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INTRODUCTIONHepatic venous pressure gradient (HVPG) measurement is recommended for prognostic and therapeutic indications in centres with adequate resources and expertise. Our study aimed to evaluate the quality of HVPG measurements at our centre before and after introduction of a standardised protocol, and the clinical relevance of the HVPG to variceal bleeding in cirrhotics.METHODS HVPG measurements performed at Singapore General Hospital from 2005-2013 were retrospectively reviewed.Criteria for quality HVPG readings were triplicate readings, absence of negative pressure values and variability of ≤ 2 mmHg. The rate of variceal bleeding was compared in cirrhotics who achieved a HVPG response to pharmacotherapy (reduction of the HVPG to < 12 mmHg or by ≥ 20% of baseline) and those who did not.RESULTS 126 HVPG measurements were performed in 105 patients (mean age 54.7 ± 11.4 years; 55.2% men). 80% had liver cirrhosis and 20% had non-cirrhotic portal hypertension (NCPH). The mean overall HVPG was 13.5 ± 7.2 mmHg, with a significant difference between the cirrhosis and NCPH groups (p < 0.001). The proportion of quality readings significantly improved after the protocol was introduced. HVPG response was achieved in 28 (33.3%, n = 84) cirrhotics. Nine had variceal bleeding over a median follow-up of 29 months. The rate of variceal bleeding was significantly lower in HVPG responders compared to nonresponders (p = 0.025). CONCLUSIONThe quality of HVPG measurements in our centre improved after the introduction of a standardised protocol. A HVPG response can prognosticate the risk of variceal bleeding in cirrhotics.

We report a case of a 55-year-old woman with hypertension and diabetes mellitus, who took tamoxifen for the past 4 years. She presented with acute pancreatitis caused by markedly elevated serum triglycerides (3,883 mg/dL). Tamoxifen is known to cause a mild increase in serum triglycerides, but it rarely increases to such high levels to cause acute pancreatitis. The patient recovered well, and tamoxifen was switched to letrozole. It is crucial to monitor serum lipids up to 4 years and beyond for patients on tamoxifen, particularly in patients with known dyslipidemia or diabetes mellitus.

Bowel perforation as the first presentation of inflammatory bowel disease is rare and unusual in young patients. A previously asymptomatic 21-year-old Asian male presented with perforated small bowel secondary to previously undiagnosed Crohn’s disease. He underwent an exploratory laparotomy and subsequent small bowel resection and was commenced on mesalazine post-operation. He recovered well with subsequent regular follow-up with gastroenterology. The main management of Crohn’s disease is multidisciplinary in nature, and collaboration between different disciplines is inherent with the aim of reducing symptoms and maximizing patient quality of life.

Symptomatic iron overload and hyperferritinemia are rarely mentioned as complications of chronic hepatitis B infection. We report a case of a 70-year-old woman who presented with symptoms of iron overload including aches in the calves, fatigue, poor appetite, and low mood. Laboratory results showed a serum ferritin of 2449 μg/L and transferrin saturation of 74%. Her symptoms completely resolved with hepatitis B antiviral treatment. Serum ferritin and transferrin saturation also normalized. Symptomatic iron overload is a rare yet clinically important complication that can result from chronic hepatitis B infection.

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