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Whether non-selective β-blockers can prevent decompensation of cirrhosis needs clarification. Carvedilol might be particularly effective since its intrinsic vasodilatory activity may ameliorate hepatic vascular resistance, a major mechanism of portal-hypertension in early cirrhosis. We assessed whether carvedilol may prevent decompensation and improve survival in compensated cirrhosis with clinically significant portal hypertension (CSPH). METHODS By systematic review we identified RCTs comparing carvedilol vs control therapy (no-active treatment or EVL) in patients with cirrhosis and CSPH without previous bleeding. We performed a competing-risk time-to-event meta-analysis using individual patient data (IPD) obtained from principal investigators of RCTs. Only compensated patients were included. Primary outcomes were prevention of decompensation (OLT and death were competing-events) and death (OLT, competing-event). Models were adjusted using propensity score for baseline covariates with the IPTW approach. RESULTS Among 125 full-text studies evaluated, 4 RCTs were eligible. The four provided IPD and were included, comprising 352 patients with compensated cirrhosis, 181 treated with carvedilol and 171 controls (79 received EVL and 92 placebo). Baseline characteristics were similar between groups. Standardized differences were

Musculoskeletal injuries (MSI) have plagued endoscopists and ancillary staff for decades without any innovative and strong ergonomic guidelines. It has placed a physical and mental strain on our endoscopists and ancillary staff. We have very have limited data supporting this claim in our region and most data is supported by western literature.To document the prevalence of MSI, and awareness and practices of ergonomics by endoscopists and ancillary staff.This is an observational cross-sectional study, conducted in Karachi, a city that boasts the maximum number of daily endoscopies in the country. An eleven-point self-administered questionnaire was distributed and used to evaluate MSI and ergonomic adjustments amongst three tertiary care setups in Karachi. An onsite surveyThere were 56 participants in total with 39 (69.6%) males. Pain and numbness were documented by 75% of the patients, with pain in the neck (41.1%), lower back (32.1%), shoulder (21.4%), thumb (12.5%), hand (23.2%), elbow (8.9%), and carpal tunnel syndrome (CTS) (7.1%). Of those, 33.3% attributed their symptoms to endoscopy, 14.2% said that symptoms were not caused by endoscopy, and 52.4% were not certain whether endoscopy had caused their symptoms. Twenty-one point four percent of patients had to take time off their work, while 33.9% took medications for pain. Ergonomic modifications to prevent musculoskeletal injury, including placement of endoscopic monitor at eye level and the cardiac monitor in front, stopping the procedure to move patients, sitting while performing colonoscopy, and navigating height-adjustable bed were used by 21.4%. Nine out of 13 ergonomic facilities were not present in all five tertiary care hospitals. Conveniences, such as anti-fatigue mats, height-adjustable computer stations, and time out between patients were not present.Three-fourth of our endoscopists reported MSI, of which more than half were not sure or attributed this problem to endoscopy. The prevalence of MSI warrants urgent attention.

IntroductionMorning report (MR) is an educational activity that uses inpatient case-based teaching. Given the rapid changes taking place in medical practice, it is important to assess the residents’ perspective regarding this teaching method.ObjectiveTo establish the perspective of residents in internal medicine on various aspects of MR and propose a format based on our observations.Study DesignObservational cross-sectional study.Place & Duration of StudyData was collected from groups of residents in the Department of Medicine at the Aga Khan University Hospital, from July 2002 to August 2007.MethodologyAn observational cross-sectional survey on MR was conducted among the residents of the Department of Medicine at Aga Khan University. A 22-item questionnaire was distributed among the residents based on the purpose, format, and contents of the morning report, as well as the most appropriate person to present and conduct it, and how frequently they should be carried out.Analyses were carried out using the statistical software ‘Statistical Package for Social Sciences’ (SPSS)Results92% of residents believed MR to be an effective teaching activity with 65% of them choosing ‘Improvement in clinical problem-solving ability’ as the primary purpose of MR followed by ‘improving presentation skills’ (62%) and ‘conveying medical knowledge to the residents’ (58%). 79 residents (87%) believed that the junior resident should present the case history. 75 residents (83%) thought that faculty on call at time of patient’s admission should conduct MR. Residents wanted to discuss diagnostic work-up (90%) and management (89%) of specific interesting cases (79%) in MR.ConclusionMR is an effective educational activity and should be an essential component of any post-graduate residency program within the country and outside.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant morbidity and mortality since its first case was discovered in December 2019. Since then, multiple countries have witnessed a healthcare system collapse due to the overwhelming demand for COVID-19 care. Drastic measures have been taken globally in order to curb the spread of the virus. However, those measures have led to the disruption of other aspects of healthcare, increasing the burden due to other medical conditions. We have also stepped back in achieving the ambitious goal set in place by World Health Organization to eliminate viral hepatitis as a public threat by 2030. Hepatitis B and C are chronic conditions with a significant worldwide burden, and COVID-19 has resulted in many hepatitis elimination programs slowing or stopping altogether. In this review, we elucidate the impact of the ongoing COVID-19 pandemic on the interventions targeted towards the elimination of hepatitis B virus and hepatitis C virus. Some of the salient features that we have covered in this review include hindrance to screening and diagnostic tests, neonatal vaccinations, the transmission dynamics affecting hepatitis B virus and hepatitis C virus, role of limited awareness, restrictions to treatment accessibility, and disparity in healthcare services. We have highlighted the major issues and provided recommendations in order to tackle those challenges.

