Clinical, laboratory and bacterial profile of spontaneous bacterial peritonitis in chronic liver disease patients

To determine the clinical and laboratory features, bacterial profile and antibiotic sensitivity pattern of Spontaneous Bacterial Peritonitis [SBP] in Chronic Liver Disease [CLD] patients presenting at a tertiary care hospital of Karachi. Cross-sectional study. PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi, from April 2010 to March 2012. CLD patients with ascites were recruited from PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi. Basic demographics, symptoms and clinical signs of patients were recorded. Patients with the history of antibiotic use within last 3 days or any intra-abdominal source of infection were excluded. Diagnostic paracentesis was done for ascitic fluid detailed report [D/R] and culture. Blood sample was collected for total leukocyte count, serum proteins and billirubin levels. Out of a total 152 CLD patients, 38 [25%] were diagnosed with SBP. Eight [24.2%] patients presented with classical SBP, 20 [52.6%] had culture negative neutrocytic ascites and 10 [26%] had bacterascites. Fever, abdominal tenderness and constipation were common in SBP patients. Ascitic fluid culture was positive in 19 [50%] patients. E. coli [65%] was the predominant pathogen followed by Enterococcus species [15%]. Resistance was high against cephalosporins [78%] and fluoroquinolones [69.6%] and least against amikacin [13%] and meropenem [12%]. Ascitic fluid D/R and culture together can lead to the accurate diagnosis of SBP and can guide for the right antibiotic choice as resistance to commonly prescribed antibiotic is common in such patients

Long term follow up of interferon treated chronic HCV patients in responders and non-responders

Interferon with ribavirin is the recommended treatment for chronic hepatitis C with a response rate ranging from 50-80% in different countries. Although sustained response is comparable to clinical cure, but whether interferon therapy slows down the disease process in non-responders and relapsers is not known. To determine the long term outcome of chronic HCV patients who have completed the interferon therapy and compare results between responders, relapsers and non-responders. Retrospective case record analysis of chronic hepatitis C patients who were treated with conventional interferon and ribavirin for 6 months during 1998 to 2002 and their follow up till 2011 were included. Depending upon the response they were divided into three groups i.e. responders, non responders and relapsers. A total of 175 patients were included. There were 126 [72%] males and 49 [28%] females, whose ages ranged from 11 to 70 years [mean 35.8 +/- 10.3]. After interferon therapy, 109 were sustained responders, 33 were relapsers and 33 non responders. Mean age of the responders [32.4 +/- 8.8 years] was significantly less as compared to non responders [40.4 +/- 12.0 years] and relapsers [42.4 +/- 8.0 years], [p < 0.05]. Responders had a much better follow up i.e four years as compared to non responders which was statistically significant[p <0.05]. During 10 years follow up, cirrhosis developed in 3 [2.8%] sustained responders, 6 [18.2%] non responders and 8 [24.2%] relapsers. During yearly followup, sustained responders had significantly lower mean ALT and AFP levels as compared to non responders and relapsers [p < 0.05] while non responders and relapsers had lower albumin levels as compared to the responders [p < 0.05]. Majority of the sustained responders had disease eradication, but non responders and relapsers should be followed for any evidence of cirrhosis

Comparison of rapid test with ELISA for the detection of hepatitis B surface antibodies

