Endoscopic Detection and Management of Esophagogastric Varices.

Introduction Gastrointestinal (GI) varices are abnormally dilated submucosal veins in the digestive tract caused due to portal hypertension. Esophagus and stomach are common locations of varices induced by portal hypertension. Their presence correlates with the severity of the liver disease. Endoscopic variceal band ligation is one of the preferred methods for bleeding and nonbleeding large varices to decrease bleeding risk. Tissue adhesives such as N-butyl-2-cyanoacrylate have been used for gastric variceal obturation. Methods This descriptive study was conducted in the Department of Gastroenterology, National Academy of Medical Sciences, Kathmandu, Nepal, from March 2014 to January 2020. The endoscopic detection of esophageal and gastric varices was observed. Endoscopic variceal ligation (EVL) was done for esophageal varices and injection of N-butyl 2-cyanoacrylate for gastric varices. Results Esopahageal varices were detected in 1266 patients (8%) and gastric varices were in 36 patients (0.2%) among 15,657 patients undergoing upper gastrointestinal (UGI) endoscopy. Nine hundred seven (71.6%) were male. Large esophageal varices were endoscopically detected in 54.8% patients, small varices in 31.4% and both (large and small varices) in 13.4%. EVL was done in 30.7% and EVL with cyanoacrylate glue injection in 35 patients (2.7%). Conclusion Esophageal and gastric varices are seen commonly in patients with chronic liver disease. This study was conducted to describe the different types of GI varices in patients undergoing UGI endoscopy. Variceal band ligation for esophageal varices and glue injection for gastric varices are viable options of management.

The Effect of Empagliflozin on Liver Fat in Type 2 Diabetes Mellitus Patients With Non-Alcoholic Fatty Liver Disease.

Background and objective The prevalence of non-alcoholic fatty liver disease (NAFLD) is 60% in patients with type 2 diabetes mellitus (T2DM). NAFLD can lead to non-alcoholic steatohepatitis (NASH), both of which are the leading causes of cirrhosis. This study was undertaken to evaluate whether empagliflozin, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, reduces liver fat content in these patients after therapy. Methods After enrolling patients of T2DM with NAFLD, they were administered empagliflozin 10 mg once daily orally for six months without modifying existing oral hypoglycemic agents (OHA) if any. All demographic data were collected, and anthropometric measurements, as well as laboratory investigations, were performed, and controlled attenuation parameter (CAP) and liver stiffness (LS) were measured using FibroScan® (Echosens, Paris, France) at baseline, and six months of therapy. The adverse effects related to therapy were also taken into account. Results There was a significant decrease in mean CAP value from 282.07 ± 47.29 dB/m to 263.07 ± 49.93 dB/m and LS from 5.89 ± 4.23 kPa to 5.04 ± 1.49 kPa along with a significant decrease in serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) among the patients. Compared to the baseline, there was a significant reduction in post-treatment weight, body mass index (BMI), and blood pressure (BP). The most commonly observed adverse effects of the therapy were urinary tract infection (UTI) (17.8%), nasopharyngitis (11.9%), and hypoglycemia (10.71%). Conclusion A reduction in hepatic fat content was seen in our prospective study cohort after six months of empagliflozin therapy. Empagliflozin also led to beneficial effects such as weight loss and reduction in transaminases and GGT. Given the absence of significant side effects of the therapy, empagliflozin could be used as an effective treatment modality for T2DM patients with NAFLD, which are two conditions commonly seen in combination.

Epidemiology of Inflammatory Bowel Diseases in Nepal.

