The impact of brushing teeth on carbon-14 urea breath test results.

OBJECTIVE: The 14C urea breath test noninvasively detects the presence of the urease-producing bacteria Helicobacter pylori in the stomach. Several sources of errors have been identified to cause false or indeterminate results on the test. The objective of this study was to identify whether brushing teeth affects the test results. METHODS: We performed the 14C urea breath test on 168 patients, with breath samples counted at 10 and 20 min after oral administration of 2 microCi (74 kBq) 14C urea. Ninety-four patients brushed their teeth before the test while 74 did not. RESULTS: Thirty-six of the 74 patients (49%) who did not brush their teeth had positive results at 10 min, which became negative at 20 min. None of the 94 patients who brushed their teeth before testing showed this pattern with agreement of results at 10 and 20 min. CONCLUSION: We recommend brushing teeth before the 14C urea breath test since it significantly decreased the ambiguous results of the test in our laboratory.

Interferon-alpha plus ribavirin combination therapy for the treatment of chronic hepatitis C in interferon non-responders.

BACKGROUND/AIMS: Only a small fraction of patients with chronic hepatitis C have a sustained biochemical or virologic response to a standard course of alpha-interferon therapy. Thus, alternative treatments are needed particularly for non-responders. The main objective of this study was to evaluate the efficacy of alpha-interferon in combination with ribavirin in patients who had not responded to a previous course of alpha-interferon. METHODOLOGY: In this prospective open trial, 26 patients who had not responded to a previous course of interferon monotherapy, were treated for 6 months with a combination of alpha-interferon 2b, 5 MU thrice weekly, plus ribavirin 1000 or 1200 mg daily. They were followed-up for at least 6 months after therapy. RESULTS: At the end of treatment, 3 patients (12%) had normal aminotransferase levels and two (8%) tested negative for HCV-RNA in serum. After 6 months of follow-up, all patients had HCV viremia and only one (3.8%) was still in biochemical remission. One patient dropped out because of side effects and another was lost during follow-up. CONCLUSIONS: alpha-interferon-ribavirin combination is ineffective in treating patients who had had no response to interferon monotherapy.

Lack of transmission of hepatitis C virus following needlestick accidents.

Healthcare workers (HCWs) have an occupational risk of infection with hepatitis C virus (HCV). However, data regarding the magnitude of this risk are limited. We conducted a prospective study on a cohort of 24 HCWs who were exposed to HCV by needlestick injuries involving 25 patients. All source patients were viremic with a mean HCV-RNA level of 1.65 megagenomic equivalents per milliliter. At least 64% of patients were infected with HCV serotype 4 (Simmond's classification). After a follow up period of at least 6 months, none of the exposed HCWs acquired HCV. Thus, HCV does not seem to be easily transmitted by needlestick injuries. However, further large-scale studies are needed for a more accurate estimation of the risk of transmission.

Findings of colonoscopy in children: experience from Kuwait.

This report summarizes our retrospective analysis of 173 colonoscopic examinations performed on 159 children over a period of 9 years in Kuwait. Ninety-six children were males, with a male to female ratio of 1.5:1. The main indications for colonoscopy were rectal bleeding, polyps, and suspected inflammatory bowel disease. Examination was done under sedation or anaesthesia. One hundred and fifty-one (87 per cent) examinations were complete up to the caecum and 89 (51 per cent) up to the terminal ileum. The most common pathology was polyps in 42 children. All but one polyp were hamartomatous and mainly localized to the rectum and sigmoid colon. The majority had a single polyp. One child had adenomatous polyposis coli. One hundred and forty-two polyps were removed endoscopically with no complications. Inflammatory bowel disease was present in 34 (21 per cent) children (17 Crohn's disease, 11 ulcerative colitis, and 6 indeterminate colitis). Tuberculosis of the ileo-caecal region was diagnosed in two cases. Seven patients had rectal ulcers presenting as rectal bleeding. In 11 (7 per cent), the lesions were limited to the right side of the colon or terminal ileum. These results suggest that colonic pathology is not uncommon in children in Kuwait. The disease pattern is similar to that reported in western countries. As we have observed in adults, inflammatory bowel disease is seen in significant numbers among children in this region. In this survey we have observed a change in the disease frequency, Crohn's disease being more common that ulcerative colitis. Without adequate examination, the existence of inflammatory bowel disease and this possible changing pattern of disease would have gone unrecognized.

A multiplex polymerase chain reaction assay for the detection of Mycobacterium paratuberculosis DNA in Crohn's disease tissue.

