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

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

Hep-net opinion about the management of patients with chronic hepatitis C in Pakistan in the era of available direct acting antivirals

In Pakistan, we have 4.9% prevalence of HCV in general population, with 79% genotype 3. Recently Sofosbuvir has been made available at compassionate price in Pakistan. Management of chronic hepatitis C includes counseling of HCV patients, their proper assessment to select those who need antiviral therapy, initiation of appropriate antiviral agents and duration of therapy, along-with careful monitoring for safety and efficacy. Hepatic status as well as previous history of HCV therapy needs to be taken in the consideration before starting antiviral therapy. Other factors include co-morbid conditions like obesity, DM, NASH, etc. Treatment of special populations like liver transplant patients, patients with HBV co-infection, chronic kidney disease and hemoglobinopathies need special considerations when initiating HCV 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

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

Efficacy of rifaximin in prevention of recurrence of hepatic encephalopathy in patients with cirrhosis of liver

To determine the efficacy of Rifaximin in prevention of repeated episodes of hepatic encephalopathy in patients with liver cirrhosis as compared to placebo. Triple-blind, randomized placebo-controlled trial. Department of Gastroenterology-Hepatology, Shaikh Zayed Hospital, Lahore, from October 2012 to April 2013. Patients in remission from recurrent hepatic encephalopathy resulting from cirrhosis were randomly assigned to receive either Rifaximin, at a dose of 550 mg twice daily [63 patients], or placebo [63 patients.] Patients were requested to take the drug orally twice daily for 6 months or until they developed a breakthrough episode of hepatic encephalopathy. Mean age of patients in treatment and control group was 40.21 +/- 2.33 years and 42.87 +/- 4.54 years respectively. The most common etiology of cirrhosis was hepatitis C followed by hepatitis B. Patients who remained free of hepatic encephalopathy during study period were 40 out of 63 patients in control group and 35 patients out of 63 patients [p = 0.56]. Most of the patients who developed breakthrough hepatic encephalopathy had a MELD score range of 21-25 in both groups. The number of deaths and adverse events was similar in both groups. Over a 6-month period, treatment with Rifaximin failed to maintain remission from hepatic encephalopathy more effectively than placebo in the studied group.

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%]

Paraneoplastic manifestations of hepatocellular carcinoma- are we different?

Objective: to determine the frequency of paraneoplastic manifestations in patients with hepatocellular carcinoma [HCC] presenting at tertiary care center

Design: descriptive study

Place of study: department of Gastroenterology - Hepatology, Shaikh Zayed Federal Post Graduate Medical Institute, Lahore

Patients and Methods: patients of hepatocellular carcinoma were interviewed for symptoms suggestive of paraneoplastic manifestations of HCC. The patients were subsequently examined and investigated. The frequency of paraneoplastic features was determined using SPSS 13.0

Results: of the total 100 patients included, musculoskeletal involvement with joint pain [11%] and muscle tenderness [4%] was noted. Skin lesions were noted in 2% of patients. On investigation 1% patient had erythrocytosis, 3% had thrombocytosis and eosinophilia was noted in 10% of patients. Calcium and cholesterol level were raised in 7% of patients each

Conclusions: paraneoplastic features are seen in significant number of patients with hepato cellular carcinoma

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

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

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

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

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

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

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