Saudi Journal of Gastroenterology
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Year : 2016  |  Volume : 22  |  Issue : 7  |  Page : 1-24

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Date of Web Publication9-Feb-2016

How to cite this article:
. Abstracts. Saudi J Gastroenterol 2016;22, Suppl S1:1-24

How to cite this URL:
. Abstracts. Saudi J Gastroenterol [serial online] 2016 [cited 2022 Jan 20];22, Suppl S1:1-24. Available from:


Urinary Neutrophil Gelatinase-associated Lipocalin: A Predictor of Acute Kidney Dysfunction in Patients with Liver Cirrhosis

Abdulrahman Aljumah 1,7 , Hani Tamim 6,7 , Mohamed Saeed 1 , Waleed Tamimi 2 , Hanan Alfawaz 7,8 , Salem Al Qurashi 5 , Abdulaziz Al Dawood 4 , Abdulla Al Sayyari 3

1 Department of Hepatobiliary Sciences, Division of Hepatology, King Abdulaziz Medical City, National Guard Health Affairs, 2 Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, National Guard Health Affairs, 3 Department of Medicine, Nephrology and Renal Transplantation Division, King Abdulaziz Medical City, National Guard Health Affairs, 4 Department of Intensive Care, King Abdulaziz Medical City, National Guard Health Affairs, 5 King Saud Bin Abdulaziz University for Health Sciences, 8 Prince Mutaib Chair for Biomarkers of Osteoporosis, King Saud University, Riyadh, Saudi Arabia, 6 Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon, 7 Department of Food Science and Nutrition, College of Food Science and Agriculture

Background: Early detection of acute kidney injury (AKI) in cirrhotic patients could permit the institution of timely renal salvage therapies. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) has been identified as an early marker of AKI. Our objective is to evaluate whether serial uNGAL can be used as a marker and predictor of AKI in liver cirrhosis patients. Materials and Methods: This is a prospective cohort study of consecutive adult patients admitted to hospital with the diagnosis of liver cirrhosis. Serial uNGAL and serum creatinine (sCr) levels were measured daily for the first 6 days of admission. Further, sCr levels were measured after 3-6 weeks. The uNGAL levels in those who develop renal impairment (as manifested by sCr level above the normal range in our laboratory) were compared to those who did not. Results: Eight of 14 patients (57%) who developed abnormal uNGAL level also had concomitant abnormal sCr level (odds ratio [OR] = 3.4, 95% confidence interval [CI]: 0.99-12.03, P = 0.053). After 6 weeks, 41% of the patients had abnormal uNGAL level and concomitant abnormal sCr (OR = 6.7, 95% CI: 1.55-28.85, P = 0.0108). Area under the receiver operating characteristic (AUROC) curve and the best cut-off point for highest NGAL in 6 days were 0.64 and 72.55 ng/mL, respectively. Conclusion: There is a significant association between highest uNGAL in the first 6 days of admission and sCr at week 6 in all participants. This indicates that in cirrhotic patients, uNGAL level during the first 6 days of admission can predict the development of abnormal sCr and renal dysfunction 6 weeks later. The AUROC of 0.64 quantifies the overall ability of uNGAL to discriminate between those individuals who will have raised sCr levels and those who do not.


Clinical Presentation and Risk Factors of Hepatocellular Carcinoma in Saudi Arabia: A Tertiary Care Center Experience

Abdulrahman Aljumah 1,2 , Hadi Kuriry 3 , Mohammed Al Zunaitan 3 , Mohammed Al Ghobain 2,3 , Mohamed Al Muaikeel 2,4 , Ashwaq Al Olayan 2,5 , Fahad Azzumeea 2,4 , Bader Al Mutairi 2,4 ,

Abduljaleel Al Alwan 1,2 , Hamdan Al Ghamdi 1,2

1 Department of Hepatobiliary Sciences, Division of Hepatology, King Abdulaziz Medical City, National Guard Health Affairs, Departments of 3 Medicine, 4 Medical Imaging and 5 Adult Medical Oncology, King Abdulaziz Medical City, National Guard Health Affairs, 2 King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. In Saudi Arabia, HCC accounts for 4.8% of all cancers and for 82% of all liver cancers. Our objectives are to describe risk factors, clinical characteristics, treatment modalities and outcomes in Saudi patients with HCC. Patients and Methods: Data were collected retrospectively and patients were stratified according to the underlying risk factors for the development of HCC. Barcelona Clinic Liver Cancer (BCLC) was used for cancer staging. Treatment was classified into surgical resection/liver transplantation; loco-regional ablation therapy; trans-arterial embolization; systemic chemotherapy; and best supportive care. Results: A total of 235 patients were included. The mean age was 65 ± 10. Male subjects had significantly higher mean age, tumor size, and incidence of portal vein thrombosis. The most common risk factor was viral hepatitis (75.7%). The most common BCLC stages were B (34.5%) and A (33.6%), and the most common radiological presentation was a single nodule of >5 cm. Metastases were present in 13.2%. Overall, 77 patients (32.8%) underwent a potentially curative treatment as the initial therapy. The most commonly utilized treatment modality was chemoembolization with 113 sessions in 71 patients. The overall median survival was 15.97 ± 27.18 months. Conclusion: HCC in Saudi Arabia is associated with a high prevalence of hepatitis C virus and more common in older patients. Potentially curative therapies were underutilized in our patients. Cancer stage; BCLC - B, was the most frequent (34.5%) followed by BCLC - A (33.6%). The overall median survival was shorter than other studies.


Clinical Presentation, Treatment Outcome, and Predictors of Severity in Autoimmune Hepatitis: A Retrospective, Multicenter Experience

Abdulrahman Aljumah 1,2 , Abdulrahman Al Khormi 2,3 , Hamad Al-Ashgar 4 , Khaled Alsaad 2,5 , Khalid Bzeizi 6 , Nasser Al Masri 6 , Hamdan Al Ghamdi 1,2 , Abduljaleel Al Alwan 1,2 , Abeer Ibrahim 4 , Hadi Kuriry 3 , Ali Albenmousa 6

Department of Hepatobiliary Sciences, Division of Hepatology, King Abdulaziz Medical City, National Guard Health Affairs, 2 King Saud Bin Abdulaziz University for Health Sciences, 3 Department of Medicine, Division of Gastroenterology, King Abdulaziz Medical City, National Guard Health Affairs, 4 Department of Medicine, Section of Gastroenterology, King Faisal Specialist Hospital and Research Centre, 5 Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, National Guard Health Affairs, 6 Department of Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Background: Autoimmune hepatitis (AIH) is a chronic hepatitis of unknown etiology. It affects adults and children and can progress into cirrhosis. The aim of this study is to investigate the mode of presentation, predictors of severity, and treatment outcome of AIH in Saudi patients. Methods: This is a multicenter retrospective study that involved patients diagnosed with AIH from three tertiary hospitals. Clinical, biochemical, radiological, and histopathological data were collected and treatment outcomes were reported. Results: A total of 212 patients were included. Female:male ratio was 3:2, and the mean age was 36.2 ± 16.8 years whereas 50 patients (23.6%) were above age of 50. Abnormal liver function tests were found in (45%). Over one fourth of patients (28.8%) had cirrhosis at presentation and 30% presented acutely, however, fulminant disease was rare (2.8%). Antinuclear antibody and anti-smooth muscle antibody were negative in 65 (30.6%) and 74 (35%) patients, respectively. Pretreatment liver biopsies in 166 patients showed advanced fibrosis (Stage 3 and 4) in 63.3%. On multivariate analysis, platelets, alanine transaminase (ALT) level, and immunoglobulin G (IgG) level were predictors of fibrosis. Complete response was achieved in 74.5% whereas 9% had partial response and 16.5% had no response to treatment. Conclusion: The majority of AIH patients had advanced fibrosis at time of diagnosis and liver cirrhosis was found in nearly one-third of cases. IgG, ALT, and platelets were predictors of advanced fibrosis. Complete response to treatment was achieved in two-third of patients. Relying on autoimmune markers for diagnosis can be misleading.


Clinical and Virological Outcome of Entecavir Therapy in Patients with Chronic Hepatitis B

Abdulrahman A. Aljumah 1,2 , Nawaf A. Bin Selayem 2 , Sultan Y. Alhowti 2 , Mutasim Dafallah 1 , Hazem Mokhtar 1 , Hamdan Al Ghamdi 1,2 , Abdulkareem M. Albekairy 2,3 , Abduljaleel Al Alwan 1,2 , Ibrahim Altraif 1,2 , Faisal M. Sanai 2,4

Departments of Hepatobiliary Sciences and Liver Transplantation and 3 Pharmacy, King Abdulaziz Medical City, 2 King Saud Bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, 4 King Abdulaziz Medical City, Jeddah, Saudi Arabia

Background: Hepatitis B virus (HBV) is a life-threatening liver infection. Entecavir (ETV) is an effective treatment alternative for nucleos(t)ide analogue (NA)-naive patients due to its low resistance rates and potent antiviral effects. Studies on the treatment of HBV in Saudi Arabia are limited. We aimed to evaluate the clinical, biochemical, and virological response to ETV therapy in NA-naive patients versus those that failed prior NA in the treatment of chronic hepatitis B. Methods: A retrospective chart review was conducted for patients with hepatitis B who were seen at King Abdulaziz Medical City, Riyadh, during the period from 2008 to 2014. The comparison was made between patients treated with ETV only (Group A) and those with ETV + nucleos(t)ide (Group B). Complete response was defined as achieving undetectable HBV-DNA level up to 15 IU/ml, partial response (PVR) as 15-200 IU/ml, and >200 IU/ml for nonresponders (NR) after 1 year of therapy. Statistical analyses were performed using the Chi-square or Fisher's exact test. Results: Overall, 155 patients were included (69 in Group A and 86 in Group B) with a mean age was 52.3 ± 15.3 years, and 78% were males. In Group A, 85%, 13%, and 2% achieved Cr, PVR, and NR at 48 weeks of therapy versus 60%, 26%, and 14% in Group B, respectively (P = 0.013). Hepatitis B surface antigen (HBsAg) seroconversion was achieved in 17% in Group A versus 9% in Group B (P = 0.038). Hepatitis B e antigen seroconversion was 27% in Group A and 30% in Group B (P = 0.84) while alanine transaminase normalization was 100% in Group A versus 91% in Group B (P = 0.53). There was no difference in mortality between Group A (6%) and Group B (5%, P = 1.00). Conclusion: ETV therapy in chronic HBV results in a high virological response, with concomitant biochemical improvements. Higher rates of HBsAg seroconversions are achieved with ETV therapy in NA-naive patients as compared to prior NA failures.


Epidemiology, Disease Burden and Treatment Strategies of Chronic Hepatitis C Virus Infections in Saudi Arabia in the New Treatment Paradigm Shift

Abdulrahman A. Aljumah 1,2 , Faisal Abaalkhail 3,4 , Hamad Al Ashgar 4,5 , Abdullah Assiri 6 , Mohamed Babatin 7 , Faleh Al Faleh 8 , Abdullah Alghamdi 7 , Raafat Al-Hakeem 6 , Almoataz Hashim 3 , Adel Alqutub 9 , Homie Razavi 10 , Faisal M. Sanai 8,11 , Khalid Al Suwat8, Jonathan Schmelzer 10 , Ibrahim Altraif 1,2

Department of Hepatobiliary Sciences and Liver Transplantation, King Abdulaziz Medical City, 2 King Saud Bin Abdulaziz University for Health Sciences, National Guard Health Affairs, 3 Departments of Liver and Small Bowel Transplantation and 5 Medicine, King Faisal Specialist Hospital and Research Center, 4 Alfaisal University, 6 Preventive Medicine Directorate, Ministry of Health, 8 Liver Disease Research Center, King Saud University, 9 Medical Specialties Department, Gastroenterology and Hepatology Section, King Fahad Medical City, Riyadh, 7 Department of Medicine, Gastroenterolgy Unit, King Fahad Hospital, Jeddah, 11 King Abdulaziz Medical City, Jeddah, Saudi Arabia, 10 Department of Epidemiology, Center for Disease Analysis, Louisville, Colorado, USA

Background: Around 101,000 individuals are estimated to be viremic for chronic hepatitis C virus (HCV) in Saudi Arabia in 2014; however, only about 20% have been diagnosed (expert consensus). We aim to assess baseline epidemiology, disease burden and evaluate strategies to control or eliminate HCV in Saudi Arabia. Methods: The infected population and disease progression were modeled using age- and gender-defined cohorts to track HCV incidence, prevalence, hepatic complications, and mortality. Baseline assumptions and transition probabilities were extracted from the literature. The impacts of two scenarios on HCV-related disease burden were considered through increases in the treatment efficacy alone or treatment and diagnosis. Results: In 2030, it is estimated by the base scenario that viremic prevalence will increase to 103,000 (75,900-186,000) (2% change), hepatocellular carcinoma (HCC) prevalence to 470 (190% increase), decompensated and compensated cirrhosis cases by 510% and 185%, respectively, and liver- related mortality to 670 deaths (225% increase). Using high efficacy treatment alone, the projection in 2030, compared to the base scenario projection, would result in 22,100 fewer viremic cases (21% reduction), 350 fewer HCC cases (27% reduction), 480 fewer liver-related deaths (28% reduction), and 34% and 26% fewer decompensated and compensated cirrhosis cases, respectively. With an aggressive treatment strategy (more efficacious treatment and diagnosis), in 2030, there will be almost 100% fewer viremic cases (1,700), 100% fewer HCC cases, 95% fewer liver-related deaths, and nearly 100% fewer cases of decompensated and compensated cirrhosis compared to the base scenario projection. Conclusions: HCV in Saudi Arabia remains constant and cases of advanced liver disease and mortality continue to rise. Considered increases in treatment efficacy and number treated would have a significantly greater impact than increased treatment efficacy alone. The projected impact will facilitate disease forecasting, resource planning, and strategies for HCV management. Increased screening and diagnosis would likely be required as part of a national strategy.


