Background. Hyperinsulinemic hypoglycemia with neuroglycopenia is a rare complication of Roux-en-Y gastric bypass (RYGB). We hypothesized that continuous glucose monitoring (CGM) would be useful to characterize glycemic variability after RYGB. Methods. CGM and mixed meal tolerance testing (MMTT) were performed on sixteen post-RYGB subjects, ten with a history of neuroglycopenia on medical treatment and six asymptomatic controls. Results. 9 of 10 subjects with neuroglycopenia developed hypoglycemia defined by glucose <70 mg/dL on CGM, and 3 of 9 on MMTT. In asymptomatic subjects, 3 of 6 had asymptomatic hypoglycemia during CGM, and 3 of 5 on MMTT. Therefore, the sensitivity and specificity to detect clinically significant hypoglycemia was 90% and 50% for CGM and 33% and 40% for MMTT. Conclusions. Asymptomatic hypoglycemia after RYGB is more frequent than commonly recognized. For clinicians evaluating patients for postbypass neuroglycopenia, CGM may be a valuable diagnostic tool.

Aims Patients with type 2 diabetes (T2DM) and chronic kidney disease (CKD) have impaired endothelial function. Vitamin D and its analogs may play a role in regulation of endothelial function and inflammation. We studied effects of paricalcitol compared to placebo on endothelial function and markers of inflammation and oxidative stress in patients with T2DM and CKD. Methods A double blind, randomized, placebo-controlled trial was conducted in 60 patients with T2DM and stage 3 or 4 CKD. Paricalcitol 1 mcg or placebo was administered orally once daily for three months. Brachial artery flow mediated dilatation (FMD), nitroglycerine mediated dilation (NMD), and plasma concentrations of inflammatory cytokines, tumor necrosis factor –α and interleukin-6, highly-sensitive C-reactive protein; endothelial surface proteins, intercellular adhesion molecule –1 and monocyte chemo attractant protein-1, and plasma glucose, insulin, free fatty acids, and urinary isoprostane were measured at baseline and end of three months. Results 27 patients in the paricalcitol group and 28 patients in the control group completed the study, though analysis of FMD at both time points was possible in 23 patients in each group. There was no significant difference in the change in FMD, NMD or the biomarkers examined after paricalcitol or placebo treatment. Conclusions Treatment with paricalcitol at this dose and duration did not affect brachial artery FMD or biomarkers of inflammation and oxidative stress. The lack of significance may be due to the fact that the study patients had advanced CKD and that effects of paricalcitol are not additive to the effects of glycemic, lipid and anti-hypertensive therapies.

Objective: To determine the association of dupA, iceA, homB genes of Helicobacter pylori with gastro-duodenal diseases such as gastritis, peptic ulcer disease PUD and gastric cancer. Materials and Methods: This cross-sectional analytical study was conducted at Gastroenterology Department, Shaikh Zayed Hospital Lahore. Patients with gastro-duodenal diseases and positive H. pylori were included. Gastric biopsies were taken from fundus, body and antrum. H. pylori DNA were removed utilizing Gentra DNA extraction Kit (Life Technologies, USA) as per the technique and Qualitative PCR for the recognition of H. Pylori DNA. The PCR primers sets were designed for the specific detection of dupA, iceA and homB genes of H. pylori. All the data was recorded in proforma and analyzed by SPSS version 20. Results: Mean age of the cases was 41.22+8.04 years. Males were more affected 118(60.2%). HomB was the most common 76(38.8%) followed by dupA and iceA 28.6% and 24.5% respectively. Peptic ulcer disease and gastritis were higher among patients having dup A and iceA positive strains as compared to homB gene patients, while gastric cancer was significantly higher among HomB gene infected patients, p-values were quite significant. Conclusion: It was concluded that homB gene was most frequent in H. pylori infected population. Peptic ulcer disease and gastritis are markedly associated with dupA and iceA genes, while homB gene infected patients are at high risk of gastric cancer.

Objective: To ascertain the prevalence of risk factors in pancreatitis after endoscopic retrograde cholangiopancreatography at Isra University Hospital in Hyderabad. Methodology: This descriptive case series study was done at the gastroenterology department of Isra University Hospital, Hyderabad, from September 2018 to March 2020. Patients aged 18 to 50 years, both genders, and diagnosed with post-ERCP pancreatitis were included. All the patients were undergoing an ERCP procedure. The procedure was done under conscious sedation or propofol where needed. The serum amylase level was assessed in all patients at 4 hours. Patients had been considered to have post-ERCP pancreatitis if they developed new or worsening pain of abdomen and had a threefold increase in serum amylase. All the cases were assessed regarding risk factors in pancreatitis after endoscopic retrograde cholangiopancreatography. All the data was recorded in the proforma. Results: The mean age of the patients was 42.7 years. The majority of the patients (65.47%) were females and 32.90% were males. The mean duration of pancreatitis was 3.1 days. Sphincter of Oddi dysfunction was found in 17.1% of cases. Precut papillotomy was done in 18(23.7%) cases. Repeated pancreatic duct injury was seen in 10(13.2%) cases. No significant difference was found in the effect of modifiers on predisposing factors in post-endoscopic retrograde cholangiopancreatography pancreatitis, p-values were almost insignificant. Conclusion: Cannulation attempts, Sphincter of Oddi dysfunction, precut papillotomy, repeated pancreatic duct injection, and female gender were observed to be the predisposing factors in post-endoscopic retrograde cholangiopancreatography pancreatitis.

