Associations Between Hypothyroidism and Subclinical Atherosclerosis Among Male and Female Patients Without Clinical Disease Referred to Computed Tomography.

OBJECTIVES: Hypothyroidism is recognized as a risk factor for coronary artery disease (CAD). However, reports are conflicting when the results are stratified by sex and the underlying risk of CAD. We examine the sex-specific associations of hypothyroidism with coronary calcification and plaques. METHODS: Retrospective cross-sectional study was conducted among adult patients referred to (64 multidetector spiral) computed tomography. Those with pre-existing CAD were excluded. Hypothyroidism was defined as thyroid-stimulating hormone ≥ 4.5 mU/L. Plaques were determined based on quantification of coronary calcium and coronary computed tomography angiography. RESULTS: A total of 2499 patients (1544 male and 955 female) were included. The prevalence of hypothyroidism was significantly higher in female than in male patients (18.0% vs 12.9%, P < .001), in all patients and those <65 years. Hypothyroidism in male patients was significantly associated with higher coronary calcium score > 0, higher coronary calcium score groups, and both soft and calcified plaques (P = .027, P = .032, P = .005, and P = .017, respectively). After adjusting for traditional coronary risk factors, the higher risk in male patients remained significant for coronary plaque but not for coronary calcium score >0 (odds ratios and CIs were 1.77, 1.08-2.90, P = .023 and .98, 0.63-1.52, P = .925, respectively). On the other hand, hypothyroidism in female patients was not significantly associated with coronary calcification nor plaques in both univariate and multivariate analyses. CONCLUSIONS: There are sex-specific differences in the association of hypothyroidism with subclinical atherosclerosis. The higher risk of coronary plaques but not calcification in male patients was independent of traditional coronary risk factors. The lack of associations in female patients may be related to lower underlying risk of CAD.

Association of blood lipids with coronary artery plaque among Saudi patients referred to computed tomography.

BACKGROUND: Blood lipids are strong risk factors for the progression of atherosclerotic plaques. However, data on gender-specific associations are limited. OBJECTIVES: To examine gender-specific associations of coronary plaque with blood lipids among a large sample of Saudi patients without CAD. METHODS: Retrospective cross-sectional study was conducted among adult patients referred to (64 multidetector spiral) computed tomography (CT) for standard indications at the Prince Sultan Cardiac Centre (Riyadh, Saudi Arabia) between July 2007 and December 2017. Those with pre-existing CAD were excluded. Plaques were determined based on quantification of coronary calcium and Coronary CT angiography. RESULTS: A total 2421 patients (1498 males and 923 females) were included. The prevalence of any plaque was 36.6% with higher burden in males than females (41.3% versus 28.9%, p < 0.001). Approximately 78.9% of all plaques were calcified. Blood lipids (mmol/L) were 4.75 ± 1.14 for total cholesterol, 2.90 ± 0.96 for LDL cholesterol, 1.20 ± 0.36 for HDL cholesterol, and 1.64 ± 1.09 for triglycerides. Males had significantly higher triglycerides and lower HDL cholesterol compared with females. In adjusted models in males and all patients, soft and/or calcified plaques were significantly associated with lower HDL cholesterol and higher triglycerides. In females, the only significant association was between soft plaques and higher triglycerides. CONCLUSIONS: Middle-aged patients without clinical CAD in Saudi Arabia have a high burden of plaques, specially calcified ones. The findings may impact the use of lipid lowering mediations, by underscoring the importance of assessing the risk of CAD in patients without clinical CAD even in case of lack of coronary calcification.

Distributions and burden of coronary calcium in asymptomatic Saudi patients referred to computed tomography.

