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Asia has intermediate-to-high prevalence and high morbidity of hepatitis B virus (HBV) infection. The use of guideline-recommended nucleos(t)ide analogs with high barrier to resistance, such as entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF), is one of the key interventions for curbing HBV infection and associated morbidity in Asia. However, there are some challenges to the use of ETV and TDF; while ETV is associated with high resistance in lamivudine (LAM)-exposed (especially LAM-refractory) patients; bone and renal safety issues are a major concern with TDF. Hence, a panel of twenty-eight expert hepatologists from Asia convened, reviewed the literature, and developed the current expert opinion-based review article for the use of TAF in the resource-constrained settings in Asia. This article provides a comprehensive review of two large, phase 3, double-blind, randomized controlled trials of TAF versus TDF in HBeAg-negative (study 0108) and HBeAg-positive (study 0110) chronic HBV patients (> 70% Asians). These studies revealed as follows: (1) non-inferiority for the proportion of patients who had HBV DNA

OBJECTIVE To evaluate the therapeutic efficacy of endoscopic dilatation of anastomotic stricture (AS). STUDY DESIGN An observational study. PLACE AND DURATION OF STUDY Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, Pakistan from November 2016 to November 2017. METHODOLOGY Patients presenting with anastomotic biliary stricture following living donor liver transplant (LDLT) underwent endoscopic retrograde cholangio-pancreaticography (ERCP) and treatment of their strictures with dilatation with or without stenting. The patients were then followed up to see adequate resolution of stricture and repeat therapeutic ERCP was performed, if required. The patients were labelled as cured if stricture resolution persisted for a period of up to six months following ERCP. RESULTS Forty-three patients (32 males and 11 females), with post-LDLT AS, who met the inclusion and exclusion criteria were enrolled in the study. Thirty-six (83.7%) patients had a single biliary anastomosis while seven (16.3%) patients had two anastomoses. Ductoplasty was done in 15 (34.9%) of the enrolled patients. Patients with post-LDLT AS required 3.65 +1.15 sessions of ERCP. Plastic type biliary stent was used in seven (16.3%) patients, balloon dilatation alone was done in five (11.6%) patients and combined balloon dilatation and stent placement was performed in 29 (67.4%) patients, and combined graduated dilator and stent placement was performed in two (4.7%) patients. Five (11.6%) patients required rendezvous procedure (whereby a radiologist placed a guidewire percutaneously into the biliary system) as guidewire placement across stricture site was endoscopically unsuccessful. The overall success rate was 88.4%. Mean stent free follow-up was 7.18 +1.38 months. Recurrence of AS was noted in one (2.3%) patient. CONCLUSION Endoscopic management of post-LDLT AS has an efficacious long-term outcome.

Beta-blockers provide secondary prophylaxis following endoscopic therapy for variceal bleeding. Guidelines recommend starting beta-blockers 6 days after endoscopy to prevent masking hemodynamic signs of re-bleeding. We aimed to see safety of earlier initiation of betablockers.Cirrhotic patients with upper GI bleed were given intravenous vasoactive agents until undergoing endoscopy. Patients with only oesophageal varices as source of bleed were recruited. Vasoactive agents were discontinued following variceal banding. The patients were observed for 12-18 hours, discharged on oral carvedilol 6.25 mg BID and monitored for 6 weeks for re-bleeding and mortality.Fifty patients were included, 27 (54%) male and 23 (46%) female. Average age was 43±3 years. Aetiology of cirrhosis was HCV in 42 (84%), HBV in 6 (12%), HCVHBV in 2 (4%) and indeterminate in 1 (2%) patient. Seventeen (34%) patients had Child A, 22 (44%) Child B and 11 (22%) had Child C disease. Hospital stay was under 24 hours in 24 (48%), 24-48 hours in 15 (30%) and 48-72 hours in 11 (22%) patients. Five (10%) patients underwent EGD within 6 hours of admission, 28 (56%) within 12 hours, 14 (28%) within 24 hours and 3 (6%) within 36 hours. No re-bleeding, mortality or drug related adverse effects were noted during 6 weeks after discharge.Our study proves possibility of shorter management of variceal bleeding by having a 12-18 hour monitoring after endoscopic banding, followed by beta-blocker initiation and discharge. This will safely reduce physical and financial burden on health services.

