Platelet Count to Prothrombin Time: A Noninvasive Predictor of Esophageal Varices in Patients With Chronic Liver Disease.

Introduction Esophageal variceal bleeding is a potentially deadly consequence of portal hypertension in patients with cirrhosis. Although upper gastrointestinal endoscopy is still the preferred method for identifying esophageal varices (EV), the present study measured the platelet count to prothrombin time (PLT/PT) ratio for the assessment of portal hypertension and subsequent diagnosis of EVs in patients with chronic liver disease (CLD). Methods This was an observational comparative study conducted in the outpatient department of Patel Hospital, Karachi, Pakistan, using a non-probability consecutive sampling technique. Ethical approval was obtained from the Patel Hospital ethical review committee (PH/IRB/2022/028). An independent sample t-test was used for parametric data, whereas the Mann-Whitney U test was used for non-parametric data. The chi-square test was used to compare the categorical data of patients with and without EV. Receiver operating characteristic (ROC) analysis was performed to evaluate the cutoff values for the PLT/PT ratio, sensitivity, specificity, and area under the curve (AUC). Results The study involved 105 patients with and without EV. Among them, 38 (63.3%) males and 22 (36.7%) females had EV, whereas 30 (66.7%) males and 15 (33.3%) females did not. The platelet (PLT) count was also significantly lower in patients with EV (87.6 ± 59.8) than in those without (176.6 ± 87.7) (p < 0.001). The PLT/PT ratio was significantly lower in patients with EV (median: 5.04, IQR: 3.12-9.21) compared to those without (median: 14.57, IQR: 8.08-20.58) (p < 0.001). The sensitivity and specificity of the PLT/PT ratio for identifying EVs were 97.80% and 83.30%, respectively. Conclusion We found a significantly lower PLT/PT ratio in cases with EV than those without EV. After defining an optimal cutoff, PLT/PT had a high sensitivity in identifying cases with EVs in CLD. Therefore, we conclude that in patients with CLD, the PLT/PT ratio is a noninvasive predictor for the presence of EV.

HepFREEPak: protocol for a multi-centre, prospective observational study examining efficacy and impact of current therapies for the treatment of hepatitis C in Pakistan and reporting resistance to antiviral drugs: study protocol.

BACKGROUND: Pakistan has one of the highest burdens of Hepatitis C virus (HCV) infection globally. To achieve the World Health Organization's goals for HCV elimination, there is a need for substantial scale-up in testing, treatment, and a reduction in new infections. Data on the population impact of scaling up treatment is not available in Pakistan, nor is there reliable data on the incidence of infection/reinfection. This project will fill this gap by providing important empirical data on the incidence of infection (primary and reinfection) in Pakistan. Then, by using this data in epidemic models, the study will determine whether response rates achieved with affordable therapies (sofosbuvir plus daclatasvir) will be sufficient to eliminate HCV in Pakistan. METHODS: This prospective multi-centre cohort study will screen 25,000 individuals for HCV antibody (Ab) and RNA (if Ab-positive) at various centers in Pakistan- Karachi (Sindh) and Punjab, providing estimates of the disease prevalence. HCV positive patients will be treated with sofosbuvir and daclatasvir for 12-weeks, (extended to 24-weeks in those with cirrhosis) and the proportion responding to this first-line treatment estimated. Patients who test HCV Ab negative will be recalled 12 months later to test for new HCV infections, providing estimates of the incidence rate. Patients diagnosed with HCV (~ 4,000) will be treated and tested for Sustained Virological Response (SVR). Questionnaires to assess risk factors, productivity, health care usage and quality of life will be completed at both the initial screening and at 12-month follow-up, allowing mathematical modelling and economic analysis to assess the current treatment strategies. Viral resistance will be analysed and patients who have successfully completed treatment will be retested 12 months later to estimate the rate of re-infection. CONCLUSION: The HepFREEPak study will provide evidence on the efficacy of available and widely used treatment options in Pakistan. It will also provide data on the incidence rate of primary infections and re-infections. Data on incidence risk factors will allow us to model and incorporate heterogeneity of risk and how that affects screening and treatment strategies. These data will identify any gaps in current test-and-treat programs to achieve HCV elimination in Pakistan. STUDY REGISTRATION: This study was registered on clinicaltrials.gov (NCT04943588) on June 29, 2021.

