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Gupta A, Mourya C. Intra-diverticular Dieulafoy's lesion in third part of duodenum. Indian J Gastroenterol 2023; 42:855-856. [PMID: 37133643 DOI: 10.1007/s12664-023-01352-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Ankur Gupta
- Department of Gastroenterology, Sahara Hospital, Viraj Khand, Gomti Nagar, Lucknow, 226 010, India.
| | - Chandan Mourya
- Department of Radiology, Sahara Hospital, Viraj Khand, Gomti Nagar, Lucknow, 226 010, India
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2
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Hu Q, Guo Y, Fan H, Wu X, Chen H, Zeng C. Pathological features of vascular wall in Dieulafoy's disease. Pathol Res Pract 2023; 249:154782. [PMID: 37639956 DOI: 10.1016/j.prp.2023.154782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/25/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
AIMS Although there are many clinical reports on Dieulafoy's disease, there are few studies on the pathological structure of vascular wall in Dieulafoy's disease. METHODS In this study, the main structural changes of the intima and media of the vascular wall were observed by special staining and immunohistochemical methods in the subjects of Dieulafoy's disease of stomach and intestine. RESULTS There were many vessels of different sizes in the submucosa, with uneven wall thickness of the vessels. Compared with the normal control group, the content of blue collagen fibers between the vascular smooth muscle cells in the lesion group was increased, the elastic fibers were thickened, and the internal elastic plate was arranged stiff or even interrupted. CONCLUSIONS The increase of collagen and elastic fibers between the smooth muscle cells of the medium membrane and the destruction of the structure of the inner elastic plate may be the structural basis of vascular lesions leading to Dieulafoy's disease.
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Affiliation(s)
- Qiaoling Hu
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China
| | - Yimin Guo
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China
| | - Huan Fan
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China
| | - Xiaobin Wu
- Department of Gastrointestinal Surgery, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, PR China.
| | - Honglei Chen
- Gastrointestinal Endoscopy Center, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China.
| | - Chao Zeng
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China.
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3
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Barrantes Murillo DF, Tillson M, Koehler JW, Sandey M. Case report: The first description of a Dieulafoy's lesion in the gastric mucosa of a dog. Front Vet Sci 2022; 9:932435. [PMID: 36072394 PMCID: PMC9441867 DOI: 10.3389/fvets.2022.932435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/28/2022] [Indexed: 12/03/2022] Open
Abstract
An approximately 12-year-old, 31 kg, male neutered Labrador Retriever was presented to the referring hospital with an acute onset (less than 1 day) of hematemesis and melena. The dog was treated supportively for a presumptive gastric ulcer for 4 days with intravenous fluids, gastro protectants, such as pantoprazole, misoprostol, sucralfate, and barium, as well as an anti-emetic (maropitant) and analgesics (fentanyl, gabapentin, and tramadol). Throughout medical management, the dog continued to require blood transfusions approximately every 24 h. Given the poor medical response, the patient was subjected to an exploratory laparotomy. During surgery, a grossly raised, blister-like lesion on the mucosal surface of the stomach was appreciated on the lesser curvature of the stomach. A partial gastrectomy was performed, and the segment was submitted for histological evaluation. Histologically, there were multiple, tortuous, medium-caliber muscular arteries (>1.0 mm in diameter) in the submucosa. A single large-caliber artery (>0.75 mm in diameter) containing a partially occlusive thrombus extruded through the mucosa and projected on the ulcerated surface. The patient's signs were similar clinically and histopathologically to Dieulafoy's lesion in people. A Dieulafoy's lesion is a potentially life-threatening disorder that causes gastrointestinal (GI) hemorrhage. This lesion is characterized by a dilated, large-caliber, aberrant submucosal artery that erodes through the epithelium and ruptures, resulting in massive and potentially fatal hemorrhage. This lesion has never been documented previously in a dog.
