Sameen Khalid | Government College University, Lahore (original) (raw)

Papers by Sameen Khalid

Cureus, 2018

Pancreatic pseudocyst is a complication that can arise in both acute and chronic pancreatitis. Ov... more Pancreatic pseudocyst is a complication that can arise in both acute and chronic pancreatitis. Overtime, this encapsulated enzyme-rich fluid collection may erode into surrounding vasculature and result in the formation of a pseudoaneurysm. Pseudoaneurysms can rupture into the gastrointestinal tract and present as upper, lower, and biliary bleeding. Evaluation of pancreatic pseudocysts involves computed tomography imaging or magnetic resonance imaging for both identification and monitoring. Esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) can be done to further visualize the lesion. In the presence of gastrointestinal bleed, management involves the combination of interventional radiology and surgery.

Cureus, 2020

Iatrogenic perforation is a known and feared complication of diagnostic and therapeutic colonosco... more Iatrogenic perforation is a known and feared complication of diagnostic and therapeutic colonoscopy. Specific locations in the gastrointestinal tract, such as the jejunum, have a higher risk of perforation owing to its difficult anatomical position. Over-the-scope clips have recently been used for the management of these perforations. We present the case of a 40-year-old male patient treated with over-the-scope (Ovesco ® , Ovesco Endoscopy AG, Tübingen, Germany) clips for an iatrogenic postpolypectomy perforation with subsequent anal pain and inability to evacuate stool occurring as a result of the migration of the clip, followed by a review of the literature.

European Journal of Radiology Open, 2021

Highlights • Learning Point #1: Small ulcers on esophagography are usually attributable to herpes... more Highlights • Learning Point #1: Small ulcers on esophagography are usually attributable to herpes esophagitis and drug-induced esophagitis. Although rare, Crohn’s disease may produce small apthoid ulcers. Large ulcers are usually attributable to CMV or HIV esophagitis.• Learning Point #2: The early findings of candida are plaques that mimic glycogenic acanthosis. When plaques are seen, consider early candida or glycogenic acanthosis. When shaggy esophagus is identified, consider candidiasis.• Learning Point #3: Varices and varicoid esophageal carcinoma may appear similar on imaging. The presence of obstruction and lack of change with time and position should sway the Radiologist to diagnosing varicoid esophageal carcinoma.• Learning Point #4: Transverse esophageal lines should suggest the entities of feline esophagus and idiopathic eosinophilic esophagitis.• Learning Point #5: Esophageal contour abnormalities may suggest extrinsic or intrinsic lesions. Extrinsic lesions include aberrant vessels. Intrinsic lesions include intramural pseudodiverticulosis, gastroesophageal reflux, Barrett’s esophagus, and esophageal cancer.

