Double trouble - primary biliary cholangitis and coeliac disease in a young female: a case report.

In this case report, we describe a patient who was diagnosed with both Primary Biliary Cholangitis and Coeliac Disease, presenting with symptoms and signs of severe malabsorption and portal hypertension. Extensive workup was done including duodenal and liver biopsies and our patient was ultimately found to have both autoimmune diseases. An association between the two diseases has been reported multiple times during the past four decades with current guidelines recommending screening patients with primary biliary cholangitis for coeliac disease.

Emergency esophagectomy: Experience of a high volume esophageal cancer center.

Objective: The objective of the study was to review the experience of dealing oncological emergency esophagectomies at a dedicated Cancer hospital. Methods: We performed a retrospective review of data of eleven esophagectomies at the Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore (SKMCH&RC) Pakistan, from 1st January, 2009 to 30th June, 2019. Out of 590 oncological esophagectomies, eleven patients had emergency resection. We collected the data of demographics, primary disease, comorbidities, location of tumor and perforation, cause of perforations, radiological and endoscopic findings, clinical findings and follow-up visits after discharge. Data was analyzed by SPSS version 21 for windows. Result: All 11 patients out of five hunded ninety had esophageal cancer. At the time of initial staging, eight (72%) had locally advanced stage (stage III and IV). Open transhiatal approach was used in six (55%) patients, and the rest had three stage esophagectomies. Primary reconstructions with gastric conduit were performed in all, except in two (18%) patients, Respiratory complications were the most common of the encountered complications, seven (63%) of the patients had palliative resection. Ninety day mortality was observed in 3(27.3%) patients. On long term follow up, six patients had recurrence, with median Disease-Free Survival (DFS) 5.88 months and Median Overall Survival (OS) was 6.37 months. Out of 11, only three patients are alive without disease, while one patient is lost during follow-up. Conclusion: Emergency esophagectomy is a lifesaving procedure; there should be multidisciplinary team approach towards the management. Early diagnosis and management is of paramount importance.

Validation and reliability of Global Operative Assessment of Laparoscopic Skills for surgical residents and consultants.

OBJECTIVE: To institute and validate the Global Assessment of Laparoscopic Surgery score as a measure of intraoperative performance. METHODS: The observational study was conducted at the Services Hospital, Lahore, and the National Hospital and Medical Centre, Lahore, from August 1, 2013, to February 28, 2014, and comprised Residents, Senior Registrars and Consultants who were divided into 3 groups. The Junior group comprised Residents from years 1, 2 and3; the Intermediate group had year 4 Residents and Senior Registrars; and the Senior group included Consultants. All participants had their evaluation using Global Assessment of Laparoscopic Surgeryscore while performing dissection of gall bladder from the liver bed during laparoscopic cholecystectomy. SPSS 20 was used for statistical analysis. RESULTS: Of the 24 subjects in the study, 12(50%) were Residents, 6(25%) Senior Registrars and 6(25%) Consultants. The mean score for Junior group was 7.64±0.988, for Intermediate group 16.25±2.602 and for Senior group 22.83±1.169The score was highly reliable with intra-class coefficient 0.96, and internal consistency was excellent with Cronbach's Alpha 0.981. CONCLUSIONS: Global Assessment of Laparoscopic Surgery was found to be a valid and reliable measure of intraoperative laparoscopic skills.

Dengue and Hypokalemic Paralysis: A Rare Association.

Dengue is one of the most common mosquito-borne viral illnesses in tropical areas, including Pakistan. Presentation varies from a self-limiting flu-like illness to life-threatening conditions like hemorrhagic shock and multi-organ dysfunction leading to death. In the absence of vomiting and diarrhea, electrolyte abnormalities are rare findings. Though Guillain-Barré syndrome is a known association of viral illnesses presenting with flaccid paralysis, there is a possibility for dengue to cause hypokalemia without apparent gut or renal losses. Dengue-associated hypokalemic paralysis is an underrecognized entity but has a favorable outcome. The clinician should suspect this in patients presenting with motor weakness in dengue-endemic areas. Neurological complications of dengue are reported frequently now, so early recognition of these neurological manifestations is needed for the successful recovery of patients. Here, we discuss a case of dengue-induced hypokalemia presenting with acute flaccid paralysis.

Knowledge, Attitude, and Practices Regarding Vitamin D in Middle-Aged Pakistani Population and the Impact of Sun Exposure on Their Serum Vitamin D Levels.

