Infection with hepatitis B virus (HBV) remains an important public health problem with a high burden worldwide. The Saudi Association for the Study of Liver diseases and Transplantation formed a working group to develop HBV practice guidelines in Saudi Arabia. The methodology used to develop these guidelines was based on reviewing the available evidence, local data, and major international practice guidelines on the management of HBV. The aim of these guidelines is to assist healthcare providers in the management of HBV in Saudi Arabia. These updated guidelines summarize the latest local studies performed on HBV epidemiology, major changes in the prevalence of this virus, and advances in disease management.

Background: With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients. Methods: We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates. Results: We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I² = 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I² = 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I² = 79.3%, P < 0.001). Conclusion: The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.

Background: Drotaverine and Mebeverine are used for alleviating the pain of IBS, but the evidence for their efficacy is scarce. In this randomised control study, we evaluated and compared their efficacy in improving severity, frequency of pain and its associated symptoms. Methods: Patients fulfilling the ROME III criteria of IBS were evaluated in this randomised control trial during 4 weeks of treatment. Group A (n = 100) received 80 mg Drotaverine and Group B (n = 100) received 135 mg Mebeverine three times a day, 1 hour before meals. Primary outcome measure was, the reduction in severity of pain (>30% reduction) assessed by VAS (0 to 10 scale) & PSS (patient symptoms scores). Results: The pain severity score fell from 6.02 to 4.8 on day 3 in Group A as compared to decrease from 6.72 to 6.62 in Group B (p < 0.01). This significant reduction in pain severity was observed till the end of the study, reducing from 6.02 to 1.78 (74% reduction) in Group A compared to 6.72 to 3.62 (46.1% reduction) in Group B (p < 0.05). There was a significant reduction in pain frequency, straining on stool, a change in one score in Bristol stool chart (BSC), achievement of complete spontaneous smooth bowel movement in Group A, compared to Group B patients. A significant improvement in Patient's evaluation of Global Assessment of Symptoms (p < 0.05) and Patient Assessment of Constipation – Quality Of Life (PAC-QOL) (p < 0.01) was observed in Group A compared to Group B. Conclusion: Drotaverine was significantly superior in efficacy as compared to Mebeverine in alleviating pain severity (starting from day 3), frequency and stools-elated symptoms of IBS.

Background: Studies have reached different conclusions regarding the accuracy of dysbiosis in predicting the diagnosis of Crohn's disease (CD). The aim of this report is to assess the utility of mucosal and fecal microbial dysbiosis as predictors in the diagnosis of this condition in Saudi children. Methods: Tissue and fecal samples were collected prospectively from children with final diagnosis of CD and from controls. Bacterial DNA was extracted and sequenced using Illumina MiSeq chemistry. The abundance and diversity of bacteria in tissue and fecal samples were determined in relation to controls. Sparse logistic regression was calculated to predict the diagnosis of CD based on subject's microbiota profile. Results: There were 17 children with CD and 18 controls. All children were Saudis. The median age was 13.9 and 16.3 years for children with CD and controls respectively. Sex distribution showed that 11/17 (65%) of the CD and 12/18 (67%) of the control subjects were boys. The mean area under the curve (AUC) was significantly higher in stool (AUC = 0.97 ± 0.029) than in tissue samples (AUC = 0.83 ±0.055) (P < 0.001). Conclusions: We found high AUC in mucosal and fecal samples. The higher AUC for fecal samples suggests higher accuracy in predicting the diagnosis of CD.

Background: We aimed to evaluate the therapeutic effect of additional ursodeoxycholic acid (UDCA) with mesalazine, compared to mesalazine alone in patients with ulcerative colitis (UC). The mechanism was evaluated by monitoring the changes of IL-23-IL-17 axis and the intestinal microflora. Methods: In this prospective, single center study, patients with UC were randomly assigned to the Mesalazine group (n=20) or the UDCA + Mesalazine group (n=20). Mayo score and Inflammatory Bowel Disease Questionnaire (IBDQ), and fecal samples for 16S rRNA sequencing and blood samples for IL-23 and IL-17 ELISA were collected for analysis. Results: Mayo scores and IBDQ score of the UDCA + Mesalazine group were significantly better than those of the Mesalazine group (P = 0.015 and P < 0.001, respectively). At post-treatment week 4, IL-23 and IL-17 levels were significantly lower in the UDCA + Mesalazine group compared to those in the Mesalazine group (both P < 0.038). In patients with UC after treatment, Firmicutes in the UDCA + Mesalazine group was higher than those in the Mesalazine group (P < 0.001). The UDCA + Mesalazine group showed lower percentage of Proteobacteria compared to those in the Mesalazine group (P < 0.001). Conclusion: Additional UDCA could provide better therapeutic effects than mesalazine alone, possibly due to the change of IL-23 and IL-17 and the proportional distribution of intestinal microflora.

