.79%)/ 0.033*/ 14 serum IgG (mg/dl) 1983.21Æ164.95 2672.72Æ578.90 0.0001* Remission at 12 (50%)/3 (12.5%) 55 (71.42%)/1 0.081/ SERONEGATIVE AUTOIMMUNE HEPATITIS 12 months/ (1.29%) 0.041* PRESENTS WITH MORE SEVERE DISEASE mortality BUT HAS SIMILAR OUTCOMES AS COMPARED TO SEROPOSITIVE PATIENTS

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Conclusion: Approximately 24% of patients with excluded. Antitubercular therapy (ATT) was impli- AIH have severe-AIH. Conventional autoantibodies cated as definite DILI in 2 cases and probable in 1 are often absent in severe-AIH; however, it does not case. Clarithromycin (6 cases), amoxicillin-clavula- alter the outcome. Liver failure induced immune nate (4 cases) and clindamycin (4 cases) were most paralysis may mask the autoantibody production common antibiotics. 25 (69.4%) recovered, 8 (21.9%) in severe-AIH. All the patients of severe AIH including expired, 2 (5.6%) developed acute on chronic liver Seronegative-AIH should be given a trial of corticos- failure and 1 (2.8%) underwent liver transplant. teroid based therapy early. Conclusion: Definitive diagnosis of DILI in CLD patients is difficult. Exposure to a known hepatotoxic fi CONFLICTS OF INTEREST agent, temporal pro le of LFT changes after initiation and withdrawal of antibiotics are useful pointers. The authors have none to declare. Early diagnosis of DILI, even if not definitive, may help in timely intervention and affect outcomes in Corresponding author: Nikhil Sonthalia. CLD patients. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.135 CONFLICTS OF INTEREST

The authors have none to declare. Corresponding author: Rajesh Gopalakrishna. 15 E-mail: [email protected] PROFILE OF DILI IN PATIENTS WITH http://dx.doi.org/10.1016/j.jceh.2016.06.136 CHRONIC LIVER DISEASE

Miscellaneous S. Shiraz, Rajesh Gopalakrishna, C.M. Neethu, P. Nair, Rama Venu 16 Amrita Institute of Medical Sciences, Kochi, India HEPATORENAL FIBROCYSTIC DISEASE Background and Aim: Patients with chronic liver SPECTRUM IN 2 SISTERS disease (CLD) may be more susceptible to drug Sajan Agarwal, Raj Gupta, Anu Bhandari, induced liver injury (DILI) via reduced drug clearance, Kalpana Mangal aberrant metabolism, altered excretion, or impaired adaptive responses. Diagnosis of DILI may identify a J K Lone Hospital, SMS Medical College, Jaipur, Rajasthan, India reversible cause for acute decompensation. The aim of the study the profile and outcomes of DILI in CLD Background: Caroli’s syndrome (CS) is a rare con- patients. genital disorder characterized by multiple segmental Methods: 200 consecutive inpatients with CLD who cystic or saccular dilatations of the intrahepatic bile had been received antibiotic therapy between Septem- ducts and congenital hepatic fibrosis(CHF). The clin- ber and December 2015 were prospectively studied ical features of this syndrome reflect both the char- for features suggestive of DILI. The Naranjo adverse acteristics of CHF such as hepatic fibrosis, portal drug reaction (ADR) probability scale was used for hypertension, and renal cystic disease and that of identifying ADRs in CLD patients. The Maria and Caroli’s disease (CD) named as recurrent cholangitis Victorino (M&V) assessment scale was used for caus- and cholelithiasis. CS is associated with renal invol- ality assessment. vement in up to 60% of patients and implies a dilata- Results: Thirty-six (18%) patients were identified by tion of the collecting renal tubules. Naranjo scale. The most common etiology of CLD in Case Report: We report a case of 2 sisters who were these patients was alcohol (50%); HCV (13.9%), NASH presented with hepatosplenomegaly, growth failure, (8.3%), cryptogenic (8.3%), HBV (5.6%) were other intrahepatic bile duct dilatation and bilateral auto- common causes. DILI was more common in Child somal polycystic kidney disease (ARPKD) on imaging class C (58.3%) as compared to Child B (27.8%) and with histopathological diagnosis of CHF. To confirm Child A (13.9%). 8 patients had hepatitic, 5 had this hepatorenal fibrocystic disease spectrum in cholestatic, and 23 had mixed pattern. By M&V scale, younger sister, genetic testing (PKHD1 gene) was there were 2 definite, 8 probable, 11 possible cases of done and report is awaited. Elder sisters also had DILI while 12 were found to be unlikely and 3 were asymptomatic stage-2 chronic kidney disease

(CKD). UGI Endoscopy of younger sister showed randomly selected. Seroprevalence was determined high risk esophageal varices (grade III with red colour by detection of IgG antibodies against soluble egg sign) which was managed with band ligation. Nutri- antigen using ELISA (DRG, USA). tional rehabilitation with high calorie diet, fat soluble Results: The age range of subjects was 13–84 years vitamin and MCT oil supplementation was started in with a mean age of 41.5 years (SD Æ16.9). The overall both the sisters along with ursodeoxycholic acid sup- seroprevalence of schistosomiasis IgG in the enrolled plementation in younger sister for cholestasis. Both subjects was 47.5% (95% CI: 39.8–55.2%). The preva- the patients have been advised regular follow-up for lence was significantly higher in cases of CLD (63.7% monitoring the progression of the disease. The family vs 39.2%) compared to non-CLD cases (P = 0.003) members of the patients were screened and both with age above 30 years (53.8% vs 31.6%, P = 0.04). parents and younger brother had a normal abdom- The prevalence was higher among females (53.1%) inal ultrasound. Prognosis is fairly good unless recur- compared to males (45.2%),however, gender differ- rent cholangitis and renal failure develops. Combined ence was not significant statistically. liver and renal transplantation seems the ultimate Conclusion: We believe that this is the first report of treatment for this disease in case of end stage renal such a seroprevalence pilot study from the North- disease (ESRD) with clinical significant portal hyper- East India. Our results show high seroprevalence of tension and/or recurrent cholangitis. schistosomiasis in CLD patients as compared to con- Conclusion: Patients with CS should be screened for trols. However, to validate this novel finding from our renal cystic lesions and vice versa even if they are state, a larger study is required to know the detailed asymptomatic. prevalence of schistosomiasis in more of Indian population, as it is a treatable cause of portal CONFLICTS OF INTEREST hypertension.

The authors have none to declare. CONFLICTS OF INTEREST Corresponding author: Sajan Agarwal. The authors have none to declare. E-mail: [email protected] Corresponding author: . http://dx.doi.org/10.1016/j.jceh.2016.06.137 E-mail: [email protected] Miscellaneous http://dx.doi.org/10.1016/j.jceh.2016.06.138

SEROPREVALENCE OF SCHISTOSOMIASIS 18 IN CLD CASES FROM UPPER ASSAM ENTERAL PARASITES DETECTED BY FECAL Tanu Arora 1, Anup Das 1, Biswajyoti Borkakoty 2, EXAM, COLONOSCOPY, OR ABDOMINAL Munmun Gohain 2 IMAGING STUDIES IN A KOREAN HEALTH 1Assam Medical College and Hospital, Dibrugarh, India, 2Regional CHECKUP CENTER FOR 10 YEARS Medical Research Centre (ICMR), Dibrugarh, India Jong In Yang

Background and Aim: Schistosomiasis is associated Seoul National University Hospital Healthcare System Gangnam Center, with hepatic granuloma formation, causing fibrosis Seoul, Republic of Korea which leads to pre-sinusoidal portal hypertension and its sequelae. Non-human schistosomiasis is also Background and Aim: Detecting enteral parasitic reported from the Indian subcontinent. Present study infection can easily be done by simple fecal exam, was conducted in Assam Medical College and Hospi- and may also be aided by organ specific exams such as tal located in upper Assam to find schistosoma abdominal ultrasonography (US), computed tomo- seroprevalence. graphy (CT), or colonoscopy. Enteral parasitic infec- Methods: A cross-sectional study was conducted in tion may be serious enough to contribute to the Assam Medical College and Hospital in Medicine carcinogenesis considering that clonorchiasis is department during 2014–2015, enrolling 162 sub- known carcinogen for cholagiocarcinoma. The aim jects. Among them 58 cases of CLD and 102 cases of our study was to explore the status of enteral other than CLD (who served as controls), were parasites detected by fecal exam in a Korean health

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checkup center for 10 years and to examine the manifestations in chronic ulcerative colitis patients. efficacy of each organ specific exam for detecting There is paucity of data on hepatobiliary alterations enteral parasites. in ulcerative colitis patients from India. The study Methods: Data about 197,406 stool samples col- was carried out to evaluate the hepatobiliary altera- lected from 99,451 subjects in a single health checkup tions in ulcerative colitis patients admitted to a ter- center for 10 years were analyzed. tiary care centre in Odisha. Results: 3472 (1.73%) stools were positive for para- Methods: Consecutive patients of ulcerative colitis sitic ova. Sort of parasitic ova were as follows: clo- admitted to Gastroenterology Department SCB Med- norchiasis 1508 (0.76%); metagonimiasis 959 ical College, Cuttack from October 2013 to April 2015 (0.49%); trichiurasis 855 (0.43%); ascariasis 142 were included in the study. Patients with history of (0.072%); trichostrongylosis 5 (0.0025%); taeniasis liver diseases were excluded. All patients were sub- 2 (0.001%); enterobiasis 1 (0.00051%). Detection rate jected to clinical examination, liver function tests and of clonorchiasis decreased significantly over the 10 ultrasonography for evaluation of hepatobiliary years and was significantly higher among initial alterations. MRCP was performed in selected examination subjects than reexamination subjects. patients. Controls were recruited from healthy sub- However, the decrease in detection rate over 10 years jects (n = 100). and the differential detection rate between initial Results: A total of 112 patients [73 (65.1%) male; 39 examination subjects and reexamination subjects (34.9%) female] with ulcerative colitis were included. were not observed in other enteral parasitic infec- The mean age and BMI were 40.2 Æ 14.01 years and tions. Colonoscopy was performed in 258 (30.18%) 21.3 Æ 3.5 kg/m2 respectively. Patients with mild, trichiurasis subjects, and among them, colonoscopy moderate and severe disease activity were 22 revealed adult worm in 23 (8.91%) subjects. Abdom- (19.6%), 67 (59.8%) and 23 (20.5%) respectively. The inal US or CT was performed in 1505 (99.8%) clo- median duration of illness was 24 months (IQR: 6.5 norchiasis subjects, and among them, only 37 (2.46%) Æ 48). 40 (35.7%) patients had arthralgia, 6 (5.3%) Miscellaneous subjects showed images compatible with had arthritis, 13 (11.6%) episcleritis, 3 (2.6%) had clonorchiasis. erythema nodosum, 1 (0.9%) had pyoderma gang- Conclusion: Regular fecal exams during health renosum. 60 (53.8%) developed hepatobiliary altera- checkup may reduce the burden of silent but carci- tions. 2 (1.7%) had jaundice, pruritus and clay nogenic clonorchiasis. Abdominal US, CT, or colono- coloured stool in whom MRCP revealed primary scopy may not be an alternative to a fecal exam for sclerosing cholangitis. 22 cases (19.6%) had hepatic screening enteral parasites during health checkup. steatosis in comparison to controls (17%) (P =0.49), 42 cases (37.5% and 28 controls (28%) had asympto- P CONFLICTS OF INTEREST matic transaminitis ( = 0.14), 17 cases (15.1%) and 8 controls (8%) had elevated alkaline phosphatase The author has none to declare. (P = 0.11). Conclusion: The study revealed that hepatobiliary http://dx.doi.org/10.1016/j.jceh.2016.06.139 alterations are the most common extra intestinal manifestations in ulcerative colitis patients and amongst hepatobiliary alterations, asymptomatic transaminitis is the most common hepatobiliary 19 alterations in the present study though it was not statistically significant when compared to HEPATOBILIARY ALTERATIONS IN controls. ULCERATIVE COLITIS: A REPORT FROM A TERTIARY CARE CENTRE IN ODISHA CONFLICTS OF INTEREST

Pradeep Padhi, Jimmy Narayan, Preetam Nath, The authors have none to declare. Prasant Parida, Kaibalya Dash, Sambit Behera, Suryakanta Parida, Girish Pati, Chitta Panda, Corresponding author: Pradeep Padhi. Shivaram Singh E-mail: [email protected]

SCB Medical College, Cuttack, India http://dx.doi.org/10.1016/j.jceh.2016.06.140

Background and Aim: Hepatobiliary manifestations are amongst the most common extraintestinal