BACKGROUND: Unlike Western and Asian populations, the prevalence and severity of coronary artery calcification (CAC) have not been adequately examined in Saudi Arabia and other nearby Arab Gulf countries. OBJECTIVES: To estimate the age and gender specific percentiles of coronary calcium score (CCS) and to study the severity of CAC in relation to patient risk in a large sample of asymptomatic Saudi patients. METHODS: Retrospective cross-sectional study was conducted between July 2007 and December 2017 at a large Cardiac Centre in Riyadh, Saudi Arabia. The target was adult patients without pre-existing CAD referred to (64 multidetector spiral) computed tomography for standard indications. RESULTS: A total 2863 patients were included in the current analysis. The 90th percentile of CCS was 95.0 in males compared with 53.2 in females and was 823.95 in patients aged ≥ 75 years compared with zero in patients < 40 years. Extensive CAC (CCS > 400) were 3.1% in males compared with 1.6% in females and 14.0% in patients aged ≥ 75 years compared with 0.0% in patients < 40 years. CCS was steadily higher with increasing European systematic coronary risk evaluation; 3.1 ± 22.5 in mild risk, 37.1 ± 201.9 in moderate risk, 116.1 ± 256.1 in high risk, and 131.0 ± 222.0 in very high risk. CONCLUSIONS: As expected, the findings confirm the higher burden of CAC in males, older age, and higher CAD risk. The burden of CAC in current patients is much lower than reported in US and other Western patients. Local cardiologist should consider using local rather than US percentiles of CCS.

Changes in chemical composition of Zilla spinosa Forssk. medicinal plants grown in Saudi Arabia in response to spatial and seasonal variations.

Extracts of different medicinal plants had been used to control several diseases in both traditional medicine and modern drugs. In the current study, we aimed to examine the changes in chemical composition of Zilla spinosa Forssk. plants collected from different habitats in Saudi Arabia in response to spatial and seasonal variations. Z. spinosa samples were collected from two different sites in Riyadh and Eastern regions in Saudi Arabia to examine the spatial variations effects on the studied parameters. Samples were collected from both sites at two different times (3:00 PM and 3:00 AM) to examine the effect of light on the chemical content and composition of these plants. Samples was, also, collected from the same sites at two different seasons (on start of January 2018 "winter season" and end of May 2018 "summer season") to examine the effect of temperature changes (seasonal variations) on the chemical content and composition of the different studied plants. In Z. spinosa plants collected from Riyadh region, squalene was found to be the major constitute of 3 samples; however, surprisingly, the sample collected in Winter at 3:00 AM showed the presence of mome inositol and (Z)-5-(formylmethylene)-4-methoxy-2(5 h)-furanone as the dominant components. Similarly, chemical compositions of essential oils extracted from Z. spinosa samples collected from Eastern region in the Summer season was dominated by squalene. Z. spinosa plants showed that all collected samples had high carbohydrate and protein contents with very low content of fats.

Comparison of Harmless Acute Pancreatitis Score with Ranson's Score in Predicting the Severity of Acute Pancreatitis.

OBJECTIVE: To determine the predictability of harmless acute pancreatitis score (HAPS) in determining the severity of acute pancreatitis (AP) and compare it with Ranson's score. STUDY DESIGN: Prospective cohort study. PLACE AND DURATION OF STUDY: King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, between January 2012 and December 2015. METHODOLOGY: All patients admitted with AP at King Saud Medical City, Riyadh, during 2012 - 2015 were studied prospectively. Patients were assessed by HAPS and Ranson's score. Predictability values of the two systems were analysed and compared. RESULTS: Out of 116 patients studied, 104 (89.6%) were HAPS positive and predicted to have mild disease. Pancreatitis was mild in 101 (87%) but severe in 3 (2.6%) patients who scored ≥ 3 Ranson's criteria. Among 12 HAPS negative patients, 10 scored ≥ 3 Ranson's criteria and developed severe pancreatitis while 2 (1.7%) with 2 positive Ranson's criteria developed mild pancreatitis. HAPS correctly predicted the disease severity in 101 (87%) patients, a sensitivity of 98% specificity of 77% and accuracy of 96%. Ranson's system predicted correctly in all but took 48 hours for assessment. Statistical analysis showed moderate agreement (Kappa = 0.776, p < 0.001), and positive relation (rs = 0.777, p < 0.001) between the two scores. CONCLUSION: HAPS is effective in rapid identification of patient who will run non-severe course of AP. Assessment can be completed within one hour from presentation. Ranson's score, although more accurate, takes 48 hours to complete.