Background: Colorectal cancer (CRC) is the second most common cancer in women and the third most common in men worldwide, with a significantly rising incidence in the Middle East region over the last few decades. This study investigates the histopathological and epidemiological characteristics of colonoscopic findings in a population with an average risk of CRC in Kuwait. Methods: In this study, 1,005 asymptomatic average-risk Kuwaiti adults aged over 40 years had their first colonoscopy screening during the 2015–2018 period. Data on lifestyle behaviors (cigarette smoking, alcohol consumption, and physical activity), body mass index (BMI), and comorbidities were routinely collected from these individuals. All colorectal polyps or masses were assessed for their site, size, and number and then resected and sent for histopathological examination. Results: The mean age of the participants was 54 years, and 52.2% were women. In screened individuals, the polyp detection rate, adenoma detection rate, and carcinoma detection rate were 43.8%, 27.7%, and 1.2%, respectively. Tubular, tubulovillous, and villous types of adenoma constituted 17.3%, 2.8%, and 1.3% of all screened participants. Neoplastic lesions, particularly in the proximal colon, were more common among men aged 40–49 years. Age of 70 years and older (OR: 9.6; 95% CI: 4.7–19.9; P < 0.001), male gender (OR: 1.6; 95% CI: 1.1–2.3; P = 0.011), increased BMI (OR: 1.05; 95% CI: 1.02–1.08; P = 0.001), and smoking (OR: 3.5; 95% CI: 2.3–5.4; P < 0.001) were the most significant independent risk factors for colorectal neoplasia. Conclusions: The high adenoma detection rate (ADR) in Kuwaiti population calls for the establishment of a national programe for CRC screening. The higher ADR in those younger than 50 years calls for assessment of the threshold age at which to start screening.

Background: The ACTION IO study (NCT03584191) aimed to identify perceptions, attitudes, behaviors, and potential barriers to effective obesity care across people with obesity (PwO) and healthcare professionals (HCPs). Results from Saudi Arabia are presented here. Methods: A survey was conducted from June to September 2018. In Saudi Arabia, eligible PwO were ≥18 years with a self reported body mass index of ≥30 kg/m². Eligible HCPs were in direct patient care. Results: The survey was completed by 1,000 PwO and 200 HCPs in Saudi Arabia. Many PwO (68%) and HCPs (62%) agreed that obesity is a chronic disease. PwO felt responsible for their weight management (67%), but 71% of HCPs acknowledged their responsibility to contribute. Overall, 58% of PwO had discussed weight with their HCP in the past 5 years, 46% had received a diagnosis of obesity, and 44% had a follow up appointment scheduled. Although 50% of PwO said they were motivated to lose weight, only 39% of HCPs thought their patients were motivated to lose weight. Less than half of PwO (39%) and HCPs (49%) regarded genetic factors as a barrier to weight loss. Many PwO had seriously attempted weight loss (92%) and achieved ≥5% weight loss (61%), but few maintained their weight loss for >1 year (5%). Conclusion: Saudi Arabian results have revealed misperceptions among PwO and HCPs about obesity, highlighting opportunities for further education and training about obesity including the biologic basis and clinical management.

Background: Malignant biliary obstruction (MBO) is usually caused by biliary tract cancer or pancreatic cancer. This study was performed to summarize the current situation regarding palliative endoscopic retrograde biliary drainage (ERBD) for MBO in Korea and to determine its clinical significance by analyzing representative nationwide data. Methods: Patients that underwent palliative ERBD for MBO between 2012 and 2015 were identified using the Health Insurance Review and Assessment database, which covers the entire Korean population. We assessed clinical characteristics and complications and compared the clinical impacts of initial metal and plastic stenting in these patients. Results: A total of 9,728 subjects (mean age, 65 ± 11.4 years; male, 61.4%) were identified and analyzed. The most common diagnosis was malignant neoplasm of liver and intrahepatic bile ducts (32.1%) and this was followed by extrahepatic or Ampulla of Vater cancer and pancreatic cancer. Initial plastic stent(s) placement was performed in 52.9% of the study subjects, and metal stent(s) placement was performed in 23.3%. The number of sessions of endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) was significantly higher in patients that underwent initial plastic stenting than in patients that underwent metal stenting (2.2 ± 1.7 vs 1.8 ± 1.4, P < 0.0001), but rates of post-ERCP pancreatitis, hospital days, and time to second ERCP or PTBD were not significantly different. Conclusion: This nationwide assessment study suggests that initial metal stenting is associated with fewer sessions of total ERCP or PTBD following the initial procedure, despite the preference for initial plastic stenting in Korea.