Chronic diarrhea is a complex symptom. The clinical approach and management should be based on pathophvsiologic considerations and stepwise laboratory investigations. In infants with severe malnutrition, nutritional support is a priority in the management of this condi­tion.

Refractory or intractable ulcer is defined as an ulcer that fails to heal completely after eight to twelve weeks, despite appropriate treatment with a modern antiulcer therapy in a compliant patient. Refractory ulcer should be suspected in individuals diagnosed to have peptic ulcer if their symptoms persist longer than usual: occurrence of complications or simply their ulcers fail to heal, since up to 25% of such patients remain asymptomatic. Conditions associated with refractory ulcer include noncompliance, continuous consumption of nonsteroidal anti-inflam­matory drugs, acid hypersecretion, smoking. male gender and other factors with questionable role like advanced age, large ulcer size, prolonged duration of symptoms and the presence of complication like bleeding. Nonpeptic ulcers like tuberculosis, malignancy, Crohn's disease and primary intestinal lymphoma should always be considered in the differential diagnosis. Colonization with H. pylori which is well-known as a cause of frequent recurrences, has not been linked with refractoriness. Patients with refractory ulcers must undergo thorough re­evaluation including repeated endoscopies, obtaining biopsies for microbiology and histology and determination of serum-gastrin level. Once diseases with identifiable etiologies have been ruled out, aggressive medical management with single or multiple antiulcer drugs should be instituted. Such treatments will virtually heal all refractory ulcers. Surgery should be reserved for patients whose ulcers fail to respond to optimal medical therapy or those who develop com­plications necessitating surgical intervention.

Viral etiology was investigated in 133 Saudi patients with acute hepatitis seen in King Khalid University Hospital, Riyadh. between July 1993-May 1994. Out of the 133 patients, 51 (38.3%) were diagnosed as having acute hepatitis due to hepatitis A virus (HAV). Hepatitis C virus (HCV) was the second most common etiological agent (20.3%). There were 35 patients with acute hepatitis (26.3%) in whom no viral marker for HAV, HBV, HCV, CMV or Epstein-Barr virus (EBV) was detected. Among the 51 patients with acute hepatitis due to HAV, the major­ity (88.2%) were children (1-12 years) and only 6 (11.8%) were adults (15-24 years). This is in contrast to patients with HCV or HBV infection where the majority were adults: 74.1% and 82.3% respectively. The diagnosis of acute hepatitis due to HAV in Saudi adults, an observa­tion not seen earlier, indicated a change in the epidemiological pattern of HAV infection in the Saudi population. This change was confirmed by the significant reduction in the prevalence of anti-HAV in 630 Saudi subjects (1-30 years old) (50.2%) investigated in 1994 compared to that of 587 subjects of the same age group investigated in 1986 (76.5%) (P < 0.005). In the light of these results, a nation-wide survey is recommended to confirm this pattern in other areas. It is important that high-risk Saudi groups be identified and evaluated for their anti-HAV status as these groups are candidates for HAV vaccination.