Right upper quadrant pain with normal hepatobiliary ultrasound: can hepatobiliary scintigraphy define the cause?

The objective of this study was to assess the value of hepatobiliary scintigraphy [HS] for the diagnosis of right upper quadrant [RUQ] abdominal pain in patients with normal hepatobiliary ultrasound [HU]. This is an observational study with a retrospective analysis of data from March 2008 to August 2010. We reviewed the HS results of 30 patients, aged 29-69 years [average 45.8 years]; 12 male and 18 female patients. Patient selection to perform the HS was RUQ abdominal pain, suspected hepatobiliary disorder, and negative HU. All patients had gone through the standard procedure of HS. Based on predefined interpretation criteria, HS results were divided into 2 patterns: Normal [n=8, 25.8%] and abnormal [n=22, 73%]: 18 patients [81.8%] having early gallbladder [GB] and common bile duct visualization, and delayed transit to small bowel [SB], which can be seen only after a fatty meal with normal or abnormal GB ejection fraction [GBEF] pattern characteristic of Oddi's sphincter dyskinesia. The remaining 4 patients [8.18%] had acalculous cholycystitis pattern: Delayed GB visualization with activity appearing in SB before GB. HS with fatty meal stimulation and GBEF estimation seems to be a reliable test, which may reveal a biliary cause in more than 70% of patients with RUQ abdominal pain and normal HU. Normal results exclude functional biliary cause. The decision for invasive or noninvasive therapeutic approach may depend on the results of HS

Moyamoya syndrome as a risk factor for stroke in Saudi children. Novel and usual associations

To report on moyamoya syndrome [MMS] as a risk factor for stroke in a prospective and retrospective cohort of Saudi children. The usual and novel associations of MMS in this cohort will also be described. Children with stroke were evaluated at the Division of Pediatric Neurology at King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia during the periods July 1992 to February 2001 [retrospective study] and February 2001 to March 2003 [prospective study]. Investigations for suspected cases included hemostatic assays, biochemical, and serological tests. Neuroimaging included CT, MRI, magnetic resonance angiography [MRA], single photon computerized tomography [SPECT] brain scan and conventional cerebral angiography. Moyamoya syndrome was the underlying risk factor for stroke in 6 [5.8%] of the 104 children [aged one month to 12 years]. They were 4 females and 2 males. Their first cerebral ischemic event occurred at a mean age of 45 months [median = 44 months, range 17-66 months]. In all 6 cases, MMS was associated with an underlying hematologic abnormality or other diseases. Protein C deficiency was identified in one girl and protein S deficiency in another. Two patients had respectively, sickle cell disease [SCD] and sickle cell-B-thalassemia [S beta-thalassemia], which had been associated in the latter with membranous ventricular septal defect. Adams-Oliver syndrome [AOS, OMIM 100300] was associated with MMS in an 18-month-old girl. A 4-year-old boy had wrinkly skin syndrome [WSS, OMIM 278250] phenotype. The association of MMS and protein C deficiency was first reported in this cohort of patients, whereas the association of the syndrome with WWS and AOS has not, hitherto, been described. The 3 patients who had MMS associated with protein C deficiency, SCD, and AOS underwent successful revascularization surgery in the form of encephaloduroarteriosynangiosis. Moyamoya syndrome constitutes an important risk factor of stroke in Saudi children. Comprehensive clinical evaluation and investigations, including screening for thrombophilia and neuroimaging studies, are required for the primary diagnosis of the disease and for unraveling other diseases associated with MMS. This will help in managing these patients and in guiding genetic counseling for their families.

