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Mitra, D.K., Reader in Medicine, Ashrafuddin, S., Lecturer in Medicine, and Talib, S.H., Registrar in Infectious Diseases, Department of Medicine, Medical College, Aurangabad, India.
Since all the patients with complications expired in the control group within a short period, subsequent biochemical values could not be assessed.
The amount of blood transfusion was decided by the severity of bleeding, raised prothrombin time and availability. Two patients in the group on Liv.52 were given 7 and 8 transfusions respectively, and in the control group without Liv.52, 1-3 transfusions were given because of short stay due to early death—the patients survived only long enough to receive from 1-3 transfusions.
DISCUSSION
To date despite all measures mortality of hepatic coma (deep) in viral hepatitis is as high as 90 percent (Sherlock, 1968). No specific treatment exists so far in preventing or treating the complications of the disease. A tendency to bleeding is a frequent complication of acute hepatic necrosis. The haemorrhagic diathesis of acute hepatic necrosis is due to intravascular coagulation in addition to impaired hepatic synthesis of the coagulation factors (Rake et al, 1970).
In the past and even today the major interest regarding the therapy of viral hepatitis has centred around the use of corticosteroids. The question has been the subject of interest and many discussions. Corticosteroids have been tried by many workers without encouraging results.
In our institute with corticosteroids the mortality rate with hepatic coma remained high. In a retrospective study 50 cases which were admitted in the recent past, were analysed (Table 6). The cases who had evidence of bleeding and were diagnosed as precoma and coma, succumbed to death. While 4 cases who had no evidence of bleeding but had manifestations of precoma/coma improved. In all, percentage improvement in complicated cases was 30.7%.
In the present study, we are particularly impressed by the clinical improvement shown after Liv.52 administration and the significant high percentage of improvement and survival in complicated cases (73.3 percent).
Prothrombin time is considered to be one of the best indices of hepatic dysfunctions (Cook et al., 1965). Prothrombin time was elevated remarkably in the complicated group and hence cases were given transfusion to bring the prothrombin time within normal limits, in order to prevent bleeding. Fifteen patients of the trial group on Liv.52 plus standard supportive therapy received blood transfusion as per criteria mentioned before. They received from one to eight units of blood. In the trial group two patients received 7-8 units of blood, the rest received 0-2 units while in the control group 11 cases received blood transfusion ranging from one to three units. Since most of the patients died early in the control group further transfusions could not be given. It was observed that in the patients who received blood transfusions either the prothrombin time dropped to normal, or despite transfusions the patient continued to bleed with elevated prothrombin time and died. The cases who showed a drop in the prothrombin time after transfusion, improved.
Even with profound changes and virtually incoagulable blood, bleeding is not particularly common unless there is a local lesion of the blood vessels (Flute, 1972). Corticosteroids are known to deplete serum vit. C level (Courtenay, Bartholomew, 1972). In cases of acute fulminating hepatitis where border line vit. C deficiency exists, corticosteroids may aggravate the condition probably by affecting the cement substance of the blood vessels (Courtenay, Bartholomew, 1972), and enable incoagulable blood to leak.
It is interesting to note the incidence of precoma and coma in pregnancy. The effect of pregnancy on the course of hepatitis, or of hepatitis on the course of pregnancy has been a subject of controversy (Bokus, 1965). There are a number of reports that warn that hepatitis does not always run a benign course in pregnancy. the reported data on hepatitis in pregnancy indicate that although the disease may occasionally be mild it has often proved fatal (Bokus, 1965). In our study (Table 4) out of 29 cases of viral hepatitis associated with pregnancy 15 were with precoma/coma (51.7 percent). While out of 71 cases of viral hepatitis other than the pregnancy group, 12 cases were in encephalopathy (16.9 percent). Urinary tract infection was detected in 20 out of 29 cases of viral hepatitis with pregnancy. We believe that urinary tract infection could be a contributing factor for higher incidence of precoma/coma in this group. In view of this higher incidence of urinary tract infection in this group, routine urine culture of these cases is of utmost importance and an appropriate non-hepatotoxic antibiotic should be administered.
In the present study, we have come across 27 patients of hepatic coma, 15 in the Liv.52 group and 12 in the control group. Eleven patients improved and survived in the Liv.52 group (73.3%), while none improved in the control group. This significantly higher survival rate in the Liv.52 treated group indicates the protective and regenerative effect of the drug Liv.52.