Introduction Inflammatory bowel diseases (IBD) comprise ulcerative colitis (UC) and Crohn's disease (CD). These are diseases of the gastrointestinal tract without a clear etiology but have strong relationships with underlying factors like genetic susceptibility, environmental factors, and intestinal bacteria. In the east, inflammatory bowel diseases predominantly affect the younger population and have an almost equal gender distribution. With urbanization and the adoption of the western lifestyle, the incidence and prevalence of IBD are increasing in Asia. In this study, we describe the epidemiology of IBD in Nepal. Methods This was an observational study conducted in nine endoscopy centers within Nepal. Two years of data of colonoscopies in these centers were collected retrospectively. IBD was diagnosed by endoscopic examination. The incidence of IBD was calculated as the number of patients with IBD per 1000 colonoscopies per year. The demographic profiles of the patients were also collected. Results A total of 7526 colonoscopies were done in nine centers within the two years study period. IBD was seen in 479 patients (6.3%). The incidence of UC was 23.7 per 1000 colonoscopies per year and the incidence of CD was 1.6 per 1000 colonoscopies per year. UC (87%) was more common than CD (13%). Both UC and CD were mostly seen in the 30 to 40 years age group. In patients with UC, the rectum was the most commonly affected site. Discussion IBD in Nepal affects young males in their thirties. Younger age of affliction with a chronic disease and lack of awareness regarding the symptoms and diagnostic modalities of IBD may result in a delayed diagnosis. The target population must be made aware of the presenting symptoms of IBD and a need for colonoscopic examination for diagnosis. There is also a need for creating a national IBD registry for Nepal.

Primary Esophageal Tuberculosis With Dysphagia.

Tuberculosis is a common infection caused by Mycobacterium tuberculosis. Tuberculosis can affect many organ systems of the human body including the gastrointestinal tract. Esophageal involvement of tuberculosis is however rare. A 60 years old male from Nepal with an occupational history suggestive of exposure to tuberculosis presented with dysphagia. He did not have any other complaints and his physical examination was unremarkable. An upper gastrointestinal endoscopic examination revealed an esophageal ulcer at 25 cm from incisors. Biopsy from the edge of the ulcer revealed granulomas with central caseous necrosis. A computed tomography scan of the chest and abdomen did not reveal additional lesions. Considering the higher prevalence of tuberculosis in the geographical area, he was started on an empirical antitubercular regimen. His dysphagia subsided within two weeks of starting therapy. A repeat upper gastrointestinal examination at six months of therapy revealed complete healing of the esophageal lesion. In this case report, we review the symptomatology, diagnosis, and treatment of esophageal tuberculosis.

Comparison of Characteristics and Inpatient Outcomes of Patients With Inflammatory Bowel Disease and Colon Cancer: A Propensity-Based Nationwide Inpatient Sample Study.

Introduction Patients with inflammatory bowel diseases (IBDs) frequently develop colon cancer. Previous studies have identified the association between IBD and colon cancer. In this study, we explored the characteristics and outcomes of IBD patients with colon cancer admitted to the hospitals of the United States. Methods Patients who were hospitalized patients with diagnoses of IBD and colon cancer were compared with patients with IBD without colon cancer. The data were extracted from the Nationwide Inpatient Sample (NIS) from January 2016 to December 2017. Comparisons were made with regards to mortality, complications, in-hospital stay, and cost of treatment between the two groups. Results We identified 1,82,025 hospitalizations from January 2016 to December 2017 admitted with a diagnosis of IBD. Of these, 181,560 patients had IBD without colon cancer, and 465 patients had IBD with colon cancer. No statistically significant difference was observed with regards to the in-hospital mortality between the two groups. There were higher odds of acute kidney injury (AKI) (OR 1.54, 95% CI 6.6-9.8; p=0.00), colectomy (OR 1.2, 95% CI 1.3-2.5; p=0.0) and lower gastrointestinal bleeding (LGIB) (OR 1.6, 95% CI 1.8-3.7; p=0.04) in patients with IBD and colon cancer. A longer length of stay (7.1±6.9 vs.5.0±5.6, p=0.00) and higher mean total charge ($20,283 vs. $12,166, p=0.00) were observed in patients with IBD with colon cancer. Conclusions Patients with IBD-associated colon cancer appear to have higher complication rates, higher costs, and more extended hospital stays. Therefore, early identification and management of complications related to IBD among patients with colon cancer are particularly crucial to reduce morbidity as well as the cost of hospitalization and treatment.

Prevalence of Portal Hypertensive Gastropathy in Chronic Liver Disease and Correlation with the Severity of Liver disease.

