Indications and yield of upper gastrointestinal endoscopy in children

Knowledge of the pattern of gastrointestinal tract [GIT] disorders detected by endoscopy is important for clinicians. The objective of this paper is to report on the indications and yield of endoscopy. Retrospective analysis of data of all patients below 18 years of age who underwent upper GIT endoscopy from 1414 H [1993 G] through to 1424 H [2002 G] over a 10-year period at King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia. One thousand and fifteen upper GIT endoscopies were performed, of which 851 diagnostic procedures were performed on 851 children. The majority [96%] were Saudi nationals, the age range was between 4 days and 18-years, and the male to female ratio was 0.7: 1. The 2 most common indications were duodenal biopsy [29%] and abdominal pain [24%]. The best diagnostic yield was in children presenting with ingestion of caustic substances, followed by hematemesis, and vomiting in 86%, 75% and 67%. The overall yield, however, was 43%. Finally, the most common diagnoses were gastritis and esophagitis occurring in 32% and 30% of the children. Age related variations are reported. The increasing practice of endoscopy in children resulted in the development of new indications such as endoscopic small bowel biopsy. The differences in indications and yield of endoscopy with age reflecting the varying pattern of diseases

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

Efficacy of hepatitis B vaccine in a cohort community-based study in Riyadh and Hail regions of Saudi Arabia

Saudi Arabia used to by hyperendemic for HBV infection. Most of infection occurs in early life. HBV vaccine was, therefore, introduced in 1989 as the seventh primary immunogen of the EPI Program. This study is conducted to evaluate the efficacy of this program in Riyadh and Hail Regions. Method and Patients: A cohort follow-up study of children from Riyadh and Hail, who had been vaccinated in 1989, evaluated in 1991 and tested for HBV markers six years later. The files of 303 children from Riyadh and Hail, who were investigated in 1991retrieved and only 119, were available for testing. Fifty% of the children have still a protective anti- HBs tittr. One vaccinated child was found to be positive for HBs Ag. According to this study, the efficacy rate against HBs Ag carriage is 88%. This study demonstrates the tremendous effect of HB vaccine on the HBV infection of Saudi children in these two regions

Pediatric colonoscopy: king Khalid University Hospital experience

Pediatric colonoscopy is now an established procedure to evaluate colonic disease. As there is no reports about pediatric colonoscopy in our community a retrospective study was carried in KKUH to analyze the pediatric conlonoscopy. Sixty-six colonoscopies were done in sixty-two patients. The age ranged from 6 month to 16 years; with 35 males and 27 females. Forty-seven of the patients were Saudi. Indication for colonoscopy were bleeding per rectum thirty- two, diarrhea ten, abdominal pain seven, ulcerative colitis in four, suspected polyps in five and other indication in seven patients. In 33 patients colonoscopy was done without premedication, 11 patients had sedation while 22 hads general anesthesia. colonoscopy revealed abnormal finding in 64%, normal findings 28.7% and due to poor preparation no endoscopic report in 7.3%. The commonest abnormal finding were ulcerative colitis in 19 patients and polyps in 17 patients. Pediatric colonoscopy is a safe, practical rewarding procedure especially in certain categories of patients suspicion of ulcerative colitis will lead to better management of patients

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

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

Limited value of argyophil nuleolar organizer regions in the assessment of esophageal lesions

To determine the usefulness of the argyophil nucleolar organizer scores in predicting malignant or aggressive behavior in neoplastic and non-neoplastic lesions of the esophagus. The silver staining technique for argyophil nucleolar organizer regions was performed on 66 specimens of formalin fixed paraffin wax embedded esophageal biopsies: Twenty six [26] normal biopsy specimens, 4 cases of squamous papilloma, 10 cases of well differentiated squamous cell carcinoma, 16 cases of moderately differentiated squamous cell carcinoma and 10 cases of adenocarcinoma were studied. The mean AgNOR scores and range of values were as follows: Normal esophageal squamous epithelium, mean 6.3 [range 4.8 to 7.4] squamous papilloma, mean 8.6 [range 6.9 to 10.2] well differentiated squamous cell carcinoma, mean 6.0 [range 4.5 to 7.7]; moderately differentiated squamous cell carcinoma mean 7.2 [range 5.5 to 8.7]; adenocarcinoma mean 5.8 [range 4.5 to 6.5]. The results of the different diagnostic categories were compared using the Kruskal-Wallis test but did not achieve statistical significance. The AgNOR scores of different esophageal lesions did not predict aggressive behavior or malignancy

Prevalence of hepatitis A virus among Saudi Arabian children: a community-based study

HAV is endemic in Saudi Arabia, with about 90% of the adult population having positive anti-HAV. A population-based survey of hepatitis B virus markers provided an opportunity to determine the age-related prevalence of anti-HAV among Saudi children and examine some of the factors that influence its transmission in the community. The overall prevalence of anti-HAV is 52.4% of 4375 children tested. There was no significant difference in HAV prevalence between males and females [51.3% vs 53.5%]. The age-specific rates, which were similar in both sexes, indicated the lowest rate in infants with a steady increase in the older age group. There was a marked regional variation in ant-HAV prevalence, the Eastern region showing the lowest prevalence [38.4%], while the Northwestern region showed the highest prevalence [67%]. In nearly all the regions, rural inhabitants had a higher prevalence than urban residents. Socioeconomic factors had a significant correlation with the prevalence of ant-HAV, with the level of education of parents having the strongest influence on HAV prevalence. The high overall HAV prevalence in children confirms that Saudi Arabia is endemic for HAV infection, despite the recent improvement in the socioeconomic standards of its population. The pattern of HAV may be changing in Saudi Arabia as the prevalence has dropped in the Central province compared to previous report reports. The need for the introduction of hepatitis A vaccination will be determined in the future definition of HAV epidemiology in Saudi Arabia

Ascites: tips on diagnosis and management

Clinical evaluation and diagnostic paracentesis with estimation of the serum-ascitic albumin gradient [SAAG] is the most important step in identifying the etiology of ascites. At a level of 1.1 g/dl, SAAG, accurately [96.7%] differentiate portal hypertension from nonportal I hypertension-associated ascites. The majority of patients with ascites [>80%] have portal hypertension associated etiology mainly, liver cirrhosis. Approximately 90% of patients with ascites complicating cirrhosis respond to salt restriction and diuretics. The remainder [10%] have refractory ascites which commonly respond well to large volume paracentesis [LVP]. Asymptomatic complications occurring in patients treated with LVP may not necessitate treatment. Other alternative methods for treatment of refractory ascites include: ascitic fluid recirculation [AR], peritoneovenous shunting [PVS],transjugular intrahepatic portosystemic stent-shunting [TIPS] and orthotopic liver transplantation [OLT]

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

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