While direct-acting antivirals (DAAs) are available for the treatment of chronic Hepatitis C virus (HCV) patients in Nepal, knowledge of the circulating genotypes/subtypes and drug target gene mutations of HCV is currently unavailable. Here, we describe HCV genotypes/subtypes and identify antiviral target gene mutations in patients at a tertiary care hospital using genome data. A cross-sectional study was conducted from December 2019 to February 2024, where PCR followed by whole genome sequencing was performed to identify HCV genotypes/subtypes and drug target gene mutations. Among all the patients who tested positive for anti-HCV, 70.6% (149/211) were HCV RNA positive, while 68.2% (30/44) were genotype/subtype 3a, followed by 1a (18.2%, 8/44) and others (13.6%, 6/44), including new subtypes 3g and 3i from Nepal. Subtype 3a was also the dominant subtype (≥70%) among intravenous drug users and sexual routes of transmission. We found 70.5% of the samples with resistant mutations in the NS3/4A region, 22.7% in NS5A, and 45.5% in NS5B. Resistant mutations against sofosbuvir, pibrentasvir, velpatasvir, daclatasvir, and dasabuvir were found at 25%, 18%, 16%, 16%, and 2%, respectively, mostly on subtype 3a. The predominant HCV genotype/subtype in our patient group was 3a, and resistance mutations against direct-acting antivirals were found in most untreated patients.

Nepal has one of the highest youth suicide rates in the world. Suicide screening is rarely performed during hospitalization, partly due to the lack of validated tools in the local language. We evaluated the validity of the Nepali version of the Ask Suicide-Screening Questions (ASQ) tool in youth population in medical inpatient settings. We conducted a cross-sectional validation study at two urban hospitals in Nepal between January and July 2022. Patients aged 10 to 24 years admitted to medical wards were recruited through convenience sampling. Patients with significant cognitive impairment, non-fluent in Nepali, or planned early discharge limiting participation were excluded. Trained nurses administered the ASQ followed by the adolescent version of Patient Health Questionnaire (PHQ − 9) and completed a demographic survey. Thereafter a separate team of psychologists, blind to ASQ results, conducted a brief suicide safety assessment (BSSA) as the gold standard for suicide risk screening. All study procedures were completed by 309 [54.0

BACKGROUND:Hepatic encephalopathy presents a significant clinical challenge in individuals with advanced liver dysfunction, manifesting as confusion, altered consciousness, and personality changes. This study aimed to compare the efficacy of lactulose and polyethylene glycol in managing Hepatic encephalopathy. METHODS:The study is conducted at Tribhuvan University Teaching Hospital in Nepal; the study enrolled 45 cirrhotic patients with altered mental status in each study group. Ethical approval and informed consent were obtained. The basic demographic and clinical data were collected, including laboratory investigation and precipitating factors for Hepatic encephalopathy. The severity of Hepatic encephalopathy was assessed using the West Haven Criteria. RESULTS:In this study there was significant difference between two groups in terms of mean time taken for complete resolution of hepatic encephalopathy, with mean of 2.98 ± 2.129 days in Polyethylene Glycol group compared to mean of 4.67 ± 3.076 days in Lactulose group, with a significant p-value of 0.004. There was also significant difference in length of hospital stay between two groups, with a mean hospital stay of 6.36 ± 3.654 days in Polyethylene Glycol group compared to 9.70 ±5.388 days in Lactulose group, with a significant p-value of 0.001. CONCLUSIONS:In conclusion, polyethylene glycol showed promising results in the treatment of Hepatic encephalopathy compared to lactulose polyethylene glycol. demonstrated an improvement and quicker resolution of Hepatic encephalopathy symptoms, highlighting its potential as a cost effective and safe alternative for managing Hepatic encephalopathy in cirrhotic patients. Keywoards: Hepatic encephalopathy; lactulose; polyethylene glycol.

