Vaccination against hepatitis A virus (HAV) has been recommended in patients with chronic liver disease to prevent any decompensation due to superinfection. This may not hold good in high endemic areas for hepatitis A like India. The aim of this study was to find out the seroprevalence of anti-HAV antibodies in patients with chronic liver disease and to justify the need for vaccination against hepatitis A virus in these patients. One hundred and thirty three consecutive patients with cirrhosis of liver attending Gastroenterology department of our Institute between June 2004 and June 2005 were enrolled. Seventy-five healthy persons were taken as controls. The diagnosis of cirrhosis was based on clinical profile, biochemical, radiological (ultrasound abdomen) and endoscopic findings. The etiology of cirrhosis was based on presence of viral markers, history of significant alcohol consumption, autoimmune and metabolic workup. All patients and controls were tested for antiHAV (total) antibodies using commercially available enzyme-linked immunosorbent assay kits. Data from patients and control group were compared by unpaired 't' test and Chi square test. All subjects were in the age group 11 to 75 years. Etiology of chronic liver disease was as follows: HBV- 29.3%, HCV - 14.28%, HBV+HCV dual -1.5%, alcohol- 21.8%, Cryptogenic -23.3%, Wilson"s Disease -1.5% and Budd chiari -1.5%. The prevalence of HAV was 93.2% in patients with cirrhosis of liver and 94.6% in controls. The prevalence was almost similar irrespective of the etiology. In view of high seroprevalence of HAV antibodies among cirrhotic patients in our study and the high cost of the vaccine, the hepatitis A vaccination may not be routinely required in this part of the world.

Hemorrhage from downhill varices is a rare manifestation. The etiology of downhill varices is due to superior vena cava obstruction while uphill varices are secondary to portal hypertension. We report a rare case of 55-year-old female with bleeding downhill varices not associated with obstruction or compression of superior vena cava, but was due to severe pulmonary artery hypertension secondary to chronic rheumatic heart disease. ( J CLIN EXP HEPA-TOL 2014;4:63-65) E sophageal varices are classified as downhill or uphill varices. Uphill varices are common, found at the lower end of the esophagus, extend upwards and develop as a consequence of portal hypertension. Downhill varices are rare, found at upper esophagus, extend downwards and usually develop due to superior vena cava obstruction. Very rarely they can develop due to pulmonary artery hypertension. We report a case presenting with upper gastrointestinal bleed from the downhill varices, which was also found to have uphill varices due to portal hypertension. The downhill varices in this patient were due to moderate pulmonary artery hypertension as a consequence of chronic rheumatic heart disease with severe mitral regurgitation, mild mitral stenosis and severe tricuspid regurgitation. CASE REPORTA 55-year-old female was admitted with repeated episodes of hematemesis and melena of 15 days duration. Patient was a diagnosed case of liver cirrhosis. General physical examination revealed pallor, raised jugular venous pressure, pedal edema and icterus. Her pulse was 82/min, regular and a blood pressure of 110/70 mmHg. Her abdomen was distended and shifting dullness was present. Cardiovascular examination revealed apical impulse in 6th intercostal space 2 cm outside mid-clavicular line, grade II parasternal heave, palpable pulmonary artery pulsations and palpable 2nd heart sound at parasternal 2nd left intercostals space, loud P2, opening snap and grade III/VI pansystolic murmur in mitral and tricuspid area. Respiratory and central nervous system examination were normal. On investigation her hemoglobin was 8 g/dL, platelet counts 0.76 lakh/mm 3 , TLC 7200/mm 3 with normal differentials, aspartate aminotransferase (AST) 40 U/L, alanine transferase (ALT) 41 U/L, alkaline phosphatase 150 mg/dL, total bilirubin 2.4 mg/dL with unconjugated fraction of 1.6 mg/dL, total serum proteins 6.2 g/dL, albumin 2.1 g/dL, prothrombin time 20 s, urea 19 mg/dL, creatinine 1 mg/dL, Na 143 meq/l and K was 3.7 meq/L. Her X-ray chest showed cardiomegaly, straightening of left heart border, findings suggestive of right atrium (RA) and left atrium (LA) enlargement, dilated pulmonary artery and superior vena cava (SVC) [ Figure 1]. Her ECG showed normal sinus rhythm with evidence of RA and LA enlargement with evidence of right ventricular hypertrophy (RVH) and left ventricular (LV) volume overload. Her serology was negative for ANA, HBsAg, anti HCV antibodies and HIV. On upper gastrointestinal endoscopy she had large varices 2 columns extending from post cricoid region downwards decreasing...

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When mice were infected with vaccinia virus via the tail vein, the number of lesions was influenced by the injection site. A site 3 cm from the base of the tail is of greatest practical value.