To compare the sensitivity and specificity of a rapid ICT test with ELISA for the detection of Hepatitis B surface antibody. Cross sectional comparative study conducted at PMRC Specialized Centre for gastroenterology and hepatology JPMC, Karachi from April 2012 - March 2013. A total of 206 apparently healthy adults were selected from a rural community. After taking informed consent, 5 ml blood was collected sera separated and tested for hepatitis B surface antibody [anti-HBs] by a rapid immuno-chromatographic test developed by Korea [Humasis] and ELISA simultaneously. As per manufacturer's guidelines, the rapid ICT test is interpreted as positive if antibody liters are > 30 mIU/ml and negative if the titers are <30 mIU/ml. For ELISA, the CDC interprets antibody titers > 10 mlU/ml as positive or prolective and < 10 mlU/ml as negative and recommends a booster dose. The results of ELISA [gold standard] were compared with rapid test using SPSS version 17.0. Out of 206 sera, using ELISA, anti-HBs was positive in 91[44.2%] sera and negative in 115[55.8%] sera. Using ICT, anti-HBs was positive in 85[41.3%] and negative in 121[58.7%] and the sensitivity and specificity of rapid test ICT was 83.5% and 92.2% respectively with overall accuracy of 88.5%. These figures fell to 70.8% sensitivity and 94.6% specificity with 81.5% accuracy when CDC cut off of 10 mlU/ml was used. The ICT kit gave good results in samples having high liters [> 100 mlU/ml] but had a limited sensitivity for cases having titers between 10 mlU/ml-100 mlU/ml, thus limiting its use and creating unnecessary demand for booster dose of vaccine. The rapid ICT for anti-HBs is not as sensitive as ELISA but can still be used for rapid decision making especially in OPD setups and remote areas

Comparison of different ICT kits for HBsAg and anti HCV using gold standard ELISA

To compare rapid tests [ICT] with 4[th] generation ELISA [gold standard] for hepatitis B and C infection. Biochemistry and Serology Laboratory of the Pakistan Medical Research Council, Research Centre, Jinnah Post Graduate Medical Centre, Karachi. Study was done over six months. ELISA confirmed 200 samples for HBsAg and 200 for Anti-HCV were selected, making a total of 400 samples. Out of 400 samples, 200 were positive and 200 negative on ELISA. These samples were further tested on three different brands of most frequently used rapid ICT Kits for HBsAg and Anti HCV. The sensitivity, specificity, negative predictive value, positive predictive value and cost effectiveness were compared using 4[th] generation ELISA as gold standard. The Rapid kits for HBsAg that were analysed included Acon [USA], Determine [Abbott] and Intec [China] and for Anti HCV they were Acon [USA], Membrane [Canada] and Nobis [Germany]. Out of 100 positive and 100 negative tests for HBsAg confirmed on ELISA, all rapid kits showed comparable results with ELISA. The sensitivity and negative predictive value of Intec China [98%] and Determine Abbot [98%] were similar to each other however, these were higher when compared to Acon USA [95%]. The rapid kit by Intec China was cheaper to the other two rapid kits and was therefore, the most cost effective rapid kit. The specificity and positive predictive value of all three HBsAg ICT kits was 100% and in agreement with ELISA. Out of 100 HCV positive and 100 HCV negative cases confirmed on ELISA, the rapid test by Acon USA showed maximum sensitivity. The sensitivity and negative predictive values of Acon USA were higher [93%] as compared to Membrane - Canada [89%] and Nobis- Germany [86%]. The specificity and positive predictive values of Acon were comparatively lower [93%] but did not significantly vary when compared with Membrane Canada [97%] and Nobis German [96%]. The rapid ICT Kits for HbsAg and anti HCV were equally sensitive and specific when compared with ELISA. These rapid kits are cheaper and easy to perform and their use should be encouraged especially in rural setting. ELISA confirmed rapid HBV, HCV kits being cheaper but sensitive and specific should be used for screening cases especially in rural setting

Factors influencing the response of interferon therapy in chronic hepatitis C patients

