Department Of Gastroenterology Research Articles

Association of Diet Consumption with Gallbladder Changes in Females After Birth of Child

The postpartum period is characterized by remarkable physiological adaptations to accommodate the demands of childbirth and lactation. These physiological changes, coupled with the unique nutritional needs of both the mother and newborn, can lead to gallbladder stasis and increased cholesterol absorption in the gallbladder. Objective: To assess the correlation between diet consumption and gallbladder changes in females after childbirth. Methods: This observational study was conducted at the department of Gastroenterology, Jinnah Medical and Dental College, Sohail University, Karachi, Pakistan from December 2022 to June 2022. Females of reproductive age who had normal child delivery were evaluated after 6 weeks of delivery. The medical examination, anthropometric measures, nutritional assessment, and laboratory testing were performed in all eligible females. An ultrasonographic was done after a typical fatty food in order to assess gallbladder changes. SPSS version 21.0 was used to do statistically analysis. Results: The mean age was 28.89 ± 4.73 and mean BMI was 22.78 ± 4.09 kg/m2. Of 100 females, 17% had gallbladder stasis, 26% had gallstones, and 17% had sludge. The females with low protein consumption had significantly higher proportion of gallbladder stasis as compared to females with high protein consumption in diet (76.5% vs 23.5%, p=0.001). Furthermore, females with high carbohydrate (61.5% vs 38.5%, p=0.011) and fructose (53.8% vs 46.2%, p=0.037) consumption had significantly higher proportion of gallstones as compared to females with low consumption. Conclusions: High protein consumption was linked to gallbladder stasis, while high carbohydrate and fructose intake were associated with an increased proportion of gallstones.

A prospective study on enterocutaneous fistula in a tertiary care centre: A single institution study

Background: Aberrant connection linking gastrointestinal tract and the skin is termed Enterocutaneous fistula. Enterocutaneous fistulas can lead to significant morbidity and mortality. Death pertaining to enterocutaneous fistulas remains enormous when juxtaposed with other surgeries. The treatment of Enterocutaneous fistula may be a significant challenge to surgeons and gastroenterologists. Method: After obtaining ethical committee clearance, a total of 25 patients of Enterocutaneous fistula who presented to Surgical department and Surgical Gastroenterology department were included in the study. The cause, site and output of fistula, clinical course and complications of fistula were studied. Patients were managed either surgically or conservatively depending on the output of the fistula, nutrition and metabolic profile. Results: 19 patients were managed conservatively and 6 patients were managed surgically. Amidst the conservative group, 16 out of 19 patients had spontaneous closure of fistula and remaining three had died as fistulas failed to close. Surgical closure was accomplished in 5 patients but failed in one patient and that patient died. 96% (24 out of 25) of patients in our study had developed fistula post operatively. Among 25 patients studied, nearly 44% each i.e., 11 out of 25 patients had colonic and small bowel fistula respectively followed by fistula at appendix accounting for 12% (i.e., Fistula Output: 11 (44%) fistulae were low output, 8 (32%) were medium output. Conclusion: Enterocutaneous fistulas are more common in postoperative period. Conservative treatment should be the mainstay in management of Enterocutaneous fistula.

Diagnostic Accuracy of Magnetic Resonance Cholangio-Pancreatography (MRCP) in Evaluating Obstructive Jaundice, Keeping Endoscopic Retrograde Cholangio-Pancreatography(ERCP) as Gold Standard

Objective: To determine the diagnostic accuracy of Magnetic Resonance Cholangiopancreatography in evaluating obstructive Jaundice, taking Endoscopic Retrograde Cholangiopancreatography as the gold standard.
 Study Design: Cross-sectional study.
 Place and Duration of Study: Armed Forces Institute of Radiology and Imaging in collaboration with the Gastroenterology Department of Military Hospital, Rawalpindi Pakistan, from Jun to Dec 2019.
 Methodology: Ninety patients with a history of obstructive Jaundice referred to the Armed Forces Institute of Radiology and Imaging for Magnetic Resonance Cholangiopancreatography were included in the study. Magnetic Resonance Cholangiopancreatography was followed by Endoscopic Retrograde Cholangiopancreatography within 48 hours. Magnetic Resonance Cholangiopancreatography results were compared with Endoscopic Retrograde Cholangiopancreatography and diagnostic accuracy was calculated.
 Results: The mean age was 57.58±14.65 years. The study constituted 40 male (44.4%) and 50 female (55.6%) patients. The sensitivity, specificity, PPV, NPV and diagnostic accuracy of Magnetic Resonance Cholangiopancreatography, keeping Endoscopic Retrograde Cholangiopancreatography as the gold standard, were calculated as 91.04%, 89.04%, 95.31%, 76.90% and 90.0%, respectively. The positive likelihood ratio was 7, while the negative likelihood ratio was 0.10.
 Conclusion: Magnetic Resonance Cholangiopancreatography is a non-invasive and safe investigation with excellent diagnostic accuracy in evaluating obstructive Jaundice. Thus, Magnetic Resonance Cholangiopancreatography may be an alternative to Endoscopic Retrograde Cholangiopancreatography, especially in cases without intervention or in pregnant females, as it is free from ionizing radiation.

