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.

Safety of prolonged use of metoclopramide and domperidone as treatment for chronic gastrointestinal dysmotility disorders in patients with systemic sclerosis.

Background: Metoclopramide and domperidone are prokinetic agents commonly used to treat gastrointestinal dysmotility disorders. This study aimed to evaluate the safety and associated side effects of prolonged-use metoclopramide and domperidone as treatment for chronic gastrointestinal dysmotility disorders in patients with systemic sclerosis (SSc). Methods: A quantitative observational survey was conducted by interview questionnaire in rheumatology outpatients at a tertiary teaching hospital in Riyadh, Saudi Arabia. The study included all patients aged 25-80 years diagnosed with SSc. All patients were on metoclopramide or domperidone for the treatment of chronic gastrointestinal dysmotility symptoms over at least 12 weeks. Results: Eighteen eligible patients were included. Most study participants were diagnosed with SSc complicated by interstitial lung disease (n = 13; 72.2 %). The most frequently reported side effect that occurred while taking prokinetic drugs was shortness of breath (n = 12; 66.7 %). None of the participants reported experiencing depression, galactorrhea, or syncope. CNS side effects were reported in 5.6 %. There were no differences in side effects based on the type and dosage of prokinetic drug used. Conclusions: Use of metoclopramide and domperidone for the treatment of chronic gastrointestinal dysmotility in SSc patients for 12 weeks or longer was not associated with any troublesome side effects. Further studies with more participants are needed to confirm our findings.

Brucellosis in a patient with Crohn's disease treated with infliximab: A case report.

Crohn's disease (CD) is an inflammatory disease that can affect any part of the gastrointestinal tract and presents with myriad symptoms. Various treatments, including biological treatments, are available. The use of biologics increases the risk of opportunistic infections, with no association with serious infections (1). To the best of our knowledge, there are no established recommendations or case studies for patients with CD infected with Brucella being actively treated with biologics and immunomodulators to date. Herein, we report the first case of brucellosis diagnosed in a patient with CD treated with biologics and immunomodulators. A 40-year-old man had been treated with anti-tumour necrosis factor (anti-TNF) drugs, namely, infliximab and azathioprine, for CD for the past eight years. During a follow-up visit, the patient complained of loss of appetite, fever, weight loss, and joint discomfort. The patient reported a history of raw milk consumption. Blood cultures indicated the growth of Brucella species. Infliximab and azathioprine were held, and brucellosis treatment was initiated, including rifampin 600 mg once daily, doxycycline 100 mg twice daily, and streptomycin 1 g intramuscularly daily. A multidisciplinary team comprising gastroenterologists and infectious disease specialists decided to initiate brucellosis treatment and resume biologics and immunomodulators 4 weeks after starting Brucella treatment.

Decision-Utility Analysis of Empiric Treatment Versus Test and Treat Strategies for Helicobacter pylori in Patients With Duodenal Ulcer.

OBJECTIVES: The optimal strategy of Helicobacter pylori eradication in patients with duodenal ulcer is unclear. In this study, we aimed to compare the utility and the ulcer recurrence rate using the empiric treatment versus the test and treat strategies in patients with uncomplicated duodenal ulcer. METHODS: A decision-utility analysis was performed using a decision tree. The empiric treatment strategy was compared with the test and treat strategy. The probabilities of recurrent ulcers were determined and utilities of the 2 strategies were compared using the quality-adjusted life-year (QALY). Sensitivity analysis was performed to evaluate for model robustness. RESULTS: The probability of recurrent ulcer with the empiric strategy was 10.5%. The probabilities of recurrent ulcer with the test and treat strategy were 12.6%, 14.7%, 16.8%, and 17.9% based on 95%, 90%, 85%, and 80% sensitivity for histopathology, respectively. At the 95% estimate for the sensitivity of histopathology, the empiric strategy was associated with greater QALY compared with the test and treat strategy, 0.9875 versus 0.9853. The empiric treatment strategy was associated with greater QALY at extreme values for the estimates in our model. CONCLUSIONS: The empiric treatment strategy is associated with 2.1% to 7.4% lower recurrence rate for a range of test sensitivity between 95% and 80%, and results in greater QALY compared with the test and treat strategy.

