Hepatology

Hepatology

Our mission is to develop Hepatology as a comprehensive discipline of medicine which can provide distinctly advanced and protocol based patient care, training and clinical and translational research. The Hepatology department at ILBS provides emergency and elective management to patients with liver, biliary and pancreatic diseases by a highly specialized and 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 alcoholic liver disease, non-alcoholic fatty liver disease (NAFLD), hepatitis B and C , A and E, auto-immune hepatitis, drug induced liver disease, and all causes of jaundice and liver failure are attended to. Gall stones and bile duct stones, pancreatic diseases, liver, gall bladder and GI cancers add to the specialized care. The following advanced care services are routinely offered through the hepatology department:

A). Liver Intensive Care:

The institute has established one of the finest liver intensive and critical care services with specialized rapid response teams. The LICU teams include specialists from Hepatology (Dr. Rakhi Maiwal I/c, Dr Rajan) and the Critical Care team(Dr. Lalita Gauri Mitra, Dr Prasant and Dr Vandana) round the clock. We provide care guided by a protocol-based treatment and rapid response by a multidisciplinary team ably supported by the nephrology, cardiology, pulmonology teams.

B). Viral Hepatitis (A,B,C,E) and Hepatocellular Carcinoma Services:

C). Alcoholic liver disease:

At ILBS, alcoholic liver disease is the most common diagnosis requiring admission. ALD constitutes more than 40% of our in-patients and 2/3rds of our patients with acute-on-chronic liver failure. We have protocol based treatments available for alcoholic hepatitis patients led by Dr Shasthr. We have recently shown survival benefits in patients not responding to the standard of care with growth factors and those not eligible for standard of care with use of new protocols using fecal microbiota transplantation (FMT) from a healthy donor. We further are trying to standardize protocols, which could in future become the standard of care in the management of severe alcoholic hepatitis patients.

D)Liver stiffness and fat measurement :

Early diagnosis and intervention can lead to a substantial reduction in morbidity and mortality from all conditions that lead to cirrhosis. Liver stiffness is important for evaluating the stage of liver fibrosis. The transient elastograpy (FibroScan®) technique measures the liver stiffness. This is used to quantify hepatic fibrosis in a totally non-invasive and painless manner, with no contra-indications for the patients. FibroScan allows accurate assessment of liver fibrosis resulting from all chronic pathologies that cause damage to the liver, including metabolic syndrome and non-alcoholic fatty liver disease, chronic viral hepatitis and excess alcohol intake. In the early stages of liver disease tests and conventional ultrasound have a poor predictive value in assessing fibrosis. Liver stiffness measurement is the ideal diagnostic tool to accurately identify liver fibrosis and fat quantification and is being increasingly used at ILBS.

E). Endoscopy Services:

The department of hepatology providesmost comprehensive endoscopic services- both diagnostic and therapeutic. Our spacious endoscopy unit has seven fully equipped rooms- two for gastroscopy, one for colonoscopy, one each for endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), cholangioscopy, Intraductal ultrasound, one balloon enteroscopy room, and one room for extra-corporeal shock wave lithotripsy (ESWL). Experienced endoscopists, nurses and anesthesiologists receive all patients in a spacious day care reception area, where they are assessed pre-procedure. All elective endoscopic procedures at ILBS are carried out with tailored sedation provided by consultant anesthesiologists. Patients undergoing prolonged procedures, and high-risk patients are administered general anesthesia with elective endotracheal intubation and ventilation. After the procedures, patients are monitored in a segregated post-procedure observation area with full monitoring facilities and privacy. The services are efficiently supervised by a Resident Medical Officer, Dr. Sakshi.
We have a round–the-clock gastrointestinal bleeding service and a round the clock, GI Bleed unit with consultant endoscopists on 24-hour call. The highlights of the gastrointestinal bleeding service include a fully equipped ambulance with on-site resuscitation facilities, to triage at admission, and all endoscopic therapeutic procedures. These include variceal banding and injection, glue injection, thermal coagulation, argon plasma coagulation (APC), and hemostatic metallic stent implantation, Dennis Ela stent placement. We take pride in having the shortest ‘door to endoscopy’ time, which is unrivalled by any other hospital.
Our interventional radiology services work in tandem, and provide salvage angioembolization , TIPS and BRTO services for difficult to control or inaccessible bleeding sources. ILBS has one of the largest experiences in emergency TIPS stent placement. All patients with gastrointestinal bleeding are managed in an intensive care setting.
We provide comprehensive pancreato-biliary endoscopy services. These include Extra-corporeal shock wave lithotripsy (ESWL) to fragment pancreatic and bile duct stones, therapeutic ERCP, and diagnostic and therapeutic endoscopic ultrasound (EUS) procedures. We have the experience of one of the highest EUS procedures done in the country. All our EUS procedures are done under anesthesia, providing unsurpassed patient comfort and safety. We are the one of the center to have dedicated on-site cytopathology services, with EUS sampling adequacy rates exceeding 97%. We are routinely doing intra-gastric balloon (IGB) placements for management of patients with morbid obesity with perceivable results. Forty-four IGB placements were done in 2018 alone.

