Endoscopic retrograde cholangiopancreatography is an advanced investigation both diagnostically and therapeutically. It does need expertise and simultaneously a complete setup with the appropriate equipment, staff and radiological backup.1 The choice of the patients has to be spot on as the procedure does come up with complications like any other one including post-ERCP pancreatitis that can be bothersome to treat and challenging even for experienced gastroenterologists.2 The hospital stay is much longer sometimes with patients needing more scrutiny by the attending physician as resultant cholangitis is very troublesome and agonising for the patient needing antibiotics. 2The rising fever and increase in inflammatory markers take days to settle. . So prevention is better than cure in a sense that misery of both the patient and doctor can be avoided.  It’s a common observation that most young gastroenterologists are more inclined towards learning ERCP.3 This is very encouraging keeping in mind there is a deficiency of skills, especially in peripheries. The problem is that eagerness to learn such advanced procedures has kept them out of the loop and rather deviated them from the basics of gastroenterology and hepatology because they tend to forget the theoretical knowledge and core concepts which are inevitably essential prerequisites for an emerging expert.2 Most ERCPS is done after a detailed workup and as a follow-up the investigation after magnetic resonance pancreatography, (MRCP) which is a non-invasive investigation for finding the cause of deranged liver function and dilated common bile duct on ultrasound abdomen for gallstones.4 Its better not to rely on a single US abdomen report if the clinical picture is different. It’s more appropriate to repeat it and go for an ERCP if the situation demands .This all comes with experience after seeing so many patients presenting with different forms and manifestations. The biggest dilemma is that most of the specialists do ERCPs directly without doing non-invasive investigations and that is when the clinical judgement of a physician is compromised and there is an increased risk of complications such as pancreatitis and perforation. The overall risk of PEP risk is 9.7% which can rise to over 14.7% in high-risk patients especially those with sphincter of Oddi dysfunction and a previous history of pancreatitis.5 It’s a better and safer approach to weigh the benefits vs. complications. Merely complications and giving reasons aren’t enough. One needs to own them as well by managing on time and counselling the patients why did they happen in the first place as there is element of colossal trust between the patient and attending physician that need to be kept As gastroenterologists we struggle with simple interpretation of deranged liver function tests rarely making wrong diagnosis by going for fancy investigations acquired from the books. There is lack of thought and wisdom at same time resulting in wastage of time and resources. The thing which arouses our curiosity is therapeutics and interventional endoscopies all the time. That shouldn’t be the aim all the time though necessary for progression of our careers. There are so many other aspects of gastroenterology that we need to focus. EASL guidelines of management of hepatitis B and C are published quite frequently. 6Every year there is an update on other diseases as well such as Barret Esophagus and Gastroesophageal Reflux Disease.7 There are innovative articles reflecting the latest trends in gastroenterology published all the time. One needs to focus on reading them and acquire the basics of subject before advancing and applying them in real clinical scenarios. These scenarios are quite tricky when it comes to diagnosis and same is the case in post graduate exams with trainees failing them quite frequently .There has to be more emphasis on ward rounds and learning from scenarios in case based discussions. Simulation is a powerful learning method in medical education that can be used in clinical settings.8Similarly one has to observe the procedures,assist,perform under supervision and then doing them independently once your mentor is confident enough about the skills acquired over the period of time. There are many areas of our subject on which we need to focus ranging from acute hepatitis to hepatocellular carcinoma.9 What we need to realise is that ERCP and EUS are advanced aspects of gastroenterology but that isn’t the end of the journey or the road. The eyes can’t see what the mind doesn’t know. There needs to be greater emphasis on the basics of gastroenterology enabling us to diagnose the patients promptly and refer the right ones for endoscopy, colonoscopy, endoscopic ultrasound, fibro scan, liver biopsy and even ERCP.10 Learning skills in a state of art of facility is must but one has to have a solid theoretical knowledge and application of it into appropriate clinical situation requiring sound clinical reasoning, critical thinking and problem solving skill.11  There are no shortcuts to experience and no stop to learning as well. It’s worth learning in a good setup with compassionate seniors and letting the time teach you the best. Hard work is the key to success and learning can’t be overnight. One has to be devoted to a cause as that is always rewarded and people working strenuously and continuous are winners eventually .The important thing is patience which most of us lack. All excellent clinicians were not made in a single day. They too went through the process of learning just like us .Some of us learn faster than others which shouldn’t matter as slow and steady wins the race. No book or can teach you practical skills and vice versa.  The skills have to be learnt properly as today you are a trainee and in future a fully fledged supervisor training so many residents. There is always a ray of hope and lightening at the end of the tunnel. As long as there is a desire and eagerness to learn from others, it will bear fruits of learning in the long run. It’s wiser not to get disappointed on a single mistake in any procedure including ERCP as long you learn from that by analysing it carefully with an intention and a strong will not to repeat in future.

