Leveraging Deep Learning for Designing Healthcare Analytics Heuristic for Diagnostics.

Healthcare Informatics is a phenomenon being talked about from the early 21st century in the era in which we are living. With evolution of new computing technologies huge amount of data in healthcare is produced opening several research areas. Managing the massiveness of this data is required while extracting knowledge for decision making is the main concern of today. For this task researchers are doing explorations in big data analytics, deep learning (advanced form of machine learning known as deep neural nets), predictive analytics and various other algorithms to bring innovation in healthcare. Through all these innovations happening it is not wrong to establish that disease prediction with anticipation of its cure is no longer unrealistic. First, Dengue Fever (DF) and then Covid-19 likewise are new outbreak in infectious lethal diseases and diagnosing at all stages is crucial to decrease mortality rate. In case of Diabetes, clinicians and experts are finding challenging the timely diagnosis and analyzing the chances of developing underlying diseases. In this paper, Louvain Mani-Hierarchical Fold Learning healthcare analytics, a hybrid deep learning technique is proposed for medical diagnostics and is tested and validated using real-time dataset of 104 instances of patients with dengue fever made available by Holy Family Hospital, Pakistan and 810 instances found for infectious diseases including prognosis of; Covid-19, SARS, ARDS, Pneumocystis, Streptococcus, Chlamydophila, Klebsiella, Legionella, Lipoid, etc. on GitHub. Louvain Mani-Hierarchical Fold Learning healthcare analytics showed maximum 0.952 correlations between two clusters with Spearman when applied on 240 instances extracted from comorbidities diagnostic data model derived from 15696 endocrine records of multiple visits of 100 patients identified by a unique ID. Accuracy for induced rules is evaluated by Laplace (Fig. 8) as 0.727, 0.701 and 0.203 for 41, 18 and 24 rules, respectively. Endocrine diagnostic data is made available by Shifa International Hospital, Islamabad, Pakistan. Our results show that in future this algorithm may be tested for diagnostics on healthcare big data.

Quality of Colonoscopy and Spectrum of Lower Gastrointestinal Disease as Determined by Colonoscopy.

OBJECTIVE: To document the quality of colonoscopy practice and the pattern of colonic disease including polyp detection rate at Shifa International Hospital, Islamabad, Pakistan. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, Pakistan, from May 2013 to June 2014. METHODOLOGY: This retrospective study recorded demographics of patients, indications and quality indices of 505 colonoscopies performed during the study period. Preparation was done with low residue diet and polyethylene glycol. Conscious sedation was generally used. Quality indices studied were compared with guideline standard. RESULTS: Out of 505 colonoscopy patients, 305 were males and 200 were females. The indications for colonoscopic examination were lower gastrointestinal bleeding (26.5%, n=134), screening for colorectal cancer (14.1%, n=71), chronic diarrhea (12.9%, n=65), abdominal pain (10.9%, n=55), anemia (9.1%, n=46), constipation (7.3%, n=37), hematochezia and diarrhea (6.3%, n=32), altered bowel habits (5.1%, n=26), weight loss (3.6%, n=18), colonic thickening on CT scan (3.0%, n=15) and others (1.2%, n=6). Bowel preparation was adequate (in 92%, n=465) cases. Cecal intubation rate was 88.71% (n=448). Endoscopic diagnoses were hemorrhoids (36.2%, n=183), normal (22%, n=111), polyps (11.3%, n=57), ulcerative colitis (8.7%, n=44), cancer (4%, n=20), diverticulosis (3.4%, n=17), infective colitis (2.6%, n=13), intestinal TB (2.6%, n=13), non-specific colitis (2.2%, n=11), proctitis (1.8%, n=9) and others (5.3%, n=27). CONCLUSION: There is room for improvement in quality of colonoscopy, cecal intubation rate is slightly below the recommended standard and polyp detection rate is quite low however, it is not clear if the low rate of polyp detection is due to missed lesions or low population incidence. Time to reach caecum and withdrawal time should clearly be documented in the notes which can help to evaluate quality of the procedure in a better way.

