Tuberculous liver abscess: a case report and review of literature.

Tuberculous liver abscess is rare worldwide. We report a 45-year-old man who presented with abdominal pain, fever and weight loss. Ultrasound and computed tomography of the abdomen showed multiple cystic lesions in the liver. Ultrasound guided needle aspiration revealed yellowish brownish aspirate, which was flooded with acid-fast bacilli. The abscess was drained under ultrasound guidance. Subsequent abdominal ultrasound a few days later showed resolution of the abscess cavity. He was concomitantly started on systemic antituberculous therapy. A tuberculous liver abscess has to be thought of in the differential diagnosis of liver abscesses and to consider the role of percutaneous drainage along with systemic antituberculous chemotherapy as an alternative to surgery in the management. A greater awareness of this clinical entity is required for successful treatment.

Hepatitis G virus (HGV) infection in Saudi dialysis patients and healthy controls.

BACKGROUND: Viral hepatitis is a global health problem with a high mortality rate. End stage renal disease (ESRD) patients have a high prevalence of Hepatitis B and C virus infection. Present study was done to identify the prevalence and course of a new isolate Hepatitis G virus (HGV) infection in Saudi dialysis patients. METHODS: The pattern of viral hepatitis infection (HBV. HCV and HGV) was investigated in 109 Saudi patients with ESRD and 100 healthy Saudi blood donors. Donated blood was tested for markers of Hepatitis B, C and G viruses. Liver functions were measured and blood picture and liver biopsies were also performed at regular intervals. RESULTS: Out of the 109 ESRD patients 68 (62.4%) were positive for at least one viral marker: 59 (54.1%) were positive for HCV, six (5.5%) were positive for HGV and three (2.8%) were positive for HBsAg. Four of the six HGV positive patients were also co-infected with HCV. Eight (8%) of the blood donors were positive for at least one viral marker. Elevated ALT levels (>4 times normal) were recorded in four out of the six HGV-positive patients including three co-infected with HCV. CONCLUSIONS: Our results are in agreement with similar studies from different countries and also raise the question about the causal relationship between HGV and liver disease among dialysis patients.

Hepatic granulomas in an arab population: a retrospective study from a teaching hospital in Riyadh.

This is a retrospective analysis of the medical records of 116 patients who presented to the gastroenterology division, department of medicine at King Khalid University Hospital (KKUH) in Riyadh, Kingdom of Saudi Arabia and subsequently had a histopathologic diagnosis of hepatic granulomas. Infections contributed to 56% and were represented mainly by schistosomiasis and to a lesser extent by tuberculosis, brucellosis and hydatid disease. Lymphomas (8%) were the major representative of noninfectious causes. The etiology of 25% of granulomas remained undetermined. Weight loss, fever, anorexia and abdominal pain were the most frequent presenting symptoms in 53, 45, 43 and 42% of patients, respectively. Ten percent of the patients were asymptomatic. Hepatomegaly and splenomegaly were the predominant physical findings in 55% and 43% of patients respectively. Hepatic granulomas in this study are mainly caused by infections. Schistosomiasis, tuberculosis and brucellosis represented the most common etiologic factors.

Pneumatic dilation of cardiac achalasia using low compliance balloon: University-Hospital experience.

Full text is available as a scanned copy of the original print version.

Mirizzi syndrome and management.

Full text is available as a scanned copy of the original print version.

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

Full text is available as a scanned copy of the original print version.

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 colonoscopies. This is a retrospective study over 15 years period in KKUH to analyze the pediatric colonoscopy. 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 patient had sedation while 22 had 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 mainly those suspected to have ulcerative colitis, rectal bleeding or diarrhea. A high index of suspicion of ulcerative colitis will lead to better management of patients.

Treatment of chronic hepatitis C genotype 4 with alpha-interferon in Saudi Arabia: a multicenter study.

