Presence of Ascites at Presentation is Associated With Absence of Long-Term Response Amongst Patients With Budd-Chiari Syndrome When Treated With Medical Therapy Alone: A Single Centre Real-Life Experience

BACKGROUND

There is lack of data on long-term outcomes of patients with Budd-Chairi Syndrome (BCS) treated with medical therapy including anticoagulation alone.

METHODS

Consecutive patients (N = 138, mean [standard deviation, SD] age 29.3 [12.9] years; 66 men) with BCS, treated with medical therapy alone including anticoagulation, with minimum follow-up of 12 months were included. Initial response was classified as complete (CR), partial (PR) or nonresponse (NR) and on follow-up as loss of response (LoR) or maintenance of response (MoR). The association of baseline, clinical and biochemical parameters with different responses was evaluated.

RESULTS

Seventy-six patients (55.1%) had CR, 26 (18.8%) had PR and 36 (26.1%) had NR. None with PR or NR had CR later. At a median follow-up of 40 (range 12-174) months, LoR was more common in PR group than in CR group (12 [46.2%] vs 18 [23.7%], P = 0.03). LoR was associated with presence of ascites (odds ratio [OR] 1.5; 95% confidence interval [CI] 0.06-0.71), gastrointestinal bleed (OR 1.33; 95% CI 0.09-0.82) or jaundice (OR 1.01; 95% CI 0.11-0.97) at baseline and duration of follow-up (OR 0.018; 95% CI 1.006-1.030). Mortality was higher in NR (28 [77.8%]) compared with CR (15 [19.7%], P = 0.001) and PR (8 [30.8%], P = 0.001). On binary logistic regression analysis, presence of ascites at baseline was associated with LoR (OR 0.303 [0.098-0.931]).

CONCLUSION

Patients with initial CR have better survival than nonresponders. One-third had LoR on follow-up. The presence of ascites at baseline is associated with LoR.

Fecograph: A graphical representation of daily stool forms to subtype irritable bowel syndrome in office practice

BACKGROUND AND AIM

Interpreting stool form diaries for subtyping patients with the irritable bowel syndrome (IBS) is cumbersome; a picture showing a trend would be easier to interpret.

METHODS

Fifty-one consecutive adults with IBS (median age 35.5 years; 47 men), diagnosed using the Rome III criteria, were given a picture of the Bristol stool form scale (BSFS) and asked to record their stool frequency and form for 7 days. The numbers were plotted by a technician as dots on a chart. On the y axis, BSFS category 4 was marked as 0, harder stools as +1 to +3, and softer stools as -1 to -3; each bowel movement was represented on the x axis. A line graph was plotted by connecting the dots. Each "fecograph" was then given for visual interpretation to three gastroenterologists (observers). When most readings appeared to be 0, +1, or -1, it was to be reported as normal; most above +1 as IBS-constipation (IBS-C); most below -1 as IBS-diarrhea (IBS-D); and readings crossing 1 on either side as IBS-mixed (IBS-M). If no clear trend was noted, it was IBS-unclassified (IBS-U). Each observer reported all graphs in different orders twice, at 1-month intervals; thus, 306 reports were available. Interclass correlation coefficient (ICC) was calculated.

RESULTS

Eighteen patients had IBS-C, 13 IBS-D, 4 IBS-M, and 16 IBS-U. The 51 fecographs were reported in mean 20 min 36 s. ICC for intra- and interobserver reliability was 0.62 (0.50-0.73).

CONCLUSION

The fecograph is a reliable and easy-to-use tool to subtype patients with IBS.

Findings from a large Asian chronic hepatitis C real-life study

There is a paucity of information on chronic hepatitis C (CHC) patients treated with direct antiviral agents (DAAs) in Asia. We invited Asia-Pacific physicians to collate databases of patients enrolled for CHC treatment, recording baseline clinical, virologic and biochemical characteristics, sustained virologic response at week 12 (SVR12) and virologic failure. SVR12 outcome was based on intention to treat (ITT). Multivariate analysis was used to assess independent risk factors for SVR12 using SPSS version 20. A total of 2171 patients from India (n = 977), Myanmar (n = 552), Pakistan (n = 406), Thailand (n = 139), Singapore (n = 72) and Malaysia (n = 25) were collected. At baseline, mean age was 49 years, 50.2% were males, and 41.8% had cirrhosis. Overall, SVR12 was 89.5% and by genotype (GT) based on ITT and treatment completion, respectively, was 91% and 92% for GT1, 100% and 100% for GT2, 91% and 97% for GT3, 64% and 95% for GT4, 87% and 87% for GT6 and 79% and 91% for GT untested. Patients with cirrhosis had SVR12 of 85% vs 93% for noncirrhosis (P < 0.001) (RR 2.1, 95% CI 1.4-3.1, P = 0.0002). Patients with GT1 and GT3 treated with sofosbuvir/ribavirin (SR) had 88% and 89% SVR12, respectively, but those GT6 treated with sofosbuvir/ledipasvir (SL) had only 77.6% SVR12. Multivariate analysis showed absence of cirrhosis was associated with higher SVR12 (OR 2.0, 95% CI 1.3-3.1, P = 0.002). In conclusion, patients with GT1 and GT3 with/without cirrhosis had surprisingly high efficacy using SR, suggesting that Asians may respond better to some DAAs. However, poor GT6 response to SL suggests this regimen is suboptimal for this genotype.

