The Prevalence of Barrett's Esophagus Among a Saudi Arabian Population.

BACKGROUND: While gastroesophageal reflux disease (GERD) is common in Middle Eastern countries, little data exists on the epidemiology of Barrett's esophagus (BE). AIMS: We aimed to determine the prevalence of BE among patients undergoing esophagogastroduodenoscopy (EGD) in a cohort of Saudi patients. METHODS: We retrospectively reviewed the endoscopy database at an academic tertiary care center. Consecutive adult patients who underwent an EGD for any indication between May 2014 and December 2018 were included. The prevalence of both endoscopically and histologically reported BE was determined. Multivariate regression analysis was used to identify factors associated with BE. RESULTS: A total of 2805 patients were included. The mean age was 48 years (± 18.6) and 38.7% were male patients. BE was reported endoscopically in 18 (0.64%) and confirmed histologically in 9 patients (0.32%). Among patients with endoscopically reported BE, the mean age was 50.3 (± 16.1) years and 13 (72.2%) were male patients. Of patients with BE, short-segment BE was reported in 14 (77.8%) patients. Among the 9 patients with histologically confirmed BE; only one patient had dysplastic BE. On univariate analysis, BE was associated with male gender (p < 0.01), but not with age > 50, hiatal hernia, obesity or EGD performed for GERD related indications. On multivariate regression analysis, male gender was the only factor associated with BE (aOR 3.77, 95% CI 1.39-11.97, p = 0.01). CONCLUSION: BE was endoscopically reported in 0.64% and histologically confirmed in 0.32% of this cohort of Saudi patients. Male gender was the only factor associated with BE.

Effects of irritable bowel syndrome on the health-related quality of life among the Saudi population.

BACKGROUND: Irritable bowel syndrome (IBS) is a digestive system disorder. Patients with IBS have a significantly lower quality of life (QoL). In this study, we aimed to assess how IBS affects the Saudi Arabian population's health-related (HR)-QoL. METHODS: A cross-sectional Web-based survey was conducted with a representative sample (n = 1346) of patients who met the Rome IV criteria for IBS from all regions of the country between February and May 2021. The questionnaire surveyed participants' socio-demographic data (nationality, sex, age, region, marital status, level of education, and occupation) and included 24 questions on IBS divided into four categories: (1) diagnosis; (2) symptoms; (3) impact on patients' lives; and (4) management methods. The HR-QoL score was calculated using a five-point Likert scale, with higher scores indicating worse QoL. RESULTS: Most patients (83.3%) were diagnosed by a physician, and 66.7% had a family member or a friend with IBS. Mixed IBS was the most common type of IBS (26.4%). Factors associated with poor QoL and significantly associated with IBS included female sex, initial diagnosis by a general physician, intermittent symptoms, and being asymptomatic for weeks to months. CONCLUSIONS: Greater attention to the QoL of patients with IBS is required to help them deal with IBS and create supportive environments to reduce its psychological effects.

Controversies in Endoscopic Ultrasound-Guided Biliary Drainage.

In this 14th document in a series of papers entitled "Controversies in Endoscopic Ultrasound" we discuss various aspects of EUS-guided biliary drainage that are debated in the literature and in practice. Endoscopic retrograde cholangiography is still the reference technique for therapeutic biliary access, but EUS-guided techniques for biliary access and drainage have developed into safe and highly effective alternative options. However, EUS-guided biliary drainage techniques are technically demanding procedures for which few training models are currently available. Different access routes require modifications to the basic technique and specific instruments. In experienced hands, percutaneous transhepatic cholangiodrainage is also a good alternative. Therefore, in this paper, we compare arguments for different options of biliary drainage and different technical modifications.

The Saudi Gastroenterology Association consensus on the clinical care pathway for the diagnosis and treatment of GERD.

ABSTRACT: Gastroesophageal reflux disease (GERD) is one of the most common problems encountered in outpatient general medicine and gastroenterology clinics. GERD may present with classic esophageal symptoms, extraesophageal symptoms, or mixed symptoms. The diagnosis and treatment of GERD are challenging due to the variety of symptoms and multifactorial pathophysiology. Since there is no consensus on the diagnosis and treatment of GERD in Saudi Arabia, the Saudi Gastroenterology Association established an expert group to formulate a consensus on the clinical care pathway for the diagnosis and treatment of GERD to update health-care providers in Saudi Arabia. The expert group reviewed the literature including recently published international guidelines, clinical trials, and expert opinion and conducted virtual and in-person meetings. A total of 22 statements on the definition, diagnosis, and treatment of GERD were formulated, and three algorithms for the clinical care of GERD were developed with a detailed description for each step. The expert group endorsed the new definition of GERD, the practical principles of interpretation of the diagnostic GERD evaluation, and the practical guidance for GERD treatment including medical, surgical, and endoscopic therapy. The expert group recommends further studies to investigate local data on the diagnosis and treatment of GERD.