BACKGROUND/AIM: Several studies have indicated that there are certain predictive factors (gender, duration of infection with HCV, cirrhosis and genotype of HCV) of a better response with alpha-interferon treatment in patients with chronic hepatitis C. The aim of this study was to evaluate these factors in Saudis and other Arab nationals with chronic hepatitis C-genotype 4-undergoing alpha-interferon treatment. METHODOLOGY: A multicenter study was conducted between 1992 and 1994 on 80 consecutive patients who were prospectively recruited and randomized in treatment and control groups. RESULTS: The results of this multicenter study indicated a low response rate to alpha-interferon with an overall response rate of 43%, of which 28% was complete. The sustained response was only 16%. Among the reasons for this low response in our study are the high percentage of patients with cirrhosis and the long infection interval, as about 80% of our HCV cases were community-acquired. CONCLUSION: Liver cirrhosis was found to be the main predetermining factor for response to interferon treatment. Genotype 4 was not a contributing factor to the difference in response rate.

Extracorporeal shock wave lithotripsy for the rescue of post-endoscopic or surgically retained biliary duct stones: does saline irrigation affect the outcome?

Extracorporeal shock wave lithotripsy (ESWL) has been found valuable in situations where obstructing stones in the common bile or intrahepatic ducts are retained following surgery or attempted endoscopic removal. However, success rates are dependent on the type of ESWL system employed and upon a high frequency rate of repeated treatment sessions. We outline our experience with 23 cases of retained, obstructing bile duct stones, ranging in size from 10 to 40 mm diameter, treated with Dornier HM3 ESWL. In the initial 12 patients in the series, successful stone fragmentation occurred in 83% of cases with a median 1.6 treatment sessions. In the latter 11 cases in the series, patients were treated prone and the stone-bearing biliary duct was irrigated with saline solution during ESWL delivery. With this technique, successful stone break up was achieved in all patients (100%) with a single treatment session. Endoscopic sphincterotomy is, however, a prerequisite for extracorporeal lithotripsy and, despite the high success rates now available with new techniques, we believe the ESWL should continue to be employed in support of primary endoscopic methods of management for obstructing bile duct stones.

Sucralfate attenuates gastric mucosal lesions and increased vascular permeability induced by ischaemia and reperfusion in rats.

Recent evidence suggests that oxygen-derived free radicals are involved in mediating gastric microvascular and parenchymal cell injuries induced by ischaemia and reperfusion. Therefore, the effect of the locally acting anti-ulcer drug, sucralfate, was studied on ischaemia and reperfusion (e.g. induced gastric lesions, intraluminal bleeding, changes in vascular permeability and non-protein sulfhydryl levels in the rat stomach). Allopurinol was used as a known standard antioxidant drug. Rats were subjected to 30 min of gastric ischaemia in the presence of 100 mmol/L hydrochloric acid and reperfusion periods of 15, 30 or 60 min duration. The gastric lesions were assessed microscopically under an inverted microscope. The vascular permeability was quantified by measuring the extravasated Evans blue in the stomach. There were significantly greater numbers of gastric lesions, intraluminal bleeding and leakage of Evans blue during all reperfusion periods as compared with those of ischaemia, with maximum effects occurring at 60 min following reperfusion. Pretreatment with sucralfate (31.25-250 mg/kg, p.o.) or allopurinol (12.5-50 mg/kg, i.p.) 30 min before the procedure, dose-dependently reduced the gastric lesions, intraluminal bleeding, and decreased the vascular permeability induced by ischaemia and reperfusion. Furthermore, sucralfate dose-dependently reverses the ischaemia and reperfusion-induced depletion of mucosal non-protein sulfhydryl levels and inhibited the superoxide radical production in both cell-free xanthine-xanthine oxidase and in the stimulated polymorphonuclear cellular systems. These results suggest that the protection produced by sucralfate against gastric injury may be due to its antioxidant effects.

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 anti-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 anti-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 reports. The need for the introduction of hepatitis A vaccination will be determined in the future definition of HAV epidemiology in Saudi Arabia.

Pattern of Helicobacter pylori sensitivity to various antimicrobial agents.