Clinical outcomes of lower gastrointestinal bleeding in patients managed with lower endoscopy: A tertiary center results.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is an urgent presentation with increasing prevalence and remains a common cause of hospitalization. The clinical outcome can vary based on several factors, including the cause of bleeding, its severity, and the effectiveness of management strategies. The aim of this study is to provide a comprehensive report on the clinical outcomes observed in patients with LGIB who underwent lower endoscopy. METHODS: All patients who underwent emergency lower endoscopy for fresh bleeding per rectum, from May 2015 to December 2021, were included. The primary outcome was to identify the rate of rebleeding after initial control of bleeding. The second was to measure the clinical outcomes and the potential predictors leading to intervention and readmission. RESULTS: A total of 84 patients were included. Active bleeding was found in 20% at the time of endoscopy. Rebleeding within 90 days occurred in 6% of the total patients; two of which (2.38%) were within the same admission. Ninety-day readmission was reported in 19% of the cases. Upper endoscopy was performed in 32.5% of the total cases and was found to be a significant predictor for intervention (OR 4.1, P = 0.013). Personal history of inflammatory bowel disease (IBD) and initial use of sigmoidoscopy were found to be significant predictors of readmission [(OR 5.09, P = 0.008) and (OR 5.08, P = 0.019)]. CONCLUSIONS: LGIB is an emergency that must be identified and managed using an agreed protocol between all associated services to determine who needs upper GI endoscopy, ICU admission, or emergency endoscopy within 12 hours.

An Asymptomatic Patient with Colonic Leiomyoma.

Subepithelial lesions (SELs) originating from muscularis mucosae of the colon are very rare findings on endoscopy. Appropriate management of SELs involves making a correct diagnosis and estimating their malignant potential. In this case study, a 58-year-old Saudi man presented with a small, 8-mm sigmoid polyp during screening colonoscopy. The polyp was removed by hot snare polypectomy and sent to pathology laboratory. Report showed an unremarkable colonic mucosa and underlying well-circumscribed submucosal lesion composed of monotonous spindle cells. Immunohistochemical (IHC) analysis ruled out CD117-/DOG1-positive GIST and confirmed the lesion as leiomyomatous polyp. Colonic leiomyomas are usually benign and often asymptomatic and discovered during CRC screening procedures. Diagnosis is made on histology/IHC analysis since endoscopically they might be indistinguishable from other SELs. Conventional polypectomy is an appropriate treatment for small colonic leiomyoma and these benign lesions typically do not recur.

Eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is an atopic disease in which eosinophils infiltrate the esophageal mucosa and may result in a variety of upper gastrointestinal symptoms. Chief among these are dysphagia, heartburn, and food bolus obstruction in adults whereas children often present with abdominal pain or vomiting. Eosinophilic esophagitis is a chronic condition that if not detected and left untreated could lead to the development of subepithelial fibrosis and esophageal stenosis. The diagnosis of EoE is confirmed in a patient presenting with characteristic EoE symptoms, classic signs on endoscopy, and biopsy results showing >15 eosinophils/hpf. A number of useful treatments against EoE are currently available with new therapeutics on the horizon. The former include PPIs, topical steroids, and elimination diet; the latter comprise novel biologics including the monoclonal antibody dupilumab. All these treatments can improve symptoms and reduce esophageal eosinophil count. This brief introductory review describes the detection, diagnosis, and management of EoE.

Feasibility, and barriers to use escitalopram in functional gastrointestinal disorders.