The effect Helicobacter pylori (Hp) infection and small intestinal bacterial over growth (SIBO) in minimal hepatic encephalopathy (MHE) is not well understood. The aim of the study was to determine the effect of eradication of Hp infection and SIBO treatment on MHE in patients with cirrhosis. Patients with cirrhosis were enrolled and MHE was determined by psychometric tests and critical flicker frequency analysis. Hp infection and SIBO were assessed by urea breath and Hydrogen breath tests respectively in patients with cirrhosis and in healthy volunteers. Patients with Hp infection and SIBO were given appropriate treatment. At six weeks follow-up, presence of Hp infection, SIBO and MHE status was reassessed. Ninety patients with cirrhosis and equal number of healthy controls were included. 55 (61.1%) patients in the cirrhotic group were diagnosed to have underlying MHE. Among cirrhotic group, Hp infection was present in 28 with MHE (50.9%) vs. in 15 without MHE (42.8%) (p = 0.45). Similarly, SIBO was present in 17 (30.9%) vs. 11 (31.4%) (p = 0.95) in patients with and without MHE respectively. In comparison with healthy controls, patients with cirrhosis were more frequently harboring Hp and SIBO (47.7% vs. 17.7% (p

Introduction: Proton pump inhibitors are one of the most commonly prescribed and most commonly used medications worldwide, both in primary, secondary, and tertiary care settings. In the majority of cases, they are used inappropriately without any clear-cut indication hence leading to lots of unnecessary health related costs both nationally and internationally. Also, misuse is associated with potential complications. Due to the current dearth of available data regarding use and misuse of PPIs in Pakistan, there is an urgent need to assess appropriateness of PPI use both in primary and tertiary care settings to avoid the potentially devastating financial and public health concerns. Materials and Methods: It is a retrospective observational study conducted in department of medicine, Aga khan university hospital karachi, over a period of one year. There was total 13,346 patients admitted in the hospital during the specified period under care of Medicine and allied 6950/13346 (52%), OBGYN 379/13346 (3%) and General surgery and allied 6017/13346 (45%). Estimated sample size was 980 patients and similar percentages of patients were taken from above groups via simple random sampling Results: Out of 797 patients, 367 (46%) had an FDA-approved indication for PPIs use, 213 (26.7%) had alternate indications as recommended by clinical practice guidelines whereas remaining 217 patients (27.2%) were treated with PPI without any approved indications Conclusion: The results of this study showed that every fourth patient in hospital is getting PPIs without fulfilling indications as per established evidence based clinical practice guidelines. Key Words: Proton pump inhibitor, PPIS misuse, Financial and health concerns, Approved indications, Inappropriate indications, potential complications

Objective Functional Gastrointestinal Disorder (FGIDs) are a heterogenous group of disorders, with Irritable Bowel Syndrome (IBS) and Functional Dyspepsia (FD) being the most common disorders worldwide. The purpose of this study was to identify the spectra of FGIDs classified according to the ROME III criteria amongst an adult Pakistani population. It also aimed to correlate the psychosocial alarm symptoms with the prevalence of FGIDs and report the overlap of all FGID. Design This was a community based cross-sectional study. Multi-stage cluster sampling technique was applied, and 1062 households were initially randomly chosen using systematic sampling technique. Only one person from each household was enrolled in the study. After eligibility screening, 860 participating individuals were requested to fill out a structured ROME III interview questionnaire, administered to them by a trained interviewer. Results FGIDs were diagnosed in 468 individuals (54.4%), out of 860 participants. FD was found to be the most prevalent (70.2%), followed by Functional Heartburn (58.9%) and Functional bloating (56.6%). Amongst a total of 468 participants diagnosed with FGIDs, 347 (74.1%) had overlapping disorders. There was also a higher incidence of psychosocial alarm symptoms including higher pain severity (62.6% vs 46.4%) and being victimized at some point in their lives (26.1% vs 6.6%) amongst FGID patients. Conclusion There is a high disease burden of FGIDs in this study population, with approximately half of the population suffering from at least one type of FGID. Overlapping disorders are also common in this part of the world.

Objective This study aimed to evaluate the impact of gastrointestinal (GI) diseases on health-related quality of life (HRQoL) in Pakistani patients. Methods A cross-sectional study was conducted from 1st January 2019 to 15th February 2019 at a tertiary care hospital in Pakistan by employing a self-administered questionnaire called Gastrointestinal Quality of Life Index (GIQLI). Questionnaires were distributed among the patients presenting to outpatient gastroenterology clinics to evaluate their HRQoL. Results A total of 199 patients were included in this study, and their mean GIQLI score was 87.8 ± 17.8. Results showed that more severe core symptoms can lead to a poorer QoL. Overall GIQLI scores and most of its domain scores were lower in females as compared to males (p-value: 0.02). Obese patients had an overall lower mean GIQLI score including in the GI, psychological, and social domains while advanced age was associated with a higher disease-specific GIQLI score. Conclusion Based on our findings, GI diseases negatively impact the HRQoL in patients. Physicians need to consider the different domains of QoL as part of a holistic approach to treating these patients.

Despite their high prevalence, lack of understanding of the exact pathophysiology of the functional gastrointestinal disorders has restricted us to symptomatic diagnostic tools and therapies. Complex mechanisms underlying the disturbances in the bidirectional communication between the gastrointestinal tract and the brain have a vital role in the pathogenesis and are key to our understanding of the disease phenomenon. Although we have come a long way in our understanding of these complex disorders with the help of studies on animals especially rodents, there need to be more studies in humans, especially to identify the therapeutic targets. This review study looks at the anatomical features of the gut-brain axis in order to discuss the different factors and underlying molecular mechanisms that may have a role in the pathogenesis of functional gastrointestinal disorders. These molecules and their receptors can be targeted in future for further studies and possible therapeutic interventions. The article also discusses the potential role of artificial intelligence and machine learning and its possible role in our understanding of these scientifically challenging disorders.

