Hepatology

Adultcritical Carehepatology Services:

Hepatology Department offers diagnosis and treatment of hepatobiliary diseases including alcohol associated liver disease, metabolic dysfunction associated fatty liver disease (MAFLD), hepatitis B and C, A and E, auto-immune hepatitis, drug induced liver disease, storage disorders, gall stones and bile duct stones, pancreatic diseases, and hepatobiliary cancers among other diseases

• 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 dedicated specialists from the Hepatology team (Dr. Rakhi Maiwall I/c, Dr Harsh Tevethia) and the Critical Care team (Dr. Deepak Tempe, Dr Prasant Aggarwal and Dr. Priyanka) 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, and pulmonology teams.

• Acute Gastrointestinal (GI) Bleeds:

  Patients with acuteGIbleedareseen immediately in the emergency room and appropriate treatment (including endotherapy, interventional radiology procedures etc.) is given immediately.

  There is a separate Gibleed ICU of 5 beds, which is looked after by Dr. AnkurJindal, Additional Professor, Hepatology, which maintains protocol-based treatment for acute UGI bleeds in portal hypertensive patients.

• Hepaticcoma:

  Hepaticencephalopathy is the occurrence of confusion, alteredlevelof consciousness, and comaasaresult of liver failure. New approaches includinguse of ammonia and bilirubin filters, continuous renal replacement therapy (CRRT) and plasma exchange (PLEX)have helped improve outcomes

• Acute Liver Failure:

  Acute liver failure is the appearance of hepatic encephalopathy rapidly after jaundice, and indicates that the liver has sustained severe damage. Common causes include HepatitisE, HepatitisA, drugs, herbal and food supplements. ILBS has beeninvolved inthe treatment of ALF patients with a rapid response team working round the clock and with the a vailability of urgent liver transplantation the outlook of this disease has improved substantially. Specialized monitoring with Optic Nerve Sheath Diameter (ONSD) measurement and transcranial Doppler improved our diagnostic capabilities. Apart from this, we do therapeutic PLEX whichremovesawidearrayofinflammatorytoxinsand cytokines, endotoxin, damage associated molecular patterns and facilitates recovery of the failing liver. We have done this therapy in more than700 patients in our ICU in 2023.

• Acute on Chronic Liver failure (ACLF):

  Liver failure can also develop on pre-existing liver disease, called as acute-on-chronic liver failure (ACLF). This entity was first defined in India and ILBS has henceforth carried intensive research in this disease and developed effective treatments for this deadly condition. ILBS serves as the nodal center for the Asian Pacific Association for the Study of the Liver ACLF Research Consortium (AARC) coordinated by Dr. Vinod Arora.

  At ILBS, there has been an ever-increasing referral of patients for management of these emergencies as shown in the figure below.

• Liver dialysis :

  Artificial liver support systems have been used 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. These include, molecular absorbent and recirculation system (MARS) and Prometheus (FPSA–fractional plasma separation and adsorption) which remove both water soluble and protein bound toxins. These newer therapies can be used as a bridge for spontaneous recovery or transplantation in patients with ALF and acute on chronic liver failure (ACLF) These therapies have also been effectively offered to patients with Drug induced liver injury , hemophagocytic lymphohistiocytic syndrome, intractable pruritus secondary to intrahepatic cholestasis and autoimmune hepatitis who have failed steroid therapy. 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

• Acute Kidney Injury (AKI): is a frequent and ominous complication in critically ill cirrhosis patients. At ILBS, we have the facility to perform biomarkers (like cystatin C and urine neutrophil gelatinase associated lipocalin) for diagnosis and prognosis of AKI. Our liver intensive care is equipped with 24x7 dialysis services and offers with the help of able nephrology team, intermittent hemodialysis, slow low exchange dialysis (SLED) as well as CRRT. We have done more than 6500 SLED procedures and more than 1950 CRRTs in patients with liver failure with AKI in 2023. We are the first center in the world globally to demonstrate in a randomized controlled trial the benefits of early initiation of dialysis in septic shock in incidence of renal recovery. We are also using several blood purification devices therapies. We have the largest experience in the country and have successfully performed blood purification therapies in around 199 patients with refractory septic shock and/or severe acute respiratory distress syndrome with favorable results

• Assessment and Management of Coagulation Failure: Critically ill patients with liver disease frequently have coagulation abnormalities. Unlike conventional coagulation tests, newer viscoelastic tests (like ROTEM and TEG) dissects the dynamics of clot formation, ultimate clot strength, and the stability of the clot. In 2023, we performed more than 5000 of these tests for managing the coagulation failure in these critically ill patients.

