Case Report: Management and Outcomes of COVID-19 in a Patient with Cirrhosis of Liver

Introduction: The outbreak of coronavirus disease 2019 (COVID-19) has recently become a major problem affecting thousands of individuals around the world. It is understood that a significant proportion of patients infected with COVID-19 have disturbed liver function tests. This is a case report of a patient with liver cirrhosis and COVID-19. Presenting Complaints and Investigations: A 39 year old female patient was admitted in AVBRH on 06/02/2021 with chief complaint of distension of abdomen, breathlessness, shortness of breath, reduced urine output over last 3 months. She had skin lesions over the hand, foot, abdomen and back with itching since 4 months. Physical examination, blood investigations and abdominal ultrasound showed cirrhosis of liver with gross ascites seen clinically. She had mild splenomegaly and gall bladder was enlarged. Laboratory tests showed elevated total bilirubin level. In peripheral blood examination, RBC count was low (3.66m/cu mm), Haemoglobin level was 8.2 gm/dl, Platelets count was low (1.19 lakh per cu. mm). WBC count was 3600 cu mm. Doctor diagnosed this as the case of cirrhosis of liver with pemphigus vulgaris with COVID-19. Past History: 6 months ago, patient was admitted in Aarogyadham hospital Yawatmal with chief complaint of abdominal pain, loss of appetites, fever. On ultrasonography, she had splenomegaly for which she took the treatment. The Main Diagnosis, Therapeutic Intervention and Outcomes: This case was diagnosed as a case of COVID-19 with Cirrhosis of liver. Interferon alpha 2b solution was given for 10 days to help improve the immunity. Tab. Ursoldiolis (ursodeoxycholic acid) was used to dissolve gallstones. Conclusion: Good clinical assessment, appropriate care, good nursing care by trained nurses and appropriate treatment can save lives even in complicated COVID-19 infected cases.

An unusual case of hemoptysis secondary to Abernethy malformation type II and hepatopulmonary syndrome, pulmonary arterial hypertension

A twenty years old male college student came with history of hemoptysis. His chest X-ray showed diffuse infiltrative shadows and he was diagnosed as a case of a case of pulmonary tuberculosis with hemoptysis. On detailed investigations he was found to have Abernethy malformation Type-II with primitive portal vein joining extrahepatic inferior vanacava leading to cirrhosis of liver, porto-pulmonary syndrome, pulmonary arterial hypertension and hemoptysis.

IL-6 and IL-10 gene polymorphisms and cirrhosis of liver risk from a comprehensive analysis

Background Different inflammatory and immune cytokines play a key role in the development of cirrhosis of liver (CL). To investigate the association between interleukin-6,10 (IL-6,10) genes polymorphisms and CL risk through comparison of the allele and genotype distribution frequencies by meta-analysis. Methods A literature search covered with the PubMed, Embase, Cochrane Library, Web of Science, Google Scholar, SinoMed (CNKI and Wanfang) through 20th April, 2021. Odds ratios (OR) and 95% confidence intervals (CI) were used to assess the strength of associations. Results After a comprehensive search, three common polymorphisms (rs1800872, rs1800871, rs1800896) in IL-10 gene were selected, and three common polymorphisms (rs1800795, rs1800796, rs1800797) in IL-6 gene were also identified. The important finding was that IL-10 rs1800872 was a risk factor for CL development. For example, there has a significantly increased relationship between rs1800872 polymorphism and CL both in the whole group (OR: 1.30, 95%CI: 1.01–1.67 in heterozygote model), Asian population (OR: 1.40, 95%CI: 1.03–1.88 in heterozygote model) and hospital-based source of control (OR: 1.40, 95%CI: 1.01–1.96 in dominant model). In addition, significant association was found between rs1800896 and primary biliary cirrhosis subtype disease (OR: 1.30, 95%CI: 1.01–1.68 in allelic contrast model). No association was observed in all three polymorphisms in IL-6 gene. Conclusion Our present study suggests that the IL-10 rs1800872 and rs1800896 polymorphisms is potentially associated with the risk of CL susceptibility.