Background and study aims: The feasibility and barriars of escitalopram use in patients with functional gastrointestinal disorders (FGIDs) are still debated. We aimed to evaluate the feasibility, safety and efficacy and barriars of escitalopram use in managing FGIDs in the Saudi population. Patients and Methods: We included 51 patients who received escitalopram for irritable bowel syndrome (n = 26), functional heartburn (n = 10), globus sensation (n = 10) or combined disorders (n = 5). We used an irritable bowel syndrome-severity scoring system IBS-SSS), GerdQ questionnaire and Glasgow Edinburg Throat Scale (GETS) to assess disease severity change before and after treatment. Results: The median age was 33 years (25th- 75th percentiles: 29-47), and 26 (50.98%) were males. Forty-one patients experienced side effects (80.39%), but most side effects were mild. The most common side effects were drowsiness/fatigue/dizziness (54.9%), xerostomia (23.53%), nausea/vomiting (21.57%) and weight gain (17.65%). IBS-SSS was 375 (255-430) and 90 (58-205) before and after treatment, respectively (p < 0.001). GerdQ score was 12 (10-13) before treatment and 7 (6-10) after treatment (p = 0.001). GETS score before treatment was 32.5 (21-46) and after treatment became 22 (13-31) (p = 0.002). Thirty-five patients refused to take the medications, and seven patients discontinued the medication. Possible causes of the poor compliance were fear of the medications and not being convinced of taking psychiatric medications for functional disorders (n = 15). Conclusion: Escitalopram could be a safe and effective treatment for functional gastrointestinal disorders. Targeting and managing factors leading to poor compliance could further improve the treatment outcome.

Quality of Life, Fatigue, and Physical Symptoms Post-COVID-19 Condition: A Cross-Sectional Comparative Study.

The magnitude of post-COVID-19 syndrome was not thoroughly investigated. This study evaluated the quality of life and persistence of fatigue and physical symptoms of individuals post-COVID-19 compared with noninfected controls. The study included 965 participants; 400 had previous COVID-19 disease and 565 controls without COVID-19. The questionnaire collected data on comorbidities, COVID-19 vaccination, general health questions, and physical symptoms, in addition to validated measures of quality of life (SF-36 scale), fatigue (fatigue severity scale, FSS), and dyspnea grade. COVID-19 participants complained more frequently of weakness, muscle pain, respiratory symptoms, voice disorders, imbalance, taste and smell loss, and menstrual problems compared to the controls. Joint symptoms, tingling, numbness, hypo/hypertension, sexual dysfunction, headache, bowel, urinary, cardiac, and visual symptoms did not differ between groups. Dyspnea grade II-IV did not differ significantly between groups (p = 0.116). COVID-19 patients scored lower on the SF-36 domains of role physical (p = 0.045), vitality (p < 0.001), reported health changes (p < 0.001), and mental-components summary (p = 0.014). FSS scores were significantly higher in COVID-19 participants (3 (1.8-4.3) vs. 2.6 (1.4-4); p < 0.001). COVID-19 effects could persist beyond the acute infection phase. These effects include changes in quality of life, fatigue, and persistence of physical symptoms.

The prevalence and risk factors for hiatal hernia among patients undergoing endoscopy: A retrospective analysis.

OBJECTIVES: To determine the prevalence of hiatal hernia (HH) and its association with age, gender, and body mass index (BMI). METHODS: We retrospectively included patients who underwent esophagogastroduodenoscopy (EGD) at an academic tertiary care hospital. Data were collected on the presence of HH as well as patient demographics including age, gender, and BMI. Univariate and multivariate analysis were done to determine risk factors for HH. RESULTS: A total of 2805 patients were included in this study. The mean age was 48.6 (±18.6) years and males constituted 28.8% of the study population. The mean BMI was 29.7 (±8.6) kg/m². The prevalence of HH was 29.8% among all patients and 48.6% among those who underwent EGD for gastroesophageal reflux disease-related indications. There was no significant association between HH and female gender (OR 1.04, 95%CI: 0.88 -1.26, p=0.53), older age (OR 0.77, 95%CI: 0.72 - 1.06, p=0.19) or BMI (OR 1.07, 95%CI: 0.9 - 1.2, p=0.39). CONCLUSION: The prevalence of HH was 28.9% based on this large endoscopy-based population. We found no association between HH and gender, age, or BMI.

