Prediction of Aspartate Aminotransferase to Platelet Ratio Index with Size of Esophageal Varices in Liver Cirrhosis.

BACKGROUND: Liver cirrhosis is one of the major causes of morbidity and mortality. The threatening complication of Liver cirrhosis is variceal bleeding. Early diagnosis and initiation of therapy can reduce mortality associated with variceal bleeding. This study is designed to predict the esophageal varices by non-invasive method using aspartate aminotransferase to platelet count ratio index (APRI). METHODS: A total of 100 patients were studied between March 2016 and February 2017 with the diagnosis of Liver cirrhosis admitted at Bir Hospital fulfilling the inclusion and exclusion criteria. Ethical approval was obtained from Institutional review board of National Academy of Medical Sciences. RESULTS: Out of one hundred patients, 80 were males and 20 females. On endoscopy, small varices were present in 28 (28%) patients and large varices in 51(51%) patients. APRI with a cutoff value of 0.908 has sensitivity of 87.3% and specificity of 71.4%, positive predictive value of 92% and negative predictive value of 60% (p=0.001) for the detection of varices. CONCLUSIONS: Aspartate aminotransferase to platelet count ratio index can be a useful tool to indirectly predict esophageal varices in a patient with Liver Cirrhosis.

An association of Helicobacter pylori infection with endoscopic and histological findings in the Nepalese population.

BACKGROUND: Helicobacter pylori (H. pylori) is one of the most common human infections worldwide particularly in the developing countries. We aimed to study an association of H. Pylori infection with endoscopic and histological findings in the Nepalese population. MATERIALS AND METHODS: We conducted a study between Oct 2014 and Jan 2015 after meeting inclusion and exclusion criteria. Institutional Review Board approval was obtained from National Academy of Medical Sciences. Endoscopic findings and histopathological diagnosis were documented and data were analysed. RESULTS: A total of 113 patients who had complete endoscopy were enrolled. The prevalence of H. pylori infections recorded was 27 (23.9%) patients. There were 17 (62%) male and 10 (37%) female infected with H. pylori (P = 0.33). All biopsied specimens were sent to pathology lab for examination. The most common endoscopic findings was erythematous antral gastritis (40.7%) followed by erosive gastritis 34 (30.1%), pangastritis 10 (8.8%), duodenal ulcer 13 (11.5%), gastric ulcer 9 (8%), erosive fundal gastritis 2 (1.8%), reflux esophagitis 10 (37%) (P < 0.04). Histology revealed that 23 (85.2%) patients had chronic active gastritis (CAG); (P < 0.001). CONCLUSIONS: Our study revealed that H. pylori infection is strongly associated with chronic active gastritis (CAG) and Reflux esophagitis in Nepalese adults.

Acute Pancreatitis Causing Descending Colonic Stricture: A Rare Sequelae.

An isolated descending colonic stricture is an unlikely complication of acute pancreatitis, with the nonspecific symptoms of colonic stricture making the overall diagnosis difficult. Crohn's disease (CD) and tuberculosis (TB) are the two common etiologies of an isolated colonic stricture and may present similarly to colonic stricture related to acute pancreatitis. Unfortunately, colonoscopy and biopsy often cannot determine the etiology, and surgical resection may be needed to provide both symptomatic relief and confirm the diagnosis. As a result, descending colonic stricture may produce a diagnostic dilemma with CD and TB as all 3 conditions may be radiologically and endoscopically indistinguishable. We describe a young male with weight loss and abdominal pain. TB testing was negative, with radiography and ELISA (enzyme-linked immunosorbent assay) testing supporting a diagnosis of the CD. The patient was initiated on sulfasalazine but worsened over the next month. Further investigations revealed that the patient had descending colonic stricture without CD. Therefore, the stricture's etiology was most likely related to an episode of acute pancreatitis the patient had 2 months before admission and was found to have left colonic segment adherent to the pancreas eventually requiring segmentectomy. Although the pathophysiology of colonic stricture after pancreatitis is unclear, we speculate that inflammatory injury to the colon is an important component. Finally, we emphasize that colonic stricture is a rare complication of pancreatitis.

Contrast-induced Nephropathy Following Percutaneous Coronary Intervention at a Tertiary Cardiac Center in Nepal.

