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Philips CA, Theruvath AH, Ravindran R, Augustine P. Complementary and alternative medicines and liver disease. Hepatol Commun 2024; 8:e0417. [PMID: 38563584 PMCID: PMC10990366 DOI: 10.1097/hc9.0000000000000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/25/2024] [Indexed: 04/04/2024] Open
Abstract
Complementary and alternative medicines (CAM) include conventional medical treatments. Patients worldwide use CAM at alarming rates; thus, reports of CAM-related DILI have been on the rise. The clinical presentations include asymptomatic liver test abnormalities, acute hepatitis with or without jaundice, acute cholestatic liver disease (bland or with hepatitis), acute liver failure, severe hepatitis with features of portal hypertension, and acute decompensation of known or unknown cirrhosis that can lead to acute-on-chronic liver failure. Acute hepatitis with or without necrosis, hepatocellular and canalicular cholestasis, herb-induced or CAM-triggered autoimmune hepatitis, granulomatous hepatitis, severe steatohepatitis, and vanishing bile duct syndrome are common liver biopsy findings in CAM-DILI. The presence of preexisting liver disease predicts severe liver injury, risk of progression to liver failure, and decreased transplant-free survival in patients with CAM-DILI. This review discusses global epidemiology and trends in CAM-DILI, clinical presentation, assessment and outcomes, commonly emerging threats in the context of hepatotoxic herbs, pragmatic assessment of "liver beneficial" herbs and health care myths, patient communication, regulatory framework, and future directions on research in CAM.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Department of Clinical Research, Division of Complementary and Alternative Medicine (AYUSH) and the Liver, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif Hussain Theruvath
- Department of Clinical Research, Division of Complementary and Alternative Medicine (AYUSH) and the Liver, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Resmi Ravindran
- Department of Clinical Research, Division of Complementary and Alternative Medicine (AYUSH) and the Liver, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
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Rajesh S, Philips CA, Ahamed R, Singh S, Abduljaleel JK, Tharakan A, Augustine P. Clinical outcomes related to portal pressures before and after embolization of large portosystemic shunts in cirrhosis. SAGE Open Med 2023; 11:20503121231208655. [PMID: 37915841 PMCID: PMC10617273 DOI: 10.1177/20503121231208655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023] Open
Abstract
Objectives Embolization of large portosystemic shunts effectively controls gastric variceal bleeding and prevents hepatic encephalopathy. The significance of dynamic changes in hepatic venous pressure gradient before and after embolization on clinical events and patient outcomes remains unknown. Methods In this retrospective single-center series, 46 patients with gastric variceal bleeding, hepatic encephalopathy, or both undergoing embolization (January 2018 to October 2020) were included, and dynamic changes in portal pressures were analyzed against patient outcomes. Results Males predominated. The most common portosystemic shunt syndrome was the lienorenal shunt. In all, 34 patients underwent embolization for hepatic encephalopathy and 11 for gastric variceal bleeding. The proportion of patients surviving at the end of 12 and 32 months was 86.96 and 54.35%, respectively. The hepatic venous pressure gradient before shunt embolization was 13.4 ± 3.2 and 16.9 ± 3.7 mm Hg after occlusion (p < 0.001). Bleeding from varices on overall follow-up was notable in five patients (10.9%), and overt hepatic encephalopathy in four (N = 42, 9.5%) patients at 6-12 months. The development of infections within 100 days and beyond the first year was associated with the risk of dying at the end of 12 and 32 months, respectively. Elevation of hepatic venous pressure gradient by >4 mm Hg from baseline and an absolute increase to >16 mm Hg immediately post-procedure significantly predicted the development of early- and late-onset ascites, respectively. Conclusion Close monitoring for the development of infections and optimization of beta-blockers and diuretics after shunt embolization may improve clinical outcomes and help identify patients who will benefit from liver transplantation pending prospective validation.
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Affiliation(s)
- Sasidharan Rajesh
- Interventional Hepatobiliary Radiology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology and Monarch Liver Laboratory, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Shobhit Singh
- Interventional Hepatobiliary Radiology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Jinsha K Abduljaleel
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Ajit Tharakan
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
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Philips CA, Ahamed R, Abduljaleel JK, Rajesh S, Tharakan A, Augustine P. Significant gut microbiota related to patterns of drinking and alcohol relapse in patients with alcoholic hepatitis undergoing stool transplant or corticosteroid therapy. Indian J Gastroenterol 2023; 42:724-730. [PMID: 37548864 DOI: 10.1007/s12664-023-01401-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/19/2023] [Indexed: 08/08/2023]
Abstract
Alcohol-induced gut microbiota (GM) alterations are linked to alcohol use disorder (AUD) pathogenesis. Healthy donor stool transplant (fecal microbiota transplant [FMT]) reduced alcohol desire and improved clinical outcomes in small animal and human studies. Baseline and post-therapy-related GM changes in a real-world cohort with severe alcohol-related liver disease and AUD, patterns of drinking, and relapse have not been studied. We prospectively analyzed retrospective clinical data and stored samples to examine GM alterations in a cohort of severe alcohol-associated hepatitis (SAH) patients who underwent FMT or corticosteroid treatment followed for at least 12 months. The GM changes at baseline in the context of a pattern of drinking (binge vs. every day) and baseline and post-treatment alcohol relapse status (relapser vs. non-relapser). We identified 28 patients on FMT and 25 on corticosteroids who survived 1 year post-treatment. After necessary exclusions, the final cohort for various grouped GM analysis included 16 patients in the FMT arm and 14 on corticosteroids. Pedobacter and Streptophyta species at the commencement of treatment predicted alcohol relapse in steroid-ineligible patients receiving FMT and steroid-treated patients, respectively. At 6-12 months post-FMT, non-relapsers had elevated short-chain fatty acid-producing bacterial taxa linked with lower alcohol cravings. Alcohol relapse was significantly more in those on steroid therapy and was associated with the upregulation of the nucleotide metabolism pathway related to ethanol metabolism. We demonstrate pertinent baseline and post-treatment intestinal bacterial alterations that impact patterns of AUD patterns and relapse in SAH patients in the context of the therapy offered.
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Affiliation(s)
- Cyriac Abby Philips
- Department of Clinical and Translational Hepatology and Monarch Liver Laboratory Center for Excellence in Gastrointestinal Sciences, Ground Floor, The Liver Institute, Rajagiri Hospital, Phase II, Tower -3, Aluva, 683 112, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, 683 112, India
| | - Jinsha K Abduljaleel
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, 683 112, India
| | - Sasidharan Rajesh
- Interventional Hepatobiliary Radiology, Center of Excellence in GI Sciences, The Liver Institute, Rajagiri Hospital, Chunangamvely, Aluva, 683 112, India
| | - Ajit Tharakan
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, 683 112, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, 683 112, India
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Philips CA, Valsan A, Theruvath AH, Ravindran R, Oommen TT, Rajesh S, Bishnu S, Augustine P. Ashwagandha-induced liver injury-A case series from India and literature review. Hepatol Commun 2023; 7:e0270. [PMID: 37756041 PMCID: PMC10531359 DOI: 10.1097/hc9.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/25/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Ashwagandha herb is commonly used in Ayurveda and a "fad" dietary supplement for a host of indications based on low levels of evidence. Recently, ashwagandha was implicated in multiple reports of herb-induced liver injury (HILI), mainly from the United States. We present the first, and currently largest, series of ashwagandha-HILI from multiple centers in India. METHODS We retrospectively analyzed the respective institutional electronic medical records for ashwagandha-HILI. Patients consuming ashwagandha as part of multiherbal formulations or along with other known hepatotoxic supplements or medicines were excluded. All patients underwent a detailed diagnostic workup to exclude competing causes reasonably. Where possible, the implicated herbal formulation was retrieved and subjected to chemical analysis. RESULTS Out of 23 patients with liver injury from ashwagandha (January 2019 to December 2022), we report 8 patients with single-ingredient formulation-related HILI. Study cohort was male predominant, and cholestatic hepatitis was the commonest presentation. Five patients had underlying chronic liver disease; 3 presented with acute-on-chronic liver failure, and all 3 died on follow-up. In others, the liver injury was prolonged, nonetheless self-limiting. Liver biopsy revealed cholestatic features predominantly with hepatocellular necrosis and lymphocyte/eosinophil predominant portal-based inflammation. One patient progressed to chronic HILI. Chemical analysis revealed only natural phytochemicals without adulteration or contamination. CONCLUSIONS Ashwagandha-HILI presents with cholestatic hepatitis and can lead to the syndrome of acute-on-chronic liver failure with high mortality in those with pre-existing liver disease. Educating the public on avoiding the use of potentially toxic and unrecommended herbal supplements can help mitigate the avoidable liver disease burden in the community.