Comparison of bone mineral density with dual energy x-ray absorptiometry, quantitative ultrasound and single energy x-ray absorptiometry

We conducted this prospective study to establish the correlation between dual energy x-ray absorptiometry [DXA], quantitative ultrasound [QUS] and single energy x-ray absorptiometry [SXA] and to establish the role of QUS and SXA as a screening tool for osteoporosis. We carried out measurements of bone mineral density [BMD] of lumbar spine and femoral neck using DXA, QUS of heel using ultrasound densitometer, and BMD of forearm using SXA. We performed all the measurements at the Nuclear Medicine Division of King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia between 2002 and 2004. We obtained the measurements of 437 female adult patients, aged 20-87 years. We expressed all the values as mean +/- SD. The BMD [g/cm2] of lumbar spine was 1 +/- 0.18, and femoral neck was 0.88 +/- 0.17. The broad band ultrasound attenuation [BUA] of the heel was 74.9 +/- 39.1 dB/MHz, the speed of sound [SOS] was 1542.5 +/- 81.4 m/s, and the estimated BMD was 0.52 +/- 0.15 [g/cm2]. The BMD of forearm showed a value of 0.44 +/- 0.10 g/cm2. The best correlation was between absolute values of BMD of lumbar spine and femoral neck [r=0.71, p=0.000]. The correlation between BMD of lumbar spine, QUS heel and forearm BMD was significant, but low to moderate [r=0.43-0.64, p=0.000]. A strong correlation existed between the various parameters of heel, namely, BUA, SOS and estimated BMD [r=0.85-0.96, p=0.000]. We used the World Health Organization [WHO] criterion of T-score to diagnose the patients with osteoporosis or osteopenia with each modality. We diagnosed a maximum number of patients to have osteoporosis with BMD estimation of lumbar spine [31%], followed by femoral neck [14%], forearm [11%], and heel [6%]. The correlation between all modalities was significant, but varied from high to low. It was high between lumbar spine and femoral neck, moderate between lumbar spine and forearm and low between lumbar spine and QUS of heel. When we used the same WHO criterion of T-score [more than -2.5 SD below normal], QUS detected significantly less numbers with osteoporosis. We conclude that with the present cut-off of T-score, the QUS may not be used as a screening tool. It may need some modification of T-score. However, we need larger multi-center studies with a larger number of patients for further validation

Prevalence of osteoperosis among postmenopausal females with diabetes mellitus

To assess the prevalence of osteopenia and osteoporosis among Saudi postmenopausal women with non-insulin dependent type 2 diabetes mellitus [T2DM]. The study was carried out at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from February 2000 to September 2002. Bone mineral density [BMD] of the lumbar spine and femoral neck using dual x-ray absorptiometry [DXA; Lunar Wisconsin], were performed in 104 postmenopausal Saudi women with T2DM, and 101 postmenopausal non-diabetic women [control]. Bone mineral density was measured in gm/cm2 and both T-score and Z-score were measured but only T-score was used for analysis based on World Health Organization criteria. Bone profile, 25[OH] Vitamin D, 1,25[OH]2 Vitamin D, parathyroid hormone and urine deoxypyridinoline [DPD] were measured in most patients and controls. Body fat measurement around the biceps muscles using Futrex [body composition analyzer] were performed in patients and controls. Years postmenopausal, duration of diabetes mellitus, parity, exercise, sun exposure and milk consumption were also recorded. In the diabetic group, the mean spine BMD was 0.928 gm/cm2 [T-score = -2.28 SD] and for femoral neck the mean BMD was 0.817 gm/cm2 [T-score = -1.21 SD]. In control group, the mean spine BMD was 1.036 gm/cm2 [T-score = -1.2] and mean femoral neck BMD was 0.914 gm/cm2 [T-score = -0.608]. In the diabetic group, there was 16 [16.64%] patients with normal BMD of the spine, 42 patients [43.68%] with osteopenia [mean T-score = -1.8 SD] and 45 [46.8%] with osteoporosis [mean T-score = -3.3 SD]. Osteoporosis is more common among Type 2 postmenopausal females in this ethnic group. Since both groups are postmenopausal, having equal percentage of Vitamin D deficiency, multi-parity, non exposure to sun, lack of exercise and negligible milk intake, one can conclude that the low BMD can be attributed to DM in the absence of other causes of osteoporosis