AIM To evaluate the impact of sepsis and non-communicable diseases (NCDs) on the outcome of decompensated chronic liver disease (CLD) patients. METHODS In this cross-sectional study, medical records of patients with CLD admitted to the Gastroenterology unit at the Aga Khan University Hospital were reviewed. Patients older than 18 years with decompensation of CLD (i.e., jaundice, ascites, encephalopathy, and/or upper gastrointestinal bleed) as the primary reason for admission were included, while those who were admitted for reasons other than decompensation of CLD were excluded. Each patient was followed for 6 wk after index admission to assess mortality, prolonged hospital stay (> 5 d), and early readmission (within 7 d). RESULTS A total of 399 patients were enrolled. The mean age was 54.3 ± 11.7 years and 64.6% (n = 258) were male. Six-week mortality was 13% (n = 52). Prolonged hospital stay and readmission were present in 18% (n = 72) and 7% (n = 28) of patients, respectively. NCDs were found in 47.4% (n = 189) of patients. Acute kidney injury, sepsis, and non-ST elevation myocardial infarction were found in 41% (n = 165), 17.5% (n = 70), and 1.75% (n = 7) of patients, respectively. Upon multivariate analysis, acute kidney injury, non-ST elevation myocardial infarction, sepsis, and coagulopathy were found to be statistically significant predictors of mortality. While chronic kidney disease (CKD), low albumin, and high Model for End-Stage Liver Disease (MELD)-Na score were found to be statistically significant predictors of morbidity. Addition of sepsis in conventional MELD score predicted mortality even better than MELD-Na (area under receiver operating characteristic: 0.735 vs 0.686; P < 0.001). Among NCDs, CKD was found to increase morbidity independently. CONCLUSION Addition of sepsis improved the predictability of MELD score as a prognostic marker for mortality in patients with CLD. Presence of CKD increases the morbidity of patients with CLD.

Introduction Liver cirrhosis is an irreversible and end-stage disease. It results from chronic liver damage characterized by the replacement of normal liver tissue by fibrosis, leading to the progressive loss of liver function. Making an early diagnosis of cirrhosis is important for patients with chronic hepatitis because early antiviral therapy can prevent the progression of cirrhosis and even induce regression. There have been efforts to develop surrogate markers for liver cirrhosis as the biopsy is invasive, costly, and difficult to standardize. Methods This was a cross-sectional study conducted at the Section of Chemical Pathology, the Department of Pathology and Laboratory Medicine in Collaboration with the Section of Gastroenterology, Department of Medicine, the Aga Khan University, from January to December 2018. A total of 90 patients (>18 years of age) with a history of chronic viral hepatitis, who were attending the FibroScan® (Echosens, Paris, France) clinic were included. Patients with a history of autoimmune liver diseases and hepatocellular carcinoma were excluded from the study. Blood samples withdrawn were analyzed on ADVIA Centaur® (Siemens Healthineers, Erlangen, Germany), and Forns scores were calculated based on the following four parameters: patient age, total cholesterol, gamma-glutamyl transferase (GGT), and platelet count. Results The median age of the patients was 38.5 years [interquartile range (IQR): 21]. Among the study population, 59 (65.6%) were males and 31 (34.4%) were females; 26 patients showed reactivity for hepatitis B surface antigen (HBsAg), and 63 patients were found chronic with hepatitis C virus (HCV). The proportion of HCV was observed to be higher as compared with that of Hepatitis B virus (HBV). Nineteen patients were found to have jaundice and only one patient had ascites. An Area Under the Receiver Operating Curve (AUROC) was generated to determine the diagnostic accuracy of the Forns score. It was observed that the Forn score value of >7.110 had an AUROC of 0.9928 (95% CI: 0.9821-1.003, p-value

Objective This study aimed to evaluate the outcome of high-resolution esophageal manometry (HRM) in the diagnosis of esophageal motility disorders in a Pakistani population. It also evaluates the outcomes of management of patients with esophageal dysphagia and no structural abnormality on endoscopy. Methods This is a cross-sectional study. Patients with symptoms of dysphagia with normal endoscopy were subjected to esophageal manometry and to barium swallow as a part of routine workup. Esophageal motility disorders diagnosed by HRM were compared to barium swallow findings. A follow-up of these patients was done after a one-year interval to evaluate improvement in their symptoms. Results A total of 202 patients underwent HRM. There were abnormal findings in 160 patients (79.2%) with achalasia being the most common diagnosis in 35.6% of the total patients. Out of 72 patients diagnosed to have achalasia on HRM, only 46 (32.6%) had similar findings on barium esophagram and this difference is statistically significant, p < 0.001). Among achalasia patients, laparoscopic surgery was performed in 22 (30.5%) patients with 59% patients reporting a good to excellent improvement (>50%) in their symptoms, balloon dilatations were done in 47 (65.27%) patients with a good to excellent improvement in symptoms in 55% patients. Only three patients (5.5%) were given botulinum toxin injections, and two of them had an improvement of >50% in their symptoms. Patients with motility disorders other than achalasia were treated with a combination of proton pump inhibitors (PPIs), calcium channel blockers and selective serotonin reuptake inhibitors (SSRIs). Conclusion Achalasia was the most common esophageal motility disorder in our population. HRM can diagnose significantly more patients with achalasia compared to barium swallow. Likewise, HRM was helpful in detecting other esophageal motility disorders and planning their management.

