The place of Sugiura operation for portal hypertension and bleeding esophageal varices.

Fifty patients with portal hypertension and bleeding varices aged 10 months to 72 years were treated with a modified Sugiura, nonshunt operation (n = 26) or shunting procedures (n = 24) in accordance with the following predetermined therapeutic protocol: after resuscitation and diagnostic endoscopy, an emergency mesocaval shunt procedure was carried out if bleeding could not be stopped (group 1, n = 10). When bleeding could be stopped, the patients underwent full investigation and were then treated with either the distal splenorenal (DSR) shunt if the criteria of Warren were satisfied (group 2, n = 14) or with a modified Sugiura procedure in all other circumstances (group 3, n = 26). Patients were evaluated at 1.5 to 6 years. The rates for operative deaths, recurrent hemorrhage, encephalopathy, late deaths, and actuarial patient survival at 6 years were as follows: 20%, 30%, 30%, 20%, and 60% for group 1; 14.3%, 14.3%, 14.3%, 7.2%, and 79% for group 2; and 7.7%, 3.4%, 0%, 0%, and 93% for group 3, respectively. Within 3 months after the Sugiura operation, varices disappeared in 95% of patients and hypersplenism was relieved in all. Major complications were gastric and esophageal leaks in two patients (fatal in one) and temporary dysphagia in six. We conclude that the modified Sugiura nonshunt operation is probably the preferable treatment for variceal hemorrhage in the nonalcoholic patient because it is effective in arresting hemorrhage, has low operative mortality, low recurrence rate, no encephalopathy, and excellent survival rates.

Hepatitis B virus (HBV) markers among patients with chronic liver disease in Kuwait.

The prevalence of hepatitis B surface antigen (HBsAg), antibody to the hepatitis B core (anti-HBc) and to surface antigen (anti-HBs), was investigated, using sensitive radioimmunoassay (RIA) systems, among patients with different clinical entities of chronic liver disease in Kuwait, and compared to a control blood donor population. 81% of patients and 44% of the controls had at lease one HBV marker. 24% of patients, but non of the controls had both HBsAg and a high titre of anti-HBc in the absence of anti-HBs, suggesting a chronic infection. 31% of our patients with hepatosplenic schistosomiasis, 20% with cryptogenic cirrhosis and chronic active liver disease and 60% with hepatocellular carcinoma had these two markers. HBV antigenaemia was significantly more prevalent among male than among female patients and was particularly high among those less than 35 years old. The high prevalence of the various HBV markers among our patients suggests that HBV is a major factor in the development of chronic liver disease in our area. Furthermore, in view of a high prevalence of antigenaemia in patients with hepato-splenic schistosomiasis, HBV infection must play a concomitant role in the development of more serious form of chronic liver disease among such patients.

Viral hepatitis and pregnancy in Kuwait.

The frequency and severity of viral hepatitis among pregnant and non-pregnant women in Kuwait was studied from 1980 to 1984. 542 female hepatitis patients were investigated, of whom 52 (9.6%) were pregnant. 35 of the 52 (67.3%) cases of viral hepatitis in pregnancy were due to hepatitis B virus while 11 of 52 (21.2%) and 6 of 52 (11.5%) had acute hepatitis non-A, non-B (NANB) and hepatitis A virus infections, respectively. The frequency and severity of viral hepatitis among the pregnant women was similar to that among non-pregnant women. Hepatitis did not have a deleterious effect on pregnancy and no death was recorded. Fulminant acute NANB hepatitis was seen in only one patient, who recovered completely.

Lack of transmission of hepatitis C virus following needlestick accidents.