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Affiliation(s)
| | - Michael Tillson
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, United States
| | - Jennifer W. Koehler
- Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, AL, United States
| | - Maninder Sandey
- Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, AL, United States
- *Correspondence: Maninder Sandey
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Zhou SY, Guo MD, Ye XH. Appendiceal bleeding: A case report. World J Clin Cases 2022; 10:6314-6318. [PMID: 35949834 PMCID: PMC9254187 DOI: 10.12998/wjcc.v10.i18.6314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/27/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute lower gastrointestinal bleeding is common in clinical practice, and the colon is responsible for the majority of cases. However, appendiceal bleeding is an extremely rare cause. Appendiceal bleeding due to vascular diseases, such as angiodysplasia and Dieulafoy’s lesion, may result in massive lower gastrointestinal bleeding. Appendectomy is a reliable and effective option for treatment.
CASE SUMMARY A 32-year-old male presented to our hospital with hematochezia that had lasted for 6 h, with approximately 600-800 mL bloody stools and loss of consciousness for a few seconds. Persistent bleeding from the orifice of the appendix was observed by colonoscopy. Following the new diagnosis of appendiceal bleeding, the patient was treated by an emergency laparoscopic appendectomy. Finally, the patient was pathologically diagnosed with appendiceal Dieulafoy’s lesion. The patient was uneventfully discharged, and follow-up 2 wk later showed no evidence of rebleeding.
CONCLUSION Although appendiceal bleeding is a rare cause of acute lower gastrointestinal bleeding, clinicians should consider it during differential diagnosis.
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Affiliation(s)
- Sheng-Yue Zhou
- Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Mao-Dong Guo
- Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Xiao-Hua Ye
- Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
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5
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Inayat F, Hussain A, Yahya S, Weissman S, Sarfraz N, Faisal MS, Riaz I, Saleem S, Saif MW. Rectal Dieulafoy's lesion: a comprehensive review of patient characteristics, presentation patterns, diagnosis, management, and clinical outcomes. Transl Gastroenterol Hepatol 2022; 7:10. [PMID: 35243119 PMCID: PMC8826214 DOI: 10.21037/tgh.2020.02.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/10/2020] [Indexed: 08/10/2023] Open
Abstract
Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying mucosa, without primary ulceration or erosion. Although these lesions predominantly involve the stomach and upper small intestine, they are being detected with increasing frequency in the rectum. We conducted a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases for adult rectal Dieulafoy's lesion. After careful review of the search results, a total of 101 cases were identified. The data on patient characteristics, clinical features, colonoscopy findings, diagnosis, treatment, and clinical outcomes were collected and analyzed. The mean age of presentation was 66±17 years (range, 18-94 years), with 54% of cases reported in males. Clinical presentation was dominated by acute lower gastrointestinal bleeding in the form of bright-red blood per rectum 47% and hematochezia 36%, whereas 16% of patients were admitted with symptoms related to other medical conditions. Major underlying disorders were hypertension 29%, diabetes mellitus 21%, and chronic kidney disease 16%. The average number of colonoscopies required for the diagnosis of rectal Dieulafoy's lesion was 1.5±0.7. In regard to treatment, endoscopic therapy was applied in 80%, direct surgical suturing in 12%, angiographic embolization in 4%, and endoscopic therapy followed by surgical ligation was performed in 4% of patients. The endoscopic treatment was a feasible choice for rectal disease, with a primary hemostasis rate of 88%. Although the overall mortality rate was 6%, the causes of death were unrelated to this entity. This review illustrates that patients with rectal Dieulafoy's lesion can have a favorable clinical outcome. Prompt diagnosis and appropriate management are of paramount importance to prevent serious hemodynamic complications. The best therapeutic modality remains to be determined but the data presented here support the use of mechanical endoscopic methods as safe and effective.
