Clinical presentation of autoimmune hepatitis in Pakistani children.

INTRODUCTION: Autoimmune hepatitis (AIH) is one of the most common disorder resulting in end stage liver disease (ESLD) among children. Scarce data is available in this regard from Pakistan. In this study we have analyzed clinical and biochemical parameters of children suffering from this disorder. METHODS: It was a cross sectional study conducted in the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation (SIUT) Karachi from January 2005 to June 2016. Patients aged up-to 18 years were included. AIH was diagnosed by using International Autoimmune hepatitis group (IAIHG) pre-treatment and simplified AIH score. Patients with both probable and definite score were included. Biochemical, serological, sonographic and demographics were recorded at the time of diagnosis, liver biopsy was also performed in most of the cases. Data was analyzed by using SPSS ver.20 and p-value of < 0.05 was considered significant. RESULTS: Total 51 patients were enrolled most of them were females (68.6%). Mean age of presentation was around 10 years. Males had statistically significant earlier age of presentation, p-value = 0.007. The most common presenting complain was jaundice. Hypergammaglobulinemia is seen in almost all patients. Type I AIH was the most common entity while Type II AIH was statistically more significant in males p-value = 0.019. Raised GGT was also seen in male patient specifically in Type II AIH, p-value = 0.001. CONCLUSION: Autoimmune hepatitis predominantly affects female children who have late age of presentation as compare to the males. Type I AIH was the most common while Type II AIH was more common in males and they also had raised GGT.

Frequency of gallstones and mean BMI in decompensated cirrhosis.

INTRODUCTION: The aim of the study was to determine the frequency of gallstones in patients with decompensated cirrhosis and to know about mean Body mass index (BMI) in patients of decompensated cirrhosis i.e End stage liver disease (ESLD) with and without gallstones. METHODS: it is a cross sectional descriptive study, conducted at the department of Hepato-gastroenterology, Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1st August 2014 to 28 February 2015. Two hundred patients were enrolled from outpatient clinics of Hepato-gastroenterology that fulfilled the defined selection criteria. Questionnaire was filled for data collection. SPSS version 20.0 was used to analyze data. Mean value of age and BMI was calculated by mean ± S.D. values. Mean ± SD was also calculated for BMI in patients with and without gallstones. Stratification of the age, gender, and liver disease severity were done and chi-Square test was applied. p-values less than 0.05 considered statistically significant. RESULTS: Two hundred consecutive patients were enrolled among them 112(56%) were male. Mean age was 46.89 ± 11.9, BMI 23.59 ± 4.7 and CTP score was 9.7 ± 1.9. Most of the patient had Child class 'B' cirrhosis 102(51%), most common etiology was found to be Hepatitis C 133 (66.5%), cholelithiasis was found in 59(29.5%), sludge in 36 (18%) and both stone and sludge in 24(12%) of the cases. Advanced liver disease that is, more CTP score and child class 'C' was associated with increased frequency of gall stone formation (p-value = 0.012), and advancing age on age stratification (p-value = 0.024) however no relation was observed with increase BMI, gender, ethnicity, cause or duration of disease in this population. CONCLUSION: Gallstone formation is associated with advanced stage of cirrhosis and hepatitis C Virus related CLD, contrary to the established risk factors, no relation of gender or BMI was found in decompensated liver disease.

Tuberculous Paraspinal Abscess Invading Esophagus: A Rare Cause of Dysphagia.

Esophageal involvement by mycobacterium tuberculosis is a rare entity even in the endemic regions. The common presenting complaint in esophageal tuberculosis are deglutition disorders in which patients primarily present with difficulty in swallowing. The most common site of esophageal involvement is the middle-third at the level of carina. Herein, the case of an adolescent boy is presented who had complains of dysphagia, abdominal pain along with weight loss for a month. On evaluation, he was found to have esophageal narrowing resulting in dysphagia. CT scan revealed a fistulous communication of tuberculous paraspinal abscess with the esophagus, which had resulted in dysphagia. The diagnosis of tuberculosis was made by using gold standard method of Polymerase Chain Reaction (PCR) of mycobacterium tuberculosis. He had marked symptomatic improvement within a month of starting anti tuberculous therapy (ATT) and was successfully treated with ATT for 9 months.