Pancreatitis in the Eastern Region of Saudi Arabia: A 5-year Review from King Fahd Hospital of the University, Dammam

Alaskar Dimah, Hejles Rayan, Al-Sardi Mais, Abdulghani Sultana, Al Qurain Abdelaziz,

Al Sulaiman Raed, Bella Abdelhaleem

Department of Medicine, King Fahd Hospital of the University, University of Dammam, Dammam, Saudi Arabia

Background: In Saudi Arabia, acute pancreatitis (AP) is found to be different from that in the western countries. This study describes the epidemiology presentation and outcome of AP in the King Fahd Hospital of the University (KFHU), Dammam, in the period from 2004 to 2009. It also compares the results to four other studies concerning AP conducted in other areas of the country. Methods: This is a descriptive retrospective study based on a review of files of patients admitted for AP to KFHU from 2004 to 2009. The diagnosis was based on the rise in serum lipase/amylase three times the upper limit of normal. The analysis included 89 patients with a total of 96 admissions. Results: Over the 5 years period, there were 96 cases of acute pancreatitis (AP). 41 were males (43%) and 55 were females (57%). The male to female ratio is 1:1.3. Their ages ranged between 15 and 90 years old with an average of 42.7 ± 16. Majority of the patients were Saudi 59%. Patients presented with the cardinal symptoms; abdominal pain in 99% is radiating to the back in 53%. On examination, 82% had epigastric tenderness and only 22% had jaundice. Regarding the etiology, biliary pancreatitis is found to be the most common diagnosis (58%). In this study, patients labeled as idiopathic and unknown pancreatitis will be considered as pancreatitis of unknown etiology with a total of 35%. One patient developed drug-induced pancreatitis secondary to Imuran. AP was associated with co-morbidities, and the most common was gall stones in 50 cases. About 86% of recurrent pancreatitis cases had gall stone disease, 43% had diabetes mellitus type 2, and 29% were obese. As for the outcome, 14 patients had complications. In total, there were five Intensive Care Units admissions resulting in only one mortality. Conclusion: AP was found to occur predominantly in females with an average age of 45. The most common symptom was abdominal pain, and the most common sign was epigastric tenderness. Biliary pancreatitis was found to be the most common etiology. The low morbidity and mortality, in this study, may reflect the early recognition of the disease and hence better management.


Jaundice in a Patient with Von Recklinghausen's Disease

Nada Al Quorain, Abdelhaleem Bella, Mohammad Anas, Abdulaziz Al Quorain

King Fahd Hospital of the University, Al-Khobar, Saudi Arabia

Neurofibromatosis (NF) is a multisystem disease with autosomal dominant inheritance. It presents with multiple cutaneous neurologic and orthopedic manifestations. NF type 1 (NF-1) has a better prognosis than NF type 2 (NF-2), and results from a mutation or deletion of the NF-1 gene with reduced production of neurofibromin (a tumor suppressor gene). This may be associated with increased risk of malignancy. We discuss a young Saudi gentleman with NF-1 who presented with Jaundice. Case Report: A 32-year-old Saudi gentleman who is known to have NF-1, hypertension, and sickle cell trait was referred to our institute with a 1-month history of right upper quadrant pain, jaundice, nausea, vomiting, pruritus, and dark urine. He had no fever, anorexia, or weight loss. On examination, he was jaundiced and had the cutaneous features of NF. An examination of the abdomen revealed an enlarged and tender liver with no ascites or splenomegaly. His liver biochemical profile showed cholestatic pattern. The imaging of the abdomen including ultrasound, computed tomography T scan and magnetic resonance imaging showed enlarged liver, dilation of the pancreatic and common bile ducts, and two masses in the porta hepatis and ampulla of Vater as well as a thoracic mass. An endoscopic retrograde cholangiopancreatography was done and showed an edematous ampulla with friable mucosa. Papillotomy was done, followed by stent placement and drainage. Following this, the patient had Whipple's procedure with removal of the tumor. The histopathology was consistent with neurofibroma (benign neurogenic tumor). Discussion: Neurofibroma presenting with jaundice is still a rare clinical entity which poses difficulties in terms of early diagnosis and therapy. Including our patient, there are only 10 patients in the medical literature describing the association of neurofibroma and the obstructive jaundice. In Morris's 2, the main cause of obstruction was multiple hepatic artery aneurysms although there was a huge retroperitoneal neurofibroma found. The cases call for an early consideration of this possibility in patients with neurofibromatosis.


Awareness of Colorectal Cancer Among Inflammatory Bowel Disease Patients at King Khalid University Hospital from 2013 to 2014

H. Alsubaie, L. Alahmari, J. Alshenaifi, R. Alanazi, O. Alharbi

King Saud University Hospital, Riyadh, Saudi Arabia

Background: Colorectal cancer (CRC) is documented to be the second most common cancer in Saudi Arabia. Inflammatory bowel disease (IBD) patients are at the higher risk for developing CRC as compared to the general population; it is also found to be the most common cancer among them. This study presents the awareness of CRC among IBD patients in Saudi Arabia. Aim: To assess the awareness of CRC among IBD patients attending King Khalid University Hospital. Methods: A quantitative, observational, cross-sectional designed study was conducted at KKUH, Riyadh, Saudi Arabia, from 2013 to 2014 using telephone-interview administered questionnaires to the patients who were purposively selected. An estimated sample of 384 was calculated using the standard equation. Patients' confidentiality was maintained. Results: Prompted awareness of CRC symptoms and risk factors was much higher than unprompted awareness. When asked about risk factors, nearly 48% of patients could not recall any risk factors without aided. Overall, the most commonly identified risk factor for CRC unaided was IBD (27.1%) and it was followed by diet (20.5%). Out of all patients, aid was needed by over half of the patients (58.4%) to recognize IBD as a risk factor. While on the other hand, 14.5% could not identify or did not know whether their own disease (IBD) is a risk factor for CRC. Conclusion: Results from our study showed that the overall awareness of CRC symptoms and risk factors among Saudi IBD patients was poor. However, the knowledge toward CRC symptoms was observed higher than knowledge of risk factors. Customization of health-promotion programs for IBD patients is urgently needed to raise the awareness of their own increased risk of developing CRC.


Solitary Rectal Ulcer Syndrome: A Single-center Case Series

Abdulaziz Al Ghulayqah, Ehab Abu-Farhaneh, Fahad Alsohaibani, Majid A. Almadi, Hadeel Al Mana

King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Background: Solitary rectal ulcer syndrome (SRUS) is a benign and chronic defecation disorder with a wide variety of presentations. The aim of the study is to summarize the clinical features, pathophysiology, diagnostic methods, and treatment strategies associated with SRUS in Saudi Arabia. Methods: This is retrospective study of all patients diagnosed with SRUS at KFSHRC in Riyadh from January 2003 to December 2013. Cases were identified using the department of pathology database. Data were abstracted from medical records and included clinical manifestation, endoscopic findings, and histopathological features. Results: Twenty patients were identified. The mean age was 42.5 years (±18.5) and 55% were females. Most of the patients presented with bleeding per rectum (85%), constipation (75%), and straining (50%) with a mean duration of 26.7 months. The most common risk factor identified was constipation (75%), digital rectal manipulation (20%), rectal prolapse (20%), and rectal trauma (5%). Endoscopic findings included a single ulcer (50%), multiple ulcers (30%), while 55% had a polypoidal appearance. On histopathologic examination, 94 % had surface ulcerations, 70.6% had fibrosis of the lamina propria, 65% had distorted architecture, and rectal wall involvement was seen in 45%. Muscle hypertrophy and increase in the mucin production was noted in 59% of patients. Serrated crypts were seen in 18%. All the patients were treated with conservative management and none required surgery. Most were treated with stool softeners and/or a high fiber diet, and 20% were treated with mesalamine either orally or topically. Budesonide foam was used in 10% while 15% with persistent symptoms had behavioral therapy in the form of biofeedback training. Conclusion: SRUS is a rare disorder with variable clinical presentations. Most of our patients have a history of chronic constipation and majority of them had polypoidal appearance on endoscopic examination and surface ulceration on histology. The mainstay of treatment is stool softeners and high fiber diet, in addition to topical mesalamine and biofeedback.


Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collection Secondary to Posttraumatic Acute Pancreatitis in Pediatric Age Group

Abdulrehman Al Robayan, Taymoor Masood Khan

Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Background: Acute pancreatitis with pancreatic fluid collection (PFC) collection is rare in children and management is challenging. Methods: Four patients (mean age ± standard deviation [SD], 7.6 ± 2.9 years) with acute pancreatitis and PFC following blunt abdominal trauma were managed in our center. All cases were appropriate for endoscopic ultrasound (EUS) guided-transgastric drainage. Results: Transgastric EUS drainage was technically successful in all cases. One patient had recurrence of PFC due to stent migration. There were no other procedure-related complications. All patients were asymptomatic on long-term follow-up of 49 ± 38.3 (mean ± SD) months. Conclusions: EUS-guided drainage of PFC was successful in pediatric patients with acute traumatic pancreatitis. We report a series of the youngest cohort, with 100% clinical success rate and no recurrence in long-term follow-up.


Colonoscopic Findings in Average Risk Saudi Subjects with Positive Fecal Occult Blood, Preliminary Report

AM Al Akwaa, A.M. Elsadig

King Abdulaziz Hospital, National Guard Health Affairs, Al Ahsa, Saudi Arabia

Background: Fecal occult blood test is a standard test used globally to screen for colon cancer and advanced adenoma. Aim: To determine the outcome of colonic examination in patients with positive fecal occult blood. Methods: Retrospective study reviewing the charts and colonoscopy reports for all patients who tested positive for guaiac and underwent colonoscopy. The demographic data, colon preparation status, and endoscopic finding were recorded. All patients had Moviprep plus Dulcolax protocol. Results: A total of 78 subjects have been included in the study. 59% of them were males. The mean age 55 years (range 26-98). 83% are aged 44-70. The main indication for the examination was screening after positive occult blood. Colon preparation was good and satisfactory in 97%. Complete examination achieved in 96%. The findings were small polyp 25.7, large polyp 2.7%, cancer 4.1% other findings; diverticula 9.6%, colitis 8.2%, piles 12.3%, ulcers 1.4%, and normal 33.8%. About 86% of polyp found in ages 49-59 years. Histology revealed adenoma 15%, hyperplastic polyp 7%. Pathological findings were more located rectum and left colon 47.4%. Cancer was found in extreme age. No pathology in subject <49 apart from piles. Conclusion: Although the majority of patients were referred for screening colonoscopy, the prevalence of polyp and the advanced polyp is low compared to other reports. No serious pathology in Saudi subjects less 50 years. The sample size of the cohort is small. Therefore, we will continue it with larger prospective sample.


Adult Hereditary Fructose Intolerance

Mohamed Ismail Yasawy, Dimah Alaskar, Mais Al Sardi, Rayan Hejles, Sultana Sami Abdulghani

King Fahd Hospital of the University, KFHU, Dammam, Saudi Arabia

Background: Hereditary fructose intolerance (HFI) is an under-recognized, preventable life-threatening condition. It is an autosomal recessive disorder with subnormal activity of Aldolase B in the liver, kidney, and small bowel. Case: A 50-year-old German woman presented with a long life history of aversion to sugary foods. She described nausea, vomiting, diffuse abdominal pain, and hypoglycemic symptoms even after the smallest amount of sugar or fruit. Her 2-year-old brother died after receiving an intravenous infusion in hospital. On examination, she had mild thoracic scoliosis with no neurological defect. Otherwise, physical examination was unremarkable. Results of laboratory investigations were all within normal. A fructose tolerance test (FTT) was performed, and a typical abnormal FTT was observed after the infusion. The diagnosis was further confirmed by histochemical analysis of an endoscopic biopsy specimen from the small intestine, which showed 70% reduction in Aldolase B activity in the mucosa, and molecular analysis of leukocyte DNA using polymerase chain reaction amplification revealed that she had inherited two doses of the mutant gene, one from each parent, as the cause of the disease. Discussion and Conclusion: The accumulation of fructose 1-phosphate results in inhibition of other enzymes, namely, phosphorylase, liver fructose 1-6 bisphosphate aldolase, and fructokinase. This results in impaired glycogenolysis and glyconeogenesis and may induce hypoglycemia. Our patient is alive at the age of 50 years with previously undiagnosed HFI and did not have complications of the disease. This patient illustrates the importance of a careful dietary history and awareness of disease symptoms to avoid complications.


An International Multicenter Prospective Observational Study to Evaluate the Epidemiology, Humanistic and Economic Outcomes of Treatment for Chronic Hepatitis C Virus in Saudi Arabia

Mohamed Q. Khan, Mohamed A. Babatin 1 , Faisal M. Sanai 2 , Nasser Al Masri 3 , Salem M. Bazarah 4

The King Faisal Specialist Hospital and Research Centre, 2 King Abdulaziz Medical City, 3 Prince Sultan Military Medical City, Riyadh, 4 King Abdulaziz University, Soliman Fakeeh Hospital, 1 King Fahd General Hospital, Jeddah, Saudi Arabia

Background/Rational: In this study, we aim to characterize patients with chronic hepatitis C virus (HCV) infection and assess the impact of interferon (IFN)-containing treatment on health-related quality of life, work-related productivity, and activities of daily living and healthcare utilization. Methods: Multicenter prospective observational study to evaluate the Epidemiology, Humanistic and Economic Outcomes of Treatment for Chronic Hepatitis C Virus in Saudi Arabia (MOSAIC) is an international prospective multicenter observational study that is conducted in 20 countries. Consecutive patients with chronic HCV infection were enrolled, and we report baseline results from Saudi cohort those who initiated an IFN-based treatment within 12 weeks of enrolment are prospectively followed for 48 weeks after start of the treatment. Patient management and all treatment regimens were selected according to the physician's judgement with documented assessments at 4, 12, and 48 weeks. Results: A total of 126 Saudi patients were enrolled; the mean age was 51.4 years with a sex ratio (male:female = 51:49). Overall, 13 (10.3%) patients had portal fibrosis, 12 patients (9.5%) bridging fibrosis, and 50 (39.7%) cirrhosis; for 28 patients (22.2%) fibrosis stage was unknown. Of enrolled patients, 56.35% were treatment-naïve and 43.65% were experienced. HCV genotype distribution was: GT1: 43.8%; GT2: 1.8%; GT3: 5.4%; GT4: 49.1%; and unknown 10.3%. Among the genotype 1 group, subtype distribution was: GT1a: 15.1%, GT1b: 11.9%, and unknown 11.9%. Overall, 93 had not started IFN containing treatment. For 78 of these patients, the rationale for not starting treatment was available. The main reasons for not starting antiviral treatment were the anticipated availability of future IFN-free antiviral treatment regimen 38.7%, contraindication to IFN 15.1%, presumed tolerability issue 14%, and presumed lack of efficacy 10.8%. In total, 33 (26.19%) patients initiated an IFN-based regimen within 12 weeks of enrolment: DAA + peg-IFN + RBV for 5 (15.15%), peg-IFN + RBV for 14 (42.42%), IFN + RBV for 1 (3.03%), and for 13 of them another IFN-containing treatment regimen was initiated (39.39%). Conclusion: Despite the presence of advanced degree of fibrosis, 75% of patients were not planning to start an IFN-containing treatment regimen. The main reason for not starting treatment was reported to be the anticipated availability of an IFN-free treatment regimen.