Fatty liver is nothing new when it comes to gastroenterology practice. In fact it is the most common finding on routine ultrasound scans while performing it for any other clinical indication. We do see a large number of patients having deranged liver function tests undergoing assessment by experienced physicians. Extensive workup is not futile and can add to the satisfaction of the doctor and patient concerned but sometimes it’s exhaustive. There has been a considerable advancement in management of NAFLD; it still remains physician’s worst nightmare especially when there is transformation to full blown cirrhosis and its devastating complications. Obesity, diabetes and hypertriglyceridemia are found inevitably with NAFLD forming metabolic syndrome do add fuel to the fire as far as treating such patients are concerned . They are integral parts of metabolic syndrome which itself can lead to disastrous complications. One of the most vital segments of NAFLD management is weight loss which doesn’t have to be vigorous rather a more steadfast approach with patience is needed. Convincing an obese patient for losing weight is a daunting task as his metabolic demands are entirely different from a normal weight or a thin lean individual. Distinction between Alcoholic Liver Disease and NALFD is not merely based on interpretation of liver function tests. The ALT and AST ratio does help but isn’t definitive. Many physicians do advise abstinence from alcohol as main treatment modality for alcoholic liver disease yet it becomes conspicuously difficult to manage them once the history of alcohol use is for decades. When nothing works, liver biopsy is a last resort showing classical pathological changes for both the diseases. That too requires experienced pathologist and sometime a second examination of the slide is needed as well. There is a need for multi-disciplinary approach for management NALFLD. There needs to be a close collaboration between hepatologist, dieticians and endocrinologists especially in case of metabolic syndrome. Non-alcoholic fatty liver disease (NAFLD) has quite high prevalence of about 25% in western countries. Patients at the greatest risk are those with obesity and type 2 diabetes mellitus. In 2019 the American Diabetes Association guidelines called, for the first time, for clinicians to screen for steato hepatitis and fibrosis all patients with type 2 diabetes and liver steatosis or abnormal plasma amino transferees. Merely screening isn’t enough. Rather more robust approach is required with target oriented results. The choice of treatment and sound clinical judgement will matter a lot. Weight loss in combination with antidiabetic drugs Iike pioglitazone have been found to reverse fibrosis and slow down the progression of disease. The role of vitamin E is also of paramount importance. The biggest dilemma is that patient with NALFD are symptomatic in the beginning with no clues whatsoever. Early diagnosis and treatment are the keys. It’s also mandatory for general physicians to refer the patients to gastroenterologists. NALFLD has raised a colossal uproar in the world over the last few years. Burnout NASH is another culprit that has raised alarms in the gastroenterology world. Being the 2nd most common cause of liver transplantation is a serious enough reason for all the medics in general and hepatologists to act vigilant and not be complacent about it.

The presence of benign esophageal diseases including gastroesophageal reflux disease, barrets esophagus,hiatal hernia and achalasia have been arousing the curiosity of young clinicians , scientists and researchers for decades and years to   follow.1 Dyspepsia is one of the most common symptoms experienced by the patients and witnessed by the doctors during routine clinical consultations. This does accompany regurgitation of food, bad taste in mouth early morning, chest pain and sometimes alarm symptoms including hematemesis, malena,  unintentional weight loss and dysphagia.That is the point where one has to rethink  and diagnosis treatment strategies and review patients accordingly.2           Barrett’s oesophagus is defined as ‘an oesophagus in which any portion of the normal squamous lining has been replaced by metaplastic columnar epithelium. Barrets esophagus is a benign condition with a potential to transform to oesophageal carcinoma.3 There is a long history gastroesopheal reflux disease symptoms. In our country  there is a trend of self medicating oneself before coming to any physician in the general practice who also treats the patients for years before referral to gastroenterologist who can think out of the box and do invasive investigations  like endoscopy, CT chest and non invasive one like barium swallow. Most of the people ponder over when is right moment for screening the patients for Barrets esophagus and Esophageal Cancer Screening. A lot depends on the biopsy report and its findings in terms of having low grade, indefinite for dysplasia and high grade dysplasia.4           Low grade dysplasia in terms of surveillance carries less significance in which the guidelines suggest the time interval can be enhanced to 2-3 years in case of permanent regression with proton pump inhibitors given for 8 weeks The high grade dysplasia is an alarm finding for any gastroenterologist requirement more aggressive screening and management as there is a 30-40% risk of oesophageal carcinoma.5 This will need discussion by multidisciplinary teams including