Hepatitis-C during Pregnancy: Antenatal period challenges, management and the way forward.

Pregnant women and the general public are both directly impacted by cirrhosis which is a chronic liver disease. It is also widely known that women who have a history of injectable drug use and cirrhosis are more prone to experience unfavorable consequences that have a negative impact on the health of both the mother and the unborn child. Higher maternal Hepatitis-C Virus (HCV) in pregnancy viral load, length of labor, use of amniocentesis or fetal scalp monitoring and protracted membrane rupture are all the risk of perinatal transmission of HCV in newborns. Globally, a large number of childbearing-age women become affected by HCV every year and vertical transmission of HCV is still a serious public health concern. Pregnancy-related immune alterations have a significant impact on the course of HCV infection throughout the third trimester and provide favorable circumstances for the spread of the virus. The exacerbation of hepatic damage during pregnancy and the postpartum period is mostly responsible for HCV-specific cell-mediated immune responses. An extensive literature search done via electronic search engine including Cochrane library databases, PubMed, Google Scholar, Science Direct and HCV in pregnancy articles were included.

Seroprevalence of Hepatitis-E Virus-Immunoglobulin G and its association with Chronic Liver Disease.

Background & Objective: Viral hepatitis is a major public health concern in low-middle income countries. Hepatitis-E infection (HEV) is found globally but most prevalent in low-income countries especially those with poor sanitation systems, access to clean drinking water and health services. Superinfection with HEV in patients with chronic liver disease (CLD) can cause severe hepatic decompensation leading to increased morbidity and mortality. To determine the frequency of seroprevalence of Hepatitis-E virus Immunoglobulin g (IgG) and its association with chronic liver disease. Methods: A cross-sectional study was conducted in Asian Institute of Medical Sciences, Hyderabad, Pakistan from January till May 2022. A total of 196 patients of aged ≥ 18 years, presenting in gastroenterology clinics were included in the study after informed consent. Result: Among 196 patients, one third of patient were male (73.5%). Out of which 162 (82.7%) had liver disease and 34 (17.3%) were without liver disease. The median age of patient was 45 (33-51) years. The overall seroprevalence of HEV IgG among study population was 69.4%. HEV IgG was present in 114 and 22 in CLD and non CLD patients respectively. Multivariable regression shows no association between seroprevalence of HEV in CLD and non-CLD patient (AOR 1.02, 95% CI 0.45-2.313). Conclusion: Our study showed high frequency of HEV seropositivity. No difference was observed in HEV seropositivity among CLD and non-CLD patients.

Innovation in direct intrahepatic portosystemic shunt; a developing country experience.

Anticoagulants are the first-line treatment option for patients with Budd-Chiari syndrome (BCS); however, intervention is required when this fails. Although, the ultimate treatment is liver transplant, other radiological procedures are for the management of the disease and bridge to definitive therapy. TIPS (trans jugular intrahepatic portosystemic shunt) is a method used by interventional radiologists to create a shunt between portal vein and hepatic vein. At times it is technically not possible, in such cases, direct intrahepatic portosystemic shunt (DIPS) is performed. This patient underwent a successful DIPS procedure for BCS along with balloon dilatation (venoplasty) for inferior vena cava (IVC) stenosis.

Problems faced by patients and health service utilization experiences of gastrointestinal patients during lockdown due to COVID-19 pandemic.

Objectives: The COVID-19 pandemic undermined the health service delivery and utilization of essential health care services globally. The current study therefore aimed to explore the health-seeking behaviors and challenges faced by patients for the management of gastrointestinal diseases. Methods: A cross-sectional study was conducted at the outpatient department of Gastroenterology, Liaquat National Hospital, Karachi from March 2020 to July 2020 during the COVID-19 lockdown phase to explore patient experiences. Data was collected using a survey questionnaire. All patients of either gender were included after informed consent. Statistical analysis of the data was conducted using SPSS 21.0. Results: A total of 184 patients were included who visited the hospital to seek medical services during the COVID-19 lockdown phase. The mean age of the population was 42.7 years (±16.13). Of these, n=94 (51.1%) were males All patients had gastrointestinal issues with different comorbid conditions. One forty-seven n=147 (79.9%) presented with active complaints whereas, n=37 (20.1%) patients visited the hospital for their follow-up checkup. Out of 184 patients, n=33 (17.9%) patients reported of having fear of visiting hospital due to COVID-19 outbreak. A statistically significant difference p<0.001 was noted between the history of comorbidities and patient delaying a visit to the healthcare due to the fear of COVID-19. Additionally, 61 (73.5%) patients with co-morbidity faced difficulty in finding public transport (p=0.01). Nevertheless, n=171 (93.0%) patients expressed satisfaction with the services provided by the hospital during the lockdown phase. Conclusion: Patients with gastrointestinal conditions were largely affected by lockdown largely due to fear of contacting COVID-19 disease and inaccessibility to the public transportation. Widely available telemedicine service might overcome these shortcomings and ensure continuity of quality care.

