Varied presentation of celiac disease in Pakistani adults

The objective of this retrospective study was to evaluate presentation of celiac disease in adults. It included 77 patients, 41 [53.2%] males with median age 26 years and median body mass index of 18 [16 - 22] kg/m[2]. Typical presentation with gastrointestinal symptoms was seen in 76.6%. Atypical presentation with extra intestinal complaints in 7.8% and silent presentation in 15.6%. Major symptoms were diarrhea in 64.9%, weight loss 36.4%, abdominal pain 35.1%, vomiting 32.5%, pallor 24.7%, and weakness 13%. Iron deficiency was documented in 20.8%, B12 deficiency in 9.1%, folic acid deficiency in 6.5% and vitamin D deficiency in 10.4%. Half of the patients had haemoglobin less than 11 g/dl. Osteoporosis and osteomalacia, hypothyroidism, diabetes and atrophic gastritis were seen in 2.6% each. Raised alanine aminotransferase was documented in 23.4%. Duodenal biopsy, done in 39 patients, revealed increased intraepithelial lymphocytes in 11, along with crypt hyperplasia in 3, partial villous atrophy in 15 and sub-total villous atrophy in 10. In conclusion, celiac disease in adults should be looked for in patients with chronic diarrhea or irritable bowel syndrome like symptoms, underweight, anaemic, or having nutritional deficiencies

Perception and knowledge about dietary intake in patients with liver cirrhosis and its relationship with the level of education

To determine patients perception and knowledge regarding diet in cirrhosis and its relationship with the level of patients education. Cross-sectional observational study. This study was conducted at Gastroenterology Outpatient Clinics at the Aga Khan University Hospital, Karachi, the Aga Khan Health Services, Malir, Karachi and Hamdard University, Karachi, from January to December 2010. Consecutive adult patients with compensated cirrhosis were enrolled. Demographic data, level of education, type and reason of food restriction as well as the source of dietary information was asked. Baseline laboratory test were performed, and nutritional status was assessed by BMI normogram. Ninety patients, 58% male were enrolled. Mean age of the patient was 49 +/- 11 years. Overall 73% of the patients were restricting fat, meat, fish and eggs in their diet; 53% were in uneducated group and 47% were in educated group [CI, 0.24-1.62, p-0.34]. Twenty two patients [62.8%] in uneducated and 21 in educated group [68%] were restricting diet on the advice of their doctors, whereas 13 in uneducated group [37%] and 11 in educated group [32%] believed these dietary components to be harmful for the liver. Thirty two of uneducated patient [71.1%] and 28 of educated patients [62.2%] believed that vegetables, fruits and sugarcane had a beneficial effect on the liver. Main source of dietary information to the patients was the doctor. On sub-group analysis those who restricted diet irrespective of their educational level, had more patients with BMI less than 18.5 kg/m[2], [CI 0.01-0.94, p-0.001], haemoglobin less than 12 g/dl [CI 0- 0.03, p-0.001] and serum albumin less than 3 g/dl [CI 0.1- 03, p-0.001]. Both educated and uneducated classes of the patients have improper knowledge and perception of diet in cirrhosis. Patients with cirrhosis who restricted diet, had relatively low BMI, haemoglobin and albumin as compared to those who did not restrict. Main source of dietary information to cirrhotic patients were health care personnels

Discriminant value of Rome III questionnaire in dyspeptic patients

Rome III criteria has modified the description of functional dyspepsia [FD] and divided this into subgroups. However, the discriminative value of Rome III questionnaire-based diagnosis of FD is yet to be determined. Objectives: To evaluate the Rome III questionnaire for the diagnosis of FD and whether it can discriminate between postprandial distress syndrome [PDS] and epigastric pain syndrome [EPS] in patients with dyspeptic symptoms. Consecutive patients, who were not on proton pump inhibitors [PPI], were asked to participate. Patients who have previously established acid peptic disease or predominantly reflux symptoms or having alarm symptoms such as weight loss and hematemesis were excluded. Rome III questionnaire for FD was used to identify the patients as having FD and divide into its subgroups; PDS or EPS. Gastro-duodenal biopsies, liver function tests and ultrasound were done to establish the diagnosis of FD. Out of 272 patients with upper gastrointestinal [GI] symptoms without alarm features, who were enrolled in the study, a total of 191 [70%] fulfilled the criteria of FD based upon Rome III questionnaire. EPS subgroup was found in 109 [57%], PDS in 17 [9%] patients, overlap between EPS and PDS was present in 56 [29%] patients. Nine [5%] patients remained indeterminate. Diagnosis of FD was established in 136/191 [71%] patients only. Gastritis was present in 116 patients [85%], Duodenitis in 44 [32%] and Helicobacter pylori infection in 70 [51%] patients. Among 55 patients [29%] who had organic diseases, EPS was seen in 35 [64%], PDS in 5 [9%]] and overlap in 15 [27%] patients. Underlying organic causes were gastric or duodenal ulcers in 14 patients, Barrett esophagus in five, chronic liver disease in seven, gall stones in five, Giardiasis and celiac disease in three each. Gastric carcinoma, Crohns disease and gastric polyps were seen in one patient each. This study indicates that 30% of patients who fulfilled the Rome III criteria for FD actually had organic disease. Almost one-third of patients with functioanl dyspepsia did not qualify for one of the two subgroups of FD of Rome III. There is also a need to further define the Rome Ill-based subgroups of FD for research purpose

