Immunogenicity of plasma-derived hepatitis B vaccine in preterm infants

The objective was to determine whether plasma-derived hepatitis B vaccine is immunogenic in preterm appropriate for gestation babies when administered at birth and to compare the immunogenicity between 5 micrograms and 10 micrograms doses of the vaccine in these babies. Fifty preterm neonates (31-36 weeks gestation) were randomized to receive 5 micrograms or 10 micrograms doses of plasma-derived hepatitis B vaccine at birth, with subsequent doses 1 and 6 months later. Serum specimens were obtained a month after each dose of the vaccine and were tested for antibody to hepatitis B surface antigen (anti-HBs). Thirty six babies (gestation 31-36 weeks), 18 from each group competed the study. While 89.2% of the babies seroconverted, 82.1% achieved seroprotective titres of anti-HBS (> 10 mIU/ml). There was no difference between weight, gestational age, age of administration of vaccine and age of estimation of anti-HBs between 5 micrograms and 10 micrograms groups. The difference in the seroprotective rates were not statistically different between the groups (5 micrograms 78.5%; 10 micrograms--85.7%). Although immune response to plasma derived hepatitis B vaccine in preterm babies is suboptimal when the first dose is administered at birth, the full course achieves adequate seroprotective levels.

Biliary changes in extrahepatic portal venous obstruction: compression by collaterals or ischemic?

BACKGROUND

The postulated mechanisms of biliary abnormalities in extrahepatic portal venous obstruction (EHPVO) are either extrinsic compression by collaterals or ischemic injury due to venous thrombosis. If the former hypothesis is correct, then biliary changes should revert to normal after portasystemic shunt surgery.

METHODS

Five patients with EHPVO who underwent portasystemic shunt surgery were studied. One of these patients had obstructive jaundice due to portal cavernoma. Endoscopic retrograde cholangiography (ERC) was performed before as well as after the shunt surgery. Doppler ultrasound and splenoportovenography were obtained to confirm the diagnosis of EHPVO as well as shunt patency.

RESULTS

All patients had biliary abnormalities on pre-shunt ERC. The post-shunt ERC showed partial reversal of biliary abnormalities in 3 patients, complete reversal in 1 patient, and no reversal in 1 patient. Smooth strictures opened after shunt surgery and proximal dilatation disappeared in most patients. The indentations and caliber irregularities disappeared after shunt surgery, whereas angulations and ectasias of biliary ducts persisted.

CONCLUSION

Shunt surgery results in regression of some of the biliary abnormalities and relieves biliary obstruction, suggesting that mechanical compression by collaterals is the mechanism behind biliary abnormalities in EHPVO. However, some biliary changes persist after shunt surgery signifying fixed obstruction due to ischemia or fibrous scarring. Thus, the two theories are not mutually exclusive.

Pregnancy and cirrhosis of the liver

Pregnancy in patients with cirrhosis of the liver is uncommon. We reviewed 9 pregnancies in 7 patients with cirrhosis. One patient conceived within 1 month of diagnosis and in another the disease was diagnosed during the index pregnancy. Four patients has associated portal hypertension and 1 of them conceived after lienorenal shunt. Complications associated with these pregnancies were jaundice (1) jaundice plus ascites (2) and gastrointestinal bleeding (1). In 2 patients endoscopic sclerotherapy was done during the index pregnancy. The incidence of preterm delivery was 50% (4 of 8) and the majority (75%) occurred in pregnancies where associated complications were present. There was 1 maternal death in the postpartum period due to fulminant hepatic failure.

Duplex Doppler sonography in patients with Budd-Chiari syndrome

BACKGROUND

Angiography has been the mainstay for diagnosis of Budd-Chiari syndrome even though other modalities are increasingly being used. We have evaluated our findings of duplex Doppler sonography (DDS) in patients with Budd-Chiari syndrome.

METHODS

Duplex Doppler sonography was performed in 37 consecutive angiographically proven patients with Budd-Chiari syndrome.

RESULTS

Real time ultrasonography showed abnormalities of right, middle and left hepatic veins (HV) in 21, 15 and 18 patients, respectively. Duplex Doppler sonography showed abnormal flow patterns in 37, 22 and 31 patients in the right, middle and left HV, respectively, thereby increasing the diagnostic yield by 40%. An abnormal waveform in one or more HV was present in all 37 patients. Uniphasic flow was the commonest abnormality and was seen in 22, nine and 14 patients, respectively, in the right, middle and left HV, while there was no flow in five, four and seven patients in the right, middle and left HV, respectively. Intrahepatic collaterals were seen in 35 of 37 patients (94.6%). Hepatopetal flow was found in the portal vein of 21 of 23 patients (91.3%), while flow was hepatofugal in one and portal vein thrombosis was found in another.

