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Asia has intermediate-to-high prevalence and high morbidity of hepatitis B virus (HBV) infection. The use of guideline-recommended nucleos(t)ide analogs with high barrier to resistance, such as entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF), is one of the key interventions for curbing HBV infection and associated morbidity in Asia. However, there are some challenges to the use of ETV and TDF; while ETV is associated with high resistance in lamivudine (LAM)-exposed (especially LAM-refractory) patients; bone and renal safety issues are a major concern with TDF. Hence, a panel of twenty-eight expert hepatologists from Asia convened, reviewed the literature, and developed the current expert opinion-based review article for the use of TAF in the resource-constrained settings in Asia. This article provides a comprehensive review of two large, phase 3, double-blind, randomized controlled trials of TAF versus TDF in HBeAg-negative (study 0108) and HBeAg-positive (study 0110) chronic HBV patients (> 70% Asians). These studies revealed as follows: (1) non-inferiority for the proportion of patients who had HBV DNA < 29 IU/mL; (2) significantly high rate of normalization of alanine aminotransferase levels; (3) no incidence of resistance; and (4) significantly better bone and renal safety, with TAF vs. TDF up to 144 weeks. Considering the benefits of TAF, the expert panel proposed recommendations for optimizing the use of TAF in Asia, along with guidance on specific patient groups at risk of renal or bone disease suitable for TAF therapy. The guidance provided in this article may help clinicians optimize the use of TAF in Asia.

The term ‘inflammatory pseudotumour’ (IPT) denotes a heterogeneous group of mass-forming lesions.1 IPT most commonly occurs in the lung, but it can be found in other locations, including the central nervous system, kidneys, ovaries, urinary bladder, breasts and liver.2 IPT of the liver (IPTL) is a rare benign lesion characterised by chronic infiltration of inflammatory cells and an area of fibrosis that closely mimics a malignant tumour.3,4 The aetiology and pathogenesis of IPTL remain unknown. There are no specific symptoms, laboratory or radiological findings that are useful for diagnosing IPTL. Differentiating between IPTs and other focal hepatic lesions remains a major problem. Treatment varies from observation and medical management to surgical resection in patients with severe symptoms or an indeterminate diagnosis.1,5,6 IPTs of the liver are extremely rare, and their exact prevalence remains unclear. This is largely because of the infrequency of the condition and its tendency to be misdiagnosed as malignant liver tumours.3 A 60-year-old Asian woman, with no relevant past medical history, presented with intermittent fever, vague abdominal pain and malaise. Laboratory tests revealed hyperbilirubinaemia, elevated liver enzymes, leucocytosis, and raised inflammatory markers. Imaging studies, including ultrasound and contrast-enhanced computed tomography (CT), showed a hypodense hepatic lesion with septations (Fig 1), initially suspected as a liver abscess. Despite empirical antibiotics and failed aspiration, the lesion persisted and progressed. Tumour markers, including CA 19-9, were elevated, raising suspicion for malignancy. Further evaluation with magnetic resonance imaging (MRI) demonstrated a targetoid enhancing lesion, prompting a CT-guided biopsy. Histopathology confirmed a diagnosis of inflammatory pseudotumor with xanthogranulomatous inflammation (Fig 2). The patient was managed conservatively with corticosteroids and monitored. The patient responded well to corticosteroid therapy, with resolution of symptoms and normalisation of liver function tests. Follow-up imaging at 6 months showed gradual regression of the lesion. IPTs are often mistaken for malignancies because of their imaging findings and non-specific presentation.4 Although elevated CA 19-9 levels have been reported in IPTs, they have low specificity and other differentials include liver abscesses and malignancies.7 Radiologically, IPTs typically appear as hypoechoic lesions with heterogeneous enhancement on CT and MRI.2 The definitive diagnosis relies on histopathology, which would reveal mixed inflammatory infiltrates, fibrosis and foamy macrophages characteristic of xanthogranulomatous inflammation.8 This case highlights the diagnostic challenge of hepatic IPTs, which can closely mimic malignancies. Since there is potential for spontaneous regression or response to corticosteroids, early histopathological confirmation is helpful to prevent unindicated hepatic resection. Radiologically guided core biopsy with immunohistochemistry should be considered in cases of atypical liver lesions with inflammatory features.

