Upper Gastrointestinal Bleeding among Patients Admitted in Department of Emergency in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Upper gastrointestinal bleeding is a common medical emergency with significant morbidity and mortality. Its causes can be classified under variceal bleeding or non-variceal bleeding. Peptic ulcer and variceal bleeding are common causes. Thus, this study aims to find the prevalence of upper gastrointestinal bleeding among patients attending the Department of Emergency in a tertiary care centre. Methods: This was a descriptive cross-sectional study conducted on patients admitted to the Department of Emergency a tertiary care centre from September 2020 to August 2021 among 3375 patients. The ethical approval was obtained from the Institutional Review Committee of the hospital (Reference number: 328). Patients presenting with the clinical features of upper gastrointestinal bleeding in the form of hematemesis or melena were enrolled after written informed consent. Data entry was done in Statistical Packages for the Social Sciences version 20.0. for descriptive analysis. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage for binary data. Results: Out of 3375 admissions in the Department of Emergency, 85 (2.52%) (1.99-3.05 at 95% Confidence Interval) patients presented with upper gastrointestinal bleeding. Conclusions: The prevalence of upper gastrointestinal bleeding is lower in comparison to other studies done in similar settings. Keywords: bleeding; emergency medicine; upper gastrointestinal tract; varices.

Urgent Endoscopic Retrograde Cholangiopancreatography (ERCP) vs. Conventional Approach in Acute Biliary Pancreatitis Without Cholangitis: An Updated Systematic Review and Meta-Analysis.

Gallstone disease is the common cause of acute pancreatitis. The role of early endoscopic retrograde cholangiopancreatography (ERCP) in biliary pancreatitis without cholangitis is not well-established. Thus, this study aims to compare the outcome of early ERCP with conservative management in patients with acute biliary pancreatitis without acute cholangitis. An online search of PubMed, PubMed Central, Embase, Scopus, and Clinicaltrials.gov databases was performed for relevant studies published till December 15, 2020. Statistical analysis was performed using RevMan v 5.4 (The Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen). Odds Ratio (OR) with a 95% confidence interval was used for outcome estimation. Among 2700 studies from the database search, we included four studies in the final analysis. Pooling of data showed no significant reduction in mortality (OR 0.59, 95% CI 0.32 to 1.09; p=0.09); overall complications (OR 0.56, 95% CI 0.30 to 1.01; p=0.05); new-onset organ failure (OR 1.06, 95% CI 0.65 to 1.75; p=0.81); pancreatic necrosis (OR 0.80, 95% CI 0.49 to 1.32; p=0.38); pancreatic pseudo-cyst (OR 0.44, 95% CI 0.16 to 1.24; p=0.12); ICU admission (OR 1.64, 95% CI 0.97 to 2.77; p=0.06); and pneumonia development (OR 0.81, 95% CI 0.40 to 1.65; p=0.56) by urgent ERCP comparing with conventional approach for acute biliary pancreatitis without cholangitis. Henceforth, early ERCP in acute biliary pancreatitis without cholangitis did not reduce mortality, complications, and other adverse outcomes compared to the conservative treatment.

Intravenous Ringers lactate versus normal saline for predominantly mild acute pancreatitis in a Nepalese Tertiary Hospital.

BACKGROUND: Acute pancreatitis (AP) is a common presentation in patients admitted with acute abdomen. Whether Ringers lactate (RL) or Normal Saline (NS) as a resuscitation fluid is better still remains unclear. The aim of this study is to compare the efficacy of RL and NS in terms of control of systemic inflammation by measuring indirect markers specifically Systemic Inflammation Response Syndrome (SIRS) scores and C- Reactive Protein (CRP) level. METHODS: This was an open label randomized trial conducted in a tertiary level hospital of Nepal. Ethical approval was obtained prior to the study. Patients with acute pancreatitis were randomized to either RL or NS group for the fluid resuscitation. The fluid was given as per the study protocol for three days for hydration. Baseline SIRS and CRP were recorded on admission and subsequently as defined. All the data were analyzed using SPSS ver 20.0 software. RESULTS: Total 51 patients were enrolled, 26 in RL and 25 in NS group. The commonest etiology of AP was alcohol (84.31%). SIRS was present in 46.2% and 64.0% of patients in RL and NS group respectively (p = 0.20) on admission. At least one SIRS criteria was still present in 44.0% of patients in the NS group compared to only 15.4% in the RL group after 24 hours (p = 0.025). The baseline CRP were comparable in both the groups. However after 72 hours, the increment of CRP was more in the NS group compared to the RL group; median value of 14.2 mg/dl (12.15, 16.45) and 22.2 mg/dl (18.20, 30.60) in RL and NS group respectively (p<0.001). CONCLUSIONS: Ringers lactate was associated with a reduction in systemic inflammation compared to normal saline in patients with acute pancreatitis. Incidence of SIRS at 72 hours and occurrence of local complications were however similar in both the groups.

