Operative and non-operative management of endoscopic retrograde cholangiopancreatography-associated duodenal injuries.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is indispensable in everyday surgical practice. Despite this, as an invasive procedure, it has its own mortality and morbidity, the most feared of which is periduodenal perforations. Our experience with ERCP related periduodenal perforations and its treatment strategies are presented. Additionally, a rarely encountered subtype is highlighted. METHODS: Patients who underwent ERCP and sustained a periduodenal perforation between August 2008 and October 2011 were reviewed. RESULTS: During the period from August 2008 to October 2011, 597 ERCP procedures were performed in our hospital. Ten of these patients (3 male, 7 female) had a perforation. The mean patient age was 56.6 years. During the procedure, injury was suspected in four patients; it passed unnoticed in the remaining six. The decision to operate or follow a conservative policy was based on a combination of clinical and radiological findings. Operative intervention was required in three patients, with one mortality, while conservative treatment was followed in the remaining seven. A laparotomy was performed early in two patients whereas it was performed after an initial period of conservative treatment in one. The presence of periduodenal fluid collection, contrast extravasation or free intraperitoneal air were decisive factors for performing laparotomy. CONCLUSIONS: ERCP-related periduodenal perforations include different categories. Certain types require operative repair while others should be treated conservatively. The choice of the management approach should be individualised, depending on the clinical picture and radiological findings. Although rare, these are potentially serious complications that may end fatally. Early recognition and appropriate intervention is the only way to avert a fatal outcome.

Molecular surveillance of Plasmodium falciparum chloroquine resistance transporter variant T76 in Jazan area, Kingdom of Saudi Arabia.

The development of chloroquine as an antimalarial drug and the subsequent evolution of drug resistant Plasmodium strains had major impacts on global public health in the 20th century. In P. falciparum, the cause of the most lethal human malaria, chloroquine resistance is linked to multiple mutations in PfCRT, a protein that likely functions as a transporter in the parasite's digestive vacuole membrane. Rapid diagnostic assays for PfCRT mutations are already employed as surveillance tools for drug resistance. However, several reports have been published demonstrating cases with CO resistance. Sporadic cases have been reported as well as one large scale study demonstrated 12.4% resistance. However, all these reports were based on treatment failure (in vivo). rather than in vitro or molecular bases. Evidence suggests a crucial role for a point mutation in the P. falciparum chloroquine resistance transporter (pfcrt) gene on chromosome 7 in conferring CQ resistance. The mutation in the K76 codon in 3 cases out of 60 (5%) using ApoI restriction enzyme was detected. Although the percentage of drug resistance was not quite disturbing, but represented the possible establishment of chloroquine-resistant P. falciparum in Saudi Arabia, or the beginning of resistant strains by labors coming from abroad. Cross-border importation of resistant strains from neighboring countries must be considered. In vivo tests must be conducted parallel with the molecular markers to estimate more precisely the actual prevalence of resistance. Validation of molecular markers is urgently required and needs strong collaborative partnerships between subregional and regional networks.

Latex agglutination and indirect immunofluorescence tests in the diagnosis of Toxoplasma gondii in Saudi Arabia.

Commercial latex agglutination (LA) was assessed for Toxoplasma antibody screening. The sensitivity and specificity were compared with the reference standard indirect immunofluorescence (IFA). A total of 186 sera were collected from May 2008-October 2008 for Toxoplasma antibody by LA & IFA. Antibody to T. gondii 51/186 (27.4%) were LA-positive and 42/186 (22.6%) were IFA-positive. The sensitivity, specificity and positive predictive value of LA were 100%, 93.7% & 82.3% respectively. The nine LA-false positive sera were examined for rheumatoid factor and antinuclear antibodies, but were negative and none exhibited nonspecific polar staining as a cause for the false positivity.

Comparison of two commercial assays and microscopy with PCR for diagnosis of malaria.

This study compared conventional PCR with microscopy and 2 rapid detection methods, the pLDH which detected lactic dehydrogenase enzyme produced by actively metabolizing organisms and the malaria antibody tests. The sensitivity of PCR was 1 parasite/microl, i.e.: 50 times more sensitive than microscopy. When PCR was compared with microscopy, the sensitivity and specificity were 90% & 100% respectively. The sensitivity recorded was pLDH test in comparison to PCR (95%). The malaria antibody test recorded the least sensitivity (68%) PCR proved as the gold standard for evaluation of applied tests and the newly introduced ones. In absence of an expert microscopist, the pLDH test could substitute for microscopy. The test proved valuable to assess clinical cure, and predict drug resistance. Its advantage over microscopy was the ability to diagnose infection with low parasitemic patients. Antibody rapid tests might be not valuable in acute cases, but still accepted as a tool in epidemiological studies and in screening patients in blood banks in malaria endemic areas.

