Effect of adding daclatasvir in sofosbuvir-based therapy in genotype 3 hepatitis C: real-world experience in Pakistan.

OBJECTIVE: To determine real-world effect of adding daclatasvir (DCV) to chronic hepatitis C treatment by comparing sustained viral response of sofosbuvir (SOF)/DCV±ribavirin (RBV) and SOF+RBV combination in patients with genotype 3 hepatitis C. PATIENTS AND METHODS: Patients with chronic hepatitis C, genotype 3, presenting at the DHMC Hepatology Clinic from October 2014 till March 2018 were treated initially with 6 months of SOF/RBV, and once DCV was available, with SOF/DCV±RBV for 3 or 6 months. Negative hepatitis C virus RNA by PCR, sustained viral response 12 weeks after treatment (SVR12), was the primary end point for per-protocol analysis. RESULTS: The mean age of the 440 enrolled patients was 51.04 (±11.9) years, and male to female ratio was 0.97/1 (217/223). Liver cirrhosis was present in 260 (59.1%) patients, and 89 (20.2%) had decompensated liver disease. Treatment-experienced patients were 124 (28.2%). We included 398 (90.4%) patients with completed follow-up in final analysis, excluding either dropped out, failed to complete therapy or died during follow-up. SVR12 was achieved in 366 (91.9%), being significantly lower (P=0.001) in patients with cirrhosis at 89.9% (205/228), and even lower SVR12 (P=0.006) in decompensated cirrhosis at 87.01% (67/77). SVR12 was also inferior (P=0.005) in treatment experienced patients at 85.8% (97/113) than treatment-naive patients at 94.3% (269/285). Among 285 patients treated with SOF/RBV, SVR12 was achieved in 264 (92.6%), which is not significantly different from SVR12 with SOF/DCV±RBV at 90.2% (102/113) (P=0.57). CONCLUSION: In patients with chronic hepatitis C genotype 3, SOF/RBV and SOF/DCV±RBV have similar sustained viral response, and patients with liver cirrhosis and past treatment experience have suboptimal response in Pakistan.

Cephalosporin resistance in community acquired spontaneous bacterial peritonitis.

OBJECTIVE: To determine 3rd generation cephalosporin resistance in patients with community-acquired spontaneous bacterial peritonitis (SBP) using early response assessment. METHODS: This prospective quasi-experimental study was carried out at Doctors Hospital & Medical Center from January 2016 to September 2018. Patients with cirrhosis and SBP were included. Third generation cephalosporins i.e. cefotaxime/ceftriaxone were used for treatment of SBP. Response after 48 hours was assessed and decline in ascitic fluid neutrophil count of < 25% of baseline was labelled as cephalosporin resistant. Carbapenem were used as second line treatment. Recovery and discharge or death of patients were primary end points. RESULTS: Male to female ratio in 31 patients of SBP was 1.2/1 (17/14). Hepato-renal syndrome was diagnosed in 11(37.9%) patients. Cefotaxime was used for 16(51.6%) patients whereas ceftriaxone for 15(48.3%) patients. Early response of SBP was noted in 26(83.8%) patients while 5 (16.2%) were non-responders to cephalosporins. SBP resolved in all non-responding patients with i/v carbapenem. In-hospital mortality was 12.9% and had no association with cephalosporin resistance. High bilirubin (p 0.04), deranged INR (p 0.008), low albumin (p 0.04), high Child Pugh (CTP) score (p 0.03) and MELD scores (p 0.009) were associated with in-hospital mortality. CONCLUSION: Cephalosporin resistance was present in 16.2% of study patients with community-acquired SBP. Mortality in SBP patients is associated with advanced stage of liver disease.

Pneumatic Balloon Dilatation for Achalasia Cardia; Early & late results, a single center study.

