Saudi Journal of Gastroenterology
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   2016| July-August  | Volume 22 | Issue 4  
    Online since August 3, 2016

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A randomized controlled trial on the effect of vitamin D3 on inflammation and cathelicidin gene expression in ulcerative colitis patients
Amrollah Sharifi, Mohammad Javad Hosseinzadeh-Attar, Homayoon Vahedi, Saharnaz Nedjat
July-August 2016, 22(4):316-323
DOI:10.4103/1319-3767.187606  PMID:27488327
Background: Inflammatory bowel disease (IBD) is an intestinal chronic inflammatory condition and includes Crohn's disease (CD) and ulcerative colitis (UC). It has been proposed that Vitamin D supplementation may have a beneficial role in IBD. Aim: To characterize the effects of Vitamin D on cathelicidin (hCAP/LL37) gene expression, ESR, and serum hs-CRP levels. Materials and Methods: Ninety UC patients on remission were randomized to receive 300,000 IU intramuscular Vitamin D or 1 mL normal saline as placebo, respectively. Before and 90 days after intervention, serum levels of 25 (OH)-Vitamin D3, PTH, Calcium, ESR, and hs-CRP were measured. Cathelicidin gene expression was also quantified using qRT-PCR. Results: Baseline serum 25-OH-Vitamin D3 levels were not different between the two groups and after intervention, increased only in Vitamin D group (P < 0.001). Hs-CRP levels were lower in Vitamin D group after intervention (Before: 3.43 ± 3.47 vs 3.86 ± 3.55 mg/L, P = 0.56; after: 2.31 ± 2.25 vs 3.90 ± 3.97 mg/L, P= 0.023). ESR decreased significantly in Vitamin D group (Before: 12.4 ± 6.1 vs 12.1 ± 5.3 mm/h, P= 0.77; after: 6.7 ± 4.5 vs 11.4 ± 5.5 mm/h, P< 0.001). The mean fold change in hCAP18 gene expression in Vitamin D group was significantly higher than placebo group. (Mean ± SD: 3.13 ± 2.56 vs 1.09 ± 0.56; median ± interquartile range: 2.17 ± 3.81 vs 0.87 ± 0.53, P<,; 0.001). Conclusion: Decreases in ESR and hs-CRP levels and increase in LL37 gene expression support the hypothesis that Vitamin D supplementation may have a beneficial role in UC patients.
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Neurokinin-1 receptor antagonists as antitumor drugs in gastrointestinal cancer: A new approach
Miguel Muñoz, Rafael Coveñas
July-August 2016, 22(4):260-268
DOI:10.4103/1319-3767.187601  PMID:27488320
Gastrointestinal (GI) cancer is the term for a group of cancers affecting the digestive system. After binding to the neurokinin-1 (NK-1) receptor, the undecapeptide substance P (SP) regulates GI cancer cell proliferation and migration for invasion and metastasis, and controls endothelial cell proliferation for angiogenesis. SP also exerts an antiapoptotic effect. Both SP and the NK-1 receptor are located in GI tumor cells, the NK-1 receptor being overexpressed. By contrast, after binding to the NK-1 receptor, NK-1 receptor antagonists elicit the inhibition (epidermal growth factor receptor inhibition) of the proliferation of GI cancer cells in a concentration-dependent manner, induce the death of GI cancer cells by apoptosis, counteract the Warburg effect, inhibit cancer cell migration (counteracting invasion and metastasis), and inhibit angiogenesis (vascular endothelial growth factor inhibition). NK-1 receptor antagonists are safe and well tolerated. Thus, the NK-1 receptor could be considered as a new target in GI cancer and NK-1 receptor antagonists (eg, aprepitant) could be a new promising approach for the treatment of GI cancer.
