BackgroundLiver injury due to dengue viral infection is not uncommon. Acute liver injury is a severe complicating factor in dengue, predisposing to life-threatening hemorrhage, Disseminated Intravascular Coagulation (DIC) and encephalopathy. Therefore we sought to determine the frequency of hepatitis in dengue infection and to compare the outcome (length of stay, in hospital mortality, complications) between patients of Dengue who have mild/moderate (ALT 23-300 IU/L) v/s severe acute hepatitis (ALT > 300 IU/L).MethodsA Cohort study of inpatients with dengue viral infection done at Aga Khan University Hospital Karachi. All patients (≥ 14 yrs age) admitted with diagnosis of Dengue Fever (DF), Dengue Hemorrhagic Fever (DHF) or Dengue Shock Syndrome (DSS) were included. Chi square test was used to compare categorical variables and fischer exact test where applicable. Survival analysis (Cox regression and log rank) for primary outcome was done. Student t test was used to compare continuous variables. A p value of less than or equal to 0.05 was taken as significant.ResultsSix hundred and ninety nine patients were enrolled, including 87% (605) patients with DF and 13% (94) patients with DHF or DSS. Liver functions tests showed median ALT of 88.50 IU/L; IQR 43.25-188 IU/L, median AST of 174 IU/L; IQR 87-371.5 IU/L and median T.Bil of 0.8 mg/dl; IQR 0.6-1.3 mg/dl. Seventy one percent (496) had mild to moderate hepatitis and 15% (103) had severe hepatitis. Mean length of stay (LOS) in patients with mild/moderate hepatitis was 3.63 days v.s 4.3 days in those with severe hepatitis (P value 0.002). Overall mortality was 33.3% (n = 6) in mild/moderate hepatitis vs 66.7% (n = 12) in severe hepatitis group (p value < 0.001). Cox regression analysis also showed significantly higher mortality in severe hepatitis group (H.R (4.91; 95% CI 1.74-13.87 and P value 0.003) and in DHF/DSS (5.43; CI 1.86-15.84 and P value 0.002). There was a significant difference for the complications like Bleeding (P value < 0.001), Acute Renal failure (ARF) (P value 0.002), Acalculus cholecystitis (P value 0.04) and encephalopathy (P value 0.02) in mild/moderate and Severe hepatitis groups respectively.ConclusionSevere hepatitis (SGPT>300IU) in Dengue is associated with prolonged LOS, mortality, bleeding and RF.

In order to determine whether obstructive pancreatobiliary lesions increase the risk of duodenal erosions and ulcers, the duodenal mucosa of patients with these lesions were prospectively examined before endoscopic retrograde cholangiopancreatography (ERCP). During the study period, 133 patients underwent ERCP for various reasons in the Department of Medicine, The Aga Khan University Hospital. One hundred and twenty-three patients were eligible for final analysis. Sixty-five patients with bilirubin > or = 35 mumol/L and alkaline phosphatase > or = 2.5 times normal levels along with radiological evidence of pancreatobiliary obstruction were included in the obstruction group. Fifty-eight patients who did not fulfil these criteria were used in the control group. Acid peptic lesions, which included erosions and ulcers, were seen in 16 patients of the obstruction group and four patients of the control group (P = 0.016, odds ratio (OR) = 4.41). Patients with carcinoma of the pancreas had a greater number of lesions than the rest of the obstruction group (P = 0.001, OR = 8.75). Individual variables like age, sex, serum bilirubin, alanine aminotransferase, alkaline phosphatase, amylase levels, and duration of jaundice did not increase the vulnerability to acid peptic injury. The degree of obstruction multiplied by duration of jaundice (alkaline phosphatase x days) increased the susceptibility for duodenal disease (P = 0.047). From this data it was concluded that patients with obstructive pancreatobiliary lesions are more prone to acid peptic duodenal lesions.