Predictors of Failure of Endoscopic Retrograde Cholangiopancreatography in Clearing Bile Duct Stones

M Eltayeb, MA Almadi, A Aljebreen, FA Al Rashed, M Al Jebreen, M Malik, O Alharbi, N Azzam, S Thaniah

King Khalid University Hospital, Riyadh, Saudi Arabia

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is performed worldwide as a first approach in the management of bile duct stones (BDSs). Identifying predictors for this failure might be helpful in selecting patients who are likely to benefit from other treatment modalities for BDS. Methods: Retrospective study included 426 patients who underwent ERCP for extraction of BDS during the period January 2008 to January 2015 at a Tertiary Hospital in Riyadh. Results: A total of 552 ERCPs were performed to extract BDS from 426 patients with a mean age of 46.3 ± 18.9 years, 57% of them were females. BDS clearance failed in 44 (10.3%) patients. The rate of successful bile duct clearance in the first session was 80.3% (341 patients) and 56% (47/84 patients) in the second session for the second procedure. ERCP failed to clear BDS in 48% of patients with stone size more than 15 mm (P < 0.0001). Failure to clear bile duct was significantly higher in patients with associated stricture compared to patients without bile duct stricture (P < 0.01). Use of mechanical lithotripsy and papillary balloon sphincteroplasty were significantly associated with successful BDS clearance (P < 0.01). Independent contributors to the failure of bile duct clearance on multivariate analysis were bile duct stricture, odds ratio (OR) = 9.186, confidence interval (CI): 1.013-83.327 P = 0.049; and BD stone(s) diameter >15 mm, OR = 0.126, CI: 0.017-0.93 P = 0.04. Conclusion: Conventional ERCP failed to clear BDSs in around 10% of patients. Independent factors that predict failure include the stone size of more than 15 mm and common bile duct stricture.


Influenza Vaccinate Uptake in Liver Transplant Recipients

Mohammed Aljawad, Paul Marotta, Karim Qumosani, Bandar Aljudaibi

King Fahad Specialist Hospital, Dammam, Saudi Arabia

Background: Influenza infection is a major source of morbidity and potential mortality particularly in those who are immunosuppressed. Annual influenza vaccine for solid organ transplant recipients has been endorsed by major medical societies. The goal of this study is to assess the uptake of influenza vaccine in short and long-term liver transplant recipients and to explore barriers to vaccination. Methods: A three-page survey was distributed to all adult liver transplant recipients attending the liver transplant clinic at London Health Science Centre (London, Ontario) from July to September 2014. Results: 106 consecutive patients completed the survey. The median age was 58.5 years; 65% were male; average time since liver transplant was 6 years. The underlying liver disease was autoimmune liver diseases in 36%, hepatitis C in 27%, distant alcohol misuse in 11%, combined hepatitis C and alcohol misuse in 9%, and other causes accounted for 18%. Majority of participants (80%) were on at least dual maintenance immunosuppressive therapy. Of all those surveyed, 48 (45%) did not receive the influenza vaccine within the last 12 months. The main reasons for not receiving the vaccine: (1) Lack of awareness for the need (40%), (2) advised against the vaccine by a health care provider (18%), and (3) was not offered (10%). Conclusion: Annual influenza vaccination is recommended to all solid organ transplant recipients. In this single center snapshot experience, just over half patients at risk received vaccination. The remainder site reasons for omission that all relate to communication within the health care system. Thus, further education to health care providers concerning the need and recommendations for annual influenza vaccination should help improve the uptake in this at-risk group.


Isolated Retropancreatic Tuberculous Lymphadenitis Mimicking Carcinoma: A Diagnostic Challenge

H Kuriry, R Alenezi, A Swied

King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background: Extrapulmonary tuberculosis (EPTB) represents around 10-25% of all TB cases and this proportion varies between counters. EPTB as the cause of obstructive jaundice is a rare entity with only a few cases reported in the literature. Patients with this condition usually present with a protracted illness, jaundice, and weight loss, which may be confused with malignancies. Case Report: We are reporting an unusual case of the isolated enlarged tuberculous lymph node in the retropancreatic region, and causing obstructive jaundice in a 20 years old immunocompetent patient. He was complaining of right upper quadrant abdominal pain associated with decreased appetite, yellowish discoloration of the sclera, itching, pale stool, and dark urine for 1 month. Endoscopic ultrasound with fine needle aspiration showed a large hypoechoic mass mixed with hyperechoic spots and septations, measuring 4 cm × 4.7 cm, sets in the retropancreatic area. Cytopathological examination showed necrotizing granulomatous lymphadenitis. TB-polymerase chain reaction (PCR) for Mycobacterium tuberculosis complex was positive. Patient condition improved after initiation of antituberculous therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol regimen. Conclusion: Isolated peripancreatic tuberculous lymphadenitis is extremely rare. It is a diagnostic challenge and for that, a high index of suspicion is needed and should be considered in the context of the peripancreatic or pancreas head mass in the endemic area, especially in a young adult. EUS guided-FNA cytology and biopsy are an excellent diagnostic modality. The combination of histologic features, microbiologic examinations including Ziehl-Neelsen stain and TB culture in addition to TB-PCR assay will improve the yield of diagnosing peripancreatic and pancreatic TB.


Neurological Complications Among Pediatric Postliver Transplant in King Abdulaziz Medical City-Riyadh

Alanoud Al-Marzoug, Hala Al-Marzoug, Abdullah Al-Zaben, Ahmed Al-Rumayyan

National Guard Hospital, Riyadh, Saudi Arabia

Background: Liver transplantation (LT) is an effective treatment for children with liver disease. Postoperative neurological complications (NCs) are common among LT recipients. The aim of this study is to identify the NCs as well as determine the predictors of these complications among pediatric post-LT in King Abdulaziz Medical City, Riyadh. Methods: Case-control study was conducted on 54 pediatric patients who had LT aged ≤14 years old. Charts were reviewed from 2001 to 2014. Patients who had NCs post-LT were identified as cases n = 12 and who did not have NCs post-LT were identified as controls n = 42. Analysis was conducted using SAS version 9.2. Results: The mean patients' age at the time of LT was (4.42 ± 0.52) year. Females were 28 (51.85%) and males were 26 (48.15%). The most common indication of LT was progressive familial intrahepatic cholestasis followed by biliary atresia. NCs after LT was seen in 12 patients, 4 (33.33%) of them had neurological manifestations before LT. All patients who underwent LT were jaundiced 54 (100%). There were significant difference between cases/controls in preoperative hepatic encephalopathy P = 0.008 and preoperative neurological manifestations P = 0.017. The most common NC post-LT was seizures 9 (52.94%) followed by encephalopathy 4 (23.53%) and weakness 4 (23.53%). There was a significant difference between the two groups in pre- and post-transplant INR P = 0.003 and P = 0.015, respectively. None of the associated risk factors (patient's age, gender, and postoperative Mg) were significant predictors for developing NCs after LT. Conclusion: NCs are common among children after LT. Early detection and management are of extreme importance.


Laparoendoscopic "Rendezvous" for Concomitant Cholecystocholedocholithiasis: A Successful Modality Even in the Most Difficult Presentations

Shirah Bader, Yaser Mohammed Dahlan, Z Mikwar, Ahmad Akram

King Khalid Hospital-King Abdulaziz Medical City, Jeddah, Saudi Arabia

Background: The "laparoendoscopic rendezvous" (LERV) technique is emerging as a preferred treatment option for concomitant cholecystocholedocholithiasis. In this paper, we report our experience in performing the rendezvous technique in patients with unusual presentations in terms of anatomical difficulty, pregnancy, multiple comorbid diseases, and post laparotomy. We aim to highlight the effectiveness of the rendezvous technique in some clinical situations where conventional methods would fail or carry high risks in adequately managing concomitant cholecystocholedocholithiasis. Methods: Four patients diagnosed to have concomitant cholecystocholedocholithiasis with associated difficult presentation or comorbid diseases were treated using the LERV technique. One patient presented with difficult anatomy where endoscopic retrograde cholangiopancreatography failed at initial attempts. Another patient was pregnant (first trimester). The third patient had complex comorbid diseases (bronchial asthma, hypertension, congestive heart failure, and end-stage renal disease on regular hemodialysis). The fourth patient had previous laparotomy and sigmoidectomy for diverticular disease. Results: All patients tolerated the LERV technique very well, with short hospital stay and no complications. Postoperative morbidity was (0%), and postoperative mortality was (0%). Conclusion: Based on our experience, the LERV procedure is a safe and effective alternative to conventional management of concomitant cholecystocholedocholithiasis. Even in difficult cases considered to be high-risk, there were no postoperative complications or mortality. More scientific studies recruiting more patients with other difficult presentations should be done to standardize the LERV procedure.


Colitis in Colonoscopies Patients at a Primary Health Center in Riyadh, KSA

MA Bajubair

Department of Internal Medicine and Gastroenterology, Faculty of Medicine, University of Sanaa, Yemen

Background: Colitis is the inflammation of the colon. There is a variety of causes of colitis including infections, ischemia, and autoimmune reactions (inflammatory bowel disease [IBD]). Our aim was to determine the clinical, epidemiological, the prevalence of various colonic diseases and characteristics of colitis in patients undergoing colonoscopy in a primary health center in Saudi Arabia. This data may provide a comparison for researchers. Methods: Data from colonoscopized patients attending a gastroenterology clinic, primary health center in Riyadh, KSA between July 2014 and July 2015 were studied. This including the record of patient characteristics, age at diagnosis, course of the disease, manifestations, colonoscopy, and histopathology reports. Results: Among 100 patients, males comprised 90% and only 10% females. According to the Montréal classification of age, the majority of our patients belonged to the A2 category for the age of diagnosis at 17-40 years 63% versus 72% of the colitis patients and 50% of IBD patients, while 36% belonged to the A3 category >40 years. Normal colonoscopy was seen in most of our series cases, and anorectal diseases (piles and fissures) were in 16%. Biopsies showing colitis in 11% of cases, 7% nonspecific, and 4% IBD (ulcerative 3% and crohns 1%). Colonic mass and cancer in 5%. Diverticula in 4% and polyps in 3%. Mean of age for the colitis patients was 36.1 years and 29 years for IBD. Conclusion: The majority of colonoscopized cases were young people similar to the colitis and IBD cases, with a male preponderance. Colitis represented more than one-tenth of cases with Ulcerative colitis more than Crohns disease in 3:1 manner.


Venous Thromboembolism Prophylaxis among Gastroenterology Patients in King Abdul-Aziz University Hospital, A Cross-Sectional Snapshot Analysis

W Alotaibi, B Albeirouti, B Alamri, E Alrehaili, N Mahde,

D Elshiekh

King Abdulaziz Hospital University, Jeddah, Saudi Arabia

Background: Venous thromboembolism (VTE) is a common condition among hospitalized patients and comprises a life-threatening condition pulmonary embolism, which is a process of deep vein thrombosis. In this literature review, we summarize the clinical data and discuss the VTE prophylaxis in gastrointestinal (GI) disease focusing on viral infections in the liver disease, GI bleeding, and inflammatory bowel disease among nonsurgical condition in King Abdulaziz University Hospital (KAUH) 2015. Methods: Using snapshot analysis looking at the use of VTE prophylaxis among gastroenterology medical patients at KAUH. Student Investigator Program of VTE prophylaxis Group collected the data on 3 rd of October 2015, after hajj holiday. Our data based on which VTE prophylaxis was taking among gastroenterology patients in the medical ward. Ethical approval was obtained, with no conflict of interest. All patients who were admitted to the medical ward on that day at KAUH were included in the study. Results: In October 3 rd of 2015, a snapshot analysis shows 25% at high-risk of VTE and the other 75% with low-risk. About 100% of high-risk was on VTE prophylaxis while 66.7% of low-risk patient was on VTE prophylaxis the rest 33.3% not on prophylaxis. Conclusion: As we find there is a strong association between VTE and GI diseases, especially among viral hepatitis, inflammatory bowel disease, and GI bleeding and there is a good level of adherence. We recommend starting risk assessment model as stander in gastroenterology patients among KAUH.


Lung Transplantation Triggered "Jackhammer Esophagus": A Case Report

MQ Khan, IY Nizami, JK Basha, HI Al-Ashgar

Section of Gastroenterology, 1 Section of Lung Transplant, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

A 19-year-old girl was referred for lung transplant due to end stage lung disease secondary to idiopathic bilateral bronchiectasis. Her routine prelung transplant evaluation showed normal esophageal high-resolution manometry (HRM) and 24-h impedance-pH monitoring. One month after the bilateral sequential lung transplantation (LTx), she developed dysphagia, chest pain, and regurgitation, complicated by aspiration pneumonia. Repeated HRM showed Jackhammer esophagus, delayed gastric emptying, and abnormal 24-h impedance-pH monitoring consistent with the diagnosis of gastroesophageal reflux disease (GERD). Three months after LTx, she was symptom-free on esomeprazole, HRM and 24-h impedance-pH monitoring returned to normal. The pathophysiology of this rare esophageal hypercontractility disorder remained obscure, but the possible etiopathogenesis includes hypercontractility precipitated by GERD, initiated by stress-induced surgical trauma, exaggerated by prokinetic drugs, or occurred due to partial vagotomy during LTx that lead to esophageal dysmotility and gastroparesis. To the best of our knowledge, this rare transient esophageal hypercontractility episode occurred after LTx and recovered without any specific treatment was never reported in literature.