A 33-year-old male patient presented to our gastroenterology clinic, in January 2020, with complains of early satiety, regurgitation, heartburn and weakness for the past several months. He denied any complains of nausea, vomiting or weight loss. His past medical history was significant for a Heineke-Mikulicz pyloroplasty secondary to gastric outlet obstruction in 2004 at the age of 17 years, after which he remained relatively asymptomatic for 10 years. He had an unremarkable family history for autoimmune disease or gastric cancer. In 2014, he developed anorexia, weight loss, weakness and numbness in the fingers, and was diagnosed with megaloblastic anaemia secondary to vitamin B12 deficiency. An endoscopy performed at that time revealed moderate-to-severe gastritis (figure 1A), and biopsy revealed atrophic gastritis. …

Background and aim In light of few established drug induced liver injury (DILI) registries, this study aims to evaluate the clinical spectrum and predictors of mortality and morbidity of hospitalized patients with suspected DILI. Patients and methods DILI cases were identified and categorized on basis of COIMS/RUCAM score and the exclusion of other liver diseases. Clinical and laboratory parameters were analyzed to identify the predictors of morbidity (prolonged hospital stay > 5 days) and mortality. Results Out of 462 patients, there were 264 (57.6%) males and the mean age of the cohort was 50.83 years (range: 20–94 years). DILI was classified as definite or highly probable in 31.1%, probable in 62.5%, and possible in 7.4% of cases. Pattern of liver injury was hepatocellular in 25.1%, cholestatic in 56.17%, and mixed in 18.72% of patients. Anti-tuberculosis drugs (ATDs) were found to be the most common category of drugs causing DILI, in 295 (63.9%) patients. Clinically, encephalopathy was present in 21.6% patients; other presenting symptoms included abdominal pain (57.1%), vomiting (57.1%), jaundice (54.1%) and pruritus (42.3%). In-hospital mortality was 26.5% and prolonged hospital stay (> 5 days) was observed in 35.93% of patients. Mortality was significantly greater in patients with encephalopathy, male gender, hepatocellular pattern of DILI, increased INR and use of ventilator support. Conclusion In our study, the most frequent cause of DILI in hospitalized patients was ATDs. More than a quarter of patients died during hospital stay. A close control of clinical and biochemical parameters are required to prevent and monitor DILI, especially in patients taking ATDs in our region.

Polycythaemia Vera (PV) is a myeloproliferative disorder in which bone marrow has increased production of red blood cells, white blood cells and platelets. The hallmarks of the disease are veno-occlusive events, secondary to increased blood viscosity. Polycythaemia Vera rarely presents with portal vein thrombosis below age of 55 years especially in absence of any chronic liver disease. We report a case of 30-years-old South Asian male presenting with abdominal pain, weight loss and vomiting for 3 months. On evaluation, he was found to have oesophageal varices. Furthermore, CT scan showed infiltration at porta-hepatis and portal venous thrombosis. Polycythaemia Vera was diagnosed with a positive JAK2 mutation and increased haemoglobin. Laparoscopy was done to perform biopsy of the porta-hepatis mass. Biopsy showed engorged vessels with no sign of malignancy. Patient underwent repeated sessions of upper GI endoscopy for band ligation and multiple sessions of venous phlebotomy which drastically improved his blood indices. He was started on lifelong aspirin and was advised regular follow-ups. With early recognition and prompt management patients can be prevented from potential complications which can prove to be detrimental.

Introduction: Stroke is a major cause of death and disability globally, with anexpected rise in number of patients with ageing and economic transition of developing countries.Pneumonia is one of the major complications after stroke. Stroke associated pneumoniaincreases risk of death by three fold and is the major cause of morbidity and mortality afterthe stroke. Objective: To determine the frequency and factors leading to stroke associatedpneumonia in all acute stroke patients admitted at a tertiary care hospital. Study Design: Caseseries. Setting: Medical Department, Aga Khan University Hospital (AKUH), Karachi. Period:six months and extended from 1st July 2015 to 31st December 2015. Material and methods:All adult patients (age 14 years and above) admitted through emergency room in the medicalward of Aga khan university hospital Karachi with the diagnosis of acute stroke on the basis ofMRI findings were enrolled after taking informed consent through Non purposive consecutivesampling technique. Demographic data like age and sex were recorded. Diagnosis of strokeassociated pneumonia was made on basis of CDC criteria for pneumonia. All analyses wasconducted by using the Statistical package for social science SPSS (Release 19.0, standardversion, copyright © SPSS; 1989-02). Results: A total of 157 patients admitted with a mean ageof the inducted patients were 61.75 ± 13.91 years. According to this stratification, 23 patients(14.65%) were aged less than 45 years and remaining 134 subjects (85.35%) were above theage of 45 years among them 110 were males (70.1 %) and 47 were females (29.9 %). Strokeassociated pneumonia was found in 33 (21%) out of 157 patients. Out of 33 patients havingstroke associated pneumonia; 14 (42.4%) patients had Diabetes mellitus. Out of 33 patientshaving stroke associated pneumonia; 28 (84.8%) patients had hypertension. Out of 33 patientshaving stroke associated pneumonia; 2 (6%) had COPD. Out of 33 patients having strokeassociated pneumonia; 2(6%) had Chronic Atrial Fibrillation. Out of 33 patients having strokeassociated pneumonia; 21 (63.6%) patients had impaired swallowing. Conclusion: Strokeassociated pneumonia is the common and serious complication after stroke. All the effortsshould be taken to control various factors leading to stroke associated pneumonia like DM,hypertension, and impaired swallowing to improve stroke outcome.

A cross-sectional study was conducted in the Gastroenterology Clinics of The Aga Khan Hospital and Jinnah Postgraduate Medical Centre in Karachi. All patients complaining of constipation were included. Patients with alarm features were excluded. Interviews were conducted by trained doctors using a structured Rome III based pre-tested questionnaire and Bristol Stool Form Scale. Out of 396 participants, 186 (47.0%) had FC and 209 (52.7%) had IBS-C. Based upon Bristol Stool Form Scale, only 214 (54%) reported to have slow transit constipation (BSS

Objectives: To determine the clinical outcome of acute pancreatitis in relation with major etiologies (Gallstones, Alcohol, and Drugs). Study Design: Cross sectional hospital based study. Setting: Aga Khan University Hospital. Period: 16 years (from 1st January 2001 to 30th June 2016). Methods: All patients with acute pancreatitis admitted. Major risk factors of pancreatitis such as gallstones, alcohol, and drugs were evaluated and outcomes assessed for the development of complications and mortality. Results: We evaluated 3049 patients with acute pancreatitis, the causative agents found, 80.35% (N = 2450), followed by Alcohol 13.05% (N = 398) and drugs 6.59% (N = 201), respectively. Patients with alcohol abuse were relatively older 53.74 years compared to patients with gallstones 39.54 years and drugs induced 43.26 years AP. Among them, the overall complication rate was 5.05% (N = 155). The most common complication was development of sepsis 45.8% (N = 71) and the overall mortality rate observed was 0.91% (N = 28). Conclusions: Gall stones are the leading cause of acute pancreatitis while drugs are the rare cause, however in significant number of patients cause remained obscure. Based on the above results patients with drug induced pancreatitis have good outcome as compared to gall stones and alcohol induced acute pancreatitis, however further studies warranted.