BACKGROUND: Mycobacterium paratuberculosis is implicated as a possible cause of Crohn's disease. However, due to lack of an appropriate diagnostic method, this has been a subject of significant controversy. Our aim was therefore to develop a multiplex polymerase chain reaction (MPCR) for the detection of M. paratuberculosis DNA in Crohn's disease tissue. METHODS: Biopsy samples were collected by endoscopic forceps from terminal ileum, and genomic DNA was isolated. M. paratuberculosis-specific marker genes were amplified by using the present MPCR method. RESULTS: Here we report a new MPCR for detection of M. paratuberculosis DNA in Crohn's disease tissue. In this technique two genetic markers, IS900 and a newly described specific marker of MP2, were amplified in a single tube simultaneously. The method was evaluated using biopsy specimens from 10 Crohn's disease patients, 6 ulcerative colitis patients, and 21 irritable bowel syndrome patients. The patients were characterized by using standard clinical and histologic observations. The present MPCR method could not detect M. paratuberculosis DNA in the biopsy specimens. However, the marker genes were amplified from the samples that were spiked with M. paratuberculosis before DNA extraction. The marker genes were also not detected in 10 closely related mycobacterial strains and human genomic DNA. CONCLUSIONS: The present MPCR method is highly specific and can detect M. paratuberculosis DNA more reliably. These findings do not support an aetiologic role of M. paratuberculosis in Crohn's disease.

Alfa-interferon therapy for chronic hepatitis B virus infection in Kuwaiti patients.

Alfa-interferon is the standard treatment of chronic hepatitis B. However, the response rate varies widely in patients from different parts of the world, reflecting differences in the natural history of the disease and the immune reactivity of the population studied. The aim of this study is to assess the efficacy of alfa-interferon in the treatment of Kuwaiti patients with chronic replicative hepatitis B infection. Twenty-two adult Kuwaiti patients with biopsy-proven chronic hepatitis B were treated with alfa-interferon after an observation period of six months. All patients had abnormal transaminase levels and were HBeAg and HBV-DNA positive. Alfa-interferon-2b, 5 million units, was administered five days a week for 16 weeks. Patients were followed for at least 12 months after completing therapy. One of the 22 patients dropped out of the study after a single dose of interferon, because of side effects. Of the remaining 21 patients, three (14%) had a sustained loss of HBV-DNA and HBeAg. None of the patients lost HBsAg. There were no episodes of hepatic decompensation or deaths during the study. One patient developed hepatocellular carcinoma 28 months after completing treatment with interferon. Overall, Kuwaiti patients with chronic replicative hepatitis B responded poorly to interferon therapy.

Short-term IgM and IgG antibody responses to hepatitis E virus infection.

53 adult patients with acute hepatitis caused by hepatitis E virus were identified by the presence of IgM antibody to hepatitis E virus, and followed for 12 months to evaluate the kinetics of anti-HEV antibodies. All but 1 female Kuwaiti patient were expatriate workers from the Indian subcontinent, temporarily working in Kuwait. Follow-up samples obtained at 1, 3, 6 and 12 months were evaluated for IgM and IgG antibodies to hepatitis E virus. IgM-class antibodies to hepatitis E virus were detectable in 12/27 (44%) patients at 1 months, in 0/26 at 3 months, in 0/8 at 6 months and 0/6 at 12 months. IgG antibodies to hepatitis E virus were detectable in 46/47 (98%) at onset, 26/27 (96%) at 1 month, in 26/29 (90%) at 3 months, 16/16 (100%) at 6 months and 8/8 (100%) at 12 months of follow-up. This study suggests that IgM antibodies to hepatitis E virus decline rapidly after an acute infection but IgG antibodies to hepatitis E virus persists for at least 1 year in many patients.

Urinary schistosomiasis associated with hepatitis C virus infection.

We studied 26 adult patients referred for cystoscopy: 13 consecutive patients with schistosome ova on bladder biopsy and antibodies to Schistosoma species in serum were classified as having urinary schistosomiasis, while 13 consecutive patients without schistosome ova on bladder biopsy and who were negative for antibodies to Schistosoma species in serum served as controls. Nine of 13 patients (70%) and none of 13 controls (p < 0.0005) had antibodies to hepatitis C virus in serum (anti-hepatitis C virus). All controls and patients who were negative for anti-hepatitis C virus had normal serum alanine aminotransferase levels, while 2 of 9 (22%) positive for anti-hepatitis C virus had elevated levels. Our study shows that patients with urinary schistosomiasis are at high risk for anti-hepatitis C virus positivity and that some of them may have active liver disease. Therefore, it is imperative to screen patients with urinary schistosomiasis for associated hepatitis C virus infection and liver disease.

Unusual presentations of abdominal tuberculosis.