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Affiliation(s)
- Cyriac A. Philips
- Clinical and Translational Hepatology, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Department of Hepatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Arun Valsan
- Department of Clinical Research, Division of Complementary and Alternative Medicine, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif H. Theruvath
- Department of Hepatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Resmi Ravindran
- Department of Hepatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Tharun T. Oommen
- Clinical and Translational Hepatology, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Gastroenterology & Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Sasidharan Rajesh
- Interventional Hepatobiliary Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Saptarshi Bishnu
- Department of Gastroenterology and Hepatology, Astha Medical Centre, Koshbagan, Burdwan, West Bengal, India
| | - Philip Augustine
- Clinical and Translational Hepatology, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Gastroenterology & Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
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Philips CA, Madhu D, Augustine P. Investigating the correlation between COVID-19 and the progression of chronic liver disease. Expert Rev Gastroenterol Hepatol 2023:1-11. [PMID: 37086388 DOI: 10.1080/17474124.2023.2206564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
INTRODUCTION The novel coronavirus disease 2019 has thrown light on various heterogeneous afflictions of newly emerging viruses on the human body. Early reports demonstrated direct effect of novel coronavirus on the liver, but subsequently, this did not stand up to validation. The SARS-CoV-2 virus affects the liver differentially; in healthy compared to those with pre-existing liver disease. AREAS COVERED This exhaustive paper reviews the current, literature on mechanisms by which COVID-19 affects the healthy liver and those with pre-existing liver disease such as alcohol-related and non-alcoholic fatty liver, autoimmune liver disease, chronic liver disease and cirrhosis, hepatocellular carcinoma, viral hepatitis, and liver transplant recipients, with special mention on drug-and herb-induced liver injury with COVID-19 therapies. Search methodology: the review (Dec. 2022 - Jan. 2023) is based on PubMed (NLM) search using the keyword 'COVID' with supplementary searches using 'fibrosis'; 'liver'; 'cirrhosis'; 'CLD'; 'NAFLD'; 'NASH'; 'hepatocellular carcinoma'; 'hepatitis'; 'fatty liver'; 'alcohol'; 'viral'; 'transplant'; and 'liver failure.' EXPERT OPINION Direct liver tropism of SARS-CoV-2 does not cause liver damage. Adverse events following infection depend on the severity of liver disease, the severity of COVID-19, and other risk factors such as metabolic syndrome and older age. Alcohol-related liver disease independently predicts adverse outcomes.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology and The Monarch Liver Laboratory, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Deepak Madhu
- Department of Gastroenterology, Lisie Hospital, Ernakulam, Kerala, India
| | - Philip Augustine
- Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
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Nadarajan A, Bhargavan R, Augustine P, Cherian K, Krishna J. P243 Is the indian population ready for acosog z0011 protocol? Breast 2023. [DOI: 10.1016/s0960-9776(23)00361-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
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Koshy A, Devadas K, Panackel C, Philip M, Premaletha N, Zacharias P, Ramachandran TM, Gopalakrishna R, Mukkada RJ, Philips CA, Augustine P, Krishnakumar R, Sebastian B, Chettupuzha AP, Sadasivan S, Thomas GK, Siyad I, Sandesh K, Abhilash VB, Antony R, Kandathil JC, Pratap T, Mahadevan P. Multi-center prospective survey of hepatocellular carcinoma in Kerala: More than 1,200 cases. Indian J Gastroenterol 2023; 42:233-240. [PMID: 37154853 DOI: 10.1007/s12664-022-01314-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 11/22/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is considered uncommon in India. The aim of this study was to document the demographic characteristics and clinical aspects of HCC in Kerala, India. METHODS A survey of HCC in Kerala was performed. All gastroenterologists in the region were invited. From May 2018 to April 2020, data was collected in a standardized questionnaire. RESULTS Forty-three doctors from 15 centers contributed the data. Total 1217 patients were analyzed. This is the largest state-wide survey of HCC in India. HCC was more common in men (90%) than in women (p < 0.01). The etiology of liver disease was hepatitis B virus (7%), hepatitis C virus (4%) and alcohol (40%). Diabetes mellitus was present in 64%, hypercholesterolemia in 17% and hypertension in 38%. Obesity was present in 33% and 15% were overweight. Non-alcoholic fatty liver disease (NAFLD) with or without metabolic syndrome was present in 44%. Serum alpha-fetoprotein was > 400 ng/mL in 24%, total tumor diameter was > 5 cm in 59%, portal vein invasion was seen in 35% and distant metastasis was seen in 15%. Specific therapy was given to 52%. Treatments given included liver transplantation (n = 24), liver resection (n = 39) and transarterial chemoembolization (TACE, n = 184). Although the study was not designed to compare survival, patients who had liver transplantation had longer survival (median 69 months) compared to matched patients given only TACE (median 18 months) (p = 0.03). CONCLUSION HCC is common in Kerala, India. NAFLD has a predominant association with HCC in Kerala. Most of the patients report late when curative treatment is not possible.
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Affiliation(s)
- Abraham Koshy
- Department of Gastroenterology, VPS Lakeshore Hospital, Kochi, 682 040, India.
| | - Krishnadas Devadas
- Department of Gastroenterology, Trivandrum Medical College, Trivandrum, 695 011, India
| | - Charles Panackel
- Department of Gastroenterology, Aster Medcity, Kochi, 682 027, India
| | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, 682 017, India
| | - N Premaletha
- Department of Gastroenterology, Kottayam Medical College, Kottayam, 686 008, India
| | - Prakash Zacharias
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, 682 017, India
| | - T M Ramachandran
- Department of Gastroenterology, Calicut Medical College, Calicut, 673 008, India
| | - Rajesh Gopalakrishna
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, 682 041, India
| | - Roy J Mukkada
- Department of Gastroenterology, VPS Lakeshore Hospital, Kochi, 682 040, India
| | | | - Philip Augustine
- Department of Gastroenterology, Rajagiri Hospital, Aluva, 683 112, India
| | - Rema Krishnakumar
- Department of Gastroenterology, Moulana Hospital, Perinthalmanna, 679 322, India
| | - Benoy Sebastian
- Department of Gastroenterology, Medical Trust Hospital, Kochi, 682 016, India
| | | | - Shine Sadasivan
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, 682 041, India
| | - George K Thomas
- Department of Gastroenterology, Pushpagiri Medical College Hospital, Thiruvalla, 689 101, India
| | - Ismail Siyad
- Department of Gastroenterology, Aster Medcity, Kochi, 682 027, India
| | - K Sandesh
- Department of Gastroenterology, Calicut Medical College, Calicut, 673 008, India
| | - V B Abhilash
- Department of Gastroenterology, ESIC Hospital, Kollam, 691 002, India
| | - Rajesh Antony
- Department of Radiology, VPS Lakeshore Hospital, Kochi, 682 040, India
| | - Julio C Kandathil
- Department of Radiology, VPS Lakeshore Hospital, Kochi, 682 040, India
| | - Thara Pratap
- Department of Radiology, VPS Lakeshore Hospital, Kochi, 682 040, India
| | - Pushpa Mahadevan
- Department of Pathology, VPS Lakeshore Hospital, Kochi, 682 040, India
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Philips CA, Theruvath AH, Raveendran R, Ahamed R, Rajesh S, Abduljaleel JK, Tharakan A, Augustine P. Clinical outcomes associated with complementary and alternative medicine-related "immunity-boosting" practices in patients with cirrhosis during the COVID-19 pandemic - an observational study. Medicine (Baltimore) 2023; 102:e33365. [PMID: 36961176 PMCID: PMC10035553 DOI: 10.1097/md.0000000000033365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/06/2023] [Indexed: 03/25/2023] Open
Abstract
During the coronavirus disease 2019 pandemic, Ayurvedic herbal supplements and homeopathic immune boosters (IBs) were promoted as disease-preventive agents. The present study examined the clinical outcomes among patients with chronic liver disease who presented with complications of portal hypertension or liver dysfunction temporally associated with the use of IBs in the absence of other competing causes. This single-center retrospective observational cohort study included patients with chronic liver disease admitted for the evaluation and management of jaundice, ascites, or hepatic encephalopathy temporally associated with the consumption of IBs and followed up for 180 days. Chemical analysis was performed on the retrieved IBs. From April 2020 to May 2021, 1022 patients with cirrhosis were screened, and 178 (19.8%) were found to have consumed complementary and alternative medicines. Nineteen patients with cirrhosis (10.7%), jaundice, ascites, hepatic encephalopathy, or their combination related to IBs use were included. The patients were predominantly male (89.5%). At admission, 14 (73.75%) patients had jaundice, 9 (47.4%) had ascites, 2 (10.5%) presented with acute kidney injury, and 1 (5.3%) had overt encephalopathy. Eight patients (42.1%) died at the end of the follow up period. Hepatic necrosis and portal-based neutrophilic inflammation were the predominant features of liver biopsies. IB analysis revealed detectable levels of (heavy metals) As (40%), Pb (60%), Hg (60%), and various hepatotoxic phytochemicals. Ayurvedic and Homeopathic supplements sold as IBs potentially cause the worsening of preexisting liver disease. Responsible dissemination of scientifically validated, evidence-based medical health information from regulatory bodies and media may help ameliorate this modifiable liver health burden.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif Hussain Theruvath
- Complementary and Alternative Medicine (Homeopathy), Department of Clinical Research, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala
| | - Resmi Raveendran
- Complementary and Alternative Medicine (Ayurveda), Department of Clinical Research, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Sasidharan Rajesh
- Interventional Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Jinsha K Abduljaleel
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Ajit Tharakan
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
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Theruvath AH, Raveendran R, Philips CA, Ahamed R, Abduljaleel JK, Tharakan A, Rajesh S, Augustine P. A series of homeopathic remedies-related severe drug-induced liver injury from South India. Hepatol Commun 2023; 7:e0064. [PMID: 36757412 PMCID: PMC9916127 DOI: 10.1097/hc9.0000000000000064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/10/2022] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Homeopathic remedies are highly diluted formulations without proven clinical benefits, traditionally believed not to cause adverse events. Nonetheless, published literature reveals severe local and non-liver-related systemic side effects. We present the first series on homeopathy-related severe drug-induced liver injury (DILI) from a single center. METHODS A retrospective review of records from January 2019 to February 2022 identified 9 patients with liver injury attributed to homeopathic formulations. Competing causes were comprehensively excluded. Chemical analysis was performed on retrieved formulations using triple quadrupole gas chromatography-mass spectrometry and inductively coupled plasma atomic emission spectroscopy. RESULTS Males predominated with a median age of 54 years. The most typical clinical presentation was acute hepatitis, followed by acute on chronic liver failure. All patients developed jaundice, and ascites were notable in one-third of the patients. Five patients had underlying chronic liver disease. COVID-19 prevention was the most common indication for homeopathic use. Probable DILI was seen in 77.8%, and hepatocellular injury predominated (66.7%). Four (44.4%) patients died (3 with chronic liver disease) at a median follow-up of 194 days. Liver histopathology showed necrosis, portal and lobular neutrophilic inflammation, and eosinophilic infiltration with cholestasis. A total of 29 remedies were consumed between 9 patients, and 15 formulations were analyzed. Toxicology revealed industrial solvents, corticosteroids, antibiotics, sedatives, synthetic opioids, heavy metals, and toxic phyto-compounds, even in 'supposed' ultra-dilute formulations. CONCLUSION Homeopathic remedies potentially result in severe liver injury, leading to death in those with underlying liver disease. The use of mother tinctures, insufficient dilution, poor manufacturing practices, adulteration and contamination, and the presence of direct hepatotoxic herbals were the reasons for toxicity. Physicians, the public, and patients must realize that Homeopathic drugs are not 'gentle placebos.'
