Saudi Journal of Gastroenterology
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   2012| May-June  | Volume 18 | Issue 3  
    Online since May 21, 2012

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Understanding the mechanism of hepatic fibrosis and potential therapeutic approaches
Areeba Ahmad, Riaz Ahmad
May-June 2012, 18(3):155-167
Hepatic fibrosis (HF) is a progressive condition with serious clinical complications arising from abnormal proliferation and amassing of tough fibrous scar tissue. This defiance of collagen fibers becomes fatal due to ultimate failure of liver functions. Participation of various cell types, interlinked cellular events, and large number of mediator molecules make the fibrotic process enormously complex and dynamic. However, with better appreciation of underlying cellular and molecular mechanisms of fibrosis, the assumption that HF cannot be cured is gradually changing. Recent findings have underlined the therapeutic potential of a number of synthetic compounds as well as plant derivatives for cessation or even the reversal of the processes that transforms the liver into fibrotic tissue. It is expected that future inputs will provide a conceptual framework to develop more specific strategies that would facilitate the assessment of risk factors, shortlist early diagnosis biomarkers, and eventually guide development of effective therapeutic alternatives.
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The protective role of Aegle marmelos on aspirin-induced gastro-duodenal ulceration in albino rat model: A possible involvement of antioxidants
Shyamal K Das, Chandan Roy
May-June 2012, 18(3):188-194
Background/Aim: Gastro duodenal ulcer is a common disorder of the gastrointestinal tract. Several Indian medicinal plants have been traditionally and extensively used to prevent different diseases. In the present research studies, Bael fruit (Aegle marmelos (AM), family: Rutaceae) which are also called as Bilva in ancient Sanskrit was used as a herbal drug and its antioxidative role in aspirin- induced gastroduodenal ulceration in albino rat was evaluated using essential biochemical parameters. Patients and Methods: Mucosal thickness (MT), ulcer index (UI), different biochemical parameters, such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), catalase (CAT), superoxide dismutase (SOD), reduced glutathione (GSH), and lipid peroxidation (LPO) were measured in all the groups, to study the possible involvement of antioxidants with gastroduodenal protection. Results: A significant decrease in MT, SOD and CAT activities and GSH level and a significant increase in UI, AST, ALT, and ALP activities and LPO level were observed in aspirin treated stomach and duodenum of albino rats. Conclusions: Pretreatment with AM fruit pulp extract for 14 consecutive days showed the reverse effects of aspirin suggesting gastro-duodenal protective and anti- ulcerogenic properties of AM through its antioxidant mechanism.
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Lactulose for minimal hepatic encephalopathy in patients with extrahepatic portal vein obstruction
Praveen Sharma, Barjesh Chander Sharma
May-June 2012, 18(3):168-172
Background/Aims: Minimal hepatic encephalopathy (MHE) is common in patients with extrahepatic portal vein obstruction (EHPVO). There is no study on the treatment of MHE using lactulose in patients with EHPVO. Patients and Methods: Consecutive EHPVO patients were assessed by psychometric (number connection test (NCT-A and B), digit symbol test (DST), serial dot test (SDT), line tracing test (LTT)), and critical flicker frequency (CFF) at inclusion. Patients diagnosed as MHE were treated with lactulose and psychometric tests, CFF, and were reassessed after 3 months. Results: Of the 70 patients screened, the prevalence of abnormal psychometric test was as follows: NCT-A (41%), NCT-B (53%), DST (38%), SDT (40%), and LTT (44%). Thirty patients (43%) had two or more than two abnormal (>2 SD) psychometry tests. Lactulose improved MHE in 16/30 (53%) of patients after 3 months of treatment. Arterial ammonia decreased after lactulose treatment compared to baseline (83.7±19.1 vs. 65.1±19.3 μmol/l, P=0.001). A total of 9 (75%) of 12 patients with large spontaneous shunt and 7 (39%) of 18 patients without spontaneous shunt improved with lactulose (P=0.07). CFF in patients with MHE (n=30) was significantly lower than those without MHE (n=40) (38.1±2.4 vs. 41.5±3.1 Hz, P=0.01). CFF was less than 38 Hz in 21 (70%) of 30 patients before treatment and in 10 (33%) patients after lactulose therapy in MHE patients. All patients could tolerate lactulose without any significant side effects. Four patients (13%) developed transient diarrhea in whom dose needed reduction, 3 (10%) did not like its taste but have continued, and 2 (6%) developed abdominal bloating sensation. Conclusions: Lactulose is effective in the treatment of MHE in patients with EHPVO.