The Saudi Gastroenterology Association guidelines for quality indicators in gastrointestinal endoscopic procedures.

The quality and safety of gastrointestinal endoscopy varies considerably across regions and facilities worldwide. In this field, quality management has traditionally focused on individual performance of endoscopists, with most indicators addressing process measures and limited evidence of improvement in health outcomes. Indicators of quality can be classified according to their nature and sequence. The various professional societies and organizations have proposed many systems of indicators, but a universal system is necessary so that healthcare professionals are not overburdened and confused with a variety of quality improvement approaches. In this paper, we propose guidelines by the Saudi Gastroenterology Association pertaining to quality in endoscopic procedures aiming to improve the awareness of endoscopy unit staff toward important quality indications to enhance and standardize quality of care provided to our patients.

Generalized Anxiety Disorder Associated With Gastroesophageal Reflux Disease Among the Saudi Population.

Objectives In Saudi Arabia, the prevalence of generalized anxiety disorder (GAD) was reported to be 29%. As a result, our goal was to examine the association between GAD and gastroesophageal reflux disease (GERD) within the general Saudi Arabian population, as well as to access the risk factors for GAD in order to gain a better understanding. Method This cross-sectional study involved 4,224 participants who completed a questionnaire. Anxiety was assessed using the General Anxiety Disorder-7 (GAD-7) scale, and the GerdQ tool was used to evaluate GERD. Result The prevalence of anxiety among participants was 29% at cutoff 10, with 73% of anxiety-positive participants being female and only 26.9% being male. Furthermore, the associations between anxiety and GERD were significant as 31.4% of participants with anxiety had GERD, compared to 15.0% of those without anxiety. Conclusion In our finding, there was a significant association between anxiety and GERD among the general Saudi population. In terms of anxiety risk factors, female, younger age, social status, body mass index, eating fried food, caffeinated drinks, diabetes miletus, high blood cholesterol, NSAID use, antidepressants, and anti-anxiety medication were found to have a significant association.

Association Between Helicobacter pylori Eradication and Kidney Function in Patients With Chronic Gastritis: A Retrospective Single-Center Study.

Background Helicobacter pylori (HP) is a common bacterium that globally infects humans. The significance of HP infection and eradication of kidney impairment remain ambiguous. Moreover, little is known about whether elimination of the bacteria has any consequence on kidney function. This study aimed to explore the relationship between HP eradication and kidney function in patients with chronic gastritis (CG). Methodology We retrospectively reviewed the records of all CG patients with eradicated HP at King Abdulaziz University Hospital between June 2002 and June 2021. All patients older than 18 years, diagnosed with CG in whom HP had been eradicated, were included. Out of 1,936 patients' records, only 46 met the criteria. Results The mean age of the study sample was 48 years; in addition, 58.7% of the patients were obese. There was no significant difference in serum creatinine, blood urea nitrogen, and glomerular filtration rate after HP eradication (P-values of 0.414, 0.112, and 0.300, respectively). Conclusions We found no relationship between the eradication of HP and improvement in renal function. However, prospective population-based studies must be conducted to assess an association between HP eradication and renal function, as well the future risk of nephropathy with the persistence of HP. As such, we recommend a multicenter study that includes a representative sample size.

Assessment of Awareness and Knowledge of Proton Pump Inhibitors Among the General Population in Saudi Arabia.

Background One of the most commonly used classes of medications that are known for their excessively expanded misuse is proton pump inhibitors (PPIs). Although they are profoundly useful, they also account for several adverse effects. Assessing the awareness of the general population may throw light on the problem and limit irrational use. This study aims to determine the knowledge, attitude, and behavior of the general population of Saudi Arabia regarding PPI use. Materials and methods This was a descriptive cross-sectional study using a structured online survey. The questionnaire comprised 1088 participants of the adult general population of Saudi Arabia to assess knowledge and awareness of proton pump inhibitors.  Results Of the 1088 participants, 59% were men and 41% were women, 44.6% were aged 20-30 years, 25.4% were 31-40 years, and 16% were 41-50 years. Only 54% of the participants had previous knowledge of PPIs. Regarding PPI use, 25.7% of participants previously used PPIs with medical consultation and 10.3% without medical consultation, while 64% had never used PPIs. Reasons for PPI use included: heartburn (56.4%), gastroesophageal reflux disease (51.1%), gastritis (21.8%), as part of Helicobacter pylori infection therapy (20%), peptic ulcer (15.7%), esophagitis (7.1%), sore throat (6.1%), gastroenteritis (5.4%), hiatal hernia (5%), hoarseness (3.2%), asthma (2.1%), and bariatric surgery (2.1%). Of all the participants, 61.2% completed the treatment course while 38.8% did not. Conclusion Generally, our population had moderate knowledge of PPI. However, it is not enough to eliminate this irrational use of PPIs.This study emphasizes the importance of effective provider-led patient education to raise awareness of potential risks and reduce inappropriate long-term use of PPIs. This is significant due to growing concern about the possibility of medication overuse and non-compliance due to a lack of awareness about PPIs. In addition, more research assessing the awareness of over-the-counter (OTC) medications should be taken into consideration.

