Most overweight and obese Indian children have nonalcoholic fatty liver disease

 Background and rationale. Nonalcoholic fatty liver disease (NAFLD) is the most common cause of pediatric liver disease in western countries. Its prevalence in Indian subcontinent is not well studied.

MATERIAL AND METHODS

In a school based cross sectional study we have screened overweight and obese children in the age group of 11 to 15 years for NAFLD. Ultrasonography, elevated serum transaminases, fibroscan were used for defining NAFLD. Dietary habits, blood pressure, serum lipid profile, blood counts and insulin resistance were recorded. The relation of fibrosis 4 score, pediatric NAFLD fibrosis index, aspartate transaminases to platelet ratio index (APRI) with fibroscan was evaluated.

RESULTS

Out of 616 students screened 198 were overweight and obese. Hundred students and their parents gave informed consent for the further evaluation. The prevalence of NAFLD was 62% in overweight and obese children. Fatty liver was found in 50 % students on ultrasonography, liver stiffness (≥ 6.1 Kilopascals) in 23% and raised alanine transaminase in 30%. Hypertension, dyslipidemia, diabetes mellitus and insulin resistance were seen in 6%, 18%, 2% and 66% students respectively. Systolic hypertension, serum triglyceride, aspartate transaminase, APRI was significantly higher in the NAFLD group. On binary logistic regression only systolic hypertension was an independent risk factor for NAFLD.

CONCLUSION

In conclusion NAFLD is common in asymptomatic overweight and obese Indian children. Systolic hypertension is the only independent factor associated with NAFLD. Fibroscan has limited role for screening. We recommend screening for NAFLD in this high risk group with alanine transaminases and ultrasonography.

Alström Syndrome with Portal Hypertension

Alstrom syndrome is an autosomal recessive multisystem disorder caused by mutation in ALMS1 (2p13). Very few cases of same are reported so far of same. We report a case of Alstrom syndrome (AS) who presented with type II diabetes mellitus and portal hypertension. Unilateral anorchia with hypergonadotropic hypogonadism is another unique feature of our case.

Congenital Esophageal Duplication Cyst: A Rare Cause of Dysphagia in an Adult

Esophageal duplication cyst is a rare congenital embryonal gastrointestinal (GI) malformation which is diagnosed most commonly in childhood. In adults, they can present with a variety of symptoms ranging from dysphagia, chest pain, epigastric discomfort, and vomiting to more serious complications including infections, hemorrhage, and ulcerations. A 30-year-old male presented with gradually progressive dysphagia to solids for 4 months without significant weight loss. Clinical examination and routine laboratory examination were unrevealing. Upper GI endoscopy revealed a well-defined submucosal lesion bulging into the esophageal lumen involving the right antero-lateral wall of the distal esophagus. The overlying mucosa was normal with mild luminal narrowing but gastroscope could be negotiated across this narrowing. Differential diagnosis included lipoma, leiomyoma or GI stromal tumors. Contrast-enhanced computed tomography of thorax revealed a 3.5 × 2.3 × 3 cm well-defined homogenous hypodense lesion involving the right antero-lateral wall of the distal thoracic esophagus with likely possibility of submucosal or intramural lesion. Subsequently, endoscopic ultrasonography (EUS) revealed a 3.3 × 2.8 cm homogenous hypoechoic lesion without any vascularity involving the distal esophagus wall suggestive of duplication cyst. The lesion was intramural in location as muscularis propria was seen to go around the lesion. Bronchogenic cyst was excluded due to absence of cartilage and close proximity of the cyst to lumen. Fine-needle aspiration was not attempted in view of high risk of introducing infection. Being symptomatic, the patient underwent complete surgical excision of the cyst with exteriorization of the base which on histopathology confirmed duplication cyst. Esophageal duplication cysts are exceedingly rare congenital embryonal malformations with estimated prevalence of 0.0122% arising from aberration of posterior division of embryonic foregut at 3 - 4 weeks of gestation. This case shows that duplication cysts can rarely masquerade as submucosal tumor in adults and EUS is highly accurate in pre-operative diagnosis and therapeutic decision making. Literature search revealed only a handful of cases of EUS-guided diagnosis of esophageal duplication cyst reported in the literature.

Changing clinical profile and factors associated with liver enzyme abnormalities among HIV-infected persons

The spectrum of liver disease among HIV-infected patients is changing. In the era of antiretroviral therapy, opportunistic infections are diminishing and deranged liver function appears to be due usually to drug-induced liver injury, alcohol, non-alcoholic steatohepatitis (NASH) or chronic hepatitis B. To test this hypothesis, 98 HIV-positive patients with deranged liver function were compared with matched HIV-positive patients with normal liver function and likewise matched HIV-negative patients with normal liver function tests.

Unusual complication of amebic liver abscess: Hepatogastric fistula

Amebic liver abscess is a parasitic disease which is often encountered in tropical countries. A hepatogastric fistula secondary to an amebic liver abscess is a rare complication of this disease and there are only a handful of reported cases in literature. Here we present a case of an amebic liver abscess which was complicated with the development of a hepatogastric fistula. The patient presented with the Jaundice, pain and distension of abdomen. The Jaundice and pain improved partially after he had an episode of brownish black colored increase in frequency of stools for 5 to 6 d. Patient also had ascites and anemia. He was a chronic alcohol drinker. Esophagogastroduodenoscopy performed in view of the above findings. It showed a fistulous opening with bilious secretions along the lesser curvature of the stomach. On imaging multiple liver abscesses seen including one in sub capsular location. The patient was managed conservatively with antiamebic medications along with proton pump inhibitors. The pigtail drainage of the sub capsular abscess was done. The patient improved significantly. The repeat endoscopy performed after about two months showed reduction in fistula size. A review of the literature shows that hepatogastric fistulas can be managed conservatively with medications and drainage, endoscopically with biliary stenting or with surgical excision.