Correlation between physician- and patient-directed disease assessments in ulcerative colitis patients from Saudi Arabia and Kuwait: Data from ICONIC.

Background: The aim of the observational, prospective study was to validate a novel, nonverbal assessment tool for perceived disease burden-Pictorial Representation of Illness and Self-Measure (PRISM)-in ulcerative colitis (UC) against established patient health questionnaires. The cumulative burden of patients recently diagnosed (<3 years) with UC was also evaluated. Methods: "ICONIC" - Understanding the impact of ulcerative colitis and its associated disease burden on patients - was a noninterventional, multicountry, multicenter study performed in a 2-year follow-up format in adult patients with recently diagnosed UC in 33 countries, regardless of disease severity or treatment. Data collection consisted of five visits, scheduled at approximately 6-month intervals. For the current analysis, patient data from Saudi Arabia and Kuwait were evaluated. The collected data comprised demographics, disease-related data, UC treatment, and healthcare resources, as well as physician- and patient-assessed quality-of-life and disease burden questionnaires. Correlations between selected questionnaire scores were performed using Spearman's rho. Results: Disease severity at baseline and throughout the study was slightly less favorable in this country analysis compared with the global study cohort. Disease burden was assessed by PRISM and improved within 24 months. Conclusions: The detected moderate correlation between PRISM and other assessment methods supports the validity of PRISM. Differences in perceptions of UC-related burden between physician and patient may reflect to some degree insufficient patient-physician communication.

Patterns of Complementary and Alternative Medicine Use in Saudi Arabian Patients With Inflammatory Bowel Disease: A Cross-Sectional Study.

Background Inflammatory bowel disease (IBD) concerns a group of chronic autoimmune diseases that results in uncontrolled inflammation of the gastrointestinal (GI) tract, which can lead to long-term complications. Conventional treatments for IBD usually target inflammation and include biologics and immunosuppressants, which have been associated with significant adverse effects. Also, non-response to biologics has been reported in up to 50% of patients. Hence, patients sometimes turn to unconventional methods of treatment, such as complementary and alternative medicine (CAM). In this study, we examine patterns of CAM use in Saudi patients diagnosed with IBD. Materials and methods We conducted a cross-sectional study of patients with IBD who were seen at the outpatient gastroenterology clinic between January 2018 and December 2019. Adult patients diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) were identified and surveyed. Clinical, laboratory, endoscopic, radiologic, and histologic data were collected. The patients completed a detailed questionnaire focusing on CAM use. Descriptive statics, quantitative variables, means, standard deviations (SDs), and minimum and maximum values or medians with interquartile ranges were used where appropriate; for qualitative variables, we reported frequencies. The prevalence of CAM use was calculated using standard prevalence formulae. Logistic regression analysis was performed to identify predictors for CAM use. A p-value of <0.05 was set as statistically significant. Results A total of 71 IBD patients were surveyed, of which 75% had CD. Severe symptoms were reported by 54% of patients, and 41% were receiving biological treatment; 90% of this cohort reported using some form of CAM, of which 78% used them within the past year, and 52% reported CAM treatment having a positive effect. Of note, 63% of patients reported using CAM therapy without the knowledge of their treating physician. The most common source of advice regarding the use of CAM medicine was relatives (66%), and the most common forms of CAM used were honey (62%), Zamzam water (54%), and physical activity (32%). Binary logistic regression analysis identified watery diarrhea (OR=5.7, 95% CI=1.0-31, P=0.04) and azathioprine (OR=18.1, 95% CI=1.3-255, P=0.03) as predictors of CAM use. Conclusions CAM use is very common in Saudi patients with IBD. The majority of patients seem to turn to CAM if their symptoms are severe. They generally appear to be influenced by culture, the Internet, local society, and family tradition in their decision to use CAM, rather than expert advice from their treating physician.

A cross-sectional survey on the psychological impact of the COVID-19 pandemic on inflammatory bowel disease patients in Saudi Arabia.