Intraoperative Dilatation and Air-Tight Testing of the Hepaticojejunostomy: A New Technique.

OBJECTIVE: To evaluate the effect of creating an air-tight anastomosis and intraoperative dilatation of the hepaticojejunostomy (HJ) in reducing the early and long-term complications. STUDY DESIGN: Interventional study. PLACE AND DURATION OF STUDY: Department of Surgery, King Saud University, Riyadh, between March 2008 and January 2016. METHODOLOGY: After completion of HJ, the anastomosis was tested for air-tightness, and dilated with Kelly clamp in all patients undergoing the procedure. The anastomosis was reinforced with extra suture in cases of air leak. Comparison was performed between the patients who underwent HJ by the same surgeon, after and before the new technique. RESULTS: Sixty-seven patients underwent HJ during the study period. Air leaks from HJ were observed in 3 patients before anastomotic dilatation. The anastomosis was reinforced in these patients. No air leak was observed after dilatation of the anastomosis. There was no postoperative bile leak in any patient. However, during the follow-up 3 patients presented with recurrent cholangitis and stricture formation at the HJ site required surgical revision. The new technique had significantly reduced the rate of bile leak (p=0.029) and stricture (p=0.037) at the site of HJ when compared with patients who underwent HJ without the new technique. CONCLUSION: Creation of air-tight HJ anastomosis has completely eliminated the postoperative bile leak and reduced the rate of HJ stricture formation. The addition technique resulted in insignificant prolongation of operative time. There was no technique related complication.

Enteric duplication cyst as a leading point for ileoileal intussusception in an adult: A rare cause of complete small intestinal obstruction.

Duplication of alimentary tract (DAT) presenting as an ileoileal intussusception is a very rare clinical entity. Herein, a case of an ileoileal intussusception due to DAT is presented. A 32-year-old woman was hospitalized due to diffuse, intermittent abdominal pain, vomiting and constipation for 3 d associated with abdominal distention. Plain abdominal X-ray revealed dilated small bowel. Abdominal computed tomography showed grossly dilated small bowel with "sausage" and "doughnut" signs of small bowel intussusception. She underwent laparotomy, with findings of ileoileal intussusception due to a cystic lesion adjacent to the mesenteric side. Resection of the cystic lesion along with the affected segment of intestine, with an end to end anastomosis was performed. The histopathology was consistent with enteric duplication cyst. This case highlights the DAT, although, an uncommon cause of adult ileoileal intussusception should be considered in the differential diagnosis of intussusception in adults, particularly when the leading point is a cystic lesion.

Pseudomyxoma Retroperitonei: ARare Cause of Retroperitoneal Cystic Mass.

Pseudomyxoma retroperitonei is a rare condition, characterized by accumulation of mucinous material in the retroperitoneal space, originating predominantly from the appendiceal mucinous neoplasms. A72-year-old male patient presented with a history of progressive right side abdominal pain for 5 months with a palpable abdominal mass. Ultrasound, computerized tomography, and magnetic resonance imaging showed large right abdominal multiloculated cystic lesion with heterogeneous echoic contents. Colonoscopy revealed normal mucosa with extramural pressure on the right colon and cecum. He underwent complete excision of the mass along with right hemicolectomy. The cystic mass was containing gelatinous material. Histopathology revealed low grade mucinous neoplasm. Pseudomyxoma retroperitonei should be considered in the differential diagnosis of patient presenting with progressive right side abdominal pain and retroperitoneal cystic mass.

