Synchronous pancreatic and scrotal tuberculosis: Double jeopardy.

We describe a patient who presented with scrotal swelling followed by non-healing and discharging scrotal sinuses, following local trauma and was initially suspected to have an infected scrotal hematoma. An evaluation revealed it to be scrotal tuberculosis. He also complained of upper abdominal pain and on transabdominal ultrasonography was detected to have a mass in the head of the pancreas. Evaluation of the pancreatic mass revealed it to be pancreatic tuberculosis. Both lesions responded well to anti-tubercular therapy. This is an unusual case of two rare sites of extrapulmonary tuberculosis presenting simultaneously in the same individual. Care needs to be exercised while evaluating any non-healing ulcers or sinuses and mass lesions in countries endemic for tuberculosis as this disease can be a great masquerader.

Serum biomarkers as an alternative to vibration controlled transient elastography in liver fibrosis staging in chronic hepatitis C.

Background: Assessment of liver disease severity in chronic Hepatitis C (CHC) is essential both in pretreatment and posttreatment period. We assessed the impact of direct-acting antiviral therapy on liver stiffness regression measured by Vibration Controlled Transient Elastography (VCTE) in patients with CHC and evaluated the diagnostic performance of the APRI and FIB-4 scores compared to VCTE in detecting advanced fibrosis and cirrhosis (F3/F4). Methodology: Retrospective analysis of consecutive patients with CHC who underwent VCTE before and after DAA therapy was done. APRI and FIB-4 scores were compared to VCTE. Results: 88 (56.78%) patients-12 (F3) and 76 (F4) according to VCTE, had advanced fibrosis pretreatment, which reduced to 69 (44.52%) - 10 (F3) and 59 (F4) after 12 weeks DAA therapy. Significant reduction in VCTE value from 14.08 ± 9.05 KPa to 11.84 ± 8.31 KPa (p=0.002) was noted. There is significant reduction in APRI, FIB-4 and GUCI score posttreatment which was not the case with Lok score and Bonacini score. Before therapy, FIB-4 outperformed others to predict advanced fibrosis with score >2.13 (AUC 0.93), having sensitivity 76%, specificity 96% and accuracy 86%. However posttreatment, APRI and GUCI score performed best to predict F3/F4 fibrosis with score >0.63 (AUC 0.97) and >0.64 (AUC 0.96), having sensitivity, specificity and accuracy of 85%, 96.6% and 92% ; 85%, 6.6% and 92% respectively. Conclusion: Before therapy, FIB-4 had the best accuracy in predicting advanced fibrosis whereas APRI and GUCI score were the best indices post-treatment.

Effect of H. pylori density by histopathology on its complications and eradication therapy.

INTRODUCTION: Helicobacter pylori (H. pylori) infection causes chronic gastritis and is a major risk factor for duodenal and gastric ulceration, gastric adenocarcinoma, and primary gastric lymphoma. Increased gastric bacterial density may lead to increased levels of inflammation and epithelial injury. AIMS AND OBJECTIVES: 1) To study the effect of H. pylori density by histological changes in stomach. 2) To study the effect of H. pylori density on the efficacy of standard triple drug eradication treatment. 3) To study the effect of H. pylori density on the complication related to H. pylori. MATERIAL AND METHODS: All the patients visiting gastroenterology OPD with the symptoms of dyspepsia not responding to proton pump inhibitor or having alarm symptoms were subjected to upper GI endoscopy and biopsy. If H. pylori was present they were included in the study. The patients were given standard 14 day triple antibiotic combination for H. pylori eradication. H. pylori eradication was confirmed by urea breath test after six weeks of completion of treatment. RESULTS: Out of 250 patients screened, 120 patients enrolled in the study. On clinical history 41.5% patients had symptoms of heart burn where as 63.3% patients had dyspeptic symptoms. Success rate of anti H. pylori triple drug therapy was 80%. Rate of eradication was significantly lower among the patients with higher H. pylori density (p < 0.05) on histopathology by Sydney classification. Duodenal ulcer, Gastric ulcer and gastric erosion were noted in higher frequencies among the patients with higher H. pylori density (p < 0.05). CONCLUSION: H. pylori density by histopathology correlates with the complication related to H. pylori i.e. duodenal ulcer, reflux esophagitis and antral erosions. It also correlates with the success of the standard triple drug eradication treatment.