Comparison of once a day rifaximin to twice a day dosage in the prevention of recurrence of hepatic encephalopathy in patients with chronic liver disease.

BACKGROUND: Rifaximin has been used for prevention of recurrence of hepatic encephalopathy in twice a day dosage. The drug is expensive and lower dising may be possible. OBJECTIVE: To determine the efficacy of rifaximin once a day dose in the prevention of hepatic encephalopathy (HE) in patients with liver cirrhosis as compared with twice daily dose of rifaximin. METHODS: This Randomized control trial was carried out at the Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad, Pakistan from November 2012 to February 2014. Patients with known chronic liver disease with at least one episode of HE in the past were randomized to group A (rifaximin 550 mg OD) and group B (rifaximin 550 mg BD), after fulfilling the inclusion criteria. Each patient was followed for 6 months for any episode of HE. Patients in each group were identified for any breakthrough episode of encephalopathy during this period. Data were analyzed using SPSS version 16. Chi-squared test and t-test were applied where required to determine the significant difference between the two groups. RESULTS: There were a total of 306 patients: 128 patients in Group A while 178 in group B. Majority of patients (75.81%) had hepatitis C virus with mean age of 52.30 ± 9.92, MELD score 13.58 ± 8.3, and 55.22% were in Child-Pugh B. Eighty-one patients had an episode of HE during the study period. There were 27 patients in group A and 54 patients in group B with breakthrough episode of HE (P = 0.088). CONCLUSION: This study suggests that there is no significant difference in rifaximin once a day or twice daily dose in preventing HE.

Renal failure in patients with end stage liver disease and its impact on clinical outcome.

OBJECTIVE: To evaluate the prevalence of renal failure (RF) in the patients of end stage liver disease (ESLD), to determine the causes of RF in these patients and its impact on patient's outcome. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, Pakistan, from May 2011 to March 2013. METHODOLOGY: A total of 523 patients with end stage liver disease (ESLD) were evaluated, renal failure (RF) and its causes were recognized in these patients according to established criteria. Outcome of these patients was assigned as reversal of RF or mortality. Data was analyzed using SPSS version 16. Chi-square test was used for comparing proportions and t-test was used for comparing mean values. P < 0.05 was considered significant. RESULTS: Out of 523 patients, 261 (49.9%) had RF. Acute kidney injury (AKI) was the most common presentation seen in 160 (61%) patients. Hypovolemia and infections were the most frequent causes of RF. Mortality was significantly higher in the patients with RF, when compared to the patients without RF (31% vs. 4.5%, p < 0.001). Reversal of RF was seen in 98 (37%) of the affected patients. Reversal was more common in the patients with hypovolemia. The mortality was higher in the patients with hepatorenal syndrome (HRS) and infections. CONCLUSION: Renal failure in the end stage liver disease is an important prognostic factor. Etiology of RF is the key factor in patients' outcome. Patients of ESLD with RF had higher mortality. Majority of the cases of RF were reversible in patients of ESLD coming in the setup.

Ammonia levels and the severity of hepatic encephalopathy.

OBJECTIVE: To evaluate the correlation between ammonia levels with the severity of HE in patients coming to the tertiary care hospital with liver cirrhosis and hepatic encephalopathy (HE). STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, from January 2011 to February 2012. METHODOLOGY: A total of 135 patients with liver cirrhosis and HE had serum ammonia levels measured on admission. The diagnosis of HE was based on clinical criteria, and its severity was graded according to the West Haven Criteria for grading of mental status. Ammonia levels were correlated with the severity of HE using Spearman rank correlation. RESULTS: Out of 20 patients with normal ammonia levels, 13 (65%) were in HE I-II, 6 (30%) were in grade-III, while 1 (5%) patient was in grade-IV HE. Out of 45 patients with mild hyperammonemia, 27 (60%) were in grade I-II, 12 (26%) were in grade-III and 6 (13%) were in grade-IV HE. Out of 34 patients with moderate hyperammonemia, 9 (26%) were in grade I-II, 18 (53%) were in grade-III, and 7 (20%) were in grade-IV HE. Out of 36 patients with severe hyperammonemia, 31 (86%) patients were in grade-IV HE (p < 0.001). CONCLUSION: Ammonia levels correlated with the severity of hepatic encephalopathy. Greater the ammonia level, severe is the grade of hepatic encephalopathy.

