Liver diseases in pregnancy and outcomes: A retrospective study from Saudi Arabia.

Liver diseases unique to pregnancy are common causes of both maternal and fetal mortality and morbidity. We retrospectively studied liver diseases unique to pregnancy, including hyperemesis gravidarum (HG); intrahepatic cholestasis of pregnancy; eclampsia; preeclampsia; hemolysis, elevated liver enzymes, and a low platelets (HELLP) syndrome; and acute fatty liver of pregnancy. We collected data including maternal age, gestational weeks at presentation and at delivery, mode of delivery, number of parity, and laboratory markers at 0, 1 week, and within 24 hours after delivery; from 112 patients (mean age, 29.8 years) from April 2015 - March 2017. SPSS 22 was used for statistical analysis. We The commonest liver disease in pregnancy was pre-eclampsia followed by HG. HG patients were younger compared with those with eclampsia and preeclampsia (P=0.025). Gestational week at presentation and the week of delivery were significantly greater for preeclampsia/eclampsia and HELLP patients compared to HG. Primigravida represented 42.9% of our patients. Fetal complications were reported in 29 (26%) of cases. Of those, 17 had fetal or neonatal death. Fourteen mothers (12.5%) had ICU admission. Pregnancy related liver diseases are important causes for fetal mortality and morbidity. Maternal age and gestational weeks are important predictors of fetal and maternal outcomes.

Prevalence and Clinical Characteristics of NAFLD in Chronic Liver Disease Patients from King Abdulaziz University Hospital, Jeddah.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a common cause of chronic liver disease (CLD). NAFLD is also related to obesity and metabolic syndromes, which are common in Saudi Arabia. However, it is yet unclear what proportion of CLD cases is because of NAFLD in Saudi Arabia. OBJECTIVE: To investigate the prevalence and clinical characteristics of NAFLD among patients with CLD in Saudi Arabia. MATERIALS AND METHODS: This retrospective study included all patients with any CLD who had successfully undergone transient elastography (FibroScan) examination at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between April 2015 and April 2018. These CLD patients were then grouped as NAFLD and non-NAFLD patients. Serum hemoglobin, alanine aminotransferase, gamma-glutamyl transferase, albumin and bilirubin levels; platelet count and international normalized ratio within 1 month after the FibroScan examination were assessed. For NAFLD patients, glycated hemoglobin levels and abdominal ultrasound examination results were also assessed. Statistical analysis was carried out using Student's t-test and linear regression. RESULTS: The prevalence of NAFLD among CLD patients was 22.5% (111 of 494 CLD patients), and it was the third most common CLD after chronic hepatitis B and C. Compared with non-NAFLD patients, NAFLD patients had significantly higher mean age (53.65 ± 12.7 vs. 48.07 ± 14.6 years; P < 0.001), mean serum alanine aminotransferase level (61.84 vs. 50.23 IU/L; P < 0.001) and mean controlled attenuation parameter (297.83 vs. 238.41; P < 0.001). NAFLD patients also had a higher rate of ultrasound-detected features of cirrhosis (16.2% vs. 3.7%, P < 0.001), but there was no significant difference in fibrosis severity. In addition, their mean glycated hemoglobin level (6.85) was elevated (range: 5-13). Age and platelet count were significantly correlated with presence of cirrhosis. CONCLUSION: NAFLD is the third most common CLD in Western Saudi Arabia, and it is associated with older age and metabolic syndromes, with one-third of the patients having advanced fibrosis or cirrhosis.

Prevalence and molecular characterization of hepatitis D virus in Saudi Arabia: A single-center study.

