Dr.Dilaram Khan Gastroenterologist/Hepatologist

29/03/2026

➡️CELIAC DISEASE:
■Chronic immune-mediated disorder triggered by gluten ingestion (present in wheat,rye and barley)→ causes small intestinal mucosal damage & malabsorption
■PATIENT PRESENTATION

●Gastrointestinal Symptoms:

□Chronic diarrhea
□Steatorrhea
□Abdominal pain, bloating
□Weight loss
●OR Extraintestinal Features
□Iron deficiency anemia
□Osteoporosis& fracture
□Infertility &recurrent sbortions
□Dermatitis herpetiformis
□Neurological symptoms:Fits
□Depression&Anxiety

⬇️SUSPECT CELIAC DISEASE:
■INITIAL TESTING (ON GLUTEN DIET)
●Anti-tTG IgA (First-line)
●Total IgA
●??EMA / DGP (if needed)
✅SEROLOGY POSITIVE ??
➡️ YES
■ENDOSCOPY + DUODENAL BIOPSY
Villous atrophy
Crypt hyperplasia
↑ Intraepithelial lymphocytes
➡️ DIAGNOSIS IS CONFIRMED:

✅CLASSIFICATION
Classical
Non-classical
Silent
Latent
Refractory
✅TREATMENT
1. LIFELONG GLUTEN-FREE DIET
🚫 Wheat | Barley | Rye
✅ Rice | Corn | Millet
2. NUTRITIONAL SUPPORT
Iron
Calcium + Vitamin D
Vitamin B12 / Folate
3. FOLLOW-UP
Symptom improvement
tTG monitoring
Dietary compliance
⬇️
4. REFRACTORY DISEASE
Steroids (Budesonide)
Immunosuppressants
COMPLICATIONS:
Osteoporosis
Infertility
Malignancy (intestinal lymphoma)
Malnutrition

29/03/2026

GERD / (معد ے کی تیزابیت )

■ Retrograde flow of Stomach contents into esophagus..OR....
Reflux (acid or non-acid mediated) with symptoms or side effects is called GERD.

CAUSES:

The pathology involves the lower esophageal sphincter. Transient relaxation occurs throughout the day, but those with pathological GERD have more frequent transient relaxation of the lower esophageal sphincter.

RISK FACTORS for GERD :

● Physical abnormalities
(diaphragm defects, hiatal hernia),
●Delayed stomach emptying ( Over eating, narcotic use, gastroparesis),
●Obesity یا موٹاپا and
●Pregnancy.

■ Symptoms/ علامات

●Heartburn/سینے کی جلن and/or
●Regurgitation /خوراک یا ترش پانی منہ میں آنا
Atypical symptoms include
●Nausea, متلی انا
●Hoarseness اواز کا خراب ھونا and
●Enamel loss دانتوں کا خراب ھونا .
●Chronic Cough/کھانسی
●Pharyngitis...گلے کا بار بار خراب ھو جانا
●chest pain
● Apthous Ulcers..منہ میں چالے پڑنا

Dysphagia or difficulty in swallowing is an alarm symptom that suggest reflux-induced ■Strictures/خوراک کی نالی کا تیزابیت کی وجہ سے تنگ ھو جانا Or
■Malignancy /کینسر , Notable weight loss (>5% body weight) in combination with dysphagia is also worrisome.

■TREATMENT:
First line drugs for treating GERD/تیزابیت include
▪Omeprazole,
▪Esomeprazole,
▪Pantoprazole.
▪Rabeprazole
▪Lansoprazole etc
(These are Called PPI OR Proton Pump Inhibitors)
If someone does not have a response to one type PPI, there is weak evidence that switching to a different type of PPI will help.

PPI for Life?

Indications for continuous PPI therapy include
▪Peptic stricture,(خوراک کی نالی کا تنگ ھونا)
▪Significant esophagitis (ie: ulceration of the distal esophagus seen through endoscopy),
and those with
▪ Barrett’s esophagus (even ifasymptomatic).

In a patient who needs a PPI and has no predisposing factors for osteoporosis, there is nothing that should be done differently,. Ensure adequate calcium intake and bone density screening as indicated by age and risk factors, but PPI should not be avoided if needed.

Patients may be at increased risk for infectious GI complications, including C. difficile when on PPI ۔ If someone is at risk for traveler’s diarrhea on an upcoming trip and has mild heartburn, cutting back on PPI may be helpful. Patients in the hospital with risk for C. difficile should not be started on PPI unless there is a clear indication (e.g. a bleeding ulcer).

