Day 1 :
Department of Gastroenterology, Saint George Hospital University Medical Center, Lebanon
Hussein A. Badran is a graduate of Balamand University medical school. He trained in internal medicine at Saint George University medical center, currently fellow gastroenterology in Saint George university medical centre and starting first november fellow gastroenterology and hepatology in George Pumpido medical centre in Paris, France.
Malakoplakia is a rare chronic granulomatous disease that may affect many organs, including the lung, brain, adrenal glands, pancreas, bone, and the genitourinary tract. The gastrointestinal tract is the most common site of involvement outside of the urinary tract. Herein, we present a case of a 65-year-old male who presented with abdominal pain and unintentional weight loss. Physical examination findings were unremarkable, but colonoscopy revealed an isolated large, flat, soft, and pale lesion in the transverse colon. Histopathological examination of the lesion showed expansion of the lamina propria due to numerous lymphocytes, plasma cells, neutrophils, and polygonal cells. Von Kossa stain showed small intracytoplasmic basophilic granular inclusions, and these histiocyte cells showed numerous Michaelis-Gutmann bodies, findings considered as diagnostic features of colonic malakoplakia. This is a rare case of isolated malakoplakia of the transverse colon diagnosed on endoscopic specimens. The majority of reported cases have shown an association between systemic diseases and colorectal adenocarcinoma. In addition, most reported cases of colonic involvement have been in the rectum, sigmoid, and right colon.
Grande International Hospital Dhapasi, Kathmandu, Nepal.
Background : To date, usually, the initial treatment of AP consists of nil per os (NPO) regimen and administration of analgesic and abundant intravenous fluids . It is assumed that the benefit without food intake that pancreatic stimulation be enteral feeding may aggravate pancreatic inflammation. However, the validity of such assumptions is pretty much debatable. On the other hand, various studies have revealed that enteral feeding significantly reduced the risk of infection, lowers the need of surgical intervention, and reduces the length of hospital stay. Results from the meta analysis show that mortality rate is significantly reduced when patients of acute pancreatitis are fed enterally. More importantly, the timing of the start of the start of nutrition, within 48 hours of hospital admission a factor that relate in the reduction of the mortality in patients with severe AP.
General objective : To determine the tolerance and efficacy of early NGT versus NPO in patients with mild to moderate acute pancreatitis
Methods : Prospective randomized Trial: The prospective randomized control trial is designed in patients with diagnosed mild to moderate pancreatitis. The patients satisfying the inclusion criteria were subjected to early nasogastric tube feeding and were compared with nil per oral group.
Results : In the present study, we investigated an alternative approach to reinitiating feeding that was based on hunger, without the remission of abdominal pain or normalization of pancreatic amylase and lipase. Our results demonstrated that early oral refeeding based on this approach significantly decreased the duration of hospitalization. We found mean difference between the groups was 1.65 (P=0.04).
Conclusion : Based on the finding illustrated above it implies that EEF could be appropriate strategy for the management of mild to moderate acute pancreatits in term of reduction of hospital stay and intensity of pain score.
Ivano-Frankivsk national medical university, Ukraine.
Nazar Omelchuk is GI surgeon in the Ivano–Frankivsk Regional Clinical Hospital and teacher assistant of General Surgery Department at Ivano–Frankivsk National Medical University. He works on new minimally invasive methods of pancreatic postnecrotic pseudocysts treatment, based on endoscopical approach. He has 3 registered patents, based on new ways of treating patients with acute pancreatitis, complicated with acute pseudocysts.
STATEMENT OF THE PROBLEM: Acute necrotic pancreatitis (ANP) remains complicated problem of urgent surgery because of high frequency of systemic, purulent and septic complications, mortality rate, which is in patients with infected pancreonecrosis 14,7 – 26,4 %.
THE PURPOSE: The purpose of this study is to evaluate efficiency and establish indications for minimally invasive methods of treatment of postnecrotic pseudocysts of pancreas.
METHODOLOGY AND THEORETICAL ORIENTATION: For diagnostics were used ultrasonography, diagnostic laparoscopy, helical CT with contrast strengthening. Endoscopic interventions were applied by duodenoscopes “Olympus” under control of X-ray machine
“Siemens BV 300”. Cystodigestive fistulas were created by prickly papilotoms. For providing of long passability of cystodigestive fistula were used two endoprostheses like “pig tail” sized 10 Fr with length 5 – 6 sm. For transpapillary drainage were used pancreatic endoprostheses like “pig tail”, sized 5 – 7 Fr with length 5 sm.
