Centre for Liver and Digestive Diseases Holy Family Hospital, Rawalpindi


 An Introduction

Centre for Liver and Digestive Diseases
Holy Family Hospital, Rawalpindi

By Shaukat Ali Jawaid

RAWALPINDI: Centre for Liver and Digestive Diseases (CLD) is a jewel in the crown of Holy Family Hospital Rawalpindi which is one of the affiliated teaching hospitals of Rawalpindi Medical College which has now been upgraded to a Medial University. It is equipped with state of the art equipment and instruments and provides specialized diagnostic and therapeutic services to the patients besides having a busy postgraduate training programme training MD and FCPS in Gastroenterology. Credit for establishing this state of the art facility goes to Prof. Muhammad Umar the present Vice Chancellor of the Rawalpindi Medical University.  It also shows that if there is a will and determination, even individuals can do miracles and this center is a testimony to this fact. A visit to this center recently was a fascinating experience.

The neat and clean environment shows this to be an Island in a public healthcare facility which has been properly maintained and sustained all these years through public private partnership. Patients visiting the center get free treatment and the running cost is born 60% by the Government while the remaining 40% is arranged through donations.

A view of the Centre for Liver Diseases at Holy Family Hospital, Rawalpindi

Mission statement of the Center says that “it will provide diagnostic and curative services to patients suffering from Gastrointestinal and Liver diseases particularly Hepatopancreatobiliary Diseases and Hepatocellular Carcinoma. It will also impart training to the GI Fellows and specialists in the field of Gastroenterology and Hepatology. It will establish Clinical Research in the field of Gastroenterology and Hepatology besides developing a Network with National and International centers and Societies of GI and Liver Diseases.”

It all started in 1985 when Prof. Umar and his wife Dr. Hamma-tul-Bushra Khaar did FCPS in General Medicine and wanted to do specialized training.  At that time there was no specialty of Gastroenterology and Hepatology in Rawalpindi Region. He along with his wife visited different centers  like Cornels University Hospital in New York, First Tiangin Hospital in China, Kings College University Hospital in UK, North West University Hospital in Chicago, USA, Massachausat General Hospital Boston USA and then decided to establish Centre for Liver and Digestive diseases at Holy Family Hospital Rawalpindi.

The Centre is located in a new building in Holy Family Hospital with a covered area of over ten thousand Sq. ft. The three story building is well planned and utilized. It has two sections, the old one is on First Floor while the newer section is at Ground Floor. The old section has two endoscopy rooms, a disinfection room, recovery room, liver biopsy room, record room and the projection room. This was established in 2008 with a donation of Rs. 6 million. Construction of the new section started in 2009 and the building was completed in 2011 at a cost of Rs. 30 Million while the Punjab Government also approved a grant of Rs.  160 Million for equipment. This new section comprises of three follow up clinics, Hepatocellular Carcinoma Clinic, The Hepatopancreato Biliary Clinic and the Liver Transplant Evaluation Clinic, library, recovery bay, one ERCP Room which has been named as David Carr –Locke ERCP Room in recognition of his services to this Centre and he has visited it four times so far conducting various training courses. There is on endoscopic ultrasound room, one Radio Frequency Ablation Room, Learning Resource Centre, Reference Library, and Projection Room.

The Centre provides services six days a week and about eighty common endoscopic procedures and about twenty advanced endoscopy procedures like EUS, ERCP, and APC are performed every week. HCC clinic is a busy clinic for follow up. The Centre provides services to other hospitals in the city like Benazir Bhutto Hospital, PIMS, KRL Hospital, DHQ Hospital, and Railways Hospital. Patients also come from Khyber PK, Azad Jammu and Kashmir. Major contribution to the construction and interior designing of the Centre, it is sad, was by two graduates of Rawalpindi Medical College Dr. Nadeem Afraz and Dr. Shahid Hameed who are known as Rawalians.

Group photograph of Fellows and Faculty of Centre for Liver Diseases at Holy Family Hospital, Rawalpindi
photographed with Prof. M. Umar who helped establish this Center and who is currently
Vice Chancellor of Rawalpindi Medical University.

Names of the visiting faculty from Pakistan and overseas are prominently displayed at the Centre.

Facilities Available

At present this Centre provides the following services all free of cost:

  1. Endoscopic Retrograde Cholangiopancreatography (ERCP)
  2. Endoscopic Ultrasound (EUS)
  3. Radiofrequency Ablation (RFA)
  4. Transcathetere Arterial Chemoembolization (TACE)
  5. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
  6. Argon Plasma Coagulation (APC)
  7. Variceal Band Ligation
  8. Gastric Glue Injection
  9. Endo Loop
  10. Polypectomy
  11. Endoscopic Mucosal Resection (EMR)
  12. Endoscopic Cyst Drainage
  13. Esophageal & Duodenal Stenting
  14. Percutaneous Endoscopic Gastrectomy (PEG)

In every room detailed SOPs on use of instruments, equipment are prominently displayed. The Centre has twenty five beds for diagnostic purposes while fifteen beds are for therapeutic procedures. The staff consists of five gastroenterologists, Sixteen Trainees, eight support staff, twelve nurses. EUS room is named as Umar and Bushra EUS room. Prof. Hamama-tul –Bushra Khaar wife of Prof. Umar who retired about two years ago is still working at the Centre daily to ensure provision of services and its efficient running.