Evaluation of a real-time polymerase chain reaction assay for the diagnosis of malaria in patients from Jazan area, Saudi Arabia.

A real-time PCR assay with conventional microscopy by Giemsa-stained blood films was used. PCR was completed in an hour and identified the Plasmodium species in a single reaction. Blood was collected, and DNA was extracted. A genus-specific primer set corresponding to 18S ribosomal RNA was used to amplify target sequence. Fluorescence resonance energy technology hybridization probes were designed for P. falciparum over a region containing base pair mismatches allowed Plasmodium species differentiation. Microscopically positive patients (n = 60) were positive with real-time assay (100% sensitivity). 58 were single-species infections caused by P. falciparum; mixed infections (P. falciparum & P. vivax) were shown by real-time assay. Six out of 30 negative microscopy specimens were positive by real-time PCR (80% specificity). The discrepant results could be due to the subjective nature of microscopy and analytical objectivity of PCR, and high analytical sensitivity of real-time assay (1 parasite/microl) compared to microscopy (50 parasites/microl). Six patients were retested with ICT malaria test and 4 were positive showing that PCR results were correct. There was low correlation between parasitemia by microscopy and gene copy number for P. falciparum (r = 0.2; P = 0.05 [Spearman]).

Anemia, interleukin-10, tumor necrosis factor alpha, and erythropoietin levels in children with acute, complicated and uncomplicated malignant malaria in Jazan, Saudi Arabia.

To gain insight into potential relationships between tumor necrosis factor alpha (TNF-alpha), interleukin 10 (IL-10), erythropoietin (EPO), and anemia in acute malaria, 90 children 3 to 11 years with acute malaria were studied. According to parasitemia and hemoglobin levels, they were divided into 3 groups: G1 (mild): asexual low-density Plasmodium falciparum parasitemia <8000 parasites/ul and hemoglobin levels >8g/dl. G2 (high-density uncomplicated): asexual high-density parasitemia (>8000 parasites/ul, with hemoglobin levels >8 g/dl. G3 (anemia): with severe malaria symptoms and parasitemia with anemia (hemoglobin levels <8 g/dl). Hospital controls included 10 children with matching age group who required inpatient management but had no malaria parasitemia. Good marrow response was in G1 & G2 showed by elevation of serum EPO and soluble transferring receptors (sTfR) and increased red cell distribution width (RDW). In G3, bone marrow suppression was in spite of increased EPO level in response to anemia. TNF-alpha level was significantly higher G2 and G3 (P.05). IL-10 levels in G1 were significantly higher than in hospital control group (P<0.05). The highest level of IL-10 was in G2. The mean IL-10 to TNF-alpha ratio in G2 (4.64) was significantly higher (P<.005) than in G3 (mean ratio, 1.77).

Spontaneous bacterial peritonitis in Saudi Arabian patients with non-alcoholic liver cirrhosis.

BACKGROUND/AIMS: Spontaneous bacterial peritonitis is a frequent and serious complication of liver cirrhosis. Its prevalence varies from one survey to another. There are only very few reports of its occurrence among Arab patients. METHODOLOGY: We studied 115 Saudi Arabian patients with cirrhotic ascites in the Gizan region, an area of hyperendemic hepatitis B, over a 2-year period. RESULTS: Of these patients 12 (10.4%) had at least 1 episode of culture-positive spontaneous bacterial peritonitis (group A), an additional 34 (29.6%) had culture-negative neutrocytic ascites. The occurrence of spontaneous bacterial peritonitis was more frequent in males but was not influenced by the severity of liver disease or age. The overall mortality was 13.9%, however, only 1 patient died of spontaneous bacterial peritonitis-related cause. The remaining deaths were due to other complications of hepatic failure and portal hypertension. The low clinical threshold for treatment and the use of effective broad-spectrum antibiotics have reduced the mortality due to spontaneous bacterial peritonitis. There were a total of 56 recurrent episodes of infection in the patients. Of these episodes 46 occurred among 29 patients with spontaneous bacterial peritonitis and 10 among 62 patients with no infection during the index admissions. CONCLUSIONS: Prophylactic therapy against spontaneous bacterial peritonitis is a feasible strategy in reducing the frequency of recurrent peritonitis and should be recommended in these patients.