Knowledge the participants have gained should bring a change in their practice-Wasim Jafri

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 WGO Workshop on Update on Gastrointestinal and Liver Disorders

Knowledge the participants have gained should
bring a change in their practice - Wasim Jafri

KARACHI: World Gastroenterology Organization, Karachi Training Center organized a workshop on Update on Gastrointestinal and Liver Disorders here on May 2, 2015. Prof. Sadick Memon from Hyderabad was the first speaker who presented a case of Non Cardiac Chest Pain (NCCP). His patient was a 29 years old who complained of chest pain. GERD, he said, is the major cause of NCCP in which only quality of life is impaired while in cardiac chest pain immediate intervention is required. The prevalence of NCCP is about 23%. He then discussed the mechanism of esophageal pain. Non cardiac chest pain, he said usually lasts for more than five minute. History, physical examination, chest X-ray, echocardiography are helpful in diagnosis. It can be classified as erosion, strictures etc. GERD patients can be treated by PPI and it helps since it has a sensitivity of over 87%. There is limited role for endoscopy in NCCP and it is indicated only in alarming situations.  Best therapy remains PPI once a day and they are also safe in pregnant patients if indicated.  GERD can also result due to calcium channel blockers, he added.

Dr. Javed Yakoob spoke about H.Pylori and GI disease. His patient was a sixty years old business man who presented with weight loss, vomiting, anaemia. This could be due to gastric ulcer, gastric carcinoma. H. pylori, he said has a high incidence of false positive hence it is not a good test in such patients.  This patient was treated with a combination of clarithromycin, amoxicillin and PPI for H.Pylori .eradication.

Dr. Nazish Butt discussed malabsorption syndrome and celiac disease. Her patient was a twenty five years old unmarried female who presented with history of weight loss, amenorrhea and diarrhoea. Diarrhoea, she stated is defined as more than three loose stools per day.  This was a case of malabsorption syndrome.  The patient had serology test and upper GI endoscopy and histopathology tests. Speaking about celiac disease she said it is chronic inflammatory disease affecting small intestine and its prevalence is about 1% in general population. Celiac disease patients might present with recurrent oral ulcers and dermatitis herpetiformis is also quite common in such patients. Celiac disease can be diagnosed with upper GI endoscopy while upper duodenal biopsy is the confirmatory test. Treatment for this is gluten free diet to be taken for life long. She laid emphasis that diagnosis must be confirmed before starting treatment and consultation with a dietician is a must. These patient suffer from nutritional deficiencies hence must be put on Vitamin B12, Folic Acid and other minerals. Refractory celiac disease, she said, was a diagnosis of exclusion.

Dr.Amna Subhan’s presentation was on parasitic infection and TB. Her patient was an eighteen years old male who had frequent episodes of soft stools. He had no history of fever, abdominal examination showed mild tenderness. This was diagnosed to be a case of giardiasis. About  5-15% of these patients have asymptomatic symptoms. The causative factors are unhygienic conditions, lack of sanitation, junk food and IDPs are also at higher risk. Diagnosis is by stool examination. Cost effective treatment consists of duodenal biopsy, Metronidazole, albendazole, tinidazole and other such preparations. Her other case was of a fifty years old lady doctor who had history of loose stools and abdominal pain. She then talked about differential diagnosis of IBD and pointed out that parasitic infection with TB is very common in tropical countries like Pakistan.

Dr. Lubna Kamani spoke about Irritable Bowel Syndrome and role of probiotics.  Her patient was a forty years old male. Digital rectal examination, it was stated, is important in such patients to make diagnosis. IBS was the most likely diagnosis which is a chronic relapsing syndrome. Due to cultural constraints in countries like Pakistan, one cannot say with certainty whether it was more prevalent in male or female since male have more access to healthcare facilities. Prof. Wasim Jafri remarked that that is why we wish to have more female gastroenterologists.

Dr. Qamar ul Arfin presented a case, 45 years old male who reported with bleeding per rectum, weight loss. It could be due to hemorrhoids which can be erosive, polyps or there could be some malignancy. There are four grades of hemorrhoids. Patients on conservative treatment should be advised to take lot of fiber. Diverticular disease, he said, is a common cause of lower GI malignancy which is seen 60-80% of patients in right colon.  He also talked about ulcerative colitis, crohn’s disease as well as colorectal cancer. Summing up the session, Prof. Badar Fayaz Zuberi said that IBS is seen in almost 30% of patients who come to GI clinics, they often have no relief, no improvement and they are always concerned about their health. They need proper counseling.

