Biliary ascariasis: report of a complicated case and literature review.

Invasion of the Ascaris worm into the biliary system leads to a wide variety of clinical syndromes. Most of the descriptions of the disease have originated from the developing world, where due to the environmental factors there is a high level of parasitism. An increased incidence of biliary ascariasis borne out of population migration and increased facilities for diagnosis has led to a renewal of interest in this disease in the developed world. Significant morbidity and mortality is associated with the concomitant complications, and early diagnosis and management is of utmost importance. Common disease presentations include biliary colic, obstructive jaundice, acalculous cholecystitis, choledocholithiasis, pancreatitis, and cholangitis. Although with a potential for serious mortality, pancreatitis, and cholangiocarcinoma constitute relatively less common threats. Recent advances in endoscopy have shifted the attention of this disease from the surgeon to the gastroenterologist and a consensus of opinion is arising for early intervention. We present here a patient with biliary ascariasis managed endoscopically and review the epidemiology, prevalence, clinical presentation, diagnosis, and management of this disease.

Comparision between per-oral and ultrathin transnasal endoscopy in unsedated patients.

BACKGROUND: This is a prospective study to evaluate the tolerance and acceptability of patients for diagnostic ultrathin transnasal esophagogastroduodenoscopy compared with the standard peroral route. PATIENTS AND METHODS: Both types of endoscopic procedures were explained to the patients. Sixty patients were included in this study and subsequently, 30 unsedated patients in each group underwent upper gastrointestinal endoscopy. An evaluation and questionnaire form both the endoscopist and the patient was recorded. Out of the 30 patients who had transnasal endoscopy, 15 had previous peroral endoscopy. Oximetry was recorded during the procedure. RESULTS: All patients in both groups tolerated the procedure well and it was successfully completed. In the transnasal group, three patients had mild epistaxis. Desaturation in the transnasal group was the same as compared to the peroral group. From the 30 patients of transnasal group, 21 were willing to repeat the procedure if required and eight patients were willing to repeat the procedure reluctantly. Only one patient expressed preference for the peroral route. The endoscopist's observation revealed that scope insertion in both groups was equally tolerated but lens washing and suction was not optimal in the transnasal approach. CONCLUSION: Both groups showed good tolerability, but the tranasal approach was found to be more acceptable to the patient. In the tranasal group, the patients found the procedure less distressing and were subsequently more willing for a repeat procedure. Therefore we believe that the tranasnal approach to esophagogastroduodenoscopy in diagnostic and follow up procedures will rapidly acquire increasing popularity.

Acute pancreatitis in Saudi patients.

BACKGROUND: The epidemiology of acute pancreatitis in Saudi Arabia is greatly different from that in Western Countries. AIM: To evaluate and compare the risk factors and clinical features of acute pancreatitis. PATIENTS AND METHODS: The course of acute pancreatitis was retrospectively analyzed in 218 patients who had their first attack and were admitted at Riyadh Armed Forces Hospital during the period 1.01.85-31.05.97. RESULTS: From these 218, 130 patients were in the age group of 20-55 yrs. (74+, 56>), 76 were > 55 yrs. Of age (42 +, 34>) and only 12 were < 20 yrs. (6 Females, 6 Males). The precipitating cause was biliary disease in 147, post-operative in ten, hyperlipidemia in seven, post-ERCP in five, infection in four and alcohol in four. Four had rare causes and 37 no obvious cause. Severe pancreatitis diagnosed in 70 patients, 51 of them were > 55 yrs. of age and 45 were precipitated by biliary disease. Twenty six developed complications (21 were > 55 yrs. old) and four deaths. Twenty two patients of these who had severe form had diabetes mellitus, 37 had fever at presentation and 56 had leukocytosis. CONCLUSIONS: The commonest etiology of acute pancreatitis was biliary in 147 patients (67.5%) followed by postoperative pancreatitis in 10 patients (4.6%). Alcohol as etiological factor was rare (1.8%). The epidemiology and the risk factors differed markedly in Saudi Arabia, where alcohol is prohibited.

Treatment of chronic hepatitis C genotype IV with interferon-ribavirin combination in Saudi Arabia: a multicentre study.

Between 1996 and 1997, we conducted a multicentre study to assess the effect of combination therapy of interferon (IFN) + ribavirin on chronic hepatitis C genotype 4. Ninety-seven patients were enrolled. Sixty-eight patients (47 male and 21 female) were non-responders to previous therapy with IFN (Group I). Twenty-nine patients (19 male and 10 female) were new (Group II). Following treatment with IFN, 23% in Group I and 9% in Group II had a sustained biochemical response. Only 12% in Group I and 5% in Group II achieved a sustained virological response. Virus load was found to be the major factor determining response, followed by histology grading and staging. Like HCV genotype 1, HCV genotype 4 seems to have a poor response to therapy.

Percutaneous treatment of heterogenous predominantly solid echopattern echinococcal cysts of the liver.

PURPOSE: We report our technique for and results of percutaneous treatment of heterogenous, predominantly solid echopattern hepatic hydatid cysts (HHC), i.e., complex type IV cysts according to Gharbi's sonographic classification of HHC. METHODS: Eight patients with nine complex type IV HHC were treated by percutaneous aspiration followed by hypertonic saline ablation, using a 14 Fr van Sonnenberg sump drainage catheter under sonographic and fluoroscopic guidance. RESULTS: Successful drainage of cysts contents was achieved in all eight patients. No major complications, such as anaphylaxis, abdominal dissemination, cyst recurrence, or death, occurred. Minor complications including pain (n = 4), mild fever (n = 5), right reactive pleural effusion (n = 4), and transient hypernatremia (n = 2) were observed and managed conservatively. Follow-up imaging studies for an average period of 15 months (range 1-48 months) showed either complete healing (n = 3) or significant reduction in the size of the cyst with solidification (n = 6). CONCLUSION: Nine complex type IV HHC were effectively treated by suction of the membranes and hypertonic saline ablation using a 14 Fr sump drainage catheter, without major complications.

