Comparison of 12-hour with 72-hour terlipressin therapy for bleeding esophageal varices

Objective: To determine the efficacy of 12-hour of Terlipressin therapy as compared to 72-hour therapy in preventing rebleeding after endoscopic therapy

Study Design: Interventional study

Place and Duration of Study: Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from January to March 2016

Methodology: Cirrhotic patients presenting to our hospital with Gl [gastrointestinal] bleeding received Terlipressin 2 mg intravenous bolus, followed by 1mg 6-hourly until undergoing endoscopy.;Those with esophageal varices as the source of bleeding underwent band ligation and were recruited. Of the 93 enrolled patients, 90 remained and were randomized into 25 [27.8%] in control Group-A and 65 [72.2%] in test Group-B. Group-A received 72-hour of Terlipressin while Group-B received it for 12-hour. Both groups were monitored for rebleeding for 5 days

Results: Rebleeding occurred in 1 [4%] patient in Group-A and 3 [4.6%] in Group-B during the 5-day period. All 4 [4.4%] underwent repeat endoscopy. The Group-A patient and 2 [3%] of 3 Group-B patients showed ulcers over band ligation sites as source of bleed. The third Group-B patient showed varices requiring repeat banding. One [4%] patient [Group-A]

died due to persistent encephalopathy. No drug related adverse effects were seen

Conclusion: A 12-hour duration of Terlipressin as an adjunct to endoscopic band ligation shows similar results to 72-hour therapy

Changes in doppler ultrasound indices of hepatic circulation after treatment with beta blockers: a pilot study

Background: Portal hypertension is a serious complication of liver cirrhosis. Doppler ultrasound assessment may be a non-invasive and cost-effective means of evaluating portal hemodynamics in patients with portal hypertension

Aims and objectives: To assess efficacy of Doppler ultrasound in detecting changes in hemodynamics of hepatic circulation after beta-blocker administration

Methodology: 11 patients with liver cirrhosis and portal hypertension were included. All underwent Doppler assessment of portal vein velocity [PVV], spleno-portal index [SPI], congestive index [CI], liver vascular index [LVI], dampening index [DI], hepatic artery velocity [HAV], splenic artery velocity [SAV], hepatic artery resistive index [HARI] and splenic artery resistive index [SARI]. They were started on beta-blocker carvedilol 6.25 mg once daily and recalled after two weeks for repeat assessment

Results: Out of 13 enrolled, 4 were lost to follow up and one stopped carvedilol. 8 remained. The changes in parameters were: PVV: reduction in 3 [37.5%], no change in 1 and increase in 4[50%] patients; SPI: reduction in 3 [37.5%] and increase in 5 [62.5%]; CI: reduction in 3 [37.5%], no change in 1 and increase in 4 [50%]; LVI: decrease in 3 [50%], no change in 1 and increase in 2; DI: decrease in 5 [62.5%] and increase in 3 [37.5%]; HAV: increase in 4 [50%], no change in 1 [12.5%] and decrease in 3 [37.5%]; SAV: decrease in 4 [50%] and increase in 4 [50%]; HARI: increase in 7 [87.5%] and decrease in 1 [12.5%]; SARI: reduction in 3 [37.5%] and increase in 3 [37.5%]. 3 patients achieved reduction in 5 [PVV, LVI, DI, SARI and SAV] parameters. DI had the largest number of patients with observable reduction and HARI with the largest number showing observable increase in measured parameters

Conclusion: Doppler ultrasound represents a cost effective means of assessing the hemodynamics of hepatic circulation and any associated changes due to diseases and drugs

Helicobacter pylori in dental plaque; is it related to brushing frequency, plaque load and oral health status?

To determine the relation between presence of H. pylori in supra-gingival dental plaque with oral hygiene habits and oral health status of patients suffering from symptomatic dyspepsia. Descriptive study. The Department of Oral Health Sciences, Shaikh Zayed FPGMI, Lahore, from September 2008 to August 2009. One hundred and fifty dyspeptic subjects with dental plaque were enrolled. After recording brushing frequency, oral health status and plaque load, the supra-gingival dental plaque samples were collected by sterile curettes. Helicobacter pylori were detected in dental plaque samples through PCR assay. Presence of H. pylori in dental plaque was found to be 37.5% in the sample. Most of the subjects brushed once daily, had plaque index score of 1 and had fair to poor oral hygiene status. Approximately 35% of the individuals who brushed once or twice a day harbored the bacterium in their dental plaque. There was no difference between bacterial detection rates among different categories of plaque index and oral health status of the study subjects. Presence of H. pylori in dental plaque was found to be associated with neither brushing frequency nor with the plaque load nor with the oral health status of individuals suffering from symptomatic dyspepsia