Digestive Diseases and Sciences, 2021

An obese 64-year-old pre-diabetic Navajo woman (BMI: 36) was initially treated for hypoxemic resp... more An obese 64-year-old pre-diabetic Navajo woman (BMI: 36) was initially treated for hypoxemic respiratory failure due to interstitial lung disease (ILD) and cryptogenic organizing pneumonia (COP). She was begun on long-term treatment with prednisone 20 mg/day and, due to an allergy to sulfa drugs, was also given atovaquone 1.5 g/day as prophylaxis for Pneumocystis jirovecii pneumonia. Two months later, she was admitted to hospital with asymmetrical leg swelling due to deep venous thrombosis (DVT) in her left leg with concurrent right pulmonary artery embolism: there was no evidence of right ventricular dysfunction; left ventricular ejection fraction was normal. A basic metabolic panel showed normal electrolytes, blood urea nitrogen and serum creatinine. A complete blood count demonstrated a slightly elevated white cell count of 12,000/μl (4000–11000 cells/ μl), consistent with steroid use, a hemoglobin of 11 mg/dl, and a platelet count of 210 × 103 (150–405 × 103 cells/μl). She was started on a therapeutic dose of apixaban in order to prevent additional thromboses. During the same admission, scleral icterus was noted on physical examination but no stigmata of chronic liver disease, e.g., palmar erythema, spider nevi, telangiectasia, ascites, hepatosplenomegaly, or asterixis were present. She denied any history of previous chronic liver disease, excessive alcohol use, family history of liver disease, or use of over-the-counter medications, herbal or nutritional supplements, or recreational drugs. She had had no exposure to fumes or other chemicals in the course of occupational or recreational activities. At her first admission, prior to initiation of systemic steroid and atovaquone therapies, she had normal liver test results, with serum concentrations of alanine aminotransferase (ALT) 32 U/L (14–67 U/L), aspartate aminotransferase (AST) 29 U/L (6–58 U/L), alkaline phosphatase (ALP) 86 U/L (38–150 U/L), total bilirubin 0.8 mg/dl (0.3–1.2 mg/dl), direct bilirubin 0.2 mg/dl (0.1–0.4 mg/dl), albumin 4.1 mmol/l (3.5–5.1 mmol/l) and internationalized normalized ratio (INR) of 1.0. Nevertheless, during her recent admission, abnormal tests included serum concentrations of AST 530 U/L, ALT 970 U/L, ALP 245 U/L, total bilirubin 2.1 mg/dl, direct bilirubin 1.8 mg/ dl, albumin 3.7 mmol/L and INR 1.3. The R factor was calculated to be 11.9, consistent with hepatocellular injury. Additional investigations revealed the following: serum TSH was mildly elevated (5.70 μU/mL [normal range: 0.5–5 μU/ mL]) and normal values of free T3 and T4; serum salicylate and acetaminophen were undetectable. Urine toxicology was unremarkable. Serologic tests for HCV Ab, CMV IgM, HBsAg, HBc Ab, HBsAb, HAV IgM, HIV, HSV IgM, EBV IgM were all negative. Serum ferritin was markedly elevated at 4079 ng/ml (20–200 ng/ml), possibly due to an acute phase reaction, though iron saturation was normal at 24%. Serum A1AT was 162 mg/dl (90–200 mg/dl) with a normal MM phenotype, and serum ceruloplasmin was 24 mg/ dl (17–46 mg/dl). Serum lactic dehydrogenase concentration of 346 units/L (117–224 units/L) was mildly elevated and her ANA titer of 1:40 (homogenous pattern) was weakly positive, but tests for anti-smooth muscle antibody, soluble anti-liver/kidney microsomal antibody and IgG concentrations were all normal. Computerized tomographic (CT) scan of abdomen and pelvis (with contrast) revealed calcified gallstones in the gallbladder without evidence of cholecystitis, and a common bile duct diameter of 3 mm, but no splenomegaly, liver parenchymal changes, abnormalities of * Aamer Abbass aabbass@salud.unm.edu

The American Journal of Gastroenterology, 2017

infection in the past, no other medical history. No previous EGD/colonoscopy. No family history o... more infection in the past, no other medical history. No previous EGD/colonoscopy. No family history of GI malignancy. Reports marijuana use and occasional cocaine use. His vital signs were unremarkable. On exam, his abdomen was soft, non-distended and non-tender in all 4 quadrants. Review of the medical records revealed previous liver ultrasound reporting SIT. Labs were unremarkable including CMP, CBC, Stool H. Pylori Ag, Hepatitis C Ab. An abdominal CT is with contrast was ordered. He was started on an empiric trial of omeprazole for symptomatic relief, and followed up in 2 months with no relief. Labs were unremarkable and imaging was notable only for SIT. He reported continued symptoms at this follow-up visit. The patient was subsequently lost to follow-up and unavailable by phone. In patients with a family history or personal history of SIT, it is important to consider the implications this may have on their presenting symptoms. This awareness can aid in the timely diagnosis of common conditions such as appendicitis, diverticulitis and biliary colic where the physical exam findings would be on the opposite side. Intestinal ischemia in SIT patients related to intestinal malrotation or mestenteric hernias is reported in the literature. Special consideration should be taken for procedural approach if abdominal interventions are required. Anatomy should not impede this, as techniques and approaches have been reported for patients with SIT requiring laparoscopic cholecystectomy, percutaneous biliary stenting, therapeutic ERCP and even liver transplantation.