  16 2,431 168
Transient elastography in clinical detection of liver cirrhosis: A systematic review and meta-analysis
Xiao-Xia Geng, Ren-Gang Huang, Jian-Mei Lin, Nan Jiang, Xing-Xiang Yang
July-August 2016, 22(4):294-303
DOI:10.4103/1319-3767.187603  PMID:27488324
Background/Aims: Transient elastography is a noninvasive method for measuring liver fibrosis. This meta-analysis assesses the diagnostic performance of transient elastography of detecting liver cirrhosis in patients with liver disease. Patients and Methods: We searched MEDLINE, Cochrane, EMBASE databases until Jan 31, 2015, using the following search terms: elastography and liver cirrhosis. Included studies assessed patients with a diagnosis of liver cirrhosis, with an index test of transient elastography, and with the reference standard being a histopathological exam by liver biopsy. Sensitivity analysis and assessment of risk of bias and publication bias were performed. Results: Fifty-seven studies were included in the meta-analysis with a total of 10,504 patients. The pooled estimate for the sensitivity of transient elastography for detecting liver fibrosis was 81% and the specificity was 88%. The imputed diagnostic odds ratio (DOR) was 26.08 and the area under the receiver-operating characteristic (AUROC) curve was 0.931. Conclusion: Our findings indicate that transient elastography shows good sensitivity, specificity and a high accuracy for detecting liver cirrhosis. Transient elastography can be used as an additional method for the clinical diagnosis of liver fibrosis and cirrhosis.
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Sequential versus concomitant therapy for eradication of Helicobacter Pylori in patients with perforated duodenal ulcer: A randomized trial
Roby Das, Sathasivam Sureshkumar, Gubbi S Sreenath, Vikram Kate
July-August 2016, 22(4):309-315
DOI:10.4103/1319-3767.187605  PMID:27488326
Objectives: Comparison of Helicobacter pylori eradication rates, side effects, compliance, cost, and ulcer recurrence of sequential therapy (ST) with that of concomitant therapy (CT) in patients with perforated duodenal ulcer following simple omental patch closure. Methods: Sixty-eight patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori positive on three months follow-up were randomized to receive either ST or CT for H. pylori eradication. Urease test and Giemsa stain were used to assess for H. pylori eradication status. Follow-up endoscopies were done after 3 months, 6 months, and 1 year to evaluate the ulcer recurrence. Results: H. pylori eradication rates were similar in ST and CT groups on intention-to-treat (ITT) analysis (71.43% vs 81.80%,P = 0.40). Similar eradication rates were also found in per-protocol (PP) analysis (86.20% vs 90%,P = 0.71). Ulcer recurrence rate in ST groups and CT groups at 3 months (17.14% vs 6.06%,P = 0.26), 6 months (22.86% vs 9.09%,P = 0.19), and at 1 year (25.71% vs 15.15%,P = 0.37) of follow-up was also similar by ITT analysis. Compliance and side effects to therapies were comparable between the groups. The most common side effects were diarrhoea and metallic taste in ST and CT groups, respectively. A complete course of ST costs Indian Rupees (INR) 570.00, whereas CT costs INR 1080.00. Conclusion: H. pylori eradication rates, side effects, compliance, cost, and ulcer recurrences were similar between the two groups. The ST was more economical compared with CT.
  10 4,240 552
Significance of BMI1 and FSCN1 expression in colorectal cancer
Nehad M Alajez
July-August 2016, 22(4):288-293
DOI:10.4103/1319-3767.187602  PMID:27488323
Background/Aims: Colorectal cancer (CRC) is the third most common type of cancer in terms of incidence and the fourth in cause of death world-wide, underscoring the need to identify novel biomarkers for early diagnosis, as well as improved disease stratification and treatment choices. Patients and Methods: The Gene Expression Omnibus (GSE21510) and the Cancer Genome Atlas (TCGA) CRC datasets were utilized in the current study. GeneSpring 13.0 was used for normalization and analysis. The log-rank test was used to compare the outcome between expression groups. Result: Significant upregulation of BMI1 (2.3 FC, P = 3.7 × 10-18) and FSCN1 (1.3 FC,P = 4.7 × 10-3) was observed in CRC. High BMI1 expression was associated with reduced overall survival (OS) [Hazard ratio (HR), 1.87; 95% CI. 1.17–3.03; P= 0.009] and reduced disease-free survival (DFS) [HR, 162; 95% CI 1.01–2.63;P = 0.045]. Similarly, high expression of FSCN1 was associated with reduced OS (HR, 2.0; 95% CI, 1.24–3.2; P= 0.0044) and reduced DFS (HR, 1.60; 95% CI, 0.99–2.57;P = 0.055). Importantly, BMI1high/FSCN1high patients experienced the worst OS (HR, 3.17; 95% CI, 1.77–6.15; P= 0.0002) and DFS (HR, 2.34; 95% CI, 1.27–4.67,P = 0.0078). Using pathway analyses, tumors overexpressing BMI1 were enriched in zinc finger proteins and genes involved in DNA binding and regulation of transcription, whereas tumors expressing FSCN1 were enriched in genes involved in cell migration. Conclusion: Our data revealed poor OS and DFS in CRC patients overexpressing BMI1 or FSCN1 and suggest that these two markers in combination may represent superior prognostic marker to either one. Targeting BMI1 and FSCN1 may also provide potential therapeutic opportunity in CRC.
