Diagnostic Accuracy of Narrow-Band Imaging in Predicting Helicobacter pylori Gastritis in Patients With Dyspepsia.

Background Helicobacter pylori (H. pylori) is one of the most prevalent causes of chronic gastritis that can lead to gastric cancer if left untreated. Currently, endoscopy and histology are the gold standard tests for the diagnosis of H. pylori gastritis. Recently, studies have shown the utility of narrow-band imaging (NBI) in predicting H. pylori gastritis. Therefore, we aimed to determine the diagnostic accuracy of NBI in predicting H. pylori gastritis in patients with dyspepsia. Methodology After obtaining approval from the Ethical Review Committee, Sindh Institute of Urology and Transplantation, this cross-sectional study was conducted in the outpatient Clinic of Hepatogastroenterology of the institute. Inclusion criteria involved all patients of either gender aged 18 to 65 years with dyspeptic symptoms. We excluded patients with a history of proton pump inhibitor use within two weeks before endoscopy, heart failure, previous gastrectomy, portal gastropathy, cirrhosis, use of antiplatelet medications, non-steroidal anti-inflammatory drugs or anticoagulant medication, and hemorrhagic or thrombophilia disorders. Each patient underwent endoscopy-guided NBI studies followed by biopsies from the antrum and body of the stomach. Multivariate logistic regression analysis was performed for the type of NBI pattern predicting H. pylori infection. The diagnostic accuracy was obtained individually for each NBI type and then for the presence of either two or all three NBI types in predicting H. pylori gastritis. Results Out of the total 775 patients enrolled in the study, abnormal NBI patterns were observed in 401 (51.7%) patients. The presence of abnormal NBI antral mucosal pattern on endoscopy was significantly associated with H. pylori infection (p < 0.001) with excellent diagnostic accuracy. Among the three NBI types, individually, NBI type III had excellent specificity and better diagnostic accuracy in predicting H. pylori gastritis than the other two types. Furthermore, the presence of all three abnormal NBI patterns (I+II+III) together was significantly associated with the presence of H. pylori gastritis with a sensitivity of 94.54%, specificity of 86.55%, and diagnostic accuracy of 90.32%. Conclusions NBI on endoscopy shows excellent diagnostic accuracy in identifying H. pylori gastritis in patients with dyspepsia. However, multicenter studies are required not only to validate our results but also to predict the pre-cancerous lesions on NBI in patients with H. pylori gastritis.

Ascitic Fluid Lactate Level as a Predictor of Mortality in Cirrhotic Patients Having Spontaneous Bacterial Peritonitis (SBP).

Introduction Limited studies are available for predicting mortality in patients with spontaneous bacterial peritonitis (SBP) based on ascitic fluid analysis. Recently, a proposition has been made regarding the role of ascitic fluid lactate as a better prognostic indicator of mortality in cirrhotic patients with SBP. Therefore, we aimed to evaluate the utility of ascitic fluid lactate in predicting mortality in cirrhotic patients with SBP. Methods This was a prospective, observational study that was conducted in the Hepato-Gastroenterology Department of Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1 January 2022 to 31 December 2022. All the patients having liver cirrhosis with ascites, aged between 18 and 65 years, and presenting with fever and/or abdominal pain were recruited in the study in the first six months (i.e., from 1 January 2022 to 30 June 2022) and were followed for six more months for the outcome. However, those patients on dialysis or those with hepatocellular carcinoma, any other malignancy as per a history of solid organ transplant, a history of HIV infection, or those underlying systemic sepsis or infections other than SBP were excluded from the study. The presence or absence of SBP was confirmed by doing the ascitic fluid analysis. Ascitic fluid lactate levels were also requested in each patient. Mortality was assessed at one, two, three, and six months, respectively. All the data were analyzed using SPSS version 23.0. The area under the receiver operating curve (AUROC) was obtained for ascitic fluid lactate for predicting mortality in SBP. At an optimal cutoff, the diagnostic accuracy of ascitic fluid lactate was obtained. Results The total number of cirrhotic patients included in the study was 123. The majority of the patients belong to Child Turcotte Pugh (CTP) class C (n = 88; 71%). Two third of the patients (65.8%; n = 81) had viral hepatitis i.e., hepatitis B, D, and/or C, as the cause of cirrhosis. Overall mortality was observed in 51(41.5%) patients. Ascitic fluid lactate was significantly raised in patients with SBP than in patients with non-SBP (p = 0.004). The AUROC of ascitic fluid lactate was highest at three months (AUROC = 0.88) followed by six months (AUROC = 0.84), two months (AUROC = 0.804), and one month (AUROC=0.773). At an optimal cut-off of more than or equal to 22.4 mg/dl, ascitic fluid lactate had a sensitivity of 84.9%, specificity of 85.7%, positive predictive value (PPV) of 97.3%, negative predictive value of 42.8% with diagnostic accuracy of 85% in predicting overall mortality in patients with SBP. On sub-analysis, the diagnostic accuracy of ascitic fluid lactate was highest at six months followed by at three, two, and one month, respectively. Conclusion Ascitic fluid lactate showed a good diagnostic utility in predicting the overall mortality in patients with SBP with the best diagnostic accuracy in predicting long-term (six months) mortality. However, further studies are required to validate our results.