Acute insults from viruses, infections, or alcohol are established causes of decompensation leading to acute-on-chronic liver failure (ACLF). Information regarding drugs as triggers of ACLF is lacking. We examined data regarding drugs producing ACLF and analyzed clinical features, laboratory characteristics, outcome, and predictors of mortality in patients with drug-induced ACLF. We identified drugs as precipitants of ACLF among prospective cohort of patients with ACLF from the Asian Pacific Association of Study of Liver (APASL) ACLF Research Consortium (AARC) database. Drugs were considered precipitants after exclusion of known causes together with a temporal association between exposure and decompensation. Outcome was defined as death from decompensation. Of the 3,132 patients with ACLF, drugs were implicated as a cause in 329 (10.5%, mean age 47 years, 65% men) and other nondrug causes in 2,803 (89.5%) (group B). Complementary and alternative medications (71.7%) were the commonest insult, followed by combination antituberculosis therapy drugs (27.3%). Alcoholic liver disease (28.6%), cryptogenic liver disease (25.5%), and non-alcoholic steatohepatitis (NASH) (16.7%) were common causes of underlying liver diseases. Patients with drug-induced ACLF had jaundice (100%), ascites (88%), encephalopathy (46.5%), high Model for End-Stage Liver Disease (MELD) (30.2), and Child-Turcotte-Pugh score (12.1). The overall 90-day mortality was higher in drug-induced (46.5%) than in non-drug-induced ACLF (38.8%) (P = 0.007). The Cox regression model identified arterial lactate (P < 0.001) and total bilirubin (P = 0.008) as predictors of mortality. Drugs are important identifiable causes of ACLF in Asia-Pacific countries, predominantly from complementary and alternative medications, followed by antituberculosis drugs. Encephalopathy, bilirubin, blood urea, lactate, and international normalized ratio (INR) predict mortality in drug-induced ACLF.

Introduction: Incidence of gastric carcinoma and gastric polyps is on rise all over the world. Chronic atrophic gastritis to intestinal metaplasia progressing to adenocarcinoma has been documented pathway for gastric carcinogenesis. Another pathway for gastric carcinoma is adenoma carcinoma sequence similar to colon cancer. Aim: To study prevalence, endoscopic, and histomorphological features of gastric polyps. Methods and Material: This was retrospective analysis of gastric polyps from 2012 to 2019 in consecutive 10,800 upper gastrointestinal endoscopies. Demographic, endoscopic, and histopathological data were obtained from hospital records. All gastric polyps were classified as per standard histologic criteria. Additional histological features noted were presence of dysplasia, focus of adenoma, or malignancy. Results: The prevalence of gastric polyps was 434 (4%) of 10,800 upper gastrointestinal endoscopies. Majority of polyps were found in the last 4 years (277: 63.8%). Mean age was 55.4 years with male to female ratio 1:1.2. Most of the polyps (94.9%) were less than 1 cm, located in gastric antrum. Multiple polyps were seen in 20.9% cases. On histopathology, fundic gland polyps were most common (147: 33.8%), followed by hyperplastic (128: 29.4%) polyps. Adenomatous polyps were nine (2%); of these, two cases of hyperplastic polyps and one each of fundic gland polyp and benign epithelial polyp showed adenomatous foci. Conclusion: Fundic gland polyps were the most common polyps. With rising incidence of gastric carcinoma, identification of gastric polyps on endoscopy with biopsy can prevent progression to carcinogenesis.