Background and aim Acute-on-chronic liver failure (ACLF) is a dynamic condition with very high short-term mortality. Although several mortality predictors have been studied, no single factor can reliably predict its course and outcome. This study aimed to evaluate various biochemical parameters and severity scores at presentation to assess their ability to predict mortality in ACLF patients. Methods An observational cross-sectional study was conducted from March 2024 to February 2025 at a tertiary care center in Nepal. A total of 51 patients were enrolled over one year. ACLF was diagnosed based on the Asia-Pacific Association for the Study of the Liver (APASL) criteria and/or the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. Clinical features, biochemical parameters, and severity scores at admission were analyzed. Results The overall mortality rate was high (56.9%), consistent with previous studies. About 28% of patients who met the APASL definition of ACLF did not fulfill the EASL-CLIF criteria. On univariate analysis, factors such as oliguria, hepatic encephalopathy (HE) grade, ACLF grade, total serum protein, urea, ascitic fluid total leukocyte count, serum lactate, and APASL-ACLF Research Consortium (AARC) score were associated with mortality. However, multivariate analysis did not identify a single independent predictor of mortality. Different scoring systems were useful in predicting mortality at admission. Among them, the CLIF-C ACLF score had the highest predictive accuracy (area under the curve (AUC): 0.990), followed by the AARC score (AUC: 0.79), Sequential Organ Failure Assessment (SOFA) score, and Model for End-Stage Liver Disease (MELD) score. However, the Child-Turcotte-Pugh (CTP) score at admission was not effective in predicting mortality. Conclusion ACLF represents an acute flare of inflammation on a background of chronic liver disease. Using multiple mortality predictors at the time of admission can help guide treatment decisions and provide better prognostication of patient outcomes.

BACKGROUND AND AIMS Sarcopenia in liver cirrhosis is a common condition associated with increased mortality and adverse clinical outcome. Early recognition and treatment is essential but challenging. Clinical detection of sarcopenia with various assessment tools gives indirect knowledge of muscle mass and strength. The aim of this study is to find the most easy and applicable assessment tool in daily clinical practice to diagnose sarcopenia. METHODS A retrospective observational study was conducted and data was taken from electronic medical records of patients admitted with cirrhosis and sarcopenia in department of gastroenterology of Tribhuvan university Teaching hospital. A total of 51 cirrhotic patients were included during one and half year study duration. Sarcopenia was assessed using assessment tool like hand grip strength, chair stand test, 400 metre walk test and CT measurement of either skeletal muscle area (SMA) or skeletal muscle index (SMI). RESULTS Among 51 patients assessed with performance based assessment tool to diagnose sarcopenia, taking CT as gold standard test, SARC-F score and chair stand test were found to have highest sensitivity and specificity of 93%, 87.5 % and 93%, 100% respectively. CONCLUSION Diagnosis of sarcopenia with simple clinic based assessment tool SARC-F score and chair stand test is very useful and comparable with more costly and resource-intensive CT scan.

Introduction and importance:Laparoscopic cholecystectomy is one of the common surgeries occurring worldwide and the gold standard for the management of gallstone disease. The non-absorbable surgical clips may slip and can migrate causing a variety of problems as such, choledocholithiasis. Case presentation:The authors report a case of 43-year-old female who presented with the complaint epigastric pain. She had undergone cholecystectomy 7 years back for symptomatic cholelithiasis. Ultrasonography of the abdomen showed a dilated common bile duct following which endoscopic retrograde cholangiopancreatography was done. A single black-colored stone with the metal clip was retrieved. Clinical discussion:Post-cholecystectomy clip migration should be considered as one of the differentials for choledocholithiasis. Ultrasonography of the abdomen shows the dilated common bile duct. Further management is done by endoscopic retrograde cholangiopancreatography. Conclusion:Surgical clips acting as nidus for choledocholithiasis is rare these days but should be considered as one of the differentials for pain abdomen.