Introduction Inappropriate use of abbreviations and acronyms in healthcare has become an international patient safety issue. The aim of this study was to assess the knowledge of medical abbreviations and acronyms among residents of the department of medicine at a tertiary-care hospital. Methods Internal medicine residents (IMRs), subspecialty residents (SRs) and students were asked to complete a self-administered questionnaire which comprised standard abbreviations used in medicine and its various subspecialties. Scores obtained by the residents were classified into three categories: >70% correct answers; 50–69% correct answers; Results A total of 77 IMRs, SRs and medical students participated. Overall, good responses were achieved by 53 (68.8%), 16 (20.8%) attained satisfactory responses, and eight (10.4%) had unsatisfactory scores. The majority of SRs achieved good responses (19/22 (86%)), followed by IMRs (30/40 (75%)) and students (4/15 (26.7%)). Evaluation of their knowledge taken from the list of ‘do not use’ abbreviations showed that 89.6% reported using ‘Q.D.’ instead of ‘once a day’, and 93% used ‘IU’ instead of the entire phrase ‘international unit’. The top five ‘not to use’ abbreviations were ZnSO4, µg, MgSO4, IU and SC, with the frequency 100%, 96%, 94.8%, 93% and 90%, respectively. Conclusions This study showed that there is a knowledge gap among trainees in medicine regarding the meaning and usage of common medical abbreviations. We therefore recommend proper education of trainees in medicine to ensure they understand the meaning of abbreviations and are aware of the list of ‘do not use’ abbreviations.

Food hypersensitivity (FH), irritable bowel syndrome (IBS) and functional dyspepsia (FD) have many overlapping symptoms, including abdominal discomfort, bloating, and altered bowel habits. We aimed to determine the frequency of FH in patients with IBS and functional FD.Adult patients of either gender diagnosed with IBS and/or FD as per the Rome III criteria were recruited. Patients underwent serological testing against 6 food allergens: beef, shrimp, egg white, milk, peanut, and soy-bean. Those testing positive were subjected to a food elimination diet for 4 weeks. Those showing improvement on elimination diet were subjected to re-challenge. Changes in symptoms were documented by the Global overall improvement scale (GOS) and Gastrointestinal symptom rating scale (GSRS).Two hundred patients were screened. Average age of the patients was 38.6, and 55 % were male. Nineteen (38%) patients tested positive, and were subjected to a food elimination diet. The most common food hypersensitivity was shrimp (17/89%), followed by 4/21% for egg-white, and peanut. Off these, 8 showed improvement. They were re-challenged, and were evaluated 2 weeks later, when all suffered symptom relapse. These 8 (4%) patients were diagnosed with FH. There was a statistically significant difference in both GSRS (total and component) and GOS scores at baseline between patients testing (+) and (-) on food allergen testing, mainly for diarrhoea (p=0.001), abdominal pain (p=0.001) and indigestion p=0.001).FH is present in 4 % of patients with a functional gastrointestinal disorder.

A cross-sectional study was conducted in the Gastroenterology Clinics of The Aga Khan Hospital and Jinnah Postgraduate Medical Centre in Karachi. All patients complaining of constipation were included. Patients with alarm features were excluded. Interviews were conducted by trained doctors using a structured Rome III based pre-tested questionnaire and Bristol Stool Form Scale. Out of 396 participants, 186 (47.0%) had FC and 209 (52.7%) had IBS-C. Based upon Bristol Stool Form Scale, only 214 (54%) reported to have slow transit constipation (BSS2). A higher proportion of women reported severe form of constipation as compared to men (81.5%, n=150 vs. 65.1%, n=138 p0.001). However, a higher percentage of men reported using medications to treat their symptoms (71.2%, n=151 vs. 57.1%, n=105 p=0.003). Proper understanding of patient's symptoms is essential for optimizing individual patient management.

Faisal W Ismail,Shahab Abid,Minaz Mawani,Wasim Jafri,Saeed S Hamid Department of Medicine, Section of Gastroenterology, The Aga Khan University, Karachi, Pakistan Purpose: Viral hepatitis B and C represent the primary health challenge confronting Asia and Pakistan. With direct-acting antiviral therapy for hepatitis C, patients will be treated by general physicians (GPs) and will need training through continuing medical education (CME). Blended learning is a combination of didactic teaching with online, self-paced learning, and it has not been evaluated as a CME tool for general physicians. We aimed to compare the change in physician’s knowledge about chronic viral hepatitis following a blended learning educational program.Methods: Participants enrolled in a 6 week blended learning program comprising three modules, each of 2 weeks duration. These were: 1) epidemiology and prevention of viral hepatitis; 2) diagnosis and assessment of hepatitis; and 3) treatment of hepatitis. Activities were primarily web based with some face-to-face interactive sessions. All study material was available on the Teach - Pak website. Discussions, questions, and comments were encouraged. An overall pre- and postintervention knowledge assessment was performed, in addition to individual module assessments.Results: A total of 48 participants completed the program; 39 passed (81.25%). The participants were from diverse backgrounds with variable previous training. The pass rate rose from 16.1% at the start of the program to 81.2% at the conclusion. The mean pretest score was 26.0 (standard deviation =4.36), while the mean posttest score was 34.6 (standard deviation =5.15), showing an increase in the mean score of 8.56 points. Eighty four percent had completed at least one credit hour for CME as compared to those who did not pass the posttest (44.4% p-value =0.02). No significant differences in results of posttest were observed in the categories of participant’s age, years since graduation, or years of experience. The participants were satisfied with the blended learning mode of teaching.Conclusion: Blended learning is an efficient way to impart hepatitis CME to a diverse group of postgraduate physicians. Keywords: blended learning, CME, hepatitis, postgraduate physicians, teaching

