Acute Upper Gastrointestinal Bleeding in a Tertiary Care Centre of Nepal

INTRODUCTION

AUGIB is characterized by hematemesis or melena or both. Peptic ulcers and variceal bleed account for majority of cases. Use of proton pump inhibitors in current era is associated with a gradual reduction in burden of peptic ulcer disease. We conducted this study to look into the cause of AUGIB in our community.

METHODS

We studied 100 patients in one year period who presented to us with hematemesis or melena. The study was conducted in department of Gastroenterology, Bir hospital, Kathmandu. We identified the culprit lesions by upper gastrointestinal endoscopy.

RESULTS

The average age of patients with AUGIB was 51.6 years with 59 (59%) males. Duodenal ulcers are most common 29 (29%), followed by varices 23 (23%) and gastric ulcers 14 (14%). More than one lesion was identified in 38 (38%) patients. Patients with variceal bleed were more likely to present with hematemesis alone as compared to those with ulcer bleed (P=0.005). Variceal bleed patients presented earlier to the hospital (P=0.005), had lower MAP at presentation (P=0.0002), had lower hemoglobin level (P=0.0001) and higher serum creatinine level at presentation (P=0.001). Patients with variceal bleed were more likely to have consumed alcohol 20 (86.9%) and patients with ulcer bleed were more likely to be smokers 29 (67.4%) or consume tobacco 14 (32.5%) (P=0.006).

CONCLUSIONS

Ulcer related bleeding is still the most common cause of AUGIB. Many patients with AUGIB have more than one lesions identified during upper gastrointestinal endoscopy.

Efficacy of Prophylactic use of Ciprofloxacin and Metronidazole in Mild and Moderately Severe Acute Pancreatitis

INTRODUCTION

There are new concepts and developments in the diagnosis and management of acute pancreatitis. Current evidence suggests that there is no role of prophylactic antibiotics use in acute pancreatitis. However, it is still a common practice to administer prophylactic antibiotics in a country like Nepal. So, we have conducted a study in mild and moderately severe acute pancreatitis to study the efficacy of prophylactic antibiotics.

METHODS

A case control study was conducted among 76 patients comparing efficacy of prophylactic antibiotics versus no antibiotics in patients with mild and moderately severe acute pancreatitis.

RESULTS

The two most common etiology of acute pancreatitis in AG and NAG were alcohol 21 (55.2%) vs. 24 (63.1%) and biliary 10 (26.3%) vs. 4 (10.5%) respectively. Pancreatic necrosis was seen in five (13.1 %) in AG and four (10.5%) in NAG. Four (10.5%) developed extra pancreatic complications in AG and five (13.1%) in NAG. There was one (2.6%) death in AG and no death in NAG. Abdominal pain improvement seen in AG vs. NAG was 3.2 days vs. 2.4 days (P=0.002). The hospital stay was 7.7±2.23 days in AG and 7.5±1.85 days in NAG (P=0.65).

CONCLUSIONS

The routine use of prophylactic antibiotics for mild and moderately severe acute pancreatitis is not associated with improvement in meaningful clinical outcomes.

Colorectal Cancer in Different Age Groups in a Tertiary Hospital in Nepal

INTRODUCTION

Some studies have suggested that colorectal cancer at a younger age had distinct biological characteristics: different clinical presentations, more advanced stage at time of diagnosis and poorly differentiated carcinoma. The aim of the study is to analyze clinical and histopathological differences between younger (≤40 years of age) and older (>40 years of age) colorectal cancer patients.

METHODS

A cross-sectional analysis was conducted amongst the colorectal cancer patients who visited Bir Hospital between July 2015 and April 2017. All colonoscopically diagnosed and histopathologically proven cases of colon cancer were included. Chi-square test and independent t - test was performed to analyze the difference between clinical presentations and histopathological findings among two groups of patients and P value of <0.05 was considered as significant.

RESULTS

Thirty younger patients and thirty older patients were enrolled without any differences in gender proportion. There were no statistical differences between clinical presentation and histological grade and type in younger and older patients. The younger patients had more complaints of altered bowel habit (P <0.001) while older patients mostly presented with per rectal bleeding (P< 0.008).

CONCLUSIONS

In this study, colorectal cancer at younger ages showed similar characteristics to those of older patients except altered bowel habit was more common in younger patients while per rectal bleeding was more common in older patients. Although colorectal cancer incidence increases with age, younger patients with altered bowel habits, weight loss, anemia and anorexia should also be given due medical attention and undergo evaluation promptly.

Why a Medical Career and What are Pros and Cons of medical profession?

