Risk factors and outcomes of peptic ulcer bleed in a Pakistani population: A single-center observational study.

BACKGROUND: Peptic ulcer disease (PUD) remains a significant healthcare burden, contributing to morbidity and mortality worldwide. Despite advancements in therapies, its prevalence persists, particularly in regions with widespread nonsteroidal anti-inflammatory drugs (NSAIDs) use and Helicobacter pylori infection. AIM: To comprehensively analyse the risk factors and outcomes of PUD-related upper gastrointestinal (GI) bleeding in Pakistani population. METHODS: This retrospective cohort study included 142 patients with peptic ulcer bleeding who underwent upper GI endoscopy from January to December 2022. Data on demographics, symptoms, length of stay, mortality, re-bleed, and Forrest classification was collected. RESULTS: The mean age of patients was 53 years, and the majority was men (68.3%). Hematemesis (82.4%) and epigastric pain (75.4%) were the most common presenting symptoms. Most patients (73.2%) were discharged within five days. The mortality rates at one week and one month were 10.6% and 14.8%, respectively. Re-bleed within 24 h and seven days occurred in 14.1% and 18.3% of patients, respectively. Most ulcers were Forrest class (FC) III (72.5%). Antiplatelet use was associated with higher mortality at 7 and 30 d, while alternative medications were linked to higher 24-hour re-bleed rates. NSAID use was associated with more FC III ulcers. Re-bleed at 24 h and 7 d was strongly associated with one-week or one-month mortality. CONCLUSION: Antiplatelet use and rebleeding increase the risk of early mortality in PUD-related upper GI bleeding, while alternative medicines are associated with early rebleeding.

Outcomes of liver diseases in pregnant females: A study from a tertiary care medical center in Pakistan.

Objective: To determine the etiologies and outcomes of liver disease in pregnancy in a developing country. Method: A total of 336 consecutive pregnant women with liver disease were included in this prospective cohort study conducted at the Department of Gastroenterology, Jinnah Postgraduate Medical Center, Karachi from August 2019 to August 2021. Patients' baseline demographic, clinical, and laboratory data and outcomes were collected on a pre-designed questionnaire. Results: Among all the pregnant females, the most common liver disease was acute hepatitis E virus (HEV) infection (37.2%), followed by preeclampsia (PEC)/eclampsia (EC), hemolysis, elevated liver enzymes & low platelets (HELLP) syndrome, and hyperemesis gravidarum (HG). The most common maternal complications were fulminant hepatic failure (FHF) in 14.9% and placental abruption in 11.0%. Fetal complications included intrauterine death (IUD) in 20.8% and preterm birth in 8.6%. The maternal and neonatal mortality rates were 11.6% and 39.6%, respectively. Among the predictors, low maternal weight, low body mass index (BMI), and low hemoglobin (Hb) were associated with increased maternal mortality. Low fetal weight, height, maternal systolic blood pressure (SBP), and low maternal Hb were independent predictors of fetal mortality. Conclusion: In our cohort of pregnant females in a tertiary care medical center, acute HEV was the most common liver disease, followed by PEC/EC, HELLP, and HG. Maternal and fetal deaths were alarming in this group of patients and demanded careful management.

Frequency and risk factors of malabsorption in patients presenting at tertiary care hospital, Karachi.

Objective: The objective of this study was to find out frequency and risk factors of malabsorption in patients presenting at tertiary care hospital, Karachi. Methods: This was a prospective-observational study conducted through a non-probability consecutive sampling technique. Ninety two adult patients presenting with a history of chronic diarrhea (diarrhea having duration of more than four weeks), age ≥14 years, both males & females, and diagnosed as malabsorption syndrome visiting out-patient or admitted in the department of Gastroenterology of the Jinnah Postgraduate Medical Center, Karachi between June 2018 and July 2020 were enrolled. Baseline and clinical data were recorded in a pre-designed questionnaire and analyzed using statistical package for the social sciences (SPSS) version 21.0. Results: The overall mean age and standard deviation of patient was 35.42±10.83 years. Diarrhea n=71 (77.17%), fever n=35 (38.04%), abdominal pain n=32 (34.78%), and weight loss n=13 (14.13%) were the most common symptoms observed in our study subjects. Most of the patients had normal upper GI endoscopy (26.56%) while multiple fundal erosions with pre-pyloric ulcer and severe pangastric erythema & classical scalloping of duodenal folds were most common findings observed, 21.87% and 17.18%, respectively. Conclusion: Our study provides evidence that malabsorption syndrome is most commonly present in males with younger age group and the most common causes were celiac disease and intestinal tuberculosis and most common presentation was diarrhea, fever, and abdominal pain.