Background/Aims: The coronavirus (COVID-19) pandemic has caused significant disruption to patients with chronic illnesses. We explored the emotional state, perception, and concerns of Saudi patients with inflammatory bowel disease (IBD) during the crisis. Materials and Methods: We conducted a cross-sectional survey from 30 March to 5 April, 2020 using a pre-designed questionnaire distributed through social media platforms to IBD patients. The five-part questionnaire included an assessment of psychological wellbeing using a previously validated Arabic version of the Hospital Anxiety and Depression Scale (HADS), which includes domains for anxiety (HADS-A) and depression (HADS-D). A logistic regression analysis was used to uncover possible associations between patient characteristics and anxiety and depression. Results: The data from 1156 IBD patients were analyzed. Normal, borderline, and HADS-A scores consistent with a diagnosis of anxiety were reported by 423 (36.6%), 174 (15.1%), and 559 (48.4%) patients, respectively. However, 635 (69%) patients had normal scores and 273 (30.1%) had borderline HADS-D scores; no patients reported scores consistent with depression. Based on a multiple logistic regression analysis, patients educated till a high school diploma (OR = 2.57, 95% CI: 0.09-6.05, P = 0.03) and that had indeterminate colitis (OR = 2.23, 95% CI: 1.27-3.89, P = 0.005) were more likely to express anxiety. Conclusions: Many patients expressed symptoms of anxiety, although not depression. Female patients, patients educated till a high school diploma, and those with indeterminate colitis were more likely to have anxiety. IBD patients require greater attention during a pandemic to avoid adverse disease-related outcomes.

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.

Arabic translation and psychometric testing of the self-screening malnutrition universal screening tool in inflammatory bowel disease patients.

OBJECTIVES: To translate and validate the malnutrition universal screening tool (MUST) for use in Arabic-speaking outpatients with inflammatory bowel disease (IBD). METHODS: We translated the MUST into Arabic by using the Brislin back-translation method. This methodological study was performed between August 2016 and November 2017 on 143 outpatients with IBD at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. The patients must completed the self-administered (PSA) Arabic version of the MUST. Then, the health-care practitioners (HCPs) administered the Arabic MUST and performed standard patient clinical assessment. The nutrition risk was defined as low (MUST score=0), medium (MUST score=1), or high (MUST score greater than 1). The chance-corrected proportional agreement between the scores from the PSA and HCP-administered Arabic MUST was evaluated using Cohen's kappa coefficient. Internal consistency was evaluated using Cronbach's alpha statistic. RESULTS: The overall agreement between the PSA and HCP-administered Arabic MUST was almost perfect (agreement=95.9%, expected agreement=72.4%, kappa=0.85, p less than 0.0001). The calculated Cronbach's alpha statistic for MUST scores in 15/143 (10%) patients was 0.79. The calculated Pearson's correlation coefficient between PSA and HCP-administered MUST scores was 0.93 (p less than 0.0001). CONCLUSIONS: The PSA and HCP-administered Arabic MUST showed perfect agreement in outpatients with IBD.

Baseline risk assessment of patients with ulcerative colitis: does initial treatment selection influence outcomes?

BACKGROUND AND AIMS: Treatment of ulcerative colitis (UC) typically follows a step-up approach and targets colonic mucosal healing. Although mucosal healing reduces the risk of colectomy, whether or not early treatment of patients with 'high-risk' features using tumor necrosis factor (TNF) antagonists reduces the risk of colectomy is not clear. Accordingly, we aim to evaluate the effect of baseline treatment selection according to the risk profile on 5-year outcomes and identify predictors of poor outcomes. PATIENTS AND METHODS: Adult patients with confirmed UC were retrospectively identified. Baseline clinical and endoscopic data were collected. Patients were assigned a risk profile on the basis of the presence or absence of 'high-risk' features within the first 6 months of diagnosis including moderate to severe endoscopic disease, frequent need for steroids, steroid dependency, and disease involving the entire colon according to endoscopy. Treatment discordance was defined as treating 'high-risk' patients with medications other than anti-TNF therapy during the first 6 months after diagnosis or treating 'low-risk' patients with anti-TNF therapy within 6 months of diagnosis. The associations between discordance and 5-year colectomy and hospitalization rates were statistically calculated through regression analysis, as were predictors of outcomes. RESULTS: A total of 108 patients were identified and studied. The median age was 36 years (interquartile range=27-50) and the average duration of disease was 6.6 (±3.1) years. Females comprised 62% of the cohort and 30% reported cigarette smoking. Seventy three percent of the patients were placed in the 'high-risk' category. The 5-year risk of colectomy was not statistically significantly higher in patients identified as 'high-risk' compared with those who were 'low-risk' (risk ratio=0.86, 95% confidence interval=0.24-3.1, P=0.81), nor was the 5-year risk of hospitalizations (risk ratio=1.63, 95% confidence interval=0.81-3.30, P=0.15). On the basis of stepwise model selection, colectomy was significantly predicted by discordance (P=0.039), arthritis (P=0.007), baseline stool frequency (P=0.019), Adalimumab use within the first 6 months of diagnosis (P=0.006), and pyoderma gangrenosum (P=0.049); hospitalization was predicted by discordance (P=0.018), baseline albumin concentrations (P=0.005), thromboembolism (P<0.005), thiopurine use within the first 6 months of diagnosis (P<0.005), Adalimumab use within the first 6 months of diagnosis (P=0.003), nationality (P=0.016), endoscopic severity (P=0.007), arthritis (P=0.005), and pyoderma gangrenosum (P=0.025). CONCLUSION: Among other clinical parameters, discordance between baseline risk and treatment selection appears to be a significant predictor of outcomes in UC.