• End of Life Care : In patients with cirrhosis, end of life is an important aspect of care. As a part of this, care is focused on palliating a terminally ill patient's pain and other symptoms and attending to their and their family's emotional and spiritual needs.

OTHER PATIENT SERVICES AT HEPATOLOGY DEPARTMENT:

• Hepatitis B and C : These are common causes of chronic liver disease in India and nearly 45 and 12 million people are estimated to be infected with these viruses in India respectively. They are also common causes of cirrhosis and liver cancer in India. The area is led by Dr Ankur Jindal and Dr Ashok Choudhury.

  ILBS sees one of the largest referrals for Hepatitis B, C and Liver cancer as shown in figure. Options for HCC include resection, Liver Transplantation, loco-regional therapies (including trans-arterial chemoembolization, radio-frequency ablation, microwave ablation), stereotactic radiotherapy, and systemic/immunotherapies as per protocol.

  A. MWA probe into the tumour site injected	B. Superselective DEB-TACE catheter with lipioidal seen inside the tumour

• Alcohol associated liver disease (ALD):

  At ILBS, liver disease due to alcoholic use 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. [Figure] We have protocol-based treatments available for alcoholic hepatitis patients led by Dr Shasthry S M. We are trying to standardize protocols, which could in future become the standard of care in the management of severe alcoholic hepatitis patients.

• 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. Controlled attenuation parameter (CAP) gives measurement of liver fat, recently splenic stiffness has been used for evaluation of portal hypertension. Splenic stiffness can also be used for prognosticating cirrhosis patients.

  ILBS has six such machines, which provide rapid and regular services to increasing number of patients. In addition to 22047 liver stiffness measurements we have also done, 6616 splenic stiffness measurements in 2023.

• Endoscopy Services :

  The department of hepatology provides most comprehensive endoscopic services- both diagnostic and therapeutic, with Dr Vikram Bhatia as overall incharge. Our spacious endoscopy unit has seven fully equipped rooms- two for gastroscopy, one for colonoscopy, one each for endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultra sound (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. 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 Officers, Dr. Ishan and Nitin Sharma.

  ‘’Our interventional radiology services work in tandem, and provide salvage angioembolization, TIPS, BRTO, PARTO or CARTO services for difficult to control or inaccessible bleeding sources. ILBS has one of the largest experiences in emergency TIPS stent placement.

  We provide comprehensive pancreato-biliary endoscopy services. These include Extra- corporeal shock wave lithotripsy (ESWL) to fragment pancreatic and bile duct stones, therapeutic ERCP, cholangioscopy, and diagnostic and therapeutic endoscopic ultrasound (EUS) procedure, intraductal ultrasound, contrast – enhanced EUS, EUS – elastography, miniprobe sonography etc. 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. Approximately 150 IGB placements have been done so far in 2023

  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.

• 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 and right heart studies, which are helpful in accurate diagnosis of porto-pulmonary hypertension and measurement of cardiac output. Simultaneous liver biopsy sampling through the transjugular route is done in patients with ascites and liver disease enabling accurate diagnosis and severity assessment of liver disease.

  ‘’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. Taking due precautions that all the steps are performed with precision and patient safety.

  Number of procedures for Transjugular liver biopsy (TJLB), HVPG: Hepatic vein pressure gradient (HVPG)

• 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. The field of liver regeneration is led by Dr. S. K. Sarin, Dr. Rakhi, Dr Anupam and Dr. Chhagan Bihari at ILBS. ILBS has done many seminal scientific works in the field of regenerative medicine. Growth factor administration was shown to be a simple and novel method of mobilizing BMSCs.

  ILBS is also researching on cell-based therapies (including mesenchymal stem cell, macrophage therapy), transplant of bone marrow cells and/ or exosome infusion from allogeneic healthy bone marrow for liver failure. ovel interventional approaches, including Recently, in collaboration with IIT Kanpur, we have worked on a bio-artificial Liver (BAL) device and use of 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

• Transplant Hepatology :