Oesophageal Varices And Associated Factors In Cirrhotic Patients With Hepatitis C.

BACKGROUND: Infection with hepatitis C virus is reported to have infected almost 71 million people worldwide. This study was done to assess the frequency and associated factors leading to oesophageal varices in patients presenting with hepatitis C related liver cirrhosis. METHODS: A cross-sectional study was conducted at Patel Hospital, Karachi, Pakistan from 9th May to 5th October 2019. Patients of either gender having age >20 years presenting with HCV related liver cirrhosis, and Child Pugh class A, B and C were consecutively enrolled in the study. Data on variables like: age, gender, Childs Pugh Score (A/B/C), smoking status, laboratory characteristics like hemoglobulin (Hb), TLC, platelets, serum albumin level, cholesterol, alkaline phosphate (ALK), alkaline transaminase (ALT), ascites and presence of oesophageal varices was recorded and analysed using SPSS-21.0. RESULTS: Out of 167 patients, mean age was 44.86±14.74 years. Eight-nine (53.3%) of the patients were males. The mean duration of cirrhosis was 5.78±1.10 months. Thrombocytopenia was observed in majority (n=130, 77.8%) of the patients. There were 33 (19.8%) patients with Child Pugh score A while Child-Pugh score B and C was found in 67 (40.1%) each. The frequency of oesophageal varices was 141 (84.4%). A significantly higher proportion of oesophageal varices were found among thrombocytopenic patients (p<0.001), ascites (p-0.024), and having "C" Child-Pugh score (p-0.012). CONCLUSIONS: Oesophageal varices were found in a considerable proportion. Thrombocytopenia, ascites and Child-Pugh class C were found as leading contributing factors to oesophageal varices.

Frequency And Factors Leading To Helicobacter Pylori Infection Among Dyspeptic Patients.

BACKGROUND: Helicobacter pylori is infecting 50 percent or more of the world's population, putting it the most ubiquitous infection on the world. This study is done with the objective to determine the frequency and risk factors of Helicobacter pylori infection among dyspepsia patients at Patel Hospital Karachi. METHODS: This cross-sectional study was conducted at the gastroenterology department at the Patel Hospital in Karachi from 10th Jan to 10th July 2021. All patients with dyspepsia for at least 6 months having age 20-60 years of either gender were included. Three samples from stomach (2 from antrum,1 from corpus) for biopsies were collected from each patient. The specimen was sent to the microbiology department of the hospital and was reported as having histopathological confirmation of Helicobacter pylori infection. RESULTS: Of 111 patients with dyspepsia, mean age of the patients was 44.19±16.41 years. Most of the patients (n=65, 58.6%) were males and 46 (41.4%) were females. The mean duration of dyspepsia was 11.48±5.53 months. Helicobacter pylori was discovered to be present in 93 percent of individuals (83.8 percent). The odds of Helicobacter pylori infection were found to be 7.99 times higher among patients over 40 years old (AOR: 7.99, 95 percent CI: 2.02-31.64, p: 0.003), 3.93 times higher among patients with >9 months of dyspepsia (AOR: 3.93, 95 percent CI: 1.09-14.16, p: 0.036), and 11.85 times higher among smokers as compared to non-smokers (AOR: 11.85, 95 percent CI: 1.42-99.08, p-value 0.023). CONCLUSIONS: The rate of Helicobacter pylori infection in patients with dyspepsia was found to be higher. Furthermore, increasing age, increase duration of dyspepsia and smoking is found to be independent risk factors.

Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training?

BACKGROUND/AIMS: Cholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience. METHODS: One hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: "Trainees," "Consultants group 1" (performed >75 ERCPs per year), and "Consultants group 2" (performed >100 ERCPs per year). RESULTS: Trainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77-0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74-0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69-0.95). CONCLUSION: This investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.

Percutaneous endoscopic gastrostomy; success and outcome of a novel modality for enteral nutrition.

