Khalid Mumtaz

Epidemiology and clinical pattern of hepatitis delta virus infection in Pakistan

Background and Aims:  The global epidemiology of hepatitis delta virus (HDV) infection is changing. This study was performed to determine the epidemiology and clinical impact of hepatitis delta in Pakistan.

Terlipressin vs. Octreotide in Bleeding Esophageal Varices as an Adjuvant Therapy With Endoscopic Band Ligation: A Randomized Double-Blind Placebo-Controlled Trial

OBJECTIVES:Data are scarce on the head-to-head efficacy of terlipressin and octreotide as an adjuvant therapy to endoscopic management of variceal bleed. The aim of this study was to compare the efficacy and safety of terlipressin with octreotide as an adjuvant therapy to endoscopic variceal band ligation in patients with esophageal variceal bleeding.METHODS:Cirrhotic patients with esophageal variceal bleed were randomized on admission to receive terlipressin (group A) or octreotide (group B) along with the placebo in the other arm in a double-blind fashion. The two groups were compared for efficacy, safety, overall survival, and length of hospital stay. “Control of variceal bleed” was the measure of efficacy of terlipressin and octreotide. Factors predicting length of stay were also assessed.RESULTS:A total of 324 patients were enrolled; 163 in the terlipressin group (group A) and 161 in the octreotide group (group B). The baseline characteristics of the two groups were comparable for age, gender, etiology of cirrhosis, hemoglobin at presentation, and Child–Pugh class, except that active bleed was seen during upper gastrointestinal endoscopy at the time of enrollment in 26 (16%) and 41 (25.5%) patients in groups A and B, respectively (P=0.034). Overall sixteen patients died (three failure to control bleed and thirteen from causes other than variceal bleed); nine in group A (5.5%) and seven (4.3%) in group B (P=0.626). In the intention to treat analysis, “control of variceal bleed” was noted in 305 patients (94.13%); 151 (92.63%) patients in group A and 154 (95.6%) patients in group B (confidence interval: 0.219–1.492). Packed cell transfusions in group A were 3.7±2.3 units, whereas in group B there were 3.9±2.5 units (P=0.273). Length of hospital stay in groups A and B was 108.40±34.81 and 126.39±47.45 h, respectively (P≤0.001). No cardiovascular side effects were observed in either group. High pulse, low hemoglobin, prothrombin time, blood in nasogastric aspirate, and portosystemic encephalopathy (PSE) were predictors of prolonged hospital stay.CONCLUSIONS:The efficacy of terlipressin was not inferior to octreotide as an adjuvant therapy for the control of esophageal variceal bleed and in-hospital survival. The length of hospital stay in the terlipressin group was significantly shorter but not of any clinical importance. The predictors of prolonged hospital stay were low hemoglobin, high pulse, prolonged prothrombin time, blood at nasogastric aspirate, and PSE.

Outcomes in culture positive and culture negative ascitic fluid infection in patients with viral cirrhosis: cohort study

BackgroundAscitic fluid infection (AFI) in cirrhotic patients has a high morbidity and mortality. It has two variants namely, spontaneous bacterial peritonitis (SBP) and culture negative neutrocytic ascites (CNNA). The aim of this study was to determine the outcome in cirrhotic patients with culture positive (SBP) and culture negative neutrocytic ascites.MethodsWe analyzed 675 consecutive hepatitis B and/or C related cirrhosis patients with ascites admitted in our hospital from November 2005 to December 2007. Of these, 187 patients had AFI; clinical and laboratory parameters of these patients including causes of cirrhosis, Child Turcotte Pugh (CTP) score were recorded.ResultsOut of 187 patients with AFI, 44 (23.5%) had SBP while 143 (76.4%) had CNNA. Hepatitis C virus (HCV) infection was the most common cause of cirrhosis in 139 (74.3%) patients. Patients with SBP had high CTP score as compared to CNNA (12.52 ± 1.45 vs. 11.44 ± 1.66); p < 0.001. Platelets count was low in patients with SBP (101 ± 53 × 109/L) as compared to CNNA (132 ± 91 × 109/L), p = 0.005. We found a high creatinine (mg/dl) (1.95 ± 1.0 vs. 1.44 ± 0.85), (p = 0.003) and high prothrombin time (PT) in seconds (24.8 ± 6.6 vs. 22.4 ± 7.2) (p = 0.04) in SBP as compared to CNNA. More patients with SBP (14/44; 31.8%) had blood culture positivity as compare to CNNA (14/143; 9.8%), p = 0.002. Escherichia. Coli was the commonest organism in blood culture in 15/28 (53.5%) patients. SBP group had a higher mortality (11/44; 25%) as compared to CNNA (12/143; 8.4%), p = 0.003. On multiple logistic regression analysis, creatinine >1.1 mg/dl and positive blood culture were the independent predictors of mortality in patients with SBP.ConclusionPatients with SBP have a higher mortality than CNNA. Independent predictors of mortality in SBP are raised serum creatinine and a positive blood culture.

