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

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Biliary leak: Endoscopic management.

The objective of this study was to evaluate the effectiveness of endoscopic treatment in patients with biliary leak. The study was performed at King Khalid University Hospital in Riyadh. We used retrospective analysis of the complete records of 18 patients with biliary leak treated endoscopically over a period of 10 years. The mean age was 41.11 +/- 14.54 years. Ten were male. The leak was complicating cholecystectomy, biliary surgery for hydatid cysts and road traffic accidents in 15, two and one patients. Of the 17 patients cystic duct remnant in 11, common bile duct in three and intrahepatic duct in four patients. Of the 17 patients who had endoscopic papillotomy (EPT), this procedure was combined with stenting in 11, with stone retrieval in two, with stone retrieval and stenting in three and with dilatation of a stricture in one patient. Another patient was treated with a stent without papillotomy. In all patients, the leak healed and the stent was removed after a mean stenting duration of 65.12 +/- 41.89 days. No complications were encountered in this group of patients. Endoscopic management of biliary leak is a simple, safe and effective therapeutic method. Therefore, we recommend its application as first-line management of biliary leaks.

Refractory duodenal ulcer.

Refractory or intractable ulcer is defined as an ulcer that fails to heal completely after eight to twelve weeks, despite appropriate treatment with a modern antiulcer therapy in a compliant patient. Refractory ulcer should be suspected in individuals diagnosed to have peptic ulcer if their symptoms persist longer than usual: occurrence of complications or simply their ulcers fail to heal, since up to 25% of such patients remain asymptomatic. Conditions associated with refractory ulcer include noncompliance, continuous consumption of nonsteroidal anti-inflammatory drugs, acid hypersecretion, smoking. male gender and other factors with questionable role like advanced age, large ulcer size, prolonged duration of symptoms and the presence of complication like bleeding. Nonpeptic ulcers like tuberculosis, malignancy, Crohn's disease and primary intestinal lymphoma should always be considered in the differential diagnosis. Colonization with H. pylori which is well-known as a cause of frequent recurrences, has not been linked with refractoriness. Patients with refractory ulcers must undergo thorough re-evaluation including repeated endoscopies, obtaining biopsies for microbiology and histology and determination of serum-gastrin level. Once diseases with identifiable etiologies have been ruled out, aggressive medical management with single or multiple antiulcer drugs should be instituted. Such treatments will virtually heal all refractory ulcers. Surgery should be reserved for patients whose ulcers fail to respond to optimal medical therapy or those who develop complications necessitating surgical intervention.

Prevalence of hepatitis B surface antigenemia among patients with schistosoma mansoni.

This case-control study was designed to determine the prevalence of persistent hepatitis B surface antigenemia (HBsAG) among patients with schistosoma mansoni and to rationalize their vaccination against hepatitis B virus (HBV) infection. Seventy consecutive patients with a confirmed diagnosis of schistosoma mansoni were matched for age, sex, nationality, and residence (for Saudis only) with 70 healthy controls. Despite identical mean ages, sex, and nationality distribution, 18 schistosomiasis patients (26%) had positive HBsAg as compared with only three of the controls (4%). The odd ratio for HBsAg antigenemia among patients as compared to controls was 7.73 (95% confidence interval (CI) = 2-35.01, P = 0.0004. Neither sex nor nationality had any influence on the positive rate for HBsAg found in schistosomiasis patients. Patients with schistosomiasis and a concomitant positive HBsAg had significantly more derangement of their hepatic enzymes (14 out of 18; 78%) as compared with those without this viral serological marker (22 out of 52; 42%) (odd ratio - 4.77; 95% CI=1.22-20.11; P = 0.009). I have concluded that patients with schistosoma mansoni are exposed to a higher risk of acquiring HBV infection and that concomitant schistosomiasis and HBV infection has a deleterious effect on hepatic enzymes as well as other liver functions. Prospective evaluation of the preventive role of HBV vaccine among these patients is warranted.

Abdominal tuberculosis in Saudi Arabia: a clinicopathological study of 65 cases.