Significance of total and free thyroid hormones in relation to serum proteins in chronic hepatitis B patients and normal controls

Hepatitis B destroys the liver cells. Proteins [albumin, pre albumin and thyroid binding globulin] produced by liver cells play an important role in metabolism and transport of thyroid hormones, therefore liver dysfunction is likely to disturb the transport of thyroid hormones resulting in disease. To determine the significance of thyroid hormones in relation to serum proteins in Chronic Hepatitis B patients. It was a cross sectional study conducted at National Health Research Complex [NHRC] and department of Gastroenterology Sheikh Zayed Medical Complex Lahore. One hundered Chronic Hepatitis B patients diagnosed by Polymerase Chain Reaction were matched with 100 healthy persons, served as control, were selected for total and free thyroid hormones using ELISA, while serum proteins were estimated spectrophotometrically. Serum total protein levels were within the normal range in both Chronic Hepatitis B patients and controls with mean value of 6.55g/dl and 7.2g/dl respectively, however serum albumin levels were lower in Chronic Hepatitis B patients [mean 2.69g/dl] as compared to controls [mean 4.1g/dl]. Serum globulin was increased [4.09g/dl] in patients as compared to controls [mean 3.1g/dl].Albumin globulin ratio was <1[mean 0.73] in Chronic Hepatitis B patients while in controls it was >1[mean13.5]. Consequently, increased globulin resulted in more binding of T4 [mean 194nmol/L] in Chronic Hepatitis B patients as compared to controls [mean 123nmol/L]. Conversion of T4 to T3 in Chronic Hepatitis B cases was also disturbed resulting in slight decrease of total T3 [mean 1.77nmol/L] as compared to controls [mean 2.3nmol/L].Free T3 [mean 3.56pmol/L] and Thyroid Stimulating Hormone [mean 0.68mIU/ml] also showed slight decrease when compared with controls [mean 4.5pmol/L, mean 1.52mIU/ml].FT4 remained within normal range in both the groups. In Chronic Hepatitis B related liver disease and cirrhosis, serum albumin levels go down while globulins go up and these changes alter the binding of thyroid hormones and Thyroid Stimulating Hormone resulting in disturbance in thyroid hormone levels

Dehiscence of laparatomy wounds in children

To assess the various causes or factors leading to dehiscence of incised surgical wounds of the abdomen in children. The record and charts of all patients who developed dehiscence of the abdominal wounds after operation for various diseases were reviewed and data was collected. The age, sex, timing of surgery, reason for surgery, place of primary surgery, operating experience of surgeon, type of suture material, surgical technique, associated medical conditions, nutritional status and the use of per operative antibiotics were the variables which were analyzed. Different causes of wound dehiscence were assessed and analyzed. During the period of 12 months 22 patients developed wound dehiscence. Age ranged from 3 days to 10 years. There were 13 male and 9 female patients. The reason for primary surgery was: intussusceptions in 2 patients; worm obstruction: 2; colostomy for recto vaginal fistula: 3; colostomy closure: 3; posterior saggital anorectoplasty combined with abdominal approach: 1; abdominal injuries [blunt and penetrating]: 5; enteric perforation: 3; mass abdomen: 2 ; band obstruction and subsequent anastomotic leak: 1. Two patients died during the treatment. 17 patients developed complete burst which was repaired while 5 patients were treated conservatively and developed incisional hernia. Wound dehiscence was commonly seen in patients with abdominal wound infection, peritonitis and malnutrition. Control of infection, correction of anemia and malnutrition along with strict adherence to surgical principles plays a vital role in preventing the dreaded complication of abdominal wound dehiscence

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding

To compare the efficacy of propranolol, propranolol with nitrate, band ligation, and band ligation with propranolol and nitrate for the prevention of esophageal variceal rebleeding. A prospective randomized trial. Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from November 2003 to July 2005. One hundred and sixty cirrhotic patients with esophageal variceal bleeding were randomized to four treatment groups [propranolol, propranolol plus isosorbide mononitrate, band ligation, band ligation plus propranolol and nitrate] with 40 patients in each group. Patients were followed for 6 months after the enrolment of last patient. Primary end points were recurrence of esophageal variceal bleeding and death. Treatment complications were noted. Four treatment groups were comparable regarding baseline characteristics. Esophageal variceal rebleeding occurred in 22% patients in band ligation plus drugs group, 26% patients in drug combination group, 31% patients in banding group and 38% patients in propranolol group [p=0.41]. Difference in mortality rates was also not significant. There was no significant difference between treatment groups in prevention of esophageal variceal rebleeding