Serum Cholinesterase Level in Patients with Cirrhosis of Liver and Its Correlation with the Severity of the Disease

Background: Serum cholinesterase mainly comes from the liver, a sensitive indicator of the synthetic capacity of the liver. It can be used as a prognostic marker for cirrhosis.
 Objectives: To measure the serum cholinesterase level in cirrhotic patients and to correlate its level with the severity of the disease as per the Child-Pugh score.
 Methodology: This cross-sectional study was conducted in the Department of Gastroenterology, Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh, from January 2018 to December 2018. Fifty adult patients with cirrhosis of the liver were enrolled. Fifty healthy individuals were also taken to compare serum cholinesterase levels. Cirrhotic patients were grouped strictly into A, B, and C classes, as per the Child-Pugh score. Serum cholinesterase level was measured in all participants. The correlation between cholinesterase level and the severity of the disease was analyzed.
 Result: Mean age of the patients was 47.42 ± 12.40 years and 47.22 ± 11.99 years in cirrhotic patients and healthy group, respectively. The number of patients in the Child-Pugh A, B, and C subgroups was 12 (24%), 20 (40%), and 18 (36%), respectively. The mean serum cholinesterase level was 2938 ± 1561 U/L in cirrhotic patients and 9036 ± 2024 U/L in the healthy group. Serum cholinesterase level in different Child-Pugh class was 4740 ± 1046 U/l (Child A), 3157 ± 1161 U/l (Child B), and 1493 ± 500 U/l (Child C). Serum Cholinesterase was positively correlated with serum albumin and negatively correlated with bilirubin, prothrombin time, and INR. A negative correlation was found between serum Cholinesterase level and the severity of the disease.
 Conclusion: Serum cholinesterase level was low in cirrhotic patients, and its level was inversely correlated with the severity of the disease. Thus it can be used as a prognostic marker of cirrhosis. However, further study with a large sample size could explain this more precisely.
 TAJ 2022; 36: No-1: 33-40

Intestinal Ultrasound for Inflammatory Bowel Diseased Patients Who Receive Biological Treatment

Abstract Background Crohn’s disease (CD) and ulcerative colitis (UC) are two forms of chronic inflammatory bowel diseases (IBDs) characterized by recurrent episodes of intestinal inflammation and a heterogeneous range of symptoms and clinical courses. In contrast to CD, UC is a mucosal and to some extent submucosal disease restricted to the colon. Depending on the involved colonic segment, UC can be divided into proctitis, left- sided colitis or extensive colitis. Aim of the Work Prospective evaluation of intestinal ultrasound (iUs) for disease monitoring of patients with ulcerative colitis (Uc) and crhons disease receiving biological treatment with following up the efficacy on intestinal wall. Newly diagnosed patients who will receive biologics and compare with colonoscopy Patients and Methods This was a cohort study in ultrasound unit of gastroenterology department at Ain shams university hospitals, the patients selected from the department of gastroenterology and gastroenterology outpatient clinic from May 2021 till January 2022 on 50 patients. Results When comparing baseline ultrasound results of inflammatory signs and colonoscopy we found non-significant results that support using intestinal ultrasound results as non-invasive tool for diagnosis of inflammatory bowel disease. and also doppler signs it showed significant results in some parts of the colon like terminal ilium, left side, transverse and sigmoid and that is very important in patient who have strictures in terminal ilium prevent terminal ilium intubation during colonoscopy. Also on comparing results of pathology and intestinal ultrasound we found the sensitivity of intestinal ultrasound is very high inflammatory signs 93.8% sensitivity and doppler signs 85.4% but specificity was 50% only that was because it depends on the operators vision and also on the machine used and the patient also he may be not fasting and distended that make the field very hard, also when comparing with ct enterography results and MR enterography it showed the same specificity and sensitivity that confirm our vision also. Conclusion For conclusion intestinal ultrasound one of the best modalities for diagnosis and follow up inflammatory bowel disease, especially in short term response, our finding give rise to not only the assumption of bowel wall thickness but also inflammatory markers, doppler signs, bowel lumen and fibrofatty nodules had significant difference at long term follow up Christian Maaser et al findings give rise to the assumption that monitoring BWT alone has the potential to predict therapeutic response. The additional monitoring of FC could add further value in monitoring patients with UC. Future prospective studies are necessary to determine the value of IUS in predicting short and long-term response and outcomes of therapies in UC

Study of MicroRNA 203 and Its Target Genes (Survivin, Cyclin-D) in Circulating Liver Cancer Stem Cells in Patients with Chronic Hepatitis C with and without HCC

