Acute Upper Gastrointestinal Bleeding in a Tertiary Care Centre of Nepal

Introduction: AUGIB is characterized by hematemesis or melena or both. Peptic ulcers and variceal bleed account for majority of cases. Use of proton pump inhibitors in current era is associated with a gradual reduction in burden of peptic ulcer disease. We conducted this study to look into the cause of AUGIB in our community. Methods: We studied 100 patients in one year period who presented to us with hematemesis or melena. The study was conducted in department of Gastroenterology, Bir hospital, Kathmandu. We identified the culprit lesions by upper gastrointestinal endoscopy. Results: The average age of patients with AUGIB was 51.6 years with 59 (59%) males. Duodenal ulcers are most common 29 (29%), followed by varices 23 (23%) and gastric ulcers 14 (14%). More than one lesion was identified in 38 (38%) patients. Patients with variceal bleed were more likely to present with hematemesis alone as compared to those with ulcer bleed (p=0.005). Variceal bleed patients presented earlier to the hospital (p=0.005), had lower MAP at presentation (p=0.0002), had lower hemoglobin level (p=0.0001) and higher serum creatinine level at presentation (p=0.001). Patients with variceal bleed were more likely to have consumed alcohol 20 (86.9%) and patients with ulcer bleed were more likely to be smokers 29 (67.4%) or consume tobacco 14 (32.5%) (p=0.006). Conclusions: Ulcer related bleeding is still the most common cause of AUGIB. Many patients with AUGIB have more than one lesions identified during upper gastrointestinal endoscopy. Keywords:  bleeding; endoscopy; peptic ulcer; upper gastrointestinal;varices. [PubMed

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

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

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