Signet ring adenocarcinoma of urinary bladder is a rare condition. Most cases reported in literature are primary and only one case of metastatic signet ring carcinoma has been reported. [1] This tumor has poor response to chemotherapy and radiotherapy, and is associated with dismal prognosis. [2] Here, we report a case of primary duodenal signet cell adenocarcinoma metastasizing to urinary bladder which is exceptionally rare and only one case is previously reported in literature. [3]

INTRODUCTION: It has been postulated that the vasoconstriction at the level of renal arcuate artery plays a key role in the development of Hepatorenal syndrome(HRS). However, the measure of renal resistive index at the level of renal arcuate artery can provide a direct measure of renal hemodynamics among cirrhotics. The aim of this study is to determine the difference in the renal resistive index amongst both compensated as well as decompensated cirrhotics and to evaluate its association with natriuresis. METHODS: This prospective study included all consecutive cirrhotic patients visited gastroenterology clinic of our hospital from May 2018 to May 2019. After obtaining informed consent, the demographic parameters were noted along with a detailed drug history (Dose and duration of diuretics and beta blocker). Later on an ultrasound abdomen was also performed for documenting the features of chronic liver disease and the renal resistive index was noted. These patients were then stratified into two groups i.e. compensated cirrhosis and decompensated cirrhosis. Chi square test was applied and P value was calculated. RESULTS: A total of 60 patients were included in the study. The mean age of the patients was 40.3 ± 18.1, and were predominantly males 31(51.7%). Hepatitis C was the most common etiology for liver disease seen in 22 patients (36.7%).The mean CTP score, MELD and MELD sodium score were as follows: 7.9 ± 1.93, 15.2 ± 6.6 and 13.3 ± 4.2 respectively. Compensated liver disease was present in 16(26.7%) patients, while decompensated liver disease was present in 44(73.3%) patients. Mean renal resistive index of patient with compensated cirrhosis was 0.59 ± 0.04, while with decompensated cirrhosis was 0.62 ± 0.04. Patients with a higher RI had poor natriuresis as manifested by low urinary sodium potassium ratio < 1.0 and AROC is 0.775. At the cut off value of RI = 0.615 sensitivity, specificity, positive predictive value and negative predictive value for nartriuresis was 65.0%, 70.0%, 73.3% and 60.1% respectively. Patient with higher RI value were having decompensated cirrhosis (P = 0.06, 0.62 vs 0.59) CONCLUSION: The renal resistive index at the level of arcuate artery were found to be higher among patients with decompensated cirrhosis. At a higher RI value ( >0.615) patients had poor natriuresis. Therefore, RI can be used to predictor of natriuresis among cirrhotic patients. Key words:

INTRODUCTION: Prediction of EV by the measurement of splenic stiffness (SS) by Transient elastography (TE) in cirrhotic patients has been recently proposed. Splenomegaly and splenic stiffness in cirrhosis can be explained by enlargement and hyper activation of the splenic lymphoid tissue, increased angiogenesis, fibrogenesis and passive congestion due to portal hypertension. Thus, the aim of this study is to assess diagnostic accuracy of spleen stiffness as a predictor for the presence of esophageal varices in liver cirrhosis using EGD as gold standard. Spleen stiffness measurement is non-invasive technique as compared to EGD so this test can be used to stratify the liver cirrhotic patient who need screening EGD compared those who do not need it. METHODS: Patients were enrolled from June 2018 to May 2019, all patient with cirrhosis undergoing screening EGD were offered to participate in the study. After fulfilling the inclusion criteria, a blood sample for platelet count, INR, CTP and MELD score was taken. Splenic stiffness was measured by fibroscan by expert radiologist prior to undergoing screening EGD. Exclusion criteria was followed strictly to avoid confounding variables. All information along including age, gender, spleen stiffness, presence or absence of EV were entered in the Performa. RESULTS: Total of 97 patients were included in the study, mean age of patients was 41.1 ± 15.1, predominantly were males 61(62.9%), while 55 (56.7%) belonged to urban areas of province. Common etiologies for cirrhosis includes HCV 49(50.5%) followed by HBV 16(16.5%), HBV and HDV coinfection 10(10.3%), autoimmune hepatitis 7(7.2%) and others were 8 (8.2%). Most patients belonged to CTP class A 58(59.8%), Mean MELD score were 11.7 ± 5.5. Mean platelets and albumin of patients were 128 ± 86.3 and 3.3 ± 0.7. Total 25 (25.7%) had ascites and 55 (56.7%) had esophageal varices on screening EGD and 6(6.2%) patient had fundal varix. Student t-test showed a significant association of low platelets (P = 0.0001, 118.3 vs 57.5) and high splenic stiffness (P = 0.0001, 37.9 vs 23.0) with the presence of esophageal varices. Area under ROC was calculated for APRI, FIB-4 and splenic stiffness was 0.81, 0.79 and 0.93 respectively. CONCLUSION: Splenic stiffness can more reliably predict the presence of esophageal varices as compare to other noninvasive test like APRI and FIB-4. So it can be used to stratify the patient who needs screening EGD and minimize the false negative results.

