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 treatment of ascariasis causing acute obstructive cholangitis.

Ascariasis lumbricoides is one of the most common helminthic infections in developing countries. Biliary ascariasis presents with recurrent cholangitis and sometimes with liver abscesses. We report the case of a young Philippino worker in Saudi Arabia who presented with obstructive jaundice, cholangitis and liver abscesses secondary to biliary tract ascariasis. The diagnosis was made at endoscopic retrograde cholangio-pancreatography (ERCP) and the obstructing worms were removed with a Dormia basket after endoscopic sphincterotomy at this procedure. Full resolution of the biliary and hepatic sepsis followed. Urgent ERCP and endoscopic decompression of the biliary system in biliary ascariasis is recommended.

Primary sclerosing cholangitis in chronic ulcerative colitis: report of cases in Arabs and review.

Primary sclerosing cholangitis (PSC), a chronic cholestatic liver disease, is increasingly recognized in association with chronic ulcerative colitis (CUC). Two cases of PSC were diagnosed among 78 Arab patients (2.7%) with CUC followed up at Riyadh Central Hospital. Detailed case reports of the patients and review of PSC are presented, in order to draw attention to a hitherto under-diagnosed condition. This is the first report of PSC among Arabs.

Upper gastrointestinal bleeding among Saudis: Etiology and prevalence the Riyadh Central Hospital experience.

Fiberoptic esophagastroduodenoscopic examination of 747 Saudi patients who presented with acute upper gastrointestinal (UGI) bleeding between January 184G to December 1986G showed that ruptured esophageal varices, erosive gastritis, duodenitis and peptic ulcer disease were the most common findings. There were 515 males and 232 females (M:F 2.2:1). Multiple lesions were detected in 83% of patients, emphasizing the need to anticipate more than one lesion at endoscopy in a patient with UGI bleeding. Sixty-seven patients (8.9%) gave a history of drug ingestion prior to the episode of bleeding; gastric and duodenal erosions were the most common lesions in these patients. No source of bleeding was apparent in 26 (3.5%) patients at the time of endoscopy. Endoscopy rather than barium studies has become established as the standard investigation in our patients with upper gastrointestinal bleeding.

Pattern of primary gastrointestinal tract malignancy among Saudi nationals: A retrospective study.

This histopathological reports from the central laboratory of Riyadh Central Hospital for between 1404 to 1406H (1984 to 1986) were reviewed retrospectively to determine the pattern of primary cancer of the gastrointestinal tract among Saudi nationals. During the study period, a total of 32,990 histopathological examinations were conducted. Neoplasms were identified in 4683 cases (14.2%); 1772 (37.8%) were malignant and 2911 (62.2%) were benign. The stomach (31%), liver (20%), and esophagus (19%) were the most commonly involved organs. The proportional frequencies of gastrointestinal malignancies differ from those seen in Western countries, although the age and sex distribution are similar. The possible etiological factors are discussed and the need for a cancer registry emphasized.

Prevalence of antibodies to hepatitis C virus in Saudi and expatriate women in Riyadh, Saudi Arabia.

Six of 511 (1.17%) parturient Saudi females were positive for antibodies to hepatitis C virus (HCV), while one of 171 (0.58%) expatriate female nurses tested positive for the antibody. The prevalence of 1.17% in Saudis compares with 1.2% among pregnant women in Spain, while none of the 40 pregnant women screened in England tested positive for anti-HCV. Antibodies to hepatitis B core antigen in the same sample from Saudi women were positive in 24.6%. Judging by the low prevalence of its antibody, HCV is not as highly endemic as hepatitis B virus (HBV) in this population.

Prevalence of antibodies to hepatitis C virus in Saudi patients with chronic liver disease.

