Pancreas divisum

Objective: To evaluate the complications, technical success, diagnostic evaluation and various endoscopic management options in patients with pancreas divisum

Study Design: Descriptive study

Place and Duration of Study: Endoscopy Suite, Surgical Unit 4, Civil Hospital, Karachi, from January 2007 to December 2013

Methodology: All Endoscopic Retrograde Cholangio-pancreatography [ERCPs] procedure performed in patients with pancreas divisum were analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy for the condition

Results: During the study period, 3600 patients underwent 4500 ERCP procedures. Pancreas divisum was found in 17 patients [0.47%]; 7 ERCPs [41.2%] were performed for diagnostic and 10 [58.8%] for therapeutic purposes. Sixteen [94.1%] had complete PD and one [5.9%] had incomplete PD. Male and Female ratio was 1:1.83 with a mean age of 26.3 years and median symptom duration of 11 months. A total of 23 procedures were performed in 17 patients; 2 had ERCP done thrice, 2 underwent the procedure twice, while the rest had single procedure done. Six [35.3%] patients had chronic pancreatitis, 7 [41.2%] had acute recurrent pancreatitis and 4 [23.5%] had acute pancreatitis. Endoscopic minor papillotomy was performed. There was no procedure-related mortality. ERCP affected management in 88.2% [15/17 procedures]

Conclusion: ERCP is a safe and feasible procedure for pancreas divisum patients

Solitary Rectal Ulcer Syndrome: demographic, clinical, endoscopic and histological panorama

Objective: To assess the demographic, clinical, endoscopic and histological spectrum of Solitary Rectal Ulcer Syndrome [SRUS]

Study Design: Cross-sectional observational study

Place and Duration of Study: Medical Unit-III, Civil Hospital Karachi [CHK] and Ward 7, Jinnah Postgraduate Medical Centre [JPMC], Karachi, from January 2009 to June 2012

Methodology: Patients with SRUS, based on characteristic endoscopic and histological findings, were enrolled. Patients were excluded if they had other causes of the rectal lesions [neoplasm, infection, inflammatory bowel disease, and trauma]. Endoscopically, lesions were divided on the basis of number [solitary or multiple] and appearance [ulcerative, polypoidal/nodular or erythematous mucosa]. Demographic, clinical and endoscopic characteristics of subjects were evaluated

Results: Forty-four patients met the inclusion criteria; 21 [47.7%] were females and 23 [52.3%] were males with overall mean age of 33.73 +/- 13.28 years. Symptom-wise 41 [93.2%] had bleeding per rectum, 39 [88.6%] had mucous discharge, 34 [77.3%] had straining, 34 [77.3%] had constipation, 32 [72.7%] had tenesmus, 5 [11.4%] had rectal prolapse and 2 [4.5%] had fecal incontinence. Twelve [27.27%] patients presented with hemoglobin less 10 gm/dl, 27 [61.36%] with 10 - 12 gm/dl and 05 [11.36%] subjects had hemoglobin more than 12 gm/dl. Endoscopically, 26 [59.1%] patients had mucosal ulceration, 11 [25.0%] had mucosal ulceration with polypoid characteristics; while only polypoid features were found in 7 [15.9%] subjects

Conclusion: Solitary rectal ulcer syndrome affects adults of both genders with diverse clinical presentation and nonspecific endoscopic features

Pneumatic balloon dilation of Achalasia Cardia

Objective: To find out frequency of improvement of symptoms and complications rate following endoscopic esophageal balloon dilation in patients with achalasia cardia

Study design: Case series

Place and duration of study: Department of Surgery Dow University of Health Sciences and Civil Hospital Karachi, from January 2006 to September 2013

Methodology: Patients in whom diagnosis of esophageal achalasia was made on investigations [barium swallow and / or manometry] were included. These patients were subjected to balloon dilation. The procedure was performed using Olympus achalasia balloon dilators. All patients were followed up and their responses were noted. Excellent response was defined as improvement of dysphagia for both solids and liquids. In good response category those patients were included who had improvement of dysphagia for both solids and liquids but problems with food intake persisted. In poor response category patients there was no improvement following balloon dilation. Time to recurrence of symptoms and complications were also noted

Results: A total of sixty patients were included. There were 31males [51.7%] and 29 [48.3%] females. Male to female ratio was 1.07:1. The age of the patients ranged from 13 to 65 year. The mean age was 35.48 +/- 13.36 year. Seventy five dilations were performed [mean 1.25 +/- 0.54]. In 35 [58.33%] patients excellent response was obtained while 19 [31.67%] patients had good response. In 6 [10%] patients no improvement was seen. These were put into poor response category. In one [1.7%] patient esophageal perforation occurred. In six patients [10%] surgery was advised as no improvement following multiple sessions of balloon dilation occurred

Conclusion: Achalasia cardia can be managed effectively with balloon dilation under fluoroscopy

Frequency and risk factors in the post-ERCP pancreatitis in a tertiary care centre

To evaluate the frequency and associated factors in the post-endoscopic retrograde cholangiopancreatography [ERCP] pancreatitis. Cross-sectional analytical study. Endoscopy Suite of Surgical Unit IV, Civil Hospital, Karachi, from December 2009 to November 2010. Patients undergoing ERCP were included. Patients who had presented with pancreatitis or raised amylase levels before procedure or patients who had previous history of surgery on the biliary or pancreatic systems were excluded from the study. Pearson chi-square and Fisher's exact test were used for qualitative data and t-test for quantitative data. Significance was taken as p

comparison of pioglitazone with metformin in management of type 2 diabetes mellitus