Awareness and safe practices of Hepatitis-B and C prevention and transmission among workers of women beauty salons.

Background & Objectives: Hepatitis-B and C is currently a major health problem all over the world including Pakistan. All beauty treatments including manicures are used by many people and can be a risk factor because of sharing of contaminated instruments. Proper sterilization needs to be achieved by an autoclave. Our study was conducted to know the awareness and safe practices of Hepatitis-B and C prevention and transmission by beauty salon workers in Karachi. Methods: This was a cross-sectional descriptive study performed from February 2021- July 2021 among workers of women's beauty salons across Karachi. Validated questioners were distributed and were filled in the presence of research worker. Data was compiled and analyzed using SPSS version 22. Workers who scored ≥ 70% were considered to have adequate knowledge. Results: Our results showed that out of 261 participants, 240 (92.3%) were females. 49(18.8%) had adequate knowledge about hepatitis-B, 63(24.1%) had adequate knowledge about hepatitis-C. 111(42.5%) had adequate practices. According to the independent T test, there was statistically significant relationship between family history of hepatitis-B and knowledge of Hepatitis-B (p=0.022), hepatitis-B vaccination and knowledge of Hepatitis-B (p=0.006). We also found significant relationship between family history of hepatitis-C and knowledge of hepatitis-C (p=0.019), also between previous blood test performed for hepatitis antibodies and knowledge about hepatitis-B and C. On Uni-Variate logistic regression we found that males participants are less likely to have adequate Hepatitis-C knowledge in comparison of female participants (OR=0.152). We also found that participants who have Hepatitis-B family history, have more likely to have adequate Hepatitis-C knowledge (OR=1.874) and males participants are less likely to have adequate Hepatitis-B knowledge in comparison of female participants (OR=0.212). Only 45(17.2%) workers were fully vaccinated with Hepatitis-B and 126(48.3%) had knowledge of adequate sterilization technique of equipment's. Conclusion: This study showed that overall awareness among workers of women beauty salon in Karachi about Hepatitis-B and C is inadequate with low vaccination rates. There is dire need to organize awareness programs with mass vaccination campaigns for safe practices and to curb viral transmission.

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.

Frequency of iron deficiency anemia (IDA) among patients with Helicobacter pylori infection.

BACKGROUND AND OBJECTIVE: Helicobacter Pylori (H. pylori) is a widespread infection across the globe having a high prevalence among the developing countries. Iron Deficiency is anticipated to be the most prevalent micronutrient deficiency globally, the most frequent cause of anemia. Our objective was to determine frequency of Iron Deficiency Anemia (IDA) among patients with H. Pylori gastritis. METHODS: It was a cross-sectional prospective study. Patients fulfilling inclusion criteria were enrolled at Liaquat National Hospital, Karachi, Pakistan. Blood samples were taken for serum iron, transferrin saturation, ferritin, and total iron-binding capacity and H.pylori assessed by urea breath test, stool for antigen, Rapid urease test or histopathology. RESULTS: 112 patients with H. Pylori infection with anemia were included. 53 (47.3%) were males & 59 (52.7%) were females with mean age of 38.4464 ± 9.00634 years. Iron deficiency anemia was seen in 42 patients (37.5%). CONCLUSION: IDA was noted in 37.5% of cases. H. Pylori infection is a frequent cause of iron-deficiency anemia of previously unidentified origin among adults.

What gastroenterologists should know during COVID-19 Pandemic!

