Diagnostic Utility of Impedance-pH Monitoring in Refractory Non-erosive Reflux Disease

BACKGROUND/AIMS: Approximately one-third of non-erosive reflux disease (NERD) patients are refractory to proton pump inhibitors (PPI) and face a therapeutic challenge. Therefore, it is important to differentiate between pathological and non-pathological reflux utilizing multichannel intraluminal impedance-pH (MII-pH) to analyze symptom-reflux association and diagnose true NERD versus hyper-sensitive esophagus (HE) and functional heartburn (FH). Herein, we evaluated the diagnostic yield of MII-pH in refractory NERD and sub-classified it based on quantity and quality of acid/non-acid reflux and reflux-symptom association. METHODS: Sixty symptomatic NERD patients on twice daily PPI for > 2 months were prospectively evaluated by MII-pH. Distal and proximal refluxes, bolus exposure time (BET), esophageal acid exposure time, symptom index (SI) and symptom association probability (SAP) were measured. RESULTS: Thirty-two (53%) patients had BET > 1.4% (MII-pH positive-true NERD), while 28 (47%) had BET 80% of symptoms were associated with non-acid reflux. The number of distal refluxes in true NERD versus FH or HE were significantly different, but not between FH and HE. CONCLUSIONS: Approximately 60% of refractory PPI NERD patients had positive reflux-symptom association, primarily due to non-acid reflux. Nearly half of NERD patients on PPI had normal MII-pH monitoring, sub-divided further into FH and HE equally.

Inflammatory bowel disease in Saudi Arabia: a hospital-based clinical study of 312 patients

The epidemiology, clinical characteristics, and natural course of inflammatory bowel disease [IBD] in Saudi Arabia are still largely unknown. Hence, we decided to conduct a large retrospective, cohort study to determine these features of the disease. Retrospective study conducted in a tertiary care hospital in Riyadh from January 1970 to December 2008. We reviewed all the cases of IBD diagnosed and collected all data pertaining to patients with IBD. A total of 312 patients with IBD were included for this analysis, including 197 [63%] patients with Crohn disease [CD] and 115 [37%] patients with ulcerative colitis [UC]. The mean age [standard deviation] of patients with IBD was 25.5 [10.6] years; 152 [48.7%] were males and 160 females. The referral rate in the past 10 years was 72.1% compared with preceding 20 years, and 56% [n=178] of patients with IBD were from the central region of Saudi Arabia. The patients were followed up for a mean duration of 9.5 years; during their follow-up, 206 patients [66%] required hospital admission and 9 patients [2.9%] with UC developed colon cancer. A total of 6 patients died during the follow-up. Fifty-three percent [n=104] of the patients with CD underwent surgeries as part of their treatment, whereas only 20% [n=23] of the patients with UC underwent colectomy. The incidence of IBD has been gradually increasing in Saudi Arabia over the years. Clinical features and morbidity in patients are not different from patients with IBD seen in the West

Wilson disease in 71 patients followed for over two decades in a tertiary center in Saudi Arabia: a retrospective review.

Wilson disease [WD] is a rare autosomal recessive disease. Our objective was to describe the diverse patterns, therapies, and outcomes of this disease. A retrospective study over two decades on WD patients in a tertiary care center in Saudi Arabia. Clinical and laboratory findings of 71 patients with WD were retrieved from their charts, referral notes and our hospital electronic records and were analyzed. The mean age and standard deviation was 16.8 [10.7] years and 56.5% were males. The main manifestations of WD were hepatic, neurological, and mixed in 39 [54.9%], 12 [16.9%], and 20 [28.2%] patients, respectively, and 11 [15.5%] were asymptomatic cases detected by family screening. A family history of WD was positive in 41 [57.7%] patients, and consanguinity of parents was found in 26 [36.6%] patients. The mean [SD] follow-up period was 92.2 [72.9] [range, 1-320] months. Ten [14.1%] patients died during follow up, while 45 [63.4%] and 16 [22.5%] were still on or lost from follow-up, respectively. The mean [SD] age at the end of follow-up was 25.3 [12] [range, 4-62] years. Hepatoma was discovered in 5 [7.0%] patients. Penicillamine therapy was used by 58 [81.7%] patients, while zinc and trientine were given to 32 [45.1%] and 11 [15.5%] patients, respectively. Sixteen [22.5%] patients underwent liver transplantation and one died [1.4%] on the waiting list. The liver condition remained stable or improved in 35 [49.3%], and the neurological status showed improvement in 11 [34.4%] of the 32 patients who had neurological involvement. This is the biggest cohort to be reported from the Middle East. WD presentation and outcome of WD are very diverse, and its diagnosis still depends on clinical, laboratory, and radiological evidence of abnormal copper metabolism. WD should be considered in patients of any age with obscure hepatic and/or neurological abnormalities.

Predictors of sustained virological response to a 48-week course of pegylated interferon alfa-2a and ribavirin in patients infected with hepatitis C virus genotype 4

Knowledge of the predictors of sustained viral response [SVR] to pegylated interferon [PEG-INF] alfa-2a and ribavirin [RBV] therapy in patients with hepatitis C genotype-4 [HCV-4] is crucial for selecting patients who would benefit most from therapy. We assessed the predictors of SVR to this combination therapy in Saudi patients with chronic HCV-4 infection. This retrospective study included 148 patients with HCV-4 infection who underwwent clinical, biochemical and virological assessments before treatment and at 12, 24, 48 and 72 weeks posttreatment. Of the 148 patients, 90 [60.8%] were males. Mean [SD] for age was 48.5 [12.7] years and BMI was 27.9 [7.5] kg/m[2]. Seventy-nine of 148 [60.1%] patients were treatment naive and 110 [74.3%] underwent pre-treatment liver biopsy. Eighteen [12.2%] patients did not complete therapy because of side effects or they were lost to follow up. Early virological response was achieved in 84 of 91 [92.3%] patients. In the 130 [87.8%] patients who completed therapy, 34 [26.2%] were non-responders and 96 [63.8%] achieved end-of-treatment virological response [ETVR]. SVR and virological relapse [24 weeks after ETVR] occurred in 66/130 [50.7%] and 30/130 [31.2%] patients, resspectively. Compared to relapsers, sustained responders were significantly younger [P = .005], non-diabetic [P = .005], had higher serum albumin [P = .028], lower alpha-fetoprotein level [P = .026], lower aspartate aminotransferase [AST] [P = .04] levels, and were treatment-naive [P = .008]. In a multivariate regression analysis, the independent predictors of SVR were younger age [P = .016], lower serum AST [P = .012], and being treatment na‹ve [P = .021]. Approximately half of HCV-4 patients who complete the course of combination therapy achieve an SVR, especially if they are young, treatment naive and have lower AST levels

Leukocyte apheresis in the management of ulcerative colitis

Ulcerative colitis is a chronic inflammatory disease that affects the colon and rectum. Its pathogenesis is probably multifactorial including the influx of certain cytokines into the colonic mucosa, causing disease activity and relapse. The hypothesis of removing such cytokines from the circulation by leukocytapheresis was implemented to reduce disease activity, maintain remission, and prevent relapse. Many recent reports not only in Japan, but also in the West, have highlighted its beneficial effects in both adult and pediatric patients. Large placebo-controlled studies are needed to confirm the available data in this regard. In this article, we shed some light on the use of leukocyte apheresis in the management of autoimmune diseases, especially ulcerative colitis