BACKGROUND/AIMS: Hepatitis D virus (HDV) is a defective RNA virus that is dependent on hepatitis B surface antigen (HBsAg) for transmission and replication. HDV significance arises from the possibility of poor prognosis of hepatitis B virus (HBV) infection. In Saudi Arabia, HDV prevalence varied from 8 to 32% before the HBV vaccination program and ranged from 0 to 14.7% after the vaccination program was started. The last study, performed in 2004, showed a prevalence of 8.6% in hospital-based HBV cases and 3.3% in healthy donors. The aim of this study was to investigate the prevalence and molecular characterization of HDV in chronic hepatitis B (CHB) patients at the King Abdulaziz University Hospital in Jeddah, Saudi Arabia by molecular and serological techniques. To the best of our knowledge, this is the first study to detect HDV at the molecular level in Saudi Arabia. PATIENTS AND METHODS: The study included samples from 182 CHB patients from Jeddah; 13 samples with HBsAg negative were excluded. Samples were tested for HDV-Ab, viral RNA by reverse transcriptase-polymerase chain reaction (RT-PCR) in the HDV L-Ag region and sequence analysis. RESULTS: The mean age of the participants was 44.36 years; 75.1% of the participants were Saudi nationals, 58% were males. Nine samples were positive for HDV-Ab and four were borderline; all were subjected to RT-PCR amplification. Three of the positive HDV-Ab cases and 1 borderline case were positive by RT-PCR. All the positive cases had HBV genotype D, and the positive RT-PCR cases were positive for HBV DNA. One of the HDV viremic samples was of genotype 1 by sequencing. The prevalence of HDV in the study was 7.7%, which was lower in Saudis (6.3%) than in non-Saudis (11.9%). CONCLUSION: HDV coinfection does not seem to have an effect on the clinical status of the recruited CHB cases in this study. More studies are needed to investigate the genetic diversity in other areas such as the southern parts of the Kingdom.

Fibroscan Compared to FIB-4, APRI, and AST/ALT Ratio for Assessment of Liver Fibrosis in Saudi Patients With Nonalcoholic Fatty Liver Disease.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is being increasingly recognized as a cause of chronic liver disease. It has also been associated with devastating outcomes such as decompensated liver cirrhosis and hepatocellular carcinoma, as well as diabetes and metabolic syndrome. OBJECTIVES: This study was conducted in order to assess liver fibrosis using Fibroscan, and to compare these results to the use of Fibrosis-4 (FIB-4) scores, AST platelet ratio index (APRI scores), and the AST/ALT ratios on NAFLD patients. PATIENTS AND METHODS: A cross sectional study was conducted on NAFLD patients who underwent Fibroscan examinations between September 1, 2011 and June 30, 2014. Demographic data was collected, including sex, age, and nationality; serum alanine aminotransferase levels (ALT, 30 - 65 U/L), serum aspartate aminotransferase levels (AST, 15 - 37 U/L), and platelet counts (150 - 400 k/µL) were also determined. The stages of fibrosis (F0 1 - 6, F1 6.1 - 7, F2 7 - 9, F3 9.1 - 10.3, and F4 ≥ 10.4) were defined in kPa. For each patient, the AST/ALT ratio was also measured. The results of APRI and FIB-4 were compared with the Fibroscan fibrosis scores. RESULTS: The results of 122 patients were analyzed, including 65 (53.3%) males with a mean age of 50.2 years (SD: 13.7; range: 18 - 86). The males were significantly younger than the females (48.7 years (SD: 16.03) versus 51.8 years (SD: 10.3 P = 0.05), respectively). The mean stiffness score was 12.02 (SD: 12.7) kPa. Forty-four patients (36%) had advanced fibrosis. The mean platelet and serum ALT levels were normal. There was a significant positive correlation between the Fibroscan results and the AST/ALT ratios, the APRI scores, and the FIB-4 results. Similarly, there was a significant positive correlation between age and fibrosis score, and a significant negative correlation between platelet count and stiffness score. CONCLUSIONS: The data showed that more than one-third of the cohort exhibited advanced fibrosis, demonstrating the need for the early diagnosis and treatment of NAFLD. The use of Fibroscan with other serum markers has been shown to be helpful for the diagnosis of severe fibrosis.

Variceal hemorrhage: Saudi tertiary center experience of clinical presentations, complications and mortality.