We have the second generation cholangioscopy system and intra-ductal ultrasound systems for difficult biliary pathologies. We also have the holmium laser fiber system for cholangioscopic treatment of difficult bile duct stones. We are also introducing magnification and image-enhanced endoscopy, contrast-enhanced EUS, EUS-elastography, miniprobe sonography, and in-vivo histology by using probe-based laser confocal system. We are setting up a state-of-the art data archiving and management system, for audit and research purposes. Our endoscopy informatics system is integrated with the hospital PACS system.

The goal of endoscopy services at ILBS is amalgamation of cutting edge technology with a humane touch. We strive to make endoscopy a pleasant experience for all patients, with attention to small details including lockers for personal belongings, clean clothes and towels, clean toilet facilities, and post-procedure discussion of the findings. Our smiling and pleasant staff is trained to put patient apprehensions at ease.

There is ever increasing load of Endoscopic Procedures  through the years as shown in figures below.

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

F). Hepatic Hemodynamic Laboratory:

 

The hepatic hemodynamic laboratory is the backbone of Hepatology services. Under the supervision of Dr. Ankur Jindal, it provides detailed insight into the liver pressure which determines the outcome of patients with liver disease. Measurement of the hepatic venous pressure gradient (HVPG) is currently the best available method to evaluate the presence and severity of portal hypertension. Other unique features of this laboratory are accurate measurement of Pulmonary pressures, which is helpful in accurate diagnosis of porto-pulmonary hypertension and measurement of cardiac output; and simultaneous liver biopsy sampling even in patients with ascites and liver disease enabling accurate diagnosis and severity of 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. Normal HVPG is <5 mm Hg and an HVPG >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. We are currently running protocols on HVPG response based approaches on primary prophylaxis of variceal bleed in cirrhotics and HVPG based approach for managing acute variceal bleed. 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 with precision and patient safety.

G). Clinical Nutrition

 

Over the last six years since its inception the Department of Clinical Nutrition is committed to patient care, along with nutrition education and research in collaboration with all the other departments at ILBS. Services for a detailed assessment of the nutritional status using a bioelectrical impedance analysis and anthropometry are provided by the department. Besides this the indirect calorimeter is the new research artillery in the department’s arsenal. More than 300 liver disease patients with NAFLD and obesity are in regular follow-up with the “Liver Nutrition Clinic” in the OPD. Several nutrition related research projects are also underway for the fulfillment of the degree of PhD, DM, MCh and DNB students. The department is also actively involved in the teaching activities scheduled for its residents, nursing students and faculty.
 

Courses Offered : DCC and Ph.D. in clinical nutrition

Three bright students are presently pursuing PhD in the department.