Correlation of Model for End Stage Liver Disease (MELD), MELD-Sodium (MELD-Na), and Child-Turcotte-Pugh (CTP) Score With Frailty in Patients With Hepatitis C Virus (HCV) Related Cirrhosis.

INTRODUCTION: The model for end stage liver disease (MELD), model for end stage liver disease-sodium (MELD Na), and Child-Turcotte-Pugh (CTP) score are independent predictors of mortality in cirrhotic patients. Approximately 43% of cirrhotic patients with advanced disease are frail and can have detrimental effects on the disease prognosis and survival including delisting from the transplant list and increased risk of post-transplant complications. Therefore, our aim was to determine the correlation of MELD, MELD-Na, and CTP score with frailty in patients with hepatitis C virus (HCV) related cirrhosis. METHODS:  This cross-sectional study was conducted at the Department of Hepato-gastroenterology, Sindh Institute of Urology and Transplantation from 1st January 2022 to 30th June 2022. All the patients of either gender aged between 18 and 70 years with serological evidence of HCV and features of cirrhosis on ultrasound abdomen were included in the study. Patients with conditions over estimating frailty were excluded from the study. Liver Frailty Index (LFI) was calculated using grip strength measured in kilograms, timed chair stands, and balance testing. CTP and MELD-Na scores for each patient were also recorded. All the data were analyzed using SPSS version 22.0 (IBM Corp., Armonk, NY). The correlation of MELD, MELD-Na, and CTP with LFI was analyzed using the Pearson correlation coefficient and a p-value < 0.05 was considered statistically significant. RESULTS:  A total of 274 patients were included in the study. Out of them, 185 (67.5%) were males. The mean CTP score was 8.1 + 2.1, MELD score of 13.6 + 7.1, MELD-Na score of 15 + 6.6, and LFI of 4.1 + 0.83. LFI was found to be weakly correlated with MELD (r = 0.278) (p < 0.001), MELD-Na score (r = 0.41) (p < 0.001), and CTP score (r = 0.325) (p < 0.001). CONCLUSION:  Weak correlation was noted between LFI, CTP, MELD, and MELD-Na scores in HCV-associated chronic liver disease. Therefore, frailty along with MELD, MELD-Na, and CTP must be assessed before considering the patients for liver transplantation.

Use of sofosbuvir based regimen in patients with end-stage renal disease and chronic hepatitis C; an open label, non-randomized, single arm, single center study from Pakistan.

AIM: we aimed to determine the virological response and safety of Sofosbuvir-based direct-acting antiviral agents (DAAs) in chronic hepatitis C (CHC) patients on long-term hemodialysis (HD). BACKGROUND: With the advent of interferon-free DAAs, the treatment of CHC has been revolutionized. Pakistan is among the countries where novel sofosbuvir (SOF)-free antiviral agents are not available. METHODS: This non-randomized, single-arm, open-label study enrolled all HD patients with chronic HCV infection after informed consent. They were treated with SOF in combination with Ribavirin (RBV) with either interferon (IFN group) or daclatasvir (DAC group), with the virological response assessed according to standard guidelines. Data were analyzed using SPSS version 20.00. RESULTS: Out of 133 patients, the majority (72.9%) were males with the mean age of 31.92 ± 9.88 years. Most patients (50.3%) had HCV genotype (GN) 1, followed by GN 3 in 42.9%, 4 in 1.48% and 2 in 0.7%, while mix GN was documented in 6 (4.4%) patients. Among these, 60 (45.1 %) patients received standard SOF, IFN, and RBV (IFN group) and 73 (54.9 %) received SOF, DAC and RBV (DAC group). End of treatment and sustained virological response at 12 weeks post-treatment were achieved in 133 (100%) and 129 (97 %) patients, respectively. The adverse effects were anemia in 58 (43.6 %) patients and elevated alanine transaminases in 11 (8.1%) patients. CONCLUSION: SOF in combination with either IFN or DAC is an equally efficacious and effective treatment regimen for patients on maintenance HD, especially in resource-poor countries.

Factors Influencing Quality of Life in Patients with Gastroesophageal Reflux Disease in a Tertiary Care Hospital in Pakistan.