Extrapulmonary tuberculosis in Lady Reading Hospital Peshawar, NWFP, Pakistan: survey of biopsy results

Tuberculosis is a disease of poor countries. In the recent years, there has been an increase in the occurrence of extra-pulmonary tuberculosis [EPTB] world over. As very little data is available regarding the situation of EPTB in NWFP, this study was conducted to asses its frequency in various organ systems of the body and to evaluate the role of demographic factors like sex and age in its causation. A total of 525 cases of EPTB diagnosed histopathologically in the Department of Pathology, Lady Reading Hospital Peshawar in the years 2002-2005 were included in the study. Age, sex and sites of biopsies were recorded. High female preponderance was noted with a M:F ratio of 1:2. Mean age was 35 years and 70% of the patients were in the age group 15-45 years. Lymph nodes were the most common site of EPTB, involved in 66.4% of the cases. EPTB has high rates in females in their reproductive age. Tuberculous lymphadenitis is the most common form of EPTB. High occurrence of EPTB in female population needs immediate attention of tuberculosis control programs

L-ornithine-L-aspartate infusion efficacy in hepatic encephalopathy

To determine the efficacy of L-ornithine-L-aspartate in treatment of hepatic encephalopathy. Randomized, placebo-controlled trial. Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from February to August 2005. Cirrhotic patients with hyperammonemia and overt hepatic encephalopathy were enrolled. Eighty patients were randomized to two treatment groups, L-ornithine-L-aspartate [20g/d] or placebo, both dissolved in 250mL of 5% dextrose water and infused intravenously for four hours a day for five consecutive days with 0.5 g/kg dietary protein intake at the end of daily treatment period. Outcome variables were postprandial blood ammonia and mental state grade. Adverse reactions and mortality were also determined. Both treatment groups were comparable regarding age, gender, etiology of cirrhosis, Child-Pugh class, mental state grade and blood ammonia at baseline. Although, improvement occurred in both groups, there was a greater improvement in L-ornithine-L-aspartate group with regard to both variables. Four patients in the placebo group and 2 in L-ornithine-L-aspartate group died. L-ornithine-L-aspartate infusions were found to be effective in cirrhotic patients with hepatic encephalopathy

Frequency of hepatopulmonary syndrome in cirrhotic patients

To determine the frequency of Hepatopulmonary Syndrome [HPS] in patients with cirrhosis of the liver. Observational cross-sectional study. Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from April 2005 to March 2006. Fifty consecutive patients admitted with liver cirrhosis were recruited. Twelve patients were excluded due to inadequate echocardiography image quality and inability to perform lung function tests. The diagnosis of cirrhosis was made on clinical, biochemical, serological and metabolic workup, ultrasound abdomen or liver biopsy. Complete blood count, liver function tests, prothrombin time, serum albumin, electrocardiography, chest radiograph, transthoracic contrast echocardiography, arterial blood gas analysis and pulmonary function tests [FEV1] were performed. Results were analyzed as percentages. Chi-square test of proportions and t-test were applied. Total patients evaluated were 38. Mean age was 47.92 +/- 11.38 years, with male [68.4%] to female [31.6%] ratio of 2.1:1. The commonest cause of cirrhosis was hepatitis C [71.1%]. Out of the 38 patients, 11 [28.9%] had HPS including 5 [13.2%] with overt HPS and 6 [15.8%] with subclinical HPS. All patients with HPS had hepatitis C with Child-Pugh- Turcotte [CPT] class C. Factors associated with HPS were digital clubbing, arterial hypoxemia and intrapulmonary vascular dilatations [p=0.02, 0.05 and 0.000 respectively]. In this study, 28.9% patients with cirrhosis of the liver had HPS. All belonged to child class C due to hepatitis C. Digital Clubbing, arterial hypoxemia and intrapulmonary vascular dilatations were important features of hepatopulmonary syndrome

Predictive value of rockall score for rebleeding and mortality in patients with variceal bleeding

