Extracorporeal shock-wave lithotripsy (ESWL)-induced erosions in upper gastrointestinal tract. Prospective study in 40 patients.

In a prospective study in 40 patients receiving ESWL treatment, gastric and/or duodenal erosions occurred in 32 patients (80%); in 24 (60%) the erosions were in the proximal part of the stomach. There was no direct relation between the patients' weight and the development of erosions. In some patients more erosions developed in relation to the number of shock waves received and the intensity of energy given. In most patients early onset of hematuria indicated development of more erosions. To our knowledge this is the first report in the literature on ESWL-induced erosions in the upper gastrointestinal tract.

Seroepidemiology of hepatitis B virus infection in Saudi Arabian children: a baseline survey for mass vaccination against hepatitis B.

Saudi Arabia is considered to be an area of endemic hepatitis B virus (HBV) infection. By adult age, 7% persons have hepatitis B surface antigen (HBsAg) and about 70% have one or more HBV markers. In order to provide a baseline for the integration of hepatitis B vaccine into the extended programme of immunisation (EPI), a population-based survey of HBV markers was made among Saudi children. The overall prevalence of HBsAg was 6.7%, with at least one HBV marker being positive in 19.7% persons tested. Two peaks of HBV prevalence were observed in the 7- and 10-year-old children respectively. The prevalence of HBsAg was steady in all age groups with identifiable but insignificant peaks in children aged 4 and 7 years respectively. Despite the apparent homogeneity of the Saudi population, the prevalence rates of HBV varied among the regions and were higher in urban dwellers. There was no significant difference in the HBsAg prevalence for the sexes (7.3% for males and 6.0% for females). Socioeconomic factors and family size did not significantly influence the prevalence of HBV among children. Of 307 HBsAg-positive children, 55 (17.9%) were positive for HBeAg. The early acquisition of HBV in the Saudi population is confirmed. The most effective strategy for HBV control, therefore, is by mass vaccination of all Saudi infants. An extension of the immunisation programme so as to include all pre-school children should further reduce the reservoir of HBV in Saudi Arabia. A repetition of a similar survey after 5 and 10 years should be made in order to measure this reduction.

Endoscopic removal of daughter Echinococcus cysts from the common bile duct.

A case report is presented of a patient in whom daughter cysts of Echinococcus granulosus were removed endoscopically from the common bile duct. We would like to suggest in this paper that in cases of operated hydatid disease of the liver with retained cysts in the common bile duct, endoscopic removal instead of surgery is possible; and in particular that anaphylactic reaction need not be expected as the cysts content is drained into the gut.

Ultrasound diagnosis of "dry type" ileocecal tuberculosis: a case report.

Abdominal tuberculosis is a common curable disease in third world countries. CT is the most sensitive imaging technique. The purpose of this paper is to report the ultrasound diagnosis of a missed dry type ileocecal tuberculosis. A 40 year old patient was admitted to hospital for loin pain and was discharged following negative ultrasound and IVU tests. Symptoms recurred and a barium enema, follow through and abdominal CT were conducted. Barium studies were non specific and CT was normal. Sigmoidoscopy was negative for inflammatory bowel disease. A second ultrasound indicated a "coned" cecum with edematous and dilated terminal ileum. A diagnosis of tuberculosis was suggested. Colonoscopy showed typical lesions in the cecum with nodular terminal ileum. Biopsies were supportive of a tuberculosis diagnosis. In conclusion, an ultrasound with a high index of clinical suspicion is a useful test for the diagnosis of ileocecal tuberculosis. The coned contracted cecum with a dilated edematous terminal ileum are important diagnostic signs.

Omeprazole versus histamine H2 receptor antagonists in the treatment of acute upper non-variceal bleeding.

