ABSTRACTS OF PAPERS AT TE 90TH RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY, 10TH SEPTEMBER 2001, 2.30 PM SP JAIN CAFETERIA (CONVENOR DR. HL DHAR)
1. CLINICO-PATHOLOGICAL AND ENDOSCOPIC PROFILE IN CROHN’S, ULCERATIVE AND TUBERCULOUS COLITIS : A COMPARATIVE ANALYSIS
Deepak Amarapurkar, Nikhil Patel, Haribhakti Seba Das
Crohn’s, ulcerative and tuberculous colitis are the commonest causes of chronic diarrhoea and they have many features in common.
Aim : The aim of our study is to compare the clinical pictures, physical findings, endoscopic picture and histopathological features in age matched diagnosed Crohn’s disease (CD), ulcerative colitis (UC) and tuberculous colitis (TB).
Age matched diagnosed CD, UC and TB colitis were studied for the clinical presentations, physical findings, colonoscopic picture and histopathological features. The variables were analyzed by Chisquare test for statistical significance. P value < 0.05 were considered as statistically significant. Twenty patients were taken from each group. The mean age of those were 30.65 years, 33.95 years and 35.4 years in CD, UC and TB respectively. Symptoms before diagnosis were 4.77 years, 2.77 years, 7.05 months in three groups respectively. Haematochezia was present in 20 (100%) cases of UC and 8 (40%) cases of Crohn’s colitis p < 0.001. Ten (50%) cases of Crohn’s had undergone treatment with AKT for their abdominal symptoms prior to diagnosis. Perianal lesions were present in 4 (20%) of Crohn’s disease, p < 0.001. Abdominal lump was present in 4 (20%) cases of CD and 7 (35%) cases of TB, P = significant. On colonoscopy rectal sparing was seen in 18 (90%) of CD, 20 (100%) cases TB colitis with 100% rectal involvement in UC, p < 0.001. Ileal involvement was found in 12 (60%), 14 (70%) cases of CD and TB colitis and none of the UC had it, p < 0.001. Skip lesions was a feature of CD and was found in 7 (35%) of cases. Stricturous lesions was found in 7 (35%) of cases of TB and none in CD and UC. On biopsy granuloma was observed in 7 (35%) of cases in CD and 10 (50%) cases in TB colitis and only one case (5%) in UC. In TB colitis 6 (60%) of the granulomas were caseating. Crypt distortion was found in 16 (80%), 7 (35%) and 0% in UC, CD and TB colitis p < 0.05. Goblet cell depletion was seen in 11 (65%), 6 (30%), and 0% cases in UC, CD and TB colitis, p < 0.05. Diarrhoea along with haematochezia with rectal involvement and crypt distortion in histopathology are hallmarks of UC. Whereas TB colitis and Crohn’s have many features in common, thus creating diagnostic difficulty, but nonresponse to AKT, skip lesion in colonoscopy and long standing symptoms with perianal lesions helps in diagnosis of Crohn’s disease.
2. PREDICTORS OF HEPATIC FIBROSIS IN NONALCOHOLIC STEATOHEPATITIS
Deepak Amarapurkar, Nikhil Patel, Haribhakti Seba Das, Girish Muzumdar, Anita Shah, Arun Chitale
Nonalcoholic steatohepatitis (NASH) has been recognized as an important cause of cirrhosis and endstage liver disease.
He was thrombolysed with Urokinase. After 1 hour of thrombolysis patient had ventricular tachycardia/ventricular fibrillation and Stoke Adams syndrome. He was successfully cardioverted with DC shock.
To predict the hepatic fibrosis in patients of biopsy proved nonalcoholic steathepatitis (NASH).
Patients of biopsy proved nonalcoholic steatohepatitis (NASH) were divided into two subsets, like NASH with fibrosis and without fibrosis. They were analyzed for the independent risk factors of age, sex, AST/ALT ratio > 1, type-2 diabetes, hyperlipidaemia and obesity. Statistical significance was calculated by chisquare test and significance of difference in means. P value < 0.05 were taken to be statistically significant.
Risk factors NASH with fibrosisn=8 NASH without fibrosisn=1 Age 44.57 yrs. ± 7.59(33-59) 35.50 yrs. ± 13.55(22-60) p < 0.005 Sex M:F 6:2 11:4 p=ns Diabetes mellitus 4 (50%) 2 (13.3%) p < 0.01 Obesity 6 (75%) 9 (60%) p=ns Hyperlipidaemia 2 (25%) 3 (20%) p=ns AST/ALT > 1 8 (100%) 4 (26.6%) p < 0.001
Age, type-2 diabetes and AST/ALT ratio > 1 were found to be independent risk factors for liver fibrosis in NASH. So patients of NASH with older age group, type-2 diabetes needs close monitoring and treatment.