Factors affecting patient satisfaction during endoscopic procedures.

OBJECTIVE: To assess the quality and patient satisfaction in Endoscopy Unit of Shifa International Hospital. STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Division of Gastroenterology, Shifa International Hospital, Islamabad, Pakistan, from July 2011 to January 2012. METHODOLOGY: Quality and patient satisfaction after the endoscopic procedure was assessed using a modified GHAA-9 questionnaire. Data was analyzed using SPSS version 16. RESULTS: A total of 1028 patients were included with a mean age of 45 ± 14.21 years. Out of all the procedures, 670 (65.17%) were gastroscopies, 181 (17.60%) were flexible sigmoidoscopies and 177 (17.21%) were colonoscopies. The maximum unsatisfactory responses were on the waiting time before the procedure (13.13 %), followed by unsatisfactory explanation of the procedure and answers to questions (7.58%). Overall, unsatisfied impression was 4.86%. The problem rate was 6.22%. CONCLUSION: The quality of procedures and level of satisfaction of patients undergoing a gastroscopy or colonoscopy was generally good. The factors that influence the satisfaction of these patients are related to communication between doctor and patient, doctor's manner and waiting time for the procedure. Feedback information in an endoscopy unit may be useful in improving standards, including the performance of endoscopists.

Severity of depression in hepatitis B and hepatitis C patients.

OBJECTIVE: To assess and compare the severity of depression in chronic hepatitis B (CHB), chronic hepatitis C (CHC) and healthy subjects. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad from July 2011 to February 2012. METHODOLOGY: A total of 206 subjects were divided in three groups. Group-I (chronic hepatitis C, n = 95), group-II (chronic hepatitis B, n = 29) and group-III (healthy subjects, n = 82). They were matched for age, gender and socioeconomic status and were compared for frequency and severity of depression as measured by Hospital Anxiety and Depression Scale (HADS). RESULTS: Some degree of depression was noted in all groups. Frequency of depression was 72.6% in group-I, 58.6% in group-II and 37.8% in group-III (p value < 0.001). CONCLUSION: Both CHC and CHB had high frequency of some degree of depression. Hepatitis C patients had more depressive features than CHB. It is worthwhile to do more close mental health observation in them. A multidisciplinary team including a psychiatric specialist can help in this approach.

Frequency of depression and somatic symptoms in patients on interferon alpha/ribavirin for chronic hepatitis C.

BACKGROUND: Large numbers of patients suffering from Chronic Hepatitis C (HCV) are seeking treatment with interferon alpha (IFN) because of significant advances in overall improvement in the course of HCV and its complications. Objectives were to estimate the frequency of depression and somatic symptoms in patients on interferon alpha/ribavirin treatment for chronic hepatitis C. METHODS: It was an observational study conducted in the out-patient Department of Gastroenterology Shaikh Zayed Hospital, Lahore during a period of three months, i.e., from September to November 2008. One hundred consecutive patients undergoing interferon alpha/ ribavirin treatment for chronic HCV were included in the study. All patients, irrespective of age, sex or duration of treatment were administered with a check list of common physical complaints and DSM-IV symptoms for Major Depressive Episode. RESULTS: Out of a total of 100 subjects 37 were male and 63 were female. In all, 39 (39%) patients fulfilled the diagnostic criteria of DSM-IV for Major Depressive Episode. Major Depression was more common in female 28 (44.4%) as compared to male 11 (28.7%) patients. Somatic symptoms were common in all the patients but they were reported more frequently by patients with Major Depression compared to those without Major Depression. Myalgias, headache, joint pain, nausea/vomiting, abdominal pain and palpitation were the most common physical symptoms. CONCLUSION: Major Depression and somatic complaints are a common consequence of interferon alpha/ribavirin treatment for chronic hepatitis C. All patients receiving this treatment should be periodically assessed for the detection of these side effects to promptly address relevant treatment options.