Healthcare workers (HCWs) have an occupational risk of infection with hepatitis C virus (HCV). However, data regarding the magnitude of this risk are limited. We conducted a prospective study on a cohort of 24 HCWs who were exposed to HCV by needlestick injuries involving 25 patients. All source patients were viremic with a mean HCV-RNA level of 1.65 megagenomic equivalents per milliliter. At least 64% of patients were infected with HCV serotype 4 (Simmond's classification). After a follow up period of at least 6 months, none of the exposed HCWs acquired HCV. Thus, HCV does not seem to be easily transmitted by needlestick injuries. However, further large-scale studies are needed for a more accurate estimation of the risk of transmission.

Interferon-alpha plus ribavirin combination therapy for the treatment of chronic hepatitis C in interferon non-responders.

BACKGROUND/AIMS: Only a small fraction of patients with chronic hepatitis C have a sustained biochemical or virologic response to a standard course of alpha-interferon therapy. Thus, alternative treatments are needed particularly for non-responders. The main objective of this study was to evaluate the efficacy of alpha-interferon in combination with ribavirin in patients who had not responded to a previous course of alpha-interferon. METHODOLOGY: In this prospective open trial, 26 patients who had not responded to a previous course of interferon monotherapy, were treated for 6 months with a combination of alpha-interferon 2b, 5 MU thrice weekly, plus ribavirin 1000 or 1200 mg daily. They were followed-up for at least 6 months after therapy. RESULTS: At the end of treatment, 3 patients (12%) had normal aminotransferase levels and two (8%) tested negative for HCV-RNA in serum. After 6 months of follow-up, all patients had HCV viremia and only one (3.8%) was still in biochemical remission. One patient dropped out because of side effects and another was lost during follow-up. CONCLUSIONS: alpha-interferon-ribavirin combination is ineffective in treating patients who had had no response to interferon monotherapy.

The impact of brushing teeth on carbon-14 urea breath test results.

OBJECTIVE: The 14C urea breath test noninvasively detects the presence of the urease-producing bacteria Helicobacter pylori in the stomach. Several sources of errors have been identified to cause false or indeterminate results on the test. The objective of this study was to identify whether brushing teeth affects the test results. METHODS: We performed the 14C urea breath test on 168 patients, with breath samples counted at 10 and 20 min after oral administration of 2 microCi (74 kBq) 14C urea. Ninety-four patients brushed their teeth before the test while 74 did not. RESULTS: Thirty-six of the 74 patients (49%) who did not brush their teeth had positive results at 10 min, which became negative at 20 min. None of the 94 patients who brushed their teeth before testing showed this pattern with agreement of results at 10 and 20 min. CONCLUSION: We recommend brushing teeth before the 14C urea breath test since it significantly decreased the ambiguous results of the test in our laboratory.

Alfa-interferon therapy for chronic hepatitis B virus infection in Kuwaiti patients.

Alfa-interferon is the standard treatment of chronic hepatitis B. However, the response rate varies widely in patients from different parts of the world, reflecting differences in the natural history of the disease and the immune reactivity of the population studied. The aim of this study is to assess the efficacy of alfa-interferon in the treatment of Kuwaiti patients with chronic replicative hepatitis B infection. Twenty-two adult Kuwaiti patients with biopsy-proven chronic hepatitis B were treated with alfa-interferon after an observation period of six months. All patients had abnormal transaminase levels and were HBeAg and HBV-DNA positive. Alfa-interferon-2b, 5 million units, was administered five days a week for 16 weeks. Patients were followed for at least 12 months after completing therapy. One of the 22 patients dropped out of the study after a single dose of interferon, because of side effects. Of the remaining 21 patients, three (14%) had a sustained loss of HBV-DNA and HBeAg. None of the patients lost HBsAg. There were no episodes of hepatic decompensation or deaths during the study. One patient developed hepatocellular carcinoma 28 months after completing treatment with interferon. Overall, Kuwaiti patients with chronic replicative hepatitis B responded poorly to interferon therapy.

Takayasu's arteritis and ulcerative colitis.

This report describes a case of Takayasu's disease and ulcerative colitis occurring simultaneously in a 35-yr-old Sri Lankan woman. It is suggested that these two diseases may be immunologically related and the possible pathogenic mechanisms by which these two disorders may be associated are discussed.