Long term PPI use could affect B12 and iron absorption, but there has not been a population level deficiency for these associations. It is physiologically possible as an acidic milieu is required for absorption of these compounds . PPI use may affect magnesium transport, and deficiency can be seen.

Associations from retrospective studies have suggested that PPI use may predispose patients to chronic kidney disease, dementia, certain infections and a host of other concerns , but the evidence is weak and does not prove causation.

Initial Counsel for Patients

Experts advise initial empiric PPI therapy for 8 weeks with follow-up afterwards to assess benefit for the patient’s symptoms. The PPI is taken once daily in the morning 30-60 minutes before a meal.

PPI therapy can be used intermittently or for short periods of time when patients know they will experience heartburn, such as when traveling or having restaurant food.

Monitoring Long Term PPI Usage :

clinicians can consider checking an annual creatinine level to assess renal function, a CBC, and serum ferritin for anemia. B12 levels can be checked every five years. Magnesium levels can be checked in symptomatic patients

Going Off PPI

If someone has been on daily therapy, they may have severe heartburn and reflux if they abruptly discontinue PPI therapy. Experts suggests tapering by taking every other day for a few weeks and then every 3rd day for a few weeks before fully discontinuing (expert opinion).

■ Lifestyle modifications

Weight loss can be helpful even in patients with a normal BMI, ● Elevation of the head of the bed at night with wedges can be helpful for those with nocturnal symptoms. Simply propping head up on pillows may not be helpful since it can put more pressure on the abdomen.
●Patients should not eat or drink for a few hours before bed (or even sooner, if they lay on the couch).
●Patients should be counseled to avoid recumbency immediately after meals.

There are foods that may aggravate symptoms (coffee, chocolate, mints, wine, spicy/citrus foods), but it is not always helpful to eliminate all these types of foods. If the patient has a clear pattern of reflux from a specific food type however, they should consider avoiding that .

Refractory GERD:
The Reflux Strikes Back
If a patient continues to have reflux symptoms despite
●PPI use, then lifestyle, medication compliance, time of administration, and dose should be assessed. Switching to another PPI or increasing to twice a day may be considered in adherent patients, Adding a nighttime H2 blocker can be beneficial in patients with breakthrough nocturnal symptoms initially but unfortunately, they tend to lose that benefit overtime due to tachyphylaxis. Severe refractory GERD after PPI therapy requires an endoscopic investigation and, if that is inconclusive, a pH and/or impedance study.

Dr.Dilaram Khan
Assistant Professor Gastroenterology
Lady Reading Hospital Peshawar.

27/03/2026

HEPATOCELLULAR CARCINOMA (HCC)
Management Guidelines:
(BCLC based)
■1.Diagnosis
High-risk patients: ●Cirrhosis, HBV/HCV
■Screening: ●Ultrasound ± AFP every 6 months
■Diagnosis criteria:
●Triphasic CT / MRI showing arterial enhancement + venous washout
□No biopsy required if typical imaging
2. ■Staging (Barcelona Clinic Liver Cancer (BCLC) staging system)

Considers:
●Tumor size& number
●Liver functions (Child-Pugh class)
●Performance status (ECOG)
3. ■Management Algorithm
■VERY EARLY STAGE:
Perfirmance status:0
Child class A
Single tumor≤2 cm
Normal bilirubin & no portal hypertension
Rx options:
●Surgical resection
●Ablation(RFA/MWA)
■EARLY STAGE: (BCLC 0–A)
Criteria:
Single tumor ≤5 cm OR ≤3 nodules ≤3 cm
Preserved liver function
Treatment options:
●Liver transplantation → (Milan criteria) if no contraindication fir transplant.
If there are contra indication for transplant, then PEI OR ablation
■ INTERMEDIATE STAGE (BCLC B)
Criteria:
●Large/Multiple lesios
●Child class A-B
Perfirmane status:0
Treatment:
TACE (Transarterial Chemoembolization) → standard of care
OR TARE if there is PVT
■ADVANCED STAGE (BCLC C)
Criteria:
●Vascular invasion OR metastasis

ECOG 1–2
Treatment:
●Systemic therapy:
□Immunotherapy:
Atezolizumab + Bevacizumab (1st line)
□TKIs:
Sorafenib / Lenvatinib
■TERMINAL STAGE (BCLC D)

Criteria:
Poor liver function (Child C)
ECOG >2
Treatment:
●Best supportive / palliative care.