Epidemiological and clinical characteristics of esophageal carcinoma: An experience from tertiary care hospital of Karachi, Pakistan.

Objectives: To describe current trends and characteristics of esophageal cancer (EC) over the past ten years largest tertiary care hospital of Karachi, Pakistan. Methods: This single center retrospective study was conducted at the Department of Gastroenterology and Oncology, Jinnah Postgraduate Medical Center, Karachi, Pakistan, between the period of ten years from 1st January 2010 to 31st December 2019. Patient data including epidemiological characteristics such as age, gender, education, residence, occupation, addictions, comorbidities, symptoms, location of EC, laboratory parameters and histopathological type were recorded. All patients with missing histological and radiological findings were excluded. Results: The mean age of all patients was 49.26±14.24 years and among them majority were females 566 (56.1%). Almost, 834 (82.7%) patients had SQC and 175 (17.3%) presented with ADS. Most common presenting symptom was dysphagia in both groups 327 (32.4%) followed by vomiting (22.8%) and weight loss 196 (19.4%). The Esophagogastroduodenoscopy (EGD) findings showed the distal esophagus involvement in most of the patients (36.3%) in both groups. CT scan findings showed that the lower region was the most involved region in 367 (36.4%) patients, followed by middle and upper in 227 (22.5%) and 156 (15.5%) patients respectively. The thickening of mass on CT- scan was circumferential in most of the patients (42.7%) in both groups. Conclusion: According to our findings, SQC is more prevalent than ADC. Female predominance especially at younger age was most common as compared to past studies. No significant association between a single risk factor has been found in our study however smoking and betel nut chewing were found as known putative risk factors.

Efficacy and Safety of Prunus mume and Choline in Patients with Nonalcoholic Fatty Liver Disease.

Aim: The primary objectives of this study include evaluating changes in lipid profile and liver enzyme levels in nonalcoholic fatty liver disease (NAFLD) patients receiving Prunus mume and choline supplementation (Revolic). Materials and methods: Two-hundred patients were recruited from the hepatology outpatient department of a public hospital between January and June 2023. Patients who had confirmed diagnosis of NAFLD, proven with ultrasound (US) followed by biopsy or US alone with age >18 years were included in this study. The study variables were fasting blood sugar, cholesterol levels, low-density lipoprotein (LDL), triglyceride, alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transferase levels (GGT). All investigations were conducted and compared between baseline, 12 and 24 weeks following treatment. Results: The mean age of all participants was 40.49 ± 10.59 years with 34 males and 166 females. The mean cholesterol levels were reduced to 179.86 ± 35.63 mg/dL from the mean baseline of 197.57 ± 42.52 mg/dL (p = 0.001). There was also a statistically significant difference found between baseline and posttreatment levels of LDL and triglyceride (p < 0.001). The ATL levels were also reduced from baseline 44.91 ± 32.40 U/L to 44.25 ± 30.66 and 41.06 ± 22.15 U/L between 12 and 24 weeks after treatment respectively. There was a statistically significant reduction in ATL, AST, and GGT levels from baseline with p-value < 0.001. Conclusion: The combination of P. mume and choline (Revolic) gives promising results with a significant reduction in lipid profile and liver enzymes. Clinical significance: The combination of P. mume and choline can be considered a reliable option for the management of NAFLD due to its efficacy and safety at 24 weeks after treatment as evident in the present study. How to cite this article: Butt N, Masood M, Ali A. Efficacy and Safety of Prunus mume and Choline in Patients with Nonalcoholic Fatty Liver Disease. Euroasian J Hepato-Gastroenterol 2023;13(2):124-127.

