Background: Ascites is the most common complication of liver cirrhosis and about 5-10% of all cases develop refractory ascites, 50% of such patients die within 6 months of its development. Aim of the Work: to assess the usefulness of adding midodrine beside the standard medical treatment for patients with liver cirrhosis and refractory ascites. Patients and Methods: This study included 78 patients with liver cirrhosis and refractory ascites or recurrent ascites, Group A: (n=37) patients on standard medical treatment (SMT) [low sodium diet + diuretic therapy (loop diuretic in a dose 40-160 mg/day and distal acting diuretic in a dose 100-400 mg/day + large volume paracentesis as needed] Group B: (n=41) patients with standard medical treatment (SMT) and midodrine tolerable dose. Results: Statistical significant difference between the SMT group and midodrine group as regard reduction in body weight and increase in mean arterial blood pressure and 24 h-urinary volume where P value was 0.05. Conclusion, midodrine is a safe treatment for patients with liver cirrhosis and its addition to standard medical treatment is associated with better control of ascites.

Introduction: Esophageal high resolution manometry (HRM) coupled with high resolution pressure topography has dramatically changed the manometric studies and now replacing the conventional manometry in diagnosing achalasia and its subtypes. Aim of the work: To assess and compare the clinical and manometric characteristics of achalasia subtypes among untreated Egyptian patients using esophageal HRM. Methods: Forty Egyptian patients with achalasia underwent HRM at the GI motility unit, Internal Medicine department, Assuit University Hospital. Clinical and manometric data from 40 achalasia patients and 400 water swallows were analyzed according to Chicago classification into 3 subtypes: type I (classic achalasia), type II (achalasia with esophageal compression), and type III (spastic achalasia). Results: Type I achalasia was diagnosed in 16 patients, type II in 19 and type III in 5. Dysphagia and regurgitation were the main symptoms in types I and II achalasia. While, type III achalasia patients had dysphagia and sometimes chest pain, high lower esophageal sphincter (LES) pressure and esophageal spasm with swallowing when compared to types I and II. Integrated relaxation pressure (IRP) was significantly lower in type I than in types II and III. Maximal esophageal pressurization was significantly higher and LES length was significantly longer in type III than types I and II. Conclusions: The clinical and manometric variables of the 3 types of achalasia are distinct. The Egyptian cohort of achalasia had comparable data as those of the western population. Further investigations are needed to identify the optimal method of treatment within each subgroup.

Background: Diabetes is important as a cause of cardiovascular disease (CVD), ranging from asymptomatic ischemia to clinically evident heart failure. Therefore, early identification of sub-clinical CVD in diabetic patients may be particularly important in leading to early initiation of treatment. The aim of the present study was to identify role of BNP (Brain natriuretic Peptide), Ankle Brachial Index (ABI) and carotid Doppler in detection of sub-clinical CVD in type 2 diabetic patients. Patients and methods: BNP was measured in 60 consecutive diabetic patients (patients group) whom were attended internal medicine outpatient clinics or admitted at endocrinology unit of Assiut university hospital. Another 40 patients; were chosen as (control group) their age and sex matched with patients. Echocardiography examinations were performed to all participants. ABI measurements were conducted on all study participants. Carotid intima Media Thickness (CIMT) and carotid Plaque were evaluated by Carotid Doppler Ultrasonography, along with the determination of anthropometric parameters, HbA1c, lipid profile, assessment of diabetic retinopathy, nephropathy, and neuropathy, in patients with type 2 diabetes mellitus (T2DM). Results: Our study revealed 11 patients had Left ventricular hypertrophy (LVH), 20 patients had Left Ventricular Diastolic Dysfunction (LVDD), and no systolic dysfunction were detected. BNP were independent determinants of mild to moderate LVDD. Prevalence of a low ABI (0.9) was 18.3%. Patients with low ABI had significant increased mean ages (P=0.038) duration of DM (P=0.004), concentration of HbA1c (P=0.044), BNP (P=0.013) and microalbuminurea (P=0.007).Patients with low ABI significantly associated with nephropathy (P=0.001), retinopathy (P=0.007), LVH (P=0.010) LVDD (P=0.018) and carotid artery atherosclerosis (P=0.018). 20 patients( 33.3%) were found to have evidence of carotid artery disease of them 5 patients (8.3%) had increased CIMT and 15 patients (25%) had carotid artery plaques. patients with carotid plaque were significantly smoker (P=0.008), male gender (P=0.013), had low HDL (P=0.008) and higher concentration of HbA1c (P=0.001). Also patients with carotid artery atherosclerosis were significantly associated with nephropathy (P=0.000), neuropathy (P=0.050), Peripheral Arterial Disease (PAD) (P=0.018), LVDD (0.002).Conclusion: Our study showed that BNP discriminated patients at high risk for mild to moderate LVDD. A low ABI were prevalent in our study and associated with age, duration of diabetes, high HbA1c, microalbuminurea and chronic complication of DM, also carotid atherosclerosis high prevalent in our study especially carotid plaques which significantly associated with male gender, smoking, high HbA1c, low HDL, LVDD, PAD, and diabetic microangiopathy.