BACKGROUND/AIMS: To compare the efficacy of omeprazole, a proton pump inhibitor, with Histamine H2 receptors antagonists in the control and recurrence of non-variceal upper gastrointestinal bleeding. PATIENTS AND METHODS: Seventy-one patients (Group A, Omeprazole) with definite diagnosis of upper gastrointestinal bleeding of non-variceal origin during January 1993-Dec.1994, compared retrospectively with 119 patients (Group B, Ranitidine) with similar criteria during 1987-1993. Patients in both groups were matched as compared to sex, age and risk factors. Active treatment was omeprazole 40 mg B.D (twice daily) and then orally in group A compared with ranitidine intravenously 50mg TDS (three times daily) and then 150 mg B.D orally in group B. All patients in both groups had endoscopy at the time of presentation or within 24 hours. Endoscopic treatment was applied in some of the patients to arrest acute bleeding. The efficacy of treatment was gauged by the number of blood transfusions needed to maintain Hb., evidence of re-bleeding and need for surgery. RESULTS: The patients were well matched for endoscopic diagnosis except duodenal ulcers, which were more common in group A (P < 0.05). In group A out of 71 patients, 5 had rebleeding and 2 required surgery. In group B, out of 119 patients 12 rebled and 10 required surgery. Statistically there was no difference between groups (p = 0.52 by using Kendall's Tau B). Nine patients in omeprazole group received 2 units blood transfusion, 6 patients > 4 units and 3 patients > 6 units, while in the H2 blocker group, 16 patients received 2 units, 15 patients received > 4 units, and 3 patients > 6 units of blood transfusion. Statistically there was no difference between groups with regard to number of transfusions, rebleed or the need for surgery. CONCLUSIONS: In our study we found no difference between omeprazole and histamine H2 receptors antagonists in controlling and recurrence of upper gastrointestinal bleeding.

Dual infection with hepatitis C and B viruses: clinical and histological study in Saudi patients.

BACKGROUND/AIMS: The purpose of this study was to assess the clinical and histological significance of dual infection with Hepatitis C virus and Hepatitis B virus. METHODOLOGY: The clinical presentation and histologic findings of 20 patients with HCV and HBV were reviewed and compared to 33 patients with only HCV, as controls. None of the patients were treated and none had anti-HDV or HIV 1/HIV2. RESULTS: The patients with dual HCV and HBV infection had more decompensated liver disease. Most of these patients were classified in the Child-Pugh group C as compared to the controls (36.8% vs 0%, p < 0.01). Liver cirrhosis was more common in patients with HCV and HBV infection than it was in the controls infected with HCV only (95% vs 48.5%, p < 0.01). Similarly, hepatocellular carcinoma was more common in patients with dual HCV and HBV infection than it was in the controls (63% vs 15%, p < 0.01). CONCLUSION: Liver disease seems to be more severe in patients with dual HCV and HBV infection than in patients with HCV infection only, both clinically and histologically.

Impact of hepatitis C virus infection on schistosomal liver disease.

BACKGROUND/AIMS: This study was conducted to determine whether Hepatitis C virus infection has a role in patients with schistosomal liver disease. METHODOLOGY: Sixty patients with hepatosplenic schistosomiasis and evidence of portal hypertension were seen at the Armed Forces Hospital Riyadh, Saudi Arabia over 5 years. The impact of Hepatitis C virus infection on chronic schistosomal liver disease was studied in 30 of these patients (group one) who were Hepatitis C virus positive and compared with the other 30 patients (group two) who were Hepatitis C virus negative (control group). RESULTS: Hepatitis C virus may be an important factor contributing to deterioration of liver function for patients with hepatosplenic schistosomiasis. Liver functions showed elevated ALT in 83.3% in group one compared to 23.4% in group two. Liver biopsy in 19 patients (group one) and 16 patients (group two) showed evidence of schistosomiasis and in patients of group one, liver biopsy also showed chronic active hepatitis together with Schistosoma in 57.9%, and cirrhosis in 31.6%. None of group two patients had cirrhosis. Alpha-fetoprotein levels were elevated in 16 patients (group one) and 3 of these patients had hepatocellular carcinoma. None of the control group had radiological or histological evidence of hepatocellular carcinoma. CONCLUSION: The mean age of HCV positive patients was less than the HCV negative patients, which may indicate that Hepatitis C virus infection leads to decompensation of liver function earlier in patients with Schistosoma and severe liver disease may be promoted at a younger age in Schistosoma patients with hepatitis C.

