The association of gastroesophageal reflux with bronchial asthma. Can asthma also trigger reflux?

BACKGROUND/AIMS: The frequency of gastroesophageal reflux (GER) among asthmatic patients was found to range from 34% to 89% at different locations. The aims of this study have been to determine the frequency of GER in patients with asthma in the Saudi environment, to ascertain the main mechanism whereby GER triggers asthma, and to seek any evidence whether asthma can also trigger GER. METHODOLOGY: Fifty asthmatic patients were consecutively recruited as they reported to King Fahd Hospital of the University (KFHU), Al-Khobar, Saudi Arabia, in the period from February 2000 to February 2001; their mean age +/- SD was 38.0 +/- 9.8 years. Twenty-two subjects without asthma or GER served as controls; their mean age +/- SD was 29.4 +/- 8.6. Both groups were subjected to a questionnaire, esophageal manometry, dual probe ambulatory 24-hour pH monitoring, and pulmonary function tests. RESULTS: Among the asthmatic group 22 patients (44%) had GER. Accordingly, the asthmatic patients were divided into two groups: asthmatic with GER (n=22), and asthmatic without GER (n=28). Hoarseness of voice and nocturnal symptoms were found to be significant predictors for the presence of GER in asthmatics. Manometry revealed that asthmatic patients with GER had higher gastric pressure (11.4 +/- 4.0 mmHg vs. 8.4 +/- 2.8 mmHg; p=0.006) and lower resting pressure at the lower esophageal sphincter (LES) (21.2 +/- 8.7 mmHg vs. 28.2 +/- 9.3 mmHg; p=0.013) when compared with controls, both factors favoring the occurrence of reflux. With regard to pH data, acid reflux occurred both at the distal and proximal esophagus but the percent total acid exposure time was about 7 times longer at the distal than at the proximal esophagus (5.80 vs. 0.9). In addition, gastric pressure was positively and significantly correlated with distal esophageal acid exposure time and the DeMeester score, negatively correlated with spirometric parameters in asthmatic patients, as well as found to be a significant predictor of the severity of asthma (p=0.006). CONCLUSIONS: Forty-four percent of the sample of asthmatic patients reporting to KFHU had GER. Since distal esophageal total acid exposure time was nearly 7 times longer than at the proximal esophagus, the main mechanism for GER triggering asthma is the vagally mediated reflex initiated by acid in the distal esophagus. In addition, the positive correlation of increased gastric pressure with the distal esophageal acid exposure time and the DeMeester score, its negative correlation with spirometric parameters and being a significant predictor of asthma severity suggest that severe asthma may trigger or aggravate GER.

Evolution of metronidazole and tetracycline susceptibility pattern in Helicobacter pylori at a hospital in Saudi Arabia.

The association of Helicobacter pylori with chronic gastritis and peptic ulcer disease led to new therapeutic approaches including the use of antibiotics. Recently, resistance of H. pylori to antibiotics has emerged as the major cause of treatment failure. This retrospective analysis was aimed at investigating the development of antimicrobial susceptibility patterns amongst H. pylori strains isolated at King Fahd Hospital of the University, Al-Khobar. Susceptibility patterns obtained using isolates from a pilot study (1987-1988) were compared with those subsequently isolated (1990-1996). Metronidazole resistance was estimated to be 35.2% in the first period but more than doubled (78.5%) during the second period. Isolates from females showed a higher resistance rate to metronidazole than those from males. Only one strain was tetracycline resistant. The extremely high resistance rate to metronidazole indicates that it may not be very effective for eradication of H. pylori. Tetracycline should prove a useful component of treatment regimens in this geographical region.

The pattern of lower gastrointestinal disease in the eastern region of Saudi Arabia: a retrospective analysis of 1590 consecutive patients.

