Frequency of hepatic hydrothorax and its association with child pugh class in liver cirrhosis patients

Objective: To determine the frequency of hepatic hydrothorax and its association with Child Pugh Class in patients with liver cirrhosis

Study Design: Descriptive, analytical study

Place and Duration of Study: Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-Ill, [Ward- 7], from June 2012 to May 2013

Methodology: All patients with established diagnosis of decompensated chronic liver disease were included. Detailed history, thorough physical examination, routine laboratory investigations, chest X-ray and abdominal ultrasound were carried out in all patients to find out the presence of pleural effusion and ascites, respectively. Fifty milliliters of pleural fluid was aspirated in all patients with pleural effusion using the transthoracic approach, taking ultrasound guidance, wherever required. Fluid was sent for microscopic, biochemical, and microbial analysis. SBEM defined if pleural fluid with polymorphonuclear [PMN] cell count > 500 cells/mm[3] or positive culture with PMN cell count > 250 cells/mm[3] with exclusion of a parapneumonic effusion

Results: Two hundred and six patients met the inclusion criteria, with mean age of 41.25 +/- 13.59 years. Among them, 149 [72.3%] were males and 57 [27.7%] females. Twenty-three [11.2%] had hydrothorax; right sided involvement was in 18 [78.3%] subjects, 3 [13%] had left sided while bilateral pleural effusion was found in 2 [8.7%] cases. SBEM was found in 07 [30.43%] cases. Mean serum albumin 3.125 +/- 0.71 gram/dl. There was association between serum albumin levels and hydrothorax. A significant association of hydrothorax with Child Pugh scoring system [p=0.018], but not with serum albumin [p=0.15]

Conclusion: The frequency of hepatic hydrothorax has a significant association with hepatic function as assessed by Child Pugh scoring system, but not with serum albumin

Solitary Rectal Ulcer Syndrome: demographic, clinical, endoscopic and histological panorama

Objective: To assess the demographic, clinical, endoscopic and histological spectrum of Solitary Rectal Ulcer Syndrome [SRUS]

Study Design: Cross-sectional observational study

Place and Duration of Study: Medical Unit-III, Civil Hospital Karachi [CHK] and Ward 7, Jinnah Postgraduate Medical Centre [JPMC], Karachi, from January 2009 to June 2012

Methodology: Patients with SRUS, based on characteristic endoscopic and histological findings, were enrolled. Patients were excluded if they had other causes of the rectal lesions [neoplasm, infection, inflammatory bowel disease, and trauma]. Endoscopically, lesions were divided on the basis of number [solitary or multiple] and appearance [ulcerative, polypoidal/nodular or erythematous mucosa]. Demographic, clinical and endoscopic characteristics of subjects were evaluated

Results: Forty-four patients met the inclusion criteria; 21 [47.7%] were females and 23 [52.3%] were males with overall mean age of 33.73 +/- 13.28 years. Symptom-wise 41 [93.2%] had bleeding per rectum, 39 [88.6%] had mucous discharge, 34 [77.3%] had straining, 34 [77.3%] had constipation, 32 [72.7%] had tenesmus, 5 [11.4%] had rectal prolapse and 2 [4.5%] had fecal incontinence. Twelve [27.27%] patients presented with hemoglobin less 10 gm/dl, 27 [61.36%] with 10 - 12 gm/dl and 05 [11.36%] subjects had hemoglobin more than 12 gm/dl. Endoscopically, 26 [59.1%] patients had mucosal ulceration, 11 [25.0%] had mucosal ulceration with polypoid characteristics; while only polypoid features were found in 7 [15.9%] subjects

Conclusion: Solitary rectal ulcer syndrome affects adults of both genders with diverse clinical presentation and nonspecific endoscopic features

