Abstracts Presented at Midterm TNISG 2024 Meeting Held on 19th and 20th October 2024 at Courtallam
Gastroenterology Hepatology and Endoscopy Practice · 2024
Optimizing Re-treatment Approaches for Chronic Hepatitis C In Chronic Kidney Disease Patients after First-line DAA Failure R. Kishwanth, M. Kannan, R. Ramani, C. Vijai Shankar, P. B. Sriram Department of Medical Gastroenterology, GRH, Madurai, Tamil Nadu, India Introduction: Chronic hepatitis C (CHC) infection presents a formidable treatment challenge in chronic kidney disease (CKD) patients, particularly those undergoing hemodialysis. Despite demonstrable sustained virological resposone (SVR) rate >95% in the general population and the proven efficacy and safety of Direct acting antiviral (DAAs) in CKD, there exists a noticeable gap in the data regarding treatment failure and subsequent retreatment strategies for CKD patients who initially underwent first-line DAA therapy. Objectives: The objective is to investigate CHC treatment failure in CKD patients. To assess the outcomes of retreatment using an alternative first-line DAA. Methods: A retrospective screening of CKD patients with CHC infection, including both those on hemodialysis and those without, who received first-line DAA from August 2021 to June 2023 was done. We identified 30 cases of treatment failure with Sofosbuvir + Daclatasvir. Predictive factors for failure were evaluated. Subsequent retreatment with Sofosbuvir + Velpatasvir was initiated and clinical outcomes were documented. Results: Of 309 patients, 200 successfully completed DAAs, but 30 (1 decompensated chronic liver disease and 2 not on maintenance hemodialysis) did not achieve SVR. They received Sofosbuvir + Velpatasvir for 24 weeks. Baseline characteristics, pre- and post-retreatment laboratory parameters were recorded for the analysis. CKD Cohort Characteristics: Treatment details: Total number of patients treated 309, patients exposed to Sofosbuvir + Daclatasvir 309; demographics: Total treatment failed patients 30, females 10 (33.3%), males 20 (67%), median age 42 (35–62); disease properties: Patients on MHD 28, no of decompensated chronic liver dsiease (DCLD) 1. Biochemical Characteristics of Treatment Failed Patients: Laboratory parameters: Mean HCV RNA load −1366713, genotype-3 21, genotype 1 9, hemoglobin (g%) 9.6 (7.11–12.09), platelets (x 103 cells/cu.mm) 186 (103–269), total bilirubin (mg%) 0.74 (0.14–1.3), aspartate transferase (IU/L) 39.9 (13.5–66.3), alanine aminotransferase (IU/L) 45.5 (5.5–85.5), creatinine (mg%) 5.3 (2–8.6), albumin (g%) 3.6 (3–4.2); fibrosis markers (non invasive test, NIT) : FIB-4 1.52 (0.62–2.42), and APRI0.59 (0.1–0.99). Discussion: Treatment failure: 15%, linked predominantly to genotype 3. Key Predictor: Pretreatment thrombocytopenia-significant (odds ratio 4.08, 95% confidence interval 2.9–5.74). Other predictive factors: Nonadherence to DAAs during hemodialysis, Type 2 diabetes, high APRI and FIB-4 values. Drug interactions: None, observed with CKD medications. Retreatment Success: Sofosbuvir + Velpatasvir achieved 100% SVR in 28 patients. Challenges: Despite success, 2 patients succumbed to CKD-related complications, highlighting dual challenges in Hepatitis C management within CKD. Limitations and scope for future studies: Small sample size, Genotyping to be done before first treatment, RAS not done due to resource constraints, EVR to be done to differentiate reinfection and treatment failure, HD unit-related factors to be considered, cutoff values for liver stiffness in CKD cohort. Conclusion: Our study reveals a 15% treatment failure rate in CHC patients with CKD, primarily influenced by pretreatment thrombocytopenia, elevated liver enzymes, high FIB-4 and APRI scores, genotype 3, and nonadherence to drugs during the dialysis. Retreatment, by switching to another first-line pangenotypic DAA regimen, yields high SVR rates across genotypes. The outcomes underscore the efficacy of retreatment in CKD cohort who experienced prior DAA failure, demonstrating success within resource limitations. A Rare Case of Plummer Vinson Syndrome in a South Indian Male G. Subburathinam Gopalan, R. Ramani, M. Kannan, P. B. Sriram, C. Vijai Shankar Department of Medical Gastroenterology, Government Rajaji Hospital, Madurai, Tamil Nadu, India Introduction: Plummer Vinson syndrome is a premalignant condition of still unclear etiology triad of dysphagia, iron-deficiency anemia, and esophageal webs. It is more commonly seen in middle-aged females. Only a handful of cases have been reported in males worldwide. We present the rare case of PVS in a South Indian male. Case Report: A 52-year-old patient with no known comorbidities, presented with gradually progressive, Grade I to II dysphagia, easy fatigability for 1 year. Pallor (+), angular stomatitis (+), glossitis (+) koilonychia (+). Endoscopy: