Hematological adverse effects in HCV patients treated with pegylated interferon and ribavirin in a Tertiary Care Hospital Peshawar

To know the frequency of common hematological adverse effects during treatment of HCV. Comparative study. This study was carried out OPD of gastroenterology unit HMC Peshawar from November 2013 to August 2014. This study comprising of 42 patients. Patient age more than 17 years, both genders, previously treatment experienced patients with normal hematologic and radiological parameters were included in the study. Patients age more than 70 years, patients with uncontrolled depressive illness, pregnant ladies, treatment naive patients and decompensated cirrhotics were excluded from the study. Patients were evaluated for treatment with pegylated and ribavirin by history, clinical examination, routine laboratory investigations, ultrasound abdomen, HCV genotyping and upper GI endoscopy where considered necessary. Patient's who fulfilled the inclusion criteria were included in the study. Total of 42 patients, 24 [57.14%] male and 18 [42.85%] female were included in this study. The mean age was 39.05 +/- 8.54 with minimum age of 18 years and maximum age of 55 years. Genotype 3 was the most frequent genotype, present in 26 [61.90%] patients followed by untypeable genotype, present in 12 [28.57%] patients. Anemia was present in 18 [42.85%], thrombocytopenia in 10 [23.80%] patients. Leucopenia was present in 6 [12.28%] patients. Haematological abnormalities are common during treatment for HCV, so patients should be regularly followed to diagnose and treat the cytopenias in time

Assessment of OPD patient's satisfaction with health care services at Al-Nafees medical hospital

Objective: To determine socio-demographic profile among the OPD patients and the overall satisfaction level of the patients utilizing the OPD

Study Design: A descriptive cross sectional study

Place and Duration: Conducted in OPD of Al-Nafees Hospital Islamabad from 12th January -12th March 2015

Methodology: Through convenient sampling a closed ended structured questionnaire was employed to collect the quantitative data. OPD patients aged 18-64 who showed willingness to participate were included in the study. Indoor patients, patients below 18 and above 64 and those who were not willing were excluded

Results: The study was conducted on 209 patients. Overall satisfaction level of patients with the OPD health services was 86.2%. Satisfaction level was found to be more in females than males. 42.6% had a family income of >15000 Rupees but satisfaction level with OPD services was same among respondents falling in different categories of family income. Patients with primary level of education were more satisfied. 41.1% waited 15-30 minutes for the examination by the doctor. 89% of the patients were satisfied from the registration staff. 73.3% were satisfied with doctor's service. The satisfaction level from the nurses was 64.6%. 63.3% were satisfied from the services provided by the pharmacy. 63.2% said that the medical expenses were affordable. 88% of the patients agreed upon the cleanliness of the building of the hospital and 77% stated that that signs and boards were easy to follow

Conclusion: In the current study it was found that majority of respondents were highly satisfied with the OPD services offered at Al-Nafees Hospital. Patients were satisfied with the behavior of registration staff, Physicians' communication skills, waiting time for examination, nursing care, pharmacy services and logistic arrangements

Management of foreign bodies in the upper gastrointestinal tract with flexible endoscope

To evaluate the management of foreign bodies in the upper Gastrointestinal tract in a tertiary care hospital in Peshawar. In this descriptive study, conducted at Gastroenterology Department Hayatabad Medical Complex Peshawar from May 2002 to May 2009, a total of 40 consecutive patients presenting with history of foreign body ingestion were included. Radiological survey was made before endoscopy in all the patients. Flexible endoscope, esophageal over tube and other accessories were used for removal of the foreign bodies. Female to male ratio was 1.5:1. The mean age of the sample was 19.92 +/- 23.5. Dysphagia [n=18, 45%] was the most common symptom in the esophageal foreign bodies followed by retrosternal pain or discomfort [n=11, 27.5%]. The most common foreign body was coin ingestion [n=24, 60%]. Meat bolus and bone chip impaction was present in 9 [22.7%] patients. The success rate in case of esophageal foreign bodies was 93.75%. While in the case of gastric foreign bodies, it was 100%. There was a small perforation which occurred in only one patient with esophageal foreign body which was managed conservatively. In the case of gastric foreign bodies, no procedure related complications occurred. Flexible endoscopy was a safe and effective technique for the management of foreign bodies in the upper gastrointestinal tract in our study

