Description: Background : this study was designed to validate and to compare accuracy of the prognostic scores; mainly Child Turcotte Pugh (CTP), creatinine-modified Child Turcotte Pugh (CTP-Cr), MELD, albumin bilirubin score (ALBI), and AIMS65, for the predicting clinical outcomes in cirrhotic Egyptian patients presenting with acute variceal bleeding (AVB). Methods : Retrospective single center study involving 725 patients presenting with AVB due to liver cirrhosis and HCV infection either alone or mixed with HBV infection. In hospital mortality prognostic scores were calculated; mainly CTP, modified CTP-Cr, MELD, ALBI, AIMS65. The endpoint is either patient improvement or death. Results : 725 patients were included over 1-year period. 547 (75%) survived and 178 (25%) died. Patients presented with hematemesis (515/71%), melena (120/16.5%) or hematemesis and melena (90/12.5%). Those with hematemesis for the first time were 241 (33%) and recurrent attacks were 484 (66.8%). The non-survivors had significantly more incidence of shock on presentation, more blood transfused units, history of NSAIDS intake, more ICU admission days and were more likely to be Childs C. Child, modified CTP-Cr, MELD, ALBI and ALMS65 scoring systems showed significant difference between survivors and non-survivors. Conclusion : Liver specific scores (Child, MELD) and gastrointestinal bleeding scoring systems (ALBI, AIMS65) are useful in predicting clinical outcomes of AVB in cirrhotic patients. CTP-Cr score had the highest prognostic capability of in hospital mortality. Presence of active bleeding at time of endoscopy, more complications, old age, shock and higher CPT-Cr score are additional independent predictors of in hospital mortality.

Description: Introduction : cesarean is one of the major surgeries after which mother will need to be hospitalized for a long period of time. One of the leading causes of the increase in the duration of hospitalization of such patients is the surgeons’ projections about the development of ileus and defecation. Given the previous studies, misoprostol can increase bowel movements. Moreover, gum-chewing has been recommended as a cheap and available technique for accelerating the resumption of normal Intestinal Movements. Methods and materials: the present study is a single-blind randomized clinical trial which has been done on 324 women over 18 years of age with singleton pregnancy who had visited Taleghani Hospital in Arak and was elective cesarean section candidates. The surgery and anesthesia techniques were similar for all patients. These patients were randomized into three groups of 108, namely control, misoprostol, and gum-chewing groups. The patients in these three groups were compared with one another in terms of normal bowel sound, gas passage, defecation and discharge. Results : the results have shown the mean age of a total of 324 patients has been 26.66 years. The results suggest that the time of hearing the first normal bowel sound, the first gas passage, and defecation have been shorter in the misoprostol group, gum-chewing group and control group, respectively. The difference observed between the three groups has been significant at a 0.05 significance level. Furthermore, no significant difference was observed between the patients in the misoprostol and gum-chewing groups and the patients in the control group while reviewing the time of discharge of these patients. Conclusion : the findings have been indicative of the positive effects of the misoprostol and gum-chewing techniques on the intestinal function of patients and mothers’ breastfeeding. Also, it has been observed that using misoprostol can be more effective than chewing gum.

Description: A 61-year-old Punjabi female patient presented with six months history of mild abdominal discomfort with bloody diarrhea. She did not have underlying chronic medical illness; she neither took steroid nor immunosuppressant. She was found anemic, thrombocytosis, and elevated C-reactive protein. Colonoscopy showed moderate left sided colitis, with histopathology evidence of ulcerative colitis (UC) with cytomegalovirus (CMV) infection. Her serum anti-CMV IgM antibody was detected. She was treated with intravenous ganciclovir, together with 5-ASA and tapering dose of steroid. Anemia was corrected. Subsequent clinic reviews and follow up endoscopies showed dramatically improvement. CMV colitis should be considered for the patients presenting with moderate to severe UC. Early prescription of antiviral would be beneficial in the treatment of flare of UC.

Description: Fistulating cholecystocutaneous abscess is a known rare complication of chronic gallstones disease. In these modern days, this complication is exceedingly rare due to early diagnosis with radiological imaging, use of broad spectrum antibiotics and early surgical management of biliary tract disease. Here we present a case of an 89-yearold with cholecystocutaneous abscess that was mistaken for simple subcutaneous abscess. The management include initial control of subcutaneous abscess and use of antibiotics followed by definitive surgical excision of gall bladder and the fistula tract.

Description: Hepatic hemangiomas are benign tumors of the liver which are often found incidentally. We present a 34-years-old man with a two-month history of upper abdominal pain and incidental finding of multiple hepatic masses. The patient sought medical attention at several healthcare facilities where he posed a diagnostic dilemma before he was referred to us. Computed tomographic scan revealed four hypodense hepatic nodules of varying sizes. The nodules demonstrated peripheral enhancement with progressive centripetal filling till they were totally filled during the delayed phase. Abdominal ultrasonography confirmed the four hepatic lesions. The largest lesion was in the left lobe measuring 73×72 mm while the smallest was in the right lobe (24×20 mm). All the masses demonstrated increased vascularity on color Doppler imaging. The paucity of reported cases of hepatic hemangioma in Nigeria, the multiplicity of the tumor and the giant size of one of them make this case remarkable and reportable.

