Type 1 Autoimmune Pancreatitis in a Young Male.

Autoimmune pancreatitis (AIP) is a rare entity leading to inflammation of the pancreas. It can be broadly categorized into two types. Type 1 AIP is more common and primarily presents with jaundice. Less commonly it can also progress to multiorgan involvement. Here we report a case of a 19-year-old male who presented to us with complaints of abdominal pain and vomiting. His laboratory investigations showed raised serum amylase and lipase. A contrast-enhanced CT revealed a diffuse enlargement of the pancreas with internal low-density foci. Due to the repeated episodes of pancreatitis, the patient's blood was tested for serum IgG4 (immunoglobulin type G4) which was markedly elevated pointing toward the diagnosis of AIP. Endoscopic ultrasound (EUS) showed a sausage-shaped pancreas with hyper- and hypoechoic strands. EUS-guided fine needle aspiration cytology of the lymph nodes performed in the celiac region showed a mixed population of lymphoid cells. Based on all the workup, our patient was diagnosed as type 1 AIP. He was managed with steroids and his condition progressively improved. This case is clinically significant because of the close resemblance of AIP with other pancreatic disorders like neoplasm. A timely diagnosis can prevent the unnecessary performance of invasive procedures in these patients.

Rapid Intrahepatic Progression of Hepatocellular Carcinoma after Transarterial Chemoembolization: A Case Report.

The prevalence of hepatocellular carcinoma (HCC) is increasing worldwide. Multiple strategies are available for its management including surgical removal, chemotherapeutic drugs, and ablative and chemoembolization procedures. Transarterial chemoembolization (TACE) is currently being used for the unresectable intrahepatic tumor with no vascular invasion or metastasis to other organs. The common adverse effects associated with this technique involve self-limiting fever, vomiting, and abdominal pain. Liver failure is reported in a few cases. In this report, we present a case of 37-year-old HCC patient who experienced rapid progression of tumor following TACE. Our patient came to the Gastroenterology & Hepatology Department, Nishtar Hospital, Multan, with signs concerning acute liver failure within a few months following TACE. On triphasic computed tomography (CT) scan, there was evidence of multiple new infiltrating lesions in both lobes of the liver and portal vein thrombosis, which were not present before TACE procedure. Hence, we made a diagnosis of acute, chronic liver disease due to the rapid intrahepatic progression of HCC. This is a rare side effect of TACE procedure and highlights the significance of proper counseling of the patients undergoing this intervention.

Sorafenib-induced Acute on Chronic Liver Failure in a Patient with Hepatocellular Carcinoma After Microwave Ablation.

Hepatocellular carcinoma (HCC) is becoming a rapidly prevalent hepatic tumor throughout the world. Initially, liver transplantation and resection were the only available options. But there is a recent advent of new treatment modalities like ablative embolization techniques and chemotherapy. Guidelines are available regarding the use of these techniques according to the stage of the tumor. Sorafenib is a chemotherapeutic agent approved for the management of advanced HCC. It works by inhibiting different tyrosine kinases, which halt the progression of the tumor. The common side effects associated with it are diarrhea, hand-foot skin reaction, and alopecia. Acute on chronic liver failure (ACLF), defined as the development of acute liver failure, in the setting of chronic liver disease, is a rare adverse event associated with sorafenib. Here, we present a case of a 65-year-old male presented to Nishtar Hospital Multan, Pakistan, who developed advanced-stage HCC due to underlying liver cirrhosis. There was no metastasis or vascular involvement. After discussing the options, he selected microwave ablation (MWA). There was a recurrence of the tumor after the procedure so he was started on sorafenib. A week after the initiation of a low dose drug (200 mg twice daily), he developed signs and symptoms of ACLF, which included hyperbilirubinemia, prolonged prothrombin time (PT), and flapping tremors. He was admitted to the intensive care unit (ICU) and was successfully managed. He was discharged with a follow-up scheduled after two weeks. This is a unique and rare adverse event of sorafenib.

Irreversible Electroporation For Liver Tumors: A Review Of Literature.

The prevalence of liver tumors is increasing worldwide. These can be broadly classified into primary and secondary types, depending upon the origin of the tumor. Multiple modalities are available for the management of these tumors. Ablative techniques are becoming the cornerstone of management especially for the tumors which are unresectable. Thermal ablative techniques include radiofrequency ablation (RFA), microwave ablation (MWA), and cryotherapy. Recently, a non-thermal technique known as irreversible electroporation (IRE) is gaining importance owing to its better clinical outcome and a good safety profile. IRE works by high voltage and intensity electrical discharge which makes pores in the membrane of the cells. Its clinical outcome is reported in different studies in terms of progression-free survival (PFS), frequency of complete ablation, and local recurrence of the tumor. Favorable results were seen especially for the small size tumors and very early hepatocellular carcinoma (HCC). It was also found to be useful for the management of tumors which are close to vital structures of the liver. The adverse effects of IRE are also comparable to other ablative techniques like RFA and MWA. The common complications associated with this procedure include liver abscess, bleeding, renal failure, pleural effusion, fever, and partial portal vein thrombosis. In view of this literature review, IRE is found to be a good alternative for the management of liver tumor in patients who cannot undergo surgery, thermal ablative procedures or tumor lying close to vital structures. The safety profile of this procedure is also encouraging. Further studies and clinical trials need to be done to explore this technique.