Injection sclerotherapy of bleeding gastric varices using absolute alcohol

To evaluate the effectiveness of absolute alcohol injection in the management of bleeding gastric varices. This descriptive study was conducted in the department of Gastroenterology, Hayatabad Medical Complex Peshawar from September 2006 to September 2009. Twenty Seven patients with portal hypertension fulfilling the inclusion criteria and consenting were included in the study. Endoscopy was arranged within 12 hours of admission to the hospital. The gastric varices were injected with 5-10 ml of absolute alcohol depending upon the size of the varices. Both intravariceal and paravariceal techniques were used. Subsequent endoscopy sessions were arranged at 2 weeks intervals. The outcomes assessed were variceal eradication, rebleed and death. Findings were noted and entered into a structured proforma. Data was analyzed using SPSSv.10. Fifteen [55.56%] patients were male and 12 [44.44%] were female with a mean age of 47.52 +/- 15.09 years. Twenty one [77.78%] patients had cirrhosis due to chronic hepatitis C, 4 [14.81%] were HBV related while 2 [7.40%] had alcoholic liver disease. Majority [70.73%] had child's class C followed by B and A [18.51% and 11.11% respectively]. Variceal eradication was achieved in 19[70.37%] patients. Three were lost to follow up while 5 died due to uncontrolled bleeding. Post sclerotheraphy ulceration was the most common complication [64%] followed by pyrexia [28%], Retrosternal/epigastric pain [16%] and dysphagia [8%]. Sclerotherapy with absolute alcohol may be effective in achieving hemostasis in bleeding gastric varices but with exceptionally high rate of complications

Frequency of organic pathologies in patients with irritable bowel syndrome

To evaluate Irritable bowel syndrome [IBS] labeled patients, meeting symptom based criteria of IBS, for organic pathologies. This descriptive study was carried out in Gastroenterology Department, Hayat Abad Medial Complex, Peshawar, during the period from March 2003 to March 2005. A total of 85 consecutive patients were included in the study, who were labeled as IBS by the General Practioners. All of them were meeting symptom based criteria [ROME II] for IBS. Informed consent was taken. Patients with alarm signs including dysphagia, rectal bleeding, anemia, weight loss, family history of colon cancer, were excluded from the study. Detailed history and physical examination was done. Laboratory evaluation, which included complete blood count, erythrocyte sedimentation rate[ESR], blood urea, serum creatinine, serum electrolytes, liver function tests, thyroid function tests, and stool examination for ova, parasites and culture when indicated, was done. Patients underwent Upper G I Endoscopy, Ultrasound of the abdomen, Flexible sigmoidosopy and/or Full length colonoscopy as indicated. Other investigations like small gut biopsy, celiac serology and biopsy from the large gut were done as needed. Out of the 85 patients, 68 [80%] were males and 17 [20%] were females. Abdominal pain was the most common, present in 65 [76%] patients out of 85 patients. All these patients had mixed type of IBS symptoms, having both diarrhea and Constipation. Laboratory investigations were normal in almost all patients except in 5 [5.8%] patients, who were having evidence of hypochromic microcytic anemia. All these five patients were having mixed pattern IBS. Three [3.5%] were males and their celiac serology and small gut biopsy showed evidence of celiac sprue. Ten [12%] of patients were having cysts of Amoeba in their stools routine examination but there were no trophozytes found. Another 15 [17%] patients were having non significant hemorrhoids on lower GI endoscopy. 17 [20%] of patients were having antral gastritis on EGD, but the biopsy showed non specific gastritis. Irritable bowel syndrome can be diagnosed clinically, using ROME II criteria and a few inexpensive and non invasive tests. In patients with IBS-D and IBS-M routine serological screening for celiac sprue may be a cost effective strategy

Can conversion rate be minimized?

