Saudi Journal of Gastroenterology
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   Table of Contents - Current issue
Coverpage
January-February 2017
Volume 23 | Issue 1
Page Nos. 1-71

Online since Friday, January 27, 2017

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EDITORIAL  

Efficacy of image enhanced endoscopy for colorectal polyps: Are we ready for prime time? p. 1
Helmut Neumann, Peter R Galle
DOI:10.4103/1319-3767.199120  PMID:28139493
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SYSTEMATIC REVIEW/META ANALYSIS Top

The diagnostic value of polymerase chain reaction for Mycobacterium tuberculosis to distinguish intestinal tuberculosis from crohn's disease: A meta-analysis p. 3
Ting Jin, Baoying Fei, Yu Zhang, Xujun He
DOI:10.4103/1319-3767.199135  PMID:28139494
Background/Aim: Intestinal tuberculosis (ITB) and Crohn's disease (CD) are important differential diagnoses that can be difficult to distinguish. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis (MTB) is an efficient and promising tool. This meta-analysis was performed to systematically and objectively assess the potential diagnostic accuracy and clinical value of PCR for MTB in distinguishing ITB from CD. Materials and Methods: We searched PubMed, Embase, Web of Science, Science Direct, and the Cochrane Library for eligible studies, and nine articles with 12 groups of data were identified. The included studies were subjected to quality assessment using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Results: The summary estimates were as follows: sensitivity 0.47 (95% CI: 0.42–0.51); specificity 0.95 (95% CI: 0.93–0.97); the positive likelihood ratio (PLR) 10.68 (95% CI: 6.98–16.35); the negative likelihood ratio (NLR) 0.49 (95% CI: 0.33–0.71); and diagnostic odds ratio (DOR) 21.92 (95% CI: 13.17–36.48). The area under the curve (AUC) was 0.9311, with a Q* value of 0.8664. Heterogeneity was found in the NLR. The heterogeneity of the studies was evaluated by meta-regression analysis and subgroup analysis. Conclusions: The current evidence suggests that PCR for MTB is a promising and highly specific diagnostic method to distinguish ITB from CD. However, physicians should also keep in mind that negative results cannot exclude ITB for its low sensitivity. Additional prospective studies are needed to further evaluate the diagnostic accuracy of PCR.
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Efficacy of proton pump inhibitors for patients with duodenal ulcers: A pairwise and network meta-analysis of randomized controlled trials p. 11
Zhan-Hong Hu, Ai-Ming Shi, Duan-Min Hu, Jun-Jie Bao
DOI:10.4103/1319-3767.199117  PMID:28139495
Background/Aim: To compare the efficacy and tolerance of different proton pump inhibitors (PPIs) in different doses for patients with duodenal ulcers. Materials and Methods: An electronic database was searched to collect all randomized clinical trials (RCTs), and a pairwise and network meta-analysis were performed. Results: A total of 24 RCTs involving 6188 patients were included. The network meta-analysis showed that there were no significant differences for the 4-week healing rate of duodenal ulcer treated with different PPI regimens except pantoprazle 40 mg/d versus lansoprazole 15 mg/d [Relative risk (RR) = 3.57; 95% confidence interval (CI) = 1.36–10.31)] and lansoprazole 30 mg/d versus lansoprazole 15 mg/d (RR = 2.45; 95% CI = 1.01–6.14). In comparison with H2receptor antagonists (H2RA), pantoprazole 40 mg/d and lansoprazole 30 mg/d significantly increase the healing rate (RR = 2.96; 95% CI = 1.78–5.14 and RR = 2.04; 95% CI = 1.13–3.53, respectively). There was no significant difference for the rate of adverse events between different regimens, including H2RA for a duration of 4-week of follow up. Conclusion: There was no significant difference for the efficacy and tolerance between the ordinary doses of different PPIs with the exception of lansoprazle 15 mg/d.
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ORIGINAL ARTICLES Top

