Symptoms suggestive of gastroparesis occur in 5% to 12% of patients with diabetes. Such a complication can affect both prognosis and management of the diabetes; therefore, practicing clinicians are challenged by the complex management of such cases. Gastroparesis is a disorder characterized by a delay in gastric emptying after a meal in the absence of a mechanical gastric outlet obstruction. This article is an evidence-based overview of current management strategies for diabetic gastroparesis. The cardinal symptoms of diabetic gastroparesis are nausea and vomiting. Gastroesophageal scintiscanning at 15-minute intervals for 4 hours after food intake is considered the gold standard for measuring gastric emptying. Retention of more than 10% of the meal after 4 hours is considered an abnormal result, for which a multidisciplinary management approach is required. Treatment should be tailored according to the severity of gastroparesis, and 25% to 68% of symptoms are controlled by prokinetic agents. Commonly prescribed prokinetics include metoclopramide, domperidone, and erythromycin. In addition, gastric electrical stimulation has been shown to improve symptoms, reduce hospitalizations, reduce the need for nutritional support, and improve quality of life in several open-label studies.

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Background/Aim: Peptic ulcer perforations are a common emergency, but available literature is silent on the exact definition, incidence, management, and complications of peritonitis due to omental patch leakage. Patients and Methods: Retrospective data were collected on 422 patients who underwent omental patch repair of perforated peptic ulcer between March 20, 1999 and March 20, 2006. The definitive diagnosis of perforated peptic ulcer and omental patch leakage was obtained at surgery. Results: Seventeen (4%) patients experienced generalized peritonitis due to omental patch leakage. Mean age was 60.6 years. Mortality rate was 29.4%, and the mean hospital stay was 23.6 days. Delay in surgical approach, shock on admission, and age were all significantly associated with increased mortality. Conclusions: Peritonitis due to omental patch leakage can result in significant morbidity and mortality. The most common causes of omental patch leakage and operative procedures were unknown and reinsertion of omentum, respectively. Factors such as shock on admission or delayed surgery, have significantly contributed to fatal outcomes and need careful attention.

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Variceal bleeding is a major event in the natural history of end-stage liver disease with a subsequent high mortality rate. Non-selective β-blockers are currently the drugs of choice for preventing first variceal bleeding. Endoscopic rubber band ligation of high risk varices features as a first line option if cirrhotic patients cannot tolerate β-blockers. Despite adequate β-blockade, some patients may still present with variceal bleeding. The effect of carvedilol, a non-selective β and α-1 receptor-blocker, on lowering portal pressure has been investigated in several clinical trials and found to be superior to propranolol in both acute and chronic hemodynamic studies. Recently, carvedilol has also been compared with band ligation for primary prophylaxis against variceal bleeding with equivalent results to band ligation. Patient tolerance to carvedilol in advanced liver disease remains a source of concern. This review examines the place of carvedilol as an alternative to the currently recommended pharmacological therapy in prophylaxis against variceal bleeding.

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Background/Aim: Eosinophilic esophagitis (EE) is a clinicopathologic entity characterized by esophageal symptoms in association with a dense eosinophilic infiltrate currently defined as >15 eosinophils per high power field in the appropriate clinical context. This is the first pediatric study in Saudi Arabia to give the experience with EE and examine its symptom, histology and endoscopy results. Materials and Methods: Retrospective chart review of all patients diagnosed with EE at National Guard Hospital, Jeddah Between 2007 and 2009. The authors identified EE on histologic criteria (≥15 eosinophils per high-power field) together with their clinical context. The authors reviewed medical records for details of clinical presentation, laboratory data, radiologic, endoscopic, and histologic findings, and the results of treatment. Results: We identified 15 patients in our database in the last three years. 100% of the patients were males. The median age at presentation was 10 years (range, 3-17 years). The commonly reported symptoms were failure to thrive (86%), epigastric abdominal pain (53%), poor eating (40%), dysphagia with solid food (26%), food impaction (13%), and vomiting (20%). Asthma was reported in 46% and allergic rhinitis in 40%. Peripheral eosinophilia (>0.7 Χ 10/l) was found in 66%. High serum IgE Level (>60 IU/ml) was found in 60%. Upper endoscopic analysis revealed esophageal trachealization in 46%, esophageal erythema in 46%, white specks on the esophageal mucosa in 33%, esophageal narrowing in 13%, and normal endoscopy in 13%. The mean eosinophils per high-power field was 30.4 (range, 20-71). Histologic characteristics included degranulated eosinophils (86%), basal cell hyperplasia (93%) and eosinophils clusters (micro-abscess) in 73%. The treatment of EE revealed that they used swallowed corticosteroid in 50%, proton pump inhibitors in 66%, elemental diet/ food elimination in 13% and systemic corticosteroid in 13%. Conclusions: Failure to thrive and abdominal pain in a male, atopic school-aged child was the most common feature of EE. Peripheral eosinophilia, high serum IgE and endoscopic esophageal erythema and trachealization should significantly raise the clinical index of suspicion for the diagnosis of EE.

