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To document the quality of colonoscopy practice and the pattern of colonic disease including polyp detection rate at Shifa International Hospital, Islamabad, Pakistan.An observational study.Shifa International Hospital, Islamabad, Pakistan, from May 2013 to June 2014.This retrospective study recorded demographics of patients, indications and quality indices of 505 colonoscopies performed during the study period. Preparation was done with low residue diet and polyethylene glycol. Conscious sedation was generally used. Quality indices studied were compared with guideline standard.Out of 505 colonoscopy patients, 305 were males and 200 were females. The indications for colonoscopic examination were lower gastrointestinal bleeding (26.5%, n=134), screening for colorectal cancer (14.1%, n=71), chronic diarrhea (12.9%, n=65), abdominal pain (10.9%, n=55), anemia (9.1%, n=46), constipation (7.3%, n=37), hematochezia and diarrhea (6.3%, n=32), altered bowel habits (5.1%, n=26), weight loss (3.6%, n=18), colonic thickening on CT scan (3.0%, n=15) and others (1.2%, n=6). Bowel preparation was adequate (in 92%, n=465) cases. Cecal intubation rate was 88.71% (n=448). Endoscopic diagnoses were hemorrhoids (36.2%, n=183), normal (22%, n=111), polyps (11.3%, n=57), ulcerative colitis (8.7%, n=44), cancer (4%, n=20), diverticulosis (3.4%, n=17), infective colitis (2.6%, n=13), intestinal TB (2.6%, n=13), non-specific colitis (2.2%, n=11), proctitis (1.8%, n=9) and others (5.3%, n=27).There is room for improvement in quality of colonoscopy, cecal intubation rate is slightly below the recommended standard and polyp detection rate is quite low however, it is not clear if the low rate of polyp detection is due to missed lesions or low population incidence. Time to reach caecum and withdrawal time should clearly be documented in the notes which can help to evaluate quality of the procedure in a better way.

To evaluate the prevalence of renal failure (RF) in the patients of end stage liver disease (ESLD), to determine the causes of RF in these patients and its impact on patient's outcome.Descriptive, analytical study.Shifa International Hospital, Islamabad, Pakistan, from May 2011 to March 2013.A total of 523 patients with end stage liver disease (ESLD) were evaluated, renal failure (RF) and its causes were recognized in these patients according to established criteria. Outcome of these patients was assigned as reversal of RF or mortality. Data was analyzed using SPSS version 16. Chi-square test was used for comparing proportions and t-test was used for comparing mean values. P0.05 was considered significant.Out of 523 patients, 261 (49.9%) had RF. Acute kidney injury (AKI) was the most common presentation seen in 160 (61%) patients. Hypovolemia and infections were the most frequent causes of RF. Mortality was significantly higher in the patients with RF, when compared to the patients without RF (31% vs. 4.5%, p0.001). Reversal of RF was seen in 98 (37%) of the affected patients. Reversal was more common in the patients with hypovolemia. The mortality was higher in the patients with hepatorenal syndrome (HRS) and infections.Renal failure in the end stage liver disease is an important prognostic factor. Etiology of RF is the key factor in patients' outcome. Patients of ESLD with RF had higher mortality. Majority of the cases of RF were reversible in patients of ESLD coming in the setup.

To assess the quality and patient satisfaction in Endoscopy Unit of Shifa International Hospital.Cross-sectional survey.Division of Gastroenterology, Shifa International Hospital, Islamabad, Pakistan, from July 2011 to January 2012.Quality and patient satisfaction after the endoscopic procedure was assessed using a modified GHAA-9 questionnaire. Data was analyzed using SPSS version 16.A total of 1028 patients were included with a mean age of 45 ± 14.21 years. Out of all the procedures, 670 (65.17%) were gastroscopies, 181 (17.60%) were flexible sigmoidoscopies and 177 (17.21%) were colonoscopies. The maximum unsatisfactory responses were on the waiting time before the procedure (13.13 %), followed by unsatisfactory explanation of the procedure and answers to questions (7.58%). Overall, unsatisfied impression was 4.86%. The problem rate was 6.22%.The quality of procedures and level of satisfaction of patients undergoing a gastroscopy or colonoscopy was generally good. The factors that influence the satisfaction of these patients are related to communication between doctor and patient, doctor's manner and waiting time for the procedure. Feedback information in an endoscopy unit may be useful in improving standards, including the performance of endoscopists.