BACKGROUND:Common bile duct stones is a common medical problem that are usually seen in association with gallstone disease. Endoscopic management of Common bile duct stones involves doing Endoscopic retrograde cholangiography for bile duct clearance which is the primary therapeutic modality of choice. This prospective study was done to identify the clinical characteristics and outcome of patients presenting with Common bile duct stones undergoing Endoscopic retrograde cholangiography. METHODS:A prospective observational study was conducted on all patients undergoing Endoscopic retrograde cholangiography in department of Gastroenterology, Tribhuvan University Teaching Hospital, for management of diagnosed or suspected choledocholithiasis from April 2023 to March 2024. Patient demographics, clinical characteristics, Endoscopic retrograde cholangiography findings and post procedure outcome data were collected and analysed. RESULTS:A total of 110 patients (61.8% male and 38.2% female) were included in the final analysis. Successful clearance of Common bile duct was obtained in 76.4% patients with overall adverse events of 18% related to the procedure. Among patients undergoing the procedure, 16.4% couldn’t be managed with Endoscopic retrograde cholangiography and were referred for surgical management. CONCLUSIONS:Endoscopic management in form of Endoscopic retrograde cholangiography is a safe and effective method to manage patients with Common bile duct stones.

Introduction: Hepatocellular carcinoma is the most common primary liver cancer. Viral hepatitis, alcohol abuse, and autoimmune hepatitis are the common causes of hepatocellular carcinoma. Usually patients present at advanced stages where curative treatment is no longer possible. This study aimed to find the prevalence of hepatocellular carcinoma among patients with chronic liver disease in a tertiary care centre. Methods: This is a descriptive cross-sectional study conducted in a single tertiary care centre from March 2020 to August 2022. The study was done among inpatients of the Department of Gastroenterology after ethical approval from the Institutional Review Committee. A total population sampling method was used and data were collected using predetermined proformas. Point estimate at 95% Confidence Interval was calculated. Results: Among 1440 patients, hepatocellular carcinoma was seen in 54 (3.75%) (2.77-4.73, 95% Confidence Interval). At the time of diagnosis, 48 (88.89%) were symptomatic. The presenting symptoms were weight loss seen in 35 (64.81%) being the most common. Out of them, 37 (68.52%) consumed alcohol and 40 (74.07%) smoked cigarettes. Conclusions: Hepatocellular carcinoma is a notable concern. Alcohol-related liver cirrhosis is the most frequent condition encountered in patients with hepatocellular carcinoma in our setting.

Introduction: Liver cirrhosis is a common medical problem associated with high morbidity and mortality. Consequences of cirrhosis leading to encephalopathy is a neuropsychiatric manifestation requiring hospital admission and poor prognosis. Similarly, sarcopenia in cirrhosis, resulting from multifactorial cause confers prognostic significance. The objective of this study is to find the relation between sarcopenia and hepatic encephalopathy. Methods: A retrospective observational study was conducted and data was taken from electronic medical records of patients admitted with hepatic encephalopathy in department of gastroenterology of Tribhuvan university Teaching hospital. A total of 96 cirrhotic patients were included during one and half year study duration. Sarcopenia was assessed using assessment tool like hand grip strength, chair stand test and CT measurement of either skeletal muscle area (SMA) or skeletal muscle index (SMI). Hepatic encephalopathy was graded according to West Haven criteria among admitted patients. Results: Among 96 patients with cirrhosis, 85 patients (88.5%) were found to have sarcopenia. Prevalence of sarcopenia was higher among female compared to male (97% vs 84%). Similarly, sarcopenia was found to be higher in patients with HE-2 and HE-3 compared to HE-1 ( 91% vs 93% vs 79% respectively). Conclusion: Sarcopenia is commonly associated with hepatic encephalopathy. Bangladesh J Medicine 2024; 35: 195-199

Introduction The role of ERCP to diagnose and manage biliopancreatic diseases is increasing since its inception with refinement of operator skill, technical advancement and better patient selection. The aim of the study was to explore common clinical and endoscopic characteristics, outcome, adverse events and safety profile of patients. MethodsAn observational study was conducted on patients undergoing ERCP in Department of Gastroenterology, Tribhuvan University Teaching Hospital, for management of biliopancreatic diseases from April 2023 to March 2024 after taking approval from IRC-IOM. Patient demographics, clinical characteristics, ERCP findings and post procedure outcome data were collected and analyzed using SPSS version 26. ResultsA total of 200 patients were included with mean age 52.36±17.04 years and female:male ratio of ~3:2. Elective procedures were done in 182 (91%) patients and in 18 (9%) as urgent procedure (within 48 hours). The most common indications were choledocholithiasis (157, 78.5%) followed by benign biliary stricture (12, 6%). The most frequent papilla was type 1 papilla (normal variant) in 48% followed by type 3 papilla (protruding) in 30%. Difficult cannulation was encountered in 130 (51.5%) cases. Post ERCP pancreatitis (8, 4%) and hypoxia (9, 4.5%) were the most common procedure and anesthesia related adverse events respectively. Common therapeutic interventions included sphincterotomy (176, 88%), CBD stenting (154, 78.5%) and precut sphincterotomy (45, 22.5%). ConclusionERCP was mostly done for benign diseases like CBD stone and benign biliary strictures. Common therapeutic procedures were sphincterotomy and CBD stenting. Complications related to procedure and anesthesia though occured, their rate was low.