To determine factors influencing response of interferon therapy in chronic hepatitis C patients. Descriptive, analytical study. Pakistan Medical Research Centre, Jinnah Postgraduate Medical Centre, Karachi, from January 1998 to December 2009. Patients of chronic hepatitis C treated with conventional interferon were retrospectively analyzed. End treatment response at 6 months for genotype 2 and 3 and one-year for genotype 1 and 4 was assessed. Sustained virological response was checked after 6 months of cessation of therapy. Non-compliant and incomplete follow-up cases were excluded. Factors influencing the response to therapy were analyzed by univariate and multivariate logistic regression analysis. A total of 932 cases received interferon therapy; 103 were lost to follow-up and were excluded. Treatment was completed in 829 cases; end treatment response was 74% [615 out of 829 cases]. Six months post-treatment follow-up was available in 492 cases. Sustained virological response was seen in 63% [308 out of 492 cases]. Univariate logistic regression analysis showed significantly better response in patients with < 40 years of age, body weight < 70 kg, normal platelet count, serum albumin > 4.0 grams, non diabetic patients and those with a normal alanine aminotransferase [ALT] at 1st month of therapy. Multiple logistic regression analysis showed that only age < 40 years was significantly important for sustained virological response. For conventional interferon therapy, age < 40 years is the best predictor for sustained virological response, however, better response can be achieved in patients with < 70 kg weight, normal platelet count, serum albumin > 4.0 grams, non-diabetics and patients having normal ALT at 1st month of therapy

Comparison of healing of duodenal ulcer with herbal medicine versus allopathic medicine

Proton pump inhibitors heal over 90% cases of duodenal ulcer but these are expensive. Many patients are reluctant to use allopathic treatment and therefore, use alternate herbal medicines to achieve the same results. There is no head to head comparison of the efficacy of herbal treatment with standard allopathic treatment available in the literature. To compare the healing rates of duodenal ulcer using either herbal drugs [Andamali + Susi + Qarheen] or allopathic medicines [proton pump inhibitor]. Endoscopically diagnosed cases of duodenal ulcer were assigned to two groups where one group received herbal medicine and the other received proton pump inhibitor for 4 weeks [Clarithromycin and Amoxicillin were added for a week for Helicobacter pylori positive cases]. Healing was checked on endoscopy at the completion of therapy. Complete blood count, liver function tests, urea and creatinine were done initially and at the end of therapy to see any adverse effects of the therapy. Other side effects were also noted during the study. A total of 42 endoscopically proven cases of duodenal ulcer were included in the study, 22 patients received proton pump inhibitor [group A] and 20 received herbal medicine [group B]. Seven cases [5 in group A and 2 in group B] were lost to follow up and were thus excluded from the study. Thirty-five cases [17 group A, 18 group B] completed the study. Out of these 35 cases, 29[82.85%] were males and 6[17.1%] females. Helicobacter pylori was present in 19[54.3%] cases [10 in group A and 9 in group B]. After 4 weeks of therapy, 16[94%] cases healed with proton pump inhibitors and 13[72%] healed in herbal medicine group. The difference in healing rates was not significant. Using proton pump inhibitors along with 2 antibiotics in the Helicobacter pylori positive cases, 9 out of 10[90%] showed healing of ulcer, while 7 out of 9[78%] cases in herbal medicine group who were positive for Helicobacter pylori, but did not receive antibiotics also showed healing. Regarding adverse effects, bitter taste in mouth was reported in 5[29%] and diarrhea in 2[12%] patients, receiving triple regimen in group 'A' against only 2[11%] patients who had similar complaints with herbal medicine. No significant change was observed in the hematological and biochemical parameters like CP, LFTs, urea and creatinine from the baseline to the end of therapy in both groups. Healing of duodenal ulcer is almost similar with both herbal and standard allopathic drugs; however, adverse effects were more common with allopathic drugs. Herbal medicine can be used to treat duodenal ulcer

Is raised helicobacter pylori antibody titre enough to decide retreatment?

