Dengue has emerged as an important arboviral disease with significant impact on the disease burden in population residing in tropical countries. Dengue is spread by the bite of Aedes mosquito. The virus seems to have some hepatotoxic effects. Affliction of liver in form of derangements in the liver function tests is common and may include mild elevations in serum bilirubin, elevated transaminases and derangements in serum albumin. Although asymptomatic in most cases, clinical manifestations like jaundice, and acute liver failure (ALF) may occasionally complicate the clinical picture. Indeed, dengue has been implicated as an important cause of ALF in endemic countries. The present review focuses on the hepatic manifestations and the pathogenesis of the liver injury in dengue.
Sleep disturbances are common in patients of cirrhosis and has a significant effect on their health related quality of life (HRQOL). Thus far, no study has demonstrated a systematically studied significant correlation between the sleep disturbance observed and the neuropsychiatric impairment status of patients of cirrhosis. On the basis of PHES, we divided 100 cirrhotics into those having minimal hepatic encephalopathy (MHE) (PHES≤-5) and those not (NMHE). Now, in these MHE (n=46) and NMHE (n=54) patients, sleep disturbance was measured with Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) and HRQOL with SF-36(v2) questionnaire. Sixty (60 %) patients were found to be 'poor sleepers' (PSQI>5) while 38 (38 %) patients had excessive daytime sleepiness (ESS≥11). Univariate and multivariate analyses showed MHE has significant effect among 'poor sleepers' (P<0.0001) as well as on those with EDS (P<0.0001). Significant correlation existed between PHES and both the sleep parameters of PSQI (r = -0.518, P <0.0001) as well as ESS (r = -0.383, P <0.0001), implying independently strong correlation between poor cognition and the presence of night time sleep disturbance and excessive daytime sleepiness among cirrhotics. Significant correlation existed between PSQI and ESS and the various scales and component scores of SF-36(v2) signifying the negative impact of sleep disturbance on the HRQOL. In conclusion, both night time sleep disturbance and excessive daytime sleepiness have significant relation with the neuropsychiatric impairment in patients of cirrhosis and are significantly associated with the observed impairment in HRQOL.
Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has led to a world-wide pandemic since its onset in December of 2019. Although, a primary respiratory pathogen, over the ensuing period, its extra-pulmonary effects have come to the forefront. The virus, having multi-organ tropism, has been shown to affect a host of other organs beyond the lung, including the pancreas. The data on pancreatic involvement by COVID-19, however, have been limited. Moreover, whether the effects on the pancreas are due to the direct effects of the virus or is just an epi-phenomenon is debatable. The prevalence of pancreatic injury and degree of injury are the other issues that need to be addressed. Pancreatic cancer has a dismal prognosis and the management of the same in the COVID era needs to be tailored assessing the risk-benefit ratio for the same. Additionally, pancreatic surgery increases not only the morbidity of the patient, but also the risk of the operator and burden on the health care system. Hence, the decision for such major procedures needs to be rationalized for optimum benefit during this pandemic. Similarly, for the endoscopist, pancreatic endoscopy needs to be carefully regulated to reduce risk to both the patient and the physician and yet deliver optimum patient care. This review gives a concise summary of various aspects of pancreatic involvement and pancreatic disease management during this pandemic.
Pancreatic fluid collections (PFCs) are seen in up to 50% of cases of acute pancreatitis. The Revised Atlanta classification categorized these collections on the basis of duration of disease and contents, whether liquid alone or a mixture of fluid and necrotic debris. Management of these different types of collections differs because of the variable quantity of debris; while patients with pseudocysts can be drained by straight-forward stent placement, walled-off necrosis requires multi-disciplinary approach. Differentiating these collections on the basis of clinical severity alone is not reliable, so imaging is primarily performed. Contrast-enhanced computed tomography is the commonly used modality for the diagnosis and assessment of proportion of solid contents in PFCs; however with certain limitations such as use of iodinated contrast material especially in renal failure patients and radiation exposure. Magnetic resonance imaging (MRI) performs better than computed tomography (CT) in characterization of pancreatic/peripancreatic fluid collections especially for quantification of solid debris and fat necrosis (seen as fat density globules), and is an alternative in those situations where CT is contraindicated. Also magnetic resonance cholangiopancreatography is highly sensitive for detecting pancreatic duct disruption and choledocholithiasis. Endoscopic ultrasound is an evolving technique with higher reproducibility for fluid-to-debris component estimation with the added advantage of being a single stage procedure for both diagnosis (solid debris delineation) and management (drainage of collection) in the same sitting. Recently role of diffusion weighted MRI and positron emission tomography/CT with (18)F-FDG labeled autologous leukocytes is also emerging for detection of infection noninvasively. Comparative studies between these imaging modalities are still limited. However we look forward to a time when this gap in literature will be fulfilled.
Background Opioids and non steroidal anti inflammatory drugs (NSAIDs) are commonly used for pain relief in acute pancreatitis (AP). Opioids carry risk of sphincter of oddi constriction. Although diclofenac prevents post endoscopic retrograde cholangio‐pancreatography (ERCP) pancreatitis, few reports of diclofenac associated AP are also present. Although, both tramadol and diclofenac are commonly used for pain relief in AP, no study has evaluated their comparative efficacy and safety. Materials and Methods Forty‐six eligible participants were randomized to either diclofenac or tramadol. Primary objectives of our study were improvement in pain intensity on visual analogue scale (VAS pain score after 1 hr of drug administration) and number of patients requiring supplementary analgesia. The secondary objectives were total number of times of supplementary analgesia requirement, time to significant decrease (33%) in VAS pain score from baseline, number of painful days (VAS pain score >5), VAS pain score on 7th day, side effects, all cause death and complications of pancreatitis between the two groups. Results Although 46 patients were randomized, the final analysis included 41 participants. Five patients were withdrawn from the study (intubation = 3, altered sensorium = 2). No significant difference was seen in terms of VAS score after 1 hr of drug administration, number of patients requiring supplementary analgesic and number of painful days. However, time taken to significant reduction of pain was lower in the diclofenac group (p = .028). Both the agents were comparable in terms of safety. Although complications were less in the diclofenac group, the difference was not statistically significant. Conclusion Both diclofenac and tramadol are equally effective in controlling pain in AP with similar safety profile. Significance There are no studies that have compared the safety and efficacy of two commonly used analgesics for pain relief in patients with AP. We found that both diclofenac and tramadol are equally effective in decreasing the pain associated with AP. There is also no significant difference in the incidence of side effects between both the groups. Hence both diclofenac and tramadol can be used safely and effectively for pain control in AP. Trial registration: The trial was registered with clinical trials registry India (Number‐ CTRI/2018/05/014309).
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