Upper gastrointestinal (GI) endoscopy: Postcricoid membranous lesion (+) → web → dilatation done, postdilatation study: Pale mucosa of stomach, D2 normal appearance, representative biopsies taken, Colonoscopy: Normal mucosal vascular pattern up to cecum; Biopsies were taken from the ruptured web and from the second part of duodenum and sent for histopathological examination. (1) Web showed epithelial atrophy, inflammatory, and fibrotic changes (2) duodenum showed changes of chronic nonspecific inflammation. Pre- and postdilatation of postcricoid web. Plummer Vinson syndrome: Features of iron-deficiency anemia, dysphagia, esophageal web, and no other identifiable cause of blood loss. Discussion: Plummer Vinson Syndrome – a premalignant condition, proper epidemiological data still not available, exact etiology not known till date, more common in the reproductive age group females due to iron deficiency caused by menstruation and nutritional deficiency, only a handful of cases of males affected have been reported worldwide, most of them from India, diagnosed by typical history, features of iron deficiency, imaging and endoscopic studies. Proposed Mechanism: Iron deficiency → Iron deficiency → Oxidative damage → mysathenic changes → Web formation → Epithelial atrophy → in deglutitive muscles. Patient was treated with iron supplementation and is on follow-up and has symptomatic improvement. Conclusion: This case illustrates quite a rare presentation of Plummer Vinson syndrome in a South Indian male. This disease should be a diagnostic consideration even in males presenting with dysphagia and iron deficiency anemia as it has a malignant potential. Spontaneous Muscle Hematoma: A Rare Complication in Chronic Liver Disease B. Javeed Ziyavudeen, M. Kannan, R. Ramani, C. Vijai Shankar, P. B. Sriram Department of Medical Gastroenterology, GRH, Madurai, Tamil Nadu, India Introduction: Liver cirrhosis is linked to hemostatic changes, leading to both bleeding and thrombosis risks. Advanced liver disease increases the likelihood of these complications due to factors such as decreased coagulation factors, thrombocytopenia, variceal bleeding, and platelet dysfunction. Primary hyperfibrinolysis is also associated with intramuscular hematomas in such cases. Common bleeding sources include gastroesophageal varices and nonvariceal such as and cases of in liver cirrhosis We present the case of in a patient with liver Case Report: A with a of presented with and and was diagnosed with decompensated chronic liver disease and liver failure including the and the the patient of the the and thrombosis were initially imaging a screening showed esophageal A vascular and the patient was treated with and leading to the of the This case a rare of due to the and treatment with hematomas in such patients. blood Liver with – Discussion: Muscle hematomas known to in with those on with the and the most commonly affected also the of intramuscular bleeding in patients with liver hemostatic Primary and Primary is due to a in platelet number and with seen in up to of patients. in is affected by and of and factors, leading to a as these patients to thrombosis bleeding, on the is also in with decreased of and and due to Treatment of bleeding associated with hyperfibrinolysis in these patients is primarily blood and the of Conclusion: Spontaneous is a rare of liver disease and hyperfibrinolysis is a common We successfully diagnosed and treated patient with an to A Rare Case of as Liver Failure R. Department of Medical Gastroenterology, Medical Tamil Nadu, India and is a caused by the is of of and nonspecific The in the and treatment of to the of complications such as kidney from to in patients. We the rare case of a patient with presenting as liver failure Case A with a of in comorbidities, presented with for 10 for before was high The was in The patient 2 before no of blood of and chronic before and after the patient was of the showed liver markers and were but for for by the the patient was treated for liver was on for after The patient gradually and with the of liver as in + with in of with Results: of liver is common in but liver failure is reported in Conclusion: and management with to In a such as India, should be done in patient with liver the of Rare Department of Tamil Nadu, India Introduction: Rare present with gastrointestinal diagnostic and Syndrome such diagnostic and management in syndrome is a rare of Type 1 liver leading to a with presents primarily with chronic due to syndrome is a by and including in the and Case syndrome diabetes, 9, C Liver nutritional screening for liver and Case 2 – syndrome for and Case syndrome is of and with for Conclusion: The gastrointestinal of and Syndrome for the and management of these rare syndrome presents with the of the liver and gastrointestinal the of a in and A Rare Case