Is celiac disease associated with cryptogenic chronic liver disease and non-cirrhotic intra-hepatic portal hypertension.

BACKGROUND AND AIMS: To study the spectrum of CD in patients with NCIPH /cryptogenic chronic liver disease (CLD) and to see the effects of gluten free diet in these patients. METHODS : Prospective case-control study looked at CD in cryptogenic CLD including NCIPH (cases) and hepatitis B/C related CLD (controls). IgA–TTG antibody (using recombinant human transglutaminase , ELISA (AESKULISA Celichek ) and anticardiolipin antibodies (IgG,IgA and IgM) (ELISA Varelisa kit) with titres at the time of diagnosis and duodenal biopsy with grading according to Marsh criteria was done.This was followed by subjecting the patients on gluten free diet and reassessing after minimum of 3 months. To study the association, bivariate analyses were done and the associations were studied using chi-square test (Fisher exact test). RESULTS : 60 cases (age 43 (10) years, (mean (SD)), males 46) and 59 controls (age 45 (11) years; males 53) were studied. Majority were from eastern India. Liver biopsy done in 20 cryptogenic CLD patients showed NCIPH (13) and cirrhosis (7). IgA TTG Ab was significantly positive in 40/58 cases (69%) with higher mean titres (70 U/ml) as compared to controls 16/59 (27%) (p = 0.00) mean titres (43 U/ml) (p 0.002). Marsh III, II/I and 0 were seen in 24%, 39% and 34% of cases and 0%, 32% and 68% of controls (p=0.002). Of 11 pts.with CD (mean age 43 yrs , 3 with silent disease) 5 of 7 who underwent liver biopsy had NCIPH. Follow up on GFD duration median 8 (3 – 14) months , TTG Antibody became negative in 5 patients and villous atrophy reversed in 3 patients. IgA anticardiolipin antibodies were not positive in any of the patients with CD. Gut permeability was increased in 4 of 8 (50%) pts of CD CONCLUSION: CD was seen in 24% pts. of cryptogenic cld which is much higher than reported prevalence in India. Of these 5 of 7 pts (71%) who underwent liver biopsy had NCIPH. NCIPH was recognised as the predominant cause of cryptogenic intrahepatic portal hypertension in our unit. Adult onset celiac disease was diagnosed in 10 patients.GI symptoms improved in all patients however an improvement in liver functions could not be determined probably because of the short follow up

Acute-on-chronic liver failure: Consensus recommendations of the Asian pacific association for the study of the liver (APASL): An update

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the APASL ACLF Research Consortium (AARC) was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the \u27Golden Therapeutic Window\u27, extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here

Model for End‐Stage Liver Disease‐Lactate and Prediction of Inpatient Mortality in Patients With Chronic Liver Disease

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163652/3/hep31199.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163652/2/hep31199_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163652/1/hep31199-sup-0001-Supinfo.pd

Extrahepatic portal vein obstruction and portal vein thrombosis in special situations: Need for a new classification

Extrahepatic portal vein obstruction is a vascular disorder of liver, which results in obstruction and cavernomatous transformation of portal vein with or without the involvement of intrahepatic portal vein, splenic vein, or superior mesenteric vein. Portal vein obstruction due to chronic liver disease, neoplasm, or postsurgery is a separate entity and is not the same as extrahepatic portal vein obstruction. Patients with extrahepatic portal vein obstruction are generally young and belong mostly to Asian countries. It is therefore very important to define portal vein thrombosis as acute or chronic from management point of view. Portal vein thrombosis in certain situations such as liver transplant and postsurgical/liver transplant period is an evolving area and needs extensive research. There is a need for a new classification, which includes all areas of the entity. In the current review, the most recent literature of extrahepatic portal vein obstruction is reviewed and summarized

Gastric varices: Classification, endoscopic and ultrasonographic management

Gastric varices (GV) are responsible for 10-30% of all variceal hemorrhage. However, they tend to bleed more severely with higher mortality. Around 35-90% rebleed after spontaneous hemostasis. Approximately 50% of patients with cirrhosis of liver harbor gastroesophageal varices. In this review, new treatment modalities in the form of endoscopic treatment options and interventional radiological procedures have been discussed besides discussion on classification and pathophysiology of GV

Plasma Proteomic Analysis Identified Proteins Associated with Faulty Neutrophils Functionality in Decompensated Cirrhosis Patients with Sepsis

Decompensated cirrhosis (DC) is susceptible to infections and sepsis. Neutrophils and monocytes provide the first line of defense to encounter infection. We aimed to evaluate proteins related to neutrophils functionality in sepsis. 70 (DC), 40 with sepsis, 30 without (w/o) sepsis and 15 healthy controls (HC) plasma was analyzed for proteomic analysis, cytokine bead array, endotoxin, cell free DNA and whole blood cells were analyzed for nCD64-mHLADR index, neutrophils-monocytes, functionality and QRT-PCR. nCD64-mHLADR index was significantly increased (p p = 0.045). Phagocytic activity of both neutrophils and monocytes were significantly decreased in sepsis (p = 0.002 and p = 0.0003). Sepsis plasma stimulated healthy neutrophils, showed significant increase in NETs (neutrophil extracellular traps) and cell free DNA (p = 0.049 and p = 0.04) compared to w/o sepsis and HC. Proteomic analysis revealed upregulated- DNAJC13, TMSB4X, GPI, GSTP1, PNP, ANPEP, COTL1, GCA, APOA1 and PGAM1 while downregulated- AHSG, DEFA1,SERPINA3, MPO, MMRN1and PROS1 proteins (FC > 1.5; p < 0.05) associated to neutrophil activation and autophagy in sepsis. Proteins such as DNAJC13, GPI, GSTP1, PNP, ANPEP, COTL1, PGAM1, PROS1, MPO, SERPINA3 and MMRN1 showed positive correlation with neutrophils activity and number, oxidative burst activity and clinical parameters such as MELD, MELD Na and Bilirubin. Proteomic analysis revealed that faulty functionality of neutrophils may be due to the autophagy proteins i.e., DNAJC13, AHSG, TMSB4X, PROS1 and SERPINA3, which can be used as therapeutic targets in decompensated cirrhosis patients with sepsis