Helicobacter pylori-associated gastritis in Kuwait: endoscopy-based study in symptomatic and asymptomatic children.

Information is limited concerning the prevalence of Helicobacter pylori infection in asymptomatic children. Since January 1989, we have endoscoped 60 children for recurrent abdominal pain or for obtaining small-intestinal biopsy (their ages were a mean of 6.6 (range 9 months-13 years); there were 37 boys and 23 girls. Antral biopsies were obtained from all subjects and these were studied for the presence of gastritis and stained for H. pylori using modified Gram's stain. All biopsies were cultured for H. pylori. Children endoscoped for small-intestinal biopsy (n = 18) were used for comparison. Of the 42 children who had abdominal pain, 24 showed histological gastritis and 13 had H. pylori on microscopy (31% H. pylori-associated gastritis). In the compared group, five showed histological gastritis, and all had H. pylori on microscopy (27.7%). Culture was positive in 15; sensitivity was 85.7%. Six children, three pairs of siblings, had H. pylori gastritis supporting environmental etiology. Two had coinfection with intestinal giardiasis. Seven children were treated with daily oral amoxycillin (50 mg/kg) and tinidazole (20 mg/kg) for 6 weeks. In 3 (42.3%) H. pylori colonization cleared with healing of gastritis and resolution of symptoms. These results indicate that H. pylori gastritis is equally prevalent in symptomatic and asymptomatic children (31 and 27.7%, respectively; p > 0.05) in our population. It seems that the combination of oral amoxycillin and tinidazole is a poor choice in the treatment of H. pylori-associated gastritis in Kuwaiti children.

A multiplex polymerase chain reaction assay for the detection of Mycobacterium paratuberculosis DNA in Crohn's disease tissue.

BACKGROUND: Mycobacterium paratuberculosis is implicated as a possible cause of Crohn's disease. However, due to lack of an appropriate diagnostic method, this has been a subject of significant controversy. Our aim was therefore to develop a multiplex polymerase chain reaction (MPCR) for the detection of M. paratuberculosis DNA in Crohn's disease tissue. METHODS: Biopsy samples were collected by endoscopic forceps from terminal ileum, and genomic DNA was isolated. M. paratuberculosis-specific marker genes were amplified by using the present MPCR method. RESULTS: Here we report a new MPCR for detection of M. paratuberculosis DNA in Crohn's disease tissue. In this technique two genetic markers, IS900 and a newly described specific marker of MP2, were amplified in a single tube simultaneously. The method was evaluated using biopsy specimens from 10 Crohn's disease patients, 6 ulcerative colitis patients, and 21 irritable bowel syndrome patients. The patients were characterized by using standard clinical and histologic observations. The present MPCR method could not detect M. paratuberculosis DNA in the biopsy specimens. However, the marker genes were amplified from the samples that were spiked with M. paratuberculosis before DNA extraction. The marker genes were also not detected in 10 closely related mycobacterial strains and human genomic DNA. CONCLUSIONS: The present MPCR method is highly specific and can detect M. paratuberculosis DNA more reliably. These findings do not support an aetiologic role of M. paratuberculosis in Crohn's disease.

Hepatitis B virus perinatal transmission among Arab women.

One thousand five hundred and fifty-four Arab women were screened at delivery for the presence of hepatitis B virus (HBV) antigenaemia in their sera. Forty-five or 2.9% were found to be positive. Only three of 41 (7.3%) of these hepatitis B surface antigen-positive (HbsAg) mothers were found to be positive for the presence of hepatitis B e antigen (HBeAg), 27 (65.8%) had anti-HBe and the remaining 11 (26.8%) had neither HBeAg nor its corresponding antibody. These results, therefore, predicted a low rate of transmission of virus from mother to newborn. Follow-up for 4-13 months after delivery on 14 of these HBsAG-positive mothers and their infants indicated that in only one infant born to an HBeAg-positive mother did HBV antigenaemia develop. Another infant died from undetermined causes. Therefore, HBV perinatal transmission among Arabs, unlike that among populations in Southeast Asia, does not appear to contribute in an important way to the pool of carriers in this population.

