Endoscopic management of acute oesophageal variceal bleeding within 12 hours of admission is superior to 12-24 hours

Background: Acute oesophageal variceal haemorrhage (AOVH) is a medical emergency. The American Association for the Study of Liver Diseases recommends endoscopy management as soon as possible and not more than 12 hours after presentation. The United Kingdom guidelines recommended endoscopy for unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and within 24 hours of admission. We aimed to evaluate the outcome of endoscopic management of AOVH in less than 12 hours compared to 12-24 hours post admission.Methods: 297 patients with AOVH were divided into groups depending on the timing of the endoscopic management: 180 within 12 h of admission and 117 patients at 12-24 hours of admission. Routine clinical and laboratory data were collected.Results: Compared to patients with endoscopic management at 12-24 hours (mean 16 hours), patients with endoscopic management within 12 hours (mean 8.3 hours) of admission had fewer hospital stay days (P = 0.001), significant reduction of ammonia levels (P < 0.0001) and significant improvement in associated hepatic encephalopathy grade 25 (p = 0.048). There were no major clinical events in the 12-hour group, but 8 events in the 12-24 hour group (p < 0.01).Conclusion: Endoscopic management of acute variceal bleeding within 12 hours of admission is superior to endoscopic management at 12-24 hours of admission regarding reduction of hospital stay, ammonia levels, correction of hepatic encephalopathy, re-bleeding and mortality rate, hence, reducing the cost of treatment benefiting patient satisfaction and improving hospital bed availability.

Serum leptin and homeostasis model assessment-IR as novel predictors of early liver fibrosis in chronic hepatitis B virus infection

BACKGROUND

The relationship between hepatitis B virus (HBV) infection, leptin and insulin resistance remains unclear. We hypothesised links between serum leptin and insulin resistance in non-diabetic patients with chronic viral hepatitis B infection and their relation to liver fibrosis.

METHODS

We recruited 190 untreated patients with chronic HBV infection and 72 healthy controls. Serum leptin, fasting glucose, insulin, liver function tests (LFTs), C-peptide and Homeostasis model assessment-IR (HOMA-IR) were measured/calculated by ELISA and standard techniques.

RESULTS

Serum leptin, C-peptide (both P < 0.001), HOMA-IR (P = 0.021) and several LFTs were increased in patients with chronic HBV-infection. In multivariate regression analysis, both HOMA-IR (P = 0.003) and leptin (P = 0.002) were significant independent predictors of HBV infection. There were significant positive correlations (P < 0.01) between leptin and HOMA-IR (r = 0.81), between serum leptin and METAVIR activity (r = 0.95), and between HOMA-IR and BMI (r = 0.75), fasting glucose (r = 0.005), and fasting insulin (r = 0.81). Several LFTs, glucose and insulin correlated modestly (r = 0.61-0.69, P < 0.05) with leptin.

CONCLUSION

Serum leptin may be related to the rate of fibrosis progression in nondiabetic patients with chronic HBV infection. Follow-up by serial measurement of serum leptin and HOMA-IR in non diabetic HBV-infected patients may be used as a non-invasive marker of early liver fibrosis.

Can combined blood neutrophil to lymphocyte ratio and C-reactive protein be used for diagnosis of spontaneous bacterial peritonitis?

BACKGROUND AND OBJECTIVE

Spontaneous bacterial peritonitis (SBP) is diagnosed by the presence of ≥250 polymorphonuclear neutrophils (PMN)/mm³ in the ascites and the absence of surgically treatable cause of intra-abdominal infection. Blood neutrophil lymphocytic ratio (NLR) is an inexpensive and simple test for inflammation. C-reactive protein (CRP) is an inflammatory marker used for the diagnosis and follow-up of many diseases and morbidities. We aimed to evaluate the clinical utility of combined blood NLR and CRP as a non-invasive test for SBP diagnosis.

