Clinical, laboratory and bacterial profile of spontaneous bacterial peritonitis in chronic liver disease patients

To determine the clinical and laboratory features, bacterial profile and antibiotic sensitivity pattern of Spontaneous Bacterial Peritonitis [SBP] in Chronic Liver Disease [CLD] patients presenting at a tertiary care hospital of Karachi. Cross-sectional study. PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi, from April 2010 to March 2012. CLD patients with ascites were recruited from PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi. Basic demographics, symptoms and clinical signs of patients were recorded. Patients with the history of antibiotic use within last 3 days or any intra-abdominal source of infection were excluded. Diagnostic paracentesis was done for ascitic fluid detailed report [D/R] and culture. Blood sample was collected for total leukocyte count, serum proteins and billirubin levels. Out of a total 152 CLD patients, 38 [25%] were diagnosed with SBP. Eight [24.2%] patients presented with classical SBP, 20 [52.6%] had culture negative neutrocytic ascites and 10 [26%] had bacterascites. Fever, abdominal tenderness and constipation were common in SBP patients. Ascitic fluid culture was positive in 19 [50%] patients. E. coli [65%] was the predominant pathogen followed by Enterococcus species [15%]. Resistance was high against cephalosporins [78%] and fluoroquinolones [69.6%] and least against amikacin [13%] and meropenem [12%]. Ascitic fluid D/R and culture together can lead to the accurate diagnosis of SBP and can guide for the right antibiotic choice as resistance to commonly prescribed antibiotic is common in such patients

Long term follow up of interferon treated chronic HCV patients in responders and non-responders

Interferon with ribavirin is the recommended treatment for chronic hepatitis C with a response rate ranging from 50-80% in different countries. Although sustained response is comparable to clinical cure, but whether interferon therapy slows down the disease process in non-responders and relapsers is not known. To determine the long term outcome of chronic HCV patients who have completed the interferon therapy and compare results between responders, relapsers and non-responders. Retrospective case record analysis of chronic hepatitis C patients who were treated with conventional interferon and ribavirin for 6 months during 1998 to 2002 and their follow up till 2011 were included. Depending upon the response they were divided into three groups i.e. responders, non responders and relapsers. A total of 175 patients were included. There were 126 [72%] males and 49 [28%] females, whose ages ranged from 11 to 70 years [mean 35.8 +/- 10.3]. After interferon therapy, 109 were sustained responders, 33 were relapsers and 33 non responders. Mean age of the responders [32.4 +/- 8.8 years] was significantly less as compared to non responders [40.4 +/- 12.0 years] and relapsers [42.4 +/- 8.0 years], [p < 0.05]. Responders had a much better follow up i.e four years as compared to non responders which was statistically significant[p <0.05]. During 10 years follow up, cirrhosis developed in 3 [2.8%] sustained responders, 6 [18.2%] non responders and 8 [24.2%] relapsers. During yearly followup, sustained responders had significantly lower mean ALT and AFP levels as compared to non responders and relapsers [p < 0.05] while non responders and relapsers had lower albumin levels as compared to the responders [p < 0.05]. Majority of the sustained responders had disease eradication, but non responders and relapsers should be followed for any evidence of cirrhosis

Screening for tuberculosis among household contacts of index patients

Household contacts of sputum positive pulmonary TB cases are at a high risk of getting infected with tuberculosis therefore symptomatic or vulnerable individuals should be screened and treated early. To determine the prevalence of pulmonary tuberculosis in the households contacts of index patients having pulmonary tuberculosis infection using standard diagnostic tests and refer the positive cases to DOTS program for treatment. This national descriptive study was conducted in seven Centers of PMRC throughout Pakistan form November 2010 to March 2012. A total of 580 index adult patients suffering from pulmonary tuberculosis, being treated at DOTs Centers of major tertiary care hospitals of Karachi, Lahore, Multan, Peshawar and Quetta living within 5-8 kilometers of the hospital, who consented to participate in the study were selected from the DOTs centres. Generally one but occasionally two close contacts of these index patients [spouses, parents or siblings] were called to the hospital for screening of TB using chest Xray, smear microscopy and tuberculin skin test. Out of 800 contacts screened, 125 [15.6%] were positive on sputum smear examination while 113 had infiltration on X-rays along with positive tuberculin skin test [Indurations of >10 mm] making a definitive diagnosis of TB. Calcified lesions were seen on X-rays in another 91 cases giving evidence of past infection, however 26 of these were AFB positive indicating either the relapse of disease or active lesion. Low grade fever and weight loss were the most significant findings in contacts that were positive on sputum smear and radiology. Almost 15.6% household contacts of pulmonary tuberculosis patients have pulmonary tuberculosis. Health care providers in general and DOTs staff in particular should be trained to inform all index cases that their close contacts especially those suffering from weight loss and fever should be screened for tuberculosis and treated if required

Screening of HBsAg and anti HCV from tertiary care, private and public sector hospitals