OBJECTIVE: Achalasia Cardia is treated by Pneumatic balloon dilatation, Heller's Myotomy and recently, by Peroral Esophagaeal Myotomy. This study reports the efficacy of pneumatic balloon dilatation as a non-surgical motility in achieving relief of dysphagia, clinical improvement and recurrence. Long-term complications were reported. METHODS: Eight hundred ninety two adult achalasia patients of both genders were treated from January 1988 till December 2011, with pneumatic balloon (Rigiflex Microvasive®) dilatation, under fluoroscopy Barium swallow was obtained prior to and five minutes after dilatation to evaluate for efficacy of dilatation as well as for complications. Patients not responding to 30 mm balloon had repeat dilatation with 35 mm balloon after 8 weeks. All patients were enrolled in regular follow up at one, six months and yearly intervals up to a period of five years. Recurrence was defined as an increase in symptom score at 8 weeks greater than 50% of their baseline value. These patients were treated with 35 mm balloon or referred for surgical intervention. RESULTS: Of 892 patients, follow up was obtained in 50% for 5 years, 9.2% for 4-years), 9.3% for 3-years, 10% for 2-years and 21.5% for 1-year of patients. One patient died after repeat dilatation. Eighty-eight patients were excluded from this analysis (20 died due to non-procedure related causes and another 68 were lost during follow up). Statistically significant improvement was noted in reduction in height and width of barium column and symptom score coupled with weight gain during follow up. Forty-eight patients were subjected to repeat dilatation with 35 mm balloon, two of these developed post-procedure perforations with one mortality. Three non-responsive patients required surgical laparoscopic myotomy. No carcinoma of esophagus was reported during follow up. One patient post dilatation, developed esophageal bezoar. A single pneumatic dilatation achieved a remission rate of 93% at four years, 90% at three years, 95% at two years and 92% at one year post dilatation. CONCLUSION: Achalasia of esophagus can be effectively and safely treated with balloon dilatation to achieve adequate short and long-term symptomatic relief with a low complication rate.

Sofosbuvir based therapy in hepatitis C patients with and without cirrhosis: Is there difference?

OBJECTIVE: To compare sustained viral response to sofosbuvir/ribavirin ±interferon therapy in patients of hepatitis C with and without liver cirrhosis. METHODS: This observational study of chronic hepatitis C patients was carried out at Doctors Hospital and Medical Center (DH&MC). After diagnostic workup, Sofosbuvir/ribavirin for 24 weeks or sofosbuvir/ribavirin/pegylated interferon for 12 weeks were prescribed. Primary outcome was negative HCV RNA by PCR 12 weeks after treatment completion (SVR12). Chi square χ2 and student's t test were used to analyze data. RESULTS: Of 216 patients included, liver cirrhosis was present in 112 (51.9%) patients and 69(31.9%) were treatment experienced. Liver disease was decompensated in 37 (17.1%) patients. Of 206 patient who completed study protocol, 173(83.1%) achieved SVR12, 89.2% (25/28) with triple therapy and 82.2% (148/180) with sofosbuvir/ribavirin therapy. Treatment response was similar between treatment naïve 86.2% (119/138) and treatment experienced 79.4% (54/68) patents. (p value 0.19) SVR12 was inferior in cirrhosis patients 75.4% (80/106) as compared to those with no cirrhosis 93% (93/100) (p value < 0.000). It was even lesser in those with decompensated liver disease 68.8% (24/35) (p value < 0.000). CONCLUSION: Treatment outcome with sofosbuvir/ribavirin combination therapy in cirrhosis patients is suboptimal especially in those with decompensation as compared to patients without liver cirrhosis.

AAA Syndrome, Case Report of a Rare Disease.

Triple A (Allgrove) syndrome, an autosomal recessive disease is characterized by achalasia, alacrimia and ACTH-resistant adrenal failure with progressive neurological syndrome including central, peripheral and autonomic nervous system impairment, and mild mental retardation. The triple A syndrome gene, designated AAAS, localized on chromosome 12q 13 encodes for a 546 amino acid protein called ALADIN (Alacrimia-Achlasia-Adrenal Insufficiency and Neurologic disorder). This report relates to two sisters, aged 8 and 12 years, who had vomiting, muscle weakness, alacrimia, excessive fatigue and dysphagia. Abdominal sonography, esophago-gastroduodenoscopy, barium swallow, esophageal manometry, CT scan abdomen and brain, biochemical profiles, as well as neurologic and ophthalmic evaluations were consistent with Allgrove's syndrome. Management consisted of pneumatic balloon dilatation for achalasia and initiation of cortisone therapy with successful resolution of dysphagia and other symptoms.

Hepatorenal syndrome:Response to terlipressin and albumin and its determinants.