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding.

OBJECTIVE: To compare the efficacy of propranolol, propranolol with nitrate, band ligation, and band ligation with propranolol and nitrate for the prevention of esophageal variceal rebleeding. STUDY DESIGN: A prospective randomized trial. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from November 2003 to July 2005. METHODOLOGY: One hundred and sixty cirrhotic patients with esophageal variceal bleeding were randomized to four treatment groups (propranolol, propranolol plus isosorbide mononitrate, band ligation, band ligation plus propranolol and nitrate) with 40 patients in each group. Patients were followed for 6 months after the enrolment of last patient. Primary end points were recurrence of esophageal variceal bleeding and death. Treatment complications were noted. RESULTS: Four treatment groups were comparable regarding baseline characteristics. Esophageal variceal rebleeding occurred in 22% patients in band ligation plus drugs group, 26% patients in drug combination group, 31% patients in banding group and 38% patients in propranolol group (p=0.41). Difference in mortality rates was also not significant. CONCLUSION: There was no significant difference between treatment groups in prevention of esophageal variceal rebleeding.

Efficacy of argon plasma coagulation in gastric vascular ectasia in patients with liver cirrhosis.

OBJECTIVE: To determine the efficacy of Argon Plasma Coagulation (APC) in terms of improvement in hemoglobin level and disappearance of telangiectasia as endoscopic treatment for Gastric Antral Vascular Ectasia (GAVE) and Diffuse Antral Vascular Ectasia (DAVE) syndrome in liver cirrhosis. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology of Shaikh Zayed Hospital/ Federal Postgraduate Medical Institute, Lahore, from January, 2006 to July, 2007. METHODOLOGY: Cirrhotic patient with gastric vascular ectasia were enrolled and followed-up for 18 months with repeated sessions of APC. Efficacy of APC was evaluated on the basis of patient's symptoms, transfusion requirements and hemoglobin levels. APC was performed by using ERBE generator set at 60 W and flow rate 2.0 L/min using primarily endfiring probes. RESULTS: Fifty patients were enrolled in the study. Mean age was 55.78+1.24 years with 32 males and 18 females giving a male to female ratio 1.7:1. Forty two patients were in Child's Class C and 8 in Child's Class B. Presenting complaints were malena and anemia. Two hundred and fifty three APC sessions were carried out; mean 5.06+1.5 sessions per patient. Mean follow-up period after the last session was 8.5+3.7 months. Mean increase in the hemoglobin level was 1.35+0.24 g/dl. There was no death of any patient during the study period. CONCLUSION: Treatment with APC is an effective and safe method to decrease blood loss in patients with GAVE and DAVE.

Interferon-ribavirin treatment in chronic hepatitis C--the less talked about aspects.

