Study of gastroesophageal reflux in cirrhotic patients with esophageal varices without endoscopic treatment

The aim of this work is to study prevalence of abnormal gastroesophageal reflux [GER] by pH recording in cirrhotic patients with esophageal varices without previous endoscopic treatment and its possible predicting factors. Sixty five patients [38 men, 27 women] with liver cirrhosis, were selected from those admitted at the Internal Medicine Department of Benha University Hospitals. Their ages ranged from 38 to 59 years [with a mean age of 54.4 +/- 10.5 years]. Diagnosis of liver cirrhosis was based on clinical, laboratory, abdominal ultrasonographic image and histological findings. All patients had esophageal varices confirmed by endoscopy and were submitted to a questionnaire about typical gastroesophageal reflux disease symptoms [heartburn and or acid regurgitation]. pH recording was performed with the probe placed 5 cm above the superior lower esophageal sphincter limit, as determined by manometry. Abnormal pH reflux [pHR] is defined as percentage total time with pH < 4 greater than 4.5%.The pH recording demonstrated abnormal pHR in 25 patients [38.5%]: 6 [24%] just in upright position, 9 [36%] in supine position and 10 [40%] in both positions. Regarding the caliber of the esophageal varices [EV], 15 patients out of 34 [44.1%] with small size varices, 6 patients out of 19 [31.6%] with medium size varices and 4 patients out of 12 [33.3%] with large size varices, had abnormal pHR. There was no statistically significant difference in the prevalence of abnormal reflux between patients with small variceal size and those with medium and large variceal sizes [P> 0.05 respectively]. As for patients with congestive gastropathy, 10 of them out of 29[34.5%] had abnormal pHR; 15 patients without congestive gastropathy out of 36[41.7%] had abnormal pHR. There was no statistical significant difference between patients with congestive gastropathy and abnormal reflux and those without [P >0.05]. Regarding the severity of the disease as assessed by Child Pugh classification, 13 patients out of 37[35.1%] with Child's A, 5 patients out of 12[41.7%] with Child's B and 7 patients out of 16[43.8%] with Child's C had abnormal pHR. There was no statistical significant difference between patients with Child's A and those with Child's B and Child's C [P>0.05 respectively] as regards presence of abnormal reflux. As for ascites, 12 of them out of 28[42.9%] patients presented with an abnormal pHR and 13 patients out of 37 [35.1%] without ascites had abnormal pHR. Abnormal reflux was not statistically significantly different between patients with ascites and those without ascites [P>0.05]. Also, no statistical significant difference was found between patients with severe ascites and those with mild and moderate degrees of ascites [P>0.05 Respectively]. Thirty five patients [53.8%] had typical reflux symptoms, 19 of them [54.3%] presented with abnormal pHR and 6 out of 30 [20%] patients without typical reflux symptoms, had abnormal pHR. There was a statistically significant difference between patients with typical reflux symptoms and abnormal reflux and those without typical reflux symptoms [P< 0.05]. Regarding the lower esophageal sphincter [LES] pressure, there was no statistical significant difference in the mean levels of the LES pressure between neither the various degres of severity of the disease[as assessed by Child's A, B and C], the degree of ascites, the grades of EV nor the presence of normal and abnormal reflux [P>0.05 Respectively]. The prevalence of abnormal gastroesophageal reflux was high [38.5%] in patients with hepatic cirrhosis and esophageal varices. Only typical gastroesophageal reflux disease symptoms predicted these findings

Study of gastroesophageal reflux in cirrhotic patients with esophageal varices and without endoscopic treatment