3. RESPONSE OF LAMIVUDINE MONOTHERAPY IN HEPATITIS B
Deepak Amarapurkar, Haribhakti Seba Das, Nikhil Patel
Lamivudine an oral antiviral agent is widely used in treatment of hepatitis B. To study the response of lamivudine in patients of chronic hepatitis B.
Methods : Patients of chronic liver disease due to hepatitis B were treated with 100 mg of lamivudine daily and in children less than 12 years of age at a dosage of 3 mg/kg body weight. Patients were tested for complete LFT, HBs Ag, HBe Ag, Anti Hbe, HBV DNA and liver biopsy when possible. Patients who had enzyme rise of at least one and half times of normal were treated. Patients who have completed one year of treatment at least were taken into account.
Following treatment the enzyme level, viral markers were tested at every three monthly interval and treatment response was considered with disappearances of HBe Ag and HBV DNA, and appearance of Anti Hbe in wild virus infection and disappearances of HBV DNA in precore mutants. Treatment was continued three months after initial response and stopped after confirmation of response. Six months after stoppage of treatment all parameters were repeated for sustained response to treatment.
Total 56 patients were treated, age range being 8-78 years, mean age of 40.49 æ 15.5 years, M:F ratio of 48:8. Sixteen patients were interferon failure. Mean treatment duration was 15.29 months æ 6.37 months. Thirty one (55.35%) patients had HBe Ag positivity and 25 (44.64%) patients were HBe negative with DNA positivity, thus presumed to be precore mutants. In wild variety 20 (64.5%) pts did not respond. Out of 11 responder 9 (29.03%) had sustained response, 1pt had relapse, another one had seroconversion of less than three months duration, thus continuing treatment. Amongst them, two had decompensation and they did not show response. In mutant variety 7 (28%) did not respond, two had sustained response, 12 had relapse (48%) and four are continuing treatment. Out of 25 mutants six had decompensation, out of which three showed initial response with relapse and one had sustained response. Three patients had death during treatment, two of which were decompensated cirrhosis and other death was due to non hepatic cause. None of the patients developed any adverse effect to therapy.
Lamivudine monotherapy showed 30% response rate at the end of one year in hepatitis B infection. In mutant virus infection, though initial response is good, relapse rate is high, thus they may benefit from long term treatment.
4. DIABETES AND CHRONIC LIVER DISEASES
Deepak N Amarapurkar, Haribhakti Seba Das
There is a consensus that type-II diabetes mellitus and obesity are risk factors for NASH and NASH has been identified as an under recognized cause of cryptogenic cirrhosis. To prove this hypothesis we studied the spectrum of liver diseases in patients of diabetes and compared the same in non diabetic controls.
We studied the patients of chronic liver disease presenting over a period of one year and their diagnosis were established by biochemical studies, imaging, endoscopic examination and liver biopsy when required. They were evaluated for the aetiological causes of liver diseases, like viral markers, workup for Wilson, autoimmune hepatitis, Alpha-1 antitrypsin deficiency, serum ferritin, iron saturation. Patients who were diabetic and on treatment were evaluated for their blood sugar as well as glycosylated haemoglobin. The spectrum of liver diseases in diabetic group were compared with age and sex matched non diabetic controls. Statistical calculations were done by using chisquare tests.
Total 53 patients of chronic liver disease with diabetics, M:F 43:8, with an age range of 35-70 years, median age of 51 years were taken as study group. Demographic picture of control group was total = 115, with M:F = 100:15, age range of 37-68 years, with a median age of 52 years.
Spectrum of liver diseases Diabeticn=53 Nondiabeticn=115 Cirrhosis 30 (56.60%) 53 (46.08%) Chr. Hepatitis 8 (15.09%) 42 (36.52%) Fatty liver 12 (22.64%) 13 (11.30%) Cirrh.+HCC 3 (5.66%) 3 (2.60%) Aetiology NASH with Cirrhosis 6 (11.32%)* 2 (1.7%) p* < 0.001 NASH 10 (18.86%)* 15 (13.0%) p* < 0.001 Cryptogenic 12 (22.64%)* 9 (7.8%) p* < 0.001 Total 52.82% 22.5%
Rest of the cases were due to HBV, HCV, alcohol and autoimmune in 16.98%, 13.2%, 16.98%, 0% respectively in diabetes group and 30.43%, 13.04%, 29.56%, 4.3% in nondiabetic group. Incidence of NASH, NASH with cirrhosis and cryptogenic cirrhosis were significantly higher in patients of diabetic group.