The prevalence of antibodies to hepatitis C virus (anti-HCV) has been measured in 113 Saudi patients with chronic liver diseases. Twenty-five percent of 20 patients with hepatocellular carcinoma (HCC) were positive for anti-HCV and 29.7% of 38 patients with cirrhosis and 27.3% of 33 patients with liver fibrosis, respectively, also tested positive. The positivity rate for a miscellany of liver diseases (22) was 13.6%. The differences between these prevalence rates were not statistically significant. By comparison, 45% of HCC tested positive for hepatitis B surface antigen (HBsAg) while 52.7% of cirrhosis cases were positive. There rates were statistically significant when compared with HBsAg positivity rates of 9.1% and 18.2% in the liver fibrosis and miscellaneous groups. The role of hepatitis C virus (HCV) may be secondary or additive in the causation of chronic liver disease and hepatocellular carcinoma in this environment in which hepatitis B virus (HBV) is highly endemic.

Prevalence of antibodies to hepatitis C virus in hemodialysis patients in Riyadh.

Prevalence of antibodies to hepatitis C virus (anti-HCV) was determined in 190 adults (mean age 40.4 years; range 15 to 75) with end-stage renal disease (ESRD) who are on regular hemodialysis in the Nephrology Unit, Riyadh Central Hospital. The overall prevalence rate was 53.7% (48.7% and 61.0% in Saudi's and expatriates, respectively). These figures are considerably higher than figures of 34.8% reported from hemodialysis units in Riyadh, 20% in Spain, 5.5% in Germany, and 1% in the United Kingdom. The possible reasons for the high prevalence of this marker of HCV in our hemodialysis unit are considered and suggestions made for its control.

Prevalence of antibodies to hepatitis C virus in blood donors in Riyadh.

Prevalence of antibodies to hepatitis C virus (anti-HCV) was determined in 580 voluntary blood donors in Riyadh. Among 403 Saudis screened, the prevalence was 1.24%, while among 177 expatriates screened the prevalence was 4.52%. The difference was statistically significant (P<0.02; x(2)test). The overall prevalence of 2.24% is lower than that reported in Spain (7.3%) but higher than reports from the United Kingdom (0.5 to 1%0, Italy (0.87%), or Germany (0.24 to 0.79%0. In view of reports that blood positive for anti-HCV can transmit non-A, non-B hepatitis, it is advisable to routinely screen donor blood for anti-HCV.

The role of ERCP in the management of gallstone-associated acute pancreatitis: A prospective study of 64 patients at Riyadh Central Hospital.

In a prospective study, consecutive patients admitted to one of the surgical units at Riyadh Central Hospital with a diagnosis of acute biliary pancreatitis (ABP) underwent, after stabilization, urgent ERCP within 72 hours of admission. A total of 64 patients (35 males, 29 females) were treated over a four-year period (1986-1990). Forty-eight patients were found to have common bile duct stones when endoscopic sphincterotomy (ES) and stone extraction was performed, including four patients with concomitant cholangitis. This was followed by a significant decrease in mean values of the biochemical parameters; serum amylase, SGOT, total bilirubin (P < 0.001) and alkaline phosphatase (P < 0.02), with a corresponding clinical improvement. Urgent ERCP+ES was not associated with any serious complications. There was no hospital mortality in this series. Details of the endoscopic findings and treatment are summarized. Based on the present study and others cited, the role of ERCP in the diagnosis and management of ABP are discussed and recommendations suggested.

Hepatocellular carcinoma: A clinicopathological analysis of 118 cases from Riyadh Central Hospital.

A review of 118 cases of histologically diagnosed hepatocellular carcinoma in Riyadh Central Hospital over a 15-year period from 1985 to 1989, showed that there were 73 Saudi nationals and 45 other nationalities. The overall sex ratio was 2.5;1, M:F (1.92:1 in Saudis; and 4:1 in other nationalities). The mean age for male Saudis was 61.2 years (range, 34-85) and for females 60.9 years (range, 18-80). Peak incidence occurred at 50 years for males and 60 years for females. Hemoperitoneum from ruptured tumor (7 cases) and 1 case of recurrent hypoglycemia were noted in the series. Tumor grading was Grade I, 10 (11.5%); Grade II, 49 (56.3%); Grade III, 28 (32.2%). Cirrhosis was associated with tumor in 58.0% of cases. Hepatitis B surface antigen was positive in 47.5% of Saudis and 47% in the whole group. Schistosomal serology was available in 21 cases and positive in 85.7%. The importance of hepatitis B virus in etiopathogenesis of hepatocellular carcinoma is reflected in this study.

