Background: Sedation during complex endoscopic procedures is important for comfort and safety of patient and ensures smooth and efficient completion of the procedure. This article evaluates safety of nonanesthesiologist-administered propofol (NAAP) sedation during endoscopic ultrasound. Materials and methods: Patients undergoing endoscopic ultrasound (EUS) with propofol sedation at Center for Liver and Digestive diseases (CLD), Holy Family Hospital, Rawalpindi, Pakistan were included. The primary outcome variable was the frequency of any sedation-related complication. Results: One hundred and ten patients fulfilling the inclusion criteria were enrolled in the study. Sixty (54.5%) patients were male and 50 (45.5%) were females. The mean age of study patients was 49 ± 18 years. The mean propofol dose was 203 ± 119 mg. There were 41% (n = 45) in ASA class I, 40% (n = 44) in ASA class II and 19% (n = 21) in ASA class III. The most common endosonographic finding was mediastinal and/ or abdominal lymphadenopathy (30.9%, n = 34) followed by a pancreatic mass in 21.8% (n = 24) patients, and a space occupying lesion (SOL) in liver in 15.5% (n = 16) patients. There were three cases with gallbladder mass (2.7%), two cases with CBD mass (1.8%), three cases (2.7%) with esophageal growth and 10 (9.1%) cases with gastric masses. Most of the patients, i.e. 98.2% (n = 108) had no sedation-related complication. Only 1.8% (n = 2) patients developed sedation-related minor complications who only required bag mask ventilation and subsequently recovered without any sequel. Conclusion: NAAP for endoscopic sedation is safe in patients undergoing EUS.

Background/Aim: Different endoscopic modalities are available for the extraction of common bile duct (CBD) stones. However, there is no clear consensus on the better therapeutic approach. Aim of the study was to analyze the effectiveness of endoscopic retrograde cholangiopancreatogram (ERCP) and endoscopic sphincterotomy (ES) and the role of ‘interim’ plastic biliary stent deployment in difficult pigmented CBD stones. Materials and methods: One hundred and sixty-three patients with CBD stone who underwent ERCP and ES between May 2006 and August 2010 were included in the study. Patients with incomplete clearance of stone underwent an ‘interim’ 10 cm 7 Fr size plastic stent. Approximately 3 weeks later, stone removal was attempted. Results: ERCP and ES with stone clearance were successful in 114 (69.9%) patients. The mean size of the stone was 1.5 cm (p < 0.0001). In 21.5% patients in whom ERCP and ES was not successful, stone retrieval was possible after plastic stent deployment after a median of 24 days. The median number and size of stones per patient was significantly reduced after biliary stenting compared with before [5 (3) vs 2 (1) (p < 0.0001)], [2.8 (1.5) vs 2 (1) (p < 0.001)], respectively. Conclusion: Plastic biliary stenting for difficult common bile stones becoming decrease in stone sizes. Unlike cholesterol stones, stent placement of 3 weeks was related with large and/or multiple stones becoming decrease in size and/or disappearing without unplanned events in pigment stones.

Objectives: Jaundice in pregnancy carries with it a high mortality rate. In this study, we examined the characteristics of women on survival of women with hepatitis E due to the stress of labor in terms of multiorgan failure after delivery. Design: A retrospective study of hospital records was done on women of hepatitis E from December 2010 to August 2011 at Civil Hospital, Ahmedabad, India. The women were divided into two groups: expired and survived. Results: Fatality rate during the epidemic months (March/ during nonepidemic months (June to February). The overall mortality rate of fulminant hepatic failure was 94%. The mean duration of jaundice, levels of bilirubin, serum glutamic pyruvic transaminase (SGPT), and prothrombin time (PT) were ! altered creatinine and PT [International Normalized Ratio (INR) >1.5] had a high mortality rate of 88 and 76%, respectively. All those who were conscious at the time of delivery (no hepatic encephalopathy) survived while those who were unconscious expired after delivery. All those who were intubated died. Conclusion: Hepatitis E is endemic in India and is an important indirect cause of maternal mortality. Study of the expired group helps understand the critical levels of liver function tests. This can help in appropriate counselling of patients and their relatives regarding the prognosis. Although delivery does not have any effect on survival, blood loss, infection and raised intracranial tension can cause liver hypoxia and worsen the disease state.

