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Dr KK Aggarwal

From the Desk of Editor in Chief
Padma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal


Dear Colleague

27th April, 2010 Tuesday

Amitabh Bachhan has Cirrhosis of Liver

Amitabh Bachhan has revealed that he has cirrhosis of liver. He had received several units of blood transfusion on account of the injury sustained during the shooting of his movie ‘Coolie’ in 1982. One of the several donors had infected blood with hepatitis B.

Cirrhosis is a severely scarring disease of the liver due to many years of continuous injury. The most common causes are longstanding alcohol abuse and hepatitis B or hepatitis C virus. Cirrhosis cannot be cured but one can prevent the disease from worsening. Here is a recap of some essential information about the disease.

  1. Liver is a large organ (around 1.5 kg), located in the right upper abdomen, beneath the rib cage and performs many essential functions.

  2. Liver can repair itself when injured but the healing process involves scar formation. Repeated or continuous injury can cause significant scarring. One can tolerate a partially scarred liver without serious consequences but eventually, the scar can become severe enough to cause symptoms.

  3. Causes of liver injury include longstanding alcohol abuse, chronic hepatitis (B or C) and nonalcoholic steatohepatitis, a condition that causes inflammation and accumulation of fat and fibrous tissue in the liver.

  4. People with early cirrhosis may or may not have symptoms.

  5. In advanced cases, scarring may make it difficult for blood to flow through the liver. As a result, veins in other areas outside of the liver become abnormally expanded are called varices.

  6. A site where varices are common is the food pipe or esophagus. When the pressure in the varices reaches a certain level, the varices can burst causing massive bleeding called variceal bleeding.

  7. Body fluids may accumulate as a result of liver scarring and a decreased ability to manufacture blood proteins. Fluid may accumulate in legs (edema), abdomen (ascites) or lung (pleural effusion).

  8. Ascites may cause the abdomen to enlarge, which can cause shortness of breath and a feeling of fullness. The fluid provides an environment where bacteria can grow, increasing the risk of infection.

  9. Patients are at risk of easy bruising and bleeding. Variceal bleeding can be fatal.

  10. Hepatic encephalopathy is a condition that develops when the liver is unable to break down toxins normally found in the bloodstream, such as ammonia. The patient may have confusion or even coma. In early stages, there may be mild symptoms, such as difficulty sleeping or sleeping too much. Advanced cases can cause confusion, delirium, and even coma. Encephalopathy can develop suddenly and may become a medical emergency.

  11. Patients with cirrhosis have a weak immune system and are vulnerable to infections.

  12. Malnutrition is common and can cause loss of muscle in various areas of the body.
  13. Patients with advanced cirrhosis have jaundice.

  14. Cirrhosis patients are at an increased risk for developing liver cancer.

  15. Tests are done to confirm the diagnosis, determine the cause and severity and also monitor for complications.

  16. Liver biopsy is the best way to confirm the diagnosis of cirrhosis.

  17. Ultrasound is done to evaluate the liver and look for complications.

  18. Blood tests are carried out to determine the underlying cause of cirrhosis and also too monitor liver functions.

  19. There are major advances in the treatment. It has now become easier to recognize, prevent, and treat complications.
  20. Patients should be regularly monitored for complications. Several treatments can minimize cirrhosis-related complications.
  21. Cirrhosis patients should avoid taking substances that can further damage the liver such as alcohol. One should not take any new prescription and non–prescription drugs, herbs, vitamins, or dietary supplements without medical advice.
  22. Paracetamol can further injure the liver in cirrhosis patients. The exact safe dose is uncertain. Patients should not take more than 650 mg per dose and no more than 2000 mg per day. However, even low doses may not be safe for those who drink alcohol.
  23. Cirrhosis patients may need an upper endoscopy to determine if varices are present in the food pipe.