To determine the efficacy of 12-hour of Terlipressin therapy as compared to 72-hour therapy in preventing rebleeding after endoscopic therapy.Interventional study.Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from January to March 2016.Cirrhotic patients presenting to our hospital with GI (gastrointestinal) bleeding received Terlipressin 2 mg intravenous bolus, followed by 1mg 6-hourly until undergoing endoscopy. Those with esophageal varices as the source of bleeding underwent band ligation and were recruited. Of the 93 enrolled patients, 90 remained and were randomized into 25 (27.8%) in control Group-Aand 65 (72.2%) in test Group-B. Group-Areceived 72-hour of Terlipressin while Group-B received it for 12-hour. Both groups were monitored for rebleeding for 5 days.Rebleeding occurred in 1 (4%) patient in Group-Aand 3 (4.6%) in Group-B during the 5-day period. All 4 (4.4%) underwent repeat endoscopy. The Group-Apatient and 2 (3%) of 3 Group-B patients showed ulcers over band ligation sites as source of bleed. The third Group-B patient showed varices requiring repeat banding. One (4%) patient (Group-A) died due to persistent encephalopathy. No drug related adverse effects were seen.A12-hour duration of Terlipressin as an adjunct to endoscopic band ligation shows similar results to 72-hour therapy.

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Cirrhosis of liver is the leading cause of portal hypertension in this part of the globe. Around thirty percent of the patient with portal hypertension develops complications. Oesophageal variceal bleeding is a serious complication of portal hypertension. Oesophageal variceal band ligation (EVBL) has become the standard of care for patients with bleeding oesophageal varices. Multiple sessions of band ligation are cumbersome and expensive.Sixty patients with acute variceal bleed were enrolled in this randomized control trial. Patients were randomly assigned to multi-session (group A) or single session (group B) oesophageal variceal band ligation group. All. patients were followed for re-bleeding and mortality up to three months.Re-bleeding occurred (20%) in group A and (17%) in group B patients, respectively. Mortality was 10% in group A and 7% in group B patients. Variceal obliteration was better in group A 63% than group B 24% (p0.05).Single session band ligation was comparable for rates of re-bleeding and mortality to multi-session band ligation.

Gastroesophageal reflux disease (GERD) is the most common acid-related disorder encountered during clinical practice in Pakistan and is associated with significant impairment of health-related quality of life. A number of guidelines and recommendations for the diagnosis and management of GERD have been published in different countries, but a Pakistani accepted directive by the standards of evidence-based medicine is still lacking. Our aim was to create an understanding of the natural history and presentations of reflux disease; evaluating possible treatment options available for the patients with complex and uncomplicated reflux ailments with the development of current and up to date evidence based endorsement, relevant to the needs of Pakistani health care providers in order to treat oesophageal manifestations of GERD. In order to make such guidelines, a comprehensive literature search was conducted with pertinent evidence reviewed, and quality of relevant data assessed. The resultant conclusions were based on the best available evidence and expert opinion of the authors of technical review panel.

SUMMARY. Achalasia cardia is a disease of adolescents and is rare in children. In total, 12 children with primary achalasia, with a mean age of 10.8 ± 2 years, were prospectively evaluated for the efficacy of a 30-mm-diameter Rigiflex balloon for relief of symptoms and weight gain after 1 and 6 months of follow up. The 12 children were evaluated and treated for achalasia, with pneumatic balloon dilatation, from January 1998 to December 2000. They were studied for basal, 1-, and 6-month post-dilatation composite symptoms for dysphagia, regurgitation, night cough and heartburn. Basal and 5-min post-dilatation barium swallow were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. There were no complications. Barium height, width, composite symptom score and weight improved significantly up to the 6-month follow up. Rigiflex balloon dilatation of 30-mm diameter is safe and effective in children with achalasia.