20 21 UTILITY OF TISSUE ELASTOGRAPHY IN AN UNUSUAL CASE OF CHRONIC MEASURING LIVER IRON OVERLOAD IN HEPATITIS COMPARISON TO MRI T2 AND SERUM Kiran D. Shinde, Praveen kumar, D. Srinivas, FERRITIN IN PATIENT WITH THALASSEMIA Pravin Mathew, Dawood Kazia, Anil Kokkat, MAJOR Prashanth Kanni, Manjunath Patil, Vishakha Khalde, Kaivan Shah, Nirav Pipaliya, Prabha Sawant Suraj Uppalapati, Mounika Kilari Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, Vydehi Institute of Medical Science & Research Center, Bangalore, India India Background: Drugs are an important cause of liver Background and Aim: We undertook this study to – establish whether tissue elastography (TE) can be injury. Drugs account for 20 40% of all instances of used as an alternative to MRI T2* to predict the fulminant hepatic failure. Drug induced hepatic degree of iron overload and in turn, the degree of injury is the more common reason cited for with- liver fibrosis in thalassemia major patients. drawal of an appropriate drug. We are reporting a Methods: We evaluated 154 patients with thalasse- unusual case of chronic hepatitis. mia major, chronically dependent on blood transfu- Case Report: We describe a case of a middle aged sion and on iron chelator therapy. All patients women who presented to us with dyspepsia and underwent routine blood investigations, serum ferri- fatigue with hepatomegaly. She was known case of tin and TE (Fibroscan®402, Echosens, Paris) within rhuematoid arthritis and hypertension. She was on one month of MRI T2* of the liver. Tab methotrexate 5 mg OD, Tab amlodepine 5 mg OD, Tab folic acid 5 mg OD since 4 years. She was on Results: Of total 154 patients, 99 (64%) were male. – Mean age of patients was 12 Æ 3.6 years (mean Tab hydroxychloroquine 400 mg OD for 4 5 months Æ standard deviation (SD)). Total serum bilirubin, and stopped since 2 months. She was on oral contra- SGPT, SGOT and serum albumin were 1.4 Æ 0.6 mg/ ceptive pills since two and a half months. There was dl, 65.0 Æ 51.8 IU/L, 62.9 Æ 44 IU/L and 4.2 Æ 0.2 g/ no evidence of lymphadenopathy or stigmata of chronic liver disease. On investigations we found d respectively. Mean liver stiffness measurement Miscellaneous (LSM), MRI T2* (3 T), corresponding MRI R2* persistent elevation of transaminase and ALP levels (3 T) and ferritin values were 8.2 Æ 4.4 kPa, 3.18 since 6 months. Her HBsAg and anti-HCV (ELISA) Æ 2.6 ms, 617.3 Æ 549 Hz and 4712 Æ 3301 ng/ml were non-reactive, IgM HAV and HEV were negative. respectively. According to MRI, 67 (43.5%), 49 USG abdomen showed fatty hepatomegaly, Ogd- (31.8%) and 22 (14.3%) patients had mild, moderate scopy showed LA grade A esophagitis, Antral gastritis. and severe iron overload (IO), respectively. A strong Her autoimmune hepatitis and Wilson disease work correlation was found between fibroscan LSM values up were negative. Percutaneous liver biopsy was per- and MRI R2* values (r = 0.85, P < 0.001). AUROC for formed and it revealed chronic granulomatous hepa- TE to detect severe, moderate and mild iron overload titis. Multiple etiologic factors like TB, sarcoidosis, was 94.8%, 84.5% and 84.7%, respectively. LSM values PBC, drug induced granulomata, etc. were consid- (kPa) more than 13.5, 7.8 and 5.5 predicts severe, ered. On discharge she was advised to stop oral con- moderate and mild IO with sensitivity and specificity traceptive pills in view of drug induced of 92% and 93%, 82% and 82% and 73% and 75%, granulomatous hepatitis. After 4 months of Follow respectively. No correlation was found between TE up she was asymptomatic and her LFTs were normal. and ferritin (r = 0.19, P = 0.11). Conclusion: Drug induced granulomatous hepatitis Conclusion: Tissue elastography can be used as an should be considered in the differential diagnosis of a alternative to MRI T2* for predicting moderate to patient with chronic hepatitis. severe liver iron overload, in chronic transfusion dependent thalassemia major patients. CONFLICTS OF INTEREST CONFLICTS OF INTEREST The authors have none to declare. The authors have none to declare. Corresponding author: Kiran D. Shinde. E-mail: [email protected] Corresponding author: Kaivan Shah. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.142 http://dx.doi.org/10.1016/j.jceh.2016.06.141

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22 CONFLICTS OF INTEREST A PROFILE OF AIH FROM INDIA The author has none to declare. Sunil Taneja http://dx.doi.org/10.1016/j.jceh.2016.06.143 Postgraduate Institute of Medical Education and Research, Chandigarh, India

Background and Aim: The spectrum of neurological 23 dysfunction in cirrhosis varies from mild cognitive impairment to a full blown extrapyramidal syndrome COLLAGEN RICH SCAFFOLDS FOR LIVER referred to as hepatocerebral degeneration. There is ENGINEERING: A STEP FORWARD TO AN however little information about the clinical signifi- ARTIFICIAL LIVER cance of extrapyramidal signs associated with cirrho- Catherine Martin 1, R. Subathra 2, V. Jayanthi 2, sis, and it is not known if the existence of the 2 2 2 fl Srinivas Reddy , Joy Varghese , Mohammed Rela , extrapyramidal signs in uences the prevalence of 1 MHE and daily-life activities or health-related quality Narayana Kalkura of life (HRQOL) of patients with cirrhosis. Hence this 1Anna University, Chennai, India, 2Global Health City, Chennai, India present study was carried out to elucidate the relationship between extrapyramidal signs and cognitive Background and Aim: Tissue engineering is a new impairment with MHE and quality of life. and emerging field which tries to regenerate human Methods: Fifty-four patients of cirrhosis without tissues with the help of cells, bioactive molecules and evidence of overt hepatic encephalopathy were biomaterials such as scaffolds. There are more than enrolled in the study and were subjected to PHES 100 liver diseases due to the complex function of the Miscellaneous and CFF for diagnosis of MHE. The assessment of liver. To overcome this condition, the present study extrapyramidal signs was evaluated using the Unified aims at developing a scaffold which will be congenial Parkinson’s Disease Rating Scale (UPDRS) parts 1, 2 for growth of hepatocytes. and 3 and HRQOL was measured using SF-36 Methods: Collagen is the major connective tissue questionnaire. and is abundant in the extra cellular matrix (ECM). Results: Out of 54 patients MHE was detected in 28 This is one of the main constituents of liver and (51.8%) patients. The extrapyramidal signs (UPDRS other organs. Other proteins are also present in the score 3) were present in 34 (62.9%). Extrapyramidal ECM of the liver which forms the microenviron- signs were demonstrated in 24 (85.7%) patients with ment for the development of a hepatocyte. For this, MHE compared to 10 (38.5%) patients without MHE the composites of collagen and other ECM mole- (P = 0003). The overall performance was poorer in cules were prepared with an interpenetrating por- patients with MHE and in patients with extrapyra- ous structure. midal signs compared to the patients who did not Results: The composites can be used for tissue engi- have MHE or extrapyramidal signs. Patients with neering as well as for drug delivery and also support extrapyramidal signs had higher MELD score cell growth and proliferation. The selection of the (P = 0.008) and serum bilirubin (P = 0.07). Of 54 material was characterized for physical properties patients both MHE and extrapyramidal signs were using Scanning Electron Microscopy (SEM), Fourier present in 24 (44.4%) patients, both were absent in 16 Transform Infra Red Spectroscopy (FTIR), Differen- (29.7%) and either were present in 14 (25.9%) patients. tial Scanning Calorimetry (DSC), swelling and wett- Patients with MHE showed poorer SF 36 scores com- ability. The extracted protein was run through pared to controls and patients without MHE. There sodium dodecyl sulphate gel (SDS), and it was con- was no significant difference in various SF 36 scores firmed to be collagen. The scaffold was also checked between control subjects and patients without MHE. for it’s cytocompatibility so that the material could Conclusion: There is a high prevalence of MHE be used for tissue engineering. Preliminary observa- among patients with cirrhosis. The prevalence of tion suggests hemocompatibility and protein adsorp- extrapyramidal signs is significantly higher in cirrho- tion and these samples can be used for the 3D culture tic patients with MHE than in those without MHE. of cells. The presence of MHE had an independent relation- Conclusion: We believe the ready availability and the ship to the presence of extrapyramidal signs and simple extraction of collagen would make this a health related quality of life. potent scaffold for tissue engineering.

CONFLICTS OF INTEREST CONFLICTS OF INTEREST

The authors have none to declare. The authors have none to declare. Corresponding author: . Corresponding author: Syed Afzal. E-mail: [email protected] E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.144 http://dx.doi.org/10.1016/j.jceh.2016.06.145

24 25 PANCREATIC EXOCRINE INSUFFICIENCY IN GRANULOMATOUS HEPATITIS DIABETES COMPLICATING INTRAVESICAL BACILLE Syed Afzal, Masi-ur-Rehman Ajmal, Ashaq Dar, CALMETTE-GUÉRIN (BCG) THERAPY FOR Sheelu Siddiqi HIGH-RISK SUPERFICIAL BLADDER CANCER J N Medical College Hospital, Aligarh, India Arun Iyer, Prasanth Sudheendran, Shanid Sathar, Background and Aim: PEI is frequently seen in DM. Sreejaya Sreesh, Krishnadas Devadas fi More than 50% of patients have pancreatic brosis Government Medical College and Hospital, Thiruvananthapuram, India and atrophy. The present study is designed to evaluate PEI in Type 1 and Type 2 DM. Primary aim: Background: Intravesical bacille Calmette-Guérin evaluate PEI in DM. Secondary aims: to co-relate (BCG) therapy is the most effective treatment for degree of PEI with duration of diabetes, PEI with high-risk superficial bladder cancer. Severe systemic diabetic neuropathy and size of pancreas with dura- complications are rare, but may occur in approxi- tion of diabetes. mately 1% of cases. Methods: 108 patients were taken up for study. It Case Report: We report a severe complication of was a hospital based, cross sectional observational intravesical BCG: a disseminated Mycobacterium bovis Miscellaneous analytical study conducted in JNMCH, AMU. Inclu- infection with biopsy-proven granulomatous hepatitis sion criteria: patients having Type 1 and Type 2 DM. in a patient with bladder cancer. In our case we did not Exclusion criteria: patients having acute and chronic start the patient on anti tubercular therapy (ATT), as pancreatitis (various etiologies). Fecal elastase 1 test opposed to the previous case reports of disseminated fi was used for PEI, Mono lament test for diabetic Mycobacterium bovis infection, in which the patient had neuropathy, USG for size of pancreas. been put on category I ATT. But in our case, the Results: 17 (15.74%) patients out of 108 had FEC patient responded to UDCA and symptomatic man- m <100 g, 22 (20.37%) had FEC between 100 and agement alone. This has not been previously described m m 200 g and 69 (63.88%) had FEC >200 g. 25.71% in literature and we want to highlight the fact that of Type 1 DM and 10.95% of Type 2 DM had severe selected patients with only granulomatous hepatitis m PEI (<100 g). Of 108 patients, 12.03%(13)showed (limited disease, as opposed to more diffuse involve- reduced size of pancreas, 5 had Type 1 and 8 had ment of lungs and liver reported in earlier cases in Type 2 DM.4 patients had a duration of disease literature) due to BCGosis may respond to conserva- between 5 and 10 years in Type 1 DM. Whereas in tive management alone. This also holds weight in the Type 2 DM, 4 had disease between 5 and 10 years and current scenario in our country as the number of 4 had >10 years of disease. 37 (50.68%) patients had resistant cases of TB has been on the rise and also diabetic neuropathy, 13 Type 1 and 24 Type 2 DM. considering the hepatotoxic profile of ATT drugs it Conclusion: The present study showed PEI is present may be prudent to observe the patient in selected cases. in both Type 1 and Type 2 DM, its more common in Type 1 DM (59.99% vs 24.65%). Both degree and CONFLICTS OF INTEREST prevalence of PEI increased with duration of disease (more frequent in Type 1 than Type 2 DM). The The authors have none to declare. prevalence of smaller pancreas increased with duration of disease (more frequent in Type 1 than Type 2 DM). Corresponding author: Arun Iyer. There is a strong co-relation between PEI and diabetic E-mail: [email protected] neuropathy (76% of neuropathy patients had PEI). http://dx.doi.org/10.1016/j.jceh.2016.06.146