Combined albendazole and praziquantel versus albendazole alone in the treatment of hydatid disease.

BACKGROUND/AIMS: This study was conducted to evaluate the effect of different regimens of medical treatment in hydatid disease at the Armed Forces Hospital, Riyadh. METHODOLOGY: Between April 1985 and August 1990 albendazole was used alone in the treatment of 22 patients with hydatid disease, mainly of the liver. Since September 1990, we have used a combination treatment of albendazole and praziquantel in 19 patients. RESULTS: For those patients treated only with albendazole, 8 patients (36.4%) showed a complete disappearance of the cyst, in 4 of which the treatment period ranged between 6 months to 2 years. The other 4 patients had ruptured liver cyst into biliary tree and had endoscopic treatment with complete recovery over a short period. For those patients treated with albendazole and praziquantel the following results were found. During a follow-up period of 2 months to 3 years and a treatment period of only 2-6 months there was complete disappearance of the hydatid cyst in 9 patients (47.4%) and over 50% reduction of the hydatid cyst in 5 patients (36.84%). CONCLUSION: Combination treatment with albendazole and praziquantel for hydatid disease is more effective than albendazole alone.

Endoscopic management for bleeding esophageal varices: sclerotherapy versus sclerotherapy plus band ligation versus band ligation alone. One year experience at a main hospital in Saudi Arabia.

BACKGROUND/AIMS: This study was done retrospectively to compare the outcome of sclerotherapy alone, band ligation alone and band ligation alternating with sclerotherapy in treatment of esophageal varices. METHODOLOGY: During 1 year 30 patients were admitted with variceal bleeding. They received either injection sclerotherapy (8 patients) or band ligation (11 patients), and 11 patients had a combination of both either during first bleed or during follow-up therapy, which is more than 2 sessions in each group. RESULTS: The success rate for stopping first bleeding was 100% in the band ligation and sclerotherapy alone group. The rebleeding rate was 27% in the combination group, 9% in the band ligation group, and none had rebleeding in the sclerotherapy group during follow-up. Eradication of varices was observed in 33% of patients after a second set of sclerotherapy and band ligation. CONCLUSIONS: Our study showed no significant difference between sclerotherapy versus band ligation in stopping initial bleeding or eradication of varices during the follow-up period, but there was a difference in re-bleeding rates among the three groups.

Transcutaneous ultrasound of gastric pathology.

BACKGROUND/AIMS: Examination of the stomach during transcutaneous upper gastrointestinal ultrasound is often ignored. Two thousand seven hundred and eighty patients were referred for endoscopy over the period of August 1994 until August 1995. Nearly half of those patients underwent transcutaneous ultrasound. We report on the ultrasonographic demonstration of gastric pathology in 18 patients. METHODOLOGY: The stomach was examined in a collapsed state after an overnight fast. No paralytic agents or water distention were used. RESULTS: Seven patients had gastric tumors. Six patients had diffuse gastric wall thickening. Large varices were seen in two patients. A patient with multiple ulcers showed irregular walls. Two patients had retained gastric contents. CONCLUSIONS: Results of the ultrasound matched well with endoscopic findings. We recommend that in all abdominal ultrasounds, the stomach should be examined carefully and evaluated systematically.

Results of sclerotherapy in 100 patients comparison of the outcome between schistosomiasis and hepatitis B.

One hundred patients received sclerotherapy for acutely bleeding esophageal varices. Seventy per cent of these patients had chronic liver disease due to schistosomiasis or hepatitis B. The remaining 30% had chronic liver disease of other etiology, including alcohol in 2%. Our study shows a favorable outcome of sclerotherapy in the schistosomal group during a mean follow-up period of 39 months. Esophageal varices were completely sclerosed in 53.3% of schistosoma patients, in 37.5% of hepatitis B, and in 42.3% of other groups. The rebleeding rate was 11.1% in schistosomiasis, 43.8% in hepatitis B and 33.3% in other groups. The overall mortality rate was 4.4% in the schistosomal group, 50.0% in the hepatitis B, and 40% in other groups. Rebleeding from gastric varices occurred in 17 patients, 13 of whom died, including 11 who were operated on for bleeding gastric varices and died following surgery.