OBJECTIVE: To determine the indications and complications of percutaneous endoscopic gastrostomy tube. METHODS: The retrospective audit study was conducted at the Department of Gastroenterology, Endoscopy Unit, Patel Hospital, Karachi, and comprised data of patients aged 4-95 years who underwent placement of percutaneous endoscopic gastrostomy under conscious sedation and for patients under 18 years of age having obtained anaesthesia fitness, under general anaesthesia, from August, 2008, to July, 2018. Pre-procedure treatment and follow-up was noted on a structured proforma. Data analysed using SPSS 21. RESULTS: Of the 367 patients, 237(64.6%) were males and the overall mean age of the sample was 63±15 years. Of the total, 257(70%) procedures were done in the day-care setting. The most common primary indication for tube placement was neurological dysphagia 259(70.6%). No procedure-related mortality was observed, but 35(9.5%) patients had PEG-site infection, and 3(8.5%) of them required removal of the tube. CONCLUSIONS: Percutaneous endoscopic gastrostomy was found to be an effective and useful feeding alternative, leading to improved nutrition.

Plastic stent migration in ERCP; a tertiary care experience.

OBJECTIVE: To evaluate the entire spectrum of endoscopic retrograde cholangiopancreatography procedure including site of stent migration, techniques of stent retrieval, success and complications. METHODS: The retrospective study was conducted at Dr Ruth Pfau Civil Hospital Karachi, and comprised data from January 2010 to January 2017of patients who underwent endoscopic retrograde cholangiopancreatography for the retrieval of stent migrated in the common bile duct, pancreatic duct or pancreatic pseudocyst or were found to have migrated stent during either stent removal or exchange and where attempts were made to remove the stent. A team of expert endoscopists had performed all the procedures. SPSS 17 was used for statistical analysis. RESULTS: There were 5700 procedures performed on 4800 patients. Pancreato-biliary stenting was done in 1229(21.56%) patients; 745(60.61%) with benign conditions and 484(39.38%) with malignant. Stent migration was found in 51(4.14%) patients; 30(58.8%) males and 21(41.2%) females. In terms of clinical presentation, right upper quadrant pain was the most common 9(17.6%). Technical success was achieved in all (100%) cases, with firstprocedure success in 45(88.2%). There was no complication or procedure-related mortality. CONCLUSIONS: In patients with stent migration, endoscopic retrograde cholangiopancreatography was found to be a safe and effective modality for stent retrieval.

Pancreas Divisum.

OBJECTIVE: To evaluate the complications, technical success, diagnostic evaluation and various endoscopic management options in patients with pancreas divisum. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Endoscopy Suite, Surgical Unit 4, Civil Hospital, Karachi, from January 2007 to December 2013. METHODOLOGY: All Endoscopic Retrograde Cholangio-pancreatography (ERCPs) procedure performed in patients with pancreas divisum were analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy for the condition. RESULTS: During the study period, 3600 patients underwent 4500 ERCPprocedures. Pancreas divisum was found in 17 patients (0.47%); 7 ERCPs (41.2%) were performed for diagnostic and 10 (58.8%) for therapeutic purposes. Sixteen (94.1%) had complete PD and one (5.9%) had incomplete PD. Male and Female ratio was 1:1.83 with a mean age of 26.3 years and median symptom duration of 11 months. Atotal of 23 procedures were performed in 17 patients; 2 had ERCP done thrice, 2 underwent the procedure twice, while the rest had single procedure done. Six (35.3%) patients had chronic pancreatitis, 7 (41.2%) had acute recurrent pancreatitis and 4 (23.5%) had acute pancreatitis. Endoscopic minor papillotomy was performed. There was no procedure-related mortality. ERCPaffected management in 88.2% (15/17 procedures). CONCLUSION: ERCPis a safe and feasible procedure for pancreas divisum patients.

Guidelines on gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is the most common acid-related disorder encountered during clinical practice in Pakistan and is associated with significant impairment of health-related quality of life. A number of guidelines and recommendations for the diagnosis and management of GERD have been published in different countries, but a Pakistani accepted directive by the standards of evidence-based medicine is still lacking. Our aim was to create an understanding of the natural history and presentations of reflux disease; evaluating possible treatment options available for the patients with complex and uncomplicated reflux ailments with the development of current and up to date evidence based endorsement, relevant to the needs of Pakistani health care providers in order to treat oesophageal manifestations of GERD. In order to make such guidelines, a comprehensive literature search was conducted with pertinent evidence reviewed, and quality of relevant data assessed. The resultant conclusions were based on the best available evidence and expert opinion of the authors of technical review panel.