Risk Stratification of Patients with Crohn's Disease: A Retrospective Analysis of Clinical Decision Making and Its Impact on Long-Term Outcome.

BACKGROUND AND AIMS: Complications such as need for bowel resections and hospitalization due to Crohn's disease (CD) occur when disease activity persists due to ineffective therapy. Certain "high-risk" features require an early introduction of anti-tumor necrosis factor-α therapy to prevent such complications. We aim to evaluate the prevalence of "high-risk" features among a cohort of patients with CD and examine the association between discordance of early therapy with baseline risk stratification and disease outcome. PATIENTS AND METHODS: All adult patients with CD were retrospectively identified and their medical records were reviewed. Clinical, endoscopic, laboratory, and radiological data were collected. Patients were divided into "low" and "high" risk groups according to the presence or absence of penetrating disease, perianal involvement, foregut involvement, extensive disease seen on endoscopy or cross-sectional imaging, young age at the time of diagnosis (<40), persistent cigarette smoking and frequent early requirements for corticosteroid therapy. Initial treatment selection and treatment approach ("step-up" vs. "accelerated step-up" vs. "top-down") within 6 months of diagnosis were recorded. Rates of CD-related bowel resections and hospitalization within 5 years of diagnosis were calculated. Logistic regression analysis was used to examine the association between "discordance" of early treatment selections and risk stratification categories with outcomes. RESULTS: Eighty-five CD patients were included. The median age and duration of disease were 25 (interquartile range [IQR] 19-32) and 5 (IQR 4-6) years, respectively. Sixty five percent were females and 66% were native Saudis. Smoking was reported in 12% of patients and perianal disease in 18%. "High-risk" features were identified in 43 (51%) patients, of which only 6 (14%) were treated with "top-down" therapy and 7 (16%) with "accelerated step-up" care. The risk of requiring a bowel resection, and hospitalization was higher for "high-risk" patients compared to "low-risk" patients (risk ratio [RR] 13.67, 95% CI 1.88-99.41; p = 0.003, and RR 1.86, 95% CI 0.03-0.43; p = 0.0312, respectively). "Discordance" occurred in 34% of cases. Bowel resection was required in 15/85 (18%) patients and 32/85 (38%) required at least one hospitalization within 5 years of diagnosis. Logistic regression analysis identified a statistically significant association between "discordance" and need for bowel resections (OR 6.50, 95% CI 1.59-26.27, p = 0.009), and hospitalizations (OR 3.01, 95% CI 1.08-8.39, p = 0.035) within 5 years of diagnosis. CONCLUSIONS: "Discordance" between patient risk-profile and treatment selection early in the course of CD has a significant impact on disease outcome, specifically need for bowel resection and hospitalization, which are more likely to occur in the presence of "high-risk" features. Early identification of "high-risk" features could help prevent long-term complications.

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.

Screening irritable bowel syndrome patients for symptoms predictive of crohn's disease using the red flag score.