Cureus, 2016

A Dieulafoy's lesion is described as a tortuous, dilated aberrant submucosal vessel that can pene... more A Dieulafoy's lesion is described as a tortuous, dilated aberrant submucosal vessel that can penetrate through the mucosa and rupture spontaneously, resulting in severe gastrointestinal bleeding. The lesion is most commonly found in the proximal stomach. Historically, it has had up to an 80% mortality rate because of its tendency to cause intermittent but severe bleeding and diagnostic challenges. We report a case of a young male with recurrent severe upper gastrointestinal bleeding with extensive prior investigations failing to reveal the source of bleeding. Computed tomography angiography of the abdomen correctly identified Dieulafoy's lesion of the stomach, and it was subsequently confirmed and successfully treated with interventional radiology (IR)-guided mesenteric angiography and embolization.

JPMA. The Journal of the Pakistan Medical Association, 2014

To assess the awareness and perception of students attending professional medicine, law and busin... more To assess the awareness and perception of students attending professional medicine, law and business schools regarding recreational use of cannabis. The cross-sectional study was conducted between June 2010 and November 2010. Using convenience sampling, 150 students from medical, business and law schools from both private and public sectors were enrolled. Government institutions included, Sindh Medical College, Institute of Business Administration and S.M. Law College, private schools were Ziauddin Medical College, SZABIST and Lecole for advanced studies. Data was collected through self-administered questionnaire. SPSS 17 was used for statistical analysis. A total of 250 students were approached out of which 150(60%) filled the questionnaire. Of them 91(60.7%) were males and the overall mean age of the respondents was 22 ± 2 years. A total of 68 (45.3%) students were from the medical field, 53 (35.3%) from business and 29 (19.3%) from law. The private and public sectors were equally...

Digestive Diseases and Sciences

Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is... more Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is commonly associated with several gastrointestinal (GI) side effects. Here we present a case of giant gastric ulcer of 5 cm from MMF use post cardiac transplant. Case Description A 56-year-old male with history of severe ischemic cardiomyopathy post heart transplant was on immunosuppression with MMF, tacrolimus and prednisone for 5 months. He presented with severe epigastric pain and intermittent episodes of melena for 1 month. His pain radiated to back that is worsened with eating. Associated with loss of appetite, vomiting and 16-pound weight loss in 3 months. He never smoked, drank alcohol or used over the counter pain medications. He was profoundly anemic requiring blood transfusions. EGD performed demonstrated very large clean-based ulcer of 5 cm diameter in the body, smaller ulcer of 8 mm diameter in pre-pyloric region and 5-10 small aphthous ulcers in the gastric body and fundus. Gastric biopsies taken from the ulcer were negative for Helicobacter pylori, cytomegalovirus and malignancy. Flexible sigmoidoscopy revealed non-bleeding inflamed internal hemorrhoids. Consequently, MMF was discontinued and switched to azathioprine. He was treated with twice daily proton pump inhibitor therapy with resolution of abdominal pain, improved appetite and weight gain. Discussion MMF is well known for common GI side-effects such as nausea, diarrhea, vomiting, ulcers, abdominal pain and rarely gastrointestinal bleeding. Few studies reported 3 to 8% incidence of ulcer perforation and GI bleeding within 6 months. Risk of gastroduodenal erosions is nearly 1.83 times for MMF, with the highest lesions associated with MMFtacrolimus-corticosteroid combination treatment as seen in our patient. Hypothesis is that GI tract is vulnerable because of dependence of enterocytes on de novo synthesis of purines, which is disrupted by MMF. Typically, upper GI mucosal injuries of mucosal irritation leading to esophagitis, gastritis and/or ulcers are seen. Endoscopy is both diagnostic and therapeutic if bleeding gastric ulcers are noted. Minor complications improve with reduction of drug dose or use of enteric coated preparation if feasible. Discontinuation of the drug is main stay in the management of MMF related ulcer disease. Simple medical treatment with either H2-receptor antagonists, proton-pump inhibitors, coating agents, prostaglandins or combination has proven effective in most cases. Considering excellent results with medical management of ulcer, role of surgery is limited.