OBJECTIVE: This study aimed to assess the knowledge, attitude, and practices regarding vitamin D (D-KAP) among middle-aged individuals in Pakistan and examine the impact of sun exposure on their serum vitamin D levels. METHODOLOGY: A cross-sectional study was conducted, involving 80 middle-aged individuals from Lahore, Pakistan. Data on demographics, sun exposure, and D-KAP were collected. Serum vitamin D levels were measured using enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: The study revealed inadequate knowledge and awareness of vitamin D among the participants. There was a positive correlation between sun exposure duration and serum vitamin D levels, indicating the importance of sun exposure for maintaining optimal vitamin D status. However, there was no significant difference in practice scores between groups, highlighting the need for interventions to bridge the gap between knowledge and practice. CONCLUSION: The study emphasizes the need to improve D-KAP in the middle-aged Pakistani population. Public health initiatives should focus on promoting accurate information, addressing cultural beliefs, and encouraging responsible sun exposure practices. Collaborative efforts are crucial to address vitamin D deficiency and its associated health consequences.

Acute Hypokalemic Paralysis And Hashimoto's Thyroiditisa.

Acute hypokalemic paralysis (AHP) is a life-threatening emergency. It is exceptionally unusual for hypothyroidism to present with AHP. This association can be either primary or secondary through distal renal tubular acidosis. We report two cases who presented with acute quadriplegia. The succeeding investigations revealed severe hypokalemia and autoimmune hypothyroidism. The second case was found to have Sjogren's syndrome additionally. The underlying aetiology of hypokalemia in both cases was found to be dRTA. The combination of such conditions is reported sporadically. Here we also discuss the potential association of AHP with autoimmune conditions by proxy through dRTA.

Laparoscopy offers better clinical outcomes and long-term survival in patients with right colon cancer: experience from national cancer center.

PURPOSE: Laparoscopic approach to colonic tumor requires skill set and resources to be established as routine standard of care in most centers around the world. It presents particular challenge in country like Pakistan due to economic constrain and lack of teaching and training opportunities available for surgeons to be trained to deliver such service. The aim of this study is to look into changing practice of our institution from conventional approach of open to laparoscopic surgery for right colon cancer. METHODS: Consecutive patients between January 2010 to December 2018 who presented to Shaukat Khanum Memorial Cancer Hospital and Research Centre with diagnosis of right colon (cecum, ascending and transverse colon) adenocarcinoma and underwent surgical resections were included in this study. RESULTS: A total of 230 patients with adenocarcinoma of the right colon underwent curative resections during the study period. Of these, 141 patients (61.3%) underwent laparoscopic surgery while open resection was performed in 89 patients (38.7%). Five-year disease-free survival (DFS) of patients with American Joint Committee on Cancer (AJCC) stage III (80.9% vs. 54.8%, P = 0.021) was significantly better if these patients underwent laparoscopic surgery while a trend toward better DFS (96.7% vs. 84.1%, P = 0.111) was also observed in AJCC stage II patients, although this difference was not significant. CONCLUSION: This study demonstrates the adoption of a laparoscopic approach for right colon cancer over 10 years. With a standardized approach and using the principle of oncological surgery, we incorporated this in our minimally invasive surgery practice at our institution.

Hepatic tumours in childhood: an experience at the Children Hospital and Institute of Child Health, Lahore.

OBJECTIVES: In this report, we share our experience about the common types of childhood hepatic tumours during 10 years (2001-2010) and compare them with other studies. METHODS: During 10 years (2001-2010), all the hepatic tumours of childhood received at Pathology Department of the Children Hospital and Institute of Child Health, Lahore Pakistan are recorded. This includes both resected specimens and biopsies. All the slides were reviewed and the pathologic diagnosis was confirmed. RESULTS: We diagnosed 48 liver tumour cases in children (below 18 years of age). Among these tumours, 39 (81.25%) were malignant. Male to female ratio was 2:1. Hepatoblastoma was the most common liver tumour in this age group accounting for 69.23% of all malignant tumours (27 cases). The second most common primary tumour was hepatocellular carcinoma diagnosed in six patients (15.38%). Other malignant tumours were undifferentiated embryonal sarcoma and biliary rhabdomyosarcoma. Benign tumours included mesenchymal hamartoma, infantile haemangioendotheloima, hemangioma and benign cyst. There were also three metastatic tumours during these 10 years. In one case there was tumour necrosis only and as such no definitive diagnosis was rendered. CONCLUSION: The spectrum of hepatic tumours in children is different from that found in the older age group and most of them are malignant.