AIM: To determine the clinical presentation, underlying etiology and short- and long-term outcomes of acute variceal bleeding (AVB). METHODS: A retrospective descriptive cohort study of cirrhotic patients with AVB who were admitted to King Abdul Aziz University Hospital between January 2005 and December 2009. We obtained demographic data for all patients. For each patient we also obtained the clinical data at presentation; cause of liver cirrhosis, bleeding presentation (hematemesis and/or melena), presence of ascites, hepatic encephalopathy and renal impairment (RI) or hepatorenal syndrome. We carried out complete blood count, prothrombin time evaluation, and liver function tests. We also report all episodes of re-bleeding after the first episode of AVB, both during the initial admission and after discharge. We recorded the length of stay for each patient and thereby calculated the mean duration of stay for all patients. The length of follow-up after the first AVB and the outcome for each patient at the end of the study period were recorded. Causes of mortality either related to liver disease or non-liver disease cause were determined. RESULTS: A 125 patients were enrolled in the study. The number of episodes of AVB for each patients varied between 1 and 10. Survival from the first attack of AVB to death was 20.38 mo (SD 30.86), while the length of follow-up for the living patients was 53.58 mo (SD 24.94). Total number of AVB admissions was 241. Chronic hepatitis C, the commonest underlying etiology for liver disease, was present in 46 (36.8%) patients. Only 35 (28%) patients had received a primary prophylactic ß-blocker before the first bleeding episode. The mean hemoglobin level at the time of admission was 8.59 g/dL (SD 2.53). Most patients had Child-Pugh Class C 41 (32.8%) or Class B 72 (57.6%) disease. Hematemesis was the predominant symptom and was found in 119 (95.2%) patients, followed by melena in 75 (60.0%) patients. Ascites of variable extent was documented in 93 (74.4%) patients. We identified hepatic encephalopathy in 31 (28.8%) patients and spontaneous bacterial peritonitis in 17 (13.6%). Bleeding gastric varices was the cause of AVB in 2 patients. AVB was associated with shock in 22 patients, 13 of whom (59.1%) had Child-Pugh class C disease. RI was noted in 19 (46.3%) of 41 patients in Child-Pugh class C and 14 (19.4%) of 72 patients in Child-Pugh class B. None of the patients with Child-Pugh class A disease had RI. Emergency endoscopy was effective in controlling the bleeding, although the re-bleeding rate was still high, 12 (9.6%) during the same admission and 55 (44%) after discharge. The re-bleeding rate was higher in patients with ascites, occurring in 40/55 (72.2%). The length of hospital stay was 1-54 d with a mean of 8.7 d. Three patients had emergency surgery due to failure of endoscopic treatment and balloon tamponade. The overall long term mortality was 65%. Survival from the first attack of AVB to death was 20.38 ± 30.86 mo, while the length of follow-up for the living patients was 53.58 ± 24.94 mo. Patients with Child-Pugh score C had a higher risk of liver disease-related mortality (67.6%). RI (developed during admission) was the main factor that was associated with mortality (P = 0.045). CONCLUSION: The majority of patients with liver disease who present at the emergency unit for AVB are at an advanced stage of the disease. The outcome is poorer for patients who develop RI during hospitalization.

Chronic hepatitis C in saudi arabia: three years local experience in a university hospital.

