Saudi consensus guidance for the management of inflammatory bowel disease during pregnancy.

ABSTRACT: The management of inflammatory bowel disease (IBD) in pregnant women is challenging and must be addressed on a patient-by-patient basis. Optimal patient management requires a multidisciplinary team and clear evidence-based recommendations that cater to this subset of patients. In this article, we provide concise guidelines and clinical care pathway for the management of IBD in pregnant women. Our recommendations were developed by a multidisciplinary working group that includes experts from the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacology. All recommendations are based on up-to-date information following an extensive literature review. A total of 23 evidence-based expert opinion recommendations for the management of IBD in pregnant women are herein provided.

Saudi Arabia consensus guidance for the diagnosis and management of adults with inflammatory bowel disease.

Optimal management of inflammatory bowel disease (IBD) relies on a clear understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This article provides concise guidelines for the management of IBD in adults, based on the most up-to-date information at the time of writing and will be regularly updated. These guidelines were developed by the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacy. After an extensive literature review, 78 evidence-and expert opinion-based recommendations for diagnosing and treating ulcerative colitis and Crohn's disease in adults were proposed and further refined by a voting process. The consensus guidelines include the finally agreed on statements with their level of evidence covering different aspects of IBD diagnosis and treatment.

Prevalence, severity and associated factors of restless leg syndrome in inflammatory bowel disease patients.

BACKGROUND: The association between restless leg syndrome (RLS) and inflammatory bowel disease (IBD) has often been an under-investigated and clinically misdiagnosed entity. An emphasis should be made on the severity and associated factors, as the prevalence of both entities is on the rise globally. In this study we aimed to investigate the prevalence, severity and associated risk factors of RLS in patients with IBD. METHODS: A multi-center, prospective cross-sectional study was conducted with age and gender matched controls in the ratio of 1:3. Cases of IBD were confirmed according to European Crohns and Colitis Organization guidelines. The study recruited 377 cases and 1131 age and gender-matched controls. RLS severity and prevalence was determined using a validated International Restless Legs Syndrome Study Group questionnaire. The anthropometric and blood biochemical measurements were retrieved from the patient's medical records. Associated factors were analyzed by regression analysis. RESULTS: The prevalence of RLS in patients with IBD and non-IBD control groups was 21.5% and 9.7%, respectively (P = 0.001). The severity index of RLS symptoms in all the three categories of mild, moderate and severe RLS was higher in the IBD group (P = 0.001). Obesity (BMI >30 Kg/m2) was more prevalent in patients with IBD with RLS than without RLS (21.9%: 10.3%, P = 0.009). Ages between 46 and 59 years (OR = 18.7 [2.6-29.4], P = 0.008), obesity (OR = 22 [2.6-29.4], P = 0.005), higher TSH levels (OR = 1.7 [1.0-3.0], P = 0.033), and lower hemoglobin levels (P = 0.028) showed a greater risk associated with RLS. CONCLUSION: Prevalence and severity of RLS was higher in patients with IBD. The risk factors for RLS in IBD include increasing age, obesity, higher TSH, and lower hemoglobin.

Predictors of failure of endoscopic retrograde cholangiography in clearing bile duct stone on the initial procedure.

BACKGROUND/AIMS: The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP. PATIENTS AND METHODS: This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded. RESULTS: A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66-12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13-1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36-15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56-6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10-8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00-0.08) on multivariate analysis. CONCLUSION: A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones.

Findings during screening colonoscopies in a Middle Eastern cohort.