Utility of Video Capsule Endoscopy in Clinical Practice, Experience at King Faisal Specialist Hospital and Research Center

Feras Aljemeeli, MQ Khan, Fahad Al-Sohaibani,

Aymen Al Muhaidb, Saad lshareef, M. Shoukri,

Adnan Al-Mahrouq, Hamad Al Ashgar

King Faisal Specialist Hospital Research Center, Riyadh, Saudi Arabia

Background: Video capsule endoscopy (VCE) is a powerful diagnostic tool that has proven, especially useful for imaging the small intestine. VCE technology offers greater magnification than traditional endoscopy while also providing excellent resolution. It is a clinically useful tool for detecting occult bleeding and superficial lesions that are not radiographically observed; it may also provide functional information as the capsule moves passively through the small intestine. VCE has been favorably compared with push endoscopy in patients with obscure gastrointestinal (GI) bleeding. VCE appears to have a clinically relevant positive impact on patient treatment and outcome. Aims and Objectives: We aim to evaluate its role as a diagnostic tool for a number of GI diseases as well as its possible complications. Study findings could be used as parameters that would aid in the design of possible future prospective studies. Patients and Methods: We performed a retrospective chart review on 227 patients who had undergone capsule endoscopy in King Faisal Specialist Hospital and Research Center. The collected data included demographic data, indications, capsule findings, and interventions following VCE. The complete vision of the small bowel was achieved in 126 (55.5%) of the patients. Results: No small-bowel lesions were identified in 75 (33.04%) patients. Patients who were referred with GI bleeding comprised 126 (55.51%), 46 (20.26%) of whom had angiodysplasia, 4 (3.23%) had bleeding ulcers, 29 (23.39%) had nonbleeding ulcers, 19 (15.32%) had unidentified bleeding sites, and 14 (11.29%) had unspecified erythemas. Study was deemed as technically difficult in 28 (12.33%) of patients. A number of patients who experienced capsule retention were 10 (2.64%). In case of GI bleeding, VCE was considered successful in 61 (48.41%) patients. However, 56 patients were referred for further investigations in the form of double-balloon enteroscopy/push enteroscopy/imaging studies. Conclusion: VCE was an effective tool for detecting lesions related to GI bleeding. This effectiveness, however, was noticed more in patients who underwent better preparation. Unremarkable VCE can be reassuring.


Prospective Assessment of Esophageal Function Tests in Patients with Advance Pulmonary Disease undergoing Lung Transplantation

Mohammed Qaseem Khan, Imran Y. Nizami, Akram Saeed 1 , Hatem Elabd 1 , Zaid Alyami
, Fahad Al-Sohaibani, Hamad Al-Ashgar

Section of Gastroenterology, 1 Section of Lung Transplant, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Background: Numerous small observational studies have shown that gastroesophageal reflux (GER) and esophageal dysmotility is prevalent among patients with end-stage pulmonary disease (ESPD). Aims: To determine the prevalence of esophageal dysmotility and GER disease (GERD) in pretransplant ESPD patients. To assess whether the presence of upper gastrointestinal symptoms in pretransplant ESPD patients can predict abnormal results of diagnostic testing. Methods: This prospective pilot study was performed between 2012 and 2015 at King Faisal Specialist Hospital and Research Centre, Riyadh. In total, 71 consecutive adult patients were evaluated during the study period before the lung transplantation. 58 patients underwent esophageal high-resolution manometry (HRM) studies and 51 finished 24-h impedance-pH monitoring (49 completed both the tests). The HRM recorded the resting lower esophageal sphincter (LES) pressure, integrated residual pressure, mean distal contractile integral, and distal esophageal amplitude 3 cm above LES. The 24-h pH-impedance monitoring recorded the mean percent time pH clearance, DeMeester score, number of distal/proximal acid and non-acid refluxes, total percentage of bolus exposure time, symptoms index, and Symptoms Association Probability. Results: The most common causes of advanced lung disease were interstitial lung disease (25), bronchiectasis (11), cystic fibrosis (6), scleroderma (6), sarcoidosis (4), and others (7). The abnormal HRM and impedance-pH results are shown in Table 1. Conclusion: There was a high prevalence of esophageal dysmotility and GERD in ESPD patients being evaluated for lung transplantation. About one-third of ESPD patients were positive for either esophageal dysmotility or quantitative reflux testing was asymptomatic.


A Prospective Study of Efficiency/Patient Experience with Anesthesiologist Assisted Sedation for Colonoscopy

Patrick Thornley, Mohammad Al Beshir, James Gregor, Andreas Antoniou, Nitin Khanna

King Fahad Specialist Hospital - Dammam, Dammam, Saudi Arabia

Aim: To determine whether anesthesiologist-administered sedation with propofol (AAP) or endoscopist-administered conscious sedation (EAC) with fentanyl/midazolam shortens colonoscopy duration/total room time. Methods: This is a prospective, nonrandomized, comparative study that enrolled patients >18 years of age undergoing colonoscopy in single Canadian Academic Outpatient Endoscopy Unit over a 3-month consecutive period. Patient demographics, procedure-related data, and adverse events were documented. A validated modified four-question, five-point Likert scale telephone survey was used to assess patient satisfaction with colonoscopy. Results: A total of 230 patients were enrolled during the period with 126 patients in the AAP group and 104 patients in the EAC group. Mean procedure time was 18.3 ± 10.1 min in the AAP group and 14.7 ± 7.1 min in the EAC group (P = 0.002). Mean total room time was 36.8 ± 13.7 with AAP and 30.1 ± 11 min with EAC (P < 0.001). Multivariate analysis revealed the use of AAP (P = 0.002), resident participation (P < 0.001), diagnostic interventions (P = 0.033), therapeutic interventions (P < 0.001), lower body mass index (P = 0.008) and American Society of Anaesthesiologist Class (P = 0.016), to be predictors of longer total room time. Patient age and gender were not significant predictors. After excluding cases in which trainees were involved, there was no significant difference in procedure time between the two groups (P = 0.941). However, total room time was still prolonged in the AAP group (P = 0.019). The amount of pain experienced was lower with AAP (P = 0.02), with a trend toward overall higher patient satisfaction (P = 0.074). There were 2 sedation-related adverse events, both in the AAP group. Conclusion: EAC results in reduced total room time compared to AAP. Resident participation doubles procedure time regardless of sedation type.


Autoantibodies in Hepatitis C Virus Infected Patients and Their Association with Hepatic Fibrosis: A Retrospective Analysis

F. Eltayab, S. Abbarah, M. Alamari, N. AL-Masri, K. Bzeizi, A Al Mdani, A. Albenmousa

Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Introduction: Positivity of autoantibodies, particularly anti-nuclear antibody (ANA) and anti-smooth muscle antibody (ASMA), is frequently encountered in hepatitis C virus ( HCV) infected patients. The clinical importance of this observation was investigated in some studies with conflicting results. Moreover, the relevance of positive ANA and/or ASMA in genotype 4 HCV patients has not been studied previously. Aims: To investigate the association of positive ANA and/or ASMA on the severity of fibrosis in HCV-infected patients in Saudi Arabia. Patients and Methods: Retrospectively, HCV-infected patients with positive ANA and/or ASMA (Group 1) were compared to a control of HCV patients with a negative autoantibodies (Group 2). The primary endpoint was the prevalence of advanced fibrosis at the time of presentation. Results: We included 241 patients in the study with a mean age of 50.6 ± 14.3 years and 49.8% were males. Group 1 had 81 patients while Group 2 had 160 patients. Group 1 had more females (60.0% vs. 45.3% P = 0.032) and younger patients (53.3 ± 13.3 vs. 49.2 ± 14.7 years, P = 0.037). At the time of presentation, advanced fibrosis was found more frequently in Group 1 compared with Group 2 patients, 49.7% and 63.7%, respectively (P = 0.039). There was no difference in baseline alanine transaminase (P = 0.871), alkaline phosphatase (P = 0.105), and gamma glutamyl transpeptidase (P = 0.198). Similarly, there was no difference between the groups in baseline HCV-RNA (P = 0.897), but the response to antiviral treatment was higher in Group 1 (50.0% vs. 35.4), however, that did not reach statistical significance (P = 0.159). Conclusion: The presence of ANA and or ASMA in HCV-infected patients was associated with increased risk of having advanced fibrosis at presentation. However, there was no impact on liver enzymes or pretreatment HCV-RNA.


Retrospective Analysis for All Stage IV Colorectal Cancer Patients Treated in King Abdul Aziz Medical City - Riyadh

Hala Al-Marzoug, Ashwaq Al-Olayan, Alanoud Al-Marzoug, Sara Al-Qubaiban, Yusra Ali 1

National Guard Hospital, Riyadh, Saudi Arabia

Background: Colorectal cancer (CRC) is considered the first most common cancer in men and the second cause of cancer among women in Saudi Arabia. Colon and rectal cancer are often referred to as CRC. Are they the same diseases? The aim of this study is to compare between metastasis colon cancer and metastasis rectal cancer in term of characteristics and prognosis. Methods: Retrospective cohort study was conducted on 245 adenocarcinoma Stage IV CRC patients treated at King Abdulaziz Medical City, Riyadh. Charts were reviewed from 2006 to 2014. Demographic, clinical and treatment characteristics analyzed by univariate analysis. Bivariate analysis was used to determine the differences between colon and rectum cancer. Multivariate analysis was used to assess the prognostic factors, utilizing SPSS statistical software. Result: Of 245 CRC patients diagnosed with Stage IV, 131 (53.5%) were males and 114 (46.5%) were females. 185 (75.5%) patients had colon cancer and 60 (24.5%) patients had rectal cancer. The mean age of patients at the time of diagnosis was 59 years. Comparing colon cancer and rectal cancer there was a significant difference between the two groups in regards to K-RAS Mutation(P = 0.009), metastatic site (liver P = 0.030, Lung P = 0.020, and Peritoneum P = 0.014), number of Metastasis (P = 0.005), and type of treatment (P = 0.001). In survival analysis, type of treatment and number of metastasis were statistically significant in both groups. Conclusion: Our findings support that CRC is not a single entity. Further studies comparing colon and rectum cancer in term of molecular data, effect of specific treatment, and more of prognostic factors are needed.


Characteristics of Colorectal Cancer in Makkah Region of Kingdom of Saudi Arabia: A Young Onset Disease

A Al-Zanbagi, BA Al-Zahrani 1 , HS Al-Tayari 1 , MK Shariff

Gastroenterology and Hepatology, King Abdullah Medical City, 1 Umm Al-Qurah University Makkah, Saudi Arabia

Background: Colorectal cancer (CRC) is topical with recent guidance published to start National CRC screening program in Kingdom of Saudi Arabia (KSA). Before the roll out of the program, it is important to understand the nature of CRC in different regions of KSA. This study describes the clinical characteristics of CRC in Makkah region of KSA. Methods: This was a retrospective study that looked at patient demographics, clinical and pathological characteristics of CRC presenting at King Abdullah Medical City, Makkah. Results: A total of 410 cases with a diagnosis of CRC were identified. All information needed was available on 360 of these, who were included in the study. The mean age at diagnosis was 55.11 years (standard deviation ±14.7), with 36.2% presenting before 50 years with male predominance (53.8%). 80.4% of CRC's were found on the left colon, most common location being the sigmoid colon (38.9%) followed by the rectum (25.9%). At the time of diagnosis, 39.9% presented with distant metastasis and only 36.5% had localized disease of which none had early cancer (T1 stage). Adenocarcinoma was the predominant pathological lesion with moderately differentiated (85%) being the most common grade; well-differentiated and poorly differentiated grades made up 11.6% and 3.3%, respectively. Conclusion: CRC was diagnosed at a younger age and presented with an advance stage in Makkah. This study lends support to the guidance that CRC screening should be implemented and at an earlier age.


Low Dose Versus High Dose Entecavir for Chronic Hepatitis B Virus Infection with Liver

S Khan, H. Alhomoud, K. Bzeizi, N. AL-Masri, A. Al-Mdani, W. Alali, A. S. Albenmousa

Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Background: Chronic hepatitis B virus (HBV) treatment outcome has significantly improved with the use of the potent nucleos(t)ide analogs. Entecavir is a leading agent in treatment of chronic HBV including patients with cirrhosis. The recommended dose of entecavir for treatment of decompensated cirrhotic patients is 1 mg, however, there is no evidence that the lower (0.5) dose is less efficacious in achieving adequate viral suppression. Aims: To compare the efficacy and Safety of low dose (0.5 mg) to high dose (1 mg) entecavir in treatment of chronically HBV-infected patients with liver cirrhosis. Patients and Methods: Retrospective review of charts for patients with chronic HBV and liver cirrhosis was carried out. Patients who were treated with 0.5 mg (Group 1) were compared to those who received 1 mg entecavir (Group 2). The primary efficacy end point was overall survival. Secondary endpoints were HBV DNA suppression and alanineaminotransferase normalization. Incidence of serious adverse events and rate of discontinuation of treatment were considered as safety endpoints. Results: A total of 102 patients were included in the study. Group 1 had 81 patients with a mean age of 58.8 ± 11.3 years and 76.5% were males. Group 2 had 21 patients with a mean age of 57.8 ± 7.8 years and 76.2% were males. E Ag was positive in 16.5% with no difference between the two groups (P =.928). At presentation, 43.2% in Group 1 and 23.8% in Group 2 had HCC (P = 0.109). There was no statistically significant difference in baseline viral load and biochemical parameters between the groups except for ALP (P = 0.001). After median follow-up of 20 months, death occurred in 17.3% in Group 1 compared to 23.8% in Group 2 (P = 0.395) while median survival was 15.8 months and 11.7 months in Group 1 and 2 respectively (P = 0.620). Viral suppression to a level below 2000 iu/ml was achieved in 86.7% in Group 1 and 77.8% in Group 2 (P = 0.493). Normalization of ALT was achieved in 66.7% in Group 1 and 71.4% in Group 2 (P = 0.682). No drug-related serious adverse event or drug discontinuation was reported. Conclusion: Low dose entecavir (0.5 mg) in this retrospective study was as effective as high dose (1 mg) in treatment of chronic HBV patients with liver cirrhosis. These results need to be confirmed in a larger prospective trial. Both doses of entecavir were safe in the population studied.