OBJECTIVE: To review unusual presenting features and diagnostic difficulties of abdominal tuberculosis in an endemic region. DESIGN: Retrospective clinical study from 1984 to 1989, illustrated by case reports. SETTING: A single hospital in Kuwait. PATIENTS: Fifty patients with abdominal tuberculosis established by the standard histologic and bacteriologic demonstration of acid-fast bacilli or tuberculous granulomas. MAIN OUTCOME MEASURES: Site of disease and unusual features at presentation. RESULTS: Tubercular lesions are most commonly seen in the ileocecal region. They are also common in the ileum but are less common in the appendix and jejunum. Involvement of the ascending colon, rectum and upper gastrointestinal tract is rare. Abdominal tuberculosis presents in many ways depending on the degrees of ulceration, fibrous healing, infection and caseating abscess formation. CONCLUSIONS: Abdominal tuberculosis should be considered in immigrants from regions where this disease is endemic who present with abdominal signs and symptoms. Imaging studies, endoscopy and laparoscopy may preclude laparotomy for the diagnosis of abdominal tuberculosis. Antituberculosis chemotherapy is the mainstay of treatment.

Acute sporadic hepatitis E in Kuwait.

Fifty-seven adult patients with acute hepatitis and 34 comparison patients without liver disease were evaluated using a newly developed Western blot assay for IgM antibody to hepatitis E virus. The mean age of patients with hepatitis was 32 years (range, 18-55 years); 88% were male. Among patients with acute hepatitis, hepatitis A (anti-HAV IgM positive) was diagnosed in two (4%), hepatitis B (anti-HBc IgM positive) in three (5%), and hepatitis E (anti-HEV IgM positive) in 34 (60%). One hepatitis patient had CMV IgM, another had EBV IgM, and 16 others (28%) were negative for all serologic markers of acute viral hepatitis. No patient with acute hepatitis A or B and none of the comparison patients without acute hepatitis had anti-HEV IgM. All but one case of acute hepatitis E were found among expatriates of Asian origin, and acute hepatitis E was associated significantly with recent travel to the Indian subcontinent. These data suggest that acute hepatitis E is common among foreign workers in Kuwait but that little HEV transmission is occurring directly in Kuwait.

Anti-HCV-positive cirrhosis associated with schistosomiasis.

Hepatosplenic schistosomiasis is occasionally associated with cirrhosis and progressive hepatic decompensation. The aim of the present study was to determine the prevalence of antibody to hepatitis C virus in patients with schistosomiasis and cirrhosis. The prevalence of anti-HCV was studied in 12 consecutive cases of schistosomiasis associated with biopsy proven cirrhosis. All patients had a past history of schistosomiasis and high titers of schistosomal antibodies in serum (1:32 to 1:4096). Five of the 12 patients had hepatic catheterization and were found to have sinusoidal involvement with corrected sinusoidal pressures ranging from 19 to 23 mm Hg. Four had ascites, six had pedal edema, and eight had peripheral signs of chronic liver disease in the form of palmar erythema, spider nevi, and/or gynecomastia. Ten of the 12 cases (83%) were repeatedly positive for anti-HCV/ELISA. These results suggest that when patients with schistosomiasis develop cirrhosis, associated hepatitis C virus infection should be suspected.

Helicobacter pylori-associated gastritis in Kuwait: endoscopy-based study in symptomatic and asymptomatic children.

Information is limited concerning the prevalence of Helicobacter pylori infection in asymptomatic children. Since January 1989, we have endoscoped 60 children for recurrent abdominal pain or for obtaining small-intestinal biopsy (their ages were a mean of 6.6 (range 9 months-13 years); there were 37 boys and 23 girls. Antral biopsies were obtained from all subjects and these were studied for the presence of gastritis and stained for H. pylori using modified Gram's stain. All biopsies were cultured for H. pylori. Children endoscoped for small-intestinal biopsy (n = 18) were used for comparison. Of the 42 children who had abdominal pain, 24 showed histological gastritis and 13 had H. pylori on microscopy (31% H. pylori-associated gastritis). In the compared group, five showed histological gastritis, and all had H. pylori on microscopy (27.7%). Culture was positive in 15; sensitivity was 85.7%. Six children, three pairs of siblings, had H. pylori gastritis supporting environmental etiology. Two had coinfection with intestinal giardiasis. Seven children were treated with daily oral amoxycillin (50 mg/kg) and tinidazole (20 mg/kg) for 6 weeks. In 3 (42.3%) H. pylori colonization cleared with healing of gastritis and resolution of symptoms. These results indicate that H. pylori gastritis is equally prevalent in symptomatic and asymptomatic children (31 and 27.7%, respectively; p > 0.05) in our population. It seems that the combination of oral amoxycillin and tinidazole is a poor choice in the treatment of H. pylori-associated gastritis in Kuwaiti children.

Hepatosplenic and small bowel calcification due to Schistosoma mansoni infection.