The clinical and pathological features of 65 patients with abdominal tuberculosis obtained during a 7-yr period were analyzed and the diagnostic procedures critically evaluated. The diagnosis was histologically confirmed in 59 patients. In two more patients, the diagnosis was based solely on a positive ascitic fluid culture for tubercle bacilli. The remaining four patients responded dramatically to anti-tuberculous chemotherapy given on suspected laparoscopic findings in cases in which no biopsy was taken. Laparoscopy was found to be safer and superior to laparatomy and is recommended as an initial investigation in the diagnostic work-up of patients in whom tuberculous peritonitis is suspected. Furthermore, the finding of granulomatous inflammation in peritoneal biopsy is a justification for immediate therapy in such patients. This is particularly valid in endemic areas if one considers the risks of delaying treatment of these patients.

Tuberculous peritonitis: the value of laparoscopy.

The laparoscopic and pathological diagnoses of 43 patients who underwent abdominal laparoscopy for various indications are presented. Major indications for the laparoscopy included hepatomegaly in 32 patients, ascites in 28, and pyrexia of unknown origin (PUO) in 18 patients. A combination of two or more of these indications was a more common feature. The most frequently encountered laparoscopic diagnoses were tuberculosis and chronic liver disease (16 patients each), followed by cancer (9 patients). However, on pathological examination of peritoneal or liver biopsy tissue and on follow-up, tuberculosis was confirmed in 12 patients, chronic liver disease in 14 patients and hepatocellular carcinoma in 11 patients. No complications were encountered during the laparoscopy. Our findings indicate that abdominal laparoscopy is a safe, quick and inexpensive diagnostic tool, particularly when appropriate and adequate tissue is taken for pathological examination. In such instances, laparoscopy would save an unnecessary laparotomy, especially where tuberculosis and cancer are considered in the differential diagnosis.

Evaluation of students' performance and examination procedures in final certifying examinations in internal medicine (1982-1988).

We conducted a retrospective analysis to evaluate the performance of 459 students on their final certifying examination in internal medicine. These examinations were taken during 1982 through 1988, and the failure rate was 17.6%. Two hundred and five students (44.6%) received grade D (60-69% of the total marks) and 139 (30.1%) grade C (70-79% of total marks). Only 7.7% of the students scored higher (80% or more). A temporal trend has been observed in that a higher percentage of lower grades and lower percentage of higher grades has been observed in recent (1986-1988) compared with earlier (1982-1984) years. Female students generally performed on a par with males, though males students performed better on multiple choice questions (MCQs). The analysis also showed lower mean scores for the essay, oral, and clinical components in recent (1986-1988) than in earlier (1982-1984) years. In studying the interrelationships between different examination components, the MCQs were found to have the highest correlation with other procedures. A lower correlation was observed for clinical examination. Factor analysis also showed that MCQs had the highest and clinical examinations the lowest factor loading. Low correlation and factor loading were also noted for the essay portion. While in the newly implemented curriculum the essay paper has been wisely eliminated, our data suggest that the traditional clinical examination should be replaced by a more objective and structural method. Our analysis may serve as a guide for formulation of final certifying examinations in medical schools throughout the Kingdom.

A single nocturnal dose of famotidine for the treatment of duodenal ulcer: evaluation of efficacy and safety.

The efficacy and safety of a single nocturnal dose of famotidine (40 mg) was evaluated in 30 consecutive patients of duodenal ulcer (DU). Three patients were lost for follow-up and therefore were excluded. The mean age of remaining 27 patients was 34.3 (+/- 9.9) years and male to female ratio was 8:1. The mean size of the DU was 1.21 (+/- 0.79) cm. After a 4-week therapy all patients showed significant improvement and repeat endoscopy in 24 out of 27 patients (89%, 95% confidence interval; 78% to 100%) showed healed ulcer. Clinical assessment of pain relief at 4-week showed significant drop in the mean score of baseline daytime (from 1.85 to 0.13) and baseline nocturnal pain (from 1.70 to 0.10) (p less than 0.0001 and less than 0.0001, respectively). Also shown was the significant decrease in the mean gastrointestinal symptoms score from 5.89 at baseline to only 0.89 at 4-week (p less than 0.0001). Despite that all those who failed to show ulcer healing at 4-week were smokers, logistic regression analysis could not identify smoking or any other risk factors as adverse predictors of ulcer healing. None of the patients experienced significant side effects or adverse reactions. We conclude, that a single nocturnal dose of famotidine is a practical, highly effective and safe approach for the management of DU.