BACKGROUND: Chronic hepatitis C (CHC) is a global infection. In Saudi Arabia, the prevalence of CHC is declining due to the implementation of a blood screening program. However, CHC still remains a leading cause of liver cirrhosis and hepatocellular carcinoma. OBJECTIVES: This is a retrospective study of CHC patients at the King Abdul Aziz University Hospital, Jeddah, Saudi Arabia. PATIENTS AND METHODS: Out of a total of 291 CHC patients from the hepatology clinic at King Abdul Aziz University hospital, Jeddah, 279 patients were included in the present study. They were primarily male (152, 54.5%), with a mean age of 50.41 ± 1.72 years. The majority of patients were either Saudi (108, 38.7%) or Egyptian (60, 21.5%). A total of 61 patients received combination treatment with pegylated interferon and ribavirin, and one patient with sickle-cell anemia received pegylated INF monotherapy. Demographic, clinical and laboratory features of the CHC patients, and their responses to treatment were studied. RESULTS: Decompensated cirrhosis was documented in 60 patients (21.5%), and hepatocellular carcinoma in 14 (5%). The mean level of serum alanine aminotransferase was 83.6 ± 231 u/L. The predominant genotype among the 70 patients tested, was genotype 4, followed by genotype 1 (39 and 18 patients, respectively). The sustained viral response (SVR) rate was 82.99%. The main predictive factors for SVR were baseline HCV viral load and rapid virologic response (RVR). The mean duration of follow-up was 4.2 ± .85 years. There were 24 patients who had liver disease-related mortality. CONCLUSIONS: our data showed that 22% of CHC patients progress to cirrhosis and another 22% had treatment. Liver related mortality was more common in patients with advanced cirrhosis.

Autoimmune hepatitis as a unique form of an autoimmune liver disease: immunological aspects and clinical overview.

Autoimmune hepatitis (AIH) is a unique form of immune-mediated disease that attacks the liver through a variety of immune mechanisms. The outcomes of AIH are either acute liver disease, which can be fatal, or, more commonly, chronic progressive liver disease, which can lead to decompensated liver cirrhosis if left untreated. AIH has characteristic immunological, and pathological, features that are important for the establishment of the diagnosis. More importantly, most patients with AIH have a favorable response to treatment with prednisolone and azathioprine, although some patients with refractory AIH or more aggressive disease require more potent immune-suppressant agents, such as cyclosporine or Mycophenolate Mofetil. In this paper, we discuss the immunological, pathological and clinical features of AIH, as well as the standard and alternative treatments for AIH.

Autoimmune liver disease - are there spectra that we do not know?

Autoimmune liver diseases (AILDs) are common leading causes for liver cirrhosis and terminal stage of liver disease. They have variable prevalence among patients with liver disease and have two major clinical and biochemical presentations. Autoimmune hepatitis (AIH) is the typical example of hepatocellular AILD, but it can also be presented under a cholestatic pattern. AIH has a scoring diagnostic system and respond in most cases to the treatment with prednisolone and azathioprine. Primary biliary cirrhosis (PBC) is the second most common AILD, with a cholestatic presentation and characterized by positive antimitochondrial antibody (AMA). It has an excellent response and long term outcome with the administration of ursodeoxycholic acid (UDCA). Another AILD that is thought to be a variant of PBC is the autoimmune cholangitis, being a disease that has biochemical and histological features similar to PBC; but the AMA is negative. Primary sclerosing cholangitis (PSC) is a rare entity of AILD that has a cholestatic presentation and respond poorly to the treatment, with the ultimate progression to advance liver cirrhosis in most patients. Other forms of AILD include the overlap syndromes (OS), which are diseases with mixed immunological and histological patterns of two AILD; the most commonly recognized one is AIH-PBC overlap (AIH-PSC overlap is less common). The treatment of OS involves the trial of UDCA and different immunosuppressants. Here we present three case reports of unusual forms of chronic liver diseases that most likely represent AILD. The first two patients had a cholestatic picture, whereas the third one had a hepatocellular picture at presentation. We discussed their biochemical, immunological and histological features as well as their response to treatment and their outcomes. Then, we compared them with other forms of AILD.

Mycophenolate mofetil as a rescue therapy for autoimmune hepatitis patients who are not responsive to standard therapy.

Autoimmune hepatitis (AIH) is a chronic liver disease of unknown etiology that is responsive to steroid and azathioprine treatment in more than 80% of patients after 3 years of treatment. There are few alternative treatment options for individuals with AIH who are unresponsive to steroids and azathioprine, and research on this is limited to open-label studies of a variety of immunosuppressive agents that involve only small numbers of patients. Mycophenolate mofetil is one of the most frequently used alternative agents for the treatment of AIH patients not responsive to standard therapy. In this article, we review and summarize currently available data regarding the use of mycophenolate mofetil as an alternative treatment option for patients with AIH.