Endoscopic Management of Post-Laparoscopic Sleeve Gastrectomy Leakage and Stenosis Using Fully Covered Stent.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed surgery to treat morbid obesity. Post-LSG leak and stenosis are serious complications that can be associated with significant morbidity and mortality. OBJECTIVE: The objective was to report the efficacy and safety profile of using specifically designed fully covered self-expandable metallic stent for the treatment of post-LSG complications. METHODS: This retrospective study included adult patients who underwent placement of a fully covered esophagogastric, self-expandable metallic stent for post-LSG leak or stenosis. The procedure was carried out at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between September 2017 and May 2019. Data regarding demographics, indication for stenting, size of the stent, procedural success and poststenting adverse events were collected. RESULTS: A total of 14 patients met the inclusion criteria, with indication for endoscopic stenting being post-LSG leak in 11 patients and stenosis in 3 patients. The technical success rate of self-expandable metallic stent placement was 100%, and the clinical success was 85.7% (12 of 14 patients). Nausea (71.4%) and vomiting (85.7%) were the most frequent mild adverse events reported. Stent-induced esophageal stricture was the only major adverse event reported in two patients. CONCLUSION: Placement of specifically designed self-expandable metallic stent for the treatment of post-LSG leak and stenosis is an effective and safe approach. Further studies with larger cohorts are needed to assess the optimal duration needed to treat such complications.

Adherence to the Saudi dietary guidelines and its relation to colorectal polyps: A university hospital-based study.

OBJECTIVES: Colorectal polyps are a known precursor to colorectal cancer (CRC). Using the Saudi dietary guidelines adherence scores, this study evaluated whether dietary intake can lead to the development of colorectal polyps in a Saudi cohort. METHODS: In a cross-sectional study, 101 patients of both sexes, aged 30-86 years (40 patients with colorectal polyps and 61 patients without polyps), were recruited from the endoscopy unit in a Saudi hospital. A questionnaire was administered to collect demographic data, anthropometric data, and information about dietary habits. RESULTS: Patients with colorectal polyps were significantly older than those without polyps (p = 0.05). The mean body mass index in both patient groups was within the overweight range, with a value of 28.6 ± 6.7 kg/m2. We did not find significant differences between patients with and without colorectal polyps. Although there was no difference in the overall scores for adherence to the Saudi dietary guidelines between the two groups, the specific adherence score for vegetables was significantly higher in patients without colorectal polyps (5.0 ± 0.0 vs. 4.9 ± 0.3, p = 0.03). CONCLUSION: Ageing and lower vegetable intake, previously reported to be risk factors for CRC, were likewise identified in this study. However, a multi-centre study with a larger sample size, utilising data from this study, is needed.

Biliary anatomy and pancreatic duct variations: A cross-sectional study.

BACKGROUND/AIM: Biliary tree and pancreatic duct can appear in different variations whose proper understanding is obligatory for surgeons. Magnetic resonance cholangiopancreatography (MRCP) is considered a safe and accurate tool for evaluating biliary tree and pancreatic duct. Typical anatomy for right hepatic duct (RHD) and left hepatic duct (LHD) is reported as 57% and 63%, respectively. The most common (4-10%) pancreatic anomaly is divisum. In the present study, we evaluated and determined the prevalence of biliary tree and pancreatic duct variations among patients at a university hospital. MATERIALS AND METHODS: The MRCP records of 370 patients from 2015 to 2017 were obtained for cross-sectional study. Images were retrospectively reviewed for variations by two independent senior radiologists. Demographic data were obtained for all the patients. Huang et al. classification was used for RHD and LHD variations. The cystic duct was reported based on its course and insertion pattern. The pancreatic duct was observed for the presence of divisum, its course, and configuration. RESULTS: Three hundred and twenty-five patients were included in the final study. Most commonly observed variant for RHD were A1 (34.2%) and A2 (32.2%). For LHD, B1 (71.4%) was the most common variant. Cystic duct insertion was commonly seen as right lateral insertion (27.7%). Pancreatic divisum was observed in 0.6% of cases. Nationality, origin, and gender-specific variations were obtained. CONCLUSION: Variations in biliary anatomy and pancreatic duct are very diverse and extend from the intrahepatic biliary system down to the pancreas. Performing a similar study on a larger population is mandatory to illustrate the range of variations present within the community.