26/03/2026

Chronic Hepatitis B in Children: ✅Summarized Guidelines
1. ■ Initial Evaluation
Assess:
●HBsAg (≥6 months confirms chronic infection)
●HBeAg / Anti-HBe
●HBV DNA (viral load)
●ALT (persistently elevated?)
●Liver fibrosis:
Non-invasive (FibroScan)
●Rarely biopsy
●Screen for:
Co-infections (HCV, HIV)
●Family history of cirrhosis / HCC
2. ■ Phases of Chronic HBV Infection:
●Immune-tolerant phase
High HBV DNA, normal ALT
●Immune-active phase
High HBV DNA + elevated ALT
●Inactive carrier phase
Low DNA, normal ALT
●HBeAg-negative hepatitis
Fluctuating ALT and DNA
👉 Treatment decisions depend mainly on phase + liver inflammation:
3. ■ Indications for Treatment:
Treat children if:
✔ Persistent ALT elevation (>6 months)
✔ HBV DNA elevated
✔ Evidence of liver inflammation or fibrosis
✔ Cirrhosis (treat
regardless of ALT)

✅Usually NOT treated:
●Immune-tolerant children (monitor only)
4. ■First-Line Antiviral Therapy

Preferred drugs:
●Tenofovir disoproxil fumarate (≥2–12 yrs depending on guideline)
●Entecavir (≥2 yrs)
■Alternative:
●Pegylated interferon alpha
(selected cases, finite duration)
5.✅ Duration of Therapy:
●Long-term (often years)
Continue until:
●HBeAg seroconversion + ●sustained suppression
Ideally HBsAg loss (rare).
6. 🔁 Monitoring:
Every 3–6 months:
●ALT
●HBV DNA
●HBeAg status
Annually:
●Liver ultrasound (if high risk)
●Growth and renal function (esp. Tenofovir)
7.6. 🔁 Monitoring
Every 3–6 months:
ALT
HBV DNA
HBeAg status
Annually:
Liver ultrasound (if high risk)
Growth and renal function (esp. Tenofovir)
7.6. 🔁 Monitoring
Every 3–6 months:
ALT
HBV DNA
HBeAg status
Annually:
Liver ultrasound (if high risk)
Growth and renal function (esp. Tenofovir)
7. ■ Special Situations:
●Cirrhosis: Treat immediately
●Immunosuppression planned: Start prophylaxis

●Adolescents: Monitor adherence closely
●Family screening & vaccination essential
8. ■ Prevention:

●Birth dose HBV vaccine (within 24 hrs)&
HBIG for exposed newborns
●Household screening
■Key Takeaways:
Most children are monitored, not treated initially
Treat only when immune-active disease develops
Tenofovir / Entecavir = mainstay therapy
Lifelong follow-up is essential

.

25/03/2026

✅Every pain in Epigastric region is not pain of stomach.
It has a wide range of causes:
■From simple acid-related issues to serious cardiac or pancreatic disease. ■Here’s a clear, clinically useful classification:
🔹 1. Gastrointestinal Causes:
(Most Common)

●Peptic ulcer disease (gastric / duodenal)
●Gastritis
●Gastroesophageal reflux disease (GERD)
●Functional dyspepsia
●Gastric carcinoma (red flag in elderly/weight loss)
🔹 2. Hepatobiliary Causes:

●Gallstones (cholelithiasis)
●Acute cholecystitis
●Biliary colic
●Cholangitis
👉 Pain may radiate to right upper abdomen or back
🔹 3. Pancreatic Causes:

●Acute pancreatitis
●Chronic pancreatitis
●Pancreatic cancer
👉 Classically severe pain radiating to back
🔹 4. Cardiac Causes:
(Must NOT Miss ⚠️)
●Myocardial infarction (especially inferior wall MI)
●Angina
👉 Can mimic acidity → Always rule out in high-risk patients.

5. Other Causes:
●Abdominal aortic aneurysm (AAA)
●Herpes zoster (before rash)
●Musculoskeletal pain
●Anxiety / functional causes
🚩 Red Flag Symptoms:
●Weight loss
●Persistent vomiting
●GI bleeding (hematemesis/melena)
●Dysphagia
●Age > 50 with new symptoms.

✅ Quick Clinical Approach:

Burning + relation to meals → PUD / GERD
Severe + radiates to back → Pancreatitis
Post-fatty meal → Gallstones
With sweating / dyspnea → Cardiac cause.

