Refractory ascites as the first presentation of systemic lupus erythematosus

Serositis [peritonitis, pleuritis, and pericarditis] can be observed in approximately 13% of patients with systemic lupus erythematosus [SLE]. However, peritoneal serositis presenting as painless massive ascites is extremely rare with only few cases been reported. Indeed, ascites in SLE has been reported to occur only when complicated by nephrotic syndrome, congestive cardiac failure, or portal hypertension. We describe herein a very unique case of SLE related serositis presenting with a massive refractory ascites, normal albumin, and absence of a clear autoimmune disorder or protein-losing enteropathy [PLE] at the time of her presentation, which only responded to a pulse course of corticosteroid. SLE was confirmed 2 years later

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system

Open access endoscopy [OAE] decreases the waiting time for patients and clinical burden to gastroenterologist; however, the appropriateness of referrals for endoscopy and thus the diagnostic yield of these endoscopies has become an important issue. The aim of this study was to determine the appropriateness of upper gastrointestinal [GI] endoscopy requests in an OAE system. A retrospective chart review of all consecutive patients who underwent an upper gastroscopy in the year 2008 was performed and was defined as appropriate or inappropriate according to the American Society for Gastrointestinal Endoscopy [ASGE] guidelines. Endoscopic findings were recorded and classified as positive or negative. Referrals were categorized as being from a gastroenterologist, internist, surgeon, primary care physicians or others, and on an inpatient or out-patient basis. A total of 505 consecutive patients were included. The mean age was 45.3 [standard deviation 18.1], 259 [51%] of them were males. 31% of the referrals were thought to be inappropriate. Referrals from primary care physicians were inappropriate in 47% of patients while only 19.5% of gastroenterologists referrals were considered inappropriate. Nearly, 37.8% of the out-patient referrals were inappropriate compared to only 7.8% for inpatients. Abnormal findings were found in 78.5% and 78% of patients referred by gastroenterologists and surgeons respectively while in those referred by primary care physicians it was [49.7%]. Inpatients referred for endoscopy had abnormal findings in [81.7%] while in out-patients it was [66.6%]. The most common appropriate indications in order of frequency were "upper abdominal distress that persisted despite an appropriate trial of therapy "[78.9%],''persistent vomiting of unknown cause "[19.2%], upper GI bleeding or unexplained iron deficiency anemia [7.6%]. The sensitivity and specificity of the ASGE guidelines in our study population was 70.3% and 35% respectively. A large proportion of patients referred for endoscopy through our open-access endoscopy unit are considered inappropriate, with significant differences among specialties. These results suggest that if proper education of practitioners was implemented, a better utilization would be expected

Clinical predictors of resectability of pancreatic adenocarcinoma

Identifying patient-related factors as well as symptoms and signs that can predict pancreatic cancer at a resectable stage, which could be used in an attempt to identify patients at an early stage of pancreatic cancer that would be appropriate for surgical resection and those at an unresectable stage be sparred unnecessary surgery. A retrospective chart review was conducted at a major tertiary care, university hospital in Riyadh, Saudi Arabia. The study population included individuals who underwent a computed tomography and a pancreatic mass was reported as well as the endoscopic reporting database of endoscopic procedures where the indication was a pancreatic mass, between April 1996 and April 2012. Any patient with a histologically confirmed diagnosis of adenocarcinoma of the pancreas was included in the analysis. We included patients' demographic information [age, gender], height, weight, body mass index, historical data [smoking, comorbidities], symptoms [abdominal pain and its duration, anorexia and its duration, weight loss and its amount, and over what duration, vomiting, abdominal distention, itching and its duration, change in bowel movements, change in urine color], jaundice and its duration. Other variables were also collected including laboratory values, location of the mass, the investigation undertaken, and the stage of the tumor. A total of 61 patients were included, the mean age was 61.2 +/- 1.51 years, 25 [41%] were females. The tumors were located in the head [83.6%], body [10.9%], tail [1.8%], and in multiple locations [3.6%] of the pancreas. Half of the patients [50%] had Stage four, 16.7% stages two B and three, and only 8.3% were stages one B and two A. On univariable analysis a lower hemoglobin level predicted resectability odds ratio 0.65 [95% confidence interval, 0.42-0.98], whereas on multivariable regression none of the variables included in the model could predict resectability of pancreatic cancer. A CA 19-9 cutoff level of 166 ng/mL had a sensitivity of 89%, specificity of 75%, positive likelihood ratio of 3.6, and a negative likelihood ratio of 0.15 for resectability of pancreatic adenocarcinoma. This study describes the clinical characteristics of patients with pancreatic adenocarcinoma in Saudi Arabia. None of the clinical or laboratory variables that were included in our study could independently predict resectability of pancreatic adenocarcinoma. Further studies are warranted to validate these results.