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Affiliation(s)
- Arif Hussain Theruvath
- Division of Complementary and Alternative Medicine (Homoeopathy), Department of Clinical Research, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Resmi Raveendran
- Division of Complementary and Alternative Medicine (Ayurveda), Department of Clinical Research, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology & Monarch Liver Laboratory, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Jinsha K Abduljaleel
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Ajit Tharakan
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Sasidharan Rajesh
- Interventional Hepatobiliary Radiology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
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Philips CA, Ahamed R, Abduljaleel JK, Rajesh S, Augustine P. Identification and Analysis of Gut Microbiota and Functional Metabolism in Decompensated Cirrhosis with Infection. J Clin Transl Hepatol 2023; 11:15-25. [PMID: 36406325 PMCID: PMC9647106 DOI: 10.14218/jcth.2021.00428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/05/2022] [Accepted: 05/10/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS Intestinal dysbiosis play a role in the adverse outcomes of sepsis and septic shock. However, variations in bacterial diversity and microbiota-related functional metabolic alterations within the gut microbiome in decompensated cirrhosis (DC) patients with infection remain unknown. METHODS We conducted 16-srRNA sequencing on stool samples (n=51: sepsis, 27/no sepsis, 24) collected from consecutive DC patients upon admission. Bacterial diversity, significant taxa, and respective metabolic profiling were performed based on subgroup comparisons. Conet/Cytoscape was utilized to identify significant non-random patterns of bacterial copresence and mutual exclusion for clinical events. RESULTS Genera associated with pathogenicity in conditions of immune exhaustion (Corynebacterium, Lautropia) were predominant in patients with sepsis. Metabolic pathways associated with oxidative stress and endotoxemia [lipopolysaccharide (LPS) synthesis and sulfur relay] were significantly upregulated in sepsis. Specific taxa were associated with sites of infection in DC patients. Protective oxidant pathways that increase glutathione were upregulated in those without sepsis. Gammaproteobacteria family of sulfur-metabolizing bacteria, exaggeration of orally predominant pathogens (Prevotella), and pathways of severe LPS-related hyperinflammatory stress were notable in those with interleukin-6 levels >1,000 pg/dL. Pathogenic genera related to an immune deficient state was significant in DC with ≥2 infection episodes. Megamonas was associated with survival during the same admission. CONCLUSIONS Specific gut microbiota and their metabolites were associated with sepsis and related events in patients with DC. Identifying beneficial strains that reduce immune exhaustion and supplementation of favorable metabolites could improve therapeutics for DC and sepsis, for which larger prospective, well controlled population-based studies remain an unmet need.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, Monarch Liver Laboratory, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Correspondence to: Cyriac Abby Philips, Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Ground Floor, Phase-II, Rajagiri Hospital, Chunangamvely, Aluva, Kerala 683112, India. ORCID: https://orcid.org/0000-0002-9587-336X. Tel: +484-290-5000 (Ext. 4049), Fax: +484-290-5000, E-mail:
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Jinsha K.P. Abduljaleel
- Gastroenterology and Advanced GI Endoscopy, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Sasidharan Rajesh
- Diagnostic and Interventional Gastroenterology and Hepatology, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
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11
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Philips CA, Tharakan A, Augustine P. Shallow Waters, Deep Secret: Trajectory of Serum Bilirubin to Predict Spontaneous Recovery in Alcohol-Associated Hepatitis. Clin Gastroenterol Hepatol 2023; 21:236-237. [PMID: 35151864 DOI: 10.1016/j.cgh.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Ajit Tharakan
- Department of Gastroenterology and Clinical Research, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
| | - Philip Augustine
- Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Kerala, India
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12
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Philips CA, Ahamed R, Rajesh S, Singh S, Tharakan A, Abduljaleel JK, Augustine P. Clinical outcomes and gut microbiota analysis of severe alcohol-associated hepatitis patients undergoing healthy donor fecal transplant or pentoxifylline therapy: single-center experience from Kerala. Gastroenterol Rep (Oxf) 2022; 10:goac074. [PMID: 36479155 PMCID: PMC9722224 DOI: 10.1093/gastro/goac074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/08/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Severe alcohol-associated hepatitis (SAH) patients with infections have a high short-term mortality rate. Gut microbiota dysbiosis plays an important role in the pathogenesis of SAH. Preliminary studies have demonstrated long-term benefits with healthy donor fecal microbiota transplantation (FMT). Data on FMT compared with pentoxifylline for SAH and relevant gut microbial changes are lacking in literature. METHODS From January 2019 to February 2021, retrospective analysis of a single hospital's records revealed 47 SAH patients undergoing FMT (100 mL/day via nasoduodenal tube for 7 days) and 25 matched patients receiving pentoxifylline (400 mg/8 h for 28 days). The primary end point was a 6-month survival rate. Secondary end points included incidence of ascites, hepatic encephalopathy, infections, acute kidney injury, and gut microbiota changes between post-therapy groups. Biomarker discovery and network analysis were also performed to identify significant taxa of gut microbiota in post-treatment groups in retrospectively stored stool samples. RESULTS All were males. The 6-month survival rate was higher in the patients undergoing FMT than in patients receiving pentoxifylline (83.0% vs 56.0%, P = 0.012). At the end of 6-month follow-up, the incidences of clinically significant ascites (56.0% vs 25.5%, P = 0.011), hepatic encephalopathy (40.0% vs 10.6%, P = 0.003), and critical infections (52.0% vs 14.9%, P < 0.001) in patients administered pentoxifylline were significantly higher than those in patients treated with FMT. At 3 months, biomarker analysis revealed a significant abundance of Bifidobacterium and Eggerthella in the FMT group and the pentoxifylline group, respectively. At 6 months, Bifidobacterium in the FMT group and pathogenic Aerococcaceae in the pentoxifylline group were notable. Network analysis showed beneficial taxa (Bifidobacterium) as a central influencer in those undergoing FMT at 6 months. CONCLUSIONS Healthy donor FMT improved survival rate and reduced liver-related complications compared with pentoxifylline. These clinical benefits were associated with favorable modulation of intestinal bacterial communities. Difficult-to-treat SAH patients may be safely bridged to transplantation using FMT. Controlled trials evaluating long-term outcomes are an unmet need.
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Affiliation(s)
- Cyriac Abby Philips
- Corresponding author. The Liver Institute, Center of Excellence in GI Sciences, Ground Floor, Phase II, Rajagiri Hospital, Chunangamvely, Aluva 683 112, Ernakulam, Kerala, India. Tel: +91-484-2905000; Fax: +91-484-7184000;
| | - Rizwan Ahamed
- Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Sasidharan Rajesh
- Diagnostic and Interventional Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Shobhit Singh
- Diagnostic and Interventional Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Ajit Tharakan
- Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Jinsha K Abduljaleel
- Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Philip Augustine
- Monarch Liver Laboratory, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India,Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
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Philips CA, Ahamed R, Abduljaleel JK, Rajesh S, Theruvath AH, Raveendran R, Augustine P. Ayurvedic treatment induced severe alcoholic hepatitis and non-cirrhotic portal hypertension in a 14-year-old girl. Oxf Med Case Reports 2022; 2022:omac113. [PMID: 36299672 PMCID: PMC9589464 DOI: 10.1093/omcr/omac113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/10/2022] [Accepted: 09/19/2022] [Indexed: 12/04/2022] Open
Abstract
We report a novel and as yet undescribed clinical scenario in a young girl with liver failure, in whom, the liver histopathology was suggestive of alcoholic hepatitis in the background of hepatoportal sclerosis and incomplete septal cirrhosis. An extensive clinical and investigational evaluation revealed chronic consumption of multiple Ayurvedic herbal medications for seizure disease. Six months after stopping herbal medicines, the repeat liver biopsy demonstrated resolution of alcohol-related changes but persistence of classical features of non-cirrhotic portal hypertension. Analysis of the retrieved agents, including state of the art chemical and toxicology analysis, using gas chromatography and mass spectroscopy methods demonstrated multiple organic and inorganic toxins associated with acute alcohol and arsenic poisoning related hepatoportal sclerosis/incomplete septal cirrhosis in the young girl.
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Affiliation(s)
- Cyriac Abby Philips
- Correspondence address. Department of Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Ground Floor, Phase II, Tower-3, Rajagiri Hospital, Aluva, Kerala 683112, India. E-mail:
| | - Rizwan Ahamed
- Gastroenterology & Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Jinsha K Abduljaleel
- Gastroenterology & Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Sasidharan Rajesh
- Interventional Hepatobiliary Radiology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif Hussain Theruvath
- Division of Complementary and Alternative Medicine (Homoeopathy), Department of Clinical Research, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Resmi Raveendran
- Division of Complementary and Alternative Medicine (Ayurveda), Department of Clinical Research, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Philip Augustine
- Gastroenterology & Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
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Philips CA, Ahamed R, Rajesh S, Abduljaleel JK, Augustine P. Long-term Outcomes of Stool Transplant in Alcohol-associated Hepatitis-Analysis of Clinical Outcomes, Relapse, Gut Microbiota and Comparisons with Standard Care. J Clin Exp Hepatol 2022; 12:1124-1132. [PMID: 35814513 PMCID: PMC9257856 DOI: 10.1016/j.jceh.2022.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/01/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Healthy donor fecal microbiota transplantation (FMT) was preliminarily shown to have clinical benefits in hepatic encephalopathy (HE), severe alcohol-associated hepatitis (SAH), and alcohol use disorder. However, the long-term outcomes of FMT and the gut microbiota (GM) changes in patients with SAH are unknown. METHODS Patients with SAH who underwent FMT (N = 35) or standard of care (SoC, N = 26) from May 2017 to June 2018 were included, and their stored stool samples were analyzed prospectively. Clinical outcomes, including infections, hospitalizations, critical illness, alcohol relapse, and survival, were evaluated. Metagenomic analysis was undertaken to identify the relative abundances (Ras) and significant taxa at baseline and post-therapy (up to three years) among survivors between the two groups. RESULTS At follow-up, the incidences of ascites, HE, infections, and major hospitalizations were significantly higher in the SoC than in the FMT group (P < 0.05). Alcohol relapse was lower (28.6% versus 53.8%), and the time to relapse was higher in the FMT than in the SoC group (P = 0.04). Three-year survival was higher in the FMT than in the SoC group (65.7% versus 38.5%, P = 0.052). Death due to sepsis was significantly higher in the SoC group (N = 13/16, 81.2%; P = 0.008). GM analysis showed a significant increase in the RA of Bifidobacterium and a reduction in the RA of Acinetobacter in the FMT group. Beyond one to two years, the RA of Porphyromonas was significantly higher and that of Bifidobacterium was lower in the SoC than in the FMT group. CONCLUSIONS In terms of treatment for patients with SAH, healthy donor FMT is associated with significantly lesser ascites, infections, encephalopathy, and alcohol relapse (with a trend toward higher survival rates) than SoC, associated with beneficial GM modulation. Larger controlled studies on FMT are an unmet need.
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Affiliation(s)
- Cyriac A. Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India,Monarch Liver Laboratory, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India,Address for correspondence. Cyriac Abby Philips M.D., D.M., The Liver Institute, Center of Excellence in GI Sciences, Ground Floor, Phase II, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala 683 112, India.
| | - Rizwan Ahamed
- Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Sasidharan Rajesh
- Diagnostic and Interventional Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Jinsha K.P. Abduljaleel
- Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Philip Augustine
- Monarch Liver Laboratory, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India,Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
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15
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Kaushal M, Sasidharan K, Kaushal A, Augustine P, Alex M. Increasing the exclusive breastfeeding rate in a private hospital in UAE through quality improvement initiatives. J Neonatal Perinatal Med 2022; 15:179-186. [PMID: 34120921 DOI: 10.3233/npm-210703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Mother's milk is the best, and ideal method for infant feeding. We found that this practice was not being followed in our hospital. A survey was conducted in the unit with regards to breastfeeding practices which revealed that most babies who were discharged from our nursery were on formula supplements. Our goal was to improve established breastfeeding rates in the unit by increasing the number of full-term healthy babies who were discharged on exclusive Breastfeeding. METHOD A project team was formed, and data were collected through direct observations and direct interviews with postnatal mothers. Exclusive Breastfeeding at discharge was defined as a baby being fully on breastfeed with no additional formula supplements for at least 12 hours prior to discharge. The primary outcome was to increase the percentage of babies being discharged on exclusive Breastfeeding. We used the FOCUS PDCA model to measure improvements and 8 PDCA cycles of 4 weeks duration were implemented to test the changes. RESULTS The interventions we put in place led to a considerable nine times overall improvement in the established breastfeeding rates. Among all the interventions, the most promising results were observed during the PDCA cycles involving staff education, the introduction of antenatal classes for mothers, skin to skin contact and rooming in. CONCLUSION Breastfeeding rates in the private sector with nursery services can be improved by reinforcing breastfeeding education for mothers in addition to training the maternal care staff, empowering them to promote and assist in breastfeeding.