BACKGROUND/AIMS: Colorectal cancer is the most common cancer in males and the third most common cancer in females. We aim to determine the polyp and adenoma prevalence in a cohort of patients who underwent opportunistic screening colonoscopies. PATIENTS AND METHODS: A retrospective cohort study was conducted using an endoscopic reporting database of individuals seen at three tertiary care hospitals (two public hospitals and one private) in Riyadh, Saudi Arabia. Consecutive patients who were 45 years of age and older and underwent opportunistic screening colonoscopies between November 2016 and October 2017 were included. We excluded those with a history of colon cancer or colonic resection for any reason, inflammatory bowel disease, gastrointestinal bleeding, or anemia. RESULTS: Around 1180 patients were included in the study with a mean age of 58.6 years (SD = 7.3), with males representing 53.6% and an overall cecal intubation rate of 92.4%. Masses were found in 1.6% of the study population (50% in the sigmoid or rectosigmoid, 37.5% in the rectum). The polyp detection rate in colonoscopies was 24.8% and the adenoma detection rate was 16.8%. The histology of removed polyps was tubular adenomas in 56.6%, hyperplastic polyps in 32.7%, tubulovillous adenomas in 8.2%, and villous adenomas in 2.5%. The majority of the polyps were in the sigmoid colon (28.3%) and rectum (22.0%), followed by the ascending colon (11.2%) and cecum (10.3%), then the transverse colon and descending colon (9.4% each), and multiple locations in the remainder. CONCLUSION: The prevalence of polyps and adenomas in this cohort is less than that reported in the Western populations.

Use of image-enhanced endoscopy in the characterization of colorectal polyps: Still some ways to go.

BACKGROUND/AIM: Instrument-based image-enhanced endoscopy (IEE) is of benefit in detecting and characterizing lesions during colonoscopy. We aimed to study the ability of community-based gastroenterologists to differentiate between neoplastic and non-neoplastic lesions using IEE modalities and to identify predictors of correct classification and the confidence of the optical diagnosis made. MATERIALS AND METHODS:: An electronic survey was sent to practicing gastroenterologists using electronic tablets during a gastroenterology meeting. Demographic and professional information was gathered and endoscopic images of various colonic lesions were shown and they were requested to classify the images based in white light, flexible spectral imaging color enhancement (FICE), iScan, and narrow band imaging (NBI). RESULTS:: Overall, 71 gastroenterologists responded to the survey, 76% were males and the majority were aged between 36 and 45 years (44%). Most of the respondents practiced both hepatology and gastroenterology (56%) and most of them had never received any training on IEE (66%). Correct identification of lesions using regular white light endoscopy was low (range 28%-84%). None of the IEE modalities increased the percentage of correct diagnoses apart from one NBI image where it increased from 28% (95%CI: 17%-38%) to 56% (95%CI: 44%-68%) (P < 0.01). Those who identified themselves as practicing mainly luminal gastroenterology were more confident 72% (95%CI: 60%-84%) compared with hepatologists 36% (95%CI: 25%-48%), or those who practiced both 48% (95%CI: 39%-56%) despite no difference in the percentage in correct answers. CONCLUSION:: There remain areas of improvement in the performance of endoscopists in practice and would recommend more dedicated training programs, which could make use of asynchronous technological platforms.

Plasma ghrelin and leptin in patients with inflammatory bowel disease and its association with nutritional status.

BACKGROUND/AIMS: Ghrelin and leptin are thought to play a role in the loss of appetite in active inflammatory bowel disease (IBD). This study seeks to probe into the association of these markers with regards to IBD and the nutritional status of these patients. A case-control study was conducted between May 2015 and March 2016 at King Khalid University Hospital (KKUH). Thirty-one patients with IBD (both active and non-active) and forty-one healthy controls (both non-fasting and fasting) were recruited. PATIENTS AND METHODS: Plasma ghrelin and leptin levels were determined using an enzyme immunoassay (EIA) technique. The nutritional status was determined through the standardized Mini-Nutritional Assessment (MNA) questionnaire. RESULTS: The difference in the plasma ghrelin between active (263.7 pg/mL) and non-active (108 pg/mL) cases was significant (P= 0.02). The difference in mean plasma leptin level between active cases (229.4 pg/mL) vs. non-active cases (359.7 pg/mL) was insignificant (P= 0.4). In fasting (2028.6 pg/mL) and non-fasting controls (438.8 pg/mL), the mean plasma ghrelin values was significantly different (P< 0.01). In contrast, the plasma leptin level difference between fasting (727.3 pg/mL) and non-fasting (577 pg/mL) controls was insignificant (P= 0.14). There is a statistically significant association in mean ghrelin levels between the case group and the control group (P< 0.01). With regards to nutritional status, the mean MNA score of active cases compared to fasting controls was 18.8 ± 5 vs. 20.8 ± 3.8, respectively (P< 0.01) Conclusion: Ghrelin levels were lower in the active IBD cases compared to the inactive ones, signifying an underlying pathology as etiology to this phenomenon. Furthermore, ghrelin levels were significantly lower in both case groups compared to the controls. These findings, along with the disparity in the MNA scores, insinuate a possible link between hormone levels and the loss of appetite from which these patients suffer.

