We read with interest the article by Mumtaz et al. [1] on the role of oral N-acetylcysteine (NAC) in adults with nonacetaminophen-induced acute liver failure. We agree that their findings are of particular relevance to many developing countries, where liver transplantation is neither available nor affordable. There has been another recent study in which intravenous NAC has been shown to improve transplant-free survival in early-stage non-acetaminophen-induced acute liver failure in adults [2]. We report our initial experience in treating acute liver failure caused by dengue infection with NAC. Use of NAC in this situation has not been previously described.Sri Lanka is experiencing its worst-ever dengue epidemic yet, with more than 250,000 reported cases and more than 250 deaths, mainly adults, since January 2009. Severe hepatic and cardiac complications and a higher than usual mortality have been notable features of this epidemic. Mild-moderate elevations in serum aminotransferase levels are very common in dengue, but acute liver failure can also occur [3] and has a poor outcome, with case fatality rates of up to 50% in children [4]. There is little information on the management of dengue-associated acute liver failure. There are isolated reports of rapid improvement in the biochemical profile and encephalopathy with molecular adsorbent recirculating system [5]. Liver transplantation is difficult because of hemodynamic instability, bleeding manifestations, and organ dysfunction caused by the infection itself, and may not be a treatment option in most countries where dengue is prevalent.We retrospectively analyzed the outcome of eight consecutive adult patients (5 men and 3 women; age range, 28-64 years) presenting during the current epidemic with serologically confirmed dengue-associated acute liver failure. In addition to other supportive management [6,7], they received NAC 150 mg/kg loading dose by intravenous administration over 15 min followed by 12.5 mg/kg/h for 4 h and then 6.25 mg/kg/h for up to 72 h. Two patients had dengue hemorrhagic fever [6], six had dengue shock syndrome [6], seven had pleural effusions, and five had ascites. Five patients had early-stage pretreatment hepatic encephalopathy (coma grades I-II), and three had advanced encephalopathy (coma grades III-IV). Time from disease onset to appearance of encephalopathy was 5-8 days. Worst recorded pretreatment value ranges for the eight patients were as follows: platelet count = 6,000-30,000/mm 3 ; international normalized ratio = 1.6-3.2; serum bilirubin = 2.7-12.2 mg/dL; alanine aminotransferase = 4,070-19,800 IU/L; aspartate aminotransferase = 4,455-26,500 IU/L; serum albumin = 2.7-3.9 g/dL; serum globulin = 3.1-3.9 g/dL; and serum creatinine = 0.7-2.5 mg/dL. None had taken acetaminophen more than the prescribed therapeutic dose, used hepatotoxic drugs, or had a history of alcohol abuse. Serology was negative for hepatitis A, B, C, and E, leptospira, and rickettsiae. All patients underwent computerized tomography of the brain to exclude intr...

Introduction. Available evidence for routine terminal ileoscopy during colonoscopy is equivocal. We investigated the place of routine terminal ileoscopy and biopsy during colonoscopy, in a tropical setting. Materials and Methods. All consenting adults undergoing colonoscopy had routine TI and biopsy. Patients with right iliac fossa (RIF) pain, diarrhoea, anaemia, suspected inflammatory bowel disease (IBD), and raised inflammatory markers were defined as Group A and all others undergoing colonoscopy as Group B. Results. Caecal intubation and TI were achieved in 988/1096 (90.15%) and 832/1096 (75.9%) cases, respectively. 764/832(91.8%) patients were included in final analysis. 81/764 (10.6%) patients had either macroscopic (34/81) or microscopic (47/81) abnormalities of terminal ileum; 20/81 had both. These were CD (28/47), tuberculosis (TB) (6/47), ileitis due to resolving infection (8/47), and drug-induced ileitis (5/47). 27/81 with macroscopically normal ileum had CD (18/27), ileitis due to resolving infection (5/27) and drug-induced ileitis (4/27) on histology. 12/764 (1.57%) patients with macroscopically normal colon had ileal CD (8/12), drug-induced ileitis (2/12), and resolving ileal infection (2/12) on histology. 47/764 (6.15%) patients had ileal pathology that influenced subsequent management. These were significantly higher in Group A (43/555 (8%)) than in Group B (4/209 (1.9%)) (P = 0.0048, χ 2 = 7.968). Conclusion. TI and biopsy improve diagnostic yield of colonoscopy in patients with RIF pain, diarrhoea, anaemia, suspected IBD, and raised inflammatory markers.

BackgroundIleal intubation is the gold standard for a complete colonoscopy. However, despite evidence of clinical benefit ileoscopy is not always attempted due to perceived technical difficulty. Our aim was to compare time taken for ileal intubation using a new position-the prone 12 o'clock position (PP) with the standard method (left lateral 6 o'clock position-LLP).MethodsWe performed a pilot study using fluoroscopy to determine the best patient position for ileal intubation. This was the prone 12 o'clock position. Patients were colonoscoped in the left lateral position and then randomized to ileal intubation in the 6 o'clock position(LL) or the 12 o'clock (PP) position.Results202 consecutive patients were referred for colonoscopy. Colonoscopy was performed on 150 patients [82 females, mean (SD) age 53 (16) years]. 75 patients were randomized for ileal intubation in the PP and 75 patients in the LLP. Overall, the ileum was successfully intubated in 145 (96%) patients [74 (98.7%) in the PP and71 (94.7%) in the LLP]. The median (Interquartile Range) ileal intubation time was 12 (10) seconds in the PP and 87 (82) seconds in the LLP (p < 0.0001; Mann-Whitney U test). The ileum was abnormal in 11 (7.5%) patients.ConclusionsDuring colonoscopy, the prone 12 o'clock position gives a more direct approach to the ileo-caecal valve and significantly reduces ileal intubation time.Trial registrationTrial registry: Sri Lanka Clinical Trial RegistryClinical trial registry number: SLCTR/2009/002

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BackgroundCefuroxime very rarely causes drug-induced liver injury. We present a case of a patient with paradoxical worsening of jaundice caused by cefuroxime-induced cholestasis following therapeutic endoscopic retrograde cholangiopancreatography for a distal common bile duct stone.Case presentationA 51-year-old, previously healthy Sri Lankan man presented to our hospital with obstructive jaundice caused by a distal common bile duct stone. Endoscopic retrograde cholangiopancreatography with stone extraction, common bile duct clearance, and stenting failed to improve the cholestasis, with paradoxical worsening of his jaundice. A liver biopsy revealed features of drug-induced intrahepatic cholestasis. Although his case was complicated by an episode of cholangitis, the patient made a complete recovery in 4 months with supportive treatment and withdrawal of the offending drug.ConclusionsThis case highlights a very rare drug-induced liver injury caused by cefuroxime as well as our approach to treating a patient with paradoxical worsening of jaundice after therapeutic endoscopic retrograde cholangiopancreatography.