Gender Differences in Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) has currently emerged as the most common liver disorder in both developed and developing countries. It has been observed that NAFLD exhibits sexual dimorphism, and there is limited understanding on the sex differences in adults with NAFLD. Nonalcoholic fatty liver disease shows marked differences in prevalence and severity with regards to gender. There are considerable biological disparities between males and females attributed to differences in the chromosomal makeup and sex hormone levels, distinct from the gender differences resulting from the sociocultural influences that lead to differences in lifestyle, which have a significant impact on the pathogenesis of this complex disorder. A multitude of factors contributes to the gender disparities seen and need to be researched in-depth to better understand the mechanisms behind them and the therapeutic measures that can be taken. In this article, we will review the gender disparities seen in NAFLD, as well as recent studies highlighting certain gender-specific factors contributing to its varying prevalence and severity. How to cite this article: Nagral A, Bangar M, Menezes S, et al. Gender Differences in Nonalcoholic Fatty Liver Disease. Euroasian J Hepato-Gastroenterol 2022;12(Suppl 1):S19-S25.

Efficacy and Safety of N-Butyl 2 Cyanoacrylate Injection for Treatment of Gastric Varices: A five year experience from a tertiary care hospital in Karachi, Pakistan.

Objectives: To evaluate the efficacy and safety of N-Butyl 2 Cyanoacrylate injection for treatment of gastric varices. Methods: This was a retrospective observational cohort conducted at Medical Unit IV, Department of Gastroenterology, JPMC, Karachi from January 2014 to December 2018 (five years). All patients irrespective of age and gender that presented to the emergency department with complain of hematemesis or stigmata of UGIB were potential candidates. Once they were resuscitated and endoscopic evidence of gastric varices requiring intervention was found, the patients were inducted into the study. N-Butyl 2 Cyanoacrylate injection was performed until hemostasis and obliteration of gastric varices was achieved. Response to therapy was analyzed at three weeks with repeat endoscopy. Mortality was analyzed at six weeks. Major and minor complications recorded as well. Results: A total of 159 patients were inducted into the study. Isolated gastric varices Type-I was mostly encountered. A singular session was sufficient to achieve obliteration and hemostasis in over three quarter of the patients. Complications affected 11.30% of the patients. Six weeks mortality was exceptionally low at 1.20%. Conclusions: N-Butyl 2 Cyanoacrylate is safe and effective for treatment of gastric varices. There were few complications seen with this procedure in this study. It significantly reduces mortality at six weeks.

Prolonged jaundice in hepatitis-E patients: Going beyond the optics.

Hepatitis E virus (HEV) is an RNA virus that is transmitted faeco-orally. Due to unhygienic living conditions and unsatisfactory treatment of drinking water, it is a major cause of acute viral hepatitis in Pakistan. Hepatitis E infection in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency may cause prolonged jaundice resulting in serious complications like, severe haemolysis, acute renal failure, encephalopathy and even demise. Although both these diseases occur frequently in our country there is a dearth of literature on the effect of Hepatitis E infection in G6PD deficient patients, leading to higher rate of complications in such patients. We report the case of a 37 years old male who was referred to our hospital with worsening jaundice. Patient had HEV infection with concomitant G6PD deficiency. This case had a different prospect, since it resulted in prolonged jaundice and severe haemolysis. However the patient's condition improved with conservative management.

Effectiveness of Sofosbuvir and Daclatasvir in treatment of Hepatitis-C: An experience of tertiary care hospital in Karachi.

