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July-August 2015
Volume 21 | Issue 4
Page Nos. 181-264
Online since Wednesday, July 29, 2015
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EDITORIALS
ERCP for common bile duct stone extraction: Sphincterotomy, balloon dilation, or both?
p. 181
Mohammad Al-Haddad
DOI
:10.4103/1319-3767.161639
PMID
:26228359
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Selecting the optimum first-line treatment for
H. pylori
eradication
p. 183
Tiing L Ang, Majid A Almadi
DOI
:10.4103/1319-3767.161638
PMID
:26228360
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SPECIAL COMMUNICATION
A Saudi Gastroenterology association position statement on the use of tumor necrosis factor-alfa antagonists for the treatment of inflammatory bowel disease
p. 185
Mahmoud H Mosli, Othman Al-Harbi, Brian G Feagan, Majid A Almadi
DOI
:10.4103/1319-3767.161635
PMID
:26228361
The objective of this position statement from the Saudi Gastroenterology Association is to guide gastroenterologists on the use of tumor necrosis factor-alfa (TNF-α) antagonists for the treatment of the idiopathic inflammatory bowel diseases, Crohn’s disease, and ulcerative colitis. In this article, we summarize the relevant literature regarding the safety and efficacy of TNF-α antagonists, highlight relevant safety concerns specific to the environment in Saudi Arabia, and provide specific recommendations for the use of these agents.
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REVIEW ARTICLE
Framework for interpretation of trypsin-antitrypsin imbalance and genetic heterogeneity in pancreatitis
p. 198
Kun Lin, Feng Gao, Qingquan Chen, Qicai Liu, Shu Chen
DOI
:10.4103/1319-3767.161643
PMID
:26228362
Early intracellular premature trypsinogen activation was interpreted as the key initiator of pancreatitis. When the balance in the homeostasis of trypsin and antitrypsin system is disequilibrated, elevated aggressive enzymes directly attack the pancreatic tissue, which leads to pancreatic destruction and inflammation. However, trypsin alone is not enough to cause complications in pancreatitis, which may play a crucial role in modulating signaling events in the initial phase of the disease. NFκB activation is the major inflammatory pathway involved in the occurrence and development of pancreatitis and it can be induced by intrapancreatic activation of trypsinogen. Synthesis of trypsinogen occurs in endoplasmic reticulum (ER), and ER stress is an important early acinar cell event. Components of ER stress response are known to be able to trigger cell death as well as NFκB signaling cascade. The strongest evidence supporting the trypsin-centered theory is that gene mutations, which lead to the generation of more trypsin, or reduce the activity of trypsin inhibitors or trypsin degradation, are associated with pancreatitis. Thus, trypsin–antitrypsin imbalance may be the first step leading to pancreatic autodigestion and inducing other pathways. Continued experimental studies are necessary to determine the specific relationships between trypsin–antitrypsin imbalance and genetic heterogeneity in pancreatitis. In this article, we review the latest advances that contributed to the understanding of the basic mechanisms behind the occurrence and development of pancreatitis with a focus on the interpretation of trypsin–antitrypsin imbalance and their relationships with other inflammation pathways. We additionally highlight genetic predispositions to pancreatitis and possible mechanisms associated with them.
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SYSTEMATIC REVIEW
The impact of
Clostridum difficile
on surgical rate among ulcerative colitis patients: A systemic review and meta-analysis
p. 208
Jiang-Chen Peng, Jun Shen, Qi Zhu, Zhi-Hua Ran
DOI
:10.4103/1319-3767.161644
PMID
:26228363
There is growing recognition of the impact of
Clostridum difficile
infection (CDI) on patients with inflammatory bowel disease. Clostridium difficile infection causes greater morbidity and mortality. This study aimed to evaluate the impact of
C. difficile
on surgical risk among ulcerative colitis (UC) patients. We searched the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, ACP Journal Club, DARE, CMR, and HTA. Studies were included if fulfilled the following criteria: (1) Cohort or case–control studies, which involved a comparison group that lacked CDI, (2) Patients were given a primary diagnosis of UC, (3) Comorbidity of CDI was evaluated by enzyme immunoassay of stool for C. difficile toxin A and B or C. difficile stool culture, (4) Studies evaluated surgical rate, and (5) Studies reported an estimate of odds ratio, accompanied by a corresponding measure of uncertainty. Five studies with 2380 patients fulfilled the inclusion criteria. Overall, meta-analysis showed that UC with CDI patients had a significant higher surgical rate than patients with UC alone. (OR=1.76, 95% CI=1.36–2.28).
C. difficile
infection increased the surgical rate in UC patients. However, results should be interpreted with caution, given the limitations of this stud.