To evaluate intraoperative difficulties during laproscopic cholecystectomy and to minimize the rate of conversion from laproscopic cholecystectomy to open cholecystectomy. It was a prospective study carried out at Department of Surgery, Ziauddin Medical University Hospital over 2 year period from Jan.2000-Dec.2001. Consecutive patients admitted with the diagnosis of cholelithiasis confirmed on ultrasonography and undergoing laproscopic cholecystectomy during the same admission. Various parameters were analyzed including gender, comorbids, past history of known gall stones, jaundice and previous surgeries Statistical analysis were carried out utilizing SPSS 10.0 for Windows. One hundred and seven patients were included in the study .Mean age was 49.8 with male to female ratio of 1:4. Laproscopic cholecystectomy was successfully done in 61 [57%], nine patients needed conversion to open cholecystectomy, the reasons for conversions were adhesions at calots triangle, bleeding and instrument failure. 37 patients were excluded from the study [28 were elective open cholecystectomy due to non approval from corporate 6 had CBD exploration and 3 had associated hernia repair. This study was done to identify factors responsible for conversion from laproscopic cholecystectomy to open cholecystectomy

Endoscopic dilatation for caustic esophageal strictures

To determine the outcome of esophageal dilatation in caustic esophageal strictures in our Patients. This descriptive study was conducted in the department of Gastroenterology and Hepatology Hayatabad medical complex from 1999 to 2007. Patients with caustic esophageal strictures and above 03 years of age were included. Patient with caustic stricture and fistulae or diverticulae, peptic stricture and malignant stricture were excluded. Patients were initially evaluated with barium swallow and meal. Consenting patient were asked to come in the morning after over night fasting. Guide wire was positioned across the strictures with the help of the endoscope [GIF-140/GIF-N130]. SavouryGilliard plastic dilators of increasing sizing were employed. Repeated sessions were performed fortnightly till a 15mm [45Fr] lumen size was achieved. Follow up session were arranged whenever dysphagia developed. Out of 20 patients, 11 patients [55%] were more than 12 years of age. Mean age is 19.25 ranging from 3 years to 65 years. There were ten males [50%] and ten females [50%]. Total dilatations were 442. Successful dilatation up to a lumen size of 15mm could be achieved in twelve patients [60%]. In six patients [30%] satisfactory dilatation could not be achieved and were referred for surgery. Two patients [10%] had perforation with an incidence rate of 0.45%. Caustic Stricture is more common in adolescent and adults in our population. Endoscopic dilatation is modestly effective in achieving adequate dilatation and relieving dysphagia

Cutaneous manifestations of chronic liver disease

Hepatobiliary diseases are frequently associated with abnormalities of the skin, nails and hair. This study was undertaken to determine the cutaneous manifestations of chronic liver disease [CLD] and particular pattern associated with aetiology of disease. Patients suffering from chronic liver disease of any aetiology presenting to department of gastroenterology Hayatabad Medical Complex, Peshawar from 1st December 2004 to 30th April 2005 were enrolled in the study. All the relevant details regarding history and clinical examination were recorded on a specially designed pro forma. A total of fifty patients, 32 males and 18 females were included. Thirty [60%] patients were suffering from chronic hepatitis C virus infection, 14 patients were suffering from Chronic hepatitis B virus infection and 2 patients each were suffering from primary biliary cirrhosis and Wilson's disease. In two cases the aetiology could not be ascertained. Different manifestations included pigmentation [82%], Terry's nails [80%], xerosis and excoriations [72%], nonscarring hair loss from axilla and pubic region [64%], and spider naevi and palmar erythema [36%]. Lichen planus was seen in 4%, vitiligo and hepatocutaneous syndrome in [2%] of patients each. Cutaneous manifestations in chronic liver disease are non-specific and do not point towards specific aetiology. Physicians caring for patients with chronic liver disease should pay attention to its multisystemic nature

Surgically treated rectal prolapse: Experience at a teaching hospital

To analyze our results regarding the surgical treatment of complete rectal prolapse performed at the Aga Khan University Hospital, from January 1988 to December 2003. Files were retrieved from our medical records and data was reviewed for all adult patients admitted and operated upon for complete rectal prolapse during our study period. Long-term follow-ups were obtained through these files and also by contacting patients through telephone and letters. Data was recorded in a standardized two-page proforma and analysis was carried out between different variables using SPSS 10.0. A total number of twenty surgeries [n=20] were performed. All patients had the presenting complaint of something coming out of anus, 70% [n=14] patients complained of some bleeding per rectum, 30% [n= 6] had anal pain and 20% [n=4] had faecal incontinence. Chronic constipation was found in 50% [n=10] patients, obstructive uropathy in 30% [n=6], weight loss, chronic cough and mental illness, each in 10% [n=2] of patients. Primary procedure was carried out in 70% patients. Mean operative time was 178 minutes; mean length of stay was 7 days with a mean follow-up of 25 months. Early complications were noted in 5% [n=1] patients, and late complications in 30% [n=6]. Based on this data, comparative analysis was carried out between different variables. Surgery is the only treatment for rectal prolapse in adults. Several procedures are done suggesting that there is no standard treatment for this ailment. The number of male patients was higher, chronic constipation was the most common risk factor, abdominal rectopexy was the favored procedure, perineal procedures were associated with shorter operative time, hospital stay, and were done more often in females and elderly. Revision surgery was associated with longer operative time and hospital stay