FINDINGS: In 62 (68,2%) patients were applied minimally invasive methods of treatment. Percutaneous external drainage in 33 (53,2 %) patients, endoscopic transmural drainage of postnecrotic pseudocysts in 11 (17,7%) patients. Combined endoscopic interventions were applied in 18 (29,1%) patients. In particular, endoscopic transmural drainage with temporary stenting of pancreatic duct in 11 (61,1%) patients, endobiliary stenting with temporary stenting of pancreatic duct in 3 (16,67%) patients, temporary stenting of pancreatic duct in 3 (16,67%) patients, endoscopic transmural drainage with percutaneous external drainage in 1 (5,56%) patient.
CONCLUSION AND SIGNIFICANCE: Usage of combined minimally invasive methods of treatment of acute necrotic pancreatitis complicated by postnecrotic pseudocysts help to improve results of treatment, reduction of complications amount, contraction of stationary treatment terms and improving of life quality.
- Clinical Gastroenterology
Senior Research Assistant, Aga Khan University, Karachi
Farheen Lubna Hashmi (BHMS, Statistician, Researcher) is a Senior Research Assistant at the Aga Khan University & Hospital ,where she has conducted research in different areas for more than 7 years, on the past era she focused on Gastroenterology & Liver disease researches, her publications were published in different journals, she got best poster presentation award on research day conducted by AKU Hospital in 2017.
Research area : Gastroneterology, Hepatitis, menometry
Background: The prevalence of GI and liver disease in the Pakistani population has increased remarkably over the recent years, reflecting an elevated burden on healthcare systems. Optimized health management and effective resource utilization in Health care facilities is based on timely documentation and reporting of disease patterns.
Aims : To present data from the GODD (gastroenterology outpatient discharge diagnosis) registry, comparing annual trends of GI & liver disease incidence among patients presenting to the Aga Khan University Hospital.
Methods: A review of electronic records was performed for all patients presenting to the Gastroenterology clinic, AKUH between 2013 and 2016. Collected information included patient characteristics and outpatient discharge diagnosis (primary and associated), based on a list of 72 approved diagnosis categories related to gastrointestinal and Liver diseases. Annual variation in this data is presented in this paper. A single visit is counted for specific year for each patient.
Result: A total of 28,493 new patients were seen in gastroenterology clinic (table 1). The mean age of the patients was 44.6+15.8 years with an overall higher representation of males (58%). The number of patients was seen to gradually increase during study period from 6410 in 2013 to 8138 in 2016. Overall, 15,956 (56%) patients presented with GI disease which comprised
Background: Phantom rectal syndrome(PRS) is a rare and a poorly understood area where patients with a background of Abdominoperineal resection (APR)/similar dissection develop symptoms arising from the resected bowel. Symptoms are either painful or non-painful. This descriptive study attempts to explore the prevalence and the burden of these symptoms.
Methods: This descriptive study was conducted at Colombo North Teaching Hospital amongst patients who underwent APR .Interviewer based questionnaire was administered to a total of 30 surviving patients within past 5 years .
Results: Out of the 30 patients, 33% had sensation arising from the resected distal bowel. And out of those with symptoms, 80% of patients had painless symptoms and only 20% of patients had intermittent painful rectal symptoms.
All patients who had such symptoms had undergone the surgery at an age less than 55 years Laparoscopic surgery had 35% risk of PRS compared to pure open procedure which is 30%.
80% patients are staged II B. Only 20% of patients with symptoms have seeked emergency medical attention and symptoms objectively halved with regular analgesics. Reassurance at clinic level was received by all patients and the perturbations to activities of daily living was minimal afterwards.
Conclusion: Phantom Rectal Syndrome is a common but poorly addressed complication of perineal surgery in APR. And the likelihood increases with younger age group, perirectal involvement.
We feel a thorough explanation of the possibility of phantom rectal symptoms preoperatively and post operatively is required and will improve symptoms.