Digestive Diseases and Sciences

Gastrointestinal Endoscopy

Gastrointestinal Endoscopy

The American Journal of Gastroenterology

Digestive Diseases and Sciences

Digestive Diseases and Sciences

American Journal of Gastroenterology

American Journal of Gastroenterology

American Journal of Gastroenterology

American Journal of Gastroenterology

Cureus, 2018

Pancreatic pseudocyst is a complication that can arise in both acute and chronic pancreatitis. Ov... more Pancreatic pseudocyst is a complication that can arise in both acute and chronic pancreatitis. Overtime, this encapsulated enzyme-rich fluid collection may erode into surrounding vasculature and result in the formation of a pseudoaneurysm. Pseudoaneurysms can rupture into the gastrointestinal tract and present as upper, lower, and biliary bleeding. Evaluation of pancreatic pseudocysts involves computed tomography imaging or magnetic resonance imaging for both identification and monitoring. Esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) can be done to further visualize the lesion. In the presence of gastrointestinal bleed, management involves the combination of interventional radiology and surgery.

Cureus, 2020

Iatrogenic perforation is a known and feared complication of diagnostic and therapeutic colonosco... more Iatrogenic perforation is a known and feared complication of diagnostic and therapeutic colonoscopy. Specific locations in the gastrointestinal tract, such as the jejunum, have a higher risk of perforation owing to its difficult anatomical position. Over-the-scope clips have recently been used for the management of these perforations. We present the case of a 40-year-old male patient treated with over-the-scope (Ovesco ® , Ovesco Endoscopy AG, Tübingen, Germany) clips for an iatrogenic postpolypectomy perforation with subsequent anal pain and inability to evacuate stool occurring as a result of the migration of the clip, followed by a review of the literature.

European Journal of Radiology Open, 2021

Highlights • Learning Point #1: Small ulcers on esophagography are usually attributable to herpes... more Highlights • Learning Point #1: Small ulcers on esophagography are usually attributable to herpes esophagitis and drug-induced esophagitis. Although rare, Crohn’s disease may produce small apthoid ulcers. Large ulcers are usually attributable to CMV or HIV esophagitis.• Learning Point #2: The early findings of candida are plaques that mimic glycogenic acanthosis. When plaques are seen, consider early candida or glycogenic acanthosis. When shaggy esophagus is identified, consider candidiasis.• Learning Point #3: Varices and varicoid esophageal carcinoma may appear similar on imaging. The presence of obstruction and lack of change with time and position should sway the Radiologist to diagnosing varicoid esophageal carcinoma.• Learning Point #4: Transverse esophageal lines should suggest the entities of feline esophagus and idiopathic eosinophilic esophagitis.• Learning Point #5: Esophageal contour abnormalities may suggest extrinsic or intrinsic lesions. Extrinsic lesions include aberrant vessels. Intrinsic lesions include intramural pseudodiverticulosis, gastroesophageal reflux, Barrett’s esophagus, and esophageal cancer.