Endoscopic therapy after laparoscopic cholecystectomy.

The role of endoscopic therapy after laparoscopic cholecystectomy (LC) was assessed in 62 patients referred for endoscopic retrograde cholangiopancreatography (ERCP). Patients were referred because of persistent biliary pain, jaundice, abnormal liver function tests, elevated serum amylase, abnormal ultrasound of the biliary system, or abnormal laparoscopic cholangiogram. Diagnostic imaging of the biliary system was abnormal in 47 of 62 (76%) cases. Sonographic abnormalities were seen in 33 of 57 (58%) patients: common bile duct (CBD) stones were present in 10 of 58 (17%); CBD >7 mm, in 22 of 58 (38%); and subhepatic fluid collection, in 10 of 58 (17%). Laparoscopic cholangiogram was done in nine cases, and CBD calculi were detected in eight. Magnetic resonance cholangiogram was abnormal in six of seven patients: CBD stones were seen in two cases; subhepatic fluid collection, in two; and clip-on CBD, in two. Endoscopic therapy was carried out in 46 of 62 (74%) patients: 40 of 47 (85%) had abnormal imaging (p = 0.0003); 29 of 33 (88%), abnormal sonography (p = 0.002); 10 of 10 (100%), CBD stones on sonography (p = 0.03); and 31 of 46 (67%), abnormal liver function tests before ERCP (p = 0.04). Twenty-five patients had a CBD stone extracted at ERCP. Bile leaks were treated successfully with papillotomy alone in 12 of 13 cases; a stent was necessary in 1 case. Endoscopic papillotomy was done in two patients with biliary pancreatitis, in one patient with recurrent idiopathic pancreatitis, and in five with suspected biliary dyskinesia. Surgery was necessary in four patients with a CBD transection. We conclude that most patients referred for ERCP after LC need endoscopic intervention. Abnormal imaging correlates best with the need for endoscopic therapy.

Endoscopic esophagitis and gastroesophageal flap valve.

The authors studied the relationship of endoscopic esophagitis and gastroesophageal flap valve (GEFV) in patients with symptomatic gastroesophageal reflux (GER). On endoscopy, the GEFV was graded as I to IV in 138 patients with acid regurgitation and heartburn relieved by antacids, and in 54 control subjects without symptoms suggestive of GER. Grade of GEFV was correlated with the grade of esophagitis, response to medical treatment, duration of symptoms, obesity, smoking, sex, and age of the patient. Abnormal GEFV (grades III and IV) was more frequent in patients with symptomatic GER, both with and without esophagitis, compared with control subjects (p = 0.000001. p = 0.03). Abnormal GEFV was significantly more common in patients with GER with esophagitis compared with those without (p < 0.00001). There was no significant difference in the distribution of normal and abnormal GEFV in patients with grade I esophagitis. However, grade 2 and grade 3 esophagitis were associated more commonly with an abnormal GEFV (p < 0.00001, p < 0.02 respectively). Hiatal hernia is always associated with an abnormal GEFV. Abnormal GEFV correlated significantly with age (more frequent when older than 40 years). Sex, duration of symptoms (>3 years), response to medical therapy, smoking, and obesity (body mass index > 30 kg/m2) did not correlate significantly with abnormal GEFV. We conclude that endoscopic esophagitis is usually associated with abnormal GEFV. It is more frequent in grades 2 and 3 but not grade 1 esophagitis. It is also encountered more commonly after the age of 40 years.

Helicobacter pylori in the dental plaque of healthy Saudis.

The objective of this study is to determine the presence of Helicobacter pylori in the dental plaque of healthy Saudis and its relation to dental care. One hundred randomly selected healthy Saudis attending the dental clinic were assessed for oral hygiene and periodontal disease by dental examination. Information about the use of toothpaste, chewing stick, smoking and dentures was obtained. Samples of dental plaque were collected after scoring it according to the plaque index. Presence of H. pylori in the plaque was sought by a commercially available rapid urease test with a sensitivity of 94% and a specificity of 100%. The presence of H. pylori was indicated by a positive rapid urease test in 81 %. There was significant correlation of heavy dental plaque (plaque index score 3) with presence of H. pylori (p=0.03). We conclude that H. pylori is present in the dental plaque of most Saudis and this is due to poor oral hygiene.