CONCLUSION

Duplex Doppler sonography is a useful procedure which helps in the diagnosis of patients with Budd-Chiari syndrome.

CT of liver cysts in patients with autosomal dominant polycystic kidney disease

PURPOSE

The purpose of this study was to illustrate the CT appearances of liver cysts in patients with autosomal dominant polycystic kidney disease (ADPKD).

MATERIAL AND METHODS

Contrast-enhanced CT images of 24 patients with ADPKD were retrospectively evaluated for the presence, number, size and distribution of liver cysts. An attempt was made to categorize these cysts into peribiliary cysts (located adjacent to larger portal triads or in the hepatic hilum) and intrahepatic cysts (within the liver parenchyma but not in contact with larger portal triads). When it was not possible to definitely categorize the cysts into either type, the cysts were labeled as indeterminate.

RESULTS

Liver cysts were seen in 13 (54%) patients. Intrahepatic cysts were seen in 12 patients, and were mainly peripheral in location with sizes ranging from less than 10 mm to 8 cm. Peribiliary cysts were seen in all 13 patients and were usually less than 10 mm in size. These cysts were seen as discrete cysts (8 patients), a string of cysts (10 patients), or as a tubular structure paralleling the portal vessels, mimicking biliary dilatation (11 patients). Twelve patients also showed indeterminate cysts which defied definite categorization into either type; two common causes of confusion included large (more than 10 mm) discrete cysts in the hilar region and the presence of a vessel adjacent to peripheral cysts.

CONCLUSION

Liver cysts in patients with ADPKD show a wide variety of appearances on CT. Familiarity with these findings is essential to avoid confusion with other abnormalities.

Endosonographic, endoscopic, and histologic evaluation of alterations in the rectal venous system in patients with portal hypertension

BACKGROUND

Colorectal varices and congestive rectopathy or colopathy have been erratically reported in patients with portal hypertension. The clinical importance of these entities has not been described. We assessed the changes in the venous system of the rectum by endoscopy and rectal endosonography (EUS). We also assessed the role of factors such as etiology of portal hypertension, grade of esophageal varices, sclerotherapy, and liver disease severity on the occurrence of these vascular changes.

METHODS

We studied changes in the venous system of the rectum using endoscopy and EUS in 60 patients with portal hypertension (cirrhotic 41, noncirrhotic 19). Ten patients with irritable bowel syndrome and 6 patients with hemorrhoids served as controls. Rectal varices were classified as tortuous, nodular, and tumorous. Corresponding appearances on rectal EUS were classified as single or discrete multiple, multiple, and innumerable submucosal veins, respectively. Evidence of congestive rectopathy was also recorded.

RESULTS

Prevalence of rectal varices was 43.3% on endoscopy (73% tortuous, 19% nodular, and 8% tumorous) and 75% on EUS (p < 0.0005). The latter showed corresponding appearances of submucosal veins in 25 of 26 patients and detected submucosal veins not identified at endoscopy in 19 other patients. Congestive rectopathy was found in 38.3% of patients. Multiple small dilated vessels in the submucosa were seen in 23.3% patients on rectal EUS. The development of these vascular changes was significantly influenced by sclerotherapy, but not by higher grade of esophageal varices, the etiology of portal hypertension, or severity of liver disease.

CONCLUSIONS

Changes in the rectal venous system are common, with rectal EUS being superior to endoscopy in detecting early, as well as florid, changes.

T-tube access for endoscopic sphincterotomy: a variant of combined percutaneous and endoscopic approach

Selective deep cannulation of the common bile duct (CBD), which is essential for successful endoscopic sphincterotomy, may not be possible in all patients. Three patients with retained CBD stones with T-tube in situ in whom selective deep cannulation failed, underwent successful sphincterotomy using a combined percutaneous and endoscopic procedure through the T-tube. CBD stones were then extracted with a Dormia basket. In situ T-tube can provide percutaneous access for combined approach in patients with retained CBD stones in whom endoscopic cannulation is not successful.