Background Portal hypertensive gastropathy (PHG) is an underappreciated condition in patients with chronic liver disease (CLD). It is a common endoscopic finding in CLD patients, but its relation with esophageal varices (EV) and the severity of the liver disease is controversial. Herein, we aimed to study the prevalence of PHG in CLD patients and to determine its association with EV and the severity of the liver disease. Methods This descriptive, cross-sectional, analytical study was conducted at the Hepatology department, Bir Hospital Kathmandu from 19th March to 30th June 2019. A total of 404 patients with CLD of various etiology fulfilling the inclusion criteria were approached, and informed consent was taken before enrolling in the study. All patients underwent EGD, and the findings related to EV and PHG were noted. The severity of PHG was graded according to the McCormack classification and EV were graded according to the American Association for the study of liver diseases guideline. The severity of liver disease was stratified based on Child-Pugh class and Model for End-Stage Liver Disease (MELD score). Data was entered on Statistical Package for the Social Sciences (SPSS) Version 25 for further analysis. Results Of 404 CLD patients, the mean (±SD) age was 49.14 (±10.5) years. Portal hypertensive gastropathy was observed in 269 (66.6%) patients, of which 80.6% (217) had mild PHG while 19.4% (52) had severe PHG. EV were present in 362 (89.6%) patients. One hundred and thirty-two (36.5%) had small EV, and 230 (63.5%) had large EV. No significant association was observed between grades of gastropathy and size of varices (p = 0.36). There was a non-significant association with the MELD score and other biochemical parameters. However, there were significant associations between Child-Pugh class and PHG and Child-Pugh class and PHG severity, p = 0.001 and p = 0.01 (p <0.05), respectively. Conclusions In our study, the prevalence of PHG in the Nepalese population in CLD is 66.6 %. PHG is significantly associated with the severity of CLD in terms of Child-Pugh class but not associated with MELD. Also, no association has been found with the size of varices.

Precipitating Factors and Treatment Outcomes of Hepatic Encephalopathy in Liver Cirrhosis.

Background Hepatic encephalopathy (HE) is a common cause of hospital admission in patients with liver cirrhosis (LC). The aims of this study were to evaluate the precipitant factors and analyze the treatment outcomes of HE in LC. Methods All the LC patients admitted between February 2017 and January 2018 for overt HE were analyzed for precipitating factors and treatment outcomes. Treatments were compared among three treatment groups: receiving lactulose, lactulose plus L-ornithine L-aspartate (LOLA), and lactulose plus rifaximin. The primary endpoints were mortality and hospital stay. The chi-square test was used to compare the different treatment outcomes with hospital stay and mortality with significance at p<0.05. Results A total of 132 patients (mean age 49.2 ± 10.2 years; male/female ratio of 103:29) were studied. The most common precipitating factor of HE was infection 65 (49.2%), followed by electrolyte imbalance 54 (41%), constipation 44 (33.33%), and gastrointestinal bleeding 21 (16%) patients. At the time of admission, 29 (22%), 76 (57.5%), 21 (16%), and six (4.5%) patients had grade I, II, III, and IV HE, respectively. The difference in mortality was not statistically significant (p=0.269) in three groups but the hospital stay was shorter among patients in groups B and C than in group A alone (7.36 ± 4.58 and 7 ± 3.69, 9.64 ± 5.28 days, respectively, p=0.015). Conclusions Infection, especially spontaneous bacterial peritonitis, was the commonest precipitating factor of HE. The combination of lactulose either with LOLA or rifaximin is equally effective in improving HE and reducing the duration of hospital stay than lactulose alone.

Variation in body mass index in patients with chronic obstructive pulmonary disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is associated with systemic inflammation. Weight loss seen in patients with COPD is a consequence of this inflammation. We hypothesized that higher grades of COPD are associated with greater degree of weight loss. MATERIALS AND METHODS: In this cross-sectional study, we assessed the body mass index (BMI) of 34 patients with COPD proven by handheld spirometer. The difference in BMI among various grades of COPD was compared. RESULTS: BMI was found to be inversely related to the grades of COPD in our study (P = 0.001). No significant difference was seen among the patients with regards to age and duration of symptoms before presentation. CONCLUSION: Advanced COPD is associated with greater degree of weight loss.