Director & Head, Center for Liver Transplant and Gastro Sciences, Saroj Super Specialty Hospital, Delhi
Tuberculosis (TB) is an infectious disease caused by acid fast bacterium (AFB) Mycobacterium tuberculosis (M.tb). India has a particularly high incidence of TB in the world. The global impact of TB disease is also significant. Any region of the body can be affected by TB. Tuberculosis of stomach is relatively rare and tubercular aortitis is even rarer; however, tubercular aorto-gastric fistula is an extremely rare entity. The primary objective of this study is to report an extremely rare case of a middle aged female presenting with aorto-gastric fistula, who is the only surviving patient in the world after such surgery to the best of the author’s knowledge, the complex surgical procedure performed and the postoperative management of such patient. In addition, the secondary objective is a comprehensive review of literature for aorto-enteric fistula, its definition, classification, manifestation, pathogenesis, diagnosis, imaging, treatment and outcome. Tuberculosis management has now been complicated with emergence of resistant strains, defaulters, immunosuppresed patients, post transplant patients and patients presenting with other co morbidities and challenges. It requires multidisciplinary management of intensivist, surgeon, radiologist and intervention radiologist. All such patients should be referred to dedicated units dealing with such patients. The medical management of such patients with anti-tubercular drugs is the direct way to manage such patients and decrease their secondary complications.
Keywords: Tuberculosis, fistula, aorto-gastric fistula, aortic fistula, gastric fistula, aortogastric, aortoenteric
- Bowel Syndrome
University of Hong Kong, Hong Kong
Introduction: The microbiome plays a crucial role in maintaining homeostasis in the human gut. Faecal Microbial transplant (FMT) is a process of transferring microbial communities from a healthy donor to a recipient; consequently, it is now being widely investigated for its ability to improve various health issues associated with gastrointestinal diseases. In this study, we investigated changes in gut microbiota following FMT in a patient with Irritable Bowel Syndrome (IBS). We describe changes in the composition of the faecal microbiome from a patient recipient before and after undergoing FMT, as a treatment for IBS condition. There was a marked loss of bacterial diversity with reduced bacterial phylum belonging to Firmicutes prior to FMT, this was corrected after post-FMT. Furthermore, an additional 13 donor bacterial species were engrafted after post-FMT belonging to Actinobacteria, Bacteroidetes and Firmicutes phylla. The observed changes in the host-gut environment following FMT procedures highlights changes in community structure dynamics reflecting changes needed for restoring a healthy and balanced gut microbiome.
Keywords: Microbiome, fecal microbiota transplant, Irritable Bowel Syndrome (IBS).
National Liver Institute, Menofiya University, Egypt
Khaled Metwally working as a assistant professor department of Hepatology and gastroenterology, National Liver Institute, Menofiya University, Egypt, . Specialization: Hepatology and Gastroenterology.
1) Discovery of novel non-invasive diagnostic techniques.
2) Management and follow up patients with decompunsated liver cirrhosis.
Spontaneous bacterial peritonitis (SBP) is a serious complication of liver cirrhosis and finding a prognostic model to predict it is needed. Objective: to test the ability of different laboratory tests and the new Wehmeyer’s SBP scoring system to predict it. Methods: Three hundred patients admitted at the National Liver Institute, University of Menoufyia, Egypt (2015-2016) with liver cirrhosis and ascites were included in our study. SBP was diagnosed if ascetic neutrophils count ≥ 250/µL with no sign of secondary peritonitis. Results: Median age 56 (29 –81 years), 60% men and primary cause of liver disease was hepatitis C, 91.7%. By univariate analysis: age, total bilirubin, AST, creatinine, international normalized ratio, MELD score, total leucocytic count, platelet count and C-reactive protein (CRP) were significant. By multivariate analysis independent predictors were age, platelet count and CRP (p = 0.004, 0.013 and < 0.001, respectively). CRP at a cutoff point ≥ 13.5 mg/L could predict SBP (sensitivity 86.4% and specificity 66.0%). Wehmeyer’s SBP scoring system was able to predict it (p < 0.001), only 4% of patients with 0 score developed SBP (CRP cutoff is 30 mg/L), while 92.8% with score of 3 or 4 developed it. By using our CRP cutoff value of 13.5 mg/L, no patient with 0 score developed SBP. Conclusion: age, CRP and platelet count are independent predictors for SBP and a scoring system including them could easily predict it. SBP diagnosis could be excluded in patients with zero score, using CRP cutoff value of 13.5 mg/L.
Menoufia University, Egypt
Background: Hepatic encephalopathy is one of the major complication that follow TIPS operatios in patients with different complications of portal hypertension as refractory ascites, refractory hydrothorax, bleeding varices, and hepatorenal syndrome, The aim of this study Was to clarify predisposing factors for post-TIPS incidence of HE in relations to Pre-TIPS hemodynamic
Dr. Abdelaleem Helal, Menoufia University Egypt
Abdelaleem Helal has his expertise in viral hepatitis and HCC from his Prof. Dr. Mohamed Akl and colleges in Department of Hepatology and Gastroenterology, National Liver Institute, Menofia University, Shebeen El-Kom, Egypt.
