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                  OR

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             M/s.Tenzin Lhamo - 09990579948

             Liver Helpline Emergency - 01129872146 / 9717792027

             E-Mail - livertransplant@hotmail.com

Causes of hepatitis B

Hepatitis B

Hepatitis B is the most common liver infection in the world and is caused by the hepatitis B virus. The hepatitis B virus enters the body and travels through the blood to the liver. In the liver, it attaches to the liver cells and multiplies. Although the patient may not have any problems at this phase, multiplication of the virus triggers a response from the body’s immune system.

Hepatitis B infection can lead to cirrhosis (scarring of the liver), liver failure or even liver cancer unless diagnosed and managed early.
There are probably 350 - 400 million people with chronic (lifelong) hepatitis B infection worldwide.

Hepatitis B infection is considered to be ’acute‘ in the first 6 months after infection. If hepatitis B virus tests (HBsAg) are positive after 6 months, this is now a ‘chronic’ (long term) hepatitis B infection, which may last a lifetime.

Symptoms of acute hepatitis B

Symptoms resulting from acute hepatitis B infection are common, with jaundice occurring approximately 12 weeks after initial infection.
The symptoms of acute hepatitis B include:

• Loss of appetite
• Nausea and vomiting
• Tiredness
• Abdominal pain
• Muscle and joint pain
• Jaundice
  

Many people with acute hepatitis B have no symptoms and never realize they had the infection. A small number of those with acute hepatitis B become very sick in a short period of time. This happens if there is massive damage to the liver and it stops working. This is called acute liver failure.

Symptoms of chronic hepatitis B

Most people with chronic hepatitis B do not have any symptoms of infection so that they feel healthy and may not be aware they are infected. However, other s may experience symptoms, which are similar to those experienced with other forms of viral hepatitis. These can include:

• Tiredness, depression and irritability
• Pain in the liver (upper, right side of abdomen)
• Nausea and vomiting
• Loss of appetite
• Joint aches and pains.
  

People with chronic hepatitis B have a significantly increased risk of developing liver cancer.

Disease course

 The main predictor of disease course is the duration of infection:

• Infants infected with hepatitis B rarely experience symptoms of acute infection, but 90% will develop chronic or lifelong infection

• Children infected with hepatitis B rarely experience symptoms of acute infection, but 30% will develop chronic or lifelong infection

• Adults or adolescents infected with hepatitis B commonly experience symptoms of acute infection, however less than 5% develop chronic or lifelong infection

Transmission of the virus

Hepatitis B is found in blood and body fluids (saliva, semen, vaginal secretions and breast milk). The most common routes of spreading include:

• Sexual contact
• Sharing of needles / syringes
• Needle stick injuries among healthcare workers
• Reuse of inadequately sterilized needles
• Child-to-child transmission through household contact such as biting
• Sharing personal items such as razors, toothbrushes or nail clippers

Hepatitis B is NOT spread by contaminated food or water, and cannot be spread through casual social contact such as kissing, sneezing, coughing, hugging or eating food prepared by a person with hepatitis B.

Tests for Hepatitis B

To understand the tests, it is important to understand two basic terms:

• Antigen— a foreign substance in the body, such as the hepatitis B virus; and

• Antibody— a protein that the immune system makes in responses to a foreign substance. Antibodies can be produced in response to a vaccine or a natural infection.

 

Test	Abbreviation	What it shows
Hepatitis B surface antigen	HBsAg	Shows that the person is infected with hepatitis B. It can be detected during acute and chronic infection.
Hepatitis B surface antibody	HBsAb or Anti-HBs	Shows that the person has developed immunity to hepatitis B. It can be detected in people who have    recovered from hepatitis B or been vaccinated against hepatitis B.
Hepatitis B e antigen	HBeAg	Shows that hepatitis B virus is multiplying.
Hepatitis B e antibody	HBeAb or Anti-HBe	Shows that the person’s immune system has responded    against hepatitis B and the virus is not actively replicating.
Hepatitis B core antibody	HBcAb or Anti-HBc	Shows that a person has been infected with hepatitis    B but does not provide any protection against infection.
Hepatitis B virus DNA	HBV DNA	Measures the amount of hepatitis B virus in the    blood and indicates how actively the virus is multiplying.