Abstract Background Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality, infecting more than 180 million people worldwide. Chronic viral infection is one of the most common causes of hepatic fibrosis, distortion of the hepatic architecture, and ultimate progression to cirrhosis of the liver. HCV infection inflames the liver which, if unmanaged, will inevitably result in fibrosis and then progress to cirrhosis which has many co-morbid complications such as hepatocellular carcinoma (HCC). HCC is an aggressive tumor usually involving late stage liver cancers when diagnosed. Although significant progress regarding the treatment options for HCC has been made in recent years, poor prognosis remains a problem because of late diagnosis and drug resistance, making recurrence almost inevitable. Objective to compare level of miRNA 203 and its target genes (Survivin, Cyclin-D) in circulating liver cancer stem cells in patients with chronic hepatitis C with and without H.C.C. Patients and Methods This study was conducted in co-operation between Gastroenterology and Hepatology Department, Ain-Shams University and the Gastroenterology and Hepatology Department, Theodor Bilharz Research Institute “between” April 2021 to October 2021.It included total participants of 80 divided to 4 GrousGroup A (HCV group): twenty patients infected with HCV without liver cirrhosis.Group B (LC group): twenty patients infected with HCV with liver cirrhosis.Group C (HCC group): twenty patients infected with HCV with HCC.Control group: twenty normal populations. Results our study demonstrated that the level of miRNA 203 showed statistically significant difference between all study groups with lowest level was found in HCC group and highest level was in control group with statistically significant decrease in HCC group than LC and other groups. The study also demonstrated that circulating level of Survivn shows significant increase in HCC group than other study groups. With no significant changes in its level between non HCC groups (Control, HCV and LC groups).The circulating Cyclin D level showed significant increase in HCC group than other study groups, With statistically significant increase in its level in LC group than control and non-cirrhotic HCV group. The study markers (miRNA 203, Survivn and Cyclin D) showed no significant relation between their levels in HCC patients and AFP level. Also, no significant relation was established between (miRNA 203, Survivn and Cyclin D) and PVT, number of focal lesions, largest diameter of the lesion or BCLC. Conclusion miRNA 203 level in circulating CSCs showed significant changes according to the stage of HCV related disease with lowest level is seen in HCC patients.Survivin level in circulating CSCs showed significant increase in HCC patients with no significant difference between other groups, and this indicates that changes in its level is highly specific for malignant transformation.Cyclin D level in circulating CSCs showed significant increase in HCC patiens than other study groups, with increase in its level in LC patients than control and non-cirrhotic HCV patients, and this indicates that the changes in its level start with cirrhosis process. No relation was established between (circulating miRNA 203, Survivn and Cyclin D) and AFP, PVT, number of focal lesions, largest diameter of the lesion or BCLC.

CD 133 Gene Polymorphisms as Predictive Markers for Development of Cancer Pancreas

Abstract Background Pancreatic cancer is one of the most aggressive human malignancies, it ranks the fourth leading cause of cancer death in the Western world and the 13th commonest cancer. Aim of the Work The aim of this study is to evaluate the genetic variants CD133 (rs1029728, rs2240688, rs2286455, and rs3130) as possible non-invasive predictive biomarker for Pancreatic cancer in the Egyptian population, this could help to detect the susceptible individuals, diagnose patients earlier, and this improve the therapeutic outcome. Patients and Methods This study was conducted in co-operation between Gastroenterology and Hepatology Department, Ain-Shams University and the Gastroenterology and Hepatology Department, Theodor Bilharz Research Institute “between” september 2020 to march 2021. It included total participants of 133 Results Our study demonstrated that there are three gene polymorphisms showed significant increase in pancreatic cancer group vs. control group, rs2240688 (TT) (65.5%) vs. (44.9%), rs1029728 (AA) (20.2%) vs. (2.0%), and rs3130 (TT) (32.1%) vs. (16.3%) respectively. There is significant increase in rs2240688 (TT), rs1029728 (AG) and rs3130 (TT) with smoking in pancreatic cancer group. And There is significant increase in males in pancreatic cancer group vs. control group in rs3130 (TT) with rs2240688 (TT) polymorphism. While rs2286455 showed no statically significance. The functional polymorphisms rs3130 (CC) and rs2240688 (CC) were found to be higher in control group vs. pancreatic cancer group that may represent a protective value against the disease. So, CD133 gene polymorphisms, rs2240688 (TT) rs1029728 (AA) and rs3130 (TT) could be used as a predictive marker for Pancreatic cancer after validation by larger studies or met analysis. Conclusion We concluded that the Genetic polymorphisms of the CD133 gene were associated with risk of Pancreatic cancer are three polymorphisms and represented as rs2240688 (TT) (65.5%) vs. (44.9%), rs1029728 (AA) (20.2%) vs. (2.0%), and rs3130 (TT) (32.1%) vs. (16.3%) Vs. control group. There is significant increase in rs2240688 (TT), rs1029728 (AG) and rs3130 (TT) with smoking in pancreatic cancer group vs. control group. rs3130 (TT) with rs2240688 (TT) gene polymorphisms showed significant increase in pancreatic cancer group group vs. control in male gender only as. According to the age as a demographic variable, mean age for pancreatic cancer group was 61.5 years with percentage of (76.2%) for age more than 50 years vs. (23.8%) for age less than or equal 50 years these. The functional polymorphisms rs3130 (CC) and rs2240688 (CC) were found to be higher in control group vs. pancreatic cancer group that may represent a protective value against the disease.