BACKGROUND: Combination therapy with interferon and ribavirin has become the standard of care in the treatment of Chronic Hepatitis C (CHC) infected patients. Treatment response, however, is not 100% and is accompanied with side effects faced by the patient as well as observed in haematologic indices. Studies are focusing on daily or high-dose induction therapy with interferon, the titration of interferon dosing to initial viral load, higher doses of interferon throughout treatment, and adjustment of interferon dosing to the viral responses. The safety and efficacy of these approaches have not been sufficiently established. Objectives were to see the response of 2 different dosage regimens, effects and side effects and to assess the efficacy and side effects of 2 treatment regimens of Interferon and Ribavirin in CHC. METHODS: A total of 32 patients with CHC at Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute Lahore from June 2001 to February 2003 were included in the study and were divided into two groups for treatment. Group A (14 patients) received 5 MU of injection Interferon alpha 2 b S/C daily for 2 weeks followed by 3 MU thrice weekly for the next 22 weeks. Group B (18 patients) received injection interferon alpha 2 b 3 MU S/C thrice weekly for 24 weeks. Ribavirin therapy was started at 1200 mg daily in 3 divided doses and later modified according to side effects. Patients were evaluated at 2, 4, 8, 12, 16, 20 and 24 weeks during the therapy and then 24 weeks after the completion of treatment. RESULTS: Out of 32 adult patients included in the study, 18 were males and 14 females. Haemoglobin was more than 12 gm/dl in females and more than 13 gm/dl in males, WBC count was more than 3.0 x 10(9)/L and Platelet count was more than 100 x 10(9)/L. Twenty patients completed 6 months combination treatment, 16 reported with their end of treatment HCV RNA PCR results, 8 from each group. Twelve patients were lost to follow up. End of treatment response (ETR) in group A was 88% and 62.5% in group B. Sustained virological response in group-A was 5/8 (62.5%) and 4/5 (50%) in group-B. The frequency and severity of flu like symptoms like fever, body aches, skin rash, hair loss, cough and psychiatric symptoms were more in group A than in group B. There was no significant difference in the 2 groups for haematologic side effects. CONCLUSIONS: Treatment with 5 MU interferon daily for initial two weeks followed by 3 MU thrice weekly for 22 weeks is more effective than 3 MU thrice weekly for 24 weeks but with more side effects.

L-ornithine-L-aspartate infusion efficacy in hepatic encephalopathy.

OBJECTIVE: To determine the efficacy of L-ornithine-L-aspartate in treatment of hepatic encephalopathy. STUDY DESIGN: Randomized, placebo-controlled trial. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from February to August 2005. METHODOLOGY: Cirrhotic patients with hyperammonemia and overt hepatic encephalopathy were enrolled. Eighty patients were randomized to two treatment groups, L-ornithine-L-aspartate (20 g/d) or placebo, both dissolved in 250 mL of 5% dextrose water and infused intravenously for four hours a day for five consecutive days with 0.5 g/kg dietary protein intake at the end of daily treatment period. Outcome variables were postprandial blood ammonia and mental state grade. Adverse reactions and mortality were also determined. RESULTS: Both treatment groups were comparable regarding age, gender, etiology of cirrhosis, Child-Pugh class, mental state grade and blood ammonia at baseline. Although, improvement occurred in both groups, there was a greater improvement in L-ornithine-L-aspartate group with regard to both variables. Four patients in the placebo group and 2 in L-ornithine-L-aspartate group died. CONCLUSION: L-ornithine-L-aspartate infusions were found to be effective in cirrhotic patients with hepatic encephalopathy.

Successful treatment of watermelon stomach / GAVE syndrome by using argon plasma coagulation.

This case report describes a 50-year-old female patient with liver cirrhosis presented with anemia. She was found to be suffering from gastric antral vascular ectasia (watermelon stomach) on upper gastrointestinal endoscopy. She underwent multiple sessions with Argon plasma coagulation, a non-contact thermal method of hemostasis for the management of watermelon stomach. After 3 sessions, the lesions disappeared and the hemoglobin increased by 2.4 gm/dl without any need of transfusion.

Frequency of hepatopulmonary syndrome in cirrhotic patients.

OBJECTIVE: To determine the frequency of Hepatopulmonary Syndrome (HPS) in patients with cirrhosis of the liver. STUDY DESIGN: Observational cross-sectional study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from April 2005 to March 2006. PATIENTS AND METHODS: Fifty consecutive patients admitted with liver cirrhosis were recruited. Twelve patients were excluded due to inadequate echocardiography image quality and inability to perform lung function tests. The diagnosis of cirrhosis was made on clinical, biochemical, serological and metabolic workup, ultrasound abdomen or liver biopsy. Complete blood count, liver function tests, prothrombin time, serum albumin, electrocardiography, chest radiograph, transthoracic contrast echocardiography, arterial blood gas analysis and pulmonary function tests (FEV1) were performed. Results were analyzed as percentages. Chi-square test of proportions and t-test were applied. RESULTS: Total patients evaluated were 38. Mean age was 47.92 +/- 11.38 years, with male (68.4%) to female (31.6%) ratio of 2.1:1. The commonest cause of cirrhosis was hepatitis C (71.1%). Out of the 38 patients, 11 (28.9%) had HPS including 5 (13.2%) with overt HPS and 6 (15.8%) with subclinical HPS. All patients with HPS had hepatitis C with Child-Pugh-Turcotte (CPT) class C. Factors associated with HPS were digital clubbing, arterial hypoxemia and intrapulmonary vascular dilatations (p=0.02, 0.05 and 0.000 respectively). CONCLUSION: In this study, 28.9% patients with cirrhosis of the liver had HPS. All belonged to child class C due to hepatitis C. Digital Clubbing, arterial hypoxemia and intrapulmonary vascular dilatations were important features of hepatopulmonary syndrome.