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Affiliation(s)
| | | | - Sidra Yahya
- Fatima Jinnah Medical University, Lahore, Pakistan
| | - Simcha Weissman
- Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | | | | | - Iqra Riaz
- Einstein Medical Center, Philadelphia, PA, USA
| | - Saad Saleem
- Mercy Saint Vincent Medical Center, Toledo, OH, USA
| | - Muhammad Wasif Saif
- The Feinstein Institute of Medical Research, Manhasset, NY, USA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Tarar ZI, Khan HA, Inayat F, Goraya MHN, Raza M, Ibrahim F, Akhtar Z, Malik A, Davis RM. Hemosuccus Pancreaticus: A Comprehensive Review of Presentation Patterns, Diagnostic Approaches, Therapeutic Strategies, and Clinical Outcomes. J Investig Med High Impact Case Rep 2022; 10:23247096211070388. [PMID: 35045737 PMCID: PMC8796068 DOI: 10.1177/23247096211070388] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hemosuccus pancreaticus is a rare but potentially torrential and life-threatening cause of acute upper gastrointestinal bleeding. It is described as an intermittent hemorrhage from the major duodenal papilla via the main pancreatic duct. Peripancreatic pseudoaneurysm following chronic pancreatitis is a common underlying etiology. However, gastroduodenal artery pseudoaneurysm-related hemosuccus pancreaticus remains exceedingly rare in the etiological spectrum of upper gastrointestinal bleeding. We hereby delineate a rare case of hemosuccus pancreaticus associated with gastroduodenal artery pseudoaneurysm in a patient who initially presented with abdominal pain and hematochezia. He was successfully managed with coil embolization without recurrence or sequelae. Furthermore, we conducted a search of the MEDLINE (PubMed and Ovid) database for relevant studies on hemosuccus pancreaticus published between inception and September 15, 2021. The available clinical evidence on causes, presentation patterns, diagnosis, and management was analyzed and summarized. This article highlights the rarity, the intermittent nature of hemorrhage, and the lack of a standardized diagnostic approach for this elusive disease. Clinicians should remain cognizant of hemosuccus pancreaticus, especially in patients presenting with symptoms and signs of intermittent gastrointestinal bleeding and abdominal pain. Prompt diagnosis carries paramount importance in saving patients from repeat hospital admissions and disease-associated morbidity and mortality. Conventional angiography with coil embolization may constitute an effective treatment strategy.
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Affiliation(s)
| | | | - Faisal Inayat
- Allama Iqbal Medical College, Lahore, Pakistan
- Faisal Inayat, MBBS, Allama Iqbal Medical College, Allama Shabbir Ahmad Usmani Road, Faisal Town, Lahore 54550, Punjab, Pakistan.
| | | | - Mohsin Raza
- Allama Iqbal Medical College, Lahore, Pakistan
| | | | | | - Adnan Malik
- Loyola University Medical Center, Maywood, IL, USA
| | - Ryan M. Davis
- University of Missouri School of Medicine, Columbia, MO, USA
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Liu L, Zhang L, Zhu X, Li M, Cao J, Ji L, Qi X, Xu W. Massive gastrointestinal haemorrhage caused by pancreatic pseudocyst complicated with Dieulafoy's disease in a child: A case report and review of the literature. Front Pediatr 2022; 10:962465. [PMID: 36160798 PMCID: PMC9493275 DOI: 10.3389/fped.2022.962465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/01/2022] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Pancreatic pseudocyst (PPC) with massive gastrointestinal bleeding is rare, especially in children. Inadvertent intraoperative examination and damage to the gastric mucosa and malformed blood vessels by the fluid content of PPC can lead to massive bleeding, which may endanger the patient's life. CASE PRESENTATION Here, we present a case of an 8-year-old boy who was diagnosed with a massive gastrointestinal haemorrhage caused by PPC complicated with Dieulafoy's disease. At his first admission, his