Saudi Journal of Gastroenterology
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November-December 2018
Volume 24 | Issue 6
Page Nos. 309-364

Online since Monday, November 19, 2018

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EDITORIAL  

Surgical resection vs radiofrequency ablation in older adults with early stage hepatocellular carcinoma: Where do we stand? p. 309
Bandar Al-Judaibi, M Katherine Dokus
DOI:10.4103/sjg.SJG_501_18  
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SYSTEMATIC REVIEW/META-ANALYSIS Top

Water exchange versus air insufflation for colonoscopy: A meta-analysis p. 311
Yang Liu, Qing-Ke Huang, Xiu-Li Dong, Piao-Piao Jin
DOI:10.4103/sjg.SJG_118_18  PMID:30226480
Background/Aims: To compare water exchange (WE) method with conventional air insufflation (AI) method for colonoscopy, evaluating the technical quality, screening efficacy, and patients' acceptance. Materials and Methods: Electronic databases were systematically searched for randomized controlled trials comparing WE colonoscopy with AI colonoscopy. The pooled data of procedure-associated and patient-related outcomes were assessed, using the weighted mean difference (WMD) with 95% confidence interval (CI) for continuous variables and relative risk (RR) with 95% CI for dichotomous variables, respectively. Results: A total of 13 studies involving 7056 patients were included. The cecum intubation rate was similar between WE and AI methods (RR = 1.01, 95% CI = 0.99–1.02,P = 0.37); however, a significantly longer cecum intubation time was shown in WE group (WMD = 1.56, 95% CI = 0.75–2.37,P = 0.002). Compared with AI, WE was associated with a higher risk of adenoma detection rate (ADR) (RR = 1.28, 95% CI = 1.18–1.38,P < 0.00001) and polyp detection rate (PDR) (RR = 1.30, 95% CI = 1.21–1.39,P < 0.00001). Patients in WE group experienced significantly less maximum pain score (WMD = −1.99, 95% CI = −2.68 to −1.30,P < 0.00001) and less requested on-demand sedation (RR = 0.58, 95% CI = 0.44–0.77,P = 0.0002). Likewise, they also experienced less abdominal compression (RR = 0.62, 95% CI = 0.51-0.74,P < 0.00001) and reposition (RR = 0.74, 95% CI = 0.63-0.86,P = 0.0001). Moreover, patients' willingness to repeat colonoscopy was significantly greater for WE (RR = 1.14, 95% CI = 1.07–1.21,P < 0.0001). Conclusion: This meta-analysis confirmed that WE method could significantly increase ADR/PDR and improve patients' acceptance of colonoscopy, while reducing the degree of pain and minimize the need for on-demand sedation and adjunct maneuvers, despite requiring more cecal intubation time.
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ORIGINAL ARTICLES Top

Radiofrequency ablation versus surgical resection in elderly patients with early-stage hepatocellular carcinoma in the era of organ shortage p. 317
Bin Yu, Youming Ding, Xiaofeng Liao, Changhua Wang, Bin Wang, Xiaoyan Chen
DOI:10.4103/sjg.SJG_261_18  PMID:30117492
Background/Aims: To compare the survival benefits of surgical resection (SR) with those of radiofrequency ablation (RFA) in elderly patients (≥65 years) with single hepatocellular carcinoma (HCC) ≤5 cm. Patients and Methods: Using the Surveillance, Epidemiology, and End Results database, a total of 461 patients who underwent SR and 575 patients who underwent RFA were enrolled from 2004 to 2012. Overall survival (OS) and liver-cancer-specific survival (LCSS) comparisons were conducted between the two groups before and after propensity score matching (PSM).Results: Elderly patients with early-stage HCC had a lower rate of utilization of liver transplantation, and they were more likely to receive SR or RFA as their first-line treatment compared with younger patients (P < 0.05). In the whole cohort, the SR group had significantly better OS [RFA, hazard ratio (HR) = 1.680 (1.390, 2.031), P < 0.001] and LCSS (RFA, HR = 1.658 (1.327, 2.070), P < 0.001) than the RFA group. After PSM, the improved survival in the SR group was further confirmed (all P < 0.001). In the subgroup analyses, according to patients' age (65–75, >75 years) and tumor size (≤3.0, 3.1–5.0 cm), the SR group still presented better OS and LCSS than the RFA group (all P < 0.05), except for those older than 75 years with tumors ≤3.0 cm (all P > 0.05), both before and after PSM. Conclusion: Treatment strategies for elderly patients (≥65 years) with single HCC ≤5 cm should emphasize SR as the primary therapy, while RFA can be an alternative to SR for those >75 years with single HCC ≤3 cm.