Role of Endoscopic Findings and Biopsies in Renal Transplant Recipients With Gastrointestinal Complications: A Tertiary Care Experience.

OBJECTIVES: We investigated the incidence of gastrointestinal disorders requiring endoscopic and histopathologic diagnoses in renal transplant recipients. MATERIALS AND METHODS: In this retrospective analysis, we examined records of patients seen at the Department of Hepato-Gastroenterology and Transplantation Sciences, Sindh Institute of Urology and Trans?lantation (Karachi, Pakistan) from January 2010 to December 2014. Renal transplant recipients with gastrointestinal disorders who required endoscopy, including proctoscopy and upper and lower gastrointestinal endoscopy as per indication, were included. RESULTS: Of 1770 patients included in this study, most were male patients (n = 1517; 85.7%). In this patient group, 1957 endoscopies, including proctoscopies, were performed, which included 1033 esophagogastroduodenoscopies (52.8%), 571 sigmoidoscopies (29.2%), and 107 colonoscopies (5.5%). The most common indications were diarrhea (n = 697; 31.2%) and weight loss (n = 690; 31%). Findings showed esophageal candidiasis in 127 patients (12%); however, biopsy revealed Candida species in 33 patients (34%). Cytomegalovirus and herpes esophagitis were observed in 8 (8.3%) and 5 patients (5.2%). Helicobacter pylori gastritis was seen in 119 patients (15.4%), cytomegalovirus gastritis in 9 patients (1.2%), and gastric lymphoma in 1 patient (0.1%). Duodenal fissuring was the most common pathology observed during endoscopy (396 patients; 33.9%), followed by decreased height of duodenal folds in 157 patients (13.4%), with biopsy showing sprue in 325 patients (37.6%) and giardiasis in 118 patients (13.7%). Lower gastrointestinal endoscopy showed ulcers in 198 patients (24.6%) and polyps in 31 patients (3.9%). Histopathologic examination showed cytomegalovirus colitis in 89 patients (15.5%), amebic colitis in 21 (3.7%), and tuberculosis in 11 (1.9%). CONCLUSIONS: We observed a wide spectrum of pathologic lesions, including opportunistic infections, in endoscopic biopsies from our renal transplant patients. Cytomegalovirus colitis was the most common infection in the lower gastrointestinal tract, whereas giardiasis was the most common in the duodenum.

ECG changes in patients with primary hyperthyroidism.

INTRODUCTION: Thyroid hormones plays key role in regulating cardiovascular system. Its imbalance leads to various electrophysiological changes in cardiovascular system. This study was done to determine the frequency of electrocardiographic (ECG) changes in patients with primary hyperthyroidism. METHODS: It was a descriptive cross-sectional study conducted in the Department of Medicine, Medical Unit III, Ward-7, Jinnah Postgraduate Medical Centre, Karachi, from October 2013 to April 2014. A total of 103 patients newly diagnosed with primary hyperthyroidism were included in this study. Venous blood samples were collected for T3, T3, TSH analyzed by radioimmunoassay. ECG was performed. Outcome variables were the ECG changes i.e. sinus tachycardia and atrial fibrillation. RESULTS: The average age of the patients was 30.09±5.57 years (95%CI: 29 to 31.18). Out of 103 cases, 19 (18.45%) were male and 84 (81.55%) were female. Sinus tachycardia was observed in 60.19% (62/103) patients whereas atrial fibrillation was found in 11.65 (12/103) of cases. CONCLUSION: In this study frequency of electrocardiographic changes in term of sinus tachycardia was high. This report has emphasized the importance of thyrotoxicosis as a cause of cardiac morbidity and mortality in patients with thyrotoxicosis. These cardiac complications are readily reversible if timely optimal treatment is offered.