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Abstract
Gut microbiota and their homeostatic functions are central to the maintenance of the intestinal mucosal barrier. The gut barrier functions as a structural, biological, and immunological barrier, preventing local and systemic invasion and inflammation of pathogenic taxa, resulting in the propagation or causation of organ-specific (liver disease) or systemic diseases (sepsis) in the host. In health, commensal bacteria are involved in regulating pathogenic bacteria, sinister bacterial products, and antigens; and help control and kill pathogenic organisms by secreting antimicrobial metabolites. Gut microbiota also participates in the extraction, synthesis, and absorption of nutrient metabolites, maintains intestinal epithelial integrity and regulates the development, homeostasis, and function of innate and adaptive immune cells. Cirrhosis is associated with local and systemic immune, vascular, and inflammatory changes directly or indirectly linked to perturbations in quality and quantity of intestinal microbiota and intestinal mucosal integrity. Dysbiosis and gut barrier dysfunction are directly involved in the pathogenesis of compensated cirrhosis and the type and severity of complications in decompensated cirrhosis, such as bacterial infections, encephalopathy, extrahepatic organ failure, and progression to acute on chronic liver failure. This paper reviews the normal gut barrier, gut barrier dysfunction, and dysbiosis-associated clinical events in patients with cirrhosis. The role of dietary interventions, antibiotics, prebiotics, probiotics, synbiotics, and healthy donor fecal microbiota transplantation (FMT) to modulate the gut microbiota for improving patient outcomes is further discussed.
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Affiliation(s)
- Cyriac A. Philips
- Department of Translational Hepatology, Monarch Liver Laboratory, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India,Address for correspondence. Cyriac Abby, The Liver Institute, Center of Excellence in GI Sciences, Ground Floor, Phase II, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, 683 112, India.
| | - Philip Augustine
- Department of Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
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17
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Philips CA, Rela M, Soin AS, Gupta S, Surendran S, Augustine P. Critical Update on the Diagnosis and Management of COVID-19 in Advanced Cirrhosis and Liver Transplant Recipients. J Clin Transl Hepatol 2021; 9:947-959. [PMID: 34966658 PMCID: PMC8666374 DOI: 10.14218/jcth.2021.00228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/15/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
The novel coronavirus disease 2019 (COVID-19) pandemic has impacted health care worldwide, with specific patient populations, such as those with diabetes, cardiovascular disease, and chronic lung disease, at higher risk of infection and others at higher risk of disease progression. Patients with decompensated cirrhosis fall into the latter category and are a unique group that require specific treatment and management decisions because they can develop acute-on-chronic liver failure. In liver transplant recipients, the atypical immunity profile due to immunosuppression protects against downstream inflammatory responses triggered by COVID-19. This exhaustive review discusses the outcomes associated with COVID-19 in patients with advanced cirrhosis and in liver transplant recipients. We focus on the immunopathogenesis of COVID-19, its correlation with the pathogenesis of advanced liver disease, and the effect of immunosuppression in liver transplant recipients to provide insight into the outcomes of this unique patient population.
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Affiliation(s)
- Cyriac Abby Philips
- Department of Clinical and Translational Hepatology and The Monarch Liver Laboratory, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Correspondence to: Cyriac Abby Philips, Department of Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Ground Floor, Phase II, Rajagiri Hospital, Aluva, Kerala, India. ORCID: https://orcid.org/0000-0002-9587-336X. Tel: +91-484-290-5000, Fax: +91-484-718-4000, E-mail:
| | - Mohamed Rela
- Institute of Liver Disease and Liver Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Arvinder Singh Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Subhash Gupta
- Max Centre for Liver and Biliary Sciences, Max Saket Hospital, New Delhi, India
| | - Sudhindran Surendran
- Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
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18
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Abstract
Primary liver cancer is a challenging global health concern with an estimated more than a million persons to be affected annually by the year 2025. The commonest type is hepatocellular carcinoma (HCC), which has been increasing in incidence the world over, mostly due to chronic viral hepatitis B infection. In the last decade, paradigm changes in the etiology, understanding of molecular biology, and pathogenesis, including the role of gut microbiota; medical and surgical treatments, and outcome trends are notable. The application of omics-based technology has helped us unlock the molecular and immune landscape of HCC, through which novel targets for drug treatment such as immune-checkpoint inhibitors have been identified. Novel tools for the surveillance and diagnosis of HCC include protein-, genomics-, and composite algorithm-based clinical/biomarker panels. Magnetic resonance imaging-based novel techniques have improved HCC diagnosis through ancillary features that enhance classical criteria while positron emission tomography has shown value in prognostication. Identification of the role of gut microbiota in the causation and progression of HCC has opened areas for novel therapeutic research. A select group of patients still benefit from modified surgical and early interventional radiology treatments. Improvements in radiotherapy protocols, identification of parameters of futility among radiological interventions, and the emergence of novel first-line systemic therapies that include a combination of antiangiogenic and immune-checkpoint inhibitors have seen a paradigm change in progression-free and overall survival. The current review is aimed at providing exhaustive updates on the etiology, molecular biology, biomarker diagnosis, imaging, and recommended treatment options in patients with HCC.
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Affiliation(s)
- Cyriac A Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, IND
| | - Sasidharan Rajesh
- Interventional Hepatobiliary Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, IND
| | - Dinu C Nair
- Interventional Hepatobiliary Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, IND
| | - Rizwan Ahamed
- Gastroenterology and Advanced Gastrointestinal (GI) Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, IND
| | - Jinsha K Abduljaleel
- Gastroenterology and Advanced Gastrointestinal (GI) Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, IND
| | - Philip Augustine
- Gastroenterology and Advanced Gastrointestinal (GI) Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, IND
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Abstract
Chronic hepatitis B virus (HBV) infection is a global healthcare burden in the form of chronic liver disease, cirrhosis, liver failure and liver cancer. There is no definite cure for the virus and even though extensive vaccination programs have reduced the burden of liver disease in the future population, treatment options to eradicate the virus from the host are still lacking. In this review, we discuss in detail current updates on the structure and applied biology of the virus in the host, examine updates to current treatment and explore novel and state-of-the-art therapeutics in the pipeline for management of chronic HBV. Furthermore, we also specifically review clinical updates on HBV-related acute on chronic liver failure (ACLF). Current treatments for chronic HBV infection have seen important updates in the form of considerations for treating patients in the immune tolerant phase and some clarity on end points for treatment and decisions on finite therapy with nucleos(t)ide inhibitors. Ongoing cutting-edge research on HBV biology has helped us identify novel target areas in the life cycle of the virus for application of new therapeutics. Due to improvements in the area of genomics, the hope for therapeutic vaccines, vector-based treatments and focused management aimed at targeting host integration of the virus and thereby a total cure could become a reality in the near future. Newer clinical prognostic tools have improved our understanding of timing of specific treatment options for the catastrophic syndrome of ACLF secondary to reactivation of HBV. In this review, we discuss in detail pertinent updates regarding virus biology and novel therapeutic targets with special focus on the appraisal of prognostic scores and treatment options in HBV-related ACLF.
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Affiliation(s)
- Cyriac A Philips
- Clinical and Translational Hepatology, The Liver Institute, Rajagiri Hospital, Aluva, IND
| | - Rizwan Ahamed
- Gastroenterology and Advanced Gastrointestinal Endoscopy, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, IND
| | - Jinsha K Abduljaleel
- Gastroenterology and Advanced Gastrointestinal Endoscopy, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, IND
| | - Sasidharan Rajesh
- Diagnostic and Interventional Radiology, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, IND
| | - Philip Augustine
- Gastroenterology and Advanced Gastrointestinal Endoscopy, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, IND
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Philips CA, Kakkar K, Joseph M, Yerol PK, Ahamed R, Rajesh S, Augustine P. Critically Ill COVID-19 Patient with Chronic Liver Disease - Insights into a Comprehensive Liver Intensive Care. J Clin Transl Hepatol 2021; 9:576-586. [PMID: 34447688 PMCID: PMC8369022 DOI: 10.14218/jcth.2020.00110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/07/2021] [Accepted: 04/07/2021] [Indexed: 12/15/2022] Open
Abstract
The novel coronavirus-related coronavirus disease 2019 (COVID-19) pandemic has been relentless in disrupting and overwhelming healthcare the world over. Clinical outcomes of COVID-19 in patients with chronic comorbidities, especially in those with metabolic syndrome, are well documented. Chronic liver disease and cirrhosis patients are a special sub-group, among whom the management of COVID-19 is challenging. Understanding the pathophysiology of COVID-19 in patients with cirrhosis and portal hypertension improves our identification of at-risk patients for disease progression that will further help compartmentalize generalized and specialized treatment options in this special patient group. In this exhaustive review, we critically review the impact of COVID-19 on the liver and in chronic liver disease and cirrhosis patients. We further discuss common features associated with the pathophysiology of COVID-19 and cirrhosis, based on the renin-angiotensin system and deliberate current literature on guidelines for the treatment of COVID-19 and extrapolate the same to the cirrhosis population to provide a concise and stepwise, evidence-based management for cirrhosis patients with severe and critical COVID-19. There are no specific management guidelines for cirrhosis patients with COVID-19 and current recommendations for treatment are as per guidelines for general population. Nevertheless, specific issues like avoiding corticosteroids in decompensated patients with variceal bleeding, suspected sepsis, high grade hepatic encephalopathy and acute kidney injury, use of early mechanical ventilation strategies in those with severe ascites and hepatopulmonary syndrome, avoidance of remdesivir in advanced liver disease, and application of liver-specific severity scores for prognostication and identification of futility need to be highlighted.