HDV seroprevalence in HBsAg positive patients

To find out the frequency of HDV seroprevalence and the demographic characteristics or HBsAg-HDV positive patients. Cross-sectional analytical study. Jinnah Postgraduate Medical Centre and Civil Hospital, Medical Unit-III, Karachi, from March 2007 to April 2011. Patients with positive HBsAg were included in the study. Those having co-infection with HCV or HIV, autoimmune hepatitis, alcoholic hepatitis, Wilson's disease and haemochromatosis were excluded. After detailed history and physical examination all the patients underwent laboratory workup including complete blood count, liver function test, viral profile [HAV, HCV, HIV and anti-HDV] and prothrombin time. While in selected patients, HBc [core] antibodies, ultrasound abdomen, serum iron profile, ANA and liver biopsy were also carried out whenever needed to establish a clinical stage of liver disease. There were 374 patients with 266 [71.1%] males and 108 [28.9%] females with overall mean age of 31.64 +/- 8.66 years. Overall frequency of anti-HDV antibodies positivity was found in 28.1% [n = 105] patients. HDV seropositivity was slightly more prevalent in males as compared to females [28.57% vs. 26.57%]. HDV seropositivity frequency was significantly higher in patients who presented with acute hepatitis/hepatic failure as compared to other clinical diagnoses [p = 0.027] and in those sub-sets of patients who had raised ALT levels [p = 0.012]. There was a high frequency of HDV seropositivity in the studied population particularly in males with acute hepatitis or hepatic failure, having raised ALT levels. The emphasis should be on preventive measures taken by other countries to reduce the prevalence of these treatment challenging infections

Stages of tuberculous meningitis: a clinicoradiologic analysis

To determine the frequencies and percentages of various clinicoradiologic variables of tuberculosis meningitis [TBM] with reference to British Medical Research Council [BMRC] staging of the disease. A case series. Department of Neurology, Jinnah Postgraduate Medical Centre, Karachi, from October 2010 to September 2011. The study included 93 adult patients with the diagnosis of tuberculous meningitis [TBM] at the study place. Patients were divided in three groups according to British Medical Research Council [BMRC] staging of TBM. Different clinical and radiological findings were analyzed at different stages of the disease. Data was analyzed using SPSS [Statistical Package of Social Sciences] version 11.0. A majority of patients were found to be in stage-II disease at the time of admission. History of illness at the time of admission was more than 2 weeks in 50% of stage-I patients but around 80% in stage-II and stage-III patients. Neck stiffness was the most commonly reported finding in all stages. Cranial nerve palsies were higher in stage-III [75%] than in stage-II [43%] and in stage-I [24%] patients. Hydrocephalus and basal enhancement was the most frequently reported radiographic abnormalities. Duration of illness and cranial nerve palsies are important variables in the diagnosis of TBM stages and if TBM is suspected, empiric treatment should be started immediately without bacteriologic proof to prevent morbidity and mortality

Frequency of portal hypertensive gastropathy and its relationship with biochemical, haematological and endoscopic features in cirrhosis

To determine the frequency of portal hypertensive gastropathy [PHG] and its relation with biochemical, haematological and endoscopic findings in cirrhotic patients. Cross-sectional analytical study. Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7, from June 2009 to December 2010. Patients with diagnosis of cirrhosis and either undergoing screening upper gastrointestinal [GI] endoscopy or presented with acute upper GI bleeding were included in the study. Portal hypertensive gastropathy and oesophageal varices were classified using Baveno scoring system. The severity of cirrhosis was classified according to the Child-Pugh criteria. Hypersplenism was assessed by the reduction of haemoglobin, leucocytes and platelets. Out of 217 patients, 148 were males [68.2%] and 69 were females [31.8%] with ages ranging from 15-85 years, [mean 48.06 years]. There were 144 HCV +ve patients [66.4%], 36 HBV +ve patients [16.6%], 15 HCV/HBV co-infected patients [6.9%] and only 1 [0.5%] had co-infection of HBV/HDV. Twenty-one patients [9.7%] were classified as having cryptogenic cirrhosis. Out of 172 patients [79.27%], 56 patients [25.8%] had mild and 116 patients [53.5%] were suffering from severe PHG. Significant positive correlation was found between esophageal variceal grade and PHG [r=0.46, p < 0.001] but not with etiology [r=0.05, p=0.41] or hypersplenism [r=0.08, p=0.22]. The frequency of PHG was 79.27% in the studied group. The grade of oesophageal varices had significant relation with PHG that is the severity of PHG increased with the grade of oesophageal varices, suggesting common pathophysiology of both entities

Comparison of Barcat-Redman technique with Duckett technique in the management of distal hypospadias