The WHO has declared a Pandemic due to Novel Corona virus-19 (COVID-19). Patients usually have respiratory symptoms but gastrointestinal and hepatic dysfunction are not uncommon presentations and can lead to a delay in diagnosis and management. Virus shedding can continue even after the nasopharyngeal swab gets negative and could lead to faecal-oral transmission. The effects of COVID-19 on patients with decompensated liver disease is still not clear. Managing immunosuppressive drugs in liver transplant and inflammatory bowel disease is a major challenge without clear guidelines. Only emergency endoscopy is to be done with personal protection equipment. Chloroquine and Hydroxychloroquine has shown some beneficial effects and is being used off-label. Without effective treatment, it is imperative to take precautionary measures.

Hepatitis-C Infection: Are we really committed to eliminate? Could it become the second Polio for Pakistan?

Pakistan's hepatitis C virus (HCV) burden is one of the highest in the world. Around eight million people live with HCV in Pakistan according to a National Hepatitis Survey. Most HCV-infected people are unaware of their infection status culminating in delayed diagnosis and treatment, progressing to end stage liver disease, cirrhosis, and hepatocellular carcinoma (HCC), thereby raising the disease load for a developing country with limited resources. Blood transfusions and injections with reused syringes lead to increased HCV rates in Pakistan. According to a survey viral infections like hepatitis C, hepatitis B and HIV were not screened in more than half of the blood transfusions done in Pakistan. Hepatitis C elimination requires financial support from the local government and private organizations, commitment from civil societies across the world and a dedicated political will. Without defining effective planning and strategy it is our fear that it could become the second Polio for Pakistan.

HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan.

Approximately one half of patients develop ascites within 10 years of diagnosis of compensated cirrhosis. It is a poor prognostic indicator, with only 50% surviving beyond two years. Mortality worsens significantly to 20% to 50% at one year if the ascites becomes refractory to medical therapy. Pakistan has one of the highest prevalence of viral hepatitis in the world and patients with ascites secondary to liver cirrhosis make a major percentage of both inpatient and outpatient burden. Studies indicate that over 80% of patients admitted with ascites have liver cirrhosis as the cause. This expert opinion suggests proper assessment of patients with ascites in the presence of underlying cirrhosis. This expert opinion includes appropriate diagnosis and management of uncomplicated ascites, refractory ascites and complicated ascites (including spontaneous bacterial peritonitis (SBP) ascites, hepatorenal syndrome (HRS) and hyponatremia. The purpose behind this expert opinion is to help consultants, postgraduate trainees, medical officers and primary care physicians optimally manage their patients with cirrhosis and ascites in a resource constrained setting as is often encountered in a developing country like Pakistan.

Zinc level assessment in patients having Viral Cirrhosis.

OBJECTIVE: Zinc is a vital trace element and its deficiency in cirrhosis might potentiate the development of hepatic encephalopathy. The objective of this study was to assess the zinc levels in serum of patients having viral cirrhosis and compare it with normal healthy controls. METHODS: This study was conducted in Department of Gastroenterology, Liaquat National hospital and medical college, Karachi, Pakistan; from January 2014 to December 2014. Total of 45 patients with the mean age of 52.44±8.7 years were included. The three groups of patients were made including Child Pugh Class Score B (Group-1), Child Pugh Class C (Group-2) and healthy controls (Group-3) having 15 patients in each group. Zinc levels in serum were evaluated by the help of atomic absorption spectrometry (Normal range50-150 µg/dl). RESULTS: Total of 45 subjects was enrolled in this study. Overall prevalence of zinc deficiency was noted in 13(28.9%) patients. Mean value of zinc levels in group 1,2 and 3 were 68.09±20.85, 50.69±15.86 and 92.91±17.18µg/dL respectively. Highly statistical difference was observed in the mean zinc level between three groups p=0.0001. An inverse correlation was observed between Child Pugh Score and the zinc level in serum r=-0.498. CONCLUSION: Patients suffering from advanced cirrhosis appeared to have lower serum zinc levels. In patients suffering from viral cirrhosis having hepatic encephalopathy, zinc supplementation might improve clinical outcome.

Safety of endoscopic N-Butyl-2 Cyanoacrylate injection for the treatment of bleeding gastric varices in children.