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26 27 A RARE CASE OF BUDD CHIARI SYNDROME ADAMTS13 MUTATIONS ASSOCIATED SECONDARY TO ANTI PHOSPHOLIPID WITH DEFECTIVE ADAMTS13 SECRETION ANTIBODY SYNDROME AND INHERITED IN A PATIENT WITH NON-CIRRHOTIC THROMBOPHILIA PORTAL HYPERTENSION Saikrishna Katepally Ashish Goel 1, V. Raghupathy 1, G.J. Amirtharaj 1, Aaron Chapla 1, Aparna Ramachandran 1, Gandhi Hospital, Hyderabad, India Saravanan Sureshkumar 1, K.A. Balasubramanian 1, Anup Ramachandran 1, B. Ramakrishna 1, Background: Budd Chiari Syndrome is a heteroge- Nihal Thomas 1, Ian Mackie 2, C.E. Eapen 1, nous condition characterised by hepatic venous out- Elwyn Elias 1,3 flow obstruction at the level of hepatic veins and/or inferior vena cava. 1Christian Medical College, Vellore, India, 2University College London, 3 Case Report: A 20 years old, non-alcoholic male London, UK, University Hospital Birmingham, Birmingham, UK presented with progressive abdominal distension, hematemesis and jaundice since 4 weeks with H/O Background and Aim: ADAMTS13 (a disintegrin similar complaints twice in the past 1 year for which like and metalloproteinase with thrombospondin he was hospitalised and managed conservatively with type 1 motifs—13)—vWF (von-Willebrand factor) medications and blood transfusions On examination imbalance in non-cirrhotic intrahepatic portal hyper- pallor+, icterus+, clubbing+, Absent pubic and axillary tension (NCIPH) raises possibility of a mutation in hair and testicular atrophy noted. Abdomen dis- CUB domain (exons 26, 27) of ADAMTS13 gene. We tended, ascites present. Engorged veins noted over looked for such ADAMTS13 mutations in NCIPH. anterior abdominal wall and flanks with direction of Methods: Plasma vWF, p-selectin (which anchors Miscellaneous flow of blood below upwards and away from umbi- vWF multimers) levels and ADAMTS13 activity (by licus. Hepatosplenomegaly: present patient was eval- in-house collagen binding assay (CBA)) were assayed uated for the cause of cirrhosis of liver and screened in NCIPH patients and healthy controls. Exons 26/27 for viral markers, Wilson’s disease, autoimmune of ADAMTS13 were sequenced in 17 NCIPH patients hepatitis are found to be negative. Color Doppler and 3 healthy controls. In the NCIPH patient with of hepatic veins revealed non-visualization of hepatic ADAMTS13 mutation, ADAMTS13 immunostatin veins. MRI abdomen with MR venogram suggested: (indirect immunofluorescence) of liver biopsy and CLD with cirrhosis of liver, portal hypertension with next-generation sequencing (NGS) (Illumina plat- ascites, caudate lobe hypertrophy causing retrohepa- form) of entire ADAMTS13 gene were done. Restric- tic IVC narrowing, non-visualisation of hepatic veins tion fragment length polymorphism (RFLP) targeting S/O Budd Chiari Syndrome. Coagulation profile: the detected mutation was done in other subjects. serum APLA IgG: 18.24 m/ml (<10), Factor V func- Results: Significantly lower ADAMTS13 activity; tional:19% (70–120%), anti-thrombin III activity: 35% higher vWF and p-selectin concentrations were seen (80–120%), serum homocysteine: 5.77 mmoles/l in 24 (liver biopsy confirmed) NCIPH patients (20 (5.46–16.40), protein S functional: 41% (60–140%). males; age: 37, 17–66 years; median, range) compared Conclusion: This patient is classified as having anti- to 22 controls (17 males; age: 33, 28–61 years). CUB phospholipid antibody syndrome as per presence of 1 domain sequencing showed novel heterozygous lab and 1 clinical criteria. This patient is also having mutation in 1 NCIPH patient at rs140450669 inherited thrombophilia along with APLA syndrome (c.3829 C>T) leading to amino acid change (p. leading to the development of Budd Chiari Syndrome R1277W). NGS detected another heterozygous muta- with cirrhosis of liver. tion at rs2301612 (exon 12, c.1342 C>G), in cystein- rich domain, leading to amino acid change (p. CONFLICTS OF INTEREST Q448E). This 21 year old male had splenorenal shunt surgery for variceal bleed and developed glomerulo- The author has none to declare. nephritis 1 year later. He had severe ADAMTS13 deficiency (CBA: 10%) and high vWF (533 IU/dl). http://dx.doi.org/10.1016/j.jceh.2016.06.147 Anti-ADAMTS13 antibody immunostaining of his liver biopsy showed punctate diffuse staining (low power) and globules of ADAMTS13 (high power) in stellate cells, unlike normal and cirrhotic controls.

RFLP analysis did not detect R1277W mutation in 23 serum alkaline phosphatase levels (ALP). 36.4% had other NCIPH patients and 22 controls. elevated angiotensin converting enzyme levels. All Conclusion: ADAMTS13 mutations may affect patients underwent a liver biopsy which revealed ADAMTS13 secretion in some NCIPH patients. granulomatous liver disease. 63.6% were treated with oral corticosteroids. Response to steroids was brisk CONFLICTS OF INTEREST with normalization of serum bilirubin, transaminases and ALP levels in most of the cases. The authors have none to declare. Conclusion: The diagnosis of HS must be made on clinico-laboratory ﬁndings combined with assess- Corresponding author: . ment of other organ affection and histological evi- E-mail: [email protected] dence of non-caseating granulomas. http://dx.doi.org/10.1016/j.jceh.2016.06.148 CONFLICTS OF INTEREST

The authors have none to declare. 28 Corresponding author: Anil Pal. HEPATIC SARCOIDOSIS E-mail: [email protected] Anil Pal, Amey Sonawane, Deepak Amarapurkar http://dx.doi.org/10.1016/j.jceh.2016.06.149 Bombay Hospital and Medical Research Centre, Mumbai, India

Background and Aim: Sarcoidosis is a multisystemic 29 granulomatous disorder of unknown etiology. It primarily affects the lungs and hilar lymph nodes. Hepa- THROMBOELASTOGRAPHY ANALYSIS IN tic sarcoidosis (HS) is an infrequent extrapulmonary PATIENTS WITH CIRRHOSIS AND ITS site of disease. The aim of our study was to assess the CORRELATION WITH CONVENTIONAL clinical features, disease characteristics and treatment

COAGULATION PARAMETERS Miscellaneous response of patients with HS. Methods: This study included 22 patients with HS Rachit Agarwal, Piyush Ranjan who attended the gastroenterology clinic between Sir Gangaram Hospital, New Delhi, India 2000 and 2016. We analysed the patient demographics, co-morbidities, presenting symptoms, Background and Aim: Conventional parameters of laboratory parameters, radiologic features, extent of coagulation such as prothrombin time (PT) do not disease, liver biopsy and response to treatment. Other accurately assess the coagulation profile in cirrhosis causes of granulomatous liver disorders were thor- because of reduction in both anticoagulant and pro- oughly ruled out prior to establishing the diagnosis coagulant factors. Thromboelastography (TEG) is a of HS. rapid viscoelastic test of coagulation that assesses clot Results: 22 patients (15 males, 7 females) were diag- formation in whole blood, including plasmatic and nosed with HS. The mean age of the cohort was 47.36 cellular components. The aim of this study was to see Æ 14.87 years. The associated co-morbidities were correlation of TEG with conventional coagulation diabetes mellitus (36.4%) and hypertension (27.3%). tests and severity of liver disease (CTP score). 40.9% had received anti-tuberculous therapy in the Methods: Consecutive patients with cirrhosis past. Two patients had family history of sarcoidosis. admitted to the Gastroenterology Department were The commonest presenting symptoms were general- included. They were investigated with TEG para- ized weakness (68.2%), weight loss (59.1%), fever (50%) meters [r time, k time, alpha angle (AA), maximum and loss of appetite (40.9%). Hepatomegaly (90.9%), amplitude (MA)] and conventional coagulation para- splenomegaly (77.3%), icterus (50%) and pallor meters namely platelet count, PT, aPTT, fibrinogen (31.8%) were common presenting signs. Cirrhosis and d-dimer. Statistical analysis was done with Spear- of liver was evident in 22.7% of the patients. Imaging man’s correlation coefficient tests. revealed mediastinal, abdominal and retroperitoneal Results: 113 patients with cirrhosis were included. lymphadenopathy in 50% of cases. Concurrent lung The etiology was alcohol 42%, cryptogenic 40%, and involvement was observed in 40.9% of the cases. The viral 18%. k time, AA and MA showed significant commonest liver function abnormalities were hyper- correlation with PT, aPTT, fibrinogen and platelet bilirubinemia, elevated transaminase levels and counts (P < 0.05). There was significant correlation of

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CTP score with k time (P = 0.03), AA (P = 0.02) and the same time period. The mean ARFI (10 measure- MA (P < 0.001). There was no significant correlation ments per patients) velocities of our study popula- of r time with either CTP (P = 0.47) or PT, fibrinogen, tions was 2.07 Æ 0.87 m/s (mean Æ SD). The d-dimer and platelet counts (P > 0.05). Spearman correlation coefficient between the median Conclusion: TEG parameters demonstrated statisti- values of the ARFI and the histologic fibrosis stage of cally significant abnormalities in patients with cir- the Modified Ishak score was highly significant rhosis. TEG parameters correlated well with severity (P < 0.001) with rho = 0.7. Area under the receiver of liver disease (child status) and also with conven- operating characteristic curve for the accuracy of tional coagulation parameters. TEG analysis proves ARFI imaging was 0.81 for the diagnosis of advanced to be a rapid, inexpensive and efficient tool to assess fibrosis (fibrosis stage, F 3). coagulation in cirrhotics. k time, AA and MA are the Conclusion: ARFI imaging has strong correlation most interesting parameters for assessing bleeding with the histologic fibrosis stage along with good risk and severity in future studies. accuracy for prediction of severe fibrosis.

CONFLICTS OF INTEREST CONFLICTS OF INTEREST

The authors have none to declare. The authors have none to declare. Corresponding author: Piyush Ranjan. Corresponding author: Mahesh Goenka. E-mail: [email protected] E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.150 http://dx.doi.org/10.1016/j.jceh.2016.06.151 Miscellaneous 30 31 ACOUSTIC RADIATION FORCE IMAGING TRANSIENT ELASTOGRAPHY (FIBROSCAN) ELASTOGRAPHY CORRELATION WITH IN PATIENTS WITH NON-CIRRHOTIC LIVER BIOPSY IN THE EVALUATION OF PORTAL FIBROSIS STAGING OF LIVER FIBROSIS Rachit Agarwal, Praveen Sharma Usha Goenka, Chinmay Bera, M.D. Nadeem Parvez, Sir Gangaram Hospital, New Delhi, India Enam Khan, Mahesh Goenka

Institute of Gastrosciences, Kolkata, India Background and Aim: Non-cirrhotic portal hypertension (NCPH) is a common cause of variceal bleed Background and Aim: Acoustic radiation force elas- in developing countries. Transient elastography (TE) tography (ARFI) is a novel technique for non-invasive using Fibroscan is a useful technique for evaluation assessment of liver fibrosis. In comparison to transi- of fibrosis in patients with liver disease. There is no ent elastography, ARFI can be done in obese patients study evaluating TE in patients with non-cirrhotic and at multiple sites of liver. Aim of this study was to portal fibrosis (NCPF). The aim of this study was to investigate the accuracy of ARFI imaging as a non- evaluate the role of TE in NCPF. invasive method for the assessment of liver fibrosis Methods: Retrospective data of consecutive patients compared to histologic liver fibrosis score. of NCPF as per Asian pacific association for the study Methods: A prospective comparison study of ARFI of liver (APASL) guidelines were noted. All patients elastography was performed in a consecutive series of had liver biopsy, TE, computed tomography of abdo- patients who underwent liver biopsy for the assess- men and hepatic venous pressure gradient (HVPG). ment of fibrosis. Mean ARFI velocities (m/s) were Twenty age and gender matched healthy subjects and compared with Modified Ishak score (F0 to F4) for 40 age matched patients with cirrhosis with Child’sA fibrosis in liver biopsy. were taken as controls. Results: One hundred and fourteen patients (mean Results: A total of 20 patients (30.1 Æ 10.1 years, M: age 44 Æ 13, M/F = 78/36) with liver diseases (crypto- F = 11:9) with a diagnosis of NCPF were enrolled genic = 39, hepatitis B = 37, non-alcoholic fatty liver from January 2011 to December 2015. Of 20 patients, disease = 32, autoimmune = 3, hepatitis C = 1 and 18 had variceal bleed and required endoscopic band others = 2) underwent ARFI and liver biopsies at ligation. There was no difference in haemoglobin and

platelet count between patients with cirrhosis and liver disease = 32, autoimmune = 3, Hepatitis C = 1 NCPF, but total leucocyte count was significantly and others = 2) underwent ARFI elastography. The lower in patients with NCPF compared to patients mean ARFI (10 measurements per patients) values of with cirrhosis (4.1 Æ 2.3 vs 6.7 Æ 4.3 Â 103/cumm, our study populations was 2.07 Æ 0.87 m/s. Varices P = 0.01). TE was high in patients with NCPF com- were found in 14% patients. Clinically significant pared to healthy controls (6.6 Æ 2.7 vs 4.7 Æ 0.5 kPa, varices (grade 2) were seen in 3.5% patients. The P = 0.001) but it was significantly low compared to ARFI values were significantly higher in patients with cirrhotic patients (6.6 Æ 2.7 vs 48.7 Æ 17.8 kPa, clinically significant varices as compared to patients P = 0.001). HVPG was significantly low in patients without significant varices (3.63 Æ 0.30 vs 2.01 with NCPF compared to patients with cirrhosis (5.6 Æ 0.08, P < 0.001). Liver stiffness was positively cor- Æ 3.0 vs 16.6 Æ 2.8 mmHg, P = 0.001). related to the grade of oesophageal varices (r = 0.78, Conclusion: Transient elastography (Fibroscan) is P < 0.043). AUROC values of liver stiffness measure- significantly low in patients with NCPF compared ment were 0.84 (95% CI: 0.78–0.90) for the presence of to patients with cirrhosis. It is a useful technique to oesophageal varices and 0.83 (0.76–0.89) for large assess whether variceal bleed is due to Child’sA varices. Large varices were seen only in patients with cirrhosis or non-cirrhotic portal fibrosis. grade 3 or grade 4 fibrosis. ARFI value of <2.0 m/s (grade 2 fibrosis) was highly predictive of the CONFLICTS OF INTEREST absence of large oesophageal varices. Conclusion: Liver stiffness measured by ARFI elas- The authors have none to declare. tography may non-invasively predict the presence or absence of clinically significant esophageal varices. Corresponding author: Praveen Sharma. E-mail: [email protected] CONFLICTS OF INTEREST http://dx.doi.org/10.1016/j.jceh.2016.06.152 The authors have none to declare. Corresponding author: Mahesh K. Goenka. E-mail: [email protected]

