Abdullah Bin Khalid

Risk factors associated with Helicobacter pylori infection treatment failure in a high prevalence area

Triple therapy is commonly used for the treatment of Helicobacter pylori infection. We determined risk factors associated with its failure in compliant patients focusing on H. pylori density, virulence marker and 23S ribosomal RNA (rRNA) point mutations associated with clarithromycin resistance. H. pylori infection was diagnosed by 14C urea breath test (14C UBT) and rapid urease test or histology. Triple therapy with esomeprazole 20 mg b.i.d., amoxicillin 1 g b.i.d. and clarithromycin 500 mg b.i.d. was prescribed for 10 days. 14C UBT was repeated 4 weeks after treatment. In total, 111 patients [69 (62%) males] with a mean age of 46±16 years were enrolled. The mean age of treatment failure was 39±14 years compared to 48±16 years with eradication (P=0·002). Treatment failure was associated with younger mean age, point mutations in the 23S rRNA gene of H. pylori and vacA s1a and m1 when associated with cagA negativity.

Microsporidial infections due to encephalitozoon intestinalis in non-HIV-infected patients with chronic diarrhoea.

We determined the prevalence of microsporidia Enterocytozoon (Ent.) bieneusi and Encephalitozoon (E.) intestinalis infection in patients with chronic diarrhoea and hepatocellular carcinoma (HCC). A total of 330 stool samples were examined from 171 (52%) patients with chronic diarrhoea, 18 (5%) with HCC while 141 (43%) were controls. Stool microscopy, polymerase chain reaction (PCR) with species-specific primers for Ent. bieneusi and E. intestinalis and sequencing were carried out. Microsporidia were found by trichrome staining in 11/330 (3%) and E. intestinalis by PCR in 13/330 (4%) while Ent. bieneusi was not detected. PCR for E. intestinalis was positive in 8/171 (5%) stool samples from patients with chronic diarrhoea, 2/141 (1·4%) samples from healthy controls and in 3/18 (17%) samples from patients with HCC. In the chronic diarrhoea group, E. intestinalis was positive in 4/171 (2·3%) (P=0·69) stool samples compared to 2/18 (11%) (P=0·06) in the HCC group and 2/141 (1·4%) from healthy controls. E. intestinalis infection was significantly associated with chronic diarrhoea and HCC in these patients who were negative for HIV. Stool examination with trichrome or species-specific PCR for microsporidia may help establish the cause of chronic diarrhoea.

Predictors of serious findings on bi-directional endoscopy in young patients with anemia and GI symptoms

Background and Objective: Iron deficiency anemia (IDA) has been cited as the most common cause of anemia globally. Gastrointestinal (GI) lesions are amongst the common cause of IDA. Endoscopic evaluation is the most effective way to investigate the IDA. The aim of this study was to show the association of alarming GI symptoms with abnormal endoscopic findings and to cut off the burden and cost of unnecessary endoscopies. Methods: This is cross sectional study of anemic patient who underwent upper and lower GI endoscopies in Aga Khan University Hospital, Karachi between July-December 2016. Results: Total 243 patients were identified after excluding ineligible patients. The mean age of subjects was 31.9 ± 6.1 years with a slight over-representation of females (57.4%). 149 (61.31%) patients underwent only upper GI endoscopic evaluation, and 83 (34.15%) patients on whom bi-directional endoscopy was performed (upper and lower). The remaining 11 (4.52%) patients underwent colonoscopy only. 16 (6.6%) subjects had negative findings on evaluation, while gastritis and serious findings were observed in 175 (72.0%) and 52 (21.4%) patients respectively. We found that patients with alarm features such as dysphagia (aOR: 2.07, 95%CI: 0.12-34.1), altered bowel habits (aOR: 1.64, 95%CI: 0.44-6.09) and weight loss (aOR: 1.25 95%CI: 0.54-2.85) demonstrated higher odds of serious findings on endoscopic evaluation as compared to the reference category, however they were not independently associated. Conclusion: Most of our patients had non-malignant pathologies, while alarm features were not found to be useful predictors of serious findings.

Value of Adjusted Blood Requirement Index in determining failure to control bleed in patients with variceal bleeding.