Background Contrast-induced nephropathy (CIN) is one of the leading causes of morbidity and mortality including increased financial burden in high risk patients undergoing percutaneous coronary intervention (PCI). Methods This is an observational prospective study. We aimed to study the incidence of CIN in Nepalese populations and compare the outcome to international reprinted values with coronary artery disease (CAD) undergoing PCI. All consecutive patients with CAD undergoing PCI between February 2010 and July 2010 were enrolled in the study. Results One hundred fifty-two patients were enrolled in the study during six months period. Twenty (13.20%) patients developed CIN following PCI. Out of them 70% were diabetics and 30% were non-diabetics. Mean age of patients was 58.5 ± 23 years; male:female ratio was 2.7:1. Mean contrast volume injected was 160.3  ±  78.3  mL. Diabetic patients 21.8% (14/64) had significant CIN compared to non-diabetic patients 6.8% (6/88) following PCI (<0.01). Conclusions CIN is a common complication following PCI especially in diabetics. Despite the use of iodinated material we had similar incidence of CIN comparing the incidence of CIN among various radiocontrast compounds used to visualize vessels. None of the patients received hemodialysis as compared to available studies and there was no observed mortality.

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.

Elevated Liver Enzymes in Patients with Type 2 Diabetes Mellitus and Non-alcoholic Fatty Liver Disease.

Background Non-alcoholic fatty liver disease (NAFLD) is emerging as the most common chronic liver condition. Approximately 70% of type 2 diabetes mellitus (T2DM) patients have a fatty liver; the progression to non-alcoholic steatohepatitis (NASH) dramatically increases the risks of cirrhosis and hepatocellular carcinoma. The aim of our study was to assess the profile of liver enzymes in subjects with T2DM and NAFLD. Method This was a cross-sectional clinic-based study in patients with T2DM. An ultrasonography of the abdomen was done in all patients in order to examine the presence of a fatty liver. Body mass index (BMI), lipid profile, and liver enzymes were also analyzed in all patients. Institutional Review Board (IRB) approval was provided by the National Academy of Medical Sciences, Bir Hospital, Nepal. Unpaired t-test, Chi-square/Fisher's exact test (for categorical variables), and the Pearson/Spearman correlation test were used to find a significant difference, association, and correlation between two or more groups, respectively. The Statistical Package for Social Sciences (SPSS)® Statistics, version 16 (IBM SPSS Statistics, Armonk, NY) was used to analyse the data. Results The study was carried out in 210 patients, and out of the 210 patients, 119 (56.6%) were male and 91 (43.3%) were female. The patients were divided into two groups, i.e., the normal alanine aminotransferase (ALT) group and the elevated ALT group. The mean age of the patients was 56.28 ± 12.3 years in the normal alanine aminotransferase (ALT) group and 58.6 ± 24.7 in the elevated ALT group. The number of T2DM patients with a fatty liver was 117 (55.7%) and those with a non-fatty liver was 93 (44.2%) based on an ultrasonography scan. Subjects with NAFLD had a significantly higher ALT (p < 0.001) but no significant rise in serum aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), and alkaline phosphatase (ALP) levels. The area under the receiver operating characteristic (AUROC) curve for the prediction of fatty liver based solely on the ALT was 0.84 with the confidence interval (CI) between 0.76 and 0.92 (p < 0.05). Conclusions Non-alcoholic fatty liver disease is highly prevalent in patients with T2DM. Timely diagnosis and management of the abnormal liver parameters may help to minimize liver-related morbidity and mortality in the diabetic population.

Incidence of Primary Biliary Cholangitis in a Rural Midwestern Population.

BACKGROUND: Primary biliary cholangitis (PBC) is a rare disease with incidence that varies with time and geography. Only two studies have assessed PBC incidence in the United States, with the most recent appearing over a decade ago. The objective of the present study was to assess PBC incidence in the United States in a more recent era. METHODS: The incidence of PBC was assessed in a population-based cohort in rural, Midwestern Wisconsin over two decades spanning from June 1992 through June 2011. Cases were initially identified in the electronic medical record and then manually verified for inclusion according to the American Association for the Study of Liver Disease criteria for PBC. Additional data were abstracted for verified cases. RESULTS: A total of 79 cases of PBC were identified over the 20-year period for an overall age- and sex-standardized incidence of 4.9 cases per 100,000 person-years. Incidence was higher in females, but changes over time were not significant. After a mean 7.3 years follow-up, all-cause mortality of those with PBC was 29%, and estimated 10-year survival was 76%. CONCLUSIONS: The overall incidence of PBC in a Midwestern population of the United States has remained relatively stable over the last two decades. Patients have better prognosis, and the survival of PBC cases has improved.