Efficacy of L-ornithine-L-aspartate as an adjuvant therapy in cirrhotic patients with hepatic encephalopathy

To evaluate the efficacy of L-ornithine-L-aspartate [LOLA] as an adjuvant therapy in cirrhotic patients with hepatic encephalopathy [HE]. Randomized placebo controlled study. The Aga Khan University Hospital, Karachi in the year 2003-2004. Patients with HE were randomized to receive LOLA or placebo medicine as an adjuvant to treatment of HE. Number connection test-A [NCT-A], ammonia level, clinical grade of HE and duration of hospitalization were assessed. Out of 120 patients, there were 62 males with mean age of 57 +/- 11 years. Improvement in HE was higher [n=40, 66.7%] in LOLA group as compared to the placebo group [n=28, 46.7%, p=0.027]. In patients with grade I or less encephalopathy, improvement was seen in 6 [35.3%] and 3 [20%] patients in LOLA and placebo groups respectively [p=0.667]. Patients with HE grade II and above showed improvement in 34 [79.1%] and 25 [55.6%] cases in LOLA and placebo group respectively [p=0.019]. On multivariate analysis patients with HE of grade II and above showed prothrombin time, creatinine level and use of LOLA influencing the outcome. Duration of hospitalization was 93.6 +/- 25.7 hours and 135.2 +/- 103.5 hours in LOLA and placebo groups respectively [p=0.025]. No side effects were observed in either groups. In cirrhotic patients with advanced hepatic encephalopathy treatment with LOLA was safe and associated with relatively rapid improvement and shorter hospital stay

Precipitating factors and the outcome of hepatic encephalopathy in liver cirrhosis

To determine precipitants of hepatic encephalopathy [HE] and their impact on hospital stay and mortality. Cross-sectional, analytical study. The Aga Khan University Hospital, from January 2005 to December 2007. Consecutive patients admitted with different grades of HE were evaluated between January 2005 and December 2007. The precipitants of HE were correlated with the different grades of HE, and length of hospital stay and mortality. Chi-square test was used to compare the proportion of precipitating factors versus hospital stay and grade with significance at p < 0.05. Of the 404 patients 252 [62%] were males. Hepatitis C virus was the cause of cirrhosis in 283 [70%]; Child Turcotte Pugh [CTP] class C was present in 317 [78%] patients. On presentation, 17% patients had grade 1 HE while 44%, 29% and 10% had grades 2, 3 and 4 respectively. The most common precipitant of HE was spontaneous bacterial peritonitis in 83 [20.5%], constipation in 74 [18.3%] and urinary tract infection in 62 [15.3%]. One hundred and forty [35%] patients had >/= 2 precipitating factors while no precipitant was noted in 50 [12%] patients. Mean hospital stay was 4 +/- 3 days. The lesser the number of precipitants, shorter was the length of stay [p < 0.01] and lesser was the grade of HE [p=0.025]. Complete reversal of HE was noted in 366 patients [91%] while the remaining had grade 1 HE on discharge. Nine [2.2%] patients died during the hospital stay. No mortality was noted in patients without precipitants. Patients presenting with >/= 2 precipitating factors and advanced grade of HE had a prolonged hospital stay. Moreover, patients without precipitants had better outcomes

Frequency and characteristic features of portal hypertensive gastropathy in patients with viral cirrhosis