To determine the pattern of lower gastrointestinal disease in the Eastern region of Saudi Arabia we analysed 1907 colorectal biopsies obtained from 1590 consecutive patients (1256 males & 334 females), evaluated during a 13 year period (1983-1996) in a tertiary care teaching hospital. The age range was 6-81 years with a mean of 37 + 15. During the same period 6874 new patients were seen in the Gastroenterology Clinics. Saudi Arabs constituted 970 (61 %) of all patients. The remaining 620 (39%) were non-Saudi, mostly of Arab origin from neighbouring countries. The most common presenting symptom for referral was abdominal pain (1193 patients, 75%) followed by diarrhea (636 patients, 40%). The most frequent histologic diagnosis was a normal mucosa followed by non specific proctocolitis accounting respectively for 37.9% and 37.4% of all cases. These were followed by schistosomiasis, 113 (7.1%), adenocarcinoma, 91 (5.7%) and ulcerative colitis, 91 cases with a relative frequency of 5.7% and a calculated prevalence of 1.3%. Of significance was the encounter of 14 cases of Crohn's disease amounting to 0.9% of all cases with a calculated prevalence of 0.2%. A minority of 83 patients (5.2%) were cases of either a benign polyp, diverticular disease, tuberculosis, ischaemia, lymphoma, pseudomembranous colitis (PMC), eosinophilic gastroenteritis or malacoplakia. These data show that although a "normal mucosa" and "nonspecific proctocolitis" were the dominant diagnoses, significantly, ulcerative colitis and Crohn's disease exist and should be considered in the differential diagnosis of lower GI disease.

Intraluminal duodenal diverticulum causing recurrent acute pancreatitis: case report and review of the literature.

Intraluminal duodenal diverticulum-(IDD) is a rare congenital anomaly. Only 16 cases of acute pancreatitis complicating IDD have been reported in the world literature. We present one additional case discuss the pathogenesis, clinical and radiological features as well as the treatment, and review the literature.

Crohn's disease in Saudi Arabia: a clinicopathological study of 12 cases.

In this report we present our experience with 12 cases of Crohn's disease out of 1279 consecutive colorectal biopsies (0.9%), seen during an l 1 years period (1983-1994) in a tertiary care teaching hospital. During the period 76 cases (6%) of Ulcerative Colitis (UC) were seen. Of the 12 patients with Crohn's disease, seven were males and five were females, all Saudi nationals aged 16-39 with a median of 23 years, relatively younger than those with UC seen during the same period. Recurrent colicky abdominal pain was the striking presenting symptoms in all patients, commonly associated with weight loss. The disease involved both small and large bowel in eight patients (67%) and the colon alone in one patient. Granulomas were seen in seven patients (58%). Surgery was offered for two patients and most of the remaining patients were symptomatic on follow up.

Non-steroidal anti-inflammatory drug-induced gastropathy: a comparative endoscopic and histopathological evaluation of the effects of tenoxicam and diclofenac.

A 4-week double-blind study compared the potential for 20 mg/day tenoxicam or 100 mg/day diclofenac sodium to induce gastropathy in 36 patients with joint disease and assessed the influence of gastric colonization by Helicobacter pylori. Endoscopic assessment at the end of 4 weeks indicated that the mucosa was normal in 79% of tenoxicam-treated patients and 59% of diclofenac-treated patients. Only 5% of patients in the tenoxicam group developed severe gastroduodenitis (> 11 haemorrhages or erosions) compared with 18% in the diclofenac group. Histological evaluation indicated that 58% and 47%, respectively, of tenoxicam-treated and diclofenac-treated patients retained normal mucosa after treatment. Diclofenac treatment was discontinued in two patients, due to a duodenal ulcer or severe erosive gastritis. Overall, 5/14 patients with moderate to severe colonization with Helicobacter pylori developed severe chronic active gastritis or ulceration, compared with the 1/22 patients in whom colonization was either absent or mild (P = 0.02). Tenoxicam and diclofenac did not show major differences in terms of gastrointestinal safety, although the trends favoured tenoxicam. The presence of severe colonization of the gastric mucosa with Helicobacter pylori appears to be an important factor for development of severe gastritis or ulceration.

Abdominal tuberculosis in Saudi Arabia: a clinicopathological study of 65 cases.