Introduction: Gastrointestinal bleeding represents an important clinical problem, which can be encountered in several presentations including overt, occult and obscure forms. The management of gastrointestinal bleeding represents an important clinical problem particularly the obscure overt bleeding. This study aimed to evaluate the role of angiography in the management of this type of bleeding. Patients and Methods: 30 patients (25 males and 5 females) The age ranged from 16-72 years with the mean age 67.9 years, the patients presented with obscure overt gastrointestinal bleeding and were studied at our interventional radiologic unit. Six patients with hematemesis and melena, 15 patients with only melena, 5 patients with melena and hematochesia and 4 patients with hematochesia only. Angiography as digital subtraction technique with embo-lotherapy was done for all. Results: Angiodiagnosis showed dysplasia in 24 patients, colonic diverticulum in 3 patients, small intestinal tumors in 2 patients and solitary rectal ulcer in one patient. The embo-lotherapy was successful in 24 patients and failed in 6 patients. Conclusion: Angiography has a definite and indispensible role in the management of obscure overt gastrointestinal bleeding. Diagnostic angiography followed by embolotherapy may represent and alternative non invasive technique that may replace surgery.

Background: Intensive Care Units are units designed to take care of patients with the most severe and life-threatening illnesses and injuries; that require constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions. Objective: Was to evaluate mortality rate in medical ICU and related risk factors, as little is known about the causes and risk factors for death in critically ill patients in our medical ICU. Methods: Data were obtained from 100 patients admitted to the 12-bed Medical Intensive Care Unit in the Department of Medicine, Assiut University Hospital, between January 1, 2012 and June 30, 2012. The admission records of each patient admitted to the ICU were reviewed prospectively during the period of 6 months. Patient characteristics including demo-graphic variables, diagnosis, acute physiology and chronic health evaluation (APACHE II) score at the time of ICU admission and length of stay in the ICU were obtained. The treatment outcome was determined by survival at the time of ICU discharge. Results: 53% of the admissions involved were female, with mean age 49.85±19.20 years, 25% patients stayed for 5- 10 days, 25% of patients were died, while 75% survived, with average APACHE II score 18.34±0.72, and predicted death rate 33.60±2.02. Predictors of non survival were higher APACHE II score (p-value 0.038), low GCS (p-value 0.001) and decreased PO2 (p-value 0.001). Conclusion: The actual death rate in our medical ICU is lower than the expected risk of death according to APACHEII scoring system.

Background: Associated symptoms of bronchogenic carcinoma other than chest complaints like dysphagia are rarely demonstrated in literature regarding prevalence, cause–effect relationship and proper management plan. Gastrointestinal motility disorder as a cause of dysphagia in lung cancer is incompletely understood. This prospective preliminary study aims to find out the prevalence and different aetiologic mechanisms for dysphagia among lung cancer patients using oesphagoscopy and oesphageal manometry. Patients and methods: All lung cancer patients with dysphagia admitted in the Cancer Institute, Assiut University during the year 2010–2012 were included in the study. All patients were subjected to oesophagoscopy and oesophagomanometry study. Results: We collected 165 cases of bronchogenic carcinoma during the study period. Dysphagia was diagnosed in 20 cases (12.1%) regardless the stage of malignancy. Four separate dysphagia causes were identified. Secondary achalasia was diagnosed in 10 cases (50%), whereas enlarged mediastinal lymph nodes and candidal oesphagitis in 4 cases each (20%), and chemoradiotherapy in 2 cases (10%). Conclusions: Dysphagia associated with bronchogenic carcinoma is not uncommon and should be asked for and documented in all cases if present. Secondary achalasia is the commonest mechanism of dysphagia based on oesphagoscopy and manometry. Further large sample multicenteric