Dengue Hemorrhagic Fever: ARare Cause of Acute Liver Failure.

Acute liver failure (ALF) is an acute medical emergency which carries high mortality without liver transplantation. Various hepatotropic viruses, drug induced liver injury, auto immune hepatitis, and metabolic liver diseases are the commonly implicated etiologic agents. Liver involvement in dengue hemorrhagic fever (DHF) is quite common, but acute liver failure is its rare complication. Neurological complications are also commonly seen in DHF. Ateenage girl presented with high grade fever and subconjunctival hemorrhage, and later developed jaundice due to acute liver failure. Liver transplantation could not be offered due to fungemia. During hospital stay, she had seizures and intracranial hemorrhage culminating in brain death. ALF with neurological involvement is a rare but very important and fatal complication of DHF; and it should be considered as a cause of acute liver failure, especially in endemic areas.

Factors leading to dyspepsia in renal transplant recipients.

INTRODUCTION: Renal transplantation is the definitive treatment for end stage renal disease. Patients subjected to transplantation require lifelong immunosuppression and are prone to several gastrointestinal disorders. Dyspepsia is a common disorder in these patients. The objective of this study was to determine factors leading to dyspepsia in renal (kidney) transplant recipients. METHODS: It was a cross sectional study conducted at department of hepatogastroenterology and transplant sciences, SIUT Karachi, from 1-6-15 to 1-12-15 for six months. All renal transplanted patients having dyspeptic symptoms for more than 6 weeks. EGD was performed, biopsy specimens obtained from antrum and duodenum, these were sent for histopathological examination. Frequency and percentages were obtained for categorical variables, mean ± SD was calculated for continuous variables. Chi square test was used for categorical variable and student t-test for continuous variables. RESULTS: Ninety patients were included in the study out of which 64 (71.1%) were males, mean age was 35.82 ± 10.04 years (range: 18-65 years). Gastritis (non H.pylori associated) in 78 (78.6%), duodenitis in 35 (38.9%) and H. pylori infection in 29 (32.2%), renal transplant recipients. Most of the patients belonged to Sindhi ethnicity, 27 (30%), followed by Punjabi. Hypertension was the most common co-morbid condition in our patients found in 29 (32.2%), while most of them don't have any co morbid condition. Duodenitis was found to be associated with tacrolimus use (p = 0.037). CONCLUSION: Gastritis is the most common factor accountable for this symptoms, followed by duodenitis and H. Pylori. Patients taking tacrolimus as immunosuppressant are more prone to develop duodenitis.

Celiac Crisis in Refractory Celiac Disease Type I with Neurological Manifestations: A Diagnostic Dilemma.

Celiac crisis is a life-threatening condition in which patients have profuse diarrhea and severe metabolic disturbances. Refractory Celiac Disease (RCD) is a rare condition defined as persistence of symptoms despite being on Gluten Free Diet (GFD) for 6 months. Neurological involvement in Celiac Disease (CD) is seen in around 8 - 10% of adult patients; however, it is rare in children. Herein we present a case of an adolescent presenting with neurological symptoms and celiac crisis and diagnosed as RCD, type 1. He was treated with high dose steroids. This case underscores the need to consider RCD in patients presenting in celiac crisis and showing no improvement on GFD.

Pill in the blister pack: a rare cause of dysphagia in an elderly adult.

Foreign body impaction in the esophagus amongst adults is not a common cause of dysphagia. Fish bone, food bolus, dentures may cause symptoms of dysphagia, odynophagia, chest pain or respiratory distress. It needs prompt evaluation along with removal of the substance either surgically or endoscopically to avoid the development of life threatening complications. Here we are reporting a case of an elderly male, who presented to us with a history of absolute dysphagia for one week, as a consequence of ingestion of a pill in blister pack.