Acute Hepatitis as a Rare Presentation of COVID-19.

Coronavirus disease 2019 (COVID-19) initially emerged in Wuhan, China, in December 2019, and now it has been declared a pandemic by the World Health Organization. COVID-19 commonly presents with respiratory manifestations like fever, cough, body aches, and shortness of breath. Neurological, myocardial, renal and gastrointestinal complications secondary to SARS-CoV-2 infection have been reported in the literature. Gastrointestinal symptoms reported with COVID-19 are mostly nausea, vomiting, and diarrhea. COVID-19 can rarely present with acute hepatitis. Here, we report a case of a 45-year male who presented with signs and symptoms of acute hepatitis secondary to SARS-CoV-2 infection. Key Words: SARS-CoV-2, COVID-19, Acute hepatitis.

A Review of Applications of Artificial Intelligence in Gastroenterology.

Artificial intelligence (AI) is the science that deals with creating 'intelligent machines'. AI has revolutionized medicine because of its application in several fields across medicine like radiology, neurology, ophthalmology, orthopedics and gastroenterology. In this review, we intend to summarize the basics of AI, the application of AI in various gastrointestinal pathologies till date as well as challenges/ problems related to the application of AI in medicine. Literature search using keywords like artificial intelligence, gastroenterology, applications, etc. were used. The literature search was done using Google Scholar, PubMed and ScienceDirect. All the relevant articles were gathered and relevant data were extracted from them. We concluded AI has achieved major feats in the past few decades. It has helped clinicians in diagnosing complex diseases, managing treatments as well as in predicting outcomes, all in all, which helps doctors from all over the globe in dispensing better healthcare services.

Pleural Tuberculosis: A Febrile Presentation Without Respiratory Symptoms.

Tuberculosis (TB) is one of the largest public health crises globally, with pleural TB comprising a large portion of cases. It has a significantly minimal presence within the United States in comparison to the rest of the world. Awareness of its presence and acumen on diagnostics and treatment are essential. Conventional tests are often time consuming, and do not always yield accurate results. We present the case of a patient presenting with fevers but no cough, who eventually found to have large pleural effusion and concluded to have pleural TB without pulmonary parenchymal involvement. He then showed measurable improvement with empiric treatment.

Laparoscopic Curative Resection for Right-Sided Colonic Tumors: Initial Experience From a Specialized Cancer Hospital of a Developing Country.

Introduction Laparoscopic colonic resection is increasingly becoming popular worldwide and aims to provide curative resection in addition to the inherent benefits of laparoscopic surgery. The aim of this study was to evaluate the long-term outcomes of laparoscopic right hemicolectomy in a Pakistani cohort of patients. Methods and procedures We retrospectively analyzed the medical records of all patients who presented to our hospital with the diagnosis of right-sided colon carcinoma from January 2010 to December 2018 and underwent laparoscopic right or extended right hemicolectomy. Demographics, operative findings, histopathology report, and follow-up of patients were recorded and the analysis was performed on Statistical Packages for the Social Sciences (SPSS) Version 20 (IBM Corp, Armonk, NY). Results Seventy-five patients were included, 56 (74.7%) of whom were males and 19 (25.3%) were females. The median age was 52 years (range 25-82 years). The median hospital stay was five days (Range 3-13 days). The median blood loss was 70 milliliters and the mean operative time was 195.5±77.6 minutes. Laparoscopic extended right hemicolectomy was performed in 23 (16.67%) patients and standard right hemicolectomy in 52 (83.33%) patients. Most (72%) of the patients had a pathological T3 tumor, and the majority (61.3%) of the patients had no nodal involvement (pN0). The mean number of lymph nodes removed was 20+8. The median numbers of involved lymph nodes were 1.14+2.19. All the patients had R0 resection. Postoperatively, two patients had pelvic collection, and there was no 30-day mortality. Local recurrence occurred in four patients and distant metastases were observed in nine patients. The median follow-up in our study was 40.5±18.35 months. The median disease-free survival was 42±2.17 months and the median overall survival was 44±2.16 months. Conclusion Our experience with laparoscopic right colon resections has confirmed the safety and feasibility of the procedure.

Stem Cell Therapies: A Way to Promising Cures.