  Our transplant hepatology team is led by Prof Shiv K Sarin and assisted by Dr Ashok Choudhury and Dr Satender Pal Singh. ILBS is one of the few public sector hospitals in Govt setting to have a successful transplant programme with nearly 100 cases per year of transplant with a total of more than 1000 cases done till date and the number is increasing. This is possible due to able lead by Transplant Surgery team by Prof Viniyendra Pamecha. Cadaver transplant, as well as maintenance of transplant waiting list in strict accordance of the NOTTO Guidelines is a great achievement where nearly 500 patients were routinely followed by Transplant Hepatology team and record maintained by Transplant Coordination department led by Ms. Vandana, a passionate and dedicated person. The immediate post-transplant care is offered by surgical, medical and anaesthesia resident doctors, nursing staff and dedicated team round the clock for any emergencies and a dedicated post-transplant ward. Post-transplant complications are uncommon; and if they occur, they are managed well. Translational research (noninvasive methods for early detection of graft rejection, cell-based therapy for steroid resistant rejection and immunoscan, etc.) is being carried out and various strategies to increase organ donation awareness, organ retrieval and promotion of cadaver transplant are our priority areas.

• Protocol Based Treatment :

  For patients with acute on chronic liver failure (ACLF), portal hypertension and variceal bleeding, hepatitis B and C, hepatic coma, SBP, and Alcoholic hepatitis, the department has been able to standardize the treatment protocols.

• Patient Support Services :

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

• Clinical Nutrition Services :

  Clinical nutrition services provided include a detailed assessment of the nutritional status using a bioelectrical impedance analysis, anthropometry and indirect calorimetry; and nutritional advice and management as appropriate. Several nutrition related research projects are also underway for the fulfillment of the degree of PhD, DM, MCh, DNB, PDCC and PGCC students. The department is also actively involved in the teaching activities scheduled for its residents, nursing students and faculty. Nutrition services lead by Prof Y K Joshi and Dr Jaya Benjamin.

Training and CME

Regular training and education 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.

Services Rendered

New services & facilities

• Fecal (Stool) Microbiota Transplantation (FMT) Unit : The human microbiota consists of trillions of microorganisms found in the human body, with the majority of organisms colonizing the gut from mouth to colon. Gut microbiota dysbiosis (imbalances in the composition and function of these intestinal microbes) have pivotal role in the development and progression of many of the liver diseases and their complications, most importantly - non-alcoholic steatohepatitis, alcoholic liver disease, alcoholic hepatitis, hepatic encephalopathy, sepsis in liver diseases etc. Fecal (stool) microbiota transplantation (FMT) involves acquiring healthy microbes from a related donor and then instilling these into the GI tract of the diseased individual. At ILBS, FMT is being used as a novel method in the treatment of severe alcoholic hepatitis, alcohol use disorders, and severe reactivation of hepatitis B virus. The work in the FMT lab is co-ordinated by Dr Shasthry, with the help of Dr. Pratibha, Dr Vikas Khillan and Dr S K Sarin.

• Albumin Ward : Due to increased demand of day care services like large volume paracenteses, pleural fluid paracentesis (in hepatic hydrothorax) albumin infusions etc. we have opened a new albumin day care in Phase-2, first floor since June 2017. The ward offers facilities to the needy patients in three shifts, with prior appointment. Dedicated telephone extension has been allocated to take appointments to avail the day care facilities- [Albumin Day Care Phone No. 011-46300000-Extn: 22152]. The ward is catering over 700-800 patients a month since its inception. 3 shifts are being run where about 15-20 patients per shift undergo paracentesis and receive albumin infusion. In the year 2023, this day care has served 5621 patients. The service is supervised by Dr Shasthry S M and Dr. Varsha.

Medical Educational Activities

• World Hepatitis Day, which took place on July 28th, 2023, aimed to raise awareness about the global burden of viral hepatitis and encourage action towards its elimination. The theme for 2023 was "We're not waiting. Hepatitis Can't Wait. "
• Decisions Reasoning Innovations Learning in Liver Diseases (DRILLS- 2023) an interactive case based annual workshop was organized by ILBS on 3-4 June 2023, with 1250 delegates attending the event. The unique format of DRILLS included presentation of multiple real-life clinical cases; the diagnostic dilemmas faced by the treating unit; the challenges in making treatment choices, and discussion on key diagnostic and management issues with active participation from the delegates, moderators and experts alike.
• 4th Annual National Conference on Critical Care & Infections in Liver Diseases (CCILBS)” with a theme “Managing Patients with Liver Failure; Challenges made easy” was organized from 3rd to 5th March 2023 (3 Days) under the aegis of Indian National Association for Study of the Liver (INASL).
• International Liver Cancer Course (ILCC) 2023 was organized on 13th to 15th Oct 2023 at ILBS with an aim to provide a platform for the exchange of the latest advancements, research findings, and clinical experiences in the field of liver cancer treatment and management.
• Hot topics at AASLD 2023 was a web based meeting (11-12 Dec 2023) providing updates on latest developments at AASLD 2023 which was held in Boston, USA. 3500 delegates attended these sessions.

