Comparative study between endoscopic band ligation, alcohol injection and cyanoacrylate injection in management of gastric varices

Haemorrhage from gastric varices [GV] is a serious complication of portal hypertension. The role of endoscopy in the management of gastric varices is still controversial, but the efficacy in management of bleeding oesophageal varices has been greatly enhanced, so, rebleeding rate has been reduced by injection sclerotherapy or band ligation. On the other hand, the management of gastric varices is still a great challenge for endoscopists as traditional methods as vasoconstrictors and balloon tamponade don't effectively reduce the rebleeding rate. The aim of our work was to compare three different endoscopic methods in the management of type I and II gastric varices: [I] gastric variceal obturation using cyanoacrylate, [II] gastric variceal sclerotherapy using absolute alcohol and [III] gastric variceal ligation by rubber [O] bands. The comparison regards the technical ease, efficacy, complications and number of sessions needed to eradicate varices. To fulfill this aim we studied 60 patients with chronic liver disease and gastric varices presented to the central endoscopy unit Ain Shams University Hospital. The patients were categorized into [3] groups: Group I included 20 patients who underwent GV obturation using cyanoacrylate, group II included 20 patients who underwent GV sclerotherapy using alcohol injection, and group III included 20 patients who underwent GV band ligation. All patients were age and sex matched. We excluded patients with type III GV, hepatic encephalopathy, hepatocellular carcinoma and prior history of sclerotherapy, band ligation or shunt operation. Our results showed that, cyanoacrylate obturation of gastric varices was more effective in controlling gastric variceal bleeding than other methods with low number of sessions and low rebleeding rate than G.V. Ligation or alcohol injection. So we conclude that gastric variceal obturation by cyanoacrylate proved more effective and safer than gastric variceal ligation or injection sclerotherapy using absolute alcohol in the management of type I and II gastric varices

value of Hetastarch in prophylaxis against renal impairment in cirrhotic patients with spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis [SBP] is an ominous complication of the late stage liver disease. Renal impairment in the course of SBP is a frequent event and constitutes the most important predictor of hospital mortality in these patients. Administration of intravenous albumin was applied for prevention of SBP related renal impairment and it reduced the incidence of renal impairment and mortality in comparison with treatment with antibiotic alone. Because albumin is expensive and not available in some settings, we worked to assess the possible use of Hetastarch and assess its beneficial effects in prevention of SBP related renal impairment. The present study was conducted on 60 patients with liver cirrhosis, ascites and SBP. The patients were divided into two groups: Group [1]: 30 subjects who received empirical antibiotic plus plasma expander for treatment of SBP and Group [2]: 30 subjects who received empirical antibiotic alone. The plasma expander chosen was Hetastarch [the colloidal solution hydroxyethyl starch [Haes-steril] in a dose of 500 cc every 8 hours/5 days [20 ml/kg B. wt/day] due to its relative less side effects on coagulation process. It was found that the administration of Hetastarch as a artificial plasma expander decreased renal impairment in patients with liver cirrhosis and spontaneous bacterial peritonitis. The incidence of renal impairment was significantly lower among patients treated with antibiotic therapy plus plasma expander [13.3%] than those treated with antibiotic alone [36.6%]. Patients received Hetastarch showed maintenance of renal function allover the follow up period, higher urine output, better renal profile than other group not treated by Hetastarch. We concluded that treatment with Hetastarch was safe and effective and it can be considered as an alternative to albumin in prophylaxis against renal impairment in cirrhotic patients with SBP

