Variceal bleeding: current issues

Portal hypertension [PHT] is a serious sequel of liver cirrhosis. Eventually, varices develop, grow in size, and bleed. Several diagnostic modalities including transient elastography [TE], capsule endoscopy, CT scanning, and platelets count/spleen diameter ratio [PSR] have recently been introduced. Predictors of bleeding include large varices, red signs, severe liver disease, and hepatic venous pressure gradient [HVPG]12 mmHg. Oral nonselective [NSBB] are recommended for primary prophylaxis in patients with medium-to-large size esophageal varices [EV] that have not bled. Patients with acute variceal bleeding [AVB] should be resuscitated and managed in an intensive care unit. Vasoactive drugs should be started immediately aimed at a better control of bleeding and facilitation of a subsequent endoscopy. Terlipressin controls bleeding and mortality and is considered as the drug of choice. Antibiotic prophylaxis significantly improves survival compared with placebo. Early diagnostic and therapeutic endoscopy in patients with major bleeding enhances control of bleeding, reduces risks of rebleeding and mortality. The use of erythromycin prior to endoscopy clears the stomach, reduces the need for second endoscopy and blood transfusion, and shortens the length of hospital stay. Restricted transfusion strategy prevents portal pressure rise and improves the survival rate. The current recommendation is to treat AVB with a combination of vasoactive agent, EVL, and antibiotics. All patients who survive an episode of AVB should undergo secondary prophylaxis. Transjugular intrahepatic portosystemic shunt [TIPS] using covered stent represents the first-choice rescue treatment. Early TIPS insertion significantly reduces treatment failure, rebleeding, and mortality. Also, insertion of esophageal SX-Ella Danis stent in patients with refractory VB effectively controls bleeding. The data required for this review were obtained mainly through PubMed and Google search

Crohn's disease. Increasing trend in Saudi Arabia

We attempted, through systematic review to explore the epidemiology and risk factors of Crohn's disease [CD] with special attention to the Kingdom of Saudi Arabia [KSA]. We selected articles that contained population-based, epidemiological, and clinical character studies of CD. We collected data concerned with the prevalence, demographic features, and the possible etiology of CD that might explain its emergence in KSA. The prevalence of CD in Western countries ranged between 11-43/100,000 with flawless evidence of CD prevalence emerging in previously low incidence areas like Asia. Prevalence in KSA has markedly increased over the last 3 decades. Combined ileal and colonic involvement was the most frequently affected site. Diet, smoking, drugs, and westernization of life are assumed to contribute to the pathogenesis. There is convincing evidence of CD emerging in Asia, including KSA. Westernization of lifestyle and smoking is probably the major contributing factors. Genetic studies are warranted

Emerging inflammatory bowel disease in Saudi outpatients: a report of 693 cases

Inflammatory bowel disease [IBD] is a chronic disease of unknown etiology and considered traditionally as a disease of the western world. Recently, rising trends have been observed in countries previously known to have a low prevalence and incidence. The aim of this study is to collect epidemiological data on IBD outpatients and to add data from the Kingdom of Saudi Arabia [KSA] to the available IBD literature. The medical records of 693 Saudi patients with IBD over a period of 17 years, between 1993 and 2009, were reviewed. The demographic and clinical data and methods of diagnosis were retrieved. The total number of patients in this cohort was 693. It constituted 238 [34.3%] ulcerative colitis [UC] and 455 [65.7%] Crohn's disease [CD] patients. UC was steady throughout the years, whereas only 1.2 CD patients were diagnosed per year in the first 11 years, and 73.7 per year in the last six years. The median age of UC patients was 34 years, ranging from 10 to 80 years with a peak between 21 and 40 years and in CD it was 27 years, ranging from 11 to 73 years with a peak between 11 and 30 years. There was a male preponderance of 1.5:1 and 2:1, respectively. The rest of the data is discussed in this study. IBD is no longer a rare disease in KSA. UC is in a steady state, whereas CD is increasing significantly and far outnumbering UC

Crohn's disease in a Saudi outpatient population: is it still rare?

