Diagnostic Value of Endoscopic Ultrasonography for Common Bile Duct Dilatation without Identifiable Etiology Detected from Cross-Sectional Imaging

Background/Aims@#Endoscopic ultrasonography (EUS) is warranted when cross-sectional imaging demonstrates common bile duct (CBD) dilatation without identifiable causes. This study aimed to assess the diagnostic performance of EUS in CBD dilatation of unknown etiology. @*Methods@#Retrospective review of patients with dilated CBD without definite causes undergoing EUS between 2012 and 2017. @*Results@#A total of 131 patients were recruited. The mean age was 63.2±14.1 years. The most common manifestation was abnormal liver chemistry (85.5%). The mean CBD diameter was 12.2±4.1 mm. The area under the receiver operating characteristic curve (AUROC) of EUS-identified pathologies, including malignancy, choledocholithiasis, and benign biliary stricture (BBS), was 0.98 (95% confidence interval [CI], 0.95-1.00). The AUROC of EUS for detecting malignancy, choledocholithiasis, and BBS was 0.91 (95% CI, 0.85-0.97), 1.00 (95% CI, 1.00-1.00), and 0.93 (95% CI, 0.87-0.99), respectively. Male sex, alanine aminotransferase ≥3× the upper limit of normal (ULN), alkaline phosphatase ≥3× the ULN, and intrahepatic duct dilatation were predictors for pathological obstruction, with odds ratios of 5.46 (95%CI, 1.74-17.1), 5.02 (95% CI, 1.48-17.0), 4.63 (95% CI, 1.1-19.6), and 4.03 (95% CI, 1.37-11.8), respectively. @*Conclusions@#EUS provides excellent diagnostic value in identifying the etiology of CBD dilatation detected by cross-sectional imaging.

Ergonomic Injuries in Endoscopists and Their Risk Factors

Background/Aims@#Prolonged repetitive strain caused by the continuous performance of complex endoscopic procedures enhances the risk of ergonomic injuries among health-care providers (HCPs), specifically endoscopists. This study aimed to assess the risk factors of ergonomic injuries among endoscopists and non-endoscopists. @*Methods@#This cross-sectional study was conducted at the Gastroenterology Department of Liaquat National Hospital, Karachi, Pakistan. A total of 92 HCPs were enrolled, of whom 61 were involved in endoscopic procedures and 31 were non-endoscopists. Data were collected through a self-administered questionnaire during national gastroenterology conferences and analyzed using SPSS version 22 (IBM Corp. Chicago, IL, USA). @*Results@#Of the total study population, 95.08% of endoscopists were observed to have ergonomic injuries, whereas only 54.83% of non-endoscopists had ergonomic injuries (p5 or <5 hr/wk). @*Conclusions@#Endoscopists are at high risk of developing ergonomic injuries, representing the negative potential of the endoscopy-associated workload. To overcome these issues, an appropriate strategic framework needs to be designed to avoid occupational compromises.

Ergonomic Injuries in Endoscopists and Their Risk Factors

Background/Aims@#Prolonged repetitive strain caused by the continuous performance of complex endoscopic procedures enhances the risk of ergonomic injuries among health-care providers (HCPs), specifically endoscopists. This study aimed to assess the risk factors of ergonomic injuries among endoscopists and non-endoscopists. @*Methods@#This cross-sectional study was conducted at the Gastroenterology Department of Liaquat National Hospital, Karachi, Pakistan. A total of 92 HCPs were enrolled, of whom 61 were involved in endoscopic procedures and 31 were non-endoscopists. Data were collected through a self-administered questionnaire during national gastroenterology conferences and analyzed using SPSS version 22 (IBM Corp. Chicago, IL, USA). @*Results@#Of the total study population, 95.08% of endoscopists were observed to have ergonomic injuries, whereas only 54.83% of non-endoscopists had ergonomic injuries (p5 or <5 hr/wk). @*Conclusions@#Endoscopists are at high risk of developing ergonomic injuries, representing the negative potential of the endoscopy-associated workload. To overcome these issues, an appropriate strategic framework needs to be designed to avoid occupational compromises.

