Role of Pancreatic Stent placement in prevention of post Endoscopic retrograde Cholangiopancreatography Pancreatitis: experience at a tertiary care hospital in Pakistan

Objective: To determine the frequency of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis [PEP] in patients who underwent prophylactic pancreatic duct stenting

Study Design: Descriptive case series

Place and Duration of Study: This descriptive case series was conducted at the department of Gastroenterology, Pak Emirates Military Hospital Rawalpindi, from Jul 2017 to Feb 2018

Material and Methods: One hundred and twenty consecutive patients were enrolled after they met inclusion and exclusion criteria. Endoscopic Retrograde Cholangiopancreatography Pancreatitis [ERCP] was performed by Olympus duodeno scope [TJF Q180V] by an endoscopist having at least 3 years experience of performingindependent ERCPs. An additional 4, 6, or 7cm long 5FrGeenen[registration sign] pancreatic plastic stent [Cook Medical] was placed in all cases where pancreatic duct was accidentally cannulated. Primary outcome variable was post ERCP pancreatitis. Data was recorded on a pre-designed proforma and analyzed by SPSS version 21.0

Results: Out of total 120 cases, PEP was found in 4 [3.3 percent] patients. All the 4 patients had mild pancreatitis

Conclusion: PEP is not an uncommon complication following ERCP. The rate of PEP appears to be lower with prophylactic pancreatic duct stenting

Predictive accuracy of model for end stage liver disease [MELD] as a prognostic marker for cirrhosis in comparison with Child - Pugh score

To compare Model for End Stage Liver Disease [MELD] and Child-Turcott-Pugh [CTG] scoring as predictors of survival in cirrhotic patients. Observational prospective study. Military Hospital, Rawalpindi from 1[st] Dec 2008 to 30[th] April 2009. The study was carried out at Military Hospital, Rawalpindi a tertiary care hospital of Pakistan. Study included 55 patients suffering from cirrhosis of both genders being above 12 years of age, admitted in medical wards during the period from 1[st] December, 2008 to 30[th] April 2009. Each patient was assigned a MELD and CTP score. On discharge, these patients were followed up at 03-months, O6months and 1-year duration through telephone. Thirty seven [67.3%] patients were male while 18 [32.7%] were female patients, with age ranging from 27 years to 75 years [mean 53]. Fourteen [25.4%] patients were dead at 3-months, 22 patients [40%] were dead at 6- months and 29 [52.7%] patients were dead at 1-year follow up. MELD score proved to be a better indicator of survival than CTP score over a period of 01 year follow-up. MELD score is a better prognostic marker for cirrhotic patients as compared to CTP score

Ruptured Hydatid cyst in biliary tract

A lady aged 26 years reported with a 2 months history of fever, upper abdominal pain and weight loss. Her abdominal ultrasonographic scan revealed a complex cystic mass in left lobe of liver suggestive of hydatid cyst that was confirmed on magnetic resonance imaging of abdomen and magnetic resonance cholangiopancreatogram. With strong suspicion of a hydatid cyst, endoscopic retrograde cholangiogram was performed which confirmed the diagnosis. During the procedure, hydatid membranes protruding from the papilla were removed after sphincterotomy. She was put on albendazole 400 mg twice daily after the procedure and showed a remarkable clinical improvement

Assessment of patients with chronic liver disease qualifying for liver transplant

To determine the frequency, etiology and pattern of patients with chronic liver disease at a tertiary care hospital qualifying for a liver transplant. Cross-sectional Study Military Hospital Rawalpindi from December 2008 to May 2009. Study included all patients of Chronic Liver Disease, admitted in medical wards. Diagnosis was made on the basis of clinical and ultrasonographic findings suggestive of chronic liver disease. Etiology was identified by serological tests [ELISA or PCR] and immunological tests. Metabolic screening was done for Wilson's disease and haemochromatosis. HCC was diagnosed and staged by biopsy and CT scan. After taking informed consent, detailed medical history, physical examination and required biochemical tests were carried out. All patients of age 12 years and above were evaluated according to Model for End Stage Liver Disease [MELD] and those below 12 years of age were evaluated by Pediatric End Stage Liver Disease [PELD]. Milan's Criteria was used for hepatocellular carcinoma and Mayo risk scores [MRS] for patients with Primary Biliary Cirrhosis and Primary Sclerosing Cholangits. A total of 212 patients suffering from chronic liver disease were included. Out of these, 164 [77.4%] were suffering from chronic hepatitis C, 16 [7.5%] from chronic hepatitis B, 2 [0.9%] from autoimmune hepatitis, 2 [0.9%] from hepatocelluar carcinoma, 1 [0.5%] from alcoholic hepatitis, 2 [0.9%] from Wilson's disease, 1 [0.5%] from haemochromatosis and 24 [11.3%] were Cryptogenic. All these patients were evaluated for liver transplant according to the appropriate criterion. Out of 212 patients, 43 [20.3%] patients had MELD/PELD Score of /=36 [79.71]. Patients with MELD/PELD score more than 10 are considered for liver transplant but the MELD/PELD score at which a patient will realistically receive a liver varies by region and organ demand as defined by the number of candidates on the waiting list and their blood type. High frequency of patients of chronic liver disease in our setup qualify for a liver transplant. It provides preliminary data for the need of liver transplant centers in our region