Eosinophilic Esophagitis in a 75-Year-Old Saudi Man: A Case Report.

The incidence and prevalence of eosinophilic esophagitis (EoE) are increasing in adults and children worldwide. Once thought primarily to affect children and young adults, EoE is now recognized in all age groups. To our knowledge, this case study is the first known report of EoE diagnosed in an elderly man in Saudi Arabia. The 75-year-old patient presented with a chief complaint of dry mouth and mild heartburn symptoms. Further history inquiry disclosed that he experienced dysphagia occasionally. His endoscopy findings revealed signs associated with EoE, which was confirmed by biopsy showing marked infiltration of eosinophils (>30/hpf) in upper and lower esophagus. Following treatment with dexlansoprazole for eight weeks, the patient reported no further symptoms, and he remained in remission three months thereafter. Elderly patients with EoE may display atypical signs and symptoms and rarely have concomitant allergy; EoE should be considered in older patients especially those with dysphagia.

Unlocking Early Cancer Detection: Exploring Biomarkers, Circulating DNA, and Innovative Technological Approaches.

Research and development improvements in early cancer diagnosis have had a significant positive impact on health. In the treatment and prevention of cancer, early detection is essential. In this context, biomarkers are essential because they offer important information on the state of cells at any particular time. Cells go through unique changes when they shift from a healthy condition to a malignant state, changes that appropriate biomarkers may pick up. Recent advancements have been made to identify and characterize circulating cancer-specific mutations in cell-free circulating DNA derived from tumors and tumor cells. A patient's delay between the time they first detect symptoms and the time they contact a doctor has been noted for many cancer forms. The tumor's location and features significantly impact the presentation of symptoms judged appropriate for early diagnosis. Lack of knowledge of the severity of the symptoms may be one cause for this delay. Our review is largely focused on the ongoing developments of early diagnosis in the study of biomarkers, circulating DNA for diagnosis, the biology of early challenges, early symptoms, liquid biopsies, detectable by imaging, established tumor markers, plasma DNA technologies, gender differences, and artificial intelligence (AI) in diagnosis. This review aims to determine and evaluate Indicators for detecting early cancer, assessing medical conditions, and evaluating potential risks. For Individuals with a heightened likelihood of developing cancer or who have already been diagnosed, early identification is crucial for enhancing prognosis and raising the likelihood of effective treatment.

The views of African and Middle Eastern Gastroenterologists on the management of mild-to-moderate, non-erosive gastro-esophageal reflux disease (GERD).

INTRODUCTION: Gastro-esophageal reflux disease (GERD) is a common gastrointestinal disorder that occurs when backflow of the gastric contents into the esophagus results in troublesome symptoms. Though GERD has been extensively studied in Western populations, literature on the management of GERD in patients in Africa and Middle East (AME) is scarce. AREAS COVERED: In this review, we provide an overview of the management of mild-to-moderate GERD in AME. Here we focus on the efficacy and safety of currently available treatments for GERD to help physicians and community pharmacists appropriately manage patients with mild-to-moderate GERD in the primary healthcare setting, detailing specific situations and patient scenarios that are relevant to the region, including management of GERD during Ramadan and post-bariatric surgery. EXPERT OPINION: Under-appreciation of the burden of GERD in the region has resulted in a lack of consensus on management. Barriers that currently prevent the adoption of treatment guidelines in the primary healthcare setting may include lack of availability of local guidelines and referral systems, a paucity of region-specific research, and dogmatic adherence to traditional practice. By increasing awareness, strengthening knowledge, and by more effective utilization of resources, physicians and pharmacists could optimize GERD management strategies to better support patients.

The Effect of Body Mass Index on the Prevalence of Gastrointestinal Symptoms Among a Saudi Population.