BACKGROUND/AIMS: The diagnosis of inflammatory bowel disease (IBD) is often delayed due to misdiagnosing patients with irritable bowel syndrome (IBS), mostly because of the under-recognition of high-risk features. The red flag score (RFS) has been recently developed to identify patients with higher risk of IBD rather than IBS. The aim of this study is to estimate the prevalence of high-risk features, according to the RFS, among patients diagnosed with IBS who would consequently be candidates for ileocolonoscopic evaluation. PATIENTS AND METHODS: Adult patients with IBS seen at the general medicine clinic were recruited and surveyed using the RFS. Clinical and demographic data were collected. The prevalence of high-risk features, defined as a RFS >5, was calculated. Logistic regression analysis was used to identify predictors of RFS >5. RESULTS: A total of 255 patients with IBS were recruited. The mean age was 30.6 years (±9.9 years); 71.4% of patients were women (182/255), and 90.2% were from Saudi Arabia (230/255). More than half of the patients we surveyed (51.4%) had not visited a gastroenterologist previously. The mean RFS was 6.6 (±3.6) and 54.9% of patients (140/255) scored more than 5 and accordingly were selected for further investigations. Statistical analysis identified no previous visits to a gastroenterologist as the only significant predictor of RFS >5 (OR = 2.2, 95% CI = 1.3-3.7, P = 0.003). CONCLUSIONS: More than half of the patients known to have IBS are candidates for further investigations to eliminate the possibility of IBD as a diagnosis according to the validated RFS. Patients who did not seek a specialized consultation with a gastroenterologist might be at a higher risk of being misdiagnosed as having IBS.

p16 protein is upregulated in a stepwise fashion in colorectal adenoma and colorectal carcinoma.

BACKGROUND/AIMS: p16 is tumor suppressor gene acting as a cell cycle regulator. The present study was conducted to compare p16 expression in normal, dysplastic, and malignant colonic mucosae, and to explore its relation to clinicopathological variables and follow-up data in colorectal carcinoma (CRC). PATIENTS AND METHODS: Tissue microarrays were performed from 25 normal colonic mucosae, 41 colonic adenomas, and 191 CRC, with corresponding 50 nodal metastases. Immunohistochemistry was performed using anti-p16 antibody, sections were scored, and statistical analysis was performed. K-ras mutation detection was also performed. RESULTS: Immunoexpression of p16 was significantly higher in CRC than in adenomas (P = 0.033) and normal colonic mucosa (P = 0.005). There was no statistically significant difference between p16 expression in CRC and nodal metastasis. There was no significant association between p16 immunoexpression in CRC and all clinicopathological data and survival probability. K-ras mutations were detected in 34% of CRC. However, there was no correlation between K-ras status and p16 expression (P = 0.325). CONCLUSION: Absence of p16 expression is correlated to a benign course of CRC adenomas. p16 has a key role in CRC progression and can be used as a marker for colorectal adenoma. On the other hand, it has no role as a predictive and/or prognostic factor in CRC. Further extended studies are required to explore the role of p16 as indicator of premalignant lesions in the colon and to test its relation with CRC histological grade, as well as to test its value as a new therapeutic target.

High expression of matrix metalloproteinases: MMP-2 and MMP-9 predicts poor survival outcome in colorectal carcinoma.

AIM: To evaluate the expression pattern of matrix metalloproteinases (MMPs); MMP-2, MMP-7 and MMP-9 in colorectal cancer (CRC) and determine its prognostic potential. PATIENTS & METHODS: CRC samples of 127 patients were studied. Protein expressions of MMP-2, -7 and -9 were analyzed by immunohistochemistry and association with clinicopathological variables was statistically analyzed. RESULTS: Overexpressions of MMP-2 and MMP-9 correlated with poor outcome as evaluated by univariate Kaplan-Meier for disease-free survival (p = 0.04, p = 0.0001) and disease-specific survival (p = 0.01, p = 0.01), respectively. Cox analysis of MMP-2 and -9 were significant independent predictors of disease-free survival (p = 0.006, p = 0.018) and disease-specific survival (p = 0.004, p = 0.049), respectively. CONCLUSION: MMPs expression patterns provide useful prognostic information in CRC, while predicting the patients at high risk for recurrent disease.

Prognostic significance of VEGFR1/Flt-1 immunoexpression in colorectal carcinoma.