OBJECTIVE: To assess the effectiveness of Sofosbuvir (SOF) and Daclatasvir (DCV) in patients with chronic hepatitis C (CHC), compensated cirrhosis (CC) and decompensated cirrhosis (DCLD) either treatment naïve or experienced. METHODS: This was a prospective, observational study, conducted from January 2017 to December 2018 at Jinnah Postgraduate Medical Centre, Karachi. All patients above 12 years of age with detectable HCV RNA PCR were included. Patients were divided into three groups: CHC, CC and DCLD. SOF and DCV for 12 or 24 weeks were given. Ribavirin (RBV) was given to treatment experienced and cirrhotic patients. Primary outcome was End of Treatment Response (ETR) and secondary outcome was Sustained Virological Response (SVR) at post treatment week 12 or 24. RESULTS: Total 300 patients with mean age of 40.49 ± 13.86 were enrolled. Majority were females 174 (58%). CHC were 200 (66.6%) while cirrhotic were 100 (33.4%). Treatment naïve patients were 267 (89%) and 33 (11%) patients were experienced. Most common genotype was 3 (83%). ETR was achieved in 292 (97.33%) and SVR in 265 (88.33%) patients respectively. CONCLUSION: SOF plus DCV with or without RBV is a highly effective treatment for chronic HCV and is still used in many centers of Pakistan. This regimen has excellent results for GT-3. The outcomes are mainly influenced by the presence or absence of cirrhosis.

Perception of Non-Alcoholic Fatty Liver Disease: Real-Life Experience From Pakistan.

Introduction Non-alcoholic fatty liver disease (NALFD) has become one of the most pervasive causes of hepatic pathology. Because of its marked association with metabolic syndrome, type II diabetes and cardiovascular disease, NAFLD has gained substantial focus recently. Its prevalence and incidence are on the rise in Pakistan. However, due to its indolent and mostly asymptomatic course, NAFLD is often overlooked. This reckless behavior towards a potentially deadly disease is influenced most notably by disinformation or flawed perception, although there are a number of other complex socioeconomic components to this as well. With respect to NAFLD, the gap between disease understanding and steps for management is growing in the Pakistani society. With this study, we hoped and aimed to evaluate just how far and wide these shortcomings were found and how was NAFLD perceived in the local populace via a self-administered survey. Methods This was a cross-sectional observational cohort study undertaken at the Department of Gastroenterology, Jinnah Postgraduate Medical Centre, and Medical Unit II, Dow University of Health Sciences, Ojha Campus, Karachi, Pakistan. All patients ≥18 years with a diagnosis of NAFLD were included in the study. NAFLD was diagnosed on the basis of sonographic evidence. All ultrasounds were done by a senior expert radiologist with at least 10 years of postgraduate experience. Ultrasounds were performed twice in all patients to rule out human error and bias. Perceptions regarding the knowledge of NAFLD were assessed using a self-administered survey questionnaire. Results The female-to-male ratio in our cohort was 3:1. The mean age and body mass index (BMI) recorded were 39.85 ± 9.79 years and 31.21 ± 3.6 kg/m2, respectively. Sixty participants (26.4%) knew about their disease (NAFLD) while only 36 (15.9%) knew what NAFLD was and only 33 (14.5%) participants knew about the cardiovascular risk associated with it. Nearly two-thirds of the patients considered themselves overweight, while 180 (79.3%) of them were willing to lose weight. However, just about half of the cohort admitted the need for improved eating habits and increased physical activity/exercise in their daily lives. Fifty-seven (25.1%) patients admitted to using alternative or quack medications and only 45 (19.8%) patients considered them harmful. Conclusions Patients harboring NAFLD have little to no knowledge about the disease and its nature or the fact that they are suffering from it despite being diagnosed clinically. Furthermore, while the general populace is willing to accept being overweight and having unhealthy eating habits, their willingness in initiating real-life practical steps to manage NAFLD is lacking.

Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey.