Hemophagocytic syndrome.

This case report is about an elderly man who presented with a long-standing history of high-grade fever and weight loss. He initially had only hepatosplenomegaly, but then developed jaundice. He also had pancytopenia and raised liver enzymes. His septic screen was negative, but he had a positive Monospot test and immunoglobulin G for Epstein-Barr virus. The liver biopsy showed sinusoidal phagocytosis and the subsequent bone marrow aspiration and biopsy showed significant hemophagocytosis, hence Hemophagocytic syndrome was diagnosed. The fever was refractory to antibiotic and anti-tuberculosis therapy, but it responded only partially to steroids. Full response was only noticed following anti-viral treatment in the form of intravenous Ganciclovir. The patient's general condition, liver enzymes, bilirubin, hematological parameters and even the weight returned back to their normal range 2 weeks after Ganciclovir therapy. Cessation of this drug resulted in relapse of his symptoms and oral antivirals did not help. Splenectomy, steroid pulse therapy and immunosuppressive treatment were only partially helpful. Reintroduction of Ganciclovir did help for a short period. We conclude that our patient had virus-associated hemophagocytic syndrome most likely related to Epstein-Barr virus infection, which was then confirmed by the splenic biopsy, and that Ganciclovir can be of great help in eradicating the virus and treating the disease, provided that it is given for a long enough period.

Gastrointestinal parasites presentations and histological diagnosis from endoscopic biopsies and surgical specimens.

OBJECTIVE: To diagnose parasitic ova or worms during endoscopy, surgery or by histology from endoscopic or surgical specimen in our patients. METHODS: The diagnosis of parasitic disease in our patients was made by histological examinations from biopsies obtained either during an upper gastrointestinal or lower gastrointestinal endoscopy or from surgical specimens. RESULTS: Parasites were seen in endoscopic biopsies from upper gastrointestinal tract in 21 patients. Schistosoma ova was seen in biopsies from stomach or duodenum (12 patients). Small intestine biopsies showed Giardiasis (8 patients) and strongyloides (1 patient). Colonic biopsies showed schistosoma ova by paraffin section or by squash technique in 216 patients. Surgical specimens from 12 patients, who presented with acute abdomen and had surgery, due to appendicitis in 8 patients, in whom specimens showed (Schistosoma in 5 patients, amoebiasis in 2 patients and Trichuria in 1 patient). Four other patients presented with acute abdomen, where ischemic bowel necrosis or mesenteric vein thrombosis was found during surgery, specimens showed schistosoma ova. CONCLUSION: The diagnosis of gastrointestinal parasites is not only made by stool but the diagnosis can be made by histology from endoscopic biopsies or surgical specimens.

Endoscopic management of postcholecystectomy bile duct injuries: review.

Injuries to the biliary tree arising as a consequence of cholecystectomy, continue to be significant complicating factors. The advent of laparoscopic cholecystectomy has resulted in a further rise in the incidence of these injuries. Various means of investigation are available to assess the site, extent and severity of the damage to the biliary tree. Lately, the endoscopic option seems to have gained popularity in the management of these patients as it can combine both the investigative and therapeutic arms in one common procedure. This procedure is recommended as the primary modality of intervention gaining precedence over the radiological and surgical options. Since limitations exist in managing these patients with endoscopic retrograde cholangiopancreatography, a combined approach between the endoscopist, surgeon and radiologist, is the most practical option. In this article, we review the various types of biliary injuries, their reported incidence, etiological factors, the diagnostic means available, and the endoscopic management of each.

Endoscopic management for bleeding esophageal varices: sclerotherapy versus sclerotherapy plus band ligation versus band ligation alone. One year experience at a main hospital in Saudi Arabia.

BACKGROUND/AIMS: This study was done retrospectively to compare the outcome of sclerotherapy alone, band ligation alone and band ligation alternating with sclerotherapy in treatment of esophageal varices. METHODOLOGY: During 1 year 30 patients were admitted with variceal bleeding. They received either injection sclerotherapy (8 patients) or band ligation (11 patients), and 11 patients had a combination of both either during first bleed or during follow-up therapy, which is more than 2 sessions in each group. RESULTS: The success rate for stopping first bleeding was 100% in the band ligation and sclerotherapy alone group. The rebleeding rate was 27% in the combination group, 9% in the band ligation group, and none had rebleeding in the sclerotherapy group during follow-up. Eradication of varices was observed in 33% of patients after a second set of sclerotherapy and band ligation. CONCLUSIONS: Our study showed no significant difference between sclerotherapy versus band ligation in stopping initial bleeding or eradication of varices during the follow-up period, but there was a difference in re-bleeding rates among the three groups.

Radiological manifestations of liver and gastrointestinal parasitic infections.

There is a wide variation in the prevalence of parasitic diseases in different countries, particularly in the Tropics. The clinical status of affected patients varies from normal to severe ill health. Radiology has acquired a major role in the diagnosis and, in some instances, the management of a significant variety of parasitic infections. Plain films, ultrasound, computed tomography and magnetic resonance imaging, together with the help of clinical and laboratory tests, can reach a diagnosis with a high percentage of accuracy.

Upper gastrointestinal endoscopy findings at Riyadh Armed Forces Hospital.

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Gastro-esophageal reflux disease: a small fire which can turn to a volcano.

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