Hurthle cell neoplasms of thyroid in south-western region of Saudi Arabia.

BACKGROUND: Thyroid Hurthle cell neoplasm (THCN) is relatively rare. OBJECTIVE: To describe the presentation, diagnostic approach and management of THCN in our institution. METHODS: This was a retrospective chart review of all thyroid Hurthle cell neoplasms diagnosed at Aseer Central Hospital (ACH), Saudi Arabia during the period from October 1998 to April 2007. Data including clinical, cytopathologic, radiologic, histopathologic and surgical treatment were extracted for analysis. RESULTS: Nine patients were diagnosed as THCN (eight females and one male). Their ages ranged from 24-49 years. Three cases were Hurthle cell carcinomas and six cases were Hurthle cell adenomas. Carcinomas presented as solitary nodules (two cases) and as multinodular goiter (one case). Adenomas presented as solitary nodules (two cases), as multinodular goiter (three cases) and as diffuse swelling (one case). Fine needle aspiration cytology (FNAC) was diagnostic for THCN in two cases of carcinoma that presented as solitary nodules and hence total thyroidectomy was performed. Total thyroidectomy was also done in one case of adenoma. Hemithyroidectomy was performed in two cases of adenoma in which FNAC showed benign lesion and in one case of carcinoma based on clinical and ultrasonographic impression of benign MNG in the involved lobe and inconclusive FNAC result. Subtotal thyroidectomy was performed in one case of adenoma. CONCLUSION: Preoperative diagnosis and management of THCN is still a dilemma. Neither clinical nor FNAC findings can exclude carcinoma. Therefore a combination of clinical, radiological, FNAC and histopathological results should be used for a more definitive subtyping and proper management.

Prevalence and risk factors of gallstone disease in a high altitude Saudi population.

To study the prevalence of gallstone disease and related risk factors in a Saudi Arabian population a cross-sectional community-based study was made of 291 people from Abha district, Asir region. A structured interview collected background data and all participants had upper abdominal ultrasonography to detect gallstones. The overall prevalence of gallstone disease was 11.7%. Using logistic regression multivariate analysis, the following were significant risk factors for gallstone disease: female sex, family history of gallstone disease and past history of pancreatitis. Age, education, blood pressure, smoking, coffee intake, overweight, diabetes mellitus, number of pregnancies and use of oral contraceptives were not significant risk factors. Discriminant analysis of symptoms showed that only right hypochondrium pain was significantly associated with gallstone disease.

Prevalence and risk factors of gallstone disease in a high altitude Saudi population

To study the prevalence of gallstone disease and related risk factors in a Saudi Arabian population a cross-sectional community-based study was made of 291 people from Abha district, Asir region. A structured interview collected background data and all participants had upper abdominal ultrasonography to detect gallstones. The overall prevalence of gallstone disease was 11.7%. Using logistic regression multivariate analysis, the following were significant risk factors for gallstone disease: female sex, family history of gallstone disease and past history of pancreatitis. Age, education, blood pressure, smoking, coffee intake, overweight, diabetes mellitus, number of pregnancies and use of oral contraceptives were not significant risk factors. Discriminant analysis of symptoms showed that only right hypochondrium pain was significantly associated with gallstone disease

An unusual cause of lower gastrointestinal bleeding: a case report and a review of literature.

This is an unusual case report of a 60-year-old man who presented with massive rectal bleeding due to angiomatous formation. He was also found to be cirrhosis and to have an ectopic left kidney in the midline over the roof of the mesenteric vessel. He was treated successfully by performing a right hemicolectomy.

Pattern of acute pancreatitis.

OBJECTIVE: The aim of this communication was to study the clinical pattern of acute pancreatitis with special reference to aetiology, severity, seasonal variation and outcome in the high altitude region of Asir. METHODS: This is a cross-sectional, hospital-based study. All consecutive cases of acute pancreatitis admitted to Asir Central Hospital, Abha, Saudi Arabia over a two and half-year period (May 1996 - October 1998) were included. Clinical and laboratory data were analyzed to determine the severity of the attack according to Ranson's criteria. RESULTS: There was a total of 73 attacks of acute pancreatitis in 69 patients. Mean patient age was 51.01 years (range = 13-120 years) and the male to female ratio was 0.6:1. In 68.5%, gallstones were the associated cause and idiopathic acute pancreatitis was diagnosed in 25%. Using Ranson's severity prediction criteria, 44% of the attacks were classified as "severe", but only 22% of the patients so classified developed complications. Pseudocysts and Pancreatic abscess complicated three cases. Complications were significantly correlated with cold seasons (P = 0.04), intervention by Endoscopic retrograde cholangiopancreatography (P = 0.02) and severity (P = 0.02). CONCLUSION: This study revealed that acute pancreatitis seen in Asir region is predominantly biliary-associated and is more frequent in females. Although near half of the attacks were classified as severe pancreatitis, according to Ranson's criteria, complications occurred in only 22% of the attacks and this may indicate that Ranson's criteria needs to be modified before application in our setting.