Effect of band ligation on portal hypertensive gastropathy and development of fundal varices.

BACKGROUND: Use of endoscopic therapies for esophageal varices has resulted in increased prevalence of fundal varices and severe portal hypertensive gastropathy. This study was meant to compare the effect of band ligation and sclerotherapy on development of fundal varices and portal hypertensive gastropathy. METHODS: Patients with esophageal varices presenting in the endoscopy unit of Shiakh Zayed Hospital, with at least one previous endoscopy were included. Patient's past record was reviewed for findings and type of treatment given for varices during first endoscopy, number of endoscopies till date, number of esophageal varices band ligation (EVBL) or sclerotherapy sessions. All patients underwent upper GI endoscopy and findings were recorded. Type of treatment patient rendered during first endoscopy either EVBL or sclerotherapy was correlated to the presence of fundal varices and severity of portal hypertensive gastropathy observed on present endoscopy, using Chi square test (chi2). RESULTS: Eighty one patients were included. Mean age of patients was 48.70 +/- 12.63. Esophageal varices band ligation was carried out during first endoscopy in 49 (60.5%) patients and sclerotherapy in 31 (38.2%) patients. On fresh endoscopy, fundal varices were seen in 25 (30.8%) patients. Severe portal hypertensive gastropathy was found in 26 (32.1%) and mild in 54 (66.7%) patients. Severity of portal hypertensive gastropathy and presence of fundal varices in recent endoscopy was significantly more in patients with EVBL in first endoscopy. CONCLUSION: Band ligation of esophageal varices is associated with more frequent development of fundal varices and worsening of portal hypertensive gastropathy compared to sclerotherapy.

A study of colorectal polyps.

OBJECTIVE: To determine various features of colorectal polyps and to evaluate the safety of colonoscopic polypectomy. DESIGN: Case series. PLACE AND DURATION OF STUDY: The Department of Gastroenterology and Hepatology, Federal Postgraduate Medical Institute, Shaikh Zayed Hospital, Lahore, from January 1987 to January 2004. PATIENTS AND METHODS: This study was based on data analysis of 393 patients who underwent colonoscopic polypectomy at our institution during 17 years from January 1987 to January 2004. Presenting complaints of patients were noted. Polyps were evaluated in terms of size, site, number and histopathology. RESULTS: Among 393 patients, 268 were male and 125 female. Presenting complaints were bleeding per rectum in 339 patients, diarrhea with blood in 34 and without blood in 6 patients, and lower abdominal pain in 12 patients. Two patients were being investigated for iron deficiency anemia. Two hundred and sixty-four patients had juvenile polyps, 39 had adenomatous polyps, 39 hyperplastic polyps, 39 inflammatory polyps, 3 malignant polyps and 2 patients had familial polyposis. Histopathological reports were not available in 7 patients. Size of the polyps ranged from 0.3 cm to 3.0 cm. Left colon was involved in 353 patients, transverse colon in 15, right colon in 8 patients and diffuse involvement of colon found in 17 patients. Bleeding following polypectomy occurred in 2% of the patients. No other procedure related complication occurred. CONCLUSION: Juvenile polyps were the commonest variety of polyps in our study. Colonoscopic polypectomy has very low complication rate.

Precut papillotomy outcome.