32 Miscellaneous http://dx.doi.org/10.1016/j.jceh.2016.06.153 ARFI ELASTOGRAPHY OF LIVER CAN PREDICT THE PRESENCE OF CLINICALLY SIGNIFICANT ESOPHAGEAL VARICES M.D. Nadeem Parvez, Mahesh K. Goenka, 33 Chinmay Bera, Usha Goenka CLINICAL, SEROLOGICAL, HISTOLOGICAL Institute of Gastrosciences, Kolkata, India CHARACTERISTICS AND TREATMENT OUTCOME OF AUTOIMMUNE HEPATITIS Background and Aim: Presence of varices is a defi- IN ELDERLY INDIAN POPULATION nite sign of portal hypertension. Periodic endoscopic Nikhil Sonthalia, Pravin Rathi, Samit Jain, screening for oesophageal varices is recommended in Ravindra Surude, Ashok Mohite, Vinay Pawar, patients with chronic liver disease to look for the Suhas Udgirkar, Qais Contractor development of clinically significant varices. Non- invasive test such as Acoustic Radiation Force Topiwala National Medical College and BYL Nair Ch Hospital, Mumbai, Impulse (ARFI) elastography can exclude the presence India of clinically significant varices. Methods: Total 114 patients with liver disease Background and Aim: Autoimmune hepatitis (AIH) (inconclusive of cirrhosis on ultrasonography) under- has been traditionally a disease of young woman. went ARFI elastography and endoscopy at the same Recent epidemiological studies have shown increase time period. The relationship between the presence of in prevalence of AIH among elderly, but it has been oesophageal varices and liver stiffness measurement rarely reported from India. The aim was to study the by ARFI was assessed. characteristics of AIH in elderly Indian population. Results: One hundred and fourteen patients (mean Methods: Patients with diagnosis of AIH based on age 44 Æ 13, M/F = 78/36) with liver diseases (cryp- the revised International autoimmune hepatitis togenic = 39, hepatitis B = 37, non-alcoholic fatty group scoring criteria were recruited from 2011 till

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2015 for this study. Patients were defined elderly as 34 more than or equal to 60 years and young as <60 years of age. Clinical, serological, histological characteris- TO DETERMINE THE UTILITY OF tics and treatment outcome with follow up till 12 THROMBOELASTOGRAPHY IN months were analyzed and compared between both COMPARISON TO CONVENTIONAL the groups. COAGULATION TESTS IN CIRRHOTICS Results: Out of 101 patients, 20 (19.8%) were elderly. UNDERGOING INVASIVE PROCEDURE Females were predominant in elderly group (95%) as well as in younger patients (88.88%). Acute liver fail- Vaibhav Somani, Deepak Amarapurkar ure was only seen in younger patients. Chronic pre- Bombay Hospital & Research Center, Mumbai, India sentation including cirrhosis was more common in P elderly patients (95% vs 71.6%, = 0.050). Total bilir- Background and Aim: Conventional tests of coagu- ubin and alanine aminotransferases level were sig- lation in cirrhotic patients only assess procoagulant fi ni cantly higher in younger patients as compared to factors and are poor predictors of bleeding risk. In P elderly group ( < 0.05). On histology presence of spite of this knowledge they are routinely used prior fi interface hepatitis, lymphoplasmacytic in ltrate, to invasive procedures and attempts are made to Rosette formation was similar but cirrhosis was sig- correct these abnormalities before invasive proce- fi ni cantly more in elderly group as compared to dures. These practices are not supported by the evi- younger group. Prevalence of conventional autoim- dence and they are also harmful to the patients. mune marker were similar in both the groups. Methods: This prospective study included 150 cir- Response to treatment at the end of 12 months were rhotics patients undergoing invasive procedures. P similar in both the groups (75% vs 65.4%, = 0.5818). Conventional coagulation tests (CCTs), thrombo- Due to increased prevalence of co-morbidities includ- plastin generation time (TGT) and thromboelasto- ing severe osteoporosis appropriate immunosup- graphy (TEG) were done in all patients and they were Miscellaneous pressant could not be started in 20% of elderly observed for post procedural bleeding. None of the patients as compared to 4.93% of younger patients patient received prophylactic transfusion before the P ( = 0.0765). procedure. Results: Of 150 patients of cirrhosis (mean age of 52 AIH group Elderly—20 Non-elderly—81 P Values years, 69% males) with 37, 31 and 62 patients in child according (19.8%) (80.2%) class A, B and C respectively. All patients underwent to age invasive procedures (liver biopsy, central line inser- Females 19 (95%) 72 (88.88%) 0.6819 tions, dental extraction, hemiarthroplasty, hepatic Chronic hepatitis 19 (95%) 58 (71.6%) 0.050 angiography, TIPSS, TACE, diagnostic laparoscopy, and cirhhosis umbilical hernia repair, etc.). Bleeding time, clotting Serum ALT (U/L) 84.76 Æ 78.56 189.75 Æ 123.56 0.0005 time and TGT were normal in all. One of 150 patients Remission by 15 (75%) 53 (65.4%) 0.5818 developed clinically significant post procedural bleed- 12 months ing. No statistically significant association was seen between aPTT, INR, platelet count and Child class Conclusion: AIH is an important differential diag- with bleeding. Comparison of abnormal TEG values nosis among elderly Indian population. They present (R time and MA value) with INR and Platelet count with chronic hepatitis and cirrhosis more commonly respectively in patients with no bleeding showed sta- than younger patients. When given appropriate tistically significant lower percentage of abnormal immunosuppressant they have similar outcome as values of R time and MA value compared to INR compared to younger population. and platelet count respectively in patients with no bleeding. But TEG values (R time and MA value) also CONFLICTS OF INTEREST showed no association with bleeding, which was prob- ably due to the fact that only one patient had bleeding. The authors have none to declare. Conclusion: Abnormal CCTs in patients of cirrhosis do not predict bleeding risk. TEG is useful in patients Corresponding author: Nikhil Sonthalia. with cirrhosis of liver undergoing invasive procedures E-mail: [email protected] to assess bleeding in place of CCTs and prevents http://dx.doi.org/10.1016/j.jceh.2016.06.154 erroneous prophylactic transfusions.

CONFLICTS OF INTEREST diagnosis was 25 years, for hepatic 24.2 years and neurologic 25.6 years (P value 0.77). Mean delay of The authors have none to declare. diagnosis was 10.9 months, for neurologic 18.1 P Corresponding author: Vaibhav Somani. months, for hepatic 3.7 months with ( value E-mail: [email protected] 0.01). 23 (88%) patients with hepatic manifestation had kf ring and all 7 (100%) patients with neurolo- http://dx.doi.org/10.1016/j.jceh.2016.06.155 gical presentation had kf ring. S ceruloplasmin was <20 mg/L in all patients and mean ceruloplasmin value was 8.3 mg/L. 24 h urine copper was high (>100 mcg/day) in 24 (73%) patients and mean value 35 was 246 mcg/day. Family history of Wilson disease was present in 4 patients. Out of 26 patients with CLINICAL PROFILE AND SURVIVAL ’ hepatic presentation, 9 patients are alive and 17 died PATTERN OF WILSON S DISEASE over a period of 5 year follow up. 4 patients under- Bincy Krishnan went liver transplantation of which one died and 3 are doing well. The Kaplan Meier survival analysis pro- College Trivandrum, Trivandrum, India vided an overall survival for the patients. The mean overall survival was 5.1 years, for hepatic 3.2 years and Background and Aim: Wilson’s disease is an inborn neurologic 14.3 years. Log rank test was done was error of copper metabolism leading to excessive accu- done to assess any significant difference in survival mulation of copper in the body which damages pri- between two groups and P value was significant marily the liver and brain. The clinical presentation of (0.01). Cox proportional hazard analysis provided Wilson disease is variable. We analysed the clinical hazard ration of 7.71 times with confidence interval profile, sensitivity of various diagnostic parameters, 0.989–60.19 for patient with hepatic presentation as and survival pattern of patients from a period of compared to neurological presentation. 2011–2016. Conclusion: There is significant delay in the diag- Methods: The medical records of all patients with nosis of Wilson’s disease in patients with initial neu- definite diagnosis of WD, who were admitted in MCH rologic presentation compared to hepatic Trivandrum from a period of 2011–2016 were ana- presentation. Patient with hepatic presentation had Miscellaneous lysed to obtain clinical manifestations. The survival a significant mortality risk compared to those with status of patient was determined by a prospective neurological presentation. follow up. The Kaplan–Meier survival curve and univariate Cox proportional hazards model were used to CONFLICTS OF INTEREST determine the survival pattern and risk for death. Results: A total of 33 patients were studied of which The author has none to declare. 17 (51.5%) were males and 16 (48.5%) were females. 26 (79%) patients presented with initial hepatic manifes- Corresponding author: Bincy Krishnan. tations and 7 (21%) patients presented with initial E-mail: [email protected] neurological manifestation and all 7 patients with http://dx.doi.org/10.1016/j.jceh.2016.06.156 initial neurological presentation progressed to cirrhosis. Out of the total 33 patients with hepatic involvement 31 had cirrhosis, 2 presented with chronic hepatitis. Out of the cirrhotic patients 16 belonged 36 to Child C, 10 belonged to Child B and 5 belonged to Child A. Mean age of onset of symptoms was 24.1 TRANSIENT ELASTOGRAPHY (FIBROSCAN) years. Most common symptom at disease onset for ASSESSMENT IN PATIENTS WITH HEPATIC those with initial hepatic manifestation was jaundice AND NEUROLOGICAL WILSON’S DISEASE 9 (34%) followed by ascites 7 (26%) UGI bleed in 3 (11%), haemolytic anemia in 2 (7%), pedal odema in 2 Tarun Joseph, Vishnu Reddy, P.V. Girish, G. Balaji, (7%), transaminitis, fatigue and hepatic encephalopa- Vishnu Raju, Mallikarjun Patil, Harshad Devarbhavi thy in one each. For those with initial neurological St. Johns Medical College, Bengaluru, India manifestation tremor 6 (85%) was the commonest symptom at disease onset, and dysarthria was present Background and Aim: Non-invasive assessment of in 2 patients along with tremor and one patient hepatic fibrosis with ultrasound based transient elas- presented with psychiatric symptoms. Mean age at tography (TE) (or Fibroscan) has been validated in a

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number of chronic liver disease. Studies involving Indrajit Suresh, H.P. Nandeesh, Deepak Suvarna, Wilson disease (WD) patients are rare. Our aim D. Chandrababu, H.R. Jeevan was to assess TE in patients with hepatic and neurological WD. JSS Hospital, Mysore, India Methods: Twenty-five patients with well characterized WD underwent TE by Fibroscan®, Echosens 402, Background: Numerous autoimmune disorders are Paris, France. Diagnosis of WD was made as per encountered frequently in patients with autoimmune Leipzig criteria. All patients were on follow up and hepatitis. The autoimmune process might be trig- gered by infectious or chemical agents in susceptible stable on treatment with D-penicillamine Æ zinc. The Fibroscan values were distinguished between hepatic individuals. and neurologic Wilson with regard to treatment and Case Report: The authors present the case of a 23 duration of illness. Continuous variables between year old male who presented with history of jaundice groups were compared by unpaired t test. P value and fever. The patient was managed elsewhere as a <0.05 was considered significant. case of malaria with malarial hepatitis and was trea- fi ted with antimalarial drugs. He also consumed ayur- Results: Twenty- ve patients (13 with hepatic and 10 fl with neurologic and 2 with both) underwent TE. vedic medications during a subsequent are. LFT showed indirect hyperbilirubinemia, while complete Seventeen were males. The mean age of the patients ’ was 20 years and the mean duration of illness was 7.2 blood count, Direct Coomb s test and peripheral years. The demographic and laboratory characteris- smear were suggestive of haemolytic anemia. Workup for autoimmune hepatitis revealed positivity for ANA tics between hepatic and neurologic WD are shown in ’ the table. There was no statistical significance & ASMA with elevated IgG levels. The patient s liver biopsy was suggestive of cholestatic jaundice with between the two in all variables except Fibroscan fl scores: neurological WD 12.94 Æ 5.03 (range 7–22) lobular and focal portal in ammation. His diagnosis kPa, hepatic WD 26.7.6 Æ 16.06 (range 12.2–75) kPa was revised to autoimmune haemolytic anemia with Miscellaneous (P value = 0.003). Scores above 8.4 kPa are considered probable autoimmune hepatitis (AIH type 1). Follow- severe in WD (Dig Liv Dis 2012;44:487). ing treatment with a course of steroids, his condition improved markedly. Variable Hepatic Neurological Age (years) 20 (12–38) 24 (10–45) CONFLICTS OF INTEREST Duration of illness 6.75 (2–17) years 13.2 (1–30) years (years) The authors have none to declare. Gender (M:F) 9:5 8:3 Corresponding author: H.P. Nandeesh. Fibroscan value 26.7 Æ 16.1 12.9 Æ 5.03 E-mail: [email protected] (kPa) (12.2–75) kPa (7.5–22) kPa http://dx.doi.org/10.1016/j.jceh.2016.06.158

