Cephalosporin resistance in community acquired spontaneous bacterial peritonitis

Objective: To determine 3rd generation cephalosporin resistance in patients with community-acquired spontaneous bacterial peritonitis [SBP] using early response assessment

Methods: This prospective quasi-experimental study was carried out at Doctors Hospital and Medical Center from January 2016 to September 2018. Patients with cirrhosis and SBP were included. Third generation cephalosporins i.e. cefotaxime/ceftriaxone were used for treatment of SBP. Response after 48 hours was assessed and decline in ascitic fluid neutrophil count of < 25% of baseline was labelled as cephalosporin resistant. Carbapenem were used as second line treatment. Recovery and discharge or death of patients were primary end points

Results: Male to female ratio in 31 patients of SBP was 1.2/1 [17/14]. Hepato-renal syndrome was diagnosed in 11[37.9%] patients. Cefotaxime was used for 16[51.6%] patients whereas ceftriaxone for 15[48.3%] patients. Early response of SBP was noted in 26[83.8%] patients while 5 [16.2%] were non-responders to cephalosporins. SBP resolved in all non-responding patients with i/v carbapenem. In-hospital mortality was 12.9% and had no association with cephalosporin resistance. High bilirubin [p 0.04], deranged INR [p 0.008], low albumin [p 0.04], high Child Pugh [CTP] score [p 0.03] and MELD scores [p 0.009] were associated with in-hospital mortality

Conclusion: Cephalosporin resistance was present in 16.2% of study patients with community-acquired SBP. Mortality in SBP patients is associated with advanced stage of liver disease

AAA syndrome, case report of a rare disease

Triple A [Allgrove] syndrome, an autosomal recessive disease is characterized by achalasia, alacrimia and ACTH-resistant adrenal failure with progressive neurological syndrome including central, peripheral and autonomic nervous system impairment, and mild mental retardation. The triple A syndrome gene, designated AAAS, localized on chromosome 12q 13 encodes for a 546 amino acid protein called ALADIN [Alacrimia-Achlasia-Adrenal Insufficiency and Neurologic disorder]. This report relates to two sisters, aged 8 and 12 years, who had vomiting, muscle weakness, alacrimia, excessive fatigue and dysphagia. Abdominal sonography, esophago-gastroduodenoscopy, barium swallow, esophageal manometry, CT scan abdomen and brain, biochemical profiles, as well as neurologic and ophthalmic evaluations were consistent with Allgrove's syndrome. Management consisted of pneumatic balloon dilatation for achalasia and initiation of cortisone therapy with successful resolution of dysphagia and other symptoms

Pneumatic Balloon Dilatation for Achalasia Cardia; Early and late results, a single center study

Objective: Achalasia Cardia is treated by Pneumatic balloon dilatation, Heller's Myotomy and recently, by Peroral Esophagaeal Myotomy. This study reports the efficacy of pneumatic balloon dilatation as a non-surgical motility in achieving relief of dysphagia, clinical improvement and recurrence. Long-term complications were reported

Methods: Eight hundred ninety two adult achalasia patients of both genders were treated from January 1988 till December 2011, with pneumatic balloon [Rigiflex Microvasive] dilatation, under fluoroscopy Barium swallow was obtained prior to and five minutes after dilatation to evaluate for efficacy of dilatation as well as for complications. Patients not responding to 30 mm balloon had repeat dilatation with 35 mm balloon after 8 weeks. All patients were enrolled in regular follow up at one, six months and yearly intervals up to a period of five years. Recurrence was defined as an increase in symptom score at 8 weeks greater than 50% of their baseline value. These patients were treated with 35 mm balloon or referred for surgical intervention

Results: Of 892 patients, follow up was obtained in 50% for 5 years, 9.2% for 4-years, 9.3% for 3-years, 10% for 2-years and 21.5% for 1-year of patients. One patient died after repeat dilatation. Eighty-eight patients were excluded from this analysis [20 died due to non-procedure related causes and another 68 were lost during follow up]. Statistically significant improvement was noted in reduction in height and width of barium column and symptom score coupled with weight gain during follow up. Forty-eight patients were subjected to repeat dilatation with 35 mm balloon, two of these developed post-procedure perforations with one mortality. Three non-responsive patients required surgical laparoscopic myotomy. No carcinoma of esophagus was reported during follow up. One patient post dilatation, developed esophageal bezoar. A single pneumatic dilatation achieved a remission rate of 93% at four years, 90% at three years, 95% at two years and 92% at one year post dilatation

Conclusion: Achalasia of esophagus can be effectively and safely treated with balloon dilatation to achieve adequate short and long-term symptomatic relief with a low complication rate