Combination therapy with interferon and ribavirin has become the standard of care in the treatment of Chronic Hepatitis C (CHC) infected patients. Treatment response, however, is not 100% and is accompanied with side effects faced by the patient as well as observed in haematologic indices. Studies are focusing on daily or high-dose induction therapy with interferon, the titration of interferon dosing to initial viral load, higher doses of interferon throughout treatment, and adjustment of interferon dosing to the viral responses. The safety and efficacy of these approaches have not been sufficiently established. Objectives were to see the response of 2 different dosage regimens, effects and side effects and to assess the efficacy and side effects of 2 treatment regimens of Interferon and Ribavirin in CHC.A total of 32 patients with CHC at Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute Lahore from June 2001 to February 2003 were included in the study and were divided into two groups for treatment. Group A (14 patients) received 5 MU of injection Interferon alpha 2 b S/C daily for 2 weeks followed by 3 MU thrice weekly for the next 22 weeks. Group B (18 patients) received injection interferon alpha 2 b 3 MU S/C thrice weekly for 24 weeks. Ribavirin therapy was started at 1200 mg daily in 3 divided doses and later modified according to side effects. Patients were evaluated at 2, 4, 8, 12, 16, 20 and 24 weeks during the therapy and then 24 weeks after the completion of treatment.Out of 32 adult patients included in the study, 18 were males and 14 females. Haemoglobin was more than 12 gm/dl in females and more than 13 gm/dl in males, WBC count was more than 3.0 x 10(9)/L and Platelet count was more than 100 x 10(9)/L. Twenty patients completed 6 months combination treatment, 16 reported with their end of treatment HCV RNA PCR results, 8 from each group. Twelve patients were lost to follow up. End of treatment response (ETR) in group A was 88% and 62.5% in group B. Sustained virological response in group-A was 5/8 (62.5%) and 4/5 (50%) in group-B. The frequency and severity of flu like symptoms like fever, body aches, skin rash, hair loss, cough and psychiatric symptoms were more in group A than in group B. There was no significant difference in the 2 groups for haematologic side effects.Treatment with 5 MU interferon daily for initial two weeks followed by 3 MU thrice weekly for 22 weeks is more effective than 3 MU thrice weekly for 24 weeks but with more side effects.

To determine the efficacy of Argon Plasma Coagulation (APC) in terms of improvement in hemoglobin level and disappearance of telangiectasia as endoscopic treatment for Gastric Antral Vascular Ectasia (GAVE) and Diffuse Antral Vascular Ectasia (DAVE) syndrome in liver cirrhosis.Quasi experimental study.Department of Gastroenterology and Hepatology of Shaikh Zayed Hospital/ Federal Postgraduate Medical Institute, Lahore, from January, 2006 to July, 2007.Cirrhotic patient with gastric vascular ectasia were enrolled and followed-up for 18 months with repeated sessions of APC. Efficacy of APC was evaluated on the basis of patient's symptoms, transfusion requirements and hemoglobin levels. APC was performed by using ERBE generator set at 60 W and flow rate 2.0 L/min using primarily endfiring probes.Fifty patients were enrolled in the study. Mean age was 55.78+1.24 years with 32 males and 18 females giving a male to female ratio 1.7:1. Forty two patients were in Child's Class C and 8 in Child's Class B. Presenting complaints were malena and anemia. Two hundred and fifty three APC sessions were carried out; mean 5.06+1.5 sessions per patient. Mean follow-up period after the last session was 8.5+3.7 months. Mean increase in the hemoglobin level was 1.35+0.24 g/dl. There was no death of any patient during the study period.Treatment with APC is an effective and safe method to decrease blood loss in patients with GAVE and DAVE.

To compare the efficacy of propranolol, propranolol with nitrate, band ligation, and band ligation with propranolol and nitrate for the prevention of esophageal variceal rebleeding.A prospective randomized trial.Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from November 2003 to July 2005.One hundred and sixty cirrhotic patients with esophageal variceal bleeding were randomized to four treatment groups (propranolol, propranolol plus isosorbide mononitrate, band ligation, band ligation plus propranolol and nitrate) with 40 patients in each group. Patients were followed for 6 months after the enrolment of last patient. Primary end points were recurrence of esophageal variceal bleeding and death. Treatment complications were noted.Four treatment groups were comparable regarding baseline characteristics. Esophageal variceal rebleeding occurred in 22% patients in band ligation plus drugs group, 26% patients in drug combination group, 31% patients in banding group and 38% patients in propranolol group (p=0.41). Difference in mortality rates was also not significant.There was no significant difference between treatment groups in prevention of esophageal variceal rebleeding.