Malignant pyloro-duodenal obstruction: role of self expandable metallic stents.

OBJECTIVE: To determine the outcome of duodenal stenting in palliation of patients with malignant pyloric and duodenal obstruction. METHODS: The non-randomised prospective descriptive study was conducted at the Endoscopy Suite, Surgical Unit-IV, Civil Hospital, Karachi, from December 2007 to November 2010. All patients presenting with inoperable ampullary, pancreatic or biliary cancers causing duodenal obstruction and patients with resectable malignancy but unfit for surgery were included. The procedure was carried out by a single expert endoscopist under local or general anaesthaesia as required. Boston Scientific stents of variable sizes were used. Follow-up was done at 1 week, 1 month and 6 months. Data analysis was done using SPSS 15. RESULTS: Over the study period, 159 (60%) males and 6 (40%) females were included in the study. The male-to-female ratio was 2:3. The overall age ranged from 25-80 years with a mean of 52.67 +/- 15.07 years. Primary diagnosis was pyloric carcinoma in 7(46.6%), carcinoma Gallbladder in 4(26.6%), Duodenal carcinoma in 3(20%) and carcinoma head of pancreas in 1(6.6%). Relief of symptoms were seen in 11 (73.3%), while complications were seen in 2 (13.3%). Stents were inserted with technical success in 14 (93%) patients. Clinical success was seen in 11 (73%), with a mean survival of 74.27 +/- 40.7 days (range: 15-180 days). No statistical significance was found when comparing the survival time with age, gender and diagnosis. CONCLUSION: Use of self-expandable metallic stents for gastroduodenal malignancies appears to be a feasible, safe and effective method, especially in those patients with limited life expectancy.

Frequency and risk factors in the post-ERCP pancreatitis in a tertiary care centre.

OBJECTIVE: To evaluate the frequency and associated factors in the post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Endoscopy Suite of Surgical Unit IV, Civil Hospital, Karachi, from December 2009 to November 2010. METHODOLOGY: Patients undergoing ERCP were included. Patients who had presented with pancreatitis or raised amylase levels before procedure or patients who had previous history of surgery on the biliary or pancreatic systems were excluded from the study. Pearson chi-square and Fisher's exact test were used for qualitative data and t-test for quantitative data. Significance was taken as p ² 0.05. Odds ratio was calculated for the qualitative data using 95% confidence interval. RESULTS: Age of the study population ranged from 9 to 90 years (mean age 46.5 ± 14.94 years, median 45 years). Male to female ratio was 1:1.87. Pancreatitis was seen in 18 patients (3.6%), mild in 15 (3%), moderate in one (0.2%) and severe in 2 (0.4%). Mean amylase level at 4 hours and 24 hours was 280.93 ± 539.13 and 168.83 ± 338.34 respectively. Pancreatitis was seen in 15/326 (4.6%) females and 3/174 (1.72%) males. Statistically significant increased risk for pancreatitis was seen in difficult cannulation (9.8%, p = 0.006), prolonged cannulation time (7.6 minute, p = 0.002), pancreatic duct cannulation (13.7%, p = 0.001) and pancreatic duct contrast injection (13.4%, p < 0.001). CONCLUSION: The frequency of post-ERCP pancreatitis was 3.6%. Difficult cannulation, pancreatic duct cannulation, pancreatic duct contrast injection and balloon sphincteroplasty were associated with higher frequency of post-ERCP pancreatitis. Reuse of ERCP accessories poses no additional risk to the frequency of pancreatitis.

Endoscopic retrograde cholangiopancreatography: a therapeutic modality in children and adolescents.

