Gastritis cystica profunda (GCP) is a rare, benign lesion of the stomach characterized by polypoid hyperplasia and/or ulcerated mucosal lesion and cystic dilatation of the gastric glands extending into the submucosa or muscularis propria of the stomach. Its etiology and pathogenesis are still incompletely understood. The most important factor is assumed to be a history of prior gastric surgery. We herein present a case of a young adult female with upper gastrointestinal (GI) symptoms. She underwent upper GI endoscopy twice, which revealed pyloric narrowing and intramural mass. Gastric endoscopic mucosal biopsies were performed, but no tumor was identified and her symptoms persisted. Imaging studies also revealed a mass lesion. Open laparotomy and partial gastrectomy with histopathology of the resected specimen revealed the true nature of the lesion. Surgery also improved her symptoms. GCP should be kept in the differential diagnosis of gastric mural mass lesions.
Spontaneous acute esophageal necrosis (AEN) has been reported to be extremely rare. The condition is defined as a dark pigmentation of the esophagus associated with histologic mucosal necrosis. The exact pathogenesis is still unknown, but several etiologies have been suggested including ischemia, gastric outlet obstruction, hypersensitivity to antibiotics, gastric volvulus and viral infection. We herein present a case of a middle-aged man with end-stage renal disease who presented with AEN following a hemodialysis session. Its diagnosis and management are discussed with reference to the pathogenesis of the condition.
Peliosis hepatis (PH) is a rare, benign condition of the liver characterized by the presence of blood-filled lacunar spaces in the parenchyma. It usually has a chronic presentation and is a rare cause of portal hypertension reported in adult patients. Its etiology is diverse and ranges from infectious agents to tumors to toxic substances and anabolic steroids; however, the cause remains unclear in 25–50% of patients. Similarly, the symptomatology and imaging findings are diverse. Biopsy is the definitive test to diagnose the condition. Herein, we present a case of a young female presenting in her seventh month of gestational amenorrhea with signs of portal hypertension and subsequently diagnosed to have PH. She was managed conservatively and delivered her baby normally. Later, she presented with spontaneous bacterial peritonitis and hepatic encephalopathy and developed hepatorenal syndrome. She later succumbed to her illness. The condition should be kept in the differential diagnosis of the atypical liver masses and liver diseases causing portal hypertension.
The risk of upper gastrointestinal bleeding (UGIB) is increased among the end-stage renal disease (ESRD) patients. The aim of the current study was to describe the causes and characteristics of UGIB in ESRD patients at our center and to assess the need for endoscopic therapeutic intervention (ETI) using Rockall (RS) and Glasgow Blatchford scores (GBS).
Material and Methods
All patients with ESRD and UGIB with age ≥14 years were included. Frequencies and percentages were computed for categorical variables. Chi square test or Fischer’s exact test was used for statistical analysis.
A total of 59 subjects had a mean age of 47.25 ± 15 years.The most common endoscopic findings seen were erosions in 33 (55.9%) patients, followed by ulcers in 18 (30.3%) patients. ETI was required in 33 (55.9%) patients, which included adrenaline injection in 19 (32.3%), hemoclip in 9 (15.2%) and argon plasma coagulation in 5 (8.4%) patients. Factors associated with the need of ETI were identified as: a combined presentation of hematemesis and melena (P=0.033), ulcer (P=0.002) and associated chronic liver disease (P=0.015). Six (10.1%) patients died. Death was more common if ETI was not performed (P=0.018).
ETI was more commonly required in patients on maintenance hemodialysis with UGIB, who had presence of combined hematemesis and melena, ulcers and associated chronic liver disease. A Glasgow Blatchford score of >14 was helpful in assessing the need for ETI in these patients.
A young female presented to us with abdominal distension along with pedal edema. She had no prior medical or surgical history apart from a caesarean section done a few years prior. Initial workup showed low hemoglobin, low serum albumin and slight raised ESR. Her LFTs were slightly deranged. Ultrasound abdomen had evidence of portal hypertension along with splenomegaly. While ultrasound hepatic Doppler revealed a portosystemic shunt between the portal vein and the left hepatic vein, with a shunt ratio of 7.1%. CT scan abdomen confirmed these findings and a diagnosis of Type III intrahepatic portosystemic shunt and spleno-renal shunt was made. Since the patient was currently asymptomatic, she was advised regular follow-ups and was managed conservatively.