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Affiliation(s)
- Cyriac Abby Philips
- Department of Clinical Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
- Correspondence to: Cyriac Abby Philips, Department of Clinical Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala 683112, India. ORCID: https://orcid.org/0000-0002-9587-336X. Tel: +91-484-2905000, Fax: +91-484-7184000, E-mail:
| | - Kamna Kakkar
- Department of Pulmonary and Critical Care Medicine, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Moby Joseph
- Great Western Hospitals, NHS Foundation Trust, Swindon, United Kingdom
| | - Praveen Kumar Yerol
- Department of Gastroenterology, State Government Medicine College and Hospital, Thrissur, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Sasidharan Rajesh
- Interventional Hepatobiliary Radiology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Chunangamvely, Aluva, Ernakulam, Kerala, India
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Rajesh S, Philips CA, Betgeri SS, George T, Ahamed R, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt (TIPS) placement at index portal hypertensive decompensation (anticipant TIPS) in cirrhosis and the role of early intervention in variceal bleeding and ascites. Indian J Gastroenterol 2021; 40:361-372. [PMID: 34324168 DOI: 10.1007/s12664-021-01179-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/01/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) placement improves survival in patients with refractory/recurrent acute variceal bleeding (RAVB) and refractory ascites/hydrothorax. Recently, early TIPS was shown to reduce rebleeding and improve survival compared to the conventional TIPS. We aimed to study outcomes in patients with cirrhosis undergoing TIPS at first significant portal hypertensive (PHT) decompensation (termed anticipant TIPS) compared to those undergoing TIPS for recurrent or persistent PHT complications (conventional) and compared the former to matched controls on standard medical management (SMT). METHODS We retrospectively analyzed the clinical, biochemical, and liver disease severity parameters and survival at baseline and post-intervention in cirrhosis patients at two major hepatobiliary intervention centers undergoing anticipant (n = 27) or conventional TIPS (n = 30) and compared the former group to matched historical controls on SMT (n = 35). RESULTS Baseline parameters were comparable between both the groups, including the Child-Pugh class and model for end-stage liver disease (MELD) scores. Length of stay in the intensive care unit, post-procedure admission rates, and sepsis events were higher among patients undergoing conventional TIPS (p < 0.05). Post-TIPS, at 1 year, overall and sub-grouped survivals were better in patients undergoing anticipant TIPS. On further sub-group analysis, based on the PHT events and stratified based on Child-Pugh and MELD scores, a higher proportion of patients survived after anticipant TIPS at 1 year. Compared to SMT, patients undergoing anticipant TIPS had significantly lesser hospitalizations, recurrence of varices, and ascites at 1 year, reducing hospital visits and financial burden. CONCLUSIONS Anticipant TIPS at the first significant PHT event could improve liver-related events and survival compared to standard medical management and conventional TIPS, respectively.
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Affiliation(s)
- Sasidharan Rajesh
- Interventional Radiology, Ernakulam Medical Center, Kochi 682 028, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Ernakulam Medical Center, Kochi 682 028, India.
- Philip Augustine Associates, Symphony, AMRA-15, Automobile Road, Palarivattom, Kochi, 682 025, India.
| | | | - Tom George
- Interventional Radiology, Ernakulam Medical Center, Kochi 682 028, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I. Endoscopy, Ernakulam Medical Center, Kochi 682 028, India
| | - Meera Mohanan
- Department of Anaesthesia and Critical Care, Ernakulam Medical Center, Kochi 682 028, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I. Endoscopy, Ernakulam Medical Center, Kochi 682 028, India
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Philips CA, Agarwal M, Rajesh S, Ahamed R, Augustine P. A novel homozygous frameshift variant in the ABCC2-gene in Dubin-Johnson syndrome may predispose to chronic liver disease. Indian J Gastroenterol 2021; 40:72-76. [PMID: 33428121 DOI: 10.1007/s12664-020-01121-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 11/09/2020] [Indexed: 02/04/2023]
Abstract
Dubin-Johnson syndrome (DJS), an autosomal recessive disorder presenting with conjugated hyperbilirubinemia, is not associated with progression to chronic liver disease (CLD). Next-generation sequencing, application of bioinformatics pipeline, and segregation analysis were performed on 8 members of a consanguineous family with DJS and CLD. A novel variant, c.4406_4407delTA (p.Leu1469fs), in the ABCC2-gene in a homozygous state was found to be associated with DJS and CLD in proband and afflicted family members. DJS may not be a benign entity and novel genetic variants may be associated with progressive liver disease.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682 028, India. .,Philip Augustine Associates, Symphony, Automobile Road, Palarivattom, Kochi, 682 025, India.
| | - Meenal Agarwal
- Clinical Genetics, GenePath Diagnostics, Pune, 411 004, India
| | - Sasidharan Rajesh
- Interventional Radiology, Department of Gastroenterology and Hepatology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682 028, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682 028, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682 028, India
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23
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology GroupErnakulam Medical Center HospitalKochiIndia
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI EndoscopyCochin Gastroenterology GroupErnakulam Medical Center HospitalKochiIndia
| | - Philip Augustine
- Gastroenterology and Advanced GI EndoscopyCochin Gastroenterology GroupErnakulam Medical Center HospitalKochiIndia
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Beyond the scope and the glue: update on evaluation and management of gastric varices. BMC Gastroenterol 2020; 20:361. [PMID: 33126847 PMCID: PMC7602314 DOI: 10.1186/s12876-020-01513-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/23/2020] [Indexed: 02/08/2023] Open
Abstract
Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Laboratory, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
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25
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Philips CA, Augustine P. Still 'dwelling in the possibility' - critical update on stem cell therapy for acute on chronic liver failure. World J Stem Cells 2020; 12:1124-1132. [PMID: 33178396 PMCID: PMC7596449 DOI: 10.4252/wjsc.v12.i10.1124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/29/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Stem cells therapy could improve survival in patients with liver failure. Studies on stem cell therapy and related growth factors in decompensated cirrhosis has been on the forefront but has shown heterogenous results. Recent high-quality studies have shown a lack of efficacy and safety. Patients with acute-on-chronic liver failure (ACLF) are a unique group with high mortality in the short-term associated with rapid onset extrahepatic organ failures. In these patients, there is an urgent need to identify treatments that can improve liver cell function and mass, prevent sepsis/organ failure, ameliorate systemic inflammation, and increase transplant-free survival. Stem cells are a novel treatment in ACLF but with unclear efficacy and safety. In this narrative review, we discuss the basics of liver regeneration in patients with ACLF and update current clinical status of stem cell use in patients with ACLF for improving our understanding of future directions.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682025, Kerala, India
| | - Philip Augustine
- Department of Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682025, Kerala, India
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Comprehensive review of hepatotoxicity associated with traditional Indian Ayurvedic herbs. World J Hepatol 2020; 12:574-595. [PMID: 33033566 PMCID: PMC7522561 DOI: 10.4254/wjh.v12.i9.574] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/16/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Abstract
With growing antipathy toward conventional prescription drugs due to the fear of adverse events, the general and patient populations have been increasingly using complementary and alternative medications (CAMs) for managing acute and chronic diseases. The general misconception is that natural herbal-based preparations are devoid of toxicity, and hence short- and long-term use remain justified among people as well as the CAM practitioners who prescribe these medicines. In this regard, Ayurvedic herbal medications have become one of the most utilized in the East, specifically the Indian sub-continent, with increasing use in the West. Recent well-performed observational studies have confirmed the hepatotoxic potential of Ayurvedic drugs. Toxicity stems from direct effects or from indirect effects through herbal metabolites, unknown herb-herb and herb-drug interactions, adulteration of Ayurvedic drugs with other prescription medicines, and contamination due to poor manufacturing practices. In this exhaustive review, we present details on their hepatotoxic potential, discuss the mechanisms, clinical presentation, liver histology and patient outcomes of certain commonly used Ayurvedic herbs which will serve as a knowledge bank for physicians caring for liver disease patients, to support early identification and treatment of those who present with CAM-induced liver injury.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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28
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Philips CA, Mohan N, Ahamed R, Kumbar S, Rajesh S, George T, Mohanan M, Augustine P. One disease, many faces-typical and atypical presentations of SARS-CoV-2 infection-related COVID-19 disease. World J Clin Cases 2020; 8:3956-3970. [PMID: 33024752 PMCID: PMC7520786 DOI: 10.12998/wjcc.v8.i18.3956] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/10/2020] [Accepted: 08/25/2020] [Indexed: 02/05/2023] Open
Abstract
Since the appearance of the novel coronavirus (severe acute respiratory syndrome-coronavirus-2) and related coronavirus disease 2019 (COVID-19) in China in December 2019, a very high number of small and large patient series have been published in literature from around the world. Even though the classical presentation of COVID-19 is one with respiratory symptoms with or without pneumonia that can be self-limiting or evolve into severe respiratory distress syndrome with multiple organ failure, and secondary bacterial sepsis, a large body of evidence suggests a plethora of other types of clinical presentation. In this exhaustive review, we reviewed all of the published literature on COVID-19 to identify different types of clinical presentations affecting various organ systems, to provide an in-depth analysis that may prove useful for clinicians and health-workers on the frontline, battling the severe pandemic.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch, Cochin Gastroenterology Group, Ernakulam Medical Center, Cochin 682025, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch, Cochin Gastroenterology Group, Ernakulam Medical Center, Cochin 682025, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Cochin 682025, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Cochin 682025, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Cochin 682025, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Cochin 682025, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Cochin 682025, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Cochin 682025, Kerala, India
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Update on diagnosis and management of sepsis in cirrhosis: Current advances. World J Hepatol 2020; 12:451-474. [PMID: 32952873 PMCID: PMC7475781 DOI: 10.4254/wjh.v12.i8.451] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/27/2020] [Indexed: 02/06/2023] Open
Abstract
Sepsis and septic shock are catastrophic disease entities that portend high mortality in patients with cirrhosis. In cirrhosis, hemodynamic perturbations, immune dysregulation, and persistent systemic inflammation with altered gut microbiota in the background of portal hypertension enhance the risk of infections and resistance to antimicrobials. Patients with cirrhosis develop recurrent life-threatening infections that progress to multiple organ failure. The definition, pathophysiology, and treatment options for sepsis have been ever evolving. In this exhaustive review, we discuss novel advances in the understanding of sepsis, describe current and future biomarkers and scoring systems for sepsis, and delineate newer modalities and adjuvant therapies for the treatment of sepsis from existing literature to extrapolate the same concerning the management of sepsis in cirrhosis. We also provide insights into the role of gut microbiota in initiation and progression of sepsis and finally, propose a treatment algorithm for management of sepsis in patients with cirrhosis.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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30
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Augustine P, Gent R, Louise J, Taranto M, Penno M, Linke R, Couper JJ. Pancreas size and exocrine function is decreased in young children with recent-onset Type 1 diabetes. Diabet Med 2020; 37:1340-1343. [PMID: 31094026 DOI: 10.1111/dme.13987] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2019] [Indexed: 12/22/2022]
Abstract
AIMS To measure pancreatic area and exocrine function in young children with recent-onset Type 1 diabetes to determine whether the exocrine pancreas is also affected in the pathophysiology of early childhood diabetes. METHODS Thirty-two children (14 boys) aged 5.5 (4.5, 7.3) median (IQR) years presenting with recent-onset Type 1 diabetes and 90 controls (44 boys) of similar age had ultrasound imaging of the pancreas. Children with Type 1 diabetes were receiving insulin and were without ketosis. Transverse and longitudinal areas of the pancreas were measured by digitalized outline. Pancreatic faecal elastase-1 was analysed using an enzyme-linked immunosorbent assay kit in recent-onset Type 1 diabetes and 38 first-degree relative control children. RESULTS Pancreatic area and exocrine function were reduced in Type 1 diabetes. Mean transverse area (SD) in Type 1 diabetes was 6.82 cm2 (1.61) vs. 8.31 cm2 (1.74) in controls, adjusted estimate (95% CI) 1.45 (-2.12, -0.79), P < 0.001; longitudinal area was 1.28 cm2 (0.44) vs. 1.55 cm2 (0.43), adjusted estimate (95% CI) -0.27 (-0.45, -0.09), P = 0.003. Faecal elastase-1 levels in Type 1 diabetes were 455 (323, 833) ug/g, median (IQR) vs. 1408 μg/g (1031, 1989) in controls, P < 0.001. CONCLUSION Pancreatic area and accompanying subclinical exocrine function were reduced in very young children with recent-onset Type 1 diabetes. This supports changes in the exocrine pancreas in the pathophysiology of Type 1 diabetes presenting in early life.