MRI Spectroscopy as a Diagnostic Model for Assessment of Liver Steatosis in NAFLD Non-Diabetic Patients

Abstract Background Non-alcoholic fatty liver disease, the hepatic pandemic of the XXI century, being the number one cause of chronic hepatic disease in the occidental world. Aim of the Work To evaluate the diagnostic performance of MRI spectroscopy for assessing hepatic steatosis in nonalcoholic fatty liver disease (NAFLD) in non diabetic patients. Patients and Methods A case control study was conducted on 40 patients inhepatology and gastroenterology department & Radiology department ain shams university hospital from Jan 2020 to November 2020 to study role of MRI spectroscopy as adiagnostic model for assessment of liver steatosis in NAFLD non diabetic patients. Results There was statically significant Positive correlation Between hepatic steatosis score, fat peak and fat fraction %, and there was statically significant Negative correlation Between Hepatic steatosis score and water peak. Conclusion MRI Spectroscopy can be reliably used as an accurate and specific noninvasive method for the diagnosis of Nonalcoholic fatty Liver Disease.

Elevated Plasma Copeptin Levels Identify the Presence and Severity of Nonalcoholic Fatty Liver Disease in Obesity

Abstract Background Non-alcoholic fatty liver disease is characterized by excessive fat accumulation in the liver with unclear mechanism may be due to epigenetic changes which take place at the transcriptional level without altering the underlying DNA sequence. this epigenetic alternation are involved in regulation of hepatic lipid metabolism, insulin resistance, mitochondrial damage, oxidative stress response, and the release of inflammatory cytokines, all of which have been implicated in the development and progression of NAFLD. Elevated copeptin, a vasopressin marker, is linked to metabolic disease, and obese rats with lowvasopressin concentration had a decreased risk of liver steatosis. Aim and objectives To Detect the elevation of plasma copeptin in obese patients with nonalcoholic fatty liver disease in relation to general population. Subjects and Methods This is A randomized case control cross sectional study, was carried out at internal medicine and gastroenterology department, Ain Shams University hospitals, on 100 patients above 18 years old with Hepatic Steatosis Index (HSI) and NAFLD-Liver Fat Score (LFS), over a period of 6 months. Result There was high statistically significant difference between the studied groups as regard Serum plasma copeptin. Conclusion Our study demonstrates for the first time that copeptin levels predict the presence of biopsy-proven NAFLD in obese individuals, regardless of body adiposity and the coexistence of other metabolic disorders. Studies with longitudinal design are warranted for exploring the possible involvement of AVP/V1aR system in the development and progression of NAFLD.

COMPARATIVE STUDY OF METRONIDAZOLE AND RIFAXIMIN IN PATIENTS WITH HEPATIC ENCEPHALOPATHY

Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome due to liver brokenness, especially in patients with cirrhosis or intense liver failure. The study's main objective is to find the comparative effectiveness of metronidazole and rifaximin in patients with hepatic encephalopathy. This prospective comparative study was conducted at Islamabad Medical and Dental College, Islamabad, over six months, from January 2023 to July 2023. The study population consisted of adult patients (age 18 years and above) diagnosed with hepatic encephalopathy admitted to the hospital's medical wards or gastroenterology department during the study duration. Patients with a confirmed diagnosis of hepatic encephalopathy based on clinical and laboratory criteria were included in the study. Out of the 150 patients enrolled in the study, 75 were randomized to receive metronidazole (Group A) and 75 to receive rifaximin (Group B). All patients completed the 10-day treatment period, and there were no dropouts during the study. In Group A (metronidazole), 60 out of 75 patients (80%) showed improvement in hepatic encephalopathy based on the West Haven criteria. In Group B (rifaximin), 70 out of 75 patients (93.33%) showed improvement in hepatic encephalopathy based on the West Haven criteria. The improvement in hepatic encephalopathy was significantly higher in Group B (rifaximin) compared to Group A (metronidazole) (p < 0.05).

Clinical, Laboratory, Endoscopic and Histological Correlation to Assess Actual Remission in Patients with Ulcerative Colitis

Abstract Background Ulcerative colitis (UC) is an idiopathic inflammatory disease of the colon which results in diffuse friability and superficial erosions on the colonic wall associated with bleeding. It is the most common form of inflammatory bowel disease (IBD) worldwide. Objective Evaluate the correlation between clinical remission, laboratory and inflammatory markers, endoscopic and histological remission in patients with ulcerative colitis. Assess to what extent clinical remission affects “treat to target” policy. Patients and Methods The present study was conducted at Internal medicine and Gastroenterology department, Ain Shams University Hospitals on 30 patients who was diagnosed with ulcerative colitis and were on clinical remission for 6 months. Patients were evaluated for laboratory, endoscopic and histological remission. Results There is significant correlation between mayo score and TLC after remission where Pvalue =0.042*, but no correlation was found with ESR, PLT or HB%. Conclusion There was significant improvement in colonoscopic picture of the study group as regard Mayo score after remission. There was significant improvement in laboratory data of the study group as regard Mayo score after remission. There was no correlation between endoscopic and histologic activity after remission. Fecal calprotectin was significantly correlated with both endoscopic and histologic activity.