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ORIGINAL ARTICLES
Superiority of 10-mm-wide balloon over 8-mm-wide balloon in papillary dilation for bile duct stones: A matched cohort study
p. 213
Dai Akiyama, Tsuyoshi Hamada, Hiroyuki Isayama, Yousuke Nakai, Takeshi Tsujino, Gyotane Umefune, Naminatsu Takahara, Dai Mohri, Hirofumi Kogure, Saburo Matsubara, Yukiko Ito, Natsuyo Yamamoto, Naoki Sasahira, Minoru Tada, Kazuhiko Koike
DOI
:10.4103/1319-3767.161634
PMID
:26228364
Background/Aims:
Endoscopic papillary balloon dilation (EPBD) is a possible alternative to endoscopic sphincterotomy (EST) for common bile duct (CBD) stones. To date, 10- and 8-mm EPBD have not been fully compared.
Patients and Methods:
Patients who underwent EPBD for CBD stones at two Japanese tertiary care centers between May 1994 and January 2014 were identified. Matched pairs with 10- and 8-mm EPBD were generated. Short- and long-term outcomes were compared between the two groups.
Results:
A total of 869 patients were identified (61 and 808 patients for 10- and 8-mm EPBD, respectively), and 61 well-balanced pairs were generated. The rate of complete stone removal within a single session was higher in the 10-mm EPBD group than in the 8-mm EPBD group (69% vs. 44%,
P
< 0.001), and use of lithotripsy was less frequent in the 10-mm EPBD group (23% vs. 56%,
P
< 0.001). The rates of post-ERCP pancreatitis were similar between the 10- and 8-mm EPBD groups (11% vs. 8%). Cumulative biliary complication-free rates were not statistically different between the two groups: 88% [95% confidence interval (CI): 79–97%] and 94% (95% CI: 88–100%) at 1 year and 69% (95% CI: 56–85%) and 80% (95% CI: 69–93%) at 2 years in the 10- and 8-mm EPBD groups, respectively. In the 10-mm EPBD group, ascending cholangitis was not observed, and pneumobilia was found in 5% of cases during the follow-up period.
Conclusions:
EPBD using a 10-mm balloon for CBD stones is safe and more effective than 8-mm EPBD. The sphincter function is highly preserved after 10-mm EPBD.
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Prospective trial in Saudi Arabia comparing the 14-day standard triple therapy with the 10-day sequential therapy for treatment of
Helicobacter pylori
infection
p. 220
Fahad Alsohaibani, Hamad Al Ashgar, Khalid Al Kahtani, Ingvar Kagevi, Musthafa Peedikayil, Abdulrahman Alfadda, Mohammed Khan
DOI
:10.4103/1319-3767.161647
PMID
:26228365
Background/Aims:
Treatment success for
Helicobacter pylori
infection in Saudi Arabia is relatively unexplored. This prospective study compared the efficacy of sequential versus standard triple therapy in curing
H. pylori
infections.
Patients and Methods
: Eligible patients underwent upper endoscopy at a single center in Saudi Arabia from October 2011 to February 2014. Patients who tested positive for
H. pylori
infection were randomly assigned to sequential therapy or standard triple therapy. Sequential treatment: Esomeprazole (20 mg bid for 10 days), amoxicillin (1000 mg for 5 days), then clarithromycin 500 mg and tinidazole 500 mg; both bid for 5 days. Standard triple treatment: Esomeprazole 20 mg, clarithromycin 500 mg, and amoxicillin 1000 mg each bid for 14 days. After 6 weeks of treatment, patients were tested for cure using a validated urea breath test. Application of the E-test determined susceptibility of
H. pylori
to different antibiotics.
Results:
Of the 115 patients who received sequential therapy, 93 completed treatment. In the triple-therapy arm, 103 of 117 patients completed treatment. The eradication rate was 58/93 (62.3%) with sequential therapy and 69/102 (67.6%) with standard triple therapy,
P
= 0.44. Risk ratio was 0.92 (95% CI; 0.75–1.13), and number needed to treat was 19. Overall primary resistance: Metronidazole (48.5%), clarithromycin (23.3%), amoxicillin (14.8%), levofloxacin (11.1%), and tetracycline (2.3%). Mild adverse events occurred in 35 and 17 patients in the sequential and standard therapy groups, respectively.
Conclusion:
Sequential and standard triple therapies were similarly effective at eradicating
H. pylori
in two-thirds of Saudi patients. Metronidazole and clarithromycin resistance to
H. pylori
strains was common.
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The expression of hepatic carboxypeptidase E is decreased in patients with cholesterol gallstone
p. 226
Shu-Long Dai, Jin Zhou, Kun-Xing Yang, Shi-Yong Yang
DOI
:10.4103/1319-3767.161640
PMID
:26228366
Background/Aims:
Decreased carboxypeptidase E (CPE) expression is associated with numerous pathophysiological conditions. This study aimed to investigate the potential function of hepatic CPE in cholesterol gallstone formation.
