Pancreatic cancer presenting with acute pancreatitis complicated by Wernicke's encephalopathy and a colonic fistula: a case report.

This account details the case of a 39-year-old male patient who presented with acute necrotizing hemorrhagic pancreatitis. The comorbid conditions of Wernicke's encephalopathy, and a pancreatic-colonic fistula developed during his care. This case is unique in that it illustrates the effects of these complications individually and through their interaction. Given that there are no firm guidelines regarding the nature and timing of interventions for a pancreatic-colonic fistula diagnosis, this case may provide helpful information. Case Presentation: As previously noted, this is the case of a 39-year-old male patient with a BMI of 46 kg/m2 who presented with acute necrotizing hemorrhagic pancreatitis. Complications developed as noted above. Multiple diagnostic imaging methods were utilized but failed to detect the presence of metastatic pancreatic adenocarcinoma. After a course of antimicrobial and nutritional therapy, we attempted surgical intervention for the pancreatic-colonic fistula and pancreatic abscess debridement. Unfortunately, during that procedure, we observed extensive carcinomatosis, at which point we did a gastrojejunostomy. Subsequently, the patient's condition did not permit chemoradiotherapy. After completion, we transferred the patient to palliative care, where he died. Clinical Discussion: This case was complex due to the previously recounted results of the underlying condition, pancreatic adenocarcinoma, and the complications of Wernicke's encephalopathy and pancreatic-colonic fistula. The presence of risk factors in patients increases the need to perform appropriate diagnostic tests. Even with tests and multiple imaging modalities, these particular events remain challenging to diagnose, given the nature of the development and presentation of the disease condition. It was only after the surgical intervention that the carcinoma became evident. Early screening and imaging could improve detection rates and prevent disease progression. Conclusion: In this case report of acute hemorrhagic necrotizing pancreatitis and its complications, we discuss the factors making this disease process particularly difficult to diagnose, detect, and manage. Even though the complications detailed herein are rare, in this case, the significance is the need to evaluate all patients with acute pancreatitis and acute confusion for Wernicke's encephalopathy, which is preventable. In addition, suggestive findings on computed tomography signal the need for further investigation of the colonic fistula. Finally, at this time, there are no clear guidelines for the surgical management of these complications. We hope that this case report will contribute to their development.

Efficacy of ursodeoxycholic acid for primary biliary cholangitis: Experience from a tertiary care centre in Saudi Arabia.

Background: Primary biliary cholangitis (PBC) is a progressive autoimmune cholestatic liver disease that primarily affects females more than males and may lead to end-stage liver disease. We studied baseline characteristics, and the biochemical and clinical response to ursodeoxycholic acid (UDCA), a first-line treatment option for patients with PBC, in a cohort of patients diagnosed with PBC from Saudi Arabia. Methods: A total of 30 patients meeting the diagnostic criteria of PBC who were being followed in the King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, between January 1, 2008, and December 31, 2017, were enrolled in the study. The patients with autoimmune hepatitis, primary sclerosing cholangitis, and overlap syndromes were excluded. The baseline characteristics of the patients were recorded. The response to UDCA treatment was assessed according to the Barcelona, Paris I, Paris II, and Toronto criteria, and clinical outcomes, and biochemical changes were ascertained. Results: The mean age was 46 years ± 11.7 with a female gender predominance of 93% (n = 28). Pruritus was the predominant symptom reported by 90% (n = 27) of the patients. A total of 23 (77.7%) patients underwent liver biopsy and all of them showed histological features suggestive of PBC. Cirrhosis was documented in 30% (n = 9) of the patients at baseline. Overall, 86.7% (n = 26) of the patients were positive for antimitochondrial antibodies. The biochemical response rates to UDCA based on Paris I, Paris II, Barcelona, and Toronto criteria were 73.3, 40, 56.7, and 53.3%, respectively. Conclusion: Over 10 years, 30 patients with PBC were diagnosed at a large referral center in Saudi Arabia. The response to UDCA treatment was inadequate.

Developing a multidisciplinary HCV direct-acting antivirals utilization management and assessment program.

BACKGROUND: The introduction of direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) infections has revolutionized outcomes for patients with HCV. Cost-effective use of these antivirals in addition to ensuring patient adherence is of paramount importance. OBJECTIVES: The goal of this article is to describe the processes by which a tertiary care, multisite institution managed the complexities involved in administering DAA treatment and managing the increased cost of therapy. Specifically, the objectives of this article are to describe the development of a multidisciplinary HCV management program and the role of pharmacists in this program, including formulary management strategies and monitoring of DAAs use in our institution, development of guidelines, electronic prescribing protocols and order sets, and specific outcomes based on a concurrent medication use evaluation. PRACTICE DESCRIPTION: King Faisal Specialist Hospital and Research Centre is a tertiary care referral hospital. As a tertiary referral hospital, it offers primary and highly specialized inpatient and outpatient medical care. The process of selecting and developing institutional HCV management program is described. PRACTICE INNOVATION: This article provides key details regarding how a multidisciplinary HCV program using DAAs can be implemented successfully at a tertiary care facility. Key facets of our innovation include establishing formulary guidelines, setting up eligibility criteria for patients, and establishing an HCV taskforce and multidisciplinary HCV program clinic. EVALUATION: Medication use evaluations were regularly conducted to monitor sustained virologic response rates, adherence to guidelines, adverse reactions, and drug interactions. METHODS: Formulary guidelines, setting up an eligibility criterion for patients, and an HCV taskforce and multidisciplinary HCV program clinic were established. RESULTS: The involvement of pharmacists in a multidisciplinary HCV program in outpatient settings resulted in improved formulary decision making, reduction of costs, and improvement of adherence to institutional guidelines. PRACTICE IMPLICATIONS: The role of a pharmacist in the management of patients with HCV with DAAs is important. Pharmacists play an integral part in medication management and overall reduction in health care expenditure. Many disease management programs can be complemented with pharmacists to improve patient care and reduce cost. CONCLUSION: HCV treatment is challenging, and a multidisciplinary approach to treat HCV is critical. It is a rapidly evolving field; therefore, it requires dynamic formulary management and collaborative practice approaches to monitor pharmacotherapy carefully and efficiently. Clinical pharmacists play a pivotal role within the multidisciplinary team by providing support to both patients and health care providers with regard to the treatment of HCV.

