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Progressive hepatocellular dysfunction in a neonate, resulting in elevated serum alpha-fetoprotein together with raised blood levels of tyrosine and methionine, a generalized amino aciduria and the absence of urinary delta-aminolevulinic acid and succinylacetone, suggests a diagnosis of tyrosinemia type Ib. Classical tyrosinemia type I arises from a deficiency of fumarylacetoacetate hydrolase while the variant tyrosinemia type Ib results from a deficiency of maleylacetoacetate isomerase.

Spontaneous rupture of amyloid liver is a fatal complication. A 48-year-old man with systemic amyloidosis secondary to multiple myeloma presented with acute hemoperitoneum. Emergency angiogram showed extravasation of contrast from the liver into the sub-hepatic space, which was successfully stopped by embolization of the right hepatic artery.

Penicillamine is the standard therapy for Wilson's disease in children. We report an 8-year-old-girl with liver disease due to Wilson's disease who developed extrapyramidal symptoms following administration of penicillamine. Symptoms resolved within 20 hours of stopping the drug but recurred within 24 hours when gradually increasing small doses were recommenced.

Background: Intussusception is the most common cause of intestinal obstruction in young children and has been reported as a complication of a recently withdrawn tetravalent reassortant rotavirus vaccine., Methods: We studied the history, clinical presentation, management and outcome of intussusception presenting to a tertiary care hospital in southern India over a 10-year period, in order to assess potential association with diarrheal disease and immunization., Results: Data from 137 index cases and 280 control subjects indicated that the risk of diarrheal disease or oral polio vaccine administration in the month prior to presentation was similar in the index cases and controls. Mean time to presentation to hospital after developing symptoms was 1.8 days, and 77.3% of patients required surgery, with 47.4% undergoing intestinal resection. Mortality was 0.006%., Conclusions: No association could be demonstrated between gastroenteritis or oral poliovirus vaccine immunization and intussusception in southern Indian children. These children presented later and required operative intervention more frequently than has been reported in other studies, but had a good outcome with low mortality.

Acute fatty liver of pregnancy is an uncommon, potentially fatal disorder. Between 1998 and 2000, two patients with acute fatty liver of pregnancy presented at the Christian Medical College Hospital, Vellore. Both patients were in the thirty-sixth week of pregnancy. jaundice and encephalopathy were the predominant symptoms. Both the mothers died after they delivered a stillborn Infant each. The maternal deaths were due to multiorgan failure and/or postpartum haemorrhage and sepsis. The route of delivery was vaginal in both the patients. Extrahepatic and metabolic complications in both cases Included renal failure, sepsis, hypoglycaemia, disseminated intravascular coagulation and gastrointestinal bleeding. Liver biopsy done in both patients was consistent with the diagnosis of acute fatty liver of pregnancy. To the best of our knowledge, this is the first report from India on acute fatty liver of pregnancy.

Objective: To investigate the occurrence of silent hepatitis B virus (HBV) infection among patients with chronic liver disease (CLD)., Methods: Plasma samples from 71 CLD patients including 9 HBsAg-positive individuals were tested for HBV DNA by nested polymerase chain reaction (nPCR), and for HBV serum markers, i.e., anti-HBc antibody, HBeAg and anti-HBe antibody. The individuals were also tested for hepatitis C virus (HCV) RNA and anti-HCV antibody., Results: Among 62 HBsAg-negative patients, silent HBV infection was seen in only two (3.2%). Silent HBV infection was not found in any of the 26 patients who had evidence of HCV infection. One HBsAg-positive patient was positive for anti-HCV in the absence of HCV RNA., Conclusions: There is a low rate of silent HBV infection among patients with CLD in India, where HBV is moderately endemic. Silent HBV infection is not associated with HCV-related CLD, which is in contrast to reports from other HBV-endemic areas in Asia.

We report a 35-year-old man, a renal allograft recipient, who presented with toxic megacolon. Segmental biopsies from the colon were consistent with cytomegalovirus colitis. Serum polymerase chain reaction for cytomegalovirus DNA confirmed the diagnosis. He was treated with ganciclovir but, though his abdominal condition improved initially, he worsened later and succumbed to his illness.