Diagnostic accuracy of fibroscan in assessment of fibrosis stage in patients with chronic liver disease

Awny A. Abdelrahman, Ahmed Helmy, Shirin Anil,

Nehal Khamis, Maha Arafah, M. Suwefy, Faisal Sanai, Ayman A. Abdo

King Khalid University, Hospital, Riyadh, Saudi Arabia

Background: Fibroscan is a noninvasive procedure to measure liver stiffness, and hence, fibrosis. Data are limited about its accuracy in patients with mixed causes of liver disease and in the Middle Eastern population. This study compared fibroscan, aspartate transaminase to platelet ratio index (APRI) and fibrosis-4 score (FIB-4) to diagnosis liver fibrosis. Methods: This cross-sectional study comprised 186 patients who underwent liver biopsy, fibroscan, hematological, and liver function tests. Fibrosis was staged using METAVIR classification. The diagnostic accuracy of Fibroscan, APRI, and FIB-4 for liver fibrosis was analyzed by calculating the area under the receiver operating characteristic (AUROC) curves. Fibrosis on liver biopsy was the reference test. Results: Fibroscan was unsuccessful in ten patients due to morbid obesity. Of 176 patients included, 38.6% had hepatitis B, 33.5% hepatitis C, and 14.7% had nonalcoholic steatohepatitis. Liver biopsy showed that 125 patients had low fibrosis (F1 + F2), and 51 had significant fibrosis (F3 + F4). AUROCs of fibroscan, APRI and FIB-4 were 0.723, 0.656, and 0.694, respectively for significant fibrosis and 0.9, 0.911, and 1.0 respectively for cirrhosis. To make a diagnosis of cirrhosis, fibroscan, APRI and FIB-4 cut-off value of 18.3 kPa 0.373 and 3.285, respectively yielded sensitivity of 100% for all tests and specificity of 88.9% for fibroscan and 100% for the other two tests. Conclusion: Fibroscan is a reliable modality for the diagnosis of cirrhosis in a group of patients with mixed liver disease etiology. It is superior to FIB-4 or APRI to diagnose significant fibrosis while FIB-4 is the most accurate test to diagnose cirrhosis.


Prevalence of Gastroesophageal Reflux in Western Region of Saudi Arabia

M. Binhussein, A. Alamoudi, A. Bajawi, M. Alghafis, M. Baz, R. Bakhsh, T. Bazuhair, R. Alsayed, B. Bokhari, M. S. Khan 1

Departments of Internal Medicine and 1 Gastroenterology and Hepatology, King Abdullah Medical City, Makkah, Saudi Arabia

Background: Gastroesophageal reflux disease (GERD) is common worldwide. The only study from Kingdom of Saudi Arabia (KSA) reported a high prevalence of GERD exceeding 45% compared to worldwide data of 10-33%. Hence, the aim of this study was to confirm whether the result would be similar in western region of KSA, Makkah. Methods: Cross-section survey of randomly approached participants at schools, hospitals, offices, government establishment, and shopping malls was done using a validated GerdQ. In addition demographic details, comorbidities and medication history were collected. Results: Of the 1423 participants who filled the GerdQ, 425 were excluded due to incomplete answers. The mean age of the 998 participants included was 29.9 years with a male to female ratio of 1:2. Based on the GerdQ questionnaire with a score of ≥8, the prevalence of GERD was 23.47% (234). Participants who were obese had a higher prevalence of GERD than who were not (body mass index ≥30 vs. <30 kg/m΂, P = 0.01). In addition, having diabetes mellitus or hypertension was associated with higher prevalence of GERD compared to does who did not (42.02% vs. 29.09%, P = 0.02 and 53.12% vs. 21.43%, P = 0.0001, respectively). However, history of chronic lung disease, ischemic heart disease, smoking or use of nonsteroids anti-inflammatory medication was not related to higher GERD prevalence. Conclusion: The prevalence of GERD in Makkah region is similar to worldwide data and is associated with other comorbidities. This raises the contention that GERD is more prevalent than actually recognized and probably undertreated.


Pharmacokinetic-derived Adjusted Dose of Ribavirin Fails to Improve Virologic Outcomes in Hepatitis C Genotype 4 Patients Treated in Combination with Peginterferon Alpha-2a

Ibrahim AlTraif, MA. Babatin, P Marquet, H Alghamdi, A Aljumah, AA. Abdo, A Alalwan, FA. Handoo, W Al-Tamimi, H I. Al-Ashgar, W AlHamoudi, KA. Alswat, AM. Al-Bekairy, F AlSohaibani, S Murtaza, SI. Altraif, V Loustaud, FM. Sanai

King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background: Sustained virologic response (SVR) in chronic hepatitis C virus (HCV) genotype (GT) 4 with peginterferon (PegIFN)/ribavirin (RBV) combination therapy is suboptimal in the range of 40-50%. Adequate RBV exposure is essential to optimize SVR rates. The concept of individualized, pharmacokinetic-derived dosage of RBV is proposed in this study to optimize SVR. Methods: Treatment naïve GT4 subjects were randomized in this open-label trial to assess the efficacy of PegIFNa-2a in combination with weight-based standard dose RBV, 1000-1200 mg/day (n = 91), or an adjusted dose based on area under the curve 0-4 h (n = 90) for RBV concentration. Darbepoetin was used to treat anemia in both treatment arms. The study endpoint was SVR rate, defined as the proportion of patients with undetectable HCV RNA 24 weeks after treatment discontinuation. Results: The mean age of the subjects was 45.66 ± 1.03 years and 50.3% were females. The majority of the patients had minimal-moderate fibrosis (METAVIR F0-2, 76.5%). Overall, 164 subjects (90.6%) completed all study-related procedures, and SVR was achieved in 99 (54.7%) subjects (ITT analysis). There was no difference in SVR rate between the adjusted RBV dose subjects, 50/90 (55.6%), and the standard dose subjects, 49/91 (53.9%, P = 0.262). Similarly, 49/181 subjects achieved rapid virologic response (RVR, 27.1%), with the rates being similar in both arms (28.6 vs. 28.4%). There was no difference in the cEVR, null response and virologic relapse rates in both arms (P > 0.05 for all). Patients in the adjusted dose arm required higher overall doses of darbepoetin (42.56 ± 6.51 μg) as compared to standard dose subjects (13.85 ± 3.85 μg, P = 0.0002). Allocation of higher doses of RBV at baseline did not predict SVR. Conclusion: Adjusted doses of RBV based on drug pharmacokinetics do not improve SVR rates in HCV GT4. In addition, patients on adjusted doses of RBV more frequently require erythropoietic factors without rendering an advantage in terms of treatment outcome.


Morbidity and Mortality Posthepatectomy Benchmark in a Saudi Tertiary Centre

Rafif Mattar, Faisal Al-alem, Ola Fadl, Abdulsalam Alsharabi, Faisal Alsaif, Mazen Hassanain

King Khalid University Hospital, Riyadh, Saudi Arabia

Background: Hepatic resection is performed for various indications and with increasing frequency. Mortality rates posthepatectomy have declined to <2.5%. Despite favorable survival outcomes, hepatectomy remains a major surgery with significant perioperative risks requiring a specialized setup. Our institution has recently invested in building a specialized hepato-pancreato-biliary (HPB) unit. We report our rates of morbidity and mortality following hepatectomy, and the predicting factors as a case study for new HPB units. Methodology: Data were collected prospectively from our HPB database on liver resections performed between 2006 and 2014. Factors associated with postoperative morbidity and mortality were retrospectively analyzed. Results: A total of 77 resections were retrieved; 71.4% for malignant etiology, mainly colorectal liver metastases (45.45%), and hepatocellular carcinoma (12.99%), respectively. 45 resections were major (3 or more segments), with a mean operative time of 5.28 h. Complications developed in 38.96%, with the majority being Clavien Grades I-III. On multivariate analysis, the Schindl liver dysfunction score showed the strongest correlation (P = 0.006). Ninety-day postoperative mortality was 5.19% (4 patients); 3 fulfilled the 50:50 liver dysfunction criteria. Overall, median survival was 13.23 months. Conclusion: The database has enabled us to benchmark our outcomes with published data and assure the care providers that we have achieved acceptable rates of both morbidity and mortality posthepatectomy, which we believe to be a major tool for starting HPB units.


Natural History of Hepatitis B Virus: Initial Analysis of 1200 Patients From the Solid Registry

Abdallah Hasan, Faisal M. Sanai, Waleed Alhamoudi, Khalid AlSwat, Mona Ismail, Mohammed Babatin, Abdullah S. Alghamdi, Faleh Al-Faleh, Abdulrahman Aljumah, Ibrahim Altraif, Hamdan Alghamdi,

Abduljaleel Alalwan Ayman A. Abdo

King Khalid University Hospital, Riyadh, Saudi Arabia

Background: The systematic observatory liver-diseases registries (SOLID) is a multinational, multicenter, observational, open-label group of medical registries designed to electronically collect data, manage, monitor, and report different liver diseases. In this study, we aim to describe the clinical characteristics and natural history of hepatitis B virus (HBV) based on a large multicenter registry of patients from Saudi Arabia. Methods: We performed a retrospective analysis of patients with HBV using data in the SOLID registry up to April 2015. We analyzed the clinical characteristics of HBV in terms of viral activity, clinical and biochemical characteristics of the liver disease, and fibrosis assessment. Results: One thousand one hundred and nighty-eight patients were included in this analysis. These represent patients recruited by SOLID investigators from five centers across Saudi Arabia over a 10 years period. Data included an initial visit and follow-up data with a mean of 35.5 ± 23.1 months. A total of 848 (70.8%) were classified as inactive carriers while 270 (22.5%) were classified as active. Cirrhosis was found in 80 (6.7%) patients in whom 27 (33.8%) had decompensated cirrhosis. Of the 13 (1.1%) patients who developed hepatocellular carcinoma over the course of the disease, 12 (92.3%) of them had cirrhosis, and 1 (7.7%) patient was an inactive HBV carrier. Liver fibrosis stage was determined through biopsy in 151 (12.6%) patients; the remaining 1047 (87.4%) patients were assessed using transient elastography (fibroscan) or APRI score. Multivariate analysis of patients with cirrhosis compared to active disease patients found that alkaline phosphatase showed an odds ratio (OR) of 1.016 (95% confidence interval [CI]: 1.007-1.024; P < 0.001) and platelet count showed an OR of 0.982 (95% CI: 0.974-0.990; P < 0.001). Multivariate analysis of patients with cirrhosis compared to inactive disease patients found that alkaline phosphatase showed OR of 1.011 (95% CI: 1.006-1.015; P < 0.001) and a platelet count showed an OR of 0.980 (95% CI: 0.975-0.985; P < 0.001). Conclusion: This is the first large-scale study to describe the epidemiology of chronic HBV in Saudi Arabia. The findings confirm that the majority of patients are inactive carriers and that the incidence of cirrhosis and decompensation remains low. We anticipate that detailed findings of this cohort will help design healthcare plans in relation to the care of hepatitis B patients.


Chronic Inactive Hepatitis B Virus: A Persisting Benign Natural History

A Hasan, FM. Sanai, W Alhamoudi, K Al-Swat,

M Ismail, Mohammed Babatin, Abdullah Alghamdi,

Faleh Al-Faleh, Abdulrahman Aljumah, Ibrahim Altraif, Hamdan Alghamdi, Abduljaleel Alalwan, Ayman A. Abdo

King Khalid University Hospital, Riyadh, Saudi Arabia

Background: Hepatitis B virus (HBV) is one of the most common viral infections worldwide, the natural history of which does not always progress in a linear fashion. We aimed to identify the natural history of chronic inactive HBV over the course of 15 years utilizing the data from the systematic observatory liver-diseases registries which is a multi-national, multi-center, observational, open-label group of medical registries designed to electronically collect data, manage, monitor, and report different liver diseases. Methods: This is a prospective cohort study following 69 patients aged 30-60 years who have inactive HBV for 15 years. APRI score was calculated at the time of diagnosis and 15 years later. Inactive HBV was identified as polymerase chain reaction <2000 IU/mL with normal liver enzymes and no clinical signs of liver cirrhosis, as well as a normal ultrasound regardless of their hepatitis B surface antigen (HBeAg) status. APRI score was used as a noninvasive measure of liver fibrosis. Results: Of the 69 patients, 37 were females (54%), and 32 were males (46%). Upon diagnosis, 87% of patients were HBeAg negative, while only 13% were positive. At the end of the 15-year follow-up, 93% of patients were HBeAg negative. No significant fluctuations of HBV DNA could be observed, and none of the patients developed active hepatitis B manifested by HBV DNA >20,000 IU/mL or elevated liver enzymes. At the time of diagnosis, the mean APRI score was 0.33 ± 0.17 suggestive of minimal fibrosis and the mean bilirubin was 9.6 ± 6.8 μmol/L. However, 15 years later, the mean APRI score remained 0.33 ± 0.36. (P = 0.12) with a decrease of mean bilirubin to 8.5 ± 4.5 μmol/L (P ≤ 0.001). Conclusion: Based on this long-term follow-up study of inactive HBV infection we confirm that the natural history of this disease is usually benign with very little if any progression to more active form of liver disease. Follow-up and management plans for these patients, who form the majority of the HBV patients, should be designed accordingly.


Medical Students' Awareness of and Compliance with the Hepatitis B Vaccine a Tertiary Care Academic Hospital: An Epidemiology Study

Firas A. Ghomraoui, Faisal A. Alfaqeeh,

Abdulrahman S. Algadheeb, Abdullah S. Al-alsheikh, Waleed K. Al-Hamoudi, Khalid A. Alswat

King Khalid University Hospital, Riyadh, Saudi Arabia

Background: The hepatitis B virus (HBV) poses a health risk to healthcare workers who are in close proximity to infected individuals. Medical students are a particularly high-risk group due to the lack of an obligatory vaccination program and a postvaccination screening program to determine immunity status, which results in a lack of awareness of and compliance with the HBV vaccine. Methods: This cross-sectional survey was conducted in King Khalid University Hospital (KKUH), a Tertiary Care Academic Hospital in Riyadh, Saudi Arabia, from November 2013 to March 2014. Medical students in their second to 5 th years (n = 444; 213 men and 231 women) completed a self-administered questionnaire regarding awareness of HBV and compliance with the HBV vaccination program in KKUH. Results: Medium to low knowledge levels were present in 53.5% of the participants, and 44.3% reported that they were not compliant with the vaccination program provided by KKUH. While 93.9% received the HBV vaccine upon entry to medical school, only 59.5% received all 3 doses, citing forgetfulness and a busy schedule as common reasons for the low compliance. There was no association between the knowledge and awareness of the participants and their compliance (P = 0.988). Conclusion: Medical students had a low level of compliance with the HBV vaccination program, regardless of their knowledge, and awareness of the disease and vaccination. We recommend that programs and campaigns be developed to increase the overall awareness of this disease. We also suggest that a mandatory HBV vaccination program should be implemented to improve the compliance rate among medical students.