  8 3,559 432
The LMS and Z scale growth reference for Saudi school-age children and adolescents
Mohammad I El Mouzan, Abdullah A Al Salloum, Mansour M Alqurashi, Abdullah S Al Herbish, Ahmad Al Omar
July-August 2016, 22(4):331-336
DOI:10.4103/1319-3767.187608  PMID:27488329
Background/Aim: To establish L, M, and S parameters and z score reference for the assessment of nutrition and growth of Saudi school-age children and adolescents. Subjects and Methods: Data from the original cross-sectional study were reanalyzed. The L, M, and S parameters and z scores were calculated for weight, height and body mass index for school-age children and adolescents. Results: A total of 19,299 subjects from 5 to 18 years of age were included. All were Saudi nationals and 9,827 (50.9%) were boys. The L M S parameters and z scores for weight for age, height for age, and BMI for age for boys and girls are presented in detailed tables across the age of commonly used z scores (+3, +2, +1, 0, -1, -2, -3). Graphs corresponding to the same parameters (weight, height, and BMI) showing the main z scores across all ages from 5 to 18 years are illustrated. Conclusion: This report provides the first reference for nutritional status and growth of Saudi school-age children and adolescents. This tool is essential for more accurate assessment of growth and nutrition in various clinical conditions and research.
  7 6,901 416
Epidemiology, disease burden, and treatment strategies of chronic hepatitis C virus infections in Saudi Arabia in the new treatment paradigm shift
Abdulrahman A Aljumah, Faisal Abaalkhail, Hamad Al-Ashgar, Abdullah Assiri, Mohamed Babatin, Faleh Al Faleh, Abdullah Alghamdi, Raafat Al-Hakeem, Almoataz Hashim, Adel Alqutub, Homie Razavi, Faisal M Sanai, Khalid Al-Swat, Jonathan Schmelzer, Ibrahim Altraif
July-August 2016, 22(4):269-281
DOI:10.4103/1319-3767.187609  PMID:27488321
Background/Aims: Around 101,000 individuals are estimated to be viremic for chronic hepatitis C virus (HCV) in the Kingdom of Saudi Arabia (KSA) in 2014; however, only about 20% have been diagnosed. We aim to assess baseline epidemiology, disease burden, and evaluate strategies to eliminate HCV in KSA. Materials and Methods: The infected population and disease progression were modeled using age- and gender-defined cohorts to track HCV incidence, prevalence, hepatic complications, and mortality. Baseline assumptions and transition probabilities were extracted from the literature. The impacts of two scenarios on HCV-related disease burden were considered through increases in treatment efficacy alone or treatment and diagnosis. Results: In 2030, it is estimated by the base scenario that viremic prevalence will increase to 103,000 cases, hepatocellular carcinoma (HCC) to 470, decompensated and compensated cirrhosis cases to 1,300 and 15,400, respectively, and liver-related mortality to 670 deaths. Using high efficacy treatment alone resulted in 2030 projection of 80,700 viremic cases, 350 HCC cases, 480 liver-related deaths, and 850 and 11,500 decompensated and compensated cirrhosis cases, respectively. With an aggressive treatment strategy, in 2030 there will be about 1,700 viremic cases, 1 HCC case, about 20 liver-related deaths, and 5 and 130 cases of decompensated and compensated cirrhosis, respectively. Delaying this strategy by one year would result in 360 additional deaths by 2030. Conclusions: HCV in KSA remains constant, and cases of advanced liver disease and mortality continue to rise. Considered increases in treatment efficacy and number treated would have a significantly greater impact than increased treatment efficacy alone. The projected impact will facilitate disease forecasting, resource planning, and strategies for HCV management. Increased screening and diagnosis would likely be required as part of a national strategy.