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Background/Aim: Duodenal injury is an uncommon finding, accounting for about about 3 - 5% of abdominal trauma, mainly resulting from both penetrating and blunt trauma, and is associated with significant mortality (6 - 25%) and morbidity (30 - 60%). Patients and Methods : Retrospective analysis was performed in terms of presentation, management, morbidity and mortality on 14 patients of duodenal injuries out of a total of 172 patients of abdominal trauma attending Subharti Medical College. Results: Epigastric pain (100%) along with vomiting (100%) is the usual presentation of duodenal injuries in blunt abdominal trauma, especially to the upper abdomen. Computed tomography (CT) was diagnostic in all cases. Isolated duodenal injury is a rare finding and the second part is mostly affected. Conclusion: Duodenal injury should always be suspected in blunt upper abdominal trauma, especially in those presenting with epigastric pain and vomiting. Investigation by CT and early surgical intervention in these patients are valuable tools to reduce the morbidity and mortality.

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Background/Aim: Variceal bleeding is a life-threatening complication of portal hypertension with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. The study has been aimed at investigating the effectiveness of endoscopic band ligation in preventing upper gastrointestinal bleeding in patients with portal hypertension and to establish the clinical outcome of patients. Patients and Methods: We analyzed in a multicenter trial, the efficacy and side effects of endoscopic band ligation for the primary and secondary prophylaxis of esophageal variceal bleeding. We assigned 603 patients with portal hypertension who were hospitalized to receive treatment with endoscopic ligation. Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The primary end point was recurrent bleeding. Results: The median follow-up period was 32 months. A total of 126 patients had recurrent bleeding. All episodes were related to portal hypertension and 79 to recurrent variceal bleeding. There were major complications in 51 patients (30 had bleeding esophageal ulcers). Seventy-eight patients died, 26 deaths were related to variceal bleeding and 1 to bleeding esophageal ulcers. Conclusions: A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.

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Background/Aim: Intestinal tuberculosis needs to be considered in the differential diagnosis when patients with intestinal pathology are encountered. Tuberculosis can mimic other disease entities like, ischemic enteritis, inflammatory bowel diseases, malignancies, intussusception etc., clinically as well as morphologically in resected intestinal specimens. We aimed to study the various clinical presentations leading to intestinal resection, with identification of different etiological factors by histopathological examination; and to illustrate, discuss and describe the various histopathological features of the lesions in these resected intestinal specimens with clinicopathological correlation. Materials and Methods: We studied 100 cases of resected intestinal specimens received during September 2002 to December 2003. We totally encountered 22 request forms with clinical suspicion of ileoceocal tuberculosis. Results: Abdominal tenderness and mass in ileoceocal region were noted in all cases. In many instances, the cases were operated for acute/subacute intestinal obstruction. Clinical and intra-operative diagnoses of tubercular enteritis, in many instances, were finally diagnosed histopathologically as ischemic enteritis (nine cases), chronic nonspecific enteritis (four cases), adenocarcinoma of the caecum, Crohn's disease, intussusception (each one case), and correctly as intestinal tuberculosis in only six cases. Conclusion: Tuberculosis can mimic various disease entities, clinically and sometimes morphologically. Vice versa is also true. An increased awareness of intestinal tuberculosis coupled with varied clinical presentations, nonspecific signs and symptoms, difficulties in diagnostic methods and need of early and specific treatment should improve the outcome for patients with this disease.