Periampullary cysts: endoscopic management.

Periampullary cysts are a rare but remediable cause of recurrent pancreatitis. Hitherto, the management of such cysts was mainly surgical. We report on two cases of periampullary cysts. The first patient, who had a cyst of the minor papilla (Santorini cyst), presented with upper gastrointestinal hemorrhage and a history of recurrent pancreatitis. The second patient presented with cholangitis. Both were successfully and safely treated by endoscopic methods alone. Details of the cases and the endoscopic techniques used are fully described.

Duodenal varices. Report of 13 cases.

Only a few cases of Duodenal Varices (DV) have been reported in the world literature mostly by radiological studies, at operations, or autopsies. Alberti described DV for the first time in 1931. The visualisation of DV by fiberoptic endoscope was first made in 1973 by Kunisaki et al. (one case) and later by Kunert and Ottenjann in 1976 (one case). In this study we present 13 cases of DV diagnosed in the period from June 1979 to May 1983 out of 5664 endoscopic examinations performed in the Endoscopy Unit of Riyadh Central Hospital and giving a prevalence of 1:435. 598 cases of Oesophageal Varices (OV) were found in these series, so that the relation DV:OV is 1:46 in this study. The etiology of DV is mostly liver fibrosis due to schistosomiasis (9 cases). In the rest of the cases we found av-malformation (one case), cancer of the head of pancreas (one case) and Hodgkin's disease with enlarged lymph-nodes and ascites in association with chronic duodenal ulcer (one case). In one case the etiology remained unknown. 4 patients had no oesophageal involvement (isolated DV). The cases will be discussed in detail.

Leukaemia cases in Central Hospital, Riyadh (Saudi Arabia)

A total of 293 cases of various types of leukaemia admitted in Central Hospital (Riyadh) were studied from January 1981 to December 1988. The incidence of leukaemia was worked out to be 0.13% of the total hospital population during this period. Acute non-lymphocytic leukaemia (ANLL) or acute myeloid leukaemia (AML) group was the most frequent (37.54%), followed by acute lymphocytic leukaemia (24.23%) followed by chronic myeloid leukaemia [corrected] (19.11%), chronic lymphocytic leukaemia (CLL) group (18.77%) and lymphosarcoma cell leukaemia (LSCL) (0.35%). Acute leukaemias were further classified into subtypes on the basis of FAB (French-American-British) classification. In ANLL or AML group, the pattern was M2 greater than M4 greater than M3 greater than M6 greater than M1 greater than M5. In ALL group, the pattern was L2 greater than L1 greater than L3. Among FAB subtypes of acute leukaemias, the pattern was L2 greater than M2 greater than M4 greater than M3 greater than M6 greater than M1 and L1 greater than L3 greater than M5. The age range of these patients was 5 years to 80 years; only 9 cases were less than 11 years of age. In childhood and young adults, acute leukaemias (ALL and AML) were the commonest types (particularly ALL was common in childhood), whereas CML was common in adults and CLL in old age. Males dominated the females in all the types of leukaemia (male to female ratio was 2.4:1). Out of 293 leukaemia cases, 149 (51.0%) were Saudi Arabs, the rest were expatriates. AML was found to be the most common type in central, western and southern Saudi Arabia.(ABSTRACT TRUNCATED AT 250 WORDS)

Transabdominal gastro-oesophageal devascularization and oesophageal transection for bleeding oesophageal varices.

Fifty consecutive unselected patients presenting with acute haematemesis and melaena from endoscopically confirmed bleeding oesophageal varices were treated by one-stage transabdominal oesophageal transection with gastro-oesophageal devascularization and splenectomy. According to Child's classification, 15 were Grade A, 29 Grade B and six Grade C. The mortality rate was 10 per cent. Postoperative complications included gastric fundal leak (4 per cent), pleural effusion (4 per cent), subphrenic abscess (2 per cent), atelectasis (2 per cent) and pneumothorax (2 per cent). Although five patients (10 per cent) complained of transient dysphagia during follow-up, only one (2 per cent) presented evidence of stricture at the site of oesophageal transection. Clinical encephalopathy was not present in the surviving patients in the postoperative period. No recurrence of bleeding has been recorded in the surviving patients over a follow-up period of 2-3 years.

