Outcome of Endoscopic Variceal Band Ligation

Introduction: Bleeding from esophageal varices in cirrhosis is an emergent condition with high mortality. One of the preferred modality of treating esophageal varices is EVL. We aimed to find out the outcome of EVL in controlling acute esophageal variceal bleeding, prophylactic banding to prevent future bleeding and the number of sessions required for complete eradication of varices. Methods: This descriptive observational study was carried out in Gastroenterology and Hepatology unit of Bir Hospital, NAMS from June 2016 to May 2017. Consecutive cases who presented in emergency room with acute variceal bleeding due to liver cirrhosis and cases of liver cirrhosis with large varices and red color signs on endoscopic examination were enrolled. They underwent EVL and subsequent re-endoscope at one month interval till the eradication of varices was achieved.  Results: Among 83 patients, 15 (18.1%) were of Child Pugh class A, 29 (34.9%) B and 39 (47%) were of C. In 20 (24.1%) cases varices could be eradicated in one session of EVL while 57 (68.7%) required two sessions and in 6 (7.2%) cases it took three sessions. Total average EVL session required for obliteration of esophageal varices was 1.84±0.53. There was only one (1.2%) of early re-bleeding post EVL. Conclusions: EVL is an effective modality of treatment in controlling acute esophageal variceal bleeding, in preventing future variceal bleeding as well as in eradicating esophageal varices, with very few complications. Keywords: acute variceal bleeding; cirrhosis; endoscopic variceal ligation; large varices; red color sign. [PubMed

Prevalence of Organic Colonic Lesions by Colonoscopy in Patients Fulfilling ROME IV Criteria of Irritable Bowel Syndrome

Introduction: Irritable bowel syndrome occurs as recurrent abdominal pain that is related to defecation and associated with change in frequency and/or form of stool. Few Patients with IBS may have organic lesions detectable at colonoscopy. Methods: A cross sectional study was carried out in 140 consecutive patients of IBS fulfilling the ROME IV criteria. The study was conducted in Gastroenterology unit, Department of Medicine, Bir hospital, Kathmandu from July 2016 to September 2017. All patients underwent full colonoscopy along with biopsy from sigmoid colon and any visibly abnormal areas. Results: The average age of patients was 37.5 years with 76 (52.8%) males. Forty-two (30%) had IBS-D, 36 (26%) had IBS-C, 31 (22%) had IBS-M and 31 (22%) had IBS-U. Dyspepsia was seen in 16 (11.4%) and fear of TB/Malignancy/IBD was seen in 27 (19.2%). Organic lesions were seen in 39 (27.85%) patients. Nonspecific colitis was seen in 10 (7.1%) followed by ileal erosions in 7 (5%), polyps in 8 (5.7%), hemorrhoids in 6 (4.2%) and diverticula in 3 (2.1%). Only one (0.71%) patient had microscopic colitis and one (0.71%) had malignant lesion seen at histopathological examination. Females with IBS-D had more organic findings than males (P=0.03, RR=4.13, 95% CI=1.21-15.71). Conclusions: The prevalence of organic lesions in patients with IBS fulfilling ROME IV criteria is 27%. Dyspepsia is the most common comorbidity and fear of TB/malignancy/IBD is the most common reason for seeking health care. Females with IBS-D have a higher risk of detecting organic lesions by colonoscopy and histopathology examination

Central pontine myelinolysis secondary to hyperglycemia in a young patient

Central pontine myelinolysis (CPM) is a neurological disorder typically caused by rapid correction of severe chronic hyponatremia. Conditions causing a hyperosmolar state can also cause CPM, but it is rarely seen in diabetes. Here we describe a case of a 34-year-old female with longstanding uncontrolled diabetes mellitus who presented with bilateral upper and lower limb weakness and dysphagia. Examination showed decreased muscle strength, and laboratory investigations showed high HbA1c, high blood glucose, increased serum osmolality, and normal sodium. A diagnosis of CPM was made after MRI showed restricted diffusion in the bilateral pons and CT showed pontine hypodensities. The patient was started on insulin therapy, and she showed clinical improvement with improving blood glucose levels. After five days of hospital stay, she was discharged home with appointments to neurology and endocrinology clinics. This case shows that CPM is a potential complication of uncontrolled diabetes mellitus in the presence of normal serum sodium. Timely treatment of hyperglycemia can lead to improvement of symptoms, but it is a potentially fatal condition. Thus, a diagnosis of CPM should be considered in diabetic patients who present with neurological symptoms and hyperglycemia