Living Donor Liver Transplant Has Similar Outcome to Deceased Donor Liver Transplant for Meld >25

Mohamed Al Sebayel 1 , Faisal Abaalkhail 1,2 , Mohamed Shoukri 3 , Hamad Albahili 1 , Saleh Alabbad 1 , Waleed AlHamoudi 1,4 , Hany Albeshbeshy 1 , Hussien Elsiesy 1,2

King Faisal Specialist Hospital and Research Center, King Faisal Liver Group 1 Liver transplantation, 2 Department of Medicine, Alfaisal University, 3 Research Center, King Faisal Specialist Hospital and Research Center, 4 Department of Medicine, King Saud University, Riyadh, Saudi Arabia

Background and Aims: Model for end-stage liver disease (MELD) score is universally used to prioritize patients on the liver transplant (LT) waiting list. There has been conflicting evidence on the use of living donor liver transplantation (LDLT) in patients with high MELD scores. We reported a single-center retrospective data comparing survival between LDLT and deceased donor liver transplantation (DDLT) for patients with MELD score 25. Methods: Between 2001 and 2015, 603 LT were performed at out institution, of which 308 were LDLT and 298 were DDLT. Of those, 178 patients had MELD score >25 (116 DDLT and 62 LDLT). A retrospective analysis was made on patients with high MELD score evaluating age, gender, history of diabetes, renal impairment (using estimated GFR), hospital stay, Intensive Care Unit stay, MELD score at the time of LT, and outcome. Results: Univariate analysis using nonparametric Mann-Whitney test was performed. The joint effect on the survival rate using the potential risk factors was estimated using Cox regression [Table 1]. The estimated 1, 3, and 5 years survival probabilities are given in Table 2. Age, body mass index (BMI), renal impairment, MELD score at the time of LT correlated with survival with P value 25, older age, high BMI, renal impairment, and higher MELD has a worse outcome in both groups.


Low Utility of 2-[fluorine 18]fluoro-2-deoxy-D-glucose-positron Emission Tomography/Computed Tomography in Patients with Hepatocellular Carcinoma Before Liver Transplantation

Hussien Elsiesy, Faisal Alotaibi, Monther Kabbani, Alicia Chorley, Hany Elbeshbeshy, Mohamed Abdelfattah, Faisal Abaalkail, Waleed Al-Hamoudi,

Mohamed Alsebayel

King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

Background: Our program uses 2-(fluorine 18)fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET CT) routinely as a part of the liver transplant (LT) evaluation in patients with hepatocellular carcinoma (HCC), our aim is to evaluate the utility of its use in this setting. Methods: Retrospective chart review of our LT database from January 2011 until December 2014, of patients with HCC who had FDG-PET CT scan then received LT, data collected as follow: (age, gender, etiology of liver disease, imaging criteria, PET-CT result, explant results, type of transplant: Living donor liver transplant (LDLT) versus deceased donor liver transplant (DDLT) and outcome. Patients beyond Milan criteria received LDLT after loco-regional therapy. Results: During the period, 275 LT were performed, 183 LDLT, and 92 DDLT. Fifty-three patients had HCC, of which the FDG-PET CT was performed on 41 patients. The average age is 58 (22-72), 28 males, the etiology of liver disease was hepatitis C (24 patients), cryptogenic cirrhosis (12 patients), and hepatitis B virus (5 patients). The majority of patients have HCC within Milan criteria (25 patients), within UCSF (7 patients) and 8 patients beyond UCSF. A total of 29 patients received LDLT while 12 patients have DDLT. Four patients died (3 within Milan, one within UCSF criteria) none with HCC recurrence. Of the 41 patients with PET-CT, one was negative with no evidence of HCC in explant, 11 patients had positive FDG-PET (27%) with evidence of HCC in explant (5 beyond UCSF, 2 within UCSF and 4 within Milan criteria), the explant showed well-differentiated HCC in 5, moderately differentiated in 3, poorly differentiated in 1, and complete necrosis in 2. The other 29 patients had negative FDG-PET CT (70.7%), 21 patients were within Milan, 5 within UCSF, and 3 beyond UCSF, the explant showed well-differentiated HCC in 8, moderately differentiated in 12, mixed HCC and cholangiocarcinoma in one, and complete necrosis in 8 patients. The FDG-PET CT was positive in 16% of patients within Milan criteria, 28% within UCSF, and 62% beyond UCSF. Conclusion: FDG-PET CT has low utility in patients with HCC within Milan criteria and should not be routinely used as part of LT work up.


Hemostatic Factors as Biomarkers of Significant Liver Fibrosis in Patients with Chronic Hepatitis C

Khalid Alswat, Naglaa Allam, Shirin Anil, Faisal Sanai, Ayman Alsebaey, EhsanNermeen 4 , Algahtani Farjah 1 ,

Al-HamoudiWaleed 1 , Gomaa Asmaa 2 , Hendy Olfat 4 ,

Waked Imam 2 , A Abdo Ayman 1

1 Liver Disease Research Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia, 2 Department of Hepatology, and 4 Department of Pathology, National Liver Institute, Menoufeya University, Egypt, 3 Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia

Background and Aims: Hemostatic factors are affected in chronic liver disease (CLD). Evidence regarding their use as noninvasive markers of CLD severity is scarce. We aimed to study, the association between the levels of hemostatic factors and the severity of liver fibrosis in a large cohort of chronic hepatitis C virus (HCV) patients. Methods: A cross-sectional study was conducted on 402 adults with HCV. Liver biopsy and blood tests including platelet count, prothrombin time, international normalized ratio (INR), thrombin time, antithrombin (AT), reptilase time, fibrinogen, factor VII, protein C (PC), protein S, free protein S, and C4 binding protein (C4BP) were performed. Variables significantly associated with significant (≥F2, Metavir) fibrosis on univariate analysis were included in a multivariate logistic regression model. Results: Of the 402 eligible participants, 377 patients were included in the analysis. Significant fibrosis was present in 37.4%. INR increased while AT and PC decreased with increase in fibrosis stage (P value for all <0.001). C4BP levels reduction was associated with significant (≥F2) fibrosis (odds ratio, 0.98; 95% confidence interval: 0.97-0.99) adjusting for other parameters at multivariable analysis, so that as C4BP increases by one point, odds of having ≥F2 fibrosis decreases by 2%. Conclusions: This study demonstrates a close relationship between hemostatic factors and histologic fibrosis progression in a large cohort of HCV patients. C4BP has the strongest association and could be used as a potential noninvasive marker of liver fibrosis. Further studies to validate this association are needed.


Donor Transmitted Rabies Outbreak Involving Four Transplant Recipients in Kuwait and Saudi Arabia

Hussien Elsiesy 1,2 , Iqbal Hussain 3 , Faisal A. Abaalkhail 1,2 , Waleed K. Al-Hamoudi 1,4 , Mohamed I. Al Sebayel 1 , Dieter C. Broering 1 , Ahmed A. Elgohary 1 , Baderaldeen Ahmed 1 , Sarah Al Fawaz 3 , Sahar I. Althawadi 3 , Jawaher M. Alotaibi 3 , Hindi Al-Hindi 3 , Lillian Orciari 5 , Andres Velasco-Villa 5 , Pamela Yager 5 , Todd Smith 5 Will Carson 5 , Mike Niezgoda 5 , Ashutosh Wadhwa 5 , Edgar R. Condori 5 , Yu Li 5 , Richard Franka 5 , Magid Halim 3 , Rodney Willoughby 6

Department of Liver Transplantation, King Faisal Specialist Hospital and Research Center, 2 Department of Medicine, Alfaisal University, 3 King Faisal Specialist Hospital and Research Center, 4 King Saud University, Riyadh, Saudi Arabia, 5 Poxvirus and Rabies Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control, Atlanta, GA, 6 Medical College of Wisconsin, Milwaukee, WI, USA

Background: There have been 10 outbreaks of rabies following solid organ or corneal transplantation. In December 2014, four organ recipients died of encephalitis in 2 countries. Methods: Chart review and verbal autopsy. Serum and cerebrospinal fluid (CSF) were analyzed for virus antibodies by indirect fluorescent-antibody and rapid-fluorescent-focus-inhibition technique. Results: A 28-year-old donor presented with chest infection, acute respiratory distress syndrome, cardiac arrest, and seizure. Computed tomography of the head was unremarkable. CSF culture was negative. A kidney recipient (Center A) developed encephalitis within 2 months of transplant and died. The second kidney recipient (Center A) developed similar symptoms a week later and died. The family of the donor confirmed that he was bitten by a domestic dog in India 2 months prior to his death and did not receive prophylaxis; the dog died. The Saudi Center of Organ Transplantation contacted our Center (B) which transplanted the heart and liver. The heart recipient had died after cardiac arrest with prodromal neuropsychiatric symptoms. The liver donor developed drooling, and hydrophobia was treated with the Milwaukee protocol and died after 34 days. Antemortem brain biopsy showed Negri bodies. Rabies RNA was detected in brain and saliva. Rabies antibodies developed in serum and CSF. Rabies was confirmed in the donor by reverse transcription polymerase chain reaction of the explanted cornea. Deceased kidney recipients had no rabies antibodies. Corneas were explanted from recipients who received prophylaxis; they remain well. Conclusion: Avoidance of transmission of rare pathogens requires wide bandwidth diagnostics and rapid-cycle surveillance within transplantation networks.


Metallic Stent Insertion for Palliation of Esophageal Cancer: Single Center Experience from Saudi Arabia

Adnan Al-Zanbagi, Ishtiaq Ahmad, Bashaer Ali Al-Zahrani 1 , Zaffar Mahmood, Shariff M.K.

Department of Gastroenterology and Hepatology, King Abdullah Medical City, 1 Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia

Background: Self-expanding metallic stents (SEMS) are increasingly used for palliation of advance esophageal cancer (EC). However, the most data on this originates from Western world where the incidence is low. There is a scarcity of data from high incidence region like Asia. The aim of this study is to evaluate the efficacy of SEMS in inoperable EC in the western region of Saudi Arabia. Methods: This is a retrospective review of SEMS placed in a single tertiary referral hospital for histological proven inoperable EC from 2012 to 2015. Demographic data, the success of stent placement, complication, re-intervention, and mortality were collected. Results: About 32 SEMS were placed in 27 patients, all were placed for palliation of dysphagia. The median age of patients was 72 years (range 33-97) with 74% (20) of the EC involving the lower third of esophagus and rest the middle third. SEMS was placed successfully in all the cases with symptomatic improvement in dysphagia. There were no stent-related complications in the form of bleeding or perforation. However, 22% (6) required re-intervention with a further SEMS placement, 5 of which were for tumor in growth and 1 for distal migration. The mortality was 81% (22). 78% (21) had partially and the remaining fully covered SEMS with no significant difference in re-intervention. Chemo and/or radiotherapy were given to 37% (10) of the patients with no difference in outcome. Conclusion: The SEMS was effective in palliating dysphagia in EC without major complications. The rates of tumor ingrowth and migration were comparable to other studies.


Clinical Experience of Telaprevir in the Middle East: Efficacy, Safety and Predictors of Response to Therapy

Adnan Al-Zanbagi, Mohammed Babatin 1 , Abdullah S. Al-Ghamdi 1 , Raaja Bakhsh, Zaffar Mahmood, Mohammed K. Shariff

Department of Gastroenterology and Hepatology, King Abdullah Medical City, Makkah, 1 Department of Gastroenterology and Hepatology, King Fahad Hospital, Jeddah, Kingdom of Saudi Arabia

Background: To evaluate the efficacy and safety of telaprevir in the western region of Kingdom of Saudi Arabia. Methods: Patients treated with peginterferon/ribavirin and telaprevir for hepatitis C virus (HCV) genotype 1 in two tertiary referral centers were retrospectively analyzed. Sustained virological response (SVR), adverse events, and predictors of response were determined. Results: A total of 42 patients received the above triple therapy of which 45% (19) were treatment naïve. 73% (30) achieved SVR, with treatment naïve achieving an SVR of 84% (16/19) and treatment experienced 61% (14/23). Achieving rapid virological response and early virological response predicted SVR, P = 0.0001, respectively. Whereas high viral load (P = 0.696), IL28B polymorphism (P = 1.000), or weight ≥85 kg (P = 0.454) were not associated with SVR. Adverse events were frequently reported with anemia, rash, nausea, mild fever, anorectal pain, and itching occurring in 49%, 14%, 60%, 75%, 75%, and 65% of patients, respectively. Apart from one patient who stopped treatment due to severe rash, none of the other adverse effects led to the termination of therapy. Conclusion: This study is one of the first to report real-life experiences in the Middle East region on the early experience of interferon-based therapy using telaprevir for HCV genotype 1. This therapy achieved SVR comparable to prospective studies in the west with acceptable side effects and low discontinuation rates.