OBJECTIVE: To determine the success and complications of precut papillotomy using needle knife technique in common bile duct cannulation. DESIGN: Quasi interventional. PLACE AND DURATION OF STUDY: The Department of Gastroenterology and Hepatology, Federal Postgraduate Medical Institute, Sheikh Zayed Hospital, Lahore from April 2001 to August 2003. MATERIALS AND METHODS: From April 2001 to August 2003, a total of 347 ERCPs were performed at our institution. During this period, precut papillotomy was carried out in 79 patients. The data of these patients was evaluated for the success of the procedure and occurrence of short-term complications. Other parameters such as age and gender of patients, appearance of ampulla, and the diagnoses were also recorded. RESULTS: Forty-five patients were women and 34 men. The mean age was 52 years (range 12-80 years). Precut helped to cannulate common bile duct in 67 patients at first attempt and in further 5 patients at second attempt with an overall success rate of 91.14%. Complications occurred in 8 (10.1%) patients. These include hemorrhage in 5 (6.3%) patients and pancreatitis in 3 (3.8%). All complications were managed conservatively. CONCLUSION: Precut papillotomy is an effective technique in cannulating common bile duct in difficult cases with margin of safety, dependent on expertise.

Bedside diagnosis of spontaneous bacterial peritonitis using reagent strips.

OBJECTIVE: To determine the efficacy of reagent strip for bedside diagnosis of spontaneous bacterial peritonitis (SBP). DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Shaikh Zayed Postgraduate Medical Institute from November 2003 to August 2004. PATIENTS AND METHODS: Patients with cirrhosis and ascites underwent diagnostic paracentesis. Fluid was checked for leukocyte esterase released by PMN by using Combur 10 urine strip and graded for color change from 0-3. Fluid was also analyzed by cytology for PMN count. Results of both methods were compared to determine sensitivity, specificity and accuracy of strip for diagnosis of SBP. RESULTS: Of 214 paracentesis performed, SBP was diagnosed in 38 patients whereas 176 were negative for infection. Strip test was 97.7% sensitive and 89.4% specific with positive predictive value of 90%, negative predictive value of 97.7% and accuracy of 96.2%, when reagent strip grade 3 was considered as positive for diagnosis. CONCLUSION: Reagent strip is a quick bedside test, highly sensitive and specific for the diagnosis of SBP, based on polymorphonuclear count in ascitic fluid, to initiate early treatment, thus improving patient's outcome.

Non-endoscopic prediction of presence of esophageal varices in cirrhosis.

OBJECTIVE: To identify hematological, biochemical and ultrasonographic predictors of esophageal varices in patients of cirrhosis. DESIGN: Cross-sectional, analytical study. PLACE AND DURATION OF STUDY: Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from September 2003 to March 2004. PATIENTS AND METHODS: One hundred and one patients with established cirrhosis and no history of variceal bleed underwent physical examination, hematological, biochemical tests and abdominal ultrasound examination. Esophagogastroduodenoscopy (EGD) was carried out in all patients. Presence of varices on EGD was correlated with hematological, biochemical and ultrasonographic variables by regression analysis. RESULTS: Esophageal varices were seen in 65 patients while 36 patients had no varices. High grade varices were seen in 15 patients and 50 patients had low grade varices. Serum albumin less than 2.95 g/dl, platelet count less than 88 x 103/muL and portal vein diameter more than 11 mm were associated with presence of varices. High grade varices were predicted by serum albumin < 2.95 g/dl and portal vein diameter more than 11 mm. CONCLUSION: Patients with serum albumin < 2.95 g/dl, platelet count < 88 x 103/muL and portal vein diameter > 11 mm are more likely to have high grade varices. These patients are candidates for surveillance endoscopy.

Ectopic intestinal varices as a rare cause of lower gastrointestinal haemorrhage.

Ectopic intestinal varices are rarely responsible for lower gastrointestinal (GI) haemorrhage. A case of 55 years old male with recurrent melena is being presented, who was found to have scattered varices on small as well as large intestine. Selective review of literature regarding presentation, diagnosis and management of these cases is also part of presentation.