Conclusion: Patients with WD have advanced hepatic fibrosis. Hepatic WD patients have significantly higher scores suggestive of cirrhosis. Neurologic WD 38 have scores suggestive of severe fibrosis. PROGNOSTIC SCORING SYSTEMS AND CONFLICTS OF INTEREST OUTCOME OF RADIOLOGICAL INTERVENTION OF CHRONIC BUDD- The authors have none to declare. CHIARI SYNDROME IN CHILDREN: A FIRST TIME APPLICATION Corresponding author: Harshad Devarbhavi. E-mail: [email protected] Sumit Singh, Moinak Sarma, Rajanikant Yadav, Sheo Kumar, Raghunandan Gangwar, http://dx.doi.org/10.1016/j.jceh.2016.06.157 Surender K. Yachha, Anshu Srivastava, Ujjal Poddar

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India 37 Background and Aim: Prognostic scoring systems AUTOIMMUNE HEPATITIS ASSOCIATED (PSI) have not been validated to identify high risk WITH AUTOIMMUNE HEMOLYTIC ANEMIA children with chronic Budd-Chiari syndrome (BCS)

who undergo radiological intervention (RI). Our aim 39 was to identify which of known PSI predict the outcomes in various subgroups of chronic BCS. LANGHERHANS CELL HISTIOCYTOSIS Methods: Admitted children with chronic BCS WITH SCLEROSING CHOLANGITIS IN (October 2011–March 2016) were analyzed in three CHILDREN: AN ENTITY FOR RECOGNITION subgroups: (a) SI: successful intervention (patent Nagendra Kumar, Anshu Srivastava, Surender Yachha, stent at last follow-up); (b) PO: poor outcome (stent Ujjal Poddar block or death) and (c) NU: naïve unintervened (undergoing endotherapy and awaiting RI). PSI Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, analyzed were PELD, Rotterdam score, BCS-TIPS, India Zeitoun and Murad prognostic indices in all and MELD (MELD-Na, iMELD, uMELD) in children Background and Aim: Langerhans cell histiocytosis >12 years. (LCH) is an important yet uncommon cause of scler- Results: 68 patients had median age at presentation osing cholangitis (SC) in children. We analyzed the 10 (1.5–17) years and duration of illness 6 (1–48) clinical presentation and outcome of patients with SC months. 23 patients lost to follow-up for >1 year and LCH. were excluded. 26 of 31 underwent 28 successful Methods: Clinical features, investigations and out- primary procedures: HV angioplasty + stenting come were noted. Diagnosis of SC was based on (n = 17), IVC angioplasty + stenting (n = 3) HV angio- typical cholangiographic findings with/without sug- plasty (n = 2), IVC angioplasty (n = 3) and modified gestive histology. Children were classified into defi- trans-jugular intrahepatic peritoneal shunt (n = 3). nite LCH (histology with CD1a positivity) and Stent patency restored in 4/9 secondary recanaliza- probable LCH (characteristic multi-systemic involve- tion. 4/5 stent block and 5 unintervened patients ment > 1 extra hepatic site). died. Finally 3 groups (SI: n = 21, PO: n = 10, NU: Results: 15 children (12 boys, age at onset of symp- n = 14) were analyzed. PELD cut-off of 11 determined toms—1.7 [0.2–7.4] years and age at diagnosis 2.5 poor outcome (AUC: 0.74, 80% sensitivity, 67% spe- [0.9–9] years) were enrolled. 7 had definite and 8 cificity, P = 0.02). Comparisons: PELD [SI: 4 (À8to had probable LCH. Jaundice (93%) was the most 68) vs. PO: 16 (9–67); P = 0.02]; Rotterdam score [NU: common symptom followed by pruritus (67%), ear 1.08 (0.04–2.45) vs. PO: 1.18 (1.09–3.43), P = 0.04; SI: discharge (54%), polyuria (54%), seborrhea (54%), Miscellaneous 1.10 (0.03–3.11) vs. PO: 1.18 (1.09–3.43), P = 0.05]; fever and weight loss (47%), skin rash (27%) and tooth Murad prognostic index [SI: 1.04 (0.01–3.03) vs. PO: fall (13%). Hepatomegaly, lymphadenopathy and 1.04 (1.04–3.05), P = 0.04; NU: 1.04 (0.01–2.32) vs. splenomegaly were present in 100%, 73% and 60% PO: 1.04 (1.04–3.05), P = 0.04]. Overall BCS-TIPS respectively. Overall, bone was involved in 10 (66%), index [1.9 (0.93–5.17)] and other scores were not skin in 8 (53%), diabetes insipidus in 8 (53%) and significant among the three groups. lungs in 6 (40%) cases. 6 (40%) patients developed Conclusion: Interventional success and survival in multi systemic involvement in follow-up over 18 (6– pediatric chronic BCS is determined by PELD and 45) months. Cholangiography showed intrahepatic Murad prognostic indices. Rotterdam score is helpful changes in 11, extrahepatic in 1 and both in 3 cases. only prior to intervention. BCS-TIPS index is not Liver biopsy (n = 10) showed changes of SC in all. applicable in children. Biopsy from bone lytic lesion (5/5), lymph nodes (2/ 2), and skin (2/4) was confirmatory, but none of the CONFLICTS OF INTEREST bone marrow (15/15) and liver biopsies (10/15) showed classical histology. Only 8 children received The authors have none to declare. chemotherapy, of which 3 improved, 3 died during chemotherapy and 2 did not show a response. Corresponding author: Surender K. Yachha. Conclusion: LCH with SC is a progressive disease E-mail: [email protected] with poor outcome. Biopsy from bone lytic lesion, fi http://dx.doi.org/10.1016/j.jceh.2016.06.159 lymph node and skin are useful in con rming the diagnosis. High index of suspicion of LCH is required in SC patients, as 40% cases do not have extra-hepatic features of LCH at presentation.

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CONFLICTS OF INTEREST 41 The authors have none to declare. THROMBOELASTOGRAPHY (TEG) DOES NOT PREDICT THROMBOPHILIA IN Corresponding author: Anshu Srivastava. HEPATIC VENOUS OUTFLOW TRACT E-mail: [email protected] OBSTRUCTION (HVOTO) http://dx.doi.org/10.1016/j.jceh.2016.06.160 Abhinav Jain, Shobna Bhatia, Akash Shukla

Seth GSMC & KEMH, Mumbai, India

40 Background and Aim: TEG assesses dynamics of clot formation and is reliable for assessing coagula- DYSPHAGIA LUSORIA DUE TO ABBERANT tion state in cirrhosis. TEG has been used to assess RIGHT SUBCLAVIAN ARTERY IN TWINS prothrombotic states. The combination of prothrom- Disha Sharma, Amit Dey botic state and liver dysfunction hampers interpreta- tion of traditional coagulation tests in HVOTO. Seth G.S. Medical College & K.E.M. Hospital, Mumbai, India However, role of TEG in HVOTO remains uninvestigated. We performed TEG in HVOTO patients to Background: An aberrant right subclavian artery is a predict prothrombotic disorder. common embryological abnormality. Most cases are Methods: Fifty-four patients with HVOTO (age 32.3 asymptomatic but may present with dysphagia, that [10.7] years; 29 women) underwent TEG. CI, R-time, is, dysphagia lusoria. But, dysphagia lusoria has never K-time, MA and alpha-angle were analysed and cor- been reported in twins. We present to you the first related with clinical profile and underlying prothrom- case of four year old female twins with dysphagia botic conditions. Patients on anticoagulation/anti- Miscellaneous lusoria. platelet drugs in last 2 weeks were excluded. IEC Case Report: Four year old female, monozygotic approval was taken. twins presented with the chief complaints of vomit- Results: CI values for Rotterdam Class I, II and III ing immediately on taking solid foods since six were À1.82 (4.1), À2.29 (7.1) and 1.5 (2.1) respectively months of age. Numerous investigations including (P > 0.05). TEG showed CI > 3 in three; R-time < 1 - indirect and direct laryngoscopy, upper GI endo- min in two; K-time < 1 min in two; alpha-angle >78 in scopy, esophageal barometry, CT and MRI, echocar- none; MA > 69 mm in eight patients. Fifteen patients diography of both the children were all inconclusive. had CI < À3, while 36 had normal CI. TEG para- Lastly, barium esophagogram was done which picked meters did not differ in patients with underlying up the vascular anomaly consistent with extrinsic thrombophilic conditions (n = 23) and those without compression by a retro-oesophageal aberrant right (n = 28) (P > 0.05). Mean LY30 was higher in Rotter- subclavian artery. Spot film from barium esophago- dam class-III (41.0) than class-I (2.93) and II (3.8); gram in the other twin sister showed similar findings. P < 0.01. The mean CI was lower (À15 vs À1.35; P They were both operated for resection and recon- value < 0.05) and R-time (15.3 vs 6.6; P < 0.05) and K- structive bypass surgery and are currently doing well. time (11.3 vs 2.6; P < 0.05) prolonged in patients with Conclusion: The main objective of this report would IVC as compared to rest. The sensitivity, specificity, be to diagnose this condition with as minimum PPV and NPV of TEG to predict thrombophilia were investigations and radiation exposure as possible. 17.3%, 71.4%, 33.3% and 51.2% respectively. Any beak like posterior esophageal wall indentation Conclusion: TEG poorly predicted presence of a on esophagogram unless proven otherwise should be prothrombotic state in HVOTO. Hyperfibrinolysis treated as vascular. A good medical history is impera- and hypo-coagulability were predominant in Rotter- tive for timely diagnosis. dam class-III.

CONFLICTS OF INTEREST CONFLICTS OF INTEREST

The authors have none to declare. The authors have none to declare. Corresponding author: Disha Sharma. Corresponding author: Akash Shukla. E-mail: [email protected] E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2016.06.161 http://dx.doi.org/10.1016/j.jceh.2016.06.162

42 remodeled liver parenchyma. Timely withdrawal of such stimuli may facilitate faster regression and bet- IS NON CIRRHOTIC PORTAL FIBROSIS ter patient prognosis. ACTUALLY CIRRHOSIS IN REGRESSION? A HISTOPATHOLOGICAL STUDY OF THE ‘‘HEPATIC REPAIR COMPLEX’’ IN INDIAN CONFLICTS OF INTEREST PATIENTS The authors have none to declare. Kavita Gaur, Shahajad Ali, Puja Sakhuja, Kaushik Majumdar, Anil Agarwal, Amarender Puri Corresponding author: Puja Sakhuja. E-mail: [email protected] GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India http://dx.doi.org/10.1016/j.jceh.2016.06.163

Background and Aim: The precise etiopathogenesis of non-cirrhotic portal fibrosis (NCPF) remains unknown. Histologically subtle pointers seen in 43 NCPF are reminiscent of regressed cirrhosis. The present study was undertaken to (a) examine whether ESOPHAGEAL VARICES ON CONGENITAL — histological features of fibrosis regression existed in ESOPHAGEAL STRICTURE WHOM TO an Indian cohort of NCPF patients; (b) correlate these TACKLE FIRST? fi features with brosis scores and glutamine synthetase Shyam S. Sharma, Lalit Bharadia (GS) immunopattern and (c) postulate a possible etiopathogenetic model explaining this entity. Fortis Escorts Hospital, Jaipur, India Methods: Thirty cases of clinically suspected NCPF were randomly selected from the pathology database Background: Esophageal stricture is a known at GIPMER, New Delhi. Retrospective analysis of 20 complication after endoscopic treatment of esopha- wedge and 10 needle biopsies was done using H&E, geal varices. Author wants to describe a c/o congenital Masson’s Trichrome and GS stained sections. The esophageal stricture which posed difficulty in endo- presence or absence of perforated septa, parenchymal scopic management of portal HT. Miscellaneous collagen fibrils, portal tract (PT) fibrous spikes, multi- Aim: To describe c/o congenital esophageal stricture ple PT vascular channels, ‘‘micro’’ PTs, prolapsed with portal hypertension. hepatocytes, aberrant parenchymal veins, venoportal Case Report: 3 years old boy was referred to pediatric approximation and inflammation (portal/lobular) GI unit with a USG report of portal cavernoma. USG was documented. Hepatic vein remnants were graded was done for pain abdomen. A UGI endoscopy was (number of aberrant GS foci/4Â)as+1to3,2+:4–6, 3 done to assess portal hypertension which revealed +: 6–8 and 4+: >8. Portal remnants were studied in lower end esophageal stricture. Stricture was dilated small tracts and calculated as a fraction of total PTs. using CRE balloon to 11 mm after which endoscope Fibrosis (f) was scored per Ishak’s criteria. GS stain was negotiated into the stomach. Stricture was 3.5 cm was noted as absent/present where its pattern (nor- long with no hiatus. Grade I to II esophageal varices mal/patchy/diminished/heterogenous) was noted. with no gastric varices. On detail history parents gave Results: Of the 11 criteria studied, majority (90%) h/o dysphagia to solids since the age of 1 year which showed the presence of a minimum of three features was never probed as child managed to thrive on soft of histological regression. This included cases with and liquid diet. Stricture appeared congenital in nat- low f scores. Prolapsed hepatocytes and aberrant ure. On FU after 2 weeks a repeat dilation was done to parenchymal veins were seen only in cases with 3 12 mm. The varix appeared grade III in size. After the + fibrosis. The most common regression feature was dilations there was significant improvement in dys- PT remnant (83.33%). HV remnants were commonly phagia. 6 months after the dilation there was an UGI grade +(43.33%). Portal inflammation was noted in bleeding. Endoscopy showed stricture which needed 66.6% cases. Patchy GS pattern predominated in the to be dilated so as to assess the lower end of esopha- study group (50%) and correlated with f scores. gus. The bleeding was variceal in nature. Because of Conclusion: Histologically NCPF has features of smaller lumen EVL was not possible and hence cirrhosis regression in our subset of Indian patients. guarded esophageal sclerotherapy (EST) was done Subsidence of infectious/immune stimuli encoun- along with secondary medical prophylaxis. On FU tered in early childhood may suppress cirrhotogenic till next 1 year child needed 2 more sessions of dila- pathways leading to fibrotic regression but evidently tion and one session of EST for minor bleeding.