Hepatitis A and B virus infections in children in Kuwait.

In a 1-year prospective study of 1788 cases of acute viral hepatitis, 26 (1.5%) presented with evidence of simultaneous hepatitis A (HAV) and hepatitis B (HBV) virus infection. Twenty-three of 26 (88.5%) of these cases had serological evidence of a recent HAV infection in a chronic HBV carrier. The remaining 3 (11.5%) showed serological evidence of a recent concomitant HAV/HBV infection. Twenty-four of the 26 (92.3%) patients with simultaneous infection were children with a mean age of 4.6 years. Clinical and laboratory data indicated that the disease in patients with a recent concomitant HAV/HBV infection was not different from that in patients who had HAV infection superimposed on a chronic HBV carrier or that in age and sex matched patients presenting with an acute viral hepatitis A infection alone. Furthermore, the outcome of the disease was not affected by the HBeAg/anti-HBe status of the hepatitis B positive patient. All patients recovered completely and on follow-up none showed any signs of chronic liver disease. Simultaneous HAV/HBV infection, therefore, does not result in a more severe disease.

Primary gastrointestinal lymphoma complicated by common bile duct obstruction: report of two cases.

This report describes two cases, a case of primary small intestinal lymphoma and a case of gastroduodenal lymphoma both producing obstructive jaundice due to invasion of the common bile duct. Oesophagogastroduodenoscopy revealed the lesions and the endoscopic biopsies confirmed the diagnosis of lymphoma in both the cases. Ultrasound examination of the biliary system, followed by percutaneous transhepatic cholangiography, delineated the dilated biliary tree with distal obstruction of the common bile ducts. While radiotherapy alone was sufficient in the case of primary small intestinal lymphoma; drainage procedures were required in the case of gastroduodenal lymphoma to relieve the obstruction of the common bile duct.

The role of gastrointestinal endoscopy in a developing country.

Eight-thousand-six-hundred-and-eighty patients were examined endoscopically over a period of six years. Significant pathological lesions were detected in 79.6% of the cases. While duodenal ulcers were seen at the same frequency as in the West, the number of gastric ulcers were considerably fewer, the ratio of gastric to duodenal ulcer being 1:8.4. Gastric cancer was also observed less commonly than in the West, but gastric lymphoma constituted 21% of all gastric malignancies. By endoscoping all bleeders within 24 hours we were able to identify the source of bleeding in 90.9% of the cases, and a lesion was detected in 96.8%. Direct visualisation of the duodenal and jejunal mucosa supported by histological examination was of paramount importance in the early detection of Immunoproliferative Small Intestinal Disease (IPSID) and its differentiation from other diseases such as tuberculosis, bilharzial jejunitis and Crohn's disease which are seen in our population.

Findings of colonoscopy in children: experience from Kuwait.

This report summarizes our retrospective analysis of 173 colonoscopic examinations performed on 159 children over a period of 9 years in Kuwait. Ninety-six children were males, with a male to female ratio of 1.5:1. The main indications for colonoscopy were rectal bleeding, polyps, and suspected inflammatory bowel disease. Examination was done under sedation or anaesthesia. One hundred and fifty-one (87 per cent) examinations were complete up to the caecum and 89 (51 per cent) up to the terminal ileum. The most common pathology was polyps in 42 children. All but one polyp were hamartomatous and mainly localized to the rectum and sigmoid colon. The majority had a single polyp. One child had adenomatous polyposis coli. One hundred and forty-two polyps were removed endoscopically with no complications. Inflammatory bowel disease was present in 34 (21 per cent) children (17 Crohn's disease, 11 ulcerative colitis, and 6 indeterminate colitis). Tuberculosis of the ileo-caecal region was diagnosed in two cases. Seven patients had rectal ulcers presenting as rectal bleeding. In 11 (7 per cent), the lesions were limited to the right side of the colon or terminal ileum. These results suggest that colonic pathology is not uncommon in children in Kuwait. The disease pattern is similar to that reported in western countries. As we have observed in adults, inflammatory bowel disease is seen in significant numbers among children in this region. In this survey we have observed a change in the disease frequency, Crohn's disease being more common that ulcerative colitis. Without adequate examination, the existence of inflammatory bowel disease and this possible changing pattern of disease would have gone unrecognized.