Virological and clinical characteristics of hepatitis delta virus in South Asia

Background & AimsThere is a paucity of data on the impact of hepatitis D virus (HDV) in patients with hepatitis B virus (HBV) infection from South Asia. We studied the impact of HDV co-infection on virological and clinical characteristics.MethodsWe collected data of 480 patients with HBsAg positive and a detectable HBV DNA PCR, who presented to the Aga Khan University, Karachi and Isra University in Hyderabad, Pakistan in the last 5 years. HDV co-infection was diagnosed on the basis of anti-HDV. ALT, HBeAg, HBeAb and HBV DNA PCR quantitative levels were checked in all patients. We divided all patients into two groups based on anti-HDV, and compared their biochemical, serological & virological labs and clinical spectrum. Clinical spectrum of disease included asymptomatic carrier (AC), chronic active hepatitis (CAH), immuno-tolerant phase (IP), and compensated cirrhosis (CC).ResultsHDV co-infection was found in 169 (35.2%). There were 164 (34.6%) HBeAg positive and 316 (65.4%) HBeAg negative patients. Mean ALT level was 66 ± 73 IU. 233 (48.5%) had raised ALT. HBV DNA level was ≥ 10e5 in 103(21.5%) patients. Overall, among HBV/HDV co-infection, 146/169 (86.4%) had suppressed HBV DNA PCR as compared to 231/311 (74.3%) patients with HBV mono-infection; p-value = 0.002. Among HBeAg negative patients 71/128(55.5%) had raised ALT levels among HBV/HDV co-infection as compared to 71/188 (37.8%) with HBV mono-infection (p-value = 0.002); levels of HBV DNA were equal in two groups; there were 27/128 (21%) patients with CC among HBV/HDV co-infection as compared to 23 (12%) in HBV mono-infection (p-value = 0.009); there were less AC (p-value = 0.009) and more CAH (p-value = 0.009) among HBV/HDV co-infection patients. Among HBeAg positive patients, serum ALT, HBV DNA levels and the spectrum of HBV were similar in the two groups.ConclusionsHBV/HDV co-infection results in the suppression of HBV DNA. A fair proportion of HBV/HDV co-infected patients with HBeAg negative have active hepatitis B infection and cirrhosis as compared to those with mono-infection.

Safety and utility of oesophago-gastro-duodenoscopy in acute myocardial infarction.

