Intravenous Ringers lactate versus normal saline for predominantly mild acute pancreatitis in a Nepalese Tertiary Hospital.

BACKGROUND: Acute pancreatitis (AP) is a common presentation in patients admitted with acute abdomen. Whether Ringers lactate (RL) or Normal Saline (NS) as a resuscitation fluid is better still remains unclear. The aim of this study is to compare the efficacy of RL and NS in terms of control of systemic inflammation by measuring indirect markers specifically Systemic Inflammation Response Syndrome (SIRS) scores and C- Reactive Protein (CRP) level. METHODS: This was an open label randomized trial conducted in a tertiary level hospital of Nepal. Ethical approval was obtained prior to the study. Patients with acute pancreatitis were randomized to either RL or NS group for the fluid resuscitation. The fluid was given as per the study protocol for three days for hydration. Baseline SIRS and CRP were recorded on admission and subsequently as defined. All the data were analyzed using SPSS ver 20.0 software. RESULTS: Total 51 patients were enrolled, 26 in RL and 25 in NS group. The commonest etiology of AP was alcohol (84.31%). SIRS was present in 46.2% and 64.0% of patients in RL and NS group respectively (p = 0.20) on admission. At least one SIRS criteria was still present in 44.0% of patients in the NS group compared to only 15.4% in the RL group after 24 hours (p = 0.025). The baseline CRP were comparable in both the groups. However after 72 hours, the increment of CRP was more in the NS group compared to the RL group; median value of 14.2 mg/dl (12.15, 16.45) and 22.2 mg/dl (18.20, 30.60) in RL and NS group respectively (p<0.001). CONCLUSIONS: Ringers lactate was associated with a reduction in systemic inflammation compared to normal saline in patients with acute pancreatitis. Incidence of SIRS at 72 hours and occurrence of local complications were however similar in both the groups.

Split Versus Non-Split Morning Dosing Regimen for Assessment of Quality of Bowel Preparation for Colonoscopy.

BACKGROUND: Different bowel preparation regimens are available. Currently we are giving the entire preparation on the day of colonoscopy. Multiple studies have shown splitting the regimen might improve the quality of bowel preparation with lesser side effects and better compliance. The study was done to compare the efficacy and tolerability of split bowel preparation regimen with non-split dosing regimen. METHODS: Single centered observational comparative study was done in a tertiary care hospital. One hundred ninety eight patients requiring elective colonoscopy were assigned to receive one of the two preparations (split versus morning) prior to colonoscopy. Main outcomes were bowel preparation quality and patient compliance and tolerability. RESULTS: There was no significant difference between the two regimen for the mean total Boston Bowel Preparation Scale (6.79VS 6.74,P value -0.777).Patient compliance was better for split dosing compared to single dosing (99 vs 5 p value-<0.001).There were more side effects in the single dosage compared to split dosing except for sleep disturbance which was more in split dosing. CONCLUSIONS: The study found that split-dose and single dose polyethylene glycol solution for bowel preparation before colonoscopy had similar efficacy in the quality of bowel preparation. Split-dose polyethylene glycol appears to be superior to single-dose PEG for patient compliance and side effects.

Prevalence of Malnutrition in Patients with Liver Cirrhosis in A Tertiary Care Hospital.

INTRODUCTION: Cirrhosis of liver is a progressively deteriorating disease. Medical management consist of treatment and prevention of complications. Nutritional intervention to improve nutritional status of the malnourished patient has favorable impact on prognosis. Traditional measures of nutritional assessment like Body Mass Index and waist circumference are inaccurate. This study was conducted to study the prevalence of malnutrition in cirrhotic patients. METHODS: This was a descriptive cross-sectional study conducted at National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal. The study included 60 cirrhotic patients from outpatient department. Subjective Global Assessment was performed for all participants and level of malnutrition recorded. Height, weight, waist circumference, body mass index were measured and recorded. RESULTS: Among the cirrhotic patients, malnutrition was detected in 46 (76.66%) [68.38 to 85.94 at Confidence Interval 95%]. Out of 46 patients who were malnourished, 20 (43.47%) had mild to moderate malnutrition whereas 26 (56.53%) had severe malnutrition. The most common cause of cirrhosis was alcohol. The mean body mass index and mean waist circumference were within normal limits. CONCLUSIONS: Malnutrition is very common among cirrhotic patients and its prevalence increased from Child A to Child C status.

Factors Predicting Mortality of Acute Variceal Bleeding in Liver Cirrhosis.

INTRODUCTION: Acute variceal bleeding in liver cirrhosis is an immediate life-threatening condition and amajor complication of portal hypertension associated with higher morbidity, mortality and hospital costs than any other causes of UGI bleeding. Therefore, early stratification and initiation of therapy based on several factors can reduce mortality associated with it. We aimed to study the predictors of mortality in acute variceal bleeding in LC. METHODS: An observational prospective study was conducted in Gastroenterology and Hepatology units of Bir Hospital, Kathmandu, Nepal from April 1, 2016 to May 30, 2017. Patients were included if they had underlying liver cirrhosis and presented upper GI bleeding which were proven to be secondary to variceal bleeding. RESULTS: Seventy-five patients with mean age of 52.5 years were available or the analysis. The M:F ratio was 2.1:1. There were 66 patients in mortality group and 9 in survivor group. The mean CTP and MELD score were 10.17±1.66 and 20.40±8.29 respectively. Among the predictors of the mortality studied, CTP score, MELD score, mean arterial pressure, Serum bilirubin, serum creatinine, need of FFP as well as PRP transfusion, presence of hepatorenal syndrome and hepatic encephalopathy were high in mortality group with statistical significance. On multivariate analysis, high CTP and high serum creatinine level were only significant predictors of mortality. Receiver operating curve for predicting accuracy of mortality was significant with higher MELD and higher CTP score. CONCLUSIONS: Strong predictors of mortality in patients with cirrhosis presenting with variceal bleeding are CTP score and high serum creatinine level.

Tuberculosis in HIV patient.

INTRODUCTION: Strict monitoring ofanti tuberculosis therapy and antiretroviral therapyis crucial for proper management of TB/HIV co-infected patients. METHODS: Between December 2006 and December 2008 a prospective observational study was conducted among 135 TB/HIV co-infected patients visiting antiretroviral therapy in Seti Zonal Hospital, Dhangadi. The diagnosed TB patients were subjected to ATT through directly observed treatment short-course (DOTS) and its response was evaluated as per WHO guidelines. RESULTS: Among 135 studied subjects, 97 (71.9%) were males and over 119 (88 %) of the patients were in the age group 21 to 50. Of the total TB cases 92 (68.1%) presented pulmonary TB and 37.20% of the Extra-pulmonary Tuberculosis cases were lymph node TB. 72 (53.33%) of them had completed ATT, 11 (8.2%) transfer out and 17 (12.6%) were default. CONCLUSIONS: Majority of the patients presented PTB, and lymph node TB was found to be the most common EPTB. Comparatively, high efficacy of ATT was found in HIV patients visiting this resource poor setting.