An association of Helicobacter pylori infection with endoscopic and histological findings in the Nepalese population.

BACKGROUND: Helicobacter pylori (H. pylori) is one of the most common human infections worldwide particularly in the developing countries. We aimed to study an association of H. Pylori infection with endoscopic and histological findings in the Nepalese population. MATERIALS AND METHODS: We conducted a study between Oct 2014 and Jan 2015 after meeting inclusion and exclusion criteria. Institutional Review Board approval was obtained from National Academy of Medical Sciences. Endoscopic findings and histopathological diagnosis were documented and data were analysed. RESULTS: A total of 113 patients who had complete endoscopy were enrolled. The prevalence of H. pylori infections recorded was 27 (23.9%) patients. There were 17 (62%) male and 10 (37%) female infected with H. pylori (P = 0.33). All biopsied specimens were sent to pathology lab for examination. The most common endoscopic findings was erythematous antral gastritis (40.7%) followed by erosive gastritis 34 (30.1%), pangastritis 10 (8.8%), duodenal ulcer 13 (11.5%), gastric ulcer 9 (8%), erosive fundal gastritis 2 (1.8%), reflux esophagitis 10 (37%) (P < 0.04). Histology revealed that 23 (85.2%) patients had chronic active gastritis (CAG); (P < 0.001). CONCLUSIONS: Our study revealed that H. pylori infection is strongly associated with chronic active gastritis (CAG) and Reflux esophagitis in Nepalese adults.

Metabolic Syndrome in Patients with Non-alcoholic Fatty Liver Disease: A Community Based Cross-sectional study.

Background Non-alcoholic fatty liver disease (NAFLD) is the deposition of fat inside liver cells in the absence of secondary causes. It is considered as a hepatic complication of metabolic syndrome. The metabolic syndrome consists of dyslipidemia, hypertension, diabetes, and obesity. This study aims to determine the prevalence of metabolic syndrome in Nepalese patients with NAFLD from mid-Western part of Nepal. Method This was a descriptive cross-sectional study. Three different sites were chosen in and around Butwal sub-metropolitan city of Rupandehi district, Nepal. A one-day health camp for the screening of fatty liver disease by ultrasonography (USG) was conducted at these sites. Participants with fatty liver were then classified into three grades by USG and the presence of metabolic syndrome was assessed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII) criteria. Results A total of 385 participants with NAFLD were evaluated. Presence of metabolic syndrome by NCEP-ATPIII criteria was found to be in 57.6% participants; whereas, at least one component of metabolic syndrome was found in 91.4% of participants with radiologic features of fatty liver. Higher proportion of patients with NAFLD were males. Increased waist circumference followed by low high-density lipoprotein (HDL) level were the most common components of metabolic syndrome in participants with NAFLD. Conclusions Metabolic syndrome is common in Nepalese community patients with NAFLD.

Contrast-induced Nephropathy Following Percutaneous Coronary Intervention at a Tertiary Cardiac Center in Nepal.

Background Contrast-induced nephropathy (CIN) is one of the leading causes of morbidity and mortality including increased financial burden in high risk patients undergoing percutaneous coronary intervention (PCI). Methods This is an observational prospective study. We aimed to study the incidence of CIN in Nepalese populations and compare the outcome to international reprinted values with coronary artery disease (CAD) undergoing PCI. All consecutive patients with CAD undergoing PCI between February 2010 and July 2010 were enrolled in the study. Results One hundred fifty-two patients were enrolled in the study during six months period. Twenty (13.20%) patients developed CIN following PCI. Out of them 70% were diabetics and 30% were non-diabetics. Mean age of patients was 58.5 ± 23 years; male:female ratio was 2.7:1. Mean contrast volume injected was 160.3  ±  78.3  mL. Diabetic patients 21.8% (14/64) had significant CIN compared to non-diabetic patients 6.8% (6/88) following PCI (<0.01). Conclusions CIN is a common complication following PCI especially in diabetics. Despite the use of iodinated material we had similar incidence of CIN comparing the incidence of CIN among various radiocontrast compounds used to visualize vessels. None of the patients received hemodialysis as compared to available studies and there was no observed mortality.