Thromboembolic complications following a first isolated episode of superficial vein thrombosis: a cross-sectional retrospective study.

Superficial vein thrombosis (SVT) may be associated with complications such as venous thromboembolism (VTE) and recurrent SVT. The purpose of this study was to explore risk factors among patients with a first isolated episode of SVT (index SVT) involving upper and lower extremities and to estimate the prevalence of VTE complications within 1 year of index SVT. Retrospective chart review of electronic records at Marshfield Clinic in Wisconsin identified 381 subjects with a first isolated SVT diagnosis (male/female: 170/211; median age 59.4 years). Patients were stratified based on whether they did (n = 44; 11.5 %) or did not (n = 337; 88.5 %) experience VTE complications and whether they did (n = 25; 6.6 %) or did not (n = 356; 93.4 %) experience pulmonary embolism (PE) and/or deep vein thrombosis (DVT) within 1 year of index SVT. There were 49 complications among 44 patients; these included DVT (n = 18, 36.7 %), propagation of SVT (n = 18, 36.7 %), PE (n = 9, 18.4 %), new SVT at different location (n = 3, 6.1 %), and recurrent SVT (n = 1, 2.0 %). Univariate analysis of all VTE complications identified seven potential risk factors and similar analysis of PE/DVT complications identified eight potential risk factors, with six common risk factors identified in both analyses. Multivariate analysis identified indwelling venous catheter 30 days prior to SVT (p = 0.044), cancer history with treatment in the previous year (p = 0.001), and non-surgical trauma 7 days prior to SVT (p < 0.001) as independent risk factors for PE/DVT complications. Independent risk factors identified in the current study may convey greater risk for VTE complications, especially PE/DVT, following an initial isolated SVT episode.

Management of post-operative Crohn's disease in 2017: where do we go from here?

INTRODUCTION: Postoperative recurrence (POR) of Crohn's disease is common after surgical resection. How to best manage POR remains uncertain. Areas covered: In this review, we will first describe the natural course and the best modalities to diagnose this surgical sequela. We will then focus on the potential risk factors for relapse and highlight the main shortcomings in the current study designs and endoscopic and clinical scoring systems, which may partly explain the unexpected outcomes of recent clinical trials. Finally, we will propose a strategy to address the management of POR. Expert commentary: Anti-tumor necrosis factor (Anti-TNF) agents are the most effective therapy to prevent POR in Crohn's disease. Patient risk stratification and active monitoring with scheduled ileocolonoscopy are cornerstones of optimal POR management. Further studies are needed to address areas of uncertainty including timing and duration of therapy and the role of therapeutic drug monitoring in this setting.

Outcomes in Dieulafoy's Lesion: A 10-Year Clinical Review.

BACKGROUND: Dieulafoy's lesion (DL) is a rare, but serious cause of gastrointestinal bleeding, most frequently treated with endoscopic therapy. We examined 10 years of data to assess clinical outcomes in DL. METHODS: Data were captured by retrospective chart review to assess 109 patients treated endoscopically for bleeding DL from 2003 to 2013. Data collected included demographics, comorbidities, presenting symptoms, risk factors, laboratory values, treatment, rebleeding, surgical intervention, and mortality. Treatment success, rebleeding rates, and mortality were the main outcomes measured. RESULTS: Of 109 patients with bleeding DL, 54 % were male and 46 % were female. Mean age was 79.4 years; mean follow-up duration was 40.4 ± 35.8 months. Clinical presentation for most patients included melena, hematemesis, hematochezia, and/or anemia with approximately one-third of patients also experiencing anemia-related symptoms. Most lesions were located in stomach (53 %) followed by duodenum/jejunum (33 %) and large intestine (13 %). Thermal endoscopic therapy (70 %) was the most frequently performed procedure followed by injection (46 %) and mechanical (46 %) endoscopy therapy at equal frequency. Combined therapy (51 %) was common, with over half of patients undergoing two or more endoscopic modalities simultaneously. The finding that only 11 (10 %) patients had rebleeding from DL suggests that endoscopic therapy resulted in successful hemostasis in the remaining 98 patients (90 %) during follow-up. Mortality related to DL was low. CONCLUSIONS: Most patients with bleeding DL presented with symptoms of acute bleeding, but many had symptoms suggesting subacute or chronic bleeding. Endoscopic therapy resulted in successful hemostasis in approximately 90 % of patients during follow-up. Rebleeding was rare and particularly uncommon in those treated with combined endoscopic therapy.