OBJECTIVE: To determine the efficacy of terlipressin and albumin in improving renal functions in patient with hepatorenal syndrome (HRS) and to identify factors determinant of better response. METHODS: In this quasi experimental interventional study patients of liver cirrhosis and ascites with HRS type I were treated with intravenous albumin and incremental dosage of terlipressin based on response with maximum dose of 12mg/day. Decline of creatinine below 1.5mg/dl was defined as complete response. Factors predictive of response to therapy were determined via linear regression analysis. RESULTS: Twenty four patients were included with male to female ratio 3.8/1(19/5) and mean age 53.3 (±10.06). Complete response to terlipressin/albumin was seen in 14 (58.3%)patients, seven (29.2%) achieved partial response with > 25% creatinine decline while three (12.5%) had no response. Lower serum creatinine at diagnosis (P value 0.003), absence of hyperkalemia (p value 0.005) and absence of portal vein thrombosis (p value 0.05) are associated with response to treatment in HRS. Baseline serum creatinine (p value 0.003) was independent predictor of response to therapy in multivariate analysis. CONCLUSION: Terlipressin and albumin is an effective treatment for HRS type I. Patients with lower baseline serum creatinine are more likely to respond to this therapy.

Response Guided Interferon Therapy for Genotype 3 of Chronic Hepatitis C: Compliance and Outcome.

OBJECTIVE: To determine compliance and improvement in sustained viral response (SVR) by following response guided therapy (RGT) plan of interferon and ribavirin, for genotype 3 in chronic hepatitis C. METHODS: Patients with chronic hepatitis C genotype 3, who were eligible for interferon-ribavirin therapy and consented for RGT, were included. Those with no rapid viral response (RVR), having coarse echotexture of liver or undergoing re-treatment, were advised 48 week treatment whereas, rest had 24 week standard therapy. PCR for HCV RNA checked 6 months after discontinuing treatment, was the primary end point of study. RESULTS: Of 154 patients, included in the study with mean age of 39.9 (±10.84) and male to female ratio 1.4/1 (94/60), majority of patients, 136 (88.4%) were treatment naïve whereas, 18 (11.6%) were being retreated. On ultrasound, 63 (40.9%) patients had coarse liver and 33 (21.4%) had splenomegaly. RVR was achieved in 99 (64.3%) patients. Overall 66(42.8%) patients merited extended duration of therapy as per RGT plan but only 22 (33%) were compliant. Treatment related side effects were the dominant reason for declining RGT in 33 (75%) patients. SVR was noted in 111 (72.1%) patients. Those patients with extended therapy (RGT), had SVR 90.9% (20/22), although, better but statistically not significant than those who stopped therapy at 6 months 77.2% (34/44) (p value 0.11). CONCLUSION: Response guided therapy plan did not improve SVR to pegylatedinterferon and ribavirin therapy in patients with genotype 3 and it has low patient compliance due to treatment related side effects.

Predicting Prognosis in Hepatocellular Carcinoma: Comparison of Staging Systems in Pakistani Cohort.

OBJECTIVE: To determine the clinical, biochemical and radiological prognostic indicators and to compare the performance of six staging systems in patients of hepatocellular carcinoma (HCC). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Gastroenterology, Doctors Hospital, Lahore, from October 2007 to December 2013. METHODOLOGY: Patients with HCC were included. Baseline clinical, hematological and radiological variables were noted. Patients were followed for 5 years or till death. Survival predictors were identified using Cox proportional hazard analysis and 6 prognostic staging systems were evaluated by determining homogeneity, discriminatory ability and monotonicity. RESULTS: Of the 228 patients included, male to female ratio was 2.6/1 (165/63) and mean age was 56.5 ±10.4 years. Majority of patients 189 (82.9%) were anti-HCV positive. Solitary HCC lesion was seen in 121 (53.1%) patients, 16 (7%) had 2 lesions while 73 (32%) had 3 or more lesions. Only 36 (15.8%) patients had palliative therapy for HCC. Survival rate was 45.2%, 25%, 12.3%, 7%, 2.2% and 1% for 6 months, 1, 2, 3, 4 and 5 years respectively. Male gender, portal vein thrombosis, serum albumin < 3.5 g/dl, tumor size ≥6 cm and alpha fetoprotein (AFP) ≥147 U/ml were bad prognostic indicators. OKUDA, GRETCH and early stages of CLIP had better homogeneity while CLIP showed superior discriminatory ability and monotonicity for predicting survival. CONCLUSION: Male gender, presence of portal vein thrombosis, low serum albumin, large tumor size and high AFP level are poor prognostic indicators in patients of HCC. CLIP has better performance in predicting mortality.