To compare the efficacy, safety and complication of Barcat-Redman technique with conventional duckett technique in the management of distal hypospadias. Prospective study carried out at urology department, services hospital, Lahore from 15th April 1998 to 14th April 2000. All Patients with distal hypospadias presenting to the Urology Department Services Hospital. Pediatric Surgery, Services Hospital and Mayo Hospital Lahore were included in the study. These patients were divided into two groups on alternate basis where Group-A patients underwent Barcat-Redman technique and Group-B Patients underwent Duckett technique for the management of hypospadias. Success of both procedures as good, fair and failure were assessed at 3 months follow up. A total of 60 patients were enrolled, 30 patients underwent Barcat-Redman technique [Group-A] and 30 patients were underwent Duckett technique [Group-B]. Ages of the patients ranged from 5 to 25 years with a mean of 11 +/- 5.8 Years. All the patients presented with dystopia of external urethral meatus and chordee [ventral curvature]. The subcoronal type of hypospadias was seen in 43[71.7%] patients and distal penile urethral opening 17[28.3%]. All patients had distal type of hypospadias associated with chordee. Of the 30 patients in Group-A who underwent Barcat-Redman technique, 21[70%] had good results, 5[16.6%] had fair results and 4[13.6%] were failure. In 30 patients of Group-B that underwent Duckett technique, 19[63.4%] patients had good result, 6[20%] had fair results while, 5[16.6%] were failure. The overall morbidity rate was 36.6% while, hospital stay was 3 days and the difference was statistically insignificant [P=0.860]. It is concluded that probably there will never be an operation for hypospadias that will be uniformly and totally successful, but Barcat-Redman technique is superior to Duckett technique

Efficacy of interferon-ribavirin therapy in chronic hepatitis C patients

To determine the efficacy of interferon-ribavirin therapy for chronic viral Hepatitis C [HCV] patients. A quasi-experimental study. Medical Unit-III, Ward-7, Jinnah Postgraduate Medical Centre, Karachi, from august 2006 to December 2007. Adult patients who had not received any prior anti-HCV therapy and had been infected with positive anti-HCV antibodies and detectable HCV RNA were enrolled in the study. Patients were excluded from the study if there was evidence of decompensated cirrhosis, coexistent HIV, or HBV infection, previous organ transplantation, psychiatric diseases, seizure disorder, serious cardiovascular disease and other co-morbid disease like uncontrolled diabetes. Patients were given Interferon-alfa-2b 3 million international units three times a week sub-cutaneously and oral all efficacy as depicted by non-detectable HCV RNA by PCR and its relation with factors of like age, gender, and serum ALT were assessed. A total of 404 patients with mean age of 36.03 +/- 9.30 years, ranging from 13 to 60 years, were offered combination therapy that satisfied the inclusion criteria. Among these, females were 243 [61.1%] and males were 161 [39.9%], age range 13-60 years with mean of 36.03 years. Out of 404, 336 [83.2%] showed response to combined interferon and significantly associated with favourable response. Combination therapy of interferon and ribavirin in chronic hepatitis C patients has still better response rate in our set-up. Younger age and female gender were the favourable predictors

Effect of carvedilol on portal pressure estimated by hepatic vein doppler ultrasound waveform and damping index in cirrhotic patients

To assess the effect of Carvedilol in reducing portal pressure estimated non-invasively by studying Doppler ultrasound waveforms [DUS] and hepatic vein Damping Index [DI]. Quasi-experimental study. Department of Medical ICU in collaboration with Department of Radiology, JPMC, over a period of 6 months [June 1st to 30th November, 2008]. Of the enrolled 65 patients, 47 patients [33 males and 14 females] completed the study. The mean age was 47.4 years. Cirrhotic patients of Hepatitis B, C, D [delta], B and C combined, B and D combined with varying degrees of portal hypertension were included in the study. Cirrhotic patients with bronchial asthma, congestive heart failure, Insulin dependent Diabetes, portal vein thrombosis and hepatorenal syndrome were excluded from the study. The patients were examined by color flow Doppler of the right hepatic vein before and after administration of Carvedilol. Their waveforms and Damping Index [Dl] were recorded and compared by Wilcoxon signed ranks test through SPSS version 12.0. Responders were described as those showing a positive change in wave forms or a decrese of 0.10 or more in Dl. Of the 47 patients, 30 [63%] showed a positive response and 10 [21%] showed no favorable response to Carvedilol, while 7 [14%] patients showed deterioration. The mean Dl on DUS dropped from 0.62 to 0.41 in responders after treatment, while in the non-responders it ranged between 0.42 and 0.57. Ultrasonography Carvedilol reduced portal pressure of cirrhotic patients, as measured indirectly by the damping index of hepatic waveform by Doppler