Introduction Variceal bleeding is a serious complication in patients with cirrhosis. Among the criteria that were proposed in Baveno conferences, the Adjusted Blood Requirement Index (ABRI) has not been validated prospectively in clinical practice. We therefore aim to evaluate the measurement of ABRI as a marker of failure to control bleeding and to evaluate the consistency of ABRI in relation to other criteria of failure to control variceal bleeding. Patients and methods All patients with variceal bleeding who presented to Aga Khan University Hospital from January 2010 to December 2012 who were administered transfusion of packed red blood cells were included after obtaining informed consent. All patients were managed as per the standard protocol with intravenous terlipressin along with band ligation and injection of cyanoacrylate in cases of esophageal and fundal varices, respectively. Hemoglobin and hematocrit were measured every 6 h for 48 h and then every 12 h until 5 days of index bleed in each patient. Packed cells were transfused if hemoglobin decreased below 8 g/dl. The number of blood units transfused, change in hemoglobin values, and ABRI were calculated after each unit of blood transfusion till 120 h. In patients in whom bleed could not be controlled, an ABRI value of 0.75 or more was compared with other Baveno IV-based parameters that define failure to control variceal bleeding. Results During the study period, 137 eligible patients with variceal bleed were admitted. The mean age of the patients was 52±12 years. The majority of patients (50.4%) were in Child–Pugh class B, followed by 38% in Child–Pugh class C. According to the Baveno IV criteria, overall failure to control acute variceal bleeding occurred in 52 (37.9%) patients. Excluding ABRI, failure to control bleeding was found in 22/137 (16%) patients, whereas ABRI-based criteria showed that in 34/137 (24.8%) patients, bleeding could not be controlled. There were only four (2.9%) patients with variceal bleeding in whom ABRI and other additional Baveno IV-based criteria for failure to control bleeding were present. When ABRI was compared with other criteria for failure to control bleeding, it showed a sensitivity and specificity of 19 and 25%, respectively. Conclusion This study showed that ABRI is not a useful additional tool to define failure to control bleeding after variceal hemorrhage in cirrhotic patients.

45 25 GRAM VERSUS 50 GRAM OF 25% ALBUMIN IN PREVENTING RENAL IMPAIRMENT AFTER LARGE VOLUME PARACENTESIS IN CIRRHOSIS

Introduction: Chronic liver disease/cirrhosis (CLD) in individuals produces a variety of symptoms which in turn lead to a negative impact on health-related quality of life (HRQOL). However, no such work has been carried out in Pakistan. The general aim of this study was to evaluate the magnitude of poor HRQOL and to assess factors related with HRQOL in patients with CLD. Method: A cross-sectional study was conducted at the Gastroenterology Clinics of Aga Khan University Hospital. All adult patients diagnosed to have cirrhosis were invited to participate. In this study, Chronic Liver Disease Questionnaire (CLDQ) was used to assess HRQOL of these patients. Patients were categorized into 2 groups based on CLDQ score; <5 as poor and ≥5 as good score for determination of the frequency of poor HRQOL. CLDQ score was used as an outcome measure to determine the factors related with HRQOL. Result: Two-hundred and seventy-three participants were recruited; 155 (57%) were males. Mean age of participants was 49 years (SD ± 11 years). In this study, the most common cause for cirrhosis was viral infection 247 (91.5%). Mean Child Turcot Pugh (CTP) score was 8 ± 1.85 and the mean model for end stage liver disease (MELD) score was 12.6 ± 6.8. Two-hundred and nine patients (76.6%) had CTP B or C class. Poor HRQOL was seen in 187 (69%) of the participants. Mean CLDQ score was 4.36 (SD ± 1.1). Among all of the domains, fatigue domain had significantly lower CLDQ score. On multivariable analysis, hemoglobin (β = 0.09 [SE = 0.04]), albumin (β = 0.32 [SE = 0.09]), diastolic blood pressure (DBP) (β = 0.01 [0.005]), and prior history of decompensation (β = 0.98 [SE = 0.39] were the significant factors associated with HRQOL in patients with liver cirrhosis. Conclusion: Frequency of poor HRQOL determined by CLDQ score is high in patients with liver cirrhosis. Hemoglobin, serum albumen, diastolic blood pressure and prior history of decompensation are associated with HRQOL. 45

Low dose albumin for the prevention of renal impairment following large volume paracentesis in cirrhosis.