BACKGROUND: While multiple studies have evaluated the effect of body mass index (BMI) on the prevalence of gastrointestinal (GI) symptoms, data from Saudi Arabia are scarce. This study aimed to evaluate the association between GI symptoms and BMI in a Saudi population. METHODS: A prospective cross-sectional study was conducted between September 2019 and April 2020. The data were collected using an electronic self-administered questionnaire. The study included adult participants and collected data on patients' demographics and GI symptoms. Participants with underlying GI diseases were excluded. A multivariate regression analysis was used to report the adjusted prevalence of GI symptoms in different BMI categories. RESULTS: A total of 4415 participants completed the survey. After applying the exclusion criteria, 3866 were included. The mean age was 26.3 (±8.8) and 58.2% were females. The mean BMI was 25.2 (±6.7), and the distribution of BMI was as follows: underweight 428 (11.1%), normal BMI 1789 (46.2%), overweight 912 (23.5%), and obese 737 (19.1%). After adjustment for age, gender, and smoking and coffee habits, obesity (BMI > 30) was significantly associated with heartburn (p < 0.01, aOR 1.6, 95% CI: 1.33 - 1.92), bloating (p < 0.01, aOR 1.31, 95% CI: 1.08 - 1.6), and diarrhea (p < 0.01, aOR 1.72, 95% CI: 1.36 - 2.17)). Underweight (BMI < 18.5) was significantly associated with abdominal pain (p < 0.01, aOR 1.4, 95% CI: 1.12 - 1.73), nausea (p < 0.01, aOR 1.6, 95% CI: 1.29 - 2.1), and vomiting (p < 0.01, aOR 2.02, 95% CI: 1.23 - 3.25). There was no significant association between BMI and constipation. CONCLUSION: Obesity was associated with heartburn, diarrhea, and bloating, while underweight status was associated with nausea, vomiting, and abdominal pain. No association between BMI and constipation was found.

Factors Associated with Missed and Cancelled Appointments in the Endoscopy Unit: Descriptive Study.

Background and aim Canceled and missed appointments at the endoscopy unit affect the quality of the provided services and can negatively impact patient outcomes. Assessing the association between the various factors relating to nonattendance will show whether the defective aspects are organizational or personal, which is essential to improve the quality of the healthcare system. Moreover, this study will be of value in our region due to the current scarcity of studies in the Middle East. Methods A descriptive study was conducted at King Khaled University Hospital in Riyadh, Saudi Arabia. A database of participants was established from those who missed/canceled their outpatient endoscopy clinic appointment; purposive sampling was applied, excluding those who are under 14 years old. Demographic data and organizational factors (e.g., referred clinic and the lead time) were collected from the patients' files and a structured interview done by phone within 7-14 days of the missed/canceled appointment.  Results A total of 919 endoscopy procedures were scheduled in an eight-week period, and 179 procedures were missed/canceled (19.48%); 84% were missed, and 16% were canceled. The highest percentage of the population had a high-school diploma or less. The results showed that roughly half of the patients were unemployed. More than two-thirds of the patients had undergone an endoscopy within the past year or less. The majority stated that they underwent the procedure in a different facility, which might be due to various reasons, one of which could be justified as long lead time.  Conclusion An annual update of patients' files is suggested. Text messages can help serve as a reminder in addition to clear appointment instructions that will aid in minimizing the absence rates. Overbooking is recommended to decrease the lead time and increase clinic efficiency. Raising patients' awareness regarding the effect of missing appointments as well as upgrading the communication methods will assist in decreasing the rate of missed appointments.

Anakinra Hepatotoxicity in a Patient With Adult-Onset Still's Disease.

We report a 46-year-old white woman with adult-onset Still's disease (AOSD) treated with anakinra, a IL-1B receptor antagonist. Within weeks, her liver enzymes deteriorated; subsequent cessation and rechallenge confirmed anakinra-related drug-induced liver injury (DILI). Although AOSD has been associated with liver involvement, little is known about the hepatotoxicity of anakinra. Heightened awareness by gastroenterologists and hepatologists is warranted.