Quality of colonoscopy and spectrum of lower gastrointestinal disease as determined by colonoscopy

To document the quality of colonoscopy practice and the pattern of colonic disease including polyp detection rate at Shifa International Hospital, Islamabad, Pakistan. An observational study. Shifa International Hospital, Islamabad, Pakistan, from May 2013 to June 2014. This retrospective study recorded demographics of patients, indications and quality indices of 505 colonoscopies performed during the study period. Preparation was done with low residue diet and polyethylene glycol. Conscious sedation was generally used. Quality indices studied were compared with guideline standard. Out of 505 colonoscopy patients, 305 were males and 200 were females. The indications for colonoscopic examination were lower gastrointestinal bleeding [26.5%, n=134], screening for colorectal cancer [14.1%, n=71], chronic diarrhea [12.9%, n=65], abdominal pain [10.9%, n=55], anemia [9.1%, n=46], constipation [7.3%, n=37], hematochezia and diarrhea [6.3%, n=32], altered bowel habits [5.1%, n=26], weight loss [3.6%, n=18], colonic thickening on CT scan [3.0%, n=15] and others [1.2%, n=6]. Bowel preparation was adequate [in 92%, n=465] cases. Cecal intubation rate was 88.71% [n=448]. Endoscopic diagnoses were hemorrhoids [36.2%, n=183], normal [22%, n=111], polyps [11.3%, n=57], ulcerative colitis [8.7%, n=44], cancer [4%, n=20], diverticulosis [3.4%, n=17], infective colitis [2.6%, n=13], intestinal TB [2.6%, n=13], non-specific colitis [2.2%, n=11], proctitis [1.8%, n=9] and others [5.3%, n=27]. There is room for improvement in quality of colonoscopy, cecal intubation rate is slightly below the recommended standard and polyp detection rate is quite low however, it is not clear if the low rate of polyp detection is due to missed lesions or low population incidence. Time to reach caecum and withdrawal time should clearly be documented in the notes which can help to evaluate quality of the procedure in a better way

Ammonia levels and the severity of hepatic encephalopathy

To evaluate the correlation between ammonia levels with the severity of HE in patients coming to the tertiary care hospital with liver cirrhosis and hepatic encephalopathy [HE]. Descriptive, analytical study. Shifa International Hospital, Islamabad, from January 2011 to February 2012. A total of 135 patients with liver cirrhosis and HE had serum ammonia levels measured on admission. The diagnosis of HE was based on clinical criteria, and its severity was graded according to the West Haven Criteria for grading of mental status. Ammonia levels were correlated with the severity of HE using Spearman rank correlation. Out of 20 patients with normal ammonia levels, 13 [65%] were in HE I-II, 6 [30%] were in grade-III, while 1 [5%] patient was in grade-IV HE. Out of 45 patients with mild hyperammonemia, 27 [60%] were in grade I-II, 12 [26%] were in grade-III and 6 [13%] were in grade-IV HE. Out of 34 patients with moderate hyperammonemia, 9 [26%] were in grade I-II, 18 [53%] were in grade-III, and 7 [20%] were in grade-IV HE. Out of 36 patients with severe hyperammonemia, 31 [86%] patients were in grade-IV HE [p < 0.001]. Ammonia levels correlated with the severity of hepatic encephalopathy. Greater the ammonia level, severe is the grade of hepatic encephalopathy