Abnormal common bile duct sonography. The best predictor of choledocholithiasis before laparoscopic cholecystectomy.

We conducted a prospective study to determine the most reliable indicator of common bile duct stones before laparoscopic cholecystectomy. One hundred thirty-seven patients were referred for endoscopic retrograde cholangiography before laparoscopic cholecystectomy for suspected choledocholithiasis due to one or more of the following abnormalities: (a) altered liver function tests, (b) increased serum amylase levels, or (c) a dilated common bile duct (> 7 mm) with or without evidence of stones on sonography. Sensitivity, specificity, positive and negative predictive values, and the likelihood of the presence or absence of morbidity were calculated for 25 different variables. Common bile duct stones were detected in 63 (46%) patients. Abnormal result of sonography of the common bile duct was the best predictor of choledocholithiasis (p < 0.0001). Abnormalities of the combined liver function tests were statistically significant predictors only when combined with abnormal sonographic results. Improving liver function tests before endoscopy had a significant negative predictive value (p = 0.01). Stepwise logistic regression analysis showed that abnormal ultrasound and the presence of common bile duct stones on ultrasound were significant (p = 0.009 and p = 0.049, respectively). Abnormal result of sonography of the common bile duct is the best predictor of choledocholithiasis before laparoscopic cholecystectomy.

Sclerotherapy in bleeding gastric varices of hepatic schistosomiasis.

We report the results of sclerotherapy in 20 patients with bleeding gastric varices due to hepatic schistosomiasis. In an endemic area, patients with hepatic schistosomiasis, and bleeding gastric varices seen on endoscopy to be inferior extension of esophageal varices, were treated with emergency endoscopic injection just proximal to the cardia. Hemostasis was achieved in 17. Obliteration of varices was achieved in all patients with sclerotherapy, combined with surgery. Thirteen patients who had not been operated on in the past and consented to surgery underwent esophagogastric devascularization with splenectomy. Surgery was carried out as an emergency in the three patients who did not respond to sclerotherapy and electively in 10 patients after control of bleeding. After surgery, sclerotherapy was required for remnant varices. One patient with Child-Pugh grade C cirrhosis died of hepatic encephalopathy after control of the bleed. During a median follow-up of 9 months (range, 1-25 months), recurrence of bleeding in one patient and recurrent varices in two others were controlled with sclerotherapy. One patient had a fatal hemorrhage at home. We conclude that sclerotherapy effectively controls acutely bleeding type 1 gastric varices. Combined with esophagogastric devascularization and splenectomy, long-term results may be encouraging in patients with hepatic schistosomiasis.

Thrombolysis of acute portal vein thrombus.

We report a middle-aged woman who presented with postpartum acute severe central abdominal pain. Portal vein, thrombosis was diagnosed by ultrasonography and confirmed by splenoportogram. She received thrombolytic therapy with symptomatic improvement and gradual disappearance of the thrombus on ultrasound. Early thrombolytic therapy seems to be effective in the treatment of acute portal vein thrombosis.

Traumatic solitary rectal ulcer in Saudi Arabia. A distinct entity?

Solitary rectal ulcer syndrome is a perplexing condition with a complex multifactorial pathophysiology. Inappropriate contraction of the puborectalis muscle and rectal mucosal prolapse have been commonly implicated, although self-induced trauma has been suspected in some cases. Eight patients who presented with rectal bleeding with excessive mucus were found to have an isolated rectal ulcer on proctosigmoidoscopy. Constipation, straining at stools, and pain in the anal region were present in seven of eight cases. All of them confessed to rectal digitation. Most of them had consulted more than two physicians and half of them had had barium enema and colonoscopy in the past. An ulcer was present on the anterior wall at 6-8 cm from the anal verge in seven of eight patients and none of them had either external or internal rectal prolapse. Rectal biopsy performed in six of eight showed histological findings consistent with the diagnosis of solitary rectal ulcer. Patients were convinced to stop finger evacuation and were given psyllium supplements. There was endoscopic healing with symptomatic improvement in the six patients who followed up for an average period of 38 weeks. We conclude that traumatic solitary rectal ulcer due to rectal digitation is a distinct entity and response to avoidance of this habit is good.