Association of Obesity Indicators with Hypertension in Type 2 Diabetes Mellitus Patients.

OBJECTIVES: To study the association of waist circumference (WC), waist to hip ratio (WHR) and body mass index (BMI) with hypertension in type 2 diabetes mellitus (DM) patients in a tertiary care hospital. METHODS: The anthropometric measures of patients were recorded in the Diabetic Outdoor of Nishtar Hospital Multan from 2013 to 2018 after taking approval from the Institutional Ethical Review Committee. All patients were evaluated in detail after obtaining informed consent. Data was entered and analyzed in SPSS version 20 (IBM Corp., Armonk, NY, USA). RESULTS: Data of 4556 type 2 DM patients, 2549 (55.9%) females, and 2007 (44.1%) males, was analyzed. Mean age of the study population was 47.72 years. Mean age of females was 47.32 years, while of males was 48.23 years. A total of 3393 (74.5%) of the patients had hypertension, 1912 females and 1481 males. The mean systolic blood pressure (SBP) was 130.84 mmHg, while the mean diastolic blood pressure (DBP) was 82.65 mmHg. Mean WC was 102.85 cm. Mean hip circumference was 100.33 cm. Mean weight was 66.93 kg. Mean height was 1.59 m. Mean WHR was 1.02. Mean BMI was 26.37 kg/m2. Obesity (BMI >27 kg/m2) was found in 1,891 (41.5%) of patients. Central obesity was found in 80.7% and 94.7% of type 2 DM patients according to the WC and WHR cutoff, respectively. Hypertension was significantly associated with all the obesity indicators (p<0.001). Type 2 DM patients with a high WHR were more likely to be hypertensive as compared to those with normal WHR (75% versus 65%, odds ratio (OR) 1.6, p<0.001). A higher than normal WC was also significantly associated with hypertension (79% versus 56%, OR 2.9, p<0.001). Similarly, obese type 2 DM patients with a BMI >27 kg/m2 were more likely to be hypertensive as compared to those with a normal range (18.5 to 22.9 kg/m2) BMI (83.1% versus 64.4%, OR 2.7, p<0.001). CONCLUSION: Diabetes is more prevalent in females and middle-aged people. Hypertension and obesity are two very common comorbidities of diabetes. Hypertension is strongly associated with all the parameters (WC, WHR, and BMI) of obesity.

Comparison by meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting in patients with a mean age of ≥70 years.

A paucity of published data evaluating the outcomes of older patients (age ≥70 years) undergoing revascularization for unprotected left main coronary artery disease is available. We performed aggregate data meta-analyses of the clinical outcomes (all-cause mortality, nonfatal myocardial infarction, stroke, repeat revascularization, and major adverse cardiac and cerebrovascular events at 30 days and 12 and 22 months) in studies comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with a mean age of ≥70 years and unprotected left main coronary artery disease. A comprehensive, time-unlimited literature search to January 31, 2013 identified 10 studies with a total of 2,386 patients (PCI, n = 909; CABG, n = 1,477). Summary odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using the random-effects model. The patients in the PCI group were more likely than those in the CABG group to present with acute coronary syndrome (59.6% vs 44.8%, p <0.001). PCI was associated with a shorter hospital stay (4.2 ± 0.8 vs 8.3 ± 0.01 days, p <0.001). No significant differences were found between PCI and CABG for all cause-mortality, nonfatal myocardial infarction, and major adverse cardiac and cerebrovascular events at 30 days and 12 and 22 months. However, PCI was associated with lower rates of stroke at 30 days (OR 0.14, 95% CI 0.02 to 0.76) and 12 months (OR 0.14, 95% CI 0.03 to 0.60) and higher rates of repeat revascularization at 22 months (OR 4.34, 95% CI 2.69 to 7.01). These findings were consistent with the findings from a subgroup analysis of patients aged ≥75 years. In conclusion, older patients (age ≥70 years) with unprotected left main coronary artery disease had comparable rates of all-cause mortality, nonfatal myocardial infarction, and major adverse cardiac and cerebrovascular events after PCI or CABG. The patients undergoing PCI had a shorter hospital stay and lower rates of early stroke; however, they experienced higher repeat revascularization rates at longer term follow-up.