Preliminary experience of infliximab treatment in Crohn's disease

This is a preliminary study of resistant Crohn's disease treated with Infliximab [Remicade], a monoclonal antibody to Tumor necrosis factor alpha [TNF]. The aim of the study was to determine the efficacy of Infliximab in patients with moderate to severe active Crohn's disease. Material and The Prospective open label observational study was conducted in the department of Medicine and Gastroenterology Al Hammadi Hospital Riyadh Saudi Arabia from December 2000 to December 2001. Ten Patients with confirmed Crohn's disease of the bowel who had less than satisfactory response to conventional treatment were given Infliximab. Amongst the 10 patients 6 had luminal crohn's disease [60%] and 4 had fistulizing crohn's disease [40%]. Three patient had an associated extra intestinal manifestation of the disease, two having arthritis and an another had erythema nodosum. Out of 10 patients, 8 cases showed improvement in their disease [80%]. All the 4 cases with fistulising disease showed improvement in their disease with disappearance of the fistula in 3 cases. Patients with luminal crohn's disease 4 out of 6 improved clinically and in 2 cases there was no change in symptomatology. The arthritis and skin lesion resolved with improvement in bowel disease. Infliximab treatment is associated with remarkable clinical improvement in patients of crohn's disease with minimal adverse effects but further assessment of its long-term efficacy and safety needs to be determined

Correlation of endoscopic extent and severity with the clinical presentationof ulcerative colitis

To evaluate whether the clinical presentation in patients with confirmed ulcerative colitis reflects the degree of colonoscopic activity in ulcerative colitis. Place and Duration of Study: This study was conducted at the Department of Gastroenterology, PGMI, Peshawar from 1994 to 2000. Subjects and Colonoscopy was performed in 550 patients with an acute attack of severe ulcerative colitis before undergoing medical therapy. The disease was graded into mild, moderate and severe. The colonoscopic activity was assessed using a modification of Baron's criteria. Colonic involvement was divided into distal, left sided and total colitis. Major bulk of the patients were male with a mean age of 31.8 years. The disease was of mild severity in 36.3%, moderate in 47.5% and severe in 16.3%. Endoscopic extent was distal colitis in 38.1%, left sided colitis in 32.7% and total colitis in 29.1%. We found a discrepancy between clinical features and endoscopic appearances of the disease. Those presented with mild constitutional symptoms had severe disease endoscopically. Endoscopy should be performed in every patient irrespective of clinical features not only for diagnostic purpose but also for endoscopic extent and assessment of severity of disease

Outcome of endoscopic injection sclerotherapy with absolute alcohol for bleeding esophageal varices

To find out the long-term consequences of endoscopic injection sclerotherapy using absolute alcohol as a sclerosing agent. Design: Study was carried out retrospectively. Place and Duration: Department of Gastroenterology, HMC, Peshawar from January, 1988 to June, 2000. Subject and 620 patients admitted for bleeding esophageal varices were studied, emergency sclerotherapy was performed in 127 [20.48%] patients whereas elective sclerotherapy was performed after 24 - 72 hours in 493 [79.52%] patients [p < 0.05]. Total sclerosis with survival was achieved in 573[92.41%] patients [p < 0.05], whereas 47[7.58%] patients died because of uncontrolled bleeding in 31[5%] patients, early rebleeding in 9[1.45%] patients, and encephalopathy in 7[1.12%] patients. Common complications included central chest pain [17%], esophageal ulceration [11%] and pyrexia [5%]. At the time of discharge from hospital, all the patients were given propranolol 20 mg QID as an adjuvant medical therapy for the secondary prophylaxis of variceal bleeding. The rate of complete eradication of esophageal varices was 92%. The overall recurrence rate of varices was 28% during follow-up period. The rate of recurrent bleeding and death was 9.42% and 3% respectively. We conclude that absolute alcohol and propranolol for bleeding esophageal varices are associated with low recurrence rate of varices, rebleeding and low mortality