OBJECTIVE: To determine the safety and efficacy of N-butyl 2-cyanoacrylate in bleeding gastric varices in children. METHODS: This retrospective observational study was conducted in the Department of Gastroenterology and Pediatric Surgery in Liaquat National Hospital Karachi between January 2010 and January 2017. Gastric fundal varices were obliterated in pediatric population with single shot of N-butyl-2 Cyanoacrylate 0.50ml diluted with 0.50ml of Lipoidal with use of forward-viewing video endoscope with 22-gauge needle. The primary outcome was primary hemostasis, Secondary outcome was complications, re-bleeding and mortality. RESULTS: Thirty patients was included in the study, 18(60%) were male with mean age of 7.12± 2.9 years. Non cirrhotic portal hypertension was the most common etiology in 15 (50%) patients, followed by liver cirrhosis secondary to hepatitis B and D co-infection in 6(20%) patients. Primary hemostasis was achieved in 29 (96.7%), while 3(10%) patients developed re-bleeding after 48 hours, and hemostasis was achieved after second session of endoscopic obliteration. Abdominal pain and fever developed in 3(10%) patients which was managed conservatively. Mortality was observed in 1(3%) of cases due to sepsis after shunt surgery. CONCLUSION: Endoscopic fundal varix obliteration with N Butyl-2 cyanoacrylate was safe and effective in treatment of gastric variceal hemorrhage in children.

MORBIDITY AND MORTALITY ASSESSMENT IN ACUTE HEPATITIS-E.

BACKGROUND: Hepatitis-E is an enterically transmitted virus causing acute hepatitis. Mostly it is a self-limiting clinical course, but can be life threatening in certain high risk groups. Pakistan is endemic for Hepatitis-E with limited published literature. The aim of this study is to evaluate the predictors of mortality in patients with acute Hepatitis-E. METHODS: We analyzed the medical records of 369 adult patients with Hepatitis-E infection admitted at Aga khan University Hospital, from January 1996 to December 2010. Details of their laboratory investigations, clinical course and complications such as FHF and mortality were noted. The outcome was compared, and determinants of mortality were evaluated in important patient subgroups. RESULTS: Out of 369 patients with Hepatitis-E, 326 (88.3%) were discharged after full recovery. Out of these 22 (6%) patients had chronic liver disease CLD in this study, of whom 10 (2.7%) expired (p-value <0.001). There were about 67 (18%) pregnant patients, with a mean gestational age of 29.19 +/- 7.68 weeks and 5 (1.4%) pregnant patients died (p-value=0.23). A total of 58 (15.7%) patients were coinfected with other hepatotropic virus, and a comparison did not find an increased risk of mortality in this group. CONCLUSION: This study showed that Hepatitis-E is significantly associated with mortality in patients suffering from pre-existing chronic liver disease. Pregnancy was not a determinant of mortality in Hepatitis-E patients in this study, and neither was coinfection with other Hepatotropic viruses.

Skin manifestations in diabetes mellitus.

Background: Diabetes mellitus affects all systems of the body. Skin is also frequently involved. The aim of the study was to assess the frequency of various skin manifestations in patients with diabetes mellitus. Methods: This descriptive study was conducted at the out-patient diabetic clinics at Aga Khan University Hospital, Karachi. One hundred consecutive patients, both male and female suffering from either type-1 or type-2 diabetes mellitus were included. Results: Out of hundred patients, skin changes were present in 84% of patients. The most frequent finding was skin infections present in 29.7% of patients and the second most common finding was diabetic dermopathy found in 28.5% of patients. Other finding were: Acanthosis Nigricans in 19%, sweating complications in 14.2%, nail involvement in 10.7%, oral involvenient in 5.9%, diabetic foot in 5.9%, xanthelasma in 4.7%, yellow skin in 1.1%, generalized Pruritus in 1.1%, limited joint mobility in 1.1%. Conclusion: The cutaneous manifestations are very common in our diabetic patients (84%) and it is important that they are identified and appropriately treated in diabetes follow up clinics.

Hepatitis B Risk Factors are Frequently Present in Children at Jinnah Postgraduate Medical Centre in Karachi.