  24. Cirrhosis patients should be vaccinated against hepatitis A and B, pneumococcal pneumonia and flu.

  25. Ascites and edema can lead to infection. Ascites can cause shortness of breath. Treatment is given to reduce the amount of fluid that collects in the lower legs and abdomen and includes diuretic fluid pills and low salt diet.

  26. In patients who do not get adequate relief with fluid pills, periodic drainage of the abdominal fluid (paracentesis) may be required. After fluid removal, one needs to continue taking fluid pill and restrict salt.
  27. If diuretics, paracentesis, and changes in diet are not completely successful then a TIPS (transjugular intrahepatic portosystemic shunts) procedure may be recommended to treat ascites.

  28. People with cirrhosis should have tests to detect cancer of the liver with an ultrasound and a blood test every 6 to 12 months.

  29. Cirrhosis patients can develop confusion, which is often subtle. Detecting confusion is important since treatment is available and the confusion itself can lead to serious problems (e.g., an automobile accident). A change in the sleep pattern (insomnia or sleeping too much) may be an early sign.
  30. People with advanced cirrhosis may require a specialized diet. Most doctors do not recommend vitamins, herbs, or other supplements for people with cirrhosis.

  31. Exercise is generally safe in whom the disease is not in an advanced stage. It may increase the risk of variceal bleeding in patients with advanced disease.

  32. Some patients with cirrhosis will require a liver transplantation. The transplant involves replacing a damaged liver with a healthy liver. Donated liver comes from people who have suffered brain death or from living donors. Eighty percent of people are alive one year after liver transplant and the majorities are alive five years after transplant. This is compared to almost certain death in patients with very advanced cirrhosis who do not undergo transplantation. Most people who undergo transplantation for hepatitis C will develop recurrent hepatitis C after transplantation.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

Photo Feature

Padma Shri and Dr BC Roy Awardee Dr KK Aggarwal being honored with the IMANDB Chikitsa Ratna Award at the Annual Day Meet at Moolchand Medcity, New Delhi on April 25, 2010. Also in the picture Dr Satish Mehta (Secretary IMANDB), Dr KB Sharma (Past President IMANDB), Dr Sanjay Sood (President IMANDB) and Dr N Saini (President DMA).

Dr k k Aggarwal

International Medical Science Academy Update (IMSA): What’s New

The projected benefits of a reduction in dietary salt by 3 g/day were estimated using a computer simulation of the incidence and prevalence of coronary heart disease and the associated mortality and costs in United States adults, and were similar to those of population–wide reductions in smoking, obesity and cholesterol levels (February 2010 Issue, N Engl J Med)

News and Views (Dr Brahma and Dr Monica Vasudeva)

Blood test that analyzes genetic activity could let heart transplant patients avoid biopsies

A blood test that analyzes genetic activity could let heart transplant patients avoid many of the invasive and uncomfortable biopsies now used to monitor whether their immune systems are rejecting their new organs. This was reported in a study scheduled to be presented at the International Society for Heart and Lung Transplantation meeting and published online by the New England Journal of Medicine.

Vaccine that could help people stop smoking shows promise in clinical trials

A vaccine designed to stimulate the immune system to generate antibodies that would latch on to nicotine in a smoker’s body and prevent it from ever entering the brain has shown promise in early clinical trials.

Experimental once–a–day malaria drug may be as effective as twice–daily pill

An experimental once–a–day malaria drug worked well at treating the mosquito–borne illness as Novartis AG’s twice–daily pill Coartem (artemether and lumefantrine), according to a study in The Lancet. Pyramax, developed by Shin Poong Pharmaceutical Co. of South Korea and the Geneva–based Medicines for Malaria Venture (MMV), cleared the disease–causing parasite from the blood of 99.5 % of patients in Africa and Asia after 28 days, compared with 99.2 % for Coartem. Pyramax is also known as pyronaridine–artesunate.