Can chronic hepatitis C resolve spontaneously? Case report and review.

Chronic hepatitis C (CHC) is variably prevalent around the world and is usually a blood-borne infection. Most patients will have subclinical infection at the onset, but patients who develop acute hepatitis can spontaneously clear the virus upon immune activation. Up to 80% of CHC patients will progress to chronic infection. CHC is unlikely to clear spontaneously. This article describes two female patients with transfusion-acquired CHC diagnosed by both positive hepatitis C virus (HCV)-Ab and hepatitis C virus-polymerase chain reaction (HCV-PCR) tests. Both patients cleared the infection spontaneously after more than 5 and 25years of CHC infection, respectively.

Chronic hepatitis B infection in a hepatology clinic at a university hospital in Jeddah.

INTRODUCTION: The outcome of chronic hepatitis B (CHB) infection in a cohort of CHB patients at the hepatology clinics of King Abdul Aziz University Hospital in Jeddah was studied. METHODOLOGY: The results of a complete blood count, prothrombin time, liver function test and hepatitis B virus polymerase chain reaction (HBV-PCR) performed over the previous two to five years of follow-up were reviewed. Results of abdominal ultrasound performed within the last year and the data on the treatment type, duration and resistance were also obtained. RESULTS:   The majority of the 109 patients studied were Hepatitis B e antigen (HBeAg-negative; 87.2%). Male patients had higher serum ALT values compared to females at follow-up. HBeAg-positive patients had higher HBV-PCR levels at diagnosis compared to HBeAg-negative patients. Patients below 40 years of age had higher HBV-PCR compared to those above 40 years. Ultrasound showed liver cirrhosis in 11% of patients. Cirrhotic patients had higher GGT levels compared to non cirrhotic patients. Drug resistance developed in 25% of the 20 Lamivudine-treated patients. The mean duration of treatment was 2.5 ± .47 years. CONCLUSION: CHB was predominantly HBeAg negative, with a benign long-term outcome in most patients. Therapy may need to be individualized for patients with high risk of progression.

Autoimmune hepatitis: Single-center experience of clinical presentation, response to treatment and prognosis in Saudi Arabia.

BACKGROUND/AIM: Autoimmune hepatitis (AIH) is a common cause of end-stage liver disease worldwide. It is a disease prevalent in children and adults, with female predominance and variable clinical presentations. AIH has favorable responses to steroids and immunomodulators. Diagnosis of AIH is based on clinical and laboratory criteria, as suggested by the International Autoimmune Hepatitis Group. Data on the disease pattern of AIH from the Middle East countries is scarce. MATERIALS AND METHODS: In this retrospective analysis, we studied clinical and laboratory features, immunological data, radiological findings, liver biopsy findings and response to therapy in patients with AIH from the hepatology clinics of King Abdul Aziz, University Hospital, Jeddah, from 1994 to 2008. RESULTS: We diagnosed 41 patients with AIH, and 33 were included in the analysis. The mean age was 32.3 years, with female predominance of 75.7%. De-compensated cirrhosis at presentation was found in 45.5% of the patients. Acute hepatitis was associated with significantly higher levels of the serum ALT and bilirubin (P=0.001 and P=0.03, respectively). All our patients had type 1 AIH. Treatment with prednisolone and azathioprine resulted in complete or partial remission in majority of the patients (54.8%). However, patients with advanced disease showed a poorer response to treatment (P=0.016). Six patients with poor compliance had relapse of AIH. Two patients had a flare of the disease during pregnancy, and they responded well with prednisolone. The longest follow-up was 14 years and the shortest was 2 months. Four patients died from liver disease. CONCLUSION: AIH patients in Saudi Arabia are likely to present with advanced disease at a young age and would have a poorer response to therapy as compared with patients in other countries worldwide.