of with Department of Medical Gastroenterology, Medical and Hospital, Tamil Nadu, India and in is rare and the present the rare case of with Methods: A known case of chronic liver hepatitis C was with and In of was done in the of the liver with done in of and was done showed in the and were Results: in is seen in of patients and is a rare but It a The most and and and in It cause with is seen in of the should be a patients presents with of of for and The in a Case of P. R. of Medical Gastroenterology, Medical Tamil Nadu, India Introduction: A known case of presented with to and by A of A known case of diagnosed the age of the follow-up with of and was diagnosed with of treated 2 presented with of of Case Indian with and and with Liver was within normal general treated for to have was as case of as imaging and were in → was with and nutritional in a a the of study to were identified 1 of C C is is of of to common in chronic Discussion: 1 in present in the second in and the most with an for the most common is Conclusion: is the first is in these the in the of in using endoscopic and Liver – of Medical Tamil Nadu, India hepatitis is a rare liver a liver in to a It for of hepatitis cases and of liver We present the case of initially as and alternative liver Case Report: A no comorbidities, not an no no symptomatic for 2 progressive, in the of for for before the of and 1 2 prior to and liver disease and were done. of on Liver parameters not the liver done with and with of was on by It is to differentiate and in patients who present with of is the to the and liver Disease and the P. Department of Medical Gastroenterology, and Madurai, Tamil Nadu, India Introduction: disease a chronic is by of the leading to a of including and loss. gastrointestinal is associated with complications, of the most an of including and thrombosis is more commonly associated with it also in The in from blood during and the of factors with the coagulation and the of a and in complications, in patients. case Case A thrombosis and diagnosed with disease Case A with thrombosis after with Case A initially with and after of treated with and an Case A diagnosed with and was to have and chronic of cases the for regarding in patients, the of and treatment to the Discussion: The disease and is chronic and and management in affected is to the and In is associated with an of in patients with This and an of the of in the maintenance of in is associated with a in the of with who have a in with with treatment with only a is associated with a in for with and was associated with the for as of to the for of FIB-4 and in the for – A P. Department of Medical Gastroenterology, Hospital, Tamil Nadu, India and Patients with liver fibrosis undergoing an of liver is to these risks. for fibrosis of liver in is not The of study was to the and of FIB-4 in liver fibrosis to in patients undergoing such as and Methods: This was a retrospective study a in The patients were August 2023 and August 30, Patients who liver liver on were in with diagnosed liver cirrhosis and failure were Patients with high liver underwent FIB-4 was using the Results: the study patients who were in the for for other were fibrosis and in In cases FIB-4 has diagnostic as to A total of patients with FIB-4 fibrosis and with fibrosis and was in patients and for of patients who underwent did not have liver Conclusion: FIB-4 high diagnostic in to in the for with FIB-4 of patients with with a FIB-4 is a alternative is to assess and patients before Case of Spontaneous R. R. of and Liver Hospital, Tamil Nadu, India for and the treatment of thrombosis and complications associated with and Patients on with have presentation of bleeding of is to be on the It a rare therapy. is in males and the age presentation is with most common cause and the is affected in up to of cases. The is to of and invasive on these patients. Case Case and ratio and Case and and and Case and 10 and Discussion: The triad of of the and is of and present in up to of the cases due to The of is It is seen in most in the in the and The in hematomas in hematomas with an of The of was to be was in the of in of associated with in on study done by is of to an the is after due to and cause gastrointestinal and in patients. with the of imaging is as be to a in most patients. in Chronic Liver Disease – A Rare P. R. of Medical and Gastroenterology, of Medical and Tamil Nadu, India Introduction: of the a rare and the hematomas caused by on We the case of of in a chronic liver disease patient caused by Case Report: A 52-year-old who was a known case of cirrhosis of presented to with of for was diagnosed with Grade and was treated with blood and other liver the of blood were done from median to with and was the of the showed with in the of of the and a in the We a of of the with underwent was was and was done. of was for