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Conclusion: This case represent unique association in Group I and 152 (60.8%) in Group II (P = 0.003). of congenital esophageal stricture with bleeding eso- SBP and sepsis was significantly associated with pre- phageal varices. Treatment of this association is a sence of AKI. Mean arterial pressure (MAP) was 78.60 challenge as treatment of any one of them worsens Æ 5.70 in Group I and 85.06 Æ 4.62 in Group II. the other. Patients on combined diuretics and beta blockers were also significantly associated with AKI. CONFLICTS OF INTEREST Conclusion: Patients with decompensated cirrhosis on NSBB should be monitored closely. It should be The authors have none to declare. stopped once there is evidence of sepsis, SBP & low MAP. Corresponding author: Shyam S. Sharma. E-mail: [email protected] CONFLICTS OF INTEREST http://dx.doi.org/10.1016/j.jceh.2016.06.164 The authors have none to declare. Corresponding author: Srijith Kadavanoor. E-mail: [email protected] 44 http://dx.doi.org/10.1016/j.jceh.2016.06.165 DO NONSELECTIVE BETA BLOCKERS (NSBB) INCREASE THE RISK OF ACUTE KIDNEY INJURY (AKI) IN DECOMPENSATED CIRRHOSIS 45 Srijith Kadavanoor, Deni Joseph, M. Ramu, A CASE REPORT ON PRIMARY HEPATIC Miscellaneous Prasanth Sudheendaran, Chethan Govindaraju, AMYLOIDOSIS Nikhil Suraj, Krishnadas Devadas Rohan Reddy, Shravan Kumar, Uma Devi, Govt. Medical College, Thiruvananthapuram, India Ramanna Macherla Background and Aim: Recent studies have shown Gandhi Medical College & Hospital, Hyderabad, India that beta blockers increase the risk of HRS in decompensated cirrhosis especially with refractory ascites Background: Hepatic amyloidosis is a rare disease and after first episode of SBP. The debate continues that presents as an infiltrative disease involving the with another group claiming that it is beneficial in liver. Amyloidosis is a systemic disease characterized certain group of patients with acute on chronic liver by extracellular deposition of amyloid protein in failure. Beta blockers still remain indispensable and many organs. Progressive organ involvement leads patient selection is paramount. The aim is to study to organ malfunction and death usually resulting whether nonselective beta blockers (NSBB) increase from renal and/or cardiac involvement. Liver and the risk of AKI in decompensated cirrhosis. spleen are major sites of involvement. The wide range Methods: We conducted a retrospective case control of presenting symptoms encountered makes rapid study of patients with decompensated cirrhosis with clinical diagnosis difficult. None of the present ima- (Group I) and without AKI (Group II) in the study ging techniques is capable of specifically demonstrat- period from 2012 to 2014. AKI was defined as a serum ing the presence of amyloid. Even when suspected creatinine >1.5 mg/dl and classified according to clinically and radiologically, the diagnosis of amyloi- AKIN criteria. dosis depends on a tissue biopsy to confirm the Results: Group I and II included 85 and 250 patients presence of amyloid deposits. respectively. Group I and II included 62 and 165 Case Report: A 38year old female was admitted with patients respectively with Child C cirrhosis. 55 the complaint of bilateral pedal edema for the last one (64.7%) patients were on beta blockers in group I month. It was associated with loss of weight (10 kg). as compared to 147 (58.8%) in Group II There was no history of decreased urine output, (P = 0.336). The mean Systolic BP in Group I was shortness of breath, abdominal distension or PND 99.04 Æ 6.54 and 111.46 Æ 7.59 in Group II episodes. On examination their was a large palpable (P < 0.001), mean dose of beta blocker was 40.73 liver which was firm in consistency. Her CBP, RFTs, Æ 13.588 in Group I and 29.93 Æ 8.317 in Group ECG, 2D-Echo were completely normal. LFTs showed II (P < 0.001). 67 (78.8%) patients were on diuretics elevated SGOT (88 U/L) and SGPT (96 U/L) with

other parameters being completely normal. USG of the majority (except 5 patients). Splenomegaly was abdomen confirmed hepatomegaly (17 cm) with nor- present in 81% (60 patients). Most of the children had mal echogenicity. CECT-abdomen confirmed similar pallor, with mean hemoglobin being 8.44 g/dL. findings. Liver biopsy was performed with an 18 G Ascites was present in 22% (16 patients), and ultra- Bard gun-biopsy needle. Microscopically, diffuse sonography revealed alteration in liver echotexture in amyloid deposits were found and the Congo red stain 30 patients (40%) and 13 patients (19%), had kidney was positive. Additional examinations were done to involvement. UGIE showed varices in 62 patients evaluate the extent of amyloidosis involvement. Bone (84%), 36 (50%) requiring EST/EVL for the eradica- marrow aspirate showed a small increase in the per- tion of varices. Two patients had a familial associa- centage of plasma cells 8%. Colonic mucosal biopsy tion. Two patients developed hepato-pulmonary also showed amyloidosis. These examinations con- syndrome and one patient was transplanted. One firmed the diagnosis of AL, which was later, classified patient died of massive GI bleed. as primary systemic AL. Conclusion: Congenital hepatic fibrosis is an important cause of portal hypertension in children. Spora- CONFLICTS OF INTEREST dic form of CHF was more common in our cohort. Enlarged liver with a firm to hard consistency and The authors have none to declare. splenomegaly are suggestive of CHF though liver histology was diagnostic. Corresponding author: Rohan Reddy. E-mail: [email protected] CONFLICTS OF INTEREST http://dx.doi.org/10.1016/j.jceh.2016.06.166 The authors have none to declare. Corresponding author: Subhamoy Das. E-mail: [email protected] 46 http://dx.doi.org/10.1016/j.jceh.2016.06.167 SPECTRUM OF CONGENITAL HEPATIC FIBROSIS (CHF) IN INFANTS AND Miscellaneous CHILDREN FROM A TERTIARY CARE CENTRE 47 Subhamoy Das, Suvradeep Mitra, P. Srikanth, SAFETY AND OUTCOME OF LIVER BIOPSY Jagadeesh Menon, Sadhna Lal, Ashim Das, IN INFANTS AND CHILDREN Babu R. Thapa P. Srikanth, Uma Devi, Jagadeesh Menon, PGIMER, Chandigarh, India Subhamoy Das, Suvradeep Mitra, Manjinder Randhawa, Sadhna Lal, Ashim Das, Babu R. Thapa Background and Aim: Congenital hepatic fibrosis (CHF) is a rare autosomal recessive disorder respon- PGIMER, Chandigarh, India sible for portal hypertension. We retrospectively analyzed the clinical spectrum of patients seen over past Background and Aim: Histological diagnosis is the 10 years. gold standard in many of the early onset liver dis- Methods: Seventy-four cases of CHF (biopsy proved) orders. Liver biopsy is one of the most common were managed over ten years from the year 2004 to invasive procedures performed by a hepatologist. 2015. Their demographic features and clinical pro- The safety and efficacy of the procedure are less files were studied. Other causes of chronic liver dis- studied in infants and children, even though it is eases were excluded. more often performed than adult patients. We retro- Results: Age of presentation of children with CHF spectively reviewed the cases of liver diseases who had (biopsy proved) was between 2 months and 15 years, undergone percutaneous liver biopsy (LB) over last (mean 46 months) with 39% being infants. Male: three years. female ratio was 2:1. The presentation was with Methods: A total of 300 LBs under 12 years were abdominal distension in 45 patients (61%), jaundice done, of which 234 cases were analyzed. All under- in 29 patients (39%) and UGIE bleeding in 16 patients went ultrasonography-guided percutaneous liver (24%). The liver was enlarged in all with a firm to hard biopsy under sedation with age-appropriate doses consistency and left lobe was distinctly palpable in of ketamine and midazolam.

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Results: Nearly 50% of the cases are accounted by NCIPH (non-cirrhotic intrahepatic portal hyperten- infants and rest in the childhood age group. Choles- sion) with preserved liver function. In this study, we tasis of infancy was most common indication (47.4%), compared systemic vascular complications in these followed by suspected glycogen storage disorder patients, during follow up. (13.7%) and rest accounted by patients of chronic Methods: From prospectively collected database of liver diseases. LB confirmed the specific etiologies patients with portal hypertension due to unexplained of cholestasis of infancy in more than 90% of cases liver disease, we selected patients with plasma and the procedure was safe in infants including neo- ADAMTS13 activity <15% (estimated by in-house nates. Various etiologies confirmed are congenital collagen binding assay). Vascular complications on hepatic fibrosis, biliary atresia, progressive familial follow up were analysed. Patients were diagnosed as intrahepatic cholestasis, the paucity of intrahepatic NCIPH (liver biopsy showing absence of advanced bile ducts, neonatal hepatitis, and metabolic liver fibrosis) or cryptogenic cirrhosis (CC-liver biopsy diseases. Chronic liver disease group had significantly either not done or showed advanced fibrosis). lower platelet counts and worse INR as compared to Results: From 2008 to 2015, 10 NCIPH and 10 CC infantile cholestasis group. Complications are extre- patients (7 did not have liver biopsy, 3—biopsy showed mely rare with major complication rate of 1.2% (n =3) bridging fibrosis or cirrhosis) with <15% ADAMTS13 and minor complication rate of 0.8% (n = 2). One activity were selected for the study. NCIPH patients patient had right sided pneumothorax and another (age: 29, 21–42 years; median, range; Child’sscore:6, had an inadverant colonic puncture and massive 5–7) were younger; well compensated compared to CC lower GI bleed requiring massive transfusion. Failure patients (age: 54, 26–73 years; P-vaue:0.001; Child’s was seen in 0.4%(1), where inadvertently intercostal score: 9, 5–13; P-value:0.01). On follow up (65 months, muscle was sampled. 6–225 months); 5 (50%) CC patients compared to Conclusion: Liver biopsy in infants and children is a none with NCIPH died. One patient in each group safe procedure, with high yield and very low rate of developed hepatocellular carcinoma. On follow up Miscellaneous serious complication (1.2%). over 67 (15–225) months, of NCIPH patients, 4 (40%) developed new onset portal vein thrombosis; — CONFLICTS OF INTEREST 3 (30%) developed microvascular complications IgA nephropathy (after splenorenal shunt surgery) (1), The authors have none to declare. avascular necrosis of hip (1), pulmonary hypertension (1). In contrast, only 1 CC patient developed portal Corresponding author: P. Srikanth. vein thrombosis, other vascular complications were E-mail: [email protected] not seen on follow up over 62 (6–192) months. http://dx.doi.org/10.1016/j.jceh.2016.06.168 Conclusion: Unlike patients with decompensated cirrhosis, ADAMTS13 deficiency is noted in NCIPH patients despite preserved liver function. ADAMTS13 deficiency may predispose to macro and micro vas- 48 cular complications in NCIPH patients. ADAMTS13 DEFICIENCY PREDISPOSES TO SYSTEMIC MACRO AND MICROVASCULAR CONFLICTS OF INTEREST COMPLICATIONS IN NCIPH PATIENTS The authors have none to declare. Ashish Goel 1, G.J. Amirtharaj 1, Corresponding author: . Sureshkumar Sarvanan 1, Banumathi Ramakrishna 1, E-mail: [email protected] Anup Ramachandran 1, K.A. Balasubramanian 1, Uday Zachariah 1, K.G. Sajith 1, Ian Mackie 2, http://dx.doi.org/10.1016/j.jceh.2016.06.169 Elwyn Elias 1, C.E. Eapen 1,3

1Christian Medical College, Vellore, India, 2University College London, London, UK, 3University Hospital Birmingham, Birmingham, UK 49 Background and Aim: ADAMTS13 (a disintegrin like and metalloproteinase with thrombospondin NON-INVASIVE MARKERS: FIBROMETER, repeats), deﬁciency, which predisposes to increased FIBROSCAN VS LIVER BIOPSY IN platelet adhesion to endothelium, is seen in DETECTING LIVER FIBROSIS IN HBV patients with decompensated cirrhosis and in PATIENTS