DEPARTMENT OF HEPATOLOGY CLINICAL TRAINING PROGRAMES:

DM Hepatology and PhD Hepatology courses:

Many trainees and students visited ILBS for observer ship in Department of Hepatology.

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. 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. (APASL) School of Hepatology has also started virtual e-Learning seminar series (three series completed till now) for students and fellows .

Asia Pacific Association Study of Liver (APASL) Liver Cancer Preceptorship Program (ALCAP) The Asia Pacific Association for the Study of the Liver (APASL) Liver Cancer Preceptorship Program (ALCAP) is an educational initiative designed to equip healthcare professionals with comprehensive knowledge and skills in the diagnosis and management of liver cancer. It focuses on the specific needs and challenges faced in the Asian Pacific region, where liver cancer is a major public health burden. Currently monthly online sessions are being organized under this program.

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 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. Till now 4 candidates from different countries have been trained under this training program.

Other trainees at ILBS:

Many trainees and students visited ILBS for observership and hands on training in Department of Hepatology.

Faculty visited department/Delivered lecture

Department's Achievements :

American Association for the study of the liver (AASLD), Boston, USA Nov 10-14, 2023 The following faculty members presented the following abstracts in the AASLD meeting

Dr. Harsh Vardhan Tevethia
Role of splenic stiffness in the prediction of variceal bleed (VB) in patients with cirrhosis- SAVIOR study

Dr. Rakhi Maiwall
A randomized controlled trial comparing sustained low efficiency dialysis with continuous renal replacement therapy for sepsis-associated acute kidney injury in critically ill patients with cirrhosis Efficacy of vitamin C on AKI outcomes in critically ill patients with cirrhosis and multidrug-resistant bacterial infections- a randomized controlled trial.
Efficacy of targeted and response guided albumin therapy versus standard medical treatment in outcomes of recurrent ascites in patients with decompensated cirrhosis Serum cystatin C predicts the development of acute kidney disease and worse outcomes in patients with refractory ascites- a prospective cohort study.
A simple dynamic score ILBS-ALF-dynamic score (ILADS) reliably predicts mortality in acute liver failure patients with cerebral edema. Early liver transplant may improve outcomes in patients with antitubercular therapy related acute liver failure-(ATT- ALF) a prospective cohort study

Dr. Ashok Kumar Choudhury Alcohol-related etiology is an independent predictor of in patient mortality in patients with cirrhosis in a prospective global consortium.

Dr. Jaya Benjamin Branched chain amino acids supplementation improves muscle mass, muscle function, and frailty inpatients with liver cirrhosis : a randomized controlled trial

• APASL COVID-19 Liver Injury Spectrum (APCOLIS) Study is a multinational data base of Asian Countries on Liver disease patients infected with SARS COV-2. This study found that Cirrhosis patients have high mortality with COVID-19, and APACOLIS score was an excellent predictor of mortality in such cases.
• TIPS was better than Danis-Ella Stent for refractory variceal bleeding.
• Stool bacteria for predicting infections in cirrhosis and ACLF
• Fecal microbiota transplantation (FMT) is superior to prednisolone therapy in patients with severe alcohol associated hepatitis.
• Newer approaches to managing hyponatremia
• Role of newer anticoagulants in portal vein thrombosis
• AKI, Ascites research
• Acute variceal bleed- Role of Tranexamic acid
• Methods to improve frailty in cirrhosis
• Newer markers and treatments for AKI, Septic shock.

• Priti Jain Comparison of bolus versus continuous infusion of terlipressin in cirrhotic patients with septic shock: a randomized controlled trial
• Varsha Shasthry It’s time to redefine calorie targets in critically ill ventilated patients with liver cirrhosis – evidence from indirect calorimeter based randomized controlled trial
• Harshita Tripathi Saturated fat favourably alters the gut microbiota and improves survival in patients with severe alcoholic hepatitis: a randomized controlled trial.
• Hitesh Singh and Dr. Priti were nominated for Annual Scientific Meet ‘Current Perspective of Liver Disease (CPLD 2023)’ held from 25th – 26th February 2023 at Department of Hepatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India.
• Jitendra Kr. Singh, Sr. Resident, DM (Hepatology) was nominated for the Young Clinician's Program (YCP) organized by ISG from Oct 6-8, 2023 in Chennai.
• Priti& Dr. Hitesh Singh attended the Kolkata Liver Meeting held on 16th - 18th December,2022.