Abstract Background & objectives: Alcohol is one of most common aetiologies of cirrhosis and decompensated cirrhosis is linked to higher morbidity and death rates. This study looked at the outcomes and mortality associated risk variables of individuals with alcoholic cirrhosis who had hospitalization with their first episode of decompensation. Methods: Individuals with alcoholic cirrhosis who were hospitalized with the first episode of decompensation [acute decompensation (AD) or acute-on-chronic liver failure (ACLF)] were included in the study and were prospectively followed up until death or 90 days, whichever was earlier. Results: Of the 227 study participants analyzed, 167 (73.56%) and 60 (26.43%) participants presented as AD and ACLF, respectively. In the ACLF group, the mortality rate at 90 days was higher than in the AD group (48.3 vs 32.3%, P=0.02). In the AD group, participants who initially presented with ascites as opposed to variceal haemorrhage had a greater mortality rate at 90 days (36.4 vs 17.1%, P=0.041). The chronic liver failure-consortium AD score and the lactate-free Asian Pacific Association for the study of the Liver-ACLF research consortium score best-predicted mortality in individuals with AD and ACLF. Interpretation & Conclusions: There is significant heterogeneity in the type of decompensation in individuals with alcoholic cirrhosis. We observed significantly high mortality rate among alcoholic participants hospitalized with initial decompensation; deaths occurring in more than one-third of study participants within 90 days.

The relationship between ammonia and liver-related complications (LRCs) in acute-on-chronic liver failure (ACLF) patients is not clearly established. This study aimed to evaluate the association between ammonia levels and LRCs in patients with ACLF. The study also evaluated the ability of ammonia in predicting mortality and progression of LRCs. The study prospectively recruited ACLF patients based on the APASL definition from the ACLF Research Consortium (AARC) from 2009 to 2019. LRCs were a composite endpoint of bacterial infection, overt hepatic encephalopathy (HE), and ascites. A total of 3871 cases were screened. Of these, 701 ACLF patients were enrolled. Patients with LRCs had significantly higher ammonia levels than those without. Ammonia was significantly higher in patients with overt HE and ascites, but not in those with bacterial infection. Multivariate analysis found that ammonia was associated with LRCs. Additionally, baseline arterial ammonia was an independent predictor of 30-day mortality, but it was not associated with the development of new LRCs within 30 days. In summary, baseline arterial ammonia levels are associated with 30-day mortality and LRCs, mainly overt HE and ascites in ACLF patients.

Background The Haematological Reference Intervals (RIs) are prone to vary on the basis of various factors such as altitude, age, sex, socioeconomic status, etc. These values play a major role in laboratory data interpretation and determine the necessary clinical treatment. Currently, India has no well–established RI for cord blood haematological parameters of newborns. This study aims to establish these intervals from Mumbai, India. Method A cross sectional study was conducted in a tertiary care hospital of India from October 2022 to December 2022 on healthy and term neonates having normal birth weight and born to healthy pregnant mothers. About 2 – 3 mL of cord blood was collected from the clamped cord into EDTA tubes from 127 term neonates. The samples were analysed in the haematology laboratory of the institute and the data was analysed. The upper and lower limits were determined using non-parametric method. The Mann–Whitney U test was used to compare the distribution of the parameters between sex of infant, modes of deliveries, maternal age and obstetric history. P value less than 0.05 was considered to declare statistical significance. Result The median values and 95% RI for umbilical cord blood haematological parameters of newborns were as follows: WBC = 12.35 [2.56–21.19] × 10 9 /L, RBC = 4.34 [2.45–6.27] × 10 12 /L, HGB = 14.7 [8.08–21.44] g/dL, HCT = 48 [29–67]%, MCV = 109.6 [59.04–159.1] fL, MCH = 34.5 [30.54–37.79] pg, MCHC = 31.3 [29.87–32.75] %, PLT = 249 [16.97–479.46] × 10 9 /L,LYM = 38 [17–62] %, NEU = 50 [26–74] %, EOS = 2.3 [0.1–4.8] %, MON = 7.3 [3.1–11.4], BAS = 0 [0–1]. This study found no statistically significant difference between sex of infants, except MCHC, and obstetric history. A significant difference was observed in WBC, EOS% and absolute NEU, LYM, MON and BAS by delivery type. A higher platelet count and absolute LYM was observed in the cord blood compared to venous blood. Conclusions For the first time, haematological reference intervals in cord blood were established for newborns in Mumbai, India. The values are applicable for newborns from this area. Larger study throughout the country is required.

