Aim: Definition of the type of appendicitis is based on examination of the peritoneum and appendix. Gomes et al. proposed a laparoscopic grading system of acute appendicitis (grades 1 and 2, noncomplicated appendicitis, grade 3–5 complicated appendicitis). The aim of this study was to evaluate the reproducibility of this score. Patients and methods: All patients managed for acute appendicitis between January 2016 and June 2016 were included in this single-center prospective study. Laparoscopic appendectomy procedures were filmed by analogy to Sugerbaker's peritoneal carcinomatosis score (9 quadrants, all of the abdomen was filmed). The videos were then analyzed by seven staff surgeons blinded to each other and the operative report. The primary endpoint was to determine the concordance between staff surgeons for grading of appendicitis using the laparoscopic grading system of acute appendicitis described by Gomes et al. Results: A total of 40 patients were included in this study. A concordance was observed between the seven staff surgeons in 85% of cases. For regional peritonitis, the mean ± (SD) number of quadrants in which the staff surgeons reported signs of peritonitis was 1.44 ± 0.63. For diffuse peritonitis, the mean (SD) number of quadrants in which the staff surgeons reported signs of peritonitis was 2.59 ± 0.51. On ROC curve analysis, two quadrants was the best cut-off between grade 4B (local peritonitis) and five (diffuse peritonitis) acute appendicitis (AUC = 0.92, Se = 100%, Sp = 92%, p = 0.005). Conclusion: The classification used to determine the type of appendicitis is reproducible. Clinical significance: To give a definition of complicated appendicitis.

Background: Laparoscopic cholecystectomy is the gold standard procedure for cholelithiasis. Pneumoperitoneum is created using carbon dioxide (CO₂), which is usually maintained at a range of 12–14 mm Hg. An emerging trend has been the use of low-pressure pneumoperitoneum in the range of 7–10 mm Hg in an attempt to lower the impact of pneumoperitoneum on the human physiology while providing adequate working space. Our study proposes to compare the effects of low-pressure pneumoperitoneum with the use of standard pressure of pneumoperitoneum. Aims and objective: To compare and analyze various factors like blood pressure, heart rate, end-tidal CO₂ and postoperative shoulder tip pain in cases undergoing laparoscopic cholecystectomy using standard pressure versus low pressure. Materials and methods: This is a prospective randomized study carried out at Santosh Medical College and Hospitals, Ghaziabad from September 2017 to December 2018. This study included 60 patients of cholelithiasis which were divided into two groups of 30 patients each. Group I was offered laparoscopic cholecystectomy under standard pressure pneumoperitoneum and group II underwent laparoscopic cholecystectomy using low-pressure pneumoperitoneum. Patients in each group were evaluated for various intraoperative physiological changes and post-operative shoulder tip pain. Observations and results: Cholelithiasis is commonly seen in middle-aged females. There is no significant difference in duration of surgery between the two groups. However, various factors like systolic blood pressure, heart rate, end-tidal CO₂ were significantly better in the low-pressure group. Postoperative shoulder tip pain (measured by VAS scoring system) was significantly less in the low-pressure group during the first 24 hours. Conclusion: Laparoscopic cholecystectomy under low-pressure pneumoperitoneum causes minimal physiological changes and less post-operative shoulder tip pain.

Aim: Prevalence of obesity and type 2 diabetes mellitus (T2DM), both of which represent are related to nonalcoholic fatty liver disease (NAFLD), is an increasing trend among Asian people. The study aimed to assess the prevalence of NAFLD in T2DM with their risk factors in the Southern part of Pakistan. Materials and methods: A cross-sectional study was accomplished during 2008–2013 at The Aga Khan University Hospital, Karachi, Pakistan. Adult patients diagnosed with T2DM during last 6 months were enrolled in this study. NAFLD was identified using ultrasound of the liver. Clinical and biochemical relevant measurements were accomplished. Results: Out of a total of 203 patients with T2DM, NAFLD was detected in 146 patients (71.9%). Multivariate analysis revealed that NAFLD was significantly associated with dyslipidemia (OR 2.38, 95% CI 1.06–5.34, p = 0.035), higher LDL (OR 1.02, 95%CI 1.01–1.03, p = 0.003), HbA1c (OR1.27, 95% CI 0.97–1.68, p = 0.045) and diastolic blood pressure (OR 1.05, 95% CI 1.01–1.10, p = 0.009). The highest odds of 10.8 for NAFLD (95% CI 4.9–24, p = 0.001) was found for the combination of hypertension, dyslipidemia, body mass index (BMI), waist circumference, lack of physical inactivity, triglycerides, lower HDL, LDL, HbA1c, and ALT (multiplicative analysis). Conclusion: High incidence of NAFLD with the association of different lifestyle-related factors has been analyzed. It unmasks the need for screening for NAFLD in newly diagnosed DM patients in Pakistan with the assessment of parameters of risk factors.