To validate Rockall scoring system for in-hospital rebleeding and mortality in cirrhotic patients with variceal bleed. Cohort type of case series. It was carried out at the Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from March 2005 to March 2006. All cirrhotic patients presenting with upper GI bleeding and later found to have variceal source of bleeding on endoscopy were included. Clinical and endoscopic features were noted to calculate Rockall score. After giving appropriate pharmacological and endoscopic therapy, patients were followed for rebleeding or death till discharge from hospital. linear regression analysis was used to determine predictive value of score and discrimination was evaluated by calculating the area under the receiver operating characteristic [ROC] curve. A total of 402 patients were included. Mean age was 52.57 [ +/- 11.39] and male to female ratio was 2:1 [269/133]. Esophageal varices were source of bleeding in 340 [84.5%], gastric fundal varix in 44 [11%] and ectopic duodenal varix in 3 [0.9%] patients. Both esophageal and gastric varices were present in 15 [3.6%] patients. In-hospital mortality was 6.7% while 22 [5.5%] patients had rebleeding. Rockall score was found to have good predictive value for mortality [p-value <0.001 and area under curve AUC 0.834] and in-hospital rebleeding [p-value < 0.001 and AUC 0.798]. Rockall scoring system has good predictive and discriminative value for in-hospital rebleeding and mortality in patients with variceal bleeding due to cirrhosis

Effect of band ligation on portal hypertensive gastropathy and development of fundal varices

Use of endoscopic therapies for esophageal varices has resulted in increased prevalence of fundal varices and severe portal hypertensive gastropathy. This study was meant to compare the effect of band ligation and sclerotherapy on development of fundal varices and portal hypertensive gastropathy. Patients with esophageal varices presenting in the endoscopy unit of Shiakh Zayed Hospital, with at least one previous endoscopy were included. Patient's past record was reviewed for findings and type of treatment given for varices during first endoscopy, number of endoscopies till date, number of esophageal varices band ligation [EVBL] or sclerotherapy sessions. All patients underwent upper GI endoscopy and findings were recorded. Type of treatment patient rendered during first endoscopy either EVBL or sclerotherapy was correlated to the presence of fundal varices and severity of portal hypertensive gastropathy observed on present endoscopy, using Chi square test [chi [2]]. Eighty one patients were included. Mean age of patients was 48.7 +/- 12.63. Esophageal varices band ligation was carried out during first endoscopy in 49 [60.5%] patients and sclerotherapy in 31 [38.2%] patients. On fresh endoscopy, fundal varices were seen in 25 [30.8%] patients. Severe portal hypertensive gastropathy was found in 26 [32.1%] and mild in 54 [66.7%] patients. Severity of portal hypertensive gastropathy and presence of fundal varices in recent endoscopy was significantly more in patients with EVBL in first endoscopy. Band ligation of esophageal varices is associated with more frequent development of fundal varices and worsening of portal hypertensive gastropathy compared to sclerotherapy

Serum alanine aminotransferase level and response to interferon ribavirin combination therapy in patients with chronic hepatitis c

To determine the difference in sustained virological response to interferon-ribavirin combination therapy between patients with normal ALT and those with raised ALT in chronic hepatitis C. Quasi-experimental study. Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from February 2004 to June 2005. Patients with positive HCV RNA by PCR and compensated liver disease were included and divided in two groups. One group with ALT below upper normal limit [UNL= 65U/L] and second group with raised ALT [> 1x UNL]. After treatment with standard interferon alpha 2a and ribavirin, both groups were checked for sustained viral response [SVR] six months after end of treatment and compared for response to therapy with Chi square test. Of the 70 patients included, 25 had normal ALT [<1 x upper normal limit UNL] and 45 had ALT above upper normal limit [> 1 x UNL]. Of these, 63 patients completed treatment. Sustained viral response [SVR] was seen in 13 of 22 patients with normal ALT who completed therapy and 22 of 41 patients with raised ALT who completed treatment. Difference in SVR in two groups was not significant [p 0.679]. When patients with raised ALT were sub-classified, significantly better response was seen in patients with ALT 2 times the upper normal limit [p 0.021]. Patients with normal baseline ALT respond equally well to combination therapy as is seen in patients with raised ALT

Bedside diagnosis of spontaneous bacterial peritonitis using reagent strips

To determine the efficacy of reagent strip for bedside diagnosis of spontaneous bacterial peritonitis [SBP]. Cross-sectional analytical study. Place and Duration of Study: Shaikh Zayed Postgraduate Medical Institute from November 2003 to August 2004. Patients with cirrhosis and ascites underwent diagnostic paracentesis. Fluid was checked for leukocyte esterase released by PMN by using Combur 10 urine strip and graded for color change from 0-3. Fluid was also analyzed by cytology for PMN count. Results of both methods were compared to determine sensitivity, specificity and accuracy of strip for diagnosis of SBP. Of 214 paracentesis performed, SBP was diagnosed in 38 patients whereas 176 were negative for infection. Strip test was 97.7% sensitive and 89.4% specific with positive predictive value of 90%, negative predictive value of 97.7% and accuracy of 96.2%, when reagent strip grade 3 was considered as positive for diagnosis. Reagent strip is a quick bedside test, highly sensitive and specific for the diagnosis of SBP, based on polymorphonuclear count in ascitic fluid, to initiate early treatment, thus improving patient's outcome