The potential protective role of the standardized leaf extract of ginkgo biloba (EGb761) on hypertension with hypercholesterolemia-induced renal injury was investigated in rats. Hypertension was induced by L-N(G)-nitroarginine methyl ester (L-NAME) and hypercholesterolemia was induced by feeding rats with a diet containing 1% cholesterol. In these animals repeated treatment with EGb761 produced a progressive reduction in the systolic, diastolic and mean arterial blood pressure (BP). EGb761 increased the progressive reduction in the systolic, diastolic and mean arterial BP induced by repeated administration of losartan with simvastatin. EGb761 corrected the compromised serum lipid profile and enhanced the effect of losartan with simvastatin on lipid profile. EGb761 protected against hypertension with hypercholesterolemia-induced renal injury as assessed by measurement of serum renal function markers and by histopathological examination. EGb761 enhanced the renoprotective effect of losartan with simvastatin in these rats. Concomitantly, hypertension with hypercholesterolemia-induced elevation of renal tissue malondialdehyde (MDA) and nitrite levels and reduction of intracellular reduced glutathione (GSH) level were inhibited by repeated treatment with EGb761. In addition, hypertension with hypercholesterolemia-induced increases in tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and interleukin-1β (IL-1β) levels in renal tissues were inhibited by treatment with EGb761. Also, EGb761 inhibited hypertension with hypercholesterolemia-induced decrease in endothelial nitric oxide synthase (eNOS) protein expression and increase in the protein expressions of inducible NO synthase (iNOS), TNF-α, IL-6 and IL-1β in the kidney tissues. Losartan with simvastatin produced similar effects on renal tissues oxidative stress, nitrite and inflammatory markers levels and on protein expressions of eNOS, iNOS, TNF-α, IL-6 and IL-1β. EGb761 enhanced losartan with simvastatin effects. These results indicate that EGb761 has the ability to protect against hypertension with hypercholesterolemia-induced renal injury. The ability of EGb761 to provide this renoprotective effect may positively correlate, besides its antihypertensive and antihypercholesterolemic effects, to its ability to suppress renal oxidative stress, nitrosative stress and inflammation.

The potential protective role of the standardized leaf extract of ginkgo biloba (EGb761) on hypertension with hypercholesterolemia-induced renal injury was investigated in rats. Hypertension was induced by L-N(G)-nitroarginine methyl ester (L-NAME) and hypercholesterolemia was induced by feeding rats with a diet containing 1% cholesterol. In these animals repeated treatment with EGb761 produced a progressive reduction in the systolic, diastolic and mean arterial blood pressure (BP). EGb761 increased the progressive reduction in the systolic, diastolic and mean arterial BP induced by repeated administration of losartan with simvastatin. EGb761 corrected the compromised serum lipid profile and enhanced the effect of losartan with simvastatin on lipid profile. EGb761 protected against hypertension with hypercholesterolemia-induced renal injury as assessed by measurement of serum renal function markers and by histopathological examination. EGb761 enhanced the renoprotective effect of losartan with simvastatin in these rats. Concomitantly, hypertension with hypercholesterolemia-induced elevation of renal tissue malondialdehyde (MDA) and nitrite levels and reduction of intracellular reduced glutathione (GSH) level were inhibited by repeated treatment with EGb761. In addition, hypertension with hypercholesterolemia-induced increases in tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and interleukin-1β (IL-1β) levels in renal tissues were inhibited by treatment with EGb761. Also, EGb761 inhibited hypertension with hypercholesterolemia-induced decrease in endothelial nitric oxide synthase (eNOS) protein expression and increase in the protein expressions of inducible NO synthase (iNOS), TNF-α, IL-6 and IL-1β in the kidney tissues. Losartan with simvastatin produced similar effects on renal tissues oxidative stress, nitrite and inflammatory markers levels and on protein expressions of eNOS, iNOS, TNF-α, IL-6 and IL-1β. EGb761 enhanced losartan with simvastatin effects. These results indicate that EGb761 has the ability to protect against hypertension with hypercholesterolemia-induced renal injury. The ability of EGb761 to provide this renoprotective effect may positively correlate, besides its antihypertensive and antihypercholesterolemic effects, to its ability to suppress renal oxidative stress, nitrosative stress and inflammation.