Optimal utilization of prime minister funds for treatment of hepatitis C

Hepatitis C virus infection is one of the major causes of chronic liver diseases throughout the world. In Pakistan, 10 million people are presumed to be infected with this disease. Hepatitis C virus has been characterized by having a higher rate of spontaneous mutation that leads to a marked degree of heterogeneity among its genotypes. HCV genotype plays an important role in the management of chronic hepatitis C. Knowing the genotype helps to decide about the duration, as well as to predict the response to treatment. But it is an expensive test, and not affordable for majority of patients. HCV RNA by PCR testing is advisable at various stages during the therapy. Early viral response [EVR] is to check the HCV RNA by PCR at 12 weeks, End of treatment response [ETR] is to do the testing at the end of treatment, while Sustained viral Response [SVR] means HCV RNA by PCR testing six months after completion of therapy. All these tests i.e. HCV genotype, EVR, ETR and SVR were checked in these patients

Aims and Objectives: the primary objective is to evaluate the proper utilization of Government funded program for the treatment of hepatitis C. Also it was aimed to determine the type of HCV genotypes as well as subtype in chronic hepatitis C patients, to check EVR, ETR and SVR in these patients, and to evaluate the cost effectiveness of these tests. A total of 1000 patients of hepatitis C virus were recruited

Results: out of 1000 patients, 506 [50.6%] were males, while 494 [49.4%] were females. The age ranged from 16 to 67 years with a predominantly larger proportion of younger patients. HCV genotype was checked in 295 patients Genotypes 1, 2, 3, mixed and untypeable were found in these patients. The predominant genotype was 3 [84%] and its subtype 3a [71%]. Early Viral Response [EVR] was checked in 142 [14.2%] patients; it was achieved in 97 patients. End of treatment response [ETR] was checked in 609 [60.9%] patients, it was achieved in 405 [66.50]. HCV RNA reports to confirm the SVR were available for only 60 [6%] of patients. Out of these 60, SVR was achieved in 46 [76.66%]

Conclusion: genotypes 2 and 3 were detected in almost 90% , while other types collectively detected in rest 10% of screened patients. Although 61% patients reported with HCV RNA reports at the end of treatment, but only 6% patients opted for follow up HCV RNA by PCR testing to look for SVR. Considering the huge cost of treatment of from government funds, measures should be adopted to have a structured program for proper evaluation of these patients before, during and after the treatment. Because of its financial implications, genotype testing is not advisable for naïve patients of chronic hepatitis C

Shifting proportions of carcinoma stomach: 18 Years experience of Shaikh Zayed Hospital

Objective: To study the demographic, endoscopic and histological features of patients with carcinoma stomach presenting in the Endoscopy suite at the Shaikh Zayed Hospital

Study Design: Cross sectional type of descriptive study

Place of study: Study was carried out at Department of Gastroenterology and Hepatology Shaikh Zayed Post-Graduate Medical Institute Lahore from November 2005 to March 2006

Method and Material: All patients diagnosed to have growth, ulcer or infiltrating lesion in stomach on upper gastrointestinal endoscopy were included from the record of the last eighteen years. Patients were divided in two groups depending on the time of endoscopy, each group comprising of endoscopies performed over nine years time. Both groups were compared using SPSS 11.1

Results: Total number of patients included was 267, male to female ratio was 1.42: 1 [158/109]. Mean age of patients was 52.11 [range 17-85 years] with 39% patients below 45 years of age. Predominant gross appearance was polypoidal, seen in 179 [67%] patients while in 151[56%] patients tumor was located in body of stomach, while 7 1[27%] patients had tumor in antrum and 45[17%] in fundus. Time based analysis oftwo groups of patients revealed no significant change in location, gross appearance or histological diagnosis over 18 years in patients presenting at the Shaikh Zayed Hospital

Conclusion: Gastric carcinoma involves younger age group in our population and is mostly located· in proximal two third of stomach. Features of gastric carcinoma have not shown much change over last 18 years in our population

Platelet count / spleen diameter ratio: can it predict the presence of varices in patients with cirrhosis of liver?

Ratio of platelet count and spleen diameter has recently been proposed as predictor of presence of esophageal varices in patients with cirrhosis. This study was carried out to evaluate predictive value of this ratio for presence of varices. One hundred and one patients with established cirrhosis and no history of variceal bleed were included. Data on physical examination, hematological, biochemical, abdominal ultrasound examination and esophagogastroduodenoscopy [EGD] was recorded for all patients. Presence of varices on EGD was correlated with platelet count/spleen diameter ratio. Esophageal varices were seen 1 in 65 patients while 36 patients had no varices. High grade varices were seen in 15 patients and 50 patients had low grade varices. Value of platelet count/spleen diameter ratio was not significantly different among patients with and without varices. Ratio of platelet count/spleen diameter can not be used to predict the presence of esophageal varices