Our mission is to develop Hepatology as a comprehensive discipline which can provide distinctly advanced and protocol based patient care, training and clinical and translational research. The department provides emergency and elective management to patients with liver, biliary and pancreatic diseases by a highly dedicated team of faculty, residents and supportive staff. With a rigorous academic program and constant monitoring and mentoring, the department is able to provide protocol and evidenced based care to an increasing number of difficult to treat patients.
The department has initiated efforts to promote the study of Hepatobiliary Sciences as a super-specialty and initiated advanced training in the field of Hepatology and Transplant Hepatology.
- Adult Hepatology Services: Diagnosis and treatment of viral hepatitis (Hepatitis B, C, E, A and D), alcoholic liver disease, fatty liver disease, auto-immune hepatitis, drug hepatitis, and all causes of jaundice. Gall stones and bile duct stones; pancreatic diseases; Liver, gall bladder and GI cancers.
- Gastrointestinal (GI) bleed unit
- Liver coma unit.
- Hepatic hemodynamic (Liver Pressure and flow measurement) and intervention laboratory
- Advanced diagnostic and therapeutic endoscopy including capsule endoscopy, single balloon enteroscopy, argon plasma coagulation (APC), heater probe, diagnostic and therapeutic endoscopic retrograde cholangio-pancreatography (ERCP), extra-corporeal shock wave lithotripsy (ESWL), diagnostic and therapeutic endoscopic ultrasound (EUS),
- Fibroscan (liver stiffness and fat measurement)
- Liver biopsy (both percutaneous and trans-jugular)
- Nutrition services
- Other interventions: Radiofrequency Ablation (RFA), Transarterial Chemoembolization (TACE) with Lipiodol, Transarterial Chemoembolization (TACE) with Doxorubicin-filled Beads, Systemic Chemotherapy; TIPS, angioembolization
- Liver Dialysis Services
A. Liver Intensive Care:
The last one year has seen the establishment of one of the finest liver intensive and critical care services with specialized rapid response teams.
- Acute G I Bleeds: Patients with acute GI bleed are seen immediately in the emergency room and appropriate treatment including emergency endoscopies (24x7) are instituted urgently, which leads to an improvement in survival. Patients who fail the combination of endotherapy and vasoactive agents are taken up for HVPG measurement and if indicated, for emergency TIPS procedure.
- Hepatic coma: Hepatic encephalopathy (also known as portosystemic encephalopathy) is the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure. It may ultimately lead to death. A substantial increase in the patients admitted with hepatic coma occurred in the past one year. These patients are managed based on standard protocols and with our state of the art hepatic coma ICU functioning according to world standards the mortality has been reduced substantially in our ICU.
- Acute Liver failure: Acute liver failure is the appearance of severe complications rapidly after the first signs of liver disease (such as jaundice), and indicates that the liver has sustained severe damage (loss of function of 80-90% of liver cells). Common causes include Hepatitis E, Hepatitis A, and drugs. ILBS has been involved in treatment of ALF patients with a rapid response team working round the clock and with the availability of urgent liver tranplantation the outlook of this disease has improved substantially.
Abbreviations: AGB: Acute GI Bleed; HE: Hepatic encephalopathy; ALF: Acute liver failure
- Liver dialysis
Artificial liver support systems can be non-cell based or cell-based systems. Several non-cell based extracorporeal liver support systems like hemodialysis, hemofiltration, plasma exchange, charcoal perfusion have been used in the past with a goal to remove the putative toxins and inflammatory cytokines to allow additional time for the liver to recover or as a bridge to liver transplantation. However, in all these protein bound toxins are removed to only a minor extent.
Single pass albumin dialysis (SPAD) , molecular absorbent and recirculation system (MARS) and recently, Prometheus (FPSA–fractional plasma separation and adsorption) which remove both water soluble and protein bound toxins have emerged as liver support therapies in patients with acute and acute on chronic liver failure. Due to the relatively small pore size of the high-ﬂux membranes used, passage of large albumin molecules is hindered, while smaller compounds diffuse freely through the membrane. Substances with a molecular weight of more than 50 Kd are not removed because of the small pore size of the MARS membrane. In 1999, Falkenhagen et al. introduced fractionated plasma separation and adsorption (FPSA). In this system a special albumin-permeable ﬁlter with a cut-off of approximately 250,000 Dalton (250 kD) is used. Thus albumin and the protein-bound toxins pass through the membrane and are then directly removed from the blood by special adsorber within the secondary circuit. The Prometheus system which combines the FPSA method with high-ﬂux hemo-dialysis (of the blood) in an extracorporeal detoxiﬁcation system.
These newer developing therapies have demonstrated benefits in biochemical parameters, systemic hemodynamics, hepatic encephalopathy and also renal functions but are expensive and enough data is available on safety of these devices. They can be used as a bridge for spontaneous recovery or transplantation in patients with ALF. In patients with acute on chronic liver failure (ACLF) with hepatorenal syndrome or hepatic encephalopathy (without contraindications for transplantation )- to improve their chances to be listed and transplanted.
We at ILBS have the Prometheus system, the first of it’s kind in India and till date have done liver dialysis in 34 patients with total sessions 57. Amongst these 7 patients had acute liver failure and one patient had post-LDLT liver failure. Of these, 3 patients i.e. 42.8% improved without liver transplantation.
We at ILBS are also trying to develop our “bioartificial liver” with extracorporeal bioreactors containing hepatocytes which can provide additional synthetic and biotransformatory liver functions, which may be more effective than completely artificial systems like Prometheus which provide excretory capacity alone.