Resident Achievements:

Ms. Harshita Tripathi
Oral presentation at APASL Liver Meeting, 14-18th March 2018, New Delhi, India. "Aggressive Nutrition Therapy Significantly improves 28 Day Survival in Critically Ill Cirrhotics with high Nutrition risk as Assessed by NUTRIC Score"

Dr. Varsha Shasthry:

I). Liver regeneration and stem cell therapy

Only about 2-5% of patients, with advanced cirrhosis are able to get liver transplant. Lack of a donor, very advanced stage, financial and social issues are the major limitations. There is therefore an urgent need to provide alternative methods of maintaining and improving liver functions. In this regard, emerging science of regenerative medicine is considered an effective alternative therapeutic approach that can effectively manage the necro-inflammatory death of hepatocytes, potentiate immunomodulation and thus promote native liver regeneration and repair.

In cirrhosis as well as in ACLF, the supportive signals for liver to regenerate get severely compromised and liver microenvironment becomes impermissible for regenerating cells, resulting in reduced liver mass and function. Potential of stem cells to differentiate into multiple cell lineages raises the exciting possibility that these cells can be used in repair and liver regeneration, when resident stem cells are not sufficient for the regeneration of a failing liver During liver regeneration, bone marrow-derived hematopoietic stem cells (HSC) may mobilize to the liver and, together with hepatocytes and intrahepatic stem cells, contribute to the proliferation of liver cells. Mechanistically, the approaches attempting to augment bone marrow stem cell can be divided into two main categories: enhancement of the endogenous stem cell response and augmentation of cell-based therapies by transplantation. The field of liver regeneration is led by Dr. Rajan, Dr Anupam and Dr. Chhagan Bihari at ILBS. The trio under the guidance of Prof Shiv Sarin has done many seminal works in the field of regenerativemedicine. Growth factor administration was shown to be a simple and novel method of mobilizing BMSCs. We at ILBS, have successfully used growth factors like granulocyte colony stimulating factor (G-CSF) and erythropoietin to mobilize stem cells to the periphery in patients with advanced cirrhosis and ACLF and shown survival benefit in a subgroup of these patients. It was shown that there is a senescence of bone marrow in patients with advanced cirrhosis. Patients with early decompensated cirrhosis (MELD<16) and those with a healthy cellular baseline BM respond better to growth factor therapy. Based on these concepts, growth factor administration after proper selection of patients is now a part of routine treatment of CLD patients at ILBS, particularly in those not having any option of transplant.

Several laboratorial and clinical studies showed that various cells, including mature hepatocytes in adult liver (adult HCs), fetal liver cells (FLCs), hepatic stem/progenitor cells (HSPCs), mesenchymal stromal cells (MSCs), are the potential sources of cell based therapies for liver failure, including acute on chronic liver failure as well as acute liver failure. Thus, our future endeavour in this field of regenerative hepatology includes novel interventional approaches, including transplant of bone marrow cells and/ or exosome infusion from allogeneic healthy bone marrow in the management of cirrhosis. Also we are studying the role of MSC transplant in management of ACLF patients. Utilization of macrophage therapy and/or CSF1 is also in our pipeline projects. Recently, in collaboration with IIT Kanpur, we have worked on a bio-artificial Liver (BAL) device tomeet the metabolic demands of body. We have also worked on an emerging new approach of using decellularized liver for this purpose. We aim for a future in which no patient with liver disease dies due to failure to get liver transplant.

With this aim and with a strive to become a centre of Excellence for Hepatic Regenerative Therapies, ILBS has received grant from Department of Science and Technology (DST) for a project titled “Development Of Non-Transplant Therapeutic Strategies For Advanced Liver Diseases”; phase 1 of which is ongoing.