  Introduction: Medicine is one of the noblest of all professions and is one of the rapidly expanding fields with increasing number of private medical colleges in the past few years. Several international studies over the years have explored perceptions and preferences of students in choosing a career in medicine. This study was done with the objective to assess students' views regarding selection of medicine as a career.   Methods: A survey study was conducted at Lumbini Medical College Teaching Hospital (LMCTH) where 300 students of both sexes were asked to fill a structured questionnaire.   Results: All medical students mentioned that they selected the medical profession because of personal interest. Of them, 285 (95%) students believed this profession offers services to humanity. However, 240 (80%) students felt that their family had an influence in their career selection. Among discouraging factors, 234 (78%) students mentioned that medical training is difficult and prolonged, 210 (70%) students said that the course is too expensive, 225 (75%) students felt that there is too much competition while 186 (62%) students expressed that doctors have excessive working hours and lack social life. Major factors in choosing LMCTH as study destination were compulsion because of failure to enroll at other colleges 180(60%), easy access to admission 120 (40%), cheaper than other medical colleges 165 (55%) and location near to hometown 24 (8%). Some of the discouraging factors were limited facilities 210 (70%), insufficient faculty members 270 (90%), newly established college and uncertain future 90 (30%).   Conclusion: Study concluded that reasons for joining medical profession are primarily based on personal interest, respect and honor, family influence and service to humanity; however, long working hours, prolonged training, expensive study, discourages many students.

Upper Gastrointestinal Endoscopy in Lumbini Medical College and Teaching Hospital

  Introduction: Upper gastrointestinal (UGI) endoscopy includes visualization of the oropharynx, esophagus, stomach, and proximal duodenum, with real time assessment and interpretation of the findings encountered. An upper endoscopy is indicated in the diagnostic evaluation of signs and symptoms of a wide variety of gastrointestinal disorders. Besides there are some therapeutic implication of the endoscopy. This study was conducted to study the spectrum of diseases found during the upper gastrointestinal endoscopy in patient presenting in Lumbini Medical College and Teaching Hospital (LMCTH).   Methods: This was a retrospective observational study carried out in LMCTH. The endoscopic record book of the patients who underwent UGI endoscopy for various reasons from February 2011 to 2013 was analysed. The risk factor of smoking and alcohol was also included and analysed in the study.   Results: All together 550 upper GI endoscopy was performed in the two years. There were 290 males (52.72%) and females were 260 (47.38%). The mean age was 45.7 years (SD=17.9). Most of the patient belonged to the age group 41 to 80 years (71%). Among total patients, 209 (38%) of them were found to be macroscopically normal. Of those who had positive endoscopic findings; 165 (48.4%) had gastritis and 36 (10.6%) had duodenal ulcer, esophageal varices was in 30 (8.8%), gastric carcinoma in nine (2.6%) of cases. Cigarette smoking was significantly associated with the presence of peptic ulcer disease (p=0.01) and malignancy of gastrointestinal tract (p=0.03). Alcohol intake was non-significantly related to peptic ulceration (p=0.07) and malignancy of gastrointestinal tract (p=0.09).   Conclusion: Upper gastrointestinal endoscopy is a safe and useful procedure for investigating patients with gastrointestinal complains. Gastritis was the most common finding among the patients who had abnormal endoscopy followed by duodenal ulcer and esophageal varices.

Characteristics of Patients with Tuberculous Pleural Effusion in Rural Nepal

  Introduction: Tuberculosis (TB) is a major cause of mortality and morbidity in developing countries. TubercularPleural effusion is the second most common form of extra pulmonary tuberculosis (EPTB), superseded in Prevalence only by lymph node tuberculosis. Pleural effusion occurs in approximately 5% of patients with TB. The purpose of this study was to assess the demographic characteristics of patients presenting with pleural effusion in rural Nepal.   Methods: A retrospective study was conducted with all the cases diagnosed and admitted with pleural effusion at Lumbini Medical College And Teaching Hospital from April 2011 to March 2013 of all the cases diagnosed andadmitted with pleural effusion were included in the study. Hundred cases diagnosed with pleural effusion by clinical Examination or chest X-ray or ultrasonography’s (USG) of the chest were included in the studied. The following parameters patients demographic profile, causes of pleural effusion, location (unilateral/bilateral), hemoglobin and complete blood count, sputum stain and culture sensitivity, Monteux test, chest X-ray and USG findings and Pleural fluid analysis (biochemical, hematological, microbiological and cytological) were analyzed by using SPSS 21.   Results: Out of 100 cases, the cause of pleural effusion in 59 patients was tuberculosis, 14 by malignancy, next 14 by Para pneumonic Effusion, 12 by congestive cardiac failure and three cases by alcoholic liver disease. Patients with tuberculous pleural effusion were younger, predominantly males, had unilateral effusion, lower blood hemoglobin, lower Pleural fluid neutrophils, higher pleural fluid Adenosine Deaminase (ADA) levels and higher level of pleural fluid to serum protein ratio as compared to the patients with non-tuberculous effusion.   Conclusion: Tuberculosis is the most common cause of pleural effusion in patients of rural Nepal.