Background: Hepatitis C infection is a major public health concern in Nepal. Epidemiological information on hepatitis C virus along with the status of co-infection with hepatitis B virus and human immunodeficiency virus is essential to controlling the hepatitis C burden. The objective of this study was to determine the sero-prevalence of hepatitis C virus infections, proportions of co-infections with human immunodeficiency virus and hepatitis B virus, and identify the demographic characters, and routes of transmission.Methods: A cross-sectional study was conducted from December 2019 to February 2024 at Tribhuvan University Teaching Hospital. The serological tests were performed by enzyme-linked immunosorbent assays from 25133 patients’ serum in four years.Results: The sero-prevalence of hepatitis C virus -infected patients was 0.8% (211/25133). Among them, 6.6% (14/211) were co-infected with human immunodeficiency virus and 1.4% (3/211) with hepatitis B virus. Among 211 hepatitis C virus patients, 174 (82.5%) were male, 156 (73.9%) were young aged 15–47 years with various professions, 167 (79.1%) were literate, and almost one-third of the patients (33.2%, 70/211) were regular alcoholics. Needle sharing among intravenous drug users (45.5%, 96/211) and sexual intercourse (28%, 59/211) were the most common modes of transmission. Conclusions: Although the prevalence of hepatitis C infections is less than 1%, it is more common among young male intravenous drug users. Awareness of the spread of hepatitis C infections among this population needs to be emphasized to control hepatitis C in Nepal.Keywords: characters; co-infection; hepatitis C, sero-prevalence.

Non-Alcoholic Fatty Liver Disease (NAFLD) represents a spectrum of histopathologic abnormalities ranging from simple steatosis to the more aggressive non-alcoholic steatohepatitis, characterized by steatosis, parenchymal inflammation, hepatocellular ballooning and other evidence of hepatic injury. The objective of this study is to evaluate the demographic and anthropometric profile of non-alcoholic fatty liver disease and non-invasive predictors of fibrosis. This is a hospital-based observational study. A total of 280 patients were included in this study from the Department of Gastroenterology, Tribhuvan University Teaching Hospital from January 2019 to August 2021 were included. Patients presenting with non-alcoholic fatty liver disease were mostly (29.64%) of 36-45 age group. Two-third of the patients (66.78%) were asymptomatic. The mean body mass index of patients was 28.10±4.10 kg/m2 and most of them (81.07%) had body mass index >25 kg/m2. More than one third of the patients (40%) with non-alcoholic fatty liver disease had presence of metabolic syndrome. The mean (±SD) ultrasound attenuation parameter was 284.22±31.58 dB/m. Fatty liver index showed a positive and a medium strength correlation with fatty liver. On Spearman rank correlation, ultrasound attenuation parameter steatosis grading was correlated positively and strongly with the USG grading of fatty liver (p<0.001). On Pearson correlation, APRI, NFS and FIB-4 were positive but weakly correlated with liver stiffness measurement by FibroTouch but still the correlation was statistically significant (p<0.01). Fatty liver index has shown a good correlation with the presence of steatosis by a FibroTouch. Similarly, APRI showed the highest correlation in predicting liver stiffness in the population of Nepal. Other multicenter large scale prospective analytical studies would be required for further clarify of the results of such a kind of research. Bangladesh Med J. 2023 Sept; 52(3): 35-40

Inflammatory bowel disease (IBD) is a chronic disease of the gastrointestinal tract. Once thought to be a disease of the developed nations, the burden of IBD has been rising in Asian countries. Inflammatory bowel disease leads to severe impairment in the quality of life of the patients. There have been numerous studies across the globe which have provided new insight into different aspects of this disease. Not only IBD is being diagnosed more but patients are also becoming more aware of this debilitating condition. It is encouraging to see a few studies from Nepal in the recent past. However, the epidemiological and demographic features of IBD remain largely unknown. Through this review, we aim to gain insight into the epidemiology and demographic features of patients with IBD in Nepal.