  5 5,387 599
Catheter-related blood stream infection in patients receiving long-term home parenteral nutrition: Tertiary care hospital experience in Saudi Arabia
Esraa S Al-Tawil, Alanoud M Almuhareb, Hamdy M Amin
July-August 2016, 22(4):304-308
DOI:10.4103/1319-3767.187604  PMID:27488325
Background/Aim: Parenteral nutrition (PN) is a lifesaving therapy for patients with many severe conditions, including intestinal failure. Some patients require long-term PN therapy, which makes home parenteral nutrition (HPN) an attractive option to improve the quality of life. Among the most common and serious complications observed in these patients are catheter-related blood stream infections (CRBSIs). The aim of our study is to determine the frequency of CRBSI among patients receiving long-term HPN. Patients and Methods: A retrospective chart review was conducted for patients enrolled in the HPN program between 2006 and 2012. Data on the demographic characteristics, indications and duration of PN therapy, catheter type, number of admissions because of CRBSI, and blood culture results were recorded. Results: Eight pediatric patients were included (mean age of 3.5 years at the start of HPN). Microvillus inclusive disease was noted in 50% of these patients, and 75% of them received HPN under parents' care. CRBSI resulted in 60 admissions with a median of 182 days of hospital stay and 74 changes of central venous catheters. The rate of CRBSI was 2.9 per 1000 catheter days. Staphylococcus species were the most prevalent pathogens (32%), followed by Klebsiella pneumoniae (5%). Conclusion: In this small group of HPN patients, the BSI rate was 2.9 infections per 1000 catheter days, and most common causative organisms were Staphylococcus species. We believe that a well-established training program for caregivers can reduce the rate of infectious complications associated with long-term PN support.
  2 3,493 453
New combined parameter of liver and splenic stiffness as determined by elastography in healthy volunteers
Laura Kassym, Mohammed A Nounou, Zauresh Zhumadilova, Asad I Dajani, Nurgul Barkibayeva, Ayan Myssayev, Tolebay Rakhypbekov, Adnan M Abuhammour
July-August 2016, 22(4):324-330
DOI:10.4103/1319-3767.187607  PMID:27488328
Background: The diagnosis of chronic liver disease (CLD) leading to fibrosis, cirrhosis, and portal hypertension had witnessed dramatic changes after the introduction of noninvasive figure accessible tools over the past few years. Imaging techniques that are based on evaluation of the liver stiffness was particularly useful in this respect. Acoustic radiation force impulse (ARFI) emerged as an interesting figure tool with reliable repute and high precision. Aims: To evaluate liver stiffness measurement (LSM) and splenic stiffness measurement (SSM) in healthy volunteers as concluded by the ARFI technique and to out a numeric calculated ratio that may reflect their correlation in the otherwise healthy liver. Patients and Methods: A ratio (splenic stiffness/liver stiffness in kPa) was determined in 207 consenting healthy subjects and was investigated with respect to age, gender, ethnic origin, body mass index (BMI), liver and spleen sizes healthy volunteers, alanine aminotransferase (ALT), aspartate aminotransferase (AST), platelet count (PLT), APRI, and FIB-4 scores. Results: Data from this work led to computing an index of 4.72 (3.42–7.33) in healthy persons on an average. Females had a higher index than males 6.37 vs 4.92, P=0.002. There was not any significant difference of the ratio in different age groups; ethnic origins; any correlation between SSM/LSM ratio and BMI; liver and spleen sizes; or ALT, AST, PLT, APRI, and FIB-4 scores. Conclusions: A quantifiable numeric relationship between splenic and liver stiffness in the healthy subjects could be computed to a parameter expressed as SSM/LSM ratio. We believe that this ratio can be a useful reference tool for further researches in CLD.