Helicobacter pylori infection causes a rise in its antibodies which take almost a year to come to baseline following successful eradication treatment. Checking these values in between a year may give falsely high values and many patients may thus be over treated. Aims: To serially determine Helicobacter pylori antibody titres in patients after giving them triple therapy for H. pylori eradication and see how these values drop over time. Longitudinal study conducted in Department of Gastroenterology and Hepatology, Pakistan Medical Research Council, Research Centre, Jinnah Post Graduate Medical Centre, Karachi, from May 2006 to April 2010. Over the period of four years, 186 patients who were found positive for campylobacter like organism test during endoscopy were further tested for anti H. pylori IgG titre before being treated for H.pylori. Patients were given triple therapy comprising of Omeprazole [20mg twice daily], Amoxicillin [1gm twice daily] and Clarythromycin [500mg twice daily] for a week and were followed at 1, 3, 6 and 12 months to check symptomatic relief and they were tested again for H. Pylori antibody titres. Data was collected on pre-designed proforma which included patient's demography, symptoms and diagnosis. Out of 186 patients who had a positive campylobacter like organism test, 173 patients consented to participate in the study. Serology for H. Pylori was positive in 119[68%] cases. A decline in mean antibody titres was observed as 11%, 21.5%, 54.7% and 59.2% at 1, 3, 6 and 12 months respectively. Sensitivity of serology for diagnosing H. pylori infection is good but using these as a tool for monitoring response to treatment is doubtful. A slow drop in H. pylori antibodies was seen over 12 months and therefore, physicians are cautioned not to retreat the already treated cases till about one year post treatment. H. pylori antibodies should be checked on regular basis to diagnose new cases but it should not be used in previously treated patients to retreat

Screening of HBsAg and anti HCV from tertiary care, private and public sector hospitals

To find out the frequency of hepatitis B surface antigen and hepatitis C antibodies in patients referred from a tertiary care public sector hospital, other public sector and private hospitals of Karachi. Pakistan Medical Research Council's Specialized Research Centre for Gastroenterology and Hepatology, at Jinnah Postgraduate Medical Centre Karachi from January to December 2009. A cross sectional study was conducted where patients were referred from different departments of Jinnah Postgraduate Medical Centre [tertiary care public sector hospital], other public sector hospitals, private hospitals and clinics for the screening of hepatitis B and C virus infection. Three ml blood was collected from each patient, serum separated and tested for HBsAg and Anti HCV using Abbott Murex 4th Generation ELISA kits. A total of 2965 cases were referred in a year. Overall seroprevalence of HBsAg and Anti-HCV was 5.9% and 12.8% respectively. HBsAg positivity in patient referred from public sector hospitals was 5.8%, those from private 12.5%, 16.7% and 8.5% respectively. Co-infection of hepatitis B virus and hepatitis C virus was seen in 0.9, 2.5 and 1.4% cases respectively. breakdown of viral positivity within different departments of Jinnah Postgraduate Medical Centre Karachi showed HBsAg positivity of 7.1%in Medical department, 5.2% in Surgical department, 5.0% in Gynaecology department, 6.6% in other departments of Jinnah Postgraduate Medical Centre while, only 1.7% were positive from Pakistan Railway, hospital Anti HCV positivity was maximally [20.3%] seen in medical department followed by 14% in other departments, 10.9% in surgical department, 7.9% in gynaecology and 5.1% in railway hospital. Co-infection of HBV and HCV was seen in 2% cases referred from medical department, while rest of the departments had less than 1% positivity of co-infection. Both genders were equally infected with HCV, but males were predominantly more infected with HBV, with a male to female ratio of 2:1 [p>0.001]. High frequency of HBV and HCV infection is due to a biased population of hospitalized cases. High referral from medical and gynaecology department indicates high awareness about these diseases in the health care providers and similar awareness needs to be created in other departments of public and private sector hospitals. Serious efforts need to be done to inculcate awareness regarding HBV and HCV in all departments of public and private hospitals