Endotherapy in symptomatic pancreas divisum: a systematic review.

Pancreas divisum (PD) is the most common congenital variant of the pancreas and has been implicated as a cause of pancreatitis; however, endoscopic treatment is controversial. Our objective was to examine patient response to endotherapy for treatment of symptomatic PD in adult patients in a systematic review of the literature. A systematic review of all case series and case-control studies with ten or more patients undergoing endotherapy for treatment of symptomatic PD indicated by acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), or chronic abdominal pain (CAP) was performed. PubMed, Embase, and Web of Science databases were searched from inception through February 2013 using [pancreas divisum] AND [endoscopic retrograde cholangiopancreatography (ERCP)] OR [endotherapy] OR [endoscopy] as search terms. Importantly, the majority of studies were retrospective in nature, significantly limiting analysis capacity. Main outcomes measures included endotherapy response rate in patients with PD and ARP, CP, or CAP. Twenty-two studies were included in the review, with a total of 838 patients. Response to endoscopy was seen in 528 patients, but response rate varied by clinical presentation. Patients with ARP had a response rate ranging from 43% to 100% (median 76%). Reported response rates were lower in the other two groups, ranging from 21% to 80% (median 42%) for patients with CP and 11%-55% (median 33%) for patients with CAP. Complications reported included perforation, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, and clogged stents. Endotherapy appears to offer an effective treatment option for patients with symptomatic PD, with the best results in patients presenting with ARP.

Hemodynamic optimization in high-risk mitral valve repairs as a key component in surgical readiness.

Ensuring optimal readiness for surgery using a preoperative checklist has been shown to reduce perioperative morbidity and mortality in both elective and urgent surgeries. We recently introduced hemodynamic optimization as part of our preoperative preparedness strategy for cardiothoracic surgery. Here we describe the case of a patient with severe mitral regurgitation and suboptimal hemodynamics that was optimized preoperatively with nesiritide to reduce pulmonary hypertension. Postoperatively, the patient had an improvement of his heart failure from New York Heart Association functional class 3 to class 1. Without hemodynamic optimization the patient may have been considered too high-risk to undergo mitral valve repair. This case report illustrates the importance of a systemic approach with high-risk surgery, and the use of strategies that optimize key patient factors, including hemodynamics, prior to all elective and urgent procedures.

Circadian patterns of ST elevation myocardial infarction in the new millennium.

OBJECTIVE: Nearly four decades ago, a circadian pattern of acute myocardial infarction (AMI) with a peak in the early morning waking hours was described. The goal of the present study was to determine whether major changes in lifestyle and significant advances in medical therapy have altered this pattern in the intervening years. DESIGN: Retrospective chart review. SETTING: Tertiary care hospital in central Wisconsin. METHODS: We examined circadian patterns of ST elevation myocardial infarction (STEMI) in 519 patients diagnosed with STEMI over a 5-year period. Time of symptom onset was obtained from patient self-reports in the medical record and was recorded over 24 hours. RESULTS: We observed a circadian pattern of STEMI occurrence with a morning peak at approximately 11:30 AM. This pattern was highly significant in patients who were not using beta-blockers (P <0.0001) and had no history of diabetes (P <0.0001), but was otherwise absent. The circadian pattern appeared to be attenuated in patients of a younger age, female gender, or who used statins or aspirin. Peak STEMI occurrence was earlier in smokers than non-smokers. CONCLUSIONS: Despite significant lifestyle changes and medical advances in the nearly four decades since a circadian pattern of AMI occurrence was first described, patients with STEMI had a circadian pattern of symptom onset with a morning peak. Use of beta-blockers and a history of diabetes mellitus abolished this pattern. Other modifying factors, including medications, age, and gender attenuated, but did not abolish, the circadian pattern.

Statin-associated polymyositis following omeprazole treatment.