A Comparison Study Between 10 and 14 Days of Triple Therapy for Eradication of Helicobacter pylori

Abdulrahman Bendahmash, Mohammad Alenezi, Saud Alomair, Abdullah Alshalan, Tariq Altwyjry, Khalid Alsayari, Majid Almadi, Nahla Azzam, WK Alhamoudi

King Khalid University Hospital, Riyadh, Saudi Arabia

Background: Helicobacter pylori infection is highly prevalent worldwide. It is a risk factor for peptic ulcer disease and gastric malignancy. H. pylori eradication therapy with a proton pump inhibitor, clarithromycin, and amoxicillin fails in >20% of cases. The liberal use of antibiotics and the reports of increasing antibiotic resistant organisms in the Kingdom of Saudi Arabia make this study of extreme importance especially with the lack of data in this area. The aim of this study is: Determine the prevalence of H. pylori among all comers for upper gastrointestinal endoscopy in a tertiary care setting. (1) To determine the overall eradication rates of H. pylori infection. (2) To compare between the outcomes of 10 and 14 days triple therapy for the treatment of H. pylori in naive patients. Methods: A prospective randomized study is evaluating the prevalence of H. pylori in all patients coming for upper gastrointestinal endoscopy. Patients were interviewed and then assigned to either 10 or 14 days course of triple therapy and outcomes were compared. Triple therapy that included amoxicillin 1 g twice a day, clarithromycin 500 mg twice a day and pantoprazole 40 mg twice a day. Results: A total of 457 patients underwent upper gastrointestinal endoscopy during the study period (December 2013 to March 2014). Abdominal pain and dyspepsia were the most common indications for endoscopy (60%) while gastritis was the most common endoscopic finding (35%). 79 patients did not meet the inclusion criteria and, therefore, were excluded. 378 patients were enrolled in the study. 92 (24.33%) patients tested positive for H. pylori. Successful H. pylori eradication was achieved in 30 (55%) patients while eradication was unsuccessful in 25 (45%) patients. The eradication was achieved in 53.8% and 55.17% of patients treated for 10 and 14 days, respectively (P = 0.92). There was no deference in the eradication rates between males and females (P = 0.17). Those who had vomiting as a presenting complaint were more likely to fail eradication 75.0% versus 37.2% (P = 0.02) also smokers were more likely to remain infected 81.8% versus 36.4% (P < 0.01). Conclusion: With the rising prevalence of antimicrobial resistance, the treatment success of standard triple therapy has recently declined to unacceptable levels. There was no difference in outcome of the treatment between 10 and 14 days, and more alarming treatment failure was 45% suggesting microbial resistance.


Biomarkers of Fibrosis in Low Replicative Chronic Hepatitis B Patients

Faisal M. Sanai 1,2 , Taha Farah 2 , Khalid Albeladi 2 , Faisal Batwa 2 , Yaser Dahlan 2 , Mohammed A. Babatin 3 , Hamad Al-Ashgar 4 , Hadeel Al Mana 5 , Khaled S. Alsaad 6 , Khalid Al Swat 1 , Abdulrahman Aljumah 7,8 , Ibrahim H. Al Traif 7,8 , Khalid I Bzeizi 9

Liver Disease Research Center, King Saud University, 9 Department of Gastroenterology, Riyadh Military Hospital, 4 Department of Medicine, Division of Gastroenterology, King Faisal Specialist Hospital and Research Center, 5 Department of Pathology, King Faisal Specialist Hospital and Research Center, Departments of 6 Pathology and 7 Hepatobiliary Sciences and Liver Transplantation, King Abdulaziz Medical City, 8 King Saud bin Abdulaziz University for Health Sciences, Riyadh, 3 Department of Medicine, Division of Gastroenterology, King Fahad General Hospital, 2 Department of Medicine, Gastroenterology Unit, King Abdulaziz Medical City, Jeddah, Saudi Arabia

Background/Aim: Biomarkers of fibrosis such as aspartate aminotransferase (AST)-to-platelet ratio index (APRI) and fibrosis-4 index (FIB-4) have been previously evaluated in chronic hepatitis B virus (HBV) patients but data is lacking in patients with low-replicative disease. We evaluated the diagnostic accuracy of APRI, FIB-4, AST/alanine aminotransferase ratio (AAR), and age-platelet index (API) for significant fibrosis (Metavir, F2-4) in low-replicative (HBV DNA <20,000 IU/mL) chronic HBV patients. Patients and Methods: The sensitivity, specificity, and area under the receiver-operating characteristic curve (AUROC) of hepatitis B e-antigen-negative, low-replicative (n=213), and high-replicative (HBV DNA ≥20,000 IU/mL, n = 153) patients was assessed. Results: Overall, 113 patients (30.9%) had F2-4 fibrosis. Of the low and high-replicative patients, 40 (18.8%) and 73 (47.7%) had F2-4, respectively (P < 0.0001). APRI ≥0.5 less frequently identified F2-4 fibrosis in low vs. high-replicative patients (48.7 vs. 69.6%, P = 0.032) and AAR identified it more frequently in low-replicative patients (37.5 vs. 19.4%, P = 0.037). FIB-4 and API were not different (P > 0.05) for identifying F2-4 fibrosis in low and high-replicative patients. Higher specificities were seen at the lowest cut-offs in low vs. high-replicative states for APRI (≥0.5, 98 vs. 68.9%), AAR (84.3 vs. 76.6%), FIB-4 (≥1.45, 97.5 vs. 87.8%), and API (>4, 94.8 vs. 93.8%). At ROC-defined thresholds, APRI (≥0.33), AAR (≥0.93), FIB-4 (≥0.70), and API (>2) showed greater AUROCs for F2-4 diagnosis in low replicative (0.80, 0.62, 0.81, and 0.71, respectively) versus high-replicative patients (0.73, 0.52, 0.67, and 0.69, respectively). Conclusion: All 4 biomarkers in both, low and high-replicative HBV demonstrate modest accuracy for fibrosis diagnosis at conventional cut-offs. Lowering the cut-offs may increase the diagnostic relevance of these biomarkers, particularly for APRI, and FIB-4 in low-replicative disease.


Quantitative HBsAg Levels Do Not Identify Significant Fibrosis in HBeAg-negative Chronic Hepatitis B Patients

Faisal M. Sanai 1,2 , Abduljaleel Alalwan 3,4 , Taha Farah 1,4 , Khalid Alsaad 5 , Ayman A Abdo 1 , Waleed Alhamoudi 1 , Abdulrahman Aljumah 3,4

Liver Disease Research Center, King Saud University, Departments of 3 Hepatobiliary Sciences and Liver Transplantation and 5 Pathology, King Abdulaziz Medical City, 4 King Saud Bin Abdulaziz University for Health Sciences, Riyadh, 2 Department of Medicine, Gastroenterology Unit, King Abdulaziz Medical City, Jeddah, Saudi Arabia

Introduction: The accurate identification of inactive chronic hepatitis B virus (HBV) carriers (serum HBV DNA <2000 IU/mL) from those with active carriers is difficult because of wide and frequent HBV DNA fluctuations. We studied whether quantitative serum hepatitis B surface antigen (qHBsAg) levels may contribute to the identification of significant fibrosis (F2-F4, METAVIR) in untreated carriers. Methods: qHBsAg levels were measured at baseline as single-point quantification prior to biopsy and correlated with virologic and biochemical profiles of consecutive carriers followed-up prospectively (median, 8; range, 4-17 months). HBeAg-negative patients (n = 75) with mean HBV DNA <2000 (n = 5), 2000-20,000 (n = 16) and >20,000 IU/mL (n = 54) were included and all had liver biopsy. A qHBsAg cutoff point of 1000 IU/mL was assessed to demonstrate whether it better-delineated patients with nonsignificant histology (F0-F1, inflammatory grade A0-A1). Results: The mean age of the patients was 39.4 ± 11.4 years and 58 were male (77.3%). Patients with qHBsAg levels >1000 IU/mL were more likely to be males (84.5%, P = 0.006) or with elevated AST (68.4%, P = 0.0002), ALT levels (72.4%, P < 0.0001), higher HBV DNA (Log10 6.4 ± 1.4, P < 0.0001), and those with F2-F4 fibrosis (48.3%, P = 0.028). Serum log10 qHBsAg were significantly lower in patients with HBV DNA <2000 (2.80 ± 1.47) and HBV DNA 2000-20,000 (2.71 ± 0.83) vs. >20,000 IU/mL (3.89 ± 0.61, P < 0.0001). Overall, qHBsAg were not different in patients with F0-F1 (3.44 ± 0.91) and F2-F4 (3.74 ± 0.85, P = 0.161). qHBsAg were higher in patients with significant inflammation, A2-A3, (3.85 ± 0.72) compared to A0-A1 (3.38 ± 0.95; P = 0.018). Serum qHBsAg demonstrated poor accuracy (AUROC, 0.606, P = 0.111) in identification of F2-F4. Conclusions: Serum qHBsAg levels do not help differentiate between those with HBV DNA <2000 or 2000-20,000 IU/mL or distinguish patients with significant fibrosis. Moreover, more than half of the patients with non-significant fibrosis have a qHBsAg level greater than 1000 IU/mL.


Clostridium Difficile Infection Causing Protein Losing Enteropathy in Peripartum Period: A Case Report

AA Almutairdi, M. Alkhathami, M. Almutairi

Security Force Hospital, Riyadh, Saudi Arabia

Background: Protein-losing enteropathy (PLE) has been attributed to multiple causes including clostridium difficile infection (CDI). Pregnancy and peripartum period were described to be potential risk factors for acquiring CDI. Case Report: A 21-year-old female who gave birth 7 days prior to admission to our department where she presented with abdominal pain, distention, and fever that was proceeded by diarrhea 7 days before delivery. She had no previous medical illness. She had no recent antibiotics use. On presentation, she was tachycardia (160 b/min) and pyrexic (39.3 C) and had a distended abdomen with positive shifting dullness with diffuse tenderness and mild pitting ankle edema. Her investigations revealed marked leukocytosis (white blood cell: 39.5 × 109/L), Na = 128, albumin = 17 g/l, total protein = 44 g/l, lactic acid = 2.3, C-reactive protein = 378, urinalysis was unremarkable. Her computed tomography (CT) abdomen showed diffuse large bowel thickening and wall enhancement and significant ascites. Echocardiogram was normal and hepatic veins were patent on Doppler study. Clostridium difficile antigen and toxin assay were positive in three samples. She was treated as complicated CDI and was admitted to Intensive Care Unit and received hydration, intravenous metronidazole, oral, and rectal vancomycin. Two weeks later, she showed significant clinical improvement with increase in her albumin and total protein and follow-up CT abdomen later showed significant interval resolution of ascites and bowel thickening. Conclusion: CDI should be sought in peripartum patients presenting with diarrhea or PLE. Further studies to be conducted to assess the causal relationship of the peripartum period as a potential risk factor for CDI.


Outcomes of Treating Acute Perforated Duodenal Ulcer in Saudi Arabia

SA Alhumaid, Atheer Alotaibi, Laura Alolayan, M. Alzahrani

King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background: Perforated duodenal ulcer (PDU) resulting from peptic ulcer disease requires emergency surgery. The mainstay treatment for PDU is laparoscopic surgery. Outcomes for treating PDU could result in septic, pulmonary, and other complications. Our aim is to look into the prevalence and outcomes of treating patients who presented with PDU over the last 15 years in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Methods: This retroprospective observational study reviewed PDU patients admitted to KAMC between 2000 and 2015. Results: The number of patients with PDU was found to be 50. 74% were male, and 26% were female. The mean age was 48 years old. 72% had chronic diseases. 28% and 10% were smokers & alcoholic, respectively. 10% had a history of nonsteroidal-anti-inflammatory-drugs use. 40% were diagnosed by computed tomography scan and 60% by chest-X-ray. 94% went through either laparoscopic or laparotomy repair, 94% of which had postoperative antibiotic and proton-pump-inhibitor. Out of those operated, all had minimal bleeding, 4% had wound infection, 9% had anastomosis leak and 11% with an abdominal abscess. One patient had a documentation of recurrence. Seven death cases were reported, 6 of which were postoperative. Cardiopulmonary-arrest was the main cause of mortality among our sample with one death case attributed to "PDU with other comorbidities." Conclusion: Fifty cases of PDU were reported at KAMC. However, lack of documentation may underestimate the prevalence and outcomes of treating PDU. Thus, we recommend that a larger sample size in different centers be studied to further elaborate on the magnitude of this disease and its management.


Plasma Endocan Levels in Nonalcoholic Fatty Liver Disease Patients

Jumanah Alshenaifi, Reema Alanazi, Mazen Hassanain

King Khalid University Hospital, Riyadh, Saudi Arabia

Background: Nonalcoholic fatty liver disease (NAFLD) is a challenging clinical diagnosis with no biomarkers for either diagnosis or prognosis. Endocan is a potential market. There have been no reported studies correlating between its level and NAFLD severity. Endocan is an endothelial-derived biomarker that is expressed in some human tissues and is expressed in hepatocytes of normal patients, but no trace was detected in the resting endothelium of the liver, which suggests that its expression can be employed to differentiate between active and dormant endothelium in liver disease. We hypothesize that endocan levels may be directly proportional to the degree of inflammation in NAFLD; this can serve as a noninvasive biomarker to stratify disease severity and to monitor the progression. Furthermore, its expression can be used to target patients for a liver biopsy if needed. Methods: A cross-sectional experiment will be conducted at the Liver Disease Research Center, KKUH from 2015 to 2016. All patients with available blood samples will be identified retrospectively from a prospective NAFLD database and will be divided into groups based on histopathological diagnosis. Endocan levels and other markers will be measured. Results: t-test between groups was insignificant. However, Levene's test resulted in a significant P-value of (0.032) for steatohepatitis and cirrhosis patients groups and (0.036) for normal and steatohepatitis groups. Conclusion: In this pilot study, endocan levels showed no significance among all the NAFLD study groups. However, an increase in sample size is needed to establish the association between endocan levels and the degree of inflammation in NAFLD patients.


Intragastric Balloon and Weight Reduction: Saudi Perspective

Ebtissam Saleh Almeghaiseeb, Muhammad Farooq Ashraf, Reem Abdullah Alamro, Abdulaziz Omar Almasoud, Abdulrahman Ali Alrobayan

Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Introduction: Lifestyle changes are of modest weight reduction success with a high rate of weight gain upon cessation of the same. There has been an increased interest in the endoscopically placed intragastric balloon (IGB) for the treatment of morbid obesity. To evaluate the safety and efficacy of IGB in weight reduction in obese patients referred to a tertiary hospital in the Kingdom of Saudi Arabia. Methods: Three hundred and one consecutive obese individuals, who had an IGB placement endoscopically at Prince Sultan Military Medical City Hospital, KSA between January 2009 and May 2015 were included in the analysis. Both men and women were aged 18-60 years and had a minimum body mass index (BMI) of 27 kg/m 2 . All were medically free from or with one or two of the comorbidities. The IGB was removed on completion of 6 months, with the duration extending by one or more months in some subjects. Anthropometric measurements were recorded during and after 6 months of IGB removal. Results: The mean body weight loss (BWL) (kg) was 12.48 ± 5.16 kg at removal and 13.67 ± 6.65 after 6 months of IGB removal. The mean BWL% was 13.08 ± 4.81 at removal and 14.30 ± 6.12 after 6 months of removal. The mean Number of Patients with BWL% >10 was 224 and 226, respectively. The mean BMI (kg/m 2 ) was 31.49 ± 4.88 at removal and 31.04 ± 5.01 after 6 months of removal. The mean BMI loss (kg/m 2 ) was 4.75 ±1.87 at removal and 5.20 ± 2.40 after 6 months of removal. No serious complications were observed during recovery from IGB implant procedure. Conclusion: IGB was effective in our cohorts. The observed weight reduction was maintained for at least 6 months post-IGB removal. IGB placement was safe and had a satisfactory rate of tolerance among our cohorts.