Narayanasamy Krishnasamy, Sajeeth Prabu, 50 Chezhian Annasamy, Senthilkumar Ramalingam, J. Janifer Jasmine, Karthick Rajendran CHARACTERIZATION OF A NOVEL MICRORNA IDENTIFIED BY SMALL RNA Madras Medical College, Chennai, India DEEP SEQUENCING AND ITS IMPLICATION IN THE DEVELOPMENT OF Background and Aim: Liver biopsy is needed to HEPATOCELLULAR CARCINOMA assess the degree of liver damage. However, its invasive nature of test, a alternative test is needed. Our Suchandrima Ghosh 1, Joyeeta Chakraborty 2, aim is to detect liver fibrosis using non-invasive mar- Priyanka Kumari 1, Amit Ghosh 1, Alip Ghosh 1, kers like Fibroscan, Fibrometer in patients with hepa- Debanjali Dasgupta 1, Shaleen Agarwal 3, titis B infection and also to compare non-invasive Subash Gupta 3, Simanti Datta 1, Abhijit Chowdhury 1, markers with invasive liver biopsy. Raghunath Chatterjee 1, Soma Banerjee 1 Methods: This cross sectional study was conducted 1Institute of Post Graduate Medical Education and Research, Kolkata, in Department of Hepatology of Rajiv Gandhi Gov- India, 2Indian Statistical Institute, Kolkata, India, 3Indrapastha Apollo ernment General Hospital, Chennai. Thirty HBV Hospital, New Delhi, India positive patients were screened for fibrosis using Fibroscan (ECHOSENS) 502 touch model, version Background and Aim: Progression of hepatocellular 5. All the clinical, biochemical, socio-demographic carcinoma (HCC) though widely studied but still lot and anthropometric details were recorded. Liver remains to decipher the complex process by which the biopsy was done using automated spring loaded gun. disease progresses. MicroRNAs are the master regu- Results: 70% (21) were male patients and 30% (9) were lators of myriads of cellular pathways involved in – females. 43.3% were in the age group of 15 30, 46.7% cancer development and progression. Next genera- – were in 31 45 and only 10% were more than 45 years tion sequencing is the powerful genomic tool to of age. We found that 63.33% had higher HBV viral profile known miRNAs in a disease precisely as well load of more than 100,000 IU/ml. Fibroscan showed as for identification of novel miRNAs. Identification fi 33.33% (10) had mild brosis of F1/F2 Metavir stage, of a novel miRNA having differential regulation in fi 20% (6) had moderate brosis. The distribution of HCC may give an insight to its development.

fi Miscellaneous brometer results were 56.67% of patients belongs to Methods: Deep sequencing of 2 HCC and normal F1 Metavir stage and 43.33% (13) to F2 stage. In the control samples was done on ion torrent platform. By frequency distribution of liver biopsy, we found that mapper.pl, miRDeep2.pl novel sequences were iden- 76.67% (23) of patients showed histopathological tified which were then subjected to RandFOLD and fi nding of suggesting chronic active hepatitis, mFOLD analysis for predicting stem loop structure fi 23.3% (7) showed non-speci c hepatitis. Our study of the pre-miRNAs. The targets of the miRNAs were fi showed that the broscan value of 8 kPa had 100% predicted by miRanda and pathways involved were fi fi fi speci city in detecting signi cant brosis with ROC predicted by Ingenuity Pathway analysis. The novel – value of 0.89 (95% CI: 0.76 0.9). The ROC value of miRNAs and their targets were validated by qRT-PCR fi fi fi brometer in detecting signi cant brosis is 0.905 and luciferase assay. – (95% CI: 0.8 0.99). Results: Deep sequencing miRNAs in liver tissues fi fi Conclusion: Both brometer and broscan has simi- generated five novel miRNAs as predicted by bioin- fi fi lar ef cacy in detecting moderate to severe brosis. formatic analysis. While four miRNAs showed fi Hence brometer is a good test and can be combined sequence similarity with miRNAs in other species, fi fi with broscan in assessing hepatic brosis in asymp- one miRNA from chromosome 12 (named as miR- tomatic hepatitis B infected patients. c12) has been recognized first time in this study. Expression of two miRNAs (miR-c3 and miR-c12) CONFLICTS OF INTEREST was found to be significantly down regulated in both HCV and HBV infected HCC and even their expres- The authors have none to declare. sions were low in premalignant cirrhotic tissues. Furthermore, the role of these two novel miRNAs Corresponding author: Narayanasamy Krishnasamy. fi E-mail: [email protected] in liver were veri ed by determining the expression of their targets identified by MiRanda and by qRT- http://dx.doi.org/10.1016/j.jceh.2016.06.170 PCR analysis in HCC tissues. Ingenuity pathway analysis revealed that most the genes (CEP350, DCUN1D1, FBN1, HNRNPC, MARK2) are associated with cell–cell signalling, cancer, inflammation.

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Conclusion: Thus, insights into the novel miRNAs through October 2014. Patients in BCLC stages B/C identified by NGS suggest its clinical significance as who had received TACE and/or sorafenib were well as to understand the development and hence included. mRECIST criteria were used to assess management of HCC. tumor response. The primary end point was overall survival. CONFLICTS OF INTEREST Results: Out of 124 patients, 47.6% were in BCLC-B and 52.4% in BCLC-C. Baseline characteristics were The authors have none to declare. comparable. The predominant etiology was cryptogenic (37.2% and 38.5%, P = NS). 49.1% in BCLC-B Corresponding author: . and 56.9% in BCLC-C had received TACE + sorafenib. E-mail: [email protected] In BCLC-B, the overall survival improved from 9 http://dx.doi.org/10.1016/j.jceh.2016.06.171 months (95% CI: 6.3–11.7) using TACE only to 16 months (95% CI: 12.9–19.1) using TACE + sorafenib (P < 0.05). In BCLC-C, addition of TACE to sorafenib improved the overall survival from 4 months (95% CI: – – P 51 3 5) to 9 months (95% CI: 6.8 11.2) ( < 0.0001). As per mRECIST criteria, patients on TACE + sorafenib COMBINATION OF TACE AND SORAFENIB had reduced progressive disease (37.8% vs. 83.3%), IMPROVES OUTCOMES IN BCLC STAGES B/ improved partial response (43.2% vs. 3.3%) and one C OF HEPATOCELLULAR CARCINOMA: A had complete response compared to those on sora- P SINGLE CENTRE EXPERIENCE fenib alone ( < 0.0001) in BCLC-C but not in BCLC- B group. Hand foot syndrome was noted in 27.7% Joy Varghese, Chandan Kumar Kedarisetty, patients on sorafenib and post TACE syndrome in Jayanthi Venkataraman, Vijaya Srinivasan, 80.2% patients, but both were reversible. No major Miscellaneous Thiruchunapalli Deepashree, adverse events were noted. Mangerira Chinnappa Uthappa, Conclusion: TACE + sorafenib was more effective Kaliamurthy Ilankumaran, Sanjay Govil, than TACE or sorafenib alone in HCC BCLC stages Mettu Srinivas Reddy, Mohamed Rela B or C with a significant survival benefit and Institute of Liver Diseases and Transplantation, Global Health city, improved tumour regression especially in BCLC-C Chennai, India patients.

Background and Aim: Transarterial chemoemboli- CONFLICTS OF INTEREST zation(TACE) or sorafenib is recommended for hepatocellular carcinoma BCLC stages B and C The authors have none to declare. respectively. We studied the role of TACE + sorafenib Corresponding author: Jayanthi Venkataraman. in BCLC stages B/C. E-mail: [email protected] Methods: We undertook an observational study on a cohort of cirrhotics with HCC from August 2010 http://dx.doi.org/10.1016/j.jceh.2016.06.172

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The inclusions of Hepatobiliary ‘Quiz’ colored, high-quality tables and fi gures to summarize critical Hepatobiliary ‘Quiz’ is published under two parts. First points are highly desirable. Liver Transplant Forum articles part, contains multiple choice questions (MCQs) with multiple correct responses. Second part will provide their Results answers with evidence from the literature. Present the major fi ndings of the study. Do not illustrate Letters to the Editor minor details if their message is conveyed adequately by simple descriptive text. Mention all tables and fi gures. Letters to the editor will be considered for publication only if they are related to articles published in recent issues of Discussion the JCEH or are relevant brief reports of preliminary data Concisely present the implications of the new fi ndings for that can be published if they provide new insights. 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Acknowledgements, if any, may be mentioned on Johnson RJ, Gretch DR, Yamabe H, et al. Membrano this page. proliferative glomerulonephritis associated with hepa- Abstract titis C virus infection. N Engl J Med 1993;328:465–70. The abstract should summarize the most important Books points in the study. Original articles should include a Abramson JH, Abramson ZH. In: Survey Methods in Commu- structured abstract of about 300 words under the following nity Medicine 5th ed. Churchill Livingston, London 1999. headings: Background/Objectives, Methods, Results, and Conclusions (See Ann Intern Med 1990;113:69–76). Book Chapters References should not be included. Less than 10 keywords, Cassidy JT. Juvenile rheumatoid arthritis. In: Textbook of not present in the title, to assist indexing, should be typed Rheumatology 6th ed, Kelly, ed. 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Tel: +91-124-4774244 AUTHOR INDEX VOLUME 6

Abdali N, S26 Banerjee S, S17, S18, S27, S101 Abdul S, S2 Bansal A, S23 Abedin MF, S24 Bansal N, S28, S45, S48, S62 Abhilash MI, S17 Bansal R, S23 Abodeya S, S35 Basunia MZH, S24 Acharya SK, S66, S70, S79, S80 Behera S, S1, S46, S84 Adhikary S, S10 Bera C, S90, S91 Afzal S, S87 Bhadauria D, S13 Afzal SN, S26 Bhandari A, S82 Agarwal A, S97 Bhansali A, S56 Agarwal R, S89, S90 Bharadia L, S97 Agarwal S, S8, S33, S74, S82, S101 Bharadwaj H, S47 Agarwala M, S9 Bhardwaj B, S13 Aggan HE, S9, S35, S64 Bhardwaj H, S13 Aggarwal R, S13 Bhargava R, S13, S51 Aggrawal R, S6 Bhat M, S12 Agrawal O, S23 Bhatia E, S74 Agrawal S, S4, S31 Bhatia S, S96 Ahmad I, S26 Bhattacharyya A, S24 Ajmal M-ur, S26 Bhrugu S, S19 Ajmal M-u-R, S87 Bhuyan P, S23 Akbar SMF, S76, S77 Biju K, S61 Alam MA, S77 Bincy B, S40 Alam S, S1 Bincy BK, S36, S38, S71 Author Index Ali S, S97 Boopathy V, S75 Allu RK, S44 Borkakoty A, S7 Amarapurkar D, S8, S39, S89, S92 Borkakoty B, S83 Ambroise J, S60, S61 Bouzin C, S61 Amirtharaj GJ, S88, S100 Brugu S, S19, S51 Ananthavadivelu M, S41, S52 Budhiraja S, S30 Anikhindi S, S28, S45 Annasamy C, S20, S100 Chakarbarti A, S2 Ansari M, S79 Chakraborty J, S101 Arora A, S28, S45, S48 Chakravarty R, S10 Arora P, S16 Chandrababu D, S94 Arora T, S83 Chapla A, S88 Arumugham A, S41, S52 Chatterjee JG, S14 Asati P, S30, S78 Chatterjee M, S18, S27 Asati PK, S65 Chatterjee R, S101 Augustine P, S30 Chaudhary A, S37 Chawla Y, S21, S56 Babu GR, S36, S38, S40, S50, S71, S78 Chawla YK, S2, S4, S7, S15, S27, S31, S46, S53, S54, S55, Babu R, S61 S57 Babu S, S20 Chethan G, S34, S50, S67, S71 Bahuleyan S, S5 Chetri K, S9 Bahuleyan SA, S2 Chettupuzha A, S30, S49 Baijal S, S59 Chhikara A, S79 Bakshi N, S60 Chooracken M, S30 Balaji G, S64, S93 Chopra M, S54, S55, S56 Balaraju G, S5, S75 Choracken M, S49 Balasubramanian KA, S88, S100 Chowdhury A, S17, S18, S27, S101 Baldin P, S60 Chowdhury MFI, S24 Bale A, S75 Contractor Q, S81, S91 Balekuduru A, S24, S41, S42 Cyriac R, S2, S50

Dadhich S, S3 Gaur K, S97 Dar A, S87 Gaurav K, S50 Das A, S83, S99 Gautam V, S46 Das C, S10 Ghosh A, S27, S101 Das D, S10 Ghosh S, S17, S80, S101 Das K, S18 Ghoshal UC, S6 Das P, S80 Girinadh Lekkala RS, S44 Das S, S99 Girinadh, S52 Dasgupta D, S18, S27, S101 Girish PV, S64, S93 Dash K, S46, S84 Goel A, S6, S13, S88, S100 Dash KR, S52 Goenka M, S90 Daswani R, S28 Goenka MK, S91 Datta S, S17, S18, S27, S101 Goenka U, S90, S91 De A, S15 Gohain M, S83 Deeb NE, S64 Gomber S, S8 Deep A, S16 Gopal S, S43 Deepashree T, S63, S102 Gopalakrishna R, S31, S82 Deshmukh S, S42 Gopalakrishnan P, S36, S38 Devadas K, S26, S36, S38, S70, S71, S87, S98 Govil S, S63, S69, S102 Devaraj E, S45 Govindarajan R, S41, S52 Devarbhavi H, S64, S93 Govindaraju C, S2, S5, S26, S70, S98 Devarbhavi HC, S67 Govindraju C, S4 Devdas K, S2, S4 Goyal O, S34 Devi MU, S17 Goyal S, S13, S33 Devi U, S98, S99 Grover S, S53, S56 Dey A, S96 Gupta A, S13 Dhali G, S17, S27 Gupta B, S79, S80 Dhali GK, S18 Gupta E, S51 Dhampalwar S, S7 Gupta G, S47 Dhiman RK, S2, S4, S7, S15, S16, S21, S27, S31, S46, S53, Gupta K, S15 Gupta M, S3