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Background/Aim: Rome III criteria has modified the description of functional dyspepsia (FD) and divided this into subgroups. However, the discriminative value of Rome III questionnaire-based diagnosis of FD is yet to be determined. Objectives: To evaluate the Rome III questionnaire for the diagnosis of FD and whether it can discriminate between postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) in patients with dyspeptic symptoms. Patients and Methods: Consecutive patients, who were not on proton pump inhibitors (PPI), were asked to participate. Patients who have previously established acid peptic disease or predominantly reflux symptoms or having alarm symptoms such as weight loss and hematemesis were excluded. Rome III questionnaire for FD was used to identify the patients as having FD and divide into its subgroups; PDS or EPS. Gastro-duodenal biopsies, liver function tests and ultrasound were done to establish the diagnosis of FD. Results: Out of 272 patients with upper gastrointestinal (GI) symptoms without alarm features, who were enrolled in the study, a total of 191 (70%) fulfilled the criteria of FD based upon Rome III questionnaire. EPS subgroup was found in 109 (57%), PDS in 17 (9%) patients, overlap between EPS and PDS was present in 56 (29%) patients. Nine (5%) patients remained indeterminate. Diagnosis of FD was established in 136/191 (71%) patients only. Gastritis was present in 116 patients (85%), Duodenitis in 44 (32%) and Helicobacter pylori infection in 70 (51%) patients. Among 55 patients (29%) who had organic diseases, EPS was seen in 35 (64%), PDS in 5 (9%) and overlap in 15 (27%) patients. Underlying organic causes were gastric or duodenal ulcers in 14 patients, Barrett esophagus in five, chronic liver disease in seven, gall stones in five, Giardiasis and celiac disease in three each. Gastric carcinoma, Crohns disease and gastric polyps were seen in one patient each. Conclusion: This study indicates that 30% of patients who fulfilled the Rome III criteria for FD actually had organic disease. Almost one-third of patients with functioanl dyspepsia did not qualify for one of the two subgroups of FD of Rome III. There is also a need to further define the Rome III-based subgroups of FD for research purpose.

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Background/Aim: Thrombocytosis is found to be associated with unfavorable prognosis in esophageal carcinoma. Platelets produce thymidine phosphorylase which is a platelet-derived endothelial cell growth factor with angiogenic activity. Increased platelet count may be translated into enhanced tumor growth. We examined the relation between platelet count and several prognostic variables in patients with esophageal cancer. Patients and Methods: Three hundred and eighty-one cases with esophageal cancer that underwent esophagectomy in a referral cancer institute during a 5-year period were studied retrospectively. The relation between preoperative platelet count and patient age, gender, site of tumor, presence of multiple cancers and clinicopathological characteristics including histological type, tumor size, depth of penetration (T), lymph node involvement (N), distant metastasis (M), degree of differentiation, presence of vascular, lymphatic and perineural invasion was examined. Results: Squamous cell carcinoma (SCC) constituted 93% and adenocarcinoma 7% of cases. Most of patients were in stage III, followed by stage II. The mean platelet count was 245±76 (Χ 10 ⁹ /L). There was no statistically significant correlation between platelet counts with prognostic factors except a weak linear correlation between platelet count and and tumor size (P= 0.03, Pearson correlation coefficient: 0.16). Patients with adenocarcinoma had a higher platelet count than those with SCC (P= 0.003). Conclusion: Platelet count does not correlate with prognostic factors in esophageal cancer. However, it is significantly different between SCC and adenocarcinoma of esophagus.