Background: To determine long-term outcome in Crohn’s disease patients hospitalized for acute abdominal pain. Methods: Retrospective chart review of consecutive Crohn’s disease patients hospitalized for acute abdominal pain at the tertiary referral centre. Results: Between 2015 and 2020, 65 patients (35M, 30F, mean 42 years) were hospitalized because of acute abdominal pain. 83% of patients had ileocolic disease and 39% of patients presented with complicated (stricturing or penetrating) disease. 32 patients (49%) had been hospitalized previously and 14% had undergone intestinal resections in the past. Acute clinical signs other than abdominal pain were: vomiting (35%), fever (45%), abdominal distension (38%), diarrhoea (52%). Leukocytosis was noted in 52% of patients, elevated C-reactive protein level in 83% of patients and severe anemia in 18% of patients. Mean follow-up time was 43 months. During the follow-up period, 14 patients (21%) underwent surgery – 6 during the same hospitalization and 8 later. The hospital readmission rate was 40%. Two patients died. Complicated disease was associated both with hospital readmission (Hazard ratio 3.9, p=0.05) and need for surgery (HR 10.3, p=0.002). Also, history of previous hospitalizations was associated with an increased readmission rate (HR 6.8, p=0.012). Conclusion: Ileocolic disease is the main cause of hospitalization for acute abdominal pain. Complicated (structuring or penetrating) disease should be diagnosed early and surveilled closely.

Introduction: Numerous obesity indices have been developed that predict non-alcoholic fatty liver disease (NAFLD). We in our study aimed at evaluating a few of these tools including waist to height ratio (WHtR), waist circumferences (WC), body mass index (BMI) and fatty liver index (FLI) and used them to determine their ability in diagnosing NAFLD. Methods: This cross sectional study was conducted at the outpatients’ department of our hospital. NAFLD was diagnosed on the basis of ultrasound abdomen. Anthropometric parameters like Height (in), weight(cm), WC (cm), BMI, WHtR were calculated and later the FLI (comprising of BMI,WC, triglyceride and gamma glutamyl transferase) was calculated. The Receiver operating characteristic analysis (ROC) was then conducted to determine the discriminatory ability and related cut-off points and a P value of ≤0.05 was taken as statiscally significant. Results: A total of 300 participants were included and the prevalence of NAFLD was 44.8% in men and 54.8% in women. Univariate analysis reported statistical significant association of NAFLD with all of the applied indices (P = 0.00). The WHtR (AUC = 0.87, 95% CI:0.77-0.97) showed slight superior ability as compared to FLI (AUC = 0.86, 95% CI:0.76-0.97) in diagnosing NAFLD. Regression analysis revealed a stronger association of WHtR (OR = 9.3, P = 0.00) with NAFLD compared to FLI (OR = 6.0, P = 0.02). The performance of WHtR was similar regardless of gender (AUC = 0.89) while different in FLI with a AUC of 0.88 in men and AUC of 0.85 in female. Conclusion: This study showed a strong association of WHtR in prediction of NAFLD and a similar discriminatory ability regardless of gender. WHtR is simple and easily performable modality for NAFLD prediction.