Case Report on Cirrhosis of Liver

Liver is the second largest organ in human body, more than 5,000 separate bodily functions .including helping blood to clot, cleansing the blood of toxins to converting food into nutrients to control hormone levels, fighting infections and illness, regenerating back after injury and metabolizing cholesterol, glucose, iron and controlling their levels. A 56- years old patient was admitted in AVBRH on date 9/12/2020 in ICU with the chief complaint of abdominal distension, breathlessness on exertion, pedal edema, fever since 8 days. After admitted in hospital all investigation was done including blood test, ECG, fluid cytology, peripheral smear, ultrasonography, etc. All investigation conducted and then final diagnosis confirmed as cirrhosis of liver. Patient was not having any history of communicable disease or any hereditary disease but he has history of hypertension and type II Diabetes mellitus for 12 years. Patient was COVID-19 negative and admitted in intensive care unit. Patient had been undergone with various investigations like physical examination, blood test, CSF fluid examination, ascitic fluid examination, fluid cytology, peripheral smear, ultrasonography, RT-PCR etc. Patient was treated with tab. farobact ER 300 mg BD, tab. Lasix 40 mg OD, tab. Udilive 300 mg BD, tab. Rifagut 300 mg BD, tab. Metformin 500 mg OD, tab. Amlo 5mg OD, syp. Duphalac 30ml HS. Monitor vital signs, maintain input output, Monitoring and managing potential complications like, bleeding and haemorrhage, hepatic encephalopathy, fluid volume excess, monitor laboratory tests as indicated, Identify and assess for pedal edema. Conclusion: Cirrhosis of the liver is one of the final stages of liver disease. It is a serious condition, causing scarring and permanent damage to the liver. Life expectancy depends on the stage and type of cirrhosis of liver. Cirrhosis progresses, more and more scar tissue forms, making it difficult for the liver to function (decompensated cirrhosis). Advanced cirrhosis is life-threatening. If liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and, rarely, reversed.

Peptic Ulcer Diseases in Patients with Liver Cirrhosis and Portal Hypertension: Experience in a Tertiary Level Hospital in Bangladesh

Introduction: Cirrhosis of liver and peptic ulcer disease (PUD) are very common in Bangladesh. PUD may coexist with cirrhosis and portal hypertension. Haematemesis and melaena in cirrhosis of liver are not always from ruptured oesophageal varices; rather it may be due to bleeding peptic ulcer disease. Objective: To find the prevalence of PUD among patients with liver cirrhosis and portal hypertension. Materials and Methods: This cross sectional, descriptive study was conducted on 96 patients of cirrhosis of liver diagnosed with oesophageal varices at endoscopy unit of Kurmitola general hospital, during endoscopic evaluations in 4 months period from september 2017 to december 2017. Results: Total cirrhotic patients enrolled were 96 (M=61, F=35), mean age was 51.8 ± 14.2 yrs (18-86years). Hepatitis B virus (HBV) was the leading cause of cirrhosis in 54.1%, Hepatitis C virus (HCV) 5.2 %, proven non-alcoholic steatohepatitis (NASH) were 11.5% and rest were from unknown aetiology. Their average Child-Turcotte-Pugh (CTP) score were 8.6 (12-5), 37.6% associated with portal hypertensive gastropathy. Grade-III oesophageal varices found in 52 patients, whereas grade-II in 25 patients. Among this 96 patients 39 (40.6%) revealed peptic ulcer disease more in the form of gastric ulcer (n=23) than duodenal ulcer (n=10) and both (n=6). Most of the ulcers belonged to Forrest class III (76.9%). Conclusions: Variceal bleeding and portal hypertensive gastropathy are the common causes of bleeding and anaemia in patients with cirrhosis of liver. Peptic ulcer disease has been found to be one of the potential causes of haematemesis, melaena, and anaemia among these patients in Bangladesh. Large multicenter controlled studies are needed to confirm the reports. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 68-71

Correlation between Serum-Ascites Albumin Gradient and Esophageal Varices in Portal Hypertension due to Cirrhosis of Liver

Introduction: Cirrhosis of the liver is a major health problem in our country. Patients with cirrhosis are at risk of developing esophageal varices and variceal bleeding with high mortality. They must undergo routine upper gastrointestinal endoscopy to screen for the presence of varices. This poses an economic, social, and medical burden. Thus, this warrants a non-invasive predictor of esophageal varices in a cirrhotic patient. The aim of this study was to find the correlation between SAAG and esophageal varices in portal hypertension due to cirrhosis of liver. Methods: Patients (45 males and 35 females) above 18 years of age and with cirrhosis of the liver underwent cross sectional observational study at Nepal Medical College Teaching hospital between October 2015 and December 2017 AD. Serum albumin and ascitic fluid albumin were analyzed on the same day and serum-ascites albumin gradient (SAAG) was calculated. Upper GI endoscopy was done to evaluate for the presence of esophageal and gastric varices. Pearson's chi-square test was applied to see the relation between SAAG and esophageal varices. Results: Among the 80 patients studied, 56.2% were male and 93.75% had varices. Majority of the patients who had esophageal varices had SAAG of more than 1.1 g/dL. A positive correlation was found between serum-ascites-albumin gradient and esophageal varices but was statistically not significant. A cut-off of >1.6 for SAAG to discriminate between presence and absence of varices yielded a sensitivity of 78.66% and a positive predictive value of 92.18%. Conclusion: This study highlighted that SAAG has a positive correlation with esophageal varices with high sensitivity and positive predictive value in estimating the presence of varices but without statistical significance. It has a low specificity. Due to statistically insignificant correlation and low specificity, SAAG cannot be used in place of upper GI endoscopy in diagnosing gastroesophageal varices