An unusual outcome of a giant ventral hernia.

Hernias are routine general surgical problems that may present in any age group, regardless of the patient's socioeconomic status. We present a rare case of a complicated ventral hernia leading to short bowel. This is an unusual case and is very rarely reported in the literature. This current case report describes a 54-year-old gentleman who presented to the hospital with a giant strangulated ventral hernia causing massive bowel ischemia and resulting in a short bowel. The literature on large abdominal wall hernias leading to short bowel is reviewed, and a discussion on short bowel syndrome is also presented.

Sigmoid colon endometriotic mass. A rare cause of complete large bowel obstruction.

Large bowel obstruction is a rare complication of gastrointestinal endometriosis. A 32-year-old female patient presented to the emergency department with complaints of diffuse abdominal pain and constipation for 10 days with progressive abdominal distention and vomiting. Plain abdominal x-ray showed grossly dilated large bowel up to the sigmoid colon with no gas in the rectum. Abdominal computed tomography revealed hugely dilated large bowel up to the sigmoid colon, with sigmoid soft tissue mass. Flexible sigmoidoscopy showed a non-ulcerating sigmoid mass, with complete obstruction of the sigmoid colon, which impeded the further advancement of the scope. She underwent exploratory laparotomy with provisional diagnosis of complete large bowel obstruction due to sigmoid tumor. Sigmiodectomy with end colostomy was performed. Histopathology revealed endometrial glands with stroma in muscularis properia of the sigmoid colon mass. Endometriosis should be considered in women of reproductive age presenting with symptoms of large bowel obstruction.

Day-case laparoscopic cholecystectomy.

OBJECTIVES: To assess the safety and feasibility of laparoscopic cholecystectomy as a day-case procedure. METHODS: All consecutive patients who were admitted to the day-surgery unit for laparoscopic cholecystectomy at the Department of Surgery, King Saud Medical City, Riyadh, Saudi Arabia from July 2009 to June 2013 were considered for this retrospective study. The medical records were reviewed for age, gender, presenting symptoms, laboratory findings, imaging studies, American Society of Anesthesiology (ASA) grade, anesthesia, conversion to open cholecystectomy, complications, the operating surgeons, pain management, nausea, and vomiting, overnight stay, readmission, morbidity, mortality, and outpatient follow up were collected and analyzed. RESULTS: A total of 487 patients underwent laparoscopic cholecystectomy as a day case (ASA I=316, ASA II=171). Surgery was performed by high surgical trainees (HSTs) (n=417) and consultants (n=70) with conversion to open cholecystectomy in 4 patients. Twenty-two (5%) patients were admitted for overnight stay for different reasons, while 465 (95%) patients were discharged before 8 pm. Two patients (0.4 %) were re-admitted to the hospital due to abdominal pain. Five patients developed umbilical port site infection (1%).  A total of 443 patients were satisfied (97%), while 14 (3%) were unsatisfied. There was no mortality or intra-abdominal septic collection. CONCLUSION: Day-case laparoscopic cholecystectomy is safe and feasible with optimal patient selection, education, and planned postoperative antiemetic and analgesia management. 

Early endoscopic retrograde cholangiopancreatography in mild gallstone pancreatitis with deranged liver function test. A 7-year experience in central Saudi Arabia.