Endemic goitre in schoolchildren in high and low altitude areas of Asir region, Saudi Arabia.

OBJECTIVE: A deficiency of iodine is characteristic of mountainous regions of the world, and the frequency of goitre in such areas has been recognized for centuries. The aim of the present study was to estimate the prevalence of goitre among schoolchildren in high and low altitude areas of Asir Region. METHODS: The study was carried out upon 940 male students randomly selected from 12 schools at 2 high altitude areas (Tamnia and Al-Soda) 3150 meters above sea level and one low altitude area (Marabah) 500 meters above sea level. All students were subjected to clinical examination of the thyroid and classification of goitre grading was based on the criteria endorsed by the World Health Organization/United Nations Children's Fund/International Council for the Control of Iodine Deficiency Disorders. RESULTS: An overall prevalence of goitre of 24% was estimated in the areas studied (24% in elementary, 24% in intermediate and 23% in secondary education). This prevalence was significantly higher (p < 0.0001) in high altitude (27%, 95% confidence interval: 24%-30%) than in low altitude areas (13%, 95% confidence interval: 8%-18%). Children of high altitudes were 2.5 times more likely to develop goitre as compared to their counterparts in low altitudes (odds ratio = 2.5, 95% confidence interval 1.6-3.8). However, comparison between the 2 high altitude areas revealed that children of Tamnia area were nearly 2 times more likely to develop goitre than their counterparts in Al-Soda (odds ratio = 1.9, 95% confidence interval: 1.3-2.6). CONCLUSION: Endemic goitre is more prevalent in mountainous, high altitude areas of Asir Region. However, the distribution of goitre in these areas is patchy and differs from area to area. Well water might have been a contributing factor for the high prevalence in Tamnia.

Pathology of the appendix.

An audit of 3374 appendectomy specimens in 2578 Saudi and 796 non-Saudi nationals revealed a diagnosis rate of 74.7% of inflamed appendix, a normal appendix range of 7.8% to 22.5% with the higher rate of normal appendix found among females. The finding of high incidence of schistosomal appendicitis among Egyptian males is not surprising given the high incidence of schistosomiasis among Egyptians in general. The alternate diagnoses, which include such conditions as neoplasm, mucocele, other inflammatory conditions such as periappendicitis, and parasitic infestations, are not different from findings in the reported literature.

Some rare presentations of hydatid cyst (Echinococcus granulosus).

Among all the cases of hydatid disease seen in an 8-year period at Asir Central Hospital, Abha, Saudi Arabia, seven cases are reported here because of their unusual presentations. One patient had a brain hydatid cyst which presented as a space-occupying lesion. The second patient presented with symptoms and signs of cardiac tamponade due to pericardial hydatidosis. The third female had multiple abdominal and pelvic hydatid cysts causing vague abdominal pain, chronic ill-health and primary infertility. The fourth case was a huge single hydatid cyst filling the whole abdominal cavity and involving multiple organs. The fifth case presented with simultaneous involvement of the liver, right diaphragm and pleura with hydatidosis. The sixth case involved the left diaphragm and the patient presented with clinical picture simulating pleurisy. The last patient presented with a hydatid cyst of the right thigh. Even though there was no mortality in these patients, there was disabling morbidity. We conclude that Echinococcus granulosus can affect any organ in the body and a high suspicion of this disease is justified in endemic regions. Moreover, medical treatment should precede and follow the surgical intervention.

Variants of papillary carcinoma of the thyroid: experience at Asir Central Hospital.