gastroenterologists, oncologists and pathologists as well.5           There is usage of proton pump inhibitors for years by the patients that is itself a risk factor for complications such as atrophic gastritis, pernicious anaemia, osteoporosis and even cancer.6 The resistance of symptoms to standard and even high doses of proton pump inhibitors is an indication for endoscopy as well. The role of PPI in asymptomatic patients is not substantiated by enough evidence in the literature However, in clinical practice, most patients are advised long term PPI based on the premise that chronic acid exposure may contribute towards Barrett’s Esophagus.6 So the bottom line is that there should be no hesitation in expediting the referral of such patients for urgent gastroenterology consultation who may do subsequent endoscopy after thorough examination of the patients.                 American Gastroenterological Association  has strong recommendations for screening  for Barrett oesophagus in  patients older than 50 years with symptomatic GERD and at least one additional risk factor for oesophageal adenocarcinoma.7 Almost similar guidelines have been formulated by other reputed societies as well including British Society Of Gastroenterology. There is a phobia of endoscopies in general public and they are reluctant to do them. But once the indication is clear then the patient should be counselled thorough as in case of oesophageal cancer for which a Barrets Oesophagus is a risk factor, early diagnosis is the key as surgery is curative. Indeed it is and should be irresistible urge for gastroenterologists to screen such patients.7

Objective: To determine the frequency and in-hospital mortality of right ventricular myocardial infarction, in patients with inferior wall myocardial infarction. Methods: This was a descriptive case series, conducted at Cardiology Department, Rehman Medical institute during time duration 18th Feb 2017 to 18th Aug 2017. The study was conducted after approval was obtained from the hospital ethical review committee. Sample selection was done through a non-probability consecutive sampling technique. Patients were included in the study based on inclusion and exclusion criteria. A detailed history was taken followed by a complete physical examination and ECG was done. Demographic and outcome data were noted on a predesigned Performa. Results: The mean age (SD) of patients in this study was 68±11.05 years. 94 (60.64%) patients were male while 61 (39.35%) patients were female. Among patients 142 (91.61%) were smokers, 136 (87.74%) patients were hypertensive and 123 (79.35%) patients were diabetic. A total of 155 patients were hospitalized with the diagnosis of acute inferior STEMI. Of the total 155 in-patients, 56(36.1%) were having right ventricular infarction. In-hospital mortality was recorded in 39/155(25.16%) patients during hospitalization having right ventricular myocardial infarction with inferior wall myocardial infarction. Conclusion: This study concluded that Right Ventricular Infarction can occur in patients with Inferior Wall Myocardial Infarction with certain adverse in-hospital outcomes such as mortality. Keywords: Coronary Artery Disease (CAD), Right Ventricle Infarction (RVI).

ABSTRACT: OBJECTIVES: The aims of this study were to determine the frequency of undetected dysfunction of thyroid in patients with diabetes, determination of correlation between glycosylated Hb and thyroid hormones, and to find out the relationship between blood glucose control and function of thyroid in patients of type 2 diabetes mellitus in comparison to normal individuals. METHODOLOGY:This study was carried out at Department of Medicine, Hayatabad Medical Complex, Peshawar. It was a cross sectional study. A sample size of 358 subjects was taken using non-probability consecutive sampling in which 179 had type-2 diabetes and 179 were healthy normal subjects. Based on the results, they were classified into either hypothyroid or hyper thyroid categories, and then a comparison was done with HbA1c to determine their correlation. The data was analyzed by using SPSS version 23. RESULTS: The mean age of both the groups was 54.35 ± 9.38 years and 42.66 ± 9.20 years respectively on comparison of median (as data lacked normality) and mean ages of cases was much higher as while drawing comparison to control group with p-value less than 0.001. In these cases, the total number of male patients were 62 (34.64%) and females were 117 (65.36%) while in controls the males and females were 124 (69.27%) and 55 (30.73%) respectively. In these cases, the number of hypothyroid patients were 13 (7.3%), hyperthyroid individuals were 26 (14.5%) and 11(6.1%) cases had subclinical hyperthyroidism. Normal thyroid function was found in all controls. In these cases, a weak positive correlation was found between HBA1c and T3 (r=0.239, p-value 0.001). Also, there was an insignificant correlation with T4 (r= - 0.017, p-value = 0.817) and correlation of insignificant nature found with TSH (r= -0.036, p-value = 0.634). Among controls same (insignificant) correlation was found between Glycosylated Hb and T3 (r= 0.070 p-value = 0.352), a weak positive correlation with T4 (r= 0.238, p-value = 0.001) and a moderate negative relationship with thyroid stimulating hormone (r= - 0.586, p-value <0.001). CONCLUSION: Early detection of thyroid dysfunction in diabetic patients can prevent complications and leads to optimum control of blood glucose level.