Colorectal carcinoma (CRC) is a major cause of morbidity and mortality. Vascular endothelial growth factor 1/Fms-like tyrosine kinase 1 (VEGFR1/Flt-1) regulates monocyte migration, recruits endothelial cell progenitors, increases the adhesive properties of natural killer cells and induces of growth factors. Flt-1 is expressed on tumour cells and has been implicated in tumour growth and progression. The objective of this study is to address the relation of Flt-1 expression to tumour prognostication. Paraffin blocks from 143 primary CRC and 48 regional nodal metastases were retrieved from the archives of the Department of Pathology at King Abdulaziz University. Tissue microarrays were designed and constructed. Immunohistochemistry for Flt-1 was performed. Staining intensity and extent of staining were assessed and combined. Results were dichotomised as low expression and high expression. Flt-1 was overexpressed in primary tumours and nodal metastasis (p < 0.001 and 0.001) with no difference between primary and nodal metastasis (p = 0.690). Flt-1 immunoexpression was not associated with the clinicopathological parameters. Flt-1 overexpression was an independent predictor of positive margin status, positive lymphovascular invasion and local disease recurrence (p < 0.001, p < 0.001 and p = 0.003, respectively). Flt-1 was not associated with survival (log-rank = 0.003, p = 0.959). Flt-1 was overexpressed in primary CRC and their nodal metastases. Flt-1 expression was an independent predictor of margin status, lymphovascular invasion and local disease recurrence. Therefore, expression profiling of Flt-1 seems to have a prognostic potential in CRC. However, to elucidate the association of overexpression of Flt-1 with tumour characteristics and prognostication, more in vivo and in vitro molecular investigations are recommended.

Variceal hemorrhage: Saudi tertiary center experience of clinical presentations, complications and mortality.

AIM: To determine the clinical presentation, underlying etiology and short- and long-term outcomes of acute variceal bleeding (AVB). METHODS: A retrospective descriptive cohort study of cirrhotic patients with AVB who were admitted to King Abdul Aziz University Hospital between January 2005 and December 2009. We obtained demographic data for all patients. For each patient we also obtained the clinical data at presentation; cause of liver cirrhosis, bleeding presentation (hematemesis and/or melena), presence of ascites, hepatic encephalopathy and renal impairment (RI) or hepatorenal syndrome. We carried out complete blood count, prothrombin time evaluation, and liver function tests. We also report all episodes of re-bleeding after the first episode of AVB, both during the initial admission and after discharge. We recorded the length of stay for each patient and thereby calculated the mean duration of stay for all patients. The length of follow-up after the first AVB and the outcome for each patient at the end of the study period were recorded. Causes of mortality either related to liver disease or non-liver disease cause were determined. RESULTS: A 125 patients were enrolled in the study. The number of episodes of AVB for each patients varied between 1 and 10. Survival from the first attack of AVB to death was 20.38 mo (SD 30.86), while the length of follow-up for the living patients was 53.58 mo (SD 24.94). Total number of AVB admissions was 241. Chronic hepatitis C, the commonest underlying etiology for liver disease, was present in 46 (36.8%) patients. Only 35 (28%) patients had received a primary prophylactic ß-blocker before the first bleeding episode. The mean hemoglobin level at the time of admission was 8.59 g/dL (SD 2.53). Most patients had Child-Pugh Class C 41 (32.8%) or Class B 72 (57.6%) disease. Hematemesis was the predominant symptom and was found in 119 (95.2%) patients, followed by melena in 75 (60.0%) patients. Ascites of variable extent was documented in 93 (74.4%) patients. We identified hepatic encephalopathy in 31 (28.8%) patients and spontaneous bacterial peritonitis in 17 (13.6%). Bleeding gastric varices was the cause of AVB in 2 patients. AVB was associated with shock in 22 patients, 13 of whom (59.1%) had Child-Pugh class C disease. RI was noted in 19 (46.3%) of 41 patients in Child-Pugh class C and 14 (19.4%) of 72 patients in Child-Pugh class B. None of the patients with Child-Pugh class A disease had RI. Emergency endoscopy was effective in controlling the bleeding, although the re-bleeding rate was still high, 12 (9.6%) during the same admission and 55 (44%) after discharge. The re-bleeding rate was higher in patients with ascites, occurring in 40/55 (72.2%). The length of hospital stay was 1-54 d with a mean of 8.7 d. Three patients had emergency surgery due to failure of endoscopic treatment and balloon tamponade. The overall long term mortality was 65%. Survival from the first attack of AVB to death was 20.38 ± 30.86 mo, while the length of follow-up for the living patients was 53.58 ± 24.94 mo. Patients with Child-Pugh score C had a higher risk of liver disease-related mortality (67.6%). RI (developed during admission) was the main factor that was associated with mortality (P = 0.045). CONCLUSION: The majority of patients with liver disease who present at the emergency unit for AVB are at an advanced stage of the disease. The outcome is poorer for patients who develop RI during hospitalization.