Non-endoscopic prediction of presence of esophageal varices in cirrhosis

To identify hematological, biochemical and ultrasonographic predictors of esophageal varices in patients of cirrhosis. Cross-sectional, analytical study. Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from September 2003 to March 2004. One hundred and one patients with established cirrhosis and no history of variceal bleed underwent physical examination, hematological, biochemical tests and abdominal ultrasound examination. Esophagogastroduodenoscopy [EGD] was carried out in all patients. Presence of varices on EGD was correlated with hematological, biochemical and ultrasonographic variables by regression analysis. Esophageal varices were seen in 65 patients while 36 patients had no varices. High grade varices were seen in 15 patients and 50 patients had low grade varices. Serum albumin less than 2.95g/dl, platelet count less than 88 x 10[3]/micro L and portal vein diameter more than 11mm were associated with presence of varices. High grade varices were predicted by serum albumin < 2.95g/dl and portal vein diameter more than 11mm. Patients with serum albumin < 2.95g/dl, platelet count < 88 x 103/mL and portal vein diameter > 11mm are more likely to have high grade varices. These patients are candidates for surveillance endoscopy

Value of Quantitative HCV RNA in management of Chronic Hepatitis C patients with genotype 2 and 3

Determination of viral load by quantitative polymerase chain reaction [PCR] for hepatitis C virus [HCV] is part of workup before initiating interferon and ribavirin combination therapy for chronic hepatitis C. This study was carried out to determine predictive value of baseline viral load in patients with viral genotype 2 and 3, for response to therapy. Patients with chronic hepatitis C and genotype 2 and 3 were included in study. Viral load was determined before starting treatment with standard interferon and ribavirin for six months in all patients. Patients were checked for cod of treatment [EOT] and sustained viral response [SVR] by qualitative PCR for HCV. Response to therapy was correlated with baseline viral load by student`s t test. Total of 55 patients were included. Male to female ratio was 1.1/1 [29/26]. Six patients were of genotype 2, one patient was harboring both genotype 2 and 3 while rest of 48 patients had genotype 3 of hepatitis C virus. Baseline viral load was less than 2 million copies/ml in 25 patients while 30 patients had viral load in excess of 2 millions copies/ml. Treatment was completed in 50 patients. Sustained viral response [SVR] was seen in 31 patients and 19 patients were non-responders. No significant association was found between response to therapy and baseline viral load. Pre-treatment viral load is not predictive of response to combination therapy with interferon in patients with genotype 2 and 3

Frequency of anti - HCV antibodies in patients with lichen planus

To determine the frequency of anti-HCV antibodies, identify risk factors associated with HCV infection and to screen asymptomatic carriers in patients with lichen planus. Design: A prospective study. Place and Duration of Study: This study was carried out in the out patient department of Dermatology, Shaikh Zayed Hospital, Lahore, from October, 1999 to September, 2001. Subjects and A total of 184 clinically diagnosed cases of lichen planus [LP] were selected for the study. Blood samples of all the patients were tested for anti hapatitis C virus antibodies [anti-HCV Ab]. Polymerase chain reaction for hapatitis C virus was done in patients with positive anti-HCV Ab. Transcutaneous liver biopsy was performed in 7 patients with positive HCV-RNA. The histopathological results were evaluated using validated Metavir and Knodell scoring systems. Out of 184 LP patients, 43 [23.4%] were anti-HCV antibodies positive. Females were predominantly affected and male to female ratio was 1:5.1. Maximum positivity for anti-HCV was observed in age group 31-40 years [39.53%] followed by 41-50 years [25.58%]. Eighty-one% patients had history of dental treatment and 63% had received multiple injections for various ailments. Forty% patients had family history of jaundice while 26% had jaundice in the past. Ten out of 16 anti-HCV antibody positive patients, checked for HCV-RNA, had high levels of virus in blood. Transcutaneous liver biopsy done in 7 patients revealed underlying liver disease at various stages. Four patients treated with a-interferon and ribazole therapy for liver disease, showed marked improvement in their skin disease. A high prevalence of HCV infection was detected in patients with lichen planus. Patients with lichen planus should be screened for HCV carrier state

Ectopic intestinal varices as a rare cause of lower gastrointestinal haemorrhage

Ectopic intestinal varices are rarely responsible for lower gastrointestinal [GI] haemorrhage. A case of 55 years old male with recurrent melena is being presented, who was found to have scattered varices on small as well as large intestine. Selective review of literature regarding presentation, diagnosis and management of these cases is also part of presentation