J). Transplant Hepatology

 

Liver disease either acute or chronic when failed to improve with medical management, liver transplant is the therapy. Acute liver failure or acute on chronic liver failure require emergent transplant where as end stage liver disease needs a prompt and timing decision for the same. Our transplant team led by Prof Shiv K Sarin and monitored by Dr Ashok Choudhury. The students get unique opportunity to be exposed to this highly specialized care during their posting that includes pre transplant evaluation of donor and recipient, pre transplant optimization and post transplant follow up. ILBS is the only public sector hospital in Govt setting to have a successful transplant programme with 101, 93, 87 and 99 liver transplant per year in 2015, 2016, 2017 and 2018 respectively. This is possible due to able lead by Transplant Surgery team by Prof Viniyendra Pamecha and Dr Senthil Kumar. Cadaver transplant, as well as mantainace of transplant waiting list in strict accordance of the NOTTO Guideline is a great achievement where nearly 250 patients were routinely followed by Transplant hepatology team and record maintained by Transplant Coordination department led by Mrs Vibhuti-a passionate and dedicated person. The immediate post transplant care is offered by surgical, medical and anaesthesia resident doctors, nursing staff; 24x7 phone support (transplant SR on call mobile no-+91 7835055601), whatsapp support (mobile no-+91 9650951049), email (livertransplant@ilbs.in) and a dedicated post-transplant ward supervised by Dr Ashok Choudhury. Post transplant complications are uncommon; and if they occur, they are managed well. These include progressive multifocal leukoencephalopathy (PML), late onset antibody mediated rejection (AMR) in ABO compatible transplant, Graft Versus Host Disease (GVHD), post-transplant lymphoproliferative disease (PTLD), post LT malignancies. An algorithmic approach to post-LT Biliary complications is undertaken by ERCP or PTBD. International (7) and national (15) fellows had been trained on transplant hepatology till date. Training of manpower (Fellowship on transplant hepatology, transplant critical care and transplant immunology, transplant nursing and co-ordination), academic excellence, translational research (noninvasive methods for early detection of graft rejection, cell based therapy for steroid resistant rejection and immunoscan, etc.) and strategies to increase organ donation awareness, organ retrieval and promotion of cadaver transplant are in pipeline for the future.

K). 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.

L). Patient support services

For patients with hepatitis B and C, and portal hypertension, highly skilled and trained nurses are now available to monitor the patient treatment and outcomes.

 

Liver Helpline

A dedicated 24 hour toll free no.1-800-11-5354 has been designated as “Liver Help Line” for the benefit of patient and their relatives. Questions related to liver diseases are answered round the clock by hospital emergency staff at this telephone number. Liver helpline also functions as telephone triage service and depending upon the urgency it helps patients and their relatives directed towards seeking appropriate level of health care.

Training and CME

Regular training programs are conducted for BLS and ACLS certification. Resident doctors, casualty medical officers, nurses and technicians have regular access to high quality clinical CMEs at the institute.

New services & facilities

EDUCATIONAL ACTIVITIES:

 

Courses Offered

 

Asia Pacific Association For Study Of Liver (Apasl) School Of Hepatology :

APASL School of Hepatology at ILBS, New Delhi, India offers a continuous teaching and training covering diverse aspects in the field of Hepatology. A combination of lectures, clinical case-based discussions, and training in various procedures, with intense interaction and time for personal discussion and personalized training. The major goal is to induct and train new generation of hepatologists. By inviting young fellows or faculty enrolled in hepatology-oriented departments throughout Asia, who want to be exposed to the newest trends in hepatology, the APASL School of Hepatology would achieve the unmet needs of the region.

Till now ILBS has trained 25 trainees in Hepatology through the APASL School of Hepatology.

World Gastroenterology Organization (Wgo) New Delhi Training Center:

The New Delhi Training Center at ILBS was inaugurated in New Delhi, India on April 26, 2015 as a WGO Training Center. The New Delhi Training Center mission is to to induct and train new generation of Hepatologists, provide continuous teaching and hands on training covering diverse aspects in the field of Hepatology and focus on the development of academic physicians in hepatology who will excel and become leaders in the field. The first batch of trainees will start their training in 2019.

Other Training Opportunities In Department Of Hepatology:

Besides APASL School of Hepatology and WGO Training center, ILBS also offers individualized hands on training courses according to needs of the candidates.