BACKGROUND AND AIMS: Patient preference for a healthcare professional is mediated by physician gender. The primary aim of this study was to assess gender preference for an endoscopist in a cohort of Muslim patients. The secondary aim was to identify factors that influence gender preference. METHODS: This was a multicenter cross-sectional study conducted at 3 tertiary care hospitals in Pakistan. Consecutive patients scheduled for elective outpatient upper endoscopy or colonoscopy were asked to complete a questionnaire immediately before and after the procedure. Data collected included patient demographics, occupation, education level, procedure type, gender preference, and reason for preference. RESULTS: A total of 1078 patients completed the questionnaire (age 43.5 ± 15.8 years; 53.2% men). Upper endoscopy was the most frequent procedure, performed in 84% of patients. Gender preference was expressed by 707 patients (65.6%), of which 511 (72.3%) were willing to wait for an average of 7 days for an endoscopist of the preferred gender. Male patients' preferences (45.1% male endoscopist, 17.1% female endoscopist, 37.8% no preference) differed from female participants' (16.9% male endoscopist, 52.6% female endoscopist, and 30.5% no preference; P < .00001). No education was associated with having a gender preference (odds ratio, .55; 95% confidence interval, .37-.81; P = .003). Reasons for gender preference included religious values and family pressure, which were more frequently expressed by women (P < .0001). CONCLUSIONS: Most Muslims in Pakistan expressed a gender preference, and both female and male patients showed a preference for a same-gender endoscopist. No education was associated with having a gender preference.

Association of serum advanced glycation (AGEs) end products, apolipoprotein-B and zinc in severity of T2DM retinopathy.

Advanced glycation end products (AGEs), lipids and lipoproteins and antioxidant enzymes are involved in the development of diabetic retinopathy (DR). AGEs and modified Apolipoprotein-B (Apo-B) lead to the formation of reactive oxygen species causing damage to the retina leading to DR. Zinc has antioxidant properties and protects the retina against reactive oxygen species. The current study aimed to compare the levels of serum AGEs, Apo-B and zinc in non-diabetics and type II diabetics without and with DR. Serum AGEs and Apo-B were measured by ELISA while zinc was measured by atomic absorption spectrophotometry. The impact of all three markers on the severity of DR was calculated, individually as well as together as a model, to determine the relationship of these markers with severity of diabetic retinopathy. Regression analysis showed that AGEs, Apo-B and zinc were all contributing significantly to the severity of DR, together having an 82.8% impact on it (R2=0.828). The model of the three parameters was best fit to indicate the severity of DR (p-value = 0.553). This study provides a basis for further validation of the suggested model with prospective studies which can then be used in clinical setups to predict the individuals at risk.

Minimal Hepatic Encephalopathy: Effect of H. pylori infection and small intestinal bacterial overgrowth treatment on clinical outcomes.

The effect Helicobacter pylori (Hp) infection and small intestinal bacterial over growth (SIBO) in minimal hepatic encephalopathy (MHE) is not well understood. The aim of the study was to determine the effect of eradication of Hp infection and SIBO treatment on MHE in patients with cirrhosis. Patients with cirrhosis were enrolled and MHE was determined by psychometric tests and critical flicker frequency analysis. Hp infection and SIBO were assessed by urea breath and Hydrogen breath tests respectively in patients with cirrhosis and in healthy volunteers. Patients with Hp infection and SIBO were given appropriate treatment. At six weeks follow-up, presence of Hp infection, SIBO and MHE status was reassessed. Ninety patients with cirrhosis and equal number of healthy controls were included. 55 (61.1%) patients in the cirrhotic group were diagnosed to have underlying MHE. Among cirrhotic group, Hp infection was present in 28 with MHE (50.9%) vs. in 15 without MHE (42.8%) (p = 0.45). Similarly, SIBO was present in 17 (30.9%) vs. 11 (31.4%) (p = 0.95) in patients with and without MHE respectively. In comparison with healthy controls, patients with cirrhosis were more frequently harboring Hp and SIBO (47.7% vs. 17.7% (p < 0.001) and 31.1% vs. 4.4% (p < 0.001) respectively. On follow-up, all patients showed evidence of eradication of Hp and SIBO infection. Treatment of SIBO significantly improved the state of MHE in cirrhotics, however eradication of Hp infection did not improve MHE significantly. Additionally, patients with low Model for End-Stage Liver Disease (MELD) score and belonging to Child class B had significantly better improvement in MHE. A large number of patients with cirrhosis had either active Hp infection or SIBO with or without MHE, compared to healthy controls. Treatment of SIBO significantly improved MHE in patients with cirrhosis, whereas eradication of Hp did not affect the outcome of MHE in these patients.