G-EYE Colonoscopy Is Superior to Standard Colonoscopy for Increasing Adenoma/Polyp Detection Rate

Abstract Background Colorectal cancer (CRC) is one of the most common cancers worldwide. Most CRCs develop from malignant potential polyps, especially adenomas, SSPs and SSLs. Screening is associated with a reduction in CRC incidence through the detection and removal of precancerous polyps and with reduction in CRC related death through reduction of the incidence and early detection of CRC. Colonoscopy is the most widely used screening tool. Unfortunately during colonoscopy examinations, a substantial number of polyps are still being missed. These missed polyps though to be at least 50% of interval CRCs. Objective comparison between G-EYE colonoscopy and standard colonoscopy (SC) for increasing adenoma/polyp detection rate. Patients and Methods prospective randomized study was conducted on 80 Patients as one group, selection done at Hepatology and Gastroenterology department in Theodor Bilharz Research Institute and Outpatient clinic of Gastroenterology unit at Ain Shams University Hospitals. From: June 2021 to November 2021, after ethical committee approval. Results prospective randomized study demonstrated that the polyp detection rate (PDR) was an increased rate by G-EYE colonoscopy, this difference was statistically significant (P ≤ 0.05) as the total number of patients having polyps detected by G-EYE was 28 (40.60%) and the total number of polyps was 43 polyps while by SC was 15 (21.70%) and the total number of polyps was 19 polyps. There is an advantage for G-EYE over SC in relation to the size of the detected polyps as this study compared the detected polyp size as diminutive (<5 mm), small (6-9 mm) and large polyps (>10 mm) by G-EYE versus SC. For the diminutive polyps, the difference was statistically significant (P ≤ 0.05) favoring the G-EYE, and for small polyps the G-EYE was superior to SC by 3 polyps, while for large polyps there was no difference. G-EYE increased the ADR in comparison with SC [22 (100%) vs 9 (13%) ] respectively as G-EYE colonoscopy detected an additional 15 adenomatous polyps in 13 patients missed from SC colonoscopy. The difference was statistically significant. Fortunately there were very few complications, abdominal pain reported in 3 cases after the end of procedures. Conclusion The study demonstrated that G-EYE is superior to SC in increasing adenoma and polyp detection rate as being more rapid and more precise for detection of diminutive and small adenomatous polyps. However G-EYE could not be done in certain conditions such as diverticulosis, masses, ulcerations or colonic strictures for fear of perforation or incomplete intubation, in this study those patients were excluded from the start as the aim of the study was polyp detection rate difference by balloon assisted colonoscopy (G-EYE) in comparison to the standard colonoscopy (SC).

Serum Clusterin Level as a Diagnostic and Prognostic Marker for Hepatocellular Carcinoma

Abstract Background Hepatocellular carcinoma (HCC) is the third deadliest and fifth most common cancer worldwide, despite the widespread use of surveillance programs in at risk populations, more than half of HCC cases are diagnosed late, and curative therapies such as surgical resection, radiofrequency ablation (RFA) or TACE are possible in less than 30% of patients. Objective To assess the diagnostic and prognostic role of detection of serum Clusterin as a biomarker of hepatocellular carcinoma among the Egyptian patients before and after interventional treatment. Patients and Methods This study has been carried out in the department of Internal Medicine and Gastroenterology in Ain Shams University Hospitals and Hepatology department in Manshiyet El Bakry General Hospital in the period between July to December 2020. Results There was significant positive correlation between Clusterin and the mRecist score with pvalue (<0.001) where it increases with advancing in stages. Conclusion AFP is significantly elevated in HCC groups than in cirrhotic (control) and with better sensitivity and specificity than Clusterin. Clusterin has significant positive correlation with Mrecist score of HCC patients which means it acts better as a prognostic tool for following HCC patients. Patients who had recurrence in both HCC groups (RF and TACE) showed less decrease in Clusterine level than those with non-recurrence among both groups. Serum clusterin level was significantly higher among patients with progressive disease (PD) than those with partial response (PR) than those with complete response (CR). Also follow up serum clusterin level after intervention was statistically significant higher among patients with progressive disease (PD) than those with partial response (PR) than those with complete response (CR).