To determine the epidemiology of Crohn's disease [CD] in an outpatient clinic and compare it with data previously reported from different centers in the Kingdom of Saudi Arabia and outside. The medical records of all patients with CD seen in the clinic in the period from January 1993 through December 2007 were reviewed. The demographic, clinical data and methods of diagnosis were retrieved. Over a period of 15 years, we saw 133 Saudi patients with CD. They were predominantly young, with a median age of 26.2 years and male preponderance [2.3:1]. The final diagnosis was established within 1 week of presentation in 47% of the patients. The leading symptoms were abdominal pain [88%], diarrhea [70%], bloating [61%], rectal bleeding [50%], weight loss [33%], constipation [24%] and perianal disease [23%]. The diagnosis was established by endoscopy and histopathology. Ileocecal involvement was encountered in 40% of the patients. From the current study, it is obviously possible to diagnose a large proportion of patients with CD in a gastroenterology outpatient clinic. The data revealed a strikingly increased incidence of CD in a mainly young Saudi population in the past few years

Histological and laboratory features of patients undergoing liver biopsy at a University Hospital in Central Saudi Arabia

To identify the most common liver pathologies seen in our center, to find the prevalence of advanced fibrosis and cirrhosis in patients with chronic hepatitis B and C, and to correlate the histological and laboratory features of the most common diseases and compare between them. Liver biopsy procedures performed in our Gastroenterology Unit at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia were traced from records between the years 1997-2003. Clinical, histopathological, and laboratory features were recorded. We identified 574 liver biopsies during the study period. Of the 502 included patients, males were 58.6%. The mean age of the patients was 43.5 years. Approximately half of the biopsies [49%] were performed for patients with hepatitis C, followed by hepatitis B, for which 17% of the biopsies were performed. Patients with hepatitis B were approximately 10 years younger than patients with hepatitis C [p=0.01]. They were 10% more likely to be males. In terms of fibrosis, only approximately 17% of patients with hepatitis B and 27% of patients with hepatitis C had advanced fibrosis. Most liver biopsies performed in our center are performed for patients with hepatitis C. Rates of advanced fibrosis in our series are significantly lower than what was previously reported in other studies

Indications and yield of upper gastrointestinal endoscopy in children

Knowledge of the pattern of gastrointestinal tract [GIT] disorders detected by endoscopy is important for clinicians. The objective of this paper is to report on the indications and yield of endoscopy. Retrospective analysis of data of all patients below 18 years of age who underwent upper GIT endoscopy from 1414 H [1993 G] through to 1424 H [2002 G] over a 10-year period at King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia. One thousand and fifteen upper GIT endoscopies were performed, of which 851 diagnostic procedures were performed on 851 children. The majority [96%] were Saudi nationals, the age range was between 4 days and 18-years, and the male to female ratio was 0.7: 1. The 2 most common indications were duodenal biopsy [29%] and abdominal pain [24%]. The best diagnostic yield was in children presenting with ingestion of caustic substances, followed by hematemesis, and vomiting in 86%, 75% and 67%. The overall yield, however, was 43%. Finally, the most common diagnoses were gastritis and esophagitis occurring in 32% and 30% of the children. Age related variations are reported. The increasing practice of endoscopy in children resulted in the development of new indications such as endoscopic small bowel biopsy. The differences in indications and yield of endoscopy with age reflecting the varying pattern of diseases

Malignant biliary strictures. Diagnosis and management

To identify the cause, methods of diagnosis and management of malignant biliary strictures in our institution and compare with studies from other communities. From March 1998 through to August 2002, we reviewed 1000 files of patients who underwent endoscopic retrograde cholangiopancreatography [ERCP] at the Gastroenterology unit, King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia for malignant biliary strictures [MBS]. Clinical, laboratory data, method of diagnosis and management were recorded. Seventy-two patients [72/1000] with MBS were encountered. Forty one [57%] were males and 31 [43%] were females and the majority were Saudi nationals [82%]. Jaundice and right upper quadrant pain were the most frequent symptoms in 84.7% and 52.8% of patients. Cholangiocarcinoma was present in 31 [43%] and pancreatic adenocarcinoma in 23 [31.9%] patients. Other malignancies found included gallbladder carcinoma in 5 patients [6.9%], ampullary carcinoma in 5 [6.9%], metastatic liver carcinoma in 4 patients [5.6%], hepatocellular carcinoma in 2 [2.8%] and lymphoma in 2 [2.8%]. The diagnosis was entertained mainly by ERCP [93%]. Endoscopic palliation was carried out in 77.8% of patients, percutaneous transhepatic drainage in 13.9% and surgery in 6 [8.3%]. The mean survival was higher for the endoscopic compared to the percutaneous transhepatic and surgery groups [6.9 +/- 4.13, 4.27 +/- 4.29 and 3.67 +/- 2.65 months]. In non-resectable tumors, ERCP is the optimal method of diagnosis and palliation of MBS