Background: Infection with the hepatitis B virus (HBV) poses a serious threat to global public health. More than 300 million instances of chronic hepatitis are brought on by it, which is the primary cause of liver disease. This study was conducted to determine the risk factors of HBV in children at Jinnah Postgraduate Medical Centre, Karachi, Sindh, Pakistan. Materials and methods: This cross-sectional study was conducted at the Department of Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi, Sindh, Pakistan from January 2019 to April 2022. A total of 134 children aged below 16 years with HBV were recruited in this study. Demographic information was recorded. Screening for HBV was done in all patients. Investigations including liver biochemistry, hepatitis B surface antigen (HBsAg), and HBV DNA polymerase chain reaction (PCR) were conducted in the hospital along with a complete blood count and ultrasound whole abdomen. All information was collected on a predesigned proforma and evaluated using statistical package for the social sciences (SPSS), version 25.0, software. Results: The mean age of patients was 11.02 ± 2.19 years. There were 57.46% males. The frequent risk factor was vertical transmission in 47% of children followed by blood transfusion in 23.9% of children, horizontal transmission in 13.4% of children, and prior history of surgical or dental intervention in 17.2% of children. Conclusion: In this study, vertical transmission was the most common route of transmission of HBV. Additionally, 11% of family members were HBV positive. None had concomitant hepatitis C virus (HCV) and HDV infection. All pregnant females should be screened. Children on chronic blood transfusion therapy should be screened annually. Additionally, birth-dose HBV vaccination should be implemented as a key step in HBV prevention among Pakistani children. How to cite this article: Butt N, Kamani L, Khemani H. Hepatitis B Risk Factors are Frequently Present in Children at Jinnah Postgraduate Medical Centre in Karachi. Euroasian J Hepato-Gastroenterol 2024;14(1):16-19.

Comparison of fatty liver index with fibroscan in non-alcoholic fatty liver disease.

Context: Non-alcoholic fatty liver disease (NAFLD) is an escalating global health issue. Early detection and precise diagnosis are imperative for effective management. Aim: To evaluate the sociodemographic and clinical attributes of study participants concerning their ultrasound grading with FibroScan and FLI values. Settings and Design: A cross-sectional study was carried out among patients visiting gastroenterology clinics at a tertiary care hospital situated in Karachi, Pakistan. Methods and Material: We included participants after written informed consent underwent an extensive array of laboratory assessments, encompassing liver function tests, lipid profile, fasting blood sugar analysis, hepatitis B and C screening, and abdominal ultrasound, while those with positive hepatitis B or C markers, documented alcohol use, or those who declined to offer informed consent were excluded from the study. Statistical Analysis: Data were analyzed using SPSS version 26. Results: Around 225 patients were studied with a median age of 42 years (IQR = 34-50 years). Metabolic syndrome (MetS) was present in 61.8%. Steatosis was not found among 4.9% of patients, whereas severe steatosis was seen among 51.1% of patients. Significant variations in BMI, WC, GGT, and TG levels were identified when comparing FLI scores. The same was observed for the frequency of MetS as FLI scores increased. The agreement between FLI and ultrasound observations was found to be slight (k = 0.077, P = 0.027). On the multivariable regression model, having diabetes, elevated serum glutamate pyruvate transaminase levels and mild disease on ultrasound were associated with increased odds of severe steatosis. Conclusion: FLI is a good predictor of frequency of MetS and NAFLD and correlates well with increasing steatosis score (CAP) on FibroScan which can be utilized for early detection of NAFLD in primary care.

The Effects of Music Therapy on Patients Undergoing Colonoscopy in a Tertiary Care Hospital at Karachi, Pakistan: A Comparative Study.

A colonoscopy is a procedure commonly used for the diagnosis of colorectal diseases but may be associated with high levels of anxiety and discomfort, which can lead to complications during sedation and decreased patient comfort and cooperation. This study was conducted at a tertiary care hospital in Karachi to assess the effectiveness of music therapy on pre-procedural anxiety, sedation requirements, pain, and procedure duration among patients undergoing colonoscopies. This comparative study included 110 outpatients. The intervention arm received non-lyrical soft music through earphones before and during the colonoscopy procedure, while the control group did not receive any music. In the intervention arm, significant reductions were seen in pre-procedural anxiety scores (p < 0.001), physiological measures (p < 0.001), sedation doses (p < 0.001), and procedure durations (p < 0.05). Control arm showed an increase in heart rate and systolic blood pressure (p < 0.001). Pain scores were similar for both groups. Music therapy is an effective tool to reduce patient anxiety pre- procedure. It is a simple, safe, and noninvasive relaxing intervention that could be used as an adjunct to sedative medications before and during the colonoscopy procedure.