Other tests are used to check how the liver is working and whether the virus has damaged it. :

Liver Function Tests (LFTs):  are a group of blood tests that show how well the liver is working. One important test is the AlanineAminotransferase (ALT). The ALT is released from liver cells into the bloodstream when the liver is injured. An ALT level above normal may indicate liver damage. ALT levels are included in the regular monitoring of all chronic hepatitis B patients; this test can also be useful in deciding whether a patient would benefit from treatment, or for evaluating how well a current treatment is working;

• Liver biopsy: involves the removal of a small piece of tissue from the liver using a fine needle. The tissue is examined under a microscope to look for inflammation or liver damage; and

• AFP: is a blood test which can sometimes detect liver cancer

Treatment

Those who have immunity and normal LFTs do not need treatment. People who are chronically infected but do not have any liver damage also do not need treatment but need close monitoring. However, if a person has liver damage they should consider having treatment for hepatitis B. The decision on when to start treatment is complex and should be made in consultation with a gastroenterologist / hepatologist.
The most common are anti-viral medications taken as tablets each day for a year or longer:

• Lamivudine

There are almost no side effects to Lamivudine, however a significant concern is the possible development of hepatitis B virus mutations and antiviral drug resistance after long-term use.

• Adefovir

There are almost no side effects except for the possibility of developing virus mutations and antiviral drug resistance.

• Entecavir (Baraclude)

Entevavir has potent activity against chronic hepatitis B. There are almost no side effects except for the possibility of developing virus mutations and antiviral drug resistance.

• Tenofovir (Viread)

Tenofovir has potent activity against chronic hepatitis B. It is particularly useful in patients who have developed drug resistance to other medications.

Treatment aims are to stop the hepatitis B virus from multiplying, or to reduce the rate of multiplication as much as possible. This decreases the risk of serious liver disease developing later in life and makes it possible for the liver to repair some of the damage and to work better. However, it is very rare that any of these medications will cure hepatitis B infection.

The main side effect of the antiviral tablets is sometimes the hepatitis B virus mutates (changes) during the course of treatment, which means the antiviral tablets are not as effective against the new form of the virus. This is called antiviral resistance.

During treatment, the patient’s blood tests are monitored very carefully to look for signs of antiviral resistance. If there are signs of resistance such as elevated liver enzymes and high levels of hepatitis B virus in the blood, the antivirals may be changed.

Lifestyle advice for people with chronic hepatitis B

There are a number of things people with chronic hepatitis B can do to stay healthy, including:

• Limit or avoid alcohol

• Do not smoke

• Eat a healthy, well-balanced diet

Prevention

• Consider being vaccinated

• Practice safe sex (use a condom)

• Wash hands after touching blood or body fluids

• Wear disposable gloves if giving someone first aid, or cleaning up blood or body fluids

• Avoid sharing toothbrushes, razors, needles, syringes, personal hygiene items or any object that may come into contact with blood or body fluids

• Use new and sterile needles / syringes for each injection

• Cover all cuts and open sores with a band aid or bandage

• Wipe up any blood spills and then clean the area with bleaching powder

• Throw away personal items such as tissues, menstrual pads, and bandages in a sealed plastic bag.

Those who have been exposed to the hepatitis B virus and who have not been vaccinated should receive hepatitis B immunoglobulin (HBIG) within 72 hours of exposure, and a dose of hepatitis B vaccine as soon as possible or within 7 days.

Vaccine

Hepatitis B can be prevented with a safe and effective vaccine that has been available since 1982. It is now recommended that all babies and adolescents be vaccinated against hepatitis B. All healthcare workers should also be vaccinated. 

Liver Diseases Hepatitis A & E

Hepatitis A & E

Hepatitis A is a viral liver disease that can cause mild to severe illness. It relates to inflammation (irritation and swelling) of the liver.The hepatitis A virus is transmitted through ingestion of contaminated food and water, or through direct contact with an infectious person.

The hepatitis A virus is one of the most frequent causes of food borne infection. Epidemics related to contaminated food or water can erupt explosively, such as the epidemic in Shanghai in 1988 that affected about 300 000 people. Hepatitis A viruses persist in the environment and can resist food-production processes routinely used to inactivate and/or control bacterial pathogens.

Improved sanitation and the hepatitis A vaccine are the most effective ways to combat the disease

Symptoms: The incubation period of hepatitis A is usually 14–28 days.
Symptoms of hepatitis A virus range from fever, malaise, and loss of appetite, diarrhea, nausea, abdominal discomfort, dark-colored urine and jaundice. Not everyone who is infected will have all of the symptoms.

Who is at risk?

Anyone who has not been vaccinated or previously infected can contract hepatitis A. Risk factors include:

• Poor sanitation
• Lack of safe water
• Injecting drugs
• Living in a household with an infected person
• Being a sexual partner of someone with acute hepatitis A infection
• Traveling to areas of high probability without being immunized. 

Treatment

There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be slow and take several weeks or months. Therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhea.

Prevention

Improved sanitation, food safety and immunization are the most effective ways to combat hepatitis A.
The spread of hepatitis A can be reduced by:

• Adequate supplies of safe drinking water
• Proper disposal of sewage within communities
• Personal hygiene practices such as regular hand washing with safe water.