The aim of this work is to study prevalence of abnormal gastroesophageal reflux [GER] by pH recording in cirrhotic patients with esophageal varices and without previous endoscopic treatment and its possible predicting factors. Sixty five patients [38 men, 27 women] with liver cirrhosis, were selected from those admitted at the Internal Medicine Department of Benha University Hospitals. Their ages ranged from 38 to 59 years [with a mean age of 54.4 +/- 10.5 years]. Diagnosis of liver cirrhosis was based on clinical laboratory, abdominal ultrasonographic image and histological findings. All patients had esophageal varices confirmed by endoscopy and were submitted to a questionnaire about typical gastroesophageal reflux disease symptoms [heartburn and or acid regurgitation]. pH recording was performed with the probe placed 5 cm above the superior lower esophageal sphincter limit as determined by manometry. Abnormal pH reflux [pHR] was defined as percentage total time with pH < 4 was greater than 4.5%. The pH recording demonstrated abnormal pHR in 25 patients [38.5%]: 6 [24%] just in upright position, 9 [36%] in supine position and 10 [40%] in both positions. Regarding the caliber of the esophageal varices [EV], 15 patients [44.1%] out of 34 with small size varices, 6 patients [31.6%] out of 19 patients with medium size varices and 4 patients [33.3%] out of 12 patients with large size varices, had abnormal pHR. There was no statistical significant difference between patients with small variceal size and abnormal reflux and those with medium and large variceal sizes [P> 0.05 respectively]. As for patients with congestive gastropathyt 10 of them [34.5%] out of 29 had abnormal pHR and 15 patients [41.7%] without congestive gastropathy out of 36 had abnormal pHR. There was no statistical significant difference between patients with congestive gastropathy and abnormal reflux and those without [P >0.05]. Regarding the severity of the disease as assessed by Child Pug classification, 13 patients [35.1%] out of 37 patients with Child's A, 5 patients [41.7%] out of 12 with Child's B and 7 patients [43.8%] out of 16 with Child's C had abnormal pHR. There was no statistical significant difference between patients with Child's A and abnormal reflux and those with Child's B and Child's C [P>0.05 respectively]. As for ascites, 12 of them [42.9%] out of 28 patients presented with an abnormal pHR and 13 patients [35.1%] oat of 37 patients without ascites had abnormal pHR. There was no statistical significant difference between patients with ascites and abnormal reflux and those without ascites [P>0.05]. Also, no statistical significant difference was found between patients with severe ascites and abnormal reflux and those with mild and moderate degree of ascites [P>0.05 respectively].Thirty five patients [53.8%] had typical reflux symptoms, 19 of them [54.3%] presented with abnormal pHR and 6 [20%] out of 30 patients without typical reflux symptoms, had abnormal pHR. There was a statistical significant difference between patients with typical reflux symptoms and abnormal reflux and those without typical reflux symptoms [P< 0.05]. Regarding the lower esophageal sphincter [LES] pressure, there was no statistical significant difference in the mean levels of the LES pressure between neither the severity of the disease [as assessed by Child's A, B and C], degree of ascites, grades of EV nor the normal and abnormal reflux disease [P>0.05 respectively]. The prevalence of abnormal gastroesophageal reflux was high [38.5%] in patients with hepatic cirrhosis and esophageal varices. Only typical gastroesophageal reflux disease symptoms predicted these findings. Long-term ambulatory follow-up of this group of patients is important since, if the "erosive" theory holds true, patients with abnormal reflux could present a higher incidence of variceal bleeding. This, however, needs to be demonstrated

Study of serum and ascitic fluid procalcitonin levels in cirrhotic patients with and without spontaneous bacterial peritonitis: diagnostic value and relationship to C-reactive protein