Frequency of delta agent infections in Kuwait.

Antibodies to delta antigen have been found among all populations in the world studied so far. The prevalence is high (40%-47%) in chronic HBsAg carriers in southern Italy. In other parts of the world, the prevalence is low (less than 5%); however, 30%-75% of polytransfused hemophiliacs and drug addicts in Europe and the United States have antibodies to delta antigen [2]. Most Arab nationalities are well represented in the population of Kuwait. Among 144 HBsAg-positive sera studied, 58 (40%) were positive for antibodies to delta antigen. Data regarding diagnosis, age, sex, and nationality were available for 80 of the patients investigated. Among these, 32 (40%) were antibody-positive. The highest number of positive patients was among those with chronic liver disease; all except two of the positive patients were Gulf or Mediterranean Arabs. Thus, infection with delta agent is an important cofactor in the pathogenesis of chronic liver disease in this region, because delta agent is known to become chronic [2]. The patients who had chronic liver disease and those who had illnesses other than liver disease or acute hepatitis are probably all chronic HBsAg carriers; however, it was not possible to differentiate between chronic and transient carrier states. Some of the patients with acute hepatitis also probably carried HBsAg with a superimposed delta infection. The carriage rate of HBsAg in the normal population in Kuwait is 2.8%-4% [3]. The only fatal case of acute hepatitis in this study occurred among the patients who were positive for delta antibody.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute non-A, non-B hepatitis in Kuwait.

In a prospective study of acute hepatitis in Kuwait covering the period February 1983 to January 1984, a total of 1781 cases were diagnosed as having an acute viral hepatitis. 1,384 (77.7%) were found to be due to hepatitis A virus (HAV), 206 (11.5%) hepatitis B virus (HBV), 8 (0.4%) coinfection with HBV and delta virus (HDV), 8 (0.4%) superinfection of HDV on chronic HBsAg carriers and 157 (9%) non-A, non-B virus (NANB). 13 cases of CMV and 5 of EBV infections were also diagnosed. NANB viral hepatitis was a disease of young adults (mean age 29 years) with a male-female ratio of 3:1. A high incidence was noted among males from the Indian subcontinent (29.1/100,000 of population, compared to 5.4/100,000 among local Arabs), the majority of whom gave a history of recent visit to the Indian subcontinent. The clinical features and biochemical findings of acute NANB infection were found to be less severe than those of acute HBV infection and similar to acute HAV infection. Three patients (2.3%) with acute NANB virus infection developed chronic hepatitis (all women), and another 3 patients died because of fulminant hepatitis.

The value of colonoscopy in schistosomal, tuberculous, and amebic colitis. Two-year experience.

Forty-six patients were diagnosed as having schistosomal, tuberculous, or amebic colitis over a two-year period using colonoscopy and biopsy. Both schistosomal and tuberculous colitis could be diagnosed by characteristic endoscopic and histologic features in the majority of cases. Colonoscopy provided the added advantage of endoscopic polypectomy at the diagnostic session itself. The yield of granulomas in tuberculous lesions was 100 percent, although acid-fast bacilli could not be recovered from any. The endoscopic picture of amebic colitis often resembles that of inflammatory bowel disease; hence endoscopic biopsies are of paramount importance in establishing a correct diagnosis, especially in developing countries where both diseases exist with considerable frequency.