To evaluate the pattern of Helicobacter pylori ( H. pylori ) susceptibility to different antimicrobial agents, we prospectively studied 45 H. pylori isolates by disc diffusion method. These isolates were obtained from patients aged between 16-75 years, of both sexes who had no prior history of metronidazole ingestion. A total of 45 patients were included, of which 36 were males with a mean age of 42.9 years and nine females with a mean age of 36.4 years, 62% of patients were Saudis. Almost all the H. pylori isolates were susceptible to clarithromycin, penicillin, erythromycin, ampicillin, tetracycline, clindamycin and cephradine. However, 64.4% of the isolates were resistant to metronidazole. No significant difference was found either in susceptibility of isolates from Saudi, non-Saudi or male and female patients.

Selenium protects against ischemia-reperfusion-induced gastric lesions in rats.

Recent studies have shown that selenium afforded protection against ethanol and stress-induced gastric lesions in rats. The present study was undertaken to investigate the effect of selenium on ischemia-reperfusion-induced gastric injuries in which rats were subjected to 30 minutes of ischemia in the presence of 100 mM HCI and a reperfusion for 60 minutes duration. Intraluminal bleeding was assessed macroscopically and gastric lesions were graded microscopically under an inverted microscope. Nonprotein sulphydryl levels were measured spectrophotometrically. The severity of gastric lesions, intraluminal bleeding as well as the depletion of nonprotein sulphydryls during the reperfusion periods was significantly different from that of control. Pretreatment with selenium (0.125-2.0 mg/kg, intraperitoneally) 30 minutes before the ischemia-reperfusion, dose-dependently attenuated the gastric lesions, reduced the severity of intraluminal bleeding and prevented the depletion of nonprotein sulphydryls in the stomach. These results suggest that the gastric protection effect of selenium may be due to its antioxidant properties. Furthermore, endogenous nonprotein sulphydryls may play a significant role in the protective mechanisms of selenium.

Natural honey prevents ischaemia-reperfusion-induced gastric mucosal lesions and increased vascular permeability in rats.

OBJECTIVE: It has been proposed that natural honey may contain a 'sucralfate-like' substance. Recent studies have shown that sucralfate affords protection against ischaemia-reperfusion-induced injuries in the rat stomach. Therefore, the effect of honey was studied on ischaemia-reperfusion-induced gastric lesions, intraluminal bleeding, vascular permeability and non-protein sulphhydryls (NP-SH) in the rat stomach. METHODS: Rats were subjected to 30 min of gastric ischaemia in the presence of 100 mM HCl and reperfusion period of 60 min. Intraluminal bleeding was assessed macroscopically and the gastric lesions were graded microscopically under an inverted microscope. Vascular permeability was quantified by measuring spectrophotometrically the extravasated Evans blue dye in the stomach. NP-SH levels were measured spectrophotometrically. A luminol-dependent chemiluminescence method was used to assess antioxidant effects of honey in vitro. RESULTS: There were significantly more gastric lesions, more severe intraluminal bleeding, more leakage of Evans blue and depletion of NP-SH during the reperfusion period as compared to controls. Pre-treatment with honey (0.078-0.625 g/kg, orally) or dimethyl sulphoxide (0.02-0.08 g/kg, intraperitoneally) 30 min before the ischaemia-reperfusion dose-dependently reduced the gastric lesions and intraluminal bleeding and decreased the vascular permeability. Furthermore, honey reversed the ischaemia-reperfusion-induced depletion of NP-SH levels and inhibited the luminol-dependent chemiluminescence induced in a cell-free xanthine-xanthine oxidase system. CONCLUSION: These results suggest that gastric protection by honey may be a result of its antioxidant effect. It is suggested that this property of honey may be due to the presence of a 'sucralfate-like' substance.

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.

Tuberculous peritonitis in chronic liver disease: Clinical features and response to treatment.