The clinical and pathological features of 65 patients with abdominal tuberculosis obtained during a 7-yr period were analyzed and the diagnostic procedures critically evaluated. The diagnosis was histologically confirmed in 59 patients. In two more patients, the diagnosis was based solely on a positive ascitic fluid culture for tubercle bacilli. The remaining four patients responded dramatically to anti-tuberculous chemotherapy given on suspected laparoscopic findings in cases in which no biopsy was taken. Laparoscopy was found to be safer and superior to laparatomy and is recommended as an initial investigation in the diagnostic work-up of patients in whom tuberculous peritonitis is suspected. Furthermore, the finding of granulomatous inflammation in peritoneal biopsy is a justification for immediate therapy in such patients. This is particularly valid in endemic areas if one considers the risks of delaying treatment of these patients.

Tuberculous peritonitis: the value of laparoscopy.

The laparoscopic and pathological diagnoses of 43 patients who underwent abdominal laparoscopy for various indications are presented. Major indications for the laparoscopy included hepatomegaly in 32 patients, ascites in 28, and pyrexia of unknown origin (PUO) in 18 patients. A combination of two or more of these indications was a more common feature. The most frequently encountered laparoscopic diagnoses were tuberculosis and chronic liver disease (16 patients each), followed by cancer (9 patients). However, on pathological examination of peritoneal or liver biopsy tissue and on follow-up, tuberculosis was confirmed in 12 patients, chronic liver disease in 14 patients and hepatocellular carcinoma in 11 patients. No complications were encountered during the laparoscopy. Our findings indicate that abdominal laparoscopy is a safe, quick and inexpensive diagnostic tool, particularly when appropriate and adequate tissue is taken for pathological examination. In such instances, laparoscopy would save an unnecessary laparotomy, especially where tuberculosis and cancer are considered in the differential diagnosis.

Cow's-milk-induced erosive gastritis in an infant.

A 3 1/2-month-old male infant presented with hematemesis due to erosive gastritis following whole-cow's-milk feeding. The presence of eosinophilic gastritis, the disappearance of symptoms after withdrawal of whole-cow's-milk feeding, and the association with facial eczema suggest that gastritis was induced by cow's milk. Cow's-milk intolerance should be considered in the etiologic differential diagnosis of hematemesis and gastritis in infancy.

Colonic malacoplakia--occurrence in a family. Report of cases.

A family with two cases of documented colonic malacoplakia is reported. Details regarding the younger sister have been published previously and those of the elder are reported in this paper. Two brothers were found to have strongly positive purified protein derivative and histologic evidence of nonspecific colitis, but without clinical, endoscopic, or histopathologic evidence of malacoplakia. The parents are first cousins and have a total of 13 children. A computer search of the literature revealed no previous reports on familial occurrence of this disease. Thus, the authors consider this to be the first report of malacoplakia in siblings of the same family and suggest adding genetic predisposition in the pathogenesis of the disease.

The effect of plantation on increased allergic rhinitis in the eastern province of Saudi Arabia.

In a study done between 1982-1986, 129 patients with allergic rhinitis were followed-up in the Outpatient Department of King Fahd University Hospital, Al-Khobar (Saudi Arabia). Eighty patients were males (62%), 49 patients were females (38%); 71% Saudis, and 29% non-Saudis. Routine laboratory investigations, IgE and skin test were performed. The commonest allergens were pollens, house dust and cat danders. We found that males were significantly more affected than females, particularly in the cases of ages between 20-30 years. Beside the known causes, other factors such as the increase of plantation and local customs are discussed.

Sex distribution and common allergens of bronchial asthma in a Saudi Arabian (eastern province) population.

In a study carried out between 1982-1986, 68 asthmatic patients of different ages were followed-up in the Outpatient Department of the King Fahd University Hospital, Al-Khobar. Fifty-two patients were Saudis (78%) while the rest were of other nationalities (22%). The sex distribution was 39 (55.9%) females and 30 males (44%). Routine and skin tests were performed; the IgE was in 70% elevated. The commonest allergens among these patients were house dust, cat danders and D. Pteronyssinus. Females were significantly more affected than males, particularly in the ages between 20-30 years. Among the multiple causes, the local ones such as customs are postulated.