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Real-world single-center experience with entecavir and tenofovir disoproxil fumarate in treatment-naïve and experienced patients with chronic hepatitis B p. 326
Young Min Kim, Hyun Phil Shin, Joung Il Lee, Kwang Ro Joo, Jae Myung Cha, Jung Won Jeon, Jin Young Yoon, Min Seob Kwak
DOI:10.4103/sjg.SJG_49_18  PMID:30004042
Background/Aim: The goal of antiviral therapy for chronic hepatitis B (CHB) is to improve survival of the patients by achieving a complete virological response (CVR). This study aimed to evaluate long-term efficacy of entecavir (ETV) and tenofovir disoproxil fumarate (TDF) in nucleos(t)ide analog (NA)-naïve and NA-experienced Korean patients with CHB and to determine the incidence of cirrhosis-related complications in these patients. Patients and Methods: We retrospectively reviewed medical records of all patients treated with ETV or TDF from July 2007 to January 2017. We examined CVR and analyzed the predictive factors influencing the rate of CVR and evaluated the incidences of cirrhosis-related complications. Results: The proportion of patients who achieved CVR was 94.2% in the ETV group and 91.1% in the TDF group (P = 0.358). Among patients who achieved CVR, the mean time to CVR was 13.5 ± 14.3 months in the ETV group and 11.5 ± 10.6 months in the TDF group (P = 0.169). Positive predictive factors for CVR included the current treatment with TDF, a low hepatitis B virus DNA level, negative hepatitis B e-antigen status, and high alanine aminotransferase level in baseline laboratory test. The annual incidence rate of HCC was 127 per 10,000 patient-years (1.27% per year) in ETV group, and 85 per 10,000 patient-years (0.85% per year) in TDF group (P = 0.526). Conclusion: Both ETV and TDF therapy resulted in a high CVR, and the annual incidence rates of HCC and other cirrhosis-related complications were not significantly different between the two treatment groups.
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Biologic agents in inflammatory bowel disease – quality of internet website information p. 336
Rymon Rofaiel, Nilesh Chande
DOI:10.4103/sjg.SJG_55_18  PMID:30004043
Background/Aims: Many patients currently seek the Internet for health-related information without discerning the quality or bias of the evidence presented. Biologic agents have become the mainstay of therapy in inflammatory bowel disease (IBD), and it is important that patients have access to high-quality information when exploring the various available agents to make informed decisions about their therapy. The primary aim of this study was to evaluate the quality of patient-searched Internet websites that describe the biologic agents used as treatment options for IBD. The secondary aim was to compare the quality of patient-searched with physician-recommended websites and to evaluate any differences. Materials and Methods: The DISCERN model was used to evaluate the quality of the information content of a total of 110 websites of all the biologic agents used in the treatment of IBD from July to September 2017. The first 10 “Google search” hits meeting the inclusion criteria for each agent were included. There were four additional physician-recommended websites that were evaluated for the purpose of the secondary aim of this study. Results: The mean DISCERN score among all websites combined was 3.21 out of a 5-point scale. The highest scoring website was “ema.europa.eu” at 4.13 whereas the lowest scoring website was “https://www.fda.gov” at 1.97 for Entyvio. There was no significant difference between patient-searched and physician-recommended websites, with a mean total score of 3.21 versus 3.63, respectively (P value of 0.158). Conclusions: The combined quality of Internet web-based resources used for each drug was fairly consistent in scoring (intermediate to slightly above average). There was no significant advantage in the overall combined scores of the pooled physician-recommended websites when compared with the patient-searched websites.