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Affiliation(s)
- P Augustine
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, South Australia
| | - R Gent
- Department of Medical Imaging, Women's and Children's Hospital, South Australia
| | - J Louise
- Adelaide Medical School and Robinson Research Institute, University of Adelaide, South Australia
| | - M Taranto
- PathWest Laboratories, Fiona Stanley Hospital Network, Western Australia
| | - M Penno
- Adelaide Medical School and Robinson Research Institute, University of Adelaide, South Australia
| | - R Linke
- Department of Medical Imaging, Women's and Children's Hospital, South Australia
| | - J J Couper
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, South Australia
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Philips CA, Rajesh S, George T, Ahamed R, Mohanan M, Augustine P. Early, late, or no shunt embolization in patients with cirrhosis- and portosystemic shunt-related hepatic encephalopathy. Indian J Gastroenterol 2020; 39:377-387. [PMID: 32929684 DOI: 10.1007/s12664-020-01042-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Portosystemic shunts (PSS) are associated with recurrent or persistent hepatic encephalopathy (HE), severe portal hypertensive (PHT) complications, and poor survival in cirrhosis patients. Shunt embolization improves HE in patients with recurrent or persistent HE. The role of early shunt embolization (ESE) in comparison with no and late SE (LSE) in cirrhosis patients with PSS and associated clinical outcomes are not studied. METHODS ESE was defined as occlusion of PSS in patients with the first episode of spontaneous HE, while LSE was that when performed in patients with recurrent/persistent PSS-related HE. We retrospectively analyzed (November 2016 to March 2019) clinical outcomes, liver disease severity, and survival between patients undergoing ESE (n = 22) vs. LSE (n = 23) and compared ESE with matched historical controls (n = 22) not undergoing shunt embolization, followed-up for 18 months. RESULTS Males predominated, and the lienorenal type of shunt was the most frequent. Significantly larger and multiple shunts were noted in the LSE group. Arterial ammonia, total bilirubin, and Child-Pugh scores were significantly higher at baseline in the LSE group. Post-procedure length of stay in the intensive unit (mean 0.6 vs. 2.1 days; p = 0.04), infections (31.8% vs. 66.7% beyond 100 days; p = 0.02), recurrence of HE in first 9 months (4.5% vs. 28.6%; p = 0.03), and liver- and PHT-related clinical events beyond 10 months were significantly higher in LSE compared with those in the ESE group respectively. HE beyond 10 months was comparable between both the groups. 18.2% died in ESE while 60.87% died in the LSE group (p = 0.002). Compared with patients on only standard medical care, the occurrence of ascites, variceal bleeding, recurrence of HE, and portal vein thrombosis were significantly lower in those undergoing ESE, even though differences in survival were not significant. CONCLUSIONS Our study demonstrates the benefits of ESE of large PSS in patients with cirrhosis, probably by improving survival through a reduction in liver and PHT events that warrant validation through prospective randomized controlled multicenter trials.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682 028, India.
| | - Sasidharan Rajesh
- Interventional Radiology, Department of Gastroenterology and Hepatology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682 028, India
| | - Tom George
- Interventional Radiology, Department of Gastroenterology and Hepatology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682 028, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced Gastrointestinal Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682 028, India
| | - Meera Mohanan
- Department of Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center
- , Kochi, 682 028, India
| | - Philip Augustine
- Department of Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center
- , Kochi, 682 028, India
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Philips CA, Ahamed R, Rajesh S, Augustine P. 'You know my name, but not my story' - Deciding on an accurate nomenclature for faecal microbiota transplantation. J Hepatol 2020; 72:1212-1213. [PMID: 32197801 DOI: 10.1016/j.jhep.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Department of Clinical and Experimental Gastroenterology and Hepatology, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India.
| | - Rizwan Ahamed
- The Liver Unit and Monarch Liver Lab, Department of Clinical and Experimental Gastroenterology and Hepatology, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Sasidharan Rajesh
- The Liver Unit and Monarch Liver Lab, Department of Clinical and Experimental Gastroenterology and Hepatology, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Philip Augustine
- The Liver Unit and Monarch Liver Lab, Department of Clinical and Experimental Gastroenterology and Hepatology, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
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Philips CA, Kumbar S, Ahamed R, Augustine P. Managing Acute Portal Hypertensive Gastropathy Bleed During the Time of COVID-19 Pandemic: Novelty or Necessity? Cureus 2020; 12:e8333. [PMID: 32489751 PMCID: PMC7255538 DOI: 10.7759/cureus.8333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Acute bleeding from portal hypertensive gastropathy (PHG) is an extremely rare event in the natural history of cirrhosis. The treatment recommendations include portal pressure reduction strategies including pharmacotherapy with vasoactive agents and beta-blockers and interventional strategies such as transjugular intrahepatic portosystemic shunt placement. In this report, we present the case of a patient with cirrhosis in whom acute PHG-related bleed was managed with endoscopic band ligation, a therapeutic modality which has not been described in current literature. Our decision to re-purpose a technique for variceal bleeding stems from the fact that during the ongoing COVID-19 pandemic, the technical assistance, resource availability, and sourcing of materials that were required for us to follow recommended management guidelines for acute PHG-related bleed was severely affected due to imposed lockdown between districts and states.
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Philips CA, Augustine P, Yerol PK, Ramesh GN, Ahamed R, Rajesh S, George T, Kumbar S. Modulating the Intestinal Microbiota: Therapeutic Opportunities in Liver Disease. J Clin Transl Hepatol 2020; 8:87-99. [PMID: 32274349 PMCID: PMC7132020 DOI: 10.14218/jcth.2019.00035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/11/2019] [Accepted: 10/27/2019] [Indexed: 12/11/2022] Open
Abstract
Gut microbiota has been demonstrated to have a significant impact on the initiation, progression and development of complications associated with multiple liver diseases. Notably, nonalcoholic fatty liver diseases, including nonalcoholic steatohepatitis and cirrhosis, severe alcoholic hepatitis, primary sclerosing cholangitis and hepatic encephalopathy, have strong links to dysbiosis - or a pathobiological change in the microbiota. In this review, we provide clear and concise discussions on the human gut microbiota, methods of identifying gut microbiota and its functionality, liver diseases that are affected by the gut microbiota, including novel associations under research, and provide current evidence on the modulation of gut microbiota and its effects on specific liver disease conditions.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Philip Augustine
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Praveen Kumar Yerol
- Department of Gastroenterology, State Government Medical College, Thrissur, Kerala, India
| | | | - Rizwan Ahamed
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Sasidharan Rajesh
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Tom George
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Sandeep Kumbar
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
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Philips CA, Padsalgi G, Ahamed R, Paramaguru R, Rajesh S, George T, Mahadevan P, Augustine P. Repurposing Pirfenidone for Nonalcoholic Steatohepatitis-related Cirrhosis: A Case Series. J Clin Transl Hepatol 2020; 8:100-105. [PMID: 32274350 PMCID: PMC7132022 DOI: 10.14218/jcth.2019.00056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/04/2020] [Accepted: 01/17/2020] [Indexed: 12/16/2022] Open
Abstract
We repurposed the antifibrotic drug pirfenidone-which is approved for treatment of idiopathic lung fibrosis-in a series of patients with nonalcoholic steatohepatitis-related cirrhosis. Our report demonstrates the observed improvements in necroinflammation and regression of cirrhosis with pirfenidone use for 12-weeks, associated with classical hepatic repair complex features on follow-up liver biopsies. This novel work could help stimulate further randomized trials of pirfenidone in patients with nonalcoholic steatohepatitis-related liver fibrosis or cirrhosis, for whom no recommended drug treatments exists currently.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
- Correspondence to: Cyriac Abby Philips, Philips Augustine Associates, The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Palarivattom, Cochin 682025, Kerala, India. E-mail:
| | - Guruprasad Padsalgi
- Department of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Rizwan Ahamed
- Department of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Rajaguru Paramaguru
- Department of Pathology, Al Salam International Hospital, Bneid Al Qar, Kuwait, India
| | - Sasidharan Rajesh
- Department of Diagnostic and Interventional Radiology, Department of Gastroenterology and The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Tom George
- Department of Diagnostic and Interventional Radiology, Department of Gastroenterology and The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Pushpa Mahadevan
- Department of Clinical Pathology, VPS Lakeshore Hospital, Kochi, Kerala, India
| | - Philip Augustine
- Department of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
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Philips CA, Augustine P, Rajesh S, Ahamed R, George T, Padsalgi G, Paramaguru R, Valiathan G, John SK. Granulocyte Colony-Stimulating Factor Use in Decompensated Cirrhosis: Lack of Survival Benefit. J Clin Exp Hepatol 2020; 10:124-134. [PMID: 32189927 PMCID: PMC7067994 DOI: 10.1016/j.jceh.2019.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/22/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Granulocyte colony-stimulating factor (GCSF) has been utilized in decompensated cirrhosis (DC) for improving transplant-free survival (TFS). Data from multiple centers are conflicting with regard to patient outcomes. In this retrospective study, we present our 'real-world experience' of GCSF use in a large group of DC. METHODS From September 2016 to September 2018, 1231 patients with cirrhosis were screened, of which 754 were found to have decompensation(s). Seventy-three patients with active ascites, jaundice, or both completed GCSF treatment (10 mcg/kg per day for 5 days, followed by 5 mcg/kg/day once every third day for total 12 doses). Per-protocol analysis (n = 56) was performed to study clinical events, liver disease severity, and outcomes at 3, 6, and 12 months after treatment. Modified intention-to-treat (mITT, n = 100) analysis was performed to study overall survival at 180 days. Outcomes were compared with a matched historical control (HC) group (n = 24). RESULTS Nine (16%, n = 56), 24 (43%, n = 56), and 36 (75%, n = 48) patients died at 3, 6, and 12-month follow-up after GCSF. The commonest cause of death was sepsis (53%) followed by progressive liver failure (33%). Nine percent of patients developed hepatocellular carcinoma on follow-up at the end of 1 year. Acute variceal bleeds, overt hepatic encephalopathy, intensive unit admissions, and liver disease severity scores were higher after treatment at the end of 1 year. The Child-Pugh score >11 and model for end-stage liver disease-sodium score >25 and > 20 predicted worse outcomes at all time points and at 6 and 12 months after GCSF, respectively. Compared to a matched HC group, patients receiving GCSF had higher mortality (75% vs 46%, P = 0.04) at one year. mITT analysis revealed poor overall survival at 6 months compared to HCs (48% vs 75%, P = 0.04). CONCLUSION Survival in DC was shorter than what was expected in the natural history of the disease after GCSF use.