  2 4,248 407
Endoscopic ultrasound-guided antegrade stenting in an occluded biliary self-expandable metal stent
Majid A Almadi, Mohanned Eltayeb, Salem Thaniah
July-August 2016, 22(4):337-340
DOI:10.4103/1319-3767.187597  PMID:27488330
Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an attractive option for patients who cannot undergo conventional endoscopic retrograde cholangiopancreatography (ERCP) and do not want surgery or percutaneous drainage procedures. We present the use of EUS-antegrade (EUS-AG) insertion of a self-expandable metal stent (SEMS) in a patient with a common hepatic duct cholangiocarcinoma, as well as a huge gastric lipoma, after recurrent biliary obstruction of a prior SEMS inserted via ERCP in the same session as a duodenal stent insertion for gastric outlet obstruction.
  1 2,974 445
A quick screening model for symptomatic bacterascites in cirrhosis
Long-Chuan Zhu, Long Xu, Wen-Hua He, Wei Wu, Xuan Zhu
July-August 2016, 22(4):282-287
DOI:10.4103/1319-3767.187600  PMID:27488322
Background: Diagnosis of spontaneous bacterial peritonitis in cirrhosis can be made when a patient has an ascites polymorphonuclear leukocyte count ≥250/mm3. However, symptomatic bacterascites, which is a variant of spontaneous bacterial peritonitis with signs of infection but an ascites polymorphonuclear leukocyte count <250/mm3, cannot be confirmed until the time-consuming ascites culture becomes positive. Currently, early indicators for symptomatic bacterascites remain undetermined. Aims: To develop a quick screening model for early detection of symptomatic bacterascites in cirrhosis. Materials and Methods: Data on patients with cirrhotic ascites from two hospitals (from 2010 to 2014) were collected retrospectively. Patients with symptomatic bacterascites were enrolled in the case group and compared with patients without any infection in the control group. Logistic regression analysis was used to build a model for screening symptomatic bacterascites, and a receiver operating characteristics curve was used to assess the model. Results: In total, 103 patients were enrolled in the case group and 204 patients were enrolled in the control group. A screening model was constructed based on body temperature, abdominal tenderness, blood neutrophil percentage, blood total bilirubin, prothrombin time, and ascites nucleated leukocyte count. The area under the receiver operating characteristic curve was 0.939; a screening score of 0.328 was the best cutoff value. Conclusion: Patients with suspected symptomatic bacterascites can be quickly screened according to the developed model, and a screening score ≥0.328 indicates symptomatic bacterascites.
  1 3,674 308
Hepatitis c eradication: It's now or never…let's get to work
Ayman A Abdo
July-August 2016, 22(4):249-250
DOI:10.4103/1319-3767.187598  PMID:27488318
  - 2,684 353
Impact of pediatric inflammatory bowel disease on linear growth: Data from a national cohort study in Saudi Arabia
Mahmood D Al-Mendalawi
July-August 2016, 22(4):341-341
DOI:10.4103/1319-3767.187596  PMID:27488331
  - 2,098 192
Is endoscopic papillary large balloon dilation safe for treating large CBD stones?
Chan Sup Shim, Ji Wan Kim, Tae Yoon Lee, Young Koog Cheon
July-August 2016, 22(4):251-259
DOI:10.4103/1319-3767.187599  PMID:27488319
In recent years, endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been shown to be an effective technique for the removal of large or difficult common bile duct (CBD) stones, as an alternative to EST. Reviewing the literature published since 2003, it is understood that EPLBD has fewer associated overall complications than EST. Bleeding occurred less frequently with EPLBD than with EST. There was no significant difference in postendoscopic retrograde cholangiopancreatography pancreatitis or perforation. Recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines. Since use of a larger balloon can tear the sphincter as well as the bile duct, possibly resulting in bleeding and perforation, a balloon size that is equal to or smaller in diameter than the diameter of the native distal bile duct is recommended. The maximum transverse diameter of the stone and the balloon-stone diameter ratio have a tendency to affect the success or failure of complete removal of stones by large balloon dilation to prevent adverse effects such as perforation and bleeding. One should take into account the size of the native bile duct, the size and burden of stones, the presence of stricture of distal bile duct, and the presence of the papilla in or adjacent to a diverticulum. Even though the results of EPLBD indicate that it is a relatively safe procedure in patients with common duct stones with a dilated CBD, the recommended guidelines should be followed strictly for the prevention of major adverse events such as bleeding and perforation.
  - 4,907 698
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