Ovarian reserve and bmi between fertile and subfertile women

To compare the ovarian reserve and BMI in fertile and subfertile women aged 20-39 years by ultrasonography. A comparative study. The Ultrasound Clinic, PECHS, Karachi, from March to December 2006. Eighty women, 40 fertile and 40 subfertile, were subdivided into age groups of 20-29 and 30-39 years. Total ovarian volume [OV] was determined transabdominally [OV-TA] and tranvaginally [OV-TV], antral follicle count [AFC] was performed transvaginally; and BMI was calculated. Unpaired t-test and Pearson correlation tests were used for analysis. In the total and subfertile females, aged 20-29 years, OV-TA obtained was 10.47 +/- 3.81 ml vs. 7.0 +/- 2.67 [p=0.015], OV-TA was 12.55 +/- 4.53 ml vs. 8.36 +/- 2.36 ml [p=0.001]; AFC was 7.35 +/- 3.02 vs. 5.7 +/- 3.57 [p=0.027] and BMI was 23.4 +/- 3.9 vs. 26.5 +/- 4.7 [p=0.006]. In the older group of fertile and subfertile females, aged 30-39 years, OV-TA was 7.92 +/- 2.01 ml vs. 6.74 +/- 2.38 [p=0.097], OV-TA was 9.97 +/- 2.99 vs. 7.73 +/- 2.40 p=0.012], AFC was 5.30 +/- 2.05 vs. 3.05 +/- 2.46 [p=0.003], and BMI was 24.4 +/- 3.8 vs. 27.4 +/- 4.80 [p=0.034]. A significant negative correlation was present between ovarian volume and BMI in the older fertile women only [p=0.001 r=0.3] whereas no significant correlation was seen in the two parameters in any other group [r=0.1]. The ovarian reserve decreased with increasing age. The lack of ovarian reserve may lead to subfertility of early ovarian ageing. Ovarian volume showed decrease with an increase in the BMI, indicating the possible decrease in fertility with an increase in a woman's weight

Implementation of directly observed treatment short course at a trust hospital in Karachi

In Pakistan directly observed treatment short course has its own limitation, as we discovered daily attendance was not acceptable to the patients as it entailed loss of working hours and extra expense of daily travel and reluctance of young unmarried girls to attend daily because of social stigma and hence weekly attendance and free drugs were introduced with a responsible member of the family, i.e. mother in case of young unmarried girls and wives to see that the husband take his daily drugs this had better compliance and we have been able to achieve cure rate. In view of the heavy burden of tuberculosis in Pakistan directly observed treatment short course strategy was adopted throughout Pakistan. To audit the results of directly observed treatment short course implemented in a clinic where some modification were made because of compelling circumstances. Chiniot General hospital, Karachi is a trust hospital where all types of patients are treated and admitted at a subsidized cost. Tuberculosis clinic in collaboration with directly observed treatment short course was established with an understanding that patients would be seen free. All patients attending the tuberculosis clinic during the last three years ending 31[st] December 2004 and diagnosed as tuberculosis pulmonary/extra pulmonary were registered and provided free drugs for 8 months. Diagnosis of tuberculosis was made mainly by direct smear microscopy for acid fast bacilli, chest X-ray and mantoux test. Extra pulmonary diagnosis was made by fine needle aspiration, biopsies and cultures were done when required. A total of 692 patients with all form of tuberculosis who attended the free clinic were analyzed. There were 237 males and 455 females [M:F ratio 1:2]. Disease was pulmonary in 487[79%] cases and extra pulmonary in 205[29.6%] cases. Majority of extra pulmonary cases had pleural effusion, adenitis, followed by abdominal and bones tuberculosis. Weekly free drugs were provided for the full course of 8 months. Seventy-five percent [519] cases completed the full course of anti-tuberculosis drugs and were discharged as being cured. Joint pains were the chief complaints expressed by the patients during therapy while drug toxicity was uncommon. Thirteen cases developed drug induced hepatitis, 4 had multiple drug resistance and referred to Ojha Institute Karachi for further therapy. Three patients died during treatment. Tuberculosis is a treatable disease and 75% cases achieved cure but there was a high default rate. Reasons for this default need to be explored and addressed

Risk Factors of hepatitis B and C transmission in patients coming to a hepatology out patients clinic