Evaluation of plasma thrombomodulin in patients with type II diabetes mellitus

Thrombumodulin is an important endothelial anticoagulant protein that decreases thrombin activity and activates protein C. Increased plasma concentrations of various markers of endothelial damage especially thrombomodulin, have been observed in type I diabetic patients particularly in those with microangiopathy. So we aimed in this study to evaluate the significance of plasma thrombomodulin as a biochemical marker for early detection of microvascular complication such as diabetic nephropathy in patients with Type II diabetes mellitus Thirty diabetic patients fulfilled the WHO criteria for type II diabetes-were included in this study together with 10 normal volunteers as normal control.-The type II diabetic patients were classified into three groups according to the level of microalbuminuria in 24hours urine: Group I: included 10 diabetic patients [without nephropathy] microalbumin/24 hours urine<30 mg, Group II included 10 diabetic patients with [incipient diabetic nephropathy] microalbomin/24 hours urine ranged from 30 to 300 mg, and Group III included 10 diabetic patients with [overt diabetic nephropathy], microalbuminl24 hours urine>300mg. For all patients and control the following were done serum creatinine, glycated hemoglobin [HbAlc] Plasma thrombomodulin [TM] and 24 hours urinary micro-albuminuria-In this study we found that, TM were highly significantly elevated in diabetic patients with microalbominuria [group II] and with macroalbuminuria [group III] as compared to the control group [P<0.01] [Table 2]. Also group III showed highly significant elevation in TM than group II [P<0.0 1]. TM showed highly significant correlation with albumin concentration in 24 hours urine HbAlc, and duration of diabetes [P<0.01] [tables]. Because plasma TM level was strongly affected by kidney function. TM index [TM[FU/ml]/serum creatinine [mg%] was used as an endothelial marker. TM index showed a highly significant elevation in diabetic patients [p<0.01] especially in patients with macroalbuminurea [group III] as compared to normal control [p<0.01] [Table 2] also its level was significantly higher in group III than both group I and group II [p<0.01] while no significant difference was found between neither group I nor group II and control group [p>0.05]. TM index showed a highly significant positive correlation with duration of diabetes, but it showed no significant correlation with HbAlc [P>0.05] [Table 6]. These results suggested that a generalized vascular endothelial damage occurs in diabetic nephropathy including the microalbuminuric stage, and TM could be used as a marker for early detection of diabetic microvascular complications

Measurement of gastric mucosal hepatocyte growth factor in helicobacter pylori gastritis

Hepatocyte growth factor [H.G.F.] which was originally identified as a growth factor for hepatocytes, has been shown to have the potentiality to stimulate the growth of gastric epithelial cells and also, can enhance motility of epithelial cells i.e. [mitogen and motogen effects]. Cell proliferation is increased in gastric mucosa infected by Helicobacter pylori [H.P.]. However, the mechanism of that proliferation is not well understood, it was supposed that mucosal inflammation by Helicobacter pylori pruduces interleukin IB which may induce H.G.F. production yielding mucosal proliferation; also, it was found that H.G.F. stimulates the production of prostaglandin E2 which may play a role in gastric mucosal cell proliferation. Was to study and measure gastric mucosal H.G.F in presence and absence of helicobacter pylori gastritis to fulfill this aim, we studied two groups of patients, one group including 30 patients with H.P-gastritis and another group including 10 patients as a control group complaining of dyspepsia without H.P. infection [negative controls], both groups were age and sex matched, both groups were subjected to thorough clinical assessment, pelviabdominal ultrasonogram, routine lab investigations. Also, upper G.I.T. endoscope with antral and fundal biopsies for histopathological examination to detect HP and to show the degree of gastritis associated and also to do immunohistochemical studies for detection of H.G.F in gastric mucosa. In our study, we found a significant correlation between the degree of severity of gastritis caused by H.P. and the degree of staining of HGF- receptor in antral mucosa, so, the more severe the inflammation, the more H.G.F production in the mucosa. Gastric mucosal H.G.F. increases in H.P. gastritis, and its increase is directly related to the degree of gastritis. The production of H.G.F which is a protective protein to maintain homeostasis and the integrity of gastric mucosa by inducing cell proliferation to replace damaged gastric mucosa by Helicobacter cytotoxic activities

occurrence of spontaneous bacterial peritonitis in patients with chronic liver disease in relation to treatment modalities of upper gastrointestinal bleeding

Patients with chronic liver disease [CLD] complicated by upper gastrointestinal [UGI] bleeding are more prone to develop spontaneous bacterial peritonitis [SBP]. SBP is defined as bacterial infection of ascitic fluid in patients with CLD in the absence of an apparent intra-abdominal source of infection. The aim of this study was to determine the incidence of developing SBP in patients with CLD suffering from UGI bleeding in relation to the mode of treatment of the bleeding episode. To fulfill this aim, we studied 50 patients [34 males and 16 females], their ages ranges from 37 to 64 years with CLD and suffering UGI bleeding. Patients were prospectively randomized according to the treatment modalities of the bleeding episodes into 3 groups: group A: 26 patients received endoscopic variceal sclerotherapy [EVS]; group B: 13 patients received endoscopic variceal ligation [EVL]; group C: 11 patients received medical treatment in the form of glypressin or somatostatin. In our study the incidence of occurrence of SBP following treatment of bleeding episodes of patients with CLD was highly significant with EVS [23%] than other modalities namely EVL [7.7%] and medical treatment [0%]. Patients with CLD receiving EVS carry a significantly higher risk for developing SBP than other modalities of treatment. EVL is safer than EVS to control UGI bleeding as regard the occurrence of postendoscopic SBP