To determine the frequency and specific characteristic features of portal hypertensive gastropathy [PHG] in cirrhosis due to viral etiology. Cross-sectional descriptive study. The Aga Khan University Hospital, Karachi, from June 2006 till June 2008. Patients with hepatitis B and C cirrhosis were included who underwent screening esophago-gastro-duodenoscopy [EGD] for varices. Baveno III consensus statement was used for diagnosing PHG on endoscopy and divided them into two subgroups i.e. mild and severe. Data related to platelet/spleen ratio, MELD score and Child Turcotte Pugh [CTP] score indicating severity of cirrhosis were recorded in all patients. Findings were compared by using independent sample t-test. Out of 360 patients who underwent screening EGD, 226 [62.8%] were males. Two hundred and eighty one [78%] had hepatitis C while 79 [22%] suffered from hepatitis B related cirrhosis. Three hundred patients [83.3%] had PHG while 71 [24%] had severe PHG. Higher proportion of esophageal varices [89.7%] was present among those who had PHG [p < 0.001]. On univariate analysis lower platelet counts [117 +/- 55 vs. 167 +/- 90; p < 0.001], increased spleen size [14.1 +/- 2.9 cm vs. 12 +/- 2.4cm; p < 0.001] were found in PHG patients as compared to those without it. Similarly, lower platelet/spleen ratio was noted in patients with severe PHG [916 +/- 400 vs. 1477 +/- 899; p < 0.001]. Furthermore, on multivariate analysis CTP score > 8 MELD score > 12 and platelets/spleen ratio < 900 were significantly associated factors with severe PHG. Frequency of PHG was 83% while severe PHG was seen in 24% cases of viral hepatic cirrhosis. MELD score > 12, CTP score >/= 8 and platelets/spleen ratio

Associations between the Plasticity Region Genes of Helicobacter pylori and Gastroduodenal Diseases in a High-Prevalence Area

BACKGROUND/AIMS: Genes associated with the Helicobacter pylori (H. pylori) plasticity region may play a role in the pathogenesis of H. pylori. We compared the genes jhp0940, jhp0947, and jhp0986 in H. pylori isolates from patients with different gastroduodenal diseases and in different age groups. METHODS: The H. pylori hyperplasticity region genes jhp0940, jhp0947, and jhp0986 were studied by PCR. We also evaluated whether these genes were related to the cytotoxin-associated gene (cagA) and histology findings. RESULTS: Of the patient cohort, 71 (62%) were positive for jhp0940, 67 (59%) for jhp0947, 12 (10%) for jhp0986, and 69 (60%) for cagA. jhp0940 (n=18, 67%) and jhp0947 (n=23, 85%) were found more frequently in duodenal ulcer (DU) patients than in gastritis patients (n=14, 39%; p=0.029 and p<0.001, respectively). Gastric ulcer (GU) was more frequently associated with jhp0940 (17 patients, 77%; p=0.003) than with gastritis (14 patients, 39%). Gastric carcinoma (GC) was more strongly associated with both jhp0940 (22 patients, 76%; p=0.003) and jhp0947 (22 patients, 76%; p=0.003) than was gastritis (14 patients, 39%). jhp0947 was more frequently associated with chronic active inflammation (58 patients, 87%; p=0.009) than with chronic inflammation (9 patients, 13%). Multivariate analysis demonstrated that jhp0947 was associated with DU (odds ratio, 6.1; 95% confidence interval, 1.87-20). CONCLUSIONS: The genes jhp0947 and jhp0940 were identified in H. pylori isolates from patients with GC and DU, while jhp0940 was also isolated from patients with GU. jhp0947 was independently associated with DU.

Model for end-stage liver disease [MELD] score as a useful prognostic marker in cirrhotic patients with infection

To determine the association of Model for End stage liver disease [MELD] score to the outcome of cirrhotic patients with bacterial infection and to compare it with Child-Turcott-Pugh [CTP] score. Descriptive study. The Aga Khan University Hospital, Karachi, from January 2005 to December 2007. Patients with diagnosis of liver cirrhosis and bacterial infection were included. Demographic features, laboratory data and type of infection were recorded. Multiple logistic regression assays were applied to determine the factors associated with poor outcome in cirrhotics with infection. Receiver-Operating Characteristics [ROC] were used to determine the cut-off values of CTP score and MELD score with the best sensitivity and specificity. A total of 530 patients, 313 male [59%] with a mean age of 53 +/- 13 years were analyzed. Spontaneous bacterial peritonitis was the predominant infection seen in 369 [69%] patients. One hundred and eighty six [35%] patients died. Factors associated with poor outcome were a CTP score of more than 11 [p=0.001], raised blood urea nitrogen [p=0.020], raised creatinine [p=0.004], shock [p=0.002], and MELD score > 22 [p=0.03]. An eight percent increase in mortality rate was noticed with every one point rise in MELD score above 22. ROC curve showed that the specificity of CTP and MELD score to predict poor outcome in these patients was 36% and 59% respectively. Child-Turcott-Pugh score more than 11, raised BUN and creatinine, shock and high MELD score were poor prognostic markers in cirrhotic patients with infection. MELD score had better specificity than CTP score in determining outcome

