Gastric emptying scintigraphy in postprandial distress syndrome

Objective: To find out the pattern of gastric emptying scintigraphy [GES] in patients with post prandial distress syndrome [PDS]

Methods: This study was carried out from January 2015 to July 2016 at Combined Military Hospital [CMH] Kharian and Nuclear Medical Centre [NMC] of Armed Forces Institute of Pathology [AFIP] Rawalpindi. Patient's inclusion criteria were dyspepsia of post prandial distress type for more than six months duration. Patients with dyspepsia due to epigastric pain syndrome and other organic disorder were excluded. Upper gastrointestinal endoscopy was performed in all patients to rules out organic causes. Four-hour Gastric emptying scintigraphy was carried out at NMC, AFIP. Results were compiled and statistical assessment was done by utilizing SPSS IBM 22 version

Results: Thirty-eight patients were included in the study with age range from 15-72 years with mean age of 37.05 +/- 13.5 years. Males were 28[73.7%] and 10[26.7%] were female. Mean gastric retention with SD at one, two, three and four hours were 63 +/- 19.04, 37 +/- 20.62, 19 +/- 16.66 and 10 +/- 12.73 percent respectively. Early gastric emptying was in 3[7.89%] and delayed gastric emptying at two and four hours was seen in 4[10.52%] and 12[32%] respectively. Seventeen [44%] of the patients had normal gastric emptying despite the classical symptoms of PDS

Conclusion: Gastric dysmotility in GES seen in half of the patients points some additional mechanism as well like gastric accommodation or visceral hypersensitivity in the patients with PDS

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

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

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

Endoscopic management of common bile duct stones experience at military hospital, Rawalpindi

To determine the characteristics of patients presenting with common bile duct [CBD] stones, to know the type of endoscopic therapy employed and to see procedure related complications. A descriptive study Palace and Duration of Study: The study was conducted in the Department of Gastroenterology of Military Hospital, Rawalpindi from Jan 2007 to Dec 2007. Adult patients with common bile duct stones who underwent endoscopic retrograde cholangiopancreatography [ERCP] enrolled in a consecutive manner. The procedure was done under sedation with midazolam and meperidine after informed and written consent. Patients data was obtained from the department and entered on a spread sheet to calculate percentages and frequencies .The data was analyzed using Statistical Package for Social Sciences [SPSS] version 10 to document the endoscopic procedures done and the procedure- related complications. Two hundred and twenty five patients underwent ERCP for evaluation and treatment of CBD stones. Mean age was 45 years with female to male ratio of 1.9: 1. Out of 225 patients, cannulation failed in 4 cases due to duodenal stenosis and 154 [70%] out of 221 cases of CBD stones mandated endoscopic treatment with balloon trail, basket extraction, placement of plastic biliary stent temporarily or use of mechanical lithotriptor. Duct clearance was achieved in 67% cases. Complication rate has been 9% with bleeding being the most common complication with no mortality. A duct clearance rate of over 67% was achieved with sphincterotomy combined with balloon trail, basket extraction and lithotripsy. Bleeding was the most common procedure- related complication. Very large CBD stones/ Mirrizi syndrome cases were referred for surgical intervention

Indications for endoscopic ultrasound and diagnosis on fine needle aspiration and cytology