There is a paucity of information on chronic hepatitis C (CHC) patients treated with direct antiviral agents (DAAs) in Asia. We invited Asia-Pacific physicians to collate databases of patients enrolled for CHC treatment, recording baseline clinical, virologic and biochemical characteristics, sustained virologic response at week 12 (SVR12) and virologic failure. SVR12 outcome was based on intention to treat (ITT). Multivariate analysis was used to assess independent risk factors for SVR12 using SPSS version 20. A total of 2171 patients from India (n = 977), Myanmar (n = 552), Pakistan (n = 406), Thailand (n = 139), Singapore (n = 72) and Malaysia (n = 25) were collected. At baseline, mean age was 49 years, 50.2% were males, and 41.8% had cirrhosis. Overall, SVR12 was 89.5% and by genotype (GT) based on ITT and treatment completion, respectively, was 91% and 92% for GT1, 100% and 100% for GT2, 91% and 97% for GT3, 64% and 95% for GT4, 87% and 87% for GT6 and 79% and 91% for GT untested. Patients with cirrhosis had SVR12 of 85% vs 93% for noncirrhosis (P < 0.001) (RR 2.1, 95% CI 1.4-3.1, P = 0.0002). Patients with GT1 and GT3 treated with sofosbuvir/ribavirin (SR) had 88% and 89% SVR12, respectively, but those GT6 treated with sofosbuvir/ledipasvir (SL) had only 77.6% SVR12. Multivariate analysis showed absence of cirrhosis was associated with higher SVR12 (OR 2.0, 95% CI 1.3-3.1, P = 0.002). In conclusion, patients with GT1 and GT3 with/without cirrhosis had surprisingly high efficacy using SR, suggesting that Asians may respond better to some DAAs. However, poor GT6 response to SL suggests this regimen is suboptimal for this genotype.

Variceal bleeding is a serious complication in patients with cirrhosis. Among the criteria that were proposed in Baveno conferences, the Adjusted Blood Requirement Index (ABRI) has not been validated prospectively in clinical practice. We therefore aim to evaluate the measurement of ABRI as a marker of failure to control bleeding and to evaluate the consistency of ABRI in relation to other criteria of failure to control variceal bleeding.All patients with variceal bleeding who presented to Aga Khan University Hospital from January 2010 to December 2012 who were administered transfusion of packed red blood cells were included after obtaining informed consent. All patients were managed as per the standard protocol with intravenous terlipressin along with band ligation and injection of cyanoacrylate in cases of esophageal and fundal varices, respectively. Hemoglobin and hematocrit were measured every 6 h for 48 h and then every 12 h until 5 days of index bleed in each patient. Packed cells were transfused if hemoglobin decreased below 8 g/dl. The number of blood units transfused, change in hemoglobin values, and ABRI were calculated after each unit of blood transfusion till 120 h. In patients in whom bleed could not be controlled, an ABRI value of 0.75 or more was compared with other Baveno IV-based parameters that define failure to control variceal bleeding.During the study period, 137 eligible patients with variceal bleed were admitted. The mean age of the patients was 52±12 years. The majority of patients (50.4%) were in Child-Pugh class B, followed by 38% in Child-Pugh class C. According to the Baveno IV criteria, overall failure to control acute variceal bleeding occurred in 52 (37.9%) patients. Excluding ABRI, failure to control bleeding was found in 22/137 (16%) patients, whereas ABRI-based criteria showed that in 34/137 (24.8%) patients, bleeding could not be controlled. There were only four (2.9%) patients with variceal bleeding in whom ABRI and other additional Baveno IV-based criteria for failure to control bleeding were present. When ABRI was compared with other criteria for failure to control bleeding, it showed a sensitivity and specificity of 19 and 25%, respectively.This study showed that ABRI is not a useful additional tool to define failure to control bleeding after variceal hemorrhage in cirrhotic patients.

Hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality worldwide. Chronic hepatitis C virus infection (HCV) is the most common cause of HCC in many European countries, Japan and Pakistan. Introduction of the new direct acting antivirals (DAAs) has revolutionized the management of HCV worldwide, with high rates of sustained virologic response in patients who could not have tolerated the previous interferon based treatments. However, recently there have been reports raising caution about the long term effects of DAAs, particularly a possible increased risk of HCC. Therefore this review explores the current molecular studies as well as clinical data that investigate the impact of DAAs on occurrence and recurrence of HCC.

The objective behind this study was to determine that Assessment for Retreatment with Transarterial chemoembolization (ART) score is really applicable in patients with hepatocellular carcinoma.A cross sectional observational study was conducted on all patients with hepatocellular carcinoma of intermediate stage and undergone ≥2 Transarterial chemoembolization. ART score was assessed before and after each session of Transarterial chemoembolization. Multi-logistic regression analysis was performed to compare the final outcome of patients with ART score of ≥2.5 into groups with two and more than two Trans-arterial chemo-embolization sessions.A total of 100 HCC patients were recruited for final analysis. Our study participants consisted of total 100 HCC patients. Mean Child Pugh score was 6.1±0.95. In our study, most of the study participants (n=63) had ART score of less than 1.5 as compared to ART score2.5 (n=37). A significant proportion of patients with ART score of1.5 prior to second Trans-arterial chemo-embolization had better median survival as compared to patients with ART score of2.5, p-value0.001. Patients with ART score of more than 2.5 did not show any survival benefit after having 3rd or 4th Trans-arterial chemo-embolization session, p=0.47.Our study findings suggest that those HCC patients who receive multiple sessions of TACE with a low ART score have more favourable outcomes with increased survival rate.

