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Syed Mudassir Laeeq, Abbas Ali Tasneem, Farina M. Hanif, Nasir Hassan Luck, Rajesh Mandhwani and Rajesh Wadhva

Abstract

Background and Objectives

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.

Results

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).

Conclusion

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.

Open access

Farina M. Hanif, Ghous Bux Soomro, Sara Nazir Akhund, Nasir Hassan Luck, Syed Mudassir Laeeq, Zaigham Abbas, Syed Mujahid Hassan and Muhammed Mubarak

Abstract

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.

Open access

Syed Mudassir Laeeq, Nasir Hasan Luck, Rajesh Kumar Wadhwa, Zaigham Abbas, Syed Mujahid Hasan, Mahira Younus and Muhammed Mubarak

Abstract

Objective: The aim of this study was to determine the significance of the ratio of diameter of left lobe of liver with serum albumin as a non-invasive predictor of esophageal varices. Materials and Methods: All consecutive patients with clinical cirrhosis were included in the study. The study was conducted in the Department of Gastroenterology and Hepatology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan. All patients underwent full history taking, clinical examination, relevant laboratory investigations and abdominal ultrasound evaluation. Measurement of the right liver lobe diameter (RLLD) and left liver lobe diameter (LLLD) was performed using ultrasound in the mid-clavicular line and central line, respectively. Esophago-gastroscopy was performed for the detection and grading of esophageal varices. Calculation of the RLLD and LLLD/serum albumin ratio was performed and analyzed for clinical significance. Results: One hundred and eleven subjects (80 males; 72%), with a mean age of 40.09 ± 13.6 years were studied. Esophageal varices were seen in 68 (61.3%) patients and Child-Pugh class A accounted for 41.4%, class B for 45.9% and class C for 12.6% cases. The mean value of RLLD/serum albumin ratio was 5.05 ± 1.90 in patients with varices versus 4.24 ± 1.64 in patients without varices (P = 0.023). The mean value of the LLLD/serum albumin ratio was 2.41 ± 0.90 in patients with varices versus 1.89 ± 0.61 in patients without varices (P < 0.001). Areas under curve were 0.377 and 0.69 for the RLLD/ serum albumin ratio and LLLD/serum albumin ratio, respectively. At a cut-off value of 1.5, the sensitivity was 88.1% and the specificity was 72.1% for the LLLD/albumin ratio. Conclusion: The LLLD/albumin ratio is a better predictor of esophageal varices than the RLLD/albumin ratio in patients with liver cirrhosis.

Open access

Jawaid Iqbal, Muhammad Ali Khalid, Farina M. Hanif, Rajesh Mandhwani, Syed Mudassir Laeeq, Zain Majid and Nasir Hassan Luck

Abstract

Background

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).

Results

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).

Conclusion

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.