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Key Words
- AKI, acute kidney injury
- AUC, area under the receiver operating curve
- AVB, acute variceal bleeding
- BMSCs, Bone marrow–derived stem cells
- CTP score, Child–Pugh score
- DC, decompensated cirrhosis
- DP, darbepoetin
- GCSF, granulocyte colony-stimulating factor
- HC, historical control
- HCC
- HCC, hepatocellular carcinoma
- HE, hepatic encephalopathy
- ICU, intensive care unit
- INR, international normalized ratio
- LT, liver transplantation
- MELD-Na, model for end-stage liver disease-sodium
- NASH, nonalcoholic steatohepatitis
- RCT, randomized controlled trial
- SBP, spontaneous bacterial peritonitis
- SMT, standard medical treatment
- TFS, transplant free survival
- encephalopathy
- erythropoietin
- growth factor
- hyponatremia
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Affiliation(s)
- Cyriac A. Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala
| | - Philip Augustine
- Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala
| | - Sasidharan Rajesh
- Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala
| | - Rizwan Ahamed
- Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala
| | - Tom George
- Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala
| | - Guruprasad Padsalgi
- Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala
| | | | - Gopakumar Valiathan
- Gastrointestinal and Hepatobiliary Surgery, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala
| | - Solomon K. John
- Hepatobiliary and Transplant Surgery, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala
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Philips CA, Augustine P, Ahamed R, Rajesh S, George T, Kumbar S, Padsalgi G, Mahadevan P. Acute exacerbated severe form of nonalcoholic steatohepatitis leading to acute-on-chronic liver failure: A case series. Indian J Gastroenterol 2020; 39:97-101. [PMID: 32291579 DOI: 10.1007/s12664-020-01028-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 02/25/2020] [Indexed: 02/04/2023]
Abstract
We present three patients with uncontrolled metabolic syndrome and acute-on-chronic liver failure in whom, after meticulous evaluation, the acute event was found to be a severe and exacerbated form of nonalcoholic steatohepatitis (NASH), a novel entry in the natural history of non-alcoholic fatty liver disease. This novel disease entity was described partially, 17 years before by Caldwell et al. We discuss current literature, pertinent features, and outcomes associated with a severe form of NASH, which is associated with high mortality.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, National Highway Bypass, Palarivattom, Kochi, 682 028, India. .,Philip Augustine Associates, 35/194 B, Symphony, Automobile Road, Palarivattom, Kochi, 682 025, India.
| | - Philip Augustine
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, National Highway Bypass, Palarivattom, Kochi, 682 028, India.,Philip Augustine Associates, 35/194 B, Symphony, Automobile Road, Palarivattom, Kochi, 682 025, India
| | - Rizwan Ahamed
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, National Highway Bypass, Palarivattom, Kochi, 682 028, India
| | - Sasidharan Rajesh
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, National Highway Bypass, Palarivattom, Kochi, 682 028, India
| | - Tom George
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, National Highway Bypass, Palarivattom, Kochi, 682 028, India
| | - Sandeep Kumbar
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, National Highway Bypass, Palarivattom, Kochi, 682 028, India
| | - Guruprasad Padsalgi
- The Liver Unit, Monarch Liver Lab and Division of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, National Highway Bypass, Palarivattom, Kochi, 682 028, India
| | - Pushpa Mahadevan
- Pathology, VPS Lakeshore Hospital, Maradu, Nettoor, Kochi, 682 018, India
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Philips CA, Rajesh S, George T, Ahamed R, Kumbar S, Augustine P. Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis - A Single Center Experience from India. J Clin Transl Hepatol 2019; 7:329-340. [PMID: 31915602 PMCID: PMC6943206 DOI: 10.14218/jcth.2019.00043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/04/2019] [Accepted: 10/24/2019] [Indexed: 12/23/2022] Open
Abstract
Background and Aims: We aimed to study clinical outcomes and liver biopsy features of alcoholic hepatitis (AH) patients on complementary and alternative medicines (CAMs) and to analyze the retrieved drugs for chemical and toxic components linked to drug-induced liver injury. Methods: We retrospectively assessed clinical, biochemical and liver biopsy features of AH patients on CAM with drug-induced liver injury (AH-CAM, n = 27) and compared them to a control group (classical AH, n = 29) on standard of care. Patients without liver biopsy evaluation and other causes for liver disease were excluded. Samples of the CAMs (n = 42) from patients were retrieved and assessed for chemical and toxins. Results: All were males, and significantly worse clinical presentation, biochemical severity, and liver disease scores were notable in patients with AH-CAM. Traditional Ayurvedic-polyherbal formulations were the most commonly used CAM. On liver histology, varying grades of severe-necrosis, severe hepatocellular, canalicular, cholangiolar cholestasis with predominant lymphocytic-portal-inflammation and varying grades of interface-hepatitis were noted in AH-CAM. Analysis of CAMs revealed presence of heavy metals up to 100,000 times above detectable range and adulterants, such as antibiotics, chemotherapy agents, nonsteroidal anti-inflammatory drugs, alcohols, antidepressants, anxiolytics, and recreational drugs. On follow up, a significantly higher number of patients with AH on CAM died at end of 1, 3- and-6-months compared to controls (37% vs. 83%, 29% vs. 62%, 18% vs. 52% respectively; p < 0.001). Conclusions: Patients with AH and CAM-related drug-induced liver injury have extremely poor short-term survival in the absence of liver transplantation compared to those patients with AH on evidence-based management. Early transplant referral and educating on and curbing of CAM use in severe liver disease through strict monitoring of unregulated traditional health practices can help ease the burden of liver-related death.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
- Correspondence to: Cyriac Abby Philips, The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Symphony, Automobile Road, Palarivattom, Cochin 682025, India. Tel/Fax: +91-484-2907000, E-mail:
| | - Sasidharan Rajesh
- Interventional Radiology, Department of Gastroenterology and Hepatology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
| | - Tom George
- Interventional Radiology, Department of Gastroenterology and Hepatology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I. Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced G.I. Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I. Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
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Philips CA, Augustine P, Ahamed R, Rajesh S, George T, Valiathan GC, John SK. Role of Granulocyte Colony-stimulating Factor Therapy in Cirrhosis, 'Inside Any Deep Asking Is the Answering'. J Clin Transl Hepatol 2019; 7:371-383. [PMID: 31915607 PMCID: PMC6943215 DOI: 10.14218/jcth.2019.00034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 09/20/2019] [Accepted: 10/05/2019] [Indexed: 12/13/2022] Open
Abstract
Liver cirrhosis progresses through multiple clinical stages which culminate in either death or liver transplantation. Availability of organs, timely listing and prompt receipt of donor-livers pose difficulties in improving transplant-listed and transplant outcomes. In this regard, regenerative therapies, particularly with granulocyte colony-stimulating factor (GCSF), has become a lucrative option for improving transplant-free survival. However, the literature is confusing with regards to patient selection and real outcomes. In this exhaustive review, we describe the basics of liver fibrosis and cirrhosis through novel insights from a therapeutic point of view, discuss preclinical studies on GCSF in advanced liver disease to improve on clinical utility, shed light on the pertinent literature of GCSF in advanced cirrhosis, and provide astute inputs on growth factor therapy in decompensated cirrhosis.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Philip Augustine
- Department of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Rizwan Ahamed
- Department of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Sasidharan Rajesh
- Interventional Radiology, Hepatobiliary Division, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Tom George
- Interventional Radiology, Hepatobiliary Division, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Gopakumar C. Valiathan
- Department of Hepatobiliary and Transplant Surgery, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Solomon K. John
- Department of Hepatobiliary and Transplant Surgery, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
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Bhargavan RV, Mirza A, Cherian K, Krishna J, Augustine P. Level III dissection in locally advanced breast cancer following neoadjuvant chemotherapy: a retrospective study. Ann R Coll Surg Engl 2019; 102:214-219. [PMID: 31755729 DOI: 10.1308/rcsann.2019.0142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Breast cancer is the most common female cancer in India, and 30-60% of patients present with locally advanced breast cancer. Level III clearance is routinely performed in India in locally advanced breast cancer following neoadjuvant chemotherapy, even in clinical complete response. We analysed our data of patients with locally advanced breast cancer post-neoadjuvant chemotherapy who have undergone level III clearance to identify any subgroup in which level III dissection can be avoided. MATERIAL AND METHODS This is a retrospective study of female patients with locally advanced breast cancer who received neoadjuvant chemotherapy and underwent breast surgery including level III nodal clearance between June 2016 and May 2018. Data collected included age, menopausal status, TNM stage at presentation, grade, estrogen, progesterone, human epidermal growth factor receptor 2 status, response to treatment, post-chemotherapy stage and final histopathology. Uni- and multivariate analysis was undertaken. RESULTS Data from 200 patients was analysed. The level III positivity rate was 15.5%. The clinical complete response rate was 43%, of which 41% had pathological complete response. A significant association was present between level III node positivity and pathological T stage (p=0.03). No association was seen between level III positivity and any other studied variables. In the subset of patients with cT3N1 and cT2N2, level III positivity was seen in only 3/49 (6.1%) and 1/31 (3%), respectively. CONCLUSION Level III positivity rate is high and so cannot be avoided in locally advanced breast cancer following neoadjuvant chemotherapy. None of the preoperative factors predict for level III positivity. Level III positivity in cT3N1 and cT2N2 is low and these subgroups require further studies.
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Affiliation(s)
- R V Bhargavan
- Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - A Mirza
- Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - K Cherian
- Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - J Krishna
- Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - P Augustine
- Regional Cancer Centre, Thiruvananthapuram, Kerala, India
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Philips CA, Augustine P, Rajesh S, Y PK, Madhu D. Complementary and Alternative Medicine-related Drug-induced Liver Injury in Asia. J Clin Transl Hepatol 2019; 7:263-274. [PMID: 31608219 PMCID: PMC6783675 DOI: 10.14218/jcth.2019.00024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 02/07/2023] Open
Abstract
The use of complementary and alternative medicines (CAMs) for treatment of acute and chronic diseases is on the rise world over, especially in Asian countries, and mostly in China and India. Drug-induced liver injury (DILI) due to CAM is increasingly reported in the literature from multiple centers all around the world and with large-number patient series published from the West, mostly based on nation-wide DILI networks and multicenter collaboration. Comprehensive DILI networks are lacking among major Asian countries with high incidence of CAM practices. Chinese medical societies dealing with drug toxicity, CAM practice and hepatobiliary disease have adopted an integrated approach to establishing identification, diagnosis and treatment of CAM-related DILI, representing a systematic approach that could be iterated by other countries for improving patient outcomes. In this exhaustive review, we provide published data on CAM-related DILI in Asia, with detail on incidences along with analysis of patient population and their clinical outcomes. Concise and clear discussion on commonly implicated CAM agents in major Asian countries and associated chemical and toxicology analyses as well as descriptions of liver biopsy findings are discussed with future directions.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
- *Correspondence to: Cyriac Abby Philips, Philip Augustine Associates, 35/194 B, Symphony, Automobile Rd, Palarivattom, Kochi, Kerala 682025, India. E-mail:
| | - Philip Augustine
- Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Sasidharan Rajesh
- Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Praveen Kumar Y
- Gastroenterology, Government Medical College, Thrissur, Kerala, India
| | - Deepak Madhu
- Gastroenterology, Aster MIMS, Calicut, Kerala, India
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Abby Philips C, Agarwal M, Phadke N, Rajesh S, Padsalgi G, Ahamed R, Augustine P. A Novel Phosphoinositide-3-kinase Adapter Protein 1 Gene Missense Mutation in Familial Cirrhosis. J Clin Exp Hepatol 2019; 9:652-656. [PMID: 31695254 PMCID: PMC6823681 DOI: 10.1016/j.jceh.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/03/2019] [Indexed: 12/12/2022] Open
Abstract
Familial cirrhosis is a condition that is associated with the presence of liver disease with genetic linkage among multiple family members in a generation or in multiple generations. With cirrhosis, most of these disease pathogeneses are related to a defect of an enzyme/transport protein leading to a deranged metabolic pathway with variable prevalence. Many studies and high-quality metanalyses have shed light on genetic linkage associated with nonalcoholic fatty liver disease and steatohepatitis such as the PNPLA3, MBOAT7, and TM6SF2 variants. In this report, we shed light on a novel missense mutation associated with cirrhosis in a family of brothers associated with phosphoinositide-3-kinase adapter protein 1 gene through high-output whole exosome gene sequencing methodology.
