Epidemiology of viral hepatitis in Saudi Arabia: are we off the hook?

Some 400 million people worldwide are currently infected with the hepatitis B virus [HBV], and the infection is common in the Middle East. Another 170 million people around the globe presently live with chronic hepatitis C virus [HCV] infection. Both HBV and HCV represent a worldwide epidemic. Despite significant decline in the prevalence of HBV and HCV infection in Saudi Arabia, these viral diseases cause significant morbidity and mortality, and impose a great burden on the country's healthcare system. On the other hand, Saudi epidemiology studies have shown that the hepatitis A virus seroprevalence in the country has reduced considerably over the past two decades. The progress in mapping the epidemiological pattern of viral hepatitis in Saudi Arabia has not only aided our understanding of the disease, but has also exposed the small but relevant gaps in our identification of the intricate details concerning the disease's clinical expression. In this review, we aim to document the timeline of viral hepatitis epidemiology in Saudi Arabia, while summarizing the relevant published literature on the subject

Quasispecies of genotype 4 of hepatitis C virus genomes in Saudi patients managed with interferon alfa and ribavirin therapy

Many patients with hepatitis C virus [HCV] infection do not respond to antiviral treatment, possibly due to viral quasispecies. We aimed to investigate whether the quasispeices population could be used as a predictor of response to therapy in our patients. The quasispecies of HCV genotype 4 [HCV-4] were studied in 25 naive Saudi patients at zero, three, and six months following interferon alfa and ribavirin combination therapy. Hypervariable region 1 within the E2/NS1 gene of the virus was analyzed by the single-strand conformation polymorphism [SSCP] technique after amplification. Pretreatment DNA bands by SSCP [2-7 bands] were detected in all patients. In those who achieved a complete virological response within six months [viral load <0.2 Meq/mL; n=7], bands ranged from 2-6 [mean = 3.71 +/- 1.25]. In six of these seven patients, the number of SSCP bands remained either the same or decreased sequentially. In those patients who did not respond [viral load >0.2 Meq/mL; n=18], the bands also ranged from 2-7; mean 3.77 +/- 1.73. In six of these non-responding patients, the SSCP bands remained the same or decreased sequentially. There was no significant difference between pretreatment quasispecies composition and response [P=.53]. Two of the four patients with pretreatment high viral load and the same or decreased composition of quasispecies bands responded to the therapy. Quasispecies in our studied patients cannot be used to predict responsiveness to treatment, but may offer an explanation for failure of most HCV-4 patients to respond to interferon alfa and ribavirin therapy

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

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

Hepatitis A in Saudi Arabia: a comparative sero-epidemiological study

To determine the prevalence of Hepatitis A Virus infection among Saudi children [1-12 years] in 1997. To compare the results with our previous study in 1989. This is a randomized community-based study involving all of the regions of Saudi Arabia. All children were tested for antibody Hepatitis A Virus immunoglobulin [IgG] class. The prevalence of anti-Hepatitis A Virus IgG among 5355 Saudi children tested ranged from 10% in Taif to 82% in Gizan regions with an overall prevalence of 25%. There is a reduction of the overall prevalence from 50.5% in 1989 to 25% in 1997. This study shows a marked decline in Hepatitis A Virus infection in Saudi children 8 years after the first study. There is an almost 50% reduction of the overall Hepatitis A Virus prevalence. This dramatic decline in Hepatitis A Virus infection among the Saudi children will lead to a later exposure of elderly population groups to the Hepatitis A Virus infection and a new preventive strategy needing to be adopted

Schistosomiasis as a possible risk factor for acquiring hepatitis C virus [HCV] infection among Saudis

Risk factors for acquiring hepatitis C virus [HCV] infection have been elucidated in many developed countries but the picture is still not clear in many Middle Eastern Countries including Saudi Arabia. Aim-To investigate possible risk factors for acquiring HCV among Saudis. Methods-Various demographic and medical risk factors that might be associated with the spread of HCV among Saudis were investigated. The population studied included 20 anti-HCV-positive with chronic liver disease [CLD], 30 anti-HCV-positive patients without CLD and 272 anti-FICV-negative Saudi blood donors. All people investigated were of the same age group [>40 years of age]. Results-None of the demographic parameters studied [type of job, type of housing, education] was found to be significantly associated with acquiring HCV infection among our Saudi patients, On the other hand up to 40% of the anti-Hey-positive patients and irrespective of the condition of liver disease had a history of surgery, and 25% of them had a history of multiple injections. Furthermore, at least 20% of our anti-HCV-positive patients had a history of schistosomiasis which is significantly higher than schistosomiasis among the blood donors [Pc0.005]. Conclusion-In addition to blood and blood products, schistosomiasis seems to be a possible risk factor for acquiring HCV among the Saudi population. The association between schistosomiasis and enhancement of HCV infection need to be further elucidated

Plasma uric acid, urea and reatinine in sickle cell disease

Plasma uric acid, urea and creatinine were estimated in a group of 45 sickle cell anaemia patients and the results were compared with the results obtained in a group of age- and sex-matched controls with normal haemoglobin [Hb AA]. The uric acid level was elevated slightly in the sickle cell anaemia patients, but the difference in the mean for the two groups was not statistically significant. Only two sickle cell anaemia cases had a uric acid level above the normal range. Urea and creatinine levels were considerably lower in the sickle cell anaemia patients and the difference in their mean compared to the mean in the normal group [Hb AA] was statistically significant [p<0.05]. It is suggested that further studies on renal clearance of uric acid, urea and creatinine are necessary on Saudi sickle cell anaemia patients, particularly adults, to assess the extent of renal damage in these patients

Hepatitis B infection in Saudi Arabia

This article on the hepatitis B virus [HBV] in Saudi Arabia reviews 24 articles on HBV which have been published in national and international journals. The data of 49, 312 Saudi individuals have been analyzed. Some conclusions have been drawn about the prevalence of HB[s]A[g], overall exposure of the population, and control of HBV infection

Effect of Ramadan fasting on the values of haematological and biochemical parameters

Ramadan is the ninth lunar month of the Muslim year during which it is obligatory for all healthy adult Muslims to fast from dawn to sunset. This study was conducted during Ramadan on a group of 36 male volunteers of middle socioeconomic status, to determine the effect of fasting on the haematological and biochemical parameters. The haemtological parameters showed only slight variations, particularly in the haemoglobin level and red blood cell count which showed a decrease, but reverted back to normal as soon as the fasting period was completed. This almost paralleled a decrease in plasma iron level during the 4 weeks of the fasting. In the biochemical parameters, cholesterol, triglyceride total protein albumin, alkaline phosphatase, chloride phosphorus, glucose, creatinine, uric acid, blood urea nitrogen, glutamate oxaloacetate transaminase and glutamate pyruvate transaminase showed an increase during the fasting period which in some cases was statistically significant while serum iron showed a decrease. For most of the parameters the values reverted back to the baseline value as soon as the fasting period was over. The effect of fasting on healthy adults is discussed

Stenosis of duodenum due to eosinophilic gastroenteritis

A student aged 24 years was found to have stenosis of the second part of the duodenum due to eosinophilic gastroenteritis. This is a rare condition which has to be considered in the differential diagnosis of recurrent peptic ulceration. The current knowledge about the pathology and management of this entity is reviewed