Pfizer halts late–stage clinical study of Sutent for liver cancer

Pfizer, announced that it had stopped a late–stage clinical study of its drug Sutent (sunitinib) as a treatment for hepatocellular carcinoma. Patients who were treated with Sutent were not surviving as long as patients who were treated with another drug, Nexavar (sorafenib).

FDA approves kidney–rejection drug

Novartis AG announced that it has received FDA approval for the organ–rejection drug Zortress (everolimus), a drug used to prevent organ rejection in kidney transplant patients.

Mnemonic of the Day (Dr Prachi Garg)

Argyll Robertson Pupil (accommodates but does not react) – SADE





What’s New

Pediatric gastroenterology

Observational studies suggest that the celiac disease risk might be reduced by continuing breastfeeding while introducing gluten into an infant’s diet, and by introducing gluten gradually.

  1. Ivarsson A, Hernell O, Stenlund H, et al. Breast–feeding protects against celiac disease. Am J Clin Nutr 2002;75:914.

  2. Akobeng AK, Ramanan AV, Buchan I, et al. Effect of breast feeding on risk of coeliac disease: a systematic review and meta–analysis of observational studies. Arch Dis Child 2006;91:39.

Quote of the Day


Diabetes Fact

CAD risk factors: DM, HT, Dyslipidemia and Smoking.

Question of the Day

What advice should be given to children, especially babies traveling by air, to reduce pain in ears while airborne and during landing and take-off?

  • Children with colds are advised antihistaminics–nasal decongestants two days prior to a flight.

  • During take–off and landing, sucking at a pacifier, chewing gum or sucking a sweet help to open up the eustachian tube. Sleeping specifically during this period should be avoided.

  • Cotton plugs in the ears could also give relief from pain during this sudden change of altitude.

Role of Healthcare Professionals: Tobacco (Dr G M Singh)

At community level
5 Ps

  1. Public awareness of health dangers–health education lectures.

  2. Prevent people from taking up tobacco, particularly youth in schools.

  3. Promote cessation by providing tobacco cessation clinics.

  4. Protect non smokers from exposure by ensuring ban in public places and homes.

  5. Politicians to be educated to regulate cultivation of tobacco crops in their constituencies and stop advertisements of tobacco products. Be proactive in guiding and reporting of offenders.

Public Forum
(Press Release for use by the newspapers)

Suspecting stroke and heart attack risk without tests

Carotid bruit, an unusual, harsh sound a doctor can hear when passing a stethoscope over the main artery to the brain could indicate an increased risk of heart attack and death from heart disease and stroke, said Padma Shri and Dr B C Roy Awardee Dr. K K Aggarwal, President Heart Care Foundation of India

The sound is caused by turbulent blood flow due to buildup of fatty deposits in one of the two arteries that carry blood to the front and middle part of the brain. It is usually regarded as a possible indicator of increased risk of stroke.

An analysis of 22 studies involving more than 17,000 patients and published in The Lancet found that people with carotid bruits were more than twice as likely to have heart attacks or to die of cardiovascular disease.

However patients who do not have carotid bruit may have other evidence of cardiovascular disease.

Physicians should routinely listen for possible carotid bruits when doing a physical examination of people who are middle–aged or older.

Studies have shown that there is a link between the risk of stroke and of coronary heart disease.

eMedinewS Try this it Works

Prefer the round hammer over a triangulated hammer

Bilateral absence of heel jerks suggests peripheral neuropathy. To make an accurate assessment use a high–quality, round neurologic hammer of adequate weight rather than a lightweight triangulated hammer.

Dr Good Dr Bad

Situation: An anemic diabetic came for foot ulcer advice.

Dr Bad: Just keep your sugar controlled.

Dr Good: You are at risk of ulcers.