B: Endoscopy Services:
There was a substatntial increase in the endoscopy work as compared to previous years.
Abbreviations: Capsule E: Capsule endoscopy; SVE: Side-viewing endoscopy, EUS FNAC: Endoscopic ultrasound guided fine needle aspiration
Abbreviations: EVL: Endoscopic variceal ligation; APC: Argon plasma laser coagulation; HP: Heater probe; Glue: Glue injection; ERCP: Endoscopic retrograde chlolangiopancreatography, Others include Extra-corporeal shock wave lithotrypsy, Polypectomy and Achalasia Dilatation
C: Hepatic Hemodynamic Laboratory:
The hepatic hemodynamic laboratory is the back bone of Hepatology services. It provides detailed insight into the liver pressure which determines the outcome of patients with liver disease. The management of patients of liver disease is based on reduction in complications (such as variceal bleed, development of ascites and renal failure) and an opportunity to regenerate the liver. All this is done in a protocol and outcome based manner at the ILBS. Measurement of the hepatic venous pressure gradient (HVPG) is currently the best available method to evaluate the presence and severity of portal hypertension. Normal HVPG is 10 mm Hg (termed ‘clinically significant portal hypertension’ or CSPH) predicts the development of various complications of cirrhosis. Importantly, HVPG above 12 mmHg is the threshold level for variceal rupture and a reduction of HVPG to <12 mmHg or by 20% of baseline considerably reduces the risk of bleeding, mortality and other complications of cirrhosis, such as spontaneous bacterial peritonitis and hepatic encephalopathy. As per global guidelines, sequential HVPG measurements, are helpful to optimize drug therapy or switch to another form of therapy. The main advantages of the hepatic vein catheterization technique are its simplicity, reproducibility, and safety. Since its result has important implications, the appropriate and correct measurement of HVPG is an important issue both in research and clinical practice.
Because of its relatively invasive nature and domain skills, this facility is available in very few centers in the world. We at ILBS regularly perform this procedure taking due precautions that all the steps are performed accurately.
D: Hepatic Hemodynamic Laboratory
At ILBS we have been able to standardize and establish two tests of quantitative liver functions, Indo-cyanin green (ICG)and 13C-Methacetin Breath Test (MBT). The MBT is a non-invasive, real-time molecular correlation spectroscopy assay which measures in expired breath, the abundance of 13C02 produced by hepatic cytochrome P450 metabolism of ingested non-radioactive 13C isotope-labeled methacetin, an acetaminophen precursor. MBT has been shown to assess the degree of derangement of liver metabolism in cirrhotics and preliminary data suggests that it correlates with the severity of portal hypertension (PHT). We at ILBS, performed a pilot study on 28 patients of cirrhosis due to various etiologies to investigate if MBT correlates with HVPG. MBT Cumulative PDR30 (Percent Dose Recovered at 30 min.) was the best variable and correctly detected CSPH, with an AUROC of 0.94 p<0.0001 irrespective of etiology of cirrhosis. Also, the PDR value of 13C-methacetin metabolites (i.e. breath 13C02) 30 minutes post-ingestion (PDR30), correlated with the degree of portal hypertension and HVPG (r=-0.54, p=0.0027). Thus, it was concluded that MBT can be recommended as a valuable non-invasive surrogate marker for the assessment of clinically significant PHT.
NEW SERVICES AND FACILITIES:
- Clinical Nutrition Services: ILBS is the first institute to have started the as a sub-specialty, Clinical nutrition in hepato-biliary diseases. Majority of patients with liver disease do need nutritional assessment and support.
- Quantitative Liver Function tests: Indocyanine Green estimation (ICG 15) was added with the help of biochemistry department. This test measures liver function quantitatively, which is helpful in liver resections.
- Protocol based treatment: For patients with acute on chronic liver failure (ACLF), portal hypertension and variceal bleeding, hepatitis B and C and non-alcoholic steatohepatitis (Fatty liver disease), the department has been able to standardize the treatment protocols. Other protocols are under development.
- Patient support services: For patients with hepatitis B and C, and portal hypertension, a highly skilled and trained nurses are now available to monitor the patient treatment and outcomes.
- Dr. Shiv Kumar Sarin, Sr. Professor
- Dr Y K Joshi Sr Professor (Clinical Nutrition)
- Dr. Seema Alam, Additional Professor (Pediatric Hepatology)
- Dr. Vikram Bhatia, Associate Professor
- Dr. Manoj Kumar, Associate Professor
- Dr. Hitendra Garg, Assistant Professor
- Dr Rajeev Khanna, Assistant Professor (Pediatric Hepatology)
- Dr Rakhi Maiwall, Assistant Professor
- Dr Chitranshu Vashishtha, Assistant Professor
- Dr. Dinesh Rawat , Assistant Professor (Pediatric Hepatology)
- Dr. Kapil Kumar Sharma,Assistant Professor
- Dr.Jaya Benjamin Assistant Professor (Clinical Nutrition)
- Dr. K N Chandan kumar, Assitant Professor
- Dr. Mohd. Zakir, Jr. Resident
- Dr. Varsha Shasthry, Jr. Resident
- Dr. Pawan Wagle, Jr. Resident
- Dr. C Molu Ozukum, Jr. Resident
- Dr. Sanjeev Kumar Kasana, Jr Resident
- Dr. Shahid Akhtar, Jr Resident
- Dr. Ripu Daman, Jr Resident
- Dr. Rahul Verma, Jr Resident
- Dr. Sandipan Chandra, Jr Resident
- Dr Manoj Marutirao, Jr Resident
- Dr Vibha Tandon , Jr Resident