Outcome of Endoscopic Management of Post Living Donor Liver Transplant Anastomotic Strictures.

OBJECTIVE: To evaluate the therapeutic efficacy of endoscopic dilatation of anastomotic stricture (AS). STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, Pakistan from November 2016 to November 2017. METHODOLOGY: Patients presenting with anastomotic biliary stricture following living donor liver transplant (LDLT) underwent endoscopic retrograde cholangio-pancreaticography (ERCP) and treatment of their strictures with dilatation with or without stenting. The patients were then followed up to see adequate resolution of stricture and repeat therapeutic ERCP was performed, if required. The patients were labelled as cured if stricture resolution persisted for a period of up to six months following ERCP. RESULTS: Forty-three patients (32 males and 11 females), with post-LDLT AS, who met the inclusion and exclusion criteria were enrolled in the study. Thirty-six (83.7%) patients had a single biliary anastomosis while seven (16.3%) patients had two anastomoses. Ductoplasty was done in 15 (34.9%) of the enrolled patients. Patients with post-LDLT AS required 3.65 +1.15 sessions of ERCP. Plastic type biliary stent was used in seven (16.3%) patients, balloon dilatation alone was done in five (11.6%) patients and combined balloon dilatation and stent placement was performed in 29 (67.4%) patients, and combined graduated dilator and stent placement was performed in two (4.7%) patients. Five (11.6%) patients required rendezvous procedure (whereby a radiologist placed a guidewire percutaneously into the biliary system) as guidewire placement across stricture site was endoscopically unsuccessful. The overall success rate was 88.4%. Mean stent free follow-up was 7.18 +1.38 months. Recurrence of AS was noted in one (2.3%) patient. CONCLUSION: Endoscopic management of post-LDLT AS has an efficacious long-term outcome.

L-ornithine-L-aspartate infusion efficacy in hepatic encephalopathy.

OBJECTIVE: To determine the efficacy of L-ornithine-L-aspartate in treatment of hepatic encephalopathy. STUDY DESIGN: Randomized, placebo-controlled trial. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from February to August 2005. METHODOLOGY: Cirrhotic patients with hyperammonemia and overt hepatic encephalopathy were enrolled. Eighty patients were randomized to two treatment groups, L-ornithine-L-aspartate (20 g/d) or placebo, both dissolved in 250 mL of 5% dextrose water and infused intravenously for four hours a day for five consecutive days with 0.5 g/kg dietary protein intake at the end of daily treatment period. Outcome variables were postprandial blood ammonia and mental state grade. Adverse reactions and mortality were also determined. RESULTS: Both treatment groups were comparable regarding age, gender, etiology of cirrhosis, Child-Pugh class, mental state grade and blood ammonia at baseline. Although, improvement occurred in both groups, there was a greater improvement in L-ornithine-L-aspartate group with regard to both variables. Four patients in the placebo group and 2 in L-ornithine-L-aspartate group died. CONCLUSION: L-ornithine-L-aspartate infusions were found to be effective in cirrhotic patients with hepatic encephalopathy.

Predictive value of Rockall score for rebleeding and mortality in patients with variceal bleeding.

OBJECTIVE: To validate Rockall scoring system for in-hospital rebleeding and mortality in cirrhotic patients with variceal bleed. STUDY DESIGN: Cohort type of case series. PLACE AND DURATION OF STUDY: It was carried out at the Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from March 2005 to March 2006. PATIENTS AND METHODS: All cirrhotic patients presenting with upper GI bleeding and later found to have variceal source of bleeding on endoscopy were included. Clinical and endoscopic features were noted to calculate Rockall score. After giving appropriate pharmacological and endoscopic therapy, patients were followed for rebleeding or death till discharge from hospital. Linear regression analysis was used to determine predictive value of score and discrimination was evaluated by calculating the area under the receiver operating characteristic (ROC) curve. RESULTS: A total of 402 patients were included. Mean age was 52.57 (+/-11.39) and male to female ratio was 2:1(269/133). Esophageal varices were source of bleeding in 340 (84.5%), gastric fundal varix in 44 (11%) and ectopic duodenal varix in 3 (0.9%) patients. Both esophageal and gastric varices were present in 15 (3.6%) patients. In-hospital mortality was 6.7% while 22 (5.5%) patients had rebleeding. Rockall score was found to have good predictive value for mortality (p-value<0.001 and area under curve AUC 0.834) and in-hospital rebleeding (p-value<0.001 and AUC 0.798). CONCLUSION: Rockall scoring system has good predictive and discriminative value for in-hospital rebleeding and mortality in patients with variceal bleeding due to cirrhosis.

Serum alanine aminotransferase level and response to interferon-ribavirin combination therapy in patients with chronic hepatitis C.

OBJECTIVE: To determine the difference in sustained virological response to interferon-ribavirin combination therapy between patients with normal ALT and those with raised ALT in chronic hepatitis C. DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from February 2004 to June 2005. PATIENTS AND METHODS: Patients with positive HCV RNA by PCR and compensated liver disease were included and divided in two groups. One group with ALT below upper normal limit (UNL= 65U/L) and second group with raised ALT (> 1x UNL). After treatment with standard interferon alpha 2a and ribavirin, both groups were checked for sustained viral response (SVR) six months after end of treatment and compared for response to therapy with Chi square test. RESULTS: Of the 70 patients included, 25 had normal ALT (< 1 x upper normal limit UNL) and 45 had ALT above upper normal limit (> 1 x UNL). Of these, 63 patients completed treatment. Sustained viral response (SVR) was seen in 13 of 22 patients with normal ALT who completed therapy and 22 of 41 patients with raised ALT who completed treatment. Difference in SVR in two groups was not significant (p 0.679). When patients with raised ALT were sub-classified, significantly better response was seen in patients with ALT > or = 2 times the upper normal limit (p 0.021). CONCLUSION: Patients with normal baseline ALT respond equally well to combination therapy as is seen in patients with raised ALT.

Predictors of fatal outcome in fulminant hepatic failure.

OBJECTIVE: To determine prognostic indicators for morbidity and mortality in patients with fulminant hepatic failure. DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from April 2003 to June 2005. PATIENTS AND METHODS: Forty five patients with confirmed diagnosis of fulminant hepatic failure were included in this study. They were investigated for acute viral serology, complete blood count, liver function tests, renal function tests, serum electrolytes, arterial blood gases, initially daily and then on alternate days. Patients were followed in high dependency/ICU at the Shaikh Zayed Postgraduate Medical Institute. Data were analyzed by logistic regression analysis to identify predictors of mortality and morbidity. RESULTS: Of the 45 subjects, 31 were males and 14 females. Twenty four patients were positive for acute hepatitis E. Twenty patients recovered fully, whereas 25 died with mortality rate of 55.6 %. Variables i.e. presence of non-A non-B viral hepatitis, serum creatinine > 2.0 mg/dl, serum phosphate > 3.5 mg/dl and sepsis were found to have significant association with mortality on linear correlation. Only serum creatinine more than 2.0 mg/dl, serum phosphate > 3.5 mg/dl and development of sepsis were found to predict the outcome after multivariate analysis. CONCLUSION: Patients with serum creatinine > 2.0 mg/dl, serum phosphate > 3.5 mg/dl and sepsis showed adverse prognosis for survival.