Frequency of occult hepatitis B in patients awaiting liver transplant

Some patients do not have conventional markers of hepatitis B i.e. HBsAg, HBeAg. However, they may still carry viral DNA. This group of patients who got negative HBsAg but detectable HBV DNA by PCR is defined to have occult hepatitis B [OHB]. Occult hepatitis B can reactivate and affect transplanted liver when given immunosuppressants. To determine the frequency of occult hepatitis B in patients on waiting list for liver transplant in Shifa International Hostpital, Islamabad, Pakistan. Prospective non-interventional study was carried out at Gastroenterology unit of Shifa International Hospitals, Islamabad from April 2012 to May 2013. Materials and One hundred and twenty three patients on the waiting list for liver transplant were included in the study after fulfilling inclusion criteria. All the baseline laboratory tests including complete hepatitis profile HBsAg, HBc IgM and IgG, Anti HCV and HBV DNA by PCR were performed. Data were collected in specially designed proforma. All the data were analyzed using SPSS version 16.0. Out of 123 patients, 67[54.4%] were male and 56[45.5%] were female. Mean age was 52.7 +/- 11.06. Nine [7.31%] patients were found to have occult hepatitis B. Out of these 9 patients, 5[55%] had HCV as primary cause of their liver disease, 2[22%] had HCC and 2[22%] had cryptogenic liver disease, which is diagnostic of exclusion. Occult hepatitis B is the ignored entity in Pakistan. Our study showed that occult hepatitis B was detectable in our population with liver disease. It is important to check its presence in all patients of chronic liver disease regardless of the primary aetiology of liver disease

Renal failure in patients with end stage liver disease and its impact on clinical outcome

To evaluate the prevalence of renal failure [RF] in the patients of end stage liver disease [ESLD], to determine the causes of RF in these patients and its impact on patient's outcome. Descriptive, analytical study. Shifa International Hospital, Islamabad, Pakistan, from May 2011 to March 2013. A total of 523 patients with end stage liver disease [ESLD] were evaluated, renal failure [RF] and its causes were recognized in these patients according to established criteria. Outcome of these patients was assigned as reversal of RF or mortality. Data was analyzed using SPSS version 16. Chi-square test was used for comparing proportions and t-test was used for comparing mean values. P < 0.05 was considered significant. Out of 523 patients, 261 [49.9%] had RF. Acute kidney injury [AKI] was the most common presentation seen in 160 [61%] patients. Hypovolemia and infections were the most frequent causes of RF. Mortality was significantly higher in the patients with RF, when compared to the patients without RF [31% vs. 4.5%, p < 0.001]. Reversal of RF was seen in 98 [37%] of the affected patients. Reversal was more common in the patients with hypovolemia. The mortality was higher in the patients with hepatorenal syndrome [HRS] and infections. Renal failure in the end stage liver disease is an important prognostic factor. Etiology of RF is the key factor in patients' outcome. Patients of ESLD with RF had higher mortality. Majority of the cases of RF were reversible in patients of ESLD coming in the setup

Factors affecting patient satisfaction during endoscopic procedures

To assess the quality and patient satisfaction in Endoscopy Unit of Shifa International Hospital. Cross-sectional survey. Division of Gastroenterology, Shifa International Hospital, Islamabad, Pakistan, from July 2011 to January 2012. Quality and patient satisfaction after the endoscopic procedure was assessed using a modified GHAA-9 questionnaire. Data was analyzed using SPSS version 16. A total of 1028 patients were included with a mean age of 45 +/- 14.21 years. Out of all the procedures, 670 [65.17%] were gastroscopies, 181 [17.60%] were flexible sigmoidoscopies and 177 [17.21%] were colonoscopies. The maximum unsatisfactory responses were on the waiting time before the procedure [13.13%], followed by unsatisfactory explanation of the procedure and answers to questions [7.58%]. Overall, unsatisfied impression was 4.86%. The problem rate was 6.22%.The quality of procedures and level of satisfaction of patients undergoing a gastroscopy or colonoscopy was generally good. The factors that influence the satisfaction of these patients are related to communication between doctor and patient, doctor's manner and waiting time for the procedure. Feedback information in an endoscopy unit may be useful in improving standards, including the performance of endoscopists.