Several hepatitis A vaccines are available. All are similar in terms of how well they protect people from the virus and their side effects. No vaccine is licensed for children younger than one year of age.

Nearly 100% of people develop protective levels of antibodies to the virus within one month after a single dose of the vaccine. Even after exposure to the virus, a single dose of the vaccine within two weeks of contact with the virus has protective effects. Still, manufacturers recommend two vaccine doses to ensure a longer-term protection of about five to eight years after vaccination.

Milestone 300 Ldlt in 2013

                         

Liver Transplant milestone in India. 300 Living Donor Liver Transplant in one year.

ANG Centre for Liver and Biliary Sciences proudly announces that it has conducted 300 Living Donor Liver transplant in 2013 and becomes the only center in India to achieve this milestone. This has meant that 600 major liver surgeries each lasting 12 to 16 hours were conducted in 2013. Truly this is an amazing exercise and very few centres in the world have managed to complete as any number of transplants in one year.

We are grateful to the patients and donors who placed their trust in us. The support from Indraprastha Apollo hospitals has been stupendous  throughout the year.

In 2013, the team has also helped other centres within India and abroad to set up liver transplantation. The team has helped hospitals in Pakistan, Bangladesh and Kazakhstan.

In 2013 because of improvements in technique the cost of liver transplant has come down from 24 lacs to 19 lacs. The group published its low cost transplant techniques in the journal “Liver Transplantation”.

The use of blood and blood products has been minimized and as a result the infection rates are lower. This year we introduced techniques that allows for transplantation of patients who are grossly overweight from a single donor. The 300 plus liver transplants included swap transplantation, combined liver kidney transplant and transplants for high-risk recipients and sequential Liver Kidney Transplant.

In 2013, we also introduced sequential liver kidney transplant for patients with both liver and kidney disease. This has been a big relief for families, as they no longer need to have three members from their family to undergo major surgery at the same time.

The group has now completed 1400 living donor liver transplants with over 90% success rate and a 10% biliary stricture rate.

An event was attended by Dr.Prathap C reddy,Chairman,Apollo Hospitals Group,Prof.MC Mishra,Director –AIIMS,Prof Subash Gupta,Liver Transplant Surgeon,Indraprastha Apollo Hospitals and the Transplant Patients along eith their families.

Dr. Subash Gupta is  well known all over the world for his  Pioneering work in liver transplantation in the Indian subcontinent. During the briefing he shared insights on his journey in India, experiences and challenges faced over the years and how the Liver Transplant vertical has developed in the recent past. He also discussed about the comprehensive management of complex conditions of HPB.

Addressing the press meet, Dr. Reddy, Chairman, Apollo Hospitals said, “Apollo's comprehensive liver transplant care programme is well known for its highly successful Adult and Pediatric Liver Transplant programmes, clinical excellence and cutting edge technology. From the inception we have successful performed liver transplant in India in 1998, the Apollo Transplant Program has successfully completed 1400 living donor liver transplants with over 90% success rate and a 10% biliary stricture rate. We strive to achieve many more such landmarks and keep alive our motto of touching lives!”

Speaking on the occasion, Prof. Subash Gupta, Chief Liver Transplant Surgeon, Apollo Hospitals said, “It is indeed a proud moment for us to achieve such a milestone in liver transplants. We feel a sense of accomplishment on the completion of 300 cases. We are grateful towards our patients who have shown faith and trust in us and helping us reach this landmark and delivering clinical excellence.”

Dr.Subash Gupta

MS (AIIMS),FRCSED,FRCS (Glas)

Chief Liver Transplant / HPB Surgeon & Director CLBS,

Indraprastha Apollo Hospital.

Dr Subash Gupta has been the pioneer of Liver Transplantation in the Indian subcontinent. It is largely due to his efforts through the last decade that this specialty has become well established in this part of the world. Liver Transplant today has given fresh lease of life to thousands of patients with liver disease as a result of his endeavors.

Dr Gupta was born in the quiet town of Asansol in the state of West Bengal in eastern India. He spent his childhood years there and began an academically brilliant career at the St Patrick’ School, Asansol.

After schooling , he joined the All India Institute of Medical Sciences ( AIIMS ), Delhi  where he obtained his medical degree. He also trained in General Surgery at the same institute before joining the Department of G I Surgery & Experimental Liver Transplantation as Senior Resident.

Encouraged by Prof Samiran Nundy, Dr Gupta proceeded to UK to train in Liver Transplantation.  He trained at the Queen Elizabeth Hospital in Birmingham and at the St James University Hospital in Leeds between 1993 and 1998 , working closely with some of the stalwarts of Liver Transplantation  including Paul McMaster, Elwin Elias & James Neuberger.