23/03/2026

Role of Neuromodulators in GI Diseases:
🔹 What are Neuromodulators?:
Neuromodulators are medications that alter gut–brain axis signaling, affecting:
●Visceral sensitivity
●GI motility
●Central pain perception
●Psychological comorbidity (anxiety/depression).

✅They are not primarily used for psychiatric disease in GI practice, but for symptom modulation.

🔹 Why are they used in GI disorders?
Many GI disorders (especially functional) involve:
●Visceral hypersensitivity
●Dysregulated gut–brain interaction
●Altered motility
➡️ Neuromodulators help by:

↓ Pain perception
↓ Gut hypersensitivity
●Normalize motility
●Improve sleep & stress response
🔹 Common GI Indications:

1. Functional GI Disorders (FGIDs / DGBIs)
●Irritable Bowel Syndrome (IBS)
●Functional dyspepsia
●Functional chest pain
●Functional abdominal pain
2. Esophageal Disorders
●Functional heartburn
●Reflux hypersensitivity
3. Chronic Nausea & Vomiting Syndromes
4. Centrally Mediated Abdominal Pain Syndrome (CAPS)
🔹 Classes of Neuromodulators & Their Roles
1. Tricyclic Antidepressants (TCAs)
Examples: ●Amitriptyline, ●Nortriptyline, ●Imipramine

Mechanism:
Anticholinergic → ○slows gut
Central analgesic effect
Best for:
●IBS-D
●Functional abdominal pain
●Diarrhea-predominant symptoms
✅Benefits:
↓ Pain
↓ Stool frequency
Side effects:
●Dry mouth
●Constipation
●Drowsiness
2. Selective Serotonin Reuptake Inhibitors (SSRIs)
Examples: ●Fluoxetine, ●Sertraline, ●Citalopram

Mechanism:
Enhance serotonergic signaling
Improve mood + gut motility
✅Best for:
●IBS-C
●Anxiety-associated GI symptoms
✅Benefits:
↑ Motility
↓ Anxiety
Limitations:

Less analgesic effect than TCAs.
3.Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
Examples: ●Duloxetine, ●Venlafaxine
✅Mechanism:
Central pain modulation
✅Best for:
●Chronic abdominal pain
●Functional pain syndromes

4. Mirtazapine
Mechanism:
□Noradrenergic & serotonergic modulation
✅Best for:
●Functional dyspepsia
●Early satiety
●Weight loss
5. Gabapentinoids
Examples: ●Gabapentin, ●Pregabalin
✅Mechanism:
Reduce visceral hypersensitivity
✅Best for:
●Refractory abdominal pain
●Esophageal hypersensitivity.

6. Buspirone

Mechanism:
5-HT1A agonist → gastric fundus relaxation
✅Best for:

●Functional dyspepsia (impaired accommodation).
🔹 Practical Clinical Approach:

Symptom
Preferred Neuromodulator
■Pain + diarrhea
●TCA
■Pain + constipation
●SSRI
■Severe pain
SNRI / TCA

■Early satiety
●Mirtazapine / Buspirone.
■Anxiety prominent
●SSRI
🔹 Key Clinical Principles:

Start low dose, titrate slowly
Effects seen after 2–4 weeks
Use doses lower than psychiatric doses
Continue for 6–12 months if effective
Combine with:
Diet (low FODMAP)
Psychological therapy (CBT)
🔹 Important Counseling Points
“This is for gut–brain modulation, not for depression alone”
Improves pain perception, not structural disease
Temporary therapy in many patients
🔹 Summary
Neuromodulators are cornerstone therapy in functional GI disorders, targeting the gut–brain axis rather than structural pathology. They significantly improve pain, motility, and quality of life when used appropriately.



.
.

23/03/2026

23/03/2026

22/03/2026

✅Treatment of Hepatitis B during pregnancy to prevent transmission to the baby:
1. ✅Screening & Initial Assessment:
■Screen all pregnant women for HBsAg
●If positive:
■Check HBV DNA level
■ALT (liver enzymes)
■HBeAg status
2.✅ Who Needs Treatment?::
A. ◇For Maternal Health ( Treatment is same as for non-pregnant) which is:
■Start antiviral therapy if:
●Elevated ALT
●High HBV DNA
●Cirrhosis or advanced fibrosis
B. ◇For Prevention of Mother-to-Child Transmission (MTCT)
If HBV DNA > 200,000 IU/mL 👉 Start antiviral therapy in 3rd trimester (28–32 weeks)
3. Preferred Antiviral Drugs:
Safe in pregnancy:
✅ Tenofovir (TDF) → Drug of choice
Alternative: Lamivudine, Telbivudine (less preferred)