Particularly striking to us is the high rate of survival of patients with hepatic coma, who started bleeding, occult or manifest, through the gastrointestinal tract, and their recovery after administering Liv.52. It would be interesting to study the various causes of bleeding in this group and whether Liv.52 has any role to play in controlling the bleeding diathesis.
Liv.52 in Viral Hepatitis with Special Reference to its use in Precoma and Coma
Mitra, D.K., Reader in Medicine, Ashrafuddin, S., Lecturer in Medicine, and Talib, S.H., Registrar in Infectious Diseases, Department of Medicine, Medical College, Aurangabad, India.
| Table 5: Table showing relation of blood transfusion, prothrombin time indices, bleeding diathesis to rate of mortality in complicated cases of infective hepatitis | |||||||||||||||||||||||||||||||||||||
| Case No. | PT | Trial group on Liv.52 | Clinical result | Case No. | P.T. | Control group without Liv.52 | Clinical result | ||||||||||||||||||||||||||||||
| Evidence of bleeding | No. of transfusions received in units | Evidence of bleeding | No. of transfusions received in units | ||||||||||||||||||||||||||||||||||
| 1. | 5’ | ++ | 3 | Expired | 1 | 60" | ++ | 2 | Expired | ||||||||||||||||||||||||||||
| 2. | 5’ | ++ | 2 | " | 2 | 45" | + | 2 | " | ||||||||||||||||||||||||||||
| 3. | 5’ | ++ | 1 | " | 3 | 40" | + | 2 | " | ||||||||||||||||||||||||||||
| 4. | 5’ | ++ | 1 | " | 4 | 5' | ++ | 1 | " | ||||||||||||||||||||||||||||
| 5. | 45’ | + | 1 | Improved | 5 | 60" | + | 1 | " | ||||||||||||||||||||||||||||
| 6. | 5’ | ++ | 7 | " | 6 | 50" | + | 1 | " | ||||||||||||||||||||||||||||
| 7. | 5’ | ++ | 8 | " | 7 | 30" | — | — | " | ||||||||||||||||||||||||||||
| 8. | 22” | — | — | " | 8 | 5' | ++ | 1 | " | ||||||||||||||||||||||||||||
| 9. | 45” | + | 2 | " | 9 | 5' | ++ | 3 | " | ||||||||||||||||||||||||||||
| 10. | 65” | ++ | 2 | " | 10 | 2' | + | 2 | " | ||||||||||||||||||||||||||||
| 11. | 20” | — | — | " | 11 | 45" | + | 1 | " | ||||||||||||||||||||||||||||
| 12. | 2’ | + | 2 | " | 12 | 5' | ++ | 2 | " | ||||||||||||||||||||||||||||
| 13. | 60” | + | 2 | " | |||||||||||||||||||||||||||||||||
| 14. | 40” | + | 1 | " | |||||||||||||||||||||||||||||||||
| 15. | 60” | + | 2 | " | |||||||||||||||||||||||||||||||||
| Table 6: Table showing percentage surviving in three groups of complicated cases | ||||||||||||
| Control group without Liv.52 | Trial group with Liv.52 | Corticosteroids group | ||||||||||
| Types of cases | No. of cases studied | No. of cases improved | Survival | Percentage survived and improved | No. of cases studied | No. of cases impro-ved | Survi-val | Percen-tage survi-ved and impro-ved | No. of cases studied | No. of cases impro-ved | Survi-val | Percen-tage survi-ved and impro-ved |
| Viral hepatitis with precoma/coma | ||||||||||||
| With bleeding | 11* | Nil | Nil | Nil | 13 | 9 | 9 | 69.23 | 9+ | Nil | Nil | Nil |
| Without bleeding | 1 | Nil | Nil | Nil | 2 | 2 | 2 | 100 | 4 | 4 | 4 | 100 |
| 12 | Nil | Nil | Nil | 15 | 11 | 11 | 73.33 | 13 | 4 | 4 | 30.7% | |
| *Out of 11 cases, 5 cases were ante-natal and one post-natal. Case was ante-natal. Out of 13 cases, 7 cases were ante-natal and one Post-natal. Out of 9 cases, 6 cases were ante-natal and one post-natal. +Out of 9 cases, 2 cases were ante-natal. Out of 4 cases, one case was post-natal and one ante-natal. The improvement and survival rate with Liv.52 was 73.3% in the cases treated with Liv.52 as compared to zero in the control group and 30.7% in the group on corticosteroids. This is highly significant. There was no death in uncomplicated cases. | ||||||||||||
Since all the patients with complications expired in the control group within a short period, subsequent biochemical values could not be assessed.