OBJECTIVE: To evaluate the indications, clinical features, complications, and effect on patient management of Endoscopic retrograde cholangiopancreatography (ERCP) in paediatric patients of varying age. METHODS: A prospective, descriptive cross sectional study was conducted at the endoscopy suite, Surgical Unit 4, Civil Hospital Karachi; from January 2007 to August 2010. All ERCPs performed during a 3-year period in patients aged 18 years or less were prospectively analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy. RESULTS: A total of 40 children and adolescents (18 Males, 22 Females; mean age 13.6 +/- 3.37 years, range 3 to 18 years) underwent 52 ERCP procedures. Indications were biliary pathology in 21, and pancreatic pathology in 19. The ERCP findings were choledocholithiasis in 12 patients, choledochal cysts in 5, chronic pancreatitis in 8, pancreatic pseudocyst in 5, recurrent pancreatitis in 5, biliary ascariasis in 2, pancreatic divisum in 1, postoperative bile leak in 1, and benign biliary stricture in 1. ERCP was successful in 51 of 52 procedures. Single procedure was performed in 36 patients, where as two patients required 2 procedures and it was repeated 4 and 6 times in the remaining two patients. Endoscopic therapy was performed in 92% of the procedures. The complication rate was 1.9% (1/52 procedures) which included mild pancreatitis, whereas asymptomatic hyperamylasaemia was seen in 11% (6/52 procedures). No mortality related to ERCP occurred. ERCP affected management in 94% (49/52 patients). CONCLUSION: ERCP is an effectual and safe therapeutic procedure in children and adolescents of different ages with a variety of pancreatobiliary disorders.

Endoscopic management of post operative bile duct injuries.

OBJECTIVE: To evaluate the pattern of post-operative bile duct injuries and their subsequent endoscopic management. METHODS: The prospective, non-randomised, cross-sectional study was conducted at the endoscopic suite of Surgical Unit-IV of the Civil Hospital, Karachi, over a period of three years. A total of 97 patients were included in the study. Post-procedure patients were followed up for resolution of symptoms and cessation of the bile leak. Patients with complete biliary cutoff or transection on Endoscopic Retrograde Cholaugio-Paucreatography (ERCP) were advised Magnetic Resonance Cholaugio-Papereatography (MRCP). Average followup of patients in our study was for 3 months. Mann Whitney U test was applied for non-parameteric data. RESULTS: Out of 97 patients in the study, 82 (84.5%) presented with post-operative bile leakage and 15 (15.5%) with obstructive jaundice. The age of the study population ranged between 20-70 years with a mean age of 40.80 +/- 13.45 years. Male-to-female ratio was 1:3. ERCP findings in our study included 41 (42.26%) patients with bile leakage out of which 27 (27.8%) had high-grade leak and 5 (5.1%) had low-grade leak, while 9 (9.3%) patients had Common Bile Duct (CBD) stones. Among the patients, 39 (40.2%) had complete cutoff of CBD. There were 15 patients with strictures and 6 with normal ERCP. As for the bile leads, 36/41 (87.8%) patients were managed successfully by endoscopic stenting, stone removal or simple sphincterotomy. Of the 41 patients, 5 (12.2%) with bile leak developed biliary stricture on subsequent ERCP. Nine of the 15 patients (60%) with complete cutoff on initial endoscopy were successfully stented on subsequent ERCP after demonstration of biliary continuity on MRCP. Six (40%) patients were referred for surgery. CONCLUSION: Patients with postoperative biliary leaks fare much better than those with complete cutoff or strictures. MRCP should be done in all patients where ERCP shows loss of biliary continuity. Re-exploration should be deferred till all other non-invasive modalities have been tried.

Benign esophageal strictures: behaviour, pattern and response to dilatation.