Background: Hepatocellular carcinoma is a common health burden in cirrhotic patients with HCV infection. New direct-acting antivirals substantially improved the cure rate to above 90%. Moreover, cancer risk persists even after 10 years of viral cure.
Aim: To evaluate Transient Elastography as predictor of HCC after Direct acting antiviral drugs (DAAs).
Methods: All patients with HCV related fibrosis who did FibroScanTM before treatment with DAAs were included retrospectively. Liver, renal function tests, CBC, INR, alpha-fetoprotien, abdominal ultrasonography, Triphasic CT, and FibroScanTM were performed at the National Liver Institute, Menofia University from January 2015 to December 2016. Patients who had a Transient Elastography measurement before treatment with DAAs were included and divided into two groups; Group (I) patients who developed De novo HCC and Group (II) are those who did not developed HCC after DAAs.
Results: Patients who developed de novo HCC after DAAs (group I, thirty patients) had higher serum AST levels (68.3 ± 38.2 vs. 48.7 ± 32.4 U/L), lower platelet count (131.5 ± 55.6 vs. 179.5 ± 69.8 ×103 /µL) and older age (59.5±6.4 vs. 51.3±10.5 years) than patients who did not developed HCC (group II, ninety patients) with a p value <0.05. Group I patients had a statistically significant higher liver stiffness measurement (LSM) by FibroscanTM (32.1 ± 10.7 vs 15.5± 11.5 kPa, p value = 0.001) than patients who did not developed HCC. With a cutoff of 18.5 kPa being the most predictive value of de novo HCC development after treatment of chronic HCV infection with DAAs (90.0% sensitivity, 80.0% specificity, 55.0% PPV, 97.3% NPV, 80.0% accuracy) as shown in figure 1.
Conclusion: The measurement of liver stiffness by FibroScanTM could be a reliable method for risk stratification and prediction of de novo HCC development after DAAs in cirrhotic patients.
Zagazig University, Zagazig Egypt.
PhD in Internal Medicine.
Gastroenterology Unit, Internal Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
Background: The use of precut papillotomy (PP) either early (EPP) or late (LPP) was not yet established in patients with liver cirrhosis. Objective: The aim of this study was to assess the efficacy and safety of PP in cirrhotic patients and to compare the results of EPP vs. LPP. Methods: We assigned 135 cirrhotic, who needs management of biliary obstruction, into three equal groups, with either, EPP adopted after < five unsuccessful biliary cannulation attempts, LPP performed after ≥ five unsuccessful attempts, or no precut (NOPP) using standard cannulation (SC) only. Technical success, morbidity and mortality were compared among groups. Results: Cannulation success rate did not differ significantly between EPP (95.56%) and LPP cases (91.11%), but was significantly lower in NOPP cases (73.33%). Overall post-procedure complication rate was 11.11%, including pancreatitis (5,19%), bleeding (5,19%) and perforation (0.74%). Hepatic encephalopathy developed in four patients with two mortalities (1.48%). Apart from a significantly lower pancreatitis rate in EPP group than LPP group (p=0.041), there were no significant differences among groups regarding complications or mortality.
Conclusion: In cirrhotic patients, EPP is as safe and effective as LPP, with a lower pancreatitis risk. Both precut techniques have superior efficacy and similar safety to SC.
Keywords: precut papillotomy, biliary cannulation, liver cirrhosis.
SKIMS College & University, Jammu and Kashmir.
Introduction: Non-alcoholic fatty liver disease (NAFLD) is the hepatic pandemic of the twenty first century. The increasing prevalence of NAFLD in the general population translates directly into an increasing prevalence of NAFLD in both, potential deceased and live liver donors. Graft steatosis, in turn, affects both, the quality and the quantity of donor livers available for transplantation. The development of primary dysfunction, early allograft dysfunction, poor overall graft survival, and other complications have been reported in recipients of steatotic grafts in liver transplantation.
Methods: A total of 124 prospective liver donors over a period from June 2014 to March 2016 from Apollo hospital Delhi were included in this study. The demographics, findings on general physical and systemic examination, anthropometric measures results of blood investigations done as part of donor work up, radiological investigations and liver biopsy findings were noted.