  12 4,615 706
Perinatal cytomegalovirus hepatitis in Saudi infants: A case series
Mohammed Y Hasosah, Suzane Y Kutbi, Abdulfattah W Al-Amri, Ashraf F Alsahafi, Ghassan A Sukkar, Khaled J Alghamdi, Kevan Jacobson
May-June 2012, 18(3):208-213
Background/Aim: Cytomegalovirus (CMV) is the most common congenital viral infection, occurring in 0.4%-2.3% of all live births. The clinical manifestations of CMV are multiorgan involvement. Currently, the numbers of studies of hepatic CMV infection in immunocompetent infants are insufficient and little information exists in the medical literature about the hepatic manifestations and complications of CMV. Patients and Methods: Nine infants diagnosed with hepatic CMV infection were included in the study. The diagnosis was based on the presence of IgM anti-CMV antibodies titer in serum and detection of CMV-DNA in blood. The authors identified clinical characteristics, biochemical characteristics, immunologic markers, and the outcome of hepatic CMV with or without treatment. Results: Jaundice was the most common clinical feature of CMV infection in infancy (100%). Hepatic abnormalities in the form of cholestasis (defined as a serum conjugated bilirubin concentration greater than 17.1 μmol/L or greater than 20% of the total serum bilirubin) were found in all patients (100%), hepatitis (77%), hypoalbuminemia (55%), elevated alkaline phosphatase, and gamma-glutamyltransferase (77%). Other findings showed hepatosplenomegaly (44%), thrombocytopenia (22%) and low birth weight (11%) The treatment of hepatic CMV infection was indicated in 66% and was not indicated in 33%. Both of them had resolved cholestasis and hepatitis. Conclusion: Jaundice and cholestasis were the most common clinical features of hepatic CMV infections. Hepatic CMV infection in young infants is often a self-limited illness that does not require antiviral therapy. Most of the patients with hepatic CMV infection had a favorable outcome.
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Hepatic-associated immunoglobulin-A nephropathy in a child with liver cirrhosis and portal hypertension
Sharifa A Alghamdi, Omar I Saadah, Nesreen Almatury, Jaudah Al-Maghrabi
May-June 2012, 18(3):214-216
Hepatic-associated immunoglobulin A (IgA) nephropathy is a relatively common condition that occurs in adults with liver cirrhosis and portal hypertension. However, it is rare in children. This condition is characterized by the deposition of IgA in the renal glomeruli. The present report describes a 14-year-old boy with cryptogenic liver cirrhosis and portal hypertension who presented with hematuria and proteinuria associated with histological changes of IgA nephropathy.
