Speciality Reviews

  • 1. A to Z of hepatitis
  • 2. Treatment of hepatic coma
  • 3. Current Concepts in Treatment of Inflammatory Bowel Diseases
  • 4. Foetal Surveillance - Demand of the Day
  • 5. Snoring and sleep apnoea : A Worrying Truth
  • 6. Protocol for treating upper G.I. Bleeding
  • 7. Children's Health
  • 8. Why Blood Component Therapy and Not Whole Blood

A to Z of hepatitis

Hepatitis is inflammation of the liver. Generally hepatitis term means viral hepatitis for most people but this is a common misunderstanding. It has varied aetiology. Some of the common causes of hepatitis are given bellow.

  • Viral hepatitis : Viruses A to H, cytomegalo, Epstein-Barr virus
  • Drug induced: isonex,rifampicillin,captopril,methyldopa
  • Alcoholic hepatitis
  • Metabolic hepatitis: Wilson's disease
  • Autoimmune hepatitis

Most of the hepatitides are self limiting but a few can go on to develop chronic hepatitis. Common amongst them are

  • Hepatitis B & C
  • Untreated autoimmune hepatitis
  • Uncontrolled alcoholic hepatitis
  • Cardinal symptoms of acute hepatitis are
  • Fever, Anorexia, malaise, Yellowish discolouration of urine and sclera, Right upper quadrant pain
  • Tests for acute hepatitis are
  • For diagnosis, S.Bilirubin, SGPT/ALT
  • For prognosis :
  • Prothombine time
  • for categorizing hepatitis Viral markers
  • Ceruloplasmin and urinary copper for Wilson's disease
  • Two normal SGPT levels 24 hr. apart rules out hepatitis for all practical purpose

Usually all acute hepatitis behave almost similarly and therefore it is not possible to clinically pinpoint type of virus involved. Having said that certain viruses do have their peculiar behaviour e.g. type A virus is known to produce relapse in up to 15% of patients. Type E virus is having up to 15% mortality in pregnant women.

Treatment of acute hepatitis : This is mainly symptomatic. Anti pyretics are avoided as far as possible. Instead tepid sponging etc. are used. Nimesulide may be used in extreme cases. Sedatives are avoided For nausea and vomiting half dose of domperidone or metochlopromide are used. Antacids are helpful in such situation as well. Vitamins and glucose are used judiciously. Too much neat glucose results in excessive gas. Light diet is useful to prevent hypoglycaemia and maintain vitality. Vit-k is used to judge hepatic reserve rather than as therapeutic tool.

Excessive vomiting, high grade fever, progressively increasing prothombine time, increasing drowsiness are cause for concern and will mandate hospital admission and close supervision.

Patients who are going into hepatic coma need to be shifted to specialist unit to reduce mortality and morbidity.

Treatment of hepatic coma

Problems associated with hepatic coma:

  • Comatose patient: to avoid aspiration put in left lateral position, maintain airway patency, care of skin, bladder and bowel. Insert indwelling catheter, as input/output needs careful monitoring.
  • Gastrointestinal bleeding: as per upper g.i. bleed and lower g.i. bleed
  • Cerebral oedema: very serious
  • Increased muscle tone and myoclonus
  • Decerebrate posture
  • Convulsions or movement of arms and legs
  • Paroxysmal or sustained hypertension, tachycardia, rapid respiration
  • Pupils unequal or dilated and not well responding to light
  • Dysconjugate eye movements and skewed position of the eyes
  • Treatment with head elevation by 45 degree, IV mannitol 20% 1gm/kg as bolus (if urine output good), hyperventilation and lastly IV pentothal 1-4mg/kg maximum 500 mg
  • Infections: up to 90% develop infections, mainly gram positive, gram negative and fungal. Fever and leucocytosis are absent at times.3rd generation cephalosporins + metronidazole +antifungals (flucanazole 400 mg o/iv initially and then 200mg/day) to be considered. Neomycin/norfloxacin +nystatin to sterilize the gut. Lactulose (30-60ml qds initially) to reduce ammonia formation and reduce bacterial load

Fungal infections:

  • 1) Deterioration in coma grade after initial improvement
  • 2) Pyrexia unresponsive to antibiotics
  • 3) Established renal failure
  • 4) Markedly elevated white cell count
  • 5) Coagulopathy: May have to give Vit-K, FFP and platelets
  • 6) Hypoglycaemia in up to 40 %. Monitor blood sugar and continuous glucose drip and boluses
  • 7) Hypokalaemia and hyponatraemia: correct with supplementation and fluid restriction
  • 8) Respiratory alkalosis more common than acidosis
  • 9) Renal failure: Hepatorenal or acute tubular necrosis. Sometimes due to hypovolaemia. Fluid challenge. Replace albumin if low. Spot urinary sodium
  • 10) Hypo tension: N-acetyl cysteine may help
  • 11) Respiratory problems: aspiration pneumonia, infections and ARDS
  • 12) Acute pancreatitis

Monitoring: pulse, blood pressure, level of consciousness (Glasgow coma scale), pupil size and reaction, urine output, respiration , bleeding, Hypoglycaemia

FOETAL SURVEILLANCE - DEMAND OF THE DAY.

Motherhood is fulfillment of life for every women. It gives her self satisfaction, self esteem and tremendous joy. But all women are not equally lucky. Women face risk of death with every pregnancy. In these days of small family norm one prenatal death of a wanted baby is a big price to pay. Mother has to face one more risk of death. If we look at world scenario advanced countries have reached results surprisingly low - PNMR 1-2 / 1000 live births. Developing countries like ours face 60/1000 live births, as prenatal mortality rate. We are behind developed world. 60 / 1000 was the rate in U.S.A. in 1960, when they utilised Routine clinical care for MCH services. Ten years later they started using Ultrasound for Foetal Monitoring - Detection of Growth and Development of foetus. They could reduce mortality rates ton 20 / 1000; and with biophysical scoring to detect foetal well being the rates fell to 1.2-2/1000 .

We in our Country do have ultrasound for more than 20 years. How much is it used for foetal evaluation ? - practically not at all. Sporadic evaluation of the foetal weight and maturity or presence or absence of pregnancy is seen. Hardly there is a case where serial sonography is done. This is in general. Few individuals or in Institutions may be using ultrasound for Antepartum Monitoring.

We still have to overcome protracted obstructed labours, haemorrhagic complications of pregnancy and infections. In addition we also should be able to treat congenital anomalies compatible with life. This, will be reached with proper utilisation of our clinical efficiency which we should not under estimate.