Patients and Methods:
Patients with cholesterol gallstone (CGS group) and patients without cholesterol gallstones (non-CGS group) were enrolled. The serum total cholesterol, triglyceride, and biliary composition were analyzed. Eight liver samples from two patients without CGS and six patients with CGS were subjected to cDNA microarray analysis. Hepatic CPE expression was detected by quantitative real-time polymerase chain reaction (qRT-PCR), Western blot, and immunohistochemical analysis. Plasma CCK level was measured by ELISA.
Results:
cDNA microarray identified CPE as a gene downregulated in the CGS group. RT-PCR showed that CPE mRNA level was lower in CGS group than in control (
P
< 0.05,
t
-test). Moreover, Western blot and immunohistochemistry analysis showed that CPE protein level was significantly lower in CGS group than in the control group. In addition, plasma CCK level was lower in CGS group than in the control group. A positive correlation was found between serum CCK level and hepatic CPE mRNA level (
r
2 = 0.713,
P
= 0.003).
Conclusions:
Down-expression of liver CPE may reduce the secretion of serum CCK and contribute to the formation of cholesterol gallstone.
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Nonalcoholic fatty liver disease progression in rats is accelerated by splenic regulation of liver PTEN/AKT
p. 232
Ziming Wang, Naishu Li, Biao Wang, Jianhua Lin
DOI
:10.4103/1319-3767.161641
PMID
:26228367
Background/Aim:
The spleen has been reported to participate in the development of nonalcoholic fatty liver disease (NAFLD), but the mechanism has not been fully characterized. This study aims to elucidate how the spleen affects the development of NAFLD in a rat model.
Materials and Methods:
Following either splenectomy or sham operation, male Sprague–Dawley (SD) rats were fed a high-fat diet to drive the development of NAFLD; animals fed a normal diet were used as controls. Two months after surgery, livers and blood samples were collected. Serum lipids were measured; liver histology, phosphatase and tensin homologue deleted on chromosome 10 (PTEN) gene expression, and the ratio of pAkt/Akt were determined.
Results:
Splenectomy increased serum lipids, except triglyceride (TG) and high-density lipoprotein (HDL), in animals fed either a high-fat or normal diet. Furthermore, splenectomy significantly accelerated hepatic steatosis. Western blot analysis and real-time polymerase chain reaction showed splenectomy induced significant downregulation of PTEN expression and a high ratio of pAkt/Akt in the livers.
Conclusions:
The spleen appears to play a role in the development of NAFLD, via a mechanism involving downregulation of hepatic PTEN expression.
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Bactericidal permeability increasing protein gene polymorphism is associated with inflammatory bowel diseases in the Turkish population
p. 239
Güray Can, Hakan Akın, Filiz T. Özdemir, Hatice Can, Bülent Yılmaz, Fatih Eren, Özlen Atuğ, Belkıs Ünsal, Hülya O. Hamzaoğlu
DOI
:10.4103/1319-3767.161642
PMID
:26228368
Background/Aims:
Inflammatory bowel disease, a chronic inflammatory disease with unknown etiology, affects the small and large bowel at different levels. It is increasingly considered that innate immune system may have a central position in the pathogenesis of the disease. As a part of the innate immune system, bactericidal permeability increasing protein has an important role in the recognition and neutralization of gram-negative bacteria. The aim of our study was to investigate the involvement of bactericidal permeability increasing protein gene polymorphism (bactericidal permeability increasing protein Lys216Glu) in inflammatory bowel disease in a large group of Turkish patients.
Patients and Methods:
The present study included 528 inflammatory bowel disease patients, 224 with Crohn’s disease and 304 with ulcerative colitis, and 339 healthy controls.
Results:
Bactericidal permeability increasing protein Lys216Glu polymorphism was found to be associated with both Crohn’s disease and ulcerative colitis (
P
= 0.0001). The frequency of the Glu/Glu genotype was significantly lower in patients using steroids and in those with steroid dependence (
P
= 0.012, OR, 0.80; 95% confidence interval [CI]: 0.68-0.94;
P
= 0.0286, OR, 0.75; 95% CI: 0.66-0.86, respectively). There was no other association between bactericidal permeability increasing protein gene polymorphism and phenotypes of inflammatory bowel disease.
Conclusions:
Bactericidal permeability increasing protein Lys216Glu polymorphism is associated with both Crohn’s disease and ulcerative colitis. This is the first study reporting the association of bactericidal permeability increasing protein gene polymorphism with steroid use and dependence in Crohn’s disease.