Introduction: Gallstone disease is one of the most common surgical diseases. Complications associated with cholelithiasis is not uncommon, but gallbladder perforation is a rare complication of acute cholecystitis with cholelithiasis. This gallbladder perforation may present in different ways like free perforation inside peritoneal cavity causing generalized peritonitis, localized collection around gallbladder fossa after perforation and in chronic cases cholecystoenteric fistula. Here we present our experience of this condition with a review of literature for a different presentation of this condition. Materials and methods: This study was done for 2 years, and patients who were diagnosed with gallbladder perforation either preoperatively or intraoperatively were included. Results: There was a total of 16 patient included in the study during this period which were either diagnosed preoperatively or intraoperatively of gallbladder perforation (GBP). Conclusion: GBP, though a rare complication of cholecystitis with high morbidity and mortality, has no specific pathognomic feature and is often misdiagnosed or late diagnosed. Nowadays most cases can be managed with improved diagnostic means and therapeutic modalities (endoscopic, laparoscopic, endostaplers).

Diabetes mellitus (DM) are common in Bangladesh, and this country is also well-known for frequent outbreaks of acute viral hepatitis (AVH). The study presented here was designed for the clinical courses of acute hepatitis with and without DM. A total of 300 patients with AVH were enrolled into two groups; group A; patients of AVH with DM (N = 140) and group B; patients with AVH without DM (N = 160). There was no significant difference regarding age, sex, and levels of alanine aminotransferase (ALT) between the two groups. The main cause of AVH was hepatitis E virus (HEV) in 100 and 112 patients of groups A and B, respectively. Jaundice persisted for more than 6 months in 68 of 140 (49%) patients of group A, whereas, this was found in only 11 of 160 patients of group B. Forty-two patients of group A showed evidence of esophageal varices; however, the endoscopic assessment did not reveal any abnormality in patients with group B. Moderate to several hepatic fibrosis was seen in 19 of 140 patients with group A, however, these were not detected in any patient of group B (patient with AVH without DM). Even more important is the fact that four patients of group A died of liver failure, whereas there was no mortality in any patient of group B. The study presented here indicates that all patients with DM with superimposed AVH should be carefully followed up with the possibility of development of severe liver diseases and even mortality.

Introduction: We investigated association of pro-BNP, troponin-I, electrocardiography (ECG) and echocardiography (ECHO) during diagnosis and identification of cirrhotic cardiomyopathy in cirrhotic patients. Materials and methods: Patients were divided into three groups as; compensated cirrhotic patients (group 1, n= 30), decompensated cirrhotic (group 2, n = 30) and control group (group 3, n = 30). ECHO, and ECG were performed, and troponin-I and levels of pro-BNP were analyzed. Results: Average age of group 1 was 46.36 ± 16 years (range 19–86), 60% were female; group 2 was 57.03 ± 13.54 years (range 22–89), 56% female; and group 3 was 49.13 ± 0.95 years (range 18–80), 56% female. A significant increase in QTc was detected in compensated cirrhotic patients compared to the control group (p <0.05). Pro-BNP levels were significantly higher (p <0.05) in the compensated cirrhotic group compared to the control group. The levels of pro-BNP were also significantly higher in the decompensated cirrhotic group compared compensated cirrhosis group and control group (p <0.001). Conclusion: The increase of pro-BNP levels with severity of the disease in cirrhotic patients and the prolongation of QTc interval supports an association between these factors with cardiomyopathy.