To determine the efficacy of L-ornithine-L-aspartate in treatment of hepatic encephalopathy.Randomized, placebo-controlled trial.Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from February to August 2005.Cirrhotic patients with hyperammonemia and overt hepatic encephalopathy were enrolled. Eighty patients were randomized to two treatment groups, L-ornithine-L-aspartate (20 g/d) or placebo, both dissolved in 250 mL of 5% dextrose water and infused intravenously for four hours a day for five consecutive days with 0.5 g/kg dietary protein intake at the end of daily treatment period. Outcome variables were postprandial blood ammonia and mental state grade. Adverse reactions and mortality were also determined.Both treatment groups were comparable regarding age, gender, etiology of cirrhosis, Child-Pugh class, mental state grade and blood ammonia at baseline. Although, improvement occurred in both groups, there was a greater improvement in L-ornithine-L-aspartate group with regard to both variables. Four patients in the placebo group and 2 in L-ornithine-L-aspartate group died.L-ornithine-L-aspartate infusions were found to be effective in cirrhotic patients with hepatic encephalopathy.

SUMMARY. Pneumatic balloon dilatation is the treatment of choice for esophageal achalasia. Rigiflex (Microvasive, Watertown, MA) polyethylene balloon dilators have been used with varying success and complications. The aim of this study was to evaluate the efficacy of graded balloon dilatation, to achieve symptomatic improvement in patients with achalasia. From January 1987 until the end of December 2003, 300 patients were evaluated and treated for achalasia, with 30 mm balloons. Patients who did not achieve satisfactory symptomatic responses during follow up underwent repeat dilatation with 35-mm balloons. They were studied at the onset then at 1 and 6 month intervals and then yearly for postdilatation symptom evaluation for dysphagia, regurgitation, night cough and heartburn. Baseline and 5-min postdilatation barium swallow studies were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. No patients developed cancer of the esophagus in 16 years follow up. Barium height, width, composite symptom score and weight improved significantly during follow up. Two patients, who needed repeat dilatation with 35-mm balloons, developed esophageal perforation; one was successfully managed with intensive medical care management, whereas the other patient died despite surgical intervention. The authors conclude that pneumatic balloon (Rigiflex) dilatation for achalasia of the esophagus is a successful first option, when applied in an incremental balloon size to achieve desired results in symptomatic relief.

To determine the success and complications of precut papillotomy using needle knife technique in common bile duct cannulation.Quasi interventional.The Department of Gastroenterology and Hepatology, Federal Postgraduate Medical Institute, Sheikh Zayed Hospital, Lahore from April 2001 to August 2003.From April 2001 to August 2003, a total of 347 ERCPs were performed at our institution. During this period, precut papillotomy was carried out in 79 patients. The data of these patients was evaluated for the success of the procedure and occurrence of short-term complications. Other parameters such as age and gender of patients, appearance of ampulla, and the diagnoses were also recorded.Forty-five patients were women and 34 men. The mean age was 52 years (range 12-80 years). Precut helped to cannulate common bile duct in 67 patients at first attempt and in further 5 patients at second attempt with an overall success rate of 91.14%. Complications occurred in 8 (10.1%) patients. These include hemorrhage in 5 (6.3%) patients and pancreatitis in 3 (3.8%). All complications were managed conservatively.Precut papillotomy is an effective technique in cannulating common bile duct in difficult cases with margin of safety, dependent on expertise.

The severity of hepatic abnormalities and extent of dysfunction of other organ systems influences prognosis for cirrhosis. The Child-Pugh system has been used to classify cirrhotic patients into good, intermediate, or poor risk categories in evaluation and therapy. Disregard for cardiorespiratory, renal, electrolyte balance, and acid base status limits its predictive accuracy. We evaluated the accuracy of Acute Physiology and Chronic Health Evaluation (APACHE III) to predict short term hospital mortality in patients with liver cirrhosis.A total of 282 patients were prospectively enrolled. Child-Pugh and APACHE III scores were recorded on day 1 for each patient.Mean age was 51.7+/-11.3 yr, with 65% men and 35% women; 57% presented with upper GI bleeding, 47% encephalopathy, 9% hepatorenal syndrome, and 7% hepatocellular carcinoma. Sixty-three patients (22%) died. Major causes of death were upper GI bleeding 38%, liver failure 21%, hepatorenal syndrome 19%, hepatocellular carcinoma 4%, and spontaneous bacterial peritonitis 6%. Child-Pugh and APACHE III scores for survivors (8.6+/-2.3 and 58.9+/-35.1) were lower than those for nonsurvivors (10.9+/-2.7 and 87.4+/-30.3) (p0.001). Using discriminant analysis, APACHE III correctly identified 75% of cases vs 67% of cases for Child-Pugh (p0.05). When information regarding ascites and prothrombin time was added to APACHE III, 81% of cases were correctly classified.The APACHE III scoring system is superior to Child-Pugh for prognosticating short term survival of cirrhotic patients. Prognostic accuracy of APACHE III can be enhanced by incorporating information regarding ascites and prothrombin time prolongation.