Prof. Baddar Fayaz Zuberi presented a case of Autoimmune Hepatitis (AIH) and also discussed its classification. Livery biopsy he opined was the most important test which should be done. AIH may overlap with PBC. Treatment is with prednisone and Azathioprime. Cirrhosis develops in 40% of the cases who require steroids. Without steroids, prognosis is very poor. AIH, he opined, is difficult to diagnose and one needs expert specialist to diagnose such cases. AIH responds well to steroids and Azathioprime and the treatment is required for many years.

Dr. Zaigham Abbas’s presentation was on NAFLD-NASH. His patient was a forty five years old housewife who complained of mild fatigue. Her BP was 150/90 and had no peripheral edema.  A survey of 928 patients showed that 142 were suffering from fatty liver on ultrasound. Insulin resistance is the most important problem in these patients as well as in Type 2 diabetics. Obesity is another serious issue in such cases. Investigations include ultrasound, CT, MRI and fibroscan if available but one must be careful of false reading. They have decrease in steatosis and fibrosis. Treatment is with diet, exercise, medications. Many preparations are used for weight reduction some of which have no scientific proof. Counseling, he said, was important for change in life style. Even 7-10% reduction in body weight will reduce inflammation of liver. Weight reduction medications do not have a much role. Bariatric surgery results are encouraging. Metformin is also being used. Statins are used to treat fibrosis. No single drug is effective and management of these patients requires multidisciplinary team approach. He also referred to the efficacy of pioglitazone in such cases.  NASH patients eventually progress to fibrosis of liver, he remarked.

Dr. Rustam Khan talked about HAV and HEV. The case he presented was a twenty four years old lady who presented with nausea, vomiting and yellowish eyes suggestive of Hepatitis A which is a self limiting disease. It has 28 days incubation period. In some cases it can also lead to liver failure and death as well. Preventive measures include good hygiene and hand wash after going to the toilets. First dose of vaccine has 95-97% positivity. Hepatitis E has 25% mortality in pregnant ladies if not treated in time. There is no specific treatment for Hepatitis E and in pregnant ladies symptomatic treatment is recommended.

Prof. Saeed Hamid discussed chronic viral hepatitis-B and said that chronic hepatitis is when the case scenario goes beyond six months. Asymptomatic HBV carriers should be followed up carefully as HBV can lead to liver cancer. His patient presented after one year again with jaundice, weight loss with acute chronic liver failure because of reactivation of HBV. The chronic carriers can live from thirty to fifty years, chronic hepatitis leads to cirrhosis, liver cancer and then death. He was of the view that all such patients should be referred to the specialists who will undertake all the required investigations before initiating appropriate treatment. Nucleoside analogues monotherapy is quite effective.

Prof. Wasim Jafary the chief organizer of this workshop was the last speaker who discussed HCV with cirrhosis and decompensating. The case he presented was a forty three years old female who presented with distension of abdomen. He was put on diuretics by the GP and had mild improvement in her symptoms. She had sleepless nights and also complained of altered mental status. She was married nineteen years ago and had three children all through C-section and had multiple blood transfusions. She had all the proper investigations. This patient was immune to Hepatitis B perhaps because of immunization. It is important to manage ascites and encephalopathy.  Hepatitis C leads to cirrhosis, Hepatocellular carcinoma and then death. HCV prevalence, Prof. Wasim Jafri stated is increasing all over the world. There are over thirty million people suffering from Hepatitis C in South Asia and in Pakistan the prevalence of this infection is found to be 6.5% and Genotype 3 is most common in Pakistan. Almost 60% of liver cancer is due to HCV. In Pakistan the prevalence of HCV is much higher in Punjab. It is a blood born disease, hence safe handling of disposables, sharp edge syringes is important. Availability of Savoldi an oral treatment at a very nominal cost as compared to the price in USA is no less than a blessing. Now we have effective drugs available to treat these patients who should be engaged in care. This patient was treated, was stable and without any diuretic therapy. Concluding the session Prof.Jasem Jafri said that the participants must have gained some knowledge from today’s presentations hence, now it must   bring change in their practice, he remarked.

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