Vesical varices in portal hypertension are rare. We report a patient with portal hypertension who developed recurrent painless hematuria. Cystoscopy was normal. Doppler ultrasound and MR angiography showed a dilated paraumbilical vein within the falciform ligament coursing down to the urinary bladder wall and draining into the right internal iliac vein. He underwent liver transplantation for decompensated chronic liver disease. He is in good health and has not had further episodes of hematuria.

We present three siblings (out of four) with intrahepatic cholestatic disease and cirrhosis. Two of the siblings, a 33-year-old woman and a 34-year-old man had advanced liver disease- with the liver histology showing established cirrhosis with chronic cholestasis and excess copper accumulation. Both died two years later due to hepatic encephalopathy. The third sibling, a 37-year-old man on routine check-up was found to have abnormal liver functions. The liver biopsy showed marked bile ductular proliferation with bridging fibrosis, reduction in interlobular bile ducts, and excess copper accumulation. The presence of antimitochondrial antibody in the serum in 1 in 320 dilutions in all three patients and 1 in 80 dilutions in the oldest healthy sibling and hypergammaglobulinemia in all the siblings confirmed the diagnosis of familial primary biliary cirrhosis. Antinuclear and smooth muscle antibodies were not present. Clinical and biochemical improvement has been noted in the third sibling after therapy with ursodeoxycholic acid.

Background: Cancer cells have alterations in energy metabolism due to defective mitochondrial function. This may be due to generation of excessive free radicals and/or defective antioxidant enzyme systems. The aim of the present study was to assess mitochondrial function and antioxidant defences in the gastric mucosa of patients with gastric carcinoma (CA)., Methods: Gastric mucosal mitochondrial function was assessed by means of the reduction of tetrazolium dye (MTT), and levels of antioxidants such as glutathione S-transferase (GST), catalase, superoxide dismutase (SOD), and thiols were measured in biopsy specimens taken from the tumour mucosa (TM) and tumour-free (TF) mucosa, 2 cm away from the tumour, in 49 patients with gastric CA and compared with that in 54 controls. In a further 10 patients with gastric CA, these studies were done on TM and TF mucosa 2 cm and > or = 5 cm away from the tumour. In 10 patients and 5 controls, specimens were obtained for electron microscopy as well. Helicobacter pylori infection was diagnosed by means of histology., Results: MTT reduction and GST and SOD activities were significantly decreased in TM and TF mucosa in patients with CA compared with controls (P < 0.01). The levels of thiols and catalase activity were significantly increased in CA as compared with controls (P < 0.01). H. pylori positivity did not influence most of these variables but did give significant decrease in MTT reduction in CA (TF) mucosa (P=0.01) and significant increase in thiol levels in CA (TM) mucosa (P=0.04). Electron microscopy showed mitochondrial alterations in tumour cells in all patients and in adjacent mucosa of 10%-50% of the cells., Conclusions: 1) In gastric CA the cancer mucosal cells and the non-involved cells adjacent to the tumour have defective mitochondrial function, which may be due to altered antioxidant defences and possibly altered free radical formation. 2) Ultrastructural mitochondrial abnormalities are shown to parallel these biochemical abnormalities.

Background: Scoring systems to predict mortality in intensive care units have been developed in western populations. There is a need to identify and validate prognostic variables in the Indian context. We compared two scoring systems to predict the discharge outcome in patients admitted to a medical intensive care unit., Methods: Five hundred patients admitted to a medical intensive care unit were studied prospectively. Modified acute physiology and chronic health evaluation II (APACHE II) score and modified organ system failure (OSF) score were applied on the day of admission to the intensive care unit. The scores obtained by the two systems were compared using the area under the curve approach. The likelihood ratios were calculated for predicting discharge outcome., Results: The modified OSF score predicted discharge outcome better than the modified APACHE II score--receiver operating characteristic curve area (standard error-area) 0.7062 (0.0244) and 0.6068 (0.0267) for the modified OSF and the modified APACHE II scores, respectively. This was statistically significant (p < 0.001). The likelihood ratio for the modified OSF score for different cut-off points varied from 0.27 to 5.49, while the likelihood ratio for the modified APACHE II score varied from 0.11 to 2.08. This means that for an intensive care unit with a 30% overall mortality, the modified OSF score could separate patients with 10% to 70% mortality, while the modified APACHE II score could predict only 5% to 47% mortality., Conclusion: The modified OSF score was superior to the modified APACHE II score in predicting mortality in patients admitted to the medical intensive care unit.