To compare hypoglycemic effect of Pioglitazone and Metformin in type 2 Diabetes Mellitus. Quasi experimental study. Department of Medicine, Military Hospital Rawalpindi Cantt from 11-01-2007 to 12-08-2007. Sixty patients of type 2 diabetes mellitus from outdoor department were selected. On arrival at OPD each patient was examined thoroughly. Therapeutic option was allocated to the patients simply by using a table of random numbers and dividing them in two equal groups. Informed written consent was obtained. Each patient was followed on monthly subsequent visits [six in total] and his HbA1c, fasting and random blood glucose were recorded carefully. All the data thus obtained was processed and analyzed using SPSS version 10.0. Mean and SD were calculated for age, BMI, fasting blood glucose, random blood glucose and HbA1c levels. Mean drop of all three parameters were compared among two groups. At the end of six months, it was revealed that fasting and random [2 hours postprandial] blood glucose dropped more in Pioglitazone group; P=0.000 and 0.02 respectively. While almost comparable effect was observed in HbA1c [P=0.2]. Pioglitazone has significantly better hypoglycemic effect than Metformin in type 2 diabetes mellitus at the end of six months therapy

Endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones

To evaluate the effectiveness of endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones. A prospective non-randomized descriptive study was conducted at the Endoscopic Service of Surgical Unit 4, Civil Hospital Karachi over a period of 2 years from February 2007 to January 2009. A total of 84 patients where the biliary calculus was either greater than 15mm or difficult to remove with standard techniques underwent ERCP with endoscopic sphincterotomy and balloon sphincteroplasty. Patients with diagnosis of cholangitis or "pancreatitis were excluded from the study. Endoscopic balloon dilatation was performed after standard sphincterotomy by using standard 15-18mm Controlled Radial Expansion [CRE] balloons. All procedures were done as day case under conscious sedation. There were 18 [21.4%] male and 66 [78.6%] females. Age of the study population ranged from 16-85 years with a mean of 48.38 +/- 17.07 years. The size of the stone ranged from 10-32mm with a mean of 14.7 +/- 0.44mm. Stones were removed with sphincteroplasty in first session in 52/84 [61.9%] patients, 11/17 [64.4%] patients in the second session and 4/4 [100%] in the third session. Patients who were lost to follow up were 14[16.7%]. Surgery was advised for 2 [2.4%] patients because of failure to remove stones by sphincteroplasty. Overall success of endoscopic sphincterotomy and large balloon dilatation in our study was 79.76%. Complications were seen in seven patients [8.3%] while one [1.2%] died. Bleeding was encountered in 3 [3.6%] patients which was controlled by adrenaline injection in 2 patients while one patient died due to severe haemorrhage before any surgical intervention could be undertaken. Moderate pancreatitis necessitating admission was seen in 3 patients [3.6%]. None of the patients had severe pancreatitis or perforation secondary to the procedure. Large balloon dilatation along with endoscopic sphincterotomy is a simple, safe and effective technique in removing large bile duct stones, in patients with distal common bile duct narrowing or in whom the size of stone is greater than the size of common bile duct with a complication rate if not less equal to that of endoscopic sphincterotomy alone

To compare the relapse rate of artesunate with tetracycline and quinine with tetracycline in uncomplicated falciparum malaria

To determine the relapse rate of falciparum malaria treated with artesunate plus tetracycline [AT] versus quinine plus tetracycline [QT] in uncomplicated patients of malaria. A cross sectional comparative study was carried out at Combined Military Hospital, Quetta from 01 May to 30 November 2006. Ninety patients of age-sex matched group with uncomplicated falciparum malaria having parasitemia >1%, age between 14-65 yrs, either sex and with no previous malaria treatment related to the present attack were recruited from emergency department, medical wards, included in the study. One group was given quinine along with tetracycline [QT] and the other group was given artemesinin and tetracycline [AT]. The patient was discharged from the hospital when three negative blood smears were obtained. Thereafter, blood smears were taken at days 7, 14, 21 and 28 after the start of the treatment, as outdoor patients. Parasitological response was regarded as radical cure with parasite clearance by day 7 without recrudescence up to day 28. Fever and parasite clearance times were noted as the time from the initiation of treatment to the first of three consecutive normal axillary temperature readings [<37°C] or negative blood peripheral film slides, respectively. Out of 90 patients of falciparum malaria, treatment was completed in 85 patients. The cure rates using treatment with AT was effective in 35 of 45 [77.7%] while QT was effective in 34 of 45 [75.5%] of the patients without any statistically significant difference [p = 0.68]. Poor compliance with the treatment schedule was observed in 2 of 45 [4.4%] in the AT group and 4 of 45 [8.8%] QT group of patients. Cure rates of 95.5% and 91.1% would have been obtained in the AT and QT groups if only compliant patients [n = 69] were considered. Parasitemia at day two cleared faster in the AT group than the QT group [91.1% versus 44.4%, respectively; p-value <0.001]. Combination of artesunate plus tetracycline is effective in the treatment of uncomplicated falciparum malaria and may provide a useful alternative to other treatment regimens