OBJECTIVE: To determine the use of liver function tests (LFTs) as a selection tool for preoperative endoscopic retrograde cholangiopancreatography (ERCP) in patients with mild gallstone pancreatitis. METHODS: All patients admitted with mild gallstone pancreatitis with deranged LFTs in King Saud Medical City, Riyadh, Kingdom of Saudi Arabia between January 2006 and February 2013 were studied retrospectively. Patients' demography, symptoms, laboratory values, imaging studies, ERCP findings, complications and its treatment, surgical intervention, intraoperative and postoperative findings, mortality, and outpatient follow up were collected and analyzed. RESULTS: A total of 245 patients were admitted as mild gallstone pancreatitis with admission day deranged LFTs. Pre-operative ERCP was performed in 74 patients based on admission day LFTs (Group A). Endoscopic retrograde cholangiopancreatography was normal in 65 patients, revealed stones in 5, and sludge in 4 patients. Six patients developed ERCP complications. Endoscopic retrograde cholangiopancreatography was deferred in 171 patients (Group B) until the LFTs were repeated in 3-4 days. Liver function tests remained persistently high in 8 patients. They were submitted to preoperative ERCP, which revealed stones (n=5) and sludge (n=3). Patients with normalized LFTs (n=163) were not submitted to ERCP. Three of them developed gallstone related complications. CONCLUSION: Patients admitted with predicted mild gallstone pancreatitis, deranged LFTs, and no evidence of cholangitis should not be submitted to ERCP unless a repeat LFT within 3-4 days shows persistently deranged LFTs. This will reduce unnecessary ERCP and its complications.

Hemobilia due to liver abscess. A rare cause of massive upper gastrointestinal bleeding.

Massive hemobilia is a rare complication of liver abscess. A 48-year-old male presented with massive hemobilia due to liver abscess. He had been complaining of right upper quadrant abdominal pain, fever, and jaundice for 10 days. This was followed by hematemesis and melena prior to emergency presentation. Upper gastrointestinal endoscopy showed fresh blood and clots coming from the orifice of the ampulla of Vater. The CT showed multiple liver abscesses, the largest one in the right lobe. Selective angiography revealed bleeding from a branch of the right hepatic artery into the biliary radicles. The bleeding was controlled by coil embolization. Drainage of the large liver abscesses was achieved under ultrasound guidance. Diagnostic modalities and management of hemobilia are discussed along with a review of the literature. A high index of suspicion, and the use of appropriate diagnostic tools can help diagnose and treat this rare cause of upper gastrointestinal bleeding.

Arterioenteric fistula on a kidney graft site. A rare cause of massive lower gastrointestinal bleeding.

Arterioenteric fistula (AEF) on a kidney graft site is a rare cause of massive lower gastrointestinal bleeding (LGIB). Emergency angiography with concomitant endovascular repair is an efficient and safe approach in controlling the acute bleeding and stabilizing patients with life-threatening bleeding from AEF. We report a 42-year-old male who underwent allograft renal transplantation in the right iliac fossa 8 months before presenting with massive LGIB. Preoperative localization of the source of bleeding with mesenteric angiography was unsuccessful. He underwent laparotomy and intraoperative endoscopy, which localized the source of bleeding from the site of the grafted kidney. An anastomotic pseudoaneurysm was found connecting the ileum and the external iliac artery at the site of transplanted kidney. Resection of an ileal loop, nephrectomy of the rejected transplanted kidney, and primary repair of the external iliac artery were performed. Such patients should undergo selective mesenteric angiogram with aorto-iliac angiogram for better localization and endovascular intervention.

Biliopleural fistula with cholethorax. A rare complication of percutaneous transhepatic biliary drainage.

Biliopleural fistula leading to cholethorax formation is a rare complication of percutaneous transhepatic cholangiography (PTC). Ideally it should be treated conservatively as it closes spontaneously in most patients. However, in complicated cases it may require surgical intervention. We report a 35-year-old male with right biliopleural fistula with cholethorax following PTC. The patient complained of shortness of breath, right pleuritic chest pain, and cough after removal of PTC catheter. Chest radiograph showed an extensive right pleural effusion. The diagnosis was confirmed by drainage of dark green pleural fluid with high bilirubin content. The initial treatment with chest tube and drainage was unsuccessful. He underwent video assisted thoracoscopic intervention. Diagnostic modalities and management options for biliopleural fistula are discussed along with a review of literature.

Cholecystectomy without intraoperative cholangiogram in gallstone pancreatitis.