NASH, NASH with cirrhosis and cryptogenic cirrhosis are the major causes of chronic liver disease in patients with diabetes mellitus. Whereas alcohol and viral causes are found to be important aetiologies in non diabetic control group. Thus diabetes mellitus can be considered as an important risk factor for chronic liver disease and progression of NASH to cirrhosis may attribute to the higher proportion of cryptogenic cirrhosis in them.
5. SPECTRUM OF CHRONIC LIVER DISEASE AND NEED FOR LIVER TRANSPLANTATION
Deepak N Amarapurkar, Haribhakti Seba Das
To study the spectrum of liver diseases, their aetiological factor and fitness for liver transplantation.
Patients of chronic liver disease presenting from January to December, 2000 were thoroughly evaluated with clinical history, physical examination, biochemical findings, imaging, endoscopic examination, isotope scan and liver biopsy whenever necessary. The aetiological diagnosis was determined by evaluating for all viral markers, like HbsAg, Total (IgG + Ig M) Anti HBc, HBV, DNA, Anti HCV, HCV RNA, autoimmune workup like serum protein electrophoresis, ANA, Anti SMA, Anti LKM, AMA, serum Iron studies including serum ferritin, serum ceruloplasmin, alpha-1 antitrypsin assays. Fitness for liver transplantation was determined by using UNOS criteria’s for liver transplantation.
Total 284 patients of chronic liver diseases were studied. The demographic pictures were as follows, M:F 232:52, Age range of 6-74 years, with a median age of 47 years. Out of 284 patients, 138 (48.59%) had cirrhosis, 9 (3.16%) cirrhosis with HCC, 98 (34.5%) chronic hepatitis and 39 (13.73%) fatty liver. Aetiologies for chronic liver diseases were HBV 78 (27.46%) cases, HBV+alcohol 8 (2.81%), alcohol 62 (21.8%), HCV 38 (13.38%), HCV+alcohol 4 (1.4%), autoimmune 10 (3.52%), NASH 40 (15.84%), NASH with cirrhosis (3.16%), Wilson disease 6 (2.11%), sclerosing cholangitis 1, secondary biliary cirrhosis 2, and cryptogenic in 29 (10.21%) cases. Out of 284 patients 55 (19.36%) fulfilled the criteria for liver transplantation. The aetiologies were 24 (43.63%) alcoholic liver disease, 11 (20%) HBV, 7 (12.75%) HCV, 6 (10.90%) had cryptogenic cirrhosis, 4 (7.2%) Wilson’s disease, 1 (1.8%) Budd-Chiari, 2 (3.6%) secondary biliary cirrhosis. Only 8 (14.54%) out of 55 accepted it as a treatment modality, though it was explained to them as the definitive treatment. Out of 8, 3 have been transplanted and three have died while waiting for transplant and two are on waiting list.
Hepatitis B, C and Alcohol are common causes of chronic liver disease and most of them present with cirrhosis. Though liver transplantation is the treatment of choice and the need for it is quite high in India, financial factor and lack of awareness are major hurdles for its acceptance.
6. PROFILE OF HEPATOCELLULAR CARCINOMA
Deepak N Amarapurkar, Haribhakti Seba Das, Sandeep Punamiya
To study the aetiological factors, presentation, tumour size, treatment modality and survival in patients of hepatocellular carcinoma.
Patients of hepatocellular carcinoma picked up on regular screening i.e. Patients with cirrhosis or symptomatic patients presenting for the first time were taken into account. Patients had undergone alpha-foetoprotein estimation, ultrasonography/CT scan of abdomen/MRI/angiography to diagnose the lesion. Patients were treated when the tumour was in a treatable stage. They were followed up for their survival.
