Low dose albumin for the prevention of renal impairment following large volume paracentesis in cirrhosis

Objectives: To evaluate the effect of low dose Albumin i.e. 4 grams per litre of ascitic fluid after large volume paracentesis [LVP] for the prevention of paracentesis induced circulatory dysfunction [PICD] related renal impairment in cirrhosis. Methods: Case records of all patients with cirrhosis who underwent LVP from January 12th, 2011 till December 29th, 2013 were reviewed. Patients were excluded if they had spontaneous bacterial peritonitis, creatinine >1.5 mg/dl, hepatoma or if volume of ascitic fluid removed was <5 litres. Data including age, gender, cause of cirrhosis, CTP score and volume of ascitic fluid drained were noted. In addition serum creatinine and serum sodium at baseline and one week post paracentesis were recorded. Results: Two hundred and fourteen patients with cirrhosis underwent LVP during the study period. One hundred and thirty nine patients met the inclusion criteria and were analyzed. Patients were divided into two groups based on the amount of albumin given. The amount of albumin given was 25 grams and 50 grams while the volume of ascitic fluid removed were 6.2+/-1 litres and 10.4+/-1.5 litres in groups A and B respectively. One hundred and eight patients were in group A while thirty one patients were in group B respectively. Both groups received albumin at a dose of 4 grams per litre of ascitic fluid removed. Mean age in both groups were 53 years. Hepatitis C was the commonest etiology in both the groups, followed by Hepatitis B. More than 70% patients in both the groups were in child class C. Serum creatinine at baseline and one week post LVP was 1.04+/-0.24 mg/dl and 1.07+/-0.35 mg/dl in GROUP A while 1.11+/-0.23 mg/dl and 1.41+/-0.94 mg/dl in GROUP B. [P value 0.35]. Similarly, serum sodium at baseline and one week post LVP was 130 +/-5.6 meq/lit and 129.6+/-5.9 meq/lit in GROUP A while 127.6+/-5.8 meq/lit and 128+/-6.2 meq/lit in GROUP B respectively. [P value 0.14] Conclusion: This study suggests that 4 grams of albumin per litre of ascitic fluid drained is effective in preventing the PICD related renal impairment following large volume paracentesis in cirrhosis

Safety and technical success of percutaneous left main coronary artery stenting

Critical stenosis of left main coronary artery [LMCA] has always remained a challenge for interventional cardiologists. Conventionally Coronary Artery Bypass Grafting [CABG] is done for these patients but recently Percutaneous Coronary Intervention [PCI] is also being tried more frequently, but data of PCI is scarce in this regard. Our objective was to determine the safety and technical success rate of percutaneous left main coronary artery stenting. This was 12 month follow up study conducted at Pakistan Institute of Medical Sciences [PIMS], Islamabad from 11th Jan 2012 to 11th Jan 2013. All symptomatic patients who underwent coronary angiogram at PIMS and were found to have either isolated LMCA disease or coexisting osteal Left Anterior Descending [LAD] artery disease were potentially eligible for the study. Patients who had previous surgical treatment for coronary artery disease and those with renal dysfunction requiring dialysis were excluded. Patients were counselled in detail regarding the pros and cons of PCI versus CABG. Those who opted for PCI were included in the study. All these patients were treated with percutaneous left main coronary artery stenting with or without osteal LAD stenting. Seventy two patients had LMCA disease during angiogram. Fifteen patients opted for CABG. Four patients did not meet the inclusion criteria, whereas 53 patients were finally enrolled. Mean age of patients were 55.45 +/- 10.275 years. Twenty nine patients were with acute coronary syndrome and 22 presented with unstable angina. PCI with stenting was technically successful in all patients. One patient died three months after PCI, there was no other mortality. Our study showed that Percutaneous Coronary Intervention [PCI] to LMS has good technical success rate; the safety of the procedure is also acceptable

Age and site of colonic neoplastic lesions: implications of screening in south Asia