Background: Hepatitis B virus (HBV) infections remain as a major health problem. It has been estimated that about 370 million people are chronically infected worldwide. Chronic infection also increases the risk of liver diseases such as cirrhosis and hepatocellular carcinoma. Current antiviral therapies fail to control viral replication in the long term. Viral persistence has cellular immunity. The limitations of the current available therapies underline the need for alternative therapies. The development of a HBV therapeutic vaccine still remains as a feasible option of treatment despite several drawbacks. Recently, approaches like adoptive T-cell therapy have been evaluated. Materials and methods: The adoptive transfer was done intraperitoneally using Balb/c mice as donors and HBsAg- IgG response and biochemical parameters was evaluated in transgenic mice sera by ELISA. The histopathological analysis of the main organs was carried out. Results and discussion: In the present work we demonstrated ! cause histopathological damage. The potent immune response transferred was developed in non-Tg Balb/c mice after multiple simultaneous intranasal and subcutaneous immunizations with NASVAC, a novel HBV therapeutic vaccine candidate. The results indicated that the transference of immunity is safe and also capable of transiently reducing the HBsAg concentration in the sera of transgenic mice. These data support the safety of the therapeutic vaccination using NASVAC and also are in line with the usefulness of the T-cell therapy for chronic hepatitis B.

Background: Recently some noninvasive tests have been studied for determining the activity of disease in ulcerative colitis.

Aim: The aim of this study is to determine the added predictive ability of mean platelet volume (MPV) and red cell distribution activity of ulcerative colitis patients.

Materials and methods: Sixty-eight patients with ulcerative colitis were enrolled in this cross-sectional study. For all subjects white blood cell (WBC) count, platelet (PLT) count, RDW and MPV tests were performed. Serum high sensitivity C-reactive protein (hs-CRP) and proinflammatory cytokine; interleukin-12 (IL-12) levels were also measured. Disease activity was determined by endoscopic and clinical activity index (Powell-Tuck).

Results: There was an inverse significant association between MPV and clinical and endoscopic activity scores (p < 0.01). The levels of hs-CRP well correlated with disease activity (p = 0.01) while serum levels of IL-12 demonstrated no correlation with disease activity. Group markers including RDW, MPV, PLT counts added the predictive ability of disease activity about 20.6%. From these markers, RDW considered as an independent predictor of disease activity.

Conclusion: Our results suggest that easily available and inexpensive ability of inflammatory markers such as RDW, MPV and PLT may improve the predictive ability of inflammatory markers in disease activity of patients with ulcerative colitis.

Background: Cancer antigen-125 (CA-125) is a high molecular weight glycoprotein used as a marker for ovarian carcinoma. But its involvement is also observed in many benign conditions particularly in liver cirrhosis and ascites. However, the reason behind it remains unclear. Materials and methods: A total of 53 patients with liver cirrhosis, Budd-Chiari syndrome and tuberculous peritonitis were enrolled in this study. The degree of ascites was graded to into mild, moderate and severe. CA-125 levels of all the patients were measured along with other liver parameters. Results: No association was observed between CA-125 levels of liver cirrhosis patients and parameters of liver function tests. All the patients with ascites had elevated level of CA-125, whereas most of the patients without ascites had CA-125 levels under the normal range. However, the levels of CA-125 were without ascites (p < 0.05). Conclusion: The elevation of CA-125 in liver cirrhosis may be related to ascites and not dependent on parameters of liver dysfunction. Therefore, CA-125 may be used as a predictor of ascites in patients with liver cirrhosis.

Introduction: Hepatitis C virus (HCV) is the leading cause for liver transplantation (LT) and viral recurrence. Objective: Whether HCV recurrence occurs earlier and severer for living donor liver transplantation (LDLT) than for deceased donor liver transplantation (DDLT). Design: We evaluated preoperative and postoperative clinical, laboratory, and histological outcomes of 180 patients with LT (65 DDLT and 115 LDLT) since 1998 till 2006. Patients diagnosed for recurrence histologically were treated by combination therapy of pegylated interferon (IFN) and ribavirin (RBV). Results: DDLT. The mean preoperative (p = 0.012) and postoperative !\"# $ % & &'*+ group than LDLT group. At onset of recurrence, laboratory - / 33 4 Histologically, 59.57 and 41.89% patients with DDLT and LDLT, < / / < > $ ? & &@+ E 4 / < $ G & &J+ - / - was higher in DDLT group. Conclusion: HCV recurrence rates and severity of reinfection - > - 4 3 < / / / < LDLT significantly increase the risk and severity of HCV recurrence than DDLT.