Elevated serum immunoglobulin G levels in patients with chronic liver disease in comparison to patients with autoimmune hepatitis.

BACKGROUND: Hypergammaglobulinemia is frequently observed in patients with chronic liver disease (CLD) of different causes. On the other hand, elevated levels of serum immunoglobulin G (IgG) are the best diagnostic marker for autoimmune hepatitis (AIH). Thus, the ability to distinguish AIH patients from patients with other liver disease, especially patients with advanced liver cirrhosis, is important since most AIH patients will a have favorable treatment response if diagnosed properly. OBJECTIVE: We conducted this study to evaluate the significance of elevated IgG levels in patients with non-autoimmune CLD and to compare these IgG levels with those in patients with AIH upon diagnosis. SETTING AND STUDY POPULATION: The serum IgG levels in 27 patients with AIH determined at the time of diagnosis were compared to the serum IgG levels in 27 patients with other CLDs of variable severity at the King Abdul Aziz University Hospital in Jeddah, Saudi Arabia. Severity of the disease was evaluated in all patients. RESULTS: We found that the patients in the CLD group with decompensated cirrhosis had significantly higher serum IgG levels compared to the compensated CLD patients (p <0.02). In addition, the AIH patients had significantly higher serum IgG levels than the non-autoimmune hepatitis CLD patients and the decompensated cirrhosis patients in the CLD group (p <0.001 and p <0.044, respectively). Most patients with elevated serum IgG of the AIH group (67%) and the CLD group (75%) had significant hypergammaglobulinemia, not just isolated elevated IgG levels. CONCLUSION: Elevated serum IgG levels with hypergammaglobulinemia are commonly found in patients with advanced CLD. The differentiation of such cases from AIH is important in order to avoid misdiagnosis and confusion with AIH.

Intestinal tuberculosis and Crohn's disease: the dilemma of similarities and misdiagnosis.

Differentiating intestinal tuberculosis from Crohn's disease is one of the most difficult and challenging issues for the gastroenterologist, radiologist and pathologist. The final diagnosis of such cases may need the gathering of all clinical, endoscopic, radiological and pathological data. In the following report three cases of intestinal tuberculosis are described. Two of these were initially misdiagnosed as Crohn's disease and the third was thought to be ovarian or colonic cancer; a fourth patient was diagnosed as having Crohn's disease but on presentation was thought to have intestinal tuberculosis. Their clinical presentations, colonoscopic findings, radiological features and the pathological diagnosis are described and the similarities between intestinal tuberculosis and Crohn's disease as compared to previous reports are discussed.

Is serum alanine transaminase level a reliable marker of histological disease in chronic hepatitis C infection?

BACKGROUND: Approximately 20-30% of patients chronically infected with hepatitis C virus (HCV) have persistently normal alanine transaminase (PNALT) levels. These patients are described to have a mild degree of histological liver damage. We aimed to assess the histological liver changes in HCV patients with PNALT. PATIENTS AND METHODS: Sixty-five patients with HCV and PNALT (group A) underwent a liver biopsy. PNALT was defined as three or more determinations identified to be within the normal range over 6 months or longer. The demographical features and histological changes were compared with 66 consecutive patients with chronic HCV infection and elevated ALT (group B). All patients had a detectable HCV RNA. Histological disease was scored according to the METAVIR system. RESULTS: Females were more likely to have normal ALT levels (65%). The mean ALT level in Group A and B was 30 and 105 IU/L respectively. No patient in either group had normal histology. The mean necro-inflammatory scores in groups A and B (2.0+/-0.68 vs 2.09+/-0.67) and the mean fibrosis scores (2.11+/-0.87 vs 2.24+/-1.04) were not significantly different. Bridging fibrosis in groups A and B was seen in 24.6 and 37.9% patients, respectively, while cirrhosis was seen in 6.2 and 7.6% patients respectively. Hepatic steatosis in groups A and B (0.94+/-0.86 vs 1.0+/-1.02 respectively) was also not significantly different and did not show any association with the fibrosis scores across the two groups. In group A, the necro-inflammatory and fibrosis scores of patients with and without steatosis were not statistically significant. Age was the only predictor of normal ALT levels. However, increasing age did not show a significant increase in histological activity in either group beyond a certain age. CONCLUSION: This study demonstrates that ALT is a poor surrogate marker for inflammation and fibrosis in HCV patients. Given the presence of significant necro-inflammation in PNALT patients, the risk/benefit ratio justifies treatment without the need for a liver biopsy.