Wheat pill: clinical characterisitcs and outcome

To determine the clinical characteristics and outcome in patients presenting with wheat pill poisoning. Retrospective study. Department of medicine, Combined Military Hospital, Kharian from 1st July 2009 to 30 December 2010. Fifty two patients with wheat pill ingestion were included in the study. All patients' history, symptoms, signs and management data was collected on a pre-designed data collection form. Mean age was 25.10 +/- 5.35 years with 51.9% females. Time interval between ingestion of pills and presentation to hospital was 2.5 +/- 1.27 hours. Numbers of pills consumed were 2.73 +/- 20. Most common symptom seen in patients was vomiting seen in 88.5% of the patients. Other common symptoms were irritability in 63.5% and confusion in 55.8% patients. Most common clinical sign hypoxia in 75% patients. Overall mortality was 86.5 percent. Wheat pills are highly toxic with rapid and high mortality rate. These patients develop refractory hypotension and metabolic acidosis which progresses to death. More research is required to develop antidote and to minimize toxicity. Strict legislations are required to control sale of aluminium phosphide over the counter

EDTA contamination in laboratory specimens-effect of an awareness campaign

To measure the effects of awareness campaign on the frequency of EDTA contamination. A cohort study. The study was carried out in Combined Military Hospital, Peshawar, from October to December 2008. A cohort of 200 doctors, nurses and paramedical staff involved in sample collection for laboratory investigations were selected for this three phased study. In all samples with plasma potassium level>6.0 mmol/L, plasma Ca++ was measured for one month before, during and after a campaign of correct filling order of sample tubes for two weeks. Renal function test and LDH were also measured to rule out chronic renal failure and in-vitro haemolysis, respectively. Fisher's exact test was used for comparison of frequency of hyperkalemia. There was a significant decrease [75%, p<0.01] in the cases of spurious hyperkalaemia and hypocalcaemia. EDTA contamination is a common and important source of pre-analytical error which can be prevented to some extent by education of medical and nursing staff

Evaluation of AST/ALT ratio as a marker of liver fibrosis and cirrhosis in patients with chronic hepatitis C

To assess the relation between serum AST/ALT ratio [AAR] and hepatic fibrosis and cirrhosis associated with chronic hepatitis C. A cross sectional study. The study was conducted in the department of medicine Military Hospital Rawalpindi from Sep 2004 - Feb 2005. Fifty diagnosed patients of chronic hepatitis C were selected whose liver biopsy was performed as a workup plan fro treatment. Serum AST/ALT ratio [AAR] was determined and degree of liver fibrosis noted on histopathology, using Knodell scoring system. ANOVA was applied to study the difference in AAR in different stages of liver fibrosis. The mean AAR was found to be higher with each increasing stage of liver fibrosis. The mean AAR in cirrhotics [1.34] was significantly higher compared to noncirrhotics [0.77], p<0.001. AAR >/= 1 had 100% sensitivity and negative predictive value in distinguishing cirrhotic from non-cirrhotic patients with 87% specificity and 45% positive predictive value. There is only a modest relation between AAR and early hepatic fibrosis [stages 1-3] in patients with chronic hepatitis C, while AAR is significantly higher in patients with advanced fibrosis/ cirrhosis

