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

Pegylated interferon and ribavirin for post liver transplant HCV recurrence

Pakistan has a very high HCV prevalence[1] with majority being genotype 3. A high number of patients with cirrhosis undergo liver transplantation. HCV recurrence following transplant is universal[2]. Interferon free therapy has recently become available and preliminary studies show 70% SVR in post transplant patients[3]. Since genotype 3 has a high response to pegylated Interferon 3, it remains a competitive agent

Aims and Methods: The aim of this study was to determine the efficacy of pegylated interferon plus ribavirin in the treatment of recurrent hepatitis C following liver transplantation. 15 patients with recurrent hepatitis C following liver transplantation were included in the study, 13 males and 2 females. Mean age was 52 years. 13 had genotype 3 disease, one genotype 2 and one genotype 1.11 were living donor and 4 were cadaveric grafts. 13 were on tacrolimus and MMF, one on tacrolimus alone and one on cyclosporine and MMF. 6 patients were treated within 2 years of transplant and remaining 9 were treated 3-5 years after transplant. Liver biopsy was done prior to therapy in 6 patients. All patients received pegylated interferon a2a 180 g weekly plus ribavirin 15mg/kg daily for 48 weeks

Results: 14 out of 15 patients [93.3%] achieved SVR. This included all 13 Genotype 3 patients [100%] and the single genotype 2 patient. One patient, genotype 1, was nonresponder to treatment. Treatment was stopped at 22 and 36 weeks in 2 patients due to anaemia. Both achieved SVR. 11 patients were administered erythropoietin for anemia. 7 patients required ribavirin dose reduction for anemia, and achieved SVR despite dose reduction

Conclusion: Pegylated interferon and ribavirin is an extremely effective combination for treatment of patients with recurrent genotype 3 hepatitis C after liver transplantation. The main side effect is anaemia, which can be managed with erythropoietin supplementation and ribavirin dose reduction without any reduction in response rate

Capsule endoscopy: is it really helpful in the diagnosis of small bowel diseases?

Objective: to determine the diagnostic yield and safety of capsule endoscopy for small bowel diseases

Introduction: the small bowel evaluation for any pathology has always been a difficult task because both upper GI endoscopy and colonoscopy could not access this area and other radiological tools like barium studies and CT enteroclysis were less sensitive with associated risk of radiation exposure. Only Push enteroscopy could evaluate the small bowel effectively but was laborious and invasive. Capsule endoscopy was introduced in year 2000 and was accepted with great enthusiasm all over the world3. Now, during the past few years it has also been used for the diagnosis of acute gastrointestinal bleeding in emergency departments and results are quite encouraging 5,6. The procedure was introduced at Department of Gastroenterology-Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan in year 2009. Since then, it has been regularly used for investigation of small bowel abnormalities

Methods: video Capsule Endoscopy [VCE] using GIVEN Imaging system was performed on 60 patients having various indications like obscure GI bleeding, undiagnosed iron deficiency anemia, abdominal pain and malabsorption. This was a retrospective analytic study carried out at the Department of Gastroenterology-Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan from February 2009 to June 2014. Statistical Analysis was done using SPSS version 22

Results: out of 60 patients, 41 [68.33%] were male, 19 [31.67%] were female. Mean age was 52 years with minimum 11 years and maximum of 85 years. No lesion was found on examination in 8.33% [n=5] patients while presence of blood in the gut resulted in poor visualization in 3.33% [n=2] patients. In remaining 88.34% [n=53] patients, the procedure detected various intestinal lesions. Our study detected presence of Angioectasias in 30.0% [n=18], visible vessels in 6.67% [n=4], strictures in 5.0% [n=3], small bowel ulcers in 10.0% [n=6], edema and erosions in 8.33% [n=5], loss of villi in 11.68% [n=7], intestinal worms in 3.33% [n=2], mass lesions in 8.33% [n=5] and Angioectasia with ulcers in 5.0% [n=3] of patients. The diagnosis in 3 patients was further verified by surgical operation, while enteroscopy was done in 2 patients for confirmation. Capsule impaction occurred in 2 patients. All images of Video Capsule Endoscopy [VCE] were of good quality

Conclusion: capsule endoscopy is a safe and effective procedure with a good diagnostic yield and can be used routinely for the diagnosis of small bowel diseases