Duration of Inflation in pneumatic balloon dilatation as treatment of achalasia has been variable ranging from 15 s to 6 min. A 60 s duration appears to be most often used. We compared the efficacy of dilation of achalasia with either 6- or 60-s inflation duration using a Rigiflex dilator of 3.0 cm diameter.Eighty-one consecutive patients were prospectively studied in a randomized fashion, 41 in the 60-s group (A) and 40 patients in the 6-s group (B). Mean age of group A was 43 +/- 16.2 yr and of group B was 40 +/- 16.4 yr. Symptoms of dysphagia, chest pain, heartburn, regurgitation, and night cough were evaluated at basal (before dilation), 1- and 6-month intervals after dilation in both groups. Barium swallow was done to assess esophageal emptying 1 wk before dilation and 5 min postdilation in both groups.Significant and sustained improvement was seen for all symptoms in both groups. In addition, the degree of improvement in symptom scores between the two groups was similar. Barium esophagram in both groups at basal and immediately postdilation showed significant improvement in barium emptying but there was no significant difference between the two groups, indicative of equal efficacy in both distention times. Two patients needed repeat dilatation in group A and one in group B, with one drop out from group A, who was lost to follow-up, and was excluded from the analysis. No perforation occurred.Short duration of pneumatic balloon dilatation (6-s) is as effective as longer duration (60-s) in treatment of achalasia.

To determine the efficacy of Rifaximin in prevention of repeated episodes of hepatic encephalopathy in patients with liver cirrhosis as compared to placebo.Triple-blind, randomized placebo-controlled trial.Department of Gastroenterology-Hepatology, Shaikh Zayed Hospital, Lahore, from October 2012 to April 2013.Patients in remission from recurrent hepatic encephalopathy resulting from cirrhosis were randomly assigned to receive either Rifaximin, at a dose of 550 mg twice daily (63 patients), or placebo (63 patients.) Patients were requested to take the drug orally twice daily for 6 months or until they developed a breakthrough episode of hepatic encephalopathy.Mean age of patients in treatment and control group was 40.21 ± 2.33 years and 42.87 ± 4.54 years respectively. The most common etiology of cirrhosis was hepatitis C followed by hepatitis B. Patients who remained free of hepatic encephalopathy during study period were 40 out of 63 patients in control group and 35 patients out of 63 patients (p = 0.56). Most of the patients who developed breakthrough hepatic encephalopathy had a MELD score range of 21-25 in both groups. The number of deaths and adverse events was similar in both groups.Over a 6-month period, treatment with Rifaximin failed to maintain remission from hepatic encephalopathy more effectively than placebo in the studied group.

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.

This case report describes a 50-year-old female patient with liver cirrhosis presented with anemia. She was found to be suffering from gastric antral vascular ectasia (watermelon stomach) on upper gastrointestinal endoscopy. She underwent multiple sessions with Argon plasma coagulation, a non-contact thermal method of hemostasis for the management of watermelon stomach. After 3 sessions, the lesions disappeared and the hemoglobin increased by 2.4 gm/dl without any need of transfusion.

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.

Acute airway obstruction from mega-esophagus is a rare presentation of achalasia. Mega-esophagus is generally considered when the transverse width of the esophagus is more than 7 cm. A 78 year old lady presented with longstanding history of productive cough and nocturnal dyspnoea. She was seen in the emergency department with acute exacerbation of dyspnoea after a bout of vomiting, containing semi-solid food with foetid smell. Her respiratory status deteriorated rapidly with onset of stridor, and cyanosis. Chest x-ray showed widening of mediastinum due to dilated esophagus with air-fluid level. Prompt, repeated, upper respiratory tract suction was carried out. A wide bore nasogastric tube was introduced, esophagus was decompressed with a gush of air and fluid, relieving the respiratory distress. This case illustrates an unusual presentation of achalasia underscoring the need for urgent, life-saving esophageal decompression. Hypotheses, regarding the mechanism of airway compromise, as well as, treatment options are reviewed.