Zinc level assessment in patients having Viral Cirrhosis

Objective: Zinc is a vital trace element and its deficiency in cirrhosis might potentiate the development of hepatic encephalopathy. The objective of this study was to assess the zinc levels in serum of patients having viral cirrhosis and compare it with normal healthy controls

Methods: This study was conducted in Department of Gastroenterology, Liaquat National hospital and medical college, Karachi, Pakistan; from January 2014 to December 2014. Total of 45 patients with the mean age of 52.44+/-8.7 years were included. The three groups of patients were made including Child Pugh Class Score B [Group-1], Child Pugh Class C [Group-2] and healthy controls [Group-3] having 15 patients in each group. Zinc levels in serum were evaluated by the help of atomic absorption spectrometry [Normal range50-150 micro g/dl]

Results: Total of 45 subjects was enrolled in this study. Overall prevalence of zinc deficiency was noted in 13[28.9%] patients. Mean value of zinc levels in group 1, 2 and 3 were 68.09+/-20.85, 50.69+/-15.86 and 92.91+/-17.18 micro g/dL respectively. Highly statistical difference was observed in the mean zinc level between three groups p=0.0001. An inverse correlation was observed between Child Pugh Score and the zinc level in serum r=-0.498

Conclusion: Patients suffering from advanced cirrhosis appeared to have lower serum zinc levels.In patients suffering from viral cirrhosis having hepatic encephalopathy, zinc supplementation might improve clinical outcome

Safety of endoscopic n-butyl-2 cyanoacrylate injection for the treatment of bleeding gastric varices in children

Objective: To determine the safety and efficacy of N-butyl 2-cyanoacrylate in bleeding gastric varices in children

Methods: This retrospective observational study was conducted in the Department of Gastroenterology and Pediatric Surgery in Liaquat National Hospital Karachi between January 2010 and January 2017. Gastric fundal varices were obliterated in pediatric population with single shot of N-butyl-2 Cyanoacrylate 0.50ml diluted with 0.50ml of Lipoidal with use of forward-viewing video endoscope with 22-gauge needle. The primary outcome was primary hemostasis, Secondary outcome was complications, re-bleeding and mortality

Results: Thirty patients was included in the study, 18[60%] were male with mean age of 7.12 +/- 2.9 years. Non cirrhotic portal hypertension was the most common etiology in 15[50%] patients, followed by liver cirrhosis secondary to hepatitis B and D co-infection in 6[20%] patients. Primary hemostasis was achieved in 29 [96.7%], while 3[10%] patients developed rebleeding after 48 hours, and hemostasis was achieved after second session of endoscopic obliteration. Abdominal pain and fever developed in 3[10%] patients which was managed conservatively. Mortality was observed in 1[3%] of cases due to sepsis after shunt surgery

Conclusion: Endoscopic fundal varix obliteration with N Butyl-2 cyanoacrylate was safe and effective in treatment of gastric variceal hemorrhage in children

Safety of conscious sedation in patients undergoing endoscopic retrograde cholangio pancreatography

Objective: to assess the safety of conscious sedation in patients undergoing endoscopic retrograde cholangio pancreaticography [ERCP]

Study Design: an observational study

Place and Duration of Study: department of Gastroenterology, Liaquat National Hospital, Karachi, from April 2010 to April 2015

Methodology: all patients underwent ERCP procedure under midazolam and/or nalbuphine were included. Safety was assessed by monitoring the hemodynamics and complications during procedure till discharge from hospital. SPSS version 20 was used for descriptive analysis

Results: a total of 550 procedures were enrolled for the study. The mean age of the patients was 50.85 +/- 15.66 years. There were 197 [35.8%] males. Out of 550 procedures, only 2 [0.4%] reported complications. The study reports a success rate of 531 [96.5%] procedures who underwent ERCP with conscious sedation. Only 19 [3.5%] cases could not be completed successfully under conscious sedation and were converted to general aneasthesia