The Centre has strict monitoring in place and every staff member bas to sigh out while going home. Every procedure performed is recorded and the quality of picture is superb due to the quality of equipment and instruments being used. When asked about the future development Prof. Umar disclosed that they have already submitted a PC-I Form for a 40-Bed separate unit. During my visit to the Centre, I also had a chance to visit the RFA Unit, Endoscopic Skills Labs where I was told over ten thousand procedures have been performed so far.

Training Programme

Giving details of the training programme for postgraduates, Prof. Muhammad Umar said that though the Centre was established in 2008 but it was recognized by the CPSP for Fellowship training in Gastroenterology in 2014. In the meantime it was also recognized for MD Gastroenterology programme by the University of Health Sciences Lahore. The training is a five tier programme. First the postgraduates read from the books which have specially been arranged. Then in the second tier they have to see the Videos of various procedures. Then they get training in the Skills Laboratory. In the fourth stage they learn basic endoscopy and in the final stage they learn advance endoscopy. Having completed all this successfully only then they are allowed to touch the patients. Apart from Prof. Muhammad Umar, Prof. Hamama-tul-Bushra Khaar and other fellows at the Centre i.e. Dr. Arslan Shahzad, Dr.Tayyaba Ali, Dr. Jahangir Khan, Dr.Arshad Saleem Shahani, Dr.Tayyab Saeed Akhter, Dr. Zahid Mahmood Minhas and Dr. Jawad Zaheer, the visiting faculty includes Gen Tassawar Hussain, Brig. Amjad Salamat, Prof. Anwaar A. Khan and Prof Waseem Uddin. Visiting Faculty from overseas  include Dr. David Carre Locke from USA, Dr.Khalid Hassan from USA, Dr. Asif Abbas Naqvi from UK and Dr. Ali Siddiqui from USA.

Multi Organ Failure Centre looks after patients suffering from kidney, liver and lungs. It provides all the services except liver transplant. Patients are provided Pre transplant and Post-transplant services. Prof. Umar pointed out that so far we have performed over two thousand ERCPs. As regards EUs, this is the only facility in the northern part. This endoscopic ultrasound facility is available only at Aga Khan University Hospital in Karachi, at Shaukat Khanum Hospital and here. RFA is very useful procedure if the tumour size is less then 3cm. At this stage complete cure is possible with RFA but is not helpful if the tumour size is more than 3cm.

Satellite Liver Transplant Centre

Prof. Umar also disclosed that since Government of Punjab is building a state of the art Pakistan Kidney and Liver Institute at Lahore, we have requested the provincial government to establish a Satellite Liver Transplant Centre in Rawalpindi near the Institute of Urology on Murree Road.  A plot of land measuring forty acres is available for such a center there.

Asked about the training courses organized by the Centre, Prof. Umar said that we organize five national and two international courses every year.  All these courses have been recorded which a unique learning treasure is for the postgraduates. Trainees come from KPK, AJK and Gilgit Baltistan as well to attend these courses, he added. These training courses are recognized  and endorsed by American College of Gastroenterology, American Society of Gastroenterology and World Endoscopy Organization which itself speak about the quality of these courses.

Since 1998, this Centre has been organizing various CME programmes, Training courses and Hands on Workshops. The CME programmes were organized on Liver symposium, ERCP, GI Endoscopy, RFA for HCC hands on training. Training courses covered Basic Skills and GI Endoscopy,  RFA, Advanced EUS and ERCP Course( 2013), Advanced EUS Course (2014),Workshop on Colonoscopy (2015) Colonoscopy Hands on Workshop(2015), Advanced Workshop  on EUS and ERCP  (2016) International Workshop on Advanced EUS and ERCP & Transplant Hepatology (2016). The Centre has an ASSGE Video Library for the Trainees.  MD programme in Gastroenterology and Hepatology started at Holy Family Hospital in 2008. It is recognized by UHS Lahore. Training programme is four years after FCPS in General Medicine. The programme component incudes Radiology, Pathology and Endoscopy procedures. The programme is monitored with a Log Book. Fellowship Programme in Gastroenterology is as per the guidelines laid down by the Colelge of Physicians &n Surgeons Pakistan.

Endoscopies performed in 2001 were just 334 which increased to 2466 in 2015 though the number was 3762 in 2013. The Upper GI bleed managed in 2001 were just ninety which increased to 516 in 2015. In 2015 the total number of sigmoidoscopy were 144 which included 95 male and 49 female. Total ERCP done in 2015 were 375 which included 234 Female and 141 Male. Obstructive jaundice was the major indication for ERCP which accounted for 131 patients followed by Pain abdomen suspected biliary origin which accounted for one hundred two patients. The Centre has also published a  book containing the details of  CME, Workshops, Training courses, procedures performed and the complications encountered from 2012-2016. It covers audit of Endoscopy (2015), Colonoscopy Audit (2015) ERCP Audit (2015 and 2016) EUS Audit (2015 & 2016) HCC Audit (2015) Fibro scan Audit (2015).

During 2015 and 2016 a total of 661 ERCP procedures were performed, EUS procedures performed during 2015 and 2016 were 198, Number of patients suffering from HCC managed during 2015 were 66 which included 23 Male and 43 Female patients. The Centre is doing lot of research work and has contributed a great deal of literature in Gastroenterology and Hepatology. From 1989 to 2016 it has published one hundred twenty five papers in national journals and fourteen in international journals and their details appear in this booklet.

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