Correlation of thrombocytopenia with grading of esophageal varices in chronic liver disease patients

To determine the severity of thrombocytopenia in different grades of esophageal varices. Cross-sectional analytical study. Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7 from January to December 2008. Subjects were eligible if they had a diagnosis of cirrhosis. Patient with advanced cirrhosis [Child-Pugh class C], human immunodeficiency virus [HIV] infection, hepatocellular carcinoma, portal vein thrombosis, parenteral drug addiction, current alcohol abuse and previous or current treatment with beta-blockers, diuretics and other vasoactive drugs were excluded from the study. All patients under went upper gastrointestinal endoscopy after consent. On the basis of platelet count patients were divided into four groups; Group I with platelets 20000/mm 3, Group II with values of 21000-50000/mm 3, Group III with count of 51000-99000/mm 3 and Group IV with count of 100000-150000/mm 3. Correlation of severity of thrombocytopenia with the grading of esophageal varices was assessed using Spearman's correlation with r-values of 0.01 considered significant. One hundred and two patients with thrombocytopenia and esophageal varices were included in the study. There were 62 [60.8%] males and 40 [39.2%] females. The mean age of onset of the disease in these patients was 49.49 +/- 14.3 years with range of 11-85 years. Major causes of cirrhosis were hepatitis C [n=79, 77.5%], hepatitis B [n=12, 11.8%], mixed hepatitis B and C infection [n=8, 7.8%] and Wilson's disease [n=3,2.9%]. Seven patients had esophageal grade I, 24 had grade II, 35 had grade III, and 36 had grade IV. Gastric varices were detected in 2 patients. Portal hypertensive gastropathy were detected in 87 patients. There was an inverse correlation of platelet count with grading of esophageal varices [r=-0.321, p<0.001]. The severity of thrombocytopenia increased as the grading of esophageal varices increased. Thrombocyte count was significantly and inversely correlated with the grade of esophageal varices

Hepatocellular carcinoma: a clinicopathological study

To describe the clinico-pathological and radiological profile of hepatocellular carcinoma. A case series. Medical Unit-III Ward-7, Jinnah Postgraduate Medical Centre, Karachi, from January to December 2008. All consecutive patients suspected of having hepatocellular carcinoma [HCC], were admitted and included in this study. Diagnosis of HCC was established by clinical, biochemical, ultrasonographic and histopathologic findings. Patients with primary carcinoma elsewhere in the body, metastatic in the liver, fibrolamellar carcinoma and benign tumours were excluded from the study. At ultrasonography, the details of tumour size and number, portal vein thrombosis and presence of ascites were recorded. Patients were staged according to Okuda staging system. Results were described in mean and percentage values. There were 82 patients with hepatocellular carcinoma including 58 males and 24 females, with male to female ratio of 2.8:1. The mean age of patients was 56.24 +/- 13.65 years. Right hypochondrial pain was the main symptom in 52 [63.4%] patients. The duration of symptoms varied from 1 month to 2 years. Tumour size was larger than 50% of liver size in 42 [51.2%] with portal vein thrombosis in 10 [12.19%]. Anti HCV was positive in 44 [53.7%], HBsAg in 26 [31.7%] and both were found positive in 2 [2.44%] patients. Ten patients [12.2/%] found negative both for anti-HCV and HBsAg. According to Okuda staging system 18 patients had stage 1, 50 had stage 2 and 14 had stage 3 hepatocellular carcinoma. The mean age of presentation of hepatocellular carcinoma was younger as compared to western countries with potentially large non-resectable lesions. Chronic hepatitis C and B was found to be the major known factors. Patients with chronic hepatitis C and B should undergo vigorous HCC surveillance to detect early, potentially respectable HCC

