pattern of esophageal manometry in progressive systemic sclerosis

The purpose of this paper is to study the esophageal motility pattern and the frequency of acid reflux in patients diagnosed to have progressive systemic sclerosis and compare the results to that of normal controls. All consecutive patients diagnosed to have progressive systemic sclerosis between 1417-1419 [Hijra year] at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia were included [Group I]. History of heartburn, dysphagia and regurgitation was reviewed. Drugs that might suppress acid or alter motility were discontinued 2 weeks before inclusion. The results were compared to that of 21 symptomatic controls of similar age and sexes that were seen at the same period [Group II]. Esophageal manometry and upper gastrointestinal endoscopy were performed in all patients. Ambulatory 24 hour-pH monitoring was carried out in 6 patients of group 1 and 20 patients of group II. Thirteen progressive systemic sclerosis patients [12 females] mean age was 38.7 years and 21 [19 females] mean age was 34.8 years were included. The symptom scores, lower esophageal sphincter pressure, esophageal contractions amplitude were significantly worse in patients compared to control, dysphagia was mostly due to aperistalsis. All progressive systemic sclerosis patients showed the typical esophageal manometry pattern of lower esophageal sphincter pressure and diminished amplitude with aperistalsis. Gastroesophageal reflux was detected in 83% of patients with progressive systemic sclerosis. Moreover, all 24-hour pH monitoring variables were significantly worse in group I. Patients with progressive systemic sclerosis usually present with heartburn, dysphagia and regurgitation. Esophageal manometry typically shows lower pressure and aperistalsis. Gastroesophageal reflux is frequent

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

Frequency of endoscopic esophagitis in nutcracker patients with pathological 24-hour pH monitoring

endoscopically, it was claimed that reflux esophagitis is less frequently seen in patients with tertiary contractions. the aim of this prospective study is to evaluate the frequency of endoscopic esophagitis in nutcracker patients with pathological 24-hours ph monitoring as compared to a matched group of patients with pathological prolonged ambulatory ph monitoring. the study included eight patients with nutcracker esophagus and pathological 24-hours ph monitoring [group 1]; mean [sd] age was 36.5 [10.6] years, mean [sd] les pressure was 11 [2.9] mmhg and% total ph<4 was 11.4 which were not statistically different from a matched control of 25 patients [group 2]. patients with underlying definable systemic diseases were excluded from the study. there nutcracker esophagus and eight control showed evidence of endoscopic esophagitis [p value = 0.9]. among group I, nutcracker patients with endoscopic esophagitis had a tendency towards a lower LES pressure [p=0.03] and total time ph<4 [p=0.003] than nutcracker without endoscopic oesophagitis. moreover, nutcracker patients with endoscopic esocphagitis had a significantly greater% total ph<4 and total time ph<4 than control group with endoscopic esophagitis is in nutcracker and a matched control with phathological 24-hours pH monitoring

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

prevalence of endoscopic esophagitis in duodenal ulcer patients and symptomatic controls

A large series of duodenal ulcer patients was examined in order to determine the prevalence rate of reflux esophagitis and compare it to that of a series of symptomatic controls, as well as to find out if complicated duodenal ulcer patients are at a higher risk of developing reflux esophagitis. All consecutive patients attending the Endoscopy unit between January and December 1996 who were found to have duodenal ulcers were prospectively recruited for this study. Consecutive patients with upper abdominal symptoms but negative gastroscopy for duodenal ulcers were used as a control. Patients known to have reflux esophagitis, those on peptic ulcer treatment for more than a week, those with dysphagia as a presenting symptom or underlying upper gastrointestinal malignancy, and patients who had undergone previous ulcer surgery were excluded from the study. A hundred and forty-one patients were found to have duodenal ulcer [Group I], and one hundred and seventy-two served as a control [Group II]. The two groups were matched for age, NSAID ingestion and smoking habit. However, Group I included significantly more patients with underlying co-morbid conditions and fewer females. The prevalence of reflux esophagitis was similar between both groups, 30.5% vs. 38.4%, P=0.18. Furthermore, bleeding duodenal ulcer patients [sub-group III] were compared to non-bleeding duodenal ulcer patients [sub-group IV]. Although Group III included significantly more smokers, NSAID ingestion and co-morbid conditions, there was no significant difference in the prevalence rate of reflux esophagitis, P=0.13. Moreover, 92.7% of afflicted patients suffer mild or moderate esophagitis. Endoscopic esophagitis is a frequent finding in both duodenal ulcer and control subjects

Pattern of helicobacter pylori sensitivity to various antimicrobial agents

To evaluate the pattern of Helicobacter pylori [H. pylori] susceptibility to different antimicrobial agents, we prospectively studied 45 H. pylori isolates by disc diffusion method. These isolates were obtained from patients aged between 16-75 years, of both sexes who had no prior history of metronidazole ingestion. A total of 45 patients were included, of which 36 were mates with a mean age of 42.9 years and nine females with a mean age of 36.4 years, 62% of patients were Saudis. Almost all the H. pylori isolates were susceptible to clarithromycin, penicillin, erythromycin, ampicillin, tetracycline, clindamycin and cephradine. However, 64.4% of the isolates were resistant to metronidazole. No significant difference was found either in susceptibility of isolates from Saudi, non-Saudi or male and female patients

importance of stone size on success rate of endoscopic extractions of common bile duct stones