Digestive Diseases and Sciences, 2021

An obese 64-year-old pre-diabetic Navajo woman (BMI: 36) was initially treated for hypoxemic resp... more An obese 64-year-old pre-diabetic Navajo woman (BMI: 36) was initially treated for hypoxemic respiratory failure due to interstitial lung disease (ILD) and cryptogenic organizing pneumonia (COP). She was begun on long-term treatment with prednisone 20 mg/day and, due to an allergy to sulfa drugs, was also given atovaquone 1.5 g/day as prophylaxis for Pneumocystis jirovecii pneumonia. Two months later, she was admitted to hospital with asymmetrical leg swelling due to deep venous thrombosis (DVT) in her left leg with concurrent right pulmonary artery embolism: there was no evidence of right ventricular dysfunction; left ventricular ejection fraction was normal. A basic metabolic panel showed normal electrolytes, blood urea nitrogen and serum creatinine. A complete blood count demonstrated a slightly elevated white cell count of 12,000/μl (4000–11000 cells/ μl), consistent with steroid use, a hemoglobin of 11 mg/dl, and a platelet count of 210 × 103 (150–405 × 103 cells/μl). She was started on a therapeutic dose of apixaban in order to prevent additional thromboses. During the same admission, scleral icterus was noted on physical examination but no stigmata of chronic liver disease, e.g., palmar erythema, spider nevi, telangiectasia, ascites, hepatosplenomegaly, or asterixis were present. She denied any history of previous chronic liver disease, excessive alcohol use, family history of liver disease, or use of over-the-counter medications, herbal or nutritional supplements, or recreational drugs. She had had no exposure to fumes or other chemicals in the course of occupational or recreational activities. At her first admission, prior to initiation of systemic steroid and atovaquone therapies, she had normal liver test results, with serum concentrations of alanine aminotransferase (ALT) 32 U/L (14–67 U/L), aspartate aminotransferase (AST) 29 U/L (6–58 U/L), alkaline phosphatase (ALP) 86 U/L (38–150 U/L), total bilirubin 0.8 mg/dl (0.3–1.2 mg/dl), direct bilirubin 0.2 mg/dl (0.1–0.4 mg/dl), albumin 4.1 mmol/l (3.5–5.1 mmol/l) and internationalized normalized ratio (INR) of 1.0. Nevertheless, during her recent admission, abnormal tests included serum concentrations of AST 530 U/L, ALT 970 U/L, ALP 245 U/L, total bilirubin 2.1 mg/dl, direct bilirubin 1.8 mg/ dl, albumin 3.7 mmol/L and INR 1.3. The R factor was calculated to be 11.9, consistent with hepatocellular injury. Additional investigations revealed the following: serum TSH was mildly elevated (5.70 μU/mL [normal range: 0.5–5 μU/ mL]) and normal values of free T3 and T4; serum salicylate and acetaminophen were undetectable. Urine toxicology was unremarkable. Serologic tests for HCV Ab, CMV IgM, HBsAg, HBc Ab, HBsAb, HAV IgM, HIV, HSV IgM, EBV IgM were all negative. Serum ferritin was markedly elevated at 4079 ng/ml (20–200 ng/ml), possibly due to an acute phase reaction, though iron saturation was normal at 24%. Serum A1AT was 162 mg/dl (90–200 mg/dl) with a normal MM phenotype, and serum ceruloplasmin was 24 mg/ dl (17–46 mg/dl). Serum lactic dehydrogenase concentration of 346 units/L (117–224 units/L) was mildly elevated and her ANA titer of 1:40 (homogenous pattern) was weakly positive, but tests for anti-smooth muscle antibody, soluble anti-liver/kidney microsomal antibody and IgG concentrations were all normal. Computerized tomographic (CT) scan of abdomen and pelvis (with contrast) revealed calcified gallstones in the gallbladder without evidence of cholecystitis, and a common bile duct diameter of 3 mm, but no splenomegaly, liver parenchymal changes, abnormalities of * Aamer Abbass aabbass@salud.unm.edu

The American Journal of Gastroenterology, 2017

infection in the past, no other medical history. No previous EGD/colonoscopy. No family history o... more infection in the past, no other medical history. No previous EGD/colonoscopy. No family history of GI malignancy. Reports marijuana use and occasional cocaine use. His vital signs were unremarkable. On exam, his abdomen was soft, non-distended and non-tender in all 4 quadrants. Review of the medical records revealed previous liver ultrasound reporting SIT. Labs were unremarkable including CMP, CBC, Stool H. Pylori Ag, Hepatitis C Ab. An abdominal CT is with contrast was ordered. He was started on an empiric trial of omeprazole for symptomatic relief, and followed up in 2 months with no relief. Labs were unremarkable and imaging was notable only for SIT. He reported continued symptoms at this follow-up visit. The patient was subsequently lost to follow-up and unavailable by phone. In patients with a family history or personal history of SIT, it is important to consider the implications this may have on their presenting symptoms. This awareness can aid in the timely diagnosis of common conditions such as appendicitis, diverticulitis and biliary colic where the physical exam findings would be on the opposite side. Intestinal ischemia in SIT patients related to intestinal malrotation or mestenteric hernias is reported in the literature. Special consideration should be taken for procedural approach if abdominal interventions are required. Anatomy should not impede this, as techniques and approaches have been reported for patients with SIT requiring laparoscopic cholecystectomy, percutaneous biliary stenting, therapeutic ERCP and even liver transplantation.