Background & Aims Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic variceal ligation (EVL) has been shown to be equal to or better than propranolol in preventing first bleed. Carvedilol is a non-selective β blocker with alpha-1 adrenergic blocker activity. Hemodynamic studies have shown carvedilol to be more effective than propranolol at reducing portal pressure. We compared efficacy of carvedilol with EVL for primary prophylaxis of esophageal variceal bleed. Methods Cirrhotic patients with esophageal varices were randomized to carvedilol 12.5mg daily or EVL at three university hospitals of Pakistan. End points were esophageal variceal bleeding, death or liver transplant. Results Two hundred and nine patients were evaluated. Eighty two and eighty six patients were randomized in carvedilol and EVL arms respectively. Mean age was 48±12.2years; 122 (72.7%) were males; 89.9% had viral cirrhosis; mean Child-Pugh score was 7.3±1.6 and mean follow up was 13.3±12.1months (range 1–50months). Both EVL and carvedilol groups had comparable variceal bleeding rates (8.5% vs. 6.9%), bleed related mortality (4.6% vs. 4.9%) and overall mortality (12.8% vs. 19.5%) respectively. Adverse events in carvedilol group were hypotension (n=2), requiring cessation of therapy, while transient nausea (n=18) and dyspnea (n=30) resolved spontaneously. In the EVL arm, post banding ulcer bleed (n=1) and chest pain (n=17), were termed as serious adverse events while transient dysphagia (n=58) resolved without treatment. Conclusions Although our study is underpowered, the findings suggest that carvedilol is probably not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis.

Introduction L’hematome surrenalien spontane(HSS) bilateral, est une affection rare d’etiologies variables pouvant se compliquer d’une insuffisance surrenalienne (ISR) mettant en jeu le pronostic vital en l’absence d’une prise en charge adequate. Observation M. A.L. âge de 44 ans, tabagique, aux antecedents d’ulcere gastrique traite medicalement, consultait pour une douleur abdominale aigue de l’hypochondre et de la fosse lombaire droits, a irradiation dorsale avec des vomissements. Une TDM abdominale montrait une volumineuse masse surrenalienne droite de densite spontanee sans prise de contraste apres injection (86 × 43 × 67 mm) associee a un epanchement retro-peritoneal ainsi qu’une masse surrenalienne gauche (20 × 16 × 22 mm). L’IRM surrenalienne confirmait les resultats scannographiques. Le reste des examens etait sans anomalies. Discussion En dehors des traumatismes, l’hemorragie surrenalienne bilaterale releve des pathologies diverses telles que ; les etats de stress, les troubles de la crase sanguine notamment apres heparinotherapie, les tumeurs surrenaliennes « angiomyolipomes, adenomes, pheochromocytomes, cortico-surrenalomes, metastases surrenaliennes », HTA et enfin l’origine idiopathique. La presentation clinique est polymorphe ; souvent des douleurs lombo-abdominales, parfois une masse palpable en rapport avec un gros hematome et rarement une insuffisance surrenalienne aigue engageant le pronostic vital. Bien que l’echographie abdominale apporte des arguments de presomption et que la TDM soit une technique d’exploration incontournable, l’IRM reste l’examen le plus sensible pour le diagnostic permettant ainsi une appreciation exacte de la localisation et caracterisation soigneuse de(s) lesion(s). Conclusion L’hematome surrenalien spontane est rare. Le diagnostic positif est souvent etabli en preoperatoire par la TDM voire l’IRM. Le diagnostic etiologique de l’hematome constitue un veritable probleme.

Objectif Decrire le profil clinique, paraclinique, etiologique, therapeutique et evolutif des masses surrenaliennes (MS). Patients et methodes Etude retrospective, menee sur 101 patients hospitalises au service de medecine interne du CHU Sahloul, Sousse et qui presentent une MS durant la periode entre 1999 et 2018. Resultats Il s’agissait de 101 patients, l’âge moyen etait de 59,8 ans avec une predominance feminine. Les circonstances de decouverte de la masse surrenalienne etaient : une hypertension arterielle (43 cas), une alteration de l’etat general (34 cas), une douleur abdominale (27 cas) et une triade de Menard (22 cas). La decouverte de la masse etait fortuite dans 65 cas. L’examen clinique revelait des palpitations (8 cas), un facies cushingoide (5 cas) et un exces de poids (48 cas). Le bilan hormonal montrait un hypercorticisme dans 3 cas, des metanephrines eleves (24 cas), un hyperaldosteronisme (14 cas) et une elevation du vanylmandelique acide (12 cas). Les explorations radiologiques etaient : une echographie surrenalienne (44 cas), une tomodensitometrie surrenalienne (94 cas), une imagerie par resonance magnetique surrenalienne (20 cas) et une scintigraphie a la MIBG (28 cas). Un traitement chirurgical etait indique chez 27 patients. L’examen anatomopathologique concluait a un pheochromocytome (11 cas), a un adenome de CONN (6 cas) et a un corticosurrenalome (5 cas). Discussion L’investigation d’une masse surrenalienne doit determiner si cette derniere est secretante, maligne ou benigne. Les resultats de cette investigation clinique, hormonale et radiologique vont poser l’indication chirurgicale.