The aim of this work is to study the serum and ascitic fluid levels of C-reactive protein [CRP] and procalcitonin [PCT] in cirrhotic patients with and without spontaneous bacterial peritonitis [SBP] to assess their predictive value in the diagnosis and the severity of the infection. Ninety patients with decompensated liver cirrhosis were selected from those admitted to Internal Medicine Department of Benha University Hospitals. Their ages ranged from 47 to 67 years [with a mean age of 55 +/- 9.2]. They were classified into 2 groups: Group I: included 45 patients with decompensated liver cirrhosis and SBP and Group II: included 45 patients with decompensated liver cirrhosis without SBP who served as a control group. The diagnosis of SBP was based on the presence of an ascitic fluid polymorphonuclear leukocyte count >250 cells/mm[3] and/or positive ascitic fluid cultures, in the absence of clinical and laboratory evidence suggesting secondary peritonitis. The mean levels of CRP concentrations were higher both in serum and in ascitic fluid in patients with SBP compared to those without SBP [88.4 +/- 61.3 vs. 19.7 +/- 18.4 mg/I and 25.7 +/- 24.3 vs. 4.6 +/- 5.2 mg/I, P< 0.001, respectively]. The mean levels of PCT concentrations in both serum and in ascites were significantly higher in patients with SBP compared to those without SBP [2.14 +/- 0.4 vs. 0.3 +/- 0.2 ng/ml and 0.58 +/- 0.7 vs. 0.19 +/- 0.1 ng/ml, P< 0.001, respectively]. For the diagnosis of SBP, the PCT in the serum with a cut-off value of 0.76 ng/ml had a sensitivity of 94% and a specificity of 97%, in comparison to sensitivity/ specificity of serum CRP and PMNs [64/93% and 59/91%, with a cut-off value of 60 mg/I and 8400/mm[3] respectively]. Interestingly, the ascitic fluid PCT, with a cut-off value of 0.3 ng/ml, had a high sensitivity [92%] and specificity [87%] in comparison to sensitivity/ specificity of aseitic fluid CRP and PMNs [82/83 and 84/86 with a cut-off value of 22 mg/I and 250/mm[3], respectively]. No correlation was found between PCT and CRP nor between PCT and PMNs in serum nor aseitic fluid [P > 0.05, respectively]. Multiple regression analysis on the biological data showed that serum PCT was the only independent predictor of SBP [P<0.05]. The mean PCT and CRP serum levels were significantly more elevated in septic shock [4.2 +/- 0.3 ng/ml and 99.1 +/- 13 mg/I than in sepsis [1.4 +/- 0.1 ng/ml and 84.2 +/- 9mg/I] and severe sepsis [2.5 +/- 0.2 ng/ml and 91.2 +/- 11mg/I] [P <0.05 and P< 0.001, respectively]. It is concluded from this study that serum PCT level may have a predictive value for the diagnosis of SBP in cirrhotic patients. Also, our data showed that PCT may he used not only as a marker of infection, but, more importantly, as a good marker for the severity of infection. Further studies are recommended on a bigger number of patients with SBP to obtain more convincing results. Also further studies are needed to illustrate the role of PCT in the detection of infection especially in immuno-suppressed patients

Study of atrial natriuretic peptide in patient with bronchial asthma and chronic obstructive pulmonary diseases

The present study was carried out to study the changes in plasma atrial natriuretic peptide [ANP] in asthmatic children and in cases with chronic obstructive pulmonary disease [COPD] and to correlate these changes with the ventilatory and cardiac functions in the COPD group. About 105 subjects were selected from Pediatric and Chest Departments, Benha University Hospital. They were classified into 20 asthmatic children [Group A[1]], who were reinvestigated 4 weeks after treatment [Group A[2]]. Their age ranged from 1.5 to 11 years old. This group of patients was compared with 15 healthy children matched for the same ages and sex. Another 60 patients with COPD were subclassified into 3 subgroups. Subgroup I: included 20 cases on hospital admission with acute infective exacerbation [subgroup la], those cases were reinvestigated 6 weeks after medical treatment [subgroup Ib]. Subgroup II included 20 patients with COPD cor-pulmonale and right-sided heart failure. Subgroup III: included 20 patients with COPD without cor-pulmonale. Their age ranged from 40 to 74 years old. This group of patients were compared with 10 healthy subjects matched for the same ages and sex. For all groups, plasma ANP was done while ventilatory functions and echocardiography was done for COPD group only. The main results of this study, showed that plasma ANP was significantly elevated in asthmatic children compared with the control group but, it was significantly higher in subgroups A[1] in comparison to subgroup A[2]. In the COPD group, ANP was significantly elevated in all subgroups. The highest level in subgroup la, the lowest level was in subgroup III. ANP was significantly elevated in subgroup II in comparison to Ib and III subgroups. Also, ANP was correlated with mean pulmonary artery pressure [PAP], surface area of right atrium [RASA], right atrial diameter [RAD], right ventricular diameter [RVD] and right ventricular anterior wall [RVAW] diameter. The decrease of ANP in subgroup Ib was associated with improvement in the ventilatory and cardiac functions. We could conclude that; ANP was elevated and correlated with the severity of the disease in both asthmatic and COPD cases. Also, it was correlated with the degree of PAP, right atrial and right ventricular dimensions. So, ANP may give a new meaning in the future for the treatment of both asthmatic and COPD cases