To find out the frequency of hepatitis B surface antigen and hepatitis C antibodies in patients referred from a tertiary care public sector hospital, other public sector and private hospitals of Karachi. Pakistan Medical Research Council's Specialized Research Centre for Gastroenterology and Hepatology, at Jinnah Postgraduate Medical Centre Karachi from January to December 2009. A cross sectional study was conducted where patients were referred from different departments of Jinnah Postgraduate Medical Centre [tertiary care public sector hospital], other public sector hospitals, private hospitals and clinics for the screening of hepatitis B and C virus infection. Three ml blood was collected from each patient, serum separated and tested for HBsAg and Anti HCV using Abbott Murex 4th Generation ELISA kits. A total of 2965 cases were referred in a year. Overall seroprevalence of HBsAg and Anti-HCV was 5.9% and 12.8% respectively. HBsAg positivity in patient referred from public sector hospitals was 5.8%, those from private 12.5%, 16.7% and 8.5% respectively. Co-infection of hepatitis B virus and hepatitis C virus was seen in 0.9, 2.5 and 1.4% cases respectively. breakdown of viral positivity within different departments of Jinnah Postgraduate Medical Centre Karachi showed HBsAg positivity of 7.1%in Medical department, 5.2% in Surgical department, 5.0% in Gynaecology department, 6.6% in other departments of Jinnah Postgraduate Medical Centre while, only 1.7% were positive from Pakistan Railway, hospital Anti HCV positivity was maximally [20.3%] seen in medical department followed by 14% in other departments, 10.9% in surgical department, 7.9% in gynaecology and 5.1% in railway hospital. Co-infection of HBV and HCV was seen in 2% cases referred from medical department, while rest of the departments had less than 1% positivity of co-infection. Both genders were equally infected with HCV, but males were predominantly more infected with HBV, with a male to female ratio of 2:1 [p>0.001]. High frequency of HBV and HCV infection is due to a biased population of hospitalized cases. High referral from medical and gynaecology department indicates high awareness about these diseases in the health care providers and similar awareness needs to be created in other departments of public and private sector hospitals. Serious efforts need to be done to inculcate awareness regarding HBV and HCV in all departments of public and private hospitals

Factors influencing the response of interferon therapy in chronic hepatitis C patients

To determine factors influencing response of interferon therapy in chronic hepatitis C patients. Descriptive, analytical study. Pakistan Medical Research Centre, Jinnah Postgraduate Medical Centre, Karachi, from January 1998 to December 2009. Patients of chronic hepatitis C treated with conventional interferon were retrospectively analyzed. End treatment response at 6 months for genotype 2 and 3 and one-year for genotype 1 and 4 was assessed. Sustained virological response was checked after 6 months of cessation of therapy. Non-compliant and incomplete follow-up cases were excluded. Factors influencing the response to therapy were analyzed by univariate and multivariate logistic regression analysis. A total of 932 cases received interferon therapy; 103 were lost to follow-up and were excluded. Treatment was completed in 829 cases; end treatment response was 74% [615 out of 829 cases]. Six months post-treatment follow-up was available in 492 cases. Sustained virological response was seen in 63% [308 out of 492 cases]. Univariate logistic regression analysis showed significantly better response in patients with < 40 years of age, body weight < 70 kg, normal platelet count, serum albumin > 4.0 grams, non diabetic patients and those with a normal alanine aminotransferase [ALT] at 1st month of therapy. Multiple logistic regression analysis showed that only age < 40 years was significantly important for sustained virological response. For conventional interferon therapy, age < 40 years is the best predictor for sustained virological response, however, better response can be achieved in patients with < 70 kg weight, normal platelet count, serum albumin > 4.0 grams, non-diabetics and patients having normal ALT at 1st month of therapy

Comparison of healing of duodenal ulcer with herbal medicine versus allopathic medicine

Proton pump inhibitors heal over 90% cases of duodenal ulcer but these are expensive. Many patients are reluctant to use allopathic treatment and therefore, use alternate herbal medicines to achieve the same results. There is no head to head comparison of the efficacy of herbal treatment with standard allopathic treatment available in the literature. To compare the healing rates of duodenal ulcer using either herbal drugs [Andamali + Susi + Qarheen] or allopathic medicines [proton pump inhibitor]. Endoscopically diagnosed cases of duodenal ulcer were assigned to two groups where one group received herbal medicine and the other received proton pump inhibitor for 4 weeks [Clarithromycin and Amoxicillin were added for a week for Helicobacter pylori positive cases]. Healing was checked on endoscopy at the completion of therapy. Complete blood count, liver function tests, urea and creatinine were done initially and at the end of therapy to see any adverse effects of the therapy. Other side effects were also noted during the study. A total of 42 endoscopically proven cases of duodenal ulcer were included in the study, 22 patients received proton pump inhibitor [group A] and 20 received herbal medicine [group B]. Seven cases [5 in group A and 2 in group B] were lost to follow up and were thus excluded from the study. Thirty-five cases [17 group A, 18 group B] completed the study. Out of these 35 cases, 29[82.85%] were males and 6[17.1%] females. Helicobacter pylori was present in 19[54.3%] cases [10 in group A and 9 in group B]. After 4 weeks of therapy, 16[94%] cases healed with proton pump inhibitors and 13[72%] healed in herbal medicine group. The difference in healing rates was not significant. Using proton pump inhibitors along with 2 antibiotics in the Helicobacter pylori positive cases, 9 out of 10[90%] showed healing of ulcer, while 7 out of 9[78%] cases in herbal medicine group who were positive for Helicobacter pylori, but did not receive antibiotics also showed healing. Regarding adverse effects, bitter taste in mouth was reported in 5[29%] and diarrhea in 2[12%] patients, receiving triple regimen in group 'A' against only 2[11%] patients who had similar complaints with herbal medicine. No significant change was observed in the hematological and biochemical parameters like CP, LFTs, urea and creatinine from the baseline to the end of therapy in both groups. Healing of duodenal ulcer is almost similar with both herbal and standard allopathic drugs; however, adverse effects were more common with allopathic drugs. Herbal medicine can be used to treat duodenal ulcer

