Endoscopic retrograde cholangiopancreatography at Dhulikhel Hospital: outcome analysis.

BACKGROUND: Endoscopic Retrograde Cholangiopancreatography (ERCP) is an important but potentially invasive therapeutic procedure in treating various pancreatobiliary conditions. In Nepal, the ERCP services is limited to a few tertiary care centers mostly in the capital, Kathmandu. Dhulikhel hospital has started ERCP since 2011 providing services to patients from all over the country. The study analyzes the outcome from data since August 2011 to 2013 August. OBJECTIVE: To analyze the results of ERCP done in Dhulikhel hospital, Kathmandu University hospital. METHOD: This is a retrospective study. The ERCP records of all the patients done since August 2011 to August 2013 were retrieved. A total of 516 attempts of ERCP were done since August 2011 to August 2013. Out of these, 423 were included for the analysis. The repeat ERCP for the same patient due to failed cannulation or patients undergone ERCP but incomplete documentation were excluded. The demographic data, indications, the findings, the outcome in terms of success or failure to cannulation, success or failure of stone extraction, stenting and complications were all derived and analyzed. SPSS 16 version was employed for data management and analysis. RESULT: The female: male ratio was found to be 1.7 : 1. The mean age of patients were 50.57±17.8 Years. The most common indication for ERCP were: choledocholithiasis 208(49.17%); followed by: obstructive jaundice 69(16.3%) of undetermined cause, acute biliary pancreatitis 26(6.4%), suspected bile duct injury during cholecystectomy 18(4.2%), periampullary growth 21( 4.96%), Cholangiocarcinoma 12(2.8%), chronic pancreatitis 10( 2.3%), CBD stent exchange 23(5.43%), dilated cbd 21(4.96%) , acute cholangitis 14(3.3%).The most common finding was CBD stone in 308(72.81%), normal in 51(12.1% ), bile duct stricture in 45(10.63%). Bile duct injury during cholecystectomy was found in 13(3.1%), biliary obstruction due to ampullary growth and pancreatic head mass was found in 21(4.96%) and 6(1.41%) respectively. Choledochal cyst was found in 5(1.2%), chronic pancreatitis in 7(1.7%). Biliary fascioliasis was found in one (0.24%); and roundworm in 1(0.24).The most common complication was acute pancreatitis in 17(4%), post-ERCP cholangitis 6(1.4%), bleeding 6(1.4%), duodenal perforation in 1(0.2%), arrhythmia in 1(0.2%) and one death (0.2%). CONCLUSION: ERCP has been a potentially emerging therapeutic tool for various pancreato-biliary disorders in Nepal.

Open label comparative trial of mono versus dual antibiotic therapy for Typhoid Fever in adults.

BACKGROUND: Emerging resistance to antibiotics renders therapy of Typhoid Fever (TF) increasingly challenging. The current single-drug regimens exhibit prolonged fever clearance time (FCT), imposing a great burden on both patients and health systems, and potentially contributing to the development of antibiotic resistance and the chronic carriage of the pathogens. The aim of our study was to assess the efficacy of combining third-generation cephalosporin therapy with azithromycin on the outcomes of TF in patients living in an endemic region. METHODS: An open-label, comparative trial was conducted at Dhulikhel Hospital, Nepal, between October 2012 and October 2014. Only culture-confirmed TF cases were eligible. Patients were alternately allocated to one of four study arms: hospitalized patients received either intravenous ceftriaxone or a combination of ceftriaxone and oral azithromycin, while outpatients received either oral azithromycin or a combination of oral azithromycin and cefexime. The primary outcome evaluated was FCT and the secondary outcomes included duration of bacteremia. RESULTS: 105 blood culture-confirmed patients, of whom 51 were treated as outpatients, were eligible for the study. Of the 88 patients who met the inclusion criteria for FCT analysis 41 patients received a single-agent regimen, while 47 patients received a combined regimen. Results showed that FCT was significantly shorter for the latter (95 versus 88 hours, respectively, p = 0·004), and this effect was exhibited in both the hospitalized and the outpatient sub-groups. Repeat blood cultures, drawn on day 3, were positive for 8/47 (17%) patients after monotherapy, versus 2/51 (4%) after combination therapy (p = 0·045). No severe complications or fatalities occurred in any of the groups. CONCLUSIONS: Combined therapy of third-generation cephalosporins and azithromycin for TF may surpass monotherapy in terms of FCT and time to elimination of bacteremia. TRIAL REGISTRATION: Trial registration number: NCT02224040.