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Therapeutic effect of captopril, pentoxifylline, and cordyceps sinensis in pre-hepatic portal hypertensive rats
Ahmed F Ahmed, Nabila N El-Maraghy, Rasha H Abdel Ghaney, Shimaa M Elshazly
May-June 2012, 18(3):182-187
Background/Aim: Portal hypertension is an important and potentially fatal complication of liver disease whereby cellular and fibrotic alterations manifest to increase portal venous pressure. The aim of this study is to investigate the effect of captopril, pentoxifylline (PTX), and cordyceps sinensis in pre-hepatic portal hypertensive rats. Settings and Design: Wister male rats were divided at random into 3 main groups: the first group: control rats. The second group: sham-operated rats and the third group: prehepatic portal hypertensive rats (PHPHT) induced by regulated pre-hepatic portal vein ligation. After 14 days, Group 3 was subdivided into 5 subgroups. Subgroup (1): portal vein-ligated (PVL) was killed at once; Subgroup (2): received distilled water for 30 days (untreated PVL group); subgroups 3-5 were treated with captopril (60 mg/kg, orally); PTX (100 mg/kg, orally); and C. sinensis (200 mg/kg, orally), respectively, as a single daily dose for 30 days. Patients a nd M ethods: Portal pressure, nitric oxide (NO), antioxidant enzymes, Liver enzymes, and creatinine levels were measured to evaluate the status of the liver state. Results: Portal vein ligation produced significant increments in liver enzymes, NO, creatinine and portal pressure concomitant with significant decrements in glutathione content and superoxide dismutase activity. Treatment with captopril, PTX, and C. sinensis resulted in a significant reduction in liver enzymes, NO, creatinine and portal pressure and observable increase in antioxidant enzymes. Conclusions: captopril, PTX, and C. sinensis have promising effect in controlling PHPHT and reducing hyperdynamic circulatory state through reduction of portal pressure and NO level.
  5 3,782 507
Frequency of low bone mineral density in Saudi patients with inflammatory bowel disease
Mona H Ismail, Abdulmohsen H Al-Elq, Mahdi E Al-Jarodi, Nahla A Azzam, Abdulrahman M Aljebreen, Sami A Al-Momen, Bahaa F Bseiso, Fatma A Al-Mulhim, Abdulaziz Alquorain
May-June 2012, 18(3):201-207
Background/Aims: Metabolic bone disease is common in patients with inflammatory bowel disease (IBD). Our aim was to determine the frequency of bone loss among Saudi patients with IBD and possible contributing risk factors. Settings and Design: We retrospectively reviewed Saudi patients with IBD, between 18 and 70 years of age, who had bone mass density (BMD) determined by dual-energy X-ray absorptiometry scanning at one of three hospitals in the Kingdom of Saudi Arabia from 2001 to 2008. Patients and Methods: Case notes and BMDs results were carefully reviewed for demographic and clinical data. Low bone mass, osteopenia, and osteoporosis were defined according to the WHO guidelines. Statistical Analysis Used: Predictive factors for BMD were analyzed using group comparisons and stepwise regression analyses. Results: Ninety-five patients were included; 46% had Crohn's disease (CD) and 54% had ulcerative colitis (UC). The average age was 30.9±11.6 years. Using T-scores, the frequency of osteopenia was 44.2%, and the frequency of osteoporosis was 30.5% at both lumbar spine and proximal femur. Only 25.3% of patients exhibited a BMD within the normal range. Our results revealed a positive correlation between the Z-score in both the lumbar spine and the proximal femur and body mass index (BMI) (P=0.042 and P=0.018, respectively). On regression analysis BMI, age, and calcium supplementation were found to be the most important independent predictors of BMD. Conclusions: Saudi patients with IBD are at an increased risk of low BMD and the frequency of decreased BMD in Saudi patients with CD and UC were similar. BMI and age were the most important independent predictors of low BMD.
  5 3,741 492
Comparison of quality of life in patients undergoing transhiatal esophagectomy with or without chemotherapy
Kamal Kataria, Ganga R Verma, Anil Malhotra, Rajni Yadav
May-June 2012, 18(3):195-200
Background/Aim: To compare the quality of life (QOL) in patients undergoing transhiatal esophagectomy (THE) with or without chemotherapy, who were admitted to the Post Graduate Institute of Medical Education and Research, Chandigarh and enrolled in the study, from July 2004 to October 2005. Patients and Methods: Thirty patients of esophageal carcinoma by purposive sampling were randomized into two groups i.e., patients undergoing THE after chemotherapy and patients undergoing THE without chemotherapy. Two QOL questionnaires, one generic i.e., EORTC-QLQ C-30 (European Organization for Research and Treatment of Cancer) and other esophageal cancer-specific i.e., EORTC OES-18 were utilized to assess the QOL. Result: Physical functional scales were better in patients, who received neoadjuvant chemotherapy. The role and social aspects of functional scales deteriorated after completion of treatment in both groups. This was primarily due to the effect of surgery. However, they were better from an emotional and cognitive point of value after surgery and radiotherapy. Fourteen out of 30 patients experienced vomiting and diarrhea due to radiotherapy. Conclusion: THE in esophageal carcinoma improves global health scales and majority of symptom scales in all patients. QOL improvement in general was better in patients who were administered neoadjuvant chemotherapy along with surgery.