The potential protective role of the standardized leaf extract of ginkgo biloba (EGb761) on hypertension with hypercholesterolemia-induced renal injury was investigated in rats. Hypertension was induced by L-N(G)-nitroarginine methyl ester (L-NAME) and hypercholesterolemia was induced by feeding rats with a diet containing 1% cholesterol. In these animals repeated treatment with EGb761 produced a progressive reduction in the systolic, diastolic and mean arterial blood pressure (BP). EGb761 increased the progressive reduction in the systolic, diastolic and mean arterial BP induced by repeated administration of losartan with simvastatin. EGb761 corrected the compromised serum lipid profile and enhanced the effect of losartan with simvastatin on lipid profile. EGb761 protected against hypertension with hypercholesterolemia-induced renal injury as assessed by measurement of serum renal function markers and by histopathological examination. EGb761 enhanced the renoprotective effect of losartan with simvastatin in these rats. Concomitantly, hypertension with hypercholesterolemia-induced elevation of renal tissue malondialdehyde (MDA) and nitrite levels and reduction of intracellular reduced glutathione (GSH) level were inhibited by repeated treatment with EGb761. In addition, hypertension with hypercholesterolemia-induced increases in tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and interleukin-1β (IL-1β) levels in renal tissues were inhibited by treatment with EGb761. Also, EGb761 inhibited hypertension with hypercholesterolemia-induced decrease in endothelial nitric oxide synthase (eNOS) protein expression and increase in the protein expressions of inducible NO synthase (iNOS), TNF-α, IL-6 and IL-1β in the kidney tissues. Losartan with simvastatin produced similar effects on renal tissues oxidative stress, nitrite and inflammatory markers levels and on protein expressions of eNOS, iNOS, TNF-α, IL-6 and IL-1β. EGb761 enhanced losartan with simvastatin effects. These results indicate that EGb761 has the ability to protect against hypertension with hypercholesterolemia-induced renal injury. The ability of EGb761 to provide this renoprotective effect may positively correlate, besides its antihypertensive and antihypercholesterolemic effects, to its ability to suppress renal oxidative stress, nitrosative stress and inflammation.

The potential protective role of the standardized leaf extract of ginkgo biloba (EGb761) on hypertension with hypercholesterolemia-induced renal injury was investigated in rats. Hypertension was induced by L-N(G)-nitroarginine methyl ester (L-NAME) and hypercholesterolemia was induced by feeding rats with a diet containing 1% cholesterol. In these animals repeated treatment with EGb761 produced a progressive reduction in the systolic, diastolic and mean arterial blood pressure (BP). EGb761 increased the progressive reduction in the systolic, diastolic and mean arterial BP induced by repeated administration of losartan with simvastatin. EGb761 corrected the compromised serum lipid profile and enhanced the effect of losartan with simvastatin on lipid profile. EGb761 protected against hypertension with hypercholesterolemia-induced renal injury as assessed by measurement of serum renal function markers and by histopathological examination. EGb761 enhanced the renoprotective effect of losartan with simvastatin in these rats. Concomitantly, hypertension with hypercholesterolemia-induced elevation of renal tissue malondialdehyde (MDA) and nitrite levels and reduction of intracellular reduced glutathione (GSH) level were inhibited by repeated treatment with EGb761. In addition, hypertension with hypercholesterolemia-induced increases in tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and interleukin-1β (IL-1β) levels in renal tissues were inhibited by treatment with EGb761. Also, EGb761 inhibited hypertension with hypercholesterolemia-induced decrease in endothelial nitric oxide synthase (eNOS) protein expression and increase in the protein expressions of inducible NO synthase (iNOS), TNF-α, IL-6 and IL-1β in the kidney tissues. Losartan with simvastatin produced similar effects on renal tissues oxidative stress, nitrite and inflammatory markers levels and on protein expressions of eNOS, iNOS, TNF-α, IL-6 and IL-1β. EGb761 enhanced losartan with simvastatin effects. These results indicate that EGb761 has the ability to protect against hypertension with hypercholesterolemia-induced renal injury. The ability of EGb761 to provide this renoprotective effect may positively correlate, besides its antihypertensive and antihypercholesterolemic effects, to its ability to suppress renal oxidative stress, nitrosative stress and inflammation.