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Bone mineral density loss in patients with cirrhosis Highly accessed article p. 342
Ibrahim N Muhsen, Omar AlFreihi, Faisal Abaalkhail, Abdullah AlKhenizan, Mohammed Khan, Abdelmoneim Eldali, Fahad Alsohaibani
DOI:10.4103/sjg.SJG_74_18  PMID:29943736
Background/Aims: Evidence of increased risk of osteoporosis and osteopenia in chronic liver disease and cirrhosis is inconsistent. This study aims to investigate this relationship and to identify the predictors of increased loss of bone mineral density in Saudi patients. Patients and Methods: One hundred and sixty-four patients and controls who are age and gender matched, were included in this study with 1:1 ratio. Patients' included in this study were adults with confirmed liver cirrhosis. Bone mineral densitometry (BMD) at both lumbar spine (LS) and femoral neck (FN) were collected for both groups. Univariate and multivariate regression analyses were performed to identify predictors of BMD loss. Results: Results showed that cirrhotic patients are at higher risk of developing osteoporosis or osteopenia at LS (OR 2.23, 95% CI [1.19–4.19], P = 0.01) but not at FN, when compared to control sample. Patients with cirrhosis were found to have lower vitamin D and PTH levels (P = 0.0005) and (P = 0.006), respectively. Of the possible predictors tested (gender, age, body mass index [BMI], phosphorus, calcium, parathyroid hormone (PTH), vitamin D, and Model for End Stage Liver Disease [MELD] score), female gender was the main predictor of loss of BMD at LS only (OR 4.80, 95% CI [1.47–15.73], P = 0.01). Conclusions: The study showed that cirrhotic patients are at increased susceptibility of having decreased BMD, particularly at the LS and it highlights the need for preventive measures, especially for female patients.
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The efficacy of temporary placement of nasobiliary drainage following endoscopic metal stenting to prevent post-ERCP cholangitis in patients with cholangiocarcinoma p. 348
Xinjian Wan, Sumin Chen, Qiuyan Zhao, Tian Li, Shengzheng Luo, Xiaobo Cai, Yingchun Ren, Lanting Yu, Baiwen Li
DOI:10.4103/sjg.SJG_94_18  PMID:30027911
Background/Aims: Although endoscopic metal biliary endoprosthesis (EMBE) is widely accepted as the most suitable drainage method for patients with unresectable malignant obstruction, uncontrolled post-procedural cholangitis is still a problem. We aimed to validate a new treatment modality to prevent post-ERCP cholangitis in patients with unresectable cholangiocarcinoma. Patients and Methods: A total of 378 patients who were diagnosed with unresectable malignant biliary obstruction and underwent EMBE or temporary endoscopic nasobiliary drainage (ENBD) following EMBE placement, from January 2010 to July 2016, were enrolled in this retrospective study. Incidence of cholangitis, related infectious indicators, success rate of biliary drainage, and occurrence of complications were evaluated. Results: The risk of overall cholangitis and related infectious indicators was significantly lower in EMBE plus ENBD group than that in EMBE group. The occurrence of cholangitis was 2.4% versus 11.9% (P = 0.004). On further analysis of subgroups, although no difference was detected in nonhilar cholangiocarcinoma subgroup, the incidence of cholangitis and related infectious indicators in hilar cholangiocarcinoma subgroup with EMBE modality were distinctly higher than that with EMBE plus ENBD modality (type I + II was 18.5% vs 0%, P < 0.05; type III + IV was 19.8% vs 3.8%, P < 0.05). No significant difference was found in successful biliary drainage rate and procedure-related complications when all subgroups were compared. Conclusions: The temporary placement of ENBD following EMBE is a simple and effective treatment modality to prevent post-ERCP cholangitis, especially in patients with hilar cholangiocarcinoma.