Helicobacter pylori-associated upper gastrointestinal disease in Saudi Arabia: a pathologic evaluation of 298 endoscopic biopsies from 201 consecutive patients.

In a prospective study, histopathological examination 298 upper gastrointestinal (UGI) biopsies, obtained from 201 consecutive patients, was made. Patients were referred with mild to severe dyspeptic symptoms. The aim of the study was to compare the rate of identification of Helicobacter pylori (H. pylori) in the histologically normal gastric mucosa with that in histologically confirmed gastritis or peptic ulcer disease. The gastroduodenal mucosa was histologically normal in 35 patients (17.4%); among those patients, H. pylori was identified in only three (9%). Chronic gastritis was histologically confirmed in 162 patients (80.6%). H. pylori was identified in 123 (76%) of those patients. The difference was statistically significant (p less than 0.00001). Furthermore, when cases with a histological diagnosis of superficial chronic active gastritis (SCAG) are considered separately, the identification rate of H. pylori increases to 88% (121 of 137). When this rate is compared with that of 8% (two of 25), found in superficial chronic quiescent gastritis (SCQG), the difference is highly significant (p less than 0.00001). Of 38 endoscopically diagnosed peptic ulcers, H. pylori was identified in the gastric mucosa of 34 (89%). The organisms were always seen in the antral gastric mucosa, but never in duodenal mucosa. Identification of H. pylori correlates significantly with the histologic activity of chronic gastritis, in both peptic ulcer disease and non-ulcer dyspepsia.

Campylobacter pylori in Saudi patients undergoing upper gastrointestinal endoscopy: prevalence and effect of conventional therapy.

Patients with symptoms of gastritis or peptic ulcer disease were recruited to study the prevalence of Campylobacter pylori. On the basis of the endoscopic diagnosis only, the isolation rates of the organisms in normal, gastritis or gastroduodenitis (GD), and peptic ulcer (PU) disease patients, were not significantly different among the 89 patients evaluated. However, analysis based on histopathological evaluation (in 73 out of these 89 patients) revealed a significant difference (p = 0.00016) in the isolation rate between histologically normal individuals (14%) and those with GD (89%). Also, a significant (p = 0.03) difference was observed in the C. pylori detection rate among patients with GD and those with PU disease (61%). After adjustment for multiple comparisons, only the difference in C. pylori prevalence between normal and GD patients was maintained. After conventional therapy, 23 patients who initially had GD or PU disease were submitted to re-endoscopy. In the latter group, a correlation between presence or absence of organisms and histological healing was noted. The potential pathogenesis of C. pylori in gastritis and peptic ulcer disease, and designs for future trials are discussed.

The pattern of colonic diseases in the Eastern Province of Saudi Arabia.

The purpose of this paper is to highlight the incidence and scope of lower gastrointestinal tract (GIT) diseases in the Eastern Province of the Kingdom of Saudi Arabia. Between August 1981 and April 1984, 288 patients with significant complaints and physical signs attributable to the lower GIT were prospectively evaluated. A complete patient history was taken in each case followed by physical examination, routine laboratory studies and a sigmoidoscopic examination. In 128 patients (44.5%), sigmoidoscopy and rectal and/or colonic biopsies did not reveal any pathological abnormalities. These patients were considered to have various disorders such as irritable bowel syndrome or parasitic infestation. Eighty-one patients (28%) were found to have mild to moderate non-specific colitis or proctitis. In another 49 patients (17%) the diagnosis of schistosomiasis mansoni was made. Ulcerative colitis and colorectal carcinoma were detected in only 11 (4%) and 4 (1.5%) patients respectively. In the remaining 15 patients (5%), other lower GIT diseases were found. Comparative analysis of the disease pattern in our series has demonstrated some differences from other series from within the Kingdom and also from other countries.