To evaluate the Age of patients and the site of Colonic Neoplastic Lesions [CNL] and to determine the appropriate screening strategy for Colorectal Carcinoma [CRC] [sigmoidoscopy versus colonoscopy] in our population. This is a cross sectional study. Data of all patients more than 16 years of age who underwent full colonoscopic examination at the Aga Khan University hospital between January 2011 till December 2013 and were diagnosed to have CRC or advanced adenomas [defined as polyp more than 1 cm and/or having villous morphology on histology] was recorded. Lesions found distal to the splenic flexure were characterized as distal lesions and while lesions found between the splenic flexure and the cecum were characterized as proximal lesions. During the study period colonic neoplastic lesions were found in 217 patients; 186 [85.7%] patients had CRC and 31 [14.3%] patients had advanced adenomatous polyps. Mean age was 55.8 +/- 14 years and amongst them 72 [33.2%] patients were less than 50 years of age while 145 [66.8%] were more than 50 years. In 144 [66.4%] patients lesions were located in the distal colon, 65 [30%] had lesions in the proximal colon while in 8 [3.7%] patients the neoplastic lesions were found both in the proximal and distal colon. The predominant symptoms were bleeding per rectum in 39.6% of patients followed by weight loss in 31.8% of patients. Only 3 patients had familial syndromes with multiple polyps. When patients younger than 50 years of age were compared with patients more than 50 years there was no statistically significant difference between the site of neoplastic lesion as well as the presenting symptoms. [p value 0.85]. Colonic Neoplastic Lesions presented at younger age in our study population and one third of the lesions were found in the right sided colon. Hence screening for CNLs should be implied at an earlier age preferably with colonoscopy. More population based data is required to further validate our results

Chronic hepatitis C virus; dermatological manifestations of interferon plus ribavirin therapy in patients

To determine the frequency and pattern of dermatological manifestations in patients receiving interferon and ribavarin for hepatitis C. The study was conducted in the Dermatology out patients department [OPD] of Dow University Hospital Karachi from April -November 2013.Patients diagnosed with hepatitis C who received interferon a[3 MIU subcutaneously thrice weekly] plus ribavirin [1200 mg daily for 24 weeks].Detailed history and dermatological examination including mucous membrane, hair and nails was performed initially and then monthly for six months and findings were recorded. A total of 109 patients were included in the study. Frequency of various skin diseases in these patients werepruritis 44[40.36%], transient alopecia 14[12.84%],generalized morbiliform rash in 22 [20.18%],photosensitivity in 8[7.33%], secondary hyperpigmentation in 17[15.59%] patients. Lichen Planus was observed in 6 [5.50%] patients while brittle nails were seen in 5 [4.58%], glossitis in 4[3.66%],chelitis in 8[7.33%]and generalized exfoliating dermatitis in 9[8.25%] patients. Apthous ulceration was observed in 7 [6.42%] patients. HCV and its treatment with interferon plus ribavirin is associated with significant dermatological complications. Physicians should be aware of these side effects and patients should be counseled before starting treatment

Yield of esophagogastroduodenoscopy and colonoscopy in cancer of unknown primary

Objectives: Carcinoma of unknown primary origin [CUP] is heterogeneous group of cancers. Role of gastrointestinal [GI] endoscopy in this entity is under investigated. Aim of this study was to evaluate yield of Colonoscopy and Esophagogastroduodenoscopy [EGD] in localizing primary tumor in patients with CUP

Methodology: Patients with histopathologically proven CUP who underwent colonoscopy / EGD to find the primary tumor from December 2009 to December 2011 were included in the study. Abdominal symptoms and cytokeratin [CK] 7 and 20 markers were correlated with presence of primary in GI tract

Results: After giving informed consent 86 patients were included in final analysis. All patients underwent colonoscopy while 60[70%] got EGD along with colonoscopy. Mean age was 55.10 +/-11.94 years with 52[60%] male. Abdominal symptoms were present in 50%. CK7+/CK20- in 34[40%]; CK7-/CK20+ in 2[2%] while CK7+/20+ in 7[8%] of metastatic tumor samples. Liver was metastatic site in 47[55%], Lymph node 12[14%] and Ascites in 8[9%]. Endoscopy detected primary in 6 [7%] patients with 3 each in stomach and colon. No association of abdominal symptoms and cytokeratin markers was found with presence of GI primary site

Conclusion: Yield of localizing primary lesion in the GI tract by pan-endoscopy was limited. Abdominal symptoms and cytokeratin markers do not predict presence of gastrointestinal malignancies