Lack of associatin of coronary artery disease with H.pylori infection

It has been suggested from previous studies that there is an associated increased risk of coronary artery disease [CAD] in patients with Helicobacter pylori [H.pylori]. However, others dispute this. We therefore evaluated this hypothesis in a group of patients with confirmed H.pylori infection. A total of 158 patients with dyspeptic symptoms were evaluated by esophago-gastro-duodenoscopy [EGD] in King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia from May through to June 1997. Endoscopic biopsies and histology as well as culture and serology for H.pylori were obtained. In patients with confirmed H.pylori a further analysis was performed looking at associated [CAD] or known risk factors for CAD. Among the 158 patients who underwent EGD, 143 patients [90.5%] were found to have H.pylori either by culture, histology or serology, or both in a percentage of [31.5%] [77.6%] and [60.8%]. There was no evidence of CAD in this group of patients based on history, electrocardiogram [ECG], echocardiography, ECG stress test, dypiridamole thallium scan or coronary angiography. Other known risk factors for CAD were cigarette smoking [12.6%], diabetes mellitus [10.5%], hypertension [1.4%] and hyperlipidemia [2.8%]. Helicobacter pylori infection does not increase the risk of CAD, and should not be considered as an independent risk factor for CAD. Further, prospective large trial is needed to confirm our finding

Mirizzi syndrome and management

The aim of this study is to report the frequency, diagnosis and management of Mirizzi syndrome in our patients' population. A retrospective review of all endoscopic retrograde cholangiography files performed over a 6 year period [1414-1419H] at King Khalid University Hospital. During that period, a total of 1,053 endoscopic retrograde cholangiography procedures were performed. Thirteen patients were found to have Mirizzi syndrome [1.2%]; mean age was 43.3 years. Mirizzi syndrome Type 1 was diagnosed endoscopically in 12 patients while Type two was found in only one patient. Endoscopic management was successful in 2 patients. Open cholecystectomies were performed in 11 patients and laparoscopic cholecystectomies were performed in 2 patients. Mirizzi syndrome is a rare complication of cholelithiasis. Open cholecystectomy is required in the majority of patients

Esophageal candidiasis among a dyspeptic population

This is a retrospective study of 59 patients endoscoped over a period of six years at a private clinic and were found to have esophageal candidiasis. The median age was 46.68 years. Thirty [51%] patients has no precipitating factors. Only 18 [30%] patients had typical symptoms. The distal part of the escophagus was more often involved. The thrush was scattered in 57 [97%] patients. The endoscopic finding was confirmed by cytology in all patients included. Symptoms improved on oral nystatin treatment and simultaneous treatment of associated conditions in all 46 patients followed up. In conclusion, esophageal cadidiasis appear to be not uncommon among dyspetic population. It presents more frequently with atypical symptoms and responds well to oral nystatin treatment

Treatment of acute pancreatitis

There is no specific treatment for acute pancreatitis. Majority of patients with acute pancreatitis. respond to medical therapy. Supportive measures and close observations represent the cornerstone of the medical therapy. Failure to respond to medical treatment may indicate choledocholithiasis or infected necrosis. Endoscopic papillotomy with stone retrieval is beneficial in patients with severe biliary pancreatitis. Image-guided fine needle aspiration and bacteriological examination of aspirate is reliable in detecting infection and deliniating causative pathogen. Surgical debridement is the method of choice for treatment of infected necrosis. In contrast, in pancreatic abscess, surgery is preserved for those, who do not respond to percutaneous drainage combined with antibiotics. The benefit of antisecretory and antiproteolytic agents is debatable. A combination of antioxidants, calcium channel antagonists and antibiotics may play a major role in the treatment of acute pancreatitis in the future

Doxycline-induced esophageal ulcerations

Over a period of six years 16 patients presented to Dr. Al Mofarreh's polyclinic with drug-induced esophageal ulcerations. One patient had esophagitis without ulcerations and two patients, who declined endoscopy were not included in this analyzis. The mean age of the remaining 13 patients was 28.92 +/- 10.39 years. The mean ulcers number was 3.69 +/- 2.76. The ulcers were located at the mid-esophagus, 29.23 +/- 3.94 cm from the incisors teeth. Odynophagea, retrosternal pain and dysphagea in 13 [100%], 12[92%] and 9[69%] patients, respectively, were the most frequent presenting symptoms. All patients took a doxycycline preparation at bed time with little water. The mean elapse between the drug intake and endoscopy was 7.85 +/- 9.96 days. The symptoms resolved within a maximum of one week of antireflux treatment despite the continuation of doxycycline therapy in three patients with brucellosis. The current data confirmed the role of oral doxycycline intake, the timing and the amount of concurrent fluid in the etiology of esophageal ulcerations