Herpes simplex esophagitis in an immunocompetent host: a case report.

Esophagitis caused by Herpes Simplex virus is a well-recognized opportunistic infection in the immunocompromised or severely ill host. However, it is uncommon in otherwise immunocompetent host. It usually responds well to a course of acyclovir. We report a case of young female without any other immunocompromised state who presented with severe dysphagia. She was diagnosed endoscopically and later with histopathology and recovered well after a course of acyclovir.

Prevalence of Malnutrition in Patients with Liver Cirrhosis in A Tertiary Care Hospital.

INTRODUCTION: Cirrhosis of liver is a progressively deteriorating disease. Medical management consist of treatment and prevention of complications. Nutritional intervention to improve nutritional status of the malnourished patient has favorable impact on prognosis. Traditional measures of nutritional assessment like Body Mass Index and waist circumference are inaccurate. This study was conducted to study the prevalence of malnutrition in cirrhotic patients. METHODS: This was a descriptive cross-sectional study conducted at National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal. The study included 60 cirrhotic patients from outpatient department. Subjective Global Assessment was performed for all participants and level of malnutrition recorded. Height, weight, waist circumference, body mass index were measured and recorded. RESULTS: Among the cirrhotic patients, malnutrition was detected in 46 (76.66%) [68.38 to 85.94 at Confidence Interval 95%]. Out of 46 patients who were malnourished, 20 (43.47%) had mild to moderate malnutrition whereas 26 (56.53%) had severe malnutrition. The most common cause of cirrhosis was alcohol. The mean body mass index and mean waist circumference were within normal limits. CONCLUSIONS: Malnutrition is very common among cirrhotic patients and its prevalence increased from Child A to Child C status.

Factors Predicting Mortality of Acute Variceal Bleeding in Liver Cirrhosis.

INTRODUCTION: Acute variceal bleeding in liver cirrhosis is an immediate life-threatening condition and amajor complication of portal hypertension associated with higher morbidity, mortality and hospital costs than any other causes of UGI bleeding. Therefore, early stratification and initiation of therapy based on several factors can reduce mortality associated with it. We aimed to study the predictors of mortality in acute variceal bleeding in LC. METHODS: An observational prospective study was conducted in Gastroenterology and Hepatology units of Bir Hospital, Kathmandu, Nepal from April 1, 2016 to May 30, 2017. Patients were included if they had underlying liver cirrhosis and presented upper GI bleeding which were proven to be secondary to variceal bleeding. RESULTS: Seventy-five patients with mean age of 52.5 years were available or the analysis. The M:F ratio was 2.1:1. There were 66 patients in mortality group and 9 in survivor group. The mean CTP and MELD score were 10.17±1.66 and 20.40±8.29 respectively. Among the predictors of the mortality studied, CTP score, MELD score, mean arterial pressure, Serum bilirubin, serum creatinine, need of FFP as well as PRP transfusion, presence of hepatorenal syndrome and hepatic encephalopathy were high in mortality group with statistical significance. On multivariate analysis, high CTP and high serum creatinine level were only significant predictors of mortality. Receiver operating curve for predicting accuracy of mortality was significant with higher MELD and higher CTP score. CONCLUSIONS: Strong predictors of mortality in patients with cirrhosis presenting with variceal bleeding are CTP score and high serum creatinine level.