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

Peripheral artery disease in type II diabetes

To determine the frequency of peripheral arterial disease [PAD] in type 2 diabetic patients. Cross-sectional observational study. Diabetes Clinic, Medical Unit III, Jinnah Postgraduate Medical Centre, Karachi, from January to June 2010. Three hundred and eighty seven [387] type II diabetic patients of either gender and any age were included in the study. Patients with a previous history of trauma to the arterial vasculature, pregnancy and those who underwent arterial graft procedures were excluded. Non-purposive convenient sampling technique was used to enroll patients in the study. PAD was diagnosed when ankle-brachial index [ABI] was less than 0.9. A p-value of less than 0.05 was considered statistically significant. Out of 387 studied patients, 128 were males [33.1%] and 259 were females [66.9%]. Mean age was 52.22 +/- 9.671 [22 -76] years in the entire cohort. Mean duration of diabetes was 9.38 +/- 6.39 years. PAD was detected in 152 [39.28%] of the total study subjects. Thirty-one of 128 male patients [24.22%] had PAD disease while 121 out of 259 female patients [46.71%] had evidence of PAD [p = 0.001]. Hypertension was a significantly associated factor [p = 0.002]. A high frequency of PAD was observed in the diabetic population particularly with hypertension and more prevalent in females

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

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

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

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

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

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

Comparative analysis of disease activity in patients of chronic hepatitis B virus, with and without super-infection with hepatitis D virus; an experience at tertiary care centre

The hepatitis D virus super-infection contributes significantly to the morbidity and mortality of hepatitis B virus infection. The objectives were to describe the incidence of Hepatitis D virus and comparative analysis of disease activity in patients of chronic hepatitis B virus, with and without super-infection of hepatitis D virus. This Cross-sectional comparative study was conducted at Department of Medicine and Gastroenterology Clinic Jinnah Postgraduate Medical Centre, Karachi, Pakistan from February 2007 to July 2007. HBsAg positive patients who attended our Gastroenterology clinic were selected for the study. After screening for Anti-HDV these patients were segregated in to Anti-HDV positive and negative groups. Data was analyzed on SPSS 12. Eighty-four patients were selected. Seventy-three patients who fulfilled the inclusion criteria were enrolled into the study. Anti-HDV was positive in 23 [31.5%] patients. Among these 23 anti-HDV positive, HDV-RNA was detected in 15 [75%] patients. The differences of age, gender, marital status and area of residence whether rural or urban were not significant between the two groups. HBV-DNA was significantly suppressed in majority of anti-HDV positive patients [p=0.019]. Mean serum ALT levels were significantly higher in patients who had HDV infection [p=0.014]. HDV infection was common in this series of patients with a frequency of 31.5%. All patients of chronic HBV should be screened for HDV whether they are asymptomatic HBV carriers or have chronic active hepatitis particularly when they have raised serum ALT

Hematological and biochemical indicators for the early diagnosis of dengue viral infection

To determine the haematological and biochemical indicators for the early diagnosis of dengue viral infection. A case series. At Medical Unit-III, Ward 7, Jinnah Postgraduate Medical Centre and referred cases from Faiz-e-Rehman Hospital, Metroville, Karachi from September to November 2007. Patients presenting with a fever of less than 2 weeks duration, generalized morbiliform rash and bleeding manifestations were included. Clinical history was recorded and patients were placed on fluid and haematological support. Diagnosis was established by Polymerase Chain Reaction [PCR] for dengue virus or detection of dengue virus specific IgM and IgG. Results: One hundred and four patients met the inclusion criteria during the study period. Sixty six patients had clinical and haematological features suggestive of grade I Dengue Hemorrhagic Fever [DHF]; 34 patients had grade II DHF and 4 had grade III DHF out of whom 3 progressed to grade IV DHF. All the patients presented with fever followed by generalized morbiliform rash [81.73%], vomiting [79.8%], abdominal pain [65.38%], backache [62.5%], depression [60.6%] and mucosal bleeding manifestations [34.6%]. Clinically, conjunctival infection was present in 93 patients [89.4%], hepatomegaly 59 [56.7%], lymphadenopathy in 17 [16.3%], splenomegaly in 13 [12.5%], pleural effusion in 11 [10.5%] and ascites in 8 [7.6%]. Common laboratory findings were thrombocytopenia in 100% patients, leucopenia in 55 [52.8%], raised hematocrit in 52 [50%], and elevated aminotransferases, gamma GT in 100 [96%] patients. The overall mortality was 2.88%. In this series clinical history and examination supported by the triad of thrombocytopenia, raised hematocrit and elevated liver enzymes was sufficient for the early diagnosis of dengue hemorrhagic fever without waiting for dengue serology

Effect of Fiber bread on the management of diabetes mellitus

To evaluate the effects of soluble fiber rich bread on lowering blood glucose, blood pressure and blood lipid levels. An interventional study. The study was undertaken at Medical Unit III, Jinnah Postgraduate Medical Centre, Karachi. Duration of the project was one year [1997-1998]. Twenty stable diabetics of both genders were included in this study. They were provided with this bread [test diet] to replace their usual breakfast bread and chapati for lunch and dinner. The intakes of other foods as well as medications were unchanged. Anthropometric measurements, fasting and 2 hours postprandial blood sugar, fasting serum cholesterol and triglyceride levels were recorded before and after 4 weeks of intervention. Blood sugar and blood pressure were checked every week. Quality of life was assessed subjectively with the help of questionnaire, which were asked before and after the end of the intervention. Glycemic control, both fasting and postprandial, improved significantly during intervention. Satisfactory reduction of blood pressure as well as serum cholesterol and triglyceride level was also observed in these cases. The medicines reduced significantly and quality of life improved in all subjects. None of these subjects complained any gastrointestinal discomfort during their consumption of this bread for 4 weeks. The use of soluble fiber rich bread helps to control blood sugar, the hyperlipidemia, and blood pressure which are elevated in poorly controlled diabetics. Thus, integrated improvement will improve the quality of life, reduce the cost of drugs as well as help to avoid harmful effect of drugs

Incidence of HLA B27 in ankylosing spondylitis patients, their first degree relatives and controls

A prospective study of patients attending Physiotherapy Outpatient Department of Jinnah Postgraduate Medical Centre, Karachi was carried during 1991. Its main objective was to find out, among cases of ankylosing spondylitis diagnosed by WHO criteria, the number who were HLA B

7 positive; their first degree relatives and some normal controls from general population, were also tested. HLA studies were performed with the courtesy of National Institute of Health Islamabad. Among 16 patients suffering from the disease, the test was performed on 12 cases, and 8 [66.67%] tested positive; 6 of the 8 [75%] asymptomatic first degree relatives and 3 of 9 [33%] healthy controls also were positive. The association of HLA B

7 with ankylosing spondylitis was found to be slightly less strong in our patients i.e. 66% as compared to 90-95% shown in caucasian population. No prognostic importance could be proved. This study can be considered as a preliminary one and may help those who want to continue it on a larger scale