16 Y/O Female with "Watermelon Stomach"?

Background. Gastric antral vascular ectasia (GAVE) also known as "watermelon stomach" (WS) is an uncommon cause of gastrointestinal (GI) blood loss. It typically presents in middle aged females. We are presenting a case of GAVE at an unusually early age with atypical symptoms. Case. A previously healthy 16 y/o Caucasian female presented to the ER with a one-month history of upper abdominal pain. Physical examination was benign except tenderness in the epigastric region. There were no significant findings on laboratory data. Upper endoscopy showed incidental findings of linear striae in the antrum indicative of GAVE but histology was equivocal. Discussion. GAVE is a poorly understood but treatable entity and an increasingly identifiable cause of chronic iron deficiency anemia or acute or occult upper GI bleeding. The pathophysiology of GAVE remains unclear. It is an endoscopic finding characterized by longitudinal columns of tortuous red ectatic vessels (watermelon stripes), pathognomonic for WS. Treatment options include endoscopic, pharmacologic, and surgical approaches. Failure to recognize GAVE can result in delayed treatment for years. Our patient with GAVE was unusually young and was diagnosed incidentally. Due to lack of anemia on laboratory examination we elected to monitor her clinically for any future development of anemia.

COMPARISON OF SINGLE VERSES MULTIPLE SESSION BAND LIGATION FOR THE TREATMENT OF BLEEDING OESOPHAGEAL VARICES.

BACKGROUND: Cirrhosis of liver is the leading cause of portal hypertension in this part of the globe. Around thirty percent of the patient with portal hypertension develops complications. Oesophageal variceal bleeding is a serious complication of portal hypertension. Oesophageal variceal band ligation (EVBL) has become the standard of care for patients with bleeding oesophageal varices. Multiple sessions of band ligation are cumbersome and expensive. METHODS: Sixty patients with acute variceal bleed were enrolled in this randomized control trial. Patients were randomly assigned to multi-session (group A) or single session (group B) oesophageal variceal band ligation group. All. patients were followed for re-bleeding and mortality up to three months. RESULTS: Re-bleeding occurred (20%) in group A and (17%) in group B patients, respectively. Mortality was 10% in group A and 7% in group B patients. Variceal obliteration was better in group A 63% than group B 24% (p<0.05). CONCLUSION: Single session band ligation was comparable for rates of re-bleeding and mortality to multi-session band ligation.

Frequency of depression and somatic symptoms in patients on interferon alpha/ribavirin for chronic hepatitis C.

BACKGROUND: Large numbers of patients suffering from Chronic Hepatitis C (HCV) are seeking treatment with interferon alpha (IFN) because of significant advances in overall improvement in the course of HCV and its complications. Objectives were to estimate the frequency of depression and somatic symptoms in patients on interferon alpha/ribavirin treatment for chronic hepatitis C. METHODS: It was an observational study conducted in the out-patient Department of Gastroenterology Shaikh Zayed Hospital, Lahore during a period of three months, i.e., from September to November 2008. One hundred consecutive patients undergoing interferon alpha/ ribavirin treatment for chronic HCV were included in the study. All patients, irrespective of age, sex or duration of treatment were administered with a check list of common physical complaints and DSM-IV symptoms for Major Depressive Episode. RESULTS: Out of a total of 100 subjects 37 were male and 63 were female. In all, 39 (39%) patients fulfilled the diagnostic criteria of DSM-IV for Major Depressive Episode. Major Depression was more common in female 28 (44.4%) as compared to male 11 (28.7%) patients. Somatic symptoms were common in all the patients but they were reported more frequently by patients with Major Depression compared to those without Major Depression. Myalgias, headache, joint pain, nausea/vomiting, abdominal pain and palpitation were the most common physical symptoms. CONCLUSION: Major Depression and somatic complaints are a common consequence of interferon alpha/ribavirin treatment for chronic hepatitis C. All patients receiving this treatment should be periodically assessed for the detection of these side effects to promptly address relevant treatment options.

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding.

OBJECTIVE: To compare the efficacy of propranolol, propranolol with nitrate, band ligation, and band ligation with propranolol and nitrate for the prevention of esophageal variceal rebleeding. STUDY DESIGN: A prospective randomized trial. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from November 2003 to July 2005. METHODOLOGY: One hundred and sixty cirrhotic patients with esophageal variceal bleeding were randomized to four treatment groups (propranolol, propranolol plus isosorbide mononitrate, band ligation, band ligation plus propranolol and nitrate) with 40 patients in each group. Patients were followed for 6 months after the enrolment of last patient. Primary end points were recurrence of esophageal variceal bleeding and death. Treatment complications were noted. RESULTS: Four treatment groups were comparable regarding baseline characteristics. Esophageal variceal rebleeding occurred in 22% patients in band ligation plus drugs group, 26% patients in drug combination group, 31% patients in banding group and 38% patients in propranolol group (p=0.41). Difference in mortality rates was also not significant. CONCLUSION: There was no significant difference between treatment groups in prevention of esophageal variceal rebleeding.