Endoscopic papillectomy for neoplastic ampullary lesions: A systematic review with pooled analysis.

Endoscopic papillectomy (EP) is a viable therapy in ampullary lesions (AL). Many series have reported low morbidity and acceptable outcomes. We performed a systematic review with pooled analysis to assess the safety and efficacy of EP for AL. Electronic databases (Medline, Scopus and EMBASE) were searched up to September 2018. Studies that included patients with endoscopically resected AL were eligible. The rate of adverse events (AEs; primary outcome) and the rates of both technical and clinical efficacy outcomes were pooled by means of a random- or fixed-effects model to obtain a proportion with a 95% confidence interval (CI). Twenty-nine studies were included (1751 patients). The overall AE rate was 24.9%. The post-procedural pancreatitis rate was 11.9%, with the only factor affecting this outcome being prophylactic pancreatic stenting. The complete resection rate was 94.2%, with a rate of oncologically curative resection of 87.1%. The recurrence rate was 11.8% (follow-up: 9.6-84.5 months). EP is a relatively safe and effective option for AL. Our study might definitively suggest the protective role of prophylactic pancreatic stenting against post-procedural pancreatitis.

COVID-19 and endoscopy services in intermediately affected countries: a position statement from the saudi gastroenterology association.

With the global pandemic due to coronavirus disease 2019 (COVID-19), there has been a significant strain on healthcare facilities. The infectivity rate, as well as the rate of healthcare workers who have fallen ill to the disease, has raised concerns globally on the proper management of patients as well as the role of safe healthcare provision utilizing personal protective equipment (PPE). Furthermore, the limited supply of PPEs has mandated rationing their use to achieve maximum utility and preservation. Multiple gastroenterology associations have issued guidance and statements that would help healthcare providers in navigating these unprecedented and difficult times, and the Saudi Gastroenterology Association has provided this statement in an effort to bring the most up to date information for the management of endoscopy units in terms of resources, manpower planning, scheduling, as well as infection control policies and leadership.

Ischemic Renal Injury Complicating Intragastric Balloon Insertion.

A 25-year-old obese woman experienced ischemic renal injury as a complication of intragastric balloon (IGB) insertion for weight reduction. Although IGB is associated with a low risk of renal injury in the form of acute renal failure, this presentation has never been reported. The patient responded well to treatment, with complete clinical and radiologic resolution after balloon removal. She did not have an apparent cause of renal ischemia other than a significant compression of the renal vessels by the balloon as seen on imaging.

Predictors of inadequate bowel preparation for inpatient colonoscopy.

BACKGROUND/AIMS: Adequate colonic cleansing is essential for achieving effective and safe colonoscopy. Inpatient status is one of several factors associated with poor bowel preparation leading to incomplete colonoscopy procedures, which in turn may cause increased patient morbidity, missed pathology, prolonged hospital stay, and increased cost. The aim of this study was to identify predictors of inadequate bowel preparation for inpatient colonoscopy. MATERIALS AND METHODS: Medical records of inpatients who underwent colonoscopy at a university hospital between January 2015 and June 2016 were reviewed. Logistic regression analysis was used to identify predictors of "inadequate" bowel preparation. Odds ratios (OR) with 95% confidence intervals (CI) were reported. RESULTS: We included 130 patients in the analysis with a mean age of 58.2 (17.3) years. Fifty-seven percent of the patients underwent the procedure before noon, and the remaining between noon and 4 pm. The most common indications for inpatient colonoscopies were gastrointestinal bleeding and screening for colorectal cancer, and the majority of patients received meperidine for sedation (38.5%). The overall bowel preparation success rate was 57%, and the success rate was higher in the morning procedures compared to the afternoon procedures (71% vs. 46%, p=0.004). Regression analysis identified procedure time as a significant predictor of bowel preparation success such that procedures performed in the afternoon had lower chances of success (OR=0.32, 95% CI=0.14-0.74, p=0.007). Aspirin use was also a positive predictor for bowel preparation success (OR=3.1, 95% CI=1.03-9.24, p=0.044). CONCLUSION: Incomplete colonoscopies for inpatients due to inadequate bowel preparation are very common. Procedures performed in the afternoon are less likely to be successful.