Efficacy of a bismuth-based quadruple therapy regimen for Helicobacter pylori eradication in Saudi Arabia.

BACKGROUND/AIM: The treatment efficacy of Helicobacter pylori (H. pylori) has been decreasing over time due to resistance to multiple antimicrobial therapies. The most effective treatment regimen for Saudi Arabian patients infected with H. pylori is still unknown. We aimed to study the eradication rate of 10 days of quadruple therapy; bismuth subcitrate potassium 140 mg, metronidazole 125 mg, and tetracycline 125 mg for H. pylori infection in a Saudi population. PATIENTS AND METHODS: This was a prospective, open-label, non-randomized controlled trial. Patients with H. pylori infection were diagnosed by upper gastrointestinal (GI) endoscopy and rapid urease test (RUT) or histology. Patients who tested positive were recruited. Eligible patients were prescribed a 10-day course of quadruple therapy and received three capsules 4 times daily for 10 days along with omeprazole 20 mg twice daily. H. pylori was considered eradicated if the urea breath test (UBT) was negative after 6 weeks of completing the treatment. RESULTS: Ninety-two patients with H. pylori infection were recruited. Three patients withdrew from the trial and another seven patients lost follow-up. We analyzed 82 patient's data as per-protocol analysis, of whom 66 (80%) were naive to H. pylori treatment. Four patients had failed previous treatment with the sequential regimen and 12 patients had treatment with clarithromycin-based triple therapy. The post-treatment UBT for H. pylori infection was negative by per-protocol analysis in 72/82 patients (87.8%), and 72/92 (78.3%) by intention-to-treat analysis. There was no correlation between previous treatment failure and treatment response to the bismuth-based quadruple therapy (P value = 0.28). CONCLUSIONS: Treatment with a bismuth-based quadruple therapy was effective in eradicating H. pylori infection in 78.3% of Saudi patients with an ITT analysis and in 87.8% as per-protocol analysis.

Knowledge and attitude toward organ donation among medical staff and outpatients at King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Organ transplantation is still the treatment of choice for end-stage organ failure. Despite the establishment of the Saudi Center for Organ Transplantation (SCOT), the organ supply still does not meet the increasing demand. This study aims to assess the knowledge of Saudis about organ donation both among the public and the medical staff and to assess the trend in the change from 1996 until now. A cross-sectional study was conducted among Saudis above the age of 18 years. A self-administered, 25-item, questionnaire was completed by participants including both outpatients and medical staff at King Abdulaziz Medical City using a convenient sampling technique. A total of 376 individuals answered the questionnaire; 238 (63.1%) heard about SCOT, of whom 124 (70.5%) were males. Health-care professionals had better attitude and knowledge on organ donation (P <0.05). Compared to the results from 1996to 2017, there was (51.22%) to (30.4%) decrease in people who allowed their families to donate their organs; on the other hand, there was an increase in the percentage of people who had the correct knowledge that Islam supports organ donation. Unsatisfactory levels of awareness impacted negatively on the knowledge and attitude of the population that is showed by the minor improvements over the years, and the slight proportion of participants who owned a donor card. Although 97.6% of the participants knew about the concept of organ donation, only 66.5% were familiar with the positive Islamic opinion. Based on the results of the comparison with the study in 1996, we conclude that more efforts from both the governmental and religious authorities are needed to increase awareness.

Tenofovir in the treatment of naïve and refractory chronic Hepatitis B: A single center experience in Saudi Arabia.

BACKGROUND/AIMS: Tenofovir disoproxil fumarate (TDF) is a nucleotide analog used in the treatment of chronic hepatitis B (CHB) infection. This study evaluated the efficacy of TDF in achieving undetectable HBV DNA after 48 weeks of treatment in a Saudi cohort of CHB patients. PATIENTS AND METHODS: This retrospective study included patients treated at a tertiary care center in Saudi Arabia from January 2009 to December 2012. Of the 68 eligible patients, 51 were treatment naïve and 17 were treatment-refractory. Twenty-three patients tested positive for HBeAg. The remaining 45 patients were HBeAg-negative. RESULTS: The mean HBV DNA viral load decreased from 95 million IU/mL at baseline to 263 IU/mL after 48 weeks of treatment (P < 0.001). Overall, 62% of patients achieved a complete virological response (CVR) and 37% a partial virological response (PVR). Respective CVR and PVR rates according to subgroup were: HBeAg-positive (21.7% and 78.3%) and HBeAg-negative (84.4% and 15.6%). At 48 weeks, HBV DNA was undetectable in 66.7% of treatment-naÏve and 53% of treatment-refractory patients (P = 0.3). Seroconversion occurred in 13 (57%) of HBeAg-positive patients. Two (3%) of the HBeAg-negative patients lost HBsAg at follow up. Mean alanine aminotransferase decreased significantly from 134 U/L before treatment to 37 U/L at 48 weeks (P < 0.001). Significant adverse events were not encountered during the study period. CONCLUSION: Forty-eight weeks of treatment with TDF reduced HBV DNA to undetectable levels in more than half of our patients regardless of whether they were treatment-naïve or refractory. HBeAg-negative (vs positive) patients experienced a better response rate.