Efficacy of argon plasma coagulation in gastric vascular ectasia in patients with liver cirrhosis.

OBJECTIVE: To determine the efficacy of Argon Plasma Coagulation (APC) in terms of improvement in hemoglobin level and disappearance of telangiectasia as endoscopic treatment for Gastric Antral Vascular Ectasia (GAVE) and Diffuse Antral Vascular Ectasia (DAVE) syndrome in liver cirrhosis. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology of Shaikh Zayed Hospital/ Federal Postgraduate Medical Institute, Lahore, from January, 2006 to July, 2007. METHODOLOGY: Cirrhotic patient with gastric vascular ectasia were enrolled and followed-up for 18 months with repeated sessions of APC. Efficacy of APC was evaluated on the basis of patient's symptoms, transfusion requirements and hemoglobin levels. APC was performed by using ERBE generator set at 60 W and flow rate 2.0 L/min using primarily endfiring probes. RESULTS: Fifty patients were enrolled in the study. Mean age was 55.78+1.24 years with 32 males and 18 females giving a male to female ratio 1.7:1. Forty two patients were in Child's Class C and 8 in Child's Class B. Presenting complaints were malena and anemia. Two hundred and fifty three APC sessions were carried out; mean 5.06+1.5 sessions per patient. Mean follow-up period after the last session was 8.5+3.7 months. Mean increase in the hemoglobin level was 1.35+0.24 g/dl. There was no death of any patient during the study period. CONCLUSION: Treatment with APC is an effective and safe method to decrease blood loss in patients with GAVE and DAVE.

Interferon-ribavirin treatment in chronic hepatitis C--the less talked about aspects.

BACKGROUND: Combination therapy with interferon and ribavirin has become the standard of care in the treatment of Chronic Hepatitis C (CHC) infected patients. Treatment response, however, is not 100% and is accompanied with side effects faced by the patient as well as observed in haematologic indices. Studies are focusing on daily or high-dose induction therapy with interferon, the titration of interferon dosing to initial viral load, higher doses of interferon throughout treatment, and adjustment of interferon dosing to the viral responses. The safety and efficacy of these approaches have not been sufficiently established. Objectives were to see the response of 2 different dosage regimens, effects and side effects and to assess the efficacy and side effects of 2 treatment regimens of Interferon and Ribavirin in CHC. METHODS: A total of 32 patients with CHC at Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute Lahore from June 2001 to February 2003 were included in the study and were divided into two groups for treatment. Group A (14 patients) received 5 MU of injection Interferon alpha 2 b S/C daily for 2 weeks followed by 3 MU thrice weekly for the next 22 weeks. Group B (18 patients) received injection interferon alpha 2 b 3 MU S/C thrice weekly for 24 weeks. Ribavirin therapy was started at 1200 mg daily in 3 divided doses and later modified according to side effects. Patients were evaluated at 2, 4, 8, 12, 16, 20 and 24 weeks during the therapy and then 24 weeks after the completion of treatment. RESULTS: Out of 32 adult patients included in the study, 18 were males and 14 females. Haemoglobin was more than 12 gm/dl in females and more than 13 gm/dl in males, WBC count was more than 3.0 x 10(9)/L and Platelet count was more than 100 x 10(9)/L. Twenty patients completed 6 months combination treatment, 16 reported with their end of treatment HCV RNA PCR results, 8 from each group. Twelve patients were lost to follow up. End of treatment response (ETR) in group A was 88% and 62.5% in group B. Sustained virological response in group-A was 5/8 (62.5%) and 4/5 (50%) in group-B. The frequency and severity of flu like symptoms like fever, body aches, skin rash, hair loss, cough and psychiatric symptoms were more in group A than in group B. There was no significant difference in the 2 groups for haematologic side effects. CONCLUSIONS: Treatment with 5 MU interferon daily for initial two weeks followed by 3 MU thrice weekly for 22 weeks is more effective than 3 MU thrice weekly for 24 weeks but with more side effects.

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.

Successful treatment of watermelon stomach / GAVE syndrome by using argon plasma coagulation.