High meld score and spontaneous bacterial peritonitis; a proven relationship

Almost a 3[rd] of patients with liver cirrhosis and ascites may develop spontaneous bacterial peritonitis [SBP]. SBP carries a high morbidity and mortality. Hence identifying predisposing factors that may cause a patient with ascites to develop SBP are of great interest. The Model for End-Stage Liver Disease [MELD] score is a measure of mortality risk in patients with end-stage liver disease7. Development of ascites and encephalopathy, two complications of end-stage liver disease that are not used in the MELD score calculation, have generally correlated with higher MELD scores

Aims and methods: The aim of this study was to determine the frequency of higher MELD score in patients of SBP with liver cirrhosis. Eighty-five patients fulfilling the inclusion criteria were selected. An informed consent was taken from all patients. Demographic data including age, sex etc. was obtained. All patients had MELD scoring on the basis of serum creatinine, serum bilirubin and INR. MELD scores were calculated according to the method used by the United Network of Organ Sharing [UNOS]

Results: A total of 85 patients were included in the study. It included 52 [61%] male patients and 33 [39%] female patients. Mean age was 48.88 years [SD +/-8.82], Serology for viral markers showed that 68[80 %] patients were positive for hepatitis C antibodies and 8[9.4%] patients were positive for hepatitis B while 3 [3.5%] patients were positive for both hepatitis B and C. In the remaining 6 patients, 2 [2.35%] patients had alcoholic cirrhosis and in 4 [4.7%] patients, etiology of liver disease could not be ascertained. MELD scores in these patients ranged from 9 to 36. Eight patients [9.41%] with SBP had a MELD score of below 15 while 15 [17.64%] patients had scores between 16 and 20. 32 [37.64%] patients had MELD scores between 21 and 25. 20 [23.52%] patients had scores between 26 and 30 while 10 [11.76%] patients had a MELD score higher than 30. Conclusion: A high MELD score [>16] is noted in a significant number of patients with spontaneous bacterial peritonitis [over 90%]

Comparison of rifaximin and lactulose with lactulose alone in the treatment of acute hepatic encephalopathy in patients with liver cirrhosis

Hepatic encephalopathy [HE] is one of the common complications of liver cirrhosis. Lactulose is conventionally used for the treatment of hepatic encephalopathy

Aims and methods: The aim of this study was to evaluate the combined efficacy of lactulose plus rifaximin versus lactulose alone in the management of hepatic encephalopathy. 80 patients with HE were given lactulose alone and another 80 were given a combination of lactulose and rifaximin. They were monitored for 7 days for response i.e., reversal of HE

Results: Initially 160 patients with HE, who met inclusion and exclusion criteria, were enrolled in this study [out of 183 screened]. 80 patients were randomized in lactulose plus rifaximin group [group A] while the other 80 were placed in lactulose alone group [group B]

Patients were given respective treatment and were monitored for improvement of HE by using West Haven [WH] criteria. Patients were assessed daily. Patients were monitored till recovery or death for 7 days, whichever occurred first. 62 [77.5%] patients in the rifaximin plus lactulose group showed reversal while 43[53.75%] patients in lactulose only group showed reversal of HE. Mortality was also less in the rifaximin plus lactulose group compared to lactulose alone group 17[21.25%] vs. 33 [41.25%] respectively [P<0.05]

Conclusion: Rifaximin and lactulose have different mechanisms of action and act synergistically in combination and show better response in treating HE. This can result in significant decrease in morbidity and mortality

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

Efficacy of argon plasma coagulation in gastric vascular ectasia in patients with liver cirrhosis

To determine the efficacy of Argon Plasma Coagulation [APC] in terms of improvement in hemoglobin level and disappearance of telangiectasia as endoscopic treatment for Gastric Antral Vascular Ectasia [GAVE] and Diffuse Antral Vascular Ectasia [DAVE] syndrome in liver cirrhosis. Quasi experimental study. Department of Gastroenterology and Hepatology of Shaikh Zayed Hospital/ Federal Postgraduate Medical Institute, Lahore, from January, 2006 to July, 2007. Cirrhotic patient with gastric vascular ectasia were enrolled and followed-up for 18 months with repeated sessions of APC. Efficacy of APC was evaluated on the basis of patient's symptoms, transfusion requirements and hemoglobin levels. APC was performed by using ERBE generator set at 60 W and flow rate 2.0 L/min using primarily endfiring probes. Fifty patients were enrolled in the study. Mean age was 55.78+1.24 years with 32 males and 18 females giving a male to female ratio 1.7:1. Forty two patients were in Child's Class C and 8 in Child's Class B. Presenting complaints were malena and anemia. Two hundred and fifty three APC sessions were carried out; mean 5.06 + 1.5 sessions per patient. Mean follow-up period after the last session was 8.5 + 3.7 months. Mean increase in the hemoglobin level was 1.35 + 0.24 g/dl. There was no death of any patient during the study period. Treatment with APC is an effective and safe method to decrease blood loss in patients with GAVE and DAVE