Department’s Achievements

Department Research activities : Department is actively involved in clinical as well as basic research in varied areas such as Portal hypertension and its complications, Viral hepatitis, Alcoholic liver diseases, Non alcoholic fatty liver disease, Acute Liver Failure, Acute on Chronic Liver Failure, Kidney injury in Liver diseases, Liver regeneration, Liver transplant. In the year 2018, due to increased burden and challenges in the field of hepatocellular carcinoma, the department has started work in immunotargeting and immunotherapy for HCC.
Department of hepatology has given important contributions to developing guidelines for treatment of various hepatological diseases like APASL guidelines for hepatitis B, hepatitis C, liver fibrosis, hepatocellular carcinoma, variceal bleed, non-cirrhotic portal hypertension, International ascites club guidelines for AKI in cirrhotics. Department is also involved in developing novel therapies for liver diseases like regeneration therapies of liver using growth factors, fecal microbiota therapy for severe alcoholic hepatitis, newer biomarkers for liver cancer, AKI etc.

APASL ACLF Research Consortium (AARC)- Largest Multinational Research Project in Liver Diseases across Asia

Liver disease is a major health burden. To have a reserchcollboration and exchange of science and knwoledge in general and “Acute on Chronic Liver Failure (ACLF)” in particular , the APASL-ACLF Research Consortium (AARC) was initiated by Asia Pacific Association for Study of Liver (APASL) under dynamic leadership of Prof Shiv Kumar Sarin. Started in early 2005 and upscaled in 2008 with a small group of like minded investigators developed the first consensus on ACLF, which was published in 2009. Subsequently, it is the contribution by all serious investigators across Asia working in this field, and unparalleled support from the APASL to hold the regular updates and consensus meetings and finally publishing our revised ACLF guidelines in 2014. Today, AARC has become one of the largest databases having more than 5400 cases from Asia (50 centre, 16 countries).
The vision of AARC is to develop a collaboration of likeminded clinicians, researchers to work on ACLF, formulate the practice guideline, follow the evidence based treatment and also to make the unified approach to this disease across the globe.

Facilities and Research Work
Protocols and Collaborative Research : AARC is actively doing the multicentric prospective reserch on various aspects of ACLF. Centres from Korea, China, Pakistan, Bangladesh as well as India doing multiple projects.
Publications : Till now 6 manuscripts under AARC have been published. A strict manuscript policy has encouraged more and more publications in pipeline in leading journals like-hepatology, hepatology international, liver international and many others. AARC has shown its interntional presence with good number of research papers as abstarct in most of the liver conferences including-AASLD, EASL, APASL, ILTS and others.
Sample Collection : Blood samples are collected of patients who give their consent for the same. It is proposed to keep them stored at -80 C.Nodal centre has facility for sample storage and thus encourages all the members to ship the samples to the centre for proper storage, which is readily available for future use by the respective centres.
The AARC nodal centre conducts monthly video conference in the Zoom cnference paltform with nodal centre being the host and other centre do join regularly to discuss the protocols, conflicts and scentific discussions. Till now AARC conducted 50 such confrences which is sheduled for the third Friday of everymonth.

The Journey so far :

ILBS hosted the 4th AARC Consensus Update, which was attended by 120 national and international experts from all countries across the Asia and a robust Pan Asia data of 5400 patients of ACLF was analyzed and consensus was updated. The work was co-ordinated by Dr Irene and Priyanka, under the supervision of Dr Ashok and guidance of Dr Sarin.

Resident’s Achievements:

Dr. Shakti Prasad Received 'Young investigator award and best abstract award’ for presenting his work on ‘Continuous infusion of terlipressin is more effective and safe than bolus administration in HVPG reduction in patients with acute esophageal variceal bleed- A randomised controlled trial’ at AASLD , USA.

Dr. Anand Kulkarni

APASL transplant quiz winner(first prize) with honorary membership in march APASL 2018 plus cash prize (10,000)

Visiting faculty to the department in 2018