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

Correlation between hepatitis B surface antigen titers and HBV DNA levels

To assess the correlation between serum HBsAg titers and hepatitis B virus [HBV] DNA levels in patients with hepatitis B envelop antigen-negative [HBeAg -ve] HBV genotype-D [HBV/D] infection. A total of 106 treatment- na‹ve, HBeAg -ve HBV/D patients were included; 78 in the inactive carrier [IC] state and 28 in the active hepatitis [AH] stage. HBV DNA load and HBsAg titers were tested using TaqMan real-time polymerase chain reaction [PCR] and automated chemiluminescent microparticle immunoassay, respectively. The median [range] log10 HbsAg titer was significantly lower in the IC group compared with AH group, 3.09 [-1 to -4.4] versus 3.68 [-0.77 to 5.09] IU/mL, respectively; P < 0.001. The suggested cutoff value of HBsAg titer to differentiate between the two groups was 3.79 log10 IU/mL. In addition, there was a significant positive correlation between HBsAg and HBV DNA levels in the whole cohort, AH, and IC groups [r = 0.6, P < 0.0001; r = 0.591, P = 0.001; and r = 0.243, P = 0.032, respectively]. Serum HBsAg titers may correlate with HBV DNA in treatment-na‹ve HBeAg -ve HBV/D patients, and supports the use of HBsAg levels in clinical practice as a predictor of serum HBV DNA levels.

Epidemiological, clinical, and biochemical characteristics of Saudi patients with nonalcoholic fatty liver disease: a hospital-based study

The estimated prevalence of nonalcoholic fatty liver disease [NAFLD] in Saudi Arabia is 7% to 10%. Despite the high prevalence of risk factors including diabetes, obesity, and hyperlipidemia, no recent epidemiological studies have measured the disease burden. We aimed to determine the characteristics of Saudi NAFLD patients attending a university hospital, and study factors affecting alanine aminotransferase [ALT] levels. A prospective study among patients referred for ultrasonography in King Khalid University Hospital in Riyadh, Saudi Arabia from February to May 2009. NAFLD was defined as an appearance of fatty liver on routine abdominal ultrasound in the absence of coexisting liver disease and alcohol consumption. Patients were classified into normal and high ALT [ALT >60 U/L] level groups for analysis. The prevalence of NAFLD was 16.6% [218/1312]. Patients with normal ALT had the mean [SD] age of 45.9 [10.6] years and the mean body mass index of 34.5 [7.9] kg/m2. Forty percent of the 151 patients with normal ALT had diabetes, 66.2% were obese, and 29.1% had hypertension. Forty-three patients [23%] had high ALT levels. These patients had significantly lower age [P=.003] and fasting blood sugar [P=.03] than the normal ALT group. Non-diabetic patients [odds ratio 0.30, 95% CI 0.1-0.8], men [female OR 0.23, 95% CI 0.1-0.5], lower cholesterol [P=.001], high-density lipoprotein [P=.006], and low-density lipoprotein [P=.008] levels were more likely to be observed among patients with high ALT levels. In a multivariate analysis, younger age [OR 0.96, 95% CI 0.93-0.99], being male [OR 0.23, 95% CI 0.09-0.57], and a lower cholesterol level [OR 0.55, 95% CI 0.37-0.82] were significant predictors of high ALT levels. Based on the high prevalence of obesity and diabetes, the prevalence of NAFLD will continue to be high, unless awareness is inculcated among the local population