complaint was being hit to the stomach by the handlebar while riding bicycle 24 h before admission. After being hospitalized, he was diagnosed with pancreatic injury by abdominal CT. Conservative treatment lasted for 1 month in the Department of Pediatric Surgery. Then, a pancreatic pseudocyst was formed. Under the guidance of ultrasonic endoscopy, cyst puncture and drainage of pseudocysts through the gastric wall were performed. Unexplained hematemesis occurred 8 days after surgery. Emergency gastroscopy was performed, and abnormal submucosal vascular haemorrhage was found at the gastric fundus. Gastric Dieulafoy's disease was diagnosed. The boy underwent gastroscopic titanium clipping of abnormal arteries. He had no complications during the 3-month follow-up. Then, the patient returned to the hospital, and the stent was removed under endoscopy. No bleeding was found, and the patient was discharged. The patient recovered smoothly and was followed up for half a year without any complications, and hematological indicators were normal. CONCLUSION Endoscopic ultrasonography-guided gastric puncture and internal drainage of cysts is a safe and effective surgical method for the treatment of pancreatic pseudocysts. However, at the same time, it is necessary to thoroughly and carefully explore the stomach cavity to prevent adverse consequences caused by a missed diagnosis of gastric Dieulafoy's disease or other abnormal abnormalities.
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Affiliation(s)
- Lintao Liu
- Department of Paediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lichao Zhang
- Department of Minimally Invasive Biliary Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoli Zhu
- Department of Paediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meng Li
- Department of Paediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Juan Cao
- Department of Paediatric Surgery, People Hospital of Xingtai, Xingtai, China
| | - Likang Ji
- Department of Paediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoyang Qi
- Department of Paediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Weili Xu
- Department of Paediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Singh R, Patel H, Patel BM, Kasmin FE. Severe Gastrointestinal Bleed Caused by a Rectal Dieulafoy Lesion. Cureus 2021; 13:e20672. [PMID: 35106215 PMCID: PMC8784918 DOI: 10.7759/cureus.20672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2021] [Indexed: 11/23/2022] Open
Abstract
Dieulafoy lesions are vessels that erode the overlying epithelium without the presence of an ulcer. When these lesions bleed, they can frequently be self-limited, but bleeding can be recurrent and prolonged. Although most commonly found in the lesser curvature of the proximal stomach, there are reports of these lesions in other gastrointestinal tract regions. This case identifies a Dieulafoy lesion found in the rectum, which was the source of this patient’s profuse rectal bleeding.
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9
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Perez Del Nogal G, Modi R, Salinas I, Chakrala K. Incidental massive lower gastrointestinal hemorrhage caused by a rectal Dieulafoy's lesion. BMJ Case Rep 2021; 14:e244264. [PMID: 34497057 PMCID: PMC8438715 DOI: 10.1136/bcr-2021-244264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 11/04/2022] Open
Abstract
A Dieulafoy's lesion is a rare cause of massive gastrointestinal (GI) bleeding. It represents an abnormally dilated submucosal artery that erodes the overlying epithelium in the absence of a primary ulcer. These lesions are usually located in the stomach, nevertheless, they have been found in all areas of the GI tract, including the oesophagus, duodenum and colon. Bleeding episodes are often self-limited, although bleeding can be recurrent and profuse. The case describes a 50-year-old woman who developed haemorrhagic shock secondary to a rectal Dieulafoy's lesion and discusses the diagnostic and therapeutic approaches.