Efficacy and Safety of Sofosbuvir-Velpatasvir combination in Hepatitis C Virus-infected Pakistani Patients without Cirrhosis or with Compensated Cirrhosis: A Prospective, Open-label Interventional Trial.

Background In Pakistan, there is a paucity of published clinical data regarding the efficacy of sofosbuvir-velpatasvir in the management of patients with hepatitis C without cirrhosis or with compensated cirrhosis. Methods A prospective, open-label, multicenter, interventional trial was conducted in patients with hepatitis C without cirrhosis or with compensated cirrhosis. Hepatitis C patients without cirrhosis or with compensated cirrhosis were screened, and 133 patients were enrolled in the study. They received sofosbuvir 400 mg plus velpatasvir 100 mg combination once daily for 12 weeks. Patients were followed up for six months after the start of therapy. Hepatitis C viral load was assessed at baseline, at week 12, and after 24 weeks following the start of the treatment. The trial was prospectively registered with the Iranian Registry of Clinical Trials (IRCT) with the identification number IRCT20170614034526N4. Results Among enrolled patients, 79 were male, and 54 were female. Ninety-five (71.4%) patients were without cirrhosis, and 38 had compensated cirrhosis. Patients without cirrhosis had a mean age of 45.90 ±10.99 years, and patients with compensated cirrhosis had a mean age of 52.60 ±12.29 years. As per the intention-to-treat analysis, all patients without cirrhosis and 35 (92.1%) patients with compensated cirrhosis achieved undetectable viral load hepatitis C virus (HCV) ribonucleic acid (RNA) of <15 IU/mL at 12 weeks from the start of treatment. Eighty-six (90.5%) patients without cirrhosis achieved sustained virologic response 12 weeks after the end of therapy. Patients with compensated cirrhosis experienced more adverse events (31.5%) than patients without cirrhosis (20.15%). Conclusion Direct-acting antiviral therapy using sofosbuvir and velpatasvir combination is effective and safe in HCV patients without cirrhosis and patients with compensated cirrhosis.

Treatment Outcomes for Patients Undergoing Hemodialysis with Chronic Hepatitis C on the Sofosbuvir and Daclatasvir Regimen.

Background Hepatitis C (HCV) infection is the most commonly acquired infection for patients on hemodialysis and is associated with significant morbidity and disease progression. Direct-acting antivirals (DAAs) have revolutionized the management of HCV. However, limited data exist regarding their efficacy in end-stage renal disease (ESRD), especially for patients on dialysis in South Asia. Aims To evaluate the treatment outcomes of patients undergoing hemodialysis with chronic hepatitis C (CHC) on the sofosbuvir (SOF) and daclatasvir (DAC) regimen. Materials and methods All patients who were 18 years or older, diagnosed cases of chronic kidney disease (stage V), and undergoing maintenance hemodialysis were inducted into this study. Active HCV infection was demonstrated by polymerase chain reaction (PCR) HCV ribonucleic acid (RNA) (qualitative). All patients were then treated with a double regimen of SOF (400 mg once daily) and DAC (60 mg once daily) taken per oral for 12 weeks. Response to treatment was assessed at four, 12, and 52 weeks. Results A total of 31 out of 80 patients were inducted into the study over two years. The prevalence of HCV in hemodialysis patients was 38.75%. Sustained virological response (SVR) was achieved by 27 (87.09%) patients at one year. Four (12.90%) patients had a relapse of HCV. There was no deterioration of hepatological status in any of the patients. Overall survival at one year was 93.54%. Conclusion HCV is highly prevalent in patients undergoing hemodialysis. Prompt treatment with SOF and DAC demonstrates a good response, with negligible side effects.