❌ Avoid:
Entecavir
Interferon (contraindicated)
4. Neonatal Management (Most Important Step)
■At birth (within 12 hours):
●HBV vaccine (1st dose) 0.5 ml
●HBIG (Hepatitis B Immunoglobulin) 0.5 ml
➡️ This reduces transmission risk to new born
5. Breastfeeding:
✅ Safe if infant received vaccine + HBIG
Tenofovir is safe during breastfeeding
6. Postpartum Management:
Continue antivirals for:
At least 12 weeks postpartum (if started for MTCT prevention)
Monitor for hepatic flare after stopping therapy
7. Follow-Up:
Monitor:
●ALT
●HBV DNA
Infant:
●Test for HBsAg and anti-HBs at 9–12 months
🔑 Key Takeaways:
●Screen All pregnant women
●Start Tenofovir at 28–32 weeks if HBV DNA >200,000 IU/mL
●Give vaccine + HBIG at birth
●Breastfeeding is safe.
.
.

22/03/2026

Cirrhosis of Liver – Summary Guidelines:
✅Definition:
Chronic, progressive liver disease characterized by:
●Fibrosis
●Regenerative nodules
●Distorted liver architecture → portal hypertension + liver failure
✅Common Causes: (Etiology)
1. ✅Alcohol-related liver disease
Most common in western world
2. ✅Chronic Viral Hepatitis
Hepatitis B
Hepatitis C
(Common in asia)
3. ✅NAFLD / NASH
Strongly linked with:
●Obesity
●Diabetes
●Metabolic syndrome
4. ✅Genetic / Metabolic
●Hemochromatosis
●Wilson’s disease
●Alpha-1 antitrypsin
deficiency
5.✅ Autoimmune
●Autoimmune hepatitis
●Primary biliary cholangitis
●Primary sclerosing cholangitis
6.✅ Drugs / Toxins:

●Methotrexate
●Amiodarone
7. ✅Others
●Congestive hepatopathy (right heart failure)
●Budd–Chiari syndrome.
✔️Clinical Features:
■Compensated Cirrhosis
●Often asymptomatic
●Mild fatigue
●Hepatomegaly
■Decompensated Cirrhosis

●Ascites
●Jaundice
Variceal bleeding

●Hepatic encephalopathy.
✔️Evaluation:
■Labs:

●LFTs (AST/ALT, bilirubin)
●INR (synthetic function)
●Albumin ↓
●Platelets ↓
✔️Scores:

■Child-Pugh score
■MELD score → transplant priority
✔️Imaging:

●Ultrasound abdomen
●Fibroscan
✔️Screening:
●HCC surveillance → ●USG ± AFP every 6 months.
✅Management Guidelines:
1. Treat Underlying Cause:
●Alcohol abstinence
●Antivirals (HBV/HCV)
●Weight loss (NAFLD)
●Immunosuppressants (autoimmune)
2. General Measures:
●Nutrition: high protein (unless encephalopathy severe)
●Vaccination:
Hep A
Hep B
●Avoid hepatotoxic drugs (NSAIDs caution)
3. Management of Complications
■Ascites:

●Salt restriction (

22/03/2026

دو ھفتے کی چھٹی مکمل ھونے کے بعد کلینک انشاءاللہ بروز منگل 24 مارچ سے کھلا رھے گا۔
03005883758

21/03/2026

Levosulpiride is a prokinetic and antipsychotic agent and is very frequently used in Gastroenterology practice.
It is not always without side effects ، however the side effects are very rare in practice
✅Common Side Effects:
■Central Nervous System
●Drowsiness / sedation
●Dizziness
Headache
✅Gastrointestinal:
●Nausea
●Constipation or sometimes diarrhea

●Abdominal discomfort
✅Endocrine (Hyperprolactinemia-related):
●Galactorrhea (milk discharge)
●Menstrual irregularities (amenorrhea)
●Decreased libido / sexual dysfunction

✅Cardiovascular:
●Palpitations (rare)
●Postural hypotension
✅Extrapyramidal Symptoms (EPS) (less common but important)
●Tremors
●Rigidity
●Akathisia (restlessness)

●Dystonia
✔️Important Clinical Note:
■Long-term use → higher risk of hyperprolactinemia and EPS
■Use cautiously in elderly patients and those with Parkinsonism۔