Amongst the primary tumors of the liver, hepatocellular carcinoma (HCC) is the most common. It is also one of the most prevalent types of cancers in Asia. Mostly, HCC occurs on a background of chronic liver disease and liver cirrhosis; however, de novo HCCs can also arise in apparently normal looking livers on imaging. There are multiple risk factors for HCC, including hepatitis B and C infections, diabetes mellitus, alcohol, and nonalcoholic steatohepatitis. Other common risk factors which are known to be involved in the pathogenesis of HCC are obesity, food contaminated with aflatoxin and hemochromatosis. Many of these factors are commonly found in this part of the world, hence the high burden of disease. Besides these, smoking and familial predisposition to HCC also seem to have an important role to play in its development. Majority of HCC are missed at an early stage despite the emphasis on adequate screening and surveillance strategies. Therefore, most of the time these tumors are diagnosed at a fairly advanced stage, when palliative treatment is the only therapeutic option left. Hence, prevention of HCC by controlling and minimizing the possible risk factors is the need of the hour.

Liver transplantation (LT) is an evolving area of medicine for the treatment of certain types of malignancies and acute and chronic liver failures. Since the topic is evolving, new literature is increasingly available. In recent years, with the emerging potent antiviral therapies, hepatitis C virus-infected patients have successful patient and graft survival outcomes. Even human immunodeficiency virus (HIV) positive patients previously contraindicated for organ transplantation are transplanted with comparable outcomes. With increasing demand for LT, the shortage of the donor pool became the rate limiting factor in this hopeful treatment. To overcome waitlist mortality and expand the donor pool, scoring systems have been modified and organs from HIV and/or hepatitis C infected donors are now accepted, under certain circumstances. The new literature also questions the 6-month alcohol abstinence rule for the transplantation of alcoholic liver disease (ALD), in light of early transplantation results from severe alcoholic hepatitis (SAH) trials.

Introduction: Gallbladder polyps (GBPs) are generally harmless, but the planning of diagnosis and treatment of the GBP is of clinical importance due to the high mortality risk of delays in the diagnosis of gallbladder carcinomas that show polypoid development. Materials and methods: GBPs are usually incidentally detected during ultrasonographic (USG) examinations of the abdomen. The risk of carcinoma development from polypoid lesions in the literature is reported as 0–27%. There is no consensus about the management of the GBPs. Herein, we reviewed the contemporary data to update our knowledge about diagnosis and treatment of gallbladder polyps. Results: Polyps can be identified in five different groups, primarily as neoplastic and non-neoplastic. Cholesterol polyps account for 60% of all cases. The most common (25%) benign polypoid lesions after cholesterol polyps are adenomyomas. Conclusion: Ultrasonography and endoscopic ultrasonography seems to be the most important tool in differential diagnosis and treatment. Ultrasonography should be repeated in every 3–12 months in cases that are thought to be risky. Nowadays, the most common treatment approach is to perform cholecystectomy in patients with polyps larger than 10 mm in diameter. Radical cholecystectomy and/or segmental liver resections should be planned in cases of malignancy.

Drug-induced liver injury (DILI) is an important cause of morbidity and mortality. DILI can even cause acute liver failure and the need for liver transplantation. Identifying DILI may be particularly difficult because it is actually an exclusion diagnosis and individuals are usually exposed to several drugs during a lifetime. Causality assessment methods are needed for objective diagnosis. The most common methods are; updated Roussel Uclaf causality assessment method (RUCAM), Narenjo adverse drug reaction probability scale and Maria and Victorino (M&V) causality assessment scale. Phenprobamate is a widely used muscle relaxant. Herein we report a rare case of repeated DILI caused by phenprobamate and review the objective diagnostic process for hepatotoxicities. Physicians should be aware of the potential adverse effects of this drug, including hepatotoxicity.

Two female siblings aged 87 and 90 years were clinically diagnosed as pancreatic cancer by abdominal ultrasonography and abdominal contrast-enhanced CT. Pancreatic cancer of these patients was confirmed during the autopsy. Both patients shared risk factors of pancreatic cancer; old age, diabetes, and passive smoking. Strong family history of pancreatic cancer was found in these two patients as their father and younger brother were also suffering from this cancer. The present study seems to report two eldest cases of familial pancreatic cancer in siblings.