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 frequency of Hepatopulmonary Syndrome (HPS) in patients with cirrhosis of the liver.Observational cross-sectional study.Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from April 2005 to March 2006.Fifty consecutive patients admitted with liver cirrhosis were recruited. Twelve patients were excluded due to inadequate echocardiography image quality and inability to perform lung function tests. The diagnosis of cirrhosis was made on clinical, biochemical, serological and metabolic workup, ultrasound abdomen or liver biopsy. Complete blood count, liver function tests, prothrombin time, serum albumin, electrocardiography, chest radiograph, transthoracic contrast echocardiography, arterial blood gas analysis and pulmonary function tests (FEV1) were performed. Results were analyzed as percentages. Chi-square test of proportions and t-test were applied.Total patients evaluated were 38. Mean age was 47.92 +/- 11.38 years, with male (68.4%) to female (31.6%) ratio of 2.1:1. The commonest cause of cirrhosis was hepatitis C (71.1%). Out of the 38 patients, 11 (28.9%) had HPS including 5 (13.2%) with overt HPS and 6 (15.8%) with subclinical HPS. All patients with HPS had hepatitis C with Child-Pugh-Turcotte (CPT) class C. Factors associated with HPS were digital clubbing, arterial hypoxemia and intrapulmonary vascular dilatations (p=0.02, 0.05 and 0.000 respectively).In this study, 28.9% patients with cirrhosis of the liver had HPS. All belonged to child class C due to hepatitis C. Digital Clubbing, arterial hypoxemia and intrapulmonary vascular dilatations were important features of hepatopulmonary syndrome.

The objective is to determine causes of low serum ascites albumin gradient (SAAG) by direct visualization and obtaining biopsy samples using laparoscopic technique. This is a hospital-based, observational study conducted at Department of Gastroenterology, Sheikh Zayed Hospital, Lahore from January 2001 to April 2002. A total of 33 patients with ascites (SAAG1.1 g/dl)) were selected. The findings on history and clinical examination, information from laboratory and radiological investigations were recorded. Laparoscopic findings and histological reporting were correlated. The mean ages were 48.38 +/- 16.7 years. Fifteen (45%) patients were male. The mean duration of the presenting complaints was 3.33 +/- 1.9 months. Ascites was present in all with mean SAAG of 0.73 +/- 0.22. Laparoscopic evaluation showed tuberculous peritonitis in 22 (66.7%) patients and carcinomatous peritonitis in 5 (15.2%) patients. Biopsies were obtained from omentum in 20, peritoneal surface in 5 and liver in 12 patients. The histopathological diagnosis was granulomatous inflammation in 20 (60.6%) and diagnosis of malignancy was made in 7 (21.2%); one (3%) had Budd Chiari Syndrome, 4 (12%) had cirrhosis of liver with super-added Hepatocellular carcinoma and biopsy was non-conclusive in 1 patient. No complication of procedure occurred in this cohort. Laparoscopy is a safe diagnostic modality to establish the cause of low SAAG ascites.

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.

To validate Rockall scoring system for in-hospital rebleeding and mortality in cirrhotic patients with variceal bleed.Cohort type of case series.It was carried out at the Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from March 2005 to March 2006.All cirrhotic patients presenting with upper GI bleeding and later found to have variceal source of bleeding on endoscopy were included. Clinical and endoscopic features were noted to calculate Rockall score. After giving appropriate pharmacological and endoscopic therapy, patients were followed for rebleeding or death till discharge from hospital. Linear regression analysis was used to determine predictive value of score and discrimination was evaluated by calculating the area under the receiver operating characteristic (ROC) curve.A total of 402 patients were included. Mean age was 52.57 (+/-11.39) and male to female ratio was 2:1(269/133). Esophageal varices were source of bleeding in 340 (84.5%), gastric fundal varix in 44 (11%) and ectopic duodenal varix in 3 (0.9%) patients. Both esophageal and gastric varices were present in 15 (3.6%) patients. In-hospital mortality was 6.7% while 22 (5.5%) patients had rebleeding. Rockall score was found to have good predictive value for mortality (p-value0.001 and area under curve AUC 0.834) and in-hospital rebleeding (p-value0.001 and AUC 0.798).Rockall scoring system has good predictive and discriminative value for in-hospital rebleeding and mortality in patients with variceal bleeding due to cirrhosis.

