Validity of modified alvarado scoring system [mass] in the diagnosis of acute appendicitis

Objective: To determine the validity of Modified Alvarado Scoring System [MASS] in the diagnosis of acute appendicitis. Study Design: Cross sectional validation study. Place and Duration of Study: Department of Surgery Combined Military Hospital [CMH] Kohat Pakistan, from Nov 2013 to Oct 2014

Material and Methods: A total of 248 patients fulfilling the inclusion criteria were enrolled in the study after getting the informed written consent. Modified Alvarado Score of all patients was calculated on a proforma which included migratory right iliac fossa pain, anorexia, nausea/vomiting, tenderness in right iliac fossa, rebound tenderness, elevated temperature and leucocytosis [>10 x 109/L]. Surgeries were performed by residents and consultant surgeons. Decision to operate upon was not only on the MASS of the patients rather it was on overall clinical condition of the patients using different scoring systems. Where required aid of different laboratory investigations, ultrasonography, CT scan and laparoscopy was also taken. After surgery histopathological examination of resected specimens was performed. Pre operative modified alvarado score and post operative histopathological results were endorsed on a proforma. A two by two table was used to determine the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of MASS

Results: Out of total 248 patients, 183 [73.8%] patients were males and 65 [26.2%] were females. Male to female ratio was 2.8:1. Sensitivity of MASS in this study was 89.39%, Specificity 84.06%, positive predictive value 93.57%, negative predictive value 75.32% and diagnostic accuracy was 87.90%

Conclusion: Modified alvarado score is a highly sensitive test with fair degree of specificity for the early diagnosis of acute appendicitis especially in the adults. It is particularly helpful for young doctors and in the peripheral hospitals where more sophisticated investigations are not available

Validity of alpha fetoprotein for diagnosis of hepatocellular carcinoma in cirrhosis

To determine the accuracy of serum alpha fetoprotein [AFP] for diagnosis of hepatocellular carcinoma [HCC] in patients with cirrhosis. Observational study. Department of Medicine, The King Edward Medical University, Lahore, from November 2007 to August 2011. Consecutive patients, diagnosed with HCC by contrast enhanced CT, MRI or biopsy were included as cases. Patients of cirrhosis with no evidence of HCC were enrolled as controls. Demographic, laboratory and radiological data were recorded. Serum AFP was determined in all patients at outset and was analyzed using ROC curve for its accuracy in diagnosing HCC. A total of 275 patients were included; of them 173 had HCC and 102 had cirrhosis. One hundred and thirty nine cases [80.3%] with HCC and 86 [84.3%] without HCC had cirrhosis due to HCV. Stage of liver disease, as determined by Child Turcotte Pugh [CTP] score, was comparable; mean CTP value 7.97 A +/- 2.17 in HCC and 7.75 A +/- 2.21 in control group [p = 0.41]. Area under curve [AUC] for AFP was 0.85 [95%, CI: 0.80 - 0.90] with optimum cut off value of 20.85 ng/ml which showed 72.2% sensitivity, 86.2% specificity, 89.9% positive predictive value, 64.7% negative predictive value and 77.4% overall accuracy in diagnosing patients with HCC. Despite sub-optimal sensitivity, alpha fetoprotein is still a valid screening test for diagnosis of hepatocellular carcinoma till other more sensitive markers are developed. Till then, it should be used in conjunction with ultrasound

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

Budd chiari syndrome: a rare complication of renal cancer

A 52 years old lady was admitted with 2 weeks history of abdominal distension and drowsiness. Laboratory workup confirmed the presence of de-compensated liver disease with negative viral serology. Abdominal ultrasound and CT abdomen revealed tumour in right kidney with tumour thrombus extending in inferior vena cava and hepatic vein resulting in Budd Chiari syndrome and ascites. Patient was managed with medications only due to advanced liver disease