Objective: The objective of this study was to evaluate the low bone mineral density (BMD) in patients with liver cirrhosis. Methodology: This cross sectional study on 151 Liver cirrhotic patients was conducted at Liaquat University Hospital Hyderabad/Jamshoro. This study duration was 6 months, July 2015 to December 2015. The Assessment of bone mineral density (BMD) for each relevant patient was done using ultrasound impedance Dual Energy X-ray Absorptiometry  (DEXA) by senior pathologist having ≥05 years of experience, across the calcaneum, at lumbar spine  (LS) and femur neck (FN),  were computed by using computer supported device. The BMD was expressed in terms of T score. The WHO standard value was utilized to define the low BMD / osteoporosis is T score -1.5. Results: The mean age of subjects was 31.32±6.18 years. Out of all, 62.9% were males whereas 37.1% were females. About 21% patients had low/abnormal bone mineral density (BMD). Among these, 17.9% had bone mineral density (BMD) of -1.5 to -2.5 and 4% had BMD of <-2.5. Rest of 78.1% patients had a normal (>-1.5) bone mineral density (BMD). Majority of patients, 63.6% had a CTP grade B of liver cirrhosis, whereas 22.5% had A grade and 13.9% had C grade of liver cirrhosis. Conclusion: Conclusively, the risk of low bone mineral density (BMD) was evidently high for patients with hepatic cirrhosis. Male gender and age above 30 years were found at greater risk and CTP grade B of cirrhosis was most common.

Objective: To document different indications and findings of upper GI Endoscopy in our endoscopy suite. Methods: A descriptive study of 500 patients who underwent upper gastrointestinal (UGI) endoscopy was conducted in the Endoscopy Unit of PNS DRIGH LUMHS Jamshoro and Civil Hospital Hyderabad from April to September 2020. Included patients underwent UGI endoscopy. Demographic data including indications and endoscopic findings of the patients was collected via study proforma. Results: Total five hundred patients were studied; their mean age was 42.4±16.8 years. Out of all 52.8% were males. Upper GI bleed was the commonest indication (33.2%) followed by dysphagia (21.6%), epigastrium pain (10%), surveillance and screening of varices (9% and 8.2% respectively).  The most common endoscopic findings were esophageal varices (32.2 %), gastritis (18.8%), and normal (11.4%). In patients with esophageal varices, 77.4% had chronic liver disease with positive serology for HCV and HBV in 63.4% and 23% respectively. Conclusion: The most common indication was upper GI bleed with esophageal varices for upper GI endoscopy. The underlying etiology of varices reflects the high burden of chronic liver disease due to viral hepatitis.

Objective: To determine the management outcome of the endoscopic bandligation in the patients with internal haemorrhoids at isra university Hospital Hyderabad Sindh.Pakistan. Materials and methods: All the patients were under went sigmoidoscopy andcolonoscopy for the complete diagnosis and the patients were excluded, if polyps or evidenceof malignancy was found at colonoscopy. Haemorrhoids were sucked with the tip of endoscopefrom the anal canal and elastic bands were applied. After first treatment session, patients wereasked to complete a questionnaire to evaluate the subjective satisfaction, which was classifiedas poor, good and best. Patients who had with multiple haemorrhoids were recalled for theligation on remaining haemorrhoids after 2 weeks, if indicated. Results: Total 100 patients wereincluded in the study, In complications, intensive pain was found in the 55% of the cases whileother complications were seen in very few patients and many patients were seen without anycomplication. Hospital stay was only one day was noted in the very few patients and mostlypatients were discharged after few hours of the procedure. Outcome of the endoscopic bandligation was found excellent in 40% of the cases, good results found in the 45% of the cases andpoor results were seen only in the 15% of the cases. Re-endoscopic band ligation was donein the 20% of the cases and recurrence of hemorrhoids was noted in the 30% of the cases.Conclusions: We concluded that the endoscopic band ligation is very good management forhaemorrhoids without typical complications, with very short hospital stay and recurrences rate.