Objectives: To evaluate the effect of low dose Albumin i.e. 4 grams per litre of ascitic fluid after large volume paracentesis (LVP) for the prevention of paracentesis induced circulatory dysfunction (PICD) related renal impairment in cirrhosis. Methods: Case records of all patients with cirrhosis who underwent LVP from January 12th, 2011 till December 29th, 2013 were reviewed. Patients were excluded if they had spontaneous bacterial peritonitis, creatinine >1.5 mg/dl, hepatoma or if volume of ascitic fluid removed was <5 litres. Data including age, gender, cause of cirrhosis, CTP score and volume of ascitic fluid drained were noted. In addition serum creatinine and serum sodium at baseline and one week post paracentesis were recorded. Results: Two hundred and fourteen patients with cirrhosis underwent LVP during the study period. One hundred and thirty nine patients met the inclusion criteria and were analyzed. Patients were divided into two groups based on the amount of albumin given. The amount of albumin given was 25 grams and 50 grams while the volume of ascitic fluid removed were 6.2±1 litres and 10.4±1.5 litres in groups A and B respectively. One hundred and eight patients were in group A while thirty one patients were in group B respectively. Both groups received albumin at a dose of 4 grams per litre of ascitic fluid removed. Mean age in both groups were 53 years. Hepatitis C was the commonest etiology in both the groups, followed by Hepatitis B. More than 70% patients in both the groups were in child class C. Serum creatinine at baseline and one week post LVP was 1.04±0.24 mg/dl and 1.07±0.35 mg/dl in GROUP A while 1.11±0.23 mg/dl and 1.41±0.94 mg/dl in GROUP B. (P value 0.35). Similarly, serum sodium at baseline and one week post LVP was 130 ±5.6 meq/lit and 129.6±5.9 meq/lit in GROUP A while 127.6±5.8 meq/lit and 128±6.2 meq/lit in GROUP B respectively. (P value 0.14) Conclusion: This study suggests that 4 grams of albumin per litre of ascitic fluid drained is effective in preventing the PICD related renal impairment following large volume paracentesis in cirrhosis

Age and site of Colonic Neoplastic Lesions: Implications of screening in South Asia

Objective : To evaluate the Age of patients and the site of Colonic Neoplastic Lesions (CNL) and to determine the appropriate screening strategy for Colorectal Carcinoma (CRC) (sigmoidoscopy versus colonoscopy) in our population. Methods : This is a cross sectional study. Data of all patients more than 16 years of age who underwent full colonoscopic examination at the Aga Khan University hospital between January 2011 till December 2013 and were diagnosed to have CRC or advanced adenomas (defined as polyp more than 1 cm and/or having villous morphology on histology) was recorded. Lesions found distal to the splenic flexure were characterized as distal lesions and while lesions found between the splenic flexure and the cecum were characterized as proximal lesions. Results: During the study period colonic neoplastic lesions were found in 217 patients; 186 (85.7%) patients had CRC and 31(14.3%) patients had advanced adenomatous polyps. Mean age was 55.8±14 years and amongst them 72 (33.2%) patients were less than 50 years of age while 145 (66.8%) were more than 50 years. In 144 (66.4%) patients lesions were located in the distal colon, 65 (30%) had lesions in the proximal colon while in 8 (3.7%) patients the neoplastic lesions were found both in the proximal and distal colon. The predominant symptoms were bleeding per rectum in 39.6% of patients followed by weight loss in 31.8% of patients. Only 3 patients had familial syndromes with multiple polyps. When patients younger than 50 years of age were compared with patients more than 50 years there was no statistically significant difference between the site of neoplastic lesion as well as the presenting symptoms. (p value 0.85). Conclusion: Colonic Neoplastic Lesions presented at younger age in our study population and one third of the lesions were found in the right sided colon. Hence screening for CNLs should be implied at an earlier age preferably with colonoscopy. More population based data is required to further validate our results.