OBJECTIVE: To evaluate the endoscopic dilatation of benign esophageal strictures and its outcome. METHODS: A prospective descriptive study was conducted at Surgical Unit 4 of Civil Hospital Karachi, over a period of 24 months, from August 2006 to July 2008. Twenty seven patients with benign esophageal strictures underwent esophageal dilatation under fluoroscopic guidance using Savary Gilliard Dilators and guide wire. Follow up was done weekly for 2 weeks and monthly for a minimum of 6 months. Treatment success was gauged according to improvement of dysphagia. RESULTS: A total of 27 patients were included in the study. There were 16 (59.3%) corrosive strictures, 10 (37%) were peptic strictures and one (3.7%) was due to extrinsic compression. Majority of the corrosive strictures, 11 (68.75%) were suicidal in intent p < 0.001. Mean dilatation frequency for strictures longer than 5cms was 7.10 +/- 5.322 vs. 3.47 +/- 3.281 for strictures < 6cms (p < 0.037). Corrosive strictures were seen more commonly in the upper esophagus as compared to peptic (Mean 22.44 +/- 5.240 cm vs. 30.20 +/- 4.780 cm), p < 0.001. Only 81.4% corrosive stricture could be adequately dilated at initial dilatation as compared to 100% in peptic strictures. Mean symptomatic recurrences per month were 0.6919 +/- 0.300 in corrosives and 0.365 +/- 0.293 in peptic strictures (p < 0.003). There were 4 procedure related perforations, all in patients with corrosive strictures. Overall mortality was 7.4%. CONCLUSION: Endoscopic dilatation is safe and effective in treating benign and corrosive esophageal strictures, which have a higher complication rate. Mean recurrence rate decreased over a period of time in both peptic and corrosive strictures.

An experience of capsule endoscopy from a tertiary care hospital in Pakistan.

OBJECTIVES: To evaluate the effectiveness of capsule endoscopy in the management of patients with obscure gastrointestinal bleeding. METHODS: A prospective descriptive study was conducted at surgical unit IV, Civil Hospital Karachi over a period of 2 years from December 2007 to November 2009. Twenty eight consecutive patients presenting with obscure gastrointestinal bleeding were included in the study. Patients having history of acute intestinal obstruction were excluded. Study was approved by the hospital ethical committee. Informed and written consent was taken from all the patients included in the study. The procedure was performed as day case. Patients were asked to swallow a capsule with a glass of water after an overnight fast and bowel preparation. Endocapsule (Olympus MAJ-1469) was used in the study. Examination was termed as complete when the capsule reached the caecum or incomplete if capsule failed to enter the caecum or the battery life was exhausted. Computer recordings were read by two examiners and finally results were interpreted. Follow up was done on telephone every 24 hours till the passage of capsule and then monthly for 4 months. In case of failure to pass the capsule after 14 days or adverse effects like vomiting, abdominal pain, an abdominal radiograph was obtained and decision regarding surgical intervention was made. RESULTS: A total of twenty eight patients were included in this study, 15 (53.6%) males and 13 (46.4%) females. Age of the patients ranged from 15-85 years (mean 56.25 +/- 19.6 years). There were 8 (28.6%) diabetics, 8 (28.6%) hypertensives and 5 (17.9%) hepatitis C positive patients. The indication for the capsule endoscopy was malena in 9 (32.1%), occult bleed in 18 (64.3%) and non specific abdominal pain in 1 (3.6%). Examination was completed in 22/28 (78.6%) patients while 6 (21.4%) patients had incomplete examination. In 2/28 (7.1%) patients endoscopic assistance was required to push the capsule through the pylorus. There was history of abdominal surgery in 3/28 (10.7%) patients prior to capsule endoscopy. Capsule entrapment occurred in 2/28 (7.1%) patients who were subjected to surgery. The results of capsule endoscopy showed ulceration and bleeding in distal ileum in 7 patients followed by Arterio Venous Malformation in 6 patients. The management and follow up was done accordingly. CONCLUSION: The diagnostic yield of CE in this study was 64.28% (18/28 patients). In a total of 28 patients referred for capsule endoscopy, bleeding was resolved in 13 patients (46.42%). Capsule endoscopy is a well tolerated and safe examination of the small bowel with a diagnostic yield superior to radiological investigations.

Endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones.