Evaluation of color doppler imaging in the diagnosis of deep vein thrombosis

To evaluate the accuracy of Color Doppler Imaging in diagnosing deep vein thrombosis [DVT] of the lower extremities taking Venography as gold standard. Cross validation study. The study was conducted in the radiology department Combined Military Hospital Peshawar from January 2007 to August 2008. Seventy four patients suspected of having deep venous thrombosis of the lower extremities were examined by Color Doppler Imaging [CDI]. But sixty nine patients underwent successful venography of the affected lower limbs and 5 patients were excluded from the study. Using venography as the reference standard fro diagnosing DVT, the sensitivity and specificity of CDI was 965 and 94.4%, respectively. Positive predictive value was found to be 98% and negative predictive value was 89.5% .Overall accuracy of the CDI was 95.6%. With meticulous technique, Color Doppler Imaging is highly accurate in diagnosing deep vein thrombosis of symptomatic lower limbs, avoiding contrast venography in most of the cases

diagnostic yield of upper gastrointestinal endoscopy in patients with iron deficiency anaemia

The aim of this study was to determine the diagnostic yield of upper gastrointestinal endoscopy in patients with iron deficiency anaemia. This was a descriptive study. The study was carried out at Military Hospital Rawalpindi from Sept 2003 to Feb 2004. Study was performed on 50 patients of iron deficiency anaemia of both sexes more than 18 years of age. Major upper gastrointestinal symptoms were asked. Esophagogastroduodenoscopy was performed on all the patients. Endoscopic biopsies of 2nd and 3rd part of duodenum were taken from the patients with insignificant endoscopic findings for histopathological examination. Endoscopic examination of the upper gastrointestinal tract showed a causative lesion in 33 [66%] patients. The most common abnormality in the upper gastrointestinal tract was peptic ulceration [duodenal ulcer in 11 patients, gastric ulcer in 4]. Seventeen [34%] patients with negative endoscopic studies underwent 4 to 5 duodenal biopsies. Histopathological examinations of biopsies from 2 patients were consistent with Coeliac disease. Symptoms as dyspepsia and epigastric pain were predictive of disease in the corresponding portion of the bowel. Upper gastrointestinal lesions are frequently found in patients with iron-deficiency anaemia particularly in patients with upper abdominal pain and dyspepsia

Radiofrequency thermal ablation: imaging guided therapeutic applications

Minimally invasive, image guided radiofrequency ablation RFA now provides an effective local treatment of isolated or localized neoplastic diseases, and is also being used as an adjunct to conventional surgery, systemic chemotherapy or radiation. It is now the front line treatment in unresectable hepatocellular carcinoma and its use in other neoplastic diseases continues to expand. This update introduces the technique to alleviate inoperable tumours and application of RFA in therapeutic imaging

case of chronic liver disease. HEV induced or cryptogenic?

Hepatitis E virus [HEV] infection is known to cause epidemic outbreaks as well as sporadic disease in many parts of the world. Clinical presentation of hepatitis E varies from acute icteric viral hepatitis to severe disease with fulminant hepatic failure, and anicteric infection [no jaundice but with ALT elevation]. According to available data HEV infection does not lead to chronic liver failure. We are reporting a case of 37 years old army soldier who was admitted as a case of HEV induced acute viral Hepatitis. Later he was found to have chronic liver disease [CLD] with persistence of HEV antibodies and absence of any other detectable cause of CLD

Current radiologic interventions in hepatocelluar carcinoma

With the rising incidence of chronic liver disease caused by viral hepatitis, hepatocellular carcinoma is showing a corresponding rise worldwide. Surgery remains the mainstay of treatment, but patients unfit for surgery or liver transplantation form the bulk of those presenting with this disease. Palliative treatments are being used to treat those and radiological modalities form the mainstay of the treatment. Radiology plays a major role in the diagnosis, treatment and follow-up of hepatocellular carcinoma. Current radiological treatment modalities include percutaneous ethanol ablation, radiofrequency ablation and trans-arterial chemoembolization. This update highlights the recent advancements in the field and compares their relative merits and demerits