During his stay in UK, Dr Gupta qualified for Fellowships of the Royal College of Surgeons of Edinburgh and of Glasgow. He trained in all aspects of Liver Transplantation, was actively involved in clinical and research work as well as in teaching / training junior doctors. His research work in various aspects of transplantation has been published in various journals, presented at numerous conferences and appreciated worldwide.

In 1998, Dr Gupta decided to return to India to take up the mantel of liver transplantation in this part of the world. He was offered the position of Consultant in Liver Transplantation & G I Surgery at the Sir Ganga Ram Hospital ( SGRH ) in New Delhi which he accepted.

There he played a pioneering role in developing the first successful liver transplant program in the Indian subcontinent. While he had trained in Liver Transplantation for a long time in the UK, he also interacted with and visited several centres in Hongkong, Seoul and Turkey to understand the innovations that were rapidly making Living Donor Liver Transplant a successful procedure outside the western world.

The Liver Transplant program at SGRH was the culmination of years of preparation, aided by a few key innovations by Dr Gupta and his colleagues. And the encouraging results ensured that the program had well and truly taken off !

After the initial years at SGRH, Dr Gupta decided that the Apollo group of hospitals were better equipped to provide the infrastructure needed to sustain a busy liver transplant & HPB program.

In 2006, Dr Subash Gupta joined Indraprastha Apollo Hospital, Delhi and stared the Liver Transplant & HPB  program there.

Over the years, the Centre of Liver & Biliary Sciences ( CLBS ) evolved to its present shape. Today CLBS is the busiest Living Donor Liver Transplant program in the world. But Dr Gupta prides over the fact that Liver Transplantation is today only a small part of the gamut of activity that CLBS is involved in.

Although a surgeon at the core, Dr Subash Gupta has always believed that Liver diseases need to be managed by specialists who are equally experienced in the medical & surgical aspects of treatment. The Liver Surgeon or the Medical Hepatologist in isolation cannot always judge what is in the best interests of the patient. Over the years of his vast experience, Dr Gupta has focused his clinical & research activities towards the medical management of patients with liver diseases. Liver Transplantation is the cure for only a select group of patients with Liver Diseases.

Acute Liver Failure is a disease which needs Urgent Liver Transplant when the patient’s parameters meet certain criteria. However, years of experience has demonstrated that some of these patients can be salvaged without a transplant. Having saved some of them without a transplant, Dr Gupta’s team is now focusing on validating new criteria to predict better which group of patients will inevitably need a transplant.

This is just one example among many paradigm changes in management that are the focus of his research interests.

At CLBS, Dr Gupta continues to guide the treatment of a large number of patients with Acute or Chronic Liver Diseases, patients with Hepatitic B or C infections, those admitted with Alcoholic Steatohepatitis as well as patients with Autoimmune Hepatitis. Children with liver diseases such as those with Neonatal hepatitis, Progressive Familial Intrahepatic Cholestasis ( PFIC ) , Biliary atresia , Hyperoxaluria and Wilson’s disease are also treated by the Pediatric Hepatology division at CLBS.

Tumours of the liver often present management dilemmas depending on the stage of presentation. Choosing the best treatment option for a patient with Hepatocellular cancer ( HCC ) can be tricky. Oral Sorafenib, simple ablation with RFA or Alcohol injection, TACE ( Trans Arterial Chemo Embolisation ),  TARE ( Trans Arterial Radio Embolisation ) , Liver Resection and Liver Transplantation are among the many treatment options available. While all these treatment modalities are available at CLBS, Dr Gupta takes a personal interest in ensuring that the patient and his family are adequately counseled and informed about the pros & cons before embarking on a particular therapy.

The common adage ‘ Treat the patient , not the disease’ remains the guiding philosophy on which Dr Gupta continues to train his team at CLBS.

In the field of Liver Transplant , CLBS continues to make giant strides not only in clinical care, but also leads surgical innovations in this specialty, trains junior doctors in this high end specialty and ensures that doctors in society become adept at treating transplanted patients in the community.

As primarily a G I Surgeon, Dr Gupta continues to treat a significant number of patients with Gastrointestinal diseases and problems of the Liver, Biliary tract & Pancreas. Liver resections, Pancreatic surgery, surgery for hydatid cyst & choledochal cyst as well as surgery for Bile duct injuries are regularly performed  at our centre.

While the team at CLBS continues to excel, Dr Gupta remains a bedside clinician at the core. He ensures that he sees all patients personally, leads the surgical team during operations and remains directly in charge of the postoperative care.

Meticulous attention to detail, both inside the Operating Room and outside on the ward / ICU, is perhaps the single most important reason behind the excellence in clinical care that Dr Gupta & his team continue to provide at CLBS.