Acute Viral Hepatitis: Simultaneous Infection from Hepatitis A, B and E Viruses.

Acute viral hepatitis is a significant health problem in the developing world. Usually, the disease runs a benign course with complete resolution of signs and symptoms within days to weeks. It can be caused by any of the hepatitis viruses as well as other pathogens. Viral hepatitis can also be caused by co-infection from multiple hepatitis viruses, however, this is rare. Here, we report a unique case of acute hepatitis caused by simultaneous infection from Hepatitis A Virus (HAV), Hepatitis B Virus (HBV) and Hepatitis E Virus (HEV). This case is rare as all work-ups for probable causes of acute hepatitis were negative; and the review of the literature showed that such a case had not been previously reported.

A Case of Polyautoimmunity: Celiac Hepatitis, Grave's Disease and Autoimmune Hemolytic Anemia.

Celiac disease (CD) is an autoimmune disorder with high incidence of multi organ involvement; especially, gastrointestinal manifestations and an increased risk of malignancies. Here we report a case of CD with celiac hepatitis, autoimmune hemolytic anemia (AIHA) and Grave's disease (GD) with their complications. Polyautoimmunity requires comprehensive analysis. While CD and GD were previously diagnosed, AIHA and cirrhosis were diagnosed during admission upon extensive work-up. Similarly, other autoimmune etiologies, such as autoimmune hepatitis (AIH), and/or primary biliary cholangitis were ruled out. All three diseases were treated afresh with strict adherence to a gluten-free diet (GFD) and carbimazole along with addition of medications for cirrhosis complicated by ascites. This was a rare case where non-adherence to a GFD led to such severe adverse events. A case of celiac hepatitis presenting with such a wide array of signs and symptoms has rarely been reported in the literature and the management of this patient was unique and challenging.

An Unusual Case of Congenital Hepatic Fibrosis with Retinitis Pigmentosa.

Congenital hepatic fibrosis (CHF) is a rare hereditary autosomal recessive disorder due to periportal fibrosis and ductal plate malformation. It is just one of many different malformations collectively named oculo-encephalo-hepato-renal syndrome. The major presenting feature is upper gastrointestinal bleeding due to portal hypertension secondary to the development of esophageal varices. Herein we report a case of CHF with retinitis pigmentosa but lacking the distinctive multisystem malformations associated with other well-known syndromes associated with CHF. In cases of CHF, search for other organ involvement is important at the time of presentation as well as during follow-up.

Esophageal Variceal Band Ligation Interval and Number Required for the Obliteration of Varices: A Multi-center Study from Karachi, Pakistan.

Introduction Esophageal variceal band ligation (EVBL) is the best form of treatment for variceal bleeding. The frequency of EVBL for the eradication of esophageal varices has no consensus. We evaluated the number and interval of EVBL sessions required for the obliteration of esophageal varices. Methods Esophagogastric varices were treated endoscopically with band ligation on initial presentation and then every after three weeks till the obliteration of the varices. Endoscopic band ligation consists of placing rubber elastic bands on large varices. Frequencies were calculated for qualitative variables and mean ± standard deviations for continuous variables. Results A total of 107 cases with esophagogastric varices were enrolled. Out of them, seven patients with small esophageal varices and large fundal varices were excluded. The remaining 100 with large esophageal varices had EVBL performed. The second session of EVBL was done in 46 patients with large esophageal varices. The third session of EVBL for the obliteration of esophageal varices required in 20 patients with large esophageal varices and the fourth session was required in only two patients. The total sessions required for the complete obliteration for esophageal varices were 2±1. Only one patient developed post-EVBL bleeding one week after band ligation. Conclusion Esophageal variceal ligation was a safe and well-tolerated procedure performed at three-week intervals in patients with large esophageal varices. On average, two to three sessions of EVBL are required for the complete obliteration of esophageal varices.