METHODS

Blood NLR was calculated, and CRP value determined in 180 cirrhotic patients with ascites (126 with and 54 without SBP). Sensitivity and specificity of combined blood NLR and CRP values for SBP diagnosis were estimated by receiver operator characteristic curve.

RESULTS

Both blood NLR and CRP values were significantly higher in SBP (p < 0.001). For SBP diagnosis, a blood NLR of >2.89 had a sensitivity 80.3% and specificity 88.9%. CRP >11.3 mg/dL had a sensitivity 88.9% and specificity 92.6%. In logistic regression analysis, combined blood NLR and CRP had a sensitivity 95.1% and specificity 96.3% at the same cut off values.

CONCLUSIONS

Combined NLR and CRP could be used as a novel, simple, low-cost, non-invasive test for SBP diagnosis.

Impact of basic lymphedema management and antifilarial treatment on acute dermatolymphangioadenitis episodes and filarial antigenaemia

Background:

A major factor in the progression of lymphedema is acute dermatolymphangioadenitis (ADLA).

Aims

To study ADLA episodes and antigenaemia in patients with different grades of filarial lymphedema at pre- and two years post-treatment.

Setting and Design:

A prospectively conducted study from May 2008 through May 2010.

Patients and Methods:

Forty five patients complaining of limb swelling with present or past history of limb redness suggestive of ADLA attacks were included. Patients were clinically examined for lymphedema grading, detection of potential entry points and diagnosis of microfilaraemia. Wuchereria bancrofti antigen titer was estimated by “Trop-Ag W. Bancrofti” ELISA kit. Basic lymphedema management and treatment with antifilarial drugs were applied.

Statistical Analysis

Mann–Whitney test and Chi-square test were used.

Results:

The number of ADLA attacks in the pretreatment period, ranged from one to three per year. Mean duration of the attacks was 3.87±0.79 days. Entry points were detected in 82% of cases. The study revealed statistical significance between extension and grade of lymphedema and number of ADLA attacks per year (P=0.018 and 0.022, respectively). Microfilaraemia was detected in four cases and positive filarial antigenaemia were detected in 29 patients (64.4). The number of ADLA attacks per year significantly decreased from the pre-treatment period (mean: 2.05±0.560) to be 1.23±0.706 after one year and 0.89±0.575 after two years post treatment. There was a significant decrease in the mean antigen titer one year and two years after treatment.

Conclusion:

Basic lymphedema management is effective for controlling ADLA attacks in areas where lymphatic filariasis is endemic.

N-Nitrosodimethylamine changes the expression of glutathione S-transferase in the liver of male mice: The role of antioxidants

The present study investigated the protective effect of gossypol, selenium, zinc, or glutathione (GSH) against dimethylnitrosamine (DMN)-induced hepatotoxicity in the livers of male mice. The expression and the activity of glutathione S-transferase (GST), levels of GSH, and free radicals (malondialdehyde (MDA)), as well as the activity of glutathione reductase were determined after the treatment of mice for seven consecutive days with low or high doses of gossypol, selenium, zinc, or GSH. In experimental groups, DMN was administered as a single dose for 2 h after the repeated dose treatments of mice for seven consecutive days with each antioxidant. DMN reduced the expression and inhibited the activity of GST. However, repeated treatments of mice with low-dose gossypol or high dose of either selenium or GSH followed by a single dose of DMN induced the expression and the activity of GST. In contrast, low-dose treatments of mice with zinc, selenium, or GSH followed by a single dose of DMN reduced the expression and the activity of GST compared to either control or DMN-treated groups. In addition, high-dose treatment with either gossypol or selenium markedly induced the levels of GSH compared to either control or DMN-treated groups. Interestingly, pretreatment of mice with high dose of either gossypol or selenium for seven consecutive days followed by a single dose of DMN decreased the levels of MDA, whereas DMN induced such levels. It is concluded that high dose of either gossypol or selenium is a stronger protector than zinc and GSH in ameliorating the toxic effects of DMN.