Stem cells carry the remarkable ability to differentiate into different cell types while retaining the capability to self-replicate and maintain the characteristics of their parent cells, referred to as potency. Stem cells have been studied extensively to better understand human development and organogenesis. Because of advances in stem cell-based therapies, regenerative medicine has seen significant growth. Ophthalmic conditions, some of which are leading causes of blindness worldwide, are being treated with stem cell therapies. Great results have also been obtained in the treatment of oral and maxillofacial defects. Stem-cell-based therapies have great potential in the treatment of chronic medical conditions like diabetes and cardiomyopathy. The unique property of stem cells to migrate towards cancer cells makes them excellent vectors for the transportation of bioactive agents or for targeting cancer cells, both primary and metastatic. While these therapeutic strategies are extremely promising, they are not without limitations. Failure to completely eradicate the tumor and tumor relapse are some of those concerns. Stem cells share some characteristics with cancer stem cells, raising concerns for increasing the risk of cancer occurrence. Ethical concerns due to the fetal origin of stem cells and cost are other major obstacles in the large-scale implementation of such therapies.

Familial Pancreatic Cancer: A Critical Review.

Up to 20% of patients with pancreatic cancer have a family history of the disease. Familial pancreatic cancer is defined as at least two first-degree relatives with pancreatic cancer that occurs without being part of a cancer syndrome. Although this does not follow a specific Mendelian pattern of inheritance, research is underway to better understand this cohort of patients. Recent expert opinion/recommendations encourage physicians treating patients with pancreatic cancer to ask them to consider having germline testing. Herein, we summarize the current peer-reviewed literature on the most common syndromes associated with pancreatic cancer, associated genetic mutations, and recommendations from various consortia regarding screening strategies. Lastly, we describe the economic impact of pancreatic cancer and the impact of screening tools in high-risk populations.

Hemoperitoneum Due to Warfarin Toxicity Presenting as Intestinal Obstruction.

The patients on anticoagulation therapy especially warfarin can develop gastrointestinal bleed, gum bleeding, hematuria or ecchymosis. Rarely do such patients present with hemoperitoneum producing symptoms. Hemoperitoneum can produce shock, cause compression symptoms or may even be fatal. Such patients can be managed conservatively or may need surgical exploration for ongoing bleeding or decompression. We had a patient taking warfarin who presented with hemoperitoneum producing intestinal symptoms. The patient was managed conservatively with fluid and blood product replacement and stopping warfarin. The benefits of thromboprophylaxis and the risks of bleeding should be carefully evaluated and the dose of warfarin carefully adjusted.

Use of box simulators for improving intraoperative laparoscopic skills - an essential tool for the surgeon in training.

OBJECTIVE: To compare the improvement of intraoperative laparoscopic skills by measuring GOALS score between residents who have undergone simulator training with those who have not received any simulator training. STUDY DESIGN: A randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Surgery, Services Hospital, Lahore, from August 2013 to February 2014. METHODOLOGY: Thirty residents belonging to year 1, 2 and 3 were included in the study. They were randomly divided into 2 groups. Both groups had a baseline evaluation with GOALS score while performing dissection of gallbladder from liver bed during laparoscopic cholecystectomy. Group-A underwent formal training on simulators whereas group-B did not receive any formal training on simulators. After 6 months, a repeat evaluation was done again by measuring GOALS score while performing gallbladder dissection. RESULTS: Baseline GOALS scores of both the groups were similar. Group-A baseline score was 7.66 ± 0.93 and group-B score was 7.46 ± 1.04 (p = 0.585). However repeat scores for group-A showed a significant improvement (an increase of 7.16 ± 1.48 to 14.76 ± 1.67, p < 0.001) from baseline scores. Residents in group-B improved their scores by 2.30 ± 0.99 to 9.76 ± 0.79 (p < 0.001). When inter group comparison was done the second score of group-A was significantly higher than that of group-B (14.76 ± 1.67 vs. 9.76 ± 0.79, p < 0.001). Inter-rater reliability was moderately significant (Kappa 0.540).

Gossypiboma as a cause of intestinal obstruction.

Gossypiboma / textiloma / retained surgical sponge is an avoidable surgical complication which can lead to patient morbidity, mortality and profound medicolegal implications. Retained surgical sponge can present early as abscess formation and septic complications or follow a silent course for many years to present later as intestinal obstruction, fistula formation or simply be extruded through rectum. A lady presented 8 months after laparotomy with symptoms of bowel obstruction due to a retained surgical sponge that had eroded into the rectosigmoid junction. The introduction of WHO Safety Checklist in operation theatres where advance tagging systems are not available, would lead to development of standard protocols and help in avoiding the occurrence of such retained surgical foreign bodies.