To evaluate the importance of common bile duct stone size on success rate of extraction. A retrospective analysis of medical records of patients with common bile duct stones. Gastroenterology unit at King Khalid University Hospital, Riyadh. Patients were admitted from our clinics or referred from the medical and surgical wards or from other hospitals. All medical records of patients with choledocholithiasis diagnosed by endoscopic retrograde cholangiopancreatography between 1985 and 1992 were reviewed. Patients' age, sex, nationality, number and size of bile duct stones and success rate of extraction were recorded. A total of 211 patients, 86 males and 125 females. Mean age 53.2+17.4 years were included in the study. Endoscopic sphincterotomy was successful in 97.6%. Endoscopic common bile duct clearance was achieved in 75.4% [group one], while 24.6% of stones could not be retrieved [group two]. There was no significant difference between stone number in both groups. However, stone size was significantly larger in group two [p<0.0001]. Ninety five percent of stones <10 mm were extracted compared to 69% of stone size less than 15 and greater than 10 mm and 31% of stones >/= 15 mm in size. Stone size has significant impact on success rate of extraction

Efficacy of metronidazole-based triple therapy on eradicating HPylori positive peptic ulcers in mainly Saudi patients

To evaluate the short-term efficacy of triple antibiotics on eradicating H.pylori from peptic ulcer patients. Design: Prospective study. Peptic ulcer patients of both sexes were included if they were H. pylori positive on culture and/or histology and were aged between between 18-75 years. Patients were excluded if they had severe coagulopathy, if the females were pregnant and if antibiotics or non-sterioidal anti-inflammatory drugs had been recently used. All patients received a combination of metronidazole 500 mg PO t.i.d., amoxicillin 500 mg PO q.i.d., both for 2 weeks and bismuth subcitrate colloidal 120 mg PO q.i.d. for 4 weeks, in addition to ranitidine 300 mg PO at night for 6 weeks. Eradication of H.pylori was defined as absence of the organism in both histology and culture 6 weeks after completing triple therapy. H.pylori susceptibility was performed using the disc diffusion method. Forty-nine patients; 38 males, mean age 41.4 years and 11 females, mean age 40.3years were included. Eighty-four percent of peptic ulcers had healed by the end of the study period. However, only 49% of H.pylori was successfully eradicated. Overall metronidazole resistance was encountered in 45.7% of H.pylori isolate. Females harbored resistant strains more frequently than males, 77.8% versus 34.6%, respectively [p=0.03]. Metronidazole based triple therapy has a low success rate which is most likely secondary to H.pylori resistance

Treatment options for large common bile duct stones

This is a retrospective analysis of the medical records of patients diagnosed to have large common bile duct stones [>/= 15 mm]. The study was designed to evaluate different modalities of large bile duct stone treatment. The setting is King Khalid University Hospital, Gastroenterology Unit. The medical records of patients [n=64] diagnosed to have large common bile duct stones by endoscopic retrograde cholangiography over a period of nine years were included. Files were reviewed and information obtained which included patients' age, sex, nationality, presenting symptoms, number and size of bile duct stones, presence of ascending cholangitis, mode of treatment received, complications and outcome. There were a total of 64 patients; 28 males and 36 females, with a mean age of 61 +/- 16.6 years. Successful stone extraction was achieved in 44 [69%] patients while surgical treatment was required in 20 patients. Surgically managed patients had significantly larger stones [P<0.003] and were more frequently jaundiced [P<0.014]. There was 7.8% of the total number of patients who developed complications that were managed conservatively with full recovery. It was concluded that large stones are difficult to extract endoscopically and more frequently require additional treatment

Frequency of peptic ulcers in patients with portal hypertension

To find the frequency of peptic ulceration in portal hypertension, 137 patients with portal hypertension were studied retrospectively. Patients with hepatocellular carcinoma, other malignancies or underlying severe systemic disease were excluded and the remaining 114 patients were included in the study. There were 81 males [mean age 49.1 +/- 13.7 years] and 33 females [mean age 52.9 +/- 10 years]. Portal hypertension was secondary to viral liver disease in 75%. Fifty-seven patients had no evidence of peptic ulcers [group I] and another 57 patients [group II] had peptic ulcers diagnosed during upper gastrointestinal endoscopy. There was no significant difference between the two groups regarding age, sex, Child-Pugh score or variceal size. Duodenal ulcers were found in 24% while gastric ulcers were found in 4.4%; other endoscopic findings included erosive gastritis and duodenitis in 21% and 18.4% respectively. Twelve percent of the patients from group II developed bleeding from the ulcers and the majority of bleeding ulcers responded to conservative treatment. The study concludes that the frequency of peptic ulcers in patients with portal hypertension is high. Bleeding peptic ulcers respond to conservative treatment

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

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis [SBP] is an infection of the ascitic fluid without obvious intra-abdominal source of sepsis; usually complicates advanced liver disease. The pathogenesis of the disease is multifactorial: low ascitic protein-content, which reflects deficient ascitic fluid complement and hence, reduced opsonic activity is thought to be the most important pathogenic factor. Frequent and prolonged bacteremia has been considered as another pertinent cause of SBP. This disease is associated with high mortality and recurrence. Therefore.prompt recognition and institution of therapy and plan of prophylaxis is vital

Endoscopic treatment of caecal lymphomatous polyp

The clinical course of a Saudi patient with a caecal lymphomatous polyp who was successfully treated endoscopically and followed up for a total of one year with no evidence of recurrence, is described