ABSTRACT
A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.
Subject(s)
Bile Duct Neoplasms , Cholangiocarcinoma , Klatskin Tumor , Humans , Klatskin Tumor/therapy , Klatskin Tumor/surgery , Treatment Outcome , Hepatectomy/methods , Bile Duct Neoplasms/diagnosis , Bile Duct Neoplasms/therapy , Bile Duct Neoplasms/pathology , Cholangiocarcinoma/diagnosis , Cholangiocarcinoma/therapy , Bile Ducts, Intrahepatic/pathology , Cholangiopancreatography, Endoscopic Retrograde , DrainageABSTRACT
Approximately one half of patients develop ascites within 10 years of diagnosis of compensated cirrhosis. It is a poor prognostic indicator, with only 50% surviving beyond two years. Mortality worsens significantly to 20% to 50% at one year if the ascites becomes refractory to medical therapy. Pakistan has one of the highest prevalence of viral hepatitis in the world and patients with ascites secondary to liver cirrhosis make a major percentage of both inpatient and outpatient burden. Studies indicate that over 80% of patients admitted with ascites have liver cirrhosis as the cause. This expert opinion suggests proper assessment of patients with ascites in the presence of underlying cirrhosis. This expert opinion includes appropriate diagnosis and management of uncomplicated ascites, refractory ascites and complicated ascites (including spontaneous bacterial peritonitis (SBP) ascites, hepatorenal syndrome (HRS) and hyponatremia. The purpose behind this expert opinion is to help consultants, postgraduate trainees, medical officers and primary care physicians optimally manage their patients with cirrhosis and ascites in a resource constrained setting as is often encountered in a developing country like Pakistan.
Subject(s)
Esophageal and Gastric Varices , Gastrointestinal Hemorrhage , Practice Guidelines as Topic , Disease Management , Esophageal and Gastric Varices/diagnosis , Esophageal and Gastric Varices/therapy , Gastrointestinal Hemorrhage/diagnosis , Gastrointestinal Hemorrhage/therapy , Humans , Varicose VeinsABSTRACT
OBJECTIVE: To determine the efficacy of 12 weeks therapy with conventional interferon and ribavirin in chronic hepatitis C genotype 2 and 3 naive patients. STUDY DESIGN: A randomized clinical trial. PLACE AND DURATION OF STUDY: Postgraduate Medical Institute, Lady Reading Hospital, Peshawar, from January 2005 to October 2006. METHODOLOGY: Two hundred and twenty seven patients with chronic hepatitis C genotype 2 or 3 naive patients were enrolled in the study. All the patients were started on conventional Interferon 3 MIU, S/C, three times a week plus Ribavirin 800 to 1200 mg in divided doses daily. HCV-RNA qualitative PCR was determined after 4 weeks. In case of undetected PCR, patients were randomized to Group-I (where antiviral therapy was given for 12 weeks, n=81) or Group-II (where antiviral therapy was given for 24 weeks, n=81). In case of detected PCR, patients were given 24 weeks antiviral therapy, n=65 (Group-III). HCV-RNA PCR was determined at the end of respective therapies and after 6 months later on. Efficacy was defined as number of patients who achieved Sustained Virological Response (SVR) i.e. HCV-RNA PCR remained undetected 6 months after the end of antiviral therapy. RESULTS: SVR was achieved in 66 patients (81.48%) in Group-I, 64 patients (79.01%) in Group-II, and 49 patients (75.35%) in Group-III. SVR rate was better in genotype 2 than genotype 3 in all the three groups (p=0.031, OR = 1.52). CONCLUSION: Conventional Interferon and Ribavirin combination therapy remains an effective therapy in chronic hepatitis genotype 2 and 3 naive patients in our region. Determination of HCV-RNA qualitative PCR at 4 weeks seems to be an important predictor of SVR and should be used to tailor antiviral therapy to 12 or 24 weeks.