Schistosoma mansoni infection is not known to produce radiologically visible calcification. In this report, we describe extensive hepatosplenic and intestinal calcification due to S. mansoni infection, demonstrated by abdominal plain x-ray and CT scan with histopathological confirmation.

Fulminant viral hepatitis in Kuwait.

This study describes the aetiology and clinical course of fulminant viral hepatitis in 34 patients. Sixteen of 34 (47%) patients presented with serological evidence that indicated that hepatitis B virus (HBV) was the cause of fulminant hepatitis, while in 13 of 34 (38%) non-A, non-B (NANB) virus was implicated as the cause. Further, in three cases (9%) and two cases (6%) the patients' serological data indicated that hepatitis A (HAV) and the delta agent superinfection, respectively, were the cause. Forty-seven per cent of cases with fulminant viral hepatitis were among those aged between 21 and 40 years. Fulminant hepatitis due to HAV was confined to children less than five years of age, while the two patients who had delta infection were 40 years or older. Fulminant hepatitis occurred with equal frequency among males and females, and with the exception of one case, who had a NANB virus infection, the outcome of fulminant viral hepatitis in this study was invariably fatal.

Hepatitis delta virus infection in acute hepatitis in Kuwait.

Over a period of 1 year, 254 patients presenting with acute hepatitis at the Infectious Disease Hospital, Kuwait were positive for hepatitis B surface antigen (HBsAg). Of these, 23 (9%) patients were found to have antibodies to hepatitis D virus (HDV) (anti-HDV). Eight of these anti-HDV positive patients were shown to have a coinfection with acute hepatitis B and 8 had a superinfection of HDV on a chronic HBsAg infection. The remaining 7 had had a previous HDV infection and were also chronic carriers of HBsAg. The cause of the acute hepatitis in this group was probably non-A, non-B virus(es). The prevalence of anti-HDV was 4% among patients with acute hepatitis B and 31% among carriers of HBsAg. In the coinfection group, 5/8 patients recovered completely, 1 developed chronic active hepatitis and 1 died due to fulminant hepatitis, while 1 patient was lost to follow up. 5/8 patients with superinfection developed chronic hepatitis on follow-up, 2 died while only 1 patient recovered completely. In the group of patients with previous delta infection, 5/7 recovered from the acute bout of hepatitis while 1 patient developed chronic active hepatitis and 1 was lost to follow-up.

Viral hepatitis and pregnancy in Kuwait.

The frequency and severity of viral hepatitis among pregnant and non-pregnant women in Kuwait was studied from 1980 to 1984. 542 female hepatitis patients were investigated, of whom 52 (9.6%) were pregnant. 35 of the 52 (67.3%) cases of viral hepatitis in pregnancy were due to hepatitis B virus while 11 of 52 (21.2%) and 6 of 52 (11.5%) had acute hepatitis non-A, non-B (NANB) and hepatitis A virus infections, respectively. The frequency and severity of viral hepatitis among the pregnant women was similar to that among non-pregnant women. Hepatitis did not have a deleterious effect on pregnancy and no death was recorded. Fulminant acute NANB hepatitis was seen in only one patient, who recovered completely.

The place of Sugiura operation for portal hypertension and bleeding esophageal varices.

Fifty patients with portal hypertension and bleeding varices aged 10 months to 72 years were treated with a modified Sugiura, nonshunt operation (n = 26) or shunting procedures (n = 24) in accordance with the following predetermined therapeutic protocol: after resuscitation and diagnostic endoscopy, an emergency mesocaval shunt procedure was carried out if bleeding could not be stopped (group 1, n = 10). When bleeding could be stopped, the patients underwent full investigation and were then treated with either the distal splenorenal (DSR) shunt if the criteria of Warren were satisfied (group 2, n = 14) or with a modified Sugiura procedure in all other circumstances (group 3, n = 26). Patients were evaluated at 1.5 to 6 years. The rates for operative deaths, recurrent hemorrhage, encephalopathy, late deaths, and actuarial patient survival at 6 years were as follows: 20%, 30%, 30%, 20%, and 60% for group 1; 14.3%, 14.3%, 14.3%, 7.2%, and 79% for group 2; and 7.7%, 3.4%, 0%, 0%, and 93% for group 3, respectively. Within 3 months after the Sugiura operation, varices disappeared in 95% of patients and hypersplenism was relieved in all. Major complications were gastric and esophageal leaks in two patients (fatal in one) and temporary dysphagia in six. We conclude that the modified Sugiura nonshunt operation is probably the preferable treatment for variceal hemorrhage in the nonalcoholic patient because it is effective in arresting hemorrhage, has low operative mortality, low recurrence rate, no encephalopathy, and excellent survival rates.