accuracy of multi-detector row computerized tomography in staging rectal cancer compared to endoscopic ultrasound

Our aim was to evaluate the diagnostic accuracy of multi-detector row computerized tomography [MDCT] in staging of rectal cancer by comparing it to rectal endoscopic ultrasound [EUS]. We prospectively included all patients with rectal cancer referred to our gastroenterology unit for staging of rectal cancer from December 2007 until February 2011, 53 patients whose biopsy had proven rectal cancer underwent both MDCT scan of the pelvis and rectal EUS. Both imaging modalities were compared and the agreement between T- and N-staging of the disease was assessed. We staged 62 patients with rectal cancer during the study period. Of these, 53 patients met the inclusion criteria and were evaluated [25 women and 28 men]. The mean age was 57.79 +/- 14.99 years [range 21-87]. MDCT had poor accuracy compared with EUS in T-staging with a low degree of agreement [kappa = 0.26], while for N-staging MDCT had a better accuracy and a moderate degree of agreement with EUS [kappa = 0.45]. MDCT has a poor accuracy for predicting tumor invasion compared to EUS for T-staging while it has moderate accuracy for N-staging

Frequency of low bone mineral density in Saudi patients with inflammatory bowel disease

Metabolic bone disease is common in patients with inflammatory bowel disease [IBD]. Our aim was to determine the frequency of bone loss among Saudi patients with IBD and possible contributing risk factors. We retrospectively reviewed Saudi patients with IBD, between 18 and 70 years of age, who had bone mass density [BMD] determined by dual-energy X-ray absorptiometry scanning at one of three hospitals in the Kingdom of Saudi Arabia from 2001 to 2008. Case notes and BMDs results were carefully reviewed for demographic and clinical data. Low bone mass, osteopenia, and osteoporosis were defined according to the WHO guidelines. Predictive factors for BMD were analyzed using group comparisons and stepwise regression analyses. Ninety-five patients were included; 46% had Crohn's disease [CD] and 54% had ulcerative colitis [UC]. The average age was 30.9 +/- 11.6 years. Using T-scores, the frequency of osteopenia was 44.2, and the frequency of osteoporosis was 30.5% at both lumbar spine and proximal femur. Only 25.3% of patients exhibited a BMD within the normal range. Our both lumbar spine and proximal femur. Only 25.3% of patients exhibited a BMD within the normal range. Our results revealed a positive correlation between the Z-score in both the lumbar spine and the proximal femur and body mass index [BMI] [P=0.042 and P=0.018, respectively]. On regression analysis BMI, age, and calcium supplementation were found to be the most important dependent predictors of BMD. Saudi patients with IBD are at an increased risk of low BMD and the frequency of decreased BMD in Saudi patients with CD and UC were similar. BMI and age were the most important independent predictors of low BMD

Unsedated colonoscopy: is it feasible?

Unsedated colonoscopy has been an evolving subject ever since its initial description four decades ago. Failure in unsedated diagnostic cases due to patient pain led to the introduction of sedation. Extension to screening cases, albeit logical, created a sedation-related barrier to colonoscopy screening. In recent years a water method has been developed to combat the pain during unsedated colonoscopy in the US. In randomized controlled trials the water method decreases pain, increases cecal intubation success, and enhances the proportion of patients who complete unsedated colonoscopy. The salvage cleansing of suboptimal bowel preparation by the water method serendipitously may have increased the detection of adenoma in both unsedated and sedated patients. The state-of-the-art lecture concludes that unsedated colonoscopy is feasible. The hypothesis is that recent advances, such as the development of the water method, may contribute to reviving unsedated colonoscopy as a potentially attractive option for colon cancer screening and deserves to be tested

Helicobacter pylori prevalence among medical students in a high endemic area

To evaluate the prevalence of Helicobacter pylori [H. pylori] among Saudi medical students. Volunteer medical students were randomly selected in the College of Medicine, King Saud University, Riyadh, Saudi Arabia from January 2005 to May 2005. A urea breath test [UBT] was performed for each medical student. Important demographic data was recorded. Each student had to answer a questionnaire on upper gastrointestinal [UGI] symptoms before the UBT. A total of 120 students were recruited [73 males [61%] and 47 females [39%]] with a mean age of 22.2 years [age varied from 18 to 28 years]. The prevalence of H. pylori was surprisingly low at 35%, compared to a previously reported high prevalence among the Saudi population [80%]. Thirty-one percent of medical students reported>/=1 UGI symptom with no significant differences between the positive and negative UBT results. Although there was a trend, there was no significant prevalence difference between the preclinical and the clinical group of students. We found a low prevalence of H. pylori in our young university medical student's population. The low prevalence of H. pylori in this young population may have important clinical and economic implications