Description: Large spontaneous portosystemic shunts in cirrhosis are implicated in recurrent and/or chronic persistent hepatic encephalopathy. In long standing cases, these shunts lead to portal vein thrombosis and hepatic dysfunction. Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique that is usually employed for shunt closure in the patients manifesting the features of chronic hepatic encephalopathy. There are several reports documenting systemic and portal vein thrombosis as a part of the procedure. We report first time a patient in whom the difficult and partial BRTO procedure led to the extensive thrombosis of the large splenorenal shunt itself without sclerosant instillation.

Description: Helicobacter pylori ( H. pylori ) can cause a wide variety of illnesses such as peptic ulcer disease, gastric adenocarcinoma and mucosa-associated lymphoid tissue (MALT) lymphoma. The diagnosis and eradication of H. pylori are crucial. The diagnosis of H . pylori is usually based on the rapid urease test (RUT) and gastric antral biopsy for histology. The aim of this study is to evaluate the numbers of needed biopsies and their location (antrum/fundus) to obtain optimal result for the diagnosis of H. pylori. Three hundred fifty consecutive patients were recruited, 210 fulfill the inclusion criteria and had nine gastric biopsies for the detection of H. pylori infection: two antral for the first RUT (RUT1), one antral and one fundic for the second (RUT2), one antral for the third (RUT3) and two antral with two fundic for histology (HES, Giemsa, PAS). The reading of the 3 types of RUT was performed at 1 hour, 3 hours and 24 hours and biopsies were read by two experienced pathologists not informed about the result of RUT. Results of RUT were considered positive if H. pylori was found on histology of at least one biopsy. The RUT1 at 1h, 3h and 24h has a sensitivity of 72%, 82% and 89% and a specificity of 100%, 99% and 87% respectively. The positive predictive value (PPV) was 100%, 99% and 85% respectively and the negative predictive value (NPV) of 81%, 87% and 90%. The RUT2 at 1h, 3h and 24h, respectively, had a sensitivity of 86%, 87% and 91% and a specificity of 99%, 97% and 90%. The PPV was 99%, 96% and 88% and NPV of 89%, 90%, 94%. The RUT3 at 1h, 3h and 24h, respectively, had a sensitivity of 70%, 74% and 84% and a specificity of 99%, 99% and 94%. The PPV was 99%, 99% and 92% and NPV of 79%, 81% and 87%. The best sensitivity and specificity were obtained for RUT1 read at 3h, for RUT2 read 1h and 3h, and the RUT3 read at 24h.This study demonstrates that the best sensitivity and specificity of rapid test for urease is obtained when fundic plus antral biopsy specimens are used with a reading time at 3 hours.

Description: Pancreaticopleural fistula is an extremely rare complication of chronic pancreatitis. Interestingly it may present without any symptoms of pancreatitis per se. The diagnosis requires a high index of suspicion due to the predominant thoracic symptoms. Cases with massive, rapidly refilling, refractory pleural effusion in the setting of pancreatitis (symptomatic or asymptomatic) should be suspected of having a pancreaticopleural fistula. We report two cases of pancreaticopleural fistula. One of the patient also had pancreatic divisum and to the best of our knowledge this is the first case report of pancreatic divisum with pancreaticopleural fistula in the literature.

Description: Mycobacterium tuberculosis can affect any organ of the body. Gastrointestinal tubercular involvement is fairly common. Esophageal tuberculosis though is uncommon. Esophageal tuberculosis accounts for only 0.3% of gastrointestinal tuberculosis. It presents with dysphagia, retrosternal pain, cough or constitutional symptoms. Complications like hemorrhage from the ulcer and development of fistulas like esophagomediastinal fistula is extremely uncommon. We report a case of a 27 years old female who presented with retrosternal pain, dysphagia and hematemesis. The patient had esophageal ulcer secondary to erosion of the esophagus by the subcarinal lymph nodes. Imaging was suggestive of esophagomediastinal fistula. Esophageal ulcer biopsy showed chronic tubercular infection. Culture from the esophageal biopsy confirmed the presence of tubercular bacilli. Patient responded to anti-tubercular therapy. Spontaneous dysphagia resolution prior to starting therapy was likely due to the rupture of the lymph node into the esophagus, which was compressing it initially. Esophageal tuberculosis presenting with hematemesis and fistula is extremely uncommon.

Description: In Lebanon, hepatitis C virus (HCV) prevalence is estimated to 0.2% among all ages, with genotype 1 the most common genotype. The age distribution shows 2 peaks reflecting 2 probable mode of transmission of HCV in Lebanon: 20-39 years and more than 40 years. The burden of HCV-related complications on the health system in Lebanon is expected to increase in the upcoming years. The number and prevalence per age group and the fibrosis stage of HCV infections is required to better estimate the burden of the disease in Lebanon. We calculated the prevalence per age group. Concerning fibrosis stage, patients recently diagnosed with HCV and never been treated previously were included and were divided into three groups according to their age Concerning the prevalence by age group, the lowest was seen in the group less than 20 years and the highest in the population aged more than 60. Concerning the fibrosis by age group, the majority of patients less than 40 years had low fibrosis stage, while in the group of more than 60 years F3 and F4 represent respectively 15.07% and 68.49%. Female gender had more significant fibrosis and cirrhosis than male gender. There is an exponential increase of significant fibrosis with age In Lebanon, the highest prevalence of hepatitis C is seen in the age group more than 60 years. In the 2 age groups (40-59 years and 〉60 years), we noted an advanced fibrosis stage and the majority of patient more than 60 years were cirrhotic at the time of diagnosis, which can reflect the burden of the disease in these groups.