Background: Insulin resistance and diabetes mellitus have been detected in patients with chronic liver diseases (CLD); however, there is paucity of information regarding these comorbidities in liver disease patients of Bangladesh. Materials and methods: Thirty patients with hepatitis B virus (HBV)-related CLD and 30 patients with hepatitis C virus (HCV)- related CLD were checked for existence of insulin resistance and diabetes mellitus. Results: The mean fasting serum glucose in HBV-related CLD and in HCV-related CLD were 4.37 ± 0.58 and 4.6 ± 0.59 mmol/l, respectively (p = 0.781). The levels of fasting serum insulin levels HCV-related CLD (p = 0.013). The cutoff value of HOMA-IR was 1.73. The mean HOMA-IR of HBV- and HCV-related CLD were 1.35 ± 0.44 and 1.89 ± 0.71 respectively (p = 0.001). Conclusion: It seems that insulin resistance is prevalent among HCV-related CLD patients in Bangladesh. This pilot study indicates that insulin resistance and diabetes mellitus should be checked in all patients of HCV-related CLD during their management.

Background: Further development and implementation of methods for early noninvasive diagnosis for prognosis and treatment efficiency in patients with chronic hepatitis and development of effective methods of conservative therapy is an important problem of modern hepatology.

Objective: To identify the correlation of proinflammatory cytokines [tumor necrosis factor alpha (TNF- ) and interleukin-6 (IL-6)] with the results of 13C-methacetin breath test (13C-MBT) (CVH), nonalcoholic steatohepatitis (NASH) and alcoholic hepatitis (AH).

Materials and methods: A total of 147 patients with chronic hepatitis and 25 healthy controls were studied. Patients were divided into three groups: I (group CVH): 50 patients with CVH B and C; II (group NASH): 49 patients with NASH; III (group AH): 48 patients with AH. TNF-  and IL-6 was determined by ELISA.
Liver biopsy was performed in 46 patients,13C-MBT in 57 patients.

A good knowledge about the incidence and types of variations is of fundamental importance to the surgeries in the biliary region. Ignorance of these anomalies can be of serious consequences to the patient in case of both the new laparoscopic procedures as well as old open surgeries performed in this region and any surgeon should be fully aware of the great number of problems in this region as far as the variation from normal these variations can be passed on to the surgical trainees who in this potentially dangerous region. The importance of these anomalies is further enhanced by the fact that in modern day surgeries like bile duct resection, hepatic duct resection or liver transplantation requires serious recognition to the normal and abnormal.

Amyand’s hernia is the presence of vermiform appendix in the inguinal hernia sac. Amyand’s hernia is rare, occurring in about 1% of inguinal hernias. We report a case of 22 years male patient with right congenital inguinoscrotal, complete, reducible hernia. He underwent elective transherniotomy, appendicectomy and hernioplasty with an uneventful postoperative recovery.

In the present days of industrialization, use of compressed air jets is common. Although industries provide employment to population at large, the misuse of pneumatic equipment at work place has relatively increased. We report a case of a male patient aged 20 years who presented to us with anal bleed, pain and distension of abdomen and severe breathlessness following for sexual stimulation. He was investigated and underwent emergency exploratory laparotomy with total colectomy of the gangrenous colon and end ileostomy. Postoperatively, the patient succumbed to a cardiac event.

Internal hernia involving the sigmoid mesocolon is extremely rare cause of intestinal obstruction. It is associated with early development of strangulation and gangrene. Therefore, high suspicion is necessary in the evaluation of such cases in order to prevent the related high morbidity and mortality. We present a case of an internal hernia occurring through a congenital defect in sigmoid mesocolon leading to strangulation of small bowel.