OBJECTIVE: To determine the long term outcome of cholecystectomy without intraoperative cholangiogram (IOC) in patients recovering from acute gallstone pancreatitis with normal preoperative liver function tests and imaging. METHODS: The medical records of all patients who underwent cholecystectomy without IOC for gallstone pancreatitis at King Saud Medical City, Riyadh, Saudi Arabia between January 2005 and December 2009 were studied retrospectively. Patients with severe pancreatitis and those who had preoperative endoscopic retrograde cholangio-pancreatography (ERCP) were excluded from the study. Data on patients' demography, symptoms, laboratory findings, intraoperative and postoperative findings, length of hospital stay, and outpatient follow up were collected and analyzed. RESULTS: A total of 160 patients were treated for acute gallstone pancreatitis. Forty-four patients with preoperative ERCP (n = 39), and severe pancreatitis (n = 5), were excluded. The remaining 116 patients initially underwent conservative treatment followed by cholecystectomy without IOC. All were followed up for an average of 2-4 visits. Five patients (4.3%) were re-admitted with gallstone related bilio-pancreatic complications. They underwent ERCP and CBD stone clearance. Four patients were lost to follow up. The remaining 107 patients have remained asymptomatic 12-55 months after cholecystectomy. CONCLUSION: The incidence of bilio-pancreatic complications from unsuspected CBD stones in patients of biliary pancreatitis that underwent cholecystectomy without IOC is very low. Therefore, a routine IOC in these patients can be omitted safely.

Duodenal duplication cyst communicating with the main pancreatic duct. A rare cause of recurrent acute pancreatitis.

Duodenal duplication cysts (DDC) are rare congenital anomalies. They are usually seen in infancy and childhood. However, rarely it can also present in adulthood. It presents as a cystic or tubular mass, which can be communicating or non-communicating. Total excision is the ideal surgical procedure. However, if total excision is not feasible, subtotal excision and cystoduodenostomy should be carried out. We present a 13-year-girl with recurrent attacks of acute pancreatitis. The diagnosis of DDC was suspected by abdominal CT, and endoscopic retrograde cholangiopancreatography. She was successfully treated with subtotal excision and intraduodenal cystoduodenostomy. Operative findings and histopathology confirmed the diagnosis. Diagnostic modalities and management options for DDC are discussed along with recommendations and review of the literature.

Alvarado score as an admission criterion for suspected appendicitis in adults.

BACKGROUND: Acute appendicitis is a common surgical problem. AIM OF THE STUDY: To assess Alvarado score as an admission criterion for adult patients with suspected appendicitis in order to decrease unnecessary admissions to surgical wards. PATIENTS AND METHODS: A prospective study of consecutive patients attending the Emergency Department (ED) of Riyadh Medical Complex with suspected appendicitis. The patients were managed according to the algorithm of the study protocol and discharged after clinical improvement either from ED or from the ward. They were followed by telephone 2-3 days later. Alvarado score was obtained in the ED in all patients. RESULTS: The study included 211 patients, 60 patients were observed in ED and discharged, 151 patients were admitted and 137 of them were operated with a negative rate of 12.5%. The remaining 14 patients were observed and discharged. No patients with a score of 4 or less had appendicitis. CONCLUSION: Though the diagnosis of acute appendicitis remains mainly clinical, Alvarado score can be recommended as a helpful tool for the admission criteria and further management in order to reduce unnecessary admissions and to reduce the morbidity and mortality of acute appendicitis.

Perforated appendicitis within paraumbilical hernia.

The appendix is not uncommonly encountered within an external hernial sac. However, acute appendicitis in hernia is quite rare. We report a female patient who was admitted and operated as a case of incarcerated, strangulated paraumbilical hernia and the hernial sac was found to contain part of the greater omentum, pus and acutely inflamed, gangrenous appendix, perforated at the tip. Appendicectomy and hernial repair were carried out through the same incision.