Portal hemodynamics after large-volume paracentesis in patients with liver cirrhosis and tense ascites

Large-volume paracentesis with a plasma expander has been extensively evaluated and shown to be an effective and safe therapy. While hepatic and systemic hemodynamics have been studied extensively, there is little information on portal hemodynamics by duplex Doppler. Portal vein diameter, portal flow velocity, and portal blood flow were measured with duplex Doppler in 11 cirrhotic patients before and 24 hr after large volume paracentesis. There were no significant changes in the portal vein diameter (9.88+/-2.62 mm vs 10.09+/-2.73 mm), portal flow velocity (10.65+/-2.60 vs 10.01+/-2.58 cm/sec), and portal blood flow (488+/-288.9 vs 502+/-73.38 ml/min), before and 24 hr after large-volume paracentesis. Thus, significant changes in portal hemodynamics do not occur after large-volume paracentesis.

Oesophageal motility and gastro-oesophageal reflux: effect of variceal eradication by endoscopic sclerotherapy

Endoscopic injection sclerotherapy (EIS) is known to produce oesophageal structural and motility changes; however, alterations in frequency and severity of gastro-oesophageal reflux (GER) following EIS have not been investigated in detail. We studied 22 patients with cirrhosis and oesophageal varices before EIS and 26 after variceal eradication with intravariceal EIS using manometry and 24 h pH monitoring. The post-EIS group had reduced oesophageal sphincter pressure (19.2+/-11.4 vs 26.1 +/-16.4 mmHg, P< 0.05) and slower velocity of oesophageal peristalsis (2.47+/-0.71 vs 3.06+/-0.77 cm/s, P< 0.01) than the pre-EIS patients. There was no difference in the amplitude or duration of the contraction. Abnormal contraction wave-forms were observed more frequently in post-EIS than in the pre-EIS patients (3/22 vs 12/26, P< 0.05). Various quantitative parameters for GER were not increased in post-EIS compared with pre-EIS patients. Abnormal GER was present in nine of 21 pre-EIS and eight of 17 post-EIS patients (no significant difference). These results suggest that although persistent oesophageal motility changes are frequent after intravariceal EIS, these do not lead to a significant increase in GER.

Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy

BACKGROUND & AIMS

Biliary cholesterol supersaturation, rapid nucleation of cholesterol, and altered gallbladder motility are prerequisite for gallstone formation. However, the pathogenesis of microlithiasis is not clear. The aim of this study was to determine the abnormalities of gallbladder emptying and bile composition in patients with microlithiasis.

METHODS

Nucleation time, cholesterol saturation index (CSI), and gallbladder emptying were studied in patients with microlithiasis (n = 10), patients with gallstones (n = 10), and healthy volunteers (n = 10). Bile analysis was repeated in 6 patients with microlithiasis treated with ursodeoxycholic acid (UDCA) for 8 weeks.

RESULTS

Nucleation time was shorter in patients with microlithiasis and those with gallstones than in healthy volunteers (P < 0.0001). Patients with microlithiasis had longer nucleation time than those with gallstones (P < 0.001). There was no difference in cholesterol levels and CSI in gallstone and microlithiasis patients. However, healthy volunteers had lower cholesterol levels (P < 0.01) and CSI (P < 0.01). Patients with microlithiasis had prolongation of nucleation time (P < 0.001) and lowering of CSI (P < 0.001) after UDCA therapy. Gallbladder ejection fraction was higher in microlithiasis patients than in gallstone patients (P < 0.01) but lower than in healthy volunteers (P < 0.01).

CONCLUSIONS

Patients with microlithiasis have longer nucleation time and better gallbladder emptying than patients with gallstones. Bile abnormalities can be successfully corrected with UDCA therapy in patients with microlithiasis.

Prognostic evaluation of early indicators in fulminant hepatic failure by multivariate analysis