Use of endoscopic therapies for esophageal varices has resulted in increased prevalence of fundal varices and severe portal hypertensive gastropathy. This study was meant to compare the effect of band ligation and sclerotherapy on development of fundal varices and portal hypertensive gastropathy.Patients with esophageal varices presenting in the endoscopy unit of Shiakh Zayed Hospital, with at least one previous endoscopy were included. Patient's past record was reviewed for findings and type of treatment given for varices during first endoscopy, number of endoscopies till date, number of esophageal varices band ligation (EVBL) or sclerotherapy sessions. All patients underwent upper GI endoscopy and findings were recorded. Type of treatment patient rendered during first endoscopy either EVBL or sclerotherapy was correlated to the presence of fundal varices and severity of portal hypertensive gastropathy observed on present endoscopy, using Chi square test (chi2).Eighty one patients were included. Mean age of patients was 48.70 +/- 12.63. Esophageal varices band ligation was carried out during first endoscopy in 49 (60.5%) patients and sclerotherapy in 31 (38.2%) patients. On fresh endoscopy, fundal varices were seen in 25 (30.8%) patients. Severe portal hypertensive gastropathy was found in 26 (32.1%) and mild in 54 (66.7%) patients. Severity of portal hypertensive gastropathy and presence of fundal varices in recent endoscopy was significantly more in patients with EVBL in first endoscopy.Band ligation of esophageal varices is associated with more frequent development of fundal varices and worsening of portal hypertensive gastropathy compared to sclerotherapy.

To determine the difference in sustained virological response to interferon-ribavirin combination therapy between patients with normal ALT and those with raised ALT in chronic hepatitis C.Quasi-experimental study.Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from February 2004 to June 2005.Patients with positive HCV RNA by PCR and compensated liver disease were included and divided in two groups. One group with ALT below upper normal limit (UNL= 65U/L) and second group with raised ALT (1x UNL). After treatment with standard interferon alpha 2a and ribavirin, both groups were checked for sustained viral response (SVR) six months after end of treatment and compared for response to therapy with Chi square test.Of the 70 patients included, 25 had normal ALT (1 x upper normal limit UNL) and 45 had ALT above upper normal limit (1 x UNL). Of these, 63 patients completed treatment. Sustained viral response (SVR) was seen in 13 of 22 patients with normal ALT who completed therapy and 22 of 41 patients with raised ALT who completed treatment. Difference in SVR in two groups was not significant (p 0.679). When patients with raised ALT were sub-classified, significantly better response was seen in patients with ALTor = 2 times the upper normal limit (p 0.021).Patients with normal baseline ALT respond equally well to combination therapy as is seen in patients with raised ALT.

To determine prognostic indicators for morbidity and mortality in patients with fulminant hepatic failure.Observational study.Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from April 2003 to June 2005.Forty five patients with confirmed diagnosis of fulminant hepatic failure were included in this study. They were investigated for acute viral serology, complete blood count, liver function tests, renal function tests, serum electrolytes, arterial blood gases, initially daily and then on alternate days. Patients were followed in high dependency/ICU at the Shaikh Zayed Postgraduate Medical Institute. Data were analyzed by logistic regression analysis to identify predictors of mortality and morbidity.Of the 45 subjects, 31 were males and 14 females. Twenty four patients were positive for acute hepatitis E. Twenty patients recovered fully, whereas 25 died with mortality rate of 55.6 %. Variables i.e. presence of non-A non-B viral hepatitis, serum creatinine2.0 mg/dl, serum phosphate3.5 mg/dl and sepsis were found to have significant association with mortality on linear correlation. Only serum creatinine more than 2.0 mg/dl, serum phosphate3.5 mg/dl and development of sepsis were found to predict the outcome after multivariate analysis.Patients with serum creatinine2.0 mg/dl, serum phosphate3.5 mg/dl and sepsis showed adverse prognosis for survival.

To determine the changes in oxygen saturation, blood pressure and pulse rate during various endoscopic procedures and to find out the risk factors for these changes.Observational study.Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan from June 2001 to December 2001 were included in the study.Oxygen saturation, blood pressure and pulse were monitored during various endoscopic procedures using pulse oximeter. These changes were recorded from the start until 5 minutes after the procedure. The important variables which were evaluated in relation to these changes included age, gender, history of smoking, associated chronic obstructive airway disease (COAD), coronary artery disease (CAD), duration of procedure, elective versus emergency and diagnostic versus therapeutic procedures.Base line mean oxygen saturation was 98.1+/-0.98 %. The saturation decreased to 93.5+/-4.8 % (p=0.002) during the procedures and returned to base line after the procedures. Mild to moderate hypoxia was found in 59 (20.2%) patients. Severe hypoxia was found in 32 (11.5%) patients. Of these 21(65.6%) patients were having history of COAD. No patient developed serious complications. The changes in blood pressure and pulse were not significant. The variables which reached statistical significance for desaturation were age50 years, history of smoking, emergency procedures, therapeutic procedures and associated COAD. Diabetes mellitus (DM) and hypertension (HTN) alone, CAD and duration of procedures did not affect oxygen saturation.Mild to moderate hypoxia is common during endoscopic procedures and of no serious consequence. Severe hypoxia is less common and is associated with underlying risk factors. Continuous monitoring is required in patients with age50 years, history of smoking, emergency procedures, therapeutic procedures and history of COAD. Routine monitoring with pulse oximetry may not be required in patients with no risk factors.