This case report describes a 50-year-old female patient with liver cirrhosis presented with anemia. She was found to be suffering from gastric antral vascular ectasia (watermelon stomach) on upper gastrointestinal endoscopy. She underwent multiple sessions with Argon plasma coagulation, a non-contact thermal method of hemostasis for the management of watermelon stomach. After 3 sessions, the lesions disappeared and the hemoglobin increased by 2.4 gm/dl without any need of transfusion.

Frequency of hepatopulmonary syndrome in cirrhotic patients.

OBJECTIVE: To determine the frequency of Hepatopulmonary Syndrome (HPS) in patients with cirrhosis of the liver. STUDY DESIGN: Observational cross-sectional study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from April 2005 to March 2006. PATIENTS AND METHODS: Fifty consecutive patients admitted with liver cirrhosis were recruited. Twelve patients were excluded due to inadequate echocardiography image quality and inability to perform lung function tests. The diagnosis of cirrhosis was made on clinical, biochemical, serological and metabolic workup, ultrasound abdomen or liver biopsy. Complete blood count, liver function tests, prothrombin time, serum albumin, electrocardiography, chest radiograph, transthoracic contrast echocardiography, arterial blood gas analysis and pulmonary function tests (FEV1) were performed. Results were analyzed as percentages. Chi-square test of proportions and t-test were applied. RESULTS: Total patients evaluated were 38. Mean age was 47.92 +/- 11.38 years, with male (68.4%) to female (31.6%) ratio of 2.1:1. The commonest cause of cirrhosis was hepatitis C (71.1%). Out of the 38 patients, 11 (28.9%) had HPS including 5 (13.2%) with overt HPS and 6 (15.8%) with subclinical HPS. All patients with HPS had hepatitis C with Child-Pugh-Turcotte (CPT) class C. Factors associated with HPS were digital clubbing, arterial hypoxemia and intrapulmonary vascular dilatations (p=0.02, 0.05 and 0.000 respectively). CONCLUSION: In this study, 28.9% patients with cirrhosis of the liver had HPS. All belonged to child class C due to hepatitis C. Digital Clubbing, arterial hypoxemia and intrapulmonary vascular dilatations were important features of hepatopulmonary syndrome.

Achalasia esophagus; presenting as acute air way obstruction.

Acute airway obstruction from mega-esophagus is a rare presentation of achalasia. Mega-esophagus is generally considered when the transverse width of the esophagus is more than 7 cm. A 78 year old lady presented with longstanding history of productive cough and nocturnal dyspnoea. She was seen in the emergency department with acute exacerbation of dyspnoea after a bout of vomiting, containing semi-solid food with foetid smell. Her respiratory status deteriorated rapidly with onset of stridor, and cyanosis. Chest x-ray showed widening of mediastinum due to dilated esophagus with air-fluid level. Prompt, repeated, upper respiratory tract suction was carried out. A wide bore nasogastric tube was introduced, esophagus was decompressed with a gush of air and fluid, relieving the respiratory distress. This case illustrates an unusual presentation of achalasia underscoring the need for urgent, life-saving esophageal decompression. Hypotheses, regarding the mechanism of airway compromise, as well as, treatment options are reviewed.

Role of laparoscopy in the diagnosis of low serum ascites albumin gradient.

The objective is to determine causes of low serum ascites albumin gradient (SAAG) by direct visualization and obtaining biopsy samples using laparoscopic technique. This is a hospital-based, observational study conducted at Department of Gastroenterology, Sheikh Zayed Hospital, Lahore from January 2001 to April 2002. A total of 33 patients with ascites (SAAG < 1.1 g/dl)) were selected. The findings on history and clinical examination, information from laboratory and radiological investigations were recorded. Laparoscopic findings and histological reporting were correlated. The mean ages were 48.38 +/- 16.7 years. Fifteen (45%) patients were male. The mean duration of the presenting complaints was 3.33 +/- 1.9 months. Ascites was present in all with mean SAAG of 0.73 +/- 0.22. Laparoscopic evaluation showed tuberculous peritonitis in 22 (66.7%) patients and carcinomatous peritonitis in 5 (15.2%) patients. Biopsies were obtained from omentum in 20, peritoneal surface in 5 and liver in 12 patients. The histopathological diagnosis was granulomatous inflammation in 20 (60.6%) and diagnosis of malignancy was made in 7 (21.2%); one (3%) had Budd Chiari Syndrome, 4 (12%) had cirrhosis of liver with super-added Hepatocellular carcinoma and biopsy was non-conclusive in 1 patient. No complication of procedure occurred in this cohort. Laparoscopy is a safe diagnostic modality to establish the cause of low SAAG ascites.