To see the possible risk factors for the transmission of hepatitis B and C in patients suffering from hepatitis B and C. Hepatitis B and C patients coming to a public sector hepatology centre and a private clinic. All patients suffering from hepatitis B and C of all ages and both gender were included in the questionnaire based study following a verbal consent form all participants. The data was collected over 1 year by 1 doctor at both the OPD and the private clinic. Data on 497 cases was collected, of the total cases 199 were suffering from chronic hepatitis B [HBV] and 298 from hepatitis C [HCV]. Males were more infected with chronic liver disease but hepatitis B was more prevalent in males. Majority of HBV [55.8%] and HCV [49.3%] cases were between 25-44 years age group and 40% HBV and 35% HCV cases were educated up to the secondary level. In 9% HBV and 10% HCV cases the father was also suffering from liver disease and 15% HBV and 13% HCV cases had a death of a family member due to liver disease. Risk factors like injections for various ailments was seen in 189 cases [95%] suffering from HBV and 286 [96%] from HCV, similarly past history of surgery and dental treatment and blood transfusion was significantly more in HCV, when compared with HBV. Though both HBV and HCV are blood born diseases but interfamilial spread of these viruses needs to interpreted with caution as it appears that the virus is coming from the community to the house hold members and the possible sources are treating physicians using a reused syringe, a dentist and barbers

experience of polypectomy in children and adults in Karachi

To see the morphological types of polyps, the acceptability of the procedure and the complications following polypectomy. Out patients department of Gastroenterology at PMRC, Research Centre, Jinnah Postgraduate Medical Centre, Karachi. All patients [children and adults] referred with history of bleeding per rectum underwent flexible sigmoidoscopy or colonoscopy without sedation or analgesia. Bowel cleansing was done using a laxative the night before the procedure and an enema on the morning of the procedure. The site, size and number of polyps were noted and polypectomy performed using Olympus PSD 10 cautry and a snare. Polyp was retrieved with a basket for histological examination. Post polypectomy patients were asked to report if there were any signs of bleed or abdominal distension. Over 3 years, 126 colonic polyps were seen [60 children and 66 adults]. The ages of the patients ranged from 2 - 82 years. The main presenting feature was rectal bleeding and the site of polyp was mostly the recto sigmoid area or the descending colon. Of 60 children, 13 were less than 5 years of age and 47 were between 5 - 15 years. The polyp was mostly single pedunculated cherry red in color. Five children had multiple polyps of whom 3 had polyposis coli. In adults majority had single polyp in the rectum or sigmoid and 11 had multiple polyps with 3 having polyposis coli. In adults most polyps had an ulcerated surface and a short pedicle. Post polypectomy 3 cases had a bleed within 24 hours, [1 child and 2 adults]. Both were admitted and transfused blood. On repeat examination the bleeding was seen from the base of the stalk which was electro coagulated with a hot biopsy forceps. None required surgery. On histology 58 polyps were hyperplasic and 51 hamartomatous including juvenile polyps. Only one adult had a tub-villous adenoma. Biopsy was not done in 9 adults and 7 children. All patients tolerated the procedure well and none required anesthesia or analgesia. Majority of the polyps in children and adults were hyperplasic or hamartomatous with only one adult having tubovillous adenoma. Only 3 [2.4%] had a post polypectomy bleed which was managed by electro coagulation of the stump

Role of ursodeoxycholic acid in lowering ALT in chronic liver disease

The objective was to see the efficacy of ursodeoxycholic acid in improving the ALT levels in patients suffering from chronic liver disease. Thirty patients suffering from chronic liver disease [either B or C] were given oral ursodeoxycholic acid in a dose of 250 mg twice a day for 4 months. Their blood biochemistry and haematology were repeated monthly for 7 months i.e. 4 months of therapy and 3 months post therapy to see the response. The mean ALT levels of 30 patients who completed the study was 101+47 IU/L. During therapy 24 cases [80%] showed lowering of their ALT levels while 6 [20%] either showed no response or worsening of ALT levels. Of 24 cases who showed an improvement in their ALT levels; over 25% drop in ALT levels was seen in 217 cases [70%] and less than 25% drop seen in 7 cases [30%]. The mean ALT values during therapy were 75 IU/L showing an overall 25% reduction from the baseline values. Following cessation of therapy the mean ALT levels showed a rise to 90 IU/L which was almost similar to 101 IU/L value in the pre treatment period. The study showed some role of ursodeoxycholic acid in improving the ALT levels in chronic liver disease