Aim To study the safety and utility of performing an oesophago-gastro-duodenoscopy (EGD) in the setting of an acute myocardial infarction (AMI). Methods Case records of all patients who underwent an EGD for various indications within 4 weeks of an AMI between January 2001 and April 2006 were analyzed. Demographic data, indications for endoscopy, outcomes and complications were noted. Main outcome measures included safety and utility of endoscopy in AMI. Results A total of 87 EGDs were performed on 85 patients with AMI. Seventy (83%) patients had a non-ST elevation MI, whereas 15 (17%) had ST elevation MI. Mean time between EGD and AMI was 6±1.8 days. Indications for EGD were hematemesis and/or melena on presentation in 38 (44.7%), hematemesis and/or melena post anticoagulation in 27 (31.8%). EGD findings were gastric ulcer/erosions in 30 (34%), oesophago-gastric varices in 20 (22%), erosive oesophagitis in 17 (20%) and duodenal ulcer in 11 (13%). Diagnostic yield of EGD was 88%. Endoscopic interventions were performed in 26 (30%) patients with high risk of bleeding lesion. There were no EGD-related mortality, whereas 14 patients re-bled. A total of 21 patients died, including 7/14 (50%) who re-bled, compared with 14/71 (19%) without rebleed (P=0.008). There were no EGD-related deaths. Fourteen patients were on mechanical ventilation and 6/14 (43%) of these died as compared with 15/88 (17%) who were not ventilated (P=0.027). Conclusion EGD is safe and useful in diagnosis and management of gastrointestinal hemorrhage in patients with AMI, and allows decisions about anticoagulation. Re-bleed and need for mechanical ventilation predicts poor outcome in these patients.

Liver biopsy for histological assessment: The case in favor.

Liver biopsy (LB) is the gold standard method for assessment of liver histology. It provides valuable, otherwise unobtainable information, regarding the degree of fibrosis, parenchymal integrity, degree and pattern of inflammation, bile duct status and deposition of materials and minerals in the liver. This information provides immense help in the diagnosis and prognostication of a variety of liver diseases. With careful selection of patients, and performance of the procedure appropriately, the complications become exceptionally rare in current clinical practice. Furthermore, the limitations of sampling error and inter-/ intra-observer variability may be avoided by obtaining adequate tissue specimen and having it reviewed by an experienced liver pathologist. Current noninvasive tools are unqualified to replace LB in clinical practice in the face of specific limitations for each tool, compounded by a poorer performance towards the assessment of the degree of liver fibrosis, particularly for intermediate stages.

Hepatic cystic echinococcosis: clinical characteristics and outcomes in Pakistan.

Hepatic cystic echinococcosis (HCE) is an emerging disease in central Asia, particularly in Pakistan, due to the migration of infected people. Medical records of patients with HCE admitted between 1995 and 2006 to a tertiary care hospital were reviewed. A total of 106 patients were admitted with a mean age of 34±17 years; 60 (56.6%) were men, 72 (67.9%) were residing in rural areas of Pakistan and 21 (19.8%) were Afghan refugees. Twenty-seven (25.4%) had extra hepatic cysts and liver cysts. All patients received albendazole. Percutaneous aspiration, instillation and reaspirarion was done in 14 (13.2%) patients and 71 (66.9%) underwent surgery. Three (2.8%) died and 14 (13.2%) had morbidity. This is one of the largest series of HCE reported from Pakistan. HCE is mostly prevalent in rural areas and among Afghan refugees with low mortality and recurrence, but with significant morbidity.

Paracentesis in cirrhotics is associated with increased risk of 30-day readmission

AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites. METHODS A retrospective analysis of the nationwide readmission database (NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission. RESULTS Of the 59597 patients included in this study, 18319 (31%) were readmitted within 30 d. Majority (58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832 (50%) patients on index admission. Independent predictors of 30-d readmission included age < 40 (OR: 1.39; CI: 1.19-1.64), age 40-64 (OR: 1.19; CI: 1.09-1.30), Medicaid (OR: 1.21; CI: 1.04-1.41) and Medicare coverage (OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity (OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis (OR: 1.16; CI: 1.10-1.23), paracentesis on index admission (OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma (OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted (P-value: 0.34); however cost of care was significantly more on 30 d readmission (

Multidisciplinary Approach to treat Liver Transplant Recipients with Hepatitis C using Sofosbuvir based Therapy

30959 ± 762) as compared to index admission (

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

12403 ± 378), P-value: < 0.001. CONCLUSION Cirrhotic patients with ascites have a 33% chance of readmission within 30-d. Younger patients, with public insurance, nonalcoholic cirrhosis and increased comorbidity who underwent paracentesis are at increased risk of readmission. Risk factors for unplanned readmission should be targeted given these patients have higher healthcare utilization.