The amount of blood transfusion was decided by the severity of bleeding, raised prothrombin time and availability. Two patients in the group on Liv.52 were given 7 and 8 transfusions respectively, and in the control group without Liv.52, 1-3 transfusions were given because of short stay due to early death—the patients survived only long enough to receive from 1-3 transfusions.
DISCUSSION
To date despite all measures mortality of hepatic coma (deep) in viral hepatitis is as high as 90 percent (Sherlock, 1968). No specific treatment exists so far in preventing or treating the complications of the disease. A tendency to bleeding is a frequent complication of acute hepatic necrosis. The haemorrhagic diathesis of acute hepatic necrosis is due to intravascular coagulation in addition to impaired hepatic synthesis of the coagulation factors (Rake et al, 1970).
In the past and even today the major interest regarding the therapy of viral hepatitis has centred around the use of corticosteroids. The question has been the subject of interest and many discussions. Corticosteroids have been tried by many workers without encouraging results.
In our institute with corticosteroids the mortality rate with hepatic coma remained high. In a retrospective study 50 cases which were admitted in the recent past, were analysed (Table 6). The cases who had evidence of bleeding and were diagnosed as precoma and coma, succumbed to death. While 4 cases who had no evidence of bleeding but had manifestations of precoma/coma improved. In all, percentage improvement in complicated cases was 30.7%.
In the present study, we are particularly impressed by the clinical improvement shown after Liv.52 administration and the significant high percentage of improvement and survival in complicated cases (73.3 percent).
Prothrombin time is considered to be one of the best indices of hepatic dysfunctions (Cook et al., 1965). Prothrombin time was elevated remarkably in the complicated group and hence cases were given transfusion to bring the prothrombin time within normal limits, in order to prevent bleeding. Fifteen patients of the trial group on Liv.52 plus standard supportive therapy received blood transfusion as per criteria mentioned before. They received from one to eight units of blood. In the trial group two patients received 7-8 units of blood, the rest received 0-2 units while in the control group 11 cases received blood transfusion ranging from one to three units. Since most of the patients died early in the control group further transfusions could not be given. It was observed that in the patients who received blood transfusions either the prothrombin time dropped to normal, or despite transfusions the patient continued to bleed with elevated prothrombin time and died. The cases who showed a drop in the prothrombin time after transfusion, improved.
Even with profound changes and virtually incoagulable blood, bleeding is not particularly common unless there is a local lesion of the blood vessels (Flute, 1972). Corticosteroids are known to deplete serum vit. C level (Courtenay, Bartholomew, 1972). In cases of acute fulminating hepatitis where border line vit. C deficiency exists, corticosteroids may aggravate the condition probably by affecting the cement substance of the blood vessels (Courtenay, Bartholomew, 1972), and enable incoagulable blood to leak.
It is interesting to note the incidence of precoma and coma in pregnancy. The effect of pregnancy on the course of hepatitis, or of hepatitis on the course of pregnancy has been a subject of controversy (Bokus, 1965). There are a number of reports that warn that hepatitis does not always run a benign course in pregnancy. the reported data on hepatitis in pregnancy indicate that although the disease may occasionally be mild it has often proved fatal (Bokus, 1965). In our study (Table 4) out of 29 cases of viral hepatitis associated with pregnancy 15 were with precoma/coma (51.7 percent). While out of 71 cases of viral hepatitis other than the pregnancy group, 12 cases were in encephalopathy (16.9 percent). Urinary tract infection was detected in 20 out of 29 cases of viral hepatitis with pregnancy. We believe that urinary tract infection could be a contributing factor for higher incidence of precoma/coma in this group. In view of this higher incidence of urinary tract infection in this group, routine urine culture of these cases is of utmost importance and an appropriate non-hepatotoxic antibiotic should be administered.
In the present study, we have come across 27 patients of hepatic coma, 15 in the Liv.52 group and 12 in the control group. Eleven patients improved and survived in the Liv.52 group (73.3%), while none improved in the control group. This significantly higher survival rate in the Liv.52 treated group indicates the protective and regenerative effect of the drug Liv.52.
Particularly striking to us is the high rate of survival of patients with hepatic coma, who started bleeding, occult or manifest, through the gastrointestinal tract, and their recovery after administering Liv.52. It would be interesting to study the various causes of bleeding in this group and whether Liv.52 has any role to play in controlling the bleeding diathesis.
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