Autoimmune hepatitis: Single-center experience of clinical presentation, response to treatment and prognosis in Saudi Arabia.

BACKGROUND/AIM: Autoimmune hepatitis (AIH) is a common cause of end-stage liver disease worldwide. It is a disease prevalent in children and adults, with female predominance and variable clinical presentations. AIH has favorable responses to steroids and immunomodulators. Diagnosis of AIH is based on clinical and laboratory criteria, as suggested by the International Autoimmune Hepatitis Group. Data on the disease pattern of AIH from the Middle East countries is scarce. MATERIALS AND METHODS: In this retrospective analysis, we studied clinical and laboratory features, immunological data, radiological findings, liver biopsy findings and response to therapy in patients with AIH from the hepatology clinics of King Abdul Aziz, University Hospital, Jeddah, from 1994 to 2008. RESULTS: We diagnosed 41 patients with AIH, and 33 were included in the analysis. The mean age was 32.3 years, with female predominance of 75.7%. De-compensated cirrhosis at presentation was found in 45.5% of the patients. Acute hepatitis was associated with significantly higher levels of the serum ALT and bilirubin (P=0.001 and P=0.03, respectively). All our patients had type 1 AIH. Treatment with prednisolone and azathioprine resulted in complete or partial remission in majority of the patients (54.8%). However, patients with advanced disease showed a poorer response to treatment (P=0.016). Six patients with poor compliance had relapse of AIH. Two patients had a flare of the disease during pregnancy, and they responded well with prednisolone. The longest follow-up was 14 years and the shortest was 2 months. Four patients died from liver disease. CONCLUSION: AIH patients in Saudi Arabia are likely to present with advanced disease at a young age and would have a poorer response to therapy as compared with patients in other countries worldwide.

Pattern of admission to hospitals during muslim pilgrimage (Hajj).

OBJECTIVE: The pattern of medical conditions necessitating admission differs according to the weather condition in that particular year. Previous studies had been conducted during the hot weather, none over the last 10 years, were carried out during, the milder weather we are experiencing. The aim of this study is to establish the pattern of admission during this mild weather and to elucidate the possible risk factors. METHODS: A prospective study was performed in 4 hospitals in 2 different locations in Al-Mashaer, Kingdom of Saudi Arabia. Data were collected during one working shift in 2 hospitals in Arafat on the 9th of Dhul Hijjah 1422, corresponding to 21st of February 2002, and another working shift in 2 hospitals in Mina on the 10th of Dhul Hijjah 1422, corresponding to 22nd of February 2002. RESULTS: A cohort of 76 patients from Arafat hospitals and 84 patients from Mina hospitals were included (total 160 patients). Males constituted 62% and females 38% with the median age of 60 +/- 15 years. The respiratory system was the most commonly affected (57%), followed by cardiovascular system (19.4%), and gastrointestinal tract (GIT) in 6.3% of cases. There were only 3 cases of heat-related admissions with only one confirmed case of heat stroke. Similarly, only one case of meningitis was confirmed in this cohort. Pneumonia was encountered in 63 cases (39.4%) and exacerbation of asthma and chronic obstructive pulmonary diseases (COPD) in 23 cases (14.4%). Pre-existing co-morbid medical conditions had included bronchial asthma and COPD (22.5%), hypertension (17.5%), and Diabetes mellitus (15%). Short-term follow up (24-48 hours) identified 2 deaths (1.3%), 94 patients (59%) were transferred to other secondary or tertiary care facilities and 64 (40%) were discharged home. CONCLUSION: Hospital admission during Hajj is related to old age and occurs in patients with associated co-morbid conditions. During this mild weather lower respiratory tract infections and exacerbation of bronchial asthma and COPD are the most commonly encountered diseases during Hajj.