Esophageal candidiasis among a dyspeptic population.

This is a retrospective study of 59 patients endoscoped over a period of six years at a private clinic and were found to have esophageal candidiasis. The median age was 46.38 years. Thirty (51 %) patients had no precipitating factors. Only 18 (30%) patients had typical symptoms. The distal part of the esophagus was more often involved. The thrush was scattered in 57 (97%) patients. The endoscopic finding was confirmed by cytology in all patients included. Symptoms improved on oral nystatin treatment and simultaneous treatment of associated conditions in all 46 patients followed up. In conclusion, esophageal candidiasis appear to be not uncommon among dyspeptic population. It presents more frequently with atypical symptoms and responds well to oral nystatin treatment.

Doxycline-induced esophageal ulcerations.

Over a period of six years 16 patients presented to Dr. Al Mofarreh's polyclinic with drug--induced esophageal ulcerations. One patient had esophagitis without ulcerations and two patients, who declined endoscopy were not included in this analyzis. The mean age of the remaining 13 patients was 28.92 +/- 10.39 years. The mean ulcers number was 3.69 +/- 2.76. The ulcers were located at the mid-esophagus, 29.23 +/- 3.94 cm from the incisors teeth. Odynophagea, retrosternal pain and dysphagea in 13 (100%), 12 (92%) and 9 (69%) patients, respectively, were the most frequent presenting symptoms. All patients took a doxycycline preparation at bed time with little water. The mean elapse between the drug intake and endoscopy was 7.85 +/- 9.96 days. The symptoms resolved within a maximum of one week of antireflux treatment despite the continuation of doxycycline therapy in three patients with brucellosis. The current data confirmed the role of oral doxycycline intake, the timing and the amount of concurrent fluid in the etiology of esophageal ulcerations.

Prevalence of antibody to hepatitis C virus among Saudi Arabian children: a community-based study.

In a population-based survey, 39 (0.90%) of 4,496 Saudi Arabian children (ages 1 to 10) were positive for antibody to hepatitis C virus. No significant difference was seen between the prevalence rate in males (0.9%) and females (0.8%) or between urban (0.7%) and rural dwellers (1.0%). A significant variation of rates (0% to 5.7%) was seen from one region to another. The Gizan population, noted for hyperendemic hepatitis B virus infection, had the highest prevalence of antibody to hepatitis C virus despite its cultural and socioeconomic similarities to other regions. In some regions of Saudi Arabia the prevalence of antibody to hepatitis C virus among children was 0% despite endemic rates for both hepatitis B virus and hepatitis A virus infections. An inverse relationship between age and antibody to hepatitis C virus positivity was noted, suggesting an early acquisition of infection in the population studied. Although the overall prevalence of antibody to hepatitis C virus in Saudi children appears low, endemic foci exist where transmission of infection appears to occur early in childhood. The significance of this characteristic for the incidence of chronic sequelae of hepatitis C virus infection needs further evaluation.

Formol-ether concentration method in the diagnosis of active schistosoma mansoni in patients with detectable IHA.

Schistosomiasis is a world wide human infection. In Saudi Arabia there are multiple endemic foci. Various methods have been used to diagnose Schistosoma mansoni. We studied 1410 patients coming from S. mansoni endemic areas with detectable antibodies by indirect hemagglutination (IHA). Stool specimens were tested for S. mansoni ova by direct smear and formol-ether concentration (FEC) methods. The objective of the study was to identify patients with active schistosomiasis using FEC method and a single direct smear. Twenty percent of IHA positive patients had active infection detected by FEC, while a single direct stool smear diagnosed only 2.4% (P< 0.0001). The percentage of positive FEC was significantly increasing in linear trend with IHA level. This trend wasn't observed with direct smear examination. The current data suggest that FEC is helpful to diagnose active schistosomiasis, therefore it is recommended in IRA positive individuals.