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Background/Aim: Hepatic encephalopathy (HE) is associated with a poor prognosis. There is paucity of data on the treatment of HE with lactulose in children with cirrhosis. Patients and Methods : Retrospective analysis of consecutive cirrhotic patients (<18 years) with HE was done. HE was defined according to West-Haven criteria. Response was defined as complete if patients recovered completely from HE, partial response was defined as improvement of encephalopathy by one or more grades from admission but not complete recovery, and defined as non response if patient did not show any improvement or deteriorated further even after 10 days of lactulose therapy. Results : A total of 300 patients were admitted with cirrhosis and HE (278 adults and 22 children). Of 22 patients, 16 (73%) patients had complete response to lactulose and six (27%) patients did not [three (13.5%) patients worsened (non response) and three (13.5%) did not recover fully even after 10 days of treatment (partial response)]. Comparing baseline characteristics of patients who had complete response (n=16) versus partial (n=3) and non response (n=3), there was significant difference in mean arterial pressure (78.1±10.7 vs 62.6±5.0 mmHg, P=0.003), serum sodium (131.3±3.2 vs 126.5±5.2, P=0.01) and serum creatinine (0.78±0.3 vs 1.1±0.3 mg/dl, P=0.02). We did not find any difference in baseline characteristics of these patients regarding CTP score (9.6±1.2 vs 10.6±1.2), MELD score (17.6±2.9 vs 17.1±3.4), severity of HE (2.5±0.6 vs 2.6±0.5) and etiology of precipitating factors (P=0.78). Conclusions: Lactulose therapy causes complete recovery from hepatic encephalopathy in 73% of pediatrics patients with cirrhosis.

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We present a case of a 12-year-old boy who developed upper gastrointestinal bleeding in the form of hematemesis and melena 1 month after blunt trauma to liver. Computed tomography (CT) angiography with multidetector-row CT demonstrated pseudoaneurysm of right hepatic artery related to old liver laceration to be the cause of the bleeding. Pseudoaneurysm was resected using the roadmap provided by CT angiography findings.

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Variceal bleeding is the most challenging emergent situation among the causes of upper gastrointestinal bleeding. Despite substantial improvement, a need remains for therapeutic armamentarium of such cases, which is easy, effective and without side-effect. Ankaferd blood stopper (ABS) is a standardized herbal extract acting as a hemostatic agent on the bleeding or injured areas. In this observational study, a total of four patients with variceal bleeding were treated with endoscopic ABS application. The lesions were bleeding gastric varices (n:3) and bleeding duodenal varix (n:1). ABS was selected as a bridge to definitive therapies due to unavailability or inappropriateness of bleeding lesions to conventional measures. ABS was instilled or flushed onto the bleeding areas by sclerotherotherapy needle or heater probe catheter. Periprocedural control of the bleeding was achieved in all instances. Thereafter, on an elective basis, two patients with gastric varices underwent cyanoacrylate injection, while third underwent Transjugular intrahepatic portosystemic shunt and embolization. The patient with duodenal varix refused further therapy, after a few hours after admission and was discharged. He again presented the same day with rebleeding, but died before any attempt could be made to control his bleeding. ABS seems to be effective in cases of variceal bleeding as a bridge to therapy. Its major advantages are the ease of use and lack of side-effects.

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Background/Aim: Some reports in the literature have linked interferon therapy for the treatment of hepatitis C (HCV) with hearing loss. The aim of this study has been to examine the effects of interferon therapy on hearing of patients treated for HCV. Patients and Methods: Patients were recruited according to preset inclusion criteria from two centers. All patients received standard dose pegylated interferon (PEG-IFN a-2b or a-2a) plus ribavirin (RBV). All patients had pure-tone audiometry (PTA), tympanogram and distortion-product otoacoustic emission (DPOAE) before treatment, three months after initiation of treatment, and three months after completion of treatment. Results: Twenty one patients were prospectively recruited. The mean age was 45.7 years. The male to female ratio was 1.1:1. The mean PTA was 15.9 ± 5.3 before treatment, 17.4 ± 6.1 during treatment and 16.5 ± 5.1 after treatment. The differences between pre and mid, pre and post, as well as mid and post were not significantly different (P>0.05) in all audiological assessments. Conclusions: Our results indicate that PEG-IFN\RBV therapy does not have any impact on the hearing thresholds of patients with HCV.

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Cervical lymphadenopathy is usually related to the presence of an inflammatory disease or to a malignant localization. In the event of metastatic findings, the thyroid gland is the most likely primary site of a tumor. Metastatic lymphadenopathy represents a challenge when the primary tumor is unknown. A 64-year-old female with a supraclavicular palpable mass in the absence of underlying thyroid disease underwent ultrasonography of the neck, biopsy of the pathological lymph node, fluorodeoxyglucose-Positron Emission Tomography (FDG-PET) and colonoscopy until right colon cancer was diagnosed. FDG-PET is a fast and reliable tool to discover the primary site of cervical masses of unknown origin.

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