Acute pancreatitis

The past few years have witnessed a tremendous progress in our knowledge regarding the pathogenesis, diagnosis, prognostic evaluation and classification of acute pancreatitis. The role of ischemia, lysosomal enzymes, oxygen free radicals, polymorphnuclear cells-byproducts and inflammatory mediators in the pathogenesis of pancreatic necrosis and multiple organ failure has been emphasized. Furthermore, the recent knowledge about agents infecting pancreatic necrosis, routes of infection, bacteriological examination of fine needle aspirate and appropriate antibiotics have changed the concept of acute pancreatitis. New diagnostic tests such as rapid urinary trypsinogen-2 test and inflammatory mediators including polymorphnuclear elastase, C-reactive protein and interleukin-6 contribute to early diagnosis, prognostic evaluation and initiation of an appropriate therapy

Management of gallstones

Asymptomatic patients with gallbladder stones rarely develop complications and therefore do not require treatment: in contrary. Symptomatic patients should be treated. Nowadays, several approaches are available to treat gallbladder and ductal stones using surgical techniques, chemical dissolvents fragmentation, endoscopic and percutaneous approaches The choice of approach is influenced by the site, size and chemical composition of stone, as well as the age, general condition and desire of patient. Surgical approaches are considered as the primary method of treatment Nonsurgical treatment is considered in patients at high risk and patients unwilling to undergo surgery. The main concern of non-surgical treatment is the high recurrence rate, especially after dissolution

Ascites: tips on diagnosis and management

Clinical evaluation and diagnostic paracentesis with estimation of the serum-ascitic albumin gradient [SAAG] is the most important step in identifying the etiology of ascites. At a level of 1.1 g/dl, SAAG, accurately [96.7%] differentiate portal hypertension from nonportal I hypertension-associated ascites. The majority of patients with ascites [>80%] have portal hypertension associated etiology mainly, liver cirrhosis. Approximately 90% of patients with ascites complicating cirrhosis respond to salt restriction and diuretics. The remainder [10%] have refractory ascites which commonly respond well to large volume paracentesis [LVP]. Asymptomatic complications occurring in patients treated with LVP may not necessitate treatment. Other alternative methods for treatment of refractory ascites include: ascitic fluid recirculation [AR], peritoneovenous shunting [PVS],transjugular intrahepatic portosystemic stent-shunting [TIPS] and orthotopic liver transplantation [OLT]

Variceal bleeding: management options

Portal hypertension with esophageal varices represents an important source of upper gastrointestinal bleeding. Variceal bleeding is associated with high rebleeding and mortality rates. Various treatment modalities are effective in control of bleeding. Endoscopic Sclerotherapy [ES] is the standard method for management of acute variceal bleeding alone or in combination with vasoactive drugs. Alternative methods are considered in case of sclerotherapy failure. Portosystemic shunt operation is complicated by systemic encephalopathy. Therefore, it is replaced by other surgical procedures, these include esophageal stapled transection, splenectomy with devascularization, distal splenorenal shunt [DSRS], DSRS combined with pancreatic disconnection, narrow diameter.mesocaval [NDMC] or portocaval [NDPC] shunts and liver transplantation. Recently, transjugular intrahepatic portosystemic stentshunting [TIPSS] has been introduced in the management of patients with refractory variceal bleeding waiting for liver transplantation

Gallstones

Gallstone prevalence is correlated with geographical and ethnic variations. It is more prevalent in Western communities. There are evidences for a high prevalence in Saudi Arabia. According to their chemical constitutes, stones are classified into cholesterol, mixed and pigment stones. Three main factors, saturation, gallbladder function and nucleation defect are implemented in the pathogenesis of stone formation. Majority of gallstones patients are asymptomatic. Dyspeptic symptoms are not specific. Ultrasonography has become the method of choice for screening and diagnosis of gallstones. Cholecystoscintigraphy is accurate in the diagnosis of acute cholecystitis, biliary obstruction and bile leak. Treatment of gallstones will be discussed in the following issue