Risk factors of persistent diarrhea in children below 5 years of age

Background: Persistent diarrhea is a known cause of mortality, morbidity, and malnutrition in developing countries. With recent improvement of rehydration therapy death due to acute diarrhea has been reduced. Though persistent diarrhea accounts for 2-20% of total diarrhea cases, it accounts for 23-62% of all diarrhea related deaths. Objective: The study was done to identify the risk factors associated with persistent diarrhea in children below 5 years of age.
 Methods: This prospective observational study was conducted in the department of Pediatric Gastroenterology, Hepatology and Nutrition of Dhaka Shishu hospital from July 2019 to June 2020. It included 50 children with persistent diarrhea age between 1 month to <5 years. Detailed history, examination and appropriate investigations were done for all children. Crude odd ratio was calculated for each risk factor by univariate analysis and adjusted odds ratio was calculated by multivariate logistic regression.
 Results: Most of the children (52%) were under the age of 6 months to 1 year. Male (84%) were more affected than female (16%). Acute malnutrition was observed in 44% cases; among them severe acute malnutrition was in 40% cases. Unsafe drinking water, severe acute malnutrition, diarrhea within past 2 months, bottle feeding, persistent of dehydration more than 24 hours, feeding of cow’s milk, lack of exclusive breast feeding, prior antibiotic used, UTI, LRTI were statistically significant risk factors by univariate analysis. Unsafe drinking water (OR-1.6; 95% CI- 0.27- 2.78), severe acute malnutrition (OR-1.92; 95% CI-0.64 - 5.72), Feeding of cow’s milk (OR-3.90; 95% CI- 1.21- 12.49), lack of exclusive breastfeeding (OR-5.77; 95% CI- 1.44- 23.10), irrational use of antibiotics (OR-3.37; 95% CI- 1.01- 11.38), LRTI (OR-1.16; 95% CI- 0.49- 1.53) were found to be independent risk factors by multivariate logistic regression analysis.
 Conclusions: The results of this study concluded that use of unsafe drinking water, severe acute malnutrition, feeding of cow’s milk, lack of exclusive breastfeeding, irrational use of antibiotics are significant risk factors for the incidence of diarrhea in the present study population.
 Northern International Medical College Journal Vol. 12 No.2 Jan 2021, Page 539-543

Amyloid A in Serum and Ascetic Fluid as a Marker of Spontaneous Bacterial Peritonitis

Abstract Background Esophageal varices (EV) are a major complication of cirrhosis secondary to the development of clinically significant portal hypertension EV can lead to life-threatening bleeding, further decompensation and death among patients with cirrhosis. Aim of the Work The aim of this study is to assess the role of the clinical usefulness of the Amyloid A (serum and ascetic fluid) in patients with ascites (liver cirrhosis) and as a diagnostic marker for Spontaneous Bacterial Peritonitis. Patients and Methods This prospective study was conducted on 240 cirrhotic patients selected randomly presented for screening for esophageal varices at Hepatology, Gastroenterology and Infectious Diseases Department, Benha University Hospital Hospitals and at Kafr El- Shiekh Liver Research center Results The cause of cirrhosis was HCV in 205 patients (85.42%), HBV in 14 patients (5.83%), BHF in 47 patients (19.58%) with, AIH in 6 patients (2.5%) and other diseases in 21 patients (8.75%). the prevalence of oesophageal varices and its staging were 55 patients (22.9%) had no oesophageal varices, 44 patients (18.3%) had esophageal varices grade I-II (Small EVs) and 141 patients (58.8%) had oesophageal varices grade III-IV (Large EVs). According to Child-Pugh (CP) Score, 129 (53.75%) patients were Child A, 72 (30%) patients were Child B and 39 (22.9%) patients were Child C. ALBI ranged from -3.2 - (-0.42) with mean value −1.94 ± - 0.74. 67 (27.9%) patients were ALBI 1, 100 (41.7%) patients were ALBI 2 and 73 (30.4%) patients were ALBI 3. 50 (20.83%) patients were ALBI-PLT 2, 30 (12.5%) patients were ALBI-PLT 3, 88 (36.67%) patients were ALBI-PLT 4, 72 (30.0%) patients were ALBI-PLT 5. There was a significant difference among cirrhotic patients regarding EVs as regard to hemoglobin, platelets, APRI, albumin, total bilirubin, ALBI, ALBI-PLT, INR, Child-Pugh (CP) score, platelet count/spleen diameter ratio, spleen size and ascites (P < 0.001). Regarding the presence of EV, ALBI, ALBI-PLT, Child-Pugh (CP) Score and platelet count/spleen diameter ratio, are good predictors for the presence of oesophageal varices. ALBI at cut-off >-2.6 can predict oesophageal varices with sensitivity 83.77, specificity 53.06, PPV 87.4, NPV 45.6, AUC 0.711 and P-value <0.001, ALBI- PLT at cut-off >2 can predict oesophageal varices with sensitivity 96.48, specificity 87.76, PPV 96.9, NPV 97.7, AUC 0.982 and P-value <0.001. Regarding differentiation between Small EVs and large EVs, This study showed that ALBI, ALBI-PLT, Child-Pugh (CP) Scores, platelet count/spleen diameter ratio, spleen size and APRI could be used in prediction of the size of EVs, ALBI at cut-off >-2.03 can predict the size with sensitivity 95.28, specificity 93.75, PPV 96.8, NPV 90.9, AUC 0.971 and Pvalue <0.001. Conclusion Combined ALBI grade and platelet count (ALBI-PLT score), albumin-bilirubin ratio (ALBI), could be used as a serum non-invasive marker of the presence of oesophageal varices which may help in reducing unnecessary endoscopies and a good selection of patients who need an endoscopy to decrease intervention and burden on endoscopy units.

