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

Acute Viral Hepatitis in Pediatric Age Groups

Introduction: Our clinical experience showed that there has been no decrease in pediatric cases of acute viral hepatitis in Kathmandu. The objective of the study was to analyze the etiology, clinical features, laboratory parameters, sonological findings and other to determine the probable prognostic factors of Acute Viral Hepatitis in pediatric population. Methods: Consecutive patients of suspected Acute Viral Hepatitis, below the age of 15 years, attending the liver clinic between January 2006 and December2010were studied. After clinical examination they were subjected to blood tests and ultrasound examination of abdomen. The patients were divided in 3 age groups; 0–5, 5–10 and 5–15 years. Clinical features, laboratory parameters, ultrasound findings were compared in three age groups. Results: Etiology of Acute Viral Hepatitis was Hepatitis A virus 266 (85%), Hepatitis E virus in 24 (8%), Hepatitis B virus in 15 (5%). In 7(2%) patients etiology was unknown. Three patients went to acute liver failure but improved with conservative treatment. There was no statistical difference in most of the parameters studied in different age groups. Ascites was more common in 5-10 years age group. Patients with secondary bacterial infection, ultrasound evidence of prominent biliary tree and ascites were associated with increased duration of illness. Patients with history of herbal medications had prolonged cholestasis. Conclusions: Hepatitis A is most common cause of Acute Viral Hepatitis in pediatric population. Improper use of herbal medications, secondary bacterial infection and faulty dietary intake was associated with prolonged illness. Patients with prominent biliary radicals should be treated with antibiotics even with normal blood counts for earlier recovery. Keywords: Acute viral hepatitis; hepatitis A; hepatitis E; herbal medications

Transient Elastographic Values of Healthy Volunteers in a Tertiary Care Hospital

Introduction:Transient elastography is a very promising non invasive procedure to determine liver stiffness for diagnosis of fibrosis in various chronic liver diseases. However, studies on normal values of liver stiffness in apparently healthy subjects are still few. We aimed to determine liver stiffness values in healthy Nepalese volunteers. Methods:Transient elastography (FibroScanR, Echosens, Paris, France) was performed to find out liver stiffness values in 45 apparently healthy volunteers after explaining study protocol. Complete medical examination with routine laboratory tests was performed. Subjects with normal liver biochemistries and normal liver ultrasonography were taken for analysis. Results:Mean liver stiffness value of study subjects was 4.24±0.70 kPa. Liver stiffness value was found higher in males than in females (4.32±0.74 vs 4.07±0.61 kPa, respectively, P=0.26) but not statistically significant. Similarly, comparison between age and liver stiffness also showed positive correlation (r=0.211) but not statistically significant (P=0.164) Conclusions: Our study showed that the mean liver stiffness value was 4.24±0.70 kPa in our population and influence of age, gender and body mass index were not significant. Keywords: chronic liver disease; FibroScanR; healthy volunteers; liver stiffness valve; transient elastography

Acute Viral Hepatitis in Pediatric Age Groups

Introduction: Our clinical experience showed that there has been no decrease in pediatric cases of acute viral hepatitis in Kathmandu. The objective of the study was to analyze the etiology, clinical features, laboratory parameters, sonological findings and other to determine the probable prognostic factors of Acute Viral Hepatitis in pediatric population. Methods: Consecutive patients of suspected Acute Viral Hepatitis, below the age of 15 years, attending the liver clinic between January 2006 and December2010were studied. After clinical examination they were subjected to blood tests and ultrasound examination of abdomen. The patients were divided in 3 age groups; 0–5, 5–10 and 5–15 years. Clinical features, laboratory parameters, ultrasound findings were compared in three age groups. Results: Etiology of Acute Viral Hepatitis was Hepatitis A virus 266 (85%), Hepatitis E virus in 24 (8%), Hepatitis B virus in 15 (5%). In 7(2%) patients etiology was unknown. Three patients went to acute liver failure but improved with conservative treatment. There was no statistical difference in most of the parameters studied in different age groups. Ascites was more common in 5-10 years age group. Patients with secondary bacterial infection, ultrasound evidence of prominent biliary tree and ascites were associated with increased duration of illness. Patients with history of herbal medications had prolonged cholestasis. Conclusions: Hepatitis A is most common cause of Acute Viral Hepatitis in pediatric population. Improper use of herbal medications, secondary bacterial infection and faulty dietary intake was associated with prolonged illness. Patients with prominent biliary radicals should be treated with antibiotics even with normal blood counts for earlier recovery. Keywords: Acute viral hepatitis; hepatitis A; hepatitis E; herbal medications