and was Results: In a rare of a common to Our patient a of with and coagulation to Conclusion: This case illustrates the of in chronic liver disease patients, who of and in the as a of in Patients with Chronic Liver Disease Department of Medical Gastroenterology, Medical and Tamil Nadu, India and is a of chronic liver disease It is and in the has and of is To assess the of in using and to and to is using as a of with etiology of and It is a study Medical from 2023 to August The study patients with The patients with anemia, and with complications of – were taken an interval of 10 and was was done by were using the were presented as the of and was done. Results: The number of patients with is 28 patients with were C the follow-up 28 patients Mean in group is a is not predictive of of males of females The age group with was those patients with C patients with liver disease to patients with liver disease who in the group was not from those be as a of It of a population and the not be It is the for the of is was not done. was not to in the of in and with of Disease Department of Medical Gastroenterology, Medical and Hospital, Tamil Nadu, India and ratio is a to inflammation. a in the of liver be as a to the of in patients with chronic liver disease To as a of in and of with of on for liver Methods: It is an study Medical from June 2023 to The study 200 patients with Baseline and were and patients were up for to assess for cirrhosis were using and were and for and were was and was We the and of to the the of patients Patients who complications a of liver disease and were also in those who of the patients who complications was to in those who did not with a cutoff a of and of and of were and a and and and be as a to the cirrhosis of the with was not was only during the of Patients with Upper and in the Department of Medical Gastroenterology, Medical and Tamil Nadu, India and Upper gastrointestinal is a to a rate of 15% and rate of of is the to the To study the clinical of patients with nonvariceal To the efficacy of and in It is an study Medical from June 2023 to The study patients presenting with nonvariceal Patients with variceal and those not for were the clinical of the patient the of blood of and disease to were to for blood and of were Patients were up for 1 to assess the of and were were using the test, exact test, using the was to the cutoff to the and of to the clinical Results: the patients with nonvariceal were and were age was and presented as of patients and is in of and for has no with both and as of for The of to patients leading to and of population and the not be was not to – The for the of Department of and Government Medical Tamil Nadu, India Introduction: is a rare but cause of in It a diagnostic challenge it is in of more common such as and This case the in these common Case Report: A presented with of of for the was of is not a no features of and there was no The patient was with and condition and was with follow-up for Discussion: is a syndrome of leading to chronic should be in patients with of for common The most common in and 1. more known for with but also a in The is for Patients with an of chronic and for to assess and In of patient the cause in a This for the of chronic and to complications, such as diabetes, and chronic The of also an for to the of the disease and for future including on Conclusion: This case illustrates the in in patients with no etiology for The such as the of In a and both the patient and of the Case of M. G. Department of and Government Medical Tamil Nadu, India Introduction: is as more of with Common and to chronic damage not Case A with a known of and both with presented with of to the by – diagnosed with not of and was Normal a of the of of Discussion: present in patients with other is not associated with with a of Treatment A invasive due to the Conclusion: should be in patients with is an for the of management with is an invasive alternative to of in a Patient with G. B. P. Department of Medical Gastroenterology, for Medical Tamil Nadu, India Introduction: is a rare of with an of for diagnostic and for We present the case of a with in during diagnostic and successfully to Case Report: A patient with follow-up for 2 was for diagnostic in of of chronic been on and was to the and on and showed and mucosa with and bleeding the and during of the a in the was and the was done after showed the of the and features of was but not of the of the the and of The was and In with the was and treated with and after 24 showed interval in and a of the of the with The patient was as to another was treated with with of with after 2 with of a normal another 2 weeks. was initially on and and were subsequent follow-up to 2 has of a from the to and and has been treated in with Discussion: factors: patients albumin the of comorbidities, of and disease patients