Pregnancy outcomes in women with Budd Chiari Syndrome before onset of symptoms and after treatment

BACKGROUND & AIMS

Pregnancy is known to have poor outcomes in women with Budd Chiari syndrome. There are no data on fertility and pregnancy outcomes prior to onset of symptoms or the effect of therapy on these parameters. We therefore evaluated reproductive profile of women with Budd Chiari Syndrome before the onset of symptoms and after therapy.

PATIENTS AND METHODS

Eighty women with Budd Chiari Syndrome (29 years [20-45]) were enrolled over 8 years. Baseline demographic characteristics, disease severity, thrombophilic disorders and treatment were reviewed. Their obstetric history before symptoms and after therapy was noted and compared.

RESULTS

Sixty women conceived at least once (150 pregnancies) before symptom onset and 20 had primary infertility. Eighty-one pregnancies resulted in live births and remaining 69 pregnancies had adverse pregnancy outcomes. Post-intervention, 28 women (15 with primary infertility) attempted conception. Thirteen patients conceived 15 times. More women had live births after successful therapy as compared to presymptomatic period (0/28 vs 5/28 P = .000, Odds ratio5.6; 95% CI: 2.16-14.5). In women with primary infertility, conception (0/15 vs 3/15 P = .007, Odds ratio 5, 95% CI: 1.44-17.27) and proportion of live births (0/15 vs 2/15 P = .002, Odds ratio 7.5, 95% CI: 1.71-32.79) was higher as compared to presymptomatic period.

CONCLUSION

Primary infertility is common and pregnancy outcomes are poor before the onset of symptoms in women with Budd-Chiari syndrome. Effective therapy of Budd-Chiari syndrome may improve fertility and pregnancy outcomes.

Long Term Outcomes of Patients with Significant Biliary Obstruction Due to Portal Cavernoma Cholangiopathy and Extra-Hepatic Portal Vein Obstruction (EHPVO) With No Shuntable Veins

AIMS

The natural history of portal cavernoma cholangiopathy (PCC) in patients with significant biliary obstruction (SBO) who cannot undergo shunt surgery, is not known. We therefore, analyzed data of patients of extra-hepatic portal venous obstruction (EHPVO) with PCC.

METHODS

Prospectively recorded details of 620 (age 21.2 [11.4] years; 400 [65%] males) patients with primary EHPVO were reviewed. Outcomes (hepatic decompensation/mortality) of patients with PCC and SBO without shuntable veins were noted at follow up of 7 [4-11] years.

RESULTS

Ninety-seven of 620 (15.6% [60 men]) EHPVO patients had PCC-SBO. Of these 57 did not have shuntable veins. The median duration from any index symptom to symptomatic PCC was 7 (0-24) years and from index bleed to symptomatic PCC was and 12 (5-24) years, respectively. Thirteen patients underwent endoscopic retrograde cholangiography; nine repeatedly over 7 (4-10) years. Decompensation was seen in 5 patients. Presentation other than variceal bleed was associated with hepatic decompensation (5/19 versus 0/38, P = 0.003).

CONCLUSIONS

Majority of patients with PCC-SBO do not have shuntable veins, and may have good long-term outcomes. Patients presenting with variceal bleed have low chance of decompensation. Symptomatic PCC appears to be a late event in EHPVO.

Tobacco use, its influences, triggers, and associated oral lesions among the patients attending a dental institution in rural Maharashtra, India

BACKGROUND

World Health Organization (WHO) predicts that tobacco deaths in India may exceed 1.5 million annually by 2020.

OBJECTIVES

The aim of this study was to estimate the prevalence of tobacco use, its influences, triggers, and associated oral lesions among the patients of Rural Dental College and Hospital of Loni, Maharashtra.

MATERIALS AND METHODS

A hospital based cross-sectional study was conducted from June - December 2010. All the patients from the outpatient department and with tobacco habits were included in the study. Patients were interviewed through a pre-tested structured questionnaire in relation to their tobacco habits, its influences and triggers. Also clinical examination was carried out to check for any tobacco related oral lesions. For the data analysis, Microsoft Excel and chi-square test was used.

RESULTS

The overall prevalence of tobacco use was 16.38%. Smokeless form of tobacco was more prevalent in both males (81.84%) and females (100%). Majority of the patients (males - 68.22%, females- 90.62%) were light tobacco users. About 76.09% males and 31.25% females admitted that they developed the habit due to initial influence of friends. The most common oral mucosal lesion in both the males (42.20%) and females (11.07%) was tobacco hyperkeratosis. Most common trigger for tobacco use was "work related" (69.14%) in males and "after meals" (53.13%) in females.

CONCLUSION

Since the number of tobacco users visiting the dental hospital is reasonably high; dentists can contribute to restrain the hazard through community educational activities such as de-addiction counseling of tobacco users to quit the habit.