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Initial experience of video capsule endoscopy at a tertiary center in Saudi Arabia p. 355
Abdulrahman Alkhormi, Mohammed Y Memon, Ahmad Elhafi, Mishal Aljohani, Abdullah Aljahdali, Adil Khatimi, Amer Rizvi, Khaled Shaban, Ghulam Yazdani, Mohammed Alnasser
DOI:10.4103/sjg.SJG_110_18  PMID:30004041
Background/Aim: No prior experience with video capsule endoscopy (VCE) has been published from Saudi Arabia. In this study, we aim to report the first Saudi experience with VCE. Patients and Methods: A prospective study was conducted between March 2013 and September 2017 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Eligible patients underwent VCE and their data (age, sex, indication for VCE, type of obscure gastrointestinal bleeding [OGIB: overt vs occult], VCE findings, and complications) were recorded. Approval was obtained from the institutional ethics board before the study began and all patients provided verbal and signed consent for the procedure. The procedure was performed according to the established guidelines. Results: During the study period, a total 103 VCE procedures were performed on 96 patients. Overall, 60 participants (62.5%) were male (mean age, 58.8 years; range, 25–97 years) and 36 (37.5%) were female (mean age, 52.8 years; range, 18–78 years). The most frequent indication for VCE was OGIB (n = 91, 88.35%; overt, n = 46, 50.55%; occult, n = 45, 49.45%). Other indications were suspected Crohn's disease (n = 4, 3.88%), suspected complicated celiac disease (n = 4, 3.88%), and unexplained chronic abdominal pain (n = 4, 3.88%). The VCE results were categorized as incomplete (n = 2, 1.94%), poor-quality (n = 7; 6.8%), normal (n = 39, 37.86%), and abnormal (n = 55, 53.4%). The completion rate was 98.06% (n = 101), and the overall diagnostic yield was 53.4%. Of the 55 patients with abnormal VCE results, 43 (78.2%) had small bowel (SB) abnormalities and 12 (21.8%) had abnormalities in the proximal or distal gut. The most frequent SB abnormalities were angiodysplasia (n = 22, 40.0%) and tumors (n = 7, 12.7%). Conclusion: The diagnostic yield of VCE for Saudi patients with OGIB is comparable to that reported internationally; however, data for other VCE indications, including inflammatory bowel disease, are still lacking.
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The characteristics of 83 giant peptic ulcers in Chinese children: Evaluation and follow-up p. 360
Zifei Tang, Jieru Shi, Min Ji, Peng Shi, Zhiheng Huang, Ying Huang
DOI:10.4103/sjg.SJG_147_18  PMID:30136703
Background/Aims: Giant peptic ulcers (GPUs) are detrimental for all patients, especially for children. However, few reports have described GPUs in children. This study aims to evaluate the characteristics of GPUs in Chinese children and to identify risk factors. Patients and Methods: We retrospectively analyzed patients at the Children's Hospital of Fudan University from April 2014 to August 2017. Patients with GPUs (>2.0 cm) were included in the study, and the clinical data, pathological characteristics and presence of Helicobacter pylori (H. pylori) infection were analyzed to evaluate the outcomes. Results: A total of 19208 children underwent gastroscopic examinations, and 83 patients with GPUs were enrolled. The mean age of onset for GPU patients was 9.7 ± 3.2 years(range, 1-15). The main complaints were abdominal pain (92.7%), anemia (53%), retching (45.8%), hematochezia (21.7%) and hematemesis (16.9%). With respect to the types of GPU, 68 patients (81.9%) had duodenal ulcers, and 15 patients (18.1%) had gastric ulcers. Compared to the group <6 years of age, the group ≥6 years was more susceptible to GPU (P < 0.05). Among GPU patients, 71.1% of cases were H. pylori (*) (59/83), and 16.9% (14/83) of patients were H. pylori (-). Compared to the H. pylori (-) group, the H. pylori (*) group showed inflammatory activity, atrophy and lymphoid follicular formation in the gastric mucosa (P < 0.05). Conclusions: This study suggests that GPUs are strongly associated with H. pylori infection in Chinese children. Duodenal ulcers are the main type of GPU in patients older than 6 years. Appropriate diagnosis, treatment and follow-up are necessary for children with GPUs.
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