Severity of depression in hepatitis B and hepatitis C patients

To assess and compare the severity of depression in chronic hepatitis B [CHB], chronic hepatitis C [CHC] and healthy subjects. Comparative study. Shifa International Hospital, Islamabad from July 2011 to February 2012. A total of 206 subjects were divided in three groups. Group-I [chronic hepatitis C, n = 95], group-II [chronic hepatitis B, n = 29] and group-III [healthy subjects, n = 82]. They were matched for age, gender and socioeconomic status and were compared for frequency and severity of depression as measured by Hospital Anxiety and Depression Scale [HADS]. Some degree of depression was noted in all groups. Frequency of depression was 72.6% in group-I, 58.6% in group-II and 37.8% in group-III [p value < 0.001]. Both CHC and CHB had high frequency of some degree of depression. Hepatitis C patients had more depressive features than CHB. It is worthwhile to do more close mental health observation in them. A multidisciplinary team including a psychiatric specialist can help in this approach

Frequency of depression and somatic symptoms in patients on interferon alpha/ribavirin for chronic Hepatitis C

Large numbers of patients suffering from Chronic Hepatitis C [HCV] are seeking treatment with interferon alpha [IFN] because of significant advances in overall improvement in the course of HCV and its complications. Objectives were to estimate the frequency of depression and somatic symptoms in patients on interferon alpha/ribavirin treatment for chronic hepatitis C. It was an observational study conducted in the out-patient Department of Gastroenterology Shaikh Zayed Hospital, Lahore during a period of three months, i.e., from September to November 2008. One hundred consecutive patients undergoing interferon alpha/ribavirin treatment for chronic HCV were included in the study. All patients, irrespective of age, sex or duration of treatment were administered with a check list of common physical complaints and DSM-IV symptoms for Major Depressive Episode. Out of a total of 100 subjects 37 were male and 63 were female. In all, 39 [39%] patients fulfilled the diagnostic criteria of DSMIV for Major Depressive Episode. Major Depression was more common in female 28 [44.4%] as compared to male 11 [28.7%] patients. Somatic symptoms were common in all the patients but they were reported more frequently by patients with Major Depression compared to those without Major Depression. Myalgias, headache, joint pain, nausea/vomiting, abdominal pain and palpitation were the most common physical symptoms. Major Depression and somatic complaints are a common consequence of interferon alpha/ribavirin treatment for chronic hepatitis C. All patients receiving this treatment should be periodically assessed for the detection of these side effects to promptly address relevant treatment options

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

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

Value of Quantitative HCV RNA in management of Chronic Hepatitis C patients with genotype 2 and 3

Determination of viral load by quantitative polymerase chain reaction [PCR] for hepatitis C virus [HCV] is part of workup before initiating interferon and ribavirin combination therapy for chronic hepatitis C. This study was carried out to determine predictive value of baseline viral load in patients with viral genotype 2 and 3, for response to therapy. Patients with chronic hepatitis C and genotype 2 and 3 were included in study. Viral load was determined before starting treatment with standard interferon and ribavirin for six months in all patients. Patients were checked for cod of treatment [EOT] and sustained viral response [SVR] by qualitative PCR for HCV. Response to therapy was correlated with baseline viral load by student`s t test. Total of 55 patients were included. Male to female ratio was 1.1/1 [29/26]. Six patients were of genotype 2, one patient was harboring both genotype 2 and 3 while rest of 48 patients had genotype 3 of hepatitis C virus. Baseline viral load was less than 2 million copies/ml in 25 patients while 30 patients had viral load in excess of 2 millions copies/ml. Treatment was completed in 50 patients. Sustained viral response [SVR] was seen in 31 patients and 19 patients were non-responders. No significant association was found between response to therapy and baseline viral load. Pre-treatment viral load is not predictive of response to combination therapy with interferon in patients with genotype 2 and 3

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

Ectopic intestinal varices as a rare cause of lower gastrointestinal haemorrhage

Ectopic intestinal varices are rarely responsible for lower gastrointestinal [GI] haemorrhage. A case of 55 years old male with recurrent melena is being presented, who was found to have scattered varices on small as well as large intestine. Selective review of literature regarding presentation, diagnosis and management of these cases is also part of presentation