Electron microscopic observations in gastric mucosa of habitual tobacco chewers.

Clinical evaluation, upper gastrointestinal endoscopy and electron microscopy of mucosal biopsies from antrum, body and fundus of stomach were performed in three control subjects and 17 habitual tobacco chewers. Electron microscopic abnormalities such as discontinuous, fragmented basement membrane with reduction in hemidesmosomes, and widened intercellular spaces filled with clusters of desmosomes were found in the gastric mucosa of habitual tobacco chewers; these were similar to those reported in experimental carcinogenesis and leukoplakia. It is concluded that habitual chewing of tobacco produces electron microscopic alterations in the human gastric mucosa which may be important precursors for gastric malignancy.

Mutagenic activity of gastric fluid from chewers of tobacco with lime.

Although tobacco chewing is strongly associated with a high risk of oral and upper alimentary tract cancers, the nature of mutagenic exposure among users has not been clearly defined. In this study, tobacco-specific and mutagenic exposure of chewers of tobacco with lime was evaluated by analysis of gastric fluid (GF). The pH, nitrite and cotinine levels of GF samples from chewers and non-chewers were determined and the samples were tested for mutagenicity in the Ames Salmonella/microsome assay using Salmonella typhimurium strains TA98, TA100 and TA102. Cotinine was not detected in GF from non-chewers while the levels ranged between 0.4-13.64 micrograms/ml in samples from chewers; however, the mean pH values (3.8 +/- 0.4 versus 2.8 +/- 0.3) and nitrite levels (29.40 +/- 1.51 versus 27.39 +/- 0.83 microM) were similar in both groups. While all GF samples from non-chewers were non-mutagenic, samples from chewers were directly mutagenic or upon nitrosation to all the three tester strains and to TA102 strain in the presence of S9. Experiments using scavengers of reactive oxygen species (ROS) showed that mannitol and benzoate abolished the mutagenic response of TA102, indicating that ROS are principally responsible for oxidative damage. The findings provide specific information regarding the mutagenic exposure among tobacco chewers and suggest that tobacco chewing may be an important risk factor in the development of gastric cancer.

Ultrastructural changes in esophageal mucosa of chronic tobacco chewers.

Seventeen chronic tobacco chewers and three control subjects underwent clinical evaluation, upper gastrointestinal endoscopy and esophageal mucosal biopsies. The esophageal biopsies were processed and examined under the electron microscope. A large number of ultrastructural abnormalities such as discontinuous, fragmented basement membrane, with reduction in hemidesmosomes, widened intercellular spaces were found in the esophageal mucosa of chronic tobacco chewers which resembled the ultrastructural features of experimental carcinogenesis and leukoplakia. It is concluded that chronic chewing of tobacco produces ultrastructural abnormalities in the esophageal mucosa which could be important precursors for esophageal malignancy.

Gastric mucosa in acute viral hepatitis.

In acute viral hepatitis, gastric biopsy and augmented histamine test were performed in 63 patients. Gastric histology was abnormal in 12 of 63 (19%) patients; 3 with superficial and 9 with atrophic gastritis. Maximal acid output was less than 10 mEq/h in 35 of 63 (55.5%) patients. Acid load tests were performed in 23 patients measuring H+, K+, Na+ fluxes; the results showed increased loss of acid from lumen to mucosa in 16 of 23 (69.6%) patients, indicating damage to the gastric mucosal barrier.

Laparoscopic appearance of the liver in Schistosoma mansoni infection.

In an area endemic for Schistosoma mansoni infection laparoscopy was performed in 45 patients with liver disease. Hepatic schistosomiasis was diagnosed by histology in 20 cases. The only complication encountered was unusual bleeding from the biopsy site in one patient. Liver lobe size was variable. Mild uniform irregularity of the liver surface was seen in most of the patients. Other changes noted were macronodularity, lumpy surface, tiny white tubercles, white patchy discoloration, and thick and thin adhesions. Characteristic features of the liver surface in Schistosoma mansoni infection as seen on laparoscopy are thus described.