Is Bioavailability of Oral Ribavirin Affected by Diet in Hepatitis C Patients?

Sara Altraif, Shazia Murtaza, Pierre Marque, A. Bekairy, Faisal Sanai, Hamdan Al-Ghamdi, A. Alwan, A. Al-Jumah, Mohammed Hussein, Naila Shaheen, Altaf Hussain Khan, Ibrahim H. Al Traif

Department of Hepatobiliary Sciences and Liver Transplantation, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

Introduction: Oral ribavirin is a nucleoside analogue used in hepatitis C therapy. Ribavirin bioavailability is increased by high-fat diet, hence, the manufacturer recommends taking ribavirin with food. Objectives: To compare ribavirin bioavailability in 18-g fat diet versus fasting state among hepatitis C genotype 4 (G4) patients. Methods: A self-controlled prospective open-label study was conducted from 01-2012 to 12-2014 and included 82 chronic hepatitis C patients. Each patient received 600 mg of oral ribavirin in the fasting and fed states (18 g-fat breakfast) at least 3 weeks apart and underwent a pharmacokinetic profile at 0.5, 1.0, 2.0 h, and area under the curve (AUC) was calculated. Demographic characteristics of the study cohort were reported using descriptive statistics. Ribavirin bioavailability in the fasting and fed states was compared using a generalized linear model. Results: Among 82 consecutive patients, 49 (59.76%) were females. The mean age was 53.40 + 1.39 and 32 (41.03%) had diabetes. Ribavirin plasma concentrations in (mg/l) were found in the fasting versus fed state with a mean + standard error as follows: At 0.5 h was (0.28 + 0.03) P value 0.004, 1 h (0.54 + 0.03 vs. 0.44 + 0.03) P value 0.021, and 2 h (0.62 + 0.03 vs. 0.73 + 0.03, P value 0.011). However, AUC for ribavirin concentrations from 0 to 4 h postdose (AUC 0-4 h) was not different between the two states (P = 0.956).

Conclusions: Among hepatitis C virus G4 adult patients, there was no significant difference in (AUC 0-4 h) between fasting and fed (18-g fat diet) states in ribavirin bioavailability. We recommend physicians to maintain patients' convenience in the timing of ribavirin oral intake.


Effectiveness of Radiofrequency Energy Delivery (Stretta) to the Gastroesophageal Junction in Refractory GERD Patients: A Prospective Controlled Therapeutic Trial

Mohammed Q. Khan, Mohammed Al-Quaiz, Adnan Al-Mahrouq, Hanaa S. Abdallah, Sahar Jbarah, Fahad Al-Sohaibani, Hamad Al-Ashgar

Department of Medicine, Section of Gastroenterology and Endoscopy, KFSH and RC, Riyadh, Saudi Arabia

Background: Gastroesophageal reflux disease (GERD) is the most common chronic gastrointestinal disorder (reported up to 45% in Saudi Arabia) and approximately 40% of patients with GERD do not respond to medical therapy. The radiofrequency energy delivery to the gastroesophageal junction (Stretta procedure), represents an alternative to refractory GERD patients and an attempt to bridge the gap between medical and surgical therapy. Aims: The objective was to assess the effectiveness of the Stretta procedure in proton pump inhibitor (PPI) refractory GERD patients, based on improvement in GERD-health related quality of life (HRQL), the reduction or elimination of medication use and level of satisfaction after the radiofrequency application. Methods: We conducted a prospective therapeutic trial among 56 adults PPI-refractory symptomatic GERD patients at KFSH and RC from 2013 to 2015. All patients had a confirmed diagnosis of GERD either by endoscopy or by pH monitoring. High-resolution manometry was performed before Stretta to rule out major motility disorders. After Stretta, the patients were allowed to take PPI therapy on PRN basis and record the GERD-HRQL symptoms satisfactory score. Results: After 6 months of Stretta procedure, only 54 patients responded to the telephonic call. The 11 patients (20%) were very satisfied with the procedure, 26 (48%) satisfied, 9 (17%) did not feel any change, 6 (11%) dissatisfied, and 2 (4%) were very dissatisfied. Only 4 (7%) patients were able to discontinue PPI after the Stretta procedure, 15 (28%) continued PPI on PRN basis, 15 (28%) reduced the dose of PPI to 20 mg daily, 19 (35%) continued PPI 40 mg daily, and one patient underwent fundoplication. All patients complained of mild to moderate epigastric pain after Stretta, but none reported any serious complication. Conclusion: Stretta procedure is well tolerated and safe procedure, showed significant improvement in GERD-HRQL symptoms in strictly selected patients and may represent an alternative to medical treatment and surgical fundoplication.


Can Fecal Calprotectin Predict the Future?

Kwapisz, Mahmoud Mosli 1 , N. Chande, B. Yan, M. Beaton, J. Micsko, W. Barnett, K. Bax, T. Ponich, J. Howard, A. Tirolese, R. Lannigan, J. Gregor

King Abdulaziz University Hospital City, Jeddah, Saudi Arabia

Background: Fecal calprotectin (FC) is a marker of bowel inflammation that is currently used to diagnose and evaluate inflammatory bowel disease (IBD). In a previously reported prospective diagnostic cohort study, rapid FC testing was helpful in identifying patients with active IBD (Kwapisz et al., Saudi J Gastro 2015). The same cohort was then followed up for 1 year and re-evaluated. The aim of this study is to assess if FC levels could predict future bowel inflammation manifesting as IBD relapse requiring escalation of therapy or diagnosis of IBD in patients previously diagnosed with IBS at baseline. Methods: A total of 126 consecutive adult patients who presented to outpatient clinics with lower gastrointestinal symptoms provided high range FC samples within 4 weeks of their baseline scheduled an endoscopic assessment. All patients were followed up for at least 1 year and monitored clinically for any change in symptomatology, escalation of therapy, or development of IBD, confirmed endoscopically. IBD flare-ups required endoscopic confirmation. Escalation of therapy included any intensification in dosage, frequency, or addition of new therapies for IBD such as 5-ASA agents, corticosteroids, immunosuppressants, tumor necrosis factors antagonists, leukocyte trafficking inhibitors, investigational drugs, or need for surgery. Diagnosis of IBD was based on conventional clinical, Results: 126 patients, of whom 66 were females, were included with a mean age of 44.4 years (±16.7). At baseline, 72 had known IBD and active endoscopic evidence of disease activity. Utilizing an FC cut-off of 100 μg/g, 66% (33/50) of patients with endoscopically active IBD went on to have an escalation in therapy within 1 year. Among those with FC levels <100 μg/g, only 18% (4/22) required an increase in therapy. Thirty-three percent (2/6) of patients with quiescent IBD at baseline who had FC levels >100 μg/g, required escalation in therapy due to disease flare up, whereas none of those with FC levels <100 μg/g (0/12) needed a change in therapy. Finally, for patients who did not have IBD and had a normal endoscopic evaluation with an FC level >100 μg/g, none (0/17) was diagnosed with IBD within 1 year. Conclusions: Elevated FC concentrations in the absence of endoscopically visible IBD can predict future relapses requiring escalation of therapy in those known to have IBD, and future development of IBD in IBS patients.


Detection of Human Papillomavirus Infection by Molecular Tests and its Relation to Colonic Polyps and Colo-Rectal Cancer: A Prospective Case-Control Study

F.S. Gazzaz, Mahmoud Mosli, H. Jawa, A.R. Sibiani

King Abdulaziz University Hospital City, Jeddah, Saudi Arabia

Background: The association of human papillomavirus (HPV) with colorectal polyps (CRPs) and colorectal cancer (CRC) has been suggested by literature originating from Western countries, but this relationship has not been clearly established in Arabic or middle eastern countries such as Saudi Arabia. The aim of this study is to prospectively examine this association. Methods: A prospective case-control study was performed at King Abdulaziz University Hospital between January 2013 and December 2014. All eligible patients consenting to participation underwent standard diagnostic colonoscopy. Patients found to have polyps, or CRC were considered cases while those with any other endoscopic finding were controls. Biopsy samples from polyps and tumors and/or from normal colonic mucosa were acquired. HPV colonization was detected using a hybrid capture technique of samples taken from both normal tissue and CRPs/CRC. Association between HPV and CRPs/CRC was evaluated through binary logistic regression analysis with conditional backward elimination model selection. Results: A total of 132 patients were recruited. Mean age was 53 (±standard deviation [SD] 15.9), and 56% of patients were males. About 51% of patients were native Saudis while 49% were of other ethnicities. A total of 60 patients had endoscopically detectable CRPs/CRC, and 70 had either inflammation or normal endoscopic evaluations. Only four (0.8%) of the 132 samples that were collected and analyzed were positive for the HPV gene. Statistical analysis did not identify any significant association between HPV colonization and the presence of CRPs/CRC. The only identified significant predictor of detecting CRPs/CRC on colonoscopy was symptomatic presentation (OR = 11.072, 95% CI 4.686-26.162, P-< 0.001). Conclusions: HPV colonic colonization is rare in Saudi Arabia. An association between HPV colonization and CRP/CRC development could not be identified in this cohort of patients.


Lack of Adherence for Opportunistic Infections Screening and Vaccinations Guideline in Inflammatory Bowel Disease Patients Before Induction of Biological Therapy

Nahla Azzam 1 , Majid Almadi 1,2 , Othman Alharbi 1 , Nada Al-Madhi 1 , Lolwah Al-Ashgar 1 , lamia Al-Ghamdi 1 , Abdulrahman Aljebreen 1

1Division of Gastroenterology, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia, 2Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada

Objective: We investigated the adherence to the European Crohn's Colitis Organization (ECCO) recommendations for opportunistic infections screening and vaccinations in patients with inflammatory bowel diseases (IBD) prior to the initiation of biological therapy. Methods: A retrospective study evaluating the adherence to ECCO guideline for screening of infections and vaccination in IBD patients prior starting biological therapy in a single tertiary care center. All patients' medical record were reviewed. Results: A total of 49 patients were included. 19 (38.7%) were females. The mean age was 28.9 years (standard deviation ±10.8). 44 patients (90%) had Crohn's disease while 5 patients (10%) had ulcerative colitis. Of 49 participating patients, 33 (67 %) received skin purified protein derivative test and a chest X-ray was done in 39 (80%). A history of previous exposure to tuberculosis was noted in 1 patients (2.5%). Screening for hepatitis B (HB) surface antigen, anti-HB core (HBc), and anti-HB surface antibody were performed only in (73%, 28%, and 28%, respectively). Thirty-one patients (63%) were screened for hepatitis C. A history of exposure to varicella zoster virus was reported in 41 patients (87%). The nonadherence to vaccination recommendations against pneumococcal and seasonal flu was high (86% and 94%, respectively). Conclusion: Only a minority of patients with Crohn's disease or ulcerative colitis on biological therapy received the ECCO recommendations concerning vaccination and hepatitis B surface antigen, anti-HBc screening. Adherence to the guideline may be enhanced by linking pharmacy dispensing of biological therapy to pretreatment screening and vaccination.


Conventional Transarterial Chemoembolization
Versus Drug-Eluting Beads for Treatment of Unresectable Hepatocellu l ar Carcinoma: A Systematic Review and Meta -analysis

Mohammad Arabi, Ali Hussain Albenmousa, Samia Alhabib, Mazen Ferwana, Wedad H. Al-Madani, Faisal Sanai
1 , Khaled Bzeizi

Department of Gastroenterology, Prince Sultan Military Medical City, Riyadh, 1 Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia

Background: Conventional transarterial chemoembolization (c-TACE) is a well-recognized treatment modality for intermediate stage hepatocellular carcinoma; however, its use in chronic liver disease patients is associated with increased incidence of systemic toxicity and decompensation. TACE with drug-eluting beads (DEB-TACE) has been recently developed to improve local tumor necrosis and to reduce the systemic side effects of chemotherapy. The superiority of DEB-TACE over c-TACE needs to be further investigated. Aims: To compare the efficacy, safety, and survival benefit of DEB-TACE to c-TACE. Materials and Methods: We searched the Cochrane Library, the Cochrane Hepato-Biliary Group Controlled Trials Register, Medline, Embase, Trip Database, and Science Citation Index. We included studies that compared DEB-TACE to c-TACE. Since a small number of randomized controlled trials (RCTs) was available, we included cohort and case-control studies. The primary outcome was tumor response based on the European Association for the Study of the Liver or Modified Response Evaluation Criteria in Solid Tumors criteria. Secondary endpoints were procedure safety and survival benefit. Results: Twenty studies were included (five RCTs and 15 retrospective case-control and cohort studies) in this systematic review enrolling a total of 2350 patients, 1242 patients in c-TACE arm and 1108 in DEB-TACE arm. DC Beads were used in 18 studies and HepaSpheres in the remaining two studies. There was no statistically significant difference between the groups in complete response (odds ratio [OR] = 1.03, 95% confidence interval [CI]: 0.66−1.62, P = 0.88). However, DEB-TACE was superior in achieving partial response (OR = 1.46, 95%CI: 1.14−1.86, P = 0.00) and disease control (OR = 1.46, 95%CI: 1.09−1.96. P = 0.01). Incidence of serious adverse events was similar in both groups (OR = 0.98, 95%CI: 0.72−1.35, P = 0.92). Mortality at 30 days postprocedure was reported in four studies with no statistical difference between the groups (OR = 0.59, 95%CI: 0.24−1.48, P = 0.26). However, analysis of death at the end of included studies showed a significant statistical difference (OR = 0.29, 95%CI: 0.10−0.79, P = 0.02) indicating survival benefit with DEB-TACE. Significant heterogeneity and publication bias were found between studies on analyzing most of the reported outcomes. Conclusion: This analysis suggests that DEB-TACE is superior to c-TACE in achieving partial response and disease control. Both techniques demonstrated similar safety profile; however, DEB-TACE seems to offer a survival benefit over c-TACE. Considering the heterogeneity of included studies, DEB-TACE superiority needs to be further evaluated in large RCTs.

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