To find out the clinical presentation, laboratory results, and treatment response of tuberculous peritonitis in patients with chronic liver disease, we retrospectively reviewed the medical records of all patients with tuberculous peritonitis diagnosed by laparoscopy at King Khalid University Hospital over a period of seven years. A total of 17 patients (Group 1, consisting of 11 males and six females with a mean age of 539 +/- 17.5 years) had both chronic liver disease and tuberculous peritonitis, while 27 patients (Group 2, consisting of 17 males and 10 females with a mean age of 39.5 +/- 16.3 years) had only tuberculous peritonitis. Tuberculous peritonitis in chronic liver disease had similar clinical and laboratory presentation compared to patients with tuberculous peritonitis but without liver disease. However, Group I were significantly older, had lower ascitic protein content and higher mortality (P values of 0.004, 0.002, and 0.02, respectively). Both groups responded favorably to specific therapy. The overall mortality was recorded as 5.6%. In conclusion, the clinical presentation of tuberculous peritonitis in patients with chronic liver disease is similar to that of patients without liver disease except for ascitic protein, which is lower in the former group of patients. The prognosis is good with specific therapy.

Colonic polyps: Experience from King Khalid University Hospital.

To find out the frequency rate and anatomical distribution of colonic polyps in patients attending King Khalid University Hospital, we retrospectively reviewed all colonscopic files between 1406-1415 AH. Of 2772 patients who underwent colonoscopic examination, 109 patients (75 males and 34 females, mean age of 43.5 +/- 19 years) were found to have a total of 188 polyps. There were 73 Saudis; 47 males with a mean age of 48.6 +/- 17.4 years and 26 females with a mean age of 42.4 +/- 17.9 years. Polyp frequency rates in the whole group and in Saudi patients were 3.93% and 4.0%, respectively. There were 124 (66%0 polyps which were sessile. The majority of polyps (82%) were located in the left side of the colon. Tubular and tubulovillous adenoma constituted 89.5% of all histological reports of neoplastic polyps. Synchronous colonic pathology was observed in 32 (29.4%) patients. This shows that the colonic polyp frequency rate is low. The left side of the colon accommodated most of these polyps.

Diagnostic yield of upper gastrointestinal endoscopy in relation to age and gender: a study of 10112 Saudi patients.

BACKGROUND/AIMS: The availability of fiberoptic endoscopy has made it relatively easy to evaluate symptoms of upper gastrointestinal disorders with a significant degree of accuracy. MATERIALS AND METHODS: To determine the pattern of upper gastrointestinal lesions in the Saudi population with particular reference to the influence of age and gender, 10,112 patients were studied. RESULTS: No abnormal findings were detected in 26.9%. The frequency of ulcer lesions was 13.7% while non-ulcer, mucosal inflammation was diagnosed with a frequency of 33.7%. In the young (less than 20 years of age), the most common lesion was duodenal ulcer or duodenitis, whereas in the elderly (above 60 years of age), esophagitis, hiatus hernia and esophageal varices were the most frequently diagnosed. The highest mean ages were observed in the group of patients with gastric and esophageal cancers (mean ages of 58.8 and 65.1 years, respectively). There was no gender-related differences with regard to the mean age of patients in all the diagnostic categories. CONCLUSIONS: This study provides baseline data on the age distribution of major upper gastrointestinal diseases among the Saudi population. The peculiarities of upper gastrointestinal endoscopic findings in advanced age are clarified. The influence of demographic changes on the pattern of these diseases in Saudi Arabia can be evaluated against our findings in the future.

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 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).

Role of oxygen-derived free radicals on gastric mucosal injury induced by ischemia-reperfusion.

A free radical is an unstable and highly-reactive chemical species capable of independent existence that contained one or more unpaired electrons in its outer orbital. A number of oxygen-derived free radicals (ODFRs) have been identified. However, superoxide (O(-)(2) and hydroxyl (OH*) radicals are extensively studied. The univalent reduction of oxygen to water produces a number of highly-reactive chemical intermediates such as O(-)2 and OH*, which are commonly-known as oxygen-derived free radicals. ODFRS may be formed from several sources as follows: a) mitochondrial cytochrome oxidase, b) xanthine oxidase, c) neutrophils and d) transitional metals. There are several important defense mechanisms to limit or to prevent the damage caused by excessive ODFRs activity. These antioxidant defenses can be divided into a) enzymatic defense mechanisms such as: superoxide dismutase (SOD): catalase: selenium-containing glutathione peroxidase and b) non-enzymatic defense mechanisms including: alpha-tocopherol; ascorbic acid; glutathione and any sulfhydryl-containing compounds.