Pattern of admission to hospitals during muslim pilgrimage (Hajj).

OBJECTIVE: The pattern of medical conditions necessitating admission differs according to the weather condition in that particular year. Previous studies had been conducted during the hot weather, none over the last 10 years, were carried out during, the milder weather we are experiencing. The aim of this study is to establish the pattern of admission during this mild weather and to elucidate the possible risk factors. METHODS: A prospective study was performed in 4 hospitals in 2 different locations in Al-Mashaer, Kingdom of Saudi Arabia. Data were collected during one working shift in 2 hospitals in Arafat on the 9th of Dhul Hijjah 1422, corresponding to 21st of February 2002, and another working shift in 2 hospitals in Mina on the 10th of Dhul Hijjah 1422, corresponding to 22nd of February 2002. RESULTS: A cohort of 76 patients from Arafat hospitals and 84 patients from Mina hospitals were included (total 160 patients). Males constituted 62% and females 38% with the median age of 60 +/- 15 years. The respiratory system was the most commonly affected (57%), followed by cardiovascular system (19.4%), and gastrointestinal tract (GIT) in 6.3% of cases. There were only 3 cases of heat-related admissions with only one confirmed case of heat stroke. Similarly, only one case of meningitis was confirmed in this cohort. Pneumonia was encountered in 63 cases (39.4%) and exacerbation of asthma and chronic obstructive pulmonary diseases (COPD) in 23 cases (14.4%). Pre-existing co-morbid medical conditions had included bronchial asthma and COPD (22.5%), hypertension (17.5%), and Diabetes mellitus (15%). Short-term follow up (24-48 hours) identified 2 deaths (1.3%), 94 patients (59%) were transferred to other secondary or tertiary care facilities and 64 (40%) were discharged home. CONCLUSION: Hospital admission during Hajj is related to old age and occurs in patients with associated co-morbid conditions. During this mild weather lower respiratory tract infections and exacerbation of bronchial asthma and COPD are the most commonly encountered diseases during Hajj.

Lamivudine in chronic hepatitis B virus.

OBJECTIVE: To access the effect of one year treatment with Lamivudine, and its durability on patients with compensated chronic hepatitis B. METHODS: Thirty-six patients with hepatitis B surface antigen positive, hepatitis B virus deoxyribonucleic acid (DNA) positive, were treated with 100 mg Lamivudine daily for one year, irrespective of their liver enzymes level, alanine aminotransferase or hepatitis B envelope antigen status. Patients with normal alanine aminotransferase and negative hepatitis B virus DNA at the end of the treatment were responders and those with persistent response 16 weeks off treatment were considered having durable response. RESULTS: Three patients dropped out and 33 patients completed the study. Eight patients (24.2%) had normal alanine aminotransferase, 25 patients (75.8%) had increased alanine aminotransferase. Thirty patients (90.9%) were hepatitis B envelope antigen negative. Two patients (25%) with initial normal alanine aminotransferase and 7 patients (28%) with increased enzyme level, responded at end of treatment. One patient with positive hepatitis B envelope antigen responded to treatment. Only one patient relapsed during follow-up period off treatment. CONCLUSION: Lamivudine is associated with durable response in patients with hepatitis B virus and negative hepatitis B envelope antigen. Longer treatment for more than one year may be required to improve response rates.

Effect of induction therapy on Hepatitis C.