Neutrophils to Lymphocytes Ratio and Platelets to Lymphocytes Ratio as Predictors of Small Intestinal Lesions Detected by Video Capsule Endoscopy

Abstract Background Capsule endoscopy (CE), also known as wireless capsule endoscopy or video capsule endoscopy, is a gastrointestinal study that uses a pill camera to take images of the intestinal lumen. Objective: Patients and Methods The study was conducted on 93 subjects from the Gastroenterology and Hepatology Department of Ain Shams University Hospital. They were divided into three different groups as following: Crohn’s disease group, arteriovenous malformation group and small intestinal tumor group. All patients and controls were subjected to routine laboratory tests and NLR and PLR was estimated. Results There was statistically significant difference between control group and AVM group and Crohn's group as regard N/L ratio, while this difference is less significant in tumor group patient. Receiver operating characteristic curve (ROC) shows that the best cut off point of N/L ratio to detect AVM group was found >1.97 with sensitivity of 67.74, specificity of 72.04% and total accuracy of 73%, and the best cut off point of P/L ratio to detect AVM group was found >158.02 with sensitivity of 61.29%, specificity of 96.77%, and total accuracy of 78%. Receiver operating characteristic curve (ROC) shows that the best cut off point of N/L ratio to detect Tumor group was found >1.97 with sensitivity of 45.16%, specificity of 72.04% and total accuracy of 59%, and Receiver operating characteristic curve (ROC) shows that the best cut off point of P/L ratio to detect Tumor group was found >145.83 with sensitivity of 32.26%, specificity of 91.40% and total accuracy of 62%. Receiver operating characteristic curve (ROC) shows that the best cut off point of N/L ratio to detect Crohn's group was found >2.44 with sensitivity of 100.0%, specificity of 84.95 and total accuracy of 96%, and Receiver operating characteristic curve (ROC) shows that the best cut off point of P/L ratio to detect Crohn's group was found >138.35 with sensitivity of 80.65%, specificity of 89.25% and total accuracy of 92%. Conclusion N/L ratio and P/L ratio can be used as non- invasive and cheap predictors for severity of crohn's disease, arteriovenous malformations and stage of malignancy in small intestinal tract.

Comparison between Size of OV, Fibroscan in Chronic Hepatitis C Patients before & after Treatment with DAAs

Abstract Background HCV infection is a global health issue and one of the major causes of chronic liver diseases, Egypt on the top of the countries with heavy HCV burden, HCV genotype 4 is the most common in Egypt and represents 92% of total infections. Objective To asses changes on the size of esophageal varices and liver stiffness after treatment of HCV with DAAs. Patients and Methods The study was carried out at Gastroenterology and hepatology Department, Ain-Shams Hospital and Kobry-Elkoba Military Hospital and included 60 patients with chronic infection of hepatitis c virus diagnosed by (HCV Ab by ELISA positive and HCV RNA by PCR positive) and was divided into 3 groups: Group I: 20 patients chronically infected with HCV received sofosbuvir (one 400 mg tablet taken once daily) & Ribavirin (weight –related dose, 75 kg or less: 400 mg orally in the morning and 600 mg in the evening, Greater than 75 g: 600 mg orally twice daily and decrease the dose in case of anaemia) for 6 months. Group II: 20 Patients chronically infected with HCV received sofosbuvir (one 400 mg tablet taken once daily) & simeprevir (one 150 mg tab taken once daily) for 3 months. Group III: 20 patients chronically infected with HCV received sofosbuvir (one 400 mg tablet taken once daily with or without food) & daclatasvir (one 60 mg tab taken once daily) for 3 months. Results In the study, patients achieved high rates of SVR 12 (98.3%) only one patient at group II relapsed after finishing the treatment and did not reach SVR12. In the study, there was decrease in fibroscan stages after treatment with different regmins of DAAs, but it was significant with group III (HCV patients who received sofosbuvir & daclatasvir for 3 months). In the study, There is significant improvement in liver enzymes (AST&ALT) and significant increase at platelet count after treatment in all the 3 groups, Also there was significant decrease in hemoglobin level in group I (SOF/RIB) in comparison to other groups. In the study, there was no significant change in OV grading in group I before and after treatment, and also in group II & III only one patient in each group had changes in OV grading after treatment from OV grade III to OV grade II. Conclusion High rates of SVR achieved after DAAs therapy associated with significant improvement of the liver function and fibrosis regression estimated by (LSM by fibroscan) but with no improvement of the degree of esophageal varices at least in short term follow up after therapy.