Objective: To evaluate the clinical presentation, possible etiological factors, management and
outcome of patients in our hospital with extrahepatic portal vein obstruction (EHPVO). Materials
and Methods: This study included patients with EHPVO followed up in our department during
last 10 years. Patients of cirrhosis with EHPVO were excluded. Patients’ clinical presentation,
etiology of EHPVO, management and outcome results were analyzed. Results: Of 30 patients,
19 (67.9%) were males. Median age was 12 years. Of 14 patients who underwent liver biopsy
9 had histological activity index stage of 1/6. History of omphalitis and pulmonary tuberculosis
was present in one case each. Of 22 patients with the available thrombophilia profile, nine
patients had a deficiency of protein C, five patients had a deficiency of protein S, one each
had reduced level S of anti-thrombin III and factor V mutation. The predominant presenting
symptom was hematemesis (15 patients, 53.6%). Seven patients (25%) had splenomegaly.
Three patients (10.7%) had no esophageal varices on endoscopy. Three patients underwent
splenectomy due to severe pancytopenia. Endoscopic retrograde cholangipancreatography
was performed in four patients (14.3%) due to portal biliopathy. Common bile duct stenting was
performed in all four patients. Of them, one patient underwent splenorenal shunt operation for
indication of hemobilia. One patient died at the age of 40 years, due to cholangitis and sepsis.
Conclusions: Results from this study show that the anticoagulant deficiency is a common
cause of EHPVO in our setup. Hematemesis is a common presenting symptom. Some of these
patients have symptomatic portal biliopathy.
Gastrointestinal symptoms are common in patients with end stage renal disease (ESRD) among which dyspepsia is frequently observed. The aim of the study was to determine the frequency and associations of dyspepsia in ESRD patients using the Leeds questionnaire.
All ESRD patients on maintenance hemodialysis were consecutively enrolled in the study. Leeds questionnaire was used to interrogate the patients for the assessment of dyspepsia. Mean and standard deviation were calculated for age, body mass index (BMI), disease duration and number of hemodialysis sessions. Independent t-test and Chi square tests were used for statistical analysis.
Total number of patients was 200, out which 118 (59.3%) were male. The mean age was of 41.4 years. According to the Leeds questionnaire, dyspepsia was present in 62 (63.9%) patients. Younger patients (age 20–40 years) more frequently had dyspeptic symptoms (61.5% patients), retrosternal pain (156 patients, 78.0%), regurgitation (127 patients, 63.5%), dysphagia (67 patients, 33.5%), and nausea (142 patients, 71.0%). Patients presented with intermittent pattern of symptoms in 179 (89.5%) cases, while continuous symptoms in 6 (3.0%). Dyspepsia was associated with aspartate aminotransferase (AST) levels > 25 U/L (P = 0.001), alanine aminotransferase (ALT) levels > 28U/L (P = 0.000) and gamma glutamyl transferase (GGT) levels > 34 U/L (P = 0.002). On multivariate analysis, urea, creatinine, and presenting symptoms of dysphagia and belching showed significant statistical association with dyspepsia.
Dyspepsia is a common problem affecting patients with end stage renal disease and is associated with raised serum AST, ALT and GGT in such patients.
The aim was to assess the diagnostic accuracy of APRI and FIB-4 in assessing the stage of liver fibrosis in end stage renal disease (ESRD) patients with chronic viral hepatitis and to compare the two tests with standard tru-cut liver biopsy.
Material and Methods
The study was conducted at Sindh Institute of Urology and Transplantation Karachi (SIUT) from May 2010 to May 2014. All ESRD patients, being considered as candidates for renal transplantation and in whom liver biopsy was performed were included. Fibrosis stage was assessed on liver biopsy using Ishak scoring system. The serum transaminases and platelet counts were used to calculate APRI and FIB-4 scores.