Thrombocytopenia in malaria

To determine the frequency of thrombocytopenia in Malarial Parasite [MP] positive patients. A cross-sectional study. Medical Unit-III, Ward-7, JPMC, Karachi, from June to October 2006. One hundred twenty four MP positive cases were included in the study. Infections with both Plasmodium falciparum and Plasmodium vivax species were included. Complete blood picture with platelet count was obtained in all patients. Thrombocytopenia was defined as platelets count of < 150.000/cmm. Among 124 patients of MP positive, 100 [80.6%] were found to have thrombocytopenia. Over all 64 patients had Plasmodium falciparum, while 60 patients were having Plasmodium vivax infection. The frequency of thrombocytopenia was 71.87% [n=46] in falciparum and 93.33% [n=56] in vivax infection. Thrombocytopenia was a common haematological finding in patients with Plasmodium infection particularly marked in vivax species infection

Clinical features, diagnostic techniques and management of dual dengue and malaria infection

To find out clinical features, diagnostic techniques and management outcome of patients having dual dengue and malaria infection. A case series. Medical Unit-III, Ward- 7, Jinnah Postgraduate Medical Centre, Karachi, from September 2007 to January 2008. Patients presented with fever of less than or equal to 10 days duration, severe body aches, rash and bleeding manifestations were included. Patients with obvious features of other diseases like typhoid, hereditary bleeding diathesis and hematological malignancies and only malarial parasite positive with high grade intermittent fever without rash and myalgia were excluded from the study. Diagnosis of dengue and malaria was based on history, clinical features, laboratory parameters and malarial parasite test by thin and thick films. Serological evaluation was done by dengue IgM and IgG by ELISA test kit. Patients were divided into three groups. Group A was dengue IgM positive plus MP positive, group B was dengue IgM positive and MP negative and group C was dengue IgM negative and were clinically suspected dengue and malaria. The clinical manifestations and laboratory parameters of dual dengue and malaria positive patients were compared with malaria and dengue negative patients. One hundred and fourteen patients were seen during the study period. Antibody titer [IgM] tested in all patients was found positive in 78 patients [69.64%]. Among those 78 patients, 26 [23.21%] were concomitantly positive for malarial parasite [Group A]. Plasmodium vivax was positive in 25 patients and falciparum in one patient. Fifty-two patients [46.42%] were dengue IgM positive and MP negative [Group B]. Thirty four [30.35%] patients were MP and dengue IgM negative [Group C] but were strongly suspected for DHF and malaria on clinical and hematological basis. The hemoglobin of 34.61% of patients of group A, 5.76% of group B and 14.7% of group C were low, hematocrit level was also low in group A[92.3%], group B [15.38%] and group C [70.58%] patients. The platelet count was markedly low in 84.61% of patients of group A, 57.69% of group B and 94.11% of group C. Leukopenia was found in 34.61% of patients of group A, 78.84% in group B and 29.411% in group C. The liver function tests were deranged in all groups. The frequency of dual dengue and malaria infection was 23.21%. The serology of the dengue and malaria showed negative results in 30.35%. The diagnosis of dual infections could be made on the basis of history, clinical examination supported by hematological results. It is recommended that all the patients suspected for dual infections should be treated concomitantly for dengue and malaria in malaria endemic areas

Hypokolemic paralysis and megaloblastic anaemia in laurence-moon-bardet-biedl syndrome

Laurence-Moon-Bardet-Biedl syndrome is a rare, genetically heterogeneous autosomal recessive disorder, characterized by progressive retinal dystrophy, polydactyly, obesity, hypogonadism, mental retardation, and renal dysfunction. Other manifestations include diabetes mellitus, heart disease, hepatic fibrosis and neurological features. Herein, 2 patients with Laurence-Moon-Bardet-Biedl syndrome are described, who had features of persistent hypokalemia and megaloblastic anemia

Intra pelvic total migration of sliding screw in intertrochanteric fracture

A type of fixation failure of Dynamic Hip Screw system [DHS] is presented following a collapse of intertrochanteric fracture fixation. The patient presented three months after DHS fixation with severe lower abdominal pain, painful stiff hip and an uncontrolled diabetes mellitus. The radiographic examination of pelvis revealed intrapelvic presence of DHS sliding screw. The intrapelvic total migration of sliding screw has never been reported so far