Perceptions regarding the impact of gender on training and career advancement among gastroenterologists in India and other South Asian countries.

BACKGROUND: There are limited studies on the impact of gender on training and career advancement in gastroenterology. AIM: The aim was to study this impact and understand the perceptions of work-life balance and beliefs regarding gender dynamics among gastroenterologists in India and other South Asian countries. METHODS: A web-based survey was conducted among trainees and attending physicians in South Asia from November 15, 2021, to March 30, 2022. The survey instrument had four components: demographic features, training, career advancement and work-life balance. RESULTS: As many as 622 gastroenterologists completed the survey, of which 467 responses were from India (mean age: 41.1 years; females: 11.5%). A higher proportion of female respondents from India believed that gender bias in recruiting and training had negatively impacted their careers (40.7% females vs. 1.5% males). Radiation hazard for fertility (11.1% females vs. 1.9% males, p < 0.001) and as a health concern (14.8% females vs. 5.1% males, p = 0.005) were significant career deterrents for females. A higher proportion of female participants from India faced a career interruption (59.3% females vs. 30.3% males, p ≤ 0.001). Common reasons were pregnancy (37%) and childcare provision (25.9%). More females believed that women were more productive than men (40.8% females vs. 16.9% males, p < 0.001) and that a salary gap existed (44.7% females vs. 29.1% males, p < 0.001). The incidence of self-perceived burnout was 63% among females and 51.6% among males (p = 0.115). CONCLUSION: Gender-related factors impact the training and career of female gastroenterologists.

Primary caregiver burden and undiagnosed mental health illness in out-patients with inflammatory bowel disease-A multicentric prospective survey from the IBD Emerging Nations' Consortium.

BACKGROUND: Mental health is an overlooked aspect of inflammatory bowel disease (IBD) patient care with limited data from the developing world. The primary caregiver burden is expected to be high, but has not been evaluated. METHODS: We conducted a questionnaire-based survey of consecutive out-patients with no diagnosed mental health illness (n = 289) and their primary caregivers (n = 247) from 10 centers across eight countries (Bangladesh, India, Iran, Malaysia, Myanmar, Nepal, Pakistan, Thailand) of IBD-Emerging Nations' Consortium (ENC). Patients were assessed for anxiety (PHQ-9), depression (GAD-7), quality of life (SIBDQ, IBDCOPE) and medication adherence (MMAS-8). Caregiver burden was assessed by Zarit-Burden Interview (ZBI), Ferrans and Power Quality of Life (QOL) scores and coping strategies (BRIEF-COPE). Multivariate logistic regression and correlation analyses were performed to identify risk factors and the impact on QOL in patients and caregivers. RESULTS: Moderate to severe depression and anxiety were noted in 33% (severe 3.5%) and 24% (severe 3.8%) patients, respectively. The risk factor for depression was active disease (p < 0.001, OR6.3), while male gender (p = 0.01, OR0.45) and medication adherence (p = 0.003, OR0.75) were protective. Risk factors for anxiety were unmarried status (p = 0.015, OR2.3), female gender (p = 0.004, OR0.41), steroid use (p = 0.016, OR2.1) and active disease (p < 0.001, OR7.97). High GAD-7 and PHQ-9 scores positively correlated with high disease activity (r = 0.55, p < 0.001, Crohn's disease; r = 0.52, p < 0.001 ulcerative colitis) and negatively with SIBDQ (r = - 0.63, p < 0.001; r = - 0.64, p < 0.001 CD; r = 0.36, p = 0.001,UC). Sixty-five per cent (159/249) primary caregivers reported high burden (ZBI ≥ 21), which positively correlated with low educational status and low-income and negatively with QOL(r = - 0.33, p < 0.001). The primary adaptive coping strategy among caregivers was religion, while maladaptive strategy was self-distraction. CONCLUSION: Nearly two-thirds of primary caregivers reported high burden of care. There was also high prevalence of undiagnosed depression and anxiety in IBD out-patients. This highlights the need for patient-caregiver integrated mental-health services in the developing world.