Therapeutic efficacy of an elemental diet for patients with crohn's disease and its association with amino acid metabolism p. 20
Masakazu Nakano, Keiichi Tominaga, Atsushi Hoshino, Takeshi Sugaya, Kazunari Kanke, Hideyuki Hiraishi
DOI:10.4103/1319-3767.199110  PMID:28139496
Background/Aim: We investigated the association between blood amino acid concentration changes caused by elemental diet (ED) and their relationship to its therapeutic effect. Patients and Methods: Patients with active Crohn's disease (CD) followed ED for 12 weeks. Patients not previously treated with ED were defined as new ED, and those with previous ED therapy (≥900 kcal/day) were defined as previous ED. Disease activity markers [Crohn's disease activity index (CDAI) and C-reactive protein (CRP) level], blood biochemistry test results, and plasma amino acid concentrations were measured before and after the treatment. Results: Histidine (His), tryptophan (Trp), valine (Val), and methionine (Met) increased after the treatment in the 17 patients with clinical remission, however, no increase occurred in plasma amino acid concentrations in the 8 patients without remission. The multivariate index using AminoIndextechnology (MIAI) was correlated with the CDAI (r = 0.475,P < 0.001), and it decreased as patients' conditions improved during the treatment. All patients in the new ED group (n = 11) exhibited increases in the nutritional indices, albumin level, and body mass index after treatment, as well as increased levels of His, Trp, Val, and phenylalanine. None of these changes were observed in the previous ED group (n = 14). Conclusions: Plasma amino acid concentrations and MIAI may provide useful noninvasive markers for evaluating disease activity and response to treatment. ED was effective in improving disease activity, nutritional status, and plasma amino acid levels, and thus it may be particularly effective for poorly nourished patients with CD who have not previously undergone this treatment.
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The expression and significance of feces cyclooxygensae-2 mRNA in colorectal cancer and colorectal adenomas p. 28
Xiaofeng Li, Lixia Kong, Suhuan Liao, Jing Lu, Lin Ma, Xiaohua Long
DOI:10.4103/1319-3767.199112  PMID:28139497
Background/Aim: This study aims to explore the expression and significance of feces cyclooxygensae-2 (COX-2) mRNA in colorectal cancer and colorectal adenomas. Materials and Methods: The expression of feces COX-2 mRNA in colorectal cancer (n = 28), colorectal adenomas (n = 54), and normal control group (n = 11) were examined by reverse transcriptase polymerase chain reaction (RT-PCR). The positive rate of fecal occult blood test (FOBT) were detected in colorectal cancer (n = 30), colorectal adenomas (n = 56), and normal control group (n = 11); the sensitivity of the two methods was also compared. Results: The positive rate of feces COX-2 mRNA in colorectal cancer was 82.1% (25/28), which was significantly higher than colorectal adenomas 59.3% (32/54), and normal tissues 18.2% (2/11), the difference being significant between the three groups (χ2= 13.842,P= 0.001). The positive rate of FOBT in colorectal cancer was 73.3% (10/30), which was significantly higher than colorectal adenomas 10.7% (6/56) and normal tissues 9.1% (1/11), the difference being significant between these three groups (χ2= 7.525,P= 0.023). There was no significant association between feces COX-2 expression and various clinical pathological features of colorectal cancer and colorectal adenomas (P > 0.05). The sensitivity of the RT-PCR method is higher than FOBT, however, the specificity of FOBT is slightly higher than RT-PCR. Conclusions: High expression of feces COX-2 mRNA in colorectal adenomas and colorectal cancer is a common event; it is an early event in the development of colorectal adenomas to colorectal cancer. Feces COX-2 mRNA has a high sensitivity for detect colorectal cancer; combination with FOBT will be the best alternative. Feces COX-2 can be potentially used in the early diagnosis and screening of colorectal cancer.
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Enhanced efficacy of 5-fluorouracil in combination with a dual histone deacetylase and phosphatidylinositide 3-kinase inhibitor (CUDC-907) in colorectal cancer cells p. 34
Rimi Hamam, Dalia Ali, Radhakrishnan Vishnubalaji, Zaid F Alsaaran, Elna Paul Chalisserry, Musaad Alfayez, Abdullah Aldahmash, Nehad M Alajez
DOI:10.4103/1319-3767.199136  PMID:28139498
Background/Aims: 5-Fluorouracil (5-FU) is widely used in the treatment of patients with colorectal cancer (CRC). However, the efficacy of 5-FU as a single agent is limited, with multiple undesired side effects. Therefore, the aim of the current study was to assess the efficacy of CUDC-907 (a dual inhibitor of histone deacetylase and phosphatidylinositide 3-kinase) in combination with 5-FU against CRC cells. Materials and Methods: Cell viability was determined using AlamarBlue and colony formation assays. Acridine orange/ethidium bromide staining and flow cytometry were used to measure apoptotic and necrotic events, as well as cell cycle progression. Immunoblotting was used to assess acetylation of histone H3 and phosphorylation of AKT. Results: Our data revealed enhanced toxicity of CUDC-907 against HCT116, RKO, COLO-205, and HT-29 CRC cells when combined with 5-FU. Similarly, the colony formation capability of HCT116 cells was suppressed by the combination treatment. Cells treated with CUDC-907 and 5-FU underwent apoptosis and necrosis, and exhibited increased polyploidy. Furthermore, CRC cells treated with CUDC-907 exhibited a higher degree of histone H3 lysine 9 acetylation (H3K9ac) and reduced AKT phosphorylation (Ser473).Conclusion: Our data revealed, for the first time, the enhanced inhibitory effect of CUDC-907 against CRC cells when combined with 5-FU, supporting the application of this combination as a potential therapeutic strategy in CRC treatment.
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Desmoplasia influenced recurrence of disease and mortality in stage III colorectal cancer within five years after surgery and adjuvant therapy p. 39
Maddalena Zippi, Giorgio De Toma, Giovanni Minervini, Claudio Cassieri, Roberta Pica, Diodoro Colarusso, Simon Stock, Pietro Crispino
DOI:10.4103/1319-3767.199114  PMID:28139499