Out of 109 patients, hepatitis C and B virus infections were present in 104 (95.4%) and 3(2.8%), respectively, while 2 (1.8%) patients had both infections. The mean Ishak fibrosis score was 1.95 ± 2. Advanced fibrosis was noted in 37 (34%) patients. Univariate analysis showed that advanced liver fibrosis was associated with lower platelets counts (P=0.001) and higher aspartate aminotransferase (AST) (P=0.001), alanine aminotransferase (ALT) (P=0.022), APRI score (P=0.001) and FIB-4 score (P=0.001). On logistic regression analysis, only APRI score (P < 0.001) was found to be the independent variable associated with advanced liver fibrosis. APRI score cutoff ≥1 indicating advanced fibrosis showed sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 91.9%, 90.3%, 82.9%, 95.6%, respectively with area under the curve (AUC) of 0.97. Similarly, a FIB-4 score cutoff ≥1.1 had sensitivity, specificity, PPV and NPV of 70.27%, 66.67%, 52% and 81.36%, respectively with AUC of 0.74.
APRI is more accurate noninvasive test for assessing advanced liver fibrosis in ESRD patients as compared to FIB-4. It can be used to obviate the need for liver biopsy in this high risk population.
Portal hypertensive gastropathy (PHG) is described endoscopically as “mosaic-like appearance” of gastric mucosa with or without the red spots. It can only be diagnosed by upper gastrointestinal (GI) endoscopy. The aim of this study was to determine the diagnostic accuracy of platelet count to spleen diameter ratio (PSR) and right liver lobe diameter to albumin ratio (RLAR) in the detection of PHG using upper GI endoscopy as a gold standard in patients with liver cirrhosis.
Material and Methods
This cross-sectional study was conducted in the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi. All consecutive patients with ages 18–65 years who were screened using esophagogastroduodenoscopy (EGD) to exclude esophageal varices were enrolled. At the same time, findings related to PHG were noted. After informed consent, all the patients had blood tests including platelet count and albumin and abdominal ultrasound determining spleen diameter and right liver lobe diameter.
Out of 111 patients, 59 (53.15%) were males with a mean age of 44 ± 12.61 years. Rate of PHG was observed in 84.68% (94/111) cases confirmed by EGD. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PSR were 87.23%, 5.88%, 83.67%, 7.69%, and 74.7%, respectively, and those of RLAR were 28.72%, 70.59%, 84.38%, 15.19%, and 35.14%, respectively.
PSR is better predictor of PHG than RLAR but at the expense of relatively lower specificities and NPV likely because of underlying pathophysiology (portal hypertension) which is similar for esophageal varices, PHG, and ascites.
Renal dysfunction is one of the dreaded complications of cirrhosis. MELD is a validated chronic liver disease (CLD) severity scoring system. Urinary (U) Na/K ratio closely correlates with renal dysfunction in terms of low GFR in cirrhotic patients.
Patients and Methods
All consecutive patients with decompensated cirrhosis between the age of 18 to 70 years, of either gender, presenting in the outpatients’ department of Sindh Institute of Urology and Transplantation, Karachi, from June 2015 to June 2017 were included. The MELD score was calculated and the UNa/K ratio less than 1 was taken as surrogate marker of renal dysfunction. Statistical analysis was performed by SPSS (version 20.0).
A total of 71 patients were enrolled. The mean age was 43.79 years and majority were male (67.6%). The most common cause of liver cirrhosis was HCV, found in 42 (59.2%) patients. The mean CTP score was 10.48 ± 2.069 (range: 6–14) with majority of the patients following in class C, that is, 48 (67.6%). Mean MELD score was 21.75 ± 8.96 (range: 8–43). In 57 patients (80.3%), MELD score was > 15.The mean serum creatinine and mean serum sodium were 1.5 ± 1.1 mg/dl (range: 0.37–5.3) and 133.79 ± 6.9 mmol/L (range: 112–152), respectively. Mean urinary sodium and urinary potassium were 38.60 ± 46.64 mmol/L (range: 5–181) and 38.15 ± 23.9 mmol/L (range: 4.3–112), respectively. In majority of study population, UNa/K ratio was below 1, that is, in 52 patients (73.2%). Statistically significant correlation was documented between MELD score and UNa/K ratio (ɤ = 0.34, P = 0.004).
The inverse correlation between MELD scores and UNa/K ratio indicates that patients with CLD and higher MELD scores might have renal dysfunction. This finding however should be corroborated by large scale studies.