Viral hepatitis is the commonest cause of fulminant hepatic failure (FHF) in developing countries. We evaluated the early indicators of prognosis in these patients by multivariate analysis. The records of 204 consecutive patients with acute liver failure admitted with hepatic encephalopathy over five years were studied. The etiology of these patients included virus related in 186 (91.1%), drug induced in 15 (7.4%), Wilson's disease in one (0.5%), acute Budd-Chiari syndrome in one (0.5%), and malignant infiltration in one (0.5%). Patients with FHF complicating viral hepatitis were analyzed by univariate and multivariate analysis. These patients were further subclassified depending upon the interval between the onset of jaundice and the onset of encephalopathy into hyperacute (HALF; interval 0-7 days), acute (ALF; interval 8-28 days) and subacute liver failure (SALF; interval 4-12 weeks). Sixty (32.3%) patients with viral hepatitis survived. Univariate analysis showed that the interval between onset of encephalopathy and onset of jaundice, grade of encephalopathy, raised intracranial pressure, prothrombin time, and serum bilirubin levels on admission were related to outcome in these patients. Multivariate logistic regression analysis showed that the presence of raised intracranial pressure at the time of admission, prothrombin time >100 sec on admission, age (>50 yr), and onset of encephalopathy seven days after onset of jaundice were associated with poor prognosis. Forty seven (37.0%) of 129 patients with HALF survived compared with 9 (22.5%) of 40 with ALF and 4 (21.1%) of 19 with SALF (P = NS). Raised intracranial pressure was more frequent in patients with HALF (48.8%) than in patients with ALF (32.5%) and SALF (15.8%; P = 0.01), while clinically detectable ascites was more frequent in patients with SALF (78.9%) compared with HALF (19.7%) and ALF (37.5%; P < 0.0001). The factors adversely affecting the outcome in our patients with FHF complicating viral hepatitis include presence of overt clinical features of raised ICP at the time of hospitalization, prothrombin time (>100 sec) on admission, age (>50 yr), and onset of encephalopathy seven days after onset of jaundice.

Membranous glomerulonephritis in association with ulcerative colitis

Glomerulonephritis is a rare association of ulcerative colitis. We report a patient with ulcerative colitis who developed proteinuria due to membranous glomerulonephritis which responded to colectomy.

Genetic polymorphism of the hepatic cytochrome P450 2C19 in north Indian subjects

One hundred unrelated healthy North Indian subjects were phenotyped with respect to their ability to metabolize omeprazole to 5-hydroxyomeprazole. Each volunteer was requested to ingest 20 mg (57.9 mumol) omeprazole. Urine was collected for a period of 8 hours and the amount of 5-hydroxyomeprazole excreted was estimated by HPLC. Histogram, probit, and normal test variable plots showed the antimode value for the log hydroxylation index of omeprazole to be 1.7. Of 100 North Indian subjects, 11 demonstrated log hydroxylation index values more than 1.7. Thus it is inferred that the frequency of occurrence of poor metabolizers of omeprazole in North Indian subjects is 11% (95% confidence interval, 5% to 17%). From the Hardy-Weinberg Law it was computed that the frequency of occurrence of the mutant allele of hepatic CYP2C19 in the North Indian subjects was 0.33.

Portal hemodynamics by duplex Doppler sonography in different grades of cirrhosis

Not much is known about the relationship between portal hemodynamics and the grades of cirrhosis. Using pulsed Doppler ultrasonography, we studied portal vein diameter, portal flow velocity, and portal blood flow rate in 37 patients with liver cirrhosis (11 Child's A, 13 Child's B, and 13 Child's C) and 10 healthy controls. There was no difference in the maximum inner diameter of the portal vein in cirrhotics and controls. However, there was a significant decrease in the portal flow velocity in patients with Child's C cirrhosis, as compared to controls and patients with Child's A and Child's B cirrhosis. The portal blood flow rate in Child's B and Child's C cirrhosis was also significantly less as compared to controls and patients with Child's A cirrhosis. Patients with ascites and encephalopathy had significantly lower portal flow velocities and blood flow rate as compared to those without ascites and encephalopathy, respectively. This study indicates that portal flow significantly decreased in cirrhotic patients with worsening Child's grade of cirrhosis.

Spontaneous bacterial peritonitis in fulminant hepatic failure

Ascites may be associated with fulminant hepatic failure (FHF), but spontaneous bacterial peritonitis (SBP) is an extremely rare complication. We report on two patients with FHF who developed SBP. One patient died and the other recovered.

Percutaneous transhepatic biliary drainage in the management of obstructive jaundice

BACKGROUND

Percutaneous transhepatic biliary drainage (PTBD) has been employed for decompression of the obstructed biliary tract to palliate jaundice and pruritus and for the management of cholangitis. We present our data to review the indications, therapeutic results and associated mortality and complications of this procedure. We have also studied the effect of size of drainage catheters on the improvement in liver functions and procedure related complications.

METHODS

PTBD was attempted in 41 patients (18 men, age 56 +/- 12 years; 23 women, age 55 +/- 11 years) with obstructive jaundice (37 malignant, 4 benign).