Knowledge, attitude, and practices of primary health care physicians toward colorectal cancer screening.

BACKGROUND/AIM: Early diagnosis of chronic illnesses and cancers mainly occurs at primary health care centers (PHCs) by primary health care physicians (PHPs). The incidence of colorectal cancer (CRC) in the Kingdom of Saudi Arabia (KSA) is rising and this has been attributed to many factors. The increasing incidence of CRC is compounded by nonadherence to screening recommendations. Therefore, evaluating PHPs knowledge, attitudes, and practices of screening for CRC is clinically important. We aimed to evaluate the knowledge, attitudes, and practices of PHPs regarding CRC screening and to identify the factors associated with nonadherence of PHPs to screening recommendations. MATERIALS AND METHODS: PHPs working at three tertiary care centers and PHCs across the city of Jeddah were randomly recruited. Participants were surveyed using a comprehensive questionnaire that recorded data on demographics, qualifications, and knowledge of various modalities and guidelines related to CRC screening. Perspectives about effectiveness of, or adherence to, factors that influence physicians' perspectives or recommendations for CRC screening were also assessed. Logistic regression analysis was used to identify physician characteristics associated with PHPs perspectives and nonadherence to CRC screening. RESULTS: A total of 127 PHPs were recruited. The average age of participants was 34 (±8.4) years, 86.6% were native Saudi's and 56.7% were females. The majority of surveys (66.9%) were completed at 24 PHCs and the remaining at hospital-based family medicine clinics. Most of the PHPs (55%) had a bachelor's degree and 31.5% were board-certified or carried a PhD in family medicine; 95% of participants believed that CRC screening in general was effective, but as much as 55% reported that they did not practice screening. The male physicians [odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.19-0.99, P = 0.048)] and PHPs with only a bachelor degree or less (OR = 0.72, 95% CI = 0.55-0.93, P = 0.011) were less likely to recommend screening for CRC. CONCLUSIONS: A considerable proportion of PHPs do not adhere to CRC screening recommendations despite a wide belief that screening is effective. Male PHPs with lower qualifications appear to be less likely to recommend screening.

A cross-sectional survey of multi-generation inflammatory bowel disease consanguinity and its relationship with disease onset.

Background\Aim: Consanguinity influences the phenotypic variations of some hereditary and immune-mediated disorders, including inflammatory bowel disease. This study estimated the prevalence of consanguinity among the ancestors of patients with inflammatory bowel disease and examined the effect of various consanguinity levels on inflammatory bowel disease onset. PATIENTS AND METHODS: Patients with inflammatory bowel disease who were seen at two gastroenterology outpatient clinics were consecutively recruited and surveyed for demographics, disease onset, and presence of ancestral consanguinity within three generations. The prevalence of different consanguinity levels was calculated. The association between age at inflammatory bowel disease onset and consanguinity was examined. RESULTS: Two hundred seventeen patients were recruited. The mean age, mean age at diagnosis, and mean illness duration were 32.9 ± 13.4, 18.6 ± 11.5, and 8.6 ± 7.7 years, respectively. Of the cohort, 53.5% were women, and 74.2% were native Saudis. Cigarette smoking was reported in 17.1%; 51% had Crohn's disease, while the remaining patients had ulcerative colitis. A family history of inflammatory bowel disease was reported in 29.5% of patients; consanguinity within three generations was reported in 57.6%. Consanguinity in more than one generation was reported in 38.7%; 17.5% had consanguinity in three consecutive generations. There was no association between inflammatory bowel disease onset and multi-generation consanguinity, but there was an association with disease subtype in favor of ulcerative colitis (b coefficient = 7.1 [95% confidence interval = 4.1, 10]). CONCLUSIONS: Consanguinity is extremely common among Saudi patients with inflammatory bowel disease but does not seem to influence age at disease onset. Genetic studies are needed to further clarify the effect of consanguinity on disease behavior.

Synchronous Gastric Metastasis of Renal Cell Carcinoma With Absence of Gastrointestinal Symptoms.

Renal cell carcinoma (RCC) is a rare adult malignancy, and one-third of cases present with distant metastases at the time of diagnosis. Early gastric metastasis is exceedingly rare. We describe an adult male with synchronous gastric metastasis of RCC at the time of diagnosis in the absence of gastrointestinal symptoms. We report the fifth case of RCC with synchronous gastric metastasis and the only case with early presentation in the absence of gastrointestinal symptoms.