treated with and during of during diagnostic screening endoscopic be due damage to common in and a due to common in and presentation on size, of and general treatment treatment is for and be to Conclusion: factors for in disease and include formation in the the Treatment on of of of and of the the Patients with and and of A Department of Medical Gastroenterology, Medical and Tamil Nadu, India Introduction: is a common gastrointestinal by It be and be is associated with particularly in such as in and has a on the of of be by disease of To assess the using in patients and the across by Methods: A study was Medical patients who underwent gastrointestinal were on for using a test, and was using the and Discussion: Results: (1) The and from patients a of general were in and and high (2) Patients with more in and to those with in was patients showed rates of in and but no in to Discussion: The of and the of both and on of with more infection was in patients, leading to outcomes such as and such as and inflammation. A high reported and The and underscore the for management particularly of patients experienced more in Conclusion: is associated with due to the high of gastrointestinal and and were more in these patients. is for the outcomes in the complications such as and patients experienced in of and with and more should on and for both should also and and The of on leading to of the of for in as a of treatment Case of R. Department of Medical Gastroenterology, Medical Hospital, Tamil Nadu, India Introduction: is an infection be in patients. infection is We present the case of invasive gastrointestinal Case Report: We the case of a patient in with and treated with and who presented with a of bleeding, and showed Total platelet and a of was the of and and antiviral were initiated due to with and was treated as associated Despite treatment with and in blood the patient to and and was for were and with in the and showed and a from the to the Biopsies were reported as invasive Patient and did not for Treatment was to due to kidney to have and a showed a leading to and was with Discussion: part of the gastrointestinal with the the most commonly affected part by the and the and gastrointestinal bleeding and common of gastrointestinal is due to nonspecific endoscopic is to features include and changes of the mucosa with associated with and thrombosis in the and be with with of and on with the and changes caused by the of include bleeding, and is in gastrointestinal and is to the disease and for an rate is as high as This case illustrates a rare of caused by invasive and the of in patients presenting with gastrointestinal – of Shankar, Department of Medical Gastroenterology, of Medical and Tamil Nadu, India Introduction: is a rare and infection caused by is more common in the other of the and the from to 15%, with more commonly affected the present such rare cases of Case A with prior of and presented with and for 1 was and general condition but there was a in Upper gastrointestinal showed with seen in the the in the the and Biopsies from the showed mucosal by and and with and also Case A 52-year-old with a prior of chronic kidney disease and presented with and of for 10 in the with of the showed with in the with showed seen in the was of was Conclusion: is a rare most commonly in but is in the patients. regarding is in and in the high Case of in Patient of Medical Tamil Nadu, India syndrome is seen in with infection, and after Patients to The of in of Case Report: A diagnosed with chronic liver liver disease underwent liver Patient was on and and to the patient by of with treated with was with and was to the on Conclusion: The of in patient should be in the patient on and for and clinical Rare of Department of Medical Gastroenterology, of Medical and Tamil Nadu, India Introduction: the of the in from liver with nonspecific changes to for liver in due to liver from to and with damage as a of the liver from failure, liver and liver and A with no known and no presented with of of and gradually progressive, associated with and 2 of before of of of has in 1 with normal also of general the patient (+), no (+) was normal not not and no blood showed showed pattern of ratio with were was and were were for showed (1) including Hepatitis A and Hepatitis (2) Liver were was Normal and was was showed normal was was of with To for alternative a liver was It showed features of and Discussion: The of associated on and of other more common of the cause of was Conclusion: drugs were the patient was treated with and The patient showed a with in and of and after 1 of was treated with therapy. follow-up showed in bilirubin of in a Common A R. Department of Tamil Nadu, India Introduction: The of anemia in is is of the for anemia due to gastrointestinal It is in of the patients undergoing and only Case A presented with