RESULTS

PTBD was successful in 39 (95%) patients. Mean serum bilirubin and alkaline phosphatase concentration declined significantly (p < 0.000001 for both) after 1 week, however thereafter decline was slow. Complete relief of pruritus and cholangitis was noted in most patients. Major complications such as cholangitis, bile leak into the peritoneum, malfunction of drainage catheter, intraperitoneal haemorrhage and renal failure, occurred in 11 (28%) patients, 2 (5%) of whom died. Large catheters (> 10 Fr) were superior to small size catheters (< 10 Fr) in relief of jaundice and had lower catheter related cholangitis.

CONCLUSIONS

We conclude that PTBD is useful for palliation of malignant obstructive jaundice with intractable symptoms and cholangitis. Catheters larger than 10 Fr should be used.

Combined percutaneous-endoscopic approach for biliary endoprosthesis placement

A nonoperative method of palliation was used in four patients with malignant obstructive jaundice in whom biliary endoprosthesis could not be placed endoscopically. A guide wire was manipulated through the lesion by a percutaneous transhepatic route and retrieved from the duodenum through an endoscope. A 10 Fr stent was then passed through the endoscope over the guide wire across the stricture. The procedure was successful in all four patients, with no complication.

Caroli's disease: a central dot means a lot

We present here a patient of congenital non-obstructive focal dilatation of intrahepatic biliary radicles (Caroli's disease). The peculiar configuration of dilated intrahepatic biliary channels with central portal vein radicles was picked up sonologically as the 'central dot' sign. Awareness of this sign allows an accurate diagnosis without resorting to more invasive and expensive investigations.

Sclerotherapy in noncirrhotic portal fibrosis

Endoscopic sclerotherapy has emerged as an effective and safe mode of treatment for long-term management of esophageal varices due to cirrhosis of liver and extrahepatic portal venous obstruction. There are few studies that have evaluated the role of sclerotherapy in the management of esophageal varices in patients with noncirrhotic portal fibrosis (NCPF). We report our results of long-term sclerotherapy in patients with NCPF. Seventy-two consecutive patients (men 29, women 43; age 32.9 +/- 11.8 years) with recurrent variceal bleeding due to NCPF were entered into the sclerotherapy program. Forty-eight patients received intravariceal absolute alcohol and 24 patients received intravariceal sodium tetradecyl sulfate (STD). Variceal obliteration was achieved in 65 (90.3%) patients with a mean of 5.7 +/- 3.0 (range 1-14) sessions. These patients were followed-up for a mean of 21.4 +/- 20.4 (range 1-96) months. Thirteen (17.3%) patients had episodes of upper gastrointestinal bleeding during sclerotherapy. Rebleed after obliteration was seen in 6 (9.2%) patients. Sclerotherapy was associated with a significant reduction in bleeding rate (bleeds per month per patient) during sclerotherapy and after obliteration of varices as compared to presclerotherapy period (P < 0.000001 for both). Recurrence of esophageal varices after obliteration was seen in 9 (13.9%) patients with reobliteration of varices in five patients in whom sclerotherapy was attempted. Complications including esophageal ulcer and stricture formation were seen in 18 (25%) and 4 (5.6%) patients respectively; strictures were restricted to patients who received absolute alcohol. Two (2.77%) patients died of massive upper gastrointestinal bleed during follow-up. We conclude that sclerotherapy is an effective and safe modality in the prevention of variceal bleeds in patients with NCPF.

Effect of endoscopic sphincterotomy on gallbladder motility

In experimental animals, sphincterotomy facilitates passage of solids from the gallbladder and inhibits gallstone formation apparently by improvement in gallbladder emptying. In humans, however, gallbladder emptying has not been studied following endoscopic sphincterotomy (ES) in patients with gallstones. We therefore prospectively studied resting and cerulin-stimulated gallbladder volumes by real time ultrasonography in 15 patients of choledocholithiasis with gallbladder in situ (eight with and seven without gallbladder calculi) before and after (after bile duct clearance) ES. ES significantly lowered resting gallbladder volume (21.2 +/- 10.6 vs 11.1 +/- 5.0; P < 0.0001) and cerulin-stimulated residual gallbladder volume (10.8 +/- 5.6 vs 4.4 +/- 2.1; P < 0.0001). ES also significantly increased the gallbladder ejection fraction (47.3 +/- 12.1% vs 58.8 +/- 11.1%; P < 0.0001). The rate constant for gallbladder emptying after cerulin infusion also increased significantly after ES (-0.022/min vs -0.031/ min; P < 0.0001). Significant improvement in gallbladder motility was observed in both groups of patients with and without gallbladder calculi. ES significantly improves gallbladder motility in humans.