Efficacy of spyglass-guided electrohydraulic lithotripsy in difficult bile duct stones.

BACKGROUND/AIMS: We aimed to evaluate the efficacy and safety of Spyglass-guided electrohydraulic lithotripsy (EHL) for difficult common bile duct stones (CBD) not amenable to conventional endoscopic therapy. DESIGN: A retrospective study evaluating the efficacy of Spyglass-guided EHL in treating difficult CBD stones, in a single tertiary care center. PATIENTS AND METHODS: All patients who underwent Spyglass-guided EHL from 2012 to 2013 were compared with a historical cohort who had ECSWL. RESULTS: A total number of 13 patients underwent Spyglass-guided EHL, 8 (61.5%) of them were males. The mean age was 46.5 ± 5.6 years. Bile duct clearance was achieved in 13 (100%) of them. Seventy-six percent required only one Endoscopic Retrograde Cholangiopancreatography (ERCP) to clear the CBD, 7.7% required two ERCPs, and 15.4% required three ERCPs. Adverse effects (cholangitis) occurred in one patient (10%), whereas only 30 patients (64.4%) of the ESWL group had complete CBD stone clearance. Thirty-seven percent required one ERCP to clear the CBD, 35.6% required two ERCPs, and 20% required three ERCPs. Adverse effects happened in seven (15.5%) patients, where five (11%) had cholangitis and two (4.4%) had pancreatitis. CONCLUSION: Although a retrospective design with a small sample size, we concluded that Spyglass-guided EHL is an effective procedure in treating difficult CBD stones.

Clinical epidemiology of ulcerative colitis in Arabs based on the Montréal classification.

AIM: To determine the clinical, epidemiological and phenotypic characteristics of ulcerative colitis (UC) in Saudi Arabia by studying the largest cohort of Arab UC patients. METHODS: Data from UC patients attending gastroenterology clinics in four tertiary care centers in three cities between September 2009 and September 2013 were entered into a validated web-based registry, inflammatory bowel disease information system (IBDIS). The IBDIS database covers numerous aspects of inflammatory bowel disease. Patient characteristics, disease phenotype and behavior, age at diagnosis, course of the disease, and extraintestinal manifestations were recorded. RESULTS: Among 394 UC patients, males comprised 51.0% and females 49.0%. According to the Montréal classification of age, the major chunk of our patients belonged to the A2 category for age of diagnosis at 17-40 years (68.4%), while 24.2% belonged to the A3 category for age of diagnosis at > 40 years. According to the same classification, a majority of patients had extensive UC (42.7%), 35.3% had left-sided colitis and 29.2% had only proctitis. Moreover, 51.3% were in remission, 16.6% had mild UC, 23.4% had moderate UC and 8.6% had severe UC. Frequent relapse occurred in 17.4% patients, infrequent relapse in 77% and 4.8% had chronic disease. A majority (85.2%) of patients was steroid responsive. With regard to extraintestinal manifestations, arthritis was present in 16.4%, osteopenia in 31.4%, osteoporosis in 17.1% and cutaneous involvement in 7.0%. CONCLUSION: The majority of UC cases were young people (17-40 years), with a male preponderance. While the disease course was found to be similar to that reported in Western countries, more similarities were found with Asian countries with regards to the extent of the disease and response to steroid therapy.

Prevalence of symptoms of gastroesopahgeal reflux in a cohort of Saudi Arabians: a study of 1265 subjects.