Introduction Anomalous pancreaticobiliary duct union (APBDU) is defined by the abnormal position of the junctional union of the common bile duct and the pancreatic duct, outside the duodenal wall above the influence of sphincter of Oddi, associated with choledochal cysts and biliary malignancies. APBDU may rarely present as recurrent acute pancreatitis (RAP) or chronic pancreatitis (CP). We aimed to study the prevalence of patients with APBDU presenting as RAP or CP and their response to endotherapy. Methods A retrospective audit of the prospectively maintained endoscopy database at our institute between January 2018 and November 2020 was conducted to identify cases of APBDU presenting as RAP or CP. Details of investigations, endoscopic retrograde cholangiopancreatography (ERCP) findings, and follow-up till six months were noted. Results We identified 26 cases of APBDU, of which five (19.2%) cases presented as RAP or CP. Of these five patients, two had RAP, while three presented with CP (median: 11 years; range: 4-25 years). Magnetic resonance cholangiopancreatography (MRCP) showed APBDU in three patients. One patient with RAP had a Komi type IIIB anomaly. Another patient with RAP had a rare anomaly with absent ventral PD, with the bile duct communicating and draining through the dorsal duct. Two patients with CP had a long common channel with Komi IIA anomaly. One patient with CP had IIIC2 anomaly. Pancreas divisum was noted in three patients, all of whom underwent minor-papilla sphincterotomy. Successful pancreatic stent placement was performed in all patients. Over one year of follow-up, patients with CP had a significant decrease in pain as measured by the visual analog scale. Those with RAP had no further episodes of pancreatitis. Conclusion APBDU is a rare cause of RAP and CP in young patients, occasionally missed on MRCP. RAP and CP caused by APBDU show good response to endotherapy.

Background and aim Pancreatic endotherapy has been established as a viable and effective modality for the management of pain in chronic pancreatitis (CP). However, its impact on endocrine insufficiency has been rarely reported. In this retrospective study, we aimed to assess the impact of endotherapy on glycemic status and the management of diabetes in these patients. Methods A retrospective review of a prospectively maintained database of patients with CP with pain presenting to the King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India, from December 2021 to May 2023 was done. Detailed clinical, laboratory, imaging, and treatment data were recorded. Endocrine dysfunction was defined as glycosylated hemoglobin (Hba1C) ≥6.5 g/dl. The status of endocrine function (Hba1C values) before and after endotherapy, as well as the requirement of oral hypoglycemic agent (OHA) and/or insulin, was recorded. Results One hundred forty-one patients underwent endoscopic retrograde cholangiopancreatography for the management of pain (mean age: 35 years, 74.5% males). Prior to endotherapy, pathological endocrine dysfunction was seen in 60 patients (42.5%). The mean HbA1c value was 8.46 g/dl (4.5-16.1g/dl). OHAs alone were used in 13/60 (21.6%), and 34/60 (56.6%) required insulin. A combination of OHA and insulin was required in 13/60 (21.6%) of patients. Post-endotherapy, none of the patients were on a combination of OHAs and insulin; 5/13 (38.4%) patients were on OHAs alone, while 8/13 (61.5%) patients were shifted to insulin. Out of the total 47 patients who required insulin, insulin could be stopped in 15/47 (31.9%) of patients. Patients who demonstrated improvement in endocrine dysfunction had significantly lower HbA1c values (6.38 vs. 8.07 g/dl, p < 0.001), a higher proportion of patients with idiopathic pancreatitis (73.3% vs. 22.2%, p = 0.004), and a lower proportion of patients with concomitant exocrine insufficiency (13.3% vs. 53.3%, p = 0.007). Conclusions One-third of the patients had improvements in endocrine dysfunction. Early ductal intervention in a selected subset of patients with CP may have the potential to improve glycemic status.