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Affiliation(s)
- Genesis Perez Del Nogal
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Rangesh Modi
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Ivania Salinas
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Kalyan Chakrala
- Gastroenterology, Medical Center Hospital, Odessa, Texas, USA
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Malik A, Inayat F, Goraya MHN, Almas T, Ishtiaq R, Malik S, Tarar ZI. Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management. J Investig Med High Impact Case Rep 2021; 9:2324709620987703. [PMID: 33472441 PMCID: PMC7829607 DOI: 10.1177/2324709620987703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/10/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022] Open
Abstract
Jejunal Dieulafoy's lesion is an exceedingly rare but important cause of gastrointestinal bleeding. It frequently presents as a diagnostic and therapeutic conundrum due to the rare occurrence, intermittent bleeding symptoms often requiring prompt clinical action, variability in the detection and treatment methods, and the risk of rebleeding. We performed a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding jejunal Dieulafoy's lesio from inception till June 2020. A total of 136 cases were retrieved from 76 articles. The mean age was 55 ± 24 years, with 55% of cases reported in males. Patients commonly presented with melena (33%), obscure-overt gastrointestinal bleeding (29%), and hemodynamic compromise (20%). Hypertension (26%), prior gastrointestinal surgery (14%), and valvular heart disease (13%) were the major underlying disorders. Conventional endoscopy often failed but single- and double-balloon enteroscopy identified the lesion in 96% and 98% of patients, respectively. There was no consensus on the treatment. Endoscopic therapy was instituted in 64% of patients. Combination therapy (34%) with two or more endoscopic modalities, was the preferred approach. With regard to endoscopic monotherapy, hemoclipping (19%) and argon plasma coagulation (4%) were frequently employed procedures. Furthermore, direct surgical intervention in 32% and angiographic embolization was performed in 4% of patients. The rebleeding rate was 13.4%, with a mean follow-up duration of 17.6 ± 21.98 months. The overall mortality rate was 4.4%. Jejunal Dieulafoy's lesion is still difficult to diagnose and manage. Although the standard diagnostic and therapeutic modalities remain to be determined, device-assisted enteroscopy might yield promising outcomes.
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Affiliation(s)
- Adnan Malik
- Loyola University Medical Center,
Maywood, IL, USA
| | - Faisal Inayat
- Allama Iqbal Medical College, Lahore,
Punjab, Pakistan
| | | | - Talal Almas
- Royal College of Surgeons in Ireland,
Dublin, Ireland
| | | | - Sohira Malik
- Nishter Medical University, Multan,
Punjab, Pakistan
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Inayat F, Ali NS, Khan M, Munir A, Ullah W. Hemosuccus Pancreaticus: A Great Masquerader in Patients with Upper Gastrointestinal Bleeding. Cureus 2018; 10:e3785. [PMID: 30854272 PMCID: PMC6395018 DOI: 10.7759/cureus.3785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Hemosuccus pancreaticus is a rare but life-threatening cause of upper gastrointestinal bleeding through the main pancreatic duct. This clinical entity is a difficult diagnosis due to its rarity, intermittent nature of the hemorrhage, and peculiar clinical presentation. It is still considered a surgical problem but advances in medical therapy may enable clinically stable patients to undergo less-invasive angiographic embolization. We chronicle here a unique case of hemosuccus pancreaticus in a patient presenting with melena who could not be diagnosed on multiple standard forward-viewing esophagogastroduodenoscopies and computed tomography angiography. Eventually, side-viewing duodenoscope identified the intermittent bleeding through the ampulla of Vater. This paper illustrates that clinicians should be vigilant for this etiology, especially in patients with intermittent crescendo-decrescendo abdominal pain, acute gastrointestinal hemorrhage, and elevated serum lipase levels. A multidisciplinary team approach with the centralization of gastrointestinal bleed services and a well-established management protocol is of paramount importance to reduce the morbidity and mortality of this disorder. Additionally, this article serves to outline our current understanding of the epidemiology of and risk factors for hemosuccus pancreaticus, the pathophysiology of this disease, and currently available approaches to diagnosis and treatment.
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Affiliation(s)
- Faisal Inayat
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | | | - Maryam Khan
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Ahmed Munir
- Internal Medicine, Services Institute of Medical Sciences, Lahore, PAK
| | - Waqas Ullah
- Internal Medicine, Abington Jefferson Health, Abington, USA
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