To determine various features of colorectal polyps and to evaluate the safety of colonoscopic polypectomy.Case series.The Department of Gastroenterology and Hepatology, Federal Postgraduate Medical Institute, Shaikh Zayed Hospital, Lahore, from January 1987 to January 2004.This study was based on data analysis of 393 patients who underwent colonoscopic polypectomy at our institution during 17 years from January 1987 to January 2004. Presenting complaints of patients were noted. Polyps were evaluated in terms of size, site, number and histopathology.Among 393 patients, 268 were male and 125 female. Presenting complaints were bleeding per rectum in 339 patients, diarrhea with blood in 34 and without blood in 6 patients, and lower abdominal pain in 12 patients. Two patients were being investigated for iron deficiency anemia. Two hundred and sixty-four patients had juvenile polyps, 39 had adenomatous polyps, 39 hyperplastic polyps, 39 inflammatory polyps, 3 malignant polyps and 2 patients had familial polyposis. Histopathological reports were not available in 7 patients. Size of the polyps ranged from 0.3 cm to 3.0 cm. Left colon was involved in 353 patients, transverse colon in 15, right colon in 8 patients and diffuse involvement of colon found in 17 patients. Bleeding following polypectomy occurred in 2% of the patients. No other procedure related complication occurred.Juvenile polyps were the commonest variety of polyps in our study. Colonoscopic polypectomy has very low complication rate.

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.

To determine the efficacy of reagent strip for bedside diagnosis of spontaneous bacterial peritonitis (SBP).Cross-sectional analytical study.Shaikh Zayed Postgraduate Medical Institute from November 2003 to August 2004.Patients with cirrhosis and ascites underwent diagnostic paracentesis. Fluid was checked for leukocyte esterase released by PMN by using Combur 10 urine strip and graded for color change from 0-3. Fluid was also analyzed by cytology for PMN count. Results of both methods were compared to determine sensitivity, specificity and accuracy of strip for diagnosis of SBP.Of 214 paracentesis performed, SBP was diagnosed in 38 patients whereas 176 were negative for infection. Strip test was 97.7% sensitive and 89.4% specific with positive predictive value of 90%, negative predictive value of 97.7% and accuracy of 96.2%, when reagent strip grade 3 was considered as positive for diagnosis.Reagent strip is a quick bedside test, highly sensitive and specific for the diagnosis of SBP, based on polymorphonuclear count in ascitic fluid, to initiate early treatment, thus improving patient's outcome.

To identify hematological, biochemical and ultrasonographic predictors of esophageal varices in patients of cirrhosis.Cross-sectional, analytical study.Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from September 2003 to March 2004.One hundred and one patients with established cirrhosis and no history of variceal bleed underwent physical examination, hematological, biochemical tests and abdominal ultrasound examination. Esophagogastroduodenoscopy (EGD) was carried out in all patients. Presence of varices on EGD was correlated with hematological, biochemical and ultrasonographic variables by regression analysis.Esophageal varices were seen in 65 patients while 36 patients had no varices. High grade varices were seen in 15 patients and 50 patients had low grade varices. Serum albumin less than 2.95 g/dl, platelet count less than 88 x 103/muL and portal vein diameter more than 11 mm were associated with presence of varices. High grade varices were predicted by serum albumin2.95 g/dl and portal vein diameter more than 11 mm.Patients with serum albumin2.95 g/dl, platelet count88 x 103/muL and portal vein diameter11 mm are more likely to have high grade varices. These patients are candidates for surveillance endoscopy.

Ectopic intestinal varices are rarely responsible for lower gastrointestinal (GI) haemorrhage. A case of 55 years old male with recurrent melena is being presented, who was found to have scattered varices on small as well as large intestine. Selective review of literature regarding presentation, diagnosis and management of these cases is also part of presentation.

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.