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Key Words
- CCDS, Consensus Coding Sequence
- DNA, Deoxyribonucleic acid
- EWAS, Epigenome wide association study
- GWAS, Genome-wide association studies
- HCC, Hepatocellular carcinoma
- HGVS, Human Genome Variation Society
- MBOAT7, Membrane bound O-acyltransferase domain-containing 7
- NAFLD, Non-alcoholic fatty liver disease
- NGS, Next generation sequencing
- OMIM, Online Mendelian Inheritance in Man
- PBC, Primary biliary cholangitis
- PI3K
- PIK3AP1, Phosphoinositide-3-Kinase Adapter Protein 1
- PNPLA3
- PNPLA3, Patatin-like phospholipase domain containing 3
- RNA, Ribosomal nucleic acid
- RefSeq, Reference Sequence Database
- TMC4, Transmembrane channel-like 4 gene
- chronic liver disease
- epigenetics
- exosome
- familial cirrhosis
- gene mutation
- genomics
- illumina
- linkage
- metagenome
- missense mutation
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | | | - Nikhil Phadke
- Molecular, Cellular and Developmental Biology, Genepath-Dx, Pune, Maharashtra, India
| | - Sasidharan Rajesh
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Guruprasad Padsalgi
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Rizwan Ahamed
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Philip Augustine
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
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Abstract
Severe acute alcoholic hepatitis (AH) is a catastrophic disease in the natural history of alcoholic liver disease with a very high 180-day mortality. It can present as acute on chronic liver failure with worse prognosis in the presence of infections and higher grades of liver disease severity. The clinical scenario involves a patient with a recent history of heavy alcohol consumption within three months of presentation with jaundice and characteristic liver enzyme elevation pattern with coagulopathy, hepatic encephalopathy, variceal bleeding and sepsis that results in extrahepatic organ failures. Several liver disease severities and therapy response indicators are in clinical use. Even though not approved, the only recommended treatment option for patients with severe AH is corticosteroids, which is without long term survival benefit. Novel efficacious treatment options awaiting high-quality multi-center studies include liver transplantation (involves strict selection criteria), growth factor therapy and fecal microbiota transplantation. In this exhaustive review, we discuss the definitions, disease severity, histopathology, and treatment options – past, present, and future, in patients with severe alcoholic hepatitis.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India
| | - Philip Augustine
- Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India
| | - Praveen Kumar Yerol
- Department of Gastroenterology, Government Medical College and Hospital, Thrissur, Kerala, India
| | - Sasidharan Rajesh
- Interventional Radiology, Hepatobiliary Division, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India
| | - Pushpa Mahadevan
- Clinical Pathology, VPS Lakeshore Hospital, Nettoor, Kerala, India
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44
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Philips CA, Paramaguru R, Rajesh S, George T, Ahamed R, Augustine P. An unusual cause of acute-on-chronic liver failure. Indian J Gastroenterol 2019; 38:278-279. [PMID: 31264044 DOI: 10.1007/s12664-019-00963-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Cyriac Abby Philips
- Gastroenterology and The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682 028, India. .,Philip Augustine Associates, Symphony, Automobile Road, Palarivattom, Kochi, 682 025, India.
| | | | - Sasidharan Rajesh
- Gastroenterology and The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682 028, India
| | - Tom George
- Gastroenterology and The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682 028, India
| | - Rizwan Ahamed
- Gastroenterology and The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682 028, India
| | - Philip Augustine
- Gastroenterology and The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682 028, India
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45
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Abstract
We present a teetotaler with compensated non-alcoholic fatty-liver-disease related cirrhosis who presented with acute worsening of his chronic liver disease. The acute event was not discernible even after extensive work up and finally a transjugular liver biopsy revealed features suggestive of severe alcoholic hepatitis. The patient and the family denied occult alcohol use when questioned over multiple times and finally, the culprit 'alcohol' was found to be the homoeopathy medicines that the patient was consuming over a month for treatment of Gilbert's syndrome. We retrieved and tested the homoeopathy drug for alcohol content and found an alarming 18% ethanol in the same, confirming our diagnosis.
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Affiliation(s)
| | - Philip Augustine
- Gastroenterology, Ernakulam Medical Centre, Kochi, Kerala, India
| | | | - Rizwan Ahamed
- Gastroenterology, Ernakulam Medical Centre, Kochi, Kerala, India
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46
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Gorijavolu N, Augustine P, Subhadra Devi L, Antony G, Kattoor J, Mathew A. Expression of immunomodulatory molecule, programmed death ligand-1 in triple negative invasive breast cancer in the Indian population. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz099.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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47
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Philips CA, Rajesh S, John SK, Valiathan GC, Augustine P. Traditional herbal medicine for liver cancer: "Let's pretend I like cooking and you pretend it tastes nice". Cancer 2019; 125:1568-1569. [PMID: 30835816 DOI: 10.1002/cncr.31707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Gastroenterology and Hepatobiliary Surgery, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Sasidharan Rajesh
- The Liver Unit, Gastroenterology and Hepatobiliary Surgery, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Solomon K John
- The Liver Unit, Gastroenterology and Hepatobiliary Surgery, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Gopakumar C Valiathan
- The Liver Unit, Gastroenterology and Hepatobiliary Surgery, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Philip Augustine
- The Liver Unit, Gastroenterology and Hepatobiliary Surgery, The Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
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48
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Philips CA, Paramaguru R, Augustine P, Rajesh S, Ahamed R, George T, Padsalgi G. A Single-Center Experience on Outcomes of Complementary and Alternative Medicine Use Among Patients With Cirrhosis. Hepatol Commun 2019; 3:1001-1012. [PMID: 31304453 PMCID: PMC6601323 DOI: 10.1002/hep4.1355] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/27/2019] [Indexed: 01/02/2023] Open
Abstract
Drug‐induced liver injury (DILI) due to complementary and alternative medicine (CAM) use is on the rise throughout the world by patients looking for “safer” alternatives. However, data on acute‐on‐chronic liver failure (ACLF) due to CAM are lacking. In a large cohort of patients with cirrhosis, we retrospectively studied CAM‐related health‐seeking behavior and attempted to identify those who developed possible CAM‐DILI‐related ACLF. In this study, we examine the clinical, biochemical, and liver histopathologic characteristics of possible CAM‐DILI‐related ACLF, describe implicated CAM agents, and discuss predictors of patient outcomes. Out of 1,666 patients with cirrhosis, 68% used CAM at some point. A total of 35.7% (n = 30/84) patients presented with CAM‐related DILI leading to ACLF in the whole CAM‐DILI‐related decompensation cohort. The most common CAM was unlabeled polyherbal Ayurvedic formulations. Of possible patients with ACLF, 63% self‐medicated with CAM based on social media sharing. Mean age ± SD was 51.9 ± 9.9 years, 83% were male patients, median follow‐up duration was 173 (range, 14‐584) days, median Child‐Turcotte‐Pugh score was 13 (range, 10‐14), Model for End‐Stage Liver Disease‐sodium score was 30.1 ± 4.8, median chronic liver failure‐organ failure (CLIF‐C‐OF) score was 11 (range, 8‐14), and median CLIF‐C‐ACLF score was 98 (range, 87‐127). Portal‐based neutrophilic predominant mixed inflammation, hepatocyte ballooning, autoimmune‐like features, and severe cholestasis were seen on liver biopsy. Overall, 53% of patients died (median survival 194 days). Baseline overt hepatic encephalopathy and CLIF‐C‐OF score, total bilirubin, hyponatremia and leukocytosis, and grade of ACLF predicted 1‐, 3‐, 6‐ and 12‐month mortality, respectively. Conclusion: Possible CAM‐DILI‐related ACLF has a high mortality. Strict monitoring and identification of CAM use among people with cirrhosis and an integrative public health educational practice can help ameliorate this modifiable risk factor that potentiates heavy liver disease burden and resource use.
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Affiliation(s)
- Cyriac Abby Philips
- Liver Unit, Cochin Gastroenterology Group Ernakulam Medical Center Hospital Kochi India
| | | | | | - Sasidharan Rajesh
- Interventional Radiology, Cochin Gastroenterology Group Ernakulam Medical Center Hospital Kochi India
| | - Rizwan Ahamed
- Gastroenterology Ernakulam Medical Center Hospital Kochi India
| | - Tom George
- Interventional Radiology, Cochin Gastroenterology Group Ernakulam Medical Center Hospital Kochi India
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49
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Philips CA, Augustine P, Padsalgi G, Ahamed R, Jose A, Rajesh S. Only in the darkness can you see the stars: Severe alcoholic hepatitis and higher grades of acute-on-chronic liver failure. J Hepatol 2019; 70:550-551. [PMID: 30470480 DOI: 10.1016/j.jhep.2018.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/03/2018] [Accepted: 10/05/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India.
| | - Philip Augustine
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Guruprasad Padsalgi
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Rizwan Ahamed
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Amal Jose
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
| | - Sasidharan Rajesh
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, Kerala, India
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50
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Abstract
We present the rare case of a young male with sinusoidal obstruction syndrome due to Ayurvedic herbal medicine which he took for management of bilateral leg swelling associated with protein-losing enteropathy due to intestinal lymphangiectasia. The patient developed progressive sinusoidal fibrosis leading to cirrhosis on long term follow-up. In a diagnosis that took three years to conclude, we showcase serial liver biopsies that reveal the rare disease progression. Complementary and alternative medicine use among apparently healthy population is a potentially modifiable risk factor for liver diseases, in the presence of adequate public health education from concerned authorities.
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Affiliation(s)
| | | | | | - Rizwan Ahamed
- Gastroenterology, Ernakulam Medical Center, Cochin, IND
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