BACKGROUND/AIMS: In this study, we aimed to determine the prevalence of gastroesophageal reflux disease (GERD) in the general population of the capital city of Riyadh and to assess its association with other factors including age, smoking, body mass index (BMI), asthma, as well as the presence of other co-morbid diseases. MATERIALS AND METHODS: We used the Gastroesophageal Reflux Disease Questionnaire (GerdQ) for diagnosing GERD, based on a GerdQ score of 8 or more. Riyadh was divided into four quadrants, and from each area, a single shopping mall was chosen randomly to conduct our surveys. Data collected included age, sex, history of smoking, history of asthma or any other medical condition, dietary habits, monthly household income, history and frequency of heartburn, epigastric pain, regurgitation of food, nausea, sleep disturbance from heartburn, the use of common over-the-counter antacids for the control of their symptoms, and their height and weight. RESULTS: Over a 4-week period from the 19 December 2012 to 17 January 2013, a total of 1265 individuals were included in the survey. The mean age was 29.97 ± 11.58 years. Females formed 67.81% of the respondents and 62.73% had one or more episodes of heartburn per week. Based on a cutoff GERDQ score of 8, the prevalence of GERD in the surveyed population was 45.4%. GERD was more prevalent in older individuals (mean age 31.9 vs. 30.0 years, P < 0.001) and in those with a higher BMI (27.29 vs. 26.31 kg/m 2 , P = 0.02). There was no difference between males (45.43%) and females (45.13%) (P = 0.92); there was a trend of a higher prevalence in smokers (51.63% vs. 44.41%), but it did not reach statistical significance (P = 0.09). CONCLUSION: Symptoms suggestive of GERD as determined by the translated GerdQ are prevalent among this study population.

Clinical epidemiology and phenotypic characteristics of Crohn's disease in the central region of Saudi Arabia.

BACKGROUND/AIMS: Despite the remarkable increase in the incidence of Crohn's disease among Saudis in recent years, data about Crohn's disease in Saudi Arabia are scarce. The aim of this study was to determine the clinical epidemiology and phenotypic characteristics of Crohn's disease in the central region of Saudi Arabia. PATIENTS AND METHODS: A data registry, Inflammatory Bowel Disease Information System (IBDIS), was used to register Crohn's disease patients who presented to the gastroenterology clinics in four tertiary care centers in Riyadh, Saudi Arabia between September 2009 and February 2013. Patients' characteristics, disease location, behavior, age at diagnosis according to the Montreal classification, course of the disease, and extraintestinal manifestation were recorded. RESULTS: Among 497 patients with Crohn's disease, 59% were males with a mean age at diagnosis of 25 years [95% Confidence Interval (CI): 24-26, range 5-75 years]. The mean duration from the time of complaint to the day of the diagnosis was 11 months, and the mean duration of the disease from diagnosis to the day of entry to the registry was 40 months. Seventy-seven percent of our patients were aged 17-40 years at diagnosis, 16.8% were ≤16 years of age, and 6.6% were >40 years of age. According to the Montreal classification of disease location, 48.8% of patients had ileocolonic involvement, 43.5% had limited disease to the terminal ileum or cecum, 7.7% had isolated colonic involvement, and 16% had an upper gastrointestinal involvement. Forty-two percent of our patients had a non-stricturing, non-penetrating behavior, while 32.8% had stricturing disease and 25.4% had penetrating disease. CONCLUSION: Crohn's disease is frequently encountered in Saudi Arabia. The majority of patients are young people with a predilection for males, while its behavior resembled that of western societies in terms of age of onset, location, and behavior.

The accuracy of multi-detector row computerized tomography in staging rectal cancer compared to endoscopic ultrasound.

BACKGROUND/AIM: Our aim was to evaluate the diagnostic accuracy of multi-detector row computerized tomography (MDCT) in staging of rectal cancer by comparing it to rectal endoscopic ultrasound (EUS). MATERIALS AND METHODS: We prospectively included all patients with rectal cancer referred to our gastroenterology unit for staging of rectal cancer from December 2007 until February 2011, 53 patients whose biopsy had proven rectal cancer underwent both MDCT scan of the pelvis and rectal EUS. Both imaging modalities were compared and the agreement between T- and N-staging of the disease was assessed. RESULTS: We staged 62 patients with rectal cancer during the study period. Of these, 53 patients met the inclusion criteria and were evaluated (25 women and 28 men). The mean age was 57.79 ± 14.99 years (range 21-87). MDCT had poor accuracy compared with EUS in T-staging with a low degree of agreement (kappa = 0.26), while for N-staging MDCT had a better accuracy and a moderate degree of agreement with EUS (kappa = 0.45). CONCLUSIONS: MDCT has a poor accuracy for predicting tumor invasion compared to EUS for T-staging while it has moderate accuracy for N-staging.