Papillary carcinoma of the thyroid is now further subclassifiable into its different variants. We report incidence, clinical behaviour and outcome of rare variants of papillary thyroid cancers at Asir Central Hospital, Saudi Arabia. These variants differ from each other not only on a morphometric basis, but also in clinical behaviour. Accordingly, we report our experience of different variants in a series of 35 papillary carcinomas. These cases were received in the surgical pathology laboratory of Asir Central Hospital from January 1987 to December 1994. We have reviewed clinical charts, microscopic slides and pathological reports of these carcinomas. The following results have been obtained: 20 cases were classical (usual) papillary thyroid carcinomas: seven were follicular variants; three were tall cell/ columnar variants; two were oxyphilic variants; and one was a diffuse sclerosing variant. There were two de-differentiated papillary carcinomas (anaplastic carcinomas with foci of well-differentiated papillary carcinomas). These variants were also correlated with clinical parameters such as age, sex and nationality of the patients, aggressiveness of the tumours, types of surgery required, and follow-up when available.

Hydatid cyst disease (Echinococcus granulosus): experience at Asir Central Hospital.

In a six-year period, starting from the commissioning of Asir Central Hospital in 1408 H (1988), 43 cases of hydatid cyst disease caused by echinococcus granulosus seen in Asir Central Hospital were studied. The pattern was not significantly different from other workers' experiences. There was equal sex distribution and the average age was 41.7 years. The clinical presentations depended essentially on the organs affected, and computed tomography usually confirmed the diagnosis. The serological test at times gave a false negative result. Most of the patients came from Abha in Asir region and the most commonly involved organ was the right lobe of the liver. All the patients had laparotomy, excision or incision and drainage of the cyst, depending on whether the cyst could be safely excised or only drained. The average hospital stay was 17 days. We believe that surgical intervention should be the first line of treatment especially when the cyst is large.

Thyroid malignancy in multinodular goitre and solitary nodule.

This is a retrospective study of 361 thyroid specimens during a 6 1/2-year period with the objective of investigating the prevalence and pattern of thyroid malignancy associated with multinodular goitre (MNG) and solitary nodule (SN). Fourteen of 172 MNG (8%) and 16 of 105 SN (15.2%) were associated with malignancy, a statistically insignificant difference (P = 0.06). Unlike in males, malignancy was significantly commoner in females with SN than those with MNG (P = 0.03) and generally occurred at a significantly older age (P < 0.05). On analysing thyroid carcinoma and lymphoma separately, patients with SN had a higher incidence of carcinoma compared with those with MNG (P = 0.01). It is concluded that surgical intervention may be the appropriate method of treating male patients presenting with MNG. However, in females, conservative management of MNG should be adopted unless surgery is indicated depending on clinical judgement and, if feasible, the result of fine needle aspiration biopsy.

Acute appendicitis in females--a clinical study of 366 cases.

A study was carried out on 366 female patients admitted consecutively to Asir Central Hospital with clinical diagnosis of acute appendicitis during the period between 1988 through 1991. In this study, 271 patients had histopathologically proven appendicitis for a diagnostic accuracy of 74%. Ninety-five (26%) patients did not have appendicitis, however, 27 (7.4%) of them had other disorders indicating surgical intervention. Consequently, 18.6% of the patients studied had negative laparotomy. This study showed insignificant (P > 0.05) relation between age, site of pain and its duration, presence of urinary symptoms, post-operative complications and hospitalization in one hand, and the final diagnosis on the other hand. The marital status, the presence of gynaecological symptoms, white blood cells count, neutrophils and lymphocytes percentages were, however, significantly related to the final diagnosis (P < 0.05). A conservative approach with in-hospital observation and repeated clinical examination of the doubted appendicitis cases are recommended so as to reduce the rate of the negative laparotomy with its considerable complications.

Schistosomal appendicitis.

This is a retrospective study involving 4708 consecutive appendix specimens removed over a period of 6.5 years for a clinical diagnosis of acute appendicitis, 64 (1.3%) of which showed histological evidence of schistosomiasis. Thirty-four schistosomal appendicitis (SA) cases were compared with 68 non-schistosomal appendicitis (NSA) cases admitted during the same period. SA patients were older in age, usually of male sex, mostly Egyptians and tended to have a higher hemoglobin and a lower leukocyte count (P<0.05). Other features were not significantly different. It is concluded that, despite these differences, there are no reliable clinical or laboratory features by which SA can be predicted preoperatively. The majority of the studied patients were either discharged before the results of the histopathology study were ready and were lost to follow-up or the reports were overlooked. Therefore, we recommend that for all post-appendectomy patients living in or coming from endemic areas of schistosomiasis, the results of the histopathology study should be processed as early as possible and before the patient can be discharged so that the treatment can be commenced. Moreover, establishing a system by which infected patients could be traced and hence treated is highly recommended.