Spirometry in Smokers and Non-smokers: A Comparative Study

Introduction: Spirometry is the physiological test that measures how an individual breathes air volumes as a function of time. Smoking produces an increase in epithelial damage, cellular inflammatory infiltrates, muscles and fibrosis in respiratory airways and is responsible for acute respiratory various illnesses. Early identification of reduction in lung function of smokers by spirometry can be very important in order to encourage them to stop smoking. Methods: This study included a total of 106 individuals, 51 were smokers and 55 were non-smokers. The participants performed spirometry in the sitting position by open circuit method. Parameters of spirometry FVC, FEV1, FEV1/FVC and PEFR were recorded in the form of a percentage of predicted. Results: The mean FVC in smokers and non-smokers was 99.98±9.88% and 102.97±8.03% respectively (p=0.092). The mean FEV1 in smokers and non-smokers was 99.65±9.61% and 104.58±10.03% respectively (p=0.011). The mean FEV1/FVC ratio in smokers and non-smokers was 103.25±4.60% and 105.57±5.10% respectively (p=0.016). The mean PEFR in smokers and non-smokers was 102.11±8.40% and 106.01±10.62% respectively (p=0.038). The mean FVC in smokers was less than in non-smokers (99.98±9.88% and 102.97±8.03%, p=0.092). FEV1, (99.65±9.61% vs 104.58±10.03%, p=0.011) FEV1/FVC ratio (103.25±4.60% vs 105.57±5.10%, p=0.016) and PEFR (102.11±8.40% vs 106.01±10.62%, p=0.038) were significantly lesser in smokers than non-smokers. Conclusion: The spirometry parameters of pulmonary function were poorer in the smoker group. Spirometry can be useful in detecting a reduction in pulmonary function before the appearance of any symptoms or before pulmonary functions become significantly abnormal. Keywords: COPD, FEV1, FVC, PEFR, pulmonary function test, smoking, spirometry DOI: https://doi.org/10.3126/jkahs.v2i3.2666

Colorectal Cancer in Different Age Groups in a Tertiary Hospital in Nepal

Introduction: Some studies have suggested that colorectal cancer at a younger age had distinct biological characteristics: different clinical presentations, more advanced stage at time of diagnosis and poorly differentiated carcinoma. The aim of the study is to analyze clinical and histopathological differences between younger (≤40 years of age) and older (>40 years of age) colorectal cancer patients. Methods: A cross-sectional analysis was conducted amongst the colorectal cancer patients who visited Bir Hospital between July 2015 and April 2017. All colonoscopically diagnosed and histopathologically proven cases of colon cancer were included. Chi-square test and independent t – test was performed to analyze the difference between clinical presentations and histopathological findings among two groups of patients and p value of <0.05 was considered as significant. Results: Thirty younger patients and thirty older patients were enrolled without any differences in gender proportion. There were no statistical differences between clinical presentation and histological grade and type in younger and older patients. The younger patients had more complaints of altered bowel habit (p <0.001) while older patients mostly presented with per rectal bleeding (p< 0.008). Conclusions: In this study, colorectal cancer at younger ages showed similar characteristics to those of older patients except altered bowel habit was more common in younger patients while per rectal bleeding was more common in older patients. Although colorectal cancer incidence increases with age, younger patients with altered bowel habits, weight loss, anemia and anorexia should also be given due medical attention and undergo evaluation promptly.   Keywords: carcinoma; colon; per rectal bleeding; younger group. [PubMed

Factors Predicting Mortality of 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

Efficacy of Prophylactic use of Ciprofloxacin and Metronidazole in Mild and Moderately Severe Acute Pancreatitis

Introduction: There are new concepts and developments in the diagnosis and management of acute pancreatitis. Current evidence suggests that there is no role of prophylactic antibiotics use in acute pancreatitis. However, it is still a common practice to administer prophylactic antibiotics in a country like Nepal. So, we have conducted a study in mild and moderately severe acute pancreatitis to study the efficacy of prophylactic antibiotics. Methods: A case control study was conducted among 76 patients comparing efficacy of prophylactic antibiotics versus no antibiotics in patients with mild and moderately severe acute pancreatitis. Results: The two most common etiology of acute pancreatitis in AG and NAG were alcohol 21 (55.2%) vs. 24 (63.1%) and biliary 10 (26.3%) vs. 4 (10.5%) respectively. Pancreatic necrosis was seen in five (13.1 %) in AG and four (10.5%) in NAG. Four (10.5%) developed extra pancreatic complications in AG and five (13.1%) in NAG. There was one (2.6%) death in AG and no death in NAG. Abdominal pain improvement seen in AG vs. NAG was 3.2 days vs. 2.4 days (p =0.002). The hospital stay was 7.7±2.23 days in AG and 7.5±1.85 days in NAG (p=0.65). Conclusions: The routine use of prophylactic antibiotics for mild and moderately severe acute pancreatitis is not associated with improvement in meaningful clinical outcomes. Keywords: Atlanta classification 2012; mild acute pancreatitis; moderately severe acute pancreatitis; prophylactic antibiotic. [PubMed