Is raised helicobacter pylori antibody titre enough to decide retreatment?

Helicobacter pylori infection causes a rise in its antibodies which take almost a year to come to baseline following successful eradication treatment. Checking these values in between a year may give falsely high values and many patients may thus be over treated. Aims: To serially determine Helicobacter pylori antibody titres in patients after giving them triple therapy for H. pylori eradication and see how these values drop over time. Longitudinal study conducted in Department of Gastroenterology and Hepatology, Pakistan Medical Research Council, Research Centre, Jinnah Post Graduate Medical Centre, Karachi, from May 2006 to April 2010. Over the period of four years, 186 patients who were found positive for campylobacter like organism test during endoscopy were further tested for anti H. pylori IgG titre before being treated for H.pylori. Patients were given triple therapy comprising of Omeprazole [20mg twice daily], Amoxicillin [1gm twice daily] and Clarythromycin [500mg twice daily] for a week and were followed at 1, 3, 6 and 12 months to check symptomatic relief and they were tested again for H. Pylori antibody titres. Data was collected on pre-designed proforma which included patient's demography, symptoms and diagnosis. Out of 186 patients who had a positive campylobacter like organism test, 173 patients consented to participate in the study. Serology for H. Pylori was positive in 119[68%] cases. A decline in mean antibody titres was observed as 11%, 21.5%, 54.7% and 59.2% at 1, 3, 6 and 12 months respectively. Sensitivity of serology for diagnosing H. pylori infection is good but using these as a tool for monitoring response to treatment is doubtful. A slow drop in H. pylori antibodies was seen over 12 months and therefore, physicians are cautioned not to retreat the already treated cases till about one year post treatment. H. pylori antibodies should be checked on regular basis to diagnose new cases but it should not be used in previously treated patients to retreat

Frequency of hepatitis C and D super infection in patients with hepatitis B related complex liver disorders

To determine the frequency of super infection of hepatitis C and D in patients with hepatitis B related complex liver disorders and the distribution of HBV genotypes in these patients. Descriptive study. The Gastroenterology Unit of PMRC in JPMC, Karachi, from July 2006 to June 2007. All patients registered for HBV associated infections were selected. Blood was drawn from 180 patients who fulfilled the inclusion criteria. Those with an incomplete test profile were excluded. All clinical conditions were investigated through liver function tests, coagulation profile, and findings at abdominal ultrasonography, upper gastrointestinal endoscopy and liver biopsy. Liver cirrhosis and hepatocellular carcinoma [HCC] were diagnosed either on the basis of histology, or on a combination of radiological, endoscopic and laboratory data. Hepatitis B virus DNA was extracted from serum, and subjected to a nested PCR using the type specific primers for HBV genotype. Descriptive statistics were used for frequency and mean determination. The 129 patients finally selected for statistical analysis included 108 [84%] males and 21 [16%] females. The age ranged from 6- 68 years [mean=31.5 +/- 12.39 years]. There were 70 [54.2%] patients of non-cirrhotic, chronic hepatitis [CLD], 38 [29.4%] carriers, 12 [9.3%] cirrhotics and 9 [6.9%] HCC patients. Among the 129 patients, 45 [34.9%] were positive for double infection with HDV. These included 35 CLD cases, 7 cirrhotic and 3 carriers, 4 [3.1%] patients were positive for double infection with HCV including one with CLD, 2 with cirrhosis and one with HCC. Triple infection with HBV/HDV/HCV was present in 4 [3.1%] patients who had CLD. Approximately 59% [n=76] patients were not coinfected, though 9 had developed HCC. The genotype distribution of HBV was observed as D in 98 [76%] patients, A in 24 [18.6%], and AD mix in 7 [5.4%]. Genotypes B, C, E or F were not found. Accordingly, genotype D strains were the predominant strains among all categories. The frequency of super infection of hepatitis C and D was found to be highest in HBV cirrhosis patients compared to patients having chronic liver disease [non-cirrhotics] and carriers. Genotype D of hepatitis B virus was found dominant in all hepatitis B related complex liver disorders