Introduction and importance:Primary biliary cholangitis (PBC) is a rare immune-mediated liver disease characterized by the destruction of intrahepatic bile ducts and a positive antimitochondrial antibody (AMA), which is considered a serological hallmark for the diagnosis. Rarely, AMA can be absent/nondetectable in a few cases and is referred to as 'AMA-negative'.Case presentation:The authors present such an uncommon case of AMA-negative PBC in a 39-year-female with Sjogren's syndrome who presented with fatigue, pruritus, and dry eyes.Clinical discussion:Previously published studies state that approximately only about 5% of patients with PBC are 'AMA-negative'. For patients negative for AMA, the diagnosis has to be based on typical pathological features of this disease. Once a diagnosis of PBC is established, regardless of whether it is positive or negative for AMAs, ursodeoxycholic acid is a widely accepted treatment.Conclusion:The presence/absence of AMAs is associated with similar clinical, biochemical, and histopathological characteristics in PBC. The identification of AMAs alone should not impact the diagnosis or treatment of PBC.

BACKGROUND Cirrhosis is the end result of varieties of chronic liver disease. A large proportion of patients with cirrhosis develop cardiopulmonary complication. The aim of this study was to evaluate the cardiopulmonary functions of patient with cirrhosis of liver and to correlate these abnormalities with CTP and MELD score. METHODS The study involved 81 cirrhotic patients admitted in Department of Gastroenterology of TUTH over a period of one year. The diagnosis of cirrhosis was established and clinical evaluation and investigation done. RESULTS The mean age of cirrhotic patients included in the study was 52 years. Alcohol was most common cause of cirrhosis (75.31%). The mean CTP score and MELD score was 10.02±1.77 and 23.59±7.53 respectively. Thirty patients (37.03%) had prolonged QTc interval, which had statistically significant association with alcohol as etiology of cirrhosis (p = 0.04). More than half (50.62%) of patients had diastolic dysfunction but it was not statistically significantly associated with CTP and MELD-Na score. Seven patients had evidence of intrapulmonary shunting, which had statistically significant association with MELD-Na score (p =0.01). Similarly, total 5 patients (6.17%) had PPHTN but there was no statistically significant association with CTP and MELD-Na score. Seventeen patients had dilated left atrium with no statistically significant association with CTP score and MELD-Na score. CONCLUSION There was significant incidence of cardiopulmonary abnormalities in cirrhotic patients. Every patient with decompensated cirrhosis irrespective of severity of disease should be evaluated for cardiopulmonary complication with a noninvasive, real-time, rapid imaging transthoracic contrast echocardiography.

Background Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Liver cancer is one of the commonest cancers worldwide in terms of incidence and mortality. Viral hepatitis, alcohol abuse, and autoimmune hepatitis are the common causes of HCC. Usually patients present at advanced stages where curative treatment is no longer possible. This study aims to analyze the demographic, clinical, and radiological profiles and treatment patterns of HCC patients. Methods We studied patients with HCC from March 2020 to August 2022 and analyzed their risk factors, clinical characteristics, and treatment modalities. Patients with at least one clinical, radiological, or biochemical evidence of HCC were considered for the study. Data were collected using predetermined proformas. Results Our study included 54 patients with a mean age of 57.17 years, and male: female ratio of 5:1. Of them, 68.52% consumed alcohol and 74.07% smoked cigarettes. At the time of diagnosis, 88.89% of them were symptomatic, weight loss (64.81%) being the most common symptom. The majority of the participants belonged to Barcelona Clinic Liver Cancer (BCLC) terminal stage (38.89%) and had more than three liver lesions (35.19%) involving the right lobe (55.56%). Only four patients underwent curative surgical resection. As most were in the terminal stage (BCLC D), supportive care was provided. Conclusion Alcohol-related liver cirrhosis is the most common cause of HCC in Nepal. Despite the significant progress in diagnostic methods, most of the patients are diagnosed at advanced and terminal stages. These patients are unsuitable for curative treatment and are treated with supportive methods. Keywords Autoimmune hepatitis, hepatitis, hepatocellular carcinoma, treatment.