To determine common indications for requesting Endoscopic Ultrasound [EUS] and to describe the diagnosis made after endoscopic ultrasound/Fine-Needle Aspiration and Cytology [FNAC] during two years at a tertiary gastrointestinal unit. Cross-sectional descriptive study. The study was carried out in Gastrointestinal Department of Military Hospital, Rawalpindi, from March 2006 to February 2008. One hundred and eighty nine patients who underwent EUS during study period at Military Hospital were included in the study. Patients too ill [hypoxemic/hypotensive] to undergo procedure safely and those with complete esophageal blockage at upper end by tumour not allowing scope/EUS probe to advance beyond were excluded. EUS was done with Olympus Exera EUS 160, linear or radial scope, as required. EUS findings were recorded against indications as enlarged lymph nodes, tumour, staging, normal or incomplete. Fine-Needle Aspiration [FNA] was done as per findings on EUS using 21-22 G needle. An on-site cytopathologist made the provisional cytopathological diagnosis. Final cytology/histopathology report was given after review of slides by consultant histopathologists at Armed Forces Institute of Pathology [AFIP], Rawalpindi, and were documented as tuberculosis, malignancy, chronic pancreatitis or reactive hyperplasia. Data was analyzed for documentation of patients' age, gender, common indications, findings on EUS/FNAC, using SPSS version 10. Percentages and frequencies were calculated for the presence of these above-mentioned variables. Of the 189 patients, 145 [77%] were male and 44 [23%] female. Age was 18-80 years [mean 49 years]. Major indications for referral were lymphadenopathy in 92 [49%], suspected growth pancreas in 57 [28%], growth of stomach in 20 [11%] and a heterogeneous group included esophageal, liver, retroperitoneal masses, rectal and other pathologies. Findings on EUS included lymphadenopathy in 76, mostly in sub-carina and AP window. Mass in pancreas was seen in 36, followed by stomach tumour in 17 and esophagus in 9. FNAC was done in 142 out of 189 patients. Final diagnosis out of 67 FNAC/histopathology of lymph nodes were tuberculosis in 26 and malignant lesions in 23. These included metastatic adenocarcinoma in 8, lymphoproliferative disorder in 7, metastatic squamous cell carcinoma in 5, small cell carcinoma in 2 and anaplastic in 1. Pancreatic tumours were adenocarcinoma in 16, poorly differentiated in 3 and neuroendocrine in 2. Stomach tumours were found in 11, and included lymphomas 5, GIST 3, carcinoids 2, metastatic choriocarcinoma 1 and adenocarcinoma in 1. Therapeutically, 3 celiac blocks and one pancreatic pseudocyst drainage was done. The main indication of EUS and pathology of mediastinal and celiac nodes were metastatic malignancy and tuberculosis. Pancreatic adenocarcinoma was another common cause for asking EUS

Diagnostic evaluation of patients presenting with bleeding per rectum by colonoscopy

Rectal bleeding is a manifestation of lower gastrointestinal bleed, which means bleeding from a site distal to ligament of Treitz. Annual incidence of this problem has been estimated to be 20% and mortality as 11%. Patients complaining of haematochezia are suspected of having lower GI bleeding and proctosigmoidoscopy followed by colonoscopy is the examination of choice for diagnosis and treatment. Previous evidence suggested that in our country, frequencies of different aetiologies of lower GI bleed are different from the West. This study validated the previous findings. The Objective of this study was to determine the causes of rectal bleeding in adult patients at Military Hospital, Rawalpindi. One hundred and five adult patients with visible rectal bleed, irrespective of their gender were selected by non-probability convenient sampling from general medical OPD and general medical wards. Patients with suspected upper GI source of bleeding; haemorrhoidal bleed and acute infectious diarrhoea were excluded from the study. All patients were subjected to fibre-optic colonoscopy after necessary preparation and findings were recorded. Biopsies taken from suspected lesions were clinically indicated. Diagnosis was based on colonoscopic and histopathologic findings. A total of 105 patients [77 male and 28 female] with mean age 41.04 yrs were part of the study. Colonoscopy showed abnormal findings in 85 [84%] patients. The commonest diagnosis was ulcerative colitis, which was found in 48 [46%] patients. It was followed by colorectal carcinoma, 11 [10%] patients, and non-specific colitis, 9 [8%] patients. Other less frequent findings were colonic diverticuli, 7 [6%] patients, solitary rectal ulcer, 5 [4%] patients, colonic polyps in 3 [2.5%] patients and one case each of telangiectasia and Crohn's disease. Colonoscopy has very high diagnostic yield and would be recommended in the workup of patients presenting with bleeding per rectum. Ulcerative colitis was the leading cause of bleeding per rectum in this study; while infrequent findings of Crohn's disease, polyps and diverticuli indicate that these are uncommon in this region

N-butyl-2-cyanoacrylate and lipoidol pulmonary embolism [glue embolism]

Glue embolisation is a rare happening and many clinicians who evaluate patients for post sclerotherapy problems may be unaware of this complication. We present a case of pulmonary embolism in a patient of cirrhosis liver secondary to gastric variceal sclerotherapy with N-Butyl-2-cyanoacrylate and lipoidol solution. This is also called glue embolism