OBJECTIVE: To assess the impact of gastroesophageal reflux disease (GERD) on quality of life (QOL) in local population. STUDY DESIGN: Cross-sectional, descriptive study. PLACE AND DURATION OF STUDY: Hepatogastroenterology Department, Sindh Institute of Urology and Transplantation, Karachi, from June 2016 to December 2017. METHODOLOGY: Patients with GERD visiting the outpatients' clinics were enrolled. Those who had history of dysphagia, malignant disease, anemia, weight loss, cardiovascular diseases, renal failure, cirrhosis, rheumatologic diseases and patients taking non-steroidal anti-inflammatory drugs (NSAIDS) or steroids during the last two weeks were exluded. A predesigned questionnaire was used to calculate GERD impact scale (GIS) score, with a value of >18 being considered as impaired QOL. Chi-square test was used to identify factors associated with impaired QOL. RESULTS: A total of 782 patients with mean age of 37.3 ±8.99 years (range: 18-65 years) were studied. Majority (505, 64.5%) were younger than 40 years of age. Predominant study population were females, i.e. 413 (52.8%). Among these, 127 (16.2%) patients had symptoms lasting more than a year, 132 (16.9%) were smokers, 82 (10.5%) had diabetes mellitus (DM), and 63 (8.1%) had hypertension. A total of 297 (38%) patients had impaired QOL. On logistic regression analysis, the impaired QOL was associated with age greater than 40 years (p=0.001), body mass index (BMI) >25 Kg/m2 (p= 0.001), smoking (p=0.001), hypertension (p=0.001) and diabetes mellitus (p=0.001). CONCLUSION: A significant proportion of patients had impaired QOL due to GERD. Factors affecting QOL in such patients were higher age, increased BMI, history of smoking, hypertension and DM.

The usage of complementary and alternative medicine in gastrointestinal patients visiting the outpatients' department of a large tertiary care centre-views from Pakistan.

INTRODUCTION: The use of complementary and alternative medicine (CAM) has increased over the last few years, and an emergent data suggests that some CAM modalities may be helpful in addressing gastrointestinal (GI) conditions. Our aim was to find out the prevalence of such practices for GI condition amongst patients visiting an OPD of a large tertiary care centre of Karachi, Pakistan. METHODS: Patients visiting outpatient department of Hepatogastroenterology department at SIUT, Pakistan from March 2014 to March 2015, were included in this cross sectional study. A pre designed questionnaire was used that included the demographic data, primary disease of the patient, CAM modality used, reason for the use of CAM therapy and reasons for stopping it. Frequencies of different variables were computed using SPSS version 18. RESULTS: 906 patients were interviewed, out of which 52% (471) were males. The mean age at presentation was 39.81±12.4 years. 234 (25.8%) of the participants used one of the CAM modalities; Herbal medicine being most common one, seen in 122 (52.13%) followed by spiritual 61 (26%), and homeopathy 33 (14%). The duration of therapy was limited to six months in 161(68%), whereas 7 patients (2.9%) had prolonged duration of use of more than five years. Reasons for using CAM therapy included advice by family and friends in 66 patients (28%), personal will in 42 (17.94%), no benefit from allopathic treatment in 34 (14.5%), while high cost was the reason of use in 3(5%) of the patients. The most common reason for discontinuation of CAM was no benefit, seen in 113 patients (48.30%), followed by physician's advice in 32 (17%) patients, and side effects in 19 (8%). On the other hand 44 patients (18.80%) reported benefit from the therapy while 14 (5.9%) were still continuing with CAM modality. Among the CAM users 140 (60.09%) were un-educated or had primary education while CAM nonusers had 328 (47%) were either uneducated or had primary education only correlation reveals P value 0.004. CONCLUSION: Significant numbers of patients used CAM therapy. A lower level of education was associated with increased usage of CAM while cost had no major impact on its usage.

Coexistence of Celiac and Crohn's Disease in a Patient Presenting with Chronic Diarrhea.

Celiac disease (CD) is one of the most common causes of malabsorption. It is an immune-mediated disease manifested by diarrhea, steatorrhea, flatulence, and weight loss, caused by ingestion of gluten containing diets. The disease has typical small intestinal biopsy features of villous atrophy, crypt hyperplasia, and intense inflammation of the mucosal layer. The disease is rarely associated with Crohn's disease (CRD). Studies on the impact of CD on the natural history of inflammatory bowel disease (IBD) have shown that the natural course of CRD is not influenced by coexistent CD. We report a case of 54-year female who presented with diarrhea and weight loss. On initial evaluation, CD was diagnosed, and responded to gluten-free diet (GFD). Later on, she developed joint pains and her diarrhea recurred. Further evaluation revealed coexistence of CRD. The treatment of CRD was also initiated and this led to marked improvement in the symptoms of the patient.