Background: It is important to identify the severity of acute pancreatitis in the early course of the disease. Methods: This prospective observational study included 83 patients with acute pancreatitis. The Acute Physiology and Chronic Health Evaluation II and the Bedside Index for Severity in Acute Pancreatitis scores were assessed within 24 hours of admission, and the modified computed tomography severity index score was calculated in those patients who underwent contrast enhanced computed tomography. The sensitivity, specificity, positive predictive value, and negative predictive value of scoring systems were calculated. The area under the curve was calculated for assessing the prognostic value of scoring systems. Results: The modified computed tomography severity index was the most accurate score in predicting severity and local complications with an area under the curve of 0.92 and 0.91, respectively. The Bedside Index for Severity in Acute Pancreatitis score was the most accurate in predicting organ failure and the need for intensive care unit admission with an area under the curve of 0.70 and 0.78 respectively. Conclusions: The results of this study demonstrate that modified computed tomography severity index and Bedside Index for Severity in Acute Pancreatitis scores had overall better predictive value than the Acute Physiology and Chronic Health Evaluation II score in predicting severity, organ failure, local complication, and need for intensive care unit admission. Keywords: Acute pancreatitis; APACHE II; BISAP; modified CTSI

Introduction: Cirrhosis in young adults is an important health problem worldwide and is a common disease. Patients usually present late in a decompensated state with varied complications. However, national data on the exact burden of the disease is lacking. The aim of this study was to find out the prevalence of liver cirrhosis among young adults admitted to the Department of Gastroenterology in a tertiary care centre. Methods: A descriptive cross-sectional study was done among patients admitted to the Department of Gastroenterology in a tertiary care centre between 25 November 2021 to 30 November 2022 after receiving ethical approval from the Institutional Review Committee [Reference number: 227(6-11)E2-078/079]. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 989 patients, liver cirrhosis in young adults was seen in 200 (20.22%) (18.12-22.32, 95% Confidence Interval). Chronic alcohol use was the primary cause of cirrhosis seen in 164 (82%) cases. The most typical presenting symptom was abdominal distension seen in 187 (93.50%) patients. The most frequent complication was ascites seen in 184 (92%) patients. The most frequent endoscopic finding was gastro-oesophagal varices seen in 180 (90%) patients. There were 145 (72.50%) men and 55 (27.50%) women. Conclusions: The prevalence of liver cirrhosis in young adults was found to be lower than the other studies done in similar settings.

Introduction: The risk for the occurrence of esophageal varices in a cirrhotic patient is assessed by two gold standard invasive tests: hepatic venous pressure gradient measurement and esophagogastroduodenoscopy. We aim to find the association between spleen and liver stiffness with the occurrence of esophageal varices in our settings. Methods: This was a prospective cross-sectional study. In the study duration of one year, 94 cirrhotic patients who met the inclusion and exclusion criteria were included. All patients were subjected to transient elastography for measuring liver and spleen stiffness and endoscopy. Results: Of 94 patients, only 77 (81.9%) had esophageal varices. The mean liver stiffness in patients with and without varices was 19.46±4.9SD kPa and 12.92±1.52 SD kPa respectively. The difference was statistically significant, p<0.001. The mean spleen stiffness in patients with and without varices was 22.26±4.6 SD kPa and 14.08±1.20 SD kPa respectively. The difference was statistically significant, p<0.001. The optimal cut-off value of liver and spleen to detect patients with any grade of esophageal varices was 14 and 16.15 kPa respectively. Conclusion: The stiffness of liver and spleen using transient elastography can be considered an equivalent method for screening cirrhotic patients for esophageal varices in clinical settings.