Critical pathway, cardiac surgery in the third world

To set up a protocol in order to provide an efficient, cost effective system for Cardiac Surgery and to reduce the waiting list in straight forward Cardiac Surgical Operations. A prospective study in all patients with Patent Ductus Arteriosus [PDA] following the Critical Care Methodology. Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore. Main outcome measures: Effectiveness of critical care methodology, reduction of cost to hospital and patient and reduction in waiting list time for PDA surgery. From June 1994 till June 1999, one hundred and fifty consecutive patients of PDA had their operation planned as day case cardiac surgery. There were 90 females and 60 males. Their mean age was 6.55 +/- 0.56 years. 134 patients were less than 18 years, mean age 4.9 +/- 0.39 years. These patients were seen in the outpatient and were accessed by the surgeon, anesthetist and intensive care sister. The parents of the children were fully briefed about the preoperative preparation, operation and post operative course. The patients were admitted on the day of the operation and kept in the ICU for 6 hours and then shifted to the high dependency unit [HDU] and discharged on the second post operative morning. We found this method of day case surgery beneficial for the patient. In that it reduced the cost of the hospital stay, surgery and led to a reduction in the waiting list time for PDA. This did not lead to an increase in the morbidity as the patients were sent home to the community early. In third world countries like Pakistan where resources are limited this method is ideal provided everyone is willing to participate

Prevalence of helicobacter pylori in a tertiary care hospital in Peshawar, Pakistan

To find out prevalence of Helicobacter pylori in tertiary care hospital in Peshawar. Design: A prospective study of 100 dyspeptic patients referred to the Department of Gastroenterology. Setting: Department of Gastroenterology / PGMI, LRH, Peshawar. Subjects: Hundred Dyspeptic patients. Mai/n Outcome Measures: The incidence of Helicobacter pylori in this study is the same as that shown in other parts of the world with only minor differences in gastritis and a significant association with carcinoma stomach. The maximum number of patients were between 41 -60 years with 72% males. Most of the patients presented with epigastric pain, followed by dyspeptic symptoms, recurrent vomiting, weight loss, anaemia and abdominal mass in that order of frequency. Duodenal ulcer was the most common underlying pathology [36%]. Out of 100 patients seventy four [74%] were positive for Helicobacter pylori. Out of these 74 [74%] positive cases, 34 [94.4%] had duodenal ulcer, followed by 1 3 [81.25%] with gastritis, 6 [60%] with gastric ulcer, 4 [40%] with reflux oesophagitis and 3 [50%] had carcinoma stomach. Conclusions: This study shows that the prevalence of Helicobacter pylori compares well with documented studies in those with dyspepsia excepting an increased incidence of gastritis and gastric carcinoma

Injection sclerotherapy using absolute alcohol in bleeding oesophageal varices

Absolute alcohol was used as a sclerosant to control acute bleeding. Reduction in variceal size was achieved in all grades of varices in 160 [98.1%] patients who had completed at least 2 or more endoscopic sclerotherapy sessions with total eradication of varices in 150 [92.2%] patients. Thirteen [7.9%] patients died-ten [6.1%] because of portosystemic encephalopathy and three [1.8%] due to massive re-bleeds despite treatment. There were no fatal complications. Complications commonly seen were retrosternal pain, bleeding from the injection site, fever and ulceration at the site of injection. This stud shows that endoscopic sclerotherapy with absolute alcohol is effective not only in controlling acute bleeding but also in preventing re-bleeds

Coronary revascularization using bilateral internal mammary artery-experience at the Punjab institute of cardiology

Three hundred and eighty four patients were operated from September, 1991, to November 30, 1993. We used single IMA's on 303 patients, Bilateral IMA's on 30 patients and Bilateral IMA with Right Gastro-Epiploic Arterial grafts on one patient. We compared early and late results on these three groups. Group I - Patients with Vein Grafts only, Group II - Patients with Single IMA Grafts, Group III - Patients with Bilateral IMA. Early results did not show much difference between these three groups as far as complications were concerned except, that there was more blood consumption in Bilateral IMA group, i.e. 300 ml, 550 ml and 700 ml respectively for the three groups. As far as late results are concerned, none of the Bilateral IMA patients was re-admitted for recurrence of Angina or any other complications