Bacterial infections in cirrhosis - does standard empirical therapy need a rethink?

Background: Patients with cirrhosis not only have a higher incidence and a greater severity of infections but infections increase the mortality and morbidity in cirrhosis. Third-generation cephalosporins and quinolones are currently the most commonly recommended first-line empirical therapy in most infections. This study was conducted to study the bacterial etiology, susceptibility of these organisms to these commonly used antibiotics.Methods: All patients of cirrhosis of liver admitted to a tertiary care centre underwent cultures from blood, urine and ascitic fluid and the incidence of infection was calculated. Sensitivity pattern of organisms to third generation cephalosporins and quinolones were studied.Results: A total of 150 patients were included in the study and 58 (37.8%) of them had one or more infections. Spontaneous bacterial peritonitis was the most common infection noted and gram-negative bacilli (E. coli) were the commonest organisms isolated. The overall response rate to quinolones and third generation cephalosporin’s was only 47%.Conclusions: Increasing use of antibiotics in empirical role has increased resistance to commonly used antibiotics. Empirical therapy should be decided based upon local epidemiological patterns and the same cannot be generalized

Hereditary hemorrhagic telangiectasia of liver: Pathophysiology with role of radiology in diagnosis and treatment

Hereditary hemorrhagic telangiectasia (HHT) or Osler–Weber–Rendu syndrome is a rare condition which can result in significant systemic and hepatobiliary abnormalities. Liver involvement in HHT consists primarily of the consequence of various intrahepatic shunts. Even though these vascular shunts are present in the majority of patients with HHT, symptoms occur only in minority with clear predilection to female gender. The symptoms and imaging findings of liver vascular malformations can be easily overlooked or misdiagnosed which can result in delay in treatment or potentially harmful vascular interventions. In this case report, we discuss the pathophysiology of HHT in liver involvement, role of imaging in diagnosis, and the possible role of interventional radiologist in the treatment

CagA and VacA genes of Helicobacter pylori and their clinical relevance

Context: Helicobacter pylori is associated with the development of a variety of gastroduodenal diseases which varies with ethnicity and the type of strains that infect the population. Aims: This study aims to evaluate the prevalence of H. pylori cagA and vacA genotypes in our region and to determine their relationship to the severity of the lesions that they cause. Settings and Design: This study was an observational cross-sectional study. Subjects and Methods: DNA was extracted from 165 gastric biopsies from patients evaluated for dyspepsia. PCR was used to detect cagA and vacA (s1, s2, m1, m2) genes of H. pylori. Statistical analysis of associations was performed between endoscopy findings and virulence genes. Statistical Analysis Used: Pearson Chi-square test and Fischer's exact test. Results: The prevalence of H. pylori infection was 37% and the dominant genotypes was vacA s1 cagA-positive strain (54.1%) in this study. The vacAs1 subtype was found in all patients with peptic ulcer disease (PUD). The entire normal study group had VacA s2 variant only. This clearly shows that vacA s1 is a significant virulence marker and patients harboring s1 strains are more prone to develop ulcers (P = 0.007). There was a significant association of cagA with s1 strain rather than s2. Variation in VacA m genotype did not seem to have any association with disease status. There was a statistically significant association between the presence of cagA gene and PUD rather than the nonulcer dyspepsia (P = 0.027). Conclusion: The predominant genotype in our population was cagA positive vacA s1, which was found to be significantly associated with patients with gastric diseases, especially PUD. VacA s1 can serve as a single best virulence marker of the disease manifestation

High-grade non-Hodgkin′s lymphoma of ovary presenting as peritonitis

Primary ovarian lymphoma is rare, with ovary more commonly involved secondarily in generalized disease. Primary ovarian lymphoma presents as mass in the ovary with chronic symptoms; an acute presentation has not been described previously. A 75-year-old female presented with acute abdomen and features of peritonism. Computed tomography and magnetic resonance imaging demonstrated large mass in left ovary along with infiltration of adjacent sigmoid colon causing perforation and pneumoperitoneum. Few jejunal loops were also involved. Intraoperatively, there was left ovarian mass infiltrating the sigmoid colon with perforation and fecal peritonitis. Distal jejunal loops were adherent to the tumor. The involved sigmoid colon was resected with total abdominal hysterectomy, bilateral salpingo-oophorectomy and resection of adherent jejunal loops. Histopathology revealed ovarian tissue with necrotic neoplasm composed of small-to medium-sized round cells exhibiting nuclear irregularity and scanty cytoplasm, forming discohesive sheets with the neoplasm infiltrating the retroperitoneal remnant tissue and resected bowel. This case highlights an unusual presentation of primary ovarian lymphoma