OBJECTIVE: To assess the response to one month induction combination therapy using alpha interferon and Ribavirin on patients with chronic hepatitis C. METHODS: Eighty patients with naive compensated chronic hepatitis C (group A) were followed at King Abdul-Aziz University Hospital, Jeddah, Kingdom of Saudi Arabia from October 1996 through February 2000 received daily subcutaneous injection of alpha interferon -2b (Intron A 3 million units) plus Ribavirin 1-1.2 grams (induction) for one month followed by Intron A, 3 times a week together with daily Ribavirin (same dose) for 11 months. Response, assessed based on viral load and liver enzymes, was compared to that of 27 patients (group B) who received Intron A 3 million units 3 times weekly and daily Ribavirin (same dose) for 12 months (standard regimen). RESULTS: A total of 39 patients in group A (48.7%) and 11 patients in-group B (40.7%) had end of treatment response. Twenty nine patients in group A (36.2%) and 5 patients in group B (18.5%) had sustained virologic response. Thirty-seven patients in group A (46.2%) and 6 patients in-group B (22.2%) had sustained biochemical response. None of the patients with cirrhosis in both groups had sustained virologic response. In addition, sustained virologic response in patients with genotype-one and 4 was 31.4% (22 out of 70 patients) in group A and 15.3% (4 out of 26 patients) in group B. CONCLUSION: Induction combination therapy improves the sustained biochemical and virologic responses most likely by early prevention of mutation of the virus, which in turn plays a role in the relapse rate.

Treatment of patients with chronic hepatitis C with normal liver enzymes.

OBJECTIVE: This is a controlled prospective study to evaluate the efficacy of induction combination therapy using alpha-interferon and ribavirin in patients with chronic hepatitis C and persistently normal liver enzymes. METHODS: Forty-six patients with compensated liver disease tested positive for hepatitis C virus antibody between October 1998 and August 2000 at King Abdulaziz University Hospital and Al-Badriyah Towers, Jeddah Clinics, Jeddah, Kingdom of Saudi Arabia. Twelve patients had persistently normal liver enzymes for 6 months and 34 patients with abnormal liver enzymes (control). Patients were treated using induction combination therapy. Viral load response was measured using branched deoxyribonucleic acid signal amplification test. RESULTS: Ten patients with normal liver enzymes (Group A) and 30 patients with abnormal liver enzymes (Group B) were included. End of treatment response in Group A was 90% as compared to 60% in group B; sustained virologic response in group A was 40% as compared to 43.3% in Group B. CONCLUSION: Response rate to induction combination therapy with alpha-interferon and ribavirin in patients with normal liver enzymes was similar to that in those with increase liver enzymes.

Effect of pegylated interferon on non-responders and relapsers with interferon.

OBJECTIVES: To assess whether a combination of pegylated interferon (interferon conjugated with polyethylene glycol) and ribavirin can improve the response rate in patients with chronic hepatitis C who either did not respond to (Non-responders), or had relapsed after responding to (Relapsers) standard interferon and ribavirin combination therapy. PATIENTS AND METHODS: In this prospective study, 20 chronic hepatitis C patients (comprising 16 Non-responders and 4 Relapsers to previous treatment with alpha interferon and ribavirin), were treated with pegylated interferon-2b weekly and ribavirin daily for one year. Eleven patients had genotype 4, eight were of genotype 1 and one patient had genotype 3. Response to treatment was determined based on normalisation of liver enzymes and negative viral load (assessed using qualitative HCV RNA PCR) at end of treatment (ETR) and 6 months off treatment (SVR). RESULTS: Seven patients (35%) achieved normalisation of liver enzymes and negative viral load at the end of treatment. However, only 2 patients (10%) managed to retain these levels after six months off treatment. The latter two patients had been previous Relapsers. CONCLUSION: Combination of pegylated interferon and ribavirin may be beneficial in previous relapsers with standard interferon-ribavirin combination therapy, but is unlikely to achieve sustained virological response in non-responders.