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Seroconversion of hepatitis B envelope antigen (HBeAg) by entecavir in a child with chronic hepatitis B
Mohammed Y Hasosah, Heba S Ghandourah, Ashraf F Alsahafi, Ghassan A Sukkar, Kevan Jacobson
May-June 2012, 18(3):217-220
Hepatitis B virus (HBV) infection is a worldwide health problem. Consensus guidelines for the treatment of chronic HBV in children have not been established, and indications for antiviral therapy in adults with chronic HBV infection may not be applicable to children. The medications that are Food and Drug Administration approved for the treatment of children with HBV include interferon (IFN)-alpha and lamivudine. Nondetectable serum HBV deoxyribonucleic acid, Hepatitis B envelope antigen (HBeAg) loss, and HBeAg seroconversion following 1 year duration of entecavir treatment. A review of the literature of entecavir treatment of chronic hepatitis B in children is also provided.
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Knowledge, attitudes, and practices of primary care physicians about irritable bowel syndrome in Northern Saudi Arabia
Ahmad H Al-Hazmi
May-June 2012, 18(3):173-181
Background/Aim: Primary health care (PHC) physicians manage most patients with irritable bowel syndrome (IBS). In Saudi Arabia, there are limited data on their knowledge, attitudes, and practices about this disorder. This study aimed to assess knowledge, attitudes, and practices of primary care physicians about IBS. Patients and Methods: A cross-sectional survey of 70 practitioners aged 36 ± 10.25 years was carried out in primary care centers in AlJouf Province of Saudi Arabia. The physicians were asked to fill a valid questionnaire containing their sociodemographic data, and well-modified questions regarding their knowledge, attitudes, and practices about IBS. Data was processed and analyzed using SPSS (version 15) program, and the level of significance was set at P<0.05. Results: A response rate of 92.9% yielded 65 questionnaires for analysis. Majority of physicians surveyed (83.1%) considered IBS as a common health problem in Saudi Arabia, and (55.4%) believed it is underestimated. There was a significant association between physicians' qualifications and using diagnostic tools to facilitate IBS diagnosis (14.3% vs 35.5%; P<0.05), while utilization of "Rome or Manning criteria" was more frequent by physicians with master's degree (35.5%) compared to residents (14.3%). Also, 35.4% of physicians (15 males and 8 females) were not sure how to diagnose IBS. Conclusions: This study suggested that PHC physicians had a suitable attitude toward IBS, but they lacked knowledge, and their practices toward this condition were inappropriate.
  2 4,177 573
Endoscopic management for delayed diagnosis of a foreign body penetrating the esophagus into the lung
Na Li, Frank Manetta, Shahzad Iqbal
May-June 2012, 18(3):221-222
A 31-year-old male presented with chest pain started after eating chicken about 2 weeks earlier. Upper endoscopy and Computed tomography scan of the chest revealed a sharp chicken bone penetrating the esophageal wall into the right lung. The foreign body was removed endoscopically using a rat-tooth forceps, followed by prophylactic placement of a metal stent across the esophageal perforation site. Foreign body-induced perforation is one of the common etiologies of benign esophageal perforations. Although the primary treatment is surgery, endoscopic therapy may be appropriate in individualized cases like our patient.
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What improves minimal hepatic encephalopathy: Probiotic yogurt, protein restriction or nonabsorbable disaccharides?
Hanan A Alfawaz, Abdulrahman A Aljumah
May-June 2012, 18(3):153-154
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Dilated biliary system
Sudipta Saha, Vivek Gautam, Manoj Andley, Ashok Kumar, Ajay Kumar
May-June 2012, 18(3):223-224
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