Frequency of NSAID induced peptic ulcer disease

To determine the frequency of peptic ulcer disease in patients on nonsteroidal anti-inflammatory drugs [NSAID]. Record of eight hundred and twenty consecutive patients undergoing upper gastrointestinal [GI] endoscopy; from January 1998 to December 2000 were reviewed. The endoscopic diagnosis varied from gastritis, peptic ulcer to duodenitis. The use of NSAID was documented by reviewing medical records of patients with peptic ulcer. Peptic ulcers were found in 43% [353/820] patients. NSAID associated peptic ulcers were identified in 14.7% [52/353] patients. Diclofenac and aspirin were most common NSAIDs associated with peptic ulcers in 32.7% [17/52] and 30.7% [16/52] patients, respectively. Duodenal ulcer was more common than gastric ulcer 65.3% [34/52] and 42.3% [22/52], respectively. H. pylori infection was present in 46% [24/52] of the cases. NSAIDs treatment and / or H. pylori infection compared to non NSAIDs and non H. pylori infected peptic ulcer disease were significantly associated with gastric ulcer [p = 0.004] and duodenal ulcer [p = 0.009] respectively. NSAID-associated peptic ulcer disease is common in Pakistan and most frequently associated with gastric and duodenal ulcer. H. pylori infection is common in association with NSAID related peptic ulcers

Sclerotherapy plus octreotide versus sclerotherapy alone in the management of gastro - oesophageal variceal hemorrhage

There are different ways for controlling oesophageal variceal bleed which include pharmacological and endoscopic methods. In this study we compare efficacy of octreotide [50 g/hr for 48 hours] combined with sclerotherapy versus sclerotherapy alone in patients with acute bleeding from gastro-oesophageal varices [GOV]. It was a randomized clinical controlled trial conducted at Aga Khan University Hospital, Karachi, from January 1997 to December 1998. We evaluated the role of octreotide [50mcg/hr for 48 hours] combined with sclerotherapy versus sclerotherapy alone in a total of 105 adult cirrhotic patients who had acute bleeding from GOV. Patients were assigned to receive octreotide plus sclerotherapy or sclerotherapy alone. Primary outcome measure was 5-day survival without rebleeding. The hospital stay in days and blood transfusion requirements were also compared in the combined treatment group versus sclerotherapy alone group. Initial control of bleeding was achieved in 46/51 [90.2%] patients who received combined treatment compared to 41/54 [75.9%] patients [p=0.05] in sclerotherapy alone group. Rebleeding after the first 48 hours was less in the octreotide treated patients 2/46 vs. 8/41 patients [p=0.003]. The octreotide treated patients had a better short term [5 days] survival without rebleeding 44/51 vs. 33/54 [p=0.003] and shorter hospital stay, 5.31 +/- 3.87 days vs. 6.63 +/- 3.86 [p=0.008] as compared to sclerotherapy alone group. The blood transfusion requirement was also less in the combined treatment group 3.88 +/- 2.80 vs. 5.37 +/- 3.15 units [p=0.002]. 1] The combination of sclerotherapy, and octreotide infusion over 48 hours is more effective than sclerotherapy alone in the treatment of acute variceal bleeding and prevention of early rebleed in cirrhotic patients. 2] It leads to shorter hospital stay and 3] less blood transfusion requirements. 4] Although early survival without rebleeding is improved, the overall mortality at the end of hospitalization period is similar in the two groups of treated patients

Morning report is an effective teaching activity: faculty and residents perspectives

Objective: To compare the perspective of faculty and residents on various aspects of morning report

Design: Cross sectional study

Place and Duration: Study conducted in July-August 2002 at the Department of Medicine, The Aga Khan University Hospital Karachi

Patients and Methods: A 22-item questionnaire was distributed to residents and faculty. It was meant to examine the perspectives of both groups about objectives and contents of the morning report. The format, person to present, participate and conduct the morning report were also examined in a Likert scale, single best response or open-ended questions

Results: Forms were distributed to 117 individuals, of whom 84 [72%] responded. Improving presentation skills, problem solving ability and conveying medical knowledge, as the objective of morning report was rated highly. The faculty [84%] indicated that the chief resident should conduct it whereas the residents [72%] preferred post-call internist to direct the report. Both groups [>90%] preferred that the junior residents should be the presenter. Both groups opted [76%] to discussly selected cases admitted previous night. Contents of morning report [discussion on diagnostic workup, disease process and management issues] was rated by the resident and the faculty as 97%, 70% and 85.5% respectively. The residents [78%] preferred morning report to be directed towards post graduate examination where as the faculty did not favor

Conclusion: A remarkable similarity was found in residents and faculty for morning report in terms of improving presentation skills, problem solving ability, conveying medical knowledge, discussion on diagnostic workup, disease process and management issues. The residents also want contrary to the faculty that the morning report should be directed towards post graduate examination