OBJECTIVE: To evaluate the effectiveness of endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones. METHODS: A prospective non-randomized descriptive study was conducted at the Endoscopic Service of Surgical Unit 4, Civil Hospital Karachi over a period of 2 years from February 2007 to January 2009. A total of 84 patients where the biliary calculus was either greater than 15 mm or difficult to remove with standard techniques underwent ERCP with endoscopic sphincterotomy and balloon sphincteroplasty. Patients with diagnosis of cholangitis or pancreatitis were excluded from the study. Endoscopic balloon dilatation was performed after standard sphincterotomy by using standard 15-18 mm Controlled Radial Expansion (CRE) balloons. All procedures were done as day case under conscious sedation. RESULTS: There were 18 (21.4%) male and 66 (78.6%) females. Age of the study population ranged from 16-85 years with a mean of 48.38 +/- 17.07 years. The size of the stone ranged from 10-32 mm with a mean of 14.7 +/- 0.44 mm. Stones were removed with sphincteroplasty in first session in 52/84 (61.9%) patients, 11/17 (64.4%) patients in the second session and 4/4 (100%) in the third session. Patients who were lost to follow up were 14 (16.7%). Surgery was advised for 2 (2.4%) patients because of failure to remove stones by sphincteroplasty. Overall success of endoscopic sphincterotomy and large balloon dilatation in our study was 79.76%. Complications were seen in seven patients (8.3%) while one (1.2%) died. Bleeding was encountered in 3 (3.6%) patients which was controlled by adrenaline injection in 2 patients while one patient died due to severe haemorrhage before any surgical intervention could be undertaken. Moderate pancreatitis necessitating admission was seen in 3 patients (3.6%). None of the patients had severe pancreatitis or perforation secondary to the procedure. CONCLUSION: Large balloon dilatation along with endoscopic sphincterotomy is a simple, safe and effective technique in removing large bile duct stones, in patients with distal common bile duct narrowing or in whom the size of stone is greater than the size of common bile duct with a complication rate if not less equal to that of endoscopic sphincterotomy alone.

Palliative management of irresectable carcinoma esophagus using self expandable metallic stent (SEMS).

OBJECTIVE: To evaluate the symptomatic relief of dysphagia after stenting in patients with carcinoma esophagus METHODS: A prospective non randomized descriptive study was conducted at Surgical Unit 4, Civil Hospital Karachi, Pakistan over a period of 1 year, from August 2006 to July 2007. A total of 41 patients with biopsy proven carcinoma esophagus having irresectable disease on the basis of CT scan or poor risk for major surgery were included in the study. Self expandable metallic stents were placed under fluoroscopic guidance in all the patients. Follow up was done weekly for 1 month and monthly for 6 months or till death of the patient. Data was analyzed using SPSS version 11. RESULTS: Age of the study population ranged from 25-80 years with mean age of 51.49 +/- 14.25 years. Male to female ratio was 1.15:1. Preoperative dysphagia for solids was seen in 4.9%, for semi solids in 31.7%, and for liquids in 63.4%. 80.5% of patients had squamous cell carcinoma and 19.5% of patients had adenocarcinoma. Dilatation prior to stenting was done up to 12.8 mm in 65.9%. Complete relief of dysphagia was seen in 73%. No procedure related mortality was seen in our study. Overall complication rate was 29.2%. CONCLUSION: SEMS is an effective method for the relief of dysphagia in patients with irresectable carcinoma esophagus.

Needle knife papillotomy for cannulating difficult papilla; two years experience.

OBJECTIVE: To evaluate the success rate and complications of precut-papillotomy using a needle knife, for cannulating difficult papilla during Endoscopic retrograde cholangiopancreatography. METHODS: Records of patients requiring a pre-cut with needle knife to access the common bile duct or pancreatic duct during a two year period wore analyzed retrospectively. The success rates and complications of needle knife papillotomy were specifically looked for along with the underlying diagnosis. RESULTS: From January 2005 to December 2006, 515 ERCPs were performed at two private centers in Karachi by a single operator. Of these 59 patients required needle knife papillotomy to access the common bile duct with a success rate of 95% (56 patients). In 39 cases, CBD was cannulated immediately while in 15, two attempts were required and in 2 cases successful cannulation was possible at the third attempt. There were three failures. Among these one had a large duodenal diverticulum, one opted for a percutaneous drainage after first attempt and the third was lost to follow up after the first attempt. No major complications occurred from needle knife pre-cut papillotomy in this series. Three patients (5%) had minor bleeding out of which one required Adrenaline injection for maintenance of haemostasis. Two patients (3.38%), developed mild pancreatitis requiring conservative management. There were no major bleeds, perforations, biliary sepsis or deaths. CONCLUSION: Needle-knife papillotomy increases the success of diagnostic and therapeutic procedures during ERCP. In the present series, minimal complications occurred as a result of precut, papillotomy.