Background/Aims: In patients with colon cancer who undergo resection for potential cure, 40–60% have advanced locoregional disease (stage III). Those who are suitable for adjuvant treatment had a definite disease-free-survival benefit. The aim of the present study was to demonstrate whether the presence of desmoplasia influenced the mortality rate of stage III colorectal cancer (CRC) within 5 years from the surgery and adjuvant therapy. Patients and Methods: Sixty-five patients with stage III CRC underwent resection and adjuvant therapy. Qualitative categorization of desmoplasia was obtained using Ueno's stromal CRC classification. Desmoplasia was related to mortality using Spearman correlation and stratified with other histological variables (inflammation, grading) that concurred to the major determinant of malignancy (venous invasion and lymph nodes) using the Chi-square test. Result: The 5-year survival rate was 65% and the relapse rate was 37%. The mortality rate in patients with immature desmoplasia was 86%, 27% in intermediate desmoplasia, and 0% in mature desmoplasia (Spearman correlation coefficient: −0.572,P= 0.05). Conclusion: Immature desmoplasia appears to be associated with disease recurrence and mortality in stage III CRC patients.
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Variation in inflammatory bowel disease care among saudi pediatric gastroenterologists p. 45
Ahmed A Al-Sarkhy
DOI:10.4103/1319-3767.199115  PMID:28139500
Background/Aim: Although international guidelines in inflammatory bowel disease (IBD) management are currently available, variations in IBD care still exist. The aim of this study was to determine the extent of the variation in IBD care among Saudi pediatric gastroenterologists.Materials and Methods: A cross-sectional survey was conducted among all pediatric gastroenterologists who were members of the Saudi Society of Pediatric Gastroenterology, Hepatology, and Nutrition (SASPGHAN) from August 2015 to December 2015. The questionnaire included items on demographic characteristics and utilization of different diagnostic and therapeutic interventions in IBD care. Results: Of the 45 registered pediatric gastroenterologists surveyed, 37 (82%) returned the survey from 20 centers across the country; 75.7% were practicing in tertiary care centers. There was a considerable variation in the use of different diagnostic tests during the initial evaluation of the disease. Utilization of calprotectin assays, magnetic resonance imaging enterography, and bone densitometry seemed to vary the most between physicians practicing at tertiary and secondary care centers. There were statistically significant differences in the prescription of biological therapy between the two groups. Conclusions: We found a considerable variation in the use of different diagnostic and therapeutic interventions in the management of pediatric IBD patients. Such variations could lead to unintended differences in patient outcomes. Implementation of the available evidence-based guidelines may limit such variations and ultimately could improve the quality of IBD care provided.
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Endoscopic resection of gastric submucosal tumors: A comparison of endoscopic nontunneling with tunneling resection and a systematic review p. 52
Qiang Zhang, Fei Wang, Gong Wei, Jian-Qun Cai, Fa-Chao Zhi, Yang Bai
DOI:10.4103/1319-3767.199116  PMID:28139501
Background/Aim: Endoscopic tunneling resection is a relatively novel endoscopic technology for removing gastric submucosal tumors. Our study aimed to compare the differences between tunneling and nontunneling resection for gastric submucosal tumors.Materials and Methods: Resections of gastric submucosal tumors (n = 97) performed from 2010 to 2015 at our endoscopy center were reviewed, and PubMed was searched for clinical studies on gastric submucosal tumor resection by endoscopic nontunneling and tunneling techniques. Results: At our endoscopy center, nontunneling (Group 1) and tunneling resection (Group 2) were performed for 78 and 19 submucosal tumors, respectively; median tumor diameters were 15 and 20 mm (P = 0.086), median procedural times were 50 and 75 min (P = 0.017), successful resection rates were 94.9% (74/78) and 89.5% (17/19) (P = 0.334), and en bloc resection rates were 95.9% (71/74) and 94.1% (16/17) (P = 0.569) in the Groups 1 and 2, respectively. Postoperative fever, delayed hemorrhage and perforation, hospitalization time, and hospitalization expense were statistically similar between the 2 groups. A literature review on gastric submucosal tumor resection suggested that the en bloc resection rates of the two methods for tumors with a median diameter of 15–30 mm were also high, and there were no relapses during the follow-up period. Conclusions: Both endoscopic nontunneling and tunneling resection seem to be effective and safe methods for removing relatively small gastric submucosal tumors. Compared with endoscopic nontunneling, tunneling resection does not seem to have distinct advantages for gastric submucosal tumors, and has a longer mean operative time.
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Diagnostic roles of calretinin in hirschsprung disease: A comparison to neuron-specific enolase p. 60
Zaidoon A Musa, Ban J Qasim, Haider F Ghazi, A. Wahab A. K Al Shaikhly
DOI:10.4103/1319-3767.199118  PMID:28139502
Background/Aim: Diagnosis of Hirschsprung's disease (HD) can be hard and requires good experience, principally for pathologists who infrequently encounter the disease. However, diagnosis is not always possible with hematoxylin and eosin (H and E) because staining has limitations in the identification of immature ganglion cells in neonates and the submucosal area. Aim: To assess the diagnostic role of calretinin immunostaining in HD in comparison to neuron-specific enolase. Patients and Methods: Formalin-fixed paraffin tissue blocks of full-thickness distal colonic and rectal biopsies for 48 patients who clinically presented with symptoms suspicious for HD were collected for the period from December 2012 to January 2016. All biopsies were already studied by routine H and E histopathological examination for the presence or absence of ganglion cells. Further confirmation of ganglion cells and nerve fibers was performed by immunohistochemical study for neuron-specific enolase and calretinin, respectively, in a private pathology laboratory. Results: According to the histopathological assessment, cases with absent ganglionic cells were considered to be HD, which comprised 40 cases out of the total 48 cases. The mean age for HD cases was 19.43 months. The male-to-female ratio in HD cases was 2.34:1. All HD cases showed negative expression of calretinin in small nerve fibers of the lamina propria, musularis mucosae, and submucosa, and negative expression of neuron-specific enolase in ganglionic cells. The sensitivity, specificity, positive predictive value, and negative predictive values for both the markers in the confirmation of diagnosis of HD were all 100%. Conclusion: Calretinin immunostaining, similar to that of neuron-specific enolase, is a highly sensitive and specific diagnostic aid to histopathological examination in suspected HD.
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CASE REPORT Top