Mesenteric vein thrombosis, non-invasive diagnosis and follow-up (US + MRI), and non-invasive therapy by streptokinase and anticoagulants.

We report on the case of a young lady on oral contraceptives for only 1 month who experienced severe central abdominal pain of a progressive nature. Mesenteric vein thrombosis was diagnosed by ultrasound and confirmed by magnetic resonance imaging. The patient was treated initially with streptokinase followed by heparin and warfarin with subjective improvement, and gradual disappearance of the thrombus was observed on ultrasound and magnetic resonance imaging. In this report we wish to emphasize the feasibility of the early diagnosis of mesenteric vein thrombosis by ultrasound and magnetic resonance imaging, and the effectiveness of early thrombolytic therapy without the need for surgical intervention.

Non surgical management of pancreatic pseudocyst: two case reports and review of the literature.

We report two patients who had non-surgical management of Pancreatic Pseudocyst. The first patient presented with acute pancreatitis and intestinal obstruction, had laparatomy and found to have hemorrhagic pancreatitis and impacted gallstone in terminal item which was removed. Two weeks after laparatomy U/S and CT showed a dilated CBD and two Pancreatic Pseudocysts. ERCP showed dilated CBD. Endoscopic sphincterotomy and stent insertion in CBD and Cystoduodenostomy was done. A percutaneous drainage was done for the pseudocyst involving the body of the pancreas. The second patient presented abdominal pain and clinically had an abdominal mass which was shown by CT as Pseudopancreatic cyst. This was drained percutaneously and given treatment with somatostatin with good outcome.

Delayed complications of pancreatic injury: role of CT in detection and management.

Pancreatic injury is rare. There is however a recent increase of incidence due to high velocity motor vehicle accidents and urban violence. Diagnosis can be missed during initial assessment. Complications are common due to associated organ injuries. We report on the role of CT in the diagnosis and management of four cases with pancreatic injury of different mechanisms and delayed complications. Advantages and pitfalls of CT are discussed.

Modern techniques in the diagnosis and treatment of gastrointestinal and biliary tree parasites.

Parasitic infestations are endemic in tropical and subtropical areas, but rarely occur in temperate zones, and are imported by tourists, immigrants and expatriates. Gastrointestinal and biliary tree parasites are the commonest helminthics in humans. Previously these were diagnosed only by stool examinations, but recently other diagnostic techniques have been used. These include fibreoptic endoscopies for upper or lower gastrointestinal tract and biliary tree. Endoscopy plays an important role in diagnosis, treatment and follow-up as in gastric anisakiasis, chronic giardiasis, strongyloides, hepatosplenic and chronic intestinal schistosomiasis. ERCP is diagnostic in biliary tree obstruction due to parasites or associated stones or cholangiocarcinoma; worm extraction will lead to biliary decompression. Endoscopic instillation of drugs such as mepa-crine in chronic giardiasis, piperazine in biliary ascariasis and hypertonic saline in a ruptured hydatid liver cyst. Imaging techniques, such as barium studies, ultra-sound, CT and MRI, play an essential part in investigations and follow-up in parasitic disease. Therapeutic techniques under ultrasound or CT guidance for amoebic liver abscess or recent percutaneous drainage of hydatid cyst of the liver have been done successfully.

Advances in diagnosis and management of hydatid disease.

Over the last decade substantial improvements have been made in the diagnosis and management of hydatid disease. New diagnostic tests, imaging procedures including ultrasonography, computerized tomography, magnetic resonance and ERCP. Until recently the only definitive treatment for hydatid disease has been surgery, which carries high morbidity, mortality and recurrence. Advances in drug therapy has been influenced by the introduction of Albendazole. In our own study, Albendazole was administered to 22 patients with hydatid disease of the liver, and encouraging results were achieved in most of the patients. Another recent improvement has been the introduction of a non-surgical endoscopic method for the management of biliary and liver echinococcus. In 1985 we published the first report on the use of this procedure. The fourth recent aspect of treatment is the percutaneous aspiration and drainage of hydatid cyst of the liver. These recent developments, used either alone or in combination, are, we believe, good potential alternatives to operative surgery that carry a smaller incidence of complications, morbidity and mortality.