This study aims to determine the prevalence of coinfection of H. pylori and hepatitis E virus (HEV) in the paediatric age group in an urban slum area of Karachi and identify risk factors associated with co-infection. Five hundred and forty children aged one to 15 years were investigated. Blood samples were collected and questionnaires completed on socio-demographic characteristics. Anti-H. pylori, HEV IgG and IgM antibodies were analysed by enzyme immunoassays (EIAs). The seroprevalence of H. pylori antibody was 47.2%, while that of HEV IgG and IgM was 14.4% and 2.4%, respectively. 12.4% exhibited seroprevalence for both H. pylori and HEV (IgG). In 67 (26%) cases positive for H. pylori IgG, HEV IgG positivity was also seen (P0.001). Only 13 (5%) positive for H. pylori were also positive for HEV IgM (P0.001). Only 11 (4%) HEV IgG-positive cases were H. pylori antibody-negative (P0.001). Hepatitis E virus was common in children who had access to municipal piped water (P = 0.025). H. pylori was common in children who used a non-flush toilet system (P0.001). Children exposed to H. pylori infection were also exposed to the risk of HEV.

SUMMARYWe studied the prevalence of Helicobacter pylori virulence markers, e.g. cytotoxin associated gene (cagA), cagA promoter, vacuolating associated cytotoxin A (vacA) alleles induced by contact with epithelium (iceA type), and outer membrane protein Q (hopQ) in expatriates and compared them with those in local residents. Gastric biopsies were obtained at endoscopy for culture, histology and PCR for virulence marker and hopQ. Of 309 patients, 236 (76%) were males with a mean age of 45 years. A total of 102 patients were expatriates. hopQ type 1 was present in 98 (47%) local residents compared to 88 (86%) expatriates (P < 0·001), while hopQ type 2 was present in 176 (85%) local residents, compared to 60 (59%) expatriates (P < 0·001). H. pylori virulence marker cagA was positive in 97 (47%) local residents compared to 86 (84%) expatriates (P < 0·001) while cagA-P was positive in 72 (35%) local residents compared to 87 (85%) expatriates (P < 0·001). iceA type 1 was positive in 157 (76%) local residents compared to 45 (44%) expatriates (P < 0·001), while iceA type 2 was positive in 81 (39%) local residents compared to 86 (84%) expatriates (P < 0·001). Distribution of H. pylori cagA, cagA promoter, iceA and hopQ type in local residents and expatriates was different. H. pylori virulence markers were associated with severe pathology in expatriates.

In the field of gastroenterology, breath tests (BTs) are used intermittently as diagnostic tools that allow indirect, non-invasive and relatively less cumbersome evaluation of several disorders by simply quantifying the appearance in exhaled breath of a metabolite of a specific substrate administered. The aim of this review is to have an insight into the principles, methods of analysis and performance parameters of various hydrogen, methane and carbon BTs which are available for diagnosing gastrointestinal disorders such as Helicobacter pylori infection, small intestinal bacterial overgrowth, and carbohydrate malabsorption. Evaluation of gastric emptying is routinely performed by scintigraphy which is however, difficult to perform and not suitable for children and pregnant women, this review has abridged the 13C-octanoic acid test in comparison to scintigraphy and has emphasized on its working protocol and challenges. A new development such as electronic nose test is also highlighted. Moreover we have also explored the limitations and constraints restraining the wide use of these BT. We conclude that breath testing has an enormous potential to be used as a diagnostic modality. In addition it offers distinct advantages over the traditional invasive methods commonly employed.

Background & Aims: Terlipressin is recommended for 3–5 days as adjuvant to endoscopic variceal band ligation (EVBL) in esophageal variceal bleeding (EVB). We assessed whether terlipressin can be administered for a shorter period of time to patients with EVB. Methods: All eligible EVB patients received 24 h of open label terlipressin at presentation. After successful EVBL, patients were randomized to receive active or dummy terlipressin for the next 48 h. We excluded patients with failure to achieve initial hemostasis, bleeding gastric varices, known hepatoma, and/or portal vein thrombosis, advanced cirrhosis (Child-Pugh score P12), and patients on a ventilator. The primary outcome was failure to control EVB. The secondary outcomes were 30-day mortality; re-bleeding and composite outcome of failure to control EVB. Results: A total of 130 eligible patients were randomized to receive terlipressin for a total of 24 (short course or SC) or 72 h (usual course or UC). Baseline patient characteristics were comparable; the majority of patients were HCV-infected and male. There was one failure to control EVB (1.5%) in UC and none in SC terlipressin (p = 0.50). The 30-day re-bleeding rate was 1.5% and 3.1% in UC, and SC terlipressin, respectively (p = 0.50). The 30-day mortality was 12, 6 (9.2%) patients in each group (p = 0.50). The 30-day failure to control bleeding was observed in 14 patients; seven in each group (p = 0.494). Conclusions: In patients with esophageal variceal bleeding, a 24h course of terlipressin is as effective as a 72-h course when used as an adjunctive therapy to successful EVBL. 2011 European Association for the Study of the Liver. Published

Upper gastrointestinal (UGI) bleeding carries high morbidity and mortality. The use of a bleeding care pathway (BCP) may improve outcomes, but the results are inconsistent in various studies.A BCP for patients with UGI bleed with admission in a bleeding care unit (BCU) has been in use at our hospital since 2005. Prior to this, a high dependency unit was used for management of all emergencies including UGI bleeding. We compared the length of stay in the bleeding care/high dependency unit, total hospital stay, time to UGI endoscopy after admission, and survival between pre-2005 and post-2005 patients.Five hundred and fifty-one patients were admitted with acute UGI bleed in the last 5 years; 121 belonged to pre-BCP (2004) period and 430 after implementation of the pathway (2005-2008). The mean (SD) time to UGI endoscopy improved from 21.3 (7.4) hours in the pre-BCU era to 9.4 (9.9) hours in BCU, p0.001. BCU stay was shorter from 2.41 (1.4) days pre-BCP to 1.93 (1.32) days post-BCP, (p0.001). The total hospital stay in pre-BCU (4.0 [2.08] days) as compared to BCU (4.13 [2.62] days; p = 0.58) was similar; there was no impact of BCU on survival.A BCU implementation showed improvement in time to UGI endoscopy, and did not reduce BCU stay or impact survival.