Total 39 patients of HCC were studied with a male : female ratio of 12:1, age range of 32-75 years and median age of 57 years. Out of 39 patients, 34 (87.17%) were cirrhotic and five were noncirrhotic, 11 were detected on screening of cirrhotic patients and 28 had presented with symptoms. Aetiology of HCC were Hep. B 17 (43.5%), Hep. B + alcohol 3 (7.6%), Hep. C 6 (15.3%), Hep. C + alcohol 1 (2.5%), alcohol 6 (15.3%), membranous obstruction 1 (2.5%), and in 5 (12.5%) cases the cause could not be identified. Alpha foetoprotein level was elevated upto 100 ng/ml in 11 (28.2%), 100-400 ng/ml in 9 (23.07%), > 400 ng/ml in 19 (48.71%) cases. Seven of them had small HCC of â 4 cm (17.94%) size, 5 (12.8%) had multiple lesions, 27 (69.2%) had large HCC. Twenty patients were not fit for treatment and 19 patients (48.7%) received treatment. One patient had undergone surgery and another had undergone chemoembolisation along with surgery. Five were treated with alcohol injection and one received chemoembolisation with alcohol injection, seven received chemoembolisation. Three patients received tamoxifen. In the treatment group the survival was from three months - three years, median survival was six months, and in the no treatment group the survival was from one month - 12 months, the median survival being three months.
Hepatitis B and C are major causes of HCC. Majority of HCCs are seen in cirrhotic livers. Almost 50% HCC are detected at a stage when treatment is not possible. Regular screening helps in picking up an early HCC, which is amenable to treatment.
7. PROFILE OF CARDIOVASCULAR DISORDERS IN HOSPITALIZED ELDERLY PATIENTS
SV Joshi, HL Dhar
In elderly population, heart disease remains the leading cause of death. Present study was aimed to note the incidence of cardiovascular disorders in hospitalised elderly patients during the year 1998.
Results show that elderly suffer multiple disorders : 53.47% suffered from two disorders, 25.54% with three, 4.11% with four and 16.89% with one disorder. Maximum number of patients were in the age group of 60-64 which declined with age. Male to female ratio was 3:1. The commonest disorder was ischaemic heart disease (59.20%) followed by hypertension (48.27%) and myocardial infarction (12.55%). Their incidence was highest in the age group 60 to 64 which declined with age. Elderly with IHD needed surgical intervention. This was confirmed by angiography (59.4%). Of these, surgery was performed on 43.53%. Coronary artery bypass graft was the preferred procedure in 41.53% compared to PTCA (18.03%). The maximum operations occurred in the 60 to 64 age group. It is interesting to note that even patients aged 90 were operated upon. Further classification of these operated revealed : Three vessels (37.28%); four vessels (32.89%), five vessels (16.23%), one vessel (4.82%), six vessels (4.39%), two vessels (22.63%) and seven vessels (1.76%). Main risk factors in these cases were either diabetes (11.11%), hypertension (25.25%) or both (14.14%). Number of vessels blocked increased with increased percentage of risk factors. Overall mortality during hospitalisation was 5.63% which increased with age.
8. MORBIDITY AND MORTALITY PROFILE AMONG HOSPITALIZED ELDERLY PATIENTS
AH Shah, SV Joshi, HL Dhar
Out of total admissions (26236) elderly constituted 18.09% (4746). Male to female ratio was 1.36:1. Most of the patients belonged to age group 65-69 - (32.14%) and 60-64 - (31.60%). Majority of the patients belonged to age group 60-69 (63.74%). Most of them (55.17%) had undergone surgical intervention, remaining 44.83% was hospitalized for medical treatment. However, highest number of elderly from medical unit were admitted in cardiology (43.42%) followed by general medicine (32.24%), neurology (17.20%) and nephrology (7.14%).
Out of surgical admission maximum number was in Ophthalmology (46.49%), followed by Urology (32.40%), Orthopaedic (20.48%), Neurosurgery (16.49%), Cancer surgery (13.45%) and only 2.36% in obstetrics and corresponding figures of surgical intervention were Gen. Surgery and Cancer (29.53%) Ophthalmology (24.56%), Urology (19.60%), Orthopaedic (16.42%), Neurosurgery (6.64%) and Obst. (3.25%).
Overall mortality was 5.28% of which 67.73% were males and 32.27% were females. It was maximum in 75+ age group, with gradual increase from 65 to 80 years.
Main cause of death was cardiovascular disorders (40.24%), Gen. Medicine (23.9%), Neurology (9.56%), and Nephrology (5.98%) in medical units. In surgical units maximum number of death occurred in General surgery + Cancer surgery (9.16%) followed by Neurosurgery (5.17%), Urosurgery (3.18%), Orthopaedic surgery (2.39%) and Obst. (0.057).
However, overall mortality in medical units was higher (79.68%) compared to surgical units (20.32%).