Endoscopic sphincterotomy in acute gallstone pancreatitis and cholangitis: a Saudi hospital experience.

Thirty-five patients with acute gallstone pancreatitis and/or cholangitis underwent endoscopic sphincterotomy. In 15 out of 18 patients with acute gallstone pancreatitis, common bile duct (CBD) stones, 5 of which were impacted, were removed. This resulted in prompt improvement in 12 of these patients. Eleven patients had acute gallstone cholangitis in ten of whom--including one patient who had cholangiocarcinoma associated with Clonorchis sinensis--CBD stones were extracted. Six other patients had both acute pancreatitis and cholangitis, one of whom had a choledochal cyst and had surgery; another patient with a post-surgical CBD fistula and retained stone, improved following stone extraction and nasobiliary tube insertion. The duration of hospitalization ranged between 5 and 19 days in the 26 patients treated endoscopically, and between 25 and 90 days in the 9 surgically treated patients.

Frequency of gastroesophageal reflux in patients with liver cirrhosis.

Twenty-five adult patients with liver cirrhosis, and another 30 patients with no liver disease but referred with symptoms suggestive of gastroesophageal reflux disease were selected at random. Twenty-four hour ambulatory intra-esophageal pH measurement and upper gastrointestinal endoscopy were carried out on all patients recruited. Applying the former test, 16 (64%) of the patients with liver cirrhosis have gastroesophageal reflux disease. This figure is comparable with the 70% (21/30) rate recorded in the group of dyspeptic patients clinically thought to have the disorder. A positive endoscopic diagnosis was much lower at 12% and 23%, respectively. No significant differences were observed among liver disease patients when they were subdivided in accordance with the etiology of liver cirrhosis and the grade of esophageal varices. We conclude that gastroesophageal reflux disease occurs at a high frequency (64%) in patients with liver cirrhosis and portal hypertension, irrespective of the etiology of cirrhosis and the grade of esophageal varices. It is therefore considered to be the main cause of esophagitis in these patients, and that it might play a role in initiating a variceal bleeding episode. The latter hypothesis needs further evaluation.

The first liver transplant in Saudi Arabia and the Arab world.

The first liver transplant in Saudi Arabia and in the Arab world was performed on the 30th of July, 1990, in the Armed Forces Hospital in Riyadh, on a 23-year-old male with end-stage liver disease due to sclerosing cholangitis. There were no major post-operative or post-transplantation complications. Now, sixteen months post-transplantation, the patient is doing well on immunosuppressive therapy with an almost normal liver function, and is already back at work and carrying out normal activities. This report shows that liver transplantation can be performed successfully in this part of the world.

Organ involvement in hepato-intestinal schistosomiasis.

The endoscopic, radiological and histological findings in several of our patients with Schistosoma mansoni infection are described. Seventy-two patients with hepatosplenic schistosomiasis. Endoscopic sclerotherapy was effective in 45 patients with bleeding varices. Ultrasound of the liver was suggestive of periportal fibrosis in 48 of these 72 patients, in 30 of whom liver biopsy demonstrated a Schistosoma granuloma or periportal fibrosis. Gastroscopy revealed congestion, erosions or ulcerations in the stomach in 40 of these patients and in the duodenum in 23 patients. Schistosoma ova and inflammatory changes were seen in endoscopic biopsies from the stomach in three out of twelve and five out of eight duodenal biopsies. The colonoscopic findings were suggestive of schistosomiasis in 98 out of 216 patients with colonic schistosomiasis. Eight patients had schistosomal polyps and one had colonic calcifications. Schistosoma ova were seen in surgical specimens from patients presenting with an acute abdomen due to appendicitis in six, cholecystitis in three and mesenteric vein thrombosis in three. In one of the latter the mesenteric angiogram showed an internal mesenteric vein blocked by ova.