Association between Blood Ammonia Level and Severity of Portal Hypertensive Gastropathy in Egyptian Patients with Post Hepatitis C Virus Cirrhosis

Abstract Background Cirrhosis often is an indolent disease; most patients remain asymptomatic until the occurrence of decompensation, characterized by ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, or variceal bleeding from portal hypertension. In most persons, approximately 80 to 90 percent of the liver parenchyma must be destroyed before liver failure is manifested clinically. When complications of cirrhosis occur, they typically are related to impaired hepatic function or actual physical disruption and re organization of the liver parenchyma. Aim of the Work The aim of this study is to assess the correlation between blood ammonia level and severity of PHG (to determine if serum ammonia level could be used as a non invasive predictor for severity of PHG). Also, to find out if there is a causal relationship between blood ammonia level and severity of PHG which encourage trials of ammonia-lowering treatments for the management of severe PHG with a tendency to bleed) Patients and Methods This case control study was conducted upon 100 Egyptian cirrhotic patients attending at Ain Shams University Hospital (gastroenterology and hepatology department) and Kafr –El Sheikh liver center after informed written consent. Results There was a significant difference between studied groups regarding ammonia levels, with a significant increase in serum ammonia level in group 1, group 2 and group 3 versus group 4 (Pvalue ˂ 0.001). There was a significant difference between studied groups regarding haemoglobin, Platelet count, serum albumin, INR, serum bilrirubin (P-value 0.006, ˂0.001, ˂0.001, ˂0.001, ˂0.001, ˂0.001 respectively). There was a significant difference between studied groups regarding SLD (P- value ˂0.001). Splenic longitudinal diameter can be used as a good predictor for OVs. There was a significant difference between studied groups regarding PVD, portal vein flow direction and PVV (P-value ˂0.001, ˂0.001,˂0.001 respectively). There was a significant positive correlation between blood ammonia level and Child Pugh score (P 0.004), PVD (P 0.005) and SLD (P˂0.001), but ammonia has a negative correlation with PVV (P ˂0.001). There was a positive correlation between PHG score and serumammonia level (r0.830, P ˂0.001). Conclusion Blood ammonia levels correlate with the presence, severity, and score of portal hypertensive gastropathy in cirrhosis

Association between Nonalcoholic Fatty Liver Disease and Carotid Artery Disease in Type 2 Diabetic Patients

Abstract Background Nonalcoholic fatty liver disease (NAFLD) is a clinic-pathological syndrome closely associated with obesity, dyslipidemia, diabetes and atherosclerosis. Some authors suggest that NAFLD is, in fact, another component of the metabolic syndrome. Aim of the Work To assess the relationship between NAFLD and Diabetes mellitus as risk factors for atherosclerosis by measuring carotid intima-media thickness (CIMT), NAFLD Fibrosis Score and FIB-4 Score. Patients and Methods This study is a prospective case control study that was conducted on (40) NAFLD Patients (aged between 18-60 years), at Gastroenterology and Hepatology department, Ain shams university hospitals and Heliopolis hospital, divided into three groups (Group 1): included 15 patients with NAFLD and controlled T2DM, (Group 2): included 15 patients with NAFLD and uncontrolled T2DM, (Group 3): included 10 patients as with NAFLD and non-diabetic as a control group, through a period of 6 months. Results There was positive correlation between IMT with FBG (p = 0.012) and HbAIC (p = 0.011). Conclusion Our results suggest that NAFLD is extremely common in people with type 2 diabetes and is associated with a higher prevalence of CVD. The association between NAFLD and CVD appears to be independent of classical risk factors, glycemic control, medications, and presence of the metabolic syndrome. Thus, these results further confirm the hypothesis that the identification of NAFLD in type 2 diabetes may help in CVD risk prediction.

Assessment of Right Lobe Size/Serum Albumin Ratio as a Non-Invasive Marker for EsophagealVarices in HCV Patients

Abstract Background Oesophageal varices are the most critical porto-systemic shunts that develop secondary to portal hypertension, which is considered the main complication of liver cirrhosis. Many studies recommend the screening of all cirrhotic patients by endoscopy, but repeated endoscopic examinations are unpleasant for patients and have a high- cost impact and burden on endoscopic units. Aim and of the work To investigate the value of measurement of (Rt. lobe diameter/ serum albumin ratio) in the prediction of esophageal varices. Subjects and Methods This was Case- control study, was carried out at outpatient clinics of Hepatology and inpatient department of Gastroenterology at Ain Shams University Hospital on 100 patients divided into 3 groups: (Group 1): 30 patients with Child-Pugh A, (Group 2): 30 patients with Child-Pugh, (Group 3): 40 patients with Child-Pugh C, during a period of 6 months. Result There were highly significant difference between both groups as regard Platelet count /spleen diameter ratio and Right liver lobe size/Serum Albumin ratio. Conclusion The use of Right liver lobe/serum albumin ratio can help physicians by restricting the use of endoscopic screening only to patients presenting a high probability of esophageal varices. This is especially useful in clinical settings where resources are limited, and endoscopic facilities are not present in all areas.