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

Successful treatment of watermelon stomach / GAVE syndrome by using argon plasma coagulation

This case report describes a 50-year-old female patient with liver cirrhosis presented with anemia. She was found to be suffering from gastric antral vascular ectasia [watermelon stomach] on upper gastrointestinal endoscopy. She underwent multiple sessions with Argon plasma coagulation, a non-contact thermal method of hemostasis for the management of watermelon stomach. After 3 sessions, the lesions disappeared and the hemoglobin increased by 2.4 gm/dl without any need of transfusion

High rates of hepatitis delta virus super infection / coinfection in Balochistan

Hepatitis B carrier rate is still very high in Pakistan, especially in Balochistan, where in some areas almost 16% of the population is positive for HBsAg. Delta virus, also known as hepatitis D virus, only affects those suffering from Hep B infection [HbsAg positive]. A study was carried out to check for Hepatitis Delta virus infection in these patients. This study showed that 35% HbsAg reactive patients had either coinfection or superinfection with the Hepatitis delta virus. These rates are much higher than the other studies, and are alarming. Vaccination against Hepatitis B virus can also prevent this infection. Awareness and prevention at community level is required

Serological markers sf hepatitis B infection in incidentally detected HBsAg positive patients

Objective: to evaluate the serological profije of the incidentally detected HBsAg positive patients, to asses the severity of disease and to identify the risk factors for the transmission

Design: an observational study

Place and duration of study: the study was conducted at Bolan medical Complex hospital, Quetta, from January 2001 to December 2003

Patients and methods: all patients who presented to gastroenterology clinic of Bolan Medical Complex hospital Quetta and at few private clinics with positive HbsAg, detected incidentally, were tested for alamine transaminase [ALT], hepatitis Be antigen [HbeAg] anti HBe antibody and hepatitis-B virus DNA [HBV DNA] by polymerase chain reaction [PCR]. Their risk factors for acquisition of infection were assessed with specific questions

Results: a total of one hundred and four [104] patients with HBsAg reactive were included, 89 were male and 15 were females. The mean age was 30 years, with minimum age of 07 years and maximum of 57 year. Out of 104 patients, 93 patients were tested for HbeAg, 14 [15%] were positive for HBeAg and 79 [85%] were negative. Anti HBe antibody was checked in 91 patients, and it was reactive in 72 [79%], while it was non-reactive in only 19[21%] patients. HBV DNA [qualitative] determination was done in 95 patients and it was detected in 11 [11.6%] and 84 [88.4%] were negative for HBV DNA. No significant correlation is seen between seroconversion and ALT levels. Normal ALT levels were observed only in 36 patients having seroconversion i.e AntiHBeantibody positive, while it was also normal in 5 HBeAg positive patients. Common risk factors detected in these patients were intramuscular injections, surgery and dental treatment, however, in a large number, risk factors were unknown

Conclusion: fifteen percent tomatic subjects with positive HBsAg were found to be HBeAg positive. Large number of patients 79% has seroconversion and only 11.6% have HBV DNA detected in their serum. Intramuscular injections surgery and dental treatment were noted to be frequent risk factors in these subjects

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

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

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

Prevalence of hepatitis b surface antigen and anti hepatitis C virus; among general population in Lahore

Objective: To assess and compare the prevalence of hepatitis B and C in normal population. Design: This is a descriptive, non-interventional study. Setting: Data was collected from a free screening camp for hepatitis B and C at Shalamar Hospital, Lahore

Subjects and Methods: Normal people of any age and either sex were included in the study. Screening was performed for HBs Ag and Anti HCV by Acu-Check one step test [Chromatographic immunoassay] in serum

Results: A total 757 subjects were screened. Prevalence of HBs Ag was 2.6% and Anti HCV 13.5%. The mean age was 24.96+ 14.67 years. Females were 55.2% and males were 44.8%. Seroprevalence in females and males of Hbs Ag was 2.2% and 3.2% and of Anti HCV 15.6% and 10.9% respectively. HBs Ag was more prevalent in younger population [up to 10 years]. The majority of Anti HCV positive subjects were in 31-50 years age group

Conclusion: Seroprevalence of HBs Ag and HCV is high in general population. Prevalence of HCV is very high in this region and HBV is very high in children up to 10 years of age. Larger population based studies are needed to confirm the results