Conclusion: the present study shows that ERCP technique is safe under conscious sedation as it delivers balanced tranquillity

Safety of trans-nasal percutaneous endoscopic gastrostomy placement

Objective: To evaluate the safety of trans-nasal percutaneous endoscopic gastrostomy [TPEG] placement for nutrition in patients where oral approach is not possible

Study Design: Case-series

Place and Duration of Study: April 2010 to April 2016 in the Department of Gastroenterology at Liaquat National Hospital, Karachi

Methodology: Patients underwent trans-nasal PEG placement and were included in this study. Inclusion criteria were either gender of any age and patients referred for PEG tube placement in whom oral PEG tube insertion was not possible. Ultrathin gastroscope [outer diameter of 5.9 mm] was passed through a nostril after assessment and lubrication, the pull technique was used for tube placement. Primary outcome variable of study was the safety of the procedure. The secondary outcome variables were procedure related complications during and 72 hours after the procedure

Results: TPEG placement was successful in all 46 cases. Thirty-one [67.4%] were males. The mean age was 56.63 +/- 12.62 years. Dysphagia was the main indication in all cases. Head and neck cancer was the most common indication present in 38 [82.6%] patients. In 36 [78.2%] cases, the procedure was performed under local anesthesia. PEG site infection occurred in one [2.1%] patient

Conclusion: TPEG is a safe procedure in patients with oro-pharyngeal obstruction, and it should be considered as an alternative approach

Hep-net opinion about the management of patients with chronic hepatitis C in Pakistan in the era of available direct acting antivirals

In Pakistan, we have 4.9% prevalence of HCV in general population, with 79% genotype 3. Recently Sofosbuvir has been made available at compassionate price in Pakistan. Management of chronic hepatitis C includes counseling of HCV patients, their proper assessment to select those who need antiviral therapy, initiation of appropriate antiviral agents and duration of therapy, along-with careful monitoring for safety and efficacy. Hepatic status as well as previous history of HCV therapy needs to be taken in the consideration before starting antiviral therapy. Other factors include co-morbid conditions like obesity, DM, NASH, etc. Treatment of special populations like liver transplant patients, patients with HBV co-infection, chronic kidney disease and hemoglobinopathies need special considerations when initiating HCV therapy

Nutritional status in patients with hepatitis C

To assess the nutritional status via the SGA [subjective global assessment] screening tool of patients at all stages of hepatitis C virus [HCV] liver disease. Descriptive study. Out-patient Clinics of the Aga Khan University Hospital, Karachi, conducted from October 2009 to January 2011. Patients with hepatitis C virus infection and their HCV-negative attendants were enrolled from the outpatient clinics, and categorized into 4 groups of 100 patients each: healthy controls [HC], those with chronic hepatitis C infection [CHC], compensated cirrhotics [CC] and decompensated cirrhotics [DC]. The validated subjective global assessment [SGA] tool was used to assess nutritional status. A total of 400 patients were enrolled. Most of the patients in the HC group were class A [best nutritional status]. In contrast, the majority [64%] in the DC group were in the class C [worst status]. The compensated cirrhosis [CC] group showed that 90% of patients were malnourished, while 98% of all patients were malnourished in the DC group, predominantly class C. Most importantly, 14% of patients with chronic hepatitis C [CHC] also scored a B on the SGA; which when compared to HC was statistically significant [p=0.005]. As the groups progressed in their disease from CHC to DC, the transition in nutritional status from A to C between groups was statistically significant. Malnutrition occurs early in the course of HCV, and progresses relentlessly throughout the spectrum of HCV disease

Haemobilia: a rare cause of gastrointestinal bleeding

Iatrogenic injury to hepatic duct leading to pseudoaneurysm and haemobilia can occur following laparoscopic cholecystectomy. We report a case of a 60 years old man presenting with haematemesis found to have pseudoaneurysm of accessory hepatic artery 4 months after laparoscopic cholecystectomy. Diagnosis was made by computed tomography [CT] scan followed by celiac and mesenteric artery angiogram. The bleeding was successfully treated with coil embolization