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Predictors of sustained virologic response after discontinuation of nucleos(t)ide analog treatment for chronic hepatitis B
p. 245
Jie Peng, Jiawei Cao, Tao Yu, Shaohang Cai, Zhandong Li, Xiaoyong Zhang, Jian Sun
DOI
:10.4103/1319-3767.161645
PMID
:26228369
Background/Aims:
The aim of this study was to identify the predictors for relapse after discontinuation of oral nucleos(t)ide analog treatment for chronic hepatitis B (CHB).
Patients and Methods:
We evaluated patients who were receiving long-term, regular antiviral therapy with nucleos(t)ide analogs, and subsequently achieved the discontinuation criteria from the Asia-Pacific guideline. After they voluntarily discontinued the drug therapy, data were prospectively collected to observe the potential virologic relapse, and the parameters that predicted recurrence were analyzed.
Results:
Sixty-five patients met the inclusion criteria, and were included in this study. Twenty-eight patients relapsed, and the accumulative recurrence rates at the 3-month, 6-month, and 1-year follow-ups were 13.85%, 32.31%, and 49.23%, respectively. There was no difference in the accumulative recurrence rate 12 months after discontinuation among patients who were positive or negative for the hepatitis B e antigen (HBeAg) before they received the medication. Logistic regression analysis revealed that the time to complete response, age at discontinuation, and HBsAg levels at discontinuation affected the rate of relapse.
Conclusions:
Among patients who received orally administrated nucleos(t)ide analogs, serum levels of HBsAg, age at discontinuation, and the time to complete response might be used as a guide to discontinue treatment. Among younger patients, those with low serum HBsAg levels, and those with an earlier complete response, the risk of relapse is lower and discontinuation is much safer.
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The international normalized ratio does not reflect bleeding risk in esophageal variceal hemorrhage
p. 254
Tammy T Hshieh, Aung Kaung, Syed Hussain, Michael P Curry, Vinay Sundaram
DOI
:10.4103/1319-3767.161646
PMID
:26228370
Background/Aims:
The international normalized ratio (INR) has not been validated as a predictor of bleeding risk in cirrhotics. The aim of this study was to determine whether elevation in the INR correlated with risk of esophageal variceal hemorrhage and whether correction of the INR prior to endoscopic therapy affects failure to control bleeding.
Patients and
Methods
: Patient records were retrospectively reviewed from January 1, 2000 to December 31, 2010. Cases were cirrhotics admitted to the hospital due to bleeding esophageal varices. Controls were cirrhotics with a history of non-bleeding esophageal varices admitted with ascites or encephalopathy. All variceal bleeders were treated with octreotide, antibiotics, and band ligation. Failure to control bleeding was defined according to the Baveno V criteria.
Results
: We analyzed 74 cases and 74 controls. The mean INR at presentation was lower in those with bleeding varices compared to non-bleeders (1.61 vs 1.74,
P
= 0.03). Those with bleeding varices had higher serum sodium (136.1 vs 133.8,
P
= 0.02), lower hemoglobin (9.59 vs 11.0,
P
< 0.001), and lower total bilirubin (2.47 vs 5.50,
P
< 0.001). Multivariable logistic regression showed total bilirubin to inversely correlate with bleeding (OR = 0.74). Bleeders received a mean of 1.14 units of fresh frozen plasma (FFP) prior to endoscopy (range 0-11 units). Of the 14 patients (20%) with failure to control bleeding, median INR (1.8 vs 1.5,
P
= 0.02) and median units of FFP transfused (2 vs 0,
P
= 0.01) were higher than those with hemostasis after the initial endoscopy.
Conclusions
: The INR reflects liver dysfunction, not bleeding risk. Correction of INR with FFP has little effect on hemostasis.
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LETTERS TO EDITOR
Noninvasive methods to diagnose NAFLD
p. 259
Binit Sureka, Kalpana Bansal, Ankur Arora
DOI
:10.4103/1319-3767.161632
PMID
:26228371
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Ribavirin-free treatment may soon be a reality
p. 260
Bandar Al-Judaibi
DOI
:10.4103/1319-3767.161633
PMID
:26228372
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RESPONSE TO LETTER TO EDITOR
Hepatitis C position statement: Taking a stand and standing by it
p. 262
Faisal M Sanai, Abdullah S Alghamdi, Mohammed Y Alghamdi
DOI
:10.4103/1319-3767.161637
PMID
:26228373
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ERRATUM
Doxorubicin-loaded drug-eluting beads versus conventional transarterial chemoembolization for nonresectable hepatocellular carcinoma: Erratum
p. 264
DOI
:10.4103/1319-3767.161648
PMID
:26228374
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© Saudi Journal of Gastroenterology (Official journal of The Saudi Gastroenterology Association) | Published by Wolters Kluwer -
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Online since 15
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