Morphological spectrum of gastric lesions - endoscopic biopsy findings

A retrospective study was carried out to determine the morphological spectrum of gastric lesions at Pathology Department of Army Medical College, Rawalpindi for the duration of 02 years. Descriptive Study. The gastric mucosal biopsies of 787 patients received from Gastroenterology unit of Military Hospital Rawalpindi from January 2002 to December 2003, were studied by routine histopathology methods. A high frequency of gastric disease in males with a male to female ratio of 6:1 and an age range of 09 years to 85 years were observed. The clinical presentations mostly seen were abdominal pain, dyspepsia, vomiting, diarrhoea, decreased appetite and weight loss. On endoscopy the most frequently suspected lesions were gastritis 662[84.12%], stomach growth 45[5.72%], gastric ulcers 10[1.27%], while 70[8.89%] cases showed unremarkable mucosa. The histopathology revealed chronic non-specific gastritis 676[85.89%] followed by malignant tumours 45[5.72%], benign neoplasms 3[0.38%] and gastric ulcer 10[1.27%]. A number of biopsies 53[6.73%] were unremarkable histologically. The more prevalent lesions in this series were chronic active gastritis followed by tumours and gastric ulcers. H. pylori associated gastritis was seen in majority of the patients. Thus gastric biopsy is an essential tool for diagnosis and confirmation of clinically suspected cases

Is it worthwhile to treat h pylori in all dyspeptic patients?

To evaluate the efficacy of H pylori eradication in patients with nonulcer dyspepsia, an interventional study was carried out in the Dept. of Gastroenterology, MH Rawalpindi from Jan to Feb 2004. Five hundred consecutive patients, who were referred for UGI Endoscopy, were studied. Out of these 500 patients, gastric biopsy was done in 245 patients. The patients in whom gastric biopsy was done, histopathology revealed gastritis in 187 patients and 129 [69%] were found H pylori positive. The subgroup of patients who were H pylori positive was further studied. These patients were given one week's course of eradication therapy and subsequently followed up. Sixty three percent [n=81] responded to treatment and reported improvement in their symptoms; whereas in thirty seven percent [n=48] of patients the dyspeptic symptoms persisted. In our set up where H pylori infection is pandemic, in the absence of alarm symptoms; all patients with nonulcer dyspepsia below 45 years of age should be considered for H pylori eradication

Comparison between serological testing and biopsy examination of helicobacter pylori

This study was conducted at the gastroenterology department of the MH Rawalpindi to compare the sensitivity and specificity of serological assay for H .Pylori with the histopathological tests. A total of 50 patients were included. 32 cases were found to have H. Pylori on the histological examination. Out of these 32 patients 28 cases were found to have anti H. Pylori antibodies. 2 cases were found to have false positive anti H. Pylori antibodies in serum. The sensitivity and specificity of tests were 87.5% and 88.8% respectively with negative predictive value of 80% and diagnostic efficacy of 88%

Small cell lung cancer chemotheryapy: a nine year experience of, London lung cancer group protocol

Lung cancer is the leading cause of cancer related deaths. Small cell lung cancer is found in 20-25% cases. Chemotherapy is cornerstone of treatment. With appropriate therapy majority of patients with small cell lung cancer can expect to achieve remission and a significant prolongation of life. Our objective was to evaluate the 'London Lung Cancer Group Protocol' for chemotherapy of Small Cell Lung Carcinoma being followed in our unit. This hospital based prospective study was carried out in Pulmonology Department of Military hospital, Rawalpindi between May 1989 to May 1998. In total 484 cases of bronchogenic carcinoma were diagnosed. Sixty eight had small cell cancer while 416 had non small cell lung cancer. 39 patients who fulfilled the inclusion criteria were subjected to thorough clinical examination and detailed investigations to ascertain the stage of the disease. The patients were then divided into groups according to the staging. Fifteen patients [38.4%] with limited disease were in Group I, while 24 patients [61.5%] with extensive stage disease and good prognosis were in Group II. Most patients [43.5%] were between age 51-60 years, [38.4%] 61-65 years of age, [12.8%] were 41-50 years and only 5.1% patients were between 31-48 years. Commonest presenting symptom [92.3%] was cough, while 58.9% had hemoptysis, 48.7% severe dyspnoea, 20.5% superior venacaval obstruction and 38.4% chest pain. The most common side effect of chemotherapy was alopecia [61.5%] followed by GI symptoms other than vomiting [30.7%]. One patient had cardiac decompensation and two had myelosupression. In total 30 cases [76.9%] completed chemotherapy. Treatment was abandoned in five cases [12.8%] due to various reasons while 4 were lost to follow up. Out of the 30 patients who completed chemotherapy 60% were complete responders while 40% were partial responders. Symptoms regressed considerably after treatment. Median survival was fifteen months in group I and nine months in group II. We concluded that 'London Lung Cancer Group Protocol being followed at our unit had good response rate, was safe and cost effective and had minimal side effects