Lesson: Male gender, previous foot ulcer, peripheral vascular disease, lack of frequent foot self–examination and peripheral neuropathy were significant factors for foot ulceration. Longer diabetes duration, poor glycemic control, anemia and presence of infection also had an impact on outcome of the disease. {Prim Care Diabetes 2009 Sep 22. (Epub ahead of print)}

Make Sure

Situation: A 62–year–old–diabetic with coronary artery disease, on treatment for the same, comes for follow up.

Reaction: Oh my God! Why did not you put him on antioxidants?

Make Sure to add antioxidants to the prescription because of their free radical scavenging and other beneficial effects.


Laughter the best medicine

A man goes to the eye doctor. The receptionist asks him why he is there. The man complains, "I keep seeing spots in front of my eyes."

The receptionist asks, "Have you ever seen a doctor?" and the man replies, "No, just spots."

Formulae in Critical Care


Formula: A decrease of 1 mmol/L of K+ value means a
total body deficiency of 200–400 mmol of K+

Milestones in Diabetes

Sir Harold Himsworth (1905–1993), was a British scientist, best known for his medical research on diabetes mellitus. He published an important paper in The Lancet in 1936, distinguishing the two main types of diabetes.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Adrenocorticotropic hormone (ACTH) : To help diagnose adrenal and pituitary diseases such as Cushing’s syndrome, Cushing’s disease, Addison's disease, adrenal tumors and pituitary tumors.

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name


Approval Date

Zoledronic Acid Solution for Infusion Addl. Indication

Prevention of clinical fractures after hip fracture in men and women


(Advertorial section)



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Contact: drkk@ijcp.com or emedinews@gmail.com

eMedinewS–PadmaCon 2010 


eMedinewS–revisiting 2010


IMSA Delhi – Workshop on Mind Body Medicine

A workshop on Mind, Body Medicine is being organized to mark the birthday of Late Acharya Sushil Ji Maharaj Date: June 13, 2010

Venue: Acharya Sushil Muni Ashram, C – 599 Defence Colony, New Delhi

Organizer: IMSA Delhi in Association with World Fellowships of Religions, IMA NDB and Heart Care Foundation of India

All Doctors and Nurses can attend. There is no fee.

Speaker: Dr K K Aggarwal

Blessings: Acharya Dr Sadhna Ji Maharaj

Timings: 8–12 noon

Workshop: Practical mind body prescriptions for doctors

Register: SMS 9811090206 or email emedinews@gmail.com


Readers Responses

  1. Congratulations Sir: Dr. Anupama

  2. Dr Aggarwal, Thanks for the emedinews, it is a great job. Can I submit my articles or news briefs? Regards: SM Kadri, MB,MPH/ICHD (Royal Tropical Institute, Amsterdam). PO Box 1143, GPO, Srinagar 190001, Kashmir, India: A:Yes we will welome any contribution.

  3. Congratulations for Padma Shri award. With warm regards. Yours sincerely. Dr Anup Dhir M.Ch (Plastic Surgery), Senior Consultant Apollo Hospital, Secretary Indian Association of Aesthetic Plastic Surgeons, Cosmetic Plastic Surgeon & ANdrologist

  4. Dear reader: We at LIFELINE LABORATORY, have introduced a new test B-CROSSLAPS ELISA. (B-CTx). It is an enzyme immunological test for the quantification of  degradation products of C- terminal telopeptides of Type I collagen in human serum and plasma. Type I collagen accounts for more than 90% of the organic matrix of bone and is synthesized primarily in bone. During renewal of the skeleton, type I collagen is degraded, and small peptide fragments are excreted into the bloodstream. These specific degradation products can be measured in both urine and serum by a competitive B CrossLaps Elisa. The serum B CrossLaps Elisa assay  is intended for in vitro diagnostic use as an indication of human bone resorption and is strongly recommend as a part of  “BONE HEALTH PANEL” in osteoporosis and in post menopausal females. The test is also indicated  subsequently for monitoring anti resorptive therapy such as HRT, Bisphosphonate therapies. Dr Asha Bhatnagar