Transient Elastographic Values of Healthy Volunteers in a Tertiary Care Hospital

Introduction:Transient elastography is a very promising non invasive procedure to determine liver stiffness for diagnosis of fibrosis in various chronic liver diseases. However, studies on normal values of liver stiffness in apparently healthy subjects are still few. We aimed to determine liver stiffness values in healthy Nepalese volunteers. Methods:Transient elastography (FibroScanR, Echosens, Paris, France) was performed to find out liver stiffness values in 45 apparently healthy volunteers after explaining study protocol. Complete medical examination with routine laboratory tests was performed. Subjects with normal liver biochemistries and normal liver ultrasonography were taken for analysis. Results:Mean liver stiffness value of study subjects was 4.24±0.70 kPa. Liver stiffness value was found higher in males than in females (4.32±0.74 vs 4.07±0.61 kPa, respectively, P=0.26) but not statistically significant. Similarly, comparison between age and liver stiffness also showed positive correlation (r=0.211) but not statistically significant (P=0.164) Conclusions: Our study showed that the mean liver stiffness value was 4.24±0.70 kPa in our population and influence of age, gender and body mass index were not significant. Keywords: chronic liver disease; FibroScanR; healthy volunteers; liver stiffness valve; transient elastography

Electrocardiograph and Chest X-ray in Prediction of Left Ventricular Systolic Dysfunction

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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

Anticoagulation Strategies in Non–Critically Ill Patients with Covid-19

BackgroundOptimal thromboprophylaxis for hospitalized patients with coronavirus disease 2019 (Covid-19) is uncertain.MethodsIn an open-label, adaptive platform trial, we randomly assigned hospitalized adults with Covid-19 to low-dose low-molecular-weight heparin thromboprophylaxis or intermediate-dose or low-dose plus aspirin. In response to external evidence, the aspirin intervention was discontinued and a therapeutic-dose arm added. The primary end point was death or the requirement for new organ support by day 28, analyzed with a Bayesian logistic model. Enrolment was closed as a result of operational constraints.ResultsBetween February 2021 and March 2022, 1574 patients were randomly assigned. Among 1526 participants included in the analysis (India, n=1273; Australia and New Zealand, n=138; and Nepal, n=115), the primary outcome occurred in 35 (5.9%) of 596 in low-dose, 25 (4.2%) of 601 in intermediate-dose, 20 (7.2%) of 279 in low-dose plus aspirin, and 7 (14%) of 50 in therapeutic-dose anticoagulation. Compared with low-dose thromboprophylaxis, the median adjusted odds ratio for the primary outcome for intermediate-dose was 0.74 (95% credible interval [CrI], 0.43 to 1.27; posterior probability of effectiveness [adjusted odds ratioConclusionsIn hospitalized non–critically ill adults with Covid-19, compared with low-dose, there was an 86% posterior probability that intermediate-dose, 65% posterior probability that low-dose plus aspirin, and a 7% posterior probability that therapeutic-dose anticoagulation reduced the odds of death or requirement for organ support. No treatment strategy met prespecified stopping criteria before trial closure, precluding definitive conclusions. (Funded by Australian National Health and Medical Research Council or Medical Research Future Fund Investigator and Practitioner Grants and others; ClinicalTrials.gov number, NCT04483960.