Endoscopic resection of asymptomatic, colonic, polypoid arteriovenous malformations: Two case reports and a literature review p. 67
Han-Hee Lee, Hyuk-Min Kwon, Sanghyun Gil, Young-Shin Kim, Minjung Cho, Kyung-Jin Seo, Hiun-Suk Chae, Young-Seok Cho
DOI:10.4103/1319-3767.199111  PMID:28139503
A colonic arteriovenous malformation (AVM) is a significant vascular lesion of the gastrointestinal tract and a common cause of lower gastrointestinal bleeding. AVMs are usually identified endoscopically as bright red, flat lesions. AVMs with a polypoid appearance are extremely rare in the large intestine. We present two cases of colonic polypoid AVM, which were detected incidentally during screening colonoscopy. Both the patients had no history of gastrointestinal bleeding such as melena or hematochezia. Colonoscopy revealed pedunculated polyps overlaid by hyperemic mucosa in the ascending colon and proximal sigmoid colon. Microscopic examination showed aberrant vessels with thickened, hypertrophic walls in the mucosa and the submucosa, and arteries were directly connected to veins without capillary beds. These features were compatible with a diagnosis of AVM with a polypoid appearance. No immediate or delayed bleeding was noted after polypectomy.
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LETTER TO EDITOR Top

Building a hepatitis C virus treatment strategy to achieve the 2030 vision for Saudi Arabia p. 71
Bandar Al-Judaibi
DOI:10.4103/1319-3767.199119  PMID:28139504
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