Cureus, 2016

A Dieulafoy's lesion is described as a tortuous, dilated aberrant submucosal vessel that can pene... more A Dieulafoy's lesion is described as a tortuous, dilated aberrant submucosal vessel that can penetrate through the mucosa and rupture spontaneously, resulting in severe gastrointestinal bleeding. The lesion is most commonly found in the proximal stomach. Historically, it has had up to an 80% mortality rate because of its tendency to cause intermittent but severe bleeding and diagnostic challenges. We report a case of a young male with recurrent severe upper gastrointestinal bleeding with extensive prior investigations failing to reveal the source of bleeding. Computed tomography angiography of the abdomen correctly identified Dieulafoy's lesion of the stomach, and it was subsequently confirmed and successfully treated with interventional radiology (IR)-guided mesenteric angiography and embolization.

JPMA. The Journal of the Pakistan Medical Association, 2014

To assess the awareness and perception of students attending professional medicine, law and busin... more To assess the awareness and perception of students attending professional medicine, law and business schools regarding recreational use of cannabis. The cross-sectional study was conducted between June 2010 and November 2010. Using convenience sampling, 150 students from medical, business and law schools from both private and public sectors were enrolled. Government institutions included, Sindh Medical College, Institute of Business Administration and S.M. Law College, private schools were Ziauddin Medical College, SZABIST and Lecole for advanced studies. Data was collected through self-administered questionnaire. SPSS 17 was used for statistical analysis. A total of 250 students were approached out of which 150(60%) filled the questionnaire. Of them 91(60.7%) were males and the overall mean age of the respondents was 22 ± 2 years. A total of 68 (45.3%) students were from the medical field, 53 (35.3%) from business and 29 (19.3%) from law. The private and public sectors were equally...

Digestive Diseases and Sciences

Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is... more Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is commonly associated with several gastrointestinal (GI) side effects. Here we present a case of giant gastric ulcer of 5 cm from MMF use post cardiac transplant. Case Description A 56-year-old male with history of severe ischemic cardiomyopathy post heart transplant was on immunosuppression with MMF, tacrolimus and prednisone for 5 months. He presented with severe epigastric pain and intermittent episodes of melena for 1 month. His pain radiated to back that is worsened with eating. Associated with loss of appetite, vomiting and 16-pound weight loss in 3 months. He never smoked, drank alcohol or used over the counter pain medications. He was profoundly anemic requiring blood transfusions. EGD performed demonstrated very large clean-based ulcer of 5 cm diameter in the body, smaller ulcer of 8 mm diameter in pre-pyloric region and 5-10 small aphthous ulcers in the gastric body and fundus. Gastric biopsies taken from the ulcer were negative for Helicobacter pylori, cytomegalovirus and malignancy. Flexible sigmoidoscopy revealed non-bleeding inflamed internal hemorrhoids. Consequently, MMF was discontinued and switched to azathioprine. He was treated with twice daily proton pump inhibitor therapy with resolution of abdominal pain, improved appetite and weight gain. Discussion MMF is well known for common GI side-effects such as nausea, diarrhea, vomiting, ulcers, abdominal pain and rarely gastrointestinal bleeding. Few studies reported 3 to 8% incidence of ulcer perforation and GI bleeding within 6 months. Risk of gastroduodenal erosions is nearly 1.83 times for MMF, with the highest lesions associated with MMFtacrolimus-corticosteroid combination treatment as seen in our patient. Hypothesis is that GI tract is vulnerable because of dependence of enterocytes on de novo synthesis of purines, which is disrupted by MMF. Typically, upper GI mucosal injuries of mucosal irritation leading to esophagitis, gastritis and/or ulcers are seen. Endoscopy is both diagnostic and therapeutic if bleeding gastric ulcers are noted. Minor complications improve with reduction of drug dose or use of enteric coated preparation if feasible. Discontinuation of the drug is main stay in the management of MMF related ulcer disease. Simple medical treatment with either H2-receptor antagonists, proton-pump inhibitors, coating agents, prostaglandins or combination has proven effective in most cases. Considering excellent results with medical management of ulcer, role of surgery is limited.

Digestive Diseases and Sciences

Gastrointestinal Endoscopy

Gastrointestinal Endoscopy

The American Journal of Gastroenterology

Digestive Diseases and Sciences

Digestive Diseases and Sciences

American Journal of Gastroenterology

American Journal of Gastroenterology

American Journal of Gastroenterology

American Journal of Gastroenterology