Frequency of Vitamin D deficiency in liver cirrhosis and its correlation with Child Pugh Score

Objective: To determine the frequency of vitamin D deficiency in patients with liver cirrhosis and the relationship of vitamin D deficiency with Child Pugh Class in patients with cirrhosis. Materials and Methods: Vitamin D and calcium levels were checked in patients with cirrhosis of liver aged 18 to 80 years admitted in Gastroenterology department of Lahore General Hospital. Investigations were also done to calculate Child Pugh (CTP) score and Child Class was assigned on the basis of score. Quantitative variables were expressed in terms of mean and standard deviation. Frequency and percentage were used for qualitative measures. The p-value was calculated by the contingency coefficient to find a relationship of vitamin D levels to CTP scores of liver cirrhosis. Data was analyzed using SPSS 24 Study Duration: The study was carried out from December 2019 to October 2020 Results: A total of 170 patients with mean age of 43.82 ± 9.72 (19-61) years were evaluated of which 144 (84.7%) were males, 26 (15.3%) were females. Vitamin D3 deficiency was found in 144/170 (84.7%) patients while insufficiency was found in 14/170(8.2 %). It was more common in male patients (86.1%) compared to female patients (76.9%). Mean vitamin D3 levels was 14.4 ± 9.4 ng/ ml. Patients with Child A cirrhosis 6/10 (60%) had deficiency, with child B 66/82 (80.5%) while with Child C 72/78 (92.3%) had deficiency of Vitamin D3. Conclusion: Vitamin D deficiency is common in patients with cirrhosis and level has decreased stepwise with higher Child Pugh Class. Keywords: Cirrhosis, Vitamin D, Child Pugh score

Study of Clinical Profile and Outcome of Metabolic Encephalopathy in Patients Admitted at HSK Hospital, Bagalkot, Karnataka

BACKGROUND Metabolic encephalopathy (ME) is one of the most frequently encountered and broadly defined diagnoses by the physicians in the intensive care setting. ME is a clinical state characterized by cerebral dysfunction in the absence of structural brain disease. The causes are many and often multifactorial. The purpose of study was to evaluate various causes, clinical profile, and outcome in patients with ME. METHODS This is a hospital based, observational, cross sectional study, conducted in ICU of Department of General medicine, S.N. Medical College, Bagalkot. Patients with head trauma, organic causes of altered sensorium, psychiatric conditions were excluded. RESULTS Mean age was 51.22 ± 17.24 years. Majority were males. Diabetes was the most common comorbidity found followed by cirrhosis of liver and hypertension. Septic causes were found to be the most common aetiology. 80.7 % recovered from the disease and death was noted in 19.3 % patients. CONCLUSIONS All the patients with ME had altered level of consciousness with fever being the most common symptom. Most of them were males, most common aetiology was septic cause, and recovery was seen in about 80.7 % of patients. KEYWORDS Metabolic Encephalopathy, Altered Sensorium, Sepsis

TO STUDY THE SEROPREVALENCE OF HEPATITIS C IN CASES OF ACUTE VIRAL HEPATITIS AND CIRRHOSIS OF LIVER

Background: Viral hepatitis is a global public health problem affecting millions of people worldwide. The main objective was to study the seroprevalence of hepatitis C in patients with acute viral hepatitis and cirrhosis of liver. Method: The study was carried out in the department of Medicine, Pt. J.N.M medical college and associated Dr B.R Ambedkar Memorial Hospital Raipur, Chhattisgarh from April 2002 to February 2003. Result: Maximum number of acute viral hepatitis cases were observed in the age group >24-34 years. Maximum numbers of cirrhosis of liver cases were observed in the age group > 44-54 years. There were 2 cases of acute viral hepatitis that tested positive for anti- HCV and both were males. There were 5 cases of cirrhosis of liver who were HBsAg Positive. Conclusion: HCV infection is quite prevalent in Raipur, Chhattisgarh and therefore, stresses the need for early detection so that further transmission could be prevented.