Results: Out of 124 study participants 73 (59%) were male and 51 (49%) were female. Mean age of participants was 31.71 years. Prevalence of fatty liver was 23% on USG abdomen, 31% On CT Liver Attenuation Index (LAI), 49% on MRS. High BMI (>25kg/m2), increased WC and WHR were significantly associated with presence of fatty liver. USG abdomen in comparison to CT LAI had sensitivity 55%, Specificity 91%, PPV 72%, NPV 82% and accuracy of 80% in diagnosing fatty liver. Similar values for CT LAI in comparison to MRS were 57%, 95%, 92%, 70% and 77% respectively and for USG abdomen in comparison to MRS the values were 43%, 95%, 96%, 63%, 69%. For MRS versus liver biopsy similar values were 100%, 33%, 92%, 100% and 92% respectively.
Conclusion: NAFLD epidemic is directly translating into higher prevalence of fatty liver among prospective liver donors. MRS is emerging as a useful test to quantify hepatic fat, comparable to liver biopsy.
Key Words: Non-Alcoholic Fatty Liver Disease (NAFLD), Liver Attenuation Index (LAI), Magnetic Resonance Spectroscopy
- Gastroenterology and Nutrition
Ministry of Health of the Republic of Uzbekistan
INTRODUCTION: Peptic ulcer disease (PUD) is a chronic recurrent disease characterized by the alternation of exacerba tion and remission periods and the formation of a defect (ulcer) in the stomach and (or) duodenum wall that penetrates into the submucosal layer. PUD represents one of the most frequent diseases of the gas trointestinal tract, with a frequency about 10% world wide. PUD might result in the loss of work capacity or even in lethality: mortality from this pathology varies in different countries, from 6 to 7.1 per 100000 for gas tric ulcer and from 0.2 to 9.7 for duodenal ulcer. The present study aimed to study the association of polymorphic variants of interleukin 1β IL1B (rs1143634) and tumor necrosis factor α TNFA (rs1800629) genes with PUD in Uzbekistan Republic (UzR).
MATERIALS AND METHODS: The material for the study included DNA samples obtained from individuals with PUD and healthy donors aged 16–80 years. The patient group was composed of 148 individuals ( diag nosed with duodenal ulcer and 67 with gastric ulcer and mixed PUD forms) of various ethnicity of Uzbekistan.
Genomic DNA was isolated from peripheral blood lymphocytes via the phenol chloroform extraction technique. Amplification of the studied polymor phisms was carried out via polymerase chain reaction of DNA synthesis on a GeneAmp PCR System 2720 (Applied Biosystems, United States).
RESULTS: An analysis of the allele and genotype frequencies of several polymorphic variants of interleukin 1β IL1B (rs1143634) and tumor necrosis factor α TNFA (rs1800629) genes was conducted in PUD patients and control individuals from the Uzbekistan Republic. The observed distribution of genotype frequencies was in accordance with that expected in accordance with the Hardy–Weinberg equilibrium.
Comparative analysis of the allele and genotype frequency distributions of rs1143634 for PUD patients and the control group demonstrated statistically significant differences in Uzbeks: the rs1143634*C allele was observed in 79.60% of patient chromosomes and in 84.20% of chromosomes from the control group, and the rs1143634*C/C genotype was detected in 69.10% in PUD individuals as compared to the relevant control group (60.50%). These variants represent markers of high risk of developing PUD (χ2 =1.50, p = 0.2; OR = 1.40; 95% CI 0.82–2.24 and χ2 = 1.0, p = 0.2; OR = 1.3; 95% CI 0.88–2.074, respectively). Moreover, markers of decreased risk of developing PUD were revealed for ethnic Uzbeks: the rare rs1143634*T allele was detected in 20.40% of patients, compared to 15.80% in the control group (χ2 < 3.80, p > 0.05;) and the heterozygous rs1143634*C/T genotype was observed in 38.30% of PUD patients and in 32.20% of healthy donors.
The distribution of allele and genotype frequencies of –308G>A (rs1800629) polymorphism located in the promoter region of the TNFA gene is shown the highest frequency was observed for the rs1800629*G allele (85.20% in PUD patients 92.10% in the control group) and for the G/G genotype (70.40% in patients, 84.20% in control group). How ever, homozygosis for the rare allele rs1800629*A/A genotype was observed in less than 3% of cases. Analysis of the allele and genotype frequency distributions demonstrated the absence of statistically significant differences between the studied PUD samples and control individuals.
DISCUSSION: Intergenic interaction was established and combinations of polymorphic variants of rs1800629 polymorphisms of gene TNFα rs1143634 of IL-1β gene were determined in the determination of the risk of duodenal ulcer and chronic gastritis. The heterozygous haplotype of these genes is a predisposing factor to the formation of duodenal ulcer and chronic gastritis..