S54, S55, S56, S57 Author Index Dhingra JS, S69 Gupta PK, S1 Dhingra R, S51 Gupta R, S74, S82 Dhus U, S42 Gupta S, S101, S80 Dixit V, S11, S30, S78 Gupta SD, S80 Dixit VK, S65 Gupta T, S4, S57 Duseja A, S2, S4, S7, S15, S16, S21, S27, S31, S46, S53, S54, Gupta UD, S24 S55, S56, S57 Gupta UR, S33 Dutta U, S54 Gurappa B, S67 Gurudath GS, S77 Eapen CE, S88, S100 Eapen M, S31 Hanchanale P, S59 Elias E, S88, S100 Hanchanale PB, S63 Elyamany A, S9 Haque MS, S15 Esa RA, S9 Hariharan M, S42 Harika K, S36, S63 Farahat N, S9 Helmy M, S64 Farhat S, S12 Fathima S, S4 Ilankumar K, S36 Fathima SS, S36, S38, S40, S71 Ilankumaran K, S63, S102 Fawzy M, S64 Iyer A, S4, S26, S36, S40, S71, S87 Foez SA, S24, S76, S77 Francis J, S30, S49 Jain A, S30, S65, S96 Jain M, S36, S59, S69 Gamanagatti SR, S79, S80 Jain P, S13 Gangwar R, S94 Jain S, S49, S81, S91 Garg G, S78 Jain V, S74

Journal of Clinical and Experimental Hepatology | July 2016 | Vol. 6 | Sup. 1 | VIII–XIII IX JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY

Janardhanan S, S61 Kumar A, S13, S16, S19, S28, S33, S45, S48, S51, S61, S62 Jasmine JJ, S20, S100 Kumar K, S6 Jayanthi V, S36, S59, S63, S86 Kumar KS, S41 Jayanti V, S69 Kumar N, S95 Jeevan HR, S94 Kumar P, S46, S51 Jha SK, S54 Kumar P, S85 Jose J, S49 Kumar PS, S17 Jose T, S61 Kumar R, S49 Joseph D, S2, S34, S50, S67, S98 Kumar S, S94, S98 Joseph R, S5 Kumar V, S15 Joseph RC, S78 Kumari P, S101 Joseph T, S64, S93 Joseph TS, S67 L MV, S31 Joshi N, S19, S51 Lal S, S99 Jothimani D, S63 Latinne D, S60 Lochan D, S57 Kadavanoor S, S34, S98 Locheruvapalli L, S24, S41, S42 Kadla S, S11, S12 Lukhi H, S72 Kalkura N, S86 Kalyanasundaram M, S41, S52 Macherla R, S17, S98 Kanianchalil K, S61 Mackie I, S88, S100 Kanni P, S85 Madan K, S51 Kapoor AK, S59 Madhusudan KS, S80 Kar SK, S23 Mahmoud S, S35 Kashyap H, S34 Mahtab MA, S15, S24, S56, S76, S77 Katepally S, S88 Maidur R, S19, S51 Author Index Kaul A, S13 Majid F, S56 Kaur S, S16 Majumdar K, S97 Kavitha S, S52 Manasa, S52 Kazia D, S85 Mangal K, S82 Kedarisetty C, S63 Manna A, S18, S27 Kedarisetty CK, S102 Manne M, S52 Kedia S, S70 Martin C, S86 Kelkar A, S9 Mathew P, S85 Khalde V, S85 Meher C, S23 Khan B, S11, S12 Mehta D, S51 Khan E, S90 Mehta M, S21, S27, S31 Khan J, S65 Menon J, S99 Khan M, S12 Minz M, S15 Khanam B, S23 Mishra S, S29 Khandelwal A, S59 Misra B, S23 Khanna R, S1 Misra D, S23 Khondaker FA, S24 Mitra S, S99 Khondoker FA, S56 Moben AL, S24, S56, S76, S77 Kilari M, S85 Mohammad JK, S77 Kiran R, S24, S41, S42 Mohan AT, S42 Kokkat A, S85 Mohan N, S59 Komuta M, S60, S61 Mohindra S, S6 Konar A, S14 Mohite A, S81, S91 Korrapati SK, S44 Mourya S, S23 Koshy A, S30, S49 Mukkada R, S30, S49 Krishan S, 16, S72 Muraleedaran R, S50 Krishna VP, S6 Muraleedharan R, S2 Krishnadas D, S5, S34, S40, S50, S67, S78 Murugan N, S42 Krishnan B, S93 Krishnan P, S40, S71 Nada N, S79 Krishnasamy N, S20, S100 Nadda N, S66, S70

Nagarajan KV, S38 Pipaliya N, S85 Nair HR, S31 Piramnayagam P, S42 Nair P, S82 Piyush M, S77 Nambiar R, S61 Poddar U, S74, S94, S95 Nampoothiri RV, S31 Prabu S, S100 Nandeesh HP, S94 Prajapati R, S48 Nandmer A, S11 Prakash S, S2 Narayan J, S1, S23, S29, S84 Prasad N, S13 Narayanan S, S4 Prasanna KS, S9 Natarajan S, S61 Prasanth KS, S36, S38, S50, S71, S78 Nath P, S1, S23, S29, S46, S84 Prasanth S, S67 Nayak B, S66, S70, S79 Prasanth TS, S34, S50, S71 Nazir S, S11, S12 Prasanth, S4 Neethu CM, S82 Prashantha B, S43 Nijhawan S, S47 Pratap SA, S70 Nithyanand S, S77 Preethi M, S42 Noor MT, S49 Premkumar K, S20 Noor-E-Alam M, S56 Priyaa V, S41 Noor-E-Alam SM, S24, S76, S77 Puri A, S97 Noronha S, S2, S5, S50, S67, S70, S71 Querishi M, S12 Padhi P, S1, S29, S84 Padhi PK, S23 Rabia T, S61 Padsalgi G, S30 Raghupathy V, S88 Pai CG, S5 Rahim MA, S24, S56, S76, S77 Pai G, S75 Rahman S, S76, S77 Pal A, S89 Rai P, S6, S13 Palakurthy MK, S44 Rai R, S28 Palaniswami KR, S42 Rajan R, S61 Palanivelu C, S65, S77 Rajendran A, S43 Rajendran K, S20, S100

Paliwal M, S51 Author Index Panda C, S84 Rajini K, S41, S52 Panda SK, S80 Raju V, S93 Pande G, S6 Raju VA, S64, S67 Panigrahi MK, S23 Ramachandran A, S88, S100 Parameswaran S, S42 Ramachandran R, S15 Parida P, S1, S29, S46, S84 Ramachandran TM, 39 Parida PK, S23 Ramakrishna B, S88, S100 Parida S, S46, S84 Ramakrishnan G, S61 Parikh P, S42 Ramalingam S, S20, S100 Parveen S, S11, S12 Ramesh KTS, S77 Parvez MDN, S90, S91 Ramesh TS, S65 Patel B, S19, S51 Ramu M, S34, S40, S50, S67, S98 Patel O, S37 Randhawa M, S99 Patel PS, S39 Rangachari B, S41, S52 Pathak M, S70 Ranjan P, S3, S89 Pati G, S1, S29, S46, S84 Rashwan M, S35 Pati GK, S23 Rastogi M, S62 Patil AS, S24 Rathi M, S31 Patil M, S64, S67, S85, S93 Rathi P, S81, S91 Pattnaik K, S23 Rathi S, S4, S55, S56, S57 Paul J, S25 Ratnaparkhi G, S19, S51 Paul SB, S66, S70, S79, S80 Ravindran R, S61 Pawar S, S81 Rawat D, S1 Pawar V, S91 Reddy DM, S69 Peter G, S2, S5, S36, S70, S71 Reddy GMM, S36 Peter L, S25 Reddy M, S63

Journal of Clinical and Experimental Hepatology | July 2016 | Vol. 6 | Sup. 1 | VIII–XIII XI JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY

Reddy MS, S102 Shetty KNK, S25 Reddy R, S98 Shetty S, S5, S75 Reddy S, S86 Shetty SB, S41 Reddy V, S93 Shinde KD, S85 Reddy VV, S64, S67 Shiraz S, S82 Reding R, S60, S61 Shrestha D, S53 Rehman I, S11 Shukla A, S96 Rela M, S36, S59, S63, S69, S86, S102 Shukla S, S11, S30, S65, S78 Rout N, S23 Siddiqi S, S87 Roy P, S9 Sidhu S, S34 Roy S, S10 Singh A, S23, S29, S46 Singh D, S3 Sabaa BE, S9 Singh H, S5 Sachan D, S36 Singh K, S60 Sachan S, S78 Singh M, S54 Sachdeva N, S31 Singh RP, S47 Sadasiv S, S31 Singh S, S2, S46, S78, S79, S84, S94 Sadequl Islam ASM, S68 Singh SP, S1, S23, S29 Sahadevan S, S61 Singh V, S2, S46, S72 Sajith KG, S100 Singla V, S28, S45, S48 Saju L, S51 Siyad I, S31 Sakhuja P, S97 Smets F, S60, S61 Sandeep S, S50 Sobhan P, S5, S70 Santhosh P, S77 Sobhan PK, S2 Saraswat VA, S6 Soin AS, S60 Sarin SK, S1 Sokal E, S60, S61 Author Index Sarker MJA, S24 Solomon R, S41 Sarma M, S74, S94 Solomon TR, S52 Sarvanan S, S100 Somani V, S92 Sathar S, S5, S26, S70, S87 Sonavane AD, S8 Satsangi S, S16, S21, S27 Sonawane A, S89 Satthar S, S4 Sonika U, S14 Satyaprakash BS, S24, S42 Sonthalia N, S81, S91 Sawant P, S85 Sood V, S1 Seehra N, S49 Sreejaya S, S50 Sengupta I, S10 Sreejith K, S50 Seshadri VP, S42 Sreenivas V, S79 Setia A, S28 Sreenivasan V, S63 Shah A, S11 Sreesh S, S2, S4, S5, S26, S67, S70, S78, S87 shah A, S12 Srijaya S, S36, S38, S40, S50, S71 Shah K, S85 Srijayadeva A, S43 Shah NA, S11, S12 Srijith K, S2, S67, S78 Shalimar, S66, S70, S79, S80 Srikanth P, S99 Shanid A, S36, S38, S40, S50, S67, S71, S78 Srinivas D, S85 Sharath KGS, S77 Srinivas M, S36 Sharma A, S15 Srinivas U, S42 Sharma D, S96 Srinivasan V, S36, S102 Sharma H, S80 Srivastava A, S74, S94, S95 Sharma P, S6, S28, S45, S48, S90 Stephenne X, S60 Sharma R, S13 Stéphenne X, S61 Sharma S, S1, S11 Subathra R, S86 Sharma SS, S97 Sudamrao G, S70 Shemin SA, 39 Sudheendaran P, S98 Shenoy S, S43 Sudheendran P, S5, S67, S70, S87 Shetti M, S25 Sudheendran PT, S2 Shetty A, S5, S41, S75 Suganya D, S77 Shetty B, S42 Sultana S, S15

Suraj N, S2, S5, S34, S50, S67, S70, S78, S98 Veeranna GP, S67 Suresh I, S94 Venkataraman J, S63, S102 Sureshkumar S, S88 Venu R, S82 Surude R, S81, S91 Venu RP, S31 Suvarna D, S94 Venugopal R, S25 Swain M, S23 Venugopalan R, S38 Verma A, S6, S23 Taneja S, S2, S4, S7, S15, S21, S27, S46, S53, S54, S55, S56, Verma N, S2 S57, S86 Vidyasagar R, S80 Tantry B, S43 Vij M, S69 Thakur BS, S49 Vij V, S62 Thakur J, S56 Vijayvargiya M, S80 Thapa BR, S99 Vyas D, S47 Thomas N, S88 Vyawahare K, S51 Thomas V, S43 Thumburu KK, S54 Wadhawan M, S62 Tiwari A, S11 Tiwari M, S49 Yachha S, S74, S95 Tripathi M, S30 Yachha SK, S94 Yadav D, S66, S70, S80 Uddin MH, S76, S77 Yadav DP, S79 Udgirkar S, S91 Yadav M, S51 Uppalapati S, S85 Yadav R, S80, S94 Uthappa M, S63 Yadav S, S71 Uthappa MC, S102 Yadav SK, S4, S36, S40 Yang JI, S83 Vaishnavi Priyaa C, S52 Yarlagadda R, S19, S51 Varghese J, S36, S59, S63, S69, S86, S102 Varma S, S60, S61 Zachariah U, S100 Varun S, S50 Zeid A, S64

Vatsya S, S3 Author Index

Journal of Clinical and Experimental Hepatology | July 2016 | Vol. 6 | Sup. 1 | VIII–XIII XIII

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