Statins are an extensively used class of drugs, and myopathy is an uncommon, but well-described side effect of statin therapy. Inflammatory myopathies, including polymyositis, dermatomyositis, and necrotizing autoimmune myopathy, are even more rare, but debilitating, side effects of statin therapy that are characterized by the persistence of symptoms even after discontinuation of the drug. It is important to differentiate statin-associated inflammatory myopathies from other self-limited myopathies, as the disease often requires multiple immunosuppressive therapies. Drug interactions increase the risk of statin-associated toxic myopathy, but no risk factors for statin-associated inflammatory myopathies have been established. Here we describe the case of a man, age 59 years, who had been treated with a combination of atorvastatin and gemfibrozil for approximately 5 years and developed polymyositis after treatment with omeprazole for 7 months. Symptoms did not resolve after discontinuation of the atorvastatin, gemfibrozil, and omeprazole. The patient was treated with prednisone and methotrexate followed by intravenous immunoglobulin, which resulted in normalization of creatinine kinase levels and resolution of symptoms after 14 weeks. It is unclear if polymyositis was triggered by interaction of the statin with omeprazole and/or gemfibrozil, or if it developed secondary to long-term use of atorvastatin only.

Stroke: a case series study in Nepal Medical College Teaching Hospital.

Stroke is a major public health burden worldwide. Prevention programme are essential to reduce the incidence of stroke and to prevent the all but inevitable stroke epidemic, which will hit our population (developing countries) hard as our population age and adopt lifestyle of the more developed countries. In this study we have tried to find the clinical characteristics of the stroke patients admitted in NMCTH and the commonest risk factors and its magnitude in our population. In these retrospective clinical case series study, we included the cases which were admitted in NMCTH over the past 2 years (from 1st April 2003 to 31st march 2005). All these patients were confirmed cases of stroke (CT scan was done in all these cases). Clinical profiles of all these patients were studied and analyzed using SPSS 11.0 version software. Seventy two patients were diagnosed as having cerebrovascular accident. The mean age of the patients having stroke in our study was 61 years. The commonest symptom was unable to move one side of the body (90.0%), other common symptoms were slurring of speech (33.0%), loss of consciousness (29.0%), headache (23.0%) and deviation of mouth (22.0%). 70 patients (97.0%) had 2 or more than 2 symptoms (i.e. multiple symptoms). Smoking (61.0%), hypertension (60.0%) and atrial fibrillation (8.0%) were the commonest modifiable risk factors, while increased age (mean 61 years) was the commonest nonmodifiable risk factor. Ischemic stroke (68.0%) was common than hemorrhagic (32.0%) stroke. In this study we found that smoking and hypertension was the commonest risk factor in our study group. Atrial fibrillation (8.0%) and diabetes mellitus (8.0%) were among the less common risk factors, whereas alcoholism and hypercholesterolemia were negligible in our study population. Multiple clinical features are common with unable to move the one side of the body being the commonest. The commonest form of stroke detected in our study group was ischemic type which is comparable to the study done in the past. Despite of these findings a bigger epidemiological study is needed to generalize this view over our community.

Sleep apnoea syndrome in Nepal.

Sleep apnoea syndrome is a well recognized entity. Sleep studies of diagnosed patients with sleep apnoea were analyzed to understand the clinical profiles of Nepalese patients with this disorder. Eighty nine patients were diagnosed to have sleep apnoea syndrome during the period of 15 months starting from November 2003. All these patients were subjected to a detailed clinical evaluation including symptoms, presence or absence of other risk factors and co-morbidities, general physical and systemic examination and relevant investigations before performing polysomnography. Clinical profiles of patients who were confirmed to have sleep apnoea syndrome with apnoea hypopnoea index (AHI) more than five were included in the study. Forty one patients (46.1%) were found to have mild disease (AHI 6-20), 22 patients (24.7%) had moderate disease (AHI 21-40) and 26 patients (29.2%) were found to have severe disease. The common symptoms were snoring, excessive daytime sleepiness, frequent awakenings, nocturia, and choking spells during sleep. Obesity was found to be the most important risk factor associated with sleep apnoea. Males having collar size more than 16 inches and females with collar size more than 14.5 inches were found to have an increased risk to develop this problem. Hypertension (66.3%), chronic obstructive pulmonary disease (43.2%) and cardiac diseases (19.1%) were the common co-morbidities associated with this disorder. Sleep apnoea syndrome is not an uncommon problem in Nepalese population. It could be the cause of various cardiovascular problems and may complicate patients with chronic obstructive pulmonary disease.